hospital_name,last_updated_on,version,location_name,hospital_address,license_number|SC,type_2_npi,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name
ROPER HOSPITAL INC,"4/1/2026",3.0.0,Roper Hospital ,"316 Calhoun Street,Charleston,SC 29401",HTL-0063,1962472860|1275503799,TRUE,Billie Jean Mounts
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,modifiers,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,median_amount,10th_percentile,90th_percentile,count,standard_charge|methodology,standard_charge|min,standard_charge|max,additional_generic_notes
CATHETER US 8FR L90CM GRN TIP OVERLAY FOR GE-VIVID I VIVID,SUP-2248457,CDM,C1759,HCPCS,0272,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
INTRODUCER LD 8 FR SINGLE CHMBR PEELABLE PERQ 6208SI] MEDTRONIC USA INC],SUP-2278887,CDM,C1892,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309711000,CDM,97110,CPT,0430,RC,,,KX|CQ|XU,both,,,195.00,126.75,,,,,,,,,,,,,
ELECTRODE ENDO 24X26FR DIA3MM YEL COAG BALL SHP FOR 24/28FR,SUP-2261192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.81,280.68,,,,,,,,,,,,,
BLADE SCRDRIVER CRUCFRM HLD SL NONCANNULATED FOR 1.3MM CORT,SUP-2187554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3396.51,2207.73,,,,,,,,,,,,,
BUR SURG L 10 MM DIA 5 MM DIAMOND STRL DISP ELAN 4 MIS,SUP-2928914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.73,316.37,,,,,,,,,,,,,
JOINT FNGR HINGED 20 16.7X3.6/6.9X2.2 MM 12.5X10.3 MM DSTL,SUP-2852888,CDM,C1776,CPT,0278,RC,,,,both,,,6911.93,4492.75,,,,,,,,,,,,,
PROBE LITHO COHERENT DIR DISP,SUP-2129216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BRACE KNEE ADULTXL UNIV FOAM POSTOP UNISX WRP ARND HNG T SCP,SUP-2150861,CDM,L1810,HCPCS,0274,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
POST EXT FIX 4 HOLE STRL TRUELOK EVO LTX,SUP-2875630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1528.90,993.78,,,,,,,,,,,,,
SYSTEM MENIS REP W/ 27DEG ORTHOCORD VLT BRAID COMP 2-0 SUT,SUP-2249482,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
PIN FIX L 14 MM DIA2.5 MM PROV SM TARGETER SYS STRL EVOS,SUP-2933798,CDM,C1713,HCPCS,0278,RC,,,,both,,,1359.31,883.55,,,,,,,,,,,,,
INSERT TIBIALXS-SM THK11MM UNI UNI GEN,SUP-2344273,CDM,C1776,CPT,0278,RC,,,,both,,,2469.61,1605.25,,,,,,,,,,,,,
BASEPLATE TIB 1F 2T CEM UNIV PRI REV STEM STD CO CHROM,SUP-2221014,CDM,C1776,CPT,0278,RC,,,,both,,,9043.20,5878.08,,,,,,,,,,,,,
CANNULA SURG GRFT 100 MM GPS,SUP-2736523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
BIT DRL L85MM OD1.5MM ADD ON,SUP-2402825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
PLATE BNE L52MM THK1.5MM 3 H R S STL T OBLQ ANG LOK COMPR,SUP-2185824,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.13,617.58,,,,,,,,,,,,,
HC Pt Orthotic Fit/Train Subsq per 15 Min,PX-4209776300,CDM,97763,CPT,0420,RC,,,,inpatient,,,160.00,104.00,,,,,,,,,,,,,
MESH HERN W10XL13IN UNCOATED MFIL POLYPR ELLIPSE LTWT ABSRB,SUP-2125903,CDM,C1781,HCPCS,0278,RC,,,,both,,,4675.46,3039.05,,,,,,,,,,,,,
CATHETER ENDOBRONCHIAL BLK SET 9 FRX65 CM 7 MM COHEN TIP STD,SUP-2759867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.97,616.83,,,,,,,,,,,,,
SHEATH TRANSSEPTAL 45 DEG L 63 CM DIA 8.5 FR GUIDEWIRE L 180 D0,SUP-2913659,CDM,C1893,HCPCS,0272,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
SCREW BONE 5X50MM LCK FT,SUP-2364651,CDM,C1713,HCPCS,0278,RC,,,,both,,,448.39,291.45,,,,,,,,,,,,,
DRILL SURG HD DIA2MM LOCON-T,SUP-2397216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.93,386.05,,,,,,,,,,,,,
PLATE BNE 156 MM HIP 5 HOLE SS BMP,SUP-2468861,CDM,C1713,HCPCS,0278,RC,,,,both,,,9168.80,5959.72,,,,,,,,,,,,,
HC Phase II Recovery - First 15 Min,PX-7100000010,CDM,7100000010,LOCAL,0710,RC,,,,both,,,1013.00,658.45,,,,,,,,,,,,,
"HC So Protein C, Activity",PX-3058530366,CDM,85303,CPT,0305,RC,,,,both,,,492.00,319.80,,,,,,,,,,,,,
COUNTERSINK SURG DRL DIA4MM CANN FOR FIXOS SYS,SUP-2378069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SPACER TALUS CUSTOM IMPLANT **OR DIRECTOR APPROVAL REQUIRED*,SUP-2823666,CDM,C1776,CPT,0278,RC,,,,both,,,47084.30,30604.79,,,,,,,,,,,,,
PLATE BONE SM 75MML HLX4 STNLSS STEEL DELTA BTTRSS ST RIGHT,SUP-2721435,CDM,C1713,HCPCS,0278,RC,,,,both,,,2406.24,1564.06,,,,,,,,,,,,,
ALLOGRAFT BNE INSRT SM 11X5.5X11 MM FD DBM XPANSE,SUP-2787772,CDM,C1713,HCPCS,0278,RC,,,,both,,,2396.45,1557.69,,,,,,,,,,,,,
HC Renal Art 2nd Order Uni,PX-4813625300,CDM,36253,CPT,0481,RC,,,,both,,,16763.00,10895.95,,,,,,,,,,,,,
STAPLE INT L20XW20MM S STL COMPR INTERAXIS NONSTERILE IMPL,SUP-2243126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.57,1939.32,,,,,,,,,,,,,
PLATE BNE LCK LG EXT LT CALCANEAL 2 HOLE STRL A.L.P.S,SUP-2459853,CDM,C1713,HCPCS,0278,RC,,,,both,,,3164.59,2056.98,,,,,,,,,,,,,
SCREW BNE MIC 1X3 MM DRILL-FREE TI CENTRE-DRIVE,SUP-2462156,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.18,134.67,,,,,,,,,,,,,
BIORESORBABLE PIN 22MM,SUP-2467625,CDM,C1713,HCPCS,0278,RC,,,,both,,,1918.85,1247.25,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5X22 CM LT DL BASIC SET HEMO-FLOW XF,SUP-2627245,CDM,C1750,HCPCS,0278,RC,,,,both,,,32.19,20.92,,,,,,,,,,,,,
DRILL SURG 20MM J SLOT PILOT LUHR,SUP-2364951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.90,224.83,,,,,,,,,,,,,
GUIDEWIRE ORTH L100CM DIA2.4MM BULL TIP FOR SENTNL RMR,SUP-2410250,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 6 MM EPTFE STR TW N RING HEMO,SUP-2761301,CDM,C1768,CPT,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,6370000000,HCPCS,0637,RC,00781-7135-93,NDC,,both,3,ML,157.60,102.44,,,,,,,,,,,,,
MESH SURG M W4.5XL10CM UNDERLAY 7CM CONN OD1.9CM ID1.3CM,SUP-2219791,CDM,C1781,HCPCS,0278,RC,,,,both,,,930.04,604.53,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.156X9 IN SS NS STEINMANN,SUP-2791596,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.24,24.21,,,,,,,,,,,,,
VALVE AORT OPN PVT DIA 31 MM CONDUIT 34 MM ORIFICE 26.8 MM,SUP-2429918,CDM,C1713,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
JOINT SHOULDER HUMERAL STEM PROXIMAL BODY EQUINOXE XSM +0MM,SUP-2855529,CDM,C1776,CPT,0278,RC,,,,both,,,11378.58,7396.08,,,,,,,,,,,,,
STEM CPT 2 HIP LNG,SUP-2205955,CDM,C1776,CPT,0278,RC,,,,both,,,10301.71,6696.11,,,,,,,,,,,,,
CATHETER DEL CARR L 152 CM LG COMP HYDRPHLC 1 LUMEN VAR PK 5,SUP-2934069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
PLATE BONE L228MM 15 HOLE RIGHT PSTRLTRL DST PRRTCLR HMRL LO,SUP-2498981,CDM,C1713,HCPCS,0278,RC,,,,both,,,3311.82,2152.68,,,,,,,,,,,,,
BURR RND SFT TCH OSTEON ELITE 4.0MM,SUP-2367553,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.34,293.37,,,,,,,,,,,,,
FILTER VASC L50MM DIA30MM INTRO 7FR L65CM VENA CAVA JUG W,SUP-2171004,CDM,C1880,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
GUIDEWIRE ORTH MULT HOLE 3.2X14 MM NS,SUP-2799309,CDM,C1769,HCPCS,0272,RC,,,,both,,,3222.30,2094.49,,,,,,,,,,,,,
CURETTE SURG MARINO 5-3/8 IN 3 MM TRNSSPHND VERTICAL RNG,SUP-2872847,CDM,C1762,CPT,0278,RC,,,,both,,,914.02,594.11,,,,,,,,,,,,,
TUBE VENT ID1.27MM INNR FLNG DIA5.8MM INTERFLNG DISTANCE,SUP-2284178,CDM,L8699,HCPCS,0278,RC,,,,both,,,96.99,63.04,,,,,,,,,,,,,
KIT METADIAPHYSEAL W/ INSTRMT STERILEXCALIBER,SUP-2316323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9737.89,6329.63,,,,,,,,,,,,,
Z DUP USE 2111355 LENS IOL SN60WF 27.5D,SUP-2111356,CDM,V2632,HCPCS,0276,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
STEM 12 CONQ BPLR 46,SUP-2347985,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
KIT PLT BNE L54MM HD SZ 22MM 6X3 H STD R DST RAD TWO CLMN TI,SUP-2418150,CDM,C1713,HCPCS,0278,RC,,,,both,,,4356.97,2832.03,,,,,,,,,,,,,
GRAFT OPHTH DIA16MM AMNIO MEM OCU PROKERA,SUP-2135266,CDM,V2790,HCPCS,0274,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
BLADE SAW 90X25X1.37MM OSC RIB FOR OXFORD PART KNEE STRYKR,SUP-2136844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
NUT SPINE BRK OFF SACR FIX ANTR SPNL SYS TI COLORADO 2,SUP-2290606,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
NUCLEUS PROFILE PLUS W/ SLIM MODIOLAR ELECTRODE (CI632),SUP-2858189,CDM,L8614,HCPCS,0278,RC,,,,both,,,75666.15,49183.00,,,,,,,,,,,,,
HC Hdr Vaginal Cyl Insertion,PX-3335715600,CDM,57156,CPT,0333,RC,,,,inpatient,,,2400.00,1560.00,,,,,,,,,,,,,
SHEATH INTRO 16FR L28CM 0.035IN GWIRE HYDRPHLC LOK,SUP-2298362,CDM,C1894,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
KIT TRNSDUC 84IN 4IN TBNG 1 SGL LN PRT AND RESVR POLE MT,SUP-2214662,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.56,58.86,,,,,,,,,,,,,
KIT ELECTROPHYSIOLOGY REF PTCH LOCATION MAG FOR AFFERA MAP,SUP-2911930,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
LINER ACET SZ D ID26MM STD HIP HGP II CUP ELEV RIM,SUP-2202730,CDM,C1776,CPT,0278,RC,,,,both,,,3830.80,2490.02,,,,,,,,,,,,,
GRAFT BNE FIB WDG RND COR FRZ DRY 6MM MATRIGRFT,SUP-2264771,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.35,987.58,,,,,,,,,,,,,
SCREW INTFR L20MM DIA7MM KNEE PLLA HA BIOABSRB FOR ACL PCL,SUP-2341562,CDM,C1713,HCPCS,0278,RC,,,,both,,,762.61,495.70,,,,,,,,,,,,,
GRAFT BNE W10MM BISECTED PAT LIG W SMER BLK FRZN FLEXIGRFT,SUP-2264728,CDM,C1713,HCPCS,0278,RC,,,,both,,,7047.35,4580.78,,,,,,,,,,,,,
ANTI-ROTATION SCREW 5.0MMX105MM,SUP-2829516,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
PROTECTOR NERVE L 4 X W 2 CM PORCINE SODIUM HYALURONATE,SUP-2890380,CDM,C1763,HCPCS,0278,RC,,,,both,,,10299.20,6694.48,,,,,,,,,,,,,
GRAFT VASC ALBOGRFT POLY 16 MMX8 MM DIAX50 CM L KNIT BIFUR,SUP-2264274,CDM,C1768,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
HC CT Angio Lower Ext W & W/O Cont,PX-3527370600,CDM,73706,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM WND MTRX NEOX CRD 1K,SUP-2135262,CDM,Q4148,HCPCS,0636,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
GRAFT BIO TISS W11.8XL17.7IN RECT ANTI BACT SURG PORCINE,SUP-2126235,CDM,C1781,HCPCS,0278,RC,,,,both,,,140836.54,91543.75,,,,,,,,,,,,,
SLEEVE GASTRECTOMY CALIB SYS VISIGI 3D 40 FR,SUP-2138633,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.41,624.92,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.054X6 IN,SUP-2107895,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
BENDING IRON FOR 2.4MM CONDYLAR PLATE,SUP-2548472,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.42,219.32,,,,,,,,,,,,,
PLATE BNE L 85 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 6 H SS 72466206,SUP-2933340,CDM,C1713,HCPCS,0278,RC,,,,both,,,4584.71,2980.06,,,,,,,,,,,,,
PATCH CV HEMSHLD L 4.8 X W 0.2 IN THK 0.76 MM POLYESTER BOV,SUP-2486938,CDM,C1768,CPT,0278,RC,,,,both,,,395.17,256.86,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 60 MM DIA22 MM LIMB L 40 MM DIA16,SUP-2217619,CDM,C1768,CPT,0278,RC,,,,both,,,36361.20,23634.78,,,,,,,,,,,,,
CATHETER EP JSN 5 MM SPC 5 FRX120 CM 1 MM,SUP-2356793,CDM,C1730,HCPCS,0272,RC,,,,both,,,120.61,78.40,,,,,,,,,,,,,
HYDRALAZINE HCL 25 MG PO TABS,RX-3700,CDM,6370000000,HCPCS,0637,RC,00904-7448-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SYSTEM TUNN PROTCT OUTER SHTH FOR VEIN GRFT,SUP-2227395,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.93,300.25,,,,,,,,,,,,,
PLATE BONE W12XL167MM THK1MM 10 H BILAT S STL SEMI TBLR LO,SUP-2184871,CDM,C1713,HCPCS,0278,RC,,,,both,,,873.74,567.93,,,,,,,,,,,,,
CANNULA ART SHT 19 FR UNCOATED HLS,SUP-2663477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1010.86,657.06,,,,,,,,,,,,,
BIT DRL L115MM DIA1.6MM FLUT,SUP-2365239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.51,566.48,,,,,,,,,,,,,
PLATE BONE W5MM THK0.9MM 2 H LT S STL L SHP OBLQ,SUP-2343840,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.73,291.02,,,,,,,,,,,,,
EXTERNAL FIXATION KIT DSTL RADIAL FASTFRAME,SUP-2494462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VIVA S DELIVERED ENERGY 36 J TI POLYUR,SUP-2282405,CDM,C1882,HCPCS,0275,RC,,,,both,,,51490.25,33468.66,,,,,,,,,,,,,
PLATE BONE RAD SHORTNG KIENBOCK RAYHACK,SUP-2397322,CDM,C1713,HCPCS,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
OBTURATOR SHTH 8FRX15CM LUERLOCK,SUP-2355472,CDM,C1894,HCPCS,0272,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
HC So Aquaporin-4 Antibody Cell-Based Imfluor Assay Ea,PX-3028605266,CDM,86052,CPT,0302,RC,,,,inpatient,,,858.00,557.70,,,,,,,,,,,,,
FILLER BNE VOID SZ 1-4 MM 10 CC DBM CANC SPNG FIL STRL APEX,SUP-2913403,CDM,C1713,HCPCS,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 170 MM DIA 6 MM CATH L 130 CM DIA 6,SUP-2128187,CDM,C1876,HCPCS,0278,RC,,,,both,,,10346.30,6725.09,,,,,,,,,,,,,
HC So Comparative Analysis Using Str,PX-3108126566,CDM,81265,CPT,0310,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
KIT INTRO ARW SHTH L 10 CM DIA 8.5 FR GUIDEWIRE 0.035 IN,SUP-2383284,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.77,104.50,,,,,,,,,,,,,
PLATE BNE W8XL96MM THK3.3MM 12 H NONSTERILE BILAT PELV S,SUP-2186239,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.93,1300.60,,,,,,,,,,,,,
CATHETERIZATION SET ART 021 22 GAX12 CM 22 GA INDWL LF,SUP-2865603,CDM,C1751,HCPCS,0278,RC,,,,both,,,71.28,46.33,,,,,,,,,,,,,
CLAMP CRAN TEXT SM 13 MM FLAPFIX FOR EXT FIX TI NS LF,SUP-2431404,CDM,C1713,HCPCS,0278,RC,,,,both,,,1062.58,690.68,,,,,,,,,,,,,
RETRACTOR NEUROSURGICAL 20 MM DOCKING PIN MARS 3V SYS,SUP-2232227,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
STEM FEM SZ 0 TRABECULAR MTL CEM NP NATURAL-HIP,SUP-2210708,CDM,C1776,CPT,0278,RC,,,,both,,,16453.60,10694.84,,,,,,,,,,,,,
PLATE BNE L85MM 6 H NONSTERILE R PROX TIB S STL LO PROF,SUP-2185811,CDM,C1713,HCPCS,0278,RC,,,,both,,,3579.73,2326.82,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II HI FLO L 4CM 6FR 0.035/0.038 IN,SUP-2385642,CDM,C1894,HCPCS,0272,RC,,,,both,,,84.87,55.17,,,,,,,,,,,,,
GRAFT VASC L 45 MM ID 7 MM CLLGN BOV CAR ART WOVEN,SUP-2880939,CDM,C1762,CPT,0278,RC,,,,both,,,8851.66,5753.58,,,,,,,,,,,,,
ANCHOR SUT L12.7MM DIA3MM SHLDR PEEK KNOTLESS W/ SZ 2,SUP-2121614,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 37 CM DIA 4 MM SPD 1200 RPM TRACH,SUP-2902052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1605.17,1043.36,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST LIFT ELEVATION PER INCH,SUP-2435719,CDM,L3334,HCPCS,0274,RC,,,,both,,,107.95,70.17,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 18H TI STRL,SUP-2546936,CDM,C1713,HCPCS,0278,RC,,,,both,,,3278.13,2130.78,,,,,,,,,,,,,
PLATE BNE CRV 4.5X301 MM RT CNDYL 14 HOLE VA LCK NS VA-LCP,SUP-2758216,CDM,C1713,HCPCS,0278,RC,,,,both,,,6320.13,4108.08,,,,,,,,,,,,,
NAIL IM TIB 10MM DIA 24CML STRL VERSANAIL DEPUY ORTHOPEDICS,SUP-2412332,CDM,C1713,HCPCS,0278,RC,,,,both,,,4288.99,2787.84,,,,,,,,,,,,,
STEM FEM L8IN DIA15MM HIP POR SM STAT STR 12/14 TAPR REV,SUP-2252164,CDM,C1776,CPT,0278,RC,,,,both,,,18993.23,12345.60,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 1 MG/ML IV SOLN,RX-78084,CDM,J2274,HCPCS,0636,RC,09999-9912-73,NDC,,both,100,ML,136.30,88.59,,,,,,,,,,,,,
HOOK SPNL SM PEDCL TI OPN FOR 5.5MM ROD EXPEDIUM,SUP-2256241,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SOLUTION IV 1000ML 0.9% SODIUM CHLORIDE INJ USP,SUP-2900296,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.13,5.28,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL BND BELT UNILAT,SUP-2435688,CDM,L2630,HCPCS,0274,RC,,,,both,,,655.51,426.08,,,,,,,,,,,,,
ALLOGRAFT BNE 100 MM FEM SHFT STRL BIO LF DISP,SUP-2632313,CDM,C1762,CPT,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
TUBING IRRIG INTEGRATEDCASSETTE DISP FOR FLD WST MGMT SYS,SUP-2361438,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
SCREW BNE L26MM DIA3.5MM MINI FT ANK TI SELF DRL ST CANN AR273026H] ARTHREX INC],SUP-2121752,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
CATHETER INFUSION 85 CM ROTATING WIRE EFFICIENT CLARIVEIN IC,SUP-2471532,CDM,C1751,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PIN FIX OD3.2MM LNG KNEE PK CLLRD ADV EVOLUTION,SUP-2304614,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE W11XL32MM THK13MM 7 H LOK COMPR GRID T SHP TI MAL,SUP-2267939,CDM,C1713,HCPCS,0278,RC,,,,both,,,2623.09,1705.01,,,,,,,,,,,,,
ALLOGRAFT BNE 100 MM PRESERVON FEM SHFT MATRIGRAFT,SUP-2741089,CDM,C1762,CPT,0278,RC,,,,both,,,2647.59,1720.93,,,,,,,,,,,,,
SCREW ABSRBBLE 50MM DIA 40MML LOW PRFLE DRCT DRIVE ARTHRTK,SUP-2724043,CDM,C1725,HCPCS,0272,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC VIABLE BNE MTRX VIBONE,SUP-2731788,CDM,C1762,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y DBL PLATE XDRV 1 PK,SUP-2935470,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.88,1514.42,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-106535,CDM,2500000003,HCPCS,0250,RC,00409-9045-17,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L20MM DIA27MM NONLOCKING,SUP-2315951,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.72,314.42,,,,,,,,,,,,,
PLATE BNE L THK1MM MINI 4 H TI STR LEV 1 PNK FOR 2MM SCR,SUP-2262738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1069.36,695.08,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA19 GA TOUPHY NDL DIA17 GA CE17TKFCN,SUP-2936703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.25,59.31,,,,,,,,,,,,,
BLADE RETRACTOR 15 CM LT INT PIN MAST QUAD,SUP-2631629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1728.73,1123.67,,,,,,,,,,,,,
BIT DRL L150MM DIA3.2MM CANN DISP,SUP-2389442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
GRAFT HUM TISS SZ C W3.5XL3.5CM FRZN ALLGRFT OCU AMNIO MEM,SUP-2135259,CDM,V2790,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
BUR SURG PRECIS 5 MMX16 CM RND BRN STRL LTX,SUP-2859533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.30,517.59,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH ULTRA L 13 CM DIA 9.5 FR GUIDEWIRE L,SUP-2159478,CDM,C1892,HCPCS,0272,RC,,,,both,,,174.62,113.50,,,,,,,,,,,,,
MINI MAXLOCK EXTRM FLAT 3 H T PLT,SUP-2400401,CDM,C1713,HCPCS,0278,RC,,,,both,,,3290.72,2138.97,,,,,,,,,,,,,
STENT GRFT VASC RELAYPRO L 150 MM CVR L 164 MM DIA 30 MM,SUP-2894701,CDM,C1768,CPT,0278,RC,,,,both,,,59503.00,38676.95,,,,,,,,,,,,,
NAIL IM LNG 11 MMX26 CM LT PERITROCHANTERIC STRL PHOENIX LTX,SUP-2861378,CDM,C1713,HCPCS,0278,RC,,,,both,,,7373.98,4793.09,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT MAGNA MITRL EASE DIA 31.5 MM SEW,SUP-2214314,CDM,C1889,HCPCS,0278,RC,,,,both,,,20253.00,13164.45,,,,,,,,,,,,,
CATHETER PERITONEAL L 42.5 CM PED LT SWAN NK MISSOURI CURL,SUP-2905041,CDM,C1750,HCPCS,0278,RC,,,,both,,,806.70,524.35,,,,,,,,,,,,,
BIT DRL L 205/110 MM DIA2.5 MM CALIB AO QC STRL DISP V,SUP-2908406,CDM,2720000010,LOCAL,0272,RC,,,,both,,,956.13,621.48,,,,,,,,,,,,,
GUIDEWIRE VASC L315CM SFT BAREWIRE,SUP-2105873,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 40 CM DIA 7 FR GUIDEWIRE 0.035 IN,SUP-2168695,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT HUM TISS W8XH6XL6MM INTBDY FUS SPCR BONE INSERTXPANSE,SUP-2294021,CDM,C1713,HCPCS,0278,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 6-4 MM EPTFE SHRT TAPR STD WALL,SUP-2761270,CDM,C1768,CPT,0278,RC,,,,both,,,1655.22,1075.89,,,,,,,,,,,,,
AMPICILLIN 500 MG PO CAPS,RX-466,CDM,6370000000,HCPCS,0637,RC,00781-2145-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L183MM 10 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177800,CDM,C1713,HCPCS,0278,RC,,,,both,,,3295.90,2142.33,,,,,,,,,,,,,
CONNECTOR SPNL SZ 4 L26-27MM STD POST S STL FIX TRNSVRS,SUP-2254367,CDM,C1713,HCPCS,0278,RC,,,,both,,,2981.43,1937.93,,,,,,,,,,,,,
STENT BILI LIFESTENT NT L 30 MM DIA 6 MM CATH L 120 CM DIA 6,SUP-2214605,CDM,C1876,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
GRAFT BONE SUB 9MM LXPANSE,SUP-2294013,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE 2 Y 1.4 MM 18 HOLE LCK 6-6-6 TI BABY GORILLA,SUP-2750964,CDM,C1713,HCPCS,0278,RC,,,,both,,,3725.61,2421.65,,,,,,,,,,,,,
SPHERE OPHTH DIA18 MM ORBIT SMTH SURF TUNN POROUS ANTR SURF,SUP-2883185,CDM,L8610,HCPCS,0278,RC,,,,both,,,2098.21,1363.84,,,,,,,,,,,,,
CENTRALIZER STEM L120MM DIA16.5MM DSTL FEM HIP CEM MOLD FOR,SUP-2251182,CDM,C1776,CPT,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PATELLAR UPCHARGE TRAB MEL,SUP-2212693,CDM,C1776,CPT,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
RESERVOIR VENTRICULAR LG 18 MM HOLTER,SUP-2666417,CDM,C1889,HCPCS,0278,RC,,,,both,,,1348.47,876.51,,,,,,,,,,,,,
AXLE TIB OSS AVL,SUP-2441790,CDM,C1776,CPT,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L75CM BAL L100MM DIA10MM RBP 18ATM GWIRE,SUP-2117081,CDM,C1725,HCPCS,0272,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
GRAFT BNE SCAFFOLD 20X20X4 MM MOLD DBM FUSIONFLEX 86082040,SUP-2859710,CDM,C1713,HCPCS,0278,RC,,,,both,,,7300.50,4745.32,,,,,,,,,,,,,
PLATE BNE H1MM BAR L8MM 6 H MAND BLU TI MINI STR LOK,SUP-2366343,CDM,C1713,HCPCS,0278,RC,,,,both,,,717.18,466.17,,,,,,,,,,,,,
COUPLING INVERTED PIN ROD,SUP-2678697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.18,288.07,,,,,,,,,,,,,
TOOL CV COR STRL DISP HEARTMATE 3,SUP-2895099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1509.08,980.90,,,,,,,,,,,,,
MRS 17X127 FEM STM W/FEM TAPER,SUP-2512647,CDM,C1776,CPT,0278,RC,,,,both,,,6114.05,3974.13,,,,,,,,,,,,,
POST EXT FIX WIRE TALL MR SAFE,SUP-2179142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.90,436.73,,,,,,,,,,,,,
PIN EXT FIX THRD L50MM DIA7MM SHANK L375MM DIA5MM S STL,SUP-2342935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2122.92,1379.90,,,,,,,,,,,,,
GRAFT HUM TISS W20XL20CM THK08 14MM THN ACELLULAR HYDRATED,SUP-2307552,CDM,Q4128,HCPCS,0636,RC,,,,both,,,38497.66,25023.48,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 25 CM LOOP DIA10 MM PRIMARY,SUP-2249276,CDM,C1889,HCPCS,0278,RC,,,,both,,,4172.75,2712.29,,,,,,,,,,,,,
ANCHOR SUT W/ ORTHOCORD BIOKNOTLESS,SUP-2256603,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.63,102.46,,,,,,,,,,,,,
LASER FBR 1000UM HOLM FLAT TIP FLEX DISP,SUP-2213045,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
BODY FEM DIA25MM +0MM OFFSET STD PROX HIP TI MOD REV CONE,SUP-2375536,CDM,C1776,CPT,0278,RC,,,,both,,,9808.10,6375.26,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 014 135 CM 3X20 MM QUANTUM MAV OTW,SUP-2139895,CDM,C1725,HCPCS,0272,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
PLATE BONE 130DEG 3 H PROX FEM LCK FOR 3.5MM SCR PEDILOC,SUP-2318556,CDM,C1713,HCPCS,0278,RC,,,,both,,,7471.00,4856.15,,,,,,,,,,,,,
IMPLANT HUM TISS L 80 MM FIBULAR SHFT PRESERVON ALLGRFT STRL,SUP-2933138,CDM,C1762,CPT,0278,RC,,,,both,,,3119.90,2027.93,,,,,,,,,,,,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,6370000000,HCPCS,0637,RC,00378-9112-93,NDC,,both,1,UN,3.70,2.40,,,,,,,,,,,,,
BLADE SHAVER CRV 4.5X460 MM DISP 4256104463,SUP-2599801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,927.74,603.03,,,,,,,,,,,,,
SHUNT CEREBROSPINAL FLUID PRESSURE RATING HORIZONTAL 0.0 CWS,SUP-2843218,CDM,C1889,HCPCS,0278,RC,,,,both,,,12600.16,8190.10,,,,,,,,,,,,,
HC L Heart W Lv & Coronary,PX-4819345800,CDM,93458,CPT,0481,RC,,,,both,,,14957.00,9722.05,,,,,,,,,,,,,
SPLINT WRST UNIV L11IN L CUTAWAY PERF FOAM CONSTR MAL,SUP-2194860,CDM,L3809,HCPCS,0274,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
NUT BONE 13.8MM SPINE HEX TI LCK,SUP-2415519,CDM,C1713,HCPCS,0278,RC,,,,both,,,677.86,440.61,,,,,,,,,,,,,
SYSTEM STENT POS 0.014X0.018 INX127 CM OSTIAL PRO,SUP-2301448,CDM,C1769,HCPCS,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE 6 H S STL LOK STR FOR ANK FRAC MGMT,SUP-2123027,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
IMPLANT COSMETIC DIA18 MM POLYETHYL ORBIT SPHR STRL DISP,SUP-2935216,CDM,C1713,HCPCS,0278,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
CAP HEALING 20MM PLUG DISP BAHA,SUP-2164955,CDM,L8614,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
HC Mra Abdomen W/O Contrast,PX-6187418501,CDM,C8901,CPT,0618,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
DEFIBRILLATOR CARD 36J RESYNCHRONIZATION THER 2 CHMBR ATLS,SUP-2356596,CDM,C1721,HCPCS,0275,RC,,,,both,,,90275.00,58678.75,,,,,,,,,,,,,
BARICITINIB 1 MG PO TABS,RX-148124,CDM,6370000000,HCPCS,0637,RC,00002-4732-30,NDC,,both,1,UN,415.20,269.88,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 10CC GEL INJECTABLE DBM REVERSE PHASE M STIMUBLAST,SUP-2120748,CDM,C1713,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
GUIDEWIRE ORTH BALL NOSE HUM STRL AFFIXUS,SUP-2606191,CDM,C1769,HCPCS,0272,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
WASHER SPNL FIX SM TI,SUP-2714456,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
HLF PN 25X120X25 BRN BLNT TIP,SUP-2722164,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC LG HI TOP AIR LIFESTRIDE,SUP-2108147,CDM,L4386,HCPCS,0272,RC,,,,both,,,112.73,73.27,,,,,,,,,,,,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IV SOLR,RX-27282,CDM,J0295,HCPCS,0636,RC,00409-2689-21,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PROFYLE/BONE SCREW 2.3X38MM S/T,SUP-2489044,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
BUR SURG L 10 MM DIA 3 MM DIAMOND X COARSE STRL DISP ELAN 4,SUP-2929035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.16,340.70,,,,,,,,,,,,,
WIRE ORTH CTRL EXT FIX UNILAT IMPLANTS JETXSMOOTH S STL,SUP-2342856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,608.28,395.38,,,,,,,,,,,,,
GRAFT BNE 2.5 CC OSTEOSURGE 100,SUP-2641797,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.41,782.22,,,,,,,,,,,,,
CANNULA PERF FMRL VSSL ARTRL 38N ACCPTNCE 21FR DIA 7NL CRMD,SUP-2725020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,839.67,545.79,,,,,,,,,,,,,
BLADE RTRCTR JNNTTA 10MMW X 95MMD SPNL PSTRR FOSSA MAL,SUP-2491082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.95,218.37,,,,,,,,,,,,,
STAPLE OSTEOTMY STP 10MM OFFSET - 10MM,SUP-2212665,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER HD SHT TERM 14 FRX20 CM MAX BARR TY 400XL STR TAPR,SUP-2550545,CDM,C1752,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
HC Wheelchair Training per 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209754200,CDM,97542,CPT,0420,RC,,,GP|CQ,both,,,154.00,100.10,,,,,,,,,,,,,
MESH CRANIAL STRAIGHT 1.5X75X75X0.8 MM RAPID RESORBABLE STER,SUP-2838586,CDM,C1713,HCPCS,0278,RC,,,,both,,,7064.37,4591.84,,,,,,,,,,,,,
GRAFT SFT TISS W6X16CM NAT BARR OPTIMIZE SURG PERF AMNIOFIX,SUP-2305727,CDM,V2790,HCPCS,0274,RC,,,,both,,,12443.82,8088.48,,,,,,,,,,,,,
SPACER CERV PAR6 FRZN VERTIGRAFT,SUP-2264933,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.35,1892.38,,,,,,,,,,,,,
DEVICE INFL BLLN FOR DEFLATION OF CATH ACCLARENT,SUP-2420256,CDM,C1726,HCPCS,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
GRAFT DERM MTRX HUM TISS HYDRATED THCK DMND ACELLULAR DERM,SUP-2307517,CDM,Q4128,HCPCS,0636,RC,,,,both,,,55263.00,35920.95,,,,,,,,,,,,,
STEM ORTH L10MM FNGR JT THMB PRI PLSM COAT CO CHROM PRSS,SUP-2137793,CDM,C1776,CPT,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
CONNECTOR T TMPLT SPINE CODE 46,SUP-2232129,CDM,C1713,HCPCS,0278,RC,,,,both,,,2122.64,1379.72,,,,,,,,,,,,,
MIXER BNE CEM 120GM 3 MIX OPTVAC VAC SYS 417300] ZB,SUP-2196559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 16X30-35 MM PRESERVON XLNG CANC FLEXIGRAFT,SUP-2741077,CDM,C1713,HCPCS,0278,RC,,,,both,,,3783.32,2459.16,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.1MM S STL DBL TRCR K,SUP-2397837,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDIC 3 PNL UNIV 14-29 IN DURABLE TIETEX,SUP-2428152,CDM,L1830,CPT,0272,RC,,,,both,,,31.62,20.55,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM BAL L15MM OD6MM DIL RX MRAIL,SUP-2140568,CDM,C1725,HCPCS,0272,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
ARM EXT FIX XLN ARTC 3 ARTH FOR SIDEKCK STLTH REARFOOT FIX,SUP-2400635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
HC Aortic Root Injection,PX-4819356700,CDM,93567,CPT,0481,RC,,,,both,,,649.00,421.85,,,,,,,,,,,,,
SET INTRO VSI L 40 CM DIA 5 FR GUIDEWIRE L 60 CM DIA 0.018,SUP-2383228,CDM,C1894,HCPCS,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
PLATE BNE L82MM 4 H L PROX TIB S STL LOK COMPR FOR 4.5MM,SUP-2185710,CDM,C1713,HCPCS,0278,RC,,,,both,,,4124.67,2681.04,,,,,,,,,,,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,0636,RC,00409-2339-34,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L105MM 8 H LOK 2 COMPR FOR 3.5MM SCR UNIV LOK SYS,SUP-2411375,CDM,C1713,HCPCS,0278,RC,,,,both,,,983.20,639.08,,,,,,,,,,,,,
PLATE BNE L207MM 13 H NONSTERILE L POSTEROLATERAL DST,SUP-2177404,CDM,C1713,HCPCS,0278,RC,,,,both,,,1858.85,1208.25,,,,,,,,,,,,,
SEALER DIVIDER DISSECTOR ELECTROSURG SHAFT L 10 CM JAW L 12 MM,SUP-2904183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
CATHETER DRNGE MULTPURP,SUP-2117063,CDM,C1729,HCPCS,0272,RC,,,,both,,,121.20,78.78,,,,,,,,,,,,,
TRAY CATHETER 3 LUMN W TIP SHERLOCK 6FR POWERPICC,SUP-2125517,CDM,C1751,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
HC So1 Hiv-1 Quantification,PX-3068753667,CDM,87536,CPT,0306,RC,,,,both,,,158.00,102.70,,,,,,,,,,,,,
GRAFT BONE SUB 10ML PUTTY CA PHOS SYNTH GRAN BIOABSRB ATTRAX,SUP-2310454,CDM,C1763,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE ZRCH 2 TLTS TRANS STR 15 18,SUP-2681414,CDM,C1713,HCPCS,0278,RC,,,,both,,,17738.58,11530.08,,,,,,,,,,,,,
SCREW BONE L60MM DIA7.3MM CORT S STL ST CANN LCK PARTIALLY,SUP-2185011,CDM,C1713,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
PLATE BNE L39MM THK3.7MM 3 H BILAT S STL STR LO PROF RIG,SUP-2184023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1759.66,1143.78,,,,,,,,,,,,,
BAR EXT FIX 128 X 210 MM CARBON KICKSTAND NS DISP MONK BARS,SUP-2909119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4136.17,2688.51,,,,,,,,,,,,,
HC Cad MRI Image,PX-6100893700,CDM,C8937,CPT,0610,RC,,,,both,,,1190.00,773.50,,,,,,,,,,,,,
SET PICC 1L 4.5FR X 55CM BP,SUP-2887066,CDM,C1751,HCPCS,0278,RC,,,,both,,,1019.46,662.65,,,,,,,,,,,,,
SCREW COMPR 6.5X40MM HEADLESS THRD LEN 16MM STRL,SUP-2546138,CDM,C1713,HCPCS,0278,RC,,,,both,,,987.06,641.59,,,,,,,,,,,,,
STRATTICE EXTRA THICK 16 X 20,SUP-2675762,CDM,Q4130,HCPCS,0636,RC,,,,both,,,31685.74,20595.73,,,,,,,,,,,,,
PLATE BNE WIDE MEDL RT 8 HOLE CLMN FUSION SS STRL SOLE MCF,SUP-2875510,CDM,C1713,HCPCS,0278,RC,,,,both,,,12156.51,7901.73,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY CANC 90CC,SUP-2113910,CDM,C1713,HCPCS,0278,RC,,,,both,,,5039.70,3275.80,,,,,,,,,,,,,
PLATE BONE W17.5XL160MM THK5.2MM 9 H BILAT S STL BROAD LIMIT,SUP-2185291,CDM,C1713,HCPCS,0278,RC,,,,both,,,1296.41,842.67,,,,,,,,,,,,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MG PO TABS,RX-18290,CDM,6370000000,HCPCS,0637,RC,00378-0503-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J3490,HCPCS,0258,RC,00338-0043-04,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED XL 8 IN RT WRST FOREARM THMB,SUP-2276640,CDM,L3809,HCPCS,0274,RC,,,,both,,,23.05,14.98,,,,,,,,,,,,,
CLIP SAFETY BONE TRANSPORT,SUP-2468106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
SET PICC 2L 5FR X 55CM W TEG CHG DLX-35552-VPSC,SUP-2887055,CDM,C1751,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
SCREW BNE L52MM THRD 55MM HD 67MM S STL LNG THRD CANN,SUP-2389533,CDM,C1713,HCPCS,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
MIXER BNE CEM VAC BRKOFF NOZ PRISM II,SUP-2253058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH DUO L 12 CM DIA10 FR CATH 5 FR,SUP-2357116,CDM,C1894,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
PLATE BONE 3 H RT LAT TALUS FOR 2.4MM SCR VLP MINI-MOD SM,SUP-2351103,CDM,C1713,HCPCS,0278,RC,,,,both,,,4918.97,3197.33,,,,,,,,,,,,,
MICROCATHETER DIAG RENEGADE HI FLO L 150 CM DSTL TIP L 20 CM,SUP-2139661,CDM,C1887,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BONE L92MM 3 H STRL PROX HUM S STL STR FOR 3.5MM SCR,SUP-2341161,CDM,C1776,CPT,0278,RC,,,,both,,,8634.84,5612.65,,,,,,,,,,,,,
SCREW BONE L80MM DIA5MM FULL THRD FOR ARTH NAIL SYS PANTA 2,SUP-2244341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.33,767.21,,,,,,,,,,,,,
"HC Wbc,Dialysate Fluid",PX-3008905000,CDM,89050,CPT,0300,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
GRAFT BNE H18XL25MM TRICORT PAT WDG FRZ DRY MATRIGRFT,SUP-2264810,CDM,C1713,HCPCS,0278,RC,,,,both,,,2288.59,1487.58,,,,,,,,,,,,,
KIT MIDLINE MAX BARRIER 4FR DUAL LUMEN PROVENA,SUP-2424482,CDM,C1751,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BONE ANGLED 2.5 MM RIGHT 7X23 HOLE RECONSTRUCTION PREC,SUP-2837760,CDM,C1713,HCPCS,0278,RC,,,,both,,,7829.28,5089.03,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 3/32X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150464,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.94,8.41,,,,,,,,,,,,,
PLATE BNE THK0.4MM ORBIT PNK TI MESH MATRIXMIDFACE,SUP-2181660,CDM,C1713,HCPCS,0278,RC,,,,both,,,4941.10,3211.71,,,,,,,,,,,,,
LENS IOL 21.5 DIOPT SIL BLU PMMA POST CHMBR BCNVX 3,SUP-2881362,CDM,V2787,HCPCS,0276,RC,,,,both,,,1.00,0.65,,,,,,,,,,,,,
HC MRI-Upper Ext W Cont,PX-6107321900,CDM,73219,CPT,0610,RC,,,,inpatient,,,4976.00,3234.40,,,,,,,,,,,,,
GRAFT BONE SUB W19XH19MM D3MM CORT STRUT FEM FRZN,SUP-2294176,CDM,C1713,HCPCS,0278,RC,,,,both,,,4308.08,2800.25,,,,,,,,,,,,,
SET HEMSTAT SPR SYR PIST APPL FLTR TBNG VITAGEL,SUP-2379527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCREW PIN HI FLX M POLYETH,SUP-2212714,CDM,C1776,CPT,0278,RC,,,,both,,,12944.46,8413.90,,,,,,,,,,,,,
BOLT ORTH FIX WIRE,SUP-2749937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG SM 4.5X104 MM 50 MM 6 NS,SUP-2653580,CDM,C1713,HCPCS,0278,RC,,,,both,,,2073.40,1347.71,,,,,,,,,,,,,
LINEZOLID 600 MG/300ML IV SOLN,RX-133069,CDM,J2020,HCPCS,0636,RC,66794-0219-43,NDC,,both,300,ML,108.70,70.65,,,,,,,,,,,,,
COIL LD EXTRACTION ONE-TIE L 14 CM DIA 6 MM GUIDEWIRE 0.018,SUP-2170095,CDM,C1889,HCPCS,0278,RC,,,,both,,,699.59,454.73,,,,,,,,,,,,,
EXPANDER BRST 375CC W12XH12CM P6.4CM SIL TEXT HI PROF,SUP-2301031,CDM,C1889,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
SCREW BNE L 24 MM DIA 4.5 MM CORTICAL ST STRL EVOS,SUP-2931126,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.94,85.76,,,,,,,,,,,,,
GRAFT BONE LT HUM WHL W/ CUF TRAD FRZN,SUP-2294177,CDM,C1713,HCPCS,0278,RC,,,,both,,,11445.30,7439.44,,,,,,,,,,,,,
CROSSLINK SPNL FIX PLATE 4.5X16 MM SS SHILLA,SUP-2630561,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
CATHETER DRAINAGE NO VLV 4 FRX10 CM 1 STP,SUP-2303153,CDM,C1729,HCPCS,0272,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
CONNECTOR SPNL TI SLT TRNSVRS ASMBLY FOR 5.5MM ROD MOSS,SUP-2254452,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
CLIP HEARING AID CONN,SUP-2430305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
CATHETER VENTRICULAR W/ CM MRK HUNT SYS BACTISEAL,SUP-2666832,CDM,C1729,HCPCS,0272,RC,,,,both,,,1953.43,1269.73,,,,,,,,,,,,,
KIT RF MULT COOLED INCL PRB INTRO BURET DISP COOLIEF,SUP-2236768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
PLATE BNE HK SM 3.5/4.5X354 MM RT FEM PROX 10 HOLE NS VA-LCP,SUP-2750914,CDM,C1713,HCPCS,0278,RC,,,,both,,,8429.93,5479.45,,,,,,,,,,,,,
HYALURONIDASE HUMAN 15 UNITS/ML IJ SYRINGE,RX-4081893,CDM,J3473,HCPCS,0636,RC,09999-9915-13,NDC,,both,0.2,ML,54.40,35.36,,,,,,,,,,,,,
ROD EXT FIX L 300 MM THRD,SUP-2898412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
KIT INSRTN GUIDEWIRE L 100 CM DIA 0.038 IN SYR 10 ML PERC,SUP-2908598,CDM,C1769,HCPCS,0272,RC,,,,both,,,178.10,115.76,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD L36CM INSRTN L19CM DIA14.5FR,SUP-2174215,CDM,C1750,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
CATHETER ETER CTRL VEN L15CM OD5FR SGL LUMN POLYUR STD SET,SUP-2167835,CDM,C1751,HCPCS,0278,RC,,,,both,,,207.71,135.01,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VIVA XT TI POLYUR SIL RUBBER 3 CHMBR DF4,SUP-2282402,CDM,C1882,HCPCS,0275,RC,,,,both,,,53257.13,34617.13,,,,,,,,,,,,,
PLATE FT 130MM FOR TRUELOK FIX SYS,SUP-2316187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1426.09,926.96,,,,,,,,,,,,,
ENDCAP SPNL 18X40MM 0 DEG X COR,SUP-2310712,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
WIRE BRST LOC 2 BARB 19 GAX7 CM 20 CM CHESBROUGH,SUP-2759082,CDM,C1819,HCPCS,0278,RC,,,,both,,,70.05,45.53,,,,,,,,,,,,,
SUPPORT ORTH SM NYL LEG LTWT XCELTRAX AIR,SUP-2197147,CDM,L4370,HCPCS,0274,RC,,,,both,,,78.06,50.74,,,,,,,,,,,,,
ANCHOR SUT BLU WHT BIORAPTOR 1 NUMBER 2 PRELD ULTRABRAID CO,SUP-2341783,CDM,C1713,HCPCS,0278,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
DEVICE BNE FILL NDL 13GA CRV TIP W TAMP KYPHON KURVE,SUP-2281728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH SAFL L 60 CM DIA 8 FR GUIDEWIRE L 145,SUP-2357179,CDM,C1893,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
HC So Somato Medin - C,PX-3018430566,CDM,84305,CPT,0301,RC,,,,both,,,255.00,165.75,,,,,,,,,,,,,
BIT DRL DIA2.7MM STD CANN ADD ON QUIK CONN FOR PERIARTC,SUP-2410866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.83,343.09,,,,,,,,,,,,,
SCREW BONE L42MM DIA5MM CORT DSTL ST FULL THRD FOR AFFIXUS,SUP-2137054,CDM,C1713,HCPCS,0278,RC,,,,both,,,717.99,466.69,,,,,,,,,,,,,
CANNULA SURG 3.5 MM FOR FIB,SUP-2857727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1265.42,822.52,,,,,,,,,,,,,
SPLINT ORTHOGNATHIC 2 JAW W/ GUIDANCE OPS VSP,SUP-2862843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13231.96,8600.77,,,,,,,,,,,,,
HC Replc Centrl Tun Cath W/O Port,PX-3613658100,CDM,36581,CPT,0361,RC,,,,both,,,4893.00,3180.45,,,,,,,,,,,,,
SEAL CERV SPRING-LOADED SL EXTENDIBLE CLLR SIL TIP OMNI LOK,SUP-2423148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.15,241.25,,,,,,,,,,,,,
PLATE BNE L217MM 18 H BILAT S STL CNTOUR 2 COMPR FOR 35MM,SUP-2411357,CDM,C1713,HCPCS,0278,RC,,,,both,,,1066.00,692.90,,,,,,,,,,,,,
PLATE BNE LP 1 MM NEURO BNE FLAP FIX Q STYL FOR SCR TI lf,SUP-2469823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1493.57,970.82,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 20 CM DIA 4 MM MICROCATHETER,SUP-2384881,CDM,C1889,HCPCS,0278,RC,,,,both,,,3191.81,2074.68,,,,,,,,,,,,,
ILLUMINATOR OPHTH RFID SAPPHIRE W ANG STRL DISP OD23GA,SUP-2109931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.08,287.35,,,,,,,,,,,,,
HANDPIECE BRST BX 9CM ST,SUP-2239988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,669.45,435.14,,,,,,,,,,,,,
SCREW BONE LOCKING 4.5X90 MM CORTICAL TIBIAL FEMUR SELFTAPPI,SUP-2837309,CDM,C1713,HCPCS,0278,RC,,,,both,,,1349.29,877.04,,,,,,,,,,,,,
GRAFT BONE SEG AO EVANS 18 X 18 X8,SUP-2854054,CDM,C1713,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
PLATE SPNL ANTR CERV 51 MM 3 LEVEL LORDTC VAN GOGH,SUP-2661670,CDM,C1713,HCPCS,0278,RC,,,,both,,,2819.72,1832.82,,,,,,,,,,,,,
PLATE D FIBULA EVOS 2.7/3.5MM 5H L 93MM,SUP-2750035,CDM,C1713,HCPCS,0278,RC,,,,both,,,6776.91,4404.99,,,,,,,,,,,,,
SCREW SPNL L 30 MM DIA 5.5 MM FIX ANGLE STRL CD HORZ MODULEX 2PK,SUP-2928495,CDM,C1713,HCPCS,0278,RC,,,,both,,,4263.49,2771.27,,,,,,,,,,,,,
GORE TAG THORACIC BRANCH ENDOPROSTHESIS 17MMX8MMX6CM,SUP-2855633,CDM,C1768,CPT,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
CATHETER EP 5FR L100CM 5MM SPC TIP 5MM DIAG MAP F CRV QPLR,SUP-2140168,CDM,C1730,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PLATE BONE L110MM 7 H RT ANTR LAT DSTL TIB TI FOR,SUP-2225375,CDM,C1713,HCPCS,0278,RC,,,,both,,,5546.50,3605.22,,,,,,,,,,,,,
PROBE LAP AR 2.3X2200 MM AX GASTRO/COLO,SUP-2466379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,666.18,433.02,,,,,,,,,,,,,
PLATE BNE ANT MED R TIBIAXYS,SUP-2242998,CDM,C1713,HCPCS,0278,RC,,,,both,,,3762.03,2445.32,,,,,,,,,,,,,
GRAFT BIO TISS W16XL20CM RECON TISS MTRX LAPSCP STRATTICE,SUP-2113205,CDM,Q4130,HCPCS,0636,RC,,,,both,,,30765.72,19997.72,,,,,,,,,,,,,
PLATE BNE X 2.3X1.5 MM THOR RIB 20 HOLE LCK LEVEL 1,SUP-2869165,CDM,C1713,HCPCS,0278,RC,,,,both,,,4271.03,2776.17,,,,,,,,,,,,,
MESH HERN REP CHST WALL 12INCH X 12INCH DISPOSABLE/SNGLE,SUP-2227329,CDM,C1781,HCPCS,0278,RC,,,,both,,,266.12,172.98,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA .035IN STIFF NIT HYDRPHL STR TIP,SUP-2743520,CDM,C1769,HCPCS,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
PLATE BNE L34MM 2 H L RAD HD RIM S STL RIG LOK COMPR FOR,SUP-2185997,CDM,C1713,HCPCS,0278,RC,,,,both,,,1750.83,1138.04,,,,,,,,,,,,,
LEAD DEFIB RELIANCE SG L 70 CM SIL EPTFE STEROID ENDOCARD RT,SUP-2863480,CDM,C1777,HCPCS,0275,RC,,,,both,,,8518.82,5537.23,,,,,,,,,,,,,
CATHETER INFUSION OCCL 5 FRX135 CM 30 CM 1 CC 20 CC FOUNTAIN,SUP-2302568,CDM,C1751,HCPCS,0278,RC,,,,both,,,262.82,170.83,,,,,,,,,,,,,
PLATE BNE L 66 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 6 H 72440606N,SUP-2932770,CDM,C1713,HCPCS,0278,RC,,,,both,,,2144.68,1394.04,,,,,,,,,,,,,
PLATE BNE L148MM 8 H T SHP FOR 45MM SCR L FRAG SYS,SUP-2411409,CDM,C1713,HCPCS,0278,RC,,,,both,,,931.45,605.44,,,,,,,,,,,,,
GUIDEWIRE VASC SPRING 0.018 IN 0.46 MMX45 CM SLD STR SFT TIP,SUP-2846974,CDM,C1769,HCPCS,0272,RC,,,,both,,,104.25,67.76,,,,,,,,,,,,,
HC Njx Aa&/Strd Ntrcost Nrv Ea,PX-3616442100,CDM,64421,CPT,0361,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
SCREW SPNL RET DIA3.5MM THRD L16MM FOR TOT DISC REPL SYS 3820104] JNJ HEALTHCARE],SUP-2256931,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
TIP APPL 8 CM STIFFER DISP,SUP-2462296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.22,475.94,,,,,,,,,,,,,
PLATE SPNL L60MM ANT CERV BILAT TI 3 LEV INTEGR LOK,SUP-2293211,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
DILATOR KIT INSUL OVL STRL SAFEOP,SUP-2800029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SYSTEM DIL BLLN L18MM DIA6MM BALL TIP L2MM MULTISINUS,SUP-2217797,CDM,C1713,HCPCS,0278,RC,,,,both,,,4311.22,2802.29,,,,,,,,,,,,,
PIN FIX 0.157X9 IN FT NS FPS STEINMAN LTX,SUP-2856432,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE PRIMARY STEM MOD NK,SUP-2212695,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
DEVICE NEUROSTIMULATOR PK MOD 30580134 FOR NEUROSTIM SYS,SUP-2278061,CDM,C1820,HCPCS,0278,RC,,,,both,,,35011.00,22757.15,,,,,,,,,,,,,
ANCHOR SUTURE TAPE 4.5X15 MM PEEK KT STRL GRAPPLER,SUP-2749834,CDM,C1713,HCPCS,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
SHEATH NDL 6FR L150MM FOR FLX CYSTO CYF-4/4A,SUP-2313302,CDM,C1894,HCPCS,0272,RC,,,,both,,,586.40,381.16,,,,,,,,,,,,,
SCREW INTRF L23MM DIA9MM NONABSORBABLE ADV PEEK MILAGRO,SUP-2256774,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
CONNECTOR ROD M L6MM DIA5.5MM TI OFFSET LOK SCR TSRH-3D,SUP-2289995,CDM,C1713,HCPCS,0278,RC,,,,both,,,2937.00,1909.05,,,,,,,,,,,,,
PLATE BNE L81MM 4 H NONSTERILE R SUP ANT CLAV S STL LOK,SUP-2184131,CDM,C1713,HCPCS,0278,RC,,,,both,,,2594.39,1686.35,,,,,,,,,,,,,
STEM HUM 6.3X125MM MOD II,SUP-2408647,CDM,C1776,CPT,0278,RC,,,,both,,,14704.62,9558.00,,,,,,,,,,,,,
LITHIUM CARBONATE 300 MG PO TABS,RX-4531,CDM,6370000000,HCPCS,0637,RC,00054-8528-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ROD EXTRNL FXTN LG TTNM MNDBLE MXLFCL PRE BENT,SUP-2679285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2513.10,1633.51,,,,,,,,,,,,,
WAND ABLAT PTR PLSM 2 ORNG DEPTH MRK REFLX ULT,SUP-2342037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,956.13,621.48,,,,,,,,,,,,,
TRAY CATH PICC RADPICC BSC 5FR 0.042N 60CM 1 LUMAN R 3165135,SUP-2632645,CDM,C1751,HCPCS,0278,RC,,,,both,,,252.14,163.89,,,,,,,,,,,,,
SCREW BNE L29MM DIA4.5MM TI MULTDIR ST LOK FULL THRD FOR,SUP-2388661,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.42,354.52,,,,,,,,,,,,,
STAPLER INT L45MM DIA3.5MM STD BLU TI LIN ARTC W/ 6 ROW STPL,SUP-2257580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,670.42,435.77,,,,,,,,,,,,,
BIT DRL L190MM DIA2.7MM FT FOR 3.5MM SCR ADVANSYS,SUP-2243128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,799.88,519.92,,,,,,,,,,,,,
GRAFT HUM TISS 12X4 CM N CROSSLINKED SCAFFOLD STRL GENTRIX,SUP-2106489,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2856.52,1856.74,,,,,,,,,,,,,
BIT DRL CANN 6.5X330 MM QC NS,SUP-2188203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1734.54,1127.45,,,,,,,,,,,,,
STEM FEM PRSS FIT LAT POR TI 12/14 9MM DIA 137MM TAPRLOK,SUP-2408381,CDM,C1776,CPT,0278,RC,,,,both,,,12748.40,8286.46,,,,,,,,,,,,,
GUIDEWIRE URO X STIFF 0.038INX145CM AMPLTZ,SUP-2168893,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.24,58.66,,,,,,,,,,,,,
BIT DRL DIA4.1MM TIB FOR ARTH NAIL SYS PANTA 2,SUP-2417298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.48,1039.01,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA18MM ANK FT BAYNT W STPR FOR,SUP-2316136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.38,349.95,,,,,,,,,,,,,
SPACER SPNL 7 DEG 12X14X6 MM HEDRON C,SUP-2433817,CDM,C1889,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq 1st 30 Minutes,PX-4209755000,CDM,97550,CPT,0420,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
STAPLER INT L90MM DIA35MM TI STPL RELD DISPOSABLE DST SER TA,SUP-2283422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1235.84,803.30,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX450 CM STRL GLIDEWIRE LF DISP,SUP-2472758,CDM,C1769,HCPCS,0272,RC,,,,both,,,847.64,550.97,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN FLX TIP L 15 CM SS PTFE,SUP-2638690,CDM,C1769,HCPCS,0272,RC,,,,both,,,185.45,120.54,,,,,,,,,,,,,
CANCELLOUS SCREW 8020090,SUP-2843466,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
INSERT HUM DIA36MM THK+9MM LAT SHLDR POLYETH AEQUALIS,SUP-2388686,CDM,C1776,CPT,0278,RC,,,,both,,,5066.39,3293.15,,,,,,,,,,,,,
PIN EXT FIX HALF 6X110 MM 50 MM THRD SS RINGFIX,SUP-2461217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BASEPLATE TIB SZ 5 KNEE PERI APATITE PRI BEAD TRIATHLON,SUP-2373102,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
RETRIEVER THROMCTMY TREVO XP PROVUE L 20 MM DIA 4 MM NIT,SUP-2367790,CDM,C1757,HCPCS,0272,RC,,,,both,,,22518.20,14636.83,,,,,,,,,,,,,
LEAD PACE PROTEGO S L 65 CM PTIR FRACTAL COAT DXA STEROID,SUP-2138291,CDM,C1777,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
BOOT WLK L TALL VECTRA,SUP-2151014,CDM,L4360,HCPCS,0272,RC,,,,both,,,95.14,61.84,,,,,,,,,,,,,
DEVICE ELECSURG W/ DISECT PLASMABLADE X 3.0S,SUP-2633899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRIMARY HI DEMAND K5SN] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351383,CDM,C1776,CPT,0278,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
PLATE BNE L 238 MM SCREW DIA 3.5 MM 20 SHFT H SS RECON VA,SUP-2907566,CDM,C1713,HCPCS,0278,RC,,,,both,,,4080.05,2652.03,,,,,,,,,,,,,
PLATE BNE W15XL20MM TIB SHTH COVERLOC STABILIS,SUP-2399166,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
FEE PROCEDURE FLOWTRIEVER THROMBECTOMY SYSTEM,SUP-2416593,CDM,C1757,HCPCS,0272,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
PLATE BNE L80MM 10 H MAXILLOFACIAL ORAL TI STR,SUP-2191405,CDM,C1713,HCPCS,0278,RC,,,,both,,,2760.69,1794.45,,,,,,,,,,,,,
KIT SHUNT HYDROCEPHALUS VLV REG PS MED STRATA NSC,SUP-2284512,CDM,C1889,HCPCS,0278,RC,,,,both,,,11921.14,7748.74,,,,,,,,,,,,,
CANNULA ART LNG 17 FR UNCOATED HLS,SUP-2663470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.64,617.92,,,,,,,,,,,,,
STEM HUM DIA8MM SHLDR CO CHROM NP COMPHSVE,SUP-2403968,CDM,C1776,CPT,0278,RC,,,,both,,,7187.46,4671.85,,,,,,,,,,,,,
MATRIX PARTICULATE AMNIOBAND 40MG,SUP-2719485,CDM,Q4168,HCPCS,0636,RC,,,,both,,,3089.76,2008.34,,,,,,,,,,,,,
FAMCICLOVIR 500 MG PO TABS,RX-13358,CDM,6370000000,HCPCS,0637,RC,00093-8119-56,NDC,,both,1,UN,14.60,9.49,,,,,,,,,,,,,
PLATE BNE L24MM 4 H TI DYN LOK COMPR FOR 2MM SCR MOD HND,SUP-2191479,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.21,661.84,,,,,,,,,,,,,
PLATE BNE L64MM THK3.3MM 5 H BILAT S STL STR LIMIT CNTCT,SUP-2185129,CDM,C1713,HCPCS,0278,RC,,,,both,,,842.09,547.36,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X12 MM FUSION HEX DRV YEL WRST SS NS,SUP-2852108,CDM,C1713,HCPCS,0278,RC,,,,both,,,684.99,445.24,,,,,,,,,,,,,
HC Drain Finger Abscess,PX-4502601100,CDM,26011,CPT,0450,RC,,,,both,,,1649.00,1071.85,,,,,,,,,,,,,
RETRACTOR OPHTH NYL SMOOTH FINISH FLX HK DISP FOR MECH IRIS,SUP-2109674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.19,213.32,,,,,,,,,,,,,
HC So Hla II Low Resolution One Antigen Equivalent Ea,PX-3108137766,CDM,81377,CPT,0310,RC,,,,outpatient,,,233.00,151.45,,,,,,,,,,,,,
SCREW BNE L14MM DIA2MM QUIK SNAP CAPTURE,SUP-2243914,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.47,730.91,,,,,,,,,,,,,
GRAFT HUM TISS W20XL20CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307572,CDM,Q4128,HCPCS,0636,RC,,,,both,,,32812.72,21328.27,,,,,,,,,,,,,
SCREW BONE L30MM OD6.5MM HDLSS CANN COMPR SH THRD,SUP-2122289,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 180CM 0.038IN TIP L 3 CM STIFF STR,SUP-2385594,CDM,C1769,HCPCS,0272,RC,,,,both,,,158.48,103.01,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 7 FR GUIDEWIRE 45 CM,SUP-2383427,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
SET INTRO CATH 5FR L10CM NDL 21GA L7CM 0.018IN S STL,SUP-2170558,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.66,47.23,,,,,,,,,,,,,
BRACE KNEE RT L ORTHOPRO HYPEREX,SUP-2324014,CDM,L1810,HCPCS,0274,RC,,,,both,,,277.04,180.08,,,,,,,,,,,,,
STENT TRACHBRONCH UFLX L 12 MM DIA 4 MM CATH L 95 CM DIA16,SUP-2141591,CDM,C1874,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
HC Drain Mouth Lesion,PX-4504080100,CDM,40801,CPT,0450,RC,,,,both,,,1337.00,869.05,,,,,,,,,,,,,
CATHETER INTVASC OCCL FOGARTY L 40 CM DIA 4 FR BALLOON DIA,SUP-2214268,CDM,C2628,HCPCS,0272,RC,,,,both,,,393.54,255.80,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SM 0.25 CC FRZN AMNIO FLUID ALLOGEN,SUP-2393044,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 120 MM DIA 6 MM CATH L 130 CM DIA 6,SUP-2128185,CDM,C1876,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
STENT PERIPH ZILVER PTX L 140 MM DIA 7 MM CATH L 125 CM SHTH,SUP-2170407,CDM,C1874,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
BIT DRL L80MM DIA2.4MM MINI QUIK CPL,SUP-2187710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.66,233.78,,,,,,,,,,,,,
PLATE BNE W24XL51MM 12 H L DST RAD TI LOK COMPR LO PROF NAR,SUP-2411822,CDM,C1713,HCPCS,0278,RC,,,,both,,,3488.54,2267.55,,,,,,,,,,,,,
PUTTY BONE 5 CC REINFORCED FAST SET STERILE CRANIOS,SUP-2838512,CDM,C1713,HCPCS,0278,RC,,,,both,,,6167.59,4008.93,,,,,,,,,,,,,
ARCH EXT FIX DIA210MM FT C FBR POLYMER FOR HOFFMANN LRF SYS,SUP-2363183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5821.56,3784.01,,,,,,,,,,,,,
PLATE BONE L83MM 7 H FIB TI STR LCK FOR 2.7/3/3.5/4MM SCR,SUP-2420209,CDM,C1713,HCPCS,0278,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
RING EXT FIX SLIDING,SUP-2362804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.80,503.62,,,,,,,,,,,,,
IMPLANT LARYN L4MM DIA20FR SFT VLV ASMBLY EMBEDDED W/ SLV,SUP-2242289,CDM,L8509,HCPCS,0274,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
ANCHOR SUT PRE THRD W NO 2 HI FI SUT ON DISPOSABLE DRV ABSRB,SUP-2166967,CDM,C1713,HCPCS,0278,RC,,,,both,,,864.66,562.03,,,,,,,,,,,,,
BONE HOLDING FORCEPS-SOFT RATCHET F/PLATES TO 22MM WIDE,SUP-2548934,CDM,C1713,HCPCS,0278,RC,,,,both,,,2285.07,1485.30,,,,,,,,,,,,,
GUIDEWIRE SURG L8IN DIA0.094IN LNG THRD W/ TRCR TIP DISP,SUP-2123197,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
CANNULA SURG RT MIDDLE/POSTERIOR ZONENAVIGATOR SYS,SUP-2417074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STEM FNGR JT SM PROX INTERPHALANGEAL BASE IMP,SUP-2319771,CDM,L8630,HCPCS,0278,RC,,,,both,,,5862.38,3810.55,,,,,,,,,,,,,
PLATE BNE L278MM 12 H NONSTERILE L CNDYL S STL LOK COMPR,SUP-2183116,CDM,C1713,HCPCS,0278,RC,,,,both,,,4470.98,2906.14,,,,,,,,,,,,,
WASHER ORTH FOR 6.5 MM CANN SCREW NS,SUP-2788658,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.97,63.68,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT ULNA WHL STRUCTURAL R,SUP-2307335,CDM,C1762,CPT,0278,RC,,,,both,,,8023.01,5214.96,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 9X30-35 MM PRESERVON XLNG CANC FLEXIGRAFT,SUP-2740990,CDM,C1762,CPT,0278,RC,,,,both,,,3783.32,2459.16,,,,,,,,,,,,,
KIT HAMRTOE CORR 16 28 35MM STP DRL IMPL HNDL DRVR SAW,SUP-2137579,CDM,C1713,HCPCS,0278,RC,,,,both,,,3460.53,2249.34,,,,,,,,,,,,,
SHEATH URET ACCS NAVIGATOR 11/13 FR X 46 CM,SUP-2141691,CDM,C1894,HCPCS,0272,RC,,,,both,,,349.26,227.02,,,,,,,,,,,,,
STEM FEM L177MM DIA13.5MM STD OFFSET CALCAR HIP CO CHROM,SUP-2203190,CDM,C1776,CPT,0278,RC,,,,both,,,20226.31,13147.10,,,,,,,,,,,,,
CATHETER ETER CARD 6FR 2 5 2MM ABLAT CSL CRV ELECTRD SPC 65CM LEN,SUP-2356836,CDM,C1730,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
CAGE VERT 37X10X6 MM MIDLN FOR VBR SYS,SUP-2320299,CDM,C1889,HCPCS,0278,RC,,,,both,,,23.02,14.96,,,,,,,,,,,,,
NUT EXT FIX W/ WASHER STRL TRUELOK EVO LTX,SUP-2875624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,117.37,76.29,,,,,,,,,,,,,
BIT DRL DIA6MM S STL TRABECULAR MTL GLEN STP CANN REUSE,SUP-2208226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
DRILL TWST 3 FLUT 3.8 MM,SUP-2606637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.61,389.75,,,,,,,,,,,,,
TUBE VENT DIA1MM TI REUT MIC FINISH 2 STD BOB W/ FLNG H FOR,SUP-2313689,CDM,L8699,HCPCS,0278,RC,,,,both,,,109.12,70.93,,,,,,,,,,,,,
VALVE MI ORIFICE DIA22.5MM TISS ANNULUS DIA27MM 85DEG,SUP-2355141,CDM,C1889,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,KX|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE GAUNTLET PREFABRICATED OFF THE SHLF,SUP-2435622,CDM,L1902,HCPCS,0274,RC,,,,both,,,211.32,137.36,,,,,,,,,,,,,
IMPLANT FUS H4XL75MM IFUSE,SUP-2337742,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
SCREW BNE L50MM DIA45MM COMPR FOR GLEN BASEPLT,SUP-2401415,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.32,191.96,,,,,,,,,,,,,
PLATE BONE T WIDE 2.8 MM 8 HOLE TITANIUM STERILE MATRIXRIB,SUP-2837696,CDM,C1713,HCPCS,0278,RC,,,,both,,,4227.23,2747.70,,,,,,,,,,,,,
TRAY CTRL VEN CATH 2.5FR L2.5CM 0.015IN GWIRE TIP NDL,SUP-2167881,CDM,C1751,HCPCS,0278,RC,,,,both,,,114.45,74.39,,,,,,,,,,,,,
CATHETER THOR 28FR L20IN PVC STR RADPQ SENTNL LN TBNG W/,SUP-2154968,CDM,C1729,HCPCS,0272,RC,,,,both,,,25.50,16.57,,,,,,,,,,,,,
SCREW BNE L29MM DIA2.4MM THRD L6MM CANC S STL SELF DRL ST,SUP-2185005,CDM,C1713,HCPCS,0278,RC,,,,both,,,987.40,641.81,,,,,,,,,,,,,
GRAFT FEM HD GRNDR FRZN ALLGRFT 43MM MATRIGRFT,SUP-2264752,CDM,C1713,HCPCS,0278,RC,,,,both,,,2752.02,1788.81,,,,,,,,,,,,,
BUR SURG DIAMOND COARSE 3 MMX10 CM MTCH HD SM BOR LEGEND,SUP-2665010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.13,209.38,,,,,,,,,,,,,
SHEATH INTRO DIA2.8 FR PEELWY STRL,SUP-2384065,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.10,48.16,,,,,,,,,,,,,
STRUT EXT FIX L70-104MM SHT ACUTE ADJ LOK UNIV HNG ON BOTH,SUP-2316066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3256.46,2116.70,,,,,,,,,,,,,
BIT DRL SHFT 4.2 MM DENT,SUP-2657076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.04,243.78,,,,,,,,,,,,,
MESH HERN SM W8XL12CM INGUINAL OVL SELF EXP PTCH KUGEL,SUP-2125975,CDM,C1781,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GUIDEWIRE ORTH FOR BIOCOMPRESSION SCR,SUP-2121893,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
FIBER LASER MOXY 532NM WAVELENGTH LIQUID COOLED SINGLE-USE F/GREENLIGHT XPS SYSTEM,SUP-2225585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
PLATE CRAN L 14 MM THK 0.4 MM SCREW DIA1.5 MM TI SHUNT LP,SUP-2883402,CDM,C1713,HCPCS,0278,RC,,,,both,,,1118.53,727.04,,,,,,,,,,,,,
BAG COLL 700ML REPL W/ ANTI REFLX VLV AND SAMP SITE,SUP-2244104,CDM,C1729,HCPCS,0272,RC,,,,both,,,515.18,334.87,,,,,,,,,,,,,
CATHETER EP CSL 5-5-5 MM 7 FRX65 CM RESPON,SUP-2356773,CDM,C1730,HCPCS,0272,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL PLASTAZOTE EQL,SUP-2435702,CDM,L3002,HCPCS,0272,RC,,,,both,,,457.25,297.21,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE LDDR WTAB NEURO SCRW2 X 2 HOLES,SUP-2681854,CDM,C1713,HCPCS,0278,RC,,,,both,,,856.78,556.91,,,,,,,,,,,,,
K WIRE FIX L400MM DIA2MM S STL SGL END SMOOTH SHRP TIP SPRD,SUP-2186872,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
STEM FEM L260MM OD9MM POR RT CALCAR REV PRESSFIT IMP,SUP-2403614,CDM,C1776,CPT,0278,RC,,,,both,,,19982.96,12988.92,,,,,,,,,,,,,
GRAFT HUMAN TISSUE PELVIC FLOOR MATRIX 12X9 CM MATRISTEM,SUP-2106487,CDM,C1763,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
PLATE BNE L237MM 14 H NONSTERILE R PROX TIB S STL VAR ANG,SUP-2177924,CDM,C1713,HCPCS,0278,RC,,,,both,,,6269.70,4075.30,,,,,,,,,,,,,
MODERATE DMD KNEE SYS/NETSHAPE,SUP-2212166,CDM,C1776,CPT,0278,RC,,,,both,,,10343.16,6723.05,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0258,RC,00990-7983-61,NDC,,both,1000,ML,297.50,193.37,,,,,,,,,,,,,
DRESSING WND FEN 3X7 CM SHT EXTRACELLULAR MTRX MATRISTEM,SUP-2106520,CDM,Q4166,HCPCS,0636,RC,,,,both,,,507.68,329.99,,,,,,,,,,,,,
SCREW BONE L36MM DIA4.5MM STD CORT S STL BLNT NONLOCKING HEX,SUP-2249403,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.45,341.54,,,,,,,,,,,,,
PLATE BNE ADV 10 MM SCREW DIA2 MM 10 H RT,SUP-2883444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.04,1285.73,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X170 MM 14 HOLE SS DCP,SUP-2569156,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
ANCHOR SUTURE MAG,SUP-2342073,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
SPEEDGUIDE DRILL AO 20MM 70MM,SUP-2704787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,868.21,564.34,,,,,,,,,,,,,
ALLOGRAFT BNE RNG 12 DEG 26X26X14 MM FRZN PRECISION-GRAFT,SUP-2787557,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.87,5909.07,,,,,,,,,,,,,
SET GUID RESECT FOR 5 TIB 4 R FEM HI PERF SIG TRUMATCH,SUP-2252964,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
GRAFT VASC IMPRA L 30 CM DIA 6 MM EPTFE FLX STD WALL RING,SUP-2761437,CDM,C1768,CPT,0278,RC,,,,both,,,1694.75,1101.59,,,,,,,,,,,,,
GRAFT BNE SUB W25XL50MM THK3MM CHRONOS SYN TISS STRP,SUP-2182831,CDM,C1713,HCPCS,0278,RC,,,,both,,,2190.15,1423.60,,,,,,,,,,,,,
ANCHOR SUTURE DIA 5.5 MM TAPE 1.4 MM BIOCOMP 3 STRND XBRAID,SUP-2908777,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
SUTURE PACK 2 2P NDL ASMBLY UHMWPE BLK STRL EASYWHIP EW0110,SUP-2875932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
ACETAMINOPHEN-CODEINE 300-30 MG PO TABS,RX-8949,CDM,6370000000,HCPCS,0637,RC,00406-0484-23,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DOXAZOSIN MESYLATE 1 MG PO TABS,RX-9894,CDM,6370000000,HCPCS,0637,RC,00904-5522-61,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2 MM W/ STP STRL,SUP-2789606,CDM,C1769,HCPCS,0272,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
PLATE BNE L107MM 7 H L DST LAT FIBULAR VAR ANG LOK FOR,SUP-2349829,CDM,C1713,HCPCS,0278,RC,,,,both,,,6167.75,4009.04,,,,,,,,,,,,,
COIL EMB 10 L8CM OD3MM HELCL STRTCH RESIST FNSH HYDRGEL,SUP-2305156,CDM,C1889,HCPCS,0278,RC,,,,both,,,4882.70,3173.75,,,,,,,,,,,,,
RING EXT FIX COMP C HALF 200MM ID FOR ILIZ FIX,SUP-2340705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9609.50,6246.17,,,,,,,,,,,,,
PLATE BNE L187MM 6 H S STL CBL NONLOCKING COMPR CBL-READY,SUP-2410268,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.06,1271.44,,,,,,,,,,,,,
STENT BILI VIABIL L 6 CM DIA10 MM CATH L 200 CM DIA 8.5 FR,SUP-2166311,CDM,C1874,HCPCS,0278,RC,,,,both,,,6462.12,4200.38,,,,,,,,,,,,,
BUR SURG L18.3MM OD4.7MM LNG BRL TPS,SUP-2363376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,804.03,522.62,,,,,,,,,,,,,
PLATE OLECRANON 65MM 3HL RT,SUP-2705076,CDM,C1713,HCPCS,0278,RC,,,,both,,,3949.81,2567.38,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM UNCOVERED L 6 MM PROX/DSTL,SUP-2423840,CDM,C1768,CPT,0278,RC,,,,both,,,57885.90,37625.83,,,,,,,,,,,,,
SET SCR SPNL S STL MULTIAXIAL REDUC FOR 5.5MM ROD CDH LEG,SUP-2288173,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 2 ML STR W/ BFD OSSEOFLEX SB OCP0212,SUP-2516670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
GRAFT SPCR SPINE PARA PEEK VISTA P TANT BEAD MRK 27MM 8MMH,SUP-2414320,CDM,C1713,HCPCS,0278,RC,,,,both,,,9923.97,6450.58,,,,,,,,,,,,,
GRAFT BNE PTTY MED 6 CC BIOACTIVE FIBERGRAFT BG GPS,SUP-2736519,CDM,C1713,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
KIT CATH HEMODIALYSI NIAG ACUTE 13.5FR DIA 20CML INS 5593200,SUP-2632908,CDM,C1752,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
COMPONENT GLEN KEELED 44 MM TOT SHLDR OLYMPIA,SUP-2535952,CDM,C1776,CPT,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
CATHETER URET 7.0FRX70CM OPN END POLYVINYLCHLORIDE,SUP-2168888,CDM,C1758,HCPCS,0278,RC,,,,both,,,32.19,20.92,,,,,,,,,,,,,
BIT DRL DIA5MM CANN QUIK CONN,SUP-2409880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1547.39,1005.80,,,,,,,,,,,,,
PORT VEN ACCS SGL LUMN TI 84FRX76CM L SIL CATHETER 9FR INTRO,SUP-2351856,CDM,C1788,HCPCS,0278,RC,,,,both,,,865.79,562.76,,,,,,,,,,,,,
HC Anterior Epitaxis Simple,PX-4503090100,CDM,30901,CPT,0450,RC,,,,inpatient,,,214.00,139.10,,,,,,,,,,,,,
PIN GALAXY FIX SYS MRI ANK 80MM TRANSFIX,SUP-2316017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
GUIDEWIRE VASC VSI TRU-TORQUE L 150 CM DIA 0.035 IN PTFE,SUP-2383183,CDM,C1769,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
KIT SUTURE SZ 1 X 4 MM STRL DISP SPEEDBUTTON,SUP-2893328,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
LINER ACET NEUT 28 MM HIP GRP 0 XLPE YEL NOVATION,SUP-2222011,CDM,C1776,CPT,0278,RC,,,,both,,,5298.75,3444.19,,,,,,,,,,,,,
PLATE BNE W7XL57MM THK1.5MM 7 H L CNDYL TI FOR 2.7MM SCR,SUP-2191039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1141.17,741.76,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC DBM OPTIUM,SUP-2264864,CDM,C1713,HCPCS,0278,RC,,,,both,,,2549.05,1656.88,,,,,,,,,,,,,
FIBER LASER 270 MH REUSE,SUP-2498675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2749.42,1787.12,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 5 MESH KT NS FACE ID,SUP-2909647,CDM,C1713,HCPCS,0278,RC,,,,both,,,43967.91,28579.14,,,,,,,,,,,,,
GUIDEWIRE VASC STR 0.014 INX200 CM 14 CM SFT TRAXCESS 14,SUP-2305455,CDM,C1769,HCPCS,0272,RC,,,,both,,,1540.17,1001.11,,,,,,,,,,,,,
CATHETER CV SET 018 6 FRX60 CM TURBO-JECT UPICTS60CTABRM1110,SUP-2759762,CDM,C1751,HCPCS,0278,RC,,,,both,,,386.06,250.94,,,,,,,,,,,,,
IMPLANT GYN TENS FREE SUPP UROLOGICAL GYNECARE TVT,SUP-2383005,CDM,C1771,HCPCS,0278,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM 0.018 IN L 5 CM SS MANDREL PLAT COIL,SUP-2823949,CDM,C1769,HCPCS,0272,RC,,,,both,,,123.37,80.19,,,,,,,,,,,,,
SPLINT KNEE L12IN UNIV WRP ARND OPN PAT WIND CLS POPLITEAL,SUP-2196739,CDM,L1830,CPT,0274,RC,,,,both,,,33.00,21.45,,,,,,,,,,,,,
SET INTRO L 50 CM DIA 9 FR HEMOSTATIC VLV PEELWY STRL,SUP-2138187,CDM,C1894,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
SYSTEM ORTH SECURITIZATION SHLDR ADJ REVERSED AEQUALIS,SUP-2715377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.47,786.81,,,,,,,,,,,,,
MIDOSTAURIN 25 MG PO CAPS,RX-138604,CDM,2500000003,HCPCS,0250,RC,00078-0698-99,NDC,,both,1,UN,1035.20,672.88,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM DIA2.5MM S STL SPADE PNT TIP,SUP-2194146,CDM,C1769,HCPCS,0272,RC,,,,both,,,134.67,87.54,,,,,,,,,,,,,
FIXTURE 3MM W/ ABUTMENT,SUP-2164943,CDM,L8614,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
PLATE BNE L247MM 8 H NONSTERILE R PROX FEM S STL LO PROF,SUP-2186136,CDM,C1713,HCPCS,0278,RC,,,,both,,,4056.60,2636.79,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-142365,CDM,Q5106,HCPCS,0636,RC,00069-1309-04,NDC,,both,1,ML,1301.60,846.04,,,,,,,,,,,,,
BLADE SCREWDRIVER 2MM2.3MM DIA 94MML CROSS DRIVE RATCHETED,SUP-2682215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
DISTRACTION EXTERNAL UPPER RED 2 BLACK QTY001 EA,SUP-2694364,CDM,C1713,HCPCS,0278,RC,,,,both,,,2005.86,1303.81,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 4 FRX11 CM W/ GUIDEWIRE PRELUDE,SUP-2303261,CDM,C1894,HCPCS,0272,RC,,,,both,,,29.20,18.98,,,,,,,,,,,,,
DEFIBRILLATOR CARD HI ENERGY W/ TI W/ CELLULAR GSM HM LUMAX,SUP-2138416,CDM,C1722,HCPCS,0275,RC,,,,both,,,42390.00,27553.50,,,,,,,,,,,,,
PLATE BNE FUSION LG MIDFOOT FT STRL A.L.P.S,SUP-2466502,CDM,C1713,HCPCS,0278,RC,,,,both,,,2546.29,1655.09,,,,,,,,,,,,,
ASSEMBLY SHUNT CATH DSTL L 120 CM SM SNAP STRL STRATAMR II,SUP-2929977,CDM,C1889,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
TAP NCB PT 4 MM QUIK CONN,SUP-2204933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
TROCAR ENDOSCP BLDELSS UNIV 11X100 MM STBL SL ENDOPATH BASX,SUP-2857937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,399.50,259.67,,,,,,,,,,,,,
SYSTEM DEL AORT TRANSCATHETER HRT VLV BIOPROSTHESIS STNT,SUP-2280902,CDM,C1894,HCPCS,0272,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
KIT GWIRE SM CO CHROM T6 CANN SCRDRVR DEPTH GA COUNTSINK FOR,SUP-2225504,CDM,C1769,HCPCS,0272,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
SET TRCR 23GA FOR STD ALONE COMP VISN SYS CONSTELLATION,SUP-2109904,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
MARKER BRST BX 2ND SITE TRIMARK EVIVA,SUP-2240068,CDM,A4648,CPT,0278,RC,,,,both,,,203.75,132.44,,,,,,,,,,,,,
BLADE SAW 12 MM MANUAL HARVESTOR,SUP-2415427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
HC CT Angio Chest W & W/O Cont,PX-3527127500,CDM,71275,CPT,0352,RC,,,,both,,,3343.00,2172.95,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM LNR ADD ON XLPE,SUP-2212519,CDM,C1776,CPT,0278,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
WIRE FIX L70MM OD0.9MM GUID TRCR TIP DISP K FIXOS,SUP-2378784,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.85,47.35,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA10 MM RNG L 50 CM EPTFE STR TW,SUP-2396173,CDM,C1768,CPT,0278,RC,,,,both,,,3786.84,2461.45,,,,,,,,,,,,,
BIT DRL AO CONN 2X105 MM SCALED,SUP-2422313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.72,395.02,,,,,,,,,,,,,
COUPLING REPROC EXT FIX 5/8/11 MM 4/5/6 MM PIN TO ROD,SUP-2516723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.31,445.45,,,,,,,,,,,,,
COMPRESSOR SURG CERV REUSE PLT COMPR,SUP-2279320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.77,742.80,,,,,,,,,,,,,
POST FIX 1 H M,SUP-2197266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST ADJ FIT STRP W/NONTORSION JT,SUP-2435772,CDM,L3905,HCPCS,0274,RC,,,,both,,,2555.14,1660.84,,,,,,,,,,,,,
ELECTRODE URLGY BAND TIP 26FR DIA 12DG WCLNCH ST DSPSBLE,SUP-2722577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,831.06,540.19,,,,,,,,,,,,,
BIT DRL TWST 3.8 MM CALIB,SUP-2862209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.29,693.74,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 3/16X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150462,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.81,12.23,,,,,,,,,,,,,
GRAFT ALLGRFT STRUT CORT CANC 60MM LX8MM W 6 EA FRZ DRY,SUP-2307181,CDM,C1713,HCPCS,0278,RC,,,,both,,,2872.16,1866.90,,,,,,,,,,,,,
MESH SURG W10XL15CM THK1MM EPTFE CORDUROY SURF CNFRM TEXT,SUP-2395330,CDM,C1781,HCPCS,0278,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.045X9 IN 4 DIAMOND SS KIRSCHNER 6PK,SUP-2876902,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.08,78.70,,,,,,,,,,,,,
BRACE WLK FULL SHELL WLK SM M SHOE SZ 4 7 FEM SHOE SZ 5,SUP-2336094,CDM,L4360,HCPCS,0272,RC,,,,both,,,126.10,81.96,,,,,,,,,,,,,
SYSTEM STENT INTRO CATH L320CM OD6X10FR 0.035IN RADPQ BND,SUP-2169523,CDM,C1894,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SPLINT ARM M L85IN L ALUMINUM FOAM PD MAL COLLES,SUP-2276767,CDM,L3809,HCPCS,0274,RC,,,,both,,,14.10,9.16,,,,,,,,,,,,,
STAPLE BNE COMPR LG 3X2 MM,SUP-2223644,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE VOLAR LT DSTL RADIAL HND DBL TIERED EXT,SUP-2137434,CDM,C1713,HCPCS,0278,RC,,,,both,,,2372.49,1542.12,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST W/NONTORSION JT FABRICATED,SUP-2435781,CDM,L3921,HCPCS,0274,RC,,,,both,,,827.64,537.97,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN STD ANG HYDRPHLC FIX COR,SUP-2302958,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.56,58.86,,,,,,,,,,,,,
HC Xr Wrist 2 Views,PX-3207310000,CDM,73100,CPT,0320,RC,,,,both,,,287.00,186.55,,,,,,,,,,,,,
STENT BILI V SYS L 70 MM DIA10 FR CHANNEL 4.2 MM POLYETHYL,SUP-2313491,CDM,C1877,HCPCS,0278,RC,,,,both,,,134.71,87.56,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 4-7 MM EPTFE TAPR STD,SUP-2396211,CDM,C1768,CPT,0278,RC,,,,both,,,1456.96,947.02,,,,,,,,,,,,,
DEVICE SUT W/ 2-0 NONABSORBABLE POLYETH SUT REPL CART,SUP-2163483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1894.93,1231.70,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM HI FLX POLYETH,SUP-2212704,CDM,C1776,CPT,0278,RC,,,,both,,,11834.69,7692.55,,,,,,,,,,,,,
HC Iadna Sarscov2& Inf a&B Mult Amp Probe|UNUSUAL NON-OVERLAPPING SERVICE|NOT REASONABLE AND NECESSARY,PX-3068763600,CDM,87636,CPT,0306,RC,,,XU|GZ,both,,,170.00,110.50,,,,,,,,,,,,,
MCCULLOCH MULTI TOOTH BLADE 30 CM TITANIUM,SUP-2676425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.95,230.72,,,,,,,,,,,,,
EXTRACTOR STONE 1.7FR L115CM 4W BSKT ATLS WIRE,SUP-2170135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.79,391.81,,,,,,,,,,,,,
PLATE CRAN SZ 3 PEEK SYN HRD TISS W/ SKULL MOD,SUP-2194241,CDM,C1713,HCPCS,0278,RC,,,,both,,,29912.58,19443.18,,,,,,,,,,,,,
PROBE PERF CNTRFUG BLD PMP CORTIVA SURF AFFIN CP,SUP-2464639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.93,512.80,,,,,,,,,,,,,
PEG KIT 20 FR NON-SAFETY PUL PLCMNT TECH DLX PUL STRL PONSKY,SUP-2125974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
STENT BILI ZILVER L 6 CM DIA 8 MM INTRO L 208 CM DIA 7 FR,SUP-2169574,CDM,C1876,HCPCS,0278,RC,,,,both,,,4640.92,3016.60,,,,,,,,,,,,,
COMPONENT FEM REV 5 LT KNEE CEM PERSONA,SUP-2435457,CDM,C1776,CPT,0278,RC,,,,both,,,26336.75,17118.89,,,,,,,,,,,,,
PLATE BONE METATARSOPHALANGEAL REVISION LEFT TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878217,CDM,C1713,HCPCS,0278,RC,,,,both,,,7488.90,4867.78,,,,,,,,,,,,,
COMPONENT HUM SM L6IN UNIV DST EL TIV PLSM INTERCHANGEABLE,SUP-2205913,CDM,C1776,CPT,0278,RC,,,,both,,,14998.84,9749.25,,,,,,,,,,,,,
SCREW BONE L35MM OD6.5MM STD TI CANC CORT ST SELF DRL CANN,SUP-2364202,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
BUR SURG 20MM DRL WIRE PASS BIT REUSE FOR ELITE,SUP-2367597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.45,265.49,,,,,,,,,,,,,
BASKET RETRV 3 FR URETHRA SEGR HMSPHR,SUP-2141705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
SCREW INTFR L23MM DIA8MM BIOCOMPOSITE BIO-TENODESIS,SUP-2121356,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
MESH HERN DIA6IN CIR W/ ECHO PS POS SYS VENTRALIGHT ST,SUP-2125915,CDM,C1781,HCPCS,0278,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
EEA CIR STPLR W TRISTAPLE TECHNOLOGY 31MM M THICK,SUP-2172450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3327.33,2162.76,,,,,,,,,,,,,
PLATE BONE CRANIAL 2 HOLE STRAIGHT 15.4X3.4MM TITANIUM NEURO,SUP-2821913,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.76,51.84,,,,,,,,,,,,,
DISTRACTOR SURG L70MM TELSCP LNR TRUELOK,SUP-2316072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.39,856.95,,,,,,,,,,,,,
PLATE BNE CLAV STD 3.5X140 MM ANTR 13 HOLE NS A.L.P.S,SUP-2457874,CDM,C1713,HCPCS,0278,RC,,,,both,,,4731.98,3075.79,,,,,,,,,,,,,
COMPONENT TIB CR 2XS UNIV PEDIATRIC 11 MM STEM NP MONOBLOCK,SUP-2376416,CDM,C1776,CPT,0278,RC,,,,both,,,3898.00,2533.70,,,,,,,,,,,,,
ROD IM TIB N-K II,SUP-2449190,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
PIN EXT FIX CONCL SET CONN ELEMENT STRL TRUELOK EVO LTX,SUP-2875605,CDM,C1713,HCPCS,0278,RC,,,,both,,,18446.28,11990.08,,,,,,,,,,,,,
GRAFT GRAN PRO OSTEON 500 15CC,SUP-2413079,CDM,C1713,HCPCS,0278,RC,,,,both,,,3130.58,2034.88,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 5 MM 4.4 FRX30 MM JAGOTOME RX 7306,SUP-2480053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,978.83,636.24,,,,,,,,,,,,,
HEAD HUM SZ 6 HA COAT SHLDR RESURF COPELAND,SUP-2403990,CDM,C1776,CPT,0278,RC,,,,both,,,13583.64,8829.37,,,,,,,,,,,,,
MESH HERN W15XL21CM ABD PTFE SYN NONABSORBABLE OVL,SUP-2126074,CDM,C1781,HCPCS,0278,RC,,,,both,,,72.85,47.35,,,,,,,,,,,,,
SCREW BONE L8MM OD1.9MM TI CANC ST FULL THRD CROSS FIT SM,SUP-2364076,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.41,132.87,,,,,,,,,,,,,
SHEATH TG0854517 85F 17MM 45CM,SUP-2298502,CDM,C1887,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
CANNULA SUCTION 3MM SINUS ANGLED,SUP-2667540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
KIT IMPL NDL TBNG CONN NAR FOR INSRTN CLS TOOL TI,SUP-2165393,CDM,C1813,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
NAIL IM L440MM DIA35MM OLECRANON LT BLU S STL E FLX,SUP-2186445,CDM,C1713,HCPCS,0278,RC,,,,both,,,947.18,615.67,,,,,,,,,,,,,
TRIAL BONE PLT 9 H RT LAT TIB BTTRS TC-100 L FRAG SYS,SUP-2343737,CDM,C1713,HCPCS,0278,RC,,,,both,,,6426.64,4177.32,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX 4X300 MM,SUP-2197278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
PLATE BNE W10.1XL82MM 7 H BILAT TI LO PROF RIG LOK COMPR,SUP-2191093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1701.69,1106.10,,,,,,,,,,,,,
CLAMP PLT HLD L6XW.45IN,SUP-2319587,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W18MM LEG L18X15MM WIRE DIA2X2MM S STL,SUP-2194222,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
VALVE VENT DRNGE IN LN W/ ANTI SIPHON DEV CERTAS +,SUP-2249016,CDM,C1729,HCPCS,0272,RC,,,,both,,,13375.90,8694.33,,,,,,,,,,,,,
ANTEROLATERAL PILON FUSION PLATE 18H RT,SUP-2814974,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
SPLINT WRST THMB XL L8IN R BLK FOAM D RNG CLSR ADJ REUSE,SUP-2336033,CDM,L3809,HCPCS,0272,RC,,,,both,,,20.82,13.53,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0035IN TAPR L105CM FLPY PLAT TIP,SUP-2168237,CDM,C1769,HCPCS,0272,RC,,,,both,,,83.27,54.13,,,,,,,,,,,,,
PLATE BNE TIB 2.7/3.5X142 MM RT MEDL DSTL 6 HOLE VA LCK SS,SUP-2177634,CDM,C1713,HCPCS,0278,RC,,,,both,,,5306.03,3448.92,,,,,,,,,,,,,
CABLE ABLATION CATH FARASTAR PULSED FLD RX GEN 2 CONN,SUP-2927924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 23X22 MM FRZN THRD CTS SVC FEE MDII,SUP-2743477,CDM,C1713,HCPCS,0278,RC,,,,both,,,12098.42,7863.97,,,,,,,,,,,,,
BRACE SHLDR L RT UNILAT LYCRA SPANDEX ORTHOSIS MFC II ROLYAN,SUP-2324867,CDM,L3660,HCPCS,0274,RC,,,,both,,,114.74,74.58,,,,,,,,,,,,,
SEGMENTAL FEM/TIB MALE-MALE 80MM,SUP-2502416,CDM,C1776,CPT,0278,RC,,,,both,,,8944.29,5813.79,,,,,,,,,,,,,
PROSTHESIS PENILE MS PMP,SUP-2139028,CDM,C1813,HCPCS,0278,RC,,,,both,,,13360.70,8684.45,,,,,,,,,,,,,
BIT DRL CANN SHT 2.5 MM FOR SCREW NS VIS DE BAROUK LTX,SUP-2861959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,582.16,378.40,,,,,,,,,,,,,
IMMOBILIZER ORTH CLOSED PAT UNIV AD 12 IN 24 IN CANVS,SUP-2194466,CDM,L1830,CPT,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
STEM HUM CEM STD UNIV 6X70 MM REV W/ ALIGN HOLE TI PLASMA,SUP-2431684,CDM,C1776,CPT,0278,RC,,,,both,,,8481.14,5512.74,,,,,,,,,,,,,
STENT BILI L12MM CATH L80CM BLLN L15MM DIA6MM 0.018IN 316L,SUP-2159076,CDM,C1876,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
SYSTEM ORTH REV MOD TIB TAPE 83 OSS,SUP-2441796,CDM,C1776,CPT,0278,RC,,,,both,,,9339.93,6070.95,,,,,,,,,,,,,
HC US Guidance for Needle Place - Anes Block|ADDITIONAL REVIEW|PBB CHARGE,PX-4027694201,CDM,76942,CPT,0402,RC,,,ZZ|PBB,both,,,978.00,635.70,,,,,,,,,,,,,
BELL CIRC 1.6 CM REUSE,SUP-2473548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.86,405.51,,,,,,,,,,,,,
ARIPIPRAZOLE 2 MG PO TABS,RX-70306,CDM,6370000000,HCPCS,0637,RC,16714-0141-01,NDC,,both,1,UN,5.40,3.51,,,,,,,,,,,,,
GUIDEROD ORTH L 600 MM DIA2 MM HUM GRAD BALL TIP STRL DISP,SUP-2932892,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
PLATE BNE L249MM 16 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185654,CDM,C1713,HCPCS,0278,RC,,,,both,,,4286.01,2785.91,,,,,,,,,,,,,
STENT ESOPH POLYFLEX L 120 CM BODY ID 18 MM FLARE ID 23 MM,SUP-2149392,CDM,C1874,HCPCS,0278,RC,,,,both,,,6170.51,4010.83,,,,,,,,,,,,,
PIN EXT FIX THRD 2.7X9 MM 80 MM LEVEL 1 TI,SUP-2423210,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.45,430.59,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDICS SM UNIV L R SHLDR SLNG,SUP-2195044,CDM,L3660,HCPCS,0272,RC,,,,both,,,25.62,16.65,,,,,,,,,,,,,
GRAFT BONE SUB SM 20CC CA SULF RAP CURE KT SYNTHECURE,SUP-2124553,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
EXTRACTOR STONE 1.7FR L115CM BSKT DIA1CM NIT TIPLSS UNIDEX,SUP-2170509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1024.90,666.18,,,,,,,,,,,,,
GRAFT HUM TISS L 60X60MM PERICARD FRZ DRY READIGRFT,SUP-2264832,CDM,C1713,HCPCS,0278,RC,,,,both,,,1583.85,1029.50,,,,,,,,,,,,,
PROBE LASER 23GA PRECIS FBR CNTR PLAS HND PC STR DISP RFID,SUP-2109918,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
CROWN DENT 7 LO LT SEC PRI M S STL GLD PREFABRICATED REPL,SUP-2322220,CDM,D6783,CPT,0278,RC,,,,both,,,25.09,16.31,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.7 MM PATELLAR SPLIT STRL EVOS,SUP-2933102,CDM,C1713,HCPCS,0278,RC,,,,both,,,8553.36,5559.68,,,,,,,,,,,,,
GUIDE DRL L4.2MM LNG REUSE NONSTERILE RADLUC,SUP-2362676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.08,239.90,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR ATLS DR V242RSTSYS] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356550,CDM,C1721,HCPCS,0275,RC,,,,both,,,57571.90,37421.73,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 3 FR VLV MAX BARR NURSING KT BIOFLO,SUP-2734866,CDM,C1751,HCPCS,0278,RC,,,,both,,,149.46,97.15,,,,,,,,,,,,,
BALLOON SPEC RETRV 0.035 IN 7-5 FRX200 CM 15 MM FUSION LTX,SUP-2737406,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
PIN FIX TROCAR PT 1 END 1/8X9 IN 1 PT STYL SMOOTH PLN STRL,SUP-2150446,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.98,10.39,,,,,,,,,,,,,
Z DISCONTINUED USE 2283977 KIT HAD CATH 12FR L20CM 3 LUMN HI PRSS CRV EXTN MAHRK,SUP-2283987,CDM,C1752,HCPCS,0278,RC,,,,both,,,253.65,164.87,,,,,,,,,,,,,
ANTENNA ABLAT SYS L15CM SHT THERMOSPHERE TECHNOLOGY FOR PERC,SUP-2172370,CDM,C1886,HCPCS,0278,RC,,,,both,,,10510.84,6832.05,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM DIA14 MM POLYESTER BOV CLLGN,SUP-2265890,CDM,C1768,CPT,0278,RC,,,,both,,,1014.44,659.39,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HYBRID ZHCHYBRID] ZIMMER BIOMET INC],SUP-2212724,CDM,C1776,CPT,0278,RC,,,,both,,,12732.17,8275.91,,,,,,,,,,,,,
TRUSS OSTEOTMY W20MM D16MM THK8MM UOTS IMPL,SUP-2101182,CDM,C1713,HCPCS,0278,RC,,,,both,,,9922.40,6449.56,,,,,,,,,,,,,
BURR SURG 1.5MM DIA HD 26MML HD CARBIDE TAPR CTTNG MICROPOWE,SUP-2605535,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63.37,41.19,,,,,,,,,,,,,
TUBE MYR 127MM DIAM BLU VENT TAB SIL DUTCHER,SUP-2313871,CDM,L8699,HCPCS,0278,RC,,,,both,,,59.41,38.62,,,,,,,,,,,,,
CURETTE SURG HOUSE 7 IN 1.3X1.1 MM STRONGLY ANGLED DBL END,SUP-2473409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.03,377.67,,,,,,,,,,,,,
UNIVERSAL WIRE FIXATION BOLT 23MM,SUP-2605902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.79,320.31,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 85 CM DIA 8 MM RNG L 45 CM,SUP-2681832,CDM,C1768,CPT,0278,RC,,,,both,,,3162.92,2055.90,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RETRO CHRONIC STD 16FR DIA 28CM 23CML I,SUP-2613315,CDM,C1750,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
PLATE BNE W12XL87MM THK1MM 5 H BILAT S STL SEMI TBLR LO,SUP-2184866,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.08,201.55,,,,,,,,,,,,,
DEVICE SUTURING CLOSURE 2-0 4 IN RELD GRN ENDOSTCH,SUP-2787723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.18,228.92,,,,,,,,,,,,,
RESERVOIR VENT DRNGE 01ML BTM INLET CONN BA IMPREG CSF,SUP-2277901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.62,581.50,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 0.018 IN 5 FRX60 CM 150 CM TURBO FLO,SUP-2170006,CDM,C1751,HCPCS,0278,RC,,,,both,,,320.75,208.49,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE GTT LCK L2405] TIDEWATER PROSTHETICS],SUP-2388183,CDM,L2405,HCPCS,0274,RC,,,,both,,,224.54,145.95,,,,,,,,,,,,,
COVER BURR HOLE 03MM 26MM DIA CMMRCLLY PURE TTNM CNTRD LOW,SUP-2694728,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.26,618.32,,,,,,,,,,,,,
JOINT TOE CANN 0 DEG LG HAMRTOE PHALINX,SUP-2397782,CDM,C1776,CPT,0278,RC,,,,both,,,1548.02,1006.21,,,,,,,,,,,,,
CATHETER ETER ABLAT 4MM N NAVIGATIONAL,SUP-2248494,CDM,C1733,HCPCS,0272,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
GRAFT HUM TISS M W40XL40MM PERICARD FRZ DRY READIGRFT,SUP-2264833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.08,780.05,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 2.5X205/230 MM 3 FLUTED STERILE TC1,SUP-2837038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2031.55,1320.51,,,,,,,,,,,,,
SYSTEM VISCOELASTIC 0.85ML PROVISC OVD 0.5ML VISCOAT OVD,SUP-2417098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.67,206.49,,,,,,,,,,,,,
ROD SPNL L120MM DIA5.5MM RT ANTR TI ALLOY SMOOTH MOSS MIAMI,SUP-2254457,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
RING EXT FIX HALF 80 MM TI NS,SUP-2799520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,972.33,632.01,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|ADJ,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|KX|CO|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
PEG BONE FIX L ANG SUBTALAR IMP STA-PEG,SUP-2397148,CDM,C1713,HCPCS,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
K WIRE FIX L285MM DIA3MM S STL SMOOTH DBL END SHRP TIP FOR,SUP-2368568,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PROSTHESIS OTO L4.25MM SHFT OD0.4MM TI BILAT MID EAR STAP,SUP-2312802,CDM,L8613,CPT,0278,RC,,,,both,,,757.87,492.62,,,,,,,,,,,,,
SYSTEM VES HARVESTING KT ENDOSCP VASOVIEW 6,SUP-2227298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
BENDING TEMPLATE FOR CALCANEAL PLATES 60MM,SUP-2548479,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.90,75.98,,,,,,,,,,,,,
MEMBRANE DURA 4X5IN REP SUTURABLE DURAMATRIX,SUP-2165132,CDM,C1763,HCPCS,0278,RC,,,,both,,,2998.45,1948.99,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 135 CM DIA 5 FR SLT PAT L 20,SUP-2118495,CDM,C1751,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA SPIROFLEX VG L 135 CM DIA,SUP-2142036,CDM,C1757,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00264-7510-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
SCREW BNE COMPR HUM C LBL AG RETROGRADE AFFIXUS NAT NAIL,SUP-2606205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
GRAFT VASC W/ RADPQ MRK SIDE BRANCH LEN THOR ARCH 12MM BOR,SUP-2385004,CDM,C1768,CPT,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
IMPLANT ORBIT THK1MM D1MM W41XL42MM L TIIUM POLYETH POR MESH,SUP-2366484,CDM,C1713,HCPCS,0278,RC,,,,both,,,3675.75,2389.24,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED POROUS CKNEESNEPHPOR] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351343,CDM,C1776,CPT,0278,RC,,,,both,,,13907.06,9039.59,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM S STL CORT ST NONCANNULATED LOK,SUP-2348800,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.82,554.33,,,,,,,,,,,,,
ILLUMINATOR PHLEBECTOMY DEV DISP PHASTIPP,SUP-2908887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
COMPONENT TALAR FLAT 1 RT TI PLASMA SPRY APEX 3D,SUP-2742156,CDM,C1776,CPT,0278,RC,,,,both,,,12756.25,8291.56,,,,,,,,,,,,,
HC Airway Insertion Emergent,PX-3703150000,CDM,31500,CPT,0370,RC,,,,outpatient,,,403.00,261.95,,,,,,,,,,,,,
GRAFT HUM TISS 10.5X69 MM QUADRICEPS TEND QUADLINK,SUP-2845954,CDM,C1762,CPT,0278,RC,,,,both,,,7755.80,5041.27,,,,,,,,,,,,,
IMMUNE GLOBULIN (PRIVIGEN) 10%,RX-4081762,CDM,J1459,HCPCS,0636,RC,44206-0436-05,NDC,,both,50,ML,2830.00,1839.50,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 5 FR NDL L 7 CM PLAT A BVL ECHOGENIC,SUP-2116529,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
HC So Chromosome Count Additional,PX-3118828566,CDM,88285,CPT,0311,RC,,,,inpatient,,,38.00,24.70,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER SGL CHMBR 30 J UPLR VVIR 20 SEC,SUP-2138082,CDM,C1722,HCPCS,0275,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
SPINDLE ORTH 2XS 25 MM 800 LB MINI TAPR COMPRESS,SUP-2441871,CDM,C1776,CPT,0278,RC,,,,both,,,11261.61,7320.05,,,,,,,,,,,,,
BOOT LEG TRAC CONVOLUTED FOAM LNR W/ STAY UNIV AD BUCK,SUP-2194992,CDM,L4360,HCPCS,0274,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
BIT DRL L225MM DIA35MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.23,325.15,,,,,,,,,,,,,
ENDCAP ORTH 0MM EXTN TI T40 STARDRV RECESS FOR EXPERT CANN,SUP-2179662,CDM,C1713,HCPCS,0278,RC,,,,both,,,755.14,490.84,,,,,,,,,,,,,
SET SUT ANCHR 1.4MM SFT SHT DISP JUGGERKNOT,SUP-2212959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,868.65,564.62,,,,,,,,,,,,,
ALLOGRAFT BNE PROX HUM W/ SFT TISS,SUP-2321814,CDM,C1713,HCPCS,0278,RC,,,,both,,,14287.00,9286.55,,,,,,,,,,,,,
COLLAR CERV SM H4.25IN FOR 10-13IN PLASTAZOTE FOAM 2 PC L,SUP-2336008,CDM,L0140,HCPCS,0274,RC,,,,both,,,30.33,19.71,,,,,,,,,,,,,
PLATE BNE L 180 MM 12 H LT PROX HUM CRV STRL EVOS,SUP-2931244,CDM,C1713,HCPCS,0278,RC,,,,both,,,6153.14,3999.54,,,,,,,,,,,,,
STENT TRACHBRONCH 7X40MM STENT GRFT 80CM 8FR DEL SYS NIT,SUP-2128293,CDM,C1874,HCPCS,0278,RC,,,,both,,,6577.52,4275.39,,,,,,,,,,,,,
PLATE BNE L59MM 12 H TI STR MOD HND SYS FOR 1.5MM SCR,SUP-2191108,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.99,721.49,,,,,,,,,,,,,
BAG COLL 700ML REPL W/ ANTI REFLX VLV FOR ACCU DRN EXT CSF,SUP-2898725,CDM,C1729,HCPCS,0272,RC,,,,both,,,101.20,65.78,,,,,,,,,,,,,
MARKER BRST BX TI NDL OD9GA US STEREOTACTIC GUID SHP 1 ATEC,SUP-2240069,CDM,A4648,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
COIL NEUROVASCULAR DELTAPAQ L 10 CM DIA 4 MM PRIMARY DIA,SUP-2460951,CDM,C1889,HCPCS,0278,RC,,,,both,,,4828.13,3138.28,,,,,,,,,,,,,
MEMBRANE CLLGN DURA REP DURAMATRIX ONLAY + 1IN X 3IN,SUP-2165124,CDM,C1763,HCPCS,0278,RC,,,,both,,,1320.87,858.57,,,,,,,,,,,,,
GRAFT STRGHT STNDRD WALL NON RNGD PLSTR KNTTD RDLLY 6MM DIA,SUP-2466495,CDM,C1768,CPT,0278,RC,,,,both,,,2798.18,1818.82,,,,,,,,,,,,,
PATCH HERN XL W10.8XL13.7IN UNCOATED MFIL PROPYLENE OVL,SUP-2125902,CDM,C1781,HCPCS,0278,RC,,,,both,,,6268.38,4074.45,,,,,,,,,,,,,
CATHETER PD COILED PED 52 CM 6.5 CM CLASSIC 1 CUF,SUP-2480210,CDM,C1750,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
CATHETER NEPHROSTOMY FOL 34 FR SUPRAPUBIC PEZ STRL,SUP-2125605,CDM,C2627,HCPCS,0272,RC,,,,both,,,46.69,30.35,,,,,,,,,,,,,
SCREW BONE L16MM OD2.7MM TI CORT SM HD T8 ST LOQTEQ,SUP-2101282,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.22,233.49,,,,,,,,,,,,,
MESH CRAN W40XL40MM THK0.6MM SLV TI ULT PRECONTOURED FOR,SUP-2402862,CDM,C1781,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
K WIRE FIX L270MM DIA2.5MM THRD FOR ANK FUS PLATING SYS,SUP-2398611,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
LASER SURG FOR SLT GLAUCOMA THER W/ 3 YR WARR SELECTA II,SUP-2713801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141300.00,91845.00,,,,,,,,,,,,,
BIT DRL CANN LG 12X190 MM QC TI NS EXPERT,SUP-2863380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1541.08,1001.70,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL 3,SUP-2435550,CDM,L0492,HCPCS,0272,RC,,,,both,,,1415.86,920.31,,,,,,,,,,,,,
PLATE BONE 5 H 5 PEG W LT VOLAR S STL BEAR,SUP-2389749,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
PLATE BNE 3.5X73 MM 6 HOLE SS DCP,SUP-2569138,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.51,158.28,,,,,,,,,,,,,
SCREW CANN COMPR HDLSS 2 THRD TI 4.0MMX20MM,SUP-2392772,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.82,366.48,,,,,,,,,,,,,
STENT URTRL 7FR DIA 8CML TCFLX OPEN WPSH CATH LTHSTNT ST SN,SUP-2721363,CDM,C2617,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
HC Cryopreservation & Storage,PX-3623820700,CDM,38207,CPT,0362,RC,,,,outpatient,,,4125.00,2681.25,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN LT WHL RAD,SUP-2740816,CDM,C1762,CPT,0278,RC,,,,both,,,11702.15,7606.40,,,,,,,,,,,,,
REAMER SURG DIA9MM CANN HD FULL THICKNESS CALIB W/ DEPTH,SUP-2121246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
GUIDE WIRE .041 DIAMETER,SUP-2812186,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
NAIL IM L280MM DIA10MM FEM TIB KNEE GLD TI CANN LCK AG RG,SUP-2347082,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
ANCHOR SUT 5MM DRL 28MM BLK HNDL SELF PUNCHING W 3 NO2 HI,SUP-2167269,CDM,C1713,HCPCS,0278,RC,,,,both,,,2169.74,1410.33,,,,,,,,,,,,,
RASP SPINE L INTBDY PYRAMETRIX,SUP-2292095,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.42,1324.32,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6MM STR TW REINF SLDE GDS,SUP-2695234,CDM,C1768,CPT,0278,RC,,,,both,,,2189.21,1422.99,,,,,,,,,,,,,
HC So Neo Gsap Dna Mcrstl Ins,PX-3108145766,CDM,81457,CPT,0310,RC,,,,both,,,5225.00,3396.25,,,,,,,,,,,,,
PACEMAKER CARD PACE 203H 2 CHMBR EXT TEMP NS,SUP-2616259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14742.30,9582.49,,,,,,,,,,,,,
PLATE BONE L82MM 4 H RT OLECRANON W/ TINES FOR 2.7/3.5MM SCR,SUP-2341159,CDM,C1713,HCPCS,0278,RC,,,,both,,,4866.37,3163.14,,,,,,,,,,,,,
AFFINITY CP CENTRIFUGAL NC,SUP-2722906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.18,291.97,,,,,,,,,,,,,
MESH BIO BOV CLLGN AND HUM FIBROBLASTS 140 MM LEN 100 MM W,SUP-2314084,CDM,Q4101,HCPCS,0636,RC,,,,both,,,5350.56,3477.86,,,,,,,,,,,,,
THROMBIN 5000 UNITS EX SOLR,RX-11548,CDM,2500000003,HCPCS,0250,RC,60793-0215-05,NDC,,both,1,UN,435.80,283.27,,,,,,,,,,,,,
KIT PROC 45DEG FIRM TIP EXT WRK CHAN CATH FOR OLY BRONCHSCP,SUP-2381763,CDM,C1887,HCPCS,0272,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
SCREW BNE 2.7X12 MM PERIARTICULAR DSTL/PROX TIB OPTILOCK,SUP-2458778,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
PROBE SURG FUKUSHIMA-GIANNOTTA 90 DEG 4.9 MM 7.25 IN,SUP-2485728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.97,224.88,,,,,,,,,,,,,
CATHETER KIT HYBRID PICC 6 FRX55 CM 145 CM WIRE PASV XCELA,SUP-2117280,CDM,C1751,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
WIRE BNE FIX L 150 MM DIA2 MM SS TRCR PT NS KIRSCHNER,SUP-2908310,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 17-19 MM FRZN ILIUM TRICORT,SUP-2717921,CDM,C1762,CPT,0278,RC,,,,both,,,5135.56,3338.11,,,,,,,,,,,,,
CROWN DENT D7 PEDIATRIC 1ST PRIMARY M UPPER RT SS,SUP-2239041,CDM,D6783,CPT,0278,RC,,,,both,,,18.81,12.23,,,,,,,,,,,,,
ELECTRODE LO TEMP TREAT CAP 3.0MM 45DEG ARTHWAND,SUP-2341961,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
HC N Block Inj Plantar Digit,PX-4506445500,CDM,64455,CPT,0450,RC,,,,both,,,920.00,598.00,,,,,,,,,,,,,
VALGANCICLOVIR HCL 450 MG PO TABS,RX-30148,CDM,6370000000,HCPCS,0637,RC,68084-0965-18,NDC,,both,1,UN,55.70,36.20,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 12X2 CM PROC SUSPEND FASC LATA TUTOPLAST,SUP-2165386,CDM,C1713,HCPCS,0278,RC,,,,both,,,3482.26,2263.47,,,,,,,,,,,,,
HC Fna Bx W/US Gdn Ea Addl,PX-3611000600,CDM,10006,CPT,0361,RC,,,,outpatient,,,2124.00,1380.60,,,,,,,,,,,,,
PLATE BONE LOK HLX12 LTRL CLMN RIGHT DST VOLAR RDL,SUP-2721390,CDM,C1713,HCPCS,0278,RC,,,,both,,,3376.50,2194.72,,,,,,,,,,,,,
SYSTEM INTRO L20CM 6FR NIT STD DBL END GWIRE L60CM,SUP-2303023,CDM,C1894,HCPCS,0272,RC,,,,both,,,195.62,127.15,,,,,,,,,,,,,
RESERVOIR SHUNT RICKHAM STYL SM,SUP-2851447,CDM,C1889,HCPCS,0278,RC,,,,both,,,939.36,610.58,,,,,,,,,,,,,
PLATE BNE L 121 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 15 H SS 72440315N,SUP-2932771,CDM,C1713,HCPCS,0278,RC,,,,both,,,1903.91,1237.54,,,,,,,,,,,,,
STENT PERIPH ENDOPROS 6MMDIA 100MML 8FR CATH 110CM TOT LEN,SUP-2396478,CDM,C1874,HCPCS,0278,RC,,,,both,,,7017.90,4561.63,,,,,,,,,,,,,
CASPOFUNGIN ACETATE 70 MG IV SOLR,RX-29568,CDM,J0637,HCPCS,0636,RC,63323-0358-10,NDC,,both,1,UN,2012.50,1308.12,,,,,,,,,,,,,
BASEPLATE GLEN DIA29 MM POST 35 MM OFFSET 3 MM SHLDR,SUP-2912691,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
PLATE BONE LNG LEFT PROXIMAL HUMERAL SYMMETRY,SUP-2483587,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
CATHETER GUID MERCI L 95 CM 9 FR 2.1MM BRAID REINF BIFURCATE,SUP-2365836,CDM,C1887,HCPCS,0272,RC,,,,both,,,3741.00,2431.65,,,,,,,,,,,,,
GRAFT BONE SUB 1CC DBM W/ RPM PUROS,SUP-2415798,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
PROBE COAG L2.2M DIA2.3MM FLX AR PLSM STRAIGHT FIRE CONIC BEAM,SUP-2217945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.84,504.95,,,,,,,,,,,,,
HC Excis Benign Lesion 0.5 Cm,PX-4501142000,CDM,11420,CPT,0450,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
VALPROIC ACID 250 MG/5ML PO SOLN,RX-107385,CDM,6370000000,HCPCS,0637,RC,00121-4675-00,NDC,,both,5,ML,6.20,4.03,,,,,,,,,,,,,
SET DIL L 45 CM DIA14 FR GUIDEWIRE 0.035 IN HYDRPHLC FOR,SUP-2170998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
INSERT ACET OD48MM ID28MM HIP ULTAMET COBAL CHROME ARTC MOD,SUP-2250323,CDM,C1776,CPT,0278,RC,,,,both,,,5442.88,3537.87,,,,,,,,,,,,,
PROXIMAL HUMERAL NAIL 1180150,SUP-2843382,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
TRANSDUCER PRSS L24IN NO STPCOCK DISP,SUP-2117231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
BIT DRL L195MM DIA6MM ST 3 FLUT QUIK CPL NONRADIOPAQUE W O,SUP-2187614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.40,437.71,,,,,,,,,,,,,
TAP SRGCL SCREW CRTCL QUICK CNNCT MINI FRGMNT TTNM 2.7MM 50M,SUP-2473968,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
INSERT HUM H+15MM DIA36MM CONSTRN SHLDR POLYETH AEQUALIS,SUP-2399864,CDM,C1776,CPT,0278,RC,,,,both,,,3744.45,2433.89,,,,,,,,,,,,,
BRACE ORTHPDC ADLT M 6 6.5N RIGHT THUMB NPRN WRAP HOOK LOOP,SUP-2472988,CDM,L3931,HCPCS,0272,RC,,,,both,,,53.57,34.82,,,,,,,,,,,,,
MESH HERN L1.9XW1.6IN L POLYPR INGUINAL NONABSORBABLE,SUP-2125788,CDM,C1781,HCPCS,0278,RC,,,,both,,,492.67,320.24,,,,,,,,,,,,,
CONNECTOR SPNL L50-60MM YEL TI LUM TRNSVRS LINK CLLT TYP ADJ,SUP-2212638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GRAFT BNE SUB 4CC DBM PRO-DENSE INJ INDUCTIVE PRO-STIM,SUP-2399130,CDM,C1713,HCPCS,0278,RC,,,,both,,,4669.18,3034.97,,,,,,,,,,,,,
CALCIUM CARB-CHOLECALCIFEROL 250-3.125 MG-MCG PO TABS,RX-160060,CDM,6370000000,HCPCS,0637,RC,20555-0025-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT ANTIREFLX 16 BEAD GASTROESOPHAGEAL TI MAG LINX,SUP-2388510,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PLATE BONE L216MM 12 H STD BILAT COMPR CNTOUR + BROAD FOR,SUP-2349005,CDM,C1713,HCPCS,0278,RC,,,,both,,,2591.98,1684.79,,,,,,,,,,,,,
CABLE VENT ASST MOD HEARTMATE 3,SUP-2356027,CDM,C1713,HCPCS,0278,RC,,,,both,,,16786.44,10911.19,,,,,,,,,,,,,
HC Ins/Rep of Single Chamb.Ppm,PX-3613321200,CDM,33212,CPT,0361,RC,,,,both,,,7145.00,4644.25,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST MOLD GAUNTLET,SUP-2435623,CDM,L1904,HCPCS,0274,RC,,,,both,,,1277.89,830.63,,,,,,,,,,,,,
DRILL HAND BUNNELL,SUP-2702381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2515.33,1634.96,,,,,,,,,,,,,
DRILL SURG 3.8 MM PEG INVISION,SUP-2850660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
CATHETER PULM ART 4FR L110CM INTRO 5FR BAL 0.60CC DIA6MM,SUP-2120571,CDM,C1727,CPT,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HC So Platelet Aggr(Invitro) Ea Agnt,PX-3058557666,CDM,85576,CPT,0305,RC,,,,inpatient,,,111.00,72.15,,,,,,,,,,,,,
COMPONENT FEM SZ 1 LT POST STBL CEM GMK,SUP-2267589,CDM,C1776,CPT,0278,RC,,,,both,,,8439.22,5485.49,,,,,,,,,,,,,
SCREW BONE L20MM DIA3.5MM CORT DSTL RAD ULN TI THRD HD FOR,SUP-2119933,CDM,C1713,HCPCS,0278,RC,,,,both,,,325.78,211.76,,,,,,,,,,,,,
PLATE BONE CRANIAL SQUARE 14X14MM TITANIUM NEURO PLATING SYS,SUP-2825988,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.99,151.44,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 23X9X14 MM PLIF CORTICAL ALLOQUENT,SUP-2736910,CDM,C1713,HCPCS,0278,RC,,,,both,,,9388.60,6102.59,,,,,,,,,,,,,
ANCHOR SUT L28MM DIA4.5MM SELF PUNCHING BIO-PUSHLOCK SP,SUP-2121508,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR,RX-10577,CDM,J2919,HCPCS,0636,RC,00009-0698-01,NDC,,both,1,UN,252.90,164.38,,,,,,,,,,,,,
GRAFT DERMAL THCK 12X6 CMX0.8-1.7 MM BRST KT ACELLULAR DERM,SUP-2307009,CDM,C1762,CPT,0278,RC,,,,both,,,12294.26,7991.27,,,,,,,,,,,,,
KIT SURG TALAR FIT TRIALS COMP LCK,SUP-2319756,CDM,C1776,CPT,0278,RC,,,,both,,,1849.46,1202.15,,,,,,,,,,,,,
CROWN FORM DENT STRP U1 PRIMARY ANTR UPPER RT CNTRL PLAS,SUP-2322241,CDM,D6783,CPT,0278,RC,,,,both,,,40.57,26.37,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.44/2.16 MM PAPARELLA SIL 510056,SUP-2535092,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.03,20.82,,,,,,,,,,,,,
PLATE BONE L140MM THK1.4MM SHFT W7.5MM 20 H STRL FLX FOR,SUP-2349697,CDM,C1713,HCPCS,0278,RC,,,,both,,,4629.62,3009.25,,,,,,,,,,,,,
COMPONENT SUBTALAR M UHMWPE ANG STA-PEG,SUP-2397147,CDM,C1776,CPT,0278,RC,,,,both,,,6926.84,4502.45,,,,,,,,,,,,,
NAIL INTRAMEDULLARY 3.6MM DIA 210MML TITANIUM LEFT RADIAL,SUP-2640060,CDM,C1713,HCPCS,0278,RC,,,,both,,,6433.86,4182.01,,,,,,,,,,,,,
PLATE BONE STRUT 0.4 MM CRANIAL 2X3 HOLE CURVED RIGID TITANI,SUP-2837704,CDM,C1713,HCPCS,0278,RC,,,,both,,,1247.21,810.69,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 3-4 EF 12 MM KNEE STRP YEL NXGN LPS,SUP-2208732,CDM,C1776,CPT,0278,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
DEVICE FIX DIA13MM CONT LOOP BTTN ZIPLOOP TECHNOLOGY FOR,SUP-2212825,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
HUMERAL TRAY STD SHLDR TI COMPHSVE,SUP-2431691,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
ANCHOR SUT L14MM OD4.5MM DBL ARM TWO NO 2 FIBERWIRE BIO,SUP-2121553,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS HD L 135 MM DIA 3 FR,SUP-2485899,CDM,C1753,HCPCS,0278,RC,,,,both,,,2747.00,1785.55,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA MRI XT VR MRI SURESCAN W 51 X H 66,SUP-2282426,CDM,C1722,HCPCS,0275,RC,,,,both,,,42052.23,27333.95,,,,,,,,,,,,,
CUP ACET DIA 43 MM SS HIP 2 MOBILITY CEM STRL NOVAE STK,SUP-2913883,CDM,C1776,CPT,0278,RC,,,,both,,,29011.21,18857.29,,,,,,,,,,,,,
STAPLE CARTRIDGE STR 16X25 MM TI,SUP-2166816,CDM,C1713,HCPCS,0278,RC,,,,both,,,425.03,276.27,,,,,,,,,,,,,
GRAFT HUM TISS 9/10MM TEND BNE PRESHAPED BIOCLEANSE,SUP-2335547,CDM,C1713,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
CUP ACET CEM 28 MM HIP HW W/ PLATE,SUP-2447856,CDM,C1776,CPT,0278,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
BURR LNG MICRO ROUND DIAMOND 4MM STER,SUP-2586367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,68.86,44.76,,,,,,,,,,,,,
NAIL IM STD 120 DEG 11X170 MM EBA 1,SUP-2719791,CDM,C1713,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
PLATE BNE HS RT 8 HOLE STRATUM RS,SUP-2861980,CDM,C1713,HCPCS,0278,RC,,,,both,,,2813.75,1828.94,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 6.25X2X0.4 CM 5 CC CRBNT APATITE VENADO,SUP-2718020,CDM,C1713,HCPCS,0278,RC,,,,both,,,2107.82,1370.08,,,,,,,,,,,,,
HC Extractable Nuclear Antigen Antibody Any Method,PX-3028623500,CDM,86235,CPT,0302,RC,,,,both,,,98.00,63.70,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN BNE MTRX GEL DBL SYR SYS ALLOSYNC,SUP-2120756,CDM,C1776,CPT,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
SET CATH L35CM DIA1.9MM DIFFUSE COMB OF ANTIBIO BACTISEAL,SUP-2243801,CDM,C1713,HCPCS,0278,RC,,,,both,,,2248.08,1461.25,,,,,,,,,,,,,
BOX JUNCTION 5DEG FEM BAL REV SYS,SUP-2315543,CDM,C1776,CPT,0278,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
SCREW IL 8.0 MM DIAM TI,SUP-2415540,CDM,C1713,HCPCS,0278,RC,,,,both,,,2943.56,1913.31,,,,,,,,,,,,,
CATHETER ETER IRRIG SNUS RELIEVA VORT 2,SUP-2106374,CDM,C1729,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CHOLECALCIFEROL 10 MCG (400 UNIT) PO TABS,RX-24559,CDM,6370000000,HCPCS,0637,RC,00904-5823-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0258,RC,00338-0023-02,NDC,,both,125,ML,26.60,17.29,,,,,,,,,,,,,
SET INTRO NEFF SHTH L 18 CM OD 7 FR ID 4 FR GUIDEWIRE 0.018,SUP-2168339,CDM,C1894,HCPCS,0272,RC,,,,both,,,214.74,139.58,,,,,,,,,,,,,
ADJ CONNECT ROD STD,SUP-2695688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1254.74,815.58,,,,,,,,,,,,,
GRAFT BNE STRP 6 CC ISOTIS PURE,SUP-2644342,CDM,C1713,HCPCS,0278,RC,,,,both,,,3366.08,2187.95,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN AD 4 FRX55 CM PWR INJ POWERPICC,SUP-2126703,CDM,C1751,HCPCS,0278,RC,,,,both,,,603.63,392.36,,,,,,,,,,,,,
PLATE BONE ANGLED 1.5 MM 3X3 HOLE PRECONTOURED TITANIUM SILV,SUP-2837750,CDM,C1713,HCPCS,0278,RC,,,,both,,,3661.87,2380.22,,,,,,,,,,,,,
IMMOBILIZER ORTH 3 PANEL UNIV KNEE COTTON CANVS FOAM,SUP-2276704,CDM,L1830,CPT,0274,RC,,,,both,,,32.88,21.37,,,,,,,,,,,,,
LITHOTRIPTER SURG MECH SM 4.2 MMX195 CM BSKT LITHOCRUSH DISP,SUP-2312980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1344.61,874.00,,,,,,,,,,,,,
SCREW CRAN 4PK L 4 MM DIA2.2 MM PLLA PGA PDLA RESRB STRL DELT,SUP-2883351,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.29,749.64,,,,,,,,,,,,,
BLADE RETRACTOR 15 CMX20 MM VES THN OLIF,SUP-2627584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.54,1502.50,,,,,,,,,,,,,
PIN ORTH L9IN OD5/64IN SMOOTH TRCR DBL SHRP TIP STRL S STL,SUP-2342705,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
RESERVOIR VENT DRNGE 0.68ML DIA1.5CM STD BUR H STYL W/ SM,SUP-2308213,CDM,C1889,HCPCS,0278,RC,,,,both,,,1343.83,873.49,,,,,,,,,,,,,
BOLT FIX L50MM DIA65MM ST MIDFOOT FUS S STL,SUP-2177259,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.06,1054.34,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK200UM AMNIO MEMBRN DEHYDR CHORION,SUP-2340448,CDM,C1762,CPT,0278,RC,,,,both,,,9869.02,6414.86,,,,,,,,,,,,,
BONE FEN PERF,SUP-2419192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
PLATE BNE SUBCONDYLAR 2 MM NS FPS LTX,SUP-2856827,CDM,C1713,HCPCS,0278,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
PROBE ELECSURG BPLR 20 GA ACTIVE ASPIR REFLX HEMOSTATIC ERAS,SUP-2309416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
KIT INTRO PTFE MIC ACCS TEARWY,SUP-2117205,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.63,77.76,,,,,,,,,,,,,
PLATE BNE X 8 HOLE RIGID THORECON,SUP-2720002,CDM,C1713,HCPCS,0278,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
BASKET SPEC RETRV STONE 65 CM BILI 3 WIR W/ SIDE ARM,SUP-2768306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1745.40,1134.51,,,,,,,,,,,,,
BOLT EXT FIX UNIV WIRE,SUP-2197245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 740 HF-T 59 X66MM 13MM CELLULAR 40J,SUP-2138411,CDM,C1882,HCPCS,0275,RC,,,,both,,,84780.00,55107.00,,,,,,,,,,,,,
CATHETER GUID L 80 CM DIA16 FR HYDRPHLC STEER FOR MITRACLIP,SUP-2661363,CDM,C1887,HCPCS,0272,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
CANNULA ENDOSCOPIC RIGHT MIDDLE FOR MENISCAL REPAIR SYSTEM Z,SUP-2824139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.99,649.34,,,,,,,,,,,,,
GRAFT VASC L20CM ID6MM RNG L40CM STD WALLED RNGED STR GORTX,SUP-2396002,CDM,C1768,CPT,0278,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X30X40X0.5 MM RAPID RESORBABLE S,SUP-2838573,CDM,C1713,HCPCS,0278,RC,,,,both,,,1593.55,1035.81,,,,,,,,,,,,,
SPECULUM VAG PEDERSON MED 7/8X3.5 IN,SUP-2475805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,72.94,47.41,,,,,,,,,,,,,
HEAD FEM POR W/ OXINIUMXLPE LNR,SUP-2347951,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN T1 FIX COR,SUP-2141994,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.86,40.21,,,,,,,,,,,,,
APPLIER CLP ENDOSCP MED LG 13 IN LIG HEMCLP +,SUP-2656752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SET HOOK RTRCTN 68MML NROSPNE BLACK FLEXI SPINE RGGLS RDMND,SUP-2672193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.44,442.29,,,,,,,,,,,,,
GRAFT VASC STR 8 MMX40 CM STD WALL EPTFE CARBOFLO CENTERFLEX,SUP-2761398,CDM,C1768,CPT,0278,RC,,,,both,,,2260.71,1469.46,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1.7-10 MM 60 CC FD CANC,SUP-2743393,CDM,C1713,HCPCS,0278,RC,,,,both,,,3318.98,2157.34,,,,,,,,,,,,,
BIT DRILL 2.5MM EVOLVE EPS,SUP-2822476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
COIL EMB L10CM OD4MM 2D HELCL SFT STRTCH RESIST DETACH,SUP-2365732,CDM,C1889,HCPCS,0278,RC,,,,both,,,5814.65,3779.52,,,,,,,,,,,,,
KIT INFLATION DEV PTCA PRIORITY PK GA 20 ATM VLV ID 0.115 IN,SUP-2105891,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BUR SURGICAL CUSHING,SUP-2792303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.27,342.73,,,,,,,,,,,,,
HC Treat Elbow Dislocation W Anes,PX-4502460500,CDM,24605,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
PLATE BONE LOK 106MML HLX6 STNLSS STEEL ST RIGHT LTRL DST FB,SUP-2588179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1858.91,1208.29,,,,,,,,,,,,,
METRONIDAZOLE 500 MG PO TABS,RX-5016,CDM,6370000000,HCPCS,0637,RC,00904-7126-61,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
PLATE BNE L183MM 14 H NONSTERILE CNTOUR LOK 2 COMPR FOR 35MM,SUP-2199392,CDM,C1713,HCPCS,0278,RC,,,,both,,,1283.35,834.18,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED LT TALUS NO CART,SUP-2867174,CDM,C1762,CPT,0278,RC,,,,both,,,8054.10,5235.16,,,,,,,,,,,,,
SM FRAG PLT STERILIZER 3.5X61 MM 5 HL,SUP-2820735,CDM,C1713,HCPCS,0278,RC,,,,both,,,1050.80,683.02,,,,,,,,,,,,,
SYSTEM FIX 16X14X8 MM CERV SPINE UNISON-C,SUP-2335268,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
HC So Lipoprotein A,PX-3018217266,CDM,82172,CPT,0301,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 10CM 6FR 0.087IN SPRING WALL PUNC,SUP-2384747,CDM,C1894,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
TUBE ET ID5MM ORAL UNCUF MURPHY EYE PREFRM BOLD MRK AT CNTR,SUP-2383863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7.69,5.00,,,,,,,,,,,,,
PLATE BONE H2.8MM 17 H MAND TI STR SEC RECON LEIBINGER,SUP-2363749,CDM,C1713,HCPCS,0278,RC,,,,both,,,3283.91,2134.54,,,,,,,,,,,,,
WIRE ORTH 7MM 1.2MM SM THRD K,SUP-2316515,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.02,57.86,,,,,,,,,,,,,
SCREW BNE L 54 MM DIA 5.5 MM LNG TI CANN HDLSS NS LEOS,SUP-2931481,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.90,662.28,,,,,,,,,,,,,
SYSTEM GRFT PREP 30MM LNG WHT W HI STRENGTH SUT FOR KNEE,SUP-2256712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,305.37,198.49,,,,,,,,,,,,,
PLATE BNE 2.7X60 MM 7 HOLE SS DCP,SUP-2569129,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.96,185.22,,,,,,,,,,,,,
HC CT Heart No Contrast Quant Eval Coronry Calcium|WAIVER OF LIABILITY ON FILE|SELF-PAY CT CALCIUM SCORING,PX-3507557100,CDM,75571,CPT,0350,RC,,,GA|CTC,both,,,175.00,175.00,,,,,,,,,,,,,
BLADE RTRCTR YOUNG 1INW X 1ND 8 14NL PRSTTE URLGCL NTCHD,SUP-2672981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.53,310.39,,,,,,,,,,,,,
NEEDLE SPNL POS FOR SPS SYS,SUP-2770145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,689.64,448.27,,,,,,,,,,,,,
SCREW BONE L65MM THRD DIA2.7MM HD DIA4.3MM COR DIA2MM PITCH,SUP-2349470,CDM,C1713,HCPCS,0278,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
SCREW BNE HEX HD SM 4X35 MM CANC,SUP-2199301,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.09,8.51,,,,,,,,,,,,,
TRAY TIB SZ 2X TI ALLOY RT ANK TOT ANAT TRI CORTICAL,SUP-2931386,CDM,C1776,CPT,0278,RC,,,,both,,,21661.29,14079.84,,,,,,,,,,,,,
HC Perq Dev Breast 1st US Image,PX-3611928500,CDM,19285,CPT,0361,RC,,,,outpatient,,,2124.00,1380.60,,,,,,,,,,,,,
HC ED Clsd Tx IP Disloc WO Anesth,PX-4502677000,CDM,26770,CPT,0450,RC,,,,outpatient,,,383.00,248.95,,,,,,,,,,,,,
GRAFT EVAR L120MM DIA28MM PROX 16MM DST AAA INTUITRAK,SUP-2217574,CDM,C1768,CPT,0278,RC,,,,both,,,32954.30,21420.29,,,,,,,,,,,,,
SHUNT PERI 7FR 90CM LO REG W/O RESVR CSF ASSEMB FLO CTRL,SUP-2284549,CDM,C1729,HCPCS,0272,RC,,,,both,,,2447.66,1590.98,,,,,,,,,,,,,
RETAINER SIDEARM,SUP-2889623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE 3.5X242 MM 20 HOLE SS DCP,SUP-2569147,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.93,296.35,,,,,,,,,,,,,
SET ACCS CATH 5FR L10CM NDL 21GA L7CM GWIRE L40CM 0.018IN,SUP-2170561,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.06,76.74,,,,,,,,,,,,,
CATHETER EMB NOVASIL SYNTEL L 40 CM DIA 5 FR BALLOON DIA11,SUP-2264198,CDM,C1757,HCPCS,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
SYSTEM TIGHTROPE II RT W/ DEPLOYING SUTURE,SUP-2719541,CDM,C1776,CPT,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
WALKER PT M LOWEST PROF W/ CRISS CROSS STRP THREE-D,SUP-2195482,CDM,L4386,HCPCS,0272,RC,,,,both,,,195.03,126.77,,,,,,,,,,,,,
MAGNESIUM GLUCONATE 500 (27 MG) MG PO TABS,RX-123645,CDM,6370000000,HCPCS,0637,RC,60258-0172-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
FIXATOR EXT NUT LK RINGFIX SYS,SUP-2495539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
CATHETER CV SET 032 10 FRX15 CM 10 GA 5 LUMEN QUINT SPECTRUM,SUP-2759731,CDM,C1751,HCPCS,0278,RC,,,,both,,,420.32,273.21,,,,,,,,,,,,,
APPLIER CLP 12FR L86CM W/ ENDOANCHOR CASS FOR EVAR HELI-FX 10 CLIPS PER APPLIER,SUP-2297452,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
STEM FEM MS 30 POLISHED OFFST CEM HIP 6.0,SUP-2204692,CDM,C1776,CPT,0278,RC,,,,both,,,10369.54,6740.20,,,,,,,,,,,,,
STENT URET 7 FRX80 CM DIV OPN TIP PERCFLX,SUP-2141654,CDM,C2617,HCPCS,0278,RC,,,,both,,,610.23,396.65,,,,,,,,,,,,,
VALVE VENTRICULAR DRAINAGE 0 WITH DISTAL CATHETER MININAV,SUP-2825681,CDM,C1889,HCPCS,0278,RC,,,,both,,,2434.03,1582.12,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH L 100 CM BER TIP S HTORQ,SUP-2865161,CDM,C1757,HCPCS,0272,RC,,,,both,,,31368.60,20389.59,,,,,,,,,,,,,
KIT SURG PWR MINIMALLY INVASIVE PROC KT FOR HRDWR STRL LF,SUP-2881085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4593.82,2985.98,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM 6 FR 2-5-2 MM D QPLR,SUP-2535655,CDM,C1730,HCPCS,0272,RC,,,,both,,,166.14,107.99,,,,,,,,,,,,,
CLAMP SURG SINGLE SHT OCPTL PROTEX CT,SUP-2584530,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
RELOAD STPL L45MM VASCULAR/MEDIUM TISS TAN CRV TIP ARTC,SUP-2283357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,805.22,523.39,,,,,,,,,,,,,
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr,PX-3612251400,CDM,22514,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
CLOFARABINE 1 MG/ML IV SOLN,RX-40404,CDM,J9027,HCPCS,0636,RC,70121-1236-01,NDC,,both,20,ML,5472.00,3556.80,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 80 CM DIA 6 MM EPTFE GRAD REINF 3 LAYR,SUP-2478316,CDM,C1768,CPT,0278,RC,,,,both,,,3761.53,2444.99,,,,,,,,,,,,,
COMPONENT FEM SZ 4 R ANT KNEE CRUCE RET CEM REFERENCING,SUP-2372973,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.76 MM 2.3 MM DONALDSON W/ TAB PC SIL,SUP-2535072,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.15,24.15,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL 2,SUP-2435549,CDM,L0491,HCPCS,0274,RC,,,,both,,,2174.29,1413.29,,,,,,,,,,,,,
ADAPTER TIB TY 3MM OFFSET BAL REV SYS,SUP-2315558,CDM,C1776,CPT,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
PPICC PROV SOLO PED 3F SLEEVE DELTA,SUP-2613523,CDM,C1751,HCPCS,0278,RC,,,,both,,,1022.38,664.55,,,,,,,,,,,,,
WALKER SHT LEG DLX BLK XL,SUP-2276714,CDM,L4387,HCPCS,0274,RC,,,,both,,,86.60,56.29,,,,,,,,,,,,,
THERASKIN LG 39SQ CM 5.1X7.6CM,SUP-2264658,CDM,Q4121,HCPCS,0636,RC,,,,both,,,3969.90,2580.43,,,,,,,,,,,,,
CATHETER PH MON INF 6FR 0CM PH CHAN W/ 7 IMPED RNG DISP ZNIS,SUP-2227938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3567.04,2318.58,,,,,,,,,,,,,
TUBE ARMSTRONG 1.14X2.5X3.8MM,SUP-2736735,CDM,L8699,HCPCS,0278,RC,,,,both,,,18.53,12.04,,,,,,,,,,,,,
CABLE ORTH DIA2MM HIP CO CHROM FOR GRP PLT ACCORD,SUP-2345212,CDM,C1776,CPT,0278,RC,,,,both,,,743.55,483.31,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ULTRATRACK L 150 CM 0.038IN ANGLED TAPR,SUP-2539338,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.24,83.36,,,,,,,,,,,,,
HC Control Throat Bleeding,PX-4504296000,CDM,42960,CPT,0450,RC,,,,both,,,706.00,458.90,,,,,,,,,,,,,
COMPONENT FEM L35MM SEG CLLR FOR 17-19MM STEM TRABECULAR,SUP-2200567,CDM,C1776,CPT,0278,RC,,,,both,,,6231.33,4050.36,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX20 CM LT DL STACKED DURAMAX LF,SUP-2458764,CDM,C1750,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER ANGIO AD 4FR L65CM COBRA 1 HYDRPHLC RADPQ,SUP-2139772,CDM,C1725,HCPCS,0272,RC,,,,both,,,158.10,102.76,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 13 MM FD IRRADIATED,SUP-2867043,CDM,C1762,CPT,0278,RC,,,,both,,,1927.02,1252.56,,,,,,,,,,,,,
PIN FXTN L45MM D4MM CABLE L508MM HIP STNLSS STEEL CABLE READ,SUP-2468796,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.72,514.62,,,,,,,,,,,,,
DISTALDORSO-ULNARDORSO-RADIALL-PLATESR6H,SUP-2816182,CDM,C1713,HCPCS,0278,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
IMPLANT COCHLEAR REUSE CNTOUR NUCLS 24,SUP-2165053,CDM,L8614,HCPCS,0278,RC,,,,both,,,60916.00,39595.40,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM LOOP 1.7 MM BIOCOMP SWIVELOCK FT CC,SUP-2882180,CDM,C1713,HCPCS,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
"HC So Immunofix Electphoresis,Othfld",PX-3028633566,CDM,86335,CPT,0302,RC,,,,inpatient,,,72.00,46.80,,,,,,,,,,,,,
PLATE BNE L42MM THK1.25MM 6 H BILAT MAXILLOFACIAL MAND ORAL,SUP-2191335,CDM,C1713,HCPCS,0278,RC,,,,both,,,1782.58,1158.68,,,,,,,,,,,,,
SCREW BNE ZURICH 1.2X9 MM CRANIOMAXILLOFACIAL HEX TI,SUP-2540159,CDM,C1713,HCPCS,0278,RC,,,,both,,,808.33,525.41,,,,,,,,,,,,,
GRAFT BNE W11XH10XL17MM CERV WDG FRZ DRY CANC TRICORT,SUP-2264848,CDM,C1713,HCPCS,0278,RC,,,,both,,,1941.40,1261.91,,,,,,,,,,,,,
STENT PANCREATIC GEENEN L 3 CM DIA11.5 FR GUIDEWIRE 0.035 IN,SUP-2737450,CDM,C2617,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
APPLIER ANEURYSM CLIP L3.5IN STANDARD FINGER TIP GRIP BAYONE,SUP-2821562,CDM,C1889,HCPCS,0278,RC,,,,both,,,5364.22,3486.74,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.035IN L 8CM 3CM HEPARIN AMPLTZ STR,SUP-2169715,CDM,C1769,HCPCS,0272,RC,,,,both,,,89.43,58.13,,,,,,,,,,,,,
CLAMP REPROC JETX BAR PIN MR SAFE 10.5MM 5MM,SUP-2475623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.56,335.11,,,,,,,,,,,,,
PLATE BNE TBLR 3.5X40 MM 3 HOLE 1/3 SS NS LCP,SUP-2185924,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.01,264.56,,,,,,,,,,,,,
HC X-Ray Exam of Femur Min 2 Views,PX-3207355200,CDM,73552,CPT,0320,RC,,,,both,,,504.00,327.60,,,,,,,,,,,,,
HANDPIECE ELECSURG L45CM DIA5MM FR ACTUATED GRP PLATFRM,SUP-2313549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1239.67,805.79,,,,,,,,,,,,,
GUIDEWIRE VASC AVIGO L 205 CM COIL L 5 CM DIA 0.014 IN,SUP-2518869,CDM,C1769,HCPCS,0272,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
KIT INTRO SHTH MICROEZ L 50 CM CATH 5 FR NDL L 10 CM FLEXURA,SUP-2125499,CDM,C1894,HCPCS,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
GRAFT BNE 45X11 MM OSTEOBALLAST,SUP-2644327,CDM,C1713,HCPCS,0278,RC,,,,both,,,5642.58,3667.68,,,,,,,,,,,,,
MESH BONE PTTSBRGH RGLR 03MM THK TTNM LATEX FREE MXLFCL,SUP-2707412,CDM,C1713,HCPCS,0278,RC,,,,both,,,1580.11,1027.07,,,,,,,,,,,,,
SLEEVE SURG DRL SGL END 43 MM DIA DISPOSABLE ST,SUP-2204937,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 80 CM DIA 5 FR SPC 5 MM D CRV,SUP-2248644,CDM,C1730,HCPCS,0272,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST SACH CUSH TYP,SUP-2435731,CDM,L3450,HCPCS,0272,RC,,,,both,,,298.77,194.20,,,,,,,,,,,,,
STEM FEM HIP LO HD CNTR FBR MTL PRI NEUT BEAD FBR MTL 00784001210] ZIMMER BIOMET INC],SUP-2203082,CDM,C1776,CPT,0278,RC,,,,both,,,15529.18,10093.97,,,,,,,,,,,,,
CAGE SPNL 40X18X8 MM COROENT XLF,SUP-2567994,CDM,C1889,HCPCS,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
ANCHOR SUTURE SFT 1 MM MINI STP DRL STRL JUGGERKNOT,SUP-2745481,CDM,C1776,CPT,0278,RC,,,,both,,,739.53,480.69,,,,,,,,,,,,,
ANCHOR NONSUTURE 10MM FIXATION MENISCAL BIOSTINGER,SUP-2828681,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.46,215.45,,,,,,,,,,,,,
BLADE ARTHSCP FULL RAD SHRP TIP ERGO HNDL HIP SPEC LEN SGL,SUP-2366732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PLATE TIBIA EVOS 13H LP 3.5X167MM,SUP-2849004,CDM,C1713,HCPCS,0278,RC,,,,both,,,11482.67,7463.74,,,,,,,,,,,,,
GRAFT BIO TISS W3XL3CM MTRX CLLGN TISSMEND,SUP-2376568,CDM,C1768,CPT,0278,RC,,,,both,,,13649.58,8872.23,,,,,,,,,,,,,
BONESYNC PUTTY 2.5CC,SUP-2816385,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SNARE VASC OPTEASE L 80 CM DIA10 FR NIT FEM LP LNG SIDE,SUP-2153947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BNE LCK LG LT FT CALCANEUS ALPS,SUP-2607127,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
CLAMP EXT FIX MULTIPIN UNIV GEM FIX NS GALAXY LTX,SUP-2875228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4361.93,2835.25,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 X W 2 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905495,CDM,Q4184,HCPCS,0636,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
STEM HUM L 90 MM SZ 7S SHRT PLASMA SPRY POROUS TI SHLDR,SUP-2912616,CDM,C1776,CPT,0278,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
BUR 8MM M CORNERSTONE,SUP-2363351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
VEST HOLSTER POCKET BATTERY CTRL,SUP-2356017,CDM,C1713,HCPCS,0278,RC,,,,both,,,1339.52,870.69,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 90 DEG L 135 CM DSTL L 40,SUP-2120496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE GREATER TUBEROSITY 53 MM SHLDR SS NS ORTHOLOC SPS,SUP-2421809,CDM,C1713,HCPCS,0278,RC,,,,both,,,8123.18,5280.07,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 4 CM DIA 3 MM MICROCATHETER 0.018,SUP-2385381,CDM,C1889,HCPCS,0278,RC,,,,both,,,628.03,408.22,,,,,,,,,,,,,
PAD ORTHOT LUMBAR CUST BOLSTER,SUP-2435573,CDM,L1030,HCPCS,0272,RC,,,,both,,,221.68,144.09,,,,,,,,,,,,,
PROSTHESIS PENILE ACCSRY KT,SUP-2140318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TAP SURGICAL RESORB-X 2.1MM 70MM 11MM ADJUSTMENT DRILL-FREE F/BOS EA,SUP-2681418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1305.27,848.43,,,,,,,,,,,,,
SCREW BONE L28MM DIA2.7MM CORT DSTL RAD NONLOCKING FULL THRD,SUP-2136252,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - Spouse,PX-9900000042,CDM,9900000042,LOCAL,0990,RC,,,,both,,,20.00,13.00,,,,,,,,,,,,,
SCREW BNE AD PED L5MM DIA12MM CORT TI ST SELF DRL,SUP-2262778,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.68,147.99,,,,,,,,,,,,,
SET JEFFREY 21GA NDL - NIT WIRE,SUP-2168369,CDM,C1769,HCPCS,0272,RC,,,,both,,,284.61,185.00,,,,,,,,,,,,,
HEAD FEM M DIA36MM HIP PNK BIOLOX DELT ALUMINA MTRX 12/14,SUP-2304836,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SYSTEM IO FIX 2.5MM 0DEG W/ UNIV INSRT FOR FRACTURES FUS,SUP-2175103,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
COMPONENT ANK CTRL FIX TRANSLATING TRAUM CLMP JET-X,SUP-2342859,CDM,C1776,CPT,0278,RC,,,,both,,,7749.21,5036.99,,,,,,,,,,,,,
GRAFT VSCLR L30CM D10MM THRCC STRGHT DBLE VLR PASS SWNG TUBE,SUP-2466785,CDM,C1768,CPT,0278,RC,,,,both,,,1823.59,1185.33,,,,,,,,,,,,,
SPLINT ARM L W25XL14IN FOR 8-21IN LIMB TRNSLUC FAB POLYSTYR,SUP-2328638,CDM,L3702,HCPCS,0274,RC,,,,both,,,31.53,20.49,,,,,,,,,,,,,
GRAFT VASC L 50 CM DIA 6 MM POLYESTER THOR ABD AORT STR TB,SUP-2227632,CDM,C1768,CPT,0278,RC,,,,both,,,1474.54,958.45,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE BLOCK 15X15X8 MM FD CANC ORAGRAFT,SUP-2740942,CDM,C1713,HCPCS,0278,RC,,,,both,,,986.43,641.18,,,,,,,,,,,,,
PROSTHESIS OSS CENTERED 0.2X1.45X1 MM PART TI PRECIS,SUP-2466218,CDM,L8613,CPT,0278,RC,,,,both,,,1115.52,725.09,,,,,,,,,,,,,
VALVE AORT L12CM DIA30MM TISS ANNULUS DIA27MM CLLGN MSTR LO,SUP-2356716,CDM,C1889,HCPCS,0278,RC,,,,both,,,21823.00,14184.95,,,,,,,,,,,,,
PLATE BNE M L52MM 0DEG 6 H ST R 1ST MTP FUS S STL VAR ANG,SUP-2178390,CDM,C1713,HCPCS,0278,RC,,,,both,,,3535.11,2297.82,,,,,,,,,,,,,
ELECTRODE ELECSURG BALL TIP 8 FRX37 CM MONOPOLAR FULG BLU,SUP-2313732,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
GRAFT BNE SM 2 CC PRO OSTEON 200R,SUP-2685763,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4 H STD CRANIOMAXILLOFACIAL G TI ORBIT,SUP-2366274,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.82,222.18,,,,,,,,,,,,,
PROBE ENDOSCP BPLR 10 FR 2 GENRTR PLUG QUICKSILVER,SUP-2737100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
HEAD FEM OD38MM +0MM M NK C CAST CO CHROM HIP PRI CONSTRN,SUP-2397308,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BNE L263MM 16 H BROAD COMPR RIG FOR 45MM SCR L FRAG,SUP-2411431,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
HC Tissue Level IV,PX-3128830500,CDM,88305,CPT,0312,RC,,,,both,,,352.00,228.80,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 6 CM OD 7 FR ID 2.3 MM GUIDEWIRE,SUP-2168596,CDM,C1894,HCPCS,0272,RC,,,,both,,,60.95,39.62,,,,,,,,,,,,,
PLATE BONE 168MML HLX8 STNLSS STEEL CLVRLF F/3.5MM SCREW SM,SUP-2494295,CDM,C1713,HCPCS,0278,RC,,,,both,,,1210.91,787.09,,,,,,,,,,,,,
SCREW BNE CANN 4X12 MM PARTIALLY THRD,SUP-2606134,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.01,294.46,,,,,,,,,,,,,
PLATE BONE W18XL30MM 5 H MIDFOOT TITANIUMXCOMPRESSION FOR,SUP-2225438,CDM,C1713,HCPCS,0278,RC,,,,both,,,4775.94,3104.36,,,,,,,,,,,,,
STAPLER INT L60MM STD TISS BLU 7/8 FIRING W/ 3.5MM 21 TI,SUP-2283418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.33,750.96,,,,,,,,,,,,,
SHUNT NEUROSURGICAL OD18MM ADJ VLV W/O DIFF PRSS UNIT PROSA,SUP-2108729,CDM,C1889,HCPCS,0278,RC,,,,both,,,10771.02,7001.16,,,,,,,,,,,,,
PLATE BNE NAVICULAR LG 1.1 MM LT 9 HOLE TI BABY GORILLA,SUP-2750974,CDM,C1713,HCPCS,0278,RC,,,,both,,,3570.18,2320.62,,,,,,,,,,,,,
MATRIX BIO L 25 X W 10 CM FET BOV DERM IONIC SLV DERMAL SLD,SUP-2909293,CDM,Q4110,HCPCS,0636,RC,,,,both,,,16249.50,10562.17,,,,,,,,,,,,,
GRAFT SYNTH TISS 10MM 4ML 40MM LEN 10MM THICKNESS BLK IMPL,SUP-2413073,CDM,C1713,HCPCS,0278,RC,,,,both,,,3457.14,2247.14,,,,,,,,,,,,,
NEEDLE MAYO 1/2 CIRCLE SIZE 4 TAPER POINT 212613,SUP-2845002,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.68,12.14,,,,,,,,,,,,,
IMPERIUM 300 OTO FIBER,SUP-2885249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2110.08,1371.55,,,,,,,,,,,,,
CATHETER REPERFUSION 0.068 INX132 CM UNIQUE ACE 68,SUP-2323549,CDM,C1757,HCPCS,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
GRAFT VASC GORTX L 100 CM DIA 8 MM RNG L 80 CM EPTFE STR TW,SUP-2396141,CDM,C1768,CPT,0278,RC,,,,both,,,3121.16,2028.75,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 23 CM DIA 6 FR STIFF STR,SUP-2740609,CDM,C1892,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
PLATE SPNL 24 H THOR PRE CNTOUR RIBFIX BLU,SUP-2137003,CDM,C1713,HCPCS,0278,RC,,,,both,,,7680.44,4992.29,,,,,,,,,,,,,
STAPLE SPNL SINGLE 13 MM CD HORZ,SUP-2630057,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
SLING URETH BLDR FIX MESH POLYPR BIOARC SP,SUP-2140250,CDM,C1771,HCPCS,0278,RC,,,,both,,,5350.56,3477.86,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE W 4.45 X H 5.02 CM THK 0.75 CM 13.7,SUP-2149249,CDM,C1785,HCPCS,0275,RC,,,,both,,,24146.60,15695.29,,,,,,,,,,,,,
CAGE SPNL 25X12X9MM LO PROF BONE GRFT CHAMBERS TANT MRK,SUP-2354700,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
RECLAIM ASSEMBLY TENSILE BAR,SUP-2515476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.58,317.58,,,,,,,,,,,,,
PLATE BONE W14.9XL264MM THK1.2MM 16 H DSTL TIB S STL,SUP-2185745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1740.16,1131.10,,,,,,,,,,,,,
GRAFT BNE W10XL250MM THK3 12MM CORT FEM FRZN HALVED STRUT,SUP-2307351,CDM,C1713,HCPCS,0278,RC,,,,both,,,6754.77,4390.60,,,,,,,,,,,,,
DRILL SURG LUG DSTL FEM W/ HUDSON END SPEC 2,SUP-2456546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
PLATE BNE PLNTR 3.5X78 MM RT MEDL CLMN FUSION VA LCK SS NS,SUP-2178432,CDM,C1713,HCPCS,0278,RC,,,,both,,,5070.60,3295.89,,,,,,,,,,,,,
SCREW BNE 28X45MM CORT G PKG 1 HEXADRIVE 7,SUP-2268292,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.61,168.10,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 32 MM ANTR CERV TETH,SUP-2379303,CDM,C1713,HCPCS,0278,RC,,,,both,,,5193.56,3375.81,,,,,,,,,,,,,
BOLT IM L38MM DIA3.9MM BLU TI ALUM NIOBIUM TRCR TIP ST LOK,SUP-2192190,CDM,C1713,HCPCS,0278,RC,,,,both,,,591.51,384.48,,,,,,,,,,,,,
INSERT ACET OD48MM ID28MM GG METASUL HIP ALPHA UNCEMENTED,SUP-2204511,CDM,C1776,CPT,0278,RC,,,,both,,,6231.33,4050.36,,,,,,,,,,,,,
FIBER LASER 365UM 6J 80HZ 120W D F L FOR LITHO MOSES,SUP-2417490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1314.28,854.28,,,,,,,,,,,,,
WAND ABLAT XL L195MM DIA375MM ARTHSCP MULTIVAC W INTEGR,SUP-2341215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.14,673.49,,,,,,,,,,,,,
CATHETER ABLATN STD 7 FRX110 CM 2.5X8 MM INTELLANAV MIFI XP,SUP-2141337,CDM,C1732,HCPCS,0272,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.7MM RED CORT MAXILLOMANDIBULAR TI HI,SUP-2137233,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
GRAFT HUM TISS 2X3CM AMNIOCORD,SUP-2305709,CDM,Q4187,HCPCS,0636,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
KIT CATH CTRL VEN AD L16CM DIA12FR BLU FLX TIP POLYUR,SUP-2120592,CDM,C1751,HCPCS,0278,RC,,,,both,,,277.70,180.50,,,,,,,,,,,,,
PLATE BNE H MTCRPL 6 HOLE,SUP-2389577,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
HANDPIECE PHACO TORSIONAL OZIL,SUP-2109897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
STRIP INT STPL 25MM VERIT CLLGN MTRX BOV PERICARD PERI-STRPS,SUP-2130370,CDM,C1713,HCPCS,0278,RC,,,,both,,,1231.26,800.32,,,,,,,,,,,,,
UNIT NAVIGATION CLR SIMP QUIK INTFACE FOR DST FEM TIB INSTR,SUP-2314149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
TRIPLE ANTIBIOTIC 5-400-5000 EX OINT,RX-8201,CDM,6370000000,HCPCS,0637,RC,45802-0143-70,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 8H 154MM RIGHT STERILE,SUP-2549637,CDM,C1713,HCPCS,0278,RC,,,,both,,,5070.38,3295.75,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 100 CM DIA 5 FR DIA1.12 MM STR,SUP-2385523,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.33,112.66,,,,,,,,,,,,,
GRAFT STENT BIFUR 23X16X166 MM AAA ENDURANT II,SUP-2295202,CDM,C1768,CPT,0278,RC,,,,both,,,31321.50,20358.97,,,,,,,,,,,,,
SCREW BONE L130MM DIA4MM SCHNZ DISP,SUP-2150266,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.08,57.90,,,,,,,,,,,,,
SHEATH RETRV L 150 CM GUIDEWIRE 0.054 IN CROSSING PROF 1.4,SUP-2146958,CDM,C1894,HCPCS,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
MESH HERN SQ 3X3 IN FULL RESRB FOR SFT TISS RECON PHASIX,SUP-2855247,CDM,C1781,HCPCS,0278,RC,,,,both,,,3623.56,2355.31,,,,,,,,,,,,,
STENT URET PATERSON-FORRESTER L 65 CM DIA 8.5 FR SUBQ,SUP-2826999,CDM,C2627,HCPCS,0272,RC,,,,both,,,309.07,200.90,,,,,,,,,,,,,
PLATE BNE L90MM THK3.5-4.5MM 4 H NONSTERILE R MED TI DST,SUP-2190911,CDM,C1713,HCPCS,0278,RC,,,,both,,,4480.43,2912.28,,,,,,,,,,,,,
PLATE BNE LCK LG LT CLAV 8 HOLE,SUP-2266344,CDM,C1713,HCPCS,0278,RC,,,,both,,,1990.57,1293.87,,,,,,,,,,,,,
SHEATH INTRO 8.5FR L71CM 8.5FR DIL GWIRE L180CM DIA0.032IN,SUP-2357285,CDM,C1766,CPT,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT BNE 60CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264825,CDM,C1713,HCPCS,0278,RC,,,,both,,,2115.73,1375.22,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7553,SUP-2525335,CDM,C1769,HCPCS,0272,RC,,,,both,,,715.48,465.06,,,,,,,,,,,,,
BIT DRILL 2.3MM TWIST L180,SUP-2858200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.51,285.68,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 6 CM PLCNTA MEMBRN ALLGRFT CROSS,SUP-2909407,CDM,Q4109,HCPCS,0636,RC,,,,both,,,65312.00,42452.80,,,,,,,,,,,,,
TRUSS ANK OSTEOTMY 22X18X5.5 MM 10D SYS,SUP-2101136,CDM,C1713,HCPCS,0278,RC,,,,both,,,11088.75,7207.69,,,,,,,,,,,,,
RELOAD STPL L100MM OPN H4.5MM CLS H2MM WIRE DIA0.23MM THCK,SUP-2220070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.89,223.53,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK OPTMA FOR ARTHSCP ROT CUF REP,SUP-2212879,CDM,C1713,HCPCS,0278,RC,,,,both,,,1223.85,795.50,,,,,,,,,,,,,
MESH SURG M THK0.4MM SLV TI MASTOID MALL CNTOUR LO PROF,SUP-2181585,CDM,C1781,HCPCS,0278,RC,,,,both,,,2812.81,1828.33,,,,,,,,,,,,,
TUBE VENT 0.78 MM 1 MM 2/1.5 MM SPN BOB TI BLU STRL 500061,SUP-2468664,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.62,45.90,,,,,,,,,,,,,
PLATE BNE SINGLE LISFRANC 2 HOLE STRATUM,SUP-2606571,CDM,C1713,HCPCS,0278,RC,,,,both,,,3675.21,2388.89,,,,,,,,,,,,,
CONTROLLER CRYOSURGICAL C2 CRYOBLLN,SUP-2422293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15637.20,10164.18,,,,,,,,,,,,,
WASHER SPNL 5 MM POST TI POLARIS,SUP-2686051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
STEM FEM STD OFFSET CERAMIC STR CEMENTLESS IMPL SZ 12,SUP-2390361,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
CATHETER SPEC RETRV 035 7-5 FRX200 CM 8.5 MM ABV TRI-EX,SUP-2738204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,0636,RC,00409-9104-20,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
BOUGIE ESOPH HURST TUNGSTEN FIL 36FR SIL,SUP-2383704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.22,276.39,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 115 CM DIA 7 FR SPC 2,SUP-2356924,CDM,C1730,HCPCS,0272,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
CATHETER VENTRICULAR 15X28 MMX15CM SHUNT SLT INNERVISION TIP,SUP-2277972,CDM,C1729,HCPCS,0272,RC,,,,both,,,639.15,415.45,,,,,,,,,,,,,
SCREW SET SPNL 179721001] JNJ HEALTHCARE],SUP-2256229,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
MESH HERN ELLIPSE 9X7 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855264,CDM,C1781,HCPCS,0278,RC,,,,both,,,22513.80,14633.97,,,,,,,,,,,,,
STAPLER INT 60 MM RELD TRISTAPLE TECHNOLOGY PUR STRL SEAMGRD,SUP-2458849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
LEAD DEFIB FIX EXT RET HELIX MIN INTRO 7FR SHOCK,SUP-2356226,CDM,C1895,HCPCS,0275,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
HC Biopsy Thyroid Perc Needle,PX-3616010000,CDM,60100,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
MESH POLYFORM 10CMX15CM,SUP-2141770,CDM,C1763,HCPCS,0278,RC,,,,both,,,1077.02,700.06,,,,,,,,,,,,,
KIT STEREOTACTIC BX GUID TRAJECTORY CRAN EXT DISP NAVIGUS,SUP-2284361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4932.94,3206.41,,,,,,,,,,,,,
METHADONE HCL 10 MG PO TABS,RX-4953,CDM,6370000000,HCPCS,0637,RC,00406-5771-23,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L2MM 14 H TI LOK REG THREADLOCK TS,SUP-2262828,CDM,C1713,HCPCS,0278,RC,,,,both,,,1893.95,1231.07,,,,,,,,,,,,,
CATHETER DRAINAGE KINK RESIST 6 FRX30 CM,SUP-2126990,CDM,C1729,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PSN REV TIB FIXED KEEL CMT SZ H L,SUP-2508660,CDM,C1776,CPT,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
DEVICE ISOLATION MIXED PACK,SUP-2887768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
IMPLANT OP RM CALC PLT CALCNL FRACT,SUP-2321443,CDM,C1713,HCPCS,0278,RC,,,,both,,,4401.50,2860.97,,,,,,,,,,,,,
DEVICE POS VAG PELV FLR COLPASSIST,SUP-2139402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1671.36,1086.38,,,,,,,,,,,,,
SCORPIO-FLEX CRX3 SZ 3 - 24,SUP-2365098,CDM,C1776,CPT,0278,RC,,,,both,,,4773.68,3102.89,,,,,,,,,,,,,
HC Sickling RBC Reduction,PX-3058566000,CDM,85660,CPT,0305,RC,,,,outpatient,,,228.00,148.20,,,,,,,,,,,,,
PLATE BNE THK 2 MM SCREW DIA2/2.3 MM MED GRD IV TI DBL,SUP-2936816,CDM,C1713,HCPCS,0278,RC,,,,both,,,6791.82,4414.68,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK0.38-1.02MM SKIN REGENERATIVE TISS,SUP-2261538,CDM,Q4107,HCPCS,0636,RC,,,,both,,,10804.74,7023.08,,,,,,,,,,,,,
HC Inj Proc Hip,PX-3612709300,CDM,27093,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
COUPLER 2MM MIC VASC,SUP-2382620,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE W17.5XL386MM THK5.2MM 18 H NONSTERILE L CNDYL FEM,SUP-2185051,CDM,C1713,HCPCS,0278,RC,,,,both,,,5101.37,3315.89,,,,,,,,,,,,,
STENT URET L 30 CM DIA 8.5 FR PTFE GUIDEWIRE L 100 CM DIA,SUP-2312689,CDM,C2617,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SCREW BNE CRTX 1.5X16 MM TI NS,SUP-2190904,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.68,92.09,,,,,,,,,,,,,
ANCHOR LD FOR SPNL CRD STIM CINCH,SUP-2356644,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
GALANTAMINE HYDROBROMIDE 4 MG PO TABS,RX-29806,CDM,6370000000,HCPCS,0637,RC,65862-0458-60,NDC,,both,1,UN,3.00,1.95,,,,,,,,,,,,,
CAP CBL VENT ASST MOD MECH CIRCULATORY SUPP HEARTMATE III,SUP-2356028,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
STAPLER 60MM POWERED ECHELON 3000 LONG 440MM,SUP-2855404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1389.17,902.96,,,,,,,,,,,,,
BASKET SPEC RETRV HELCL POLYP 2X4 CM 7 FR NS MEM BSKT,SUP-2737566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
CAGE SPNL H14MM INTBDY FUS OCTAVE POST PLT,SUP-2264529,CDM,C1889,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
KIT FIX SCR L30MM DIA2.7MM W/ PIN DRL BIT DISP TRIM-IT,SUP-2121847,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SCREW INTRF CANN 7X35 MM 2 MM GUIDEWIRE 8 MM HD STD TI RCI,SUP-2878045,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP FUSION LOOPTIP L 260 CM DIA 0.035 IN LOOP,SUP-2170835,CDM,C1769,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
PROBE LASER 25GA STD STR TAPR TIP DISP ENDOPRB,SUP-2247213,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.56,343.56,,,,,,,,,,,,,
STENT BILI L29MM CATH L80CM BLLN L30MM DIA5MM 0.035IN 316L,SUP-2159242,CDM,C1876,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PACEMAKER CRD CONTAK RENEWAL TR 871F,SUP-2149121,CDM,C1786,HCPCS,0275,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM PLCNTA MEM CRYOPRESERVED CHORION,SUP-2319166,CDM,Q4132,HCPCS,0636,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 4 FR TIP 7 CM SS WIRE/TIP STD MIC,SUP-2116534,CDM,C1894,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
HC Pericardiocentesis Including Imag Guid When Performed,PX-4503301600,CDM,33016,CPT,0450,RC,,,,both,,,3477.00,2260.05,,,,,,,,,,,,,
SCREW BONE L50MM OD4.7MM WR FIX ANG LCK IMP MAESTRO,SUP-2407345,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
SCREW BNE COMPR SHT THRD 5.5X24 MM CANN HDLSS NS LTX,SUP-2856135,CDM,C1713,HCPCS,0278,RC,,,,both,,,2047.28,1330.73,,,,,,,,,,,,,
CATHETER DEL ACCS FOR CHOLANGIOPANCREATOSCOPY SPYSCOPE DS,SUP-2149617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 73 CM DIA 8.5 FR GUIDEWIRE 0.032 IN,SUP-2357112,CDM,C1893,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BNE NAR 4.5X215 MM 13 HOLE SS DCP,SUP-2569171,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.76,243.59,,,,,,,,,,,,,
TROCAR ENDOSCP L90MM DIA5MM SHT CANN DIL W/ RADIALLY SELF,SUP-2283338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.65,270.82,,,,,,,,,,,,,
EVOS VOL PLATE 4H LEFT STD TI 56MM NS,SUP-2818638,CDM,C1713,HCPCS,0278,RC,,,,both,,,5314.92,3454.70,,,,,,,,,,,,,
HC I&D Simple,PX-7611006000,CDM,10060,CPT,0761,RC,,,,inpatient,,,632.00,410.80,,,,,,,,,,,,,
GRAFT BONE SUB 15ML CRUSH DBM GRFTON,SUP-2293913,CDM,C1713,HCPCS,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.3MM LNG S STL CORT ANK FT ST SELF DRL,SUP-2397701,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
BOOT ANK AD L8 13IN FOR 16IN CALF UNIV DK BLU FLEECE LN,SUP-2165483,CDM,L4631,HCPCS,0274,RC,,,,both,,,145.38,94.50,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH L 25 CM DIA 9 FR GUIDEWIRE L 80 CM,SUP-2329848,CDM,C1894,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SHUNT NEUROSURGICAL EXT 3.3X5 DIA P/D INLET 30CML SIL ELASTM,SUP-2615567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2585.04,1680.28,,,,,,,,,,,,,
DRIVER SURG HEX 3.5 MM N CANN N STRL,SUP-2232024,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 12.5CM X 17.5CM,SUP-2874123,CDM,A2007,HCPCS,0636,RC,,,,both,,,27946.00,18164.90,,,,,,,,,,,,,
PLATE BNE L 159 MM 18 H SCREW DIA2.7 MM TI ALLOY MINI FRAG,SUP-2902359,CDM,C1713,HCPCS,0278,RC,,,,both,,,4255.42,2766.02,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 4 KT STRL DISP EVO,SUP-2935104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
GRAFT HUM TISS W137XH7XL95MM STD LORD FRZ DRY SPCR CC NAT,SUP-2306982,CDM,C1713,HCPCS,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
SYSTEM ENDOPLEDGE HRTPORT FOR ALTERNATIVE TO CONVENTIONAL,SUP-2214470,CDM,C1730,HCPCS,0278,RC,,,,both,,,6210.92,4037.10,,,,,,,,,,,,,
KIT PI PICC 2-L 5.5 FR X 55 CM WITH CHG AND VPS,SUP-2565197,CDM,C1751,HCPCS,0278,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
GRAFT BONE 5X11X11MM LMASR HUM TISS TRICORT SPCR MECHANISM,SUP-2293951,CDM,C1713,HCPCS,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
FIBER LASER SINGLE 200 MH TRAC TIP FLEXIVA ID,SUP-2462861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1325.61,861.65,,,,,,,,,,,,,
PERI-LOC VLP 3.5MM S-T LOCK SCREW 26MM,SUP-2818974,CDM,C1713,HCPCS,0278,RC,,,,both,,,1014.25,659.26,,,,,,,,,,,,,
NEEDLE INJ L12.5CM DIA12GA BNE CEM DEL NORIAN,SUP-2194178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.75,420.39,,,,,,,,,,,,,
CAGE SPNL 15 DEG 45X22X10 MM COHERE XLW,SUP-2736439,CDM,C1889,HCPCS,0278,RC,,,,both,,,16799.00,10919.35,,,,,,,,,,,,,
ELECTRODE LOOP LINA G 200MM X100MM,SUP-2265060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1153.95,750.07,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN J2 TIP MOVABLE COR,SUP-2147065,CDM,C1769,HCPCS,0272,RC,,,,both,,,42.26,27.47,,,,,,,,,,,,,
SHELL ACET LIMIT H 23 54 MM HIP LCK MECHANISM TI RINGLOC+,SUP-2409128,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
LOOP TISS FIX L 120 MM ADJ OPN BTTN STRL PROCINCH,SUP-2906386,CDM,C1713,HCPCS,0278,RC,,,,both,,,1676.76,1089.89,,,,,,,,,,,,,
SYSTEM CPRP CONC UP TO 18X BASELINE ADJ LEUK CONC ANGEL,SUP-2120730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 3X7CM,SUP-2261685,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3661.24,2379.81,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 157MML HLX12 STNLSS STEEL CNTRD,SUP-2588607,CDM,C1713,HCPCS,0278,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7 MM STR HELIX REINF,SUP-2681145,CDM,C1768,CPT,0278,RC,,,,both,,,1120.63,728.41,,,,,,,,,,,,,
ANCHOR SUT DIA45MM HA PLLA COMP 2 W O NDL 3 LOOP UNIQUE PUL,SUP-2366670,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.78,889.06,,,,,,,,,,,,,
CATHETER HD KT 8 FRX24.5 CM 15 CM 1 CC 1 LUMEN STR ARGY,SUP-2754726,CDM,C1750,HCPCS,0278,RC,,,,both,,,121.05,78.68,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CELLULAR BNE MTRX SYGNACEL CBM,SUP-2929809,CDM,C1713,HCPCS,0278,RC,,,,both,,,14632.40,9511.06,,,,,,,,,,,,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,0636,RC,10019-0925-01,NDC,,both,1,UN,105.90,68.83,,,,,,,,,,,,,
COMPONENT FEM OPTETRAK AK,SUP-2223151,CDM,C1776,CPT,0278,RC,,,,both,,,5.02,3.26,,,,,,,,,,,,,
SUPPORT ORTHOT CUST HEEL WDG,SUP-2435721,CDM,L3350,HCPCS,0274,RC,,,,both,,,64.75,42.09,,,,,,,,,,,,,
GRAFT BNE BLOCK 11X11X7 MM FD CORTICAL,SUP-2277897,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
PLATE CRAN 140X60X40 MM PT SPEC IMPL PEEK,SUP-2860134,CDM,C1713,HCPCS,0278,RC,,,,both,,,33119.46,21527.65,,,,,,,,,,,,,
PLATE BNE 12 H G ORBIT RIM CRANIOMAXILLOFACIAL TI RIG FOR,SUP-2191140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.75,892.94,,,,,,,,,,,,,
GUIDEWIRE ORTH L12IN BLNT TIP DISP,SUP-2212566,CDM,C1769,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE BNE 6 H MIC TI NONSTERILE 1.5MM SCR .6MM,SUP-2262680,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.52,104.34,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR DS L 115 CM 7 FR F CRV ORN,SUP-2248941,CDM,C1732,HCPCS,0278,RC,,,,both,,,7215.72,4690.22,,,,,,,,,,,,,
BLADE SHAVER 3.7 MMX10.5 CM 30 DEG BEND IRRIG RHINOTEC GTR,SUP-2607696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,268.12,174.28,,,,,,,,,,,,,
PLATE BNE L 18 MM THK 0.6 MM 4 H SCREW DIA1. 5 MM LNG TI,SUP-2883946,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
CURETTE SURG RHOTON 14 7.5 IN ANGLED TI NS,SUP-2473498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.63,365.71,,,,,,,,,,,,,
PLATE BNE THK0.8MM BAR 12MM UNIV 6 H CRANIOMAXILLOFACIAL TI,SUP-2366264,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.17,503.86,,,,,,,,,,,,,
CATHETER LD DEL AVEIR VR L 105 CM DIA 6.8 MM SINGLE CHMBR,SUP-2880902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
IMPLANT ANTIREFLX 15 BEAD GASTROESOPHAGEAL TI MAG LINX,SUP-2388509,CDM,C1889,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
SHUNT SURG L 8.9 MM VENTRICULAR CATH L 180 MM PRESSURE 10 CM FV694T,SUP-2929006,CDM,C1889,HCPCS,0278,RC,,,,both,,,4178.74,2716.18,,,,,,,,,,,,,
HC Unlisted Cardiovascular Service or Procedure,PX-4819379900,CDM,93799,CPT,0481,RC,,,,both,,,491.00,319.15,,,,,,,,,,,,,
STEM FEM REV 0+ MM LNG 19 MM LT HIP POLISHED BOW EMPERION,SUP-2434543,CDM,C1776,CPT,0278,RC,,,,both,,,14293.28,9290.63,,,,,,,,,,,,,
SHELL ACET SLD BK COCR ALLOY 52MM VITALOCK,SUP-2364626,CDM,C1776,CPT,0278,RC,,,,both,,,3980.33,2587.21,,,,,,,,,,,,,
BLADE SURG 11 LT MIDLN MAST MIDLF,SUP-2631593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
STAPLER INT CIR XL EXTRA THICK 28 MM 4-5 MM BLK EEA,SUP-2787719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4992.76,3245.29,,,,,,,,,,,,,
PLATE BNE L230MM 10 H NONSTERILE L DST FEM LOK FOR 4.5MM,SUP-2348456,CDM,C1713,HCPCS,0278,RC,,,,both,,,10797.36,7018.28,,,,,,,,,,,,,
HC Guide Cathet Fluid Drainage,PX-3611003000,CDM,10030,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
BUR SURG 1.4X12.8MM FLUT ROUTER FOR 5.9CM TURQ ATTCH,SUP-2176849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
SHUNT PERI 7FR 90CM 13MM IDX25MMOD SM W OUT RESVR,SUP-2284555,CDM,C1713,HCPCS,0278,RC,,,,both,,,4013.05,2608.48,,,,,,,,,,,,,
KIT HEMSTAT MTRX 8ML PORCINE GEL HUM THROM ABSRB FLOWABLE 2993] JNJ HEALTHCARE],SUP-2256904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.74,330.68,,,,,,,,,,,,,
GRAFT DERMAL MESH 3X7 CM FEN WND MTRX MIRODERM,SUP-2431548,CDM,Q4175,HCPCS,0636,RC,,,,both,,,4431.17,2880.26,,,,,,,,,,,,,
SHUNT CV DIA275MM 14MM BTWN BLB IC SIL TAPR TIP RADPQ,SUP-2278142,CDM,C1889,HCPCS,0278,RC,,,,both,,,255.41,166.02,,,,,,,,,,,,,
SCREW BNE ST 1.5X14 MM LCK W/ T4 STARDRV RECESS,SUP-2569504,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.35,43.78,,,,,,,,,,,,,
METRONIDAZOLE 250 MG PO TABS,RX-5015,CDM,6370000000,HCPCS,0637,RC,60687-0526-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ASPIRIN 300 MG RE SUPP,RX-693,CDM,6370000000,HCPCS,0637,RC,00574-7034-12,NDC,,both,1,UN,10.10,6.56,,,,,,,,,,,,,
PLEDGET SURGICAL W3/8XL1/16IN THK1.5MM PTFE RECTANGLE,SUP-2425485,CDM,C1768,CPT,0278,RC,,,,both,,,74.45,48.39,,,,,,,,,,,,,
ELECTRODE MONOPOLAR L HK 3.5 MMX20 CM FOR HNDL GN230,SUP-2852497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.57,248.02,,,,,,,,,,,,,
SCREW SPNL 27X16MM RESRB FT,SUP-2400588,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
ABUTMENT HEARING AID 10 DEG ANGLED PONTO,SUP-2430339,CDM,L8690,HCPCS,0278,RC,,,,both,,,6330.24,4114.66,,,,,,,,,,,,,
COMPONENT ULN L3.5IN REG LT ELBW TIV PLSM INTERCHANGEABLE,SUP-2205938,CDM,C1776,CPT,0278,RC,,,,both,,,10606.92,6894.50,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 55CM 5,SUP-2613283,CDM,C1750,HCPCS,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 10 CC PRESERVON CANC READIGRAFT,SUP-2741066,CDM,C1713,HCPCS,0278,RC,,,,both,,,377.11,245.12,,,,,,,,,,,,,
BUR SURG DIA6MM EXTRA COARSE RND DMND CUT ELITE,SUP-2363995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.96,288.57,,,,,,,,,,,,,
LEAD PACE CAPSUR EPI L 35 CM SIL INSUL STEROID EPICARD,SUP-2278399,CDM,C1898,HCPCS,0275,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
HC Facial Bones Less Than 3 Views,PX-3207014000,CDM,70140,CPT,0320,RC,,,,inpatient,,,446.00,289.90,,,,,,,,,,,,,
CONNECTOR SPNL 5.5-6/6.35X12 MM LAT SGL HD OPN,SUP-2421858,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY E STRP 40IN CIRC 28IN,SUP-2194900,CDM,L1830,CPT,0274,RC,,,,both,,,115.65,75.17,,,,,,,,,,,,,
GUIDEWIRE VASC DIA0.9MM ITS,SUP-2247390,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE EXTERNAL FIXATION 160MM FOOT ALUMINUM,SUP-2586491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5638.31,3664.90,,,,,,,,,,,,,
DEVICE INFLATION NS QUANTUM DISP,SUP-2738153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
SCREW INTFR 11MM 35MM 1MM CANN KNEE ABSRB POLY L LACTIC ACID,SUP-2366523,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
TUBING SET CAN FOR VAC PMP,SUP-2859792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HC N Block Inj Intercost Sng|BILATERAL PROCEDURE|PO,PX-3606442000,CDM,64420,CPT,0360,RC,,,50|PO,outpatient,,,2230.00,1449.50,,,,,,,,,,,,,
PLATE BNE L176MM THK3.4MM 13 H BILAT S STL STR LOK COMPR,SUP-2185148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1246.11,809.97,,,,,,,,,,,,,
PIN FIX L9IN DIA48MM ST S STL 2 SIDE SGL DMND 1 END PNT,SUP-2150531,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.84,16.80,,,,,,,,,,,,,
SET ENDOSCP ELECTROCAUTERY L 220 CM DIA2.8 MM BALLOON L 180,SUP-2881766,CDM,C1769,HCPCS,0272,RC,,,,both,,,5240.66,3406.43,,,,,,,,,,,,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,0258,RC,00338-0125-03,NDC,,both,500,ML,51.00,33.15,,,,,,,,,,,,,
CATHETER KIT 4 FRX20 CM MIDLN TRIM,SUP-2384035,CDM,C1751,HCPCS,0278,RC,,,,both,,,110.53,71.84,,,,,,,,,,,,,
PLATE BNE MINI WRST TI 4 CORNER LIMIT FUS MOD HUB CAP,SUP-2107844,CDM,C1713,HCPCS,0278,RC,,,,both,,,3573.32,2322.66,,,,,,,,,,,,,
BLOCK EXT FIX 150MM RIG COMPRESSION/DISTRACTION STRUT,SUP-2197296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
IMPLANT COCHLEAR HEARING STRL NUCLS,SUP-2140411,CDM,L8614,HCPCS,0278,RC,,,,both,,,61500.83,39975.54,,,,,,,,,,,,,
PLATE BNE L158MM 6 H R DST EXTRAARTICULAR HUM S STL LOK,SUP-2184042,CDM,C1713,HCPCS,0278,RC,,,,both,,,3729.50,2424.17,,,,,,,,,,,,,
OXYGENATOR W/ INTEGR HARDSHELL RESERVOIRXCOATING RIGHTINLET,SUP-2384844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SLEEVE DRL DIA2.7MM MEAS FOR ALPS PROX HUM PLATING SYS,SUP-2411561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.79,341.76,,,,,,,,,,,,,
KIT INSTR BLU DISP PRO-TOE VO,SUP-2397814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
HC Injection Treatment of Nerve,PX-3616468000,CDM,64680,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 15MM R MED L LAT KNEE HEMI STP LEGION,SUP-2346588,CDM,C1776,CPT,0278,RC,,,,both,,,5025.57,3266.62,,,,,,,,,,,,,
PLATE BNE L 94 MM TI EXTRATHORACIC PREBENT NS RIBFIX TITAN,SUP-2905456,CDM,C1713,HCPCS,0278,RC,,,,both,,,12019.92,7812.95,,,,,,,,,,,,,
RING SPNL SZ 2 L22MM DIA17MM 0DEG STD TI FOR MESH,SUP-2256181,CDM,2780000010,LOCAL,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
JOINT FNGR MP 30 SIL PREFLEX STRL,SUP-2536095,CDM,C1776,CPT,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
PROCEDURE KIT ARRY INSRTN ELECTRD TUBE D-ZAP STAR,SUP-2665072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,925.04,601.28,,,,,,,,,,,,,
GRAFT HUM TISS W1XL12CM THK08 17MM THCK HYDRATED ACELLULAR,SUP-2307451,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2532.88,1646.37,,,,,,,,,,,,,
GUIDEWIRE .047IN DIA NON STERILE 1 1/5INL,SUP-2574078,CDM,C1769,HCPCS,0272,RC,,,,both,,,44.49,28.92,,,,,,,,,,,,,
SCREW BONE L60MM DIA5.5MM PARTIALLY THRD HD L CANN,SUP-2225349,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
GRAFT HUM TISS NRML THK230-320UM CLR PRE HYDRATION CORNEA W/,SUP-2261409,CDM,V2785,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
CONNECTOR SPNL THORLUM TI PARA SM STAT FOR 5MM ROD USS II,SUP-2193432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
STENT CAR ENROUTE L 20 MM DIA 6 MM WORKING L 57 CM CROSSING,SUP-2431164,CDM,C1876,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 4-6 MM SHRT TAPR SLDE GDS,SUP-2476142,CDM,C1768,CPT,0278,RC,,,,both,,,848.65,551.62,,,,,,,,,,,,,
HC Place Cath Xtrnl Carotid,PX-3613622700,CDM,36227,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SPACER SCREW SELF RET 2 MM MAND X DRV TI THREADLOCK TS,SUP-2493717,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.62,182.40,,,,,,,,,,,,,
ENDOPROSTHESIS TRACHBRONCH VIABAHN L 5 CM DIA 9 MM CATH L,SUP-2396460,CDM,C1874,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
PLATE SPNL 4 LEVEL 61 MM ANTR CERV C-TEK,SUP-2414503,CDM,C1713,HCPCS,0278,RC,,,,both,,,6245.46,4059.55,,,,,,,,,,,,,
HC So1 Immunoassay,PX-3018351667,CDM,83516,CPT,0301,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BONE L THK1.5MM 6X24X6 H MAND TI LCKING DBL ANG FOR,SUP-2191270,CDM,C1713,HCPCS,0278,RC,,,,both,,,9466.79,6153.41,,,,,,,,,,,,,
INTRODUCER SHTH 14FR L30CM 0.035IN HEMSTAS VLV SIDEPRT 2,SUP-2355618,CDM,C1894,HCPCS,0272,RC,,,,both,,,89.49,58.17,,,,,,,,,,,,,
CATHETER INFUS 5FR 65CM SHFT 7CM INFUS LEN,SUP-2168147,CDM,C1751,HCPCS,0278,RC,,,,both,,,277.54,180.40,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA26 MM BRANCH L 15 CM ANTE FLO,SUP-2385048,CDM,C1768,CPT,0278,RC,,,,both,,,3284.44,2134.89,,,,,,,,,,,,,
SCREW INTFR L23MM DIA7MM BIOCRYL RAPIDE ABSRB MILAGRO,SUP-2249499,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
KIT FIX ANG REPLICATOR EQUINOXE,SUP-2223288,CDM,C1713,HCPCS,0278,RC,,,,both,,,3494.19,2271.22,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X2 CM CRYOPRESERVED AMNIOX CLARIX 100,SUP-2648668,CDM,Q4156,HCPCS,0636,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC So1 Hla I Typing Complete Hr,PX-3108137967,CDM,81379,CPT,0310,RC,,,,both,,,380.00,247.00,,,,,,,,,,,,,
CAP RIB LCK X DRV NS ADVANTAGERIB,SUP-2908963,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE CRAN 180X80X40 MM PT SPEC IMPL PEEK,SUP-2860143,CDM,C1713,HCPCS,0278,RC,,,,both,,,35561.44,23114.94,,,,,,,,,,,,,
SCREW BNE L 11 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2931621,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.62,88.15,,,,,,,,,,,,,
KIT INTRO ENVI L 20 CM DIA 6 FR L 65 CM DIA 0.018 CHIBA,SUP-2752502,CDM,C1894,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
LINER KT WLK BOOT VENTURE AIR TALL M,SUP-2151042,CDM,L4386,HCPCS,0272,RC,,,,both,,,67.51,43.88,,,,,,,,,,,,,
STEM RAD L28MM DIA8MM ANT DST EL TI POR STR CEM MOD EXPLOR,SUP-2404379,CDM,C1776,CPT,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
PLATE CRAN 200X200X40 MM PT SPEC IMPL PEEK,SUP-2860165,CDM,C1713,HCPCS,0278,RC,,,,both,,,59594.37,38736.34,,,,,,,,,,,,,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,0636,RC,72205-0036-01,NDC,,both,1,UN,570.30,370.69,,,,,,,,,,,,,
RETRACTOR SURG MINI LIGHT SAPHO FIBEROPTIC,SUP-2227093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1269.22,824.99,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN IRRADIATED PAT TEND W/ QUAD,SUP-2867110,CDM,C1762,CPT,0278,RC,,,,both,,,9396.45,6107.69,,,,,,,,,,,,,
SET NEPHSTMY 4FR L20CM NDL L15CM 22GA 0.018IN HYDRPHLC,SUP-2168585,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.21,173.04,,,,,,,,,,,,,
PLATE BNE LCK 2.7 MM 6 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2468222,CDM,C1713,HCPCS,0278,RC,,,,both,,,807.26,524.72,,,,,,,,,,,,,
HC Iabp Insertion,PX-3613396700,CDM,33967,CPT,0361,RC,,,,outpatient,,,8633.00,5611.45,,,,,,,,,,,,,
NAIL IM L180MM OD11MM 130DEG S STL TROCHANTERIC LOK CANN,SUP-2371034,CDM,C1713,HCPCS,0278,RC,,,,both,,,2492.38,1620.05,,,,,,,,,,,,,
TROCAR SURG SPL DISP,SUP-2243814,CDM,C1894,HCPCS,0272,RC,,,,both,,,806.48,524.21,,,,,,,,,,,,,
STENT PERIPH LIFESTREAM L 58 MM DIA 9 MM CATH L 135 CM,SUP-2128350,CDM,C1874,HCPCS,0278,RC,,,,both,,,7567.40,4918.81,,,,,,,,,,,,,
BUR SURG FLUT 3X48 MM RND OTOTOM CARBIDE OSTEON,SUP-2166446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.18,228.92,,,,,,,,,,,,,
TRAY CATH PICC Q CATH BSC 2FR 30CM 1 LUMAN W/EXCLBR INTRO W/,SUP-2613409,CDM,C1751,HCPCS,0278,RC,,,,both,,,125.91,81.84,,,,,,,,,,,,,
SYSTEM SUT DEL SGL INCIS CRV HNDL TRIG DISPOSABLE FLEXISHAFT,SUP-2165322,CDM,C2631,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
PIN KNOWL S STL 7.3 MM BRKOFF DIAM 10.2 CM BRKOFF LEN 18.1,SUP-2409699,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.95,248.92,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST DBL UPR EXTN FLX ASST FABRICATED,SUP-2435758,CDM,L3730,HCPCS,0274,RC,,,,both,,,2335.16,1517.85,,,,,,,,,,,,,
ANCHOR SFT TISS PROX TENODESIS BTTN,SUP-2121682,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
BEARING TIB STANDARD+ THK12.5MM UNIV POLYETH MENIS PRI NEUT,SUP-2250083,CDM,C1776,CPT,0278,RC,,,,both,,,3888.58,2527.58,,,,,,,,,,,,,
RISPERIDONE 0.5 MG PO TBDP,RX-35686,CDM,6370000000,HCPCS,0637,RC,49884-0311-52,NDC,,both,1,UN,15.80,10.27,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 4 FR GUIDEWIRE L 40 CM NIT,SUP-2303251,CDM,C1769,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
INTRODUCER HEMSTAS 6FRX23CM SHTH W/ .038IN GWIRE 6FR DIL,SUP-2355416,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
WIRE EXT FIX BAYNT 370X1.8 MM TRUELOK,SUP-2316139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST DBL UPR PREFABRICATED OFF THE SHLF,SUP-2435619,CDM,L1852,HCPCS,0274,RC,,,,both,,,2371.58,1541.53,,,,,,,,,,,,,
HC Nras/Kras Gene Analys,PX-3000111066,CDM,0111U,CPT,0300,RC,,,,outpatient,,,797.00,518.05,,,,,,,,,,,,,
PLATE BNE L87MM THK2MM CALCNL TI Y SHP FOR SM FRAG SET,SUP-2190980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1850.84,1203.05,,,,,,,,,,,,,
PLATE CRAN 100X80X40 MM PT SPEC IMPL PEEK,SUP-2860139,CDM,C1713,HCPCS,0278,RC,,,,both,,,32398.52,21059.04,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 3.0 X 24MM H,SUP-2320884,CDM,C1713,HCPCS,0278,RC,,,,both,,,994.75,646.59,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 3.25X8 MM CORONARY APEX MRAIL,SUP-2139940,CDM,C1725,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 5FR L130CM BAL L120CM DIA7MM DRUG COAT,SUP-2128376,CDM,C2623,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SCREW BNE FT 8X75 MM CANN STRL,SUP-2501041,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.82,510.78,,,,,,,,,,,,,
BIT DRL L30MM DIA2.8MM FOR GLEN SHLDR SYS BIO MOD,SUP-2408384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.13,230.83,,,,,,,,,,,,,
LEAD PACE UPLR/BPLR 80 CM 2 ELECTRD PASS FIX IS-1 EASYTRAK 2,SUP-2148690,CDM,C1900,HCPCS,0275,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BOOT CAST W/ CUF XL BLK,SUP-2277491,CDM,L4386,HCPCS,0274,RC,,,,both,,,267.06,173.59,,,,,,,,,,,,,
HOOD O2 M-L INF NK DISP DISPOSA-HOOD,SUP-2391750,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.54,18.55,,,,,,,,,,,,,
ETHANOLAMINE OLEATE 5 % IV SOLN,RX-9984,CDM,J1430,HCPCS,0636,RC,67871-4790-06,NDC,,both,1.5,ML,1700.70,1105.45,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO STR PLT XDRV 1 PK,SUP-2935200,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
STEM FEM L190MM DIA20MM 135DEG STD OFFSET DST HIP BILAT,SUP-2420931,CDM,C1776,CPT,0278,RC,,,,both,,,9372.27,6091.98,,,,,,,,,,,,,
SCREW INTRF L30MM OD7MM CANN N ABSRB TI ADVNTG,SUP-2249494,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
CAGE SPNL L16XW16XH70MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317744,CDM,C1889,HCPCS,0278,RC,,,,both,,,18613.92,12099.05,,,,,,,,,,,,,
SYSTEM EMB 18 FR SZ 15 CM LEN PERIPH HYDRGEL HYDROLYSER,SUP-2385399,CDM,C1889,HCPCS,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
HC Elbow Min 3 Views,PX-3207308000,CDM,73080,CPT,0320,RC,,,,both,,,660.00,429.00,,,,,,,,,,,,,
KIT TSR GLEN CAPITATED P-M UPCHARGE PERFORM,SUP-2912708,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GRAFT BIO TISS W5.9XL7.9IN RECT XENMATRIX,SUP-2125846,CDM,C1781,HCPCS,0278,RC,,,,both,,,20934.38,13607.35,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.418,SUP-2859982,CDM,C1713,HCPCS,0278,RC,,,,both,,,33317.28,21656.23,,,,,,,,,,,,,
HANDPIECE LASER OTO MICRO-G,SUP-2713744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1106.85,719.45,,,,,,,,,,,,,
PIN HALF 3X80 MM,SUP-2197280,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
HC Inj Uretero/Pyelogr Indwell Ca,PX-3615068400,CDM,50684,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL KT BRK 1 SM CURL INTRO NXT STEER SHTH,SUP-2357289,CDM,C1766,CPT,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PLATE BNE L283MM 10 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186045,CDM,C1713,HCPCS,0278,RC,,,,both,,,4346.67,2825.34,,,,,,,,,,,,,
GRAFT SFT TISS W6X16CM NAT BARR OPTIMIZE SURG PERF AMNIOFIX,SUP-2305727,CDM,V2790,HCPCS,0278,RC,,,,both,,,12443.82,8088.48,,,,,,,,,,,,,
"HC So Spectrophotometry, Analyte Nes",PX-3018431166,CDM,84311,CPT,0301,RC,,,,outpatient,,,298.00,193.70,,,,,,,,,,,,,
BUR SURG L9CM HD L7.7MM DIA6MM ACORN FLUT L BOR MIDAS REX,SUP-2284654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.84,215.70,,,,,,,,,,,,,
CLAMP EXT FIX CONV STRL DISP SMRT TSF,SUP-2933217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.49,636.67,,,,,,,,,,,,,
SPLINT FNGR SZ 2 OPN TIP FOR FNGRTIP NAILBED INJ STAX,SUP-2195098,CDM,L3933,HCPCS,0274,RC,,,,both,,,7.03,4.57,,,,,,,,,,,,,
SYSTEM TKR SZ 6-7 HNG LINK ASMBLY LEGION,SUP-2346314,CDM,C1776,CPT,0278,RC,,,,both,,,3347.24,2175.71,,,,,,,,,,,,,
GUIDEWIRE ORTH SPNL NTHRD SHRP TIP L720MM OD142MM,SUP-2286839,CDM,C1769,HCPCS,0272,RC,,,,both,,,221.94,144.26,,,,,,,,,,,,,
COMPONENT KNEE CEM K8 STD,SUP-2351386,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SPHERE ORBIT DIA16MM PMMA FOR RET EYE SOCK CNTOUR,SUP-2236375,CDM,L8610,HCPCS,0278,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
KIT STPL BNE FIX BRDG W8XL20MM LEG L15MM CNTR DST SPEEDTRIAD,SUP-2194271,CDM,C1713,HCPCS,0278,RC,,,,both,,,3079.43,2001.63,,,,,,,,,,,,,
PIN EXT FIX L150MM DIA5MM THRD L50MM CORT S STL ST SELF DRL,SUP-2372360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PASSER SUT 45DEG CRV TIP FOR ARTHSCP BANKART SLAP AND ROT,SUP-2121808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
COMPONENT TIB KNEE LOK BAR COMPLT SYS VANGUARD,SUP-2405365,CDM,C1776,CPT,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
STEM HUM L130MM DIA12MM NK 130DEG ANG UNIV SHLDR CO CHROM,SUP-2388623,CDM,C1776,CPT,0278,RC,,,,both,,,12156.51,7901.73,,,,,,,,,,,,,
SYSTEM AIRWAY NASAL CLEAR FLOW RELTOK,SUP-2707513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
HC NM Radioimmunotherapy Procedure,PX-3427940300,CDM,79403,CPT,0342,RC,,,,both,,,6197.00,4028.05,,,,,,,,,,,,,
BIT DRL L 255 MM DIA2.1 MM STP 22 MM SEEG NS DISP,SUP-2935163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
GRAFT HUM TISS 30 MG MICRONIZED PARTIC MICROMATRIX,SUP-2106469,CDM,Q4118,HCPCS,0636,RC,,,,both,,,305.49,198.57,,,,,,,,,,,,,
SET CATHETER DRAINAGE FUHRMAN PNEUMOTHORAX CPPD850WCEIMH,SUP-2759699,CDM,C1729,HCPCS,0272,RC,,,,both,,,462.84,300.85,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA16 MM POLYESTER GEL,SUP-2385016,CDM,C1768,CPT,0278,RC,,,,both,,,1156.81,751.93,,,,,,,,,,,,,
MESH SURG VERTESSA LITE Y 26X5X4CM,SUP-2716340,CDM,C1781,HCPCS,0278,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
BRACE ORTH L8IN FOR 10IN WRST UNIV R NYL QUICK FIT,SUP-2197071,CDM,L3908,HCPCS,0272,RC,,,,both,,,30.30,19.69,,,,,,,,,,,,,
TRIAL FIX PIN L40MM DIA2.7MM FOR SM FRAG SYS,SUP-2343973,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.07,910.70,,,,,,,,,,,,,
BUR SURG 6MM D14X11MM CUT FOR CRNRSTN,SUP-2290950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.20,405.73,,,,,,,,,,,,,
HC N Block Paravert Thoracic 1st,PX-3606449000,CDM,64490,CPT,0360,RC,,,,both,,,4864.00,3161.60,,,,,,,,,,,,,
CATHETER THROMCTMY COR 3FR DISTAFLEX,SUP-2277427,CDM,C1757,HCPCS,0272,RC,,,,both,,,5746.20,3735.03,,,,,,,,,,,,,
SCREW BNE L64MM DIA4.5MM HD DIA8MM CORT S STL FULL THRD HEX,SUP-2184402,CDM,C1713,HCPCS,0278,RC,,,,both,,,119.89,77.93,,,,,,,,,,,,,
GUARD SET 2 WT 20X14 CM 35 GM HYDRPHLC LIGHT 3 PK TI TILENE,SUP-2402549,CDM,C1781,HCPCS,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
BLADE SAW W25MM THK1.24MM D79.5MM LNG SAG CUT EDGE,SUP-2367180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.37,54.84,,,,,,,,,,,,,
SCREW SPNL THN LNG 4.5X50 MM TSRH 3DX OSTEOGRIP,SUP-2631147,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SCREW BONE CANNULATED 55MM DIA 95MML,SUP-2721042,CDM,C1713,HCPCS,0278,RC,,,,both,,,601.56,391.01,,,,,,,,,,,,,
STAPLE BNE COMPR 16 X 10 X 10MM,SUP-2401352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2923.34,1900.17,,,,,,,,,,,,,
COUNTERSINK SURG HD DISP FOR 4MM MINI MONSTER HD SCR,SUP-2320964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1-24 CM FASC,SUP-2321778,CDM,C1762,CPT,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PLATE BONE W14.9XL120MM THK1.2MM 7 H DSTL TIB S STL,SUP-2185736,CDM,C1713,HCPCS,0278,RC,,,,both,,,1013.50,658.77,,,,,,,,,,,,,
CATHETER ANGIOPLSTY WORKHORSE II 75 CM 5 FR 8 MM 4 MM,SUP-2117083,CDM,C1725,HCPCS,0272,RC,,,,both,,,71.12,46.23,,,,,,,,,,,,,
HC Rh With Coron With Graft Nolv,PX-4819345700,CDM,93457,CPT,0481,RC,,,,outpatient,,,17800.00,11570.00,,,,,,,,,,,,,
HC Perc Drug-El Cor Stent Sing,PX-4810960000,CDM,C9600,CPT,0481,RC,,,,both,,,17936.00,11658.40,,,,,,,,,,,,,
SHEPARD GRMMT VENT TUBE WWRE 1.14MM ID BLUE FLRPLSTC 30 PAC,SUP-2681461,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.60,17.29,,,,,,,,,,,,,
MICROCATHETER INFUSION RENEGADE 18 150CM 20CM 0.027IN MIC 2,SUP-2361801,CDM,C1725,HCPCS,0272,RC,,,,both,,,2461.63,1600.06,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST LIMIT RANG OF MOTN,SUP-2435653,CDM,L2184,HCPCS,0274,RC,,,,both,,,327.94,213.16,,,,,,,,,,,,,
STEM HUM L115MM DIA7MM UNIV DST SHLDR TI PRI REV CEM FOR UP,SUP-2372850,CDM,C1776,CPT,0278,RC,,,,both,,,10163.55,6606.31,,,,,,,,,,,,,
PLATE BNE L 97 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 9 H SS LT,SUP-2933198,CDM,C1713,HCPCS,0278,RC,,,,both,,,2842.33,1847.51,,,,,,,,,,,,,
SCREW BONE LOCKING 2X6 MM MANDIBULAR SELFTAPPING 20/PK TITAN,SUP-2842325,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.25,272.51,,,,,,,,,,,,,
RESERVOIR VENTRICULAR DRAINAGE 60CM CATHETER LENGTH 20MM DIA,SUP-2830488,CDM,C1729,HCPCS,0272,RC,,,,both,,,944.01,613.61,,,,,,,,,,,,,
CYLINDER MED GAS 20ML SULPHUR HEXAFLUORIDE W/O REG ACCURUS,SUP-2109993,CDM,C1784,HCPCS,0278,RC,,,,both,,,3677.82,2390.58,,,,,,,,,,,,,
SCREW BNE L24MM DIA2.7MM LOK FOR R3CON PLATING SYS GORILLA,SUP-2321284,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 75 X W 11 MM MYRIAD HNDPC L 13 CM NN-2002,SUP-2930266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18168.07,11809.25,,,,,,,,,,,,,
HC So Antistreptolysin O Ab,PX-3028606067,CDM,86060,CPT,0302,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST STD RUBBER,SUP-2435733,CDM,L3460,HCPCS,0274,RC,,,,both,,,97.28,63.23,,,,,,,,,,,,,
AUGMENTED CAGE LEFT LARGE,SUP-2512450,CDM,C1776,CPT,0278,RC,,,,both,,,5913.25,3843.61,,,,,,,,,,,,,
KIT CATH L16CM DIA8FR CTRL VEN POLYUR DBL LUMN NONTUNNELED,SUP-2120583,CDM,C1751,HCPCS,0278,RC,,,,both,,,133.14,86.54,,,,,,,,,,,,,
PLATE BNE L 14 MM THK 0.6 MM 4 H SCREW DIA1. 5 MM MED TI,SUP-2883917,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
INTRODUCER SHTH POLYMER COAT WIRE 0.014 IN 4 FRX6.5 CM RED,SUP-2157405,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.27,65.83,,,,,,,,,,,,,
SEGMENT FEM SZ 34C PROX MTPHSEAL CALCAR HIP MALLORY-HEAD TI,SUP-2403418,CDM,C1776,CPT,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
CAGE SPNL H12-17MM OD14MM 0DEG SM TI ANT THORLUM INTBDY FUS,SUP-2390792,CDM,C1889,HCPCS,0278,RC,,,,both,,,12520.75,8138.49,,,,,,,,,,,,,
CATHETER ART LN IRRIGATION 6 FRX80 CM FOGARTY,SUP-2214042,CDM,C1757,HCPCS,0272,RC,,,,both,,,69.55,45.21,,,,,,,,,,,,,
COMPONENT HIP CMNTLS UPLR HA LD/FX,SUP-2212770,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
ANCHOR SUT DIA2.8MM MAG KNOTLESS FIX,SUP-2342076,CDM,C1713,HCPCS,0278,RC,,,,both,,,1096.27,712.58,,,,,,,,,,,,,
REV BICONVEX PAT 32MM,SUP-2827854,CDM,C1776,CPT,0278,RC,,,,both,,,2832.28,1840.98,,,,,,,,,,,,,
PLATE BNE THK0.6MM 10 H STD CRANIOMAXILLOFACIAL G TI CRV,SUP-2366293,CDM,C1713,HCPCS,0278,RC,,,,both,,,836.21,543.54,,,,,,,,,,,,,
BODY HUM TI POR PROX EL STD MOSAIC,SUP-2403496,CDM,C1776,CPT,0278,RC,,,,both,,,11253.76,7314.94,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM DIA 0.038 IN PTFE PERIPH,SUP-2301912,CDM,C1769,HCPCS,0272,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
CEFPODOXIME PROXETIL 200 MG PO TABS,RX-9469,CDM,6370000000,HCPCS,0637,RC,65862-0096-20,NDC,,both,1,UN,16.80,10.92,,,,,,,,,,,,,
GRAFT BNE INJ 5 CC INDUCTIVE PRO-STIM,SUP-2759592,CDM,C1713,HCPCS,0278,RC,,,,both,,,7900.24,5135.16,,,,,,,,,,,,,
DASATINIB 70 MG PO TABS,RX-76719,CDM,6370000000,HCPCS,0637,RC,00003-0524-11,NDC,,both,1,UN,1518.60,987.09,,,,,,,,,,,,,
CHISEL SURG 8MM BX REUSE PYRAMETRIX ADV,SUP-2292608,CDM,C1713,HCPCS,0278,RC,,,,both,,,2074.47,1348.41,,,,,,,,,,,,,
COIL EMB L8CM DIA4MM STD PUSH DSGN USE ACE TRK TECHNOLOGY,SUP-2323494,CDM,C1889,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
WEDGE BNE BIOFOAM CANC TI ALLGRFT 14MMX10MMX22MMX5MM,SUP-2397883,CDM,C1713,HCPCS,0278,RC,,,,both,,,6393.04,4155.48,,,,,,,,,,,,,
ALLOGRAFT BNE COTTON WDG 22X16X10 MM FD STRL LF DISP,SUP-2461017,CDM,C1889,HCPCS,0278,RC,,,,both,,,2388.76,1552.69,,,,,,,,,,,,,
PROBE ABLATN MICROWAVE 14 GAX200 MM AMICA,SUP-2303521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
DRILL TWST L 21 MM DIA1 MM STP 8 MM DENT SHFT NS DISP,SUP-2883162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.73,268.92,,,,,,,,,,,,,
PLATE BNE SM TI MANDIBULAR PMI ORTHOGNATHIC 3D PRNT NS DISP,SUP-2934875,CDM,C1713,HCPCS,0278,RC,,,,both,,,18202.58,11831.68,,,,,,,,,,,,,
BONE BPSY NDLE CMPTBLE WTH 11 G 10 CM KTS/NDLS 13 G,SUP-2479587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE MEDL CLMN LNG TI NC2M2 FOR DORS MIDFOOT RECON NS UNITE,SUP-2896767,CDM,C1713,HCPCS,0278,RC,,,,both,,,5334.86,3467.66,,,,,,,,,,,,,
DEFIBRILLATOR 2 CHMBR CARDIOVERTER 36 J W/ 1 LD BPLR REMOT,SUP-2356546,CDM,C1721,HCPCS,0275,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 0.035 INX260 CM SS JAGWIRE DISP,SUP-2141542,CDM,C1769,HCPCS,0272,RC,,,,both,,,628.79,408.71,,,,,,,,,,,,,
SPACER SPNL 0 DEG 22X10X9-15 MM SABLE,SUP-2763880,CDM,C1889,HCPCS,0278,RC,,,,both,,,17756.70,11541.85,,,,,,,,,,,,,
SPACER 7771128 ELEV STD 28X11MM,SUP-2289152,CDM,C1713,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
APPLIER CLP FOR RAPIDLOC MENIS REP,SUP-2249478,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
CATHETER ANGIO STR 0.035 IN 5 FRX65 CM HI FLO IMAGER II,SUP-2653482,CDM,C1758,HCPCS,0278,RC,,,,both,,,30.71,19.96,,,,,,,,,,,,,
PLATE CRAN 160X140X40 MM PT SPEC IMPL PEEK,SUP-2860157,CDM,C1713,HCPCS,0278,RC,,,,both,,,48239.51,31355.68,,,,,,,,,,,,,
INSERT TIB L THK9MM STD UNIV NEUT PRI PCA,SUP-2362129,CDM,C1776,CPT,0278,RC,,,,both,,,2217.50,1441.37,,,,,,,,,,,,,
HOOK SPNL CONN 3.5-4 MM TRNSVRS YUKON OCT,SUP-2732180,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
VALVE SHUNT ADJUSTABLE PRSS BUR H IMPL STRATA NSC,SUP-2278346,CDM,C1889,HCPCS,0278,RC,,,,both,,,12977.90,8435.63,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X14 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851922,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.09,327.01,,,,,,,,,,,,,
HC Strapping Hand/Finger,PX-4502928000,CDM,29280,CPT,0450,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
FILTER VASC 2.25 MMX190 CM FOR EZ SYS FILTERWIRE EZ,SUP-2140772,CDM,C1884,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
BIT DRL L80MM DIA2.5MM SLD SIDE CUT FOR EL STBL SYS IJS,SUP-2340182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
PLATE BNE L27MM THK1.2MM 0DEG 4 H BILAT S STL STR RIG LIMIT,SUP-2186167,CDM,C1713,HCPCS,0278,RC,,,,both,,,969.38,630.10,,,,,,,,,,,,,
GUIDEPIN ORTH L279MM OD4MM SMOOTH SHRP TIP W/ EYELOOP GRFT,SUP-2341288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.32,383.71,,,,,,,,,,,,,
LID STERILIZTION CASE FOR CASE MOD SPNL SM FRAG,SUP-2489341,CDM,C1892,HCPCS,0272,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
HANDPIECE LASER 900 MM MALL FIBERLASE ACUPULSE,SUP-2713713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.99,571.99,,,,,,,,,,,,,
HC Thrombolytic Venous Therapy,PX-3613721200,CDM,37212,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
ANCHOR SUT SM 1.9MM NO5 AND NO1 POLY SFT DBL LD W/ TWO NO2,SUP-2341895,CDM,C1713,HCPCS,0278,RC,,,,both,,,1094.60,711.49,,,,,,,,,,,,,
COIL VASC AZUR L 50 CM DIA20 MM MICROCATHETER 0.035 IN LOOP,SUP-2385433,CDM,C1889,HCPCS,0278,RC,,,,both,,,4286.01,2785.91,,,,,,,,,,,,,
SCREW SPNL L 30 MM DIA 6.5 MM BLACKARMOR CARBON PEEK TI-IT,SUP-2917066,CDM,C1713,HCPCS,0278,RC,,,,both,,,14287.00,9286.55,,,,,,,,,,,,,
SPLINT ORTHOPEDIC COLLES LG WRST MONTREAL,SUP-2330387,CDM,L3808,HCPCS,0274,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
CATHETER IR PICC 2 LUMN KT 145CM L GWIRE W/ PASV VLV 5FR,SUP-2118956,CDM,C1751,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
HC Urinalysis W/ Microscopy,PX-3078100100,CDM,81001,CPT,0307,RC,,,,both,,,179.00,116.35,,,,,,,,,,,,,
BLADE 50X14MM MIC VLT BLNT ALUM,SUP-2161649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,708.86,460.76,,,,,,,,,,,,,
IMPL BUTTON DX STAINLESS STEEL,SUP-2718030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
TISSUE T20673 FEM CORT STRUT1/3 200MM,SUP-2281652,CDM,C1713,HCPCS,0278,RC,,,,both,,,3376.29,2194.59,,,,,,,,,,,,,
TUBE EXT FIX HUM T2,SUP-2496956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.71,411.26,,,,,,,,,,,,,
FILTER VASC CELECT L 49 MM DIA 30 MM CATH L 79 CM SHTH L 65,SUP-2170217,CDM,C1880,HCPCS,0278,RC,,,,both,,,2919.04,1897.38,,,,,,,,,,,,,
IMPLANT PIP 3X30MM 10DEG BEND PEEK DART W/ INSRTR DRL AND,SUP-2121837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE BNE L L110MM VIT TROCHANTERIC GRP 2 2MM CBL DALL-MILE,SUP-2377574,CDM,C1713,HCPCS,0278,RC,,,,both,,,2721.75,1769.14,,,,,,,,,,,,,
PIN FIX L9IN DIA3.2MM FOR COMPHSVE REV SHLDR SYS STNMN,SUP-2408538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
PLATE BONE FAN 44.6X0.8 MM SMOOTH REINFORCED POROUS POLYETHY,SUP-2837807,CDM,C1713,HCPCS,0278,RC,,,,both,,,4899.34,3184.57,,,,,,,,,,,,,
BIT DRL L110MM DIA27MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.75,276.09,,,,,,,,,,,,,
SCREW BNE L6MM DIA2MM CRANIOMAXILLOFACIAL SIL TI LOK CRSS 5PK,SUP-2366127,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.03,195.67,,,,,,,,,,,,,
HANDPIECE SURG OPN 5 MMX7 CM PRECIS CUT COAG PLASMAJET DISP,SUP-2328051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PHENYLEPHRINE HCL 1 % NA SOLN,RX-6245,CDM,6370000000,HCPCS,0637,RC,00225-0810-47,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L 90 X W 11 MM THK 2 MM SCREW DIA 3.5 MM 5 H SS RT,SUP-2933313,CDM,C1713,HCPCS,0278,RC,,,,both,,,7452.01,4843.81,,,,,,,,,,,,,
VALVE AORT 21 MM 19X14 MM LEAFLET FLEXFIT STENTED LP EPIC,SUP-2355830,CDM,C1713,HCPCS,0278,RC,,,,both,,,13486.30,8766.09,,,,,,,,,,,,,
SET PANCREATIC STENT GEENEN L 12 CM DIA 8.5 FR PUSH L 170 CM,SUP-2737433,CDM,C2625,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SCREW BNE L50MM DIA5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412128,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
BIT DRL CINCHLOCK SS REUSE,SUP-2663979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.26,579.32,,,,,,,,,,,,,
ALLOGRAFT BNE BOAT 100X25 MM 10 CC FD DBM CORTICAL FIBER,SUP-2717787,CDM,C1713,HCPCS,0278,RC,,,,both,,,8365.37,5437.49,,,,,,,,,,,,,
PLATE QUIKFLAP 3X2 RIGID SD AXS,SUP-2718049,CDM,C1713,HCPCS,0278,RC,,,,both,,,6226.62,4047.30,,,,,,,,,,,,,
PASSER SUT WIRE STR DISP,SUP-2120920,CDM,C1769,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PROBE ENDOSCP ARTHSCP 90 DEG 3.5 MM,SUP-2314075,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
BLADE RETRCT W2XL4CM NAR MUSC REUSE MCCULLOCH,SUP-2161007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.21,258.84,,,,,,,,,,,,,
SPACER SPNL W32XH13.5MM D26MM 8DEG ANT LUM INTBDY FUS G,SUP-2182848,CDM,C1821,HCPCS,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
NAIL IM L 380 MM DIA 9 MM TYP II,SUP-2902177,CDM,C1713,HCPCS,0278,RC,,,,both,,,10092.75,6560.29,,,,,,,,,,,,,
INTRODUCER SHTH MANDREL 7 FRX7 CM BOWTIE GUIDE WIRE PRELUDE,SUP-2798460,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.54,56.25,,,,,,,,,,,,,
BLADE LARYNSCP SZ 2 G PROF MILLER,SUP-2381618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
KIT MICROINTRODUCER 4FR ECHOGENIC NDL L7CM 21GA STIFF COAX,SUP-2118822,CDM,C1894,HCPCS,0272,RC,,,,both,,,71.91,46.74,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRSS FT,SUP-2212535,CDM,C1776,CPT,0278,RC,,,,both,,,14877.32,9670.26,,,,,,,,,,,,,
BRACE ORTH LACE CLOSURE SM 5.5X6.25 IN WRST RT SPECTR,SUP-2319268,CDM,L3931,HCPCS,0274,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
MARKER BRST BX OD8GA COIL S STL BRL VACORA ATEC ENCORMR,SUP-2195589,CDM,A4648,CPT,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
BASKET EXTR STONE FUS 8 FRX200 CM SHTH 2 CMX4CM BSKT,SUP-2170083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
SIZER BRST OD14.2CM 425ML P4.1CM NACL SMOOTH RND MOD PROF,SUP-2300496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ROD SPNL L55MM DIA5.5MM POST THORLUM TI CRV SMOOTH NTHRD,SUP-2229463,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE L87MM 4X9 H CALCNL S STL Y LOK COMPR FOR 3.5MM,SUP-2185995,CDM,C1713,HCPCS,0278,RC,,,,both,,,2908.14,1890.29,,,,,,,,,,,,,
PROSTHESIS OSS MIC 3X3.5 MM 0.9 MM MONOLITHIC CENTERED TI,SUP-2638165,CDM,L8613,CPT,0278,RC,,,,both,,,1037.64,674.47,,,,,,,,,,,,,
KIT COOL PD SM HYDRGEL FOR TEMP MGMT SYS ARCTIC SUN,SUP-2127457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4155.79,2701.26,,,,,,,,,,,,,
CLAMP EXT FIX 45 MM UNILAT MULTIPIN NS DISP MAV,SUP-2931268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3306.42,2149.17,,,,,,,,,,,,,
HEALICOIL KNOTLESS PK ST,SUP-2823709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.90,998.33,,,,,,,,,,,,,
TPS RECIP PRECIS THN SAW BLDE 40.5X.38MM,SUP-2367391,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.87,259.27,,,,,,,,,,,,,
ARMSTRONG R VENT TUBE WTAB,SUP-2695102,CDM,L8699,HCPCS,0278,RC,,,,both,,,1226.48,797.21,,,,,,,,,,,,,
CATHETER PICC SGL LUMN MST KT INTVENT RAD N PWR INJ N COAT N,SUP-2117115,CDM,C1751,HCPCS,0278,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
BLOCK CUT FEM GUID FOR JOURNEY II KNEE SYS VISIONAIRE,SUP-2351451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SCREW EXT FIX L200MM DIA5MM S STL HA BLNT TRCR PNT MR,SUP-2418493,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.72,357.97,,,,,,,,,,,,,
CENTRALIZER STEM DIA20MM DSTL FEM HIP PMMA INVIS,SUP-2344517,CDM,C1776,CPT,0278,RC,,,,both,,,451.06,293.19,,,,,,,,,,,,,
MESH HERN 10X10 CMX1.5 MM HYDRATED PORCINE CLLGN PERMACOL,SUP-2174699,CDM,C1781,HCPCS,0278,RC,,,,both,,,6878.42,4470.97,,,,,,,,,,,,,
PROSTHESIS LARYN L6MM LO AIRFLO RESISTANCE EZ MAINT FOR,SUP-2124337,CDM,L8509,HCPCS,0274,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
SYSTEM MOD KNEE W/ PROLONG POLY,SUP-2212168,CDM,C1776,CPT,0278,RC,,,,both,,,11972.82,7782.33,,,,,,,,,,,,,
TUBE MYR 1.14MM DIAM VENT SIL DONALDSON,SUP-2313874,CDM,L8699,HCPCS,0278,RC,,,,both,,,30.43,19.78,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE MYNX ACE DIA 5/6/7 FR FEM ART GRP,SUP-2155682,CDM,C1760,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
MESH HERN W15XL20CM OVL PREPERI BIOMATERIAL COMP POLYPR,SUP-2395764,CDM,C1781,HCPCS,0278,RC,,,,both,,,4622.08,3004.35,,,,,,,,,,,,,
BLOCK RECON SM 5X10X30 MM POROUS HA,SUP-2637871,CDM,L8613,CPT,0278,RC,,,,both,,,2181.55,1418.01,,,,,,,,,,,,,
SET VASC ACCS BNCHMRK BMX96 L 100 CM OD 8 FR ID 0.096 IN,SUP-2653460,CDM,C1887,HCPCS,0272,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
PLATE BNE L63MM 3 H 135DEG S STL HIP COMPR LO PROF STD BRL,SUP-2374147,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT BONE SUB 5ML CA PHOS RESRB FIL,SUP-2256575,CDM,C1763,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
PLATE VA DISTAL MEDIAL TIBIA 6H,SUP-2858201,CDM,C1713,HCPCS,0278,RC,,,,both,,,6080.39,3952.25,,,,,,,,,,,,,
OYSTER SHELL CALCIUM 500 MG PO TABS,RX-5955,CDM,6370000000,HCPCS,0637,RC,00904-1883-61,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
SPACER SPNL VERT 8 DEG 26X24X10 MM TANTALUM MARKER TI ZUMA,SUP-2245545,CDM,C1713,HCPCS,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
PLATE BNE THK0.8MM 10 H LOK COMPR BILAT NEUT MAL STR FOR,SUP-2107084,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
ALLOGRAFT TISS ASEPTICALLY PROC 4X200 MM SEMITENDINOSUS,SUP-2264582,CDM,C1713,HCPCS,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
TUBING SUCT INFLO OUTFLO FORKED SET ST DISP INTELJET,SUP-2341416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.67,494.44,,,,,,,,,,,,,
VEST PT CERV HALO,SUP-2322423,CDM,L0112,HCPCS,0272,RC,,,,both,,,19625.00,12756.25,,,,,,,,,,,,,
CATHETER LD DEL CPS DIR SL II L 50.7 CM AVAILABLE L 47 CM OD,SUP-2356368,CDM,C1893,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
COMPONENT TIB 1PC PROX 65MM LGTH 13MM DIA FINN - 65MM LEN,SUP-2406143,CDM,C1776,CPT,0278,RC,,,,both,,,20767.96,13499.17,,,,,,,,,,,,,
GUIDEWIRE EMBOLIC PROTCT ANGIOGUARD L 300 MM DIA 0.014 IN,SUP-2157306,CDM,C1769,HCPCS,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CEMENT BNE TOBRA SIMPLEX P,SUP-2365916,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
HEAD FEM OD28MM -3.5MM OFFSET CO CHROM HIP MOD METAFIX,SUP-2378835,CDM,C1776,CPT,0278,RC,,,,both,,,2235.68,1453.19,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 40 CM DIA 5.5 FR BALLOON DIA,SUP-2214017,CDM,C1757,HCPCS,0272,RC,,,,both,,,393.54,255.80,,,,,,,,,,,,,
BRACE WRST L AD FOR 10 LESS THAN 11IN L1375IN R HND BLK,SUP-2196553,CDM,L3807,HCPCS,0272,RC,,,,both,,,276.01,179.41,,,,,,,,,,,,,
BIT DRL QC 4 MMX7.68 IN 3 FLUT FOR 4.9 MM LCK BOLT NS,SUP-2905554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.34,301.82,,,,,,,,,,,,,
SPACER 46X3MM M LT,SUP-2209017,CDM,C1776,CPT,0278,RC,,,,both,,,12629.08,8208.90,,,,,,,,,,,,,
VALVE SHUNT CONTROL RESERVOIR,SUP-2711648,CDM,C1889,HCPCS,0278,RC,,,,both,,,1198.76,779.19,,,,,,,,,,,,,
PROSTHESIS PENILE 65ML INHIBZN ERECTILE RESTR INFL RESVR MS,SUP-2138961,CDM,C1813,HCPCS,0278,RC,,,,both,,,9960.08,6474.05,,,,,,,,,,,,,
PLATE BNE LINDORF LEFORT 1 13X1.4 MM RT ORTHOGNATHIC MOD TI,SUP-2457042,CDM,C1713,HCPCS,0278,RC,,,,both,,,971.08,631.20,,,,,,,,,,,,,
VASOPRESSIN 20 UNIT/ML SOLN (MIXTURES ONLY),RX-430007,CDM,J2598,HCPCS,0636,RC,42023-0164-25,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
STEM FEM PRSS FIT TI ALLOY HA SIZE9 OSTEONICS SECUR FIT,SUP-2364222,CDM,C1776,CPT,0278,RC,,,,both,,,8950.22,5817.64,,,,,,,,,,,,,
GRAFT BNE CUBE 8X8X8 MM DBM ALLOSYNC,SUP-2845372,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.39,946.00,,,,,,,,,,,,,
SCREW BONE L26MM DIA2.5MM CORT WR TI HEXADRIVE 7 TRILOK,SUP-2268232,CDM,C1713,HCPCS,0278,RC,,,,both,,,437.75,284.54,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN SHT 7 FR W/ GUIDEWIRE NDL PRELUDE,SUP-2303313,CDM,C1894,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
KIT DRL XL FOR 3MM KNOTLESS HIP SUTURETAK W STP DRL SPEAR,SUP-2121608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PIN FIX L40MM DIA2.7MM PROV FOR TARGETER PLATING SYS,SUP-2343985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1541.17,1001.76,,,,,,,,,,,,,
AIRWAY ESOPH 1.5 INF LMA PROSEAL LF REUSE,SUP-2383623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,856.59,556.78,,,,,,,,,,,,,
PROSTHESIS EAR L4MM PIST DIA0.6MM TI CLASS STAP,SUP-2312798,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.26,455.82,,,,,,,,,,,,,
ORTHOPAEDIC SET 60 MM CAP ROD COMB LCK NEWPORT MIS,SUP-2245601,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
IMPLANT HEARING AID 4 MM PONTO BIOHELIX,SUP-2430349,CDM,L8690,HCPCS,0278,RC,,,,both,,,5162.16,3355.40,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST SUPCNDYL SOCKET MOLD,SUP-2435620,CDM,L1860,HCPCS,0272,RC,,,,both,,,3530.36,2294.73,,,,,,,,,,,,,
CATHETER HEMODIALYSI SLXACUTE 14FR DIA LG 20CM STRGHT TAPR T,SUP-2610568,CDM,C1752,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE L11MM THK1MM 4 H NONSTERILE TI BX RECTANG VAR ANG,SUP-2181014,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.43,802.38,,,,,,,,,,,,,
SCREW BNE L10MM DIA35MM CORT TAN ST T15 STARDRV RECESS SM,SUP-2181064,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.45,49.04,,,,,,,,,,,,,
BIT DRL L180MM DIA4.5MM ST TI JCBS CHK NONRADIOPAQUE W/O,SUP-2187292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.86,270.31,,,,,,,,,,,,,
SUPPORT WR SM AD FOR 7-8IN RT CRPL TUNN REG FIRM SUPP,SUP-2324888,CDM,L3931,HCPCS,0274,RC,,,,both,,,47.32,30.76,,,,,,,,,,,,,
HEAD ULN MOD 19 MM ELBW,SUP-2610431,CDM,C1776,CPT,0278,RC,,,,both,,,5046.29,3280.09,,,,,,,,,,,,,
HC Natriuretic Peptide,PX-3018388000,CDM,83880,CPT,0301,RC,,,,both,,,179.00,116.35,,,,,,,,,,,,,
BIT DRL L80MM OD2.2MM NONSTERILE REUSE,SUP-2242907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,708.01,460.21,,,,,,,,,,,,,
STAPLE CARTRIDGE 10X10 MM FOR ANGLED BNE ASMBLY,SUP-2421817,CDM,C1713,HCPCS,0278,RC,,,,both,,,4824.61,3136.00,,,,,,,,,,,,,
IMPLANT OTO W4MM W/ 12MM ABUTMENT BKUP PONTO SYS,SUP-2319889,CDM,L8690,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 6 MM RNG L 50 CM EPTFE STR TW,SUP-2396119,CDM,C1768,CPT,0278,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
LENS IOL CONVEXOPLANO 10.5+ DIOPT 5.5X13.5 MM,SUP-2431933,CDM,V2630,CPT,0276,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PIN 5MMX180MM HALF ORTH RECON,SUP-2342846,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.15,871.10,,,,,,,,,,,,,
BIT DRL L145MM DIA3.2MM ST TI 3 FLUT NDL PNT USED W/ RADLUC,SUP-2178870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.39,583.95,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2 MM 4 HOLE STAINLESS STEEL STERILE TC10,SUP-2836684,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.78,293.01,,,,,,,,,,,,,
SUPPORT ORTHOT SACROILIAC PELV CUST FLX STRP PREFABRICATED,SUP-2435551,CDM,L0621,HCPCS,0272,RC,,,,both,,,244.10,158.66,,,,,,,,,,,,,
CATHETER EP STEER 5 MM 5 FRX110 CM 20 MM,SUP-2357450,CDM,C1730,HCPCS,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GRAFT BNE SUB W12 20XL45MM ILIUM BICORT STRP FRZ DRY,SUP-2307127,CDM,C1713,HCPCS,0278,RC,,,,both,,,1782.17,1158.41,,,,,,,,,,,,,
FIBER LASER 270UM DISPOSABLE  HOLM,SUP-2436279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,843.62,548.35,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.416,SUP-2859980,CDM,C1713,HCPCS,0278,RC,,,,both,,,35952.69,23369.25,,,,,,,,,,,,,
PROBE CYBERWAND RENALBLDR EA,SUP-2313963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
LEAD DBS L 42 CM DIA 0.5 MM DIR STRL DISP SENSIGHT,SUP-2882974,CDM,C1778,HCPCS,0278,RC,,,,both,,,11708.28,7610.38,,,,,,,,,,,,,
SPACER ORTHOPEDIC +12MM 39 MM SHLDR RVS,SUP-2123333,CDM,C1776,CPT,0278,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
PLATE BONE W10XL58MM THK2.8MM 5 H S STL STR NONCOMPRESSION,SUP-2343762,CDM,C1713,HCPCS,0278,RC,,,,both,,,2735.13,1777.83,,,,,,,,,,,,,
STEM FEM CMNTLS 5X145 MM HIP CLS,SUP-2205698,CDM,C1776,CPT,0278,RC,,,,both,,,14197.82,9228.58,,,,,,,,,,,,,
PROGESTERONE 100 MG PO CAPS,RX-127951,CDM,6370000000,HCPCS,0637,RC,69452-0233-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PROBE ENDOSCP ARTHSCP CRV LIGMNT CHSL,SUP-2314079,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SPACER SPNL 12 DEG 45X20X10-5.8 MM TITAN TI STRL ANTERALIGN,SUP-2859335,CDM,C1889,HCPCS,0278,RC,,,,both,,,21025.44,13666.54,,,,,,,,,,,,,
BURR CARBIDE BALL FLUTED 5.0MM S5BC10FG1,SUP-2843316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.69,463.25,,,,,,,,,,,,,
COIL NEUROVASCULAR TARGET XL 360 DEG L 15 CM DIA 5 MM,SUP-2368047,CDM,C1889,HCPCS,0278,RC,,,,both,,,8286.46,5386.20,,,,,,,,,,,,,
KIT REP FOR HALLUX VALGUS MINI TIGHTROPE,SUP-2122784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PLATE BNE Y MED 1.5X29X0.8 MM MIDFACE 7 HOLE W/ TAB STRL,SUP-2518106,CDM,C1713,HCPCS,0278,RC,,,,both,,,825.19,536.37,,,,,,,,,,,,,
SUPPORT ORTHOT CUST BILATERAL W/VERTICAL EXTN,SUP-2435579,CDM,L1085,HCPCS,0272,RC,,,,both,,,495.90,322.33,,,,,,,,,,,,,
SCREW BNE 2X10 MM 8 MM DRILL-FREE STRL L1 MAXDRIVE 251980877,SUP-2460545,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.57,311.07,,,,,,,,,,,,,
KIT ACP MAX COUNTER BALANCE,SUP-2867292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SHEATH INTRO 12FR L28CM 0.035IN GWIRE HYDRPHLC LOK,SUP-2298360,CDM,C1894,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BONE SM L31MM THK1MM CENTRE SPACE 3.4MM 4 H MAND TI,SUP-2191213,CDM,C1713,HCPCS,0278,RC,,,,both,,,2226.57,1447.27,,,,,,,,,,,,,
KIT DRNGE L35CM DIA14FR NDL DIA22GA 0.038IN FIRM K,SUP-2147876,CDM,C1729,HCPCS,0272,RC,,,,both,,,471.47,306.46,,,,,,,,,,,,,
CONNECTOR SPNL TI END TO END ROD TO ROD FOR 5.5MM ROD MNRCH,SUP-2254577,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SPACER SPNL W26XH12MM SM PEEK THORLUM INTBDY FUS FLAT ADD,SUP-2291493,CDM,C1889,HCPCS,0278,RC,,,,both,,,8977.26,5835.22,,,,,,,,,,,,,
BURR ROUTER FLUTED 1.12MM X 6.35MM SHD6RG1,SUP-2843321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.71,288.41,,,,,,,,,,,,,
PACEMAKER CARD CONTAK RENEWAL TR W 4.50 X H 5.40 CM D 0.85,SUP-2140443,CDM,C1786,HCPCS,0275,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
AUGMENT TIB SZ 5/6 THK10MM L MED R LAT KNEE CO CHROM,SUP-2420912,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SET INFUSION CATH L 40 CM DIA 5 FR SEG L 15 CM GUIDEWIRE,SUP-2168326,CDM,C1751,HCPCS,0278,RC,,,,both,,,277.54,180.40,,,,,,,,,,,,,
STEM HUM DSTL 50 MM LT SHLDR W/ BODY COMPHSVE SRS,SUP-2441468,CDM,C1776,CPT,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
PERFORATOR SURG 11MM DIA 14MM CRANIAL SHARP COLOR-CODED DISP,SUP-2243194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
GUIDEWIRE VASC WORKER L 260CM 0.035IN 6.5CM 3.5CM AMPLTZ STR,SUP-2876077,CDM,C1769,HCPCS,0272,RC,,,,both,,,255.91,166.34,,,,,,,,,,,,,
PLATE BNE PATELLAR 2.4/2.7 MM LAT VA LCK RIM SS STRL,SUP-2750830,CDM,C1713,HCPCS,0278,RC,,,,both,,,6805.51,4423.58,,,,,,,,,,,,,
BIT DRL 2.5X14 MM CERV SPINE EZ PLATE DISP,SUP-2430802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
BIT DRILL JUGGERKNOT RIGID LNG,SUP-2589271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.51,205.73,,,,,,,,,,,,,
MESH CRAN W100XL100MM THK0.8MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194074,CDM,C1781,HCPCS,0278,RC,,,,both,,,11036.16,7173.50,,,,,,,,,,,,,
STABILIZER SURG FOR NEUROFORM 3 CATH,SUP-2368105,CDM,C1874,HCPCS,0278,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 1S 6X10 CM,SUP-2383092,CDM,C1781,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
PLATE BONE L257MM 17 H TI RT PROX LAT TIB FOR 3.5MM SCR,SUP-2418799,CDM,C1713,HCPCS,0278,RC,,,,both,,,4836.86,3143.96,,,,,,,,,,,,,
NEEDLE BX 21 GAX4 CM ALWAYS-ON TIP TRACKED,SUP-2797907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2670.57,1735.87,,,,,,,,,,,,,
WASHER BONE SCR FPS 2MM,SUP-2319590,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL INTFACE,SUP-2435560,CDM,L0651,HCPCS,0272,RC,,,,both,,,3667.77,2384.05,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FEN 16X6 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871305,CDM,C1762,CPT,0278,RC,,,,both,,,22199.80,14429.87,,,,,,,,,,,,,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-40840058,CDM,2580000003,HCPCS,0250,RC,00264-7751-00,NDC,,both,250,ML,6.40,4.16,,,,,,,,,,,,,
PLATE BNE W175XL386MM THK52MM 18 H NONSTERILE R CNDYL FEM S,SUP-2185050,CDM,C1713,HCPCS,0278,RC,,,,both,,,5807.81,3775.08,,,,,,,,,,,,,
GLOBAL UNITE REV STEM SZ 6 TR,SUP-2513427,CDM,C1776,CPT,0278,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR SPNL PERC 8 CHAN INT PULSE GENRTR,SUP-2356745,CDM,C1767,HCPCS,0278,RC,,,,both,,,33896.30,22032.59,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 0.25 CC INJ AMNIO FLUID STRATOGEN FLO,SUP-2777564,CDM,C1762,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE THK0.6MM 24 H STD CRANIOMAXILLOFACIAL G TI STR,SUP-2366267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1449.64,942.27,,,,,,,,,,,,,
HOLDER PLATE RING WIRE SS STRL,SUP-2875235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
HC CT Chest Screening Low Dose Wout Cont,PX-3527127100,CDM,71271,CPT,0352,RC,,,,outpatient,,,529.00,343.85,,,,,,,,,,,,,
SCREW BNE LCK 2.4X9 MM VARIAX,SUP-2435318,CDM,C1713,HCPCS,0278,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
SHELL ACET SZ 46MM GRP 0 UNIV YEL TI CLUS H W/ PLSM SPRY,SUP-2222457,CDM,C1776,CPT,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
PARACENTESIS SET PIG 6 FRX12 CM SLIP LUER VLV ONESTEP,SUP-2474107,CDM,C1729,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 8 FRX15 CM DL J TIP SPECTRUM,SUP-2759815,CDM,C1751,HCPCS,0278,RC,,,,both,,,431.31,280.35,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 90 X 73 X 19 MM MED POLYETHYL RT,SUP-2934483,CDM,C1713,HCPCS,0278,RC,,,,both,,,6408.74,4165.68,,,,,,,,,,,,,
HC So Aso Titer,PX-3028606066,CDM,86060,CPT,0302,RC,,,,outpatient,,,129.00,83.85,,,,,,,,,,,,,
KIT ORTH INSTR FT PREP STRL,SUP-2897919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
SLING GYN POLYPR TRNSVAG MIDURETHRAL MESH DEL DEV FOR,SUP-2139447,CDM,C1771,HCPCS,0278,RC,,,,both,,,5513.53,3583.79,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA IR 3FR 55CM 1 LUMA S3193335,SUP-2632838,CDM,C1751,HCPCS,0278,RC,,,,both,,,445.53,289.59,,,,,,,,,,,,,
MARKER GRFT SIL DISK LTWT BIOCOMPATIBLE RADPQ DISP,SUP-2336956,CDM,A4648,CPT,0278,RC,,,,both,,,59.03,38.37,,,,,,,,,,,,,
VALVE SPEAK TRACH,SUP-2138739,CDM,L8501,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BNE L154MM 10 H ST L PROX BILAT TIB S STL NEUT LOK,SUP-2177837,CDM,C1713,HCPCS,0278,RC,,,,both,,,4314.11,2804.17,,,,,,,,,,,,,
BIT DRL L62MM DIA2MM WRK L13MM REPOS PIN DISP FOR,SUP-2366435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.77,326.15,,,,,,,,,,,,,
CANNULA ARTHSCP VENT HIP BHR ID2.3MM,SUP-2351309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
GRAFT BNE 1 CC DEMINERALIZED BNE FIBER PROGRAFT,SUP-2858503,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.13,399.83,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA26 MM SIDE BRANCH L 15 CM,SUP-2894702,CDM,C1768,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
RING OPEN 180MM,SUP-2480146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4569.33,2970.06,,,,,,,,,,,,,
IMMOBILIZER SHLDR L10.5-17IN D7IN SLNG W/ 15DEG ABD PLLW,SUP-2196388,CDM,L3650,HCPCS,0272,RC,,,,both,,,106.92,69.50,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L4MM ESOPH TRACH INDWL W/ L FLNG,SUP-2242385,CDM,L8509,HCPCS,0274,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
MESH SURG CRANIOPLASTY XL PROS CUST,SUP-2419450,CDM,C1713,HCPCS,0278,RC,,,,both,,,53339.18,34670.47,,,,,,,,,,,,,
STEM FEM L150MM DIA15MM PROX KNEE TI PPS PUREFIX BOW,SUP-2376546,CDM,C1776,CPT,0278,RC,,,,both,,,11547.04,7505.58,,,,,,,,,,,,,
PORT IMPL INFUSION LP 6 FR ATTCH POLY CATH SUTURE SMRT PRT,SUP-2494792,CDM,C1788,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
FORCEPS SURG L5 3 8IN CUP W1MM SATIN FINISH STR RHOT,SUP-2160870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1013.40,658.71,,,,,,,,,,,,,
ROD SPNL L270MM OD55MM TI ALLY POST R SMOOTH STR CDH,SUP-2279612,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.76,1532.54,,,,,,,,,,,,,
CATHETER EP DBL LOOP 1 MM 7 FRX110 CM INQUIRY,SUP-2867387,CDM,C1731,HCPCS,0278,RC,,,,both,,,5548.38,3606.45,,,,,,,,,,,,,
LIDOCAINE HCL 0.5 % IJ SOLN (MIXTURES ONLY),RX-430041,CDM,J2003,HCPCS,0636,RC,63323-0491-57,NDC,,both,50,ML,83.40,54.21,,,,,,,,,,,,,
PLATE BONE 3.7MM 9 H PROX HUM USE W/ 2.7MM 3.5MM SCR,SUP-2225495,CDM,C1713,HCPCS,0278,RC,,,,both,,,4619.57,3002.72,,,,,,,,,,,,,
MESH DERM IMPL SFT TISS MTRX PORCINE 8X12CM INTEXEN LP,SUP-2140306,CDM,C1763,HCPCS,0278,RC,,,,both,,,3564.69,2317.05,,,,,,,,,,,,,
STEM EXTN TIB 10MM DIA 89MM LEN FINN - 10MM DIAM 89MM LEN,SUP-2406049,CDM,C1776,CPT,0278,RC,,,,both,,,3984.66,2590.03,,,,,,,,,,,,,
SYSTEM INTRO L60CM 6FR S STL STD DBL END GWIRE L60CM,SUP-2303016,CDM,C1769,HCPCS,0272,RC,,,,both,,,192.73,125.27,,,,,,,,,,,,,
COMPONENT TIB SZ 5 THK7MM LT MEDL RT LAT ANTR POST KNEE ALL,SUP-2251269,CDM,C1776,CPT,0278,RC,,,,both,,,4596.96,2988.02,,,,,,,,,,,,,
BRACE WR L LT COT FOAM LAM INSTABILITY INJ REG EXTN D RNG W/,SUP-2326132,CDM,L3908,HCPCS,0274,RC,,,,both,,,47.57,30.92,,,,,,,,,,,,,
ENVELOP TISS XX LG SFT SUPPLE CORMATRIX CANGAROO EMC,SUP-2653873,CDM,C1889,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
CATHETER HD SET 15 FRX23 CM RETROGRADE REPL HUB VECTORFLOW,SUP-2763044,CDM,C1750,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
"HC So Dihydroxyvitamin D, 1 25|NOT REASONABLE AND NECESSARY",PX-3018265266,CDM,82652,CPT,0301,RC,,,GZ,both,,,229.00,148.85,,,,,,,,,,,,,
BIT DRL L330MM DIA4.2MM CALIB L100MM ST 3 FLUT QUIK CPL FOR,SUP-2178856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,840.83,546.54,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA PLU MAXBARR 3FR 20CM 1 LUMAN RVRSE T S4153108BDP,SUP-2613546,CDM,C1751,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
DRILL SURG 4 MM CORTICAL,SUP-2644808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2274.46,1478.40,,,,,,,,,,,,,
CATHETER CV BEDSIDE SET 018 5 FRX60 CM 1 LUMEN TURBO-JECT,SUP-2759939,CDM,C1751,HCPCS,0278,RC,,,,both,,,328.38,213.45,,,,,,,,,,,,,
TROCAR NEUROENDOSCOPY 3.2MMX150MM MINOP WITH 1 WORKING CHANN,SUP-2826330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6227.12,4047.63,,,,,,,,,,,,,
CATHETER INTVENT L90CM OD6FR BAL L40MM OD7MM,SUP-2353074,CDM,C1725,HCPCS,0272,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
PLATE BONE L54MM THK2.3MM 3 H RT DSTL RAD VOLAR BLK,SUP-2152597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2778.74,1806.18,,,,,,,,,,,,,
PLATE BNE 5DEG LNG R MT GORILLA,SUP-2321470,CDM,C1713,HCPCS,0278,RC,,,,both,,,4963.08,3226.00,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN FULL KT DBL LUMN SIL CVD,SUP-2174232,CDM,C1881,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 12.5CML INSER,SUP-2613243,CDM,C1752,HCPCS,0278,RC,,,,both,,,885.35,575.48,,,,,,,,,,,,,
CLIP BLLDG FIX APPL REMV 125MM 37CM,SUP-2108995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6810.94,4427.11,,,,,,,,,,,,,
SCREW BNE LCK 3.5X10 MM NORMED,SUP-2321725,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.97,310.03,,,,,,,,,,,,,
IMPLANT BRST NACL SMOOTH RND SIL SHELL ANTR DIAPH VLV STYL,SUP-2113250,CDM,C1789,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC VIABLE MTRX NEO MTX,SUP-2901719,CDM,C1713,HCPCS,0278,RC,,,,both,,,15112.82,9823.33,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 90 CM OD 9 FR ID 0.098 IN NYL,SUP-2158086,CDM,C1887,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
SHEATH URET ACC 12FR 28CML W/ DIL,SUP-2119489,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X25 MM WRST LCK CAP STRL FRDM,SUP-2852884,CDM,C1713,HCPCS,0278,RC,,,,both,,,1457.37,947.29,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM MED CP TI RT MANDIBULAR HEMI,SUP-2883704,CDM,C1713,HCPCS,0278,RC,,,,both,,,14439.51,9385.68,,,,,,,,,,,,,
PORT INFUS 8FR L45CM POLYUR ATTCH CATHETER PLAS STD PROF SGL,SUP-2126325,CDM,C1788,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GRAFT BONE 10CC DEMIN CORT OSTEOCONDUCTIVE FRZ DRY FIBEROS,SUP-2314099,CDM,C9359,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR TEMP EXT STRL,SUP-2138030,CDM,C1785,HCPCS,0275,RC,,,,both,,,13878.80,9021.22,,,,,,,,,,,,,
CATHETER EMB NOVASIL L 80 CM DIA 7 FR BALLOON DIA14 MM 1.75,SUP-2589469,CDM,C1757,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SCREW BNE L65MM OD7.5MM PUR TI LO EXT ST SELF DRL CANN FIX,SUP-2242858,CDM,C1713,HCPCS,0278,RC,,,,both,,,1754.16,1140.20,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.7MM DST VOLAR RAD NONLOCKING FULL THRD,SUP-2411803,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.97,123.48,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC VI DBM DYNAGRAFT II,SUP-2641741,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.50XH5.50CM D1.20CM 40J 20SEC 6YR STD 3,SUP-2138075,CDM,C1722,HCPCS,0275,RC,,,,both,,,40502.86,26326.86,,,,,,,,,,,,,
LINER ACET LP 22X24 MM HIP SYS RINGLOK ARCOMXL,SUP-2449980,CDM,C1776,CPT,0278,RC,,,,both,,,3037.95,1974.67,,,,,,,,,,,,,
JETXHALF PINS/EXTERNAL FIXATION/UNILATERAL/5 MM HALF PINS/5,SUP-2342929,CDM,C1713,HCPCS,0278,RC,,,,both,,,1806.16,1174.00,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.410,SUP-2859974,CDM,C1713,HCPCS,0278,RC,,,,both,,,32330.38,21014.75,,,,,,,,,,,,,
SPLINT FT AD SM SZ 3-6 UNISX RT PREFABRICATED POST LEAF,SUP-2325043,CDM,L4398,HCPCS,0272,RC,,,,both,,,79.44,51.64,,,,,,,,,,,,,
CATHETER DIL L200CM TAPR L2CM OD6FR 0.035IN BILI PUR CONN,SUP-2170679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
PLATE BNE STR 2.7X48 MM 6 HOLE RECON FOR SCR SS NS,SUP-2465692,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.18,484.37,,,,,,,,,,,,,
PACEMAKER CARD EVIA SR-T D 65 MM TI SINGLE CHMBR PREM VVIR,SUP-2138286,CDM,C1786,HCPCS,0275,RC,,,,both,,,11366.80,7388.42,,,,,,,,,,,,,
STEM HUM MOD STD 10X120 MM SHLDR COCR POROUS GLOB FX,SUP-2249924,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 4 H TI STR LP NS STERNALOCK,SUP-2894450,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
PLATE BNE W12XL183MM THK1MM 11 H BILAT S STL SEMI TBLR LO,SUP-2184872,CDM,C1713,HCPCS,0278,RC,,,,both,,,905.07,588.30,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 100 CM DIA 7 MM POLYESTER BOV CLLGN STR,SUP-2227529,CDM,C1768,CPT,0278,RC,,,,both,,,1927.11,1252.62,,,,,,,,,,,,,
CLIP IMPL ALIGN NS DISP FATHOM,SUP-2884711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SPACER HUM DIA39MM +12MM OFFSET SHLDR TI UNIVERS REVERS,SUP-2123377,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GRAFT HUM TISS PTCH MED 2X3 CM AMNION RESTORIGIN,SUP-2321880,CDM,Q4191,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SROM*STXXL36+8LNK20X15X325R,SUP-2540398,CDM,C1776,CPT,0278,RC,,,,both,,,17097.93,11113.65,,,,,,,,,,,,,
KIT PROC W/ 90DEG FIRM TIP EXT WRK CHN LOCATABLE GUID FOR,SUP-2381768,CDM,C1887,HCPCS,0272,RC,,,,both,,,5601.76,3641.14,,,,,,,,,,,,,
LINER ACET OD64MM ID52MM 0DEG CO CHROM HIP R3,SUP-2345314,CDM,C1776,CPT,0278,RC,,,,both,,,10500.95,6825.62,,,,,,,,,,,,,
RELOAD STPLR 60 MM FOR SIGNIA INTELLIGENT LD UNIT,SUP-2858010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1817.46,1181.35,,,,,,,,,,,,,
COIL AXIUM PRIME DETACHBL FRAME 5MMX10CM,SUP-2469308,CDM,C1889,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
PLATE BNE INJ RELEASE MILLER,SUP-2437006,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
SCREW BONE L130MM DIA8MM STD CORT TI ST SELF DRL CANN,SUP-2343506,CDM,C1713,HCPCS,0278,RC,,,,both,,,1775.70,1154.20,,,,,,,,,,,,,
ELECTRODE ELECSURG RESECT LOOP 12 DEG HI FREQ ENDOSCP TURIS,SUP-2313572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1410.39,916.75,,,,,,,,,,,,,
BIT DRL L165MM DIA4.5MM JCBS CHK L135MM STP CANN,SUP-2187051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1119.32,727.56,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.035IN TAPR 8CM STR TIP STD SHFT,SUP-2139341,CDM,C1769,HCPCS,0272,RC,,,,both,,,143.22,93.09,,,,,,,,,,,,,
COUPLER FIX ANG OFFSET FEM KNEE LEGION,SUP-2346814,CDM,C1776,CPT,0278,RC,,,,both,,,4157.36,2702.28,,,,,,,,,,,,,
KIT PICC COMPLT BD INTROSYTE INTRO W/ 26GA 1.9FRX50CM SL 1ST,SUP-2133176,CDM,C1751,HCPCS,0278,RC,,,,both,,,321.38,208.90,,,,,,,,,,,,,
SHAFT RMR L510MM OD8MM IM FEM MOD TRINKLE NONSTERILE BIXCUT,SUP-2368273,CDM,C1713,HCPCS,0278,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
PLATE BNE L177MM 11 H NONSTERILE R LAT DST FIBULAR S STL,SUP-2184165,CDM,C1713,HCPCS,0278,RC,,,,both,,,1835.17,1192.86,,,,,,,,,,,,,
FRACSURE HIP STEM SOLID-CEMENTED COCR SZ 1,SUP-2207899,CDM,C1776,CPT,0278,RC,,,,both,,,3072.18,1996.92,,,,,,,,,,,,,
SCREW SPNL SHANK 7.5X35 MM CANN PPS,SUP-2561556,CDM,C1713,HCPCS,0278,RC,,,,both,,,8087.07,5256.60,,,,,,,,,,,,,
HC So Vitamin B-1,PX-3018442566,CDM,84425,CPT,0301,RC,,,,both,,,89.00,57.85,,,,,,,,,,,,,
KIT ABLAT PRB 17GA L20MM SGL OSTEOCOOL RF,SUP-2293684,CDM,C1886,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 5FR 60CML PU RADPQ PEEL AWAY INT 3255115,SUP-2632661,CDM,C1751,HCPCS,0278,RC,,,,both,,,328.44,213.49,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ASEP PERONEUS LONGUS TEND,SUP-2867038,CDM,C1762,CPT,0278,RC,,,,both,,,4989.46,3243.15,,,,,,,,,,,,,
HC So Bcr/Abl1 Gene Minor Bp,PX-3108120766,CDM,81207,CPT,0310,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
PLATE BONE THK2MM 4 H STRNL TI SH LCK,SUP-2262568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
HC Bronchoscopy W or WO Fluoro,PX-3613162200,CDM,31622,CPT,0361,RC,,,,both,,,1724.00,1120.60,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA28 MM BRANCH SIDE L 10 CM DIA,SUP-2894690,CDM,C1768,CPT,0278,RC,,,,both,,,12456.38,8096.65,,,,,,,,,,,,,
GUIDEWIRE ORTH L 450 MM DIA2.8 MM THRD FOR CANN SYS PK NS,SUP-2907915,CDM,C1769,HCPCS,0272,RC,,,,both,,,923.63,600.36,,,,,,,,,,,,,
INTRODUCER SHTH STR 0.018 INX45 CM 7 FRX11 CM VENEFIT,SUP-2874946,CDM,C1894,HCPCS,0272,RC,,,,both,,,95.77,62.25,,,,,,,,,,,,,
AGENT HEMOSTATIC NOZ L 10 CM 1.65 GM THROM PRELD BLLW STRL,SUP-2898789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW BONE L60MM OD5.5MM PNK MIDFOOT HINDFOOT ANK CANN LNG,SUP-2320941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
GRAFT OPHTH SZ B THK50-100UM W1.5XL2CM CONJUNCTIVOCHALASIS,SUP-2135256,CDM,V2790,HCPCS,0274,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
CONNECTOR SPNL RT POST TI FIX MINI OFFSET SLT XLNK TRNSVRS,SUP-2256192,CDM,C1713,HCPCS,0278,RC,,,,both,,,2996.03,1947.42,,,,,,,,,,,,,
AUGMENT WDG TIB LEGION FIN SZ 7 10MM RT,SUP-2418589,CDM,C1776,CPT,0278,RC,,,,both,,,5658.28,3677.88,,,,,,,,,,,,,
HC Treat Humerus Fx,PX-4502362500,CDM,23625,CPT,0450,RC,,,,both,,,4794.00,3116.10,,,,,,,,,,,,,
SCREW SPNL STBL SYS CDH SPIRE,SUP-2292650,CDM,C1713,HCPCS,0278,RC,,,,both,,,10519.00,6837.35,,,,,,,,,,,,,
HC So1 Mycoplasma Igg,PX-3028673867,CDM,86738,CPT,0302,RC,,,,outpatient,,,545.00,354.25,,,,,,,,,,,,,
GRAFT BONE 30ML SUB VOID FIL GRAN PLEXUR P,SUP-2293937,CDM,C1713,HCPCS,0278,RC,,,,both,,,4577.34,2975.27,,,,,,,,,,,,,
TIP SUCT L45CM OD5MM SPAT TIP REPOSABLE STRYKEPROBE,SUP-2361204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.44,578.79,,,,,,,,,,,,,
STANDARD DRL BIT D15X125MM QUIK CONN,SUP-2315949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,627.97,408.18,,,,,,,,,,,,,
STENT URET CNTOUR VL L 22-30 CM DIA 6 FR TIP L 5 CM SENSOR,SUP-2729976,CDM,C2617,HCPCS,0278,RC,,,,both,,,518.23,336.85,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X388 MM RT PROX 12 HOLE NS VA-LCP,SUP-2757668,CDM,C1713,HCPCS,0278,RC,,,,both,,,9249.81,6012.38,,,,,,,,,,,,,
COMPONENT FEM 3X2MM OFFSET SM ARTC IMPL UNICAP,SUP-2123717,CDM,C1776,CPT,0278,RC,,,,both,,,13109.50,8521.17,,,,,,,,,,,,,
FRACTURE KIT BNE CEMENT SATURATE MIXING SYS STABILIT,SUP-2460164,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
HC So Additional Panel Charge,PX-3028687066,CDM,86870,CPT,0302,RC,,,,outpatient,,,381.00,247.65,,,,,,,,,,,,,
COIL EMB L30CM DIA7MM MICROCATHETER DIA0.0165IN,SUP-2305181,CDM,C1889,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
LENS IO +110 DIOPT L13MM DIA65MM A CONSTANT 1189 10DEG,SUP-2110359,CDM,V2632,HCPCS,0276,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
FOOTPLATE EXT FIX 100 MM TRUELOK +,SUP-2645677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1273.74,827.93,,,,,,,,,,,,,
IMMOBILIZER KNEE L19IN ELAS STRP AND T BAR CUTAWAY,SUP-2194898,CDM,L1830,CPT,0272,RC,,,,both,,,53.63,34.86,,,,,,,,,,,,,
TROCAR ENDOSCP DIA10 MM SZ 5/ 7/8 MM POLYUR BALLOON BLNT TIP,SUP-2896351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.20,405.08,,,,,,,,,,,,,
PLATE MEDL CLMN STD TI RT TALONAVICULOCUNEIFORM METATRSL NS,SUP-2897093,CDM,C1713,HCPCS,0278,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
SCREW SPNL L35MM DIA5.5MM MULT AX REV ANG THRD LOK,SUP-2287976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE CRAN 60X60X40 MM PT SPEC IMPL PEEK,SUP-2860130,CDM,C1713,HCPCS,0278,RC,,,,both,,,27650.84,17973.05,,,,,,,,,,,,,
PLATE BNE 0 DEG SCREW DIA 3/3.5/4 MM MED TI ALLOY RT 1ST,SUP-2907582,CDM,C1713,HCPCS,0278,RC,,,,both,,,6880.56,4472.36,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 40 MM DIA10 MM DEL SYS L 80 CM,SUP-2155369,CDM,C1876,HCPCS,0278,RC,,,,both,,,2904.25,1887.76,,,,,,,,,,,,,
MESH BIO GRFT HERN PORCINE MTRX INGUINAL 15CM LEN 8CM W,SUP-2170063,CDM,C1781,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
INTRODUCER SHTH J 0.035 IN STRAIGHTENER FLSH PRELUDE,SUP-2303469,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.97,16.88,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC DEMINERALIZED BONE MTRX ALLOCRAFT,SUP-2636997,CDM,C1713,HCPCS,0278,RC,,,,both,,,4504.33,2927.81,,,,,,,,,,,,,
TUBE LARYNCTMY BLOM SINGER VOICE PROS PT CHANGEABLE LO PRSS,SUP-2242313,CDM,L8509,HCPCS,0274,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
LOOP OSS TRAPEZ RIBBON 4.5 MM FLATTENED BND WIDE PLAT,SUP-2637832,CDM,L8613,CPT,0278,RC,,,,both,,,540.58,351.38,,,,,,,,,,,,,
CONNECTOR CSF RT ANGLE 1X2 MM RADIOPAQUE POLYPR STRL,SUP-2851298,CDM,C1889,HCPCS,0278,RC,,,,both,,,1399.78,909.86,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.4X8 MM CORTICAL CRUCIFORM RECESS S,SUP-2837811,CDM,C1713,HCPCS,0278,RC,,,,both,,,118.69,77.15,,,,,,,,,,,,,
TROCAR SURG L176MM DIA4MM FOR PROTCT SL,SUP-2188222,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.27,491.58,,,,,,,,,,,,,
GRAFT ENDOVASC L50MM DIAM 10MM IL VIABAHN,SUP-2396462,CDM,C1874,HCPCS,0278,RC,,,,both,,,8801.42,5720.92,,,,,,,,,,,,,
SCREW BNE L13MM OD2MM DRL FREE ORTHOANCHOR SFT CLLR,SUP-2262928,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.57,222.67,,,,,,,,,,,,,
PLATE SPNL L60MM UNIV CERV ANT 4 LEV TI STD REFLX,SUP-2380879,CDM,C1713,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
PLATE SPNL LCK CVR NO PROF MERID,SUP-2711068,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SCREW BONE L100MM DIA10.5MM LAG FOR AFFIXUS HIP FX NAIL SYS,SUP-2137049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2799.78,1819.86,,,,,,,,,,,,,
PLATE BONE STRUT 2X4 HOLE TITANIUM NON STERILE LOW PROFILE N,SUP-2838366,CDM,C1713,HCPCS,0278,RC,,,,both,,,2225.00,1446.25,,,,,,,,,,,,,
CAGE SPNL ACCULIF TL 6 9MM,SUP-2379556,CDM,C1889,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
DEVICE CLOSURE PDLOK CLP PRO-SELECT L 162 CM OD 19 MM ID 11,SUP-2360695,CDM,C1760,HCPCS,0278,RC,,,,both,,,1497.28,973.23,,,,,,,,,,,,,
BUR SURG L12CM DIA3MM PROX CRV 2 RIB MTCH HD MIDAS REX,SUP-2281565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
PATCH CV IMPRA L 90 X W 20 MM THK 0.4 MM EPTFE OVL SHP TW,SUP-2127806,CDM,C1768,CPT,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
GUIDEWIRE 062INX9IN FLX NIT TRCR,SUP-2166837,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.06,46.84,,,,,,,,,,,,,
TUBE GASTSTMY 20FR CONN STRL SIL EASY-FEED,SUP-2102903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
IMMOBILIZER ELBW SM L7IN FOR 7-9IN BICEP 6-8IN WR COT W/O,SUP-2269055,CDM,L3650,HCPCS,0274,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
SCREW SPNL L13MM DIA4.5MM CANC ANTR CERV TI ST LCK VAR ANG,SUP-2254601,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
SCREW BNE L7MM DIA1.2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189159,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.88,230.02,,,,,,,,,,,,,
DEFIBRILLATOR CARD HI ENERGY SYS W/ TI W/ LANDLINE HM 2,SUP-2138414,CDM,C1722,HCPCS,0275,RC,,,,both,,,58090.00,37758.50,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SPRL MOLD TO PT PLAS,SUP-2435629,CDM,L1950,HCPCS,0274,RC,,,,both,,,2177.31,1415.25,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 10H RT 171MM-STER,SUP-2549577,CDM,C1713,HCPCS,0278,RC,,,,both,,,4701.87,3056.22,,,,,,,,,,,,,
KIT SUTURING SUTURE L 48 IN DIA2 MM K WIRE L 200 MM DIA1.6,SUP-2910461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3280.52,2132.34,,,,,,,,,,,,,
COMPONENT HIP 7 MTL,SUP-2254060,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
BRACE WR AD L LT INSTABILITY INJ LOOP LCK W/ STAY ELAS PUL,SUP-2197949,CDM,L3931,HCPCS,0274,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
ULNAR HD 16X1.5MM OFFSET,SUP-2398595,CDM,C1776,CPT,0278,RC,,,,both,,,4077.92,2650.65,,,,,,,,,,,,,
SCREW BNE L 42 MM DIA 4 MM SHRT TI CANN HDLSS NS LEOS,SUP-2931452,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.01,592.81,,,,,,,,,,,,,
CANNULA LNG,SUP-2488483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1097.24,713.21,,,,,,,,,,,,,
GRAFT NRV PROTCT L4CM ID7MM CLLGN ABSRB PERIPH NEURAWRAP,SUP-2245948,CDM,C9353,HCPCS,0278,RC,,,,both,,,4642.84,3017.85,,,,,,,,,,,,,
IMPLANT BRST NACL SMOOTH RND SIL SHELL ANT DIAPH VLV STYL,SUP-2113254,CDM,C1789,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
HC Bladder Irrigation Simple,PX-4505170000,CDM,51700,CPT,0450,RC,,,,both,,,935.00,607.75,,,,,,,,,,,,,
PLATE BONE L81MM 10 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348297,CDM,C1713,HCPCS,0278,RC,,,,both,,,5467.21,3553.69,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 150 MM DIA 7 MM CATH L 80 CM DIA 6,SUP-2128195,CDM,C1876,HCPCS,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
DEHYDRATED ALCOHOL IA SOLN,RX-172312,CDM,2500000003,HCPCS,0250,RC,16729-0710-31,NDC,,both,5,ML,3755.50,2441.07,,,,,,,,,,,,,
SHEETING SILAS 8X6 .030,SUP-2242093,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
PLATE BNE H MINI LNG TI 10064709,SUP-2459575,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.84,267.05,,,,,,,,,,,,,
SCREW SLF-DRL LK MATRIXMAND 2.0X8MM,SUP-2718089,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.15,318.60,,,,,,,,,,,,,
SCREW SPNL L11MM DIA3.5MM ANT CERV SELF DRL F/ STD ALONE 2PK,SUP-2293581,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
TAP SURG DIA4.5MM PLATING SYS TUNGSTEN CARBIDE-100,SUP-2343963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,944.20,613.73,,,,,,,,,,,,,
HALF RING 180 MM INT DIAM,SUP-2818050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9320.15,6058.10,,,,,,,,,,,,,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,J0675,HCPCS,0636,RC,43598-0917-11,NDC,,both,1,ML,1834.20,1192.23,,,,,,,,,,,,,
PLATE SPNL MULTAXL 58-80 MM TI CD HORZ X10 CROSSLINK,SUP-2289544,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
DRILL TWST DIA1.2MM 4MM STP J LATCH END DISP FOR UNIV NEURO,SUP-2364178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.36,411.03,,,,,,,,,,,,,
PLATE BNE LCK 2.7X26 MM 2 HOLE CNTOUR 2 COMPR SS STRL,SUP-2457983,CDM,C1713,HCPCS,0278,RC,,,,both,,,796.93,518.00,,,,,,,,,,,,,
STEM ULN L1CM DIA5MM DSTL RAD EXT,SUP-2119916,CDM,C1776,CPT,0278,RC,,,,both,,,7432.38,4831.05,,,,,,,,,,,,,
ADAPTER LD L 10 CM SIL INSUL UPLR 5 MM RECEPTACLE IS1 CONN,SUP-2616256,CDM,C1883,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
HC Replace Icd Sgl Lead System,PX-3613326200,CDM,33262,CPT,0361,RC,,,,outpatient,,,7823.00,5084.95,,,,,,,,,,,,,
INSERT ACET OD62MM ID44MM HIP ULTAMET ARTC MOD STBL PINN,SUP-2250310,CDM,C1776,CPT,0278,RC,,,,both,,,9553.76,6209.94,,,,,,,,,,,,,
CORT SCREW 115MM 3.5,SUP-2818735,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.08,219.75,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 12H /90MM/200MM,SUP-2547495,CDM,C1713,HCPCS,0278,RC,,,,both,,,3176.02,2064.41,,,,,,,,,,,,,
SHEATH INTRO CHARIOT L 65 CM DIA 6 FR STR TIP XCUT LG LUMEN,SUP-2140842,CDM,C1725,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
BASEPLATE GLEN EXT CAGE 10+ MM SM SHLDR REVERSED EQUINOXE,SUP-2451449,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
NEEDLE BRST LOC L5CM DIA20GA WIRE L15CM BEAD BARD GHIATAS 10/CA,SUP-2127822,CDM,C1819,HCPCS,0278,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 15 CM FLX TIP 6,SUP-2167732,CDM,C1769,HCPCS,0272,RC,,,,both,,,50.71,32.96,,,,,,,,,,,,,
DEVICE INFL SYR DGT W HONOR HEMSTAS VLV BASIXCOMPAK 30 ATM,SUP-2302691,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM FANELLI 0.021 IN 5 FRX90 CM SET,SUP-2737156,CDM,C1769,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7030,HCPCS,0258,RC,00338-0049-04,NDC,,both,250,ML,10.70,6.95,,,,,,,,,,,,,
HC So Creatine Kinase Isoenzyme,PX-3018255266,CDM,82552,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
IMPLANT BIO L 3 X W 7 CM FISH SKIN DERMAL FEN 11 INTACT 10/BX,SUP-2909460,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
GRAFT HUM TISS L 60 MM FIB SHFT LYOPH,SUP-2913248,CDM,C1762,CPT,0278,RC,,,,both,,,3196.52,2077.74,,,,,,,,,,,,,
SET PICC L 15 CM DIA 4.5 FR SHTH L 7 CM DIA 4.5 FR GUIDEWIRE,SUP-2887022,CDM,C1751,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
GUIDEWIRE VASC VIPERWIRE ADV L 475 CM DIA 0.018 IN SS SIL,SUP-2418055,CDM,C1769,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
STENT BILI PRECIS L 40 MM DIA 5 MM CATH L 135 CM DIA 8 FR,SUP-2158903,CDM,C1876,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
HEAD HUM ECC 14X36 MM 4 MM SHLDR COFIELD2,SUP-2344317,CDM,C1776,CPT,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
SCREW BNE 2.7X44 MM,SUP-2183088,CDM,C1713,HCPCS,0278,RC,,,,both,,,161.08,104.70,,,,,,,,,,,,,
CONNECTOR SPNL L15MM OD5.5MM S STL THORLUM OFFSET REVERE,SUP-2230983,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
PLATE SPNL 3 LEVEL 45 MM CERV,SUP-2415476,CDM,C1713,HCPCS,0278,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
STEM HUM L140MM DIA16MM UNIV DSTL SHLDR TI PRI REV CEM FOR,SUP-2372858,CDM,C1776,CPT,0278,RC,,,,both,,,9534.92,6197.70,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 94 MM DIA10 MM CATH TOT L 100,SUP-2148390,CDM,C1876,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SCREW BNE LCK 2X14 MM CROSS DRV TI NS,SUP-2754968,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
FIXATION KIT 11X12/10 MM 1.3X1.5 MM SPEEDARC,SUP-2135443,CDM,C1776,CPT,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR DF1 IS1 CONN W/ RF TELMTRY,SUP-2356291,CDM,C1722,HCPCS,0275,RC,,,,both,,,36568.44,23769.49,,,,,,,,,,,,,
SCREW CBS H COMPR 26MM,SUP-2321407,CDM,C1713,HCPCS,0278,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
PLATE BNE W10XL74MM THK15MM 3X5 H R TI T SHP OBLQ LO PROF,SUP-2190919,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.57,740.72,,,,,,,,,,,,,
SCREW BNE L22MM DIA3.5MM CORT TI N ST FULL THRD FOR WRST,SUP-2189851,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.80,36.27,,,,,,,,,,,,,
SHAFT SCRDRVR M DIA1.5MM SELF HLD HEX CPL FOR MATRIXMANDIBLE,SUP-2179198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2230.97,1450.13,,,,,,,,,,,,,
SCREW BNE CANN 5X30 MM CAPTURE HIGH-TORQUE,SUP-2609468,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
SYSTEM MGMT INCIS CLOSE NEG PRSS CUSTOMIZABLE DRSG,SUP-2262373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
LINER ACET CUP THCK PRI CEM MTL ON POLYETH STD NEUT 39MM OD,SUP-2406717,CDM,C1776,CPT,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
"HC So Coombs,Direct",PX-3028688066,CDM,86880,CPT,0302,RC,,,,outpatient,,,218.00,141.70,,,,,,,,,,,,,
GRAFT HUM TISS M W12XL16CM THK1.6MM +/-0.4MM WHL ALLGRFT,SUP-2113184,CDM,Q4116,HCPCS,0636,RC,,,,both,,,22441.58,14587.03,,,,,,,,,,,,,
BISACODYL 5 MG PO TBEC,RX-1079,CDM,6370000000,HCPCS,0637,RC,00904-6407-61,NDC,,both,1,UN,0.30,0.19,,,,,,,,,,,,,
KIT INTERNAL FIXATION WITH 2MM ORTHOSORB LS STRAIGHT PIN,SUP-2483079,CDM,C1713,HCPCS,0278,RC,,,,both,,,670.08,435.55,,,,,,,,,,,,,
PATCH AMNION 2 LAYR PROTCT 4 X 4CM STERISHIELD II,SUP-2138664,CDM,C1762,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
SCREW BNE L10MM DIA1.5MM S STL ST LOK FULL THRD T4 STARDRV,SUP-2184856,CDM,C1713,HCPCS,0278,RC,,,,both,,,297.45,193.34,,,,,,,,,,,,,
PLATE BNE L137MM 10 H NONSTERILE L PROX TIB S STL LO PROF,SUP-2185816,CDM,C1713,HCPCS,0278,RC,,,,both,,,3806.25,2474.06,,,,,,,,,,,,,
DARBEPOETIN ALFA 25 MCG/0.42ML IJ SOSY,RX-131221,CDM,J0881,HCPCS,0636,RC,55513-0057-04,NDC,,both,0.42,ML,570.90,371.08,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN PSTE,SUP-2335297,CDM,C1713,HCPCS,0278,RC,,,,both,,,2304.76,1498.09,,,,,,,,,,,,,
PLATE BNE TIB 274 MM LT LAT 13 HOLE BUTTRESS HD TI NS LC-DCP,SUP-2569064,CDM,C1713,HCPCS,0278,RC,,,,both,,,2895.52,1882.09,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|DOCUMENTATION ON FILE,PX-4409753000,CDM,97530,CPT,0440,RC,,,GO|CO|KX,both,,,191.00,124.15,,,,,,,,,,,,,
SET PANCREATIC STENT GEENEN L 3 CM DIA10 FR PUSH L 170 CM,SUP-2737423,CDM,C2625,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 9 MM OSTEOCHNDRL,SUP-2866830,CDM,C1762,CPT,0278,RC,,,,both,,,11424.89,7426.18,,,,,,,,,,,,,
ANCHOR SUT 5 MM DIA NO 0 SUT ABSRB ANCHRLOC,SUP-2398008,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
INTRODUCER CATH 16FR ORNG SUPRPUB PLAS SHRP TIP BVL TRCR,SUP-2391835,CDM,C1894,HCPCS,0272,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM STR TW REINF,SUP-2525449,CDM,C1768,CPT,0278,RC,,,,both,,,952.02,618.81,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 15CM 8MM 75CM 8FR HEPARIN,SUP-2396622,CDM,C1874,HCPCS,0278,RC,,,,both,,,11906.88,7739.47,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 DR-T 55X 66MM 13MM 40J LANDLINE,SUP-2138262,CDM,C1721,HCPCS,0275,RC,,,,both,,,67010.74,43556.98,,,,,,,,,,,,,
CLIP DIL STRL PHANTOM XL DISP,SUP-2536923,CDM,2720000010,LOCAL,0272,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
MESH SYNTH INGUINAL N ABSRB TITANIZED POLYPR LT 15CM LEN,SUP-2402531,CDM,C1781,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
CATHETER THROMCTMY EKOS + L 106 CM DIA 7.8 FR TREAT ZONE L 8,SUP-2867277,CDM,C1887,HCPCS,0272,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
KIT BNE CEMENT SZ 40 45.3 GM PWDR 38.2 GM/0.5 GM LIQ 20 ML,SUP-2916789,CDM,C1713,HCPCS,0278,RC,,,,both,,,10917.78,7096.56,,,,,,,,,,,,,
AXLE TIB SZ 3 OXIN FEM THRD STRL LEGION HK,SUP-2910083,CDM,C1776,CPT,0278,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
TUBE GASTROJEJU 14FR JEJU L22CM STOMA L1.2CM EN LO PROF,SUP-2119811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
BIT DRL FOR IM FIBULAR ROD,SUP-2106893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
STYLET 50MM SGL STP,SUP-2114059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
BASKET SPEC RETRV 5 FRX60 CM STONE W/ 3 RNG HNDL  COIL,SUP-2767786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6384.84,4150.15,,,,,,,,,,,,,
FIXATOR WRST DYN PENNIG II,SUP-2316046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4760.81,3094.53,,,,,,,,,,,,,
STAPLE BNE COMPR 201X20 IN SS,SUP-2122157,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
HC Spine Thoracolumbar 2 Views,PX-3207208000,CDM,72080,CPT,0320,RC,,,,outpatient,,,286.00,185.90,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 4 ML STR OSSEOFLEX SB OCP0141,SUP-2516667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
JOINT TOE 1ST METATARSOPHALANGEAL SM 17 MM CANN HEMI,SUP-2609649,CDM,L8642,HCPCS,0278,RC,,,,both,,,6800.83,4420.54,,,,,,,,,,,,,
SCREW BNE L16MM DIA2MM STD CORT TI NCANNULATED FULL THRD N,SUP-2189310,CDM,C1713,HCPCS,0278,RC,,,,both,,,96.87,62.97,,,,,,,,,,,,,
ANTEROLATERAL PILON FUSION PLATE 7H LT,SUP-2815224,CDM,C1713,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
BONE CEMENT TRAY 20/3 IBT FRAC W/ ADV OSTEO INTRO SYS KYPHON,SUP-2293653,CDM,C1894,HCPCS,0272,RC,,,,both,,,10846.82,7050.43,,,,,,,,,,,,,
AGENT HEMOSTATIC 3 ML 2.5 PEPTIDE STRL PURAGEL,SUP-2880696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
CATHETER LD DEL CPS DIR SL II L 57.7 AVAILABLE L 54 CM OD 9,SUP-2356369,CDM,C1893,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 6 DEG 12X14X12 MM CERV FD LORDTC CANC,SUP-2736814,CDM,C1713,HCPCS,0278,RC,,,,both,,,2783.48,1809.26,,,,,,,,,,,,,
WIRE EXT FIX L 355 MM DIA1.8 MM CORTICAL DRL TIP NS DISP,SUP-2932913,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.73,464.57,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA10 MM EPTFE STR STD WALL,SUP-2681769,CDM,C1768,CPT,0278,RC,,,,both,,,1723.17,1120.06,,,,,,,,,,,,,
CATHETER DRNGE 14FR L25CM 0.038IN 9 H POLYUR HYDRPHLC ORNG,SUP-2303341,CDM,C1729,HCPCS,0272,RC,,,,both,,,189.81,123.38,,,,,,,,,,,,,
RING EXT FIX 150 MM 5/8 MR SAFE TI NS,SUP-2799571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1832.19,1190.92,,,,,,,,,,,,,
ARCH FOOT 155MM,SUP-2488383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5174.72,3363.57,,,,,,,,,,,,,
SET LD EXTRACTION BYRD SHTH L 41/46CM 13.9FR 11.6FR SZ A YEL,SUP-2169010,CDM,C1894,HCPCS,0272,RC,,,,both,,,460.01,299.01,,,,,,,,,,,,,
EXTENSION GUIDEWIRE VASSALLO GT L 165 CM DIA 0.014-0.018 IN,SUP-2909226,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.48,47.76,,,,,,,,,,,,,
EXPANDER BRST TISS 550CC SIL M HT SMOOTH W/ SUT TAB INTEGR,SUP-2418652,CDM,C1789,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
COMPONENT HUM W10XL8MM SHLDR ASMBLY GLOB,SUP-2250012,CDM,C1776,CPT,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
GRAFT BNE BLOCK 12X12X12 MM DBM CANC PUREBONE,SUP-2424599,CDM,C1713,HCPCS,0278,RC,,,,both,,,2504.15,1627.70,,,,,,,,,,,,,
SHEATH URET PROXIS L 25 CM OD 14 FR ID 12 FR ACCS SHRT DIL,SUP-2655866,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.55,66.01,,,,,,,,,,,,,
TRYPAN BLUE 0.06 % IO SOSY,RX-159671,CDM,6370000000,HCPCS,0637,RC,68803-0612-10,NDC,,both,0.05,ML,33.00,21.45,,,,,,,,,,,,,
SURESPACE TIB SPACER MOLD SML,SUP-2540679,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 2 G IV SOLR,RX-27309,CDM,J0696,HCPCS,0636,RC,00409-7336-04,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
WIRE EXT FIX L 400 MM DIA2 MM TI SMTH HALF PT NS DISP MONK,SUP-2899223,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.66,297.48,,,,,,,,,,,,,
IMPLANT HUM TISS 1ML DBM PTTY ALLGRFT BIOSET PSTE SYR OPN,SUP-2335610,CDM,C9359,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT BNE PTTY 7.5 GM BIOACTIVE OSTEOFUSE,SUP-2225964,CDM,C9359,HCPCS,0278,RC,,,,both,,,6683.49,4344.27,,,,,,,,,,,,,
COIL EMB FRAME 0.010 IN 6 MMX26 CM SPHR CERECYTE PRESIDIO,SUP-2466410,CDM,C1889,HCPCS,0278,RC,,,,both,,,9650.10,6272.56,,,,,,,,,,,,,
BONE TNDN BONE HEMI WTH QDRCPS 10 13MM WIDTH FRZN X MSRMNT 4,SUP-2573321,CDM,C1762,CPT,0278,RC,,,,both,,,7311.08,4752.20,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK MINI IV TI SINGLE CHMBR V IS1BI,SUP-2139653,CDM,C1722,HCPCS,0275,RC,,,,both,,,70650.00,45922.50,,,,,,,,,,,,,
HC Hand 2 Views,PX-3207312000,CDM,73120,CPT,0320,RC,,,,both,,,348.00,226.20,,,,,,,,,,,,,
SCREW BNE L55MM DIA2.7MM CORT S STL ST FULL THRD FOR SM,SUP-2183469,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.77,83.70,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 30 CM DIA 4-7 MM SHRT TAPR SLDE GDS,SUP-2484639,CDM,C1768,CPT,0278,RC,,,,both,,,690.08,448.55,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC OSTEOSURGE 300,SUP-2644321,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
PLATE BNE TBLR 3.5 MM 7 HOLE 1/3 2 COMPR LCK FOR SCR TI STRL,SUP-2479960,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.83,343.09,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 360 DEG L 13 CM DIA 3 MM 5000 RPM STR,SUP-2901903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
BIT DRL L7IN OD4.5MM ID2.4MM TI CANN DISP FOR ENDOBUTTON,SUP-2340990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,441.48,286.96,,,,,,,,,,,,,
PLATE BNE L 32.49 MM THK 1 MM SCREW DIA2 MM GAP 15 MM WIDE,SUP-2936770,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
INTRODUCER LD PLCMNT 9FR 30CM N PEEL AWAY N COR SNUS ACCS,SUP-2357204,CDM,C1894,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
CHARCOAL ACTIVATED PO LIQD,RX-27099,CDM,6370000000,HCPCS,0637,RC,00574-0521-74,NDC,,both,120,ML,60.00,39.00,,,,,,,,,,,,,
GRAFT BNE SUB 9ML VOID FILL RESRB PTTY MASTERGRFT,SUP-2288543,CDM,C9359,HCPCS,0278,RC,,,,both,,,3463.42,2251.22,,,,,,,,,,,,,
DEVICE TARGET STD RADLUC GUID R VOLAR DST RAD PLATING SYS,SUP-2107094,CDM,C1713,HCPCS,0278,RC,,,,both,,,4072.58,2647.18,,,,,,,,,,,,,
PLATE BNE STR MINI MED 4 HOLE W/ BREAK-AWAY TAB TI,SUP-2459517,CDM,C1713,HCPCS,0278,RC,,,,both,,,821.68,534.09,,,,,,,,,,,,,
LEAD DBS L 42 CM DIA1.5 MM DIRECTIONAL W/ MARKER STRL DISP,SUP-2882977,CDM,C1778,HCPCS,0278,RC,,,,both,,,12006.58,7804.28,,,,,,,,,,,,,
CATHETER PTCA L110CM DIA18MM BLLN L6CM SHTH 10FR 0.035IN,SUP-2156191,CDM,C1725,HCPCS,0272,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
CLAMP EXT FIX SM DIA4MM OPN ROD TO ROD CONN,SUP-2188701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,939.77,610.85,,,,,,,,,,,,,
KIT PROCEDURE BARIATRIC,SUP-2752113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5734.27,3727.28,,,,,,,,,,,,,
PLATE BNE L 333 MM SCREW DIA 3.5/4.5 MM H 16 RT DSTL FEM,SUP-2931189,CDM,C1713,HCPCS,0278,RC,,,,both,,,19782.79,12858.81,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX L 4 CM 2 MM 0.0165 IN HELCL,SUP-2305142,CDM,C1889,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
STEM FLUTED MOB OPT TIB PLT SZ 1,SUP-2200826,CDM,C1776,CPT,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
CATHETER HD STR EXTN 12.5 FRX32 CM LT DL STP TIP SIL HEMCATH,SUP-2627318,CDM,C1750,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
HC So Ab Toxoplasma,PX-3028677766,CDM,86777,CPT,0302,RC,,,,both,,,190.00,123.50,,,,,,,,,,,,,
ANKLE FUSION PLATE LATERAL TTC 6H,SUP-2815311,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SPACER CUT GUID MONOGRAM 5MM,SUP-2364869,CDM,C1776,CPT,0278,RC,,,,both,,,763.33,496.16,,,,,,,,,,,,,
PLATE BNE L177MM 10 H NONSTERILE L PROX TIB S STL VAR ANG,SUP-2184331,CDM,C1713,HCPCS,0278,RC,,,,both,,,5383.40,3499.21,,,,,,,,,,,,,
PLATE BONE BROAD 4.5X303 MM 16 HOLE,SUP-2837422,CDM,C1713,HCPCS,0278,RC,,,,both,,,3121.95,2029.27,,,,,,,,,,,,,
PLATE BNE W13.5XL178MM THK4.2MM 10 H BILAT S STL NAR LIMIT,SUP-2185244,CDM,C1713,HCPCS,0278,RC,,,,both,,,1565.82,1017.78,,,,,,,,,,,,,
CENTRALIZER STEM DIA10MM UNIV DST HIP,SUP-2210692,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE ST 2X14 MM LCK TI SLV NS MATRIXMANDIBLE LF DISP,SUP-2181725,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.97,165.73,,,,,,,,,,,,,
SLING SHLDR PCH 13X19IN SWTH 5X54IN UNIV FOAM ADJ STRP,SUP-2195491,CDM,L3660,HCPCS,0274,RC,,,,both,,,30.33,19.71,,,,,,,,,,,,,
ANCHOR SUTURE SYS MIC ABD BNE DRL BIT CANN ACUTRK 2,SUP-2257130,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
COMPONENT PATELLAR 45 MM KNEE RESURF GEN II,SUP-2450689,CDM,C1776,CPT,0278,RC,,,,both,,,2625.04,1706.28,,,,,,,,,,,,,
PROSTHESIS OSS 2.5-7 MM 1.5X2.5 MM 0.86X1.27 MM OFFSET NANO,SUP-2476831,CDM,L8613,CPT,0278,RC,,,,both,,,1524.94,991.21,,,,,,,,,,,,,
KNIFE SURG Y SHP 5X111 MM STR MENISCOTOME PVC FREE ULTRA LF,SUP-2487778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SCREW BNE L40MM DIA6MM CORT ST NONCANNULATED NONLOCKING,SUP-2377554,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.06,521.99,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 MM DIA 32 MM BRANCH SZ,SUP-2479195,CDM,C1768,CPT,0278,RC,,,,both,,,5545.30,3604.44,,,,,,,,,,,,,
ROD MIS NEWPORT 80MM,SUP-2245616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA14MM FOR MTP FUS SYS MINI MAXLOCK EXTRM,SUP-2400497,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
STAPLER SUREFORM 60 DA VINCI XI,SUP-2246800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1747.41,1135.82,,,,,,,,,,,,,
SET SCR LCK SPINE TI ICON DEV,SUP-2317371,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
HEAD FEM DIA36MM +1.5MM OFFSET 12/14 TAPR HIP CERAMIC TI SL,SUP-2251118,CDM,C1776,CPT,0278,RC,,,,both,,,5917.02,3846.06,,,,,,,,,,,,,
SEALANT HEMOSTATIC FLOSEAL W/RECOTHROM 5 ML 75X13.25 IN 10CC,SUP-2863036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,817.50,531.37,,,,,,,,,,,,,
PIN GUIDE L 300 MM DIA1.9 MM NTHRD FOR CANN SCREW STRL DISP,SUP-2932939,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.60,124.54,,,,,,,,,,,,,
FLEXIGRAFT CONN PRE SUTURED TEND,SUP-2264629,CDM,C1713,HCPCS,0278,RC,,,,both,,,4029.94,2619.46,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CATH 7FR TRCE METRO DIR 0.035IN ACC,SUP-2171107,CDM,C1769,HCPCS,0272,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
SCREW CEPHALIC 10.5X90MM,SUP-2717573,CDM,C1713,HCPCS,0278,RC,,,,both,,,1626.52,1057.24,,,,,,,,,,,,,
CATHETER SET CV STR 0.018 IN 12 CM 21 GA TY DL DRUG COAT,SUP-2428124,CDM,C1751,HCPCS,0278,RC,,,,both,,,524.29,340.79,,,,,,,,,,,,,
ORTHOPEDIC KIT SEG PROX TIB WASHER,SUP-2437238,CDM,C1713,HCPCS,0278,RC,,,,both,,,5312.88,3453.37,,,,,,,,,,,,,
CATHETER UMB DL PREMI INF 5 FRX15 IN SMOOTH ROUNDED ARGY,SUP-2174251,CDM,C1751,HCPCS,0278,RC,,,,both,,,90.65,58.92,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEM ADD ON,SUP-2137373,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BLADE RTRCTR RVL LNG TOOTH 35MML BLUE F/ANTRR CRVCL FSN RMVL,SUP-2458469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.06,313.99,,,,,,,,,,,,,
PLATE BONE CRANIAL 6 HOLE STRAIGHT 25.9X3.4MM TITANIUM NEURO,SUP-2825990,CDM,C1713,HCPCS,0278,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
SHEATH INTRO 0.021 IN 5 FRX10 CM 19-21 GAX40 MM GLIDESHEATH,SUP-2851654,CDM,C1894,HCPCS,0272,RC,,,,both,,,256.22,166.54,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 90 MM DIA18/22 MM DEL 31ML,SUP-2936823,CDM,C1713,HCPCS,0278,RC,,,,both,,,17138.28,11139.88,,,,,,,,,,,,,
GRAFT HUM TISS LT LAT HEMITIBIAL PLT FRSH OSTEOCHNDRL,SUP-2113929,CDM,C1713,HCPCS,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
GENII TIB BSPL SZ5 LT HA COAT,SUP-2822760,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE W17.5XL314MM THK5.2MM 14 H NONSTERILE R CNDYL FEM,SUP-2185035,CDM,C1713,HCPCS,0278,RC,,,,both,,,4664.88,3032.17,,,,,,,,,,,,,
SCREW DISTRCTN 14MM TI STRL ULTRA LF,SUP-2475863,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.87,79.87,,,,,,,,,,,,,
SPEAR TRCR CONCL PT OBT BIO-FASTAK,SUP-2121025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
CATHETER PERI DLYS AD 15FR L47CM UNIV DBL CUF LIN STR RADPQ,SUP-2283889,CDM,C1750,HCPCS,0278,RC,,,,both,,,181.49,117.97,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X45 MM WRST LCK CAP STRL FRDM,SUP-2852947,CDM,C1713,HCPCS,0278,RC,,,,both,,,1503.12,977.03,,,,,,,,,,,,,
RETRACTOR RNG MALYUGIN 7 MM IRIS,SUP-2304013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.47,305.81,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 22MM POLYESTER BOV CLLGN STR,SUP-2265928,CDM,C1768,CPT,0278,RC,,,,both,,,4697.44,3053.34,,,,,,,,,,,,,
COMPONENT TOT KNEE BICOMPARTMENTAL LT MEDL W/O PATELLAR,SUP-2165962,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
HC So Drug Assay Voriconazole,PX-3018028566,CDM,80285,CPT,0301,RC,,,,both,,,256.00,166.40,,,,,,,,,,,,,
RELOAD STPL 2.5 WHT 6 ROW DISP FOR DA VINCI X AND DA VINCI,SUP-2246804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.31,492.90,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA 7 FR DIL 20 CM GUIDEWIRE,SUP-2168014,CDM,C1892,HCPCS,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
SCREW BNE CANN 4.5X40 MM PARTIALLY THRD TI MAXICAN,SUP-2321695,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.58,444.33,,,,,,,,,,,,,
SYSTEM ENDOSCP INNR RNG SZ 11 CM TRNSVAG GELSEAL CAP ALEXIS,SUP-2885195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BIT DRL L356MM DIA5MM CALIB L126MM 3 FLUT QUIK CPL,SUP-2178833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,918.48,597.01,,,,,,,,,,,,,
LINER ACET SZ 3 ID28MM 0DEG POLY ARCM LOK RNG HI RIM RNGLOC,SUP-2403698,CDM,C1776,CPT,0278,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
SCREW BONE L100MM DIA6.5MM THRD L20MM CANN GUID ASNS 2,SUP-2362441,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.16,617.60,,,,,,,,,,,,,
HEAD HUM 18X44 MM SHLDR RESURF TITAN,SUP-2244071,CDM,C1776,CPT,0278,RC,,,,both,,,15725.12,10221.33,,,,,,,,,,,,,
STAPLER INT CIR X THCK 33 MM 4/4.5/5 MM TRI-STAPLE BLK EEA,SUP-2858014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3414.15,2219.20,,,,,,,,,,,,,
GRAFT HUM TISS 23MMX16MM DWL BONE IMPL HUM TISS CANC CORT,SUP-2293891,CDM,C1713,HCPCS,0278,RC,,,,both,,,11278.88,7331.27,,,,,,,,,,,,,
COIL NEUROVASCULAR DELTAMAXX CERECYTE L 55 CM DIA18 MM,SUP-2462153,CDM,C1889,HCPCS,0278,RC,,,,both,,,9163.90,5956.53,,,,,,,,,,,,,
HC Perq Device Breast 1st Image,PX-3611928100,CDM,19281,CPT,0361,RC,,,,outpatient,,,5152.00,3348.80,,,,,,,,,,,,,
PLATE BNE BLDE L40MM SHFT L92MM THK45 52MM 95DEG 5 H ST,SUP-2186792,CDM,C1713,HCPCS,0278,RC,,,,both,,,3490.14,2268.59,,,,,,,,,,,,,
WASHER COUNTSINK BICONCAVE RND,SUP-2364320,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.30,384.99,,,,,,,,,,,,,
KNIFE NDL 5.5FR L200CM GWIRE 0.035IN CUT WIRE 5MM SPHINTOM,SUP-2149308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.85,391.85,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC INJ DBM BEAST,SUP-2742043,CDM,C1713,HCPCS,0278,RC,,,,both,,,3194.95,2076.72,,,,,,,,,,,,,
CLAMP SPINE SUSP ANTR CERV SYS S STL COLORADO 2,SUP-2290522,CDM,C1713,HCPCS,0278,RC,,,,both,,,2389.54,1553.20,,,,,,,,,,,,,
SYRINGE DELIVERY KIT 4 IN W/ NDL ALIQUOT,SUP-2379528,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
SCREW INTFR BIOSURE REGENESORB 7MM X 25MM,SUP-2341913,CDM,C1713,HCPCS,0278,RC,,,,both,,,1172.88,762.37,,,,,,,,,,,,,
GRAFT BONE H1.7-10MM 30ML CANC CHIP FRZ DRY,SUP-2294031,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.73,643.32,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM NOM THK0.5MM LO PROF HUM DERM REGEN,SUP-2399061,CDM,Q4107,HCPCS,0636,RC,,,,both,,,2964.16,1926.70,,,,,,,,,,,,,
CANNULA SURG 12 MM STPLR ENDOWRIST,SUP-2246756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4122.82,2679.83,,,,,,,,,,,,,
PLATE BONE W3.8XL49MM THK0.9MM 3X9 H S STL T SHP,SUP-2343827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1696.51,1102.73,,,,,,,,,,,,,
HEAD HUM RESURF HA COAT SZ 3 COPELAND,SUP-2403987,CDM,C1776,CPT,0278,RC,,,,both,,,13976.14,9084.49,,,,,,,,,,,,,
STENT BILI L L24MM BLLN L30MM DIA10MM CATH L80CM 10ATM,SUP-2159239,CDM,C1876,HCPCS,0278,RC,,,,both,,,3598.44,2338.99,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRIMARY CEM STEM SUMMIT,SUP-2257248,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BONE FUS STD LT,SUP-2397485,CDM,C1713,HCPCS,0278,RC,,,,both,,,3205.94,2083.86,,,,,,,,,,,,,
PROSTHESIS PENILE SPHIN DEACTIVATION PK,SUP-2138916,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.34,288.82,,,,,,,,,,,,,
STOCKING COMPR OPN TOE MED PET 30-40 MMHG UNISX BGE ASSURE,SUP-2724358,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.43,79.58,,,,,,,,,,,,,
HC CT T-Spine W/ Contrast,PX-3527212900,CDM,72129,CPT,0352,RC,,,,outpatient,,,2630.00,1709.50,,,,,,,,,,,,,
PIN FIX CLLRD 50 MM THRD,SUP-2315867,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
REAMER SURG SZ 18MM MTP ORTHOLOC 3DI,SUP-2900518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
SPLINT HND ANTIMICROBIAL LG 8 IN WRST LT ROLYAN HANZ WHFO,SUP-2326334,CDM,L3906,HCPCS,0274,RC,,,,both,,,138.03,89.72,,,,,,,,,,,,,
PLATE BNE 3 HOLE SINGLE LISFRANC STRATUM,SUP-2475552,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE 0.030 IN PLATFORM IN-LINE W/ REINF BK,SUP-2863650,CDM,C1889,HCPCS,0278,RC,,,,both,,,16875.43,10969.03,,,,,,,,,,,,,
SLEEVE IM 120DEG LT BLU TI LOK FOR SPRL BLDE 9-12MM NAIL,SUP-2191880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1217.44,791.34,,,,,,,,,,,,,
LINER ACET OD50MM ID28MM 20DEG HIP MARTHN LAT NEUT PINN,SUP-2250516,CDM,C1776,CPT,0278,RC,,,,both,,,4664.78,3032.11,,,,,,,,,,,,,
HC I&D Finger Abscess Simple,PX-4502601000,CDM,26010,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
GRAFT NRV REP L3CM DIA3MM TYP 1 CLLGN ABSRB SEMIPERMEABLE,SUP-2244351,CDM,C9352,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
DRILL HND L15MM SOLITAIRE C,SUP-2415026,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
DRESSING BIO 250 MG PORCINE EXTRACELLULAR MTRX PWDR WND STRL,SUP-2911924,CDM,A2004,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE LG ECON BUCK,SUP-2336329,CDM,L4398,HCPCS,0274,RC,,,,both,,,27.60,17.94,,,,,,,,,,,,,
HALF PIN 4X40 TIN180MM LONG,SUP-2853191,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
IMPLANT OTO L6MM PIST DIA0.4MM S STL FLROPLAS FISCH TYP,SUP-2312552,CDM,L8613,CPT,0278,RC,,,,both,,,221.06,143.69,,,,,,,,,,,,,
CATHETER GUID GL3 AD 8 FRX100 CM RADIOPAQUE TIP VKG OPTMA,SUP-2103860,CDM,C1887,HCPCS,0272,RC,,,,both,,,218.17,141.81,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 200 MM 80 MM 12 HOLE NS DCP,SUP-2569033,CDM,C1713,HCPCS,0278,RC,,,,both,,,1891.00,1229.15,,,,,,,,,,,,,
CAGE SPNL L12XW12XH12MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317732,CDM,C1889,HCPCS,0278,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
CATHETER ANGIOPLSTY DYNAMIS AV L 75 CM BALLOON L 40 MM DIA16,SUP-2676387,CDM,C1769,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
IMPLANT OP RM MTP PLTS MTP 5 LNG PLT L,SUP-2321453,CDM,C1713,HCPCS,0278,RC,,,,both,,,4608.58,2995.58,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR LACER N MOLD,SUP-2435677,CDM,L2530,HCPCS,0272,RC,,,,both,,,678.96,441.32,,,,,,,,,,,,,
GUIDE NDL 9GA ANCIL PROD FOR EVIVA STEREOTACTIC BRST BX,SUP-2239965,CDM,C1819,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE BNE L260MM BRL L15IN 135DEG PELVIS BILAT S STL STD 12,SUP-2342442,CDM,C1713,HCPCS,0278,RC,,,,both,,,5969.77,3880.35,,,,,,,,,,,,,
CATHETER CNTRL VENOU LUMENX1 2.7FR DIA 71CML SIL 0.15ML PRIM,SUP-2613065,CDM,C1751,HCPCS,0278,RC,,,,both,,,924.73,601.07,,,,,,,,,,,,,
VALVE VENT DRNGE REG ADJ W/ SNAP RESVR PS MED STRATA II,SUP-2284521,CDM,C1889,HCPCS,0278,RC,,,,both,,,13711.22,8912.29,,,,,,,,,,,,,
GUIDEWIRE ORTH L400MM DIA3.1MM TRCR TIP DISP,SUP-2277483,CDM,C1769,HCPCS,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CATHETER SINUS BAL L16MM DIA6MM RELIEVA SOLO PRO,SUP-2106318,CDM,C1726,HCPCS,0272,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.0 X 9MM HE,SUP-2320334,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.69,378.10,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 55 CM OD 5 FR GUIDEWIRE 0.038 IN,SUP-2168809,CDM,C1894,HCPCS,0272,RC,,,,both,,,121.83,79.19,,,,,,,,,,,,,
CATHETER PACE 5FR L110CM 6FR INTRO D10CM 1MM SPACE POLYUR,SUP-2355209,CDM,C1894,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM W/ ULTRATAPE COBRAID BLU HEALICOIL,SUP-2341902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1623.66,1055.38,,,,,,,,,,,,,
PLATE BNE FUSION LT ANTR ANK 9 HOLE CONSTRUCT,SUP-2609569,CDM,C1713,HCPCS,0278,RC,,,,both,,,6163.76,4006.44,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR CUST SAG CTRL STRP PADDING STAY,SUP-2435556,CDM,L0641,HCPCS,0274,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
PLATE BONE 4 H RT MINI PREBENT FOR ANG FX,SUP-2365248,CDM,C1713,HCPCS,0278,RC,,,,both,,,1007.94,655.16,,,,,,,,,,,,,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,6370000000,HCPCS,0637,RC,00536-1268-12,NDC,,both,222,ML,25.00,16.25,,,,,,,,,,,,,
GRAFT BIO TISS W20XL30CM THK18 4MM ACELLULAR DERM MTRX ULT,SUP-2307489,CDM,Q4128,HCPCS,0636,RC,,,,both,,,54474.35,35408.33,,,,,,,,,,,,,
"HC So2 Spectrophotometry, Analyte Nes",PX-3018431168,CDM,84311,CPT,0301,RC,,,,inpatient,,,191.00,124.15,,,,,,,,,,,,,
STEM TIB DIA14MM BILAT ANK PLSM MID CEM PROPHECY INBONE,SUP-2397066,CDM,C1776,CPT,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
DRILL SURG CTRL CEM MBT HI PERF SIG LCS,SUP-2456249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
PLATE BNE SEMI TBLR 39 MM 2 HOLE FOR LG FRAG SYS SS NS,SUP-2458804,CDM,C1713,HCPCS,0278,RC,,,,both,,,161.46,104.95,,,,,,,,,,,,,
SCREW BNE BICORTICAL 30 MM SELF TAPPING NO-PROFILE,SUP-2608701,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.72,370.32,,,,,,,,,,,,,
APPLIER CLP ENDOSCP LG 12 MMX14 IN LIG HORZ MTL LIG SYS,SUP-2656788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2851.12,1853.23,,,,,,,,,,,,,
FOOTPLATE EXT FIX LNG 180 MM SET W/ RNG RX STRUT TRUELOK EVO,SUP-2875592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,37664.30,24481.79,,,,,,,,,,,,,
CATHETER ABLATION L 35 MM DIA12 FR CARD PULSED FLD STRL DISP,SUP-2930291,CDM,C1732,HCPCS,0278,RC,,,,both,,,26533.00,17246.45,,,,,,,,,,,,,
PLATE BONE W16XL285MM THK5MM 15 H LT CNDYL FEM S STL BTTRS,SUP-2185796,CDM,C1713,HCPCS,0278,RC,,,,both,,,2849.27,1852.03,,,,,,,,,,,,,
CLAMP EXT FIX DIA4MM DST RAD TI ALLY ADJ FOR SCHNZ SCR,SUP-2188538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2237.72,1454.52,,,,,,,,,,,,,
GRAFT BNE SUB W13XH35XL25MM 13DEG B TRICALCIUM PHSPTE GRAN,SUP-2194026,CDM,C1713,HCPCS,0278,RC,,,,both,,,2367.94,1539.16,,,,,,,,,,,,,
CATHETER PULM ART 5FR L100CM PVC 3 LUMN TRUE SZ THRMDIL,SUP-2214747,CDM,C1751,HCPCS,0278,RC,,,,both,,,978.93,636.30,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 30 CC CORTICAL FIBER,SUP-2899200,CDM,C1713,HCPCS,0278,RC,,,,both,,,15499.83,10074.89,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 13 CM DIA13 GA,SUP-2930213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46398.78,30159.21,,,,,,,,,,,,,
KIT SUTURE OPN SFT TISS REP CONVENIENCE CONTAIN HS FIBER,SUP-2906323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
PLUG SZ 5MM,SUP-2388881,CDM,C1776,CPT,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PROCEDURE KIT SD LOCATE GUIDE,SUP-2381760,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
INSERT TIB SZ 3 THK12MM UNIV UNI KNEE POLYETH UNI PRI NEUT,SUP-2251236,CDM,C1776,CPT,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
KIT INTRO VSI DE-CLOT SHTH L 4 CM DIA 6 FR GUIDEWIRE L 40 CM,SUP-2120537,CDM,C1757,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
GRAFT BNE EVANS WDG 20X25X6 MM BONUS,SUP-2861833,CDM,C1713,HCPCS,0278,RC,,,,both,,,2535.61,1648.15,,,,,,,,,,,,,
HC Ot Performnce Test Ea 15 Min,PX-4309775000,CDM,97750,CPT,0430,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
INFINITY ADAPTIS TALDOME SZ2 INFINITY ADAPTIS,SUP-2822348,CDM,C1776,CPT,0278,RC,,,,both,,,16579.20,10776.48,,,,,,,,,,,,,
CONNECTOR SPNL S STL THORLUM LO PROF INLINE FOR 5.5/5.5MM,SUP-2230991,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
SCREW BNE L40MM DIA7MM THRD L16MM CANC S STL ST SELF DRL,SUP-2397732,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
PLATE BNE L CNDYL TI FOR 1.5MM SCR MOD HND SYS,SUP-2191169,CDM,C1713,HCPCS,0278,RC,,,,both,,,1531.75,995.64,,,,,,,,,,,,,
PLATE BNE 100DEG 4X6 H L TI OBLQ L SHP FOR 2MM SCR,SUP-2191290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.36,745.78,,,,,,,,,,,,,
HC Screening Breast Tomo,PX-4037706300,CDM,77063,CPT,0403,RC,,,,outpatient,,,110.00,71.50,,,,,,,,,,,,,
INSERT TIB ROTATING HINGED 6 14 MM RT-PLUS,SUP-2450897,CDM,C1776,CPT,0278,RC,,,,both,,,2097.52,1363.39,,,,,,,,,,,,,
SHUNT CSF L87CM DIA4.5FR LP CATH T TB CONN FIX TAB N,SUP-2284531,CDM,C1889,HCPCS,0278,RC,,,,both,,,1850.90,1203.08,,,,,,,,,,,,,
ENDOPROSTHESIS TRACHBRONCH FLUENCY + L 40 MM DIA 8 MM CATH L,SUP-2128286,CDM,C1874,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
BIT DRL QR LNG 3.5 MM SURGIBIT,SUP-2518548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
SCREW BNE LAG 2X24 MM CROSS PIN NS LTX,SUP-2862738,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.98,129.34,,,,,,,,,,,,,
HC Smr Prim Src Wet Mount Nfct Agt,PX-3008721001,CDM,87210,CPT,0300,RC,,,,outpatient,,,208.00,135.20,,,,,,,,,,,,,
GUIDEWIRE ORTH L20IN TRCR TIP POLARUS,SUP-2106881,CDM,C1769,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
BUR SURG L104MM DIA126MM TOOL BORING AGG FOR TPS MIDAS,SUP-2363346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.49,253.17,,,,,,,,,,,,,
GRAFT HUM TISS W40XL70MM THK1.5MM DECELLULARIZED DERM RM,SUP-2264662,CDM,Q4125,HCPCS,0636,RC,,,,both,,,8147.36,5295.78,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC BSC 5FR 55CM 1 LUMAN RVS TA 3175118,SUP-2632657,CDM,C1751,HCPCS,0278,RC,,,,both,,,409.36,266.08,,,,,,,,,,,,,
PROSTHESIS OSS 4X4X8 MM 5.7 MM RICHARDS CENTERED HA,SUP-2637876,CDM,L8613,CPT,0278,RC,,,,both,,,1214.65,789.52,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 25X95 MM FD PERIO FASC LATA ORAGRAFT,SUP-2740992,CDM,C1762,CPT,0278,RC,,,,both,,,728.98,473.84,,,,,,,,,,,,,
GRAFT BNE 451842,SUP-2684156,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
NAIL IM L24CM DIA8MM RT ANTR POST FEM LCK CANN RG FOR,SUP-2318898,CDM,C1713,HCPCS,0278,RC,,,,both,,,11567.63,7518.96,,,,,,,,,,,,,
BUR SURG DIAMOND X COARSE 6.5 MMX10 CM CYL SM BOR LEGEND,SUP-2627635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.19,229.57,,,,,,,,,,,,,
CATHETER URETERAL BLLN DILATION 5MM X 4CM URO EZDILATE,SUP-2727217,CDM,C1758,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
HC So Diphtheria Antibody,PX-3028664866,CDM,86648,CPT,0302,RC,,,,inpatient,,,202.00,131.30,,,,,,,,,,,,,
SET STPLR 3.5MM HEMORRHOID PROLAPSE TECHNOLOGY EEA DST SER,SUP-2283288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1464.31,951.80,,,,,,,,,,,,,
BIT DRILL 2.1MM BIO INSTABILITY,SUP-2828537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,958.33,622.91,,,,,,,,,,,,,
KNIFE SCHUCKNECHT SICKLE,SUP-2668912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.21,266.64,,,,,,,,,,,,,
MESH SURG VERTESSA LITE 4X22CM STRIPS,SUP-2716339,CDM,C1781,HCPCS,0278,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
OMNI BASE HYSTEROSCOPE,SUP-2721031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO LUMBAR S/C SHELL/PANEL PREFABRICATED,SUP-2265012,CDM,L0450,HCPCS,0272,RC,,,,both,,,4998.88,3249.27,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED LT TALUS,SUP-2867078,CDM,C1762,CPT,0278,RC,,,,both,,,9262.22,6020.44,,,,,,,,,,,,,
DEVICE RESECTING SZ 2.9 MM FLX FOR POLYP FIBROID STRL DISP,SUP-2914680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE L 147 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 9 H SS 72467109N,SUP-2932861,CDM,C1713,HCPCS,0278,RC,,,,both,,,5774.15,3753.20,,,,,,,,,,,,,
CARTRIDGE TPE DIA3.1MM W/ ASAHI PLSMFLO PLSM SEP,SUP-2312277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,968.16,629.30,,,,,,,,,,,,,
SCREW BNE ST 2X5 MM CRTX FT W/ FLUT TIP TI NS,SUP-2189365,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.99,151.44,,,,,,,,,,,,,
HC X-Ray Exam Entire Spine 2/3 Vw,PX-3207208200,CDM,72082,CPT,0320,RC,,,,inpatient,,,969.00,629.85,,,,,,,,,,,,,
PLATE BNE W512XL512MM THK06MM CRAN SM GRID MESH RESORB X,SUP-2263019,CDM,C1713,HCPCS,0278,RC,,,,both,,,2990.19,1943.62,,,,,,,,,,,,,
TRAY TIB SZ 9 UNIV CO CHROM UHMWPE TOT STBL CEM WFL H STEM,SUP-2378564,CDM,C1776,CPT,0278,RC,,,,both,,,6013.73,3908.92,,,,,,,,,,,,,
KIT FIX PROX INTERPHALANGEAL JT BIOSYMMETRIC,SUP-2408290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3028.53,1968.54,,,,,,,,,,,,,
BIT DRL DIA3MM HD REL ADD ON,SUP-2136140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.70,268.90,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 101-159 MMX0.1 CM FRZN,SUP-2717861,CDM,C1762,CPT,0278,RC,,,,both,,,3656.09,2376.46,,,,,,,,,,,,,
ALLODERM SELECT 5X10 THICK 2.0-2.8,SUP-2822076,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5532.68,3596.24,,,,,,,,,,,,,
NEEDLE PUNC W/ FNGR VLV 2 MM TIP 5 MMX45 CM LL,SUP-2850976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.47,263.56,,,,,,,,,,,,,
SHEATH INTRO STEADYSHEATH EVOLUTION L 36.5 CM OD 21.3 FR ID,SUP-2169519,CDM,C1893,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE W25.5XL68MM WIDE 7X4 H ST R DST RAD VOLAR S STL,SUP-2420724,CDM,C1713,HCPCS,0278,RC,,,,both,,,2511.09,1632.21,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 0.5X0.5X0.5 CM 5 CC PRESERVON READIGRAFT,SUP-2740781,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.12,152.83,,,,,,,,,,,,,
HC Simple Rep Wnd Face <2.5 Cm,PX-4501201100,CDM,12011,CPT,0450,RC,,,,both,,,421.00,273.65,,,,,,,,,,,,,
LPS POROUS STEM 12.5X100MM STR,SUP-2513223,CDM,C1776,CPT,0278,RC,,,,both,,,11154.22,7250.24,,,,,,,,,,,,,
PLATE BNE L 231 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 20 H 72440720N,SUP-2932846,CDM,C1713,HCPCS,0278,RC,,,,both,,,3805.99,2473.89,,,,,,,,,,,,,
SCREW BONE L15MM DIAMETER 5MM HEX 2.5MM INTERFERENCE GUARDSM,SUP-2824110,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.19,442.77,,,,,,,,,,,,,
PLATE BNE 6 H ST BILAT MIDFOOT TALUS S STL MAL LO PROF LOK,SUP-2177141,CDM,C1713,HCPCS,0278,RC,,,,both,,,2478.94,1611.31,,,,,,,,,,,,,
DEVICE EMB CATERPILLAR DEL WIRE L 170 CM CATH 0.027 IN RVD,SUP-2655905,CDM,C1889,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SPLINT DORSAL AFO SPLNT M RT W STRP,SUP-2163836,CDM,L4396,HCPCS,0274,RC,,,,both,,,111.03,72.17,,,,,,,,,,,,,
GRAFT SYN GRAN 30CC INQU,SUP-2247317,CDM,C1713,HCPCS,0278,RC,,,,both,,,8277.04,5380.08,,,,,,,,,,,,,
PLATE BNE W14XL181MM THK3.8MM 90DEG 9 H L TIB S STL L SHP,SUP-2185791,CDM,C1713,HCPCS,0278,RC,,,,both,,,4189.45,2723.14,,,,,,,,,,,,,
BAR ORTHOT HIP PELV THGH CUST BND SPRED,SUP-2435598,CDM,L1640,HCPCS,0274,RC,,,,both,,,1340.21,871.14,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR W/ PT CTRL PROCLAIM + 5,SUP-2858398,CDM,C1767,HCPCS,0278,RC,,,,both,,,71205.78,46283.76,,,,,,,,,,,,,
SET VASC ACCS TRANSSEPTAL DIL L 93 CM DIA13 FR GUIDEWIRE L,SUP-2887623,CDM,C1769,HCPCS,0272,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
R-T TIB LOCK NL 13MMX36.0,SUP-2818301,CDM,C1713,HCPCS,0278,RC,,,,both,,,9594.27,6236.28,,,,,,,,,,,,,
HC So Mthfr Gene Analysis,PX-3108129166,CDM,81291,CPT,0310,RC,,,,both,,,229.00,148.85,,,,,,,,,,,,,
PLATE BNE LCK SHT 126 MM RT DSTL MEDL HUM 7 HOLE PUR STRL,SUP-2482566,CDM,C1713,HCPCS,0278,RC,,,,both,,,2877.15,1870.15,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.7X8 MM MANDIBULAR CORTICAL SELFTAPPIN,SUP-2838772,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.84,258.60,,,,,,,,,,,,,
PLATE BNE L23MM 6 H TI STR FOR 1.3MM SCR,SUP-2190687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.68,662.79,,,,,,,,,,,,,
STEM FEM L102MM DIA9MM KNEE TI POR BODY STR CEM GMRS,SUP-2376419,CDM,C1776,CPT,0278,RC,,,,both,,,9248.09,6011.26,,,,,,,,,,,,,
PLATE BNE L214MM 10 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185679,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.46,3051.40,,,,,,,,,,,,,
CROWN DENT 2 1ST PRIMARY M UPPER RT SS,SUP-2100174,CDM,D6783,CPT,0278,RC,,,,both,,,33.54,21.80,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RESPON L 65 CM 6FR 2-5-2 COURNAND,SUP-2481476,CDM,C1730,HCPCS,0272,RC,,,,both,,,230.41,149.77,,,,,,,,,,,,,
PROCEDURE PACK 30 CC BMAC2-30-02 BMAC,SUP-2384753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
SCREW BNE L54MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413583,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
PLATE BNE 16 H SS LT PELV ANTR CLMN ANAT STRL PRO,SUP-2902438,CDM,C1713,HCPCS,0278,RC,,,,both,,,7084.15,4604.70,,,,,,,,,,,,,
TEMPLATE DERM W4XL10IN REGEN SZ FOR BURN RECON SURG,SUP-2243492,CDM,Q4105,HCPCS,0636,RC,,,,both,,,14315.26,9304.92,,,,,,,,,,,,,
STEM HUM 6B L109MM 132.5DEG LNG TI CEM AEQUALIS ASCEND FLX,SUP-2388754,CDM,C1776,CPT,0278,RC,,,,both,,,9553.14,6209.54,,,,,,,,,,,,,
KIT GWIRE L DIA2MM CO CHROM T25 CANN SCRDRVR DEPTH GA,SUP-2225507,CDM,C1769,HCPCS,0272,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
HC Cast - Long Leg,PX-4502934500,CDM,29345,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
HALF PIN 5MMX70MM,SUP-2820679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.91,514.74,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4409753000,CDM,97530,CPT,0440,RC,,,GO|CO|XU,both,,,191.00,124.15,,,,,,,,,,,,,
"HC Inj Proc Nfrosgrm/Urtrgrm, Complete",PX-3615043100,CDM,50431,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,0636,RC,42494-0415-25,NDC,,both,1,ML,120.50,78.32,,,,,,,,,,,,,
COMPONENT FEM PAT PFJ L W OXINIUM AND RND,SUP-2347993,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SHEATH DIL 8 FRX15 CM 8 FR REINF W/ HEMSTAS VLV DIL,SUP-2517606,CDM,C1894,HCPCS,0272,RC,,,,both,,,120.20,78.13,,,,,,,,,,,,,
CATHETER CTRL VEN KT TRIFUSION 19CM STR TIP TO CUF 3 LUMN,SUP-2127761,CDM,C1751,HCPCS,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
CATHETER EP LG CURL BI DIR IRRIG SAFIRE,SUP-2357045,CDM,C2630,CPT,0272,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 110 CM 7FR TIP 1 MM 2XL,SUP-2705586,CDM,C1730,HCPCS,0272,RC,,,,both,,,1226.20,797.03,,,,,,,,,,,,,
GRAFT BNE SUB W15XL15MM TRICORT ILIUM CREST BLK FRZ DRY,SUP-2293828,CDM,C1713,HCPCS,0278,RC,,,,both,,,3158.84,2053.25,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 180 CM 0.035 IN TIP 1.5 MM J FIX,SUP-2301896,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
GRAFT TISSUE WHOLE FEMORAL CONDYLE LEFT,SUP-2880218,CDM,C1762,CPT,0278,RC,,,,both,,,67039.00,43575.35,,,,,,,,,,,,,
BLADE SHV L19CM DIA4.2MM TORPEDO HIP LEN TAPR TIP SCIS LIKE,SUP-2121978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
COMPONENT HIP CEM STD LNR XLPE,SUP-2212721,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA 7 MM EPTFE STR STD WALL N RING,SUP-2396428,CDM,C1768,CPT,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
PLATE 12MM ASPN 62110012,SUP-2209277,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
PROXIMAL LAT TIB PLATE LEFT 14 HOLE,SUP-2829403,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
ANCHOR SUT DIA2.8MM TI W/ NO1 PRELD SUT TWINFIX,SUP-2341586,CDM,C1713,HCPCS,0278,RC,,,,both,,,542.91,352.89,,,,,,,,,,,,,
CATHETER DRNGE BILI 12FRX40CM 0.038IN GWIRE SKATER LCK PGTL,SUP-2120144,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
BIT DRL L 10 IN DIA 4.8/1.8 MM HALF PIN DIA 6 MM CANN GRAD,SUP-2932838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1573.23,1022.60,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2.7MM RM ROD BALL TIP FOR PEDINAIL SYS,SUP-2318962,CDM,C1769,HCPCS,0272,RC,,,,both,,,1359.31,883.55,,,,,,,,,,,,,
CATHETER ATHRCTMY CROSSER L 146 CM DIA1.6 MM GUIDEWIRE 0.014,SUP-2128075,CDM,C1714,HCPCS,0272,RC,,,,both,,,8003.86,5202.51,,,,,,,,,,,,,
KIT BNE CEM ANK SHLDR EL APPLICATIONS W/ SM APPL MIX AND,SUP-2120719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 12X0.5 MM SLGHT CONTOURED PDLLA STRL,SUP-2467302,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.53,586.64,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED LOCATOR NRV 16HZ SURG STIM HD AND NK,SUP-2163797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
HC ED Clsd Tx Elbow Disclocation,PX-4502460000,CDM,24600,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,6370000000,HCPCS,0637,RC,00536-5896-88,NDC,,both,1,UN,14.80,9.62,,,,,,,,,,,,,
STABILIZER FEMORALXL DURAC RT KNEE MOD MONO IMP,SUP-2364847,CDM,C1776,CPT,0278,RC,,,,both,,,5172.71,3362.26,,,,,,,,,,,,,
SUTURE ANCHOR AR1920SF1,SUP-2843750,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
MODULUS XL 10X18X45MM 10 DEG INDIV ST PKG,SUP-2309897,CDM,C1713,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
GUIDEWIRE ORTH DBL RND 1.3X400 MM,SUP-2766039,CDM,C1769,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
VALVE AORT CRYOVALVE SZ 22 MM AORT ALLGRFT NONROTATABLE,SUP-2175205,CDM,C1889,HCPCS,0278,RC,,,,both,,,34524.30,22440.79,,,,,,,,,,,,,
SYSTEM THERMOABLATION COBRA ADHEREXL SURG ASMBLY STRL,SUP-2124413,CDM,C1713,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
GRAFT VASC IMPRA L 30 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761262,CDM,C1768,CPT,0278,RC,,,,both,,,1357.01,882.06,,,,,,,,,,,,,
ASSEMBLY VALGUS BUSHING,SUP-2359179,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ROD EXT FIX THRD 25 MM DNE25TR] DNE LLC],SUP-2197274,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
SET DILATOR 18FR SUPRAPUBIC  PEEL AWAY,SUP-2665179,CDM,C2627,HCPCS,0272,RC,,,,both,,,492.35,320.03,,,,,,,,,,,,,
KIT GRAFT BONE SM RHBMP-2 4.2MG INJ 5ML CONTAIN NDL 20GA,SUP-2287848,CDM,C1713,HCPCS,0278,RC,,,,both,,,11947.70,7766.00,,,,,,,,,,,,,
BIOFOAM COTTON WEDGE 16X14X10X4.5 STERILE,SUP-2900567,CDM,C1713,HCPCS,0278,RC,,,,both,,,9245.73,6009.72,,,,,,,,,,,,,
CEMENT BNE 40GM HI VISC RADPQ FOR REV SURG,SUP-2403495,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 18X2 CM PROC SUSPEND FASC LATA TUTOPLAST,SUP-2165385,CDM,C1762,CPT,0278,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
MATRIX HUM TISS L 5 X W 5 CM DECELL PLCNTA MEMBRN,SUP-2909325,CDM,Q4201,HCPCS,0636,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
SCREW SPNL 11X35 MM STRL FIREBIRD SI,SUP-2657863,CDM,C1713,HCPCS,0278,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2+X230 MM W/ CALIB QUIK RELEASE FIT FIXOS,SUP-2457199,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 4 FR L 7 CM NIT,SUP-2633279,CDM,C1894,HCPCS,0272,RC,,,,both,,,71.22,46.29,,,,,,,,,,,,,
STAPLE DEPALMA 3/4 X 3/4,SUP-2487923,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
GRAFT ALLGRFT PARTICULATE CORT DEMIN FRZ DRY READIGRFT 20CC,SUP-2264721,CDM,C1713,HCPCS,0278,RC,,,,both,,,1322.91,859.89,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER SGL CHMBR 40 J BPLR PREM DDD 20,SUP-2138265,CDM,C1722,HCPCS,0275,RC,,,,both,,,62501.86,40626.21,,,,,,,,,,,,,
COLLAR CERV ADJ LP THERMOPLASTIC OSSUR MIAMI J,SUP-2388136,CDM,L0180,HCPCS,0272,RC,,,,both,,,939.80,610.87,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 57 X 39 X 5 MM SM POLYETHYL LT MAND,SUP-2935193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.18,1096.02,,,,,,,,,,,,,
CATHETER DIAG 5.3X5.6FR L115CM ID0.058IN DST ACCS AXS,SUP-2368074,CDM,C1887,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
DEVICE PROTCT CEREB MOMA,SUP-2296569,CDM,C1884,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
PLATE BONE L97.2MM 14 H STRL BILAT VAR LCK NONCOMPRESSION,SUP-2349960,CDM,C1713,HCPCS,0278,RC,,,,both,,,8254.12,5365.18,,,,,,,,,,,,,
HC Treat Humerus Fracture,PX-4502457700,CDM,24577,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
STENT BILI L14MM BLLN L17MM DIA5MM CATH L135CM 14/12ATM,SUP-2159004,CDM,C1876,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
TROCAR 25GA 2ND CONSTELLATION,SUP-2109940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.06,284.74,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM OD 5 FR ID 1.7 MM GUIDEWIRE 0.021,SUP-2168445,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.22,81.39,,,,,,,,,,,,,
CANNULA ENDOSCP L 70 MM DIA 5 MM SHRT BLDELSS TROCAR SLV,SUP-2896434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.28,228.98,,,,,,,,,,,,,
HC Diagnostic Lumbar Puncture,PX-7616227000,CDM,62270,CPT,0761,RC,,,,both,,,2232.00,1450.80,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3 CM 035X150 STD COR HYDRPHLC CANALIZER,SUP-2120015,CDM,C1769,HCPCS,0272,RC,,,,both,,,95.46,62.05,,,,,,,,,,,,,
PATCH CV GORTX NOM L 15 X W 10 CM THK 0.6 MM EPTFE CNFRM,SUP-2395303,CDM,C1768,CPT,0278,RC,,,,both,,,4628.36,3008.43,,,,,,,,,,,,,
"HC Assess of Aphasia,per Hour",PX-4449610500,CDM,96105,CPT,0444,RC,,,,both,,,554.00,360.10,,,,,,,,,,,,,
SLEEVE CANN DIA12 MM SHRT RADIALLY EXPANDABLE STRL DISP,SUP-2896315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.39,206.30,,,,,,,,,,,,,
SEPARATOR THROMCTMY L175CM DST DIA0045IN COMPATIBLE W CAT5,SUP-2323710,CDM,C1757,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 180 CM DIA 0.035 IN CRV RAD 1.5 MM,SUP-2157296,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.90,45.43,,,,,,,,,,,,,
NAIL FEMORAL 14MM RETROGRADE,SUP-2752470,CDM,C1713,HCPCS,0278,RC,,,,both,,,11194.10,7276.16,,,,,,,,,,,,,
COMPONENT 3.5X124MM HUMERAL ELBOW FLANGED C LEFT DISCOVERY,SUP-2879166,CDM,C1776,CPT,0278,RC,,,,both,,,16061.10,10439.71,,,,,,,,,,,,,
SYSTEM VLV 23GA 6MM 3 COUNT ASSY SHIP DISP OTH ACCURUS DISP,SUP-2109964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PACK PROC ANT VITRCTMY CUT HI SPD 30CPM 5000CPM 20GA,SUP-2129345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.59,437.18,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 5.5X22 MM HD TI NS EXTREMIFIX LTX,SUP-2856320,CDM,C1713,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
GUIDEWIRE ORTH 2X8 MM NS,SUP-2799283,CDM,C1769,HCPCS,0272,RC,,,,both,,,470.62,305.90,,,,,,,,,,,,,
PLATE BNE W8XL20MM THK2MM 0DEG 2 H BILAT TI STR RIG DYN,SUP-2191067,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.49,577.52,,,,,,,,,,,,,
DRESSING BIO W4XL10IN BOV TEND CLLGN MESHED GLYCOSAMINOGLYCAN,SUP-2244274,CDM,C9363,HCPCS,0636,RC,,,,both,,,22684.49,14744.92,,,,,,,,,,,,,
CROWN DENT 4U REFIL UP CUSPID S STL PRI PRE TRIMMED PREFRM,SUP-2322230,CDM,D6783,CPT,0278,RC,,,,both,,,34.29,22.29,,,,,,,,,,,,,
KWIRE FIX L6IN DIA16MM NONSTERILE S STL 3 SIDE DBL TRCR,SUP-2150336,CDM,C1713,HCPCS,0278,RC,,,,both,,,7.44,4.84,,,,,,,,,,,,,
IMPLANT WR JT RAD COMP LT CO CHROM MOLYBDENUM SZ 1,SUP-2243497,CDM,C1776,CPT,0278,RC,,,,both,,,25615.84,16650.30,,,,,,,,,,,,,
PORT INFUS 8FR L45CM POLYUR ATTACH CATH TI OPN SUT PLUG LO,SUP-2127787,CDM,C1788,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 6 CM DIA 5 MM STD,SUP-2323357,CDM,C1889,HCPCS,0278,RC,,,,both,,,6386.76,4151.39,,,,,,,,,,,,,
ILLUMINATOR OPHTH DIA23GA RFID STR SMOOTH ROUNDED DSTL TIP,SUP-2109913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.75,242.94,,,,,,,,,,,,,
SPLINT WRST THMB L L8IN R BLK FOAM D RNG CLSR ADJ REUSE,SUP-2336030,CDM,L3809,HCPCS,0272,RC,,,,both,,,42.20,27.43,,,,,,,,,,,,,
HC Niv Venous Duplex Bilat Study,PX-9219397000,CDM,93970,CPT,0921,RC,,,,both,,,2312.00,1502.80,,,,,,,,,,,,,
COIL EMB L24CM DIA9MM MICROCATHETER DIA0.0165IN,SUP-2305187,CDM,C1889,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
PLATE BNE DOGBONE 30 MM W/ COMPR GORILLA,SUP-2321544,CDM,C1713,HCPCS,0278,RC,,,,both,,,4461.94,2900.26,,,,,,,,,,,,,
PLATE BONE THK1MM 2X2 H BILAT HND RECTANG LCK TRILOK FOR 2MM,SUP-2267928,CDM,C1713,HCPCS,0278,RC,,,,both,,,1301.22,845.79,,,,,,,,,,,,,
SPLINT ORTH NT ANK FT,SUP-2388199,CDM,L4397,HCPCS,0274,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE THK1.5MM 4X4 H MAND TI NONCOMPRESSION FRAC ANG,SUP-2263009,CDM,C1713,HCPCS,0278,RC,,,,both,,,713.41,463.72,,,,,,,,,,,,,
GUIDEWIRE ORTH L20IN DIA2MM NIT FOR MOD SHLDR SYS POLARUS,SUP-2107887,CDM,C1769,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
PRX HUM HI PLT RT 14H 234MM,SUP-2587058,CDM,C1713,HCPCS,0278,RC,,,,both,,,5802.72,3771.77,,,,,,,,,,,,,
BIT DRL STP OPENING 6 MM FOR OLECRANON OSTEOTMY NAIL NS,SUP-2757679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1136.77,738.90,,,,,,,,,,,,,
FOOTPLATE EXT FIX 180 MM NS TRUELOK LTX,SUP-2875087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.03,765.07,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB W/ 10100 INS5010 HERM LUMBAR,SUP-2883469,CDM,C1729,HCPCS,0272,RC,,,,both,,,1033.22,671.59,,,,,,,,,,,,,
SCREW BONE L34MM OD4MM CANN TAPR LAG ANK INTRAOSSEUS FIX,SUP-2223797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
STAPLER ENDO THORACOSCOPIC SEAMGRD,SUP-2396263,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
JIG KNEE IMPL CR IDENTITY IMPRNT,SUP-2904395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR KT PRECIS SPECTR,SUP-2141896,CDM,C1820,HCPCS,0278,RC,,,,both,,,51182.00,33268.30,,,,,,,,,,,,,
PLATE SPNL L35MM POST LUM INTERSPINOUS BLADED AFFIX,SUP-2311354,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
PERC NGAGE NITINOL TIPLESS STONE EXTRACTOR,SUP-2827470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.42,396.77,,,,,,,,,,,,,
BIT DRL 1.2X85 MM 4 MM STP TPS END NS UNIV NEURO III LTX,SUP-2862795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.55,461.21,,,,,,,,,,,,,
CATHETERIZATION KIT ART 025 18 GAX12 CM 25 GA 3 CC LF,SUP-2865602,CDM,C1751,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
IMPLANT OSS L6MM HD 4MM THK3MM 1.17MM HA HD HAPEX SHFT FULL,SUP-2313861,CDM,L8613,CPT,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
IMMOBILIZER KNEE SIZED CANVS 16 IN L,SUP-2336062,CDM,L1830,CPT,0272,RC,,,,both,,,35.76,23.24,,,,,,,,,,,,,
MODULE NEUROSURGICAL MAS TRANSFORAMINAL LUM INTBDY FUS HOOP,SUP-2311773,CDM,C1713,HCPCS,0278,RC,,,,both,,,5118.83,3327.24,,,,,,,,,,,,,
HC ED Rep Cpx Sc Arm Le Addl 5cm,PX-4501312200,CDM,13122,CPT,0450,RC,,,,both,,,2071.00,1346.15,,,,,,,,,,,,,
INTRODUCER TRACH 8FR 24-28FR 0.52IN PERC TRACH CIAGLIA,SUP-2167990,CDM,C1894,HCPCS,0272,RC,,,,both,,,1399.84,909.90,,,,,,,,,,,,,
PLATE BNE TBLR 6 HOLE 1/4 LCK TI STRL,SUP-2525170,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.76,591.99,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 80 CM DIA 0.018 IN NIT MANDREL TUNGSTEN,SUP-2763454,CDM,C1769,HCPCS,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
MESH HERN W15XL15CM THK0.5MM SYNTH ABD ABSRB COAT POLYPR,SUP-2265977,CDM,C1781,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
BUR SURG CYL 5X13.5 MM 9 CM FLUT LG BOR MIDAS REX 8,SUP-2664872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.38,285.60,,,,,,,,,,,,,
ALLOGRAFT BNE 1-4 MM 30 CC FD IRRADIATED CORTICAL CANC,SUP-2866826,CDM,C1762,CPT,0278,RC,,,,both,,,987.37,641.79,,,,,,,,,,,,,
GRAFT HUM TISS ANT TIBIALIS TEND SM DIAM (ALL FLD DIAM,SUP-2307280,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
BIT DRL LP STRL JUGGERKNOTLESS DISP,SUP-2608565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,309.48,201.16,,,,,,,,,,,,,
ALLOSYNC DBM STRIP 10X20X7MM,SUP-2811277,CDM,C1713,HCPCS,0278,RC,,,,both,,,2614.05,1699.13,,,,,,,,,,,,,
HC So Voltage-Gated Calcium Channel Antibody Each,PX-3028659666,CDM,86596,CPT,0302,RC,,,,both,,,72.00,46.80,,,,,,,,,,,,,
COLLAR CERV CAPITAL ENH,SUP-2336002,CDM,L0120,HCPCS,0274,RC,,,,both,,,84.62,55.00,,,,,,,,,,,,,
GRAFT BIO W4XL4CM DERM,SUP-2321663,CDM,Q4126,HCPCS,0636,RC,,,,both,,,5731.13,3725.23,,,,,,,,,,,,,
BOOT CAST L AD UNISX OPN TOE VELC CLSR TCC-EZ,SUP-2194357,CDM,L4386,HCPCS,0274,RC,,,,both,,,259.33,168.56,,,,,,,,,,,,,
PLATE BNE SM L58MM 5 H BILAT S STL LO PROF RIG LIMIT CNTCT,SUP-2186224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.82,753.23,,,,,,,,,,,,,
MESH SURG W8X15CM DIA5MM POLYPR RECT FLAT FOR SFT TISS REP,SUP-2219796,CDM,C1781,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
CLIP EXT FIX L1.5-1.8MM GRY WIRE DISC FOR ILIZ TAY SPAT FRME,SUP-2342994,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.82,35.63,,,,,,,,,,,,,
MESH ORBIT THK0.3MM MIDFACE TI FOR 0.6MM SCR,SUP-2262594,CDM,C1713,HCPCS,0278,RC,,,,both,,,934.15,607.20,,,,,,,,,,,,,
"HC So Heavy Metals,Quant Ea",PX-3018301866,CDM,83018,CPT,0301,RC,,,,inpatient,,,70.00,45.50,,,,,,,,,,,,,
PLATE BNE W5XL41MM THK1.5MM 7 H TI METATARSAL FOREFOOT,SUP-2398012,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ELECTRODE ES BPLR WIRE DISP SUPERLOOP,SUP-2313934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1633.62,1061.85,,,,,,,,,,,,,
HC So Hepatitis B Core Antibody,PX-3028670466,CDM,86704,CPT,0302,RC,,,,both,,,59.00,38.35,,,,,,,,,,,,,
BLOCK TIB THK10MM W/ SCR PROVEN,SUP-2359284,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
BUR SURG DR LNG 8X14 MM FLUT SLIDE CUT QD14-S/QD14-G1/QD14,SUP-2848150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.57,273.37,,,,,,,,,,,,,
FORCEP GRASPING STEVENSON 6 INX15.2 CM ALLIGATOR TYP STR JAW,SUP-2423954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.61,231.80,,,,,,,,,,,,,
PLATE BNE L240MM 15 H ST R DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177220,CDM,C1713,HCPCS,0278,RC,,,,both,,,4781.78,3108.16,,,,,,,,,,,,,
CATHETER HD PRECRV 13.5 FRX13 CM DL HI FLO IC TY MAHRK ELITE,SUP-2626905,CDM,C1752,HCPCS,0278,RC,,,,both,,,283.51,184.28,,,,,,,,,,,,,
CAGE SPNL 20 DEG 34X24X8 MM ALIF MODULUS,SUP-2736327,CDM,C1889,HCPCS,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
POST EXT FIX OUTRIG 8 MM 90 DEG,SUP-2188519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.99,240.49,,,,,,,,,,,,,
CATH BLLN SCORING 7X40MM X 137CM OTW PTA ANGIOSCULPT XL,SUP-2353075,CDM,C1725,HCPCS,0272,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR 21 MM BOV PERICARD COCR REDUC,SUP-2214068,CDM,C1889,HCPCS,0278,RC,,,,both,,,18777.20,12205.18,,,,,,,,,,,,,
TISSUE 16X26X26MM F TS PROGENIX +,SUP-2293924,CDM,C1713,HCPCS,0278,RC,,,,both,,,12154.94,7900.71,,,,,,,,,,,,,
HC CT Heart Scan,PX-3527557200,CDM,75572,CPT,0480,RC,,,,both,,,2388.00,1552.20,,,,,,,,,,,,,
HC Special Stain I&R Group III Enzyme Consituents,PX-3128831900,CDM,88319,CPT,0312,RC,,,,both,,,349.00,226.85,,,,,,,,,,,,,
DISPENSER GUIDEWIRE 1.1 MMX6 IN,SUP-2607261,CDM,C1769,HCPCS,0272,RC,,,,both,,,540.52,351.34,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.420,SUP-2859984,CDM,C1713,HCPCS,0278,RC,,,,both,,,35350.43,22977.78,,,,,,,,,,,,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,0636,RC,00409-1178-30,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
HC CT T-Spine W/O Contrast,PX-3527212800,CDM,72128,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
BASKET STONE 3FR L90CM 16MM 4 WIR FLATWIRE SURLOK,SUP-2312749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.70,273.45,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK04 07MM THN HYDRATED ACELLULAR,SUP-2307447,CDM,Q4128,HCPCS,0636,RC,,,,both,,,3539.09,2300.41,,,,,,,,,,,,,
EASYFUSE STAPLE MTP S NITINOL 4-LEG,SUP-2830242,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
SET INTRO PEELWY ECHOTIP L 9 CM DIA 4 FR GUIDEWIRE L 65 CM,SUP-2168657,CDM,C1892,HCPCS,0272,RC,,,,both,,,146.83,95.44,,,,,,,,,,,,,
SNARE ENDOSCP POLYP 2.8 MMX165 CM SET COLONSCP SNAREMASTER +,SUP-2481032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1163.75,756.44,,,,,,,,,,,,,
BAR EXT FIX 11X400 MM TRAFFIX,SUP-2205343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.97,484.23,,,,,,,,,,,,,
FOLLOWER URO 18FR L36CM HLLW PLAS URETH 1 EYE POLYMER BOUG,SUP-2384624,CDM,C1726,HCPCS,0272,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
MANIFOLD ANGIO 3 PRT 200PSI LT ORIENTATION ADPT HALF BODY,SUP-2301387,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.22,8.59,,,,,,,,,,,,,
PLATE BONE 6 H LCK SCAPHOID FOR 1.5MM SCR TRILOK,SUP-2267911,CDM,C1713,HCPCS,0278,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
REAMER SURG SPNL ADJUSTABLE POST,SUP-2286810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1031.62,670.55,,,,,,,,,,,,,
KIT BNE BX SZ 3 8GA DIA42MM NDL 18GA COMPLT W FILL NOZ,SUP-2280931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0.035IN PTFE MOD J SHP TIP INTMED,SUP-2173638,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CATH CSF EXTERNAL DRAIN SYS NATUS EDS3 W/O CATH,SUP-2843356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.90,389.93,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE DIA 4 FR NIT PERIPH ECHOGENIC STRL,SUP-2168405,CDM,C1894,HCPCS,0272,RC,,,,both,,,114.23,74.25,,,,,,,,,,,,,
SCREW BNE MAXILLOMANDIBULAR 2X12 MM 8 MM MAXDRIVE 250983805,SUP-2470897,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.71,198.71,,,,,,,,,,,,,
HEAD RADIAL MOD 20 STD ELBW,SUP-2610425,CDM,C1776,CPT,0278,RC,,,,both,,,8207.39,5334.80,,,,,,,,,,,,,
SCREW BNE L14MM DIA2MM TI QUICKSNAP TQ SER,SUP-2244465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.63,757.01,,,,,,,,,,,,,
NECK FEM SZ 1 LNG CO CHROM HIP ANTEVERSION RETRO VARUS,SUP-2304838,CDM,C1776,CPT,0278,RC,,,,both,,,8572.20,5571.93,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ULTRA ICE + L 110 CM DIA 8.5 FR,SUP-2140873,CDM,C1753,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
DRIVER POWER 2 DRIVE DISP,SUP-2136973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 60 DEG L 11 CM DIA 3.5 MM SPD 5000 RPM HRE,SUP-2902790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,836.50,543.72,,,,,,,,,,,,,
STEM FEM STD OFFSET 11-14 W/ TRUNNION MALLORY-HEAD XR SER,SUP-2442622,CDM,C1776,CPT,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX15 CM 3L POLYETH,SUP-2760053,CDM,C1751,HCPCS,0278,RC,,,,both,,,234.53,152.44,,,,,,,,,,,,,
SCREW FIX ANCHR TIMBERLINE,SUP-2415842,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
GRAFT BNE CHIP 4-10 MM 30 CC CANC PUREBONE,SUP-2424604,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
SPACER SPNL 11 MM ANCHR COALITION,SUP-2433815,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BLADE SHAVER SERRATED 4 MM DSTL SUCTION,SUP-2648911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,535.62,348.15,,,,,,,,,,,,,
CATHETER DIAG MEWISSEN STRL,SUP-2140127,CDM,C1751,HCPCS,0278,RC,,,,both,,,249.63,162.26,,,,,,,,,,,,,
CATHETER EP 7FR L95CM 5-5-5MM SPC 2MM TIP SUP L CURL,SUP-2356913,CDM,C1731,HCPCS,0278,RC,,,,both,,,3432.02,2230.81,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.429,SUP-2859993,CDM,C1713,HCPCS,0278,RC,,,,both,,,37928.69,24653.65,,,,,,,,,,,,,
CATHETER ETER EP 6FR L115CM 2 2 2MM SPC STABILENE OCTAPOLAR FIX,SUP-2142594,CDM,C1730,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
COMPONENT FEM SZ 4 L POST KNEE NP PRI BICRUCIATE CEM STBL,SUP-2350305,CDM,C1776,CPT,0278,RC,,,,both,,,13755.56,8941.11,,,,,,,,,,,,,
BASKET POLYP RETRV L6CM OD3CM CATH L240CM OD7FR 2.8MM MIN,SUP-2171320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BNE L355MM 14 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186049,CDM,C1713,HCPCS,0278,RC,,,,both,,,4971.22,3231.29,,,,,,,,,,,,,
COLLAR CERV ADJ CHIN CUP THERMOPLASTIC,SUP-2388133,CDM,L0150,HCPCS,0274,RC,,,,both,,,295.82,192.28,,,,,,,,,,,,,
LEVOFLOXACIN 250 MG PO TABS,RX-18918,CDM,6370000000,HCPCS,0637,RC,00904-6351-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HMRS BEARING - 18 x 24,SUP-2512639,CDM,C1776,CPT,0278,RC,,,,both,,,698.02,453.71,,,,,,,,,,,,,
STENT URET L 28 CM DIA 8 FR TIP L 3 CM ZIPWIRE 0.038 IN,SUP-2722598,CDM,C2617,HCPCS,0278,RC,,,,both,,,413.76,268.94,,,,,,,,,,,,,
DEVICE EMB L18MM OD3.25MM 55DEG SFT DST TIP BRAID 4 FLX,SUP-2296711,CDM,C1884,HCPCS,0278,RC,,,,both,,,41831.08,27190.20,,,,,,,,,,,,,
HC Antibody Rubella,PX-3028676200,CDM,86762,CPT,0302,RC,,,,inpatient,,,137.00,89.05,,,,,,,,,,,,,
PLATE BONE L120.5MM 7 H LT DSTL FIB TI ANAT FOR,SUP-2225371,CDM,C1713,HCPCS,0278,RC,,,,both,,,5796.13,3767.48,,,,,,,,,,,,,
SET CATH HEMODIALYSI SPLIT CATH RG CHRONIC BASIC 14FR DIA 24,SUP-2610622,CDM,C1750,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT BNE 1 CC,SUP-2644304,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
GRAFT HUM TISS 1ML SYR PASTE IMPL BONE DBM FRZN DEMIN,SUP-2293735,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
BRACE STRNL PD KT TLSO BLK SM,SUP-2123926,CDM,L0462,HCPCS,0272,RC,,,,both,,,281.60,183.04,,,,,,,,,,,,,
HEAD FEM DIA28MM NK +0MM CERAMIC PRI TAPR 12/14 ALUMINA TRIL,SUP-2202659,CDM,C1776,CPT,0278,RC,,,,both,,,4900.28,3185.18,,,,,,,,,,,,,
MIXER CEMENT M4 W/ HV BONE CEMENT,SUP-2885535,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.81,2594.03,,,,,,,,,,,,,
PORT IMPL INFUSION PRECON 5 FR TI VORT,SUP-2240130,CDM,C1788,HCPCS,0278,RC,,,,both,,,953.30,619.64,,,,,,,,,,,,,
CATHETER OPHTH PED BLLN L13MM DIA2MM LACR BILAT FOR,SUP-2330964,CDM,C1726,HCPCS,0272,RC,,,,both,,,871.35,566.38,,,,,,,,,,,,,
PLATE BNE THK1MM 0DEG SM MINI TI ORAL MAXILLOFACIAL 4 H,SUP-2262736,CDM,C1713,HCPCS,0278,RC,,,,both,,,975.41,634.02,,,,,,,,,,,,,
HC CT Angio Abdomen W & W/O Cont,PX-3527417500,CDM,74175,CPT,0352,RC,,,,both,,,4683.00,3043.95,,,,,,,,,,,,,
HC Treat Wrist Bone Fx,PX-4502565000,CDM,25650,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
HC Incisional Biopsy Skin Single Lesion,PX-4501110600,CDM,11106,CPT,0450,RC,,,,both,,,1941.00,1261.65,,,,,,,,,,,,,
BUR SURG DIA1.4 MM HUB II ROSEN STRL REUSE HI-LINE,SUP-2929495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.81,220.88,,,,,,,,,,,,,
CAGE SPNL W21XH36 56XL22MM 5DEG MIDTHORACIC INTBDY FUS TI,SUP-2182813,CDM,C1889,HCPCS,0278,RC,,,,both,,,20724.00,13470.60,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM NONROTATABLE CRV SHFT RAD 40,SUP-2284145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,736.52,478.74,,,,,,,,,,,,,
PLATE BNE L 151 MM SCREW DIA2.7/3.5 MM 12 H SS RT DSTL,SUP-2931210,CDM,C1713,HCPCS,0278,RC,,,,both,,,6015.61,3910.15,,,,,,,,,,,,,
PLATE BNE L255MM 16 H BILAT S STL STR NONCOMPRESSION RECON,SUP-2410187,CDM,C1713,HCPCS,0278,RC,,,,both,,,1562.78,1015.81,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 025 5 FRX12 CM 3L STRL,SUP-2759915,CDM,C1751,HCPCS,0278,RC,,,,both,,,459.13,298.43,,,,,,,,,,,,,
DRIVER SURGICAL T 15 PROXIMAL HUMERUS PLATING SYSTEM ALPS,SUP-2466066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
CATHETER DRAIN 12F 25CM STD LOOP W/ RADIOPAQUE MRKR BND PG,SUP-2659158,CDM,C1729,HCPCS,0272,RC,,,,both,,,235.44,153.04,,,,,,,,,,,,,
IMPLANT TOE JT COCR OD13.25 MM METATRSL PHLANG NP COAT,SUP-2137766,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CATHETER PICC DBL LUMN FULL TY NRS PWR INJ POLYUR N COAT CT,SUP-2125544,CDM,C1751,HCPCS,0278,RC,,,,both,,,601.62,391.05,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA 9 FR HYDRPHLC,SUP-2383417,CDM,C1894,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
PLATE LCP 20 HL 2.7 X 184MM STERILE,SUP-2740108,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.07,975.05,,,,,,,,,,,,,
HC So Special Stain Grp 2,PX-3128831366,CDM,88313,CPT,0312,RC,,,,both,,,239.00,155.35,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBM CA SULF W/ 1-4MM CANC CHIP ALLMTRX,SUP-2399074,CDM,C9359,HCPCS,0278,RC,,,,both,,,3435.16,2232.85,,,,,,,,,,,,,
HC So Cold Agglutinin,PX-3028615766,CDM,86157,CPT,0302,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
PLATE BONE 6X17 H RT MAND HMSPHR TI RECON LEIBINGER,SUP-2363750,CDM,C1713,HCPCS,0278,RC,,,,both,,,4018.13,2611.78,,,,,,,,,,,,,
SCREW SPNL L32MM DIA5.2MM CORT ANTR LUM ST VAR ANG AEGIS,SUP-2256321,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE L125MM 7 H ST R DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177216,CDM,C1713,HCPCS,0278,RC,,,,both,,,4725.54,3071.60,,,,,,,,,,,,,
CATHETER PERIPH 20/22GA MULT LUMN RADPQ RND WALL NDL TWIN,SUP-2383470,CDM,C1751,HCPCS,0278,RC,,,,both,,,25.87,16.82,,,,,,,,,,,,,
SCREW BNE LCK 3.5X50 MM MULT DIR FOR T16,SUP-2411601,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.84,317.75,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE PELVIS GALAXY FIX GEM LTX,SUP-2875646,CDM,C1713,HCPCS,0278,RC,,,,both,,,43288.35,28137.43,,,,,,,,,,,,,
HOOK SPNL 6MM ROD DIA 6.5MM BLDE W 9.5MM LAM NEUT CLOSE,SUP-2415571,CDM,C1713,HCPCS,0278,RC,,,,both,,,1310.89,852.08,,,,,,,,,,,,,
SPACER SPNL TRAPEZOIDAL LG 9 MM LAT TI SUSTAIN,SUP-2584074,CDM,C1821,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
IMPLANT BRST RND BASE 5.7 CM 11.9 CM 370 CC TEXT SHP HI GEL,SUP-2339891,CDM,C1789,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CATHETER BLLN DIL 6 FRX180 CM 15-18 MMX8 CM CRE,SUP-2149684,CDM,C1726,HCPCS,0272,RC,,,,both,,,605.89,393.83,,,,,,,,,,,,,
PLATE BNE L 55.19 X W 33.91 MM THK 0.6 MM SCREW DIA1.5 MM 20,SUP-2935846,CDM,C1713,HCPCS,0278,RC,,,,both,,,3004.98,1953.24,,,,,,,,,,,,,
IVERMECTIN 3 MG PO TABS,RX-25820,CDM,6370000000,HCPCS,0637,RC,75907-0167-10,NDC,,both,1,UN,18.70,12.15,,,,,,,,,,,,,
TUBE TRACH NEO L36MM OD6MM ID4MM SIL CUF V NK FLNG BIVONA,SUP-2352445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.10,388.11,,,,,,,,,,,,,
TRAY HUM THK+6MM 0MM OFFSET CEM REVERSED AEQUALIS ASCEND,SUP-2388721,CDM,C1776,CPT,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
DEVICE PESSARY 3 IN INCONT RNG,SUP-2171747,CDM,A4562,HCPCS,0272,RC,,,,both,,,181.90,118.23,,,,,,,,,,,,,
CATHETER PICC KT 3 LUMN 6FR FULL LO MORPHEUS SMRT,SUP-2116998,CDM,C1751,HCPCS,0278,RC,,,,both,,,346.03,224.92,,,,,,,,,,,,,
ROD SPNL L25MM DIA5.5MM OPN OFFSET CONN CREO,SUP-2228689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CONNECTOR SPNL 6.35X15 MM OFFSET SS REVERE,SUP-2594667,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
PIN EXT FIX SZ 4 X 120 X 30 MM HALF NS DISP MAV MINI,SUP-2932736,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
PLATE BNE L 3.54 CM THK 0.6 MM SCREW DIA2 MM 8 H TI ORBIT NS,SUP-2936567,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
INSERT TIB M THK11MM KNEE DUR CNDYL STBL LIP DURAC,SUP-2377697,CDM,C1776,CPT,0278,RC,,,,both,,,3147.54,2045.90,,,,,,,,,,,,,
WASHER ORTHOPEDIC RND CUP 11 MM SM FRAG LOCKED TI NS VISION,SUP-2457915,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
VALVE SHUNT BURR HOLE 12 MM LO PRESSURE PUDENZ,SUP-2852584,CDM,C1889,HCPCS,0278,RC,,,,both,,,2248.84,1461.75,,,,,,,,,,,,,
MATRIX HUM TISS L 4 X W 3 CM DECELL PLCNTA MEMBRN,SUP-2909224,CDM,Q4201,HCPCS,0636,RC,,,,both,,,2841.70,1847.10,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED XL COMPLX + PEEK NS LTX,SUP-2862813,CDM,C1713,HCPCS,0278,RC,,,,both,,,62645.64,40719.67,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZ DRY ALLGRFT IL CREST BICORTICAL STRP,SUP-2294078,CDM,C1713,HCPCS,0278,RC,,,,both,,,2813.44,1828.74,,,,,,,,,,,,,
SET SUPRPUB CATH 16FR L30CM NDL 15GA MCOT FOR PERC URIN,SUP-2171110,CDM,C2627,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
GRAFT HUM TISS W100XL180MM FASC LATA FRZN,SUP-2307273,CDM,C1762,CPT,0278,RC,,,,both,,,3656.56,2376.76,,,,,,,,,,,,,
KIT SHTH L22CM SM DEL CRV SPNL CLMN DORS ROOT GANG FOR LO,SUP-2357683,CDM,C1894,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GUIDEWIRE ENDO L450CM DIA0.025IN STR,SUP-2141520,CDM,C1769,HCPCS,0272,RC,,,,both,,,720.94,468.61,,,,,,,,,,,,,
CATHETER INTVASC OCCL ECLIPSE 2L BALLOON L 7 MM DIA 6 MM TIP,SUP-2717628,CDM,C2628,HCPCS,0272,RC,,,,both,,,6590.86,4284.06,,,,,,,,,,,,,
GRAFT TEND GRACILIS ALLGRFT FRZ DRY 20 38CM L 3 10MM W,SUP-2307121,CDM,C1762,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CATHETER URET 6/10FRX50CM ACC 2 LUMN STD W/ RADPQ MRK FLEXI,SUP-2168937,CDM,C1758,HCPCS,0278,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
TOOL SZ GASTROESOPHAGEAL NICKEL DISP FOR LINX REFLX MGMT,SUP-2388508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT TISS 7.6X15.2CM 116SQ CM THERASKIN XL,SUP-2264659,CDM,Q4121,HCPCS,0636,RC,,,,both,,,10611.00,6897.15,,,,,,,,,,,,,
CATHETER ANGIO ACCU-VU L 70 CM DIA 5 FR 0.035 IN 20 CM OMNI,SUP-2118544,CDM,C1887,HCPCS,0272,RC,,,,both,,,271.67,176.59,,,,,,,,,,,,,
BUR ENDOSCP SHAVER 40 DEG L 13 CM DIA 3 MM ENT PWR 30K,SUP-2902065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1449.27,942.03,,,,,,,,,,,,,
CATHETER GUID ENVOY L 90 CM OD 7 FR ID 0.078 IN MPD,SUP-2459999,CDM,C1887,HCPCS,0272,RC,,,,both,,,1781.32,1157.86,,,,,,,,,,,,,
DEVICE OCCL CLP L50MM LNG HD ARTC THMB CTRL MAL SHFT FOR,SUP-2124456,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE RECON 3.5X70 MM 6 HOLE SS,SUP-2569081,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
FIBER LASER HOLMIUM DISPOSABLE 11553,SUP-2264315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUET CHRONIC STD 10FR DIA 19/22CMLAV IN,SUP-2613274,CDM,C1750,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
STEM HUM REVERSED LNG 9X210 MM SHLDR FRAC AEQUALIS REVERSED,SUP-2715637,CDM,C1776,CPT,0278,RC,,,,both,,,18243.40,11858.21,,,,,,,,,,,,,
SCREW COMPR 6.5X30MM HEADLESS TI THRD LEN 16MM STRL,SUP-2547113,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.33,597.56,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|ADJ|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|ADJ|CQ,both,,,191.00,124.15,,,,,,,,,,,,,
GRAFT HUM TISS L 8 X W 5 CM SZ 40 SQCM AMNION-CHORION-AMNION,SUP-2909306,CDM,Q4137,HCPCS,0636,RC,,,,both,,,19574.54,12723.45,,,,,,,,,,,,,
BUTTON GASTROSTMY 18FR L44CM LO PROF FOR REPL GASTROSTMY TB,SUP-2141575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,363.74,236.43,,,,,,,,,,,,,
CATHETER PACE SSPC1 C CRV STRL,SUP-2863104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
DEVICE LAPSCP SM DIA5CM HND ASST LAP-DISC,SUP-2257666,CDM,C1788,HCPCS,0278,RC,,,,both,,,1476.21,959.54,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SAVVY LNG L 150 CM BALLOON L 120 MM,SUP-2156637,CDM,C1725,HCPCS,0272,RC,,,,both,,,1252.29,813.99,,,,,,,,,,,,,
SET NEPHSTMY PERC ENTRY W/ 22GA 18GA S STL 20CM NDL SAFE T,SUP-2171232,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
DILATOR URETH SET M BAL 8MMX8CM BAL 7 FRX30CM CATH,SUP-2171271,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.26,409.02,,,,,,,,,,,,,
MODULAR UPLR CONSTRUCT,SUP-2212084,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
MESH SURG W10XL15CM THK1MM EPTFE BIOMATERIAL OVL ANTIMIC,SUP-2395340,CDM,C1781,HCPCS,0278,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
SET FEED TUBE 24FR L150CM PUL METH FOR PERC ENDO PLCMNT PEG,SUP-2419560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
CATHETER VENT DRNGE L18CM STD SIL 7 FLNG DISP PORTNOY,SUP-2308215,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.05,589.58,,,,,,,,,,,,,
SCREW BONE L11MM DIA2.3MM CRANIOMAXILLOFACIAL TI CROSSDRIVE,SUP-2262619,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
CATHETER THROMCTMY HI FLO ASPIR TBNG DEV 3MAX ACE 68,SUP-2473985,CDM,C1757,HCPCS,0272,RC,,,,both,,,29641.60,19267.04,,,,,,,,,,,,,
CATHETER ART HEP COAT L22 CM OD9.3 FR,SUP-2416141,CDM,C1751,HCPCS,0278,RC,,,,both,,,1629.28,1059.03,,,,,,,,,,,,,
HC Assay of Prostate Specific Antigen Total,PX-3018415300,CDM,84153,CPT,0301,RC,,,,both,,,242.00,157.30,,,,,,,,,,,,,
PLATE BNE L35MM 9 H ORBIT RIM TI FOR 1.3MM SCR MOD FIX SYS,SUP-2190642,CDM,C1713,HCPCS,0278,RC,,,,both,,,1039.65,675.77,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 035X180 STIFF COR CANALIZER,SUP-2120025,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
MESH HERN PRE SHP 4X1.8 IN SFT W/ KEYHOLE KNIT STRUCT POLYPR,SUP-2125782,CDM,C1781,HCPCS,0278,RC,,,,both,,,167.68,108.99,,,,,,,,,,,,,
RETRACTOR ENDOSCP SHFT L31MM DIA10MM TEAL ATRAUM ARTC 5,SUP-2283175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1235.90,803.33,,,,,,,,,,,,,
BIT DRL GRADUAL SUPLMNT,SUP-2644807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3018.61,1962.10,,,,,,,,,,,,,
AMINOCAPROIC ACID 500 MG PO TABS,RX-9063,CDM,6370000000,HCPCS,0637,RC,69238-1637-03,NDC,,both,1,UN,48.80,31.72,,,,,,,,,,,,,
COMPONENT FEM CEM 4 KNEE UC-PLUS,SUP-2450905,CDM,C1776,CPT,0278,RC,,,,both,,,5947.16,3865.65,,,,,,,,,,,,,
RECON PLATE 6X93MM 4.5MM,SUP-2818428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3274.24,2128.26,,,,,,,,,,,,,
SCREW BNE CANN 7.3X70 MM FT TI STRL TRAUM FIX LTX,SUP-2861357,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.40,479.31,,,,,,,,,,,,,
TROCAR ENDOSCP L150MM DIA5MM BLDELSS STBL SL CAM PRT W/,SUP-2218269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.16,477.20,,,,,,,,,,,,,
ADAPTER LD PACEMKR VEN LL TUOHY,SUP-2148885,CDM,C1883,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON SM 8 IN LT WRST PLUSH FOAM LNR NYL,SUP-2276659,CDM,L3908,HCPCS,0272,RC,,,,both,,,17.05,11.08,,,,,,,,,,,,,
PLATE BENDING PLIERS 1.0/1.5/2.0,SUP-2497455,CDM,C1713,HCPCS,0278,RC,,,,both,,,799.44,519.64,,,,,,,,,,,,,
TI ENDCAP T25 STRDRV 0MM EXTN NON-LCKNG/HUMERAL NAIL EX-STER,SUP-2546233,CDM,C1889,HCPCS,0278,RC,,,,both,,,516.81,335.93,,,,,,,,,,,,,
MICROSPHERE EMB EMBOSPHERE DIA 500-700 UM 2 CC 20 CC SYR GRA,SUP-2660775,CDM,C1889,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CATHETER HD TEMP 14 FRX20 CM,SUP-2217983,CDM,C1752,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
COMPONENT ULNA DISCOVERY WITH BEARING E+ RIGHT 2.5X84MM,SUP-2879106,CDM,C1776,CPT,0278,RC,,,,both,,,17693.90,11501.03,,,,,,,,,,,,,
TRAY CTRL VEN CATH 3FR L8CM 0.018IN POLYUR SGL LUMN CATH STR,SUP-2167839,CDM,C1751,HCPCS,0278,RC,,,,both,,,208.40,135.46,,,,,,,,,,,,,
LENS INTOCU +27.00 DIOPT L13MM DIA6MM HAPTIC REFRACTIVE,SUP-2129535,CDM,V2632,HCPCS,0276,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
INSERT TIB SZ 1 THK12.5MM UNIV KNEE GVF POLYETH ROT PLATFRM,SUP-2253442,CDM,C1776,CPT,0278,RC,,,,both,,,3796.89,2467.98,,,,,,,,,,,,,
LINER ACET 40X27 MM SCR IN +5 RINGLOC+ MAX-ROM,SUP-2447215,CDM,C1776,CPT,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
STEM FEM L195MM DIA18MM BOW CONIC TI ALLY HA DST HIP REV,SUP-2375844,CDM,C1776,CPT,0278,RC,,,,both,,,7855.02,5105.76,,,,,,,,,,,,,
COLLAR CERV UNIV 13 19INCH VISTA TX,SUP-2196896,CDM,L0172,HCPCS,0272,RC,,,,both,,,128.43,83.48,,,,,,,,,,,,,
HC Asp Injection Major Joint,PX-4502061000,CDM,20610,CPT,0450,RC,,,,inpatient,,,1092.00,709.80,,,,,,,,,,,,,
PROBE SURG CALIB ELITE,SUP-2849110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
GRAFT DERM PLIABLE FLD SUPPLE ULT THCK ACELLULAR DERM IMPL,SUP-2307565,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4255.49,2766.07,,,,,,,,,,,,,
CAGE SPNL XL W18XH12XL60MM 10DEG LUMBER INTBDY FUS PEEK,SUP-2311022,CDM,C1889,HCPCS,0278,RC,,,,both,,,12120.40,7878.26,,,,,,,,,,,,,
HC Tcat Perm Occls/Embolj Perq Non-Cns Head/Neck,PX-3616162600,CDM,61626,CPT,0361,RC,,,,both,,,20354.00,13230.10,,,,,,,,,,,,,
ONABOTULINUMTOXINA 200 UNITS IJ SOLR,RX-102327,CDM,J0585,HCPCS,0636,RC,00023-3921-02,NDC,,both,1,UN,3840.90,2496.58,,,,,,,,,,,,,
PROBE MICROWAVE ABLATION L 15 CM DIA15-17 GA CABLE L 2.9 M,SUP-2908906,CDM,C1886,HCPCS,0278,RC,,,,both,,,9215.90,5990.33,,,,,,,,,,,,,
ALLODERM SELECT 5X6 XTHIN 0.3-0.8 MESH,SUP-2827008,CDM,Q4116,HCPCS,0636,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
KIT EXT FIX STD STRUT ID BND CAP STRL DISP SMRT,SUP-2932946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.75,557.54,,,,,,,,,,,,,
CATHETER MIDLINE 4.5FR 15CM 1 LUMN PRSS INJ ARROWG+ARD,SUP-2120615,CDM,C1751,HCPCS,0278,RC,,,,both,,,481.36,312.88,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ACROBAT L 260 CM DIA 0.025 IN RADIOPAQUE,SUP-2170137,CDM,C1769,HCPCS,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
ALLOGRAFT BNE COSTAL CART 5 CM,SUP-2321773,CDM,C1762,CPT,0278,RC,,,,both,,,1742.70,1132.75,,,,,,,,,,,,,
PROBE MPLR INCREMENTING PRASS TIP FOR NIM RESPON NIM NEURO,SUP-2284322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.12,423.88,,,,,,,,,,,,,
KIT DRL BIT OD1.8MM DEPTH MEAS DRL GUID FOR 2.4MM SCR,SUP-2225431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
PLATE BONE L14MM THK0.6MM 4 H CRANIOMAXILLOFACIAL STR FOR,SUP-2402920,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
VALVE AORT 23MM PERICARD BIOPROSTHESIS PERIMT,SUP-2214071,CDM,C1713,HCPCS,0278,RC,,,,both,,,13863.10,9011.01,,,,,,,,,,,,,
CANNULATED DRILL 15MM,SUP-2816447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
CABLE ORTHOT HIP KNEE ANK PELV CUST TORSION,SUP-2435641,CDM,L2050,LOCAL,0272,RC,,,,both,,,1379.62,896.75,,,,,,,,,,,,,
STEM HUM L132MM DIA10MM STD UNIV SHLDR TI GLOB AP,SUP-2249966,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
THIORIDAZINE HCL 25 MG PO TABS,RX-7899,CDM,6370000000,HCPCS,0637,RC,51079-0566-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT PROC OD44FR 20MM SPHINTOM L260CM OD0035IN GWIRE CHOLGM,SUP-2149824,CDM,C1713,HCPCS,0278,RC,,,,both,,,986.43,641.18,,,,,,,,,,,,,
IMPLANT SPCR ARTELON ARTH,SUP-2120682,CDM,C1776,CPT,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
PLATE BONE SM W11XL56MM THK1.2MM 4X4 H RT DSTL S STL T SHP,SUP-2343783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1072.12,696.88,,,,,,,,,,,,,
BAR EXT FIX 11X400 MM CARBON XTRAFIX,SUP-2477119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,755.52,491.09,,,,,,,,,,,,,
HC So Microbe Suspect Mycobacteri,PX-3008719066,CDM,87190,CPT,0300,RC,,,,both,,,42.00,27.30,,,,,,,,,,,,,
CATHETER INFUS L134CM BAL L20MM DIA2.5MM 0.014IN LOC THER,SUP-2266026,CDM,C1751,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC MRI Lower Ext W/ Cont,PX-6107371900,CDM,73719,CPT,0610,RC,,,,inpatient,,,5019.00,3262.35,,,,,,,,,,,,,
PACEMAKER CRD 52X42X6 MM 11 CC 23 GM TI VERITY ADX XL SR,SUP-2357330,CDM,C1786,HCPCS,0275,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
CLIP IMPL BLADE L 7.5/6.7 MM MAXIMAL OPEN 5 MM CLS FORC FEN UP,SUP-2930704,CDM,C1889,HCPCS,0278,RC,,,,both,,,1588.15,1032.30,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 4 FR BALLOON DIA 9 MM,SUP-2214009,CDM,C1757,HCPCS,0272,RC,,,,both,,,97.50,63.37,,,,,,,,,,,,,
PLATE BNE L 107 MM SCREW DIA2.7 MM 12 SHFT H TI ADPT COMB,SUP-2907698,CDM,C1713,HCPCS,0278,RC,,,,both,,,3290.41,2138.77,,,,,,,,,,,,,
PIN FIX L9IN OD9/64IN S STL TYP D STNMN,SUP-2342721,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.57,154.42,,,,,,,,,,,,,
ANCHOR SUT HIP BIOCRYL RAPIDE PUSH IN W/ ORTHOCORD 2-0 ROT,SUP-2249333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
BRACE WLK FULL SHELL WLK M M SHOE SZ 7 10 FEM SHOE SZ 8,SUP-2336093,CDM,L4360,HCPCS,0274,RC,,,,both,,,128.61,83.60,,,,,,,,,,,,,
STENT COR 26MM 4MM RADPQ MRK RX MICROTRAC DEL,SUP-2296996,CDM,C1874,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CLAMP SURG PARL CONN 18 MM 6.5-6.5 MM SINGLE REVERE,SUP-2584883,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EPIC + DR THK 12.9 MM 30 J 33 CC 70 GM TI,SUP-2356542,CDM,C1721,HCPCS,0275,RC,,,,both,,,80070.00,52045.50,,,,,,,,,,,,,
COUNTERSINK DENT 1.2/2/2.4MM W/ DENT SHFT PROFYLE,SUP-2419548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
PLATE BONE 3D EXTRA SM 04MM THK TTNM RIGHT ORBTL FLOOR,SUP-2681175,CDM,C1713,HCPCS,0278,RC,,,,both,,,3059.84,1988.90,,,,,,,,,,,,,
SYSTEM SURGICAL HEMOSTATIC STERILE DISPOSABLE NEXPOWDER,SUP-2934149,CDM,C1052,HCPCS,0278,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
CENTER PC DCOMPR H20-28MM DIA20MM THORLUM TI SIMP FAST EZ TO,SUP-2390808,CDM,C1889,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
AGENT HEMSTAT 4.5ML GEL VITAGEL 21130000] STRYKER SPINE HOWM],SUP-2379548,CDM,C1713,HCPCS,0278,RC,,,,both,,,1571.57,1021.52,,,,,,,,,,,,,
SHUNT CSF SHUNT SYSTEM WITH CONTROL RESERVOIR WITHOUT GRAVIT,SUP-2825821,CDM,C1889,HCPCS,0278,RC,,,,both,,,8478.47,5511.01,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0258,RC,00264-7520-10,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
CENTRALIZER 11MM HERITAGE PROX HIP SL VERSYS,SUP-2211369,CDM,C1776,CPT,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC Ep Tx L/R Atrial Fib Addl,PX-4819365700,CDM,93657,CPT,0481,RC,,,,both,,,2141.00,1391.65,,,,,,,,,,,,,
"HC So Oxalate Urine, 24hr",PX-3018394566,CDM,83945,CPT,0301,RC,,,,both,,,78.00,50.70,,,,,,,,,,,,,
ROD EXT FIX L400MM DIA11MM C FBR MR CONDITIONAL 39487R] DEPUY SYNTHES USA],SUP-2188667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,831.69,540.60,,,,,,,,,,,,,
RING PESSARY 6 3.25 IN W/ SUPP SIL,SUP-2171734,CDM,A4562,HCPCS,0274,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
IMPLANT RAMUS W/ INFERIOR RIDGE LT E 5,SUP-2366465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
LINER ACET SZ 26 OD41MM ID28MM +5MM THK10.3MM HIP UHMWPE,SUP-2404289,CDM,C1776,CPT,0278,RC,,,,both,,,5242.23,3407.45,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.9X10 MM LOCKING TITANIUM MATRIXRIB,SUP-2837687,CDM,C1713,HCPCS,0278,RC,,,,both,,,754.07,490.15,,,,,,,,,,,,,
RIB PLATE DRILL 10MMX2.7MM,SUP-2841929,CDM,2720000010,LOCAL,0272,RC,,,,both,,,756.74,491.88,,,,,,,,,,,,,
KIT DRNGE SUMP J TIP TRCR STYL .038IN GUIDWIRE CANN AIR,SUP-2147875,CDM,C1729,HCPCS,0272,RC,,,,both,,,471.47,306.46,,,,,,,,,,,,,
CLAMP EXT FIX SM TI ALLY COMB MR CONDITIONAL CLP ON SELF,SUP-2188534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,994.53,646.44,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X15 MM 6 LOBE,SUP-2602074,CDM,C1889,HCPCS,0278,RC,,,,both,,,8302.16,5396.40,,,,,,,,,,,,,
BRACE QXXLG,SUP-2174973,CDM,L1820,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
PIN FIX L200MM DIA1.5MM ANK FT NIT ORIENTATION SGL END TRCR,SUP-2321612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,450.59,292.88,,,,,,,,,,,,,
CATHETER HD DL 14 FRX24 CM ADMIN BASIC KT SPLIT STRM,SUP-2267084,CDM,C1750,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE 6 HOLE P MANDIBLE,SUP-2843359,CDM,C1713,HCPCS,0278,RC,,,,both,,,2239.89,1455.93,,,,,,,,,,,,,
CATHETER BAL DIL 9X4X5.8X75 SYNERGY,SUP-2139688,CDM,C1725,HCPCS,0272,RC,,,,both,,,551.86,358.71,,,,,,,,,,,,,
SCREW BONE L76MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190397,CDM,C1713,HCPCS,0278,RC,,,,both,,,73.07,47.50,,,,,,,,,,,,,
PLATE BNE L104MM 6 H R LAT PROX PERIARTC TIB S STL LOK COMPR,SUP-2198429,CDM,C1713,HCPCS,0278,RC,,,,both,,,3829.29,2489.04,,,,,,,,,,,,,
ROD SPNL 3.5 MMX8 CM TI,SUP-2414630,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
CATHETER CV SET 12 FRX20 CM 18 GAX6.35 CM 3L LG BOR INTRO,SUP-2763394,CDM,C1751,HCPCS,0278,RC,,,,both,,,256.22,166.54,,,,,,,,,,,,,
PLATE BNE L54MM 2X8 H TI T SHP RIG NONCOMPRESSION FOR 2.4MM,SUP-2191471,CDM,C1713,HCPCS,0278,RC,,,,both,,,1912.10,1242.86,,,,,,,,,,,,,
PACEMAKER SGL CHMBR RATE RESPON IMP TRIL SR +,SUP-2356703,CDM,C1786,HCPCS,0275,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
PRESSURIZER BNE CEMENT FEM HIP OPTVAC,SUP-2217083,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
ROD EXT FIX CARBON,SUP-2362750,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.28,271.88,,,,,,,,,,,,,
HC Phlebotomy Therapeutic,PX-7619919500,CDM,99195,CPT,0940,RC,,,,both,,,330.00,214.50,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THK2 279MM RDY TO USE ALLDERM,SUP-2423046,CDM,Q4116,HCPCS,0636,RC,,,,both,,,11222.36,7294.53,,,,,,,,,,,,,
CATHETER DILATATION CRE RX BILIARY 18 20 MM 55 CM,SUP-2676539,CDM,C1726,HCPCS,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
"HC ER Level 5|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE",PX-4509928500,CDM,99285,CPT,0450,RC,,,25,outpatient,,,3911.00,2542.15,,,,,,,,,,,,,
CHOLANGIOGRAM KIT 0.025 INX260 CM 20 MM JAGTOME 39 SPHINTOM,SUP-2525334,CDM,C1769,HCPCS,0272,RC,,,,both,,,805.32,523.46,,,,,,,,,,,,,
SCREW SPNL 7146016,SUP-2599237,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SNARE ENDOSCP 15 MMX230 CM POLYP OVL LOOP SD-12U-1 WIRE REPL,SUP-2468176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.93,330.80,,,,,,,,,,,,,
PLATE BNE 4X8 H TI T SHP ADPT DYN COMPR FOR 1.3MM SCR,SUP-2190693,CDM,C1713,HCPCS,0278,RC,,,,both,,,1148.46,746.50,,,,,,,,,,,,,
OCCLUDER CV WATCHMAN DIA 30 MM SHTH L 75 CM DIA14 FR DEL SYS,SUP-2141823,CDM,C1889,HCPCS,0278,RC,,,,both,,,73790.00,47963.50,,,,,,,,,,,,,
LEAD PACE STR 7 FRX46 CM ENDOCARD OPTIM INSUL ISOFLEX,SUP-2356691,CDM,C1898,HCPCS,0275,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
DRILL 15MM,SUP-2841574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
MICROCATHETER GUID CANTATA L 135 CM OD 2.8 FR ID 0.025 IN,SUP-2171038,CDM,C1887,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE L119MM 6 H L MED PROX TIB S STL LOK COMPR LO PROF,SUP-2185637,CDM,C1713,HCPCS,0278,RC,,,,both,,,4210.49,2736.82,,,,,,,,,,,,,
AGENT HEMOSTATIC SURGIFLOW MATRIX KIT W/THROMBIN,SUP-2218263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,583.51,379.28,,,,,,,,,,,,,
LAPAROSCOPE RIGID L270MM OD10MM 0DEG OPERATIVE AUTOCLAVABLE,SUP-2808675,CDM,C1776,CPT,0278,RC,,,,both,,,11065.36,7192.48,,,,,,,,,,,,,
SUPPORT LUM VISTA 627,SUP-2123916,CDM,L0457,HCPCS,0272,RC,,,,both,,,331.27,215.33,,,,,,,,,,,,,
HC CT L-Spine W/ Contrast,PX-3527213200,CDM,72132,CPT,0352,RC,,,,outpatient,,,1973.00,1282.45,,,,,,,,,,,,,
HC Treat Humerus Fx,PX-4502360000,CDM,23600,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
HC Collect Blood From Arterial Line,PX-7613779900,CDM,37799,CPT,0761,RC,,,,outpatient,,,1845.00,1199.25,,,,,,,,,,,,,
PLATE BONE L24MM THK0.8MM ORBIT FLR POLYETH TI REINF SMOOTH,SUP-2182843,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
PLATE BNE 7 H CALCANEAL S7 MIS NS VARIAX,SUP-2900795,CDM,C1713,HCPCS,0278,RC,,,,both,,,5154.62,3350.50,,,,,,,,,,,,,
HC Remv/Revisn Boot/Body Cast,PX-7612970000,CDM,29700,CPT,0761,RC,,,,both,,,294.00,191.10,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,0636,RC,00409-7332-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PIN DISTRACTOR L12MM TI,SUP-2181850,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
SPLINT ORTH HND M 80DEG PLAS R MTCRPL JT W O STRP BRN,SUP-2112605,CDM,L3807,HCPCS,0274,RC,,,,both,,,167.71,109.01,,,,,,,,,,,,,
GRAFT DURA W2.63XL3.93IN BOV PERICARD ENDURA,SUP-2244039,CDM,C1763,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
DEVICE PESSARY RNG 5 3 IN W/ KNOB FOLDING,SUP-2421606,CDM,A4562,HCPCS,0274,RC,,,,both,,,109.15,70.95,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBM BIOCOMPOSITE OSTEOSET PTTY INJ,SUP-2399059,CDM,C9359,HCPCS,0278,RC,,,,both,,,3457.14,2247.14,,,,,,,,,,,,,
STABILIZER SURG TISS W/ CANSTR TBNG EVOLUTION OCTPS,SUP-2283006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 18MM DISK,SUP-2905517,CDM,Q4151,HCPCS,0636,RC,,,,both,,,1599.36,1039.58,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.3MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189170,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.23,209.45,,,,,,,,,,,,,
SCREW EXT FIX L250MM DIA5MM THRD L80MM S STL HA SELF DRL MR,SUP-2177034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.33,559.86,,,,,,,,,,,,,
WALKER PT M LOWEST PROF W/ CRISS CROSS STRP THREE-D,SUP-2195482,CDM,L4386,HCPCS,0274,RC,,,,both,,,195.03,126.77,,,,,,,,,,,,,
PLATE BNE L MINI REG 2-2.5X1 MM RT LCK SMRT TI LEVEL 1,SUP-2485992,CDM,C1713,HCPCS,0278,RC,,,,both,,,1495.83,972.29,,,,,,,,,,,,,
FORCEPS ES L20CM DIA15MM SLIM BPLR NONSTICK DISPOSABLE,SUP-2364936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
RING EXT FIX DIA180MM C LO EXT OPN FOR HYBRID SYS TENXOR,SUP-2372237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER DIL BAL L16MM DIA5MM SINUS RELIEVA SOLO PRO,SUP-2106311,CDM,C1726,HCPCS,0272,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV IR 3FR 45CM 1 LUMAN RVRS 3173335,SUP-2632651,CDM,C1751,HCPCS,0278,RC,,,,both,,,439.16,285.45,,,,,,,,,,,,,
HC Thawing of Cryo Hpc No Wash,PX-3623820800,CDM,38208,CPT,0362,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
ALLOGRAFT BNE MENIS LT MEDL FRZN,SUP-2321823,CDM,C1762,CPT,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
COMPONENT ARTC SURF 46X52 MM GLEN TRABECULAR MTL,SUP-2199087,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BNE SUB W22XL60MM ILIUM BICORT STRP FRZ DRY STRUCTURAL,SUP-2307124,CDM,C1713,HCPCS,0278,RC,,,,both,,,3330.97,2165.13,,,,,,,,,,,,,
BALLOON VERT AUG SYS L20MM W/ 11GA NDL 4ML SYR CVD RADPQ,SUP-2361556,CDM,C1894,HCPCS,0272,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
CATHETER PERIPH 5FR L135CM 0.014IN DST TIP 0.028IN RADPQ,SUP-2383147,CDM,C1887,HCPCS,0272,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
PLATE BNE W11XL246MM THK37MM 14 H ST R MED DST TIB S STL LOK,SUP-2185599,CDM,C1713,HCPCS,0278,RC,,,,both,,,5206.81,3384.43,,,,,,,,,,,,,
POSITIONER RAD THER SCREW HD SET 4 CT BLK,SUP-2395103,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.32,5.41,,,,,,,,,,,,,
GUIDEWIRE VASC VICTORY 18 L 300 CM DIA 0.018 INL TIP L 2 CM,SUP-2140830,CDM,C1769,HCPCS,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
NUT SPNL LCK PARL GUIDE SAMBASCREW,SUP-2601144,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
"HC So2 Quantation of Therapuetic Drug, Nes",PX-3018029968,CDM,80299,CPT,0301,RC,,,,inpatient,,,1562.00,1015.30,,,,,,,,,,,,,
BUTTON GASTROSTMY 18 FRX1.7 CM LP FEED DEV MINIONE,SUP-2424399,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.27,215.33,,,,,,,,,,,,,
KIT PERC INSRT 17GA SPNL NDL 1.1MM NIT GWIRE PORTAL DIL,SUP-2121523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
HC So T3 Reverse,PX-3018448266,CDM,84482,CPT,0301,RC,,,,both,,,181.00,117.65,,,,,,,,,,,,,
PROSTHESIS OSS L 9 MM SHFT DIA1 MM HD DIA 3.25 MM HA FLX H/A,SUP-2901965,CDM,L8613,CPT,0278,RC,,,,both,,,1338.90,870.28,,,,,,,,,,,,,
GRAFT BNE SUB 10ML HA FAST SET PTTY FILL BNE VOID CA PHSPTE,SUP-2194291,CDM,C9359,HCPCS,0278,RC,,,,both,,,9161.89,5955.23,,,,,,,,,,,,,
BIT DRL SCALED 1.6X96 MM AO CPL VARIAX,SUP-2435339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
PLATE BONE W5XL32MM THK1MM 0DEG 6 H BILAT S STL STR RIG DYN,SUP-2186164,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.34,381.77,,,,,,,,,,,,,
ADAPTER BASEPLT GLEN VERSA-DIAL STD 25 MM,SUP-2421377,CDM,C1776,CPT,0278,RC,,,,both,,,569.91,370.44,,,,,,,,,,,,,
ANCHOR SUT TWIN LOOP DBL STRND 35MM,SUP-2366682,CDM,C1713,HCPCS,0278,RC,,,,both,,,655.85,426.30,,,,,,,,,,,,,
IMPLANT HAMRTOE CORR 45MM FOR PROX PHALANX CORR NEXTRA,SUP-2137582,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.68,1316.69,,,,,,,,,,,,,
CHARGER NEUROSTIMULATOR EXT SPNL CRD FOR RECHARGING,SUP-2284643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE W9XL97MM THK1MM 8 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190953,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.21,351.14,,,,,,,,,,,,,
IMPLANT IO 24MM M DRVR ASSEMB DISPOSABLE FOR HAMRTOE FIX SYS,SUP-2400046,CDM,C1713,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
PIN FIX SD 3X60X15 MM CORTICAL THRD MINIRAIL,SUP-2435292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
IMPLANT STRNL CLSR PEEK CBL W/ NDL ZIPFIX 5 PER PK,SUP-2182840,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.29,213.39,,,,,,,,,,,,,
DEVICE CLOSURE VES SEAL DIA 6-12 FR FEM VEIN FASTEST HEMOSTAS STRL,SUP-2909166,CDM,C1760,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 4 CM AMNION-CHORION-AMNION LAYR,SUP-2909220,CDM,Q4140,HCPCS,0636,RC,,,,both,,,11370.32,7390.71,,,,,,,,,,,,,
BUR REPROC SHV 4MM ABRADER ELITE AQUA,SUP-2652934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,102.21,66.44,,,,,,,,,,,,,
GUIDEWIRE ORTH DBL RND 1.3X480 MM AOS,SUP-2766040,CDM,C1769,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
AGENT HEMSTAT 4.5ML GEL VITAGEL 21130205] STRYKER CORP],SUP-2361945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
PLATE BNE W13.5XL152MM THK4.2MM 8 H BILAT S STL NAR LOK,SUP-2185240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1289.06,837.89,,,,,,,,,,,,,
CATHETER GUID CXI L 150 CM DIA 2.3FR 0.014IN SS ANGLED 2 TIP,SUP-2638647,CDM,C1887,HCPCS,0272,RC,,,,both,,,479.20,311.48,,,,,,,,,,,,,
NAIL INTRAMEDULLARY 130 DEGREE 16 MMX44 CM LEFT FEMORAL TITA,SUP-2837106,CDM,C1713,HCPCS,0278,RC,,,,both,,,22599.84,14689.90,,,,,,,,,,,,,
BUTTON SUT DIA5 8IN POLY 2 H PEARL,SUP-2431814,CDM,C1713,HCPCS,0278,RC,,,,both,,,4.77,3.10,,,,,,,,,,,,,
INT HEX SCREW 4.5MMX20MM,SUP-2819500,CDM,C1713,HCPCS,0278,RC,,,,both,,,922.88,599.87,,,,,,,,,,,,,
PIN EXTRNL FXTN L120MM D3MM THRD L20MM BROWN CNNLTD XTRFX SS,SUP-2467633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
PLATE BNE L 83 MM SCREW DIA 3.5 MM 7 SHFT H SS 1/3 TUBLR VA ST,SUP-2913393,CDM,C1713,HCPCS,0278,RC,,,,both,,,1834.80,1192.62,,,,,,,,,,,,,
STENT BILI SELF EXP OVR THE WIRE 6FR CATH 80CM CATH LEN,SUP-2159276,CDM,C1876,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
PLATE BNE XL L LOK CALCANEUS,SUP-2413699,CDM,C1713,HCPCS,0278,RC,,,,both,,,3445.68,2239.69,,,,,,,,,,,,,
NUT EXT FIX SPD,SUP-2898613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE L 53.3 X W 7.1 MM THK 2 MM SCREW DIA2/2.3 MM 6 H,SUP-2936112,CDM,C1713,HCPCS,0278,RC,,,,both,,,1453.82,944.98,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION|DISCARDED DRUG NOT ADMINISTE,RX-40840102,CDM,2580000003,HCPCS,0258,RC,00264-7800-10,NDC,JW,both,250,ML,14.90,9.68,,,,,,,,,,,,,
FIBER LASER 550 MH OPTIMUM PERF HOLM SLM LN SIS EZ DISP,SUP-2479584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1353.53,879.79,,,,,,,,,,,,,
SHUNT KIT MED FLO CTRL CNTOUR SM ASMBLY UNITZ MR SAFE,SUP-2631360,CDM,C1729,HCPCS,0272,RC,,,,both,,,2528.14,1643.29,,,,,,,,,,,,,
FIBER LASER DIA550UM HOLM 2 WVLNGTH DEL SYS REUSE SLM LN,SUP-2139042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1464.15,951.70,,,,,,,,,,,,,
KIT BNE GRFT XSM 1.4CC RHBMP-2 ABSRB CLLGN SPNG INFUSE,SUP-2287847,CDM,C1713,HCPCS,0278,RC,,,,both,,,5981.70,3888.10,,,,,,,,,,,,,
COMPONENT FEM L125MM DIA9MM HIP CO CHROM ANS,SUP-2406612,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE SPNL CERV ANT UNIV 2 LEV TI 12 H 39MM LEN STD SPIDER,SUP-2402148,CDM,C1713,HCPCS,0278,RC,,,,both,,,5286.03,3435.92,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 100 MM DIA 8 MM DEL SHTH 6.7ML,SUP-2936836,CDM,C1713,HCPCS,0278,RC,,,,both,,,11501.82,7476.18,,,,,,,,,,,,,
PLATE BNE W102XL208MM THK27MM RAD 88MM 16 H R PELV S STL J,SUP-2186282,CDM,C1713,HCPCS,0278,RC,,,,both,,,2117.84,1376.60,,,,,,,,,,,,,
STENT URET STR TIP 0.038 INX150 CM 3 CM 8 FRX22 CM PERCFLX,SUP-2464970,CDM,C2617,HCPCS,0278,RC,,,,both,,,413.76,268.94,,,,,,,,,,,,,
FORCEPS GRSP OPN DIA20MM WRK L2300MM CHN 28MM TRIPOOD REUSE,SUP-2312678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1270.19,825.62,,,,,,,,,,,,,
BAR EXT FIX 7 MMX17.8 CM PECTUS NUSS,SUP-2136286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5623.74,3655.43,,,,,,,,,,,,,
AUGMENT FEM 2XL THK8MM STD UNIV RT MEDL LT LAT DSTL KNEE CEM,SUP-2407002,CDM,C1776,CPT,0278,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
GRAFT VASC 24-32 WPI 6 MMX20 CM VASC ACCS VECTRA REV,SUP-2127772,CDM,C1768,CPT,0278,RC,,,,both,,,3362.94,2185.91,,,,,,,,,,,,,
EXTENSION CONN THORLUM TI SM STAT FOR 6MM ROD USS II,SUP-2193436,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
STENT ENDOPROS L2.5CM DIA7MM CATH 8FR L75CM BAL DIA7MM,SUP-2396553,CDM,C1874,HCPCS,0278,RC,,,,both,,,8870.50,5765.82,,,,,,,,,,,,,
ROD EXT FIX THRD 60 MM FOR SM BNE SHFT FIX SS,SUP-2525826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
DRILL 10MM,SUP-2841573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
COLLAR CERV FLX N ADJ PREFABRICATED OFF THE SHLF BRAC,SUP-2388131,CDM,L0120,HCPCS,0272,RC,,,,both,,,71.59,46.53,,,,,,,,,,,,,
SCREW BNE L30MM DIA4.5MM THRD L12MM S STL PARTIALLY THRDED,SUP-2184428,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.46,41.25,,,,,,,,,,,,,
SM FRAG PLT STERILIZER 3.5X73 MM 6 HL,SUP-2818112,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
PLATE SPNL 2 LEV 6 H ANTR CERV L38MM SNOWCAP,SUP-2207832,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ARCH EXT FIX L120MM FOR RNG FIX SYS TRUELOK,SUP-2316154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.13,1502.23,,,,,,,,,,,,,
HC Stent Place Venous Ea Add,PX-3603723900,CDM,37239,CPT,0360,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
GRAFT SYNTHECEL DURA REPAIR 4X5IN,SUP-2717545,CDM,C1763,HCPCS,0278,RC,,,,both,,,5164.52,3356.94,,,,,,,,,,,,,
SCREW BATTALION LLIF BIFUR LT CBL TIP,SUP-2419601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
GRAFT BNE STRP 50X10X5 MM DBM FIBER,SUP-2860953,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
GRAFT BNE 5ML DEMIN BNE MTRX PTY INTERGRO,SUP-2414010,CDM,C9359,HCPCS,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
PLATE BNE RECON 2.7 MM 10 HOLE 2 COMPR LCK FOR SCR TI STRL,SUP-2460408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1107.42,719.82,,,,,,,,,,,,,
ELECTRODE ELECSURG POWERBALL 24 FR FOR PRO SER RESECTOSCOPE,SUP-2754291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.77,241.00,,,,,,,,,,,,,
STEM FEM REV 145 DEG 12/14 14X385 MM HIP TAPR WAGNER SL,SUP-2206040,CDM,C1776,CPT,0278,RC,,,,both,,,19001.71,12351.11,,,,,,,,,,,,,
PLATE SPNL L6MM FULL TI STD ALONE INTBDY FUS SYS ALTA,SUP-2211549,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
STEM FEM LAT 8-10 PROX HIP REDUC PROF BIMTRC X SER INTEGR,SUP-2450452,CDM,C1776,CPT,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
ALLOGRAFT BNE 17 MM INSTR PROCHONDRIX DISP,SUP-2718025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6239.75,4055.84,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 80 CM DIA 9 FR HYDRPHLC,SUP-2383420,CDM,C1894,HCPCS,0272,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
INTRODUCER HEMSTAS 4FRX5CM SHTH W/ .035IN GWIRE ULTIMUM EV,SUP-2355596,CDM,C1894,HCPCS,0272,RC,,,,both,,,38.47,25.01,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK04 07MM DERM HUM ACELLULAR,SUP-2307043,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4750.82,3088.03,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 4X44 MM HD P2014044S] PARAGON 28],SUP-2320581,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
CUTTER ENDOSCP DISP FOR MAXBRAID SUT,SUP-2212871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
SPLINT ORTH PNEUMATIC ANK FT CTRL,SUP-2388196,CDM,L4350,HCPCS,0272,RC,,,,both,,,246.96,160.52,,,,,,,,,,,,,
CANC SCREW STERILIZER 6.5X45 MM 32MM THREAD,SUP-2818179,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.18,223.72,,,,,,,,,,,,,
BIT DRL L 155/60 MM DIA2.5 MM CALIB AO QC NS REUSE V,SUP-2907606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,809.43,526.13,,,,,,,,,,,,,
LOOP CUT 21FR BPLR,SUP-2261118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1197.19,778.17,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT SHFT RAD TRAD 60MM,SUP-2294110,CDM,C1713,HCPCS,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
WASHER SPNL LP 4.5 MM THORLUM PEDCL FOR 8.5MM SCREW TI XIA,SUP-2379339,CDM,C1713,HCPCS,0278,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
BUR SHV L18CM DIA5.5MM ABRAD HI VISIBILITY SHTH DYONIC,SUP-2341867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.13,251.63,,,,,,,,,,,,,
CATHETER ANGIO TORC NB ADVANTAGE BEAC TIP 125 CM 5 FR VTK,SUP-2168681,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
IMPLANT EYELID 16X27X0.45MM RT LO SPCR POREX,SUP-2366497,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
PACEMAKER CARD INGENIO TI SINGLE CHMBR 1 LD CONN BATTERY PWR,SUP-2149154,CDM,C1786,HCPCS,0275,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
COMPONENT GLEN 52 MM SHLDR W/ 56 MM ARTC SURF TRABECULAR MTL,SUP-2436900,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
MESH PTCH SYNTH ABD N ABSRB OVL POLYPR OBLONG OVL 30CM LEN,SUP-2265970,CDM,C1781,HCPCS,0278,RC,,,,both,,,3887.32,2526.76,,,,,,,,,,,,,
GRAFT BNE 5 CC JR LG DEFCT SUBSTITUTE DBM GRFT ORTHOBLEND,SUP-2293914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.73,1459.72,,,,,,,,,,,,,
GRAFT BNE W5XL40MM FIB FRZN SHFT,SUP-2307377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.61,1265.30,,,,,,,,,,,,,
VALVE CSF BURR HOLE 16 MM LO PRESSURE ANTI SIPHON DEV PUDENZ,SUP-2852583,CDM,C1889,HCPCS,0278,RC,,,,both,,,2248.84,1461.75,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 95 CM DIA 5 FR SPC,SUP-2869129,CDM,C1731,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
STYLET PACE L49CM BALL TIP OD0.014 GRY ATR VENT FOR LD,SUP-2282063,CDM,C1894,HCPCS,0272,RC,,,,both,,,110.75,71.99,,,,,,,,,,,,,
GRAFT ALLGRFT PTTY DBM INTERGRO,SUP-2414012,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
GRAFT BONE 1ML DEMIN BONE MTRX PUTTY STRL IMP ACCELL,SUP-2242680,CDM,C9359,HCPCS,0278,RC,,,,both,,,789.18,512.97,,,,,,,,,,,,,
PIN EXT FIX L 40 MM DIA 5 MM HA HALF STRL DISP,SUP-2933031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.05,466.08,,,,,,,,,,,,,
BUPROPION HCL 75 MG PO TABS,RX-9322,CDM,6370000000,HCPCS,0637,RC,00904-6635-61,NDC,,both,1,UN,5.50,3.57,,,,,,,,,,,,,
SCREW SPNL MULTAXL 8.5X55 MM 6.35 MM PEDCL FOR ROD RED LEG,SUP-2289023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
BOLT ORTH TROCH CALCAR PLUG OBLONG MOD FOR MLRY HD HIP SYS,SUP-2405214,CDM,C1776,CPT,0278,RC,,,,both,,,1306.24,849.06,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR HANDHELD WAND RECHRG EON,SUP-2356763,CDM,C1787,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW BNE PART THRD 2.7X32 MM TI MINICAN,SUP-2458857,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.57,413.77,,,,,,,,,,,,,
LOCK SMOOTH PEG 2.2X16MM STER,SUP-2587123,CDM,C1713,HCPCS,0278,RC,,,,both,,,293.59,190.83,,,,,,,,,,,,,
NAIL IM 10X240 MM LT TI STRL AGILE NAIL,SUP-2646469,CDM,C1713,HCPCS,0278,RC,,,,both,,,9451.40,6143.41,,,,,,,,,,,,,
IMMUNE GLOBULIN (PRIVIGEN) 10%|DISCARDED DRUG NOT ADMINISTE,RX-4081762,CDM,J1459,HCPCS,0636,RC,44206-0436-05,NDC,JW,both,50,ML,2830.00,1839.50,,,,,,,,,,,,,
SCREW BNE L28MM DIA3.8MM 90DEG TI CORT LOK V-LOCK,SUP-2414111,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
FIXATION PIN,SUP-2397042,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
SLEEVE 14MM OUTER SPNL LUM TAPR FUS DBL BRL L CAGE,SUP-2291605,CDM,C1713,HCPCS,0278,RC,,,,both,,,2169.90,1410.43,,,,,,,,,,,,,
PLATE BNE W10XL75MM THK1.2MM 90DEG 4X6 H BILAT S STL T SHP,SUP-2185872,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.17,843.16,,,,,,,,,,,,,
SYSTEM LD DEL L5IN INTRO NDL GWIRE STR CVD KINK RESIST STYL,SUP-2356682,CDM,C1769,HCPCS,0272,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
DRILL SURG CRWN GAMMA3,SUP-2457416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2329.88,1514.42,,,,,,,,,,,,,
PLATE CRAN 200X40X40 MM PT SPEC IMPL PEEK,SUP-2860129,CDM,C1713,HCPCS,0278,RC,,,,both,,,28837.76,18744.54,,,,,,,,,,,,,
COMPONENT TIB L80MM DIA16MM STD PROX MOD GMRS,SUP-2376522,CDM,C1776,CPT,0278,RC,,,,both,,,17264.03,11221.62,,,,,,,,,,,,,
GRAFT HUM TISS W14-18XL60MM FIB SHFT STRUCTURAL FRZ DRY,SUP-2307193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1925.39,1251.50,,,,,,,,,,,,,
SLING URO L7CMX4CM INCONT M SCR 6 LONESTAR W/ STAY CYSTO,SUP-2140282,CDM,C1771,HCPCS,0278,RC,,,,both,,,8870.50,5765.82,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ACTICOR 7 HF-T QP W 75 X H 60 MM D 10 MM,SUP-2739245,CDM,C1882,HCPCS,0275,RC,,,,both,,,69529.02,45193.86,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CATHETER ANGIO FL3 6 FRX100 CM EXPO,SUP-2142024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,70.34,45.72,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 29MMW X74MML 0.64MM THK 0.64MM THK CUT LG,SUP-2605583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.86,74.01,,,,,,,,,,,,,
ALLOGRAFT DERMAL 4X12 CMX1.04-2.28 MM ABD WALL REP ALLDERM,SUP-2112993,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
BLADE SHV L27.5CM DIA3.5MM 60-500RPM LO PROF S STL LARYN DBL,SUP-2284139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1616.88,1050.97,,,,,,,,,,,,,
WAND ABLAT DIA23MM ARTHSCP RF EFF END TIP W HND CTRL FOR,SUP-2256735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
PLATE BNE CRANIOMAXILLOFACIAL THK08MM 4 H STR PROF MIDFACE,SUP-2262684,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.97,280.13,,,,,,,,,,,,,
CONNECTOR SPNL ANCHR SHT CASPIAN,SUP-2517371,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
PLATE BONE L33MM 6 H CRANIOFACIAL VIT STR COND FOR 1.3MM SCR,SUP-2364693,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
PERI-LOC 2.7MM S-T CRTX SCREW 40MM,SUP-2819124,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.89,168.28,,,,,,,,,,,,,
HC CT Orbit/Ear/Fossa W/ Contrast,PX-3517048100,CDM,70481,CPT,0351,RC,,,,outpatient,,,1973.00,1282.45,,,,,,,,,,,,,
STABILIZER ORTH CHST CIRC 30-34 IN SM SZ 2 POLYESTER LYCRA,SUP-2914907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.29,277.74,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 12 CM LOOP DIA 5 MM PRIMARY,SUP-2249268,CDM,C1889,HCPCS,0278,RC,,,,both,,,3883.40,2524.21,,,,,,,,,,,,,
BUR SURG BALL 3 MM 10 CM SYMTRC SM BOR MIDAS REX 8 LEGEND,SUP-2664486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.39,324.60,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ LOOP LOK FIRM SUPP VYN STRP,SUP-2276619,CDM,L3908,HCPCS,0274,RC,,,,both,,,15.86,10.31,,,,,,,,,,,,,
STEM FEM SZ 4 L183MM L32MM 131DEG LNG STD PROTASUL-100 HIP,SUP-2205690,CDM,C1776,CPT,0278,RC,,,,both,,,14531.92,9445.75,,,,,,,,,,,,,
AUGMENT ACET PART HMSPHR SZ 48 MM 10 MM THCK MULT H POR,SUP-2199308,CDM,C1776,CPT,0278,RC,,,,both,,,8251.92,5363.75,,,,,,,,,,,,,
ROD SPNL 5.5 MM DIAM 35 MM LEN POST SMOOTH PRE CVD RT,SUP-2415457,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
SIZER SURG NOVEL DSGN LEN DIAM MEAS ACCURACY LO COST,SUP-2302402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 15 CM DIA 6.5 FR PTFE PERC LNG,SUP-2127715,CDM,C1894,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
CABLE SURG L750MM DIA1.7MM CERCLAGE CO CHROM SMOOTH W/ CRMP,SUP-2193974,CDM,C1776,CPT,0278,RC,,,,both,,,1336.42,868.67,,,,,,,,,,,,,
GRAFT HUM TISS 12X19MM OSTEOCHNDRL VIABLE CHONDROCYTES,SUP-2314091,CDM,C1762,CPT,0278,RC,,,,both,,,17662.50,11480.62,,,,,,,,,,,,,
BIT DRL L230MM DIA32MM 3 FLUT CALIB QUIK CONN,SUP-2199210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
PLATE CRAN 120X60X40 MM PT SPEC IMPL PEEK,SUP-2860133,CDM,C1713,HCPCS,0278,RC,,,,both,,,31681.97,20593.28,,,,,,,,,,,,,
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-102338,CDM,J3480,HCPCS,0636,RC,00264-7625-00,NDC,,both,1000,ML,57.50,37.37,,,,,,,,,,,,,
SPLINT FNGR M 3IN DYN KNCK BENDR RVS SGL DGT WIRE FOAM RUB,SUP-2324851,CDM,L3809,HCPCS,0274,RC,,,,both,,,41.95,27.27,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 400 MG/20ML IV SOLN,RX-167521,CDM,Q5135,HCPCS,0636,RC,65219-0594-20,NDC,,both,20,ML,5777.30,3755.24,,,,,,,,,,,,,
HC So Hemoglobin Chromatography,PX-3018302166,CDM,83021,CPT,0301,RC,,,,inpatient,,,267.00,173.55,,,,,,,,,,,,,
COIL EMB L45CM OD0.020IN LOOP OD16MM NIT STRTCH RESIST FILL,SUP-2323420,CDM,C1889,HCPCS,0278,RC,,,,both,,,8088.64,5257.62,,,,,,,,,,,,,
KIT DRL BIT DIA2/3.2MM SHLDR REV PLATFRM EQUINOXE,SUP-2223409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
PLATE BONE L77MM THK3.3MM HK D18MM 8 H LT CLAV TI RIG NEUT,SUP-2190921,CDM,C1713,HCPCS,0278,RC,,,,both,,,2461.35,1599.88,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EP XT L 110 CM DIA 6 FR SPC 10 MM,SUP-2142245,CDM,C1730,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SYSTEM BUR H CVR CRAN BASE HLDR 2 SCR 1 SCRDRIVER CLP INSRTN,SUP-2357353,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
HC Ribs Bilat 3 Vw W/O Chest,PX-3207111000,CDM,71110,CPT,0320,RC,,,,inpatient,,,732.00,475.80,,,,,,,,,,,,,
"HC So Phosphorus, Urine 24 Hr",PX-3018410566,CDM,84105,CPT,0301,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
LINER ACET OD54MM ID32MM +4MM OFFSET HIP CROSSLINKED,SUP-2250552,CDM,C1776,CPT,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
HC NM Liver Imaging Static Only,PX-3417820100,CDM,78201,CPT,0341,RC,,,,both,,,2934.00,1907.10,,,,,,,,,,,,,
DEVICE BNE FILL BX 8 GA OSSEOFLEX BFD,SUP-2464015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12.5X15X6 MM FD PARL CORTICAL CANC ACF,SUP-2736825,CDM,C1713,HCPCS,0278,RC,,,,both,,,4180.91,2717.59,,,,,,,,,,,,,
STENT BILI L24MM BLLN L25MM DIA5MM CATH L80CM DIA6FR,SUP-2159026,CDM,C1876,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BLADE SURG L100MM S STL HELIX FOR LCP DHHS SYS,SUP-2186784,CDM,C1776,CPT,0278,RC,,,,both,,,1050.77,683.00,,,,,,,,,,,,,
TRIAL BNE PLT 130DEG FEM DHS,SUP-2187954,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.90,581.03,,,,,,,,,,,,,
DRILL SURG N CEM 4-6 FBT HI PERF SIG,SUP-2456274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
ANCHOR SUTURE SFT 2.9 MM NDL SHT PNCH JUGGERKNOT,SUP-2608805,CDM,C1713,HCPCS,0278,RC,,,,both,,,1621.24,1053.81,,,,,,,,,,,,,
KIT SLEEVE SURGICAL SYSTEM 10PK,SUP-2266521,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER THERMOABLATION CLOSUREFAST L 100 CM DIA 6 FR HEAT,SUP-2874944,CDM,C1888,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GRAFT BONE CERV SPCR LORDTC H 11MM,SUP-2415408,CDM,C1713,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
SET CATH HEMODIALYSI ACTE 12FR DIA 16CM 2LM INDWL BLU FLEXTI,SUP-2613327,CDM,C1752,HCPCS,0278,RC,,,,both,,,174.08,113.15,,,,,,,,,,,,,
ROD TI LONG STRAIGHT 5.5X500,SUP-2840503,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
STENT PERIPH L40MM DIA10MM CATH L120CM GWIRE 0.035IN SHTH,SUP-2416730,CDM,C1876,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
KIT TRACH AD TB L60MM OD73MM ID5MM SIL W OBT SIDEPRT,SUP-2352052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,313.31,203.65,,,,,,,,,,,,,
PLATE L FUSION VA LCP 2.4/2.7MM STD RT TI STRL,SUP-2546992,CDM,C1713,HCPCS,0278,RC,,,,both,,,2692.55,1750.16,,,,,,,,,,,,,
HC So Antidepressant Tricyclic 1/2,PX-3018033566,CDM,G0480,CPT,0301,RC,,,,inpatient,,,380.00,247.00,,,,,,,,,,,,,
AGBA PICC/DELTA FG: 2-L 5.5 FRX40 CM,SUP-2822088,CDM,C1751,HCPCS,0278,RC,,,,both,,,1015.26,659.92,,,,,,,,,,,,,
PLATE BNE MTP L FLAT MINI MAXLOCK EXTRM,SUP-2400411,CDM,C1713,HCPCS,0278,RC,,,,both,,,5702.24,3706.46,,,,,,,,,,,,,
WAND ABLAT DIA3.75MM 90DEG ANG INTEGR CBL SUP TURBOVAC,SUP-2342002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
DISTRACTOR BTTRSS FOOT PLATE SHRT 3 HOLE BI DRCTNL MXLLRY DV,SUP-2681265,CDM,C1713,HCPCS,0278,RC,,,,both,,,3288.93,2137.80,,,,,,,,,,,,,
DARIFENACIN HYDROBROMIDE ER 7.5 MG PO TB24,RX-40402,CDM,6370000000,HCPCS,0637,RC,69097-0431-02,NDC,,both,1,UN,9.80,6.37,,,,,,,,,,,,,
CATHETER GUID 8FR L150CM GUID SEG L25CM PLAT IRIDIUM HELCL,SUP-2140878,CDM,C1887,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
COMPONENT FEM PS 3 UNISX LT KNEE PRIMARY CEM STEMLESS,SUP-2378132,CDM,C1776,CPT,0278,RC,,,,both,,,9553.76,6209.94,,,,,,,,,,,,,
BIT DRILL T2 TRIFLAT 42 X 130MM,SUP-2701073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.95,443.92,,,,,,,,,,,,,
STEM HUM DSTL 15X210 MM SHLDR AEQUALIS FLX REVIVE PTC,SUP-2715481,CDM,C1776,CPT,0278,RC,,,,both,,,30615.00,19899.75,,,,,,,,,,,,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,0636,RC,00049-0013-83,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
WIRE OLV THRD 1.3X70MM,SUP-2321637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
SCREW BNE L34MM DIA3.5MM CO CHROM ST LOK FULL THRD SQ DRV,SUP-2413771,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
SURFACE ARTC SZ 5-6/CD H28MM AP46MM ML74MM UNIV CNDYL TIV,SUP-2201828,CDM,C1776,CPT,0278,RC,,,,both,,,6143.41,3993.22,,,,,,,,,,,,,
INSTRUMENT ENDO DIA7MM ACL TIGHTROPE DB,SUP-2121398,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
BIT DRL FISH TAIL UNIV 25 MM SOLITAIRE,SUP-2685253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
CATHETER INFUSION PMP 4 ML/HR 2X5 IN 550 CC,SUP-2365201,CDM,C1781,HCPCS,0278,RC,,,,both,,,690.17,448.61,,,,,,,,,,,,,
PLATE BNE 2 T-SHAPE1.5MM 2-HOLE,SUP-2247343,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP XS RT WRST,SUP-2196555,CDM,L3931,HCPCS,0274,RC,,,,both,,,15.26,9.92,,,,,,,,,,,,,
PLATE 3.5MM TI LCP OLECRANON 10 HOLES RIGHT 190MM-STERILE,SUP-2549530,CDM,C1713,HCPCS,0278,RC,,,,both,,,3942.62,2562.70,,,,,,,,,,,,,
SPACER CEM SM SHT L94MM DIA54MM PMMA HI REL GENT IMPREG,SUP-2223674,CDM,C1776,CPT,0278,RC,,,,both,,,11649.40,7572.11,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RANG L 135 CM BALLOON L 100 MM DIA 4 MM,SUP-2653303,CDM,C2623,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
KIT CATH 5FR L13CM CTRL VEN POLYUR DBL LUMN BLU FLEXTIP W/,SUP-2383294,CDM,C1751,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
PLATE BNE BAR L12MM 2 H CRANIOMAXILLOFACIAL TI RIG FOR UNIV,SUP-2366213,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.34,212.12,,,,,,,,,,,,,
CLIP ANEURYSM OPENING W1.5MM BLADE L2MM MICRO STRAIGHT CLOSI,SUP-2825393,CDM,C1889,HCPCS,0278,RC,,,,both,,,801.05,520.68,,,,,,,,,,,,,
LINER ACET ECC 32X64 MM HIP,SUP-2202295,CDM,C1776,CPT,0278,RC,,,,both,,,3485.75,2265.74,,,,,,,,,,,,,
COLLAR CERV 2 PC SM AD 10-20X2 IN ADJ EMS MIAMI J PLAS FOAM,SUP-2247597,CDM,L0190,HCPCS,0274,RC,,,,both,,,174.84,113.65,,,,,,,,,,,,,
PLATE BONE FAN 43.6X1.5 MM WITH FIXATION HOLE SMOOTH REINFOR,SUP-2837809,CDM,C1713,HCPCS,0278,RC,,,,both,,,4763.07,3096.00,,,,,,,,,,,,,
HC So2 Ptt,PX-3058573068,CDM,85730,CPT,0305,RC,,,,both,,,9.00,5.85,,,,,,,,,,,,,
ROD IM 8 MM KNEE PERSONA,SUP-2447959,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
TOOL ANCHR FIX INTUITIVE DESIGN EZ TO HLD DEPLOY TACTILE,SUP-2896053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
LARGE EXTERNAL FIXATOR PELVIC FRAME KIT-STERILE,SUP-2546226,CDM,C1713,HCPCS,0278,RC,,,,both,,,14524.42,9440.87,,,,,,,,,,,,,
EXPANDER BRST W14.6XH12.6CM P7.6CM 650CC SIL NACL SHELL RND,SUP-2300635,CDM,C1789,HCPCS,0278,RC,,,,both,,,4207.60,2734.94,,,,,,,,,,,,,
PATCH CV HEMSHLD PLAT FINESSE L 152 X W 25 MM THK 0.36 MM,SUP-2481899,CDM,C1768,CPT,0278,RC,,,,both,,,563.32,366.16,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 70 MM DIA13/10 MM DEL,SUP-2934223,CDM,C1713,HCPCS,0278,RC,,,,both,,,15468.27,10054.38,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 30 MM BLB DIA2.25 MM SIL RUBBER INT,SUP-2130337,CDM,C1760,HCPCS,0278,RC,,,,both,,,253.37,164.69,,,,,,,,,,,,,
CEMENT BNE 20ML 40GM HALF DOSE PMMA W/O GENT HI VISC RADPQ,SUP-2197461,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
BRACE ORTH 2X UPR ELBW CUF EO,SUP-2388190,CDM,L3720,HCPCS,0272,RC,,,,both,,,1683.35,1094.18,,,,,,,,,,,,,
GRAFT HUM TISS 4X6CM THN UMB CRD CYGNUS SOLO,SUP-2393057,CDM,Q4170,HCPCS,0636,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
HC So Theophylline,PX-3018019866,CDM,80198,CPT,0301,RC,,,,both,,,437.00,284.05,,,,,,,,,,,,,
BLADE SURG SAW SAG 105MM LEN 18MM W 2 CUT,SUP-2362663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,231.07,150.20,,,,,,,,,,,,,
WASHER ORTH FOR 3.5/4/4.5MM SCR FLOWERCUBE,SUP-2225525,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
CATHETER ANGIOPLSTY DIA13MM BAL DIA4.5MM HYDRCOAT RAP EXCHG,SUP-2101510,CDM,C1725,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER PERFSN L 20 CM DIA 9 FR BLLN 9 MM POLYUR PRESHP,SUP-2881189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,299.21,194.49,,,,,,,,,,,,,
RAIL EXT FIX T HNDL SYS,SUP-2197311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7503,SUP-2496623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL FUSION NS LTX,SUP-2857132,CDM,C1713,HCPCS,0278,RC,,,,both,,,9498.50,6174.02,,,,,,,,,,,,,
BOLT EXT FIX WIRE FIX STRL TRUELOK EVO LTX,SUP-2875625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,333.63,216.86,,,,,,,,,,,,,
SCREW SPNL REDUCTION 4X12 MM PYRENEES,SUP-2531426,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.90,126.03,,,,,,,,,,,,,
MESH BONE LATEX FREE MID FACE BODY,SUP-2676921,CDM,C1713,HCPCS,0278,RC,,,,both,,,12170.51,7910.83,,,,,,,,,,,,,
ALLOGRAFT BNE FILL 1-8 MM 2.5 CC FD SPNG CANC READIGRAFT BLX,SUP-2740802,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.63,489.86,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX60 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761468,CDM,C1768,CPT,0278,RC,,,,both,,,3000.05,1950.03,,,,,,,,,,,,,
BLADE RETRACTOR UNIVERSAL RING 3INW X 6IND MALLEABLE,SUP-2676581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1001.09,650.71,,,,,,,,,,,,,
PARTICLE EMB BNDL S220PRO MAESTRO 28MC24150SN EMBOSPHEREPRO,SUP-2798605,CDM,C1889,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
DRILL SURG DIA4.2MM GLD POST/PEG DISP FOR MTP FUS PLATING,SUP-2223992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 3X3.5CM,SUP-2261684,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2295.34,1491.97,,,,,,,,,,,,,
COMPONENT HIP 6 MTL,SUP-2254059,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
SPACER SPNL W10XH9XL23MM 0DEG PEEK OPTMA INTERVERTEBRAL LUM,SUP-2137150,CDM,C1821,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GRAFT DERMAL MESH 5X5 CM FEN + WND MTRX MIRODERM,SUP-2431541,CDM,Q4175,HCPCS,0636,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 3.5 MM DRVR USE W/ 10313 NS REUSE,SUP-2762184,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
IMPLANT OPHTH 1.8X3.75MM SIL RETIN STYL 3084 SL OVL,SUP-2263420,CDM,C1784,HCPCS,0278,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
PLATE TBL 25MM SCREW TTNM OPEN WEDGE OSTEO BONE LEFT ULTRA,SUP-2675410,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.47,55.56,,,,,,,,,,,,,
HC Drainage Mouth Roof Lesion,PX-4504200000,CDM,42000,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
DEVICE CATH MEAS,SUP-2140281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM 2 ERGO HNDL LSR BND W/O NDL DBL END HA,SUP-2366673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1604.54,1042.95,,,,,,,,,,,,,
NUT ORTH COMPR OLECRANON IMP STRL OD10MM,SUP-2106885,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG SM 4.5X60 MM 50 MM 4 STRL,SUP-2653573,CDM,C1713,HCPCS,0278,RC,,,,both,,,2146.66,1395.33,,,,,,,,,,,,,
KIT INTRO VSI L 12 CM DIA 4 FR GUIDEWIRE L 40 CM DIA 0.018,SUP-2763483,CDM,C1892,HCPCS,0272,RC,,,,both,,,130.62,84.90,,,,,,,,,,,,,
INTRODUCER INCUBATING CATH 14FR L65CM DIA3MM W/ STIFFING,SUP-2168692,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CAGE SPNL W20XH16XL26MM TI ANT THORLUM INTBDY FUS OVL TAPR,SUP-2291589,CDM,C1889,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
LOW PROFILE SUTURE LASSO 45 DEGREE,SUP-2812975,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BIT DRL 1.9X115 MM 35 MM END NS LTX,SUP-2862798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,878.67,571.14,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 8 MM THK 0.35 MM POLYESTER,SUP-2227615,CDM,C1768,CPT,0278,RC,,,,both,,,2113.94,1374.06,,,,,,,,,,,,,
INSERTER SUTURE WIRE FOR RC REP ARTHROTUNNELER,SUP-2908648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
IMPLANT ANK JT L15MM OD9MM TI SUBTALAR SFT THRD CANN CONIC,SUP-2388616,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
BRACE KNEE ACL PLC MCL ICL SIZED TO FIT UNIV UNISX FASTEN ON,SUP-2150832,CDM,L1810,HCPCS,0272,RC,,,,both,,,1375.57,894.12,,,,,,,,,,,,,
PLATE BONE SH STRL TARSAL METATRSL FUS FOR 2.7MM SCR VLP,SUP-2349942,CDM,C1713,HCPCS,0278,RC,,,,both,,,5010.34,3256.72,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 11 CM DIA 6 FR NIT PD WIRE,SUP-2740597,CDM,C1892,HCPCS,0272,RC,,,,both,,,181.34,117.87,,,,,,,,,,,,,
PLATE BNE SZ MINI CALCANEUS,SUP-2243229,CDM,C1713,HCPCS,0278,RC,,,,both,,,6945.40,4514.51,,,,,,,,,,,,,
GRAFT ENDOVASC L7CM DIA12MM IL EXT EXCLUDER,SUP-2395950,CDM,C1768,CPT,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
PLATE SLOTTED 10X60MM,SUP-2469917,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.85,218.30,,,,,,,,,,,,,
PLATE BNE STR 25 MM TCP 08125,SUP-2535851,CDM,C1713,HCPCS,0278,RC,,,,both,,,3604.72,2343.07,,,,,,,,,,,,,
KIT PERI DRNGE STRT W/ 1 INSRTN TY 15.5FR CATH 1L BG WIPE,SUP-2416418,CDM,C1729,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GRAFT HUM TISS L45MM FEM HD FRZN ALLGRFT TRAD,SUP-2294154,CDM,C1713,HCPCS,0278,RC,,,,both,,,3322.12,2159.38,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAG CTRL STRP STAY PENDULOUS,SUP-2435558,CDM,L0649,HCPCS,0272,RC,,,,both,,,811.85,527.70,,,,,,,,,,,,,
STENT URET 0.038 IN 8 FRX22 CM 6 FR FLX FIRM PERCFLX +,SUP-2460000,CDM,C2617,HCPCS,0278,RC,,,,both,,,510.72,331.97,,,,,,,,,,,,,
COUNTERSINK DRL DIA4MM G,SUP-2400357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 7 CM DIA 6 FR GUIDEWIRE L 40 CM DIA,SUP-2303288,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.84,59.05,,,,,,,,,,,,,
CATHETER IV REINF TIP 20 GAX10 CM PWR INJ POWERGLIDE PRO F320108PT,SUP-2125671,CDM,C1751,HCPCS,0278,RC,,,,both,,,379.44,246.64,,,,,,,,,,,,,
SHUNT SURG DELT ASMBLY 1 REG SPNL CEREB FLUID,SUP-2284557,CDM,C1889,HCPCS,0278,RC,,,,both,,,4013.05,2608.48,,,,,,,,,,,,,
WAND ABLAT SABER STR,SUP-2341973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
PLATE BNE L34MM 4X4 H BILAT MAND ORAL MAXILLOFACIAL TI ANG,SUP-2191466,CDM,C1713,HCPCS,0278,RC,,,,both,,,4648.77,3021.70,,,,,,,,,,,,,
ECLIPSE CAGE SCREW M 35MM,SUP-2817809,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PIN GUIDE L 358 MM DIA 3.2 MM COCR FLUT TIP STRL DISP,SUP-2932801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,918.01,596.71,,,,,,,,,,,,,
HC Iabp Insertion,PX-3613396700,CDM,33967,CPT,0361,RC,,,,inpatient,,,8633.00,5611.45,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3 CM 0.035 INX150 CM STD STIFF GLIDEWIRE,SUP-2385566,CDM,C1769,HCPCS,0272,RC,,,,both,,,104.91,68.19,,,,,,,,,,,,,
STEM FEM MAG 11-14 STD HIP EXACT INTEGR,SUP-2450407,CDM,C1776,CPT,0278,RC,,,,both,,,1116.27,725.58,,,,,,,,,,,,,
BIT DRL 1.7 MM MEMOFIX,SUP-2244267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.47,812.16,,,,,,,,,,,,,
CUTTER ENDOSCP 15 MMX125 CM ROTOCUT G1 ADIPOSE MORCELLATOR,SUP-2261065,CDM,C1713,HCPCS,0278,RC,,,,both,,,1750.68,1137.94,,,,,,,,,,,,,
SHELL ACET OD58MM ID24MM HIP TI ALLY MH LOK MECHANISM,SUP-2409109,CDM,C1776,CPT,0278,RC,,,,both,,,6493.52,4220.79,,,,,,,,,,,,,
CATHETER CV KT AD 7 FRX20 CM 3L PRESSURE INJ N TUNNELED,SUP-2763383,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.75,220.84,,,,,,,,,,,,,
LACTULOSE 10 GM/15ML PO SOLN,RX-38245,CDM,340b,HCPCS,0637,RC,00121-0873-16,NDC,,both,15,ML,2.70,1.75,,,,,,,,,,,,,
THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR,RX-89570,CDM,6370000000,HCPCS,0637,RC,00338-0322-01,NDC,,both,1,UN,494.50,321.42,,,,,,,,,,,,,
PLATE BNE DBL Y LG 1.5X19X1 MM MIDFACE 6 HOLE W/ TAB TI STRL,SUP-2463082,CDM,C1713,HCPCS,0278,RC,,,,both,,,915.62,595.15,,,,,,,,,,,,,
RING EXT FIX HALF 240 MM TI NS,SUP-2800049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1909.18,1240.97,,,,,,,,,,,,,
CATHETER HD STR 13.5 FRX13 CM DL HI FLO PASS TY MAHRK ELITE,SUP-2626886,CDM,C1752,HCPCS,0278,RC,,,,both,,,417.81,271.58,,,,,,,,,,,,,
HC Drain Arm Bursa,PX-4502393100,CDM,23931,CPT,0450,RC,,,,both,,,1649.00,1071.85,,,,,,,,,,,,,
HC Intrvasc US Noncoronary 1st,PX-3613725200,CDM,37252,CPT,0361,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
SET INTRO DIA12 FR CATH 14 GA NDL 21 GA1 CC/20 CC TRNSJUG,SUP-2117071,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
SLING ORTHOT CUST TRAPEZIUS,SUP-2435577,CDM,L1070,HCPCS,0274,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
GRAFT 5X6CM TERMINALLY MTRX STRL TISSUEMEND,SUP-2366722,CDM,C1713,HCPCS,0278,RC,,,,both,,,13649.58,8872.23,,,,,,,,,,,,,
SCREW BNE FT 4X24 MM CANN STRL,SUP-2457840,CDM,C1713,HCPCS,0278,RC,,,,both,,,484.28,314.78,,,,,,,,,,,,,
DEVICE FIX L36MM 5MM 30 TACKS ABSRB POLY COPOLYMER ERGO,SUP-2283225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1273.11,827.52,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA 6 MM EPTFE FLX STD WALL RING,SUP-2126887,CDM,C1768,CPT,0278,RC,,,,both,,,3614.17,2349.21,,,,,,,,,,,,,
AMILORIDE HCL 5 MG PO TABS,RX-391,CDM,6370000000,HCPCS,0637,RC,00574-0292-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BONE SUB 10CC DEMIN BONE MTRX RM TEMP OPTEFORM,SUP-2223560,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
BUR SURG L75MM DIA2MM S STL RND CUT,SUP-2284224,CDM,C1713,HCPCS,0278,RC,,,,both,,,168.12,109.28,,,,,,,,,,,,,
CRANIAL KT W TWO DRL BITS,SUP-2244101,CDM,C1713,HCPCS,0278,RC,,,,both,,,864.07,561.65,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.6X4 MM PISTON TI,SUP-2471196,CDM,L8613,CPT,0278,RC,,,,both,,,391.31,254.35,,,,,,,,,,,,,
PLATE CRAN 60X40X20 MM PT SPEC IMPL PEEK,SUP-2860175,CDM,C1713,HCPCS,0278,RC,,,,both,,,26356.22,17131.54,,,,,,,,,,,,,
SET PUTTY BONE SYNTH CARB APATITE 5CC PRELD SYR DILUTANT,SUP-2316472,CDM,C1713,HCPCS,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
PLATE BNE L95MM 2 H TIB TI LOK FOR 4MM SCR AXSOS 3,SUP-2375505,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
SLEEVE IM 100DEG LT BLU TI LCK FOR SPRL BLDE 9-12MM NAIL,SUP-2191876,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.60,770.64,,,,,,,,,,,,,
PLATE BONE L67MM 8 H STRL S STL COMPR FOR 2.7MM SCR EVOS,SUP-2349623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1663.01,1080.96,,,,,,,,,,,,,
GRAFT EXCLUDER 23 X 12 X 12CM,SUP-2395969,CDM,C1768,CPT,0278,RC,,,,both,,,22915.72,14895.22,,,,,,,,,,,,,
EXTENSION POST 10+ MM TI HUMELOCK II,SUP-2741763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ISOLYTE-S IV SOLN,RX-4014,CDM,2580000003,HCPCS,0250,RC,00264-7703-00,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
COLLAR CERV SM PED W25XL14IN FOAM M DENS BRTH COT STOCK LNR,SUP-2194384,CDM,L0120,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
HC So Chromosome Count Additional,PX-3118828566,CDM,88285,CPT,0311,RC,,,,outpatient,,,38.00,24.70,,,,,,,,,,,,,
SCREW BNE L 17 MM DIA2.4 MM SS LCK T8 STARDRV AQUA HD TUBE,SUP-2905730,CDM,C1713,HCPCS,0278,RC,,,,both,,,848.99,551.84,,,,,,,,,,,,,
CANNULA KYPHOPLASTY NDL 11GA SPNL W/ CEM INFL VERT AUG SYS,SUP-2366875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4152.21,2698.94,,,,,,,,,,,,,
COLLAR CERV SM FOAM LF,SUP-2330406,CDM,L0120,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TIBIAL NAIL TRAY,SUP-2811218,CDM,C1713,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
PRBE COAG L2.2MD2.3MM FLX AR PLSM CRFRTL BM-ORDR MULTI 10 EA,SUP-2217948,CDM,C1886,HCPCS,0278,RC,,,,both,,,820.48,533.31,,,,,,,,,,,,,
MESH HERN OVL 8X6 IN INTRA-ABDOMINAL,SUP-2126048,CDM,C1781,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER EP SM CRV INQUIRY,SUP-2357441,CDM,C1730,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
OCCLUDER CV CARDIOFORM DIA 30 MM CATH L 75 CM DIA10 FR PLAT,SUP-2395775,CDM,C1817,HCPCS,0278,RC,,,,both,,,29817.44,19381.34,,,,,,,,,,,,,
SPLINT CLAV M AD BCKL CLSR PD MCLEOD,SUP-2197364,CDM,L3660,HCPCS,0274,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
PROBE ULTRASOUND TRIPLANE,SUP-2225698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.025IN TIP L3CM NIT HYDRPHLC STIFF,SUP-2417975,CDM,C1769,HCPCS,0272,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
STENT CAR NEXSTENT L 30 MM DIA 4-9 MM NIT OTW SELF,SUP-2140174,CDM,C1876,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
DRIVER SURG T10 TORX HEX FOR EVOLUTION C CERV IMPL REM SYS,SUP-2293611,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.11,155.42,,,,,,,,,,,,,
SCREW BNE L110MM DIA1035MM PROX FEM G TI CANN PARTIALLY THRD,SUP-2180726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1922.65,1249.72,,,,,,,,,,,,,
SYSTEM OCCL DEL AMPLATZER 45 DEG L 60 CM OD 2.44 MM ID 3.05,SUP-2116318,CDM,C1817,HCPCS,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
PLATE BNE THK06MM 6 H CRAN TI MESH MIC RECT FOR 15MM SCR,SUP-2262708,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.89,419.18,,,,,,,,,,,,,
PLATE BNE THK 0.8 MM SCREW DIA2 MM 6 H MED CRV NS DISP,SUP-2934840,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
CATHETER ABLAT 7FR TIP L5MM 2.5MM SPC QPLR L CRV STD LEN HI,SUP-2141282,CDM,C1733,HCPCS,0272,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS AXIOFILL 500MG,SUP-2865149,CDM,C1762,CPT,0278,RC,,,,both,,,4097.70,2663.50,,,,,,,,,,,,,
ANCHOR SUTURE DBL LD SLIDING 2 2.9 MM W/ NDL JUGGERKNOT,SUP-2745264,CDM,C1776,CPT,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
CATH 7/110/2.5/7-4 QUAD STD,SUP-2424678,CDM,C1732,HCPCS,0272,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
POLYVINYL ALCOHOL-POVIDONE PF 1.4-0.6 % OP SOLN,RX-141221,CDM,6370000000,HCPCS,0637,RC,00023-0506-50,NDC,,both,0.05,ML,1.00,0.65,,,,,,,,,,,,,
SURFACE ARTC SZ 1-2 AB THK11MM LT KNEE HIGHLY CROSSLINKED,SUP-2206698,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
CATHETER ATHRCTMY JETSTREAM G3 SF TIP DIA1.85 MM PERIPH STRL,SUP-2139500,CDM,C1724,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
BIT DRL DIA11MM DISP CHONDROFIX,SUP-2200257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BONE 4X16 H RT MAND TI ANG RIG NONCOMPRESSION,SUP-2191414,CDM,C1713,HCPCS,0278,RC,,,,both,,,4995.74,3247.23,,,,,,,,,,,,,
CATHETER VENTRICULAR STYL 15 CM W/ CM MRK HOLTER,SUP-2666803,CDM,C1729,HCPCS,0272,RC,,,,both,,,513.58,333.83,,,,,,,,,,,,,
HC Pseudo-Aneurysm Compression,PX-4027693600,CDM,76936,CPT,0402,RC,,,,inpatient,,,3211.00,2087.15,,,,,,,,,,,,,
CLIP ANEUR T BAR 45 DEG 5 MM PERM TI STRL YASRG,SUP-2108698,CDM,C1889,HCPCS,0278,RC,,,,both,,,4515.32,2934.96,,,,,,,,,,,,,
SCREW BNE L55MM DIA75MM THRD L16MM CALCNL ANK TI CANN HD,SUP-2399014,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
BIT DRL OD4.3MM SHT VALOR,SUP-2397589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
WIRE LIG 24GA DIA0.02IN S STL INSTR,SUP-2136072,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
STAPLE BNE FIX 18X18 MM KEEL LCK NIT SUPERELASTIC TRIMAX,SUP-2866447,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
KIT INTRO L 14 CM DIA12 FR GUIDEWIRE L 50 CM DIA 0.038 IN,SUP-2615895,CDM,C1894,HCPCS,0272,RC,,,,both,,,108.30,70.39,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SM 1.3 CC CORTICOCANCELLOUS VIABLE,SUP-2933521,CDM,C1762,CPT,0278,RC,,,,both,,,1585.07,1030.30,,,,,,,,,,,,,
COLLAR CERV M FIRM DENS AD CNTOUR HK AND LOOP CLSR W COT CVR,SUP-2276592,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.63,4.31,,,,,,,,,,,,,
HC So Adamts-13 Activity,PX-3058539766,CDM,85397,CPT,0305,RC,,,,outpatient,,,196.00,127.40,,,,,,,,,,,,,
WAND ARTHSCP ENT 45 DEG REFLX ULT COBLATOR II,SUP-2342028,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.89,546.58,,,,,,,,,,,,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,0636,RC,72603-0152-01,NDC,,both,1,UN,1209.00,785.85,,,,,,,,,,,,,
HEAD FEM DIA28MM NK L+0MM HIP ALUMINA CERAMIC 12/14 TAPR,SUP-2344797,CDM,C1776,CPT,0278,RC,,,,both,,,4837.17,3144.16,,,,,,,,,,,,,
PLATE BNE L 48 MM SCREW DIA2.7 MM 6 SHFT H TI STR COMPACT,SUP-2907744,CDM,C1713,HCPCS,0278,RC,,,,both,,,3511.31,2282.35,,,,,,,,,,,,,
IMPLANT HUM TISS W5XL5CM THK1MM PERICARD MULTDIR TUTOPLAST,SUP-2335276,CDM,C1768,CPT,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
TAP ST 2.8 MM REUNITE SM SCR FIX SYS,SUP-2212976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
PLATE BONE STRL LT METATARSOPHALANGEAL REV FOR 2.7MM SCR VLP,SUP-2349940,CDM,C1713,HCPCS,0278,RC,,,,both,,,6380.95,4147.62,,,,,,,,,,,,,
IMPLANT ANK JT SM GAITWAY,SUP-2397257,CDM,C1776,CPT,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
CAGE SPNL STATIC 18X16 MM TI X-CORE 2 7180016P2,SUP-2561279,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
TUNNELER SURG VAGUS NRV S STL HAFT BULL TIP SL FLUOROCARBON,SUP-2265175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
"HC So1 Antidiuretic Hormone, Plasma",PX-3018458867,CDM,84588,CPT,0301,RC,,,,both,,,1003.00,651.95,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-10 MM 30 CC FD CRUSH CANC READIGRAFT,SUP-2741026,CDM,C1713,HCPCS,0278,RC,,,,both,,,1204.10,782.66,,,,,,,,,,,,,
SODIUM CHLORIDE 2.5 MEQ/ML IJ SOLN,RX-7320,CDM,2500000003,HCPCS,0250,RC,00409-6660-75,NDC,,both,40,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 40 CM DIA10 MM POLYESTER BOV CLLGN STR,SUP-2227539,CDM,C1768,CPT,0278,RC,,,,both,,,1737.61,1129.45,,,,,,,,,,,,,
BUTTON FIX TI UHMWPE RND GRFT SELF REINF FOR PCL RECON,SUP-2121401,CDM,C1713,HCPCS,0278,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
VLP MINI-MOD 1.5MM OVERDRILL MINI QUIK CONN,SUP-2341193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,688.35,447.43,,,,,,,,,,,,,
KIT DRL BIT DIA2.65MM CORRESPONDING INCL DRL GUID HNDL LOC,SUP-2194164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.35,511.13,,,,,,,,,,,,,
HC Veeg by Tech 2-12 Hr Cont R-T Monitoring,PX-7409571300,CDM,95713,CPT,0740,RC,,,,outpatient,,,4222.00,2744.30,,,,,,,,,,,,,
PLATE BNE L 69 MM SCREW DIA2.4/2.7 MM 6 HD 4 SHFT H RT DSTL,SUP-2913571,CDM,C1713,HCPCS,0278,RC,,,,both,,,6173.65,4012.87,,,,,,,,,,,,,
PACKING NASAL SINUS FRM SINGLE USE,SUP-2866534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.05,390.03,,,,,,,,,,,,,
HC Anoscopy Diagnostic,PX-4504660000,CDM,46600,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
REAMER CONE METATARSOPHALANGEAL FUS GEN II 20 MM,SUP-2398339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
STEM FEM SZ 3 L155MM NK L55MM 10 12 TAPR HA HIP CEM PRI STD,SUP-2253370,CDM,C1776,CPT,0278,RC,,,,both,,,9589.56,6233.21,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CORONAL CTRL PREFABRICATED,SUP-2388152,CDM,L0640,HCPCS,0272,RC,,,,both,,,2694.81,1751.63,,,,,,,,,,,,,
SYSTEM DRAINAGE BURET SAMPLING NEEDLELESS,SUP-2666769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.78,315.11,,,,,,,,,,,,,
BAG TISS CLSR DIA6CM TRNSPAR SIL SILO TAPR SPR LD PROX OPN,SUP-2134676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
CATHETER STEER LIVEWIRE 7FR QPLR 2-5-2MM ELECTRD SPC SM SWP,SUP-2356859,CDM,C1730,HCPCS,0272,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SM VIABLE AMNION MTRX ESSENCE,SUP-2538797,CDM,C1762,CPT,0278,RC,,,,both,,,4289.24,2788.01,,,,,,,,,,,,,
LEAD NERVE STIM KT PNE,SUP-2568743,CDM,C1778,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
MICROCATHETER DIAG L160CM OD2.95/2.6IN ID0.025IN MIC NIT,SUP-2323716,CDM,C1887,HCPCS,0272,RC,,,,both,,,3253.04,2114.48,,,,,,,,,,,,,
MESH SURG 49X49X0.6 MM 3D TI LEVEL 1 NEURO,SUP-2470450,CDM,C1713,HCPCS,0278,RC,,,,both,,,1327.47,862.86,,,,,,,,,,,,,
TI LCP DIA-META VOLAR DISTAL RADIUS PL 7H SHAFT/LT-STERILE,SUP-2546644,CDM,C1713,HCPCS,0278,RC,,,,both,,,5107.37,3319.79,,,,,,,,,,,,,
SPHERE GLEN DIA41MM +3MM OFFSET CO CHROM SHLDR REV SYS,SUP-2404723,CDM,C1776,CPT,0278,RC,,,,both,,,3397.48,2208.36,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM CORT CRANIOMAXILLOFACIAL S STL SELF 4/EA,SUP-2366114,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.81,255.33,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 6 MM TITANIUM SILVER NON STERILE MAT,SUP-2837723,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.75,212.39,,,,,,,,,,,,,
GUIDEWIRE ORTH L98CM DIA3MM S STL BEAD TIP DISP FOR UNIFLEX,SUP-2412676,CDM,C1769,HCPCS,0272,RC,,,,both,,,356.70,231.85,,,,,,,,,,,,,
PLATE BNE THK 1 MM SCREW DIA2/2.3 MM 10 H GRD II TI SLV,SUP-2936080,CDM,C1713,HCPCS,0278,RC,,,,both,,,1557.44,1012.34,,,,,,,,,,,,,
ALLOGRAFT DRML EXTRA THICK 20X16 CM READY USE TSSUE MTRX ALL,SUP-2474052,CDM,Q4116,HCPCS,0636,RC,,,,both,,,37406.82,24314.43,,,,,,,,,,,,,
MESH SURG MXLFCL 85X50X0.3 MM SM GRID FOR 1.5 MM SCREW TI,SUP-2485036,CDM,C1713,HCPCS,0278,RC,,,,both,,,2864.47,1861.91,,,,,,,,,,,,,
ALLOGRAFT DERMAL PERF THN 20X12 CMX0.7-1.4 MM FLEXHD PLIABLE,SUP-2457809,CDM,Q4128,HCPCS,0636,RC,,,,both,,,19688.40,12797.46,,,,,,,,,,,,,
VALVE MITRL CARP EDW TISS ANNULUS 29 MM SEW RNG DIA 38 MM,SUP-2214274,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
HC Endovenous Rf Vein Add-On,PX-3613647600,CDM,36476,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
SEALANT HEMSTAT TISS 1ML FIBRIN EVICEL,SUP-2218324,CDM,C1713,HCPCS,0278,RC,,,,both,,,544.57,353.97,,,,,,,,,,,,,
OBTURATOR ENDO OD5.5MM STD,SUP-2340734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
GUIDEWIRE ORTH OLV 8X800 MM ESTREMO,SUP-2719786,CDM,C1769,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
CATHETER IRRIG 3FR L40CM 6MM DST 2 LUMN 230234] LEMAITRE VASCULAR INC],SUP-2264228,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
PLATE BNE PROF THK 0.6 MM 2 X 2 H SCREW DIA2 MM LNG TI LT,SUP-2883753,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
DECOMPRESSION KIT CRV 17 GAX6 IN PRB 1 INTRO CANN 1 PRB CLN,SUP-2366994,CDM,C1894,HCPCS,0272,RC,,,,both,,,5874.81,3818.63,,,,,,,,,,,,,
IMPLANT WR OD15MM ID7MM +4MM CRPL HD IMPLABLE FOR TOT WR SYS,SUP-2407356,CDM,C1776,CPT,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCREW PIN GENDER SPEC FLX ZCKPINGSF] ZIMMER BIOMET INC],SUP-2212713,CDM,C1776,CPT,0278,RC,,,,both,,,13858.77,9008.20,,,,,,,,,,,,,
K ORBITAL PLATE 2MM CP TITANIUM,SUP-2707257,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.32,1157.86,,,,,,,,,,,,,
MARKER BX SITE TI CORK SHP US GUID MAG ATEC TRIMARK,SUP-2240071,CDM,A4648,CPT,0278,RC,,,,both,,,203.75,132.44,,,,,,,,,,,,,
PLATE SPNL W27.5MM ANT CERV ATLNTS VISN ELITE,SUP-2287284,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
CATHETER INTVASC OCCL CODA L 100 CM DIA10 FR BALLOON DIA 32,SUP-2750738,CDM,C2628,HCPCS,0272,RC,,,,both,,,1349.29,877.04,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE TRK L 300 CM DIA 0.014 IN,SUP-2880693,CDM,C1769,HCPCS,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,6370000000,HCPCS,0637,RC,47781-0428-11,NDC,,both,1,UN,124.10,80.66,,,,,,,,,,,,,
PLATE BNE L 149 MM SCREW DIA 4.5 MM 8 H SS NAR COMPR NLCK,SUP-2932850,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.29,1072.04,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV 8.2 L 90 CM OUTER SHFT DIA 7 FR,SUP-2327232,CDM,C1753,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
RING EXT FIX FULL 180 MM CARBON FIBER NS,SUP-2799523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3494.22,2271.24,,,,,,,,,,,,,
SCREW CRANIO MAXILLOFACIAL CNTR DRV HD TI 2.0MMDIA 9MML,SUP-2262649,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
PLATE BONE 12 H BILAT TI MALL LCK COMPR MAND DBL ROW FOR 2MM,SUP-2191248,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.21,1134.39,,,,,,,,,,,,,
GRAFT BONE LT PROX TIB TRAD FRZN,SUP-2294147,CDM,C1713,HCPCS,0278,RC,,,,both,,,11586.60,7531.29,,,,,,,,,,,,,
SYSTEM HRT VLV REP MITRL TRICSP ANNULPLSTY W/ DURAFLO 26MM,SUP-2214204,CDM,C1889,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 3",PX-7619921300,CDM,99213,CPT,0761,RC,,,,outpatient,,,257.00,167.05,,,,,,,,,,,,,
SPLINT FNGR BASEBL 425IN M,SUP-2276752,CDM,L3933,HCPCS,0272,RC,,,,both,,,3.11,2.02,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 10 MG/ML IJ SOLN,RX-142245,CDM,J2272,HCPCS,0636,RC,63323-0451-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
NXSTAGE PUREFLOW B RFP-400,RX-4082402,CDM,2580000003,HCPCS,0258,RC,40861-0102-77,NDC,,both,5000,ML,136.60,88.79,,,,,,,,,,,,,
TRIAL NERVE STIM LD 90 CM KT AXIUM SLIMTIP,SUP-2357676,CDM,C1778,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
WALKER SHT LEG DLX BLK XL,SUP-2276714,CDM,L4387,HCPCS,0272,RC,,,,both,,,86.60,56.29,,,,,,,,,,,,,
BRACE ANK AIR STRRP PED HT 6 IN,SUP-2336084,CDM,L4350,HCPCS,0274,RC,,,,both,,,31.81,20.68,,,,,,,,,,,,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT,RX-855,CDM,6370000000,HCPCS,0637,RC,58232-0403-49,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER EP XL 2-2-2-3 1 MM 5 FRX110 INQUIRY,SUP-2462097,CDM,C1730,HCPCS,0272,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
BIT DRVR FOR 3/4MM CANN SCR,SUP-2390541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ENDOSCOPIC PACK 1.5 MM RAP PAC LTX,SUP-2848583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,840.74,546.48,,,,,,,,,,,,,
DRILL SURG 1.8 MM TCP,SUP-2521531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 30 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2669629,CDM,C1768,CPT,0278,RC,,,,both,,,609.13,395.93,,,,,,,,,,,,,
PLATE S PROFYLE CONDYLAR 5 HL 17MM,SUP-2703007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1043.27,678.13,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 23 CM DIA 5 FR 0.018 IN 4 CM 21GA NIT,SUP-2740723,CDM,C1894,HCPCS,0272,RC,,,,both,,,148.37,96.44,,,,,,,,,,,,,
PERI-LOC 3.5MM S-T LOCK SCREW 65MM,SUP-2819491,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.81,726.58,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.533,SUP-2860050,CDM,C1713,HCPCS,0278,RC,,,,both,,,40093.72,26060.92,,,,,,,,,,,,,
COMPONENT SHLDR CAPPED HUM REVERSED STEM CEM TRAB MTL,SUP-2212296,CDM,C1776,CPT,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
HEAD ULN 19 WRST MOD COCR 1ST CHOICE,SUP-2852860,CDM,C1776,CPT,0278,RC,,,,both,,,5751.91,3738.74,,,,,,,,,,,,,
PATCH DURAL SUB 10X12.5CM ONLAY LYCOPLANT,SUP-2717537,CDM,C1763,HCPCS,0278,RC,,,,both,,,3113.69,2023.90,,,,,,,,,,,,,
NERVE STIMULATOR KIT LD PERIPH NERVE SYS CHANNEL B STIMQ,SUP-2423764,CDM,C1778,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SYSTEM INFL BAL L16MM DIA6MM MAX M-110C F-70 S-0 PRECIS SGL,SUP-2106364,CDM,C1729,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
STEM FEM LAT 15-21 126.5 DEG PROX HIP W/ TRUNION REDUC PROF,SUP-2450451,CDM,C1776,CPT,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
PLUG FIST DIA0.4CM ANAL/RECTOVAGINAL BTTN BIODESIGN,SUP-2171042,CDM,C1781,HCPCS,0278,RC,,,,both,,,4185.62,2720.65,,,,,,,,,,,,,
NEEDLE INTRO EXCALIBUR L 35 MM NDL 19 GA PERC ART VEN ACCS,SUP-2125565,CDM,C1894,HCPCS,0272,RC,,,,both,,,42.08,27.35,,,,,,,,,,,,,
STENT URET 8FR L26CM W/ HYDROGLIDE GWIRE INLAY OPTMA,SUP-2126652,CDM,C2617,HCPCS,0278,RC,,,,both,,,719.34,467.57,,,,,,,,,,,,,
PIN FIX STD SPNL TEMP FOR SCR H,SUP-2255662,CDM,C1713,HCPCS,0278,RC,,,,both,,,224.51,145.93,,,,,,,,,,,,,
HC 25 Hydroxy Includes Fractions if Performed|NOT REASONABLE AND NECESSARY,PX-3018230600,CDM,82306,CPT,0301,RC,,,GZ,both,,,233.00,151.45,,,,,,,,,,,,,
CYCLOSPORINE MODIFIED 100 MG/ML PO SOLN,RX-28844,CDM,J7502,HCPCS,0636,RC,00078-0274-22,NDC,,both,1,ML,57.70,37.50,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLE 9 BA ACCU-FLO,SUP-2666405,CDM,C1729,HCPCS,0272,RC,,,,both,,,804.69,523.05,,,,,,,,,,,,,
BIT DRL DIA3.2MM PROX HUM CALIB DISP,SUP-2411559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
CATHETER EPIDURAL BEND MRK 19 GAX24 IN E-CAP STYL TUN-L-XL,SUP-2164784,CDM,C1754,HCPCS,0278,RC,,,,both,,,256.13,166.48,,,,,,,,,,,,,
PLATE BNE SM L63MM 3X4 H BILAT TI T OBLQ LIMIT CNTCT DYN,SUP-2190942,CDM,C1713,HCPCS,0278,RC,,,,both,,,873.17,567.56,,,,,,,,,,,,,
GRAFT FIB SHFT FRZ DRY ALLGRFT 76-98MM,SUP-2335273,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PLATE BONE L234MM 9 H LT PROX FEM LCK FOR 4.5MM SCR PERI-LOC,SUP-2351170,CDM,C1713,HCPCS,0278,RC,,,,both,,,12076.60,7849.79,,,,,,,,,,,,,
BIT DRL CANN 6 MM 4.5 MM CALIB FOR 6.5 MM HDLSS COMPR SCREW,SUP-2863414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.92,673.35,,,,,,,,,,,,,
HC So Tissue in Situ Hybridization,PX-3128836566,CDM,88365,CPT,0312,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 80 MM DIA20 MM SHTH 11 FR CATH L,SUP-2142678,CDM,C1876,HCPCS,0278,RC,,,,both,,,5670.09,3685.56,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ POWERTURN L 300 CM DIA 0.014 IN,SUP-2105428,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
CATHETER NEPHROSTOMY SET 12 FRX19.5 CM COPE LOOP,SUP-2835683,CDM,C1729,HCPCS,0272,RC,,,,both,,,571.98,371.79,,,,,,,,,,,,,
STEM FEM HIP REV NEUT CEM POR TAPR 145DEG NK ANG 14.0MM DIA,SUP-2206028,CDM,C1776,CPT,0278,RC,,,,both,,,18654.74,12125.58,,,,,,,,,,,,,
CATHETER GUID 5 FRX135 CM MULTLYR TURNPIKE,SUP-2383150,CDM,C1887,HCPCS,0272,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
PLATE BNE W12XL160MM THK3.7MM LNG 6 H ST PROX HUM S STL LOK,SUP-2186018,CDM,C1713,HCPCS,0278,RC,,,,both,,,4692.98,3050.44,,,,,,,,,,,,,
SPLINT WR FRARM PED L4IN LT TIETEX COCK UP LOOP LCK W/ STAY,SUP-2195514,CDM,L3931,HCPCS,0272,RC,,,,both,,,24.43,15.88,,,,,,,,,,,,,
LINER ACET OD37MM ID28MM M2A RINGLOK,SUP-2405939,CDM,C1776,CPT,0278,RC,,,,both,,,5366.26,3488.07,,,,,,,,,,,,,
VALVE MITRL OPN PVT AP360 DIA24 MM ORIFICE 22.8 MM TISS,SUP-2278413,CDM,C1889,HCPCS,0278,RC,,,,both,,,9840.76,6396.49,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 3 MM EPTFE STR TW N RING HEMO,SUP-2761229,CDM,C1768,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
FENOFIBRATE 160 MG PO TABS,RX-28252,CDM,6370000000,HCPCS,0637,RC,50268-0313-15,NDC,,both,1,UN,14.40,9.36,,,,,,,,,,,,,
PLATE BNE L 77 MM SCREW DIA 4.5 MM 4 H NAR COMPR NLCK NS,SUP-2933398,CDM,C1713,HCPCS,0278,RC,,,,both,,,1574.71,1023.56,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA PHSPTE HYALURONIC ACID CEM VOID FILL,SUP-2378762,CDM,C1713,HCPCS,0278,RC,,,,both,,,8600.46,5590.30,,,,,,,,,,,,,
SPHERE EMB RESIN SIR-SPHERES Y-90,SUP-2340133,CDM,C1889,HCPCS,0278,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
RELOAD STPL M L60MM THCK TISS GRN W/ GRIPPING SURF,SUP-2283359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.88,906.67,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.514,SUP-2860031,CDM,C1713,HCPCS,0278,RC,,,,both,,,37126.42,24132.17,,,,,,,,,,,,,
SCREW BNE L35MM DIA4MM SM HEX DIA2.5MM CANC S STL ST,SUP-2411117,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.11,40.37,,,,,,,,,,,,,
COMPONENT FEM NP HIP CRUCE RET HI FLX LEGION,SUP-2348020,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
COMPONENT HUM SHLDR RESURF TITAN,SUP-2244435,CDM,C1776,CPT,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
CINCH ENDOSCP CRV TIP FOR MENIS REP,SUP-2121859,CDM,C1776,CPT,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
BLADE RETRACTOR BALFOUR 9.75 IN 3.5X1.75 IN ABD CENTER STD,SUP-2472667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,205.83,133.79,,,,,,,,,,,,,
GRAFT VASC CARBOFLO 8 MMX50 CM EPTFE FLX THN WALL SM BEAD,SUP-2126881,CDM,C1768,CPT,0278,RC,,,,both,,,7093.04,4610.48,,,,,,,,,,,,,
PIN EXT FIX L 60 MM DIA 5 MM LNG TI HALF STRL DISP JET-X,SUP-2933205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.01,336.71,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0003,SUP-2759795,CDM,C1751,HCPCS,0278,RC,,,,both,,,367.76,239.04,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 20-22 MM FRZN ILIUM TRICORT,SUP-2717922,CDM,C1762,CPT,0278,RC,,,,both,,,5466.58,3553.28,,,,,,,,,,,,,
MICRODEBRIDER ABLAT TOPAZ ARTHCARE,SUP-2341971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
CATHETER VID GUID SPNL ENDO CATH 2 LUMN 3.0MM,SUP-2307775,CDM,C1725,HCPCS,0272,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
RESORB X ST TMPLTE CRNL MRKNG GUIDE CP TTNM QT001 EA,SUP-2500222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2486.31,1616.10,,,,,,,,,,,,,
GRAFT HUMAN TSSUE ARCH WEDGE 16MMW X 22MML X 6MMH FRZE DRIED,SUP-2727149,CDM,C1762,CPT,0278,RC,,,,both,,,2738.39,1779.95,,,,,,,,,,,,,
STENT INTOCU H0.33XL1MM SNORKEL L0.25MM DIA120UM RT EYE TI,SUP-2227950,CDM,C1783,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
KIT INTRO MAK-NV L 20 CM DIA 6 FR DIL 4 FR NONVASCULAR,SUP-2677151,CDM,C1894,HCPCS,0272,RC,,,,both,,,114.61,74.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CROSPERIO L 150 CM L 200MM DIA 2.5 MM RX,SUP-2385490,CDM,C1725,HCPCS,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
PROBE VAPORFLEX BIPOLAR 320MM X 2.5MM W/ BALL TIP DISP,SUP-2848821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
"HC Plate,Leuk Red,Cmv-Neg,Irr Ea",PX-3900905300,CDM,P9053,CPT,0390,RC,,,,both,,,2279.00,1481.35,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT ABSRB POLY 3.5MM DIA 9.04MM LEN STATAK,SUP-2410530,CDM,C1713,HCPCS,0278,RC,,,,both,,,567.15,368.65,,,,,,,,,,,,,
PLATE BNE L286MM 13 H L DST LAT FEM S STL LOK FOR 4.5MM SCR,SUP-2348212,CDM,C1713,HCPCS,0278,RC,,,,both,,,14589.38,9483.10,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA 40 UM 2 ML HYDRGEL POLYZENE MIC WHT,SUP-2139503,CDM,C1889,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE SPNL ANCHR 45 MM OCPTL ASCNT POCT,SUP-2601972,CDM,C1713,HCPCS,0278,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
PLATE BNE DIA17 MM THK 0.5 MM SCREW DIA1.7 MM MAXILLOFCL,SUP-2909635,CDM,C1713,HCPCS,0278,RC,,,,both,,,2210.18,1436.62,,,,,,,,,,,,,
POSITIONER PT LEG FOR SALVATION EXT FIX,SUP-2401156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
PLATE BNE L80MM 4 H S STL T SHP BTTRS LO PROF RIG,SUP-2185763,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
SCREW BNE L 7 MM DIA2.3 MM TI TEMPOROMANDIBULAR JT FOSSA,SUP-2934764,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.00,221.65,,,,,,,,,,,,,
IMPLANT OTOLARYN 0.8MM DIAM 4MM LEN CUP PLAT FLROPLAS STAP,SUP-2312553,CDM,2780000010,LOCAL,0278,RC,,,,both,,,323.26,210.12,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV,SUP-2435690,CDM,L2650,HCPCS,0274,RC,,,,both,,,391.78,254.66,,,,,,,,,,,,,
D-RAD VOLAR PLATE 5H RIGHT WIDE TI,SUP-2818635,CDM,C1713,HCPCS,0278,RC,,,,both,,,3776.79,2454.91,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG ACUTE 13.5FR DIA 15CML IN 5766150,SUP-2632924,CDM,C1752,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
HC So Candida Dna Amp Probe,PX-3068748166,CDM,87481,CPT,0306,RC,,,,inpatient,,,101.00,65.65,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 6 HOLE DOUBLE Y-PLATE 17MM TI,SUP-2826364,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.24,125.61,,,,,,,,,,,,,
MAGNESIUM SULFATE 4 GM/100ML IV SOLN,RX-131193,CDM,J3475,HCPCS,0636,RC,63323-0106-00,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN,RX-16825,CDM,2500000003,HCPCS,0250,RC,00942-0641-04,NDC,,both,1000,ML,57.50,37.37,,,,,,,,,,,,,
SPACER TIB CONCV 14 MM UNI M/G,SUP-2437230,CDM,C1776,CPT,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
TRAY THORCENT 11FR L13MM TRCR ASPIR CANN SUCT TBNG NDL SYR,SUP-2391583,CDM,C1729,HCPCS,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
ALLOGRAFT BNE FEM FRZN DSTL,SUP-2321784,CDM,C1713,HCPCS,0278,RC,,,,both,,,8047.82,5231.08,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 3 CM DIA 5 MM CATH DIA 0.035 IN,SUP-2170419,CDM,C1889,HCPCS,0278,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
PLATE BONE L45MM THK1.4MM SHFT W6MM HD 12.9MM 5 H STRL Y SHP,SUP-2349686,CDM,C1713,HCPCS,0278,RC,,,,both,,,5193.09,3375.51,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7148,SUP-2525313,CDM,C1769,HCPCS,0272,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
HANDPIECE LASER MALL CLN KT FIBERLASE,SUP-2713735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3912.44,2543.09,,,,,,,,,,,,,
HC So Cystic Fibrosis Gene Analysis,PX-3108122066,CDM,81220,CPT,0310,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
GUIDEWIRE FLUT,SUP-2362517,CDM,C1769,HCPCS,0272,RC,,,,both,,,451.06,293.19,,,,,,,,,,,,,
WASHER ORTH SM HUM STRL AFFIXUS NAT NAIL,SUP-2606870,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
LENS IO +28.0 DIOPT L10.5MM,SUP-2392376,CDM,V2632,HCPCS,0276,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PORT IMPL INFUSION CHST VAXCEL,SUP-2117112,CDM,C1788,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CATHETER DIAG ZOOM 88-T L 110 CM DIA 0.088 IN HYDRPHLC LG,SUP-2739214,CDM,C1757,HCPCS,0272,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
GUIDEPIN ORTH L18IN DIA2.4MM SMOOTH SGL BAYNT TIP W/ EYELET,SUP-2249398,CDM,C1769,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SLEEVE CNTR L14MM PMMA FOR FEM HIP FRAC,SUP-2406641,CDM,C1776,CPT,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
SHEATH INTRO DESTINO TWST L 55 CM DIA 6.5 FR DIL L 73 CM CRV,SUP-2217697,CDM,C1894,HCPCS,0272,RC,,,,both,,,2791.46,1814.45,,,,,,,,,,,,,
COMPONENT FEM SZ 8 CO CHROM RT KNEE REV STEMLESS POST STBL,SUP-2346137,CDM,C1776,CPT,0278,RC,,,,both,,,19427.78,12628.06,,,,,,,,,,,,,
STENT TRACHBRONCH AERO FULL CVR DIR VIS 16MMX40MM,SUP-2302399,CDM,C1874,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
IMPLANT BRST 450-470ML W13XH13.5CM P5.3CM NACL STYL 468,SUP-2113304,CDM,C1789,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE BNE RECON 2.4X184 MM LCK TI,SUP-2569455,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.91,358.09,,,,,,,,,,,,,
SHEATH INTRO INPUT TS L 11 CM DIA 5 FR GUIDEWIRE 0.038 IN,SUP-2277545,CDM,C1894,HCPCS,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRAFT VASC GORTX 80 CM 10MM RNG L 70 CM STR TW REMOVABLE RNG,SUP-2396143,CDM,C1768,CPT,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
CATHETER VALVULOPLASTY L 90 CM MODEL VB STRL,SUP-2141044,CDM,C1725,HCPCS,0272,RC,,,,both,,,993.94,646.06,,,,,,,,,,,,,
WIRE FIX 3X400 MM KIRSCHNER,SUP-2316010,CDM,C1713,HCPCS,0278,RC,,,,both,,,149.15,96.95,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10CM 11MM 120CM EPTFE,SUP-2719588,CDM,C1768,HCPCS,0278,RC,,,,both,,,8650.70,5622.95,,,,,,,,,,,,,
CEMENT BONE 20ML W/ GENTMYCN M VISC CO,SUP-2196558,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.95,971.72,,,,,,,,,,,,,
ANCHOR SUT 4.5MM PEEK KNOTLESS INSITE FT,SUP-2388895,CDM,C1713,HCPCS,0278,RC,,,,both,,,2223.12,1445.03,,,,,,,,,,,,,
BIT DRL CANN 4.9 MM ASNS III,SUP-2365004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2634.46,1712.40,,,,,,,,,,,,,
SYSTEM BNE BX 11 GAX10 CM WESTBROOK,SUP-2477883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE SPNL L19MM 2 H UNIV ANT LUM TI TRIANG PYRAMID,SUP-2291658,CDM,C1713,HCPCS,0278,RC,,,,both,,,15623.64,10155.37,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 7 FRX15 CM 3L DRY SPECTRUM,SUP-2759883,CDM,C1751,HCPCS,0278,RC,,,,both,,,533.74,346.93,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE 150X20-30 MM FRZN IRRADIATED TIB,SUP-2866917,CDM,C1762,CPT,0278,RC,,,,both,,,1616.79,1050.91,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. L 120 MM DIA 6 MM CATH L 135 CM,SUP-2158904,CDM,C1876,HCPCS,0278,RC,,,,both,,,5796.44,3767.69,,,,,,,,,,,,,
FILTER VASC ACCUNET SZ 5.5 MM CATH 8 FR SHTH 6 FR GUIDEWIRE,SUP-2104678,CDM,C1884,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
GRAFT HUM TISS NONBONE SEMITENDINOSUS TEND SGL STRND FRZN,SUP-2165607,CDM,C1762,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HC R&L Heart Cath W Graft,PX-4819346100,CDM,93461,CPT,0481,RC,,,,both,,,20492.00,13319.80,,,,,,,,,,,,,
INSERT TIB THICKNESS 11MM UNIV STD POLYETH PRI NEUT IMPL,SUP-2200354,CDM,C1776,CPT,0278,RC,,,,both,,,6714.89,4364.68,,,,,,,,,,,,,
SET PICC L 15CM DIA 5.5FR SHTH L 7CM DIA 5.5FR PR-41552-BAS,SUP-2887216,CDM,C1751,HCPCS,0278,RC,,,,both,,,396.27,257.58,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.543,SUP-2860224,CDM,C1713,HCPCS,0278,RC,,,,both,,,46228.34,30048.42,,,,,,,,,,,,,
PLATE BONE THK0.3MM NONSTERILE LT MEDL WALL TI FOR 1MM SCR,SUP-2190578,CDM,C1713,HCPCS,0278,RC,,,,both,,,4705.92,3058.85,,,,,,,,,,,,,
PLATE BNE THK1.5MM 4 H CRANIOMAXILLOFACIAL G FRAC ANG W/,SUP-2366367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.33,775.66,,,,,,,,,,,,,
ADAPTER PACE LD NS,SUP-2137987,CDM,C1883,HCPCS,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
PLATE BNE HUM MED RT DSTL 5 HOLE SS NS LCP,SUP-2185887,CDM,C1713,HCPCS,0278,RC,,,,both,,,3648.18,2371.32,,,,,,,,,,,,,
PUMP PAIN MGMT 600ML 2-14ML/HR 2 ELASTOMERIC NONNARCOTIC,SUP-2236814,CDM,C9804,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SYSTEM INTRO ACUSTK II L 60 CM DIA 0.018 IN TIP L 7.5 CM SS,SUP-2147726,CDM,C1887,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
BUR SURG DIA1.8 MM HUB II NEURO CUT STRL REUSE HI-LINE,SUP-2929129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,931.04,605.18,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 5X40 MM TITANIUM NITRIDE STERILE,SUP-2836781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1559.45,1013.64,,,,,,,,,,,,,
HC So Adenovirus Antibody,PX-3028660366,CDM,86603,CPT,0302,RC,,,,both,,,418.00,271.70,,,,,,,,,,,,,
PROSTHESIS OSS 3-7 MM 4X3.25 MM 0.86X1.27 MM DORNHOFFER HA,SUP-2460430,CDM,L8613,CPT,0278,RC,,,,both,,,1425.06,926.29,,,,,,,,,,,,,
PLATE BNE LG 4 H STRNL BX SHP NS,SUP-2909889,CDM,C1713,HCPCS,0278,RC,,,,both,,,1348.76,876.69,,,,,,,,,,,,,
TUBE HARV L7MM BNE DWL DISPOSABLE,SUP-2212800,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
SCREW SPNL L45MM DIA8.5MM CANC PEDCL S STL NO CUT ISOLA VSP,SUP-2255688,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
HUMERAL LINER 40MM +2.5,SUP-2512475,CDM,C1776,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
BRACE ANK L M 115 13 WOM 13 145 L FOAM FILL SEMI RIG SHELL,SUP-2196376,CDM,L4350,HCPCS,0274,RC,,,,both,,,72.38,47.05,,,,,,,,,,,,,
NAIL IM L280MM DIA9MM GRN FEM TI CANN LOK RG BEND RND FOR,SUP-2180058,CDM,C1713,HCPCS,0278,RC,,,,both,,,4791.80,3114.67,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,KX|CO,both,,,144.00,93.60,,,,,,,,,,,,,
WASHER ORTH OD6MM TI RND,SUP-2122406,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SCREW BNE LAG PARTIALLY THRDED TI 30MM THRD 11MM CANN 16MM,SUP-2392892,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.43,305.13,,,,,,,,,,,,,
IMPLANT FEM L29MM DIA10MM INSRT APERFIX AM,SUP-2402621,CDM,C1776,CPT,0278,RC,,,,both,,,3175.67,2064.19,,,,,,,,,,,,,
SPLINT SLD BGE 3/32IN TAILORSPLNT,SUP-2324804,CDM,L4350,HCPCS,0274,RC,,,,both,,,132.79,86.31,,,,,,,,,,,,,
ENDO FUSE  FUSION ROD 3 X 30MM,SUP-2469817,CDM,C1713,HCPCS,0278,RC,,,,both,,,4016.06,2610.44,,,,,,,,,,,,,
MESH HERN RECTANGULAR 8X16 CM INTRAPERITONEAL ENFORM,SUP-2539547,CDM,C1781,HCPCS,0278,RC,,,,both,,,7432.38,4831.05,,,,,,,,,,,,,
BLADE SHAVER SUCTION 40 DEG 3 MMX12 CM DBL SERRATED YEL STRL,SUP-2602792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.92,388.65,,,,,,,,,,,,,
STEM FEM L165MM DIA15MM 12/14 TAPR HIP 5/8 POR STD NK AML,SUP-2252057,CDM,C1776,CPT,0278,RC,,,,both,,,11655.68,7576.19,,,,,,,,,,,,,
DEVICE INT FIX W ZIPLOOP INLINE TECHNOLOGY FOR ACL RECON,SUP-2136091,CDM,C1713,HCPCS,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
BLADE LARYNSCP L135MM DSTL W15MM MAC 3 FBROPT CLASS,SUP-2238179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
CATHETER DRNGE 18FR PROPORTIONATE HD 2 EYE FOR NEPHSTMY,SUP-2128977,CDM,C1729,HCPCS,0272,RC,,,,both,,,53.98,35.09,,,,,,,,,,,,,
CATHETER ANGIO WORLEY L 75 CM DIA 0.046 IN DIA 5 FR STD SFT,SUP-2301870,CDM,C1894,HCPCS,0272,RC,,,,both,,,309.92,201.45,,,,,,,,,,,,,
HC So1 Immunoassay|UNUSUAL NON-OVERLAPPING SERVICE,PX-3018351667,CDM,83516,CPT,0301,RC,,,XU,both,,,471.00,306.15,,,,,,,,,,,,,
LINER ACET CUP 26 MM ID 0 DEG CERAMIC ON POLY SZ E LTX FRE,SUP-2202729,CDM,C1776,CPT,0278,RC,,,,both,,,3422.60,2224.69,,,,,,,,,,,,,
COLLAR CERV FIRM 4X22IN UNIV,SUP-2276587,CDM,L0120,HCPCS,0272,RC,,,,both,,,7.69,5.00,,,,,,,,,,,,,
SEAT REDUC 6.35MM TI VAR ANG LCK,SUP-2415522,CDM,C1713,HCPCS,0278,RC,,,,both,,,2115.36,1374.98,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7600,SUP-2462324,CDM,C1769,HCPCS,0272,RC,,,,both,,,986.43,641.18,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA1.2 MM CRANIOMAXILLOFACIAL ST NS AXS 5PK,SUP-2884111,CDM,C1713,HCPCS,0278,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
KIT HAD CATH 12.5FR L20CM 3 LUMN CRV EXTN MAHRK ELITE,SUP-2283977,CDM,C1752,HCPCS,0278,RC,,,,both,,,326.53,212.24,,,,,,,,,,,,,
TIP ASPIR L4.6IN OD2.46MM ID2.01MM SFT TISS CUT ABLAT DISP,SUP-2367530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1681.47,1092.96,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5CM 7MM 120CM 7FR RADIOPAQUE,SUP-2396651,CDM,C1874,HCPCS,0278,RC,,,,both,,,10013.46,6508.75,,,,,,,,,,,,,
SET ENDO L40CM OD8FR 0.038IN BILI DRNGE 6 H KINK RESIST LCK,SUP-2117064,CDM,C1729,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
ROD EXT FIX L360MM DIA8MM C FBR CONN REUSE,SUP-2188750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,479.51,311.68,,,,,,,,,,,,,
BLADE EXPLANT FULL 42MM,SUP-2210645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HEAD HUM H21MM DIA52MM SFT TISS BALANCING SIMPLICITI,SUP-2388563,CDM,C1776,CPT,0278,RC,,,,both,,,11468.85,7454.75,,,,,,,,,,,,,
COLLAR EXTRIC AD 2IN 17IN XSH TWO PC TRACH OPN VELC CLSR W,SUP-2194464,CDM,L0172,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW TITANIUM 3.5 X 8MM,SUP-2462166,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
PLATE BNE L91MM THK3.7MM 7 H BILAT S STL STR LO PROF RIG,SUP-2184027,CDM,C1713,HCPCS,0278,RC,,,,both,,,2086.75,1356.39,,,,,,,,,,,,,
CATHETER ATHRCTMY L130CM DIA2MM VES DIA3MM GUID CATH DIA8FR,SUP-2353050,CDM,C1724,HCPCS,0278,RC,,,,both,,,10344.73,6724.07,,,,,,,,,,,,,
SET PNEUMOTHRAX CATH 10.2FR L30CM NDL 18GA L20CM 18,SUP-2168504,CDM,C1729,HCPCS,0272,RC,,,,both,,,311.90,202.73,,,,,,,,,,,,,
SCREW BNE L6MM DIA1.8MM LT BLU TI ST FULL THRD EMGCY,SUP-2181641,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.50,212.87,,,,,,,,,,,,,
MESH HERN L DIA4IN POLYPR EPTFE CIR SELF EXP PTCH FOR SFT,SUP-2125713,CDM,C1781,HCPCS,0278,RC,,,,both,,,1683.98,1094.59,,,,,,,,,,,,,
CATHETERIZATION KIT 0.025 IN 7 FRX6 IN CV ARROWG+ARD,SUP-2383310,CDM,C1751,HCPCS,0278,RC,,,,both,,,140.58,91.38,,,,,,,,,,,,,
IMPLANT BIO W 7 X H 4 CM THK 2P PORCINE SM INTEST SUBMUCOSA,SUP-2884036,CDM,C1768,CPT,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SAVVY L 150 CM DIA 3-3.5 FR BALLOON L 10,SUP-2153845,CDM,C1725,HCPCS,0272,RC,,,,both,,,962.72,625.77,,,,,,,,,,,,,
BLADE SHV DIA4MM STR IRRIG DISECT SERR FOR DIEGO,SUP-2313823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.70,226.65,,,,,,,,,,,,,
CATHETER DRAINAGE 2 EYE 14 FR PROPORTIONATE HD PEZ,SUP-2126191,CDM,C2627,HCPCS,0272,RC,,,,both,,,22.07,14.35,,,,,,,,,,,,,
GUIDEWIRE ORTH L 150 MM DIA1.1 MM SCREW DIA2.5/3 MM THRD FOR,SUP-2907642,CDM,C1769,HCPCS,0272,RC,,,,both,,,389.58,253.23,,,,,,,,,,,,,
PASSER SUT SHUTTLE J HK STRL ACCU-PASS,SUP-2341082,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.72,272.17,,,,,,,,,,,,,
GRAFT BNE SUB W7XL30MM WDG FOR OSTEOTMY OSFERION,SUP-2121046,CDM,C1713,HCPCS,0278,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
NEEDLE BRST LOC BLNT 20 GAX3 CM STRL HAWK3 LTX,SUP-2876180,CDM,C1819,HCPCS,0278,RC,,,,both,,,176.78,114.91,,,,,,,,,,,,,
ACYCLOVIR 200 MG/5ML PO SUSP,RX-8970,CDM,340b,HCPCS,0637,RC,31722-0681-47,NDC,,both,5,ML,3.90,2.53,,,,,,,,,,,,,
PLATE BONE 6 H DBL Y SHP W/ BAR LO PROF FOR 1.5MM SCR CRAN,SUP-2363636,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.06,564.89,,,,,,,,,,,,,
KIT INSTR 3.5X8.5MM DISP FOR SL ANCHR THMB COLLATERAL LIGMNT,SUP-2419624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
KYPHOPLASTY KIT 1ST FRAC 10/3 IBT KYPHON 1 STP,SUP-2743784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
CATHETER ATHRCTMY 5FR L135CM DMND TIP BUR DIA1.25MM PROTCT,SUP-2141003,CDM,C1724,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
SPACER SPNL SQ 12X1 MM CERV ANTR VUMESH,SUP-2707716,CDM,C1889,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
OBTURATOR ENDOSCP SPEAR TRCR TIP FOR 3.7MM SUTURETAK AND,SUP-2121487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC So Tissue Cult of Neoplastic Dis,PX-3118823766,CDM,88237,CPT,0311,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
DEXTROSE 70 % IV SOLN,RX-2367,CDM,2580000003,HCPCS,0258,RC,00338-0719-06,NDC,,both,2000,ML,170.00,110.50,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION MED 12-30 DEG PLASMALOOP DISP,SUP-2477088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1615.47,1050.06,,,,,,,,,,,,,
COUNTERSINK SURG OD4.5MM HDLSS SGL USE MONSTER,SUP-2320973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.93,338.60,,,,,,,,,,,,,
CLAMP ROD 5.5-5.5MM SGL,SUP-2230103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
FIBER LASER N CONTACT SUBMERSIBLE FLAT,SUP-2227278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
HC Arterial Line Insertion,PX-7613662001,CDM,36620,CPT,0370,RC,,,,inpatient,,,789.00,512.85,,,,,,,,,,,,,
SCREW BONE L90MM DIA7.3MM CORT S STL ST CANN LCK PARTIALLY,SUP-2185012,CDM,C1713,HCPCS,0278,RC,,,,both,,,4477.07,2910.10,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X30 MM CANN EXT TAB VOYAGER 4.75,SUP-2629439,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT HUM TISS L 30-53 X W 10 MM BNE L 25-30 X W 10 X H 10,SUP-2913417,CDM,C1762,CPT,0278,RC,,,,both,,,11395.06,7406.79,,,,,,,,,,,,,
GRAFT BNE SYNTH 50X10X2 MM 2 CC CLLGN COMP FOAM BI OSTETIC,SUP-2134723,CDM,C1713,HCPCS,0278,RC,,,,both,,,3179.25,2066.51,,,,,,,,,,,,,
BLADE RETRACTOR MALL UNIV 4X10 IN ABD RNG W/ LIP,SUP-2472282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1725.24,1121.41,,,,,,,,,,,,,
CUBE EXT FIX 3 H RANCHO FEMALE,SUP-2898424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
MATRIX BIO L 7 X W 10 CM SZ 126 SQCM FISH SKIN DERMAL MESHED 10/BX,SUP-2909436,CDM,Q4158,HCPCS,0636,RC,,,,both,,,8151.44,5298.44,,,,,,,,,,,,,
SET NASOLACHRYMAL INTUB LOOP DIA 0.64 MM WIDER SEG DIA 0.94,SUP-2911953,CDM,A4263,CPT,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SET INTRO SUPER SHTH L 10 CM DIA 5 FR NIT WIRE TEARWY SUPER,SUP-2627264,CDM,C1894,HCPCS,0272,RC,,,,both,,,10.77,7.00,,,,,,,,,,,,,
T-PLT RIGHT ANGLE 56MM STERIGHT HEAD 4HL SHAFT 4HL,SUP-2820732,CDM,C1713,HCPCS,0278,RC,,,,both,,,974.66,633.53,,,,,,,,,,,,,
PLATE BONE L155MM RIB RIBLOC U+,SUP-2107919,CDM,C1713,HCPCS,0278,RC,,,,both,,,5394.52,3506.44,,,,,,,,,,,,,
BOLT IM L38MM DIA4.9MM GRN TI SELF CUT TRCR TIP LOK FULL,SUP-2192383,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.09,365.36,,,,,,,,,,,,,
DRIVER SURG OD3MM M HEX FOR EVOLUTION C CERV IMPL REM SYS,SUP-2293607,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.42,103.62,,,,,,,,,,,,,
TREPHINE ORTH SZ 4MM STR SCR REM CRWN DRL,SUP-2368625,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
MANIPULATOR SURG MICRO-CHOP 90 DEG 120 MM LENS FOR CHOPPING,SUP-2484866,CDM,C1713,HCPCS,0278,RC,,,,both,,,689.86,448.41,,,,,,,,,,,,,
SPACER SPNL W10XH8-12XL26MM CALIB,SUP-2230680,CDM,C1821,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
SCREW BNE L50MM DIA4.5MM THRD L12MM S STL PARTIALLY THRDED,SUP-2184438,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.82,51.88,,,,,,,,,,,,,
PLATE PL DSTL HUM LAT SUPP 3.5MM 9H RT 143MM LCP STRL,SUP-2547567,CDM,C1713,HCPCS,0278,RC,,,,both,,,3725.08,2421.30,,,,,,,,,,,,,
BIT DRL L70MM DIA3.5MM CANN NONRADIOPAQUE W/O STP DISP,SUP-2413876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.82,519.23,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST BAR CHROM PLT NICKEL,SUP-2435694,CDM,L2750,HCPCS,0274,RC,,,,both,,,221.28,143.83,,,,,,,,,,,,,
INSERT TIB PS HI FLX 9MM SZ 0,SUP-2223192,CDM,C1776,CPT,0278,RC,,,,both,,,4195.04,2726.78,,,,,,,,,,,,,
VALVE SHUNT L23.7MM 15CM H2O PRSS TI 2 CONN GRAVITATIONAL,SUP-2108715,CDM,C1729,HCPCS,0272,RC,,,,both,,,4341.65,2822.07,,,,,,,,,,,,,
PLUG ORTH THRD 3.5 MM STARDRV NS LCP,SUP-2863373,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.96,194.32,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1274108D3,SUP-2632801,CDM,C1751,HCPCS,0278,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
PLATE BNE L284MM THK3MM 15 H BILAT S STL STR LOK COMPR RECON,SUP-2185352,CDM,C1713,HCPCS,0278,RC,,,,both,,,2110.43,1371.78,,,,,,,,,,,,,
BUNDLE CVC L 16 CM DIA 7 FR MAX BARR 3 LUMEN TEGDERM,SUP-2930819,CDM,C1751,HCPCS,0278,RC,,,,both,,,329.98,214.49,,,,,,,,,,,,,
STEM FEM L180MM OD19MM HA POR HIP PRI PRESSFIT MLRY HD,SUP-2408314,CDM,C1776,CPT,0278,RC,,,,both,,,16645.14,10819.34,,,,,,,,,,,,,
TRAY KYPHOPLASTY BLLN 4ML L15MM DIA17.7MM NDL 11GA SYR 20ML,SUP-2367077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-155550,CDM,2500000003,HCPCS,0250,RC,00264-4460-10,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
SET SCR GUID,SUP-2211150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SCREW BONE L5MM DIA1.5MM CRANIOMAXILLOFACIAL TI SELF DRL FOR,SUP-2181593,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.99,168.99,,,,,,,,,,,,,
SHEATH INTRO SUPER SHTH XL L 25 CM DIA10 FR GUIDEWIRE 0.038,SUP-2147297,CDM,C1894,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
AUTOTRANSFUSION PACK 1 SOURC 120 MU M AUTOLOG ATLS00,SUP-2490022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT L12XW12XH12MM IRRADIATED SCAFFOLD BLK,SUP-2125417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SET BILI STENT ZMMN L 12 CM DIA 7 FR PUSH L 170 CM GUIDEWIRE,SUP-2738159,CDM,C2625,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
IMPLANT TOE JT 24X15MM PROX SL CANNULINK,SUP-2400048,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.4MM CORT TI ST NONCANNULATED,SUP-2189567,CDM,C1713,HCPCS,0278,RC,,,,both,,,165.76,107.74,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK TRICORT 800129,SUP-2743374,CDM,C1713,HCPCS,0278,RC,,,,both,,,10267.80,6674.07,,,,,,,,,,,,,
GUIDEWIRE HYBRID .012/.014 DOUBLE ANGLE,SUP-2854079,CDM,C1769,HCPCS,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
GRAFT HUM TISS L 2-2.4 X W 0.7-0.9 CM THK 1.8-2.2 MM 2XS,SUP-2895200,CDM,C1762,CPT,0278,RC,,,,both,,,1187.49,771.87,,,,,,,,,,,,,
CONNECTOR EXT FIX PIN ANGLED,SUP-2898450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
PUSHER KNOT CLARKE REICH 5-0 5 MMX45 CM FOR LAP,SUP-2421588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1664.70,1082.05,,,,,,,,,,,,,
PLATE BONE 4 H COMPR LCK FOR 2.7MM SCR,SUP-2318661,CDM,C1713,HCPCS,0278,RC,,,,both,,,2171.25,1411.31,,,,,,,,,,,,,
PLATE BNE THK0.6MM 8 H STD CRANIOMAXILLOFACIAL G STR UNIV 2,SUP-2366289,CDM,C1713,HCPCS,0278,RC,,,,both,,,793.48,515.76,,,,,,,,,,,,,
DRILL SURG DIA3MM CRWN FOR UNIV SCR EXTR,SUP-2368624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
PLATE BONE L95MM 8 HOLE LOK DUAL CMPRSSN 27MM SCREW UNVRSL L,SUP-2481077,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.12,598.73,,,,,,,,,,,,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,0636,RC,63323-0229-30,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
HC So1 Acetylcholn Rcptr Blckg Antb,PX-3028604267,CDM,86042,CPT,0302,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 260CM 0.025IN TIP L 3 CM STD STR,SUP-2385102,CDM,C1769,HCPCS,0272,RC,,,,both,,,201.75,131.14,,,,,,,,,,,,,
BLADE REPROC SHV 4.5MM YEL STR FULL RAD,SUP-2652902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.56,67.31,,,,,,,,,,,,,
PLATE ADAPTER DIST LAT FEMUR LEFT,SUP-2704703,CDM,C1713,HCPCS,0278,RC,,,,both,,,4548.29,2956.39,,,,,,,,,,,,,
BLADE SAW 11.5X7X0.64 MM INT ORAL OSCILLATING SAW THN STRL,SUP-2862528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.41,213.47,,,,,,,,,,,,,
SCREW SPNL L13MM DIA4MM ANT CERV ST VAR ANG HELIX,SUP-2311594,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE BONE L114MM 6 H LT DSTL FIBULAR FOR PICCOLO COMP PLT,SUP-2152519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2804.81,1823.13,,,,,,,,,,,,,
GUIDEWIRE EXT FIX L350MM DIA18MM FOR ANK COMPR NAILING SYS,SUP-2316009,CDM,C1769,HCPCS,0272,RC,,,,both,,,342.89,222.88,,,,,,,,,,,,,
HC Nose to Rectum Child,PX-3207601000,CDM,76010,CPT,0320,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
GRAFT VASC L10CM DIA37MM THOR NIT EPTFE STR GORE-TAG,SUP-2396373,CDM,C1713,HCPCS,0278,RC,,,,both,,,40035.00,26022.75,,,,,,,,,,,,,
HC Platelets Pheresis Ea Unit,PX-3900903400,CDM,P9034,CPT,0390,RC,,,,both,,,2399.00,1559.35,,,,,,,,,,,,,
PASSER SUT CRESC MGR REACH NANOPASS,SUP-2366744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,962.98,625.94,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 60 CM DIA 8 MM EPTFE CARBON PERIPH,SUP-2128078,CDM,C1768,CPT,0278,RC,,,,both,,,6295.70,4092.20,,,,,,,,,,,,,
IMMUNE GLOBULIN (FLEBOGAMMA) 10%|DISCARDED DRUG NOT ADMINISTE,RX-4081761,CDM,J1459,HCPCS,0636,RC,44206-0439-40,NDC,JW,both,400,ML,22639.50,14715.67,,,,,,,,,,,,,
CONNECTOR SPNL W55XH45MM TI SIDE LD,SUP-2279796,CDM,C1713,HCPCS,0278,RC,,,,both,,,2539.13,1650.43,,,,,,,,,,,,,
CATHETER INFUS L150CM OD2.1 1.7FR ID.017IN L2.5MM .014IN,SUP-2172497,CDM,C1887,HCPCS,0272,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
SCREW BONE LOCKING 3.5MM DIA 46MML CORTICAL STERILE,SUP-2588150,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.93,75.35,,,,,,,,,,,,,
RING EXT FIX DIA100 MM FULL SINGLE ROW MONK RING,SUP-2898994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4136.17,2688.51,,,,,,,,,,,,,
STRUT EXT FIX L 57-79 MM XS BALL JT NS DISP MONK RING BONOBO,SUP-2899005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4576.55,2974.76,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INOGEN MINI TI 2 CHMBR DF4 CONN 2 LD CLR,SUP-2140377,CDM,C1722,HCPCS,0275,RC,,,,both,,,57462.00,37350.30,,,,,,,,,,,,,
FEMORAL VG CEM POR TIB/ARC/PAT,SUP-2137307,CDM,C1713,HCPCS,0278,RC,,,,both,,,13542.82,8802.83,,,,,,,,,,,,,
BIT DRL L25IN TEND GRFT DISPOSABLE,SUP-2166848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,807.04,524.58,,,,,,,,,,,,,
KNIFE SURG STR 500 MH LRI STRL LSREDG + DISP,SUP-2469193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
GUIDEWIRE VASC ARW GLIDEWHEEL L 60 CM DIA 0.032 IN NIT,SUP-2763343,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.66,38.13,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 33 CM DIA 0.025 IN SS PERIPH,SUP-2383970,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
DOUBLE DRILL GUIDE 35/25MM,SUP-2696009,CDM,C1713,HCPCS,0278,RC,,,,both,,,2797.61,1818.45,,,,,,,,,,,,,
COUNTERSINK SURG 2MM HD MONSTER,SUP-2320960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.23,298.50,,,,,,,,,,,,,
HC X-Ray Exam Abdomen 1 View,PX-3207401800,CDM,74018,CPT,0320,RC,,,,both,,,674.00,438.10,,,,,,,,,,,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,0258,RC,00338-0117-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
BUR SURG CUT 18 DEG 3 MM MED GRIT CONVX SIDE SHIELDED DIEGO,SUP-2638100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE DBL MECH ACT,SUP-2435632,CDM,L2005,HCPCS,0272,RC,,,,both,,,11601.23,7540.80,,,,,,,,,,,,,
KIT FIX GRFT PASS PIN DRL PNT K WIRE NIT GWIRE ACL BNE PLUG,SUP-2212935,CDM,C1713,HCPCS,0278,RC,,,,both,,,1737.30,1129.24,,,,,,,,,,,,,
CLIP HEMOSTATIC REPOSITIONABLE 235 CMX11 MM DURACLIP,SUP-2428103,CDM,C1713,HCPCS,0278,RC,,,,both,,,682.45,443.59,,,,,,,,,,,,,
SCREW BNE CANC 3X12 MM NS MTRX SMARTLOCK,SUP-2472468,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 4H RT 93MM-STER,SUP-2549565,CDM,C1713,HCPCS,0278,RC,,,,both,,,4531.68,2945.59,,,,,,,,,,,,,
HC 2d Echo W Contrast - W Dop/Color Flow,PX-4839330600,CDM,C8929,HCPCS,0483,RC,,,,both,,,3299.00,2144.35,,,,,,,,,,,,,
CATHETER EP THER COOL PATH,SUP-2463047,CDM,C2630,CPT,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SET ENDOSCP BIOCOMPOSITE ACL TIGHTROPE FOR MED,SUP-2121123,CDM,C1776,CPT,0278,RC,,,,both,,,5297.18,3443.17,,,,,,,,,,,,,
TRAY 4FX20CM FULL NRS CT MIDLN,SUP-2267040,CDM,C1751,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE 5 H TI X FOR 1MM PLUSDRIVE SCR,SUP-2190615,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.59,581.48,,,,,,,,,,,,,
FOLLOWER URETH 10FR L34CM POLYMER DISP PHIL,SUP-2384622,CDM,C1726,HCPCS,0272,RC,,,,both,,,43.24,28.11,,,,,,,,,,,,,
SLEEVE INSRT FOR ASNS III CANN SCR SYS 32MM GWIRE,SUP-2377942,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLUG IMPL BRAIN STIM L 17.1 MM SHFT L 12.8 MM DIA 1.3 MM CON,SUP-2889675,CDM,C1787,HCPCS,0278,RC,,,,both,,,900.08,585.05,,,,,,,,,,,,,
PACK KNE SCR W/INSTR CONVENIENCE W/ MPFL RECON TMPLT 4.75MM,SUP-2121122,CDM,C1713,HCPCS,0278,RC,,,,both,,,4669.18,3034.97,,,,,,,,,,,,,
COMPONENT FEM SZ 1 KNEE POST STBL SYMMETRICAL POR COAT,SUP-2223008,CDM,C1776,CPT,0278,RC,,,,both,,,12371.60,8041.54,,,,,,,,,,,,,
SOCKET PROS TST,SUP-2388206,CDM,L5620,HCPCS,0274,RC,,,,both,,,730.74,474.98,,,,,,,,,,,,,
LEAD NERVE STIM 2X8 CONTACT 70 CM KT ARTISAN,SUP-2423219,CDM,C1778,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
GRAFT VASC IMPRA L 60 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761312,CDM,C1768,CPT,0278,RC,,,,both,,,2218.10,1441.76,,,,,,,,,,,,,
PIN FIX L50MM ANCHR DISPOSABLE AERO LL,SUP-2381022,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PPICC PROVENA SOLO SP 3F SLEEVE IR W/NIT70,SUP-2613537,CDM,C1751,HCPCS,0278,RC,,,,both,,,508.33,330.41,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ 10IN LOOP LOK FIRM SUPP VYN,SUP-2276624,CDM,L3809,HCPCS,0272,RC,,,,both,,,17.40,11.31,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST CLASP ATTCH SHOE BAR SINGLE,SUP-2435626,CDM,L1910,HCPCS,0272,RC,,,,both,,,793.98,516.09,,,,,,,,,,,,,
CANNULA W/ RND TIP STYL,SUP-2366997,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
CLIP ANEURYSM T BAR 5MM FENESTRATED STANDARD 60 DEGREE ANGLE,SUP-2821640,CDM,C1889,HCPCS,0278,RC,,,,both,,,5892.87,3830.37,,,,,,,,,,,,,
SPLINT WRST UNIV L11IN R CUTAWAY PERF FOAM CONSTR MAL,SUP-2194859,CDM,L3931,HCPCS,0272,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
CATHETER MAP 8FR L105CM LOOP DIA15MM 3-3-3MM ELECTRD SPC,SUP-2357573,CDM,C1732,HCPCS,0278,RC,,,,both,,,5143.32,3343.16,,,,,,,,,,,,,
PLATE BNE THK 2.6 MM SM TI RAMUS DBL ANGLE NS DISP TRAUMAONE,SUP-2935755,CDM,C1713,HCPCS,0278,RC,,,,both,,,9781.10,6357.71,,,,,,,,,,,,,
GRAFT BONE SUB W7XH35XL25MM 7DEG B TRICALCIUM PHOS GRAN,SUP-2194024,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.89,2365.93,,,,,,,,,,,,,
PLATE BONE L94MM 7 H T SHP LCK 3 HD FOR 3.5MM SCR,SUP-2318683,CDM,C1713,HCPCS,0278,RC,,,,both,,,2389.85,1553.40,,,,,,,,,,,,,
KIT NEG PRSS SM W15XL20CM MULTISITE DSG PIONEERING DSGN W,SUP-2351609,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.40,450.06,,,,,,,,,,,,,
COMPONENT FEM SZ 1 LT KNEE CO CHROM ROT PLATFRM FIX REF MOB,SUP-2253413,CDM,C1776,CPT,0278,RC,,,,both,,,9391.11,6104.22,,,,,,,,,,,,,
MESH HERN W20XL20CM SYN BIOABSRB REINF BIO-A,SUP-2395753,CDM,C1781,HCPCS,0278,RC,,,,both,,,8430.90,5480.08,,,,,,,,,,,,,
GRAFT BNE SUB W25XL10CM DBX STRP FRZ DRY FOR VOID FILL,SUP-2306998,CDM,C1713,HCPCS,0278,RC,,,,both,,,3937.56,2559.41,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY LG AD 3.25 IN 16-19 IN PHILADELPHIA,SUP-2319293,CDM,L0172,HCPCS,0274,RC,,,,both,,,39.60,25.74,,,,,,,,,,,,,
FIBER LASER 200 MH HOLM SU200TRUE] FORTEC MEDICAL INC],SUP-2225719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.76 MM 2.3 MM DONALDSON FLROPLAS 525051,SUP-2462379,CDM,L8699,HCPCS,0278,RC,,,,both,,,23.68,15.39,,,,,,,,,,,,,
STENT BILI ST-2 SOEH TANNENBAUM L 15 CM DIA10 FR ENDOSCP,SUP-2738113,CDM,C2625,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
DRILL SURG CANN 2.7 MM MANUAL NS LTX,SUP-2855973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
SCREW BNE LCK 3X12 MM DBL STRT THRD SS JPS,SUP-2645499,CDM,C1713,HCPCS,0278,RC,,,,both,,,1068.86,694.76,,,,,,,,,,,,,
PROSTHESIS LARYN L6MM OD17FR INDWL LO AIRFLO RESISTANCE FOR,SUP-2124302,CDM,L8509,HCPCS,0274,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PHENELZINE SULFATE 15 MG PO TABS,RX-10933,CDM,6370000000,HCPCS,0637,RC,59762-0119-01,NDC,,both,1,UN,3.00,1.95,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 100 MM DIA 6 MM DEL SYS L 120,SUP-2158568,CDM,C1876,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
CLAMP SPNL S STL THORLUM FOR 5.5/5.5MM ROD REVERE,SUP-2230979,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
DEFIBRILLATOR CRD 40 J 74X51X13 MM 36.3 CC 83 GM COBALT XT,SUP-2601071,CDM,C1882,HCPCS,0275,RC,,,,both,,,43646.00,28369.90,,,,,,,,,,,,,
PLATE BONE L10MM 1LEVEL NONSTERILE TEMPUS SPINE,SUP-2879276,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC Ot Eval Mod Complex,PX-4349716600,CDM,97166,CPT,0434,RC,,,,both,,,239.00,155.35,,,,,,,,,,,,,
CONE WAGNER 135 DEG 15MM,SUP-2505549,CDM,C1776,CPT,0278,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
SPLINT FNGR W325XL325IN ALUMINUM LN W FOAM PLASTALUME RADLUC,SUP-2276771,CDM,L3933,HCPCS,0274,RC,,,,both,,,3.17,2.06,,,,,,,,,,,,,
GUIDEWIRE ORTH L100CM DIA3MM S STL BALL NOSE,SUP-2412710,CDM,C1769,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
EXPANDER TISS 11.6 CM PROJCT 14.9X16 CM 1445 CC TALL HT CPX4,SUP-2758788,CDM,C1889,HCPCS,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
HALF RNG 200MM FRDM CIR FIX,SUP-2400665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2285.92,1485.85,,,,,,,,,,,,,
DISPOSABLES KIT 2.4MM PUSHLOCK,SUP-2812587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
HC Antistreptolysin O Screen,PX-3028606300,CDM,86063,CPT,0302,RC,,,,both,,,339.00,220.35,,,,,,,,,,,,,
CATHETER UMB SINGLE LUMEN PEDIATRIC 3.5/5 FRX15 IN VEN ARGY,SUP-2174249,CDM,C1751,HCPCS,0278,RC,,,,both,,,469.90,305.43,,,,,,,,,,,,,
ROPIVACAINE HCL 2 MG/ML IJ SOLN,RX-18192,CDM,J2795,HCPCS,0636,RC,63323-0285-23,NDC,,both,20,ML,63.50,41.27,,,,,,,,,,,,,
STENT BILI PALMAZ XL L 30 MM DIA10 MM SHTH 10 FR SS TRNSHEP,SUP-2158990,CDM,C1877,HCPCS,0278,RC,,,,both,,,4879.56,3171.71,,,,,,,,,,,,,
PACK FIX CL SZ CALC W/ CANN ENDO DRL BIT GWIRE PASS PIN CANN,SUP-2341042,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
LEVONORGESTREL 1.5 MG PO TABS,RX-96881,CDM,6370000000,HCPCS,0637,RC,68180-0852-11,NDC,,both,1,UN,60.80,39.52,,,,,,,,,,,,,
COUNTERSINK SND PROC 3MM W BKUP FOR PONTO SYS,SUP-2319894,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
HEADGEAR MASK CPAP COMB W/ LOOPS SWIFT FX,SUP-2193982,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
STENT PERIPHERAL L30MM DIAMETER 7MM CATHETER L80CM VASCULAR STRAIGHT ARTERIOVENOUS FLAIR,SUP-2128216,CDM,C1874,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
WAND ABLAT TIP DIA0.81MM 45DEG BALL ELECTRD SM JT COOLCUT,SUP-2123446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
EXTRACTOR STONE 1.7FR L115CM BSKT DIA11MM NIT FOR URET STONE,SUP-2170591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,740.13,481.08,,,,,,,,,,,,,
PLATE BNE H1MM BAR L4MM 4 H MAND BLU TI MINI STR LOK,SUP-2366341,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.44,208.29,,,,,,,,,,,,,
TUBE NSL 3 LUMN,SUP-2306843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
VALVE AORT AVALUS H 18 MM DIA29 MM ORIFICE 27.5 MM RNG DIA,SUP-2429902,CDM,C1713,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
NAIL IM L345MM DIA10MM TIB GRN TI CANN LOK BEND,SUP-2192803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2687.84,1747.10,,,,,,,,,,,,,
DRILL SURG BUNNELL 5/32 IN HND,SUP-2795266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1583.00,1028.95,,,,,,,,,,,,,
MESH HERN RECT 12X8 IN MONOFILAMENT SCAFFOLD PHASIX,SUP-2736741,CDM,C1781,HCPCS,0278,RC,,,,both,,,25214.20,16389.23,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX15 CM DL J TIP CUDLM401JLSCABRMHC,SUP-2759853,CDM,C1751,HCPCS,0278,RC,,,,both,,,325.02,211.26,,,,,,,,,,,,,
TRIAL PLATE MTCRPL NK 1.3 MM RT,SUP-2525723,CDM,C1713,HCPCS,0278,RC,,,,both,,,2103.80,1367.47,,,,,,,,,,,,,
DEVICE FIX 8MM DIR ENDOBUTTON,SUP-2341086,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
BUR SURG DIA1.6 MM TUNGSTEN CARBIDE TAPR 2 RNG STRL DISP,SUP-2928847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.19,306.27,,,,,,,,,,,,,
TAP SURG SCR CANN CANC BNE SPNL THOR 40MM TAPMAS,SUP-2286834,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.28,293.33,,,,,,,,,,,,,
STRAP FNGR W5/8IN BGE BUDDY HK LOOP CLSR ROLYAN,SUP-2324809,CDM,L3933,HCPCS,0274,RC,,,,both,,,4.24,2.76,,,,,,,,,,,,,
PLATE BONE CONDYLAR 2 MM RIGHT 6 HOLE STAINLESS STEEL STERIL,SUP-2836693,CDM,C1713,HCPCS,0278,RC,,,,both,,,2065.05,1342.28,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.035IN TIP L3MM PTFE J TIP FIX COR,SUP-2302726,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
BIT DRL OD13MM DISK FOR UDRV 3 ULTRASONIC REV SYS,SUP-2136773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
PLATE BNE EXT BUTTERFLY MID/FLAT FT,SUP-2222608,CDM,C1713,HCPCS,0278,RC,,,,both,,,6028.80,3918.72,,,,,,,,,,,,,
PLATE BONE W8XL80MM THK3.3MM 10 H STRL BILAT PELV S STL,SUP-2186238,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.63,816.81,,,,,,,,,,,,,
LINER ACET DIA28MM 0DEG STD GRP 1 HIP UHMPE POLYETH POR,SUP-2304440,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5.0 CC DBM PTTY FIBER XCITE,SUP-2881445,CDM,C1713,HCPCS,0278,RC,,,,both,,,5074.24,3298.26,,,,,,,,,,,,,
HC Iadna S Aureus Methicillin Resist Amp Probe Tq,PX-3068764100,CDM,87641,CPT,0306,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
FILGRASTIM-AAFI 300 MCG/ML IJ SOLN,RX-145105,CDM,Q5110,HCPCS,0636,RC,00069-0293-01,NDC,,both,1,ML,1259.30,818.54,,,,,,,,,,,,,
TRUMATCH MIDFACE/MANDIBLE TI 3D PRNT GUIDE/ ORBIT,SUP-2194247,CDM,C1713,HCPCS,0278,RC,,,,both,,,9655.81,6276.28,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 30X20 CM RECON TISS MTRX STRATTICE,SUP-2475439,CDM,Q4130,HCPCS,0636,RC,,,,both,,,59405.66,38613.68,,,,,,,,,,,,,
PLATE BNE X 2.3X1.5 MM THOR RIB 16 HOLE LCK SLD LEVEL 1,SUP-2869172,CDM,C1713,HCPCS,0278,RC,,,,both,,,3709.60,2411.24,,,,,,,,,,,,,
GRAFT HUM TISS DIA21MM THK5MM MT LENGTHENING DISC,SUP-2321679,CDM,C1776,CPT,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 4 MM DEL SHTH 1.5ML,SUP-2937069,CDM,C1713,HCPCS,0278,RC,,,,both,,,4873.28,3167.63,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 100 MG MATRISTEM MICROMATRIX,SUP-2106472,CDM,Q4118,HCPCS,0636,RC,,,,both,,,1065.53,692.59,,,,,,,,,,,,,
"HC Mono Spot Test,Agglutination",PX-3028630800,CDM,86308,CPT,0302,RC,,,,both,,,363.00,235.95,,,,,,,,,,,,,
GRAFT BNE 3 CC X4 AUG,SUP-2463200,CDM,C1713,HCPCS,0278,RC,,,,both,,,39507.48,25679.86,,,,,,,,,,,,,
BIT DRL 4.5 MM ACTIFLIP,SUP-2762116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN W/ GROWTH PLATE RT WHL FEM,SUP-2740873,CDM,C1713,HCPCS,0278,RC,,,,both,,,32818.97,21332.33,,,,,,,,,,,,,
IMPLANT K-WIRE 9X.035 IN,SUP-2363583,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.18,15.72,,,,,,,,,,,,,
DISC ARTIFICIAL SZ 2 0DEG UNIV INTERVERTEBRAL LUM MTL ON,SUP-2255726,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE LCK 2X6X1 MM 4 HOLE CRV FOR SCREW TI BLU NS,SUP-2424094,CDM,C1713,HCPCS,0278,RC,,,,both,,,799.51,519.68,,,,,,,,,,,,,
JOINT FNGR CARPOMETACARPAL 1X1X1 CM ARTHRPLSTY ARTELON CMC,SUP-2365447,CDM,C1776,CPT,0278,RC,,,,both,,,5868.66,3814.63,,,,,,,,,,,,,
HC Level VI Surg Pathology Gross&Microscopic Exam,PX-3128830900,CDM,88309,CPT,0312,RC,,,,both,,,1380.00,897.00,,,,,,,,,,,,,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,6370000000,HCPCS,0637,RC,70700-0106-15,NDC,,both,15,GR,54.00,35.10,,,,,,,,,,,,,
PLATE BNE L58MM THK1.3MM 2X8 H L HND TI L SHP LOK TRILOK,SUP-2267944,CDM,C1713,HCPCS,0278,RC,,,,both,,,1838.78,1195.21,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND FNGR W/JT ELASTIC FABRICATED,SUP-2435765,CDM,L3766,HCPCS,0272,RC,,,,both,,,3498.56,2274.06,,,,,,,,,,,,,
HYDROCODONE BIT-HOMATROP MBR 5-1.5 MG/5ML PO SOLN,RX-157651,CDM,340b,HCPCS,0637,RC,00121-1036-40,NDC,,both,5,ML,57.60,37.44,,,,,,,,,,,,,
SPACER SPNL W28XH10MM 12DEG NAR TI ANTR INTBDY FUS LORDTC,SUP-2414761,CDM,C1821,HCPCS,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
COMP FEM AUG BTN SM/MED 10 DTL,SUP-2513643,CDM,C1776,CPT,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
PLATE BNE T 3.5X57 MM 3X4 HOLE RT ANGLED SS LCP,SUP-2569404,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.57,289.62,,,,,,,,,,,,,
INTRODUCER CATH 26GA L1.9CM PRECIS INTROSYTE-N,SUP-2133170,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.85,85.70,,,,,,,,,,,,,
BLANK RST PAN POS SP 1 8 INFIN M,SUP-2163841,CDM,L3807,HCPCS,0274,RC,,,,both,,,39.00,25.35,,,,,,,,,,,,,
SPLINT DENT OCCLUSAL IPS CUST,SUP-2263023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.520,SUP-2860201,CDM,C1713,HCPCS,0278,RC,,,,both,,,32508.42,21130.47,,,,,,,,,,,,,
DIAZEPAM 2 MG PO TABS,RX-2404,CDM,6370000000,HCPCS,0637,RC,51079-0284-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ENDCAP ORTH TI FOR SLD TIB IM NAIL,SUP-2192162,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.89,278.78,,,,,,,,,,,,,
CHOICE INTERMEDIATE 182CM MAG J 5PK,SUP-2664363,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
DEVICE PESSARY L 55 MM SZ 1 SIL SUPP WHT NS LF GEHRUNG,SUP-2895812,CDM,A4562,HCPCS,0272,RC,,,,both,,,108.27,70.38,,,,,,,,,,,,,
CATHETER IV DL 5 FR MAX BARR TY POWERMIDLINE,SUP-2126992,CDM,C1751,HCPCS,0278,RC,,,,both,,,561.75,365.14,,,,,,,,,,,,,
STENT BILI SENTINOL L 79 MM DIA 6 MM CATH L 135 CM SHTH 6 FR,SUP-2140678,CDM,C1876,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
HEAD HUM L17.7MM OD46MM 4MM OFFSET SHLDR AEQUALIS ASCEND,SUP-2388547,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SET PICC 2L 5FR X 55CM W TEG CHG,SUP-2887044,CDM,C1751,HCPCS,0278,RC,,,,both,,,2662.72,1730.77,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL CUST ARCH ATTCH TO SHOE,SUP-2435708,CDM,L3080,HCPCS,0272,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
CATHETER HAD AD 13FR L24CM POLYUR STR TAPR TIP NO CUF,SUP-2125595,CDM,C1752,HCPCS,0278,RC,,,,both,,,947.62,615.95,,,,,,,,,,,,,
GUIDEWIRE VASC DRIVEWIRE 24 L 204 CM RADIOPAQUE L 40 CM COAT,SUP-2930281,CDM,C1769,HCPCS,0272,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
SCREW BNE L30MM DIA4.75MM CORT FIX ANG NONCANNULATED,SUP-2407397,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM DIA0.014IN STR TIP L3CM W/ HYDRCOAT,SUP-2105898,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
KIT INTRO MAK-NV L 20 CM DIA 6 FR GUIDEWIRE L 60/80 CM DIA,SUP-2303021,CDM,C1894,HCPCS,0272,RC,,,,both,,,207.33,134.76,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM 6 H TI LOWER EXTREMITY Y SHP NS,SUP-2905676,CDM,C1713,HCPCS,0278,RC,,,,both,,,2680.18,1742.12,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY II DR W 44 X H 47 MM THK 7 MM 24.9,SUP-2148604,CDM,C1785,HCPCS,0275,RC,,,,both,,,16996.82,11047.93,,,,,,,,,,,,,
CLIP SURG OCPTL,SUP-2245459,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
SCREW BONE L140MM OD6.5MM THRD L32MM STD S STL CANC ST,SUP-2371170,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.48,82.86,,,,,,,,,,,,,
IMPACTOR SURG BALL 36 MM ID LNR G7,SUP-2440304,CDM,C1776,CPT,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
MORPHINE 5 MG/ML HIGH DOSE PCA (DISCRETE DOSING),RX-4081984,CDM,J2270,HCPCS,0636,RC,99999-9901-22,NDC,,both,30,ML,457.20,297.18,,,,,,,,,,,,,
CUBE EXT FIX 5 HOLE RANCHO,SUP-2749950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
ROD IM L345MM OD10.7MM 10DEG AG TIB FOR LIMB LENGTHENING,SUP-2312268,CDM,C1713,HCPCS,0278,RC,,,,both,,,56598.50,36789.02,,,,,,,,,,,,,
PLATE BONE THK2.5MM 20 H CRANIOMAXILLOFACIAL ORAL LT BLU TI,SUP-2181775,CDM,C1713,HCPCS,0278,RC,,,,both,,,5200.47,3380.31,,,,,,,,,,,,,
RING FT ID150MM EXT FIX SYS,SUP-2316277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3463.11,2251.02,,,,,,,,,,,,,
INTRODUCER NAVIGATION TIP PASS CATHETER,SUP-2280195,CDM,C1894,HCPCS,0272,RC,,,,both,,,1469.05,954.88,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN VBX L 15 MM 5/8 MM 80 CM 7 FR,SUP-2395634,CDM,C1874,HCPCS,0278,RC,,,,both,,,7601.94,4941.26,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 60 CC FRZN IRRADIATED CANC,SUP-2867099,CDM,C1762,CPT,0278,RC,,,,both,,,2493.79,1620.96,,,,,,,,,,,,,
THUMBWHEEL EXT FIX HEX 10 HOFFMANN LRF,SUP-2474934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,237.07,154.10,,,,,,,,,,,,,
BLADE SAW OSCILLATING 95X21X1.27 MM 1.27 MM HALL,SUP-2607471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BNE W10XL101MM THK1.2MM 90DEG 4X8 H BILAT S STL T SHP,SUP-2185878,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.19,1259.17,,,,,,,,,,,,,
DEVICE SUT TRNSVAG CAPT CAPIO CL,SUP-2139399,CDM,C2631,HCPCS,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
SPACER SPINE 27MM 10MMW 10MM HT TANT ZM,SUP-2414299,CDM,C1776,CPT,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
SLEEVE LD SZ 5-6 MM,SUP-2137906,CDM,C1883,HCPCS,0278,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
LEAD PACE AD L25CM INTRO 56FR ATR VENT TI NITRIDE TIP IS 1,SUP-2356096,CDM,C1898,HCPCS,0275,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
PLATE BNE STR 3.5X66 MM 5 HOLE RECON LCK SS STRL,SUP-2464583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.55,780.36,,,,,,,,,,,,,
PLATE BNE W24XL31MM 5 H NONSTERILE BILAT HINDFOOT MIDFOOT S,SUP-2186359,CDM,C1713,HCPCS,0278,RC,,,,both,,,2396.07,1557.45,,,,,,,,,,,,,
BIT DRL DIA6MM CARB DISP FOR 5/7.3MM SCR,SUP-2187125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,924.98,601.24,,,,,,,,,,,,,
BLADE RTRCTR SM 24MMW X 130MML TTNM SPNL TTHX3 THIN LIGHT BL,SUP-2703607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1018.02,661.71,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 90 MM DIA13/10 MM DEL 9ML,SUP-2936839,CDM,C1713,HCPCS,0278,RC,,,,both,,,12142.38,7892.55,,,,,,,,,,,,,
SHUNT SURG VENTRICULOPERITONEAL UNI-SHUNT NS0172,SUP-2666779,CDM,C1889,HCPCS,0278,RC,,,,both,,,2304.23,1497.75,,,,,,,,,,,,,
PLATE BNE 135DEG 12 H SUPCNDYL S STL COMPR FREE LOK,SUP-2197730,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM 2 ZIP 2 STRND PEEK FORC FBR,SUP-2366667,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
WIRE FIX L80MM OD0.86MM K,SUP-2122279,CDM,C1769,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
TUBE SUCTION T FUKUSHIMA 10 FRX4 IN 7 IN TEARDROP TAPR MALL,SUP-2496259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.87,233.27,,,,,,,,,,,,,
CATHETER CRYOABLATION C2 CRYOBALLOON L 105 CM 3.7 MM 30 MM,SUP-2422296,CDM,C2618,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
GRAFT HUM TISS 2CC PLCNTA MTRX FLOWABLE IMMUNOSUPPRESSIVE W/,SUP-2340458,CDM,C1762,CPT,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
HOOK SPNL REDUC HELCL FLNG 4.5MM ALTIUS MINI OCT,SUP-2414670,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
GRAFT BNE SUB 1CC 1 4MM DEMIN CANC SPNG CHIP FLEXIGRFT,SUP-2264609,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.50,285.02,,,,,,,,,,,,,
NAIL IM L260MM DIA9.5MM 120DEG ST BLU L/R HUM TI CANN LOK,SUP-2192516,CDM,C1713,HCPCS,0278,RC,,,,both,,,5231.74,3400.63,,,,,,,,,,,,,
TRIAL HD 28MM -4MM OFFSET SH FEM TAPR LFIT HMSPHR V40,SUP-2364470,CDM,C1776,CPT,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
EXPLORATION SET STRANGE 7.5 FRX40 CM BILE DUCT STONE,SUP-2737154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
PLATE BNE L 43.18 X W 5.08 MM THK 1 MM 7 H GRD III TI STR NS,SUP-2937039,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
PLATE SPNL L30MM 2 H TI LOK BTTRS,SUP-2193070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
SCREW C806 CCD CL IMP 6MM PLG C806,SUP-2280605,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PIN SECUR 6X2MM TWO H K WIRE FOR SHEFFIELD FIX,SUP-2316249,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.41,344.77,,,,,,,,,,,,,
TIBIA TRIAL SIZE 5 4,SUP-2473186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.38,455.90,,,,,,,,,,,,,
EPOPROSTENOL SODIUM 1.5 MG IV SOLR,RX-15898,CDM,J1325,HCPCS,0636,RC,62756-0060-40,NDC,,both,1,UN,255.90,166.33,,,,,,,,,,,,,
DRESSING BIO 95 SQ CM FISH SKIN MIC STRL DISP SURGICLOSE,SUP-2909165,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12858.30,8357.89,,,,,,,,,,,,,
GRAFT BNE FOAM 50X10X5 MM 5 CC 2 STRP STRL BI-OSTETIC,SUP-2134724,CDM,C1713,HCPCS,0278,RC,,,,both,,,4450.95,2893.12,,,,,,,,,,,,,
PLATE BNE SM TI ORBIT 3D PRNT NS DISP ACCUPLATE,SUP-2934969,CDM,C1713,HCPCS,0278,RC,,,,both,,,29453.20,19144.58,,,,,,,,,,,,,
PLATE BNE W175XL247MM THK52MM 13 H ST BILAT S STL BROAD CRV,SUP-2185302,CDM,C1713,HCPCS,0278,RC,,,,both,,,2233.29,1451.64,,,,,,,,,,,,,
COIL VASC AZUR CX L 24 CM DIA 8 MM MICROCATHETER 0.018 IN,SUP-2385450,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
DEVICE TORQUE MULTIGLIDECATH GUIDWIRE 0.01-0.038 IN MLTI,SUP-2140132,CDM,C1769,HCPCS,0272,RC,,,,both,,,9.99,6.49,,,,,,,,,,,,,
PLATE D32MM W9MM 115DEG BIFURCATED BLADE SPHER HOLES CLAMP ALTDORF,SUP-2108879,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.41,226.47,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.3MM GLD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189048,CDM,C1713,HCPCS,0278,RC,,,,both,,,324.86,211.16,,,,,,,,,,,,,
RESTRICTOR CEM DIA14MM UNIV FEM CNL UHMWPE BIOSTP G,SUP-2253101,CDM,C1776,CPT,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
VLP TI 3.5MMX28MM LCK SCREW T15 S-T,SUP-2820373,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.39,405.85,,,,,,,,,,,,,
GRAFT HUM TISS W4XL16CM THK1MM PROC DERM CLLGN RECTANG,SUP-2126256,CDM,C1781,HCPCS,0278,RC,,,,both,,,4485.80,2915.77,,,,,,,,,,,,,
SNARE VASC 1 SNR L 65 CM DIA25 MM DIA 6 FR SATIN FINISH L 65,SUP-2303146,CDM,C1773,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
MICRO PLATE 4 X 2 HOLES SQRE SGMNTS .6MM 1.5MM SSTM CP TTNM,SUP-2487654,CDM,C1713,HCPCS,0278,RC,,,,both,,,792.85,515.35,,,,,,,,,,,,,
COMPONENT TIB TY MOD REV PROVEN SZ 3T3F,SUP-2359296,CDM,C1776,CPT,0278,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 0.062X8 IN ACUTRK 2,SUP-2657754,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
DRESSING BIO 300 SQ CM FISH SKIN MESHED 21 STRL DISP,SUP-2909183,CDM,Q4158,HCPCS,0636,RC,,,,both,,,35748.90,23236.78,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK08 17MM THCK ACELLULAR HYDRATED,SUP-2307467,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2651.13,1723.23,,,,,,,,,,,,,
HC So1 Fta-Abs,PX-3028678067,CDM,86780,CPT,0302,RC,,,,both,,,72.00,46.80,,,,,,,,,,,,,
KIT CATH BA SIL RIFAMPICIN CLINDAMYCIN HCI SHUNT RADPQ W/,SUP-2243804,CDM,C1729,HCPCS,0272,RC,,,,both,,,2684.61,1745.00,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB PATELLAR MONOBLOCK,SUP-2402813,CDM,C1776,CPT,0278,RC,,,,both,,,22746.16,14785.00,,,,,,,,,,,,,
PLATE BONE CONDYLAR 2.7 MM LEFT 3 HOLE OBLIQUE STAINLESS STE,SUP-2836694,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.55,283.11,,,,,,,,,,,,,
HC Signal Average Ekg,PX-7309327800,CDM,93278,CPT,0730,RC,,,,both,,,502.00,326.30,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM GENDER SPEC M HXLPE,SUP-2212705,CDM,C1776,CPT,0278,RC,,,,both,,,12933.69,8406.90,,,,,,,,,,,,,
PLATE BNE CRV 2.3X35 MM FRAC COMPR FOR SCR TI LEVEL 1,SUP-2498880,CDM,C1713,HCPCS,0278,RC,,,,both,,,856.18,556.52,,,,,,,,,,,,,
SLEEVE PROTECTION 8MM/11MM -,SUP-2896469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1124.34,730.82,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME L 120 CM DIA 5 FR CSL,SUP-2480684,CDM,C1730,HCPCS,0272,RC,,,,both,,,186.05,120.93,,,,,,,,,,,,,
PIN CRANIOMAXILLOFACIAL BONE REPOS FOR 3.2MM SCR,SUP-2364440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1453.63,944.86,,,,,,,,,,,,,
BRACE BK M FOR 35 40IN WAIST BLK ALUMINUM NYL STRNL BAR POLY,SUP-2196478,CDM,L0464,HCPCS,0272,RC,,,,both,,,599.83,389.89,,,,,,,,,,,,,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,6370000000,HCPCS,0637,RC,64980-0513-05,NDC,,both,5,ML,23.40,15.21,,,,,,,,,,,,,
TUBING SURG DRN 29FR OD0.375IN ID0.250IN SIL SIL-TEC,SUP-2383036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
MICROSPHERE EMB 700-900UM GRN TRISACRYL IN 2ML PREFIL SYR,SUP-2303422,CDM,C1889,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
SCREW BONE PARTIAL THREADED 3.5X16 MM 6 MM SHAFT SMALL FRAGM,SUP-2837068,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.52,129.69,,,,,,,,,,,,,
IMPLANT ANK JT TALAR COMP RT CO CHROM SALTO TALARIS SZ 1,SUP-2244124,CDM,C1776,CPT,0278,RC,,,,both,,,9787.38,6361.80,,,,,,,,,,,,,
DRILL SURG BI-DIAMETER 1.8/2.3 MM 40 MM AO SHFT,SUP-2472981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.87,237.17,,,,,,,,,,,,,
KIT ANCHR SWIVELOCK W/ NO2 FIBERTAPE SUT GWIRE TRCR TIP DRL,SUP-2121451,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
SCREW SPNL L25MM OD4MM 0DEG TI POST MONOAX DBL LD THRD LO,SUP-2229293,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 20 HOLE-STERILE,SUP-2546105,CDM,C1713,HCPCS,0278,RC,,,,both,,,3196.74,2077.88,,,,,,,,,,,,,
SHUNT SURG L 6.5 CM SNAP INNR W/ VENTRICULAR CATH,SUP-2628509,CDM,C1729,HCPCS,0272,RC,,,,both,,,824.72,536.07,,,,,,,,,,,,,
SCREW BNE 6.5X120 MM FIX BEAM FOR CHARCOT FIX SYS AXIS,SUP-2433773,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BNE 2 X 32 H STR DBL STRP NS,SUP-2883276,CDM,C1713,HCPCS,0278,RC,,,,both,,,4731.45,3075.44,,,,,,,,,,,,,
SCREW BNE L 120 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2932168,CDM,C1713,HCPCS,0278,RC,,,,both,,,180.61,117.40,,,,,,,,,,,,,
GUIDEWIRE VASC VISTA BRT TIP L 55 CM DIA 8 FR SS PTFE IM,SUP-2155547,CDM,C1769,HCPCS,0272,RC,,,,both,,,444.31,288.80,,,,,,,,,,,,,
KIT SPNL ROD PT SPEC EXP ANY LEVEL UNID,SUP-2926536,CDM,C1713,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM CORT DST RAD VOLAR TI NONLOCKING,SUP-2340292,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
TRAY CATH PICC LUMENX1 3FR DIA POLYURETHANE BASIC W/MCRZ MIC,SUP-2613427,CDM,C1751,HCPCS,0278,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
HC Central Ven Cath 5+ Yrs,PX-4503655600,CDM,36556,CPT,0450,RC,,,,outpatient,,,9955.00,6470.75,,,,,,,,,,,,,
HC Hiv Rapid Ag Ab,PX-3008780666,CDM,87806,CPT,0300,RC,,,,both,,,308.00,200.20,,,,,,,,,,,,,
PLATE BNE L 294 X W 12 MM THK 4 MM SCREW DIA2.7/3.5 MM 25 H 72469225N,SUP-2933616,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.63,4694.71,,,,,,,,,,,,,
BRACE LS M FOR 35 41IN HIP COT POLYAMIDE LYCRA AVG SUPP 2,SUP-2325578,CDM,L0625,HCPCS,0274,RC,,,,both,,,207.81,135.08,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LG 10 CC OSTEOCONDUCTIVE MTRX + NUCEL 12/EA,SUP-2716039,CDM,C1762,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
GRAFT BONE MAR M + CONC,SUP-2163083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
BIT DRILL CALIBRATED 4.2MM EXTRA LONG,SUP-2739157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2454.16,1595.20,,,,,,,,,,,,,
GRAFT HUM AMNION L FLD MTRX,SUP-2309717,CDM,C1713,HCPCS,0278,RC,,,,both,,,8368.10,5439.26,,,,,,,,,,,,,
NECK FEM SZ 0 1 STD OFFSET SEG FOR TAPR HIP SYS SUMMIT,SUP-2436176,CDM,C1776,CPT,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
DHHS HELIX BLADE 150MM-STERILE,SUP-2547641,CDM,C1713,HCPCS,0278,RC,,,,both,,,1216.53,790.74,,,,,,,,,,,,,
STENT GRFT CVR VIABAHN 7MMX10.0X110CM,SUP-2396488,CDM,C1874,HCPCS,0278,RC,,,,both,,,8587.90,5582.13,,,,,,,,,,,,,
IMMOBILIZER KNEE PREMIER PRO TRI PNL 24INCH FOAM TIETEX PAT,SUP-2336078,CDM,L1830,CPT,0274,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
INTRODUCER ENDOSCP KIT 20 FR MIC-KEY G,SUP-2236585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.59,493.08,,,,,,,,,,,,,
BENDING IRON FOR 3.5MM LCP(TM) PILON PLATES,SUP-2548471,CDM,C1713,HCPCS,0278,RC,,,,both,,,2523.37,1640.19,,,,,,,,,,,,,
VALVE SHUNT L23.7MM 20CM H2O PRSS TI 2.0 CONN GRAVITATIONAL,SUP-2711652,CDM,C1889,HCPCS,0278,RC,,,,both,,,4501.28,2925.83,,,,,,,,,,,,,
IMPLANT HEARING 12MM THK8-9MM HA ABUTMENT IMPL HEARINGABLE,SUP-2164983,CDM,L8613,CPT,0278,RC,,,,both,,,10487.60,6816.94,,,,,,,,,,,,,
GRAFT DERM L16XW6CM THCKNESS 8-1.7MM ACELLULAR DERM,SUP-2307476,CDM,C1713,HCPCS,0278,RC,,,,both,,,7196.88,4677.97,,,,,,,,,,,,,
GRAFT DURA W3XL3IN ULTRAPURE DURAGN+ EACH=5 UNITS,SUP-2922558,CDM,C1713,HCPCS,0278,RC,,,,both,,,2100.06,1365.04,,,,,,,,,,,,,
SCREW BNE L 40 MM DIA 7 MM SHRT TI CANN HDLSS NS LEOS,SUP-2931473,CDM,C1713,HCPCS,0278,RC,,,,both,,,1324.45,860.89,,,,,,,,,,,,,
STAPLE INT L18XW14XH14MM NIT MEMOFIX,SUP-2244265,CDM,C1713,HCPCS,0278,RC,,,,both,,,4586.63,2981.31,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA 8 MM EPTFE STR STD WALL,SUP-2396197,CDM,C1768,CPT,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
SCREW BNE PART THRD 3X18 MM CANN STRL,SUP-2460883,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.79,336.56,,,,,,,,,,,,,
PLATE BNE W3.8XL100MM THK0.8MM 20 H BILAT TI STR,SUP-2191138,CDM,C1713,HCPCS,0278,RC,,,,both,,,1195.37,776.99,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX15 CM 3L CUTLM701JABRMHCRDCAH,SUP-2759977,CDM,C1751,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SUMMIT SZ6/7 STD NECK SEGMENT,SUP-2515371,CDM,C1776,CPT,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
BIT DRILL CALIBRATED SHORT 3.5 MMX5.1 IN WITH QUICK CONNECT,SUP-2837019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.25,399.91,,,,,,,,,,,,,
HC Apply Finger Splint,PX-4502913100,CDM,29131,CPT,0450,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CANN 4.9 FRX20 MM 0.035 IN JAGTOME,SUP-2149817,CDM,C1713,HCPCS,0278,RC,,,,both,,,978.83,636.24,,,,,,,,,,,,,
COMPONENT FEM 10X25 MM W/ INSRTR APERFIX II,SUP-2745500,CDM,C1776,CPT,0278,RC,,,,both,,,3472.84,2257.35,,,,,,,,,,,,,
HC So Antibody Screen With Enzymes,PX-3008697166,CDM,86971,CPT,0300,RC,,,,both,,,361.00,234.65,,,,,,,,,,,,,
SCREW BONE L13MM DIA3.5MM NONLOCKING HEXALOBE FOR ACU-LOC 2,SUP-2106640,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA15 MM DEL SHTH 33ML,SUP-2937082,CDM,C1713,HCPCS,0278,RC,,,,both,,,14462.84,9400.85,,,,,,,,,,,,,
SPACER SPNL 10 MM COR POST FUSION OCTAVE,SUP-2264524,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PLATE BNE TIB UNIV ANTR 3 HOLE TI NS LTX,SUP-2856995,CDM,C1713,HCPCS,0278,RC,,,,both,,,5862.38,3810.55,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 200 CM BALLOON L 100 MM DIA 7 MM SHTH,SUP-2890556,CDM,C1725,HCPCS,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
PLATE BNE NAR 4.5X214 MM 12 HOLE SS LC-DCP,SUP-2569264,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.49,232.37,,,,,,,,,,,,,
SPLINT WR AD SM FOR 2.5-3IN RT MCP REG FIRM OUTER FAB HND,SUP-2324879,CDM,L3809,HCPCS,0272,RC,,,,both,,,51.75,33.64,,,,,,,,,,,,,
SYSTEM DRAINAGE W/ VENTRICULAR CLR EDS 3,SUP-2851438,CDM,C1729,HCPCS,0272,RC,,,,both,,,818.72,532.17,,,,,,,,,,,,,
IMMOBILIZER KNEE SM L19IN FOR 14 16IN BLU CANVS T BAR STAY,SUP-2336065,CDM,L1830,CPT,0274,RC,,,,both,,,40.07,26.05,,,,,,,,,,,,,
PIN FIX 0.213X9 IN PARTIALLY THRD NS FPS STEINMAN,SUP-2856434,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
SCREW BONE ST OMEGA 21 FIX TI 5.5 X45 MM,SUP-2414706,CDM,C1713,HCPCS,0278,RC,,,,both,,,1801.48,1170.96,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 5 CM DIA 4 MM EPTFE STR TW N RING,SUP-2396327,CDM,C1768,CPT,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
ROD EXT FIX THRD 25 MM DNETR25] DNE LLC],SUP-2197314,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE CANN 6.5X100 MM HDLSS NS EPIC,SUP-2221599,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE SPNL CERV 40 MM ANTR INVIZIA,SUP-2414405,CDM,C1713,HCPCS,0278,RC,,,,both,,,5166.40,3358.16,,,,,,,,,,,,,
GRAFT VASC ALBOGRAFT L 30 CM DIA16 MM POLYESTER STR KNITTED,SUP-2264279,CDM,C1768,CPT,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PLATE BNE TBLR 97 MM 8 HOLE 1/3 STRL,SUP-2518443,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
PLATE BNE DBL Y 2-2.5X1 MM 10 MM GENIOPLASTY W/ TAB STP TI,SUP-2539565,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.84,463.35,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 24 H TI STR LP NS STERNALOCK,SUP-2894481,CDM,C1713,HCPCS,0278,RC,,,,both,,,7366.44,4788.19,,,,,,,,,,,,,
PLATE BNE L4.5MM 6 H TI FOR 4.5/5.5/6.5MM SCR L FRAG,SUP-2412040,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
SCREW SPNL 7.5X45 MM 4.75 MM FOR ROD CD HORZ SOLERA VOYAGER,SUP-2422086,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
SPACER SHLDR HD DIA50MM 06GM GENT BASE PMMA BNE CEM MOD HUM,SUP-2319843,CDM,C1776,CPT,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
WASHER SPNL 15MM TI BNE GRFT,SUP-2292219,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
GRAFT HUM TISS L W13XL22CM THK07 14MM THN ACELLULAR,SUP-2307616,CDM,Q4128,HCPCS,0636,RC,,,,both,,,30573.08,19872.50,,,,,,,,,,,,,
SKTRPN W/CV PT 60X22X3 HP,SUP-2818401,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.59,760.23,,,,,,,,,,,,,
PLATE BNE L W20XL36MM NONSTERILE BILAT S STL X SHP LO PROF,SUP-2186323,CDM,C1713,HCPCS,0278,RC,,,,both,,,2363.51,1536.28,,,,,,,,,,,,,
PLATE BONE W10XL16MM THK0.3MM 4 H TI BX ULT LO PROF,SUP-2181544,CDM,C1713,HCPCS,0278,RC,,,,both,,,795.05,516.78,,,,,,,,,,,,,
SCREW BONE L10MM DIA4.5MM CORT FEM S STL ST NONLOCKING FULL,SUP-2318712,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.32,103.56,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.415,SUP-2859979,CDM,C1713,HCPCS,0278,RC,,,,both,,,35049.31,22782.05,,,,,,,,,,,,,
PROSTHESIS OSS 2X1.32 MM FTPLT,SUP-2465816,CDM,L8613,CPT,0278,RC,,,,both,,,329.98,214.49,,,,,,,,,,,,,
SCREW BNE L50MM DIA3.5MM CALCNL TI NONLOCKING HEXALOBE,SUP-2106679,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
COMPONENT PATELLAR 8X29 MM KNEE POROUS MILLER-GALANTE II,SUP-2199561,CDM,C1776,CPT,0278,RC,,,,both,,,5204.86,3383.16,,,,,,,,,,,,,
PLATE BONE L134MM 6 H LT MEDL DSTL TIB LCK FOR 3.5MM SCR,SUP-2348244,CDM,C1713,HCPCS,0278,RC,,,,both,,,16630.07,10809.55,,,,,,,,,,,,,
BIT DRL L180MM DIA4.2MM FOR TIB FEM AND PROX FEM NAILING,SUP-2152589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.19,230.22,,,,,,,,,,,,,
BASKET STONE RETRIVAL 10 MMX250 CM SFT WIRE LL CONN STRL,SUP-2480878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1864.38,1211.85,,,,,,,,,,,,,
STENT NEURO SURPS EVOLVE L 15 MM DIA 5 MM COCR PLAT FLO,SUP-2541461,CDM,C2617,HCPCS,0278,RC,,,,both,,,42898.68,27884.14,,,,,,,,,,,,,
PLATE BNE STR 15X0.6 MM NEURO 2 HOLE TI STRL LEVEL 1,SUP-2518091,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.16,229.55,,,,,,,,,,,,,
GRAFT EVAR L49MM DIA28X28MM EXTN FREE FLO CLS WEB FOR ABD,SUP-2295232,CDM,C1768,CPT,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
SCREW SPNL L70MM OD7.5MM 10DEG S STL CANC PEDCL IL VAR ANG,SUP-2287016,CDM,C1713,HCPCS,0278,RC,,,,both,,,3039.05,1975.38,,,,,,,,,,,,,
PACK BTTRY SURG SCRDRVR VARISPEED,SUP-2364443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.36,576.78,,,,,,,,,,,,,
SMOG ENEMA,RX-408105755,CDM,2500000003,HCPCS,0250,RC,09999-9996-74,NDC,,both,330,ML,44.60,28.99,,,,,,,,,,,,,
BRACE WALKING MED LT LOWER LEG AIRSEL ACHILLES,SUP-2914932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
NEEDLE PROC TRANSSEPTAL,SUP-2535511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
SHEATH GUID R2P DESTINATION SLENDER L 80 CM WORKING L 75 CM,SUP-2615637,CDM,C1894,HCPCS,0272,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
PLATE BNE L 22 MM 4 H SCREW DIA2 MM PROF MINI FRAG NS VARIAX,SUP-2902422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.71,1449.31,,,,,,,,,,,,,
GUIDEPIN SURG KT FOR MED SURG LPS-FLEX,SUP-2212344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
KIT EXT FIX DST RAD FRME W/ TI SELF DRL SCHNZ SCR L200MM C,SUP-2179168,CDM,C1713,HCPCS,0278,RC,,,,both,,,7978.52,5186.04,,,,,,,,,,,,,
HC MRI-Upper Ext Jnt W Cont,PX-6107322200,CDM,73222,CPT,0610,RC,,,,outpatient,,,3764.00,2446.60,,,,,,,,,,,,,
FELT PTFE NOM THICKNESS 2.87MM 4INX4IN DIAM,SUP-2126672,CDM,C1781,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
ANCHOR SUT L38IN OD5MM SZ 2 PLLA DBL ARMED ABSRB ULTRABRAID,SUP-2341745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.41,782.22,,,,,,,,,,,,,
KIT INTRO ARW FLX SHTH L 10 CM DIA 9 FR GUIDEWIRE 0.035 IN,SUP-2763401,CDM,C1892,HCPCS,0272,RC,,,,both,,,218.54,142.05,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 4X58 MM CORTICAL HUMERAL TITANIUM NON,SUP-2837144,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.07,651.35,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 13 CM DIA 5.5 FR GUIDEWIRE 0.035 IN,SUP-2168062,CDM,C1892,HCPCS,0272,RC,,,,both,,,129.05,83.88,,,,,,,,,,,,,
INSERT TALAR SZ 4 THK11MM ANK POLYETH FOR PROPHECY INBONE 2,SUP-2397177,CDM,C1776,CPT,0278,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
DISSECTOR SURG US 48 CM CRV JAW CRDLSS STRL SONICISION 7 LF,SUP-2863485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1447.67,940.99,,,,,,,,,,,,,
BIT DRILL JUGGERKNOT FLEXBL LNG,SUP-2589270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.71,233.16,,,,,,,,,,,,,
SPHERE GLEN DIA36MM CO CHROM CNTR FOR 25MM GLEN BASEPLT,SUP-2388676,CDM,C1776,CPT,0278,RC,,,,both,,,11318.13,7356.78,,,,,,,,,,,,,
WEIGHT EYELID 1GM STD GLD SMOOTH SURF RND TAPR EDGE STRL IMP,SUP-2247198,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
PLATE EXT FIX SHT 140 MM FT RNG TI NS,SUP-2800128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2811.93,1827.75,,,,,,,,,,,,,
BUR SURG 4.1X13 MM FOR WDG MICA,SUP-2431609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1290.54,838.85,,,,,,,,,,,,,
PLATE BNE L W12XL119MM THK1MM 7 H BILAT TI SEMI TBLR LO,SUP-2190705,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.94,319.11,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT SHFT FEM 70MM LX10MM D,SUP-2307346,CDM,C1762,CPT,0278,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
KIT MICROINTRODUCER 21GA L7CM 4FR 0.018IN GWIRE COAX STD S,SUP-2308254,CDM,C1894,HCPCS,0272,RC,,,,both,,,116.02,75.41,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA MRI S DR SURESCAN W 51 X H 66 MM D,SUP-2282400,CDM,C1721,HCPCS,0275,RC,,,,both,,,42514.44,27634.39,,,,,,,,,,,,,
HC Rem Neph Tube,PX-3615038900,CDM,50389,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
TI DSTL FEM LISS PLT 11 HOLES/276MM-RIGHT,SUP-2190743,CDM,C1713,HCPCS,0278,RC,,,,both,,,5454.18,3545.22,,,,,,,,,,,,,
SCREW BONE L25MM OD9MM CORT,SUP-2166544,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.75,279.99,,,,,,,,,,,,,
PEG KIT FEED 16 FR TUBE RNG PUL N ENFIT LIDO CORFLO,SUP-2764876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.37,245.29,,,,,,,,,,,,,
CUP HUM DIA42MM NEUT OFFSET SHLDR COAT UNIVERS REVERS,SUP-2123342,CDM,C1776,CPT,0278,RC,,,,both,,,4596.02,2987.41,,,,,,,,,,,,,
PLATE BNE L 107 MM SCREW DIA2.4 MM 12 SHFT H TI ADPT COMB,SUP-2907636,CDM,C1713,HCPCS,0278,RC,,,,both,,,2848.61,1851.60,,,,,,,,,,,,,
"HC Dest Botox-1 Extrm,5 or > Musc",PX-7616464400,CDM,64644,CPT,0761,RC,,,,outpatient,,,2138.00,1389.70,,,,,,,,,,,,,
GRAFT VASC BIFUR 16X9 MMX50 CMX0.49 MM RVS LOCKNIT HEMGRD,SUP-2464396,CDM,C1768,CPT,0278,RC,,,,both,,,2492.44,1620.09,,,,,,,,,,,,,
SHEATH GUID L 25 CM DIA 6 FR DIL L 32.5 CM GUIDEWIRE 0.035,SUP-2890405,CDM,C1887,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPLR CHIPSTRYKUNIP] STRYKER CORP],SUP-2365435,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BNE IM 0 DEG HI PERF LCS HP,SUP-2456396,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
ROD EXT FIX 9 MM SUBFIX,SUP-2366066,CDM,C1776,CPT,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PORT INFUS CATH DIA6FR TI ATTACH POLYUR PEEL APART INTRO SGL,SUP-2126576,CDM,C1788,HCPCS,0278,RC,,,,both,,,1723.23,1120.10,,,,,,,,,,,,,
TRAY PICC 6FR L55CM POLYUR FULL TRIM LEN 3 LUMN NRS PWR INJ,SUP-2125555,CDM,C1751,HCPCS,0278,RC,,,,both,,,648.72,421.67,,,,,,,,,,,,,
GRAFT BNE SUB 25CC PTTY DBM FIBERS AND GLYC FRZ DRY OPTIUM,SUP-2264862,CDM,C1713,HCPCS,0278,RC,,,,both,,,808.71,525.66,,,,,,,,,,,,,
GRAFT HUM TISS 2CC LIQ FLOWABLE AMNION,SUP-2120776,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
COLLAR EXTRIC AD TALL HI DENS POLYETH PD SET XTW,SUP-2194473,CDM,L0172,HCPCS,0274,RC,,,,both,,,107.61,69.95,,,,,,,,,,,,,
PLATE BNE L210MM 15 H NONSTERILE L ANTLAT DST TIB S STL LO,SUP-2185964,CDM,C1713,HCPCS,0278,RC,,,,both,,,4237.15,2754.15,,,,,,,,,,,,,
BEARING HUM DIA36-44MM +3MM OFFSET STD E1 FOR COMPHSVE RVS,SUP-2408947,CDM,C1776,CPT,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
SPACER SPNL H8XL23MM LORD LUM PEEK FOR BNE FUS ELEV,SUP-2291292,CDM,C1889,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
RAIL EXT FIX STRL,SUP-2875233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7975.60,5184.14,,,,,,,,,,,,,
SPIRONOLACTONE 25 MG PO TABS,RX-7437,CDM,6370000000,HCPCS,0637,RC,00904-6927-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MATRIX BIO L 7 X W 10 CM FISH SKIN DERMAL SLD INTACT STRL 10/BX,SUP-2909440,CDM,Q4158,HCPCS,0636,RC,,,,both,,,7363.30,4786.14,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX15 CM SHT TERM DL TAPR SOFT-LINE,SUP-2627327,CDM,C1752,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
GRAFT BONE POST LUM SPCR IRRADIATED FRZ DRY H 7MM SM GRFTECH,SUP-2294232,CDM,C1713,HCPCS,0278,RC,,,,both,,,5815.28,3779.93,,,,,,,,,,,,,
GUIDEWIRE VASC MAGIC TORQUE DLVR L 315 CM DIA 0.035 IN TIP 5,SUP-2653352,CDM,C1769,HCPCS,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LNR HD E1 POLYETH CERM H1AZIMMER] ZIMMER BIOMET INC],SUP-2212569,CDM,C1776,CPT,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
"HC Aortography, Thoracic WO Serialography, S&I",PX-3237560000,CDM,75600,CPT,0323,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW BNE CONN CANN FOR STD INSRTN HNDL NS,SUP-2863434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1528.83,993.74,,,,,,,,,,,,,
CANNULA SUCTION CONNOR 23GA 19MML STAINLESS STEEL,SUP-2487901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.43,305.13,,,,,,,,,,,,,
BRACE THMB AD SM FOR 3.875-9.5IN IP TO WR CREASE LNG LT CMC,SUP-2324971,CDM,L3931,HCPCS,0272,RC,,,,both,,,62.58,40.68,,,,,,,,,,,,,
PIN FIX L35IN DIA1 8IN S STL HDLSS SQ END,SUP-2150348,CDM,C1713,HCPCS,0278,RC,,,,both,,,186.74,121.38,,,,,,,,,,,,,
PLATE BNE L421MM 18 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186068,CDM,C1713,HCPCS,0278,RC,,,,both,,,5387.11,3501.62,,,,,,,,,,,,,
SEED BRACHYTHERAPY STD LOAD,SUP-2135322,CDM,C2638,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
GRAFT BNE W14XL24MM THK6X2.5MM CANC COT WDG FOR OSTEOTMY,SUP-2399090,CDM,C1713,HCPCS,0278,RC,,,,both,,,4807.34,3124.77,,,,,,,,,,,,,
GRAFT BNE SUB 5ML ALLGRFT PTTY OSTEOAMP,SUP-2420672,CDM,C9362,HCPCS,0278,RC,,,,both,,,3198.09,2078.76,,,,,,,,,,,,,
DRILL SURG 1.6 MMX6 IN,SUP-2607263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.76,320.29,,,,,,,,,,,,,
PLATE BONE LOK 2MM THK HLX26 CP TTNM ANGLD FRCNSTRCTN RIGHT,SUP-2669749,CDM,C1713,HCPCS,0278,RC,,,,both,,,5286.66,3436.33,,,,,,,,,,,,,
CARRIER FBR OPT LT L50CM FOR ESOPHAGOSCOPES,SUP-2261091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1824.15,1185.70,,,,,,,,,,,,,
CATHETER SUPP L 135 CM DIA 0.0375 IN GUIDEWIRE 0.018 IN SS,SUP-2892948,CDM,C1725,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
HC Superselective Renal Art Bil,PX-3233625400,CDM,36254,CPT,0323,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
PLATE BNE L 70 X W 9.5 MM THK 1.5 MM SCREW DIA 3.5 MM 6 H SS,SUP-2933006,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.02,227.51,,,,,,,,,,,,,
FENTANYL-BUPIVACAINE-NACL 0.5-0.125-0.9 MG/250ML-% EP SOLN,RX-139976,CDM,J7999,HCPCS,0636,RC,71286-2082-02,NDC,,both,250,ML,122.20,79.43,,,,,,,,,,,,,
SAWBLADE STRYKER 1.27 X 19 X 100MM,SUP-2890788,CDM,C1776,CPT,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
SCREW BONE L85MM DIA6.5MM THRD L16MM STD CANC S STL LAG HEX,SUP-2344184,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.73,291.02,,,,,,,,,,,,,
GRAFT BNE PAT TISS,SUP-2391739,CDM,C1713,HCPCS,0278,RC,,,,both,,,9143.68,5943.39,,,,,,,,,,,,,
PROBE ENDOSCP ARTHSCP 90 DEG 3 MM ABLATN,SUP-2314074,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
BRACE BI CRUC DESIGNED TO RESTORE NAT KNEE MOTN ALLOW BOTH,SUP-2347989,CDM,C1776,CPT,0278,RC,,,,both,,,19081.78,12403.16,,,,,,,,,,,,,
HC Drainage Catheter Exchange,PX-3614942300,CDM,49423,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC C-Spine Complete W/ Flex/Ext,PX-3207205200,CDM,72052,CPT,0320,RC,,,,inpatient,,,1157.00,752.05,,,,,,,,,,,,,
SCREW BNE L 42 MM DIA 5.5 MM SHRT TI CANN HDLSS NS LEOS,SUP-2931461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1202.46,781.60,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA11 FR DIL L 20 CM GUIDEWIRE,SUP-2168018,CDM,C1892,HCPCS,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
CATHETER DRAINAGE OPN TIP 14 GAX8.8 CM 0.7X1.5 MM ADPT HERM,SUP-2244105,CDM,C1729,HCPCS,0272,RC,,,,both,,,424.06,275.64,,,,,,,,,,,,,
COMPONENT FEM G A/P60MM M/L26MM ZMLY R LAT L MED KNEE PRI,SUP-2342167,CDM,C1776,CPT,0278,RC,,,,both,,,7333.47,4766.76,,,,,,,,,,,,,
JIGS CR RIGHT INDENTITY ITOTAL,SUP-2719730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BNE LCK 5X14 MM DBL STRT THRD STRL JPS LTX,SUP-2875355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1439.22,935.49,,,,,,,,,,,,,
BIOINDCTIVE IMPLNT W/ARTH DEL SYS 1 MED,SUP-2334698,CDM,C1763,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.5 MMX40 CM NIT NS DISP,SUP-2599295,CDM,C1769,HCPCS,0272,RC,,,,both,,,174.36,113.33,,,,,,,,,,,,,
ARTHROFLEX 40 X70X2.0 MM,SUP-2816388,CDM,Q4125,HCPCS,0636,RC,,,,both,,,10744.45,6983.89,,,,,,,,,,,,,
ALLOGRAFT DISC PART DBM AND CORT CANC BONE CHIP FRZN,SUP-2223557,CDM,C1762,CPT,0278,RC,,,,both,,,6374.20,4143.23,,,,,,,,,,,,,
SYSTEM VARICOSE VEIN CLOSURE VENASEAL,SUP-2717590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6088.46,3957.50,,,,,,,,,,,,,
SCREW INTRF 8X40 MM TI CROSS-SCREW,SUP-2608260,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
CATHETER BAL DIL L160CM THROMBOSIS MICCATH INTIME,SUP-2141043,CDM,C1751,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
PORT TI IMPL SIL FILL SUT H 6 FR ATTCH CHRONOFLEX POLYUR W/,SUP-2127781,CDM,C1788,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
SHELL ACET DIA58MM LNR SZ F 2 H MPACT,SUP-2267377,CDM,C1776,CPT,0278,RC,,,,both,,,4547.98,2956.19,,,,,,,,,,,,,
INSERT HUM DIA36MM THK+6MM B-12.5DEG SHLDR REVERSED,SUP-2388712,CDM,C1776,CPT,0278,RC,,,,both,,,3631.41,2360.42,,,,,,,,,,,,,
BRACE ORTH THGH CIRC 21-29.5 IN 3XL C-6 TECHNOLOGY RT MEDL,SUP-2915204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.25,454.51,,,,,,,,,,,,,
PLATE BNE L85MM THK3.3MM 7 H BILAT S STL RIG STR DYN COMPR,SUP-2186331,CDM,C1713,HCPCS,0278,RC,,,,both,,,974.78,633.61,,,,,,,,,,,,,
BASKET SPEC RETRV 5 FRX60 CM FLX SHTH,SUP-2767787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1695.22,1101.89,,,,,,,,,,,,,
PROCESSOR SND CHESTNUT BRN PWR BAHA 3 BP110,SUP-2164976,CDM,L8690,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RIVAL L 135 CM BALLOON L 4 CM DIA 4 MM,SUP-2128430,CDM,C1725,HCPCS,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE LDDR CVD NEURO SCRW3 X 2 HOLES 2,SUP-2707443,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.69,722.60,,,,,,,,,,,,,
PLATE BNE L148MM 4X6 H NONSTERILE PELV BILAT S STL RIG,SUP-2186751,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.95,1442.97,,,,,,,,,,,,,
SCREW BNE L 110 MM DIA 4.7 MM PARTIALLY THRD OSTEOPENIA NS,SUP-2931472,CDM,C1713,HCPCS,0278,RC,,,,both,,,299.81,194.88,,,,,,,,,,,,,
BAND EXT FIX ACUTE ADJ NS DISP SMRT TSF,SUP-2933829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.37,160.79,,,,,,,,,,,,,
DRILL HND OD12MM,SUP-2354594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PROBE SURG PEDIATRIC FOR 6/7 MM CANN SCR ACUTRK REUSE,SUP-2535348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
BIT DRL L160MM DIA27MM QUIK CPL CANN FOR 4MM SCR,SUP-2179010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1266.86,823.46,,,,,,,,,,,,,
CATHETER ETER TY 2 ST MAXIMAL BARR IPA 4FR POWERPICC,SUP-2126383,CDM,C1751,HCPCS,0278,RC,,,,both,,,625.68,406.69,,,,,,,,,,,,,
SAFETY PRCNTSS TRAY WTH ONSTP CATH 8F 7CM LOK LUER,SUP-2487936,CDM,C1729,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
GUIDEWIRE SURG BALL TIP 3X800 MM,SUP-2644702,CDM,C1769,HCPCS,0272,RC,,,,both,,,498.00,323.70,,,,,,,,,,,,,
CATHETER CV KT 0.018 IN PEDIATRIC 4 FRX5 CM 0.64 MMX45 CM,SUP-2763321,CDM,C1751,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
HC MRI-Upper Ext Jnt W Cont|BILATERAL PROCEDURE,PX-6107322200,CDM,73222,CPT,0610,RC,,,50,outpatient,,,3764.00,2446.60,,,,,,,,,,,,,
PLATE BNE LCK 3.5X66 MM 5 HOLE CNTOUR 2 COMPR SS STRL,SUP-2463043,CDM,C1713,HCPCS,0278,RC,,,,both,,,848.68,551.64,,,,,,,,,,,,,
SCREW BNE ST 2.4X22 MM LCK W/ CRUCFRM RECESS TI,SUP-2570001,CDM,C1713,HCPCS,0278,RC,,,,both,,,108.80,70.72,,,,,,,,,,,,,
GUIDEWIRE ORTH L12IN OD2.4MM LNG KNEE DRL TIP NO EYELET,SUP-2341540,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
AUGMENT FEM SZ 4 THK15MM L DST KNEE CO CHROM PRESSFIT REV,SUP-2373517,CDM,C1776,CPT,0278,RC,,,,both,,,2828.51,1838.53,,,,,,,,,,,,,
SCREW BNE L55MM DIA35MM STD CORT TI DST FEM ST NONCANNULATED,SUP-2204958,CDM,C1713,HCPCS,0278,RC,,,,both,,,289.79,188.36,,,,,,,,,,,,,
PLATE BNE 2 H PELV ACET POST RIM BROAD STRL PRO,SUP-2902429,CDM,C1713,HCPCS,0278,RC,,,,both,,,2687.21,1746.69,,,,,,,,,,,,,
WRENCH TORQ AUDIBLE FOR OASYS SPNL SYS,SUP-2362952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,666.68,433.34,,,,,,,,,,,,,
BLADE SHAVER EXPANDABLE NS FLAREHAWK 7 LTX,SUP-2877232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 180 CM TIP L 12 CM DIA 0.035 IN SS,SUP-2148181,CDM,C1769,HCPCS,0272,RC,,,,both,,,370.65,240.92,,,,,,,,,,,,,
STENT PERIPH EPIC L 120 MM DIA 7 MM CATH L 120 CM NOM DIA,SUP-2145788,CDM,C1876,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
HC So Hla Class I&II Antibody Qual,PX-3028682866,CDM,86828,CPT,0302,RC,,,,both,,,168.00,109.20,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE SHTH L 7 CM DIA 5 FR GUIDEWIRE L 40,SUP-2167897,CDM,C1894,HCPCS,0272,RC,,,,both,,,107.29,69.74,,,,,,,,,,,,,
GRAFT BNE 25X25X8 MM 5 CC POROUS COLLAGEN MATRIX SIGNAFUSE,SUP-2731800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2896.65,1882.82,,,,,,,,,,,,,
GRAFT HUM TISS LESS THAN L5CM FIB FRZ DRY,SUP-2165544,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
IMPLANT BIO TISS W5XL5CM PORCINE DERM MTRX RECON THINNER,SUP-2388573,CDM,C1763,HCPCS,0278,RC,,,,both,,,8305.30,5398.44,,,,,,,,,,,,,
COLLAR CERV FIRM 3X21IN XL,SUP-2276594,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.69,4.35,,,,,,,,,,,,,
HC Ot Group Therapy,PX-4309715000,CDM,97150,CPT,0430,RC,,,,inpatient,,,135.00,87.75,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 16X8 CMX1.8-4 MM BRST KT,SUP-2307515,CDM,Q4128,HCPCS,0636,RC,,,,both,,,21866.65,14213.32,,,,,,,,,,,,,
HC Rmvl of Subq Defibrillator,PX-3603327200,CDM,33272,CPT,0360,RC,,,,inpatient,,,12107.00,7869.55,,,,,,,,,,,,,
KIT DRAINAGE VONSONNENBERG SUMP L 30 CM DIA12 FR GUIDEWIRE,SUP-2142256,CDM,C1729,HCPCS,0272,RC,,,,both,,,323.45,210.24,,,,,,,,,,,,,
EXPANDER BRST W15.6XH13.3CM P8CM 800CC W/ SUT TAB M HT STYL,SUP-2300657,CDM,C1789,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
CATHETER DIAG L155CM OD2.6X2FR ID0.015IN 0.012IN MIC,SUP-2367849,CDM,C1887,HCPCS,0272,RC,,,,both,,,2892.57,1880.17,,,,,,,,,,,,,
COMPONENT FEM M DURAC NP RT KNEE CRUC RET REV CEM STEM MOD,SUP-2364833,CDM,C1776,CPT,0278,RC,,,,both,,,7022.83,4564.84,,,,,,,,,,,,,
Z DUPLICATE USE 2431329 STENT NEURO NEUROFORM ATLS L 15 MM DIA 3 MM DEL WIRE L 185,SUP-2417547,CDM,C1874,HCPCS,0278,RC,,,,both,,,25748.00,16736.20,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 35X60 MM FRZN TRICORT ILIUM MATRIGRAFT,SUP-2740789,CDM,C1713,HCPCS,0278,RC,,,,both,,,7809.90,5076.43,,,,,,,,,,,,,
CROWN FORM DENT STRP U4 PRIMARY ANTR UPPER RT CNTRL PLAS,SUP-2322244,CDM,D6783,CPT,0278,RC,,,,both,,,32.09,20.86,,,,,,,,,,,,,
GUIDEPIN SURG L300MM DIA2.8MM DISP FOR DRL TIP,SUP-2411556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.71,271.51,,,,,,,,,,,,,
SCREW BONE CANN SELF-COMPRESSIVE 2.6MMX24MM,SUP-2224026,CDM,C1713,HCPCS,0278,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
CATHETER GUID PTFE S STL BRAIDING SHP INT MAMM .098IN VASC,SUP-2158066,CDM,C1887,HCPCS,0272,RC,,,,both,,,55.74,36.23,,,,,,,,,,,,,
STEM FEM CMNTLS 12/14 135 DEG 24X127.6 MM 36.8 MM TAPR,SUP-2440497,CDM,C1776,CPT,0278,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
MATRIX HEMSTAT 5ML FULL FLOSEAL,SUP-2130321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,793.70,515.90,,,,,,,,,,,,,
COLLAR ASPN AD REG EA,SUP-2196889,CDM,L0172,HCPCS,0274,RC,,,,both,,,73.57,47.82,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 10 L 200 CM DIA 0.010 IN DSTL SEG L,SUP-2367858,CDM,C1769,HCPCS,0272,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
RING EXT FIX DIA105 MM FULL RED NS DISP SMRT TSF,SUP-2933002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4377.32,2845.26,,,,,,,,,,,,,
FILLER BNE VOID 0.5 CC CORTICAL BNE SODIUM HYALURONATE,SUP-2927232,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
SCREW BONE L14MM DIA2.4MM TI CANN LAG HDLSS DISP FOR HND,SUP-2319466,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
PLATE BONE THK0.6MM 8 H ORBIT RIM SLV FOR 2MM SCR LORENZ,SUP-2402931,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
PLATE BNE 4 H SHT BSSO FOR 2MM SCR CRANIOMAXILLOFACIAL FRAC,SUP-2319393,CDM,C1713,HCPCS,0278,RC,,,,both,,,522.81,339.83,,,,,,,,,,,,,
PLATE BNE L67MM 8 H BILAT S STL STR MINI FRAG ST LO PROF,SUP-2186377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.42,1061.07,,,,,,,,,,,,,
SCREW BNE 7 X 20 MM BIOSURE REGENESORB,SUP-2341912,CDM,C1713,HCPCS,0278,RC,,,,both,,,1156.59,751.78,,,,,,,,,,,,,
ALLOPURINOL 100 MG PO TABS,RX-310,CDM,6370000000,HCPCS,0637,RC,60687-0677-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DIGOXIN 0.05 MG/ML PO SOLN,RX-43556,CDM,340b,HCPCS,0637,RC,69292-0605-60,NDC,,both,2.5,ML,26.70,17.35,,,,,,,,,,,,,
SCREW BONE L6MM DIA1.5MM STD CORT HEX HD ECT,SUP-2205632,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
ELECTRODE ES 14GA L25CM SEMI FLX FOR TISS ABLAT STARBURST,SUP-2118720,CDM,C1894,HCPCS,0272,RC,,,,both,,,7897.10,5133.11,,,,,,,,,,,,,
BIPOLAR LINER 53/54/55MM OD X 28MM ID,SUP-2501863,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC Perq Transcath Cls Paravalvr Leak Each Occls Dev,PX-4819359200,CDM,93592,CPT,0481,RC,,,,inpatient,,,4113.00,2673.45,,,,,,,,,,,,,
DILATOR ENDO CATH 7FR BAL L8CM DIA10MM ESOPH QNT TTC,SUP-2169338,CDM,C1726,HCPCS,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
CAGE SPNL 0 DEG 13X16X18-21 MM CORPECTOMY W/ SET SCREW CAPRI,SUP-2520289,CDM,C1889,HCPCS,0278,RC,,,,both,,,19782.00,12858.30,,,,,,,,,,,,,
BEARING HUM STD 40 MM SHLDR VIVACIT-E PROLONG COMPHSVE,SUP-2418152,CDM,C1776,CPT,0278,RC,,,,both,,,3246.76,2110.39,,,,,,,,,,,,,
SYSTEM IMPL SZ 4 MM SUTURE SZ 2-0 BTB-IB FLX PIN STRL DISP,SUP-2882297,CDM,C1713,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 1-4 MM 60 CC FD IRRADIATED CANC,SUP-2866921,CDM,C1762,CPT,0278,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
COLLAR CERV REG DENS SHT TWO PC PED ATLS,SUP-2319289,CDM,L0140,HCPCS,0274,RC,,,,both,,,48.32,31.41,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.7MM CORT CRANIOMAXILLOFACIAL G S STL ST 5PK,SUP-2366093,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.36,112.68,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 17-19 MM FD ILIUM TRICORT,SUP-2717915,CDM,C1713,HCPCS,0278,RC,,,,both,,,5275.99,3429.39,,,,,,,,,,,,,
INTRODUCER SET G2-MULTI PERC 7.5/8.5/9 MM EVAC DIL BLU RHINO,SUP-2759708,CDM,C1769,HCPCS,0272,RC,,,,both,,,1438.91,935.29,,,,,,,,,,,,,
BIT DRL 230/200MM CALIB DIA2.5MM 3 FLUT QUIK CPL,SUP-2187615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.55,333.81,,,,,,,,,,,,,
WIRE FIX L200MM DIA2.5MM S STL DBL SHRP TIP SMOOTH TIBIAXYS,SUP-2242888,CDM,C1769,HCPCS,0272,RC,,,,both,,,224.89,146.18,,,,,,,,,,,,,
BLADE RETRACTOR 17 CM LT INT PIN MAST QUAD,SUP-2631631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1571.57,1021.52,,,,,,,,,,,,,
CATHETER DRNGE ABSC ALL PURP TIGHT LOOP SET W/ TEMP TIP,SUP-2147896,CDM,C2617,HCPCS,0278,RC,,,,both,,,421.61,274.05,,,,,,,,,,,,,
PLATE DISTAL POSTERIOR LATERAL 6HL RT,SUP-2703369,CDM,C1713,HCPCS,0278,RC,,,,both,,,4354.24,2830.26,,,,,,,,,,,,,
PLATE BNE L79MM 3 H ST R DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177711,CDM,C1713,HCPCS,0278,RC,,,,both,,,2418.40,1571.96,,,,,,,,,,,,,
COLLAR CERV PADDED LG TALL COMFORT ADJ MIAMI J,SUP-2434343,CDM,L0174,HCPCS,0272,RC,,,,both,,,155.46,101.05,,,,,,,,,,,,,
SET ORTH TRAC 43-66CM CRWN FULL ASMBLY BREMER HALO SYS,SUP-2255680,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
ROD RMR L950MM DIA3MM W/ OFFSET BALL TIP,SUP-2188110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.91,268.39,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X252 MM 14 HOLE SS LCP,SUP-2569375,CDM,C1713,HCPCS,0278,RC,,,,both,,,911.86,592.71,,,,,,,,,,,,,
IMPLANT TOE JT L15MM OD6.6MM 60DEG GRN IOFIXX-POST,SUP-2223896,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GRAFT BONE SUB 20ML LESS THAN 2MM GROWTH FACT GRAN OSTEOAMP,SUP-2138494,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
PLATE SPNL 1 LEVEL 14 MM ANTR CERV TETH,SUP-2379299,CDM,C1713,HCPCS,0278,RC,,,,both,,,4813.62,3128.85,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L 115 CM 7/15 FR,SUP-2248626,CDM,C1730,HCPCS,0272,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
SCREW STRNL CLOSURE L 10 MM DIA 3 MM TI STRL STERNALOCK XP,SUP-2895213,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER ETER URETH 5FR L30CM SIL HYSTEROSALPINGOGRAPHY BLLN,SUP-2168929,CDM,C2628,HCPCS,0272,RC,,,,both,,,255.50,166.07,,,,,,,,,,,,,
INJECTOR MONARCH IV IOL,SUP-2859221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5288.67,3437.64,,,,,,,,,,,,,
PLATE BNE LCK 2.7 MM 2 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2492819,CDM,C1713,HCPCS,0278,RC,,,,both,,,724.46,470.90,,,,,,,,,,,,,
IMPLANT TOTAL OSSCLR UNVRSL NTCHD 35MM DIA 10MM SHAFT 80M,SUP-2680128,CDM,L8613,CPT,0278,RC,,,,both,,,1360.81,884.53,,,,,,,,,,,,,
DIST MED HUM PLT PROV,SUP-2725825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.27,1083.08,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X251 MM LT PROX 8 HOLE NS VA-LCP,SUP-2757661,CDM,C1713,HCPCS,0278,RC,,,,both,,,7003.20,4552.08,,,,,,,,,,,,,
SCREW IM L 42.5 MM DIA 5 MM TI CORTICAL NS CARBOFIX,SUP-2930829,CDM,C1713,HCPCS,0278,RC,,,,both,,,387.41,251.82,,,,,,,,,,,,,
NAIL IM L160MM DIA10MM NONSTERILE AQUA L/R DSTL FEM TI LCK,SUP-2191706,CDM,C1713,HCPCS,0278,RC,,,,both,,,5612.94,3648.41,,,,,,,,,,,,,
VALVE CSF FLO CTRL REG CONTOURED MED PRESSURE W/ BIOGLDE,SUP-2631417,CDM,C1889,HCPCS,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
BOOT CAST PEDIATRIC 5.5X2.5 IN ROCKER SHOE CANVS,SUP-2336135,CDM,L4387,HCPCS,0272,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
INSERTER LCK CAP,SUP-2207862,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
HC So T Cell Total,PX-3028635966,CDM,86359,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
GRAFT BNE SUB 05CC REHYDRATED PTTY OSTEOAMP,SUP-2138513,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
PURAPLY 5X5CM 25SQ CM,SUP-2314122,CDM,Q4195,HCPCS,0636,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
CATHETER ANGIO ACCU-VU L 70 CM DIA 5 FR 0.038 IN 2 CM OMNI,SUP-2117050,CDM,C1725,HCPCS,0272,RC,,,,both,,,747.01,485.56,,,,,,,,,,,,,
GRAFT BNE ANT H10MM DIA8 15MM PARA FIBULAR CRSS SECT FRZ DRY,SUP-2264871,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.50,1526.52,,,,,,,,,,,,,
HEMOSTASIS VALVE PACK ADVANTAGE+ WATCHDOG,SUP-2798392,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.92,380.85,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 30-50X10 MM 10X25 MM FRZN PATELLAR TEND,SUP-2866895,CDM,C1762,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST W/ADJACENT JT ROT CNTRL MOLD,SUP-2435613,CDM,L1844,LOCAL,0274,RC,,,,both,,,4311.38,2802.40,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GAX5 CM,SUP-2174902,CDM,C1819,HCPCS,0278,RC,,,,both,,,93.89,61.03,,,,,,,,,,,,,
SPLINT DORSAL AFO SPLNT S RT W STRP,SUP-2163834,CDM,L4396,HCPCS,0274,RC,,,,both,,,99.04,64.38,,,,,,,,,,,,,
STENT URET 5FR L22CM PROX PGTL POLYUR AQ SFT MFIL TETH,SUP-2169454,CDM,C2617,HCPCS,0278,RC,,,,both,,,423.24,275.11,,,,,,,,,,,,,
PLATE BONE 14 H ANTR LAT PROX FOR 4.5MM SCR,SUP-2349068,CDM,C1713,HCPCS,0278,RC,,,,both,,,1121.64,729.07,,,,,,,,,,,,,
PLATE BNE L303MM THK3MM 16 H BILAT S STL STR LOK COMPR RECON,SUP-2185353,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.66,1408.33,,,,,,,,,,,,,
RING EXT FIX LNG 160 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29084.31,18904.80,,,,,,,,,,,,,
STEM FEM SZ 6 CO CHROM CEM LD FX NAT HIP,SUP-2210730,CDM,C1776,CPT,0278,RC,,,,both,,,4104.61,2668.00,,,,,,,,,,,,,
SET REMEEX FOR FEM URIN INCONT,SUP-2308305,CDM,C1771,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
TRAY CATH 5FR 3 LUMN MAX BARR SHERLOCK 3CG TPS STYL PWR,SUP-2125516,CDM,C1751,HCPCS,0278,RC,,,,both,,,990.23,643.65,,,,,,,,,,,,,
HC N-Invas Est C Ffr Sw Aly Cta,PX-3297558000,CDM,75580,CPT,0480,RC,,,,both,,,5678.00,3690.70,,,,,,,,,,,,,
ANCHOR SUT L17.9MM DIA6.5MM TI W/ 2 FIBERWIRE BIO CRKSCR,SUP-2121526,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CATHETER CV 2 LUMEN 5 FRX160 CM CT MORPHEUS SMRT PICC,SUP-2116957,CDM,C1751,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK TRICORT 800131,SUP-2743375,CDM,C1713,HCPCS,0278,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
EXTENSION LD DBS L 40 CM W/ MARKER STRL DISP SENSIGHT,SUP-2883109,CDM,C1883,HCPCS,0278,RC,,,,both,,,2994.93,1946.70,,,,,,,,,,,,,
GUIDEWIRE VASC L 70 CM DIA 0.038 IN TIP L 3 MM DEPTH MARKING,SUP-2117325,CDM,C1769,HCPCS,0272,RC,,,,both,,,52.75,34.29,,,,,,,,,,,,,
HC Remote Afterld Brachy 1 Channe,PX-3337777000,CDM,77770,CPT,0333,RC,,,,outpatient,,,4654.00,3025.10,,,,,,,,,,,,,
CATHETER HD DL 10 FRX18 CM STR CUF TIP SPLIT CATH III,SUP-2269496,CDM,C1752,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 5 CM 5 MM 0.035 IN SUPERALLOY,SUP-2167555,CDM,C1889,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CATHETER 6-2X5.3X135 SYNERGY,SUP-2147627,CDM,C1725,HCPCS,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
EPOCH POR ST/HA CUP/LGXLPE LINER/LG CER HD,SUP-2212322,CDM,C1776,CPT,0278,RC,,,,both,,,16382.29,10648.49,,,,,,,,,,,,,
SET PANCREATIC STENT ZMMN L 2 CM 5 FR 0.035 IN 2MM POLYETHYL,SUP-2169211,CDM,C2625,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
MESH HERN W20XL30CM POLY SYN REABSORBABLE CLLGN BARR 3D,SUP-2174723,CDM,C1781,HCPCS,0278,RC,,,,both,,,4061.56,2640.01,,,,,,,,,,,,,
GRAFT HUM TISS 21MM AORT VLV CRYOPRESERVED CARDIOGRFT,SUP-2264801,CDM,C1762,CPT,0278,RC,,,,both,,,61470.68,39955.94,,,,,,,,,,,,,
SYSTEM 7FR 90CM ULT SM CSF SNAP SHUNT ASSEMB FLOW CTRL VLV,SUP-2278382,CDM,C1729,HCPCS,0272,RC,,,,both,,,2901.83,1886.19,,,,,,,,,,,,,
BLADE LARYN L27CM DIA4MM 360DEG ROT ANG TIP DBL CVD LO PROF,SUP-2277874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1838.78,1195.21,,,,,,,,,,,,,
LAPAROSCOPE RIGID L330MM OD10MM 30DEG DIRECT VIEW AUTOCLAVAB,SUP-2801945,CDM,C1776,CPT,0278,RC,,,,both,,,9539.10,6200.41,,,,,,,,,,,,,
IMPLANT SUBTALAR W9XH17MM DISCO,SUP-2878333,CDM,C1776,CPT,0278,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
PLATE EXT FIX L75MM S STL 6 H SH CONN IMP ILIZ,SUP-2342294,CDM,C1713,HCPCS,0278,RC,,,,both,,,727.95,473.17,,,,,,,,,,,,,
PLATE CRAN 100X60X40 MM PT SPEC IMPL PEEK,SUP-2860132,CDM,C1713,HCPCS,0278,RC,,,,both,,,30240.08,19656.05,,,,,,,,,,,,,
NECK FEM H+10MM CO CHROM HI OFFSET MOD REDAPT,SUP-2345461,CDM,C1776,CPT,0278,RC,,,,both,,,2858.66,1858.13,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-JEJUNAL 18 FRX30 CM 7-10 CC MIC-KEY,SUP-2764492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.62,479.45,,,,,,,,,,,,,
KIT HEMO DYLS OR HD 15.5FR L24CM BASIC LNG TERM ADMIN POLYUR,SUP-2354971,CDM,C1750,HCPCS,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
SET DIL 6/8/10/12/14/16FR GWIRE 0.038IN URET PTFE HYDR+ C,SUP-2139212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.43,334.38,,,,,,,,,,,,,
KIT TKR TRABECULAR MTL FEM TIB STD SURF AND VIT E PAT,SUP-2212232,CDM,C1776,CPT,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
HC Drug Screen Quantitative Lithium,PX-3018017800,CDM,80178,CPT,0301,RC,,,,both,,,267.00,173.55,,,,,,,,,,,,,
PLATE BNE SM 11 H ANT TIB TI DELT LOK COMPR FOR 3.5/4MM SCR,SUP-2398401,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
PROBE LITHO 6MMX120CM OD2FR EHL,SUP-2313059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.57,617.87,,,,,,,,,,,,,
IMPLANT ANK JT SUBTALAR IMPLABLE L15MM OD9MM BIOARCH,SUP-2401348,CDM,C1776,CPT,0278,RC,,,,both,,,2659.58,1728.73,,,,,,,,,,,,,
DILATOR SURG FOR CD HORZ SEXTANT ROD INSRTN SYS POLYMER BLU,SUP-2279981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,582.60,378.69,,,,,,,,,,,,,
SYSTEM RENAL INFUS L35CM BENEPHIT XT,SUP-2117234,CDM,C1751,HCPCS,0278,RC,,,,both,,,6210.92,4037.10,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 20H TI STRL,SUP-2546937,CDM,C1713,HCPCS,0278,RC,,,,both,,,3489.80,2268.37,,,,,,,,,,,,,
CATHETER PULM ART 8.5FR L20CM SAFT OXMTR 3 LUMN W/ INTEGR,SUP-2214765,CDM,C1751,HCPCS,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
COUPLER FIX OFFSET +2MM FEM KNEE LEGION,SUP-2346815,CDM,C1776,CPT,0278,RC,,,,both,,,3811.96,2477.77,,,,,,,,,,,,,
PLATE ROT CORR 2MM 2H HD 4H SHFT TI STRL LCP,SUP-2549722,CDM,C1713,HCPCS,0278,RC,,,,both,,,2946.61,1915.30,,,,,,,,,,,,,
TRANSILLUMINATOR OPHTH 25GA EXAM W ANG DISP SAPPHIRE FOR,SUP-2109943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.74,363.83,,,,,,,,,,,,,
SYSTEM MESH HRNIA PANEL BOWLS SM 03MM THK TTNM ORBTL CNTRD,SUP-2676690,CDM,C1713,HCPCS,0278,RC,,,,both,,,983.13,639.03,,,,,,,,,,,,,
GRAFT BNE PTTY 1-2 MM 20 CC CALCIUM PHOSPHATE ACTIFUSE ABX,SUP-2130292,CDM,C9359,HCPCS,0278,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 45 CM OD 8 FR GUIDEWIRE 0.018/0.038,SUP-2170662,CDM,C1894,HCPCS,0272,RC,,,,both,,,155.93,101.35,,,,,,,,,,,,,
BAR EXT FIX L60MM DIA4MM S STL CONN FOR SM FIX,SUP-2188725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,95.83,62.29,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 23 MM FD ILIUM TRICORT,SUP-2717917,CDM,C1713,HCPCS,0278,RC,,,,both,,,5837.70,3794.50,,,,,,,,,,,,,
CONFORMER OPHTH AD SM W/ H BILAT METHYLMETHACRYLATE POSTOP,SUP-2129498,CDM,L8610,HCPCS,0278,RC,,,,both,,,46.16,30.00,,,,,,,,,,,,,
COMPONENT ULN XSM L3IN L EL TIV PLSM CRV INTERCHANGEABLE,SUP-2205932,CDM,C1776,CPT,0278,RC,,,,both,,,14543.91,9453.54,,,,,,,,,,,,,
SET CATH HAD 10FR L52CM CUF AT 27 AND 30CM POLYUR TWO,SUP-2266953,CDM,C1881,HCPCS,0278,RC,,,,both,,,921.90,599.23,,,,,,,,,,,,,
GRAFT HUM TISS W40XL70MM THK176 225MM ACELLULAR DERM MTRX,SUP-2418429,CDM,Q4125,HCPCS,0636,RC,,,,both,,,9168.96,5959.82,,,,,,,,,,,,,
TUBE VENT 1.02 MM 0.8 MM 1.47 MM SHEA PARASOL TAB SIL STRL,SUP-2464610,CDM,L8699,HCPCS,0278,RC,,,,both,,,55.11,35.82,,,,,,,,,,,,,
EQUINOXE REVERSE 36MM HUMERAL LINER +2.5,SUP-2512471,CDM,C1776,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
PLATE BONE L177MM 14 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349641,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.38,1659.05,,,,,,,,,,,,,
PORT IMPL INFUSION OPN END 9.6 FR 1 LUMEN VEN CATH X-PORT,SUP-2127752,CDM,C1751,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
GRAFT BNE PTTY 0.5 CC FD DBM STRL GRFT,SUP-2430048,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
PLATE H EXT 1.5MM RT W/GUIDES STRL TI LCP,SUP-2546743,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.75,973.54,,,,,,,,,,,,,
BIT DRL L30MM OD2MM ADD ON FIT SPEEDGUIDE,SUP-2378001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CASE TRAVEL,SUP-2356034,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC Iaad Ia Hpylori Stool,PX-3068733800,CDM,87338,CPT,0306,RC,,,,both,,,332.00,215.80,,,,,,,,,,,,,
IMPLANT HUM TISS W2XL4CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2125851,CDM,C1781,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BIT DRL ENDOSCP UNIV FOR JT PRESERVATION MICROFX OCD DISP,SUP-2366638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1740.41,1131.27,,,,,,,,,,,,,
PLATE BONE L190MM 11 H LT PROX HUM LO ALPS,SUP-2402732,CDM,C1713,HCPCS,0278,RC,,,,both,,,8273.90,5378.03,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR CUST FIT,SUP-2435674,CDM,L2520,HCPCS,0274,RC,,,,both,,,1521.74,989.13,,,,,,,,,,,,,
TIP ASPIR 0.3MM STR MIC COAX INTREPID,SUP-2109919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
COLLAR CERV M PD H25IN FOR 10 20IN NK PLAS HK AND LOOP CLSR,SUP-2196887,CDM,C1874,HCPCS,0278,RC,,,,both,,,138.03,89.72,,,,,,,,,,,,,
GUIDE NDL BX FOR TRANSDUCER DISP,SUP-2835416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
BUTTON FIX DIA20MM BNE TO BNE ENDOBTTN CL,SUP-2341034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
PLATE BNE W22XL51MM 12 H R DST VOLAR RAD WRST NAR LOK,SUP-2411815,CDM,C1713,HCPCS,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
NEEDLE BRST LOC L10CM OD20GA HAWK II,SUP-2120049,CDM,C1819,HCPCS,0278,RC,,,,both,,,109.21,70.99,,,,,,,,,,,,,
PLUG VASC W5.3XL12MM VES 1.5-3MM PERIPH NIT PTFE MIC,SUP-2281185,CDM,C1889,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
PROSTHESIS OSSCLR TOTAL 25MM/35MM DIA HEAD 08MM DIA TROP,SUP-2680305,CDM,L8613,CPT,0278,RC,,,,both,,,1357.89,882.63,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PATELLOFEMORAL UNI NXGN N-K II,SUP-2212500,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
VALVE AORT PRIMA + DIA25 MM PORCINE WOVEN POLYESTER STNTLSS,SUP-2214045,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STENT BILI L11MM BLLN L15MM DIA5MM CATH L80CM 14/12ATM,SUP-2158996,CDM,C1876,HCPCS,0278,RC,,,,both,,,3975.24,2583.91,,,,,,,,,,,,,
STEM EXTN L120MM OD10MM FEM KNEE PRSS FIT POST STBL LEGION,SUP-2349131,CDM,C1776,CPT,0278,RC,,,,both,,,4540.44,2951.29,,,,,,,,,,,,,
PLATE BNE CHAMPY MINI 110 DEG 2 MM RT MAND 4 HOLE TI LEVEL 1,SUP-2460822,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.67,584.14,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX4 TTNM CNTRD F2.7MM LOK SCREW ST,SUP-2724125,CDM,C1713,HCPCS,0278,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
SYSTEM TISS CLOSURE ENDOSCP STD PDLOK CLP,SUP-2736730,CDM,C1889,HCPCS,0278,RC,,,,both,,,1468.20,954.33,,,,,,,,,,,,,
MORPHINE SULFATE 15 MG PO TABS,RX-5178,CDM,6370000000,HCPCS,0637,RC,00054-0235-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHELL ACET OD46MM ID40MM UNIV HIP CEMENTLESS PRI BHR 74121146] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2350856,CDM,C1776,CPT,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
PACEMAKER CARD INGENIO TI 2 CHMBR 2 LD CONN BATTERY PWR STRL,SUP-2149153,CDM,C1785,HCPCS,0275,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
CATHETER EP 5FR L115CM 2-2-2 SPC 2MM TIP 1MM BND OCTAPOLAR,SUP-2356877,CDM,C1730,HCPCS,0272,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
PLATE BNE CALCANEAL RT 2 HOLE LCK SM EXTN ALPS MIS,SUP-2423261,CDM,C1713,HCPCS,0278,RC,,,,both,,,2869.33,1865.06,,,,,,,,,,,,,
COIL VASC I-ED COIL L 40 CM DIA 0.014 IN SECONDARY 10 MM,SUP-2865314,CDM,C1889,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
GRAFT BONE SUB 10ML DBM GRFTON,SUP-2281668,CDM,C1713,HCPCS,0278,RC,,,,both,,,2949.72,1917.32,,,,,,,,,,,,,
INSERT FEM STD NK HIP CO CHROM TAPR ENDO II,SUP-2405245,CDM,C1776,CPT,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
MESH HERN W8XL12CM THK1MM EPTFE RECTANG 2 SIDE,SUP-2125740,CDM,C1781,HCPCS,0278,RC,,,,both,,,1104.65,718.02,,,,,,,,,,,,,
MANIFOLD KYPHOPLASTY NDL 10GA 8GM CEM DEL ASST UNIV,SUP-2361480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1543.31,1003.15,,,,,,,,,,,,,
PLATE BONE 16 H BLU STR FOR MICROFIXATION STRNL CLSR,SUP-2414186,CDM,C1713,HCPCS,0278,RC,,,,both,,,2549.68,1657.29,,,,,,,,,,,,,
COMPONENT TOT ANK ANTR OFFSET 1 12 MM 2 MM VIT E APEX 3D,SUP-2742222,CDM,C1776,CPT,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 25 CM DIA 4-7 MM EPTFE CARBON STP N,SUP-2128782,CDM,C1768,CPT,0278,RC,,,,both,,,5513.46,3583.75,,,,,,,,,,,,,
PANEL CERV CLLR L BK FOR VISTA,SUP-2123901,CDM,L0190,HCPCS,0274,RC,,,,both,,,103.75,67.44,,,,,,,,,,,,,
CONNECTOR SPNL TI FOR VAR AXIS SCR AND ROD,SUP-2193307,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BUR SURG DIAMOND 1 MM 9 CM BALL CRV MIDAS REX LEGEND,SUP-2631891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,897.82,583.58,,,,,,,,,,,,,
FLEXI-TIP URETERAL CATHETER,SUP-2826939,CDM,C1758,HCPCS,0278,RC,,,,both,,,37.71,24.51,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP POST TIBIALIS,SUP-2867037,CDM,C1762,CPT,0278,RC,,,,both,,,5273.94,3428.06,,,,,,,,,,,,,
PIN FIX TROCAR PT 1 END 3/16X9 IN 1 PT STYL SMOOTH PLN STRL,SUP-2150448,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.15,12.45,,,,,,,,,,,,,
CAGE SPNL CONVX 17X14X12 MM TI X-CORE MINI,SUP-2559854,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE TIB LT ANTEROLATERAL DSTL 19 HOLE,SUP-2751187,CDM,C1713,HCPCS,0278,RC,,,,both,,,5633.16,3661.55,,,,,,,,,,,,,
SCREW INTRF CANN 12X25 MM 1.5 MM RND HD SFT THRD SOFTSILK,SUP-2878059,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,2580000003,HCPCS,0250,RC,00338-0023-02,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
BRACE CLAV INTO JACKET VEST HALO,SUP-2388153,CDM,L0810,HCPCS,0272,RC,,,,both,,,6444.03,4188.62,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 25 CM OD 5 FR ID 1.7 FR GUIDEWIRE,SUP-2168274,CDM,C1894,HCPCS,0272,RC,,,,both,,,89.14,57.94,,,,,,,,,,,,,
BLADE RETRACTOR CLOWARD 6.75X7 MM CERV ULTRA,SUP-2483556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1859.73,1208.82,,,,,,,,,,,,,
BUR SURG X COARSE DIAMOND 6 MM 9 CM BALL FLUT LG BOR,SUP-2631870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.00,254.80,,,,,,,,,,,,,
COVER BUR H DIA20MM 7 H W/ TAB CNTOUR NONCOMPRESSION LO PROF,SUP-2363634,CDM,C1713,HCPCS,0278,RC,,,,both,,,864.69,562.05,,,,,,,,,,,,,
PLATE BNE LAT LNG 95 MM RT 11 HOLE EVOLVE EPS ORTHOLOC,SUP-2535928,CDM,C1713,HCPCS,0278,RC,,,,both,,,3796.26,2467.57,,,,,,,,,,,,,
SCREW BNE 2.4MM DIA 14MML STAINLES STL CANCELLOU HEXHD FLLY,SUP-2604357,CDM,C1713,HCPCS,0278,RC,,,,both,,,48.32,31.41,,,,,,,,,,,,,
SPHERE GLEN DIA40MM CO CHROM GLENOSPHR,SUP-2265042,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KNIFE SINGLE-PIECE ANNULOTOMY,SUP-2889567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE CALCANEAL DSTL TIB SET PERI-LOC,SUP-2351350,CDM,C1713,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-135448,CDM,J2401,HCPCS,0636,RC,00143-9209-01,NDC,,both,30,ML,183.90,119.53,,,,,,,,,,,,,
PLATE BNE CRV 4.5X439 MM RT CNDYL 22 HOLE VA LCK STRL VALCP,SUP-2789400,CDM,C1713,HCPCS,0278,RC,,,,both,,,9063.14,5891.04,,,,,,,,,,,,,
SCREW BNE SD 3-2.5X60/20 MM CORTICAL STRL SOLE LTX,SUP-2875653,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.11,295.17,,,,,,,,,,,,,
KIT THR HYBRID CEM STEM TRABECULAR MTL CUP VIT E LNR AND,SUP-2212107,CDM,C1776,CPT,0278,RC,,,,both,,,16745.62,10884.65,,,,,,,,,,,,,
RING EXT FIX ID180MM 2/3 W/ FT ADD H FOR SPAT FRME,SUP-2343033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6228.66,4048.63,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 5 CC MAP 3,SUP-2335292,CDM,C1889,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
CANNULA PERF AD 17FR 31.8CM LENGTH FEM ART VENT BIO MEDICUS,SUP-2282866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1150.18,747.62,,,,,,,,,,,,,
HC So Growth Hormone,PX-3018300366,CDM,83003,CPT,0301,RC,,,,both,,,688.00,447.20,,,,,,,,,,,,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,0636,RC,00409-7809-11,NDC,,both,250,ML,90.60,58.89,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 035X150 STD COR CANALIZER,SUP-2120018,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SLEEVE PROTCT LNG TISS REUSE,SUP-2362053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.00,510.90,,,,,,,,,,,,,
TUBE VENT 1.14 MM ARMSTR BVL GRMMT FLUORO-PACIFIC,SUP-2434177,CDM,L8699,HCPCS,0278,RC,,,,both,,,58.18,37.82,,,,,,,,,,,,,
LEAD PACE AD L52CM PERM ATR BPLR J+TINES FIX IS 1 CONN,SUP-2356085,CDM,C1898,HCPCS,0275,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
THIOTEPA 100 MG IJ SOLR,RX-138288,CDM,J9342,HCPCS,0636,RC,72205-0046-01,NDC,,both,1,UN,5368.10,3489.26,,,,,,,,,,,,,
BONE MARROW KIT SM BIO ART BMC,SUP-2163086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5997.40,3898.31,,,,,,,,,,,,,
TUBING ASPIR ZOOM STROKE SOLUTION STRL,SUP-2739215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
PATCH CV IMPRA L 30 X W 30 MM THK 0.6 MM EPTFE RECTANGULAR,SUP-2761260,CDM,C1768,CPT,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
SOTALOL HCL 80 MG PO TABS,RX-11421,CDM,6370000000,HCPCS,0637,RC,68084-0654-01,NDC,,both,1,UN,5.80,3.77,,,,,,,,,,,,,
SHEATH INTRO PRELUDE ROADSTER L 90 CM DIA 6 FR COAT L 35 CM,SUP-2911979,CDM,C1894,HCPCS,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
TUNNELER SURG 17GA L8IN DISP FOR ABD APPRCH UNIV TUNN,SUP-2236791,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
VALVE CSF STD SM RICKHAM-STYLE RESERVOIR HI ULTRAVS,SUP-2666749,CDM,C1889,HCPCS,0278,RC,,,,both,,,3032.49,1971.12,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 15CM 6MM 120CM 6FR HEPARIN,SUP-2396649,CDM,C1874,HCPCS,0278,RC,,,,both,,,12616.52,8200.74,,,,,,,,,,,,,
PIN FIX L 60 MM DIA2.5 MM PROV SM TARGETER SYS STRL EVOS,SUP-2933430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1867.52,1213.89,,,,,,,,,,,,,
ADAPTER PIN HLDR 90DEG FISCHER,SUP-2414034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SUPPORT TENNIS ELBW GEL AIR FRARM CIRC 8-14IN REG,SUP-2324441,CDM,L3702,HCPCS,0274,RC,,,,both,,,31.97,20.78,,,,,,,,,,,,,
PIN EXT FIX HALF L150MM DIA4MM CONT THRD L35MM,SUP-2202029,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
DRAINAGE SET 20 CMX35 CM NEEDLE-FREE EDS EXT SET STRL LF,SUP-2666659,CDM,C1729,HCPCS,0272,RC,,,,both,,,806.04,523.93,,,,,,,,,,,,,
SPACER SPNL W14XH7MM D12MM 7DEG ANT CERV INTBDY FUS INTEGR,SUP-2231372,CDM,C1821,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PLATE FT 170MM FOR TRUELOK FIX SYS,SUP-2316193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PIN REINF L 12 MM LG FOR TIB INSRT STRL,SUP-2929676,CDM,C1776,CPT,0278,RC,,,,both,,,3924.75,2551.09,,,,,,,,,,,,,
PLATE BNE CRV NAR 4.5 MM 18 HOLE SS NS LCP,SUP-2178063,CDM,C1713,HCPCS,0278,RC,,,,both,,,3562.27,2315.48,,,,,,,,,,,,,
OLANZAPINE 5 MG PO TABS,RX-17936,CDM,6370000000,HCPCS,0637,RC,60505-3111-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW CAP FOR HETTICH BUCKET,SUP-2841235,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
PLATE BONE 6X17X6 H LT MAND SEC HMSPHR TI RECON LEIBINGER,SUP-2363753,CDM,C1713,HCPCS,0278,RC,,,,both,,,4880.35,3172.23,,,,,,,,,,,,,
KIT HAD 14.5FR CATH L29CM INSRT L24CM LNG TERM ALPHACURVE,SUP-2127866,CDM,C1750,HCPCS,0278,RC,,,,both,,,1470.46,955.80,,,,,,,,,,,,,
PLATE BNE W24.4XL56.6MM STD R DST DORS VOLAR RAD FAST GUID,SUP-2414023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2938.13,1909.78,,,,,,,,,,,,,
MICROCATHETER GUID TREVO PRO 14 L 157 CM PROX/DSTL OD,SUP-2367794,CDM,C1887,HCPCS,0272,RC,,,,both,,,2195.49,1427.07,,,,,,,,,,,,,
KIT INT FIX DIA29MM INCL DRL GUID AND GUID PIN DISPOSABLE,SUP-2136137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.78,445.76,,,,,,,,,,,,,
ECH STRAIGHT 190MM SZ 20 STD COLLAR,SUP-2822792,CDM,C1776,CPT,0278,RC,,,,both,,,19059.80,12388.87,,,,,,,,,,,,,
SCREW BONE OSTEOTMY CORT FULL THRD N CANN ST N LCK NSTERILE,SUP-2199955,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.26,240.02,,,,,,,,,,,,,
STEM HUM L194MM OD10MM UNIV CO CHROM SHLDR REV CEM PRESSFIT,SUP-2402741,CDM,C1776,CPT,0278,RC,,,,both,,,16045.40,10429.51,,,,,,,,,,,,,
CATHETER DRAINAGE LCK PIG 16 FR,SUP-2381893,CDM,C1729,HCPCS,0272,RC,,,,both,,,57.15,37.15,,,,,,,,,,,,,
SLING GYN TRANSOBTURATOR MID URETH HALO W/ PRECISIONBLUE,SUP-2139453,CDM,C1771,HCPCS,0278,RC,,,,both,,,5561.29,3614.84,,,,,,,,,,,,,
BAG 200 L CAP TISS RETRV,SUP-2330507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.34,442.22,,,,,,,,,,,,,
SCREW BONE 5X40MM BICORTICAL CANN TRNSVRS FT ALTA,SUP-2363418,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.08,308.80,,,,,,,,,,,,,
REAMER SURG M 19MM,SUP-2321576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HANDPIECE PHACO FRAGMENTATION STELLARIS PC LF,SUP-2472660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15429.96,10029.47,,,,,,,,,,,,,
CATHETER DRNAGE 10FR L35CM POLYUR HYDRPHLC W/ LCK PGTL M DRN,SUP-2303557,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
BAND LAPAROSCOPY GASTRIC ADJUSTABLE ACCESS PORT II STERILE LAP-BAND VG,SUP-2119233,CDM,C1889,HCPCS,0278,RC,,,,both,,,9828.20,6388.33,,,,,,,,,,,,,
GUIDEWIRE VASC CHIKAI L 200 CM 0.014IN L 5CM STR DURABLE TIP,SUP-2123855,CDM,C1769,HCPCS,0272,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OPTA LP L 80 CM BALLOON L 20 MM DIA 7 MM,SUP-2156112,CDM,C1725,HCPCS,0272,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
BRACE BACKXSM FOR 25-30IN WAIST HK RECV MAT SFT BRTH LNR ABD,SUP-2194511,CDM,L0625,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE L W135XL62MM THK42MM 3 H BILAT TI NAR RIG NEUT,SUP-2190806,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.45,481.94,,,,,,,,,,,,,
PLATE BNE L79MM 6 H LOK 2 COMPR FOR 3.5MM SCR UNIV LOK SYS,SUP-2411370,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
KNIFE SURG MIKAEEL 10 SCKL STR MOD,SUP-2469981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1121.73,729.12,,,,,,,,,,,,,
PACK GUIDE DRILL MORPHIX 4.5MM SINGLE-USE,SUP-2878757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
K WIRE FIX DIA1.8MM SHT SMOOTH OLV TIP,SUP-2321639,CDM,C1769,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
STENT PANCREATIC ZMMN L 60 MM 7 FR 3.2 MM S-SHAPED SFT ERCP,SUP-2474978,CDM,C1877,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
STAPLE BNE FIX L 18 X W 14 MM TI ALLOY TOE COMPR LCK RAPID,SUP-2893051,CDM,C1713,HCPCS,0278,RC,,,,both,,,9533.04,6196.48,,,,,,,,,,,,,
HEAD HUM H22MM DIA44MM STD SHLDR CO CHROM PRI BPLR BIO MOD,SUP-2404615,CDM,C1776,CPT,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
WEDGE ACF FIB TRAD ALLGRFT 6 MM FRZ DRY,SUP-2294092,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
GUIDEPIN ORTH FLX FOR ACL RECON DISP VERSITOMIC,SUP-2366529,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.09,734.56,,,,,,,,,,,,,
PLATE BNE L246MM 8 H HIP S STL 8 BND CBL RDY,SUP-2410269,CDM,C1713,HCPCS,0278,RC,,,,both,,,2545.97,1654.88,,,,,,,,,,,,,
SCREW CONN 3MM W COCHLEAR W/ ABUTMENT 6MM PREMOUNTED PONTO,SUP-2319891,CDM,C1713,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
BUR SURG RND 6 MM 51 MM FLUT FOR DRL SYS SS,SUP-2628956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,211.26,137.32,,,,,,,,,,,,,
CABLE ELECSURG FT PEDAL ADPT NS LTX,SUP-2859254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1034.35,672.33,,,,,,,,,,,,,
BUR SURG OD7.5MM S STL RND TWO FLUT ELITE SABER SHANK,SUP-2367544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.32,511.11,,,,,,,,,,,,,
KIT PROCEDURE PROSTATEC CRYO ABL 6X CVA2400,SUP-2855081,CDM,C2618,HCPCS,0272,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
RETROGRADE FEMORAL NAIL 11MMX26CM,SUP-2829134,CDM,C1713,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
BIT DRL DIA2MM FAST W/ MINI QUIK CONN DISP FOR HND FRAC SYS,SUP-2412645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 40-5-0.9 MEQ/L-%-% IV SOLN,RX-102352,CDM,2500000003,HCPCS,0250,RC,00338-0807-04,NDC,,both,1000,ML,57.50,37.37,,,,,,,,,,,,,
CONNECTOR SPNL PARA 6.5MM TO 6.5MM,SUP-2228083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
POSTERIOR PILON FUSION PLATE 7H,SUP-2815015,CDM,C1713,HCPCS,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 0.035 IN 120 CM 6X80 MM POLARCATH,SUP-2141212,CDM,C1725,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
STEM SEG LIMB SALV LO BODY CEM STR FLUT ELEOS 32MM,SUP-2314047,CDM,C1776,CPT,0278,RC,,,,both,,,14459.70,9398.80,,,,,,,,,,,,,
ANCHOR SFT TISS FIBERWIRE SZ 2-0 SUTURE POLYESTER STR RC NS,SUP-2882258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|KX|CQ|XU,both,,,144.00,93.60,,,,,,,,,,,,,
TAP SURG CANN FOR 3.5MM SCR REPROC,SUP-2187400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1934.15,1257.20,,,,,,,,,,,,,
HEAD FEMORAL UNIPOLAR 12/14 50MM,SUP-2504171,CDM,C1776,CPT,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP FIXED 35MM,SUP-2749351,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
PLATE BNE SZ 2.6 MM TI MANDIBULAR DBL ANGLE NS DISP,SUP-2934853,CDM,C1713,HCPCS,0278,RC,,,,both,,,63877.02,41520.06,,,,,,,,,,,,,
CATHETER PERITONEAL MED PRESSURE GRAD SLT VLV PUDENZ,SUP-2852592,CDM,C1729,HCPCS,0272,RC,,,,both,,,650.55,422.86,,,,,,,,,,,,,
BLOCK TIB AUG L71MM THK16MM L MED R LAT KNEE TI ALLY CEM,SUP-2405505,CDM,C1776,CPT,0278,RC,,,,both,,,3403.76,2212.44,,,,,,,,,,,,,
ROD SPNL POST RT CVD SMOOTH 3.5MM DIA 60MM LEN,SUP-2317561,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
HC So Magnesium|NOT REASONABLE AND NECESSARY|REPEAT CLINICAL DIAGNOSTIC LABORATORY TEST,PX-3018373566,CDM,83735,CPT,0301,RC,,,GZ|91,both,,,58.00,37.70,,,,,,,,,,,,,
PACEMAKER DR SYS ACCENT,SUP-2356459,CDM,C1785,HCPCS,0275,RC,,,,both,,,16579.20,10776.48,,,,,,,,,,,,,
PLATE EXT FIX 120 DEG 240 MM FEM ARCH CARBON FIBER NS,SUP-2799528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2763.07,1796.00,,,,,,,,,,,,,
HC So1 Alpha Fetoprotein,PX-3018210567,CDM,82105,CPT,0301,RC,,,,outpatient,,,107.00,69.55,,,,,,,,,,,,,
COMPONENT KNEE CEM W/ PSI,SUP-2212346,CDM,C1776,CPT,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
PLATE BNE L 1.5X0.8 MM 10 MM MIDFACE 2X2 HOLE W/ TAB TI NS,SUP-2494977,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.39,597.60,,,,,,,,,,,,,
METHYLPREDNISOLONE 16 MG PO TABS,RX-4992,CDM,J7509,HCPCS,0636,RC,59762-0050-01,NDC,,both,1,UN,12.80,8.32,,,,,,,,,,,,,
HANDLE DRVR REDUC SCR CAP,SUP-2232118,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
CATHETER INFUSION FASTRACKER 325 L 105 CM OD PROX/DSTL,SUP-2147318,CDM,C1887,HCPCS,0272,RC,,,,both,,,1270.88,826.07,,,,,,,,,,,,,
SYSTEM PRT CLOSURE 15 MM SUTURE GUIDE CARTER-THOMASON,SUP-2756022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.29,315.44,,,,,,,,,,,,,
REGULATOR SUCTION ADAPTOR TBNG,SUP-2226272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.62,589.95,,,,,,,,,,,,,
PLATE BNE L 122 X W 122 MM THK 0.75 MM SCREW DIA1.7 MM PLL,SUP-2883166,CDM,C1713,HCPCS,0278,RC,,,,both,,,20441.09,13286.71,,,,,,,,,,,,,
SCREW BNE L 140 MM DIA 6.5 MM TI ST SD CANN FULL THRD RVS,SUP-2900916,CDM,C1713,HCPCS,0278,RC,,,,both,,,1250.44,812.79,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0018IN NIT PLAT TIP FOR COAX INTRO,SUP-2302989,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.69,59.60,,,,,,,,,,,,,
PLATE BONE CRESCENT 2 MM MANDIBULAR 7 HOLE INTERMEDIATE TITA,SUP-2838412,CDM,C1713,HCPCS,0278,RC,,,,both,,,2085.90,1355.83,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM 7FR 4.5MM DACRON D,SUP-2538039,CDM,C1730,HCPCS,0272,RC,,,,both,,,756.55,491.76,,,,,,,,,,,,,
PLATE BONE LOK SHRT 230MML HLX15 PRPLE ST RIGHT MED DST HMRL,SUP-2588209,CDM,C1713,HCPCS,0278,RC,,,,both,,,3373.93,2193.05,,,,,,,,,,,,,
PIN FIX TEMP DIA3.2MM THRD ACCS FOR COMPHSVE TOT SHLDR SYS STNMN,SUP-2411555,CDM,C1713,HCPCS,0278,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
POST EXT FIX 5DEG DSTL RAD KICKSTAND FOR ACU-LOC,SUP-2107133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SPLINT A SPA BALL SP S LF,SUP-2163829,CDM,L3807,HCPCS,0272,RC,,,,both,,,108.33,70.41,,,,,,,,,,,,,
VALVE SPEAK SZ 6 SIL CANN MONT,SUP-2138745,CDM,L8501,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
CITRELOCK XPRESS IMPLANT SYSTEM 6MM X 23MM,SUP-2900572,CDM,C1713,HCPCS,0278,RC,,,,both,,,5127.62,3332.95,,,,,,,,,,,,,
BIT DRL TWST CYL 16 MM STP 15 X 50 MM S STL,SUP-2262748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
PATCH DURAL SUBSTITUTE NON ABSORBABLE POLYURETHANE STERILE C,SUP-2821555,CDM,C1763,HCPCS,0278,RC,,,,both,,,2975.02,1933.76,,,,,,,,,,,,,
SCREW SPNL LCK 6X27 MM NANOMETALENE VU APOD PRIM,SUP-2244815,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
GRAFT HUM TISS W12XL16CM THK18 4MM ACELLULAR DERM MTRX,SUP-2307485,CDM,Q4128,HCPCS,0636,RC,,,,both,,,18390.32,11953.71,,,,,,,,,,,,,
IMPLANT BRST DIA95CM P3CM 125 150CC SIL NACL FILL SHELL RND,SUP-2300541,CDM,C1789,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
IMMOBILIZER SHLDR SM ENV L13IN D7IN POLY COT CLIN SLNG W/,SUP-2196915,CDM,L3650,HCPCS,0272,RC,,,,both,,,12.59,8.18,,,,,,,,,,,,,
CABLE ORTH DIA2MM HIP CO CHROM W/ CLMP ACCORD,SUP-2345204,CDM,C1776,CPT,0278,RC,,,,both,,,1109.05,720.88,,,,,,,,,,,,,
LINER ACET 20 DEG 36X54 MM HIP XLPE R3,SUP-2345001,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SET URET STENT L 55 CM DIA 4 FR KID INT SPLNT FOR,SUP-2171260,CDM,C2625,HCPCS,0278,RC,,,,both,,,302.95,196.92,,,,,,,,,,,,,
KIT ARTHSCP INSTR W/ MTL SPEAR AND DRL DISP FOR 3.5MM,SUP-2121533,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CAGE SPNL H30XL10MM ANT THORLUM INTBDY TI RND PYRAMESH,SUP-2291997,CDM,C1889,HCPCS,0278,RC,,,,both,,,6452.61,4194.20,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP OCCUPATIONAL THERAPY SERV,PX-4409712900,CDM,97129,CPT,0440,RC,,,GO,both,,,186.00,120.90,,,,,,,,,,,,,
COMPONENT FEM CEM 15 DEG STD UNIV UNISX RT PROX CR PRIMARY,SUP-2376508,CDM,C1776,CPT,0278,RC,,,,both,,,12975.11,8433.82,,,,,,,,,,,,,
TI LCP DIA-META VOLAR DISTAL RADIUS PL 11H SHAFT/LT-STERILE,SUP-2546646,CDM,C1713,HCPCS,0278,RC,,,,both,,,5548.41,3606.47,,,,,,,,,,,,,
PLATE 14HL 2.7X113,SUP-2471359,CDM,C1713,HCPCS,0278,RC,,,,both,,,1376.48,894.71,,,,,,,,,,,,,
FIXATION STPL 19X18X18MM,SUP-2401354,CDM,C1713,HCPCS,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
SCREW BNE 35MM X 12MM S STL SURFIT INTEGRA TOT WRST FUS SYS,SUP-2243407,CDM,C1713,HCPCS,0278,RC,,,,both,,,1159.29,753.54,,,,,,,,,,,,,
WIRE FIX L100MM DIA125MM S STL THRD DBL SHRP TIP FOR MINI,SUP-2186880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.41,820.57,,,,,,,,,,,,,
PLATE BNE L 28.2 X W 7 MM THK 0.6 MM SCREW DIA1.5 MM 2 H LNG,SUP-2936535,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
PLATE BNE CALCANEAL 4X96 MM REG LT LAT SS STRL,SUP-2495463,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.23,928.35,,,,,,,,,,,,,
MARKER BRST BX FOR 11GA MAMTOM PRB MAMMOMARK2 11,SUP-2195639,CDM,A4648,CPT,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
PLATE BNE SM TI MEDL MALL PEG NS UNITE,SUP-2897724,CDM,C1713,HCPCS,0278,RC,,,,both,,,4392.86,2855.36,,,,,,,,,,,,,
PLATE BNE STR MED 1.5X28X0.8 MM MIDFACE 6 HOLE W/ TAB TI NS,SUP-2471286,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.81,326.83,,,,,,,,,,,,,
RESORB X TEMPLATE MANDIBULAR FORMING DEVICE,SUP-2679364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1173.61,762.85,,,,,,,,,,,,,
GUIDEWIRE MOVABLE COR W/ STR TIP STD .035INX150CM GUIDERIGHT,SUP-2355317,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
TEMPLATE SURG SM W6XL16MM 0DEG IM CHT FIX SYS ANG SZ NIT,SUP-2194206,CDM,C1776,CPT,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
STIMULATOR NERVE 8 CHANNEL GEN,SUP-2355962,CDM,C1767,HCPCS,0278,RC,,,,both,,,33896.30,22032.59,,,,,,,,,,,,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-143501,CDM,6370000000,HCPCS,0637,RC,75907-0023-11,NDC,,both,1,UN,59.70,38.80,,,,,,,,,,,,,
BIT DRL J NOTCH 1.5X115 MM TWST MORRISON STYL DISP,SUP-2422297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.60,388.44,,,,,,,,,,,,,
SCREW SPNL 3.5 MM DIAM,SUP-2415759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
CONN PL W/THD ED 5HLS 135,SUP-2818042,CDM,C1713,HCPCS,0278,RC,,,,both,,,2049.82,1332.38,,,,,,,,,,,,,
WIRE FIX THRD 1.6X150 MM KIRSCHNER,SUP-2316487,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
SCREW BNE L40MM DIA4.5MM PROX FEM S STL ST LOK FULL THRD,SUP-2350245,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.79,855.26,,,,,,,,,,,,,
"HC Inj Proc Nfrosgrm/Urtrgrm, Complete",PX-3615043100,CDM,50431,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PIN KUNTSCH FEM GUID W/O FLAG 2.8MM DIA - 2.8MM DIAM,SUP-2362262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
FORCEPS SURG L7 3 4IN DBL ACT CUT BLDE JANSEN STRUYCKEN,SUP-2161536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,905.58,588.63,,,,,,,,,,,,,
INTRA-AORTIC PUMP KIT ADPT 7.5 FR 40 CC BLLN CATH LINEAR,SUP-2525609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.31,1653.15,,,,,,,,,,,,,
BLADE REPROC CUTTER RESECT FORUMLA 3.5MM,SUP-2653123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63.90,41.53,,,,,,,,,,,,,
ALLOGRAFT BNE FLOWABLE 5 CC OSTEOAMP,SUP-2731798,CDM,C1776,CPT,0278,RC,,,,both,,,5268.67,3424.64,,,,,,,,,,,,,
BRACE ANK SM H875IN L SEMI RIG ANATOMICALLY DESIGNED SHELL,SUP-2196369,CDM,L4350,HCPCS,0272,RC,,,,both,,,61.80,40.17,,,,,,,,,,,,,
BLOCK TIB AUG REV 7 5 MM RL/LM KNEE BKRS,SUP-2434287,CDM,C1776,CPT,0278,RC,,,,both,,,2788.32,1812.41,,,,,,,,,,,,,
HC Dexa Axial Skeleton,PX-3207708000,CDM,77080,CPT,0320,RC,,,,outpatient,,,541.00,351.65,,,,,,,,,,,,,
HC Clotting Inhibitors Antithrombin III Activity,PX-3058530000,CDM,85300,CPT,0305,RC,,,,both,,,496.00,322.40,,,,,,,,,,,,,
CABLE VENT ASST DEV L EXTN DRIVELINE HEARTWARE,SUP-2282531,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
BASKET STONE HELCL 2.5 FR 16 MMX120 CM 4 WIR W/ TIP NIT STRL,SUP-2769751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1039.12,675.43,,,,,,,,,,,,,
SETS W/ ECHOGENIC TIP NDL ANGIODYNAMICS 4.0F MIC ACC SET,SUP-2116526,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV UNIV CONTACT CLOSURE NYL PROCARE,SUP-2196992,CDM,L3650,HCPCS,0274,RC,,,,both,,,21.76,14.14,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 25X25 MM FD PERIO FASC LATA ORAGRAFT,SUP-2741085,CDM,C1762,CPT,0278,RC,,,,both,,,349.95,227.47,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX70 CM STD WALL SM BEAD EPTFE CARBOFLO,SUP-2761477,CDM,C1768,CPT,0278,RC,,,,both,,,3413.87,2219.02,,,,,,,,,,,,,
CANNULA LAP VERY LO PROF 3.5 MMX15 CM N THRD SMOOTH GRN,SUP-2767466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,810.31,526.70,,,,,,,,,,,,,
BLOCK CUT SZ 3 TIB L MED CT APPRCH NONSTERILE MYKNEE,SUP-2267758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC DEMINERALIZED CORTICAL BNE FIBER,SUP-2933347,CDM,C1762,CPT,0278,RC,,,,both,,,837.69,544.50,,,,,,,,,,,,,
PLATE BONE L THK1.5MM RT TI MEDL CLMN ARCH GORILLA,SUP-2321509,CDM,C1713,HCPCS,0278,RC,,,,both,,,6583.01,4278.96,,,,,,,,,,,,,
PLATE BONE L26MM 5X3 H S STL RAD HD ELBW POLYAX LCK LO PROF,SUP-2397934,CDM,C1713,HCPCS,0278,RC,,,,both,,,4810.48,3126.81,,,,,,,,,,,,,
CATHETER DRAINAGE 5 FRX15 CM 51IN SAFETY SPIN-LOCK ACCEL,SUP-2659273,CDM,C1729,HCPCS,0272,RC,,,,both,,,104.09,67.66,,,,,,,,,,,,,
BLADE SAW DISP OXFORD,SUP-2408667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 120 DEG L 150 CM OD,SUP-2383138,CDM,C1887,HCPCS,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
ROD SPNL L40MM DIA5.5MM R POST TI PRECUT CNTOUR SMOOTH CRV,SUP-2289823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.62,667.30,,,,,,,,,,,,,
STEM HUM CEM 132.5 DEG 200 MM LEN PRI LT 7 MM DIAM FX TI,SUP-2223297,CDM,C1776,CPT,0278,RC,,,,both,,,16786.44,10911.19,,,,,,,,,,,,,
RING PESSARY 6 3.25 IN W/ SUPP SIL,SUP-2171734,CDM,A4562,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
KIT INTRO VSI DE-CLOT SHTH L 4 CM DIA 5 FR GUIDEWIRE L 40 CM,SUP-2763460,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
TUBE GAST JEJU 14FR L15CM STOMA L1.5CM G GRN TECHNOLOGY LO,SUP-2119813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.14,1124.59,,,,,,,,,,,,,
NEEDLE SURG TONSIL 30 DEG 23 GAX13 MM ANGLED LL,SUP-2484855,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.55,100.46,,,,,,,,,,,,,
BLADE SAW L 85 MM L 27 MM THK MATERIAL 0.4 MM CUT 0.6 MM,SUP-2929252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,572.39,372.05,,,,,,,,,,,,,
MIXER BNE CEM MINI SMARTMIX,SUP-2253059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
ROD X MEDULLARY PROX TIB UP ATTUNE,SUP-2454754,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
KNIFE 3722022 FLAP 2X5MM BLADE,SUP-2702664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.80,287.82,,,,,,,,,,,,,
PLATE BNE L W10.1XL252MM THK3.5MM 18 H BILAT S STL STR RIG,SUP-2186229,CDM,C1713,HCPCS,0278,RC,,,,both,,,2148.92,1396.80,,,,,,,,,,,,,
GRAFT BNE 10 CC CELLULAR BNE MTRX OSSEOGEN,SUP-2858501,CDM,C1713,HCPCS,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 10CM X 12.5CM,SUP-2874122,CDM,A2007,HCPCS,0636,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BIT DRL L 173 MM DIA 3.8 MM SLD FOR A.L.P.S. PLATING SYS,SUP-2882084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,949.85,617.40,,,,,,,,,,,,,
HEAD HUM H15MM DIA44MM SHLDR CO CHROM PRI BIO MOD STD NK,SUP-2404613,CDM,C1776,CPT,0278,RC,,,,both,,,4688.02,3047.21,,,,,,,,,,,,,
TRAY CTRL VEN CATH 3FR 20GA L5CM TIP L2MM 0.018IN POLY STR J,SUP-2167946,CDM,C1751,HCPCS,0278,RC,,,,both,,,172.07,111.85,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA IR 3FR 55CM PED 1 S3173355P,SUP-2632836,CDM,C1751,HCPCS,0278,RC,,,,both,,,445.53,289.59,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CROME VR MRI SURESCAN W 51 X H 66 MM D 13,SUP-2665354,CDM,C1722,HCPCS,0275,RC,,,,both,,,31079.72,20201.82,,,,,,,,,,,,,
MARKER BRST BX 17GA L10CM BIODUR 108 INDEPENDENTLY THRU A 864017D] BARD PERIPHERAL VASCULAR],SUP-2127914,CDM,A4648,CPT,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
GRAFT EVAR MAIN BODY L90MM DIA28MM LIMB L30MM DIA20MM IL,SUP-2217661,CDM,C1768,CPT,0278,RC,,,,both,,,34524.30,22440.79,,,,,,,,,,,,,
ALLOGRAFT BNE PROX TIB DSTL HUM FRZN LT W/ PAT QUADRICEP,SUP-2717964,CDM,C1762,CPT,0278,RC,,,,both,,,25386.90,16501.48,,,,,,,,,,,,,
GRAFT BNE 25CC DBM CRUSH MIX PREHYDRATED TENSIX,SUP-2400563,CDM,C1713,HCPCS,0278,RC,,,,both,,,3733.46,2426.75,,,,,,,,,,,,,
BUR SURG LNG 3X20 MM MICA DISP,SUP-2398174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
HC Drainage of Eyelid Abscess,PX-4506770000,CDM,67700,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
STEM FEM SZ 15 L150MM HIP CO CHROM STD OFFSET CEMENTLESS,SUP-2344546,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SCREW FIX L200MM DIA5MM S STL BLNT TRCR PNT MR CONDITIONAL,SUP-2186957,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.60,174.59,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 4.5X170/196 MM 3 FLUTED STERILE TC1,SUP-2837040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1583.82,1029.48,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 10MM KNEE REV FULL STP LEGION,SUP-2346592,CDM,C1776,CPT,0278,RC,,,,both,,,4603.24,2992.11,,,,,,,,,,,,,
PLATE BONE 6X24X6 H BILAT TI DBL ANG RIG NONCOMPRESSION,SUP-2191424,CDM,C1713,HCPCS,0278,RC,,,,both,,,14054.64,9135.52,,,,,,,,,,,,,
WASHER ORTH DIA 3.5 MM CORTICAL ELBW LP STRL DISP A.L.P.S.,SUP-2885053,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.08,189.20,,,,,,,,,,,,,
PIN DRL 12 PIN STRL DISP,SUP-2420173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2890.37,1878.74,,,,,,,,,,,,,
STAPLE INT L13XW11MM S STL COMPR INTERAXIS NONSTERILE IMPL,SUP-2243118,CDM,C1776,CPT,0278,RC,,,,both,,,2983.57,1939.32,,,,,,,,,,,,,
PLATE SPNL ANTR CSPN TI,SUP-2280000,CDM,C1713,HCPCS,0278,RC,,,,both,,,3143.14,2043.04,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 5CC CB DBM PUTTY STIMUBLAST,SUP-2120749,CDM,C1713,HCPCS,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
CATHETER NEPHSTMY L27CM DIA12FR LOK LOOP W/ FADER TIP,SUP-2139314,CDM,C1729,HCPCS,0272,RC,,,,both,,,308.85,200.75,,,,,,,,,,,,,
PPICC PROV PED 3F SLEEVE DELTA,SUP-2613521,CDM,C1751,HCPCS,0278,RC,,,,both,,,735.67,478.19,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH PREMOLDED LONGITUDINAL,SUP-2435706,CDM,L3060,HCPCS,0274,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
BUTTON GAST 18FR STOMA L3.4CM OBT ANTIREFLX VLV NONBLLN,SUP-2125954,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
COMPONENT TALAR DOMED 1 LT FT ANK SLOPED XT,SUP-2244192,CDM,C1776,CPT,0278,RC,,,,both,,,33252.60,21614.19,,,,,,,,,,,,,
BODY FEM SZ 16.5 STD L DST TEXT APR,SUP-2210919,CDM,C1776,CPT,0278,RC,,,,both,,,28228.60,18348.59,,,,,,,,,,,,,
OSTEOTOME SMITH PETERSON CRV 6MM 21CM,SUP-2161288,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.43,193.98,,,,,,,,,,,,,
CATHETER NEPHSTMY 26FR MALECOTS DRNGE 4 WNG DISP,SUP-2129076,CDM,C2627,HCPCS,0272,RC,,,,both,,,83.08,54.00,,,,,,,,,,,,,
PACEMAKER CARD EDORA SR-T W 40 X H 48 MM D 6.5 MM 10 CC 21,SUP-2138477,CDM,C1786,HCPCS,0275,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
MESH SURG ELLIP 7X9 IN W/ FEN PORCINE COLLAMEND FM,SUP-2126253,CDM,C1763,HCPCS,0278,RC,,,,both,,,14217.61,9241.45,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRIMARY POLYETH,SUP-2365629,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC TYP S HD CUSTOMIZABLE WIDE UNIFRAME SYS,SUP-2220714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
MESH SURG W4XL4CM SCAFFOLD DERM ACELLULAR CLLGN MTRX BOV,SUP-2243716,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
BIT DRILL 6.4MM DIA 203MML STRGHT SHANK FLTD JACOB CHUCK END 6PK,SUP-2501028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1138.44,739.99,,,,,,,,,,,,,
SCREW BNE L80MM DIA7.3MM THRD L32MM TI CANN PARTIALLY,SUP-2190165,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.17,439.51,,,,,,,,,,,,,
MICROCATHETER DIAG DIREXION HI FLO L 105 CM DIA,SUP-2652836,CDM,C1887,HCPCS,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
CATHETER CV TY 7 FRX15 CM 3L CUTLMY701JABRMCUSTOM0014,SUP-2759904,CDM,C1751,HCPCS,0278,RC,,,,both,,,510.31,331.70,,,,,,,,,,,,,
GRAFT HUM TISS W1.5XL2CM THK35UN AMNIO MEMBRN DEHYDR SGL,SUP-2247193,CDM,V2790,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
STERILIZATION SET SPARE HUM AIMING BLOCK,SUP-2469831,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PLATE BNE LCK 142 MM LT DSTL LAT TIB PERIARTICULAR 10 HOLE,SUP-2474840,CDM,C1713,HCPCS,0278,RC,,,,both,,,4388.18,2852.32,,,,,,,,,,,,,
RESERVOIR SHUNT L16MM OD20MM TITANIUM SET INTEGRATED L600MM,SUP-2830494,CDM,C1889,HCPCS,0278,RC,,,,both,,,1543.37,1003.19,,,,,,,,,,,,,
CATHETER HEMODIALYSI TRI FLO ACTE 11.5FR DIA 20CM PCED TAPR,SUP-2610638,CDM,C1752,HCPCS,0278,RC,,,,both,,,122.49,79.62,,,,,,,,,,,,,
KIT PROCEDURE ISSUMISITE CATHETER 45,SUP-2741798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5413.36,3518.68,,,,,,,,,,,,,
PLATE BONE W10XL63MM THK1.5MM 3X4 H BILAT S STL T SHP OBLQ,SUP-2185886,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.76,545.19,,,,,,,,,,,,,
TENSIONER SURG STRNL FOR CABLE STRL DISP STERNALOCK XP,SUP-2894320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
ROD RMR L950MM DIA3MM NONSTERILE TI STR BALL TIP FOR IM,SUP-2188115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.99,240.49,,,,,,,,,,,,,
SIZER VLV SZ 31/33/35 MM LG AORT 2 KT DISP AVNEO,SUP-2895324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3749.16,2436.95,,,,,,,,,,,,,
DRILL SURG 24X33MM PROX SL CANN,SUP-2400090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BNE 4.5MM ANAT REPLICATOR O/S EQUINOXE,SUP-2223285,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BNE 5 H STD R VOLAR DST RAD TI,SUP-2122808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
BIOPSY KIT BNE LESION 11 GAX10 CM 12 GAX14.8 CM TREK,SUP-2754746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
STEM FEM 14X30MM CEM ATTUNE,SUP-2251473,CDM,C1776,CPT,0278,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
CATHETER THORACENTESIS SET 14 FRX30 CM PNEUMOTHORAX SIMP,SUP-2760075,CDM,C1729,HCPCS,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
HC Mra Chest W/O Contrast,PX-6107155501,CDM,C8910,CPT,0610,RC,,,,both,,,4146.00,2694.90,,,,,,,,,,,,,
SALVATION L BRKT NEW GEN,SUP-2401141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
PLATE BONE L25MM 6 H TI GAP FOR CRAN CLSR SYS,SUP-2243974,CDM,C1713,HCPCS,0278,RC,,,,both,,,355.89,231.33,,,,,,,,,,,,,
SCREW BONE CANN HDLSS 4MMX48MM EXTREMIX,SUP-2319487,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
GRAFT SURG W7.5XL11IN RECT ANTIBACT COAT REGEN CLLGN MTRX,SUP-2125840,CDM,C1781,HCPCS,0278,RC,,,,both,,,57955.61,37671.15,,,,,,,,,,,,,
POST EXT FIX 3 HOLE W/ THRD ATTCH,SUP-2749945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
CATHETERIZATION KIT 7 FRX20 CM 3L,SUP-2383967,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.01,286.01,,,,,,,,,,,,,
BEAM ANK FUS L165MM DIA7MM 11MM PROX SALVATION,SUP-2400803,CDM,C1713,HCPCS,0278,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
BUR SURG L77MM DIA2MM XLN S STL DMND RND NONFLUTED INDIGO,SUP-2284189,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.21,292.64,,,,,,,,,,,,,
BOOT WALKING SURG,SUP-2265017,CDM,L3260,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
BEARING TIB KNEE COMP KINEMATIC,SUP-2376287,CDM,C1776,CPT,0278,RC,,,,both,,,6834.68,4442.54,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S9294108D,SUP-2632877,CDM,C1751,HCPCS,0278,RC,,,,both,,,702.76,456.79,,,,,,,,,,,,,
MICROSPHERE EMB 120-240UM ORNG VYN ACETT METH ACRYLATE VI,SUP-2303490,CDM,C1889,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
STEM HUM SZ 1 L137MM DIA10MM STD SHLDR CO CHROM HA CEM,SUP-2250980,CDM,C1776,CPT,0278,RC,,,,both,,,9853.32,6404.66,,,,,,,,,,,,,
LENGTHENER EXT FIX VERTICAL AXIS MINIRAIL,SUP-2316440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3259.70,2118.80,,,,,,,,,,,,,
APPLIER CLP L4.375IN STD STR FOR PHYNOX YASRG,SUP-2108330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4831.36,3140.38,,,,,,,,,,,,,
DART SURG L30MM DIA25MM 10DEG PEEK PIP,SUP-2121833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
BAG SPEC LAP 9X7.5 IN 12 MM 1500 CC MEM WIRE CANN NYL,SUP-2166300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,173.67,112.89,,,,,,,,,,,,,
GRAFT HUM TISS 5MM CERV PARA MAINTAIN,SUP-2232316,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
BRACE ORTHOSIS SPNL SM M EXOS FRM II 626,SUP-2196545,CDM,L0641,HCPCS,0274,RC,,,,both,,,244.64,159.02,,,,,,,,,,,,,
NARROW PLATE 4.5MM 14X231MM,SUP-2818811,CDM,C1713,HCPCS,0278,RC,,,,both,,,2558.47,1663.01,,,,,,,,,,,,,
CATHETER NEPHSTMY L35CM OD14FR LCK PGTL M-DRAIN,SUP-2303559,CDM,C1729,HCPCS,0272,RC,,,,both,,,40.85,26.55,,,,,,,,,,,,,
INSERT HUM REVERSED 7.5 DEG 42X+9 MM SHLDR RETENTIVE TI,SUP-2421801,CDM,C1776,CPT,0278,RC,,,,both,,,5270.49,3425.82,,,,,,,,,,,,,
HC Antinuclear Antibodies Ana,PX-3028603800,CDM,86038,CPT,0302,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),RX-40850049,CDM,2580000003,HCPCS,0258,RC,00338-0553-11,NDC,,both,50,ML,61.70,40.10,,,,,,,,,,,,,
HEAD FEM 0+ 36 MM HIP CERM BIOLOX DELT,SUP-2390425,CDM,C1776,CPT,0278,RC,,,,both,,,8116.90,5275.98,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 4FR 20CM 2 LUMAN S4254108BD,SUP-2632864,CDM,C1751,HCPCS,0278,RC,,,,both,,,611.14,397.24,,,,,,,,,,,,,
GUIDEWIRE ORTH ANGLED PROP 3 MM FOR 3.5 MM PLATE,SUP-2644637,CDM,C1769,HCPCS,0272,RC,,,,both,,,1017.08,661.10,,,,,,,,,,,,,
GRAFT HUM TISS 3X8CM AMNION CYGNUS MAX,SUP-2393051,CDM,Q4170,HCPCS,0636,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-112653,CDM,J1953,HCPCS,0636,RC,67457-0266-10,NDC,,both,100,ML,163.90,106.53,,,,,,,,,,,,,
GRAFT BNE L50MM W20-24MM THICKNESS 5-30MM ILIUM TRICORT,SUP-2307165,CDM,C1713,HCPCS,0278,RC,,,,both,,,4895.26,3181.92,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 4 MM EPTFE STR STD WALL,SUP-2681083,CDM,C1768,CPT,0278,RC,,,,both,,,1337.70,869.50,,,,,,,,,,,,,
STENT VASC 3.5-4.5X8 MM ANEUR NK T SHP RECON DEV PULSERIDER,SUP-2248964,CDM,C1876,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
CATHETER HD SET 15 FRX23 CM DL RETROGRADE ACCS VECTORFLOW,SUP-2762973,CDM,C1750,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CLIP ENDOSCP 7 FRX230 CM 2.8 MM INSTINCT,SUP-2858585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
INSERT SYS 12 10DEG DURATN P3 28MM,SUP-2376145,CDM,C1776,CPT,0278,RC,,,,both,,,2004.11,1302.67,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 14X14X14 MM FD SPNG CANC READIGRAFT BLX,SUP-2740885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1791.34,1164.37,,,,,,,,,,,,,
GRAFT VASC 6 MMX70 CM MINI CUF BYPS FLX SM BEAD DISTAFLO,SUP-2432023,CDM,C1768,CPT,0278,RC,,,,both,,,7238.49,4705.02,,,,,,,,,,,,,
LEAD PACE POLYUR ENDOCARD RT ATR J+ EXT RETRACTABLE SCREW,SUP-2140090,CDM,C1883,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GRAFT TEND ANTR TIBIALIS HUM TISS 8.5MMX250ML,SUP-2257909,CDM,C1762,CPT,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
SHEATH INTRO CHARIOT L 90 CM DIA 8 FR STR TIP XCUT LG LUMEN,SUP-2140081,CDM,C1894,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
KIT SOFT TISSUE FIXATION TACTILE ACCESS AND EZ SAWITCH PORTA,SUP-2824688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
PLATE BNE L 83 MM SCREW DIA2.7/3.5 MM 5 H SS RT OLECRANS,SUP-2931222,CDM,C1713,HCPCS,0278,RC,,,,both,,,5392.64,3505.22,,,,,,,,,,,,,
COMPONENT FEM AP55MM ML65MM POLYETH BEAD CRUCE RET DURAC,SUP-2377033,CDM,C1776,CPT,0278,RC,,,,both,,,6007.51,3904.88,,,,,,,,,,,,,
COMPONENT FEM 8X2MM OFFSET UNICAP,SUP-2123703,CDM,C1776,CPT,0278,RC,,,,both,,,16271.48,10576.46,,,,,,,,,,,,,
SHEATH INTRO ACCEL L 20 CM DIA 6 FR L 60 CM DIA 21 GA SS,SUP-2659243,CDM,C1894,HCPCS,0272,RC,,,,both,,,226.52,147.24,,,,,,,,,,,,,
BIT DRL DIA35MM NONSTERILE FOR MULT AX CORR SYS MAXFRAME,SUP-2176978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
IMPLANT TOE L16MM 0DEG PROX INTERPHALANGEAL NIT NEUT 1 PC,SUP-2379129,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
MODEL ANAT MANDIBULAR 3D CT BASE OSTEOVIEW,SUP-2883586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3661.55,2380.01,,,,,,,,,,,,,
"HC So1 Amino Acids, 6 or < Ea Spec",PX-3018213967,CDM,82139,CPT,0301,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
PLATE 3D PROFYLE 3 X 2 HL 23MM,SUP-2702852,CDM,C1713,HCPCS,0278,RC,,,,both,,,1486.63,966.31,,,,,,,,,,,,,
SPACER SPNL 10X16MM 7 DEG 10MM H COALITION AGX R,SUP-2231101,CDM,C1821,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
BASKET SPEC RETRV 1.2 MM 286 CM 1 MM DIR VIS SPYGLS,SUP-2419081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1641.53,1066.99,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0250,RC,00264-1800-32,NDC,,both,250,ML,57.40,37.31,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING STRTCH 6MM DIA 20CM LEN GORTX,SUP-2396000,CDM,C1768,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4409753000,CDM,97530,CPT,0440,RC,,,CO|XU,both,,,191.00,124.15,,,,,,,,,,,,,
MORCELLATOR ENDOSCP BPLR DURABLE FOR PK G400 GENRTR PKS,SUP-2313950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS BK ALIGNABLE SYS,SUP-2388219,CDM,L5910,HCPCS,0274,RC,,,,both,,,958.74,623.18,,,,,,,,,,,,,
ELECTRODE RESECT 24FR WIRE 02IN,SUP-2313575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1692.46,1100.10,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 280 MM DIA15 MM DEL SHTH 49ML,SUP-2937085,CDM,C1713,HCPCS,0278,RC,,,,both,,,15778.50,10256.02,,,,,,,,,,,,,
PLATE BONE L155MM 11 H LT DSTL LAT FIBULAR VAR ANG LCK FOR,SUP-2349831,CDM,C1713,HCPCS,0278,RC,,,,both,,,6837.82,4444.58,,,,,,,,,,,,,
NEURO MD SCREW 15MM DIA X 4MM TI 6AL 4V TITANIUM ALLOY,SUP-2677102,CDM,C1713,HCPCS,0278,RC,,,,both,,,192.64,125.22,,,,,,,,,,,,,
DESMOPRESSIN ACETATE PF 4 MCG/ML IJ SOLN,RX-153915,CDM,J2597,HCPCS,0636,RC,69918-0899-10,NDC,,both,0.25,ML,54.70,35.55,,,,,,,,,,,,,
DEXAMETHASONE 0.5 MG PO TABS,RX-2322,CDM,J8540,HCPCS,0636,RC,00054-4179-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 118MML HLX9 STNLSS STEEL CNTRD S,SUP-2588603,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM RT VA LCK COMPR TI STRL VALCP,SUP-2789618,CDM,C1713,HCPCS,0278,RC,,,,both,,,3737.48,2429.36,,,,,,,,,,,,,
SUP MED CLAV LCK PL 10H RIGHT SMP,SUP-2818688,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.45,1532.34,,,,,,,,,,,,,
DEVICE FLTR INT LUMN 50/200UM GLAUCOMA P MOD EX-PRESS,SUP-2109669,CDM,C1783,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
LENS INTOCU +28.5 DIOPT L13MM DIA5.5MM D3.39MM 0.5DEG,SUP-2110854,CDM,V2630,CPT,0276,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HC Place Xrt Guide Percu-Thoracic,PX-3613255300,CDM,32553,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE 3.5MM TI LCP EXTRA-ARTICLR DSTL HUM 14H/LT 302MM-STER,SUP-2546627,CDM,C1713,HCPCS,0278,RC,,,,both,,,6326.88,4112.47,,,,,,,,,,,,,
PEG BONE L14MM DIA3.5MM ANK FT ANTI ROT,SUP-2321067,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
PIN FIX L9IN DIA9/64IN S STL DBL END TRCR PT FULL THRD TYP,SUP-2342684,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.36,231.63,,,,,,,,,,,,,
KIT BNE CEM 8CC CA PHSPTE MACROPOROUS INJ 2 CHAMBERED SYR,SUP-2120762,CDM,C1713,HCPCS,0278,RC,,,,both,,,5637.87,3664.62,,,,,,,,,,,,,
SCREW BNE L22MM DIA3.5MM CORT FOR VERSANAIL UNIV HUM,SUP-2412538,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA16 MM EPTFE STR STD WALL,SUP-2396221,CDM,C1768,CPT,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
KIT INTRO ARW FLX SHTH L 10 CM DIA 8.5 FR POLYUR INTEGR,SUP-2763349,CDM,C1892,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
CARBIDOPA-LEVODOPA 25-100 MG PO TABS,RX-9407,CDM,6370000000,HCPCS,0637,RC,00904-7501-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHEATH URET ACCS DIL 6 12FR OD14FR ID12FR L38CM PTFE LN,SUP-2312758,CDM,C1894,HCPCS,0272,RC,,,,both,,,448.77,291.70,,,,,,,,,,,,,
GUIDEWIRE VASC MIRACLEBROS 4.5 L 300 CM DIA 0.014 IN,SUP-2123728,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT TEND ACHILLES W/ STRUT 200MML,SUP-2137245,CDM,C1776,CPT,0278,RC,,,,both,,,4802.63,3121.71,,,,,,,,,,,,,
PLATE 3.5MM TI CURVED NARROW LCP 14 HOLE-STERILE,SUP-2546920,CDM,C1713,HCPCS,0278,RC,,,,both,,,2693.52,1750.79,,,,,,,,,,,,,
PEG BONE FXTN 2.5MM DIA 30MML CBLT CHRMM DST RDL VOLAR PRTLL,SUP-2589000,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
BATTERY VENT ASST L PT WAIST PK,SUP-2282573,CDM,Q0498,HCPCS,0274,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
IMPLANT EAR RT BRN BONE ANCHORED AD UNILAT W/ SLEEPER BAHA,SUP-2165009,CDM,L8614,HCPCS,0278,RC,,,,both,,,14428.30,9378.39,,,,,,,,,,,,,
POUCH PIN TUBERCLE STRL,SUP-2223542,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE BONE L52MM 4 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349636,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.34,619.67,,,,,,,,,,,,,
CALIPER SURG FEM,SUP-2437564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2416.23,1570.55,,,,,,,,,,,,,
KIT PLT RATIO DISPNS KT 2IN CANN TIP SPRY TIP DISP MAGELLAN,SUP-2120693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
DARIFENACIN HYDROBROMIDE ER 15 MG PO TB24,RX-40403,CDM,6370000000,HCPCS,0637,RC,33342-0277-07,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
KIT MIDLN 20GA L10CM FLO RATE 5ML/SEC MIDLN PWR INJ FULL TY,SUP-2125666,CDM,C1751,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
NAIL ORTH DUMMY,SUP-2563945,CDM,C1713,HCPCS,0278,RC,,,,both,,,1457.78,947.56,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 14FRX30CM SHTH W/ L LUMN 0.038,SUP-2355552,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.59,41.33,,,,,,,,,,,,,
HC Assay of Sex Hormone Binding Globulin,PX-3018427000,CDM,84270,CPT,0301,RC,,,,outpatient,,,465.00,302.25,,,,,,,,,,,,,
STEM VERSYS CEM/REV/CALCAR 13X170MM,SUP-2504507,CDM,C1776,CPT,0278,RC,,,,both,,,11366.80,7388.42,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR PULSE SENZA OMNIA,SUP-2719958,CDM,C1822,CPT,0278,RC,,,,both,,,60251.58,39163.53,,,,,,,,,,,,,
HC Atomic Absrpj Spectroscopy Ea Analyte,PX-3008219066,CDM,82190,CPT,0300,RC,,,,outpatient,,,526.00,341.90,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 5MM L MED R LAT KNEE HEMI STP SCR ON,SUP-2346178,CDM,C1776,CPT,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 95 X 58 X 4.5 MM POLYETHYL CRAN STRL,SUP-2935409,CDM,C1713,HCPCS,0278,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED 28D/32E/32F INSRT ALUM TRIDENT,SUP-2364444,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
SCREW BNE COMRESSION 2.7X16 MM STRL RE+LINE,SUP-2458038,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.78,293.01,,,,,,,,,,,,,
KNIFE SURG BALLENGER SWVL 8 IN 5 MM BAYNT SHP,SUP-2469584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,521.68,339.09,,,,,,,,,,,,,
BOLT EXT FIX CLMP 2 PC FOR SCHNZ SCREW NS,SUP-2799565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.00,455.00,,,,,,,,,,,,,
HEAD HUM H19MM OD56MM SHLDR OFFSET BIGLIANI FLATOW,SUP-2199051,CDM,C1776,CPT,0278,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
HEAD FEM OD44MM +0 NK 12/14 TAPR MTL ON POLY CO CHROM PRI,SUP-2204807,CDM,C1776,CPT,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
CATHETER CV SET 032 10 FRX20 CM 11 GA 5 LUMEN QUINT,SUP-2759730,CDM,C1751,HCPCS,0278,RC,,,,both,,,421.58,274.03,,,,,,,,,,,,,
GRAFT FEM SHFT ALLGRFT FRZN GREATER THAN 11.0CM,SUP-2165574,CDM,C1762,CPT,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
ANTERIOR ANKLE FUSION PLATE SLIM LEFT,SUP-2604351,CDM,C1713,HCPCS,0278,RC,,,,both,,,7287.94,4737.16,,,,,,,,,,,,,
IODINE STRONG 5 % PO SOLN,RX-3961,CDM,6370000000,HCPCS,0637,RC,48433-0230-15,NDC,,both,14,ML,167.60,108.94,,,,,,,,,,,,,
POST EXT FIX 3 H FOR SIDEKCK FREE CIR FIX M,SUP-2400684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
HC So Zonisamide Level,PX-3018020366,CDM,80203,CPT,0301,RC,,,,both,,,92.00,59.80,,,,,,,,,,,,,
PLATE ULNA 2.5 8 HOLES,SUP-2713863,CDM,C1713,HCPCS,0278,RC,,,,both,,,3255.55,2116.11,,,,,,,,,,,,,
ENDCAP ORTH 8.2X5 MM FEM T40 STARDRV TI TAN DK PUR STRL,SUP-2546391,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.15,377.10,,,,,,,,,,,,,
HC So Delta Aminolevulinic Acid,PX-3018213566,CDM,82135,CPT,0301,RC,,,,inpatient,,,520.00,338.00,,,,,,,,,,,,,
HC So Flt3 Gene Analysis,PX-3108124666,CDM,81246,CPT,0310,RC,,,,both,,,110.00,71.50,,,,,,,,,,,,,
DRESSING BIO L 3.76 X W 3.76 CM PORCINE CLLGN PHMB CROSS,SUP-2909403,CDM,Q4196,HCPCS,0636,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV 4FR 55CM 2 LUMAN RVS TAP 1274108,SUP-2632634,CDM,C1751,HCPCS,0278,RC,,,,both,,,797.62,518.45,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 2 4.5X0.875X1 IN GRN SPEC,SUP-2149971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,142.21,92.44,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.035IN TIP 2.5CM RAD 1.5MM PTFE,SUP-2167599,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.63,34.86,,,,,,,,,,,,,
BIT DRILL NON QUICK COUPLING 3.2X165/180 MM JACOBS CHUCK END,SUP-2837047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1184.82,770.13,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST ABDUCTN BAR JOINTED ADJ,SUP-2435658,CDM,L2300,HCPCS,0272,RC,,,,both,,,712.75,463.29,,,,,,,,,,,,,
IMPLANT BRST 560CC DIA13.4-13.1CM P5.7-7.3CM COHESIVE I SIL,SUP-2300321,CDM,C1789,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
"HC So West Nile Ab, Igm",PX-3028678866,CDM,86788,CPT,0302,RC,,,,outpatient,,,49.00,31.85,,,,,,,,,,,,,
PLATE HOLDING FORCEPS WITH SWIVEL FOOT/SIZE 2,SUP-2548917,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.85,2144.25,,,,,,,,,,,,,
BRUSH CYTO W2.1MMXL200CM CATH 8FR 0.035IN BILI DUCT MTL TB,SUP-2149564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.55,220.06,,,,,,,,,,,,,
IMPLANT HUM TISS LT PAT BNE,SUP-2884887,CDM,C1762,CPT,0278,RC,,,,both,,,38465.00,25002.25,,,,,,,,,,,,,
GRAFT BIO W2.5XL2.5CM FOR OTO REP BIODESIGN,SUP-2170501,CDM,C1763,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PUTTY T50101 GRFT DBF 1CC,SUP-2417486,CDM,C9359,HCPCS,0278,RC,,,,both,,,1002.29,651.49,,,,,,,,,,,,,
COMPLETION REV FEM AP BLCK STD,SUP-2513649,CDM,C1776,CPT,0278,RC,,,,both,,,7523.44,4890.24,,,,,,,,,,,,,
PLATE EXT FIX 90 DEG 240 MM FEM ARCH CARBON FIBER NS,SUP-2799527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2609.18,1695.97,,,,,,,,,,,,,
ROD SPNL PREBENT 5.5X95 MM,SUP-2256250,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
IMPLANT BIO L 7 X W 20 CM FISH SKIN DERMAL FEN 11 INTACT,SUP-2909250,CDM,Q4158,HCPCS,0636,RC,,,,both,,,13627.60,8857.94,,,,,,,,,,,,,
PIN EXT FIX L85MM OD5MM TI CIR HALF HEX FIX RANCHO,SUP-2342567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.30,661.24,,,,,,,,,,,,,
PLATE BONE 8 H ORBIT CRANIOMAXILLOFACIAL CVD FOR 1MM SCR,SUP-2402921,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
BIT DRL OD3.4MM CANN ANK FOR IOFIX + SYS,SUP-2223749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
COLLAR CERV CNTOUR LG 22.5X4.5 IN 15-20 IN MED FOAM PROCARE,SUP-2196862,CDM,L0180,HCPCS,0274,RC,,,,both,,,9.01,5.86,,,,,,,,,,,,,
BIT DRL TWST 1.5X22 MM 9 MM W/ STP DENT LATCH LEVEL 1 DISP,SUP-2459583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.70,290.35,,,,,,,,,,,,,
KIT INTRO S-MAK L 10 CM DIA 5 FR GUIDEWIRE L 40 CM PLAT TIP,SUP-2740507,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.35,38.58,,,,,,,,,,,,,
SET INTRO 10FR CATH 8FR L70X30CM FOR RG AG URET ACC,SUP-2168949,CDM,C1894,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
DEVICE FIX HERN STATTACK,SUP-2165306,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH L 13 CM DIA 8 FR GUIDEWIRE 0.038 IN,SUP-2137992,CDM,C1892,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 4 FRX23 CM GUIDEWIRE PRELUDE,SUP-2303263,CDM,C1894,HCPCS,0272,RC,,,,both,,,41.64,27.07,,,,,,,,,,,,,
COMPONENT GLEN KEELED 3XL SHLDR AEQUALIS ASCEND FLX,SUP-2715528,CDM,C1776,CPT,0278,RC,,,,both,,,6276.86,4079.96,,,,,,,,,,,,,
PI PICC: 2-L 5FRX50CM WITH 80CM HYDRO NI,SUP-2826702,CDM,C1751,HCPCS,0278,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
CATHETER CV DL 5 FR PWR INJ N COAT CT COMPATIBLE POWERPICC,SUP-2126707,CDM,C1751,HCPCS,0278,RC,,,,both,,,549.78,357.36,,,,,,,,,,,,,
PLATE BONE L290MM 10 H TI CVD CBL SUPERCBL,SUP-2262263,CDM,C1713,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 30 CM DIA 7 MM EPTFE CARBON STR N,SUP-2761539,CDM,C1768,CPT,0278,RC,,,,both,,,1971.64,1281.57,,,,,,,,,,,,,
PLATE BNE CRANIOMAXILLOFACIAL THK06MM 6 H STR PROF MIDFACE,SUP-2262675,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.81,326.83,,,,,,,,,,,,,
AXOGUARD NERVE CAP 6MMX20MM,SUP-2885543,CDM,C1763,HCPCS,0278,RC,,,,both,,,7507.74,4880.03,,,,,,,,,,,,,
MESH HERN W6XL13.5CM SYNTH ABD N ABSRB PRESHAPED KEYHOLE,SUP-2265908,CDM,C1781,HCPCS,0278,RC,,,,both,,,130.18,84.62,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 55 CM OD 7 FR ID 2.54 MM DIL 56.5,SUP-2169824,CDM,C1894,HCPCS,0272,RC,,,,both,,,181.81,118.18,,,,,,,,,,,,,
ELECTRODE KIT ENSITE PRECIS,SUP-2357587,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SUTR ANCH AR1902SF1,SUP-2843743,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
BLADE RTRCTR 1 1/2NW X 3 1/4ND STNLSS STEEL GRRTT JARIT LATE,SUP-2457803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,767.26,498.72,,,,,,,,,,,,,
PLATE BNE L65MM 3 H NONSTERILE R POSTEROLAT DST HUM S STL,SUP-2185899,CDM,C1713,HCPCS,0278,RC,,,,both,,,2641.74,1717.13,,,,,,,,,,,,,
GRAFT EVAR L150MM DIA44X40MM PROX DST THOR C DSGN VALIANT,SUP-2281717,CDM,C1768,CPT,0278,RC,,,,both,,,54871.50,35666.47,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-40840053,CDM,J3490,HCPCS,0250,RC,00338-0043-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
WIRE GUIDE.FLEXIBLE.F/27090A,SUP-2574042,CDM,C1769,HCPCS,0272,RC,,,,both,,,104.06,67.64,,,,,,,,,,,,,
PLATE BONE L 4X4 H MAND TI ANG FOR 2MM SCR FIX LCKING SYS,SUP-2191241,CDM,C1713,HCPCS,0278,RC,,,,both,,,4374.02,2843.11,,,,,,,,,,,,,
SYSTEM EXTR BG 6500ML RNG DIA17CM CONTAINED W/ GELPOINT MINI,SUP-2119766,CDM,C1713,HCPCS,0278,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
PLATE BNE W11XL194MM THK3.7MM 10 H NONSTERILE R MED DST TIB,SUP-2185590,CDM,C1713,HCPCS,0278,RC,,,,both,,,4550.33,2957.71,,,,,,,,,,,,,
COMPONENT PART KNEE CAPPED K1 RESURF CAPARTHROSFK1] ARTHROSURFACE],SUP-2123630,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
BLADE RETRACTOR ABH 3X1 IN RENAL ALUM,SUP-2458343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1330.10,864.56,,,,,,,,,,,,,
SLEEVE FEM OFFSET 4 MM LG TI HIP REV FOR CERAMYS CHOICE,SUP-2929687,CDM,C1776,CPT,0278,RC,,,,both,,,418.88,272.27,,,,,,,,,,,,,
STEM FEM SZ 0 STD UNIV + HIP,SUP-2351177,CDM,C1776,CPT,0278,RC,,,,both,,,5768.18,3749.32,,,,,,,,,,,,,
PLUG VASC AMPLATZER II L 10 MM DIA14 MM DEL SYS L 135 CM,SUP-2116309,CDM,C1889,HCPCS,0278,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
CEMENT BNE SM 4ML CA PHSPTE VOID FILL INJ RESRB,SUP-2293453,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
HEAD FEM DIA28MM +0MM OFFSET 14/16 TAPR CO CHROM MTL ON,SUP-2249722,CDM,C1776,CPT,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0002,SUP-2759794,CDM,C1751,HCPCS,0278,RC,,,,both,,,444.62,289.00,,,,,,,,,,,,,
GRAFT BONE PUTTY 10CC GRFTON,SUP-2319848,CDM,C9359,HCPCS,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
GRAFT BNE CRUSH 1-10 MM 60 CC CANC,SUP-2766763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2987.08,1941.60,,,,,,,,,,,,,
HEAD FEM DIA32MM +5MM OFFSET 10/12 TAPR CO CHROM SKIRTED,SUP-2253276,CDM,C1776,CPT,0278,RC,,,,both,,,2071.14,1346.24,,,,,,,,,,,,,
PLATE BNE RECON 3.5X130 MM 10 HOLE LCK LP SS NS,SUP-2184030,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.47,1514.16,,,,,,,,,,,,,
MESH SURG SYN UNCOATED MFIL POLYFORM MACROPOROUS POLYPR,SUP-2139414,CDM,C1781,HCPCS,0278,RC,,,,both,,,1468.42,954.47,,,,,,,,,,,,,
WASHER ORTH THRD 10 MM 4.5 MM FOR CANN SCR TI NS,SUP-2190558,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.42,52.92,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H LNG TI NEURO STR PLT 12 PK,SUP-2935689,CDM,C1713,HCPCS,0278,RC,,,,both,,,15159.92,9853.95,,,,,,,,,,,,,
ALLOGRAFT GRAFTLINK: D=9.5 L=79 MM,SUP-2815865,CDM,C1762,CPT,0278,RC,,,,both,,,6895.44,4482.04,,,,,,,,,,,,,
BLADE SURG SAW GRFT HARV S STL ACL 20MM LEN 8.0MM W,SUP-2236515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
ATTACHMENT POSER 360DEG ARTC STBL FOR POS THE APEX OF THE,SUP-2385709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1620.87,1053.57,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 FT IR 5FR 55CM 2 LUM 3295335F,SUP-2632677,CDM,C1751,HCPCS,0278,RC,,,,both,,,323.29,210.14,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 101 X 85 X 19 MM LG POLYETHYL RT,SUP-2934175,CDM,C1713,HCPCS,0278,RC,,,,both,,,6710.18,4361.62,,,,,,,,,,,,,
BLADE SAW L8IN AMP CHARRIERE,SUP-2161343,CDM,C1713,HCPCS,0278,RC,,,,both,,,783.12,509.03,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK TOT CONTACT,SUP-2388207,CDM,L5637,HCPCS,0274,RC,,,,both,,,894.59,581.48,,,,,,,,,,,,,
NIMODIPINE 30 MG PO CAPS,RX-10722,CDM,6370000000,HCPCS,0637,RC,69452-0209-07,NDC,,both,1,UN,13.00,8.45,,,,,,,,,,,,,
PLATE BONE W14.9XL88MM THK1.2MM 5 H DSTL TIB S STL SCALLOPED,SUP-2185734,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.76,584.19,,,,,,,,,,,,,
KIT ARTHSCP INCLUDE 1.1MM MINI TIGHTROPE ANCHR S STL 2.6MM,SUP-2122787,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
IMPLANT BRST SIL SIENTRA SMOOTH RND MOD PROJCT 350CC,SUP-2264567,CDM,C1789,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
CATHETER CV DL 5 FRX50 CM MAXIMAL BARR W/ VPS STYL,SUP-2120613,CDM,C1751,HCPCS,0278,RC,,,,both,,,886.89,576.48,,,,,,,,,,,,,
STAPLER ROBOT SURG SEAMGRD INTUITIVE SUREFORM 60 ENDOSCP BLK,SUP-2762591,CDM,C1768,CPT,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
NAIL IM L 90 CM DIA13 MM TI RT FEM AG KNEE FUSION STRL,SUP-2933174,CDM,C1713,HCPCS,0278,RC,,,,both,,,8711.15,5662.25,,,,,,,,,,,,,
PLATE BONE L48MM 6 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348295,CDM,C1713,HCPCS,0278,RC,,,,both,,,4827.59,3137.93,,,,,,,,,,,,,
WASHER ORTH REDUCTION WIRE 7 MM SLT,SUP-2749889,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
AMPICILLIN SODIUM 2000 MG IJ SOLR (MIXTURES ONLY),RX-430021,CDM,J0290,HCPCS,0636,RC,00781-9408-95,NDC,,both,1,UN,77.10,50.11,,,,,,,,,,,,,
SCREW BNE ST 2X6 MM CRTX COARSE PITCH TI GLD NS,SUP-2189662,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.69,162.30,,,,,,,,,,,,,
STEM SPLINE 12.0X170MM STRAIGHT,SUP-2505070,CDM,C1776,CPT,0278,RC,,,,both,,,9646.08,6269.95,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA10 MM EPTFE STR STD WALL,SUP-2695224,CDM,C1768,CPT,0278,RC,,,,both,,,1337.70,869.50,,,,,,,,,,,,,
CATHETER PERFSN L 32 CM DIA14 FR BLLN 18 MM POLYUR,SUP-2881193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,309.26,201.02,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 260 CM 0.035IN 11CM 75/15MM DBL,SUP-2170505,CDM,C1769,HCPCS,0272,RC,,,,both,,,673.84,438.00,,,,,,,,,,,,,
GUIDEWIRE ORTH OD2.4MM DRL TIP W/O EYELET DISP,SUP-2341124,CDM,C1769,HCPCS,0272,RC,,,,both,,,205.45,133.54,,,,,,,,,,,,,
BASEPLATE TIB STD UNIV PRI STEM PRESSFIT POR PUR SZ A 58MM,SUP-2199510,CDM,C1776,CPT,0278,RC,,,,both,,,14524.38,9440.85,,,,,,,,,,,,,
SEATING CHISEL FOR ADULT ANGLED BLADE PLATES 320MM,SUP-2548620,CDM,C1713,HCPCS,0278,RC,,,,both,,,2280.64,1482.42,,,,,,,,,,,,,
PLATE BNE W10XL17MM 7 H TI HUM OVL BTTN,SUP-2418464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1135.11,737.82,,,,,,,,,,,,,
BALLOON EUSTACHIAN TUBE L 16 MM DIA 6 MM PLAS AD ATRAUM TIP,SUP-2902104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3280.20,2132.13,,,,,,,,,,,,,
SCREW BNE SELF RET MIC 1.5X3.5 MM MXLFCL X DRV DRILL-FREE TI,SUP-2497000,CDM,C1713,HCPCS,0278,RC,,,,both,,,179.86,116.91,,,,,,,,,,,,,
SCREW BNE CONN SHT CANN FOR TIB NAIL NS,SUP-2799671,CDM,C1713,HCPCS,0278,RC,,,,both,,,1568.78,1019.71,,,,,,,,,,,,,
CATHETER SUPP QUICK-CROSS L 90 CM 4FR 0.044/0.03 IN 0.018 IN,SUP-2823683,CDM,C1887,HCPCS,0272,RC,,,,both,,,501.52,325.99,,,,,,,,,,,,,
BENDER ROD RT CORONAL PLANE,SUP-2232094,CDM,2780000010,LOCAL,0278,RC,,,,both,,,3702.06,2406.34,,,,,,,,,,,,,
HEAD HUM 38X21X38 MM SHLDR TI COMPHSVE VERSA-DIAL,SUP-2450141,CDM,C1776,CPT,0278,RC,,,,both,,,5708.52,3710.54,,,,,,,,,,,,,
ANCHOR SUT WHT BLU W/ 1.3MM SUTTAPE FIBERTAK,SUP-2121775,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
CUP HUM DIA36MM +2MM OFFSET LT SHLDR CAP COAT UNIVERS,SUP-2123336,CDM,C1776,CPT,0278,RC,,,,both,,,4420.27,2873.18,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 1.5X300 MM STERNAL 30 HOLE TITANIUM,SUP-2842223,CDM,C1713,HCPCS,0278,RC,,,,both,,,7863.35,5111.18,,,,,,,,,,,,,
KIT INSTR CAPITAL FRAG CTRL GUIDE STRL DISP MINIBUNION,SUP-2893288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
HC Doppler Echo,PX-4839332000,CDM,93320,CPT,0483,RC,,,,both,,,2133.00,1386.45,,,,,,,,,,,,,
SPACER SPNL H14MM PEEK OPTMA POST LUM INTBDY FUS ESL,SUP-2415500,CDM,C1821,HCPCS,0278,RC,,,,both,,,12625.94,8206.86,,,,,,,,,,,,,
SCREW BONE LOCKING 2.7MM DIA 18MML CONICAL STERILE,SUP-2588215,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.71,148.01,,,,,,,,,,,,,
RING ALUMINUM 6 TAB 160MM,SUP-2853243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCREW BNE L12MM DIA5MM NONSTERILE UNICORTICAL TI ST,SUP-2181299,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.42,413.67,,,,,,,,,,,,,
MESH SURG W8XL10IN UNCOATED MFIL POLYPR ABSRB HYDRGEL LO,SUP-2125910,CDM,C1781,HCPCS,0278,RC,,,,both,,,3623.56,2355.31,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X2 CM TERMINALLY STRL WND NEOX CRD RT,SUP-2648696,CDM,Q4148,HCPCS,0636,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
UB BLADE BIG BOY 3IN 6 1/2IN,SUP-2674155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2393.59,1555.83,,,,,,,,,,,,,
PLATE BONE L147MM 8 H S STL T SHP,SUP-2198575,CDM,C1713,HCPCS,0278,RC,,,,both,,,664.74,432.08,,,,,,,,,,,,,
BRACE WRISTXL L8IN RT FOAM LOOP LCK CLSR W/ THMB SPICA,SUP-2324354,CDM,L3931,HCPCS,0272,RC,,,,both,,,70.68,45.94,,,,,,,,,,,,,
SHEATH URO L55CM ID12FR HYDRPHLC URIN TRACT URET ACCS FLX,SUP-2171319,CDM,C1894,HCPCS,0272,RC,,,,both,,,444.62,289.00,,,,,,,,,,,,,
PROSTHESIS VOICE LO PRESSURE 16 FRX22 MM BLOM-SINGER,SUP-2242433,CDM,L8507,HCPCS,0274,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
SEGMENT FEM OD21MM 5DEG SM TRAPEZOIDAL FLARE COMP SCR FORGED,SUP-2222171,CDM,C1776,CPT,0278,RC,,,,both,,,6004.94,3903.21,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X46X1-2 MM 6 HOLE BSSO C LCK FOR 8 MM BRG,SUP-2464459,CDM,C1713,HCPCS,0278,RC,,,,both,,,1897.31,1233.25,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X20 MM WRST TI STRL FRDM,SUP-2851949,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.49,521.62,,,,,,,,,,,,,
SCREW BNE L6MM DIA1.5MM CRANIOMAXILLOFACIAL NEURO ST LO,SUP-2366089,CDM,C1713,HCPCS,0278,RC,,,,both,,,163.06,105.99,,,,,,,,,,,,,
SET SHEATH INTRO PGTL 180 CM 45 DEG 8.5 FRX63 CM STD VERSACROSS W/CONN CBL,SUP-2516361,CDM,C1893,HCPCS,0272,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
CATHETER DIAG 2.4X1.7FR L150CM ID0.0165IN 45DEG MIC,SUP-2367862,CDM,C1887,HCPCS,0272,RC,,,,both,,,8286.46,5386.20,,,,,,,,,,,,,
BRUSH ES OD18GA CRD CRV,SUP-2110003,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
KIT CATH 20GA L5IN POLYUR W/ INTEGR SUT WNG 0.025X13.75IN,SUP-2383271,CDM,C1751,HCPCS,0278,RC,,,,both,,,85.41,55.52,,,,,,,,,,,,,
BALLOON EXTR DIA8.5X10X12X15MM CATH 6.6FR L200CM ACC CHN,SUP-2170588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 25X0.6 MM TRIANG PLLA-PGA STRL RESORB XG,SUP-2472559,CDM,C1713,HCPCS,0278,RC,,,,both,,,2537.43,1649.33,,,,,,,,,,,,,
DRILL TWST 1.6MM DIA 4.5INL 2.0/2.3MM SCR DENT SHFT END,SUP-2366421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.04,332.18,,,,,,,,,,,,,
BUSHING EXT FIX FOR SALVATION EXT FIX,SUP-2401147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
SALVATION LIN DISTRACTOR,SUP-2401140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
STRAP CLAV STD L,SUP-2276600,CDM,L3650,HCPCS,0272,RC,,,,both,,,14.19,9.22,,,,,,,,,,,,,
STRAP CLAV SELF-ADJSTBLE L,SUP-2195528,CDM,L3650,HCPCS,0272,RC,,,,both,,,21.38,13.90,,,,,,,,,,,,,
BUR SURG DIAMOND COARSE 3 MMX10 CM BALL SM BOR LEGEND,SUP-2627613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.89,214.43,,,,,,,,,,,,,
FILTER VASC 6FR INTRO 3MM TEMP NICKEL TI EMBOSHIELD,SUP-2240287,CDM,C1884,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
ABUTMENT SNAP COUPLING 5.5MM,SUP-2858176,CDM,L8690,HCPCS,0278,RC,,,,both,,,4357.28,2832.23,,,,,,,,,,,,,
CATHETER PERITONEAL OPN END 90 CM W/ SLT BA IMPREG,SUP-2851431,CDM,C1729,HCPCS,0272,RC,,,,both,,,540.61,351.40,,,,,,,,,,,,,
CUTTER CLP PROCTOLOGY OTSC,SUP-2881867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
SCREW BONE L18MM D2.5MM HEX DRVR D1.5MM MGNTA SELF TPPNG CNN,SUP-2478550,CDM,C1713,HCPCS,0278,RC,,,,both,,,1053.85,685.00,,,,,,,,,,,,,
BUR SURG L72MM OD5MM LNG RND DMND NONFLUTED S STL ST,SUP-2284212,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.51,307.78,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X50X0.8 MM RAPID RESORBABLE STER,SUP-2838578,CDM,C1713,HCPCS,0278,RC,,,,both,,,5288.39,3437.45,,,,,,,,,,,,,
Z DISCONTINUED USE 2753109 KIT PRB 17GA L75MM COOLED RF NONSURGICAL MINIMALLY INVASIVE,SUP-2236751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
TIP EXTR FOR 2-2.5MM STRIPPED SCR HD,SUP-2337698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
GRAFT VASC GELSFT L 30 CM DIA14 MM POLYESTER GEL ABD PERIPH,SUP-2384958,CDM,C1768,CPT,0278,RC,,,,both,,,1028.63,668.61,,,,,,,,,,,,,
PSN REV TM TIB CENTRAL CONE FIX TIB,SUP-2508664,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
ASSEMBLY FRME 180MM FOR EXT FIX SYS SALVATION 2,SUP-2401161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,26410.54,17166.85,,,,,,,,,,,,,
INSERT KNEE DIA35MM PAT,SUP-2165966,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
DEVICE BRST IMPL TISS EXP W/ 7.7CM PROJCT,SUP-2300523,CDM,C1789,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
CUP ACET CMNTLS FEM HIP PREMIER STEM POROUS,SUP-2379161,CDM,C1776,CPT,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
PLATE PROX TIB 3.5MM 6H RT STRL,SUP-2547547,CDM,C1713,HCPCS,0278,RC,,,,both,,,4238.62,2755.10,,,,,,,,,,,,,
COMPONENT FEM 7X3MM OFFSET UNICAP,SUP-2123702,CDM,C1776,CPT,0278,RC,,,,both,,,17427.00,11327.55,,,,,,,,,,,,,
ALLOGRAFT BNE 20X50X4 MM MOLD SCAFFOLD DBM FUSIONFLEX,SUP-2759531,CDM,C1713,HCPCS,0278,RC,,,,both,,,9370.55,6090.86,,,,,,,,,,,,,
HC So Histamine,PX-3018308866,CDM,83088,CPT,0301,RC,,,,both,,,138.00,89.70,,,,,,,,,,,,,
SET INTRODUCER BREAST BIOPSY 9GA 12CML LOCALIZATION W/PETIT,SUP-2240022,CDM,C1894,HCPCS,0272,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 7 FRX15 CM 3L STD,SUP-2759917,CDM,C1751,HCPCS,0278,RC,,,,both,,,369.67,240.29,,,,,,,,,,,,,
SCREW BNE L45MM DIA5MM TI THRD LO PROF,SUP-2316343,CDM,C1713,HCPCS,0278,RC,,,,both,,,688.10,447.26,,,,,,,,,,,,,
BLADE SAW W10XL70MM THK1.19MM RECIP CEM PK FOR SYNTHES PWR,SUP-2136840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1214.40,789.36,,,,,,,,,,,,,
PLATE BNE T 4.5X116 MM 6 HOLE TI NS LCP,SUP-2569055,CDM,C1713,HCPCS,0278,RC,,,,both,,,2216.15,1440.50,,,,,,,,,,,,,
PIN EXT FIX HALF LNG 6X180 MM 25 MM THRD TIN SIDEKCK FRDM,SUP-2851273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
COIL VASC I-ED COIL L 20 CM DIA 0.012 IN SECONDARY 6 MM,SUP-2865310,CDM,C1889,HCPCS,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
BUR SURG BORING TOOL 9.5MMDIA 10.4MML FOR TPS MIDAS REX,SUP-2363377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.12,160.63,,,,,,,,,,,,,
CUBE EXT FIX POST 1 H THRD ATTACH NS DISP MONK RING,SUP-2899072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.17,443.41,,,,,,,,,,,,,
CATHETER ABLATN STD 7 FRX110 CM 2.5X8 MM INTELLANAV MIFI XP,SUP-2141337,CDM,C1732,HCPCS,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
STAPLE BNE FIX W13XL10MM NIT W/ INSTR LO PROF COMPRESSIVE,SUP-2122343,CDM,C1713,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
SET SCR SPNL M6 PEDCL TI ALLOY FUS FOR DYN STBL SYS DYNESYS,SUP-2414260,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.63,612.71,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IN-LINE BACTISEAL CATH CERTAS +,SUP-2666576,CDM,C1889,HCPCS,0278,RC,,,,both,,,15765.06,10247.29,,,,,,,,,,,,,
SPACER SPNL 8 DEG 22X8X8 MM HEDRON P,SUP-2763887,CDM,C1889,HCPCS,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
BOLOGNA SMPHSS DSTRCTR INCLDNG ACTVTNG WIRE 15MM DISTR T 6L,SUP-2669807,CDM,C1713,HCPCS,0278,RC,,,,both,,,9201.55,5981.01,,,,,,,,,,,,,
MESH SURG W9XL13CM POLY HYDRPHLC 2D FLAT SHT PARIETEX,SUP-2174771,CDM,C1781,HCPCS,0278,RC,,,,both,,,235.66,153.18,,,,,,,,,,,,,
NEEDLE BX 20GA L15CM COAX TEMNO,SUP-2133830,CDM,C1713,HCPCS,0278,RC,,,,both,,,698.84,454.25,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 40DEG M4 ROT CRV SHFT TIP ROHS RAD,SUP-2284146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.66,786.93,,,,,,,,,,,,,
WIRE FIX L229MM DIA1.6MM S STL 7 DMND PNT TWO END BAYNT TIP,SUP-2412984,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.66,51.13,,,,,,,,,,,,,
BASKET STONE REMV L45CM L24CM OD22CM ODSEC12FR NIT BILI,SUP-2168101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.62,764.15,,,,,,,,,,,,,
HC Thrmbc/Nfs Dialysis Circuit,PX-3613690400,CDM,36904,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
SCREW BONE L10MM OD3.5MM STD CORT ST LO PROF,SUP-2343754,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.77,24.55,,,,,,,,,,,,,
SYSTEM PACEMKR 23FR L105CM TRANSCATHETER MICRA,SUP-2281167,CDM,C1786,HCPCS,0275,RC,,,,both,,,60602.00,39391.30,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INVENTRA HF-T W 58.5 X H 65 MM D 12.5 MM,SUP-2138468,CDM,C1882,HCPCS,0275,RC,,,,both,,,86114.50,55974.42,,,,,,,,,,,,,
BODY HUM +10MM OFFSET PROX ELBW TI POR MOSAIC,SUP-2403497,CDM,C1776,CPT,0278,RC,,,,both,,,11580.32,7527.21,,,,,,,,,,,,,
HC Lower Xtr Fascial Plane Block Uni Injection,PX-3606447300,CDM,64473,CPT,0360,RC,,,,both,,,1238.00,804.70,,,,,,,,,,,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,0636,RC,00781-3114-95,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CATHETER EMB L 40 CM DIA 6 FR 1 LUMEN HIGHLY RUPTURE RESIST,SUP-2264181,CDM,C1757,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
CAGE SPNL L16XW16XH15MM 4 LOBE MESH NGAGE,SUP-2317742,CDM,C1889,HCPCS,0278,RC,,,,both,,,7909.66,5141.28,,,,,,,,,,,,,
FEEDING TUBE KIT LP 12 FRX0.8 CM BUTTON MINI 1 LF,SUP-2754596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.03,276.27,,,,,,,,,,,,,
PLATE BNE L37MM 6 H TI LAT MED REARFOOT LOK COMPR RECON RPS,SUP-2399637,CDM,C1713,HCPCS,0278,RC,,,,both,,,2584.22,1679.74,,,,,,,,,,,,,
PLATE BNE COMPR 2.7X84X2.5 MM 10 HOLE,SUP-2424219,CDM,C1713,HCPCS,0278,RC,,,,both,,,610.64,396.92,,,,,,,,,,,,,
CARTRIDGE MENIS REP SZ 2-0 SUT NOVOSTITCH +,SUP-2419748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1794.26,1166.27,,,,,,,,,,,,,
SCREW SPNL L30MM DIA6MM CANC SACR TI POLYAX NONCANNULATED,SUP-2254428,CDM,C1713,HCPCS,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 154 MM DIA 30 MM NIT POLYPRO,SUP-2751297,CDM,C1874,HCPCS,0278,RC,,,,both,,,33073.81,21497.98,,,,,,,,,,,,,
COMPONENT TALAR DOMED 5 LT RT TOT ANK INBONE,SUP-2850352,CDM,C1776,CPT,0278,RC,,,,both,,,8503.12,5527.03,,,,,,,,,,,,,
LEAD PACE ATTAIN ABIL + MRI SURESCAN L 78 CM DIA 5.3 FR SIL,SUP-2281927,CDM,C1900,HCPCS,0275,RC,,,,both,,,3818.24,2481.86,,,,,,,,,,,,,
HC So2 Ptt / Thromboplastin Subs,PX-3058573268,CDM,85732,CPT,0305,RC,,,,both,,,11.00,7.15,,,,,,,,,,,,,
BIT DRILL LONG 4.5MM QC,SUP-2818686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,944.20,613.73,,,,,,,,,,,,,
PLATE BNE L 75 MM SCREW DIA2 MM HD 2 SHFT 10 H SS TINE SLV,SUP-2905644,CDM,C1713,HCPCS,0278,RC,,,,both,,,3031.61,1970.55,,,,,,,,,,,,,
STRAP CLAV XS STD MTL TOOTH BCKL,SUP-2428779,CDM,L3650,HCPCS,0274,RC,,,,both,,,23.17,15.06,,,,,,,,,,,,,
COUPLER FLO DIA2.5MM 20MHZ DOPP,SUP-2382621,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
KIT INSTR BONE TEND DISP,SUP-2137212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1893.42,1230.72,,,,,,,,,,,,,
HEAD FEM DIA28MM NK L+8MM CO CHROM V40 TAPR PRI LFIT,SUP-2364467,CDM,C1776,CPT,0278,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
HOFFMANN XPRESS 5 HOLE PIN CLAMP 2 POST,SUP-2488105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SCREW BONE L12MM DIA2.7MM CORT DSTL RAD LCK FULL THRD SQ DRV,SUP-2136254,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
SODIUM THIOSULFATE 250 MG/ML IV SOLN,RX-156090,CDM,J0209,HCPCS,0636,RC,60267-0705-50,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L70MM OD4MM THRD L20MM CORT OSTEOTITE HA COAT,SUP-2316320,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.39,266.10,,,,,,,,,,,,,
CATHETER HAD L40CM INSRT L23CM 2 LUMN PERMCATH,SUP-2283904,CDM,C1750,HCPCS,0278,RC,,,,both,,,539.45,350.64,,,,,,,,,,,,,
SHEARS ENDOSCP CRV FOR DA VINCI S HARM,SUP-2246580,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CATH 7/110/2.5/7-4 QUAD STD,SUP-2424678,CDM,C1732,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 3.5X166 MM 14 HOLE FOR SCREW STERI,SUP-2836657,CDM,C1713,HCPCS,0278,RC,,,,both,,,4203.20,2732.08,,,,,,,,,,,,,
CATHETER GUID 8FR 0.090IN COR NYL STD JL4 L LUMN FLX RADPQ,SUP-2296413,CDM,C1887,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
GRAFT BNE WDG 100X10-12 MM FIB PUROS,SUP-2335233,CDM,C1713,HCPCS,0278,RC,,,,both,,,10713.68,6963.89,,,,,,,,,,,,,
TREPHINE ORTH DIA5MM CRWN DRL FOR UNIV SCR EXTR,SUP-2368626,CDM,C1713,HCPCS,0278,RC,,,,both,,,2240.39,1456.25,,,,,,,,,,,,,
BOLT EXT FIX OFFSET WIRE MR CONDITIONAL FOR DISTR,SUP-2179132,CDM,C1713,HCPCS,0278,RC,,,,both,,,136.15,88.50,,,,,,,,,,,,,
SCREW INTFR L23MM DIA7MM BIOCRYL RAPIDE ABSRB MILAGRO ADV,SUP-2249508,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
CPT REVISION CENTRALIZER,SUP-2507460,CDM,C1776,CPT,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
SCREW BONE PARTIAL THREADED 4.5X34 MM 12 MM SHAFT LARGE FRAG,SUP-2837080,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.61,133.65,,,,,,,,,,,,,
HC Hcg (Urine) Pregnancy Test,PX-3078102500,CDM,81025,CPT,0307,RC,,,,both,,,260.00,169.00,,,,,,,,,,,,,
DRILL ENDOSCP D6MM 45DEG S STL OSSEOUS TISS POWERPICK,SUP-2122173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
CANNULA EOPA DIL 22FR,SUP-2727091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.29,222.49,,,,,,,,,,,,,
BASEPLATE GLEN SZ 8 MM MOD TAPR KT WDG STRL ALTIVATE RVS,SUP-2904158,CDM,C1776,CPT,0278,RC,,,,both,,,24667.84,16034.10,,,,,,,,,,,,,
GUIDEWIRE REGATTA MIDWT 195CM STR,SUP-2154111,CDM,C1769,HCPCS,0272,RC,,,,both,,,244.54,158.95,,,,,,,,,,,,,
CLIP EASY BICORT FIX DEV 10X15X13,SUP-2706413,CDM,C1713,HCPCS,0278,RC,,,,both,,,3150.05,2047.53,,,,,,,,,,,,,
MESH HERN L25XW20CM RECT COMP REP VENTRAL PROC ELP SYN,SUP-2174719,CDM,C1781,HCPCS,0278,RC,,,,both,,,5084.23,3304.75,,,,,,,,,,,,,
ORTHOPEDIC KIT HAMRTOE CCI STD W/1.25 KWIRE TI STRL,SUP-2433923,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4170.49,2710.82,,,,,,,,,,,,,
SYSTEM TRACTIONXL ADJ OPN BK HALO RNG COMPLT C GRAPHITE TI,SUP-2328134,CDM,L0810,HCPCS,0274,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SCREW BNE ST 2X18 MM CORTICAL LCK W/ PLUSDRIVE RECESS TI NS,SUP-2189398,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.78,327.46,,,,,,,,,,,,,
CATHETER EP CSL CRV 4MM SPC 7 FRX90 CM MARINR,SUP-2281828,CDM,C1730,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PLATE SPNL 3 LEVEL 52 MM ANTR CERV NEO-SL,SUP-2430706,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
BUR SURG PRECIS 15 DEG 4 MMX12.5 CM RND DSTL BEND ORNG IBUR,SUP-2859501,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.19,752.82,,,,,,,,,,,,,
PIMECROLIMUS 1 % EX CREA,RX-32052,CDM,6370000000,HCPCS,0637,RC,68462-0609-35,NDC,,both,30,GR,2282.60,1483.69,,,,,,,,,,,,,
SCREW BNE 1.5X17 MM SS NS,SUP-2183168,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.13,43.63,,,,,,,,,,,,,
IMIPRAMINE HCL 50 MG PO TABS,RX-3862,CDM,6370000000,HCPCS,0637,RC,69584-0427-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MESH HERN W3XL6IN POLYPR MID WT MFIL RECTANG OVL FLAT SH,SUP-2265904,CDM,C1781,HCPCS,0278,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
IMPLANT HUM TISS W61-150MMXL6-15CM PERICARD FRZ DRY,SUP-2307107,CDM,C1762,CPT,0278,RC,,,,both,,,2037.26,1324.22,,,,,,,,,,,,,
Finger Splint Application,PX-4302913000,CDM,29130,CPT,0430,RC,,,,both,,,363.00,235.95,,,,,,,,,,,,,
MICROCATHETER GUID FINECROSS M3 L 150 CM PROX/DSTL OD,SUP-2892551,CDM,C1887,HCPCS,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
SAW BLDE W7XL12.7MM L TEAR RECIP FOR TOT PERF SYS COR,SUP-2367378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.57,214.22,,,,,,,,,,,,,
FLUDROCORTISONE ACETATE 0.1 MG PO TABS,RX-10054,CDM,6370000000,HCPCS,0637,RC,68084-0288-11,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
SCREW BONE L12MM DIA2.7MM NONSTERILE CORT S STL ST,SUP-2177097,CDM,C1713,HCPCS,0278,RC,,,,both,,,319.62,207.75,,,,,,,,,,,,,
PLATE BNE STR NEUT 2.4 MM STRNL 30 HOLE LCK LP COMPR TI NS,SUP-2421472,CDM,C1713,HCPCS,0278,RC,,,,both,,,10220.70,6643.45,,,,,,,,,,,,,
GRAFT TEND BTB HEMI W SHP BNE BLK ALLGRFT FRZ DRY 8 13CM L,SUP-2307049,CDM,C1713,HCPCS,0278,RC,,,,both,,,8485.94,5515.86,,,,,,,,,,,,,
CUTTER VITRECTOMY 23 GA POST STAND ALONE WIDE FLD HI SPD,SUP-2490264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PLATE BONE LCK L CRV LT 11 H TI PROX TIB PLATING SYS ALPS,SUP-2413717,CDM,C1713,HCPCS,0278,RC,,,,both,,,4123.61,2680.35,,,,,,,,,,,,,
COLLAR CERV REG DENS SHT TWO PC PED ATLS,SUP-2319289,CDM,L0140,HCPCS,0272,RC,,,,both,,,48.32,31.41,,,,,,,,,,,,,
HC Add 15 Minutes (Anesthesia),PX-3700000001,CDM,3700000001,LOCAL,0370,RC,,,,both,,,368.00,239.20,,,,,,,,,,,,,
PLATE BNE L142MM 6 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185671,CDM,C1713,HCPCS,0278,RC,,,,both,,,4592.34,2985.02,,,,,,,,,,,,,
GRAFT BONE SUB 11MM DWL ILIUM BICORTICAL,SUP-2307095,CDM,C1713,HCPCS,0278,RC,,,,both,,,2185.91,1420.84,,,,,,,,,,,,,
STABILIT MX FRACTURE KIT BASE LNG,SUP-2702592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
GENERATOR PULSE REACTIV8,SUP-2877966,CDM,C1730,HCPCS,0272,RC,,,,both,,,43140.46,28041.30,,,,,,,,,,,,,
MODULE MULT AX SCR SET SCR,SUP-2287246,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DRILL SURG OD52MM L CANN,SUP-2244277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1042.70,677.75,,,,,,,,,,,,,
CATHETER INFUS L165CM OD2.7X1.5FR ID0.013IN L1.5CM 0.010IN,SUP-2284374,CDM,C1887,HCPCS,0272,RC,,,,both,,,6242.32,4057.51,,,,,,,,,,,,,
STRAP CORRECT PD VARUS VALGUS,SUP-2388177,CDM,L2270,HCPCS,0274,RC,,,,both,,,136.24,88.56,,,,,,,,,,,,,
KIT PULSE STIMULATOR IMPL GENRTR TORQUE WRNCH VERCISE,SUP-2845261,CDM,C1820,HCPCS,0278,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
HC Image Cath Fluid Colxn Visc,PX-3614940500,CDM,49405,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
BIT DRL 3.8X210 MM STRL VERSANAIL,SUP-2606668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.81,620.63,,,,,,,,,,,,,
SET INTRO SHTH 6FR L11CM W/ INTEGR SIDE PRT HEMSTAS VLV 3 W,SUP-2383402,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
GRAFT STENT MAIN BODY ENDOVASC,SUP-2217643,CDM,C1768,CPT,0278,RC,,,,both,,,36361.20,23634.78,,,,,,,,,,,,,
STEM ULN SZ 4 L75MM RT CEM CONSTRN NEXEL,SUP-2135759,CDM,C1776,CPT,0278,RC,,,,both,,,16227.52,10547.89,,,,,,,,,,,,,
VITASURE ABSRB HEMSTAT 3 GM ABSRB HEMSTAT W/ FLO CTRL,SUP-2379554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
COMPONENT FEM STD LT KNEE NONBEADED NP MOD CRUC RET CEM REV,SUP-2250935,CDM,C1776,CPT,0278,RC,,,,both,,,12132.96,7886.42,,,,,,,,,,,,,
COIL EMB L12CM OD4MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305168,CDM,C1889,HCPCS,0278,RC,,,,both,,,4584.40,2979.86,,,,,,,,,,,,,
HC Veno Hepatic W/O Hemo Eval S&I,PX-3207589100,CDM,75891,CPT,0320,RC,,,,inpatient,,,5468.00,3554.20,,,,,,,,,,,,,
ANG BLADE PL 130 4H 50/60,SUP-2818825,CDM,C1713,HCPCS,0278,RC,,,,both,,,4812.36,3128.03,,,,,,,,,,,,,
VALVE AORT SM 21ML SUTURELESS PERCEVAL,SUP-2352660,CDM,C1889,HCPCS,0278,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
HC So1 Nuclear Antigen Antibody,PX-3028623567,CDM,86235,CPT,0302,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
PLATE BNE L 266 MM SCREW DIA 4.5 MM 16 H BOW COMPR LCK STRL,SUP-2933517,CDM,C1713,HCPCS,0278,RC,,,,both,,,4792.43,3115.08,,,,,,,,,,,,,
CATHETER GUID MERCI L 95 CM OD 8 FR ID 0.078 IN SS POLYUR,SUP-2367772,CDM,C1887,HCPCS,0272,RC,,,,both,,,3741.00,2431.65,,,,,,,,,,,,,
NAIL IM FEM LT CANN TI ALLOY STRL 10.3MMX34CM SIRUS,SUP-2204957,CDM,C1713,HCPCS,0278,RC,,,,both,,,3908.20,2540.33,,,,,,,,,,,,,
FILIFORM URETH 6FR L18IN PLAS WVN DIL STR TIP REUSE,SUP-2128951,CDM,C1726,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X3 CM TERMINALLY STRL WND NEOX CRD RT,SUP-2648700,CDM,Q4148,HCPCS,0636,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
HC Intra Art Admin Radpharm,PX-3407944500,CDM,79445,CPT,0340,RC,,,,inpatient,,,3319.00,2157.35,,,,,,,,,,,,,
SLING GYN POLYPR MESH SUBURETHRAL TAPE FEM,SUP-2220078,CDM,C1771,HCPCS,0278,RC,,,,both,,,4584.40,2979.86,,,,,,,,,,,,,
BROACH SURG STD HUM,SUP-2372571,CDM,C1776,CPT,0278,RC,,,,both,,,3173.91,2063.04,,,,,,,,,,,,,
RING EXT FIX DIA150MM FULL FOR RNG FIX SYS TRUELOK,SUP-2316170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3033.37,1971.69,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 43 CM DIA 7 FR GUIDEWIRE 0.038 IN,SUP-2168450,CDM,C1894,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
NEEDLE BRST LOC L10CM OD20GA N REPOSITIONABLE W/ FLEXSTRAND,SUP-2269621,CDM,C1819,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
PLATE BNE L73MM 3 H L PROX HUM LO ALPS,SUP-2411632,CDM,C1713,HCPCS,0278,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
SCREW BNE L9MM DIA24MM SHT THRD L4MM ST CANC S STL ST SELF,SUP-2178490,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.67,593.24,,,,,,,,,,,,,
GUIDEWIRE VASC AQUALINER 150CM 0.035IN TIP 3CM ANGLED REG,SUP-2118709,CDM,C1769,HCPCS,0272,RC,,,,both,,,173.33,112.66,,,,,,,,,,,,,
PLATE SPNL SH POST LUM TI 1 H MNRCH,SUP-2254512,CDM,C1713,HCPCS,0278,RC,,,,both,,,4132.24,2685.96,,,,,,,,,,,,,
ARTHROFLEX 30X40X0.5 MM,SUP-2811253,CDM,Q4125,HCPCS,0636,RC,,,,both,,,3583.37,2329.19,,,,,,,,,,,,,
KIT CHOLGM PROC L53CM OD8FR CUT AWAY GUID LD COR SNUS,SUP-2148990,CDM,C1887,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HC Cta Heart Ejection Fract,PX-3507557300,CDM,75573,CPT,0480,RC,,,,both,,,3184.00,2069.60,,,,,,,,,,,,,
BASEPLATE TIB XL SZ 1 AP58MM ML82MM UNIV KNEE HA POR CEM,SUP-2377190,CDM,C1776,CPT,0278,RC,,,,both,,,3321.87,2159.22,,,,,,,,,,,,,
BLADE SHAVER 4.2 MMX10.5 CM IRRIG STRL LYNX,SUP-2607700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,323.92,210.55,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM SLV CORT TI SELF DRL NONCANNULATED,SUP-2181628,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.14,214.59,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA SULF STIMULAN RAP CURE,SUP-2135333,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST DYN FLX HINGE FABRICATED,SUP-2435769,CDM,L3900,HCPCS,0272,RC,,,,both,,,4173.94,2713.06,,,,,,,,,,,,,
MESH SURG W20XL25CM OVL FOR TISS SEPARATING AND HERN FIX,SUP-2219762,CDM,C1781,HCPCS,0278,RC,,,,both,,,4868.51,3164.53,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE ANTR CRUC LIGMNT CUST DEROTATION,SUP-2435612,CDM,L1840,HCPCS,0272,RC,,,,both,,,2662.44,1730.59,,,,,,,,,,,,,
WIRE BNE FIX DIA1.6 MM SMTH NS LEOS KIRSCHNER,SUP-2931299,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.75,76.54,,,,,,,,,,,,,
COMPONENT FEM SEG 55 MM M FEMALE KNEE,SUP-2437248,CDM,C1776,CPT,0278,RC,,,,both,,,9269.28,6025.03,,,,,,,,,,,,,
SUTURE ANCHOR SET 17 GAX12 CM 2 NDL ENTUIT,SUP-2170292,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SCREW BNE CORT ST W T8 STARDRV RECESS TI IN ST TB 24MM X,SUP-2418148,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.77,135.05,,,,,,,,,,,,,
LIGATOR ENDOSCP L2.8MM DIA8.6-11.5MM MULT BND SPEEDBAND,SUP-2149561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.52,487.84,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO DIA 7 FR LOOP DIA20 MM SPC,SUP-2248481,CDM,C1730,HCPCS,0272,RC,,,,both,,,3033.24,1971.61,,,,,,,,,,,,,
KIT CHST TB INTRO CHLORAPREP 1 STP L GLV ADH BK FEN DRP,SUP-2227360,CDM,C1729,HCPCS,0272,RC,,,,both,,,264.58,171.98,,,,,,,,,,,,,
SET STENT URTRL 8FR DIA 30CML PRCFLX PLS DBLE PGTL W0.038N,SUP-2725693,CDM,C2617,HCPCS,0278,RC,,,,both,,,472.13,306.88,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL GUID BRAID SL2 CRV TYP 8FRX8FR W/,SUP-2357255,CDM,C1894,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
KNIFE SURG L150MM 45MM LIBERATOR,SUP-2166550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,994.31,646.30,,,,,,,,,,,,,
POST SURG L ANK IOFIX PLUSXPOST GRN INTOSS FIX IMPL 20MM,SUP-2223897,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
APPLIER CLIP 8.25IN ANEURYSM VARIO STANDARD BAYONET SWIVEL R,SUP-2825294,CDM,C1889,HCPCS,0278,RC,,,,both,,,5839.80,3795.87,,,,,,,,,,,,,
CROSSLINK SPNL M CAPLOX II,SUP-2152469,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER DRAINAGE 2 EYE 16 FR PROPORTIONATE HD PEZ,SUP-2126192,CDM,C2627,HCPCS,0272,RC,,,,both,,,53.98,35.09,,,,,,,,,,,,,
DEVICE SUTURING N ABSRB 0 4 IN LD UNIT ENDOSTCH DISP,SUP-2787726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.76,218.24,,,,,,,,,,,,,
BIT DRL L120MM DIA2MM JCBS CHK END,SUP-2399751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
INQUIRY 1107 5 25170 L1 CATHETER,SUP-2699065,CDM,C1730,HCPCS,0272,RC,,,,both,,,1720.72,1118.47,,,,,,,,,,,,,
BRACE WALKING POSTOP XS PEDI PROCARE MAXTRAX,SUP-2195785,CDM,L4360,HCPCS,0272,RC,,,,both,,,84.00,54.60,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA 38 MM POLYESTER GEL,SUP-2385027,CDM,C1768,CPT,0278,RC,,,,both,,,1231.67,800.59,,,,,,,,,,,,,
GUIDEPIN ORTH L300MM OD3.2MM NTHRD,SUP-2340962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN RESRB OVITEX 1S 16X20 CM,SUP-2383105,CDM,C1781,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PROBE SUCT BLU ANG TACS DYONIC,SUP-2341611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
GRAFT HUM TISS PATELLAR TEND BNE 11 MM FRZN PRE-SHAPED,SUP-2430949,CDM,C1762,CPT,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
HC So Hiv2 Probe,PX-3068753868,CDM,87538,CPT,0306,RC,,,,inpatient,,,118.00,76.70,,,,,,,,,,,,,
STENT BILI ABS L 100 MM UNCONSTRAINED DIA 8 MM CATH L 135 CM,SUP-2101756,CDM,C1876,HCPCS,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
STEM FEM L150MM DIA11MM NEUT KNEE CO CHROM BOW CEM MOD SALV,SUP-2252628,CDM,C1776,CPT,0278,RC,,,,both,,,10386.96,6751.52,,,,,,,,,,,,,
PLATE BNE CRV 4.5X195 MM LT CNDYL 8 HOLE VA LCK NS VA-LCP,SUP-2758212,CDM,C1713,HCPCS,0278,RC,,,,both,,,5544.86,3604.16,,,,,,,,,,,,,
BETAMETHASONE VALERATE 0.1 % EX OINT,RX-1033,CDM,6370000000,HCPCS,0637,RC,00168-0033-15,NDC,,both,15,GR,73.30,47.64,,,,,,,,,,,,,
BIT DRL DIA2 MM SUBCHONDRAL NS DISP LEOS,SUP-2933830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,333.47,216.76,,,,,,,,,,,,,
PROSTHESIS OSS 4X3.25 MM 1.45X2 MM DSTL END TI HA DORNHOFFER,SUP-2232510,CDM,L8613,CPT,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
BIT DRL CANN 9 MM KNEE FOR ACL/PCL STRL DISP,SUP-2849070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
SPHINCTEROTOME ENDO L20MM OD6-5FR 2 LUMN GWIRE BRAID,SUP-2169135,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
ALLOGRAFT DERMAL SHP THCK LG 22X13 CMX1.5-2.2 MM FLEXHD,SUP-2463664,CDM,Q4128,HCPCS,0636,RC,,,,both,,,14426.79,9377.41,,,,,,,,,,,,,
AUGMENT FEM SZ 5 THK5MM L DST KNEE CO CHROM TOT STBL FULL,SUP-2373487,CDM,C1776,CPT,0278,RC,,,,both,,,1821.92,1184.25,,,,,,,,,,,,,
FORCEPS SURG NK TRL ACCOLADE,SUP-2361691,CDM,C1776,CPT,0278,RC,,,,both,,,2539.00,1650.35,,,,,,,,,,,,,
PIN FIX L32MM MINI WRST S STL LO PROF RIG FIX ANG DORS,SUP-2389360,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
SHELL ACET SZ D DIA46MM STD TI POR SPIK REFLCT,SUP-2345039,CDM,C1776,CPT,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
SNARE VASC EXPRO ELITE L 150 CM DIA10 MM GUIDEWIRE 0.035 IN,SUP-2104764,CDM,C1773,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HC Cytp Fine Ndl Aspirate Immt Cytohist Std Ea Eval,PX-3118817700,CDM,88177,CPT,0311,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
BIT DRL STP 9.3 MM NS GOTFRIED PCCP,SUP-2644768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.51,324.68,,,,,,,,,,,,,
HC Dx Breast Tomo Uni,PX-4017706100,CDM,G0279,HCPCS,0401,RC,,,,inpatient,,,153.00,99.45,,,,,,,,,,,,,
CATHETER NEPHSTMY 14FR L25CM FLEXIMA REG PGTL TIP RADPQ MTL,SUP-2147844,CDM,C1729,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
CATHETER EMB ACCUNET 2 L 141 CM DIA1.6 MM SHTH 6 FR CAR,SUP-2101770,CDM,C1757,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
AMSCO 7052HP 460 480V 3 PH 60 HZ STEAM HEATED,SUP-2721188,CDM,C1713,HCPCS,0278,RC,,,,both,,,234834.89,152642.68,,,,,,,,,,,,,
HC So Osmolality Serum,PX-3018393066,CDM,83930,CPT,0301,RC,,,,inpatient,,,26.00,16.90,,,,,,,,,,,,,
ALLOGRAFT DEMIN BONE PUTTY 1ML SYR,SUP-2247314,CDM,C1889,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
SHOE ORTHOT ADDITION TOE TAP STD,SUP-2435739,CDM,L3550,HCPCS,0272,RC,,,,both,,,25.31,16.45,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.434,SUP-2859998,CDM,C1713,HCPCS,0278,RC,,,,both,,,40544.31,26353.80,,,,,,,,,,,,,
ALLOGRAFT HUM TISS UNMESHED 6X12 CMX1.25-2 MM DECELL DERM,SUP-2264720,CDM,Q4122,HCPCS,0636,RC,,,,both,,,6742.05,4382.33,,,,,,,,,,,,,
KIT ENDOPROS 12FR L15CM SFT W/ TEMPTIP HYDRPHLC TIP,SUP-2147746,CDM,C2617,HCPCS,0278,RC,,,,both,,,259.21,168.49,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.25X150 MM DMND PT NS,SUP-2607877,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.67,40.74,,,,,,,,,,,,,
DRESSING BIO W2XL2IN BOV TEND CLLGN MESHED GLYCOSAMINOGLYCAN,SUP-2244272,CDM,C9363,HCPCS,0636,RC,,,,both,,,10059.90,6538.93,,,,,,,,,,,,,
INTERBODY ASMBLY 16X14X7 - 7,SUP-2335267,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
WIRE EXT FIX L360MM DIA1.8MM,SUP-2197288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
TAP SURG NONSTERILE REUSE ORTH NEURO PROC L13MM OD4MM,SUP-2279323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.16,251.00,,,,,,,,,,,,,
SPACER 38X2MM M LT,SUP-2209008,CDM,C1776,CPT,0278,RC,,,,both,,,11366.17,7388.01,,,,,,,,,,,,,
SYSTEM DRAINAGE RT ANGLE 32 FRX21 IN THOR SFT CATH FIRM PVC,SUP-2227085,CDM,C1729,HCPCS,0272,RC,,,,both,,,223.44,145.24,,,,,,,,,,,,,
FOOTPLATE BONE MEDIUM 20 MM 12 MM POSTERIOR MAXILLARY OFFSET,SUP-2837829,CDM,C1713,HCPCS,0278,RC,,,,both,,,4147.63,2695.96,,,,,,,,,,,,,
STENT BILI OMLNK L 28 MM DIA10 MM DIL DIA11 MM CATH L 135 CM,SUP-2101525,CDM,C1876,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
COLLAR CERV ADJ FLX THERMOPLASTIC,SUP-2388132,CDM,L0130,HCPCS,0272,RC,,,,both,,,487.64,316.97,,,,,,,,,,,,,
STEM FEM SZ 0 CO CHROM LD,SUP-2210724,CDM,C1776,CPT,0278,RC,,,,both,,,3857.49,2507.37,,,,,,,,,,,,,
CEMENT BNE 10ML 20GM HALF DOSE PMMA W/O ANTIBIO M VISC,SUP-2374940,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
PLATE BNE 110 DEG PEDIATRIC 3.5X73 MM 19/12 MM 3 HOLE LCP,SUP-2799195,CDM,C1713,HCPCS,0278,RC,,,,both,,,2364.99,1537.24,,,,,,,,,,,,,
GRAFT HUM TISS SM W10XL17CM THK0.7-1.4MM THN PERF FLEXHD,SUP-2307601,CDM,Q4128,HCPCS,0636,RC,,,,both,,,8896.25,5782.56,,,,,,,,,,,,,
ELECTRODE ES WIRE 0.35IN ANG 12DEG MPLR HF RESECT,SUP-2312903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,498.51,324.03,,,,,,,,,,,,,
ANCHOR SUT DIA2.3MM 2 COBRAID BLK ULTRABRAID SUT OSTEORAPTOR,SUP-2341804,CDM,C1713,HCPCS,0278,RC,,,,both,,,943.60,613.34,,,,,,,,,,,,,
GRAFT HUM TISS W7XL7CM CRYOPRESERVED AMNIO MEM LO PROF FOR,SUP-2116287,CDM,Q4148,HCPCS,0636,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
BIT DRL KNOTLESS FOR SUTURE ANCHR ROT CUF REP STRL CROSS FT,SUP-2423297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.93,475.75,,,,,,,,,,,,,
PLATE BONE L21MM THK2MM 6X21 H RT MAND ORAL MAXILLOFACIAL TI,SUP-2191273,CDM,C1713,HCPCS,0278,RC,,,,both,,,8033.69,5221.90,,,,,,,,,,,,,
HC Electrolyte Panel,PX-3018005100,CDM,80051,CPT,0301,RC,,,,inpatient,,,317.00,206.05,,,,,,,,,,,,,
SCREW SPNL L45MM DIA7MM TI SGL INNR POLYAX FOR 5.5MM ROD,SUP-2254635,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
DILTIAZEM HCL-SODIUM CHLORIDE 100-0.72 MG/100ML-% IV SOLN,RX-171777,CDM,2500000003,HCPCS,0250,RC,44567-0662-01,NDC,,both,100,ML,220.80,143.52,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX20 CM KT STR J TIP,SUP-2383338,CDM,C1751,HCPCS,0278,RC,,,,both,,,278.05,180.73,,,,,,,,,,,,,
PROBE LARYNGEAL RT HND 90 DEG MIRRORED W/ SMK EVAC,SUP-2713696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1655.85,1076.30,,,,,,,,,,,,,
PLATE BNE FIBULAR 3.5X147 MM LT LAT DSTL 11 HOLE EVOS,SUP-2349745,CDM,C1713,HCPCS,0278,RC,,,,both,,,5132.17,3335.91,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER LNG 30X11X15 MM BIO AVS UNILIF,SUP-2637048,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
COMPONENT GLEN CAGED SHLDR MTL-BK,SUP-2223617,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
ACCESSORY KIT WEARABLE FOR PC HEARTMATE II GOGEAR,SUP-2356022,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE ECHOTIP NDL L 2.5 CM DIA21 GA,SUP-2633260,CDM,C1894,HCPCS,0272,RC,,,,both,,,216.72,140.87,,,,,,,,,,,,,
PROVOX VEGA VOICE PROS IS AN INDWL LO RESISTANCE VOICE PROS,SUP-2124400,CDM,L8509,HCPCS,0274,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
IMPLANT NSL CART LAT ABSORB,SUP-2217800,CDM,C1889,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
KIT CVC BODY FOR 9.5FR 2 LUMN PEEL APART INTRO GROSH,SUP-2127902,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
ROD EXT FIX L150MM DIA11MM C CONN FOR HOFFMANN III MRI SYS,SUP-2372226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.61,704.35,,,,,,,,,,,,,
GUIDE DRL FISHMOUTH STBL LUPINE,SUP-2249383,CDM,C1713,HCPCS,0278,RC,,,,both,,,1295.72,842.22,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 111 MM DIA 32 MM SHTH 20 FR SS,SUP-2170036,CDM,C1768,CPT,0278,RC,,,,both,,,24652.14,16023.89,,,,,,,,,,,,,
COOLCUT BALL ELCTRODE,SUP-2815767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BAR EXT FIX L100MM DIA11MM FOR XTRAFIX SYS,SUP-2199708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
BIT DRILL 2.0MM EVOLVE EPS,SUP-2822394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
CATHETERIZATION SET ART 021 22 GAX8 CM 20 GA INDWL LF,SUP-2865600,CDM,C1751,HCPCS,0278,RC,,,,both,,,64.68,42.04,,,,,,,,,,,,,
BOLT ARCOS LATERAL TROCH 36MM,SUP-2506132,CDM,C1776,CPT,0278,RC,,,,both,,,1840.98,1196.64,,,,,,,,,,,,,
MESH HERN RND 25X20 CM COMP PARIETENE DS,SUP-2430046,CDM,C1781,HCPCS,0278,RC,,,,both,,,5338.44,3469.99,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X216 MM 12 HOLE SS LCP,SUP-2569373,CDM,C1713,HCPCS,0278,RC,,,,both,,,820.33,533.21,,,,,,,,,,,,,
GRAFT HUM TISS 100MG PARTICULATE INJ MICRONIZED AMNIO MEM,SUP-2305720,CDM,V2790,HCPCS,0278,RC,,,,both,,,4381.87,2848.22,,,,,,,,,,,,,
HC MRI-Angio Head W Contrast,PX-6157054500,CDM,70545,CPT,0615,RC,,,,both,,,4278.00,2780.70,,,,,,,,,,,,,
HC Perq Clsr Tcat L Atr Apndge W/Endocardial Implnt,PX-4813334000,CDM,33340,CPT,0481,RC,,,,both,,,30004.00,19502.60,,,,,,,,,,,,,
PLATE BNE W10.2XL91MM THK2.7MM 7 H BILAT S STL STR LO PROF,SUP-2186194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1377.86,895.61,,,,,,,,,,,,,
END CAP 16X10MM EXT T40 STARDRV TI STRL,SUP-2546238,CDM,C1889,HCPCS,0278,RC,,,,both,,,755.14,490.84,,,,,,,,,,,,,
BEAM FIX 8.5X140 MM,SUP-2610033,CDM,C1713,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
MESH CRAN L 55 X W 55 MM THK 0.5 MM SCREW DIA1.7 MM PLLA PUR,SUP-2883565,CDM,C1713,HCPCS,0278,RC,,,,both,,,7101.30,4615.84,,,,,,,,,,,,,
ANCHOR SUT L76MM DIA27MM TI ST SELF DRL FOR 2 0 FORC FBR,SUP-2399136,CDM,C1776,CPT,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SUCTION BLADE ANGLD 40DGRS DBL SRRTD EDGE RECT WNDW3MMX12CM5,SUP-2574173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.92,388.65,,,,,,,,,,,,,
ATTACHMENT RETRCT FLEX 2 FNGR ASST SH 3.2X5.1 CM STABLESOFT,SUP-2218012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,124.97,81.23,,,,,,,,,,,,,
HC Sacroiliac Jnts Min 3 Views,PX-3207220200,CDM,72202,CPT,0320,RC,,,,inpatient,,,938.00,609.70,,,,,,,,,,,,,
PLATE BNE L142MM 6 H ST R MED DST TIB S STL LOK COMPR FOR,SUP-2185583,CDM,C1713,HCPCS,0278,RC,,,,both,,,4991.00,3244.15,,,,,,,,,,,,,
SCREW BNE L50MM OD3.5MM S STL CORT ST NONCANNULATED LOK,SUP-2348816,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
PIN FIX POLY LIMB LCK SALV FINN,SUP-2406068,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SCREW BNE 4 MM HD KT,SUP-2175155,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
SCREW BNE L38MM OD3MM DST THRD L14MM LNG THRD CANN COMPR,SUP-2268359,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.13,987.43,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.1X150 MM FOR CANN SCREW NS 03333011,SUP-2789094,CDM,C1769,HCPCS,0272,RC,,,,both,,,257.98,167.69,,,,,,,,,,,,,
HC So Protein Western Blot Test,PX-3018418266,CDM,84182,CPT,0301,RC,,,,both,,,67.00,43.55,,,,,,,,,,,,,
PLATE CRAN 200X160X40 MM PT SPEC IMPL PEEK,SUP-2860162,CDM,C1713,HCPCS,0278,RC,,,,both,,,58312.94,37903.41,,,,,,,,,,,,,
GRAFT BONE PROX TIB W/ TUBEROSITY FZ IRR,SUP-2875987,CDM,C1762,CPT,0278,RC,,,,both,,,8859.51,5758.68,,,,,,,,,,,,,
CATHETER HD STR 13 FRX24 CM SHT TERM DL KT DUOGLIDE,SUP-2431943,CDM,C1752,HCPCS,0278,RC,,,,both,,,375.54,244.10,,,,,,,,,,,,,
PLATE BONE W14.9XL136MM THK1.2MM 8 H DSTL TIB S STL,SUP-2185737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1073.60,697.84,,,,,,,,,,,,,
COUNTERSINK SURG CANN FOR 4MM SCR,SUP-2187349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.17,648.81,,,,,,,,,,,,,
SCREW BNE L 30 MM DIA2 MM SS CORTICAL T6 STARDRV SLV TUBE PK,SUP-2905750,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.54,303.25,,,,,,,,,,,,,
PLATE BNE OLECRANON XLN ELBW,SUP-2107786,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE EXT FIX 3 H ANK FT FOR TRUELOK FRME ASSEMB HEXAPOD,SUP-2316199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.45,418.24,,,,,,,,,,,,,
KIT PEDCL ACCS SPNL IMPL,SUP-2232070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
INTERSPACE ATS 60/12 KNEE ATS 60/12,SUP-2810984,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
EPOPROSTENOL SODIUM 0.5 MG IV SOLR,RX-15897,CDM,J1325,HCPCS,0636,RC,62756-0059-40,NDC,,both,1,UN,128.00,83.20,,,,,,,,,,,,,
DILATOR ENDOSCP 6 FRX180 CM 4X40 MM BILI CATH MAXPASS DISP,SUP-2312952,CDM,C1726,HCPCS,0272,RC,,,,both,,,692.24,449.96,,,,,,,,,,,,,
MESH HERN CIR 4.5 IN W/ ECHO 2 POS SYS PHASIX ST,SUP-2422302,CDM,C1781,HCPCS,0278,RC,,,,both,,,6766.70,4398.35,,,,,,,,,,,,,
NERVE STIMULATOR KIT PROC EMG/NMJ NDL ELECTRD SAFEOP,SUP-2725212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP PRECUT ACHILLES TEND,SUP-2867184,CDM,C1762,CPT,0278,RC,,,,both,,,6473.11,4207.52,,,,,,,,,,,,,
BUTTON GAST ACCS L2.4CM DIA24FR LO PROF PUL PEG KT 1 STP,SUP-2149747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
GRAFT BIO TISS W4XL12CM THK08 17MM THCK STRUCTURAL,SUP-2307469,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4461.34,2899.87,,,,,,,,,,,,,
PLATE BNE L131MM 6 H NONSTERILE R PROX ULN EXTRA ARTC S STL,SUP-2177197,CDM,C1713,HCPCS,0278,RC,,,,both,,,3726.83,2422.44,,,,,,,,,,,,,
HC Rad Exam Upr GI Tract Single Contrast Study,PX-3207424000,CDM,74240,CPT,0320,RC,,,,both,,,1855.00,1205.75,,,,,,,,,,,,,
HC Inject Tendon Origin/Insert,PX-3612055100,CDM,20551,CPT,0361,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
GRAFT BNE PTTY 3.75 GM BIOACTIVE OSTEOFUSE,SUP-2225963,CDM,C9359,HCPCS,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
DVR LOCK MED R ST,SUP-2587116,CDM,C1713,HCPCS,0278,RC,,,,both,,,2849.55,1852.21,,,,,,,,,,,,,
TUBING STBL 12 MM FOR DA VINCI S SI ENDOWRIST CLEARFIELD,SUP-2246648,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
HC So Drug Assay Posaconazole,PX-3018018766,CDM,80187,CPT,0301,RC,,,,both,,,368.00,239.20,,,,,,,,,,,,,
STENT GRFT VASC AFX L 75 MM DIA PROX/DSTL 25 MM COCR,SUP-2217590,CDM,C1874,HCPCS,0278,RC,,,,both,,,10785.90,7010.83,,,,,,,,,,,,,
ROD SPNL HEX 6.35 MMX6 CM LEVEL-1 TI SYNERGY,SUP-2415478,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.47,459.21,,,,,,,,,,,,,
SCREW UNIV,SUP-2209055,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
PLATE BNE NC FUSION LG 2.7 MM NS FPS LTX,SUP-2856864,CDM,C1713,HCPCS,0278,RC,,,,both,,,5614.32,3649.31,,,,,,,,,,,,,
SCREW BNE LCK 2.7X18 MM,SUP-2199257,CDM,C1713,HCPCS,0278,RC,,,,both,,,325.40,211.51,,,,,,,,,,,,,
HC Peripheral Block - Tap Bilateral Injection,PX-3606448800,CDM,64488,CPT,0360,RC,,,,both,,,1238.00,804.70,,,,,,,,,,,,,
CATHETER NEPHROSTOMY 63FR 20CML FLEXIMA PIGTAIL TIP,SUP-2722033,CDM,C1729,HCPCS,0272,RC,,,,both,,,47.48,30.86,,,,,,,,,,,,,
SYSTEM DEL FLEXNAV L 107 CM SHTH L 30 DIA15 FR VLV CAPSULE,SUP-2892348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
"HC Coombs,Direct",PX-3028688000,CDM,86880,CPT,0302,RC,,,,both,,,328.00,213.20,,,,,,,,,,,,,
CATHETER NEPHSTMY L 6FR L20CM HYDRPHLC MULTPURP ABSC TAPR,SUP-2303529,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
CATHETER URET POLYVINYLCHLORIDE OPN END MOD ACCEPTS INSTR,SUP-2168915,CDM,C1758,HCPCS,0278,RC,,,,both,,,43.55,28.31,,,,,,,,,,,,,
MESH CRAN W206XL123MM THK0.6MM SLV TI CNTOUR FOR 1.5MM,SUP-2135905,CDM,C1713,HCPCS,0278,RC,,,,both,,,8625.58,5606.63,,,,,,,,,,,,,
HC Thyroglobulin Antibody|UNUSUAL NON-OVERLAPPING SERVICE,PX-3028680000,CDM,86800,CPT,0302,RC,,,XU,both,,,86.00,55.90,,,,,,,,,,,,,
PAROXETINE HCL 10 MG/5ML PO SUSP,RX-22959,CDM,340b,HCPCS,0637,RC,70954-0319-10,NDC,,both,5,ML,33.10,21.51,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 15CM STRGHT 2,SUP-2613265,CDM,C1752,HCPCS,0278,RC,,,,both,,,814.05,529.13,,,,,,,,,,,,,
ANCHOR ABSORBABLE 14 MM MENIS,SUP-2166730,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 35X25 CM BIOLOGIC TISSUE MATRIX STERILE X,SUP-2838621,CDM,C1763,HCPCS,0278,RC,,,,both,,,43740.20,28431.13,,,,,,,,,,,,,
NAIL IM L200MM DIA11MM 130DEG R ANK GRN TI CANN LOK FLUT,SUP-2368725,CDM,C1713,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
SHEATH INTRO BASE CAMP 2.0 L 90 CM CATH 8 FR GUIDEWIRE 0.035,SUP-2928390,CDM,C1887,HCPCS,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
STENT CORONARY SYNERGY L 28 MM DIA2.25 MM CATH L 144 CM DIA,SUP-2146166,CDM,C1874,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX60 CM 1LUMEN RAD PWR INJ TURBO-JECT,SUP-2759822,CDM,C1751,HCPCS,0278,RC,,,,both,,,403.02,261.96,,,,,,,,,,,,,
K WIRE DBL TROCAR 1.4X127MM ST,SUP-2587153,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.18,37.17,,,,,,,,,,,,,
CLAMP EXT FIX TRAUM CAPPED RNG DONE,SUP-2197258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
ANCHOR SUT L14MM DIA4.5MM BIOCOMP FULL THRD W/ DRL BIT GUID,SUP-2122831,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THCK 4CMX7CM,SUP-2306911,CDM,C1762,CPT,0278,RC,,,,both,,,2651.13,1723.23,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135 CM DIA 5 FR SLT PAT L 50 CM,SUP-2118485,CDM,C1757,HCPCS,0272,RC,,,,both,,,356.70,231.85,,,,,,,,,,,,,
HC X-Ray Knee Rout Inc Tun Pat Min 4 View,PX-3207356400,CDM,73564,CPT,0320,RC,,,,outpatient,,,616.00,400.40,,,,,,,,,,,,,
PIN ORTH 2X229MM SGL SHRP TIP STYL 5 TRCR PNT S STL ST,SUP-2207914,CDM,C1713,HCPCS,0278,RC,,,,both,,,47.60,30.94,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 3 CM PLCNTA MEMBRN ALLGRFT CROSS,SUP-2909400,CDM,Q4109,HCPCS,0636,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
COMPONENT TIB ROTATIONAL NEUT LG KNEE CONN MOLYBDENUM UHMWPE,SUP-2423700,CDM,C1776,CPT,0278,RC,,,,both,,,4573.72,2972.92,,,,,,,,,,,,,
POTASSIUM PHOSPHATE MONOBASIC 500 MG PO TABS,RX-11087,CDM,6370000000,HCPCS,0637,RC,00486-1111-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT PANCREATIC GEENEN L 7CM 5 FR 0.035IN SOFFLX OFFSET,SUP-2170683,CDM,C2617,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
HC So Protein Electrophoresis Fluid,PX-3018416666,CDM,84166,CPT,0301,RC,,,,both,,,445.00,289.25,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X320 MM RT PROX 10 HOLE STRL VALCP,SUP-2789579,CDM,C1713,HCPCS,0278,RC,,,,both,,,8634.15,5612.20,,,,,,,,,,,,,
PLATE BONE L 12 H BILAT MANUBRIUM STRNL TI LCK STAR COKING,SUP-2192440,CDM,C1713,HCPCS,0278,RC,,,,both,,,3360.74,2184.48,,,,,,,,,,,,,
STAPLE BNE FIX W15XL15MM NIT COMPR W/ INSTR LO PROF FOR,SUP-2122350,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
HC Intraosseous Needle Placement,PX-7613668000,CDM,36680,CPT,0761,RC,,,,inpatient,,,954.00,620.10,,,,,,,,,,,,,
GYN ESG PLASMABUTTON 12 30 DEG,SUP-2497213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1688.25,1097.36,,,,,,,,,,,,,
KIT TKR KNEE REPL BUSHING MOST OPTIONS,SUP-2208279,CDM,C1776,CPT,0278,RC,,,,both,,,17266.86,11223.46,,,,,,,,,,,,,
PLATE BNE FUSION MINI WRST SS STRL SPIDER,SUP-2610409,CDM,C1713,HCPCS,0278,RC,,,,both,,,5574.57,3623.47,,,,,,,,,,,,,
SPACER SPNL W28XH10XL33MM 8DEG PEEK ANT LUM INTBDY FUS LORD,SUP-2380526,CDM,C1889,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
INSERT SYS 12 NEUT DURATN P4 28MM,SUP-2376138,CDM,C1776,CPT,0278,RC,,,,both,,,1338.43,869.98,,,,,,,,,,,,,
SPLINT THMB M L5IN SH RT 1 STRP THERMOPLASTIC INSRT,SUP-2324196,CDM,L3931,HCPCS,0272,RC,,,,both,,,42.23,27.45,,,,,,,,,,,,,
CATHETER IV 22 GAX1.25 IN ECHOGENIC GUIDEWIRE ACCUCATH,SUP-2125657,CDM,C1751,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
CATHETER VENTRICULAR SUBDURAL F8 TBNG W/ A FLATTENED EXAFLOW,SUP-2666676,CDM,C1729,HCPCS,0272,RC,,,,both,,,565.23,367.40,,,,,,,,,,,,,
PUMP INFUS 275ML 4ML/HR W/ 5IN 2ML CATH PAINPMP,SUP-2361465,CDM,C2626,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
PLATE IMPL 4.5MM LCPTM MEDL PROX TIB,SUP-2177070,CDM,C1713,HCPCS,0278,RC,,,,both,,,68903.53,44787.29,,,,,,,,,,,,,
SCREW BONE L65MM OD4.5MM BLU MIDFOOT HINDFOOT ANK CANN SH,SUP-2320934,CDM,C1713,HCPCS,0278,RC,,,,both,,,1351.77,878.65,,,,,,,,,,,,,
SCREW BNE L42MM DIA3.5MM TI CORT DST TIB ST NONCANNULATED,SUP-2411698,CDM,C1713,HCPCS,0278,RC,,,,both,,,148.21,96.34,,,,,,,,,,,,,
SET PD SM SURF COOL STX,SUP-2416135,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.10,1305.91,,,,,,,,,,,,,
CATHETER LD DEL ACUITY PRO 130 DEG L 54 CM DIA 9 FR SS PTFE,SUP-2149032,CDM,C1887,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SPACER TEND NO3 W3XH15XL24MM SIL SWNSN HUNTER,SUP-2397186,CDM,C1713,HCPCS,0278,RC,,,,both,,,3133.72,2036.92,,,,,,,,,,,,,
CATHETERIZATION KIT 8.5 FRX16 CM CV ARROWG+ARD BLU +,SUP-2383387,CDM,C1751,HCPCS,0278,RC,,,,both,,,411.78,267.66,,,,,,,,,,,,,
RING EXT FIX DIA130 MM U SHP NS DISP SMRT TSF,SUP-2932933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6352.91,4129.39,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 8MM STR STD WALL SLDE GDS,SUP-2669691,CDM,C1768,CPT,0278,RC,,,,both,,,1286.21,836.04,,,,,,,,,,,,,
GADOTERIDOL 279.3 MG/ML IV SOLN,RX-10100,CDM,A9579,HCPCS,0636,RC,00270-1111-03,NDC,,both,20,ML,18.80,12.22,,,,,,,,,,,,,
HC Beta Cath Delivery System Proc,PX-4819297400,CDM,92974,CPT,0481,RC,,,,both,,,6762.00,4395.30,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 TI CTX SCREW 40MM S-T,SUP-2819744,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.14,308.84,,,,,,,,,,,,,
CATHETER DRNGE 10FR L25CM FLEXIMA GLDEX ALL PURP LOOP RADPQ,SUP-2147782,CDM,C1729,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
THERAPY ABLATION CATH THERMISTOR 1304 7 25 E TE8 TH,SUP-2698838,CDM,C1733,HCPCS,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP FIXED 55MM,SUP-2749355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1905.98,1238.89,,,,,,,,,,,,,
SCREW BNE L11MM DIA1.5MM HD DIA3MM CORT S STL NONCANNULATED,SUP-2183109,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.11,74.17,,,,,,,,,,,,,
STEM FEM L160MM DIA10.5MM HIP POR L STAT STD OFFSET AML,SUP-2252043,CDM,C1776,CPT,0278,RC,,,,both,,,19888.76,12927.69,,,,,,,,,,,,,
PLEDGET VASC W5/16XL5/16IN THK1.65MM PTFE SQ FELT,SUP-2126673,CDM,C1768,CPT,0278,RC,,,,both,,,37.99,24.69,,,,,,,,,,,,,
BUR SURG L 7.5 CM DIA1 MM LNG BALL DIAMOND FN DISECT TOOL,SUP-2929992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.78,428.86,,,,,,,,,,,,,
EVOS CABLE STAINLESS STEEL W/CRIMP,SUP-2931366,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
TUBING CNTRST DEL L 51 CM 1.36 CC AIRLESS ROTATING KEEP FLX,SUP-2302649,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
CATHETER INFUSION BERN 200 CM 2.7/2.4 FRX155 CM FATHOM-16,SUP-2653478,CDM,C1887,HCPCS,0272,RC,,,,both,,,3061.81,1990.18,,,,,,,,,,,,,
SCREW 2.0MMX28MM HEADED DART-FIRE,SUP-2857925,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
ENTECAVIR 0.5 MG PO TABS,RX-41147,CDM,6370000000,HCPCS,0637,RC,31722-0833-30,NDC,,both,1,UN,6.00,3.90,,,,,,,,,,,,,
DISTRACTION INTRNL DIST CLEFT MICRO ZRCH 2 LIOU TRANS LEFT 1,SUP-2491407,CDM,C1713,HCPCS,0278,RC,,,,both,,,11174.48,7263.41,,,,,,,,,,,,,
GRAFT BONE SUB 5ML HUM CORT DEMIN FBR STAGRFT,SUP-2136831,CDM,C1713,HCPCS,0278,RC,,,,both,,,2881.20,1872.78,,,,,,,,,,,,,
IMMOBILIZER SHOULDERXL FOR 42-48IN CHST ELAS W/O NK STRP M,SUP-2197392,CDM,L3660,HCPCS,0272,RC,,,,both,,,70.02,45.51,,,,,,,,,,,,,
PLATE BNE 11 H NONSTERILE NAVICULAR S STL LO PROF VAR ANG,SUP-2184811,CDM,C1713,HCPCS,0278,RC,,,,both,,,3654.52,2375.44,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0258,RC,00338-0049-11,NDC,,both,50,ML,24.70,16.05,,,,,,,,,,,,,
PLATE STRNL SM 10 H TI LADDER NS MATRIXSTERNUM,SUP-2904249,CDM,C1713,HCPCS,0278,RC,,,,both,,,2740.15,1781.10,,,,,,,,,,,,,
KIT CHOLGM 4.4FR L30MM 5FR 0.035IN CATH L260CM SPHINTOM,SUP-2149002,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MESH SURG L8XW6IN IMPL SEPRAMESH,SUP-2125924,CDM,C1781,HCPCS,0278,RC,,,,both,,,1880.55,1222.36,,,,,,,,,,,,,
HC Cardiac Rehab Outpatient,PX-9439379800,CDM,93798,CPT,0943,RC,,,,outpatient,,,412.00,267.80,,,,,,,,,,,,,
DISC ARTIFICIAL SZ 5 H10.5MM UNIV INTERVERTEBRAL LUM UHMWPE,SUP-2255759,CDM,C1889,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BONE L113MM 6 H RT OLECRANON,SUP-2364578,CDM,C1713,HCPCS,0278,RC,,,,both,,,3557.78,2312.56,,,,,,,,,,,,,
RING EXT FIX 5/8 200 MM SALVATION,SUP-2850669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3780.56,2457.36,,,,,,,,,,,,,
GRAFT BNE SUB W25XL100MM THK6MM CHRONOS SYN TISS STRP,SUP-2182834,CDM,C1713,HCPCS,0278,RC,,,,both,,,6565.74,4267.73,,,,,,,,,,,,,
HC Peripheral Block - Tap Unilateral Injection,PX-3606448600,CDM,64486,CPT,0360,RC,,,,both,,,996.00,647.40,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 6 CM DIA 4 MM MICROCATHETER 0.035,SUP-2385371,CDM,C1889,HCPCS,0278,RC,,,,both,,,926.33,602.11,,,,,,,,,,,,,
HC Ablate Arrhythmia Add On,PX-4819365500,CDM,93655,CPT,0481,RC,,,,both,,,1285.00,835.25,,,,,,,,,,,,,
SCREW GLEN FIX 25MM SHLDR CTRL MOD UNIVERS REVERS,SUP-2123398,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-6 MM SHRT TAPR HELIX,SUP-2525466,CDM,C1768,CPT,0278,RC,,,,both,,,1944.51,1263.93,,,,,,,,,,,,,
SET SHTH DESTINO L 87 CM L 67 CM 12FR CRV BEND 22 MM 50 DEG,SUP-2616110,CDM,C1766,CPT,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
ANCHOR SUTURE BLU MICRORAPTOR REGENESORB,SUP-2879933,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.95,750.07,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD FEM TIB FLX OPT CEM SURF,SUP-2212244,CDM,C1776,CPT,0278,RC,,,,both,,,13032.19,8470.92,,,,,,,,,,,,,
MARKER TISS BIOMARC 1X3MM 18G,SUP-2152633,CDM,A4648,CPT,0278,RC,,,,both,,,303.54,197.30,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC URLGCL 0.35N DIA 150CML 3CML TIP HDRPHLC C,SUP-2466362,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.78,98.01,,,,,,,,,,,,,
SCREW BNE L 70 MM DIA2.4 MM TI CORTICAL T8 STARDRV BRZ TUBE,SUP-2905740,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.73,409.32,,,,,,,,,,,,,
BRACE LUMBOSACRALXL 15DEG BK HK RECV MAT SFT BRTH LNR RIG,SUP-2195547,CDM,L0625,HCPCS,0272,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
BUR SURG SHT EXTN CEBOTOME,SUP-2607450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4341.99,2822.29,,,,,,,,,,,,,
GRAFT BNE CHIP FRZN CRUSH CANC 01MM 4MM RANG 90CC,SUP-2307402,CDM,C1713,HCPCS,0278,RC,,,,both,,,5720.67,3718.44,,,,,,,,,,,,,
COMPONENT FEM CEM 2XS UNISX LT KNEE REV CR STEM N BEAD VIT,SUP-2377026,CDM,C1776,CPT,0278,RC,,,,both,,,11068.50,7194.52,,,,,,,,,,,,,
MESH CRAN L 90 X W 90 MM THK 0.3 MM SCREW DIA1.5/1.7 MM MED,SUP-2883430,CDM,C1713,HCPCS,0278,RC,,,,both,,,4870.86,3166.06,,,,,,,,,,,,,
HOOK SPNL LT ANGLED 5.5X6.5 MM MALIBU,SUP-2244637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN TIP L3MM STD EXCHG PTFE J,SUP-2302722,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.28,20.98,,,,,,,,,,,,,
KIT TKR HYBRID CEM FEM TRABECULAR MTL TIB VIT E SURF AND PAT,SUP-2212221,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
SEED BRACHYTHERAPY VAR LOAD,SUP-2135328,CDM,C2639,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
IMPLANT FACE L 55 X H 27 MM THK 5 MM LG POLYETHYL LT MALAR,SUP-2883370,CDM,C1713,HCPCS,0278,RC,,,,both,,,1462.39,950.55,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND SHLDR CUST CAP DESIGN W/O JT,SUP-2435792,CDM,L3961,HCPCS,0272,RC,,,,both,,,4329.02,2813.86,,,,,,,,,,,,,
PLATE BONE L109MM 8 HOLE RIGHT LTRL DST PRRTCLR TBL,SUP-2485430,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.18,1466.52,,,,,,,,,,,,,
PLATE BNE L271MM 12 H NONSTERILE R PERIARTC PROX HUM S STL,SUP-2177816,CDM,C1713,HCPCS,0278,RC,,,,both,,,5631.31,3660.35,,,,,,,,,,,,,
SYSTEM AUTOTRNS INTRAOP FOR ELECTIVE AORT SURG CELL SAVR,SUP-2225926,CDM,C1713,HCPCS,0278,RC,,,,both,,,1953.08,1269.50,,,,,,,,,,,,,
BUR SURGICAL DIAMETER 15MM PERFORATING FOR SKULL OPENING NEU,SUP-2804979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.21,275.09,,,,,,,,,,,,,
BUR DENT DIAMOND 0.6X70 MM STRL PM2 80K,SUP-2134820,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
BIO-COMPOSITE TRANSFIX 5X40MM,SUP-2811824,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
HC Lum Discogram/Inj Each Level,PX-3616229000,CDM,62290,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PIN FIX REFLX,SUP-2362936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.37,242.04,,,,,,,,,,,,,
CHEST TUBE KIT W/O LIDO PLEURAGUIDE DISP,SUP-2227301,CDM,C1729,HCPCS,0272,RC,,,,both,,,241.47,156.96,,,,,,,,,,,,,
PLATE BONE 14 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413756,CDM,C1713,HCPCS,0278,RC,,,,both,,,1589.97,1033.48,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DECATHLON DF CHRONIC EXCHANGE DF19IT24K,SUP-2632977,CDM,C1750,HCPCS,0278,RC,,,,both,,,1134.17,737.21,,,,,,,,,,,,,
DISTRACTOR EXT FIX 30 MM 1.5-1.8 MM 5 MM 31 HOLE END DRIVEN,SUP-2480421,CDM,C1713,HCPCS,0278,RC,,,,both,,,19177.77,12465.55,,,,,,,,,,,,,
CATHETER HD 14 FRX28 CM ASH SPLIT CATH,SUP-2269571,CDM,C1751,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
SCREW BNE OSTEOPENIA 4X65 MM PART THRD T8 DRVR EVOS,SUP-2349588,CDM,C1713,HCPCS,0278,RC,,,,both,,,566.52,368.24,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 16 MM FD ASEP,SUP-2867010,CDM,C1762,CPT,0278,RC,,,,both,,,1959.83,1273.89,,,,,,,,,,,,,
GUIDEWIRE 1.0MMX14IN ACL INTRF SCR SYS NIT,SUP-2362048,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
COLLAR CERV L20XW4IN L CNTOUR COT STOCK M DENS STOUT AD FOR,SUP-2196871,CDM,L0120,HCPCS,0272,RC,,,,both,,,12.75,8.29,,,,,,,,,,,,,
VALVE AORTIC TRANSCATH SYS NAVITOR RDPQ MRKRS 27MM,SUP-2929880,CDM,C1889,HCPCS,0278,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
GRAFT HUM TISS L W10.2XL21.1CM CORTIVA 1MM TAILORED ALLGRFT,SUP-2335288,CDM,C1762,CPT,0278,RC,,,,both,,,13068.30,8494.39,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 130 CM DIA 0.018 IN DSTL/PROX L 7,SUP-2384060,CDM,C1769,HCPCS,0272,RC,,,,both,,,455.83,296.29,,,,,,,,,,,,,
CRANIAL ACCESS KIT 5.31 MM W/ DRUG DRL BIT RAZOR,SUP-2852687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1257.38,817.30,,,,,,,,,,,,,
BRACE ORTHOPEDIC LSO BK POST OPERATIVE RIGID PANEL,SUP-2138675,CDM,L0630,HCPCS,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
DRILL SURG CANN 7.5X25 MM TRABECULAR MTL RVS +,SUP-2436962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
SCREW BNE ST 2X7 MM LCK,SUP-2569629,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.99,49.39,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB X L UNIV R,SUP-2276647,CDM,L3931,HCPCS,0274,RC,,,,both,,,28.42,18.47,,,,,,,,,,,,,
IMPLANT FEM L29MM DIA11MM INSRT APERFIX AM,SUP-2416335,CDM,C1776,CPT,0278,RC,,,,both,,,3884.18,2524.72,,,,,,,,,,,,,
SCREW BONE L50MM DIA4MM STD CANC S STL PARTIALLY THRD HEX HD,SUP-2344146,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.11,130.07,,,,,,,,,,,,,
HC Inject R Ventr/Atrial Angio,PX-4819356600,CDM,93566,CPT,0481,RC,,,,both,,,571.00,371.15,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA10 MM THK 0.49 MM POLYESTER,SUP-2227581,CDM,C1768,CPT,0278,RC,,,,both,,,1839.04,1195.38,,,,,,,,,,,,,
SEED BRACHYTHERAPY 1-2MCI I-125 LD IN EYE PHYSICS PLAQ,SUP-2247260,CDM,C2642,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
RING EXT FIX SWVL HNDL 4.75 IN W/ MULTIPLE TEETH LASER BINOC,SUP-2481829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,749.42,487.12,,,,,,,,,,,,,
CROWN DENT PED SZ 1 SEC PRI M LO R ANTR CUSPID PREFABRICATED,SUP-2238797,CDM,D6783,CPT,0278,RC,,,,both,,,19.97,12.98,,,,,,,,,,,,,
LINER ACETABLUAR SZ F DIA48.5MM HD OD42MM ID28MM THK6.5MM,SUP-2377721,CDM,C1776,CPT,0278,RC,,,,both,,,6914.28,4494.28,,,,,,,,,,,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,0636,RC,63323-0377-01,NDC,,both,0.2,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT HUM TISS M W10XL16CM THK1.6MM +/-0.4MM WHL ALLGRFT,SUP-2113183,CDM,Q4116,HCPCS,0636,RC,,,,both,,,18698.70,12154.15,,,,,,,,,,,,,
TRIAL PAT 26MM INSRT,SUP-2379227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
KIT BLD SALV AUTOTRNS 5 AD CELLSAVER,SUP-2236473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1167.83,759.09,,,,,,,,,,,,,
PIN EXT FIX HALF 3X80 MM 25MM TI NITRIDE COAT CORETRAK,SUP-2473799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
STIMULATOR NERVE IMPL 5 IPG,SUP-2637206,CDM,C1767,HCPCS,0278,RC,,,,both,,,65229.86,42399.41,,,,,,,,,,,,,
GRAFT HUM TISS 2CC ACELLULAR DERM MTRX GRFTJACKET RTM,SUP-2262295,CDM,C1713,HCPCS,0278,RC,,,,both,,,6079.04,3951.38,,,,,,,,,,,,,
ALLOGRAFT BNE CART 6.1X1 CM NACL COSTAL,SUP-2717802,CDM,C1762,CPT,0278,RC,,,,both,,,4722.53,3069.64,,,,,,,,,,,,,
PLATE BONE L107MM 8 H BILAT ELBW 1/3 TBLR LCK COMPR FOR,SUP-2348938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.05,1082.93,,,,,,,,,,,,,
INSERT HUM SHLDR TRABECULAR MTL REV 2 TAPR,SUP-2199138,CDM,C1776,CPT,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
TAP SURG L35MM CORT THRD CANN FOR 4.2MM 2 COR SCR,SUP-2187424,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE H0.6MM 6X6 H UP FACE G TI 3D LEIBINGER UNIV 2,SUP-2366270,CDM,C1713,HCPCS,0278,RC,,,,both,,,2874.89,1868.68,,,,,,,,,,,,,
CLONIDINE HCL 0.1 MG PO TABS,RX-1755,CDM,6370000000,HCPCS,0637,RC,00904-7442-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CAGE SPNL FACEPLT 14 MM 2 HOLE NO PROF,SUP-2750635,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ELECTRODE ELECSURG PED 11.5FR CUT LOOP FOR RESECTSCP,SUP-2332847,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
WASHER ORTH CONVX SPHR,SUP-2749961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
WAND ABLAT 50DEG KNEE FOR CART REP SYS FLO 50 COBLATION,SUP-2341943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 3X3 CM UMB CRD RESTORIGIN,SUP-2321892,CDM,Q4191,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SCREW SPNL L10MM DIA4MM CANC TI ST NONCANNULATED NONLOCKING,SUP-2190141,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
PLATE BNE STR WRST FUSION NS,SUP-2610352,CDM,C1713,HCPCS,0278,RC,,,,both,,,3309.47,2151.16,,,,,,,,,,,,,
FORCEPS ES L23CM DIA1MM SLIM BPLR NONSTICK DISPOSABLE,SUP-2364938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1337.61,869.45,,,,,,,,,,,,,
KIT INTRO MAK L 15 CM DIA 5 FR GUIDEWIRE L 60 CM DIA 0.018,SUP-2303006,CDM,C1894,HCPCS,0272,RC,,,,both,,,110.69,71.95,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 120 MM DIA 5 MM CATH L 80 CM DIA 5,SUP-2541389,CDM,C1876,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
DRIVER SHFT SURG UNIV NONCANNULATED NEURO 1.5MM,SUP-2365253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.95,788.42,,,,,,,,,,,,,
GRAFT BNE SUB 20CC DBM PRO-DENSE INJ INDUCTIVE PRO-STIM,SUP-2399132,CDM,C1713,HCPCS,0278,RC,,,,both,,,14685.78,9545.76,,,,,,,,,,,,,
CROWN DENT LR6 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176712,CDM,D6783,CPT,0278,RC,,,,both,,,20.35,13.23,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF 115CM 8FR DD,SUP-2248620,CDM,C1732,HCPCS,0278,RC,,,,both,,,9492.22,6169.94,,,,,,,,,,,,,
GRAFT BNE GRAN 10 CC RESRB MACR CALCIUM PHOSPHATE VITOSS,SUP-2368171,CDM,C1713,HCPCS,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
DRILL MEASURING SLEEVE 4.5MM,SUP-2587232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1090.71,708.96,,,,,,,,,,,,,
ANCHOR SUTURE 2 6.5 MM 2 ULTRABRAID TI BLU BLU TWINFIX,SUP-2849151,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
SOCK PROSTHETIC LNG FRAC,SUP-2388188,CDM,L2850,HCPCS,0274,RC,,,,both,,,152.76,99.29,,,,,,,,,,,,,
HC JONES BOLT STERILE 4.5MMX47MM,SUP-2841255,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
CANNULA ENDO DIA5.5MM OP DYONICS,SUP-2340736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1677.86,1090.61,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST COUNT REINF LTHR,SUP-2435730,CDM,L3440,HCPCS,0272,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
HC Surgery Level 5 Base,PX-3600000005,CDM,3600000005,LOCAL,0360,RC,,,,both,,,8060.00,5239.00,,,,,,,,,,,,,
ROD SPNL 7550552000] ZIMMER SPINE],SUP-2415721,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
STEM FEM TAPR 12/14 UNCEMENTED TI ALLOY HA/TCP SM MAYO,SUP-2210415,CDM,C1776,CPT,0278,RC,,,,both,,,15838.16,10294.80,,,,,,,,,,,,,
DEVICE KNEE ALIGN,SUP-2237247,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
SCREW BNE HDLSS 2.5X28 MM COMPR PART THRD NS,SUP-2458356,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.82,554.33,,,,,,,,,,,,,
HC So Dna/Rna Probe,PX-3068750766,CDM,87507,CPT,0306,RC,,,,both,,,434.00,282.10,,,,,,,,,,,,,
BIT DRILL NAV LONG 3.5MM,SUP-2711623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1806.63,1174.31,,,,,,,,,,,,,
ROD EXT FIX L214MM DIA8MM SPAN L207MM 45DEG C FBR CRV,SUP-2188721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1105.53,718.59,,,,,,,,,,,,,
KIT BX 14GA L10CM DISP MPTY,SUP-2127775,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.43,53.58,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 4.25X4.25 IN FNGR W/ BLB RADLUC,SUP-2276773,CDM,L3933,HCPCS,0274,RC,,,,both,,,4.33,2.81,,,,,,,,,,,,,
NEEDLE ENDOSCP SPARE 5 MMX31 CM FHF REPL FOR 30675ND MANHES,SUP-2767121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.68,283.19,,,,,,,,,,,,,
STEM FEM L203MM OD38MM LNG CO CHROM HIP PRESSFIT FEN IMP,SUP-2198850,CDM,C1776,CPT,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
CATHETER ETER IV THER L8CM OD18GA REINF TIP BASIC BIOPATCH,SUP-2125667,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.58,163.53,,,,,,,,,,,,,
HC Debrid Wound Tis Addl 20 Cm<,PX-7619759800,CDM,97598,CPT,0761,RC,,,,outpatient,,,194.00,126.10,,,,,,,,,,,,,
CATHETER CV DL 26 FRX60 CM 20 GA N COAT L-CATH,SUP-2133178,CDM,C1751,HCPCS,0278,RC,,,,both,,,249.44,162.14,,,,,,,,,,,,,
SHELL ACET OD55MM UNIV CSTI HIP PROTRUSIO REV PRESSFIT,SUP-2208508,CDM,C1776,CPT,0278,RC,,,,both,,,6674.07,4338.15,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST RIGID W/O JT PREFABRICATED,SUP-2435761,CDM,L3762,HCPCS,0274,RC,,,,both,,,277.01,180.06,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH L 115 CM BER TIP SEP12,SUP-2865165,CDM,C1757,HCPCS,0272,RC,,,,both,,,31368.60,20389.59,,,,,,,,,,,,,
DRILL TWST L48MM OD1.2MM 4MM W/O STP N RADLUC,SUP-2365235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE MYNXGRIP DIA 6/7 FR 10 ML FEM ART ADV,SUP-2155681,CDM,C1760,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM OD0.035IN NIT HYDRPHLC TAPR STD ANG,SUP-2168287,CDM,C1769,HCPCS,0272,RC,,,,both,,,82.36,53.53,,,,,,,,,,,,,
MEGESTROL ACETATE 400 MG/10ML PO SUSP,RX-76824,CDM,6370000000,HCPCS,0637,RC,69339-0160-01,NDC,,both,10,ML,27.00,17.55,,,,,,,,,,,,,
SCREW BNE L 9 MM DIA2.3 MM XDRV NS DISP LORENZ,SUP-2935116,CDM,C1713,HCPCS,0278,RC,,,,both,,,95.46,62.05,,,,,,,,,,,,,
BLADE SHAVER BONECUTTER PLATINUM 3.5MM,SUP-2740122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.66,354.03,,,,,,,,,,,,,
REAMER SURG OD10MM IM MOD HD FWD SIDE CUT DBL WND SHFT,SUP-2368230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW BNE L6MM OD3.8MM BLU TI CORT IM FUS LOK HEX HD ST,SUP-2388908,CDM,C1713,HCPCS,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
HC Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX-3068748300,CDM,87483,CPT,0306,RC,,,,inpatient,,,907.00,589.55,,,,,,,,,,,,,
SCREW BNE STR 0 DEG MED 2.5X19 MM HAMRTOE KT OSSIOFIBER,SUP-2641882,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
CLAMP EXT FIX TRANSITION LG MED,SUP-2645925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1546.95,1005.52,,,,,,,,,,,,,
CLIP INT LIG MED TI BLU NS VESOCCLUDE,SUP-2757593,CDM,C1889,HCPCS,0278,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
CLAMP ORTH L FOR ORTHOFIX GALAXY FIX SYS,SUP-2316294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
KIT ORTH GLEN TIGERLINK FIBERLINK SHUTTLE SUTURE CANN DRL,SUP-2882186,CDM,C1713,HCPCS,0278,RC,,,,both,,,5513.84,3584.00,,,,,,,,,,,,,
STEM HUM L170MM DIA12MM TRABECULAR MTL REV,SUP-2199127,CDM,C1776,CPT,0278,RC,,,,both,,,16879.07,10971.40,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED BROAD LCP TM 22 HOLES 408MM STERILE,SUP-2549500,CDM,C1713,HCPCS,0278,RC,,,,both,,,4731.48,3075.46,,,,,,,,,,,,,
HC Peripheral Nerve Neurolysis,PX-3600007519,CDM,3600007519,LOCAL,0360,RC,,,,inpatient,,,9630.00,6259.50,,,,,,,,,,,,,
HANDPIECE ENDO L9CM OPN FN JAW THUNDERBEAT,SUP-2313546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
PLATE BNE ACTIVE COMPR BROAD 4.5 MM 7 HOLE NS,SUP-2525139,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
PLATE BNE 1.5/2X55X1.5 MM 9 HOLE SS LC-DCP,SUP-2569199,CDM,C1713,HCPCS,0278,RC,,,,both,,,293.59,190.83,,,,,,,,,,,,,
HC Extrem Up Elbow Arthrogram,PX-3227308500,CDM,73085,CPT,0322,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
STAPLER INT LN 55 MM 6 FIRING ENDO GIA II,SUP-2129891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SCREW BNE LCK STARDRV RECESS FOR CONN ATTCH PLATE TI NS LCP,SUP-2800002,CDM,C1713,HCPCS,0278,RC,,,,both,,,522.43,339.58,,,,,,,,,,,,,
IMPLANT CRAN CUST PEEK,SUP-2431413,CDM,C1889,HCPCS,0278,RC,,,,both,,,23762.58,15445.68,,,,,,,,,,,,,
WEDGE TIB FULL 10MM 67MM RT LATERAL/LT MEDL FINN - 10MM 67MM,SUP-2406071,CDM,C1776,CPT,0278,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
BRACE THMB AD LNG POLYPR FELT LNR PERF SUEDE ALUM STAY V,SUP-2324405,CDM,L3931,HCPCS,0274,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
ORTHO ANCHRGE C TUBE PLATE CROSS SHPD RNDD LG TB3T1.5MM CP T,SUP-2492285,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.77,904.65,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE W/ SIPHONGUARD UNITZ CERTAS +,SUP-2666585,CDM,C1889,HCPCS,0278,RC,,,,both,,,13375.90,8694.33,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 38 MM CABLE L 1 M PRASS PR 2 CHANNEL,SUP-2902080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,534.87,347.67,,,,,,,,,,,,,
SCREW INTRF L30MM DIA9MM PLLA KNEE BIOABSRB BLNT THRD ENLD,SUP-2340995,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
PLATE BNE 0MM LAT CLMN LENGTHENING LOK POLYAX,SUP-2363893,CDM,C1713,HCPCS,0278,RC,,,,both,,,5530.48,3594.81,,,,,,,,,,,,,
SYSTEM ABLAT CARD SURG BPLR TRANSMURALITY PEN CARDIOBLATE,SUP-2278865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ TAB 1.14 MM ID SIL STRL,SUP-2277568,CDM,L8699,HCPCS,0278,RC,,,,both,,,245.86,159.81,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 3FR 0.024IN 60CM 1 LUMAN 3153107,SUP-2632641,CDM,C1751,HCPCS,0278,RC,,,,both,,,314.94,204.71,,,,,,,,,,,,,
SUPPORT ORTHOT HIP KNEE ANK CUST TORSON BALL BEAR J,SUP-2435642,CDM,L2060,HCPCS,0272,RC,,,,both,,,1725.68,1121.69,,,,,,,,,,,,,
SCREW BONE L60MM DIA6.5MM STD CONCL PARTIALLY THRD CANN LCK,SUP-2351137,CDM,C1713,HCPCS,0278,RC,,,,both,,,1793.98,1166.09,,,,,,,,,,,,,
PLATE BONE W12XL55MM 3 H SEMI TBLR ECT,SUP-2198535,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.95,86.42,,,,,,,,,,,,,
ROD EXT FIX 60MM GRAD TELSCP FOR ILIZ FIX SYS,SUP-2340703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2385.77,1550.75,,,,,,,,,,,,,
ANKLE JOINT ARSENAL 4.5MM 80MM TITANIUM ALLOY MALLEOLUS,SUP-2879042,CDM,C1713,HCPCS,0278,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
PIN ORTH L203.2MMM OD3.1MM S STL SMOOTH BLNT TIP RND BVL PT,SUP-2342642,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
OCCLUDER GORE CARDIOFORM ASD 27MM 10FR,SUP-2855590,CDM,C1817,HCPCS,0278,RC,,,,both,,,26234.70,17052.55,,,,,,,,,,,,,
HUMERAL TRAY REVERSED 1.5 MM 12+ MM SHLDR LO OFFSET,SUP-2715761,CDM,C1776,CPT,0278,RC,,,,both,,,5666.13,3682.98,,,,,,,,,,,,,
NARROW PLATE 4.5MM 15X247MM,SUP-2818525,CDM,C1713,HCPCS,0278,RC,,,,both,,,2704.67,1758.04,,,,,,,,,,,,,
PASSER SUTURE SPECTRUM AUTOPASS,SUP-2828669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,28683.90,18644.53,,,,,,,,,,,,,
IMPLANT URO AD 2.5ML INJ BULK AGNT FEM FOR TREAT STRESS,SUP-2165099,CDM,L8606,HCPCS,0278,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
OSS SPLINED STEM 10X120MM,SUP-2506341,CDM,C1776,CPT,0278,RC,,,,both,,,4931.37,3205.39,,,,,,,,,,,,,
SCREW OSTEOTOMY JACK,SUP-2811975,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ADV MIC 14 L 50 CM BALLOON L 4 CM DIA1.5,SUP-2169584,CDM,C1725,HCPCS,0272,RC,,,,both,,,1271.32,826.36,,,,,,,,,,,,,
SCREW 3.5MM TI CONICAL SLF-TPNG FULLY THREADED 55MM,SUP-2549319,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.34,271.27,,,,,,,,,,,,,
KIT INSTR AUTOCUFF COMPRISING OM-8000 OM-9010 OM-9015,SUP-2342102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8933.30,5806.64,,,,,,,,,,,,,
HC Immunoassay Tumor Antigen Quantitative Ca 125,PX-3028630400,CDM,86304,CPT,0302,RC,,,,both,,,506.00,328.90,,,,,,,,,,,,,
HEAD HUM STD 40X15 MM SHLDR AFFINITI,SUP-2715318,CDM,C1776,CPT,0278,RC,,,,both,,,7082.27,4603.48,,,,,,,,,,,,,
STENT URET L 30 CM DIA 6 FR PTFE GUIDEWIRE L 100 CM DIA BLK,SUP-2312680,CDM,C2617,HCPCS,0278,RC,,,,both,,,439.57,285.72,,,,,,,,,,,,,
HC So Unlisted Chemistry Procedure,PX-3018499966,CDM,84999,CPT,0301,RC,,,,both,,,78.00,50.70,,,,,,,,,,,,,
CATHETER INFUSION ENDOVASC DEV 12 FRX135 CM US COR EKOSONIC,SUP-2214804,CDM,C1887,HCPCS,0272,RC,,,,both,,,20676.90,13439.98,,,,,,,,,,,,,
BUTTON BACKSTOP ALL SUTURE RADIOLUCENT MICROLINK,SUP-2828520,CDM,C1713,HCPCS,0278,RC,,,,both,,,6069.62,3945.25,,,,,,,,,,,,,
DRESSING BIO 5 CC PORCINE URINARY BLDR MTRX 2 SYR SYS STRL,SUP-2909174,CDM,A2028,HCPCS,0636,RC,,,,both,,,8595.56,5587.11,,,,,,,,,,,,,
SCREW DISC RET FOR RNG CUT SYS GEM,SUP-2421503,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
SCREW CANN SHRT 12.5MM OD 8.0MM ID,SUP-2457974,CDM,C1713,HCPCS,0278,RC,,,,both,,,1718.02,1116.71,,,,,,,,,,,,,
GUIDE SURG PLN TI LP DISTRCTN CUSTOMIZABLE VSP,SUP-2883940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
PIN FIX L40MM OD1.5MM LACTOSORB COPOLYMER ABSRB SGL USE,SUP-2137294,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
CATHETER ETER PICC DIA3FR POLYUR SGL LUMN INTMED TY W SFTY,SUP-2125524,CDM,C1751,HCPCS,0278,RC,,,,both,,,254.65,165.52,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL BND BELT BILATERAL,SUP-2435689,CDM,L2640,HCPCS,0274,RC,,,,both,,,889.62,578.25,,,,,,,,,,,,,
LOANER TRABECULAR MTL IMPLE,SUP-2414455,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
PIN FIX L40MM DIA2MM PROV FOR EVOS SM PLATING SYS,SUP-2344054,CDM,C1713,HCPCS,0278,RC,,,,both,,,968.56,629.56,,,,,,,,,,,,,
STEM FEM SEG 5 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449807,CDM,C1776,CPT,0278,RC,,,,both,,,10905.53,7088.59,,,,,,,,,,,,,
IMPLANT HUMAN TSSUE W107XH104 228XL215MM ACLLLR DRML TSSUE,SUP-2676575,CDM,Q4116,HCPCS,0636,RC,,,,both,,,18299.92,11894.95,,,,,,,,,,,,,
NEEDLE BX MENG LIV 3.5 MMX30 CM 16 MM,SUP-2766981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.99,488.14,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 2 PLATE CUSTOMIZED FACE ID,SUP-2883365,CDM,C1713,HCPCS,0278,RC,,,,both,,,34299.38,22294.60,,,,,,,,,,,,,
STYLET RETRV INOUE-BALLOON L 80 CM DIA 0.038 IN SS PERC,SUP-2388519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
SCREW BNE L10MM OD35MM CANC ACET HIP ST SELF DRL X CHANGE,SUP-2368348,CDM,C1713,HCPCS,0278,RC,,,,both,,,96.77,62.90,,,,,,,,,,,,,
CANNULA SUCTION HASSON 5 MM AUTO-VALVE,SUP-2484301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2016.82,1310.93,,,,,,,,,,,,,
BAR EXT FIX SM SZ 2 FOR XTRAFIX SYS,SUP-2199702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4036.28,2623.58,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 5FR 0.021IN SS,SUP-2385480,CDM,C1894,HCPCS,0272,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-141354,CDM,J1806,HCPCS,0250,RC,44567-0811-10,NDC,,both,250,ML,687.20,446.68,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0250,RC,00338-0017-31,NDC,,both,250,ML,108.40,70.46,,,,,,,,,,,,,
BRACE WRST AND FA R CIRC LESS THAN 13IN LEN 10IN SZ UNIV,SUP-2197069,CDM,L3931,HCPCS,0272,RC,,,,both,,,25.28,16.43,,,,,,,,,,,,,
GABAPENTIN 400 MG PO CAPS,RX-18307,CDM,6370000000,HCPCS,0637,RC,00904-6667-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE 1.5/2X73X1.5 MM 12 HOLE SS LC-DCP,SUP-2569201,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.86,214.41,,,,,,,,,,,,,
BUR SURG DIA5MM SIL S STL CRNRSTN MIC HVY DUTY DISPOSABLE,SUP-2363369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1197.63,778.46,,,,,,,,,,,,,
CATHETER PTCA 3.7FR L80CM DURALYN BLLN L2CM DIA6MM GUID 6FR,SUP-2156712,CDM,C1725,HCPCS,0272,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
BALL CARPAL WRIST MED NEUT,SUP-2696157,CDM,C1776,CPT,0278,RC,,,,both,,,3346.93,2175.50,,,,,,,,,,,,,
GRAFT BIO TISS W3.9XL3.9IN PORCINE DERM RIFAMPIN,SUP-2125834,CDM,C1781,HCPCS,0278,RC,,,,both,,,10716.19,6965.52,,,,,,,,,,,,,
KIT PICC CATH TRAY 4 FR WITHOUT CHG WITH VPS,SUP-2120612,CDM,C1751,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
SCREW BONE L16MM OD3.5MM COARSE THRD CRUCFRM WDRUFF HD,SUP-2362292,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN 1000 ML,RX-40861025,CDM,J7030,HCPCS,0250,RC,00338-9793-01,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
PLATE BONE L121MM 10 H S STL SELF COMPR FOR 3.5MM SCR ECT,SUP-2198567,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.28,195.18,,,,,,,,,,,,,
PLATE BNE THK05MM 6X2 H UNIV CRANIOMAXILLOFACIAL TI 3D MAL,SUP-2366230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.83,937.19,,,,,,,,,,,,,
PLATE BNE STR MIC 1.5X1 MM 24 HOLE TI,SUP-2472729,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.95,545.32,,,,,,,,,,,,,
BUR SURG MTCH HD 1.7 MMX10 CM FLUT SM BOR MIDAS REX LEGEND,SUP-2665009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,294.97,191.73,,,,,,,,,,,,,
GRAFT BNE SUB L CANC FRZN MORSELIZED W/ VIABLE CELL TRINITY,SUP-2307241,CDM,C1713,HCPCS,0278,RC,,,,both,,,10330.60,6714.89,,,,,,,,,,,,,
MESH HERN RECT 10X6 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855252,CDM,C1781,HCPCS,0278,RC,,,,both,,,16406.50,10664.22,,,,,,,,,,,,,
NAIL IM L440MM DIA25MM OLECRANON ROSE RED S STL E FLX,SUP-2186443,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.53,552.19,,,,,,,,,,,,,
KIT VERTEBROPLASTY BONE CEM DEL W/ INJ,SUP-2308557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CROWN DENT PED SZ LL5 LO LT ANTR CUSPID 1ST PRI M S STL,SUP-2238889,CDM,D6783,CPT,0278,RC,,,,both,,,19.41,12.62,,,,,,,,,,,,,
SCREW BNE L16MM DIA4MM TI MID FT POLYAX LOK LO PROF OP,SUP-2401183,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SCREW BNE LCK 2.7 MM TOT WR STARDRV FUSION BLK NS SURFIX,SUP-2610309,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.96,296.37,,,,,,,,,,,,,
SYSTEM OPHTH IRRIGATION STRL DISP STREAMLINE,SUP-2891353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
CATHETER LD DEL ATTAIN L 48.5 CM OD 9 FR ID 7.2 FR POLYETHER,SUP-2282153,CDM,C1887,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE CRV MIC 1.5X0.6 MM NEURO 3X2 HOLE LADDER SQ SEG,SUP-2476261,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.35,493.58,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK L 32 MM DIA 3 MM MICROCATHETER,SUP-2551059,CDM,C1757,HCPCS,0272,RC,,,,both,,,11547.98,7506.19,,,,,,,,,,,,,
PLATE BNE CLVRLF 3.5X200 MM 10 HOLE 2 COMPR FOR SCR SS NS,SUP-2471579,CDM,C1713,HCPCS,0278,RC,,,,both,,,1304.04,847.63,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM MAND 36 HOLE FULL MAND LCK TI NS,SUP-2477692,CDM,C1713,HCPCS,0278,RC,,,,both,,,6925.96,4501.87,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR NIT SHFT SS TIP STIFF DIL MIC,SUP-2615876,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
PLATE BNE CLAV 3.5X115 MM RT 8 HOLE SS NS,SUP-2177136,CDM,C1713,HCPCS,0278,RC,,,,both,,,2981.24,1937.81,,,,,,,,,,,,,
MESH HERN L35.6XW30.5CM POLYPR ABD ABSRB RECTANG SEPRAMESH,SUP-2125921,CDM,C1781,HCPCS,0278,RC,,,,both,,,4567.13,2968.63,,,,,,,,,,,,,
CATHETER ABLATN LG 1 2-5-2 4 MM 1304-CP-7-25-L1-AB THER,SUP-2484445,CDM,C2630,CPT,0272,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
DISSECTOR ENDOSCP 5 MM W/ MONOPOLAR CAUT,SUP-2787741,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.31,454.55,,,,,,,,,,,,,
PROSTHESIS VOICE RAPID EXCHANGE 20 FRX10 MM NS BLOM-SINGER,SUP-2242337,CDM,L8509,HCPCS,0272,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
SUPPORT EL NEOPRENE11 13IN L,SUP-2276611,CDM,L3702,HCPCS,0274,RC,,,,both,,,10.61,6.90,,,,,,,,,,,,,
COVERLOC VOLAR PLATE 22MM 3 HOLE RIGHT,SUP-2830148,CDM,C1713,HCPCS,0278,RC,,,,both,,,2050.42,1332.77,,,,,,,,,,,,,
INTRODUCER SHTH GUID 0.038 IN 8.5 FRX60 CM DIL FAST-CATH,SUP-2357188,CDM,C1894,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
FIBER LASER W/ LITHO HOLM,SUP-2225710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 15.5 CM DIA 5 FR DIL 20 CM GUIDEWIRE,SUP-2168169,CDM,C1894,HCPCS,0272,RC,,,,both,,,111.63,72.56,,,,,,,,,,,,,
BRACE ORTH POST LUMBAR BK PREFABRICATED LSO,SUP-2388149,CDM,L0630,HCPCS,0272,RC,,,,both,,,417.09,271.11,,,,,,,,,,,,,
HC Clsd Tx Fx Great Toe W Manip,PX-4502849500,CDM,28495,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-3603399500,CDM,33995,CPT,0360,RC,,,,outpatient,,,7747.00,5035.55,,,,,,,,,,,,,
COMPONENT KNEE RJP POROUS ATTUNE,SUP-2427743,CDM,C1776,CPT,0278,RC,,,,both,,,14731.81,9575.68,,,,,,,,,,,,,
DESILETS-HOFFMAN INTRODUCER SET,SUP-2827464,CDM,C1894,HCPCS,0272,RC,,,,both,,,203.75,132.44,,,,,,,,,,,,,
FORCEPS SPEC RETRV L135CM OD3FR S STL VASC BRAID,SUP-2168281,CDM,C1773,HCPCS,0272,RC,,,,both,,,1921.52,1248.99,,,,,,,,,,,,,
BRACE ORTHOSIS SPNL S M EXOS FRM II 637,SUP-2196548,CDM,L0641,HCPCS,0272,RC,,,,both,,,488.40,317.46,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 8MM 4 ELECTRD FJ,SUP-2248501,CDM,C1733,HCPCS,0272,RC,,,,both,,,3746.02,2434.91,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 33 CM DIA14 FR BODY DIA 5.3 MM,SUP-2395728,CDM,C1894,HCPCS,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CATHETER HAD L28CM DIA16FR HYDRPHLC TIP BASIC CHRONIC SGL,SUP-2117395,CDM,C1750,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
HANDPIECE ENDO L35CM DIA5MM THUNDERBEAT FR ACTUATED GRP,SUP-2313548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
CATHETER DRNGE 10FR L25CM SGL LUMN SFT LOOP GLDEX COAT,SUP-2139736,CDM,C1729,HCPCS,0272,RC,,,,both,,,253.49,164.77,,,,,,,,,,,,,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,6370000000,HCPCS,0637,RC,61314-0656-25,NDC,,both,2.5,ML,47.30,30.74,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC W/ CHIP DBM PUROS,SUP-2335223,CDM,C9359,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DBM GEL FRZ DRY OPTIUM,SUP-2264857,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.30,1103.89,,,,,,,,,,,,,
SCREW BONE L20MM DIA3.4MM HEX DRVR DIA2MM BLU ST CANN FULL,SUP-2136634,CDM,C1713,HCPCS,0278,RC,,,,both,,,937.26,609.22,,,,,,,,,,,,,
HC Antibody Screen,PX-3028685000,CDM,86850,CPT,0302,RC,,,,both,,,160.00,104.00,,,,,,,,,,,,,
GRAFT EVAR L16CM AORT OD23MM ID19-21MM IL OD12MM ID10-11MM,SUP-2395971,CDM,C1768,CPT,0278,RC,,,,both,,,23945.64,15564.67,,,,,,,,,,,,,
ANCHOR SUTURE L11MM DIAMETER 3.1MM PRE THREADED WITH ONE NO,SUP-2825036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.01,656.51,,,,,,,,,,,,,
STABILIZER SURG NOT IMPL OCTPS 4.3,SUP-2282583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
STAPLER INT 3.4 MMX35 MM RELD SS STRL MULTFI PREM DISP,SUP-2787675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,313.50,203.77,,,,,,,,,,,,,
PLATE BNE L94MM 8 H BILAT S STL CRV RECON NONLOCKING,SUP-2197681,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.49,760.17,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA BASIC 4FR 55CM 2 LUMAN RVS,SUP-2613560,CDM,C1751,HCPCS,0278,RC,,,,both,,,603.23,392.10,,,,,,,,,,,,,
COMPONENT TALAR SZ 1 L ANK CO CHROM FLAT CUT SALTO TALARIS,SUP-2244185,CDM,C1776,CPT,0278,RC,,,,both,,,33576.02,21824.41,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CELLULAR BNE MTRX OSTEOCEL +,SUP-2310451,CDM,C1713,HCPCS,0278,RC,,,,both,,,14365.50,9337.57,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL DIA20 GA SGL SHT LIDO NACL SYR BLU,SUP-2936714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,58.18,37.82,,,,,,,,,,,,,
BIOPSY SET LIV ACCS 7 FRX60 CM 19 GAX20 MM PRE CRV MECH NDL,SUP-2638571,CDM,C1887,HCPCS,0272,RC,,,,both,,,1753.91,1140.04,,,,,,,,,,,,,
BIT DRL L300X250MM DIA5MM 3 FLUT CANN CALIB FOR QUIK CPL,SUP-2178977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.87,751.32,,,,,,,,,,,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,0636,RC,60505-6146-04,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PIN DISTRACTOR 16 MM TI STRL 0460002910S,SUP-2591710,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PLATE BNE L L36MM 4 H NONSTERILE BILAT FOREFOOT TI X SHP VAR,SUP-2181211,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.54,2255.20,,,,,,,,,,,,,
BLADE SURG BLACKLINE 45X22.5 MM TEETHED 2 LEVEL SS TI LF,SUP-2763779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.11,338.07,,,,,,,,,,,,,
PLATE BNE L65MM 3 H L DST POSTEROLATERAL HUM S STL LOK,SUP-2185891,CDM,C1713,HCPCS,0278,RC,,,,both,,,2302.84,1496.85,,,,,,,,,,,,,
LACTATED RINGERS IV BOLUS,RX-40840057,CDM,J7120,HCPCS,0258,RC,00338-0117-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
PLATE BONE W8XL44MM THK2MM 0DEG 5 H BILAT S STL STR RIG DYN,SUP-2186176,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.92,324.95,,,,,,,,,,,,,
INTRODUCER VASC HEMSTAS VLV W/ 60 DEG CRV 7FRX40CM FAST CATH,SUP-2355590,CDM,C1894,HCPCS,0272,RC,,,,both,,,124.82,81.13,,,,,,,,,,,,,
COMPONENT TIBIAL STERILE LATEX MEDIUM VERSION STAR,SUP-2879177,CDM,C1776,CPT,0278,RC,,,,both,,,18197.24,11828.21,,,,,,,,,,,,,
STENT URETH KOYLE DIAP L 50 CM DIA 8 FR,SUP-2835761,CDM,C2617,HCPCS,0278,RC,,,,both,,,127.33,82.76,,,,,,,,,,,,,
SYSTEM SPINAL CORUS X,SUP-2859206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
NAIL IM L420MM OD11.5MM 130DEG ANG LIME LOK CANN TI L FEM,SUP-2347982,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PUSHER KNOT 32CM 5MM ULTRA INSTR LATEX FREE PVC FREE DEHP FR,SUP-2679943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,521.18,338.77,,,,,,,,,,,,,
BONE MATRIX CELLULAR VIAFORM MOLDABLE 1CC,SUP-2854489,CDM,C1713,HCPCS,0278,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
HC CT Lower Ext W/ Cont,PX-3527370100,CDM,73701,CPT,0352,RC,,,,both,,,2769.00,1799.85,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE LG FRZN ASEP TIB,SUP-2867059,CDM,C1762,CPT,0278,RC,,,,both,,,2523.62,1640.35,,,,,,,,,,,,,
BUR SURG L14CM HD L38MM DIA3MM MTCH HD DMND TELSCP MIDAS,SUP-2281647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.56,263.61,,,,,,,,,,,,,
LEAD DEFIB RIATA ST OPTIM TI POLYUR SIL BPLR SINGLE COIL,SUP-2357372,CDM,C1777,HCPCS,0275,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
BURR ENDOSCP SHAVER 70 DEG DIA 4 MM ENT DIAMOND ANGLED,SUP-2900163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
GRAFT VASC IMPRA L 90 CM DIA 8 MM EPTFE STR STD WALL N RING,SUP-2761375,CDM,C1768,CPT,0278,RC,,,,both,,,2905.76,1888.74,,,,,,,,,,,,,
SCREW BONE L10MM OD2.5MM MIC TI ST SELF DRL CANN COMPR HDLSS,SUP-2321405,CDM,C1713,HCPCS,0278,RC,,,,both,,,700.06,455.04,,,,,,,,,,,,,
ENDOSCOPIC SET FOR AUTOGRFT TRANSFER SYS DISP,SUP-2121639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
HC Ffp,PX-3900901700,CDM,P9017,CPT,0390,RC,,,,both,,,548.00,356.20,,,,,,,,,,,,,
MESH SURG L 15 X W 10 CM POLYETHYL TEREPHTHALATE ABD WHT,SUP-2901759,CDM,C1781,HCPCS,0278,RC,,,,both,,,3418.58,2222.08,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5 CM DIA11 MM CATH L 110 CM,SUP-2396465,CDM,C1874,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
COIL NEUROVASCULAR L 30 CM DIA 0.135 IN MICROCATHETER DIA,SUP-2896805,CDM,C1889,HCPCS,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
MESH CRAN L 90 X W 90 MM THK 0.6 MM SCREW DIA1.5/1.7 MM MED,SUP-2883503,CDM,C1713,HCPCS,0278,RC,,,,both,,,20563.39,13366.20,,,,,,,,,,,,,
"HC So2 Antibody Virus, Nos",PX-3028679068,CDM,86790,CPT,0302,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
TRAY CV CATH ARW TI PRT SIL CATH NDL SYR FOR VASC ACCS,SUP-2383954,CDM,C1788,HCPCS,0278,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
PROBE STIM SIDE BY SIDE INSUL TIP POLARIZED CBL HNDL KARTUSH,SUP-2279926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.01,302.91,,,,,,,,,,,,,
SHEATH INTRO AD 8FR L59CM DIL L67CM 0032IN PTFE INTCARD,SUP-2294364,CDM,C1893,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT HIP CONSUM,SUP-2378875,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
RASP SURG RIORDAN NSL HANDHELD SGL END STR TAPR FLAT BLDE,SUP-2367146,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.83,313.19,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX25 CM 13 GA 3L RIFAMPIN SPECTRUM,SUP-2759718,CDM,C1751,HCPCS,0278,RC,,,,both,,,357.49,232.37,,,,,,,,,,,,,
CATHETER THROMCTMY L 65 CM DIA 6 FR S WAVE WIRE SYNTH GRFT,SUP-2227490,CDM,C1757,HCPCS,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
BEARING TIB PS 11X87/91 MM ASCNT,SUP-2449795,CDM,C1776,CPT,0278,RC,,,,both,,,3254.14,2115.19,,,,,,,,,,,,,
ROD SPNL L35 MM STR CRD STRL TRANSITION,SUP-2230037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1676.76,1089.89,,,,,,,,,,,,,
INDOMETHACIN 25 MG PO CAPS,RX-3897,CDM,6370000000,HCPCS,0637,RC,31722-0542-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE SURG PARL 4-4.5 MM SCR RIVAL,SUP-2644843,CDM,C1769,HCPCS,0272,RC,,,,both,,,1951.20,1268.28,,,,,,,,,,,,,
INSERTER SURG W/ BIOABSORBABLE 2 ANCHR STRL LF,SUP-2867242,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PLATE BONE W16XL124MM BLDE L50MM THK4.8MM 95DEG 7 H STRL,SUP-2185499,CDM,C1713,HCPCS,0278,RC,,,,both,,,3112.37,2023.04,,,,,,,,,,,,,
PLATE BNE L91MM THK385MM 7 H BILAT S STL STR WIDE ANG LO,SUP-2177154,CDM,C1713,HCPCS,0278,RC,,,,both,,,1292.02,839.81,,,,,,,,,,,,,
KIT BONE MAR ASPIR CONC SYS BOS,SUP-2137031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
KIT CATHETER 14FR L9IN PERC CAV DRNGE ASSEMB CRV BLU FLEXTIP,SUP-2383258,CDM,C1729,HCPCS,0272,RC,,,,both,,,716.89,465.98,,,,,,,,,,,,,
TRIAL SPACER STR 10X23X11 MM,SUP-2690483,CDM,C1889,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.045X6 IN SS NS KIRSCHNER DISP,SUP-2791232,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.57,5.57,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SABER L 150 CM BALLOON L 250 MM DIA 4.5,SUP-2909664,CDM,C1725,HCPCS,0272,RC,,,,both,,,807.77,525.05,,,,,,,,,,,,,
HEMI TOE IMPL K2 SZ 1,SUP-2243069,CDM,C1776,CPT,0278,RC,,,,both,,,4681.74,3043.13,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT STEM SHELL EPOCH TRAB MEL,SUP-2212733,CDM,C1776,CPT,0278,RC,,,,both,,,15814.61,10279.50,,,,,,,,,,,,,
ALLOGRAFT CUBE CANC IRRADIATED 60CC,SUP-2212021,CDM,C1889,HCPCS,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 8 MM RNG L 20 CM EPTFE STR TW,SUP-2396164,CDM,C1768,CPT,0278,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
CATHETER EP 7FR L4MM STR TIP 2.5MM ASYM CRV QPLR BLZR PRIM,SUP-2141853,CDM,C1725,HCPCS,0272,RC,,,,both,,,2859.91,1858.94,,,,,,,,,,,,,
NAIL IM L150MM OD10MM TI LO EXT FOR RECON SURG PANTA,SUP-2243605,CDM,C1713,HCPCS,0278,RC,,,,both,,,12842.51,8347.63,,,,,,,,,,,,,
WIRE FIX BOLT,SUP-2197304,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GRAFT VASC STENT L 60 MM DIA 8 MM CATH L 117 CM GUIDEWIRE,SUP-2889371,CDM,C1874,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
MESH HERN DIA4.5IN OMEGA 3 FATTY ACID POLYPR RND,SUP-2265995,CDM,C1781,HCPCS,0278,RC,,,,both,,,1701.88,1106.22,,,,,,,,,,,,,
ROD EXT FIX L100MM DIA11MM UNIV C FBR NONRADIOPAQUE REUSE 39480R] DEPUY SYNTHES USA],SUP-2188648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.62,493.10,,,,,,,,,,,,,
SUPPORT LO PROF LUM LSO VISTA 631,SUP-2123915,CDM,L0631,HCPCS,0274,RC,,,,both,,,629.41,409.12,,,,,,,,,,,,,
DRILL SURG CTRL MBT LCS COMPLETE,SUP-2453458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
HC Venous Sel Cath Plcmt 2nd Ord,PX-3613601200,CDM,36012,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
KIT DRNGE 1000ML VAC BTL FOR PLEUR EFFUSIONS MALIG ASCITES,SUP-2133746,CDM,C1729,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SHELL ACET PRESSFIT PRI 48 MM OD UNIV CLUS H,SUP-2210277,CDM,C1776,CPT,0278,RC,,,,both,,,5939.31,3860.55,,,,,,,,,,,,,
CONNECTOR SHUNT 1X1.9X11 MM STR SS STRL ACCU-FLO,SUP-2666410,CDM,C1889,HCPCS,0278,RC,,,,both,,,340.56,221.36,,,,,,,,,,,,,
CATHETER VENTRICULAR 14 CM RT ANGLED ADAPTOR BACTISEAL,SUP-2666472,CDM,C1729,HCPCS,0272,RC,,,,both,,,1697.01,1103.06,,,,,,,,,,,,,
SCREW SPNL L28MM DIA5.2MM CORT ANT LUM ST VAR ANG AEGIS,SUP-2255178,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 3X44 MM SS NS,SUP-2183417,CDM,C1713,HCPCS,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
KIT CRAN DRL 025IN,SUP-2244100,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.41,544.97,,,,,,,,,,,,,
COIL NEUROVASCULAR TRUFILL DCS ORBIT L 12 CM SHP DIA 5 MM,SUP-2458341,CDM,C1889,HCPCS,0278,RC,,,,both,,,3243.37,2108.19,,,,,,,,,,,,,
BLADE SURG SAFETY SZ 23 STAINLES STL BARD PARKER LTXFRDM STR,SUP-2605895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5.81,3.78,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S1294108D,SUP-2632808,CDM,C1751,HCPCS,0278,RC,,,,both,,,931.86,605.71,,,,,,,,,,,,,
TRUMATCH HP FEM O KIT SZ2,SUP-2823514,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT HUM TISS W10XL60MM FIBULAR STRUT RND,SUP-2307390,CDM,C1713,HCPCS,0278,RC,,,,both,,,3585.57,2330.62,,,,,,,,,,,,,
SCREW BNE 4MMX28MM CANN HI TORQ CAPTURE,SUP-2243994,CDM,C1713,HCPCS,0278,RC,,,,both,,,1170.44,760.79,,,,,,,,,,,,,
FECAL KIT PROTECT FMS FILL PROTCT FLEXI-SEAL,SUP-2151525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.58,240.23,,,,,,,,,,,,,
MESH CRAN L 70 X W 80 MM SCREW DIA2 MM TI PANEL NS DISP,SUP-2936737,CDM,C1713,HCPCS,0278,RC,,,,both,,,3632.98,2361.44,,,,,,,,,,,,,
CAGE SPNL LORDTC 15 DEG 30X24X13 MM ALIF ALEUTIAN,SUP-2536830,CDM,C1889,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
DRILL SURG CANN SHT LG 4.8 MM AO QR NS LTX,SUP-2856035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
HC Babygram/Osseous Survey,PX-3207707600,CDM,77076,CPT,0320,RC,,,,both,,,473.00,307.45,,,,,,,,,,,,,
LINER ACET CONSTRN NEUT TI POLYETH LOK RNG HIP IMPL + 4MM,SUP-2250294,CDM,C1776,CPT,0278,RC,,,,both,,,11388.78,7402.71,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 2 1.8 MM HIP FIBERTAK,SUP-2423106,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
SYSTEM THR PART CO CHROM R3,SUP-2348016,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
HC Xr Aortogram Thorac S&I,PX-3237560500,CDM,75605,CPT,0323,RC,,,,both,,,3892.00,2529.80,,,,,,,,,,,,,
PRE-LOADED APPLICATORS 5MM DIAMETER - 42CM LENGTH 50MMX5MMX1,SUP-2826788,CDM,C1763,HCPCS,0278,RC,,,,both,,,231.73,150.62,,,,,,,,,,,,,
"HC Spinal Puncture,Therapeutic",PX-3616227200,CDM,62272,CPT,0361,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
LIDOCAINE HCL (CARDIAC) PF 100 MG/5ML IV SOLN,RX-145135,CDM,J2003,HCPCS,0636,RC,63323-0208-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE LOCKING LARGE STERNAL 8 HOLE PRECONTOURED TITANIU,SUP-2838430,CDM,C1713,HCPCS,0278,RC,,,,both,,,3292.60,2140.19,,,,,,,,,,,,,
SCREW BNE HDLSS SHT 6.5X105 MM CANN COMPR NS LTX,SUP-2861222,CDM,C1713,HCPCS,0278,RC,,,,both,,,1746.47,1135.21,,,,,,,,,,,,,
CATHETER HEMODIALYSI TRI FLO ACTE 11.5FR DIA 15CM STRGHT TAP,SUP-2610548,CDM,C1752,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
SCREW BONE L40MM DIA4.5MM HD NONLOCKING LO PROF FOR INTOSS,SUP-2223847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
SYSTEM DEL CARDPLG TRILLIUM SURF MYOTHERM XP,SUP-2473482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.95,222.27,,,,,,,,,,,,,
STENT CORONARY XIENCE SKYPOINT L 38 MM DIA 3.5 MM SYS L 145,SUP-2845184,CDM,C1874,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COUPLER EXT FIX INVRT PIN TO ROD DELT FOR HOFFMANN III SYS,SUP-2372220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2046.34,1330.12,,,,,,,,,,,,,
CATHETER INTVASC OCCL FOGARTY L 40 CM DIA 8 MM BALLOON DIA,SUP-2214269,CDM,C2628,HCPCS,0272,RC,,,,both,,,421.07,273.70,,,,,,,,,,,,,
PLATE BNE 2/2.4X41X1.7 MM 5 HOLE SS LC-DCP,SUP-2569204,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.05,180.73,,,,,,,,,,,,,
FIBER LASER 272UM EXCALIBUR DUST THULIUM,SUP-2885332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BNE TIBIOTALAR RT LAT ANK FUSION ALIGNX,SUP-2610039,CDM,C1713,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
GRAFT BONE 10ML DEMIN MTRX PASTE OSTEOFIL RT,SUP-2293738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2914.55,1894.46,,,,,,,,,,,,,
WEDGE FEM SZ 3 THK20MM DSTL KNEE FOR HNG SYS LEGION,SUP-2346405,CDM,C1776,CPT,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
PLATE BONE STRL CLMN FUS FOR 3.5MM SCR VLP,SUP-2349957,CDM,C1713,HCPCS,0278,RC,,,,both,,,8452.10,5493.86,,,,,,,,,,,,,
GRAFT URO SYR SYN INJ COAPTITE,SUP-2139476,CDM,L8606,HCPCS,0278,RC,,,,both,,,1665.77,1082.75,,,,,,,,,,,,,
DIS HUM POSTLAT LT 25H 250MM,SUP-2499005,CDM,C1713,HCPCS,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
TUBE MYR DIA1.14MM 0.045 BVL FLROPLAS VENT ARMSTR GRMMT,SUP-2312541,CDM,L8699,HCPCS,0278,RC,,,,both,,,58.00,37.70,,,,,,,,,,,,,
COMPONENT PATELLOFEMORAL 1 LT KNEE N-K II,SUP-2208961,CDM,C1776,CPT,0278,RC,,,,both,,,14336.30,9318.59,,,,,,,,,,,,,
DEVICE SURG 23X121 MM TIV TROCHANTERIC 2 CABLE,SUP-2410260,CDM,C1713,HCPCS,0278,RC,,,,both,,,5050.53,3282.84,,,,,,,,,,,,,
RING EXT FIX HALF 110 MM CARBON FIBER RINGFIX,SUP-2365274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2913.92,1894.05,,,,,,,,,,,,,
GRAFT HUM TISS L 1.5-2.9 X W 0.7-0.9 CM THK 3 MM SM COSTAL,SUP-2895219,CDM,C1762,CPT,0278,RC,,,,both,,,1623.07,1055.00,,,,,,,,,,,,,
PLATE BNE L 1.5X23X0.6 MM MIDFACE 4X3 HOLE W/ TAB TI STRL,SUP-2518097,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.68,552.29,,,,,,,,,,,,,
KIT ARTHSCP FIBROCARTILAGE REP TRIANG COMPLX GWIRE DRL BIT,SUP-2122599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GUIDEWIRE SURG DIA3MM BEAD TIP FOR VALOR HINDFOOT FUS SYS,SUP-2397546,CDM,C1769,HCPCS,0272,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
POST EXT FIX 30DEG ANG JET-X,SUP-2342957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1696.51,1102.73,,,,,,,,,,,,,
BALLOON STONE EXTR OD8.5X12X15MM CATH L275CM OD6.6FR 0.035IN,SUP-2170825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
PIN EXT FIX PRE DRL 3X20 MM,SUP-2862038,CDM,C1713,HCPCS,0278,RC,,,,both,,,252.27,163.98,,,,,,,,,,,,,
LINER WLK BOOT VENTURE TALL M,SUP-2151035,CDM,L4386,HCPCS,0272,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
BISMUTH SUBSALICYLATE 262 MG/15ML PO SUSP,RX-1090,CDM,340b,HCPCS,0637,RC,09999-9909-88,NDC,,both,15,ML,2.70,1.75,,,,,,,,,,,,,
KIT DRNGE PERI ESSENTIAL ASPIRA,SUP-2126464,CDM,C1729,HCPCS,0272,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
PLATE CRAN 80X20X40 MM PT SPEC IMPL PEEK,SUP-2860115,CDM,C1713,HCPCS,0278,RC,,,,both,,,25204.47,16382.91,,,,,,,,,,,,,
THIAMINE MONONITRATE 100 MG PO TABS,RX-11538,CDM,6370000000,HCPCS,0637,RC,77333-0934-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ANCHOR SUT L3.5MM KNOTLESS FIX SYS PINTON,SUP-2388893,CDM,C1776,CPT,0278,RC,,,,both,,,2967.61,1928.95,,,,,,,,,,,,,
HC Assay of Iron|NOT REASONABLE AND NECESSARY,PX-3018354000,CDM,83540,CPT,0301,RC,,,GZ,both,,,105.00,68.25,,,,,,,,,,,,,
STEM FEM SZ 3 L250MM 12 14 TAPR R HIP BOW REV CEM ENDUR,SUP-2251948,CDM,C1776,CPT,0278,RC,,,,both,,,12472.08,8106.85,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS TENCK INF 31 CM 2 CUF SIL QUINT,SUP-2754738,CDM,C1752,HCPCS,0278,RC,,,,both,,,217.66,141.48,,,,,,,,,,,,,
INSERT TIB THK 6 MM SZ 2 UHMWPE RT ANK ANTR BIASED STRL,SUP-2932744,CDM,C1776,CPT,0278,RC,,,,both,,,11770.45,7650.79,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-3606232200,CDM,62322,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
TUBE VENT OD1.27MM 3.1IFD WHT SHEEHY TYP BTTN FLPL ST,SUP-2284044,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.85,26.55,,,,,,,,,,,,,
BLADE SAW THK0.38MM CUT EDGE 11.5MM CUT D7MM INTRAORAL THN,SUP-2363668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.34,249.82,,,,,,,,,,,,,
PLATE BNE 44 CM,SUP-2136805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SEGMENT FEM COMP L SZ 1 W75XH20MM RT MEDL TILASTAN-S,SUP-2418364,CDM,C1776,CPT,0278,RC,,,,both,,,2555.96,1661.37,,,,,,,,,,,,,
CATHETER EP CSL 2-2-2 MM 7 FRX120 CM RESPON,SUP-2356770,CDM,C1730,HCPCS,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
HC Rsf Lab Ecmc - Ihc,PX-9900000127,CDM,9900000127,LOCAL,0990,RC,,,,both,,,50.00,32.50,,,,,,,,,,,,,
IMPLANT SHLDR TI NIOBIUM NITRIDE RVS GRS BASEPLT,SUP-2888598,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BIT DRL L 296 MM DIA 3.2 MM THK 5 MM DSTL MEDL FEM NS REUSE,SUP-2902361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,595.03,386.77,,,,,,,,,,,,,
PLATE BNE 5DEG SHT L MT REV GORILLA,SUP-2321459,CDM,C1713,HCPCS,0278,RC,,,,both,,,4545.15,2954.35,,,,,,,,,,,,,
CATHETER ABLAT 8FR L115CM 2-5-2MM SPC TIP 3.5MM 6 ELECTRD D,SUP-2248601,CDM,C1732,HCPCS,0272,RC,,,,both,,,4374.02,2843.11,,,,,,,,,,,,,
SPONGE SCLER DIA5MM SIL RND BULK STYL 505,SUP-2213494,CDM,L8610,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
STEM FEM SEG 23 CM DPHSEAL KNEE TAPR OSS,SUP-2441757,CDM,C1776,CPT,0278,RC,,,,both,,,15119.10,9827.41,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 IN 3 CM 4.8 FRX22-30 CM 6 FR,SUP-2537694,CDM,C2617,HCPCS,0278,RC,,,,both,,,417.59,271.43,,,,,,,,,,,,,
AUGMENT TIBIAL KNEE EMPOWR HALF BLK 6BU 5MM,SUP-2891099,CDM,C1776,CPT,0278,RC,,,,both,,,8275.47,5379.06,,,,,,,,,,,,,
COLLAR CERV SFT 375X17IN M,SUP-2276589,CDM,L0120,HCPCS,0274,RC,,,,both,,,5.97,3.88,,,,,,,,,,,,,
PLATE BONE L220MM 13 H LT PROX HUM LCK FOR 4.5MM SCR,SUP-2348286,CDM,C1713,HCPCS,0278,RC,,,,both,,,16843.27,10948.13,,,,,,,,,,,,,
NAIL IM L150MM DIA9MM UNIV PROX HUM BLU TI CANN LOK RND,SUP-2179631,CDM,C1713,HCPCS,0278,RC,,,,both,,,4735.69,3078.20,,,,,,,,,,,,,
BLADE SAW CRESC 9.5 MM,SUP-2632409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.95,222.27,,,,,,,,,,,,,
CATHETER SZ PTS L 80 CM BALLOON L 3 CM DIA25 MM INTRO 8 FR,SUP-2659780,CDM,C1725,HCPCS,0272,RC,,,,both,,,926.05,601.93,,,,,,,,,,,,,
NAIL IM L240MM DSTL LCK POLARUS 3,SUP-2106899,CDM,C1713,HCPCS,0278,RC,,,,both,,,7529.72,4894.32,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC DBM B201010P] FRONTIER MEDICAL PRODUCTS INC],SUP-2225960,CDM,C9359,HCPCS,0278,RC,,,,both,,,5962.86,3875.86,,,,,,,,,,,,,
KIT ASPIR SM VOL BONE MAR,SUP-2163071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
INTRODUCER 4FRX25CM SHTH W/ .035IN GWIRE ENGAGE,SUP-2355798,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
SCREW COMPR 1.5X9MM HEADLESS SS STRL,SUP-2546183,CDM,C1713,HCPCS,0278,RC,,,,both,,,751.68,488.59,,,,,,,,,,,,,
IBALANCE PFJ BLADE KIT AR60228L,SUP-2843870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4678.60,3041.09,,,,,,,,,,,,,
CURETTE ENDOSCP CUP 7 CM NANO ARTHSCP STRL BONESYNC LTX,SUP-2859817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CEMENT FLX FM/CEM TB/PRLG SUR/XLPE PT/TP PL,SUP-2212173,CDM,C1776,CPT,0278,RC,,,,both,,,15699.94,10204.96,,,,,,,,,,,,,
ORTHOSIS LUMSACR PREFABRICATED SAG CTRL SACROCOCCYGEAL,SUP-2237268,CDM,L0648,HCPCS,0274,RC,,,,both,,,3128.51,2033.53,,,,,,,,,,,,,
SET ANCHR GI W/ SAF-T-PEXY T-FASTENERS,SUP-2236743,CDM,C1713,HCPCS,0278,RC,,,,both,,,371.12,241.23,,,,,,,,,,,,,
CEMENT BNE 5 GM 3.45 CC HA ALPHA TCP RADIOPAQUE STRL MIMIX,SUP-2883758,CDM,C1713,HCPCS,0278,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
PROBE ABLATION INTERCEPT BIPOLAR L3 BASIVERTEBRAL NERVE RADIOFREQUENCY,SUP-2757212,CDM,C1889,HCPCS,0278,RC,,,,both,,,13878.80,9021.22,,,,,,,,,,,,,
GUIDEWIRE ORTH L950MM DIA2.4MM NIT ROUNDED TIP DISP PICCOLO,SUP-2152522,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.10,81.31,,,,,,,,,,,,,
SUPPORT ORTH CLOSED POPLITEAL 15.5-18 IN SM KNEE DLX,SUP-2336342,CDM,L1810,HCPCS,0272,RC,,,,both,,,51.15,33.25,,,,,,,,,,,,,
HC So Vitamin K,PX-3018459766,CDM,84597,CPT,0301,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
GRAFT VASC GORTX L 90 CM DIA 6 MM EPTFE STR TW N RING STRL,SUP-2396700,CDM,C1768,CPT,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
GUIDEWIRE VASC 025X180 GLIDEWIRE,SUP-2148189,CDM,C1769,HCPCS,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
GRAFT HUM TISS FIRM 6X6 CM RECON DERMAL TISS MTRX STRATTICE,SUP-2112973,CDM,Q4130,HCPCS,0636,RC,,,,both,,,3708.34,2410.42,,,,,,,,,,,,,
SYSTEM FIX DIA8-8.5MM FEM HRD SCR SHTH INTRAFIX,SUP-2256825,CDM,C1713,HCPCS,0278,RC,,,,both,,,2028.44,1318.49,,,,,,,,,,,,,
ARCHBAR ORTHODONTIC PREFRM FOR MAXILLOMANDIBULAR FIX SYS,SUP-2135878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC So Free Valproic Acid,PX-3018016566,CDM,80165,CPT,0301,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ADV 18LP L 170 CM BALLOON L 8 CM DIA 6,SUP-2169885,CDM,C1725,HCPCS,0272,RC,,,,both,,,350.11,227.57,,,,,,,,,,,,,
PLATE BONE W200XL200MM THK1.5MM NONSTERILE TI RECTANG CNTOUR,SUP-2191103,CDM,C1713,HCPCS,0278,RC,,,,both,,,21757.06,14142.09,,,,,,,,,,,,,
ENDCAP ORTH L4MM DIA8MM L ANK TI EXTN,SUP-2369013,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
ROD IM T HNDL VANGUARD MICROPLASTY,SUP-2446402,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
PLATE BNE L W10.1XL154MM THK3.5MM 11 H BILAT S STL STR RIG,SUP-2186218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1647.21,1070.69,,,,,,,,,,,,,
HC Cyanocobalamin Vitamin B-12,PX-3018260700,CDM,82607,CPT,0301,RC,,,,both,,,93.00,60.45,,,,,,,,,,,,,
SEALANT SURG 8ML SYN HYDRGEL DESIGNED REDUC POST SURG,SUP-2130351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3697.98,2403.69,,,,,,,,,,,,,
AGENT HEMOSTATIC ABSORBABLE 1 GM PWD NACL STRL SURGFOAM,SUP-2517134,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.32,226.41,,,,,,,,,,,,,
CATHETER ETER CTRL VEN OD12FR L16CM 035IN AD BLU 3 LUMN,SUP-2120593,CDM,C1751,HCPCS,0278,RC,,,,both,,,374.92,243.70,,,,,,,,,,,,,
GRAFT SOFT TISSUE FEM 9X24 MM WITH INSERTER AFX,SUP-2664011,CDM,C1713,HCPCS,0278,RC,,,,both,,,3404.26,2212.77,,,,,,,,,,,,,
TUBE TRACH SZ 11 CLR STRL SER 4200 SAFE-T-TUBE,SUP-2140097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
COVER SCR TI UNIGRIP HEX CONN FOR BAHA SYS,SUP-2164931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SCREW BONE L100MM DIA5MM 3.5MM HEX TIBIOTALOCALCANEAL PA,SUP-2277471,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IFORIA 7 DR-T W 55 X H 65 MM D 11 MM 40 J,SUP-2138359,CDM,C1721,HCPCS,0275,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN XS 15X9 CMX0.7-1.4 MM PERF FLEXHD,SUP-2307599,CDM,Q4128,HCPCS,0636,RC,,,,both,,,8607.37,5594.79,,,,,,,,,,,,,
SET PNEUMOTHOR WAYNE,SUP-2171161,CDM,C1729,HCPCS,0272,RC,,,,both,,,754.54,490.45,,,,,,,,,,,,,
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,0636,RC,50633-0120-11,NDC,,both,1,UN,14673.30,9537.64,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.90CM 40J 20SEC 10YR 3 CHMBR CARD,SUP-2138121,CDM,C1882,HCPCS,0275,RC,,,,both,,,82259.33,53468.56,,,,,,,,,,,,,
VALVE HEMOSTAS HONOR DIA 7.2 FR POLYCARB SIL SM BOR STRL,SUP-2303047,CDM,C1713,HCPCS,0278,RC,,,,both,,,49.46,32.15,,,,,,,,,,,,,
INSERT TIB L STANDARD+ THK10MM POLYETH UNIV MENIS BEAR PRI,SUP-2250754,CDM,C1776,CPT,0278,RC,,,,both,,,3982.78,2588.81,,,,,,,,,,,,,
PAD ORTHOT LUMBAR RIB CUST,SUP-2435574,CDM,L1040,HCPCS,0274,RC,,,,both,,,251.01,163.16,,,,,,,,,,,,,
SCREW SPNL MULTAXL 9.5X50 MM CANC CD HORZ TCS,SUP-2628376,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
MINI PLATE 16 HOLE REGULAR CP TITANIUM,SUP-2668087,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.36,244.63,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT 160 MM FRZN GAM ACHILLES TEND,SUP-2866903,CDM,C1762,CPT,0278,RC,,,,both,,,3394.65,2206.52,,,,,,,,,,,,,
PORT PWR INJ 2 LUMN PLAS W/ SIL FILL SUT H ATTCH POLYUR,SUP-2118812,CDM,C1788,HCPCS,0278,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
COUPLER EXT FIX FOR 8MM ROD TO ROD OR POST HOFFMANN II MRI,SUP-2372211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BASEPLATE TIB L74XW50MM SZ 2 M DURAC KNEE CRUCFRM NONBEADED,SUP-2377170,CDM,C1776,CPT,0278,RC,,,,both,,,3291.72,2139.62,,,,,,,,,,,,,
INSERT ACET OD44MM THK7.3MM BPLR HD 22MM OD36MM 0DEG UHMWPE,SUP-2377733,CDM,C1776,CPT,0278,RC,,,,both,,,7075.05,4598.78,,,,,,,,,,,,,
CANNULA SURG W/ STOPCOCK 70 MM 4.5 MM IRRIGATION OBTUTATOR,SUP-2794072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.57,379.97,,,,,,,,,,,,,
NERVE STIMULATOR KIT CHARGER LUMBAR ACCESSORIES,SUP-2858401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCR QUINONEZ DF15MMX5MM4MM THD WSC,SUP-2676774,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.28,357.03,,,,,,,,,,,,,
WIRE BNE FIX L 228.6 MM DIA1.6 MM TROCAR END NS KIRSCHNER,SUP-2885112,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.89,214.43,,,,,,,,,,,,,
STEM FEM SZ 1 POR HIP 12/14 TAPR PRESSFIT RESTORIS Z,SUP-2370439,CDM,C1776,CPT,0278,RC,,,,both,,,4018.89,2612.28,,,,,,,,,,,,,
STEM FEM REV CEM DEF PM SZ 00,SUP-2375346,CDM,C1776,CPT,0278,RC,,,,both,,,9418.12,6121.78,,,,,,,,,,,,,
HEAD HUM 58X27 MM SHLDR TI BIO MOD,SUP-2449914,CDM,C1776,CPT,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
BLADE BNE MILL L3.2MM SPNL FN,SUP-2367527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
Z DUP USE 2693978 BLADE KEL 2INX6IN BKWALT,SUP-2248990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.63,1173.66,,,,,,,,,,,,,
KIT PAINBUSTER SIL SOAK 270ML X4ML HR 2 2ML HR PER SITE ON Q,SUP-2236847,CDM,C9804,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US|LEFT SIDE,PX-5102060500,CDM,20605,CPT,0510,RC,,,LT,both,,,908.00,590.20,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.7MM STD CORT NONLOCKING LO PROF RESRB 4/EA,SUP-2364991,CDM,C1713,HCPCS,0278,RC,,,,both,,,1194.83,776.64,,,,,,,,,,,,,
WEDGE TIB SZ 7-8 THK10MM FULL STP HNG REV KNEE LEGION,SUP-2346602,CDM,C1776,CPT,0278,RC,,,,both,,,5042.84,3277.85,,,,,,,,,,,,,
KIT DRN L5IN DIA1/8IN PVC TRCR CLS WND COMP EVAC HEMVAC SYS,SUP-2198689,CDM,C1729,HCPCS,0272,RC,,,,both,,,190.60,123.89,,,,,,,,,,,,,
HC Removal Subcutaneous Cardiac Rhythm Monitor,PX-3613328600,CDM,33286,CPT,0361,RC,,,,both,,,6475.00,4208.75,,,,,,,,,,,,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,0636,RC,76329-3399-05,NDC,,both,10,ML,488.80,317.72,,,,,,,,,,,,,
WASHER EXT FIX DYNAMIZATION STRL DISP SMRT TSF,SUP-2933914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,194.52,126.44,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 5FR 55CM 3 LUMAN R S9395108,SUP-2632880,CDM,C1751,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN,RX-2332,CDM,J1100,HCPCS,0636,RC,67457-0423-00,NDC,,both,.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE W8XL192MM THK3.3MM 24 H NONSTERILE BILAT PELV S,SUP-2186251,CDM,C1713,HCPCS,0278,RC,,,,both,,,3481.63,2263.06,,,,,,,,,,,,,
GRAFT HUM TISS L HUM WHL W O CUF FRZN,SUP-2307323,CDM,C1713,HCPCS,0278,RC,,,,both,,,13584.61,8830.00,,,,,,,,,,,,,
ADAPTER O2 BAFFLED TEE 18X22 MM ARM FOR SM NEB PLAS AIRLFE,SUP-2724360,CDM,C1713,HCPCS,0278,RC,,,,both,,,2.07,1.35,,,,,,,,,,,,,
LUBIPROSTONE 8 MCG PO CAPS,RX-91534,CDM,6370000000,HCPCS,0637,RC,00480-3479-06,NDC,,both,1,UN,8.00,5.20,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA 9 MM DEL SHTH,SUP-2934320,CDM,C1713,HCPCS,0278,RC,,,,both,,,16095.95,10462.37,,,,,,,,,,,,,
BLADE SHV L20CM DIA37MM 45DEG BEND LARYN SNUS DISPOSABLE,SUP-2167126,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.14,214.59,,,,,,,,,,,,,
CANNULA ENDOSCP TERMANIAN ENDOTIP 6 MMX10.5 CM W/SIL LEAFLET,SUP-2767564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2012.77,1308.30,,,,,,,,,,,,,
DRILL SURG 27X36MM PROX SL CANN,SUP-2400092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
FORCEPS BNE CUT L 131 MM NAR LNG RATCH REDUCTION NS DISP,SUP-2908153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4263.02,2770.96,,,,,,,,,,,,,
PLATE BNE TBLR UNIV 3.5 MM 6 HOLE 1/3 2 COMPR LCK FOR SCR TI,SUP-2468115,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
FIXATOR EXT HING RINGFIX SYS M,SUP-2496821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.9 MM CRANIOMAXILLOFACIAL EMER ST NS 5PK,SUP-2884116,CDM,C1713,HCPCS,0278,RC,,,,both,,,1407.98,915.19,,,,,,,,,,,,,
PLATE SPNL MESH 90X90X.6 MM 1.7 MM GLD,SUP-2363683,CDM,C1713,HCPCS,0278,RC,,,,both,,,3112.93,2023.40,,,,,,,,,,,,,
INQUIRY H CURVE STEER DEC 110 6 291 H,SUP-2676235,CDM,C1731,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X450 MM FOR CANN SCREW STRL,SUP-2789108,CDM,C1769,HCPCS,0272,RC,,,,both,,,804.97,523.23,,,,,,,,,,,,,
LENS TORIC ACRYSOF IQ 30.0,SUP-2112046,CDM,V2787,HCPCS,0276,RC,,,,both,,,435.00,282.75,,,,,,,,,,,,,
CATHETER GUID XL L50CM HYDRPHLC EXT HK L HRT DEL SYS ATTAIN,SUP-2282196,CDM,C1887,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
HANDPIECE PULSED LAV 5 MM L7 CM ABD OPN SURG GEN CUT COAG,SUP-2328050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
HC So Hla I Typing Complete Hr,PX-3108137966,CDM,81379,CPT,0310,RC,,,,outpatient,,,413.00,268.45,,,,,,,,,,,,,
CATHETER HAD 11.5FR L20CM STR SIL DBL LUMN HEM CATH ST,SUP-2267079,CDM,C1881,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
HC So Tiss Trnsgltmnase Ea Ig Clas,PX-3028636466,CDM,86364,CPT,0302,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
PLATE BNE W8XL144MM THK3.3MM 18 H NONSTERILE BILAT PELV S,SUP-2186245,CDM,C1713,HCPCS,0278,RC,,,,both,,,2481.23,1612.80,,,,,,,,,,,,,
Z DUP USE 2676487 STENT ES L15CM DIA18MM CATH 18.5FR L120CM MTL PARTIALLY CVR,SUP-2149873,CDM,C1874,HCPCS,0278,RC,,,,both,,,7104.60,4617.99,,,,,,,,,,,,,
CARDIOVASCULAR PROC KT CUST 41 MYOCARDIAL SET,SUP-2384963,CDM,C1768,CPT,0278,RC,,,,both,,,377.59,245.43,,,,,,,,,,,,,
WAND ABLAT DIA3MM 30DEG INTEGR CBL SABER COBLATION,SUP-2341984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.52,376.69,,,,,,,,,,,,,
ALLOGRAFT BNE 90XX22X5 MM,SUP-2138662,CDM,C1889,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
VALVE PRESSURE PUDENZ 12 MM ANTISIPH DEV HI,SUP-2666753,CDM,C1889,HCPCS,0278,RC,,,,both,,,2760.09,1794.06,,,,,,,,,,,,,
GRAFT HUM TISS 1X4CM THN ACELLULAR DERM DERMAMATRIX,SUP-2306889,CDM,C1762,CPT,0278,RC,,,,both,,,489.87,318.42,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 40 CM DIA 30 MM POLYESTER GEL,SUP-2385038,CDM,C1768,CPT,0278,RC,,,,both,,,1497.34,973.27,,,,,,,,,,,,,
TUBE VENT BOB 1.02 MM 1 MM 2.7 MM FLROPLAS STRL 520026,SUP-2490416,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.85,14.20,,,,,,,,,,,,,
NEEDLE BRST LOC KOPAN 21 GAX7.5 CM 19.4 CM SPRINGHOOK ACCURA,SUP-2876716,CDM,C1819,HCPCS,0278,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
DEVICE BX NDL 9GA L13CM APER 20MM FOR BRST SYS -SEE COMMENT,SUP-2240015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.95,439.37,,,,,,,,,,,,,
STEM HUM CEM SHLDR TOT,SUP-2379210,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE BNE NAR 4.5X87 MM 5 HOLE SS DCP,SUP-2569163,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.33,154.91,,,,,,,,,,,,,
HEAD HUM 39X14 MM SHLDR AEQUALIS DWD802,SUP-2715627,CDM,C1776,CPT,0278,RC,,,,both,,,14349.80,9327.37,,,,,,,,,,,,,
HC Path Consltj Surg Cytologic Exam Initial Site,PX-3118833300,CDM,88333,CPT,0311,RC,,,,both,,,954.00,620.10,,,,,,,,,,,,,
IMPLANT SH SIL .040 2X3IN,SUP-2383034,CDM,C1781,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TUBE TRACH BIVONA PED L60MM OD4.7MM ID3MM SIL UNCUFFED,SUP-2933969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,553.90,360.03,,,,,,,,,,,,,
NEEDLE SPNL Y 200 MM ES2 LT,SUP-2532843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1163.37,756.19,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 5.01-6.0 MCI STRL ADVANTAGE 2029FLS2] ISOAID LLC],SUP-2247273,CDM,C2642,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
WASHER ORTH FOR 35 4MM SCR DART FIRE,SUP-2398286,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
ELECTRODE ENDOSCP 24FR 90DEG MPLR HF RESECT NDL DISPOSABLE,SUP-2312907,CDM,C1713,HCPCS,0278,RC,,,,both,,,377.33,245.26,,,,,,,,,,,,,
HC So Vdrl (Titer),PX-3028659366,CDM,86593,CPT,0302,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
KIT CA 5MM SPINEJACK,SUP-2361514,CDM,C1062,HCPCS,0278,RC,,,,both,,,11770.29,7650.69,,,,,,,,,,,,,
CEMENT BONE 20ML PCH W/ GENTMYCN M VISC CO,SUP-2217401,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
IMMOBILIZER KNEE WRP II W PAT UNIV,SUP-2196844,CDM,L1810,HCPCS,0274,RC,,,,both,,,40.47,26.31,,,,,,,,,,,,,
STENT ENDOVASC L29MM DIA5-8MM CATH L80CM INTRO SHTH 7FR,SUP-2395638,CDM,C1874,HCPCS,0278,RC,,,,both,,,9200.20,5980.13,,,,,,,,,,,,,
HC So Infectious Agent Ab Quant,PX-3028631766,CDM,86317,CPT,0302,RC,,,,outpatient,,,118.00,76.70,,,,,,,,,,,,,
ROD SPNL L450MM DIA6.35MM R ANT TI STR SMOOTH MNRCH,SUP-2254522,CDM,C1713,HCPCS,0278,RC,,,,both,,,2057.33,1337.26,,,,,,,,,,,,,
PATCH CV PERICARD TISS STRL,SUP-2321867,CDM,C1713,HCPCS,0278,RC,,,,both,,,2150.90,1398.08,,,,,,,,,,,,,
GRAFT BNE COTTON WDG 8 MM STRL TITAN 3-D,SUP-2742081,CDM,C1713,HCPCS,0278,RC,,,,both,,,5137.83,3339.59,,,,,,,,,,,,,
STEM FEM SZ 8 L205MM OD12MM 5MM OFFSET HA DST HIP STR,SUP-2379097,CDM,C1776,CPT,0278,RC,,,,both,,,16781.73,10908.12,,,,,,,,,,,,,
SYSTEM LD INTRO SELECTRA L 55 CM DIA 7 FR HK CRV PEELWY,SUP-2418818,CDM,C1893,HCPCS,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
GRAFT VASC 6MM DIA 40CM LEN 4CM STR STRTCH STD WALL N RNGD,SUP-2395841,CDM,C1768,CPT,0278,RC,,,,both,,,1742.70,1132.75,,,,,,,,,,,,,
PLATE BONE LOW PROFILE 30X0.4 MM CONTOURABLE MESH MALLEABLE,SUP-2838372,CDM,C1713,HCPCS,0278,RC,,,,both,,,2592.38,1685.05,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L130CM BAL L200MM DIA4MM GWIRE 0.035IN,SUP-2280383,CDM,C2623,HCPCS,0278,RC,,,,both,,,5793.30,3765.64,,,,,,,,,,,,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,0636,RC,00409-2347-31,NDC,,both,250,ML,224.30,145.79,,,,,,,,,,,,,
TRAY TIB SZ 4 LNG ANK PROPHECY INFIN,SUP-2397279,CDM,C1776,CPT,0278,RC,,,,both,,,13985.56,9090.61,,,,,,,,,,,,,
COMPONENT FEM ROTATIONAL ENDOMODEL M 145,SUP-2265096,CDM,C1776,CPT,0278,RC,,,,both,,,30360.66,19734.43,,,,,,,,,,,,,
STENT URETH UROLUME L 1.5 CM DIA 42 FR ELGILOY SELF,SUP-2140272,CDM,C1876,HCPCS,0278,RC,,,,both,,,13781.46,8957.95,,,,,,,,,,,,,
MATRIX BIO L 6 X W 8 CM SZ 86 SQCM FISH SKIN DERMAL MESHED 10/BX,SUP-2909437,CDM,Q4158,HCPCS,0636,RC,,,,both,,,7765.22,5047.39,,,,,,,,,,,,,
TIP LAPSCP L30.14CM ID1.98MM 23KHZ FLUE EXT NONSTERILE,SUP-2243955,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 2 END 0.035X6 IN STRL LTX,SUP-2857933,CDM,C1769,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
BLADE SAW PROPHECY INFIN,SUP-2397078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE BNE L41MM SM 3 H GRN TI POST TIB ANK LOK COMPR FOR,SUP-2398411,CDM,C1713,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM BIOCOMPOSITE TAPR TIP W/ DISP,SUP-2121208,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 4FR 20CM 2 LUMAN S4254108BDP,SUP-2632865,CDM,C1751,HCPCS,0278,RC,,,,both,,,682.35,443.53,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.156X9 IN RND END SS NS STEINMANN,SUP-2791294,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.42,23.67,,,,,,,,,,,,,
ROD SPNL POST SMOOTH 5.5MM DIA 30MM LEN,SUP-2289297,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CATHETER HD 2 L LUMEN 13.5 FRX36 CM 19 CM CHRONIC SURCUF KT,SUP-2127705,CDM,C1750,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
MESH HERN W10XL10CM MFIL RESRB SQ W/ HYDRGEL BARR PHASIX ST,SUP-2127355,CDM,C1781,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
FORCEPS ES BPLR VEOA,SUP-2164089,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BOLT IM L24MM DIA3.9MM STRL BLU CORT TI ST FULL THRD LCK,SUP-2192176,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.93,470.55,,,,,,,,,,,,,
GRAFT BIO TISS W2XL4CM THK0.8-1.7MM ACELLULAR DERM MTRX,SUP-2307454,CDM,Q4128,HCPCS,0636,RC,,,,both,,,487.96,317.17,,,,,,,,,,,,,
COMPONENT TALAR CEM 0 RT ANK COCR SALTO TALARIS,SUP-2244123,CDM,C1776,CPT,0278,RC,,,,both,,,21125.92,13731.85,,,,,,,,,,,,,
LINER ACET CONSTRN 32 MM HIP FRDM,SUP-2423252,CDM,C1776,CPT,0278,RC,,,,both,,,20221.60,13144.04,,,,,,,,,,,,,
CATHETER EP ABLAT C CRV QPLR 2-5-2MM SPC 4MM TIP BI DIR RF,SUP-2142282,CDM,C1733,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK0.4-.8MM ACELLULAR DERM MTRX MESH,SUP-2402504,CDM,Q4126,HCPCS,0636,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SCREW BONE L120MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190372,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
HC So Immunofluoresc per Spec 1st Ab,PX-3128834666,CDM,88346,CPT,0312,RC,,,,both,,,495.00,321.75,,,,,,,,,,,,,
KIT THROMCTMY BOBBY SOFIA + L 131 CM DIA 6 FR GUIDE CATH L,SUP-2915895,CDM,C1757,HCPCS,0272,RC,,,,both,,,13833.27,8991.63,,,,,,,,,,,,,
WASHER ORTH LT FEM NK LCK STRL CONQ FN,SUP-2933443,CDM,C1713,HCPCS,0278,RC,,,,both,,,6208.57,4035.57,,,,,,,,,,,,,
WIRE FIX THRD SMOOTH CAPTURE 1MM OD 70MM LEN K,SUP-2243922,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.13,72.88,,,,,,,,,,,,,
GRAFT EVAR L120MM DIA25MM PROX 16MM DST AAA INTUITRAK,SUP-2217564,CDM,C1768,CPT,0278,RC,,,,both,,,33896.30,22032.59,,,,,,,,,,,,,
CLAMP REPROC MULTI PIN 4 POS MR SAFE LG,SUP-2457728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.66,357.93,,,,,,,,,,,,,
TUBE MYR DIA1.02MM VENT SIL W/O TAB ST PAPARELLA,SUP-2313716,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.09,24.76,,,,,,,,,,,,,
COVER BUR H 5 H TI LO PROF FOR 2MM SCR,SUP-2363681,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.48,379.91,,,,,,,,,,,,,
PLATE BONE L153MM 11 H STRL LT ANTEROLATERAL DSTL TIB S STL,SUP-2349732,CDM,C1713,HCPCS,0278,RC,,,,both,,,12792.36,8315.03,,,,,,,,,,,,,
ART BMC + PROC KT,SUP-2163075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
ADJUSTABLE CONNECT ROD 5MM,SUP-2695692,CDM,2720000010,LOCAL,0272,RC,,,,both,,,848.43,551.48,,,,,,,,,,,,,
PLATE BONE STRL L SHP LT VAR LCK 2.7MM SCR VLP FT PERC,SUP-2349925,CDM,C1713,HCPCS,0278,RC,,,,both,,,2878.28,1870.88,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 2-10 MM 60 CC FD IRRADIATED CANC,SUP-2867140,CDM,C1762,CPT,0278,RC,,,,both,,,2640.74,1716.48,,,,,,,,,,,,,
HC Treat Humerus Fx,PX-4502450000,CDM,24500,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SCREW BONE L20MM OD3.5MM CORT,SUP-2412506,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.53,58.84,,,,,,,,,,,,,
BURR SURG 5MM DIA HD XLN 95MML SM BNE RND DIAMOND MICROPOWER,SUP-2605841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.94,221.61,,,,,,,,,,,,,
ALBUTEROL SULFATE 2 MG PO TABS,RX-253,CDM,6370000000,HCPCS,0637,RC,68084-0949-25,NDC,,both,1,UN,28.10,18.26,,,,,,,,,,,,,
PACEMAKER PERM 2 CHMBR DDDR NON MRI S404 ALTRUA 40,SUP-2149276,CDM,C1785,HCPCS,0275,RC,,,,both,,,12792.36,8315.03,,,,,,,,,,,,,
SPACER SPNL SM W12XH25XL14MM 3.5/3.5DEG LORDTC THORLUM,SUP-2231168,CDM,C1821,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
PLATE EXT FIX LNG 160 MM FT RNG TI NS,SUP-2799580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2922.93,1899.90,,,,,,,,,,,,,
INVISION  TIBIAL TRAY SZ 4 8MM UNIVERSAL LNG,SUP-2458083,CDM,C1776,CPT,0278,RC,,,,both,,,18199.44,11829.64,,,,,,,,,,,,,
HEAD HUM DIA48MM THK18MM SHLDR CO CHROM REPL PROS AEQUALIS,SUP-2388629,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PROSTHESIS PENILE 100ML INHIBZN ERECTILE RESTR INFL RESVR,SUP-2138962,CDM,C1813,HCPCS,0278,RC,,,,both,,,7190.60,4673.89,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 20 MM DIA12 MM SHTH 9 FR CATH L 75,SUP-2142675,CDM,C1876,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN VBX 79 MM 8/16MM 135 CM 8 FR LNR,SUP-2395715,CDM,C1874,HCPCS,0278,RC,,,,both,,,11049.66,7182.28,,,,,,,,,,,,,
PLATE T 8 H,SUP-2321417,CDM,C1713,HCPCS,0278,RC,,,,both,,,3286.01,2135.91,,,,,,,,,,,,,
CEMENT KIT 33 CC 60 GM HI ADH STRENGTH HY-BOND,SUP-2238570,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.87,229.37,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 65 CM DIA12 FR BODY DIA 4.7 MM,SUP-2570723,CDM,C1894,HCPCS,0272,RC,,,,both,,,2716.10,1765.46,,,,,,,,,,,,,
DISTRACTOR SURG L 20 MM MIDFACE NS,SUP-2883385,CDM,C1713,HCPCS,0278,RC,,,,both,,,11446.78,7440.41,,,,,,,,,,,,,
SPLINT CLAV HVY PD 24 - 30IN SZ SM,SUP-2196988,CDM,L3650,HCPCS,0274,RC,,,,both,,,17.24,11.21,,,,,,,,,,,,,
TOURNIQUET PNEUMAT W HOSES ATS 2200,SUP-2208753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18608.27,12095.38,,,,,,,,,,,,,
COMPONENT TIB BASEPLT UNI LM/RL 9MM S EIUS,SUP-2364884,CDM,C1776,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
IMPLANT OP RM UNIV PLTS TED BEAR PLT SM,SUP-2321553,CDM,C1713,HCPCS,0278,RC,,,,both,,,4462.73,2900.77,,,,,,,,,,,,,
PROBE ABLAT 17GA L15CM MICWV LN,SUP-2219548,CDM,C1713,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|CO|XU|KX,both,,,144.00,93.60,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT FEM DST VARIES MATRIGRFT,SUP-2264748,CDM,C1713,HCPCS,0278,RC,,,,both,,,11380.80,7397.52,,,,,,,,,,,,,
SCREW BNE CANN 6.5 X 30 MM TI NS,SUP-2530787,CDM,C1713,HCPCS,0278,RC,,,,both,,,1162.74,755.78,,,,,,,,,,,,,
PLATE CRAN PEEK CUST PATIENTMATCHED NS,SUP-2934133,CDM,C1713,HCPCS,0278,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
CONNECTOR SPNL FRONT LD 3X5.5 MM SIDE BY SIDE FOR ROD SFS,SUP-2589734,CDM,C1713,HCPCS,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
ARGATROBAN IN SODIUM CHLORIDE 50-0.9 MG/50ML-% IV SOLN,RX-145884,CDM,J0891,HCPCS,0636,RC,55150-0241-01,NDC,,both,50,ML,1121.30,728.84,,,,,,,,,,,,,
COMPONENT FEM THK10MM STD KNEE BUMPER HNG ROT KINEMATIC,SUP-2376453,CDM,C1776,CPT,0278,RC,,,,both,,,1489.30,968.04,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 4FR 55CM 2 LUMAN RVS TAPR S,SUP-2613539,CDM,C1751,HCPCS,0278,RC,,,,both,,,557.32,362.26,,,,,,,,,,,,,
NAFCILLIN SODIUM 1 G IJ SOLR,RX-5333,CDM,J2290,HCPCS,0250,RC,44567-0221-10,NDC,,both,1,UN,63.30,41.14,,,,,,,,,,,,,
PLATE BONE L73MM 6 H LT SUP MEDL CLAV LCK PERI-LOC,SUP-2348754,CDM,C1713,HCPCS,0278,RC,,,,both,,,6533.24,4246.61,,,,,,,,,,,,,
NIKO CORPECTOMY CAGE 29MM,SUP-2228346,CDM,C1713,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
SCREW BNE L6MM DIA1.2MM CORT TI ALLY ST SELF DRL LO PROF,SUP-2268004,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.83,176.69,,,,,,,,,,,,,
SHELL ACET OD62MM LNR SZ G NO H MPACT,SUP-2267386,CDM,C1776,CPT,0278,RC,,,,both,,,3390.10,2203.56,,,,,,,,,,,,,
WIRE FIX L102MM DIA1.6MM S STL SMOOTH DBL BAYNT TIP K,SUP-2412981,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.04,115.73,,,,,,,,,,,,,
BIT DRL CANN 2X230 MM QC,SUP-2392916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.109X9 IN SS NS STEINMANN,SUP-2791830,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.67,10.84,,,,,,,,,,,,,
ANCHOR SUT NO2 DIA145MM SHT RIG JUGGERKNOT,SUP-2136094,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.99,593.44,,,,,,,,,,,,,
OSTEOTOME SURG SHT DIA9.5MM FOR ULTRASONIC REV SYS UDRV 3,SUP-2408566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
BUTTON SUT DIA3.5MM TI FOR PRI BKUP FIBERWIRE FIX OF ACL,SUP-2122814,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HC Transrectal Ultrasound,PX-4027687200,CDM,76872,CPT,0402,RC,,,,both,,,971.00,631.15,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP,RX-103569,CDM,6370000000,HCPCS,0637,RC,61314-0630-06,NDC,,both,5,ML,81.00,52.65,,,,,,,,,,,,,
PAD ORTHOT CERV THOR LUMBAR SACR CUST KYPHOSIS,SUP-2435571,CDM,L1020,HCPCS,0274,RC,,,,both,,,305.08,198.30,,,,,,,,,,,,,
KIT MICROINTRODUCER COAX STIFF NIT TUNGSTEN 0.018IN GWIRE,SUP-2118827,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
ATTACHMENT EXTRACTOR FOR HINDFOOT TTC NAIL SYS NS DISP,SUP-2909002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1562.15,1015.40,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2525468,CDM,C1768,CPT,0278,RC,,,,both,,,2399.09,1559.41,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.439,SUP-2860003,CDM,C1713,HCPCS,0278,RC,,,,both,,,42737.91,27779.64,,,,,,,,,,,,,
GUIDEPIN ORTH L230MM OD2.4MM DISTRACTOR COMPR THRD TIP,SUP-2319584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
DRILL SURG 2 MM P88802000,SUP-2751420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.17,443.41,,,,,,,,,,,,,
HYDROCORTISONE SOD SUC (PF) 100 MG IJ SOLR (ACT-0-VIAL),RX-159344,CDM,J1720,HCPCS,0636,RC,00009-0011-04,NDC,,both,1,UN,135.90,88.33,,,,,,,,,,,,,
HC Pt Ultrasound Each 15 Min,PX-4209703500,CDM,97035,CPT,0420,RC,,,,inpatient,,,194.00,126.10,,,,,,,,,,,,,
PLATE BNE L 257 MM SCREW DIA 3.5/4.5 MM 9 H LT TROCHANTERIC 72583109,SUP-2932912,CDM,C1713,HCPCS,0278,RC,,,,both,,,21181.66,13768.08,,,,,,,,,,,,,
SCREW HYBRID 3 X 20,SUP-2741739,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.035 IN STR TIP STRL,SUP-2214529,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.58,19.88,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TAPR L 8 CM FLPY TIP L,SUP-2169711,CDM,C1769,HCPCS,0272,RC,,,,both,,,95.02,61.76,,,,,,,,,,,,,
GRAFT BONE L12XW12XH5MM 5DEG UNIV PEEK TI COMP SPCR ANTR,SUP-2317023,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE BRIM W 10.5 MM THK 2.5 MM H SPC 12 MM 14 H SCREW,SUP-2902402,CDM,C1713,HCPCS,0278,RC,,,,both,,,6479.70,4211.80,,,,,,,,,,,,,
COIL EMB L3CM DST DIA2MM PROX DIA3MM FBR DETACH GDC-18,SUP-2367913,CDM,C1889,HCPCS,0278,RC,,,,both,,,6000.54,3900.35,,,,,,,,,,,,,
LINER ACET 40X58-60 MM HIP FACE CHANGING UHMWPE VIT E,SUP-2308987,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
STEM FEM L120MM DIA13MM KNEE CEM TAPR PFC SIG,SUP-2253327,CDM,C1776,CPT,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
SCREW BNE COMPR 6.5X90 MM 16 MM CANN HDLSS THRD NS LTX,SUP-2856182,CDM,C1713,HCPCS,0278,RC,,,,both,,,3058.36,1987.93,,,,,,,,,,,,,
SYSTEM INTRO SHTH 6FR L13CM GRN HUB W O SIDEPRT SPLITTABLE,SUP-2303228,CDM,C1892,HCPCS,0272,RC,,,,both,,,102.21,66.44,,,,,,,,,,,,,
KIT INTRO SHTH L 10 CM DIA 5.5 FR GUIDEWIRE L 65 CM DIA,SUP-2120532,CDM,C1894,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
ANCHOR SUTURE 4.75 MM W/ 1MM HI-FI RIBBON ARGO KNOTLESS,SUP-2846775,CDM,C1713,HCPCS,0278,RC,,,,both,,,2534.39,1647.35,,,,,,,,,,,,,
DEVICE FIX SM TAILORS BUNION PROSTEP,SUP-2846073,CDM,C1713,HCPCS,0278,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
SET PICC L 55 CM DIA 6 FR SHTH L 7 CM DIA 6 FR,SUP-2886961,CDM,C1751,HCPCS,0278,RC,,,,both,,,2917.06,1896.09,,,,,,,,,,,,,
KIT PENILE PROS PT RECORD LBL ASMBLY TOOL STRL DISP TITAN,SUP-2905153,CDM,C1813,HCPCS,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
KIT INTRO SHTH 5 CM GUIDEWIRE L 30 CM DIA 6 FR NDL L 1.5 IN,SUP-2734926,CDM,C1894,HCPCS,0272,RC,,,,both,,,10.68,6.94,,,,,,,,,,,,,
SLING ARM M FOR 11-13IN UNIV PREM QUAL BRTH EXTRA PD FAB,SUP-2196420,CDM,L3660,HCPCS,0272,RC,,,,both,,,164.38,106.85,,,,,,,,,,,,,
CATHETER GUID BOBBY L 95 CM OD 8.4 FR ID 2.18 MM BALLOON L,SUP-2915969,CDM,C1887,HCPCS,0272,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PTCH THN 7X7 CM AMNIO TISS MEMBRN CYGNUS,SUP-2422825,CDM,Q4170,HCPCS,0636,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
VALVE MI OD31MM ID26.1MM 5.18SQCM 85DEG PYROLYTIC C,SUP-2355159,CDM,C1889,HCPCS,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
HC So 17-Hydroxyprogesterone,PX-3018349866,CDM,83498,CPT,0301,RC,,,,outpatient,,,553.00,359.45,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 12 MM DIA 4 MM SS RX BALLOON,SUP-2142461,CDM,C1876,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
HC Blood Draw per Port,PX-7613659100,CDM,36591,CPT,0761,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
CLIP ANEUR BLDE L12/17MM MAX OPN 9.6MM 180GM TI PERM STD,SUP-2108622,CDM,C1889,HCPCS,0278,RC,,,,both,,,1361.79,885.16,,,,,,,,,,,,,
CATHETER ETER THROMB 8FR 80CM 19MM,SUP-2214113,CDM,C1757,HCPCS,0272,RC,,,,both,,,199.11,129.42,,,,,,,,,,,,,
FIBER LASER IMPERIUM 500 MICRON CO2,SUP-2931429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
HC So Allergen Specific Ige Qual Mul,PX-3058600566,CDM,86005,CPT,0305,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
TUNNELER SURG L 12 IN DIA16 GA STRL DISP ON-Q,SUP-2917192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BLADE SURG 0.25-25 MM ACCUVISION DISP,SUP-2685789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
FILGRASTIM-AYOW 300 MCG/0.5ML SC SOSY,RX-157755,CDM,Q5125,HCPCS,0636,RC,70121-1568-01,NDC,,both,0.5,ML,469.10,304.91,,,,,,,,,,,,,
STENT MOD 25MM 2.50 NIR ON RANG,SUP-2140506,CDM,C1876,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
BIT DRL N CANN 3.7 MM,SUP-2598293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE SYNDESMOTIC L 29 MM SHFT W 10.8 MM 2 H TI PEEK ANK GRN,SUP-2894143,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X4.50 MM SCHKNT STAPE WIRE SS,SUP-2637739,CDM,L8613,CPT,0278,RC,,,,both,,,339.03,220.37,,,,,,,,,,,,,
SPACER KNEE DRL TIP 8 MM PATELLAR 1 PEG VANGUARD,SUP-2446515,CDM,C1776,CPT,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
LINER GLEN SM THK4MM SHLDR POLY POR MOD BIOMOD,SUP-2404670,CDM,C1776,CPT,0278,RC,,,,both,,,2263.47,1471.26,,,,,,,,,,,,,
BRACE ORTH AD SM FOR 8 9IN HND SHT R THMB SPICA BLK,SUP-2196531,CDM,L3923,HCPCS,0272,RC,,,,both,,,123.75,80.44,,,,,,,,,,,,,
PLATE BNE L183MM 11 H NONSTERILE R DST LAT FIBULAR S STL,SUP-2177733,CDM,C1713,HCPCS,0278,RC,,,,both,,,2914.55,1894.46,,,,,,,,,,,,,
SCREW BNE L20MM DIA5MM CNDYL S STL ST VAR ANG CANN LOK FULL,SUP-2178725,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.08,487.55,,,,,,,,,,,,,
WIRE FIX 2 MM KIRSCHNER ANC600] PROGRESSIVE MEDICAL],SUP-2330465,CDM,C1713,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
BUNDLE CASE DISTRCTN CRAN MXLFCL 4 FULL SKULL RECON VSP,SUP-2862828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,34414.49,22369.42,,,,,,,,,,,,,
HC Change Cystostomy Tube Smpl,PX-4505170500,CDM,51705,CPT,0450,RC,,,,inpatient,,,383.00,248.95,,,,,,,,,,,,,
BRACE KNEE SM HNG PAT STBL BILAT AD PUL ON STRP CLSR,SUP-2196833,CDM,L1810,HCPCS,0272,RC,,,,both,,,56.99,37.04,,,,,,,,,,,,,
BIT DRL L 13 CM DIA 3.5 MM TIB SQ TIP FOR TOT ANK REPL SYS,SUP-2899034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1071.53,696.49,,,,,,,,,,,,,
KIT BNE CEMENT HIP MIXING SYS BRKWY FEM NOZ ADV FEM,SUP-2884227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,400.95,260.62,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL LSO,SUP-2388146,CDM,L0626,HCPCS,0272,RC,,,,both,,,200.71,130.46,,,,,,,,,,,,,
PATCH VASC W6XL75MM KNIT POLY CAR ULT THN WALL N TAPR N RING,SUP-2395789,CDM,C1768,CPT,0278,RC,,,,both,,,425.53,276.59,,,,,,,,,,,,,
SCREW BNE CANC LG 6.5X150 MM 16 MM HEX NS LTX,SUP-2861492,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.46,138.75,,,,,,,,,,,,,
KIT INTRO ARW DIA 9 FR GUIDEWIRE 0.035 IN POLYUR PERC SHRP,SUP-2383944,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.89,77.93,,,,,,,,,,,,,
ANCHOR SUT TWINFIX PK FT 5.5MM W/ TWO SUTS AND DISP AWL,SUP-2341094,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
SOLIDLOK HEX TIP 35MM STE,SUP-2724020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA 8 MM EXTERNALLY SUPP,SUP-2266011,CDM,C1768,CPT,0278,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
GUIDEWIRE ORTH 2X200 MM SS,SUP-2646004,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.51,60.78,,,,,,,,,,,,,
BIT DRL L54MM DIA1.4MM 8MM STP FOR 1.7MM SCR MID FACE,SUP-2366410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.25,285.51,,,,,,,,,,,,,
STRAP CLAV DLX COT L,SUP-2276604,CDM,L3650,HCPCS,0272,RC,,,,both,,,23.93,15.55,,,,,,,,,,,,,
PLATE BNE L147MM 8 H NONSTERILE L PROX TIB S STL VAR ANG,SUP-2177916,CDM,C1713,HCPCS,0278,RC,,,,both,,,5322.87,3459.87,,,,,,,,,,,,,
PLATE BNE L 132 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 12 HL,SUP-2937078,CDM,C1713,HCPCS,0278,RC,,,,both,,,1950.73,1267.97,,,,,,,,,,,,,
PLATE BNE LOWER RAMUS 2.3 MM LT FRAC SMRT FOR SCR TI LEVEL 1,SUP-2498565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1746.84,1135.45,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.443,SUP-2860007,CDM,C1713,HCPCS,0278,RC,,,,both,,,51285.93,33335.85,,,,,,,,,,,,,
PLATE BNE LT MANDIBULAR PRIMARY HEMI W/ TMPLT NS,SUP-2883234,CDM,C1713,HCPCS,0278,RC,,,,both,,,5690.81,3699.03,,,,,,,,,,,,,
PLATE BNE L208MM THK2.1/2.5MM 14 H THOR STRNL PEEK LOK LSS,SUP-2262586,CDM,C1713,HCPCS,0278,RC,,,,both,,,1601.21,1040.79,,,,,,,,,,,,,
GRAFT BNE L25MM H15MM IL CREST WDG FRZ DRY MATRIGRFT,SUP-2264803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2369.54,1540.20,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 75-79 CM SAPH VEIN BLD TYP A B AB,SUP-2884052,CDM,C1768,CPT,0278,RC,,,,both,,,34065.86,22142.81,,,,,,,,,,,,,
SCREW BNE L75MM DIA73MM THRD L20MM S STL ST CANN T40 STARDRV,SUP-2178293,CDM,C1713,HCPCS,0278,RC,,,,both,,,837.66,544.48,,,,,,,,,,,,,
GRAFT HUM TISS W6-20X9-21XL14-25MM THK16-18MM IL CREST WDG,SUP-2307144,CDM,C1762,CPT,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
REGULATOR ENDO AERO W/O VENT,SUP-2402575,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
VALVE CSF MULTPURP HI PRESSURE ON-OFF FLSH W/O ANTI SIPHON,SUP-2852569,CDM,C1889,HCPCS,0278,RC,,,,both,,,4204.21,2732.74,,,,,,,,,,,,,
BIT DRL L200MM DIA4.3MM CANN QUIK CPL W/O STP REUSE FOR 5MM,SUP-2187329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.98,673.39,,,,,,,,,,,,,
CLAMP EXTRNL FXTN CHRNLEY 47MM DIA F/LWR EXTRMTY ARTHRDSS P,SUP-2720696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2608.08,1695.25,,,,,,,,,,,,,
BURR CRANIAL DGR-I 11MM/7MM ACRA CUT,SUP-2842436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
GUIDEWIRE VASC STRT L 125 CM DIA 0.025 IN TIP L 3 CM SS PTFE,SUP-2148302,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.54,14.00,,,,,,,,,,,,,
PULSE OXIMETER KIT STRT AD PEDIATRIC 12 FT CRD LNOP DCI,SUP-2265856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
PLATE BNE L 333 MM SCREW DIA 4.5 MM 20 H COMPR LCK NS EVOS,SUP-2933272,CDM,C1713,HCPCS,0278,RC,,,,both,,,3686.89,2396.48,,,,,,,,,,,,,
LENS IOL 3 PC 22+ DIOPT 6 MM POST CHMBR MLPC TECNIS,SUP-2102332,CDM,V2632,HCPCS,0276,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
SLEEVE FEM SM SZ 26-27 TI STIKTITE HA HIP REV MOD REDAPT,SUP-2345443,CDM,C1776,CPT,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
BLADE SCREWDRIVER 27MM DIA STAINLESS STEEL CROSS DRIVE,SUP-2679090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.10,285.41,,,,,,,,,,,,,
PLATE BONE SM L85MM THK1MM 7 H BILAT S STL 1/3 TBLR NEUT DYN,SUP-2185838,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL STD LT POST FLAT,SUP-2751237,CDM,C1713,HCPCS,0278,RC,,,,both,,,5690.47,3698.81,,,,,,,,,,,,,
DEVICE EXTR BLLN 12MM 200CM CLR CONN PUR DEV EXTR DBL LUMN,SUP-2169100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 21 GAX7 CM TRANSCAROTID ACCS KT,SUP-2431177,CDM,C1894,HCPCS,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
PROSTHESIS OSSCLR LITE TOTAL 3MM DIA HEAD 08MM/23MM DIA DS,SUP-2681501,CDM,L8613,CPT,0278,RC,,,,both,,,1381.25,897.81,,,,,,,,,,,,,
DISTAL TIB CLOSING WEDG OSTEOTOME PLT,SUP-2811863,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
CAGE SPNL W14XH9XL14MM PEEK ANTR CERV INTBDY FUS LORDTC,SUP-2415976,CDM,C1889,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
HC Sleep Study Unattended,PX-9209580000,CDM,95800,CPT,0920,RC,,,,both,,,898.00,583.70,,,,,,,,,,,,,
CATHETER PULM ART 7FR L110CM INTRO 7X8FR BAL 1.5CC DIA12MM,SUP-2383250,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
SUMATRIPTAN SUCCINATE 25 MG PO TABS,RX-15327,CDM,6370000000,HCPCS,0637,RC,16714-0796-01,NDC,,both,1,UN,8.00,5.20,,,,,,,,,,,,,
PORT IMPL INFUSION 9.6 FR PREATTACH CATH POWERPORT MRI,SUP-2126336,CDM,C1788,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BLADE SHAVER CRV SUCTION 65 DEG 4 MMX12 CM SERRATED YEL STRL,SUP-2602791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,670.33,435.71,,,,,,,,,,,,,
KIT PICC CATH L 55 CM DIA 4 FR GUIDEWIRE 0.018 IN NDL L 7 CM,SUP-2884238,CDM,C1751,HCPCS,0278,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
KIT BEAD OSTEOCURE RESRB CA SULF BONE VOID FIL FAST SET 7MM,SUP-2400547,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
ART SURF LPS MOBILE IMPL SZ C/234 10MM,SUP-2200837,CDM,C1776,CPT,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
KIT ENDOPYELOTOMY STARTER SYSTEM TAMPONADE BLLN CATHETER URETERAL ACCESS 7 10 SHEATHS ACUCISE,SUP-2119498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7470.37,4855.74,,,,,,,,,,,,,
MESH HERN 11X6CM MACROPOROUS KEYHOLE PARIETENE,SUP-2172439,CDM,C1781,HCPCS,0278,RC,,,,both,,,402.01,261.31,,,,,,,,,,,,,
CATHETER OCCL 12FR L100CM VES DIA10-50MM TAPR FLX TIP STR,SUP-2395996,CDM,C2628,HCPCS,0272,RC,,,,both,,,1502.18,976.42,,,,,,,,,,,,,
TIZANIDINE HCL 4 MG PO TABS,RX-14793,CDM,6370000000,HCPCS,0637,RC,68084-0645-11,NDC,,both,1,UN,2.90,1.88,,,,,,,,,,,,,
CATHETER ETER EDI 6FR L50CM PHT FREE,SUP-2227268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
HC Repr Smp Nt Face 7.6-12.5cm,PX-4501200400,CDM,12004,CPT,0450,RC,,,,both,,,861.00,559.65,,,,,,,,,,,,,
SCREW BNE L46MM DIA5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412126,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT HEMORRHOIDAL DEARTERIAL SLIDE 1,SUP-2385925,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.28,1211.13,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA11 MM DEL SHTH,SUP-2934261,CDM,C1713,HCPCS,0278,RC,,,,both,,,13897.64,9033.47,,,,,,,,,,,,,
DISTRACTION INTRNL MESH MESH MDFC8 X 8 HOLE T07 MM CP TTNM,SUP-2707282,CDM,C1713,HCPCS,0278,RC,,,,both,,,4127.78,2683.06,,,,,,,,,,,,,
BIT DRL DIA2MM CANN FOR QUICKFIX SCR AND COMPHSVE FT SYS,SUP-2122860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
TUBES SOUND ABR EARTIP SANIBEL,SUP-2719737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
HC Rem Impact Cerumen Irrigat Uni,PX-4506920900,CDM,69209,CPT,0450,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
RETRACTOR SPNL L4CM DIA22MM D1.57IN S STL TB MED LAT DIL,SUP-2292982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1167.92,759.15,,,,,,,,,,,,,
DRILL TWST 25MMDIA 4INL J LATCH DISPOSABLE,SUP-2262904,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
Appl Splint Fa-Hand Dynamic,PX-4302912600,CDM,29126,CPT,0430,RC,,,,both,,,404.00,262.60,,,,,,,,,,,,,
LEAD PACING UFM 1 ORANGE AND 1 WHITE,SUP-2850072,CDM,C1898,HCPCS,0275,RC,,,,both,,,85.57,55.62,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC CORTICOCANCELLOUS ALLGRFT,SUP-2933719,CDM,C1762,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
WEDGE FEM SZ 6 THK20MM DSTL KNEE FOR HNG SYS LEGION,SUP-2346408,CDM,C1776,CPT,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
DA VINCI TIBIAL NAIL 8MMX31.5CM,SUP-2828905,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
CONNECTOR SPNL ROD TO ROD MED 34-44 MM BLACKBIRD,SUP-2564723,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CONNECTOR CSF STEPDOWN 0.8X1.8-1.5 MM SS STRL,SUP-2851468,CDM,C1889,HCPCS,0278,RC,,,,both,,,2894.48,1881.41,,,,,,,,,,,,,
SET THERMOABLATION PROCERVA,SUP-2139316,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
GUIDEWIRE ORTH PARL 2.8 MM ADJ NS,SUP-2789125,CDM,C1769,HCPCS,0272,RC,,,,both,,,3887.70,2527.00,,,,,,,,,,,,,
PERFORATOR CRAN AD PED 11/7MM MINI DISP FOR THK1MM AREA DGR,SUP-2106554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
VERAPAMIL HCL 40 MG PO TABS,RX-8529,CDM,6370000000,HCPCS,0637,RC,00591-0404-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA13 FR DIL L 20 CM GUIDEWIRE,SUP-2168020,CDM,C1892,HCPCS,0272,RC,,,,both,,,125.91,81.84,,,,,,,,,,,,,
NAIL INTRMDLLRY 9MM X 420MM 125DG RIGHT F/HIP FRAC AFFXS,SUP-2588660,CDM,C1713,HCPCS,0278,RC,,,,both,,,6752.38,4389.05,,,,,,,,,,,,,
PLATE BNE L90MM 4 H L PROX HUM HI ALPS,SUP-2411639,CDM,C1713,HCPCS,0278,RC,,,,both,,,4628.36,3008.43,,,,,,,,,,,,,
GRAFT BNE 1.5 CC ACTIFUSE ABX,SUP-2208432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
CATHETER HD KT 12 FRX16 CM DL INTRO INJ NDL TISS DIL SUTURE,SUP-2762984,CDM,C1752,HCPCS,0278,RC,,,,both,,,271.30,176.34,,,,,,,,,,,,,
BUR SURG BALL 6 MM FLUT FOR MIA16-G1/MIA16,SUP-2848321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.56,305.21,,,,,,,,,,,,,
POST EXT FIX 2 H M,SUP-2898594,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 14 CM DIA 0.025 IN PERIPH AV SWG POS,SUP-2826706,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.73,14.12,,,,,,,,,,,,,
SYSTEM OCCL DEL AMPLATZER 45 DEG L 60 CM SHTH 6 FR NIT MESH,SUP-2116316,CDM,C1894,HCPCS,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
CATHETER CTRL VEN DBL LUMN N TUNNELED BASIC KT POLYUR,SUP-2120599,CDM,C1751,HCPCS,0278,RC,,,,both,,,177.72,115.52,,,,,,,,,,,,,
GRAFT BNE SUB 20CC VI DIA4.8MM CA SULF PELLET RESRB PRELD,SUP-2399031,CDM,C1713,HCPCS,0278,RC,,,,both,,,3307.77,2150.05,,,,,,,,,,,,,
BUR SURG DIAMOND MIC 0.38 MM FOR SALIVARY TONE,SUP-2773263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,964.17,626.71,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135 CM DIA 4 FR SLT PAT L 10 CM,SUP-2117048,CDM,C1725,HCPCS,0272,RC,,,,both,,,356.70,231.85,,,,,,,,,,,,,
CATHETER CTRL VEN L20CM OD5FR .032IN GWIRE KT SGL LUMN N AK04210] TELEFLEX ARROW INTL INC],SUP-2383264,CDM,C1751,HCPCS,0278,RC,,,,both,,,53.69,34.90,,,,,,,,,,,,,
HINGE EXT FIX 90DEG LO PROF FOR ILIZ,SUP-2342309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1583.82,1029.48,,,,,,,,,,,,,
SLING UROLOGICAL MALE ADVANCE XP,SUP-2138909,CDM,C1771,HCPCS,0278,RC,,,,both,,,27991.53,18194.49,,,,,,,,,,,,,
SPLINT WR AD L 9IN LNG RT COT W/ STAY ELAS SUPP FOR,SUP-2324569,CDM,L3809,HCPCS,0274,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
CAP ORTH CEPHALOMEDULLARY NAIL TI STRL ZNN,SUP-2862127,CDM,C1713,HCPCS,0278,RC,,,,both,,,2949.59,1917.23,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC EZE-SIT TRU-INCISE CATH L 91 CM CUT,SUP-2390667,CDM,C1726,HCPCS,0272,RC,,,,both,,,11928.86,7753.76,,,,,,,,,,,,,
KNIFE 3734123 JAKO MICRO LARYN SICKLE,SUP-2706869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.46,356.50,,,,,,,,,,,,,
POR ST/ POR CUP/ XLPE LINER/ DELT CER HD,SUP-2212059,CDM,C1776,CPT,0278,RC,,,,both,,,13556.29,8811.59,,,,,,,,,,,,,
SPACER TIB SZ 1 THK4MM UNIV MEDL PRI ASYM CEM N-K II,SUP-2209339,CDM,C1776,CPT,0278,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
BLADE SAW L 93 X W 5 MM L 10 MM RECIP RASP DOWNWARD ANGLE,SUP-2929470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,595.28,386.93,,,,,,,,,,,,,
SPACER SPNL 9X11X26MM 15DEG TI TLX,SUP-2431846,CDM,C1821,HCPCS,0278,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
HC So1 Porphyrinsquantitive,PX-3018412067,CDM,84120,CPT,0301,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
HALF PIN 6MMX75MM,SUP-2818664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1535.08,997.80,,,,,,,,,,,,,
KIT ACC HIP CRV BLDE,SUP-2249574,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
TRANSDUCER PRSS CBL L48IN WNG HSNG M SWVL NUT FEM FIX LUER,SUP-2303074,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.24,23.56,,,,,,,,,,,,,
GRAFT HUM TISS 220 300MM 65 85MM TIBIALIS POST,SUP-2335541,CDM,C1762,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER UMB 3L 5 FRX15 IN ATRAUM TIP ROUNDED VES ARGY,SUP-2174252,CDM,C1751,HCPCS,0278,RC,,,,both,,,111.91,72.74,,,,,,,,,,,,,
STENT BILI WALLFLEX L 60 MM DIA 8 MM CATH L 75 CM DIA 8 FR,SUP-2141601,CDM,C1876,HCPCS,0278,RC,,,,both,,,8079.22,5251.49,,,,,,,,,,,,,
STEM MONOBLOCK SZ 2 L30MM NONCEMENTED + PROMOS,SUP-2351248,CDM,C1776,CPT,0278,RC,,,,both,,,6421.30,4173.84,,,,,,,,,,,,,
GRAFT BNE 5 CC DEMINERALIZED BNE FIBER PROGRAFT,SUP-2858505,CDM,C1713,HCPCS,0278,RC,,,,both,,,1929.53,1254.19,,,,,,,,,,,,,
COIL NEUROVASCULAR L 20 CM DIA 6 MM PLAT TUNGSTEN DETACHABLE,SUP-2884372,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
DEVICE FIX 5 MM HELCL 30 MESH ASSEMBLED HERN REP TCKR,SUP-2283317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.20,622.18,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L115CM 7/20FR 6MM,SUP-2248628,CDM,C1732,HCPCS,0272,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
DEVICE DRNGE CLR TUTOPLAST 1/3 CORNEA SCLER,SUP-2247190,CDM,V2785,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
EXTENSION NERVE STIM PERC 2.16 MM ISTM QUAD INTERSTIM,SUP-2640136,CDM,C1883,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
HC So Serotonin,PX-3018426066,CDM,84260,CPT,0301,RC,,,,both,,,75.00,48.75,,,,,,,,,,,,,
STEM XL TAPER 20X235MM,SUP-2505016,CDM,C1776,CPT,0278,RC,,,,both,,,8817.12,5731.13,,,,,,,,,,,,,
KIT INTRO INTROFLEX L 10 CM DIA 8.5 FR HEPARIN BONDED ADJ,SUP-2214542,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.63,42.66,,,,,,,,,,,,,
SPLINT WRST XL L8IN L BLK FOAM D RNG CLSR LO PROF MAL,SUP-2336047,CDM,L3809,HCPCS,0272,RC,,,,both,,,18.21,11.84,,,,,,,,,,,,,
PLATE BONE LNG STRL TARSAL METATRSL FUS FOR 2.7MM SCR VLP,SUP-2349943,CDM,C1713,HCPCS,0278,RC,,,,both,,,6045.91,3929.84,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 16MM DISC,SUP-2261688,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1626.52,1057.24,,,,,,,,,,,,,
PIN EXT FIX HALF 6X120 MM 30 MM THRD SS RINGFIX,SUP-2459716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 11 MMX0.4 CM FD CROSS SECT,SUP-2717811,CDM,C1762,CPT,0278,RC,,,,both,,,2883.74,1874.43,,,,,,,,,,,,,
HEAD FEM BPLR 28X49 MM HIP,SUP-2340085,CDM,C1776,CPT,0278,RC,,,,both,,,5262.64,3420.72,,,,,,,,,,,,,
WASHER SCRW 17MM,SUP-2695514,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.80,100.62,,,,,,,,,,,,,
SUPPORT WR SM AD LT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324889,CDM,L3931,HCPCS,0272,RC,,,,both,,,42.83,27.84,,,,,,,,,,,,,
CLAMP CONN FOR 5MM SUSP ROD TI ANTR CERV,SUP-2290604,CDM,C1713,HCPCS,0278,RC,,,,both,,,1300.75,845.49,,,,,,,,,,,,,
"HC So Alpha-1,Antitrypsin,Phenotype",PX-3018210466,CDM,82104,CPT,0301,RC,,,,both,,,156.00,101.40,,,,,,,,,,,,,
PIN EXT FIX SZ 4 X 80 X 15 MM HALF NS DISP MAV MINI,SUP-2933100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
PATCH DURAL 1.5X3CM NEURO PATCH,SUP-2826140,CDM,C1763,HCPCS,0278,RC,,,,both,,,210.95,137.12,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM SCREW DIA2 MM TI RT CRANIOMAXILLOFACIAL,SUP-2935828,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
CATHETER HD CRV EXTN 12 FRX20 CM CATH NDL DUOFLO,SUP-2627073,CDM,C1752,HCPCS,0278,RC,,,,both,,,343.52,223.29,,,,,,,,,,,,,
TUBE TRACH PED L40MM OD53MM ID35MM SIL CUF STR NK FLNG FLX,SUP-2352325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.52,385.79,,,,,,,,,,,,,
ADAPTER LD L 15 CM DF1 CONN TO TERM,SUP-2148908,CDM,C1883,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE RECON 4.5X127 MM 8 HOLE STR NC RIGID CLLRD SS,SUP-2410179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.75,726.54,,,,,,,,,,,,,
STENT GRFT VASC AFX L 75 MM UNCOVERED L 20 MM DIA 28 MM,SUP-2217600,CDM,C1768,CPT,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
KNOTLESS MINI TR IMPLANT AR8906DS,SUP-2843916,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
STENT BILI SYM L 20 MM DIA 7 FR CATH L 75 CM DIA10 MM NIT AD,SUP-2141182,CDM,C1876,HCPCS,0278,RC,,,,both,,,3415.69,2220.20,,,,,,,,,,,,,
BLADE SAW L 16 MM D 11 MM THK MATERIAL 0.5 MM CUT 0.7 MM GC279R,SUP-2928827,CDM,2720000010,LOCAL,0272,RC,,,,both,,,554.40,360.36,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM OD32MM TRCR TIP PLN,SUP-2243925,CDM,C1769,HCPCS,0272,RC,,,,both,,,266.27,173.08,,,,,,,,,,,,,
CATHETER DIL L75CM BLLN L10CM DIA12FR BLLN HYDR+ HI PRSS,SUP-2139206,CDM,C1726,HCPCS,0272,RC,,,,both,,,864.54,561.95,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST DBL UPR W/AIR OFF THE SHLF,SUP-2435616,CDM,L1848,HCPCS,0272,RC,,,,both,,,1628.40,1058.46,,,,,,,,,,,,,
IMPLANT MPJ 11MM HEMI THE LESSER,SUP-2137763,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
STEM HUM SZ 1B L88MM 1325DEG LNG PTC FOR CONV SHLDR SYS,SUP-2399875,CDM,C1776,CPT,0278,RC,,,,both,,,14742.30,9582.49,,,,,,,,,,,,,
GRAFT BNE W5XL120MM FIB FRZN SHFT,SUP-2307381,CDM,C1713,HCPCS,0278,RC,,,,both,,,2622.87,1704.87,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM POROUS HA,SUP-2365947,CDM,C1776,CPT,0278,RC,,,,both,,,13881.94,9023.26,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 16H LT 249MM-STER,SUP-2549591,CDM,C1713,HCPCS,0278,RC,,,,both,,,5144.36,3343.83,,,,,,,,,,,,,
GUIDEROD L900MM DIA2MM SMOOTH STR BLNT TIP,SUP-2343597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
PLATE TIBIA 4.5MM LCPV TM PROXIMAL 20 HOLES 370MM RT STERILE,SUP-2547544,CDM,C1713,HCPCS,0278,RC,,,,both,,,4861.69,3160.10,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM DIA 6 FR TIP 4 MM SPC BLU,SUP-2248666,CDM,C1733,HCPCS,0272,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN IRRADIATED GRACILIS TEND 921748,SUP-2867183,CDM,C1762,CPT,0278,RC,,,,both,,,2285.92,1485.85,,,,,,,,,,,,,
SET ADPT FOR 44 CABLE PK,SUP-2137937,CDM,C1883,HCPCS,0278,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
SAW NASAL JOSEPH LEFT,SUP-2677504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,521.68,339.09,,,,,,,,,,,,,
COMPONENT FEM 10 MM PS FLEXED,SUP-2136960,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
PIN DRL L9.5MM KNEE GUID RG RMR FLIPCUTTER II,SUP-2120819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PACEMAKER CARD ADVISA SR MRI SURESCAN W 51 X H 42 MM D 8 MM,SUP-2282301,CDM,C1786,HCPCS,0275,RC,,,,both,,,9043.04,5877.98,,,,,,,,,,,,,
COMPONENT TIB XSM-XL KNEE POLYETH MOD CEM STEM ROT HNG REV,SUP-2376362,CDM,C1776,CPT,0278,RC,,,,both,,,7104.56,4617.96,,,,,,,,,,,,,
CATHETER DRAINAGE 25 MMX8CM UNITZ SNAP ASMBLY RESERVOIR BASE,SUP-2278323,CDM,C1729,HCPCS,0272,RC,,,,both,,,481.52,312.99,,,,,,,,,,,,,
SCREW BNE CANN 6.5X40 MM 16 MM COMPR HDLSS THRD EXTREMIFIX,SUP-2319489,CDM,C1713,HCPCS,0278,RC,,,,both,,,3058.36,1987.93,,,,,,,,,,,,,
GRAFT SFT TISS 16X10 CM PLIABLE RECON TISS MTRX STRATTICE,SUP-2467751,CDM,Q4130,HCPCS,0636,RC,,,,both,,,7344.46,4773.90,,,,,,,,,,,,,
NEEDLE ASPRIRATION 22GA EXPECT PULMONARY - BOX OF 5,SUP-2855141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.75,400.24,,,,,,,,,,,,,
CARRIER ENDO 17R F/50-2040 LT LARYNSCP REPL,SUP-2383871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,845.23,549.40,,,,,,,,,,,,,
"HC So Culture, Chlamydia, Any Source",PX-3008711066,CDM,87110,CPT,0300,RC,,,,inpatient,,,185.00,120.25,,,,,,,,,,,,,
BLADE SAW S STL RESECT FOR PART KNEE STRYKR SYS 3 OXFORD,SUP-2408668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BONE BLLRD 6MM BRDGE TTNM RIGHT HOOK LATEX FREE ST,SUP-2677533,CDM,C1713,HCPCS,0278,RC,,,,both,,,911.64,592.57,,,,,,,,,,,,,
ELECTRODE EMG L12MM SUBDERM 4 CHN PR SHRP LANC TIP TWISTED,SUP-2279928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,557.82,362.58,,,,,,,,,,,,,
MESH SURG W75XL15CM WHT MACROPOROUS,SUP-2752154,CDM,C1781,HCPCS,0278,RC,,,,both,,,196.34,127.62,,,,,,,,,,,,,
DEFIBRILLATOR AED IMPL MED DEV,SUP-2863121,CDM,C1833,HCPCS,0278,RC,,,,both,,,32185.00,20920.25,,,,,,,,,,,,,
BASKET REPLACMENT SGL USE 30MM,SUP-2313287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,903.25,587.11,,,,,,,,,,,,,
HEAD HUM 4+ MM 42 MM SHLDR DELT EXT,SUP-2456980,CDM,C1776,CPT,0278,RC,,,,both,,,3403.76,2212.44,,,,,,,,,,,,,
COMP ST/POLY GLD/VRSDL HD,SUP-2212460,CDM,C1776,CPT,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
GRAFT BNE GEL 1 CC INJ DBM GRFT 41120A] MEDTRONIC USA INC],SUP-2278318,CDM,C1713,HCPCS,0278,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
PLATE SPNL MINI 12X23 MM 2.5 MM OFFSET TITAN STRL ANTERALIGN,SUP-2859407,CDM,C1713,HCPCS,0278,RC,,,,both,,,7664.74,4982.08,,,,,,,,,,,,,
HC Assay of Blood/Uric Acid,PX-3018455000,CDM,84550,CPT,0301,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ARMADA18 L 150 CM BALLOON L 120 MM DIA 6,SUP-2105397,CDM,C1725,HCPCS,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
PATCH DURAL SUB 2.5X2.5CM ONLAY LYCOPLANT,SUP-2717534,CDM,C1763,HCPCS,0278,RC,,,,both,,,520.77,338.50,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 4 MM STR STD WALL HELIX,SUP-2681771,CDM,C1768,CPT,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min|OP PT SERVICES|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE,PX-4209711600,CDM,97116,CPT,0420,RC,,,GP|XU|KX,both,,,164.00,106.60,,,,,,,,,,,,,
BOOT CAST ASMBLY ROCKER BTM,SUP-2162677,CDM,L4361,HCPCS,0274,RC,,,,both,,,4220.16,2743.10,,,,,,,,,,,,,
MESH HERN W6XH4IN INT ABD OMEGA 3 FATTY ACID POLYPR OBLONG,SUP-2265983,CDM,C1781,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
COVER BURR H DIA20 MM THK 0.5 MM TI CRANIOFACIAL PLATE SHUNT,SUP-2883645,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.43,636.63,,,,,,,,,,,,,
GENDER FLX CEM FEM/CEM TIB/ PRLNG SURF/NO PAT,SUP-2212249,CDM,C1776,CPT,0278,RC,,,,both,,,12213.19,7938.57,,,,,,,,,,,,,
CATHETER DRNGE 6FR UNIV NIT LOK PGTL NAVARRE,SUP-2128421,CDM,C1729,HCPCS,0272,RC,,,,both,,,235.41,153.02,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM AMNION-CHORION-AMNION LAYR,SUP-2909209,CDM,Q4140,HCPCS,0636,RC,,,,both,,,5806.27,3774.08,,,,,,,,,,,,,
SPLINT WRST FA 6IN UNIV BLU L LOOP LOK W STAY COCK UP CANVS,SUP-2194434,CDM,L3809,HCPCS,0272,RC,,,,both,,,35.86,23.31,,,,,,,,,,,,,
PLATE ATTACHMENT 3.5MM TI LCKNG PL F4.5MM LCP 8H-STER,SUP-2546835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1925.42,1251.52,,,,,,,,,,,,,
BLADE SAW 35X10 MM STRNM FOR PRIMARY,SUP-2607460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1731.46,1125.45,,,,,,,,,,,,,
ALLODERM SELECT RESTORE LARGEPERFORATED - THICK 2.4 0.4MM,SUP-2822079,CDM,Q4116,HCPCS,0636,RC,,,,both,,,45470.34,29555.72,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-142362,CDM,Q5106,HCPCS,0636,RC,00069-1306-10,NDC,,both,1,ML,97.70,63.50,,,,,,,,,,,,,
GUIDEWIRE VASC L50CM DIA0038IN TIP L3MM S STL DBL END,SUP-2303470,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
ELECTRODE CONCL COAG 24/26FR,SUP-2261202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CATHETER ANGIO DIA 5 FR COBRA STRL,SUP-2383192,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DRILL TWST OD2MM L75MM QUIK CONN,SUP-2397202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
ELECTRODE LOOP DIA24-26FR YEL CUT BPLR DSTL TIP,SUP-2261166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1607.18,1044.67,,,,,,,,,,,,,
GRAFT BNE PTTY DEMIN BNE MTRX 2CC,SUP-2402605,CDM,C1713,HCPCS,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
CATHETER KIT 3L 7 FRX8 IN GUIDE RAULERSON CVC POLYURETHANE,SUP-2383299,CDM,C1751,HCPCS,0278,RC,,,,both,,,141.46,91.95,,,,,,,,,,,,,
HC Insert Ureteral Tube,PX-3615069300,CDM,50693,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
BLADE RTRCTR SM 24MMW X 80MML TTNM SPNL TTHX3 THIN SIL LMBRT,SUP-2466205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.73,630.97,,,,,,,,,,,,,
RELUGOLIX 120 MG PO TABS,RX-153031,CDM,6370000000,HCPCS,0637,RC,72974-0120-01,NDC,,both,1,UN,414.40,269.36,,,,,,,,,,,,,
AWL SURG DIA 8 MM CANN STR,SUP-2934410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1434.98,932.74,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE STARCLOSE SE DIA 5-6 FR NIT FEM ART,SUP-2105706,CDM,C1760,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
PROSTHESIS 3MM DIAM 5.6MM LEN PORP PARTIALLY CANN HA SHEA,SUP-2312574,CDM,L8613,CPT,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
APPLIER CLP ENDOSCP MED 10 MMX11 IN TAKE APART HORZ MTL LIG,SUP-2656770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
SHEET THERMOPLASTIC W18XL24IN THK0.09IN STD CHAR SLD SPLNT,SUP-2323989,CDM,L4350,HCPCS,0272,RC,,,,both,,,156.97,102.03,,,,,,,,,,,,,
SCREW BNE ST 1.85X14 MM 1.52X3 MM COARSE PITCH THRD LT BLU,SUP-2181794,CDM,C1713,HCPCS,0278,RC,,,,both,,,315.63,205.16,,,,,,,,,,,,,
HC So Braf Gene,PX-3108121066,CDM,81210,CPT,0310,RC,,,,both,,,406.00,263.90,,,,,,,,,,,,,
PLATE BONE W7XL57MM THK1.5MM 7 H RT CNDYL TI FOR 2.7MM SCR,SUP-2191040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1098.18,713.82,,,,,,,,,,,,,
STOP EXT FIX POS FOR RED II TI,SUP-2460630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
APPLIER CLP ENDOSCP MED LG 10 MMX13 IN LIG HORZ MTL LIG SYS,SUP-2656779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2851.12,1853.23,,,,,,,,,,,,,
PARTICLE EMB 1ML 900-1200UM MICROSPHERE PVA CNTOUR SE,SUP-2148450,CDM,C1889,HCPCS,0278,RC,,,,both,,,413.22,268.59,,,,,,,,,,,,,
HC 3d Rendering Requiring Sep Wor,PX-3507637700,CDM,76377,CPT,0350,RC,,,,outpatient,,,1344.00,873.60,,,,,,,,,,,,,
PLATE BNE NAR 3.5X143 MM 8 HOLE SS LCP,SUP-2569352,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.47,331.16,,,,,,,,,,,,,
HUMERAL NAIL CAP 0MM,SUP-2818962,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.72,463.27,,,,,,,,,,,,,
GUIDEWIRE VASC STBL L 300 CM DIA 0.014 IN COR DIA 0.135 IN,SUP-2157474,CDM,C1769,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
PLATE BNE MINI MAXLOCK EXTRM CLVRLF,SUP-2401266,CDM,C1713,HCPCS,0278,RC,,,,both,,,2932.76,1906.29,,,,,,,,,,,,,
NAIL IM L460MM DIA10MM 130DEG STRL GRN FEM TI CANN LCK AG,SUP-2192607,CDM,C1713,HCPCS,0278,RC,,,,both,,,4340.83,2821.54,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.8 MM THOR 2X2 HOLE LCK LADDER LEVEL 1,SUP-2869223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.62,662.75,,,,,,,,,,,,,
PIN BUTTRESS TI LCP 1.8X20MM,SUP-2548967,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.79,226.06,,,,,,,,,,,,,
ROD ORTHOPEDIC 2 MM SZR GRN ORTHOFLEX,SUP-2319097,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE 150-20 MM FRZN IRRADIATED FEM,SUP-2866858,CDM,C1762,CPT,0278,RC,,,,both,,,1900.17,1235.11,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 9X25-29 MM PRESERVON CANN CANC FLEXIGRAFT,SUP-2421829,CDM,C1762,CPT,0278,RC,,,,both,,,3222.83,2094.84,,,,,,,,,,,,,
COVER BUR H DIA15MM 6 H BILAT TI NONCOMPRESSION RIG FOR,SUP-2191187,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
GRAFT SKIN L220XW60XH0.34-0.51MM MESHED DERM TISS FRZ DRY,SUP-2113070,CDM,C9364,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT + DIA21 MM BOV PERICARD COCR,SUP-2214289,CDM,C1713,HCPCS,0278,RC,,,,both,,,17144.40,11143.86,,,,,,,,,,,,,
PIN FIX L18MM DIA3.5MM PROV FOR TARGETER PLATING SYS,SUP-2343987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1087.35,706.78,,,,,,,,,,,,,
PLATE 3.5MM TI LCP OLECRANON 2 HOLES LEFT 86MM-STERILE,SUP-2549520,CDM,C1713,HCPCS,0278,RC,,,,both,,,3455.73,2246.22,,,,,,,,,,,,,
NAIL IM SHT 125 DEG 11 MM HIP FRAC SYS STRL CHIMAERA,SUP-2646602,CDM,C1713,HCPCS,0278,RC,,,,both,,,4101.91,2666.24,,,,,,,,,,,,,
KIT CV SHTH 10FR 30CM LEN N SPLITTABLE 18GA .038IN DIAM N,SUP-2355547,CDM,C1894,HCPCS,0272,RC,,,,both,,,58.88,38.27,,,,,,,,,,,,,
BLADE SURG 67 MM EZX,SUP-2745652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.70,2140.90,,,,,,,,,,,,,
NAIL IM SQ HD BHR,SUP-2351311,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
CATHETER HD DL 12 FRX16 CM CRV CONCL TIP MAHRK ELITE,SUP-2283960,CDM,C1752,HCPCS,0278,RC,,,,both,,,144.13,93.68,,,,,,,,,,,,,
COMPONENT HUM SHLDR POLY CONSTRUCT COMPHSVE,SUP-2212461,CDM,C1776,CPT,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
STAPLE STEP 6MM,SUP-2470706,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE HUM 85 MM LT DSTL LAT 9 HOLE STRL LTX,SUP-2861606,CDM,C1713,HCPCS,0278,RC,,,,both,,,3434.72,2232.57,,,,,,,,,,,,,
SCREW BONE L9MM DIA1.7MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189203,CDM,C1713,HCPCS,0278,RC,,,,both,,,297.17,193.16,,,,,,,,,,,,,
VALVE CSF FLO CTRL ULTRA SM LOW-LOW MED PRESSURE DELT,SUP-2629161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2064.61,1342.00,,,,,,,,,,,,,
HC So Serpina 1 Gene,PX-3108133266,CDM,81332,CPT,0310,RC,,,,both,,,225.00,146.25,,,,,,,,,,,,,
BUR SURG OD4.5MM CUT RND FLUT STRL TIP FOR SHANK ELITE,SUP-2364010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.36,282.33,,,,,,,,,,,,,
PLATE BNE L 220 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 20 H 72440620N,SUP-2932806,CDM,C1713,HCPCS,0278,RC,,,,both,,,3591.85,2334.70,,,,,,,,,,,,,
CATHETER DRNGE PGTL MDC MAC LOC LOK LOOP MULT PURP GWIRE 5,SUP-2168158,CDM,C1729,HCPCS,0272,RC,,,,both,,,276.70,179.85,,,,,,,,,,,,,
HC Imhchem/Imcytchm 1st Single Antb Stain Procedure,PX-3128834200,CDM,88342,CPT,0312,RC,,,,both,,,371.00,241.15,,,,,,,,,,,,,
BUR SURG L 95 MM DIA2.35 MM HD DIA1.4 MM DIAMOND NS REUSE,SUP-2928938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.87,237.82,,,,,,,,,,,,,
BIT DRL L115MM DIA1.9MM 20MM STP DENT END FOR 2/2.3MM SCR,SUP-2366429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,636.20,413.53,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 40 J 4X7.1X1.4 CM 35 CC 75 GM,SUP-2356261,CDM,C1722,HCPCS,0275,RC,,,,both,,,56834.00,36942.10,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 300 CM DIA 0.014 IN COAT L 12,SUP-2909243,CDM,C1769,HCPCS,0272,RC,,,,both,,,539.04,350.38,,,,,,,,,,,,,
COLLAR CERV X TALL AD 2 PC ATLS,SUP-2319264,CDM,L0172,HCPCS,0274,RC,,,,both,,,56.11,36.47,,,,,,,,,,,,,
SPACER SPNL 11X14X10MM 7 DEG CERV LORD CALIX,SUP-2402243,CDM,C1821,HCPCS,0278,RC,,,,both,,,5286.03,3435.92,,,,,,,,,,,,,
PLATE BNE T 2X28X1.5 MM 7 HOLE ORTHOGNATHIC FOR SCR LEVEL 1,SUP-2492614,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.31,585.85,,,,,,,,,,,,,
PATCH VASC W20XL30CM THK2MM SFT TISS GOR TX,SUP-2395292,CDM,C1768,CPT,0278,RC,,,,both,,,10465.62,6802.65,,,,,,,,,,,,,
SHELL ACET AUG LG 13 MM HIP GRP 2 INTEGRIP,SUP-2433606,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BONE COMPRESSION 2 MM MANDIBULAR 5 HOLE INTERMEDIATE L,SUP-2838407,CDM,C1713,HCPCS,0278,RC,,,,both,,,1604.54,1042.95,,,,,,,,,,,,,
PLATE BONE L29MM THK1MM 3X4 H BILAT HND T SHP LCK TRILOK FOR,SUP-2267924,CDM,C1713,HCPCS,0278,RC,,,,both,,,2039.12,1325.43,,,,,,,,,,,,,
PLATE BONE W8XL44MM THK2MM 0DEG 5 H BILAT TI STR RIG DYN,SUP-2191069,CDM,C1713,HCPCS,0278,RC,,,,both,,,1207.46,784.85,,,,,,,,,,,,,
STENT CAR PRECIS PRO L 30 MM DIA 9 MM CATH L 135 CM DIA 8 FR,SUP-2159045,CDM,C1876,HCPCS,0278,RC,,,,both,,,6650.52,4322.84,,,,,,,,,,,,,
BIT DRL HRD BNE CINCHLOCK FLX DISP,SUP-2663984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.01,541.46,,,,,,,,,,,,,
HC Radiation Treatment Delivery Level 1,PX-3337740200,CDM,77402,CPT,0333,RC,,,,inpatient,,,614.00,399.10,,,,,,,,,,,,,
PLATE BNE L 4 H L TARSOMETATARSAL S STL BILAT POLYAX U SHP,SUP-2397475,CDM,C1713,HCPCS,0278,RC,,,,both,,,4314.36,2804.33,,,,,,,,,,,,,
PLATE BNE 90 DEG 5 H SCREW DIA1 MM TI CRANIOMAXILLOFACIAL T,SUP-2883139,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.21,436.29,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 1S 25X40 CM,SUP-2383099,CDM,C1781,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO L 150 CM PROX/DSTL DIA,SUP-2417269,CDM,C1757,HCPCS,0272,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
PATCH EP CATH RHYTHMIA HDX LOCATION REF MAP NS,SUP-2744816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP LT LAT MENIS W/ BNE,SUP-2867142,CDM,C1762,CPT,0278,RC,,,,both,,,16830.09,10939.56,,,,,,,,,,,,,
GUIDEWIRE MONGO18 300CM PRE US,SUP-2878242,CDM,C1769,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC Speech Therapy Group,PX-4439250800,CDM,92508,CPT,0443,RC,,,,inpatient,,,249.00,161.85,,,,,,,,,,,,,
PLATE BONE W12XL103MM THK4MM 6 H S STL STR NAR COMPR FOR,SUP-2343808,CDM,C1713,HCPCS,0278,RC,,,,both,,,1376.70,894.85,,,,,,,,,,,,,
PIN EXT FIX HALF LNG 2X180 MM 25 MM THRD TIN SIDEKCK,SUP-2472329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 7.5 FR B-B CRV,SUP-2248522,CDM,C1732,HCPCS,0272,RC,,,,both,,,7583.10,4929.01,,,,,,,,,,,,,
GRAFT DERMAL RECT 25X20 CM REGENERATIVE CLLGN MTRX XENMATRIX,SUP-2126242,CDM,C1781,HCPCS,0278,RC,,,,both,,,32185.00,20920.25,,,,,,,,,,,,,
DISSECTOR ENDOSCP L RND FOR TISS PLANE SEP BLLN SPCMKR PDB,SUP-2283310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.34,483.82,,,,,,,,,,,,,
HC Myelogram Cervical,PX-3616230200,CDM,62302,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING XTALL ADLT 4.5 IN TRNS ATLS PROCARE,SUP-2195753,CDM,L0180,HCPCS,0274,RC,,,,both,,,74.51,48.43,,,,,,,,,,,,,
KIT PT PULSE PREC PRGMR,SUP-2141944,CDM,C1787,HCPCS,0278,RC,,,,both,,,2802.45,1821.59,,,,,,,,,,,,,
ENVELOPE DEFIB BIOENVELOPE MED SINGLE PK STRL,SUP-2138479,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK VITRECTOMY 23 GA BVL,SUP-2110980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1914.74,1244.58,,,,,,,,,,,,,
SLEEVE TIB L3CM TI POR PROX KNEE REDUC SZ OSS MARTI VIERZON,SUP-2406485,CDM,C1776,CPT,0278,RC,,,,both,,,5892.21,3829.94,,,,,,,,,,,,,
CIRCUIT BREATHING INF 38 IN HEATED WIRE,SUP-2162516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.98,277.54,,,,,,,,,,,,,
HC Basic Metabolic Panel Calcium Ionized,PX-3018004700,CDM,80047,CPT,0301,RC,,,,both,,,82.00,53.30,,,,,,,,,,,,,
EPINEPHRINE-NACL 5-0.9 MG/250ML-% IV SOLN,RX-151011,CDM,J0163,HCPCS,0636,RC,70004-0608-40,NDC,,both,250,ML,330.70,214.95,,,,,,,,,,,,,
BRACE WLK FULL SHELL WLK SM M SHOE SZ 4 7 FEM SHOE SZ 5,SUP-2336094,CDM,L4360,HCPCS,0274,RC,,,,both,,,126.10,81.96,,,,,,,,,,,,,
DRILL TWST L 50 MM DIA 0.7 MM STP 3 MM NTC FOR 1 MM SYS NS,SUP-2934746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
NEEDLE BX L50.5CM 16GA TRANSEPTAL ROSS MOD COLAPINTO DSGN,SUP-2170008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,780.48,507.31,,,,,,,,,,,,,
SCR MMF DF HEX ETCHD2X15MM TEMP USE,SUP-2669057,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.63,387.16,,,,,,,,,,,,,
SCREW BNE L 16 MM DIA2.7 MM LCK VA NS LEOS,SUP-2931343,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.41,301.87,,,,,,,,,,,,,
COMPONENT ULN L53MM 2.5MM OFFSET BOND COAT RT ELBW BEAR,SUP-2215464,CDM,C1776,CPT,0278,RC,,,,both,,,13172.30,8561.99,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT ILIUM SEG 1/3 SPL,SUP-2113902,CDM,C1713,HCPCS,0278,RC,,,,both,,,4904.68,3188.04,,,,,,,,,,,,,
RESERVOIR PERF R-14 SEAMLESS BLDR ECMO,SUP-2500318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI PWR TRIALYSI ACUTE 13FR DIA 24CML INSE,SUP-2613250,CDM,C1752,HCPCS,0278,RC,,,,both,,,1041.41,676.92,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MMX14 CM TRI-FLAT MIDAS REX LEGEND,SUP-2627701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.32,268.66,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 16X14X7 MM PARL CC-ACS,SUP-2736995,CDM,C1713,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
GRAFT VASC GORTX L 100 CM DIA10 MM RNG L 80 CM EPTFE STR TW,SUP-2396176,CDM,C1768,CPT,0278,RC,,,,both,,,5278.34,3430.92,,,,,,,,,,,,,
COVER ULTRSNC HNDPC HRD TISS FOR BONESCALPEL SYS STRL DISP,SUP-2887850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
BIT DRL DIA2MM QUIK REL MSDCL20] ACUMED LLC],SUP-2107721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
IMPLANT CLLR DENT 4.7X4.5X,SUP-2212675,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE VENTRICULOSTOMY COMB W/ INS5HND,SUP-2883592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3590.50,2333.82,,,,,,,,,,,,,
DEFIBRILLATOR CARD 79GM 42CC W50XH76MM THK14MM DF1 IS1 CONN,SUP-2356257,CDM,C1722,HCPCS,0275,RC,,,,both,,,33629.40,21859.11,,,,,,,,,,,,,
SCREW BONE L50MM DIA9.5MM CTRL GLEN TI ST T SHP HNDL FOR,SUP-2388787,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
BLADE SAW RECIP 12.5X73.5X0.8MM,SUP-2586294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,99.73,64.82,,,,,,,,,,,,,
VALVE SHUNT SM EXTRACTED STRATA NSC,SUP-2628625,CDM,C1889,HCPCS,0278,RC,,,,both,,,11581.54,7528.00,,,,,,,,,,,,,
INSERT TIBIAL REVISION XXSMALL 18 MM KNEE AOX ATTUNE LPS,SUP-2838627,CDM,C1776,CPT,0278,RC,,,,both,,,9211.35,5987.38,,,,,,,,,,,,,
GUIDE RESECT TIB LT TRIATHLON,SUP-2364721,CDM,C1776,CPT,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-3603399500,CDM,33995,CPT,0360,RC,,,,inpatient,,,7747.00,5035.55,,,,,,,,,,,,,
CALCIUM CARBONATE 1500 (600 CA) MG PO TABS,RX-1301,CDM,6370000000,HCPCS,0637,RC,80681-0005-00,NDC,,both,1,UN,0.30,0.19,,,,,,,,,,,,,
LOOP LAPSCP BPLR EFFECTIVE HEMSTAT CUT ERGO HNDL PKS BILL,SUP-2312971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PLATE BNE L STD CALCNL POLYAX PERIMETER TAB LOK ORTHOLOC,SUP-2398085,CDM,C1713,HCPCS,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE GT L 180CM 0.016IN TIP 2 CM NIT STR,SUP-2538032,CDM,C1769,HCPCS,0272,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
STAPLER SKIN POWERED L320MM 35MM VASC TISS 12 FIRING B FRM,SUP-2219819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1104.02,717.61,,,,,,,,,,,,,
TRABECULAR MTL IMPLANTS TM-100 IMPLANTS LEN 11MM W 11MM HT,SUP-2414451,CDM,C1713,HCPCS,0278,RC,,,,both,,,6966.09,4527.96,,,,,,,,,,,,,
ADAPTER FEM SEG STK DIAPHYSIS ORTH SALV SYS,SUP-2405834,CDM,C1776,CPT,0278,RC,,,,both,,,357.18,232.17,,,,,,,,,,,,,
WASHER ORTH FOR 4.5/5.5MM SCR ANK FUS PLATING SYS ORTHOLOC,SUP-2398587,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
"HC So Folic Acid, RBC",PX-3018274766,CDM,82747,CPT,0301,RC,,,,outpatient,,,108.00,70.20,,,,,,,,,,,,,
PLATE BNE L106MM 7 H ST L ANTLAT DST TIB S STL LO PROF NEUT,SUP-2185949,CDM,C1713,HCPCS,0278,RC,,,,both,,,4460.62,2899.40,,,,,,,,,,,,,
BURR ACORN FLUTED 9.2MM SHD9ACG1,SUP-2843322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.71,300.11,,,,,,,,,,,,,
EXTENDER SPNL BLADE NAR 26 MM SIG LTP,SUP-2800500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BONE STRUT 2X3 HOLE TITANIUM NON STERILE LOW PROFILE N,SUP-2838365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1576.91,1024.99,,,,,,,,,,,,,
HC Cryopreservation & Storage,PX-3623820700,CDM,38207,CPT,0362,RC,,,,inpatient,,,4125.00,2681.25,,,,,,,,,,,,,
PLATE BNE L W135XL368MM THK42MM 20 H BILAT TI NAR RIG NEUT,SUP-2190837,CDM,C1713,HCPCS,0278,RC,,,,both,,,3772.46,2452.10,,,,,,,,,,,,,
SPACER SPNL 15-30 DEG 65X20X11-20 MM ELSA,SUP-2732455,CDM,C1889,HCPCS,0278,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
SHEATH LASER 12FR L50CM DIA4.17MM 15DEG 25-40 REPETITION RATE,SUP-2353103,CDM,C2629,CPT,0272,RC,,,,both,,,9545.60,6204.64,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110CM 5FR TIP 1MM PED FIX A CRV,SUP-2248875,CDM,C1730,HCPCS,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
GUIDEWIRE VASC HYBRID L 200 CM PROX/DSTL DIA,SUP-2895575,CDM,C1769,HCPCS,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST BAR CHROM PLT NICKEL,SUP-2435694,CDM,L2750,HCPCS,0272,RC,,,,both,,,221.28,143.83,,,,,,,,,,,,,
PLATE DERMATOME 1.5 IN,SUP-2603273,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE BNE THRD 1.6 MM TAK,SUP-2319690,CDM,C1713,HCPCS,0278,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
TAP SURG L130MM QUIK CPL FOR 4.5MM CORT SHFT SCR 3.2MM DRL,SUP-2187414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.57,379.97,,,,,,,,,,,,,
SHEATH CATH INTRO 8.5FR L71CM TRANSSEPTAL SM CURL BRK CRV,SUP-2357288,CDM,C1894,HCPCS,0272,RC,,,,both,,,3231.06,2100.19,,,,,,,,,,,,,
NUT SPNL TI ALLOY THORLUM BRKWY NS PASS LP,SUP-2926459,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
FIBER LASER INSTRUMENT PRT STONE BASKETS WIRE FIX ENDOSCP,SUP-2772962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
VALVE TRACH AD OD22MM ID15MM AQUA PLAS SWALLOWING SPEAK W/,SUP-2134640,CDM,L8501,HCPCS,0272,RC,,,,both,,,294.06,191.14,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 5 CC 42030050] CROSSROADS EXTREMITY SYSTEMS],SUP-2175162,CDM,C1889,HCPCS,0278,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
COMPONENT FEM SZ 6 L KNEE CO CHROM NAR POST STBL CEM,SUP-2206166,CDM,C1776,CPT,0278,RC,,,,both,,,10738.80,6980.22,,,,,,,,,,,,,
GRAFT EVAR L70MM DIA36X36MM C DST DSGN FOR ABD AORT ANEUR,SUP-2295274,CDM,C1768,CPT,0278,RC,,,,both,,,24256.50,15766.72,,,,,,,,,,,,,
GUIDE SURG DIA3.5MM LCK DRL FOR CONG ELBW CLAV SCAPULAR,SUP-2107726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC Replac Central Nt Cath WO Port,PX-3613658000,CDM,36580,CPT,0361,RC,,,,outpatient,,,1961.00,1274.65,,,,,,,,,,,,,
PLATE NSL W40XL50MM THK0.25MM PUR POLYDIOXANONE FLX RECTANG,SUP-2301042,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
SCREWDRIVER PWR DISP FOR COMP CRAN CLSR SYS,SUP-2243987,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.87,492.62,,,,,,,,,,,,,
PIN FIXATION L10MM DIAMETER 1.1MM PLLA SELF REINFORCED FRACT,SUP-2855235,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 300-500 UM 1 ML PVA PREFIL SYR,SUP-2148447,CDM,C1889,HCPCS,0278,RC,,,,both,,,794.55,516.46,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM CRV 6 HOLE SS NS,SUP-2905600,CDM,C1713,HCPCS,0278,RC,,,,both,,,2129.33,1384.06,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE THGH CALF CUST SINGLE FREE STIRRUP,SUP-2435631,CDM,L2000,HCPCS,0274,RC,,,,both,,,3167.13,2058.63,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION SMALL 2.5 MM LEFT PREFORMED TITANI,SUP-2837778,CDM,C1713,HCPCS,0278,RC,,,,both,,,10236.09,6653.46,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED MED PRIORITY + PEEK NS LTX,SUP-2862816,CDM,C1713,HCPCS,0278,RC,,,,both,,,51389.11,33402.92,,,,,,,,,,,,,
ARIPIPRAZOLE 20 MG PO TABS,RX-34371,CDM,6370000000,HCPCS,0637,RC,43547-0306-03,NDC,,both,1,UN,7.60,4.94,,,,,,,,,,,,,
TRIAL KNEE THK4MM DST FEM AUG PFC SIG SPEC 2,SUP-2253884,CDM,C1776,CPT,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
SCREW BONE L28MM D4MM HEX HEAD D6.2MM CRTCL DST FMRL TTNM SE,SUP-2466427,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.48,201.81,,,,,,,,,,,,,
PROCESSOR HEARING AID DMND BLK LT EAR DISP PONTO PRO PWR,SUP-2319880,CDM,L8690,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L15CM OD14FR TAPR TIP CVD EXTN SH,SUP-2269512,CDM,C1752,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
GUIDEWIRE VASC TREASURE 12 L 300 CM DIA 0.018 IN RADIOPAQUE,SUP-2123849,CDM,C1769,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
STENT BILI DYNALINK L 56 MM DIA 8 MM CATH L 120 CM GUIDEWIRE,SUP-2104147,CDM,C1876,HCPCS,0278,RC,,,,both,,,4232.72,2751.27,,,,,,,,,,,,,
PLATE BONE L245MM 6 H TROCHANTERIC TI GRP SUPERCABLE,SUP-2262262,CDM,C1713,HCPCS,0278,RC,,,,both,,,8619.30,5602.54,,,,,,,,,,,,,
BLADE SHAVER MULT FUNC 5 MM 3 IN 1 DISP,SUP-2745539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PIN DRL DIA1.5MM FOR BICEPTOR TENODESIS SYS TEND SHLDR,SUP-2341815,CDM,C1769,HCPCS,0272,RC,,,,both,,,383.99,249.59,,,,,,,,,,,,,
SCREW BNE L 105 MM DIA 3.5 MM TI LCK T15 STARDRV STRL V,SUP-2905835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1294.06,841.14,,,,,,,,,,,,,
CATHETER IRRIGATION L 60 CM DIA 3 FR DSTL 6 MM BALLOON 0.5,SUP-2159450,CDM,C2628,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC BONE STABILIZATION SYSTEM 22/13 X 260MM,SUP-2881213,CDM,C1713,HCPCS,0278,RC,,,,both,,,16924.60,11000.99,,,,,,,,,,,,,
MESH HERN M W1.3XL1.6IN SYN POLY-4-HYDROXYBUTYRATE PLUG AND,SUP-2125874,CDM,C1781,HCPCS,0278,RC,,,,both,,,1380.94,897.61,,,,,,,,,,,,,
COMPONENT PAT SZ S39 OD39MM THK11MM TRITANIUM MTL BK KNEE,SUP-2373674,CDM,C1776,CPT,0278,RC,,,,both,,,3472.21,2256.94,,,,,,,,,,,,,
COIL VASC AZUR CX L 39 CM DIA16 MM MICROCATHETER 0.018 IN,SUP-2385242,CDM,C1889,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SOUNDSTAR ECO 3D L 90 CM 8 FR GE,SUP-2497682,CDM,C1759,HCPCS,0272,RC,,,,both,,,4081.06,2652.69,,,,,,,,,,,,,
BIT DRL DIA3/8IN FEM LUG FOR SCORP NRG IM TRIATHLON,SUP-2378552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.24,219.21,,,,,,,,,,,,,
HC Treatment Devices Complex,PX-3337733400,CDM,77334,CPT,0333,RC,,,,outpatient,,,2276.00,1479.40,,,,,,,,,,,,,
ENDCAP ORTHOPEDIC 0-15 MM EXTN FOR SLD HUM NAIL TI NS,SUP-2192528,CDM,C1713,HCPCS,0278,RC,,,,both,,,699.34,454.57,,,,,,,,,,,,,
WRIST SPANNING PLATE 16 HOLE,SUP-2493413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
BRACE ORTHOPEDIC ADJ SAG RIGID PANEL PREFABRICATED LO,SUP-2124234,CDM,L1810,HCPCS,0272,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
PLATE BONE L41MM THK1.25MM 6 H BILAT MAXILLOFACIAL MAND ORAL,SUP-2191336,CDM,C1713,HCPCS,0278,RC,,,,both,,,2002.38,1301.55,,,,,,,,,,,,,
SCREW WRIST 15MM,SUP-2706177,CDM,C1776,CPT,0278,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 180 CM 6X120 MM PACIFIC+,SUP-2281322,CDM,C1725,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BONE 7MM TI FULL,SUP-2211550,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.038IN L3CM STD SM VES NIT,SUP-2385581,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.26,65.17,,,,,,,,,,,,,
INSULIN GLARGINE-YFGN 100 UNIT/ML SC SOLN,RX-155721,CDM,S5553,HCPCS,0637,RC,83257-0014-11,NDC,,both,10,ML,50.40,32.76,,,,,,,,,,,,,
DX KNOTLESS SWVLK PEEK 4.75 MM WITH FT,SUP-2817675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 2.5CC PUTTY GRFTON,SUP-2307527,CDM,C9359,HCPCS,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
DRILL SURG BASEPLT 7.5 MM CRTX TRABECULAR MTL RVS +,SUP-2436861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 200 CM BALLOON L 250 MM DIA 7 MM SHTH,SUP-2937101,CDM,C1725,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE VOLAR 2XL STD 2.7X100 MM LT DSTL RADIAL 8 HOLE,SUP-2691427,CDM,C1713,HCPCS,0278,RC,,,,both,,,5885.15,3825.35,,,,,,,,,,,,,
GRAFT VASC L40CM DIA8MM RAD L40CM EPTFE HEP THN WALLED,SUP-2395860,CDM,C1768,CPT,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
GRAFT HUM TISS L 245 MM DIA 6 MM SEMITENDINOSUS TEND FRZN,SUP-2913179,CDM,C1762,CPT,0278,RC,,,,both,,,8763.74,5696.43,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 2 MESH NS FACE ID,SUP-2909541,CDM,C1713,HCPCS,0278,RC,,,,both,,,30117.37,19576.29,,,,,,,,,,,,,
FILLER BONE VOID 10ML HA SYNTH CA PHOS PUTTY TISS IMPL CEM,SUP-2194293,CDM,C1713,HCPCS,0278,RC,,,,both,,,9161.89,5955.23,,,,,,,,,,,,,
SCREW BNE L50MM DIA8MM THRD L22MM DIA12.7MM CANC CNDYL S,SUP-2186523,CDM,C1713,HCPCS,0278,RC,,,,both,,,1027.09,667.61,,,,,,,,,,,,,
BIT DRL FOR LAG SCR META-TAN TRIGEN,SUP-2347057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2503.65,1627.37,,,,,,,,,,,,,
TUBE VENT 1.14 MM 1 MM 2.5X3.5 MM POPE SIL STRL,SUP-2477440,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.86,27.86,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE FROZEN GRACILIS TENDONGR-11,SUP-2913479,CDM,C1762,CPT,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
CATHETER THROMCTMY SMARTCLAW L 145 CM DIA 4.95 FR BSKT DIA20,SUP-2933958,CDM,C1757,HCPCS,0272,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
SLEEVE LCK 130 DEG NAIL FEM SPRL BLADE TI NS,SUP-2191882,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.60,770.64,,,,,,,,,,,,,
WOOD ZRCH INTRRL DSTRCTR 10 15MM LFT T 6L 4V,SUP-2694290,CDM,C1713,HCPCS,0278,RC,,,,both,,,14252.11,9263.87,,,,,,,,,,,,,
PACEMAKER CARD AVEIR AR L 32 MM DIA 6.5 MM TI ATR SINGLE,SUP-2905602,CDM,C1605,HCPCS,0275,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
HC Access Thoracic Lymph Duct,PX-3613879400,CDM,38794,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC So1 Encephalitis St.Louis,PX-3028665367,CDM,86653,CPT,0302,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
ADAPTER HEAD FEMORAL UNIPOLAR 12/14 +14.0MM,SUP-2504176,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BIT SOLAR TOT SHLDR UP EXTRM DRL SM HND,SUP-2374049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.75,340.44,,,,,,,,,,,,,
BAR EXT FIX 11X300 MM CARBON XTRAFIX,SUP-2480498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
HC Transesophageal Echo,PX-4809331300,CDM,93313,CPT,0480,RC,,,,inpatient,,,3039.00,1975.35,,,,,,,,,,,,,
TUBE VENT ID1.27MM BLU SIL LUMN TAPR W/ TWIN SPN FLNG,SUP-2312835,CDM,L8699,HCPCS,0278,RC,,,,both,,,62.74,40.78,,,,,,,,,,,,,
SCREW BNE 7/8X30 MM STRL BIORCI-HA,SUP-2848556,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.46,602.20,,,,,,,,,,,,,
BIT DRL L 205/110 MM DIA2.8 MM CALIB AO QC STRL DISP V,SUP-2907957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,946.24,615.06,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 220 CM 0.038 IN TAPR L 22 CM ANGLED,SUP-2170349,CDM,C1769,HCPCS,0272,RC,,,,both,,,448.20,291.33,,,,,,,,,,,,,
KIT INTRO ARW SHTH L 10 CM DIA 7 FR GUIDEWIRE L 45 CM DIA,SUP-2763320,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.45,69.19,,,,,,,,,,,,,
PLATE BNE TIB 80 MM LT DSTL,SUP-2265101,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.36,1532.28,,,,,,,,,,,,,
BUR HOLE COVER KIT PRE ASSEMBLED SURETEK,SUP-2836331,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 2.8 MM 20 HOLE TITANIUM MATRIXMAND,SUP-2837766,CDM,C1713,HCPCS,0278,RC,,,,both,,,6455.53,4196.09,,,,,,,,,,,,,
MICROCATHETER GUID CARAVEL L 135 CM SHFT OD PROX/DSTL,SUP-2123831,CDM,C1725,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KIT NDL 17GA L20CM MRK L3MM DIA1.2MM SFT TISS G PLCMNT,SUP-2420704,CDM,A4648,CPT,0278,RC,,,,both,,,253.30,164.64,,,,,,,,,,,,,
STENT URET OPN END 8.5 FRX22 CM LUB FLX,SUP-2312724,CDM,C2617,HCPCS,0278,RC,,,,both,,,242.47,157.61,,,,,,,,,,,,,
GUIDE WIRE THRD 400 MM,SUP-2316308,CDM,C1769,HCPCS,0272,RC,,,,both,,,826.89,537.48,,,,,,,,,,,,,
HC So Tsh 3rd Generation|NOT REASONABLE AND NECESSARY,PX-3018444366,CDM,84443,CPT,0301,RC,,,GZ,both,,,26.00,16.90,,,,,,,,,,,,,
PLATE SPNL 39 MM ANTR LUMBAR 4 HOLE PYRAMID +4,SUP-2631826,CDM,C1713,HCPCS,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
ORTHOPEDIC KIT PIN TRACTION,SUP-2164818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
BRACE KNEE UNIV L22 27IN 10DEG FLX TELSCP PDDLE POSTOP FOAM,SUP-2195288,CDM,L1810,HCPCS,0274,RC,,,,both,,,220.59,143.38,,,,,,,,,,,,,
"HC So1 Spectrophotometry, Analyte Nes",PX-3018431167,CDM,84311,CPT,0301,RC,,,,both,,,80.00,52.00,,,,,,,,,,,,,
SYSTEM CEREB PROTCT SENTNL FILTER SZ 15/10 MM RVD,SUP-2707488,CDM,C1884,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
PLATE SPNL L45MM 6 H LEV 2 ANT BILAT CERV TI LOK LO PROF,SUP-2254588,CDM,C1713,HCPCS,0278,RC,,,,both,,,4473.81,2907.98,,,,,,,,,,,,,
COLLAR PREMIER PRO CERV RIG 3.25INCH SM LTX FREE,SUP-2336005,CDM,L0140,HCPCS,0272,RC,,,,both,,,36.99,24.04,,,,,,,,,,,,,
POST EXT FIX SLT SM/LG,SUP-2162668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.27,377.18,,,,,,,,,,,,,
CATHETER NEPHSTMY L35CM OD12FR GWIRE OD0.038IN SKATER DRNGE,SUP-2120147,CDM,C1729,HCPCS,0272,RC,,,,both,,,301.63,196.06,,,,,,,,,,,,,
NORTRIPTYLINE HCL 75 MG PO CAPS,RX-5677,CDM,6370000000,HCPCS,0637,RC,00093-0813-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCW MMF DF HEX ETCHD2X19MM TEMP USE,SUP-2681349,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.63,387.16,,,,,,,,,,,,,
REPAIR KIT KNOTLESS OPN AC IMPL STRL LTX,SUP-2859828,CDM,C1713,HCPCS,0278,RC,,,,both,,,5479.30,3561.54,,,,,,,,,,,,,
CONTROL REMOT VERCISE DP BRAIN STIM SYS,SUP-2140422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
INFLATION KIT 15 FRX10 CM URET URETEROSCOPY DEV EZDILATE,SUP-2471739,CDM,C1726,HCPCS,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
RIFAMPIN 150 MG PO CAPS,RX-11292,CDM,6370000000,HCPCS,0637,RC,60687-0575-11,NDC,,both,1,UN,14.40,9.36,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/O JT PREFABRICATED SFT INTFACE,SUP-2435782,CDM,L3923,HCPCS,0274,RC,,,,both,,,248.88,161.77,,,,,,,,,,,,,
AUGMENT GLEN FIX SM L SHLDR UHMWPE CAGE EQUINOXE,SUP-2435979,CDM,C1776,CPT,0278,RC,,,,both,,,5913.25,3843.61,,,,,,,,,,,,,
DEVICE FIX TULIP STD 5.5 MM ASMBLY POLYAX MOD REFORM,SUP-2720026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
STAPLER INT CIR MED THCK 33 MM 3/3.5/4 MM TRI-STAPLE PUR EEA,SUP-2858013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3327.36,2162.78,,,,,,,,,,,,,
SCREW BONE CANNULATED LARGE 7X135 MM 32 MM SELFDRILLING PART,SUP-2836864,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
MOLD BEAD 7MM TOP AND BTM ASSEMB OSTEOSET,SUP-2399035,CDM,C1713,HCPCS,0278,RC,,,,both,,,861.40,559.91,,,,,,,,,,,,,
SIZER BRST 600CC P57CM DIA138CM SIL STYL MSZ20 HI PROF,SUP-2113527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
BRACE ANK SWVL STRP STD 10 IN AIR/GEL BLDR LP BLK STIRRUP,SUP-2336325,CDM,L4350,HCPCS,0272,RC,,,,both,,,28.79,18.71,,,,,,,,,,,,,
COMPONENT TIB SHT 1 LT APEX 3D ARC,SUP-2742085,CDM,C1776,CPT,0278,RC,,,,both,,,14031.88,9120.72,,,,,,,,,,,,,
CUP GLEN SUCTION AS INVERSE,SUP-2440764,CDM,C1776,CPT,0278,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2 MM FOR PFNA BLADE,SUP-2851917,CDM,C1769,HCPCS,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
TRIAL SHELL REV ACET 49906048] ENCORE MEDICAL - DJO SURGICAL],SUP-2217283,CDM,C1776,CPT,0278,RC,,,,both,,,15511.60,10082.54,,,,,,,,,,,,,
SPHINCTEROTOME ENDO L25MM OD5-4FR 0.021IN BLK PRECRV ULT,SUP-2169379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
ROD SPNL 5X60 MM,SUP-2564516,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.17,40.41,,,,,,,,,,,,,
CAGE SPNL MESH 22X28X15 MM LUMBAR INTBDY TI PYRAMESH,SUP-2292040,CDM,C1889,HCPCS,0278,RC,,,,both,,,6452.61,4194.20,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.7MM DST RAD LOK FULL THRD SQ DRV HD LO,SUP-2411796,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
BUR SURG ACORN CUT NONFLUTED CARB L L640MM OD50MM,SUP-2278138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.64,358.57,,,,,,,,,,,,,
HC Rep Lac Smp Face 12.6-20cm,PX-4501201600,CDM,12016,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
STENT URETH ZAONTZ L 12 CM CATH L 8.0 FR FOR,SUP-2649949,CDM,C2617,HCPCS,0278,RC,,,,both,,,176.47,114.71,,,,,,,,,,,,,
NEEDLE SPNL 2 TRCR TIP DISP,SUP-2290632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.63,264.31,,,,,,,,,,,,,
KNIFE SURG 2.4 MM RETROGADE SM JT,SUP-2765730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,531.48,345.46,,,,,,,,,,,,,
GUIDEWIRE ORTH FLUT 2.8X300 MM,SUP-2657803,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
PEG BNE FIX L8MM DIA2.5MM FULL THRD FOR ALPS HND FRAC SYS,SUP-2414055,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.63,166.16,,,,,,,,,,,,,
PLATE SPNL LCK 10 MM ANTR CVR MERID,SUP-2710909,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
HC So T Cell Absolute,PX-3028636066,CDM,86360,CPT,0302,RC,,,,both,,,253.00,164.45,,,,,,,,,,,,,
PLATE BNE L 209 MM SCREW DIA 4.5 MM 11 H RT PROX LAT TIB NS,SUP-2933534,CDM,C1713,HCPCS,0278,RC,,,,both,,,10215.21,6639.89,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY DEMIN CANC CORT 4MM-10MM RANG 15CC,SUP-2294042,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
LEAD PACE SWEET PICOTIP RX L 59 CM SIL ENDOCARD RT,SUP-2148636,CDM,C1898,HCPCS,0275,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SET URET STENT AMPLTZ L 20 CM DIA10.2 FR GUIDEWIRE 0.038 IN,SUP-2168644,CDM,C2625,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
PLATE BNE W10XL50MM THK1.5MM 3X3 H BILAT S STL T SHP R ANG,SUP-2185864,CDM,C1713,HCPCS,0278,RC,,,,both,,,846.54,550.25,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 035X150 M00146151B17,SUP-2141140,CDM,C1769,HCPCS,0272,RC,,,,both,,,97.09,63.11,,,,,,,,,,,,,
PLATE BNE STD TI LT MALL HK NS UNITE,SUP-2896839,CDM,C1713,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
CROSSLINK SPNL L39-45MM POST THORLUM TI MSPAN PLT LO PROF,SUP-2289529,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
COMPONENT GLEN FIX DIA10MM SHLDR METAGLENE LNG PEG GLOB,SUP-2251207,CDM,C1776,CPT,0278,RC,,,,both,,,4744.54,3083.95,,,,,,,,,,,,,
INSTRUMENT SFT TISS REL ENDOSCP CENTERLINE,SUP-2122776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
MORPHINE SULFATE ER 100 MG PO TBCR,RX-120981,CDM,6370000000,HCPCS,0637,RC,00904-6560-61,NDC,,both,1,UN,15.80,10.27,,,,,,,,,,,,,
CATHETER HD PRE CRV 15.5 FRX32 CM SIDE H FULL SET TITAN HD,SUP-2268418,CDM,C1881,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
KIT PRB 17GA L7MM RF ABLAT OSTEOCOOL,SUP-2293682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11068.50,7194.52,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC STD 14.5FR DIA 20CM 1,SUP-2613289,CDM,C1750,HCPCS,0278,RC,,,,both,,,1374.85,893.65,,,,,,,,,,,,,
SET INT FIX PLATE SZ 18.5 MM SCREW DIA1.5 MM TI NEURO SHUNT,SUP-2935898,CDM,C1713,HCPCS,0278,RC,,,,both,,,24903.34,16187.17,,,,,,,,,,,,,
FORCEPS BX AD L195CM CHN 22MM 3MM CUP OPN STD GI FEN STATIC,SUP-2313121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.53,765.39,,,,,,,,,,,,,
SET SCR SPNL L45MM DIA6MM PEDCL TI ALLOY FUS FOR DYN STBL,SUP-2414264,CDM,C1713,HCPCS,0278,RC,,,,both,,,7759.73,5043.82,,,,,,,,,,,,,
AUGMENT FEM SZ 10 KNEE REV NP RT STRL EMPOWR 3D KNEE,SUP-2890702,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
HC Biopsy of Pancreas Perc Needle,PX-3614810200,CDM,48102,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
VALVE AORT STENTED LO PROF PORCINE IMP H14MM ID19MM 21MM,SUP-2355763,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
KIT INTRO L15CM DIA6FR 0018IN TRCR STYL MAK NV,SUP-2303017,CDM,C1894,HCPCS,0272,RC,,,,both,,,207.33,134.76,,,,,,,,,,,,,
CEMENT BNE 20GM PMMA 30% BA SULF HALF DOSE HI VISC W/MIXER,SUP-2366942,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SYSTEM THERMOABLATION COBRA FUSION 50 L 50 MM INTEGR PACE,SUP-2124418,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BUR SURG ROUTER TAPR OD1.5MM ELITE,SUP-2364035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.96,249.57,,,,,,,,,,,,,
ANCHOR SUT 5MM DIA 2 SUT ABSRB W/ NDL TI DURABRAID TWINFIX,SUP-2341046,CDM,C1713,HCPCS,0278,RC,,,,both,,,848.99,551.84,,,,,,,,,,,,,
GRAFT HUM TISS 2X2CM EPIFIX,SUP-2305749,CDM,Q4186,HCPCS,0636,RC,,,,both,,,3173.91,2063.04,,,,,,,,,,,,,
GRAFT 6X6CM LT PERICARD,SUP-2400553,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 60 CM CRV DIA18 MM DIA 8.5 MM,SUP-2357205,CDM,C1894,HCPCS,0272,RC,,,,both,,,502.97,326.93,,,,,,,,,,,,,
REAMER SURG DIA85MM CANN HD FOR AC GRAFTROPE SYS,SUP-2121243,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PIN FIX HALF SELF DRL APEX 5X250 MM W/ 70 MM THRD,SUP-2363230,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.72,319.62,,,,,,,,,,,,,
INSTRUMENT REPROC SEAL/DIVIDE LAP BLUNT TP LIGASURE NANO-COAT 5MMX37CM,SUP-2527602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.014 IN COIL L 12,SUP-2909257,CDM,C1769,HCPCS,0272,RC,,,,both,,,101.48,65.96,,,,,,,,,,,,,
POROUS KN SYS W/PROLONG POLY,SUP-2212149,CDM,C1776,CPT,0278,RC,,,,both,,,12894.44,8381.39,,,,,,,,,,,,,
PASSER CATH LNG L55CM MAL STR UNI SHUNT KT DISP FOR,SUP-2249014,CDM,C1894,HCPCS,0272,RC,,,,both,,,388.89,252.78,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 12 CM DIA13 FR GUIDEWIRE L 50 CM,SUP-2355542,CDM,C1894,HCPCS,0272,RC,,,,both,,,51.03,33.17,,,,,,,,,,,,,
MARKER BRST BX XR 11 GA MAMTOM FLX MINIMALLY INVASIVE TISS,SUP-2195652,CDM,A4648,CPT,0278,RC,,,,both,,,253.77,164.95,,,,,,,,,,,,,
GUIDEWIRE ORTH NIT SGL PRECIS FLX RM SYS,SUP-2136105,CDM,C1769,HCPCS,0272,RC,,,,both,,,731.49,475.47,,,,,,,,,,,,,
WIRE SURG PRECUT 22 GAX6 MM,SUP-2185885,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
CATHETER ATHRCTMY ROTLNK L 135 MM DIA 0.058 IN BUR DIA2 MM,SUP-2147021,CDM,C1724,HCPCS,0278,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
PLATE BONE W50XL50MM 3X3MM H SPC CRAN TI MESH FOR 1MM SCR,SUP-2190568,CDM,C1713,HCPCS,0278,RC,,,,both,,,6033.51,3921.78,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 70 CM OD 6 FR GUIDEWIRE 0.038 IN,SUP-2168678,CDM,C1894,HCPCS,0272,RC,,,,both,,,152.29,98.99,,,,,,,,,,,,,
PLATE BNE 9 H LAT FIB LOK FOR ANK PLATING SYS,SUP-2106975,CDM,C1713,HCPCS,0278,RC,,,,both,,,5736.78,3728.91,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEM CHIPBIOCEM] ZIMMER BIOMET INC],SUP-2137372,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
BLADE TNG DNGMN SIZE 2 MED 29MMW X 136MML X 65MMD JARIT,SUP-2702781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,583.35,379.18,,,,,,,,,,,,,
PLATE SPNL 17MM LAT STBL 4 H PLYMOUTH,SUP-2228575,CDM,C1713,HCPCS,0278,RC,,,,both,,,10801.60,7021.04,,,,,,,,,,,,,
GRAFT HUM TISS PARTICULATE 100 MG CONNECTIVE TISS INTERFYL,SUP-2845980,CDM,Q4171,HCPCS,0636,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
PLATE BNE THK 0.3 MM SCREW DIA1.5 MM TI ORBIT FLR PREFRM NOE,SUP-2883818,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
LINER ACET SZ K OD70-76MM ID32MM THK17MM 0DEG HIPXLPE MTL ON,SUP-2344857,CDM,C1776,CPT,0278,RC,,,,both,,,4857.58,3157.43,,,,,,,,,,,,,
FELT SURG L4IN OD1IN THICKNESS 1.65MM PTFE POLY LO POROSITY,SUP-2419778,CDM,C1768,CPT,0278,RC,,,,both,,,306.59,199.28,,,,,,,,,,,,,
COMPONENT FEM HIP UPLR CEM LO DEMAND KT,SUP-2347954,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GUIDEWIRE VASC ACCS 4FR W CO AX INTRO S STL ECHOGENIC SET,SUP-2424403,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.09,37.76,,,,,,,,,,,,,
STEM FEM L250MM OD9MM TI POR LT HIP PRI BOW LNG BODY REV,SUP-2403319,CDM,C1776,CPT,0278,RC,,,,both,,,17335.94,11268.36,,,,,,,,,,,,,
STENT URET OPN END 6 FRX24 CM KID CURL TAPR SIL MULTI-FLEX,SUP-2313765,CDM,C2617,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,2500000003,HCPCS,0250,RC,69918-0735-11,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
BODY FEM DIA29MM +30MM CALCAR HIP MOD REV SYS RESTR,SUP-2375613,CDM,C1776,CPT,0278,RC,,,,both,,,10227.61,6647.95,,,,,,,,,,,,,
SYSTEM FIX IO L DISPOSABLE DRVR ASSEMB,SUP-2400053,CDM,C1776,CPT,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
HEAD HUM MOD 45 MM SHLDR REMEDY,SUP-2718145,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
COLLAR CERV AD TALL CUSH FLX TAB OCCIPITAL SUPP STRP,SUP-2123893,CDM,L0180,HCPCS,0274,RC,,,,both,,,59.63,38.76,,,,,,,,,,,,,
REAMER IM PRSS FLX 260MM DIA SENTNL,SUP-2198042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1769.77,1150.35,,,,,,,,,,,,,
SENSOR SLEEP STUDY SNORING SENSE EMBLA,SUP-2307707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
KIT VASC ACC GWIRE L100CM ELITE,SUP-2124560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RNGD STRTCH 6MM DIA 45CM LEN,SUP-2395839,CDM,C1768,CPT,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
PLATE BNE THK0.6MM 3X2 H CRANIOMAXILLOFACIAL TI RECTANG 3D,SUP-2366280,CDM,C1713,HCPCS,0278,RC,,,,both,,,761.89,495.23,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PARASPINAL UPR CUST THOR CTRL,SUP-2435692,CDM,L2670,HCPCS,0274,RC,,,,both,,,451.56,293.51,,,,,,,,,,,,,
ENDCAP ORTH EXTN 0MM TIB GRY TI CANN T40 STARDRV RECESS EXT,SUP-2189029,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.09,326.36,,,,,,,,,,,,,
CATHETER NEPHSTMY L35CM DIA20FR TIP L18CM DIA8FR MCOT,SUP-2138888,CDM,C1729,HCPCS,0272,RC,,,,both,,,252.68,164.24,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME LT KNEE PCL S/TH S/CF ADJ OA,SUP-2914992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1338.27,869.88,,,,,,,,,,,,,
CATHETER HD 2 LUMEN 14 FRX28 CM KT,SUP-2159458,CDM,C1750,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DRILL SURG OD48MM SPNL FIX VANATGE,SUP-2292757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.41,770.52,,,,,,,,,,,,,
NAIL IM L440MM DIA3.5MM 8DEG UNIV ST LT BLU TIB CANN LOK,SUP-2192732,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.83,657.04,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM THK0.1-0.2MM AMNIO MEM 2 LAYR,SUP-2421268,CDM,Q4150,HCPCS,0636,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
SPACER SPNL 6 DEG 30X8 MM 0.81 CC TI CRESCENT,SUP-2630182,CDM,C1889,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
PLATE BNE CONN 5 HOLE THRD NS,SUP-2800188,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.69,229.90,,,,,,,,,,,,,
PROBE RF COOLED 17 GAX150 MM STR COOLIEF TRANSDISCAL DISP,SUP-2859196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
MATRIX BIO L 3.5 X W 3.2 IN SZ 73.8 SQCM PORCINE TEND,SUP-2909298,CDM,A2008,HCPCS,0636,RC,,,,both,,,8308.44,5400.49,,,,,,,,,,,,,
VALVE AORT PORCINE BIOPROSTHESIS STNTLSS 25MM TORONTO SPV,SUP-2357721,CDM,C1889,HCPCS,0278,RC,,,,both,,,16321.72,10609.12,,,,,,,,,,,,,
CATHETER PERI DLYS AD L57CM DIA15FR DBL CUF COILED LIN,SUP-2283900,CDM,C1750,HCPCS,0278,RC,,,,both,,,345.71,224.71,,,,,,,,,,,,,
STAPLER MED 21 MM TRNSOR CIR ANVIL EEA ORVIL,SUP-2787686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1017.83,661.59,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ACHILLES TEND FRZN PRESHAPED W/ BNE,SUP-2321838,CDM,C1762,CPT,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 8 MM EPTFE GRAD REINF 3 LAYR,SUP-2265950,CDM,C1768,CPT,0278,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
SYMALIGN EVANS OSTEOTMY WDG HEIGHT18MM LENGTH18MM,SUP-2264625,CDM,C1713,HCPCS,0278,RC,,,,both,,,5918.77,3847.20,,,,,,,,,,,,,
PLATE BONE L326MM 20 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185281,CDM,C1713,HCPCS,0278,RC,,,,both,,,1562.59,1015.68,,,,,,,,,,,,,
AIRWAY LARYNGEAL INFANT CHILDREN 10-20KG SIZE 2 CONNECTOR 15,SUP-2824815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SLEEVE TIB L7CM PROX KNEE FOR ORTH SALV SYS,SUP-2406465,CDM,C1776,CPT,0278,RC,,,,both,,,11289.87,7338.42,,,,,,,,,,,,,
HC Clsd Tx Mcp IP Fx W Manip,PX-4502674200,CDM,26742,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL L 3.5 IN DIA20 GA SGL SHT LIDO NACL,SUP-2936776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,49.36,32.08,,,,,,,,,,,,,
LEAD PACE L80CM ENDO LV UNI/BIPOLAR LV1 SGL ELECTRD PASS,SUP-2148679,CDM,C1898,HCPCS,0275,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
FORCEPS SURG 23GA TEXT PLATFRM GLARE FRE FINISH ADAPTIVE,SUP-2393140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,308.60,200.59,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.018IN TIP L5CM S STL SIL STR LNG,SUP-2148235,CDM,C1769,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.5MM CORT DST FEM TI ST NONLOCKING FULL,SUP-2413522,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
PIN FIX BUTTRESS 1.8X18 MM LCK NS HPS LTX,SUP-2856894,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN,RX-15950,CDM,340b,HCPCS,0637,RC,00436-0936-16,NDC,,both,473,ML,51.10,33.21,,,,,,,,,,,,,
CATHETER ESOPH BAL,SUP-2237242,CDM,C1726,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER ERCP 5.5-4.5FR L320CM ACCSRY CHAN 2.8MM 0.035IN,SUP-2169432,CDM,C1887,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT HUM TISS W1XL12CM NOM THK1.5MM MAXSTRIP HUM DERM,SUP-2399108,CDM,Q4107,HCPCS,0636,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
KIT NEUROSTIMULATOR 8 CHN ADPT B,SUP-2355917,CDM,C1883,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SCREW BNE S STL CONN FOR LOK ATTCH PLT STARDRV,SUP-2177789,CDM,C1713,HCPCS,0278,RC,,,,both,,,575.69,374.20,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 150 CM BALLOON L 150 MM,SUP-2141971,CDM,C1725,HCPCS,0272,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 15 DEG L 13 CM DIA2.9 MM SPD 60-500 RPM,SUP-2902071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
GUIDEWIRE ORTH BALL NOSE 3X900 MM STRL,SUP-2766027,CDM,C1769,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
KIT DBS LD CAP STRL DISP SENSIGHT,SUP-2882980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL AD 18GA L71CM 30DEG BVL BRK-1 XS CRV S,SUP-2357591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,739.25,480.51,,,,,,,,,,,,,
TRAY INTRO DIA 8.5 FR 1 PC STYL STRL,SUP-2876455,CDM,C1894,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SYSTEM ENTRY 23GA 4MM VLV FOR VITRCTMY EDGEPLUS,SUP-2109958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
STENT NEURO NEUROFORM ATLS L 24 MM DIA 3 MM DEL WIRE L 185,SUP-2417549,CDM,C1874,HCPCS,0278,RC,,,,both,,,20943.80,13613.47,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 6 MMX15 CM 7 FRX75 CM EPTFE VIABAHN,SUP-2396500,CDM,C1874,HCPCS,0278,RC,,,,both,,,10864.40,7061.86,,,,,,,,,,,,,
PLATE BONE 30 H STRL STRNL TI STR LO PROF NEUT LCK COMPR FOR,SUP-2192434,CDM,C1713,HCPCS,0278,RC,,,,both,,,11247.17,7310.66,,,,,,,,,,,,,
JACKET ORTHOT CUST POST OPERATIVE BODY,SUP-2435594,CDM,L1310,HCPCS,0272,RC,,,,both,,,5082.28,3303.48,,,,,,,,,,,,,
SCREW BONE 5.5 MMX25MM SLD CORT FT PROX VERSANAIL TIB,SUP-2412186,CDM,C1713,HCPCS,0278,RC,,,,both,,,564.89,367.18,,,,,,,,,,,,,
CATH REPROC EP DIAG DYNAM XT STRBL LG4 10POL 2-5-2MM 6FR,SUP-2526003,CDM,C1730,HCPCS,0272,RC,,,,both,,,424.97,276.23,,,,,,,,,,,,,
CAP SPNL DIA5.5MM LOK CREO,SUP-2228664,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
BROACH SURG DSTL 1 LESSER METATRSL PHLANG SYS,SUP-2609667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1827.07,1187.60,,,,,,,,,,,,,
SHEATH NEPHSTMY 11 FRX30CM,SUP-2141701,CDM,C1894,HCPCS,0272,RC,,,,both,,,185.39,120.50,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.534,SUP-2860051,CDM,C1713,HCPCS,0278,RC,,,,both,,,44188.59,28722.58,,,,,,,,,,,,,
SLEEVE TIB XSM THK40MM KNEE TI REGENEREX,SUP-2407891,CDM,C1776,CPT,0278,RC,,,,both,,,2110.08,1371.55,,,,,,,,,,,,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,6370000000,HCPCS,0637,RC,00496-0882-06,NDC,,both,5,GR,31.50,20.47,,,,,,,,,,,,,
PLATE BNE L103MM THK2.3MM 16 H NONCOMPRESSION FRAC,SUP-2262992,CDM,C1713,HCPCS,0278,RC,,,,both,,,1390.45,903.79,,,,,,,,,,,,,
SCREW BNE L34MM DIA4MM THRD L14MM STD CANC S STL ST CANN,SUP-2342500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.66,892.88,,,,,,,,,,,,,
BLADE SAW BONE CEM KEEL CUT OXFORD,SUP-2136845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
STRIP BONE GRAFT VIASORB 10MM X 50MM X 5MM ALLOGRAFT DBM,SUP-2893589,CDM,C1713,HCPCS,0278,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF ADULT 6X200 MM 50 MM ANKLE FOOT H,SUP-2836743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4629.62,3009.25,,,,,,,,,,,,,
PLATE BNE SCAPULA LT GLEN 4 HOLE,SUP-2846278,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
STAPLER INT STR 2.5/3.5X60 MM RELD BIOABSORBABLE WHT SEAMGRD,SUP-2478040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.29,357.69,,,,,,,,,,,,,
LINER ACET OD68MM ID36MM +4MM OFFSET MARATHON CROSSLINKED,SUP-2250490,CDM,C1776,CPT,0278,RC,,,,both,,,5827.84,3788.10,,,,,,,,,,,,,
HC So Legionnaires Titer,PX-3028671366,CDM,86713,CPT,0302,RC,,,,inpatient,,,668.00,434.20,,,,,,,,,,,,,
CONNECTOR SPNL SLT ROD BOLT SPNL SYS TI 6.35MMXSM CD HORZ,SUP-2293324,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
PLATE BONE RT NAVICULAR TIM FOR 2.5MM SCR ALPS,SUP-2413836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1973.80,1282.97,,,,,,,,,,,,,
RESERVOIR CSF 20MM TI LO PROF MCLANAHAN,SUP-2108714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1883.25,1224.11,,,,,,,,,,,,,
GRID RAD FAST FIND FOR BX,SUP-2352842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.79,277.41,,,,,,,,,,,,,
SYSTEM LOADING 23-29 MM EVOLUT FX,SUP-2854105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,J3379,HCPCS,0636,RC,63323-0494-05,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE LCK,SUP-2136961,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
INSERT HUM COMBINATION 9+ MM 42 MM SHLDR 36/42 AEQUALIS,SUP-2715655,CDM,C1776,CPT,0278,RC,,,,both,,,4417.98,2871.69,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 10 CC FD CRUSH CANC READIGRAFT,SUP-2740770,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.63,357.91,,,,,,,,,,,,,
ALLOGRAFT BNE ACHILLES TEND N SUTURED W/O BNE BLOCK,SUP-2424193,CDM,C1889,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
K WIRE FIX L100MM DIA1.6MM S STL W/ THRD TIP,SUP-2186896,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.41,820.57,,,,,,,,,,,,,
STEM FEM CLLRD HI OFFSET FORGED CO CHROM PRSS FIT P SER SZ,SUP-2221761,CDM,C1776,CPT,0278,RC,,,,both,,,15448.80,10041.72,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 2X150 MM TI NS KIRSCHNER,SUP-2905550,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.47,21.11,,,,,,,,,,,,,
BLADE SAW SAG 4MM CUT EDGE 34MM CUT DEPTH 0.4MM THCK FLT FLF,SUP-2605394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.06,54.64,,,,,,,,,,,,,
PROBE STIM 0.5MM GRN SUBDERM MPLR BALL INSUL YINGLING,SUP-2279925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.04,380.28,,,,,,,,,,,,,
PLATE BNE W8XL64MM THK2.5MM 8 H BILAT CALCNL S STL RIG NEUT,SUP-2186284,CDM,C1713,HCPCS,0278,RC,,,,both,,,988.63,642.61,,,,,,,,,,,,,
COIL STONE RETRV L115CM DIA7MM SHTH 3FR NIT URO STONE CONE,SUP-2138886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,820.33,533.21,,,,,,,,,,,,,
GRAFT BONE 5MM SPCR LORDTC MAINTAIN ALLGRFT,SUP-2232324,CDM,C1889,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
SYSTEM BUR H SHUNT YEL M PRSS W/ VLV DRNGE CATH VENT CATH,SUP-2308187,CDM,C1713,HCPCS,0278,RC,,,,both,,,2750.70,1787.95,,,,,,,,,,,,,
DRAINAGE KIT CATH SUBDURAL STL DRL BIT STP EXAFLOW DISP,SUP-2666675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,885.26,575.42,,,,,,,,,,,,,
CANNULA ARTHSCP TERMANIAN ENDOTIP 6 MMX10.5 CM THRD BLK LF,SUP-2768019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1899.29,1234.54,,,,,,,,,,,,,
IMPLANT TEND REP CONEXTIONS TR,SUP-2900742,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BONE STRUT 2 MM 2X10 HOLE RAPID RESORBABLE STERILE RAP,SUP-2838595,CDM,C1713,HCPCS,0278,RC,,,,both,,,1967.21,1278.69,,,,,,,,,,,,,
CATHETER PTCA L142CM BLLN L9MM DIA2MM MRAIL RAP EXCHG FULL,SUP-2144436,CDM,C1725,HCPCS,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
BIT DRL DIA3MM FOR ANK FUS PLATING SYS ORTHOLOC 3DI,SUP-2398588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLUG BNE POLYPLUG MDLLRY 11MM,SUP-2197457,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.63,162.26,,,,,,,,,,,,,
CUP ACET OD60MM ID52MM THK4MM FULL POR HIP REDAPT,SUP-2345479,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
VALVE AORT DIA29MM ASCEND CONDUIT CARBO-SEAL VALSALVA,SUP-2352651,CDM,C1889,HCPCS,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
SCREW BNE MENIS,SUP-2608742,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.06,416.04,,,,,,,,,,,,,
UB BLADE KELLY 1IN 3IN,SUP-2674154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1032.02,670.81,,,,,,,,,,,,,
TWISTER WIRE OCHSNER 10.5 IN TUNGSTEN CARBIDE,SUP-2472774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.75,493.84,,,,,,,,,,,,,
PLATE 2.7 VAL ANT PATELLA PL SS 3 HL/SM/ST,SUP-2718096,CDM,C1713,HCPCS,0278,RC,,,,both,,,6186.68,4021.34,,,,,,,,,,,,,
SHEATH INTRO 7 FRX23 CM 29.5 CM TEARWY VLV DIL SAFSHTH II,SUP-2329871,CDM,C1892,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM OD 6 FR ID 2 MM DIL L 20 CM,SUP-2168223,CDM,C1894,HCPCS,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
SHEATH INTRO FLX BLKN L 45 CM OD 6 FR ID 2.2 MM GUIDEWIRE,SUP-2168593,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.20,95.03,,,,,,,,,,,,,
CANNULA ART SHT 21 FR UNCOATED HLS,SUP-2663478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.96,653.22,,,,,,,,,,,,,
KIT CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 15CML INSER 200 3,SUP-2613236,CDM,C1752,HCPCS,0278,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
BRACE ORTH SLD ANK FT,SUP-2388165,CDM,L1960,HCPCS,0272,RC,,,,both,,,1458.81,948.23,,,,,,,,,,,,,
CATHETER INFUS L135CM DIA4MM GWIRE 0.035IN INFUS L20CM VLV,SUP-2172512,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
KIT INTRO VAXCEL MINI-STICK SHTH 15 CM 6 FR SS PLAT TIP,SUP-2118969,CDM,C1894,HCPCS,0272,RC,,,,both,,,12.09,7.86,,,,,,,,,,,,,
CANNULATED 3.0 X 13MM SS PRO TOE  VO NON STERILE,SUP-2496216,CDM,C1776,CPT,0278,RC,,,,both,,,1934.24,1257.26,,,,,,,,,,,,,
PROBE BX 10 GAX118 MM VACORA,SUP-2128771,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
INTRODUCER HEMSTAS 8FR L85CM GWIRE 0.038IN 5CM J W/ DIL FAST,SUP-2355578,CDM,C1894,HCPCS,0272,RC,,,,both,,,151.51,98.48,,,,,,,,,,,,,
PLATE BNE W17.5XL300MM THK5.2MM 16 H S STL BROAD CRV LOK,SUP-2185311,CDM,C1713,HCPCS,0278,RC,,,,both,,,2588.49,1682.52,,,,,,,,,,,,,
CATHETER ABLATN J-J 2-5-2 MM 3.5 MM 8 FRX115 CM THERMOCOOL,SUP-2248539,CDM,C1732,HCPCS,0278,RC,,,,both,,,7583.10,4929.01,,,,,,,,,,,,,
HC Pain Major,PX-3600007516,CDM,3600007516,LOCAL,0360,RC,,,,outpatient,,,2879.00,1871.35,,,,,,,,,,,,,
PLATE BNE L 43.2 X W 11.4 MM THK 1.6 MM SCREW DIA2/2.3 MM,SUP-2936891,CDM,C1713,HCPCS,0278,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
HYALURONIDASE HUMAN 15 UNITS/ML IJ SYRINGE,RX-4081893,CDM,J3473,HCPCS,0636,RC,09999-9915-14,NDC,,both,0.2,ML,54.40,35.36,,,,,,,,,,,,,
HC So Phospholipid Antibody,PX-3028614866,CDM,86148,CPT,0302,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
INSERT TIB THK10MM STD R MED L LAT ULT HI MOL WT POLYETH,SUP-2408378,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SPLINT CLAV XL W3XL41IN SHLDR PD STRP MCLEOD,SUP-2197366,CDM,L3650,HCPCS,0274,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
HC So 17 - Hydroxyprynenolone,PX-3018414366,CDM,84143,CPT,0301,RC,,,,both,,,74.00,48.10,,,,,,,,,,,,,
CATHETER GUID CYB BALLOON L 55 CM DIA 8 FR POLYETHER BLOCK,SUP-2141012,CDM,C1887,HCPCS,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 50 X W 11 MM MYRIAD HNDPC L 13 CM,SUP-2930233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18059.55,11738.71,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TRUE L 110 CM BALLOON L 4.5 CM DIA21,SUP-2431942,CDM,C1725,HCPCS,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM CORT ANK FT TI ST LOK FULL THRD,SUP-2371922,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
PLATE BNE LCK MINI NAR BROAD 2 MM MAND 4 HOLE FOR SCREW TI,SUP-2191212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
GRAFT BONE SUB 5ML SYR PASTE DEMIN MTRX GRFTON +,SUP-2293917,CDM,C1713,HCPCS,0278,RC,,,,both,,,1763.42,1146.22,,,,,,,,,,,,,
BUR SURG OD3MM MTCH HD NEURO DRL AM-8 TPS,SUP-2363482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.44,327.24,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX55 CM LT DL VASCPAK KT DURAFLO 2,SUP-2487490,CDM,C1750,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.548,SUP-2860229,CDM,C1713,HCPCS,0278,RC,,,,both,,,54818.12,35631.78,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SM LT WRST,SUP-2330434,CDM,L3908,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
RESERVOIR VENT DRNGE ID2.5CM CONN OD1.9MM ID1.1MM SIL,SUP-2308214,CDM,C1889,HCPCS,0278,RC,,,,both,,,1615.53,1050.09,,,,,,,,,,,,,
CONDYLAR PLATE GUIDE,SUP-2548638,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.21,373.24,,,,,,,,,,,,,
NEEDLE SUT FOR EXPRESSEW LL AND LLL SUT PASS EXPRESSEW LLL,SUP-2249389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1194.46,776.40,,,,,,,,,,,,,
PIN BIORESORBABLE 26MM,SUP-2704181,CDM,C1713,HCPCS,0278,RC,,,,both,,,2466.16,1603.00,,,,,,,,,,,,,
IMPLANT OSS L475MM PIST DIA06MM STAP PLAT FLROPLAS RBBN LOOP,SUP-2313670,CDM,L8613,CPT,0278,RC,,,,both,,,495.55,322.11,,,,,,,,,,,,,
HC So Igh Gene Rearrange Am,PX-3108126166,CDM,81261,CPT,0310,RC,,,,both,,,662.00,430.30,,,,,,,,,,,,,
CATHETER THORACENTHESIS 9 FRX20 IN EYES TOP,SUP-2227236,CDM,C1729,HCPCS,0272,RC,,,,both,,,49.20,31.98,,,,,,,,,,,,,
PLATE BNE TI R CRANIOMAXILLOFACIAL 11 H ADV NONSTERILE LE,SUP-2366359,CDM,C1713,HCPCS,0278,RC,,,,both,,,1113.92,724.05,,,,,,,,,,,,,
GRAFT BONE SUB 1ML DEMIN MTRX GEL INJ,SUP-2307523,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BIT DRILL SURG DIA2 MM NS DISP LEOS,SUP-2931262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.29,260.84,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 10 KT STRL DISP EVO,SUP-2934927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2973.58,1932.83,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA15 MM SHRT OPT FIX CANN DOLPHIN,SUP-2896220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,554.05,360.13,,,,,,,,,,,,,
PLATE BNE L 58 MM SCREW DIA2.4/2.7 MM 6 HD 3 SHFT H LT DSTL,SUP-2913549,CDM,C1713,HCPCS,0278,RC,,,,both,,,8023.27,5215.13,,,,,,,,,,,,,
PLATE BONE 11 H CRANIOMAXILLOFACIAL TI H SHP FOR 1.3MM,SUP-2190675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1096.80,712.92,,,,,,,,,,,,,
APPLIER CLP CRV MED 8 IN OPN MANUAL LOAD LCK LIG HEM-O-LOK,SUP-2656794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
FIBER LASER 365 MH OPTIMUM PERF HOLM SLM LN SIS EZ DISP,SUP-2462831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1030.52,669.84,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX7 CM 20 GA ECHOGENIC NDL ACCEL,SUP-2659250,CDM,C1729,HCPCS,0272,RC,,,,both,,,65.12,42.33,,,,,,,,,,,,,
BIT DRL DIA2MM FOR 27MM DST LOK SCR,SUP-2121750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
COMPONENT TIB TY REV 3 LT KNEE,SUP-2392622,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BRACE ORTHOSIS SPNL SM M EXOS FRM II 626,SUP-2196545,CDM,L0641,HCPCS,0272,RC,,,,both,,,244.64,159.02,,,,,,,,,,,,,
ELECTRODE ELECSURG RESECT W/ HF CABLE PLASMABUTTON SP,SUP-2430210,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.40,1083.16,,,,,,,,,,,,,
CASE STRL INSTR FOR L FRAG TI SCR SET GRPHC LCK COMPR PLT,SUP-2194001,CDM,C1713,HCPCS,0278,RC,,,,both,,,3138.81,2040.23,,,,,,,,,,,,,
TERBINAFINE HCL 250 MG PO TABS,RX-12724,CDM,6370000000,HCPCS,0637,RC,16714-0795-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Rep Cpx Ey/ER/Ns/Lp 1.1-2.5,PX-4501315100,CDM,13151,CPT,0450,RC,,,,both,,,1227.00,797.55,,,,,,,,,,,,,
HC So Fructosamine,PX-3018298566,CDM,82985,CPT,0301,RC,,,,inpatient,,,274.00,178.10,,,,,,,,,,,,,
CAGE SPNL L12XW12XH8MM 4 LOBE MESH L ANAT FOOTPRINT MOD IMP,SUP-2317728,CDM,C1889,HCPCS,0278,RC,,,,both,,,4179.34,2716.57,,,,,,,,,,,,,
HC L Heart W Lvgram,PX-4819345200,CDM,93452,CPT,0481,RC,,,,outpatient,,,7469.00,4854.85,,,,,,,,,,,,,
CAGE SPNL 18 DEG L 22 X W 9 X H 14 MM TI ALLOY POST LUMBAR,SUP-2926401,CDM,C1889,HCPCS,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
CANNULA DRNGE 20DEG W/ DIL EXCORP CIRC BUB TRAP ANGIOVAC,SUP-2420160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,45530.00,29594.50,,,,,,,,,,,,,
OBTURATOR ENDOSCP COR BX LG,SUP-2487605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,962.50,625.62,,,,,,,,,,,,,
SCREW BNE CANN 4X36 MM COMPR FT TI STRL,SUP-2788104,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.39,614.50,,,,,,,,,,,,,
DRILL HUDSON MOD TRINKLE,SUP-2362649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3063.54,1991.30,,,,,,,,,,,,,
GRAFT STRGHT ULTRA THIN WALL NON RNGD PLSTR 6MM DIA 40CM LNG,SUP-2463963,CDM,C1768,CPT,0278,RC,,,,both,,,1564.91,1017.19,,,,,,,,,,,,,
STEM FEM LT N CLLRD POR HA NAT HIP SZ 2,SUP-2210785,CDM,C1776,CPT,0278,RC,,,,both,,,15368.73,9989.67,,,,,,,,,,,,,
CATHETER ABLAT 7.5FR L110CM TIP L4MM 2.5MM SPC L CRV STD,SUP-2148489,CDM,C2630,CPT,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
GRAFT BNE SUB 16MM WDG SUBTUBULAR FOR DISTR ARTH,SUP-2321683,CDM,C1713,HCPCS,0278,RC,,,,both,,,10022.88,6514.87,,,,,,,,,,,,,
VALVE DRAINAGE NEONATAL STD MED PRESSURE IN LN CYL ULTRA VS,SUP-2852576,CDM,C1889,HCPCS,0278,RC,,,,both,,,2330.85,1515.05,,,,,,,,,,,,,
NAIL IM L480MM DIA11MM 130DEG NONSTERILE GRN FEM TI LCK,SUP-2192578,CDM,C1713,HCPCS,0278,RC,,,,both,,,3356.22,2181.54,,,,,,,,,,,,,
COMPONENT FEM CRUCE RET POR LEGION,SUP-2348063,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 0.7-1.0 MCI STRL ADVANTAGE 2029ALS2] ISOAID LLC],SUP-2247258,CDM,C2642,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
ROD REPROC EXT FIX ATTCH FOR LG MULTIPIN CLMP,SUP-2188491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
KIT CAGE SPINAL APREVO 2-LEVEL,SUP-2912823,CDM,C1889,HCPCS,0278,RC,,,,both,,,100480.00,65312.00,,,,,,,,,,,,,
HC So Sgot (Ast),PX-3018445066,CDM,84450,CPT,0301,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
PORT INFUS 9.6FR SGL,SUP-2126567,CDM,C1788,HCPCS,0278,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
HEAD FEM PRI CERAMIC ON CERAMIC ZIRCONIA 32MM DIA +0 NK LEN,SUP-2211114,CDM,C1776,CPT,0278,RC,,,,both,,,6301.98,4096.29,,,,,,,,,,,,,
SPACER SPNL 20MM LO ENDPLATE 25X30MM FOOTPRINT 12DEG PEEK,SUP-2231235,CDM,C1821,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PIN POS 5 MM TI STRL,SUP-2563986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,655.88,426.32,,,,,,,,,,,,,
SCREW BONE 4.5MMDIA 16MML STD CORT FULL THRD N CANN N SELF,SUP-2198204,CDM,C1713,HCPCS,0278,RC,,,,both,,,38.97,25.33,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 45 CM DIA 4-7 MM SUPP L 10 CM EPTFE,SUP-2227651,CDM,C1768,CPT,0278,RC,,,,both,,,1722.35,1119.53,,,,,,,,,,,,,
LEAD PACE QPLR 47 MM SPC 75 CM LT VENTRIC LG TRAD S QUARTET,SUP-2356663,CDM,C1900,HCPCS,0275,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SHEET CRAN W50XL50MM THK0.8MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194076,CDM,C1781,HCPCS,0278,RC,,,,both,,,3567.35,2318.78,,,,,,,,,,,,,
GRAFT BNE GRAN 1-6 MM 30 CC CANC BI-OSTETIC,SUP-2134725,CDM,C1889,HCPCS,0278,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
CANNULA OUTFLO VERSASCOPE,SUP-2257609,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
STEM FNGR JT 4 L49.3MM DIA7.1MM FLEXSPAN PROX NONCOATED FLX,SUP-2399928,CDM,C1776,CPT,0278,RC,,,,both,,,3212.22,2087.94,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 115 CM 5 FR 2-5-2MM XL,SUP-2538070,CDM,C1730,HCPCS,0272,RC,,,,both,,,677.99,440.69,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 20 MM DIA 8 MM DEL SYS L 190 CM,SUP-2866177,CDM,C1876,HCPCS,0278,RC,,,,both,,,3422.88,2224.87,,,,,,,,,,,,,
BIT DRL DIA13MM TRIFLAT FOR ATLNTS ANT CERV PLT SYS,SUP-2291124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.23,333.60,,,,,,,,,,,,,
CATHETER DRNGE N LOK .038 GUID WIRE STR 10FR 25CM RESOLV,SUP-2303381,CDM,C1729,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
TAP SURG 30MM ACUTWIST ACUTRK,SUP-2107217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ LOOP LOK W STAY E SUPP COT,SUP-2276652,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.55,6.21,,,,,,,,,,,,,
SCREW BNE L60MM DIA5.5MM TOT ANK PARTIALLY THRD ORTHOLOC,SUP-2398580,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
KIT FIX SFT TISS CRSS PIN FOR 3.3MM RIGIDFIX,SUP-2249325,CDM,C1713,HCPCS,0278,RC,,,,both,,,2703.54,1757.30,,,,,,,,,,,,,
CATHETER THERMODILUTION 5 FRX110 CM CRITCATH TD,SUP-2848489,CDM,C1727,CPT,0278,RC,,,,both,,,295.63,192.16,,,,,,,,,,,,,
ANCHOR SUT SM DIA1.7MM NO5 POLY SFT SGL LD W/ 1 NO2 SLD BLU,SUP-2341893,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
TUBE VENT L7MM ID1.14MM WHT FLROPLAS PLN STR SHANK,SUP-2277598,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.24,32.01,,,,,,,,,,,,,
DRILL TWST L 50 MM DIA1.8 MM SCREW DIA 3/4 MM HEX NS DISP,SUP-2909525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1246.14,809.99,,,,,,,,,,,,,
BIT DRL L145MM DIA4.2MM TI 3 FLUT NDL PNT USED W/ RADLUC,SUP-2187055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 6FR DIA DST TIP 6MML TIP 15MML CUT WI,SUP-2677701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1469.87,955.42,,,,,,,,,,,,,
IMPLANT BRST MOD PROF + X SILTEX,SUP-2748665,CDM,C1789,HCPCS,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
BIT DRL DIA4.5MM TWST CROWE PNT FOR PHOENIX AG FEM NAIL SYS,SUP-2412151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
ATTACHMENT HNDPC L9CM DIA3.2MM STR L BOR MIDAS REX LEGEND,SUP-2284668,CDM,C1713,HCPCS,0278,RC,,,,both,,,3764.36,2446.83,,,,,,,,,,,,,
SCREW SPNL L25MM OD4MM 0DEG STD TI CORT CANC ST,SUP-2415605,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
STENT BILI QUICKPLACE V L 60 MM 10FR SCP 3.7MM DUODENAL BEND,SUP-2675681,CDM,C2617,HCPCS,0278,RC,,,,both,,,677.93,440.65,,,,,,,,,,,,,
KIT SURG PWR HI SPD HNDPC SAG SAW STRL LF DISP FJ-2000,SUP-2881118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG PO TB24,RX-27659,CDM,6370000000,HCPCS,0637,RC,00904-7081-06,NDC,,both,1,UN,7.60,4.94,,,,,,,,,,,,,
MESH HERN W10XL15CM OVL BIOMATERIAL PTFE KNIT DURABLE SGL,SUP-2395758,CDM,C1781,HCPCS,0278,RC,,,,both,,,2345.58,1524.63,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 350CM 0.035IN NIT POLYUR STD STR,SUP-2761854,CDM,C1769,HCPCS,0272,RC,,,,both,,,245.86,159.81,,,,,,,,,,,,,
BUTTON GAST 14FR STOMA L17CM APPLE SHP BLLN DURABLE EXT,SUP-2119875,CDM,C1889,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
GRAFT BIO TISS W4XL7CM THCK 4 PLY PORCINE FOR PERICARD CLSR,SUP-2172038,CDM,C1768,CPT,0278,RC,,,,both,,,2608.71,1695.66,,,,,,,,,,,,,
SPACER FEM HD DIA54MM HIP 1.6GM GENTMYCN 1.6GM VANCO PMMA,SUP-2319828,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
SHELL ACET OD48MM TI-COAT HIP RESTORIS Z KLASSIC HD,SUP-2371076,CDM,C1776,CPT,0278,RC,,,,both,,,8037.74,5224.53,,,,,,,,,,,,,
GENTAMICIN SULFATE 2 MG/ML IVPB (PED-NEO) >/= 50 ML,RX-4090290,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
FEEDING TUBE KIT LP 18 FRX2 CM BLLN BUTTON SIL CLR MINI 1,SUP-2754577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.49,389.67,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L40CM 16X8MM POLYESTER BOV BIFURCATE,SUP-2265914,CDM,C1768,CPT,0278,RC,,,,both,,,2210.56,1436.86,,,,,,,,,,,,,
TUBE VENT BOB 1.02 MM 1 MM 2.7 MM FLROPLAS BLU STRL,SUP-2465880,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.45,14.59,,,,,,,,,,,,,
ALLOGRAFT DERMAL 8X16CMX2.4/0.4 MM RDY TO USE ALLDERM,SUP-2463126,CDM,Q4116,HCPCS,0636,RC,,,,both,,,14962.10,9725.36,,,,,,,,,,,,,
BLADE SHV L L18CM DIA4.5MM LNG FULL RAD BONECUTTER CLR,SUP-2341683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.16,226.30,,,,,,,,,,,,,
INSERT TIB SZ 3-4 THK9MM STD KNEE POLY POST STBL CONSTRN,SUP-2345950,CDM,C1776,CPT,0278,RC,,,,both,,,6380.48,4147.31,,,,,,,,,,,,,
TIGHTROPE II BTB RECON IB,SUP-2811991,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
CATHETER ETER PLCMNT KT,SUP-2126771,CDM,C1751,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STEM HUM L197MM DIA8MM 135DEG UNIV SHLDR TI ARTHROPLASTY,SUP-2249964,CDM,C1776,CPT,0278,RC,,,,both,,,15508.46,10080.50,,,,,,,,,,,,,
IMPLANT PATELLA SUTPLT II STAR POLE FRAC S STRL,SUP-2751544,CDM,C1713,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
FIBER LASER ROBOTIC OMNIGUIDE,SUP-2225672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 9MM 120CM HEPARIN,SUP-2719620,CDM,C1768,HCPCS,0278,RC,,,,both,,,10368.28,6739.38,,,,,,,,,,,,,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,0636,RC,50242-0085-27,NDC,,both,1,UN,50602.10,32891.36,,,,,,,,,,,,,
VIASORB STRP 20X50X5MM,SUP-2419482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
CABLE ORTH L91CM DIA1.8MM CO CHROM SMOOTH CBL-READY 00223200228] ZIMMER BIOMET TRAUMA],SUP-2410266,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.66,820.73,,,,,,,,,,,,,
BLADE RTRCTR JNNTTA 5MM X 95MMW SPNL MAL RGGLS RDMND,SUP-2668358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,172.76,112.29,,,,,,,,,,,,,
PLATE BNE W13.5XL88MM THK4.2MM 5 H BILAT S STL NAR LIMIT,SUP-2185232,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.17,665.06,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV 18-20 IN 2XS PEDIATRIC PROCARE,SUP-2196975,CDM,L3670,HCPCS,0274,RC,,,,both,,,14.57,9.47,,,,,,,,,,,,,
KIT SHUNT CATH DSTL L 120 CM VENTRICULAR L 23 CM REG,SUP-2929980,CDM,C1889,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
BOOT ORTHOT LOWER EXTREMITY CUST MOLD INNR BOOT,SUP-2435657,CDM,L4386,HCPCS,0274,RC,,,,both,,,1598.23,1038.85,,,,,,,,,,,,,
SCREW FNGR JT L10MM DIA5.5MM HEX DIA4.5MM IM DST HALLUX IPJ,SUP-2388914,CDM,C1713,HCPCS,0278,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
PLATE BONE M W13XL101MM THK3.7MM 7 H TI STR REV FOR,SUP-2225500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.99,883.34,,,,,,,,,,,,,
CLAMP CRAN TEXT 11 MM FLAPFIX FOR EXT FIX TI NS LF,SUP-2431407,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.17,652.71,,,,,,,,,,,,,
CONNECTOR SCR FOR EXT FIX XCALIBER,SUP-2316284,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.26,553.97,,,,,,,,,,,,,
OSS MD TAPERED OSSEOTI AUGMENT,SUP-2506339,CDM,C1776,CPT,0278,RC,,,,both,,,4822.57,3134.67,,,,,,,,,,,,,
STEM HUM 10X75 MM IM COMPHSVE SEG REV SYS MOD W/SCREW,SUP-2435450,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
PLATE BNE 14 H ST BILAT S STL NAR CRV LOK COMPR FOR 35MM SCR,SUP-2178046,CDM,C1713,HCPCS,0278,RC,,,,both,,,2468.61,1604.60,,,,,,,,,,,,,
STEM FEM L240MM OD18MM POR DSTL CALCAR MOD RL HARDENED,SUP-2403946,CDM,C1776,CPT,0278,RC,,,,both,,,9539.32,6200.56,,,,,,,,,,,,,
DRILL SURG 2X95 MM,SUP-2766116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
SCREW BNE CORTICAL 4.5X46 MM SS NS,SUP-2186998,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
CATHETER EP CSL 2-8-2 MM 4 FRX65 CM SUPREME,SUP-2356906,CDM,C1730,HCPCS,0272,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.038IN TIP L3CM NIT HYDRPHLC STIFF,SUP-2169839,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.67,107.69,,,,,,,,,,,,,
PACEMAKER CARD ADVISA DR MRI SURESCAN W 51 X H 45 MM D 8 MM,SUP-2282300,CDM,C1785,HCPCS,0275,RC,,,,both,,,11123.51,7230.28,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|CO,both,,,144.00,93.60,,,,,,,,,,,,,
INSERT TIB CONSTRN CNDYL 18MM SZ 1,SUP-2223084,CDM,C1776,CPT,0278,RC,,,,both,,,4075.09,2648.81,,,,,,,,,,,,,
PIN EXT FIX HALF 3X100 MM 15 MM BLNT BLU XTRAFIX,SUP-2488023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
RETRIEVER ENDOSCP L200CM BLLN DIA9-12MM CATH 6-7FR BILI PRO,SUP-2149619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.96,304.82,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840053,CDM,2580000003,HCPCS,0258,RC,00338-0043-04,NDC,JW,both,250,ML,12.80,8.32,,,,,,,,,,,,,
STIMULATOR BNE GROWTH OL1000,SUP-2196347,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE 10 GBQ YTTRIUM-90 GLS DOSE VI,SUP-2135281,CDM,C2616,HCPCS,0278,RC,,,,both,,,54322.00,35309.30,,,,,,,,,,,,,
COMPONENT KNEE CMNTLS 30 MM MOD W/ FEMALE TAPR FOR 6 MM NOSE,SUP-2423134,CDM,C1776,CPT,0278,RC,,,,both,,,16883.78,10974.46,,,,,,,,,,,,,
BUR SURG MTCH HD STD 4X4 MM 3 MM DISECT TOOL PEG MIDAS REX,SUP-2137640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.89,235.88,,,,,,,,,,,,,
MESH HERN 3 DIM PLUG SM 1.55X1.30 IN PRE FRM REP PROLOOP,SUP-2227250,CDM,C1781,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
CURETTE SURG BAYNT STR 36MM,SUP-2293073,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.40,585.91,,,,,,,,,,,,,
SCREW BONE STEM LCK KNEE AGC,SUP-2406283,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
IMPL KIT PROCDR 36.5MM MSP RT ST,SUP-2475302,CDM,C1713,HCPCS,0278,RC,,,,both,,,3164.59,2056.98,,,,,,,,,,,,,
CATHETER URET 4.8FR L70CM 8FR CONE TIP FOR RG PYELOGRAM,SUP-2168891,CDM,C1758,HCPCS,0278,RC,,,,both,,,48.83,31.74,,,,,,,,,,,,,
HC Surgery Robot Base,PX-3600000009,CDM,3600000009,LOCAL,0360,RC,,,,both,,,9659.00,6278.35,,,,,,,,,,,,,
ANCHOR SUT NO1 FIBERWIRE UHMWPE W/ NDL FIBERTAK DX,SUP-2123219,CDM,C1713,HCPCS,0278,RC,,,,both,,,667.25,433.71,,,,,,,,,,,,,
MESH CRAN W200XL200MM PROF H0.6MM MIC MID FACE,SUP-2363673,CDM,C1713,HCPCS,0278,RC,,,,both,,,3902.99,2536.94,,,,,,,,,,,,,
BRACE WLK SM M GRY LO PROF ANK LEG ROCK SOLE 5 LOOP LCK STRP,SUP-2334818,CDM,L4361,HCPCS,0272,RC,,,,both,,,171.13,111.23,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 14 28MM 20ML B TRICALCIUM PHSPTE SYN,SUP-2194012,CDM,C1713,HCPCS,0278,RC,,,,both,,,2653.58,1724.83,,,,,,,,,,,,,
KIT INSTR W S STL STNMN PIN DRL BIT,SUP-2253297,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
ROD SPNL 5.5X500 MM 50 MM MESA RAIL 801H55500T50,SUP-2732242,CDM,C1713,HCPCS,0278,RC,,,,both,,,6929.51,4504.18,,,,,,,,,,,,,
BRACE KNEE 2XL POPLITEAL FAB W ADV STRTCH POLYCENTRIC HNG,SUP-2276698,CDM,L1810,HCPCS,0272,RC,,,,both,,,391.34,254.37,,,,,,,,,,,,,
SYSTEM DEL 8 FR AMPLATZER PFO,SUP-2357465,CDM,C1887,HCPCS,0272,RC,,,,both,,,2427.22,1577.69,,,,,,,,,,,,,
BUR SURG GRD SHT FOR 5091 HALL SS MICROCHOICE,SUP-2846896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1963.76,1276.44,,,,,,,,,,,,,
MATRIX BIO L 3 X W 3 CM SZ 16 SQCM FISH SKIN DERMAL 10/BX,SUP-2909361,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
HOOK SPNL BLDE W5.5MM BILAT TI TRNSVRS PROC OFFSET OPN FOR,SUP-2254440,CDM,C1713,HCPCS,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
PLATE BNE RADIAL XLN MED LT VOLAR DSTL,SUP-2646871,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.99,1979.89,,,,,,,,,,,,,
HC Veeg by Tech Ea Incr 12-26 Hr Intermittent Mntr,PX-7409571500,CDM,95715,CPT,0740,RC,,,,both,,,4222.00,2744.30,,,,,,,,,,,,,
KIT CATH L5MM PRI OR REVISIONAL DCR UNILAT STENT TUBE AQL,SUP-2330967,CDM,C1726,HCPCS,0272,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
TRAY CATH MIDLN POWERMIDLINE 4FR 20CM 2 LUMAN RVS T P4254108,SUP-2632779,CDM,C1751,HCPCS,0278,RC,,,,both,,,495.84,322.30,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 3-4 10 MM KNEE,SUP-2200805,CDM,C1776,CPT,0278,RC,,,,both,,,87.95,57.17,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST PER EXTN BAR,SUP-2435695,CDM,L2760,HCPCS,0272,RC,,,,both,,,160.86,104.56,,,,,,,,,,,,,
BOLT ORTH FUSION 6.5X155 MM MIDFOOT TI NS,SUP-2799619,CDM,C1713,HCPCS,0278,RC,,,,both,,,1422.26,924.47,,,,,,,,,,,,,
PACKAGE GRFT DEL BNE W CANN LT BIO,SUP-2380352,CDM,C1713,HCPCS,0278,RC,,,,both,,,1841.99,1197.29,,,,,,,,,,,,,
BLADE RTRCTR CSPR 50MM X 23MM ILIAC BALL SNAP MED FNSTRTD F,SUP-2667359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.87,275.52,,,,,,,,,,,,,
SCREW BNE L 24 MM DIA 4 MM SHRT TI CANN HD NS LEOS,SUP-2931528,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.97,625.28,,,,,,,,,,,,,
SCREW BONE CNNLTD 8MM DIA 65MML TIMAX 16MML THRDD NON ST,SUP-2586857,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.83,487.39,,,,,,,,,,,,,
HC CT Guide Visc Tissue Ablation,PX-3507701300,CDM,77013,CPT,0350,RC,,,,inpatient,,,2630.00,1709.50,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 60 MM DIA16 MM SHTH 10 FR CATH L,SUP-2147036,CDM,C1876,HCPCS,0278,RC,,,,both,,,3340.71,2171.46,,,,,,,,,,,,,
SHEATH INTRO SUPER SHTH XL L 11 CM DIA11 FR GUIDEWIRE 0.038,SUP-2147289,CDM,C1894,HCPCS,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
PLATE BNE 1.5/2X31X1.2 MM 5 HOLE SS LC-DCP,SUP-2569193,CDM,C1713,HCPCS,0278,RC,,,,both,,,253.87,165.02,,,,,,,,,,,,,
VALVE AORT L10CM DIA22MM ORIFICE DIA18.6MM TISS ANNULUS,SUP-2355099,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
NEEDLE BRST LOC L7CM DIA20GA WIRE L20CM BARB PIN GHIATAS 10/CA,SUP-2847881,CDM,C1819,HCPCS,0278,RC,,,,both,,,65.97,42.88,,,,,,,,,,,,,
SEATING CHISEL FOR INFANT OSTEOTOMY PLATE/260MM,SUP-2548623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.61,955.25,,,,,,,,,,,,,
CEMENT BNE 40GM 1GM 25% GENT 1GM 25% VANCO BASE GV HIP AND,SUP-2319845,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
TUBE VENT BVL 1.4 MM EAR POPE GRMMT POLYETH BLU LF,SUP-2312807,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.96,32.47,,,,,,,,,,,,,
PLATE BONE STRUT 0.4 MM CRANIAL 2X4 HOLE CURVED RIGID TITANI,SUP-2837705,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.73,1153.57,,,,,,,,,,,,,
STEM FEM HIP L 115 MM DIA15 MM CONCL STR SHOT PEENED TAPR,SUP-2889761,CDM,C1776,CPT,0278,RC,,,,both,,,9185.44,5970.54,,,,,,,,,,,,,
BRACE WR RT INSTABILITY INJ LACE AD SM,SUP-2197946,CDM,L3809,HCPCS,0274,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
ANCHOR SUTURE 6.5MM WITH 2 SUTURES HI-FI NEEDLE GENESYS CROS,SUP-2824355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1618.92,1052.30,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,J7060,HCPCS,0250,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
HC C-Reactive Protein,PX-3028614000,CDM,86140,CPT,0302,RC,,,,both,,,205.00,133.25,,,,,,,,,,,,,
HC Special Plan Calculation,PX-3337732100,CDM,77321,CPT,0333,RC,,,,both,,,3253.00,2114.45,,,,,,,,,,,,,
PLATE BONE L100MM 2X20 H BILAT CRANIOMAXILLOFACIAL TI LO,SUP-2191332,CDM,C1713,HCPCS,0278,RC,,,,both,,,2213.39,1438.70,,,,,,,,,,,,,
SCREW BNE CANN 3.5X28 MM HDLSS,SUP-2221502,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
INTRODUCER REPROC STRBL AGILIS NXT 8.5FR 16.4MM,SUP-2527276,CDM,C1766,CPT,0272,RC,,,,both,,,1681.78,1093.16,,,,,,,,,,,,,
SPLINT FNGR L W1XL18IN ALUMINUM MAL,SUP-2276741,CDM,L3933,HCPCS,0274,RC,,,,both,,,2.92,1.90,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE XL 16 CC CORTICOCANCELLOUS VIABLE 004,SUP-2936806,CDM,C1762,CPT,0278,RC,,,,both,,,16174.14,10513.19,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.4X4.5 MM RICHARD SPRING BK FLROPLAS,SUP-2637900,CDM,L8613,CPT,0278,RC,,,,both,,,535.12,347.83,,,,,,,,,,,,,
PLATE BNE L35MM SHT 2X2 H NONSTERILE BILAT 1ST MTP FUS S,SUP-2184831,CDM,C1713,HCPCS,0278,RC,,,,both,,,2780.00,1807.00,,,,,,,,,,,,,
CATHETER EP CSL CRV 2-5-2MM 5FRX90CM TORQR,SUP-2281825,CDM,C1730,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STENT URET MARD L 24-30 CM DIA 7 FR PERCFLX HYDROPLUS SFT,SUP-2141626,CDM,C1874,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BIT DRL L152MM DIA3.5MM FOR IM LIMB LENGTHENING SYS PRECICE,SUP-2312224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
FORCEPS BX ALGTR JAW W BSKT BITE 11 CM X 3 MM WIDE 360 ROT,SUP-2161771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3212.69,2088.25,,,,,,,,,,,,,
CATHETER EP CRD 5 MM 4 FR 10 FIX CRV INQUIRY,SUP-2357389,CDM,C1730,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
KIT EXT FIX TIB HOFFMANN II,SUP-2372210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12751.92,8288.75,,,,,,,,,,,,,
CATH BLLN SCORING 4X200MM X 137CM OTW PTA ANGIOSCULPT,SUP-2353233,CDM,C1725,HCPCS,0272,RC,,,,both,,,4231.15,2750.25,,,,,,,,,,,,,
SEED BRACHYTHERAPY PROST PALLADIUM-103 MICK CART THERASEED,SUP-2129124,CDM,C2640,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
KIT INFUS PMP 100ML 5IN NONNARCOTIC ELASTOMERIC PMP W/ ON-Q,SUP-2420886,CDM,C9804,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.4MM CORT S STL ST T8 STARDRV RECESS,SUP-2183262,CDM,C1713,HCPCS,0278,RC,,,,both,,,150.97,98.13,,,,,,,,,,,,,
GRAFT VASC TAPR STD WALL N RING EPTFE SM BEAD 7MM DIAX4MM,SUP-2126885,CDM,C1768,CPT,0278,RC,,,,both,,,3559.91,2313.94,,,,,,,,,,,,,
CANNULA ENDOSCP DIL 3 MM FOR INTRO OF 27091S 2ND SAFETY PRB,SUP-2767836,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.38,566.40,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 10 CM DIA 5 MM STD,SUP-2323358,CDM,C1889,HCPCS,0278,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
BRACE KNEE HNG WRP L,SUP-2276700,CDM,L1820,HCPCS,0274,RC,,,,both,,,56.68,36.84,,,,,,,,,,,,,
STEM HUM L121MM DIA12MM STD SHLDR PORCOAT FOR PLATFRM,SUP-2249855,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
BUR SURG OD75MM 95MM XLN CUT ACORN N FLUT TPS,SUP-2363411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.33,227.71,,,,,,,,,,,,,
COLLAR CERV L H3XL20IN M DENS FOAM COT STOCK LNR,SUP-2194404,CDM,L0120,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
BIT REPROC DRL CANN AO CPL 2MM,SUP-2653248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.90,292.43,,,,,,,,,,,,,
BLADE SHV 40DEG STD SERR DS 4MM,SUP-2313527,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.31,280.35,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7532,SUP-2525328,CDM,C1769,HCPCS,0272,RC,,,,both,,,726.60,472.29,,,,,,,,,,,,,
CRX IMPLANT 4.0X110MM,SUP-2841607,CDM,C1713,HCPCS,0278,RC,,,,both,,,11272.60,7327.19,,,,,,,,,,,,,
COMPONENT TOT HIP ONCOLOGY B-O1,SUP-2137346,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TUBE VENT 1.27 MM 2.45 MM 2.35 MM TRIUNE TRMPT SIL 510301,SUP-2472217,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.39,32.10,,,,,,,,,,,,,
BOOT CASTXL AD 13.5IN 5.5IN CUSH ROCK OPN TOE AND OPN HEEL,SUP-2205564,CDM,L4387,HCPCS,0274,RC,,,,both,,,29.67,19.29,,,,,,,,,,,,,
NEEDLE ASPIR 19GA SHTH DIA1.73MM CHAN 2.8MM ADJ FLEX ENDO US,SUP-2141502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1352.40,879.06,,,,,,,,,,,,,
COIL NEUROVASCULAR TRUFILL DCS ORBIT 24CM 8MM DSTL LOOP,SUP-2459445,CDM,C1889,HCPCS,0278,RC,,,,both,,,6926.78,4502.41,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4MM 15DEG MINI CANC POST OCCIPITAL CERV,SUP-2254407,CDM,C1713,HCPCS,0278,RC,,,,both,,,3064.64,1992.02,,,,,,,,,,,,,
PILLOW FETAL BLLN CEPHALIC ELEVATION FOR C-SECT,SUP-2662072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2571.13,1671.23,,,,,,,,,,,,,
KIT INTRO SHTH 5 CM GUIDEWIRE L 30 CM DIA 5 FR NDL L 1.5 IN,SUP-2734925,CDM,C1894,HCPCS,0272,RC,,,,both,,,9.42,6.12,,,,,,,,,,,,,
ALLOGRAFT HUM TISS BLOCK FRZN RT MEDL MENIS FLEXIGRAFT,SUP-2740785,CDM,C1762,CPT,0278,RC,,,,both,,,13032.00,8470.80,,,,,,,,,,,,,
STENT URET L 24 CM DIA 7/10 FR SL-6 ENDOPYLTMY 2 DIAMETER,SUP-2119475,CDM,C2617,HCPCS,0278,RC,,,,both,,,358.53,233.04,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE SEL L 90 CM OD 6 FR GUIDEWIRE 0.038,SUP-2170004,CDM,C1894,HCPCS,0272,RC,,,,both,,,341.13,221.73,,,,,,,,,,,,,
BIT DRL CANN 4.4 MM DENS QR NS ACUTRK 4/5 LF DISP,SUP-2518468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
RASP SURG L18.3MM DIA3.2MM CUT ANG TAPR HELICOIDAL BLDE 5130080030] STRYKER INSTRUMENT DIV],SUP-2367488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.73,239.02,,,,,,,,,,,,,
GUIDEWIRE SURG SZ 1 2 METATARSAL DCOMPR IMPL,SUP-2398631,CDM,C1769,HCPCS,0272,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH ULTRA L 23 CM DIA 7 FR GUIDEWIRE L,SUP-2159481,CDM,C1892,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BLADE SAW NAR FOR HALL LINVATEC SYS PROPHECY INBONE,SUP-2397081,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SHEATH INTRO 0.038 IN 8 FRX11 CM 18 GAX7 CM PRELUDE ACT,SUP-2798470,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.08,24.10,,,,,,,,,,,,,
HC Excis Nail Matrix Perm Rmvl,PX-4501175000,CDM,11750,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE PERCLOSE PROGLIDE DIA 6 FR ART DIA,SUP-2105663,CDM,C1760,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
NICOTINE POLACRILEX 2 MG MT LOZG,RX-34769,CDM,6370000000,HCPCS,0637,RC,45802-0344-05,NDC,,both,1,UN,3.40,2.21,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 15 CM DIA 8 MM CLLGN BOV CAR ART,SUP-2880942,CDM,C1768,CPT,0278,RC,,,,both,,,10311.76,6702.64,,,,,,,,,,,,,
SCREW BNE NAIL NAIL HOLDING GTN,SUP-2475646,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.71,309.21,,,,,,,,,,,,,
CATHETER DRNGE L35CM DIA8FR 0.038IN POLYUR SLIP COAT KINK,SUP-2120145,CDM,C1729,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GRAFT BNE TISS 20X40 MM 0.8-1.8MM DBM PUROS,SUP-2210630,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.39,597.60,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE Z FRAME GALAXY FIX GEM LTX,SUP-2875647,CDM,C1713,HCPCS,0278,RC,,,,both,,,26128.51,16983.53,,,,,,,,,,,,,
MESH CRAN THK 0.6 MM SCREW DIA1.5 MM TI CNTOUR PANEL NS DISP,SUP-2935942,CDM,C1713,HCPCS,0278,RC,,,,both,,,12431.26,8080.32,,,,,,,,,,,,,
NEEDLE ASPIR 22GA L80MM WRK L1400MM CHN 28MM FN ROUNDED STYL,SUP-2313400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.58,560.03,,,,,,,,,,,,,
PLATE BONE LOK 184MML HLX12 STNLSS STEEL ST RIGHT LTRL DST F,SUP-2588182,CDM,C1713,HCPCS,0278,RC,,,,both,,,2343.19,1523.07,,,,,,,,,,,,,
INSERTER BNE STPL PTCH DEPLOYMENT REINF SHFT 2 EXIT PT STRL,SUP-2902033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PLATE STRAIGHT LOQTEQ 7 HOLE,SUP-2713860,CDM,C1713,HCPCS,0278,RC,,,,both,,,2121.20,1378.78,,,,,,,,,,,,,
TROCAR SURG L13MM DIA32MM FOR DST FEM NAIL,SUP-2188208,CDM,C1713,HCPCS,0278,RC,,,,both,,,735.55,478.11,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 54 MM DIA DSTL 10 MM SHTH 14 FR SS,SUP-2168725,CDM,C1768,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW SPNL FT 3.5X34 MM BLACKBIRD,SUP-2570091,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GUIDEWIRE ORTH 83.2X.5 MM FOR RECON LCK NS,SUP-2799279,CDM,C1769,HCPCS,0272,RC,,,,both,,,587.56,381.91,,,,,,,,,,,,,
CAGE SPNL W36XH14MM D27MM 14DEG ANT LUM PEEK OPTMA,SUP-2415922,CDM,C1889,HCPCS,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
BLADE SHAVER DEBULKING 18 DEG 4X270 MM LARYNGEAL DBL BEND,SUP-2638096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.06,663.04,,,,,,,,,,,,,
PROSTHESIS OSS 2.25-5.6 MM 1.5X2.5 MM OFFSET NANO HA TI SIL,SUP-2473607,CDM,L8613,CPT,0278,RC,,,,both,,,1223.56,795.31,,,,,,,,,,,,,
PLUG TIB TAPR ASCNT STEM MAXM,SUP-2405445,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
COVER SCR H ACET REFLCT,SUP-2344764,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 124 MM BLADE L 50 MM 7 H SS CNDYL,SUP-2908254,CDM,C1713,HCPCS,0278,RC,,,,both,,,3239.38,2105.60,,,,,,,,,,,,,
GUIDEWIRE VASC DURAFLO TOT LUMEN STRL,SUP-2214451,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
CLAMP SURG OFFSET EXTN 200 MM 6-6.5 MM LT 6.35 MM ROD,SUP-2584892,CDM,C1713,HCPCS,0278,RC,,,,both,,,8333.56,5416.81,,,,,,,,,,,,,
RETRIEVER ENDOSCP MINI 2.5X4.5 CM BODY ROTH NET,SUP-2736669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
HC Complex Intracavitary Appl,PX-3337776300,CDM,77763,CPT,0333,RC,,,,both,,,10165.00,6607.25,,,,,,,,,,,,,
STEM FEM SEG 15 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449812,CDM,C1776,CPT,0278,RC,,,,both,,,11768.88,7649.77,,,,,,,,,,,,,
PLEDGET CV SAUVAGE L 10.2 X W 10.2 CM THK 0.61 MM POLYESTER,SUP-2761341,CDM,C1768,CPT,0278,RC,,,,both,,,319.50,207.67,,,,,,,,,,,,,
PROSTHESIS OSS L 5 MM SHFT DIA1.14 MM HD DIA 4 MM HA PART,SUP-2902034,CDM,L8613,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
EAR CARVING TEMPLATE YAMADA HARADA A52 I PPSU 2PK,SUP-2682130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,268.66,174.63,,,,,,,,,,,,,
PLATE BONE L34MM 8 H ORBIT RIM CRANIOMAXILLOFACIAL TI FOR,SUP-2191137,CDM,C1713,HCPCS,0278,RC,,,,both,,,1226.48,797.21,,,,,,,,,,,,,
PLATE BNE T SM 2.7X32 MM 2/3 HOLE TI,SUP-2486001,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.94,187.16,,,,,,,,,,,,,
PLATE BONE 13 H LT DSTL MEDL TIB LCK W/O TAB FOR 3.5MM SCR,SUP-2349083,CDM,C1713,HCPCS,0278,RC,,,,both,,,3408.16,2215.30,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 6 MM DEL SHTH 2.4ML,SUP-2936809,CDM,C1713,HCPCS,0278,RC,,,,both,,,7315.63,4755.16,,,,,,,,,,,,,
COLLAR CERV CHILD SZ PD1 1 18MON 21 33IN FOR 075IN NK UP EXT,SUP-2123899,CDM,L0190,HCPCS,0274,RC,,,,both,,,89.46,58.15,,,,,,,,,,,,,
GRAFT HUM TISS AMBIENT 2 CC FLOWABLE PLCNTA TISS VIAFLOW,SUP-2759544,CDM,C1762,CPT,0278,RC,,,,both,,,9562.59,6215.68,,,,,,,,,,,,,
STAPLER INT L33MM 48MM STPL HEMORRHOIDOPEXY PROLAPSE SET DST,SUP-2787664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.57,906.47,,,,,,,,,,,,,
PIN VERIF LANDMARK CKPT NAVIO,SUP-2341232,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BONE L12MM OD2.5MM FOREFOOT CANN SH THRD HDLSS SHRP,SUP-2320874,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.17,592.91,,,,,,,,,,,,,
IMPLANT SYNTH L 106 X W 97 MM THK 6 MM POLYETHYL CRAN GRID,SUP-2883617,CDM,C1713,HCPCS,0278,RC,,,,both,,,12509.48,8131.16,,,,,,,,,,,,,
"HC So Oligoclonal Bands,CSF",PX-3018391666,CDM,83916,CPT,0301,RC,,,,both,,,59.00,38.35,,,,,,,,,,,,,
APPLIER CLP 13IN M L 20 5MM CLPS ENDOSCP LIG POLYMER SGL,SUP-2384288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3072.49,1997.12,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 8 H TI DBL V LP NS STERNALOCK,SUP-2894462,CDM,C1713,HCPCS,0278,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 CM DIA12 X 6 MM THK 0.38 MM,SUP-2477864,CDM,C1768,CPT,0278,RC,,,,both,,,2244.75,1459.09,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 4.5X120/145 MM STERILE TC100 DISPOS,SUP-2837036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
STENT CAR ENROUTE L 30 MM DIA 9 MM WORKING L 57 CM CROSSING,SUP-2431171,CDM,C1876,HCPCS,0278,RC,,,,both,,,8098.06,5263.74,,,,,,,,,,,,,
BIT DRL 3.5 MM VERTELOC DISP,SUP-2431582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
HYDROXYZINE HCL 10 MG/5ML PO SYRP,RX-3771,CDM,340b,HCPCS,0637,RC,54838-0502-80,NDC,,both,5,ML,3.90,2.53,,,,,,,,,,,,,
SCREW BNE L17MM OD23MM X DRV TI EMGCY SELF RET,SUP-2262813,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.43,138.73,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 100 MM DIA 6 MM CATH L 80 CM DIA 6,SUP-2420392,CDM,C1876,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CAGE ACET OD60MM ID57MM R TI RECON PROTRUSIO,SUP-2249681,CDM,C1776,CPT,0278,RC,,,,both,,,6174.50,4013.42,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 10 CM OD 5FR ID 0.074IN 0.021IN,SUP-2385317,CDM,C1894,HCPCS,0272,RC,,,,both,,,305.27,198.43,,,,,,,,,,,,,
BURR ZYPHR ELITE RND FLUT 5.0MM,SUP-2367564,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
ALLOGRAFT BNE 15 CC DBM BONUS TRIAD,SUP-2607052,CDM,C1889,HCPCS,0278,RC,,,,both,,,15307.50,9949.87,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR NIT SHFT GLD TIP STD DIL MIC STD,SUP-2615955,CDM,C1894,HCPCS,0272,RC,,,,both,,,92.60,60.19,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD UNI OXIN,SUP-2351347,CDM,C1776,CPT,0278,RC,,,,both,,,8179.70,5316.80,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X0.2 MM MESHED BOWLE SHP TI GLD STRL,SUP-2485830,CDM,C1713,HCPCS,0278,RC,,,,both,,,1265.42,822.52,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX15 CM 3L CUTLM501JLSCABRMHC,SUP-2759860,CDM,C1751,HCPCS,0278,RC,,,,both,,,355.73,231.22,,,,,,,,,,,,,
KIT ORTH ANK SYNDESMOSIS REP FRAC INCL CONSTRUCT AND DRL,SUP-2349222,CDM,C1713,HCPCS,0278,RC,,,,both,,,3940.70,2561.45,,,,,,,,,,,,,
PROBE 25GA + STD ALONE ENDO ILLUMINATOR CONSTELLATION,SUP-2109934,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.25,264.06,,,,,,,,,,,,,
ALLOGRAFT BNE MATCHSTICK SM 60X3-6 MM CORTICAL CANC 18A006,SUP-2866840,CDM,C1762,CPT,0278,RC,,,,both,,,1774.89,1153.68,,,,,,,,,,,,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,J0571,HCPCS,0636,RC,60687-0492-21,NDC,,both,1,UN,15.80,10.27,,,,,,,,,,,,,
LO PLATE ORBTL RIGID BLUE 12 HOLE 10MM 20 TRMA SSTM T 6L 4,SUP-2682190,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.27,436.98,,,,,,,,,,,,,
STEM FEM L130MM DIA13MM EXT OFFSET HIP ZMLY CEM CLLRD,SUP-2203446,CDM,C1776,CPT,0278,RC,,,,both,,,9980.18,6487.12,,,,,,,,,,,,,
BLADE SURG ULTRA AGGRESSIVE 3.5 MM + STRL FMS VUE DISP,SUP-2637146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,234.87,152.67,,,,,,,,,,,,,
PIN FIX HIP AGG PK ODYSSEY,SUP-2304615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
INSERT TIB 2 8 MM RT POLYETH,SUP-2244172,CDM,C1776,CPT,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
STEM FEM 4.5 HIP ACCOLADE TMZF,SUP-2364197,CDM,C1776,CPT,0278,RC,,,,both,,,7175.53,4664.09,,,,,,,,,,,,,
PLATE BONE L125MM THK3.4MM 8 H BILAT S STL LCK COMPR NEUT,SUP-2348984,CDM,C1713,HCPCS,0278,RC,,,,both,,,3259.01,2118.36,,,,,,,,,,,,,
PLATE BONE CRANIAL 5 HOLE Y-PLATE 20.1X9.8MM TITANIUM NEURO,SUP-2825991,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.27,173.08,,,,,,,,,,,,,
TUBE ENDOBRONCH 35 FR RT BRONCHUS DBL LUMN W/OUT CPAP SYS,SUP-2384497,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.79,239.71,,,,,,,,,,,,,
ALLOGRAFT BNE 20X15-17X15 MM FD VERTEFILL,SUP-2736761,CDM,C1713,HCPCS,0278,RC,,,,both,,,6449.25,4192.01,,,,,,,,,,,,,
DRESSING WOND KERECIS MARIGEN 3CM X 3.5CM,SUP-2866742,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1912.26,1242.97,,,,,,,,,,,,,
SCREW BNE L 44 MM DIA 4 MM SHRT TI FT ST SD CANN PARTIALLY,SUP-2900621,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
PACEMAKER CARD PHILOS DR-B 2 CHMBR 6 CONN UPLR DDDR,SUP-2137961,CDM,C1785,HCPCS,0275,RC,,,,both,,,9630.38,6259.75,,,,,,,,,,,,,
PATELLAR COMP OVL RESURFACE,SUP-2349040,CDM,C1776,CPT,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
CATHETER KIT DL 8 FRX6 IN CV BLU FLEXTIP ARROWG+ARD BLU,SUP-2120597,CDM,C1751,HCPCS,0278,RC,,,,both,,,200.33,130.21,,,,,,,,,,,,,
LEAD DEFIB PLEXA PROMRI S DX L 65 CM TIP DISTANCE 15 CM DF4,SUP-2418479,CDM,C1895,HCPCS,0275,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
GUIDEWIRE VASC SPECTRE L 200 CM DIA 0.014 IN RADIOPAQUE TIP,SUP-2383180,CDM,C1769,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
MESH CRAN THK 0.6 MM SCREW DIA1.5 MM LG TI GRD II RT PARIETL,SUP-2934682,CDM,C1713,HCPCS,0278,RC,,,,both,,,19392.64,12605.22,,,,,,,,,,,,,
DISSECTOR DBL END,SUP-2319920,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SYNERGY L 150 CM DIA 5.3 FR BALLOON L 10,SUP-2141048,CDM,C1725,HCPCS,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
MESH CRAN KASSAM 0.3 MM SLD PANEL W/ HOLE REG CP TI,SUP-2498071,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.97,765.68,,,,,,,,,,,,,
SCREW BNE MIC MINI 2.4X8 MM CRANIOMAXILLOFACIAL FIX,SUP-2364645,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.03,84.52,,,,,,,,,,,,,
DRILL SURG RVS SHLDR KIT FOR 2-3.2 MM DRL BIT GPS DISP,SUP-2451485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.79,618.01,,,,,,,,,,,,,
SCREW BNE L38MM DIA4MM THRD L15MM CANC TI SELF DRL ST,SUP-2189941,CDM,C1713,HCPCS,0278,RC,,,,both,,,52.53,34.14,,,,,,,,,,,,,
CATHETER ABLATN STD 2-5 MM 4.5 MM 7.5 FRX110 CM INTELLATIP,SUP-2424671,CDM,C1732,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
PLATE BONE L64MM THK0.6MM REG 16 H SLV TI STR FOR 1.5MM SCR,SUP-2402876,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.038 IN TAPR L 9 CM HEPARIN,SUP-2167585,CDM,C1769,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
CATHETER URETH MEAS 4FR L50CM INFLATED BLLN 75FR 12CC,SUP-2138933,CDM,C1758,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
VALVE NEUROSURGICAL OD1.4MM CATHETERL90CM 30CM VERTICAL WATE,SUP-2825679,CDM,C1889,HCPCS,0278,RC,,,,both,,,7124.94,4631.21,,,,,,,,,,,,,
PLATE BNE L7MM THK06MM 3X3 H BILAT CHIN ORAL MAXILLOFACIAL,SUP-2262920,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.29,422.04,,,,,,,,,,,,,
STAPLER INT CUT LN 51MM STPL 51MM BLU CRV HD B FRM,SUP-2716239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1581.52,1027.99,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 11 HOLES/276MM/LEFT-STERILE,SUP-2549454,CDM,C1713,HCPCS,0278,RC,,,,both,,,5487.75,3567.04,,,,,,,,,,,,,
SCREW BNE L18MM DIA3.5MM CORT FT ANK TI LOK FULL THRD FOR,SUP-2398263,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165427,CDM,6370000000,HCPCS,0637,RC,72485-0617-10,NDC,,both,5,ML,29.30,19.04,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ANGIOSCULPT L 137 CM 20 MM 3 MM,SUP-2353192,CDM,C1725,HCPCS,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
BRACE KNEE BIOSKIN Q PAT TRK M,SUP-2174970,CDM,L1820,HCPCS,0274,RC,,,,both,,,165.67,107.69,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2MM THRD L15MM S STL W/ TRCR TIP,SUP-2186906,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.57,307.82,,,,,,,,,,,,,
MESH CRAN L 65.02 X W 38 MM THK 0.6 MM SCREW DIA1.5 MM XL TI,SUP-2935882,CDM,C1713,HCPCS,0278,RC,,,,both,,,10478.18,6810.82,,,,,,,,,,,,,
ATTACHMENT BUR MTL CUT LEGEND MIDAS REX,SUP-2284670,CDM,C1713,HCPCS,0278,RC,,,,both,,,5473.71,3557.91,,,,,,,,,,,,,
BLADE LARYNGOSCOPE GERMAN PROFILE STRONG CURVE EVALUEMED MAC,SUP-2828245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.26,213.37,,,,,,,,,,,,,
PLATE BONE 135DG 14 HOLE STNLSS STEEL FMRL BLTRL STNDRD TUBE,SUP-2467104,CDM,C1713,HCPCS,0278,RC,,,,both,,,2421.79,1574.16,,,,,,,,,,,,,
HC NM I 131 Thyroid Treatment,PX-3427900500,CDM,79005,CPT,0342,RC,,,,outpatient,,,1313.00,853.45,,,,,,,,,,,,,
PASSER SUT L2.75MM UP TIP 45DEG BIRDBEAK,SUP-2120793,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SET INTRO MICRO-STICK L 9 CM DIA 4 FR GUIDEWIRE L 45 CM DIA,SUP-2267051,CDM,C1894,HCPCS,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
DEVICE FIX 3.9X50 MM W/ 14 MM NOTCH BABY GORILLA R3LEASE,SUP-2751391,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
"HC So Morphometric Analy, Comp Asst/Discrt Serv",PX-3128836166,CDM,88361,CPT,0312,RC,,,,inpatient,,,410.00,266.50,,,,,,,,,,,,,
LOOP OSS PISTON 5 MM RIBBON SPRING BK PLAT,SUP-2637828,CDM,L8613,CPT,0278,RC,,,,both,,,589.60,383.24,,,,,,,,,,,,,
ADAPTER  FRACTURE SZ 10-15 SHOULDER IMPLANT,SUP-2751552,CDM,C1776,CPT,0278,RC,,,,both,,,7112.10,4622.86,,,,,,,,,,,,,
BOOT CAST PEDIATRIC 5.5X2.5 IN ROCKER SHOE CANVS,SUP-2336135,CDM,L4387,HCPCS,0274,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
DILATOR SURG 1 PC SILIC1 REUSE STERILIZABLE USED FOR UP SZ,SUP-2124334,CDM,L8514,HCPCS,0274,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
CRIMPER SURG FOR ATLS CBL SYS TSRH 3D MPA,SUP-2289626,CDM,C1713,HCPCS,0278,RC,,,,both,,,3310.41,2151.77,,,,,,,,,,,,,
IMPLANT KNEE LT TRICOMPARTMENTAL FEM TIB INSRT W/ O PAT,SUP-2165976,CDM,C1776,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
TITAN HUM RESURF ARTHROPLASTY INSTR THRD STNMN PIN,SUP-2243667,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
FORCEPS SURG 6IN 2MM STR ALGTR MIC CUP PIT RHOT,SUP-2382449,CDM,C1713,HCPCS,0278,RC,,,,both,,,937.48,609.36,,,,,,,,,,,,,
ROD SPNL 5.5X120 MM ARM15T TI ARMDA,SUP-2562284,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PATELLA COMP BTTN 20MM 2.5MM X 2.5MM CE,SUP-2123674,CDM,C1776,CPT,0278,RC,,,,both,,,1857.88,1207.62,,,,,,,,,,,,,
INSERT TIB WEDGED 80 MM KNEE REMEDY,SUP-2718143,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
BAND ORTHODONTIC M SZ 33.5 UP MAX S STL SEAMLESS CHAIRSIDE,SUP-2176619,CDM,D6783,CPT,0278,RC,,,,both,,,17.24,11.21,,,,,,,,,,,,,
STEM FEM L220MM OD15MM TI 40% POR PLSM SPR DST CALCAR MOD,SUP-2403932,CDM,C1776,CPT,0278,RC,,,,both,,,6393.04,4155.48,,,,,,,,,,,,,
CATHETER PA L 110 CM DIA 7.5 FR INTRO DIA 8.5 FR BALLOON,SUP-2894080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
DRILL SURG TAPR RELEASE COMPRESS,SUP-2445807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2246.67,1460.34,,,,,,,,,,,,,
DISC SURG ALUM SHIM,SUP-2417198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ENDOPROSTHESIS BILI VIABIL L 6 CM DIA 8 MM L 40 CM NIT NO H,SUP-2396669,CDM,C1874,HCPCS,0278,RC,,,,both,,,8543.94,5553.56,,,,,,,,,,,,,
VALVE AORT HANCOCK II ULTRA SZ 23 MM PORCINE STENT ACETAL,SUP-2650235,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
INTRODUCER CATH OD12FR WHT SUPRA-FOLEY,SUP-2391834,CDM,C2627,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
BOLT EXT FIX SHLDR FOR ILIZ TAY SPAT FRME EXT FIX,SUP-2342995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.90,211.83,,,,,,,,,,,,,
IMPLANT BIO TISS W2XL4CM PORCINE DERM MTRX RECON THINNER,SUP-2388570,CDM,C1713,HCPCS,0278,RC,,,,both,,,3800.97,2470.63,,,,,,,,,,,,,
PIN FIX MOTOBAND,SUP-2175001,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.83,266.39,,,,,,,,,,,,,
LEAD SURG L50CM 4X8 COVEREDGE,SUP-2138840,CDM,C1778,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
COUPLER ANAS DIA1MM GRY POLYETH S STL DISP GEM,SUP-2382616,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
FELT SURG W6XL6IN THK1.65MM PTFE FOR THE REP OF SEPT DEFCT,SUP-2127903,CDM,C1768,CPT,0278,RC,,,,both,,,1011.99,657.79,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.541,SUP-2860058,CDM,C1713,HCPCS,0278,RC,,,,both,,,52400.32,34060.21,,,,,,,,,,,,,
PLATE BNE L6MM THK0.6MM CHIN MIDFACE SIL TI FOR 2MM SCR,SUP-2402857,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
CAP SPNL LCK REVOLVE,SUP-2230508,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
HC Assay of Free Thyroxine|NOT REASONABLE AND NECESSARY,PX-3018443900,CDM,84439,CPT,0301,RC,,,GZ,both,,,348.00,226.20,,,,,,,,,,,,,
PUMP INFUS 40ML 0.048ML/DAY DIA87.5MM THK19.5MM ITH TI,SUP-2284622,CDM,C1772,HCPCS,0278,RC,,,,both,,,37230.98,24200.14,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5X100X100X0.8 MM MESH RAPID RESORBABLE,SUP-2838585,CDM,C1713,HCPCS,0278,RC,,,,both,,,10921.86,7099.21,,,,,,,,,,,,,
KIT PICC 5FR L40CM DBL LUMN PRSS INJ CATHETER W BLU FLEXTIP,SUP-2383369,CDM,C1751,HCPCS,0278,RC,,,,both,,,422.80,274.82,,,,,,,,,,,,,
WAND ABLAT SHFT 3.7MM 90DEG BVL COBLATION STARVAC 90,SUP-2342004,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE L195MM THK34MM 15 H BILAT S STL STR LIMIT CNTCT,SUP-2185152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1857.37,1207.29,,,,,,,,,,,,,
CATHETER HD 14.5 FRX28 CM 45 CM STR SYMTRC TIP PALINDROME,SUP-2283944,CDM,C1750,HCPCS,0278,RC,,,,both,,,1004.36,652.83,,,,,,,,,,,,,
COMPONENT TOT KNEE CEM STD S-STEM,SUP-2379193,CDM,C1776,CPT,0278,RC,,,,both,,,13737.50,8929.37,,,,,,,,,,,,,
STENT BILI ROYAL L 19 MM DIA 6 FR CATH L 90 CM DIA 6 MM AD,SUP-2141185,CDM,C1876,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
GRAFT BNE SUB THK10 12MM CALCANEUS CRSS SECT FRZ DRY,SUP-2307161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2185.28,1420.43,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 210 CM DIA 0.035 IN TIP L 3 MM PTFE,SUP-2499040,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.43,20.43,,,,,,,,,,,,,
GRAFT BNE LCL WDG MED 8 MM TI,SUP-2609850,CDM,C1713,HCPCS,0278,RC,,,,both,,,9107.44,5919.84,,,,,,,,,,,,,
STENT URET L 22 CM DIA 6 FR PERCFLX SFT TEMP W/O DEL SYS,SUP-2141643,CDM,C2617,HCPCS,0278,RC,,,,both,,,329.64,214.27,,,,,,,,,,,,,
DEVICE CTRL MOB DGT IPOD TCH,SUP-2417135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE OLECRANON LNG ELBW EXT,SUP-2266346,CDM,C1713,HCPCS,0278,RC,,,,both,,,1990.76,1293.99,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE PROSTAR XL DIA 8.5-10 FR HYDRPHLC TIP,SUP-2105646,CDM,C1760,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
MESH HERN COMP 40X24 CM MONOFILAMENT ELLIP X1 SYMBOTEX,SUP-2752207,CDM,C1781,HCPCS,0278,RC,,,,both,,,10400.31,6760.20,,,,,,,,,,,,,
SPACER SPNL 11X11MM H5MM TRABECULAR MTL,SUP-2414452,CDM,C1821,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
FIBER LASER LIGHT PATH ASST,SUP-2217803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
BIT DRL L110MM DIA15MM 2 FLUT J LATCH NONRADIOPAQUE W O,SUP-2187192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,441.01,286.66,,,,,,,,,,,,,
CATHETER BLLN DIL EXTR OVR THE WIRE ABV INJ ERCP INFL TO,SUP-2312988,CDM,C1726,HCPCS,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
GUIDEWIRE BENSTON .035 X 80CM,SUP-2859245,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
DEVICE FIX 5MM TI FOR LAP HERN REP PROTACK,SUP-2283142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,986.24,641.06,,,,,,,,,,,,,
REAMER RMR 22MM CONCV HD,SUP-2390566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SYSTEM SLNG POLYPR SGL INCIS DEL DEV FOR STRESS URIN INCONT,SUP-2139454,CDM,C1771,HCPCS,0278,RC,,,,both,,,6233.21,4051.59,,,,,,,,,,,,,
SET GUIDEPIN L FEM ORTH COMP TRUMATCH,SUP-2252967,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SCREW BNE COMPR 4.5X20 MM ANK FUSION CONSTRUCT,SUP-2609762,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.78,608.26,,,,,,,,,,,,,
STENT GRFT VASC BIFURCATE 2 AORT LIMB EXT,SUP-2777590,CDM,C1768,CPT,0278,RC,,,,both,,,41127.72,26733.02,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8 MM STR TW HELIX,SUP-2695230,CDM,C1768,CPT,0278,RC,,,,both,,,1785.00,1160.25,,,,,,,,,,,,,
PIN EXT FIX SZ 3 X 120 X 30 MM HALF NS DISP MAV MINI,SUP-2933300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,519.83,337.89,,,,,,,,,,,,,
PROSTHESIS OSS EAR 0.5X3.75 MM,SUP-2312788,CDM,L8613,CPT,0278,RC,,,,both,,,468.43,304.48,,,,,,,,,,,,,
HC Speech Therapy Group,PX-4439250800,CDM,92508,CPT,0443,RC,,,,outpatient,,,249.00,161.85,,,,,,,,,,,,,
SET PNEUMOTHOR EMER,SUP-2419755,CDM,C1729,HCPCS,0272,RC,,,,both,,,395.20,256.88,,,,,,,,,,,,,
FILLER BNE 10 CC 14 DWL BI-OSTETIC,SUP-2115821,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SET PRB 2.5MM PERC DISCECTOMY NUCLEOTOME,SUP-2164733,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
BIT DRL L12MM DIA2.3MM CERV STP W/ EPOXY RNG DISP PYRENEES,SUP-2258764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
KIT SPNL CEM 11CC PMMA HI VISC W/ 2 INTRO BX NDL RESVR MIX,SUP-2255657,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840052,CDM,2580000003,HCPCS,0258,RC,00264-7800-10,NDC,JW,both,250,ML,14.90,9.68,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT CLEARVUE BASIC 4FR 0.033N 6 7655405,SUP-2632682,CDM,C1751,HCPCS,0278,RC,,,,both,,,366.00,237.90,,,,,,,,,,,,,
HC So2 Nuclear Antigen Antibody,PX-3028623568,CDM,86235,CPT,0302,RC,,,,both,,,672.00,436.80,,,,,,,,,,,,,
PASSER CATH L65CM X LNG MALL STR UNI SHUNT KT DISP FOR,SUP-2243783,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.89,252.78,,,,,,,,,,,,,
SHUNT ASCITES SGL VA DENV,SUP-2133690,CDM,C1713,HCPCS,0278,RC,,,,both,,,597.54,388.40,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.094X87 MM TROCAR PT 1 END,SUP-2106430,CDM,C1769,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
NEEDLE BRST LOC L7CM DIA20GA KOPANS-STYLE STIFF PRE-LOADED,SUP-2331832,CDM,C1819,HCPCS,0278,RC,,,,both,,,72.53,47.14,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00264-1510-32,NDC,,both,100,ML,21.30,13.84,,,,,,,,,,,,,
ALLOGRAFT BNE PROX METATRSL SEG FD STRL LF DISP,SUP-2458254,CDM,C1889,HCPCS,0278,RC,,,,both,,,3733.15,2426.55,,,,,,,,,,,,,
PLATE BNE SM W11XL77MM THK3.3MM 0DEG 6 H BILAT TI STR LIMIT,SUP-2190778,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.69,357.95,,,,,,,,,,,,,
STENT GRFT VASC AFX2 VELA L 100 MM DIA PROX/DSTL 34 MM,SUP-2217610,CDM,C1768,CPT,0278,RC,,,,both,,,14224.20,9245.73,,,,,,,,,,,,,
HC So1 Hepatitis C Virus Antibody,PX-3028680367,CDM,86803,CPT,0302,RC,,,,both,,,145.00,94.25,,,,,,,,,,,,,
PLATE BNE L25.9MM THK1MM 15 H TI SM T SHP FOR 1.5MM SCR,SUP-2411744,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PIN FIX L229MM DIA2MM S STL SMOOTH SGL BAYNT TIP STNMN,SUP-2252368,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
PLATE BONE LOK HLX35 HDSHFT TTNM T SHPD OBLQUE ST,SUP-2722677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1106.10,718.96,,,,,,,,,,,,,
VLP TI 2.4MMX25MM CTX SCREW T7 S-T,SUP-2821437,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.99,176.79,,,,,,,,,,,,,
DRAINAGE SET EXT 35 CM VENTRICULAR EVD CSF RADIOPAQUE STR,SUP-2851435,CDM,C1729,HCPCS,0272,RC,,,,both,,,863.15,561.05,,,,,,,,,,,,,
TAP SURG DIA4.5MM CANN QUIK CONN W/O HNDL REUSE,SUP-2123147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CUP HUM DIA38MM +9MM OFFSET STD SHLDR POLYETH DELT XTEND,SUP-2251005,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BALLOON ENDOSCP EUS CUF US FOR GFUM20 JFUM20 GFUC140PAL5,SUP-2313288,CDM,C1753,HCPCS,0278,RC,,,,both,,,92.25,59.96,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 20 CC CALCIUM SULF CALCIUM PHOSPHATE LO,SUP-2889960,CDM,C1713,HCPCS,0278,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
CHEST TUBE KIT INSRTN,SUP-2270510,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.43,440.98,,,,,,,,,,,,,
HEAD FEM DIA40MM CO CHROME POR CEM HEMI RESURF BIRMINGHAM,SUP-2350871,CDM,C1776,CPT,0278,RC,,,,both,,,8919.96,5797.97,,,,,,,,,,,,,
PACK ACCESSORY VPS RHYTHM ECG JOHANS ADAPTER,SUP-2855520,CDM,C1751,HCPCS,0278,RC,,,,both,,,91.03,59.17,,,,,,,,,,,,,
PLATE BNE RECON 2-2.7X3 MM RT MAND 26 HOLE ANGLED TI GLD,SUP-2480512,CDM,C1713,HCPCS,0278,RC,,,,both,,,8474.48,5508.41,,,,,,,,,,,,,
SCHANZ SCREW {} 6.0MM,SUP-2820929,CDM,C1713,HCPCS,0278,RC,,,,both,,,3365.61,2187.65,,,,,,,,,,,,,
"HC Prostate Biopsy, Any Mthd",PX-3140041600,CDM,G0416,CPT,0314,RC,,,,both,,,2821.00,1833.65,,,,,,,,,,,,,
CATHETER STONE REMV 5FR L23CM 0.4ML BILI BLLN PRB ATRAUM,SUP-2214135,CDM,C1726,HCPCS,0272,RC,,,,both,,,529.97,344.48,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2X8 MM MANDIBULAR SELF DRILLING LOCK,SUP-2838330,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.98,354.89,,,,,,,,,,,,,
SYSTEM FIX FEM 10X20 MM TI RETROSCREW,SUP-2849260,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HC Glucose Tolerance Test,PX-3018295100,CDM,82951,CPT,0301,RC,,,,outpatient,,,445.00,289.25,,,,,,,,,,,,,
PLATE BNE SZ 185MM THK05MM FOR NEURO SHUNT USE LORENZ,SUP-2402903,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
GRAFT BNE SUB 18X18MM PARA WDG SUBTALAR DISTR ARTH UNIV,SUP-2321684,CDM,C1713,HCPCS,0278,RC,,,,both,,,7449.65,4842.27,,,,,,,,,,,,,
SHEATH INTRO CATAPULT L 15 CM DIA 4 FR GUIDEWIRE 0.018/0.035,SUP-2913621,CDM,C1894,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS PEDCL REDUCTION MULTAXL STRL,SUP-2926487,CDM,C1713,HCPCS,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
BIT DRL L238MM OD31MM M LOK ST,SUP-2365051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1046.25,680.06,,,,,,,,,,,,,
PLATE BNE CABLE DBL,SUP-2101216,CDM,C1713,HCPCS,0278,RC,,,,both,,,2363.04,1535.98,,,,,,,,,,,,,
CROWN DENT 2 S STL 1ST PRI M LO RT ANTR CUSPID PREFABRICATED,SUP-2238896,CDM,D6783,CPT,0278,RC,,,,both,,,18.90,12.28,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX20 CM LT DL VASCPAK KT DURAMAX LF,SUP-2477392,CDM,C1750,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM TI TRCR PNT,SUP-2193146,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.14,184.69,,,,,,,,,,,,,
SCREW BONE L11MM DIA2MM MAND TI SELF DRL INTRAMAXILLARY FIX,SUP-2137237,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
DISTRACTOR SURG L L480MM DIA14MM THRD SPINDLE,SUP-2188633,CDM,C1713,HCPCS,0278,RC,,,,both,,,1737.49,1129.37,,,,,,,,,,,,,
ARCOS 12X150MM PRX TPR DIST,SUP-2505956,CDM,C1776,CPT,0278,RC,,,,both,,,7812.32,5078.01,,,,,,,,,,,,,
HEAD REAMER 14.5 MM KT FOR RIA 2 STRL,SUP-2432238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2478.59,1611.08,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX 5X300 MM W/ WIRE HOLE TIP TIN SIDEKCK,SUP-2476923,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 0 DEG 8X26X8 MM LORDTC ALLOCRAFT TL,SUP-2632296,CDM,C1713,HCPCS,0278,RC,,,,both,,,11420.18,7423.12,,,,,,,,,,,,,
TAP BLADE 27MM SCREW SYSTEM SINGLE USE,SUP-2681341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.91,222.24,,,,,,,,,,,,,
CATHETER HD 14 FRX28 CM CV,SUP-2159459,CDM,C1750,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EPIC DR THK 12.9 MM 33 ML 70 GM 2 CHMBR,SUP-2320138,CDM,C1721,HCPCS,0275,RC,,,,both,,,69865.00,45412.25,,,,,,,,,,,,,
ROD DISTR 4MM DIA 100MML CRBN FIBER F/CNSLDTN 3DX,SUP-2489176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.13,209.38,,,,,,,,,,,,,
GRAFT BONE CHIP MILLED FRZN CANC CORT 2MM-5MM RANG 90CC,SUP-2307429,CDM,C1713,HCPCS,0278,RC,,,,both,,,8013.85,5209.00,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-6 MM SHRT TAPR SLDE GDS,SUP-2461619,CDM,C1768,CPT,0278,RC,,,,both,,,1496.43,972.68,,,,,,,,,,,,,
BIT OVERDRILL DIA 4.5 MM AO QC LG TARGETER SYS STRL DISP,SUP-2933307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
STEM RAD L29X19MM DIA7MM NK OFFSET 4MM TI ALIGN,SUP-2340142,CDM,C1776,CPT,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
CLIP INT USE DIA16.5 MM THRD L 165CM ENDOSCP DIA 8.5-11MM BLUNT,SUP-2881845,CDM,V2787,HCPCS,0276,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
PLATE BONE SM L65MM 5 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348992,CDM,C1713,HCPCS,0278,RC,,,,both,,,1279.24,831.51,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4FR SS WIRE TUNGSTEN TIP MIC B BVL STD,SUP-2752717,CDM,C1894,HCPCS,0272,RC,,,,both,,,71.31,46.35,,,,,,,,,,,,,
SCREW SPNL POLYAX 4X40 MM DEFORMITY MESA,SUP-2531600,CDM,C1713,HCPCS,0278,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
BRONCHOSCOPE GS BFLEX 2 SLIM 3.8 SU,SUP-2864556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.14,529.84,,,,,,,,,,,,,
POTASSIUM BICARB-CITRIC ACID 10 MEQ PO TBEF,RX-87911,CDM,6370000000,HCPCS,0637,RC,51801-0014-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMP SHRT ST/RGX GLD/VRSDL/INS,SUP-2212448,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
PLATE BNE L55MM +20DEG 8 H DST DORS RAD S STL L VAR ANG LOK,SUP-2184183,CDM,C1713,HCPCS,0278,RC,,,,both,,,2016.48,1310.71,,,,,,,,,,,,,
PLATE BNE W15XL168MM THK2MM 8 H BILAT S STL COVERLEAF RIG,SUP-2186010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1711.96,1112.77,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA 40 UM 3 ML HYDRGEL POLYZENE MIC WHT,SUP-2139504,CDM,C1889,HCPCS,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
EXTENSION GUIDEWIRE CINCH QR L 145 CM DIA 0.014 IN STR,SUP-2157215,CDM,C1769,HCPCS,0272,RC,,,,both,,,239.74,155.83,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 5MM 120CM 7FR HEPARIN,SUP-2396592,CDM,C1876,HCPCS,0278,RC,,,,both,,,10654.02,6925.11,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX8 CM 3L J TIP RIFAMPIN SPECTRUM,SUP-2759972,CDM,C1751,HCPCS,0278,RC,,,,both,,,383.11,249.02,,,,,,,,,,,,,
NAIL LAPIDUS 4HOLE RIGHT 44MM,SUP-2741750,CDM,C1713,HCPCS,0278,RC,,,,both,,,5454.18,3545.22,,,,,,,,,,,,,
WEDGE SPNL 21X7X7 IN,SUP-2167324,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 5MM THREADED DISPOSABLE WITHOU,SUP-2804209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.51,243.43,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR 10MM HRD VLV INDWL BLOM-SINGER ADVNTG,SUP-2242280,CDM,L8509,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2.7 MM TI HI TORQUE XDRV FOR 2.4 MM SYS,SUP-2934690,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.38,221.25,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 6 KT STRL DISP EVO,SUP-2935141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2376.98,1545.04,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO DIA 6 FR PTFE HYDRPHLC MARKER BND,SUP-2383128,CDM,C1757,HCPCS,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
PLATE BNE 5 H LT OBLQ T2,SUP-2899032,CDM,C1713,HCPCS,0278,RC,,,,both,,,2581.87,1678.22,,,,,,,,,,,,,
CATHETER CV STD SET 018 4 FRX60 CM DL PWR INJ SS TURBO-JECT,SUP-2759816,CDM,C1751,HCPCS,0278,RC,,,,both,,,367.69,239.00,,,,,,,,,,,,,
LO PLATE X SHAPE 8 HOLE 1.0MM 2.0 TRMA SSTM CP TTNM,SUP-2495084,CDM,C1713,HCPCS,0278,RC,,,,both,,,522.87,339.87,,,,,,,,,,,,,
DRILL SURG CANN FOR STREAMLINE OCT SYS STREAMLINE MIS,SUP-2713164,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CROWN DENT PED SZ UL3 LT UP CTRL PRI M TRNSPAR PLAS GLS,SUP-2100383,CDM,D6783,CPT,0278,RC,,,,both,,,23.86,15.51,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC FD DBM GRFT,SUP-2787762,CDM,C1713,HCPCS,0278,RC,,,,both,,,4277.75,2780.54,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 28H TI STRL,SUP-2546941,CDM,C1713,HCPCS,0278,RC,,,,both,,,3503.08,2277.00,,,,,,,,,,,,,
BUR SURG X COARSE DIAMOND 4 MM 12 CM BALL SM BOR MIDAS REX 8,SUP-2664535,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 DR-T 55 X 66MM 13 MM 40J MOB,SUP-2138261,CDM,C1721,HCPCS,0275,RC,,,,both,,,37052.00,24083.80,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR DF4-LLHH/IS-1 CONN W/ RF TELMTRY,SUP-2356292,CDM,C1721,HCPCS,0275,RC,,,,both,,,39412.65,25618.22,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT FILTERWIRE EZ 3.2FR L190CM VES DIA3.5-5.5MM NIT,SUP-2143662,CDM,C1884,HCPCS,0278,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
SCREW BONE L14MM OD3MM CANN DYN COMPR LAG SMOOTH CONCL BVL,SUP-2321044,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.17,448.61,,,,,,,,,,,,,
MARKER BRST BX 10GA BARBELL CLP MAMMOSTAR,SUP-2195622,CDM,A4648,CPT,0278,RC,,,,both,,,23.24,15.11,,,,,,,,,,,,,
BLADE SAW W8XL75MM THK1MM 2.5DEG HUB RECIP SMOOTH DISP,SUP-2361584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
K WIRE FIX L70MM DIA0.9MM MET TRCR TIP MRK FOR FIXOS,SUP-2378785,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
IMMOBILIZER ORTH 30-36IN M SHLDR UNIV ELAS M,SUP-2197391,CDM,L1830,CPT,0272,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
PLATE CRAN 180X60X40 MM PT SPEC IMPL PEEK,SUP-2860136,CDM,C1713,HCPCS,0278,RC,,,,both,,,31407.22,20414.69,,,,,,,,,,,,,
SCREW BNE LNG THRD 4X26 MM,SUP-2315916,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
PROSTHESIS EAR BCKT HNDL 0.4X3.5 MM 2 TRANSAXIAL HOLE TI,SUP-2312847,CDM,L8613,CPT,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
PLATE BONE L56MM CALCNL FT PLATING SYS,SUP-2319609,CDM,C1713,HCPCS,0278,RC,,,,both,,,4298.66,2794.13,,,,,,,,,,,,,
SET URET STENT C FLX L 12 CM CATH L 70 CM DIA 3.7 FR,SUP-2171251,CDM,C2617,HCPCS,0278,RC,,,,both,,,614.03,399.12,,,,,,,,,,,,,
ALLOGRAFT BNE 10X2.5 CM FD DBM GRFT FLX,SUP-2787763,CDM,C1713,HCPCS,0278,RC,,,,both,,,4132.24,2685.96,,,,,,,,,,,,,
PLATE BNE L 47.7 X W 30.02 MM THK 2 MM SCREW DIA2 MM 8 H TI,SUP-2936416,CDM,C1713,HCPCS,0278,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
EXTRACTOR STONE 2.4FR L115CM BSKT DIA1CM 4/16 WIRE URIN,SUP-2171364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.453,SUP-2860017,CDM,C1713,HCPCS,0278,RC,,,,both,,,67483.00,43863.95,,,,,,,,,,,,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,0636,RC,42494-0416-01,NDC,,both,0.5,ML,156.30,101.59,,,,,,,,,,,,,
PLATE 11HL LK LT,SUP-2491866,CDM,C1713,HCPCS,0278,RC,,,,both,,,3063.45,1991.24,,,,,,,,,,,,,
PLATE BNE 90 DEG BLADE L 50 MM DISPLC 20 MM 4 DCP H SS HIP,SUP-2907755,CDM,C1713,HCPCS,0278,RC,,,,both,,,3166.85,2058.45,,,,,,,,,,,,,
MESH CRAN L 39.83 X W 23.57 MM THK 0.61 MM SCREW DIA1.5 MM,SUP-2937014,CDM,C1713,HCPCS,0278,RC,,,,both,,,5297.18,3443.17,,,,,,,,,,,,,
SPLINT ORTHOPEDIC DLX MED 8-9.5 9.5-11 RT ANK FT CLOSED HEEL,SUP-2195191,CDM,L1930,HCPCS,0274,RC,,,,both,,,103.68,67.39,,,,,,,,,,,,,
SCREW HUMERAL LOCKING EQUINOXE TAPERED SIZE 25 ORN,SUP-2855531,CDM,C1713,HCPCS,0278,RC,,,,both,,,1091.94,709.76,,,,,,,,,,,,,
HC Methacoline Challenge Test,PX-4609407000,CDM,94070,CPT,0460,RC,,,,inpatient,,,1867.00,1213.55,,,,,,,,,,,,,
PLATE BNE L195MM 8 H R CNDYL S STL VAR ANG LOK COMPR CRV,SUP-2177848,CDM,C1713,HCPCS,0278,RC,,,,both,,,5485.99,3565.89,,,,,,,,,,,,,
HYDRALAZINE HCL 10 MG PO TABS,RX-3698,CDM,6370000000,HCPCS,0637,RC,60687-0811-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CLAMP SPNL 6MM TI DISPOSABLE UNIV IMPL,SUP-2416029,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
GRAFT BNE L60MM TIB SHFT FRZ DRY MATRIGRFT,SUP-2264860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1860.98,1209.64,,,,,,,,,,,,,
PLATE BNE L15MM THK0.3MM 2 H CRANIOMAXILLOFACIAL TI STR FOR,SUP-2402997,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
PLATE 95 DEG CONDYLAR 7 HOLES 40MM 124MM,SUP-2547714,CDM,C1713,HCPCS,0278,RC,,,,both,,,3322.03,2159.32,,,,,,,,,,,,,
CATHETER CTRL VEN L55CM L70CM OD6FR .018IN POLYUR 3 LUMN,SUP-2125557,CDM,C1751,HCPCS,0278,RC,,,,both,,,585.61,380.65,,,,,,,,,,,,,
GRAFT HUM TISS L 22 X W 22 X H 10/5 MM IL CREST UNICORTICAL,SUP-2913413,CDM,C1762,CPT,0278,RC,,,,both,,,7887.68,5126.99,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2X300 MM,SUP-2646017,CDM,C1769,HCPCS,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
TRAY CATH L 13 CM DIA13.5 FR ACUTE 2 LUMEN HI FLO STR EXT IC,SUP-2905035,CDM,C1752,HCPCS,0278,RC,,,,both,,,383.21,249.09,,,,,,,,,,,,,
WEDGE TIB AUG HALF 26 DEG,SUP-2201700,CDM,C1776,CPT,0278,RC,,,,both,,,2320.46,1508.30,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 150 CM BALLOON L 20 MM DIA1.5 MM SHTH,SUP-2909763,CDM,C1725,HCPCS,0272,RC,,,,both,,,708.86,460.76,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.5MM POLYAX ST VAR ANG NONCANNULATED,SUP-2415750,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
NEBULIZER AEROSOL O2 TBNG ADPT AEROGEN ULTRA AEROGEN SOLO,SUP-2777858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2641.12,1716.73,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-40840054,CDM,J7042,HCPCS,0258,RC,00264-7610-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
PLATE BNE L69MM 1 H SHT R LAT DST HUM S STL VAR ANG LOK,SUP-2177609,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.08,2438.85,,,,,,,,,,,,,
INTRODUCER PEEL AWAY 5FRX6CM W NDL,SUP-2357089,CDM,C1892,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
COMPONENT TIB SLIDE LCK 4 HINTERMANN SER H2,SUP-2751894,CDM,C1776,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
COMPONENT FEM UNI XS KNEE GEN,SUP-2344261,CDM,C1776,CPT,0278,RC,,,,both,,,9041.63,5877.06,,,,,,,,,,,,,
SCREW BNE L24MM INTERPHALANGEAL TI ST CANN FULL THRD HDLSS,SUP-2107364,CDM,C1713,HCPCS,0278,RC,,,,both,,,2782.04,1808.33,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 49 MM DIA10 MM CATH TOT L 100,SUP-2148426,CDM,C1876,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
HC Fluoroscopy Up to 1 Hour,PX-3207600000,CDM,76000,CPT,0320,RC,,,,both,,,714.00,464.10,,,,,,,,,,,,,
JIG SURG KNEE PS REPL STRL IDENTITY IMPRNT,SUP-2904759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2425.65,1576.67,,,,,,,,,,,,,
CLIP ANEURYSM 3MM STANDARD PERMANENT YASARGIL  FE942K,SUP-2844504,CDM,C1889,HCPCS,0278,RC,,,,both,,,1118.84,727.25,,,,,,,,,,,,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-104344,CDM,J1652,HCPCS,0636,RC,55111-0680-02,NDC,,both,0.6,ML,312.40,203.06,,,,,,,,,,,,,
TESTER VENTILATOR CIRC LUNG 05 LT VENTI +,SUP-2352861,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
WEDGE TIB SZ 7-8 THK5MM RT MEDL LT LAT KNEE HNG REV HEMI STP,SUP-2346709,CDM,C1776,CPT,0278,RC,,,,both,,,4496.48,2922.71,,,,,,,,,,,,,
COLLAR EXTRIC FR 1 3/4IN CIRC 8IN-18IN PED AQUA CERV,SUP-2194419,CDM,L0172,HCPCS,0274,RC,,,,both,,,22.67,14.74,,,,,,,,,,,,,
PLATE BNE SELLA RECON 20X20X0.3 MM MXLFCL W/ TAB PDLLA STRL,SUP-2466202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2112.00,1372.80,,,,,,,,,,,,,
K WIRE FIX L100MM DIA1.1MM SGL TRCR,SUP-2392811,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
HC Level II Surg Pathology Gross&Microscopic Exam,PX-3128830200,CDM,88302,CPT,0312,RC,,,,both,,,368.00,239.20,,,,,,,,,,,,,
RESOLVE CIRQ NPHRSTMY CATH 10F CRV.MRKR BAND 0.038N 0.97 MM,SUP-2497665,CDM,C1729,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
STEM XL TAPER 17X135MM,SUP-2505005,CDM,C1776,CPT,0278,RC,,,,both,,,7046.16,4580.00,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.45MM BLNT THRD FOR VIPER 2 MINIMALLY,SUP-2256878,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SCREW BNE L45MM DIA65MM THRD L16MM ST TAN CANN SELF DRL,SUP-2417606,CDM,C1713,HCPCS,0278,RC,,,,both,,,1041.48,676.96,,,,,,,,,,,,,
HC So in Situ Hybrid per Specimen,PX-3128836866,CDM,88368,CPT,0312,RC,,,,both,,,360.00,234.00,,,,,,,,,,,,,
HC Thaw/Wash Cord Blood,PX-3623820900,CDM,38209,CPT,0362,RC,,,,both,,,3218.00,2091.70,,,,,,,,,,,,,
ANCHOR VERSALOOP 2.5MM DL TAPE,SUP-2756503,CDM,C1713,HCPCS,0278,RC,,,,both,,,1840.04,1196.03,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE STEM ENDO NAT LD/FX,SUP-2212690,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
QFIX 1.8 MINI SUT ANCHR DISP KITXL,SUP-2341147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1979.77,1286.85,,,,,,,,,,,,,
CATHETER INFUSION 2.6 FRX150 CM 5+ IN SAME PO CORSAIR PRO,SUP-2472440,CDM,C1887,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 50 MM DIA 36 MM SHTH 20 FR RVD,SUP-2170456,CDM,C1874,HCPCS,0278,RC,,,,both,,,6101.02,3965.66,,,,,,,,,,,,,
CATHETER INTVENT .038IN 65 GLDECATH,SUP-2141091,CDM,C1887,HCPCS,0272,RC,,,,both,,,757.21,492.19,,,,,,,,,,,,,
STENT BILI 7FR L7CM PLAS DUODENAL BEND RAP EXCHG PRELD,SUP-2149478,CDM,C2625,HCPCS,0278,RC,,,,both,,,422.33,274.51,,,,,,,,,,,,,
PROBE SET W/DRAPE,SUP-2880916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 80 CM DIA 5 FR TIP 3 MM SPC,SUP-2248649,CDM,C1730,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE L 16 MM DIA 3.5 MM TI WR ST LCK T15 DRV STRL EVOS,SUP-2931547,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.55,296.11,,,,,,,,,,,,,
LEAD PACE L58CM S STL UPLR DF-1 CONN,SUP-2282276,CDM,C1896,HCPCS,0275,RC,,,,both,,,6796.78,4417.91,,,,,,,,,,,,,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,6370000000,HCPCS,0637,RC,00078-0501-61,NDC,,both,1,UN,102.90,66.88,,,,,,,,,,,,,
PREGABALIN 50 MG PO CAPS,RX-42163,CDM,6370000000,HCPCS,0637,RC,60687-0484-01,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
RING EXT FIX FULL 210 MM ALUM HOFFMANN,SUP-2465578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4031.76,2620.64,,,,,,,,,,,,,
CLAMP EXT FIX SINGLE UNIV GEM FIX NS GALAXY LTX,SUP-2875226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.71,1806.16,,,,,,,,,,,,,
"HC So Amino Acids, 6 or < Ea Spec",PX-3018213966,CDM,82139,CPT,0301,RC,,,,both,,,219.00,142.35,,,,,,,,,,,,,
HEAD HUM H18MM OD53MM ID46MM SHLDR CO CHROM MOD NECKLESS,SUP-2404499,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 8 MM EPTFE STR TW REINF 2,SUP-2669628,CDM,C1768,CPT,0278,RC,,,,both,,,606.37,394.14,,,,,,,,,,,,,
FIBERS CORT ALLOSYNC DEMINERALIZ INJ 10CC,SUP-2719764,CDM,C1713,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
ROD IM L200MM DIA8MM HUM TI CANN LOK TAPR PROF POLARUS 2,SUP-2107689,CDM,C1713,HCPCS,0278,RC,,,,both,,,6283.14,4084.04,,,,,,,,,,,,,
PLATE BNE L 47 MM RT DORS DSTL RADIAL NAR SHRT NS VARIAX 2,SUP-2902196,CDM,C1713,HCPCS,0278,RC,,,,both,,,4300.54,2795.35,,,,,,,,,,,,,
LONG CALCNL DRL 4.1MM,SUP-2244337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1230.19,799.62,,,,,,,,,,,,,
SYSTEM IMPL SZ 4 MM SUTURE SZ 2-0 FLX PIN STRL DISP,SUP-2882327,CDM,C1713,HCPCS,0278,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
BUR SURG DIA2.35 MM HUB II TUNGSTEN CARBIDE SIDE RASP STRL,SUP-2928903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.79,218.26,,,,,,,,,,,,,
CATHETER ETER HAD ADMIN BASIC SET 155FRX28CM HEMO FLOW XF,SUP-2269538,CDM,C1881,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 50 MM FRZN ASEP WHL PATELLAR TEND W/ QUAD,SUP-2866894,CDM,C1762,CPT,0278,RC,,,,both,,,10770.20,7000.63,,,,,,,,,,,,,
STENT BILI UNCOVERED 0.035 IN 3.2 MM 8X60 MM 7.5 FRX1900 MM,SUP-2463295,CDM,C1876,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
GRAFT HUM TISS DERM ACELLULAR ULT THCK ALLGRFT 12CM WX12CM L,SUP-2307481,CDM,Q4128,HCPCS,0636,RC,,,,both,,,13873.93,9018.05,,,,,,,,,,,,,
CLIP ANEURYSM TITANIUM FENESTRATED PERMANENT 90DEG ANGLED 3.,SUP-2825571,CDM,C1889,HCPCS,0278,RC,,,,both,,,1242.09,807.36,,,,,,,,,,,,,
IMPLANT FINGER JOINT SM METACARPOPHALANGEAL FOR ARTHROPLASTY SYSTEM SR MCP,SUP-2879154,CDM,C1776,CPT,0278,RC,,,,both,,,12010.50,7806.82,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 7 MM EPTFE STR STD WALL N RING,SUP-2126226,CDM,C1768,CPT,0278,RC,,,,both,,,4452.52,2894.14,,,,,,,,,,,,,
DRILL TWST L50MM OD13MM 8MM STP J LATCH N RADLUC DISPOSABLE,SUP-2366402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.86,214.41,,,,,,,,,,,,,
PLATE BNE W11XL12MM 4 H BILAT TI H SHP RIG NONCOMPRESSION,SUP-2191062,CDM,C1713,HCPCS,0278,RC,,,,both,,,726.72,472.37,,,,,,,,,,,,,
DEFIBRILLATOR CARD 36ML PARYLENE DF-1 IS-1 SENSE PACE CONN,SUP-2356320,CDM,C1882,HCPCS,0275,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
GRAFT DERM 4CMX7CM THCK 0.4-0.8MM MTRX HUM TISS ACELLULAR,SUP-2306895,CDM,C1762,CPT,0278,RC,,,,both,,,1689.70,1098.30,,,,,,,,,,,,,
FORCEP BX CRV 30 DEG 7 MMX25 CM 14 MM JAW DBL ACT INSUL HNDL,SUP-2850476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4939.35,3210.58,,,,,,,,,,,,,
SCREW BNE L78MM OD7MM THRD L17MM PUR HINDFOOT ANK CANN SHT,SUP-2320769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
BLADE US 4-9 CM HK TIP SEAL ADJ HARMONY SYNERGY,SUP-2257773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4123.35,2680.18,,,,,,,,,,,,,
IMPLANT BIO TISS W6XL6CM FEN PRIMATRIX,SUP-2243711,CDM,Q4110,HCPCS,0636,RC,,,,both,,,4874.85,3168.65,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 22H TI STRL,SUP-2546938,CDM,C1713,HCPCS,0278,RC,,,,both,,,3673.27,2387.63,,,,,,,,,,,,,
SNARE VASC 3.2FR L175CM DIA4-8MM CATH L150CM MINI NIT LOOP,SUP-2302533,CDM,C1773,HCPCS,0272,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP RT FEM SHFT,SUP-2867030,CDM,C1762,CPT,0278,RC,,,,both,,,5297.81,3443.58,,,,,,,,,,,,,
HC So1 Phenotype Infect Agent Drug,PX-3068790067,CDM,87900,CPT,0306,RC,,,,both,,,862.00,560.30,,,,,,,,,,,,,
PORT INFUS IV APHERESIS CATH 9.6FR ATTCH POLYUR AIRGUARD,SUP-2125652,CDM,C1788,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
BUR SURG L9CM HD L79MM DIA5MM CYL FLUT L BOR MIDAS REX,SUP-2280237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.19,208.12,,,,,,,,,,,,,
KIT CATH W/ 14GA 8IN POLYUR CTRL VEN CATH 0.032IN GWIRE SGL,SUP-2383983,CDM,C1751,HCPCS,0278,RC,,,,both,,,43.93,28.55,,,,,,,,,,,,,
PLATE TIB MED DIST TI AXSOS 3 6HL 123MM,SUP-2704972,CDM,C1713,HCPCS,0278,RC,,,,both,,,6666.53,4333.24,,,,,,,,,,,,,
HC X-Ray Toes Min 2 Views,PX-3207366000,CDM,73660,CPT,0320,RC,,,,both,,,414.00,269.10,,,,,,,,,,,,,
PLATE BNE ELBW SET PERI-LOC,SUP-2351352,CDM,C1713,HCPCS,0278,RC,,,,both,,,16861.80,10960.17,,,,,,,,,,,,,
GUIDEWIRE URLGCL 0.035N DIA 145CML 3CML TIP HDRPHLC CTD ANGL,SUP-2487525,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.43,67.23,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 5X2.5 CM FIBER KORE,SUP-2736958,CDM,C1713,HCPCS,0278,RC,,,,both,,,5628.45,3658.49,,,,,,,,,,,,,
PLATE BNE THK0.5MM 2MM BAR 5 H 100DEG UNIV,SUP-2366242,CDM,C1713,HCPCS,0278,RC,,,,both,,,616.57,400.77,,,,,,,,,,,,,
TUBE TRACHEOSTOMY REGULAR ADULT 9.9MM SILVER FENESTRATED UNC,SUP-2793416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,173.74,112.93,,,,,,,,,,,,,
HC So Mycobacteria ID by Maldi,PX-3008711866,CDM,87118,CPT,0300,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 CM AORT DIA10 MM AORTOILIAC ART ALLGRFT,SUP-2933089,CDM,C1762,CPT,0278,RC,,,,both,,,77602.37,50441.54,,,,,,,,,,,,,
STAPLER ENDOSCP L60MM DIA12MM TI THCK TISS LIN CUT 6 ROW,SUP-2219910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1234.77,802.60,,,,,,,,,,,,,
PLATE BNE W10XL57MM THK1.5MM 4X3 H BILAT S STL T SHP R ANG,SUP-2185868,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.78,586.81,,,,,,,,,,,,,
SCREW BNE POS 5.5X45 MM STRL LG QWIX,SUP-2242939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
BIT DRILL CANN TAP S CP 5.0MM,SUP-2587567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1026.18,667.02,,,,,,,,,,,,,
PLATE SPNL 1 LEVEL 85X54X0.2 MM NEURO TI,SUP-2262593,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.94,1072.46,,,,,,,,,,,,,
ANCHOR PK CINCH SIZE: 4.0MM,SUP-2300758,CDM,C2631,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC So Anaerobic ID,PX-3008707666,CDM,87076,CPT,0300,RC,,,,both,,,95.00,61.75,,,,,,,,,,,,,
FULL RING DIA120 MM CARBON,SUP-2701759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4838.11,3144.77,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.038 IN TAPR L 6 CM FLX TIP L,SUP-2167618,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
GUIDEWIRE VASC L60CM DIA0.018IN TIP L6CM NIT STR RADPQ IMAG,SUP-2147744,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.16,69.00,,,,,,,,,,,,,
PLATE BNE L51MM 6 H BILAT S STL STR MINI FRAG ST LO PROF,SUP-2186376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1511.06,982.19,,,,,,,,,,,,,
BUR SURG DMND RND N FLUT EXTRA COARSE SABER SHANK ST 40MM,SUP-2363993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,493.58,320.83,,,,,,,,,,,,,
WIRE FIX L150MM DIA16MM S STL DBL TRCR K,SUP-2397838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
WIRE TRCR .045X4.72IN K,SUP-2402826,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
FOOTPLATE BONE 10 MM RIGHT ANTERIOR MAXILLARY MONOAXIAL SPLI,SUP-2837821,CDM,C1713,HCPCS,0278,RC,,,,both,,,2090.30,1358.69,,,,,,,,,,,,,
SYSTEM REP MFIL POLYPR SYNTH W/ INTEPRO LT PLIABLE FOR VAG,SUP-2140236,CDM,C1771,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
SET NEPHSTMY PERC ACCS SHTH L20CM OD7FR ID4FR NDL TRCR TIP,SUP-2168359,CDM,C1894,HCPCS,0272,RC,,,,both,,,214.74,139.58,,,,,,,,,,,,,
EXPANDER TISS BRST SMOOTH SURF RND,SUP-2748614,CDM,C1889,HCPCS,0278,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
SOUND PROC HEARING DEV TWO PT KT RONDO 3,SUP-2905133,CDM,L8691,HCPCS,0278,RC,,,,both,,,37513.58,24383.83,,,,,,,,,,,,,
SUPPORT ORTH CLOSED POPLITEAL 15.5-18 IN SM KNEE DLX,SUP-2336342,CDM,L1810,HCPCS,0274,RC,,,,both,,,51.15,33.25,,,,,,,,,,,,,
PLATE BNE L163.6MM THK3.7MM 0DEG 12 H TI TIM THN LOK COMPR,SUP-2413711,CDM,C1713,HCPCS,0278,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2 MM FLARE CUSTER LCK NS REUSE,SUP-2885139,CDM,C1769,HCPCS,0272,RC,,,,both,,,1455.39,946.00,,,,,,,,,,,,,
HC Heparin Assay,PX-3058552000,CDM,85520,CPT,0305,RC,,,,inpatient,,,200.00,130.00,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK FD ASEP CANC,SUP-2867067,CDM,C1762,CPT,0278,RC,,,,both,,,1745.06,1134.29,,,,,,,,,,,,,
PLATE BNE 14 H SS RT PELV BRIM ANAT STRL PRO,SUP-2902246,CDM,C1713,HCPCS,0278,RC,,,,both,,,6351.91,4128.74,,,,,,,,,,,,,
PLATE BONE 8 H CRANIOMAXILLOFACIAL TI DBL Y SHP LO PROF RIG,SUP-2191313,CDM,C1713,HCPCS,0278,RC,,,,both,,,1072.62,697.20,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM S STL ST VAR ANG NONCANNULATED LOK,SUP-2348520,CDM,C1713,HCPCS,0278,RC,,,,both,,,1087.35,706.78,,,,,,,,,,,,,
SYSTEM INTRO SAFSHTH II WORLEY RIGHT-SIDED W/ TEARWY SIDEPRT,SUP-2329876,CDM,C1894,HCPCS,0272,RC,,,,both,,,294.66,191.53,,,,,,,,,,,,,
INSERT TIB THICKNESS 19MM L CNDYL KNEE PRI STBL NEUT UNIV,SUP-2377418,CDM,C1776,CPT,0278,RC,,,,both,,,2479.82,1611.88,,,,,,,,,,,,,
SCREW BONE 2.8X23MM BICORTICAL FT OPTMA INION OTPS,SUP-2365493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.02,754.66,,,,,,,,,,,,,
SYRINGE MX 14CC W/ LUER CAP,SUP-2120741,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
METAL CANNULA X-LARGE HIP 5.0MM,SUP-2812750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
WEDGE FEM 2 5X10 MM KNEE LEGION,SUP-2797208,CDM,C1776,CPT,0278,RC,,,,both,,,5920.47,3848.31,,,,,,,,,,,,,
SUPPORT ORTHOT HIP KNEE ANK CUST TORSON BALL BEAR J,SUP-2435642,CDM,L2060,HCPCS,0274,RC,,,,both,,,1725.68,1121.69,,,,,,,,,,,,,
MESH HERN W20XL20CM POLY HYDRPHLC SQ KNIT HNYCMB 3D FLAT,SUP-2752165,CDM,C1781,HCPCS,0278,RC,,,,both,,,763.99,496.59,,,,,,,,,,,,,
BONE CEMENT SURG 3 CC HA CRAN SELF SET PREFIL DBL BRL SYR,SUP-2883510,CDM,C1713,HCPCS,0278,RC,,,,both,,,4165.71,2707.71,,,,,,,,,,,,,
CATHETER ABLAT 7.5FR L110CM TIP L4MM 2.5MM SPC QPLR L CRV,SUP-2141331,CDM,C2630,CPT,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ABDUCTN ROT BAR W/SHOE,SUP-2435711,CDM,L3140,HCPCS,0274,RC,,,,both,,,252.05,163.83,,,,,,,,,,,,,
INTRODUCER SURG KT 0.018 IN 4 FR SFT TIP REG NIT VSI,SUP-2606004,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.74,41.43,,,,,,,,,,,,,
COLLAR CERV AD M H4.25IN FOR 13-16IN NK FOAM TRACH OPN,SUP-2195537,CDM,L0172,HCPCS,0274,RC,,,,both,,,45.28,29.43,,,,,,,,,,,,,
PLATE BNE 110 DEG MINI LNG LT 6 HOLE BAR TURNED TI,SUP-2468566,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.06,323.09,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 20X10 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838614,CDM,C1763,HCPCS,0278,RC,,,,both,,,18559.91,12063.94,,,,,,,,,,,,,
BLADE SAW W70XL10MM THK1.19MM RECIP CEM FOR OXFORD KNEE,SUP-2408670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1470.09,955.56,,,,,,,,,,,,,
SPACER SPNL W10XH14XL32MM REVOLVE OPAL,SUP-2257766,CDM,C1889,HCPCS,0278,RC,,,,both,,,17310.82,11252.03,,,,,,,,,,,,,
GUIDEWIRE VASC STR 0.035 INX300 CM SELECTIVA,SUP-2424960,CDM,C1769,HCPCS,0272,RC,,,,both,,,202.00,131.30,,,,,,,,,,,,,
NAIL IM FEM 9X420 MM RETROGRADE STRL DISP,SUP-2461444,CDM,C1713,HCPCS,0278,RC,,,,both,,,5818.42,3781.97,,,,,,,,,,,,,
COLLAR SPNL TI FOR VAR AXIS SCR,SUP-2193306,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SPACER SPNL EXPANDABLE 18 MM PROC POST FUSION AILERON-TRX,SUP-2430748,CDM,C1713,HCPCS,0278,RC,,,,both,,,22529.50,14644.17,,,,,,,,,,,,,
KIT DUAL K2 PROCESSOR W/ TWO KANSO 2 PROCESSORS (CP1150),SUP-2858181,CDM,L8690,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
SIZER SURG W13XH12.2CM 95ML P6.5CM SIL GEL BRST 323 STYL HI,SUP-2300816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
VERAPAMIL HCL 120 MG PO TABS,RX-8528,CDM,6370000000,HCPCS,0637,RC,23155-0486-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMPONENT FEM CR 3 UNISX LT KNEE PRIMARY STEMLESS CEM WFL,SUP-2378037,CDM,C1776,CPT,0278,RC,,,,both,,,9124.21,5930.74,,,,,,,,,,,,,
STEM FEM CLLRD 16 MM KNEE REV LCS COMPLETE,SUP-2453518,CDM,C1776,CPT,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
ALLOGRAFT BNE LAMINOPLASTY 4 MM PRESERVON CORTICAL VG1,SUP-2740851,CDM,C1713,HCPCS,0278,RC,,,,both,,,2414.00,1569.10,,,,,,,,,,,,,
HANDLE RATCH STRL DISP MOTOBAND CP,SUP-2893429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
HC Perc D-E Cor Revasc W Ami S,PX-4810960600,CDM,C9606,CPT,0481,RC,,,,outpatient,,,31210.00,20286.50,,,,,,,,,,,,,
IMPLANT HUM TISS L 30-80 MM W 25-50 MM PA PTCH BRANCH REDUC,SUP-2932857,CDM,C1762,CPT,0278,RC,,,,both,,,17121.32,11128.86,,,,,,,,,,,,,
GRAFT HUM TISS W15XL30MM THK15MM FRZ DRY ALLGRFT BLK CANC,SUP-2307112,CDM,C1713,HCPCS,0278,RC,,,,both,,,2880.13,1872.08,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR TW HELIX,SUP-2695229,CDM,C1768,CPT,0278,RC,,,,both,,,1790.46,1163.80,,,,,,,,,,,,,
STYLET SPNL SZ 55 MM NS DISP INVICTUS,SUP-2886458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
POST EXT FIX 4 H S STL M SUPP FOR ILIZ TAY SPAT FRME EXT,SUP-2342288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1002.07,651.35,,,,,,,,,,,,,
SCREW BNE LCK 2.4X10 MM T7 DRVR STRL EVOS,SUP-2349399,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.98,431.59,,,,,,,,,,,,,
PLATE BNE L202MM 12 H ST R ANTEROMEDIAL DST TIB S STL VAR,SUP-2177683,CDM,C1713,HCPCS,0278,RC,,,,both,,,6538.77,4250.20,,,,,,,,,,,,,
INLAY ANK 1 7 MM POLYETH HINTERMANN SER H3,SUP-2751676,CDM,C1776,CPT,0278,RC,,,,both,,,8741.76,5682.14,,,,,,,,,,,,,
WEDGE ENOPHTHALMOS W22XL31MM THK7MM L POLYETH REG MEDPOR,SUP-2366496,CDM,C1713,HCPCS,0278,RC,,,,both,,,1847.07,1200.60,,,,,,,,,,,,,
PLATE BNE W14XL86MM THK3.8MM 90DEG 4 H L TIB S STL L SHP,SUP-2185788,CDM,C1713,HCPCS,0278,RC,,,,both,,,1515.65,985.17,,,,,,,,,,,,,
IMPLANT OTO 30 X 59 MM LT EAR 2PC EXT BASE RECON POROUS TRIM,SUP-2883428,CDM,L8699,HCPCS,0278,RC,,,,both,,,3665.64,2382.67,,,,,,,,,,,,,
HC Cryptosporidium,PX-3008732866,CDM,87328,CPT,0300,RC,,,,both,,,127.00,82.55,,,,,,,,,,,,,
TIP ASPIR L79IN OD192MM ID15MM SFT TISS STR SUPERLONG,SUP-2363699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2596.31,1687.60,,,,,,,,,,,,,
BOOT WALKING CUST FABRIC ANK FT,SUP-2237265,CDM,L4631,HCPCS,0274,RC,,,,both,,,4492.59,2920.18,,,,,,,,,,,,,
GRAFT HUM TISS L 250 MM DIA 8.5 MM SEMITENDINOSUS GRACILIS,SUP-2913221,CDM,C1762,CPT,0278,RC,,,,both,,,11687.08,7596.60,,,,,,,,,,,,,
SCREW BNE CANN 2X14 MM FIXOS,SUP-2366009,CDM,C1713,HCPCS,0278,RC,,,,both,,,1390.39,903.75,,,,,,,,,,,,,
PLATE BNE L90MM 4 H R PROX HUM HI ALPS,SUP-2411642,CDM,C1713,HCPCS,0278,RC,,,,both,,,6138.70,3990.15,,,,,,,,,,,,,
SCREW INTRF ABSRB CANN STRL TAPR FT 11X33MM,SUP-2166526,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.99,237.24,,,,,,,,,,,,,
CATHETER THROMCTMY AXS VECTA 74 L 132 CM PROX/DSTL OD,SUP-2551068,CDM,C1757,HCPCS,0272,RC,,,,both,,,8521.96,5539.27,,,,,,,,,,,,,
DISC ARTIFICIAL W15XH5XL15MM CERV CO CHROM MOLYBDENUM ALLOY,SUP-2263922,CDM,C1889,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
GRAFT SKIN L 20 X W 16 CM THK 1-2 MM XL ACELLULAR DERMAL,SUP-2905637,CDM,C1762,CPT,0278,RC,,,,both,,,31274.40,20328.36,,,,,,,,,,,,,
PIN EXT FIX SZ 150 X 50 X 5 MM HALF,SUP-2932987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1552.79,1009.31,,,,,,,,,,,,,
NUT 14MM STERILE,SUP-2761698,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.78,506.21,,,,,,,,,,,,,
SYSTEM GYN ANTR BIOLOGIC W/ INTEXEN FOR TRANSOBTURATOR,SUP-2140308,CDM,C1771,HCPCS,0278,RC,,,,both,,,6547.69,4256.00,,,,,,,,,,,,,
PLATE BONE LOK 161MML HLX20 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2720494,CDM,C1713,HCPCS,0278,RC,,,,both,,,1882.30,1223.49,,,,,,,,,,,,,
KIT INTRO TSX 30 DEG L 60 CM DIA 8.5 FR GUIDEWIRE L 135 CM,SUP-2148496,CDM,C1894,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE L92MM 7 H RECON FOR 35MM SCR UNIV LOK SYS,SUP-2411373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1448.92,941.80,,,,,,,,,,,,,
PLATE BNE LNG L EXTN ACU-LOC 2 VDR,SUP-2107046,CDM,C1713,HCPCS,0278,RC,,,,both,,,3557.62,2312.45,,,,,,,,,,,,,
SHEATH INTRDCR VSCLR 4FR 11CML NTNL0018N DIA 157NL GDWRE M,SUP-2699687,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.55,87.46,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY AVT 31 J 30 CC TI 2 CHMBR A IS1,SUP-2149155,CDM,C1721,HCPCS,0275,RC,,,,both,,,58247.00,37860.55,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-40840053,CDM,J3490,HCPCS,0258,RC,00338-0043-04,NDC,,both,250,ML,12.80,8.32,,,,,,,,,,,,,
CLAV SUP PLT LT 8H 90MM NS,SUP-2482500,CDM,C1713,HCPCS,0278,RC,,,,both,,,4367.74,2839.03,,,,,,,,,,,,,
PLATE BNE L29MM 6 H ST S STL ADPT LOK COMPR W SHT THRD DRL,SUP-2177472,CDM,C1713,HCPCS,0278,RC,,,,both,,,1374.88,893.67,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19MM CUT EDGE 95MM CUT DEPTH 0.9MM CUT TH,SUP-2605460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63.68,41.39,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2 MM RECON PT SPEC,SUP-2860080,CDM,C1713,HCPCS,0278,RC,,,,both,,,25848.48,16801.51,,,,,,,,,,,,,
WIRE FIX TRCR PT 3.2X320 MM KIRSCHNER,SUP-2417023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.37,275.84,,,,,,,,,,,,,
SIZER SURG W9XH85CM 140ML P38CM SIL GEL BRST 322 STYL HI,SUP-2300777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
HEAD HUM H16MM DIA38MM 0.5MM OFFSET SH SHLDR CO CHROM,SUP-2223330,CDM,C1776,CPT,0278,RC,,,,both,,,6047.64,3930.97,,,,,,,,,,,,,
CATHETER ABLATN D CRV 1-4-1 MM 4 MM 8 FRX115 CM FLEXABILITY,SUP-2463718,CDM,C2630,CPT,0272,RC,,,,both,,,7432.38,4831.05,,,,,,,,,,,,,
ROD LNG FOR PREFIX FIX 125MM,SUP-2316291,CDM,C1713,HCPCS,0278,RC,,,,both,,,391.37,254.39,,,,,,,,,,,,,
GRAFT BONE RIB FROZEN DRIED,SUP-2863662,CDM,C1762,CPT,0278,RC,,,,both,,,5017.72,3261.52,,,,,,,,,,,,,
IMPL SPNE DB VG-VLAG-0050,SUP-2431580,CDM,C1889,HCPCS,0278,RC,,,,both,,,16767.60,10898.94,,,,,,,,,,,,,
DEVICE SUTURING,SUP-2330450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
PEDIALYTE PO PACK,RX-108900,CDM,6370000000,HCPCS,0637,RC,00851-0000-05,NDC,,both,1,UN,22.60,14.69,,,,,,,,,,,,,
BUR SURG BALL 4 MMX12 CM SYMMETRI MIDAS REX LEGEND,SUP-2627650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.11,273.72,,,,,,,,,,,,,
DEFIBRILLATOR IMPL SQ-RX W 65.5 X H 78.2 MM D 15.7 MM 69.9,SUP-2148592,CDM,C1722,HCPCS,0275,RC,,,,both,,,117.53,76.39,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 25-30X12X7-10 MM TRICORT STERIGRAFT,SUP-2319335,CDM,C1889,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
SEED BRACHYTHERAPY I-125 MICK 15 CART PROST BRACHYSOURCE,SUP-2129111,CDM,C2638,HCPCS,0278,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
RING SPNL SPCR 5MM DIA 0DEG,SUP-2291556,CDM,C1713,HCPCS,0278,RC,,,,both,,,358.09,232.76,,,,,,,,,,,,,
CATHETER PARACENT 5FR L10CM 4 H TAPR TIP CLR HUB W/ 19GA,SUP-2303174,CDM,C1729,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
PLATE BNE W175XL170MM THK52MM 6 H ST L CNDYL FEM S STL LOK,SUP-2185017,CDM,C1713,HCPCS,0278,RC,,,,both,,,4513.91,2934.04,,,,,,,,,,,,,
PLATE BNE 6 X 2 H CRANIOMAXILLOFACIAL 3D CRV SQ SEG NS,SUP-2883260,CDM,C1713,HCPCS,0278,RC,,,,both,,,1506.82,979.43,,,,,,,,,,,,,
AMANTADINE HCL 100 MG PO CAPS,RX-364,CDM,6370000000,HCPCS,0637,RC,50268-0069-11,NDC,,both,1,UN,9.00,5.85,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450394401,SUP-2844114,CDM,C1713,HCPCS,0278,RC,,,,both,,,12254.79,7965.61,,,,,,,,,,,,,
ANCHOR SUT DIA13MM SGL LD 1 STRND NO2 HI FI Y KNOT,SUP-2167261,CDM,C1713,HCPCS,0278,RC,,,,both,,,2160.32,1404.21,,,,,,,,,,,,,
PLATE BNE W22XL62MM THK1.6MM LNG 12 H TRILOK NAR CORR R DST,SUP-2267966,CDM,C1713,HCPCS,0278,RC,,,,both,,,3714.62,2414.50,,,,,,,,,,,,,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,6370000000,HCPCS,0637,RC,33342-0405-35,NDC,,both,35.44,GR,45.00,29.25,,,,,,,,,,,,,
PROSTHESIS OSS SHEA 0.8X10.9 MM 1.15 MM SPNR STRUT TRIM BLK,SUP-2637890,CDM,L8613,CPT,0278,RC,,,,both,,,1173.79,762.96,,,,,,,,,,,,,
GUIDEWIRE SURG 0.062X9 IN HYPRFLX,SUP-2765872,CDM,C1769,HCPCS,0272,RC,,,,both,,,118.16,76.80,,,,,,,,,,,,,
BLADE INTREX 25X90X1.19,SUP-2166665,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 0.5 CC DEMINERALIZED CORTICAL BNE FIBER,SUP-2933253,CDM,C1762,CPT,0278,RC,,,,both,,,474.55,308.46,,,,,,,,,,,,,
DEVICE MENIS REP SEQUENT CRV 7 IMPLANTS,SUP-2167209,CDM,C1713,HCPCS,0278,RC,,,,both,,,4635.46,3013.05,,,,,,,,,,,,,
FIBER LASER FLT RNDD TIP HIGH POWER W/SHTH 200UM F/RDTN SCPS,SUP-2574062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1017.14,661.14,,,,,,,,,,,,,
DRILL SURG CANN FLX SHFT FOR 4 MM SCREW CORRIDOR,SUP-2598328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
BLADE RETRACTOR HOHMN 11 CMX29 MM WIDE OLIF,SUP-2629247,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1431.24,930.31,,,,,,,,,,,,,
BLADE SHV L13CM DIA5.5MM RESECT RASP RECIP MOTN POWERASP,SUP-2122259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM OD0.032IN L7CM TIP J TIP VASC IMAG,SUP-2355273,CDM,C1769,HCPCS,0272,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 HF-T 59X 66MM 13MM 40J SCOUTPRO,SUP-2138192,CDM,C1882,HCPCS,0275,RC,,,,both,,,72063.00,46840.95,,,,,,,,,,,,,
NOREPINEPHRINE-DEXTROSE 4-5 MG/250ML-% IV SOLN,RX-135183,CDM,2500000003,HCPCS,0250,RC,00338-0112-20,NDC,,both,250,ML,129.40,84.11,,,,,,,,,,,,,
INSERTER SURG M/L 10 UNIV GEN,SUP-2349825,CDM,C1776,CPT,0278,RC,,,,both,,,1258.98,818.34,,,,,,,,,,,,,
CANNULA SURG LNG 8 MM SCREW 00249004080,SUP-2459611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1511.03,982.17,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED ULTRA HI DEMAND 1 FIX BEAR STRYKERK1FIX] STRYKER CORP],SUP-2365982,CDM,C1776,CPT,0278,RC,,,,both,,,19405.20,12613.38,,,,,,,,,,,,,
PLATE CRAN W30XL30MM BILAT ORBIT FLR NONCOMPRESSION RIG,SUP-2194055,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
VALVE CSF 15 CM 2PC SHUNT SYS 15 CM CATH W/ ANTECHAMBER,SUP-2666652,CDM,C1889,HCPCS,0278,RC,,,,both,,,9553.86,6210.01,,,,,,,,,,,,,
TROCAR ENDOSCP BLDELSS 12X75 MM STBL SL ENDOPATH BASX,SUP-2857942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.58,312.38,,,,,,,,,,,,,
WIRE FIX L450MM OD1.6MM SHRP TIP FOR TRANSCONTINENTAL SPCR,SUP-2232206,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ELECTRODE RF L160MM DIA35MM END EFF VAPR,SUP-2256719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
SCREW SET M4X0.75 MM RND TIP 2.5 MM HEX PROTEX CT,SUP-2593143,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
SET INTRO L 10 CM DIA 4 FR GUIDEWIRE L 45 CM DIA 0.018 IN,SUP-2117386,CDM,C1894,HCPCS,0272,RC,,,,both,,,84.91,55.19,,,,,,,,,,,,,
COMPONENT FEM CRUC RET RT SZ 1 OXINIUM GEN II SMITH,SUP-2345845,CDM,C1776,CPT,0278,RC,,,,both,,,8209.53,5336.19,,,,,,,,,,,,,
COMPONENT TIB TY 6 LT TOT ANK INBONE,SUP-2850351,CDM,C1776,CPT,0278,RC,,,,both,,,3771.14,2451.24,,,,,,,,,,,,,
CALCIUM CARB-CHOLECALCIFEROL 600-10 MG-MCG PO TABS,RX-159842,CDM,6370000000,HCPCS,0637,RC,20555-0017-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PROCEDURE PACK SHLDR HEARTWARE,SUP-2282560,CDM,Q0498,HCPCS,0274,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 3 CM DIA 4 MM CATH DIA 0.035 IN,SUP-2170418,CDM,C1889,HCPCS,0278,RC,,,,both,,,323.39,210.20,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2931733,CDM,C1713,HCPCS,0278,RC,,,,both,,,136.62,88.80,,,,,,,,,,,,,
HC Cast - Short Arm,PX-4502907500,CDM,29075,CPT,0450,RC,,,,both,,,802.00,521.30,,,,,,,,,,,,,
INTRODUCER MICPUNC SET SILHOUETTE TRNSTLSS S STL WIRE GUID W,SUP-2170551,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.01,48.11,,,,,,,,,,,,,
STAPLE INT WHT BLU G GRN BLK REINF FOR ENDOPATH ECHELON FLX,SUP-2395281,CDM,C1781,HCPCS,0278,RC,,,,both,,,523.34,340.17,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 6 MM EPTFE STD REINF 3 LAYR,SUP-2525477,CDM,C1768,CPT,0278,RC,,,,both,,,2910.75,1891.99,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM CORT MAXILLOMANDIBULAR GRN TI SELF,SUP-2403072,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA24 MM POLYESTER GEL AORT ARCH,SUP-2894579,CDM,C1768,CPT,0278,RC,,,,both,,,4210.74,2736.98,,,,,,,,,,,,,
STEM FEM L230MM DIA26X21MM 40MM LAT OFFSET L36MM +21MM ANG,SUP-2253211,CDM,C1776,CPT,0278,RC,,,,both,,,14079.13,9151.43,,,,,,,,,,,,,
PLATE BNE L54MM THK1.2MM 8 H BILAT HINDFT MIDFT S STL,SUP-2186127,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.25,1381.41,,,,,,,,,,,,,
CATHETER ABLAT 4MM OD7.5FR STD OPN IRRIG INTELLANAV,SUP-2141345,CDM,C1732,HCPCS,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PLATE BNE 5MM LAPIDUS STP,SUP-2243210,CDM,C1713,HCPCS,0278,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
BEAM FIX L145MM DIA6.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223950,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CUP HD LNR ST POROUS XLPE CERM,SUP-2212319,CDM,C1776,CPT,0278,RC,,,,both,,,16068.26,10444.37,,,,,,,,,,,,,
WASHER ORTH FIX SM,SUP-2205628,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
HC So Gastrin,PX-3018294166,CDM,82941,CPT,0301,RC,,,,outpatient,,,341.00,221.65,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 25 CM DIA 4 FR DIL PROTRUDING,SUP-2385178,CDM,C1894,HCPCS,0272,RC,,,,both,,,208.50,135.52,,,,,,,,,,,,,
HC Ins/Repos Leads/Gen Cd Sin/Dual,PX-4803324900,CDM,33249,CPT,0481,RC,,,,both,,,115473.00,75057.45,,,,,,,,,,,,,
PLATE BNE W10XL56MM THK1.2MM 90DEG 4X4 H BILAT S STL T SHP,SUP-2185866,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.34,607.97,,,,,,,,,,,,,
CATHETER VENOGRAPHY COR SNUS BLLN (MIN 5/EA OR 1 BOX)),SUP-2356256,CDM,C1725,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
STENT ES L10CM DIA18MM CATH 18.5FR L120CM MTL PARTIALLY CVR,SUP-2149418,CDM,C1874,HCPCS,0278,RC,,,,both,,,7600.37,4940.24,,,,,,,,,,,,,
PLATE BNE W7XL34MM THK1MM 3 H R S STL L OBLQ NEUT MAL LOK,SUP-2186086,CDM,C1713,HCPCS,0278,RC,,,,both,,,947.18,615.67,,,,,,,,,,,,,
PLATE BNE PNUT 1 HOLE STRATUM RS,SUP-2862033,CDM,C1713,HCPCS,0278,RC,,,,both,,,2425.65,1576.67,,,,,,,,,,,,,
ANCHOR SUT L19.1MM DIA4.75MM PEEK CLOSE EYELET W/ BLU,SUP-2121702,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CATHETER DRAINAGE TY 10 FR 8/10 FRX20 CM LCK BG MAK-NV,SUP-2467954,CDM,C1729,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
IMPLANT BIO TISS W15XL20CM THK1.5MM PORCINE CLLGN FOR HERN,SUP-2174701,CDM,C9364,HCPCS,0278,RC,,,,both,,,20635.20,13412.88,,,,,,,,,,,,,
ELECTRODE ELECSURG LOOP W/ CABLE HF-RESECTION PLASMA BUTTON,SUP-2430209,CDM,C1713,HCPCS,0278,RC,,,,both,,,1600.83,1040.54,,,,,,,,,,,,,
ALLOGRAFT BNE LG 5 CC FD DBM GRFT ORTHOBLEND,SUP-2787767,CDM,C1713,HCPCS,0278,RC,,,,both,,,2996.82,1947.93,,,,,,,,,,,,,
SLIDER TI,SUP-2415541,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.90,615.48,,,,,,,,,,,,,
HEAD FEM DIA42MM CO CHROM POR CEM RESURF BIRMINGHAM,SUP-2350855,CDM,C1776,CPT,0278,RC,,,,both,,,11490.83,7469.04,,,,,,,,,,,,,
COLLAR HUM DIA48MM ECC SUT FOR SHLDR ARTHROPLASTY SYS GLOB,SUP-2249864,CDM,C1776,CPT,0278,RC,,,,both,,,1401.70,911.10,,,,,,,,,,,,,
SURGICAL NAVIGATION PACK SUPL NAVIO,SUP-2342142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BRACE BK ASPN QUICKDRAW PRO BLK M,SUP-2123910,CDM,L0628,HCPCS,0272,RC,,,,both,,,264.67,172.04,,,,,,,,,,,,,
LIDOCAINE HCL 100 MG/5ML IJ SOSY,RX-134289,CDM,J2003,HCPCS,0636,RC,76329-3390-01,NDC,,both,2.5,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT HUM TISS 2X3CM 2 LAYR AMNION PTCH STERISHIELD II,SUP-2390577,CDM,C1713,HCPCS,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
CATHETER HD STR 14 FRX32 CM LT SET W/ 2 STYL SPLIT CATH III,SUP-2627122,CDM,C1750,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 11 CM DIA 45 CM 0.021 IN 5 FR,SUP-2740586,CDM,C1892,HCPCS,0272,RC,,,,both,,,174.74,113.58,,,,,,,,,,,,,
TROCAR ENDOSCP BLDELSS UNIV 5X100 MM STBL SL ENDOPATH BASX,SUP-2857939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.23,231.55,,,,,,,,,,,,,
PLATE BNE 6 H NONSTERILE MANUBRIUM STRNL TI STAR SHP LOK,SUP-2192437,CDM,C1713,HCPCS,0278,RC,,,,both,,,2846.41,1850.17,,,,,,,,,,,,,
INTERFACE LOWER EXTREMITY SFT BK PLAS,SUP-2388186,CDM,L2820,HCPCS,0274,RC,,,,both,,,214.27,139.28,,,,,,,,,,,,,
KIT INTCRAN PRSS MON SUBDURAL CATH CAMINO,SUP-2308097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3937.56,2559.41,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN IRRADIATED BONE-PATELLAR TENDON-BONE,SUP-2867182,CDM,C1762,CPT,0278,RC,,,,both,,,10500.16,6825.10,,,,,,,,,,,,,
DEVICE PESSARY RNG 3 64 MM W/ SUPP,SUP-2273825,CDM,A4562,HCPCS,0272,RC,,,,both,,,108.39,70.45,,,,,,,,,,,,,
OCCLUDER CV HELEX L 75 CM DIA 30 MM NIT EPTFE HYDRPHLC DBL,SUP-2395830,CDM,C1817,HCPCS,0278,RC,,,,both,,,20218.46,13142.00,,,,,,,,,,,,,
PROSTHESIS VOICE SZ 3MM 7MM NSL SEPT PERF RND,SUP-2242444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT BONE PASTE DEMIN BONE MTRX 8CC TREL-XC,SUP-2244468,CDM,C1713,HCPCS,0278,RC,,,,both,,,4518.46,2937.00,,,,,,,,,,,,,
HC Pt Vasopneumatic Device Therapy|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701600,CDM,97016,CPT,0420,RC,,,GP|CQ,outpatient,,,206.00,133.90,,,,,,,,,,,,,
SCREW BNE L30MM OD65MM THRD L16MM CANC NONCANNULATED STD,SUP-2373830,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.29,81.44,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - 15 Visits,PX-9900000040,CDM,9900000040,LOCAL,0990,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
RING EXT FIX L160MM 2 H FT FOR SIDEKCK FREE CIR FIX,SUP-2400652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4845.02,3149.26,,,,,,,,,,,,,
GRAFT BNE 5 CC VOID FILL CERAMENT,SUP-2138669,CDM,C1713,HCPCS,0278,RC,,,,both,,,3264.03,2121.62,,,,,,,,,,,,,
ALLOGRAFT HUM TISS HEMI BTB FRZN PRESHAPED NO-RAD,SUP-2321837,CDM,C1762,CPT,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
REAMER SURG W12MM METATRSL IMPL ENCOMPASS,SUP-2319782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
ALLOGRAFT BNE DBM 10 CC VESUVIUS 4104K1010DC,SUP-2717988,CDM,C1713,HCPCS,0278,RC,,,,both,,,1823.56,1185.31,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO BK W/ SHLDR SHUT,SUP-2265010,CDM,L0454,HCPCS,0272,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
HC Cytp Fine Ndl Aspirate Immt Cytohist Std Dx 1st,PX-3118817200,CDM,88172,CPT,0311,RC,,,,both,,,257.00,167.05,,,,,,,,,,,,,
PIN AX DSTL LIMB SALV LO BODY ELEOS 1 SZ,SUP-2314043,CDM,C1776,CPT,0278,RC,,,,both,,,9115.42,5925.02,,,,,,,,,,,,,
CATHETER ETER EP 7FR L99CM 63MM ELECTRD SPC 10 POLE SYMMETRIC DST,SUP-2357568,CDM,C1731,HCPCS,0278,RC,,,,both,,,5504.42,3577.87,,,,,,,,,,,,,
SHUNT SURG L 28 MM RESERVOIR 20 MM CATH L DSTL 600 MM,SUP-2931097,CDM,C1729,HCPCS,0272,RC,,,,both,,,8431.28,5480.33,,,,,,,,,,,,,
PLATE BONE 7 H L115MM RT LAT FIBULAR ANK NONCOMPRESSION,SUP-2107093,CDM,C1713,HCPCS,0278,RC,,,,both,,,5482.44,3563.59,,,,,,,,,,,,,
PROSTHESIS PENILE RESVR 100ML FLAT INFL W/ MS PMP PRECONN,SUP-2138911,CDM,C1813,HCPCS,0278,RC,,,,both,,,9961.34,6474.87,,,,,,,,,,,,,
RESERVOIR PENILE PROSTHESIS BIOFLEX 75CC,SUP-2300750,CDM,C1813,HCPCS,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,0636,RC,72485-0417-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CATHETER GUID L100CM OD6FR MULTPURP TIP W/O HYDRPHLC COAT AD,SUP-2103429,CDM,C1887,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
ROD SPNL REDUCTION STATIONARY TEMP CD HORZ,SUP-2630474,CDM,C1713,HCPCS,0278,RC,,,,both,,,1541.27,1001.83,,,,,,,,,,,,,
KIT INTRO ACCS 4FR L10CM GWIRE 0018IN NDL 21GA L7CM STD,SUP-2302999,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
NEEDLE BRST LOC L10CM OD20GA HAWK II 252100,SUP-2269618,CDM,C1819,HCPCS,0278,RC,,,,both,,,141.36,91.88,,,,,,,,,,,,,
PLATE BNE BSSO 2X35 MM SLIDING COLOGNE FOR SCR TI NS LEVEL 1,SUP-2475338,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.52,1066.34,,,,,,,,,,,,,
PROSTHESIS OSS CAUSSE BCKT HNDL 0.4X5 MM 1.32 MM FLROPLAS,SUP-2638169,CDM,L8613,CPT,0278,RC,,,,both,,,450.72,292.97,,,,,,,,,,,,,
NIFEDIPINE 10 MG PO CAPS,RX-5558,CDM,6370000000,HCPCS,0637,RC,00904-7229-61,NDC,,both,1,UN,4.90,3.18,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10CM 5MM 120CM 7FR HEPARIN,SUP-2719621,CDM,C1768,HCPCS,0278,RC,,,,both,,,10368.28,6739.38,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA10 MM EPTFE STR TW N RING HEMO,SUP-2761372,CDM,C1768,CPT,0278,RC,,,,both,,,3015.28,1959.93,,,,,,,,,,,,,
IMPLANT OSS L4.5MM PIST DIA0.6MM STAP PLAT S STL RBBN LOOP,SUP-2312547,CDM,L8613,CPT,0278,RC,,,,both,,,429.30,279.04,,,,,,,,,,,,,
CATHETER EP MAP DIAG 6FR 110CM LEN XL CRV DECAPOLAR 5MM SPC,SUP-2357625,CDM,C1730,HCPCS,0272,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
HC Blood Count Hemoglobin,PX-3058501800,CDM,85018,CPT,0305,RC,,,,both,,,59.00,38.35,,,,,,,,,,,,,
IMPLANT CAPSULAR TENS RNG COMPR 12-10 MM PMMA PRELD INJ FLX,SUP-2884216,CDM,L8699,HCPCS,0278,RC,,,,both,,,581.69,378.10,,,,,,,,,,,,,
PRESS SURG L75IN 23X31MM PLT FASC SHEEHY,SUP-2382504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,399.09,259.41,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 30CML INSER 40,SUP-2613242,CDM,C1752,HCPCS,0278,RC,,,,both,,,838.47,545.01,,,,,,,,,,,,,
K WIRE FIX DIA1.4MM SMOOTH THRD OLV TIP,SUP-2321638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
SHEATH INTRF L L30MM POLYPR FOR INTRAFIX ADV TIB FAST SYS,SUP-2256836,CDM,C1776,CPT,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
SHEETING SIL TRNSLUC REINF FOR APPL ON BODY,SUP-2134688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
CATHETER THOR 32FR L20IN CLR PVC THERMOSENSITIVE STR RADPQ,SUP-2154969,CDM,C1729,HCPCS,0272,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
"HC So1 Immunoassay,Analyte,Nos",PX-3018352067,CDM,83520,CPT,0301,RC,,,,both,,,366.00,237.90,,,,,,,,,,,,,
COVER BUR H DIA12MM THK0.3MM TI ULT LO PROF NONCOMPRESSION,SUP-2255848,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.99,559.64,,,,,,,,,,,,,
POST EXT FIX 90 DEG UNILAT NS MAV,SUP-2931139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
BLADE REPROC SAW SAGITTAL SYS 4 AND 2000 29X1.32X84MM,SUP-2525943,CDM,C1776,CPT,0278,RC,,,,both,,,50.93,33.10,,,,,,,,,,,,,
SCREW BNE L24MM DIA2.5MM CO CHROM LOK SQ DRV MULTDIR PEGGED,SUP-2411666,CDM,C1713,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
SADDLE SPNL OPEN/OPEN 4.75 POLARIS 5.5/5.5,SUP-2136369,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
UPCHARGE PERFORM REVSE AUG BP,SUP-2388599,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
KIT PACE ROT LD HELIX STRL,SUP-2282052,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.18,28.07,,,,,,,,,,,,,
BIT DRL LNG 2X5.5 MM PROF FOR 4.5MM SCREW NS ACUTRK 2,SUP-2518457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SCREW 6.0MM TI ANGLR STABLE LCKNG T25 44MM F IM NAILS STR,SUP-2546362,CDM,C1713,HCPCS,0278,RC,,,,both,,,622.91,404.89,,,,,,,,,,,,,
KNIFE SURGICAL APFELBAUM DURA LG 8 34INL LATEX FREE,SUP-2671894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.90,343.13,,,,,,,,,,,,,
HEAD FEM 12/14 TAPR ZIRCONIA 36MM + 0 NOVATION ELEMENT,SUP-2222117,CDM,C1776,CPT,0278,RC,,,,both,,,5086.80,3306.42,,,,,,,,,,,,,
BLADE RETRACTOR 2 12INW LATERAL WIRE ULTRA,SUP-2670316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,254.18,165.22,,,,,,,,,,,,,
BIOCOMP SWVLK BICEPS TENO 9X23 KIT,SUP-2811898,CDM,C1713,HCPCS,0278,RC,,,,both,,,2257.66,1467.48,,,,,,,,,,,,,
STRAP ORTHOT HIP KNEE ANK CUST TORSON UNILAT ROT,SUP-2435643,CDM,L2070,HCPCS,0274,RC,,,,both,,,439.41,285.62,,,,,,,,,,,,,
SPACER SPNL M H13MM 8DEG ANTR LUM INTBDY FUS MONUMENT,SUP-2231099,CDM,C1821,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
CATHETER VALVULOPLASTY ZMED II L 100 CM DIA 8 FR 4 CM 20 MM,SUP-2125251,CDM,C1725,HCPCS,0272,RC,,,,both,,,2344.42,1523.87,,,,,,,,,,,,,
LENS INTOCU 6.0 TO 30.0 DIOPT 118.7 A CONSTANT 0DEG ANG,SUP-2111276,CDM,V2632,HCPCS,0276,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
GRAFT VASC BIFUR 20 MMX40 CM 1 LAYR POLYESTER WOVEN HEMSHLD,SUP-2473904,CDM,C1768,CPT,0278,RC,,,,both,,,1778.81,1156.23,,,,,,,,,,,,,
MATRIX 1.1MM BIT DRILL/HXC,SUP-2823018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.23,541.60,,,,,,,,,,,,,
CUTTER ENDOPATH ETS45 COMP FLX 45MM ENDOSCP LIN CTS45NK,SUP-2218888,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
GUIDEWIRE ANGIO COR CANALIZ 0.035X150CM,SUP-2120024,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.70,94.70,,,,,,,,,,,,,
KIT CRAN ACCS NDL FRCP XYLOCAINE BIT DRL,SUP-2243818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
INTRODUCER SHTH RAD MINI ACCS GRN HUB 6FRX11CM PRELUDE,SUP-2303278,CDM,C1894,HCPCS,0272,RC,,,,both,,,100.92,65.60,,,,,,,,,,,,,
LINER ACET HOOD 36X52-54 MM HIP XLPE LOGICAL,SUP-2322495,CDM,C1776,CPT,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
LEAD DEFIB 5.6FR 65CM VENT ACT FIX BPLR PERM STEROID ELUT,SUP-2356666,CDM,C1777,HCPCS,0275,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
LINER ACET 36X62 MM HIP CERM BIOLOX FORTE R3,SUP-2434793,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
END CAP NEWTON HUMERAL NAIL 2MM,SUP-2828881,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
HC Renal Art 2nd Order Bil,PX-4813625400,CDM,36254,CPT,0481,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
BIT DRL DIA2.9 MM PROX CORTICAL MANUAL NS DISP HPS,SUP-2913321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
COUPLING ABUTMENT SNAP 5.5MM BAHA,SUP-2164928,CDM,L8614,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
STAPLE BNE FIX 10X10X10MM FOR HND AND FT BNE FRAG SURG,SUP-2175096,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SCREW SPNL LOK FOR 6.25MM ROD SPHERX PPS,SUP-2311510,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
ALLOGRAFT DERMAL 2X4 CMX0.76-1.25 MM DECELL DERM ORACELL,SUP-2741068,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
DEVICE FIX QUAD ADJ STRL ULTRABUTTON LTX,SUP-2880213,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
SHEATH GUID 115X85FR L71MM L CRV L50MM BIDIR STEER CARTO,SUP-2248639,CDM,C1766,CPT,0272,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + SM MEDPOR PTERIONAL +,SUP-2862744,CDM,C1713,HCPCS,0278,RC,,,,both,,,41443.73,26938.42,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 0.5 CC INJ AMNIO FLUID STRATOGEN FLO,SUP-2777565,CDM,C1762,CPT,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
SCREW BONE L36MM DIA5MM ST LCK W/ T25 STARDRV,SUP-2190248,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.32,345.36,,,,,,,,,,,,,
PROSTHESIS NSL 7X2MM SEPT PERF RND 2 PC MAGNETICALLY COUPLED,SUP-2242443,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
KIT PICC MAX BARRIER PRLOADED 4FR X 55CM 1L,SUP-2864579,CDM,C1751,HCPCS,0278,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
PLATE BONE 25MM 6 H N COMPR BUR H CVR BILAT RIG TI FOR 1.5MM,SUP-2402907,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
EXPANDER BRST 550CC W7.1XL13.7CM P7.7CM SIL NACL SMOOTH,SUP-2300338,CDM,C1789,HCPCS,0278,RC,,,,both,,,3344.10,2173.66,,,,,,,,,,,,,
GRAFT SYN TISS W10XL15CM THK2MM EPTFE SFT PTCH RECTANG FOR,SUP-2395290,CDM,C1781,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
PROSTHESIS LARYN L8MM DIA20FR PRELD W/ SMRT INSRTR TRNSPAR,SUP-2124374,CDM,L8509,HCPCS,0274,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM PANEL 2.2 MM 1 X 21 H MAXILLOFCL PART,SUP-2909611,CDM,C1713,HCPCS,0278,RC,,,,both,,,9910.37,6441.74,,,,,,,,,,,,,
SURGICAL KIT MAND MIDFACE ZYG TRUMATCH,SUP-2860365,CDM,C1713,HCPCS,0278,RC,,,,both,,,28969.64,18830.27,,,,,,,,,,,,,
PLATE BNE LCK 2.7 MM 8 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2499602,CDM,C1713,HCPCS,0278,RC,,,,both,,,890.06,578.54,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19MMW X90MML 1.47MM THK LG BNE COARSE MID,SUP-2605800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,207.96,135.17,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 60 CC FD IRRADIATED CANC 921852,SUP-2867191,CDM,C1762,CPT,0278,RC,,,,both,,,1852.44,1204.09,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR (MIXTURES ONLY),RX-430069,CDM,J2919,HCPCS,0636,RC,00009-0758-01,NDC,,both,1,UN,139.70,90.80,,,,,,,,,,,,,
KIT KYPHOPLASTY NDL 11GA BAL L10MM VERT PROC AVAMAX,SUP-2361539,CDM,C1726,HCPCS,0272,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
STEM FEM 3 240 MM LT MOLD PROSTALAC,SUP-2454731,CDM,C1776,CPT,0278,RC,,,,both,,,33180.38,21567.25,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 3 MM EPTFE STR TW N RING HEMO,SUP-2761274,CDM,C1768,CPT,0278,RC,,,,both,,,1801.26,1170.82,,,,,,,,,,,,,
BOLT ORTHOPEDIC FUSION 6.5X145 MM MIDFOOT SS NS,SUP-2184104,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.42,988.92,,,,,,,,,,,,,
SHEATH INTRO 22FR L28CM ID 7.5MM GORE DRYSEAL,SUP-2396259,CDM,C1894,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
CONNECTOR SPNL L30.5-43MM OD4.5MM LO PROF CROSS,SUP-2228097,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
LIDOCAINE HCL 1% INJ (MIXTURES ONLY),RX-430017,CDM,J2003,HCPCS,0636,RC,63323-0492-27,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE FEM 120 DEG 240 MM ARCHED MR SAFE NS,SUP-2863419,CDM,C1713,HCPCS,0278,RC,,,,both,,,3174.51,2063.43,,,,,,,,,,,,,
PACK ROOT REP MENIS W/ ULTRABRAID DISP,SUP-2416995,CDM,C1713,HCPCS,0278,RC,,,,both,,,2499.44,1624.64,,,,,,,,,,,,,
CATHETER HD 55 CM 50 CM CHRONIC DLYS COMPLETE KT SH,SUP-2484233,CDM,C1750,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM POLYETH,SUP-2212716,CDM,C1776,CPT,0278,RC,,,,both,,,11049.69,7182.30,,,,,,,,,,,,,
PLATE BNE L385MM 16 H ST PROX FEM S STL HK LO PROF LOK COMPR,SUP-2186067,CDM,C1713,HCPCS,0278,RC,,,,both,,,5742.31,3732.50,,,,,,,,,,,,,
CATHETER GUID SUPER BKUP SUPP 3.75 8 FRX100 CM CONCIERGE,SUP-2798622,CDM,C1887,HCPCS,0272,RC,,,,both,,,122.90,79.88,,,,,,,,,,,,,
CATHETER INFUSION CLEARWAY BALLOON L 50 MM DIA2 MM PERIPH,SUP-2227354,CDM,C1725,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SLEEVE SURG DRL MICA MINIBUNION,SUP-2435410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
ALLOGRAFT BNE SHFT 11 CM FD FEM,SUP-2321793,CDM,C1713,HCPCS,0278,RC,,,,both,,,2625.04,1706.28,,,,,,,,,,,,,
PLATE BNE L109MM 3 H R PROX PERIARTC HUM S STL LOK COMPR,SUP-2184285,CDM,C1713,HCPCS,0278,RC,,,,both,,,4734.43,3077.38,,,,,,,,,,,,,
BRIVARACETAM 100 MG PO TABS,RX-133985,CDM,6370000000,HCPCS,0637,RC,50474-0770-09,NDC,,both,1,UN,110.50,71.82,,,,,,,,,,,,,
SCREW BONE CNNLTD CMPRSSN 5.5MM DIA 35MML TTNM ALLOY FLLY TH,SUP-2586464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1485.03,965.27,,,,,,,,,,,,,
STEM FEM L127MM DIA11MM PROX HIP STR CEM W/O POR BODY GMRS,SUP-2376427,CDM,C1776,CPT,0278,RC,,,,both,,,6699.03,4354.37,,,,,,,,,,,,,
SCREW 1.7X4MM,SUP-2363744,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.32,106.81,,,,,,,,,,,,,
WIRE K THRD GRV 23 X 230MM,SUP-2321631,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
FORCEP ENDOSCP BX 5 FRX105 CM 1.5 MM STR FRMBL SS JAWZ LTX,SUP-2876093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
HC External Ecg Rec>48hr<7d Recording,PX-7309324200,CDM,93242,CPT,0731,RC,,,,both,,,113.00,73.45,,,,,,,,,,,,,
MATRIX BIO SZ 114 SQCM FISH SKIN DERMAL MIC STRL GRAFTGUIDE 10/BX,SUP-2909431,CDM,Q4158,HCPCS,0636,RC,,,,both,,,13115.78,8525.26,,,,,,,,,,,,,
PROBE SUCT L5.5MM OD3.75MM 90DEG ARTHSCP ABLAT BPLR GRATED,SUP-2341116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
DEVICE PESSARY RNG 5 3 IN W/ KNOB FOLDING,SUP-2421606,CDM,A4562,HCPCS,0272,RC,,,,both,,,109.15,70.95,,,,,,,,,,,,,
PLATE CRANIOFACIAL CVD UP TI 2.3MM 4 H 35MML,SUP-2263006,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
SCREW BONE LOK 2.7MM DIA UNVRSL 14MML STNLSS STEEL CRTCL SEL,SUP-2588494,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.62,49.80,,,,,,,,,,,,,
SYSTEM WST MGMT AVETA,SUP-2739119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
STAPLE INTERNAL FIXATION W20XH26XL20MM DYNACLIP FORTE,SUP-2878758,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
VLP TI 3.5MMX28MM CTX SCREW T15 S-T,SUP-2820342,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.03,195.02,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.4MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189493,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
PLATE BONE 12 H ANTR BOW LAT PROX FOR 3.5 SCR,SUP-2349061,CDM,C1713,HCPCS,0278,RC,,,,both,,,977.01,635.06,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 102 X 10 X 4.7 X 0.6 MM POLYETHYL,SUP-2935666,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 22 HOLE-STERILE,SUP-2546106,CDM,C1713,HCPCS,0278,RC,,,,both,,,3368.40,2189.46,,,,,,,,,,,,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,6370000000,HCPCS,0637,RC,00904-7142-12,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
PLATE BNE L 32 X W 8 MM THK 3.2 MM SCREW DIA2.7 MM 4 H SS 72440104N,SUP-2933303,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.53,1228.84,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 0.035 INX260 CM STIFF SHFT ZIPWIRE,SUP-2148203,CDM,C1769,HCPCS,0272,RC,,,,both,,,134.08,87.15,,,,,,,,,,,,,
PLATE BONE SM W10XL73MM THK1.5MM 3X5 H S STL DSTL OBLQ T SHP,SUP-2343785,CDM,C1713,HCPCS,0278,RC,,,,both,,,2046.78,1330.41,,,,,,,,,,,,,
DRILL SURG CANN 2.8X20 MM 6 MM COUNTSINK TENOTAC,SUP-2749820,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
BUR SURG L8CM DIA1.1MM HD L6.4MM TAPR SIDE CUT L BALL FLUT,SUP-2284628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,250.32,162.71,,,,,,,,,,,,,
LENGTHENER EXT FIX CLMP T SHP FOR DIA2 3MM PIN MINIRAIL,SUP-2316438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.10,405.01,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSTAR CHRONIC STD 14.5FR DIA LG LUMA,SUP-2613297,CDM,C1750,HCPCS,0278,RC,,,,both,,,1470.46,955.80,,,,,,,,,,,,,
LO-PRO SCRW SYS CS 2.0/2.3/3.0MM,SUP-2814763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BNE COMPR SM 3.5X97 MM 8 HOLE DYN NS DCP LTX,SUP-2861908,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.51,264.88,,,,,,,,,,,,,
STEM FEM L N CLLRD POR HA NAT HIP SZ 0,SUP-2210783,CDM,C1776,CPT,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + S,SUP-2195531,CDM,L1830,CPT,0272,RC,,,,both,,,46.66,30.33,,,,,,,,,,,,,
PATCH PERICARD SJM W/ ENCAP AC TECHNOLOGY 2X5CM,SUP-2355778,CDM,C1768,CPT,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 9 HOLES 170MM,SUP-2549509,CDM,C1713,HCPCS,0278,RC,,,,both,,,1796.68,1167.84,,,,,,,,,,,,,
BASKET UROLOGY STONE SEGR MULT WIRE 70CML DISP GUIDWIRE,SUP-2141084,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.7 MM PLA GLYCOLIDE CRANIOMAXILLOFACIAL 10PK,SUP-2884149,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.05,1622.43,,,,,,,,,,,,,
HC Transcatheter Renal Sympath Denervation Bilat,PX-3610339000,CDM,0339T,CPT,0361,RC,,,,outpatient,,,14967.00,9728.55,,,,,,,,,,,,,
GRAFT VASC FLIXENE 60 DEG L 90 CM DIA 8 MM BRANCH L 50 CM,SUP-2681858,CDM,C1768,CPT,0278,RC,,,,both,,,6637.93,4314.65,,,,,,,,,,,,,
GRAFT BONE SUB 5ML PUTTY BIOLOGIC SPINE SURG BIOACTIVE KINEX,SUP-2232312,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
PROSTHESIS VOICE 16 FRX4 MM INDWL SFT VLV NS BLOM-SINGER,SUP-2242283,CDM,L8509,HCPCS,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
PROBE SURG OSTIUM 1.25 MM BALL TIP 1 END 90 DEG 8.25 IN SS,SUP-2483575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.57,286.37,,,,,,,,,,,,,
INSERT TIB SZ 3 THK10MM RT ARTC CRUC RET CNFRM NEUT PRI,SUP-2347009,CDM,C1776,CPT,0278,RC,,,,both,,,3132.94,2036.41,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA12 MM EPTFE STR STD WALL,SUP-2396208,CDM,C1768,CPT,0278,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
AUGMENT FEM SZ 5 THK10MM L DST KNEE CO CHROM TOT STBL FULL,SUP-2373503,CDM,C1776,CPT,0278,RC,,,,both,,,2696.63,1752.81,,,,,,,,,,,,,
PLATE BNE L 62 MM SCREW DIA2.7 MM 8 SHFT H TI STR COMPACT,SUP-2907766,CDM,C1713,HCPCS,0278,RC,,,,both,,,5266.97,3423.53,,,,,,,,,,,,,
POST EXTERNAL FIXATION SM STAINLESS STEEL SLOTTED,SUP-2586504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.63,357.91,,,,,,,,,,,,,
BLADE RTRCTR SHRT TEETH 15MMW X 75MML SPNL BLACK FLEXI SPINE,SUP-2669119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.94,586.91,,,,,,,,,,,,,
ENDCAP IM NAIL 0MM OFFSET TIB FOR PHOENIX SYS,SUP-2412149,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
KIT SUT ANCHR DISPOSABLES FOR SH 2.9MM PUSHLOCKXL,SUP-2121758,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
GRAFT BONE SUB 10ML DEMIN BONE MTRX ACCELL CONNEXUS,SUP-2242682,CDM,C1713,HCPCS,0278,RC,,,,both,,,4177.96,2715.67,,,,,,,,,,,,,
TIBIAL NAIL D10XL345,SUP-2701446,CDM,C1713,HCPCS,0278,RC,,,,both,,,8206.70,5334.35,,,,,,,,,,,,,
HC So Hcv Ultraquant,PX-3068752266,CDM,87522,CPT,0306,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
NAIL IM L200MM DIA2.75MM ANK FT LSR MRK MEAS W/ GUIDEPIN,SUP-2321050,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 15 DEG 1.2X150 MM TI,SUP-2751496,CDM,C1769,HCPCS,0272,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 39FR DIA 20MML CUT WIRE BLRY W/0025,SUP-2707100,CDM,C1769,HCPCS,0272,RC,,,,both,,,902.34,586.52,,,,,,,,,,,,,
SCREW BNE NLCK 3.5X44 MM STRL MOTOBAND CP,SUP-2427190,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE TIB CUST FRAC SEMI RIGID,SUP-2435649,CDM,L4396,HCPCS,0274,RC,,,,both,,,1789.02,1162.86,,,,,,,,,,,,,
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-102329,CDM,J3480,HCPCS,0636,RC,00264-7865-00,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
DRESSING WND MULTLYR CLLGN MTRX 5X5 CM SHT MATRISTEM,SUP-2106525,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 25 X 50 X 6 MM POLYETHYL BLOCK STRL DISP,SUP-2935699,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.14,1430.74,,,,,,,,,,,,,
SEALER BPLR 5MM H1.59XL12.75IN SHTH W/ 2 ELECTRD TIP,SUP-2281806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1910.38,1241.75,,,,,,,,,,,,,
WASHER ORTH TI DOME FOR 7MM SCR MONSTER,SUP-2320329,CDM,C1713,HCPCS,0278,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
HC So Esterase Inhibitor,PX-3028616166,CDM,86161,CPT,0302,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
HC So Liver Ds Alys 3 Bmrk Srm Alg,PX-3108151766,CDM,81517,CPT,0310,RC,,,,inpatient,,,465.00,302.25,,,,,,,,,,,,,
PLATE BNE CRANIOMAXILLOFACIAL THK08MM 12 H ORBIT MIDFACE TI,SUP-2262686,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.30,554.64,,,,,,,,,,,,,
BRACE WR LEN 9 1/8IN CIRC OVR 8 3/4INXL BGE D RNG LNG LEN LT,SUP-2324967,CDM,L3931,HCPCS,0274,RC,,,,both,,,44.49,28.92,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3.5 CM 0.038 INX145 CM ST INQUIRE AMPLATZ,SUP-2464716,CDM,C1769,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
KIT INSRT 40ML INT AORT CATH OD9.5FR 650MM 90 SER EXT,SUP-2227307,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
PLATE BNE RECT 1.5 MM MIDFACE 2X4 HOLE TI SLV,SUP-2754966,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
KIT SUTURE ANCHR DIA2.8 MM ALL PRELD 1.5 MM PASS TAPE ON,SUP-2899250,CDM,C1713,HCPCS,0278,RC,,,,both,,,1459.32,948.56,,,,,,,,,,,,,
SCREW BNE L60MM DIA3MM THRD L20MM CORT SELF DRL,SUP-2316449,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
REAMER SURG OD6MM ANT CERV SPNL,SUP-2286460,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.02,738.41,,,,,,,,,,,,,
PIN FIX OLV 1.6 MM,SUP-2223127,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HEAD FEM DIA28MM +0MM M NK CO CHROM HIP SLOT TAPR N,SUP-2304436,CDM,C1776,CPT,0278,RC,,,,both,,,3775.85,2454.30,,,,,,,,,,,,,
FIXATOR EXT HING RINGFIX SYS F,SUP-2474967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
KIT SUT DEV L31CM DIA5MM PUR TARGET WIRE W/ SNR CRV HNDL,SUP-2265300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SET BILI DRNGE 12FR L30CM GWIRE 0.038IN 5 H PGTL POLYETH,SUP-2141064,CDM,C1729,HCPCS,0272,RC,,,,both,,,550.91,358.09,,,,,,,,,,,,,
HC Aspiration of Corpora Cavernos,PX-4505422000,CDM,54220,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
DENOSUMAB 120 MG/1.7ML SC SOLN|DISCARDED DRUG NOT ADMINISTE,RX-107208,CDM,J0897,HCPCS,0636,RC,55513-0730-01,NDC,JW,both,1.7,ML,10176.80,6614.92,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 30 MM DIA 7 MM CATH TOT L 116 CM,SUP-2141191,CDM,C1874,HCPCS,0278,RC,,,,both,,,7083.84,4604.50,,,,,,,,,,,,,
PLATE BNE W12XL232MM THK3.7MM LNG 10 H NONSTERILE PROX HUM,SUP-2186021,CDM,C1713,HCPCS,0278,RC,,,,both,,,4906.09,3188.96,,,,,,,,,,,,,
PLATE BNE 100DEG 3X4 H L TI OBLQ L SHP FOR 2MM SCR,SUP-2191282,CDM,C1713,HCPCS,0278,RC,,,,both,,,1057.24,687.21,,,,,,,,,,,,,
PLUG IM SZ 3 13.5MM BONE AP STUHMER WEBER,SUP-2205843,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.32,264.11,,,,,,,,,,,,,
PLATE HLDR,SUP-2207866,CDM,C1713,HCPCS,0278,RC,,,,both,,,1769.08,1149.90,,,,,,,,,,,,,
KIT DRL BIT OD2.10MM FOR MDLLRY CNL HAMMERLOCK 2,SUP-2194166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.69,493.80,,,,,,,,,,,,,
BIT DRL DIA 4 MM LAG DBL BANDED MAG NS DISP LEOS,SUP-2933395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.54,268.80,,,,,,,,,,,,,
BRACE WLK SM SHOE MAN 4 7 WOMAN 5 8 SHT PNEUMAT SEMI RIG,SUP-2196357,CDM,L4361,HCPCS,0272,RC,,,,both,,,113.35,73.68,,,,,,,,,,,,,
LINER ACET 23 10 DEG 32 MM FEM HIP ARCOMXL RINGLOK,SUP-2136078,CDM,C1776,CPT,0278,RC,,,,both,,,4483.92,2914.55,,,,,,,,,,,,,
MESH CRAN KASSAM REG 0.3 MM SCRN PANEL NEURO SCREW CP TI,SUP-2472595,CDM,C1713,HCPCS,0278,RC,,,,both,,,812.41,528.07,,,,,,,,,,,,,
STENT COR RX 0.014 IN 3.5X16 MM 144 CM TAXUS LIBERTE,SUP-2140599,CDM,C1874,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
HC MRI-Spine Thoracic WO&W Cont,PX-6127215700,CDM,72157,CPT,0612,RC,,,,both,,,3486.00,2265.90,,,,,,,,,,,,,
BIT DRL DIA 4.8/1.8 MM SHRT CANN FOR HALF PIN NS DISP,SUP-2933734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1653.78,1074.96,,,,,,,,,,,,,
MESH CRAN W41XL42MM D0.5MM THK1MM R ORBIT FLR WALL TIIUM,SUP-2366483,CDM,C1713,HCPCS,0278,RC,,,,both,,,4799.05,3119.38,,,,,,,,,,,,,
PLATE BNE LINDORF LEFORT 1 1.5X1 MM LT ORTHOGNATHIC TI,SUP-2461910,CDM,C1713,HCPCS,0278,RC,,,,both,,,1143.49,743.27,,,,,,,,,,,,,
CATHETER PTCA L142CM BLLN L10MM DIA3MM COR MRAIL CUT,SUP-2146975,CDM,C1725,HCPCS,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HOLDER SURG SZ 8 HUM STEM FOR PRSS EPOCA,SUP-2194185,CDM,C1776,CPT,0278,RC,,,,both,,,982.88,638.87,,,,,,,,,,,,,
FRAME EXT FIX UNIV SPD JT,SUP-2197310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
KIT INFUS MULTIRATE 2 4 6,SUP-2210564,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE CRAN 140X20X40 MM PT SPEC IMPL PEEK,SUP-2860118,CDM,C1713,HCPCS,0278,RC,,,,both,,,23843.90,15498.53,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|ADJ,PX-4409753000,CDM,97530,CPT,0440,RC,,,GO|CO|ADJ,both,,,191.00,124.15,,,,,,,,,,,,,
SYSTEM AUTOGRFT TRNSF 10MM SM JT OSTEOCHNDRL DISP,SUP-2123218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
PLATE BNE W11XL164MM THK33MM 12 H BILAT MTPHSEAL TI LOK,SUP-2190766,CDM,C1713,HCPCS,0278,RC,,,,both,,,3689.56,2398.21,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT BSC 5FR 0.026N 55CM 2 LUMAN 9927505,SUP-2632712,CDM,C1751,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12.5X15X11 MM FD PARL ADV ACF,SUP-2736838,CDM,C1713,HCPCS,0278,RC,,,,both,,,4414.31,2869.30,,,,,,,,,,,,,
PLATE BNE H0.8MM 8 H CRANIOMAXILLOFACIAL GRY TI CRV LOK,SUP-2366260,CDM,C1713,HCPCS,0278,RC,,,,both,,,576.82,374.93,,,,,,,,,,,,,
SHELL ACET SZ A DIA42MM 3 CLUS H TRITANIUM PRESSFIT PRI,SUP-2377890,CDM,C1776,CPT,0278,RC,,,,both,,,7156.69,4651.85,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ ACTIVE CTRL DBL UPR FABRICATED,SUP-2435759,CDM,L3740,HCPCS,0272,RC,,,,both,,,2768.51,1799.53,,,,,,,,,,,,,
CANNULA IRRIGATION SIMCOE RVS DOUBLE-BARRELED UNIT ULTRA LF,SUP-2467846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.03,233.37,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 5 MM SCR IN TI WHT BLU BLK V-LOX,SUP-2762304,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
EXTENSION STEM L45MM GTT DN FOR TIB PLT NXGN MIS,SUP-2200893,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM DIA10 FR GUIDEWIRE 0.038 IN,SUP-2140488,CDM,C1876,HCPCS,0278,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
PLATE BNE 3.5X27 MM 2 HOLE SS LCP,SUP-2569315,CDM,C1713,HCPCS,0278,RC,,,,both,,,309.13,200.93,,,,,,,,,,,,,
HC So Thyroglobulin,PX-3018443266,CDM,84432,CPT,0301,RC,,,,inpatient,,,63.00,40.95,,,,,,,,,,,,,
SPACER KNEE 10MM L-2XL DSTL POST DURAC,SUP-2364868,CDM,C1776,CPT,0278,RC,,,,both,,,947.02,615.56,,,,,,,,,,,,,
RESIN ORTHODONTIC 12 OZ LIQ PNK,SUP-2176745,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.57,81.62,,,,,,,,,,,,,
WIRE FIX 1.6 MM KIRSCHNER,SUP-2400530,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
BURR CUTTING ACORN FLUTED 6MM SHD6ACG1,SUP-2843320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,441.74,287.13,,,,,,,,,,,,,
TAPESTRY RC BIOINTEGRATIVE 30X20 MM LAT LF,SUP-2867246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED 3 PART ADD ON,SUP-2212530,CDM,C1776,CPT,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
MINOCYCLINE HCL 100 MG IV SOLR,RX-10612,CDM,J2265,HCPCS,0636,RC,70842-0160-10,NDC,,both,1,UN,1486.40,966.16,,,,,,,,,,,,,
RING EXT FIX ID140MM COMP C HALF FOR ILIZ,SUP-2342280,CDM,C1713,HCPCS,0278,RC,,,,both,,,6776.91,4404.99,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2479774,CDM,C1768,CPT,0278,RC,,,,both,,,460.14,299.09,,,,,,,,,,,,,
HC So Toxoplasma Igm,PX-3028677866,CDM,86778,CPT,0302,RC,,,,both,,,219.00,142.35,,,,,,,,,,,,,
LENS IOL 3 PC 2.5+ DIOPT 6X13 MM POST CHMBR SOFLEX,SUP-2391943,CDM,V2632,HCPCS,0276,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
HANDLE DETACH PENUMBRA COIL DH1] PENUMBRA INC],SUP-2323581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
GRAFT HUM TISS W7XL10CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2125856,CDM,C1781,HCPCS,0278,RC,,,,both,,,6939.40,4510.61,,,,,,,,,,,,,
COMPONENT FEM SM L PROX KNEE POLYETH MOD ROT HNG CEM REV,SUP-2376349,CDM,C1776,CPT,0278,RC,,,,both,,,12961.45,8424.94,,,,,,,,,,,,,
PADS SOUND PROCESSOR SOFTWEAR,SUP-2858178,CDM,L8690,HCPCS,0278,RC,,,,both,,,4.02,2.61,,,,,,,,,,,,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,0636,RC,70655-0088-06,NDC,,both,200,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5 MM 9 HOLE CONTOURED 2 COMPR RECON,SUP-2468353,CDM,C1713,HCPCS,0278,RC,,,,both,,,1459.28,948.53,,,,,,,,,,,,,
INSERT ACET 28X61 MM HIP PIERCED POLYETH,SUP-2494897,CDM,C1776,CPT,0278,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
MESH HERN VENTRAL MED 2.5X2.5 IN O3FA COAT C-QUR V-PATCH,SUP-2227252,CDM,C1781,HCPCS,0278,RC,,,,both,,,1384.11,899.67,,,,,,,,,,,,,
GUIDEROD ORTH L950MM DIA3MM S STL SMOOTH TIP,SUP-2188171,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.62,355.95,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 8H 133MM RIGHT-STER,SUP-2549546,CDM,C1713,HCPCS,0278,RC,,,,both,,,3506.06,2278.94,,,,,,,,,,,,,
PLATE BNE MINI THK1MM 2X2 H NAR CRANIOMAXILLOFACIAL ORAL,SUP-2181763,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.95,894.37,,,,,,,,,,,,,
SCREW BNE AD PED L32MM DIA2MM TI ALLY DGT FUS CANC PARTIALLY,SUP-2243897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1214.43,789.38,,,,,,,,,,,,,
CAGE SPNL C 20 MM EXPANDABLE CORPECTOMY T2 STRATOSPHERE,SUP-2423275,CDM,C1889,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
TRAY CATH MIDLN POWERMIDLINE MAXBARR 5FR 20CM 2 LUMAN RVS TA,SUP-2613520,CDM,C1751,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
"HC So TB Test, Cell Immun Measure",PX-3028648066,CDM,86480,CPT,0302,RC,,,,both,,,400.00,260.00,,,,,,,,,,,,,
TRACKER NAVIGATION SPINE NONINVASIVE SPINEMASK,SUP-2364165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1135.86,738.31,,,,,,,,,,,,,
SYSTEM FIX ORTHO BOLT WIRE EXT LNG LRF,SUP-2472243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,295.69,192.20,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SPC 5 MM SM ANAT DIAG STRL,SUP-2248648,CDM,C1730,HCPCS,0272,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
DEVICE FIX OPN ABSORBABLE 20 ABSORBABLE FAST OPTIFIX,SUP-2855239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
SCREW BNE CANN 4X44 MM FT TI STRL ASNS III,SUP-2374569,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SPACER SPNL L W10XH10XL25MM 5DEG PEEK THORLUM OBLQ COROENT,SUP-2310885,CDM,C1821,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
PIN EXT FIX TRANSFIXATION 5X325 MM CENTRALLY THRD,SUP-2749989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
BLADE RETRCT D6IN FOR CHARNLEY TYP FRME,SUP-2242484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1022.70,664.75,,,,,,,,,,,,,
GRAFT BONE 40X15MM 10DEG WDG MTRX REGENERATIVE TISS BONE,SUP-2293941,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
NEEDLE BX L210MM DIA25MM DISPOSABLE SEDAN,SUP-2364149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1534.83,997.64,,,,,,,,,,,,,
STRAP CLAV XL PD W3XL4IN STD FOAM PD STOCKINET MTL TOOTH,SUP-2276603,CDM,L3650,HCPCS,0274,RC,,,,both,,,15.32,9.96,,,,,,,,,,,,,
STAPLE BNE FIX W11XH10-10MM WIRE W1.5XL1.5MM SMOOTH OSSTPL,SUP-2194214,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,2500000003,HCPCS,0250,RC,00338-0004-02,NDC,,both,500,ML,60.40,39.26,,,,,,,,,,,,,
STEM FEM L225MM DIA15X20MM NK L36+21+8MM LNG HIP NEUT STR,SUP-2253195,CDM,C1776,CPT,0278,RC,,,,both,,,15359.62,9983.75,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 145 CM DIA 0.035 IN SS COR STRL,SUP-2148182,CDM,C1769,HCPCS,0272,RC,,,,both,,,66.44,43.19,,,,,,,,,,,,,
WAND ABLAT BVL 60DEG 3MM,SUP-2341965,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
PLATE BNE LEFORT 2X7X1 MM LT MOD SUNDHEIMER TI,SUP-2460357,CDM,C1713,HCPCS,0278,RC,,,,both,,,804.44,522.89,,,,,,,,,,,,,
BIT DRL OD7MM CANN COUNTSINK,SUP-2315876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
GRAFT DURA PTCH LG 10X10 CM DURAMATER,SUP-2321734,CDM,C1713,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 3.5X3CM FEN,SUP-2909163,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
SCREW BNE ST 2.7X22 MM CRTX,SUP-2364671,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.30,44.39,,,,,,,,,,,,,
SET CBL SL SM DIA2MM VIT BEAD DALL-M,SUP-2377566,CDM,C1776,CPT,0278,RC,,,,both,,,790.02,513.51,,,,,,,,,,,,,
CATHETER INFUSION 018IN 29FRX150CM 5CM MULTIPLE SH MICROMEWI,SUP-2172533,CDM,C1751,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 0.035 INX450 CM 6.5 FR DOME TIP DASH,SUP-2737238,CDM,C1769,HCPCS,0272,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
IMP SYS T-ROPE BTB-J W/10.5MM FLPCTR IIS,SUP-2811806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
CATHETER ABLATION L 115 CM DIA12 FR DSTL DIA 35 MM GUIDEWIRE,SUP-2885416,CDM,C1733,HCPCS,0272,RC,,,,both,,,26533.00,17246.45,,,,,,,,,,,,,
KIT CTRL VEN CATH AD L20CM DIA12FR BLU FLX TIP POLYUR,SUP-2383318,CDM,C1752,HCPCS,0278,RC,,,,both,,,363.61,236.35,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT DIA 4 FR SS DL STOPCOCK LL FIT,SUP-2264229,CDM,C1757,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
KNIFE SONOPET 12CM IQ STANDARD,SUP-2719780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2721.69,1769.10,,,,,,,,,,,,,
GRAFT STENT TAPR LIMB 16X24X146 MM 16 FR AAA C E ENDURANT II,SUP-2749554,CDM,C1768,CPT,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L19IN FOR UP TO 27IN THGH UNIV FOAM NYL,SUP-2205521,CDM,L1830,CPT,0272,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
SCREW SWVL L36CM POLYPR SUT,SUP-2140290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.93,921.00,,,,,,,,,,,,,
HC Ot Iontophoresis per 15 Min,PX-4309703300,CDM,97033,CPT,0430,RC,,,,both,,,221.00,143.65,,,,,,,,,,,,,
CATHETER VASC ANGIO DIAG STR FLSH PERIPH W/O HYDRPHLC COAT,SUP-2117056,CDM,C1887,HCPCS,0272,RC,,,,both,,,459.07,298.40,,,,,,,,,,,,,
BLADE SURG 10 MM BLNT SHTH TUBESET MIS NEXUS BONESCALPEL,SUP-2745901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2321.46,1508.95,,,,,,,,,,,,,
STEM HUM L120MM DIA8MM UNIV DST SHLDR TI PRI REV CEM FOR UP,SUP-2372851,CDM,C1776,CPT,0278,RC,,,,both,,,8535.27,5547.93,,,,,,,,,,,,,
GRAFT BIO TISS W7XL10CM 4 LAYR PORCINE MTRX ABD HERN,SUP-2168772,CDM,C1781,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTEXSM SZ 0.5-0.7MM 0.5ML B TRICALCIUM,SUP-2194005,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.34,182.87,,,,,,,,,,,,,
NEEDLE BRST LOC L7.5CM OD20GA N REPOSITIONABLE W/ FLEXSTRAND,SUP-2269620,CDM,C1819,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SET INTRO FLX ROSCH-UCHIDA L 40 CM OD 10 FR TROCAR STYL L,SUP-2168186,CDM,C1894,HCPCS,0272,RC,,,,both,,,1538.57,1000.07,,,,,,,,,,,,,
KIT MULT LUMN CTRL VEN,SUP-2120609,CDM,C1751,HCPCS,0278,RC,,,,both,,,403.80,262.47,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO MAXBARR 20GA 8CM WNG 1 LUMAN,SUP-2613478,CDM,C1751,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
CATHETER PULM ART L16CM OD8.5FR 3 LUMN OXMTR PRESEP,SUP-2214761,CDM,C1751,HCPCS,0278,RC,,,,both,,,1302.79,846.81,,,,,,,,,,,,,
KIT GUIDEPIN DIA2MM DISP FOR TEMP FIX,SUP-2123520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
ALLOGRAFT BNE FD IRRADIATED FEM SHFT,SUP-2867204,CDM,C1762,CPT,0278,RC,,,,both,,,5014.42,3259.37,,,,,,,,,,,,,
HC Radiation Treatment Delivery Level 2,PX-3337740700,CDM,77407,CPT,0333,RC,,,,both,,,2411.00,1567.15,,,,,,,,,,,,,
MATRIX BIO L 4 X W 6 CM SZ 43 SQCM FISH SKIN DERMAL MESHED,SUP-2909241,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
PROSTHESIS OSS MIC 2-10 MM OFF CENTERED ADJ TI TORP,SUP-2638132,CDM,L8613,CPT,0278,RC,,,,both,,,1086.66,706.33,,,,,,,,,,,,,
BURR ROUTER FLUTED 2.5MM X 25.4MM LCRNG1,SUP-2843298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.48,268.76,,,,,,,,,,,,,
HC Reconstruct Nail Bed,PX-4501176200,CDM,11762,CPT,0450,RC,,,,both,,,6021.00,3913.65,,,,,,,,,,,,,
STEM HUM L115MM OD9MM UNIV CO CHROM SHLDR MOD PRI BODY CEM,SUP-2376484,CDM,C1776,CPT,0278,RC,,,,both,,,8671.58,5636.53,,,,,,,,,,,,,
DEVICE BONE NEEDLING GWIRE A CRV PLEURISTIK NANOFX,SUP-2123634,CDM,C1769,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ARCH N REMOVABLE ATTCH TO SHOE,SUP-2435707,CDM,L3070,HCPCS,0272,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
HC Iaad Ia Rotavirus,PX-3068742500,CDM,87425,CPT,0306,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
HC Puncture/Aspiration Hematoma,PX-3611016000,CDM,10160,CPT,0361,RC,,,,both,,,1386.00,900.90,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 8 23-27X21 MM FD NAR LORDTC ANTR FRA,SUP-2736743,CDM,C1713,HCPCS,0278,RC,,,,both,,,13018.03,8461.72,,,,,,,,,,,,,
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-131732,CDM,J3590,HCPCS,0636,RC,00597-0197-05,NDC,,both,50,ML,7526.10,4891.96,,,,,,,,,,,,,
BIT DRL L254MM DIA8MM FOR DH-DC 3 RMR,SUP-2187942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1617.60,1051.44,,,,,,,,,,,,,
PIN SYS SCHNZ 4MM,SUP-2399234,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PROSTHESIS OTO L5MM OD0.6MM LOOP 0.8MM STAP PIST L LOOP,SUP-2284055,CDM,L8613,CPT,0278,RC,,,,both,,,258.36,167.93,,,,,,,,,,,,,
SEAT SPNL 6.35MM TI ALIGNING VAR ANG LCK,SUP-2415646,CDM,C1713,HCPCS,0278,RC,,,,both,,,1231.76,800.64,,,,,,,,,,,,,
SYSTEM PLATE BONE 206MML HOLEX7 STAINLESS STEEL BMP HIP,SUP-2721323,CDM,C1713,HCPCS,0278,RC,,,,both,,,9498.50,6174.02,,,,,,,,,,,,,
BIT DRILL SURG DIA 4.5 MM LNG FLUT FOR 6 MM PIN NS MAV,SUP-2931209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
LENS INTOCU +12.5 DIOPT L12.5MM DIA5.5MM D3.39MM 0.5DEG,SUP-2110698,CDM,V2630,CPT,0276,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SET INTRO PEELWY L 32 CM DIA 9 FR DIL L 37 CM STRL,SUP-2835672,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.19,102.17,,,,,,,,,,,,,
INSERT TIB L THK9MM UNIV CNDYL KNEE NEUT PRI STBL DURAC,SUP-2377414,CDM,C1776,CPT,0278,RC,,,,both,,,1921.18,1248.77,,,,,,,,,,,,,
GUIDEPIN SURG L16IN OD3/32IN PK INSRT,SUP-2212926,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
MATRIX BIO L 2.4 X W 1.6 IN SZ 24 SQCM PORCINE TEND DERIVED,SUP-2909330,CDM,A2008,HCPCS,0636,RC,,,,both,,,5615.89,3650.33,,,,,,,,,,,,,
CATHETER NAVI-STAR J CRV SFT TIP 7FR,SUP-2248475,CDM,C1732,HCPCS,0278,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 145 CM TIP L 9 CM DIA 0.035 IN SS,SUP-2148178,CDM,C1769,HCPCS,0272,RC,,,,both,,,537.82,349.58,,,,,,,,,,,,,
CLAMP EXT FIX OD25MM RED PIN FOR MONOTUBE TRIAX SYS,SUP-2372623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
STENT PERIPH SUPERA L 120 MM DIA 5.5 MM SHFT L 120 CM SHTH 6,SUP-2106236,CDM,C1876,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,PX-3606232100,CDM,62321,CPT,0360,RC,,,,outpatient,,,2230.00,1449.50,,,,,,,,,,,,,
ACCESSORY KIT SEERLT 3CH AHA,SUP-2226176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,695.20,451.88,,,,,,,,,,,,,
PROSTHESIS VOICE 22.5FR 4MM PRELD W/ SMRT INSRTR AND BRSH,SUP-2124407,CDM,L8509,HCPCS,0274,RC,,,,both,,,1029.35,669.08,,,,,,,,,,,,,
PLATE BNE CRV 4.5X195 MM LT CNDYL 8 HOLE VA LCK STRL VALCP,SUP-2789395,CDM,C1713,HCPCS,0278,RC,,,,both,,,6098.16,3963.80,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL PRIORITY + PEEK,SUP-2862819,CDM,C1713,HCPCS,0278,RC,,,,both,,,51056.02,33186.41,,,,,,,,,,,,,
PLATE 2 HL TWST ALUM RINGFIX SYS,SUP-2500275,CDM,C1713,HCPCS,0278,RC,,,,both,,,381.82,248.18,,,,,,,,,,,,,
ALLOGRAFT DERMAL 3X4 CM DERMAPURE,SUP-2388442,CDM,Q4152,HCPCS,0636,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PIN FIX THRD UNIV 3.2X67 MM HD FOR SYNTHES KNEE INSTR SYS SS,SUP-2877753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.94,370.46,,,,,,,,,,,,,
PLATE BONE LOK HLX26 25MM THK TTNM ANGLD RCNSTRCTN NON BRDG,SUP-2679035,CDM,C1713,HCPCS,0278,RC,,,,both,,,8295.94,5392.36,,,,,,,,,,,,,
CATHETER URET 5FR L70CM UNIV PVC OPN END TIP SGL LUMN W/OUT,SUP-2171224,CDM,C1758,HCPCS,0278,RC,,,,both,,,90.15,58.60,,,,,,,,,,,,,
SPLINT ORTH AD W21XL80CM PVC DURABLE SGL CHMBR LNG ARM FOR,SUP-2309123,CDM,L3908,HCPCS,0272,RC,,,,both,,,149.43,97.13,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.3MM CORT CRANIOMAXILLOFACIAL G TI ST 5PK,SUP-2366159,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.77,130.50,,,,,,,,,,,,,
PLATE BONE 6X18 H RT MAND TI ANG RIG NONCOMPRESSION,SUP-2191418,CDM,C1713,HCPCS,0278,RC,,,,both,,,6016.24,3910.56,,,,,,,,,,,,,
STENT VASC OTW 3X9 MM 6 FRX135 CM WINGSPAN LF,SUP-2368132,CDM,C1876,HCPCS,0278,RC,,,,both,,,19766.30,12848.09,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM DNE5160] DNE LLC],SUP-2197283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
CATHETER STONE REMV 6FR L23CM 1.25ML BILI BLLN PRB ATRAUM,SUP-2214136,CDM,C1726,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
HEAD RADIAL 18 MM LT ANAT SOL STRL SLIDE-LOC,SUP-2657732,CDM,C1776,CPT,0278,RC,,,,both,,,9944.38,6463.85,,,,,,,,,,,,,
GRAFT HUM TISS L6-11X4-11CM DIA8-15X4-5MM AORTOILIAC ART,SUP-2175268,CDM,C1768,CPT,0278,RC,,,,both,,,77856.30,50606.59,,,,,,,,,,,,,
"HC Urine,Microalbumin,Quantitativ",PX-3078204300,CDM,82043,CPT,0307,RC,,,,both,,,129.00,83.85,,,,,,,,,,,,,
SCREW BNE L8MM DIA1.5MM HND 316L S STL ST VAR ANG LOK T4,SUP-2177992,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.91,233.94,,,,,,,,,,,,,
PLATE LOQTEQ VA VOLAR DISTAL RADIUS 2.5 NARROW XL L,SUP-2713861,CDM,C1713,HCPCS,0278,RC,,,,both,,,8138.88,5290.27,,,,,,,,,,,,,
PLATE BNE 0MM SPCR STD TI REARFOOT LAT CLMN LENGTHENING PIA,SUP-2399632,CDM,C1713,HCPCS,0278,RC,,,,both,,,3086.62,2006.30,,,,,,,,,,,,,
COMPONENT TIB EXT X LG 3 ANK COCR SALTO TALARIS,SUP-2244191,CDM,C1776,CPT,0278,RC,,,,both,,,19527.03,12692.57,,,,,,,,,,,,,
TRIAL TIB STEM TIB PROV SZ 4 NXGN,SUP-2201511,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
PLATE BNE 2.7X68 MM 8 HOLE SS DCP,SUP-2569130,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.77,194.20,,,,,,,,,,,,,
PLATE BNE LISFRANC MED RT OMNI,SUP-2610166,CDM,C1713,HCPCS,0278,RC,,,,both,,,5557.80,3612.57,,,,,,,,,,,,,
HEAD SURG 95 RMR IM FEM MOD S STL BIXCUT,SUP-2368229,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT HUM TISS ACHILLES TEND CALCANEOUS,SUP-2281656,CDM,C1713,HCPCS,0278,RC,,,,both,,,7426.10,4826.96,,,,,,,,,,,,,
GRAFT SPNL ALLGRFT,SUP-2293972,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.7MM CORT TI ST NONLOCKING CRUCFRM,SUP-2189540,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.21,275.74,,,,,,,,,,,,,
HC Transcatheter Renal Sympath Denervation Bilat,PX-3610339000,CDM,0339T,CPT,0361,RC,,,,inpatient,,,14967.00,9728.55,,,,,,,,,,,,,
DEVICE 12 WATCHPAT ONE,SUP-2848789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
BIT DRL L390MM DIA15MM PERC CANN FLX L QUIK CPL FOR RECON,SUP-2178901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2438.12,1584.78,,,,,,,,,,,,,
NAIL FEM TROCHANTERIC 10MM DIA 130 DEG 360MML RT STRL TI,SUP-2349038,CDM,C1713,HCPCS,0278,RC,,,,both,,,9237.88,6004.62,,,,,,,,,,,,,
PLEDGET SURGICAL W3/8XL0.374IN THK1.5MM PTFE RECTANGLE,SUP-2425486,CDM,C1768,CPT,0278,RC,,,,both,,,92.66,60.23,,,,,,,,,,,,,
COMPONENT GLEN FIX DIA48X44MM OFFSET OVOID POST HUM ARTC,SUP-2123577,CDM,C1776,CPT,0278,RC,,,,both,,,20008.08,13005.25,,,,,,,,,,,,,
WASHER ORTH DIA10MM S STL FOR 4.5MM CANN SCR,SUP-2184668,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.50,42.57,,,,,,,,,,,,,
MESH HERN RECT OVL 4X2 IN FLAT SHT KNITTED POLYPR PROLITE,SUP-2227232,CDM,C1781,HCPCS,0278,RC,,,,both,,,82.14,53.39,,,,,,,,,,,,,
CATHETER PERF 5FR L136CM 0.054IN PROX WRK POS CONT ASPIR,SUP-2323624,CDM,C1757,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
BIT DRL DIA32MM CANN FOR GUID GROWTH EIGHT PLATE SYS,SUP-2316400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,605.77,393.75,,,,,,,,,,,,,
DEVICE SUTURING ABSORBABLE 3-0 6 IN RELD GRN ENDOSTCH,SUP-2787725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.71,250.06,,,,,,,,,,,,,
HC So Heroin Metabolite,PX-3018035666,CDM,G0480,CPT,0301,RC,,,,both,,,238.00,154.70,,,,,,,,,,,,,
APPLIER CLP M L11IN TI MULT RNG HNDL 30 CLP STR LIGACLP,SUP-2219673,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.92,116.30,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. L 80 MM DIA10 MM GUIDEWIRE 0.018 IN,SUP-2158897,CDM,C1876,HCPCS,0278,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
CAGE SPNL 20 DEG 35X27X16 MM 3D 3 HOLE NO PROF,SUP-2750689,CDM,C1889,HCPCS,0278,RC,,,,both,,,18604.50,12092.92,,,,,,,,,,,,,
SET ORTH PT SPEC INSTR CAPITATED BNE MOD GUID PIN DRL KT,SUP-2212345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER HD DL 14 FRX24 CM PRECRV STP TIP HEMO-FLOW,SUP-2266976,CDM,C1750,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PI PICC 2-LUMEN: 5FRX55CM WITH 80CM SS S,SUP-2822095,CDM,C1751,HCPCS,0278,RC,,,,both,,,350.42,227.77,,,,,,,,,,,,,
PROBE ARTHSCP MINI TIP DIA35MM 5MM GRADUATIONS STR FIRM GRP,SUP-2166512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.32,281.01,,,,,,,,,,,,,
SHEATH INTRO L 90 CM DIA 6 FR SS COIL NYL OUTER PTFE INNR,SUP-2139613,CDM,C1894,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4 FR NIT WIRE TUNGSTEN TIP MIC STIFF,SUP-2752609,CDM,C1894,HCPCS,0272,RC,,,,both,,,84.91,55.19,,,,,,,,,,,,,
IMPLANT HUM TISS 1 CC AMNIO STEM CELL ECT3 EXTRACELLULAR -RSFH,SUP-2881354,CDM,C1762,CPT,0278,RC,,,,both,,,14368.64,9339.62,,,,,,,,,,,,,
TRAY DRNGE 8FR SAFE-T-CENTESIS,SUP-2133896,CDM,C1729,HCPCS,0272,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.554,SUP-2860235,CDM,C1713,HCPCS,0278,RC,,,,both,,,23166.92,15058.50,,,,,,,,,,,,,
TROCAR FOR 6.5MM AND 7.3MM CANNULATED SCREWS-LONG,SUP-2548324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2376.82,1544.93,,,,,,,,,,,,,
IOBP KNEE OPEN TIP PROCEDURE KIT,SUP-2816371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
STENT BILI XPERT L 60 MM DIA 6 MM DEL SYS L 120 CM INTRO 5,SUP-2105871,CDM,C1876,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
TROCAR ENDOPATH XCEL W/OPTIVIEW TECH DILATING TIP 5MM 75MM,SUP-2855494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.35,412.98,,,,,,,,,,,,,
SCREW IM NAIL L 70 MM DIA10.5 MM TI ALLOY RC LAG STRL GAMMA4,SUP-2904041,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
BLADE REPROC M4 TURBINATE INFERIOR,SUP-2526000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.27,287.48,,,,,,,,,,,,,
SCREW BNE L 3.5 MM DIA1.8 MM MIDFACE EMER CNTR DRV NS DISP,SUP-2934705,CDM,C1713,HCPCS,0278,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
STAPLER INT AD L45MM STD THCK TISS GRN TI LIN NONCUTTING 2,SUP-2283416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1310.35,851.73,,,,,,,,,,,,,
PACK PENILE PROS INSRTN INFL STR BLDE RNG HNDL AMS 800,SUP-2138912,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.98,440.04,,,,,,,,,,,,,
STEM FEM SZ 5 LAT HIP HA AMISTEM-H,SUP-2267272,CDM,C1776,CPT,0278,RC,,,,both,,,9574.49,6223.42,,,,,,,,,,,,,
PLATE BONE W13.6XL222MM THK3.3MM 12 H S STL RT PERIARTC TIB,SUP-2362733,CDM,C1713,HCPCS,0278,RC,,,,both,,,2839.82,1845.88,,,,,,,,,,,,,
PLATE BNE MESHED 11 XL 0.6 MM RT CONTOURED TI STRL,SUP-2472097,CDM,C1713,HCPCS,0278,RC,,,,both,,,17444.58,11338.98,,,,,,,,,,,,,
LEVOFLOXACIN 500 MG PO TABS,RX-18919,CDM,6370000000,HCPCS,0637,RC,00904-6352-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUR SURG DIAMOND LNG 8 MM BALL FOR QD14-S/QD14-G1/QD14,SUP-2848151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.31,255.00,,,,,,,,,,,,,
SCREW BNE CANC 4.5X25 MM CRPL PLATE TI NS UNIV 2,SUP-2851987,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.22,459.04,,,,,,,,,,,,,
KIT INSRTN INTRO L 6 IN CATH DIA 7.5 FR 40 CC PACKAGED STRL,SUP-2908666,CDM,C1894,HCPCS,0272,RC,,,,both,,,486.57,316.27,,,,,,,,,,,,,
ENDCAP ORTH S STL HI COMPR G-BEAM FUS BEAMING SYS,SUP-2417458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
CUP 1 PC ACET NEUT POR W/ SCR H TI ALLOY ULT HI MOL POLYETH,SUP-2202894,CDM,C1776,CPT,0278,RC,,,,both,,,8123.18,5280.07,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 45.1-50 MM BONE-PATELLAR TENDON-BONE,SUP-2866884,CDM,C1762,CPT,0278,RC,,,,both,,,6681.92,4343.25,,,,,,,,,,,,,
HC Assay of Erythropoietin,PX-3018266800,CDM,82668,CPT,0301,RC,,,,both,,,384.00,249.60,,,,,,,,,,,,,
HC Eye 1-3 Vws for Foreign Body,PX-3207003000,CDM,70030,CPT,0320,RC,,,,both,,,1197.00,778.05,,,,,,,,,,,,,
SCREW BNE ST 2.4X20 MM LCK,SUP-2569656,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,J2865,HCPCS,0636,RC,00703-9514-03,NDC,,both,10,ML,72.20,46.93,,,,,,,,,,,,,
MICROCATHETER DIAG 2.8FR L130CM 900PSI HYDRPHLC HEMSTAT VLV,SUP-2385149,CDM,C1887,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
DEVICE BNE BX 13GA BVL STYL 11GA TRCR 11GA KT FOR VERTPLSTY,SUP-2281725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BLADE RETRACTOR 10 CM LT INT PIN MAST QUAD,SUP-2631624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1728.73,1123.67,,,,,,,,,,,,,
PROBE NERVE MONITORING CNTRL BLADE STRL DISP,SUP-2711123,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED TIB UPCHARGE BASEPLT TRAB MEL,SUP-2212694,CDM,C1776,CPT,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
LGN POR HA TIB BASE WITHOUT HOLES SZ 4 RT,SUP-2822665,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
STEM TIB L16MM KNEE MTPHSEAL PROFIX,SUP-2347006,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BNE L60MM FIBULAR SHFT SEG FRZ DRY MATRIGRFT,SUP-2264769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1628.18,1058.32,,,,,,,,,,,,,
SHEARS REPROC HARMONIC FOCUS+ W/O ADAP,SUP-2527351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.47,285.01,,,,,,,,,,,,,
LINER ACET 38X26 MM SCR IN +5 HI WALL RINGLOC+,SUP-2447219,CDM,C1776,CPT,0278,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
IMMOBILIZER SHLDR XL L20IN D10IN UNIV POLY COT W/ FOAM STRP,SUP-2196946,CDM,L3650,HCPCS,0274,RC,,,,both,,,24.21,15.74,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT L 23 CM DIA 9 FR DL STOPCOCK LL,SUP-2264272,CDM,C2628,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SPLINT WR AD SM UPTO W3.5IN LT MCP DLX KAY-SPLNT III,SUP-2324559,CDM,L3906,HCPCS,0272,RC,,,,both,,,79.41,51.62,,,,,,,,,,,,,
GRAFT BNE SUB 15ML 0.1-4MM CANC CRUSH CHIP MORSELIZED FRZ,SUP-2307064,CDM,C1713,HCPCS,0278,RC,,,,both,,,871.35,566.38,,,,,,,,,,,,,
BLADE RTRCTR RVL MICRO 14MMW X 35MML SHRT TOOTH BLUE F/ANTRR,SUP-2493096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.17,307.56,,,,,,,,,,,,,
PLATE BNE T 25 MM TCP,SUP-2535852,CDM,C1713,HCPCS,0278,RC,,,,both,,,3950.12,2567.58,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC FD DBM GRFT,SUP-2787761,CDM,C1713,HCPCS,0278,RC,,,,both,,,2803.93,1822.55,,,,,,,,,,,,,
FOSPHENYTOIN SODIUM 100 MG PE/2ML IJ SOLN,RX-88011,CDM,Q2009,HCPCS,0636,RC,00069-5471-02,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX W 59 MM 27 J TI EPOXY RESIN SIL 2,SUP-2138108,CDM,C1721,HCPCS,0275,RC,,,,both,,,53122.52,34529.64,,,,,,,,,,,,,
HC So Factor VII,PX-3058523066,CDM,85230,CPT,0305,RC,,,,outpatient,,,280.00,182.00,,,,,,,,,,,,,
GRAFT VASC GORTX L 60 CM DIA 6 MM EPTFE STR TW N RING STRL,SUP-2396697,CDM,C1768,CPT,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT TI ST PLUSDRIVE RECESS,SUP-2189322,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.64,172.02,,,,,,,,,,,,,
VITAMIN B-1 100 MG PO TABS,RX-8647,CDM,6370000000,HCPCS,0637,RC,68094-0116-59,NDC,,both,1,UN,1.70,1.10,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE LG 11 CC CORTICOCANCELLOUS VIABLE 003,SUP-2936805,CDM,C1762,CPT,0278,RC,,,,both,,,11321.90,7359.23,,,,,,,,,,,,,
MANUAL STONE BSKT INSTR,SUP-2312880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
SCREW BNE L40MM DIA4MM CORT TIB TALAR FUS TIBIAXYS,SUP-2243002,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.96,585.62,,,,,,,,,,,,,
BASEPLATE TIB KEELED 3-4 KNEE MOD FIN STEMMABLE NXGN MIS,SUP-2201020,CDM,C1776,CPT,0278,RC,,,,both,,,3326.83,2162.44,,,,,,,,,,,,,
BIT DRL L 140/45 MM DIA2.8 MM CALIB AO QC NS REUSE V,SUP-2908552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.89,439.33,,,,,,,,,,,,,
PLATE POS TRIANG 110 DEG/60 DEG/10 DEG,SUP-2548633,CDM,C1713,HCPCS,0278,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
EXPANDER TISS BRST SMOOTH ULTRA HI PROF,SUP-2748661,CDM,C1889,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 160-200 MMX0.3 CM FRZN,SUP-2717853,CDM,C1762,CPT,0278,RC,,,,both,,,6454.58,4195.48,,,,,,,,,,,,,
IMPLANT FRESH CORNEA LEFT,SUP-2855178,CDM,V2785,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CATHETER ULTRASOUND NAVIGATIONAL 10 FRX90 CM VIVID I ACUNAV,SUP-2248451,CDM,C1759,HCPCS,0272,RC,,,,both,,,7862.56,5110.66,,,,,,,,,,,,,
REAMER SURG 10.5MM W/ FLEX GUID PIN,SUP-2121210,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 0.018 INX180 CM STIFF SELECTIVA,SUP-2424959,CDM,C1769,HCPCS,0272,RC,,,,both,,,177.94,115.66,,,,,,,,,,,,,
NORTRIPTYLINE HCL 10 MG PO CAPS,RX-5674,CDM,6370000000,HCPCS,0637,RC,00093-0810-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
INTRODUCER 7FR 14CM PEEL AWAY,SUP-2142735,CDM,C1894,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT HUMAN TISSUE PELVIC FLOOR MATRIX 5X5 CM MATRISTEM,SUP-2106485,CDM,C1763,HCPCS,0278,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM BIOCOMP STRL HD SCORPION LNT,SUP-2910030,CDM,C1713,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
PORT HND ACC DIA8.5MM GUID CANN INSRTN DA VINCI,SUP-2246701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CEMENT INTRODUCTORY PK DURELON 3M ESPE,SUP-2238644,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.29,191.94,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM 6FR 4MM A CRV QPLR UNIDIR,SUP-2248663,CDM,C1733,HCPCS,0272,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
WAND ABLAT AMBIENT 70 IFS 70DEG 3MM COVAC,SUP-2342014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.19,578.62,,,,,,,,,,,,,
INSTRUMENT CUP REM 60MM FINISH BLDE FIX HNDL INOMED ACET,SUP-2363414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM BIOCRYL RAPIDE ABSRB 2 DYNACORD SZ 2,SUP-2256645,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
CATHETER CNTSS 5FR DIA 19GA INTRDCR NDLE 10CML TPRD TIP LOW,SUP-2484882,CDM,C1729,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
AUGMENT TIB THK 5 MM SZ 6 RT MEDL LL KNEE REV HINGE STRL,SUP-2889813,CDM,C1776,CPT,0278,RC,,,,both,,,4869.83,3165.39,,,,,,,,,,,,,
"HC So Cryoglobulin,Qualitative",PX-3018259566,CDM,82595,CPT,0301,RC,,,,outpatient,,,214.00,139.10,,,,,,,,,,,,,
CABLE ORTH HIP MINI CLEAT DALL M,SUP-2377583,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.83,385.34,,,,,,,,,,,,,
PLATE BNE L139MM 2 H ST R PROX FEM S STL LO PROF LOK COMPR,SUP-2186131,CDM,C1713,HCPCS,0278,RC,,,,both,,,4092.11,2659.87,,,,,,,,,,,,,
KIT INSRT REV TAPR SGL LUMN 4FR,SUP-2116995,CDM,C1751,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SPLINT RST PAN MIT SP S RT,SUP-2163831,CDM,L3807,HCPCS,0272,RC,,,,both,,,81.29,52.84,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 14 28MM 5ML B TRICALCIUM PHSPTE SYN,SUP-2194008,CDM,C1713,HCPCS,0278,RC,,,,both,,,964.95,627.22,,,,,,,,,,,,,
ALPRAZOLAM 0.5 MG PO TABS,RX-325,CDM,6370000000,HCPCS,0637,RC,59762-3720-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TENSIONER SUTURE,SUP-2749338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,J1808,HCPCS,0636,RC,63323-0184-10,NDC,,both,0.2,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT SHLDR LT SHLDR TOT GUIDE BNE MODEL COMPHSVE,SUP-2424042,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 24X24X0.8 MM POROUS POLYETHYLENE ST,SUP-2837795,CDM,C1713,HCPCS,0278,RC,,,,both,,,1826.54,1187.25,,,,,,,,,,,,,
CAP NUT VLS ALIGNING TI,SUP-2415645,CDM,C1713,HCPCS,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
SPLINT POLYCENTRIC ULN DEVIATION RT SM,SUP-2324606,CDM,L3906,HCPCS,0274,RC,,,,both,,,177.35,115.28,,,,,,,,,,,,,
GRAFT BIO TISS W3.9XL5.9IN PORCINE DERM RIFAMPIN,SUP-2125835,CDM,C1781,HCPCS,0278,RC,,,,both,,,11256.90,7316.98,,,,,,,,,,,,,
HC So Inhibin-A,PX-3028633666,CDM,86336,CPT,0302,RC,,,,both,,,182.00,118.30,,,,,,,,,,,,,
COMPONENT FEM SZ 2 RT POST STBL CEM GMK,SUP-2267591,CDM,C1776,CPT,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
WAND ELECSURG 90 DEG 3.5 MM INTEGR CABLE HALO COBLATION,SUP-2848687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.00,811.85,,,,,,,,,,,,,
STAPLE INT BIOABSORABLE LN REINF 29 PROX 29 ETHICON SEAMGRD,SUP-2395312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X10 CM AMNION/CHORION MEMBRN EPIFIX,SUP-2305744,CDM,Q4186,HCPCS,0636,RC,,,,both,,,11194.13,7276.18,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 20 CM DIA 8 MM EPTFE STR STD WALL,SUP-2227641,CDM,C1768,CPT,0278,RC,,,,both,,,679.90,441.93,,,,,,,,,,,,,
SCREW EXT FIX L200MM DIA6MM THRD L80MM S STL HA SELF DRL MR,SUP-2186996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.11,593.52,,,,,,,,,,,,,
SET INTRO L 14 CM DIA 9 FR GUIDEWIRE 0.038 IN PTFE TEARWY,SUP-2226016,CDM,C1892,HCPCS,0272,RC,,,,both,,,60.29,39.19,,,,,,,,,,,,,
STIMULATOR COCHLEAR BILATERAL AD SLEEPER BAHA,SUP-2165012,CDM,L8614,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
SCREW SPNL 16 DEG 43 MM NS TRINICA,SUP-2684829,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3373,HCPCS,0636,RC,25021-0158-99,NDC,,both,1,UN,569.20,369.98,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD 14FR L32CM SIL ADMIN FULL KT DBL,SUP-2269572,CDM,C1751,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
SHAFT FEM TRAD ALLGRFT 100 MM FRZN,SUP-2294168,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
GUIDEWIRE VASC CRV 7 CM 0.025 INX145 CM 2.5 CMX3 MM SAFE-T-J,SUP-2167592,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.06,24.74,,,,,,,,,,,,,
PLATE BNE STR 8 HOLE OMNI,SUP-2610113,CDM,C1713,HCPCS,0278,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1.7-10 MM 90 CC FD CANC READIGRAFT,SUP-2740804,CDM,C1713,HCPCS,0278,RC,,,,both,,,3194.20,2076.23,,,,,,,,,,,,,
PLATE STRNL 12 H TI ANGLED NS MATRIXSTERNUM,SUP-2904200,CDM,C1713,HCPCS,0278,RC,,,,both,,,3434.72,2232.57,,,,,,,,,,,,,
CROSSLINK SPNL SM OCCIPITOCERVICAL ROD TO ROD INFIN,SUP-2631936,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
ORTHOSES THERMOPLASTIC WRST HND COCKUP,SUP-2319134,CDM,L3908,HCPCS,0274,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
ALIGNRITE WRIST BLK LNG RGHT XS,SUP-2458402,CDM,L3906,HCPCS,0274,RC,,,,both,,,55.95,36.37,,,,,,,,,,,,,
LENS INTOCU L13.75MM OD6.0MM A-CONSTANT 115.8 DIOPT DIOPT,SUP-2129493,CDM,V2630,CPT,0276,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COLLAR CERV MED DENS X LG 24X4.5 IN FRM FIT COTTON PROCARE,SUP-2195746,CDM,L0120,HCPCS,0272,RC,,,,both,,,9.86,6.41,,,,,,,,,,,,,
HC So Rubeola Igg / Igm,PX-3028676566,CDM,86765,CPT,0302,RC,,,,outpatient,,,121.00,78.65,,,,,,,,,,,,,
KIT REV ULN EL BEAR DISCVR,SUP-2215462,CDM,C1776,CPT,0278,RC,,,,both,,,10252.10,6663.86,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA26 MM BRANCH SZ 12/10/8/8,SUP-2694337,CDM,C1768,CPT,0278,RC,,,,both,,,5589.64,3633.27,,,,,,,,,,,,,
COLLAR CERV H3XL22IN UNIV COT M DENS FOAM BRTH ADJ,SUP-2335994,CDM,L0120,HCPCS,0272,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
GRAFT VSCLR L50CM D34MM BRNCH D10MM THRCC CLLGN BFRCTD WOVEN,SUP-2464342,CDM,C1768,CPT,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
"HC Uro/Pyelo, IV W/WO Kub, W/WO Tomography",PX-3207440000,CDM,74400,CPT,0320,RC,,,,both,,,930.00,604.50,,,,,,,,,,,,,
ADAPTER UPLR FEM 12 14 TAPR +6MM OFFSET SOLITUDE,SUP-2314490,CDM,C1776,CPT,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
LEVEL NEURO MESH 3D NEURO SCRW125 X 125 MM T10 MM CP TTNM Q,SUP-2681433,CDM,C1713,HCPCS,0278,RC,,,,both,,,8569.75,5570.34,,,,,,,,,,,,,
NEEDLE LASER 90 DEG SIDE FIRE OMNITIP,SUP-2225653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SET SUT ANCHR 17GA INTRO NDL L12CM GI CART SPEC STR 0.035IN,SUP-2168016,CDM,C1713,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
SPLINT WRST AND THMB BLK FOAM XS 8 IN R,SUP-2336034,CDM,L3809,HCPCS,0274,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 1 MG/ML IV SOLN,RX-78084,CDM,J2274,HCPCS,0636,RC,09999-9911-80,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR,RX-33230,CDM,340b,HCPCS,0637,RC,09999-9911-17,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
INSERT SCRDRVR TORX STARDRV T40 FOR SCREW STRL DISP OPERACE,SUP-2913596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2748.07,1786.25,,,,,,,,,,,,,
WAND ABLAT DIA3.5MM 90DEG SUCT TURBOVAC 90,SUP-2341988,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
WIRE GUIDE 13.5MM/3.2MM,SUP-2548797,CDM,C1769,HCPCS,0272,RC,,,,both,,,1333.43,866.73,,,,,,,,,,,,,
PLATE BONE L249MM THK6MM 11 H LT FEM CNDYL TI BTTRS RIG CLLR,SUP-2190903,CDM,C1713,HCPCS,0278,RC,,,,both,,,3120.31,2028.20,,,,,,,,,,,,,
STRAP CLAV SM BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194669,CDM,L3670,HCPCS,0272,RC,,,,both,,,14.82,9.63,,,,,,,,,,,,,
CUTTER D31MM DISPOSABLE HI LINE XS NEURO III,SUP-2108791,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.49,223.92,,,,,,,,,,,,,
SHEATH GUID DESTINATION W/ 5CM HYDRPHLC COAT TOUHY BORST,SUP-2385272,CDM,C1894,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
INSTRUMENT TEMP FIX 2.3 MM RIB 69 MM SCR TI LEVEL 1 MAXDRIVE,SUP-2869185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1060.06,689.04,,,,,,,,,,,,,
MESH SCAFFOLD GALAFLEX 10CMX20CM BIORESRB,SUP-2903931,CDM,C1781,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
SCREW BNE MAXILLOMANDIBULAR 2X16 MM 12 MM MAXDRIVE 250984261,SUP-2469866,CDM,C1713,HCPCS,0278,RC,,,,both,,,309.98,201.49,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING 6MM DIA 10CM LEN GORTX,SUP-2395721,CDM,C1768,CPT,0278,RC,,,,both,,,3444.58,2238.98,,,,,,,,,,,,,
PLUG FEN HIP STEM NO 4,SUP-2377822,CDM,C1776,CPT,0278,RC,,,,both,,,295.79,192.26,,,,,,,,,,,,,
PROBE LAP 5 MM W/ HANDSWITCH,SUP-2225599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CETIRIZINE HCL 10 MG PO TABS,RX-9506,CDM,6370000000,HCPCS,0637,RC,00904-7510-61,NDC,,both,1,UN,1.20,0.78,,,,,,,,,,,,,
WIRE FIX BLNT SS STRL KIRSCHNER,SUP-2207918,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
SYSTEM IMPL INCL 2 4.75MM BIOCOMPOSITE SWIVELOCK C ANCHR,SUP-2121717,CDM,C1713,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
UNIVERSAL GLENOID - INLAY LARGE PLUS,SUP-2817692,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 8 FRX20 CM DL J TIP SPECTRUM,SUP-2759877,CDM,C1751,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZN 5CMX7CM M HMTRX,SUP-2125442,CDM,Q4134,HCPCS,0636,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PLATE BNE ANGLED 2 MM LT 7X23 HOLE RECON PT SPEC,SUP-2860074,CDM,C1713,HCPCS,0278,RC,,,,both,,,23122.96,15029.92,,,,,,,,,,,,,
SHEATH INTRO HALO 1 L 25 CM DIA 4 FR DIL L 32.5 CM GUIDEWIRE,SUP-2877983,CDM,C1894,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
IMPLANT TOE JT METATRSL CO CHROM N POR 12.5MM BIOPRO,SUP-2137765,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
CATHETER HEMODIALYSIS 27X22X9 CM 165 CC SET WITH HF1000 HEMO,SUP-2838669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.24,577.36,,,,,,,,,,,,,
TWIST DRILL ANGULUS 1.9 X 19MM,SUP-2495883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.59,487.88,,,,,,,,,,,,,
MODULAR CUP REPLACEMENT LOCK RING 60MM,SUP-2503596,CDM,C1776,CPT,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
METOCLOPRAMIDE HCL 5 MG PO TABS,RX-5006,CDM,6370000000,HCPCS,0637,RC,00093-2204-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER PD COILED AD 62 CM 7 CM 16.5 CM CLASSIC LG 2 CUF,SUP-2477228,CDM,C1750,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
BIT DRL PAT STP W/ MOD AO FIT N-K II,SUP-2449173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GAX15 CM 28.9 CM D WIRE ACCURA,SUP-2876722,CDM,C1819,HCPCS,0278,RC,,,,both,,,144.75,94.09,,,,,,,,,,,,,
REAMER SURG DIA2 MM PIP DEPTH STRL DISP TENFUSE,SUP-2902388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.78,565.36,,,,,,,,,,,,,
GRAFT BNE SUB 5CC FOAM PK VERSATILE COMPR RESIST VITOSS 21022105] STRYKER ORTHOBIOLOGICS],SUP-2368195,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE L 257 MM SCREW DIA 4.5 MM 14 H LT PROX LAT TIB NS,SUP-2932855,CDM,C1713,HCPCS,0278,RC,,,,both,,,10638.32,6914.91,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.02 MM 1.6 MM 2.3 MM SIL,SUP-2469512,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.20,18.98,,,,,,,,,,,,,
HC So Quantitative Enzyme Immunoassy,PX-3028631666,CDM,86316,CPT,0302,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
CUTTER ENDO OD6.5MM CANN 2 RETROCUT,SUP-2120861,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
PIN FIX L65MM THRD HDLSS FOR TIB AND DSTL FEM NAVIGATION,SUP-2314150,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BNE Z MINI 2-2.5X11X1 MM RT 4 HOLE TI LEVEL 1,SUP-2479524,CDM,C1713,HCPCS,0278,RC,,,,both,,,1192.76,775.29,,,,,,,,,,,,,
BRACE THMB W ADJUSTABLE STRP UNIV,SUP-2276642,CDM,L3931,HCPCS,0272,RC,,,,both,,,12.21,7.94,,,,,,,,,,,,,
BIT DRL L 175/90 MM DIA1.8 MM SCREW DIA2.4 MM CALIB AO QC,SUP-2907684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.68,589.34,,,,,,,,,,,,,
CATHETER GUID L90CM DIA7FR 0.078IN S STL NYL PTFE COR AR1,SUP-2158414,CDM,C1887,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN SINGLE AXIS MANUAL LCK,SUP-2388216,CDM,L5810,HCPCS,0274,RC,,,,both,,,1312.87,853.37,,,,,,,,,,,,,
STAPLE BNE 18X14X14 MM EASYCLIP,SUP-2365481,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
DRILL TWST L 114.94 MM DIA1.8 MM STP 26 MM SS QC NS DISP,SUP-2936562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
PLATE SPNL 12 H THOR PRE CNTOUR RIBFIX BLU,SUP-2137001,CDM,C1713,HCPCS,0278,RC,,,,both,,,4088.28,2657.38,,,,,,,,,,,,,
PLATE BONE L159MM 20 H MAND TI LCK FOR 2MM SCR,SUP-2191234,CDM,C1713,HCPCS,0278,RC,,,,both,,,4633.38,3011.70,,,,,,,,,,,,,
KIT NEUROSTIMULATOR LD L28CM DIA1.27MM ELECTRD SPC 1.5MM,SUP-2284490,CDM,C1883,HCPCS,0278,RC,,,,both,,,10723.10,6970.01,,,,,,,,,,,,,
CATHETER GUID 5.2FRX115CM 0.070IN ST NAVIEN,SUP-2173353,CDM,C1887,HCPCS,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
GRAFT BNE GRAN 1 CC VI RESRB CERM MASTERGRAFT,SUP-2743369,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
IMPLANT FACE W38XL50MM THK085MM CHN BARR SHT MEDPOR,SUP-2366495,CDM,C1713,HCPCS,0278,RC,,,,both,,,2913.98,1894.09,,,,,,,,,,,,,
HC Change G to Gj Tube,PX-3614944600,CDM,49446,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
PROBE LASER 25GA DIR FOR VISION,SUP-2129222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.63,361.81,,,,,,,,,,,,,
HC Methacoline Challenge Test,PX-4609407000,CDM,94070,CPT,0460,RC,,,,outpatient,,,1867.00,1213.55,,,,,,,,,,,,,
CATHETER EP 120CML 6FR 2-5-2MM MAP HEXAPOLAR ELECTRD SPC,SUP-2101983,CDM,C1730,HCPCS,0272,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
BLOCK TIB AUG 3 10 MM KNEE,SUP-2201564,CDM,C1776,CPT,0278,RC,,,,both,,,3605.82,2343.78,,,,,,,,,,,,,
IMMOBILIZER SHLDR SLNG L,SUP-2276606,CDM,L3660,HCPCS,0272,RC,,,,both,,,10.80,7.02,,,,,,,,,,,,,
CATHETER AORT L65CM ENDOCLAMP,SUP-2214466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9467.10,6153.61,,,,,,,,,,,,,
SCREW BNE L45MM OD45MM TI CANC GLEN ST NONLOCKING COMPR,SUP-2401414,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BONE L70MM DIA6.5MM THRD L16MM TI CANN,SUP-2403466,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.77,590.05,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.5/3 MM TI ALLOY LAT NK TALAR BUTTERFLY,SUP-2907638,CDM,C1713,HCPCS,0278,RC,,,,both,,,5555.82,3611.28,,,,,,,,,,,,,
EXTRACTOR SURG L2.5-3.5 MMXTRACT ALL DISP FOR 2.5-3.5 MM,SUP-2337711,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
BLADE SHAVER BPLR STD 40 DEG 4 MM ANGLE SERRATED EDGE FRM,SUP-2638394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,566.77,368.40,,,,,,,,,,,,,
HC Surgery Ohs Base,PX-3600000008,CDM,3600000008,LOCAL,0360,RC,,,,outpatient,,,9658.00,6277.70,,,,,,,,,,,,,
AMOXICILLIN 250 MG/5ML PO SUSR,RX-454,CDM,340b,HCPCS,0637,RC,09999-9903-75,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
IMPLANT PEDALVERB MOD PDS 3000 BANDWIDTH 20HZ TO 12KHZ WT,SUP-2332647,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
HEAD FEM DIA36MM +0MM OFFSET ZIRCONIUM UNIV TAPR STD OFFSET 65190136] STRYKER CORP],SUP-2364698,CDM,C1776,CPT,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
COMPONENT HUM STD L STEM DST STR SOLAR,SUP-2372321,CDM,C1776,CPT,0278,RC,,,,both,,,17115.26,11124.92,,,,,,,,,,,,,
CATHETER GUID CXI L 135 CM DIA 2.3FR 0.014IN SS ANGLED 2 TIP,SUP-2638646,CDM,C1887,HCPCS,0272,RC,,,,both,,,609.38,396.10,,,,,,,,,,,,,
ANCHOR SUTURE 4.5MM IMPLANT CROSSFT,SUP-2824396,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
STENT PERIPH L60MM DIA7MM CATH L120CM SHTH 6FR 0.035IN NIT,SUP-2395886,CDM,C1874,HCPCS,0278,RC,,,,both,,,4461.94,2900.26,,,,,,,,,,,,,
CATHETER ENDOBRONCHIAL BLK SET 9 FRX65 CM COHEN,SUP-2760001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.39,630.75,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SPRL MOLD TO PT PLAS,SUP-2435629,CDM,L1950,HCPCS,0272,RC,,,,both,,,2177.31,1415.25,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209711600,CDM,97116,CPT,0420,RC,,,GP|CQ,both,,,164.00,106.60,,,,,,,,,,,,,
STEM FEM VERSYS 8 INCH BEADED FC REV 15.0X200MM BWD LT,SUP-2504261,CDM,C1776,CPT,0278,RC,,,,both,,,14557.04,9462.08,,,,,,,,,,,,,
SCREW BNE ZURICH 1.2X7 MM 9 MM DRILL-FREE 2 MM STRL LEVEL 1,SUP-2540290,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.46,359.75,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|DOCUMENTATION ON FILE,PX-4309711000,CDM,97110,CPT,0430,RC,,,GO|CO|KX,both,,,195.00,126.75,,,,,,,,,,,,,
SPLINT ORTH M HND THMS SUSP,SUP-2112602,CDM,L3807,HCPCS,0274,RC,,,,both,,,96.96,63.02,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM TAPE 1.8/1.4 MM BIOCOMP 1 STRND,SUP-2908710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1450.68,942.94,,,,,,,,,,,,,
BARRIER ADH ABSRB GYNECARE INTCEED ST L6XW5IN,SUP-2218344,CDM,C1765,HCPCS,0278,RC,,,,both,,,1142.55,742.66,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE",PX-4209711000,CDM,97110,CPT,0420,RC,,,GP|CQ|XU|KX,both,,,195.00,126.75,,,,,,,,,,,,,
SCREW BNE L 70 MM DIA 5.7 MM SS CANN LCK NS EVOS,SUP-2931203,CDM,C1713,HCPCS,0278,RC,,,,both,,,1170.91,761.09,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 90 X 40 CM DIA 8 X 8 MM EPTFE,SUP-2396237,CDM,C1768,CPT,0278,RC,,,,both,,,7601.94,4941.26,,,,,,,,,,,,,
BLADE REPROC SAW SAGITTAL SYS 4 AND 2000 29X0.89X73MM,SUP-2525942,CDM,C1776,CPT,0278,RC,,,,both,,,60.88,39.57,,,,,,,,,,,,,
PLATE BNE RECON 3.5X98 MM 7 HOLE SS LCP,SUP-2569391,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.12,262.68,,,,,,,,,,,,,
WAND ELECSURG 90 DEG 4.5 MM INTEGR CABLE N SUCTION ELIM 90,SUP-2848688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.95,396.47,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J3490,HCPCS,0258,RC,00338-0043-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
PLATE BNE WIRE DORS WRST 3 HOLE,SUP-2389787,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
XXL VOLAR DR TRIAL NARROW RIGHT 8 HOLE,SUP-2695485,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
MESH SURG L10XW8INXL POLYPR ABD OBLONG BIOABSRB OVL IMP,SUP-2265969,CDM,C1781,HCPCS,0278,RC,,,,both,,,3632.98,2361.44,,,,,,,,,,,,,
INSERTION KIT 2.4 MM PERC PUSHLOCK ANCHR,SUP-2423443,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SET SPEC RETRV L 220 CM OD 2.2 MM ID 1.9 MM CAP OD 19.5 MM,SUP-2881870,CDM,C1889,HCPCS,0278,RC,,,,both,,,4361.46,2834.95,,,,,,,,,,,,,
BANDAGE SUPP ANK AK SILESIAN,SUP-2388215,CDM,L5698,HCPCS,0272,RC,,,,both,,,276.13,179.48,,,,,,,,,,,,,
CANNULA IRRIGATION SIMCOE 23 GAX15 MM DOUBLE-BARRELED RVS,SUP-2475629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.36,205.63,,,,,,,,,,,,,
EXTENSION STEM L120MM DIA11MM NK L75MM TIB KNEE TIV FLUT,SUP-2208711,CDM,C1776,CPT,0278,RC,,,,both,,,2529.27,1644.03,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA12 FR GUIDEWIRE 0.038 IN,SUP-2168409,CDM,C1894,HCPCS,0272,RC,,,,both,,,190.06,123.54,,,,,,,,,,,,,
PLATE BNE CLAV 2.7 MM RT MEDL VA LCK COMPR TI STRL VALCP,SUP-2789635,CDM,C1713,HCPCS,0278,RC,,,,both,,,4800.43,3120.28,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV 20-24 IN XS PRNG BCKL PROCARE,SUP-2196976,CDM,L3650,HCPCS,0274,RC,,,,both,,,14.57,9.47,,,,,,,,,,,,,
KIT LD DEL ACCSRY IS1 CTRL HEMOSTAS VLV INTRO TORQUE,SUP-2148849,CDM,C1894,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L POR CRUCE RET BAL REV SYS,SUP-2314659,CDM,C1776,CPT,0278,RC,,,,both,,,7008.48,4555.51,,,,,,,,,,,,,
HC Allo Manual Plasma Re,PX-3623821400,CDM,38214,CPT,0362,RC,,,,inpatient,,,3672.00,2386.80,,,,,,,,,,,,,
BIT DRL DIA 4.8 MM LG CANN AO QR NS DISP,SUP-2913217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
GRAFT SHFT HUM CRSS SECT SPNL ALLGRFT FRZ DRY 10MM,SUP-2264983,CDM,C1713,HCPCS,0278,RC,,,,both,,,4810.98,3127.14,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 8 FRX22 CM 6 FR PERCFLX POLARIS,SUP-2457662,CDM,C2617,HCPCS,0278,RC,,,,both,,,490.53,318.84,,,,,,,,,,,,,
TROCAR SURG SINUS 4 MM 180 MM 90 MM W/ CANN,SUP-2476423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,583.10,379.01,,,,,,,,,,,,,
STENT BILI 5.5FR L18MM DIA8MM CATH L80CM 0.035IN OVR THE,SUP-2101605,CDM,C1876,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PLATE BNE X 14X0.35 MM NEURO 4 HOLE W/ TAB TI STRL LEVEL 1,SUP-2471251,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.59,619.83,,,,,,,,,,,,,
HC Cytp Smrs Any Oth Src Extnd Std > 5 Slides,PX-3118816200,CDM,88162,CPT,0311,RC,,,,both,,,182.00,118.30,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM 0035IN S STL STR CRV HEP COAT DBL FLX,SUP-2167576,CDM,C1769,HCPCS,0272,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL AD 18 GAX89 CM CRV BRK1 STYL BRK SS,SUP-2357595,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
CATHETER THROMCTMY L 100 CM DIA 5 FR INFUSION L 5 CM,SUP-2141147,CDM,C1751,HCPCS,0278,RC,,,,both,,,237.16,154.15,,,,,,,,,,,,,
KIT INSTR DIA1.4MM INCL GUID DRL AND OBT DISP JUGGERKNOT,SUP-2212952,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.02,614.91,,,,,,,,,,,,,
GRAFT ENDOVASC L14CM AORT IL DIA28.5X14.5MM TRUNK,SUP-2396085,CDM,C1768,CPT,0278,RC,,,,both,,,32169.30,20910.04,,,,,,,,,,,,,
SCREW BNE 35MM LOK SCR SURFIT TOT WRST FUS SYS,SUP-2243055,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.78,268.31,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5 FRX32 CM CHRONIC LT DL FULL DURAFLO,SUP-2497789,CDM,C1750,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE PROF THK 0.6 MM 7 H SCREW DIA1 MM CMF DBL Y SHP NS,SUP-2883803,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM PEEK CC FIBERTAK ACHILLES,SUP-2910468,CDM,C1713,HCPCS,0278,RC,,,,both,,,9066.75,5893.39,,,,,,,,,,,,,
STENT URET SILHOUETTE COMFORT L 24 CM DIA 4.6 FR NIT SYNTH,SUP-2119483,CDM,C2617,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE L 118 MM SCREW DIA 4.5 MM 5 H RT PROX HUM STRL,SUP-2932775,CDM,C1713,HCPCS,0278,RC,,,,both,,,9317.17,6056.16,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MMX12 CM FLUT SM BOR MIDAS REX LEGEND,SUP-2627657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
PLATE BNE COMPR SM 2.7X84 MM 10 HOLE DYN NS DCP LTX,SUP-2861903,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
CATHETER HD PRECRV 11.5 FRX15 CM SHT TERM DL TAPR SOFT-LINE,SUP-2627328,CDM,C1752,HCPCS,0278,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
CATHETER CENTESIS 5FR L10CM 4 DRNGE H FIX LUERLOCK NDL STYL,SUP-2303168,CDM,C1729,HCPCS,0272,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
FILTER VENA CAVA FEM SHTH DIL SET SIMN NIT,SUP-2127813,CDM,C1880,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL CLEVIS TYP,SUP-2435680,CDM,L2570,HCPCS,0274,RC,,,,both,,,1260.90,819.58,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UNI OXIN,SUP-2351430,CDM,C1776,CPT,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
KIT OSIA 2 SOUND PROCESSOR,SUP-2858185,CDM,L8690,HCPCS,0278,RC,,,,both,,,12983.90,8439.53,,,,,,,,,,,,,
DISC DENT DIA1/2IN X THN MAUVE ALUM OXIDE CNTOUR POL COARSE,SUP-2100104,CDM,D6783,CPT,0278,RC,,,,both,,,2.26,1.47,,,,,,,,,,,,,
ROCKER BOTTOM EXTERNAL FIXATION ALUMINUM SILICONE RUBBER,SUP-2586509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4625.16,3006.35,,,,,,,,,,,,,
PLATE 4 HL TWST ALUM RINGFIX SYS,SUP-2473213,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
PLATE BNE MIDFACE 1.5X42X19X0.6 MM LT PARANASAL 22 HOLE NS,SUP-2494988,CDM,C1713,HCPCS,0278,RC,,,,both,,,2330.67,1514.94,,,,,,,,,,,,,
GRAFT VASC ADVANTA SST L 80 CM DIA 6 MM RNG L 20 CM EPTFE,SUP-2227385,CDM,C1768,CPT,0278,RC,,,,both,,,4684.91,3045.19,,,,,,,,,,,,,
LENS INTOCU +15.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111015,CDM,V2632,HCPCS,0276,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
SPACER HLD CHMBR TEAL VLV COLLAPSIBLE FLUT BREATHERITE,SUP-2389314,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
STEM HUM REV LNG SHLDR ASCEND FLX,SUP-2388598,CDM,C1776,CPT,0278,RC,,,,both,,,27475.00,17858.75,,,,,,,,,,,,,
BRACE ORTHOPEDIC ANK,SUP-2112657,CDM,L1930,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7050,HCPCS,0250,RC,00264-7800-20,NDC,,both,1000,ML,93.50,60.77,,,,,,,,,,,,,
"HC Transluminal Peripheral Atherectomy, Brachiocephal and Branches, Ea",PX-3610237000,CDM,0237T,HCPCS,0361,RC,,,,both,,,10136.00,6588.40,,,,,,,,,,,,,
BRACE WR CIRC 7 1/4IN TO 8IN L RT REG IMMOB LOOP LCK W/ STAY,SUP-2324900,CDM,L3931,HCPCS,0272,RC,,,,both,,,30.27,19.68,,,,,,,,,,,,,
NAIL IM L460MM DIA11MM UNIV L R DST FEM TI CANN LOK RG DYN,SUP-2191763,CDM,C1713,HCPCS,0278,RC,,,,both,,,7534.12,4897.18,,,,,,,,,,,,,
PLATE BNE LCK 3.5X130 MM RT DSTL MEDL HUM 7 HOLE FIX ANGLE,SUP-2525041,CDM,C1713,HCPCS,0278,RC,,,,both,,,2918.57,1897.07,,,,,,,,,,,,,
CATHETER SUPRAPUBIC MUSHRM 2 36 FR PEZ,SUP-2126756,CDM,C2627,HCPCS,0272,RC,,,,both,,,31.56,20.51,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 5 HOLE 145MM LT STRL,SUP-2546858,CDM,C1713,HCPCS,0278,RC,,,,both,,,5912.46,3843.10,,,,,,,,,,,,,
IFIX INTERFERENCE SCR 7X25MM,SUP-2589274,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.44,740.64,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS GLD L 80 CM BALLOON L 4 CM DIA12 MM,SUP-2127947,CDM,C1725,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HC So RBC Serum Pretx ID Dilution,PX-3028697666,CDM,86976,CPT,0302,RC,,,,both,,,133.00,86.45,,,,,,,,,,,,,
PLATE BNE L262MM 14 H NONSTERILE R LAT PROX TIB S STL LOK,SUP-2185726,CDM,C1713,HCPCS,0278,RC,,,,both,,,4364.44,2836.89,,,,,,,,,,,,,
STEM FEM HI OFFSET 10 SHT HIP TAPR POROUS,SUP-2450684,CDM,C1776,CPT,0278,RC,,,,both,,,14883.60,9674.34,,,,,,,,,,,,,
CATHETER CV SET 032 10 FRX15 CM 11 GA 5 LUMEN QUINT,SUP-2759729,CDM,C1751,HCPCS,0278,RC,,,,both,,,408.80,265.72,,,,,,,,,,,,,
RING EXT FIX ID155MM ALUM FULL FOR TAY SPAT FRME ILIZ,SUP-2342961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6198.20,4028.83,,,,,,,,,,,,,
CONNECTOR SPNL TI AX FOR 5.5-5.5MM ROD CDH LEG,SUP-2290020,CDM,C1713,HCPCS,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
SCREW BNE L 7 MM DIA1.5 MM FT CANN LAG STRL NANOPHIX,SUP-2912795,CDM,C1713,HCPCS,0278,RC,,,,both,,,2618.76,1702.19,,,,,,,,,,,,,
HC So Phenotype Infect Agent Drug,PX-3068790066,CDM,87900,CPT,0306,RC,,,,inpatient,,,442.00,287.30,,,,,,,,,,,,,
FIXATOR EXT HING RINGFIX SYS 90DEG STD,SUP-2696090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,765.85,497.80,,,,,,,,,,,,,
HC So1 Trichomonas Vaginalis Amplif,PX-3068766167,CDM,87661,CPT,0306,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
PACEMAKER CARD W44XH43MM THK6MM 18GM 2 CHMBR SYS W/ LD,SUP-2356217,CDM,C1785,HCPCS,0275,RC,,,,both,,,21524.70,13991.05,,,,,,,,,,,,,
KIT INTRO VSI L 15 CM DIA 4 FR NIT TUNGSTEN TIP SIL REG,SUP-2763488,CDM,C1892,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
COIL VASC I-ED COIL PRIMARY L 15 CM DIA 0.010 IN SECONDARY,SUP-2865282,CDM,C1889,HCPCS,0278,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
KIT LUM DRNGE CEREBROSPINAL FLD VERSION II,SUP-2308152,CDM,C1729,HCPCS,0272,RC,,,,both,,,709.39,461.10,,,,,,,,,,,,,
ELECTRODE ELECSURG GRN MAIN CBL 9 TO 14 PIN STARBURSTXL,SUP-2117213,CDM,C1819,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PIN FIX DIAMOND PT 1 END 3/16X9 IN 3 PT STYL SMOOTH PLN STRL,SUP-2150476,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.06,12.39,,,,,,,,,,,,,
SCREW KNEE ARTHROPLASTY FEM DST VIT ST DURAC 5MML,SUP-2377212,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.94,162.46,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 18MMX6X110CM BAL DIL PTV NUCLEUSX,SUP-2309685,CDM,C1725,HCPCS,0272,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
KIT PAIN PMP 270ML 4ML HR ELASTOMERIC NONNARCOTIC ON Q,SUP-2236815,CDM,C9804,HCPCS,0272,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
KIT CVC 7FR FOR 2 LUMN CATHETER HCKMN,SUP-2126564,CDM,C1894,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
MESH HERN SQ 4X4 IN FULL RESRB FOR SFT TISS RECON PHASIX,SUP-2855249,CDM,C1781,HCPCS,0278,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
MESH HERN DIA20CM POLY SYN CLLGN COAT RND OPTIMIZED COMP,SUP-2174717,CDM,C1781,HCPCS,0278,RC,,,,both,,,2345.36,1524.48,,,,,,,,,,,,,
PLATE SPNL L40MM THORLUM TRUSS,SUP-2230316,CDM,C1713,HCPCS,0278,RC,,,,both,,,13407.80,8715.07,,,,,,,,,,,,,
KIT HAD AD L33CM OD14.5FR STD BASIC SGL LUMN POLYUR PRECRV,SUP-2127854,CDM,C1750,HCPCS,0278,RC,,,,both,,,1529.81,994.38,,,,,,,,,,,,,
PROCHLORPERAZINE MALEATE 10 MG PO TABS,RX-6582,CDM,Q0164,HCPCS,0637,RC,00904-7382-06,NDC,,both,1,UN,6.20,4.03,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR CUST FIG OF EIGHT DESIGN ABDUCTN,SUP-2435750,CDM,L3650,HCPCS,0274,RC,,,,both,,,185.67,120.69,,,,,,,,,,,,,
CATHETER HD STR 15.5 FRX32 CM SHT TERM 3L T-3 CT,SUP-2627216,CDM,C1752,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
MESH CRAN SM THK0.4MM LT ORBIT TI CNTOUR W/ CUT GUID FOR,SUP-2135915,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
HC Inj Proc Ankle Arthrography,PX-3612764800,CDM,27648,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
HC Transcatheter Biopsy,PX-3613720000,CDM,37200,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BNE STR 1.5X28X0.8 MM MIDFACE 6 HOLE W/ TAB TI STRL,SUP-2483854,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
HC Endo Level 3 Addl 15 Min,PX-3600007513,CDM,3600007513,LOCAL,0360,RC,,,,both,,,2331.00,1515.15,,,,,,,,,,,,,
CATHETER VALVULOPLASTY ZMED L 85 CM DIA 6 FR 3 CM 10 MM,SUP-2659352,CDM,C1725,HCPCS,0272,RC,,,,both,,,1252.64,814.22,,,,,,,,,,,,,
TRAY TK2 INSTRUMENT,SUP-2724037,CDM,C1725,HCPCS,0272,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
BIT DRL QC 4.3X230 MM PROX TIB NCB,SUP-2457075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,848.68,551.64,,,,,,,,,,,,,
CAP END DIA12MM EXTN 0MM TI CANN LOK HD FOR 9-12MM FEM NAIL,SUP-2192362,CDM,C1713,HCPCS,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
PLATE BNE 4 SLOT 120 DEG PEDIATRIC,SUP-2535994,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.93,1431.25,,,,,,,,,,,,,
CUTTER SURG OD15MM BLK CUT ST DISP FOR ROTOCUT G1 MORSLZR,SUP-2261064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2136.46,1388.70,,,,,,,,,,,,,
HC Onc Sol Tum Cfdna&Rna Ngs IR Gm CHIP Tum-Drv Snv,PX-3100485066,CDM,0485U,CPT,0310,RC,,,,both,,,3831.00,2490.15,,,,,,,,,,,,,
JOINT TOE 10 DEG 2.4 MM NS EXTREMIFUSE LTX,SUP-2856276,CDM,C1776,CPT,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
STEM FEM CEM STD OFFSET FORGED TI ALLOY SZ 1 ACUMATCH L SER,SUP-2221718,CDM,C1776,CPT,0278,RC,,,,both,,,4647.20,3020.68,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40 CM 7 MM POLYESTER BOV CLLGN STR,SUP-2266035,CDM,C1768,CPT,0278,RC,,,,both,,,1637.54,1064.40,,,,,,,,,,,,,
HANDLE DETACH FOR EMB COIL RUBY,SUP-2323706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
HC External Ecg Rec>7d<15d Recording,PX-7309324600,CDM,93246,CPT,0731,RC,,,,both,,,381.00,247.65,,,,,,,,,,,,,
KIT SCR L90-95MM LAG COMPR INTEGR META-TAN,SUP-2340869,CDM,C1713,HCPCS,0278,RC,,,,both,,,4096.60,2662.79,,,,,,,,,,,,,
STAPLE INT FIX W20XL20MM THK2.5X1.6MM ANK FT SUP E EASYCLIP,SUP-2378848,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
COMPONENT FEM ENDO KNEE SM LT,SUP-2265071,CDM,C1776,CPT,0278,RC,,,,both,,,18312.48,11903.11,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|CQ|XU,both,,,144.00,93.60,,,,,,,,,,,,,
PATCH BIO L 4 X W 4 CM BOV PERICARD STRL XENOSURE,SUP-2884021,CDM,C1768,CPT,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
BLADE EXTR 58MM FULL HMSPHR FOR ACET SHELL REM SYS EXPLANT,SUP-2202794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC Rmvl FB Cornea WO Slit Lamp,PX-4506522000,CDM,65220,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
BUR SURG OD2.1MM XCUT FISS RND N FLUT TPS ELITE,SUP-2419777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.96,288.57,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MESHED 4X2 CMX0.3 MM PERITONEUM MTRX MESO,SUP-2491346,CDM,C1762,CPT,0278,RC,,,,both,,,1185.41,770.52,,,,,,,,,,,,,
PLATE BONE L89MM 7 H LCK COMPR FOR 3.5MM SCR,SUP-2349158,CDM,C1713,HCPCS,0278,RC,,,,both,,,1195.15,776.85,,,,,,,,,,,,,
GUIDE WIRE USE WITH BOUGIES 745710/11/12/13,SUP-2574268,CDM,C1769,HCPCS,0272,RC,,,,both,,,102.55,66.66,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN TAPR L7CM FLPY TIP L3CM,SUP-2167925,CDM,C1769,HCPCS,0272,RC,,,,both,,,76.02,49.41,,,,,,,,,,,,,
ASSEMBLY BLDE DISP FOR SMARTREL ENDOSCP CRPL TUNN REL SYS 6,SUP-2303824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,795.46,517.05,,,,,,,,,,,,,
REDUCER ORTH RADLUC STRL DISP DYNABUNION,SUP-2907568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3759.90,2443.93,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE ER 1000-62.5 MG PO TB12,RX-33862,CDM,6370000000,HCPCS,0637,RC,00781-1943-82,NDC,,both,1,UN,30.40,19.76,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC DEMINERALIZED BNE MTRX FIBER ALLOFIBER,SUP-2759529,CDM,C1713,HCPCS,0278,RC,,,,both,,,4735.12,3077.83,,,,,,,,,,,,,
PLATE BNE 5 H 7 PEG STD R VOLAR S STL BEAR,SUP-2389757,CDM,C1713,HCPCS,0278,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
SYSTEM FIX ACL KNEE ADJ 4 PT LCK W/ 9MM FLIPCUTTER II,SUP-2121389,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
PIN DRL 9MM ACL PCL KNEE RG ALL IN 1 GUID RMR FLIPCUTTER II,SUP-2120818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DBM PTTY INJ BIOCOMPOSITE ALLMTRX,SUP-2399057,CDM,C9359,HCPCS,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
WIRE FIX DBL END TROCAR PT 0.9X150 MM SMOOTH KIRSCHNER,SUP-2321642,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.58,558.73,,,,,,,,,,,,,
STRYKER REPLACEMENT BLADE 13X90X0.89MM,SUP-2605749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,101.48,65.96,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK CATH AXS VECTA 46 VECTA 71,SUP-2878080,CDM,C1757,HCPCS,0272,RC,,,,both,,,12566.28,8168.08,,,,,,,,,,,,,
HEAD HUM DIA45MM THK18MM SHLDR CO CHROM PRI STD OFFSET NK 53504518] STRYKER ORTHOPEDICS HOWM],SUP-2372837,CDM,C1776,CPT,0278,RC,,,,both,,,4468.19,2904.32,,,,,,,,,,,,,
LOSARTAN POTASSIUM 50 MG PO TABS,RX-14824,CDM,6370000000,HCPCS,0637,RC,00904-7048-61,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
CAGE SPNL W18XH10XL45MM 15DEG C FBR REINF POLYMER,SUP-2418473,CDM,C1889,HCPCS,0278,RC,,,,both,,,334.88,217.67,,,,,,,,,,,,,
HEAD FEM SZ -6MM CO CHROM SLD MOD M2A 38,SUP-2404335,CDM,C1776,CPT,0278,RC,,,,both,,,4108.53,2670.54,,,,,,,,,,,,,
PLATE BNE MESHED 0.6X90X90 MM UN3 GLD,SUP-2363581,CDM,C1713,HCPCS,0278,RC,,,,both,,,4970.62,3230.90,,,,,,,,,,,,,
CAGE SPNL XL 12X22X55 MM COROENT,SUP-2310950,CDM,C1889,HCPCS,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED MED 8 IN LT WRST FOREARM THMB,SUP-2276633,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.58,14.68,,,,,,,,,,,,,
LIDOCAINE HCL (PF) 4 % IJ SOLN,RX-133084,CDM,J2003,HCPCS,0636,RC,00409-4283-01,NDC,,both,2.5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW INTFR L20MM OD9MM UNIV TI KNEE CANN FULL THRD TAPR,SUP-2137211,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
BAND INT FIX WIDE 4 MM,SUP-2734577,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.95,826.77,,,,,,,,,,,,,
HC Elbow 2 Views,PX-3207307000,CDM,73070,CPT,0320,RC,,,,both,,,496.00,322.40,,,,,,,,,,,,,
ELECTRODE EMG GRND PD STIMULUS RET NDL NONSTERILE DISPOSABLE,SUP-2292835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1647.87,1071.12,,,,,,,,,,,,,
URETEROSCOPE DGT FLX SHTH GLOB STD MOB CART CMSO IMAGER,SUP-2139385,CDM,C1747,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
IMPLANT PHALANX 45MM MID ST NEXTRA,SUP-2137581,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.78,786.36,,,,,,,,,,,,,
GRAFT ALLODERM SELECT REGENERATIVE TISSUE MATRIX 2X4,SUP-2665173,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
KIT TKR 3 STD TIB PREP CRUCE RET DISPOSABLE TRIATHLON PRECIS,SUP-2373668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
OVERTUBE ENDOSCP 50 CM GAST GUARDUS DISP,SUP-2847340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,708.86,460.76,,,,,,,,,,,,,
GRAFT ENDOVASC UNCVR L20MM CVR L95MM DIA28X28MM AFX,SUP-2217604,CDM,C1768,CPT,0278,RC,,,,both,,,13313.60,8653.84,,,,,,,,,,,,,
NAIL IM AD L34MM DIA8.5MM RT TROCHANTERIC FEM ROSE TI CANN,SUP-2347332,CDM,C1713,HCPCS,0278,RC,,,,both,,,12091.83,7859.69,,,,,,,,,,,,,
PLATE BNE CRV 3.5X213 MM RT PROX HUM 15 HOLE EVOS,SUP-2424160,CDM,C1713,HCPCS,0278,RC,,,,both,,,10310.03,6701.52,,,,,,,,,,,,,
VALVE CSF PRESSURE STD HI ULTRAVS,SUP-2666748,CDM,C1889,HCPCS,0278,RC,,,,both,,,1657.29,1077.24,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 5 MM STR STD WALL REINF,SUP-2461766,CDM,C1768,CPT,0278,RC,,,,both,,,914.27,594.28,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 15 MM BALLOON L 17 MM DIA 6.5 MM,SUP-2155764,CDM,C1876,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
GUIDEWIRE VASC L 200 CM 0.035IN L 6CM 2.5CM SAFE-T-J FIX COR,SUP-2167606,CDM,C1769,HCPCS,0272,RC,,,,both,,,66.60,43.29,,,,,,,,,,,,,
SUPPORT ORTHOT CERV THOR LUMBAR SACR CUST ANTR POST LAT CTRL,SUP-2435561,CDM,L0700,HCPCS,0274,RC,,,,both,,,5636.11,3663.47,,,,,,,,,,,,,
HC So1 Acetylcholn Rcptr Bndng Antb,PX-3028604167,CDM,86041,CPT,0302,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
STEM FEM L140MM OD7MM CO CHROM INTLOK HIP PRI CEM TAPR NEUT,SUP-2403345,CDM,C1776,CPT,0278,RC,,,,both,,,9551.88,6208.72,,,,,,,,,,,,,
GUIDEWIRE UROLOGY ANGLED 0.025 INX150 CM COR HIWIRE,SUP-2835976,CDM,C1769,HCPCS,0272,RC,,,,both,,,105.41,68.52,,,,,,,,,,,,,
COMPONENT TOE SZ 1 METATARSAL DCOMPR IMPL,SUP-2398622,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
COMPONENT FEM L R TROCHLEAR LCS,SUP-2250099,CDM,C1776,CPT,0278,RC,,,,both,,,9570.72,6220.97,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP LT DSTL FEM NO CART,SUP-2867023,CDM,C1762,CPT,0278,RC,,,,both,,,12349.62,8027.25,,,,,,,,,,,,,
PLATE BNE L LG 100 DEG 1.5X24X1 MM MIDFACE 7 W/ TAB STRL,SUP-2461633,CDM,C1713,HCPCS,0278,RC,,,,both,,,855.34,555.97,,,,,,,,,,,,,
MESH GYN L W8XL24CM FLAT POLYPR FOR TRANSABDOMINAL PELV,SUP-2165310,CDM,C1781,HCPCS,0278,RC,,,,both,,,2923.34,1900.17,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-9.5 MM 90 CC FD CANC,SUP-2717773,CDM,C1713,HCPCS,0278,RC,,,,both,,,2733.65,1776.87,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-15861,CDM,J3490,HCPCS,0258,RC,00338-0085-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
INTRODUCER LAT VEIN L62CM OD5.5FR ADV TELSCP SYS RENAL,SUP-2303515,CDM,C1894,HCPCS,0272,RC,,,,both,,,1205.54,783.60,,,,,,,,,,,,,
CATHETER NEPHSTMY L25CM DIA14FR BLLN L15CM DIA12MM TAMP FOR,SUP-2171207,CDM,C1729,HCPCS,0272,RC,,,,both,,,579.49,376.67,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.035 IN CRV RAD 3 MM SS PTFE,SUP-2167828,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.39,45.10,,,,,,,,,,,,,
PLATE BNE MESHED 82X82X0.3 MM SM GRID PDLLA STRL RESORB X,SUP-2463856,CDM,C1713,HCPCS,0278,RC,,,,both,,,7554.53,4910.44,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 55 CM OD 7 FR GUIDEWIRE 0.018/0.038,SUP-2169823,CDM,C1894,HCPCS,0272,RC,,,,both,,,181.68,118.09,,,,,,,,,,,,,
PANEL CERV CLLR L BK FOR VISTA,SUP-2123901,CDM,L0190,HCPCS,0272,RC,,,,both,,,103.75,67.44,,,,,,,,,,,,,
CEMENT FLX FM/CEM TB/PRLG SURF/TM PT/TP PL,SUP-2212174,CDM,C1776,CPT,0278,RC,,,,both,,,17169.46,11160.15,,,,,,,,,,,,,
BIT DRL 9.3 MM NS GOTFRIED PCCP,SUP-2644757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,764.72,497.07,,,,,,,,,,,,,
CAGE SPNL MESH 28X22X10 MM 6 LOBE,SUP-2602086,CDM,C1889,HCPCS,0278,RC,,,,both,,,8459.16,5498.45,,,,,,,,,,,,,
COMPONENT FEM KNEE YOKE REINF ORTH SALV SYS,SUP-2405843,CDM,C1776,CPT,0278,RC,,,,both,,,3640.83,2366.54,,,,,,,,,,,,,
POST REPROC EXT FIX OUTRIG STR,SUP-2468581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,127.36,82.78,,,,,,,,,,,,,
RADIOGRAPHIC RULER FOR SMALL FRAGMENT PLATES 360MM,SUP-2548115,CDM,C1713,HCPCS,0278,RC,,,,both,,,936.10,608.46,,,,,,,,,,,,,
GRAFT BNE BLOCK 6.25X2X0.4 CM 5 CC PLATFORM CM,SUP-2691580,CDM,C1713,HCPCS,0278,RC,,,,both,,,4304.94,2798.21,,,,,,,,,,,,,
GRAFT CORNEA HUMAN,SUP-2738102,CDM,V2785,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0032IN TIP L3CM STD FLX STR,SUP-2139339,CDM,C1769,HCPCS,0272,RC,,,,both,,,113.70,73.90,,,,,,,,,,,,,
PLATE 4.5MM LCP CONDYLAR 16 HOLES 350MM LEFT STERILE,SUP-2547445,CDM,C1713,HCPCS,0278,RC,,,,both,,,5029.06,3268.89,,,,,,,,,,,,,
PLATE BNE BSSO 2X40 MM SLIDING COLOGNE FOR SCR TI STRL,SUP-2477757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1861.74,1210.13,,,,,,,,,,,,,
PLATE BNE 2 H L CORONOID EL CONG,SUP-2107778,CDM,C1713,HCPCS,0278,RC,,,,both,,,3435.16,2232.85,,,,,,,,,,,,,
DRILL CANNULATED 4.5 MM X 210 MM SONOMA CRX,SUP-2431212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER CTRL VEN QUAD LUMN N TUNNELED FULL KT POLYUR CDC42854PIA] ARROW INTERNATIONAL],SUP-2120622,CDM,C1751,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
PLATE SPNL EXPANDABLE SM PROC AILERON-TRX,SUP-2430758,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
COLLAR CERV ADJ BAR FLX THERMOPLASTIC,SUP-2388137,CDM,L0190,HCPCS,0274,RC,,,,both,,,1222.12,794.38,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ASEP SEMITENDINOSUS W/ GRACILIS,SUP-2867086,CDM,C1762,CPT,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR,RX-37642,CDM,340b,HCPCS,0637,RC,16714-0483-01,NDC,,both,5,ML,10.70,6.95,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 2.7X100/125 MM STERILE TC100 DISPOS,SUP-2837031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,895.47,582.06,,,,,,,,,,,,,
MESH CRANIAL STRAIGHT 1.5X100X100X0.5 MM RAPID RESORBABLE ST,SUP-2838583,CDM,C1713,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
PLATE BNE STR 12X0.6 MM NEURO 2 HOLE TI STRL 251521371,SUP-2459762,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.19,213.32,,,,,,,,,,,,,
CAGE SPNL W11XH4XL14MM CERV FUS SYS CRNRSTN,SUP-2286348,CDM,C1889,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
TAP SURG L110MM QUIK CONN FOR 4MM SCR,SUP-2410964,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
GUIDEWIRE VASC MEISTER L 180 CM DIA 0.016 IN L 5 CM RND CRV,SUP-2879068,CDM,C1769,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
CATHETER THOR L21IN DIA32FR R ANG HYDRAGLIDE SFT RADPQ STRP,SUP-2227334,CDM,C1729,HCPCS,0272,RC,,,,both,,,50.55,32.86,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM LO AIRFLO RESISTANCE PROVOX2,SUP-2124340,CDM,L8509,HCPCS,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,6370000000,HCPCS,0637,RC,00186-0372-28,NDC,,both,6.9,GR,622.90,404.88,,,,,,,,,,,,,
HC Rmvl of Subq Defibrillator,PX-3603327200,CDM,33272,CPT,0360,RC,,,,outpatient,,,12107.00,7869.55,,,,,,,,,,,,,
TAP ORTH OD7MM CANN FOR DARCO 7MM HDLSS COMPR SCR,SUP-2399605,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
HEAD HUM M DIA52MM ECC FOR TOT SHLDR ARTHROPLASTY GLOB,SUP-2250028,CDM,C1776,CPT,0278,RC,,,,both,,,4955.55,3221.11,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY OCTARAY SPLINE 2CM 8FR 2-5-2MM D,SUP-2737873,CDM,C1732,HCPCS,0278,RC,,,,both,,,6810.66,4426.93,,,,,,,,,,,,,
PLATE BNE L48MM THK075MM 12 H NONSTERILE HND TI STR LOK FOR,SUP-2180986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1411.02,917.16,,,,,,,,,,,,,
PIN FIX N THRD 3.5X508 MM ZNN,SUP-2517811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
APPLIER CLP L DIA1.7MM ROT SHFT AND INTEGR CART FOR VES CLSR,SUP-2264247,CDM,C1889,HCPCS,0278,RC,,,,both,,,1676.76,1089.89,,,,,,,,,,,,,
DRILL ENDOSCP 9.5 MM,SUP-2849106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
SCREW BNE L HIP TI LOK SM HD,SUP-2405826,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
FORCEPS SURG SCR FOR CONVENTUS CAGE SYS,SUP-2167424,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HC So Adamts-13 Activity,PX-3058539766,CDM,85397,CPT,0305,RC,,,,inpatient,,,196.00,127.40,,,,,,,,,,,,,
BIT DRL DIA 4.8 MM SHRT FOR HALF PIN NS DISP,SUP-2933111,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1585.76,1030.74,,,,,,,,,,,,,
SYSTEM DBM DEL CRV FINAL ASMBLY STRL DISP,SUP-2884246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2326.74,1512.38,,,,,,,,,,,,,
PACK SURGICAL PROC CUSTOM TISSUE PERFUSION SYSTEM SPY ELITE,SUP-2850065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2028.47,1318.51,,,,,,,,,,,,,
CATHETER HD DL 14.5X23 CM 40 CM ADMIN FULL KT MAHRK MAXID,SUP-2283919,CDM,C1750,HCPCS,0278,RC,,,,both,,,576.50,374.72,,,,,,,,,,,,,
DEVICE PAIN CTRL 100ML 2ML/HR W/ FIX HUB CATH,SUP-2196472,CDM,E0783,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
RETRACTOR ESPOPHAGEAL ESOSURE,SUP-2877141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
PLATE BNE 1MM LAPIDUS STP,SUP-2243209,CDM,C1713,HCPCS,0278,RC,,,,both,,,4641.67,3017.09,,,,,,,,,,,,,
TAP NAV2001 SOLERA AWLTIPTAP 40MM,SUP-2281193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1683.83,1094.49,,,,,,,,,,,,,
GRAFT TISS 1X2 ENT REP BIODESIGN,SUP-2170295,CDM,C1763,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
BLADES HOOK 25 DEGREE STR,SUP-2705990,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.76,341.74,,,,,,,,,,,,,
BIT DRL OD3.2MM HUM AO ADPT SURESHOT,SUP-2347933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 90 CM DIA 7.5 FR GUIDEWIRE 0.038 IN,SUP-2355528,CDM,C1894,HCPCS,0272,RC,,,,both,,,80.07,52.05,,,,,,,,,,,,,
SPLINT ARM M W18XL13IN FOR 6-17IN LIMB TRNSLUC FAB POLYSTYR,SUP-2328639,CDM,L3702,HCPCS,0274,RC,,,,both,,,34.95,22.72,,,,,,,,,,,,,
GRAFT BNE SUB 3CC FILL CALLOS INJ,SUP-2106907,CDM,C1713,HCPCS,0278,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
PLATE BONE L53MM 3X3 H MAND TI LCK FOR 2MM SCR,SUP-2191231,CDM,C1713,HCPCS,0278,RC,,,,both,,,2936.53,1908.74,,,,,,,,,,,,,
PROGRAMMER PT HANDHELD REMOT FOR 7427 SYNERGY EZ,SUP-2284582,CDM,C1787,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM STR STD WALL HELIX,SUP-2695227,CDM,C1768,CPT,0278,RC,,,,both,,,1196.94,778.01,,,,,,,,,,,,,
HC Revasc Intra Lithotrip-Stent,PX-4810976500,CDM,C9765,CPT,0481,RC,,,,inpatient,,,57405.00,37313.25,,,,,,,,,,,,,
IMPLANT FACE 40 X 40 MM THK 8.45 MM POLYETHYL LL ORBIT RIM,SUP-2883315,CDM,C1713,HCPCS,0278,RC,,,,both,,,2144.24,1393.76,,,,,,,,,,,,,
PACK ARTHRO HIP DISP,SUP-2758960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ROD EXT FIX L350MM S STL THRD TELSCP ORIG CIR FOR TAY SPAT,SUP-2342307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.87,296.97,,,,,,,,,,,,,
SHUNT SURG REG 16 GA SNAP ASMBLY BLNT NDL BIOGLDE STRATA II,SUP-2628598,CDM,C1729,HCPCS,0272,RC,,,,both,,,15834.02,10292.11,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO FLO ACTE 11.5FR DIA 24CM MCDLT4424,SUP-2633020,CDM,C1750,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
RADIAL HD INSRT KIT; CONTENTS: CO CHROM TRL HD STEM INSTR,SUP-2397254,CDM,C1776,CPT,0278,RC,,,,both,,,11633.70,7561.90,,,,,,,,,,,,,
PLATE BNE L155MM 6 H NONSTERILE L DST FEM LOK FOR 4.5MM SCR,SUP-2348454,CDM,C1713,HCPCS,0278,RC,,,,both,,,10020.68,6513.44,,,,,,,,,,,,,
SPACER SPNL 12X12X9MM 5DEG CORT FORTIS AC,SUP-2136725,CDM,C1889,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
CATHETER GUID CXI L 150 CM DIA 2.3 FR 0.014 IN SS ANGLED TIP,SUP-2168962,CDM,C1887,HCPCS,0272,RC,,,,both,,,659.37,428.59,,,,,,,,,,,,,
CATHETER 3 LUMN PICC MAXIMAL BARR W/ SHERLOCK 3CG TPS STYL,SUP-2125515,CDM,C1751,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
PLATE BNE 6 H ANODIZATION TYP II CALCANEAL FLAT LP UNIV ANAT,SUP-2902262,CDM,C1713,HCPCS,0278,RC,,,,both,,,5968.51,3879.53,,,,,,,,,,,,,
MESH SURG W25XL45IN POLY NONABSORBABLE RECT MERS,SUP-2219872,CDM,C1781,HCPCS,0278,RC,,,,both,,,502.31,326.50,,,,,,,,,,,,,
CATHETER URET 5/10FR L50CM INJ LUMN DIA0.05IN AQ 2 LUMN,SUP-2168943,CDM,C1758,HCPCS,0278,RC,,,,both,,,153.04,99.48,,,,,,,,,,,,,
IMPLANT TAILORS BUNION MEDIUM,SUP-2662918,CDM,C1713,HCPCS,0278,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
SCREW BNE L40MM DIA4.5MM HUM G TI SELF CUT FULL THRD BLNT,SUP-2180227,CDM,C1713,HCPCS,0278,RC,,,,both,,,874.30,568.29,,,,,,,,,,,,,
SCREW BNE L80MM OD7MM THRD L21MM PUR HINDFOOT ANK CANN M,SUP-2320772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1307.81,850.08,,,,,,,,,,,,,
SPLINT RST PAN MIT SP S LF,SUP-2163830,CDM,L3807,HCPCS,0274,RC,,,,both,,,81.29,52.84,,,,,,,,,,,,,
CATHETER EMB 6FR EPS CTRL FLO PROXIS,SUP-2356604,CDM,C1751,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
BODY TOP LD ILLIAC FIX FOR DEFORMITY CORR SYS FIREBIRD,SUP-2316794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
VALVE PULM SPIRATION CARTRIDGE 5MM BRONCHIAL 1-WAY PRELOADED F/POSTOP AIR LEAK CONTROL,SUP-2313515,CDM,C1889,HCPCS,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
POST EXT FIX 2 H WIRE,SUP-2176966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.90,436.73,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM OD0.025IN OD14FR INTRO 3CM ANG TIP,SUP-2139344,CDM,C1769,HCPCS,0272,RC,,,,both,,,163.03,105.97,,,,,,,,,,,,,
CATHETER INFUSION PMP 4 ML/HR 2X5 IN 275 CC,SUP-2365200,CDM,C2626,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
EXPANDER TISS BRST 6-7.3 CM 14X11.2 460-550 DERMASPAN LPP14R,SUP-2749165,CDM,C1889,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
GUIDEWIRE ORTH 4.3X190 MM SS,SUP-2646008,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.33,61.31,,,,,,,,,,,,,
HC So Bcr/Abl1 Translocation Anal,PX-3108120666,CDM,81206,CPT,0310,RC,,,,both,,,211.00,137.15,,,,,,,,,,,,,
IMPACTOR SURG STR FOR GRFT PYRAMETRIX,SUP-2292625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1382.98,898.94,,,,,,,,,,,,,
PLATE BNE SM L214MM 18 H BILAT S STL LO PROF RIG LIMIT,SUP-2186213,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.41,1395.82,,,,,,,,,,,,,
HC Veno Hepatic W/O Hemo Eval S&I,PX-3207589100,CDM,75891,CPT,0320,RC,,,,outpatient,,,5468.00,3554.20,,,,,,,,,,,,,
GRAFT HUM TISS SZ 7 MM BICORTICAL FT WDG PRESHAPED COTTON,SUP-2913257,CDM,C1713,HCPCS,0278,RC,,,,both,,,6575.16,4273.85,,,,,,,,,,,,,
ROD SPNL STBL SYS AXIALIF 1L +,SUP-2330899,CDM,C1713,HCPCS,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
BRUSH CLN 1.6 MM,SUP-2467620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X28X1.5 MM 4 HOLE FRAC TI STRL LEVEL 1,SUP-2491647,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.87,935.27,,,,,,,,,,,,,
PLATE BNE LINDORF LEFORT MIC 1.5X3X1 MM LT TI LEVEL 1,SUP-2262906,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.90,590.13,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.7 MM 2.54X3.81 MM ARMSTR R TAB SIL STRL,SUP-2535118,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.86,27.86,,,,,,,,,,,,,
PLATE BONE L140MM 135DEG 6 H PELVIS BILAT S STL STD BRL RIG,SUP-2342586,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.00,2593.50,,,,,,,,,,,,,
SPLINT WRST SM L8IN L BLK FOAM D RNG CLSR LO PROF MAL,SUP-2336046,CDM,L3809,HCPCS,0274,RC,,,,both,,,19.19,12.47,,,,,,,,,,,,,
CUTTER ENDOSCP PAT,SUP-2365163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,739.50,480.67,,,,,,,,,,,,,
GRAFT BNE SUB 5CC SYN TISS TRICALCIUM PHSPTE RESRB MORSL,SUP-2368163,CDM,C1713,HCPCS,0278,RC,,,,both,,,1613.02,1048.46,,,,,,,,,,,,,
PROBE HEMSTAS 2.3MM BPLR SGL PLUG DISP,SUP-2313017,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.50,323.37,,,,,,,,,,,,,
INTRODUCER SHTH 11CM X 7FR 40CM X 0.018N NTNL/PLTNM GDWRE 21,SUP-2469012,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.55,87.46,,,,,,,,,,,,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,0636,RC,70069-0301-25,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
KIT EMR L1650MM HRD STR DST CAP DIA139MM W RIM FOR UP GI,SUP-2313207,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.05,427.73,,,,,,,,,,,,,
HC Ivus Initial Vessel,PX-4819297800,CDM,92978,CPT,0481,RC,,,,both,,,2583.00,1678.95,,,,,,,,,,,,,
BLADE SHV DIA4MM STD STR SERR CLS ELITE COMPATIBLE DIEGO DS,SUP-2313525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.87,254.07,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE ADJ MOTN,SUP-2388174,CDM,L2186,HCPCS,0274,RC,,,,both,,,464.97,302.23,,,,,,,,,,,,,
SCREW BNE CANN 8X80 MM TI ASNS III,SUP-2559089,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
ALLOGRAFT BNE 10CC MTRX VIABLE BIO4,SUP-2370454,CDM,C1713,HCPCS,0278,RC,,,,both,,,12151.80,7898.67,,,,,,,,,,,,,
HC So Molec Cytogenics,PX-3118827166,CDM,88271,CPT,0311,RC,,,,both,,,74.00,48.10,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX HUMERUS LONG 6H SHAFT 160MM STER,SUP-2549716,CDM,C1713,HCPCS,0278,RC,,,,both,,,5464.04,3551.63,,,,,,,,,,,,,
PLATE BONE W16XL16MM 4 H BILAT TI BOXED SHP LO PROF RIG NEUT,SUP-2191134,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
TUBE GASTROJEJU 14FR JEJU L15CM STOMA L1.2CM EN LO PROF,SUP-2119810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1527.61,992.95,,,,,,,,,,,,,
CLIP INT DIA21 MM THRD L 165 CM ENDOSCP DIA11.5-14 MM POINTED,SUP-2881855,CDM,C1889,HCPCS,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
COIL EMB L8CM OD4MM 360DEG USFT STRTCH RESIST BIG LOOP,SUP-2365791,CDM,C1889,HCPCS,0278,RC,,,,both,,,7762.71,5045.76,,,,,,,,,,,,,
WIRE OLV SMOOTH 1.6MM COMP/DIST,SUP-2321640,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA 9 FR DIL L 20 CM GUIDEWIRE,SUP-2168024,CDM,C1892,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,CQ,both,,,195.00,126.75,,,,,,,,,,,,,
DEVICE ULTRAGUIDE TFR HANDHELD SINGLE USE,SUP-2860383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
PLATE BNE HK 0.8 MM HND AVULSION STRL,SUP-2518380,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
WASHER ORTH MONSTER FOR 5.5MM SCR FLAT,SUP-2320328,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
CONNECTOR SPINE SPNL SYS TI TSRH 3D ROD 635MM M,SUP-2290000,CDM,C1713,HCPCS,0278,RC,,,,both,,,4107.12,2669.63,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L15MM SYR 30ML 11GA 1ST FRAC,SUP-2293651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
PLATE BONE L35MM THK1MM 2X5 H BILAT HND Y SHP LCK TRILOK FOR,SUP-2267925,CDM,C1713,HCPCS,0278,RC,,,,both,,,2004.26,1302.77,,,,,,,,,,,,,
CONNECTOR SHUNT OD1.9MM TITANIUM STRAIGHT,SUP-2825884,CDM,C1889,HCPCS,0278,RC,,,,both,,,254.75,165.59,,,,,,,,,,,,,
GRAFT SPREADER  AR19007GS,SUP-2843742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.025 INX150 CM EZGLIDER,SUP-2540063,CDM,C1769,HCPCS,0272,RC,,,,both,,,114.92,74.70,,,,,,,,,,,,,
BLADE SURG SAFETY SZ 15C STAINLES STL FLFCRTRDGE BARD PARKER,SUP-2605896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4.36,2.83,,,,,,,,,,,,,
HC Repair of Vagina,PX-4505720000,CDM,57200,CPT,0450,RC,,,,both,,,3074.00,1998.10,,,,,,,,,,,,,
PATCH DURAL 6X8CM POLYESTER URETHANE SYNTHETIC SUBSTITUTE NO,SUP-2826138,CDM,C1763,HCPCS,0278,RC,,,,both,,,1737.83,1129.59,,,,,,,,,,,,,
HC Analysis Pump W/Reprg & Refill,PX-7616236900,CDM,62369,CPT,0761,RC,,,,both,,,925.00,601.25,,,,,,,,,,,,,
BIT DRL DIA9MM ENTRY FOR ANK COMPR NAILING SYS,SUP-2316005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.66,616.63,,,,,,,,,,,,,
SPACER SPNL W12XH18XL14MM 0DEG PEEK OPTMA INTERVERTEBRAL LUM,SUP-2211873,CDM,C1821,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,0636,RC,71288-0115-30,NDC,,both,1,UN,129.60,84.24,,,,,,,,,,,,,
STENT BILI L200MM DIA7MM CATH L135CM DIA6FR 0.035IN NIT OVR,SUP-2420405,CDM,C1876,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
PLATE CRAN 120X80X40 MM PT SPEC IMPL PEEK,SUP-2860140,CDM,C1713,HCPCS,0278,RC,,,,both,,,33842.61,21997.70,,,,,,,,,,,,,
BLADE RTRCTR 1 12NW X 1 14ND STNLSS STEEL GRRTT JARIT LATE,SUP-2703325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,669.01,434.86,,,,,,,,,,,,,
MEMBRANE AMNIO AMNIOFIX ALLGRFT 4.0X4.0CM,SUP-2305730,CDM,V2790,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.7MM STD CORT TI ST NONLOCKING FULL,SUP-2189542,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
FORCEPS BX WRK L110MM CHN L2MM DIA1.7MM SUPERDIMENSION,SUP-2381730,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.28,225.73,,,,,,,,,,,,,
CLIP ANEUR BLDE L5MM 7.8MM OD3.5MM 5.8MM OPN 110GM CLS FORC,SUP-2108528,CDM,C1889,HCPCS,0278,RC,,,,both,,,1361.79,885.16,,,,,,,,,,,,,
SCREW BNE L50MM DIA4.5MM HD DIA6.5MM S STL ST SELF DRL CANN,SUP-2184493,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.06,327.64,,,,,,,,,,,,,
SCREW BNE L11MM OD2.0MM CRANIO MAXILLOFACIAL TI ALLY MINI,SUP-2262638,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.54,69.25,,,,,,,,,,,,,
COLLAR CERV M H3.25IN FOR 13-16IN PLASTAZOTE FOAM 2 PC L,SUP-2336004,CDM,L0140,HCPCS,0272,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
MULTIVIT-MIN GUMMIES CHILDRENS PO CHEW,RX-153023,CDM,6370000000,HCPCS,0637,RC,16500-0599-18,NDC,,both,1,UN,1.00,0.65,,,,,,,,,,,,,
CLAMP EXT FIX SM DIA4/2.5MM OPN ROD TO ROD CONN,SUP-2188700,CDM,C1713,HCPCS,0278,RC,,,,both,,,939.77,610.85,,,,,,,,,,,,,
GRAFT HUM TISS W1.5XL1.5CM AMNIO MEMBRN FOR WND COVERING IN,SUP-2135264,CDM,Q4148,HCPCS,0636,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
WIRE FIX SM KIRSCHNER,SUP-2418530,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
GRAFT DURA L 3 X W 3 IN TYP I CLLGN BOV ACHILLES TEND RESRB,SUP-2889756,CDM,C1763,HCPCS,0278,RC,,,,both,,,2463.55,1601.31,,,,,,,,,,,,,
PLATE BNE SM 2 H 5DEG SHT L DST MTP,SUP-2321454,CDM,C1713,HCPCS,0278,RC,,,,both,,,3713.05,2413.48,,,,,,,,,,,,,
PLATE BNE L260MM 11 H NONSTERILE R LAT PROX TIB TI LOK COMPR,SUP-2190717,CDM,C1713,HCPCS,0278,RC,,,,both,,,4479.87,2911.92,,,,,,,,,,,,,
PLATE BONE L232MM 12 H S STL NAR NONLOCKING COMPR CNTOUR FOR,SUP-2348968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.72,1241.32,,,,,,,,,,,,,
"HC So Morphometric Analy, Comp Asst/Discrt Serv",PX-3128836166,CDM,88361,CPT,0312,RC,,,,outpatient,,,410.00,266.50,,,,,,,,,,,,,
PLATE BNE MINI 4 X 2 HOLE STRUT SLD END THCK MID POST CP TI,SUP-2465522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1295.75,842.24,,,,,,,,,,,,,
ALLOGRAFT BNE SHT 45X20X7 MM DBM CONFORM Q-PACK,SUP-2737086,CDM,C1713,HCPCS,0278,RC,,,,both,,,6899.37,4484.59,,,,,,,,,,,,,
INSERT WEDGE TRIAL,SUP-2473324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1053.28,684.63,,,,,,,,,,,,,
MICRO PLATE 3 X 2 HOLES SQRE SGMNTS 6MM 15MM SSTM CP TTNM,SUP-2681100,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.89,419.18,,,,,,,,,,,,,
HC Ot Vasopneumatic Device Therapy,PX-4309701600,CDM,97016,CPT,0430,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE DIA 7.5 MM SZ 5 CART ARAGONITE POROUS,SUP-2913309,CDM,C1763,HCPCS,0278,RC,,,,both,,,23079.00,15001.35,,,,,,,,,,,,,
BUR SURG OD6MM CRNRSTN,SUP-2363337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.46,444.90,,,,,,,,,,,,,
SPACER TIB SM L10MM DURAMER SL GRDIAN,SUP-2304389,CDM,C1776,CPT,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
STAPLE CARTRIDGE STR 10X7 MM TI,SUP-2166818,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BASKET RETRIEVAL HELICAL PLYP 3X6CM,SUP-2736180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
KIT TRNSPRT CART BX CARTICEL,SUP-2227073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE L116MM THK3.7MM 4 H NONSTERILE R DST MED TIB S,SUP-2185525,CDM,C1713,HCPCS,0278,RC,,,,both,,,3742.63,2432.71,,,,,,,,,,,,,
SPLINT HND M PALM W3-3.5IN RT DORS CRPL TUNN HEAT MOLD,SUP-2332646,CDM,L3808,HCPCS,0274,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
EXPANDER TISS BRST 5.7 CM PROJCT 12X11 CM 340 CC MOD HT ACX,SUP-2340086,CDM,C1789,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
COUNTERSINK SURG OD4.5MM HD SGL USE MONSTER,SUP-2320965,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
DRILL SURG 7.5MM CANN DISP FOR CHARCOT DEFORMITY AXIS,SUP-2223917,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,0636,RC,00264-1944-20,NDC,,both,250,ML,135.20,87.88,,,,,,,,,,,,,
SCREW BNE L16MM OD2MM THRD L12MM TI BRK OFF MONSTER BITE,SUP-2320998,CDM,C1713,HCPCS,0278,RC,,,,both,,,1000.88,650.57,,,,,,,,,,,,,
PL LCKNG RCN ANG ANG34H T28MM,SUP-2680211,CDM,C1713,HCPCS,0278,RC,,,,both,,,8977.98,5835.69,,,,,,,,,,,,,
SCREW STEM SIDE LCK MAK OSS,SUP-2449822,CDM,C1713,HCPCS,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1.7-10 MM 60 CC FD CANC READIGRAFT,SUP-2741072,CDM,C1713,HCPCS,0278,RC,,,,both,,,2186.57,1421.27,,,,,,,,,,,,,
PLATE BNE STR 6 HOLE COMPR NS LTX,SUP-2855839,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
SIZER SURG NACL 13.3-13.2 CM 350-370 CC 68LP NATRELLE,SUP-2493745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
BRACE KNEE BLEDSOE BRAC II,SUP-2341214,CDM,L1810,HCPCS,0274,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
SCREW BNE 1.5X18MM CORT HEXADRIVE 4,SUP-2268057,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.66,158.38,,,,,,,,,,,,,
BOOT FT FLEECE MED ANK CONTRACTURE W/ OUT SOLE,SUP-2336234,CDM,L4396,HCPCS,0274,RC,,,,both,,,137.41,89.32,,,,,,,,,,,,,
KIT BNE CEM MIX W/ SHT EXTN TB HV W/OUT NDL PRECIS SYS,SUP-2367031,CDM,C1713,HCPCS,0278,RC,,,,both,,,1815.64,1180.17,,,,,,,,,,,,,
SET LD EXTRACTION BYRD WORKSTATION INTRO 16 FR SHTH 12 FR,SUP-2169003,CDM,C1773,HCPCS,0272,RC,,,,both,,,3035.69,1973.20,,,,,,,,,,,,,
STEM HUM SZ 5 L100MM NEXEL,SUP-2402659,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
"HC Neuromuscular Re-Education, Ot|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS",PX-4309711200,CDM,97112,CPT,0430,RC,,,GP|CQ,both,,,159.00,103.35,,,,,,,,,,,,,
MESH HERN SM DIA7.6CM VENTRAL POLYPR EPTFE CIR SELF EXP,SUP-2125712,CDM,C1781,HCPCS,0278,RC,,,,both,,,1166.20,758.03,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7050,HCPCS,0250,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
SCREW DIAM 5MM L35MM PARTIALLY THRD,SUP-2243624,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.84,764.30,,,,,,,,,,,,,
LINER ACET 36X58 MM HIP CERM BIOLOX FORTE R3,SUP-2434792,CDM,C1776,CPT,0278,RC,,,,both,,,5545.24,3604.41,,,,,,,,,,,,,
PACEMAKER RATE RESPON SGL CHMBR IS 1 CONN W/ WIRELESS,SUP-2357690,CDM,C1786,HCPCS,0275,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
TUBE SUCTION BARON 3.3 MMX19 CM,SUP-2473711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,809.27,526.03,,,,,,,,,,,,,
PLATE LOCKING STRAIGHT 1.3MM 6 HOLES-STERILE,SUP-2546060,CDM,C1713,HCPCS,0278,RC,,,,both,,,1247.90,811.13,,,,,,,,,,,,,
HC Crystals-Joint Fluid,PX-3008906000,CDM,89060,CPT,0300,RC,,,,both,,,159.00,103.35,,,,,,,,,,,,,
SYSTEM VAC MX 3 CLEARMIX,SUP-2206138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HC C-Reactive Protein High Sensitivity,PX-3028614100,CDM,86141,CPT,0302,RC,,,,outpatient,,,192.00,124.80,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL SIL GEL,SUP-2435703,CDM,L3003,HCPCS,0274,RC,,,,both,,,493.26,320.62,,,,,,,,,,,,,
ROD GUIDE ALIGN SET PROPHECY,SUP-2304848,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SCREW BONE CRANIO MAXILLOFACIAL CROSS FIT ST TI 2MM DIA 20MM,SUP-2363432,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.25,182.16,,,,,,,,,,,,,
BEARING TIB M A5 THK5MM UNIV R LAT L MED CO CHROM ARCM UNI,SUP-2409282,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BNE W175XL443MM THK52MM 24 H S STL BROAD CRV LOK,SUP-2185326,CDM,C1713,HCPCS,0278,RC,,,,both,,,4259.35,2768.58,,,,,,,,,,,,,
SHEATH INTRO L28CM DIA20FR POLYETH HYDRPHLC W/O CRV HEMSTAT,SUP-2396258,CDM,C1894,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
COMPONENT PATELLAR AUG KNEE,SUP-2201425,CDM,C1776,CPT,0278,RC,,,,both,,,11705.92,7608.85,,,,,,,,,,,,,
ENTACAPONE 200 MG PO TABS,RX-26547,CDM,6370000000,HCPCS,0637,RC,27241-0049-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ELECTRODE ES RESECT W HF CBL PLSM RLER,SUP-2419640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1673.21,1087.59,,,,,,,,,,,,,
CUP ACET OD56MM ID48MM HA FOR DYSPLASIA BIRMINGHAM,SUP-2350869,CDM,C1776,CPT,0278,RC,,,,both,,,12795.50,8317.07,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH ULTRA L 13 CM DIA 8 FR GUIDEWIRE L,SUP-2159475,CDM,C1894,HCPCS,0272,RC,,,,both,,,873.08,567.50,,,,,,,,,,,,,
PLATE BNE SPCR 3MM 4 H NONSTERILE MIDFOOT S STL VAR ANG LOK,SUP-2184806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.28,1946.93,,,,,,,,,,,,,
PLATE BONE W8XL76MM THK2MM 0DEG 9 H BILAT TI STR RIG DYN,SUP-2191073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1644.54,1068.95,,,,,,,,,,,,,
AMNION THICK 2X2,SUP-2811351,CDM,C1762,CPT,0278,RC,,,,both,,,2784.80,1810.12,,,,,,,,,,,,,
SCREW SET 0.25-32 IN FLSH BRK STRL CD HORZ,SUP-2629305,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
STEM FEM SZ 9 L155MM DIA15MM -5MM OFFSET DST HIP TI ALLY HA,SUP-2379090,CDM,C1776,CPT,0278,RC,,,,both,,,12426.86,8077.46,,,,,,,,,,,,,
BIT DRL J NOTCH 1.19X115 MM TWST,SUP-2423220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
GRAFT SFT TISS 4 MMX26 CM ACTIVE TEND HUNTER,SUP-2517187,CDM,C1763,HCPCS,0278,RC,,,,both,,,4267.26,2773.72,,,,,,,,,,,,,
PROBE ARTHROSCOPIC X-LARGE 18CM 90DEG EXTENDED LENGTH WITH S,SUP-2824213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
STEM FEM PRSS FT 4 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267798,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 6 CM OD 5.5 FR ID 1.8 MM 0.035IN,SUP-2633272,CDM,C1894,HCPCS,0272,RC,,,,both,,,82.24,53.46,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 8 CM TIP L 3 CM,SUP-2638712,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.54,123.85,,,,,,,,,,,,,
GRAFT HUM TISS FRZN HEMI PAT LIGMNT,SUP-2113903,CDM,C1713,HCPCS,0278,RC,,,,both,,,8870.50,5765.82,,,,,,,,,,,,,
COMPONENT KNEE INLAY 11 UNI,SUP-2378876,CDM,C1776,CPT,0278,RC,,,,both,,,10799.97,7019.98,,,,,,,,,,,,,
DRILL GUIDE HANDLE 23MM LAG SCREW TECHNIQUE,SUP-2696051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
COMPONENT FEM 7 LT KNEE OXINIUM PRI CEM BICOMPARTMENTAL,SUP-2346428,CDM,C1776,CPT,0278,RC,,,,both,,,13470.60,8755.89,,,,,,,,,,,,,
HC Repair Tongue Laceration,PX-4504125100,CDM,41251,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
ELECTRODE ELECSURG COAG 24/26 FR BPLR PT EXT LEN,SUP-2433932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1472.09,956.86,,,,,,,,,,,,,
CONNECTOR SPNL DOMINO 3.5-4.75 MM AX INFIN,SUP-2631931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
BIT DRL QC 2X110 MM 30 MM CALIB NS,SUP-2757822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.14,256.84,,,,,,,,,,,,,
ANCHOR SUT L16.3MM DIA5.5MM TI W/ TWO SZ 2 TIGERTAIL CRKSCR,SUP-2121573,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
MARKER SURG R HK DISPOSABLE FOR M8 SPNL SYS CDH,SUP-2293465,CDM,A4648,CPT,0278,RC,,,,both,,,427.17,277.66,,,,,,,,,,,,,
GUIDEWIRE STR BENT TYP STIFF 0038INX150CM ZIPWIRE,SUP-2139351,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.56,109.56,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CATH 6FR L480CM 0.025IN DOME TIP FOR,SUP-2169530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
GRAFT VASC STR WVN DBL VEL 22MM DIAX15CM L HEMSHLD PLAT,SUP-2227696,CDM,C1768,CPT,0278,RC,,,,both,,,1446.13,939.98,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN PTFE STR TIP,SUP-2147057,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.08,18.90,,,,,,,,,,,,,
CAGE SPNL MESH 22X17X15 MM 6 LOBE,SUP-2602083,CDM,C1889,HCPCS,0278,RC,,,,both,,,10066.84,6543.45,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA IR 4FR 55CM 2 LUMA S3294335,SUP-2632847,CDM,C1751,HCPCS,0278,RC,,,,both,,,466.98,303.54,,,,,,,,,,,,,
GRAFT WEDGE BNE COTTON 8MM 30X16MM BONUS,SUP-2656709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1485.85,965.80,,,,,,,,,,,,,
IMMOBILIZER SHLDR XL L20IN D10IN UNIV POLY COT W/ FOAM STRP,SUP-2196946,CDM,L3650,HCPCS,0272,RC,,,,both,,,24.21,15.74,,,,,,,,,,,,,
SET DLYS HEMDLYS ACCS HEM CATH,SUP-2117387,CDM,C1881,HCPCS,0278,RC,,,,both,,,160.77,104.50,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SFT LN ACTE 11.5FR DIA 12CM IN T114IJ2,SUP-2633026,CDM,C1752,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
MESH BONE 126MMW X 126MML 1MM THK RSRB X GRDN STYLE LATEX FR,SUP-2681140,CDM,C1713,HCPCS,0278,RC,,,,both,,,11274.04,7328.13,,,,,,,,,,,,,
COLLAR CERV REG AD XTW EXT WR LF,SUP-2335999,CDM,L0120,HCPCS,0274,RC,,,,both,,,51.43,33.43,,,,,,,,,,,,,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,J0571,HCPCS,0637,RC,00904-7154-04,NDC,,both,1,UN,10.60,6.89,,,,,,,,,,,,,
INTRODUCER SHTH RED HUB 4FRX23CM PRELUDE,SUP-2303264,CDM,C1894,HCPCS,0272,RC,,,,both,,,44.09,28.66,,,,,,,,,,,,,
CATHETER HD SHT TERM 11.5 FRX18 CM FULL KINK RESIST HEMCATH,SUP-2627418,CDM,C1752,HCPCS,0278,RC,,,,both,,,732.88,476.37,,,,,,,,,,,,,
PLATE BNE 1X2 H CRANIOMAXILLOFACIAL TI DBL Y SHP FOR 1MM,SUP-2190611,CDM,C1713,HCPCS,0278,RC,,,,both,,,1061.63,690.06,,,,,,,,,,,,,
SCREW BNE L 95 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931848,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.84,71.40,,,,,,,,,,,,,
AIRWAY ESOPH 4 AD 30 CC FLX CUF REINF WIRE TBNG LMA FASTRACH,SUP-2383563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.86,568.01,,,,,,,,,,,,,
S-T CRTX SCRW 18MM 3.5MM,SUP-2844053,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.30,151.64,,,,,,,,,,,,,
CUTTER LINEAR PWR LNG 45 MM ARTICULATING ENDOSCP ECHELON,SUP-2851474,CDM,2720000010,LOCAL,0272,RC,,,,both,,,959.33,623.56,,,,,,,,,,,,,
CATHETER ANGIO ARW BERMAN L 90 CM DIA 6 FR BALLOON DIA10 MM,SUP-2383246,CDM,C1725,HCPCS,0272,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
CATHETER GUID L49CM OD8FR INTRO LD PLCMNT COR SNUS ACCS N,SUP-2148926,CDM,C1887,HCPCS,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
SUTURE ANCHR Q-FIX MINI ALL SUT 1.8MM,SUP-2341944,CDM,C1713,HCPCS,0278,RC,,,,both,,,1259.93,818.95,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,,both,1000,ML,93.50,60.77,,,,,,,,,,,,,
KIT URO STENT L24CM DIA6FR DBL PGTL RADPQ THRD HYDRPHLC FLEX,SUP-2171443,CDM,C2617,HCPCS,0278,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
TUBE JEJUSTMY 26FR BLLN 7 10ML JEJU L579CM SIL INFL GAST,SUP-2236871,CDM,C1713,HCPCS,0278,RC,,,,both,,,559.33,363.56,,,,,,,,,,,,,
SET INTRO PEELWY L 24 CM OD 7 FR DIL 34 IN GUIDEWIRE 0.038,SUP-2638745,CDM,C1894,HCPCS,0272,RC,,,,both,,,409.90,266.43,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP 0.035 INX150 CM TRCE HYBRID,SUP-2759288,CDM,C1769,HCPCS,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
GRAFT BONE SUB 5ML PUTTY W/ RPM INJ CANC RESRB PUROS,SUP-2415794,CDM,C1713,HCPCS,0278,RC,,,,both,,,3717.76,2416.54,,,,,,,,,,,,,
STENT URET MARD L 24-30 CM DIA 6 FR PERCFLX HYDROPLUS SFT,SUP-2141625,CDM,C2617,HCPCS,0278,RC,,,,both,,,402.71,261.76,,,,,,,,,,,,,
NEEDLE PROC CRV PEDIATRIC 19/22 GAX56 CM BRCKNBRGH,SUP-2749550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GUIDEWIRE URO L145CM OD0.038IN TIP L7CM SLIP COAT NIT PLAT,SUP-2171305,CDM,C1769,HCPCS,0272,RC,,,,both,,,147.71,96.01,,,,,,,,,,,,,
COLLAR CERV L AD H5XL21.5IN M DENS CNTCT CLSR FOAM W/ STOCK,SUP-2198741,CDM,L0120,HCPCS,0272,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
NEEDLE BX 19GA L137.5-141.5CM CHN 2.8MM SHTH DIA1.73MM US,SUP-2149651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1681.78,1093.16,,,,,,,,,,,,,
GRAFT HUM TISS 2X4CM 0.4-1MM THN REGENERATIVE TISS MTRX,SUP-2399078,CDM,C1713,HCPCS,0278,RC,,,,both,,,3275.33,2128.96,,,,,,,,,,,,,
KIT SEP W/ BLD DRAW TB SYR NDL TRNQT PD,SUP-2402596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE BONE BIOBRIDGE 110MM RIB 18 HOLE RESORBABLE,SUP-2837606,CDM,C1713,HCPCS,0278,RC,,,,both,,,3372.36,2192.03,,,,,,,,,,,,,
IMPLANT SYNTH L 70 X W 70 MM THK 10 MM SM POLYETHYL TEMPORAL,SUP-2883391,CDM,C1713,HCPCS,0278,RC,,,,both,,,4812.11,3127.87,,,,,,,,,,,,,
INSERT TIB THK 10 MM SZ 4 UHMWPE RT ANK ANTR BIASED STRL,SUP-2932796,CDM,C1776,CPT,0278,RC,,,,both,,,13145.77,8544.75,,,,,,,,,,,,,
COLLAR CERV L13-16IN H2.5IN UNIV TRACH OPN ADJ AD SIERRA,SUP-2123895,CDM,L0172,HCPCS,0274,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
MATRIX BIO L 6 X W 4 CM FISH SKIN DERMAL INTACT STRL OMEGA3,SUP-2909263,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
PLATE BNE L239MM 14 H ST R MED DST TIB S STL LOK COMPR LO,SUP-2177455,CDM,C1713,HCPCS,0278,RC,,,,both,,,4294.89,2791.68,,,,,,,,,,,,,
SCREW SPNL STR RAIL 4.5X500 MM DEFORMITY COCR MESA RAIL 4D,SUP-2538577,CDM,C1713,HCPCS,0278,RC,,,,both,,,6343.05,4122.98,,,,,,,,,,,,,
STEM RADIAL MED 6.5 ULN WRST MOD COCR 1ST CHOICE,SUP-2852862,CDM,C1776,CPT,0278,RC,,,,both,,,14249.45,9262.14,,,,,,,,,,,,,
PLATE PL LAT SUPP 2.7/3.5MM 9H LT 153MM XLNG TI DHP STRL,SUP-2546779,CDM,C1713,HCPCS,0278,RC,,,,both,,,4646.79,3020.41,,,,,,,,,,,,,
LINER HUM DIA52MM SHLDR ARCM BPLR ABS,SUP-2404525,CDM,C1776,CPT,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
HFN RH 130 DEG 15MM X 360MM,SUP-2588704,CDM,C1713,HCPCS,0278,RC,,,,both,,,7503.03,4876.97,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LG FD IRRADIATED FASC LATA,SUP-2867198,CDM,C1762,CPT,0278,RC,,,,both,,,4182.17,2718.41,,,,,,,,,,,,,
GRAFT VASC GELSFT ERS L 40 CM SUPP L 20 CM DIA 8 MM,SUP-2384972,CDM,C1768,CPT,0278,RC,,,,both,,,1407.72,915.02,,,,,,,,,,,,,
PIN FIX ACL PCL WIRE PAC A FOR FAST-FIX 360 MENIS REP SYS,SUP-2341564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE CUST DR BERGER,SUP-2110978,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.09,411.51,,,,,,,,,,,,,
BIT DRL CANN MINI 4 MM BLU,SUP-2543593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,782.49,508.62,,,,,,,,,,,,,
PLATE BONE TI 8 HOLEXSHAPED FOR 2.4MM SCR RIG STRNL SYS,SUP-2136977,CDM,C1713,HCPCS,0278,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
PLATE BNE Y 1.5X29X1 MM MIDFACE 7 HOLE W/ TAB TI LEVEL 1,SUP-2422379,CDM,C1713,HCPCS,0278,RC,,,,both,,,815.93,530.35,,,,,,,,,,,,,
PLATE BNE L109MM 6 H NONSTERILE R PROX TIB S STL,SUP-2185698,CDM,C1713,HCPCS,0278,RC,,,,both,,,3692.80,2400.32,,,,,,,,,,,,,
OSSEOFLEX SB STRAIGHT BLLN 10GA2ML,SUP-2702114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2705.64,1758.67,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE 2X2CM,SUP-2307618,CDM,Q4128,HCPCS,0636,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
LINER ACET OD56MM ID32MM 10DEG MARATHON CEMENTLESS RECON,SUP-2250545,CDM,C1776,CPT,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
SET INT FIX DIA18.5 MM TI NEURO XDRV 12 PK STRL DISP LORENZ,SUP-2935186,CDM,C1713,HCPCS,0278,RC,,,,both,,,26099.68,16964.79,,,,,,,,,,,,,
SCREW BONE 40MM LENGTH 45MM LOCKING CAP,SUP-2586706,CDM,C1713,HCPCS,0278,RC,,,,both,,,1005.68,653.69,,,,,,,,,,,,,
GUIDEWIRE VASC L600MM DIA3.2MM FOR IMPL NAIL PANTA 2,SUP-2244338,CDM,C1769,HCPCS,0272,RC,,,,both,,,687.19,446.67,,,,,,,,,,,,,
SYSTEM GWIRE L300CM DIA0035IN STD STEER HYDROPHOBIC STR TIP,SUP-2281749,CDM,C1769,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
INSERT TIB XL THK13MM AP58MM ML82MM UNIV CNDYL KNEE NEUT,SUP-2377421,CDM,C1776,CPT,0278,RC,,,,both,,,1957.35,1272.28,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 40 CM DIA 7 MM THK 0.35 MM POLYESTER,SUP-2227610,CDM,C1768,CPT,0278,RC,,,,both,,,1566.36,1018.13,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM DIA28 MM POLYESTER BOV CLLGN,SUP-2265924,CDM,C1768,CPT,0278,RC,,,,both,,,1921.30,1248.84,,,,,,,,,,,,,
STEM TIB SM-XL L3IN OD10MM KNEE FIN ADVTM,SUP-2304377,CDM,C1776,CPT,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
CANNULA ENDOSCP STD 2 MMX95 CM STYL BVL TIP HRD RETROGRADE,SUP-2539546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,240.15,156.10,,,,,,,,,,,,,
PIN HALF THRD 3X100 MM 20 MM,SUP-2197279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CATHETER ABLATN A 2-5-2 MM 4 MM 6 FRX92 CM UNIDIR LF,SUP-2248664,CDM,C1733,HCPCS,0272,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
PLATE BNE TIB ANTR DSTL 15 HOLE,SUP-2751182,CDM,C1713,HCPCS,0278,RC,,,,both,,,4304.94,2798.21,,,,,,,,,,,,,
KIT CATH PICC ERGOPACK MAX BARRIER SAFETY 5FR 55CM 2-LUMEN,SUP-2887020,CDM,C1751,HCPCS,0278,RC,,,,both,,,556.41,361.67,,,,,,,,,,,,,
HC Tissue Homogenization,PX-3008717600,CDM,87176,CPT,0300,RC,,,,both,,,41.00,26.65,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L25CM EXTN NEUROMODULATION,SUP-2138802,CDM,C1883,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
AUGMENT FEMORALXSM THK4MM STD RT POST KNEE TI CEM BLK,SUP-2406979,CDM,C1776,CPT,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
MINI PLATE 20 3 ROUND HOLES L 17,SUP-2704952,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.38,154.30,,,,,,,,,,,,,
DEVICE PESSARY NO5 DIA1.75IN SIL CUBE VAULT TRIMO SAN JEL,SUP-2171732,CDM,A4562,HCPCS,0272,RC,,,,both,,,112.79,73.31,,,,,,,,,,,,,
KIT INSRT 7FR L1900MM COMPATIBLE W STNT SZ 1 ACT BILI STNT,SUP-2421735,CDM,C1769,HCPCS,0272,RC,,,,both,,,262.50,170.62,,,,,,,,,,,,,
NAIL IM 1/8 IN HOOKED FIX,SUP-2364712,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.14,86.54,,,,,,,,,,,,,
LEAD NERVE STIM 50 CM 3-6 CONTACT LINEAR,SUP-2458237,CDM,C1778,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 51-150 MMX0.3 CM FD,SUP-2717848,CDM,C1762,CPT,0278,RC,,,,both,,,4644.09,3018.66,,,,,,,,,,,,,
DEVICE OCCL CLP L50MM 60DEG HD ARTC DEPLOYMENT LAA EXCLUSION,SUP-2124470,CDM,C1713,HCPCS,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
CATHETER CV STD SET 018 3 FRX40 CM 1 LUMEN SS TURBO-JECT,SUP-2760083,CDM,C1751,HCPCS,0278,RC,,,,both,,,400.76,260.49,,,,,,,,,,,,,
PLATE SPNL LG MINI 12X23 MM TITAN NANOLOCK STRL ANTERALIGN,SUP-2859405,CDM,C1713,HCPCS,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
INTRODUCER SHTH 9FR L13CM NDL 18GA GWIRE 0.035IN SYR VLV,SUP-2281846,CDM,C1892,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
FRAME EXT FIX 220 MM SALVATION,SUP-2538205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,26652.32,17324.01,,,,,,,,,,,,,
SCREW BNE L 160 MM DIA 7.5 MM THRD L 16 MM TI CANN SHRT THRD,SUP-2905747,CDM,C1713,HCPCS,0278,RC,,,,both,,,1341.94,872.26,,,,,,,,,,,,,
POST HOFFMANN3 90DEG ANG DIA 11MM,SUP-2493635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
AZITHROMYCIN 250 MG PO TABS,RX-20943,CDM,6370000000,HCPCS,0637,RC,00904-7350-06,NDC,,both,1,UN,5.60,3.64,,,,,,,,,,,,,
WIRE EXT FIX DIA2MM FOR SALVATION EXT FIX,SUP-2401142,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
HC Add 2nd/3rd Order Abd/Le,PX-3613624800,CDM,36248,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
BLOCK DISTRCTN 75 MM STRUT RIGID COMPR 66,SUP-2197303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1071.53,696.49,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUP CS L 60 CM DIA 5 FR SPC 2-8-2,SUP-2475506,CDM,C1730,HCPCS,0272,RC,,,,both,,,244.32,158.81,,,,,,,,,,,,,
PLATE BNE THK1.5MM TI ORAL MAXILLOFACIAL MAND 3X3 H,SUP-2263007,CDM,C1713,HCPCS,0278,RC,,,,both,,,691.11,449.22,,,,,,,,,,,,,
GRAFT BNE SUB W15 18XL80MM RAD ULN SHFT FRZ DRY,SUP-2307202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.88,1466.97,,,,,,,,,,,,,
CATHETER CV DL 4 FR INTERMED NURSING TY PWR INJ,SUP-2125536,CDM,C1751,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
PIN CLMP L72MM 2 BAR FOR XTRAFIX FIX SYS,SUP-2199705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4139.78,2690.86,,,,,,,,,,,,,
CATHETER CV FULL TY 7 FRX15 CM 3L CUTLMY701JABRMCUSTOM0053,SUP-2759701,CDM,C1751,HCPCS,0278,RC,,,,both,,,556.09,361.46,,,,,,,,,,,,,
PLATE BNE W9XL81MM THK1MM 7 H TI 1/3 TBLR W/ CLLR LOK COMPR,SUP-2190952,CDM,C1713,HCPCS,0278,RC,,,,both,,,510.56,331.86,,,,,,,,,,,,,
SCREW CONN FOR DSTL FEM TI NAIL,SUP-2188205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1539.17,1000.46,,,,,,,,,,,,,
GRAFT BNE SUB 5CC 2-4MM GROWTH FACT ALLGRFT OSTEOAMP,SUP-2138497,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
CAGE SPNL MED 11X14X7 MM TANTALUM TRABECULAR MTL,SUP-2414454,CDM,C1889,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
ALLOGRAFT HUMERUS PROX+HD+CUF RT FZ IRR,SUP-2875977,CDM,C1762,CPT,0278,RC,,,,both,,,14932.90,9706.38,,,,,,,,,,,,,
CATH ANGIO BLN EVERCROSS PTA 8 X 20MM  80CM,SUP-2172912,CDM,C1725,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5 DEG 8X22X14 MM LORDTC PLIF,SUP-2632325,CDM,C1713,HCPCS,0278,RC,,,,both,,,7928.50,5153.52,,,,,,,,,,,,,
COUNTERSINK SURG SCREW DIA 6.5/7.5 MM LG CANN HD QC STRL,SUP-2905604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2315.28,1504.93,,,,,,,,,,,,,
IMPLANT GYN W4XL7CM DERM TUTOPLAST PROC ALLGRFT TISS FOR,SUP-2165389,CDM,C1762,CPT,0278,RC,,,,both,,,4191.90,2724.73,,,,,,,,,,,,,
SYSTEM CLOSURE 6-12 FR VEN VASC VASCADE MVP,SUP-2653507,CDM,C1760,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
IMPLANT TISSUE CONNECTIVE PASTE MED,SUP-2880205,CDM,C1762,CPT,0278,RC,,,,both,,,11285.16,7335.35,,,,,,,,,,,,,
APIXABAN 5 MG PO TABS,RX-120104,CDM,6370000000,HCPCS,0637,RC,00003-0894-31,NDC,,both,1,UN,45.50,29.57,,,,,,,,,,,,,
CLIP MED LD CROCODILE 122 CMX48 IN,SUP-2517526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
CATHETER VASC L135CM OD4FR INFUS L50CM MATCHING OCCL WIRE,SUP-2302766,CDM,C1751,HCPCS,0278,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
STAPLER INT DIA25MM CLS STPL H1.5-2.2MM OPN LEG L5.2MM 22,SUP-2218870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1430.62,929.90,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6 MM STR STD WALL HELIX,SUP-2525443,CDM,C1768,CPT,0278,RC,,,,both,,,2416.23,1570.55,,,,,,,,,,,,,
Blade Surgical Laminectomy W1.5in D.75in Taylor 13-1054,SUP-2853252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.30,253.69,,,,,,,,,,,,,
MESH SURG PELV FLR REP FEM INNOVATIVE DSGN RDY TO USE SFT,SUP-2219785,CDM,C1771,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
CUTTER TIP VITRCTMY POST DISPOSABLE,SUP-2129359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.90,276.18,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 125 CM OD 0.084 IN ID 0.072 IN FLX,SUP-2522812,CDM,C1887,HCPCS,0272,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
APPLIER CLP L12.99IN TI CLP GRY PSTL GRP DISP ENDO CLP II,SUP-2283176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,962.63,625.71,,,,,,,,,,,,,
IMPLANT ARTHROPLASTY SZ 1 CMC STABYLX,SUP-2419550,CDM,C1776,CPT,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
SHEATH CLEARPETRA NEPHROSTOMY 18/20FR 21CM,SUP-2874892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
SCREW BNE GLENOSPHERE SHLDR PRI LOK REV EQUINOXE,SUP-2223384,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BNE STR SHT NEURO ULTRA LO PROF W/ TAB FOR SCR TI,SUP-2483895,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.41,170.57,,,,,,,,,,,,,
ELECTRODE NDL CANN L15CM ARRY DIA3.5CM FOR OPN AND PERC RF,SUP-2149299,CDM,C1713,HCPCS,0278,RC,,,,both,,,6003.68,3902.39,,,,,,,,,,,,,
TRANSMITTER SND PROC HEARING AID STREAMER REMOT CTRL WHT,SUP-2319868,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PLATE BNE L MINI 2X17 MM OBLQ ANGLED TI,SUP-2536098,CDM,C1713,HCPCS,0278,RC,,,,both,,,250.57,162.87,,,,,,,,,,,,,
PLATE BONE THK1.7MM 14 H STR RESRB STRL DELT SYS,SUP-2364973,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.36,367.48,,,,,,,,,,,,,
IMPLANT WR JT STD POLY MAESTRO,SUP-2407380,CDM,C1776,CPT,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
NAIL IM SHT HINDFOOT SHOULDERED END CAP PHANTOM,SUP-2743165,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
SPLINT THMB SM FOR 6-7IN RT CARPOMETACARPAL JT RESTRICT ELAS,SUP-2324695,CDM,L3931,HCPCS,0274,RC,,,,both,,,57.56,37.41,,,,,,,,,,,,,
SPACER SPNL W9XH9XL30MM 0DEG PEEK OPTMA LUM TRANSFORAMINAL,SUP-2211933,CDM,C1821,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
PLATE BNE W17.5XL318MM THK5.2MM 17 H NONSTERILE BILAT S STL,SUP-2185314,CDM,C1713,HCPCS,0278,RC,,,,both,,,2714.28,1764.28,,,,,,,,,,,,,
FIBER LASER END FIRE REVOLIX,SUP-2225647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2943.75,1913.44,,,,,,,,,,,,,
PLATE 95 DEG CONDYLAR 9 HOLES 40MM 156MM STERILE,SUP-2547717,CDM,C1713,HCPCS,0278,RC,,,,both,,,3914.01,2544.11,,,,,,,,,,,,,
GRAFT HUM TISS 25X30MM DECELLULARIZED DERM W/MATRACELL,SUP-2718701,CDM,Q4125,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 15 CC FRZN CANC READIGRAFT,SUP-2741038,CDM,C1713,HCPCS,0278,RC,,,,both,,,831.66,540.58,,,,,,,,,,,,,
PARTICLE EMB SZ 150 250UM POLYVI ALC N RADIOACTIVE CNTOUR 5,SUP-2148438,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
PLATE BNE L MINI REG 0.6 MM RT MXLFCL MULDER STYL LP TI LF,SUP-2463536,CDM,C1713,HCPCS,0278,RC,,,,both,,,620.59,403.38,,,,,,,,,,,,,
NEEDLE BX ASPIR 1 MMX48 CM,SUP-2772738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,738.43,479.98,,,,,,,,,,,,,
CATHETER BLLN DIL PRESSURE MONITORING SET AD 5 FRX36 IN,SUP-2756350,CDM,C1725,HCPCS,0272,RC,,,,both,,,154.52,100.44,,,,,,,,,,,,,
DYNANITE COMP PLATE 3-HOLE T 22MM,SUP-2814520,CDM,C1713,HCPCS,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
KIT CAGE SPINAL APREVO 5-LEVEL,SUP-2912826,CDM,C1889,HCPCS,0278,RC,,,,both,,,157000.00,102050.00,,,,,,,,,,,,,
STAPLER INT L30MM DIA48MM TI STPL RELD DISPOSABLE DST SER TA,SUP-2283410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1173.58,762.83,,,,,,,,,,,,,
KIT KYPHOPLASTY VUE CEMENT MIXER COMBO,SUP-2798686,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
STEM HUM SZ 9 L130MM 135DEG CO CHROM MOLYBDENUM CEM,SUP-2204819,CDM,C1776,CPT,0278,RC,,,,both,,,15329.42,9964.12,,,,,,,,,,,,,
PLATE BNE L MINI MED 3X3 MM RT FOR SCR TI LEVEL 1,SUP-2466439,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
HC Speech Gen Device Eval 1 Hr,PX-4449260700,CDM,92607,CPT,0444,RC,,,,both,,,698.00,453.70,,,,,,,,,,,,,
CATHETER CTRL VEN 5FR L60CM PERIPHERALLY INSERTED STD 2 LUMN,SUP-2168839,CDM,C1751,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
SCREW BNE LOK MINI TI NONSTERILE 20MMX5MM MAXDRIVE,SUP-2262884,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.50,238.22,,,,,,,,,,,,,
DEVICE FIX NO LOOP VERSITOMIC G-LOK,SUP-2421258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.32,707.41,,,,,,,,,,,,,
NEEDLE SPNL Y 300 MM ES2 LT,SUP-2532844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.08,989.35,,,,,,,,,,,,,
CATHETER THROMCTMY ZOOM 71 L 137 CM DIA 6 FR DSTL OD/ID 6,SUP-2739213,CDM,C1757,HCPCS,0272,RC,,,,both,,,7802.90,5071.88,,,,,,,,,,,,,
PLATE BNE DPHSEAL-MTPHSEAL RT VOLAR DSTL RADIAL 9 HOLE STRL,SUP-2546639,CDM,C1713,HCPCS,0278,RC,,,,both,,,5228.76,3398.69,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN PTFE J TAPR MOVEABLE,SUP-2147067,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.93,24.65,,,,,,,,,,,,,
SPACER SPNL L20XW9XH7MM 4DEG PEEK POST THORLUM INTBDY FUS,SUP-2380559,CDM,C1713,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
SET PICC 3L 6FR X 55CM W BP,SUP-2887059,CDM,C1751,HCPCS,0278,RC,,,,both,,,978.64,636.12,,,,,,,,,,,,,
GUIDEWIRE ORTH 13 MM PERC FOR FEM NAIL NS,SUP-2799288,CDM,C1769,HCPCS,0272,RC,,,,both,,,472.10,306.86,,,,,,,,,,,,,
CAGE SPNL MESH 33X26X90 MM 6 LOBE,SUP-2602093,CDM,C1889,HCPCS,0278,RC,,,,both,,,21317.46,13856.35,,,,,,,,,,,,,
KIT ART LN CATHETER 20GA L3IN NDL 21GA L1IN GWIRE L25CM,SUP-2120114,CDM,C1751,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
COMPONENT FEM SZ 55 L KNEE CO CHROM POR POST STABILIZING,SUP-2406178,CDM,C1776,CPT,0278,RC,,,,both,,,20023.78,13015.46,,,,,,,,,,,,,
BLOCK TIB AUG CONSTRN 64X5 MM CNDYL KNEE,SUP-2205993,CDM,C1776,CPT,0278,RC,,,,both,,,5875.57,3819.12,,,,,,,,,,,,,
TUBE TRACHEOSTOMY STERLING ADULT L69MM OD12MM ID9.2MM STERLI,SUP-2793421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.14,282.84,,,,,,,,,,,,,
SCREW BNE 2X28 MM FUSION NS LTX,SUP-2856973,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
PLATE BNE TEMPORAL SM 1.5X32X18X0.6 MM MESHED JANNETTA TI NS,SUP-2487803,CDM,C1713,HCPCS,0278,RC,,,,both,,,974.31,633.30,,,,,,,,,,,,,
ELECTRODE LOOP 24FR 90DEG 0.012IN CUT,SUP-2361448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.52,215.49,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP FIXED 50MM,SUP-2749354,CDM,C1713,HCPCS,0278,RC,,,,both,,,2216.84,1440.95,,,,,,,,,,,,,
PLATE BNE 110 DEG BAR 10 MM MINI RT CRANIOMAXILLOFACIAL L,SUP-2883280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.59,812.23,,,,,,,,,,,,,
CABLE ORTH L889MM DIA1.3MM S STL SMOOTH NDL,SUP-2410274,CDM,C1776,CPT,0278,RC,,,,both,,,941.81,612.18,,,,,,,,,,,,,
GRAFT HUMAN TSSUE 4CMW X 4CML 08 17MM THK ACLLLR DRMS ULTR,SUP-2727660,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4425.20,2876.38,,,,,,,,,,,,,
GRAFT HUM TISS W35XL35MM THK2MM ACELLULAR DERM MTRX,SUP-2264663,CDM,Q4125,HCPCS,0636,RC,,,,both,,,8084.24,5254.76,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM 0.035 IN CRV RAD 3 MM HVY DBL FLX TIP,SUP-2760020,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.48,112.11,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK0.8-1.7MM ACELLULAR DERM ORAL CAV,SUP-2306908,CDM,C1762,CPT,0278,RC,,,,both,,,599.90,389.93,,,,,,,,,,,,,
COLLAR CERV FIRM DENS AD HK AND LOOP CLSR FOAM W COT CVR,SUP-2276586,CDM,L0120,HCPCS,0272,RC,,,,both,,,7.03,4.57,,,,,,,,,,,,,
"HC So Zinc, Serum",PX-3018463066,CDM,84630,CPT,0301,RC,,,,both,,,295.00,191.75,,,,,,,,,,,,,
FILGRASTIM-AYOW 480 MCG/0.8ML SC SOSY,RX-157757,CDM,Q5125,HCPCS,0636,RC,70121-1570-01,NDC,,both,0.8,ML,750.50,487.82,,,,,,,,,,,,,
OCCLUDER CV CARDIOFORM DIA15 MM CATH L 75 CM DIA10 FR PLAT,SUP-2395772,CDM,C1817,HCPCS,0278,RC,,,,both,,,21970.58,14280.88,,,,,,,,,,,,,
JOINT WRST 1 TIE-INTM,SUP-2535948,CDM,C1776,CPT,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
SCREW BNE L36MM DIA3.5MM CORT S STL ST FULL THRD LOK T15,SUP-2184691,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.08,44.25,,,,,,,,,,,,,
HEAD FEM CO CHROM CEM POLY CUP,SUP-2347940,CDM,C1776,CPT,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
GRAFT HUM TISS W25XL30MM THK25MM FRZ DRY ALLGRFT BLK CANC,SUP-2307115,CDM,C1713,HCPCS,0278,RC,,,,both,,,3437.04,2234.08,,,,,,,,,,,,,
PLATE RECON 3.5MM 8HL,SUP-2717532,CDM,C1713,HCPCS,0278,RC,,,,both,,,3296.25,2142.56,,,,,,,,,,,,,
TUBING ASPIR RIPTIDE,SUP-2280540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
CADDY SCR 4.5X16 MM OCPTL VIRAGE,SUP-2684915,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT VASC GORTX L 45 CM DIA 4-7 MM OFFSET RNG L 5 CM EPTFE,SUP-2396104,CDM,C1768,CPT,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
ELECTRODE ELECSURG ARRY MIC RECORDING,SUP-2665141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PSN REV 3MM OFFSET STEM EXT 17X135MM,SUP-2508806,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
HC Revasc Lithotrip Tibi/Perone,PX-4810977200,CDM,C9772,CPT,0481,RC,,,,both,,,35474.00,23058.10,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 4 MM EPTFE STR TW N RING HEMO,SUP-2761318,CDM,C1768,CPT,0278,RC,,,,both,,,2644.07,1718.65,,,,,,,,,,,,,
MESH MIDFACIAL CUSTOMIZED KT AUG HOST MEDPOR,SUP-2862743,CDM,C1713,HCPCS,0278,RC,,,,both,,,23302.03,15146.32,,,,,,,,,,,,,
GADOTERIDOL 279.3 MG/ML IV SOLN,RX-10100,CDM,A9579,HCPCS,0636,RC,00270-1111-02,NDC,,both,15,ML,14.10,9.16,,,,,,,,,,,,,
SET DIL 8-30FR L35CM RENAL SHTH AMPLATZ,SUP-2139238,CDM,C1894,HCPCS,0272,RC,,,,both,,,752.41,489.07,,,,,,,,,,,,,
PACEMAKER CRD 2 CHAMBERED SYM DR,SUP-2265199,CDM,C1785,HCPCS,0275,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
PLATE BNE L1865MM THK25MM 12 H PELV S STL CRV,SUP-2362694,CDM,C1713,HCPCS,0278,RC,,,,both,,,2903.56,1887.31,,,,,,,,,,,,,
KIT KNEE IMPL CAPPED K3 HYBRID K3ZIMMERBIOMET,SUP-2431895,CDM,C1776,CPT,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
BUR SURG OVL 3.5X130 MM W/ LAT PROTCT VIO STRL DISP,SUP-2599841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.59,262.98,,,,,,,,,,,,,
HC US Guidance or Line Place W/ Permanent Image,PX-4027693700,CDM,76937,CPT,0402,RC,,,,both,,,593.00,385.45,,,,,,,,,,,,,
FEMORAL VG CEM POR TIB/E1/PAT,SUP-2137308,CDM,C1713,HCPCS,0278,RC,,,,both,,,15112.82,9823.33,,,,,,,,,,,,,
BLADE SCREWDRIVER 2.3/2.7MM DIA DISTAL RADIAL T7,SUP-2704887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
REAMER SURG DIA 3.2 MM STRL DISP DYNAFORCE,SUP-2893421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
PLATE BNE L363MM 18 H R PROX PERIPROSTHETIC FEM TI NCB,SUP-2205041,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.75,2959.94,,,,,,,,,,,,,
IMPL CAPITELLUM RADIO LT LG SBI,SUP-2701552,CDM,C1776,CPT,0278,RC,,,,both,,,9435.23,6132.90,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY II SINGLE CHMBR IS1 CONN UPLR BPLR,SUP-2148597,CDM,C1786,HCPCS,0275,RC,,,,both,,,12798.64,8319.12,,,,,,,,,,,,,
SEED BRACHYTHERAPY PALLADIUM 103 LOOSE VI THERASEED ST,SUP-2129127,CDM,C2641,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
LOOP ENDOSCP BPLR LG 200X100 MM FOR SUPRACERVICAL HYS STRL,SUP-2423020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CANN SCREW THD 4.0X14MM,SUP-2586804,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.76,274.14,,,,,,,,,,,,,
SCREW INTFR L8MM DIA5.5MM EL PEEK BIO-TENODESIS,SUP-2121426,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
EAR POSITIONING TEMPLATE YAMADA HARADA PPSU,SUP-2677944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.40,394.81,,,,,,,,,,,,,
ANKLE ARTHRODESIS CYLINDRICAL PIN,SUP-2701071,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.79,150.01,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX14 TTNM CNTRD F3.5MM LOK SCREW S,SUP-2724128,CDM,C1713,HCPCS,0278,RC,,,,both,,,1959.93,1273.95,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 7FR L210CM NDL OD0.51MM ID0.24MM MIN,SUP-2149701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.37,441.59,,,,,,,,,,,,,
FEMUR POR MET HD WO SCR D,SUP-2212574,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SET PERI DLYS CATH,SUP-2130773,CDM,C1755,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ANCHOR SUT DIA5MM W/ HNDL INSRT 2 FIBERWIRE 1/2 CIR NDL,SUP-2121498,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
KWIRE 3X285MM,SUP-2701537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
PUMP ANALGESIC ELASTOMERIC PIB PCA V1.5 SPIKE FILTER,SUP-2892585,CDM,C9806,HCPCS,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
EXTERNAL FIXATION KIT META DPHSEAL XCALIBER PVC FREE STRL,SUP-2646342,CDM,C1713,HCPCS,0278,RC,,,,both,,,13149.50,8547.17,,,,,,,,,,,,,
SCREW BNE CANN 4X22 MM FT,SUP-2606137,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.76,274.14,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.025IN 3CM PTFE COAT FLEXTIP,SUP-2313703,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.15,46.25,,,,,,,,,,,,,
PROSTHESIS VOICE 16FR SZ 14MM LO PRSS BLOM SINGER,SUP-2242311,CDM,L8507,HCPCS,0274,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE BNE L275MM 18 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185658,CDM,C1713,HCPCS,0278,RC,,,,both,,,4439.90,2885.93,,,,,,,,,,,,,
GRAFT BIO TISS W5XL10MM THK1MM PORCINE DERM CLLGN FOR HERN,SUP-2173076,CDM,C9364,HCPCS,0278,RC,,,,both,,,1991.14,1294.24,,,,,,,,,,,,,
STEM HUM L122MM DIA14MM STD CO CHROM POR PRI PRESSFIT CEM,SUP-2404596,CDM,C1776,CPT,0278,RC,,,,both,,,13109.50,8521.17,,,,,,,,,,,,,
HC Cervical Disc/Inj Each Level,PX-3616229100,CDM,62291,CPT,0361,RC,,,,inpatient,,,2224.00,1445.60,,,,,,,,,,,,,
MATRIX HUM TISS L 5 X W 7 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909229,CDM,Q4122,HCPCS,0636,RC,,,,both,,,7682.01,4993.31,,,,,,,,,,,,,
CATHETER INFUS SOLEX OD9.3 FRXL25 CM 3 LUMN DISP FOR INT JUG,SUP-2416146,CDM,C1751,HCPCS,0278,RC,,,,both,,,2597.03,1688.07,,,,,,,,,,,,,
UNIT DRNGE INF 2000ML SGL COLL WET SUCT WET SEAL REGULATED,SUP-2384317,CDM,C1729,HCPCS,0272,RC,,,,both,,,645.87,419.82,,,,,,,,,,,,,
UNIT OUTPT DGT SIGNAL,SUP-2241825,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
KIT DEV TRNS VAG TAPING,SUP-2154528,CDM,C1771,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
GRAFT HUM TISS W40XL70MM THK1MM ACELLULAR ARTHROFLEX,SUP-2264666,CDM,C1762,CPT,0278,RC,,,,both,,,6305.53,4098.59,,,,,,,,,,,,,
HC So Pretx Serum RBC Antibody Incubation Drugs Each,PX-3028697566,CDM,86975,CPT,0302,RC,,,,both,,,204.00,132.60,,,,,,,,,,,,,
SCREW EXT FIX L60MM DIA4MM THRD L20MM CORT TI SELF DRL SCHNZ,SUP-2193159,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.84,314.50,,,,,,,,,,,,,
HC So1 in Situ Hybrid per Specimen,PX-3128836867,CDM,88368,CPT,0312,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
SYSTEM CLSR M SZ 1.1MM SHFT L8CM VASC DURA ANAS TI 35 CLP,SUP-2264249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
TRIAL HIP BPLR 26MMX51 CENTRAX,SUP-2364942,CDM,C1776,CPT,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
SPHERE GLEN DIA36MM CNTR CO CHROM FOR 29MM GLEN BASEPLT,SUP-2388677,CDM,C1776,CPT,0278,RC,,,,both,,,9344.64,6074.02,,,,,,,,,,,,,
KIT ENDO L15MM DIA9MM GUIDPIN GUID ROD INTRF SCR FOR,SUP-2341123,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
GRAFT HUM TISS L2.5XW2.5CM THK1MM WND MTRX CRYOPRESERVED,SUP-2135265,CDM,Q4148,HCPCS,0636,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
KIT MICROINTRODUCER 4FR ECHOGENIC NDL L7CM 21GA COAX NIT,SUP-2118821,CDM,C1769,HCPCS,0272,RC,,,,both,,,76.74,49.88,,,,,,,,,,,,,
CATHETERIZATION SET ART 021 22 GAX5 CM 22 GA INDWL LF,SUP-2865586,CDM,C1751,HCPCS,0278,RC,,,,both,,,60.60,39.39,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - 45 Visits,PX-9900000041,CDM,9900000041,LOCAL,0990,RC,,,,both,,,113.00,73.45,,,,,,,,,,,,,
ADAPTER AUDIO,SUP-2430340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
ANCHOR SUT L11.7MM DIA2.8MM W/ CANN INSRTR AND SZ 2,SUP-2121024,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SYSTEM SINUS IRRIGATION 360 DEG ROTATING FAN SPRY WSH DEL,SUP-2902093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BNE 6 H S STL TARSOMETATARSAL LOK RECON BRDG FOR,SUP-2397629,CDM,C1713,HCPCS,0278,RC,,,,both,,,2756.92,1792.00,,,,,,,,,,,,,
ALLOGRAFT BNE LG FRZN IRRADIATED CORTICAL SEG,SUP-2867223,CDM,C1762,CPT,0278,RC,,,,both,,,2657.85,1727.60,,,,,,,,,,,,,
APPLIER CLP L12.99IN W/ 16 TI CLP GRY PSTL GRP DISP ENDO,SUP-2283170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,658.43,427.98,,,,,,,,,,,,,
PLATE BNE SM W11XL78MM THK1.2MM 90DEG 4X6 H TI T SHP R ANG,SUP-2190934,CDM,C1713,HCPCS,0278,RC,,,,both,,,506.67,329.34,,,,,,,,,,,,,
CUFF TRNQT 30IN SURG SGL BLDR SGL PRT PNEUMAT ELECTR AD,SUP-2208890,CDM,C1713,HCPCS,0278,RC,,,,both,,,576.13,374.48,,,,,,,,,,,,,
INTRODUCER NERVE STIM 8 FRX67 CM TRANSSEPTAL GUIDE,SUP-2355064,CDM,C1893,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BNE MESHED 26X26X0.6 MM SM GRID PLLA-PGA STRL,SUP-2468007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1487.79,967.06,,,,,,,,,,,,,
HEAD FEM DIA40MM A CLASS HIP BACKFILLED BFH TECHNOLOGY,SUP-2304509,CDM,C1776,CPT,0278,RC,,,,both,,,10713.68,6963.89,,,,,,,,,,,,,
SCREW BONE L8MM OD2.7MM S STL CORT ST T10 HEXALOBE PEDIFRAG,SUP-2318667,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.97,122.83,,,,,,,,,,,,,
CROWN DENT 5L ANTR LOWER CUSPID PRIMARY REFILL SS UNITEK,SUP-2322236,CDM,D6783,CPT,0278,RC,,,,both,,,36.83,23.94,,,,,,,,,,,,,
ELECTRODE SUCT DIA23MM CBL L85MM SHT SIDE EFF RF SYS W,SUP-2256734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,269.91,175.44,,,,,,,,,,,,,
PLATE BNE W24XL62MM 12 H R DST RAD TI LOK COMPR LO PROF NAR,SUP-2411817,CDM,C1713,HCPCS,0278,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
HC Cystostomy Tube Change,PX-7615170500,CDM,51705,CPT,0761,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
KYPHOPLASTY TRAY 15/3 1 STP OSTEO INTRO CDS KYPHOPAK XPANDER,SUP-2632077,CDM,C1713,HCPCS,0278,RC,,,,both,,,12898.49,8384.02,,,,,,,,,,,,,
BLADE SURG FULL SM 52 MM EXTRACTOR EXPLANT,SUP-2204475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
BIT DRL PED DIA3.2MM AO QUIK CPL CANN DISP PEDIPLATES,SUP-2318876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
GRAFT DERMAL MESH 8X15 CM FEN + WND MTRX MIRODERM,SUP-2431540,CDM,Q4175,HCPCS,0636,RC,,,,both,,,26376.00,17144.40,,,,,,,,,,,,,
ANCHOR SUTURE DA 4.75 MM PEEK KNOTLESS SYS OMEGA,SUP-2435279,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
STEM HUM 5MM MINI SHLDR CO CHROM COMPHSVE REV PRI CEM,SUP-2404558,CDM,C1776,CPT,0278,RC,,,,both,,,15389.14,10002.94,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 6MM REINFORCING O DEG 201740,SUP-2844622,CDM,C1889,HCPCS,0278,RC,,,,both,,,868.30,564.39,,,,,,,,,,,,,
BATTERY SACRAL NERVE R20,SUP-2858719,CDM,C1820,HCPCS,0278,RC,,,,both,,,32031.14,20820.24,,,,,,,,,,,,,
COIL NEUROVASCULAR AXIUM PRIM L 30 CM SECONDARY DIA12 MM,SUP-2429568,CDM,C1889,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
BAR ORTHOT HIP PELV THGH CUST BND SPRED,SUP-2435598,CDM,L1640,HCPCS,0272,RC,,,,both,,,1340.21,871.14,,,,,,,,,,,,,
CATHETER INFUSION FOUNTAIN L 135 CM DIA 4 FR SEG L 10 CM,SUP-2302762,CDM,C1751,HCPCS,0278,RC,,,,both,,,365.03,237.27,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X65 MM CANN EXT TAB VOYAGER 4.75,SUP-2629441,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
STEM FEM CLLRLSS 11-14 STD 131.5 DEG PROX W/ TRUNION,SUP-2450444,CDM,C1776,CPT,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
PLATE BNE LCK 3.5X130 MM LT DSTL MEDL HUM 7 HOLE FIX ANGLE,SUP-2468169,CDM,C1713,HCPCS,0278,RC,,,,both,,,2918.57,1897.07,,,,,,,,,,,,,
STENT COR 18MM 3MM DEL SYS 143CM 0.014IN CO CHROM,SUP-2104412,CDM,C1874,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM PHOSPHORYLCHOLINE COAT SIL 510136C,SUP-2535104,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.40,24.31,,,,,,,,,,,,,
SFS PROV FIXATION PIN LNG STE,SUP-2724034,CDM,C1725,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
MICONAZOLE NITRATE 2 % EX CREA,RX-5039,CDM,J3490,HCPCS,0637,RC,00536-1375-75,NDC,,both,30,GR,19.80,12.87,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 23 CM DIA 5 FR 0.018 IN 7 CM 21GA NIT,SUP-2479385,CDM,C1894,HCPCS,0272,RC,,,,both,,,168.18,109.32,,,,,,,,,,,,,
COMPONENT PAT OD38MM RESURF OVL IMP GEN II,SUP-2349041,CDM,C1776,CPT,0278,RC,,,,both,,,1858.35,1207.93,,,,,,,,,,,,,
WIRE LIG BLNT 0.5X160 MM 24 GA THRD N ABSRB SS UNIV 2 10/EA,SUP-2361095,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.36,23.63,,,,,,,,,,,,,
RELOAD STPLR CRV TIP SM SHT SIGNIA,SUP-2787711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2519.07,1637.40,,,,,,,,,,,,,
SCREW BNE ST 1.3X10 MM CRTX W/ FLUT TIP TI MTRX GLD NS LF,SUP-2189184,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.75,178.59,,,,,,,,,,,,,
CATHETER ANGIO MULTI-TRACK L 100 CM DIA 5 FR INTRO 7 FR,SUP-2125287,CDM,C1725,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
CATHETER PERI PED L42CM LT SWAN NK CURLE CATH 2 CUF ARGY,SUP-2174282,CDM,C1750,HCPCS,0278,RC,,,,both,,,518.60,337.09,,,,,,,,,,,,,
BRACE WRST M L7IN FOR 65 75IN R COT E CNTOUR ALUMINUM STAY,SUP-2197008,CDM,L3931,HCPCS,0274,RC,,,,both,,,11.21,7.29,,,,,,,,,,,,,
MESH CS LEFT EXTRA-LARGE 12CM X 17CM,SUP-2655638,CDM,C1781,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SITAGLIPTIN PHOSPHATE 25 MG PO TABS,RX-77615,CDM,6370000000,HCPCS,0637,RC,00006-0221-31,NDC,,both,1,UN,49.50,32.17,,,,,,,,,,,,,
KIT INTRO L 14 CM DIA 7 FR GUIDEWIRE L 50 CM DIA 0.038 IN SS,SUP-2226018,CDM,C1892,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.5X18 MM SELFTAPPING PLUSDRIVE RECESS T,SUP-2838128,CDM,C1713,HCPCS,0278,RC,,,,both,,,215.40,140.01,,,,,,,,,,,,,
STENT ENDOPROS L10CM DIA8MM CATH 8FR L120CM 0.035IN VES,SUP-2396537,CDM,C1874,HCPCS,0278,RC,,,,both,,,8744.90,5684.18,,,,,,,,,,,,,
HC Trim Nondystrophic Nails,PX-3611171900,CDM,11719,CPT,0361,RC,,,,inpatient,,,195.00,126.75,,,,,,,,,,,,,
GRAFT NERVE REP 2X2 CM SFT TISS MEMBRN AVIVE,SUP-2423444,CDM,C1762,CPT,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
PLATE BNE RECTANGULAR SM 1.5X0.2 MM SCRN MESH JANNETTA TI NS,SUP-2496615,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.54,587.95,,,,,,,,,,,,,
BUR SURG RND 1 MM ELITE,SUP-2361689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,218.23,141.85,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0258,RC,00990-7922-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
WASHER SUT 3.5MM 5 H,SUP-2167395,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN TIP L 1.5 MM SS PTFE,SUP-2120090,CDM,C1769,HCPCS,0272,RC,,,,both,,,48.89,31.78,,,,,,,,,,,,,
SCREW BONE L14MM THRD DIA2.7MM HD DIA4.3MM COR DIA2MM PITCH,SUP-2349442,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.49,288.27,,,,,,,,,,,,,
COLLAR EXTRIC AD TALL HI DENS POLYETH PD SET XTW,SUP-2194473,CDM,L0172,HCPCS,0272,RC,,,,both,,,107.61,69.95,,,,,,,,,,,,,
ALLOGRAFT BNE FEM HD 4.7 CM FRZN W/O CART,SUP-2717884,CDM,C1762,CPT,0278,RC,,,,both,,,5667.20,3683.68,,,,,,,,,,,,,
FIBER LASER HOLMIUM SIDE FIRE  LOW POWER,SUP-2885369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
ZAFIRLUKAST 20 MG PO TABS,RX-17960,CDM,6370000000,HCPCS,0637,RC,68084-0059-11,NDC,,both,1,UN,13.00,8.45,,,,,,,,,,,,,
BIT DRL OD3MM UNIV GUID NONSTERILE REUSE STEALTHSTATION,SUP-2253540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4907.19,3189.67,,,,,,,,,,,,,
BARRIER ADH SHT 6X5 IN SODIUM HYALURONATE CMC SEPRAFILM,SUP-2227089,CDM,C1765,HCPCS,0278,RC,,,,both,,,1254.56,815.46,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 6 MM EPTFE FLX STD WALL SM BEAD,SUP-2761453,CDM,C1768,CPT,0278,RC,,,,both,,,2297.22,1493.19,,,,,,,,,,,,,
HC Iadna Sarscov2& Inf a&B Mult Amp Probe|NOT REASONABLE AND NECESSARY,PX-3068763600,CDM,87636,CPT,0306,RC,,,GZ,both,,,170.00,110.50,,,,,,,,,,,,,
HEAD HUM DIA50MM THK19MM SHLDR TRL AEQUALIS FX,SUP-2388631,CDM,C1776,CPT,0278,RC,,,,both,,,12157.45,7902.34,,,,,,,,,,,,,
ROD SPNL L75MM DIA4.75MM THORACOLUMBOSACRAL CO CHROM CDH,SUP-2284745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE ADJ MOTN,SUP-2388174,CDM,L2186,HCPCS,0272,RC,,,,both,,,464.97,302.23,,,,,,,,,,,,,
PLEDGET SURGICAL W3XL7MM THK15MM SOFT PRE PUNCHED,SUP-2425487,CDM,C1768,CPT,0278,RC,,,,both,,,81.92,53.25,,,,,,,,,,,,,
SYSTEM BNE BX PERF 11 GAX6.5 CM W/ DRL MADISON,SUP-2489550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE BNE L263MM 16 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.09,811.91,,,,,,,,,,,,,
SYSTEM ANNULPLSTY OD38MM SYS FOR MITRL TRICSP POSITIONS,SUP-2214209,CDM,C1889,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
BLADE REAMER 38 MM PATELLAR FOR RM SYS,SUP-2201494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
POR ST/G7 CP/LGXL/LG HD,SUP-2212369,CDM,C1776,CPT,0278,RC,,,,both,,,13545.96,8804.87,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 80 CM BALLOON L 100 MM DIA 5,SUP-2141855,CDM,C1725,HCPCS,0272,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM PHOSPHORYLCHOLINE COAT SIL 510133C,SUP-2535103,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
ENDCAP ORTH L5MM FOR FEM IM NAIL SYS TRIGEN,SUP-2347069,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
ROD TI PREBENT 5.5X25,SUP-2840371,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
"HC So Encephalitis, Eastern Equine",PX-3028665266,CDM,86652,CPT,0302,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
SCREW INTRF 9MM 20MM 35MM 2MM DIA GWIRE FIX KNEE CANN N,SUP-2340987,CDM,C1713,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
DRILL SURG CANN STD 3.7 MM AO QR NS LTX,SUP-2856021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
ASSEMBLY ADPT 36MM HUM HD UNIVERS REVERS,SUP-2123334,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
STENT BILI WALLFLEX L 60 MM DIA 8 MM CVR L 48 MM CATH L 194,SUP-2141594,CDM,C1874,HCPCS,0278,RC,,,,both,,,7785.63,5060.66,,,,,,,,,,,,,
GRAFT HUMAN TSSUE SGMNT 8MML MPJ ARTHRDSS FRZN IRRDTD ENHNCE,SUP-2727664,CDM,C1713,HCPCS,0278,RC,,,,both,,,4021.40,2613.91,,,,,,,,,,,,,
STAPLER INT MEDIUM THICK 60 MM W/ TRI-STAPLE PUR GIA,SUP-2787695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1500.73,975.47,,,,,,,,,,,,,
PROBE SURG SCRP 8X180 MM NS OSCAR 3 LTX,SUP-2875737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 1.85X8 MM MAXILLOMANDIBULAR 5/PK TIT,SUP-2842357,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.49,305.17,,,,,,,,,,,,,
RESERVOIR EXT DRNGE 0.31ML L1.5CM SM FLAT BTM SIDE INLET,SUP-2244288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,999.90,649.93,,,,,,,,,,,,,
BASKET RETRV 1.9 FR NIT,SUP-2540077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
TAP SURG L175X140MM CALIB FOR 4.5MM CORT SCR,SUP-2187415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.20,830.18,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 50 MG UMB CRD CLARIX FLO,SUP-2648678,CDM,Q4155,HCPCS,0636,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
"HC Culture, Fungus Blood",PX-3008710300,CDM,87103,CPT,0300,RC,,,,inpatient,,,454.00,295.10,,,,,,,,,,,,,
SPACER SPNL H7MM STD ANTR CERV PEEK OPTMA TI PLT INTBDY FUS,SUP-2182388,CDM,C1821,HCPCS,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
IMPLANT BRST GEL 4.9 CM PROJCT 11.6 CM 350-380 CC NATRELLE,SUP-2113257,CDM,C1789,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
COLLAR CERV COT DIAL HT ADJ XL PT ACCS WIND VISTA,SUP-2123900,CDM,L0190,HCPCS,0274,RC,,,,both,,,102.71,66.76,,,,,,,,,,,,,
KIT PAIN PMP 270ML 2ML/HR CATH L2.5IN ON-Q PAINBUSTER,SUP-2236778,CDM,C2626,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CATHETER ANGIOPLSTY APEX MR L 142 CM BALLOON L 8 MM DIA2.5,SUP-2144619,CDM,C1725,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PUSHER SURG L195CM TAPR 50CM COIL TRUPUSH,SUP-2158114,CDM,C1769,HCPCS,0272,RC,,,,both,,,1877.09,1220.11,,,,,,,,,,,,,
PLATE BENDING PLIERS TRACK 15MM,SUP-2680408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.06,867.14,,,,,,,,,,,,,
ENDCAP ORTH 5MM EXTN TI ALLY CANN T40 STARDRV RECESS G FOR,SUP-2179789,CDM,C1713,HCPCS,0278,RC,,,,both,,,789.96,513.47,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT MAGNA DIA 25/27/29/31/33 MM,SUP-2214301,CDM,C1889,HCPCS,0278,RC,,,,both,,,29516.00,19185.40,,,,,,,,,,,,,
DEVICE SPEC RETRV L175CM OD.4MM ODSEC3MMX3IN 3MM ARD INTCRAN,SUP-2280934,CDM,C1773,HCPCS,0272,RC,,,,both,,,9655.50,6276.07,,,,,,,,,,,,,
GRASPER SUT 60DEG SHRP TIP LO PROF FOR RAP ACCS IN SHLDR,SUP-2249551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED LT FEM TROCHLEA,SUP-2740868,CDM,C1713,HCPCS,0278,RC,,,,both,,,36594.06,23786.14,,,,,,,,,,,,,
PROSTHESIS OSS EAR 3X6.9 MM BOJRAB,SUP-2313859,CDM,L8613,CPT,0278,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
GRAFT BIO TISS 5X8CM 1MM 1:1 MESHED PROLAYER,SUP-2370455,CDM,C1763,HCPCS,0278,RC,,,,both,,,9831.97,6390.78,,,,,,,,,,,,,
PACEMAKER CARD 27GM 15CC W59XH56MM THK6MM RESYNCH THER,SUP-2356472,CDM,C2621,HCPCS,0275,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
CABLE UNIT PT REF SENSOR,SUP-2356617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X12 MM 6 LOBE,SUP-2602071,CDM,C1889,HCPCS,0278,RC,,,,both,,,7953.62,5169.85,,,,,,,,,,,,,
COLLAR CERV L H3.25IN FOR 16-19IN PLASTAZOTE FOAM 2 PC L,SUP-2336003,CDM,L0140,HCPCS,0272,RC,,,,both,,,30.11,19.57,,,,,,,,,,,,,
POST EXT FIX FEMALE 1 H W/O THRD ATTACH NS DISP MONK RING,SUP-2899261,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
PLATE BNE 130 DEG SHFT L 60 MM BLADE L 100 MM 4 H SS PROX,SUP-2907696,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.88,1735.42,,,,,,,,,,,,,
ANCHOR SUT L19.1MM DIA6.25MM CLS EYELET TENODESIS FOR PROX,SUP-2121430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
BIT DRL CALIB 3.3 MM HUM C LBL INSTRUMENT CASE NS AFFIXUS,SUP-2606174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1406.72,914.37,,,,,,,,,,,,,
TUBE SUCTION TEARDROP 6 FRX5.75 IN 8.25 IN TAPR SUPER MALL,SUP-2473491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.05,172.93,,,,,,,,,,,,,
DRESSING BIO CORNEAL BNDG PROKERA SLIM,SUP-2135267,CDM,V2790,HCPCS,0278,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
"HC New Pt, E/M Level 4",PX-5109920400,CDM,99204,CPT,0510,RC,,,,outpatient,,,344.00,223.60,,,,,,,,,,,,,
MIDAZOLAM HCL (PF) 10 MG/2ML IJ SOLN,RX-147448,CDM,J2250,HCPCS,0636,RC,00409-2308-22,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 18GA 8CM WNGD 1 LUMA F318088T,SUP-2632764,CDM,C1751,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
RELOAD STPL H35XL60MM BLU REG B FORM NAT ARTC ECHELON,SUP-2218989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.25,335.56,,,,,,,,,,,,,
PLATE BONE SZ 6+ GLD 3 SCR CONSTRUCT TAPR LCK TECHNOLOGY,SUP-2223766,CDM,C1713,HCPCS,0278,RC,,,,both,,,4389.72,2853.32,,,,,,,,,,,,,
PLATE BNE COMPR 95 DEG 299 MM FEM HIP 18 HOLE KEYED TUBE,SUP-2470679,CDM,C1713,HCPCS,0278,RC,,,,both,,,2566.67,1668.34,,,,,,,,,,,,,
CLAMP EXT FIX MULTI PIN HII 2080 MRI 10HL,SUP-2732231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3196.21,2077.54,,,,,,,,,,,,,
GRAFT BNE PTTY 2 CC,SUP-2335248,CDM,C9359,HCPCS,0278,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
SYSTEM RETRV RECOVERY CONE CATH L 75 CM INTRO 10 FR VENA,SUP-2128233,CDM,C1773,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-15882,CDM,J7042,HCPCS,0258,RC,00338-0089-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
WEDGE FEM L SZ 3 DST CO CHROME POR STACKED GEN II,SUP-2346026,CDM,C1776,CPT,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
COOLCUT 50 ASP ABLATOR,SUP-2815766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE ORTHOGNATHIC 2 PLATE NS FACE ID,SUP-2883353,CDM,C1713,HCPCS,0278,RC,,,,both,,,24833.16,16141.55,,,,,,,,,,,,,
GRAFT BIO TISS W5.9XL9.8IN PORCINE DERM RIFAMPIN,SUP-2125839,CDM,C1781,HCPCS,0278,RC,,,,both,,,35949.86,23367.41,,,,,,,,,,,,,
SCREW BONE L25MM OD28MM LCTSRB CPLMR SHLDR SOLID FLLY THRDD,SUP-2724201,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
SLEEVE TROCAR L60MM DIAMETER 5MM THREADED WITH TAP DISPOSABL,SUP-2803688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.77,304.70,,,,,,,,,,,,,
HC Bx Breast Add Lesion US Img,PX-3611908400,CDM,19084,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
HC So Intrinsic Factor Antibodies,PX-3028634066,CDM,86340,CPT,0302,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT DIA19 MM BOV PERICARD COCR,SUP-2214053,CDM,C1889,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
PPICC PROV SOLO 5F TL BASIC W/TLS,SUP-2613562,CDM,C1751,HCPCS,0278,RC,,,,both,,,793.54,515.80,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM TIP 4MM 2-5-2MM SPC 4 ELECTRD F,SUP-2248808,CDM,C1730,HCPCS,0272,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
STENT NEURO FRED TOT L 19 MM WORKING L 14 MM DIA 3 MM NIT,SUP-2754669,CDM,C1876,HCPCS,0278,RC,,,,both,,,44025.16,28616.35,,,,,,,,,,,,,
GRAFT BNE 5 CC DBM GRFT,SUP-2319846,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ANCHOR SUT PEEK W/ ORTHOCORD GRYPHON,SUP-2249323,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
HC Wound Debridement Tis 20 Cm/<|ADJ,PX-4509759700,CDM,97597,CPT,0450,RC,,,ADJ,both,,,413.00,268.45,,,,,,,,,,,,,
RING FIX 160MM 3/4IN,SUP-2197250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA 9 MM DEL SHTH 15ML,SUP-2936820,CDM,C1713,HCPCS,0278,RC,,,,both,,,16731.08,10875.20,,,,,,,,,,,,,
TUBE VENT ID114MM S STL W O WIRE REUT BOB STYL,SUP-2313687,CDM,L8699,HCPCS,0278,RC,,,,both,,,95.71,62.21,,,,,,,,,,,,,
HC Auto Cryo Pbpc Infusion,PX-3623824100,CDM,38241,CPT,0362,RC,,,,both,,,1752.00,1138.80,,,,,,,,,,,,,
SCREW BONE L90MM OD10.5MM TI HIP U BLDE LAG FOR GAMMA3 NAIL,SUP-2362205,CDM,C1713,HCPCS,0278,RC,,,,both,,,3035.60,1973.14,,,,,,,,,,,,,
ADAPTER FEM STEM 7DEG TRAIL ASSY PFC SIG SPEC,SUP-2253664,CDM,C1776,CPT,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
ECLIPSE CAGE SCREW X-LARGE 45MM,SUP-2817810,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
BLOCK TIB AUG SZ 3 THK15MM RT LAT LT MEDL KNEE TRABECULAR,SUP-2200134,CDM,C1776,CPT,0278,RC,,,,both,,,4672.32,3037.01,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 12FR L70CM BAL L2.5CM DIA26MM 0.025IN,SUP-2388516,CDM,C1725,HCPCS,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
CAP NERVE AXOGUARD 2MM X 15MM,SUP-2707506,CDM,C1763,HCPCS,0278,RC,,,,both,,,6568.88,4269.77,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0250,RC,00264-7510-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
INTRODUCER MIC KT VSI 5FR S STL MANDREL TUNGSTEN SFT TIP,SUP-2383173,CDM,C1894,HCPCS,0272,RC,,,,both,,,180.55,117.36,,,,,,,,,,,,,
PLATE BNE CP TITATNIUM LT ANTEROLATERAL ANK FUSION STRL,SUP-2902276,CDM,C1713,HCPCS,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
ELECTRODE ENDO MPLR NDL ELECTRD DISP 15CM,SUP-2139746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
GLIDEWIRE ENDO L450CM OD0.035IN ANG NO REPL BILI DEV,SUP-2141516,CDM,C1769,HCPCS,0272,RC,,,,both,,,720.94,468.61,,,,,,,,,,,,,
PLATE BNE L84MM 6 H TIB S STL LOK COMPR WAISTED FOR 4MM SCR,SUP-2371949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
HC So Immunoglob G Subclasses Each,PX-3018278766,CDM,82787,CPT,0301,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
HC Dialysis Other Than Hemo (Crt/Peritoneal),PX-8029094500,CDM,90945,CPT,0802,RC,,,,inpatient,,,1278.00,830.70,,,,,,,,,,,,,
COIL EMB L31CM OD7MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305182,CDM,C1889,HCPCS,0278,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
PERFORATOR SURG 9X6MM CRAN SHRP HUDSON END DISP,SUP-2243195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
BUR SURG L21CM DIA9MM BALL FLUT L BOR MIDAS REX LEGEND,SUP-2277906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,399.75,259.84,,,,,,,,,,,,,
MESH DULEX 1MM THICKNESS OVL 10.2 IN X 13.4 IN,SUP-2125809,CDM,C1781,HCPCS,0278,RC,,,,both,,,5277.40,3430.31,,,,,,,,,,,,,
SCREW BNE SD 2X8 MM LCK TI SLV NS MATRIXMANDIBLE LF,SUP-2423439,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.34,182.87,,,,,,,,,,,,,
LOCKING PLATE SGTTL 8 HOLE CRVD LNG 10MM THICK CP TTNM,SUP-2676885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1150.43,747.78,,,,,,,,,,,,,
DRESSING BIOLOGICAL L4XW2CM PORCINE EXTRACELLULAR MATRIX SHEET STERILE DISPOSABLE FOR SOFT TISSUE REINFORCEMENT MATRISTEM RS,SUP-2106514,CDM,Q4166,HCPCS,0636,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 10 CM DIA 5 FR GUIDEWIRE 0.021 IN,SUP-2385634,CDM,C1894,HCPCS,0272,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 80 MM DIA22 MM LIMB L 40 MM DIA16,SUP-2217622,CDM,C1874,HCPCS,0278,RC,,,,both,,,34398.70,22359.15,,,,,,,,,,,,,
HC Canalith Repositioning Proc,PX-4209599200,CDM,95992,CPT,0420,RC,,,,outpatient,,,333.00,216.45,,,,,,,,,,,,,
STAPLE SKIN LN REINF 60 MM ECHELON ENDOPATH,SUP-2636323,CDM,C1781,HCPCS,0278,RC,,,,both,,,866.55,563.26,,,,,,,,,,,,,
BLADE SAW L 88 MM L 33 MM THK MATERIAL 0.4 MM CUT 0.6 MM,SUP-2929256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.92,354.20,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK KNOTLESS HEALIX ADV,SUP-2249441,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
CANNULA VENT ASST 32FR L10MM LT ART AB KT BYPS FOR BLD PMP,SUP-2106273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141300.00,91845.00,,,,,,,,,,,,,
PLATE EXT FIX SHT REAR FT BRAC ARTH SIDEKCK,SUP-2400636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
PLATE SPNL L24MM ANT CERV TI LEV 2 REFLX,SUP-2380858,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
HANDLE SURG T DRVR NONCANNULATED FOR IM NAIL TRIGEN,SUP-2347052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
PLATE 4.5MM LCP CONDYLAR 12 HOLES 278MM RIGHT STERILE,SUP-2547440,CDM,C1713,HCPCS,0278,RC,,,,both,,,4677.56,3040.41,,,,,,,,,,,,,
TIP ASPIR 25GA ADV BACKFLUSH SFT PASS OR ACT DISP,SUP-2109648,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.37,186.79,,,,,,,,,,,,,
CATHETER INT THCL 110 CM,SUP-2225534,CDM,C1755,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 2.5CM X 5.0CM,SUP-2874117,CDM,A2007,HCPCS,0636,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115CM 7.5FR D-F,SUP-2248506,CDM,C1732,HCPCS,0272,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
SUPPORT ANK ACHILLIES INVISION,SUP-2473835,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
GRAFT HUM TISS RT TALAR ASEP FRSH FOR ARTC CART SUBCHNDRL FT,SUP-2113921,CDM,C1713,HCPCS,0278,RC,,,,both,,,36643.80,23818.47,,,,,,,,,,,,,
SPACER SPNL SM H12MM 24X32MM FOOTPRINT 7DEG ANTR LUM PEEK,SUP-2415807,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
GRAFT HUMAN TISSUE PELVIC FLOOR MATRIX 12X4 CM MATRISTEM,SUP-2106484,CDM,C1763,HCPCS,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
SCREW ANCHR ORTHODONTIC 2X8 MM 13 MM BRACKET HD TI,SUP-2493034,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.65,237.02,,,,,,,,,,,,,
BIT DRL FLXIBLE DISP FOR SUT TWIN LOOP FLX,SUP-2366680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SET PANCREATIC STENT ZMMN L 8 CM 7 FR 0.035 IN 2.8 MM,SUP-2738164,CDM,C2617,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
GRAFT BIO TISS W8XL16CM THK0.8-1.7MM THCK STRUCTURAL,SUP-2307479,CDM,C1713,HCPCS,0278,RC,,,,both,,,10132.15,6585.90,,,,,,,,,,,,,
IMMOBILIZER SHLDR M PCH W8XL16.5IN UNIV TIETEX FOAM STRP,SUP-2195497,CDM,L3650,HCPCS,0272,RC,,,,both,,,15.39,10.00,,,,,,,,,,,,,
KIT CATH ARROWG+ARD BLU + L 16 CM DIA 7 FR GUIDEWIRE L 45 CM,SUP-2745250,CDM,C1751,HCPCS,0278,RC,,,,both,,,441.48,286.96,,,,,,,,,,,,,
GRAFT VASC GORTX L 45 CM DIA 4-7 MM RNG L 15 CM EPTFE TAPR,SUP-2396106,CDM,C1768,CPT,0278,RC,,,,both,,,2103.80,1367.47,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY 40MM 45.3MM 38.7MM 804SQMM FLX2,SUP-2214164,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
GUIDEWIRE VASC GO2WIRE L 155 CM DIA 0.035 IN SS COR PTFE,SUP-2665404,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
INVISION SIZE 4 TALAR DOME,SUP-2459068,CDM,C1776,CPT,0278,RC,,,,both,,,17213.48,11188.76,,,,,,,,,,,,,
NAIL IM DSTL TIB GRY 10MMX26CM,SUP-2347126,CDM,C1713,HCPCS,0278,RC,,,,both,,,4065.20,2642.38,,,,,,,,,,,,,
MICRO ACC SET 5F NIT,SUP-2116525,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 15 CM DIA 4 MM 0.018 IN HELCL,SUP-2518910,CDM,C1889,HCPCS,0278,RC,,,,both,,,1172.63,762.21,,,,,,,,,,,,,
PLATE THRD RINGFIX SYS 7 HL 175MM,SUP-2704819,CDM,C1713,HCPCS,0278,RC,,,,both,,,994.75,646.59,,,,,,,,,,,,,
UPCHARGE HIP TRITANIUM CUP STRYKER,SUP-2501355,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER DRAINAGE 0.038 IN 14 FRX60 CM MAC LOC LCK MP,SUP-2638509,CDM,C1729,HCPCS,0272,RC,,,,both,,,415.77,270.25,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 6 MM L 50 CM STR TW,SUP-2396315,CDM,C1768,CPT,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP DOME 5.5 FR 0.021 INX260 CM OMNI,SUP-2737410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
PLATE BNE L241MM THK3.4MM 18 H BILAT S STL STR LOK COMPR,SUP-2185156,CDM,C1713,HCPCS,0278,RC,,,,both,,,2039.40,1325.61,,,,,,,,,,,,,
SLEEVE SURG DIA12MM STR OUTER PROTCT DISPOSABLE FOR 8 11MM,SUP-2178904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.72,217.57,,,,,,,,,,,,,
SCREW LCK PERIPRSTHTIC ST 5X18MM STRL,SUP-2547436,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.68,470.39,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X3.50 MM ARMSTR STYL PLASTI PORE,SUP-2637835,CDM,L8613,CPT,0278,RC,,,,both,,,514.71,334.56,,,,,,,,,,,,,
ROD SPNL STR OD6.35MM L55MM BEAC,SUP-2230201,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BLADE SAW L 21X85MM W LAT MALL PROTECTED W/ RBBN RETRCT,SUP-2388890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.21,275.74,,,,,,,,,,,,,
PLATE BNE W175XL116MM THK52MM 6 H BILAT TI RIG NEUT LOK,SUP-2190841,CDM,C1713,HCPCS,0278,RC,,,,both,,,1235.78,803.26,,,,,,,,,,,,,
REAMER SURG CUP OD24MM,SUP-2400254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
PACEMAKER CARD 67X259 MM 0.8 CC SINGLE CHMBR,SUP-2281166,CDM,C1786,HCPCS,0275,RC,,,,both,,,27475.00,17858.75,,,,,,,,,,,,,
MULTI DIR THREADED PEG 30MM,SUP-2587091,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.16,264.00,,,,,,,,,,,,,
CATHETER PRSS MON 4FR L12CM TIP 2MM 0.021IN STR J TIP W/ NDL,SUP-2167820,CDM,C1751,HCPCS,0278,RC,,,,both,,,106.79,69.41,,,,,,,,,,,,,
PLATE BNE LAT IMPL 15 H TI L EL FRAC SYS DST FIB 142MM ALPS,SUP-2411718,CDM,C1713,HCPCS,0278,RC,,,,both,,,4708.12,3060.28,,,,,,,,,,,,,
BIT DRL L110MM DIA2.7MM STRL TI JCBS CHK NONRADIOPAQUE W/O,SUP-2187246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.57,261.02,,,,,,,,,,,,,
HC Iaad Ia Hiv-1 Ag W/Hiv-1 & Hiv-2 Antbdy Single,PX-3068738900,CDM,87389,CPT,0306,RC,,,,both,,,482.00,313.30,,,,,,,,,,,,,
ELECTRODE ELECSURG OD22FR KNF COLLINGS,SUP-2361457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,491.54,319.50,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 35 CM DIA 4 TO 7 MM EPTFE TAPR REINF,SUP-2483365,CDM,C1768,CPT,0278,RC,,,,both,,,4797.83,3118.59,,,,,,,,,,,,,
CRIMPER CABLE 11INL STAINLESS STEEL NON STERILE,SUP-2725759,CDM,C1713,HCPCS,0278,RC,,,,both,,,5630.11,3659.57,,,,,,,,,,,,,
HC So Aml Kit Mutation,PX-3108127266,CDM,81272,CPT,0310,RC,,,,both,,,585.00,380.25,,,,,,,,,,,,,
PLATE BONE L 40X65MM THK0.4MM SUBOCCIPITAL RIG FOR 1.5MM SCR,SUP-2363579,CDM,C1713,HCPCS,0278,RC,,,,both,,,3154.82,2050.63,,,,,,,,,,,,,
GRAFT BONE SUB 0.5ML DEMIN BONE MTRX PUTTY BONE BIOREADY,SUP-2335609,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
DISPOSABLES KIT ACL ALL INSIDE,SUP-2811845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1485.22,965.39,,,,,,,,,,,,,
LOCKING PLATE ANGLE ANGLE 32 HOLE 255MM THICK CP TTNM,SUP-2669745,CDM,C1713,HCPCS,0278,RC,,,,both,,,6369.77,4140.35,,,,,,,,,,,,,
STENT BILI BLLN EXPANDABLE 0.035 IN 7X25 MM 6 FRX80 CM,SUP-2102318,CDM,C1876,HCPCS,0278,RC,,,,both,,,3440.18,2236.12,,,,,,,,,,,,,
CHIPS BNE GRFT 30CC 1-4MM ALLGRFT CANC FRZ DRY PRESERVATION,SUP-2293748,CDM,C1713,HCPCS,0278,RC,,,,both,,,1756.39,1141.65,,,,,,,,,,,,,
MESH SURG W8XL12CM THK1MM EPTFE CORDUROY SURF FOR VENTRAL,SUP-2395329,CDM,C1781,HCPCS,0278,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
STENT BILI HANAROSTENT L 50 MM DIA 8 MM L 1800 MM SHRT WIRE,SUP-2461954,CDM,C1876,HCPCS,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
PROBE ABLAT DIA2MM 60DEG BLK MPLR PWR PKT ELECTRD HI FLO,SUP-2341023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,526.83,342.44,,,,,,,,,,,,,
WIRE FIX OLV 2 MM MP,SUP-2465402,CDM,C1713,HCPCS,0278,RC,,,,both,,,4496.48,2922.71,,,,,,,,,,,,,
PLATE 2 23 3+3 H GRID 6 TRILOK,SUP-2267951,CDM,C1713,HCPCS,0278,RC,,,,both,,,2685.42,1745.52,,,,,,,,,,,,,
BIT DRL L41MM DIA3.3MM NONRADIOLUCENT W/O STP,SUP-2414006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 12H /70MM/200MM STRL,SUP-2547492,CDM,C1713,HCPCS,0278,RC,,,,both,,,3494.22,2271.24,,,,,,,,,,,,,
MESH CRNL 50MMW X 85MML TTNM MXLFCL LATEX FREE,SUP-2707373,CDM,C1713,HCPCS,0278,RC,,,,both,,,3062.57,1990.67,,,,,,,,,,,,,
HC Spinal Angiography/Selective,PX-3237570500,CDM,75705,CPT,0323,RC,,,,both,,,3269.00,2124.85,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 150 CM BALLOON L 200 MM DIA 3.5 MM,SUP-2909693,CDM,C1725,HCPCS,0272,RC,,,,both,,,830.84,540.05,,,,,,,,,,,,,
LINER ACETABULAR CONSTR E1 SIZE H 36MM,SUP-2505370,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
GRAFT BNE SUB 07ML W9XH9XL9MM DEMIN CANC CUBOID CNFRM,SUP-2306902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.30,1060.99,,,,,,,,,,,,,
KIT NEUROSTIMULATOR EPI ANCHR LD FOR N300,SUP-2308582,CDM,C1889,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HC CT Abd/Pel W Cont,PX-3527417700,CDM,74177,CPT,0352,RC,,,,both,,,4901.00,3185.65,,,,,,,,,,,,,
WEDGE FEM SZ 1 THK5MM STD UNIV DST KNEE CO CHROM PRI,SUP-2346018,CDM,C1776,CPT,0278,RC,,,,both,,,2237.25,1454.21,,,,,,,,,,,,,
PLATE EXT FIX 30 MM STP OFF NS DISP SMRT TSF,SUP-2932868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2125.03,1381.27,,,,,,,,,,,,,
STENT BILI WALLFLEX L 40 MM DIA10 MM CATH L 75 CM SHTH 9 FR,SUP-2141604,CDM,C1874,HCPCS,0278,RC,,,,both,,,12305.66,7998.68,,,,,,,,,,,,,
TUBE VENT 1.27 MM 2.45 MM 2.35 MM TRIUNE TRMPT SIL 510302,SUP-2535120,CDM,L8699,HCPCS,0278,RC,,,,both,,,68.77,44.70,,,,,,,,,,,,,
BIT DRL TWST 1.5X115 MM AO ATTCH LEVEL 1 DISP,SUP-2467329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1005.59,653.63,,,,,,,,,,,,,
ATTACHMENT DRL ELITE SABER LNG,SUP-2363305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4351.79,2828.66,,,,,,,,,,,,,
CATHETER EP DIAG VIK JOSEPHSON CRV 2MM HEXAPOLAR POLES 6FR,SUP-2142583,CDM,C1730,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
IMPLANT SYNTH TISS L 46 X W 43 MM THK 6 MM LT PERITONEAL,SUP-2883132,CDM,C1713,HCPCS,0278,RC,,,,both,,,3659.04,2378.38,,,,,,,,,,,,,
SEED BRACHYTHERAPY CESIUM LOOSE,SUP-2247304,CDM,C2643,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
KIT HUM COMP SZ 4 ELBW ARTC NEXEL,SUP-2135761,CDM,C1776,CPT,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
TRIAL KNEE IMPL SZ 4 LT FEM NS REUSE N-K,SUP-2209388,CDM,C1713,HCPCS,0278,RC,,,,both,,,2398.96,1559.32,,,,,,,,,,,,,
PLATE BNE L274MM BLDE W48XL25MM 95DEG 16 H ST HIP S STL RIG,SUP-2186763,CDM,C1713,HCPCS,0278,RC,,,,both,,,3618.50,2352.02,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 80 CM DIA 0.018 IN SS HYDRPHLC PERIPH,SUP-2844901,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.27,71.03,,,,,,,,,,,,,
CANNULA SURG BNE CEMENT L 60 MM DIA15 GA SUBCHONDRAL DRL,SUP-2893168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
CHUCK SURG DRL KEYLESS 5 MM AO CONN RM QUIK RELEASE APEX,SUP-2363255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER NEPHROSTOMY PIG 038 IN 10 FRX25 CM REPL KT JINRO,SUP-2520663,CDM,C1729,HCPCS,0272,RC,,,,both,,,59.38,38.60,,,,,,,,,,,,,
PLATE BNE VOLAR DST RAD NEUT EXTN EXTRA ARTC ACU-LOC 2,SUP-2107045,CDM,C1713,HCPCS,0278,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
WASHER ORTH FOR 6.5/7.3 MM SCR NS LTX,SUP-2855920,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
CHLOROPROCAINE HCL 1 % IJ SOLN,RX-9523,CDM,J2401,HCPCS,0636,RC,63323-0475-37,NDC,,both,30,ML,103.70,67.40,,,,,,,,,,,,,
WIRE BRST LOC L15CM NDL 20GA L5CM N REPOSITIONAL BARB STIFF,SUP-2126457,CDM,C1819,HCPCS,0278,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
GRAFT L SEG AND RECON TISS FRZN TIB TIB DST L,SUP-2307314,CDM,C1713,HCPCS,0278,RC,,,,both,,,7699.28,5004.53,,,,,,,,,,,,,
PLATE BONE W5.4XL47MM THK1.5MM 8 H FOREFOOT TI STR FOR,SUP-2225448,CDM,C1713,HCPCS,0278,RC,,,,both,,,2032.21,1320.94,,,,,,,,,,,,,
OSTEOTOME SURG L2413MM DIA64MM STR HIBBS,SUP-2198748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
PLATE BNE L187MM 10 H ST R MED DST TIB S STL LOK COMPR LO,SUP-2177449,CDM,C1713,HCPCS,0278,RC,,,,both,,,4194.22,2726.24,,,,,,,,,,,,,
SCREW BONE L36MM DIA4.5MM CORT S STL ST NONCANNULATED,SUP-2363883,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.16,46.90,,,,,,,,,,,,,
COMPONENT TOE JT L15MM 0DEG NEUT PROX INTERPHALANGEAL YEL STO15P] STRYKER CORP],SUP-2365953,CDM,C1713,HCPCS,0278,RC,,,,both,,,2576.06,1674.44,,,,,,,,,,,,,
SYSTEM MIXER BONE CEMENT W/90DEG LONG EXT TUBE PCD VERTAPLEX,SUP-2875967,CDM,C1713,HCPCS,0278,RC,,,,both,,,2193.04,1425.48,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED XL 8 IN RT WRST FOREARM THMB,SUP-2276640,CDM,L3809,HCPCS,0272,RC,,,,both,,,23.05,14.98,,,,,,,,,,,,,
HC Puncture Ea Add Breast Cyst,PX-3611900100,CDM,19001,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 4",PX-7619921400,CDM,99214,CPT,0761,RC,,,,outpatient,,,313.00,203.45,,,,,,,,,,,,,
ADAPTER LD BRADY 6 MM UPLR IS-1 CONN,SUP-2473470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE CUBOID 2.4/2.7 MM LT LCK SS NS,SUP-2799093,CDM,C1713,HCPCS,0278,RC,,,,both,,,2280.64,1482.42,,,,,,,,,,,,,
REAMER SURG FOR UP EXT SYS STRT,SUP-2372565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BONE L309MM 16 H LT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348226,CDM,C1713,HCPCS,0278,RC,,,,both,,,15594.50,10136.42,,,,,,,,,,,,,
RING FIX LO EXT TEF PANTSA NAIL SYS,SUP-2243642,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
DRILL TWST SHFT END DISP UNIV CMF 1.15MM TIP DIA 1.5MM SCR,SUP-2364177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
PASSER SUT DIA1.8MM 45DEG L CRV STIFF SHFT SHRP ATRAUM TIP,SUP-2121814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
DRILL SURG 0.25 IN STR JCBS CHK W/ KEY HI TORQUE BSPMAX II,SUP-2745857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2003.32,1302.16,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0250,RC,00409-7101-67,NDC,,both,100,ML,37.40,24.31,,,,,,,,,,,,,
ANCHOR SUTURE T KUMAR TRNS FACE,SUP-2330506,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.39,129.60,,,,,,,,,,,,,
PLATE CRANIO-FACIAL L MAX 4 H MALL RT REG TI 0.6MM THCK,SUP-2135909,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
ASSEMBLY ENDOSCP FIX STR AB FOR MENIS REP SYS ULT FAST-FIX,SUP-2341776,CDM,C1713,HCPCS,0278,RC,,,,both,,,1198.76,779.19,,,,,,,,,,,,,
CATHETER LD DEL CPS AIM SL L 65 CM DIA 7.62 FR SS PEBAX,SUP-2421250,CDM,C1887,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ARH PARTIAL BLAST STEM 11.0MMX8.0MM,SUP-2841880,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
BIT DRL L50MM DIA1.5MM 2 FLUT W/ 6MM STP FOR J LATCH CPL,SUP-2179212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.86,388.61,,,,,,,,,,,,,
SYSTEM EXT DRNGE MON EXACTA,SUP-2284552,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.00,267.80,,,,,,,,,,,,,
MESH HERN L37XW28MM COMP FOR LAP OPN VENTRAL REP SYMBOTEX,SUP-2283404,CDM,C1781,HCPCS,0278,RC,,,,both,,,8666.97,5633.53,,,,,,,,,,,,,
GUIDE RMR L850MM DIA2.5MM RM ATTCH CALIB W/ BALL TIP,SUP-2188274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.63,298.76,,,,,,,,,,,,,
STAPLE POD CLOVER 4 LEG 12.5 MMX16 MMX18 MM,SUP-2137800,CDM,2780000010,LOCAL,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
RELOAD STPLR D 30 MM DIA 8 MM SZ 3.5 MM CRV TIP 4 ROW BLU,SUP-2908900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSPLIT CHRONIC MICROINTRODUC 5744420,SUP-2632967,CDM,C1750,HCPCS,0278,RC,,,,both,,,1605.64,1043.67,,,,,,,,,,,,,
HC Blood Count Hematocrit,PX-3058501400,CDM,85014,CPT,0305,RC,,,,both,,,66.00,42.90,,,,,,,,,,,,,
SCREW BONE L8MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST FULL,SUP-2189431,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.75,586.79,,,,,,,,,,,,,
KIT INSTR PLT STRL DISP MOTOBAND CP DYNAFORCE,SUP-2893439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
PLATE BONE L95MM 12 H BILAT TI LCK COMPR RECON LO PROF RIG,SUP-2191427,CDM,C1713,HCPCS,0278,RC,,,,both,,,3501.41,2275.92,,,,,,,,,,,,,
BLADE BPLR OD4MM STD STR SERR ELITE COMPATIBLE DS DIEGO,SUP-2312959,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.81,335.93,,,,,,,,,,,,,
SET SCR SPNL L25MM DIA5.5MM TI FOR 5.5MM ROD EXPEDIUM,SUP-2254610,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
STEM HUM N SLT 8X175 MM TOT SHLDR REV OLYMPIA,SUP-2535964,CDM,C1776,CPT,0278,RC,,,,both,,,12638.50,8215.02,,,,,,,,,,,,,
MESH CRANIAL DELTA 122MM X 122MM 0.75MM THK CRANIOFACIAL,SUP-2884145,CDM,C1713,HCPCS,0278,RC,,,,both,,,9514.73,6184.57,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,6370000000,HCPCS,0637,RC,45802-0562-02,NDC,,both,60,ML,217.10,141.11,,,,,,,,,,,,,
STENT PERIPH EXPRESS LD L 17 MM DIA 7 MM CATH L 75 CM DIA 6,SUP-2144310,CDM,C1876,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
TUBE ENTRL FEED GAST-JEJU 16 FRX1.5X30 CM LP G-JET BUTTON,SUP-2754594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2786.97,1811.53,,,,,,,,,,,,,
ULS 20MM STANDARD CANNULA,SUP-2722403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
PLATE BNE L314MM 14 H NONSTERILE L CNDYL S STL LOK COMPR,SUP-2183117,CDM,C1713,HCPCS,0278,RC,,,,both,,,4562.77,2965.80,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 5 MM STR STD WALL REINF,SUP-2488337,CDM,C1768,CPT,0278,RC,,,,both,,,356.30,231.59,,,,,,,,,,,,,
SCREW BNE FIX 8734100S] ZIMMER BIOMET INC],SUP-2137138,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
DILATOR ENDOSCP THRD 5 MM SUTURE ANCHR STRL TWINFIX AB LTX,SUP-2879123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
TAP SURG L125MM DIA3.5MM G SCR AO FIT AXSOS,SUP-2377949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SEALER ENDOSCP L37CM NANO COAT BLNT TIP LAP DIV,SUP-2283560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
STENT GRFT VASC AFX L 95 MM DIA PROX/DSTL 25 MM COCR,SUP-2217594,CDM,C1768,CPT,0278,RC,,,,both,,,11570.90,7521.08,,,,,,,,,,,,,
BLADE SHAVER CUT 4.2X120 MM END STRL UNIDRIVE DISP,SUP-2585879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,133.95,87.07,,,,,,,,,,,,,
KIT CATH 4.5FR L15CM SHTH L2.75IN NDL 25GA L1.5IN SYR 5ML,SUP-2120614,CDM,C1751,HCPCS,0278,RC,,,,both,,,736.86,478.96,,,,,,,,,,,,,
SCREW INTRF L 15 MM DIA 7 PM STRL CITRELOCK XPRESS,SUP-2900560,CDM,C1713,HCPCS,0278,RC,,,,both,,,5127.62,3332.95,,,,,,,,,,,,,
GUIDEWIRE VASC 1.5 MM 0.014 INX300 CM STD,SUP-2280904,CDM,C1769,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
NAIL IM 2.6X270 MM FIBULAR STRL LTX,SUP-2857587,CDM,C1713,HCPCS,0278,RC,,,,both,,,10616.34,6900.62,,,,,,,,,,,,,
CATHETER EP 7 MM 7 FRX110 1525 MM INQUIRY,SUP-2538005,CDM,C1730,HCPCS,0272,RC,,,,both,,,4785.36,3110.48,,,,,,,,,,,,,
TUBE VENT 7 MM 0.9 MM STR FLROPLAS,SUP-2461765,CDM,L8699,HCPCS,0278,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM DIA16 MM POLYESTER BOV CLLGN,SUP-2266033,CDM,C1768,CPT,0278,RC,,,,both,,,1286.24,836.06,,,,,,,,,,,,,
SUPPORT FACE L FOR 27IN EAR CHEEK CHIN E FOR FACIOPLASTY,SUP-2151622,CDM,L0150,HCPCS,0274,RC,,,,both,,,61.80,40.17,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.537,SUP-2860218,CDM,C1713,HCPCS,0278,RC,,,,both,,,40080.53,26052.34,,,,,,,,,,,,,
GUIDEWIRE ORTH SMOOTH 3.2X300 MM,SUP-2693950,CDM,C1769,HCPCS,0272,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 40 CM DIA1.8 MM SHRT EXPANDABLE,SUP-2264163,CDM,C1713,HCPCS,0278,RC,,,,both,,,4235.86,2753.31,,,,,,,,,,,,,
SCREW BNE L120MM OD75MM PUR TI LO EXT ST SELF DRL CANN NO,SUP-2242951,CDM,C1713,HCPCS,0278,RC,,,,both,,,1753.53,1139.79,,,,,,,,,,,,,
BLADE SHV STR STD TYP A 4MM,SUP-2313524,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.97,271.68,,,,,,,,,,,,,
ALLODERM THIN FENESTRATED 4X4,SUP-2826657,CDM,Q4116,HCPCS,0636,RC,,,,both,,,4323.78,2810.46,,,,,,,,,,,,,
RESTRICTOR CEM DIA12MM UNIV FEM CNL UHMWPE BIOSTP G,SUP-2253100,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
"HC So F8,Vw Factor Antigen",PX-3058524666,CDM,85246,CPT,0305,RC,,,,both,,,196.00,127.40,,,,,,,,,,,,,
COIL NEUROVASCULAR CEREPAK UNIF XL L 12.2 CM DIA 6 MM SLV,SUP-2865189,CDM,C1889,HCPCS,0278,RC,,,,both,,,8497.69,5523.50,,,,,,,,,,,,,
HC IV Push Same Drug,PX-2609637600,CDM,96376,CPT,0260,RC,,,,both,,,92.00,59.80,,,,,,,,,,,,,
SCREW BONE L35MM DIA6.5MM TI ST FULL THRD CTRL FOR GLEN,SUP-2388784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
CATHETER EP DAO CRV 5 MM 6 FRX120 CM RESPON,SUP-2356798,CDM,C1730,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
DRONABINOL 2.5 MG PO CAPS,RX-9904,CDM,Q0167,HCPCS,0637,RC,00904-7144-61,NDC,,both,1,UN,38.30,24.89,,,,,,,,,,,,,
KIT CVC L 20 CM DIA12 FR TL TEGDERM DRSG LG BOR FOR HI VOL,SUP-2909914,CDM,C1751,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
MOORSE/C-TAPER ADAPTER SLEEVE,SUP-2512482,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SYSTEM LD CATH TIP CAPSULE GUIDE TUBE VLV ENVEO R PRO,SUP-2281141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
PLATE BONE W12XL167MM THK4MM 10 H S STL STR NAR COMPR FOR,SUP-2343812,CDM,C1713,HCPCS,0278,RC,,,,both,,,1809.21,1175.99,,,,,,,,,,,,,
PLATE CNDLR CMMRCLLY PURE TTNM FRAC 3D LOK RHMBS LATEX FREE,SUP-2676762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1194.33,776.31,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM N-K,SUP-2212609,CDM,C1776,CPT,0278,RC,,,,both,,,11597.31,7538.25,,,,,,,,,,,,,
FELT CV L 4 X W 4 IN PTFE,SUP-2266054,CDM,C1768,CPT,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
GUIDE PIN ORTH DBL TROCAR 1.5X250 MM,SUP-2766036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
ENDCAP SPNL TI IMPL H19MM OD13MM 13B T2 ALTITUDE,SUP-2292774,CDM,C1889,HCPCS,0278,RC,,,,both,,,21477.60,13960.44,,,,,,,,,,,,,
GRAFT BNE L100MM TIB SHFT FRZ DRY MATRIGRFT,SUP-2264859,CDM,C1713,HCPCS,0278,RC,,,,both,,,2333.96,1517.07,,,,,,,,,,,,,
RING EXT FIX FULL 160 MM ALUM,SUP-2162654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
PLATE BNE THK0.6MM 7 H STD CRANIOMAXILLOFACIAL G TI DBL Y,SUP-2366272,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.51,363.03,,,,,,,,,,,,,
VEST HALO CERV TRAC ASMBLY M,SUP-2328130,CDM,L0861,HCPCS,0274,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
RECORDER CARD MON REVEAL LINQ MYCARELINK LNQSYS] MEDTRONIC USA INC],SUP-2281139,CDM,C1764,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
LINER ACET OD42MM ID28MM +3MM NEUT XLPE ESCALADE,SUP-2315257,CDM,C1776,CPT,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
COMPONENT PAT DIA26MM THK7.5MM POLYETH CEM CONVENTIONAL,SUP-2207281,CDM,C1776,CPT,0278,RC,,,,both,,,3202.49,2081.62,,,,,,,,,,,,,
MESH SYNTH ABD N ABSRB OVL POLYPR OBLONG OVL 36CM LEN 26CM,SUP-2265971,CDM,C1781,HCPCS,0278,RC,,,,both,,,5074.24,3298.26,,,,,,,,,,,,,
SCREW SPNL L40MM OD5.5MM CO CHROM VAR ANG CANN MULTIAXIAL,SUP-2285899,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BONE L168MM THK3.7MM 8 H LT DSTL MEDL TIB TI LCK COMPR,SUP-2190883,CDM,C1713,HCPCS,0278,RC,,,,both,,,4564.30,2966.79,,,,,,,,,,,,,
SCREW BONE L30MM DIA4MM PARTIALLY THRD HDLSS M CANN COMPR,SUP-2418754,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.23,438.90,,,,,,,,,,,,,
GRAFT BNE 1 CC OSTEOSURGE 100,SUP-2641796,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.35,506.58,,,,,,,,,,,,,
BOLT SET 6.5MM MIDFOOT FUS,SUP-2177068,CDM,C1713,HCPCS,0278,RC,,,,both,,,86307.74,56100.03,,,,,,,,,,,,,
PASSER SHUNT 36 CM PERITONEAL CATH DISP,SUP-2852598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2931.91,1905.74,,,,,,,,,,,,,
CROWN REFIL SEC M 41104103 E-LR-2,SUP-2322183,CDM,D6783,CPT,0278,RC,,,,both,,,29.58,19.23,,,,,,,,,,,,,
MEMBRANE PERICARD 16CM X 8CM X 0.1MM THICKNESS GORE PRECL,SUP-2395369,CDM,C1768,CPT,0278,RC,,,,both,,,1971.92,1281.75,,,,,,,,,,,,,
FIXATION KIT 11X15/12 MM 1.3X1.5 MM SPEEDARC,SUP-2135444,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CATHETERIZATION KIT 7 FRX30 CM CV 3L NDL HOWES,SUP-2120584,CDM,C1894,HCPCS,0272,RC,,,,both,,,206.61,134.30,,,,,,,,,,,,,
MESH GORE SYNECOR 30CM X 30CM RECTANGLE,SUP-2763179,CDM,C1781,HCPCS,0278,RC,,,,both,,,21832.42,14191.07,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.550,SUP-2860067,CDM,C1713,HCPCS,0278,RC,,,,both,,,62697.95,40753.67,,,,,,,,,,,,,
SHUNT PERI SM DST CATH L120CM INCL STRATA II VLV,SUP-2284561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12562.89,8165.88,,,,,,,,,,,,,
SCREW BONE L26MM DIA4.7MM STRL S STL PARTIALLY THRD FOR,SUP-2349592,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.09,263.31,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.014IN ANG TIP TAPR L7CM JOURNEY,SUP-2148155,CDM,C1769,HCPCS,0272,RC,,,,both,,,531.92,345.75,,,,,,,,,,,,,
PULSE SPRY PRO INFUS CATH 3FX135CMX2CM,SUP-2117034,CDM,C1757,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 22 CM 1.2 CM 3-5 CC LP MIC-KEY,SUP-2764459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1267.56,823.91,,,,,,,,,,,,,
WIRE EXT FIX TIN TIP SIDEKCK EZ FRAME,SUP-2851086,CDM,C1713,HCPCS,0278,RC,,,,both,,,4060.02,2639.01,,,,,,,,,,,,,
TAP BNE SPNL PEDCL SCR QUIK CONN DYNALOK 65MM DIA,SUP-2289598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1084.40,704.86,,,,,,,,,,,,,
COMPONENT TOT KNEE CEM FIX BEAR RP XLINKED,SUP-2249590,CDM,C1776,CPT,0278,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
COMPONENT FEM A ZMLY LT KNEE PRI CEM PRESSFIT CRUC RET,SUP-2201252,CDM,C1776,CPT,0278,RC,,,,both,,,9082.45,5903.59,,,,,,,,,,,,,
SCREW BNE L26MM OD3MM HDLSS,SUP-2365592,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
SIZER SURG SURG ID MANDIBULAR PLATE RECON NS DISP,SUP-2884163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.37,360.99,,,,,,,,,,,,,
PATCH HERN L DIA3.2IN CIR W/ STRP SEPRA TECHNOLOGY ABSRB,SUP-2125893,CDM,C1781,HCPCS,0278,RC,,,,both,,,1683.98,1094.59,,,,,,,,,,,,,
HC Urea Breath Test C-14 Isotopic Acquisj Analysis,PX-3417826700,CDM,78267,CPT,0341,RC,,,,both,,,1160.00,754.00,,,,,,,,,,,,,
VALVE SWALLOING AND SPEAK OD23MM ID15MM CLR LO PROF LTWT,SUP-2322023,CDM,L8501,HCPCS,0274,RC,,,,both,,,365.68,237.69,,,,,,,,,,,,,
MESH HERN SM W3.1XL4.7IN POLYPR EPTFE OVL SELF EXP PTCH FOR,SUP-2125710,CDM,C1781,HCPCS,0278,RC,,,,both,,,1523.21,990.09,,,,,,,,,,,,,
VALVE CSF STD 15 CM STR CATH MED PRESSURE RADIOPAQUE YEL DP,SUP-2852668,CDM,C1889,HCPCS,0278,RC,,,,both,,,3560.85,2314.55,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT CLEARVUE INTERMED 4FR 0.033IN 60CM,SUP-2613420,CDM,C1751,HCPCS,0278,RC,,,,both,,,322.54,209.65,,,,,,,,,,,,,
PLATE BNE L54MM BRL L38MM 135DEG 2 H ST BILAT PELV HIP S STL,SUP-2186803,CDM,C1713,HCPCS,0278,RC,,,,both,,,1908.30,1240.39,,,,,,,,,,,,,
GRAFT ALLODERM SELECT REGENERATIVE TISSUE MATRIX 4X7,SUP-2665174,CDM,Q4116,HCPCS,0636,RC,,,,both,,,3105.46,2018.55,,,,,,,,,,,,,
PLATE BNE THK06MM 34 H MIDFACE TI STR LO PROF LEV 1 SIL FOR,SUP-2262720,CDM,C1713,HCPCS,0278,RC,,,,both,,,939.49,610.67,,,,,,,,,,,,,
DEFIBRILLATOR CARD 80GM 41CC W50XH74MM THK14MM DF1 IS1 CONN,SUP-2356283,CDM,C1721,HCPCS,0275,RC,,,,both,,,36568.44,23769.49,,,,,,,,,,,,,
TRIAL ARTC SURF UNI HI FLX PROV SZ 3 8MM,SUP-2200485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.25,331.66,,,,,,,,,,,,,
LINER ACET OD60MM ID36MM +4MM OFFSET 10DEG HIP CROSSLINKED,SUP-2250569,CDM,C1776,CPT,0278,RC,,,,both,,,4654.74,3025.58,,,,,,,,,,,,,
SET DRL PIN AND GRFT PASS WIRE TRANSFIX II,SUP-2121629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
HC Bilirubin Total,PX-3018224700,CDM,82247,CPT,0301,RC,,,,both,,,252.00,163.80,,,,,,,,,,,,,
IMPLANT OPHTH GLAUCOMA 32X350 MM EYE SMOOTH SIL BAERVELDT,SUP-2102257,CDM,L8610,HCPCS,0278,RC,,,,both,,,2766.34,1798.12,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EPSTAR L 65 CM DIA 6 FR SPC 2-8-2,SUP-2641909,CDM,C1730,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SPACER SPNL LG ENDPLATE SCREW STRL XLR,SUP-2592034,CDM,C1889,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BONE L12MM 4 H CRANIOFACIAL VIT FOR 1.3MM SCR PANFIX,SUP-2364702,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
SPLINT ORTH W4IN RT HND BASE THMB SPICA ROLYAN,SUP-2324965,CDM,L3931,HCPCS,0272,RC,,,,both,,,102.74,66.78,,,,,,,,,,,,,
TRANSFIX SCREW 3X50MM,SUP-2811821,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH REMOVABLE PREMOLDED,SUP-2435705,CDM,L3050,HCPCS,0272,RC,,,,both,,,133.26,86.62,,,,,,,,,,,,,
TRAY HAD 13FR L15CM 3 LUMN CATH SHT TERM CRV EXTN LEG,SUP-2125601,CDM,C1752,HCPCS,0278,RC,,,,both,,,996.13,647.48,,,,,,,,,,,,,
PPICC PROV PED 3F SLEEVE MAXDELTA,SUP-2613522,CDM,C1751,HCPCS,0278,RC,,,,both,,,799.63,519.76,,,,,,,,,,,,,
OSTEOTOME SURG OD8MM BLDE THN FLX,SUP-2408593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
GRAFT HUM TISS W1XL12CM THK04 07MM DERM HUM ACELLULAR,SUP-2307440,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2177.90,1415.63,,,,,,,,,,,,,
HEAD FEM 28 MM HIP CERM 111152012] PAXEON RECONSTRUCTION],SUP-2322446,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INVENTRA UHE DX TI EPOXY RESIN SIL SINGLE,SUP-2138432,CDM,C1722,HCPCS,0275,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.7X6 MM MANDIBULAR SELFTAPPING 20/PK T,SUP-2842299,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.86,257.31,,,,,,,,,,,,,
CONFORMER EYE SM AD BILAT OCU METHYLMETHACRYLATE M W/O H,SUP-2391939,CDM,L8610,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
COMPONENT HIP PRSS FT BPLR HD PART,SUP-2379205,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY MED AD 3.25 IN 13-16 IN PHILADELPHIA,SUP-2319294,CDM,L0172,HCPCS,0274,RC,,,,both,,,22.48,14.61,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LIFT LOOP FOR GTT LCK RNG,SUP-2435671,CDM,L2492,HCPCS,0274,RC,,,,both,,,332.06,215.84,,,,,,,,,,,,,
NKII REV/CONS FEM NP DISTAL SPCR RTSZ 0 4MM LAT,SUP-2509694,CDM,C1776,CPT,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
BIT DRL L 120/50 MM DIA1.5 MM SCREW NS DIA2 MM CALIB AO QC CLR,SUP-2913757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,664.36,431.83,,,,,,,,,,,,,
PLATE BONE W9XL25MM THK1.1MM 2 H DSTL ULN FIBULAR S STL 1/3,SUP-2343773,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.43,364.28,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA20 MM POLYESTER GEL,SUP-2385018,CDM,C1768,CPT,0278,RC,,,,both,,,1445.44,939.54,,,,,,,,,,,,,
VALVE TRACH WHT SPEAK VENT PASSY MUIR,SUP-2322021,CDM,L8501,HCPCS,0274,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 12 MM BLB DIA2.25 MM SIL RUBBER,SUP-2130328,CDM,C1760,HCPCS,0278,RC,,,,both,,,266.02,172.91,,,,,,,,,,,,,
CAPSULE ENDO IMAG SM BWL SB3,SUP-2227942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8829.68,5739.29,,,,,,,,,,,,,
LEAD DEFIB PLEXA PROMRI SD L 60 CM SIL SIL-GLYDE SURF 2,SUP-2739227,CDM,C1777,HCPCS,0275,RC,,,,both,,,9627.24,6257.71,,,,,,,,,,,,,
DILATOR ENDO 36FR L180CM BAL L8CM ESOPH PET DISP ELIM,SUP-2166034,CDM,C1726,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
BOX JUNCTION OFFSET 5 DEG FEM BKRS,SUP-2434214,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
INTRODUCER KYPHOPLASTY SZ 3 8GA 4.2MM TRCR AND DMND OSTEO,SUP-2293706,CDM,C1894,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
CUTTER SURG L9.5CM DIA12MM DISP FOR LAPSCP,SUP-2261062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE HUM 94 MM RT DSTL POSTEROLATERAL 11 HOLE STRL LTX,SUP-2861608,CDM,C1713,HCPCS,0278,RC,,,,both,,,3861.63,2510.06,,,,,,,,,,,,,
CATHETER HD STR 14 FRX24 CM LT SET W/ 2 STYL SPLIT CATH III,SUP-2627109,CDM,C1750,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
PLUG MTRX 14X10MM 42314,SUP-2278334,CDM,C1713,HCPCS,0278,RC,,,,both,,,2064.61,1342.00,,,,,,,,,,,,,
KIT ELECTROPHYSIOLOGY EPSTAR L 65 CM DIA 6 FR SPC 2-8-2 MM,SUP-2641911,CDM,C1730,HCPCS,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
KIT ATHRCTMY PHOENIX L 130 CM INTRO 7 FR GUIDEWIRE 0.014 IN,SUP-2859708,CDM,C1885,CPT,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
IMPL TOE SMART 16MM,SUP-2476622,CDM,C1776,CPT,0278,RC,,,,both,,,2583.12,1679.03,,,,,,,,,,,,,
CATHETER HD DL 14 FRX15 CM SLX TEMP DLYS FULL TY,SUP-2267000,CDM,C1752,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
PLATE BNE L 287 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 24 H 72463124,SUP-2933309,CDM,C1713,HCPCS,0278,RC,,,,both,,,8326.81,5412.43,,,,,,,,,,,,,
DISSECTOR ELECSURG SHFT L 27 CM LUMITIP PEN ABLATION,SUP-2124420,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
BIT OVERDRILL L 229 MM DIA 5.5 MM LG AO NS DISP LEOS,SUP-2932991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.84,722.70,,,,,,,,,,,,,
CEMENT DENT 60GM CARBOXYLATE LUTING PWD 3 PK DURELON,SUP-2238646,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.44,174.49,,,,,,,,,,,,,
PLATE BONE DOUBLE ANGLE LARGE 1.5 MM PRECONTOURED RECONSTRUC,SUP-2842355,CDM,C1713,HCPCS,0278,RC,,,,both,,,8708.48,5660.51,,,,,,,,,,,,,
KNEE SYS TOT KNEE,SUP-2351378,CDM,C1776,CPT,0278,RC,,,,both,,,13031.00,8470.15,,,,,,,,,,,,,
COUNTERSINK SURG DIA4X45MM CANN BITE COMPR SCR QUIK CONN,SUP-2315944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1178.82,766.23,,,,,,,,,,,,,
CATHETER PRSS MON 4FR L12CM TIP L2MM GWIRE 0.021IN ART STR J,SUP-2167837,CDM,C1751,HCPCS,0278,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
TUBE MYR 127MM DIAM VENT SIL FLNG TAB PAPARELLA ULTRASIL,SUP-2312837,CDM,L8699,HCPCS,0278,RC,,,,both,,,56.08,36.45,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2CHMBR 5.37X7.68X0.99 CM 31 CC RESONATE EL,SUP-2424806,CDM,C1721,HCPCS,0275,RC,,,,both,,,48428.22,31478.34,,,,,,,,,,,,,
BRACE KNEE HNG LAT L L OA ADJ 3,SUP-2196482,CDM,L1852,HCPCS,0272,RC,,,,both,,,1314.40,854.36,,,,,,,,,,,,,
PLATE BONE L80MM THK2MM 4 H LAT TIB T SHP BTTRS FOR,SUP-2343788,CDM,C1713,HCPCS,0278,RC,,,,both,,,3106.72,2019.37,,,,,,,,,,,,,
CANNULA VEN SHT 23 FR UNCOATED HLS,SUP-2663486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.50,816.72,,,,,,,,,,,,,
FOSPHENYTOIN 50 MG PE/ML IJ SOLN (MIXTURES ONLY),RX-430014,CDM,Q2009,HCPCS,0636,RC,00069-6001-21,NDC,,both,2,ML,139.50,90.67,,,,,,,,,,,,,
SCREW CORTEX ST 2.4X22MM TI W/T8 STARDRV STRL,SUP-2548981,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.09,140.46,,,,,,,,,,,,,
KIT LAPSCP L100MM L5MM PRT CANN OBT ADPT TAUT,SUP-2383783,CDM,C1788,HCPCS,0278,RC,,,,both,,,94.01,61.11,,,,,,,,,,,,,
CATHETER ART DL 0.018 IN 6 FRX110 CM PULM HEPCOAT LTX,SUP-2662681,CDM,C1751,HCPCS,0278,RC,,,,both,,,86.38,56.15,,,,,,,,,,,,,
PLATE BNE L87MM 4 H NONSTERILE L PROX TIB S STL VAR ANG LOK 02127211],SUP-2177908,CDM,C1713,HCPCS,0278,RC,,,,both,,,4626.60,3007.29,,,,,,,,,,,,,
FLUCONAZOLE (DIFLUCAN) 2 MG/ML (PED-NEO) >/= 50 MLS,RX-4090490,CDM,J1450,HCPCS,0250,RC,25021-0184-66,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
PATCH HERN SM W3.1XL4.7IN UNCOATED MFIL PROPYLENE OVL ABSRB,SUP-2125896,CDM,C1781,HCPCS,0278,RC,,,,both,,,1597.00,1038.05,,,,,,,,,,,,,
ALLOGRAFT BNE EVANS WDG 22X22X16 MM FD STRL LF DISP,SUP-2489620,CDM,C1889,HCPCS,0278,RC,,,,both,,,2922.56,1899.66,,,,,,,,,,,,,
SCREW SPNL LOK SPHERX,SUP-2311149,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SOCK PROSTHETIC BLK,SUP-2388224,CDM,L8420,HCPCS,0274,RC,,,,both,,,53.85,35.00,,,,,,,,,,,,,
CANNULA ENDOSCP DIA 5.6 MM CUT W/ HOLE NONSTERILE LTX FREE,SUP-2906537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
SCREW SET REPL,SUP-2610317,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.61,478.80,,,,,,,,,,,,,
SLEEVE REDUC DIA 55MM L14MM SPNL CDH,SUP-2287806,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.61,491.80,,,,,,,,,,,,,
CLAMP SWVL TMPLT FOR LIMB RECONSTRUCT SYS ORTHOFIX,SUP-2405364,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
GRAFT VASC GORTX L 90 CM DIA 8 MM RNG L 80 CM EPTFE STR TW,SUP-2396140,CDM,C1768,CPT,0278,RC,,,,both,,,4047.46,2630.85,,,,,,,,,,,,,
COLLAR CERV 9-24 MO PEDIATRIC 29-37 IN FLEXTABS HK,SUP-2427924,CDM,L0172,HCPCS,0274,RC,,,,both,,,103.87,67.52,,,,,,,,,,,,,
PLATE BNE L213MM 12 H ST R MED DST TIB S STL LOK COMPR LO,SUP-2177452,CDM,C1713,HCPCS,0278,RC,,,,both,,,4240.13,2756.08,,,,,,,,,,,,,
SPACER SPNL W35XH27MM THICKNESS 14MM TI ANT THORLUM FUS,SUP-2244711,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
DEVICE MENIS REP 25 CRV INFIN AIM,SUP-2846785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KIT DOLPHIX STARTER,SUP-2854265,CDM,C1713,HCPCS,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
QUININE SULFATE 324 MG PO CAPS,RX-6781,CDM,6370000000,HCPCS,0637,RC,68180-0560-06,NDC,,both,1,UN,25.50,16.57,,,,,,,,,,,,,
SCREW CANNULATED 6.5X140MM SS FULL THRD,SUP-2547260,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.20,413.53,,,,,,,,,,,,,
HC NM Sest. Rest Stress Mult,PX-3407845200,CDM,78452,CPT,0340,RC,,,,both,,,4883.00,3173.95,,,,,,,,,,,,,
PROSOURCE NO CARB PO LIQD,RX-102212,CDM,6370000000,HCPCS,0637,RC,70074-0583-02,NDC,,both,237,ML,10.70,6.95,,,,,,,,,,,,,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,2500000003,HCPCS,0250,RC,09999-9904-09,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
IMMUNE GLOBULIN (FLEBOGAMMA) 10%,RX-4081761,CDM,J1459,HCPCS,0636,RC,44206-0438-20,NDC,,both,200,ML,11319.80,7357.87,,,,,,,,,,,,,
TRAY EPIDURAL NDL TUOHY DIA20 GA HYPO L 1.5 IN DIA18 GA SGL,SUP-2936580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
SET PICC CONV FOR 5FR CATHETER SELD,SUP-2384041,CDM,C1751,HCPCS,0278,RC,,,,both,,,70.02,45.51,,,,,,,,,,,,,
PLATE BNE STR 27X0.35 MM NEURO 6 HOLE W/ TAB TI NS LEVEL 1,SUP-2499461,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.31,459.10,,,,,,,,,,,,,
GRAFT BNE FIB SHFT 40X14-18 MM FD,SUP-2294102,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.01,749.46,,,,,,,,,,,,,
PLATE SPNL L28MM UNIV CERV ANT 2 LEV TI STD REFLX,SUP-2380860,CDM,C1713,HCPCS,0278,RC,,,,both,,,5761.90,3745.23,,,,,,,,,,,,,
PLATE BNE W54XL85MM THK03MM 2 H CRAN TI BILAT MIC MESH,SUP-2262588,CDM,C1713,HCPCS,0278,RC,,,,both,,,2448.38,1591.45,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.556,SUP-2860237,CDM,C1713,HCPCS,0278,RC,,,,both,,,24450.55,15892.86,,,,,,,,,,,,,
DRESSING BIO L 10 X W 7 CM SZ 200 UM PORCINE SM INTEST,SUP-2905515,CDM,Q4103,HCPCS,0636,RC,,,,both,,,2706.30,1759.09,,,,,,,,,,,,,
PLATE BNE THK1.5MM 6 H CRANIOMAXILLOFACIAL G FRAC UNIV 2,SUP-2366364,CDM,C1713,HCPCS,0278,RC,,,,both,,,1351.99,878.79,,,,,,,,,,,,,
PLATE BNE L L 1ST 2ND 4 TMT CORNER GORILLA,SUP-2321518,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
TREPHINE SURG OD10MM CRWN DRL,SUP-2368637,CDM,C1713,HCPCS,0278,RC,,,,both,,,2014.31,1309.30,,,,,,,,,,,,,
RESTRICTOR CEM L25MM FEM FOR TOT PREP-IM KT BUCK,SUP-2342753,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE PL LAT SUPP 2.7/3.5MM 9H RT 153MM XLNG TI DHP STRL,SUP-2546773,CDM,C1713,HCPCS,0278,RC,,,,both,,,4683.78,3044.46,,,,,,,,,,,,,
GRAFT BIO TISS 5X5CM THK04-10MM MESHED 1:1 ACELLULAR DERM,SUP-2632332,CDM,C1763,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
BLADE CHSL SM W10XL60MM THK1MM RIG SGL END STR DISP FOR KNEE,SUP-2351289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
KIT STRNL CLOSURE SS TWR CABLE PLATE SCREW STRL THORECON,SUP-2894479,CDM,C1713,HCPCS,0278,RC,,,,both,,,4320.95,2808.62,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT L 24CM 12FR 43MM ABD LEAK ANEUR,SUP-2332927,CDM,C2628,HCPCS,0272,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
TUBE T SILICONE 16FR STRL,SUP-2715876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1215.37,789.99,,,,,,,,,,,,,
COMPONENT SHLDR REVERSED RSP,SUP-2217517,CDM,C1776,CPT,0278,RC,,,,both,,,25905.00,16838.25,,,,,,,,,,,,,
DEVICE LASER DEL LNG 2.5 MR ENT ANGLED STRL OTOPROBE,SUP-2225620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
CATHETER ETER CTRL VEN 1LUMEN 7FRENCH W SURCUF GROSH,SUP-2127893,CDM,C1751,HCPCS,0278,RC,,,,both,,,939.17,610.46,,,,,,,,,,,,,
"HC So1 Antibody Virus, Nos",PX-3028679067,CDM,86790,CPT,0302,RC,,,,inpatient,,,473.00,307.45,,,,,,,,,,,,,
GRAFT BNE 30CC 1 4MM CANC CRUSH CHIP READIGRFT,SUP-2264820,CDM,C1713,HCPCS,0278,RC,,,,both,,,1333.24,866.61,,,,,,,,,,,,,
PIN FIX L4.5MM S STL CERCLAGE THRD POS,SUP-2187033,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.76,324.19,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.038IN INTRO 14FR URIN TRACT,SUP-2139322,CDM,C1769,HCPCS,0272,RC,,,,both,,,50.96,33.12,,,,,,,,,,,,,
COLLAR CERV 4 MONTH-10YR CH FOR TORTICOLLIS TREAT TOT,SUP-2324278,CDM,L0180,HCPCS,0272,RC,,,,both,,,131.06,85.19,,,,,,,,,,,,,
CATHETER HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 24 5551240,SUP-2632900,CDM,C1752,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
BAND GASTRIC STANDARD ADULT FOR ADJUSTABLE SYSTEM LAP BAND AP RAPIDPORT OMNIFORM,SUP-2119250,CDM,C1713,HCPCS,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
CATHETER THERMOABLATION DIA 6 FR SUPERFICIAL VEIN RF,SUP-2883975,CDM,C1888,HCPCS,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
ANCHOR SUT DIA5MM TI SELF STARTING THRD DBL STRND MAG WIRE,SUP-2341374,CDM,C1714,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
ANCHOR SUT SZ 3-0 BRAID ORTHOCORD V-4 NDL 1.3X5MM DRL BIT,SUP-2249370,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SYSTEM ORTHOPEDIC 4.75 MM FDL,SUP-2431993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 40X12X5 MM 2.4 CC PRO OSTEON 500R,SUP-2684311,CDM,C1713,HCPCS,0278,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
PLATE BNE L111MM 4 H LNG L MED DST HUM S STL VAR ANG LOK,SUP-2177603,CDM,C1713,HCPCS,0278,RC,,,,both,,,3871.46,2516.45,,,,,,,,,,,,,
MIRTAZAPINE 15 MG PO TBDP,RX-29531,CDM,6370000000,HCPCS,0637,RC,65862-0021-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MATRIX BIO SZ 300 SQCM FISH SKIN DERMAL SLD INTACT STRL SINGLE,SUP-2909456,CDM,Q4158,HCPCS,0636,RC,,,,both,,,31086.00,20205.90,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0250,RC,00264-7520-10,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
SUPPORT ORTHOT CUST CLUBFOOT WDG,SUP-2435724,CDM,L3380,HCPCS,0272,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
DRILL SURG DIA6MM 0.5CC FOR BNE GRFT HARV,SUP-2107381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5394.52,3506.44,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 8 MM RNG L 30 CM EPTFE STR STD,SUP-2396101,CDM,C1768,CPT,0278,RC,,,,both,,,2502.58,1626.68,,,,,,,,,,,,,
RING EXT FIX DIA 300 MM FULL NS DISP TSF,SUP-2933274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9158.60,5953.09,,,,,,,,,,,,,
SHAFT RMR L510MM DIA8MM MOD TRINKLE BIXCUT,SUP-2366799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1775.67,1154.19,,,,,,,,,,,,,
HEAD HUM DIA40MM THK20MM 4MM OFFSET SHOULDERX3 ECC SGL RAD,SUP-2373624,CDM,C1776,CPT,0278,RC,,,,both,,,4787.24,3111.71,,,,,,,,,,,,,
SCREW BNE PEDIATRIC 2-3/4 IN,SUP-2460205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1434.20,932.23,,,,,,,,,,,,,
BUR SURG CYL LG 4 MM LEADER PT,SUP-2521574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
PLATE CRAN 180X20X40 MM PT SPEC IMPL PEEK,SUP-2860120,CDM,C1713,HCPCS,0278,RC,,,,both,,,24613.20,15998.58,,,,,,,,,,,,,
SCREWDRIVER SURG DBL END PLUG STRT CDH LEG,SUP-2287701,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.80,504.92,,,,,,,,,,,,,
LOOP SURG 2-0 INFIN W/ NDL THRDR WHT BLU ACTIFLIP SB,SUP-2761966,CDM,C1713,HCPCS,0278,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
DOXORUBICIN HCL 2 MG/ML IV SOLN,RX-2616,CDM,J9000,HCPCS,0636,RC,00143-9091-01,NDC,,both,100,ML,86.40,56.16,,,,,,,,,,,,,
CROWN DENT AD SZ DUL4 LT UP 1ST PRI M S STL REST PRETRIMMED,SUP-2238909,CDM,D6783,CPT,0278,RC,,,,both,,,27.98,18.19,,,,,,,,,,,,,
SPLINT WR AD L 9IN LNG LT COT W/ STAY ELAS SUPP FOR,SUP-2324570,CDM,L3809,HCPCS,0274,RC,,,,both,,,36.86,23.96,,,,,,,,,,,,,
SCREW HD POS,SUP-2232095,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
CLIP HEMSTAS L2300MM DIA275MM OPNING 11MM OPN CLOSE,SUP-2313203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.98,421.84,,,,,,,,,,,,,
BLADE ARTHRO OD4.5MM ENDOSCP SHV BOXED INCIS CUT AGG + STR,SUP-2351476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE BNE H MINI LNG TI,SUP-2466582,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.06,323.09,,,,,,,,,,,,,
BUR SURG DIA 4.5 MM HUB III DIAMOND X COARSE STRL REUSE,SUP-2928850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.77,265.70,,,,,,,,,,,,,
JOINT TOE METATARSOPHALANGEAL 10 MM CARTIVA,SUP-2519595,CDM,C1776,CPT,0278,RC,,,,both,,,11972.82,7782.33,,,,,,,,,,,,,
SET GUID SYS OSTEOTMY ACCU CUT 2 STG PASA DMAA,SUP-2137807,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
COMPONENT TALAR 5 LT TOT ANK TRABECULAR MTL,SUP-2477211,CDM,C1776,CPT,0278,RC,,,,both,,,13074.11,8498.17,,,,,,,,,,,,,
WEDGE EVANS 3D PRNT TI SM 17X8MM,SUP-2320323,CDM,C1713,HCPCS,0278,RC,,,,both,,,6868.75,4464.69,,,,,,,,,,,,,
SHOULDER AUGMENT IMPL STANDARD LEFT EXTENSION W/SCREW,SUP-2512468,CDM,C1776,CPT,0278,RC,,,,both,,,5581.66,3628.08,,,,,,,,,,,,,
HC Placement of J-Tube,PX-3614401500,CDM,44015,CPT,0361,RC,,,,inpatient,,,10303.00,6696.95,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK XL INTUITRAK L 100 MM CVR L 80 MM,SUP-2217582,CDM,C1768,CPT,0278,RC,,,,both,,,11602.30,7541.49,,,,,,,,,,,,,
PLATE BNE L 179 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 12 H 72465612N,SUP-2933213,CDM,C1713,HCPCS,0278,RC,,,,both,,,5908.54,3840.55,,,,,,,,,,,,,
VALVE MITRL STENTED PORCINE 29 MM,SUP-2357532,CDM,C1889,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
GRAFT BNE INJ 2 CC INDUCTIVE PRO-STIM,SUP-2759437,CDM,C1713,HCPCS,0278,RC,,,,both,,,3491.68,2269.59,,,,,,,,,,,,,
BUR SURG L3.8MM OD3MM LNG NEURO DMND MTCH HD DRL REUSE FOR,SUP-2367491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.99,224.24,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 6 MESH KT NS FACE ID,SUP-2909612,CDM,C1713,HCPCS,0278,RC,,,,both,,,46232.32,30051.01,,,,,,,,,,,,,
CATHETER PICC 4FR SGL LUMN MAX BARR TY W/ TPS STYL,SUP-2125507,CDM,C1751,HCPCS,0278,RC,,,,both,,,641.91,417.24,,,,,,,,,,,,,
HC Temp External Pacing,PX-4819295300,CDM,92953,CPT,0481,RC,,,,both,,,1976.00,1284.40,,,,,,,,,,,,,
SOLUTION HEMOSTATIC NDL L 4 MM DIA25 GA WORKING L 230 CM 30,SUP-2912525,CDM,C1889,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
KIT PICC OD5FR ID17.5/17.5GA RVS TAPR 7FR WIRE L70CM NIT 2,SUP-2118834,CDM,C1751,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19.5MMW X95MML 1.27MM THK CUT BRAZOL CTD,SUP-2605461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,86.41,56.17,,,,,,,,,,,,,
PLATE BONE LOK 34MML HLX3 STNLSS STEEL NON ST RIGHT STLD RDL,SUP-2721442,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.55,1324.41,,,,,,,,,,,,,
SPACER SPNL W10XH6XL28MM 0DEG PEEK OPTMA THORLUM INTBDY FUS,SUP-2136950,CDM,C1821,HCPCS,0278,RC,,,,both,,,15119.54,9827.70,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE DR BELLIAPPA,SUP-2110979,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.70,486.00,,,,,,,,,,,,,
LENS IOL TECNIS SYNERGY TORIC II DFW150U180,SUP-2853109,CDM,V2788,HCPCS,0276,RC,,,,both,,,1095.00,711.75,,,,,,,,,,,,,
METHIMAZOLE 10 MG PO TABS,RX-10552,CDM,6370000000,HCPCS,0637,RC,60687-0680-11,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
SET CATH HEMODIALYSI BIOFLXTESIO CHRNC SNGLE 10FR DIA 52CM 2,SUP-2610497,CDM,C1750,HCPCS,0278,RC,,,,both,,,162.78,105.81,,,,,,,,,,,,,
ROD SPNL 5.5X500 MM SS SHILLA,SUP-2630619,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
CATHETER ANGIOPLSTY PFLX PRO L 80 CM BALLOON L 100 MM DIA 6,SUP-2156791,CDM,C1725,HCPCS,0272,RC,,,,both,,,561.43,364.93,,,,,,,,,,,,,
KIT INTRO ARW THMS L 10 CM DIA 8.5 FR GUIDEWIRE 0.035 IN,SUP-2383282,CDM,C1894,HCPCS,0272,RC,,,,both,,,83.40,54.21,,,,,,,,,,,,,
MESH HERN 75X15CM MACROPOROUS ULTRAPRO ADV,SUP-2257825,CDM,C1781,HCPCS,0278,RC,,,,both,,,410.15,266.60,,,,,,,,,,,,,
SHEATH INTRO L 10 CM DIA 3 FR NIT WIRE TEARWY SUPER,SUP-2627256,CDM,C1894,HCPCS,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
RECON PLATE 9X141MM 4.5MM,SUP-2818431,CDM,C1713,HCPCS,0278,RC,,,,both,,,4675.30,3038.94,,,,,,,,,,,,,
BLADE IM L80MM DIA12.5MM ST CANC TI SPRL NTHREADED CANN N,SUP-2192132,CDM,C1713,HCPCS,0278,RC,,,,both,,,2402.98,1561.94,,,,,,,,,,,,,
STENT PERIPH ZILVER VENA L 100 MM DIA10 MM CATH L 120 CM,SUP-2647182,CDM,C1876,HCPCS,0278,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
DRESSING BIO W4XL5IN BOV TEND CLLGN MESHED GLYCOSAMINOGLYCAN,SUP-2244273,CDM,C9363,HCPCS,0636,RC,,,,both,,,16944.23,11013.75,,,,,,,,,,,,,
K WIRE FXTN L95MM D0.9MM CBLT CHRME MAX VPC SCREW SSTM,SUP-2467869,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.24,53.46,,,,,,,,,,,,,
MESH HERN W15XL15CM POLYGLACTIN 910 WVN KNIT VCRL,SUP-2220333,CDM,C1781,HCPCS,0278,RC,,,,both,,,1539.60,1000.74,,,,,,,,,,,,,
PLATE BONE ORAL MAXILLOFACIAL SMITH GENIOPLASTY DIAM 2.0MM,SUP-2262915,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
BASEPLATE TIB L71MM KNEE MOD OSS,SUP-2405773,CDM,C1776,CPT,0278,RC,,,,both,,,8802.99,5721.94,,,,,,,,,,,,,
WASHER SPNL SZ 5 S STL FIX TAPR VSP,SUP-2255573,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SCREW BNE COMPR 8X34 MM 27.9 MM CORTICAL FT GOTFRIED PCCP,SUP-2644733,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.64,103.77,,,,,,,,,,,,,
INTRODUCER HEMSTAS 7FRX85CM SHTH 7CM J CRV .038IN GWIRE FAST,SUP-2355585,CDM,C1894,HCPCS,0272,RC,,,,both,,,167.21,108.69,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1.3X10 MM CORTEX CRANIOMAXILLOFACIAL,SUP-2838149,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.11,210.02,,,,,,,,,,,,,
PIN BNE FIX DIA 5 MM REDUCTION CANC THRD NS VARIAX,SUP-2900539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1627.78,1058.06,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.032 IN TIP 3 MM PTFE J FIX COR,SUP-2147056,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.79,18.71,,,,,,,,,,,,,
CUP ACET 66 MM FEM HIP,SUP-2202536,CDM,C1776,CPT,0278,RC,,,,both,,,9216.53,5990.74,,,,,,,,,,,,,
DEVICE PESSARY RNG 3 64 MM W/ SUPP,SUP-2273825,CDM,A4562,HCPCS,0274,RC,,,,both,,,108.39,70.45,,,,,,,,,,,,,
WIRE SAW SURG FOR AMPUTATION GIGLI 300 MM LEN FLEX UNIV MTL,SUP-2257307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
SHEATH INTRO FLEXCATH CNTOUR L 65.5 CM DIA10 FR TIP SZ 13 MM,SUP-2882554,CDM,C1766,CPT,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
TRAY CATH 4FR SGL LUMN NONCOATED VLV COMPATIBLE TRIM LEN,SUP-2125635,CDM,C1751,HCPCS,0278,RC,,,,both,,,698.59,454.08,,,,,,,,,,,,,
SET URET STENT MARD L 22 CM DIA 4.8 FR PERCFLX HYDROPLUS SFT,SUP-2141629,CDM,C2617,HCPCS,0278,RC,,,,both,,,428.52,278.54,,,,,,,,,,,,,
CUP ACET DIA62MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH,SUP-2250728,CDM,C1776,CPT,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
SHEATH GUID 8FR L65CM HYDRPHLC COAT L35CM S STL COIL STR,SUP-2384898,CDM,C1894,HCPCS,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
SET SCR IM HIP,SUP-2351366,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.94,298.31,,,,,,,,,,,,,
POST EXT FIX DIA8MM 90DEG TRAC OUTRIG,SUP-2188520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
WIRE GUID TRANSRADIAL HYDRPHLC STIFF STIFFNESS SHT TAPR ANG,SUP-2158677,CDM,C1769,HCPCS,0272,RC,,,,both,,,175.21,113.89,,,,,,,,,,,,,
KIT BNE MAR ASPIR J NDL SYR,SUP-2399065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
SCREW SPNL L10MM OD4MM 18DEG VAR ANG N CANN THRD SELF DRL,SUP-2228496,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
STENT URET DBL PGTL 8.5 FRX24 CM TECOFLEX OPN END DUROMETER,SUP-2312738,CDM,C2617,HCPCS,0278,RC,,,,both,,,189.25,123.01,,,,,,,,,,,,,
CATHETER HD CRV EXTN LEG 12 FRX20 CM SHT TERM SLIM KT NIAG,SUP-2126483,CDM,C1752,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
MESH HERN 30X20 CMX1.5 MM HYDRATED PORCINE CLLGN PERMACOL,SUP-2174703,CDM,C1781,HCPCS,0278,RC,,,,both,,,45397.40,29508.31,,,,,,,,,,,,,
BUR SURG OD3.1MM TUNGSTEN CARB DISP ROSEN FOR HNDPC I HI,SUP-2108765,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.35,264.78,,,,,,,,,,,,,
Elite H Continuous Compression Implant 25x25x13mm 4 Legs,SUP-2550449,CDM,C1713,HCPCS,0278,RC,,,,both,,,6775.05,4403.78,,,,,,,,,,,,,
BRACE ORTHOPEDIC CTRL KNEE POS LIN,SUP-2315981,CDM,L1833,HCPCS,0272,RC,,,,both,,,360.47,234.31,,,,,,,,,,,,,
PACEMAKER CARD 23GM 11CC H42XL52MM THK6MM TI PARYLENE EPOXY,SUP-2356209,CDM,C1786,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
PLATE BNE L237MM 14 H ST R PROX TIB S STL VAR ANG LOK COMPR,SUP-2177925,CDM,C1713,HCPCS,0278,RC,,,,both,,,6897.01,4483.06,,,,,,,,,,,,,
SPACER SPNL 7 DEGREEX25LX7 MM ZYSTON TRANSFORM,SUP-2137077,CDM,C1821,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
RING EXT FIX CIR 5/8 200 MM SIDEKCK,SUP-2850514,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
BUR SURG RND CUT NONFLUTED S STL ULT LNG L710MM OD50MM,SUP-2278151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.02,160.56,,,,,,,,,,,,,
PIN EXT FIX 6 H JET-X,SUP-2342953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4142.29,2692.49,,,,,,,,,,,,,
SCREW BNE BLNT PT 5X25 MM 175 MM THRD SCHNZ STRL 02172525S,SUP-2750867,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.49,296.07,,,,,,,,,,,,,
SUPPORT ORTHOT ANK JT TORSION CTRL ANK JT HALF SLD STIRRUP,SUP-2435663,CDM,L2375,HCPCS,0274,RC,,,,both,,,348.35,226.43,,,,,,,,,,,,,
SPLINT KNEE L20IN FOR 32IN THGH UNIV FOAM 3 PC DSGN TRIMMED,SUP-2196754,CDM,L1830,CPT,0272,RC,,,,both,,,39.19,25.47,,,,,,,,,,,,,
GRAFT BNE 30ML CANC CHIP DEMIN VOID DEFCT FILL FRZ DRY,SUP-2307253,CDM,C1713,HCPCS,0278,RC,,,,both,,,2054.22,1335.24,,,,,,,,,,,,,
PLATE SPINAL MEDIUM 16X16 MM 4 HOLE LOW PROFILE BOX NEURO TI,SUP-2838358,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
COIL NEUROVASCULAR L 1.5 MM DIA1 MM DIA 0.01 IN DEL CATH,SUP-2894578,CDM,C1889,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
PLATE BNE THK0.6MM 3X3 H L HND NONCOMPRESSION GRID FOR,SUP-2267891,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
HEAD HUM SZ 7 HA COAT SHLDR RESURF COPELAND,SUP-2403991,CDM,C1776,CPT,0278,RC,,,,both,,,13976.14,9084.49,,,,,,,,,,,,,
SYSTEM ACCS PLATFORM PRT GELPOINT,SUP-2119760,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0250,RC,00264-7520-00,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
PLATE BONE CURVED 3.5X94 MM 8 HOLE RECONSTRUCTION FOR SCREW,SUP-2836669,CDM,C1713,HCPCS,0278,RC,,,,both,,,3456.98,2247.04,,,,,,,,,,,,,
SET NEPHSTMY PERC PGTL CATH ONLY 8.3 FRX30 CM,SUP-2168885,CDM,C1729,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
BLADE RTRCTR JNNTTA 20MM X 95MMW SPNL MAL RGGLS RDMND,SUP-2465307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,172.76,112.29,,,,,,,,,,,,,
HC Replac Central Tun Cath W/Port,PX-3613658200,CDM,36582,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
HC Perq P-Art Revsc St 1st Nml Native Connj Bi,PX-4813390100,CDM,33901,CPT,0481,RC,,,,outpatient,,,35474.00,23058.10,,,,,,,,,,,,,
COMPONENT TOE L18MM DIA9.5MM MT CE TAPR POST HEMICAP,SUP-2123594,CDM,C1776,CPT,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
K WIRE 07X152MM TROCAR STE,SUP-2721585,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.52,108.89,,,,,,,,,,,,,
CATHETER CVC 2LUM HANDS-OFF 7FR 30CM,SUP-2664442,CDM,C1751,HCPCS,0278,RC,,,,both,,,65.12,42.33,,,,,,,,,,,,,
MITOMYCIN 40 MG IV SOLR (1 MG/ML),RX-1150448,CDM,J9280,HCPCS,0636,RC,00143-9280-01,NDC,,both,1,UN,2880.00,1872.00,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 10/11X30X12 MM FRZN T-PLIF LUMINARY,SUP-2736969,CDM,C1713,HCPCS,0278,RC,,,,both,,,14737.09,9579.11,,,,,,,,,,,,,
SCREW BNE ST 1.2X5 MM NS AXS LTX 5PK,SUP-2862772,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.74,203.28,,,,,,,,,,,,,
TRAY NAIL ATTCH ROD INSRT INSTR LO CENTRONAIL,SUP-2316000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1257.16,817.15,,,,,,,,,,,,,
BASEPLATE TIB L67MM LNG KNEE UHMWPE STEM NONMODULAR ORTH,SUP-2405771,CDM,C1776,CPT,0278,RC,,,,both,,,8633.43,5611.73,,,,,,,,,,,,,
LEAD NERVE STIM 16 60 CM LAMITRODE TRIPOLE,SUP-2615510,CDM,C1778,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BRUSH TISS EXTRACTOR PWR STRL DISP,SUP-2517589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,196.25,127.56,,,,,,,,,,,,,
COIL EMB L14.2CM DIA10-4MM COMPATIBLE GWIRE 0.018IN PLAT,SUP-2168428,CDM,C1889,HCPCS,0278,RC,,,,both,,,257.73,167.52,,,,,,,,,,,,,
ADAPTER NAVIGATION PRB STRL DISP BRAINPATH,SUP-2930245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1518.19,986.82,,,,,,,,,,,,,
HYSTEROSCOPE RIGID CORAL AVETA DISP,SUP-2739124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
PLATE BNE W17.5XL160MM THK5.2MM 9 H TI BROAD LIMIT CNTCT,SUP-2190846,CDM,C1713,HCPCS,0278,RC,,,,both,,,1427.32,927.76,,,,,,,,,,,,,
INTRODUCER SHTH L62CM OD0.12IN ID0.09IN LAT VEIN RENAL CRV,SUP-2303511,CDM,C1892,HCPCS,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
GRAFT BNE 200X25X8 MM 40 CC POROUS COLLAGEN MATRIX SIGNAFUSE,SUP-2731803,CDM,C1713,HCPCS,0278,RC,,,,both,,,21242.10,13807.36,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SZ 100 X 25 X 6 MM 15 CC CER GRAN,SUP-2930806,CDM,C1763,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
GRAFT BIO TISS OASIS ULTRA 3LAYER MATRIX 7X20CM MESHED,SUP-2341244,CDM,Q4124,HCPCS,0636,RC,,,,both,,,5534.53,3597.44,,,,,,,,,,,,,
KIT INTRO DIL DIA16 FR ENDOSCP OR RADIOLOGIC FOR GASTMY FEED,SUP-2764590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.71,448.96,,,,,,,,,,,,,
PIN FIX L229MM DIA3.2MM S STL STYL 6 STNMN,SUP-2409662,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.98,18.84,,,,,,,,,,,,,
PLATE BNE 24 H MIC TI NONSTERILE 15MM SCR 06MM,SUP-2262719,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.95,545.32,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 6X50 MM ARROW STAINLESS STEEL JET,SUP-2836755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1873.17,1217.56,,,,,,,,,,,,,
GUIDEWIRE ORTH L5.75IN DIA0.035IN TI SGL TRCR THRD FOR MAYO,SUP-2107906,CDM,C1769,HCPCS,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
CURETTE BONE RVS ANG SZ 0 MTRX,SUP-2292916,CDM,C1713,HCPCS,0278,RC,,,,both,,,2546.54,1655.25,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761278,CDM,C1768,CPT,0278,RC,,,,both,,,1411.81,917.68,,,,,,,,,,,,,
TAP SURG DIA2 MM MIDFACE CNTR DRV NO HNDL NS DISP LORENZ,SUP-2937013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
STEM VERSYS FM MC CLRLSS 12X140MM STD BODY STD NECK,SUP-2504326,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
VALVE VENT DRNGE L120CM CEREB LN PROGRAMMABLE UNITZ,SUP-2194064,CDM,C1889,HCPCS,0278,RC,,,,both,,,14281.94,9283.26,,,,,,,,,,,,,
CATHETER NEPHSTMY 16FR 4 WNG MCOT DISP,SUP-2128991,CDM,C1729,HCPCS,0272,RC,,,,both,,,37.02,24.06,,,,,,,,,,,,,
STEM FEM L140MM OD13MM CO CHROM HIP NEUT REV CEM LNG BODY,SUP-2203471,CDM,C1776,CPT,0278,RC,,,,both,,,15205.45,9883.54,,,,,,,,,,,,,
DEVICE ENDOSCP SUTURING 12 MM STD W/O SUTURE CAPIO,SUP-2139400,CDM,C1713,HCPCS,0278,RC,,,,both,,,2186.92,1421.50,,,,,,,,,,,,,
CEMENT BNE 40 GM RADIOPAQUE BA SIMPLEX P,SUP-2374943,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
"HC So Sugars, Single, Quant",PX-3018437866,CDM,84378,CPT,0301,RC,,,,outpatient,,,74.00,48.10,,,,,,,,,,,,,
PLATE BNE W7XL63MM THK1MM 8 H BILAT TI 1/4 TBLR RIG,SUP-2191006,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.94,233.96,,,,,,,,,,,,,
PEDIATRIC SLOT HEAD COMP SCREW,SUP-2818327,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.75,378.14,,,,,,,,,,,,,
HC X-Ray Exam Entire Spine 6/> Vw,PX-3207208400,CDM,72084,CPT,0320,RC,,,,both,,,1492.00,969.80,,,,,,,,,,,,,
SCREW BNE FIX 5.5X45 MM LG QWIX 11545SND] INTEGRA LIFESCIENCES CORP],SUP-2242892,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
PLATE BNE L 161 MM SCREW DIA 4.5 MM 8 H LT PROX LAT TIB NS,SUP-2933304,CDM,C1713,HCPCS,0278,RC,,,,both,,,9792.09,6364.86,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HD ADD ON CERM,SUP-2212521,CDM,C1776,CPT,0278,RC,,,,both,,,808.55,525.56,,,,,,,,,,,,,
BIT DRL CANN 6 MM KNEE SINGLE FLUT MTO,SUP-2849078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
BALLOON CERV 18FR 80ML RIPENING W/ STYL FOR DIL,SUP-2168996,CDM,C1726,HCPCS,0272,RC,,,,both,,,226.52,147.24,,,,,,,,,,,,,
BIT DRL L130MM OD3.5MM W/O STP NONRADIOLUCENT AO QUIK CPL,SUP-2361775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.35,383.08,,,,,,,,,,,,,
EXPANDER BRST 700CC W13.5XH13.5CM P8.3CM SIL TEXT ULT HI,SUP-2301036,CDM,C1789,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,J7060,HCPCS,0250,RC,00264-7510-10,NDC,,both,250,ML,17.00,11.05,,,,,,,,,,,,,
TRAY NERVE BLOCK ST200C OPM BPSK STRL LF DISP DESIGN OPTIONS,SUP-2936588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36.68,23.84,,,,,,,,,,,,,
SHUNT VALVE SYSTEM SINGLE VALVE PRESSURE LEVEL H2O LAYING 14,SUP-2821788,CDM,C1889,HCPCS,0278,RC,,,,both,,,5525.43,3591.53,,,,,,,,,,,,,
LINER ACET OD68MM ID32MM +4MM OFFSET 10DEG HIP MARATHON,SUP-2250425,CDM,C1776,CPT,0278,RC,,,,both,,,4797.92,3118.65,,,,,,,,,,,,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-131188,CDM,Q5101,HCPCS,0636,RC,61314-0326-01,NDC,,both,0.8,ML,1295.00,841.75,,,,,,,,,,,,,
SPACER SPNL W27XH16XL37MM 12DEG TI ANT LUM INTBDY FUS SCR,SUP-2289229,CDM,C1713,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
SPHERE OPHTH DIA16MM EYE PMMA LTWT PERM,SUP-2129494,CDM,L8610,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
INTRODUCER HEMSTAS 5FRX5CM WYSHAM SHTH .038IN GWIRE FAST,SUP-2355425,CDM,C1894,HCPCS,0272,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
LOCK SPNL BLU TI ALLOY FOR RIB SUPP VEPTR,SUP-2193301,CDM,C1713,HCPCS,0278,RC,,,,both,,,1331.36,865.38,,,,,,,,,,,,,
SHEATH INTRO PERFRMR CKFLO L 13 CM DIA 5 FR 0.035 IN,SUP-2642114,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.11,104.07,,,,,,,,,,,,,
PLATE BNE THK0.6MM 8MM BAR 6 H 100DEG UNIV,SUP-2366308,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.41,434.47,,,,,,,,,,,,,
PLATE BONE SM LT HEVANS,SUP-2321670,CDM,C1713,HCPCS,0278,RC,,,,both,,,3789.35,2463.08,,,,,,,,,,,,,
KIT PICC MAX BARR ANTIMICR/ANITTHROM PRELOAD 6FR X 55CM 3L,SUP-2864583,CDM,C1751,HCPCS,0278,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MAV XL MR L 153 CM BALLOON L 15 CM DIA 5,SUP-2140562,CDM,C1725,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE BNE L18MM THK03MM 2 H CRANIOMAXILLOFACIAL TI STR WIDE,SUP-2136515,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
KIT TKR IMPL CAPPED K1 IDEN1XE STD CEM,SUP-2905017,CDM,C1776,CPT,0278,RC,,,,both,,,12952.50,8419.12,,,,,,,,,,,,,
GRAFT BNE SUB 1CC DBM BIOCOMPOSITE OSTEOSET PTTY INJ,SUP-2399056,CDM,C9359,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
GRAFT VASC L30CM DIA38MM THOR CLLGN SFT FLX WVN DBL VEL,SUP-2227719,CDM,C1768,CPT,0278,RC,,,,both,,,1921.30,1248.84,,,,,,,,,,,,,
MESH HERN W13XL25CM SYN MFIL RESRB RECT PHASIX ST,SUP-2126270,CDM,C1781,HCPCS,0278,RC,,,,both,,,16500.70,10725.45,,,,,,,,,,,,,
CAP END IMPING 5 MM HUM UNIV NAILING SYS 2ND SCREW VERSANAIL,SUP-2497878,CDM,C1889,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BONE CRANIAL MESH 40.2X50.2X0.3MM TITANIUM NEURO PLATI,SUP-2827184,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.33,971.31,,,,,,,,,,,,,
CATHETER KT CTRL VEN PWR INJ 4 LUMN 8.5FRX8IN 20CM,SUP-2120604,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
HC Ot Elec Stim Unattended|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309701400,CDM,97014,CPT,0430,RC,,,GO|CO,outpatient,,,206.00,133.90,,,,,,,,,,,,,
HC Hemodialysis,PX-8019093500,CDM,90935,CPT,0821,RC,,,,outpatient,,,924.00,600.60,,,,,,,,,,,,,
ANCHOR SUT DIA5MM ROTATORY CUF W/ SZ 2 GRN WHT STRND ETHBND,SUP-2249445,CDM,C1713,HCPCS,0278,RC,,,,both,,,897.41,583.32,,,,,,,,,,,,,
SCREW BONE 2.2X6MM EMER LEIBINGER DELT SYS 2/EA,SUP-2364999,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.59,118.68,,,,,,,,,,,,,
ALLOGRAFT BNE FD ASEP FIBULAR SHFT,SUP-2867016,CDM,C1762,CPT,0278,RC,,,,both,,,3248.49,2111.52,,,,,,,,,,,,,
CASSETTE ANCHR ANCIL W/ 5 IMPL FOR EVAR ENDOANCHR,SUP-2280763,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA 9 MM DEL SHTH 11ML,SUP-2937081,CDM,C1713,HCPCS,0278,RC,,,,both,,,12622.80,8204.82,,,,,,,,,,,,,
ANCHOR SUT 5.5MM 3 SUT W/O NDL ROPH BIOSTEON INTRALINE,SUP-2366672,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 3.5X70 MM 6 HOLE FOR SCREW STERILE,SUP-2836651,CDM,C1713,HCPCS,0278,RC,,,,both,,,3115.85,2025.30,,,,,,,,,,,,,
CLIP ANEURYSM BLADE L9MM 45DEG OPENING 5.5MM T BAR PERMANENT,SUP-2825664,CDM,C1889,HCPCS,0278,RC,,,,both,,,5721.80,3719.17,,,,,,,,,,,,,
PLATE BNE L 185 MM SCREW DIA 4.5 MM 10 H NAR COMPR NLCK NS,SUP-2933931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1761.54,1145.00,,,,,,,,,,,,,
ASPIRATION TRAY PORTED NDL 11 GAX102 MM ONCONTROL,SUP-2766679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.09,314.66,,,,,,,,,,,,,
HC Perq Device Breast 1st Image,PX-3611928100,CDM,19281,CPT,0361,RC,,,,inpatient,,,5152.00,3348.80,,,,,,,,,,,,,
CATHETER ENDOSCP 1.9 MMX110 CM INSPECTION OPT USB CTRL SFTWR,SUP-2765097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9396.45,6107.69,,,,,,,,,,,,,
SLING GYN TVT EXACT CONTINENCE SYS POLYPR BLU DESARA,SUP-2152278,CDM,C1771,HCPCS,0278,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
PIN POS KRENKEL FIG 11 9.5 IN CNDYL,SUP-2472331,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.03,297.07,,,,,,,,,,,,,
PLATE BNE TBLR 85 MM 7-HOLE 1/3,SUP-2518440,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
SUTURE ANCHR TI ANCHR TWINFIX TI 6.5 MM SUT ANCHR W/ TWO NO,SUP-2341052,CDM,C1713,HCPCS,0278,RC,,,,both,,,886.89,576.48,,,,,,,,,,,,,
GRAFT BNE SUB COMPRESSIBLE SPNG SM TALL GROWTH FACT OSTEOAMP,SUP-2138506,CDM,C1713,HCPCS,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
SCREW BNE 4/PK L 8 MM DIA2.2 MM PLA GLYCOLIDE CRANIOMAXILLOFACIAL,SUP-2884156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1289.79,838.36,,,,,,,,,,,,,
IMPLANT BONE STRP MOLD HUM TISS MTRX 50MMX17MMX4MM FRZN,SUP-2284710,CDM,C1713,HCPCS,0278,RC,,,,both,,,4571.84,2971.70,,,,,,,,,,,,,
CROWN DENT 5 S STL SEC PRI M LO RT ANTR CUSPID PREFABRICATED,SUP-2238830,CDM,D6783,CPT,0278,RC,,,,both,,,27.82,18.08,,,,,,,,,,,,,
MATRIX BIO LG SZ 196 SQCM FISH SKIN RT DORSUM LT PALMAR MANO,SUP-2909238,CDM,Q4158,HCPCS,0636,RC,,,,both,,,16924.60,11000.99,,,,,,,,,,,,,
LINER ACET OD74MM ID32MM +4MM OFFSET HIP GVF POLYETH TI NEUT,SUP-2250260,CDM,C1776,CPT,0278,RC,,,,both,,,10294.18,6691.22,,,,,,,,,,,,,
CABLE SURG L750MM DIA1MM STRNL S STL SMOOTH NDL CUT EDGE W/,SUP-2186852,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X22 MM FUSION HEX DRV YEL WRST SS NS,SUP-2852005,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.59,450.83,,,,,,,,,,,,,
SCREW BONE L8MM DIA2.4MM CORT TI ST NONCANNULATED FULL THRD,SUP-2181729,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.75,237.74,,,,,,,,,,,,,
STEM FEM L190MM DIA16MM STD CO CHROME POR + HA HIP REV,SUP-2345322,CDM,C1776,CPT,0278,RC,,,,both,,,17703.32,11507.16,,,,,,,,,,,,,
PLATE BNE THK1MM 0DEG M MINI TI ORAL MAXILLOFACIAL 4 H,SUP-2262737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1022.38,664.55,,,,,,,,,,,,,
SCREW EXT FIX 6X190 MM SPADE PT MR CONDITIONAL FOR ADJ FIX,SUP-2418494,CDM,C1713,HCPCS,0278,RC,,,,both,,,512.29,332.99,,,,,,,,,,,,,
KIT CUT GUID R FEM KNEE NYLON-12 VISIONAIRE JOURNEY II,SUP-2351444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
NAIL IM ZCKL II SUBTROCHANTERIC 95MM NAIL,SUP-2364783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1030.39,669.75,,,,,,,,,,,,,
KNIFE SRGCL SCHKNCHT 7MM BLADE 6 14NL SCKLE ANGLD LATEX FRE,SUP-2673272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.85,218.30,,,,,,,,,,,,,
"HC So1 Herpes Simplex, Type 2",PX-3028669667,CDM,86696,CPT,0302,RC,,,,both,,,35.00,22.75,,,,,,,,,,,,,
NAIL IM 10S L36CM DIA10MM 125DEG LT ORTHOAPEDIC RECON,SUP-2347680,CDM,C1713,HCPCS,0278,RC,,,,both,,,14741.67,9582.09,,,,,,,,,,,,,
HC Transcatheter Biopsy S&I,PX-3207597000,CDM,75970,CPT,0320,RC,,,,both,,,1637.00,1064.05,,,,,,,,,,,,,
BIT DRILL L305MM DIA25MM QUICK CONNECTOR CALIBRATOR,SUP-2468551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
DRESSING BIO COVERAGE AREA 35 SQ CM 200 MG PORCINE SM INTEST,SUP-2905507,CDM,Q4102,HCPCS,0636,RC,,,,both,,,1627.78,1058.06,,,,,,,,,,,,,
SCREW BNE L10MM DIA1.5MM CORT TI ST FULL THRD COMPR T4,SUP-2181283,CDM,C1713,HCPCS,0278,RC,,,,both,,,139.10,90.41,,,,,,,,,,,,,
ELECTRODE LAP L32CM DIA5MM PIN 4MM L HK EXT INSUL NONCOATED,SUP-2166743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.20,299.78,,,,,,,,,,,,,
SCREW BNE FIX SM 7X30 MM W/ 30MM SHTH SS NS,SUP-2249570,CDM,C1713,HCPCS,0278,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
GUIDEWIRE VASC HYDRPHLC L180 CM OD.035 IN STR STIFF ZIPWIRE,SUP-2141155,CDM,C1769,HCPCS,0272,RC,,,,both,,,178.35,115.93,,,,,,,,,,,,,
KIT FIX W/ CANN DRL GUID PIN MRK PEN SURG RUL MAXBRAID SUT,SUP-2212941,CDM,C1776,CPT,0278,RC,,,,both,,,4775.81,3104.28,,,,,,,,,,,,,
HC So Cmv Culture,PX-3008725466,CDM,87254,CPT,0300,RC,,,,both,,,151.00,98.15,,,,,,,,,,,,,
KIT NPHRSTMY MLCT 14FR DIA CATH PRCTNS WC FLXBLE GDWRE .038,SUP-2721823,CDM,C1729,HCPCS,0272,RC,,,,both,,,312.05,202.83,,,,,,,,,,,,,
SYSTEM CLOSURE PK SHTH VENASEAL,SUP-2883969,CDM,C1888,HCPCS,0272,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
CALCIUM GLUCONATE-NACL 2-0.675 GM/100ML-% IV SOLN,RX-146762,CDM,J0612,HCPCS,0636,RC,80830-2363-01,NDC,,both,100,ML,227.20,147.68,,,,,,,,,,,,,
PLATE BNE L 157 X W 12 MM THK 3 MM SCREW DIA 4.5 MM DISTANCE,SUP-2908103,CDM,C1713,HCPCS,0278,RC,,,,both,,,2011.45,1307.44,,,,,,,,,,,,,
SPLINT FNGR L L3.25IN ALUM PD LTWT COT,SUP-2196692,CDM,L3809,HCPCS,0274,RC,,,,both,,,2.32,1.51,,,,,,,,,,,,,
PATCH CV W0.8XL7.5CM THK0.5MM FOR RECON ACUSEAL,SUP-2395323,CDM,C1781,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
PIN EXT FIX L150MM DIA5MM THRD L40MM TI ST SELF DRL U SHP,SUP-2372357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC Leukored Rbcs Irradiated,PX-3900904000,CDM,P9040,CPT,0390,RC,,,,both,,,1536.00,998.40,,,,,,,,,,,,,
WIRE FIX BLNT 1.4 MMX21 IN W/ RND END SS,SUP-2430607,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
LORAZEPAM 1 MG PO TABS,RX-4573,CDM,6370000000,HCPCS,0637,RC,00093-3426-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN STIFF HYDRPHLC ANG TIP,SUP-2302966,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.79,60.96,,,,,,,,,,,,,
SCREW BNE L100MM DIA65MM CANC TI ST SELF DRL NONCANNULATED,SUP-2190555,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.64,65.42,,,,,,,,,,,,,
SCR MD LCKNG EMERG31X17MM,SUP-2668812,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.71,321.56,,,,,,,,,,,,,
CLAMP AD STR CTRL FOR LIMB RECON SYS,SUP-2316076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2070.14,1345.59,,,,,,,,,,,,,
PLATE BNE L319MM 12 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186047,CDM,C1713,HCPCS,0278,RC,,,,both,,,4602.71,2991.76,,,,,,,,,,,,,
SCREW SPNL L70MM DIA6.5MM CANC PEDCL S STL VAR ANG,SUP-2287078,CDM,C1713,HCPCS,0278,RC,,,,both,,,3965.66,2577.68,,,,,,,,,,,,,
OMEPRAZOLE 20 MG PO CPDR,RX-27694,CDM,6370000000,HCPCS,0637,RC,00904-6917-61,NDC,,both,1,UN,2.00,1.30,,,,,,,,,,,,,
BUR SURG L21CM DIA65MM CYL EXTRA COARSE DMND MIDAS REX,SUP-2277907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.70,261.10,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X15X25X0.5 MM RAPID RESORBABLE S,SUP-2838575,CDM,C1713,HCPCS,0278,RC,,,,both,,,1079.22,701.49,,,,,,,,,,,,,
COIL DETACH 3D SHP 7MM BIG LOOP OD 12CM INTRO GDC 10,SUP-2365674,CDM,C1889,HCPCS,0278,RC,,,,both,,,4900.44,3185.29,,,,,,,,,,,,,
HEAD FEM UPLR MOD SYS,SUP-2449746,CDM,C1776,CPT,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
GRAFT BONE RT DSTL HUM TRAD FRZN,SUP-2294182,CDM,C1713,HCPCS,0278,RC,,,,both,,,3984.66,2590.03,,,,,,,,,,,,,
GRAFT 1-8MM BONE CANCELLOUS CHIP 40ML,SUP-2655884,CDM,C1713,HCPCS,0278,RC,,,,both,,,1420.22,923.14,,,,,,,,,,,,,
SPLINT WR AD SM UPTO W3.5IN LT MCP DLX KAY-SPLNT III,SUP-2324559,CDM,L3906,HCPCS,0274,RC,,,,both,,,79.41,51.62,,,,,,,,,,,,,
STEM TIB L150MM DIA10MM TI KNEE PRI GEN II LEGION,SUP-2346006,CDM,C1776,CPT,0278,RC,,,,both,,,3112.53,2023.14,,,,,,,,,,,,,
TUBING SET INFL EXP ACCULIF TL ST,SUP-2381475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BONE SM W11XL208MM THK3.3MM 0DEG 16 H BILAT TI STR RIG,SUP-2190795,CDM,C1713,HCPCS,0278,RC,,,,both,,,1360.44,884.29,,,,,,,,,,,,,
FIBER LASER 200 SER BALL TIP COMPATIBLE HOLM DISP,SUP-2540069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1629.69,1059.30,,,,,,,,,,,,,
DESIPRAMINE HCL 25 MG PO TABS,RX-2286,CDM,6370000000,HCPCS,0637,RC,50742-0113-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 92 MM BLADE L 50 MM 5 H SS CNDYL,SUP-2907935,CDM,C1713,HCPCS,0278,RC,,,,both,,,3072.52,1997.14,,,,,,,,,,,,,
TRAY TRACH INTRO GUID CATH NDL SYR CONN HEMSTAT HYDRPHLC,SUP-2171014,CDM,C1769,HCPCS,0272,RC,,,,both,,,1395.76,907.24,,,,,,,,,,,,,
RETRACTOR PEER 12.5IN 5MM,SUP-2243666,CDM,C1713,HCPCS,0278,RC,,,,both,,,5285.78,3435.76,,,,,,,,,,,,,
GRAFT VASC ACUSEAL L 10 CM DIA 6 MM EPTFE CBAS HEPARIN 3,SUP-2655618,CDM,C1768,CPT,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
SCREW BNE L20MM DIA3.5MM S STL LOK WSHR SURFIX,SUP-2243392,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.46,721.15,,,,,,,,,,,,,
CATHETER EMB NOVASIL SYNTEL L 80 CM DIA 6 FR BALLOON DIA13,SUP-2264200,CDM,C1757,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
MOLD TIB SPCR SM AP39MM ML58MM PMMA URETHANE GENT KASM,SUP-2315777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
IMPLANT LARYN L4MM DIA20FR SFT VLV ASMBLY EMBEDDED W/ SLV,SUP-2242289,CDM,L8509,HCPCS,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
TRUVIEW 22MM 27MM PEEK,SUP-2400029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
CATHETER VENTRICULAR 120 CM DSTL BA STRP CLR,SUP-2666785,CDM,C1729,HCPCS,0272,RC,,,,both,,,760.76,494.49,,,,,,,,,,,,,
HC Treat Vaginal Bleeding,PX-4505718000,CDM,57180,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
SPHINCTEROTOME STONETOME BELOW CUT WIRE 30MM TIP 5MM,SUP-2149503,CDM,C1713,HCPCS,0278,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
BIT DRL L 145/60 MM DIA2 MM AO QC CALIB NS REUSE V,SUP-2905694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.65,394.32,,,,,,,,,,,,,
PATCH CV FLUOROPASSIV L 120 X W 25 MM POLYESTER,SUP-2385075,CDM,C1768,CPT,0278,RC,,,,both,,,448.02,291.21,,,,,,,,,,,,,
DRIVER SURG AO CONN FINAL FOR POLYAX LOK SCR DST VOLAR RAD,SUP-2421214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.63,222.06,,,,,,,,,,,,,
ENDCAP SPNL 16 MM T2 STRATOSPHERE,SUP-2432046,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
ANCHOR SUTURE POLYMER SMALLEST SMTH SECUR DESIGN PERM,SUP-2895981,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.03,80.62,,,,,,,,,,,,,
CATHETER DRNGE 8FR L30CM UNIV NIT LOK PGTL NAVARRE,SUP-2128423,CDM,C1729,HCPCS,0272,RC,,,,both,,,247.18,160.67,,,,,,,,,,,,,
ELECTRODE ECG MEDI-TRACE 5,SUP-2835249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.39,286.25,,,,,,,,,,,,,
GUIDE NERVE REP MTRX 3 MMX3 CM STRL NEURAGEN 3D LF,SUP-2877628,CDM,C9352,HCPCS,0278,RC,,,,both,,,10520.07,6838.05,,,,,,,,,,,,,
SHEATH INTRO HIPOINT 88 TENZING 8 HYBRID 088 ACCS SYS STRL,SUP-2878100,CDM,C1887,HCPCS,0272,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
TRAY HUM OFFSET 0 MM SHLDR RVS ADPT STRL EQUINOXE,SUP-2889628,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
IMPLANT HUM TISS L 7 X W 7 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881941,CDM,C1762,CPT,0278,RC,,,,both,,,18651.60,12123.54,,,,,,,,,,,,,
INSERT HUM H10MM OD42MM STD ARW,SUP-2224541,CDM,C1776,CPT,0278,RC,,,,both,,,5191.36,3374.38,,,,,,,,,,,,,
HC Perq Transcath Cls Paravalvr Leak 1 Mitral Valve,PX-4819359000,CDM,93590,CPT,0481,RC,,,,both,,,41135.00,26737.75,,,,,,,,,,,,,
SHUNT MICRO STENT WITH APPLIERS CYPASS ULTRA,SUP-2109981,CDM,C1783,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
STENT ENDOPROS L25CM DIA6MM CATH 7FR L120CM 0.035IN VES,SUP-2396603,CDM,C1874,HCPCS,0278,RC,,,,both,,,20425.70,13276.70,,,,,,,,,,,,,
PLATE SPNL L27MM 4MM SPC MINI TI DBL BEND FOR 2MM SCR,SUP-2191051,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SCREW BNE CROSS DRV 1.5X7 MM 4 MM 3X5 MM THRD DRL FREE,SUP-2467923,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.61,185.00,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST DBL SLD STIRRUP BND,SUP-2435634,CDM,L2020,HCPCS,0272,RC,,,,both,,,3119.94,2027.96,,,,,,,,,,,,,
NUT SPNL W11MM TI 12 PNT,SUP-2193680,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
BOOT TRAC FT FOAM INSRT VELC STRP AD,SUP-2360615,CDM,L4387,HCPCS,0274,RC,,,,both,,,595.50,387.07,,,,,,,,,,,,,
CLIP ANEUR BLDE L5MM OPN 4MM CLS FORC 70GM MINI TI CRV TEMP,SUP-2108363,CDM,C1713,HCPCS,0278,RC,,,,both,,,1273.05,827.48,,,,,,,,,,,,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,2500000003,HCPCS,0250,RC,67457-0163-02,NDC,,both,2,ML,449.30,292.04,,,,,,,,,,,,,
EZETIMIBE 10 MG PO TABS,RX-34153,CDM,6370000000,HCPCS,0637,RC,51660-0200-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PIN FIX SMOOTH 1/8 DRL BIT,SUP-2267682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
WEDGE FEM SZ 5-6 THK5MM LNG STD UNIV POST PRI CEM LEGION,SUP-2346387,CDM,C1776,CPT,0278,RC,,,,both,,,3479.12,2261.43,,,,,,,,,,,,,
BUR SURG SZ 2 X 22 X 72 MM SHANNON STYL CORTA BNE AO STRL,SUP-2899168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.79,510.76,,,,,,,,,,,,,
PLATE BNE LG LAT LEN NS,SUP-2534747,CDM,C1713,HCPCS,0278,RC,,,,both,,,2244.75,1459.09,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC EXCHANGE 16FR DIA 5,SUP-2613288,CDM,C1750,HCPCS,0278,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
BRACE SHLDR L FA L15 16IN UNIV AIRMESH BRTH SLNG 15DEG ABD,SUP-2150869,CDM,L3650,HCPCS,0272,RC,,,,both,,,171.16,111.25,,,,,,,,,,,,,
GRAFT HUM TISS BIOINTEGRATIVE 70X50 MM W/ INSRTN SL TAPESTRY,SUP-2867241,CDM,C1763,HCPCS,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
FLUOROURACIL 500 MG/10ML IV SOLN,RX-82200,CDM,J9190,HCPCS,0636,RC,63323-0117-10,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 13 MM 33 CC 71 GM EPIC II VR V158SYS] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356514,CDM,C1722,HCPCS,0275,RC,,,,both,,,46220.80,30043.52,,,,,,,,,,,,,
ECLIPSE TRUNION 41 MM TPS CTD,SUP-2830121,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
ENDPLATE INTERVERTEBRAL THORACO LUM MTL ON MTL TI SPIK 3DEG,SUP-2205505,CDM,C1889,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 120 MM DIA22 MM DEL SHTH,SUP-2934230,CDM,C1713,HCPCS,0278,RC,,,,both,,,17975.24,11683.91,,,,,,,,,,,,,
SLEEVE SURG PERC 2.7 MM UNIV LCK SYS,SUP-2534561,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
SOCKS PROSTHETIC MULT PLY BK,SUP-2314055,CDM,L8420,HCPCS,0274,RC,,,,both,,,98.63,64.11,,,,,,,,,,,,,
PLATE BNE LG LT MEDL CLMN FUSION STRATUM,SUP-2607235,CDM,C1713,HCPCS,0278,RC,,,,both,,,5276.61,3429.80,,,,,,,,,,,,,
SYS K ORBITAL T04MM,SUP-2681107,CDM,C1713,HCPCS,0278,RC,,,,both,,,2011.14,1307.24,,,,,,,,,,,,,
CARD DATA SYS MONITOR FOR COLLECTING LOG FILE INFO,SUP-2355991,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE L170MM THK3MM 9 H BILAT S STL STR LOK COMPR RECON,SUP-2185341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1633.87,1062.02,,,,,,,,,,,,,
PLATFORM SUT ANCHR DIA2.3MM W/ NO2 TWO STRND FORC FBR,SUP-2366693,CDM,C1713,HCPCS,0278,RC,,,,both,,,1407.69,915.00,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 120 MM DIA28 MM SHTH 20 FR RVD,SUP-2171017,CDM,C1874,HCPCS,0278,RC,,,,both,,,37975.16,24683.85,,,,,,,,,,,,,
BRACE ORTH ADJACENT FIT ELBW CUST FIT,SUP-2388191,CDM,L3760,HCPCS,0274,RC,,,,both,,,1755.26,1140.92,,,,,,,,,,,,,
SHEATH INTRO SUREFLEX L 72 CM DIA 8.5 FR DSTL CRV DIA17 MM,SUP-2131524,CDM,C1766,CPT,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
MEPIVACAINE HCL (PF) 1.5 % IJ SOLN,RX-155558,CDM,J0670,HCPCS,0636,RC,63323-0293-37,NDC,,both,1.333333333333333333,ML,54.10,35.16,,,,,,,,,,,,,
SYSTEM SUC IRR SINONASAL 2 ACT SINGLE HND DESIGN RESHAPEABLE,SUP-2900106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC X-Ray Exam Chest 3 Views,PX-3247104700,CDM,71047,CPT,0324,RC,,,,inpatient,,,827.00,537.55,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 9 FRX25 CM 11 GA 3L SPECTRUM,SUP-2759740,CDM,C1751,HCPCS,0278,RC,,,,both,,,499.67,324.79,,,,,,,,,,,,,
CATHETER CV PRESSURE MONITORING SET 018 PEDIATRIC 3 FRX5 CM,SUP-2760145,CDM,C1751,HCPCS,0278,RC,,,,both,,,108.17,70.31,,,,,,,,,,,,,
BUPIVACAINE-MELOXICAM ER 200-6 MG/7ML IJ SOLN,RX-154730,CDM,J0668,HCPCS,0636,RC,47426-0303-01,NDC,,both,7,ML,902.50,586.62,,,,,,,,,,,,,
IMPLANT KINEMATCH PAT FEM REPL,SUP-2262255,CDM,C1776,CPT,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
KIT EMB LAVA 6 ML FOR MIXING W/ DMSO MANIFOLD STRL,SUP-2899724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM 0.035 IN BENT CRV STR,SUP-2665403,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.94,25.31,,,,,,,,,,,,,
KIT INTRO VSI L 12 CM DIA 6 FR NIT MANDREL SS TIP HYDRPHLC,SUP-2763486,CDM,C1892,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
HC CT Brain W/ Contrast,PX-3517046000,CDM,70460,CPT,0351,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
AMIODARONE HCL IN DEXTROSE 360-4.14 MG/200ML-% IV SOLN,RX-108516,CDM,2500000003,HCPCS,0250,RC,43066-0360-20,NDC,,both,200,ML,265.70,172.70,,,,,,,,,,,,,
CLAMP EXT FIX M SELF HLD CLP ON COMB,SUP-2188521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1548.05,1006.23,,,,,,,,,,,,,
DRESSING NEG PRSS M W1.8XH8XL11CM FOAM SH RUL LBL NO STING,SUP-2261617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
REMOTE SLEEP PATIENT CONTROL,SUP-2849863,CDM,C1787,HCPCS,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
GUIDE PIN FIX 2.5MM TRABECULAR REV SHLDR SYS,SUP-2199079,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
CLAMP EXT FIX STR MRI SAFE FOR MULT PIN JET-X,SUP-2342894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.76,465.24,,,,,,,,,,,,,
RING EXT FIX DIA180 MM LNG FT NS DISP SMRT TSF,SUP-2933201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5135.47,3338.06,,,,,,,,,,,,,
SCISSOR OPHTH PHACO 60 DEG DEL BLNT 5MM 0.05IN GRIESHABER,SUP-2109708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.79,430.81,,,,,,,,,,,,,
PLATE BNE L W135XL296MM THK42MM 16 H BILAT TI NAR RIG NEUT,SUP-2190832,CDM,C1713,HCPCS,0278,RC,,,,both,,,2443.42,1588.22,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X119 MM LT PROX 2 HOLE STRL VALCP,SUP-2789282,CDM,C1713,HCPCS,0278,RC,,,,both,,,5378.22,3495.84,,,,,,,,,,,,,
CAGE SPNL LG OSTEOTMY CUST SYS TRUSS,SUP-2101150,CDM,C1889,HCPCS,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
DRESSING WND W8XL10IN CROSSLINKED BOV TEND CLLGN,SUP-2243935,CDM,Q4104,HCPCS,0636,RC,,,,both,,,35084.60,22804.99,,,,,,,,,,,,,
PLATE 2H LOCKING 2.7/3.0/3.5/4.0MM,SUP-2752088,CDM,C1713,HCPCS,0278,RC,,,,both,,,1715.70,1115.20,,,,,,,,,,,,,
SET URET STENT UNIVERSA L 18 CM DIA 5 FR HYDRPHLC SFT,SUP-2169452,CDM,C2617,HCPCS,0278,RC,,,,both,,,207.55,134.91,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CATHETER GUID VENTURE L 144.5 CM SHFT OD 4.1 FR ID 0.015 IN,SUP-2383161,CDM,C1887,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
HC So Tissue Culture Lymphocyte,PX-3118823066,CDM,88230,CPT,0311,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
PICK MEMBRN ECKARDT 25 G STRL DISP,SUP-2213469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER HD RAULERSON 11.5 FRX15 CM IJ DL TAPR TIP DUOFLO,SUP-2627384,CDM,C1752,HCPCS,0278,RC,,,,both,,,141.68,92.09,,,,,,,,,,,,,
CROWN DENT LL5 SPACE MAINTAINER 1ST PERM STR WALLED SS,SUP-2176716,CDM,D6783,CPT,0278,RC,,,,both,,,21.79,14.16,,,,,,,,,,,,,
BIT DRL FLX ANAT LABRUM RESTR SYS DISP NANOTACK,SUP-2366742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,696.39,452.65,,,,,,,,,,,,,
ARM DISTRACTOR 25MML EXTERNAL MANDIBULAR 3DX 51 601 25 09,SUP-2500751,CDM,C1713,HCPCS,0278,RC,,,,both,,,875.18,568.87,,,,,,,,,,,,,
CROWN DENT PED NO7 SEC PRI M ANTR UP L CUSPID PREFABRICATED,SUP-2238929,CDM,D6783,CPT,0278,RC,,,,both,,,19.15,12.45,,,,,,,,,,,,,
DIST HUM LAT RT 11H 103MM STE,SUP-2588820,CDM,C1713,HCPCS,0278,RC,,,,both,,,2718.49,1767.02,,,,,,,,,,,,,
NAIL IM 12 MMX37.5 CM TIB,SUP-2252428,CDM,C1713,HCPCS,0278,RC,,,,both,,,4541.26,2951.82,,,,,,,,,,,,,
BB-TAK THREADED STRL,SUP-2811920,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
HC Ultrasound Chest,PX-4027660400,CDM,76604,CPT,0402,RC,,,,both,,,1369.00,889.85,,,,,,,,,,,,,
GRAFT BNE SUB 6MM IL CREST WDG TREAT W PRESERVON,SUP-2264835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1862.68,1210.74,,,,,,,,,,,,,
PLATE BNE M THK0.6MM 2X2 H L TI L SHP LO PROF LEV 1 FIX FOR,SUP-2262936,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.65,343.62,,,,,,,,,,,,,
HC So Hep B Ultraquant,PX-3068751766,CDM,87517,CPT,0306,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
SCREW BNE L 7 MM DIA2 MM TI MAND ST LCK AXS NS UNIV,SUP-2909600,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.78,309.91,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX15 RCNSTRCTN F3.5MM LOK SCREW ST,SUP-2724422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.95,1337.02,,,,,,,,,,,,,
GRAFT BONE TRICORT BLK FRZ DRY,SUP-2165604,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BNE L W135XL170MM THK42MM 9 H BILAT TI NAR RIG NEUT,SUP-2190818,CDM,C1713,HCPCS,0278,RC,,,,both,,,1484.40,964.86,,,,,,,,,,,,,
SCREW INTFR L23MM DIA7MM PEEK W/ DISP SHTH,SUP-2121150,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STENT BILI SOLOPS L 70 MM DIA12 FR AD STRL,SUP-2141425,CDM,C1876,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
BRACE KNEE HNG WRP X L,SUP-2276703,CDM,L1820,HCPCS,0272,RC,,,,both,,,50.11,32.57,,,,,,,,,,,,,
IVABRADINE HCL 5 MG PO TABS,RX-129773,CDM,6370000000,HCPCS,0637,RC,55513-0800-60,NDC,,both,1,UN,47.00,30.55,,,,,,,,,,,,,
RETRACTOR SPNL 125INW 3IN DEPTH SHRP TAY MED LAT HND HELD,SUP-2409708,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305760,CDM,V2790,HCPCS,0274,RC,,,,both,,,4606.38,2994.15,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING REG PEDIATRIC INF 1.25 IN PROCARE,SUP-2195748,CDM,L0180,HCPCS,0272,RC,,,,both,,,80.01,52.01,,,,,,,,,,,,,
HC Pt Parrafin Bath,PX-4209701800,CDM,97018,CPT,0420,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
JOINT TOE 1ST MTP 16 MM HA COAT ENCOMPASS LTX,SUP-2857529,CDM,C1776,CPT,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
INTRODUCER SHTH TRANSSEPTAL 032 8 FRX61 CM 67 CM MULLINS,SUP-2463416,CDM,C1893,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
IMPLANT SPNL 35X27MM NM 14MM 10 DEG,SUP-2245145,CDM,C1713,HCPCS,0278,RC,,,,both,,,18902.80,12286.82,,,,,,,,,,,,,
ANCHOR SUT KNOTLESS CINCHLOCK 2.4 MM,SUP-2378803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2929.62,1904.25,,,,,,,,,,,,,
GUIDEPIN SURG DIA32MM N FORCE,SUP-2414093,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.51,205.73,,,,,,,,,,,,,
PEMETREXED DISODIUM 1 GM/40ML IV SOLN,RX-158848,CDM,J9294,HCPCS,0636,RC,00409-0004-04,NDC,,both,40,ML,380.70,247.45,,,,,,,,,,,,,
CONNECTOR SPINE 5.5MM SACR AND SACROILIAC TI COLORADO 2,SUP-2290605,CDM,C1713,HCPCS,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
SCREW BNE L55MM DIA6MM CORT TI ST CANN LOK FULL THRD HEX HD,SUP-2191838,CDM,C1713,HCPCS,0278,RC,,,,both,,,708.35,460.43,,,,,,,,,,,,,
GRAFT BNE VOID FILL 10 CC MG,SUP-2742076,CDM,C1713,HCPCS,0278,RC,,,,both,,,11209.80,7286.37,,,,,,,,,,,,,
SODIUM CHLORIDE 3% IV BOLUS,RX-4082505,CDM,J7131,HCPCS,0258,RC,00338-0054-03,NDC,,both,100,ML,11.10,7.21,,,,,,,,,,,,,
MARKER BRST BX TI UND MRI TRIMARK,SUP-2382009,CDM,A4648,CPT,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 4 HOLE ATTCH VA COMPR STRL VALCP,SUP-2789944,CDM,C1713,HCPCS,0278,RC,,,,both,,,2224.41,1445.87,,,,,,,,,,,,,
PLATE SPNL CERV 57.5 MM ANTR TI ZEPHIR,SUP-2280050,CDM,C1713,HCPCS,0278,RC,,,,both,,,3798.71,2469.16,,,,,,,,,,,,,
SCREW CRAN L 4 MM DIA1.5 MM 100 SD DISK NS DISP,SUP-2929038,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.88,51.92,,,,,,,,,,,,,
AFFINITI CORTILOC PEGGED GLENOID SIZE: 56,SUP-2713890,CDM,C1776,CPT,0278,RC,,,,both,,,6287.85,4087.10,,,,,,,,,,,,,
HC Treat Ankle Fx,PX-4502780800,CDM,27808,CPT,0450,RC,,,,both,,,692.00,449.80,,,,,,,,,,,,,
K WIRE FIX L9IN DIA0.9MM NONSTERILE S STL 2 SIDE DBL DMND,SUP-2150683,CDM,C1713,HCPCS,0278,RC,,,,both,,,20.19,13.12,,,,,,,,,,,,,
BLADE SHAVER CRV SUCTION 65 DEG 4 MMX12 CM CONCV EDGE GRN,SUP-2602789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.16,421.95,,,,,,,,,,,,,
SHUNT CV MED CAR ART NL8505500,SUP-2633898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,728.32,473.41,,,,,,,,,,,,,
CATHETER CRICO CUF SPEC OP MELK EMER,SUP-2169662,CDM,C1769,HCPCS,0272,RC,,,,both,,,1121.61,729.05,,,,,,,,,,,,,
FIBER LASER HOLMIUM GI,SUP-2885367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
STEM HUM LNG 44X21 MM SHLDR AFFINITI EH2,SUP-2715335,CDM,C1776,CPT,0278,RC,,,,both,,,8655.41,5626.02,,,,,,,,,,,,,
SHEATH INTRO SUPER SHTH L 7 CM DIA 4.5 FR GUIDEWIRE L 70 CM,SUP-2269574,CDM,C1892,HCPCS,0272,RC,,,,both,,,45.53,29.59,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2 MM RECON PT SPEC,SUP-2860083,CDM,C1713,HCPCS,0278,RC,,,,both,,,26989.24,17543.01,,,,,,,,,,,,,
ANCHOR SUT OD3.7MM NONABSORBABLE TAG WDG,SUP-2341289,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.82,345.03,,,,,,,,,,,,,
CATHETER ART THERMODILUTION 6 FRX110 CM 4 LUMEN SWAN,SUP-2213978,CDM,C1725,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE FREE MOLD PLAS,SUP-2435638,CDM,L2037,HCPCS,0272,RC,,,,both,,,4694.99,3051.74,,,,,,,,,,,,,
HC Viral/Hsv Culture,PX-3008725200,CDM,87252,CPT,0300,RC,,,,both,,,288.00,187.20,,,,,,,,,,,,,
IMPLANT TOE JT GREAT MP CO CHROM N POR SM 17MM,SUP-2137755,CDM,C1776,CPT,0278,RC,,,,both,,,4587.54,2981.90,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 95 X W 13.5 MM MYRIAD HNDPC L 13 NN-3010,SUP-2930304,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22705.03,14758.27,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COMPIA MRI SURESCAN W 51 X H 71 MM D 13,SUP-2421029,CDM,C1882,HCPCS,0275,RC,,,,both,,,43646.00,28369.90,,,,,,,,,,,,,
PLATE BNE W195XL72MM NAR 6X5 H ST R DST RAD VOLAR TI VAR ANG,SUP-2180842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2841.39,1846.90,,,,,,,,,,,,,
PLATE SPNL L68MM STD ANTR CERV TI LEV 4 FIX LCK MAXAN,SUP-2205443,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
GUIDEWIRE VASC TORQ-FLEX L 130 CM DIA 0.018 IN FLX TIP L 8,SUP-2638734,CDM,C1769,HCPCS,0272,RC,,,,both,,,140.11,91.07,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 100 MM 10 CC DBM VESUVIUS,SUP-2717999,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
MESALAMINE 400 MG PO CPDR,RX-120377,CDM,6370000000,HCPCS,0637,RC,00093-5907-86,NDC,,both,1,UN,15.10,9.81,,,,,,,,,,,,,
SPHINCTEROTOME BILI 3 LUMN WIRE GUID LNG NOSE 20MM UTOM XL,SUP-2149505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.29,251.74,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. L 80 MM DIA 6 MM NIT TRNSHEP SELF,SUP-2158911,CDM,C1876,HCPCS,0278,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
CATHETER THROMCTMY STROKE FAST PK PTFE PEBAX COIL SS STRL,SUP-2551070,CDM,C1757,HCPCS,0272,RC,,,,both,,,9624.51,6255.93,,,,,,,,,,,,,
GRAFT BNE PTTY 0.5 CC JR DBM GRFT,SUP-2278348,CDM,C9359,HCPCS,0278,RC,,,,both,,,243.66,158.38,,,,,,,,,,,,,
RING EXT FIX DIA170MM HALF FOR RNG FIX SYS TRUELOK,SUP-2316179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
MESH SURG W7.6XL15CM RECT PARTIALLY ABSRB FLAT FOR SFT TISS,SUP-2220106,CDM,C1781,HCPCS,0278,RC,,,,both,,,421.73,274.12,,,,,,,,,,,,,
CLIP ANEUR BAYNT FEN L TYP SUGITA,SUP-2305999,CDM,C1889,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BONE LEFORT 1.5X6 MM MIDFACE ADVANCEMENT FOR SCREW TITANIUM,SUP-2754965,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SONICATH ULTRA DIA 9 FR FREQ 9,SUP-2139881,CDM,C1753,HCPCS,0278,RC,,,,both,,,2034.22,1322.24,,,,,,,,,,,,,
KIT BNE CEM 180GM CART 200MM BRKWY FEM NOZ AND RESTRIC M,SUP-2366880,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.16,306.25,,,,,,,,,,,,,
BIT DRL ADJ DEPTH,SUP-2598578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSOSTAR NAV LOOP DIA25 MM SZ,SUP-2882598,CDM,C1730,HCPCS,0272,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
C WIRE FIX L5IN DIA0.045IN SPADE TIP FOR SM BNE TRAUM,SUP-2166606,CDM,C1713,HCPCS,0278,RC,,,,both,,,22.42,14.57,,,,,,,,,,,,,
MARKER BRST BX OD10GA PET BARBELL CLP MAMMOSTAR,SUP-2195624,CDM,A4648,CPT,0278,RC,,,,both,,,232.42,151.07,,,,,,,,,,,,,
TUBE TRACH AD L88MM OD11MM ID8MM SIL CUF W TLK ATTCH MID,SUP-2352454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
GRAFT BNE SUB 90CC 4 10MM CORT CANC CHIP COARSE FRZN,SUP-2307431,CDM,C1713,HCPCS,0278,RC,,,,both,,,6862.78,4460.81,,,,,,,,,,,,,
STEM FEM SEG 8.5 CM RT KNEE REDUC RESECT TAPR COMPRESS,SUP-2441847,CDM,C1776,CPT,0278,RC,,,,both,,,18821.16,12233.75,,,,,,,,,,,,,
CATHETER ATHRCTMY L 9.5 CM BUR 2.25 MM EXCHG STRL,SUP-2147779,CDM,C1724,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DISTRACTION PIN 20MM X 62MM 7MM CTTNG SHAFT PKG/2 T 6L 4V S,SUP-2669823,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.77,292.35,,,,,,,,,,,,,
ROD IM TIB MILLING NXGN,SUP-2438143,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
HANDLE LITHO EMGCY STRL LTX DISP,SUP-2865623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1416.93,921.00,,,,,,,,,,,,,
STEM FEM L13MM DIA6MM EXT HIP CEM ENCOMPASS,SUP-2314454,CDM,C1776,CPT,0278,RC,,,,both,,,6079.04,3951.38,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 135 CM BALLOON L 120 MM DIA,SUP-2141988,CDM,C1725,HCPCS,0272,RC,,,,both,,,3174.54,2063.45,,,,,,,,,,,,,
PRE 20MM 0035 VISIGLIDE 0025 ANG,SUP-2679396,CDM,C1769,HCPCS,0272,RC,,,,both,,,1745.24,1134.41,,,,,,,,,,,,,
GRAFT BNE 2.5 CC CELLULAR BNE MTRX V92 FC+,SUP-2742068,CDM,C1713,HCPCS,0278,RC,,,,both,,,4749.25,3087.01,,,,,,,,,,,,,
DEVICE FIX 55 MM CL ULTRA ENDOBUTTON,SUP-2848587,CDM,C1713,HCPCS,0278,RC,,,,both,,,959.43,623.63,,,,,,,,,,,,,
HC So Thyroxine Total,PX-3018443666,CDM,84436,CPT,0301,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
GUIDEWIRE VASC STR 7 CM 0.035 INX260 CM 3 CM AMPLATZ,SUP-2167952,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.80,40.17,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA 30 MM POLYESTER GEL,SUP-2385055,CDM,C1768,CPT,0278,RC,,,,both,,,1988.62,1292.60,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM 2.5MM SPC QPLR ASYM 4 CRV STR TIP,SUP-2141266,CDM,C1733,HCPCS,0272,RC,,,,both,,,4609.52,2996.19,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 15 CM DIA10 FR PTFE PERC NO CRV,SUP-2127709,CDM,C1892,HCPCS,0272,RC,,,,both,,,488.30,317.39,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN TIP L 3 MM PTFE AD J,SUP-2117312,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
BENZOCAINE-MENTHOL 20-0.26 % MT GEL,RX-146575,CDM,6370000000,HCPCS,0637,RC,10310-0430-28,NDC,,both,7,GR,16.90,10.98,,,,,,,,,,,,,
BIT DRL STR STRL PILLAR,SUP-2316058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2188.58,1422.58,,,,,,,,,,,,,
PLATE BNE L253MM 14 H NONSTERILE R PROX TIB S STL,SUP-2185706,CDM,C1713,HCPCS,0278,RC,,,,both,,,3857.90,2507.63,,,,,,,,,,,,,
PROGUIDE CHRNC DLSS CATH HOLES 2 24CM TIP HUB 2 28CM TIP HUB,SUP-2676388,CDM,C1894,HCPCS,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
WIRE FIX THRD OLV MAXLOCK EXTRM,SUP-2315908,CDM,C1769,HCPCS,0272,RC,,,,both,,,146.80,95.42,,,,,,,,,,,,,
COLLAR CERV UNIV AD L13-19IN TRACH OPN TWO PC RIG POLYETH,SUP-2124202,CDM,L0120,HCPCS,0272,RC,,,,both,,,115.05,74.78,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.6MM FT 2X TRCR TIP END FOR VAR ANG,SUP-2343050,CDM,C1769,HCPCS,0272,RC,,,,both,,,1096.49,712.72,,,,,,,,,,,,,
HC Trach Change,PX-7613150200,CDM,31502,CPT,0761,RC,,,,outpatient,,,694.00,451.10,,,,,,,,,,,,,
PLATE BNE L157MM THK3MM 9 H TI TIM R DST ANTLAT TIB LOK,SUP-2413678,CDM,C1713,HCPCS,0278,RC,,,,both,,,6418.16,4171.80,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB II ROSEN STRL REUSE HI-LINE,SUP-2929219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.91,251.49,,,,,,,,,,,,,
SLING GYN ANT PELV FLR RECON MESH GYNECARE PROLIFT+M,SUP-2219782,CDM,C1771,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
LEAD PACE CAPSURFIX NOVUS MRI SURESCAN L 58 CM DIA 6 FR SIL,SUP-2281974,CDM,C1898,HCPCS,0275,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
GRAFT ENDOVASC L18CM AORT DIA26MM IL DIA12MM ABD EXCLUDER,SUP-2396076,CDM,C1768,CPT,0278,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ESOPHASTAR L 125 CM DIA 8 FR BLU,SUP-2248921,CDM,C1732,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PLATE BONE 11 H PRI RECON W TEMPLT,SUP-2365246,CDM,C1713,HCPCS,0278,RC,,,,both,,,7326.25,4762.06,,,,,,,,,,,,,
BRACE ORTH LUMBAR X SM LT EVERGREEN,SUP-2123875,CDM,L0626,HCPCS,0274,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
PLATE SURFACE 3.5MM QUADRILATERAL SHORT STERILE,SUP-2546017,CDM,C1713,HCPCS,0278,RC,,,,both,,,1638.04,1064.73,,,,,,,,,,,,,
ROD REPROC SPNL 11 MM CARBON FIBER,SUP-2558714,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.03,263.27,,,,,,,,,,,,,
MINI CMPRSSN PLATE STRGHT 6 HOLE 20MM CP TTNM,SUP-2707262,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.27,436.98,,,,,,,,,,,,,
SET UROLOGICAL SHTH 810 SET L 30 CM DIA 8.5 FR DIL L 88 CM,SUP-2835702,CDM,C2617,HCPCS,0278,RC,,,,both,,,138.85,90.25,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST DYN FLX HINGE FABRICATED,SUP-2435769,CDM,L3900,HCPCS,0274,RC,,,,both,,,4173.94,2713.06,,,,,,,,,,,,,
PLATE BNE 12.5 DEG RT STRL AXI+LINE LTX,SUP-2861969,CDM,C1713,HCPCS,0278,RC,,,,both,,,3492.94,2270.41,,,,,,,,,,,,,
CAP ORTH FEM NAIL TI STRL ZNN,SUP-2862126,CDM,C1713,HCPCS,0278,RC,,,,both,,,3104.83,2018.14,,,,,,,,,,,,,
INSERT TIB SZ 4 THK10MM UNIV KNEE POLYETH FIX BEAR PRI NEUT,SUP-2253552,CDM,C1776,CPT,0278,RC,,,,both,,,4907.19,3189.67,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ LOOP LOK W STAY E SUPP COT,SUP-2276652,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.55,6.21,,,,,,,,,,,,,
SCREW INTRF N CANN 12X25 MM,SUP-2662018,CDM,C1713,HCPCS,0278,RC,,,,both,,,696.33,452.61,,,,,,,,,,,,,
GUIDE SURG PLN TI LP CUSTOMIZABLE JAW IN A DAY RECON VSP,SUP-2883955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,35080.08,22802.05,,,,,,,,,,,,,
HC Replace Cv Cath Only,PX-3613657800,CDM,36578,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
NEXGEN ROTATING HINGE FULL TIB AGMT BLK 10MM SZ 3,SUP-2502524,CDM,C1776,CPT,0278,RC,,,,both,,,3899.88,2534.92,,,,,,,,,,,,,
EXTRACTOR SURG EASYOUT 3 MM QR ACUTRK,SUP-2857693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
COLLAGEN REP PTCH,SUP-2172379,CDM,C9364,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
HC US Guidance for Needle Place - Anes Block,PX-4027694201,CDM,76942,CPT,0402,RC,,,,both,,,978.00,635.70,,,,,,,,,,,,,
ADAPTER HRT ALRM CTRL,SUP-2282559,CDM,Q0508,HCPCS,0274,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X15 MM WRST LCK CAP STRL FRDM,SUP-2852844,CDM,C1713,HCPCS,0278,RC,,,,both,,,1498.85,974.25,,,,,,,,,,,,,
PLATE BNE L87MM 4 H L PROX TIB S STL VAR ANG LOK COMPR SM,SUP-2177909,CDM,C1713,HCPCS,0278,RC,,,,both,,,5090.79,3309.01,,,,,,,,,,,,,
SPACER FEM SZ 4 THK12MM RT LAT ASYM REV CEM NP N-K II,SUP-2209182,CDM,C1776,CPT,0278,RC,,,,both,,,3253.04,2114.48,,,,,,,,,,,,,
COLLAR CERV H3XL15IN SM AD TRACH CLS HK AND LOOP CLSR W CHIN,SUP-2276593,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.56,4.26,,,,,,,,,,,,,
NAIL IM 125 DEG SHT 10 MMX21.5 CM LT CEPHALOMEDULLARY FEM TI,SUP-2208131,CDM,C1713,HCPCS,0278,RC,,,,both,,,4450.26,2892.67,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX10 LEFT MEDIAL DISTAL TIBIAL,SUP-2499627,CDM,C1713,HCPCS,0278,RC,,,,both,,,4305.38,2798.50,,,,,,,,,,,,,
CATHETER THORACIC 20FR L20IN SILICONE 5 EYELET STRAIGHT SOFT,SUP-2825067,CDM,C1729,HCPCS,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
HC So1 Immunofixation Serum,PX-3028633467,CDM,86334,CPT,0302,RC,,,,both,,,225.00,146.25,,,,,,,,,,,,,
TRIAL SPNL 16MM IMPL ALLGRFT DANEK,SUP-2292302,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.99,708.49,,,,,,,,,,,,,
SLING GYN POST PELV FLR RECON MESH GYNECARE PROLIFT+M,SUP-2219784,CDM,C1771,HCPCS,0278,RC,,,,both,,,4537.30,2949.24,,,,,,,,,,,,,
INSTRUMENT TEMP FIX 2X12 MM RIB THOR SCR TI LEVEL 1 MAXDRIVE,SUP-2869183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,560.18,364.12,,,,,,,,,,,,,
SCREW BNE L36MM OD4.2MM NONLOCKING LO PROF TUFFNEK,SUP-2321227,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.43,359.73,,,,,,,,,,,,,
WIRE FIX OD1.8MM END L6MM PLT SZ 2.4MM SH PROV,SUP-2351115,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.97,344.48,,,,,,,,,,,,,
JOINT SUBTALAR 12.5 MM ANK,SUP-2318979,CDM,C1713,HCPCS,0278,RC,,,,both,,,3727.18,2422.67,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X124 MM 7 HOLE SS LC-DCP,SUP-2569266,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.85,239.10,,,,,,,,,,,,,
PLATE BNE RECON 3.5X260 MM 20 HOLE W/ WIDE ANGLE STR LP NS,SUP-2799253,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.26,1357.37,,,,,,,,,,,,,
KIT BARIATRIC SIGNIA TRISTAPLE 1,SUP-2716331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5430.25,3529.66,,,,,,,,,,,,,
CATHETER THROMCTMY AXS VECTA 71 L 125 CM ID 1.8 MM,SUP-2551061,CDM,C1757,HCPCS,0272,RC,,,,both,,,7799.76,5069.84,,,,,,,,,,,,,
ROD GRP 5.5MM,SUP-2232025,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.78,1381.76,,,,,,,,,,,,,
TROCAR ENDOSCP L 70 MM DIA 5 MM LAPSCP SHRT BLADED SMTH CANN,SUP-2896368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.38,247.90,,,,,,,,,,,,,
CABLE SPNL DIA11MM ST TI SGL LOOP W BAR CRMP SONGER,SUP-2420957,CDM,C1713,HCPCS,0278,RC,,,,both,,,2452.34,1594.02,,,,,,,,,,,,,
PLATE BONE W14XL240MM THK3.8MM 13 H RT LAT TIB HD BTTRS S,SUP-2185779,CDM,C1713,HCPCS,0278,RC,,,,both,,,4350.25,2827.66,,,,,,,,,,,,,
NEGATIVE PRESSURE KIT 20X15 CM DRSG PMP CLP PICO 7,SUP-2429339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,677.02,440.06,,,,,,,,,,,,,
CATHETER ANGIO RAVI MG1 038 4 FRX125 CM SS GLIDECATH,SUP-2852405,CDM,C1887,HCPCS,0272,RC,,,,both,,,166.99,108.54,,,,,,,,,,,,,
TUBE ET 5MM ORAL LSR RESIST 2 CUF MURPHY EYE NONFLAMMABLE S,SUP-2283782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,129.62,84.25,,,,,,,,,,,,,
GRAFT BIO L8CM W8CM THK1MM MESH BOV MTRX WND TISS N PERF,SUP-2364670,CDM,C9359,HCPCS,0278,RC,,,,both,,,7174.90,4663.68,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP T9,SUP-2435538,CDM,L0455,HCPCS,0274,RC,,,,both,,,981.88,638.22,,,,,,,,,,,,,
CD BONE SCR 23X16MM 5/PKG,SUP-2679408,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.22,132.09,,,,,,,,,,,,,
HOUSING EXT FIX SM BNE ASMBLY,SUP-2525824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
COMPONENT TIB BASEPLT UNI 37MM X 6.5MM REPICCI II,SUP-2403267,CDM,C1776,CPT,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
IMPLANT SH W50XL76MM THK0.45MM MIC THN BIOMATERIAL OFF THE,SUP-2365182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1905.98,1238.89,,,,,,,,,,,,,
PLATE BONE 13 H DSTL RAD VOLAR LT LNG 2.5 ADAPTIVE II TRILOK,SUP-2267962,CDM,C1713,HCPCS,0278,RC,,,,both,,,4612.66,2998.23,,,,,,,,,,,,,
ALLOGRAFT ARTHROFLEX DECELLURIZ W/MATRACELL 20X25MM,SUP-2720119,CDM,Q4125,HCPCS,0636,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
CATHETER INFUS L100CM DIA5FR INFUS L10CM 0.035IN 1 LUMN VLV,SUP-2172522,CDM,C1751,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
NAIL IM RETROGRADE 13X180 MM TI NS,SUP-2417495,CDM,C1713,HCPCS,0278,RC,,,,both,,,5074.02,3298.11,,,,,,,,,,,,,
GRAFT HUM TISS 1000 MG PURAPLY MZ,SUP-2849178,CDM,C1763,HCPCS,0278,RC,,,,both,,,7269.10,4724.91,,,,,,,,,,,,,
WASHER ORTH DIA5MM FOR 2MM SCR,SUP-2349661,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.86,126.01,,,,,,,,,,,,,
DRILL SURG L120-200MM DIA2MM TWST,SUP-2194235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE STR 2X23 MM 4 HOLE,SUP-2569071,CDM,C1713,HCPCS,0278,RC,,,,both,,,143.34,93.17,,,,,,,,,,,,,
SCREW BNE L19MM OD2.7MM LOK FOR PLT TUFFNEK TECHNOLOGY,SUP-2321106,CDM,C1713,HCPCS,0278,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
PLUG TIB 12MM AS COLUMBUS,SUP-2108985,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KIT CATHETER BECKER EXT DRNGE MON VENT BA IMPREG,SUP-2284404,CDM,C1713,HCPCS,0278,RC,,,,both,,,940.84,611.55,,,,,,,,,,,,,
GRAFT TEND PERONEUS LONGUS ALLGRFT FRZ DRY 22 38CM L 6 12MM,SUP-2307130,CDM,C1762,CPT,0278,RC,,,,both,,,4370.63,2840.91,,,,,,,,,,,,,
PLATE BNE 6X2 H LOK BILAT GRID TRAPEOID HND DISP FOR 2MM,SUP-2267933,CDM,C1713,HCPCS,0278,RC,,,,both,,,1479.57,961.72,,,,,,,,,,,,,
SYSTEM DETACH NXT,SUP-2173075,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
KIT SHUNT T TB CSF CATH RESVR SYR PERI EDWARDS-BARBARO,SUP-2308211,CDM,C1713,HCPCS,0278,RC,,,,both,,,2855.55,1856.11,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.035X9 IN SS NS KIRSCHNER,SUP-2791242,CDM,C1713,HCPCS,0278,RC,,,,both,,,9.11,5.92,,,,,,,,,,,,,
CATHETER DRNGE 20FR L40CM 0.038IN L BOR 6 SIDEPRT FLX RIG,SUP-2168762,CDM,C1729,HCPCS,0272,RC,,,,both,,,269.51,175.18,,,,,,,,,,,,,
BIT DRL L115MM DIA1.6MM SKINNY RAINBOW INCORPORATED DEPTH,SUP-2365252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.08,410.85,,,,,,,,,,,,,
GLIDESHEATH SLENDER TP NI KT 0021 GW 5 FR 10CM,SUP-2385454,CDM,C1894,HCPCS,0272,RC,,,,both,,,279.30,181.54,,,,,,,,,,,,,
HOOK SPNL 5.5-6 MM RT TRNSVRS CD HORZ,SUP-2629469,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
BIT DRL L65MM DIA1.1MM ST S STL J LATCH NONRADIOPAQUE W/O,SUP-2187176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.55,265.56,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 60 CM DIA 0.018 IN NIT MANDREL SS TIP,SUP-2763451,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
CEFAZOLIN SODIUM-DEXTROSE 1-4 GM-%(50ML) IV SOLR,RX-143619,CDM,J0690,HCPCS,0636,RC,00264-3103-11,NDC,,both,1,UN,75.50,49.07,,,,,,,,,,,,,
PLATE BONE L169MM 9 H RT PROX HUM LCK FOR 4.5MM SCR PERI-LOC,SUP-2348277,CDM,C1713,HCPCS,0278,RC,,,,both,,,15868.62,10314.60,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 0.7-1.0 MCI NS ADVANTAGE,SUP-2247259,CDM,C2643,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CATHETER MIDLINE AGBA PI 1-L 4.5FR X 15CM,SUP-2850034,CDM,C1751,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
KIT PICC XCELA CATH L 55 CM DIA 5 FR 2 LUMEN ANGIO CUST STRL,SUP-2118855,CDM,C1751,HCPCS,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
DIPHENHYDRAMINE HCL 25 MG PO TABS,RX-2513,CDM,6370000000,HCPCS,0637,RC,68094-0018-61,NDC,,both,1,UN,1.90,1.23,,,,,,,,,,,,,
GUIDEWIRE VASC TRANSEND L 200 CM DIA 0.010 IN TIP L 2 CM,SUP-2367924,CDM,C1769,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
BLOCK MEAS SCREW LEN LEN MEAS PLATE,SUP-2318989,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.5MM TI SGL INNR POLYAX FOR 5.5MM ROD,SUP-2256227,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
IMPLANT NSL SHT LG 40X9X1.1 MM POLYETH MEDPOR LF,SUP-2431316,CDM,C1889,HCPCS,0278,RC,,,,both,,,649.32,422.06,,,,,,,,,,,,,
BLADE SAW W0.70XL1.17IN THK0.20IN OSC CRESC THN PRECIS TPS 2296031417] STRYKER INSTRUMENT DIV],SUP-2367267,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.67,227.29,,,,,,,,,,,,,
NAIL IM TIB 13.5X240 MM PHOENIX,SUP-2534608,CDM,C1713,HCPCS,0278,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
CRANIAL ACCESS KIT MANUAL CRAN ROTARY HNDPC DISP HITHSP04,SUP-2666707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.32,600.16,,,,,,,,,,,,,
RIB PLATE 14MMX76MM,SUP-2841915,CDM,C1713,HCPCS,0278,RC,,,,both,,,4075.72,2649.22,,,,,,,,,,,,,
SYSTEM IMPL DIA2.6/4.75 MM KNOTLESS SCORPION MULTFI NDL WHT,SUP-2930500,CDM,C1713,HCPCS,0278,RC,,,,both,,,7929.29,5154.04,,,,,,,,,,,,,
KWIRE FIX L102MM DIA11MM LMH,SUP-2398600,CDM,C1776,CPT,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
PROSTHESIS OSS W2.3XL4.25MM RECON INCUS HD HA FULL CANN,SUP-2312576,CDM,L8613,CPT,0278,RC,,,,both,,,1016.54,660.75,,,,,,,,,,,,,
SHEATH RESECTSCP 26FR YEL OBLQ BEAK CONN TB W/ CERAMIC,SUP-2261179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2442.10,1587.36,,,,,,,,,,,,,
BRACE KNEE POSTOP UNIV UNISX FASTEN ON HNG ROM STRP CLSR AD,SUP-2196449,CDM,L1832,HCPCS,0272,RC,,,,both,,,401.45,260.94,,,,,,,,,,,,,
BSS PLUS IO SOLN,RX-834,CDM,2500000003,HCPCS,0250,RC,00065-0795-15,NDC,,both,15,ML,57.00,37.05,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 14 MM 33 CC 77 GM RST ATLS II VR,SUP-2356517,CDM,C1722,HCPCS,0275,RC,,,,both,,,56206.00,36533.90,,,,,,,,,,,,,
BLADE RTRCTR BLFR HRGN 2INW X 15 3/4NL X 6 1/2ND ABDMNL CNTR,SUP-2476917,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.39,325.25,,,,,,,,,,,,,
CATHETER SET SALIVARY DUCT 0.014 IN 20 MMX2 CM ADV,SUP-2422285,CDM,C1726,HCPCS,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
SCREW BNE ST 5X16 MM PERIPROSTHETIC VA LCK OPTILINK STRL,SUP-2789484,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.95,622.02,,,,,,,,,,,,,
WASHER ORTH DIA 4 MM NS LEOS,SUP-2932986,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.41,323.97,,,,,,,,,,,,,
GRAFT HUM TISS ACELLULAR DERM THK.4-.8 MM OD4 CM N MESHED,SUP-2366752,CDM,Q4126,HCPCS,0636,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
HC Aspirate Pleura W/ Imaging,PX-3203255500,CDM,32555,CPT,0320,RC,,,,both,,,3598.00,2338.70,,,,,,,,,,,,,
CAP ORTH SM LT ULN ELBW LATITUDE,SUP-2399817,CDM,C1776,CPT,0278,RC,,,,both,,,6132.42,3986.07,,,,,,,,,,,,,
HC Assay of Free Thyroxine,PX-3018443900,CDM,84439,CPT,0301,RC,,,,both,,,348.00,226.20,,,,,,,,,,,,,
HC Soft Tissue Neck US,PX-4027653600,CDM,76536,CPT,0402,RC,,,,both,,,1670.00,1085.50,,,,,,,,,,,,,
PIN FIX DOCKING 3.3X20 MM,SUP-2232044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
PLATE WDG OPN VA LCK 2.4/2.7MM 5MM SPACER TI STRL,SUP-2546960,CDM,C1713,HCPCS,0278,RC,,,,both,,,3593.98,2336.09,,,,,,,,,,,,,
CATHETER ETER URET 5FR WHSTL TIP WVN L DRNGE LUMN REUSE,SUP-2126130,CDM,C1758,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
PRASUGREL HCL 10 MG PO TABS,RX-98283,CDM,6370000000,HCPCS,0637,RC,65862-0830-30,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
LENS IOL ASPHERIC 31+ DIOPT 6X13 MM ACRYLATE RESTOR,SUP-2111461,CDM,V2788,HCPCS,0276,RC,,,,both,,,495.00,321.75,,,,,,,,,,,,,
HEAD HUM H19MM DIA48MM SHLDR CO CHROM PRI BIO MOD STD NK,SUP-2404618,CDM,C1776,CPT,0278,RC,,,,both,,,3001.84,1951.20,,,,,,,,,,,,,
BLADE SAW OSTEOTMY HUB STYL DS,SUP-2535308,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 6H LT 142MM STER,SUP-2549607,CDM,C1713,HCPCS,0278,RC,,,,both,,,3470.52,2255.84,,,,,,,,,,,,,
CATHETER HD SWAN NK 62.5 CM MONCRIEF-POPOVICH CURL CATH ARGY,SUP-2626975,CDM,C1750,HCPCS,0278,RC,,,,both,,,578.58,376.08,,,,,,,,,,,,,
PLATE BNE W255XL77MM WIDE 7X5 H ST R DST RAD VOLAR S STL VAR,SUP-2177316,CDM,C1713,HCPCS,0278,RC,,,,both,,,2604.82,1693.13,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM SPC 2-5-2MM TIP 3.5MM CRV 75MM,SUP-2357693,CDM,C1733,HCPCS,0272,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
HC So Aluminum,PX-3018210866,CDM,82108,CPT,0301,RC,,,,inpatient,,,497.00,323.05,,,,,,,,,,,,,
SCREW BONE L36MM OD4.5MM TI CORT T25 ST,SUP-2101302,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.90,53.88,,,,,,,,,,,,,
HYDROCHLOROTHIAZIDE 12.5 MG PO CAPS,RX-19146,CDM,6370000000,HCPCS,0637,RC,60687-0683-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L105MM 4 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177794,CDM,C1713,HCPCS,0278,RC,,,,both,,,3106.46,2019.20,,,,,,,,,,,,,
COMPONENT TIB CR 00 16 MM LT KNEE PRIMARY STEM CEM NP CONG,SUP-2210053,CDM,C1776,CPT,0278,RC,,,,both,,,4143.23,2693.10,,,,,,,,,,,,,
STEM FEM VERSYS 8 INCH BEADED FC 13X200MM STR STD BODY/NECK,SUP-2504238,CDM,C1776,CPT,0278,RC,,,,both,,,14217.92,9241.65,,,,,,,,,,,,,
PROBE NERVE STIM DIA2.3 MM MONOPOLAR BALL TIP HNDL STRL DISP,SUP-2902085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.79,341.76,,,,,,,,,,,,,
BRACE WR CIRC 7 1/4IN TO 8IN L RT REG IMMOB LOOP LCK W/ STAY,SUP-2324900,CDM,L3931,HCPCS,0274,RC,,,,both,,,30.27,19.68,,,,,,,,,,,,,
SET URET STENT SOFFLX L 22 CM DIA 7 FR GUIDEWIRE L 145 CM,SUP-2168907,CDM,C2617,HCPCS,0278,RC,,,,both,,,434.07,282.15,,,,,,,,,,,,,
CATH EP ABLATION VARIPULSE BIDIR 8.5FR,SUP-2928125,CDM,C1733,HCPCS,0272,RC,,,,both,,,19383.22,12599.09,,,,,,,,,,,,,
GRAFT OTO 0.6-0.9CM POR PORCINE SM INTEST SUBMUCOSA LAM,SUP-2170503,CDM,C1763,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
GRAFT BNE SUB 5CC B TRICALCIUM PHSPTE CLLGN HA POR ALLGRFT,SUP-2288531,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.51,506.68,,,,,,,,,,,,,
PLATE BNE L79MM 6 H STR LOK RECON FOR 3.5MM SCR UNIV LOK,SUP-2411371,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.84,901.45,,,,,,,,,,,,,
DRILL SURG HND XCALIBER,SUP-2645908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,993.87,646.02,,,,,,,,,,,,,
BLADE SHAVER ARTHSCP MINI 2.9 MMX7 CM CUT DYONICS PWR EP 1,SUP-2340748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BUDESONIDE 3 MG PO CPEP,RX-31576,CDM,6370000000,HCPCS,0637,RC,65162-0778-10,NDC,,both,1,UN,10.10,6.56,,,,,,,,,,,,,
STENT CORONARY PK PAPYRUS L 15 MM DIA2.5 MM CATH L 140 CM OD,SUP-2422128,CDM,C1874,HCPCS,0278,RC,,,,both,,,11398.20,7408.83,,,,,,,,,,,,,
NEEDLE CRYOABLATION ICESPHERE 1.5MM,SUP-2225663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4356.75,2831.89,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR 15 MMX0.2 CM FD CROSS SECT,SUP-2717832,CDM,C1762,CPT,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
REPAIR KIT KNOTLESS ARTHSCP AC SYS STRL LTX,SUP-2859827,CDM,C1713,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC VIABLE MTRX NEO MTX,SUP-2901736,CDM,C1713,HCPCS,0278,RC,,,,both,,,19775.72,12854.22,,,,,,,,,,,,,
COVER BUR H DIA24MM LO PROF W/ TAB FOR 1.5MM SCR CRAN FIX,SUP-2363635,CDM,C1713,HCPCS,0278,RC,,,,both,,,952.17,618.91,,,,,,,,,,,,,
GRAFT HUM TISS L23CM FLD DIA6MM FRZN DBL STRND ANT TIBIALIS,SUP-2113922,CDM,C1713,HCPCS,0278,RC,,,,both,,,5243.52,3408.29,,,,,,,,,,,,,
BUR SURG L8MM DIA2MM MICA PROSTEP,SUP-2398171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
COMPONENT FEM SZ 4 LT KNEE NP PRI CRUC STABILIZING CRUC RET,SUP-2304562,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
KIT STEREOTACTIC CKPT,SUP-2368431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,227.65,147.97,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA22 MM EPTFE STR STD WALL,SUP-2396232,CDM,C1768,CPT,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0258,RC,00264-1800-32,NDC,,both,100,ML,23.00,14.95,,,,,,,,,,,,,
GRAFT BIO TISS W8XL12CM MESHED FET BOV ACELLULAR DERM MTRX,SUP-2243706,CDM,Q4110,HCPCS,0636,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
COMPONENT FEM AP43MM ML68MM RT KNEE CO CHROM NONBEADED NP,SUP-2252372,CDM,C1776,CPT,0278,RC,,,,both,,,8980.40,5837.26,,,,,,,,,,,,,
HOOK SPNL 6MM ROD DIA 8.9MM BLDE W 5.0MM PEDCL NEUT OPN,SUP-2415554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.33,1081.81,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 6 HOLE DOUBLE Y-PLATE 15MM TI,SUP-2825443,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.92,112.40,,,,,,,,,,,,,
CANNULATED FULLY THREADED COMPRESSION SCREW 2.6MM X 36MM.,SUP-2883432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD FEM TIB PATELLAR CEM SURF TIV,SUP-2212332,CDM,C1776,CPT,0278,RC,,,,both,,,12850.07,8352.55,,,,,,,,,,,,,
SPLINT WRST L L THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326138,CDM,L3908,HCPCS,0274,RC,,,,both,,,63.05,40.98,,,,,,,,,,,,,
SPLINT WRST ADJ 10 IN UNIV 7.5 IN LT COOL SFT QUIK FIT,SUP-2197068,CDM,L3908,HCPCS,0274,RC,,,,both,,,24.90,16.18,,,,,,,,,,,,,
SCREW CONN HIP HNG KNEE GUID LCK INSRT LEGION,SUP-2346398,CDM,C1713,HCPCS,0278,RC,,,,both,,,403.18,262.07,,,,,,,,,,,,,
CATHETER URET L70CM OD10FR HYDR+,SUP-2139214,CDM,C1726,HCPCS,0272,RC,,,,both,,,172.95,112.42,,,,,,,,,,,,,
GRAFT VASC TW 4-7 MMX80 CM STR XLN W/ SLDE GDS ADVANTA VXT,SUP-2463137,CDM,C1768,CPT,0278,RC,,,,both,,,3931.69,2555.60,,,,,,,,,,,,,
TUBE GAST VISIGI 3D 32FR,SUP-2138630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
FINASTERIDE 5 MG PO TABS,RX-10037,CDM,6370000000,HCPCS,0637,RC,50268-0314-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
LITHOTRIPTER SURG FIBER SUREFLEX REUSE RLLF273TG] LASER VENTURES],SUP-2263897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
REAMER SURG 4.0MM BONE CANN,SUP-2342389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2649.85,1722.40,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILESTO HF-T TI EPOXY RESIN SIL 3 CHMBR,SUP-2138455,CDM,C1882,HCPCS,0275,RC,,,,both,,,47885.00,31125.25,,,,,,,,,,,,,
MESALAMINE ER 500 MG PO CPCR,RX-39575,CDM,6370000000,HCPCS,0637,RC,54092-0191-12,NDC,,both,1,UN,27.40,17.81,,,,,,,,,,,,,
GRAFT BIO TISS W7.9XL7.9IN PORCINE DERM RIFAMPIN,SUP-2125842,CDM,C1781,HCPCS,0278,RC,,,,both,,,43610.83,28347.04,,,,,,,,,,,,,
ANCHOR SUT SZ 2 PNCRYL WHT ROT CUF BIOKNOTLESS RC,SUP-2256605,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
HC Intrvasc US Noncoronary 1st,PX-4023725200,CDM,37252,CPT,0402,RC,,,,inpatient,,,1485.00,965.25,,,,,,,,,,,,,
PIN FIX 27X50MM RESRB RFS,SUP-2400585,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
CLAMP SPNL FOR 5.5/6.5MM ROD TO ROD REVERE ADDITION,SUP-2230106,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SET ORTH MOD W/ DRL GUID STARDRV SCR DRVR X ARTC PLT LCK,SUP-2177066,CDM,C1713,HCPCS,0278,RC,,,,both,,,85853.19,55804.57,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING EPTFE 6MM DIA 80CM LEN,SUP-2126679,CDM,C1768,CPT,0278,RC,,,,both,,,2850.96,1853.12,,,,,,,,,,,,,
BIT DRL TWST 1.1X105 MM CYL LEVEL 1 DISP,SUP-2483493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.33,274.51,,,,,,,,,,,,,
HC Pt Estim-Manual Each 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209703200,CDM,97032,CPT,0420,RC,,,GP|CQ,both,,,206.00,133.90,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE|ADJ,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|CQ|XU|ADJ,both,,,191.00,124.15,,,,,,,,,,,,,
PLATE BNE SM W11XL67MM THK15MM 90DEG 4X5 H TI T SHP R ANG,SUP-2190933,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.27,708.03,,,,,,,,,,,,,
PEDIATRIC LCP(TM) HIP PLATE 5.0MM 110-STERILE,SUP-2546028,CDM,C1713,HCPCS,0278,RC,,,,both,,,2706.87,1759.47,,,,,,,,,,,,,
TRAY TIB SZ 2 AP42.6MM ML64.6MM THK25MM STEM L61.8MM THCK,SUP-2250930,CDM,C1776,CPT,0278,RC,,,,both,,,17933.17,11656.56,,,,,,,,,,,,,
BRACE THMB LT FUNC POS ABDUCTED THMB W/ STAY STRP ON AD 8IN,SUP-2324312,CDM,L3931,HCPCS,0274,RC,,,,both,,,69.52,45.19,,,,,,,,,,,,,
COUPLER ANAS DIA1.5MM VES RANG 1.3-1.7MM SGL DBL END DISP,SUP-2419428,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE W10XL67MM THK1.2MM 90DEG 3X5 H BILAT S STL T SHP,SUP-2185869,CDM,C1713,HCPCS,0278,RC,,,,both,,,1112.35,723.03,,,,,,,,,,,,,
CATHETER GUID 6FR L140CM WIRE CTRL VENTURE,SUP-2356606,CDM,C1887,HCPCS,0272,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
SYSTEM RETROPUBIC TENS FREE SUPP DISP FOR INCONT GYNECARE,SUP-2218516,CDM,C1771,HCPCS,0278,RC,,,,both,,,5906.15,3839.00,,,,,,,,,,,,,
IMMOBILIZER SHOULDER SLING SWATHE DLX,SUP-2196951,CDM,L3660,HCPCS,0274,RC,,,,both,,,22.98,14.94,,,,,,,,,,,,,
PLATE 4.5MM LCP CONDYLAR 14 HOLES 314MM RIGHT STERILE,SUP-2547442,CDM,C1713,HCPCS,0278,RC,,,,both,,,4933.69,3206.90,,,,,,,,,,,,,
PLATE BONE L21MM 4 H CRANIOFACIAL VIT STR COND FOR 1.3MM SCR,SUP-2364692,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 33 CM DIA12 FR BODY DIA 4.7 MM,SUP-2395726,CDM,C1894,HCPCS,0272,RC,,,,both,,,1645.36,1069.48,,,,,,,,,,,,,
BEARING HUM STD 36 MM SHLDR VIVACIT-E PROLONG COMPHSVE,SUP-2418441,CDM,C1776,CPT,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
BLOCKER ENDOBRONCH SET W/ SPHR BAL DISP ARNDT,SUP-2170492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.31,612.50,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 50 CM DIA 7 MM CLLGN BOV CAR ART,SUP-2120671,CDM,C1768,CPT,0278,RC,,,,both,,,13122.06,8529.34,,,,,,,,,,,,,
CATHETER CV 4 LUMEN 8.5 FR,SUP-2383334,CDM,C1751,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
HC Visceral Arteriogram,PX-3237572600,CDM,75726,CPT,0323,RC,,,,both,,,9017.00,5861.05,,,,,,,,,,,,,
PARTICLE EMB SZ 250 355UM POLYVI ALC N RADIOACTIVE CNTOUR 2,SUP-2148439,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
KNIFE 3734038 FISHER TONSIL 15MM CVD,SUP-2706763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.72,255.92,,,,,,,,,,,,,
SUPPORT ANK XL FOR 14-15IN BLK BALLISTIC NYL L R FT STBL LO,SUP-2269721,CDM,L1930,HCPCS,0272,RC,,,,both,,,64.87,42.17,,,,,,,,,,,,,
CAGE HUM STEMLESS 3 EQUINOXE,SUP-2606123,CDM,C1889,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT 018 25 CM 21 GA VENA CAVA NEVERTOUCH,SUP-2752526,CDM,C1888,HCPCS,0272,RC,,,,both,,,921.75,599.14,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.451,SUP-2860015,CDM,C1713,HCPCS,0278,RC,,,,both,,,59482.28,38663.48,,,,,,,,,,,,,
GRAFT BNE SUB 10CC FOAM PK VERSATILE COMPR RESIST VITOSS 21022110] STRYKER ORTHOBIOLOGICS],SUP-2368196,CDM,C1713,HCPCS,0278,RC,,,,both,,,5049.12,3281.93,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI PWR TRIALYSI SLIM CATH ACTE 12 5865240,SUP-2632940,CDM,C1752,HCPCS,0278,RC,,,,both,,,1028.48,668.51,,,,,,,,,,,,,
SCREW INTRF L25MM DIA7MM ANTR KNEE PLLA HA CANN FOR CRUC,SUP-2341099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.35,685.98,,,,,,,,,,,,,
SUTURE TENSIONER CUTTER FOR KNEE,SUP-2121949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SCREW BNE L16MM OD2.3MM TI CORT ST FULL THRD STD NONLOCKING,SUP-2372648,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.15,355.65,,,,,,,,,,,,,
PLATE MEDL CLMN FUSION 78MM RT STRL VA LCP,SUP-2546131,CDM,C1713,HCPCS,0278,RC,,,,both,,,5285.88,3435.82,,,,,,,,,,,,,
GRAFT HUM TISS M W16XL20CM THK1.2-2MM ACELLULAR DERM,SUP-2113185,CDM,Q4116,HCPCS,0636,RC,,,,both,,,37406.82,24314.43,,,,,,,,,,,,,
GRAFT VASC ADVANTA SST L 70 CM DIA 6 MM EPTFE STR TW REINF 3,SUP-2265943,CDM,C1768,CPT,0278,RC,,,,both,,,3764.45,2446.89,,,,,,,,,,,,,
CROWN DENT PED SZ LL5 LO LT ANTR CUSPID SEC PRI M S STL,SUP-2238793,CDM,D6783,CPT,0278,RC,,,,both,,,19.72,12.82,,,,,,,,,,,,,
GRAFT BNE SUB W18XH3XL47MM ST CHRONOS STRP MX CUT T,SUP-2182835,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3047.06,1980.59,,,,,,,,,,,,,
PLATE BNE L L70MM ST R CALCNL S STL VAR ANG LOK FOR 27MM SCR,SUP-2178425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3363.57,2186.32,,,,,,,,,,,,,
CATHETER BLLN DIL FIX WIRE 5-6-7-8-9 MM 8 CM ELATION 5,SUP-2488614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
STEM ULN L50MM DIA7.5MM STD E-CENTRIX,SUP-2398596,CDM,C1776,CPT,0278,RC,,,,both,,,3604.41,2342.87,,,,,,,,,,,,,
WAND ELECTROSURG IRONMAN,SUP-2342012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
THERASKIN SM 2.5X5.1CM 13SQ CM,SUP-2264657,CDM,Q4121,HCPCS,0636,RC,,,,both,,,3399.05,2209.38,,,,,,,,,,,,,
PENICILLIN V POTASSIUM 500 MG PO TABS,RX-6093,CDM,6370000000,HCPCS,0637,RC,65862-0176-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT SYN TISS W15XL20CM THK2MM EPTFE SFT PTCH RECTANG FOR,SUP-2395291,CDM,C1781,HCPCS,0278,RC,,,,both,,,6057.06,3937.09,,,,,,,,,,,,,
DISTRACTOR SURG L 20 MM 2 X 2 H LT MANDIBULAR PED NS,SUP-2883526,CDM,C1713,HCPCS,0278,RC,,,,both,,,22137.00,14389.05,,,,,,,,,,,,,
STEM FEM CLLRD 11X220 MM LT HIP BIMTRC,SUP-2449882,CDM,C1776,CPT,0278,RC,,,,both,,,12183.20,7919.08,,,,,,,,,,,,,
CATHETER THROMCTMY LATIS L 80 CM DIA 4 FR PEBAX PTFE GRFT,SUP-2119468,CDM,C1757,HCPCS,0272,RC,,,,both,,,391.12,254.23,,,,,,,,,,,,,
CARTRIDGE CO2 MED C DIOX GAS,SUP-2239970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
JOINT EXT FIX SPHR STRL TRUELOK LTX,SUP-2875240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11162.70,7255.75,,,,,,,,,,,,,
PIN FIX 20 MM A.L.P.S,SUP-2467719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
SCREW BNE L95MM DIA11MM FEM G TI CANN FOR TROCHANTERIC NAIL,SUP-2180366,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.56,1173.61,,,,,,,,,,,,,
DEVICE MICRO COR KNOT PRELOADED,SUP-2752112,CDM,C1889,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SEEDS COMS SZ 14N PLAQ P/N 2029CLS1,SUP-2247263,CDM,C2642,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
KIT LASER L45CM MICRO ACCESS VENACURE NEVERTOUCH,SUP-2116796,CDM,C1888,HCPCS,0272,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
COMPONENT PAT 3 STD PEG RND REV ROT CEM POR WITHOUTXRAY WIRE,SUP-2252413,CDM,C1776,CPT,0278,RC,,,,both,,,3830.80,2490.02,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 13-15.5 IN CTR 12-13 IN CALF 10-12 IN RT MEDIAL,SUP-2916924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.48,673.71,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7544,SUP-2525333,CDM,C1769,HCPCS,0272,RC,,,,both,,,937.92,609.65,,,,,,,,,,,,,
PLATE BONE DIA100MM THK1.5MM NONSTERILE CRANIOMAXILLOFACIAL,SUP-2191128,CDM,C1713,HCPCS,0278,RC,,,,both,,,6524.29,4240.79,,,,,,,,,,,,,
KNIFE OPHTHLMC 45DG 4.5NL 1MMW 0.2MM THK DMND ANGLD SNGLE ED,SUP-2467717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2238.98,1455.34,,,,,,,,,,,,,
SPACER SPNL W18XH10XL60MM PEEK LAT LUM INTBDY FUS,SUP-2310914,CDM,C1821,HCPCS,0278,RC,,,,both,,,12120.40,7878.26,,,,,,,,,,,,,
PORT STD MRI PLAS SGL LUMN W/ 7.5FR DETACHED SIL CATH AND,SUP-2169589,CDM,C1788,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
STAPLE BNE FIX 20X20X20MM NIT SUPERPLASTIC DYNAFORCE,SUP-2175190,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND 9.5-13 MM 122 CM 6 SHOT SAEED,SUP-2737555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
DEVICE CLSR 10/12MM XL PRT SYS SUT PASS ST DISP CARTER,SUP-2171695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,617.54,401.40,,,,,,,,,,,,,
SCREW BNE ST 3.5X65 MM CONCL PARTIAL THRD W/ STARDRV RECESS,SUP-2184318,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.51,239.53,,,,,,,,,,,,,
STAPLER INT REG 60-3.8 IN KNIFELESS SINGLE RELD W/ DST SER,SUP-2787703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1261.87,820.22,,,,,,,,,,,,,
HC Apply Finger Splint,PX-4302913100,CDM,29131,CPT,0430,RC,,,,both,,,606.00,393.90,,,,,,,,,,,,,
TIP INSTRUMENT LASER 20 DEG OMNITIP,SUP-2225652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
FILLER BONE VOID 3ML HA SYNTH CA PHOS PUTTY TISS IMPL CEM,SUP-2194287,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
DISTRACTOR EXT FIX FEARON MOD MATTHEWS-TESSIER 40 MM 1 MM,SUP-2458296,CDM,C1713,HCPCS,0278,RC,,,,both,,,16816.87,10930.97,,,,,,,,,,,,,
KIT SPNL DISP MAXCESS,SUP-2310426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
STAPLER ECHELON 3000 45MM COMPACT,SUP-2858744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.61,797.95,,,,,,,,,,,,,
COLLAR CERVICALXSM H2.75XL22.5IN EXTRIC EMS 1 PC PLAS FOAM,SUP-2197905,CDM,L0120,HCPCS,0274,RC,,,,both,,,89.80,58.37,,,,,,,,,,,,,
BOLT IM L56MM DIA3.9MM HD DIA8MM TI ST LOK HEX RECESS TRCR,SUP-2192212,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.02,389.36,,,,,,,,,,,,,
HOOK SPNL PEDCL LG 5.5 MM,SUP-2175457,CDM,C1713,HCPCS,0278,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
ALLOPATCH HD MESHED THIN 04 07MM 2CM X 5CM HYDRATED,SUP-2727151,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
PLATE RINGFIX SYS 8 HL ALUM,SUP-2473058,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
COMPONENT FEM F LT KNEE OPT NXGN LPS-FLEX,SUP-2437984,CDM,C1776,CPT,0278,RC,,,,both,,,10141.51,6591.98,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT REUT BOB W/ FLNG H 1.14 MM ID,SUP-2277564,CDM,L8699,HCPCS,0278,RC,,,,both,,,41.39,26.90,,,,,,,,,,,,,
CABLE ORTHOT HIP KNEE ANK CUST UNILAT TORSON,SUP-2435644,CDM,L2080,LOCAL,0272,RC,,,,both,,,1056.52,686.74,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6MM STR STD WALL SLDE GDS,SUP-2681785,CDM,C1768,CPT,0278,RC,,,,both,,,2852.47,1854.11,,,,,,,,,,,,,
BIT DRL 5 MM XO BUTTON,SUP-2765786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.79,371.66,,,,,,,,,,,,,
HC Peripheral Block - Caudal,PX-3606444900,CDM,64449,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
INTRODUCER PEEL AWAY 7FR 23CM SGL,SUP-2357087,CDM,C1892,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
CATHETER DRAINAGE 6 FRX70 CM ANGLED TIP W/ GUIDEWIRE FLEXIMA,SUP-2141722,CDM,C1758,HCPCS,0278,RC,,,,both,,,86.51,56.23,,,,,,,,,,,,,
SCREW BONE L10MM DIA2MM MAND SLV NONLOCKINGXDRIVE FOR LORENZ,SUP-2136748,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
ATTACHMENT REPROC ROD MULTIPIN CLAMP LG,SUP-2500274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.66,357.93,,,,,,,,,,,,,
WASHER ORTHOPEDIC 2/2.5 MM NS EPIC,SUP-2221462,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 15MM R MED L LAT KNEE HEMI STP LEGION,SUP-2346587,CDM,C1776,CPT,0278,RC,,,,both,,,5025.57,3266.62,,,,,,,,,,,,,
PORT INFUS CATH OD9.6FR ID1.5MM TI SGL LUMN W/ DETACHED SIL,SUP-2332930,CDM,C1788,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
HC T-Spine 2 Views,PX-3207207000,CDM,72070,CPT,0320,RC,,,,both,,,233.00,151.45,,,,,,,,,,,,,
DRILL 35MM,SUP-2841578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
BONE MARROW ASPIRATION KIT CLOSED TIP 13 GA STRL LTX,SUP-2859801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1342.35,872.53,,,,,,,,,,,,,
KIT GASTSTMY TUBE 20FR STD NONSAFETY PUSH GWIRE PLCMNT TECH,SUP-2127664,CDM,C1769,HCPCS,0272,RC,,,,both,,,277.76,180.54,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 21-26X27-32X21 MM FD ALIF ANTR APPRCH,SUP-2736758,CDM,C1713,HCPCS,0278,RC,,,,both,,,15087.17,9806.66,,,,,,,,,,,,,
SCREW BONE L16MM OD2.5MM S STL ELBW CANN FULL THRD EVOLVE,SUP-2397950,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
IMPLANT SYNTH 25 X 50 MM THK 3 MM POLYETHYL CRANIOFACIAL,SUP-2883277,CDM,C1713,HCPCS,0278,RC,,,,both,,,2680.30,1742.19,,,,,,,,,,,,,
BANDAGE SUPP ANK AK PELV,SUP-2388214,CDM,L5697,HCPCS,0272,RC,,,,both,,,222.03,144.32,,,,,,,,,,,,,
HC Before / After Bronchodilator,PX-4609406000,CDM,94060,CPT,0460,RC,,,,outpatient,,,569.00,369.85,,,,,,,,,,,,,
GRAFT HUM TISS W2XL7CM SFT REGEN MTRX REP REPLFRM,SUP-2139388,CDM,C1762,CPT,0278,RC,,,,both,,,2378.42,1545.97,,,,,,,,,,,,,
KIT SUT DEV PUR TARGET WIRE W/ SNR CRV HNDL COR-KNOT MINI,SUP-2265306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
BIT DRL 2MM SPNL,SUP-2400583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
MESH BNE 4 H RT ORBIT PREFRM NS DISP,SUP-2934740,CDM,C1713,HCPCS,0278,RC,,,,both,,,8415.20,5469.88,,,,,,,,,,,,,
INTRODUCER SHTH L61CM PERI S STL REUSE,SUP-2243832,CDM,C1894,HCPCS,0272,RC,,,,both,,,305.71,198.71,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 40 X 35 CM DIA24 X 10 MM THK 0.38 MM,SUP-2227519,CDM,C1768,CPT,0278,RC,,,,both,,,4011.32,2607.36,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L70CM SURG FOR SPNL CRD STIM ARTISAN,SUP-2138837,CDM,C1778,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SPACER FEM STD UNIV POST PRI CEM SM 10MM THCK,SUP-2377233,CDM,C1776,CPT,0278,RC,,,,both,,,2366.30,1538.09,,,,,,,,,,,,,
LINER ACET CUP OD51MM ID32MM STD MTL ON POLY THCK PRI CEM,SUP-2406737,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
MATRIX BNE EXTRACELLULAR REP STEM CELL OVATION 0.3ML,SUP-2319180,CDM,C1713,HCPCS,0278,RC,,,,both,,,5325.44,3461.54,,,,,,,,,,,,,
GUARD BUR 20DEG LNG FOR SM BNE MICROPOWER MICRO100 SYS,SUP-2166319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2960.55,1924.36,,,,,,,,,,,,,
COMPONENT HUM DIA40MM SHLDR SUT CLLR FOR PLATFRM,SUP-2249859,CDM,C1776,CPT,0278,RC,,,,both,,,1245.95,809.87,,,,,,,,,,,,,
HOLDER NDL W5MMXL30CM W/O SUT STR REUSE ENDOPATH,SUP-2218975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1930.79,1255.01,,,,,,,,,,,,,
PLATE BNE W24XL45MM 8 H ST BILAT MIDFOOT HINDFOOT TI RIG LOK,SUP-2191458,CDM,C1713,HCPCS,0278,RC,,,,both,,,2936.28,1908.58,,,,,,,,,,,,,
MESH HERN W12XL15CM OPN TISS SEPARATING PHYSIOMESH,SUP-2219745,CDM,C1781,HCPCS,0278,RC,,,,both,,,2099.94,1364.96,,,,,,,,,,,,,
CATHETER PERIPHERALLY INSERTED CTRL VEN SPL NDL 2FRX30CM,SUP-2394008,CDM,C1751,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
STAPLER INT HERN 65 DEG 12 MM TI ENDO UNIV DISP,SUP-2752171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.29,315.44,,,,,,,,,,,,,
SCREW ANCHR ORTHODONTIC 2X8 MM 15 MM EXT HK HD TI,SUP-2481001,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
PLATE BONE L105MM 8 HOLE NNSTRLE CNTRBLE LOK DUAL CMPRSSN 35,SUP-2476536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.59,935.08,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 100 MM DIA25 MM LIMB 40 MM 20 MM,SUP-2217670,CDM,C1874,HCPCS,0278,RC,,,,both,,,37441.36,24336.88,,,,,,,,,,,,,
KIT INTRO PERFRMR L 40 CM DIA 8 FR GUIDEWIRE 0.038 IN PERIPH,SUP-2168617,CDM,C1894,HCPCS,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
GUIDEWIRE ENDO L250CM S STL PROG FLEX TIP TO INTRODUCE DIL,SUP-2169222,CDM,C1769,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAG CTRL PANEL STRP STAY,SUP-2435557,CDM,L0643,HCPCS,0274,RC,,,,both,,,458.57,298.07,,,,,,,,,,,,,
SYSTEM EXT DRNGE VOL LIMITING W/ 30ML BURET LIMITORR,SUP-2244113,CDM,C1713,HCPCS,0278,RC,,,,both,,,812.95,528.42,,,,,,,,,,,,,
SPLINT REST HND ADL R S DRBLUE BROAD,SUP-2165487,CDM,L3807,HCPCS,0274,RC,,,,both,,,123.25,80.11,,,,,,,,,,,,,
STEM FEM HI OFFSET BCD MAG NK W/ TRUNNION ARCOS,SUP-2443222,CDM,C1776,CPT,0278,RC,,,,both,,,1907.55,1239.91,,,,,,,,,,,,,
CANNULA SUCTION EXTRACTION 270 DEG 3 MMX30 CM 8 MM PAL,SUP-2760833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
CHARGER BTTRY FOR VENT ASST DEV HEARTWARE,SUP-2282565,CDM,Q0495,HCPCS,0272,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
MESH BONE 262MMW X 262MML 03MM THK RSRB X SM GRID LATEX F,SUP-2681446,CDM,C1713,HCPCS,0278,RC,,,,both,,,1327.97,863.18,,,,,,,,,,,,,
BIT DRL 3.2 MM 5 MM FOR HALF PIN,SUP-2162652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
SET INTRO SILHOUETTE PEELWY L 13 CM DIA16 FR GUIDEWIRE 0.038,SUP-2169689,CDM,C1894,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
SHEATH INTRO FLX L 45 CM OD 5 FR GUIDEWIRE 0.038 IN SM CKFLO,SUP-2633289,CDM,C1894,HCPCS,0272,RC,,,,both,,,144.69,94.05,,,,,,,,,,,,,
POLARIS ULTRA STENT SET,SUP-2494639,CDM,C2617,HCPCS,0278,RC,,,,both,,,544.63,354.01,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX23 CM PALINDROMIC EMERALD,SUP-2174237,CDM,C1750,HCPCS,0278,RC,,,,both,,,2314.37,1504.34,,,,,,,,,,,,,
PLATE BNE L 55 MM SCREW DIA2.7 MM 7 SHFT H SS COMPACT STR VA,SUP-2907651,CDM,C1713,HCPCS,0278,RC,,,,both,,,3193.13,2075.53,,,,,,,,,,,,,
OLOPATADINE HCL 0.1 % OP SOLN,RX-19452,CDM,6370000000,HCPCS,0637,RC,58602-0006-40,NDC,,both,0.05,ML,2.70,1.75,,,,,,,,,,,,,
PLATE BONE L245MM 9 HOLE NNSTRLE PRPRSTHTC RIGHT PRXML FMRL,SUP-2481444,CDM,C1713,HCPCS,0278,RC,,,,both,,,3891.40,2529.41,,,,,,,,,,,,,
SURFACE ARTC SZ 5-6 CH THK14MM AP46MM ML74MM KNEE UHMWPE GRN,SUP-2201370,CDM,C1776,CPT,0278,RC,,,,both,,,3683.22,2394.09,,,,,,,,,,,,,
ULS 2.0MM PERC CANNULA,SUP-2495640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,983.20,639.08,,,,,,,,,,,,,
CATHETER REPROC EP 6FRX115CM 10-ELECTRD 2-5-2MM,SUP-2653047,CDM,C1730,HCPCS,0272,RC,,,,both,,,441.77,287.15,,,,,,,,,,,,,
GRAFT DURA REP L7 X W 7 CM THK 0.4 MM ELECTROSPUN FIBER,SUP-2904024,CDM,C1763,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
HC Chem Cautery Gran Tissue,PX-5101725000,CDM,17250,CPT,0510,RC,,,,inpatient,,,280.00,182.00,,,,,,,,,,,,,
PLATE BNE L233MM 15 H ST R POSTEROLATERAL DST FIBULAR S STL,SUP-2177407,CDM,C1713,HCPCS,0278,RC,,,,both,,,2165.19,1407.37,,,,,,,,,,,,,
CONE TIB W29MM MTPHSEAL OPTETRAK LOGIC,SUP-2435970,CDM,C1776,CPT,0278,RC,,,,both,,,8394.16,5456.20,,,,,,,,,,,,,
CUP ACET DIA58MM LT HIPX3 MOB BEAR FOR 28MM HD REST ADM,SUP-2361604,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 45 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120670,CDM,C1768,CPT,0278,RC,,,,both,,,9982.06,6488.34,,,,,,,,,,,,,
RETRACTOR SURG BVL 9 CMX18 MM METRX II DISP,SUP-2280169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1259.49,818.67,,,,,,,,,,,,,
SPLINT ANK REG UNIV STRRP AIR AND GEL FOR CLD THER,SUP-2276708,CDM,L4350,HCPCS,0272,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
SET CATH HEMODIALYSI ARW EDGE CHRONIC 15FR DIA 24CM 19CML TI,SUP-2613329,CDM,C1750,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
GRAFT BONE M CELLULAR MTRX OSTEOCEL PRO,SUP-2310456,CDM,C1762,CPT,0278,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
HC Venography Canal Inferior|UNUSUAL NON-OVERLAPPING SERVICE,PX-3207582500,CDM,75825,CPT,0320,RC,,,XU,outpatient,,,3006.00,1953.90,,,,,,,,,,,,,
HEAD RADIAL MOD 2 26 MM ELBW EVOLVE,SUP-2397062,CDM,C1776,CPT,0278,RC,,,,both,,,4537.30,2949.24,,,,,,,,,,,,,
ADAPTER TI LCK 2 PC,SUP-2130777,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.66,437.88,,,,,,,,,,,,,
BLOCK ILIUM TRICORT TRAD ALLGRFT L 19 - 21 MM FRZ DRY,SUP-2294070,CDM,C1713,HCPCS,0278,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
GRAFT UMBILICAL CORD 3X6 CRYOPRESERVED CRYO-CORD,SUP-2664296,CDM,C1762,CPT,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
WIRE FIX REDUCTION 1.5 MM HALF PT TIP NS,SUP-2799566,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
SET CLLR AD H2 1/4IN FOR 13-21IN NK SHT BLU PLAS HK AND,SUP-2124215,CDM,L0172,HCPCS,0274,RC,,,,both,,,96.96,63.02,,,,,,,,,,,,,
HC Leukored Platelet Pheres Irrad,PX-3900903700,CDM,P9037,CPT,0390,RC,,,,both,,,2828.00,1838.20,,,,,,,,,,,,,
VALVE VENT SM L36MM DIA13MM THK6MM PERF LEV 1.5 DELT,SUP-2284514,CDM,C1889,HCPCS,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
CATHETER ETER PICC AD 6FR L55CM 3 LUMN NRS PWR INJ N COAT CT,SUP-2126715,CDM,C1751,HCPCS,0278,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
PLATE BNE L189.6MM THK3.7MM 0DEG 14 H TI TIM THN LOK COMPR,SUP-2413712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1225.07,796.30,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-9.5 MM 50 CC FRZN IRRADIATED CANC,SUP-2717937,CDM,C1713,HCPCS,0278,RC,,,,both,,,3336.25,2168.56,,,,,,,,,,,,,
BUR SURG DIA15MM TAPR ROUTER CUT ACC,SUP-2363689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.70,235.75,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 7FR L300CM CHN 2.8MM STD CONN DISP G,SUP-2149699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.42,256.37,,,,,,,,,,,,,
HC So Factor 5,PX-3058522066,CDM,85220,CPT,0305,RC,,,,both,,,280.00,182.00,,,,,,,,,,,,,
HC X-Ray Xm Esophagus Double Cntrst,PX-3207422100,CDM,74221,CPT,0320,RC,,,,both,,,1077.00,700.05,,,,,,,,,,,,,
TEMPLATE DERM REGEN IMPANT BIO TISS CLLGN MTRX ST 25CM LEN,SUP-2243548,CDM,Q4105,HCPCS,0636,RC,,,,both,,,30066.38,19543.15,,,,,,,,,,,,,
METOLAZONE 5 MG PO TABS,RX-10588,CDM,6370000000,HCPCS,0637,RC,00185-0055-01,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
GRAFT VASC W1XL6IN ULT THN FAB PLAT KNIT DBL VEL NONTAPERED,SUP-2265860,CDM,C1768,CPT,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
SCREW BNE L15MM OD23MM TI CORT ST FULL THRD CRSS FIT SM HEX,SUP-2364120,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.65,237.67,,,,,,,,,,,,,
ROD SPNL 2 DIAMETER 1 3.5/5.5 MM OCT TI UNID,SUP-2730562,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
STEM XL POROUS 18.0X260MM BOWED,SUP-2504984,CDM,C1776,CPT,0278,RC,,,,both,,,9520.48,6188.31,,,,,,,,,,,,,
PLATE BNE CONN 1 HOLE,SUP-2422098,CDM,C1713,HCPCS,0278,RC,,,,both,,,1270.32,825.71,,,,,,,,,,,,,
PLATE BNE L 70 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 4 H 72463104,SUP-2933302,CDM,C1713,HCPCS,0278,RC,,,,both,,,6721.64,4369.07,,,,,,,,,,,,,
SCREW BONE L6MM DIA2MM STD CORT S STL ST FULL THRD HEX HD,SUP-2343867,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.81,173.43,,,,,,,,,,,,,
BRACE ANK AD H10IN STD BILAT STRP CLSR OPN HEEL AND TOE,SUP-2195182,CDM,L4397,HCPCS,0272,RC,,,,both,,,54.51,35.43,,,,,,,,,,,,,
KIT PICC CATHETER AD 5FR L50CM GWIRE L1775IN 0018IN POLYUR 2,SUP-2383478,CDM,C1751,HCPCS,0278,RC,,,,both,,,197.79,128.56,,,,,,,,,,,,,
SCREW BNE L30MM DIA5MM CORT CONIC S STL ST CANN LOK FULL,SUP-2184910,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.87,441.27,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 5 FR CANN L 11 CM GUIDEWIRE 0.035 IN,SUP-2156063,CDM,C1894,HCPCS,0272,RC,,,,both,,,31.46,20.45,,,,,,,,,,,,,
SUPPORT THMB STBL SM 2.25-2.75 IN LT PROCARE THUMBGUARD,SUP-2195766,CDM,L3931,HCPCS,0274,RC,,,,both,,,30.77,20.00,,,,,,,,,,,,,
FIBER LASER 550UM 6J 80HZ 120W D F L FOR LITHO MOSES,SUP-2417491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1780.07,1157.05,,,,,,,,,,,,,
DRILL ENDOSCP FLX 9 MM CLANCY,SUP-2849119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3395.91,2207.34,,,,,,,,,,,,,
BLADE RETRACTOR KARLIN 4 IN 0.75 IN CRANK,SUP-2864706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,885.57,575.62,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 5 FR GCI STRL,SUP-2876512,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
COIL NEUROVASCULAR L 15 CM DIA 0.135 IN MICROCATHETER DIA,SUP-2896835,CDM,C1889,HCPCS,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
PLATE BONE L25MM THK0.9MM 6 H BILAT CRANIOMAXILLOFACIAL TI,SUP-2191329,CDM,C1713,HCPCS,0278,RC,,,,both,,,2266.14,1472.99,,,,,,,,,,,,,
COMPONENT CLMP EXT FIX STR CLMP JET-X,SUP-2342858,CDM,C1776,CPT,0278,RC,,,,both,,,2595.21,1686.89,,,,,,,,,,,,,
CATHETER KIT 3 W 0.025 IN 8 FR 40 CC REPL INSRTN LUER,SUP-2877620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CATHETER ANGIO ZOOM L 143 CM DIA 6 FR DSTL OD 5 FR PROX ID,SUP-2913641,CDM,C1887,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
ALLOGRAFT DERMAL 2X4 CMX1.26-1.75 MM DECELL DERM ORACELL,SUP-2740797,CDM,C1762,CPT,0278,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
BIT DRL 3.5X24 MM,SUP-2608416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
FIBER LASER 940 MH SOLTIVE DISP,SUP-2540085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2374.72,1543.57,,,,,,,,,,,,,
CANNULA PERF 21FR FEM VEN NVENT PERC BIO MEDICUS,SUP-2282877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1291.67,839.59,,,,,,,,,,,,,
SCREW BNE L30MM DIA3MM S STL ST COMPR ENH LCP DHHS,SUP-2178479,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.51,167.38,,,,,,,,,,,,,
TROCAR SURG AUTOCLV FOR 4MM CANN SPEEDLOCK,SUP-2366601,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.89,261.88,,,,,,,,,,,,,
PLATE BNE 2 COMPR NAR 4.5X71 MM 4 HOLE CONTOURED FOR SCR,SUP-2471132,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
IMPLANT 17MM M PAT FLNG CO CHROM ALLOY,SUP-2419630,CDM,C1776,CPT,0278,RC,,,,both,,,27324.28,17760.78,,,,,,,,,,,,,
STENT CORONARY L 8 MM DIA2.5 MM EVEROLIMUS RX DRUG ELUT,SUP-2101778,CDM,C1876,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
CATHETER CV SET 032 REG 8 FRX15 CM 12 GA DL J TIP SPECTRUM,SUP-2759723,CDM,C1751,HCPCS,0278,RC,,,,both,,,238.11,154.77,,,,,,,,,,,,,
RESERVOIR CSF RICKHAM STYL LG,SUP-2852578,CDM,C1889,HCPCS,0278,RC,,,,both,,,939.36,610.58,,,,,,,,,,,,,
SHUNT VLV PRECHAMBER 4X9X14 CM 19 CM H2O 1 CONN PAEDIGAV,SUP-2846926,CDM,C1889,HCPCS,0278,RC,,,,both,,,6315.83,4105.29,,,,,,,,,,,,,
COMPONENT FEM CR CEM SYMMETRICAL SZ 0,SUP-2222521,CDM,C1776,CPT,0278,RC,,,,both,,,9219.04,5992.38,,,,,,,,,,,,,
PLATE BNE DPHSEAL-MTPHSEAL RT VOLAR DSTL RADIAL 13 HOLE STRL,SUP-2546641,CDM,C1713,HCPCS,0278,RC,,,,both,,,5384.13,3499.68,,,,,,,,,,,,,
BAR EXT FIX L150MM DIA6MM COMP FOR JET-X FIX SYS,SUP-2342913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,919.83,597.89,,,,,,,,,,,,,
SCREW BNE CORTICAL 5X84 MM DBL LD TI STRL PHOENIX LTX DISP,SUP-2861149,CDM,C1713,HCPCS,0278,RC,,,,both,,,698.59,454.08,,,,,,,,,,,,,
HYDROCORTISONE 2.5 % EX OINT,RX-3732,CDM,6370000000,HCPCS,0637,RC,00168-0146-30,NDC,,both,28.35,GR,14.80,9.62,,,,,,,,,,,,,
CATHETER CTO 5FR L110CM CROSSING PROF 2MM SHTH 6FR 0.014IN,SUP-2124796,CDM,C1769,HCPCS,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
DEVICE VES CLOSURE MONOPOLAR TIP 335 DEG 5 MMX34 CM LIGASURE,SUP-2174893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
CATHETER THRMDIL 7FR L110CM STD PULM ART 4 INFUS LUMN SWN,SUP-2214026,CDM,C1751,HCPCS,0278,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
DABIGATRAN ETEXILATE MESYLATE 150 MG PO CAPS,RX-106476,CDM,6370000000,HCPCS,0637,RC,00597-0360-82,NDC,,both,1,UN,14.90,9.68,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MM 12 CM DSTL BEND MIDAS REX 8 CLRVW,SUP-2632177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5 MM 3X3 HOLE PRECONTOURED TITANIUM SI,SUP-2837748,CDM,C1713,HCPCS,0278,RC,,,,both,,,2661.78,1730.16,,,,,,,,,,,,,
MESH HERN W16XL12CM LAP MFIL POLY TEREPHTHALATE MFIL,SUP-2174687,CDM,C1781,HCPCS,0278,RC,,,,both,,,1271.86,826.71,,,,,,,,,,,,,
BLADE SCRDRVR 1.2 CROSS PIN,SUP-2419549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,705.87,458.82,,,,,,,,,,,,,
CATHETER INFUSION 85 CM ROTATING WIRE TIP INTRO CLARIVEIN IC,SUP-2466562,CDM,C1751,HCPCS,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 6X16 CMX0.75-1.5 MM DERMACELL,SUP-2264718,CDM,Q4122,HCPCS,0636,RC,,,,both,,,8083.93,5254.55,,,,,,,,,,,,,
HC So Antb Severe Aqt Respir Synd Sars-Cov-D Covid-19,PX-3028676966,CDM,86769,CPT,0302,RC,,,,inpatient,,,74.00,48.10,,,,,,,,,,,,,
SYSTEM IMPL W/ BIOCOMPOSITE SUT ANCHR 2X5IN JUMPSTART DSG,SUP-2122833,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
CLIP ANEUR BLDE W3MM DIA4MM OPN S STL GRFT SLIM-LINE,SUP-2243075,CDM,C1713,HCPCS,0278,RC,,,,both,,,3545.06,2304.29,,,,,,,,,,,,,
BOOT TRAC FT FOAM INSRT VELC STRP AD,SUP-2360615,CDM,L4387,HCPCS,0272,RC,,,,both,,,595.50,387.07,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 2 CHMBR IS-1 DF-1 CONN EPIC II DR,SUP-2356560,CDM,C1721,HCPCS,0275,RC,,,,both,,,70179.00,45616.35,,,,,,,,,,,,,
ALLOGRAFT BNE MED 3.5-4X0.7-0.9 CMX 1.8-2.2 MM FD NAR PROF,SUP-2460913,CDM,C1889,HCPCS,0278,RC,,,,both,,,1930.00,1254.50,,,,,,,,,,,,,
GUIDE RM BNE AND IMPL MOD COMPHSVE VRS,SUP-2402733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
SHEATH INTRO COMPASS L 90 CM OD 6 FR ID 2.25 MM GUIDEWIRE,SUP-2846726,CDM,C1894,HCPCS,0272,RC,,,,both,,,298.33,193.91,,,,,,,,,,,,,
CEMENT FLX FEM/CEM TIB/PRLNGSURF/NO PAT,SUP-2212154,CDM,C1776,CPT,0278,RC,,,,both,,,11252.35,7314.03,,,,,,,,,,,,,
WEDGE TRIAL 6MM,SUP-2465287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
PIN FIX STD UP EXT AXLE MRS,SUP-2372334,CDM,C1713,HCPCS,0278,RC,,,,both,,,6975.45,4534.04,,,,,,,,,,,,,
CATHETER IRRIGATION L 80 CM DIA 4 FR FOR VASC CLOT MGMT STRL,SUP-2119768,CDM,C1757,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
GRAFT EVAR L100MM DIA42X42MM CATH 25FR THOR CLS WEB STR DST,SUP-2281716,CDM,C1768,CPT,0278,RC,,,,both,,,58859.30,38258.54,,,,,,,,,,,,,
CROWN DENT PED NO7 SEC PRI M UP R ANTR CUSPID PREFABRICATED,SUP-2238773,CDM,D6783,CPT,0278,RC,,,,both,,,19.47,12.66,,,,,,,,,,,,,
FORCEP TISS ROSANO,SUP-2245978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.37,309.64,,,,,,,,,,,,,
CUP ACET MH NEUT 22X44 MM HIP MONOBLOCK NAT W/ SCREW HOLE,SUP-2202896,CDM,C1776,CPT,0278,RC,,,,both,,,9772.31,6352.00,,,,,,,,,,,,,
SHELL ACET OD48MM TI HA W O DOME H IMPL SECUR FIT XTRA,SUP-2370256,CDM,C1776,CPT,0278,RC,,,,both,,,5659.54,3678.70,,,,,,,,,,,,,
SCREW BNE CANN FOR NAIL EXTRACTION,SUP-2653750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2481.39,1612.90,,,,,,,,,,,,,
RING EXT FIX DIA160MM FULL FOR RNG FIX SYS TRUELOK,SUP-2316171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3062.25,1990.46,,,,,,,,,,,,,
SCREW SPNL L30MM DIA6.5MM TI FOR ANT FIX SYS Z PLT II,SUP-2289594,CDM,C1713,HCPCS,0278,RC,,,,both,,,1645.05,1069.28,,,,,,,,,,,,,
PLATE BNE L H1MM REG MINI 4 H R CRANIOMAXILLOFACIAL FOR 2MM,SUP-2366317,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.20,393.38,,,,,,,,,,,,,
WASHER EXT FIX OD12MM ID6.4MM THK1.5MM SPC FOR ILIZ TAY,SUP-2342312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.24,356.36,,,,,,,,,,,,,
CATHETER PTCA 5FR L130CM BLLN L150MM DIA4MM GWIRE 0.035IN,SUP-2128358,CDM,C2623,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
FORCEP DISECT ENDOSCP 5 MMX45 CM STRL DISP,SUP-2313743,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
GRAFT DURA W1XL1IN ULTRAPURE CLLGN ADH BARR MTRX DURAGN +,SUP-2244004,CDM,C1763,HCPCS,0278,RC,,,,both,,,928.25,603.36,,,,,,,,,,,,,
PROBE BRST BX 11GA HANDHELD MAMTOM,SUP-2195648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ADAPTER NEUROSTIM PKT FOR DP BRAIN STIM,SUP-2284579,CDM,2780000010,LOCAL,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM 1.3 MM 2.75 MM CLLR BUTTON SIL,SUP-2459529,CDM,L8699,HCPCS,0278,RC,,,,both,,,28.20,18.33,,,,,,,,,,,,,
TUBE OPHTH IMPL 250 MM DIAM 32 MM TUBE LEN STRL SIL,SUP-2326687,CDM,C1783,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
PLATE BNE H1.5MM 6 H 115DEG MAND G TI LO PROF W/ BAR FULL,SUP-2366368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1983.79,1289.46,,,,,,,,,,,,,
CATHETER CV KT 12 FRX20 CM 3L INTRO NDL SHRP SAFETY LG BOR,SUP-2763326,CDM,C1751,HCPCS,0278,RC,,,,both,,,434.58,282.48,,,,,,,,,,,,,
AMPICILLIN SODIUM 1 G IJ SOLR (MIXTURES ONLY),RX-430024,CDM,J0290,HCPCS,0636,RC,00781-9404-95,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA2.4 MM TI FUSION FOR HND PLATING SYS NS,SUP-2913056,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
CATHETER GUID R2P SLENGUIDE L 120 CM COAT L 300 MM OD 7 FR,SUP-2761864,CDM,C1887,HCPCS,0272,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
SCREW SPNL L 100 MM DIA 7.5 MM TI ALLOY IL CANN CONCL 2 LD,SUP-2926406,CDM,C1713,HCPCS,0278,RC,,,,both,,,5917.20,3846.18,,,,,,,,,,,,,
PROBE LARYNGEAL STR,SUP-2713694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,988.63,642.61,,,,,,,,,,,,,
HC Compatibility Test Electric,PX-3008692300,CDM,86923,CPT,0300,RC,,,,both,,,172.00,111.80,,,,,,,,,,,,,
WASHER ORTH DIA 5.5 MM NS LEOS,SUP-2932966,CDM,C1713,HCPCS,0278,RC,,,,both,,,324.14,210.69,,,,,,,,,,,,,
TRAZODONE HCL 50 MG PO TABS,RX-8085,CDM,6370000000,HCPCS,0637,RC,60687-0443-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-4502725200,CDM,27252,CPT,0450,RC,,,,both,,,4754.00,3090.10,,,,,,,,,,,,,
GRAFT BNE FIBER XS 1.25 CC SYR DBM,SUP-2431095,CDM,C1889,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM D CRV UNIDIR,SUP-2475051,CDM,C1732,HCPCS,0278,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
ANCHOR SUT 5.5MM IMPL W/ ORTHOCORD HEALIX ADV BR,SUP-2249434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1560.58,1014.38,,,,,,,,,,,,,
SUP MED CLAV LCK PL 10H L SMP,SUP-2818689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1501.58,976.03,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM THK100UM AMNIO MEMBRN AMBIO5,SUP-2247196,CDM,V2790,HCPCS,0274,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
CATH 6F 125CMS 8E 40 3MM EMC,SUP-2424787,CDM,C1730,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
CONN PL W/THD 9HOLES 215,SUP-2818122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2622.43,1704.58,,,,,,,,,,,,,
SLEEVE DRL DIA3.2MM FOR PROX HUM MEAS,SUP-2411560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.15,360.85,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RANG L 150 CM BALLOON L 150 MM DIA 4 MM,SUP-2653305,CDM,C2623,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
JGRKNT LNG 1 2 BLUE MB 10 PK,SUP-2589016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
INSERT TIB SULCUS 4+ 16 MM LT RT TOT ANK POLYETH INBONE II,SUP-2850358,CDM,C1776,CPT,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
PLATE BNE L LNG LT 6 HOLE W/ INTERMED SPACE STRL RESORB X,SUP-2478805,CDM,C1713,HCPCS,0278,RC,,,,both,,,680.69,442.45,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 105 CM OD 0.084 IN ID 0.072 IN FLX,SUP-2522810,CDM,C1887,HCPCS,0272,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
AUGMENT TIB STD SZ 11 COMPLT 5 DEG CEM UNIV WDG SCORP,SUP-2378538,CDM,C1776,CPT,0278,RC,,,,both,,,4495.22,2921.89,,,,,,,,,,,,,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,2500000003,HCPCS,0250,RC,00517-2502-10,NDC,,both,1,ML,112.60,73.19,,,,,,,,,,,,,
CATHETER ANGIO SLIP-CATH L 100 CM DIA 3 FR GUIDEWIRE 0.025,SUP-2168702,CDM,C1751,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE L32MM 6 H ZYG TI STR DYN COMPR FOR 2MM CRUCFRM,SUP-2191061,CDM,C1713,HCPCS,0278,RC,,,,both,,,1112.19,722.92,,,,,,,,,,,,,
MICROCATHETER GUID CORSAIR ARMET L 60 CM SHFT OD,SUP-2480207,CDM,C1887,HCPCS,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 65CM 6FR COAT L 35CM STR,SUP-2385211,CDM,C1894,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT 55 CM SPOTLT OPS SHTH VENACURE EVLT,SUP-2752487,CDM,C1888,HCPCS,0272,RC,,,,both,,,886.61,576.30,,,,,,,,,,,,,
SUPPORT ORTHOT CUST HEEL WDG SACH,SUP-2435720,CDM,L3340,HCPCS,0274,RC,,,,both,,,241.31,156.85,,,,,,,,,,,,,
KIT INTRO INTROFLEX L 10 CM DIA 6 FR BONDED ADJ VLV DSTL LCK,SUP-2214541,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.63,42.66,,,,,,,,,,,,,
PLATE STRNL CLOSURE 16 H TI LADDER NAR NS STERNALOCK BLU,SUP-2894505,CDM,C1713,HCPCS,0278,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
STENT VASC RX 6X100 MM 6 FRX200 CM SELF EXP R2P MISAGO,SUP-2422180,CDM,C1876,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BNE L79MM 5 H R MED DST HUM LOK FOR 2.7/3.5MM SCR,SUP-2348596,CDM,C1713,HCPCS,0278,RC,,,,both,,,10081.60,6553.04,,,,,,,,,,,,,
CUTTER SURG L MED R LAT FEM ACCURIS ST,SUP-2344211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.41,595.67,,,,,,,,,,,,,
LINER ACET 15 DEG STD POLYETH 36MM SZ H ACUMATCH,SUP-2221921,CDM,C1776,CPT,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 12.5CML INSER 4,SUP-2613241,CDM,C1752,HCPCS,0278,RC,,,,both,,,750.90,488.08,,,,,,,,,,,,,
HC So Immunoassay Quant,PX-3018351966,CDM,83519,CPT,0301,RC,,,,both,,,104.00,67.60,,,,,,,,,,,,,
BIOTENE DRY MOUTH MOIST SPRAY MT SOLN,RX-138581,CDM,6370000000,HCPCS,0637,RC,48582-0001-55,NDC,,both,44.3,ML,25.40,16.51,,,,,,,,,,,,,
ANCHOR BNE SINGLE 6.5 MM KNOTLESS ANCHR SYS OMEGA,SUP-2660823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
OBTURATOR ENDO T25,SUP-2287777,CDM,C1713,HCPCS,0278,RC,,,,both,,,975.50,634.07,,,,,,,,,,,,,
DETECTOR CARBON DIOX PEDIATRIC EZ CAP II DISP,SUP-2264516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
EVOS 3.5/4.5 PP DIS FEM PL L 19H 387MM,SUP-2931160,CDM,C1713,HCPCS,0278,RC,,,,both,,,21380.26,13897.17,,,,,,,,,,,,,
DRILL SURG CEM 4-6 FBT HI PERF SIG,SUP-2456272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLE 1.4X2.7 MMX25 CM ELASTMR TBNG,SUP-2666330,CDM,C1729,HCPCS,0272,RC,,,,both,,,419.94,272.96,,,,,,,,,,,,,
DISTRACTION INTRNL EXTN RIGID ACT ARM20 MM T 6L 4V QT001 EA,SUP-2679178,CDM,C1713,HCPCS,0278,RC,,,,both,,,2965.48,1927.56,,,,,,,,,,,,,
CATHETER ETER DRNGE 14FR L35CM GWIRE 0038IN BILI FLEXIMA SFT,SUP-2147835,CDM,C1729,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
MTOSCRINTF.NON-CANN 5.5X30 N/S,SUP-2341308,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 7 DEG 28X10X8 MM TLIF MONOLITHIC CRV,SUP-2538528,CDM,C1889,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 22X50 MM PRESERVON TRICORT MATRIGRAFT,SUP-2740870,CDM,C1713,HCPCS,0278,RC,,,,both,,,5765.48,3747.56,,,,,,,,,,,,,
SHEET SPLNT THK0.13IN STD W18XL24IN BILAT WR AND HND WHT SLD,SUP-2324794,CDM,L3730,HCPCS,0272,RC,,,,both,,,116.05,75.43,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5X5 CM DBM GRFT,SUP-2743371,CDM,C1713,HCPCS,0278,RC,,,,both,,,6283.14,4084.04,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.156X9 IN SS NS STEINMANN,SUP-2791600,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.55,23.76,,,,,,,,,,,,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,0636,RC,51991-0144-17,NDC,,both,1,ML,113.70,73.90,,,,,,,,,,,,,
LINER ACET OD68MM ID28MM HIP MARATHON LIP SNAP IN REV PINN,SUP-2250381,CDM,C1776,CPT,0278,RC,,,,both,,,3850.90,2503.08,,,,,,,,,,,,,
LEAD DEFIB 9 FRX59 CM TINED DF4-LLHO ENDOTK RELIANCE S 0272,SUP-2457472,CDM,C1777,HCPCS,0275,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
BUR SURG L 95 MM DIA2.35 MM HD DIA 7 MM DIAMOND NS REUSE,SUP-2929092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.64,257.82,,,,,,,,,,,,,
CATHETER EP TPLR DAMATO FIX CRV WVN POLYUR SHFT 7FRX110CM,SUP-2142011,CDM,C1730,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
COMPONENT PAT SZ 2 L FEM CO CHROM RESTORIS MCK,SUP-2368537,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SPLINT WRST FA UNIV R 8 IN,SUP-2276644,CDM,L3809,HCPCS,0274,RC,,,,both,,,14.63,9.51,,,,,,,,,,,,,
ROD SPNL L600MM DIA3-5.5MM RT POST THORLUM TI ALLOY SMOOTH,SUP-2254422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.56,1743.01,,,,,,,,,,,,,
COIL NEUROVASCULAR TARGET 360 DEG L 6 CM DIA 3 MM STD,SUP-2367994,CDM,C1889,HCPCS,0278,RC,,,,both,,,5888.44,3827.49,,,,,,,,,,,,,
SCREW INTRF BIOSURE REGENESORB 8MMX25MM,SUP-2341918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1126.63,732.31,,,,,,,,,,,,,
PLATE X VA LCK 2.4/2.7MM SM STRL,SUP-2546955,CDM,C1713,HCPCS,0278,RC,,,,both,,,3681.43,2392.93,,,,,,,,,,,,,
CANNULA ENDOSCP HEINKELSEMM DIL SET FOR 9916,SUP-2766870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1371.08,891.20,,,,,,,,,,,,,
GRAFT BNE SUB 4CC DBM OSTEOINDUCTIVE OSTEOGENIC AUTOLGS BNE,SUP-2399143,CDM,C1713,HCPCS,0278,RC,,,,both,,,4914.32,3194.31,,,,,,,,,,,,,
GUIDEWIRE SURGICAL L12IN DIA24MM REUSABLE APERFIX,SUP-2589282,CDM,C1769,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
CONNECTOR SPNL LCK BRK OFF AX IMP OD5.5X5.5MM COLORADO 2,SUP-2290610,CDM,C1713,HCPCS,0278,RC,,,,both,,,5363.12,3486.03,,,,,,,,,,,,,
KIT PICC MAX BARR ANTIMICR/ANITTHROM PRELOAD 5.5FR X 55CM 2L,SUP-2864582,CDM,C1751,HCPCS,0278,RC,,,,both,,,856.18,556.52,,,,,,,,,,,,,
SCREW SPNL L45MM DIA5.5MM THORLUM TI VAR ANG TRUSS,SUP-2230344,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
LEAD PACE 5.3FR L88CM L VENT TRNSVEN STEROID ELUT IS-4-LLLL,SUP-2281930,CDM,C1900,HCPCS,0275,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PLATE BNE W102XL78MM THK27MM RAD 108MM 6 H BILAT PELV S STL,SUP-2186269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1997.95,1298.67,,,,,,,,,,,,,
HC N Block Paravert Lumbar 3+,PX-3606449500,CDM,64495,CPT,0360,RC,,,,both,,,3113.00,2023.45,,,,,,,,,,,,,
BEARING TIB 14X79 MM K-GEL INLAY POLYETH AGC TOTAL,SUP-2441773,CDM,C1776,CPT,0278,RC,,,,both,,,1183.15,769.05,,,,,,,,,,,,,
CATHETER HD STR 14 FRX24 CM SHT TERM 400 XL FULL TY TAPR TIP,SUP-2266971,CDM,C1752,HCPCS,0278,RC,,,,both,,,293.90,191.03,,,,,,,,,,,,,
MESH SRGCL 41MMW X 160MML 1MM THK MXLFCL FOA STRIP RSRB X LA,SUP-2681134,CDM,C1713,HCPCS,0278,RC,,,,both,,,15218.45,9891.99,,,,,,,,,,,,,
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,0636,RC,00517-1820-01,NDC,,both,1,UN,920.00,598.00,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED COCR JOURNEY,SUP-2348007,CDM,C1776,CPT,0278,RC,,,,both,,,22934.56,14907.46,,,,,,,,,,,,,
SLING GYN W1XL60CM MIDURETHRAL SYN PERM LO ELASTICITY,SUP-2165381,CDM,C1771,HCPCS,0278,RC,,,,both,,,3161.98,2055.29,,,,,,,,,,,,,
MESH PLATE SHORT TI,SUP-2814960,CDM,C1713,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
TOCILIZUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430062,CDM,J3262,HCPCS,0636,RC,50242-0137-01,NDC,,both,20,ML,7834.70,5092.55,,,,,,,,,,,,,
CUP ACET DIA68MM THK2MM LT COMMERCIALLY PURE TI MOD,SUP-2405116,CDM,C1776,CPT,0278,RC,,,,both,,,13564.80,8817.12,,,,,,,,,,,,,
SCREW BONE L16MM DIA4.5MM CORT LCK FULL THRD FOR PEDINAIL,SUP-2318933,CDM,C1713,HCPCS,0278,RC,,,,both,,,952.24,618.96,,,,,,,,,,,,,
PLATE BNE L135MM 8 H BROAD CNTOUR 2 COMPR FOR 45MM SCR L,SUP-2411411,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.33,410.36,,,,,,,,,,,,,
HC Rep Blood Vessel Direct Up Ext,PX-4503520600,CDM,35206,CPT,0450,RC,,,,both,,,3355.00,2180.75,,,,,,,,,,,,,
PLATE BNE MESH PANEL STD 1.5X80X53X0.6 MM NEURO REG GRID,SUP-2480638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2373.02,1542.46,,,,,,,,,,,,,
SCREW BEND INSRT FOR LOK RECON TI PLT,SUP-2193365,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.23,124.30,,,,,,,,,,,,,
COLLAR EXTRIC AD SHT TWO PC TRACH OPN VELC CLSR W/ CHIN,SUP-2194467,CDM,L0180,HCPCS,0274,RC,,,,both,,,54.10,35.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.403,SUP-2859967,CDM,C1713,HCPCS,0278,RC,,,,both,,,30484.06,19814.64,,,,,,,,,,,,,
SPHERE EMB 900 1200 MIC 20ML BLU PREFIL SYR EMBGLD,SUP-2303389,CDM,C1889,HCPCS,0278,RC,,,,both,,,861.46,559.95,,,,,,,,,,,,,
PIN FIX POLY LACTIC ACID ANTR CRUC LIGMNT SFT TISS CRV KT,SUP-2256610,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
BLADE SRGCL SFTY LOCK DVCE SIZE 12 STNLSS STEEL RIB DSGN CNS,SUP-2570643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5.43,3.53,,,,,,,,,,,,,
DRILL SURG 5MM J SLOT PILOT PAN FIX LUHR,SUP-2364711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,233.02,151.46,,,,,,,,,,,,,
DRILL SURG MOD 4-6 15 MM TIB CEM SPEC,SUP-2456582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
HC Arthrocent/Aspiration Maj Jnt|BILATERAL PROCEDURE,PX-3612061000,CDM,20610,CPT,0361,RC,,,50,both,,,1245.00,809.25,,,,,,,,,,,,,
BAG TISS CLSR DIA75CM TRNSPAR SIL SILO SPR LD PROX OPN SFT,SUP-2134674,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
PLATE BNE L 250.62 MM THK 2.8 MM LG TI DBL ANGLE NS DISP,SUP-2936878,CDM,C1713,HCPCS,0278,RC,,,,both,,,10519.00,6837.35,,,,,,,,,,,,,
PACEMAKER CARD OPTIMIZER SMRT MINI IMPL PULSE GENRTR ALLEN,SUP-2866322,CDM,C1824,HCPCS,0278,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
HC Place Cath Thoracic Aorta,PX-3613622100,CDM,36221,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA11 MM DEL SHTH,SUP-2934584,CDM,C1713,HCPCS,0278,RC,,,,both,,,17223.06,11194.99,,,,,,,,,,,,,
PLATE BONE L25MM HUM S STL LCK BLDE EQUINOXE,SUP-2223414,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
FIXATION KIT KNOTLESS TENSIONABLE BICEPS DRL GUIDE FIBERTAK,SUP-2859830,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
BLADE RTRCTR CSPR 50MM X 23MM BALL SNAP MED F/ANTRR CRVCL FS,SUP-2464768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.52,270.09,,,,,,,,,,,,,
ACTIVATION NUT FOR,SUP-2823437,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.44,255.74,,,,,,,,,,,,,
BLADE RTRCTR 60MMW X 90MML TTNM SPNL WIDE PRNGX6 GOLD LMBRTR,SUP-2668629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1164.85,757.15,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2 MM RAPID RESORBABLE STERILE RAPIDSORB,SUP-2838587,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.95,324.32,,,,,,,,,,,,,
RIGHT/LEFT IBO BLDE SET FOR USE W/ STRYKR TPS RECIP SAW,SUP-2363316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.31,377.85,,,,,,,,,,,,,
PLATE BNE L147MM 8 H R PROX TIB S STL VAR ANG LOK COMPR SM,SUP-2177915,CDM,C1713,HCPCS,0278,RC,,,,both,,,5855.97,3806.38,,,,,,,,,,,,,
GUIDEWIRE L65IN S STL ENT HSE,SUP-2159976,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.15,254.90,,,,,,,,,,,,,
MESH BIO PORCINE MTRX ABD 10CM LEN 20CM W 1.5MM THICKNESS 151020] TISSUE SCIENCE LABORATORIES],SUP-2388448,CDM,C9364,HCPCS,0278,RC,,,,both,,,11605.44,7543.54,,,,,,,,,,,,,
BELT RIB XL 6 IN M ELASTIC VELCRO CLOSURE,SUP-2194761,CDM,L0220,HCPCS,0274,RC,,,,both,,,22.95,14.92,,,,,,,,,,,,,
REAMER SURG DIA12MM,SUP-2291549,CDM,C1713,HCPCS,0278,RC,,,,both,,,4079.39,2651.60,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq Ea Addl 15 Min,PX-4409755100,CDM,97551,CPT,0440,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM S STL SGL END SMOOTH SGL SHRP,SUP-2371657,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
STAPLER SURG L60MM BLU RELD DISP W/ 3.5MM TI STPL DST SER,SUP-2283417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.93,369.15,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE",PX-4209711000,CDM,97110,CPT,0420,RC,,,GO|KX|CO|XU,both,,,195.00,126.75,,,,,,,,,,,,,
MICROCATHETER VASC RENEGADE HI FLO L 135 CM DSTL L 20 CM,SUP-2367868,CDM,C1887,HCPCS,0272,RC,,,,both,,,2397.70,1558.50,,,,,,,,,,,,,
SCREW BNE FT LG 5X20 MM COMPR,SUP-2122526,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
KNIFE ACCUTOME 600 550 OR 500UM 6MM POLISHED WNG FTPLT FULL,SUP-2106443,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
STEM FEM L200MM OD9MM RT HIP POR NONCOATED TYP 1 TAPR PRI,SUP-2406644,CDM,C1776,CPT,0278,RC,,,,both,,,17885.44,11625.54,,,,,,,,,,,,,
GUIDEWIRE ORTH L350MM DIA1.6MM SHT TRCR TIP,SUP-2290628,CDM,C1769,HCPCS,0272,RC,,,,both,,,105.57,68.62,,,,,,,,,,,,,
RECON PLATE 5X77MM 4.5MM,SUP-2818427,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.03,1989.67,,,,,,,,,,,,,
NEEDLE VENT 18GA 2 H CONE W/ LUERLOCK,SUP-2382315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
AMIODARONE HCL 450 MG/9ML IV SOLN,RX-97603,CDM,J0282,HCPCS,0636,RC,67457-0153-09,NDC,,both,3,ML,54.10,35.16,,,,,,,,,,,,,
KIT NEUROSTIM PASS ELEV ACC FOR INTERSTIM SPNL CRD STIM,SUP-2284445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
PLATE BNE RECON 3.5X58 MM 5 HOLE SS,SUP-2569080,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.49,220.02,,,,,,,,,,,,,
BAND ANNULPLSTY COSGROVE-EDWARDS SZ 38 MM L 83.1 MM OD 45.6,SUP-2214203,CDM,C1713,HCPCS,0278,RC,,,,both,,,8446.60,5490.29,,,,,,,,,,,,,
IMMOBILIZER ORTH 2 AXIS LNG 26 IN 36 IN KNEERANGER II,SUP-2197134,CDM,L3702,HCPCS,0272,RC,,,,both,,,122.62,79.70,,,,,,,,,,,,,
GRAFT BNE SUB 5CC VIABLE MTRX COMPRESSIBLE MOLD RDY TO USE,SUP-2370453,CDM,C1713,HCPCS,0278,RC,,,,both,,,6075.90,3949.33,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 15 CM DIA10 FR PTFE PERC LNG T,SUP-2126180,CDM,C1894,HCPCS,0272,RC,,,,both,,,488.30,317.39,,,,,,,,,,,,,
STAPLER ENDOSCP 75MM STPL OPN H42MM CLS H18MM REG TISS LIN,SUP-2693599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,512.61,333.20,,,,,,,,,,,,,
HC So1 Encephalitis Eastern Equine,PX-3028665267,CDM,86652,CPT,0302,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
BUTTON CERCLAGE DIA3.5MM S STL T25 STARDRV RECESS HEX FOR,SUP-2178462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,498.76,324.19,,,,,,,,,,,,,
NEBULIZER IN-LINE REPLACEMENT AERONEB SOLO,SUP-2720067,CDM,2720000010,LOCAL,0272,RC,,,,both,,,450.09,292.56,,,,,,,,,,,,,
ROD SPNL L450MM DIA6.35MM POST BILAT S STL SMOOTH STR,SUP-2255704,CDM,C1713,HCPCS,0278,RC,,,,both,,,1693.46,1100.75,,,,,,,,,,,,,
HC Thoracic Fascial Plane Block Uni Injection,PX-3606446600,CDM,64466,CPT,0360,RC,,,,both,,,996.00,647.40,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 6 MM RNG L 10 CM EPTFE STR TW,SUP-2396112,CDM,C1768,CPT,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
NEEDLE PUNC LL 2 MM TIP 5 MMX33 CM,SUP-2852224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.08,227.55,,,,,,,,,,,,,
SPLINT ARM MP LG,SUP-2274800,CDM,L3809,HCPCS,0274,RC,,,,both,,,40.73,26.47,,,,,,,,,,,,,
COIL EMB L3CM LOOP OD2MM OD0.020IN NIT STRTCH RESIST CRV,SUP-2323440,CDM,C1889,HCPCS,0278,RC,,,,both,,,5560.94,3614.61,,,,,,,,,,,,,
CUP ACET MULT H 48MM ACUMATCH A SER,SUP-2221817,CDM,C1776,CPT,0278,RC,,,,both,,,6028.80,3918.72,,,,,,,,,,,,,
STAPLER INT L L28MM DIA5MM GI BLU TI BARIATRIC CIR CUT 2 ROW,SUP-2283258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1086.91,706.49,,,,,,,,,,,,,
CATHETER PTCA L80CM L2CM OD4FR ODSEC5MM .018IN 14ATM PERIPH,SUP-2170756,CDM,C1725,HCPCS,0272,RC,,,,both,,,650.14,422.59,,,,,,,,,,,,,
AMPHOTERICIN B 50 MG IV SOLR,RX-145510,CDM,J0285,HCPCS,0636,RC,39822-1055-05,NDC,,both,1,UN,276.00,179.40,,,,,,,,,,,,,
KNIFE SURG SCHKNT 150 DEG 165X7 MM SCKL ANGLED SHFT,SUP-2469747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.46,257.70,,,,,,,,,,,,,
GRAFT OTO 0.4-0.6CM POR PORCINE SM INTEST SUBMUCOSA LAM,SUP-2170504,CDM,C1763,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
STAPLE BNE FIX W9XL7MM DIA1.5MM WIRE OSSTPL,SUP-2194212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
PLATE BNE FUSION LNG 3.5/4 MM MEDL CLMN NS LTX,SUP-2857066,CDM,C1713,HCPCS,0278,RC,,,,both,,,8327.28,5412.73,,,,,,,,,,,,,
BURR DIAMOND DISK 25.4MM MHD25DDG1,SUP-2843307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.07,510.95,,,,,,,,,,,,,
MODULAR NAIL 9.0MMX44CM,SUP-2828713,CDM,C1713,HCPCS,0278,RC,,,,both,,,8101.20,5265.78,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-40840054,CDM,2580000003,HCPCS,0250,RC,00338-0089-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
PLATE BNE L15MM THK0.6MM MIC 4 H CP TI STR FOR 1.5MM SCR,SUP-2262669,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
TOTAL KNEE REPLACEMENT KIT END-DELIVERY 15 GAX60 MM 3 CC ANK,SUP-2866913,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
STENT BILI L18MM DIA5MM BLLN L20MM S STL SELF EXP LO PROF,SUP-2173165,CDM,C1876,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
SURFACE ARTC SZ 3-4/EF H20MM PROLONG HXLPE UNIV PRI POST,SUP-2402782,CDM,C1776,CPT,0278,RC,,,,both,,,2926.48,1902.21,,,,,,,,,,,,,
CATHETER DRNGE L25CM OD7FR ACC GB PERC SH TERM LCK PGTL,SUP-2141077,CDM,C1729,HCPCS,0272,RC,,,,both,,,234.31,152.30,,,,,,,,,,,,,
CATHETER BLLN OCCL 2.8X2.2FR L150MM BLLN L15MM DIA4MM TIP,SUP-2172470,CDM,C2628,HCPCS,0272,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
PLATE SPNL L39MM LEV 1 ANTR BILAT CERV TI LCK LO PROF,SUP-2254585,CDM,C1713,HCPCS,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
BRACE WR M L8IN LT FOAM LOOP LCK CLSR W/ THMB SPICA R-SOFT,SUP-2324348,CDM,L3931,HCPCS,0274,RC,,,,both,,,72.13,46.88,,,,,,,,,,,,,
EXPANDER BRST 475CC W13XH13CM P6.8CM SIL TEXT HI PROF,SUP-2301033,CDM,C1789,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|KX|CO|XU,both,,,144.00,93.60,,,,,,,,,,,,,
DRILL SURG 4.5X12 MM,SUP-2391410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER BLLN 6X12 MM SINUS ACELLA,SUP-2106316,CDM,C1726,HCPCS,0272,RC,,,,both,,,11225.50,7296.57,,,,,,,,,,,,,
SHELL ACET OD48MM UNIV TI HA POR CLUS H PRESSFIT PRI IMPL,SUP-2370239,CDM,C1776,CPT,0278,RC,,,,both,,,5359.98,3483.99,,,,,,,,,,,,,
CELECOXIB 400 MG PO CAPS,RX-33653,CDM,6370000000,HCPCS,0637,RC,16714-0734-01,NDC,,both,1,UN,11.00,7.15,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X323 MM 17 HOLE SS LCP,SUP-2569370,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.95,588.22,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DEMIN BNE MTRX ORTHOBLEND FOR SM DEFCT,SUP-2294020,CDM,C1713,HCPCS,0278,RC,,,,both,,,5397.66,3508.48,,,,,,,,,,,,,
STEM HUM 14MM MINI SHLDR CO CHROM COMPHSVE REV PRI CEM,SUP-2404567,CDM,C1776,CPT,0278,RC,,,,both,,,16010.86,10407.06,,,,,,,,,,,,,
CATHETER REPERFUSION 138 CM KT TBNG RED62,SUP-2716393,CDM,C1757,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
COMPONENT PAT 34MM KNEE ARCM 1 PEG W/ WIRE FOR ONC SALV SYS,SUP-2404186,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
DEVICE COMPR PRELUDESYNC EVO L 24 CM 30 CC POLYCARB RADIAL,SUP-2430077,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.35,38.58,,,,,,,,,,,,,
BIT DRL 1.2X50 MM 6 MM W/ DENT INTFACE NS UNIV NEURO III LTX,SUP-2862794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.36,411.03,,,,,,,,,,,,,
HC So Acth,PX-3078202466,CDM,82024,CPT,0307,RC,,,,both,,,288.00,187.20,,,,,,,,,,,,,
PLATE BNE ACTIVE COMPR BROAD LG 4.5X109 MM 6 HOLE NS,SUP-2488517,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
PUMP CTRL URETH INHIBZN FOR AMS 800 SYS,SUP-2138948,CDM,C1815,HCPCS,0278,RC,,,,both,,,22155.84,14401.30,,,,,,,,,,,,,
TUBE FEEDING KANGAROO IRIS WITH IRIS TECHNOLOGY 12FR 43IN,SUP-2719883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.94,446.51,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM AMNIO MEMBRN TRNSLUC GRID PAT,SUP-2113883,CDM,Q4154,HCPCS,0636,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
BRACE WLK L SHOE MAN 10 13 WOMAN 11 15 SHT PNEUMAT SEMI RIG,SUP-2196355,CDM,L4361,HCPCS,0272,RC,,,,both,,,122.96,79.92,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LG CEM HD CUP LNR ST TRAB MTL CERM,SUP-2212106,CDM,C1776,CPT,0278,RC,,,,both,,,15186.77,9871.40,,,,,,,,,,,,,
ALLOGRAFT HUM TISS HEMI BTB FRZN LO-RAD,SUP-2321875,CDM,C1762,CPT,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK INNR SOCKET CUSH LNR,SUP-2388210,CDM,L5679,HCPCS,0272,RC,,,,both,,,1538.82,1000.23,,,,,,,,,,,,,
GUIDEWIRE VASC L200CM DIA0.014IN DST SEG L35CM NIT HYDRPHLC,SUP-2367901,CDM,C1769,HCPCS,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
EVOS 3.5MM LCK COMP PL 10H 116MM,SUP-2931191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1589.56,1033.21,,,,,,,,,,,,,
IMPLANT BRST 420 450CC P45CM DIA134CM NACL STYL 68MP SMOOTH,SUP-2113377,CDM,C1789,HCPCS,0278,RC,,,,both,,,1494.64,971.52,,,,,,,,,,,,,
SET ANCHR SUTURE 12CML NDL GI STRGHT BRAIDED PRE LDD FIXCOR,SUP-2638533,CDM,C1889,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
MESH HERN XL W1.6XL2IN INGUINAL WHT POLYPR MFIL PLUG PTCH,SUP-2125753,CDM,C1781,HCPCS,0278,RC,,,,both,,,725.65,471.67,,,,,,,,,,,,,
PLATE BNE L62MM 3 H S STL LOK COMPR FOR 3.5MM SCR LCP,SUP-2184179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1784.84,1160.15,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 30X13X13 MM FD CANC,SUP-2792177,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
HC So1 Infectious Agent Ab Quant,PX-3028631767,CDM,86317,CPT,0302,RC,,,,inpatient,,,44.00,28.60,,,,,,,,,,,,,
PROBE SNR L230CM DIA2.3MM CLR SUCT N CNTCT COAG TARGETED VIS,SUP-2166256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
APPLIER CLP CRV MED 14 IN OPN SURG HORZ MTL LIG SYS,SUP-2656767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
LEVOBUNOLOL HCL 0.5 % OP SOLN,RX-10394,CDM,6370000000,HCPCS,0637,RC,24208-0505-05,NDC,,both,5,ML,80.60,52.39,,,,,,,,,,,,,
GUIDEWIRE ORTH L4MM OD.035IN PARTIALLY THRD EXTREMIFIX,SUP-2319455,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
WEDGE TIB SM SZ 1 THK10MM KNEE PRI PRESSFIT FULL FLAT BLK,SUP-2377111,CDM,C1713,HCPCS,0278,RC,,,,both,,,3244.12,2108.68,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-15861,CDM,J3490,HCPCS,0258,RC,00338-0085-04,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
CANNULA 96670 115 BIO MEDICUS 15FR EA,SUP-2725857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1119.10,727.41,,,,,,,,,,,,,
TUBE MYR 127MM DIAM WHT RED BLK CLLR BTTN PACIFIC COAT,SUP-2313849,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.68,16.04,,,,,,,,,,,,,
RING EXT FIX HALF 90 MM CARBON FIBER RINGFIX,SUP-2365282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
VALVE SHUNT RIGHT ANGLE GUIDE,SUP-2711647,CDM,C1889,HCPCS,0278,RC,,,,both,,,292.15,189.90,,,,,,,,,,,,,
PLATE BNE FRAC WRST COLLES STRL LTX,SUP-2861191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1668.85,1084.75,,,,,,,,,,,,,
BUR SURG OD7MM DMND STRL CORNERSTONE MAESTRO,SUP-2363389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,302.54,196.65,,,,,,,,,,,,,
NAIL IM L200MM DIA12MM NONSTERILE AQUA L/R DSTL FEM TI LCK,SUP-2191772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4988.96,3242.82,,,,,,,,,,,,,
KIT INST PREP JOINT STERILE,SUP-2715950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
CATHETER PERIPH 1820GA MULT LUMN RADPQ RND WALL NDL TWIN,SUP-2570504,CDM,C1751,HCPCS,0278,RC,,,,both,,,13.85,9.00,,,,,,,,,,,,,
IMPLANT FACE L 50 X W 38 MM THK 1.5 MM POLYETHYL EMBEDDED TI,SUP-2883378,CDM,C1713,HCPCS,0278,RC,,,,both,,,3218.53,2092.04,,,,,,,,,,,,,
ROD SPNL L35MM OD4.75MM CO CHROM NONSTERILE IMPL CDH,SUP-2284737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
PLATE BONE TUBULAR BROAD 4.5 MM 6 HOLE PROVISIONAL FIXATION,SUP-2836962,CDM,C1713,HCPCS,0278,RC,,,,both,,,2144.24,1393.76,,,,,,,,,,,,,
SADDLE CBL ORTH SHT AND TY HEX PERI-LOC,SUP-2351133,CDM,C1713,HCPCS,0278,RC,,,,both,,,1324.92,861.20,,,,,,,,,,,,,
PROSTHESIS CNTR 2.5MM DIA 8MM LEN HA TORP STRASNICK,SUP-2313850,CDM,L8613,CPT,0278,RC,,,,both,,,982.82,638.83,,,,,,,,,,,,,
NEEDLE EPIDURAL L 4 IN STRL DISP PHARM COUD,SUP-2917079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
HC Ureteral Embolization/Occl W Img Guide/Si,PX-3615070500,CDM,50705,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
INSERT LOK OD3MM S STL KNEE SM FRAG AXSOS,SUP-2371463,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
VALVE AORT H14MM CUF DIA25MM TISS ANNULUS DIA19MM EPIC SUP,SUP-2355841,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
HC NM Cisternography,PX-3417863000,CDM,78630,CPT,0341,RC,,,,inpatient,,,3207.00,2084.55,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI PWR TRIALYSI ACUTE 13FR DIA 12.5CML IN,SUP-2613248,CDM,C1752,HCPCS,0278,RC,,,,both,,,1041.41,676.92,,,,,,,,,,,,,
STENT BILI FORMULA 418 L 24 MM DIA 8 MM DEL SYS L 80 CM SHTH,SUP-2170446,CDM,C1876,HCPCS,0278,RC,,,,both,,,2750.26,1787.67,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED TIB UPCHARGE COMP MIS,SUP-2212687,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SCREW INTFR L30MM DIA11MM KNEE PLLA CANN ABSRB RND HD,SUP-2249527,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
TUBE TRACH 5.5 MM PEDIATRIC 5.5X8X46 MM STRL BIVONA AIRE-CUF,SUP-2352008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.95,405.57,,,,,,,,,,,,,
"HC So Cyclic Citrullinated Peptd,Ab",PX-3028620066,CDM,86200,CPT,0302,RC,,,,both,,,207.00,134.55,,,,,,,,,,,,,
DRILL ENDOSCP 7.5 MM,SUP-2849104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
WIRE BNE FIX L 152 MM DIA 0.9 MM SINGLE END TROCAR TIP NS,SUP-2933571,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.33,52.86,,,,,,,,,,,,,
TRAY CATH L 24 CM DIA11.5 FR PRIMING ART 1.7 ML VEN 1.8 ML,SUP-2905033,CDM,C1752,HCPCS,0278,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
CEMENT BONE 80GM DBL DOSE CA PHOS W/ GENTMYCN HI VISC N,SUP-2222169,CDM,C1713,HCPCS,0278,RC,,,,both,,,2150.90,1398.08,,,,,,,,,,,,,
TRIAL HIP OD43MM ID28MM ACET SHELL FOR MOD ENDO HD SELF CNTR,SUP-2252704,CDM,C1776,CPT,0278,RC,,,,both,,,1488.36,967.43,,,,,,,,,,,,,
WIRE FIX 2 SHRP TIP K S STL L150MM OD1.6MM,SUP-2242887,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.19,85.27,,,,,,,,,,,,,
RESERVOIR CSF 0.23ML MINI SIDE INLET,SUP-2244283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1254.21,815.24,,,,,,,,,,,,,
LINER ACET LAT J 35 DEG 36X66-68 MM HIP XLPE REFLECTION,SUP-2434811,CDM,C1776,CPT,0278,RC,,,,both,,,7429.24,4829.01,,,,,,,,,,,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2312,HCPCS,0636,RC,67457-0292-00,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.536,SUP-2860053,CDM,C1713,HCPCS,0278,RC,,,,both,,,46674.53,30338.44,,,,,,,,,,,,,
GRAFT BONE SUB 4-10MM 15CC CANC CHIP FIL OSTEOSPONGE,SUP-2125411,CDM,C1713,HCPCS,0278,RC,,,,both,,,3603.15,2342.05,,,,,,,,,,,,,
DEVICE ELECSURG TIPTOOL SONICFUSION 19102020,SUP-2517217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
CATHETER URET CONE TIP OPN END 5FRX70CM,SUP-2141717,CDM,C1758,HCPCS,0278,RC,,,,both,,,82.36,53.53,,,,,,,,,,,,,
"HC So Porphyrins,Quantitive",PX-3018412066,CDM,84120,CPT,0301,RC,,,,outpatient,,,1044.00,678.60,,,,,,,,,,,,,
DEVICE CLSR L3.3MM L TI ST DISP FOR ANAS VES ANASTOCLIP VCS,SUP-2264239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
WASHER ORTH SQ FOR HUM NAILING SYS T2,SUP-2369201,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
STENT URET L28CM OD8FR HYDR+ TAPR TIP DBL PGTL THRD POS W/O,SUP-2139650,CDM,C2617,HCPCS,0278,RC,,,,both,,,406.94,264.51,,,,,,,,,,,,,
PLATE BONE W14.9XL200MM THK1.2MM 12 H DSTL TIB S STL,SUP-2185741,CDM,C1713,HCPCS,0278,RC,,,,both,,,1374.10,893.16,,,,,,,,,,,,,
BAR EXT FIX 11X500 MM CARBON,SUP-2750001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1742.70,1132.75,,,,,,,,,,,,,
IMPLANT OP RM TUFFNEK SCR 2.7 X 34MM,SUP-2321189,CDM,C1713,HCPCS,0278,RC,,,,both,,,506.33,329.11,,,,,,,,,,,,,
STAPLER INT L100MM THK48MM TI RELD TWO DBL STAGGERED ROW,SUP-2283277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,658.80,428.22,,,,,,,,,,,,,
DEVICE FIX 35MM AC JT FEM 1 ZIPLOOP TECHNOLOGY ZIPTIGHT,SUP-2137182,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.32,1710.36,,,,,,,,,,,,,
KIT KYPHOPLASTY SZ 3 CEM GUN W/ BNE FILL INJ KYPHON,SUP-2293483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
CUP HUM DIA39MM NEUT OFFSET SHLDR CAP UNIVERS REVERS,SUP-2123339,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BONE SUB 1ML PUTTY CANC DEMIN INJ W/ CHIP PUROS,SUP-2205386,CDM,C1734,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
KIT CATH L58CM OD4FR W/ PEEL AWAY SHTH INTRO CTRL VEN PICC,SUP-2168400,CDM,C1751,HCPCS,0278,RC,,,,both,,,245.23,159.40,,,,,,,,,,,,,
IMPLANT SUBTALAR L14MM DIA9MM ANK JT FOR ARTHROERESIS,SUP-2121855,CDM,C1776,CPT,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
CATHETER VENTRICULAR DRAINAGE L600MM SILICONE PERITONEAL BAR,SUP-2830497,CDM,C1729,HCPCS,0272,RC,,,,both,,,393.38,255.70,,,,,,,,,,,,,
ROD SPNL THRD LNG 400 MM MR SAFE NS,SUP-2863418,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.75,203.94,,,,,,,,,,,,,
SCREW BNE TWST OFF 2X10 MM CORTICAL NS,SUP-2435436,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.38,532.60,,,,,,,,,,,,,
BIT DRL DIA2 MM CANN FUSION QR NS DISP HPS,SUP-2912796,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
GUIDEWIRE VASC BENT L 260 CM DIA 0.035 IN TAPR L 15 CM FLPY,SUP-2168540,CDM,C1769,HCPCS,0272,RC,,,,both,,,55.70,36.20,,,,,,,,,,,,,
PLATE BONE L358MM 22 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185282,CDM,C1713,HCPCS,0278,RC,,,,both,,,1699.18,1104.47,,,,,,,,,,,,,
GRAFT HUM TISS R TIB FRZN,SUP-2307332,CDM,C1713,HCPCS,0278,RC,,,,both,,,4692.10,3049.86,,,,,,,,,,,,,
GRAFT BONE 30ML CORT CANC CRUSH CHIP FRZN,SUP-2294136,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM MULTAXL STRL CD HORZ 559200039,SUP-2927815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1.66,1.08,,,,,,,,,,,,,
PLATE BNE L203MM 13 H ST R LAT DST FIBULAR S STL LOK COMPR,SUP-2177427,CDM,C1713,HCPCS,0278,RC,,,,both,,,2199.26,1429.52,,,,,,,,,,,,,
PLATE BONE W8XL68MM THK2MM 0DEG 8 H BILAT TI STR RIG DYN,SUP-2191072,CDM,C1713,HCPCS,0278,RC,,,,both,,,1510.69,981.95,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA 9 MM DEL SHTH,SUP-2934164,CDM,C1713,HCPCS,0278,RC,,,,both,,,12789.22,8312.99,,,,,,,,,,,,,
KNIFE SURG FUKUSHIMA CHEN 7.5 INX8 MM SCKL RUGGLES-REDMOND,SUP-2471686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.61,355.30,,,,,,,,,,,,,
SCREW POLYAX 3.5X14MM 7902-3514,SUP-2211408,CDM,C1713,HCPCS,0278,RC,,,,both,,,3168.26,2059.37,,,,,,,,,,,,,
BARRIER ADH W3XL4IN UTER PELV ABSRB GYNECARE INTCEED,SUP-2218343,CDM,C1765,HCPCS,0278,RC,,,,both,,,1562.02,1015.31,,,,,,,,,,,,,
BENDING IRON FOR 3.5MM,SUP-2548469,CDM,C1713,HCPCS,0278,RC,,,,both,,,1552.51,1009.13,,,,,,,,,,,,,
DIGITAL SCREW 2.0 X 30MM,SUP-2586643,CDM,C1713,HCPCS,0278,RC,,,,both,,,1357.30,882.24,,,,,,,,,,,,,
ROD EXT FIX L 100 MM DIA11 MM LG CARBON FIBRE MR CONDITIONAL,SUP-2908429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,749.05,486.88,,,,,,,,,,,,,
PLATE BONE L31MM 4 H S STL 1/4 TBLR QTR SLGHT CONCV W/O CLLR,SUP-2186070,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
COMPONENT FEM L7CM RT DSTL HIP POLY REDUC SZ ELLIP SEG ORTH,SUP-2406471,CDM,C1776,CPT,0278,RC,,,,both,,,18905.94,12288.86,,,,,,,,,,,,,
KIT VASC FLTR L11IN SGL CANN SM FLTR EMBOL-X GLDE,SUP-2214498,CDM,C1884,HCPCS,0278,RC,,,,both,,,1440.16,936.10,,,,,,,,,,,,,
WASHER ORTHOPEDIC 3.5 MM FOR 4 MM SCREW,SUP-2398284,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
PLATE BNE RECON 2.8 MM 20 HOLE PT SPEC TI,SUP-2860107,CDM,C1713,HCPCS,0278,RC,,,,both,,,15728.89,10223.78,,,,,,,,,,,,,
ADAPTER LD L 10 CM UPLR RECEPTACLE QUADRIFILAR COIL SIL,SUP-2282472,CDM,C1883,HCPCS,0278,RC,,,,both,,,1384.30,899.79,,,,,,,,,,,,,
INTRODUCER SHTH 14FR L30CM DIA0.038IN CLOSE TOL EXTRUSION,SUP-2355437,CDM,C1894,HCPCS,0272,RC,,,,both,,,57.31,37.25,,,,,,,,,,,,,
LENS INTOCU +10.0 DIOPT L12.5MM DIA5.5MM 5DEG HAPTIC ANG A,SUP-2110304,CDM,V2632,HCPCS,0276,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
GUIDEWIRE ORTH L300MM DIA32MM W CALIB AND QUIK REL FIT FOR,SUP-2377941,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SHELL ACET CLUS H COCR ALLOY 62MM VITALOCK,SUP-2364623,CDM,C1776,CPT,0278,RC,,,,both,,,2892.73,1880.27,,,,,,,,,,,,,
SCREW BNE LAG 12.7X95 MM HIP COMPR TALON,SUP-2391519,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
MESH HERN PROGRIP ANAT 15X15 CM SELF GRIPPING BASE POLYPR,SUP-2752184,CDM,C1781,HCPCS,0278,RC,,,,both,,,724.74,471.08,,,,,,,,,,,,,
SCREW BONE L32MM DIA4MM CANN SH THRD HDLSS MINI-MONSTER,SUP-2320926,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.68,589.34,,,,,,,,,,,,,
HC X-Ray Clavicle,PX-3207300000,CDM,73000,CPT,0320,RC,,,,both,,,1049.00,681.85,,,,,,,,,,,,,
DEVICE TISS FIX L 23 MM DIA 8 MM STRL CITRELOCK XPRESS,SUP-2900540,CDM,C1713,HCPCS,0278,RC,,,,both,,,5127.62,3332.95,,,,,,,,,,,,,
STIMULATOR NERVE CHARGER SYS EON MINI,SUP-2355971,CDM,C1820,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BNE 8 H MTCRPL T SHP,SUP-2389598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
BUR SURG L9CM DIA3MM MTCH HD DMND L BOR MIDAS REX LEGEND,SUP-2284665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.40,245.96,,,,,,,,,,,,,
PLATE BNE TRAP LNG 20 MM GORILLA,SUP-2751129,CDM,C1713,HCPCS,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
INTRODUCER CARD LD PLCMNT STR 50CM LEN 9FR HEMSTAT VLV COR,SUP-2282360,CDM,C1892,HCPCS,0272,RC,,,,both,,,899.80,584.87,,,,,,,,,,,,,
PLATE SPNL L35MM UNIV TI POST LUM STR STD OFFSET BILAT CD,SUP-2293334,CDM,C1713,HCPCS,0278,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
CATHETER DRAINAGE SET 12 FRX15 CM PNEUMOPERICARDIAL FURMAN,SUP-2759780,CDM,C1729,HCPCS,0272,RC,,,,both,,,407.45,264.84,,,,,,,,,,,,,
SHEETING IMPL 0.03X6X8IN REINF SIL SILAS,SUP-2134689,CDM,C1763,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
GUIDEWIRE ORTH SM L160MM DIA0.8MM CO CHROM RDY FOR SURG,SUP-2418951,CDM,C1769,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
BIT DRL STP 3 MMX8 IN NS VERSANAIL,SUP-2486351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 3FR 20CM 1 LUMAN S4153108DGP,SUP-2632861,CDM,C1751,HCPCS,0278,RC,,,,both,,,587.40,381.81,,,,,,,,,,,,,
PACK PROCEDURE SURGICAL 20GA VLV CPM 10K,SUP-2717577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1918.26,1246.87,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE L 110 CM OD 7 FR GUIDEWIRE 0.038 IN,SUP-2170726,CDM,C1894,HCPCS,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
PLATE BNE TWST 3 HOLE,SUP-2481591,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.43,262.88,,,,,,,,,,,,,
STENT BILI L24MM BLLN L25MM DIA7MM CATH 6FR L80CM 0.018IN,SUP-2159030,CDM,C1876,HCPCS,0278,RC,,,,both,,,3975.24,2583.91,,,,,,,,,,,,,
BLADE RTRCTR MED 45MMW X 70MML TTNM SPNL PRNGX5 DARK BLUE LM,SUP-2670391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.71,567.91,,,,,,,,,,,,,
BIT DRILL CANN 11.2 LRG QC,SUP-2718103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1915.34,1244.97,,,,,,,,,,,,,
DEVICE SUTURE ADH RETENTION RIGID HEMI BRIDGE LAYR,SUP-2881029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HEAD FEM OD36MM +0MM 12/14 MTL ON MTL PRI TAPR HIP CO CHROM,SUP-2222058,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
TUBE VENT 0.76 MM 1 MM 2/1.5 MM TINY TEF FLROPLAS 520152,SUP-2535143,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.20,18.98,,,,,,,,,,,,,
SCREW BNE L65MM OD7MM SELF DRL CANN LNG THRD MAXTORQUE,SUP-2400319,CDM,C1713,HCPCS,0278,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
FILLER BNE GRFT L 9 X W 9 X H 9 MM DEMINERALIZED CANC CUBE,SUP-2894885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
WAND ABLAT CROSS 50 DYONICS RFS,SUP-2341117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
BOLT IM L48MM DIA3.9MM HD DIA8MM TI ST LOK HEX RECESS TRCR,SUP-2192202,CDM,C1713,HCPCS,0278,RC,,,,both,,,591.51,384.48,,,,,,,,,,,,,
SCREW BONE POLYAX 6.5MMX45MM,SUP-2311152,CDM,C1713,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
SPLINT WR AD SM FOR 2.5-3IN LT MCP REG FIRM OUTER FAB HND,SUP-2324878,CDM,L3809,HCPCS,0274,RC,,,,both,,,46.19,30.02,,,,,,,,,,,,,
IMPLANT BLGCL TSSUE MTRX 475SQCM 55CMW X 10CML PRCNE INGNL,SUP-2676574,CDM,Q4130,HCPCS,0636,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM SZ 3 CART ARAGONITE,SUP-2913299,CDM,C1763,HCPCS,0278,RC,,,,both,,,24806.00,16123.90,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7511,SUP-2525323,CDM,C1769,HCPCS,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
OXYGENATOR PERFSN BARB CONN SZ 3/8 IN BLD FLO RATE 0.5-4,SUP-2895279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SCREW BONE L12MM OD3.5MM CORT DSTL VOLAR RAD TI POLYAX ST,SUP-2361567,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SCREW MYOMA L7.5IN DOYEN,SUP-2804355,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.98,141.69,,,,,,,,,,,,,
NEPHROMAX CLEAR 10 12755,SUP-2726023,CDM,C1726,HCPCS,0272,RC,,,,both,,,965.52,627.59,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM 0.018 IN L 5 CM NIT MANDREL PLAT COIL,SUP-2823945,CDM,C1769,HCPCS,0272,RC,,,,both,,,113.98,74.09,,,,,,,,,,,,,
PLATE BNE CALCANEAL 2.7X64 MM LT ANGLED STR SS STRL,SUP-2177442,CDM,C1713,HCPCS,0278,RC,,,,both,,,4603.55,2992.31,,,,,,,,,,,,,
PLATE BNE 1.5/2X83X1.5 MM 12 HOLE SS LCP,SUP-2569293,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.48,257.06,,,,,,,,,,,,,
SCREW SPNL G4 POST THORLUM CANN BRK OFF INT HEX SET CDH LEG,SUP-2288455,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
BASEPLATE GLEN 10 DEG SHLDR CNTRL SCREW SUP AUG STRL,SUP-2908903,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
HC Vasc Embolize Occlude Bleed,PX-3613724400,CDM,37244,CPT,0361,RC,,,,outpatient,,,11772.00,7651.80,,,,,,,,,,,,,
SCREW BONE L65MM DIA7MM THRD L16MM S STL CANN,SUP-2183894,CDM,C1713,HCPCS,0278,RC,,,,both,,,949.07,616.90,,,,,,,,,,,,,
INSERT TROCAR FOR PEDCL ACCS NDL STRL DISP,SUP-2910299,CDM,C1776,CPT,0278,RC,,,,both,,,579.02,376.36,,,,,,,,,,,,,
CATHETER EP 7FR L115CM 2-8-2MM SPC TIP 2MM DF CRV ADV COMPR,SUP-2248491,CDM,C1730,HCPCS,0272,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-102358,CDM,2500000003,HCPCS,0250,RC,00264-7635-00,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
CANNULA KIT OBLQ 7.5 CMX3 MM W/ TROCAR,SUP-2774114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,619.96,402.97,,,,,,,,,,,,,
GRAFT HUM TISS L50MM WDG FIBULAR STRUT,SUP-2293970,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SCREW BONE L64MM DIA4.5MM THRD L18MM CORT S STL ST SELF DRL,SUP-2184443,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.83,40.84,,,,,,,,,,,,,
WASHER ORTH DIA7MM S STL,SUP-2122783,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.79,65.51,,,,,,,,,,,,,
CATHETER JET VENT 13G,SUP-2662065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
HC So Triglycerides,PX-3018447866,CDM,84478,CPT,0301,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7MM STR TW REINF SLDE GDS,SUP-2681201,CDM,C1768,CPT,0278,RC,,,,both,,,2189.21,1422.99,,,,,,,,,,,,,
CLAMP L6 MULT PIN POS,SUP-2188488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
BIT DRL OCCIPITOCERVICAL UP THOR NAVIGATED INFIN,SUP-2421075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1609.03,1045.87,,,,,,,,,,,,,
CATHETER CV DL 6 FR PASV VLV MAX BARR NURSING KT BIOFLO,SUP-2734868,CDM,C1751,HCPCS,0278,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
HEAD FEM MOD 0+ MM 22 MM HIP MTRX,SUP-2435185,CDM,C1776,CPT,0278,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
GRAFT VASC STR THN WALL N RNGD EPTFE SM BEAD 8MM DIA 80CM,SUP-2128212,CDM,C1768,CPT,0278,RC,,,,both,,,9659.14,6278.44,,,,,,,,,,,,,
BIT DRL CALIB XLN 4.3 MM VAR THRD STRL,SUP-2789174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.02,436.16,,,,,,,,,,,,,
CEMENT BONE POLYMETHYLMETHACRYLATE,SUP-2351722,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309714000,CDM,97140,CPT,0430,RC,,,GP|CQ,both,,,194.00,126.10,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW AORTOILIAC ART BLD TYP A B AB O STRL,SUP-2884049,CDM,C1768,CPT,0278,RC,,,,both,,,74195.06,48226.79,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J3490,HCPCS,0250,RC,00338-0043-04,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
PLATE BNE SM W11XL59MM THK34MM 4 H BILAT TI RIG NEUT LOK,SUP-2190775,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.64,546.42,,,,,,,,,,,,,
GRAFT BNE 0.8 CC PREFILLED PRO OSTEON 200R 2RGS05,SUP-2685766,CDM,C1713,HCPCS,0278,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
CENTRALIZER STEM REV LG 12/14 16 MM DSTL HIP TAPR SPECTRON,SUP-2434612,CDM,C1776,CPT,0278,RC,,,,both,,,298.93,194.30,,,,,,,,,,,,,
FERROUS SULFATE 300 (60 FE) MG/5ML PO SOLN,RX-165426,CDM,6370000000,HCPCS,0637,RC,58526-0005-57,NDC,,both,5,ML,29.50,19.17,,,,,,,,,,,,,
OBTURATOR SHTH 5FRX26CM LUERLOCK,SUP-2355474,CDM,C1894,HCPCS,0272,RC,,,,both,,,17.27,11.23,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX6 MM INDWL ESOPH FLANGE BLOM-SINGER,SUP-2242390,CDM,L8509,HCPCS,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
PEG BONE FXTN L20MM D2.2MM DST VOLAR RDL SMOOTH LOK CRSSLCK,SUP-2478013,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC Convert Nephrostomy Catheter,PX-3615043400,CDM,50434,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 7.01-8.0 MCI STRL ADVANTAGE 2029HLS1] ISOAID LLC],SUP-2247278,CDM,C2642,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BIT DRL THRD L10MM DIA5 73MM FOR SLIPPED CAPITAL FEM,SUP-2179056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1337.89,869.63,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTLAT DISTAL HUMERUS LAT SUPPORT 9H LT,SUP-2549691,CDM,C1713,HCPCS,0278,RC,,,,both,,,4351.13,2828.23,,,,,,,,,,,,,
SLING URETH W2XL10CM PORCINE CLLGN SURGISIS BIODESIGN,SUP-2168973,CDM,C1763,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
KIT GASTSTMY TUBE DIA20FR PEG SYS SAFT PUSH TECH ENTAKE,SUP-2167137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CATHETER SHUNT PERI L27CM OD15.5FR FOR DENV ASCITES,SUP-2133692,CDM,C1729,HCPCS,0272,RC,,,,both,,,75.99,49.39,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6 MM STR TW SLDE GDS,SUP-2475168,CDM,C1768,CPT,0278,RC,,,,both,,,3119.12,2027.43,,,,,,,,,,,,,
CATHETER ETER GUID L100CM OD65FR COR AL10 SHEATHLESS EAUCATHETER,SUP-2123837,CDM,C1725,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,0636,RC,76179-0025-01,NDC,,both,50,ML,276.00,179.40,,,,,,,,,,,,,
HC Perq Dev Breast 1st Strtctc,PX-3611928300,CDM,19283,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE TIB 36 MM POST 5 HOLE Y SHP,SUP-2865069,CDM,C1713,HCPCS,0278,RC,,,,both,,,4311.22,2802.29,,,,,,,,,,,,,
RETAINER IMPL NOSTRIL 3,SUP-2352032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
PLATE BONE W27XL44MM 5 H DSTL TIB TI A FOR 2.7/3.5/4MM SCR,SUP-2225361,CDM,C1713,HCPCS,0278,RC,,,,both,,,2019.65,1312.77,,,,,,,,,,,,,
SCREW BONE CANN POLYAX THRESHOLD PEDICULAR FIX 5.5 MMX50 MM,SUP-2354664,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + L,SUP-2195533,CDM,L1830,CPT,0272,RC,,,,both,,,61.32,39.86,,,,,,,,,,,,,
SCREW BONE L51MM OD3.5MM 6 CRUCFRM RECESS COARSE THRD WDRUFF,SUP-2362303,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.49,15.92,,,,,,,,,,,,,
SCREW IM LCK DSTL 6.28MM 20MM FT STRL F/HOWMEDICA OSTEONICS,SUP-2370997,CDM,C1713,HCPCS,0278,RC,,,,both,,,617.64,401.47,,,,,,,,,,,,,
SUPPORT WR M AD LT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324891,CDM,L3931,HCPCS,0274,RC,,,,both,,,48.92,31.80,,,,,,,,,,,,,
STENT URET DBL PGTL 7 FRX24 CM UNCOATED CLASSIC OPN END NYL,SUP-2312735,CDM,C2617,HCPCS,0278,RC,,,,both,,,166.70,108.35,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE 1.5X1.5CM,SUP-2307621,CDM,Q4128,HCPCS,0636,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
PLATE BNE INFRAPECTINEAL LG LT QUADRILATERAL SURF STRL PRO,SUP-2536009,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
PLATE BNE 2.7X82 MM 9 HOLE SS LC-DCP,SUP-2569218,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.04,205.43,,,,,,,,,,,,,
GRAFT DURAGEN W3XL3IN REABSORBABLE MTRX EACH=5 UNITS,SUP-2922516,CDM,C1763,HCPCS,0278,RC,,,,both,,,1464.03,951.62,,,,,,,,,,,,,
SCREW BONE 4MM DIA 60MML TTNM CRTCL HXGNL HEAD PRTLLY THRDD,SUP-2588280,CDM,C1713,HCPCS,0278,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
SET CATH PERITONEAL DIALYSI V SER BASIC 15FR DIA MC20VS43RS,SUP-2633016,CDM,C1752,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SHUNT SURG PLEUR EFFUS DENV,SUP-2133700,CDM,C1889,HCPCS,0278,RC,,,,both,,,5007.26,3254.72,,,,,,,,,,,,,
OXYCODONE HCL 10 MG PO TABS,RX-87795,CDM,6370000000,HCPCS,0637,RC,68084-0968-01,NDC,,both,1,UN,3.30,2.14,,,,,,,,,,,,,
DISTRACTOR TIB L L330MM DIA14MM THRD SPINDLE,SUP-2188634,CDM,C1713,HCPCS,0278,RC,,,,both,,,1487.39,966.80,,,,,,,,,,,,,
GRAFT BNE SUB W10XL15MM TRICORT ILIUM CREST BLK FRZ DRY,SUP-2293824,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
TIP ASPIR SPETZLER MIC UNIV 1.2X2 MMX4 IN OPN ANGLE SONOPET,SUP-2791038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2020.31,1313.20,,,,,,,,,,,,,
ANCHOR SFT TISS OPN ADJ CORT 4 PNT KNOTLESS FIX SYS,SUP-2121400,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
HC Angio Int Mammary S&I,PX-3217575600,CDM,75756,CPT,0321,RC,,,,both,,,6654.00,4325.10,,,,,,,,,,,,,
HC Immunoglobulin Light Chains Free Each,PX-3018352100,CDM,83521,CPT,0301,RC,,,,both,,,88.00,57.20,,,,,,,,,,,,,
SHEATH GUID R2P DESTINATION SLENDER L124CM 119CM 6FR 0.038IN,SUP-2385124,CDM,C1894,HCPCS,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
CAGE SPNL H32MM DIA12MM ANT THORLUM TI RND MESH INTBDY FUS,SUP-2193219,CDM,C1889,HCPCS,0278,RC,,,,both,,,9018.08,5861.75,,,,,,,,,,,,,
BIT DRL DIA2.5MM,SUP-2175006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2.5MM LOK SMOOTH DRL TIP FLX THRD FOR,SUP-2187225,CDM,C1769,HCPCS,0272,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
PLATE BNE L277MM 10 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186060,CDM,C1713,HCPCS,0278,RC,,,,both,,,4836.54,3143.75,,,,,,,,,,,,,
BUR SURG BUD DMND N FLUT,SUP-2227829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46.63,30.31,,,,,,,,,,,,,
PUMP INFUS 100ML 2ML/HR PAINPMP,SUP-2361459,CDM,C2626,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CONNECTOR SPNL STD POST S STL FIX SLT ANG XLNK FOR 6.35MM,SUP-2255708,CDM,C1713,HCPCS,0278,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
KIT CATH AD L40CM DIA14.5FR 1.9ML SIL DBL LUMN CVD SYMMETRIC,SUP-2174231,CDM,C1750,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
PROBE ACTIVE FIBER PTEYE,SUP-2716312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1822.93,1184.90,,,,,,,,,,,,,
BUTTON FIX OVL MED 11X18 MM 7.5 MM PEG STRL XTENDOBUTTON LTX,SUP-2877815,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 40 CM DIA 6 FR GUIDEWIRE 0.038 IN,SUP-2168449,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.27,104.18,,,,,,,,,,,,,
COMPONENT KNEE 7L PATELLAR FEM RESTORIS MCK,SUP-2265747,CDM,C1776,CPT,0278,RC,,,,both,,,8849.09,5751.91,,,,,,,,,,,,,
AUGMENT FEM 3.5MM KNEE TI FLNG OSS,SUP-2405803,CDM,C1776,CPT,0278,RC,,,,both,,,2218.41,1441.97,,,,,,,,,,,,,
SHUNT LP L87CM OD15MM ID07MM OD20GA BLNT NDL CSF LO PRSS,SUP-2277930,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2205.72,1433.72,,,,,,,,,,,,,
PLATE BNE SM W11XL293MM THK34MM 22 H BILAT TI RIG NEUT LOK,SUP-2190800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2492.28,1619.98,,,,,,,,,,,,,
HC So1 Serotonin,PX-3018426067,CDM,84260,CPT,0301,RC,,,,inpatient,,,436.00,283.40,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 100 CM 5 FR 0.035 IN HN2 BRAIDED,SUP-2116844,CDM,C1887,HCPCS,0272,RC,,,,both,,,124.66,81.03,,,,,,,,,,,,,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125560,CDM,J7168,HCPCS,0636,RC,63833-0387-02,NDC,,both,1,UN,8791.00,5714.15,,,,,,,,,,,,,
SET INTRO SUPER SHTH L 5 CM DIA 6.5 FR NIT WIRE TEARWY,SUP-2627269,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.58,19.88,,,,,,,,,,,,,
CATHETER GUID CXI L 135 CM DIA 2.6 FR 0.018 IN SS STR TIP,SUP-2638642,CDM,C1887,HCPCS,0272,RC,,,,both,,,690.77,449.00,,,,,,,,,,,,,
CATHETER CV KT PEDIATRIC 2 FRX9 CM 24 GA SINGLE LUMEN,SUP-2763318,CDM,C1751,HCPCS,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L143CM BAL L20MM DIA3.25MM 14ATM BURST,SUP-2103632,CDM,C1725,HCPCS,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
VEST TRAC L112CM DIA76MM SYNTH LNR TALL COMPATIBLE ADV,SUP-2255764,CDM,L0810,HCPCS,0272,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
NEBIVOLOL HCL 5 MG PO TABS,RX-89284,CDM,6370000000,HCPCS,0637,RC,60687-0641-11,NDC,,both,1,UN,13.20,8.58,,,,,,,,,,,,,
PLATE PELVIC CVD 6 HOLE R108,SUP-2473598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
HC Carboxyhemoglobin Quantitative,PX-3018237500,CDM,82375,CPT,0301,RC,,,,inpatient,,,120.00,78.00,,,,,,,,,,,,,
CEMENT 40.8ML 12 SYR CD 3 SZ LIQ DURELON,SUP-2238645,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.79,239.06,,,,,,,,,,,,,
CAGE SPNL SHIM 7X33 MM LORDTC TI VERSION C FLAREHAWK 9,SUP-2871237,CDM,C1889,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CATHETER GUID VERIPATH L 50 CM OD 7 FR ID 0.078 IN INNR PTFE,SUP-2101521,CDM,C1887,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SPLINT WR ADULTXL LT THMB NEOPRNE TRIOXON LNR FIRM STRP ON,SUP-2326120,CDM,L3908,HCPCS,0274,RC,,,,both,,,138.00,89.70,,,,,,,,,,,,,
SCREW BNE NLCK 2.7 X20 MM T10 DRV FT STRL VARIAX 2,SUP-2457403,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 5FR 45CML SIL RADPQ SHERLOCK MAG 9827507,SUP-2632709,CDM,C1751,HCPCS,0278,RC,,,,both,,,493.61,320.85,,,,,,,,,,,,,
BLADE SHAVER CLOSED STD TYP A,SUP-2648982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
STENT ENDOPROS L10CM DIA8MM CATH 8FR L120CM BLLN DIA8MM,SUP-2396566,CDM,C1874,HCPCS,0278,RC,,,,both,,,10927.20,7102.68,,,,,,,,,,,,,
GRAFT BIO TISS L5CMXW3.5CM PORCINE CLLGN 4 LAYR GEN,SUP-2168861,CDM,C1781,HCPCS,0278,RC,,,,both,,,959.43,623.63,,,,,,,,,,,,,
GRAFT OPHTH SZ B THK50-100UM W1.5XL2CM CONJUNCTIVOCHALASIS,SUP-2135256,CDM,V2790,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
COLLAR CERV M FIRM DENS AD CNTOUR HK AND LOOP CLSR W COT CVR,SUP-2276592,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.63,4.31,,,,,,,,,,,,,
STAPLE BNE FIX L 12 X W 12 MM THK 12 MM NIT GREAT WHT STR,SUP-2881087,CDM,C1713,HCPCS,0278,RC,,,,both,,,3629.84,2359.40,,,,,,,,,,,,,
JACKET ORTHOT CUST BODY MOLD TO PT,SUP-2435593,CDM,L1300,HCPCS,0272,RC,,,,both,,,4879.40,3171.61,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 4-7 MM EPTFE XLN TAPR TW,SUP-2525473,CDM,C1768,CPT,0278,RC,,,,both,,,2669.44,1735.14,,,,,,,,,,,,,
SET PROC AUTO 3 SENS TECHNOLOGY FOR APPL TO ORTH PRP SITE,SUP-2120729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SHUNT KIT FLO CTRL SM SHUNT CONTOURED MED PRESSURE,SUP-2631350,CDM,C1729,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH L 115 CM BER TIP HTORQ,SUP-2865163,CDM,C1757,HCPCS,0272,RC,,,,both,,,30677.80,19940.57,,,,,,,,,,,,,
ANCHOR SUT OD5MM PLLA ABSRB TWO SZ 2 PRELD DURABRAID NDL,SUP-2341653,CDM,C1713,HCPCS,0278,RC,,,,both,,,1134.17,737.21,,,,,,,,,,,,,
WAND ARTHSCP DIA3.75MM TIP DIA3MM 50DEG W/ INTEGR FNGR SWCH,SUP-2342011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BIT DRL L190MM DIA10MM ST TI CANN QUIK CPL W/O STP,SUP-2420744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1743.39,1133.20,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENESTRATED ADULT 8MM 4 UNCUFFED ADAPTER O,SUP-2793418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.38,272.60,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE MED PEDIATRIC IMPL YEL DP,SUP-2666617,CDM,C1889,HCPCS,0278,RC,,,,both,,,2367.12,1538.63,,,,,,,,,,,,,
PASSER SUT L162MM CANN DIA6MM BITE D18MM MINI SELF CAPTURE 224038] SMITH AND NEPHEW ENDOSCOPY],SUP-2341371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.71,530.21,,,,,,,,,,,,,
BIT DRL 4.2 MM DSTL,SUP-2644797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1692.05,1099.83,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 10 CM FEM VEIN BLD TYP A B AB O,SUP-2884018,CDM,C1768,CPT,0278,RC,,,,both,,,17047.06,11080.59,,,,,,,,,,,,,
"HC New Pt, E/M Level 2",PX-5109920200,CDM,99202,CPT,0510,RC,,,,outpatient,,,296.00,192.40,,,,,,,,,,,,,
HC Electrolyte Panel,PX-3018005100,CDM,80051,CPT,0301,RC,,,,outpatient,,,317.00,206.05,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 110 CM 5 FR 5 DECAPOLAR,SUP-2480413,CDM,C1730,HCPCS,0272,RC,,,,both,,,578.80,376.22,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM SZ 5 CART ARAGONITE,SUP-2913176,CDM,C1763,HCPCS,0278,RC,,,,both,,,26219.00,17042.35,,,,,,,,,,,,,
PLATE CNDYL 1.5MM 2H HD 6H SHFT TI STRL VAL,SUP-2546893,CDM,C1713,HCPCS,0278,RC,,,,both,,,1797.84,1168.60,,,,,,,,,,,,,
REAMER SURG DIA6.6MM FOR INTOSS FIX IOFIX PLUSX-POST,SUP-2223758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
BLADE IM L75MM DIA12.5MM ST TI CANN FR CUT EDGE SPRL FOR RG,SUP-2180044,CDM,C1713,HCPCS,0278,RC,,,,both,,,1719.15,1117.45,,,,,,,,,,,,,
PLATE BONE THK1MM 4 H MAND SLV TI STR FOR 2/2.3MM SCR SYS,SUP-2136770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1453.82,944.98,,,,,,,,,,,,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,0636,RC,67457-0220-05,NDC,,both,0.5,ML,698.20,453.83,,,,,,,,,,,,,
COUPLER ANAS MICROVASCULAR 1MM GRY,SUP-2419427,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
GRAFT PROC FASC LATA SCLER TUTOPLAST ALLGRFT 0.6X1.0CM,SUP-2247192,CDM,L8610,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
HC Cart-T Therapy Prepj Bld Drv T Lmphcyt F/Trans,PX-8723822600,CDM,38226,CPT,0872,RC,,,,inpatient,,,1184.00,769.60,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DEMIN BNE MTRX PTTY,SUP-2306997,CDM,C9359,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
HC Declotting Central Vad,PX-3613659300,CDM,36593,CPT,0361,RC,,,,both,,,1120.00,728.00,,,,,,,,,,,,,
ANCHOR SUT 35 MM DIA #2 SUT HERCULINE,SUP-2166907,CDM,C1713,HCPCS,0278,RC,,,,both,,,954.75,620.59,,,,,,,,,,,,,
PIN EXT FIX DIA 4/5 MM HALF CAP,SUP-2898418,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 4 FRX7 CM 51 IN KT SPIN-LOCK ACCEL,SUP-2659255,CDM,C1729,HCPCS,0272,RC,,,,both,,,129.15,83.95,,,,,,,,,,,,,
PLATE BNE L370MM BLDE W48XL25MM 95DEG 22 H NONSTERILE HIP S,SUP-2186775,CDM,C1713,HCPCS,0278,RC,,,,both,,,4524.27,2940.78,,,,,,,,,,,,,
CANNULATED HIP PIN 115MM,SUP-2818076,CDM,C1713,HCPCS,0278,RC,,,,both,,,2421.41,1573.92,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA12MM BLDELSS CANN DIL W/ RADIALLY,SUP-2283344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.34,313.52,,,,,,,,,,,,,
HC Removal FB Foot Subcutaneous,PX-4502819000,CDM,28190,CPT,0450,RC,,,,both,,,730.00,474.50,,,,,,,,,,,,,
PIN EXT FIX L80MM OD25MM THRD L15MM HALF FOR CORETRAK FIX,SUP-2400675,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
"HC So West Nile Ab, Igm",PX-3028678866,CDM,86788,CPT,0302,RC,,,,inpatient,,,49.00,31.85,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH REMOVABLE PREMOLDED,SUP-2435705,CDM,L3050,HCPCS,0274,RC,,,,both,,,133.26,86.62,,,,,,,,,,,,,
RESERVOIR 20MM 15 WITH SHUNT ASSISTANT HYDRO VORKAMMER PROGA,SUP-2821841,CDM,C1889,HCPCS,0278,RC,,,,both,,,7988.51,5192.53,,,,,,,,,,,,,
INLAY SPNL LG 10 MM W/ TANTALUM MARKER POLYETH PRODISC,SUP-2163210,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT BONE SUB 2.5ML PUTTY DYNAGRFT,SUP-2247315,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
KIT PICC 4FR L50CM PRSS INJ SGL LUMN BLU FLEXTIP W,SUP-2383370,CDM,C1751,HCPCS,0278,RC,,,,both,,,437.84,284.60,,,,,,,,,,,,,
CONNECTOR ROD AND SCR SM FOR POST SCRS TI TSRH-3D 5.5MM DIA,SUP-2289994,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
CATHETER INFUSION FASTRACKER 325 L 135 CM OD PROX/DSTL,SUP-2147320,CDM,C1887,HCPCS,0272,RC,,,,both,,,1288.50,837.52,,,,,,,,,,,,,
GRAFT BIO TISS W2XL4CM THK02 04MM ACELLULAR DERM MTRX ULT,SUP-2307505,CDM,Q4128,HCPCS,0636,RC,,,,both,,,602.53,391.64,,,,,,,,,,,,,
ADAPTER LD L 10 CM SIL INSUL BPLR LV1/IS1 CONN QUADRIFILAR,SUP-2616246,CDM,C1883,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
SHEET WND 130X200X0.02 MM BIORESORBABLE PROTCT POLYLACTIDE,SUP-2175201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
SCREWDRIVER SURG 3X4MM OVR DRL CANN TI,SUP-2244047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.21,479.19,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES PATTEN BTM TYP,SUP-2435606,CDM,L1755,HCPCS,0274,RC,,,,both,,,5069.15,3294.95,,,,,,,,,,,,,
KIT INTRO L 14CM DIA 9FR GUIDEWIRE L 50 CM DIA 0.038 IN PTFE,SUP-2125277,CDM,C1892,HCPCS,0272,RC,,,,both,,,103.34,67.17,,,,,,,,,,,,,
PATCH CV HEMSHLD PLAT FINESSE L 76 X W 8 MM THK 0.36 MM,SUP-2227665,CDM,C1768,CPT,0278,RC,,,,both,,,392.34,255.02,,,,,,,,,,,,,
LOOP SUT DIA8MM GUID ROD BRAID FOR G-FORCE TENODESIS,SUP-2399124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
IMPLANT SHLDR TOT W/PERFO,SUP-2388594,CDM,C1776,CPT,0278,RC,,,,both,,,24963.00,16225.95,,,,,,,,,,,,,
DISC SPNL 6 DEG 18X15 MM ENDPLATE ASMBLY ANGLED SECURE-C,SUP-2602758,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
DRILL TWST L 70 MM DIA2.2 MM STP 12 MM TEMPOROMANDIBULAR JT,SUP-2934179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SNARE ENDOSCP MUCOSECTOMY XL 1.5X2.5 CM 7 FR 11-14 MM DUETTE,SUP-2737290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
ELECTRODE ELECSURG CUT LOOP LNG 24 FR,SUP-2332863,CDM,C1713,HCPCS,0278,RC,,,,both,,,396.17,257.51,,,,,,,,,,,,,
SCREW BNE AD AND PED L33MM DIA32MM HD DIA35MM CANC TI,SUP-2200774,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
STEM HUM L120MM DIA9MM UNIV DST SHLDR TI PRI REV CEM FOR UP,SUP-2372852,CDM,C1776,CPT,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
KIT DRNGE EMGCY VLV REPL INCLUDE CAP SLDE CLMP SCIS BLU,SUP-2133385,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
CATHETER CARD ABLATION FREEZOR MAX L 90 CM DIA 9 FR TIP 8 MM,SUP-2281879,CDM,C1733,HCPCS,0272,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PLATE BNE T MINI,SUP-2206143,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
TRIAL SURG 20X75MM BIOFOAM,SUP-2397848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 26 CM DIA 6 FR POLYUR AQ BRAIDED,SUP-2170688,CDM,C2617,HCPCS,0278,RC,,,,both,,,498.95,324.32,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.093X9 IN RND END SS NS STEINMANN,SUP-2791594,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.87,7.72,,,,,,,,,,,,,
BIT DRL CANN LG 6/10X435 MM CERV QC CALIB STP SS NS,SUP-2188234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1755.29,1140.94,,,,,,,,,,,,,
CANNULA SIZE 11 MM,SUP-2801027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1024.80,666.12,,,,,,,,,,,,,
KIT INT FIX ACL GUID PIN K WIRE DRL BIT SUT LOOP PASS BNE,SUP-2212934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
TUBING HEMCONC L36IN DIA0.25IN DHF W/ CONN,SUP-2352706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
RING EXT FIX FULL 240 MM ALUM NS MAXFRAME,SUP-2799530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3540.07,2301.05,,,,,,,,,,,,,
HC Rad Guide for Perc Drain Tube,PX-3207598900,CDM,75989,CPT,0320,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 30X30X1.5 MM POROUS POLYETHYLENE ST,SUP-2837798,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.83,1261.54,,,,,,,,,,,,,
SCREW BONE L5MM OD1.8MM ORAL MAXILLOFACIAL TI EMER MIC,SUP-2262606,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.74,74.58,,,,,,,,,,,,,
PROSTHESIS OTO L8MM DIA0.8-1MM POLYCEL TOT OVL HD SHEEHY,SUP-2284068,CDM,L8613,CPT,0278,RC,,,,both,,,739.53,480.69,,,,,,,,,,,,,
PLATE BNE FIBULAR 86 MM LT LAT DSTL 4 HOLE TI NS,SUP-2180876,CDM,C1713,HCPCS,0278,RC,,,,both,,,2523.62,1640.35,,,,,,,,,,,,,
HC So Muscle-Specific Kinase Antibody,PX-3028636666,CDM,86366,CPT,0302,RC,,,,both,,,513.00,333.45,,,,,,,,,,,,,
IMPLANT HUM TISS L 8 X W 4 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905488,CDM,Q4184,HCPCS,0636,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
GRAFT ENDOVASC L113MM PROX L59MM DSTL L54MM OD28X12MM SHTH,SUP-2171095,CDM,C1874,HCPCS,0278,RC,,,,both,,,21000.32,13650.21,,,,,,,,,,,,,
EGR XPRESS DISPOSABLE,SUP-2465174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC MICROINTRODU 5904270,SUP-2632975,CDM,C1750,HCPCS,0278,RC,,,,both,,,1803.46,1172.25,,,,,,,,,,,,,
BIT DRL STP UNIT 48 MM DYN AX FIX SYS SET,SUP-2644553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.97,55.23,,,,,,,,,,,,,
GENII CONST ART ISRT SZ5-6 9MM,SUP-2822847,CDM,C1776,CPT,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
CONNECTOR SPNL L20MM CROSS REVERE,SUP-2229619,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
ELECTRODE EMG W2XL12MM SUBDERM GRN WHT S STL NDL 2 CHN PR,SUP-2284323,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.97,225.53,,,,,,,,,,,,,
SET PLEURAL PNEUMOPERICARDIAL DRAINAGE FUHRMAN,SUP-2759700,CDM,C1729,HCPCS,0272,RC,,,,both,,,462.84,300.85,,,,,,,,,,,,,
PLATE BNE W10.2XL260MM THK2.7MM 20 H BILAT S STL STR LO,SUP-2186205,CDM,C1713,HCPCS,0278,RC,,,,both,,,2419.75,1572.84,,,,,,,,,,,,,
NEEDLE ASPIR 19GA FLX L2.8MM SHTH DIA1.73MM FN ENDO ULT SND,SUP-2141503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1340.34,871.22,,,,,,,,,,,,,
SNARE ENDOSCP 25 MMX230 CM POLYP BARB LOOP SD-16U-1 REPL,SUP-2467334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.51,545.03,,,,,,,,,,,,,
STENT BILI SYM L 40 MM DIA 7 FR CATH L 110 CM DIA 6 MM NIT,SUP-2141180,CDM,C1876,HCPCS,0278,RC,,,,both,,,3723.41,2420.22,,,,,,,,,,,,,
CATHETER DIL BAL 20.0MMX4.5CMX100CM Z MED II,SUP-2125228,CDM,C1725,HCPCS,0272,RC,,,,both,,,2344.42,1523.87,,,,,,,,,,,,,
BLADE RTRCTR MRDNG LG 2INW X 3 34NL TTNM F  UNVRSL RING UL,SUP-2676582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1092.19,709.92,,,,,,,,,,,,,
SHANK SPNL SCR 4.5MMX55MM RELINE MAS MOD,SUP-2310255,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
STENT ESOPH AGILE L 97 MM DIA18 MM PROX/DSTL FLARE,SUP-2745387,CDM,C1874,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
PLATE BUR H L DIA18.5MM 5 H TI BENT W/O TAB NONCOMPRESSION,SUP-2136516,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA 22 MM L 15 CM 10 MM PRECRV,SUP-2894632,CDM,C1889,HCPCS,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
PLATE BNE L42MM THK1.3MM 5X2 H LOK COMPR GRID TRAP BILAT,SUP-2267949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1969.41,1280.12,,,,,,,,,,,,,
PIN FIX STD LCK STRL IMP FRELOK,SUP-2197721,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.42,129.62,,,,,,,,,,,,,
STENT PERIPH EXPRESS SD MR L 15 MM DIA 5 MM CATH L 90 CM,SUP-2142389,CDM,C1876,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
DRILL W/QC 2.0MM,SUP-2841805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,319.81,207.88,,,,,,,,,,,,,
SCREW BONE L8MM DIA2MM HND VAR ANG LCK FLOWERCUBE,SUP-2225440,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.97,243.08,,,,,,,,,,,,,
LINER ACET OD68MM ID36MM +4MM OFFSET 10DEG HIP MARATHON,SUP-2250477,CDM,C1776,CPT,0278,RC,,,,both,,,5105.64,3318.67,,,,,,,,,,,,,
HALOPERIDOL DECANOATE 50 MG/ML IM SOLN,RX-10163,CDM,J1631,HCPCS,0636,RC,70069-0866-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BNE PASTE 3 CC SYR DBM ORTHOBLAST II,SUP-2641747,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT BNE GRAN 15 CC,SUP-2861515,CDM,C1713,HCPCS,0278,RC,,,,both,,,2762.01,1795.31,,,,,,,,,,,,,
SCREW INTRF CANN 7X40 MM 2 MM BLNT THREADS ENLARGED HD RCI,SUP-2877906,CDM,C1713,HCPCS,0278,RC,,,,both,,,511.04,332.18,,,,,,,,,,,,,
BLADE RETRACTOR THERAPON CLAY COLLEY 40X100 MM SET ULTRA,SUP-2464698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2161.86,1405.21,,,,,,,,,,,,,
CLAMP SURG OFFSET CONN 6.35X100 MM REVERE,SUP-2584684,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 6 HOLE,SUP-2518362,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.035IN TAPR 10CM FLPY TIP 3CM RAD7.5MM,SUP-2167631,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.86,27.21,,,,,,,,,,,,,
ANCHOR SUT L14.7MM DIA5.5MM PEEK W/ 3 SZ 2 FIBERWIRE CRKSCR,SUP-2121566,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
COLLAR CERV PED 3IN 16IN M HEADMASTER,SUP-2324112,CDM,L0180,HCPCS,0274,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
KNIFE SURG VON GRAEFE 4 5 IN CATRCT,SUP-2464951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
"HC Plmt Nephrostomy Catheter,Perc|SEPARATE PRACTITIONER|LEFT SIDE",PX-3615043200,CDM,50432,CPT,0361,RC,,,XP|LT,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE SPNL L20MM ANT CERV LEV 1 SONOMA,SUP-2244669,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.03,29.92,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X0.3 MM CONTOURED FOR SCREW TI NS LF,SUP-2476448,CDM,C1713,HCPCS,0278,RC,,,,both,,,3059.84,1988.90,,,,,,,,,,,,,
BLADE RETRACTOR CASPAR 23MMW X 50MMD LATERAL TOOTHED ULTRA,SUP-2676423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.14,367.34,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 20MM STRAIGHT 201605,SUP-2844586,CDM,C1889,HCPCS,0278,RC,,,,both,,,820.48,533.31,,,,,,,,,,,,,
BIT DRILL SURG DIA 5.5/4.75 MM STRL REUSE ALPHAVENT OMEGA,SUP-2906519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
SET BX NDL 16GA L15CM INTRO L22CM VERT BNE DMND TIP REM HUB,SUP-2168190,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.53,322.74,,,,,,,,,,,,,
SYRINGE BONE GRFT PRECIS MX L,SUP-2402790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
TWISTER WIRE CORWIN 6 IN SERRATED JAW PADGETT,SUP-2473332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1293.05,840.48,,,,,,,,,,,,,
COOLCUT 45 BALL ELECTRODE SJ,SUP-2817908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 15 MM IL CREST,SUP-2867100,CDM,C1762,CPT,0278,RC,,,,both,,,4295.52,2792.09,,,,,,,,,,,,,
KIT INTRO VSI L 30 CM DIA 5 FR GUIDEWIRE L 80 CM DIA 0.018,SUP-2383169,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER PERITONEAL OPN END 91 CM FULL BA W/ SLT,SUP-2851309,CDM,C1729,HCPCS,0272,RC,,,,both,,,475.55,309.11,,,,,,,,,,,,,
PLATE BNE LCK UNIV 2.3X1.5 MM THOR RIB 14 HOLE LEVEL 1,SUP-2869213,CDM,C1713,HCPCS,0278,RC,,,,both,,,4417.98,2871.69,,,,,,,,,,,,,
BOOT TRAC AD UNIV LEG FELT CONVOLUTED FOAM LNR FULL FT OPN,SUP-2194994,CDM,L4398,HCPCS,0272,RC,,,,both,,,59.25,38.51,,,,,,,,,,,,,
HC Insert Bladder Catheter Non-Indwelling,PX-4505170100,CDM,51701,CPT,0450,RC,,,,both,,,204.00,132.60,,,,,,,,,,,,,
COIL EMB L25CM OD0.020IN LOOP OD9MM STD NIT COMPLX FRME,SUP-2323368,CDM,C1889,HCPCS,0278,RC,,,,both,,,6933.12,4506.53,,,,,,,,,,,,,
SET CATH CATH L 15 CM DIA 5.5 FR GUIDEWIRE 0.018 IN NDL L 7,SUP-2884239,CDM,C1751,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
HC Remove Tun Cath Vad W/Port,PX-3613659000,CDM,36590,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW BONE L6MM THRD DIA2MM HD DIA3MM COR DIA1.3MM PITCH,SUP-2349226,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.86,126.01,,,,,,,,,,,,,
GUIDEWIRE ORTH L100MM DIA3MM BALL TIP FOR S2 IM NAIL,SUP-2368573,CDM,C1769,HCPCS,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
COMPONENT FEM CEM 15 DEG STD UNISX LT PROX KNEE CR STEMLESS,SUP-2376507,CDM,C1776,CPT,0278,RC,,,,both,,,12971.34,8431.37,,,,,,,,,,,,,
ANCHOR SUT W/ ORTHOCORD SZ 3-0 L18IN COMP BRAID V-4 L5MM,SUP-2249375,CDM,C1713,HCPCS,0278,RC,,,,both,,,3055.22,1985.89,,,,,,,,,,,,,
PIN PASS SPADE TIP 3MM STRL,SUP-2341131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
SYSTEM CPAP PORTABLE MACH LIGHTWEIGHT Z1,SUP-2240643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 5 HOLES/156MM/LEFT-STERILE,SUP-2549448,CDM,C1713,HCPCS,0278,RC,,,,both,,,5169.54,3360.20,,,,,,,,,,,,,
TROCAR SURG LNG ENTRY PORTAL VERSANAIL,SUP-2412786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1406.72,914.37,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 5/64X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150468,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.72,8.92,,,,,,,,,,,,,
DRILL SURG HUDSON LUG PATHWY,SUP-2453507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
SCREW BNE L22MM THRD 3.5MM HD 4.5MM TI LNG THRD CANN HDLESS,SUP-2389524,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
SCREW EXT FIX L14MM FOR DISTRCTN,SUP-2359062,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
RECON PLATE 14X166MM 3.5MM,SUP-2818476,CDM,C1713,HCPCS,0278,RC,,,,both,,,4644.85,3019.15,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL TIP 14 FRX33 CM W/ TAL PALINDROMIC,SUP-2174221,CDM,C1750,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW IM HEX DIA 3.5 MM COMPR SET STRL TRIGEN MAX,SUP-2931570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
AXLE TIB CHROM ALLOY FOR ORTH SALV SYS TOT FINN,SUP-2406070,CDM,C1776,CPT,0278,RC,,,,both,,,1015.95,660.37,,,,,,,,,,,,,
BRACE KNEE OFF THE SHLF W ACCUTRAC TECHNOLOGY STD PCL MOD L,SUP-2319280,CDM,L1810,HCPCS,0272,RC,,,,both,,,1125.94,731.86,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA10 MM SIDE BRANCH L 10/10/10,SUP-2894597,CDM,C1768,CPT,0278,RC,,,,both,,,7768.36,5049.43,,,,,,,,,,,,,
DRIVER SURG SCR ADJ TORQ,SUP-2328121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
STENT CAR ART 10MM DIA 30MML .018 WIRE SZ NIT,SUP-2158978,CDM,C1876,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
BAR EXT FIX L L150MM DIA10.5MM C FBR JET-X,SUP-2342871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1568.59,1019.58,,,,,,,,,,,,,
PLATE BNE STR 3.5X237 MM 20 HOLE RECON FOR SCR SS NS,SUP-2480321,CDM,C1713,HCPCS,0278,RC,,,,both,,,1811.15,1177.25,,,,,,,,,,,,,
SCREW BNE L 105 MM DIA 3.5 MM ST LCK STRL EVOS,SUP-2931816,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.14,341.99,,,,,,,,,,,,,
PILLAR EXT FIX L 350 MM THRD MONK RING,SUP-2899149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1770.18,1150.62,,,,,,,,,,,,,
BLADE LUM 27X80MM TURQ MCCULLOCH,SUP-2161659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
GRAFT BONE SUB 30CC PARTIC 1-4MM CANC FRZ DRY CRUSH,SUP-2113912,CDM,C1713,HCPCS,0278,RC,,,,both,,,1398.18,908.82,,,,,,,,,,,,,
DRILL SURG STR SELF CNTR FORTIFY I LF,SUP-2598889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
PLATE BNE THK07MM 4X4 H BILAT ORAL MAXILLOFACIAL MAND TI DBL,SUP-2262953,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
RETRACTOR OPHTH NYL SMOOTH FINISH IRIS FLX HK DISP,SUP-2109676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.58,207.08,,,,,,,,,,,,,
CONNECTOR SPNL 55X30 35MM TRNSVRS PROLIANT,SUP-2163946,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PIN SPNL COMPR 16 MM,SUP-2719357,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PROBE RF CRV 200 MM DURABLE NIT REUSE,SUP-2753294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
VICI STENT SYS 14X120MM 100CM,SUP-2419658,CDM,C1876,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM UNIV FEM S STL,SUP-2186417,CDM,C1713,HCPCS,0278,RC,,,,both,,,3537.68,2299.49,,,,,,,,,,,,,
BUR H RESVR SET W/CATHETER,SUP-2108707,CDM,C1729,HCPCS,0272,RC,,,,both,,,1460.95,949.62,,,,,,,,,,,,,
CLAMP SPNL DEV 2 5.5MM DIA ROD TENOR SPNL SYS,SUP-2289283,CDM,C1713,HCPCS,0278,RC,,,,both,,,2100.66,1365.43,,,,,,,,,,,,,
URETERORENOSCOPE FLX L 600 MM DIA 9 FR WORKING CHANNEL 6-65,SUP-2883367,CDM,C1747,HCPCS,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 260CM 0.035IN TIP 3 CM STIFF ANGLED,SUP-2385591,CDM,C1769,HCPCS,0272,RC,,,,both,,,180.55,117.36,,,,,,,,,,,,,
PIN EXT FIX L 230 MM DIA 3.2 MM OAL AO CONN SMTH DRL TIP NS,SUP-2899114,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.47,331.16,,,,,,,,,,,,,
KIT INTCRAN PRSS MON PARENCHYMAL VENT TRNSDUC TIP CATH,SUP-2308096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
PROCEDURE KIT TARGETING SINGLE INSRTN ELECTRD D-ZAP SINGLE,SUP-2665071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2304.76,1498.09,,,,,,,,,,,,,
PLATE BNE DIA24 MM THK 0.5 MM SCREW DIA1.7 MM MAXILLOFCL,SUP-2909564,CDM,C1713,HCPCS,0278,RC,,,,both,,,4416.91,2870.99,,,,,,,,,,,,,
PLATE SPNL L55MM BILAT SACR ANTR CONN,SUP-2290523,CDM,C1713,HCPCS,0278,RC,,,,both,,,3356.66,2181.83,,,,,,,,,,,,,
BLADE RTRCTR 18MMW X 7NL SLGHTLY CRVD RGGLS RDMND,SUP-2460247,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.32,315.46,,,,,,,,,,,,,
INTRODUCER LD L12CM OD5FR 0.038IN PLCMNT N PEEL AWAY N COR,SUP-2356158,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
PLATE BNE W12XL142MM THK3.7MM LNG 5 H ST PROX HUM S STL LOK,SUP-2186016,CDM,C1713,HCPCS,0278,RC,,,,both,,,4518.33,2936.91,,,,,,,,,,,,,
HEAD RADIAL 3+ MM 9X19 MM 7.5 MM ELBW STRL,SUP-2789483,CDM,C1776,CPT,0278,RC,,,,both,,,8324.83,5411.14,,,,,,,,,,,,,
HC So Tetanus Antibodies,PX-3028677466,CDM,86774,CPT,0302,RC,,,,inpatient,,,225.00,146.25,,,,,,,,,,,,,
ANCHOR SFT TISS FIX L116MM DIA8MM 18DEG BIOABSRB ANG HD FOR,SUP-2341628,CDM,C1713,HCPCS,0278,RC,,,,both,,,959.43,623.63,,,,,,,,,,,,,
GUIDEWIRE ENDO L145CM 0.035IN FIX COR STR TIP,SUP-2128989,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
CAGE SPNL 7 DEG 16X14 MM 12 MM UPPER ENDPLATE FOOTPRINT TI,SUP-2230024,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COMPONENT TALAR W30MM D31MMXSM RT ANK STAR CO CHROM TI IMP,SUP-2362580,CDM,C1776,CPT,0278,RC,,,,both,,,13834.21,8992.24,,,,,,,,,,,,,
IMPLANT BNE CONDUCTION KT BCI 602 STRL BONEBRIDGE,SUP-2905142,CDM,L8690,HCPCS,0278,RC,,,,both,,,17491.06,11369.19,,,,,,,,,,,,,
INSTRUMENT SET HOFFMANN3 MILITARY EXTERNAL FIXATOR,SUP-2705836,CDM,C1713,HCPCS,0278,RC,,,,both,,,105142.90,68342.88,,,,,,,,,,,,,
HEAD FEM MED 32 MM HIP,SUP-2364576,CDM,C1776,CPT,0278,RC,,,,both,,,2749.07,1786.90,,,,,,,,,,,,,
ROD SPNL L 40 MM DIA 5.5 MM TI PRECONTOURED,SUP-2930577,CDM,C1889,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SUTURE PACK 2 2P NDL ASMBLY UHMWPE BLK STRL EASYWHIP DISP,SUP-2875931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.528,SUP-2860209,CDM,C1713,HCPCS,0278,RC,,,,both,,,36108.74,23470.68,,,,,,,,,,,,,
INTRODUCER LD 7 FR,SUP-2356645,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
TUBE NASOENT AD 20FR L8IN BLLN L1.5IN DISP BLAKMR,SUP-2127131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1165.79,757.76,,,,,,,,,,,,,
CAUTERY ELECSURG BATTERY OPERATED,SUP-2106405,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 0.018 IN 4 FRX60 CM 65 CM TURBO FLO,SUP-2168788,CDM,C1751,HCPCS,0278,RC,,,,both,,,293.46,190.75,,,,,,,,,,,,,
PLATE BNE SCREW DIA 3.5 MM LG SS LT INTRAPELVIC ACET EXT,SUP-2905610,CDM,C1713,HCPCS,0278,RC,,,,both,,,9033.56,5871.81,,,,,,,,,,,,,
HEAD FEM HIP,SUP-2437030,CDM,C1776,CPT,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
KIT SHRP FOR GEN STPL PLATE STRL DISP MOTOBAND CP DYNAFORCE,SUP-2893436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BRACE KNEE SM HNG PAT STBL BILAT AD PUL ON STRP CLSR,SUP-2196833,CDM,L1810,HCPCS,0274,RC,,,,both,,,56.99,37.04,,,,,,,,,,,,,
VALVE CSF FLO BURR HOLE 12 MM CTRL HI PRESSURE DELT,SUP-2629163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2103.39,1367.20,,,,,,,,,,,,,
DRILL SURG ANGLED SELF CNTRG FORTIFY I LF,SUP-2598888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
BIT DRL CANN SHT 12 MM NS,SUP-2757693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2100.69,1365.45,,,,,,,,,,,,,
PLATE BONE 33MM 4 H 1 LEV THOR STRNL FIX DEV DISP,SUP-2262569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1818.06,1181.74,,,,,,,,,,,,,
BASEPLATE TIB SZ 4 STD CO CHROM PRI NP CEM STEM ADV II,SUP-2304787,CDM,C1776,CPT,0278,RC,,,,both,,,7094.52,4611.44,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT TIB WHL STRUCTURAL L,SUP-2307315,CDM,C1713,HCPCS,0278,RC,,,,both,,,21804.66,14173.03,,,,,,,,,,,,,
CAGE SPNL MESH 17X13X20 MM 6 LOBE,SUP-2602081,CDM,C1889,HCPCS,0278,RC,,,,both,,,11002.56,7151.66,,,,,,,,,,,,,
BUR SURG FN DIAMOND LNG 1 MM 10 CM BALL MIDAS REX 8 LEGEND,SUP-2664471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,490.59,318.88,,,,,,,,,,,,,
HC Gases Blood Ph Direct Meas Xcpt Pulse Oximitry,PX-3018280500,CDM,82805,CPT,0301,RC,,,,both,,,323.00,209.95,,,,,,,,,,,,,
NEEDLE VENTING 14 GAX3.5 IN,SUP-2256976,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
NAIL IM L440MM DIA3.5MM PROX TIB BLU TI ALLY,SUP-2192731,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.55,598.36,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 14 CM DIA12 MM STD SFT HELCL,SUP-2385127,CDM,C1889,HCPCS,0278,RC,,,,both,,,240.15,156.10,,,,,,,,,,,,,
COIL NEUROVASCULAR L 27 CM DIA 98 MM DIA 0.0135 IN DEL CATH,SUP-2894689,CDM,C1889,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA15 MM DEL SHTH,SUP-2934166,CDM,C1713,HCPCS,0278,RC,,,,both,,,18184.49,11819.92,,,,,,,,,,,,,
PLATE BNE SM W10XL77MM THK15MM 90DEG 3X6 H TI T SHP R ANG,SUP-2190936,CDM,C1713,HCPCS,0278,RC,,,,both,,,1268.34,824.42,,,,,,,,,,,,,
PLATE BNE L100MM 7 H L SUP CLAV S STL LOK COMPR FOR 3.5MM,SUP-2184146,CDM,C1713,HCPCS,0278,RC,,,,both,,,2736.48,1778.71,,,,,,,,,,,,,
PLATE BNE L30MM BLDE W9.2XL80MM 90DEG 6 H BILAT S STL LOK,SUP-2185367,CDM,C1713,HCPCS,0278,RC,,,,both,,,3502.61,2276.70,,,,,,,,,,,,,
PLATE BNE L27MM 2 H NONSTERILE BILAT TARSOMETATARSAL S STL,SUP-2184840,CDM,C1713,HCPCS,0278,RC,,,,both,,,2485.69,1615.70,,,,,,,,,,,,,
SCREW BNE L 46 MM DIA 3.5 MM TI CANN HD NS LEOS,SUP-2932609,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.72,586.77,,,,,,,,,,,,,
PASSER SUT 10/12-15MM DISP CARTER-THOMASON CLOSESURE SYS XL,SUP-2171694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
INSERT TALAR SZ 3+ THK10MM ANK POLYETH FOR PROPHECY INBONE,SUP-2397172,CDM,C1713,HCPCS,0278,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK18 4MM ULT THCK ACELLULAR,SUP-2307491,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2701.03,1755.67,,,,,,,,,,,,,
PLATE BNE L 163 X W 115 MM THK 0.3 MM SCREW DIA1.5 MM TI CMF,SUP-2883720,CDM,C1713,HCPCS,0278,RC,,,,both,,,6251.74,4063.63,,,,,,,,,,,,,
GRAFT BNE 10 CC VIABLE TRIFECTA 81370010S,SUP-2740428,CDM,C1713,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.032 IN TIP CRV RAD 0.3 MM FIX,SUP-2759849,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.28,55.43,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 25CM 8MM 120CM 7FR RADIOPAQUE,SUP-2396661,CDM,C1874,HCPCS,0278,RC,,,,both,,,20658.06,13427.74,,,,,,,,,,,,,
MOUNT VERT FOR RADIOGRAPHIC MRK MAXFRAME,SUP-2255818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1016.73,660.87,,,,,,,,,,,,,
LINER ACET NEUT G 5+ MM 32 MM PROV G7,SUP-2441119,CDM,C1776,CPT,0278,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
BIT DRL CANN 3X215 MM QC STRL,SUP-2563802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1453.19,944.57,,,,,,,,,,,,,
BRACE WLK M M 7 10 WOM 8 11 EXTRA PNEUMAT LTWT DURABLE SEMI,SUP-2196364,CDM,L4361,HCPCS,0274,RC,,,,both,,,184.22,119.74,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 13X18-25 MM FD IRRADIATED,SUP-2866873,CDM,C1762,CPT,0278,RC,,,,both,,,1503.43,977.23,,,,,,,,,,,,,
SYSTEM RETRV RECOVERY CONE VENA CAVA ENDOSCP FB REMOVAL STRL,SUP-2126999,CDM,C1880,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
COLLAR CERV H3XL22IN UNIV COT M DENS FOAM BRTH ADJ,SUP-2335994,CDM,L0120,HCPCS,0274,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
CATHETER INFUS 31FR L31CM 0.375IN CONN 2 LUMN BI CAVAL,SUP-2124559,CDM,C1729,HCPCS,0272,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
VALVE PROGRAMMABLE INLINE SM W/ SIPHONGUARD DEV CERTAS +,SUP-2558675,CDM,C1889,HCPCS,0278,RC,,,,both,,,13375.90,8694.33,,,,,,,,,,,,,
MESH HERN OVL 10X6 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855263,CDM,C1781,HCPCS,0278,RC,,,,both,,,20331.50,13215.47,,,,,,,,,,,,,
IMPLANT METATRSL SHORTNG SLOT 4.2 NS,SUP-2899074,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
PIN FIX L40MM OD2MM LACTOSORB COPOLYMER ABSRB SGL USE,SUP-2212968,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STEM FEM L160MM DIA15MM 135DEG TIV HIP FBR MTL MIDCOAT,SUP-2203145,CDM,C1776,CPT,0278,RC,,,,both,,,13674.70,8888.55,,,,,,,,,,,,,
PLATE BNE L16MM S STL QUAD FOR GUID GROWTH SYS,SUP-2316427,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.40,802.36,,,,,,,,,,,,,
NUT ORTH ACROSS FLAT 11 MM,SUP-2719396,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
BLADE SURG DIA2 MM,SUP-2934100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.14,1124.59,,,,,,,,,,,,,
PLATE BONE W12XL71MM THK4MM 4 H S STL STR NAR COMPR FOR,SUP-2343806,CDM,C1713,HCPCS,0278,RC,,,,both,,,1233.55,801.81,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 35 A WITH SHUNT ASSISTANT PRECHAMBER PRO,SUP-2825833,CDM,C1889,HCPCS,0278,RC,,,,both,,,9078.68,5901.14,,,,,,,,,,,,,
ABRASOR DIAMOND COARSE 265MM X 3.5MM X 4.4MM BALL TIP JOIMAX,SUP-2848825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
HC NM Cystogram,PX-3417874000,CDM,78740,CPT,0341,RC,,,,both,,,940.00,611.00,,,,,,,,,,,,,
SCREW BNE 20X25 MM,SUP-2397621,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
CATHETER DRNGE 10FR L11CM WRK L40CM 17 H BILI LOK ATRAUM,SUP-2303327,CDM,C1729,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
SCREW BONE L10MM DIA3MM STRNL TI SELF DRL LCK FOR STBL INT,SUP-2181529,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.13,357.58,,,,,,,,,,,,,
HC Ins Ppm Only Exist Mult Leads,PX-4813322100,CDM,33221,CPT,0481,RC,,,,outpatient,,,65472.00,42556.80,,,,,,,,,,,,,
COMPONENT FEM B CO CHROM LT KNEE PRI CEM CRUC RET STEMLESS,SUP-2200959,CDM,C1776,CPT,0278,RC,,,,both,,,12184.77,7920.10,,,,,,,,,,,,,
STENT GRFT VASC AFX L 75 MM UNCOVERED L 20 MM DIA 25 MM,SUP-2217591,CDM,C1768,CPT,0278,RC,,,,both,,,11115.60,7225.14,,,,,,,,,,,,,
WARFARIN SODIUM 1 MG PO TABS,RX-11664,CDM,6370000000,HCPCS,0637,RC,00093-1712-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
RISPERIDONE 1 MG/ML PO SOLN,RX-17377,CDM,340b,HCPCS,0637,RC,27808-0002-01,NDC,,both,0.25,ML,2.70,1.75,,,,,,,,,,,,,
PLATE BNE TIB NEUT 2.7/3.5X232 MM RT DSTL 12 HOLE VA LP SS,SUP-2177662,CDM,C1713,HCPCS,0278,RC,,,,both,,,5908.13,3840.28,,,,,,,,,,,,,
T-PLT STERILIZER 4 HL 84 MM LENGTH,SUP-2820741,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.90,1249.23,,,,,,,,,,,,,
HYOSCYAMINE SULFATE 0.5 MG/ML IJ SOLN,RX-10239,CDM,J1980,HCPCS,0636,RC,54288-0111-01,NDC,,both,0.5,ML,310.50,201.82,,,,,,,,,,,,,
LOCK SMOOTH PEG 2.2X14MM STER,SUP-2477512,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
CATHETER GUID AR1 XLG 8 FRX100 CM VISTA BRT TIP,SUP-2157984,CDM,C1887,HCPCS,0272,RC,,,,both,,,111.47,72.46,,,,,,,,,,,,,
CATHETER URET 6FR L70CM SFT PERCFLX SGL LUMN OPN END TAPR,SUP-2139286,CDM,C1758,HCPCS,0278,RC,,,,both,,,37.18,24.17,,,,,,,,,,,,,
BIT DRL QC LG 12.8 MM CANN STRL,SUP-2789167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2107.88,1370.12,,,,,,,,,,,,,
HC N-Invas Est C Ffr Sw Aly Cta,PX-4807558000,CDM,75580,CPT,0480,RC,,,,both,,,7572.00,4921.80,,,,,,,,,,,,,
BUPROPION HCL 100 MG PO TABS,RX-9321,CDM,6370000000,HCPCS,0637,RC,60505-0157-01,NDC,,both,1,UN,3.30,2.14,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 X W 4 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905522,CDM,Q4184,HCPCS,0636,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SCREW BNE L25MM DIA6.5MM CANC HIP FOR ACET CUP SYS LINEAGE,SUP-2304371,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.81,382.08,,,,,,,,,,,,,
SCAFFOLD SFT TISS FLOWABLE 1CC GRFTJKT,SUP-2399101,CDM,Q4113,HCPCS,0636,RC,,,,both,,,2818.15,1831.80,,,,,,,,,,,,,
BIT DRL L30MM DIA3.2MM S STL FLX W/O STP NONRADIOLUCENT,SUP-2202677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
SYSTEM LSR INDIGO 830E,SUP-2257670,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SCREW BONE 24X16MM SS,SUP-2699088,CDM,C1713,HCPCS,0278,RC,,,,both,,,214.78,139.61,,,,,,,,,,,,,
NAIL IM L 230 MM DIA 4 MM ULN TAPERED/OFFSET TIP FIXED-ANGLE,SUP-2912762,CDM,C1713,HCPCS,0278,RC,,,,both,,,11796.98,7668.04,,,,,,,,,,,,,
PLATE BNE L46MM 3 H R RAD S STL RIM RIG LOK COMPR FOR 2.4MM,SUP-2185998,CDM,C1713,HCPCS,0278,RC,,,,both,,,1804.09,1172.66,,,,,,,,,,,,,
ALLOGRAFT DERM 0.4-1.0MM THIN: L8.0XW6.0CM MESHED MTRX,SUP-2420217,CDM,C1781,HCPCS,0278,RC,,,,both,,,6769.84,4400.40,,,,,,,,,,,,,
HC Clsd Tx Nasal Bone Fracture,PX-4502131500,CDM,21315,CPT,0450,RC,,,,both,,,1586.00,1030.90,,,,,,,,,,,,,
PLATE BNE 1 H POST RIM NAR NS PRO,SUP-2902296,CDM,C1713,HCPCS,0278,RC,,,,both,,,1832.35,1191.03,,,,,,,,,,,,,
POTASSIUM PHOSPHATE 3 MMOL/ML IV SOLN (MIXTURES ONLY),RX-430008,CDM,2500000003,HCPCS,0250,RC,00409-7295-01,NDC,,both,15,ML,85.10,55.31,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV MAXBARR 4FR 55CM 2 LUMAN RVS TAP,SUP-2613435,CDM,C1751,HCPCS,0278,RC,,,,both,,,734.19,477.22,,,,,,,,,,,,,
PIN EXT FIX L9IN DIA9/64IN S STL TRCR PNT W/ FLAT TYP B,SUP-2342720,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.43,926.53,,,,,,,,,,,,,
DEVICE VASC HEARTSTRING II DIA 4.3 MM PROX SEAL AORT ANAS,SUP-2227560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1756.77,1141.90,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.450,SUP-2860014,CDM,C1713,HCPCS,0278,RC,,,,both,,,59236.10,38503.46,,,,,,,,,,,,,
STENT PERIPH L17MM DIA7MM CATH L80CM BLLN L20MM SHTH 6FR,SUP-2173266,CDM,C1876,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SCREW BNE HD 6.5X105 MM 16 MM,SUP-2398634,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
BLADE SHV L13CM DIA43MM AUTO EM TRK FUS ROT QUADCUT,SUP-2277876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1205.57,783.62,,,,,,,,,,,,,
CLAMP EXT FIX 10.5MM BAR TO RNG FRDM JET-X,SUP-2342880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5132.17,3335.91,,,,,,,,,,,,,
IMPLANT LARYN L8MM DIA16FR INDWL RADPQ RNG CLASS BLOM-SINGER,SUP-2242359,CDM,L8509,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
BASKET STONE STR 3 FR 12 MMX120 CM 4 WIR W/O TIP NIT STRL,SUP-2767781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,980.31,637.20,,,,,,,,,,,,,
HC So Epstein-Barr Virus Vca,PX-3028666566,CDM,86665,CPT,0302,RC,,,,both,,,163.00,105.95,,,,,,,,,,,,,
SUPPORT ORTHOT CUST BILATERAL W/VERTICAL EXTN,SUP-2435579,CDM,L1085,HCPCS,0274,RC,,,,both,,,495.90,322.33,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MARSH L 90 CM DIA 5.2 FR BALLOON L 1.5,SUP-2147579,CDM,C1725,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
HOOK ARTHSCP CRV BLNT TIP CROCHET,SUP-2121870,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
STENT PERIPH S.M.A.R.T. L 80 MM DIA10 MM CATH L 80 CM DIA10,SUP-2158632,CDM,C1876,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
NAIL FLEX PRECURVED 175X300MM,SUP-2700541,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.68,589.34,,,,,,,,,,,,,
HC Transcatheter Renal Sympath Denervation Unilat,PX-3610338000,CDM,0338T,CPT,0361,RC,,,,outpatient,,,14967.00,9728.55,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 2 FRX30 CM PER-Q-CATH,SUP-2126427,CDM,C1751,HCPCS,0278,RC,,,,both,,,154.49,100.42,,,,,,,,,,,,,
PLATE BNE STR 12X0.6 MM NEURO 2 HOLE TI STRL LEVEL 1,SUP-2518093,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.69,187.65,,,,,,,,,,,,,
BIT DRL CANN 1.6X95 MM QC STRL,SUP-2563796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1396.04,907.43,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115CM 7FR 25MM 3FR D CRV,SUP-2248769,CDM,C1730,HCPCS,0272,RC,,,,both,,,1456.96,947.02,,,,,,,,,,,,,
SPHINCTEROTOME ENDO DIA5.5FR CATH L200CM WIRE L30MM TIP L5MM,SUP-2139757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLE 1.5X3.1 MMX4 CM HOLTER,SUP-2666425,CDM,C1729,HCPCS,0272,RC,,,,both,,,488.87,317.77,,,,,,,,,,,,,
VALVE AORT INTUITY ELITE BOV PERICARD COCR POLYESTER SIL,SUP-2214325,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
DEFIBRILLATOR IMPL KRONOS LV-T W 55 X H 55 MM D 13 MM 30 J,SUP-2138092,CDM,C1882,HCPCS,0275,RC,,,,both,,,81906.90,53239.48,,,,,,,,,,,,,
PROSTHESIS OSS VELEGRAKIS 0.8-0.6X4.5 MM PISTON PLAT,SUP-2651567,CDM,L8613,CPT,0278,RC,,,,both,,,584.17,379.71,,,,,,,,,,,,,
SCREW BONE L7MM DIA2MM TEAL CRANIOMAXILLOFACIAL TI ST FULL,SUP-2188979,CDM,C1713,HCPCS,0278,RC,,,,both,,,1012.65,658.22,,,,,,,,,,,,,
STEM TIB SMOOTH MID 16 MM TOT ANK COAT INBONE II,SUP-2468750,CDM,C1776,CPT,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
LINER HUM DIA 42 MM OFFSET 2.5 MM SHLDR RVS STRL EQUINOXE,SUP-2889618,CDM,C1776,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
ADAPTER SEAL PEELABLE INNR CATH SFSHTH CPS DIR,SUP-2355663,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
BAR EXT FIX 11X450 MM CARBON,SUP-2750000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1705.02,1108.26,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IN-LINE VENTRICULAR CATH CERTAS +,SUP-2666571,CDM,C1889,HCPCS,0278,RC,,,,both,,,12086.77,7856.40,,,,,,,,,,,,,
SCREW BNE L38MM DIA4MM PERIARTC S STL ST LOK FULL THRD FOR,SUP-2184955,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.89,341.83,,,,,,,,,,,,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU|DISCARDED DRUG NOT ADMINISTE,RX-24916,CDM,J7614,HCPCS,0636,RC,00093-4148-45,NDC,JW,both,3,ML,7.20,4.68,,,,,,,,,,,,,
PLATE BONE L W13.5XL394MM THK4.2MM 22 H BILAT TI STR RIG,SUP-2190838,CDM,C1713,HCPCS,0278,RC,,,,both,,,2059.78,1338.86,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED S4 REVERSED CAPBIOMETS4] ZIMMER BIOMET INC],SUP-2137369,CDM,C1776,CPT,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
SPLINT CLAV XSM 20 24IN WHT HVY PD FELT FOAM CNTCT CLSR,SUP-2196987,CDM,L3650,HCPCS,0274,RC,,,,both,,,17.40,11.31,,,,,,,,,,,,,
BRACE ANK SM AD FOR 7-8.5IN UNIV VLY CNTOUR STL STAY CNTCT,SUP-2197932,CDM,L4350,HCPCS,0274,RC,,,,both,,,110.21,71.64,,,,,,,,,,,,,
KIT VENT ASST FOR HEARTMATE III IMPL,SUP-2356026,CDM,C1713,HCPCS,0278,RC,,,,both,,,338865.66,220262.68,,,,,,,,,,,,,
COMPONENT PART KNEE CEM PATELLOFEMORAL TROCH UPLR,SUP-2249578,CDM,C1776,CPT,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
PLATE BNE ANTEROLATERAL SHT 2.7X40 MM RT CALCANEAL LCK STRL,SUP-2568770,CDM,C1713,HCPCS,0278,RC,,,,both,,,3356.85,2181.95,,,,,,,,,,,,,
THORACIC AND LUM CD HORION LEG PEEK ROD SYS CA SCR MOD,SUP-2279435,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GRAFT BONE SUB 18CC CA SULF HA INJ BIPHASIC OSTEOCONDUCTIVE,SUP-2402600,CDM,C1713,HCPCS,0278,RC,,,,both,,,16676.54,10839.75,,,,,,,,,,,,,
ALLOGRAFT BNE DEMINERALIZED CORTICAL 125-710 MIC 3 CC FD,SUP-2717747,CDM,C1713,HCPCS,0278,RC,,,,both,,,729.58,474.23,,,,,,,,,,,,,
ENDPLATE SPNL VA 12X13 MM UPPER W/ FOOTPRINT FORTIFY,SUP-2732982,CDM,C1889,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
BIT DRILL ARTHRO DIA15MM BLK FLX DISPOSABLE FOR SFT ANCHR SYS,SUP-2137227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.06,212.59,,,,,,,,,,,,,
IMPLANT ANK JT FIX INSRT RT UHMWPE SALTO TALARIS SZ 0 9MM,SUP-2244132,CDM,C1776,CPT,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
WEDGE TIB SZ 2.5 THK16MM 10DEG MOD CEM FULL REV STP PFC SIG,SUP-2253295,CDM,C1776,CPT,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 15 CM DIA 8 MM POLYESTER GEL,SUP-2384993,CDM,C1768,CPT,0278,RC,,,,both,,,3877.90,2520.63,,,,,,,,,,,,,
DEVICE UTER MANIP CERV CUP FORNISEE DISP,SUP-2427798,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 40X15MM,SUP-2466286,CDM,C1713,HCPCS,0278,RC,,,,both,,,7645.90,4969.83,,,,,,,,,,,,,
PROGUIDE 28CM BASIC KIT HOLES 16F PLWAY SHTH 18 G INTRDCR ND,SUP-2701766,CDM,C1894,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
KIT TKR CEM FEM TIB STD SURF AND VIT E PAT PERSONA 98000240120] ZIMMER BIOMET INC],SUP-2212218,CDM,C1776,CPT,0278,RC,,,,both,,,14601.00,9490.65,,,,,,,,,,,,,
SCREW BNE CROSSING 5X50 MM HINDFOOT HD THRD NAIL PHANTOM,SUP-2749709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SYSTEM CRAN FIX LG 16 MM STRL LOOP,SUP-2430764,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
STENT BILI COT-LNG L 9 CM DIA10 FR 0.035 IN SOFFLX CRV,SUP-2737215,CDM,C2617,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
HC Inject Congenital Card Cath,PX-4819356300,CDM,93563,CPT,0481,RC,,,,both,,,620.00,403.00,,,,,,,,,,,,,
ALLOGRAFT BNE SHFT PEDIATRIC LT RT FEM,SUP-2321797,CDM,C1713,HCPCS,0278,RC,,,,both,,,8572.20,5571.93,,,,,,,,,,,,,
STENT GRFT 17.5FR STNT L35MM DIA24MM OCCL CV FOR HYDR DEL,SUP-2296680,CDM,C1768,CPT,0278,RC,,,,both,,,8399.50,5459.67,,,,,,,,,,,,,
PLATE BONE 3D PRNT SM MIDFACE MAND TI TRUMATCH SD980.107,SUP-2860371,CDM,C1713,HCPCS,0278,RC,,,,both,,,32187.51,20921.88,,,,,,,,,,,,,
DEVICE REP SZ 30 MEMO 3D RECHORD,SUP-2352769,CDM,C1889,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
WAND ARTHSCP ABLAT SHFT 2.3MM 35DEG SHT BVL SM JT RF FOR,SUP-2341979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1541.74,1002.13,,,,,,,,,,,,,
LCK FRAC PL6 H43MM NON COM T 25MM CP,SUP-2694249,CDM,C1713,HCPCS,0278,RC,,,,both,,,1533.89,997.03,,,,,,,,,,,,,
BLADE SAW RCPRCTNG 9.4MMW X54.5MML 1.5MM THK 1.5MM THK CUT L,SUP-2605423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63.93,41.55,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-142364,CDM,Q5106,HCPCS,0636,RC,00069-1308-10,NDC,JW,both,1,ML,325.40,211.51,,,,,,,,,,,,,
HEAD FEM OD38MM NK L-6MM CO CHROM MOLYBDENUM ALLY MOD 12/14,SUP-2408805,CDM,C1776,CPT,0278,RC,,,,both,,,8509.40,5531.11,,,,,,,,,,,,,
DEVICE FIX ARTICULATING RELD W/ 3X 8 DP RELIATACK,SUP-2752196,CDM,C1713,HCPCS,0278,RC,,,,both,,,1589.72,1033.32,,,,,,,,,,,,,
LEAD DEFIB SPRNT QUATTRO SECUR S MRI SURESCAN L 58 CM DIA,SUP-2282262,CDM,C1895,HCPCS,0275,RC,,,,both,,,9744.24,6333.76,,,,,,,,,,,,,
RETRIEVER ENDOSCP FIRM 2.5X6 MM 180 CM MERCI 2.5 V SER,SUP-2365839,CDM,C1757,HCPCS,0272,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
BLADE RETRACTOR CASPR 60X23 MM CERV BALL SNAP MEDL ULTRA,SUP-2465498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,560.52,364.34,,,,,,,,,,,,,
SPACER SCREW SELF RET 2.7 MM MAND TI THREADLOCK TS 256779291,SUP-2466625,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.93,181.30,,,,,,,,,,,,,
KIT REP DISP ASPIRA,SUP-2301572,CDM,C1729,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
SCREW BONE L45MM DIA5MM CORT VOLAR S ST NONCANNULATED LCK,SUP-2348625,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.49,100.42,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN TIP L3CM STIFF NIT,SUP-2385585,CDM,C1769,HCPCS,0272,RC,,,,both,,,164.76,107.09,,,,,,,,,,,,,
SCREW INT HEX CAPT 5.0MMX32.5MM,SUP-2349089,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.32,340.81,,,,,,,,,,,,,
STENT PANCREATIC ZMMN L 4 CM DIA 3 FR GUIDEWIRE 0.018 IN PUR,SUP-2169489,CDM,C2617,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
SPACER SPNL TI INTBDY FUS C RNG XLNK FOR 55MM CDH LEG SYS,SUP-2292827,CDM,C1713,HCPCS,0278,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
GRAFT BNE SM 5 CC PRO OSTEON 200R,SUP-2685764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2364.42,1536.87,,,,,,,,,,,,,
PLATE BNE VA NAR XLN 2.4/2.7X105 MM RT RADIAL 6X7 TWO CLMN,SUP-2184115,CDM,C1713,HCPCS,0278,RC,,,,both,,,4622.14,3004.39,,,,,,,,,,,,,
INSERTER SPNL CATLYST ALLGRFT,SUP-2285270,CDM,C1713,HCPCS,0278,RC,,,,both,,,479.32,311.56,,,,,,,,,,,,,
GRAFT HUM TISS W4XL3CM THK1MM UMB CRD AMNIO MEM CLARIX 1K,SUP-2116280,CDM,Q4148,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
TIP SUCT L45CM OD5MM J TIP REPOSABLE STRYKEPROBE,SUP-2361205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,864.94,562.21,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1.5X1.5 CM AMNIOX CLARIX CRD 1K,SUP-2648671,CDM,Q4148,HCPCS,0636,RC,,,,both,,,1588.84,1032.75,,,,,,,,,,,,,
LEVEL CMF ST PLATE RECON TLTS SMART RGHT20 25 MM SCREW 22,SUP-2679032,CDM,C1713,HCPCS,0278,RC,,,,both,,,9806.41,6374.17,,,,,,,,,,,,,
CATHETER PTCA L130CM BLLN L150MM DIA4MM PACLITAXEL OVR THE,SUP-2280381,CDM,C2623,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
GRAFT BNE WDG 12 DEG 12 MM LAPIDUS,SUP-2321728,CDM,C1713,HCPCS,0278,RC,,,,both,,,4914.73,3194.57,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 3 CM DIA2 MM CATH DIA 0.018 IN LOOP,SUP-2638543,CDM,C1889,HCPCS,0278,RC,,,,both,,,326.53,212.24,,,,,,,,,,,,,
DISPOSABLE KT 11MM,SUP-2200254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
SCREW BNE L8MM DIA24MM WRST S STL FOR LIMIT FUS SYS SPIDER,SUP-2242699,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.68,168.79,,,,,,,,,,,,,
KIT PAIN PMP 100ML 1ML/HR CATH L1IN W/ SOAK CATH ON-Q,SUP-2420883,CDM,C9804,HCPCS,0272,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN W/ ROT CUF RT PROX HUM,SUP-2740790,CDM,C1762,CPT,0278,RC,,,,both,,,16603.38,10792.20,,,,,,,,,,,,,
PLATE BONE 18MM SPINOUS,SUP-2209280,CDM,C1713,HCPCS,0278,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
PROSOURCE TF PO LIQD,RX-126124,CDM,6370000000,HCPCS,0637,RC,94688-0114-44,NDC,,both,45,ML,5.70,3.70,,,,,,,,,,,,,
PLATE BONE 86MM PROX HUM LCK,SUP-2167417,CDM,C1713,HCPCS,0278,RC,,,,both,,,2819.72,1832.82,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED HYBRID CKNEESNEPHHYB] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351342,CDM,C1776,CPT,0278,RC,,,,both,,,12613.38,8198.70,,,,,,,,,,,,,
GRAFT BNE SUB 10CC VI DIA4.8MM CA SULF PELLET RESRB PRELD,SUP-2399032,CDM,C1713,HCPCS,0278,RC,,,,both,,,2285.70,1485.70,,,,,,,,,,,,,
SYSTEM MENIS REP SUQUENT CRV NDL 4 IMPLANTS,SUP-2167208,CDM,C1713,HCPCS,0278,RC,,,,both,,,3638.57,2365.07,,,,,,,,,,,,,
DRILL SURG 6 ANTIROTATION NOTCH INBONE,SUP-2850356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
CONNECTOR SPNL L20MM DIA5.5MM TI IL LAT CONN CLS CDH LEG,SUP-2287161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
GRAFT HUM (see comments)  TISS BIOINTEGRATIVE 30X30 MM STRL TAPESTRY LF,SUP-2867239,CDM,C1763,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PRIMAGEN 1CC,SUP-2137604,CDM,C1734,HCPCS,0278,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
HC Group Caregiver Training Strategies & Technique,PX-4209755200,CDM,97552,CPT,0420,RC,,,,both,,,56.00,36.40,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|KX|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE BNE L 76.8 X W 33 MM CLP L 15 MM TRIJOINT VERO NS,SUP-2913511,CDM,C1713,HCPCS,0278,RC,,,,both,,,7439.70,4835.80,,,,,,,,,,,,,
PLATE BNE MESHED 126X126X1 MM SPECIALITY SUN PAT PLLA-PGA,SUP-2477756,CDM,C1713,HCPCS,0278,RC,,,,both,,,12064.16,7841.70,,,,,,,,,,,,,
NEEDLE LIGATURE L7.5IN MALLEABLE TIP AL MEFTY,SUP-2805560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,793.82,515.98,,,,,,,,,,,,,
SCREW BNE L 6 MM DIA1.7 MM MANDIBULAR ST CROSS PIN INCREASED,SUP-2884166,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.88,209.22,,,,,,,,,,,,,
SCREW BONE MINI L6MM DIA2MM LUHR,SUP-2364680,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
LENS IOL TORIC PANOPTIX CLAREON CNWTT3 13.0D,SUP-2754345,CDM,V2788,HCPCS,0276,RC,,,,both,,,1121.25,728.81,,,,,,,,,,,,,
PLATE BONE SM 47MM THK0.3MM SKULL BASE RND MALL FOR 1.5MM,SUP-2363577,CDM,C1713,HCPCS,0278,RC,,,,both,,,2892.32,1880.01,,,,,,,,,,,,,
NAIL IM L32CM DIA10MM 2MM POST BOW LNG RT HINDFOOT FUS,SUP-2340957,CDM,C1713,HCPCS,0278,RC,,,,both,,,12585.59,8180.63,,,,,,,,,,,,,
WIRE EXT FIX OLV 2X350 MM HYBRID DFS DYNAFIX,SUP-2474086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PLATE BNE L 219 X W 12.7 MM THK 3.5 MM SCREW DIA2.7/3.5 MM 72464317,SUP-2933239,CDM,C1713,HCPCS,0278,RC,,,,both,,,8382.54,5448.65,,,,,,,,,,,,,
NAIL IM TIB 7.5X290 MM PHOENIX,SUP-2472772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4954.92,3220.70,,,,,,,,,,,,,
BIT DRL TWST 0.8X4 MM 7 CM SM BOR MIDAS REX 8 LEGEND,SUP-2664811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.01,307.46,,,,,,,,,,,,,
STEM TIB PRSS FIT STR SALV REV POR TI ALLOY OD19.5MM L 89MM,SUP-2408829,CDM,C1776,CPT,0278,RC,,,,both,,,5393.42,3505.72,,,,,,,,,,,,,
SYSTEM BX NDL 19GA SHTH W/ MTL STIFFENER 7FR L60CM CATH STR,SUP-2120185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
PLATE BONE L249MM THK6MM 11 H RT FEM CNDYL TI BTTRS RIG CLLR,SUP-2190900,CDM,C1713,HCPCS,0278,RC,,,,both,,,3681.21,2392.79,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX8 CM DL J TIP CUDLM401JABRMHC,SUP-2759850,CDM,C1751,HCPCS,0278,RC,,,,both,,,334.16,217.20,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA 30 MM L 15CM 8 MM ANTE FLO,SUP-2385477,CDM,C1768,CPT,0278,RC,,,,both,,,3696.53,2402.74,,,,,,,,,,,,,
SAW SURG RECIP W/O HOSE FLFORTHPDC ORLORALMXLLFCL OTOLARYN S,SUP-2605428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11110.51,7221.83,,,,,,,,,,,,,
PLATE BNE L300MM BRL L15IN 135DEG PELVIS BILAT S STL STD 14,SUP-2342445,CDM,C1713,HCPCS,0278,RC,,,,both,,,7462.21,4850.44,,,,,,,,,,,,,
K ORBITAL PLATE 3MM CP TITANIUM,SUP-2681040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.32,1157.86,,,,,,,,,,,,,
STABILIT MX FRACTURE KIT WITH POWERCURVE SHRT,SUP-2701994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9548.58,6206.58,,,,,,,,,,,,,
DILATOR SURG TUNN GENTLE THREADS 905651,SUP-2745480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2650.79,1723.01,,,,,,,,,,,,,
ANCHOR SUT DIA65MM TRCR TIP DBL HELIX THRD PEEK ZIP,SUP-2366669,CDM,C1713,HCPCS,0278,RC,,,,both,,,610.42,396.77,,,,,,,,,,,,,
CANNULA ARTHSCP L55MM ID8.2MM STRL DISP CAPS-LOCK,SUP-2341366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BLADE RTRCTR MED 45MMW X 60MML TTNM SPNL PRNGX5 GREEN LMBRTR,SUP-2668619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.55,504.76,,,,,,,,,,,,,
KNOTLESS TENSIONTIGHT BUTTON IMPLANT SYS,SUP-2812569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
COMPONENT TIB POR FIN 1F/1T 2F/1T,SUP-2222768,CDM,C1776,CPT,0278,RC,,,,both,,,7674.16,4988.20,,,,,,,,,,,,,
SCREW BNE ST FIX FRAMELESS GUID NAVIGATION SYS,SUP-2365166,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.26,102.87,,,,,,,,,,,,,
BOTTLE DRNGE 500ML ACT VAC TECHNOLOGY W/ DRNGE LN PLEURX,SUP-2133739,CDM,C1729,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
NEEDLE SUTURE L9IN BLUNT STEEP TURN LIGATURE FOR LEFT HAND D,SUP-2803011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.23,205.55,,,,,,,,,,,,,
IMPLANT HUM TISS LT DSTL FIBULAR OSTEOARTICULAR CUST MATCHED,SUP-2933013,CDM,C1762,CPT,0278,RC,,,,both,,,11416.10,7420.46,,,,,,,,,,,,,
SHEATH PERIPH 65FR L90CM DEFLECTION L9MM AT 180DEG,SUP-2298496,CDM,C1887,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 30 CM EPTFE STR STD,SUP-2396094,CDM,C1768,CPT,0278,RC,,,,both,,,2603.06,1691.99,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X60 MM 7 HOLE SS,SUP-2473099,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.05,252.88,,,,,,,,,,,,,
CATHETER EP DIAG MAP A CRV QPLR 5MM SPC 5MM TIP FIX EXP 360,SUP-2141286,CDM,C1730,HCPCS,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
BIT DRL OD2MM,SUP-2366046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
BIT DRL L445MM DIA07MM STP 6MM L8MM ST MAXILLOFACIAL S,SUP-2187644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.62,378.05,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL FREE,SUP-2435682,CDM,L2600,HCPCS,0274,RC,,,,both,,,603.82,392.48,,,,,,,,,,,,,
CATHETER BAL DIL 12FR L70CM 0.025IN PVC GWIRE DIL STRETCHING,SUP-2388518,CDM,C1725,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
EVOS 3.5MM LCK 1/3 TUBULAR PL 7H 82MM,SUP-2819632,CDM,C1713,HCPCS,0278,RC,,,,both,,,1599.05,1039.38,,,,,,,,,,,,,
SHEATH DEL AMPLATZER TORQVUE TIP 45 DEG L 80 CM DIA14 FR OD,SUP-2858705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
MESH GYNEMESH PS PROL SQ 25 CMX25 CM,SUP-2219080,CDM,C1781,HCPCS,0278,RC,,,,both,,,2294.99,1491.74,,,,,,,,,,,,,
SCREW BONE L75MM DIA4.5MM THRD L34MM MALL S STL ST SELF DRL,SUP-2184558,CDM,C1713,HCPCS,0278,RC,,,,both,,,104.47,67.91,,,,,,,,,,,,,
CATHETER DUAL ACCESS 3.5F TWIN PASS V2,SUP-2172773,CDM,C1725,HCPCS,0272,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
ANCHOR SUT OD2.9MM MICROMAX FLX,SUP-2137186,CDM,C1713,HCPCS,0278,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
PLATE BNE W10XL75MM THK1.5MM 90DEG 4X6 H BILAT S STL T SHP,SUP-2185873,CDM,C1713,HCPCS,0278,RC,,,,both,,,1121.83,729.19,,,,,,,,,,,,,
SCREW BNE L60MM DIA4MM CORT CANC HIP S STL ST SELF DRL CANN,SUP-2370611,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.17,295.86,,,,,,,,,,,,,
SURGICAL KIT PERIARTICULAR 5 MM REDUC AXSOS,SUP-2484856,CDM,C1713,HCPCS,0278,RC,,,,both,,,10033.43,6521.73,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 24CML 5626240,SUP-2632919,CDM,C1752,HCPCS,0278,RC,,,,both,,,885.35,575.48,,,,,,,,,,,,,
GUIDEWIRE ORTH CANN 0.80X70 MM FIX FUSION SYS DIGIFUSE,SUP-2609635,CDM,C1769,HCPCS,0272,RC,,,,both,,,115.87,75.32,,,,,,,,,,,,,
NAIL IM RT HINDFOOT FUSION W/ 2M POST BOW STRL TRIGEN,SUP-2931389,CDM,C1713,HCPCS,0278,RC,,,,both,,,8388.98,5452.84,,,,,,,,,,,,,
SHEATH INTRO MAX L 12 CM DIA 7 FR GUIDEWIRE 0.038 IN,SUP-2356160,CDM,C1894,HCPCS,0272,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
SCREW BNE L16MM DIA35MM HEXADRIVE 15 TRILOK,SUP-2268378,CDM,C1713,HCPCS,0278,RC,,,,both,,,429.65,279.27,,,,,,,,,,,,,
PLATE BONE W3.5XL36MM THK0.9MM 7 H RT CNDYL S STL,SUP-2343830,CDM,C1713,HCPCS,0278,RC,,,,both,,,2384.86,1550.16,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM 22X14 XS STRL,SUP-2547594,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.54,1510.30,,,,,,,,,,,,,
CATHETER ART THERMODILUTION 0.025 IN 7 FRX110 CM STD 4 LUMEN,SUP-2662684,CDM,C1751,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BNE MESHED 126X11X0.8 MM SM GRID PLLA-PGA STRL,SUP-2477191,CDM,C1713,HCPCS,0278,RC,,,,both,,,2112.00,1372.80,,,,,,,,,,,,,
PLATE BNE T 139 MM RT DSTL RADIAL DORS PERIARTICULAR 12 HOLE,SUP-2525045,CDM,C1713,HCPCS,0278,RC,,,,both,,,2897.84,1883.60,,,,,,,,,,,,,
PLATE BONE DOUBLE ANGLE THICK 2.5 MM MANDIBLE PATIENT SPECIF,SUP-2838602,CDM,C1713,HCPCS,0278,RC,,,,both,,,32062.23,20840.45,,,,,,,,,,,,,
COUPLER MULTDIR SPNL TI OMEGA 21,SUP-2414707,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.62,1241.25,,,,,,,,,,,,,
MESH CRAN W90XL90MM THK0.6MM CRANIOMAXILLOFACIAL G TI DYN,SUP-2366219,CDM,C1713,HCPCS,0278,RC,,,,both,,,4798.45,3118.99,,,,,,,,,,,,,
GUIDE WIRE THRDED 2.4 MMX304 MM STR,SUP-2815032,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
CONNECTOR SPNL L120MM OD5.5MM S STL THORLUM LO PROF CLOSE,SUP-2230998,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
CEMENT FLX FEM /ST TIB / FLX ART SURF /STD PAT,SUP-2212158,CDM,C1776,CPT,0278,RC,,,,both,,,12071.35,7846.38,,,,,,,,,,,,,
BLADE RETRACTOR 16 CM ANTR POST DLIF,SUP-2628718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
GUIDEROD ORTH BALL TIPPED 3X800 MM HINDFOOT FOR NAIL PHANTOM,SUP-2749693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
IMPLANT FACE L 102 X W 4 MM THK 3.6 MM L 102 X W 4.6 MM THK,SUP-2883454,CDM,C1713,HCPCS,0278,RC,,,,both,,,1119.10,727.41,,,,,,,,,,,,,
PLATE B1 THK1.8MM 6 H STRNL THOR CP TI STR LCK LEV 1 FOR,SUP-2262580,CDM,C1713,HCPCS,0278,RC,,,,both,,,1415.20,919.88,,,,,,,,,,,,,
DEVICE CLSR 6FR SUT MEDICATED SYS PERCLOSE AT,SUP-2105647,CDM,C1760,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM DIA 4 FR GUIDEWIRE 0.018 IN CKFLO,SUP-2168783,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.66,77.13,,,,,,,,,,,,,
ENDCAP ORTH DIA10 MM THRD T15 STRL FLEX-THREAD,SUP-2900408,CDM,C1889,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
ALLOGRAFT BNE PWD 30 CC FD ASEP CORTICAL,SUP-2867156,CDM,C1762,CPT,0278,RC,,,,both,,,1557.13,1012.13,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER SGL CHMBR 40 J BPLR ADV VVED 20,SUP-2138123,CDM,C1722,HCPCS,0275,RC,,,,both,,,48310.31,31401.70,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 120 CM DIA18-30 MM,SUP-2120070,CDM,C1773,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
CATHETER VENT SHUNT SLT STR STYL FLO H 1.2MM ID 2.5MM DIA,SUP-2108713,CDM,C1729,HCPCS,0272,RC,,,,both,,,722.99,469.94,,,,,,,,,,,,,
SCREW LAG T2 RECON 65X110MM,SUP-2701900,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.17,431.06,,,,,,,,,,,,,
SCREW INTFR L25MM DIA8MM BIOSURE REGENESORB,SUP-2341917,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.39,751.00,,,,,,,,,,,,,
GRAFT BNE 1 GM DBM FIBERSTACK,SUP-2861495,CDM,C1713,HCPCS,0278,RC,,,,both,,,2829.93,1839.45,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM DIA3MM VAGUS NRV SIL BPLR HELCL,SUP-2175912,CDM,C1767,HCPCS,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
HC Thyroglobulin Antibody,PX-3028680000,CDM,86800,CPT,0302,RC,,,,both,,,86.00,55.90,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE DISC OR DIAL LCK FOR ADJ KNEE FLX,SUP-2435669,CDM,L2425,HCPCS,0272,RC,,,,both,,,405.85,263.80,,,,,,,,,,,,,
TISSUE BIO MATRIDERM 10.5 X 14.8CM 1MM MED,SUP-2866498,CDM,A2027,HCPCS,0636,RC,,,,both,,,15793.23,10265.60,,,,,,,,,,,,,
SYSTEM ENDOSCP ULTRASOUND DEL 19 GA PRE LD NDL BEAC F1905] MEDTRONIC COVIDIEN GIVEN IMAGING],SUP-2173693,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
HC Gonadotropin Luteinizing Hormone,PX-3018300200,CDM,83002,CPT,0301,RC,,,,outpatient,,,443.00,287.95,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 10H LT 214MM STER,SUP-2549615,CDM,C1713,HCPCS,0278,RC,,,,both,,,3544.53,2303.94,,,,,,,,,,,,,
GRAFT HUM TISS L 240 MM ACHILLES TEND FRZN STRL STERIGRAFT,SUP-2913197,CDM,C1762,CPT,0278,RC,,,,both,,,6462.12,4200.38,,,,,,,,,,,,,
HC Fetal Eval 2-3 Trim @ Addl Gest,PX-4027681000,CDM,76810,CPT,0402,RC,,,,both,,,793.00,515.45,,,,,,,,,,,,,
CATHETER CV DL 5 FR TY W/ MICROINTRODUCER POWERPICC SOLO 2,SUP-2126387,CDM,C1751,HCPCS,0278,RC,,,,both,,,472.32,307.01,,,,,,,,,,,,,
THREADED BM RECOVERY SYSTEM 13G,SUP-2816416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
IMMOBILIZER KNEE SIZED CANVS 19 IN 2XL,SUP-2336067,CDM,L1830,CPT,0274,RC,,,,both,,,39.66,25.78,,,,,,,,,,,,,
OLANZAPINE 5 MG PO TBDP,RX-28159,CDM,6370000000,HCPCS,0637,RC,55111-0262-79,NDC,,both,1,UN,7.80,5.07,,,,,,,,,,,,,
STEM FEM L330MM OD18X11.5MM 9 TI HX COAT HIP CEMENTLESS 03,SUP-2397015,CDM,C1776,CPT,0278,RC,,,,both,,,19342.40,12572.56,,,,,,,,,,,,,
STEM HUM SZ 0 L144MM DIA12MM STD SHLDR CO CHROM HA,SUP-2250984,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
HC CT Facial Bones W/WO Contrast,PX-3517048800,CDM,70488,CPT,0351,RC,,,,outpatient,,,2630.00,1709.50,,,,,,,,,,,,,
SET INTRO REMINGTON L 13 CM DIA 7 FR GUIDEWIRE 0.038 IN NDL,SUP-2137980,CDM,C1892,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
SCREW SPNL 5.5X60 MM HA TSRH 3DX OSTEOGRIP,SUP-2631178,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 80 MM DIA 8 MM DEL SYS L 150 CM,SUP-2866175,CDM,C1876,HCPCS,0278,RC,,,,both,,,3949.49,2567.17,,,,,,,,,,,,,
FIBER LASER KIT PROC,SUP-2225707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SHUNT KIT FLO CTRL SM SHUNT CONTOURED HI PRESSURE,SUP-2631351,CDM,C1729,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
SCREW BNE L 60 MM DIA 6.5 MM SS CANN STRL EVOS,SUP-2931538,CDM,C1713,HCPCS,0278,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
LINE GAS SAMP L10FT 0.05MM LUER TO M LUER UNFILTERED,SUP-2882145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2.45,1.59,,,,,,,,,,,,,
BIT DRL 1.1X15 MM 8 MM W/ STP FOR 90 DEG SCREWDRIVER NS LTX,SUP-2859719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,958.33,622.91,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 2 X 2 H SCREW DIA2 MM TI MIDFACE,SUP-2883814,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
HC Replace G-J Tube,PX-3614945200,CDM,49452,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
KIT THROMCTMY 4MAX L 139 CM PROX/DSTL OD 6 FR/1.42 MM,SUP-2323545,CDM,C1887,HCPCS,0272,RC,,,,both,,,5683.40,3694.21,,,,,,,,,,,,,
DILATOR SURG INSUL 8/13/18 MM STRL,SUP-2710542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 4FR 20CM 2 LUMAN S4254108DGP,SUP-2632868,CDM,C1751,HCPCS,0278,RC,,,,both,,,675.57,439.12,,,,,,,,,,,,,
BIT DRL 3.5 MM W/ K-WIRE CONTOURSLPS,SUP-2646743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.29,405.14,,,,,,,,,,,,,
GRAFT HUM TISS LT RT WHL HUM STRUCTURAL FRZN,SUP-2165584,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
HC Ep Eval Single/Dual Icd Flw Up,PX-4819364200,CDM,93642,CPT,0481,RC,,,,both,,,9405.00,6113.25,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 80 CM DIA11 FR HYDRPHLC,SUP-2383424,CDM,C1894,HCPCS,0272,RC,,,,both,,,315.57,205.12,,,,,,,,,,,,,
MESH NEURO SQ RECT TI TIMESH CRAN FIX 1.5MM SCR DIA,SUP-2277535,CDM,C1713,HCPCS,0278,RC,,,,both,,,1862.02,1210.31,,,,,,,,,,,,,
STEM FEM TIB STR 28X145 MM 28X100X145 MM KNEE,SUP-2201648,CDM,C1776,CPT,0278,RC,,,,both,,,2621.12,1703.73,,,,,,,,,,,,,
SOLID LOCKING LAG SCREW 10.5MMX80MM,SUP-2828885,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
BLADE IM 125 MM HELIX SS STRL LCP DHHS,SUP-2547636,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.85,740.90,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 3 CC CORTICOCANCELLOUS KT CELLULAR BNE,SUP-2932945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8914.46,5794.40,,,,,,,,,,,,,
COMPONENT FEM L + RT CNDYL POR TOT MOD ADVTM,SUP-2397051,CDM,C1776,CPT,0278,RC,,,,both,,,16390.80,10654.02,,,,,,,,,,,,,
INBONE  POLY SZ 4 20MM SULCUS TOTAL ANKLE,SUP-2465176,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
CANNULA KYPHOPLASTY ACC 13GA BONE FOR IVAS,SUP-2361357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.41,1034.42,,,,,,,,,,,,,
KIT PI PICC 1-L 4.5 FR X 55 CM WITH CHG AND VPS,SUP-2565195,CDM,C1751,HCPCS,0278,RC,,,,both,,,778.09,505.76,,,,,,,,,,,,,
ANCHOR SUTURE KINSA,SUP-2341738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
OSELTAMIVIR PHOSPHATE 75 MG PO CAPS,RX-26546,CDM,6370000000,HCPCS,0637,RC,68180-0677-11,NDC,,both,1,UN,11.70,7.60,,,,,,,,,,,,,
SHEATH BAN PEAL 16FR 30MM,SUP-2141075,CDM,C1892,HCPCS,0272,RC,,,,both,,,160.08,104.05,,,,,,,,,,,,,
PLATE BNE STR 7 HOLE,SUP-2864953,CDM,C1713,HCPCS,0278,RC,,,,both,,,3943.84,2563.50,,,,,,,,,,,,,
ROD SPNL L210MM OD55MM TI ALLY POST R SMOOTH STR CDH,SUP-2279606,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
PLATE BNE W17.5XL124MM THK5.2MM 7 H BILAT S STL BROAD LIMIT,SUP-2185287,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.98,745.54,,,,,,,,,,,,,
CAP ORTH L0MM EXTN FOR IM NAIL TRIGEN,SUP-2347140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.43,882.98,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 6 MM L 50CM STR STD WALL,SUP-2396269,CDM,C1768,CPT,0278,RC,,,,both,,,3981.52,2587.99,,,,,,,,,,,,,
PEG BONE FXTN 2.5MM DIA 14MML CBLT CHRMM THRDD LOK F/DVR PLT,SUP-2588999,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
HC Pt Neuro Facilitation Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209711200,CDM,97112,CPT,0420,RC,,,GO|CO,both,,,159.00,103.35,,,,,,,,,,,,,
BUR SURG 5MM D14X11MM CUT FOR CRNRSTN,SUP-2290949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.87,416.57,,,,,,,,,,,,,
HC ED Cl Red Fx Phlx Not Grt Toe,PX-4502851500,CDM,28515,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
CLOZAPINE 25 MG PO TABS,RX-9648,CDM,6370000000,HCPCS,0637,RC,00904-7089-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
RASP SURG W9.5XL30.5MM RND SHANK RECIP FOR SM BNE,SUP-2166365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.74,423.63,,,,,,,,,,,,,
CATHETER ABLATN D CRV 2-5-2 MM SPC 6 FRX120 CM CRD QPLR RF,SUP-2356801,CDM,C1730,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BIT DRL L140MM OD2MM LNG SLD MEAS AO,SUP-2321587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
AMIODARONE HCL IN DEXTROSE 150-4.21 MG/100ML-% IV SOLN,RX-108515,CDM,2500000003,HCPCS,0250,RC,43066-0150-10,NDC,,both,100,ML,199.60,129.74,,,,,,,,,,,,,
HEAD HUM CAST 46X18 MM 53 MM SHLDR VERSA-DIAL,SUP-2441686,CDM,C1776,CPT,0278,RC,,,,both,,,4394.43,2856.38,,,,,,,,,,,,,
SCREW BNE NAIL HOLDING SPI,SUP-2474223,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 10 CM DIA13 GA,SUP-2930237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46200.33,30030.21,,,,,,,,,,,,,
PROSTHESIS PENILE L23CM DIA9.5MM HYDRPHLC MALL TAIL CAP TRIM,SUP-2165369,CDM,C2622,HCPCS,0278,RC,,,,both,,,30147.14,19595.64,,,,,,,,,,,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-112652,CDM,J1953,HCPCS,0636,RC,43598-0757-10,NDC,,both,50,ML,86.30,56.09,,,,,,,,,,,,,
SYSTEM PROTCT L INT AORT FLTR,SUP-2214487,CDM,C1884,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
TUBE TRACH DIA7MM PVC SPRL REINF CUF TRACHFLX,SUP-2384498,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRUT CORT TRAD 60X5MM SM,SUP-2294111,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
WASHER ORTH 4.5-8 MM 430290SINGLE,SUP-2609254,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.44,284.99,,,,,,,,,,,,,
CABLE SPNL FLANGE W/ CRMP SS SONGER,SUP-2713123,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
TREPHINE BONE BX ORTH DISECT SZ 4.5 MM,SUP-2205288,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GRAFT BIO TISS W10XL25CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113003,CDM,Q4130,HCPCS,0636,RC,,,,both,,,24036.70,15623.85,,,,,,,,,,,,,
WIRE BNE FIX L 20 CM DIA1.22 MM LOOP NS LUQ,SUP-2882138,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.93,76.00,,,,,,,,,,,,,
SCREW SPNL L20MM DIA4MM S STL MONOAX REVERE,SUP-2230768,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 5 FRX23 CM SET CK FLO ACCS RADIAL,SUP-2168777,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
BIT DRILL FOR 3.5MM SCR SH IMPL,SUP-2232054,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
KIT PICC 4FR CATH L20CM SGL LUMN MIDLN MAX BARR TWO NIT,SUP-2118842,CDM,C1751,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC Perq Cervicothoracic Inject,PX-3612251000,CDM,22510,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC Spleenoportography S&I,PX-3207581000,CDM,75810,CPT,0320,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.7MM CORT TI ST FULL THRD SM HEX FOR,SUP-2189698,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.49,58.17,,,,,,,,,,,,,
GRAFT HUM TISS L 3 X W 2 CM AMNION PLCNTA MEMBRN 2 LAYR,SUP-2913214,CDM,C1762,CPT,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
SCREW BNE CORTICAL 1.5X9 MM,SUP-2199235,CDM,C1713,HCPCS,0278,RC,,,,both,,,44.53,28.94,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,2580000003,HCPCS,0250,RC,00264-7520-00,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
BLADE GROSSMAN RETRACTOR WIDE REPLACEMENT,SUP-2707288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.99,219.69,,,,,,,,,,,,,
SCREW BNE L135MM DIA6.5MM THRD L32MM CANC TI ST SELF DRL,SUP-2190536,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.31,80.80,,,,,,,,,,,,,
ANCHOR SUT W/ SZ 2 ETHBND SUT CP-2 NDL GII QUICKANCHR +,SUP-2249348,CDM,C1713,HCPCS,0278,RC,,,,both,,,3102.32,2016.51,,,,,,,,,,,,,
STENT PERIPH S.M.A.R.T. CTRL L 60 MM DIA 8 MM DEL SYS L 120,SUP-2158601,CDM,C1876,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
PLATE BNE L 29.08 X W 5.72 MM THK 1.6 MM 4 H GRD III TI MOD,SUP-2936985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
HC CT T-Spine W/WO Contrast,PX-3527213000,CDM,72130,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
SCREW BNE ST 1.3X7 MM MXLFCL CRTX CRUCFRM HD W/ FLUT TIP TI,SUP-2189179,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
PROBE LITHO PNEUMATIC 0.89X940 MM FLX SWISS LITHOCLAST DISP,SUP-2457040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,790.12,513.58,,,,,,,,,,,,,
CANNULA RF CRV 22 GAX10 CM,SUP-2308568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
MESH SURG 40X20 CM BIOMATERIAL PREPERITONEAL ENFORM,SUP-2435401,CDM,C1781,HCPCS,0278,RC,,,,both,,,33422.16,21724.40,,,,,,,,,,,,,
WASHER ORTH 2 MM EXIT FOR CABLE STRL,SUP-2563697,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.90,292.43,,,,,,,,,,,,,
STEM HUM REVERSED 11X90 MM SHLDR ADJ AEQUALIS PTC,SUP-2715347,CDM,C1776,CPT,0278,RC,,,,both,,,10836.14,7043.49,,,,,,,,,,,,,
GUIDEWIRE VASC L 30 CM TIP L 2 MM DIA 0.018 IN STR CRV DBL,SUP-2760170,CDM,C1769,HCPCS,0272,RC,,,,both,,,133.51,86.78,,,,,,,,,,,,,
SET IMPL PELVIC PRO STRYKER,SUP-2496129,CDM,C1713,HCPCS,0278,RC,,,,both,,,113400.97,73710.63,,,,,,,,,,,,,
SLING GYN UNIV MESH ASMBLY HALO NDL MID URETH POLYPR IMP,SUP-2141793,CDM,C1771,HCPCS,0278,RC,,,,both,,,2273.67,1477.89,,,,,,,,,,,,,
AUTOINJECTOR ENDOGRFT O-PRIME,SUP-2390656,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
GRAFT BNE DRILLABLE 3 CC VOID FILL STRL LTX,SUP-2865882,CDM,C1713,HCPCS,0278,RC,,,,both,,,3961.74,2575.13,,,,,,,,,,,,,
HYDROMORPHONE HCL 4 MG PO TABS,RX-3761,CDM,6370000000,HCPCS,0637,RC,00406-3244-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT STRNL CLOSURE FIBERTAPE L 36 IN DIA2 MM SUTURE X6 BLU,SUP-2930487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4368.53,2839.54,,,,,,,,,,,,,
DRESSING BIO W4XL5IN THN CLLGN GLYCOSAMINOGLYCAN WND MTRX,SUP-2243650,CDM,Q4108,HCPCS,0636,RC,,,,both,,,17272.98,11227.44,,,,,,,,,,,,,
SYRINGE VERT AUG MSTR ASMBLY CPLR ELBW STABILIT,SUP-2421787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE W22XL75MM STD 6X5 H NONSTERILE R DST RAD VOLAR S,SUP-2184119,CDM,C1713,HCPCS,0278,RC,,,,both,,,2367.06,1538.59,,,,,,,,,,,,,
SCREW BNE L16MM DIA35MM RAREFT LOK PLT FOR TOT FT SYS 2,SUP-2243293,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.80,618.67,,,,,,,,,,,,,
GRAFT HUM TISS 20X25MM DISC CRYOPRESERVED VIABLE OSTEOCHNDRL,SUP-2120740,CDM,C1713,HCPCS,0278,RC,,,,both,,,31086.00,20205.90,,,,,,,,,,,,,
DRILL SURG 2.9 MM CERV FOR 4 MM SCREW S4,SUP-2108735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT SKIN 5X5 CM ANTIMICROBIAL PURAPLY,SUP-2314118,CDM,Q4195,HCPCS,0636,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
PLATE BNE Y MED 1.5X29X0.8 MM MIDFACE 7 HOLE W/ TAB NS,SUP-2494949,CDM,C1713,HCPCS,0278,RC,,,,both,,,815.93,530.35,,,,,,,,,,,,,
PLATE SPNL L40MM 6 H ANT CERV BILAT TI 2 LEV INTEGR LOK,SUP-2293203,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
MESH HERN W5XL10CM POLYPR FLAT L PORE MFIL SFT KNIT LTWT,SUP-2125777,CDM,C1781,HCPCS,0278,RC,,,,both,,,203.47,132.26,,,,,,,,,,,,,
SCREW BNE L20MM DIA2MM CORT S STL ST LOK FULL THRD T6,SUP-2183213,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.30,82.74,,,,,,,,,,,,,
GRAFT BNE 50X25X8 MM 10 CC POROUS COLLAGEN MATRIX SIGNAFUSE,SUP-2731801,CDM,C1713,HCPCS,0278,RC,,,,both,,,5310.53,3451.84,,,,,,,,,,,,,
SPACER KNEE FEM POST SYS REV STABILIZING ATTUNE,SUP-2454502,CDM,C1776,CPT,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
SHEARS ENDO L23CM DIA5MM CVD PSTL GRP HND CTRL HARM ACE,SUP-2257346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1152.79,749.31,,,,,,,,,,,,,
BRACE THMB UNIV LT SPICA,SUP-2319328,CDM,L3906,HCPCS,0274,RC,,,,both,,,25.28,16.43,,,,,,,,,,,,,
SCREW BONE SLD SH THRD BLNT TIP PRECIS JMF 5.5MMX56MM,SUP-2321008,CDM,C1713,HCPCS,0278,RC,,,,both,,,2582.65,1678.72,,,,,,,,,,,,,
SPHERE EMB PREFIL SYR ACRYL GEL 900-1200 MIC 1ML 20ML SYR N,SUP-2303390,CDM,C1889,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PIN POS THRD 1.2X63 MM POS,SUP-2321705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN,RX-2331,CDM,J1100,HCPCS,0636,RC,00641-0367-21,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
DEVICE COCHLEAR PEDIATRIC SLEEPER SIMULATOR LEVEL,SUP-2165014,CDM,L8614,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 15ML TYP 1 BOV CLLGN B TRICALCIUM,SUP-2316225,CDM,C9359,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
KYPHOPLASTY TRAY 20/2 OSTEO INTRO BNDL KYPHOPAK EXPRESS II,SUP-2665109,CDM,C1713,HCPCS,0278,RC,,,,both,,,8415.20,5469.88,,,,,,,,,,,,,
DEVICE EXTR BAL ERCP 3 LUMN INJ DSTL WIRE GUID BILI DISP,SUP-2312950,CDM,C1725,HCPCS,0272,RC,,,,both,,,300.87,195.57,,,,,,,,,,,,,
EXPANDER TISS GEL 6.3 CM 16X11.3 CM 550 CC SV-T NATRELLE,SUP-2484236,CDM,C1889,HCPCS,0278,RC,,,,both,,,5099.36,3314.58,,,,,,,,,,,,,
CLIP NERVE STIM STIMULATING SAFEOP,SUP-2725218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON LG 8 IN RT WRST PLUSH FOAM LNR NYL,SUP-2276662,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.64,10.82,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IV SOLN,RX-104398,CDM,J1459,HCPCS,0636,RC,44206-0438-20,NDC,,both,200,ML,11319.80,7357.87,,,,,,,,,,,,,
ANCHOR SUT DIA475MM BIOCOMPOSITE LAT ROW KNOTLESS CROSSFT,SUP-2418756,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.41,1357.47,,,,,,,,,,,,,
GLIPIZIDE 10 MG PO TABS,RX-10116,CDM,6370000000,HCPCS,0637,RC,60505-0142-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER DRAINAGE PLUG 5 FRX9 CM 19 GAX11 CM DRAINER,SUP-2763481,CDM,C1729,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
NEEDLE BRONCHSCP 21GA HNDL SHTH NDL STYL PERIVIEW FLX,SUP-2418795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,947.84,616.10,,,,,,,,,,,,,
SCREW BONE L26MM DIA4.9MM CORT S STL NONCANNULATED FULL THRD,SUP-2186379,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.75,292.99,,,,,,,,,,,,,
CLAMP SURG PARL CONN 7.5 MM 4.75 TO 5.5-6.5 MM DBL CREO,SUP-2584168,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC Perq Trluml Revsc Tot/Stot Occls Ami 1maj C Art,PX-4819294100,CDM,92941,CPT,0481,RC,,,,outpatient,,,23915.00,15544.75,,,,,,,,,,,,,
PLATE BNE L 220 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 20 H,SUP-2936251,CDM,C1713,HCPCS,0278,RC,,,,both,,,2441.19,1586.77,,,,,,,,,,,,,
GRAFT BIO TISS MARIGEN EXPANSE 2X2CM MESHED,SUP-2909358,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3149.42,2047.12,,,,,,,,,,,,,
LEAD PACE L46CM DIA5.6FR VENT BPLR TI NITRIDE HELIX TIP SIL,SUP-2357747,CDM,C1722,HCPCS,0275,RC,,,,both,,,65940.00,42861.00,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR IS-1 ATLS DR,SUP-2356551,CDM,C1721,HCPCS,0275,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
DEVICE PROSTHETIC FT KNEELING EXT,SUP-2388222,CDM,L5970,HCPCS,0274,RC,,,,both,,,577.04,375.08,,,,,,,,,,,,,
STEM FEM L138MM DIA13MM STD NK OFFSET HIP PROS TRABECULAR,SUP-2203543,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SHEATH DESTIN SL 6FR R2P 105CM,SUP-2633196,CDM,C1894,HCPCS,0272,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
GRAFT BNE 10 CC DBM FIBER STRND +,SUP-2644299,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 6 FR 0.021IN NIT,SUP-2384887,CDM,C1894,HCPCS,0272,RC,,,,both,,,261.84,170.20,,,,,,,,,,,,,
STENT ESOPH L7CM OD18MM ODSEC23MM .038IN SELF EXP,SUP-2139595,CDM,C1874,HCPCS,0278,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
PACK SURG PROC 1.2 GWIRE PASS PIN TUNN PLUG GA DISP RAP-PAC,SUP-2341130,CDM,C1769,HCPCS,0272,RC,,,,both,,,869.34,565.07,,,,,,,,,,,,,
FORCEPS GRSP L700MM DIA8MM CHN 2MM SHARK TOOTH RAT REUSE FOR,SUP-2313149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2645.89,1719.83,,,,,,,,,,,,,
RETRACTOR SURG SM 6CM SFT TISS GREATER TEAR RESISTANCE LO,SUP-2214621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
HC Assay of Ferritin|NOT REASONABLE AND NECESSARY,PX-3018272800,CDM,82728,CPT,0301,RC,,,GZ,both,,,255.00,165.75,,,,,,,,,,,,,
INTRODUCER SHTH J 0.038 IN 5 FRX14 CM 18 GAX50 CM PEELWY,SUP-2357058,CDM,C1892,HCPCS,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
PLATE LK COMPRSS 12 HOLE,SUP-2704415,CDM,C1713,HCPCS,0278,RC,,,,both,,,1223.66,795.38,,,,,,,,,,,,,
SPHERE GLEN LNG L15MM POST FIX PRESSFIT AEQUALIS PERFORM,SUP-2388774,CDM,C1776,CPT,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
RESTRICTOR CEM SM DIA10MM UNIV FEM CNL UHMWPE SUMMIT BASIC,SUP-2253094,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.52,75.09,,,,,,,,,,,,,
KIT PI PICC 1-L 4 FRX55 CM WITH PRELO,SUP-2826670,CDM,C1751,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
COMPONENT TIB UNI RM/LL 9MM SM EIUS,SUP-2364886,CDM,C1776,CPT,0278,RC,,,,both,,,8729.20,5673.98,,,,,,,,,,,,,
KIT SURG BONE CEM MX AND DEL FOR VERT FX,SUP-2256274,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA28 MM POLYESTER GEL,SUP-2385049,CDM,C1768,CPT,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
PLATE BONE SM THK0.4MM NONSTERILE RT ORBIT DK PUR TI PREFRM,SUP-2181781,CDM,C1713,HCPCS,0278,RC,,,,both,,,5939.00,3860.35,,,,,,,,,,,,,
URETEROSCOPE FLX 270 DEG FLD OF VW 90 DEG WORKING L 680 MM,SUP-2929753,CDM,C1747,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER TEMP PACE L 110 CM DIA 4 FR PROX 1 CM POLYUR SS,SUP-2126010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.16,429.75,,,,,,,,,,,,,
ALLOGRAFT BNE WDG LG FD IRRADIATED IL CREST,SUP-2867214,CDM,C1762,CPT,0278,RC,,,,both,,,2550.47,1657.81,,,,,,,,,,,,,
PLATE BNE STR MINI MED 2X0.6 MM 4 HOLE LP FOR SCR TI STRL,SUP-2496290,CDM,C1713,HCPCS,0278,RC,,,,both,,,252.83,164.34,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|ADJ,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|CQ|ADJ,both,,,191.00,124.15,,,,,,,,,,,,,
BIT DRILL FLEXIBLE 12MM LONG,SUP-2718099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2977.19,1935.17,,,,,,,,,,,,,
HC Removal Pg Wcs Lv Pacing Both Components,PX-4810861000,CDM,0861T,CPT,0481,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
HC Cor Angio/Vent W/Ffr,PX-4810755700,CDM,C7557,CPT,0481,RC,,,,both,,,7672.00,4986.80,,,,,,,,,,,,,
CATHETER DRNGE L40CM DIA22FR 0.038IN COAX L BOR CRV FOR,SUP-2168763,CDM,C1729,HCPCS,0272,RC,,,,both,,,221.24,143.81,,,,,,,,,,,,,
HC I&D Abscess Scrotal Wall,PX-4505510000,CDM,55100,CPT,0450,RC,,,,both,,,1649.00,1071.85,,,,,,,,,,,,,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,6370000000,HCPCS,0637,RC,60505-0829-01,NDC,,both,16,GR,81.00,52.65,,,,,,,,,,,,,
Z DISCONTINUED USE 2149666 GUIDEWIRE BILI ENDO JAGWIRE RX 0.025 INX260 CM,SUP-2141538,CDM,C1769,HCPCS,0272,RC,,,,both,,,322.35,209.53,,,,,,,,,,,,,
BUR SURG BALL 4 MM 12 CM PROX BEND MIDAS REX 8 SD/SP,SUP-2664945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,995.25,646.91,,,,,,,,,,,,,
PIN DISTRACTOR L16MM ST CERV S STL W UNIV FIT,SUP-2194310,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
SEATING CHISEL FOR TODDLER OSTEOTOMY PLATES,SUP-2548624,CDM,C1713,HCPCS,0278,RC,,,,both,,,1286.08,835.95,,,,,,,,,,,,,
HC Intubation Emergent,PX-7613150000,CDM,31500,CPT,0761,RC,,,,outpatient,,,403.00,261.95,,,,,,,,,,,,,
PIN ABSORBABLE 3.2X50.0MM STERILE F / ARTHROTEK,SUP-2498686,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
ONDANSETRON HCL 8 MG PO TABS,RX-10779,CDM,Q0162,HCPCS,0637,RC,68084-0221-11,NDC,,both,1,UN,4.40,2.86,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED ULTRA HI DEMAND 1 FIX BEAR BIOMETK1FIX] ZIMMER BIOMET INC],SUP-2137339,CDM,C1776,CPT,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
GUIDEWIRE VASC STR 035X150 N LT,SUP-2264475,CDM,C1769,HCPCS,0272,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
FLOSS CLEANING PROBE TIP 3 IN 1,SUP-2719736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
DRILL SURG STP 2X2.5 MM PIN,SUP-2464811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
SUTURE ANCHR SUTFIX CVD 1.9MM W/ TWO 1-0 ULTRABRAID SUT BLU,SUP-2341935,CDM,C1713,HCPCS,0278,RC,,,,both,,,1404.68,913.04,,,,,,,,,,,,,
BOLT ORTH LCK 16-100 MM MEAS DEV FOR FEM NAIL NS,SUP-2563931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1848.20,1201.33,,,,,,,,,,,,,
TICAGRELOR 90 MG PO TABS,RX-110035,CDM,6370000000,HCPCS,0637,RC,00186-0777-39,NDC,,both,1,UN,34.90,22.68,,,,,,,,,,,,,
COLLAR CERV PROGLIDE UNIV,SUP-2276573,CDM,L0172,HCPCS,0274,RC,,,,both,,,219.55,142.71,,,,,,,,,,,,,
KIT CATH 45DEG FIRM TIP EXT WRK CHN LOCATABLE GUID EDGE SDK3450OLYMPUS] SUPERDIMENSION INC],SUP-2381764,CDM,C1713,HCPCS,0278,RC,,,,both,,,4703.72,3057.42,,,,,,,,,,,,,
DEVICE FIX DIA8MM TIB PRELD TUNNELOC,SUP-2137203,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.45,1218.39,,,,,,,,,,,,,
KIT INSTR GUID FLX DRL BIT OBT FOR 2.9MM SFT SUT ANCHR,SUP-2212956,CDM,C1713,HCPCS,0278,RC,,,,both,,,1205.76,783.74,,,,,,,,,,,,,
ANCHOR SUTURE 6.5MM WITH 3 NO 2 SUTURES HI-FI NEEDLE CROSSFT,SUP-2825119,CDM,C1713,HCPCS,0278,RC,,,,both,,,1545.29,1004.44,,,,,,,,,,,,,
INTRODUCER SHTH KT PERC BONDED ADJ VLV 6FRX10CM INTRO FLX,SUP-2272869,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.55,104.36,,,,,,,,,,,,,
SCREW BNE 2X8 MM 6 MM DRILL-FREE TI L1 MAXDRIVE,SUP-2468792,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.05,282.78,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H LNG TI NEURO SQ XDRV 1 PK,SUP-2935558,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
PLATE BNE L26MM 3X3 H BILAT MAND ORAL MAXILLOFACIAL TI ANG,SUP-2191465,CDM,C1713,HCPCS,0278,RC,,,,both,,,4305.88,2798.82,,,,,,,,,,,,,
NICOTINE 14 MG/24HR TD PT24,RX-27862,CDM,6370000000,HCPCS,0637,RC,43598-0447-70,NDC,,both,1,UN,18.10,11.76,,,,,,,,,,,,,
WASHER RESRB M CLOVER CENTRALOC RESRB TIB FIX,SUP-2212865,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
HC Immunoassay Analyte Quantitative Nos,PX-3018352000,CDM,83520,CPT,0301,RC,,,,both,,,93.00,60.45,,,,,,,,,,,,,
HC Extremity Arteriogram Bilateral,PX-3237571600,CDM,75716,CPT,0323,RC,,,,both,,,6098.00,3963.70,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4 H STD CRANIOMAXILLOFACIAL G TI CRV,SUP-2366294,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.47,285.66,,,,,,,,,,,,,
WASHER CLAVICLE,SUP-2812278,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ANCHOR NONSUTURE 16MM IMPLANT FIXATION MENISCAL BIOSTINGER,SUP-2824742,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.46,215.45,,,,,,,,,,,,,
SCREW BNE L42MM DIA4.5MM CORT HIP S STL ST NONCANNULATED,SUP-2343711,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.61,18.60,,,,,,,,,,,,,
DRILL SURG L11MM BUD REUSE,SUP-2107586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 05 5MM CORT CANC GRAN FRZ DRY,SUP-2307055,CDM,C1713,HCPCS,0278,RC,,,,both,,,968.34,629.42,,,,,,,,,,,,,
DEFIBRILLATOR CARD W523XH714CM D099CM SGL CHMBR VR IS 1 DF 1,SUP-2149180,CDM,C1722,HCPCS,0275,RC,,,,both,,,35029.84,22769.40,,,,,,,,,,,,,
SHEET ORBIT W4XL4CM THK0.3MM NYL SMOOTH SQ FOR PLAS SURG,SUP-2335971,CDM,C1765,HCPCS,0278,RC,,,,both,,,14.92,9.70,,,,,,,,,,,,,
GRAFT BIO TISS W4XL16CM THK08 17MM THCK STRUCTURAL,SUP-2307470,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5776.44,3754.69,,,,,,,,,,,,,
ANCHOR SFT TISS L16MM DIA1.1MM KNEE COPOLYMER SGL SELF REINF,SUP-2166731,CDM,C1776,CPT,0278,RC,,,,both,,,380.88,247.57,,,,,,,,,,,,,
GRAFT HUM TISS 9X67 MM QUADRICEPS TEND FLEXIGRAFT QUADLINK,SUP-2845904,CDM,C1762,CPT,0278,RC,,,,both,,,8245.64,5359.67,,,,,,,,,,,,,
INTRODUCER CATH CANN L 10 CM WIRE L 45 CM DIA 0.021 IN SHTH,SUP-2909808,CDM,C1894,HCPCS,0272,RC,,,,both,,,145.07,94.30,,,,,,,,,,,,,
STRAP CLAV L BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194673,CDM,L3670,HCPCS,0274,RC,,,,both,,,13.47,8.76,,,,,,,,,,,,,
WAND ABLAT 70DEG ICW 3MM COVAC,SUP-2341995,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
CAGE SPNL 12X22 MM COR MONOLITH,SUP-2559968,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
BOOT EQL BLK XL EA,SUP-2319312,CDM,L4360,HCPCS,0274,RC,,,,both,,,72.97,47.43,,,,,,,,,,,,,
NAIL IM L360MM DIA10MM FEM TIB KNEE G TI CANN LOK AG RG,SUP-2347086,CDM,C1713,HCPCS,0278,RC,,,,both,,,2963.66,1926.38,,,,,,,,,,,,,
DRAIN SURG SGL COLL PT TB FOR ATS BG OASIS,SUP-2227402,CDM,C1729,HCPCS,0272,RC,,,,both,,,144.31,93.80,,,,,,,,,,,,,
NEEDLE HARVEST BONE MARROW,SUP-2737869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
PIN 45MM FLAT HD FIX,SUP-2400113,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvc/Le Init 2nd,PX-3613624600,CDM,36246,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW BNE LCK,SUP-2898940,CDM,C1713,HCPCS,0278,RC,,,,both,,,289.67,188.29,,,,,,,,,,,,,
COLLAR CERV FIRM DENS W CHIN SUPP AD CNTOUR W COT CVR SERP,SUP-2276598,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.30,6.69,,,,,,,,,,,,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,J7682,HCPCS,0636,RC,16714-0119-02,NDC,,both,5,ML,314.70,204.55,,,,,,,,,,,,,
PLATE VARIAX HAND 17 6 HOLE L ANG,SUP-2695489,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.59,683.53,,,,,,,,,,,,,
BIT DRL DIA 4.3 MM LNG STP AO QC STRL DISP TRIGEN MAX,SUP-2933140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
SPACER SPNL H10XL10MM 8DEG M PEEK THORLUM INTBDY FUS LORD,SUP-2285328,CDM,C1821,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
SCREW SPNL TIGHTENER FOR MIS SPNL FIX SYS TELLURIDE,SUP-2211187,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
GRAFT BONE POSTEROLATERAL 2.5CMX10CM MAGNIFUSE,SUP-2293966,CDM,C1713,HCPCS,0278,RC,,,,both,,,14230.48,9249.81,,,,,,,,,,,,,
RESTRICTOR BONE CEM HARDINGE,SUP-2253883,CDM,C1713,HCPCS,0278,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
BUTTON SUT L PEC FOR FIX OF SFT TISS TO BONE,SUP-2121668,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
STEM FEM L250MM OD19MM TI DST HIP REV MOD TAPR FOR EXT,SUP-2404434,CDM,C1776,CPT,0278,RC,,,,both,,,9193.92,5976.05,,,,,,,,,,,,,
BUTTON FIX DIA15MM NONABSORBABLE FOR SFT TISS ENDOBTTN,SUP-2341013,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.02,619.46,,,,,,,,,,,,,
HC IV Push Initial Drug,PX-2609637400,CDM,96374,CPT,0260,RC,,,,both,,,320.00,208.00,,,,,,,,,,,,,
KIT CATHETERIZATION ARROWG+ARD BLUE HEMODIALYSIS 2-L 14 FR X 15 CM,SUP-2930754,CDM,C1752,HCPCS,0278,RC,,,,both,,,582.78,378.81,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA LOW BEND 4H 76MM LT STER,SUP-2546866,CDM,C1713,HCPCS,0278,RC,,,,both,,,4546.47,2955.21,,,,,,,,,,,,,
ASSEMBLY SHUNT 120 CM NSC BURR HOLE OPN END WALL SLT STRATA,SUP-2664455,CDM,C1889,HCPCS,0278,RC,,,,both,,,15818.69,10282.15,,,,,,,,,,,,,
COMPONENT FEM KNEE CRUC RET LT UNISX PRI CEM STEMLESS PC,SUP-2199586,CDM,C1776,CPT,0278,RC,,,,both,,,17365.46,11287.55,,,,,,,,,,,,,
GUIDEWIRE SM VES ANG TIP ZIPWIRE 0.018IN 150CM,SUP-2142692,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.07,94.30,,,,,,,,,,,,,
PLATE BNE C 1 40 MM RT METATARSOPHALANGEAL 4 HOLE TI GRN,SUP-2608933,CDM,C1713,HCPCS,0278,RC,,,,both,,,2179.54,1416.70,,,,,,,,,,,,,
LOOP PIST .5MMX4.25 MCGEE MOD,SUP-2277635,CDM,L8613,CPT,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
VALVE DRAINAGE 110 CM 3 PC SHUNT SYS SLD BA OSCV II LO PRO,SUP-2243848,CDM,C1729,HCPCS,0272,RC,,,,both,,,9378.40,6095.96,,,,,,,,,,,,,
SYSTEM RETRV TISS ANCHR,SUP-2432214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1257.10,817.11,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM 8 IN RT WRST CNTOUR,SUP-2124889,CDM,L3931,HCPCS,0272,RC,,,,both,,,45.53,29.59,,,,,,,,,,,,,
KIT ENDOSCP FLUID MGMT IN-FLOPAK OUT-FLOPAK TISS TRAP WSTE,SUP-2913560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,849.68,552.29,,,,,,,,,,,,,
ENVELOPE PACEMKR L W2.9XL3.3IN ABSRB ANTIBACT TYRX,SUP-2282348,CDM,C1889,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
PLATE BNE L 231 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 20 H,SUP-2936314,CDM,C1713,HCPCS,0278,RC,,,,both,,,3645.07,2369.30,,,,,,,,,,,,,
STENT GRFT VASC AFX L 75 MM DIA PROX/DSTL 28 MM COCR,SUP-2217599,CDM,C1768,CPT,0278,RC,,,,both,,,10785.90,7010.83,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ W STAY COCK UP FIRM SUPP,SUP-2276617,CDM,L3809,HCPCS,0274,RC,,,,both,,,15.95,10.37,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2.5 MM RECON MAXILLA PT SPEC,SUP-2860104,CDM,C1713,HCPCS,0278,RC,,,,both,,,31583.06,20528.99,,,,,,,,,,,,,
STENT COLON EVOLUTION L 8 CM BODY DIA25 MM FLANGE DIA 30 MM,SUP-2170563,CDM,C1876,HCPCS,0278,RC,,,,both,,,7209.44,4686.14,,,,,,,,,,,,,
HC Repositioning Vad Cath,PX-3613659700,CDM,36597,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE PELVIC CVD 8 HOLE R88,SUP-2464792,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
ELECTRODE ES 6FR L53CM UPLR COAG BALL,SUP-2261253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.73,383.97,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT 35X15 MM FRZN WHL PATELLAR TEND,SUP-2866893,CDM,C1762,CPT,0278,RC,,,,both,,,9312.93,6053.40,,,,,,,,,,,,,
PORT INFUS OD2.7MM ID1.5MM INTRO 8FR TI POLYUR CATH DETACH CT80STPD] ANGIODYNAMICS INC],SUP-2117292,CDM,C1788,HCPCS,0278,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 3.5X58 MM 5 HOLE FOR SCREW STERILE,SUP-2836650,CDM,C1713,HCPCS,0278,RC,,,,both,,,2476.24,1609.56,,,,,,,,,,,,,
HC So Immunology Procedure,PX-3028684966,CDM,86849,CPT,0302,RC,,,,outpatient,,,27.00,17.55,,,,,,,,,,,,,
HC So Dpyd Gene Common Variants,PX-3108123266,CDM,81232,CPT,0310,RC,,,,both,,,443.00,287.95,,,,,,,,,,,,,
GRAFT BNE H20MM IL CREST WDG PRESERVON MATRIGRFT,SUP-2264844,CDM,C1713,HCPCS,0278,RC,,,,both,,,2780.47,1807.31,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA 7 MM DEL SHTH 7ML,SUP-2936818,CDM,C1713,HCPCS,0278,RC,,,,both,,,16932.92,11006.40,,,,,,,,,,,,,
SYSTEM CATH DEL 145CM GUID INTRO PEEL AWAY INTRO APEEL CS +,SUP-2357280,CDM,C1894,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE THK0.6MM 6 H MAND TI DBL Y LO PROF FOR 2MM SCR,SUP-2262946,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
ALLOGRAFT BNE WDG SM 18-25X9X7-14 MM FD IRRADIATED IL CREST,SUP-2866876,CDM,C1762,CPT,0278,RC,,,,both,,,1930.00,1254.50,,,,,,,,,,,,,
BASEPLATE TIB SM SZ 1 AP42MM ML67MM UNIV KNEE HA POR CEM,SUP-2377184,CDM,C1776,CPT,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 2 X 8 H SCREW DIA2 MM TI MIDFACE,SUP-2883767,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
HC Gastrostomy Tube Change W Flouro,PX-3614945000,CDM,49450,CPT,0361,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 6 MM STR HELIX SLDE GDS,SUP-2475708,CDM,C1768,CPT,0278,RC,,,,both,,,1775.23,1153.90,,,,,,,,,,,,,
COMPONENT GLEN SM 4MM SHLDR POLY KEELED MOD NONCONSTRAINED,SUP-2404637,CDM,C1776,CPT,0278,RC,,,,both,,,3884.02,2524.61,,,,,,,,,,,,,
HC CT C-Spine W/WO Contrast,PX-3527212700,CDM,72127,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
ANCHOR SUT 48 MM DIA SGL ARMED REGENESORB ABSRB THRDR,SUP-2341139,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
GRAFT BIO TISS 4X8CM THK04 1MM PROLAYER,SUP-2362228,CDM,C1763,HCPCS,0278,RC,,,,both,,,8279.55,5381.71,,,,,,,,,,,,,
LEAD PACE L 64 CM DIA11 FR ENDOCARD 2 COIL STRL,SUP-2139604,CDM,C1895,HCPCS,0275,RC,,,,both,,,21116.50,13725.72,,,,,,,,,,,,,
SEALANT HEMOSTATIC 10 CC GEL MTRX PTCH THROM CACL2 FLOSEAL,SUP-2129855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1080.51,702.33,,,,,,,,,,,,,
PLATE BONE LNG DSTL VOLAR RAD CROSSLOCK LT STRL,SUP-2137041,CDM,C1713,HCPCS,0278,RC,,,,both,,,6966.47,4528.21,,,,,,,,,,,,,
JIG DISTAL RADIAL VOLAR LAT COLUMN PLATE RT,SUP-2724613,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.18,484.37,,,,,,,,,,,,,
HC X-Ray Exam Entire Spine 2/3 Vw,PX-3207208200,CDM,72082,CPT,0320,RC,,,,outpatient,,,969.00,629.85,,,,,,,,,,,,,
HC So Dhea Level,PX-3018262666,CDM,82626,CPT,0301,RC,,,,inpatient,,,131.00,85.15,,,,,,,,,,,,,
GUIDEWIRE EXT FIX L400MM DIA3.2MM ENTRY FOR ANK COMPR,SUP-2316007,CDM,C1769,HCPCS,0272,RC,,,,both,,,509.81,331.38,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 4-7 MM EPTFE SHRT TAPR,SUP-2487439,CDM,C1768,CPT,0278,RC,,,,both,,,1144.18,743.72,,,,,,,,,,,,,
SPACER SPNL 12 DEG 55X22X17 MM INTBDY SKYHAWK,SUP-2658122,CDM,C1748,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
PLATE BONE METACARPAL MINI 2.7100X8X2.5 MM METATARSAL PHALAN,SUP-2837000,CDM,C1713,HCPCS,0278,RC,,,,both,,,2607.20,1694.68,,,,,,,,,,,,,
GRAFT HUM TISS 10ML FRMBL CELLULAR BNE MTRX CRYOPRESERVED,SUP-2264671,CDM,C1713,HCPCS,0278,RC,,,,both,,,11321.90,7359.23,,,,,,,,,,,,,
PLATE BNE 2 X 2 H CRANIOMAXILLOFACIAL 3D BX LP NS UNIV NEURO,SUP-2883186,CDM,C1713,HCPCS,0278,RC,,,,both,,,884.63,575.01,,,,,,,,,,,,,
TRIAL KNEE DIA32MM THK10MM ASYM TOT STBL TRIATHLON,SUP-2363806,CDM,C1776,CPT,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PLATE BNE L370MM 18 H NONSTERILE L CNDYL S STL CRV LOK,SUP-2177868,CDM,C1713,HCPCS,0278,RC,,,,both,,,6791.04,4414.18,,,,,,,,,,,,,
HEAD FEM DIA36MM -6MM OFFSET 12/14 CONSTRN FRDM,SUP-2405359,CDM,C1776,CPT,0278,RC,,,,both,,,3824.52,2485.94,,,,,,,,,,,,,
PLATE BNE COMPR 2.7X161 MM 20 HOLE ADPT LCK TI STRL LCP,SUP-2789465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.95,1184.27,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 40 MM ANTR CERV NEO-SL,SUP-2430719,CDM,C1713,HCPCS,0278,RC,,,,both,,,7771.50,5051.47,,,,,,,,,,,,,
SULBACTAM SOD-DURLOBACTAM SOD 1-1 G IV SOLR,RX-165034,CDM,J3376,HCPCS,0636,RC,68547-0111-10,NDC,,both,1,UN,956.50,621.72,,,,,,,,,,,,,
PLATE BNE SM W10.1XL129MM THK3.5MM 10 H BILAT S STL CRV RIG,SUP-2186263,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.96,1418.92,,,,,,,,,,,,,
BOOT CASTXL AD 13.5IN 5.5IN CUSH ROCK OPN TOE AND OPN HEEL,SUP-2205564,CDM,L4387,HCPCS,0272,RC,,,,both,,,29.67,19.29,,,,,,,,,,,,,
HC Sel Cath Thor/Brachioceph 1st,PX-3613621500,CDM,36215,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PROCESSOR SND 2 MM EXT SNAP CPL SLV NS BAHA LTX,SUP-2858116,CDM,L8693,HCPCS,0278,RC,,,,both,,,11628.58,7558.58,,,,,,,,,,,,,
SCREW BONE L12MM DIA2.8MM TI FIX CORT CANN FULL THRD ST,SUP-2107372,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
PROBE RF MPLR LIGMNT CHSL HK MIC ABLAT VULCAN,SUP-2341614,CDM,C1713,HCPCS,0278,RC,,,,both,,,567.08,368.60,,,,,,,,,,,,,
ROD SPNL THORLUM STR TOP LD HEX END LO PROF S STL OD5.5MM 424521] DEPUY SYNTHES USA],SUP-2190804,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.07,477.15,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE 40 MM PRECIS CYL UNITZ CATH LO HAKIM,SUP-2666439,CDM,C1889,HCPCS,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
DEVICE MARROW SHOT SMART,SUP-2707511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PROVENTM REV KNEE SYS MOD FEM SZ 1 THRU 6,SUP-2359350,CDM,C1776,CPT,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
FIBER LASER 0.4 MM FOR KTP/YAG,SUP-2225667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1205.76,783.74,,,,,,,,,,,,,
STENT BILI RAPID EXCHANGE 0.035 IN 10X60 MM 8.5 FRX194 CM,SUP-2141242,CDM,C1874,HCPCS,0278,RC,,,,both,,,8132.60,5286.19,,,,,,,,,,,,,
GRAFT BNE 5 CC BIOACTIVE FOAM PK VITOSS,SUP-2368191,CDM,C1713,HCPCS,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
BRACE ELBW C SHP REINF ADJ COUNTERFORCE VISCOELASTIC POLYMER,SUP-2324053,CDM,L3702,HCPCS,0272,RC,,,,both,,,137.66,89.48,,,,,,,,,,,,,
SCREW SPINE BONE IMPL T6 2X18MM,SUP-2661362,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
PRIMIDONE 250 MG PO TABS,RX-6544,CDM,6370000000,HCPCS,0637,RC,68084-0203-01,NDC,,both,1,UN,4.00,2.60,,,,,,,,,,,,,
HC Thyroid Metastases Imaging; Whole Body,PX-3417801800,CDM,78018,CPT,0341,RC,,,,inpatient,,,2192.00,1424.80,,,,,,,,,,,,,
SALINE SPRAY 0.65 % NA SOLN,RX-14469,CDM,6370000000,HCPCS,0637,RC,96295-0131-60,NDC,,both,44,ML,13.10,8.51,,,,,,,,,,,,,
BIT DRL L110MM DIA16MM SLD ADD ON,SUP-2321583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.89,240.43,,,,,,,,,,,,,
GRAFT HUM TISS L160MM ACHILLES TEND FRZN W/ BNE BLK,SUP-2264725,CDM,C1762,CPT,0278,RC,,,,both,,,6943.48,4513.26,,,,,,,,,,,,,
PLATE BNE L141MM 12 H BILAT S STL STR RECON NONLOCKING,SUP-2197677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1231.60,800.54,,,,,,,,,,,,,
INTRODUCER SHTH 6FR L11CM W/OUT GWIRE GRN HUB W/ HEMSTAS,SUP-2303277,CDM,C1894,HCPCS,0272,RC,,,,both,,,28.42,18.47,,,,,,,,,,,,,
TAP SURG SCR CANN JONES FIX INSTR 65MM,SUP-2398107,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SHELL ACET SZ 23 OD52MM HIP LIMIT H LOK RNG RANAWAT,SUP-2403845,CDM,C1776,CPT,0278,RC,,,,both,,,4710.63,3061.91,,,,,,,,,,,,,
CATHETER CV DL 8 FRX20 CM FULL KT ARROWG+ARD BLU +,SUP-2383392,CDM,C1751,HCPCS,0278,RC,,,,both,,,384.34,249.82,,,,,,,,,,,,,
GRAFT ENDOVASC L7X2CM ID8-10MM INTRO SHTH 10FR 0.035IN,SUP-2395927,CDM,C1874,HCPCS,0278,RC,,,,both,,,9332.08,6065.85,,,,,,,,,,,,,
CATHETER INTVASC OCCL L 100 CM DIA 7 FR BALLOON DIA11.5 MM,SUP-2147466,CDM,C2628,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
HEAD FEM M 14/16 DIA36MM +5 OFFSET HIP CO CHROM TAPR PRI,SUP-2249728,CDM,C1776,CPT,0278,RC,,,,both,,,3671.29,2386.34,,,,,,,,,,,,,
HC Endoven Ther Chem Adhes Sbsq,PX-3613648300,CDM,36483,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 30 CM ART CUF SINGLE SET TESIO,SUP-2627147,CDM,C1750,HCPCS,0278,RC,,,,both,,,472.57,307.17,,,,,,,,,,,,,
BRACE WRIST SM 14.6 16.5CM LEFT PRTCTVE PDDNG ADJSTBLE BAR D,SUP-2480988,CDM,L3931,HCPCS,0272,RC,,,,both,,,36.64,23.82,,,,,,,,,,,,,
COMPONENT FEM CEM KNEE FIX BEAR ATTUNE,SUP-2249621,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SHUNT CEREBROSPINAL FLD L80CM TUOHY NDL L3.5IN LUM PERI KT,SUP-2308229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1861.71,1210.11,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,0636,RC,25021-0813-10,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PLATE BNE LG RT MIS HV REV,SUP-2896856,CDM,C1713,HCPCS,0278,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
PEG FIX L24MM DIA2.7MM CORT TI THRD NONLOCKING FOR DSTL,SUP-2340280,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
CATHETER EPIDURAL 20 GAX40 IN SFT CLOSED TIP 3 SP PERIFIX,SUP-2125021,CDM,C1755,HCPCS,0278,RC,,,,both,,,22.77,14.80,,,,,,,,,,,,,
CATHETER DASH ERCP TIP 4.5FR RECOMMENDED WIRE GUID .025IN,SUP-2169553,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
CATHETER INFUSION L 145 CM DIA 6 FR STRL,SUP-2383131,CDM,C1887,HCPCS,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
CATHETER HD CATH ON OFF,SUP-2263924,CDM,C1752,HCPCS,0278,RC,,,,both,,,8.35,5.43,,,,,,,,,,,,,
SCREW SPNL FT 3.5X36 MM CORRIDOR,SUP-2593534,CDM,C1713,HCPCS,0278,RC,,,,both,,,1196.34,777.62,,,,,,,,,,,,,
BUR SURG SPHR 4.5 MMX10.8 CM UNHOODED RHINOTEC,SUP-2607705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,287.94,187.16,,,,,,,,,,,,,
SCREW BNE DIGITAL FUSION 2X34 MM TI TI6,SUP-2609625,CDM,C1713,HCPCS,0278,RC,,,,both,,,1357.30,882.24,,,,,,,,,,,,,
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML PO SOLN,RX-37848,CDM,340b,HCPCS,0637,RC,60687-0417-44,NDC,,both,5,ML,6.20,4.03,,,,,,,,,,,,,
ROD SPNL TI OD45 MM X L200 MM SAG,SUP-2279805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM DIA 0.018 IN CRV RAD 2 MM HVY DBL FLX,SUP-2760014,CDM,C1769,HCPCS,0272,RC,,,,both,,,137.97,89.68,,,,,,,,,,,,,
KIT INFUS PRT CATH L76CM OD9.6FR IMP LO PROF N INJ SGL LUMN,SUP-2127748,CDM,C1788,HCPCS,0278,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
CERAMIC BALL HD 12/14 28 IN E M,SUP-2267744,CDM,C1776,CPT,0278,RC,,,,both,,,3833.94,2492.06,,,,,,,,,,,,,
OSTEOTOME SURG PWR LNG CRV ULT DRV 6MM,SUP-2408570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
HC Amylase,PX-3018215000,CDM,82150,CPT,0301,RC,,,,both,,,193.00,125.45,,,,,,,,,,,,,
ENDOSCOPIC KIT SIDP,SUP-2121761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
HC Chest Tube Insertion,PX-7613255100,CDM,32551,CPT,0761,RC,,,,outpatient,,,4942.00,3212.30,,,,,,,,,,,,,
CLAMP EXT FIX DBL MULTIPIN MED STRL GALAXY FIX GEM LTX,SUP-2875645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6315.80,4105.27,,,,,,,,,,,,,
ELECTRODE ELECSURG MED 12-30 DEG CUT ANGLED LOOP PLASMALOOP,SUP-2313588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1593.55,1035.81,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM B CRV UNIDIR,SUP-2248936,CDM,C1732,HCPCS,0278,RC,,,,both,,,5567.22,3618.69,,,,,,,,,,,,,
PLATE BNE 4 H R 1ST MP TI FUS PRECONTOURED POLISHED ROUNDED,SUP-2107819,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
SCREW WR INTEGRA FRDM ARTHROPLASTY LCK CAP ARE USED IN THE,SUP-2243512,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.06,718.29,,,,,,,,,,,,,
SYSTEM ANCHOR 4.75 BC LOOP N TRACK,SUP-2717578,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE STR SHT CRANIOFACIAL NEURO 2 HOLE LP STRL LEVEL 1,SUP-2487703,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
BUR SURG DIAMOND 70 DEG 4 MM TAPR SUCTION IRRIGATING,SUP-2638218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,669.39,435.10,,,,,,,,,,,,,
PLATE BNE 5 H TI ALLOY Y SHP ALPHA NS LEOS,SUP-2932910,CDM,C1713,HCPCS,0278,RC,,,,both,,,3325.26,2161.42,,,,,,,,,,,,,
PLATE BONE LNG L27MM THK0.6MM 6 H MIDFACE SLV TI STR FOR,SUP-2402874,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
ALLOSYNC DBM CORTICAL FIBERS 10CC,SUP-2816366,CDM,C1713,HCPCS,0278,RC,,,,both,,,3362.94,2185.91,,,,,,,,,,,,,
SET GUID RESECT FOR 25 TIB 3 L FEM HI PERF SIG TRUMATCH,SUP-2256962,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 5 CC FD IRRADIATED CANC,SUP-2867097,CDM,C1762,CPT,0278,RC,,,,both,,,590.63,383.91,,,,,,,,,,,,,
SPINE CATH XL,SUP-2341605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3683.22,2394.09,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 117 MM DIA 38 MM SHTH 18 FR,SUP-2170242,CDM,C1874,HCPCS,0278,RC,,,,both,,,49612.00,32247.80,,,,,,,,,,,,,
HC Iadna Human Papillomavirus Hi-Rsk Typ Poold Rslt,PX-3068762400,CDM,87624,CPT,0306,RC,,,,both,,,226.00,146.90,,,,,,,,,,,,,
TAP BNE PEDCL SCR QUIK CONN 65MM DIA,SUP-2290730,CDM,C1713,HCPCS,0278,RC,,,,both,,,2311.54,1502.50,,,,,,,,,,,,,
PLATE BNE CALCANEOCUBOID SM LT STRATUM,SUP-2656714,CDM,C1713,HCPCS,0278,RC,,,,both,,,4599.03,2989.37,,,,,,,,,,,,,
BIT DRL CANN LG 14 MM QC STRL,SUP-2563710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.05,1040.68,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ PISTON 0.6X3.50 MM SS FLROPLAS,SUP-2638112,CDM,L8613,CPT,0278,RC,,,,both,,,501.02,325.66,,,,,,,,,,,,,
PLATE BNE ROT CORRECTION 1.5/2X32 MM 2X5 HOLE TI STRL,SUP-2569068,CDM,C1713,HCPCS,0278,RC,,,,both,,,2962.28,1925.48,,,,,,,,,,,,,
CEFAZOLIN SODIUM 100 G IJ SOLR,RX-31086,CDM,J0690,HCPCS,0636,RC,66288-1100-01,NDC,,both,1,UN,603.80,392.47,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.3MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189050,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.11,210.02,,,,,,,,,,,,,
CATHETER BAL DIL 7FR L40CM SHTH 10-12FR TMS,SUP-2141079,CDM,C1725,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SPLINT WRST XL L8IN L BLK FOAM D RNG CLSR LO PROF MAL,SUP-2336047,CDM,L3809,HCPCS,0274,RC,,,,both,,,18.21,11.84,,,,,,,,,,,,,
STENT COR DRUG ELUT RX PACLITAXEL S STL 2.25MM TAXUS EXPRESS,SUP-2139982,CDM,C1874,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
HC Ins Icd Gen Only Exist Mult Ld,PX-3613323100,CDM,33231,CPT,0361,RC,,,,inpatient,,,107193.00,69675.45,,,,,,,,,,,,,
SLEEVE TIB L9CM PROX KNEE FOR ORTH SALV SYS,SUP-2406466,CDM,C1776,CPT,0278,RC,,,,both,,,14101.74,9166.13,,,,,,,,,,,,,
BIT DRL DIA4.3MM SHT 2IN1 AO FOR HALLU-LOCK MTP ARTH SYS,SUP-2242910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,805.16,523.35,,,,,,,,,,,,,
SET STRL FOR 4.5MM CNDYL LCP PLT,SUP-2183063,CDM,C1713,HCPCS,0278,RC,,,,both,,,61413.25,39918.61,,,,,,,,,,,,,
GUIDEWIRE VASC L 100 CM DIA 0.025 IN CRV RAD 5 MM SS REUT,SUP-2638688,CDM,C1769,HCPCS,0272,RC,,,,both,,,210.16,136.60,,,,,,,,,,,,,
BIT DRILL 2.3MM TIGON,SUP-2842564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
PLATE BNE L 130 MM SCREW DIA2.7/3.5 MM 9 H SS MEDL DSTL TIB,SUP-2931319,CDM,C1713,HCPCS,0278,RC,,,,both,,,4637.15,3014.15,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MAVERICK2 L 142 CM BALLOON L 9 MM DIA 3,SUP-2143670,CDM,C1725,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BNE VOLAR NAR RT DSTL RADIAL 1 HOLE NS LTX,SUP-2857369,CDM,C1713,HCPCS,0278,RC,,,,both,,,4791.64,3114.57,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.37MM SMOOTH BLNT TIP DISP VIPER 2,SUP-2255667,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
BLADE 279MM 11IN DISPOSABLE BAN HIP PRESERVATION SYS,SUP-2167157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,790.87,514.07,,,,,,,,,,,,,
WIRE FIX L230MM OD2.3MM NICKEL CHROM SMOOTH SGL END TRCR,SUP-2321630,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
PLATE BNE L267MM THK34MM 20 H BILAT S STL STR LIMIT CNTCT,SUP-2185157,CDM,C1713,HCPCS,0278,RC,,,,both,,,2181.48,1417.96,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST W/O JT PREFABRICATED,SUP-2435768,CDM,L3809,HCPCS,0274,RC,,,,both,,,644.23,418.75,,,,,,,,,,,,,
BUNDLE CASE DISTRCTN CRAN MXLFCL 5 FULL SKULL RECON VSP,SUP-2862829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,24334.50,15817.42,,,,,,,,,,,,,
GRAFT HUM TISS CORTICAL 4 DEG 10 MM CERV CANC STRL LF DISP,SUP-2463162,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE L262MM 19 H NONSTERILE R ANTLAT DST TIB S STL LO,SUP-2185970,CDM,C1713,HCPCS,0278,RC,,,,both,,,4454.72,2895.57,,,,,,,,,,,,,
PLATE BNE ANTEROLATERAL LNG 2.7X56 MM RT CALCANEAL LCK STRL,SUP-2568774,CDM,C1713,HCPCS,0278,RC,,,,both,,,3489.73,2268.32,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 3 CM LOOP DIA 3 MM PRIMARY,SUP-2249261,CDM,C1889,HCPCS,0278,RC,,,,both,,,3776.79,2454.91,,,,,,,,,,,,,
RING EXT FIX ARCH 180 MM,SUP-2749882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2251.38,1463.40,,,,,,,,,,,,,
ENDCAP SPNL RND 4 DEG 22X22 MM TI X-CORE 2 7222204P2,SUP-2561379,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE SZ 2.6 MM TI MANDIBULAR HEMI NS DISP ACCUPLATE,SUP-2934735,CDM,C1713,HCPCS,0278,RC,,,,both,,,52004.68,33803.04,,,,,,,,,,,,,
PLATE BNE L62MM 3 H ST TI HK LOK COMPR FOR 35MM SCR,SUP-2180907,CDM,C1713,HCPCS,0278,RC,,,,both,,,2141.51,1391.98,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX15 CM 3L POLYURETHANE,SUP-2759970,CDM,C1751,HCPCS,0278,RC,,,,both,,,240.96,156.62,,,,,,,,,,,,,
PLATE BNE SM W11XL33MM THK34MM 2 H BILAT TI RIG NEUT LOK,SUP-2190771,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.52,504.09,,,,,,,,,,,,,
TRACKER SURG NAVIGATION PT TRUDI,SUP-2883970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
HC Pseudo-Aneurysm Compression,PX-4027693600,CDM,76936,CPT,0402,RC,,,,outpatient,,,3211.00,2087.15,,,,,,,,,,,,,
IMPLANT 14X26MM DISC INTBDY FUS LUM ANT W/ CAPINTERNAL FIX,SUP-2291442,CDM,2780000010,LOCAL,0278,RC,,,,both,,,13685.00,8895.25,,,,,,,,,,,,,
GRAFT BNE FOAM PK 12 CC VERSATILE SCAFFOLD VITOSS BBTRAUMA,SUP-2431359,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
HC Dx Laryngoscopy Excl Nb,PX-4503152500,CDM,31525,CPT,0450,RC,,,,both,,,1754.00,1140.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SLOM L 135 CM DIA 3.7 FR BALLOON L 20 MM,SUP-2153854,CDM,C1725,HCPCS,0272,RC,,,,both,,,787.51,511.88,,,,,,,,,,,,,
GRAFT BNE SUB W18X10MM D18MM THK10MM TI CANC RIG FIX FOR,SUP-2397885,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GRAFT 21 23CM WX295 31 LX08 17MM THCK L DMND FLEXHD,SUP-2307516,CDM,Q4128,HCPCS,0636,RC,,,,both,,,48125.65,31281.67,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 6 MM TRMPT TAPR STD HELIX,SUP-2483747,CDM,C1768,CPT,0278,RC,,,,both,,,2383.26,1549.12,,,,,,,,,,,,,
KIT VOID FILL STIMULAN RAP CURE 20CC,SUP-2135335,CDM,C1713,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
QUETIAPINE FUMARATE 400 MG PO TABS,RX-70398,CDM,6370000000,HCPCS,0637,RC,50268-0635-11,NDC,,both,1,UN,4.30,2.79,,,,,,,,,,,,,
COVER BUR H DIA7MM STD UNIV CRANIOMAXILLOFACIAL TI LO PROF,SUP-2366286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,790.81,514.03,,,,,,,,,,,,,
LIGHT CURING LED COLTOLUX,SUP-2322060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1445.50,939.57,,,,,,,,,,,,,
NEEDLE SPNL 24GA L3.5IN GERTIE MARX PNCL PT W/ INTRO,SUP-2241844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.74,240.33,,,,,,,,,,,,,
SET PICC L 40 CM DIA 6 FR SHTH L 7 CM DIA 6 FR,SUP-2887028,CDM,C1751,HCPCS,0278,RC,,,,both,,,714.04,464.13,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR W/SINGLE LEAD FOR MODEL 1000,SUP-2175903,CDM,C1767,HCPCS,0278,RC,,,,both,,,129766.78,84348.41,,,,,,,,,,,,,
SCREW BNE 1.5X6 MM 3.5 MM THRD BROWLIFT BEAL HEX DRL FREE,SUP-2489129,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.74,207.18,,,,,,,,,,,,,
ALLOGRAFT BNE CROSS SECT 8 MM PRESERVON CALCANEUS MATRIGRAFT,SUP-2740959,CDM,C1713,HCPCS,0278,RC,,,,both,,,1784.24,1159.76,,,,,,,,,,,,,
COLLAR EXTRIC PED 1.5IN FOR 8-18IN FR 1 PC FLAT LOK TAB CLS,SUP-2194417,CDM,L0120,HCPCS,0274,RC,,,,both,,,18.09,11.76,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 22 MM DIA 5 MM CATH L 80 CM,SUP-2884885,CDM,C1874,HCPCS,0278,RC,,,,both,,,7917.35,5146.28,,,,,,,,,,,,,
PLATE BONE M THK0.6MM 2 H MIDFACE SLV TI STR FOR 2MM SCR,SUP-2402932,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
LEVEL CMF ST SIZER SET MDFCE TRMA ALMNM QT001 EA,SUP-2677520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.08,206.10,,,,,,,,,,,,,
HC So1 Prothrombin Time|NOT REASONABLE AND NECESSARY,PX-3058561067,CDM,85610,CPT,0305,RC,,,GZ,both,,,7.00,4.55,,,,,,,,,,,,,
PLATE BNE CONN 8 HOLE,SUP-2472597,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE L36MM THK0.9MM 7 H R CNDYL S STL LO PROF RIG NEUT,SUP-2186298,CDM,C1713,HCPCS,0278,RC,,,,both,,,1392.65,905.22,,,,,,,,,,,,,
BRACE ANK AIR STRRP PED HT 6 IN,SUP-2336084,CDM,L4350,HCPCS,0272,RC,,,,both,,,31.81,20.68,,,,,,,,,,,,,
PUMP PERF IMPELLA 2.5,SUP-2106287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IFORIA 7 VR-T DX W 55 X H 65 MM D 11 MM,SUP-2138360,CDM,C1722,HCPCS,0275,RC,,,,both,,,50868.00,33064.20,,,,,,,,,,,,,
IMPLANT SYNTH 93 X 74 MM THK 20 MM MED POLYETHYL RT TEMPORAL,SUP-2883542,CDM,C1713,HCPCS,0278,RC,,,,both,,,4963.96,3226.57,,,,,,,,,,,,,
GRAFT VASC HERO L 50 CM DIA 6 MM SIL NIT ART CO STRL,SUP-2874108,CDM,C1768,CPT,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
ULTRABAG/DIANEAL/2.5% DEXTROSE 395 MOSM/L IP SOLN,RX-21546,CDM,2580000003,HCPCS,0258,RC,00941-0430-53,NDC,,both,1000,ML,69.00,44.85,,,,,,,,,,,,,
SCREW BNE CANN 3X29 MM SD HALF THRD SS,SUP-2409879,CDM,C1713,HCPCS,0278,RC,,,,both,,,512.45,333.09,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA S DELIVERED ENERGY 36 J TI POLYUR,SUP-2282423,CDM,C1722,HCPCS,0275,RC,,,,both,,,36642.45,23817.59,,,,,,,,,,,,,
BRACE ORTH CLOSURE SM AD BK SHLDR BLK QUIKDRAW PRO,SUP-2123908,CDM,L0628,HCPCS,0272,RC,,,,both,,,165.64,107.67,,,,,,,,,,,,,
VALVE CSF PERF LEVEL 2 NEONATE 90 CM DELT,SUP-2628520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3473.56,2257.81,,,,,,,,,,,,,
OCCLUDER UTER DISP COLPO-PNEUMO,SUP-2171682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
STEM FEMORAL SOL SYS 10/15.0 R LRG STAT,SUP-2513075,CDM,C1776,CPT,0278,RC,,,,both,,,19643.84,12768.50,,,,,,,,,,,,,
KIT STEERABLE VERSACROSS WIRE/SHEATH MD,SUP-2525909,CDM,C1766,CPT,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 200X200X0.6 MM RIGID TI SLV STRL,SUP-2859900,CDM,C1713,HCPCS,0278,RC,,,,both,,,25673.27,16687.63,,,,,,,,,,,,,
HALOPERIDOL 5 MG PO TABS,RX-3583,CDM,6370000000,HCPCS,0637,RC,68382-0079-01,NDC,,both,1,UN,2.90,1.88,,,,,,,,,,,,,
SCREW BNE L90MM DIA3.5MM S STL CORT PERIARTC ST,SUP-2410854,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
BIT DRL ATTCH REUSE FOR CBL TENSIONER,SUP-2188555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,532.80,346.32,,,,,,,,,,,,,
COVER BUR H DIA15MM TI SHUNT FOR CRAN CLSR SYS,SUP-2243978,CDM,C1713,HCPCS,0278,RC,,,,both,,,272.90,177.38,,,,,,,,,,,,,
CHRONOS(TM) BETA-TCP BLOCK 20MM X 20MM X 10MM-STERILE,SUP-2550431,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.76,1188.04,,,,,,,,,,,,,
SHANK SPNL SCREW L 30 MM DIA 5 MM OSTEOGRIP STRL CD HORZ 2PK,SUP-2928379,CDM,C1713,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
PLATE BONE ADAPTION 2 MM 20 HOLE RAPID RESORBABLE STERILE RA,SUP-2838590,CDM,C1713,HCPCS,0278,RC,,,,both,,,1202.31,781.50,,,,,,,,,,,,,
FILTER VASC OPTEASE L 55 CM NIT FEM ACCS OBTURATOR BRT TIP,SUP-2157005,CDM,C1880,HCPCS,0278,RC,,,,both,,,4012.92,2608.40,,,,,,,,,,,,,
BLADE SHV DIA4MM ENT MICRODEBRIDER AGG,SUP-2366838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.36,193.93,,,,,,,,,,,,,
HC Duplex Av Dialysis Shunt,PX-9219399000,CDM,93990,CPT,0921,RC,,,,inpatient,,,1222.00,794.30,,,,,,,,,,,,,
GRAFT BONE SUB W14XH7XL14MM CORT INTBDY FUS FRZ DRY BLK SPCR,SUP-2277891,CDM,C1889,HCPCS,0278,RC,,,,both,,,2650.16,1722.60,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO LP L 140 CM DIA 6 FR GUIDEWIRE,SUP-2383130,CDM,C1757,HCPCS,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
CATHETER HD DL 11.5 FRX15 CM FULL KT PRECRV DUOFLO,SUP-2267010,CDM,C1752,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
PROBE SURG PEDCL SCREW STRL PHANTOM XL DISP,SUP-2731890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.49,585.97,,,,,,,,,,,,,
CUFF ORTHOT HIP BILATERAL THGH CUST W/SPRD BAR,SUP-2435600,CDM,L1652,HCPCS,0274,RC,,,,both,,,1009.23,656.00,,,,,,,,,,,,,
PLATE BNE W12XL196MM THK3.7MM LNG 8 H NONSTERILE PROX HUM S,SUP-2186019,CDM,C1713,HCPCS,0278,RC,,,,both,,,4728.49,3073.52,,,,,,,,,,,,,
BUR SURG L14CM DIA6MM BALL FLUT L BOR MIDAS REX LEGEND,SUP-2284378,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
CATHETER CNTRL VNOU LUMENX1 5FR DIA 34CML SIL 0.3ML JUG SUBC,SUP-2613071,CDM,C1751,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE BNE ADPT 2.7X161 MM 20 HOLE LCK COMPR SS STRL LCP,SUP-2789587,CDM,C1713,HCPCS,0278,RC,,,,both,,,1655.28,1075.93,,,,,,,,,,,,,
NEEDLE BRST LOC BLNT 20 GAX3 CM W/ ECHOGENIC TIP STRL HAWK3,SUP-2876185,CDM,C1819,HCPCS,0278,RC,,,,both,,,151.03,98.17,,,,,,,,,,,,,
GRAFT DERM MTRX HUM TISS FLD HYDRATED THCK KT BILAT BRST,SUP-2307584,CDM,Q4128,HCPCS,0636,RC,,,,both,,,11838.59,7695.08,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.5MM SIL TI SELF DRL FULL THRD,SUP-2760173,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.99,168.99,,,,,,,,,,,,,
PLATE BNE NAVICULAR GRID,SUP-2864967,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
"HC So Organic Acid, Single,Quant",PX-3018392166,CDM,83921,CPT,0301,RC,,,,both,,,382.00,248.30,,,,,,,,,,,,,
HC I&D Simple,PX-7611006000,CDM,10060,CPT,0761,RC,,,,outpatient,,,632.00,410.80,,,,,,,,,,,,,
BRACE WR M AD FOR 6.75-7.75IN RT ADJ MALL STAY COCKUP LOOP,SUP-2197947,CDM,L3931,HCPCS,0274,RC,,,,both,,,46.63,30.31,,,,,,,,,,,,,
STRIP SUTURE STRL DISP ZIPSEAL 24,SUP-2904128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1476.37,959.64,,,,,,,,,,,,,
BLADE MID SZ GLIDESCOPE TIP TO FR OF HNDL 82MM THICKNESS AT,SUP-2392651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
BUR SURG RND DMND NONFLUTED L750MM OD05MM,SUP-2284185,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.48,294.76,,,,,,,,,,,,,
GRAFT BNE SUB 20CC DBM BIOCOMPOSITE OSTEOSET PTTY INJ,SUP-2399060,CDM,C1734,HCPCS,0278,RC,,,,both,,,6289.42,4088.12,,,,,,,,,,,,,
PLATE BONE SM L78MM 6 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348993,CDM,C1713,HCPCS,0278,RC,,,,both,,,1343.20,873.08,,,,,,,,,,,,,
SOCKET EXT FIX L30MM S STL THRD FOR ILIZ TAY SPAT FRME,SUP-2342276,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.86,253.41,,,,,,,,,,,,,
TIP CATH 0DEG SPHENOID SNUS GUID FOR BLLN SINUPLASTY SYS,SUP-2106373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
HC N Block Inj Intercost Sng|LEFT SIDE|PO,CASE-64420,LOCAL,64420,CPT,0360,RC,,,LT|PO,outpatient,,,4274.83,2564.90,,,,,,,,,,,,,
Rhytidectomy Smas Flap,CASE-15829,LOCAL,15829,CPT,0360,RC,,,,outpatient,,,61414.18,36848.51,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE,CASE-27695,LOCAL,27695,CPT,0360,RC,,,LT,outpatient,,,38842.92,23305.75,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38792,LOCAL,38792,CPT,0361,RC,,,XU,outpatient,,,44899.70,26939.82,,,,,,,,,,,,,
Incision & Drainage Leg/Ankle Abscess/Hematoma|LEFT SIDE,CASE-27603,LOCAL,27603,CPT,,,,,LT,outpatient,,,20212.50,12127.50,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE,CASE-27601,LOCAL,27601,CPT,0360,RC,,,RT,outpatient,,,33279.22,19967.53,,,,,,,,,,,,,
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE|PO,CASE-25628,LOCAL,25628,CPT,,,,,LT|PO,outpatient,,,20715.72,12429.43,,,,,,,,,,,,,
HC App Skin Sub T/a/L Tot <100 1st 25,CASE-15271,LOCAL,15271,CPT,0361,RC,,,,outpatient,,,8561.38,5136.83,,,,,,,,,,,,,
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,LOCAL,G0105,CPT,0360,RC,,,74,outpatient,,,7667.07,4600.24,,,,,,,,,,,,,
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE,CASE-28300,LOCAL,28300,CPT,0360,RC,,,LT,outpatient,,,52734.25,31640.55,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,LOCAL,52005,CPT,,,,,50|XU,outpatient,,,28847.67,17308.60,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,LOCAL,64491,CPT,,,,,RT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
Biopsy Urethra,CASE-53200,LOCAL,53200,CPT,0360,RC,,,,outpatient,,,19746.45,11847.87,,,,,,,,,,,,,
Excision/Curettage Cyst/Tumor Femur|LEFT SIDE,CASE-27355,LOCAL,27355,CPT,0360,RC,,,LT,outpatient,,,17556.60,10533.96,,,,,,,,,,,,,
BLADE SHAVER SERRATED 0-40 DEG 4 MM MALL DSTL SUCTION STRL,SUP-2638417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.12,304.93,,,,,,,,,,,,,
OBTURATOR ENDOSCP DISECT NS ECTRA II LTX,SUP-2877788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,900.08,585.05,,,,,,,,,,,,,
PROBE SURG MCCULLOCH 18 MM 9.5 IN FORAMINAL ULTRA,SUP-2470135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.23,243.25,,,,,,,,,,,,,
PROBE LITHO DIA7FR ELEC HYDRLC,SUP-2261214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.75,586.79,,,,,,,,,,,,,
BRACE OPN POPLITEAL 28IN 305IN SZ 3XL FREDDIE,SUP-2196843,CDM,L1810,HCPCS,0272,RC,,,,both,,,66.13,42.98,,,,,,,,,,,,,
CONTROLLER SYS MONITOR LT VENTRICULAR HEARTMATE II,SUP-2356031,CDM,C1713,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
CONNECTOR EXT FIX SM QUIK XTRAFIX,SUP-2468261,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
PLATE BNE SM W10.1XL149MM THK3.5MM 12 H BILAT S STL CRV RIG,SUP-2186264,CDM,C1713,HCPCS,0278,RC,,,,both,,,2286.83,1486.44,,,,,,,,,,,,,
ROD EXT FIX L200MM DIA11MM C FBR MAG RESONANCE CONDITIONAL,SUP-2188654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,594.34,386.32,,,,,,,,,,,,,
ALLOGRAFT BNE STRP IRRADIATED TRICORT IL CREST,SUP-2867130,CDM,C1762,CPT,0278,RC,,,,both,,,6174.81,4013.63,,,,,,,,,,,,,
PLATE BNE L185MM 12 H NONSTERILE R LAT PROX TIB S STL LOK,SUP-2185618,CDM,C1713,HCPCS,0278,RC,,,,both,,,3973.70,2582.90,,,,,,,,,,,,,
RETRACTOR SURG W 26 MM BLADE EXT NS DISP SIG LTP,SUP-2886550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO LUMBAR 4 MOD SACR SCRAP PRE,SUP-2265011,CDM,L0464,HCPCS,0274,RC,,,,both,,,5736.78,3728.91,,,,,,,,,,,,,
SCREW BONE L5MM DIA1.85MM TI ST MATRIXORTHOGNATHIC 1 PER PK,SUP-2181786,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.31,204.30,,,,,,,,,,,,,
OCD DISPOSABLES KIT,SUP-2812881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,LOCAL,52356,CPT,0360,RC,,,RT,outpatient,,,30154.68,18092.81,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.5 Cm/<,CASE-11400,LOCAL,11400,CPT,,,,,,outpatient,,,11550.72,6930.43,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,LOCAL,64415,CPT,0360,RC,,,LT|XU|PO,outpatient,,,45363.33,27218.00,,,,,,,,,,,,,
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26357,LOCAL,26357,CPT,0360,RC,,,,outpatient,,,21815.82,13089.49,,,,,,,,,,,,,
Optx Greater Humeral Tuberosity Fx W/Int Fixj,CASE-23630,LOCAL,23630,CPT,,,,,,outpatient,,,57059.65,34235.79,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|PO,CASE-64454,LOCAL,64454,CPT,0360,RC,,,PO,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Injection Intralesional Up to & Includ 7 Lesions,CASE-11900,LOCAL,11900,CPT,,,,,,outpatient,,,33259.95,19955.97,,,,,,,,,,,,,
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE|PO,CASE-27792,LOCAL,27792,CPT,,,,,LT|PO,outpatient,,,32104.32,19262.59,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F9|PO,outpatient,,,10505.60,6303.36,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,LOCAL,G0260,CPT,,,,,50,outpatient,,,4421.95,2653.17,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,LOCAL,52005,CPT,,,,,XU,outpatient,,,24893.75,14936.25,,,,,,,,,,,,,
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,LOCAL,58552,CPT,0360,RC,,,,outpatient,,,32085.30,19251.18,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|RIGHT SIDE|PO,CASE-23430,LOCAL,23430,CPT,,,,,RT|PO,outpatient,,,48936.28,29361.77,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,LOCAL,45385,CPT,0360,RC,,,PT|XU,outpatient,,,23559.47,14135.68,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT|PO",CASE-26727,LOCAL,26727,CPT,0360,RC,,,F3|PO,outpatient,,,10491.15,6294.69,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE|PO,CASE-29807,LOCAL,29807,CPT,,,,,LT|PO,outpatient,,,49076.20,29445.72,,,,,,,,,,,,,
Repair Dislocating Peroneal Tendon W/Fib Osteot|LEFT SIDE|PO,CASE-27676,LOCAL,27676,CPT,0360,RC,,,LT|PO,outpatient,,,32962.88,19777.73,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE|PO,CASE-29883,LOCAL,29883,CPT,0360,RC,,,LT|PO,outpatient,,,81502.78,48901.67,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,LOCAL,64494,CPT,0360,RC,,,,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Fasciectomy Plantar Fascia Partial Spx|BILATERAL PROCEDURE|PO,CASE-28060,LOCAL,28060,CPT,0360,RC,,,50|PO,outpatient,,,13107.12,7864.27,,,,,,,,,,,,,
Open Treatment Tarsometatarsal Joint Dislocation,CASE-28615,LOCAL,28615,CPT,,,,,,outpatient,,,37055.32,22233.19,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp,CASE-27691,LOCAL,27691,CPT,0360,RC,,,,outpatient,,,102832.62,61699.57,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE|PO",CASE-64708,LOCAL,64708,CPT,,,,,LT|PO,outpatient,,,19134.67,11480.80,,,,,,,,,,,,,
ELECTRODE ELECSURG COAG 3 FRX110 CM BUGBY FLX XC STRL,SUP-2585776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,271.83,176.69,,,,,,,,,,,,,
PLATE BNE L223MM 14 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185650,CDM,C1713,HCPCS,0278,RC,,,,both,,,4007.77,2605.05,,,,,,,,,,,,,
WIRE TEMP FIX 3 MM DIAM S STL DBL END SMOOTH DBL SHRP TIP,SUP-2342718,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.16,136.60,,,,,,,,,,,,,
HC Specific Gravity Except Urine,PX-3018431500,CDM,84315,CPT,0301,RC,,,,both,,,70.00,45.50,,,,,,,,,,,,,
COMPONENT FEM L67.5MM KNEE SEG IMP MOST OPTIONS,SUP-2208263,CDM,C1776,CPT,0278,RC,,,,both,,,8647.56,5620.91,,,,,,,,,,,,,
CATHETER HD TWO LUMEN 12 FRX6 IN LG BOR KT ARROWG+ARD BLU,SUP-2627031,CDM,C1752,HCPCS,0278,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 2-5-2MM SPC TIP L4MM BND 1MM QPLR,SUP-2357029,CDM,C1733,HCPCS,0272,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
PLATE BONE L117MM 10 HOLE BLTRL STNLSS STEEL STRGHT RCNSTRCT,SUP-2499132,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.11,733.27,,,,,,,,,,,,,
CATHETER URET 5FR L70CM OPN END SGL LUMN INJ HUB FLEXIMA,SUP-2139290,CDM,C1758,HCPCS,0278,RC,,,,both,,,32.81,21.33,,,,,,,,,,,,,
PLATE BNE L23MM 4 H NONSTERILE S STL LOK COMPR W/ SHT THRD,SUP-2184180,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.18,471.37,,,,,,,,,,,,,
ROD ORTH THRD 250 MM PILLAR,SUP-2749921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
OXYGENATOR PERF HPRN QUADROX ID BIOLINE,SUP-2266018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4135.38,2688.00,,,,,,,,,,,,,
GUIDEWIRE VASC MINI HYDRPHLC HYBRID SFT TRAXCESS,SUP-2305451,CDM,C1769,HCPCS,0272,RC,,,,both,,,1766.25,1148.06,,,,,,,,,,,,,
FIBER LASER 30 DEG INFRATOME,SUP-2225607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
LENS INTOCU +6.0 TO +34.0 DIOPT CYL PWR 5.25 DIOPT L13MM,SUP-2111949,CDM,V2787,HCPCS,0276,RC,,,,both,,,415.00,269.75,,,,,,,,,,,,,
Excision Tumor Soft Tis Back/Flank Subq 3 Cm/>,CASE-21931,LOCAL,21931,CPT,,,,,,outpatient,,,21275.58,12765.35,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn,CASE-64415,LOCAL,64415,CPT,0360,RC,,,,outpatient,,,42758.73,25655.24,,,,,,,,,,,,,
Excision/Curettage Cyst/Tumor Femur|RIGHT SIDE,CASE-27355,LOCAL,27355,CPT,,,,,RT,outpatient,,,33172.63,19903.58,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE|PO,CASE-64454,LOCAL,64454,CPT,0360,RC,,,50|PO,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28299,LOCAL,28299,CPT,0360,RC,,,T5|PO,outpatient,,,21750.43,13050.26,,,,,,,,,,,,,
Laparoscopy Surg Partial Nephrectomy|RIGHT SIDE,CASE-50543,LOCAL,50543,CPT,0360,RC,,,RT,outpatient,,,112424.60,67454.76,,,,,,,,,,,,,
Rhinp Prim Complete Xtrnl Parts,CASE-30410,LOCAL,30410,CPT,0360,RC,,,,outpatient,,,20894.78,12536.87,,,,,,,,,,,,,
Arthrt Elbow Capsular Excision Capsular Rls Spx|LEFT SIDE|PO,CASE-24006,LOCAL,24006,CPT,0360,RC,,,LT|PO,outpatient,,,29722.00,17833.20,,,,,,,,,,,,,
Partial Excision Bone Tibia|LEFT SIDE|PO,CASE-27640,LOCAL,27640,CPT,,,,,LT|PO,outpatient,,,35793.97,21476.38,,,,,,,,,,,,,
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64448,LOCAL,64448,CPT,0360,RC,,,XU|RT|PO,outpatient,,,45972.65,27583.59,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64418,LOCAL,64418,CPT,0360,RC,,,XU|RT|PO,outpatient,,,57312.20,34387.32,,,,,,,,,,,,,
Gastrocnemius Recession|LEFT SIDE|PO,CASE-27687,LOCAL,27687,CPT,0360,RC,,,LT|PO,outpatient,,,36063.18,21637.91,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT|PO",CASE-26727,LOCAL,26727,CPT,,,,,F9|PO,outpatient,,,15865.68,9519.41,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH DUO L 23 CM DIA 9 FR CATH 4/5 FR,SUP-2357121,CDM,C1894,HCPCS,0272,RC,,,,both,,,33.91,22.04,,,,,,,,,,,,,
BENDING PLIERS FOR PLATES COMPLETE WITH TWO ANVILS,SUP-2548473,CDM,C1713,HCPCS,0278,RC,,,,both,,,5327.89,3463.13,,,,,,,,,,,,,
BASKET SPEC RETRV STONE 3.1 FRX90 CM 5 MM LESLIE PARACHUTE,SUP-2141708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.46,372.75,,,,,,,,,,,,,
BLADE SAW SZ 7 UNIV WIDE SAG FOR PROPHECY INBONE TOT ANK,SUP-2397086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
TROCHANTERIC NAIL 11MMX20CMX120 DEGREE,SUP-2811014,CDM,C1713,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
IMPLANT PENILE L15CM CYL INFL MINOCYCLINE RIFAMPIN,SUP-2140297,CDM,C1813,HCPCS,0278,RC,,,,both,,,17536.90,11398.98,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA22 MM POLYESTER GEL,SUP-2385019,CDM,L8670,HCPCS,0278,RC,,,,both,,,1445.44,939.54,,,,,,,,,,,,,
SHAFT CUP REM 52MM STRT FIX HNDL W/ BLDE,SUP-2242466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
DILATOR PROS OD17FR PROVOX,SUP-2124314,CDM,L8514,HCPCS,0274,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
SCREW BONE L10MM D24MM LOK MTRSL SHRTNNG SSTM MSPT,SUP-2588982,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
CATHETER CV PRESSURE MONITORING TY 015 2.5 FRX2.5 CM,SUP-2760150,CDM,C1751,HCPCS,0278,RC,,,,both,,,214.87,139.67,,,,,,,,,,,,,
ANCHOR SUT OD55MM 2 3 PEEK OPTMA POLYMER TANT MRK MACBRIDE,SUP-2212836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,LOCAL,G0260,CPT,0360,RC,,,RT,outpatient,,,4422.92,2653.75,,,,,,,,,,,,,
HC Wound Vac <=50 Sq Cm Dme|ADJ,CASE-97605,LOCAL,97605,CPT,0761,RC,,,ADJ,outpatient,,,1648.83,989.30,,,,,,,,,,,,,
Revj Opn Arven Fstl W/O Thrmbc Dial Grf,CASE-36832,LOCAL,36832,CPT,0360,RC,,,,outpatient,,,37125.75,22275.45,,,,,,,,,,,,,
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26536,LOCAL,26536,CPT,0360,RC,,,F9|PO,outpatient,,,18730.98,11238.59,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PO|SEPARATE STRUCTURE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,RT|PO|XS,outpatient,,,5380.92,3228.55,,,,,,,,,,,,,
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,LOCAL,58573,CPT,0360,RC,,,,outpatient,,,77235.17,46341.10,,,,,,,,,,,,,
Partial Excision Bone Fibula|RIGHT SIDE|PO,CASE-27641,LOCAL,27641,CPT,0360,RC,,,RT|PO,outpatient,,,32164.05,19298.43,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE|PO,CASE-29882,LOCAL,29882,CPT,,,,,RT|PO,outpatient,,,37790.18,22674.11,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, THUMB|PO",CASE-26765,LOCAL,26765,CPT,,,,,F5|PO,outpatient,,,15926.08,9555.65,,,,,,,,,,,,,
Open Repair of Rotator Cuff Chronic|LEFT SIDE,CASE-23412,LOCAL,23412,CPT,0360,RC,,,LT,outpatient,,,52273.90,31364.34,,,,,,,,,,,,,
Revascularization Iliac Art Angiop Ea Ipsi Vsl|LEFT SIDE,CASE-37222,LOCAL,37222,CPT,0360,RC,,,LT,outpatient,,,56908.88,34145.33,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME LT KNEE ACL DROPLOCK HINGE S/TH,SUP-2915019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.49,1010.42,,,,,,,,,,,,,
SYSTEM ACCS WATCHMAN FXD L 75 CM OD 5 MM ID 4.2 MM SINGLE,SUP-2754214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
ORTHO ANCHRGE CROSS SHAPE PLATE SCREW STYLE HEAD 9MM BRDGE C,SUP-2676796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1306.71,849.36,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM CORT DST RAD VOLAR TI NONLOCKING,SUP-2340287,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.58,155.73,,,,,,,,,,,,,
WEDGE BNE LG 10 MM TITAN 3D,SUP-2321682,CDM,C1713,HCPCS,0278,RC,,,,both,,,6868.75,4464.69,,,,,,,,,,,,,
GRAFT HUM TISS 100MM FRZN ALLGRFT HUM W ROT CUF PROX,SUP-2307320,CDM,C1713,HCPCS,0278,RC,,,,both,,,11410.26,7416.67,,,,,,,,,,,,,
SYSTEM INT FIX INCL RIG INTFR SCR AND BIOCOMPOSITE,SUP-2121445,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
WASHER ORTH 1 MM,SUP-2749959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
CUP ACET DIA 67 MM SS TI SPRY HA HIP 2 MOBILITY CMTLS PF 3,SUP-2913847,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER ETER PEEL A WAY SHTH,SUP-2384050,CDM,C1751,HCPCS,0278,RC,,,,both,,,32.88,21.37,,,,,,,,,,,,,
CONNECTOR SPNL 21MM LEN LAT XLNK POST FIX 4.5 TO 6.5MM ROD,SUP-2229620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2X22 MM MANDIBULAR 4 HOLE TENSION BAND T,SUP-2838418,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.79,1008.66,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64415,LOCAL,64415,CPT,0360,RC,,,XU|LT|PO,outpatient,,,34095.55,20457.33,,,,,,,,,,,,,
Conv Prev Hip Tot Hip Arthrp W/WO Agrft/Algrft,CASE-27132,LOCAL,27132,CPT,0360,RC,,,,outpatient,,,82195.42,49317.25,,,,,,,,,,,,,
Laparoscopy Nephrectomy W/Partial Ureterect|RIGHT SIDE,CASE-50546,LOCAL,50546,CPT,0360,RC,,,RT,outpatient,,,97230.95,58338.57,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,LOCAL,28296,CPT,,,,,T5,outpatient,,,32022.20,19213.32,,,,,,,,,,,,,
Surg Tx Anal Fistula Subq,CASE-46270,LOCAL,46270,CPT,0360,RC,,,,outpatient,,,16115.98,9669.59,,,,,,,,,,,,,
HC Pbb Carpal Tunnel Inj Pmc|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-20526,LOCAL,20526,CPT,0510,RC,,,LT|PO|XS,outpatient,,,15271.40,9162.84,,,,,,,,,,,,,
Excision Olecranon Bursa|RIGHT SIDE|PO,CASE-24105,LOCAL,24105,CPT,0360,RC,,,RT|PO,outpatient,,,15782.53,9469.52,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,LOCAL,64415,CPT,0360,RC,,,RT|XU|PO,outpatient,,,38150.23,22890.14,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|PO",CASE-64491,LOCAL,64491,CPT,,,,,PO,outpatient,,,5111.60,3066.96,,,,,,,,,,,,,
Wmhc Perc Implant Stim Lead Ea,CASE-63650,LOCAL,63650,CPT,0360,RC,,,,outpatient,,,10599.43,6359.66,,,,,,,,,,,,,
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|LEFT FOOT, SECOND DIGIT|PO",CASE-28092,LOCAL,28092,CPT,0360,RC,,,T1|PO,outpatient,,,12995.53,7797.32,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT|PO",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F1|PO,outpatient,,,11434.45,6860.67,,,,,,,,,,,,,
Fth/Gft Fr W/Dir Clsr S/a/L Ea Addl 20 Cm/<,CASE-15221,LOCAL,15221,CPT,0360,RC,,,,outpatient,,,39572.23,23743.34,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,LOCAL,49651,CPT,,,,,50,outpatient,,,60107.72,36064.63,,,,,,,,,,,,,
Removal Shoulder Foreign Body Deep Subfascial/Im,CASE-23333,LOCAL,23333,CPT,0360,RC,,,,outpatient,,,14326.22,8595.73,,,,,,,,,,,,,
Bladder Instillation Anticarcinogenic Agent,CASE-51720,LOCAL,51720,CPT,,,,,,outpatient,,,19649.38,11789.63,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,LOCAL,29881,CPT,0360,RC,,,RT,outpatient,,,21012.33,12607.40,,,,,,,,,,,,,
HC Wound Vac <=50 Sq Cm Dme|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,LOCAL,97605,CPT,0761,RC,,,XU,outpatient,,,915.42,549.25,,,,,,,,,,,,,
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FIFTH DIGIT|PO",CASE-26125,LOCAL,26125,CPT,,,,,F4|PO,outpatient,,,16072.42,9643.45,,,,,,,,,,,,,
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion,CASE-52354,LOCAL,52354,CPT,0360,RC,,,,outpatient,,,18153.38,10892.03,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64418,LOCAL,64418,CPT,0360,RC,,,XU|RT,outpatient,,,44974.10,26984.46,,,,,,,,,,,,,
Axillary Lymphadenectomy Complete|RIGHT SIDE,CASE-38745,LOCAL,38745,CPT,,,,,RT,outpatient,,,48449.03,29069.42,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,LOCAL,23430,CPT,0360,RC,,,LT|XU,outpatient,,,75673.05,45403.83,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,LOCAL,64491,CPT,,,,,LT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
Open Treatment Fracture Distal Tibia & Fibula|RIGHT SIDE,CASE-27828,LOCAL,27828,CPT,,,,,RT,outpatient,,,45913.63,27548.18,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only,CASE-27601,LOCAL,27601,CPT,0360,RC,,,,outpatient,,,34921.98,20953.19,,,,,,,,,,,,,
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26536,LOCAL,26536,CPT,,,,,F4|PO,outpatient,,,41540.47,24924.28,,,,,,,,,,,,,
Excision Malignant Lesion S/N/H/F/G 2.1-3.0 Cm,CASE-11623,LOCAL,11623,CPT,0360,RC,,,,outpatient,,,24072.42,14443.45,,,,,,,,,,,,,
NAIL IM HUM 7X230 MM RT STRL AEQUALIS DISP,SUP-2715506,CDM,C1713,HCPCS,0278,RC,,,,both,,,6430.72,4179.97,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 9 FRX20 CM 3L STRL,SUP-2759922,CDM,C1751,HCPCS,0278,RC,,,,both,,,446.07,289.95,,,,,,,,,,,,,
SIMVASTATIN 20 MG PO TABS,RX-11365,CDM,6370000000,HCPCS,0637,RC,68084-0512-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEPIN ORTH 1.6X3.5 MM DRL TIP SS NS,SUP-2485885,CDM,C1769,HCPCS,0272,RC,,,,both,,,178.04,115.73,,,,,,,,,,,,,
COMPONENT TIBIAL 9MM CORE STERILE LATEX SLIDING STAR,SUP-2879172,CDM,C1776,CPT,0278,RC,,,,both,,,6421.61,4174.05,,,,,,,,,,,,,
FORCEPS GRSP L2300MM DIA28MM RAT TOOTH AUTOCLV REUSE FOR REM,SUP-2313135,CDM,C1713,HCPCS,0278,RC,,,,both,,,1682.47,1093.61,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 8 MM EPTFE STR STD WALL N RING,SUP-2396432,CDM,C1768,CPT,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
COLLAR CERV M H3XL17IN HK AND LOOP CLSR W/ STOCK,SUP-2194569,CDM,L0180,HCPCS,0274,RC,,,,both,,,45.50,29.57,,,,,,,,,,,,,
GRAFT 4 10MM 15ML ALLGRFT CHIP CRUSH CANC FRZN READIGRFT,SUP-2264733,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.87,463.37,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM PWR INJ N COAT SIL GROSH NXT,SUP-2126669,CDM,C1751,HCPCS,0278,RC,,,,both,,,302.01,196.31,,,,,,,,,,,,,
Partial Excision Bone Olecranon Process|RIGHT SIDE|PO,CASE-24147,LOCAL,24147,CPT,0360,RC,,,RT|PO,outpatient,,,15485.38,9291.23,,,,,,,,,,,,,
Suture Quadriceps/Hamstring Rupture Primary|RIGHT SIDE,CASE-27385,LOCAL,27385,CPT,,,,,RT,outpatient,,,31734.22,19040.53,,,,,,,,,,,,,
Syndactylization Toes,CASE-28280,LOCAL,28280,CPT,,,,,,outpatient,,,21840.08,13104.05,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open,CASE-24358,LOCAL,24358,CPT,0360,RC,,,,outpatient,,,17366.70,10420.02,,,,,,,,,,,,,
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE|PO,CASE-28300,LOCAL,28300,CPT,,,,,LT|PO,outpatient,,,37900.83,22740.50,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE,CASE-29876,LOCAL,29876,CPT,,,,,LT,outpatient,,,22068.90,13241.34,,,,,,,,,,,,,
Sesamoidectomy First Toe Spx|BILATERAL PROCEDURE|PO,CASE-28315,LOCAL,28315,CPT,0360,RC,,,50|PO,outpatient,,,26572.58,15943.55,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|LEFT SIDE|PO,CASE-28309,LOCAL,28309,CPT,0360,RC,,,LT|PO,outpatient,,,53463.60,32078.16,,,,,,,,,,,,,
Partial Excision Bone Metacarpal|LEFT SIDE|PO,CASE-26230,LOCAL,26230,CPT,,,,,LT|PO,outpatient,,,10847.07,6508.24,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26765,LOCAL,26765,CPT,,,,,F8|PO,outpatient,,,22563.88,13538.33,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, THUMB|PO",CASE-26765,LOCAL,26765,CPT,0360,RC,,,F5|PO,outpatient,,,15926.08,9555.65,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,LOCAL,38525,CPT,0360,RC,,,RT|XU,outpatient,,,47697.25,28618.35,,,,,,,,,,,,,
HC Tib per Territory Plasty|LEFT SIDE,CASE-37228,LOCAL,37228,CPT,0361,RC,,,LT,outpatient,,,46607.03,27964.22,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,LOCAL,64494,CPT,0360,RC,,,LT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Cervical Node,CASE-38510,LOCAL,38510,CPT,,,,,,outpatient,,,23761.63,14256.98,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT",CASE-28285,LOCAL,28285,CPT,,,,,T2,outpatient,,,27750.93,16650.56,,,,,,,,,,,,,
SPRINT PNS SINGLE LEAD SYSTEM,SUP-2355008,CDM,C1778,HCPCS,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
KIT GWIRE DIA2/2.4MM FOR ORTH BONE FIX RDY FOR SURG,SUP-2225501,CDM,C1769,HCPCS,0272,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
CAP NAIL FEM HIP FOR ESSENTIAL INSTR,SUP-2347911,CDM,C1776,CPT,0278,RC,,,,both,,,604.64,393.02,,,,,,,,,,,,,
KIT INTRO PED,SUP-2417197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
GRAFT DURA 1X3IN PURIFIED CLLGN MTRX REGEN DURAGN SECUR,SUP-2244018,CDM,C1713,HCPCS,0278,RC,,,,both,,,1703.29,1107.14,,,,,,,,,,,,,
CATHETER CTRL VEN 3 LUMN N TUNNELED BASIC KT POLYUR N COAT,SUP-2120589,CDM,C1751,HCPCS,0278,RC,,,,both,,,124.34,80.82,,,,,,,,,,,,,
HC Simulation Simple,PX-3337728000,CDM,77280,CPT,0333,RC,,,,both,,,1230.00,799.50,,,,,,,,,,,,,
BIT DRL LP 9 MM W/ EZ SHUTTLE SUTURE LOOP STRL,SUP-2608860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.43,1010.38,,,,,,,,,,,,,
CEMENT BNE RADIOPAQUE FAST SET ACRYL RESIN HI VISC SIMPLEXHV,SUP-2374946,CDM,C1776,CPT,0278,RC,,,,both,,,328.29,213.39,,,,,,,,,,,,,
STAPLER ENDO DIA12MM SIZE3.5MM L45MM BLU TISS LNAR CUT LN 6,SUP-2257592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,752.09,488.86,,,,,,,,,,,,,
SCREW BONE L34MM DIA3.5MM CORT PERIARTC S STL ST,SUP-2205644,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.15,173.00,,,,,,,,,,,,,
HC ED Cltx Rad Ulnr Shft Fx Manip,PX-4502556500,CDM,25565,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0 X 32MM HD CANN LNG THRD SCR,SUP-2320546,CDM,C1713,HCPCS,0278,RC,,,,both,,,839.95,545.97,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0250,RC,00990-7983-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT|PO",CASE-28285,LOCAL,28285,CPT,,,,,T1|PO,outpatient,,,21700.38,13020.23,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,LOCAL,36245,CPT,0361,RC,,,RT|XU,outpatient,,,25692.53,15415.52,,,,,,,,,,,,,
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64450,LOCAL,64450,CPT,0450,RC,,,RT|XU,outpatient,,,95883.12,57529.87,,,,,,,,,,,,,
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE,CASE-27822,LOCAL,27822,CPT,,,,,RT,outpatient,,,36422.03,21853.22,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO,CASE-62323,LOCAL,62323,CPT,,,,,PO,outpatient,,,4115.68,2469.41,,,,,,,,,,,,,
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE|PO,CASE-64421,LOCAL,64421,CPT,0360,RC,,,RT|PO,outpatient,,,5424.57,3254.74,,,,,,,,,,,,,
Ostectomy Prtl 5th Metar Head Spx|RIGHT SIDE|PO,CASE-28110,LOCAL,28110,CPT,,,,,RT|PO,outpatient,,,15830.75,9498.45,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE,CASE-29806,LOCAL,29806,CPT,,,,,RT,outpatient,,,44989.63,26993.78,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE|PO,CASE-64483,LOCAL,64483,CPT,,,,,RT|PO,outpatient,,,3914.52,2348.71,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT",CASE-28285,LOCAL,28285,CPT,,,,,T7,outpatient,,,34797.97,20878.78,,,,,,,,,,,,,
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,LOCAL,46260,CPT,0360,RC,,,,outpatient,,,16283.80,9770.28,,,,,,,,,,,,,
Thoracoscopy W/Exc Mediastinal Cyst Tumor/Mass,CASE-32662,LOCAL,32662,CPT,0360,RC,,,,outpatient,,,96443.17,57865.90,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|PO,CASE-11422,LOCAL,11422,CPT,0360,RC,,,PO,outpatient,,,11119.73,6671.84,,,,,,,,,,,,,
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,LOCAL,54410,CPT,0360,RC,,,,outpatient,,,89264.03,53558.42,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT HAND, FIFTH DIGIT|PO",CASE-26356,LOCAL,26356,CPT,0360,RC,,,F9|PO,outpatient,,,18158.58,10895.15,,,,,,,,,,,,,
COMPONENT FEM SM L65MM R DST KNEE ROT HNG GMRS,SUP-2376511,CDM,C1776,CPT,0278,RC,,,,both,,,17297.95,11243.67,,,,,,,,,,,,,
TSSERIES BIT DRILL 2.5MM SCREW,SUP-2586644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.22,327.09,,,,,,,,,,,,,
LARYNGECTOMY KIT PULM 10/36 10/55 STD W/ PROVOX LARYTUBE,SUP-2424441,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI HEM CATH CHRONIC 12.5FR DIA LNG 28CM P,SUP-2610597,CDM,C1750,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
STUD FIX L18.5MM DIA7.5MM PATELLOFEMORAL JT HEMICAP,SUP-2123693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL MOD,SUP-2435540,CDM,L0458,HCPCS,0274,RC,,,,both,,,2524.97,1641.23,,,,,,,,,,,,,
TROCAR LONG F/NAILS 8-13 SILE,SUP-2720071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.18,212.02,,,,,,,,,,,,,
GRAFT VASC STR 12 MMX15 CM X0.038 MM AORT CV BOV INTERGARD,SUP-2465833,CDM,C1768,CPT,0278,RC,,,,both,,,1365.24,887.41,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-9.5 MM 25 CC FRZN N PURGED ASEP CANC,SUP-2717933,CDM,C1713,HCPCS,0278,RC,,,,both,,,2158.75,1403.19,,,,,,,,,,,,,
CIPROFLOXACIN HCL 250 MG PO TABS,RX-25118,CDM,6370000000,HCPCS,0637,RC,65862-0076-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc,CASE-24341,LOCAL,24341,CPT,0360,RC,,,,outpatient,,,33273.60,19964.16,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,LOCAL,29824,CPT,,,,,LT,outpatient,,,46233.03,27739.82,,,,,,,,,,,,,
"Open Treatment Metatarsal Fracture Each|RIGHT FOOT, FIFTH DIGIT",CASE-28485,LOCAL,28485,CPT,,,,,T9,outpatient,,,19549.83,11729.90,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, GREAT TOE",CASE-28124,LOCAL,28124,CPT,0360,RC,,,T5,outpatient,,,18787.82,11272.69,,,,,,,,,,,,,
ROD SPNL LORDOSED END SPOOL CRD ST TRANSITION,SUP-2230049,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SCREW BONE L9MM OD2MM T6 CRTX ST TI VLP,SUP-2350907,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.44,187.49,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5 MM 5X38 MM DSTL FEM ST LCK TI NS NCB,SUP-2500515,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
PEG BONE FXTN L525MM OD4MM STNLSS STEEL PRXML HMRL LOK THRD,SUP-2721540,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC Rep Cpx Sc Arm Lg 2.6-7.5cm,PX-4501312100,CDM,13121,CPT,0450,RC,,,,both,,,2071.00,1346.15,,,,,,,,,,,,,
COLLAR CERV H3XL22IN 1 SZ FIT MOST ADJ HK AND LOOP CLSR,SUP-2194445,CDM,L0180,HCPCS,0272,RC,,,,both,,,7.47,4.86,,,,,,,,,,,,,
BIT DRL CANN 2.1 MM,SUP-2362781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.521,SUP-2860202,CDM,C1713,HCPCS,0278,RC,,,,both,,,33948.11,22066.27,,,,,,,,,,,,,
BOOT CAST L TOT CNTCT SYS TCC-EZ,SUP-2244448,CDM,L4387,HCPCS,0272,RC,,,,both,,,355.39,231.00,,,,,,,,,,,,,
WASHER SFT TISS OD35MM 6.25MM BIO-POST,SUP-2121117,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 16 GAX30 CM STYL,SUP-2133136,CDM,C1751,HCPCS,0278,RC,,,,both,,,11.74,7.63,,,,,,,,,,,,,
BIT DRL L260MM DIA8MM CANN FOR IM LIMB LENGTHENING SYS,SUP-2312222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt|RIGHT SIDE|PO,CASE-27602,LOCAL,27602,CPT,,,,,RT|PO,outpatient,,,20832.28,12499.37,,,,,,,,,,,,,
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|LEFT SIDE,CASE-37765,LOCAL,37765,CPT,,,,,LT,outpatient,,,38612.17,23167.30,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,LOCAL,29880,CPT,0360,RC,,,RT,outpatient,,,22355.77,13413.46,,,,,,,,,,,,,
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,LOCAL,46945,CPT,,,,,,outpatient,,,20061.38,12036.83,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64446,LOCAL,64446,CPT,0360,RC,,,XU|RT|PO,outpatient,,,44409.87,26645.92,,,,,,,,,,,,,
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|BILATERAL PROCEDURE,CASE-37722,LOCAL,37722,CPT,,,,,50,outpatient,,,39797.12,23878.27,,,,,,,,,,,,,
Dcmprn Fasct Leg Ant&/Lat Compartments Only|RIGHT SIDE|PO,CASE-27600,LOCAL,27600,CPT,,,,,RT|PO,outpatient,,,20812.13,12487.28,,,,,,,,,,,,,
Aspiration Bladder Insert Suprapubic Catheter|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51102,LOCAL,51102,CPT,0360,RC,,,XU,outpatient,,,28249.65,16949.79,,,,,,,,,,,,,
Excision Lesion Tendon Sheath/Capsule Leg&/Ank,CASE-27630,LOCAL,27630,CPT,0360,RC,,,,outpatient,,,24787.32,14872.39,,,,,,,,,,,,,
Open Treatment Calcaneal Fracture|LEFT SIDE|PO,CASE-28415,LOCAL,28415,CPT,,,,,LT|PO,outpatient,,,38117.17,22870.30,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, SECOND DIGIT",CASE-28308,LOCAL,28308,CPT,0360,RC,,,T1,outpatient,,,19207.23,11524.34,,,,,,,,,,,,,
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm/1pct,CASE-15002,LOCAL,15002,CPT,0360,RC,,,,outpatient,,,22521.73,13513.04,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THUMB|PO",CASE-26055,LOCAL,26055,CPT,,,,,FA|PO,outpatient,,,10333.88,6200.33,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, THIRD DIGIT|PO",CASE-28270,LOCAL,28270,CPT,0360,RC,,,T2|PO,outpatient,,,23884.05,14330.43,,,,,,,,,,,,,
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE,CASE-28730,LOCAL,28730,CPT,,,,,RT,outpatient,,,87131.53,52278.92,,,,,,,,,,,,,
Unlisted Procedure Abdomen Peritoneum & Omentum,CASE-49999,LOCAL,49999,CPT,,,,,,outpatient,,,78216.28,46929.77,,,,,,,,,,,,,
Litholapaxy Comp/Lg > 2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52318,LOCAL,52318,CPT,,,,,XU,outpatient,,,36113.70,21668.22,,,,,,,,,,,,,
Axillary Lymphadenectomy Complete,CASE-38745,LOCAL,38745,CPT,,,,,,outpatient,,,48449.03,29069.42,,,,,,,,,,,,,
CATHETER CTRL VEN 3.5FR 20CM LEN SGL LUMN N TUNNELED BASIC,SUP-2383451,CDM,C1751,HCPCS,0278,RC,,,,both,,,36.96,24.02,,,,,,,,,,,,,
ANCHOR SUTURE SIZE 1 LNG SOFT SINGLE LOADED JUGGERKNOT,SUP-2589015,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.59,680.28,,,,,,,,,,,,,
PLATE BONE TIBIAL 246X14X4 MM RIGHT LATERAL TIBIAL HEAD 13 H,SUP-2836988,CDM,C1713,HCPCS,0278,RC,,,,both,,,8726.22,5672.04,,,,,,,,,,,,,
RING EXT FIX 5/8 160 MM SALVATION,SUP-2850370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
STEM FEM L290MM TI FINN TOT DPHSEAL SEG,SUP-2407265,CDM,C1776,CPT,0278,RC,,,,both,,,21716.24,14115.56,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 25 CM OD 4 FR ID 0.061 IN TIP DIA,SUP-2384848,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
CATHETER PICC L 55 CM DIA 4.5 FR 1 LUMEN PRELD VPS STYL BLU,SUP-2886214,CDM,C1751,HCPCS,0278,RC,,,,both,,,1013.18,658.57,,,,,,,,,,,,,
PLATE BNE LCK 32 MM LT DSTL RADIAL VOLAR MEDL 2 HOLE CLMN,SUP-2462600,CDM,C1713,HCPCS,0278,RC,,,,both,,,2152.69,1399.25,,,,,,,,,,,,,
CATHETER KIT 8.5 FR 50 CC REPL INSRTN FOR USE W/ ALL OF IAB,SUP-2877618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
CATHETER REPROC EP 4FRX120CM JSN 4-ELECTRD 5-5-5MM,SUP-2653049,CDM,C1730,HCPCS,0272,RC,,,,both,,,146.20,95.03,,,,,,,,,,,,,
PLATE BONE L64MM 3 H STRL RT MEDL DSTL TIB S STL PART ARTC,SUP-2349715,CDM,C1713,HCPCS,0278,RC,,,,both,,,6868.28,4464.38,,,,,,,,,,,,,
CLIP HEMOSTASIS MANTIS 2.8MM X 235CM 10/BX,SUP-2855491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR STRL PROCLAIM + 7 LTX,SUP-2858408,CDM,C1767,HCPCS,0278,RC,,,,both,,,68295.00,44391.75,,,,,,,,,,,,,
Revascularization Iliac Artery Angiop 1st Vsl|RIGHT SIDE,CASE-37220,LOCAL,37220,CPT,0360,RC,,,RT,outpatient,,,86014.20,51608.52,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE|PO,CASE-24359,LOCAL,24359,CPT,,,,,RT|PO,outpatient,,,18340.05,11004.03,,,,,,,,,,,,,
Rpr Aa Hernia 1st < 3 Cm Reducible,CASE-49591,LOCAL,49591,CPT,,,,,,outpatient,,,33015.18,19809.11,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO,CASE-27691,LOCAL,27691,CPT,,,,,LT|PO,outpatient,,,47905.90,28743.54,,,,,,,,,,,,,
Litholapaxy Smpl/Sm <2.5 Cm|SEPARATE STRUCTURE,CASE-52317,LOCAL,52317,CPT,0360,RC,,,XS,outpatient,,,37159.03,22295.42,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT HAND, FOURTH DIGIT",CASE-28285,LOCAL,28285,CPT,,,,,F8,outpatient,,,32022.20,19213.32,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|PO,CASE-64454,LOCAL,64454,CPT,,,,,PO,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Partial Excision Bone Talus/Calcaneus|LEFT SIDE,CASE-28120,LOCAL,28120,CPT,0360,RC,,,LT,outpatient,,,42614.05,25568.43,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, THIRD DIGIT",CASE-28270,LOCAL,28270,CPT,0360,RC,,,T7,outpatient,,,39850.62,23910.37,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,LOCAL,29880,CPT,0360,RC,,,LT,outpatient,,,21791.13,13074.68,,,,,,,,,,,,,
SCREW BONE LAG 10MM DIA 75MML FNAIL,SUP-2724205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1688.25,1097.36,,,,,,,,,,,,,
GRAFT HUM TISS H10MM DIA7MM OSTEOCHNDRL CHONDROFIX,SUP-2200258,CDM,C1713,HCPCS,0278,RC,,,,both,,,8521.96,5539.27,,,,,,,,,,,,,
SLEEVE FEM +3.5MM LNG NK TI HIP DYNASTY,SUP-2304514,CDM,C1776,CPT,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
CHUCK DRL 5/32IN COR ORAL MAX JCBS,SUP-2362645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3120.69,2028.45,,,,,,,,,,,,,
BIT DRL OD42MM CALIB FOR RADLUC TARGET DEV,SUP-2371642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BONE THK2.5MM 12 H CRANIOMAXILLOFACIAL ORAL LT BLU TI,SUP-2181774,CDM,C1713,HCPCS,0278,RC,,,,both,,,3756.38,2441.65,,,,,,,,,,,,,
KIT THROMCTMY TREVO XP PROVUE L 190 CM RETRV L 36 MM DIA 3,SUP-2367763,CDM,C1713,HCPCS,0278,RC,,,,both,,,23534.30,15297.29,,,,,,,,,,,,,
SCREW BONE L6MM DIA2.7MM STD CORT S STL ST FULL THRD HEX HD,SUP-2343877,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.06,152.14,,,,,,,,,,,,,
TRAY GLEN SM SHLDR HA POR MOD BIOMOD,SUP-2404645,CDM,C1776,CPT,0278,RC,,,,both,,,3690.13,2398.58,,,,,,,,,,,,,
ANCHOR SUT PNCRYL 2-0 ABSRB 12DEG CRV NDL POLY BRAID FOR,SUP-2249491,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
FLUMAZENIL 1 MG/10ML IV SOLN,RX-39745,CDM,2500000003,HCPCS,0250,RC,00143-9683-10,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
TAP SURG SCR CANN CORT S CPL QUIK CONN 4.5MM,SUP-2412629,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
Cystourethroscopy With Biopsy,CASE-52204,LOCAL,52204,CPT,,,,,,outpatient,,,18014.98,10808.99,,,,,,,,,,,,,
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO|UNUSUAL NON-OVERLAPPING SERVICE,CASE-14040,LOCAL,14040,CPT,,,,,PO|XU,outpatient,,,26381.72,15829.03,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,LOCAL,52287,CPT,0360,RC,,,XS,outpatient,,,36225.73,21735.44,,,,,,,,,,,,,
Unlisted Px Skin Muc Membrane & Subq Tissue,CASE-17999,LOCAL,17999,CPT,0360,RC,,,,outpatient,,,34777.38,20866.43,,,,,,,,,,,,,
Arthrodesis Midtarsometatarsal Single Joint|RIGHT SIDE,CASE-28740,LOCAL,28740,CPT,,,,,RT,outpatient,,,85871.93,51523.16,,,,,,,,,,,,,
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-27680,LOCAL,27680,CPT,0360,RC,,,XS|RT|PO,outpatient,,,27808.43,16685.06,,,,,,,,,,,,,
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, SECOND DIGIT",CASE-28234,LOCAL,28234,CPT,0360,RC,,,T1,outpatient,,,11454.52,6872.71,,,,,,,,,,,,,
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE,CASE-28615,LOCAL,28615,CPT,0360,RC,,,LT,outpatient,,,31089.57,18653.74,,,,,,,,,,,,,
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|RIGHT SIDE|PO,CASE-27619,LOCAL,27619,CPT,,,,,RT|PO,outpatient,,,13561.68,8137.01,,,,,,,,,,,,,
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,LOCAL,46200,CPT,0360,RC,,,,outpatient,,,20061.38,12036.83,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT|PO",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T2|PO,outpatient,,,29936.68,17962.01,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,LOCAL,64483,CPT,,,,,LT,outpatient,,,3983.85,2390.31,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|PO|LEFT SIDE,CASE-64415,LOCAL,64415,CPT,0360,RC,,,XU|PO|LT,outpatient,,,21787.00,13072.20,,,,,,,,,,,,,
Rhytidectomy Smas Flap,CASE-15829,LOCAL,15829,CPT,,,,,,outpatient,,,61414.18,36848.51,,,,,,,,,,,,,
Rpr Nonunion/Malunion Radius/Ulna W/Autograft,CASE-25405,LOCAL,25405,CPT,,,,,,outpatient,,,30707.65,18424.59,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-24358,LOCAL,24358,CPT,0360,RC,,,XS|LT|PO,outpatient,,,26185.22,15711.13,,,,,,,,,,,,,
"Amp Mtcrpl W/Finger/Thumb W/WO Inteross Transfer|RIGHT HAND, FIFTH DIGIT|PO",CASE-26910,LOCAL,26910,CPT,,,,,F9|PO,outpatient,,,10837.33,6502.40,,,,,,,,,,,,,
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE,CASE-28740,LOCAL,28740,CPT,0360,RC,,,LT,outpatient,,,65701.70,39421.02,,,,,,,,,,,,,
HC Biopsy Liver Percutan Needle,PX-3614700000,CDM,47000,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SHELL ACET SZ 58D TI G SER MH STRL LOGICAL,SUP-2929682,CDM,C1776,CPT,0278,RC,,,,both,,,6906.12,4488.98,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM THN THK0.4-1MM REGENERATIVE TISS MTRX,SUP-2399079,CDM,C1713,HCPCS,0278,RC,,,,both,,,5460.46,3549.30,,,,,,,,,,,,,
SYSTEM FIX STD FEM W/ SHTH 8MM SCR L23MM DIA8-8.5MM,SUP-2249565,CDM,C1713,HCPCS,0278,RC,,,,both,,,2753.78,1789.96,,,,,,,,,,,,,
SCREW BNE L 50 MM DIA 8 MM SS ST SD CANN FULL THRD RVS CUT,SUP-2901056,CDM,C1713,HCPCS,0278,RC,,,,both,,,1039.31,675.55,,,,,,,,,,,,,
PLATE FT 160MM DBL H FOR EXT FIX SYS,SUP-2197252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV 4FR 55CM 2 LUMAN RVS TAP 3274108,SUP-2632663,CDM,C1751,HCPCS,0278,RC,,,,both,,,459.38,298.60,,,,,,,,,,,,,
REAMER SURG L12MM OD8MM STP CONIC T2,SUP-2361771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2635.09,1712.81,,,,,,,,,,,,,
PLATE BNE COMPR NAR 5 HOLE,SUP-2205650,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.22,267.94,,,,,,,,,,,,,
STENT URETH FIRLIT-KLUGE L 31 CM DIA 8 FR SIL BALL/TUBING NO,SUP-2171269,CDM,C2617,HCPCS,0278,RC,,,,both,,,120.20,78.13,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 100 MM DIA 8 MM DEL SHTH,SUP-2934346,CDM,C1713,HCPCS,0278,RC,,,,both,,,15049.77,9782.35,,,,,,,,,,,,,
KIT OXMTR CATH 8.5FR L16CM 3 LUMN CTRL LUMN OLIGON PRESEP,SUP-2214762,CDM,C1751,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
PROCEDURE KIT STPL 8X8 MM STRL ARCUS,SUP-2308934,CDM,C1713,HCPCS,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
PLATE BNE L35MM THK13MM 6 H NONSTERILE HND TI STR LOK VAR,SUP-2176870,CDM,C1713,HCPCS,0278,RC,,,,both,,,1685.14,1095.34,,,,,,,,,,,,,
NAIL IM TROCHANTERIC TI NS,SUP-2180364,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
GRAFT TISS LIGMNT PAT W/ QUAD BISC,SUP-2165548,CDM,C1713,HCPCS,0278,RC,,,,both,,,5510.70,3581.95,,,,,,,,,,,,,
IMPLANT SPINE INTERBOD ANTER CERV DAKOTA 14MM X 12MM X 10MM,SUP-2858713,CDM,C1889,HCPCS,0278,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE|PO,CASE-64483,LOCAL,64483,CPT,,,,,50|PO,outpatient,,,4090.33,2454.20,,,,,,,,,,,,,
Lateral Retinacular Release Open|RIGHT SIDE|PO,CASE-27425,LOCAL,27425,CPT,,,,,RT|PO,outpatient,,,21598.42,12959.05,,,,,,,,,,,,,
Nerve Repair W/Conduit Each Nerve|LEFT SIDE|PO,CASE-64910,LOCAL,64910,CPT,,,,,LT|PO,outpatient,,,56748.52,34049.11,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE|PO,CASE-15823,LOCAL,15823,CPT,,,,,50|PO,outpatient,,,70250.82,42150.49,,,,,,,,,,,,,
HC Removal FB Skin,CASE-10120,LOCAL,10120,CPT,0450,RC,,,,outpatient,,,11912.43,7147.46,,,,,,,,,,,,,
Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT SIDE|PO,CASE-28750,LOCAL,28750,CPT,,,,,RT|PO,outpatient,,,46277.97,27766.78,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open|RIGHT SIDE|PO,CASE-24358,LOCAL,24358,CPT,0360,RC,,,RT|PO,outpatient,,,16398.15,9838.89,,,,,,,,,,,,,
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE,CASE-27680,LOCAL,27680,CPT,,,,,LT,outpatient,,,85907.05,51544.23,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,LOCAL,29882,CPT,0360,RC,,,RT,outpatient,,,41914.63,25148.78,,,,,,,,,,,,,
Arthrt Elbow W/Exploration Drainage/Removal FB,CASE-24000,LOCAL,24000,CPT,0360,RC,,,,outpatient,,,40834.40,24500.64,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-24358,LOCAL,24358,CPT,,,,,XS|LT|PO,outpatient,,,26185.22,15711.13,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,LOCAL,64490,CPT,0361,RC,,,LT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
Arthrt Elbow W/Exploration Drainage/Removal FB,CASE-24000,LOCAL,24000,CPT,,,,,,outpatient,,,40834.40,24500.64,,,,,,,,,,,,,
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE|PO,CASE-25607,LOCAL,25607,CPT,,,,,RT|PO,outpatient,,,31155.25,18693.15,,,,,,,,,,,,,
Ercp Dx Collection Specimen Brushing/Washing,CASE-43260,LOCAL,43260,CPT,,,,,,outpatient,,,21575.25,12945.15,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg,CASE-29881,LOCAL,29881,CPT,0360,RC,,,,outpatient,,,24656.93,14794.16,,,,,,,,,,,,,
Thorcoscpy W/Mediastinl & Regionl Lymphdenectomy,CASE-32674,LOCAL,32674,CPT,0360,RC,,,,outpatient,,,96443.17,57865.90,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 37 MM DIA DSTL 22 MM SHTH 16 FR SS,SUP-2168746,CDM,C1874,HCPCS,0278,RC,,,,both,,,8992.96,5845.42,,,,,,,,,,,,,
BLADE SURG L28CM DIA4MM TIP L13MM 1 PC BEAV STR SHRP ROUNDED,SUP-2256843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
HOLDER SURG IMPL PLT TACK,SUP-2107840,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
GRAFT BNE PTTY DEMIN BNE MTRX 1CC TREL-XC,SUP-2244466,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
PLATFORM ACC 5.5CM CHAN W/ INTRO GELPOINT,SUP-2119680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309711000,CDM,97110,CPT,0430,RC,,,GO|CO|XU,both,,,195.00,126.75,,,,,,,,,,,,,
CATHETER ETER EP L115CM OD7FR L4MM 2 5 2MM SPC M QPLR BIDIR STEER,SUP-2356990,CDM,C1733,HCPCS,0272,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
NAIL IM 120 DEG L 240 MM DIA10 MM LNG TI ALLOY RT HIP,SUP-2904173,CDM,C1713,HCPCS,0278,RC,,,,both,,,10341.56,6722.01,,,,,,,,,,,,,
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,LOCAL,52318,CPT,0360,RC,,,,outpatient,,,41887.20,25132.32,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-28090,LOCAL,28090,CPT,,,,,XU|LT|PO,outpatient,,,21840.08,13104.05,,,,,,,,,,,,,
Rhinp Prim Complete Xtrnl Parts,CASE-30410,LOCAL,30410,CPT,,,,,,outpatient,,,20894.78,12536.87,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28270,LOCAL,28270,CPT,,,,,XS|T3|PO,outpatient,,,27333.98,16400.39,,,,,,,,,,,,,
Removal Intrauterine Device Iud,CASE-58301,LOCAL,58301,CPT,,,,,,outpatient,,,19280.30,11568.18,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE|PO,CASE-29806,LOCAL,29806,CPT,0360,RC,,,RT|PO,outpatient,,,38273.60,22964.16,,,,,,,,,,,,,
Blepharoplasty Lower Eyelid|BILATERAL PROCEDURE,CASE-15820,LOCAL,15820,CPT,,,,,50,outpatient,,,36231.00,21738.60,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT|PO",CASE-26860,LOCAL,26860,CPT,,,,,F9|PO,outpatient,,,52028.68,31217.21,,,,,,,,,,,,,
Dilat Rct Strix Spx Under Anes Oth/Thn Local,CASE-45910,LOCAL,45910,CPT,,,,,,outpatient,,,16099.63,9659.78,,,,,,,,,,,,,
Open Treatment Fracture Distal Tibia Only|RIGHT SIDE|PO,CASE-27827,LOCAL,27827,CPT,,,,,RT|PO,outpatient,,,24184.28,14510.57,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2|LEFT SIDE|PO,CASE-29822,LOCAL,29822,CPT,,,,,LT|PO,outpatient,,,40714.32,24428.59,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,LOCAL,64491,CPT,0360,RC,,,LT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,LOCAL,50590,CPT,,,,,RT,outpatient,,,21962.30,13177.38,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,LOCAL,38525,CPT,,,,,RT,outpatient,,,41466.28,24879.77,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, GREAT TOE",CASE-28124,LOCAL,28124,CPT,,,,,T5,outpatient,,,18787.82,11272.69,,,,,,,,,,,,,
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt|LEFT SIDE|PO,CASE-27602,LOCAL,27602,CPT,,,,,LT|PO,outpatient,,,20916.57,12549.94,,,,,,,,,,,,,
HC NM Thyroid Imaging,PX-3417801300,CDM,78013,CPT,0341,RC,,,,both,,,1847.00,1200.55,,,,,,,,,,,,,
PLATE BNE L 1.5X0.6 MM MIDFACE 10 HOLE W/ TAB FOR SCREW STRL,SUP-2518098,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.83,571.89,,,,,,,,,,,,,
KWIRE FIX L530MM S STL OLV,SUP-2242952,CDM,C1713,HCPCS,0278,RC,,,,both,,,996.60,647.79,,,,,,,,,,,,,
BASEPLATE TIB L47MM LNG MEDL LAT KNEE CO CHROM RESURF,SUP-2406481,CDM,C1776,CPT,0278,RC,,,,both,,,8633.43,5611.73,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X17 MM 6 LOBE,SUP-2602076,CDM,C1889,HCPCS,0278,RC,,,,both,,,9969.50,6480.17,,,,,,,,,,,,,
GRAFT VASC HERO L 53 CM OD 7.4 MM ID 6 MM SIL NIT VEN OUTFLO,SUP-2490844,CDM,C1768,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
TROCAR FLEXIPATH FLX THORACIC PAK W/15MM OBT 15MM FLX SLVS,SUP-2855499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.77,589.40,,,,,,,,,,,,,
PLATE BNE W5XL50MM THK1MM 3X9 H BILAT S STL T SHP RIG NEUT 24323] DEPUY SYNTHES USA],SUP-2186152,CDM,C1713,HCPCS,0278,RC,,,,both,,,682.95,443.92,,,,,,,,,,,,,
ARCH EXT FIX FT 100 MM,SUP-2497487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5375.68,3494.19,,,,,,,,,,,,,
PLATE BNE TBLR 145 MM 12-HOLE 1/3,SUP-2518446,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
CATHETER SUPP SOFIA EX L 105 CM DSTL L 9 CM OD 5.2 FR PROX,SUP-2739137,CDM,C1887,HCPCS,0272,RC,,,,both,,,5524.83,3591.14,,,,,,,,,,,,,
HC Collect Blood From Arterial Line,PX-7613779900,CDM,37799,CPT,0761,RC,,,,inpatient,,,1845.00,1199.25,,,,,,,,,,,,,
GRFT CHIPS CANC 4-9.5MM 5CC PUROS,SUP-2693922,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
BLADE RTRCTR 2INW X 65NL ALMNM MAL NON RDPQUE NON ST,SUP-2703356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1480.13,962.08,,,,,,,,,,,,,
CATHETER MIDLINE AGBA PI 2-L 5.5FR X 15CM,SUP-2850035,CDM,C1751,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,LOCAL,55040,CPT,0360,RC,,,LT,outpatient,,,21700.47,13020.28,,,,,,,,,,,,,
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, SECOND DIGIT|PO",CASE-26111,LOCAL,26111,CPT,,,,,F1|PO,outpatient,,,12366.98,7420.19,,,,,,,,,,,,,
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE,CASE-29891,LOCAL,29891,CPT,0360,RC,,,RT,outpatient,,,29753.75,17852.25,,,,,,,,,,,,,
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE|PO,CASE-28200,LOCAL,28200,CPT,0360,RC,,,RT|PO,outpatient,,,35678.48,21407.09,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,LOCAL,64483,CPT,0360,RC,,,50,outpatient,,,3990.02,2394.01,,,,,,,,,,,,,
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE,CASE-27829,LOCAL,27829,CPT,,,,,RT,outpatient,,,36581.78,21949.07,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,LOCAL,64633,CPT,,,,,RT,outpatient,,,12105.48,7263.29,,,,,,,,,,,,,
Arthrs Knee Drill Osteochondritis Dissecans Grfg,CASE-29885,LOCAL,29885,CPT,0360,RC,,,,outpatient,,,37993.68,22796.21,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,LOCAL,58662,CPT,,,,,50,outpatient,,,64158.35,38495.01,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|PO,CASE-64718,LOCAL,64718,CPT,0360,RC,,,RT|PO,outpatient,,,13112.32,7867.39,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE|PO,CASE-G0260,LOCAL,G0260,CPT,0360,RC,,,50|PO,outpatient,,,4478.50,2687.10,,,,,,,,,,,,,
Open Treatment Metatarsal Fracture Each|RIGHT SIDE,CASE-28485,LOCAL,28485,CPT,,,,,RT,outpatient,,,34208.55,20525.13,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE",CASE-28299,LOCAL,28299,CPT,,,,,TA,outpatient,,,40130.43,24078.26,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L >4.0 Cm|RIGHT SIDE,CASE-11406,LOCAL,11406,CPT,,,,,RT,outpatient,,,11523.42,6914.05,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,LOCAL,60220,CPT,,,,,RT,outpatient,,,46464.52,27878.71,,,,,,,,,,,,,
GRAFT HUM TISS CHORION BASE THCK 4X4 CM AMNIO ACTISHIELD,SUP-2759475,CDM,C1762,CPT,0278,RC,,,,both,,,6864.04,4461.63,,,,,,,,,,,,,
PLATE BNE L117MM 7 H R DST POSTEROLATERAL HUM S STL LOK,SUP-2185895,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.49,1826.82,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
SYSTEM EXT CSF DRNGE HERM II,SUP-2244302,CDM,C1729,HCPCS,0272,RC,,,,both,,,498.10,323.76,,,,,,,,,,,,,
PLATE BNE ULN LO PROF SHORTNG GENERATION II RAYHACK,SUP-2397320,CDM,C1713,HCPCS,0278,RC,,,,both,,,3353.52,2179.79,,,,,,,,,,,,,
PLATE INTERPEDICULAR ANTR STD TI UNIV 54MM LEN,SUP-2290570,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
GRAFT DURA W2XL2IN PURIFIED CLLGN MTRX REGEN DURAGN SECUR,SUP-2244019,CDM,C1713,HCPCS,0278,RC,,,,both,,,1770.33,1150.71,,,,,,,,,,,,,
TI PLUG SYS 7 CM 3PK,SUP-2402542,CDM,C1781,HCPCS,0278,RC,,,,both,,,590.32,383.71,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 75 CM OD 10 FR ID 3 MM GUIDEWIRE,SUP-2168382,CDM,C1894,HCPCS,0272,RC,,,,both,,,264.98,172.24,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM DIA 9 FR DIL 20 CM GUIDEWIRE 0.038,SUP-2168241,CDM,C1894,HCPCS,0272,RC,,,,both,,,67.92,44.15,,,,,,,,,,,,,
HOLDER IMPL PIN ANT CERV FIX FOR PLT ATLNTS,SUP-2291119,CDM,C1713,HCPCS,0278,RC,,,,both,,,221.43,143.93,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE|PO,CASE-64483,LOCAL,64483,CPT,,,,,LT|PO,outpatient,,,3914.52,2348.71,,,,,,,,,,,,,
HC Bladder Irrig Simple or Continuous,CASE-51700,LOCAL,51700,CPT,0761,RC,,,,outpatient,,,20920.03,12552.02,,,,,,,,,,,,,
Colonoscopy Flx W/Endoscopic Mucosal Resection|COLORECTAL CANCER SCREEN,CASE-45390,LOCAL,45390,CPT,,,,,PT,outpatient,,,11346.18,6807.71,,,,,,,,,,,,,
Exc Tumor Soft Tiss Shoulder Subfasc <5cm|LEFT SIDE,CASE-23076,LOCAL,23076,CPT,,,,,LT,outpatient,,,13966.12,8379.67,,,,,,,,,,,,,
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28160,LOCAL,28160,CPT,,,,,T9|PO,outpatient,,,21238.90,12743.34,,,,,,,,,,,,,
Arthroscopy Ankle Surgical Debridement Extensive|RIGHT SIDE,CASE-29898,LOCAL,29898,CPT,0360,RC,,,RT,outpatient,,,35045.92,21027.55,,,,,,,,,,,,,
Laparoscopy Surg Pyeloplasty,CASE-50544,LOCAL,50544,CPT,0360,RC,,,,outpatient,,,75551.85,45331.11,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|LEFT SIDE,CASE-49507,LOCAL,49507,CPT,0360,RC,,,LT,outpatient,,,24059.18,14435.51,,,,,,,,,,,,,
"Excision/Curettage Cyst/Tumor Phalanx Finger|RIGHT HAND, SECOND DIGIT|PO",CASE-26210,LOCAL,26210,CPT,,,,,F6|PO,outpatient,,,10788.45,6473.07,,,,,,,,,,,,,
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,LOCAL,49320,CPT,,,,,,outpatient,,,40052.20,24031.32,,,,,,,,,,,,,
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,LOCAL,43248,CPT,0360,RC,,,,outpatient,,,11923.00,7153.80,,,,,,,,,,,,,
ANCHOR SUTURE DIA1.4 MM SUTURE SZ 1 1 STRND XBRAID S WHT BLU,SUP-2908825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
HC Remv & Replc Pm Gen Sing,PX-4813322700,CDM,33227,CPT,0481,RC,,,,inpatient,,,28682.00,18643.30,,,,,,,,,,,,,
LIGATOR OD8.5-9.2MM 122CMXSM TAMP TRIG CRD MULT BND BRL,SUP-2169551,CDM,C1713,HCPCS,0278,RC,,,,both,,,874.02,568.11,,,,,,,,,,,,,
HC So1 Anti Nuclear Antibody,PX-3028603867,CDM,86038,CPT,0302,RC,,,,both,,,43.00,27.95,,,,,,,,,,,,,
SCREW BONE L10MM SUBTALAR TI CONCL SFT THRD ARTHROEREISIS,SUP-2319755,CDM,C1713,HCPCS,0278,RC,,,,both,,,7350.74,4777.98,,,,,,,,,,,,,
METHOTREXATE SODIUM PF 25 MG/ML IJ SOLN (MIXTURES ONLY),RX-1150418,CDM,J9260,HCPCS,0636,RC,61703-0408-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BONE L90MM DIA6.4MM TIB KNEE BLU TI PARTIALLY THRD HEX,SUP-2347266,CDM,C1713,HCPCS,0278,RC,,,,both,,,2342.22,1522.44,,,,,,,,,,,,,
SCREW BNE L20MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413565,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
STAPLE FRACTURE 7/8X7/8IN,SUP-2695768,CDM,C1713,HCPCS,0278,RC,,,,both,,,537.57,349.42,,,,,,,,,,,,,
GRAFT BIO TISS W6XL5CM THK2MM NONDENATURED CLLGN BOV RECTANG,SUP-2243679,CDM,C9360,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
SCREW BONE 4.5X12MM CANC ST,SUP-2202663,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.43,262.88,,,,,,,,,,,,,
SUPPORT ORTHOT THOR ANTR CUST DEROTATION,SUP-2435589,CDM,L1260,HCPCS,0274,RC,,,,both,,,267.03,173.57,,,,,,,,,,,,,
HC So Hiv-1 & Hiv-2 Ab,PX-3068738966,CDM,87389,CPT,0306,RC,,,,inpatient,,,121.00,78.65,,,,,,,,,,,,,
PLATE TUB 8H 95MM,SUP-2695655,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.43,832.93,,,,,,,,,,,,,
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE,CASE-29898,LOCAL,29898,CPT,,,,,LT,outpatient,,,40869.75,24521.85,,,,,,,,,,,,,
Mastectomy Partial|LEFT SIDE,CASE-19301,LOCAL,19301,CPT,0360,RC,,,LT,outpatient,,,34335.15,20601.09,,,,,,,,,,,,,
Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,CASE-49592,LOCAL,49592,CPT,,,,,,outpatient,,,35690.37,21414.22,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FOURTH DIGIT",CASE-28810,LOCAL,28810,CPT,,,,,T8,outpatient,,,24993.17,14995.90,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,LOCAL,64446,CPT,0360,RC,,,LT|XU|PO,outpatient,,,44565.32,26739.19,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT|PO",CASE-28285,LOCAL,28285,CPT,,,,,T7|PO,outpatient,,,29334.38,17600.63,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE|PO,CASE-29827,LOCAL,29827,CPT,,,,,RT|PO,outpatient,,,51622.62,30973.57,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvc/Le Init 2nd,CASE-36246,LOCAL,36246,CPT,0361,RC,,,,outpatient,,,33676.83,20206.10,,,,,,,,,,,,,
SHEATH DESTIN SL 6FR R2P 149CM,SUP-2633198,CDM,C1894,HCPCS,0272,RC,,,,both,,,947.50,615.87,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM UNIAXIAL STRL CD HORZ 2PK,SUP-2928050,CDM,C1713,HCPCS,0278,RC,,,,both,,,4584.40,2979.86,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA12 X 6 MM EPTFE BIFURCATE,SUP-2396244,CDM,C1768,CPT,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
DRILL SURG CANN 2.2 MM STRL LTX DISP,SUP-2860993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.91,277.49,,,,,,,,,,,,,
SCREW BONE L55MM D35MM UNVRSL CRTCL PLVC STNLSS STEEL SELF T,SUP-2479301,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.87,55.17,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE TRACELET REG STRP L 19.2 CM PUR,SUP-2429852,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC W/ OLV 3 MMX980 CM STRL,SUP-2316303,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|PO,CASE-64636,LOCAL,64636,CPT,,,,,PO,outpatient,,,12211.98,7327.19,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|SEPARATE STRUCTURE,CASE-52332,LOCAL,52332,CPT,0360,RC,,,50|XS,outpatient,,,39664.38,23798.63,,,,,,,,,,,,,
Partial Excision Bone Metacarpal,CASE-26230,LOCAL,26230,CPT,0360,RC,,,,outpatient,,,10847.07,6508.24,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,LOCAL,45380,CPT,,,,,,outpatient,,,12669.70,7601.82,,,,,,,,,,,,,
Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>|RIGHT SIDE,CASE-23073,LOCAL,23073,CPT,0360,RC,,,RT,outpatient,,,25669.90,15401.94,,,,,,,,,,,,,
Syndactylization Toes|LEFT SIDE,CASE-28280,LOCAL,28280,CPT,,,,,LT,outpatient,,,26726.37,16035.82,,,,,,,,,,,,,
Laps Tot Hysterectomy Resj Malignancy W/Omntc,CASE-58575,LOCAL,58575,CPT,,,,,,outpatient,,,95238.53,57143.12,,,,,,,,,,,,,
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,LOCAL,44970,CPT,0360,RC,,,XU,outpatient,,,32026.38,19215.83,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, SECOND DIGIT|PO",CASE-26860,LOCAL,26860,CPT,,,,,F1|PO,outpatient,,,19353.77,11612.26,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,LOCAL,45380,CPT,,,,,PT,outpatient,,,11052.48,6631.49,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj 1st Metar|LEFT SIDE|PO,CASE-28306,LOCAL,28306,CPT,0360,RC,,,LT|PO,outpatient,,,19110.08,11466.05,,,,,,,,,,,,,
Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,CASE-21552,LOCAL,21552,CPT,0360,RC,,,,outpatient,,,16781.58,10068.95,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28270,LOCAL,28270,CPT,0360,RC,,,T9|PO,outpatient,,,24033.37,14420.02,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 6 FR 0.021IN,SUP-2385482,CDM,C1894,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
ROD SPNL 5.5X16 MM TI UNID,SUP-2269767,CDM,C1713,HCPCS,0278,RC,,,,both,,,5523.26,3590.12,,,,,,,,,,,,,
COMPONENT FEM A/P60MM UNIV CO CHROM LT MEDL RT LAT KNEE PRI,SUP-2200426,CDM,C1776,CPT,0278,RC,,,,both,,,8408.92,5465.80,,,,,,,,,,,,,
PLATE BONE L104MM 4 H STRL BILAT CLVRLF NONCOMPRESSION BTTRS,SUP-2343787,CDM,C1713,HCPCS,0278,RC,,,,both,,,2686.40,1746.16,,,,,,,,,,,,,
GRAFT SO 6CMX16CM SURGIMEND PRS,SUP-2243677,CDM,C9360,HCPCS,0278,RC,,,,both,,,6330.24,4114.66,,,,,,,,,,,,,
MARKER BRST BX L10CM 18GA Q SHP INTRO FREE HND NIT TUMARK,SUP-2427467,CDM,A4648,CPT,0278,RC,,,,both,,,258.89,168.28,,,,,,,,,,,,,
COUNTERSINK SURG SM DISP FOR IO FIX X-POST IOFIX 2.0,SUP-2223763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
BLADE SAW 90X19.5X1.2 MM 1.2 MM FOR LG BNE,SUP-2607462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,145.01,94.26,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ADV STRYBIPOLA] STRYKER CORP],SUP-2365969,CDM,C1776,CPT,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 4 CM DIA 5 FR GUIDEWIRE L 40 CM DIA,SUP-2303306,CDM,C1893,HCPCS,0272,RC,,,,both,,,103.46,67.25,,,,,,,,,,,,,
GUIDEWIRE ORTH SHT SALVATION,SUP-2852538,CDM,C1769,HCPCS,0272,RC,,,,both,,,1811.78,1177.66,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 8 H SCREW DIA2 MM MED TI MIDFACE STR,SUP-2883949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
Removal Implant Deep|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20680,LOCAL,20680,CPT,,,,,LT|XU,outpatient,,,41782.87,25069.72,,,,,,,,,,,,,
Destruction Mal Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-17266,LOCAL,17266,CPT,0360,RC,,,,outpatient,,,15776.15,9465.69,,,,,,,,,,,,,
HC Fem Pop Terr Plasty and Stent|LEFT SIDE,CASE-37226,LOCAL,37226,CPT,0361,RC,,,LT,outpatient,,,53642.18,32185.31,,,,,,,,,,,,,
Capsulectomy/Capsulotomy Mtcarphlngl Joint Each|LEFT SIDE|PO,CASE-26520,LOCAL,26520,CPT,,,,,LT|PO,outpatient,,,15418.95,9251.37,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28825,LOCAL,28825,CPT,0360,RC,,,TA,outpatient,,,17145.92,10287.55,,,,,,,,,,,,,
Trurl Dstrj Prstate Tiss Rf Thermoth,CASE-53852,LOCAL,53852,CPT,,,,,,outpatient,,,40566.52,24339.91,,,,,,,,,,,,,
HC 3rd Order Sel Abd/Lower Ext|BILATERAL PROCEDURE,CASE-36247,LOCAL,36247,CPT,0361,RC,,,50,outpatient,,,49478.52,29687.11,,,,,,,,,,,,,
HC Removal FB Skin|PO,CASE-10120,LOCAL,10120,CPT,0450,RC,,,PO,outpatient,,,6227.00,3736.20,,,,,,,,,,,,,
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|LEFT SIDE,CASE-27446,LOCAL,27446,CPT,0360,RC,,,LT,outpatient,,,66643.50,39986.10,,,,,,,,,,,,,
"Inject Nerv Blck,Paravert Sympath|RIGHT SIDE",CASE-64520,LOCAL,64520,CPT,,,,,RT,outpatient,,,3925.23,2355.14,,,,,,,,,,,,,
Tnols Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|RIGHT SIDE|PO,CASE-25295,LOCAL,25295,CPT,,,,,RT|PO,outpatient,,,18778.17,11266.90,,,,,,,,,,,,,
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,LOCAL,58260,CPT,0360,RC,,,,outpatient,,,40428.58,24257.15,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,LOCAL,49650,CPT,,,,,RT,outpatient,,,42379.33,25427.60,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE|PO,CASE-25608,LOCAL,25608,CPT,,,,,LT|PO,outpatient,,,31093.13,18655.88,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,LOCAL,29881,CPT,,,,,LT,outpatient,,,23483.85,14090.31,,,,,,,,,,,,,
HC Rt Bronch Dx W/Brushing,PX-3613162300,CDM,31623,CPT,0361,RC,,,,both,,,5261.00,3419.65,,,,,,,,,,,,,
SCREW BNE LCK 2.7X5 MM CRANIOMAXILLOFACIAL MAXDRIVE LEVEL 1,SUP-2461495,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.89,291.13,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 7 MM EPTFE STR TW N RING STRL,SUP-2396704,CDM,C1768,CPT,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
SPACER SPNL ANGLED 7 DEG 11X14X10 MM LORDTC FUSION PEEK TM-S,SUP-2246224,CDM,C1821,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
LOCK DISTAL FIBULA PLT SS LT 4H,SUP-2815007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
SHEATH GUID 11.5X8.5FR L71MM M CRV L22MM BIDIR STEER CARTO,SUP-2248638,CDM,C1766,CPT,0272,RC,,,,both,,,3111.74,2022.63,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2 MM RECON MAXILLA PT SPEC,SUP-2860084,CDM,C1713,HCPCS,0278,RC,,,,both,,,27382.68,17798.74,,,,,,,,,,,,,
CATHETER EP H CRV 7 FR STEER 3D MAP INQUIRY,SUP-2357426,CDM,C1730,HCPCS,0272,RC,,,,both,,,2019.71,1312.81,,,,,,,,,,,,,
SYSTEM LD DEL RAPIDO ADV STRL,SUP-2149267,CDM,C1887,HCPCS,0272,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|RIGHT SIDE|PO,CASE-25609,LOCAL,25609,CPT,,,,,RT|PO,outpatient,,,38150.23,22890.14,,,,,,,,,,,,,
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28160,LOCAL,28160,CPT,0360,RC,,,T3|PO,outpatient,,,21238.90,12743.34,,,,,,,,,,,,,
Laps Insertion Tunneled Intraperitoneal Catheter,CASE-49324,LOCAL,49324,CPT,,,,,,outpatient,,,20854.85,12512.91,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,LOCAL,52351,CPT,0360,RC,,,LT,outpatient,,,17316.98,10390.19,,,,,,,,,,,,,
Axillary Lymphadenectomy Complete|RIGHT SIDE,CASE-38745,LOCAL,38745,CPT,0360,RC,,,RT,outpatient,,,48449.03,29069.42,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, GREAT TOE",CASE-28810,LOCAL,28810,CPT,,,,,T5,outpatient,,,52733.95,31640.37,,,,,,,,,,,,,
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,LOCAL,43235,CPT,,,,,,outpatient,,,10139.13,6083.48,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,LOCAL,64483,CPT,,,,,50,outpatient,,,3990.02,2394.01,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,LOCAL,64446,CPT,0360,RC,,,LT|XU,outpatient,,,48593.33,29156.00,,,,,,,,,,,,,
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE|PO,CASE-29891,LOCAL,29891,CPT,0360,RC,,,LT|PO,outpatient,,,31467.45,18880.47,,,,,,,,,,,,,
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49594,LOCAL,49594,CPT,0360,RC,,,XU,outpatient,,,32599.72,19559.83,,,,,,,,,,,,,
HC Hospice Room,PX-1150000000,CDM,1150000000,LOCAL,,,,,,outpatient,,,2644.42,1586.65,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|PO,CASE-64636,LOCAL,64636,CPT,0360,RC,,,PO,outpatient,,,12211.98,7327.19,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,LOCAL,64708,CPT,0360,RC,,,RT,outpatient,,,30270.30,18162.18,,,,,,,,,,,,,
HC Debride/Musc/Fasc First 20 Sq Cm,CASE-11043,LOCAL,11043,CPT,0361,RC,,,,outpatient,,,16557.77,9934.66,,,,,,,,,,,,,
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|RIGHT SIDE|PO,CASE-28119,LOCAL,28119,CPT,,,,,RT|PO,outpatient,,,27854.85,16712.91,,,,,,,,,,,,,
PLATE BONE L40MM THK0.3MM 10 H CRANIOMAXILLOFACIAL TI CVD,SUP-2136523,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
IMPLANT BIO TISS W2XL8CM BOV PERICARD CLLGN MTRX MESH SGL,SUP-2130297,CDM,C9354,HCPCS,0278,RC,,,,both,,,1405.46,913.55,,,,,,,,,,,,,
DRILL TWST L 67 MM DIA1.1 MM STP 5 MM HND HEX NS DISP LORENZ,SUP-2935678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
CATHETER ATHRCTMY ROTAPRO L 135 CM BUR DIA1.25 MM CORONARY,SUP-2140853,CDM,C1724,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
PLATE BNE SIDE L 30 X W 30 MM THK 0.5 MM SCREW DIA1.7 MM PLL,SUP-2883208,CDM,C1713,HCPCS,0278,RC,,,,both,,,2851.09,1853.21,,,,,,,,,,,,,
PLATE BONE L80MM 3 H LT MEDL DSTL HUM FOR 2.7/3.5MM SCR EVOS,SUP-2341158,CDM,C1713,HCPCS,0278,RC,,,,both,,,6974.88,4533.67,,,,,,,,,,,,,
VALVE GLAUCOMA W13XL16MM THK2.1MM SIL NONOBSTRUCTIVE SYS,SUP-2308657,CDM,C1783,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW BONE 3.5MM DIA 110MML CORTICAL SELF TAPPING STERILE,SUP-2588564,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.73,52.47,,,,,,,,,,,,,
GRAFT DERMAL MICROPREFORATED 8X20CM X 0.6-1.05MM DERMACELL,SUP-2866527,CDM,Q4122,HCPCS,0636,RC,,,,both,,,14569.60,9470.24,,,,,,,,,,,,,
Arthrotomy W/Meniscus Repair Knee|LEFT SIDE,CASE-27403,LOCAL,27403,CPT,,,,,LT,outpatient,,,63869.23,38321.54,,,,,,,,,,,,,
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, SECOND DIGIT",CASE-28234,LOCAL,28234,CPT,,,,,T1,outpatient,,,11454.52,6872.71,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,LOCAL,28122,CPT,,,,,RT,outpatient,,,30270.30,18162.18,,,,,,,,,,,,,
Arthroscopy Knee Lateral Release,CASE-29873,LOCAL,29873,CPT,,,,,,outpatient,,,25584.97,15350.98,,,,,,,,,,,,,
Tenolysis Flexor Tendon Palm/Finger Each Tendon,CASE-26440,LOCAL,26440,CPT,0360,RC,,,,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,LOCAL,28825,CPT,0360,RC,,,T6,outpatient,,,17785.52,10671.31,,,,,,,,,,,,,
Partial Excision Bone Olecranon Process|RIGHT SIDE|PO,CASE-24147,LOCAL,24147,CPT,,,,,RT|PO,outpatient,,,15485.38,9291.23,,,,,,,,,,,,,
Repair Non/Malunion Humerus W/O Graft|RIGHT SIDE,CASE-24430,LOCAL,24430,CPT,0360,RC,,,RT,outpatient,,,70276.58,42165.95,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB|PO",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F5|PO,outpatient,,,12467.95,7480.77,,,,,,,,,,,,,
Open Tx Tibial Fracture Proximal Unicondylar|LEFT SIDE,CASE-27535,LOCAL,27535,CPT,0360,RC,,,LT,outpatient,,,63869.23,38321.54,,,,,,,,,,,,,
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE|PO,CASE-27829,LOCAL,27829,CPT,,,,,LT|PO,outpatient,,,33391.62,20034.97,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,LOCAL,49505,CPT,0360,RC,,,RT,outpatient,,,26451.93,15871.16,,,,,,,,,,,,,
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs,CASE-25115,LOCAL,25115,CPT,,,,,,outpatient,,,20045.78,12027.47,,,,,,,,,,,,,
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|LEFT SIDE|PO,CASE-29884,LOCAL,29884,CPT,0360,RC,,,LT|PO,outpatient,,,26503.10,15901.86,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|RIGHT SIDE|PO,CASE-28309,LOCAL,28309,CPT,,,,,RT|PO,outpatient,,,50809.40,30485.64,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|PO,CASE-27695,LOCAL,27695,CPT,,,,,LT|PO,outpatient,,,41161.53,24696.92,,,,,,,,,,,,,
STABILIZER PELV TPOD ORNG TRAUM ORTHOT DEV TPODOR,SUP-2150009,CDM,L0469,HCPCS,0274,RC,,,,both,,,423.87,275.52,,,,,,,,,,,,,
LINER ACET SZ B ID22MM STD HIP HGP II CUP ELEV RIM,SUP-2202715,CDM,C1776,CPT,0278,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
GRAFT L SEG RECON TISS FRZN PELV ILIUM WHL R,SUP-2307412,CDM,C1713,HCPCS,0278,RC,,,,both,,,22284.93,14485.20,,,,,,,,,,,,,
PLATE BNE L63MM 3X4 H S STL T LOK COMPR OBLQ L ANG FOR,SUP-2186026,CDM,C1713,HCPCS,0278,RC,,,,both,,,996.01,647.41,,,,,,,,,,,,,
CATHETER INFUSION TEGTMEYER DIA 30 GA LYMPHATIC DUCT STRL,SUP-2118901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
NAIL GAM 3 LNG 120DEG 10X360MM ST,SUP-2703241,CDM,C1713,HCPCS,0278,RC,,,,both,,,8694.66,5651.53,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.2MM CORT CRANIOMAXILLOFACIAL SIL S STL 5PK,SUP-2366083,CDM,C1713,HCPCS,0278,RC,,,,both,,,228.12,148.28,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,J7060,HCPCS,0258,RC,00264-7510-10,NDC,,both,250,ML,17.00,11.05,,,,,,,,,,,,,
PLATE BNE THK2MM REG 20 H TI L LOK MINI FOR 23MM SCR,SUP-2262972,CDM,C1713,HCPCS,0278,RC,,,,both,,,3158.56,2053.06,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER L 115 CM 8 FR 4 MM F-J CRV,SUP-2486857,CDM,C1733,HCPCS,0272,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
ADAPTER FEM 4MM SM TI HIP ENDOPROS STRL IMP METASUL LDH,SUP-2204651,CDM,C1776,CPT,0278,RC,,,,both,,,469.43,305.13,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE|PO,CASE-27601,LOCAL,27601,CPT,,,,,RT|PO,outpatient,,,32616.33,19569.80,,,,,,,,,,,,,
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea,CASE-43277,LOCAL,43277,CPT,0360,RC,,,,outpatient,,,41987.65,25192.59,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|PO,CASE-64494,LOCAL,64494,CPT,,,,,PO,outpatient,,,4412.95,2647.77,,,,,,,,,,,,,
Tnols Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|LEFT SIDE|PO,CASE-25295,LOCAL,25295,CPT,0360,RC,,,LT|PO,outpatient,,,10124.93,6074.96,,,,,,,,,,,,,
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28313,LOCAL,28313,CPT,,,,,XS|T3|PO,outpatient,,,57075.62,34245.37,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,LOCAL,29882,CPT,,,,,RT,outpatient,,,41914.63,25148.78,,,,,,,,,,,,,
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE|PO,CASE-25607,LOCAL,25607,CPT,,,,,LT|PO,outpatient,,,27790.10,16674.06,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|LEFT SIDE,CASE-19120,LOCAL,19120,CPT,,,,,LT,outpatient,,,19209.77,11525.86,,,,,,,,,,,,,
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,LOCAL,52240,CPT,,,,,,outpatient,,,23949.20,14369.52,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,LOCAL,28270,CPT,0360,RC,,,XS|T6|PO,outpatient,,,27783.90,16670.34,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE|PO,CASE-64493,LOCAL,64493,CPT,0360,RC,,,RT|PO,outpatient,,,4626.15,2775.69,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,LOCAL,28296,CPT,0360,RC,,,T5,outpatient,,,32022.20,19213.32,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|PO,CASE-64718,LOCAL,64718,CPT,,,,,LT|PO,outpatient,,,15212.78,9127.67,,,,,,,,,,,,,
Removal Implant Deep|RIGHT SIDE,CASE-20680,LOCAL,20680,CPT,0360,RC,,,RT,outpatient,,,34646.93,20788.16,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,LOCAL,29882,CPT,0360,RC,,,LT,outpatient,,,29992.30,17995.38,,,,,,,,,,,,,
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,LOCAL,55040,CPT,,,,,RT,outpatient,,,20812.13,12487.28,,,,,,,,,,,,,
BUR SURG L9CM HD L351MM DIA3MM TAPR L BOR MIDAS REX LEGEND,SUP-2280240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.24,228.31,,,,,,,,,,,,,
GRAFT HUM TISS M W9.6XL19.3CM THCK THK2.4MM REGENERATIVE,SUP-2113441,CDM,Q4116,HCPCS,0636,RC,,,,both,,,31186.48,20271.21,,,,,,,,,,,,,
SPACER SPNL C RNG FOR 55MM SCR CDH LEG,SUP-2292826,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
HC So Cholesterol,PX-3018246566,CDM,82465,CPT,0301,RC,,,,both,,,53.00,34.45,,,,,,,,,,,,,
COMPONENT FEM SZ 1 LT KNEE REV CEM ROT HNG UNISX IMP MOST,SUP-2208347,CDM,C1776,CPT,0278,RC,,,,both,,,21562.38,14015.55,,,,,,,,,,,,,
HC Bone Survey Complete,PX-3207707500,CDM,77075,CPT,0320,RC,,,,both,,,1477.00,960.05,,,,,,,,,,,,,
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64450,LOCAL,64450,CPT,0450,RC,,,XU|RT,outpatient,,,56060.50,33636.30,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27691,LOCAL,27691,CPT,,,,,LT|PO|CG,outpatient,,,25385.63,15231.38,,,,,,,,,,,,,
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|LEFT SIDE,CASE-37225,LOCAL,37225,CPT,,,,,LT,outpatient,,,55057.63,33034.58,,,,,,,,,,,,,
Ostectomy Complete 5th Metatarsal Head|RIGHT SIDE|PO,CASE-28113,LOCAL,28113,CPT,,,,,RT|PO,outpatient,,,42596.50,25557.90,,,,,,,,,,,,,
HC Insert Ivc Filter,CASE-37191,LOCAL,37191,CPT,0361,RC,,,,outpatient,,,137700.13,82620.08,,,,,,,,,,,,,
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|RIGHT SIDE|PO,CASE-28238,LOCAL,28238,CPT,,,,,RT|PO,outpatient,,,34347.48,20608.49,,,,,,,,,,,,,
Repair Dislocating Peroneal Tendon W/Fib Osteot,CASE-27676,LOCAL,27676,CPT,0360,RC,,,,outpatient,,,28524.17,17114.50,,,,,,,,,,,,,
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,LOCAL,11606,CPT,0360,RC,,,,outpatient,,,35089.77,21053.86,,,,,,,,,,,,,
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE|PO,CASE-27680,LOCAL,27680,CPT,,,,,LT|PO,outpatient,,,23884.05,14330.43,,,,,,,,,,,,,
Debridement Nail Any Method 1-5,CASE-11720,LOCAL,11720,CPT,,,,,,outpatient,,,120565.82,72339.49,,,,,,,,,,,,,
LEAD CARD PACE AD L52CM PERM ATR LD PACE BPLR PASS FIX IS 1,SUP-2356673,CDM,C1779,HCPCS,0275,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CANNULA LAP FOR FACE CLOSURE NDL SPARE SUTURE PASS,SUP-2748430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.92,278.80,,,,,,,,,,,,,
PLATE BONE W11.7XL45.3MM 8 H WR TI RT ANG LCK COMPR HI,SUP-2411670,CDM,C1713,HCPCS,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
TI CONNECTING SCREW F/LCKNG ATTACHMENT PL/STARDRIVE-STER,SUP-2546836,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.47,506.01,,,,,,,,,,,,,
FIBER LASER SURG FIBER 365 MH HOLM SUREFLEX,SUP-2225688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SMALL PLATE 2X25MM 3.5MM,SUP-2820873,CDM,C1713,HCPCS,0278,RC,,,,both,,,992.93,645.40,,,,,,,,,,,,,
CATHETER PICC 4FR L55CM LUMN 17GA GWIRE L45CM TAPE L92CM SGL,SUP-2118965,CDM,C1751,HCPCS,0278,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
NAIL IM L360MM DIA9MM 130DEG LNG RT HIP TIM CANN LCK FOR AG,SUP-2419524,CDM,C1713,HCPCS,0278,RC,,,,both,,,10059.46,6538.65,,,,,,,,,,,,,
SCREW BONE L6MM OD1.2 CORT CRANIOMAXILLOFACIAL NONCANNULATED,SUP-2363326,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.89,87.03,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115CM 7.5FR D-F,SUP-2248506,CDM,C1732,HCPCS,0278,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
PLATE BNE FUSION 0 DEG 2.4/2.7X53 MM RT 1ST MTP REV VA SS,SUP-2184826,CDM,C1713,HCPCS,0278,RC,,,,both,,,4054.81,2635.63,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 3X4CM THICK AMNIOTIC UMBILICAL CORD PRO3C,SUP-2880640,CDM,C1762,CPT,0278,RC,,,,both,,,6778.48,4406.01,,,,,,,,,,,,,
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|BILATERAL PROCEDURE,CASE-37766,LOCAL,37766,CPT,0360,RC,,,50,outpatient,,,23217.13,13930.28,,,,,,,,,,,,,
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|LEFT SIDE,CASE-37722,LOCAL,37722,CPT,0360,RC,,,LT,outpatient,,,29073.12,17443.87,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE|PO",CASE-64708,LOCAL,64708,CPT,0360,RC,,,LT|PO,outpatient,,,19134.67,11480.80,,,,,,,,,,,,,
Thoracoscopy W/Thoracic Sympathectomy,CASE-32664,LOCAL,32664,CPT,0360,RC,,,,outpatient,,,96443.17,57865.90,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, SECOND DIGIT|SEPARATE STRUCTURE|PO",CASE-28124,LOCAL,28124,CPT,,,,,T6|XS|PO,outpatient,,,27151.63,16290.98,,,,,,,,,,,,,
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,LOCAL,43275,CPT,0360,RC,,,,outpatient,,,25796.43,15477.86,,,,,,,,,,,,,
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,LOCAL,31652,CPT,,,,,,outpatient,,,26164.02,15698.41,,,,,,,,,,,,,
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|RIGHT SIDE|PO,CASE-28119,LOCAL,28119,CPT,0360,RC,,,RT|PO,outpatient,,,27854.85,16712.91,,,,,,,,,,,,,
Patellectomy/Hemipatellectomy,CASE-27350,LOCAL,27350,CPT,,,,,,outpatient,,,21647.35,12988.41,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F8|PO,outpatient,,,10190.27,6114.16,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,LOCAL,64495,CPT,0360,RC,,,,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|BILATERAL PROCEDURE,CASE-64494,LOCAL,64494,CPT,,,,,50,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|SEPARATE STRUCTURE|PO",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F2|XS|PO,outpatient,,,12880.15,7728.09,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Complicated,CASE-11772,LOCAL,11772,CPT,,,,,,outpatient,,,31686.82,19012.09,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit|RIGHT SIDE,CASE-36901,LOCAL,36901,CPT,0361,RC,,,RT,outpatient,,,20042.75,12025.65,,,,,,,,,,,,,
Partical Excision Bone Phalanx Toe|LEFT SIDE|PO,CASE-28124,LOCAL,28124,CPT,,,,,LT|PO,outpatient,,,21983.18,13189.91,,,,,,,,,,,,,
Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent,CASE-36903,LOCAL,36903,CPT,0360,RC,,,,outpatient,,,51133.50,30680.10,,,,,,,,,,,,,
Syndactylization Toes|RIGHT SIDE|PO,CASE-28280,LOCAL,28280,CPT,,,,,RT|PO,outpatient,,,42596.50,25557.90,,,,,,,,,,,,,
Arthroplasty Glenohumeral Joint Total Shoulder|LEFT SIDE,CASE-23472,LOCAL,23472,CPT,,,,,LT,outpatient,,,78080.70,46848.42,,,,,,,,,,,,,
Thoracoscopy W/Thoracic Sympathectomy,CASE-32664,LOCAL,32664,CPT,,,,,,outpatient,,,96443.17,57865.90,,,,,,,,,,,,,
COIL EMB L4CM DIA0.02IN LOOP DIA2MM COMPLX EXTRA SFT FILL,SUP-2323427,CDM,C1889,HCPCS,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
GRAFT SFT TISS 1 CC CRYOPRESERVED PLCNTA VIAFLOW C,SUP-2495869,CDM,C1713,HCPCS,0278,RC,,,,both,,,6063.34,3941.17,,,,,,,,,,,,,
FLUCONAZOLE (DIFLUCAN) IVPB|DISCARDED DRUG NOT ADMINISTE,RX-4081084,CDM,J1450,HCPCS,0636,RC,70655-0088-06,NDC,JW,both,50,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL L30MM DIA3.8MM FLX W/O STP QUIK NONRADIOLUCENT,SUP-2252737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1637.67,1064.49,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK,SUP-2860183,CDM,C1713,HCPCS,0278,RC,,,,both,,,26028.72,16918.67,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED TUBE TYMPANOSTOMY U SHP UNINTERRUPTED BLD SUPL EZ INSRT,SUP-2247579,CDM,L8699,HCPCS,0278,RC,,,,both,,,80.07,52.05,,,,,,,,,,,,,
IMPLANT SYNTH 38 X 63 MM THK 9.5 MM POLYETHYL CRANIOFACIAL,SUP-2883272,CDM,C1713,HCPCS,0278,RC,,,,both,,,4025.98,2616.89,,,,,,,,,,,,,
BUTTON SEPT DIA3CM THK4MM STD NSL SILIC1 1 PC TRIMMED FOR,SUP-2381500,CDM,C1889,HCPCS,0278,RC,,,,both,,,415.42,270.02,,,,,,,,,,,,,
SHEETING SILAS W2XL2IN THK0.20IN BIOCOMPATIBLE SIL,SUP-2284111,CDM,C1781,HCPCS,0278,RC,,,,both,,,61.92,40.25,,,,,,,,,,,,,
BLADE SAW SAG FOR STRNOTMY HALL,SUP-2166598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
HC Sputum Obtaining Spec Aerosol Induced Tx Spx,PX-4108922000,CDM,89220,CPT,0300,RC,,,,inpatient,,,39.00,25.35,,,,,,,,,,,,,
HC So1 Sgpt (Alt),PX-3018446067,CDM,84460,CPT,0301,RC,,,,both,,,15.00,9.75,,,,,,,,,,,,,
RONGEUR SURG 5X230MM BX MOUTH,SUP-2183471,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.61,74.50,,,,,,,,,,,,,
ANCHOR SUT SZ 2-0 PEEK CRV TIP NDL MENIS FIBERWIRE,SUP-2121861,CDM,C1776,CPT,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,LOCAL,52287,CPT,,,,,XU,outpatient,,,25913.65,15548.19,,,,,,,,,,,,,
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,LOCAL,58558,CPT,0360,RC,,,,outpatient,,,19552.00,11731.20,,,,,,,,,,,,,
Carpectomy 1 Bone|RIGHT SIDE|PO,CASE-25210,LOCAL,25210,CPT,,,,,RT|PO,outpatient,,,16093.22,9655.93,,,,,,,,,,,,,
Claviculectomy Partial|LEFT SIDE|PO,CASE-23120,LOCAL,23120,CPT,0360,RC,,,LT|PO,outpatient,,,38630.25,23178.15,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT",CASE-28270,LOCAL,28270,CPT,,,,,T6,outpatient,,,39850.62,23910.37,,,,,,,,,,,,,
Tenolysis Extensor Foot Single Tendon,CASE-28225,LOCAL,28225,CPT,,,,,,outpatient,,,21325.52,12795.31,,,,,,,,,,,,,
Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt,CASE-25020,LOCAL,25020,CPT,0360,RC,,,,outpatient,,,12738.37,7643.02,,,,,,,,,,,,,
Exc Benign Tumor/Cyst Maxl Intra-Oral Osteot,CASE-21048,LOCAL,21048,CPT,,,,,,outpatient,,,28307.82,16984.69,,,,,,,,,,,,,
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|RIGHT SIDE|PO,CASE-27619,LOCAL,27619,CPT,0360,RC,,,RT|PO,outpatient,,,13561.68,8137.01,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO",CASE-26055,LOCAL,26055,CPT,,,,,F8|PO,outpatient,,,10190.27,6114.16,,,,,,,,,,,,,
Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT SIDE|PO,CASE-28160,LOCAL,28160,CPT,0360,RC,,,RT|PO,outpatient,,,18216.12,10929.67,,,,,,,,,,,,,
Arthrs Aid Tibial Fracture Proximal Unicondylar,CASE-29855,LOCAL,29855,CPT,,,,,,outpatient,,,44662.20,26797.32,,,,,,,,,,,,,
HC Tib per Territory Plasty,CASE-37228,LOCAL,37228,CPT,0361,RC,,,,outpatient,,,124503.83,74702.30,,,,,,,,,,,,,
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,LOCAL,31628,CPT,,,,,,outpatient,,,22274.95,13364.97,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvic/Le 1st Ord|BILATERAL PROCEDURE,CASE-36245,LOCAL,36245,CPT,0361,RC,,,50,outpatient,,,66231.85,39739.11,,,,,,,,,,,,,
Circumcision Age >28 Days,CASE-54161,LOCAL,54161,CPT,,,,,,outpatient,,,21219.90,12731.94,,,,,,,,,,,,,
PATCH HERN W20XL30CM THK1MM EPTFE MICROPOROUS SFT TISS GOR,SUP-2395298,CDM,C1781,HCPCS,0278,RC,,,,both,,,6323.96,4110.57,,,,,,,,,,,,,
NUT ORTH DOME SPINE OCCIPITAL-CERVICO-THORACIC VIRAGE,SUP-2685023,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
KIT CRAN ACCS W/O DRUG,SUP-2243819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1802.36,1171.53,,,,,,,,,,,,,
NAIL FEM RG 12MM 320MM,SUP-2405539,CDM,C1713,HCPCS,0278,RC,,,,both,,,9137.40,5939.31,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM DIA 6 MM POLYESTER BOV CLLGN,SUP-2265920,CDM,C1768,CPT,0278,RC,,,,both,,,1988.09,1292.26,,,,,,,,,,,,,
GRAFT BNE SPNG 20X15X7 MM DBM CANC,SUP-2641783,CDM,C1713,HCPCS,0278,RC,,,,both,,,2819.41,1832.62,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,LOCAL,29827,CPT,,,,,LT,outpatient,,,50810.77,30486.46,,,,,,,,,,,,,
Partial Excision Bone Fibula|LEFT SIDE,CASE-27641,LOCAL,27641,CPT,,,,,LT,outpatient,,,38842.92,23305.75,,,,,,,,,,,,,
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE|PO,CASE-26615,LOCAL,26615,CPT,,,,,LT|PO,outpatient,,,19276.60,11565.96,,,,,,,,,,,,,
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE|PO,CASE-28238,LOCAL,28238,CPT,0360,RC,,,LT|PO,outpatient,,,28424.68,17054.81,,,,,,,,,,,,,
Open Treatment Tarsometatarsal Joint Dislocation|RIGHT SIDE|PO,CASE-28615,LOCAL,28615,CPT,0360,RC,,,RT|PO,outpatient,,,25249.70,15149.82,,,,,,,,,,,,,
Bone Graft Any Donor Area Major/Large,CASE-20902,LOCAL,20902,CPT,,,,,,outpatient,,,85871.93,51523.16,,,,,,,,,,,,,
HC Trigger Point 3 or More|LEFT SIDE|PO,CASE-20553,LOCAL,20553,CPT,0510,RC,,,LT|PO,outpatient,,,5556.73,3334.04,,,,,,,,,,,,,
HC Repr Smp Not Face 2.6-7.5cm,CASE-12002,LOCAL,12002,CPT,0450,RC,,,,outpatient,,,20402.73,12241.64,,,,,,,,,,,,,
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,LOCAL,50590,CPT,,,,,LT,outpatient,,,21921.35,13152.81,,,,,,,,,,,,,
HC Debrid Wound Tis 20 Cm/<|PBB CHARGE,CASE-97597,LOCAL,97597,CPT,0761,RC,,,PBB,outpatient,,,601.25,360.75,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT HAND, FOURTH DIGIT",CASE-28308,LOCAL,28308,CPT,,,,,F8,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,LOCAL,52356,CPT,,,,,RT,outpatient,,,30154.68,18092.81,,,,,,,,,,,,,
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,LOCAL,57260,CPT,0360,RC,,,,outpatient,,,29078.93,17447.36,,,,,,,,,,,,,
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,LOCAL,28270,CPT,,,,,,outpatient,,,27750.93,16650.56,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS REDUCTION MULTAXL STRL CD 559200021,SUP-2927812,CDM,C1713,HCPCS,0278,RC,,,,both,,,2.70,1.75,,,,,,,,,,,,,
NUSHIELD 1.6CM DISC 2SQ CM,SUP-2314106,CDM,Q4160,HCPCS,0636,RC,,,,both,,,545.73,354.72,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 700-900 UM 2 ML PVA PREFIL SYR,SUP-2141199,CDM,C1889,HCPCS,0278,RC,,,,both,,,831.79,540.66,,,,,,,,,,,,,
NAIL FEM ANTEGRADE/RETROGRADE 12MM 280MM TI F/BIOMET - 12MM,SUP-2412885,CDM,C1713,HCPCS,0278,RC,,,,both,,,3651.82,2373.68,,,,,,,,,,,,,
ALLOGRAFT BNE MED FRZN ASEP FIBULAR SEG,SUP-2867015,CDM,C1762,CPT,0278,RC,,,,both,,,1879.29,1221.54,,,,,,,,,,,,,
BRACE KNEE 2XL FOR 255 28IN NEOPRENE OPN POPLITEAL WRP ARND,SUP-2196842,CDM,L1810,HCPCS,0272,RC,,,,both,,,65.56,42.61,,,,,,,,,,,,,
PORT INFUS 8FR PWR INJ CT FOR VASC ACCS CATH,SUP-2126607,CDM,C1788,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
PLATE SPNL J-HOOK X25 TI EXPEDIUM MCC,SUP-2718827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
VALVE AORT OD23MM HRT TRANSCATHETER ASCENDRA + TRANSAPICAL,SUP-2214358,CDM,C1889,HCPCS,0278,RC,,,,both,,,102050.00,66332.50,,,,,,,,,,,,,
PLATE BNE L75MM THK3MM 4 H BILAT S STL STR LOK COMPR RECON,SUP-2185331,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.22,782.09,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 13 HOLES 246MM,SUP-2549513,CDM,C1713,HCPCS,0278,RC,,,,both,,,1659.05,1078.38,,,,,,,,,,,,,
K WIRE FIX L400MM DIA1.8MM S STL SGL TRCR SMOOTH DRL PNT,SUP-2372157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,532.54,346.15,,,,,,,,,,,,,
SCREW BONE 1.8X4MM STERILE RESCUE SELF TAPPING TITANIUM NEUR,SUP-2826030,CDM,C1713,HCPCS,0278,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
SLEEVE DRL MEAS DIA4.3MM SGL END DISP FOR AFFIXUS HIP FRAC,SUP-2412614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
Surg Tx Anal Fistula Subq,CASE-46270,LOCAL,46270,CPT,,,,,,outpatient,,,16115.98,9669.59,,,,,,,,,,,,,
Proctosgmdsc Rgd Dx W/WO Collj Spec Br/Wa Spx,CASE-45300,LOCAL,45300,CPT,,,,,,outpatient,,,12411.63,7446.98,,,,,,,,,,,,,
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE|PO,CASE-25447,LOCAL,25447,CPT,,,,,LT|PO,outpatient,,,18647.28,11188.37,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE|PO,CASE-27695,LOCAL,27695,CPT,,,,,RT|PO,outpatient,,,32164.05,19298.43,,,,,,,,,,,,,
Suture Quadriceps/Hamstring Rupture Primary|LEFT SIDE,CASE-27385,LOCAL,27385,CPT,,,,,LT,outpatient,,,29254.98,17552.99,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FIFTH DIGIT|PO",CASE-26440,LOCAL,26440,CPT,0360,RC,,,F9|PO,outpatient,,,16093.22,9655.93,,,,,,,,,,,,,
Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,CASE-26125,LOCAL,26125,CPT,,,,,,outpatient,,,16072.42,9643.45,,,,,,,,,,,,,
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE|PO,CASE-28730,LOCAL,28730,CPT,,,,,RT|PO,outpatient,,,84914.28,50948.57,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT|PO",CASE-28270,LOCAL,28270,CPT,0360,RC,,,XS|T7|PO,outpatient,,,27783.90,16670.34,,,,,,,,,,,,,
HC >= 12 Lead Ekg|ADJ|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,LOCAL,93005,CPT,0730,RC,,,ADJ|XU,outpatient,,,37058.77,22235.26,,,,,,,,,,,,,
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE,CASE-29898,LOCAL,29898,CPT,0360,RC,,,LT,outpatient,,,40869.75,24521.85,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,LOCAL,26055,CPT,,,,,F8,outpatient,,,13294.77,7976.86,,,,,,,,,,,,,
KIT STEREOTAXIC POD DISPOSABLE IASSIST,SUP-2205585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
POLARUS 3 CAP SCREW 6MM,SUP-2639518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
GRAFT BIO TISS 8X12CM MESH FET BOV DERM IONIC DERM REP SLV,SUP-2243718,CDM,Q4110,HCPCS,0636,RC,,,,both,,,11555.20,7510.88,,,,,,,,,,,,,
CATHETER KIT 3L 7 FRX8 IN GUIDE RAULERSON CVC ARROWG+ARD BLU,SUP-2383322,CDM,C1751,HCPCS,0278,RC,,,,both,,,151.10,98.21,,,,,,,,,,,,,
WIRE FIX SMOOTH 2X400 MM NS,SUP-2863403,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.54,141.40,,,,,,,,,,,,,
GRAFT PELV RECON INTEGRFT 2CMX7CM,SUP-2140208,CDM,C1771,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SLING URETH VAG PROLAPSE REP W/ INTEPRO,SUP-2140310,CDM,C1771,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
ANCHOR SUTURE 4.5X11MM KNOTLESS DEPLOYED POPLOK,SUP-2828588,CDM,C1713,HCPCS,0278,RC,,,,both,,,1677.07,1090.10,,,,,,,,,,,,,
COMPONENT FEM L7CM R DST KNEE RESURF ORTH SALV SYS,SUP-2405705,CDM,C1776,CPT,0278,RC,,,,both,,,19287.45,12536.84,,,,,,,,,,,,,
FORCEPS BPLR L33MM DIA5MM INSUL CUT COAGULATE PRB RF DISP,SUP-2313949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
CROWN DENT 2 1ST PRIMARY M UPPER LT SS,SUP-2100173,CDM,D6783,CPT,0278,RC,,,,both,,,34.79,22.61,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE,CASE-27695,LOCAL,27695,CPT,,,,,LT,outpatient,,,38842.92,23305.75,,,,,,,,,,,,,
Open Treatment Talus Fracture|RIGHT SIDE,CASE-28445,LOCAL,28445,CPT,,,,,RT,outpatient,,,35280.80,21168.48,,,,,,,,,,,,,
Blepharoplasty Lower Eyelid Herniated Fat Pad,CASE-15821,LOCAL,15821,CPT,,,,,,outpatient,,,43856.37,26313.82,,,,,,,,,,,,,
HC Iliac Territory Plasty Stent|RIGHT SIDE,CASE-37221,LOCAL,37221,CPT,0361,RC,,,RT,outpatient,,,38713.23,23227.94,,,,,,,,,,,,,
Open Tx Metatarsophalangeal Joint Dislocation,CASE-28645,LOCAL,28645,CPT,,,,,,outpatient,,,34797.97,20878.78,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT|PO",CASE-28285,LOCAL,28285,CPT,,,,,T2|PO,outpatient,,,29936.68,17962.01,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26735,LOCAL,26735,CPT,0360,RC,,,F9|PO,outpatient,,,19472.57,11683.54,,,,,,,,,,,,,
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE|PO,CASE-28200,LOCAL,28200,CPT,,,,,RT|PO,outpatient,,,35678.48,21407.09,,,,,,,,,,,,,
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE|POLICY CRITERIA APPLIED,CASE-27570,LOCAL,27570,CPT,,,,,RT|CG,outpatient,,,12213.62,7328.17,,,,,,,,,,,,,
Excision Vaginal Cyst/Tumor,CASE-57135,LOCAL,57135,CPT,,,,,,outpatient,,,20948.63,12569.18,,,,,,,,,,,,,
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE,CASE-28238,LOCAL,28238,CPT,0360,RC,,,LT,outpatient,,,42614.05,25568.43,,,,,,,,,,,,,
HC Rehab R&B,PX-1180000000,CDM,1180000000,LOCAL,,,,,,outpatient,,,2724.58,1634.75,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE|PO,CASE-24342,LOCAL,24342,CPT,0360,RC,,,RT|PO,outpatient,,,17543.07,10525.84,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 8 FRX2 CM PWR INJ POWERHICKMAN,SUP-2126210,CDM,C1751,HCPCS,0278,RC,,,,both,,,1052.37,684.04,,,,,,,,,,,,,
WASHER ORTH L RND FOR 65 73MM CANN SCR,SUP-2184675,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.34,296.62,,,,,,,,,,,,,
INSERT TIB SM THK9MM AP42MM ML67MM STD L KNEE PCA ARTC CRUCE,SUP-2377290,CDM,C1776,CPT,0278,RC,,,,both,,,5685.91,3695.84,,,,,,,,,,,,,
PIN EXT FIX HALF 4X100X35 MM BLU XTRAFIX,SUP-2435434,CDM,C1713,HCPCS,0278,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
SCREW BNE CANC 4X10 MM DSTL RADIAL FORTE,SUP-2462778,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.59,126.48,,,,,,,,,,,,,
WASHER SURG DIA4MM FLAT FOR MINI MONSTER SCR SYS,SUP-2320327,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
ANCHOR BONE TOGGLELOC 7 PE W/ZIPLOOP,SUP-2589109,CDM,C1713,HCPCS,0278,RC,,,,both,,,2067.88,1344.12,,,,,,,,,,,,,
NAIL IM L400MM DIA13MM 130DEG LNG LT HIP TIM CANN LCK FOR,SUP-2137056,CDM,C1713,HCPCS,0278,RC,,,,both,,,8518.88,5537.27,,,,,,,,,,,,,
BLADE SURG SAW 40X44.60 MM REPEAT STERNOTOMY HALL,SUP-2166588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
SCREWDRIVER SURG 3.5MM REDUC SCR,SUP-2232117,CDM,C1713,HCPCS,0278,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
BLADE SURG SAW CRESC STRL S STL 32MM LEN 18.5MM W .51MM THCK,SUP-2361979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
SHEATH INTRO FLX L 30 CM OD 10 FR ID 3.4 MM GUIDEWIRE 0.038,SUP-2168815,CDM,C1894,HCPCS,0272,RC,,,,both,,,176.66,114.83,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 7X80 MM 9 FRX80 CM ENDOVASC FLUENCY +,SUP-2464831,CDM,C1874,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64718,LOCAL,64718,CPT,0360,RC,,,RT|XS|PO,outpatient,,,18340.05,11004.03,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Mtcarphlngl Joint Each|RIGHT HAND, FIFTH DIGIT|PO",CASE-26520,LOCAL,26520,CPT,0360,RC,,,F9|PO,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-23430,LOCAL,23430,CPT,,,,,73,outpatient,,,17170.50,10302.30,,,,,,,,,,,,,
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,LOCAL,11606,CPT,,,,,,outpatient,,,35089.77,21053.86,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28825,LOCAL,28825,CPT,,,,,TA,outpatient,,,17145.92,10287.55,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THUMB|PO",CASE-26765,LOCAL,26765,CPT,,,,,FA|PO,outpatient,,,17714.68,10628.81,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,LOCAL,45385,CPT,0360,RC,,,,outpatient,,,11909.62,7145.77,,,,,,,,,,,,,
"Tenolysis Extensor Tendon Hand/Finger Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26445,LOCAL,26445,CPT,,,,,F7|PO,outpatient,,,15631.72,9379.03,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening,CASE-25390,LOCAL,25390,CPT,0360,RC,,,,outpatient,,,37299.03,22379.42,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, SECOND DIGIT|PO",CASE-26727,LOCAL,26727,CPT,0360,RC,,,F1|PO,outpatient,,,10791.63,6474.98,,,,,,,,,,,,,
Cystourethroscopy With Biopsy,CASE-52204,LOCAL,52204,CPT,0360,RC,,,,outpatient,,,18014.98,10808.99,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2,CASE-29822,LOCAL,29822,CPT,,,,,,outpatient,,,26409.28,15845.57,,,,,,,,,,,,,
Unlisted Laparoscopy Procedure Stomach,CASE-43659,LOCAL,43659,CPT,0360,RC,,,,outpatient,,,128435.58,77061.35,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE|PO",CASE-64708,LOCAL,64708,CPT,,,,,RT|PO,outpatient,,,18052.53,10831.52,,,,,,,,,,,,,
INTRODUCER SHTH L13CM OD10.5FR DIL L20CM SPL AWAY VLV,SUP-2289322,CDM,C1892,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST CABLE DRIVEN FABRICATED,SUP-2435770,CDM,L3901,HCPCS,0274,RC,,,,both,,,5470.16,3555.60,,,,,,,,,,,,,
"HC So Fungus, Nes",PX-3028667166,CDM,86671,CPT,0302,RC,,,,both,,,43.00,27.95,,,,,,,,,,,,,
SPACER SPNL CNTRL PC B 20X32-44 MM VBR,SUP-2430767,CDM,C1889,HCPCS,0278,RC,,,,both,,,14660.66,9529.43,,,,,,,,,,,,,
PLATE BONE LOK HLX6 3MM THK TTNM 120DG ANGLD LVLX1 RCNSTRCTN,SUP-2679063,CDM,C1713,HCPCS,0278,RC,,,,both,,,3383.95,2199.57,,,,,,,,,,,,,
NEEDLE BX DIA25GA FN ENDOSCP SHARKCORE,SUP-2174335,CDM,C1713,HCPCS,0278,RC,,,,both,,,1125.38,731.50,,,,,,,,,,,,,
PUNCH ENDOSCP 4MM DIA SUT STR JAW 4MM DIA W O SUT REUSE,SUP-2166509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6113.83,3973.99,,,,,,,,,,,,,
GRAFT GYN 6X10CM FET BOV DERM MTRX SFT TISS REP CNFRM QUIK,SUP-2139396,CDM,C1763,HCPCS,0278,RC,,,,both,,,3917.12,2546.13,,,,,,,,,,,,,
STEM EXTN TIB 13MMDIA 45MML POR MLRY HD,SUP-2408821,CDM,C1776,CPT,0278,RC,,,,both,,,30574.18,19873.22,,,,,,,,,,,,,
SCREW INTFR L30MM DIA11MM FULL THRD STAR DRV FOR ACL RECON,SUP-2212844,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
VALVE AORT OPN PVT DIA26 MM ORIFICE 24.8 MM TISS ANNULUS,SUP-2282674,CDM,C1889,HCPCS,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
CATHETER DRAINAGE LCK 038 14 FRX14 CM 5 CM BILI RESOLV,SUP-2467946,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
Rpr Nonunion Scaphoid Carpal Bne W/WO Rdl Stylec|RIGHT SIDE|PO,CASE-25440,LOCAL,25440,CPT,,,,,RT|PO,outpatient,,,24858.07,14914.84,,,,,,,,,,,,,
Musc Myocutaneous/Fasciocutaneous Flap Trunk,CASE-15734,LOCAL,15734,CPT,,,,,,outpatient,,,78216.28,46929.77,,,,,,,,,,,,,
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,LOCAL,57425,CPT,,,,,,outpatient,,,93190.15,55914.09,,,,,,,,,,,,,
Unlisted Px Skin Muc Membrane & Subq Tissue|PO,CASE-17999,LOCAL,17999,CPT,,,,,PO,outpatient,,,38630.25,23178.15,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO|SEPARATE STRUCTURE",CASE-28270,LOCAL,28270,CPT,0360,RC,,,T6|PO|XS,outpatient,,,30820.38,18492.23,,,,,,,,,,,,,
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,LOCAL,58120,CPT,,,,,,outpatient,,,24392.00,14635.20,,,,,,,,,,,,,
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|RIGHT SIDE,CASE-37225,LOCAL,37225,CPT,,,,,RT,outpatient,,,75093.20,45055.92,,,,,,,,,,,,,
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs,CASE-25115,LOCAL,25115,CPT,0360,RC,,,,outpatient,,,20045.78,12027.47,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,LOCAL,29807,CPT,0360,RC,,,,outpatient,,,40724.82,24434.89,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,LOCAL,64493,CPT,,,,,RT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Rcnstj Angular Dfrm Toe Soft Tiss Px Only|BILATERAL PROCEDURE|SEPARATE STRUCTURE|PO,CASE-28313,LOCAL,28313,CPT,,,,,50|XS|PO,outpatient,,,15759.98,9455.99,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE|PO,CASE-64483,LOCAL,64483,CPT,0360,RC,,,RT|PO,outpatient,,,3914.52,2348.71,,,,,,,,,,,,,
MESH HERN 30.5X30.5CM POLYPR W/ POLYDIOXANONE PROCEED RECT,SUP-2219764,CDM,C1781,HCPCS,0278,RC,,,,both,,,7046.60,4580.29,,,,,,,,,,,,,
KIT DISINFECTION NOW TEST,SUP-2765073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
DEVICE RECON EMBOLIC COIL ARCH W86MM ANEUR NK W8MM VES,SUP-2248963,CDM,C1876,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
SCREW BONE PED L14MM DIA4.5MM LT RT CORT PROX FEM S STL ST,SUP-2318573,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.61,142.10,,,,,,,,,,,,,
COVER BURR H DIA18.5 MM PROF THK 0.3 MM CRAN NS THINFLAP,SUP-2883901,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
HC Cardiac Nonmonitored Exer Sess,PX-9439379700,CDM,93797,CPT,0943,RC,,,,outpatient,,,309.00,200.85,,,,,,,,,,,,,
CATHETER CARD 6FR 2-5-2MM ABLAT CSL CRV ELECTRD SPC 120CM,SUP-2356837,CDM,C1730,HCPCS,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
CAGE SPNL H4MM DIA10MM ANT CERV THORLUM TI RND CORPECTOMY,SUP-2193206,CDM,C1889,HCPCS,0278,RC,,,,both,,,4336.34,2818.62,,,,,,,,,,,,,
PIN FIX L9IN OD5/64IN S STL TYP A STNMN,SUP-2342708,CDM,C1713,HCPCS,0278,RC,,,,both,,,201.02,130.66,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE|PO,CASE-64484,LOCAL,64484,CPT,,,,,LT|PO,outpatient,,,3914.52,2348.71,,,,,,,,,,,,,
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE,CASE-27829,LOCAL,27829,CPT,0360,RC,,,LT,outpatient,,,34840.13,20904.08,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|SEPARATE STRUCTURE,CASE-52332,LOCAL,52332,CPT,,,,,50|XS,outpatient,,,39664.38,23798.63,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64418,LOCAL,64418,CPT,0360,RC,,,XU|LT|PO,outpatient,,,56283.73,33770.24,,,,,,,,,,,,,
Open Treatment Proximal Fibula/Shaft Fracture|RIGHT SIDE|PO,CASE-27784,LOCAL,27784,CPT,,,,,RT|PO,outpatient,,,48649.82,29189.89,,,,,,,,,,,,,
HC Cv Cath Plac WO Port>5yr (Tun),CASE-36558,LOCAL,36558,CPT,0361,RC,,,,outpatient,,,12541.22,7524.73,,,,,,,,,,,,,
Rhytidectomy Smas Flap|PO,CASE-15829,LOCAL,15829,CPT,0360,RC,,,PO,outpatient,,,61605.28,36963.17,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Mtcarphlngl Joint Each|RIGHT HAND, FIFTH DIGIT|PO",CASE-26520,LOCAL,26520,CPT,,,,,F9|PO,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
Open Repair of Rotator Cuff Chronic|LEFT SIDE,CASE-23412,LOCAL,23412,CPT,,,,,LT,outpatient,,,52273.90,31364.34,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE|PO,CASE-29807,LOCAL,29807,CPT,0360,RC,,,LT|PO,outpatient,,,49076.20,29445.72,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,LOCAL,G0121,CPT,0360,RC,,,74,outpatient,,,7219.43,4331.66,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE|PO,CASE-29875,LOCAL,29875,CPT,0360,RC,,,LT|PO,outpatient,,,18319.27,10991.56,,,,,,,,,,,,,
Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|LEFT SIDE|PO,CASE-25290,LOCAL,25290,CPT,,,,,LT|PO,outpatient,,,12902.80,7741.68,,,,,,,,,,,,,
Removal Implant Deep|LEFT SIDE,CASE-20680,LOCAL,20680,CPT,0360,RC,,,LT,outpatient,,,18251.88,10951.13,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE|PO,CASE-29879,LOCAL,29879,CPT,,,,,LT|PO,outpatient,,,48468.53,29081.12,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT HAND, THUMB",CASE-28750,LOCAL,28750,CPT,0360,RC,,,F5,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28299,LOCAL,28299,CPT,0360,RC,,,TA|PO,outpatient,,,25037.65,15022.59,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT",CASE-28270,LOCAL,28270,CPT,0360,RC,,,T6,outpatient,,,39850.62,23910.37,,,,,,,,,,,,,
PACEMAKER CARD LUMAX 540 HF-T 40 J SCOUTPRO HOME MONITORING,SUP-2138264,CDM,C1882,HCPCS,0275,RC,,,,both,,,85046.90,55280.48,,,,,,,,,,,,,
CATHETER EP L115CM OD6FR 2 7MM SPC 6 POLE F 10 PIN DR FIX,SUP-2248460,CDM,C1730,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
GRAFT BNE 0.75ML SUB VOID FILL RESRB PTTY MASTERGRFT,SUP-2288539,CDM,C9359,HCPCS,0278,RC,,,,both,,,231.01,150.16,,,,,,,,,,,,,
PLATE BONE L207MM 9 H RT SHFT FOR BUTTRESSING MULTIFRAGMENT,SUP-2152511,CDM,C1713,HCPCS,0278,RC,,,,both,,,4231.15,2750.25,,,,,,,,,,,,,
BLADE SAW RCPRCTNG 12MMW X76MML 1.3MM THK 1.3MM THK CUT LG B,SUP-2605425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,71.69,46.60,,,,,,,,,,,,,
HC Vasc Emb/Occ W/Prs Cath,PX-3610979700,CDM,C9797,CPT,0361,RC,,,,both,,,54207.00,35234.55,,,,,,,,,,,,,
SCREW BNE LCK 3X30 MM STRL MOTOBAND CP,SUP-2175145,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
GRAFT BONE SUB 10ML DBM PUTTY IRRADIATED SYR,SUP-2293910,CDM,C1713,HCPCS,0278,RC,,,,both,,,2719.24,1767.51,,,,,,,,,,,,,
BLADE ENDO FOR SFT TISS PLNTR FASC REL SYS ENDOBLDE,SUP-2122780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
PLATE BNE T 2.3 MM LT 6 HOLE COMPR OBLQ PROFYLE-L,SUP-2691429,CDM,C1713,HCPCS,0278,RC,,,,both,,,1273.11,827.52,,,,,,,,,,,,,
STEM POROUS 12.0X115MM STRAIGHT,SUP-2505104,CDM,C1776,CPT,0278,RC,,,,both,,,7460.64,4849.42,,,,,,,,,,,,,
Transperineal Plmt Biodegradable Matrl 1/Mlt Njx,CASE-55874,LOCAL,55874,CPT,0360,RC,,,,outpatient,,,37395.83,22437.50,,,,,,,,,,,,,
Arthroscopy Knee Lateral Release,CASE-29873,LOCAL,29873,CPT,0360,RC,,,,outpatient,,,25584.97,15350.98,,,,,,,,,,,,,
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr,CASE-28238,LOCAL,28238,CPT,0360,RC,,,,outpatient,,,34347.48,20608.49,,,,,,,,,,,,,
Excision Single External Papilla or Tag Anus,CASE-46220,LOCAL,46220,CPT,0360,RC,,,,outpatient,,,22882.95,13729.77,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,LOCAL,38900,CPT,0360,RC,,,RT,outpatient,,,41466.28,24879.77,,,,,,,,,,,,,
Tenolysis Flexor Tendon Palm/Finger Each Tendon,CASE-26440,LOCAL,26440,CPT,,,,,,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, SECOND DIGIT|PO",CASE-26356,LOCAL,26356,CPT,0360,RC,,,F1|PO,outpatient,,,21815.82,13089.49,,,,,,,,,,,,,
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE|PO,CASE-64450,LOCAL,64450,CPT,0450,RC,,,LT|PO,outpatient,,,3565.57,2139.34,,,,,,,,,,,,,
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf|LEFT SIDE,CASE-36825,LOCAL,36825,CPT,,,,,LT,outpatient,,,32989.25,19793.55,,,,,,,,,,,,,
Excision Mal Lesion Trunk/Arm/Leg 3.1-4.0 Cm,CASE-11604,LOCAL,11604,CPT,0360,RC,,,,outpatient,,,35367.78,21220.67,,,,,,,,,,,,,
HC Add 2nd/3rd Order Abd/Le,CASE-36248,LOCAL,36248,CPT,0361,RC,,,,outpatient,,,46699.20,28019.52,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,LOCAL,64494,CPT,0360,RC,,,RT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
HC Inj Tendon Sheath/Ligament|PO,CASE-20550,LOCAL,20550,CPT,0510,RC,,,PO,outpatient,,,4882.90,2929.74,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,LOCAL,38525,CPT,0360,RC,,,LT,outpatient,,,43729.70,26237.82,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE,CASE-29806,LOCAL,29806,CPT,,,,,LT,outpatient,,,52750.32,31650.19,,,,,,,,,,,,,
Arthrs Knee Debridement/Shaving Artclr Crtlg|LEFT SIDE|PO,CASE-29877,LOCAL,29877,CPT,0360,RC,,,LT|PO,outpatient,,,21367.02,12820.21,,,,,,,,,,,,,
Arven Anast Opn Upr Arm Basilic Vein Trpos,CASE-36819,LOCAL,36819,CPT,,,,,,outpatient,,,37621.32,22572.79,,,,,,,,,,,,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,0636,RC,63323-0507-20,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
SNARE VASC 7FR L120CM DIE-45MM CATH L100CM STD INTERLACED,SUP-2302539,CDM,C1773,HCPCS,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
INTRODUCER CATH 9FR L23CM W/ GWIRE DIA0.038IN DI-LOCK DIL,SUP-2357081,CDM,C1892,HCPCS,0272,RC,,,,both,,,17.27,11.23,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 X 40 CM DIA 8 X 8 MM EPTFE,SUP-2396236,CDM,C1768,CPT,0278,RC,,,,both,,,6449.56,4192.21,,,,,,,,,,,,,
IMPLANT LARYN 1ML GEL INJ VOCAL CRD MEDIALIZATION PROLARYN,SUP-2303664,CDM,L8607,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
SCREW SPNL RECON 4X20 MM POSTED EXT BLU VERTEX SEL,SUP-2630724,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG 1.14 MM ID FLROPLAS STRL WHT,SUP-2284043,CDM,L8699,HCPCS,0278,RC,,,,both,,,28.51,18.53,,,,,,,,,,,,,
DISTRACTION INTRNL ACT ARM RIGID RMTE DTCH43 MM T 6L 4V QT00,SUP-2669788,CDM,C1713,HCPCS,0278,RC,,,,both,,,3681.08,2392.70,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX25 CM 3L POLYETH,SUP-2760144,CDM,C1751,HCPCS,0278,RC,,,,both,,,234.93,152.70,,,,,,,,,,,,,
CATHETER ANGIOPLSTY AGNT L 144 MM BALLOON L 12 MM DIA2.75 MM,SUP-2892823,CDM,C9610,HCPCS,0272,RC,,,,both,,,19389.50,12603.17,,,,,,,,,,,,,
DRILL SURG CANN 4 MM N-FORC DISP,SUP-2471360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
IMMOBILIZER SHOULDER SLING SWATHE DLX,SUP-2196951,CDM,L3660,HCPCS,0272,RC,,,,both,,,22.98,14.94,,,,,,,,,,,,,
TOURNIQUET RED 18 X 4 DISP,SUP-2719743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|LEFT SIDE|PO,CASE-28465,LOCAL,28465,CPT,,,,,LT|PO,outpatient,,,37055.32,22233.19,,,,,,,,,,,,,
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE|PO,CASE-27792,LOCAL,27792,CPT,,,,,RT|PO,outpatient,,,31031.63,18618.98,,,,,,,,,,,,,
Removal Implant Deep|PO,CASE-20680,LOCAL,20680,CPT,0360,RC,,,PO,outpatient,,,21472.18,12883.31,,,,,,,,,,,,,
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-27680,LOCAL,27680,CPT,,,,,XS|RT|PO,outpatient,,,27808.43,16685.06,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52352,LOCAL,52352,CPT,,,,,LT|XU,outpatient,,,30801.07,18480.64,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, FIFTH DIGIT|PO",CASE-28308,LOCAL,28308,CPT,0360,RC,,,T4|PO,outpatient,,,66002.80,39601.68,,,,,,,,,,,,,
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,LOCAL,49329,CPT,0360,RC,,,,outpatient,,,48028.78,28817.27,,,,,,,,,,,,,
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|LEFT SIDE,CASE-37766,LOCAL,37766,CPT,0360,RC,,,LT,outpatient,,,29073.12,17443.87,,,,,,,,,,,,,
HC Cystostomy Tube Change,CASE-51705,LOCAL,51705,CPT,0761,RC,,,,outpatient,,,27232.07,16339.24,,,,,,,,,,,,,
Arthrotomy W/Meniscus Repair Knee,CASE-27403,LOCAL,27403,CPT,,,,,,outpatient,,,63869.23,38321.54,,,,,,,,,,,,,
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>,CASE-25071,LOCAL,25071,CPT,0360,RC,,,,outpatient,,,17666.23,10599.74,,,,,,,,,,,,,
Corrj Hallux Valgus W/Sesmdc W/2 Osteot,CASE-28299,LOCAL,28299,CPT,0360,RC,,,,outpatient,,,25142.88,15085.73,,,,,,,,,,,,,
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|SEPARATE STRUCTURE,CASE-14040,LOCAL,14040,CPT,0360,RC,,,XS,outpatient,,,22334.18,13400.51,,,,,,,,,,,,,
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|LEFT SIDE|PO,CASE-28730,LOCAL,28730,CPT,0360,RC,,,LT|PO,outpatient,,,76940.20,46164.12,,,,,,,,,,,,,
Fth/Gft Free W/Direct Closure S/a/L 20 Cm/<,CASE-15220,LOCAL,15220,CPT,,,,,,outpatient,,,39572.23,23743.34,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE|PO,CASE-29828,LOCAL,29828,CPT,,,,,LT|PO,outpatient,,,54366.32,32619.79,,,,,,,,,,,,,
SPHINCTEROTOME ENDO CATH 7FR ACROBAT 0.035IN ACCSRY CHAN,SUP-2170219,CDM,C1769,HCPCS,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PLATE BNE L81MM 10 H NONSTERILE STR RECON FOR 27MM SCR UNIV,SUP-2199376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1148.80,746.72,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 5000RPM N ROT LNG CRV SHFT AUTO EM,SUP-2284151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.00,475.80,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0038IN SUP STIFF STD STR TIP HI,SUP-2141504,CDM,C1769,HCPCS,0272,RC,,,,both,,,440.79,286.51,,,,,,,,,,,,,
STEM XL POROUS 16.5X220MM BOWED,SUP-2504979,CDM,C1776,CPT,0278,RC,,,,both,,,9382.32,6098.51,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115 CM 7FR 4MM C CRV SFT,SUP-2248471,CDM,C1732,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE L W10.1XL140MM THK3.5MM 10 H BILAT S STL STR LOK,SUP-2186217,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.95,987.97,,,,,,,,,,,,,
ADAPTER ORTH RNG LNG SLT OFFSET,SUP-2749955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,LOCAL,45380,CPT,0360,RC,,,XU,outpatient,,,14574.40,8744.64,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE|PO,CASE-25608,LOCAL,25608,CPT,0360,RC,,,LT|PO,outpatient,,,31093.13,18655.88,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE,CASE-52005,LOCAL,52005,CPT,,,,,LT,outpatient,,,13374.02,8024.41,,,,,,,,,,,,,
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|LEFT SIDE|PO,CASE-25260,LOCAL,25260,CPT,,,,,LT|PO,outpatient,,,23567.05,14140.23,,,,,,,,,,,,,
"HC Excis Nail Matrix Perm Rmvl|LEFT FOOT, GREAT TOE|PO",CASE-11750,LOCAL,11750,CPT,0450,RC,,,TA|PO,outpatient,,,25077.23,15046.34,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening|LEFT SIDE|PO,CASE-25390,LOCAL,25390,CPT,,,,,LT|PO,outpatient,,,34095.55,20457.33,,,,,,,,,,,,,
Laps Surg Esopg/Gstr Fundoplasty,CASE-43280,LOCAL,43280,CPT,,,,,,outpatient,,,81634.53,48980.72,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28820,LOCAL,28820,CPT,0360,RC,,,T7,outpatient,,,45726.50,27435.90,,,,,,,,,,,,,
Arthrt Elbow W/Exploration Drainage/Removal FB|RIGHT SIDE|PO,CASE-24000,LOCAL,24000,CPT,0360,RC,,,RT|PO,outpatient,,,40834.40,24500.64,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US,CASE-20610,LOCAL,20610,CPT,0510,RC,,,,outpatient,,,1407.35,844.41,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT|PO",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F3|PO,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,LOCAL,G0121,CPT,0360,RC,,,KX,outpatient,,,10162.85,6097.71,,,,,,,,,,,,,
Excision Interdigital Morton Neuroma Single Each|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-28080,LOCAL,28080,CPT,0360,RC,,,XU|RT,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 125 MCG PO TABS,RX-4424,CDM,6370000000,HCPCS,0637,RC,00904-6955-61,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IV SOLN,RX-104397,CDM,J1459,HCPCS,0636,RC,44206-0437-10,NDC,,both,100,ML,5659.90,3678.93,,,,,,,,,,,,,
GENERATOR FLO BIPAP AIR TBNG CONN PWR CRD SULLIVAN COMFORT,SUP-2331922,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
GUIDEWIRE SURG L150MM DIA1.6MM,SUP-2405548,CDM,C1769,HCPCS,0272,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
COLLAR EXTRIC AD SHT TWO PC TRACH OPN VELC CLSR W/ CHIN,SUP-2194467,CDM,L0180,HCPCS,0272,RC,,,,both,,,54.10,35.16,,,,,,,,,,,,,
CATHETERIZATION SET ROSCH-THURMOND 5.5 FR FALLOPIAN TUBE,SUP-2755162,CDM,C1769,HCPCS,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
"Inject Nerv Blck,Paravert Sympath|PO",CASE-64520,LOCAL,64520,CPT,,,,,PO,outpatient,,,5780.23,3468.14,,,,,,,,,,,,,
Rhytidectomy Neck W/Platysmal Tightening,CASE-15825,LOCAL,15825,CPT,,,,,,outpatient,,,36231.00,21738.60,,,,,,,,,,,,,
"Amp Mtcrpl W/Finger/Thumb W/WO Inteross Transfer|RIGHT HAND, FIFTH DIGIT|PO",CASE-26910,LOCAL,26910,CPT,0360,RC,,,F9|PO,outpatient,,,10837.33,6502.40,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T1,outpatient,,,25077.23,15046.34,,,,,,,,,,,,,
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE|PO,CASE-29877,LOCAL,29877,CPT,0360,RC,,,RT|PO,outpatient,,,17946.17,10767.70,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26540,LOCAL,26540,CPT,,,,,F6|PO,outpatient,,,16141.85,9685.11,,,,,,,,,,,,,
Bone Graft Any Donor Area Major/Large|PO,CASE-20902,LOCAL,20902,CPT,0360,RC,,,PO,outpatient,,,61983.88,37190.33,,,,,,,,,,,,,
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|RIGHT FOOT, SECOND DIGIT|PO",CASE-28092,LOCAL,28092,CPT,,,,,T6|PO,outpatient,,,12964.35,7778.61,,,,,,,,,,,,,
Laps Supracrv Hysterec >250 G Rmvl Tube/Ovary,CASE-58544,LOCAL,58544,CPT,0360,RC,,,,outpatient,,,84701.17,50820.70,,,,,,,,,,,,,
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28645,LOCAL,28645,CPT,,,,,T8|PO,outpatient,,,60113.25,36067.95,,,,,,,,,,,,,
Synovectomy Tendon Sheath Foot Extensor|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28088,LOCAL,28088,CPT,0360,RC,,,LT|XU,outpatient,,,22918.45,13751.07,,,,,,,,,,,,,
Partial Excision Bone Tibia|LEFT SIDE,CASE-27640,LOCAL,27640,CPT,0360,RC,,,LT,outpatient,,,29585.72,17751.43,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64718,LOCAL,64718,CPT,,,,,XS|RT|PO,outpatient,,,18911.10,11346.66,,,,,,,,,,,,,
Ligj & Div Short Saph Vein Saphenopop Junct Spx|LEFT SIDE,CASE-37780,LOCAL,37780,CPT,,,,,LT,outpatient,,,39737.47,23842.48,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, SECOND DIGIT|PO",CASE-26418,LOCAL,26418,CPT,,,,,F1|PO,outpatient,,,15514.98,9308.99,,,,,,,,,,,,,
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE|PO,CASE-28322,LOCAL,28322,CPT,,,,,LT|PO,outpatient,,,48283.90,28970.34,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|RIGHT FOOT, GREAT TOE|PO",CASE-28297,LOCAL,28297,CPT,,,,,T5|PO,outpatient,,,46038.33,27623.00,,,,,,,,,,,,,
Ercp Dx Collection Specimen Brushing/Washing|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43260,LOCAL,43260,CPT,,,,,74,outpatient,,,23073.50,13844.10,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO,CASE-27601,LOCAL,27601,CPT,,,,,LT|PO,outpatient,,,37078.38,22247.03,,,,,,,,,,,,,
MARKER BIOPSY HYDROMARK PLUSACOPE 5 BRONCHO HG 5.6/2.8,SUP-2882668,CDM,A4648,CPT,0278,RC,,,,both,,,288.03,187.22,,,,,,,,,,,,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,340b,HCPCS,0637,RC,63739-0160-70,NDC,,both,.5,ML,2.70,1.75,,,,,,,,,,,,,
"HC Trans, Esb, L/S, Single|BILATERAL PROCEDURE|PO",PX-3606448300,CDM,64483,CPT,0360,RC,,,50|PO,both,,,2817.00,1831.05,,,,,,,,,,,,,
BASEPLATE TIB SZ 6 OXIN TI RT KNEE STRL LEGION HK,SUP-2910024,CDM,C1776,CPT,0278,RC,,,,both,,,23738.40,15429.96,,,,,,,,,,,,,
NAIL IM 8X300 MM TIB TI STRL EXPERT,SUP-2179812,CDM,C1713,HCPCS,0278,RC,,,,both,,,3809.45,2476.14,,,,,,,,,,,,,
GRAFT BNE SUB 10ML SIL SOD CA PHOS OXIDE FOAM PK RECT CONT,SUP-2368184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HANDPIECE PHACO SURG MILL,SUP-2391877,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
CATHETER DEL 4MAX L 134 CM WORKING L 130 CM DIA,SUP-2323546,CDM,C1725,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,LOCAL,28820,CPT,0360,RC,,,T1,outpatient,,,28436.42,17061.85,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-29827,LOCAL,29827,CPT,,,,,73,outpatient,,,17170.50,10302.30,,,,,,,,,,,,,
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion,CASE-52354,LOCAL,52354,CPT,,,,,,outpatient,,,18153.38,10892.03,,,,,,,,,,,,,
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,LOCAL,46255,CPT,0360,RC,,,,outpatient,,,17499.95,10499.97,,,,,,,,,,,,,
Open Tx Radial&Ulnar Shaft Fx W/Fixj Radius&Ulna|RIGHT SIDE|PO,CASE-25575,LOCAL,25575,CPT,,,,,RT|PO,outpatient,,,46185.27,27711.16,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO|SEPARATE STRUCTURE",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F8|PO|XS,outpatient,,,16513.35,9908.01,,,,,,,,,,,,,
Arthrp Kne Condyle&Platu Medial&Lat Compartments|RIGHT SIDE,CASE-27447,LOCAL,27447,CPT,0360,RC,,,RT,outpatient,,,56419.12,33851.47,,,,,,,,,,,,,
Rpr Nonunion/Malunion Radius/Ulna W/Autograft|LEFT SIDE|PO,CASE-25405,LOCAL,25405,CPT,,,,,LT|PO,outpatient,,,30707.65,18424.59,,,,,,,,,,,,,
Gastrocnemius Recession|LEFT SIDE,CASE-27687,LOCAL,27687,CPT,0360,RC,,,LT,outpatient,,,49796.85,29878.11,,,,,,,,,,,,,
Implnt Bio Implnt for Soft Tissue Reinforcement,CASE-15777,LOCAL,15777,CPT,,,,,,outpatient,,,97810.18,58686.11,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT|PO",CASE-26055,LOCAL,26055,CPT,,,,,F3|PO,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
Arthrodesis Midtarsometatarsal Single Joint|RIGHT SIDE,CASE-28740,LOCAL,28740,CPT,0360,RC,,,RT,outpatient,,,85871.93,51523.16,,,,,,,,,,,,,
Trurl Rescj Residual/Regrowth Obstr Prstate Tiss,CASE-52630,LOCAL,52630,CPT,,,,,,outpatient,,,24336.97,14602.18,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,LOCAL,64418,CPT,0360,RC,,,LT|XU,outpatient,,,46233.03,27739.82,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO|SEPARATE STRUCTURE",CASE-28270,LOCAL,28270,CPT,,,,,T6|PO|XS,outpatient,,,30820.38,18492.23,,,,,,,,,,,,,
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,LOCAL,49594,CPT,,,,,,outpatient,,,54843.77,32906.26,,,,,,,,,,,,,
LENS INTOCU 21.5 DIOPT TRIFOCAL UV ABSRB AND BLU LT,SUP-2418691,CDM,V2788,HCPCS,0276,RC,,,,both,,,995.00,646.75,,,,,,,,,,,,,
ELECTRODE ELECSURG ROBOTIC CAUT HK TIP DA VINCI S/SI,SUP-2246576,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SUPPORT ORTHOT CUST FULL SOLE HEEL WDG BTWN SOLE,SUP-2435728,CDM,L3420,HCPCS,0274,RC,,,,both,,,154.83,100.64,,,,,,,,,,,,,
TM STEM POR UPLR S,SUP-2212127,CDM,C1776,CPT,0278,RC,,,,both,,,29641.60,19267.04,,,,,,,,,,,,,
HC MRI Face Neck Eye W & WO Cont,PX-6107054300,CDM,70543,CPT,0610,RC,,,,both,,,5040.00,3276.00,,,,,,,,,,,,,
HC So Lipoprotein-Assoc Phospholipas,PX-3018369866,CDM,83698,CPT,0301,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
PLATE BNE GOTFRIED,SUP-2644725,CDM,C1713,HCPCS,0278,RC,,,,both,,,1606.68,1044.34,,,,,,,,,,,,,
HC Assay of Progesterone,PX-3018414400,CDM,84144,CPT,0301,RC,,,,outpatient,,,332.00,215.80,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X50X2 MM FD SPNG CANC READIGRAFT BLX,SUP-2740799,CDM,C1713,HCPCS,0278,RC,,,,both,,,3357.88,2182.62,,,,,,,,,,,,,
ANKLE FUSION PLATE ANTERIOR TT RIGHT 4H,SUP-2815297,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
SET DIL SEQ STRL,SUP-2431882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PLATE BONE LOK 132MML HLX8 STNLSS STEEL ST RIGHT LTRL DST FB,SUP-2588180,CDM,C1713,HCPCS,0278,RC,,,,both,,,2093.25,1360.61,,,,,,,,,,,,,
CAGE BNE GRFT L 2.5-5 CM 96 POLYCAPROLACTONE 4 HA CALCIUM,SUP-2905646,CDM,C1713,HCPCS,0278,RC,,,,both,,,54265.32,35272.46,,,,,,,,,,,,,
SPOOL HUM RT SM CNTR OFFSET FOR TOT ELBW ARTHROPLASTY,SUP-2399818,CDM,C1776,CPT,0278,RC,,,,both,,,14308.98,9300.84,,,,,,,,,,,,,
PLATE BNE L177MM 10 H R PROX TIB S STL VAR ANG LOK COMPR SM,SUP-2420737,CDM,C1713,HCPCS,0278,RC,,,,both,,,5921.57,3849.02,,,,,,,,,,,,,
BRACE KNEE SZ 4 16-17INXL MID PAT Q FR CLSR IN 2SL BIOSKIN,SUP-2174972,CDM,L1820,HCPCS,0272,RC,,,,both,,,181.96,118.27,,,,,,,,,,,,,
BENAZEPRIL HCL 5 MG PO TABS,RX-9223,CDM,6370000000,HCPCS,0637,RC,50268-0109-15,NDC,,both,1,UN,2.90,1.88,,,,,,,,,,,,,
GRAFT 1CC ALLGRFT DBM MAXXEUS,SUP-2165612,CDM,C9359,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PIN FIX 26030000] SPINAL ELEMENTS INC],SUP-2353288,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
NAIL IM HUM 7X255 MM LT STR CANN TI BLU STRL MULTILOC,SUP-2541271,CDM,C1713,HCPCS,0278,RC,,,,both,,,6083.66,3954.38,,,,,,,,,,,,,
SHEATH ENDO OD27.6FR WHT CONT FLO INNR RND TIP RESECTOSCOPIC,SUP-2313069,CDM,C1894,HCPCS,0272,RC,,,,both,,,4191.49,2724.47,,,,,,,,,,,,,
WIRE FIX DIAMOND PT 2 END 0.035X9 IN SS NS KIRSCHNER KI71211,SUP-2791278,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.98,5.84,,,,,,,,,,,,,
PLATE BNE L202MM 10 H NONSTERILE R DST MED TIB S STL VAR,SUP-2184189,CDM,C1713,HCPCS,0278,RC,,,,both,,,4920.91,3198.59,,,,,,,,,,,,,
CLAMP EXT FIX M CLP ON SELF HLD,SUP-2188527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.20,830.18,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL RT 7 HOLE,SUP-2609040,CDM,C1713,HCPCS,0278,RC,,,,both,,,6494.65,4221.52,,,,,,,,,,,,,
COMPASS VENTRICULAR DRAINAGE FOR HYDROCEPHALUS VALVE PROGAV,SUP-2821850,CDM,C1729,HCPCS,0272,RC,,,,both,,,4672.19,3036.92,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ PISTON 0.6X4 MM SS FLROPLAS,SUP-2638110,CDM,L8613,CPT,0278,RC,,,,both,,,310.45,201.79,,,,,,,,,,,,,
PLATE BONE L146MM BLDE W4.8XL25MM 95DEG 8 H STRL HIP S STL,SUP-2186774,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.80,36.27,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL DIA20 GA SGL SHT LIDO NACL SYR CLR,SUP-2936485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,51.12,33.23,,,,,,,,,,,,,
SET HAD CATHETER 155FR L15CM BASIC STR EXTN DIL SCALP VLV,SUP-2266989,CDM,C1752,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SCREW STRNL CLOSURE L 10 MM TI LCK MINT NS STERNALOCK EZ,SUP-2894455,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
SLEEVE FEM +0MM 12/14 TI UPLR TAPR PLSM SPRY,SUP-2221656,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
CLAMP EXT FIX 6MM BAR TO 4MM PIN FRDM JET-X,SUP-2342897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4142.29,2692.49,,,,,,,,,,,,,
KIT VASC ACCS GWIRE L210CM ELITE,SUP-2227330,CDM,C1769,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BNE L 405 MM SCREW DIA 3.5/4.5 MM 20 H SS RT DSTL FEM 72585220N,SUP-2932787,CDM,C1713,HCPCS,0278,RC,,,,both,,,21907.00,14239.55,,,,,,,,,,,,,
SCREW BONE L10MM DIA4MM STD CANC ST NONCANNULATED NONLOCKING,SUP-2198249,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.68,23.84,,,,,,,,,,,,,
INTRODUCER SHTH MRK RADPQ 4FRX6CM PINN R O II,SUP-2385176,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.30,49.59,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR DD,SUP-2248604,CDM,C1732,HCPCS,0272,RC,,,,both,,,9730.86,6325.06,,,,,,,,,,,,,
TUBE JEJU 12FR PGTL TIP THRU THE PEG 3 PRT FEED ENDOVIVE,SUP-2141584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.41,272.62,,,,,,,,,,,,,
SPLINT DORSAL AFO SPLNT L RT W STRP,SUP-2163838,CDM,L4396,HCPCS,0274,RC,,,,both,,,110.94,72.11,,,,,,,,,,,,,
MATRIX DEMIN BONE 5CC STERIFUSE CRUNCH,SUP-2138659,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
HC Stress Echo W Contrast,PX-4839335000,CDM,C8928,HCPCS,0483,RC,,,,inpatient,,,1944.00,1263.60,,,,,,,,,,,,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,2500000003,HCPCS,0250,RC,00409-3299-06,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE STD MT FT ANK TI STR LO PROF FOR COMPHSVE SYS,SUP-2123062,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
GRAFT BNE STRP 20X15X7 MM COMPRESSIBLE BNE MTRX,SUP-2644319,CDM,C1713,HCPCS,0278,RC,,,,both,,,2819.41,1832.62,,,,,,,,,,,,,
BLADE SHAVER SERRATED 40 DEG 4 MM DSTL SUCTION ROTATABLE,SUP-2638420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BIT DRL DIA25MM HI SPD,SUP-2187153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.86,486.76,,,,,,,,,,,,,
PLUG BNE DIA28X32MM W/ DISP INSRT ALLEN,SUP-2203674,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
GRAFT DERMAL FEN 20X8 MM CLLGN TISS MTRX,SUP-2243674,CDM,C9360,HCPCS,0278,RC,,,,both,,,10550.40,6857.76,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 01 4MM CRUSH CANC CHIP FRZN,SUP-2307399,CDM,C1713,HCPCS,0278,RC,,,,both,,,1241.74,807.13,,,,,,,,,,,,,
RING EXT FIX CIR 5/8 160 MM SIDEKCK,SUP-2472870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1557.44,1012.34,,,,,,,,,,,,,
BUTTON NSL SEPT DIA3CM MED SIL 2 PART ADJ,SUP-2284096,CDM,C1889,HCPCS,0278,RC,,,,both,,,804.15,522.70,,,,,,,,,,,,,
CATHETER SINUS BAL L16MM DIA7MM RELIEVA SOLO PRO,SUP-2106323,CDM,C1729,HCPCS,0272,RC,,,,both,,,2577.31,1675.25,,,,,,,,,,,,,
KIT PELV FLR REP POST PINN,SUP-2141764,CDM,C1771,HCPCS,0278,RC,,,,both,,,5281.48,3432.96,,,,,,,,,,,,,
SET FUS NAIL RT FEM TIB KNEE CO CHROM MOLYBDENUM UHMWPE MOD,SUP-2265070,CDM,C1776,CPT,0278,RC,,,,both,,,17785.59,11560.63,,,,,,,,,,,,,
BIT DRL L155MM DIA3.5MM SHT SHANK DISP FOR PERI LOC 4.5MM,SUP-2343998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1105.63,718.66,,,,,,,,,,,,,
CATHETER EP DIAG VIK DAMATO CRV 2MM QPLR POLES 6FR 115CM,SUP-2142574,CDM,C1730,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
KIT SHTH DESTINO L 87 CM DIA12 FR CRV BEND L 22 MM DIL 50,SUP-2616111,CDM,C1766,CPT,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
HC ED Clsd Tx Prox Hum Fx Manip,PX-4502360500,CDM,23605,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
MESH HERN W10XL14IN RECT PROCEED,SUP-2219769,CDM,C1781,HCPCS,0278,RC,,,,both,,,7290.14,4738.59,,,,,,,,,,,,,
TUBE VENT ARMSTR 1.14 MM STR FLROPLAS,SUP-2458645,CDM,L8699,HCPCS,0278,RC,,,,both,,,23.58,15.33,,,,,,,,,,,,,
HC CT Soft Tissue Neck W/O Contrast,PX-3517049000,CDM,70490,CPT,0351,RC,,,,both,,,2388.00,1552.20,,,,,,,,,,,,,
PLATE CRANIAL UN3 2 H W /TAB DOGBONE LOW-PROFILE,SUP-2363622,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.91,272.94,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH MED 5X10 CM ACELLULAR HYDRATED DERM,SUP-2321754,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
ENDCAP ORTH L10MM DIA12MM ST GRN FEM TI NAIL EXTN LOK HD,SUP-2192364,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.90,484.18,,,,,,,,,,,,,
BIT DRL DIA4.5MM CANN W/ QUIK CONN FOR PLATING SYS PERI-LOC,SUP-2344002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4172.75,2712.29,,,,,,,,,,,,,
SCREW BONE LNG W/ FRE SPINNING WSHR RESRB TIB FIX INTRF,SUP-2212867,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
HC So Hla Dqb1 06:02 Genotype,PX-3108138366,CDM,81383,CPT,0310,RC,,,,outpatient,,,276.00,179.40,,,,,,,,,,,,,
OCCLUDER CV WATCHMAN FLX PRO DIA 35 MM DEL SYS DIA12 FR NIT,SUP-2882252,CDM,C1889,HCPCS,0278,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
T-PLATE 5 HOLEX100MM,SUP-2819049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.94,1467.01,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L30CM OD11FR CK VLV BAL W/O RESVR,SUP-2214696,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.29,345.99,,,,,,,,,,,,,
BRACE ANK 2 X SM M SHOE 3-5 WOMEN SHOE 4-6 AD SWEDE O X8,SUP-2325306,CDM,L1930,HCPCS,0274,RC,,,,both,,,68.42,44.47,,,,,,,,,,,,,
TUBE VENT ARMSTR R 1.14 PHOSPHORYLCHOLINE COAT SIL 510281C,SUP-2535119,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.80,32.37,,,,,,,,,,,,,
HALF PIN 6MMX80MM,SUP-2818307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1017.30,661.24,,,,,,,,,,,,,
IMPLANT OPHTH SPNG EYE RETINAL STYL 505 G GROOVED BCKL COMP,SUP-2213499,CDM,L8610,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
STIMLTR BN PHSTM LT EXTERNL,SUP-2316212,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
MICROCATHETER GUID TELEMARK WORKING L 150 CM SHFT DIA PROX,SUP-2759028,CDM,C1887,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
KIT SPNL H 35 MM DIA19 MM MED BLACKARMOR CARBON PEEK THORLUM,SUP-2917136,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 50 CM DIA 6 MM SUPP L 50 CM EPTFE,SUP-2227647,CDM,C1768,CPT,0278,RC,,,,both,,,1768.86,1149.76,,,,,,,,,,,,,
HC Wound Cautery-Chemical,PX-3611725000,CDM,17250,CPT,0361,RC,,,,outpatient,,,280.00,182.00,,,,,,,,,,,,,
PLATE PELVIC STR 4 HOLE,SUP-2491098,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SET STENT URTRL 8FR DIA 20CML PRCFLX DBLE PGTL STRGHT TIP DU,SUP-2724130,CDM,C2617,HCPCS,0278,RC,,,,both,,,531.45,345.44,,,,,,,,,,,,,
SOLUTION WND LAVAGE 500 ML CIT ACD SODIUM CIT SODIUM LAURYL,SUP-2900364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SABER L 200 CM BALLOON L 20 MM DIA1.5 MM,SUP-2909781,CDM,C1725,HCPCS,0272,RC,,,,both,,,817.66,531.48,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X3 CM DEHYDR AMNIO MEMBRN ALLOPATCH HD,SUP-2480485,CDM,Q4128,HCPCS,0636,RC,,,,both,,,8520.08,5538.05,,,,,,,,,,,,,
PUNCH SURG FOR 5.5MM CRKSCR FT AND 5.5MM SWIVELOCK,SUP-2121559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
HC Pulmonary Arteriogram Uni,PX-3237574100,CDM,75741,CPT,0323,RC,,,,both,,,3092.00,2009.80,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0250,RC,00990-7983-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
HC Rsf Lab Ecmc - Autopsy Blocks,PX-9900000126,CDM,9900000126,LOCAL,0990,RC,,,,both,,,7.00,4.55,,,,,,,,,,,,,
PLATE BNE 100 DEG L 22.58 MM THK 0.6 MM SCREW DIA1.5 MM SZ,SUP-2935762,CDM,C1713,HCPCS,0278,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
BLADE SAW W0.80IN THK0.050IN FOR SYS 4 AND 2000 SAG,SUP-2367217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,168.59,109.58,,,,,,,,,,,,,
PIN FIX PLT HLD REUSE ZEVO,SUP-2278052,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.51,243.43,,,,,,,,,,,,,
COMPR SRS PROX BDY - SM 48MM,SUP-2506565,CDM,C1776,CPT,0278,RC,,,,both,,,11360.52,7384.34,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL SHELL,SUP-2435548,CDM,L0490,HCPCS,0272,RC,,,,both,,,800.86,520.56,,,,,,,,,,,,,
CONNECTOR BRONCHSCP TWO PRONGED FR OER PRO TO BF 30 40 240,SUP-2313262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1146.95,745.52,,,,,,,,,,,,,
INSERT TIB SZ 2-3 THK18MM KNEE HNG ROT PLATFRM LEGION,SUP-2346658,CDM,C1776,CPT,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DIA 6 FR STEER DYN STRL,SUP-2126348,CDM,C1733,HCPCS,0272,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 2-5-2 SPC TIP ELECTRD 3.5MM 65MM,SUP-2357692,CDM,C2630,CPT,0272,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
BUR IRRIG STR 3MM,SUP-2313830,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.79,252.71,,,,,,,,,,,,,
CATHETER PULM ART 8.3FR ENDOVENT MINIMAL INCIS VLV ENDOVENT,SUP-2214477,CDM,C1725,HCPCS,0272,RC,,,,both,,,4242.14,2757.39,,,,,,,,,,,,,
ROD REPROC EXT FIX CRV 90 DEG 11X382 MM MR NS,SUP-2188644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
INTRODUCER PIN L203CM OD8GA BVL TIP SGL USE,SUP-2354633,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SLEEVE CANN DIA15 MM RADIALLY EXPANDABLE STRL DISP VERSASTEP,SUP-2896204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.84,233.90,,,,,,,,,,,,,
PIN EXT FIX L 50 MM DIA 5 MM LNG TI HALF STRL DISP JET-X,SUP-2933290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.31,284.90,,,,,,,,,,,,,
FIXATOR EXT SHT PELV BODY NS LTX,SUP-2874950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
BLADE SCRDRVR 2.5/2.8 HD7 AO,SUP-2267811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.46,445.55,,,,,,,,,,,,,
GRAFT BONE SUB W14XH7XL20MM DBM STRP OSTEOSPONGE,SUP-2125422,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
GRAFT HUMAN TSSUE FIRM 30X15 CM RCNSTRCTVE TSSUE MTRX STRTTC,SUP-2485459,CDM,Q4130,HCPCS,0636,RC,,,,both,,,43262.92,28120.90,,,,,,,,,,,,,
STEM HUM L122MM DIA11MM STD CO CHROM POR PRI PRESSFIT CEM,SUP-2404593,CDM,C1776,CPT,0278,RC,,,,both,,,9909.06,6440.89,,,,,,,,,,,,,
DISTRACTION INTRNL ACT ARM RIGID CRDNC35 MM T 6L 4V QT001 EA,SUP-2496570,CDM,C1713,HCPCS,0278,RC,,,,both,,,2477.96,1610.67,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SL2 4FR 55CM 1 LUMAN RVS TAPR PWR I,SUP-2613368,CDM,C1751,HCPCS,0278,RC,,,,both,,,629.60,409.24,,,,,,,,,,,,,
STD STAPLE 10MM OBLIQUE,SUP-2721828,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER LNG 30X11X9 MM BIO AVS UNILIF,SUP-2637045,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
PLATE BNE L220MM THK3.7MM 12 H NONSTERILE R DST MED TIB S,SUP-2185534,CDM,C1713,HCPCS,0278,RC,,,,both,,,3901.98,2536.29,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY KNEE CTRL CNDYL PD,SUP-2435699,CDM,L2810,HCPCS,0274,RC,,,,both,,,231.23,150.30,,,,,,,,,,,,,
PLATE BNE W6.3XL49MM THK1.6MM 3X4 H R DST RAD VOLAR S STL T,SUP-2186100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.11,1146.67,,,,,,,,,,,,,
COMPONENT PAT RND PRI STD PRESSFIT POR UHMWPE WITHOUTXRAY,SUP-2199553,CDM,C1776,CPT,0278,RC,,,,both,,,8706.59,5659.28,,,,,,,,,,,,,
ANCHOR SUT 23MM DIA W THRDR ULTRAFIX,SUP-2166460,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.27,308.28,,,,,,,,,,,,,
TUBE ET OD10.7MM ID8MM STD PVC DISP FOR EMG NIM TRIVANTANGE,SUP-2284334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.66,740.78,,,,,,,,,,,,,
SPACER SPNL W9XH9XL25MM 0DEG PEEK OPTMA LUM TRANSFORAMINAL,SUP-2402806,CDM,C1889,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS TEND NONIRRADIATED FRZN,SUP-2335549,CDM,C1762,CPT,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
SET VENT CATH L35CM OD2.9MM ID1.6MM BA STRP L STYL LUER,SUP-2244096,CDM,C1729,HCPCS,0272,RC,,,,both,,,352.94,229.41,,,,,,,,,,,,,
BLADE SAW KNEE 13MM CUT EDGE 95MM CUT DEPTH 1.27MM CUT THICK,SUP-2605520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,205.67,133.69,,,,,,,,,,,,,
STRAP ORTHOT PERONEAL CUST PREFABRICATED OFF THE SHLF,SUP-2435566,CDM,L0980,HCPCS,0274,RC,,,,both,,,48.39,31.45,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE STRGHT 2 HOLE LNG CP TTNM ST,SUP-2677535,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
CATHETER INFUSION ENDOVASC DEV 18 FRX106 CM US COR EKOSONIC,SUP-2214799,CDM,C1887,HCPCS,0272,RC,,,,both,,,18887.10,12276.61,,,,,,,,,,,,,
PLATE BONE L 6 H GAP LO PROF FOR 1.5MM SCR CRAN FIX SYS UNIV,SUP-2363640,CDM,C1713,HCPCS,0278,RC,,,,both,,,1148.11,746.27,,,,,,,,,,,,,
ELECTRODE ES URLGY 26FR DIA PNTD TIP FACMI USAELTE LATEX F,SUP-2721389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.93,241.75,,,,,,,,,,,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,0636,RC,09999-9909-54,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L85MM DIA5MM TI FOR HINDFOOT FUS SYS VALOR,SUP-2397581,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 60 CC FD ASEP CANC,SUP-2867133,CDM,C1762,CPT,0278,RC,,,,both,,,2120.91,1378.59,,,,,,,,,,,,,
COLLAR CERV PHILLY MED 4.25 IN 13-16 IN REHAB FOAM PROCARE,SUP-2196879,CDM,L0172,HCPCS,0272,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
PROBE NERVE STIM ELECTRD L 255 MM BALL DIA2.3 MM WIRE L 1.9,SUP-2895970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 3CMD SPNL MSCLE MULTI TTHD BLACK FNSH U,SUP-2459197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.51,396.83,,,,,,,,,,,,,
AWL ASSY STARTER AWL,SUP-2472912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,547.62,355.95,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST ANTR SWNG BND,SUP-2435660,CDM,L2335,HCPCS,0272,RC,,,,both,,,795.86,517.31,,,,,,,,,,,,,
BASEPLATE TIB STD UNIV REV STEM CEM SZ 2 AMK,SUP-2251228,CDM,C1776,CPT,0278,RC,,,,both,,,7840.58,5096.38,,,,,,,,,,,,,
CATHETER PTA BAL 0.035 IN OTW CATH LEN 80CM BAL SZ 10MMX20MM,SUP-2265999,CDM,C1725,HCPCS,0272,RC,,,,both,,,413.70,268.90,,,,,,,,,,,,,
PATCH DURA BIOABSRB SUB PLIABLE N IMMUNOGENIC LOOSE FIBROUS,SUP-2108184,CDM,C1763,HCPCS,0278,RC,,,,both,,,877.25,570.21,,,,,,,,,,,,,
HC Trluml Balo Angiop 1st Vein,PX-3613724800,CDM,37248,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
IMPLANT HUM TISS L 22 X 6 MM CANC FT EVANS WDG TEXT OSTEOTOM,SUP-2933244,CDM,C1762,CPT,0278,RC,,,,both,,,5918.77,3847.20,,,,,,,,,,,,,
FIBER LASER 200 MH FLEXSHIELD BALL SHP OUTPT TIP ETFE SIL,SUP-2417488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1417.84,921.60,,,,,,,,,,,,,
CURETTE BONE ANG SZ 0,SUP-2292914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L80CM BAL L20MM DIA4MM SHTH DIA5FR,SUP-2104282,CDM,C1725,HCPCS,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
DRIVER SURG FOR 23MM BIOTENODESIS FT ANK SCR,SUP-2121352,CDM,C1713,HCPCS,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
HC So Antithyroglobulin Antibody,PX-3028680066,CDM,86800,CPT,0302,RC,,,,both,,,69.00,44.85,,,,,,,,,,,,,
KIT THROMCTMY TREVO PROVUE NIT PLAT TUNGSTEN HYDRPHLC SLD,SUP-2367762,CDM,C1757,HCPCS,0272,RC,,,,both,,,23095.96,15012.37,,,,,,,,,,,,,
DRILL ARTHROSCOPICXL DIA1.7MM FOR SUT ANCHR SHLDR,SUP-2341892,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.15,441.45,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 70 CM DIA 6 MM RNG L 20 CM THK 0.35 MM,SUP-2483675,CDM,C1768,CPT,0278,RC,,,,both,,,3244.09,2108.66,,,,,,,,,,,,,
PLATE BNE RNG ATTCH SM 3.5 MM RT PROX GTR TROCH NS VA-LCP,SUP-2757652,CDM,C1713,HCPCS,0278,RC,,,,both,,,4281.55,2783.01,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 65 CM 5 FR 0.038 IN PIG NONBRAIDED,SUP-2116594,CDM,C1887,HCPCS,0272,RC,,,,both,,,96.08,62.45,,,,,,,,,,,,,
PLATE BNE RADIAL 2.4X54 MM RT VOLAR CLMN DSTL 6X4 HOLE LCK,SUP-2177239,CDM,C1713,HCPCS,0278,RC,,,,both,,,2660.96,1729.62,,,,,,,,,,,,,
CATHETER GUID 6FR L50CM ID0.068IN S STL NYL JKT PTFE INNR 100559706] ABBOTT],SUP-2101520,CDM,C1887,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
CATHETER INTVASC OCCL L 90 CM DIA10 FR BALLOON L 4 CM,SUP-2395865,CDM,C2628,HCPCS,0272,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
CLAMP EXT FIX STD PENNIG MINIFIXATOR,SUP-2316458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.95,1039.32,,,,,,,,,,,,,
PLATE BNE W8XL176MM THK3.3MM 22 H ST BILAT PELV S STL,SUP-2186250,CDM,C1713,HCPCS,0278,RC,,,,both,,,2488.58,1617.58,,,,,,,,,,,,,
GRFT CHIPS CORT CANC 1-4MM 4.59MM 15CC PUROS,SUP-2693919,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
TAP BNE SPNL CANN QUIK CONN SEXTANT 45MM DIA,SUP-2290637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.60,1051.44,,,,,,,,,,,,,
STEM FEM L140MM OD8MM CO CHROM HIP TAPR NEUT PRI CEM INTLOK,SUP-2136440,CDM,C1776,CPT,0278,RC,,,,both,,,5582.92,3628.90,,,,,,,,,,,,,
SHELL ACET OD60MM UNIV TI HIP RNG SCR H RECON RESTR GAP,SUP-2370312,CDM,C1776,CPT,0278,RC,,,,both,,,5908.22,3840.34,,,,,,,,,,,,,
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-104409,CDM,J0744,HCPCS,0636,RC,25021-0114-87,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
IMPLANT FNGR JT 3X30MM 10DEG PROX INTERPHALANGEAL DART PEEK,SUP-2121835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2 MM RECON PT SPEC TI,SUP-2860088,CDM,C1713,HCPCS,0278,RC,,,,both,,,22828.43,14838.48,,,,,,,,,,,,,
TUBE TRACH AD L110MM OD9.2MM ID6MM SIL UNCUF EXTRA LEN FIX,SUP-2351991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.72,221.47,,,,,,,,,,,,,
CLIP ENDSCPC 28MM DIA 165CML CHNNL RTTBLE LATEX NON RDLCNT,SUP-2679369,CDM,C1889,HCPCS,0278,RC,,,,both,,,648.98,421.84,,,,,,,,,,,,,
CANNULA SRGCL 48MML TRNSBCCL STNDRD SMOOTH FTRCR SSTM,SUP-2680126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.93,263.20,,,,,,,,,,,,,
SIZER BRST 525CC P5.8CM W14.5XH13.2CM SIL STYL MF MOD HT,SUP-2113578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KIT MICROCATHETER RENEGADE HI FLO L 105 CM DSTL TIP L 10 CM,SUP-2141040,CDM,C1887,HCPCS,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PROBE SURG BEYER 8X143 MM PGTL CRV BLNT RND KNURLED HNDL,SUP-2461814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.05,228.18,,,,,,,,,,,,,
COMPONENT TIB TY L69MM A/P56MM M/L75MM STD TIV L KNEE PRI,SUP-2208444,CDM,C1776,CPT,0278,RC,,,,both,,,2906.13,1888.98,,,,,,,,,,,,,
DRIVER 3030002 HLD PIN DRVR,SUP-2278051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.56,765.41,,,,,,,,,,,,,
CATHETER ABLATN MULTI 2-5-2MM 7 FRX110CM 40-60MM MARINR MC,SUP-2281837,CDM,C1733,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE LP 21X0.4 MM 8 HOLE ARM BURR HOLE CVR Q-STYLE TI,SUP-2461721,CDM,C1713,HCPCS,0278,RC,,,,both,,,3230.78,2100.01,,,,,,,,,,,,,
SPHERE GLEN LAT SM 36 MM SHLDR GLENOSPHERE RVS EXP EQUINOXE,SUP-2451441,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 3 FR 5MM/4.5FR 0.018 IN,SUP-2755078,CDM,C1757,HCPCS,0272,RC,,,,both,,,310.48,201.81,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 65 CM DIA20 FR BODY DIA 7.5 MM,SUP-2395733,CDM,C1894,HCPCS,0272,RC,,,,both,,,2160.32,1404.21,,,,,,,,,,,,,
SCREW BONE L30MM DIA3.5MM PROX FEM CANN T15 HEXALOBE PEDILOC,SUP-2318561,CDM,C1713,HCPCS,0278,RC,,,,both,,,1826.66,1187.33,,,,,,,,,,,,,
PLATE BNE H1MM 16 H MAND BLU TI MINI STR COND LOK LEIBINGER,SUP-2366344,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.35,813.38,,,,,,,,,,,,,
TROCH NAIL RIGHT 12.5MMX42CMX130 DEGREE,SUP-2828988,CDM,C1713,HCPCS,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
MESH CRAN L 122 X W 122 MM THK 0.5 MM SCREW DIA1.7 MM PLLA FLX,SUP-2884160,CDM,C1713,HCPCS,0278,RC,,,,both,,,16115.67,10475.19,,,,,,,,,,,,,
PLATE BNE L97MM THK1.3MM 100DEG 8 H TI TBLR FOR 3.5MM SCR,SUP-2412038,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.05,172.28,,,,,,,,,,,,,
PLATE ANCHR ORTHODONTIC 12 MM 1 MM W/ FLAT 5 MM AREA CP TI,SUP-2476748,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.84,347.65,,,,,,,,,,,,,
CAGE SPNL PARL 18X12X55 MM COUGAR LS,SUP-2256436,CDM,C1889,HCPCS,0278,RC,,,,both,,,21728.80,14123.72,,,,,,,,,,,,,
BRACE THMB AD LNG POLYPR FELT LNR PERF SUEDE ALUM STAY V,SUP-2324405,CDM,L3931,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
HC Mod Sed Same Phys/Qhp Ea,PX-3729915300,CDM,99153,CPT,0372,RC,,,,both,,,297.00,193.05,,,,,,,,,,,,,
NEEDLE MAYO 1/2 CRCLE SZ 4 TAPER POINT FINE 222204,SUP-2845003,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
HC Rh Lh W Coron & Lvgram,PX-4819346000,CDM,93460,CPT,0481,RC,,,,both,,,17800.00,11570.00,,,,,,,,,,,,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,6370000000,HCPCS,0637,RC,60758-0119-05,NDC,,both,5,ML,198.00,128.70,,,,,,,,,,,,,
SHEATH INTRO L 25 CM DIA 7 FR HEMOSTAS CLASSIC STRL,SUP-2148794,CDM,C1892,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PACEMAKER CARD CYLOS DR-T TI POLYUR SIL 2 CHMBR IS1 CONN,SUP-2138080,CDM,C1785,HCPCS,0275,RC,,,,both,,,20378.60,13246.09,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0.035IN TIP L10CM S STL PTFE 2 FLX,SUP-2167670,CDM,C1769,HCPCS,0272,RC,,,,both,,,40.98,26.64,,,,,,,,,,,,,
HEAD METATARSOPHALANGEAL CANN MINI 11X13X3 MM TOE RND COCR,SUP-2392821,CDM,C1776,CPT,0278,RC,,,,both,,,7507.74,4880.03,,,,,,,,,,,,,
PLATE EXT FIX L45MM SH 3 H CONN S STL FOR ILIZ TAY SPAT FRME,SUP-2340709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,727.95,473.17,,,,,,,,,,,,,
PLATE BNE L45MM STD 3X2 H NONSTERILE BILAT 1ST MTP FUS TI,SUP-2181242,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.55,2038.76,,,,,,,,,,,,,
BLADE SURG HK ANGLED ENDOTRAC 2055A6,SUP-2459363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.76,341.74,,,,,,,,,,,,,
K WIRE FIX L6IN DIA1.6MM NONSTERILE S STL 2 SIDE DBL DMND,SUP-2150659,CDM,C1713,HCPCS,0278,RC,,,,both,,,45.09,29.31,,,,,,,,,,,,,
NEEDLE TRANSEPTAL HEARTSPAN 50 DEG 98CM,SUP-2141301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SCREW BNE MALL 4.5X55 MM,SUP-2530685,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
SPACER CUT GUID MONOGRAM 10MM,SUP-2364870,CDM,C1776,CPT,0278,RC,,,,both,,,742.92,482.90,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA5MM REDUC ADD ON FIT,SUP-2362536,CDM,C1713,HCPCS,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
METAPHYSEAL TIBIAL CONE ML48MM,SUP-2511819,CDM,C1776,CPT,0278,RC,,,,both,,,8394.16,5456.20,,,,,,,,,,,,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133085,CDM,J3290,HCPCS,0250,RC,00013-1114-20,NDC,,both,10,ML,115.00,74.75,,,,,,,,,,,,,
KIT MAC 2-LUMEN 9 FR 11.5CM,SUP-2660675,CDM,C1894,HCPCS,0272,RC,,,,both,,,529.22,343.99,,,,,,,,,,,,,
DISC ARTIFICIAL SZ 4 5DEG UNIV INTERVERTEBRAL LUM CO CHROM,SUP-2255732,CDM,C1889,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2MM BAR 5 H 100DEG UNIV,SUP-2366304,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.68,406.69,,,,,,,,,,,,,
PLATE BNE L262MM 14 H ST R MED DST TIB S STL VAR ANG LOK,SUP-2177649,CDM,C1713,HCPCS,0278,RC,,,,both,,,7046.66,4580.33,,,,,,,,,,,,,
PLATE BNE L 52 MM TI RT DSTL VOLAR RADIAL EXT STD NS VARIAX,SUP-2900649,CDM,C1713,HCPCS,0278,RC,,,,both,,,4656.90,3026.98,,,,,,,,,,,,,
MARKER RAD 5CM DEL NDL AND REFLCT SAVI SCOUT,SUP-2164407,CDM,C1819,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
SLING GYN SYS II SACR COLPOPEXY STRL,SUP-2140287,CDM,C1771,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
VALVE MI H17MM DIA25MM TISS ANNULUS DIA27MM PORCINE LEAFLET,SUP-2355835,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
GRAFT DURA W3XL3IN ABSRB POR CLLGN MTRX BOV DP FLX TEND FOR,SUP-2244083,CDM,C1763,HCPCS,0278,RC,,,,both,,,1753.82,1139.98,,,,,,,,,,,,,
BIT DRL L177.5MM OD7MM ID2.4MM CANN FOR ACUFEX ACL PCL,SUP-2340695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
PLEDGET CV SAUVAGE L 10.2 X W 2.5 CM THK 0.61 MM POLYESTER,SUP-2761350,CDM,C1768,CPT,0278,RC,,,,both,,,197.79,128.56,,,,,,,,,,,,,
PLATE BNE H0.6MM BAR L4MM 5 H MID FACE G TI Y LEIBINGER,SUP-2366250,CDM,C1713,HCPCS,0278,RC,,,,both,,,537.13,349.13,,,,,,,,,,,,,
TUBE VENT ARMSTR R 1.14 MM 1 MM 2.7 MM FLROPLAS STRL 520501,SUP-2535145,CDM,L8699,HCPCS,0278,RC,,,,both,,,46.25,30.06,,,,,,,,,,,,,
BASKET SPEC RETRV POLYP 2X4 CM 7 FRX240 CM NS MEM BSKT,SUP-2737565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC So Pryridoxal Phosphate Vit B-6,PX-3018420766,CDM,84207,CPT,0301,RC,,,,both,,,129.00,83.85,,,,,,,,,,,,,
PLATE BONE L50MM CRANIOMAXILLOFACIAL MAND MOD 3 DIM MCS LUHR,SUP-2364675,CDM,C1713,HCPCS,0278,RC,,,,both,,,908.90,590.78,,,,,,,,,,,,,
HC Dexa Axial Skeleton,PX-3207708000,CDM,77080,CPT,0320,RC,,,,inpatient,,,541.00,351.65,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP,SUP-2435537,CDM,L0450,HCPCS,0272,RC,,,,both,,,460.07,299.05,,,,,,,,,,,,,
INTRODUCER MICPUNC 4FR L10CM L40CM 0.018IN GWIRE S STL W/,SUP-2170556,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.16,56.00,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB XLIII DIAMOND STRL DISP HI-LINE XS,SUP-2929109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,782.27,508.48,,,,,,,,,,,,,
BODY FEM SZ 10.5 12/14 TAPR CO CHROM L NP APR,SUP-2210893,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PLATE BNE RECON 3.5X130 MM 11 HOLE SS,SUP-2569086,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.66,272.78,,,,,,,,,,,,,
ROD SPNL L25MM SPINOUS PROC PIVOTING SP-FIX,SUP-2230597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM 8 MM POLYESTER BOV CLLGN STR,SUP-2265921,CDM,C1768,CPT,0278,RC,,,,both,,,1981.56,1288.01,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 30X0.6 MM TRIANG PLLA-PGA STRL RESORB XG,SUP-2460045,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.09,1785.61,,,,,,,,,,,,,
SCREW BONE L10MM LCK TALAR,SUP-2365933,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
CATHETER GUID CXI L 90 CM DIA 2.3 FR 0.014 IN SS STR TIP,SUP-2168959,CDM,C1887,HCPCS,0272,RC,,,,both,,,609.38,396.10,,,,,,,,,,,,,
HAGIE PIN 3/16X6X11.4,SUP-2818340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ELLIPSE DR W 51 X H 70 MM THK 12 MM 36 J,SUP-2357555,CDM,C1721,HCPCS,0275,RC,,,,both,,,59660.00,38779.00,,,,,,,,,,,,,
COMPONENT PAT 25MM OFFSET HEMICAP,SUP-2123680,CDM,C1776,CPT,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
HC CT Pelvis W/ Contrast,PX-3527219300,CDM,72193,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
HC Repr Smp Not Face 12.6-20cm,PX-4501200500,CDM,12005,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
HC Treat Clavicle Fx,PX-4502350000,CDM,23500,CPT,0450,RC,,,,both,,,630.00,409.50,,,,,,,,,,,,,
PLATE BNE L 118 MM SCREW DIA 3.5 MM 10 H SS 1/3 TUBLR LCK LP,SUP-2931342,CDM,C1713,HCPCS,0278,RC,,,,both,,,1226.17,797.01,,,,,,,,,,,,,
LEVER ROD,SUP-2232112,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.80,2592.07,,,,,,,,,,,,,
BUR SURG HD L12MM OD1.5MM ROUTER TAPR D-57 DURAGUARD,SUP-2363357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,262.35,170.53,,,,,,,,,,,,,
PLATE BNE L133MM 10 H TI FIBULAR COMP LOK COMPR FOR,SUP-2413684,CDM,C1713,HCPCS,0278,RC,,,,both,,,886.33,576.11,,,,,,,,,,,,,
LOW PROFILE SCREW CASE TRAY INSERT 3,SUP-2815084,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
GRAFT HUM TISS W50 55XL15MM FASC LATA,SUP-2307108,CDM,C1762,CPT,0278,RC,,,,both,,,2088.13,1357.28,,,,,,,,,,,,,
CANNULA 25GA ANTERIOR CHAMBER STORZ HESLIN,SUP-2462221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.97,225.53,,,,,,,,,,,,,
CATHETER ETER DRNGE 038IN LOK LOOP MULT PURP GWIRE 5 SIDEPRT,SUP-2168355,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.12,208.08,,,,,,,,,,,,,
PLATE BNE L74MM 3X5 H S STL T LOK COMPR OBLQ R ANG FOR,SUP-2185827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1037.46,674.35,,,,,,,,,,,,,
PLATE BNE L 201 MM SCREW DIA 4.5 MM 12 H COMPR LCK STRL EVOS,SUP-2933446,CDM,C1713,HCPCS,0278,RC,,,,both,,,3194.95,2076.72,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE LG FRZN IRRADIATED FEM,SUP-2867178,CDM,C1762,CPT,0278,RC,,,,both,,,2443.08,1588.00,,,,,,,,,,,,,
PLATE STRNL CLOSURE 12 H TI Y NS STERNALOCK BLU,SUP-2894525,CDM,C1713,HCPCS,0278,RC,,,,both,,,3023.82,1965.48,,,,,,,,,,,,,
MENISCAL ROOT REP PK W/ ULTRATAPE,SUP-2341434,CDM,C1713,HCPCS,0278,RC,,,,both,,,2926.48,1902.21,,,,,,,,,,,,,
CATHETER ABLAT 7FR L100CM 0.025IN ENDOVENOUS RF CLOSUREFAST,SUP-2393078,CDM,C1888,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SPLINT THMB M L8IN LNG RT THERMOPLASTIC INSRT THERMO-FORM,SUP-2324197,CDM,L3931,HCPCS,0274,RC,,,,both,,,57.65,37.47,,,,,,,,,,,,,
PLATE BNE CUT DELTO PECTORAL SHLDR DELTA-XTEND,SUP-2454176,CDM,C1713,HCPCS,0278,RC,,,,both,,,3419.46,2222.65,,,,,,,,,,,,,
STEM FEM L300MM OD9MM TI POR LAT R HIP PRI CLLRD OFFSET BOW,SUP-2406597,CDM,C1776,CPT,0278,RC,,,,both,,,17847.76,11601.04,,,,,,,,,,,,,
CARTRIDGE SAW TIP OSCILLATING FALCON 25 x 1.27 x 90mm,SUP-2364923,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
PLATE BONE L87MM THK3.8MM 14 H BILAT S STL NAR DYN COMPR FOR,SUP-2185214,CDM,C1713,HCPCS,0278,RC,,,,both,,,830.47,539.81,,,,,,,,,,,,,
GRAFT HUM TISS W3XL7CM THK.9-1.99MM ACELLULAR DERM MTRX,SUP-2402506,CDM,Q4126,HCPCS,0636,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
SCREW BNE L35MM OD45MM STD CANC HIP NONLOCKING BLNT SECURFIT,SUP-2370009,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.63,204.51,,,,,,,,,,,,,
PLATE CRAN 160X160X40 MM PT SPEC IMPL PEEK,SUP-2860160,CDM,C1713,HCPCS,0278,RC,,,,both,,,46780.03,30407.02,,,,,,,,,,,,,
STEM HUM LNG 8 MM SHLDR REUNION RFX,SUP-2451919,CDM,C1776,CPT,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
INSTRUMENT ROD CUT STRL DISP CARBOCLEAR,SUP-2883028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BNE DELT SM 96 MM LT DSTL DORS RADIAL 6 HOLE BUTTRESS,SUP-2467567,CDM,C1713,HCPCS,0278,RC,,,,both,,,2050.48,1332.81,,,,,,,,,,,,,
TIB RET CCK 58WX15HGT,SUP-2199948,CDM,C1776,CPT,0278,RC,,,,both,,,5963.49,3876.27,,,,,,,,,,,,,
NAIL IM L150MM DIA7.5MM NONSTERILE HUM TI CANN LCK PROX,SUP-2192536,CDM,C1713,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
INTRODUCER THERMOABLATION STARBURST XL L 6 CM HRD COAX ACCS,SUP-2752607,CDM,C1894,HCPCS,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
SCREW SQ FIT 1.7X6MM,SUP-2363521,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.42,65.27,,,,,,,,,,,,,
STEM HUM 5X100 MM RT SHLDR DISCOVERY,SUP-2136216,CDM,C1776,CPT,0278,RC,,,,both,,,12550.58,8157.88,,,,,,,,,,,,,
AUGMENT TIB SZ B KNEE TRITANIUM SYMMETRICAL CONE REV,SUP-2373578,CDM,C1776,CPT,0278,RC,,,,both,,,11065.36,7192.48,,,,,,,,,,,,,
HC Repair Cv Cath WO Subq Port or Pump,PX-4503657500,CDM,36575,CPT,0450,RC,,,,both,,,706.00,458.90,,,,,,,,,,,,,
GRAFT VASC VECTRA L 50 CM DIA 5 MM POLYUR STR STD WALL N,SUP-2127040,CDM,C1768,CPT,0278,RC,,,,both,,,3207.13,2084.63,,,,,,,,,,,,,
KIT GJ TB 16FR BLLN 3-5ML JEJU L25.4CM SIL GASTROENT INT,SUP-2124600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.33,363.56,,,,,,,,,,,,,
PLATE BNE L LT 5 HOLE,SUP-2864960,CDM,C1713,HCPCS,0278,RC,,,,both,,,4534.16,2947.20,,,,,,,,,,,,,
IMPLANT NSL MID TURB ST MEDIENT,SUP-2123501,CDM,L8613,CPT,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
PATCH REP 2X9 CM DURA-GUARD,SUP-2129885,CDM,C1763,HCPCS,0278,RC,,,,both,,,966.49,628.22,,,,,,,,,,,,,
GRAFT BNE W22XL20MM THK35X8MM BICORT EVANS WDG FOR OSTEOTMY,SUP-2399094,CDM,C1713,HCPCS,0278,RC,,,,both,,,6204.64,4033.02,,,,,,,,,,,,,
POSITIONER PT ACC MAINTAINS HEMODYNAMICSXPOSE4,SUP-2266083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2667.02,1733.56,,,,,,,,,,,,,
PROSTHESIS OSS 0.4X5.25 MM PISTON NIT/FLROPLAS SMRT 360,SUP-2651574,CDM,L8613,CPT,0278,RC,,,,both,,,1004.96,653.22,,,,,,,,,,,,,
SCREW 9X30MM INTERFERENCE CANNULATED SOFT SILK,SUP-2880371,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
SCREW BNE L18MM DIA3MM CORT S STL ST LOK FULL THRD T8 DRV,SUP-2371473,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.49,220.02,,,,,,,,,,,,,
EXPANDER TISS MAMM TEXT CNTOUR PROF S,SUP-2300521,CDM,C1789,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ IMMOB LOOP LOK ABDUCTED,SUP-2276637,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.17,14.41,,,,,,,,,,,,,
PLATE BONE ULTRA LOW PRFLE LNG HLX2 03MM THK TTNM STRGHT W/,SUP-2676569,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.03,208.67,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1.5X6 MM CORTICAL HEXAGONAL HEAD STAI,SUP-2836702,CDM,C1713,HCPCS,0278,RC,,,,both,,,236.19,153.52,,,,,,,,,,,,,
CATHETER KIT DL 8 FRX6 IN GUIDE RAULERSON CVC POLYURETHANE,SUP-2383947,CDM,C1750,HCPCS,0278,RC,,,,both,,,1396.73,907.87,,,,,,,,,,,,,
GRAFT DERMACELL DERMAL 12CM X 21CM�MESHED MATRIX,SUP-2866795,CDM,Q4122,HCPCS,0636,RC,,,,both,,,24418.90,15872.28,,,,,,,,,,,,,
GRAFT BNE SYR 1 CC DBM ACCELL CONNEXUS,SUP-2641752,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.35,506.58,,,,,,,,,,,,,
BOLT EXT FIX 2 MM MP SALVATION,SUP-2851285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
STEM FEM HIP CNL PRB WAGNER CONE PROS,SUP-2449519,CDM,C1776,CPT,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
COUNTERSINK DRL FOR 7MM SCR HD MONSTER,SUP-2320967,CDM,C1713,HCPCS,0278,RC,,,,both,,,818.60,532.09,,,,,,,,,,,,,
TRAY APPL BRACHYTHERAPY SAVI 6-1,SUP-2164401,CDM,C1728,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 5 CC W/ CHIP RPM DBM PUROS,SUP-2415791,CDM,C1889,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
GRAFT TISS FRZN FEM CORT STRUT 150MML HALF 3MM,SUP-2307355,CDM,C1713,HCPCS,0278,RC,,,,both,,,4611.91,2997.74,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 90CM 7FR COAT L 15CM MP,SUP-2385203,CDM,C1894,HCPCS,0272,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
NAIL ULNA 2 3.0MM X 120MM STRAIGHT,SUP-2855486,CDM,C1713,HCPCS,0278,RC,,,,both,,,7595.66,4937.18,,,,,,,,,,,,,
Z DISCONTINUED USE 2522798 CEMENT BNE ANTIBIO HI VISC W/ GENTAMICIN SIMPLEX HV,SUP-2364373,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SUPPORT KNEE BASE PLT ASMBLY ALVARADO,SUP-2197867,CDM,C1776,CPT,0278,RC,,,,both,,,2459.09,1598.41,,,,,,,,,,,,,
BOLT EXT FIX WIRE PRE ASSEMBLED MP SALVATION,SUP-2851275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6236.04,4053.43,,,,,,,,,,,,,
GRAFT BNE PTTY SYN CLLGN 15CC MOZAIK,SUP-2244490,CDM,C9359,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
CONDUIT CV 22 MM STD BIOPROS POROSITY VLV MODEL 150 HANCOCK,SUP-2429955,CDM,C1713,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
SCREW BNE L 115 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931728,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.33,113.31,,,,,,,,,,,,,
IMPLANT COCHLEAR SLIM STR ELECTRD NUC CI24RE,SUP-2165055,CDM,L8614,HCPCS,0278,RC,,,,both,,,66646.50,43320.22,,,,,,,,,,,,,
BRACE KNEE HNG WRP X L,SUP-2276703,CDM,L1820,HCPCS,0274,RC,,,,both,,,50.11,32.57,,,,,,,,,,,,,
HEAD HUM H23MM DIA52MM STEM L40MM SHLDR HA TI STD STEM,SUP-2388684,CDM,C1776,CPT,0278,RC,,,,both,,,14349.80,9327.37,,,,,,,,,,,,,
PLATE BURR H DIA21.77 MM THK 1.32 MM SCREW DIA1.5 MM SZ 17,SUP-2935900,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
SCREW INTFR L23MM DIA8MM BIOCRYL RAPIDE ABSRB MILAGRO ADV,SUP-2249509,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
STREAMER OTOLOGICAL WHT,SUP-2430286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X234 MM 13 HOLE SS LCP,SUP-2569374,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.14,566.89,,,,,,,,,,,,,
PLATE BNE STR 15X0.6 MM NEURO 2 HOLE TI STRL 251521271,SUP-2472256,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.70,243.55,,,,,,,,,,,,,
CATHETER UMB DL PEDIATRIC 5 FRX15 IN VEN PREP TY ARGY,SUP-2174254,CDM,C1751,HCPCS,0278,RC,,,,both,,,203.47,132.26,,,,,,,,,,,,,
CLAMP REPROC FIX PIN 6 POS MR SAFE MED,SUP-2477358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,498.04,323.73,,,,,,,,,,,,,
PLATE BNE L138MM 8 H L LAT PROX PERIARTC HUM LOK COMPR,SUP-2410732,CDM,C1713,HCPCS,0278,RC,,,,both,,,4429.57,2879.22,,,,,,,,,,,,,
HC Extrem Low Hip 1 Vw,PX-3207350100,CDM,73501,CPT,0320,RC,,,,both,,,460.00,299.00,,,,,,,,,,,,,
DOFETILIDE 125 MCG PO CAPS,RX-26965,CDM,6370000000,HCPCS,0637,RC,69452-0131-17,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MIS LOCK CALC PLT SM LT,SUP-2492116,CDM,C1713,HCPCS,0278,RC,,,,both,,,2345.27,1524.43,,,,,,,,,,,,,
GUIDE SURG FOR TIB TALUS ALIGN PROPHECY INBONE,SUP-2400573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
PLATE BONE CRANIAL 6 HOLE DOUBLE Y-PLATE 18.8X9.8MM TITANIUM,SUP-2825985,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.79,209.81,,,,,,,,,,,,,
IMPLANT HUM TISS L 175-260 MM DIA 9-11 MM TEND FRZN,SUP-2881955,CDM,C1762,CPT,0278,RC,,,,both,,,7573.24,4922.61,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA 3.5 MM LCK VA NS LEOS,SUP-2931362,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.97,327.58,,,,,,,,,,,,,
PUNCH UP BIG BITE 34MM 15DEG,SUP-2361349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3223.30,2095.14,,,,,,,,,,,,,
GLYBURIDE 5 MG PO TABS,RX-3489,CDM,6370000000,HCPCS,0637,RC,00093-8344-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HOLDER NDLE MICRO 8 1/2NL 1MMW JAW TTNM BNT STRGHT ROUND HND,SUP-2477032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5253.53,3414.79,,,,,,,,,,,,,
STENT PANCREATIC GEENEN L 5CM 7 FR 0.035IN NO INT FLAP,SUP-2169093,CDM,C2617,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
DRESSING POST OPERATIVE RIGID ANK,SUP-2388202,CDM,L5420,HCPCS,0274,RC,,,,both,,,3995.27,2596.93,,,,,,,,,,,,,
BIT DRL CANN 2X145 MM QC STRL,SUP-2563798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1400.94,910.61,,,,,,,,,,,,,
BUTTON CERCLAGE DIA4MM S STL STEM CANN FOR 4.5MM SCR,SUP-2178463,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.19,327.07,,,,,,,,,,,,,
SCREW BNE LOK MINI TI NONSTERILE 20MMX11MM MAXDRIVE,SUP-2262888,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.40,229.06,,,,,,,,,,,,,
HARVESTING SET 8.5 MM CHSL TAMP DRL BIT RED MOSAICPLASTY DP,SUP-2878034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1325.39,861.50,,,,,,,,,,,,,
HC Change Cystostomy Tube Smpl,PX-4505170500,CDM,51705,CPT,0450,RC,,,,outpatient,,,383.00,248.95,,,,,,,,,,,,,
CARBAMAZEPINE 200 MG PO TABS,RX-1357,CDM,6370000000,HCPCS,0637,RC,51672-4005-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-HC 1 % OT SOLN,RX-19632,CDM,6370000000,HCPCS,0637,RC,24208-0631-10,NDC,,both,10,ML,377.60,245.44,,,,,,,,,,,,,
PLATE EXT FIX L 115 MM 10 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2932898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,782.61,508.70,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX8 CM 3L POLYETH,SUP-2760048,CDM,C1751,HCPCS,0278,RC,,,,both,,,235.25,152.91,,,,,,,,,,,,,
SYSTEM OCCL DEL L80CM SHTH 6FR 180DEG CRV EXCHG WIRE HEMSTAS,SUP-2355719,CDM,C1713,HCPCS,0278,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
PLUG VASC UNCONSTRAINED L11MM DIA6MM GWIRE 0.038IN W/ SELF,SUP-2355705,CDM,C1889,HCPCS,0278,RC,,,,both,,,3830.80,2490.02,,,,,,,,,,,,,
BAND GAST ADJ DISECT REALIZE C,SUP-2219868,CDM,C1889,HCPCS,0278,RC,,,,both,,,9043.20,5878.08,,,,,,,,,,,,,
SET URET STENT SEIDMON AG AQ L 50 CM DIA 6 FR INTRO L 32 CM,SUP-2822055,CDM,C2617,HCPCS,0278,RC,,,,both,,,311.21,202.29,,,,,,,,,,,,,
GRAFT BNE SUB W12XL30MM SPCR EXTENSURE H2,SUP-2310519,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
DRILL TWST L 50 MM DIA1.5 MM STP 6 MM NUT NS DISP,SUP-2936472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
FOOTPLATE EXT FIX DBL HOLE 200 MM,SUP-2197269,CDM,C1713,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
BIT DRL QC 40-44 MM CTRL GLOB APG+,SUP-2453896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
STENT URET L 95 CM DIA 7 FR PTFE GUIDEWIRE 0.038 IN ADPT,SUP-2141655,CDM,C2617,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
CLAMP REPROC PIN 4 HOLE MR SAFE,SUP-2483971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.78,271.56,,,,,,,,,,,,,
CATHETER ANGIO BUMPER 5 FRX100 CM 2 CM 1 PERFORMA ULT,SUP-2301659,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.07,43.60,,,,,,,,,,,,,
LEAD PACE L35CM L5CM OD7.5FR POLYUR SIL TRNSVEN UPLR DF-1,SUP-2282252,CDM,C1896,HCPCS,0275,RC,,,,both,,,1856.87,1206.97,,,,,,,,,,,,,
SIDEKICK  TRANSFIX PIN 4MM TIN 300MM LNG,SUP-2489346,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ LG AD PEDIATRIC LT HND WRST FNGR SEP,SUP-2264311,CDM,L3807,HCPCS,0272,RC,,,,both,,,171.92,111.75,,,,,,,,,,,,,
LINER ACET SZ J OD66-68MM ID26MM +4MM 20DEG XLPE ANTEVERTED,SUP-2344892,CDM,C1776,CPT,0278,RC,,,,both,,,3775.85,2454.30,,,,,,,,,,,,,
SCREW CORT 3.5MM DIAX24MM LNG,SUP-2198414,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.31,37.25,,,,,,,,,,,,,
PLATE DIST MEDIAL TIB 3.5MM 12H LT,SUP-2854200,CDM,C1713,HCPCS,0278,RC,,,,both,,,7414.51,4819.43,,,,,,,,,,,,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS,RX-2516,CDM,6370000000,HCPCS,0637,RC,00406-1236-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PATCH CV XENOSURE L 8 X W 6 CM BOV PERICARD BIOLOGIC UNIF,SUP-2217971,CDM,C1768,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT VASC GELSFT L 30 CM DIA 8 MM POLYESTER GEL ABD PERIPH,SUP-2384955,CDM,C1768,CPT,0278,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
STEM HUM CEM 15X100 MM SHLDR REVERSED COCR HA,SUP-2431492,CDM,C1776,CPT,0278,RC,,,,both,,,6491.95,4219.77,,,,,,,,,,,,,
CATHETER ETER CARD 6F EVALUATOR JSN CRV 5 5 5 ELECTRD SPC,SUP-2357017,CDM,C1730,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
DECOMPRESSION KIT STD 20 MM MIC HK SHAVER TUBESET NEXUS,SUP-2748590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
SYSTEM SCREW INTERFERENCE FASTTHREAD 6MM 20MM,SUP-2811822,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
KIT STPL BONE FIX SUP ELAS MOTOCLIP 18MMX18MMX18MM,SUP-2175099,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SET INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 8.5 FR GUIDEWIRE L,SUP-2383327,CDM,C1894,HCPCS,0272,RC,,,,both,,,169.72,110.32,,,,,,,,,,,,,
INTRODUCER SHTH PERC 0.035 IN 8.5 FRX10 CM KT VLV SIDE PRT,SUP-2383949,CDM,C1894,HCPCS,0272,RC,,,,both,,,91.53,59.49,,,,,,,,,,,,,
INSERT TIB SZ 2 THK10MM LT KNEE EMPOWR 3D E +,SUP-2215901,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT BNE TISS DOWELS WDG FIBULAR THICKNESS 6MM 9 13MM,SUP-2307134,CDM,C1713,HCPCS,0278,RC,,,,both,,,1870.97,1216.13,,,,,,,,,,,,,
HOOK SPNL SM THORLUM LAM STD BLADE TI XIA II,SUP-2361400,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW BONE TI FEM KNEE REV IMP ASCNT,SUP-2406978,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
PLATE BNE L 100 DEG STD 1.7X8X0.55 MM RT 6 HOLE BAR MALL,SUP-2366247,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
BLADE TRPHNE ELLT UNVRSL HNDLE PEEK EYE SQRE RING WUNVRSL H,SUP-2668443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.27,420.08,,,,,,,,,,,,,
MATRIX WOUND THERAGENESIS MESHED BILYR 12X24CM,SUP-2737593,CDM,A2008,HCPCS,0636,RC,,,,both,,,19782.00,12858.30,,,,,,,,,,,,,
FLIPCUTTER II SHORT 11.5MM,SUP-2811332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HC Assay of Lipase,PX-3018369000,CDM,83690,CPT,0301,RC,,,,both,,,264.00,171.60,,,,,,,,,,,,,
SCISSORS DENT L16.5CM STD SHARP/SHARP 1 SERR BLDE S STL DEAN,SUP-2238685,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.81,216.33,,,,,,,,,,,,,
SCREW BONE L18MM OD3.5MM NONLOCKING TI,SUP-2321023,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.33,190.01,,,,,,,,,,,,,
SYSTEM UROLIFT2 ATC W/IMPLANT,SUP-2895948,CDM,C1889,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 6 CM DIA 4 MM MICROCATHETER 0.018,SUP-2385384,CDM,C1889,HCPCS,0278,RC,,,,both,,,785.03,510.27,,,,,,,,,,,,,
KIT BNE PLATE SCREW DIA2.8 MM TI MANDIBULAR SECONDARY RECON,SUP-2883322,CDM,C1713,HCPCS,0278,RC,,,,both,,,33205.50,21583.57,,,,,,,,,,,,,
SEAT REDUC 6.35MM SM EZ STRT VLS,SUP-2415644,CDM,C1713,HCPCS,0278,RC,,,,both,,,1578.13,1025.78,,,,,,,,,,,,,
SHELL ACET SZ D DIA48MM STD TI POR SPIK REFLCT,SUP-2345040,CDM,C1776,CPT,0278,RC,,,,both,,,6320.82,4108.53,,,,,,,,,,,,,
GRAFT BNE SUB SM W8XH10XL8MM COMPRESSIBLE SPNG PROVIDE,SUP-2138502,CDM,C1713,HCPCS,0278,RC,,,,both,,,2523.30,1640.14,,,,,,,,,,,,,
BRACE KNEE OFF THE SHLF STD MED R L UNLOADER 1 +,SUP-2319283,CDM,L1844,LOCAL,0272,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
SCREW BNE L34MM DIA3.5MM PROX HUM NONLOCKING T15 LO PROF 110017734] ZIMMER BIOMET TRAUMA],SUP-2411570,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.37,101.64,,,,,,,,,,,,,
SYSTEM MICROCATHETER 2.8FR L130CM HYDRPHLC L70CM GWIRE,SUP-2385155,CDM,C1887,HCPCS,0272,RC,,,,both,,,1863.90,1211.53,,,,,,,,,,,,,
PLATE DST BONE FBLA SHAFT HLX5 HEAD HLX4 TTNM ACMD,SUP-2640041,CDM,C1713,HCPCS,0278,RC,,,,both,,,4383.44,2849.24,,,,,,,,,,,,,
PLATE BONE X LNG THK1MM 4 H MIDFACE GLD STR FOR 2MM SCR,SUP-2402948,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
IMMOBILIZER SHLDR SLNG L,SUP-2276606,CDM,L3660,HCPCS,0274,RC,,,,both,,,10.80,7.02,,,,,,,,,,,,,
KIT BONE GRFT SUB 3CC END DEL CANN NDL 11GA L120MM COMPLT FT,SUP-2208436,CDM,C1713,HCPCS,0278,RC,,,,both,,,7771.50,5051.47,,,,,,,,,,,,,
KIT TRK KNEE PROC VIZADISC,SUP-2265694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.20,355.03,,,,,,,,,,,,,
HC Remove Foreign Body/Intranasal,PX-4503030000,CDM,30300,CPT,0450,RC,,,,both,,,396.00,257.40,,,,,,,,,,,,,
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-157665,CDM,J1650,HCPCS,0636,RC,63323-0609-90,NDC,,both,.8,ML,137.20,89.18,,,,,,,,,,,,,
CATHETER BLLN DIL 8 FRX100 CM 16 MMX4 CM LP VIDA,SUP-2551038,CDM,C1725,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
TRIAL BONE PLT 3 H CLVRLF TC-100 SM FRAG SYS,SUP-2343732,CDM,C1713,HCPCS,0278,RC,,,,both,,,2750.36,1787.73,,,,,,,,,,,,,
LENS IOL BCNVX 3+ DIOPT 6 MM POST CHMBR SIL SOFPORT,SUP-2418483,CDM,V2630,CPT,0276,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HINGE EXT FIX L100MM ANK FT INLINE FOR TRUELOK FRME ASSEMB,SUP-2316080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.73,814.27,,,,,,,,,,,,,
CATHETER HD DL FLEXTIP KT FOR HI VOL INFUSION,SUP-2383289,CDM,C1752,HCPCS,0278,RC,,,,both,,,297.04,193.08,,,,,,,,,,,,,
BLADE RETRACTOR ANKENEY,SUP-2382094,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CATHETER BRACHYTHERAPY CONTURA,SUP-2126755,CDM,C1725,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SCREW BNE OD65MM S STL HINDFOOT LOK REPL SURFIX,SUP-2243058,CDM,C1713,HCPCS,0278,RC,,,,both,,,554.74,360.58,,,,,,,,,,,,,
SPLINT ORTH NT ANK FT,SUP-2388199,CDM,L4397,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 5 MG PO TABS,RX-4398,CDM,6370000000,HCPCS,0637,RC,69315-0184-03,NDC,,both,1,UN,5.10,3.31,,,,,,,,,,,,,
STEM FEM HNR PR1 160X43MM,SUP-2364448,CDM,C1776,CPT,0278,RC,,,,both,,,6874.12,4468.18,,,,,,,,,,,,,
BASEPLATE GLEN STD POST AUG BILAT SHLDR POLY INVERSE,SUP-2344286,CDM,C1776,CPT,0278,RC,,,,both,,,6551.61,4258.55,,,,,,,,,,,,,
CATHETER GRFT POS DIA18 FR RVD 16-32 MM POLYUR TRILOBE,SUP-2395632,CDM,C1725,HCPCS,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
OCCLUDER SEPT 6FR WAIST L3MM DIA10MM ATR DISC DIA18X22MM,SUP-2355678,CDM,C1817,HCPCS,0278,RC,,,,both,,,24806.00,16123.90,,,,,,,,,,,,,
CLAMP EXT FIX L PIN 4 POS MAG RESONANCE CONDITIONAL,SUP-2188502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1196.69,777.85,,,,,,,,,,,,,
Z DUP USE 2341990 ELECTRODE ENDOSCP L3.75MM 90DEG XL TURBOVAC 90 ASC133601] SMITH AND NEPHEW ENDOSCOPY],SUP-2341999,CDM,C1713,HCPCS,0278,RC,,,,both,,,1196.34,777.62,,,,,,,,,,,,,
PROBE LITHO 1.6FR L120CM ELEC HYDRLC CALCUTRIPT,SUP-2261217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1034.63,672.51,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC 6FR 55CM 3 LUMAN RVS TAPR PWR INJ W,SUP-2613371,CDM,C1751,HCPCS,0278,RC,,,,both,,,892.55,580.16,,,,,,,,,,,,,
COMPONENT GLEN LIP POLYETH COFLD SM,SUP-2344312,CDM,C1776,CPT,0278,RC,,,,both,,,3722.78,2419.81,,,,,,,,,,,,,
SCREW BONE 2X6MM CORT HEX S STL ECT,SUP-2198242,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.38,22.35,,,,,,,,,,,,,
NEEDLE BX 19GA L155MM TIP TRACKED,SUP-2392616,CDM,C1713,HCPCS,0278,RC,,,,both,,,2246.67,1460.34,,,,,,,,,,,,,
AP CLASSIC REVISION SLL STEM SZ 10,SUP-2506658,CDM,C1776,CPT,0278,RC,,,,both,,,10399.68,6759.79,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 76 MM ANTR LUMBAR TI CITADEL,SUP-2584598,CDM,C1713,HCPCS,0278,RC,,,,both,,,20485.36,13315.48,,,,,,,,,,,,,
HEAD FEM UPLR 58 MM HIP,SUP-2207891,CDM,C1776,CPT,0278,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
CITRELOCK XPRESS IMPL SYS 5MM X 10MM,SUP-2900673,CDM,C1713,HCPCS,0278,RC,,,,both,,,5127.62,3332.95,,,,,,,,,,,,,
KIT ADPT BLU M8 LD NEVRO,SUP-2308594,CDM,C1822,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
LINER REPL SZ REG,SUP-2197117,CDM,L4396,HCPCS,0274,RC,,,,both,,,31.49,20.47,,,,,,,,,,,,,
SPADE TIP DRILL FOR 2.9MM PUSHLOCK,SUP-2812459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 40 CM DIA 6 MM EPTFE CARBON STR STD,SUP-2127045,CDM,C1768,CPT,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
KIT DISECT BLNT TIP TRCR W/ OVL BLLN SPCMKR PRO,SUP-2283391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1275.03,828.77,,,,,,,,,,,,,
CATHETER HD 7.5 FRX18 CM LT VLV INTRO GLIDEPATH AIRGUARD,SUP-2627025,CDM,C1750,HCPCS,0278,RC,,,,both,,,2093.60,1360.84,,,,,,,,,,,,,
EFAVIRENZ 600 MG PO TABS,RX-32298,CDM,6370000000,HCPCS,0637,RC,69097-0301-02,NDC,,both,1,UN,12.10,7.86,,,,,,,,,,,,,
COMPONENT TIB NEUT MOD ROTATIONAL ENDO-MODEL-M,SUP-2265073,CDM,C1776,CPT,0278,RC,,,,both,,,9539.32,6200.56,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 63 CM OD 12 FR ID 4 MM GUIDEWIRE,SUP-2633271,CDM,C1894,HCPCS,0272,RC,,,,both,,,111.91,72.74,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X285 MM LT PROX 9 HOLE NS VA-LCP,SUP-2757663,CDM,C1713,HCPCS,0278,RC,,,,both,,,7426.51,4827.23,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 200 MG IJ SOLR,RX-15426,CDM,J0640,HCPCS,0636,RC,00143-9553-01,NDC,,both,1,UN,70.80,46.02,,,,,,,,,,,,,
IMPL HAMMERTOE NEXTRA 4.5/3.2MM ST,SUP-2500329,CDM,C1713,HCPCS,0278,RC,,,,both,,,2342.22,1522.44,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X1 CM CRYOPRESERVED UMB CRD NEOX CRD 1K,SUP-2648683,CDM,Q4148,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CLAMP CRAN L 12 MM NEURO CRANIOTOMY LN 12 PK STRL DISP,SUP-2935348,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.59,573.68,,,,,,,,,,,,,
HC Strep a Ag Eia,PX-3068743000,CDM,87430,CPT,0306,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
KIT ART LN DIA20GA W/ SHRP SFTY,SUP-2383455,CDM,C1751,HCPCS,0278,RC,,,,both,,,183.38,119.20,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST W/ADJACENT FLX EXTN ROT MOLD,SUP-2435614,CDM,L1846,HCPCS,0274,RC,,,,both,,,3312.54,2153.15,,,,,,,,,,,,,
ELECTRODE ENDOSCP ELECTROCAUTERY TL 175 CM EXPOSE L 11 MM,SUP-2904075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.016IN TIP L10CM NIT HYDRPHLC STR,SUP-2148345,CDM,C1769,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 2 MESH KT NS FACE ID,SUP-2909543,CDM,C1713,HCPCS,0278,RC,,,,both,,,37171.35,24161.38,,,,,,,,,,,,,
KIT ANK CARE AD H95IN UNIV BILAT W BRAC WRP CLD PK EXER,SUP-2196372,CDM,L4350,HCPCS,0274,RC,,,,both,,,53.91,35.04,,,,,,,,,,,,,
CATHETER GUID SKR L 135 CM SHTH 4 FR GUIDEWIRE 0.018 IN,SUP-2128482,CDM,C1887,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
CAGE SPNL 7 MM LORDTC TI ACIS PRO 360,SUP-2539621,CDM,C1889,HCPCS,0278,RC,,,,both,,,8726.06,5671.94,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2112988,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
K WIRE FIXATION L229MM DIA16MM STYLE 6 THREADED,SUP-2464600,CDM,C1713,HCPCS,0278,RC,,,,both,,,51.75,33.64,,,,,,,,,,,,,
KIT CATHETER L45CM OD6FR 018IN GWIRE NDL STYL SWABSTK SCIS 3,SUP-2118891,CDM,C1751,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
PLATE BONE LCK L CRV LT 7 H TI PROX TIB PLATING SYS ALPS,SUP-2413716,CDM,C1713,HCPCS,0278,RC,,,,both,,,4083.57,2654.32,,,,,,,,,,,,,
PLATE BNE L52MM THK13MM 3X7 H NONSTERILE HND S STL Y SHP LOK,SUP-2178036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1668.34,1084.42,,,,,,,,,,,,,
PROSTHESIS OSS GROTE LG 16X15X20 MM CNL WALL POROUS HA,SUP-2637870,CDM,L8613,CPT,0278,RC,,,,both,,,1430.65,929.92,,,,,,,,,,,,,
HC Myelogram 2 or More Regions,PX-3616230500,CDM,62305,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
MESH HERN 20X20 CM VENTRAL N ABSRB MACROPOROUS PARIETENE LF,SUP-2752194,CDM,C1781,HCPCS,0278,RC,,,,both,,,246.21,160.04,,,,,,,,,,,,,
SHEATH INTRO 10FR L63CM DIL 10FR L67CM GWIRE L180CM 0032IN,SUP-2357208,CDM,C1892,HCPCS,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
HC Insj/Rplc Car Modulj Sys Pls Gen Transvns Eltrd,PX-3600408000,CDM,0408T,CPT,0360,RC,,,,both,,,101702.00,66106.30,,,,,,,,,,,,,
PLATE BNE L 29.21 X W 25.22 MM THK 0.6 MM ADV 10 MM SCREW LT,SUP-2937356,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
SET URET STENT SOFFLX L 75 CM DIA 8.4 FR GUIDEWIRE L 100 CM,SUP-2168922,CDM,C2617,HCPCS,0278,RC,,,,both,,,385.40,250.51,,,,,,,,,,,,,
ALLOGRAFT DRML 2X12 CMX2.31 3.30 MM TSSUE MTRX ALLDRM,SUP-2498490,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
NAIL IM L255MM DIA10MM STRL GRN TIB TI NONLOCKING UNREAMED,SUP-2192735,CDM,C1713,HCPCS,0278,RC,,,,both,,,4133.21,2686.59,,,,,,,,,,,,,
PROSTHESIS 3MM DIAM 51MM LEN PORP W LINK PARTIALLY CANN HA,SUP-2313681,CDM,L8613,CPT,0278,RC,,,,both,,,1280.84,832.55,,,,,,,,,,,,,
MIDODRINE HCL 5 MG PO TABS,RX-10610,CDM,6370000000,HCPCS,0637,RC,00245-0212-89,NDC,,both,1,UN,4.00,2.60,,,,,,,,,,,,,
PLATE BNE 1.5/2X69X1.5 MM 10 HOLE SS LCP,SUP-2569292,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.49,244.72,,,,,,,,,,,,,
BRACE ORTH SZ M 5 TO 7 WOM 6 TO 8 SM WLK LOEST PROF X LO,SUP-2195484,CDM,L4386,HCPCS,0274,RC,,,,both,,,221.84,144.20,,,,,,,,,,,,,
IMPLANT HUMAN TSSUE W96XH104 228XL193MM ACLLLR DRML TSSUE,SUP-2680187,CDM,Q4116,HCPCS,0636,RC,,,,both,,,14732.88,9576.37,,,,,,,,,,,,,
IMPLANT BIO TISS W10XL15MM THK1MM BOV CLLGN SEMI OVL FEN,SUP-2243669,CDM,C1781,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
CATHETER THROMCTMY FETCH ASPIR STRL,SUP-2277426,CDM,C1729,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
SCREW BNE FT 4X26 MM CANC TI NS LCP,SUP-2189936,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.14,40.39,,,,,,,,,,,,,
BALLOON KYPHOPLASTY MED 15 MM VERT MITTEL STRL SYNFLATE,SUP-2758538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
MORCELLATOR LAP CRDLSS DISP FOR CUT THRU FIBROTIC UTERI,SUP-2265062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2466.47,1603.21,,,,,,,,,,,,,
METHADONE HCL 5 MG PO TABS,RX-4954,CDM,6370000000,HCPCS,0637,RC,00406-5755-62,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE ST 2X20 MM CRTX FT W/ FLUT TIP TI NS,SUP-2189376,CDM,C1713,HCPCS,0278,RC,,,,both,,,196.25,127.56,,,,,,,,,,,,,
PROBE ABLAT 17GA L15CM MICWV NEUWAVE LK,SUP-2219546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
SCORPION NEEDLE HIP LENGTH,SUP-2812253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
BIT DRL 3.8X40 MM QUICKSET,SUP-2453995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,299.56,194.71,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7030,HCPCS,0258,RC,00338-0049-04,NDC,,both,250,ML,10.70,6.95,,,,,,,,,,,,,
WIRE ORTH SMOOTH SGL SHRP TIP TRCR S STL NONSTERILE 1.1MM,SUP-2304033,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.39,10.65,,,,,,,,,,,,,
IMPLANT HUM TISS H10XL10MM FEM WHL FRSH NO ANG,SUP-2257907,CDM,C1762,CPT,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
WASHER 14MM PROF,SUP-2589107,CDM,C1713,HCPCS,0278,RC,,,,both,,,1097.24,713.21,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT RIB SEG 50 -300MM LX5-30MM W,SUP-2307296,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
BOUGIE SURG CATH L 95 CM DIA 38 FR BALLOON L 16.6 CM SYR 60,SUP-2901848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
CEMENT RESTRICTOR XXS EXTRA EXTRA SMALLSZ8,SUP-2545987,CDM,C1776,CPT,0278,RC,,,,both,,,130.62,84.90,,,,,,,,,,,,,
GRAFT BONE CALCANEUS WEDGE FD,SUP-2875986,CDM,C1713,HCPCS,0278,RC,,,,both,,,2550.47,1657.81,,,,,,,,,,,,,
GUIDEWIRE ENDO EXCHG TUBE DISP,SUP-2152523,CDM,C1769,HCPCS,0272,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN (MIXTURES ONLY),RX-430020,CDM,2500000003,HCPCS,0250,RC,00409-7391-72,NDC,,both,15,ML,231.30,150.34,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 75 MM DIA25 MM DEL SYS,SUP-2217569,CDM,C1768,CPT,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
GRAFT BNE TIB 220 MM POST TEND,SUP-2335258,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
STEM HUM CEM 14-100 MM SHLDR TI ASHCOM ANAT SHLDR,SUP-2440620,CDM,C1776,CPT,0278,RC,,,,both,,,6415.02,4169.76,,,,,,,,,,,,,
HC So2 Drg Scrn Class List A,PX-3018030768,CDM,80307,CPT,0301,RC,,,,both,,,452.00,293.80,,,,,,,,,,,,,
RESTRICTOR CEM D16MM DIA10MM FOR BAL KNEE REV SYS,SUP-2314458,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
TUBE SALIVARY BYPASS RADIOPAQUE MONTGOMERY 191X40X14MM,SUP-2713904,CDM,C1889,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
PLATE BNE L83MM 4 H L PROX HUM LO ALPS,SUP-2411633,CDM,C1713,HCPCS,0278,RC,,,,both,,,6330.24,4114.66,,,,,,,,,,,,,
SPINAL KIT FACET FUSION SM NORTHSTAR,SUP-2741241,CDM,C1713,HCPCS,0278,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
SPLINT WRST XL L7IN FOR 85 95IN COT R SLIP ON SFT DURABLE,SUP-2276656,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.73,6.32,,,,,,,,,,,,,
PLATE BNE L338MM BLDE W48XL25MM 95DEG 20 H ST HIP S STL RIG,SUP-2186770,CDM,C1713,HCPCS,0278,RC,,,,both,,,4764.01,3096.61,,,,,,,,,,,,,
PLATE BNE 6 H TI ALLOY 2ND-3RD TMT NS LEOS,SUP-2933476,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
DEVICE ULTRASONIC SHR COAG LAP W/ HND CTRL HARM,SUP-2219545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1255.53,816.09,,,,,,,,,,,,,
GRAFT VASC L45CM DIA6MM RAD L5CM PTFE HEP STD WALLED INTEGR,SUP-2395834,CDM,C1768,CPT,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
PLATE BNE 3 H L DST VOLAR RAD TI NAR GEMINUS,SUP-2340196,CDM,C1713,HCPCS,0278,RC,,,,both,,,2187.01,1421.56,,,,,,,,,,,,,
SET NDL DISCOGRAM FOR PAIN MGMT DOCKING,SUP-2353382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
CANNULA SUCTION HAGAN 23 GAX20 MM SS,SUP-2471430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
PLATE BNE MESHED 104X29X1 MM LG GRID PLLA-PGA STRL RESORB XG,SUP-2476307,CDM,C1713,HCPCS,0278,RC,,,,both,,,5298.62,3444.10,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7172,SUP-2525319,CDM,C1769,HCPCS,0272,RC,,,,both,,,656.54,426.75,,,,,,,,,,,,,
GUIDEWIRE CATH J STR 0.035 INX70 CM SS STRL,SUP-2626779,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.34,20.37,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN L 480 CM DIA 0.018 IN NIT PLAT PTFE,SUP-2759287,CDM,C1769,HCPCS,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
HANDPIECE ABLATION L 6.1 CM BPLR LT CRV STRL,SUP-2124458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7322.48,4759.61,,,,,,,,,,,,,
SPLINT HND THM ADL NVY TERRY,SUP-2165485,CDM,L3807,HCPCS,0272,RC,,,,both,,,198.10,128.76,,,,,,,,,,,,,
KIT EXT FIX ANK HOFFMANN II,SUP-2372209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12145.27,7894.43,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-2 MM 30 CC PRESERVON CANC READIGRAFT,SUP-2741067,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.73,771.37,,,,,,,,,,,,,
JOINT SUBTALAR 5 SINUS TARSI ANK,SUP-2236091,CDM,C1713,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-107187,CDM,J1453,HCPCS,0636,RC,31722-0165-31,NDC,,both,1,UN,69.80,45.37,,,,,,,,,,,,,
COLLAR CERV AD H25XL19IN FIRM DENS CNTOUR HK AND LOOP CLSR,SUP-2276595,CDM,L0120,HCPCS,0274,RC,,,,both,,,8.04,5.23,,,,,,,,,,,,,
BRACE ORTH GAUNTLET ANK FT OTS,SUP-2388167,CDM,L1971,HCPCS,0274,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|ADJ,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|CO|ADJ,both,,,191.00,124.15,,,,,,,,,,,,,
PUMP ASPIR MAP-1000,SUP-2281164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
MESH HERN 9X13CM POLY CLLGN COAT PRESHAPED W SLT 3 DIM,SUP-2752163,CDM,C1781,HCPCS,0278,RC,,,,both,,,522.87,339.87,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X45 MM ESSENCE KT,SUP-2631914,CDM,C1713,HCPCS,0278,RC,,,,both,,,8102.77,5266.80,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X3.50 MM ARMSTR STYL PLASTI PORE,SUP-2637842,CDM,L8613,CPT,0278,RC,,,,both,,,505.16,328.35,,,,,,,,,,,,,
ALLODERM SELECT 1X1- XTHICK 2.8-4.0,SUP-2822077,CDM,Q4116,HCPCS,0636,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SPLINT ORTHOPEDIC NT LG 10.5 IN RT HND FOREARM COLLES PADDED,SUP-2306271,CDM,L3906,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115 CM F-J BLK,SUP-2248508,CDM,C1732,HCPCS,0278,RC,,,,both,,,4411.70,2867.60,,,,,,,,,,,,,
SCREW BNE LG HEX STYL 4 MM HD 14.6 MM,SUP-2471318,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.83,296.29,,,,,,,,,,,,,
APPLICATOR ENDOSCP SPARE DEL ENDOCLOT,SUP-2865625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,155.74,101.23,,,,,,,,,,,,,
CATHETER EP MAP RESPON 6FR QPLR 5MM ELECTRD SPC JSN CRV,SUP-2356797,CDM,C1730,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,0636,RC,00003-2560-16,NDC,,both,1,UN,171.00,111.15,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX19 CM TAL KT PALINDROMIC,SUP-2174233,CDM,C1881,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST MOLD GAUNTLET,SUP-2435623,CDM,L1904,HCPCS,0272,RC,,,,both,,,1277.89,830.63,,,,,,,,,,,,,
PLATE BNE L 95 MM SCREW DIA2.4 MM 5 HD 10 SHFT H TI Y SHP NS,SUP-2927235,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.97,1810.88,,,,,,,,,,,,,
COMPONENT FEM TIB TRABECULAR MTL IMPCT PROLONG SURF POR,SUP-2212251,CDM,C1776,CPT,0278,RC,,,,both,,,16660.78,10829.51,,,,,,,,,,,,,
SCREW INTRF L25MM DIA7MM PLLA KNEE CANN BIOABSRB TAPR HD,SUP-2341552,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.54,439.75,,,,,,,,,,,,,
HC Stent Place Initial Artery Ang,PX-3603723600,CDM,37236,CPT,0360,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
PPICC PROVENA SOLO 4F DL BASIC,SUP-2613541,CDM,C1751,HCPCS,0278,RC,,,,both,,,512.92,333.40,,,,,,,,,,,,,
COLLAR TRACH H2 1/4IN SM PHIL,SUP-2120429,CDM,L0172,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
BIT DRL DIA5MM FOR SALVATION SYS,SUP-2400808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X190X2.5 MM LT MAND 26 HOLE ANGLED STRL,SUP-2539585,CDM,C1713,HCPCS,0278,RC,,,,both,,,6372.82,4142.33,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA11 MM STD LAPSCP BLADED SMTH CANN,SUP-2896203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.38,294.05,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W2XL4CM THK0.33 0.76MM THIN RGNRTVE TSSUE,SUP-2470381,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1610.82,1047.03,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX12 CM DL J TIP RIFAMPIN SPECTRUM,SUP-2759852,CDM,C1751,HCPCS,0278,RC,,,,both,,,333.66,216.88,,,,,,,,,,,,,
PATCH EVER CORNEAT,SUP-2890361,CDM,C1781,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
COIL EMB L10CM OD0.020IN LOOP OD6MM STD NIT COMPLX FRME,SUP-2323359,CDM,C1889,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
CEMENT BNE L VOID FILL,SUP-2293454,CDM,C1713,HCPCS,0278,RC,,,,both,,,8741.76,5682.14,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 90 CM DIA 4 FR SLT PAT L 40 CM,SUP-2117144,CDM,C1751,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 3 CM 0.038 IN X150 CM FIX STIFF LF,SUP-2498415,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.60,25.74,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MESH 3X2 CM SMR2T AMNION CHORION EPIFIX,SUP-2871319,CDM,Q4186,HCPCS,0636,RC,,,,both,,,3517.43,2286.33,,,,,,,,,,,,,
BLADE IM L105MM DIA12.5MM NSTERILE LT BLU CANC TI SPRL,SUP-2191886,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.83,1431.19,,,,,,,,,,,,,
GRAFT BNE TEND PALMARIS LONGUS MUSCLE,SUP-2321739,CDM,C1762,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CATHETER HD STR 8 FRX24 CM LT DL STP BASIC SET SIL HEMCATH,SUP-2627311,CDM,C1750,HCPCS,0278,RC,,,,both,,,794.42,516.37,,,,,,,,,,,,,
CATHETER PICC 4FR SGL LUMN W/ MICEZ SFTY MIC INTRO FULL,SUP-2125613,CDM,C1751,HCPCS,0278,RC,,,,both,,,536.37,348.64,,,,,,,,,,,,,
INSERT HUM H10MM OD36MM STD ARW,SUP-2224535,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PLATE HOLDING WAND 20MM SYSTEM 18CM,SUP-2707264,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.72,625.12,,,,,,,,,,,,,
CORD ELECSURG BPLR RESECT NS FORCETRIAD LTX,SUP-2862411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
BASEPLATE GLEN HD DIA40/42MM REG BILAT UHMWPE PEGGED,SUP-2193838,CDM,C1776,CPT,0278,RC,,,,both,,,3608.71,2345.66,,,,,,,,,,,,,
GUIDEWIRE ENDO L210CM MRK SPR TIP SAFEGUIDE,SUP-2277388,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
COMPONENT PAT DIA33MM STD POR PRI ASYM W O XR WIRE TI AND,SUP-2377459,CDM,C1776,CPT,0278,RC,,,,both,,,4132.24,2685.96,,,,,,,,,,,,,
DRESSING WND FEN 3X3 CM SHT EXTRACELLULAR MTRX MATRISTEM,SUP-2106519,CDM,Q4166,HCPCS,0636,RC,,,,both,,,253.84,165.00,,,,,,,,,,,,,
PLATE BONE L45MM 7 H RT 1ST METATARSOPHALANGEAL,SUP-2137081,CDM,C1713,HCPCS,0278,RC,,,,both,,,2594.27,1686.28,,,,,,,,,,,,,
STEM HUM HA FRAC 12MM REUNION,SUP-2379014,CDM,C1776,CPT,0278,RC,,,,both,,,15015.48,9760.06,,,,,,,,,,,,,
SCREW BNE SD 2X10 MM IMF,SUP-2859951,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.89,504.33,,,,,,,,,,,,,
SLEEVE PROTCT THRD LCK FOR SYNFIX EVOLUTION SYS,SUP-2255825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE SM W11XL129MM THK3.3MM 0DEG 10 H BILAT TI STR,SUP-2190784,CDM,C1713,HCPCS,0278,RC,,,,both,,,654.88,425.67,,,,,,,,,,,,,
INTRODUCER SHTH SL0 0.032 IN 10 FRX180 CM J STIFF FAST-CATH,SUP-2357207,CDM,C1893,HCPCS,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR L4MM PROVOX VEGA,SUP-2124378,CDM,L8509,HCPCS,0274,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
HFN A/R SCREW 55MM STER,SUP-2588684,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.79,486.06,,,,,,,,,,,,,
BRACE WALKING LP XL 14-17 IN AD M FOAM MAXTRAX AIR,SUP-2427325,CDM,L4360,HCPCS,0272,RC,,,,both,,,97.50,63.37,,,,,,,,,,,,,
CONNECTOR SPNL Z 16X150-300 MM OFFSET,SUP-2659060,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
LEVEL CMF PLATE MINI FRN CVD 20 MM SCRW5 HOLE T10 MM CP TT,SUP-2677936,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.47,311.01,,,,,,,,,,,,,
GRAFT HUM TISS W2.5XL2.5CM THK1MM CRYOPRESERVED AMNIO MEM,SUP-2116279,CDM,Q4148,HCPCS,0636,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
GUIDE RESECT NK ACCOLADE,SUP-2361536,CDM,C1776,CPT,0278,RC,,,,both,,,1141.39,741.90,,,,,,,,,,,,,
BASEPLATE TIB SZ 4 RT W/ LCK JOURNEY LEGION,SUP-2340960,CDM,C1776,CPT,0278,RC,,,,both,,,9633.52,6261.79,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA SOLENT DISTA L 145 CM DIA,SUP-2142040,CDM,C1757,HCPCS,0272,RC,,,,both,,,6225.84,4046.80,,,,,,,,,,,,,
SET SCR SPNL L50MM DIA7.2MM PEDCL TI ALLOY FUS FOR DYN STBL,SUP-2414270,CDM,C1713,HCPCS,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
CATHETER FIST WAVELINQ ENDOAVF WORKING L ART VEN 50/42 CM,SUP-2422090,CDM,C1725,HCPCS,0272,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 45 CM 5FR SLT 5CM 0.035 IN BALL,SUP-2117037,CDM,C1757,HCPCS,0272,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
CATHETER HD DL 14 FRX12 CM ADMIN BASIC KT DURAFLO,SUP-2266958,CDM,C1750,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
ENDRING SPNL DIA15MM 0DEG BLU TI RND PRESSFIT FOR VERT BODY,SUP-2193239,CDM,C1889,HCPCS,0278,RC,,,,both,,,416.21,270.54,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6MM TI POLYAX EXT TAB FOR MINIMALLY,SUP-2255023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
DEVICE FIXAITON MENIS QUICK-T TWINFIX TI 3.5MM,SUP-2341596,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.68,589.34,,,,,,,,,,,,,
SET URET STENT SOFFLX POLYUR RADIOPAQUE SFT MLTI LEN STRL,SUP-2835717,CDM,C2617,HCPCS,0278,RC,,,,both,,,466.01,302.91,,,,,,,,,,,,,
CABLE ORTH L559MM DIA1.8MM HIP S STL W/ CERCLAGE CBL-READY,SUP-2410258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1097.05,713.08,,,,,,,,,,,,,
HANDPIECE ELECSURG ANGLE 45 DEG ABC TECHNOLOGY,SUP-2225644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,588.75,382.69,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X3 CM CRYOPRESERVED WND NEOX 100,SUP-2648680,CDM,Q4156,HCPCS,0636,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
SYSTEM REP SYNTH GRFT W/ TENS ADJ SUT NDL DP CONN TOOL W/,SUP-2140238,CDM,C1771,HCPCS,0278,RC,,,,both,,,6352.22,4128.94,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 10H 190MM RIGHT STERILE,SUP-2549641,CDM,C1713,HCPCS,0278,RC,,,,both,,,5122.19,3329.42,,,,,,,,,,,,,
HC So Hiv1 Probe,PX-3068753568,CDM,87535,CPT,0306,RC,,,,inpatient,,,118.00,76.70,,,,,,,,,,,,,
TI TOMOFIX MEDIAL DISTAL FEMUR PL/4 HOLES/RIGHT-STERILE,SUP-2546832,CDM,C1713,HCPCS,0278,RC,,,,both,,,3846.44,2500.19,,,,,,,,,,,,,
DRILL SURG CALIB 4.8 MM STP,SUP-2766149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CATHETER DRNGE 10FR L40CM 0.038IN BILI LCK PGTL SLIP SKATER,SUP-2120143,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
CATHETER CARD ABLATION RF MARINR MC L 110 CM DIA 7 FR TIP L,SUP-2749540,CDM,C1732,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
BRONCHOSCOPE GS BFLEX 2 LARGE 5.8 SU,SUP-2864558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,939.49,610.67,,,,,,,,,,,,,
RESOLVE BLRY LOK DRNGE CATH 10 FR 14CM 5CM PGTL DST 17 DRNGE,SUP-2677280,CDM,C1729,HCPCS,0272,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SCREW BNE SD 2X5 MM CRUCFRM AUTO DRV,SUP-2319378,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.36,91.88,,,,,,,,,,,,,
SLEEVE FIX L 30 MM DIA2.1 MM TYP 40 BND L 2 MM DIA 0.75 MM,SUP-2914798,CDM,C1784,HCPCS,0278,RC,,,,both,,,33.82,21.98,,,,,,,,,,,,,
STEM FEM L150MM DIA15.5MM NEUT KNEE CO CHROM POR BOW MOD,SUP-2252643,CDM,C1776,CPT,0278,RC,,,,both,,,11087.81,7207.08,,,,,,,,,,,,,
IMPLANT HUM TISS L 21 CM DIA 5-17 MM SZ 17 CM FEM VEIN,SUP-2933021,CDM,C1762,CPT,0278,RC,,,,both,,,15347.32,9975.76,,,,,,,,,,,,,
HEAD BPLR OD44MM ID28MM S STL UHMWPE,SUP-2267729,CDM,C1776,CPT,0278,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
GRAFT BNE STRP 50X20X5 MM DBM CANC PUREBONE,SUP-2424611,CDM,C1713,HCPCS,0278,RC,,,,both,,,6934.56,4507.46,,,,,,,,,,,,,
GRAFT BNE COTTON WDG 20X6.5 MM TI,SUP-2609844,CDM,C1713,HCPCS,0278,RC,,,,both,,,8496.21,5522.54,,,,,,,,,,,,,
PLATE BNE L 142 X W 9.5 MM THK 1.5 MM SCREW DIA 3.5 MM 12 H 72440512N,SUP-2933099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1368.85,889.75,,,,,,,,,,,,,
MESH 55MMX55MM 1.7MM RESRB PLT STRL DELT SYS,SUP-2364986,CDM,C1713,HCPCS,0278,RC,,,,both,,,2237.09,1454.11,,,,,,,,,,,,,
UNIT THER COMB CRYO W/ PD KNEE W/ TUBE PWR OPERATED W/ BD,SUP-2150871,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
HC Insj Perq Vad Trnsptal W/Image Art&Venous Access,PX-3603399100,CDM,33991,CPT,0360,RC,,,,both,,,7747.00,5035.55,,,,,,,,,,,,,
GRAFT VASC L70CM DIA6MM EPTFE PERIPH BYPS STD WALL NONRINGED,SUP-2126816,CDM,C1768,CPT,0278,RC,,,,both,,,6289.17,4087.96,,,,,,,,,,,,,
PLATE BONE L81MM 7 H STRL S STL LCK COMPR FOR 3.5MM SCR EVOS,SUP-2349630,CDM,C1713,HCPCS,0278,RC,,,,both,,,2180.79,1417.51,,,,,,,,,,,,,
PLATE BONE SM 117MML HLX8 STNLSS STEEL DELTA BTTRSS ST RIGHT,SUP-2727196,CDM,C1713,HCPCS,0278,RC,,,,both,,,2639.11,1715.42,,,,,,,,,,,,,
MESH GORE SYNECOR 35CM X 35CM RECTANGLE,SUP-2763181,CDM,C1781,HCPCS,0278,RC,,,,both,,,29713.82,19313.98,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5 DEG 8X22X12 MM LORDTC PLIF,SUP-2632324,CDM,C1713,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
MESH GORE SYNECOR 40CM X 40CM RECTANGLE,SUP-2763182,CDM,C1781,HCPCS,0278,RC,,,,both,,,38813.54,25228.80,,,,,,,,,,,,,
PLATE BONE LOK 170MML HLX13 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2461083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1759.40,1143.61,,,,,,,,,,,,,
PLATE BNE X 1.5X0.6 MM 6 MM 5 HOLE C PALE BRIDGE TI NS,SUP-2485735,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.27,266.68,,,,,,,,,,,,,
SYSTEM CEMENT MIXING VAC STRL DISP SMARTMIX CEMVAC,SUP-2891677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.03,326.97,,,,,,,,,,,,,
MICROCATHETER GUID SASUKE L 145 CM SHFT OD DSTL/PROX,SUP-2487288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
CUTTER PIN 63MM SIDE CUT L22 3 8IN S STL,SUP-2161239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2059.15,1338.45,,,,,,,,,,,,,
PLATE BNE L142MM 6 H TI L MED DST TIB LOK COMPR FOR 3.5MM,SUP-2413705,CDM,C1713,HCPCS,0278,RC,,,,both,,,4370.72,2840.97,,,,,,,,,,,,,
SCREW BONE L5MM DIA1.7MM ST LO PROF 5PK,SUP-2418784,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.86,181.26,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 70MM H2O + OR MINUS 10MM H2O,SUP-2666797,CDM,C1889,HCPCS,0278,RC,,,,both,,,3288.49,2137.52,,,,,,,,,,,,,
GRAFT BNE FIBER SM 2.5 CC SYR DBM,SUP-2431096,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT REUT BOB W/O FLNG H 1.14 MM ID,SUP-2312591,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.95,14.27,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X11 MM 6 LOBE,SUP-2602070,CDM,C1889,HCPCS,0278,RC,,,,both,,,7074.42,4598.37,,,,,,,,,,,,,
SHEATH INTRO PROTRIEVE L 38 CM OD 26 FR ID 20 FR DEPLOYED,SUP-2862339,CDM,C1894,HCPCS,0272,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SOCK PROSTHETIC IA BODY,SUP-2388155,CDM,L0984,HCPCS,0274,RC,,,,both,,,166.80,108.42,,,,,,,,,,,,,
HC Ot Wheelchair Mngment Training,PX-4309754200,CDM,97542,CPT,0430,RC,,,,inpatient,,,154.00,100.10,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X41 MM 5 HOLE 1/4 TI,SUP-2536106,CDM,C1713,HCPCS,0278,RC,,,,both,,,371.46,241.45,,,,,,,,,,,,,
PLATE BNE L21MM THK0.4MM 20 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1710.67,1111.94,,,,,,,,,,,,,
CLIP ANEUR W10XL10MM OPN DIA3.5MM CO CHROM ALLOY FEN L TYP,SUP-2306014,CDM,C1889,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 8.5 FR PRB DIL,SUP-2383377,CDM,C1894,HCPCS,0272,RC,,,,both,,,265.64,172.67,,,,,,,,,,,,,
CLIP MED INT USE SM TI SMALLER TIGHTER LEG GAP SMTH RED,SUP-2895516,CDM,C1889,HCPCS,0278,RC,,,,both,,,1.19,0.77,,,,,,,,,,,,,
SPACER SPNL W8XH7-14XL26MM THORACOLUM TI SELF EXP LUM INTBDY,SUP-2230599,CDM,C1821,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
BIT DRL L L300MM DIA17MM W/O STP CANN QUIK CPL REUSE,SUP-2188227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2272.10,1476.86,,,,,,,,,,,,,
PLATE BONE L239MM 95DEG 12 H BILAT SUPCNDYL PELV TI LO PROF,SUP-2412162,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.28,1228.68,,,,,,,,,,,,,
DILATOR FASCIAL SET 14FR 20CM,SUP-2665305,CDM,C2627,HCPCS,0272,RC,,,,both,,,50.55,32.86,,,,,,,,,,,,,
BIT DRILL REUSABLE 2.7MM BIO-ANCHOR,SUP-2828535,CDM,2720000010,LOCAL,0272,RC,,,,both,,,677.30,440.24,,,,,,,,,,,,,
LOXAPINE SUCCINATE 5 MG PO CAPS,RX-4601,CDM,6370000000,HCPCS,0637,RC,00591-0369-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUR DENT 1X70 MM CARBIDE STRL PM2 80K,SUP-2134826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
CATHETER GUID CS-EH ST-R 14X40 MM ACUITY CUT-AWAY,SUP-2148928,CDM,C1887,HCPCS,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
PLATE BONE SM L143MM 11 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348998,CDM,C1713,HCPCS,0278,RC,,,,both,,,1583.82,1029.48,,,,,,,,,,,,,
PLATE BNE L 208 MM SCREW DIA 4.5 MM 12 H NAR COMPR LCK STRL,SUP-2933076,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.20,1442.48,,,,,,,,,,,,,
DEFIBRILLATOR CARD RESYNCHRONIZATION THER DEFIB CRT D 3,SUP-2138120,CDM,C1882,HCPCS,0275,RC,,,,both,,,64363.78,41836.46,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THCK ACELLULAR DERM MTRX FRZ DRY,SUP-2306916,CDM,C1762,CPT,0278,RC,,,,both,,,8891.26,5779.32,,,,,,,,,,,,,
SCREW BONE,SUP-2137312,CDM,C1713,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X5.75 MM SCHKNT MALL ATTCH SS,SUP-2637741,CDM,L8613,CPT,0278,RC,,,,both,,,344.49,223.92,,,,,,,,,,,,,
KIT HAD CATHETER 12FR L20CM 2 LUMN ACUTE STR EXTN 2 SEAL CAP,SUP-2283957,CDM,C1752,HCPCS,0278,RC,,,,both,,,161.33,104.86,,,,,,,,,,,,,
BIT DRL 8 GA STR HND COMPATIBLE OSSEOFLEX,SUP-2480478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
MESH HERN 15X10CM L POLY CLLGN COAT ANAT W LAT SLT,SUP-2752159,CDM,C1781,HCPCS,0278,RC,,,,both,,,716.64,465.82,,,,,,,,,,,,,
PLATE BNE L147MM 7 H S STL LOK COMPR CRUCFRM FOR 27 35MM,SUP-2185747,CDM,C1713,HCPCS,0278,RC,,,,both,,,4875.01,3168.76,,,,,,,,,,,,,
CANNULA SURG PERC FOR 3/4MM SCREW,SUP-2483349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,994.75,646.59,,,,,,,,,,,,,
HC Repr Smp Not Face >30cm,PX-4501200700,CDM,12007,CPT,0450,RC,,,,both,,,1445.00,939.25,,,,,,,,,,,,,
STAPLE BNE 20X20X20 MM EASYCLIP,SUP-2365482,CDM,C1776,CPT,0278,RC,,,,both,,,4482.04,2913.33,,,,,,,,,,,,,
STEM FEM L160MM DIA15MM HIP L MTPHSEAL BODY STR NK TIV,SUP-2210353,CDM,C1776,CPT,0278,RC,,,,both,,,10915.71,7095.21,,,,,,,,,,,,,
ANCHOR N SUT FIX 3 MM SZ 40 MM LEN ACL TRANSFIX,SUP-2121109,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
HC Diffusing Capacity,PX-4609472900,CDM,94729,CPT,0460,RC,,,,both,,,509.00,330.85,,,,,,,,,,,,,
GRAFT DERMAL FEN 25X10 CM CLLGN TISS MTRX,SUP-2243689,CDM,Q4110,HCPCS,0636,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6X2 CM BLOCKADE AMNIO PROTCT BARR,SUP-2538795,CDM,C1762,CPT,0278,RC,,,,both,,,9347.78,6076.06,,,,,,,,,,,,,
CATHETER THRMDIL 7FR L110CM 4 LUMN S TIP FOR FEM VEIN INSRT,SUP-2214034,CDM,C1751,HCPCS,0278,RC,,,,both,,,371.93,241.75,,,,,,,,,,,,,
COMPONENT FEM L80MM L KNEE CONN PC GMRS,SUP-2376551,CDM,C1713,HCPCS,0278,RC,,,,both,,,10436.42,6783.67,,,,,,,,,,,,,
IMPLANT BRST M W12.3-11.9XH10.5-10.1CM P5.3-6.9CM 350-420CC,SUP-2300537,CDM,C1789,HCPCS,0278,RC,,,,both,,,3877.90,2520.63,,,,,,,,,,,,,
MESH HERN W30XL36CM RECT POLYPR NONABSORBABLE PROL SFT,SUP-2219922,CDM,C1781,HCPCS,0278,RC,,,,both,,,1790.84,1164.05,,,,,,,,,,,,,
GRAFT BNE SUB 15CC 17 10MM CANC CHIP READIGRFT,SUP-2264673,CDM,C1713,HCPCS,0278,RC,,,,both,,,691.96,449.77,,,,,,,,,,,,,
STRAP CORRECT PD VARUS VALGUS,SUP-2388177,CDM,L2270,HCPCS,0272,RC,,,,both,,,136.24,88.56,,,,,,,,,,,,,
HC Continuous Inhale Tx Addl Hour,PX-4109464500,CDM,94645,CPT,0410,RC,,,,inpatient,,,16.00,10.40,,,,,,,,,,,,,
BODY RAD W15XH7MM 7.5MM WRST BEAR IMPL MAESTRO,SUP-2407293,CDM,C1776,CPT,0278,RC,,,,both,,,5204.55,3382.96,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM MULTIFIX P PEEK KNOTLESS FIX,SUP-2342074,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BRACE WRST FA HND L INSTABILITY INJ 8IN IMMOB LOOP LOK,SUP-2276635,CDM,L3809,HCPCS,0274,RC,,,,both,,,21.82,14.18,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN BASIC KT DBL LUMN SIL STR SPL,SUP-2266950,CDM,C1750,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
HC Remove FB,PX-4501012100,CDM,10121,CPT,0450,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
BEARING TIB 10X67 MM POST STBL MAXM VI ARCM,SUP-2441597,CDM,C1776,CPT,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
PACK SURG CUST ADULT ECMO LF SVMC,SUP-2741857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.37,305.09,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 40X20X20 MM FD IRRADIATED CANC,SUP-2867235,CDM,C1762,CPT,0278,RC,,,,both,,,1357.27,882.23,,,,,,,,,,,,,
NAIL IM FEM 15X250 MM RT PROX PIRIFORMIS FOSSA STRL DISP,SUP-2475337,CDM,C1713,HCPCS,0278,RC,,,,both,,,5215.54,3390.10,,,,,,,,,,,,,
PLATE BNE L 100 DEG XLN 1.5 MM RT 3X3 HOLE LORENZ,SUP-2402869,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.43,322.68,,,,,,,,,,,,,
CANNULA PERF ART 6 FRX9 IN 3/16 IN THN VENTED GRY HUB DLP,SUP-2494940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,288.16,187.30,,,,,,,,,,,,,
PLATE BNE THK10MM SHT R MED LOK POLYAX CLMN FUS FOR 24 27MM,SUP-2364496,CDM,C1713,HCPCS,0278,RC,,,,both,,,6180.78,4017.51,,,,,,,,,,,,,
STENT GRFT VASC TAG L 15 CM DIA28 MM SHTH 20 FR AORT,SUP-2396367,CDM,C1713,HCPCS,0278,RC,,,,both,,,40035.00,26022.75,,,,,,,,,,,,,
WIRE FIXATION 2IN 60MM KIRSCHNER,SUP-2210660,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
SCREW EBA ONE CEPHALIC,SUP-2714106,CDM,C1713,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
TUBE VNTLTN SHHY CLLR BTTN 127MM ID 15MML FLRPLSTC EAR F/M,SUP-2681455,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.04,14.33,,,,,,,,,,,,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT,RX-11566,CDM,6370000000,HCPCS,0637,RC,00078-0876-01,NDC,,both,3.5,GR,1341.50,871.97,,,,,,,,,,,,,
INBONE  POLY SZ 3 18MM SULCUS TOTAL ANKLE,SUP-2482081,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
BUR SURG SM L18.3MM DIA3.2MM HELICOIDAL SGL END ANG TAPR,SUP-2363319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.57,269.47,,,,,,,,,,,,,
BLADE SCREWDRVR W2.4MM PRI CLSR SYS PWR DRVR STERNALOCK BLU,SUP-2420206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
COMPRESSOR SURG OPN FOR SM EXT FIX,SUP-2188699,CDM,C1713,HCPCS,0278,RC,,,,both,,,1987.62,1291.95,,,,,,,,,,,,,
SUPPORT LUM VISTA 627,SUP-2123916,CDM,L0457,HCPCS,0274,RC,,,,both,,,331.27,215.33,,,,,,,,,,,,,
NAIL IM TIB 9X255 MM TI STRL TNADVANCED,SUP-2789171,CDM,C1713,HCPCS,0278,RC,,,,both,,,4559.15,2963.45,,,,,,,,,,,,,
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML PO SUSP (WRAPPER),RX-430083,CDM,340b,HCPCS,0637,RC,46287-0006-60,NDC,,both,60,ML,111.60,72.54,,,,,,,,,,,,,
PLATE BONE L28MM 12 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413748,CDM,C1713,HCPCS,0278,RC,,,,both,,,990.20,643.63,,,,,,,,,,,,,
MICROFIBRILLAR COLL HEMOSTAT EX POWD,RX-10606,CDM,6370000000,HCPCS,0637,RC,53276-1010-02,NDC,,both,1,GR,390.10,253.56,,,,,,,,,,,,,
HC Bedside Swallowing Eval|OP SPEECH LANGUAGE SERVICE|DOCUMENTATION ON FILE,PX-4449261000,CDM,92610,CPT,0444,RC,,,GN|KX,both,,,355.00,230.75,,,,,,,,,,,,,
BRACE KNEE L17-27IN FOR 30.5IN UNIV FOAM HNG STRP CLSR,SUP-2150858,CDM,L1810,HCPCS,0274,RC,,,,both,,,280.25,182.16,,,,,,,,,,,,,
BIT DRL L195MM DIA43 45MM FOR NCB PERIPROSTHETIC FEM SYS,SUP-2204939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
KIT MAG AUXILIARY SPNL CLMN DORS ROOT GANG FOR LO LIMB PAIN,SUP-2357687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.01,298.36,,,,,,,,,,,,,
SCREW BNE L 75 MM DIA2.7 MM TI LCK T8 RECESS CLR CODE STRL,SUP-2902127,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.43,463.08,,,,,,,,,,,,,
PIN BNE FIX L 40 MM DIA 3.5 MM PROV COMPR STRL EVOS,SUP-2931406,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.93,475.75,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 80 CM DIA 6 MM SUPP L 80 CM EPTFE,SUP-2227649,CDM,C1768,CPT,0278,RC,,,,both,,,2637.95,1714.67,,,,,,,,,,,,,
SHUNT SURG REG PERF LEVEL 1.0 DELT,SUP-2628316,CDM,C1729,HCPCS,0272,RC,,,,both,,,1323.82,860.48,,,,,,,,,,,,,
PLATE BONE SM NONSTERILE CRAN TI ARC CNTOUR MESH MALL FOR,SUP-2190626,CDM,C1713,HCPCS,0278,RC,,,,both,,,2753.78,1789.96,,,,,,,,,,,,,
ALLOGRAFT BNE CHIPS 1-8 MM 60 CC CORTICAL CANC BIO,SUP-2632304,CDM,C1713,HCPCS,0278,RC,,,,both,,,1905.98,1238.89,,,,,,,,,,,,,
PACEMAKER CARD ADAPTA SM 2 CHMBR IS1 BIPOLAR/UNIPOLAR CONN,SUP-2282312,CDM,C1785,HCPCS,0275,RC,,,,both,,,10766.90,6998.48,,,,,,,,,,,,,
INTRODUCER PACE LD WORLEY ADV SHTH L 50 CM DIA 9 FR TIP DIA,SUP-2303506,CDM,C1892,HCPCS,0272,RC,,,,both,,,1071.53,696.49,,,,,,,,,,,,,
CONQUEST FN 2.8MMX300MM DRILL TIP GP,SUP-2820938,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.64,287.07,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 15 CM DIA12 MM L 15/30/30CM TRIFURCATE,SUP-2894647,CDM,C1768,CPT,0278,RC,,,,both,,,13065.54,8492.60,,,,,,,,,,,,,
STAPLER INT CIR XLN MED THCK 33 MM 3/3.5/4 MM TRI-STAPLE EEA,SUP-2858017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5173.75,3362.94,,,,,,,,,,,,,
SCREW BNE ST 1X6 MM CORTICAL THRD CRUCFRM RECESS TI GRN NS,SUP-2189093,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.02,142.36,,,,,,,,,,,,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,6370000000,HCPCS,0637,RC,00023-6153-01,NDC,,both,1,UN,382.50,248.62,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM 1 ULTRATAPE HEALICOIL REGENESORB,SUP-2341890,CDM,C1713,HCPCS,0278,RC,,,,both,,,1104.50,717.92,,,,,,,,,,,,,
SCREW BNE L15MM DIA2.5MM CO CHROM MULTDIR LOK THRD PEGGED,SUP-2411661,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
SPLINT ORTHOPEDIC BOUTONNIERE 4 FNGR BEAUTY STRENGTH,SUP-2325004,CDM,L3927,HCPCS,0274,RC,,,,both,,,250.76,162.99,,,,,,,,,,,,,
RING ACET 70X74 MM LT HIP RECON CNTOUR,SUP-2434770,CDM,C1776,CPT,0278,RC,,,,both,,,9784.24,6359.76,,,,,,,,,,,,,
BIT DRL OD1.4MM RIG FOR SFT ANCHR JUGGERKNOT,SUP-2212950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PROBE TEMP SINGLE LUMEN COMPLETE BRAIN PRB KT LICOX,SUP-2666701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1675.98,1089.39,,,,,,,,,,,,,
PERMETHRIN 5 % EX CREA,RX-10917,CDM,6370000000,HCPCS,0637,RC,21922-0021-07,NDC,,both,60,GR,135.00,87.75,,,,,,,,,,,,,
BASKET URO DIA1.8CM SHTH L50CM DIA5/8FR NIT FOR STONE REM,SUP-2168209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1175.62,764.15,,,,,,,,,,,,,
SPACER KNEE 3-10 16 MM DSTL SYS REV GUIDE ATTUNE,SUP-2454501,CDM,C1776,CPT,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
GUIDE NDL BX 2 PURP FOR 14L3E TRANSDUCER 4 IN-PLANE INSRT,SUP-2835413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
PLATE BNE TIB SHT RT MEDL DSTL 6 HOLE TRIBRID TECHNOLOGY TI,SUP-2399844,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GUIDEWIRE VASC J 3 MM 0.035 INX200 CM STD FIX COR SAFE T-J,SUP-2167688,CDM,C1769,HCPCS,0272,RC,,,,both,,,56.14,36.49,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 23 MM FRZN ILIUM TRICORT,SUP-2717923,CDM,C1762,CPT,0278,RC,,,,both,,,5712.32,3713.01,,,,,,,,,,,,,
DRIVER SHFT SURG NONCANNULATED CROSS PIN QUIK CPL UNIV NEURO,SUP-2364404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,959.62,623.75,,,,,,,,,,,,,
INTRODUCER HEMSTAS ULTIMUM 4FRX23CM SHTH W/ .038IN GWIRE,SUP-2355646,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
BIT DRL JCBS 2.9 MM HUM CALIB NS,SUP-2474901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
MAND ANGLE PLATE T.S.LCKNG RT LNG 3 X 3 2.3MM SSTM T 6L 4V T,SUP-2501151,CDM,C1713,HCPCS,0278,RC,,,,both,,,1471.03,956.17,,,,,,,,,,,,,
PLATE 3.5MM TI CURVED NARROW LCP 20 HOLE-STERILE,SUP-2546923,CDM,C1713,HCPCS,0278,RC,,,,both,,,3633.33,2361.66,,,,,,,,,,,,,
PACK INSTR CONVENIENCE W/ MPFL TMPLT 4.75 BIO SWIVELOCK,SUP-2121120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4330.06,2814.54,,,,,,,,,,,,,
T2 EXTRACION NUT,SUP-2823765,CDM,C1713,HCPCS,0278,RC,,,,both,,,711.21,462.29,,,,,,,,,,,,,
HC Remote Afterld Brachy 1 Channe,PX-3337777000,CDM,77770,CPT,0333,RC,,,,inpatient,,,4654.00,3025.10,,,,,,,,,,,,,
STIMULATOR NERVE CHARGER GENRTR EON,SUP-2355967,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
PLATE BONE L22MM 110DEG MINI RT L LHR,SUP-2364917,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.20,265.98,,,,,,,,,,,,,
BLADE SURG FASCIAL PRECEPT,SUP-2312035,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
TUBE SET TRUVIC,SUP-2855180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT BNE MTRX LG 12.5 CC STRL FIBERGRAFT AERIDYAN 59000125,SUP-2874925,CDM,C1713,HCPCS,0278,RC,,,,both,,,12434.40,8082.36,,,,,,,,,,,,,
PLATE BONE STRAIGHT FOOT 8 HOLE STRATUM,SUP-2469491,CDM,C1713,HCPCS,0278,RC,,,,both,,,3337.69,2169.50,,,,,,,,,,,,,
IMPLANT ANK FUS W18MM D18MM THK8MM COT WDG FOR OSTEOTMY,SUP-2101116,CDM,C1713,HCPCS,0278,RC,,,,both,,,11088.75,7207.69,,,,,,,,,,,,,
BUTTON FIX 14MM ACL PCL FOR SFT TISS BNE TEND ENDOBTTN,SUP-2341303,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.12,147.63,,,,,,,,,,,,,
BOLT IM L62MM DIA3.9MM STRL BLU CORT TI ST FULL THRD LCK,SUP-2192220,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.93,470.55,,,,,,,,,,,,,
TUNNELER SURG L 300 MM SM RIGID NO RNG MARKING STRL DISP 10/PK,SUP-2928805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.11,245.12,,,,,,,,,,,,,
MESH SURG L 30 X W 20 CM GLYCOLIDE LACTIDE COPOLYMER,SUP-2931123,CDM,C1781,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
SCREW SCHANZ SELF DRILLING 4.0MM 175MM HA COATING STER,SUP-2547743,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.42,507.92,,,,,,,,,,,,,
PLATE BONE THK1MM 7 H MAND SLV TI STR FOR 2/2.3MM SCR SYS,SUP-2136772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1453.82,944.98,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM OD 4 FR ID 1.3 MM GUIDEWIRE 0.021,SUP-2168444,CDM,C1894,HCPCS,0272,RC,,,,both,,,89.87,58.42,,,,,,,,,,,,,
ELECTRODE ELECSURG 26FR EVAP WNG LF STRL DISP,SUP-2332860,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
KIT NRG RF TRANSSEPTAL,SUP-2739134,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
PLATE BNE STR NAR 202 MM 14 HOLE BRIDGE N CONTACT POLYAX,SUP-2485042,CDM,C1713,HCPCS,0278,RC,,,,both,,,1728.38,1123.45,,,,,,,,,,,,,
STENT BILI FLEXXUS L 6 CM DIA10 MM CATH L 190 CM DIA 7.5 FR,SUP-2166291,CDM,C1876,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
AUG PAT 3-PEG ROT POR LCS 177974000] JNJ DEPUY SYNTHES ORTHOPEDICS],SUP-2252415,CDM,C1776,CPT,0278,RC,,,,both,,,4345.76,2824.74,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 20 MG MATRISTEM MICROMATRIX,SUP-2106467,CDM,Q4118,HCPCS,0636,RC,,,,both,,,185.89,120.83,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE SM SHT ANK ROCKER BTM INLINE,SUP-2336131,CDM,L4361,HCPCS,0274,RC,,,,both,,,78.75,51.19,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L15MM ADD FRAC IBT KYPHON,SUP-2293660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 90 CM DIA 6 MM EPTFE CARBON PERIPH,SUP-2128086,CDM,C1768,CPT,0278,RC,,,,both,,,9865.88,6412.82,,,,,,,,,,,,,
SCREW BNE BLNT PT 6X30 MM 175 MM THRD VAR LEN SCHNZ SS NS,SUP-2750874,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.57,272.72,,,,,,,,,,,,,
"HC Blood Typing, Abo",PX-3008690000,CDM,86900,CPT,0300,RC,,,,both,,,180.00,117.00,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 0.038 IN X150 CM MOVABLE COR FLX,SUP-2500963,CDM,C1769,HCPCS,0272,RC,,,,both,,,84.37,54.84,,,,,,,,,,,,,
BRACE WR AD L LT INSTABILITY INJ LOOP LCK W/ STAY ELAS PUL,SUP-2197949,CDM,L3931,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
PLATE BNE THK0.6MM 6X2 H BILAT HND TRAPEZOIDAL,SUP-2267897,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
CATHETER TRAY 5 FRX70 CM DL PEEL AWAY SHTH SELD,SUP-2384057,CDM,C1751,HCPCS,0278,RC,,,,both,,,206.42,134.17,,,,,,,,,,,,,
NEEDLE SUT NIT W WIRE LOOP END,SUP-2120933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER IV SINGLE LEMEN 4 FR DOT KT MBP POWERMIDLINE,SUP-2626733,CDM,C1751,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
PLATE BNE LAPIDUS LG 0 MM RT W/ STP TI RIVAL VW,SUP-2645192,CDM,C1713,HCPCS,0278,RC,,,,both,,,5705.38,3708.50,,,,,,,,,,,,,
HOOK OBT ACET MOD SCR FOR CUP FIX PAR 5,SUP-2403455,CDM,C1713,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
PLATE BNE L194MM THK3.3MM 16 H BILAT S STL RIG STR DYN,SUP-2186337,CDM,C1713,HCPCS,0278,RC,,,,both,,,2032.11,1320.87,,,,,,,,,,,,,
DEVICE LAPSCP UNIV FOR HND ACC GELPORT,SUP-2119621,CDM,C1788,HCPCS,0278,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
HC CT Perc Asp Disc Para Vent Tis,PX-3616226700,CDM,62267,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,J1271,HCPCS,0636,RC,70748-0338-01,NDC,,both,1,UN,95.90,62.33,,,,,,,,,,,,,
SHELL ACET OD56MM UNIV HA POR PLSM SPRY HIP REV PRESSFIT,SUP-2408350,CDM,C1776,CPT,0278,RC,,,,both,,,14139.42,9190.62,,,,,,,,,,,,,
HANDPIECE ASPIR EXTRUSION 1.5 MM 23 GAX6.1 IN SFT TIP CANN,SUP-2493889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,867.43,563.83,,,,,,,,,,,,,
COIL VASC I-ED COIL PRIMARY L 30 CM DIA 0.010 IN SECONDARY,SUP-2865284,CDM,C1889,HCPCS,0278,RC,,,,both,,,6327.10,4112.61,,,,,,,,,,,,,
FILTER VASC OPTEASE DIA28 MM INTRO 8 FR NIT CLOSED CAGE LP,SUP-2157002,CDM,C1880,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 16X16X16MM DEMIN CANC CNFRM FLX,SUP-2307020,CDM,C1713,HCPCS,0278,RC,,,,both,,,2252.95,1464.42,,,,,,,,,,,,,
PLATE BNE T 98 MM RT DSTL RADIAL DORS PERIARTICULAR 8 HOLE,SUP-2494551,CDM,C1713,HCPCS,0278,RC,,,,both,,,2649.47,1722.16,,,,,,,,,,,,,
ROPIVACAINE ELASTOMERIC INFUSION 0.5%,RX-4082401,CDM,J2795,HCPCS,0636,RC,63323-0286-38,NDC,,both,100,ML,97.20,63.18,,,,,,,,,,,,,
BRACE ANK AIR STRRP SM HT 85 IN,SUP-2336085,CDM,L1930,HCPCS,0274,RC,,,,both,,,28.79,18.71,,,,,,,,,,,,,
GUIDEWIRE SURG L150MM DIA1.25MM L STP S STL THRD FOR DST,SUP-2184109,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.18,271.17,,,,,,,,,,,,,
ELECTRODE NDL W/ EXTRM LAT INTBDY FUS XLIF 90 NV MOD II,SUP-2311745,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
BUR SURG 9.1 MM ACORN FLUT DISECT TOOL LEGEND,SUP-2176903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
PLATE COMPRSS VARIAX2 NRW 5H 66MM,SUP-2703712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1766.88,1148.47,,,,,,,,,,,,,
HC Rsf Lab Block Cases,PX-9900000122,CDM,9900000122,LOCAL,0990,RC,,,,both,,,9.00,5.85,,,,,,,,,,,,,
ENDCAP ORTH LCK STD 15 MM 0 MM EXTN TI NS,SUP-2564344,CDM,C1713,HCPCS,0278,RC,,,,both,,,578.42,375.97,,,,,,,,,,,,,
SHEATH DIL L 16FR L43CM OD0.293IN ID0.236IN STR TORQ DEL,SUP-2353111,CDM,C1894,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE DERMACELL AWM 5CM X 7CM 0.2-1MM,SUP-2909512,CDM,Q4122,HCPCS,0636,RC,,,,both,,,7665.53,4982.59,,,,,,,,,,,,,
BIT DRL DIA 5 MM CANN LG TARGETER HALL-JACOBS STRL DISP EVOS,SUP-2931341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2156.24,1401.56,,,,,,,,,,,,,
COLLAR CERV M H4.25IN POLYETH FOAM CA,SUP-2196884,CDM,L0120,HCPCS,0274,RC,,,,both,,,43.05,27.98,,,,,,,,,,,,,
PLATE BONE L102MM 8 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349638,CDM,C1713,HCPCS,0278,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
BIT CANNULATED DRIVER,SUP-2878748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|ADJ,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|KX|CQ|ADJ,both,,,191.00,124.15,,,,,,,,,,,,,
MESH HERN W30XL30CM POLYGLACTIN 910 WVN KNIT VCRL,SUP-2220332,CDM,C1781,HCPCS,0278,RC,,,,both,,,2797.90,1818.63,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STEJK4A] STRYKER CORP],SUP-2365946,CDM,C1776,CPT,0278,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,0636,RC,63323-0286-23,NDC,,both,15,ML,71.30,46.34,,,,,,,,,,,,,
HC So Mycoplasma Igg,PX-3028673866,CDM,86738,CPT,0302,RC,,,,outpatient,,,218.00,141.70,,,,,,,,,,,,,
CATHETER GUID L 100 CM OD 5 FR ID 0.056 IN PTFE LNR XB 3.5,SUP-2910577,CDM,C1887,HCPCS,0272,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
WIRE GUID SET EXCHG 6.3FR AND 8.0FR 20CM 21CM AND 15CM,SUP-2168700,CDM,C1769,HCPCS,0272,RC,,,,both,,,268.34,174.42,,,,,,,,,,,,,
TOOL DIL L18MM DIA7MM MALL MULT BAL COMPATIBLE EZ TO USE,SUP-2217798,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X198 MM 15 HOLE SS LC-DCP,SUP-2569249,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.30,253.69,,,,,,,,,,,,,
PLATE BONE W5.4XL26MM THK1.5MM 4 H FOREFOOT TI STR FOR,SUP-2225449,CDM,C1713,HCPCS,0278,RC,,,,both,,,2832.12,1840.88,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 27MMW X 60MML SPNL MSCLE WIDE RGGLS RDM,SUP-2668028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1624.60,1055.99,,,,,,,,,,,,,
AUGMENT FEM SZ D THK5MM STD UNIV POST KNEE TRABECULAR MTL,SUP-2200230,CDM,C1776,CPT,0278,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 6 FR E CRV,SUP-2148873,CDM,C1732,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ELECTRODE TRAY PACE 5 FRX110 CM TRNSVEN,SUP-2848490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.98,456.29,,,,,,,,,,,,,
HC Imrt Planning,PX-3337730100,CDM,77301,CPT,0333,RC,,,,both,,,14532.00,9445.80,,,,,,,,,,,,,
SCREW BONE 2.8X14MM CANN PART THRD BIODRIVE,SUP-2408399,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.80,431.47,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 CERECYTE L 19 CM DIA12 MM,SUP-2457374,CDM,C1889,HCPCS,0278,RC,,,,both,,,6594.44,4286.39,,,,,,,,,,,,,
CATHETER CNTRL VENOU LUMENX1 4.2FR 90CML SIL CLMP BRVC,SUP-2613066,CDM,C1751,HCPCS,0278,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
RING EXT FIX HALF 150 MM CARBON FIBER RINGFIX,SUP-2365278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3246.76,2110.39,,,,,,,,,,,,,
IMPLANT EL JT HD RAD TRANSFORMING EXTREMITIES ASCENSION MOD,SUP-2244259,CDM,C1776,CPT,0278,RC,,,,both,,,8421.48,5473.96,,,,,,,,,,,,,
PASSER SUTURE STR 12 GAX16 CM SFT TISS NOVAPASS,SUP-2863653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
ALLOGRAFT BNE FD ETO WHL MAND,SUP-2867075,CDM,C1762,CPT,0278,RC,,,,both,,,11544.21,7503.74,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLAIR L 70 MM DIA 7 MM CATH L 80 CM DIA,SUP-2126891,CDM,C1874,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
TRAY TIB SZ 5 AP53.1MM ML80.6MM THK4.8MM KNEE CO CHROM ALLY,SUP-2250927,CDM,C1776,CPT,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLE CLP STD 1.3X2.5 MMX23 CM ADPT,SUP-2631410,CDM,C1729,HCPCS,0272,RC,,,,both,,,487.64,316.97,,,,,,,,,,,,,
MOST HINGED TIBIA INSERTS SIZE 2 9MM,SUP-2509232,CDM,C1776,CPT,0278,RC,,,,both,,,5100.93,3315.60,,,,,,,,,,,,,
STRUT EXT FIX L75-96MM X SH STD FOR ILIZ TAY SPAT FRME EXT,SUP-2342983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7096.71,4612.86,,,,,,,,,,,,,
LEAD DEFIB L58CM INTRO 7FR PROX TIP 17CM BPLR 2 COIL TINES,SUP-2357381,CDM,C1895,HCPCS,0275,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
MALLET 3714105 NYLON SURFACE,SUP-2705131,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.09,343.26,,,,,,,,,,,,,
ORTHOSIS ANK FT SM SZ M 6-7.5 WOM 7.5-9 RT CLOSE HEEL DLX,SUP-2195190,CDM,L1930,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CEFAZOLIN 3000 MG IN NS 100 ML IVPB,RX-4081571,CDM,J0690,HCPCS,0636,RC,09999-9912-52,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 6H /90MM/104MM,SUP-2547511,CDM,C1713,HCPCS,0278,RC,,,,both,,,2505.59,1628.63,,,,,,,,,,,,,
DEVICE KYPHOPLASTY BNE ACCS OSTEO INTRO ADV KYPHON EXPRESS,SUP-2665002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.52,716.64,,,,,,,,,,,,,
EXTENSION FEM KNEE L 25 MM DIA15 MM STRL EMPOWR,SUP-2890694,CDM,C1776,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
BLADE SURG SAW W48.1XL61MM THK64MM THN W FLARE,SUP-2361934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,88.83,57.74,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 100 CM DIA 8 MM THK 0.49 MM POLYESTER,SUP-2227571,CDM,C1768,CPT,0278,RC,,,,both,,,1927.11,1252.62,,,,,,,,,,,,,
KIT INTRO MINI STK MAX L 10 CM DIA 5 FR 7 CM ECHOGENIC STD,SUP-2118823,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.63,77.76,,,,,,,,,,,,,
IMPLANT PENILE L 15 CM INFPUB PRECONNECT INFLATABLE,SUP-2930710,CDM,C1813,HCPCS,0278,RC,,,,both,,,43685.25,28395.41,,,,,,,,,,,,,
DEFIBRILLATOR IMPL MOMENTUM W 5.37 X H 8.18 CM D 0.99 CM,SUP-2149205,CDM,C1882,HCPCS,0275,RC,,,,both,,,63208.20,41085.33,,,,,,,,,,,,,
OSS 9CM OSSEOTI PROX TIB SLV,SUP-2506335,CDM,C1776,CPT,0278,RC,,,,both,,,14917.04,9696.08,,,,,,,,,,,,,
CATHETER INFUSION STR TIP 1.9 FRX165 CM PROGREAT LAMBDA,SUP-2852404,CDM,C1887,HCPCS,0272,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
BLADE CRV NAR 1MM ARACH,SUP-2306288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1028.95,668.82,,,,,,,,,,,,,
HC Relocation Pg Wcs Lv Pacg Battery Component Only,PX-4810862000,CDM,0862T,CPT,0481,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
IMPLANT BIO L 3 X W 12 CM FISH SKIN DERMAL SLD INTACT FLAT,SUP-2909242,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
KIT SLNG NDL PASS PERC RETRCT RNG BLNT STAY HK FOR STRESS,SUP-2138903,CDM,C1771,HCPCS,0278,RC,,,,both,,,20978.34,13635.92,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE CERM ON CERM UPCHGCERCER] ZIMMER BIOMET INC],SUP-2212676,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
HC Rem Central Venous Cath,PX-3613658900,CDM,36589,CPT,0361,RC,,,,both,,,1901.00,1235.65,,,,,,,,,,,,,
INTRODUCER PIN DISPOSABLE FOR PARAPEDICULAR OPTIMESH 1500DS,SUP-2354623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE 95 DEG CONDYLAR 5 HOLES 40MM 92MM,SUP-2547642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3174.04,2063.13,,,,,,,,,,,,,
BUR DENT L70MM DIA1.8MM 80000RPM DMND DISP BOHRER PM2,SUP-2134822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC Beta 2 Glycoprotein I Antibody Each,PX-3028614600,CDM,86146,CPT,0302,RC,,,,both,,,138.00,89.70,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 180 CM DIA 0.035 IN TIP L 3 CM,SUP-2141158,CDM,C1769,HCPCS,0272,RC,,,,both,,,156.75,101.89,,,,,,,,,,,,,
SET INTRO OUTER CATH 4FR L10CM NDL 21GA L4CM 0.018IN PLAT,SUP-2170547,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.34,45.72,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 3/32 X9 IN 4 PT STYL SMOOTH PLN,SUP-2150492,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.78,8.31,,,,,,,,,,,,,
PIN DISTRACTOR L14MM DSTL LORDTC STK FOR BENGAL CAGE SYS,SUP-2256855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SCREW BNE COMPR 7.2X120 MM 22 MM HIP GOTFRIED PCCP,SUP-2644729,CDM,C1713,HCPCS,0278,RC,,,,both,,,623.10,405.01,,,,,,,,,,,,,
SCREW BNE CANN 2.5X32 MM FT EVOLVE TRIAD,SUP-2423626,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
PLATE BNE THK0.8MM 16 H CRANIOMAXILLOFACIAL GRY TI STR LOK,SUP-2366254,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.26,775.62,,,,,,,,,,,,,
GRAFT BONE SUB 1-4MM 15CC CANC FN PARTICULATE FRZ DRY,SUP-2165537,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
CLAMP EXT FIX L1.344XW1.044XH2.27IN 6MM ALUMINIUM ANODIZIED,SUP-2342900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
IMPLANT STAP LOOP PIST S STL 0.6MM DIA 3.5MM LEN MCGEE,SUP-2312539,CDM,L8613,CPT,0278,RC,,,,both,,,277.76,180.54,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM L155CM OD.028IN FLXIBLE REPERFUSION,SUP-2323627,CDM,C1769,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
CATHETER EP JSN 5 MM SPC 6 FRX120 CM SUPREME,SUP-2458911,CDM,C1730,HCPCS,0272,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
POST SHRT 44MM,SUP-2469399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 4.5FR DIA DST TIP 7MML TIP 30MML CUT,SUP-2489149,CDM,C1769,HCPCS,0272,RC,,,,both,,,581.69,378.10,,,,,,,,,,,,,
ANCHOR SUT OD2.3MM 2 WHT ULTRABRAID OSTEORAPTOR,SUP-2341113,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
MESH SURG L 5 X W 10 CM D 1.5 MM PORCINE DERMAL CLLGN ABD,SUP-2901711,CDM,C9364,HCPCS,0278,RC,,,,both,,,3275.43,2129.03,,,,,,,,,,,,,
IMPLANT BRST 300-330CC P4.1CM DIA11.9CM NACL STYL 168MP,SUP-2113209,CDM,C1789,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC INSTRUMENT 1.1 MMX31.49 CM INTRAFIX ADV,SUP-2257894,CDM,C1769,HCPCS,0272,RC,,,,both,,,241.25,156.81,,,,,,,,,,,,,
CATHETER HD STR EXTN 13.5 FRX16 CM DL HI FLO MAHRK ELITE,SUP-2626876,CDM,C1752,HCPCS,0278,RC,,,,both,,,209.75,136.34,,,,,,,,,,,,,
HC So Potassium 24hr Urine,PX-3018413366,CDM,84133,CPT,0301,RC,,,,both,,,23.00,14.95,,,,,,,,,,,,,
BAR EXT FIX 11X400 MM CARBON,SUP-2749999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
HC Splint App Short Arm Stat,PX-4502912500,CDM,29125,CPT,0450,RC,,,,both,,,700.00,455.00,,,,,,,,,,,,,
COLLAR CERV ADJ CHIN CUP THERMOPLASTIC,SUP-2388133,CDM,L0150,HCPCS,0272,RC,,,,both,,,295.82,192.28,,,,,,,,,,,,,
CATHETER INFUSION 0.021 INX2.8/2.3 FRX150 CM RAPID TRANSIT,SUP-2257075,CDM,C1751,HCPCS,0278,RC,,,,both,,,3206.41,2084.17,,,,,,,,,,,,,
PROBE ARTHSCP SUCT ASD 3.5MM DIA 90DEG,SUP-2362165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.84,356.75,,,,,,,,,,,,,
CHLOROTHIAZIDE 28 MG/ML IJ SOLN (PED-NEO),RX-4090152,CDM,J1205,HCPCS,0636,RC,25021-0305-66,NDC,,both,1,UN,182.20,118.43,,,,,,,,,,,,,
INSERT GLEN PRSS FIT BASEPLT SHLDR SYS AEQUALIS,SUP-2388655,CDM,C1713,HCPCS,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
GRASPER ENDOSCP JAW RANG 130 DEG L 220 CM DIA2.8 MM STRL LF,SUP-2881767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SET NDL 15GA L45MM STBL KT FOR IO VASC ACCS SYS EZ-IO,SUP-2383226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,447.76,291.04,,,,,,,,,,,,,
GRAFT SURG 7CMX6CM AMNIOFIX,SUP-2305731,CDM,V2790,HCPCS,0278,RC,,,,both,,,7231.42,4700.42,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR 10MM HRD VLV INDWL BLOM-SINGER ADVNTG,SUP-2242280,CDM,L8509,HCPCS,0274,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
ELECTRODE KIT EMG NDL SAFEOP,SUP-2736618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
TUBE ENDOTRACHEAL CONT MONITORING 8X11X323 MM VIVASIGHT-SL,SUP-2752999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
FERROUS SULFATE 325 (65 FE) MG PO TABS,RX-3074,CDM,6370000000,HCPCS,0637,RC,00904-7591-61,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
CATHETER ABLATN D-D 1-7-4 MM 8MM 7 FRX115 CM EZ STEER LF,SUP-2248511,CDM,C1732,HCPCS,0278,RC,,,,both,,,7074.42,4598.37,,,,,,,,,,,,,
KIT INFUS PRT L76CM DIA9.6FR PLAS ATTCH SIL SGL LUMN FULL,SUP-2127735,CDM,C1788,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SCREW LCK FOR TI TIB NAIL IMPLANTS TI GRN 5.0MM 70MM,SUP-2192345,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.78,398.96,,,,,,,,,,,,,
RIGHT EXTRA ART NARROW PLATE STERILE,SUP-2488801,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.03,1526.22,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR 4 CM NIT SHFT SS TIP STD DIL MIC,SUP-2615881,CDM,C1894,HCPCS,0272,RC,,,,both,,,73.95,48.07,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 6 MM DEL SHTH,SUP-2934182,CDM,C1713,HCPCS,0278,RC,,,,both,,,5432.20,3530.93,,,,,,,,,,,,,
ANCHOR SUT NO 3 SUT ABSRB FIBERWIRE 2.2MM DIA 7MM LEN V TAK,SUP-2122458,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE L72MM BRL L25MM 130DEG 3 H ST BILAT PELV HIP S STL,SUP-2186821,CDM,C1713,HCPCS,0278,RC,,,,both,,,1957.98,1272.69,,,,,,,,,,,,,
PROCESSOR HEARING AID DMND BLK LT EAR PONTO + PWR,SUP-2319905,CDM,L8691,HCPCS,0274,RC,,,,both,,,14679.50,9541.67,,,,,,,,,,,,,
BLADE SCREWDRIVER 2MM DIA 35MML CROSS DRIVE,SUP-2495995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.19,434.32,,,,,,,,,,,,,
CONNECTOR SPNL L12MM DIA45MM LAT S STL CDH LEG,SUP-2279235,CDM,C1713,HCPCS,0278,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
SCREW BONE L14MM DIA3MM PARTIALLY THRD HD M CANN FLOWERCUBE,SUP-2225321,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.21,420.04,,,,,,,,,,,,,
SCREW INTFR L28MM DIA8MM FULL THRD BIO INTFR,SUP-2121167,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
CATHETER CTRL VEN OD8FR SGL LUMN SURCUF 2 TISS INGROWTH,SUP-2127895,CDM,C1751,HCPCS,0278,RC,,,,both,,,2237.85,1454.60,,,,,,,,,,,,,
PROSTHESIS OSS EAR 0.6X0.9X4 MM,SUP-2312796,CDM,L8613,CPT,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
NAIL GAM 3 TI RT 125DEG 15X440MM ST,SUP-2701718,CDM,C1713,HCPCS,0278,RC,,,,both,,,8077.65,5250.47,,,,,,,,,,,,,
COMPONENT FEM SZ 1 UNI OPTETRAK,SUP-2223228,CDM,C1776,CPT,0278,RC,,,,both,,,7121.52,4628.99,,,,,,,,,,,,,
SMALL ACP PLATE 27 5 HOLES L 44,SUP-2706085,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.08,231.45,,,,,,,,,,,,,
MESH MIDFACIAL CUSTOMIZED PRIORITY AUG MEDPOR LTX,SUP-2862756,CDM,C1713,HCPCS,0278,RC,,,,both,,,26588.45,17282.49,,,,,,,,,,,,,
BURR SURG 4MM DIA HD LNG MIC 8MML HD SM BNE OVL DIAMOND DERM,SUP-2605571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,72.09,46.86,,,,,,,,,,,,,
NAIL IM L420MM OD13MM UNIV TI FEM CANN LCK VERSANAIL,SUP-2412455,CDM,C1713,HCPCS,0278,RC,,,,both,,,5398.01,3508.71,,,,,,,,,,,,,
FORCEP ENDOSCP DISMANTLING 6 CM NUCLS 24 CNTOUR CRV TO LT,SUP-2558686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2618.76,1702.19,,,,,,,,,,,,,
PLATE BNE SM 6 H CRANIOMAXILLOFACIAL TI LO PROF GAP FOR,SUP-2366209,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.73,571.82,,,,,,,,,,,,,
KIT GUIDEPIN DIA2MM DRL TIP SHT THRD PIN UNICAP,SUP-2123695,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC MAXBARR 5FR 55CM 1 LUMAN R 3175108D,SUP-2632656,CDM,C1751,HCPCS,0278,RC,,,,both,,,513.45,333.74,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 15 CM DIA25 MM CATH DIA 0.038 IN,SUP-2638537,CDM,C1889,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SCREW BNE AD L48MM DIA24MM UNICORTICAL TI ST NONCANNULATED,SUP-2181162,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.51,252.53,,,,,,,,,,,,,
HANDPIECE ABLAT DIA6MM ENDOMET IMPED CTRL DEV DISP NOVASURE,SUP-2239893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3332.58,2166.18,,,,,,,,,,,,,
DRILL SURG CANN 2.65 MM PATENT PENDING HAMMERTUBE,SUP-2749757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
STEM HUM L74MM 3C 135DEG TI SHLDR ANAT MONOLITHIC AEQUALIS,SUP-2388549,CDM,C1776,CPT,0278,RC,,,,both,,,5771.32,3751.36,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX20 CM TW N RING HD ACCS EPTFE CARBOFLO,SUP-2761254,CDM,C1768,CPT,0278,RC,,,,both,,,1089.27,708.03,,,,,,,,,,,,,
GRAFT BNE SUB 3CC DBM BIOCOMPOSITE OSTEOSET PERIARTC FOR SM,SUP-2399099,CDM,C1734,HCPCS,0278,RC,,,,both,,,2077.24,1350.21,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 55 MM DIA25 MM DEL SYS,SUP-2217568,CDM,C1768,CPT,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
CATHETER OCCL SNIPER WORKING L 150 CM PROX/DSTL OD,SUP-2164817,CDM,C2628,HCPCS,0272,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
RAIL INT FIX COMP SPANNING TEMPFIX,SUP-2487359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7285.55,4735.61,,,,,,,,,,,,,
CATHETER VENTRICULAR TUNNELED CAMINO FLX,SUP-2244471,CDM,C1729,HCPCS,0272,RC,,,,both,,,4738.26,3079.87,,,,,,,,,,,,,
NEEDLE MAYO 1/2 CIRCLE SIZE 4 TROCAR POINT 217004,SUP-2844697,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.44,12.64,,,,,,,,,,,,,
WAND ABLAT FOR TNSLCTMY ADENOIDECTOMY COBLATION PROCISE MAX,SUP-2342050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1178.88,766.27,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X36 MM STRL,SUP-2412514,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.64,79.07,,,,,,,,,,,,,
BAR EXT FIX 11X200 MM CARBON,SUP-2749995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
IMMOBILIZER SHLDR SLNG M,SUP-2276607,CDM,L3660,HCPCS,0272,RC,,,,both,,,10.52,6.84,,,,,,,,,,,,,
HC So Lidocaine,PX-3018017666,CDM,80176,CPT,0301,RC,,,,outpatient,,,387.00,251.55,,,,,,,,,,,,,
GUIDE DRL DIA1.7MM INSRT LCK,SUP-2364409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,655.22,425.89,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 10X15X8 MM UNICORTICAL IL ORAGRAFT,SUP-2740829,CDM,C1713,HCPCS,0278,RC,,,,both,,,682.95,443.92,,,,,,,,,,,,,
SCREW BNE L4MM DIA2MM MAND CRANIOMAXILLOFACIAL SIL SELF DRL 5PK,SUP-2366148,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.18,152.22,,,,,,,,,,,,,
PLATE BNE L240MM 140DEG 10 H S STL HIP LOK BILAT COMPR RIG,SUP-2370889,CDM,C1713,HCPCS,0278,RC,,,,both,,,2305.70,1498.70,,,,,,,,,,,,,
PLATE BNE L 81 MM 7 H LT VOLAR DSTL RADIAL WIDE EXT NS,SUP-2902157,CDM,C1713,HCPCS,0278,RC,,,,both,,,5848.22,3801.34,,,,,,,,,,,,,
PLATE BNE RIBBON UNIV 3.5X47 MM FOR RECON SYS NS LTX DISP,SUP-2861125,CDM,C1713,HCPCS,0278,RC,,,,both,,,1300.15,845.10,,,,,,,,,,,,,
OSTEOTOME ACET 66MM CVD STRL FOR GRY SYS,SUP-2364387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
KIT LD L60CM TIP 3MM ELECTRD 4MM SPC 8 ELECTRD,SUP-2356726,CDM,C1778,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SCREW BONE LAG CANC SLD PART THRD TIM,SUP-2136330,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.84,88.30,,,,,,,,,,,,,
KIT PACE STYL L 85 CM STR STD WIDE NAR J CLP ON/IMPLANT TOOL,SUP-2356350,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTEROLATERAL DISTAL HUMERUS 7H RIGHT,SUP-2549680,CDM,C1713,HCPCS,0278,RC,,,,both,,,3612.60,2348.19,,,,,,,,,,,,,
HALF PIN 4X180MM 40MM THR,SUP-2818452,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.06,607.79,,,,,,,,,,,,,
ALLOGRAFT BNE 150-25 MM FD FEM SHFT,SUP-2866859,CDM,C1762,CPT,0278,RC,,,,both,,,3516.96,2286.02,,,,,,,,,,,,,
SYSTEM 1 DEL DEV AND 1 MESH ASMBLY PREFYX PPS,SUP-2141797,CDM,C1771,HCPCS,0278,RC,,,,both,,,3554.17,2310.21,,,,,,,,,,,,,
CATHETER SNUS BLLN L16MM DIA5MM HI PERF DIL INT SNUS IRRIG,SUP-2106310,CDM,C1726,HCPCS,0272,RC,,,,both,,,2452.34,1594.02,,,,,,,,,,,,,
SROM NRH TIB PLAT ASSY SM 12MM,SUP-2515637,CDM,C1776,CPT,0278,RC,,,,both,,,8479.26,5511.52,,,,,,,,,,,,,
SCREW BONE DIA1.8MM L5MM EMER TITANIUMXDRIVE TIMESH CRAN,SUP-2277541,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.64,87.52,,,,,,,,,,,,,
KIT REP INCL 3 L PEC BTTN ATTCH INSRT FIBERTAPE SUTS W/ NDL,SUP-2121670,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
BIT DRL CANN 5 MM KNEE TRANSTIBIAL,SUP-2422800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
ROD SPNL 4+ LEVEL 2 5.5 MM COCR UNID,SUP-2730615,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
IMMOBILIZER KNEE L19IN ELAS STRP AND T BAR CUTAWAY,SUP-2194898,CDM,L1830,CPT,0274,RC,,,,both,,,53.63,34.86,,,,,,,,,,,,,
CHUCK HOFF 3 FOR PIN INSTR,SUP-2363108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2142.74,1392.78,,,,,,,,,,,,,
LENS IOL BCNVX 0+ DIOPT 6X12.5 MM ACRYL ENVISTA,SUP-2129601,CDM,V2632,HCPCS,0276,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CAGE SPNL 8MM L PEEK VBR,SUP-2211946,CDM,C1889,HCPCS,0278,RC,,,,both,,,10774.60,7003.49,,,,,,,,,,,,,
HOLDER PLT NONSTERILE REUSE ATLNTS,SUP-2279324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1238.16,804.80,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR PRSS FT CHIPSNEPHBIPPRS] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351332,CDM,C1776,CPT,0278,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
TRIAL HD -3MM OFFSET UNIV FEM BPLR UPLR UHT V-40,SUP-2361590,CDM,C1776,CPT,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PAD THER X LG KNEE WRP ON PLR CARE,SUP-2150872,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
PLATE BNE SM L90MM 2X3 H L MT TI POLYAX LOK COMPR LO PROF,SUP-2398513,CDM,C1713,HCPCS,0278,RC,,,,both,,,5912.62,3843.20,,,,,,,,,,,,,
SCREW BNE L100MM DIA35MM ST CORT S STL ST FULL THRD T15,SUP-2178271,CDM,C1713,HCPCS,0278,RC,,,,both,,,247.24,160.71,,,,,,,,,,,,,
KIT NEUROSURGICAL ACC DIL SET MPLR PRB STIM CLP,SUP-2354672,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
"HC Repair Trnscath Mitral Valve, Addit Prosthesis",PX-3603341900,CDM,33419,CPT,0360,RC,,,,outpatient,,,8530.00,5544.50,,,,,,,,,,,,,
BLADE SCRDRIVER CRUCFRM HLD SL NONCANNULATED FOR 1.5/2MM,SUP-2187569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3315.15,2154.85,,,,,,,,,,,,,
SCREW BNE ST 3.5X50 MM CRTX,SUP-2348817,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.02,411.46,,,,,,,,,,,,,
CARTRIDGE SUT PERFECT PASS COBRAID BLK MAGNUMWIRE,SUP-2341230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.50,285.02,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.018IN TIP L8CM STR TIP POLY V-18,SUP-2148249,CDM,C1769,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR UPLR CEM BIOMETHBIOC] ZIMMER BIOMET INC],SUP-2137332,CDM,C1776,CPT,0278,RC,,,,both,,,5699.10,3704.41,,,,,,,,,,,,,
SET NUCLS REM L25CM 4.5MM SPINE SHV,SUP-2284309,CDM,C1713,HCPCS,0278,RC,,,,both,,,2138.65,1390.12,,,,,,,,,,,,,
HC Ther Speech Genrating Device Prgrmg&Modification,PX-4409260900,CDM,92609,CPT,0440,RC,,,,both,,,410.00,266.50,,,,,,,,,,,,,
IMPLANT IM SMRT TOE II,SUP-2365964,CDM,C1713,HCPCS,0278,RC,,,,both,,,2576.06,1674.44,,,,,,,,,,,,,
IMMOBILIZER KNEE UNIV L19IN FOR 12-24IN THGH FOAM T BAR,SUP-2336080,CDM,L1830,CPT,0274,RC,,,,both,,,46.91,30.49,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP XS RT WRST,SUP-2196555,CDM,L3931,HCPCS,0272,RC,,,,both,,,15.26,9.92,,,,,,,,,,,,,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-3613622200,CDM,36222,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
HC Gastric Lavage/Decomp by Phys,PX-4504375300,CDM,43753,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
IMPLANT INTERPHALANGEAL JT DIA2.75MM 0DEG CANN HAMMERTUBE,SUP-2321071,CDM,C1776,CPT,0278,RC,,,,both,,,5092.30,3309.99,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR ROPT ATLS DR,SUP-2356547,CDM,C1721,HCPCS,0275,RC,,,,both,,,42955.20,27920.88,,,,,,,,,,,,,
PLATE BNE L MIC XLN 100 DEG 1.5 MM LT 3X3 HOLE TI NS,SUP-2482046,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.29,422.04,,,,,,,,,,,,,
SET SCR EXT FIX L8MM HEX FIX FOR ILIZ TAY SPAT FRME SYS,SUP-2342377,CDM,C1713,HCPCS,0278,RC,,,,both,,,730.99,475.14,,,,,,,,,,,,,
HC Pt Neuro Facilitation Ea 15 Min|OP OCCUPATIONAL THERAPY SERV,PX-4209711200,CDM,97112,CPT,0420,RC,,,GO,both,,,159.00,103.35,,,,,,,,,,,,,
PLATE BONE L95MM 12 H MAND TI LCK FOR 2MM SCR,SUP-2191233,CDM,C1713,HCPCS,0278,RC,,,,both,,,3365.14,2187.34,,,,,,,,,,,,,
TRAY BNE MAR CPRP BMA PLT SENS 1 BTTN AUTOMATION USED TO,SUP-2120732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2769.48,1800.16,,,,,,,,,,,,,
SCREW BNE L 30 MM DIA2.4 MM SS CORTICAL T8 STARDRV SLV TUBE,SUP-2905714,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.38,273.25,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 10CC DBM W/ RPM GEL AND PASTE CANC,SUP-2415800,CDM,C1713,HCPCS,0278,RC,,,,both,,,3256.18,2116.52,,,,,,,,,,,,,
SPECULUM OPHTHLMC MRDCH 24MM SPRD 57MML 14MMW BLADE STNLSS S,SUP-2484779,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
NKII REV NP FEMORAL SPACER LT SIZE 4 4MM LAT,SUP-2509619,CDM,C1776,CPT,0278,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
GRAFT SKIN 4X2CM DERMAMTRX ACELLULAR DERM MTRX REHYDRATED,SUP-2306891,CDM,Q4126,HCPCS,0636,RC,,,,both,,,469.37,305.09,,,,,,,,,,,,,
TRIAL NERVE STIM LD KT FREEDOM-8A,SUP-2423985,CDM,C1897,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
TITANIUM MESH TRAY HEMI MANDIBLE LEFT CP TITANIUM,SUP-2489193,CDM,C1713,HCPCS,0278,RC,,,,both,,,10268.40,6674.46,,,,,,,,,,,,,
PLATE T FUSION VA LCP 2.4/2.7MM 2H HD STD TI STRL,SUP-2546988,CDM,C1713,HCPCS,0278,RC,,,,both,,,3424.11,2225.67,,,,,,,,,,,,,
SHELL ACET 46 MM HIP CERM REFLECTION,SUP-2434645,CDM,C1776,CPT,0278,RC,,,,both,,,5928.32,3853.41,,,,,,,,,,,,,
PROSTHESIS OSS L W2.5XH1.2XL2MM DIA1MM INCUDSTAP HA FULL,SUP-2312580,CDM,L8613,CPT,0278,RC,,,,both,,,990.17,643.61,,,,,,,,,,,,,
SET INTRO PERFRMR L 23 CM OD 5 FR ID 1.7 MM GUIDEWIRE L 80,SUP-2168552,CDM,C1894,HCPCS,0272,RC,,,,both,,,110.84,72.05,,,,,,,,,,,,,
BIT DRILL 7 MM FOR COMPRESSION SCREW TRIGEN INTERTAN,SUP-2837135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1273.14,827.54,,,,,,,,,,,,,
PLATE BNE L20MM 2 H COMPR GORILLA,SUP-2321426,CDM,C1713,HCPCS,0278,RC,,,,both,,,3756.23,2441.55,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309753000,CDM,97530,CPT,0430,RC,,,CO|XU,both,,,144.00,93.60,,,,,,,,,,,,,
CANNULA THRMCPL SENS AIRFLOW NSL ORAL 1 CHAN AD 1.5MM CONN,SUP-2330161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
EXTRACTOR STONE 3FR L115CM BSKT DIA1CM NIT TIPLSS UNIDEX,SUP-2171307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
NAIL IM L360MM OD12MM TIB PLATFRM CANN LCK VERSANAIL,SUP-2412367,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.80,2592.07,,,,,,,,,,,,,
DEVICE SPNL STBL 12 MM INTERLAMINAR TECHNOLOGY TI STRL COFLX,SUP-2867272,CDM,C1889,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
BIT DRL DIA2.3MM DISP FOR ICONIX,SUP-2366697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,691.68,449.59,,,,,,,,,,,,,
RESTRICTOR CEM FOR 20/22MM P.F.C.,SUP-2253287,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
CONNECTOR ROD Y OFFSET FOR SM ROD REVERE ADDITION,SUP-2230100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HEAD RADIAL ANAT 26 MM LT,SUP-2107859,CDM,C1776,CPT,0278,RC,,,,both,,,9206.48,5984.21,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE 12 GBQ YTTRIUM-90 GLS DOSE VI,SUP-2135285,CDM,C2616,HCPCS,0278,RC,,,,both,,,57603.30,37442.14,,,,,,,,,,,,,
GUIDEWIRE LD 60 CM,SUP-2615480,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SHEATH RAIN RAD INTRO SHTH W/ HYDRPHLC WIRE 10 CM 506410H,SUP-2639012,CDM,C1894,HCPCS,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
SET SCR SPNL DIA6.35MM IL TI HEX BRK OFF CDH SOLERA,SUP-2288547,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CORE SLIDING UHMPWE 7MM,SUP-2878147,CDM,C1776,CPT,0278,RC,,,,both,,,6421.61,4174.05,,,,,,,,,,,,,
GRAFT BNE SUB 15ML FRZ DRY IC GRFT CHMBR,SUP-2264799,CDM,C1713,HCPCS,0278,RC,,,,both,,,4215.73,2740.22,,,,,,,,,,,,,
SET DIL LAT THOR NIM STIMULATED DIR,SUP-2292840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2219.35,1442.58,,,,,,,,,,,,,
MATRIX BIO L 10 X W 7 CM FISH SKIN DERMAL INTACT OMEGA3 10/BX,SUP-2909377,CDM,Q4158,HCPCS,0636,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
CURETTE CERV SZ 4 0 VIO ANG 254MM OVL CUP,SUP-2162120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.00,446.55,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 5FR 55CM S3385108D,SUP-2632850,CDM,C1751,HCPCS,0278,RC,,,,both,,,637.92,414.65,,,,,,,,,,,,,
SCREW BNE L115MM DIA6.5MM THRD L32MM CANC TI ST SELF DRL,SUP-2190532,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.87,101.97,,,,,,,,,,,,,
BIT DRL L91MM DIA1.9MM STP 35MM TWST QUIK NONRADIOLUCENT,SUP-2267850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,306.46,199.20,,,,,,,,,,,,,
PLATE BNE RND 1.5X100X0.4 MM MESH MALL CONTOURABLE TI NS LF,SUP-2191125,CDM,C1713,HCPCS,0278,RC,,,,both,,,6524.29,4240.79,,,,,,,,,,,,,
ENDCAP ORTH L5MM DIA11MM ST GRN TI NAIL EXTN TROCHANTERIC,SUP-2191918,CDM,C1776,CPT,0278,RC,,,,both,,,712.28,462.98,,,,,,,,,,,,,
SHEATH INTRO SENTRANT L 64 CM DIA22 FR GUIDEWIRE 0.035 IN,SUP-2749561,CDM,C1894,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC So Lactate Dehydrogenase (Ld) Isoenzymes,PX-3018362567,CDM,83625,CPT,0301,RC,,,,both,,,25.00,16.25,,,,,,,,,,,,,
BLADE SAW NAR FOR STRYKR SYS 5 PROPHECY INFIN 2001381015S] WRIGHT MEDICAL TECHNOLOGY INC],SUP-2397082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
BOLT ORTH FUSION 6.5X160 MM MIDFOOT TI NS,SUP-2799620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.25,1092.81,,,,,,,,,,,,,
GRAFT BIO TISS MESH 16X10 CM MIROMATRIX MIROMESH,SUP-2115025,CDM,C1781,HCPCS,0278,RC,,,,both,,,14519.36,9437.58,,,,,,,,,,,,,
BOOT WLK VENTURE 61 TALL M,SUP-2150951,CDM,L4386,HCPCS,0274,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
BALLOON ENDO FOR CLR VISIBILITY OF EUS PROC FITS OLY PENTAX,SUP-2360903,CDM,C1726,HCPCS,0272,RC,,,,both,,,56.36,36.63,,,,,,,,,,,,,
IMPLANT BIO SZ 250 SQCM FISH SKIN DERMAL SLD INTACT FLAT DRY,SUP-2909272,CDM,Q4158,HCPCS,0636,RC,,,,both,,,23314.50,15154.42,,,,,,,,,,,,,
BRACE THMB IP TO WR CREASE UP TO 3 3/4INXSM COLLUM CMC REG,SUP-2324972,CDM,L3931,HCPCS,0274,RC,,,,both,,,70.08,45.55,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM RT WRST LTHR,SUP-2194875,CDM,L3931,HCPCS,0272,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
GRAFT HUM TISS DERMACELL POROUS 5X5CM 25SQCM,SUP-2909334,CDM,Q4122,HCPCS,0636,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER CV DL 6 FRX135 CM TY IRRIGATION POWERPICC SOLO 2,SUP-2126391,CDM,C1751,HCPCS,0278,RC,,,,both,,,589.82,383.38,,,,,,,,,,,,,
PLATE SPNL MOD 14 MM LAT 1 HOLE TLH STRL ENDOSKELETON TL,SUP-2730526,CDM,C1713,HCPCS,0278,RC,,,,both,,,10982.15,7138.40,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 1.4X150 MM NS,SUP-2789083,CDM,C1769,HCPCS,0272,RC,,,,both,,,956.82,621.93,,,,,,,,,,,,,
ROMIPLOSTIM 500 MCG SC SOLR,RX-93567,CDM,J2802,HCPCS,0636,RC,55513-0222-01,NDC,,both,1,UN,16242.80,10557.82,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5 FR NIT MANDREL TUNGSTEN TIP,SUP-2383172,CDM,C1894,HCPCS,0272,RC,,,,both,,,53.22,34.59,,,,,,,,,,,,,
PLATE BNE COMPR NAR 231 MM 14 HOLE DYN NS DCP LTX,SUP-2861920,CDM,C1713,HCPCS,0278,RC,,,,both,,,582.16,378.40,,,,,,,,,,,,,
KIT INTRO SHTH L 10 CM DIA 4.5 FR GUIDEWIRE L 65 CM DIA,SUP-2120531,CDM,C1892,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
DRILL SURG BASE FEM STEM KNEE ROTATING HINGE NXGN,SUP-2437347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
COIL VASC TORNADO EMBOLUS L 2 CM DIA 3-2 MM 0.018IN MR,SUP-2424200,CDM,C1889,HCPCS,0278,RC,,,,both,,,361.07,234.70,,,,,,,,,,,,,
INSERT TIB SZ 6 THK8MM UNI KNEE UHMWPE ONLAY MAKO X3,SUP-2368707,CDM,C1776,CPT,0278,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 4-6 MM EPTFE GRAD TAPR REINF,SUP-2486972,CDM,C1768,CPT,0278,RC,,,,both,,,3111.14,2022.24,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH 10 CM 4 FR 7 CM NIT PLAT STIFF,SUP-2170555,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.06,76.74,,,,,,,,,,,,,
MESH HERN L W14XL18CM INGUINAL OVL SELF EXP PTCH KUGEL,SUP-2125976,CDM,C1781,HCPCS,0278,RC,,,,both,,,450.59,292.88,,,,,,,,,,,,,
TRIHEXYPHENIDYL HCL 5 MG PO TABS,RX-8167,CDM,6370000000,HCPCS,0637,RC,70954-0211-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COIL EMB L20CM DIA6MM HELI DETACH TARGET XL,SUP-2365817,CDM,C1889,HCPCS,0278,RC,,,,both,,,5929.11,3853.92,,,,,,,,,,,,,
MARKER RADIOGRAPHIC L10MM DIA0.018IN PLAT CONSTRUCTION,SUP-2420155,CDM,A4648,CPT,0278,RC,,,,both,,,537.94,349.66,,,,,,,,,,,,,
HC Forearm Infant Ue Min 2 Views,PX-3207309200,CDM,73092,CPT,0320,RC,,,,both,,,276.00,179.40,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPLR CHIPZIMUNI] ZIMMER BIOMET INC],SUP-2212526,CDM,C1776,CPT,0278,RC,,,,both,,,4042.75,2627.79,,,,,,,,,,,,,
CAGE SPNL W15.5XH9XL12MM PEEK ANT CERV INTBDY FUS LORD,SUP-2416003,CDM,C1889,HCPCS,0278,RC,,,,both,,,6247.50,4060.87,,,,,,,,,,,,,
GRAFT HUM TISS POST TIBIALIS TEND >22CM FRZN (FOLDED DIAM,SUP-2307281,CDM,C1762,CPT,0278,RC,,,,both,,,4929.11,3203.92,,,,,,,,,,,,,
PUTTY BNE MORPHOGENETIC PROT OP 1,SUP-2282592,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.38,52.25,,,,,,,,,,,,,
HC Eval of Speech Production,PX-4449252200,CDM,92522,CPT,0444,RC,,,,inpatient,,,693.00,450.45,,,,,,,,,,,,,
COIL NEUROVASCULAR MATRIX2 360 DEG L 15 CM DIA 7 MM,SUP-2363109,CDM,C1889,HCPCS,0278,RC,,,,both,,,8087.38,5256.80,,,,,,,,,,,,,
RING FIX 180 HALF IMP DNE,SUP-2197260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
SYSTEM PT MON W WIRELESS COMMUNICATOR LATITUDE,SUP-2140198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 4 FR CANN L 23 CM POLYUR PLAS SS RED,SUP-2156057,CDM,C1894,HCPCS,0272,RC,,,,both,,,23.71,15.41,,,,,,,,,,,,,
COIL EMB L20CM OD7MM ODSEC0135IN 1847MM PGLA INTCRAN,SUP-2173114,CDM,C1889,HCPCS,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
BODY FEM B OD45MM HA POR PLSM SPR PROX CALCAR HIP MTPHSEAL,SUP-2408321,CDM,C1776,CPT,0278,RC,,,,both,,,16993.68,11045.89,,,,,,,,,,,,,
HEPATITIS B VAC RECOMBINANT 20 MCG/ML IJ SUSY,RX-159676,CDM,90740,HCPCS,0636,RC,58160-0821-52,NDC,,both,1,ML,325.10,211.31,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6MM STR TW REMOVABLE RNG,SUP-2396297,CDM,C1768,CPT,0278,RC,,,,both,,,4581.26,2977.82,,,,,,,,,,,,,
SUPPORT BK LO FRIC PUL,SUP-2276691,CDM,L0641,HCPCS,0274,RC,,,,both,,,74.23,48.25,,,,,,,,,,,,,
LEAD PACE OSCOR SIL INSUL MYOCARDIAL RT ATRIOVENTRICULAR,SUP-2356431,CDM,C1898,HCPCS,0275,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
STEM HUM L150MM OD5MM TI POR R DST CEM FLNG IMPL DISCVR,SUP-2136222,CDM,C1776,CPT,0278,RC,,,,both,,,12550.58,8157.88,,,,,,,,,,,,,
SHIM FIX SCR LNG 28 MM NS PHANTOM XL DISP,SUP-2750542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
CATHETER BLLN DIL FOR BRONCH THERMOPLASTY ALAIR ATS 2-5,SUP-2149864,CDM,C1886,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL INTFACE,SUP-2435560,CDM,L0651,HCPCS,0274,RC,,,,both,,,3667.77,2384.05,,,,,,,,,,,,,
BIT DRL L125MM DIA2.3MM QUIK CPL NONRADIOLUCENT CANN W/O,SUP-2319434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
CATHETER PTCA BLLN PERIPH OVR THE WIRE N COMPLIANT 10.0MM,SUP-2156685,CDM,C1725,HCPCS,0272,RC,,,,both,,,1329.16,863.95,,,,,,,,,,,,,
FRACTURE KIT COMPLETE W/ POWERCURVE STABILIT,SUP-2474805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SET INTRO 12FR L22CM GWIRE SAFT,SUP-2171203,CDM,C1894,HCPCS,0272,RC,,,,both,,,123.59,80.33,,,,,,,,,,,,,
HC Main Pul Art/Rt Heart,PX-3237574600,CDM,75746,CPT,0323,RC,,,,both,,,3214.00,2089.10,,,,,,,,,,,,,
PLATE BNE PERIPROSTHETIC 115 MM PROX FEM RT NCB,SUP-2435495,CDM,C1713,HCPCS,0278,RC,,,,both,,,3767.22,2448.69,,,,,,,,,,,,,
PLATE BONE L18MM THK1.5MM 2X2 H MINI TI RT,SUP-2319359,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
WASHER ORTH HD FOR 2.7/3.5MM SCR DARCO,SUP-2401363,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX20 CM BASIC KT ARROWG+ARD,SUP-2383313,CDM,C1751,HCPCS,0278,RC,,,,both,,,170.19,110.62,,,,,,,,,,,,,
ALLOGRAFT BNE CHIPS 1-4 MM 60 CC CORTICAL CANC BIO,SUP-2637023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1906.61,1239.30,,,,,,,,,,,,,
PATCH DURA W1XL3IN REGEN CLLGN MTRX BASE SUTURABLE DURAGN,SUP-2244023,CDM,C1763,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 18X15+ MM PRESERVON MATRIGRAFT,SUP-2740899,CDM,C1762,CPT,0278,RC,,,,both,,,1712.59,1113.18,,,,,,,,,,,,,
PLATE BNE HK LG 3.5 MM PERIPROSTHETIC PROX SS NS VA-LCP,SUP-2750909,CDM,C1713,HCPCS,0278,RC,,,,both,,,5654.98,3675.74,,,,,,,,,,,,,
HC Brachytherapy Isodose Plan Simple,PX-3337731600,CDM,77316,CPT,0333,RC,,,,outpatient,,,953.00,619.45,,,,,,,,,,,,,
ELECTRODE ENDSCPC URLGY 24 28FR DIA LNG 12DG ANGLD CTTNG LOO,SUP-2730007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.69,361.85,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR 8 CNTCT L70CM TRL STYL LIN ST,SUP-2138786,CDM,C1778,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER HD PRECRV 13 FRX20 CM SHT TERM BASIC SET DUO-SPLIT,SUP-2627190,CDM,C1752,HCPCS,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2X10 MM CORTICAL HEXAGONAL HEAD STAIN,SUP-2836715,CDM,C1713,HCPCS,0278,RC,,,,both,,,242.00,157.30,,,,,,,,,,,,,
WIRE FIXATION THREADED 15X150 MM CALIBRATED TROCAR POINT 1 E,SUP-2837833,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.76,73.29,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 10 IN WRST FOREARM LT,SUP-2336335,CDM,L3809,HCPCS,0272,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
VENETOCLAX 100 MG PO TABS,RX-133767,CDM,J8999,HCPCS,0636,RC,00074-0576-11,NDC,,both,1,UN,585.70,380.70,,,,,,,,,,,,,
BUPIVACAINE 0.25% ELASTOMERIC INFUSION,RX-408722,CDM,J0665,HCPCS,0636,RC,00409-1159-02,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
SYSTEM RIGIDLOOP ADJ CORTICAL XL,SUP-2749358,CDM,C1713,HCPCS,0278,RC,,,,both,,,2408.38,1565.45,,,,,,,,,,,,,
BIT DRL 11 MMX9 IN BADGER,SUP-2765732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,594.43,386.38,,,,,,,,,,,,,
TRAY NERVE BLOCK CANN DIA25 GA S25BKN NRFIT STRL DISP,SUP-2936465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,48.54,31.55,,,,,,,,,,,,,
SCREW TIB STEM LCK MOD VANGUARD 360 AGC,SUP-2406042,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PACEMAKER CARD INSIGNIA I ENTRA W 4.4 X H 5.2 CM THK 0.65 CM,SUP-2148600,CDM,C1786,HCPCS,0275,RC,,,,both,,,15046.88,9780.47,,,,,,,,,,,,,
PATCH DURA L 5.5 X W 3.1 IN SURF AREA17.1 SQ IN BOV PERICARD,SUP-2884058,CDM,C1763,HCPCS,0278,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
PLATE BUR H L18.5MM CRAN W/ SLOT THINFLAP,SUP-2137622,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
LEAD PACE ENDO RA RV IS-1 CONN BPLR SIL INSUL FINELINE II,SUP-2148668,CDM,C1779,HCPCS,0275,RC,,,,both,,,2555.96,1661.37,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS 18 L 135 CM DIA 3.5 FR,SUP-2146906,CDM,C1753,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 35 CM DIA 7 FR TIP L 5 MM SPC 5,SUP-2141325,CDM,C1725,HCPCS,0272,RC,,,,both,,,4027.68,2617.99,,,,,,,,,,,,,
PLATE BNE L109MM 4 H L LAT EL TI LOK COMPR MAL FOR,SUP-2376022,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
CATHETER HD STR 9 FRX15 CM SHT TERM DL TAPR TIP DUOFLO,SUP-2627401,CDM,C1752,HCPCS,0278,RC,,,,both,,,139.73,90.82,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.4X10 MM LOCKING TITANIUM MATRIXMAN,SUP-2837735,CDM,C1713,HCPCS,0278,RC,,,,both,,,585.11,380.32,,,,,,,,,,,,,
CAGE SPNL LORDTC 8 MM LUMBAR,SUP-2256280,CDM,C1889,HCPCS,0278,RC,,,,both,,,13268.07,8624.25,,,,,,,,,,,,,
GRAFT BONE SUB 1-4MM 30ML ALLGRFT CHIP CANC DEMIN COPIOS,SUP-2205387,CDM,C1734,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
SCREW BONE 6.5MMDIA 100MML STD CANC PARTIALLY THRD CANN ST N,SUP-2198304,CDM,C1713,HCPCS,0278,RC,,,,both,,,71.06,46.19,,,,,,,,,,,,,
HOOK SPNL BILAT PEDCL S STL OPN NEUT FOR 4MM ROD MOSS MIAMI,SUP-2254423,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
KIT GASTROSTMY L25CM OD16FR UTHANE 6 SIDEPRT RADPQ CATHETER,SUP-2167776,CDM,C1729,HCPCS,0272,RC,,,,both,,,259.02,168.36,,,,,,,,,,,,,
SPLINT ANK FT 3-6 SM ORTHOSIS AD UNISX WMN SHOE R STRP CLSR,SUP-2326061,CDM,L4350,HCPCS,0272,RC,,,,both,,,123.59,80.33,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840056,CDM,J7042,HCPCS,0258,RC,00338-0085-04,NDC,JW,both,250,ML,12.80,8.32,,,,,,,,,,,,,
STAPLER FIX SEPT FLAP CLSR DISP ENTACT,SUP-2341428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.57,418.32,,,,,,,,,,,,,
COMPONENT FEM 12X21MM TAPR POST UNICAP,SUP-2123698,CDM,C1776,CPT,0278,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
REAMER SURG OD8MM HUM SHLDR ST ACORN MILAGRO,SUP-2249536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
PREDNISONE 5 MG PO TABS,RX-6497,CDM,J7512,HCPCS,0637,RC,64380-0783-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STAPLE BONE FIX W12XL25MM CO CHROM LAT LIGMNT 2 PRNG N THRD,SUP-2342730,CDM,C1713,HCPCS,0278,RC,,,,both,,,2954.43,1920.38,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 9 CM RND SKIRTED POLYESTER PARIETEX,SUP-2752192,CDM,C1781,HCPCS,0278,RC,,,,both,,,1762.29,1145.49,,,,,,,,,,,,,
PACEMAKER CARD PERM SGL CHMBR STD UPLR BPLR SSIR IS 1 CONN,SUP-2357332,CDM,C1786,HCPCS,0275,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
SYSTEM CONC WHL BLD INPUT 30ML PLT RICH POOR PLSM OUTPT,SUP-2402588,CDM,C1713,HCPCS,0278,RC,,,,both,,,3571.75,2321.64,,,,,,,,,,,,,
GRAFT BNE SUB CANC CORT DEMIN 3/4 FILL DIVERTED TB AFT G2,SUP-2307037,CDM,C1889,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
IMPLANT ORTH L60MM DIA7MM IFUSE,SUP-2337787,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
VALVE SPEAK PMV 2000,SUP-2433847,CDM,L8501,HCPCS,0274,RC,,,,both,,,324.08,210.65,,,,,,,,,,,,,
CONNECTOR SPNL XLNK ASSEMB FIX POST ST360 6.35MM ROD 15MM,SUP-2289999,CDM,C1713,HCPCS,0278,RC,,,,both,,,2875.77,1869.25,,,,,,,,,,,,,
MESH SURG POLYPR VENTRAL CIR 12.5CM 12.5CM 11.4CM,SUP-2265974,CDM,C1781,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
PLATE BNE L315MM 2 H ST BILAT S STL SPR LO PROF RIG,SUP-2177156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1179.54,766.70,,,,,,,,,,,,,
DYNAMIZER EXT FIX RADLUC STRL TRUELOK,SUP-2875239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10424.80,6776.12,,,,,,,,,,,,,
PROSTHESIS 16F 5MM SPEC LEN INDWL VOICE,SUP-2242346,CDM,L8509,HCPCS,0272,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
ADAPTER FEM TI FEM LUERLOCK COMPR OSS,SUP-2406934,CDM,C1776,CPT,0278,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
PLATE BONE TUBULAR NARROW 4.5 MM 7 HOLE PROVISIONAL FIXATION,SUP-2836973,CDM,C1713,HCPCS,0278,RC,,,,both,,,1602.09,1041.36,,,,,,,,,,,,,
LEAD DEFIB LINOX S L 65 CM DIA2.6 MM SIL INSUL IRIDIUM OXIDE,SUP-2138049,CDM,C1777,HCPCS,0275,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
SET INTRO PERFRMR L 35 CM DIA 5 FR TIP 3 MM GUIDEWIRE 0.035,SUP-2169704,CDM,C1894,HCPCS,0272,RC,,,,both,,,93.26,60.62,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK L 100 CM DIA 5.5 FR 2 CM 6 MM,SUP-2659383,CDM,C1725,HCPCS,0272,RC,,,,both,,,2431.18,1580.27,,,,,,,,,,,,,
HC So Brucella Antibody,PX-3028662266,CDM,86622,CPT,0302,RC,,,,outpatient,,,253.00,164.45,,,,,,,,,,,,,
PLATE BNE L24MM THK1MM MINI 4 H CP TI STR TLTS FOR 2 23MM,SUP-2262827,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.99,627.89,,,,,,,,,,,,,
TUBE ET L295MM OD10.8MM ID7.5MM NSL IVRY PVC DIR NORTH,SUP-2351741,CDM,2720000010,LOCAL,0272,RC,,,,both,,,33.66,21.88,,,,,,,,,,,,,
STEM HUM SZ 7 L130MM 135DEG CO CHROM MOLYBDENUM CEM,SUP-2204817,CDM,C1776,CPT,0278,RC,,,,both,,,11285.16,7335.35,,,,,,,,,,,,,
HALF PIN 6MMX35MM,SUP-2820784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1921.90,1249.23,,,,,,,,,,,,,
SUPPORT THMB STBL SM 2.25-2.75 IN LT PROCARE THUMBGUARD,SUP-2195766,CDM,L3931,HCPCS,0272,RC,,,,both,,,30.77,20.00,,,,,,,,,,,,,
HC Debride Subq First 20 Sq Cm,PX-3611104200,CDM,11042,CPT,0361,RC,,,,inpatient,,,1247.00,810.55,,,,,,,,,,,,,
PEMETREXED DISODIUM 500 MG/20ML IV SOLN,RX-158742,CDM,J9294,HCPCS,0636,RC,00409-0021-03,NDC,,both,20,ML,193.40,125.71,,,,,,,,,,,,,
CRANIO SCULPT CRANIAL BONE VOID FILLER3 CC QTY001 EA,SUP-2477084,CDM,C1713,HCPCS,0278,RC,,,,both,,,3803.33,2472.16,,,,,,,,,,,,,
ROD SPNL L35MM POST PEDCL TI LORDOSED VIPER 2,SUP-2255064,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SCREW BNE COMPR 2X22 MM LP HD BITE,SUP-2644978,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.20,524.03,,,,,,,,,,,,,
BUR SURG L7CM BALL DIA05MM FLUT MIDAS REX MEDNEXT LEGEND,SUP-2279891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.83,194.24,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT WDG IL CREST 9MM,SUP-2307415,CDM,C1713,HCPCS,0278,RC,,,,both,,,2320.46,1508.30,,,,,,,,,,,,,
TUBE FEED NG 10 FR 109 CM SGL LUMN POLYUR LTX FREE PED W OUT,SUP-2124654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,50.77,33.00,,,,,,,,,,,,,
BIT DRL STR 14-16X250 MM,SUP-2440891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5750.91,3738.09,,,,,,,,,,,,,
ANCHOR SUT 25MM LOOP VERSITOMIC G LOK,SUP-2366633,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.22,918.59,,,,,,,,,,,,,
ENDPLATE SPNL 3 DEG LG SUP PRODISC-L,SUP-2741245,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
WAND ABLATOR LIGHT WAVE WITH SUCTION 4MMX165MM 90DEG,SUP-2824436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,738.72,480.17,,,,,,,,,,,,,
NUSHIELD 4X6CM 24SQ CM,SUP-2314112,CDM,Q4160,HCPCS,0636,RC,,,,both,,,4672.32,3037.01,,,,,,,,,,,,,
GRAFT BNE SUB 25X100X4MM 10ML STRP,SUP-2361879,CDM,C1713,HCPCS,0278,RC,,,,both,,,9437.71,6134.51,,,,,,,,,,,,,
PLATE BONE TEMPORAL 9 HOLE MESH 42.2X25.1X0.4MM TITANIUM NEU,SUP-2827191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1294.62,841.50,,,,,,,,,,,,,
EXTRACTOR SURG FOR BNE SCR REM INBNE II,SUP-2400024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
PLATE 8MM DISPLC DWYER,SUP-2243235,CDM,C1713,HCPCS,0278,RC,,,,both,,,5631.72,3660.62,,,,,,,,,,,,,
LEAD PACE BPLR 40 CM 100 CM TRNSVEN TEMP ACTIVE FIX DISP,SUP-2282229,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
PLATE PERIARTICULAR PROX HUM 3.5MM 14H 307MM RT SS LCP STRL,SUP-2546058,CDM,C1713,HCPCS,0278,RC,,,,both,,,6158.17,4002.81,,,,,,,,,,,,,
PLATE TBL LEFT MED HLSX6 LATEX FREE MRCRY FREE PVC FREE,SUP-2588831,CDM,C1713,HCPCS,0278,RC,,,,both,,,3811.58,2477.53,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00264-7510-10,NDC,JW,both,250,ML,17.00,11.05,,,,,,,,,,,,,
TUBE STOR 1.8ML EXTERNALLY THRD UNIV NUNC,SUP-2124936,CDM,C1894,HCPCS,0272,RC,,,,both,,,7.44,4.84,,,,,,,,,,,,,
CATHETER ATHRCTMY PHOENIX L 130 CM DIA2.2 MM INTRO 6 FR,SUP-2823717,CDM,C1724,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
CATHETER CTRL VEN 3 LUMN N TUNNELED BASIC KT POLYUR ANTIMIC,SUP-2383308,CDM,C1751,HCPCS,0278,RC,,,,both,,,192.61,125.20,,,,,,,,,,,,,
PIN FIX SHT THRD,SUP-2267681,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ELECTRODE LAP MNPLR OLSEN 5MM DIA SHAFT 12 12NL L HOOK WIRE,SUP-2675667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,943.57,613.32,,,,,,,,,,,,,
CATHETER ATHRCTMY SILVERHAWK L 135 MM EFFECTIVE L 132 CM TIP,SUP-2173079,CDM,C1714,HCPCS,0272,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
CARRIER WIRE M L17MM LOOP DIA32MM ROD DIA46MM S STL RUSH SLT,SUP-2409756,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.43,585.28,,,,,,,,,,,,,
EZY DOSE PILL CUTTER MISC,RX-164638,CDM,2500000003,HCPCS,0250,RC,25715-0677-08,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PROPRANOLOL HCL ER 60 MG PO CP24,RX-38224,CDM,6370000000,HCPCS,0637,RC,60687-0215-01,NDC,,both,1,UN,9.00,5.85,,,,,,,,,,,,,
KETAMINE HCL 50 MG/5ML IJ SOSY,RX-143112,CDM,2500000003,HCPCS,0250,RC,71266-9080-04,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BONE L6MM DIA1.5MM CORT MAXILLOMANDIBULAR GRN TI SELF,SUP-2137242,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
ANCHOR SUT SZ 2 DIA5.5MM DBL LD ABSRB LACTOSCREW MAXBRAID,SUP-2212849,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.038 IN TIP L 3 MM TEF HYDRPHLC,SUP-2429606,CDM,C1769,HCPCS,0272,RC,,,,both,,,114.86,74.66,,,,,,,,,,,,,
PLATE BONE W5MM THK1.2MM 4X9 H S STL T SHP NONCOMPRESSION,SUP-2343837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1790.93,1164.10,,,,,,,,,,,,,
BLADE SURG 11 RT MIDLN MAST MIDLF,SUP-2631612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
PLATE BONE BOX 10X16 MM 4 HOLE TITANIUM NON STERILE LOW PROF,SUP-2838364,CDM,C1713,HCPCS,0278,RC,,,,both,,,870.41,565.77,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 0.7-1.0 MCI STRL ADVANTAGE 2029ALS1] ISOAID LLC],SUP-2247257,CDM,C2642,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
DEVICE DCOMPR 8MM GRY ALUM TI VANADIUM INTERLAMINAR,SUP-2320315,CDM,C1889,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
FIXATOR ORTH WRST LO PROF W 4 3MM SELF DRL SCHNZ SCR 220MM C,SUP-2179123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3779.84,2456.90,,,,,,,,,,,,,
STIMULATOR BNE GROWTH SZ 1 2 COIL,SUP-2196348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7959.90,5173.93,,,,,,,,,,,,,
BIT DRL DIA6.5MM NONSTERILE COUNTSINK CONIC STP,SUP-2178941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,992.11,644.87,,,,,,,,,,,,,
PROCEDURE PACK SHLDR HEARTWARE,SUP-2282560,CDM,Q0498,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
LEAD PACE L90CM ENDO LV UNI/BIPOLAR LV1 SGL ELECTRD PASS 451390] GUIDANT SALES CORP],SUP-2236354,CDM,C1779,HCPCS,0275,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
HC Wound Vac <=50 Sq Cm Dme,PX-7619760500,CDM,97605,CPT,0761,RC,,,,both,,,275.00,178.75,,,,,,,,,,,,,
ANCHOR SUT L14.5MM OD3MM 2 INSRTR HNDL SHLDR PLDLA,SUP-2121581,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT NRV L25CM ID6MM CLLGN CONDUIT BEND 60DEG W O FORMING,SUP-2378816,CDM,C9353,HCPCS,0278,RC,,,,both,,,4830.01,3139.51,,,,,,,,,,,,,
CUP ACET 32X50 MM MARBURG AP,SUP-2441691,CDM,C1776,CPT,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
PLATE BNE SQ MINI 2 MM 6X2 HOLE MESH STRP LADDER TI NS,SUP-2475662,CDM,C1713,HCPCS,0278,RC,,,,both,,,732.62,476.20,,,,,,,,,,,,,
ELECTRODE ELECSURG BUTTON 10 FR HI FREQ FLX ENDOSCP UROLOGY,SUP-2475780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
SET URET STENT UTHANE L 28 CM DIA 6-9.5 FR PROX SEG L 13 CM,SUP-2835748,CDM,C2617,HCPCS,0278,RC,,,,both,,,374.88,243.67,,,,,,,,,,,,,
KIT REPL INDWL LO PRSS VOICE PROSTHESES SER 6MM BLOM SINGER,SUP-2246403,CDM,L8509,HCPCS,0274,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SCREW BNE LCK FIX BOLT,SUP-2609714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2061.66,1340.08,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC IR 4FR 55CM 1 LUMAN RVS TAP 3174155,SUP-2632653,CDM,C1751,HCPCS,0278,RC,,,,both,,,202.06,131.34,,,,,,,,,,,,,
HC CT-Guided Aspiration,PX-3507598900,CDM,75989,CPT,0350,RC,,,,outpatient,,,7563.00,4915.95,,,,,,,,,,,,,
IMPLANT OP RM TUFFNEK SCR 2.7 3.5 AND,SUP-2321239,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.48,221.96,,,,,,,,,,,,,
GRAFT HUM TISS W40 X L70MM THK2.5-3.5MM ACELLULAR DERM MTRX,SUP-2264664,CDM,Q4122,HCPCS,0636,RC,,,,both,,,11264.44,7321.89,,,,,,,,,,,,,
MODULE PT POS 2.0 LIF-PTP ATEC,SUP-2739132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SET INTRO V-STICK DIA 5 FR SS COAX NONECHOGENIC STIFF,SUP-2120084,CDM,C1769,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS TENCK INF 31 CM 1 CUF SIL QUINT,SUP-2754739,CDM,C1752,HCPCS,0278,RC,,,,both,,,169.40,110.11,,,,,,,,,,,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-103564,CDM,J0665,HCPCS,0636,RC,00409-1159-02,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE CANN MIC 28 MM ASNS,SUP-2362774,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
HC Mra Pelvis W&W/O Contrast,PX-6100892000,CDM,C8920,HCPCS,0610,RC,,,,both,,,4893.00,3180.45,,,,,,,,,,,,,
SCREW BNE CADDY COMP MOTIONLOC,SUP-2485239,CDM,C1713,HCPCS,0278,RC,,,,both,,,2413.50,1568.77,,,,,,,,,,,,,
HC Clsd Tx Patella Disloc WO,PX-4502756000,CDM,27560,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PIN FIX L 60 MM DIA 3.5 MM PROV LG TARGETER SYS STRL EVOS,SUP-2933596,CDM,C1713,HCPCS,0278,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 9 PACK,SUP-2855643,CDM,C2642,HCPCS,0278,RC,,,,both,,,16397.77,10658.55,,,,,,,,,,,,,
DRESSING 4INX10.0YD DOME PASTE OR UNNA BOOT GELOCAST,SUP-2324582,CDM,L4387,HCPCS,0272,RC,,,,both,,,31.75,20.64,,,,,,,,,,,,,
SIZER BRST IMPL EXTRA FULL PROF SIL 370 CC FILL VOL 6 CM,SUP-2113593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
BLOCK CUT FOR CAPPED C1B CAPCONFORMISC1B] CONFORMIS INC],SUP-2165814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
ELECTRODE NDL CANN L25CM ARRY DIA3.5CM FOR OPN AND PERC RF,SUP-2139747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5761.90,3745.23,,,,,,,,,,,,,
WIRE EXT FIX DIA2MM OLV FOR SALVATION EXT FIX,SUP-2401143,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
KIT FTPLT SUPP MAXFRAME,SUP-2176969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2674.31,1738.30,,,,,,,,,,,,,
SCREW BONE L75MM DIA5MM IM LCK FOR FEM NAIL RECON RICHARDS,SUP-2342531,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.34,144.52,,,,,,,,,,,,,
PROBE OPHTH DIA0.3MM S STL REUSE RITLENG,SUP-2224375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
TRAY PARACENTESIS/THORACENTESIS 18GA VLV DRNGE,SUP-2133917,CDM,C1729,HCPCS,0272,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
MESH HERN RECT 10X4 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855251,CDM,C1781,HCPCS,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
SCREW BNE CANN 2.7X18 MM TI CAPTURE QUICKSNAP,SUP-2609590,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.74,802.58,,,,,,,,,,,,,
SET CATH RALRSN INTRNL DUOFLO CH,SUP-2358809,CDM,C1752,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ALLOGRAFT BNE GEL 1 CC DBM BIO,SUP-2637041,CDM,C1713,HCPCS,0278,RC,,,,both,,,930.19,604.62,,,,,,,,,,,,,
HEAD HUM STD H17MM DIA44M BIO MOD,SUP-2404614,CDM,C1776,CPT,0278,RC,,,,both,,,3702.37,2406.54,,,,,,,,,,,,,
CATHETER URET WHSTL TIP 6FRX70CM FLEXIMA,SUP-2139296,CDM,C1758,HCPCS,0278,RC,,,,both,,,607.65,394.97,,,,,,,,,,,,,
GRAFT BONE SUB W19XH7XL26MM DBM STRP OSTEOSPONGE,SUP-2125423,CDM,C1713,HCPCS,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
CABLE EP CATH INQUIRY L 110 CM DIA 6 FR SPC 2-5-2 MM STEER,SUP-2677781,CDM,C1730,HCPCS,0272,RC,,,,both,,,578.80,376.22,,,,,,,,,,,,,
LOCK LAT HOOK PLATE TI 5H,SUP-2815774,CDM,C1713,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
PLATE K ORBITAL 3 MM CP TITANIUM,SUP-2681106,CDM,C1713,HCPCS,0278,RC,,,,both,,,1917.60,1246.44,,,,,,,,,,,,,
SPACER FEM NS TRAC FLX,SUP-2445536,CDM,C1776,CPT,0278,RC,,,,both,,,2303.19,1497.07,,,,,,,,,,,,,
HC Inj for Si Joint Therapeutic,PX-3610026000,CDM,G0260,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER VENOGRAPHY CORODYN P1 POLYUR FIX CRV VENOGRAM LD,SUP-2137966,CDM,C1893,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
FORCEPS SURG AD L6IN PLT HLD W SWVL FT REUSE FOR MOD HND SYS,SUP-2188843,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.85,2144.25,,,,,,,,,,,,,
GRAFT BONE SUB 5ML CA PHOS FIL VOID CEM NORIAN CRS,SUP-2193980,CDM,C1713,HCPCS,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
CATHETER PICC TRIM LEN SGL LUMN FULL TY NRS PWR INJ POLYUR,SUP-2125633,CDM,C1751,HCPCS,0278,RC,,,,both,,,560.96,364.62,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 60 CM DIA 7 MM EPTFE CARBON PERIPH,SUP-2128077,CDM,C1768,CPT,0278,RC,,,,both,,,12840.09,8346.06,,,,,,,,,,,,,
GRAFT DURA L 3 X W 1 IN TYP I CLLGN BOV ACHILLES TEND RESRB,SUP-2889748,CDM,C1763,HCPCS,0278,RC,,,,both,,,1293.62,840.85,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HYBRID HD SHELL TRAB MEL CERM,SUP-2212726,CDM,C1776,CPT,0278,RC,,,,both,,,13831.17,8990.26,,,,,,,,,,,,,
CEMENT BNE PMMA OSSEOFLEX CD-H,SUP-2490951,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.52,661.39,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.508,SUP-2860025,CDM,C1713,HCPCS,0278,RC,,,,both,,,36765.95,23897.87,,,,,,,,,,,,,
HC Rfl&Main Implt Pmp/Rsvr Dlvr Spi/Brn Phy/Qhp,PX-5109599100,CDM,95991,CPT,0510,RC,,,,inpatient,,,908.00,590.20,,,,,,,,,,,,,
SUPPORT ORTHOT ANK JT TORSION CTRL ANK JT HALF SLD STIRRUP,SUP-2435663,CDM,L2375,HCPCS,0272,RC,,,,both,,,348.35,226.43,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 2.7X46X12 MM HIP 2 HOLE SS STRL,SUP-2546021,CDM,C1713,HCPCS,0278,RC,,,,both,,,2499.66,1624.78,,,,,,,,,,,,,
POST ORTHOPEDIC 1 HOLE W/ 12MM BOLT TRUELOK,SUP-2316106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
WASHER ORTH TI FLAT FOR 7MM SCR MONSTER,SUP-2320330,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
STYLET PACE L65CM DEFL LOC +,SUP-2356064,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PIN FXTN 2.1MM DIA 5MML FLAT HEAD RSRBBLE US ACTVTN SNCWLD,SUP-2497375,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.38,175.10,,,,,,,,,,,,,
ENDCAP HUM L50MM TI PROX SHLDR INTERCALARY FLUT MRS,SUP-2376503,CDM,C1713,HCPCS,0278,RC,,,,both,,,3054.91,1985.69,,,,,,,,,,,,,
SCREW SPNL 9X50 MM SAMBASCREW,SUP-2601141,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
GUIDE SURG ENDONASAL ACCS LG STRL SPIWAY LTX,SUP-2877808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
TROCAR STNMN PIN 0.079INX9IN,SUP-2363711,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.44,17.84,,,,,,,,,,,,,
FIBER LASER HOLM 550 M FOR USE W/ SMA-905 RED SMARTSYNC,SUP-2835956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1185.32,770.46,,,,,,,,,,,,,
IMPLANT ANK JT FIX INSRT L UHMWPE SALTO TALARIS SZ 1 8 MM,SUP-2244149,CDM,C1776,CPT,0278,RC,,,,both,,,7740.10,5031.06,,,,,,,,,,,,,
PI PICC 3-LUMEN: 6FRX55CM WITH 130CM SS,SUP-2826705,CDM,C1751,HCPCS,0278,RC,,,,both,,,342.89,222.88,,,,,,,,,,,,,
IMPLANT GYN L 16 X W 6 CM ALLGRFT DERM PROC OMNI DIR STRL,SUP-2896112,CDM,C1762,CPT,0278,RC,,,,both,,,10120.22,6578.14,,,,,,,,,,,,,
SLEEVE CENTERING STEM 7 MM HUM BIO MOD,SUP-2431669,CDM,C1776,CPT,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
POSITIONER RADIOTHERAPY HYDRGEL SPCR SYN ABSRB DEL SYS,SUP-2124544,CDM,C1889,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
ENDCAP ORTH DIA12MM EXTN 5MM LAT FEM GRY TI CANN T40,SUP-2188986,CDM,C1776,CPT,0278,RC,,,,both,,,638.64,415.12,,,,,,,,,,,,,
STENT URET RESONANCE L 20 CM CATH L 71.5 CM DIA 6 FR SHTH L,SUP-2171368,CDM,C2625,HCPCS,0278,RC,,,,both,,,3830.17,2489.61,,,,,,,,,,,,,
PLATE BNE L276MM 11 H NONSTERILE R DST FEM S STL LOK COMPR,SUP-2184899,CDM,C1713,HCPCS,0278,RC,,,,both,,,4574.57,2973.47,,,,,,,,,,,,,
RHS RADIAMETERL HEAD DIAMETER 22MM,SUP-2822289,CDM,C1776,CPT,0278,RC,,,,both,,,4813.62,3128.85,,,,,,,,,,,,,
WAND ABLAT DIA3MM TIP DIA4.5MM 15DEG ANG INTEGR CBL PARAGON,SUP-2341986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
HC Iaadiadoo Influenza,PX-3068780400,CDM,87804,CPT,0306,RC,,,,outpatient,,,225.00,146.25,,,,,,,,,,,,,
CATHETER HAD ADMIN FULL KT DBL LUMN POLYUR STR SPL TIP NO,SUP-2118065,CDM,C1752,HCPCS,0278,RC,,,,both,,,613.52,398.79,,,,,,,,,,,,,
CATHETER REPROC ULTRASOUND 9 FR VIEWFLEX XTRA ICE,SUP-2763557,CDM,C1759,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 8 MM STR STD WALL HELIX,SUP-2483442,CDM,C1768,CPT,0278,RC,,,,both,,,1799.97,1169.98,,,,,,,,,,,,,
SCREW BNE L10MM DIA2MM STD TI CORT MAND CRANIOMAXILLOFACIAL,SUP-2319343,CDM,C1713,HCPCS,0278,RC,,,,both,,,107.39,69.80,,,,,,,,,,,,,
TRAY PICC CATHETER 6FR POLYUR FULL 3 LUMN NRS NONPOWER INJ,SUP-2126397,CDM,C1751,HCPCS,0278,RC,,,,both,,,596.91,387.99,,,,,,,,,,,,,
PLATE BONE SZ 2 LT TIB FIX BEAR CEM,SUP-2223477,CDM,C1713,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
PLATE BONE W10XL112MM THK1.5MM 90DEG 4X9 H BILAT S STL T SHP,SUP-2185881,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.33,1120.16,,,,,,,,,,,,,
CATHETER URET SET FIRM STAMEY OPN TIP 6FRX70CM C FLX,SUP-2139288,CDM,C1758,HCPCS,0278,RC,,,,both,,,87.54,56.90,,,,,,,,,,,,,
LEADWIRE SPNL W/ CLP,SUP-2415718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,0636,RC,00641-6282-01,NDC,,both,0.2,ML,54.10,35.16,,,,,,,,,,,,,
PIN DRL POS 2 MM,SUP-2223973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN,RX-3497,CDM,J1596,HCPCS,0636,RC,63323-0578-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER SAMPLING 16 FR MUSHRM TIP BALLARD MINI-BAL,SUP-2236603,CDM,C1757,HCPCS,0272,RC,,,,both,,,132.79,86.31,,,,,,,,,,,,,
SPECULUM NSL COTTLE 140X80 MM,SUP-2473851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.25,340.11,,,,,,,,,,,,,
NAIL IM L340MM DIA9MM 130DEG ST GRN FEM TI LOK UNREAMED AG,SUP-2192542,CDM,C1713,HCPCS,0278,RC,,,,both,,,3524.02,2290.61,,,,,,,,,,,,,
RESERVOIR CSF SM LUMPERITON TWO MTL CONN SPETZLER,SUP-2852601,CDM,C1889,HCPCS,0278,RC,,,,both,,,1109.55,721.21,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER NAV L 115 CM 4 MM D-F CRV,SUP-2248520,CDM,C1732,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
INSERT TIB THK 15 MM SZ 00 POLYETHYL RT ANK FIX XT REV STRL,SUP-2932743,CDM,C1776,CPT,0278,RC,,,,both,,,8505.16,5528.35,,,,,,,,,,,,,
SCREW BNE L6MM OD1.5MM TI ST BRNZ MATRIXMIDFACE,SUP-2181612,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
SHUNT CAR 12FR TAPR TO 9FR L15.5CM BYPS SFT SMOOTH POLISHED,SUP-2127016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.89,171.53,,,,,,,,,,,,,
BASKET STONE METALIC 2 IN UTIL,SUP-2501196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,274.91,178.69,,,,,,,,,,,,,
SCREW FIX 5.0 VAL SCREOPTILINK(TM),SUP-2715835,CDM,C1776,CPT,0278,RC,,,,both,,,570.13,370.58,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM AMNIO MEMBRN AMNIOEXCEL,SUP-2194322,CDM,Q4137,HCPCS,0636,RC,,,,both,,,6854.62,4455.50,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE L 13 CM DIL L 20 CM OD 7 FR ID 2.3,SUP-2168785,CDM,C1894,HCPCS,0272,RC,,,,both,,,123.81,80.48,,,,,,,,,,,,,
LNG BRIDGE W/23MM POSTS,SUP-2908967,CDM,C1713,HCPCS,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
PLATE BNE L12MM STP 8MM 4 H 2 REARFOOT SLOT TI DISPLC CALCNL,SUP-2243233,CDM,C1713,HCPCS,0278,RC,,,,both,,,4226.44,2747.19,,,,,,,,,,,,,
ISAVUCONAZONIUM SULFATE 186 MG PO CAPS,RX-129589,CDM,6370000000,HCPCS,0637,RC,00469-0520-02,NDC,,both,1,UN,520.90,338.58,,,,,,,,,,,,,
MESH SURG ELLIP 10X8 IN W/ FEN PORCINE COLLAMEND FM,SUP-2126254,CDM,C1781,HCPCS,0278,RC,,,,both,,,14943.20,9713.08,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM TIP 3 MM DIA 0.035 IN SS PTFE J FIX,SUP-2120078,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.44,46.44,,,,,,,,,,,,,
IMPLANT SYNTH LG PMMA CRAN CUSTOMIZED IMPL KT STRL MEDPOR,SUP-2883598,CDM,C1713,HCPCS,0278,RC,,,,both,,,52294.78,33991.61,,,,,,,,,,,,,
BALLOON STONE REM 7FR L15MM CATH L210CM DBL LUMN BILI,SUP-2149636,CDM,C1726,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE LG SHT ANK ROCKER BTM INLINE,SUP-2336133,CDM,L4361,HCPCS,0272,RC,,,,both,,,99.85,64.90,,,,,,,,,,,,,
MARKER BRST BX RIBBON 17 GAX10 CM FOR MRI TI ULTRACLIP II,SUP-2759097,CDM,A4648,CPT,0278,RC,,,,both,,,350.27,227.68,,,,,,,,,,,,,
PROSTHESIS TESTICULAR L L4.5CM DIA2.9CM SIL ELASTMR SHELL,SUP-2165304,CDM,C1889,HCPCS,0278,RC,,,,both,,,7542.28,4902.48,,,,,,,,,,,,,
HC So2 Drvvt,PX-3058561368,CDM,85613,CPT,0305,RC,,,,both,,,13.00,8.45,,,,,,,,,,,,,
GUIDEPIN ORTH L300MM DIA1.9MM CO CHROM FULL THRD,SUP-2343574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.95,213.82,,,,,,,,,,,,,
MESH BONE 45MML MODIFIED LATEX FREE MID FACE BODY,SUP-2677342,CDM,C1713,HCPCS,0278,RC,,,,both,,,7900.96,5135.62,,,,,,,,,,,,,
CATHETER EP D CRV 2-5-2 MM 6 FRX115 CM,SUP-2303653,CDM,C1733,HCPCS,0272,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
PEG BNE FIX L22MM DIA2.5MM FULL THRD FOR ALPS HND FRAC SYS,SUP-2414066,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
STENT BILI L80MM 7FR 120CM CATH LEN 6MM DIAM AD SUPERA,SUP-2241759,CDM,C1876,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
SYSTEM KYPHOPLASTY 15MM BALL UNIPEDICULAR ZVPLASTY,SUP-2402388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SPACER HIP L150MM HD 54MM S STL 1 PC CEM GNTMYCN POLY METH,SUP-2223675,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,J7611,HCPCS,0636,RC,00378-8270-31,NDC,,both,3,ML,2.70,1.75,,,,,,,,,,,,,
REFILL KIT 4.5 CC NANO TECHNOLOGY ADH PRIM,SUP-2176752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
PLATE BNE GENIOPLASTY 2X10 MM TI,SUP-2457619,CDM,C1713,HCPCS,0278,RC,,,,both,,,666.53,433.24,,,,,,,,,,,,,
REAMER SURG CUP SET X-REAM,SUP-2401423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
ALBENDAZOLE 200 MG PO TABS,RX-8979,CDM,6370000000,HCPCS,0637,RC,00591-2712-02,NDC,,both,1,UN,435.80,283.27,,,,,,,,,,,,,
K WIRE FIX L229MM DIA1.1MM STYL 7 S STL DBL DMND PNT,SUP-2409634,CDM,C1713,HCPCS,0278,RC,,,,both,,,22.07,14.35,,,,,,,,,,,,,
KIT INTRO VAXCEL MINI-STICK SHTH 15 CM 5 FR SS PLAT TIP,SUP-2118968,CDM,C1894,HCPCS,0272,RC,,,,both,,,12.09,7.86,,,,,,,,,,,,,
SCREW BNE PART THRD 80 5 MM PANTA,SUP-2422233,CDM,C1713,HCPCS,0278,RC,,,,both,,,1770.52,1150.84,,,,,,,,,,,,,
K WIRE FIX L6IN DIA1.6MM FEM TIB SMOOTH BAYNT TOT FT FOR,SUP-2412144,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.90,53.88,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE L 80 CM OD 8 FR GUIDEWIRE 0.038 IN,SUP-2633276,CDM,C1894,HCPCS,0272,RC,,,,both,,,503.94,327.56,,,,,,,,,,,,,
CLAMP SURG ROD TO ROD 18 MM ASMBLY REVERE,SUP-2584887,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX5 CM BLLN BUTTON MINI1,SUP-2754597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.01,363.36,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH L 100 CM H1 TIP XTORQ,SUP-2865169,CDM,C1757,HCPCS,0272,RC,,,,both,,,30301.00,19695.65,,,,,,,,,,,,,
BIT DRL 5.5MM CANN CNTRSNK,SUP-2315875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
STEM HIP SZ 2 STD OFFSET PROS ZZ ENDUR,SUP-2251938,CDM,C1776,CPT,0278,RC,,,,both,,,9219.04,5992.38,,,,,,,,,,,,,
BUR 17MM PREC NEURO MTCH HD,SUP-2367604,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GRAFT HUM TISS SAPH VEIN DONOR,SUP-2175269,CDM,C1768,CPT,0278,RC,,,,both,,,24806.00,16123.90,,,,,,,,,,,,,
GUIDEWIRE AMPLATZ SUP STIFF PTFE COAT 0035 IN X 145CM J TIP,SUP-2141746,CDM,C1769,HCPCS,0272,RC,,,,both,,,99.13,64.43,,,,,,,,,,,,,
FILTER VASC DENALI SHTH L 55 CM VENA CAVA KT EMB JUG SUBCLAV,SUP-2126819,CDM,C1880,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
KIT INTRO MAK L 15 CM DIA 5 FR COAX DIL PR STRL,SUP-2303014,CDM,C1894,HCPCS,0272,RC,,,,both,,,64.68,42.04,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X116 MM RT POST LAT DSTL 6 HOLE SS,SUP-2184152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1756.74,1141.88,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 20 CM DIA 4-7 MM EPTFE CARBON STP N,SUP-2128780,CDM,L8670,HCPCS,0278,RC,,,,both,,,5391.35,3504.38,,,,,,,,,,,,,
PLATE BNE SM MED LT MTP STRL ORTHOLOC 3DI,SUP-2900604,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
HC So Carotene,PX-3018238066,CDM,82380,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
SCREW BONE L60MM DIA3.5MM CORT S STL ST FOR SM PLATING SYS,SUP-2349360,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.21,113.24,,,,,,,,,,,,,
INSERT TIB L87/91MM THK10MM UNIV STD KNEE PRI POST STBL NEUT,SUP-2407098,CDM,C1776,CPT,0278,RC,,,,both,,,4688.02,3047.21,,,,,,,,,,,,,
TRAY PERCUTANEOUS INTRODUCE BL RHINO,SUP-2525924,CDM,C1769,HCPCS,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 7 MM EPTFE STR TW N RING STRL,SUP-2396703,CDM,C1768,CPT,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
ALLOGRAFT BNE PROX TIB FRZN W/ TUBEROSITY RT,SUP-2717965,CDM,C1762,CPT,0278,RC,,,,both,,,13991.84,9094.70,,,,,,,,,,,,,
STIMULATOR NERVE 47X17 MM BLDR BWL RECHRG INTERSTIM,SUP-2550569,CDM,C1820,HCPCS,0278,RC,,,,both,,,35011.00,22757.15,,,,,,,,,,,,,
FLAVOXATE HCL 100 MG PO TABS,RX-10039,CDM,6370000000,HCPCS,0637,RC,00574-0115-01,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
SODIUM POLYSTYRENE SULFONATE PO POWD,RX-7356,CDM,6370000000,HCPCS,0637,RC,11534-0166-16,NDC,,both,15,GR,56.30,36.59,,,,,,,,,,,,,
PLATE BONE RT ANTR ANK FUS SLIM ALIGNX,SUP-2417727,CDM,C1713,HCPCS,0278,RC,,,,both,,,7287.94,4737.16,,,,,,,,,,,,,
HOOK RETRCT GREENBERG STRL DISP BRAINPATH SHEPHARD'S,SUP-2930207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.05,279.53,,,,,,,,,,,,,
BEARING TIB THK20MM 71/75MM KNEE ARCM POST STBL CONSTRN REV,SUP-2407734,CDM,C1776,CPT,0278,RC,,,,both,,,4973.76,3232.94,,,,,,,,,,,,,
HC Leukopoor Plt Pher,PX-3900903500,CDM,P9035,CPT,0390,RC,,,,both,,,2210.00,1436.50,,,,,,,,,,,,,
PIN BONE FIX L50MM OD4MM LACTOSORB L15 BIOABSRB ACL,SUP-2212876,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FLUID 0.5 CC AMNIO MEMBRN PROVENDA FLO,SUP-2762321,CDM,C1762,CPT,0278,RC,,,,both,,,5375.68,3494.19,,,,,,,,,,,,,
SCREW BNE 9 MM CANN STRL GAITWAY,SUP-2487986,CDM,C1713,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
HC Demo/Eval Aer Neb Mdi Ippb,PX-4109466400,CDM,94664,CPT,0410,RC,,,,both,,,660.00,429.00,,,,,,,,,,,,,
MARKER SM18-1-20 MAGSEED-18G-20CM,SUP-2902928,CDM,A4648,CPT,0278,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
COMPONENT TIB TY SZ 3 STD POLYETH R ANK NONCOATED PRI,SUP-2397115,CDM,C1776,CPT,0278,RC,,,,both,,,3771.14,2451.24,,,,,,,,,,,,,
CATHETER NEPHSTMY 8FR L25CM PERCFLX GLDEX PGTL TIP RADPQ,SUP-2147785,CDM,C1729,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
COUNTERSINK DRL DIA7MM BLU,SUP-2400359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
KIT BNE CEM PREP FEM QUIK-USE EACH ONLY,SUP-2199467,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
MARKER RAD KNURLED PLCMNT NDL STRL GLDN L3MM L20CM OD.9MM,SUP-2418125,CDM,A4648,CPT,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
PLATE BNE L85MM THK1.3MM 100DEG 7 H TI TBLR FOR 3.5MM SCR,SUP-2412037,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
TIP IRR ASPIR 180 DEG 16GA,SUP-2391892,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
CATHETER INFUSION CLEARWAY BALLOON L 10 MM DIA1 MM PERIPH,SUP-2227350,CDM,C1725,HCPCS,0272,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
CATHETER ETER ANGIO 14FR 12CM SCHON XL,SUP-2118061,CDM,C1752,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTEROLATERAL DISTAL HUMERUS 3H LEFT,SUP-2549677,CDM,C1713,HCPCS,0278,RC,,,,both,,,2958.48,1923.01,,,,,,,,,,,,,
BONE SCREW 2.7MMX12MM,SUP-2841622,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BNE SIDE 135 DEG STD BRL 38 MM HIP 2 HOLE TALON,SUP-2391521,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.04,770.28,,,,,,,,,,,,,
HC M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual,PX-3128836000,CDM,88360,CPT,0312,RC,,,,both,,,371.00,241.15,,,,,,,,,,,,,
KIT NEUROVISION EMG HERNESS 8010016,SUP-2311742,CDM,C1713,HCPCS,0278,RC,,,,both,,,4681.74,3043.13,,,,,,,,,,,,,
CAGE SPNL BULLETED 10 DEG 50X22X9 MM COROENT XLW,SUP-2557538,CDM,C1889,HCPCS,0278,RC,,,,both,,,13982.42,9088.57,,,,,,,,,,,,,
PLATE BNE L 186 MM SCREW DIA 3.5/4.5 MM 6 H RT TROCHANTERIC 72586206,SUP-2933283,CDM,C1713,HCPCS,0278,RC,,,,both,,,20896.70,13582.85,,,,,,,,,,,,,
CATHETER NEPHSTMY 10FR L19.5CM CANN COPE LOOP,SUP-2167498,CDM,C1729,HCPCS,0272,RC,,,,both,,,422.96,274.92,,,,,,,,,,,,,
TRAY CRANIOFIX 2 CRAN REP,SUP-2370392,CDM,C1713,HCPCS,0278,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
SHUNT VENTRICULOPERTIONEAL 7FR 90CM M ULT SM W SNAP RESVR,SUP-2278383,CDM,C1889,HCPCS,0278,RC,,,,both,,,2901.83,1886.19,,,,,,,,,,,,,
REAMER LAG SCR LNG 32MM FOR CEPHALOMEDULLARY NAT NAIL SYS,SUP-2198640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1511.03,982.17,,,,,,,,,,,,,
CATHETER GUID UPSIZED WIDE 47 CM CPS DIR SL II,SUP-2356376,CDM,C1893,HCPCS,0272,RC,,,,both,,,553.90,360.03,,,,,,,,,,,,,
GRAFT DERMAL 10X5 CM PORCINE DERMAL CLLGN REINF MTRX STRL,SUP-2852967,CDM,C1763,HCPCS,0278,RC,,,,both,,,9591.88,6234.72,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN TIP L 3 MM PTFE HEPARIN,SUP-2301942,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.91,16.84,,,,,,,,,,,,,
GRAFT ENDOVASC L110MM DIA13MM IL VIABAHN,SUP-2396471,CDM,C1874,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BEARING TIBIAL STAR UHMWPE H8 MM ANKLE SLIDE CORE,SUP-2880136,CDM,C1776,CPT,0278,RC,,,,both,,,6421.61,4174.05,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY OPTMA + L 110 CM DIA 7 FR,SUP-2102281,CDM,C1731,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
DEVICE FIX RND DBL 2 HOLE W/ POST SST STRL ENDOBUTTON LTX,SUP-2877810,CDM,C1713,HCPCS,0278,RC,,,,both,,,964.36,626.83,,,,,,,,,,,,,
FLUCONAZOLE (DIFLUCAN) IVPB|DISCARDED DRUG NOT ADMINISTE,RX-4081084,CDM,J1450,HCPCS,0636,RC,25021-0184-82,NDC,JW,both,50,ML,54.10,35.16,,,,,,,,,,,,,
HC Alkaline Phosphatase,PX-3018407500,CDM,84075,CPT,0301,RC,,,,outpatient,,,161.00,104.65,,,,,,,,,,,,,
SPLINT ORTHOPEDIC MED LT MTCRPL,SUP-2124892,CDM,L3808,HCPCS,0274,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT MAXBARR 5FR 0.026IN 45CM 2 9827508D,SUP-2632710,CDM,C1751,HCPCS,0278,RC,,,,both,,,787.98,512.19,,,,,,,,,,,,,
ANCHOR SUT 1MM W/ 3-0 SUT AND NDL AND DRL MINI SFT,SUP-2212961,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.23,945.90,,,,,,,,,,,,,
OXYCODONE HCL 100 MG/5ML PO CONC,RX-10812,CDM,340b,HCPCS,0637,RC,09999-9900-24,NDC,,both,0.25,ML,2.70,1.75,,,,,,,,,,,,,
BIT DRL L58MM DIA1.9MM FOR 0.2MM SCR REUSE,SUP-2365241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
BARRIER ADH W2.5XL3IN 4 SECT USED IN PT UNDERGOING ABD OR,SUP-2227076,CDM,C1765,HCPCS,0278,RC,,,,both,,,1259.67,818.79,,,,,,,,,,,,,
HFN IN CAP FLUSH IMPINGING STER,SUP-2588691,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.95,371.77,,,,,,,,,,,,,
BASEPLATE TIB SZ 5 FLUT NXGN,SUP-2200849,CDM,C1776,CPT,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
CATHETER EMB 4FR 0.75ML LIQCAP 1.7ML GASCP L40CM DIA9MM 5FR,SUP-2213997,CDM,C1757,HCPCS,0272,RC,,,,both,,,221.50,143.97,,,,,,,,,,,,,
IMPLANT WRIST JOINT SIZE 20 SM CARPOMETACARPAL NUGRIP,SUP-2586708,CDM,C1776,CPT,0278,RC,,,,both,,,7501.37,4875.89,,,,,,,,,,,,,
BIT DRL L100MM DIA2MM 3 FLUT QUIK CPL FOR OSC DRL ATTCH,SUP-2187578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,306.34,199.12,,,,,,,,,,,,,
GRAFT BNE FIX LNG 2.5X6.5 MM PROX,SUP-2430101,CDM,C1713,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
SCREW BNE CANN 6.5X85 MM 16 MM THRD AXSOS 3,SUP-2613625,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
BINDER BRST SM,SUP-2223739,CDM,L4386,HCPCS,0274,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
LAT TIB HEAD BUTT PLT STERILIZER 7HL 149 MM LT,SUP-2820745,CDM,C1713,HCPCS,0278,RC,,,,both,,,5436.75,3533.89,,,,,,,,,,,,,
PROBE MICROWAVE ABLATION L 35 CM DIA11-13 GA CABLE L 2.9 M,SUP-2908899,CDM,C1886,HCPCS,0278,RC,,,,both,,,10785.90,7010.83,,,,,,,,,,,,,
CATHETER HD 55 CM GLD DECATHLON,SUP-2165201,CDM,C1750,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
SCREW INTFR DIA9.5-11MM POLY LACTIC ACID DELT TAPR CANN BIO,SUP-2121918,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
SCREW BNE CANN 6.5X50 MM COMPR HDLSS,SUP-2609998,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
IMPLANT FACE L 40 X W 40 MM THK 0.73 MM THK 2.5 MM LG,SUP-2883493,CDM,C1713,HCPCS,0278,RC,,,,both,,,2130.62,1384.90,,,,,,,,,,,,,
CUSTOM KT PTCA INFL DEV K05 00052M,SUP-2302817,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.83,151.34,,,,,,,,,,,,,
ANCHOR SUTURE 2 NDL THRD TWINFIX,SUP-2848585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.11,750.82,,,,,,,,,,,,,
STENT VASC L150MM DIA6MM CATH L130CM SHTH 6FR DRUG ELUT,SUP-2853968,CDM,C1874,HCPCS,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
HC Ablate Bone Tumor(S) Perq,PX-3612098300,CDM,20983,CPT,0361,RC,,,,inpatient,,,10314.00,6704.10,,,,,,,,,,,,,
INJECTOR UTER AIR BUB BASE W/ H/S ELLIPTOSPHERE CATH ABBI,SUP-2756089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,330.83,215.04,,,,,,,,,,,,,
COLLAR CERV AND PD SET CAPITAL ENH,SUP-2336001,CDM,L0174,HCPCS,0274,RC,,,,both,,,112.88,73.37,,,,,,,,,,,,,
POR ST/OSS CP/LG E1 LN/LG HD,SUP-2212416,CDM,C1776,CPT,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
HC Unlisted Proc Urinary System,PX-3615389900,CDM,53899,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
WIRE PACE MYO/WIRE II SS DBL FOR STERNOTOMY CLOSURE 4 PER,SUP-2101198,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.47,51.66,,,,,,,,,,,,,
PLATE BNE L 177 MM SCREW DIA2.4 MM 20 SHFT H TI ADPT COMB,SUP-2907791,CDM,C1713,HCPCS,0278,RC,,,,both,,,3883.87,2524.52,,,,,,,,,,,,,
CATHETER ABLATION L 117 CM DIA 4 FR TIP DIA19 MM GUIDE CATH,SUP-2914757,CDM,C1735,HCPCS,0272,RC,,,,both,,,49235.20,32002.88,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 40 CM DIA 8 MM THK 0.35 MM POLYESTER,SUP-2493733,CDM,C1768,CPT,0278,RC,,,,both,,,1612.17,1047.91,,,,,,,,,,,,,
COMPONENT ARTC SURF PS 10-11 EF 14 MM LT TIB KNEE FIX BEAR,SUP-2206670,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE FUS INTCARP 2.4MM 7H 17MM SS VAL STRL,SUP-2546045,CDM,C1713,HCPCS,0278,RC,,,,both,,,3437.58,2234.43,,,,,,,,,,,,,
HC L Heart W Lvgram,PX-4819345200,CDM,93452,CPT,0481,RC,,,,inpatient,,,7469.00,4854.85,,,,,,,,,,,,,
PLATE BNE SIDE L 36 X W 36 MM THK 0.5 MM SCREW DIA1.7 MM PLL,SUP-2883147,CDM,C1713,HCPCS,0278,RC,,,,both,,,2914.36,1894.33,,,,,,,,,,,,,
KIT INTRO OSCOR DIA10 FR PEELWY STRL,SUP-2148777,CDM,C1892,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
HC Removal of Foreign Body Simple,PX-4502052000,CDM,20520,CPT,0450,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
PLATE BONE 17 H STR PROF TEMPLT,SUP-2365251,CDM,C1713,HCPCS,0278,RC,,,,both,,,8608.06,5595.24,,,,,,,,,,,,,
TI T-BUTTRESS PLATE 5 HOLES/96MM,SUP-2549655,CDM,C1713,HCPCS,0278,RC,,,,both,,,2005.64,1303.67,,,,,,,,,,,,,
DISC SHIM LENGTHENING FOR MARS 3V SYS,SUP-2232224,CDM,C1776,CPT,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
PLATE BNE L97MM THK3.3MM 8 H BILAT S STL RIG STR DYN COMPR,SUP-2186332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.58,665.98,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 4.5X190 CM APL32C 3LUMEN,SUP-2126017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SCREW BNE ST 2.4X70 MM CRTX T8 STARDRV RECESS SS NS,SUP-2750877,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.86,113.01,,,,,,,,,,,,,
VALVE VENT PUR TRACH TBNG SWALLOING LO PROF DISP PASSY MUIR,SUP-2322024,CDM,L8501,HCPCS,0274,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
PRISMASATE B22GK 4/0 DIALYSIS SOLUTION,RX-40840083,CDM,2580000003,HCPCS,0250,RC,09999-9999-45,NDC,,both,5000,ML,103.50,67.27,,,,,,,,,,,,,
CLAMP SPNL 55MM UNIV TI ALLY,SUP-2416028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
ROSUVASTATIN CALCIUM 10 MG PO TABS,RX-35134,CDM,6370000000,HCPCS,0637,RC,50268-0709-11,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS GLD L 80 CM BALLOON L 4 CM DIA24 MM,SUP-2127963,CDM,C1725,HCPCS,0272,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
SET SCR 5.5MM,SUP-2256299,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.89,529.03,,,,,,,,,,,,,
HOLE PIN CLAMP 2 POSTS STRAIGHT DIA 456MM,SUP-2701731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
BOOT CAST XL L13.5IN TOE W6IN BLK CANVS NONSLIP ROCK SOLE,SUP-2196785,CDM,L4631,HCPCS,0272,RC,,,,both,,,14.85,9.65,,,,,,,,,,,,,
GUIDE NERVE 2.3X40 MM GEM ABSORBABLE MESH SYNOVIS NEUROTUBE,SUP-2382608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
ALLOGRAFT BNE 60 MM PRESERVON FIBULAR SHFT MATRIGRAFT,SUP-2740902,CDM,C1762,CPT,0278,RC,,,,both,,,1717.49,1116.37,,,,,,,,,,,,,
COUNTERSINK SURG DRL CANN 2/2.4 MM SCREW,SUP-2319445,CDM,C1713,HCPCS,0278,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
MESH HERN 28X18 CMX1.5 MM HYDRATED PORCINE CLLGN PERMACOL,SUP-2174702,CDM,C1781,HCPCS,0278,RC,,,,both,,,38133.82,24786.98,,,,,,,,,,,,,
PROBE ARTHROSCOPIC 50DEG ENERGY WITH SUCTION,SUP-2824212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.95,358.77,,,,,,,,,,,,,
HC Bladder Irrig Simple or Continuous,PX-7615170000,CDM,51700,CPT,0761,RC,,,,both,,,935.00,607.75,,,,,,,,,,,,,
GRAFT BNE 5MMX100MM CORT MTCH STK FEM FRZ DRY ALLGRFT,SUP-2264710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1106.07,718.95,,,,,,,,,,,,,
PLATE BONE W50XL85MM THK0.2MM MH TI SH FOR 1.5MM SCR LORENZ,SUP-2402908,CDM,C1781,HCPCS,0278,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
BRACE KNEE XL L17 27IN FOR 355IN THGH UNIV POSTOP TELSCP,SUP-2151049,CDM,L1832,HCPCS,0274,RC,,,,both,,,294.69,191.55,,,,,,,,,,,,,
PLATE BNE L112MM WRST S STL STR LOK COMPR FOR FUS LCP,SUP-2177230,CDM,C1713,HCPCS,0278,RC,,,,both,,,4601.23,2990.80,,,,,,,,,,,,,
WIRE EXT FIX BUCKLES FOR USE W/ COMP RING ILIZ,SUP-2342267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1937.13,1259.13,,,,,,,,,,,,,
KIT CAGE SPINAL APREVO 1-LEVEL,SUP-2912822,CDM,C1889,HCPCS,0278,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
STAPLE CARTRIDGE LINE-REINFORCEMENT STRP VERIT,SUP-2130371,CDM,C1713,HCPCS,0278,RC,,,,both,,,521.99,339.29,,,,,,,,,,,,,
BUTTON RIGIDLOOP XL,SUP-2749357,CDM,C1713,HCPCS,0278,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
PLUG VASC L18.4MM VES DIA5-7MM PERIPH NIT PTFE MIC,SUP-2281188,CDM,C1884,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
IMPLANT OPHTH 22X285MM RETIN SL SCLER BCKL SIL STYL 70,SUP-2129438,CDM,C1784,HCPCS,0278,RC,,,,both,,,17.05,11.08,,,,,,,,,,,,,
NAIL IM ELASTIC 2X440 MM TI GRN NS,SUP-2192725,CDM,C1713,HCPCS,0278,RC,,,,both,,,765.12,497.33,,,,,,,,,,,,,
COUNTERSINK DRL S STL QUIK CONN FOR 27MM SCR,SUP-2199213,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
EXTRACTOR BILI STONE 7FR TAPR TO 5FR CATH L200CM DIA8.5MM,SUP-2149631,CDM,C1726,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
PLATE BNE 16 H ST BILAT S STL NAR CRV LOK COMPR FOR 45MM SCR,SUP-2178062,CDM,C1713,HCPCS,0278,RC,,,,both,,,3210.05,2086.53,,,,,,,,,,,,,
SCREW BNE L95MM DIA10.5MM TI U BLDE LAG GAM 3,SUP-2370429,CDM,C1713,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
DRILL SURG CANN 2 MM FUSION MANUAL NS HPS LTX,SUP-2855998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
IMPLANT FACE L 59 X W 29 MM THK 7 MM D 11 MM POLYETHYL RT,SUP-2883141,CDM,C1713,HCPCS,0278,RC,,,,both,,,2004.04,1302.63,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.4MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189411,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.34,156.87,,,,,,,,,,,,,
BEARING HUM DIA44-41MM +3MM OFFSET ARCOMXL FOR COMPHSVE REV,SUP-2409557,CDM,C1776,CPT,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
HC Relocation Pg Wcs Lv Pacg Transmittr Compnt Only,PX-4810863000,CDM,0863T,CPT,0481,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
NAIL ELASTIC SS 4.0MM 440MM,SUP-2547602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1016.73,660.87,,,,,,,,,,,,,
CATHETER EP DIAG MAP D CRV QPLR 5MM SPC 5MM TIP UNI DIR RF,SUP-2356794,CDM,C1730,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GUIDE SURG GLEN CT AND BNE MOD L SIGN,SUP-2403463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.8 MM THOR 6 HOLE LCK BODY NS LEVEL 1,SUP-2869221,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.87,1147.17,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 10ML DBM PTTY ST IMPL DYNAGRFT II,SUP-2242679,CDM,C9359,HCPCS,0278,RC,,,,both,,,2875.74,1869.23,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|KX|CO|XU,both,,,144.00,93.60,,,,,,,,,,,,,
POLARUS 3 NAIL TARGETING LOCKING BOLT,SUP-2639742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1613.96,1049.07,,,,,,,,,,,,,
SYSTEM CHARGING AC PWR SUPL RECHARGER ANT SHLDR BELT RC,SUP-2284469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
PLATE STRNL CLOSURE TI STR NS STERNALOCK BLU,SUP-2894549,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
PLATE BNE RADIAL 2.4X45 MM RT VOLAR CLMN DSTL 6X3 HOLE LCK,SUP-2177235,CDM,C1713,HCPCS,0278,RC,,,,both,,,2579.60,1676.74,,,,,,,,,,,,,
DEVICE TRACTION DGT TRAP HANDSTAND DISP,SUP-2846768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
HC NM Brain With Flow,PX-3417860600,CDM,78606,CPT,0341,RC,,,,outpatient,,,2873.00,1867.45,,,,,,,,,,,,,
DISTAL RADIAL DORSAL T PLATE JIG LEFT,SUP-2723173,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.18,484.37,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PATELLAR UPCHARGE MTL BK,SUP-2212688,CDM,C1776,CPT,0278,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
CATHETER ANGIOPLSTY IMPACT L 75 CM SHFT 6 FR BALLOON L 4 CM,SUP-2124915,CDM,C1725,HCPCS,0272,RC,,,,both,,,989.89,643.43,,,,,,,,,,,,,
KIT INTRO PEELPRO L 14 CM DIA12 FR PTFE TEARWY STD,SUP-2118933,CDM,C1894,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
DEVICE EXT FIX DISTRCTN 25 MM COMPR RED,SUP-2461623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2749.07,1786.90,,,,,,,,,,,,,
PROSTHESIS OSS STAP 4.5 MM 0.5 MM ECLIPSE FLAT RIBBON NIT,SUP-2466541,CDM,L8613,CPT,0278,RC,,,,both,,,1051.27,683.33,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7050,HCPCS,0250,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 100 CM DIA 5 FR DIA1.12 MM JB1,SUP-2385531,CDM,C1887,HCPCS,0272,RC,,,,both,,,164.85,107.15,,,,,,,,,,,,,
RING EXT FIX 160MM 5/8 CIR FRDM,SUP-2400648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
SCREW BNE L90MM DIA12.7MM THRD L21MM STD IM HIP CANN LAG,SUP-2342399,CDM,C1713,HCPCS,0278,RC,,,,both,,,2308.72,1500.67,,,,,,,,,,,,,
SCREW CANN 32MM THRD 5.5X150MM,SUP-2665195,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.83,385.34,,,,,,,,,,,,,
PLATE BNE FIBULAR RT LAT 11 HOLE GLD,SUP-2865046,CDM,C1713,HCPCS,0278,RC,,,,both,,,4656.62,3026.80,,,,,,,,,,,,,
LEAD NERVE STIM PNE,SUP-2568745,CDM,C1778,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
INTRODUCER SHTH L66CM DIA55FR RENAL TELSCP WORLEY ADV LVI,SUP-2303516,CDM,C1892,HCPCS,0272,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
CABLE FBROPT SGL USE VEOA VEO,SUP-2164088,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC Herpes Virus-6 Direct Probe,PX-3018753200,CDM,87532,CPT,0301,RC,,,,both,,,89.00,57.85,,,,,,,,,,,,,
DEVICE FEED G-JET 14F X 1.2CM X 22CM LP TRANSGASTRIC-JEJUNAL,SUP-2849683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
RETRIEVER STENT 8.5FR L180CM 0.035IN 3.2 CHAN PUR FOR SOEH,SUP-2169123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
HC Cardioversion,PX-4809296000,CDM,92960,CPT,0480,RC,,,,both,,,1401.00,910.65,,,,,,,,,,,,,
COMPONENT TIB SZ 1 AP40MM ML58MM MIC KNEE PURPLE/STRIPPED,SUP-2201515,CDM,C1776,CPT,0278,RC,,,,both,,,8878.35,5770.93,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 50 CM DIA 6 MM EPTFE STR TW STRL,SUP-2227654,CDM,C1768,CPT,0278,RC,,,,both,,,1560.27,1014.18,,,,,,,,,,,,,
HEAD HUM DIA19MM +2MM NK CO CHROM MOLYBDENUM STD OFFSET PRI,SUP-2351217,CDM,C1776,CPT,0278,RC,,,,both,,,3414.75,2219.59,,,,,,,,,,,,,
PLATE BNE L128MM 8 H L LAT PROX PERIARTC TIB S STL LOK COMPR,SUP-2198431,CDM,C1713,HCPCS,0278,RC,,,,both,,,3891.40,2529.41,,,,,,,,,,,,,
CAGE SPNL 13 MM POST LUMBAR IF PEEK,SUP-2194085,CDM,C1889,HCPCS,0278,RC,,,,both,,,18130.36,11784.73,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4X2 H L HND NONCOMPRESSION GRID FOR,SUP-2267894,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.02,478.41,,,,,,,,,,,,,
HEAD FEM CO CHROM W/ ALL POLY TIB INSRT JOURNEY UNI,SUP-2347997,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
HYSTEROSCOPE SHTH 1 PC DSGN 5MM,SUP-2261124,CDM,C1894,HCPCS,0272,RC,,,,both,,,4666.98,3033.54,,,,,,,,,,,,,
NEEDLE VENTRICULAR CONE 17 GAX3.5 IN 2 HOLE LUER LCK HUB,SUP-2666367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.51,320.13,,,,,,,,,,,,,
GRAFT HUM TISS BURN 5X5 CM MESHED CYTAL,SUP-2106462,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
STEM HUM 12 TI SHLDR UNCEMENTED FLUT,SUP-2204814,CDM,C1776,CPT,0278,RC,,,,both,,,13907.06,9039.59,,,,,,,,,,,,,
BLADE SAW SAG 9.5MMW X13.5MML 0.4MM/0.6MM THK CUT SM BNE 70D,SUP-2605378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,81.29,52.84,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-3612060400,CDM,20604,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40 CM DIA16 X 9 MM POLYESTER BOV,SUP-2474289,CDM,C1768,CPT,0278,RC,,,,both,,,2570.75,1670.99,,,,,,,,,,,,,
PLATE BNE 4 H LAPIDUS FT SLIM SLOTLOCK TECHNOLOGY,SUP-2883769,CDM,C1713,HCPCS,0278,RC,,,,both,,,5174.72,3363.57,,,,,,,,,,,,,
MATRIX BIO L 7 X W 20 CM FISH SKIN DERMAL STD INTACT STRL SINGLE,SUP-2909433,CDM,Q4158,HCPCS,0636,RC,,,,both,,,19565.34,12717.47,,,,,,,,,,,,,
TRAY CATH PICC Q CATH BSC 2FR 30CM 1 LUMAN W/EXCLBR INTRO FL,SUP-2613411,CDM,C1751,HCPCS,0278,RC,,,,both,,,154.80,100.62,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 15X100 MM FD TIB MATRIGRAFT,SUP-2740782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.67,946.19,,,,,,,,,,,,,
PLUNGER DRVR ASMBLY FOR ACUTRK 2 SCR SYS,SUP-2107357,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
ANCHOR SUT LABRUM KNOTLESS WHT LABRALOCK P + W/ INSRTR HNDL,SUP-2342084,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
ROD EXT FIX EL HNG JT,SUP-2188628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3779.78,2456.86,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ACHILLES TEND FRZN W/ BNE NO-RAD,SUP-2321828,CDM,C1762,CPT,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
SONICWELD RX STERILE SONICPIN RXG 21 X 4 MM PLLA PGA,SUP-2681199,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.47,186.86,,,,,,,,,,,,,
SCREW BONE L10MM OD2.6MM TI REDUC FOR TOT COMPR PLT,SUP-2396927,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137274,CDM,J2590,HCPCS,0636,RC,09999-9900-87,NDC,,both,500,ML,66.20,43.03,,,,,,,,,,,,,
WIRE K LANC 1.6X150 MM,SUP-2267996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
SPHERE EMB HYDROPEARL DIA 600 UM 2 ML PEG BIOCOMPATIBLE RED,SUP-2385597,CDM,C1889,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
MESH HERN COMP 20X15 CM MONOFILAMENT EZ TO USE PARIETENE DS,SUP-2752203,CDM,C1781,HCPCS,0278,RC,,,,both,,,10035.31,6522.95,,,,,,,,,,,,,
BLADE SHAVER DIA 3.5 MM 2 EDGE STRL DISP CROSSBLADE,SUP-2908772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
CARTRIDGE KYPHOPLASTY SZ 3 FULL DOSE BNE CEM RADPQ GUN AND,SUP-2293467,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
TROCAR SURG SH ENTRY PORTAL VERSANAIL,SUP-2412760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
TUBE CJ TT ORIG W/ 15MM ADPT SZ 6,SUP-2384437,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
GUIDEWIRE VASC AQUALINER 260CM 0.038IN TIP 3CM STR STIFF,SUP-2117149,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 74 CM DIA 8.5 FR CRV L 16.4 CM,SUP-2677051,CDM,C1893,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCREW BONE L40MM OD3.5MM FT ANK TI NONLOCKING,SUP-2321029,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
GLUCAGON EMERGENCY 1 MG/ML IJ SOLR,RX-148605,CDM,J1611,HCPCS,0636,RC,63323-0582-82,NDC,,both,1,UN,1608.90,1045.78,,,,,,,,,,,,,
ROD SPNL L50MM DYN STBL SYS DYNESYS,SUP-2414279,CDM,C1713,HCPCS,0278,RC,,,,both,,,7571.33,4921.36,,,,,,,,,,,,,
SAW SURG CAPTURE 0.050 IN W/ HNDL N-K II MIS,SUP-2449237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
NAIL IM HUM 7 MMX30 CM NS LTX DISP,SUP-2861165,CDM,C1713,HCPCS,0278,RC,,,,both,,,4812.49,3128.12,,,,,,,,,,,,,
HC So Amoebic Antibodies by Iha,PX-3028675366,CDM,86753,CPT,0302,RC,,,,both,,,129.00,83.85,,,,,,,,,,,,,
BLADE RTRCTR CHRNLEY LNG 1NW X 6 34NL X 4IND FINTL INCSN J,SUP-2700975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.13,255.53,,,,,,,,,,,,,
SCREW SPNL L35MM DIA5.5MM CANC TI MULTAXL ST REDUC EXT ARRY,SUP-2137269,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.5MM CORT WRST TI HEXADRIVE 7 TRILOK,SUP-2268228,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.53,353.29,,,,,,,,,,,,,
VALVE AORT SZ 21MM MECH ROT POLY FLX CUF MSTR SER HP,SUP-2355087,CDM,C1889,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
MESH CRAN L 23.6 X W 13.2 CM THK 0.07 CM SZ 2 MM TI NS DISP,SUP-2935627,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,0636,RC,00338-0704-34,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
PASSER SUT W/ HK FLEX REUSE EXPRESSEW III,SUP-2256621,CDM,C1713,HCPCS,0278,RC,,,,both,,,22595.44,14687.04,,,,,,,,,,,,,
PACEMAKER CARD ALTRUA 40 W 42 X H 44 MM THK 8 MM 25.4 GM 2,SUP-2149275,CDM,C1785,HCPCS,0275,RC,,,,both,,,17995.34,11696.97,,,,,,,,,,,,,
PEG KIT LP 24 FRX4.4 CM PUSH W/ ENFIT 1 STP BUTTON ENDOVIVE,SUP-2463811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 15X6 CM MATRISTEM,SUP-2106509,CDM,Q4166,HCPCS,0636,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
"HC So Fecal Fat, Qualitative",PX-3018270566,CDM,82705,CPT,0301,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
SCREW BNE LAG 2.3X36 MM TI,SUP-2468650,CDM,C1713,HCPCS,0278,RC,,,,both,,,253.27,164.63,,,,,,,,,,,,,
TI MATRIXMANDIBLE 20H PLATE,SUP-2827977,CDM,C1713,HCPCS,0278,RC,,,,both,,,4400.40,2860.26,,,,,,,,,,,,,
BLADE SURG TREPHINE 10.8 MM,SUP-2363353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,294.19,191.22,,,,,,,,,,,,,
SPACER SPNL 10X25/28MM 6DEG SELF EXP INTBDY FUS ELITE,SUP-2354647,CDM,C1821,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PLATE BNE L24MM 5 H CRANIOMAXILLOFACIAL TI Y SHP FOR 2MM,SUP-2191308,CDM,C1713,HCPCS,0278,RC,,,,both,,,1015.48,660.06,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 5 FRX16 CM DL J TIP STRL,SUP-2759911,CDM,C1751,HCPCS,0278,RC,,,,both,,,442.08,287.35,,,,,,,,,,,,,
TRIAL SURG DIA1.8MM LNG PROV FOR WIRE,SUP-2351112,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.97,344.48,,,,,,,,,,,,,
PLATE BONE L45.7MM 0/5DEG 5 H NAR RT 1ST MTP FUS FOR 2.7MM,SUP-2417474,CDM,C1713,HCPCS,0278,RC,,,,both,,,8578.48,5576.01,,,,,,,,,,,,,
BAR EXT FIX L100MM STD LENGTHENING W SPCR PENNING,SUP-2316462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1050.52,682.84,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 95 MM L 75 MM 28 MM,SUP-2217581,CDM,C1768,CPT,0278,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
HANDPIECE SURG 9 IN BEND-A-BEAM ABC,SUP-2225596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.05,474.53,,,,,,,,,,,,,
COMPONENT ACET TRIFLANGED 25 MM LT HIP,SUP-2402835,CDM,C1776,CPT,0278,RC,,,,both,,,37366.00,24287.90,,,,,,,,,,,,,
SUPPORT ORTHOT PIP FNGR DSTL INTERPHALANGEAL CUST W/O JT,SUP-2435785,CDM,L3927,HCPCS,0274,RC,,,,both,,,90.21,58.64,,,,,,,,,,,,,
DEVICE SEAL L23CM NANO COAT MARYLAND JAW OPN DIV LIGASURE,SUP-2283563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1480.04,962.03,,,,,,,,,,,,,
COVER BUR H DIA14MM PLT LO PROF W TAB UNIV NEURO III,SUP-2363631,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.53,471.59,,,,,,,,,,,,,
SCREW BNE CRTX 4.5X36 MM ST,SUP-2569781,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.27,23.58,,,,,,,,,,,,,
ROD SPNL REDUCTION TEMP POINTER SEXTANT II,SUP-2630475,CDM,C1713,HCPCS,0278,RC,,,,both,,,1369.51,890.18,,,,,,,,,,,,,
SHEATH INTRO BRT TIP L 23 CM DIA 8 FR DIL TIP L 35 MM BLU,SUP-2156046,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM THK.9-1.99MM ACELLULAR DERM MTRX 480900510] ZIMMER BIOMET BIOLOGICS],SUP-2402510,CDM,Q4126,HCPCS,0636,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
CATHETER DRAINAGE 0.038 IN 14 FRX25 CM MP LCK LOOP UTHANE,SUP-2168133,CDM,C1729,HCPCS,0272,RC,,,,both,,,358.93,233.30,,,,,,,,,,,,,
JOINT TOE STR 16 MM INTER-PHALANGEAL PROX W/ INSTR DYNANITE,SUP-2550531,CDM,C1776,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
PLATE BNE L29MM THK1MM NONSTERILE DORS MTCRPL HND TI LOK VAR,SUP-2181015,CDM,C1713,HCPCS,0278,RC,,,,both,,,1875.21,1218.89,,,,,,,,,,,,,
SUTURE PROL SZ 8 0 L24IN NONABSORBABLE BLU L65MM BV130 5 3 8 M8732,SUP-2219635,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.78,165.61,,,,,,,,,,,,,
NAIL LAPIDUS 4-HOLE RT 42MM,SUP-2321064,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
VALVE AORT L10CM DIA20MM ORIFICE DIA167MM TISS ANNULUS,SUP-2355084,CDM,C1713,HCPCS,0278,RC,,,,both,,,21823.00,14184.95,,,,,,,,,,,,,
SCREW BNE RECON 2.3 MM THOR STR TI STRL TALON LEVEL 1 LTX,SUP-2869273,CDM,C1713,HCPCS,0278,RC,,,,both,,,6392.69,4155.25,,,,,,,,,,,,,
INSERT TIB SZ B KNEE POLYETH SEG,SUP-2200500,CDM,C1776,CPT,0278,RC,,,,both,,,890.19,578.62,,,,,,,,,,,,,
KIT MINI ACCS STIFF DIL ECHO ENH S STL PLAT 7CM NDL,SUP-2303434,CDM,C1893,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN L 115CM 4-4-4,SUP-2248592,CDM,C1732,HCPCS,0278,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
TUBE VNTLTN RUBE 114MM ID LUMEN 1MM DIA INNER FLNGE DSTNCE,SUP-2669492,CDM,L8699,HCPCS,0278,RC,,,,both,,,44.09,28.66,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH ULTRA L 13 CM DIA10.5 FR GUIDEWIRE L,SUP-2159468,CDM,C1892,HCPCS,0272,RC,,,,both,,,143.81,93.48,,,,,,,,,,,,,
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-102328,CDM,J0585,HCPCS,0636,RC,00023-1145-01,NDC,,both,1,UN,1920.50,1248.32,,,,,,,,,,,,,
PROBE ULTRASOUND TX-BONE,SUP-2418577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZ DRY DEMIN CANC CORT 0.5MM-3MM RANG 15CC,SUP-2294039,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
PLATE SPNL 4 LEVEL 74 MM ANTR CERV NEO-SL,SUP-2430709,CDM,C1713,HCPCS,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
SCREW ACET MOD TIB SPACER,SUP-2449279,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
HC So1 Heparin Asso1c Platelet Antibo,PX-3028602267,CDM,86022,CPT,0302,RC,,,,inpatient,,,465.00,302.25,,,,,,,,,,,,,
DRILL SURG 10GA VERT AUG AVAMAX,SUP-2361560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
PACEMAKER CARD SERENA CRT-P MRI SURESCAN W 46.5 X H 59 MM D,SUP-2282508,CDM,C2621,HCPCS,0275,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
COVER BUR H SM DIA13MM THK0.5MM 5 H NEURO TI FOR 1.5MM SCR,SUP-2402904,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
PLATE SPNL L25MM UNIV LEV 1 CERV ANT LOK BILAT VAR ANG TI,SUP-2293155,CDM,C1713,HCPCS,0278,RC,,,,both,,,2392.05,1554.83,,,,,,,,,,,,,
PLATE LOCKING STRAIGHT 1.3MM 12 HOLES-STERILE,SUP-2546061,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.84,880.00,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 3FR 55CM 1 LUMAN R S9173108,SUP-2632871,CDM,C1751,HCPCS,0278,RC,,,,both,,,567.68,368.99,,,,,,,,,,,,,
MICROCATHETER GUID CANTATA L 110 CM OD 2.9 FR ID 0.027 IN,SUP-2638529,CDM,C1887,HCPCS,0272,RC,,,,both,,,982.19,638.42,,,,,,,,,,,,,
GRAFT BONE SUB 5MMX11MMX11MM CANC CORT LORDTC CANN BLK,SUP-2278190,CDM,C1713,HCPCS,0278,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
"HC X-Ray, Ribs, Pa Chest, 3",PX-3207110100,CDM,71101,CPT,0320,RC,,,,both,,,546.00,354.90,,,,,,,,,,,,,
EXTENDER EXT FIX BNE TRNSPRT,SUP-2898543,CDM,2720000010,LOCAL,0272,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
SCREW BNE ST 1.5X6 MM NS UNIV NEURO III AXS LTX,SUP-2862782,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.18,151.57,,,,,,,,,,,,,
ALLOGRAFT BNE 4-10 MM 15 CC FD IRRADIATED CORTICAL CANC,SUP-2866844,CDM,C1762,CPT,0278,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
HLF PN 2.5X80X20 BRN BLNT TIP,SUP-2489271,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
SCREW BNE L38MM DIA5MM DST LAT FEM S STL ST LOK FULL THRD,SUP-2371498,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X18 MM TOT WR SS STRL,SUP-2610361,CDM,C1713,HCPCS,0278,RC,,,,both,,,463.40,301.21,,,,,,,,,,,,,
BUR REPROC SHV OD2.9MM MINI PURPLE,SUP-2652896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.59,67.33,,,,,,,,,,,,,
GII PS INSERT SZ 3-4 9MM,SUP-2822743,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0 X 28MM H,SUP-2320541,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins,PX-4309712900,CDM,97129,CPT,0430,RC,,,,inpatient,,,186.00,120.90,,,,,,,,,,,,,
HC Lyr Clos Nk Hnd Ft 2.6-5 Cm,PX-4501204200,CDM,12042,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
MESH SYNTH ABD BIOMATERIAL N ABSRB EXP,SUP-2395360,CDM,C1781,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
SYSTEM DEL FLIPPER L 80 CM DIA 0.041 IN GUIDEWIRE 0.035 IN,SUP-2168802,CDM,C1889,HCPCS,0278,RC,,,,both,,,348.23,226.35,,,,,,,,,,,,,
CATHETER CHST DRNGE 14FR L25CM PERCFLX GLDEX LOOP STR VAN,SUP-2147784,CDM,C1729,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
CATHETER ETER 5FR PED MICPUNC INTR,SUP-2170539,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.46,45.80,,,,,,,,,,,,,
CATHETER .014 6.0X150X135 POLARCATH,SUP-2141238,CDM,C1725,HCPCS,0272,RC,,,,both,,,3463.42,2251.22,,,,,,,,,,,,,
COIL VASC HILAL MICROCOIL EMBOLUS L 1 CM CATH 0.018 IN SYNTH,SUP-2611906,CDM,C1889,HCPCS,0278,RC,,,,both,,,241.15,156.75,,,,,,,,,,,,,
CATHETER ANGIO PERFORMA L 125 CM 5 FR 0.046 IN ULT4 1 SIDE H,SUP-2665878,CDM,C1887,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
CONDYLAR PLATE RIGHT 11X221MM,SUP-2818529,CDM,C1713,HCPCS,0278,RC,,,,both,,,7736.33,5028.61,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 2 KT STRL DISP EVO,SUP-2934961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
INTRODUCER SHTH SL1 0.032 IN 8.5 FRX63 CM FAST-CATH,SUP-2357168,CDM,C1893,HCPCS,0272,RC,,,,both,,,556.97,362.03,,,,,,,,,,,,,
PLATE BNE SCREW DIA 3.5 MM LG SS RT INTRAPELVIC ACET STD,SUP-2905560,CDM,C1713,HCPCS,0278,RC,,,,both,,,8684.89,5645.18,,,,,,,,,,,,,
PLATE BNE 135DEG 8 H S STL FEM BILAT STD TB RIG CLLR DYN,SUP-2197772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1831.88,1190.72,,,,,,,,,,,,,
ASSEMBLY SPNL HEADBODY STD,SUP-2175620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
EXCHANGE SET FOR SV 900A/B/C/D/E SERVO 1000HR MAINT,SUP-2227271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
HC So Anti Dnase B,PX-3028621566,CDM,86215,CPT,0302,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
CABLE ORTH L750MM DIA1MM TI SURG SMOOTH W CRMP,SUP-2193595,CDM,C1713,HCPCS,0278,RC,,,,both,,,1496.27,972.58,,,,,,,,,,,,,
SET INTRO ARROW-TREROTOLA PTD SHTH L 2 IN DIA 7 FR DIL L 5,SUP-2383423,CDM,C1894,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK CATH AXS VECTA 71 L 132 CM,SUP-2884577,CDM,C1757,HCPCS,0272,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
STAPLE BNE FIX W8XL8MM SUP E NIT SYS MEMOFIX,SUP-2244262,CDM,C1713,HCPCS,0278,RC,,,,both,,,3645.54,2369.60,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X5 MM 0.6 MM FLROPLAS,SUP-2637731,CDM,L8613,CPT,0278,RC,,,,both,,,277.76,180.54,,,,,,,,,,,,,
GRAFT HUM TISS L150MM DIA4-5.5MM SEMITENDINOSUS FRZN ROPE,SUP-2264787,CDM,C1762,CPT,0278,RC,,,,both,,,2568.80,1669.72,,,,,,,,,,,,,
CATHETER THROMBS RETRV ERIC L 20 MM DIA 3 MM DSTL TIP L 5 MM,SUP-2898705,CDM,C1757,HCPCS,0272,RC,,,,both,,,20017.50,13011.37,,,,,,,,,,,,,
PLATE BONE STR 10 H 0.8 MM STRL,SUP-2107085,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
HC So Creatinine,PX-3018256566,CDM,82565,CPT,0301,RC,,,,both,,,159.00,103.35,,,,,,,,,,,,,
SCREW SPNL CERV FACET DISP DTRAX,SUP-2330584,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
SWEEP 6FR REPROS DEC MED STRYKER 401575,SUP-2845131,CDM,C1730,HCPCS,0272,RC,,,,both,,,329.20,213.98,,,,,,,,,,,,,
HC 1st Deg Burn Trtmnt,PX-4501600000,CDM,16000,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC CORTICAL FIBER,SUP-2899186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1942.88,1262.87,,,,,,,,,,,,,
GRAFT DURA PTCH SM 5X10 CM DURAMATER,SUP-2321732,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
KIT DRNGE CATH 6FR SAFE-T-CENTESIS,SUP-2133893,CDM,C1729,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
BASEPLATE GLEN 24MM LAT +2 SHLDR MOD,SUP-2123392,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
SUPPORT LUMBAR LP,SUP-2388156,CDM,L1220,HCPCS,0274,RC,,,,both,,,616.66,400.83,,,,,,,,,,,,,
COMPONENT KNEE,SUP-2366062,CDM,C1776,CPT,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
HC So Aspergillus Galactomannan,PX-3068730566,CDM,87305,CPT,0306,RC,,,,both,,,356.00,231.40,,,,,,,,,,,,,
IMPLANT PENILE 5CM CYL INFL MINOCYCLINE RIFAMPIN INHIBIZONE,SUP-2140299,CDM,C1813,HCPCS,0278,RC,,,,both,,,18353.30,11929.64,,,,,,,,,,,,,
HEAD HUM CEM 8 REG STD SHLDR RESURF STEM COCR MACROBOND,SUP-2403984,CDM,C1776,CPT,0278,RC,,,,both,,,9580.14,6227.09,,,,,,,,,,,,,
SCREW BNE CONCL 2.7X38 MM PERIARTICULAR,SUP-2457639,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.71,148.01,,,,,,,,,,,,,
MICROCATHETER ETER VASC PROXIMAL DISTAL 3X24FR L155CM LUMN,SUP-2141053,CDM,C1887,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 1 FIBER OPTIC SS GRN SPEC,SUP-2149970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,200.93,130.60,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF XSHORT 5X35 MM TITANIUM NITRIDE S,SUP-2836776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.58,716.68,,,,,,,,,,,,,
KIT NEPHSTMY CATH DIA7FR LINGEMAN 0.035IN SUP STIFF J DIL,SUP-2140115,CDM,C1726,HCPCS,0272,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
WIRE FIX 2.5X150 MM PANTA KIRSCHNER,SUP-2422994,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.74,215.63,,,,,,,,,,,,,
PACK PHACO 30DEG US FMS MIC SL TAPR ABS KELMAN,SUP-2109893,CDM,C1713,HCPCS,0278,RC,,,,both,,,971.23,631.30,,,,,,,,,,,,,
GRAFT BNE PLIF SPCR RND FRZ DRY H 11MM OSTEOSTIM,SUP-2415424,CDM,C1713,HCPCS,0278,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
HC Ot Electricl Stim Attended 15|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309703200,CDM,97032,CPT,0430,RC,,,GP|CQ,outpatient,,,206.00,133.90,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L230CM DIA0.038IN DEPTH MRK STR FLX DST,SUP-2172401,CDM,C1769,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
CATHETER SUPP L150CM 15MM MRK BND SPC GWIRE 0.014IN,SUP-2173450,CDM,C1887,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.3MM CORT LOK FOR VOLAR DST RAD PLATING,SUP-2107576,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
HEAD RADIAL BPLR 18 MM ELBW KATALYST,SUP-2851910,CDM,C1776,CPT,0278,RC,,,,both,,,10528.99,6843.84,,,,,,,,,,,,,
PLATE BONE 6X21 H RT MAND TI ANG RIG NONCOMPRESSION,SUP-2191420,CDM,C1713,HCPCS,0278,RC,,,,both,,,6572.02,4271.81,,,,,,,,,,,,,
COMPONENT FEM L7CM ELP SEG R DST KNEE RESURF ORTH SALV SYS,SUP-2405707,CDM,C1776,CPT,0278,RC,,,,both,,,20446.11,13289.97,,,,,,,,,,,,,
CATHETER EMB TUFTEX L 80 CM DIA 6 FR BALLOON DIA13 MM,SUP-2264190,CDM,C1757,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
GRAFT DURA XS 7X5 IN REGEN MTRX DURAGN,SUP-2624232,CDM,C1763,HCPCS,0278,RC,,,,both,,,6215.38,4040.00,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST OFF-THE-SHELF W/MTL JT ELASTIC,SUP-2435757,CDM,L3710,HCPCS,0272,RC,,,,both,,,367.91,239.14,,,,,,,,,,,,,
SYSTEM IMPL W/ MINI SCORPION DX NDL MIC SUTLASSOS FIBERWIRE,SUP-2122322,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
SLIDER NDL CRESC L,SUP-2366703,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.91,498.49,,,,,,,,,,,,,
ENDPLATE SPNL DISK L12MM 14X16MM FOOTPRINT 7DEG VERT BODY,SUP-2420874,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
IMPLANT FEM 10X24MM W INSRT AFX,SUP-2402820,CDM,C1713,HCPCS,0278,RC,,,,both,,,3404.26,2212.77,,,,,,,,,,,,,
ROD EXT FIX L300MM DIA11MM C CONN FOR HOFFMANN III MRI SYS,SUP-2372229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1140.76,741.49,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 8 MM MIDFACIAL 20/PK TITANIUM SILVER,SUP-2842262,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.83,214.39,,,,,,,,,,,,,
SHEATH /DILATOR GLIDETHRU 4FR X 7CM,SUP-2655673,CDM,C1894,HCPCS,0272,RC,,,,both,,,46.16,30.00,,,,,,,,,,,,,
ACETAZOLAMIDE 250 MG PO TABS,RX-113,CDM,6370000000,HCPCS,0637,RC,51672-4023-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SLING GYN TROCAR DIA2.8 MM INTRO 58 DEG POLYPRO BLU,SUP-2929649,CDM,C1771,HCPCS,0278,RC,,,,both,,,3874.76,2518.59,,,,,,,,,,,,,
COMPONENT TIB KNEE CROSSOVER BEAR MOD ROT HNG REV GMRS,SUP-2376367,CDM,C1776,CPT,0278,RC,,,,both,,,7104.56,4617.96,,,,,,,,,,,,,
COLLAR CERV L H3.25IN FOR 16-19IN PLASTAZOTE FOAM 2 PC L,SUP-2336003,CDM,L0140,HCPCS,0274,RC,,,,both,,,30.11,19.57,,,,,,,,,,,,,
STEM HUM L130MM DIA13MM UNIV DST SHLDR TI PRI REV CEM FOR,SUP-2372855,CDM,C1776,CPT,0278,RC,,,,both,,,11278.57,7331.07,,,,,,,,,,,,,
BIT DRILL SURG 1.5MM W/ 7MM STP IQ,SUP-2136989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SCREW SPNL L100MM OD8.5MM 10DEG TI CANC PEDCL IL VAR ANG,SUP-2287188,CDM,C1713,HCPCS,0278,RC,,,,both,,,3232.94,2101.41,,,,,,,,,,,,,
CARD MEAS CREDIT FOR X10 XLNK PLT,SUP-2289439,CDM,C1713,HCPCS,0278,RC,,,,both,,,381.67,248.09,,,,,,,,,,,,,
IMPLANT LARYN L10MM DIA16FR INDWL RADPQ RNG CLASS,SUP-2242367,CDM,L8509,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER EP 6FR L115CM SPC 2-8-2MM XL SWP CSL CRV DECAPOLAR,SUP-2356920,CDM,C1730,HCPCS,0272,RC,,,,both,,,2813.44,1828.74,,,,,,,,,,,,,
CATHETER THOR 20FR L22IN PVC 4 EYELET STR ATRAUM,SUP-2227430,CDM,C1729,HCPCS,0272,RC,,,,both,,,23.24,15.11,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM RT MAND 26 HOLE TI LEVEL 1 LF,SUP-2539579,CDM,C1713,HCPCS,0278,RC,,,,both,,,7163.06,4655.99,,,,,,,,,,,,,
CATHETER ATHRCTMY L135CM DIA1.75MM MAX DIA0.58IN COR BUR,SUP-2142304,CDM,C1724,HCPCS,0278,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 26 HOLE SS NS LCP,SUP-2799303,CDM,C1713,HCPCS,0278,RC,,,,both,,,3247.04,2110.58,,,,,,,,,,,,,
PLATE BNE L 142 X W 9 MM THK 1.1 MM SCREW DIA 3.5 MM 12 H SS,SUP-2933088,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.62,237.65,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 4 MESH NS FACE ID,SUP-2909524,CDM,C1713,HCPCS,0278,RC,,,,both,,,34646.19,22520.02,,,,,,,,,,,,,
GRAFT VASC L30CM ID6MM RING SECT L20CM STD WALLED STR GORTX,SUP-2396001,CDM,C1768,CPT,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
INSERT ACET SZ F OD58X60MM ID32MM HIP ALUMINA CERAMIC,SUP-2375165,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
DEVICE TISS REM DIA3MM L25.25IN ENDOSCP F/ IU POLYPS,SUP-2239913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2064.02,1341.61,,,,,,,,,,,,,
CENTERPIECE SPNL EXPANDABLE B 25 MM T2 STRATOSPHERE,SUP-2730856,CDM,C1889,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
SHEATH INTRO SAFSHTH L 13 CM DIA 7 FR DIL L 20 CM TEARWY,SUP-2281001,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.95,95.52,,,,,,,,,,,,,
SHEATH URET ACCS 13 15FR L35CM DIL 11FR SMOOTH ATRAUM INSRT,SUP-2126284,CDM,C1894,HCPCS,0272,RC,,,,both,,,403.24,262.11,,,,,,,,,,,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,0636,RC,00143-9574-25,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
FORCEP ENDOSCP BX 1050 MM 2 MM HOT OVL FEN W/ CHANNEL BLK,SUP-2865646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT HUM TISS W1XL1CM THK0.5MM PERICARD PTCH ALLGRFT,SUP-2308663,CDM,C1762,CPT,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BONE L14MM THK.5MM NEURO BUR H CVR FOR 1.7MM SCR DELT,SUP-2365072,CDM,C1713,HCPCS,0278,RC,,,,both,,,2032.84,1321.35,,,,,,,,,,,,,
PLATE BNE HK LG 3.5/4.5X291 MM RT FEM PROX 8 HOLE NS VA-LCP,SUP-2750913,CDM,C1713,HCPCS,0278,RC,,,,both,,,7796.49,5067.72,,,,,,,,,,,,,
ANCHOR SUTURE NO2 DIAMETER 1.3MM LABRAL SHOULDER BLUE SINGLE,SUP-2828684,CDM,C1713,HCPCS,0278,RC,,,,both,,,1456.46,946.70,,,,,,,,,,,,,
CATHETER EP 8FR L105CM LOOP DIA15MM 3-3-3MM SPC D CRV CIR,SUP-2357571,CDM,C1732,HCPCS,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
HC So2 Nephelometry Ea Analyte Nes,PX-3018388368,CDM,83883,CPT,0301,RC,,,,both,,,84.00,54.60,,,,,,,,,,,,,
HEAD FEM 40 MM HIP REMEDY SPECTRUM GV,SUP-2718134,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PIN BNE FIX DIA 6 MM CANC THRD REDUCTION STRL VARIAX,SUP-2900756,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.87,833.22,,,,,,,,,,,,,
PLATE THK1.7MM 2X5 H LADDER RESRB STRL DELT SYS,SUP-2364983,CDM,C1713,HCPCS,0278,RC,,,,both,,,814.23,529.25,,,,,,,,,,,,,
DEVICE GRSP SHTH L160CM DIA2.5MM S STL 4 PRNG W/ INWARD,SUP-2391613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,493.92,321.05,,,,,,,,,,,,,
METFORMIN HCL 500 MG PO TABS,RX-10544,CDM,6370000000,HCPCS,0637,RC,60687-0155-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BLADE SHVR ARTHSCP 4MM DIA 120MML STRGHT RCTNGLR WNDW RDS DB,SUP-2574155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.42,341.52,,,,,,,,,,,,,
SCREW BNE CANN 7.3X100 MM 16 MM PART THRD TI STRL TRAUM FIX,SUP-2861360,CDM,C1713,HCPCS,0278,RC,,,,both,,,931.45,605.44,,,,,,,,,,,,,
SYSTEM FIX 5MM TI TWINFIX QUICK-T,SUP-2341595,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CATHETER INTVASC OCCL ECLIPSE 2L BALLOON L 9 MM DIA 6 MM,SUP-2717629,CDM,C2628,HCPCS,0272,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY OCTARAY SPLINE 2CM 8FR 2-5-2MM D,SUP-2737873,CDM,C1732,HCPCS,0272,RC,,,,both,,,6810.66,4426.93,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0250,RC,00338-0023-02,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
HC Dress or Debride Burn Large,PX-4501603000,CDM,16030,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
ALLOGRAFT BNE 60-115 MM FD RIB ORAGRAFT,SUP-2740906,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.64,686.17,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins,PX-4409712900,CDM,97129,CPT,0440,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
PEG 3350-KCL-NABCB-NACL-NASULF 236 G PO SOLR,RX-10839,CDM,6370000000,HCPCS,0637,RC,43386-0090-19,NDC,,both,4000,ML,108.00,70.20,,,,,,,,,,,,,
STEM FEM L225MM DIA14MM +30MM OFFSET NEUT CALCAR HIP REV,SUP-2344483,CDM,C1776,CPT,0278,RC,,,,both,,,11281.39,7332.90,,,,,,,,,,,,,
MATRIX PLCNTA FLOWABLE CYROPRESERVED CRYOMTRX 0.5CC,SUP-2340463,CDM,C1762,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
WASHER ORTH LCK 2.7 MM BNE THRD LIP SOCKET SS STRL SURFIX,SUP-2852097,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.96,297.02,,,,,,,,,,,,,
CLAMP EXT FIX STD SINGLE STRL GALAXY FIX GEM LTX DISP,SUP-2875641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3605.03,2343.27,,,,,,,,,,,,,
PLATE BNE SZ 0 L40MM 5DEG R S SHP FOR HALLU-LOCK MTP ARTH,SUP-2243426,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.71,3255.66,,,,,,,,,,,,,
SLEEVE TIB 29MM CEM REV ATTUNE,SUP-2251460,CDM,C1776,CPT,0278,RC,,,,both,,,9334.28,6067.28,,,,,,,,,,,,,
GRAFT BNE LG,SUP-2424567,CDM,C1713,HCPCS,0278,RC,,,,both,,,5834.12,3792.18,,,,,,,,,,,,,
GRAFT BONE SUB 1CC DEMIN BONE MTRX GEL ALLOSYNC,SUP-2120755,CDM,C1776,CPT,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
COMPONENT PATELLAR AUG MED THCK 22 MM FOR CONTINUUM KNEE SYS,SUP-2200594,CDM,C1776,CPT,0278,RC,,,,both,,,7919.08,5147.40,,,,,,,,,,,,,
BUR SURG 4MMDIA 8MML LNG FLUT DR FOR TPS MIDAS REX UPWR,SUP-2363366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.23,230.90,,,,,,,,,,,,,
GUIDE NERVE REP MTRX 4 MMX2 CM STRL NEURAGEN 3D LF,SUP-2877629,CDM,C9352,HCPCS,0278,RC,,,,both,,,7680.53,4992.34,,,,,,,,,,,,,
PLATE BNE W24XL62MM 12 H L DST RAD TI LOK COMPR LO PROF RIG,SUP-2411823,CDM,C1713,HCPCS,0278,RC,,,,both,,,3234.20,2102.23,,,,,,,,,,,,,
CONNECTOR SPNL CRSS L20MM CERV TI OFFSET OASYS,SUP-2380738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BIT DRL L4MM OD4.1MM S STL WIDENING COUNTSINK DISP FOR BAHA,SUP-2164970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GUIDE SUTURE KNOTLESS 3 MM OPN REP ANCHR KT SUTURE TAK DISP,SUP-2419282,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BNE ANGLED 2.8 MM LT 7X23 HOLE RECON MAXILLA PT SPEC,SUP-2860109,CDM,C1713,HCPCS,0278,RC,,,,both,,,30398.34,19758.92,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,GO|KX|CO,both,,,195.00,126.75,,,,,,,,,,,,,
SCREW BNE L 145 MM DIA 8 MM THRD L 40 MM SS ST SD CANN RVS,SUP-2900875,CDM,C1713,HCPCS,0278,RC,,,,both,,,1351.11,878.22,,,,,,,,,,,,,
PIN FIX 240905000] JNJ HEALTHCARE],SUP-2256789,CDM,C1713,HCPCS,0278,RC,,,,both,,,501.30,325.84,,,,,,,,,,,,,
SCREW SPNL L25MM DIA13MM STR NONCANNULATED,SUP-2414462,CDM,C1713,HCPCS,0278,RC,,,,both,,,9881.58,6423.03,,,,,,,,,,,,,
BIT DRILL D33MM FRHND TRGTNG TBL NAT NAIL SSTM,SUP-2467095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.83,343.09,,,,,,,,,,,,,
INTRODUCER SHTH BLU HUB W O GWIRE 8FRX23CM PRELUDE,SUP-2303303,CDM,C1894,HCPCS,0272,RC,,,,both,,,36.27,23.58,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.038IN NIT HYDRPHLC STR TIP,SUP-2139349,CDM,C1769,HCPCS,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 30X30X0.8 MM SMOOTH STERILE SYNPOR,SUP-2837802,CDM,C1713,HCPCS,0278,RC,,,,both,,,2068.32,1344.41,,,,,,,,,,,,,
CLIP ANEUR 8X1.143 MM SLIGHTLY CRV NS SLIM-LINE SUNDT-KEES,SUP-2183225,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.43,91.93,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0.035IN CRV RAD 3MM TAPR L7CM FLPY,SUP-2167914,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.18,41.72,,,,,,,,,,,,,
KIT INFANT EARCUP SANIBEL W TAB ELECTRODES,SUP-2858584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,711.37,462.39,,,,,,,,,,,,,
HC Dilate Biliary Duct/Ampulla,PX-3614754200,CDM,47542,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GRAFT HUM TISS L12MM MPJ ARTH SEG FOR DEFORMITY CORR,SUP-2436366,CDM,C1713,HCPCS,0278,RC,,,,both,,,4309.65,2801.27,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 60 X W 11 MM MYRIAD HNDPC L 13 CM,SUP-2930210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18113.75,11773.94,,,,,,,,,,,,,
GRAFT BNE SUB M W20XH7XL30MM COMPRESSIBLE SPNG STRP PROVIDE,SUP-2138508,CDM,C1713,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
COMPONENT FEM UNI 4 KNEE PRESERVATION,SUP-2427742,CDM,C1776,CPT,0278,RC,,,,both,,,9052.62,5884.20,,,,,,,,,,,,,
IMPLANT ORBIT W28XL40MM THK7.5MM L LT MALAR EXT ENOPHTHALMOS,SUP-2365319,CDM,C1713,HCPCS,0278,RC,,,,both,,,2003.32,1302.16,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 6 MM RNG L 30 CM STR TW,SUP-2396157,CDM,C1768,CPT,0278,RC,,,,both,,,3356.66,2181.83,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 6 MM EPTFE FLX TW RING HEMO,SUP-2761455,CDM,C1768,CPT,0278,RC,,,,both,,,2747.53,1785.89,,,,,,,,,,,,,
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,J7639,HCPCS,0636,RC,50242-0100-40,NDC,,both,2.5,ML,769.30,500.04,,,,,,,,,,,,,
TUBE TRACH SZ 8.0 CUF X HORZ LEN PVC BLU LN,SUP-2351967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,178.89,116.28,,,,,,,,,,,,,
SCREW BNE LCK 4.5X16 MM ANK FUSION CONSTRUCT,SUP-2609759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1007.19,654.67,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 60 CM DIA 6.5 FR GUIDEWIRE 0.032 IN,SUP-2357145,CDM,C1893,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
SCISSORS ENDO L33CM L5MM SMOOTH ROTICULATING NONRETRACTABLE,SUP-2312662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
FILLER SCR BONE H DIA4.5MM S STL PERI-LOC,SUP-2351135,CDM,C1713,HCPCS,0278,RC,,,,both,,,1035.57,673.12,,,,,,,,,,,,,
GRAFT BONE PROSTHETIC COMP HUM PROX RT W/ ROT CUF,SUP-2307436,CDM,C1762,CPT,0278,RC,,,,both,,,26533.00,17246.45,,,,,,,,,,,,,
CATHETER GUID NEURON L 115 CM DSTL FLX ZONE 6 CM,SUP-2323602,CDM,C1887,HCPCS,0272,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
SCREW BNE L36MM OD3MM FT AUTOFIX S STL IMPL FRAC SM BNE,SUP-2361676,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.79,456.16,,,,,,,,,,,,,
STAPLER INT L340MM 45MM STD 12 FIRING B FRM PWR + GRIPPING,SUP-2219816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.77,712.25,,,,,,,,,,,,,
TAP SURG POST OCCIPITOCERVICOTHORACIC FOR 3.5MM SCR ELLIPSE,SUP-2232211,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT ALLGRFT TEND PAT BISECTED FRZN,SUP-2165587,CDM,C1713,HCPCS,0278,RC,,,,both,,,6710.18,4361.62,,,,,,,,,,,,,
TRAY TIB SZ 2 STD ANK PROPHECY INFIN,SUP-2397274,CDM,C1776,CPT,0278,RC,,,,both,,,13985.56,9090.61,,,,,,,,,,,,,
PLATE BNE 45MM MPJ FUS TI ST,SUP-2243232,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,J7060,HCPCS,0258,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
STEM TIB L127MM OD11MM PRI STABILIZING EXTN MRS,SUP-2376467,CDM,C1776,CPT,0278,RC,,,,both,,,9161.89,5955.23,,,,,,,,,,,,,
KIT CATH PICC G+ARD BL ADV MAX BARRIER SAFETY 6FR 55CM 3LUM,SUP-2855039,CDM,C1751,HCPCS,0278,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
ROD RELINE MAS TI 5.5X55MM LORDOTIC,SUP-2880394,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE 2 H SPRING NS PRO,SUP-2902477,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.51,728.33,,,,,,,,,,,,,
PAPARELLA VENT TUBE 114MM ID SILICONE 30 PACK,SUP-2682415,CDM,L8699,HCPCS,0278,RC,,,,both,,,30.77,20.00,,,,,,,,,,,,,
TWIST DRILL 22MM DIA X 105 M CYLINDRICAL SINGLE USE,SUP-2669018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.74,253.98,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM TAPE 1.4 MM PEEK 3 STRANDS W/ NDL,SUP-2906382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1149.24,747.01,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 12 FRX25 CM BILI 6 HOLE UTHANE,SUP-2168132,CDM,C1729,HCPCS,0272,RC,,,,both,,,345.75,224.74,,,,,,,,,,,,,
SHELL ACET CLUS H COCR ALLOY 52MM VITALOCK,SUP-2364618,CDM,C1776,CPT,0278,RC,,,,both,,,2676.85,1739.95,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 75 X W 13.5 MM MYRIAD HNDPC L 13,SUP-2930203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22436.93,14584.00,,,,,,,,,,,,,
SLING URETH W2XL20CM PORCINE CLLGN SURGISIS BIODESIGN,SUP-2171314,CDM,C1763,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
NATEGLINIDE 60 MG PO TABS,RX-29437,CDM,6370000000,HCPCS,0637,RC,55111-0328-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
RETRACTOR SPNL L7CM DIA22MM D275IN S STL TB MED LAT DIL BLNT,SUP-2292985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1167.92,759.15,,,,,,,,,,,,,
FILIFORM URO 5FR L125IN WVN COUDE TIP DIL CATHETER REUSE,SUP-2128965,CDM,C1726,HCPCS,0272,RC,,,,both,,,200.21,130.14,,,,,,,,,,,,,
SLEEVE UPLR DIA14-16MM +4MM OFFSET FEM 14/16 TAPR,SUP-2342620,CDM,C1776,CPT,0278,RC,,,,both,,,435.20,282.88,,,,,,,,,,,,,
ELECTRODE ENDOSCP OD24-28FR 0.35 WIRE 12DEG 30DEG MPLR W/,SUP-2312895,CDM,C1713,HCPCS,0278,RC,,,,both,,,787.57,511.92,,,,,,,,,,,,,
CAGE SPNL L14XW14XH15MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317737,CDM,C1889,HCPCS,0278,RC,,,,both,,,7545.42,4904.52,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L15MM SYR 30ML 11GA ADD FRAC,SUP-2293649,CDM,C1894,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
JOINT WRST 5 FOR PYROCARBON LUNATE,SUP-2852855,CDM,C1776,CPT,0278,RC,,,,both,,,19911.53,12942.49,,,,,,,,,,,,,
BASEPLATE GLEN SZ 8 MM REV 2 TAPR STRL ALTIVATE RVS,SUP-2904165,CDM,C1776,CPT,0278,RC,,,,both,,,4699.01,3054.36,,,,,,,,,,,,,
ELECTRODE ENDO MPLR DISP VPR RL DIMPLED COMPATIBLE W/ STORZ,SUP-2171428,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.70,298.80,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L RIFAMPIN SPECTRUM,SUP-2759832,CDM,C1751,HCPCS,0278,RC,,,,both,,,367.79,239.06,,,,,,,,,,,,,
RING EXT FIX 200 MM,SUP-2197267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION|DISCARDED DRUG NOT ADMINISTE,RX-40840102,CDM,2580000003,HCPCS,0258,RC,00338-0049-04,NDC,JW,both,250,ML,10.70,6.95,,,,,,,,,,,,,
SCREW BNE L 30 MM DIA 6.5 MM SS ST SD CANN FULL THRD RVS CUT,SUP-2900958,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.50,650.97,,,,,,,,,,,,,
STENT PERIPH L20MM DIAM 10MM CATH L135CM CAR PRECIS,SUP-2158977,CDM,C1876,HCPCS,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
PLATE MESH TI CONTOURABLE 100X100MM MALLEABLE LPROF SYNTHES,SUP-2848978,CDM,C1713,HCPCS,0278,RC,,,,both,,,6556.32,4261.61,,,,,,,,,,,,,
PLATE CRAN 30X30X20 MM PT SPEC IMPL PEEK,SUP-2860166,CDM,C1713,HCPCS,0278,RC,,,,both,,,21151.35,13748.38,,,,,,,,,,,,,
PIN POS DIA3MM FOR EASYCLIP,SUP-2378781,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER LD DEL OD9FR ID7FR L51CM STR OUTER GUID PEELABLE,SUP-2356187,CDM,C1887,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
HC Treat Humerus Fx,PX-4502453000,CDM,24530,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE 5DEG L MT GRFT SPANNING GORILLA,SUP-2321462,CDM,C1713,HCPCS,0278,RC,,,,both,,,6363.21,4136.09,,,,,,,,,,,,,
GUIDEPIN ORTHOPAEDIC CALIBRATED 2.4X152 MM THREADED TIP WITH,SUP-2836610,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.38,93.85,,,,,,,,,,,,,
SCREW BNE ST 5X70 MM VA T25 SS NS,SUP-2178696,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
COMPONENT FEM A A/P44.5MM M/L55MM ZMLY POR LT KNEE PRI,SUP-2201315,CDM,C1776,CPT,0278,RC,,,,both,,,11000.99,7150.64,,,,,,,,,,,,,
PLATE BNE W11XL194MM THK37MM 10 H ST R MED DST TIB S STL LOK,SUP-2185591,CDM,C1713,HCPCS,0278,RC,,,,both,,,5089.34,3308.07,,,,,,,,,,,,,
CROWN DENT AD SZ DLL7 RT LO 1ST PRI M S STL REPL THCK,SUP-2238869,CDM,D6783,CPT,0278,RC,,,,both,,,19.78,12.86,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.8MM HEX 1.5MM UP LO EXT TI ST CANN,SUP-2107377,CDM,C1713,HCPCS,0278,RC,,,,both,,,3221.64,2094.07,,,,,,,,,,,,,
LEAD PACE L75CM CRV H16MM INTRO 5FR L HRT LO PROF STEER TIP,SUP-2356058,CDM,C1900,HCPCS,0275,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
LOCKING FRAC PLATE 6 HOLE 43MM NON CMPRSSN 20MM THICK T 6L,SUP-2694215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1847.14,1200.64,,,,,,,,,,,,,
CATHETER CV BEDSIDE SET 018 4 FRX60 CM DL NIT TURBO-JECT,SUP-2759823,CDM,C1751,HCPCS,0278,RC,,,,both,,,371.40,241.41,,,,,,,,,,,,,
ANCHOR SUTURE DIL,SUP-2341591,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.69,144.75,,,,,,,,,,,,,
SEALANT SURG 10ML FBRN FRZN GLUE PREFIL SPRY SET ARTISS,SUP-2129854,CDM,C9250,HCPCS,0636,RC,,,,both,,,2564.60,1666.99,,,,,,,,,,,,,
KETAMINE HCL 100 MG/ML IJ SOLN,RX-4237,CDM,2500000003,HCPCS,0250,RC,00143-9509-10,NDC,,both,0.05,ML,54.10,35.16,,,,,,,,,,,,,
SCREW FIX PEDCL FIX SCREW NS REUSE VADER,SUP-2917086,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
CATHETER HD IJ 20 CM DUOFLO,SUP-2217982,CDM,C1752,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
FENTANYL 10 MCG/ML INFUSION (BAG),RX-4081958,CDM,J3010,HCPCS,0636,RC,99999-1758-10,NDC,,both,100,ML,162.80,105.82,,,,,,,,,,,,,
CAGE SPNL SM W8XH10MM 5DEG ANT THORLUM C FBR REINF POLYMER,SUP-2255159,CDM,C1889,HCPCS,0278,RC,,,,both,,,14294.85,9291.65,,,,,,,,,,,,,
TOOL REMOVAL DIA 3.5 MM STRL DISP FLEX-THREAD,SUP-2900444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2179.16,1416.45,,,,,,,,,,,,,
PIN EXT FIX 6 MM GRN,SUP-2205339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.82,285.23,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR|DISCARDED DRUG NOT ADMINISTE,RX-159345,CDM,J1720,HCPCS,0636,RC,00009-0013-05,NDC,JW,both,1,UN,256.10,166.46,,,,,,,,,,,,,
PLATE BONE L28MM 10MM STP MIDFOOT HINDFOOT TI FOR 3.5/4MM,SUP-2319680,CDM,C1713,HCPCS,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM CART ARAGONITE,SUP-2913154,CDM,C1763,HCPCS,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
PATCH SURG GORTX L 34 X W 26 CM THK 1 MM EPTFE SFT TISS OVL,SUP-2679939,CDM,C1768,CPT,0278,RC,,,,both,,,8157.72,5302.52,,,,,,,,,,,,,
SET TRAVENOL A/O 5 PRNG MFLD,SUP-2130775,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.17,427.16,,,,,,,,,,,,,
NAIL IM HUM UNIV 9X240 MM LCK CANN ENTRY TI STRL VERSANAIL,SUP-2461659,CDM,C1713,HCPCS,0278,RC,,,,both,,,4644.06,3018.64,,,,,,,,,,,,,
BUR SURG DIAMOND X COARSE 4 MMX10 CM BALL SM BOR LEGEND,SUP-2627620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.94,234.61,,,,,,,,,,,,,
CATHETER CV 3L 6 FR BASIC TY PASV VLV POWERPICC SOLO 2,SUP-2126404,CDM,C1751,HCPCS,0278,RC,,,,both,,,686.72,446.37,,,,,,,,,,,,,
HC So Hla I Typing 1 Locus Lr,PX-3018137366,CDM,81373,CPT,0301,RC,,,,both,,,804.00,522.60,,,,,,,,,,,,,
SCREW EXT SD 6X250 MM 80 MM THRD TI SCHNZ,SUP-2193176,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.05,364.03,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 4CMD SPNL MSCLE MULTI TTHD BLACK FNSH U,SUP-2476158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.05,401.73,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK04 07MM DERM HUM ACELLULAR,SUP-2307044,CDM,Q4128,HCPCS,0636,RC,,,,both,,,3608.49,2345.52,,,,,,,,,,,,,
COIL EMB L50CM OD0.020IN LOOP OD14MM STD NIT COMPLX FRME,SUP-2323379,CDM,C1889,HCPCS,0278,RC,,,,both,,,7366.44,4788.19,,,,,,,,,,,,,
TUBE MYR VENT SIL ST 114MM DIA PAPARELLA,SUP-2313873,CDM,L8699,HCPCS,0278,RC,,,,both,,,39.12,25.43,,,,,,,,,,,,,
PLATE BNE L 299 MM SCREW DIA 4.5 MM 18 H BOW COMPR LCK NS,SUP-2933225,CDM,C1713,HCPCS,0278,RC,,,,both,,,5120.56,3328.36,,,,,,,,,,,,,
PLATE BNE RECON 2.7X64 MM 8 HOLE SS,SUP-2569078,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.75,268.29,,,,,,,,,,,,,
IMPLANT HUM TISS L 7 X W 7 CM PLCNTA MTRX MEMBRN MINIMALLY,SUP-2905531,CDM,C1762,CPT,0278,RC,,,,both,,,14616.70,9500.85,,,,,,,,,,,,,
TAMP BNE SZ 3 L10MM BNE INFL BLLN KYPHX XPANDER,SUP-2281087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
ANCHOR TEND 8 FOR REGENETEN BIOINDUCTIVE IMPL SYS,SUP-2600835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1813.35,1178.68,,,,,,,,,,,,,
COIL VASC RETRACTA L 7 CM DIA 8 MM CATH 0.035 IN LOOP 2.8,SUP-2638513,CDM,C1889,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
CATHETER THOR 36FR L20IN DIA12MM CLR PVC THERMOSENSITIVE,SUP-2154970,CDM,C1729,HCPCS,0272,RC,,,,both,,,34.63,22.51,,,,,,,,,,,,,
WIRE EXT FIX L 400 MM DIA1.8 MM STOPPER STRL DISP ILIZ,SUP-2933833,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.51,439.73,,,,,,,,,,,,,
ADAPTER TIB TY L5MM OFFSET INTLOK FOR VANGUARD COMPLT SYS,SUP-2405430,CDM,C1776,CPT,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
COIL EMB COMPLX 0.02 IN 3 MMX6 CM SFT FILLING COIL 400 DISP,SUP-2323390,CDM,C1889,HCPCS,0278,RC,,,,both,,,6964.52,4526.94,,,,,,,,,,,,,
BAND ORTHODONTIC M SZ 31 LO MAND S STL SEAMLESS CHAIRSIDE,SUP-2176640,CDM,D6783,CPT,0278,RC,,,,both,,,23.08,15.00,,,,,,,,,,,,,
CATHETER HD 24 CM 19 CM CHRONIC DLYS COMPLETE KT W/ MAK,SUP-2462131,CDM,C1750,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
CAGE SPNL 30X25X16MM 12DEG,SUP-2353267,CDM,C1889,HCPCS,0278,RC,,,,both,,,31243.00,20307.95,,,,,,,,,,,,,
KIT EXP CATH DBL LUMN MULT MED 7GAX20CM DBL MULT MED CATH,SUP-2214561,CDM,C1751,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
SPHERE EMB BEAD BLOCK DIA100-300 UM CATH 0.010 IN 2 ML YEL,SUP-2385092,CDM,C1889,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GRAFT HUM TISS GLEN DIA33MM 10X29MM GLENOJET,SUP-2123639,CDM,C1776,CPT,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
SET PICC L 55 CM DIA 4.5 FR SHTH L 7 CM DIA 4.5 FR,SUP-2887065,CDM,C1751,HCPCS,0278,RC,,,,both,,,639.52,415.69,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL L W120XL120MM THK0.3MM MALL,SUP-2419461,CDM,C1713,HCPCS,0278,RC,,,,both,,,7374.79,4793.61,,,,,,,,,,,,,
LINER ACET OD70MM ID28MM THK15.3MM 0DEG HIP POLYETH MTL MOD,SUP-2202064,CDM,C1776,CPT,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
NEEDLE PHACO 30 DEG 2.2 MM NS MICROFLOW 2.2 LF REUSE,SUP-2467799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,925.80,601.77,,,,,,,,,,,,,
CATHETER INFUS L134CM STENT L20MM DIA1MM 0.014IN THER LOC,SUP-2266023,CDM,C1751,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
OXYCODONE HCL 100 MG/5ML PO CONC,RX-10812,CDM,340b,HCPCS,0637,RC,00406-8557-30,NDC,,both,0.25,ML,4.20,2.73,,,,,,,,,,,,,
SPONGE DENT ABSORBABLE 12 2X6 CMX7 MM STRL GELFOAM,SUP-2322375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.96,322.37,,,,,,,,,,,,,
PASSER SUT NIT PLAS SGL DISP BIPASS,SUP-2212805,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
DIST HUM LAT LT 11H 103MM STE,SUP-2493154,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
INTRODUCER SHTH LNG 8 FR SAFSHTH,SUP-2465231,CDM,C1894,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 6FR DIA DST TIP 30MML CUT WIRE 195CML,SUP-2495294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1116.99,726.04,,,,,,,,,,,,,
PLATE BNE W10XL50MM THK1.5MM 4X3 H BILAT S STL T SHP R ANG,SUP-2185865,CDM,C1713,HCPCS,0278,RC,,,,both,,,868.74,564.68,,,,,,,,,,,,,
GRAFT BNE SUB 80CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264811,CDM,C1713,HCPCS,0278,RC,,,,both,,,2757.80,1792.57,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 100 MM DIA25 MM LIMB 40 MM 16 MM,SUP-2217669,CDM,C1768,CPT,0278,RC,,,,both,,,37441.36,24336.88,,,,,,,,,,,,,
NAIL IM 10 MM FEM RETRO AG TI STRL EXPERT,SUP-2180080,CDM,C1713,HCPCS,0278,RC,,,,both,,,5017.72,3261.52,,,,,,,,,,,,,
STYLET NAVIGATION 2 COIL PRB SGL STEREOTACTIC SURG SYS DISP,SUP-2284347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1703.45,1107.24,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 5FR 55CM S3395108D,SUP-2632853,CDM,C1751,HCPCS,0278,RC,,,,both,,,713.50,463.77,,,,,,,,,,,,,
BOOT CAST SM W5XL11 1 4IN OPN TOE AND HEEL MOLD ROCK,SUP-2276728,CDM,L4386,HCPCS,0272,RC,,,,both,,,16.17,10.51,,,,,,,,,,,,,
GRAFT DERMAL RECT 5.9X11.8 IN ANTIBACT XENMATRIX AB,SUP-2855242,CDM,C1781,HCPCS,0278,RC,,,,both,,,48663.72,31631.42,,,,,,,,,,,,,
SPLINT FNGR L W1XL18IN ALUMINUM MAL,SUP-2276741,CDM,L3933,HCPCS,0272,RC,,,,both,,,2.92,1.90,,,,,,,,,,,,,
HC Temp Pacer Insertion,PX-3613321000,CDM,33210,CPT,0361,RC,,,,outpatient,,,1599.00,1039.35,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY OPTRELL SM D-F CRV TRUEREF,SUP-2880079,CDM,C1732,HCPCS,0272,RC,,,,both,,,9014.94,5859.71,,,,,,,,,,,,,
PLATE BNE ORBIT FLR SM 1.5X35X35X0.5 MM LT SMRT TI NS,SUP-2460540,CDM,C1713,HCPCS,0278,RC,,,,both,,,3878.65,2521.12,,,,,,,,,,,,,
HEAD RAD H16MM OD20MM UNIV CO CHROM ANT DST EL STR MOD,SUP-2404362,CDM,C1776,CPT,0278,RC,,,,both,,,3432.96,2231.42,,,,,,,,,,,,,
IMPLANT BIO TISS W4XL4CM PORCINE DERM MTRX RECON THINNER,SUP-2388572,CDM,C1713,HCPCS,0278,RC,,,,both,,,6100.24,3965.16,,,,,,,,,,,,,
PLATE BNE X 1.5X1 MM 12 MM 4 HOLE OPN LOOP C-TUBE BRIDGE NS,SUP-2471280,CDM,C1713,HCPCS,0278,RC,,,,both,,,958.49,623.02,,,,,,,,,,,,,
WIRE FIX KIRSCHNER 110118] ZIMMER SPINE],SUP-2414586,CDM,C1769,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
GYN ESG PLASMA OVALBUTTON LNG 12 30 DEG,SUP-2727525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.44,1220.34,,,,,,,,,,,,,
SYSTEM TOT KNEE CEM FEM TIB COMP STD TIB INSRT STD PAT,SUP-2212213,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
SCREW IC NAIL LCK,SUP-2362475,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.66,153.18,,,,,,,,,,,,,
STENT BILI E-LUMINEXX L 20 MM DIA 5 MM CATH L 135 CM DIA 6,SUP-2128906,CDM,C1876,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG ACUTE 13.5FR DIA 24CML IN 5575240,SUP-2632906,CDM,C1752,HCPCS,0278,RC,,,,both,,,608.53,395.54,,,,,,,,,,,,,
COMPONENT FEM CNDYL END LT SZ 6,SUP-2208258,CDM,C1776,CPT,0278,RC,,,,both,,,26649.18,17321.97,,,,,,,,,,,,,
LEVEL NEURO ST MESH 3D ULTRNE NEURO SCRW100 MM DIA T06 MM C,SUP-2676605,CDM,C1713,HCPCS,0278,RC,,,,both,,,6333.88,4117.02,,,,,,,,,,,,,
SCREW BNE L18MM DIA4.2MM NONLOCKING PLT GORILLA R3CON,SUP-2321383,CDM,C1713,HCPCS,0278,RC,,,,both,,,522.03,339.32,,,,,,,,,,,,,
ALLOGRAFT BNE 200X25 MM FRZN RT PROX FEM SHFT W/ HD,SUP-2866865,CDM,C1762,CPT,0278,RC,,,,both,,,17748.85,11536.75,,,,,,,,,,,,,
REAMER BLDE PAT 47MM SCORP - 47MM,SUP-2365124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
BAND SPNL 5.5 MM 2 MALL END VERSATIE,SUP-2562505,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BONE 6 H INFERIOR DSTL CLAV LCK PERI-LOC,SUP-2349100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1700.15,1105.10,,,,,,,,,,,,,
GRAFT BIO TISS W0.8XL8CM DECELLULARIZED BOV PERICARD PTCH,SUP-2175265,CDM,C1763,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
WIRE FIX DIAMOND PT 2 END 0.045X9 IN SS NS KIRSCHNER KI71212,SUP-2791592,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.79,5.71,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.532,SUP-2860213,CDM,C1713,HCPCS,0278,RC,,,,both,,,38541.93,25052.25,,,,,,,,,,,,,
GRAFT BONE PRO DENS 12CC,SUP-2399149,CDM,C1713,HCPCS,0278,RC,,,,both,,,10152.00,6598.80,,,,,,,,,,,,,
PLATE BNE CORONOID EXT RT ELBW LCK TI,SUP-2518745,CDM,C1713,HCPCS,0278,RC,,,,both,,,3896.74,2532.88,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RESPON L 120CM 6FR 2-2-2MM SZ 2MM,SUP-2538049,CDM,C1730,HCPCS,0272,RC,,,,both,,,254.03,165.12,,,,,,,,,,,,,
NAIL INTRMDLLRY LOK CNNLTD UNVRSL 8MM DIA 255MML TTNM ALLOY,SUP-2587449,CDM,C1713,HCPCS,0278,RC,,,,both,,,3716.94,2416.01,,,,,,,,,,,,,
CLIP ENDO L165CM NIT PT PRELD HND WHL MOD 112/6T FOR GASTSCP,SUP-2319930,CDM,C1889,HCPCS,0278,RC,,,,both,,,1739.56,1130.71,,,,,,,,,,,,,
KIT CATHETER ARTERIAL ARROW SAFETY 18GA 12CM INDWELLING,SUP-2865695,CDM,C1751,HCPCS,0278,RC,,,,both,,,271.92,176.75,,,,,,,,,,,,,
CLAMP EXT FIX CORR 4 ANGULAR,SUP-2197307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
PLATE BNE W17.5XL106MM THK5.2MM 6 H TI BROAD LIMIT CNTCT,SUP-2190840,CDM,C1713,HCPCS,0278,RC,,,,both,,,848.15,551.30,,,,,,,,,,,,,
SCREW SPNL L13MM DIA3.5MM CANC ANT CERV TI ALLY SELF DRL,SUP-2291182,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CUP ACET OD44MM CO CHROM HA POR HIP IMPCT ST IMPL DISP FOR,SUP-2350842,CDM,C1776,CPT,0278,RC,,,,both,,,15562.63,10115.71,,,,,,,,,,,,,
PROSTHESIS PENILE L20CM DIA13MM CYL MALL 650,SUP-2140268,CDM,C1813,HCPCS,0278,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 6 FRX20 CM 21 GAX15 CM SS TROCAR,SUP-2303020,CDM,C1894,HCPCS,0272,RC,,,,both,,,192.73,125.27,,,,,,,,,,,,,
SHUNT CV L14MM DIA3MM IC SIL TAPR TIP RADPQ CLRVW,SUP-2278146,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
NEEDLE ASPIR L10CM NTHRD FOR SPNL CRD STIM,SUP-2419161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
CATHETER CV 2 LUMEN 5 FR INJ PICC CT,SUP-2342114,CDM,C1751,HCPCS,0278,RC,,,,both,,,595.97,387.38,,,,,,,,,,,,,
GUIDEWIRE ORTHPDC 2.4MM DIA 100CML TEAR DROP NAT NAIL ST,SUP-2459213,CDM,C1769,HCPCS,0272,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
KIT SPL NEUROSTIMULATOR 2X8 CNTCT 30 CM,SUP-2138804,CDM,C1883,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
HANDLE OBTURATOR DETACHABLE NS ECTRA II LTX,SUP-2877785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,867.11,563.62,,,,,,,,,,,,,
HC Perq Lumbosacral Injection,PX-3612251100,CDM,22511,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
ARSENIC TRIOXIDE 10 MG/10ML IV SOLN,RX-29071,CDM,J9017,HCPCS,0636,RC,14789-0600-10,NDC,,both,10,ML,1619.30,1052.54,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH PERM RECV,SUP-2917082,CDM,C1816,LOCAL,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BNE L113MM 6 H R PROX MED PERIARTC TIB S STL,SUP-2410552,CDM,C1713,HCPCS,0278,RC,,,,both,,,2338.99,1520.34,,,,,,,,,,,,,
RETRIEVER THROMCTMY TREVO XP PROVUE L 20 MM DIA 3 MM NIT,SUP-2367791,CDM,C1757,HCPCS,0272,RC,,,,both,,,22518.20,14636.83,,,,,,,,,,,,,
CATHETER DRAINAGE 2.1X20 MM 1 CC VENTRICULAR FLAT DOME,SUP-2277915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.31,628.75,,,,,,,,,,,,,
PLATE BNE HK LNG 2.7X12 MM LT CLAV VA LCK NS VA-LCP,SUP-2758175,CDM,C1713,HCPCS,0278,RC,,,,both,,,3830.55,2489.86,,,,,,,,,,,,,
PLATE BNE TBLR 73 MM 6 HOLE 1/3 STRL,SUP-2518439,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
PLATE BONE 4 H S STL T SHP BTTRS ECT,SUP-2198568,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.56,390.36,,,,,,,,,,,,,
GRAFT BNE STRP 22X18X8 MM DBM,SUP-2327816,CDM,C9362,HCPCS,0278,RC,,,,both,,,10412.24,6767.96,,,,,,,,,,,,,
ORAL SWEETENER (MIXTURES ONLY),RX-430033,CDM,2580000003,HCPCS,0250,RC,00395-2661-16,NDC,,both,473,ML,66.00,42.90,,,,,,,,,,,,,
CATHETER THOR DIA36FR SIL STR W/ CLOT STP STAB-PULL END,SUP-2124836,CDM,C1729,HCPCS,0272,RC,,,,both,,,66.57,43.27,,,,,,,,,,,,,
CABLE VENTILATOR NEONATAL EDI MOD W/ TST PLUG FOR SERVO,SUP-2747016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1244.95,809.22,,,,,,,,,,,,,
ROD EXT FIX L80MM LNG THRD SLT MR CONDITIONAL FOR DISTRCTN,SUP-2187909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,189.44,123.14,,,,,,,,,,,,,
HC So1 Microsomal Antibody,PX-3028637667,CDM,86376,CPT,0302,RC,,,,both,,,495.00,321.75,,,,,,,,,,,,,
MESH CRAN W100XL100MM THK0.6MM PNK TI RIG CNTOUR,SUP-2181604,CDM,C1781,HCPCS,0278,RC,,,,both,,,6933.12,4506.53,,,,,,,,,,,,,
PLATE BONE W9.2XL49MM THK1.3MM 100DEG 4 H TI TBLR FOR 3.5MM,SUP-2412034,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.79,150.01,,,,,,,,,,,,,
NUT EXT FIX DIA10 MM QR LCK HEX NS DISP MONK RING,SUP-2899081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.87,555.67,,,,,,,,,,,,,
HC Intro Cath in Svc or Ivc,PX-3613601000,CDM,36010,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
TROCAR SURG CEPHALOMEDULLARY LAG SCREW DBL BRL,SUP-2459867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
PLATE ADAPTER DIST LAT FEMUR RIGHT,SUP-2706389,CDM,C1713,HCPCS,0278,RC,,,,both,,,4548.29,2956.39,,,,,,,,,,,,,
HINGE EXT FIX STRL TRUELOK TORNADO LTX,SUP-2875238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11869.20,7714.98,,,,,,,,,,,,,
HC Group Exercise Pt,PX-4209715000,CDM,97150,CPT,0420,RC,,,,inpatient,,,135.00,87.75,,,,,,,,,,,,,
PLATE BONE L100MM BRL L1IN 140DEG SH BILAT 4 SLOT KEYLESS,SUP-2342464,CDM,C1713,HCPCS,0278,RC,,,,both,,,3715.88,2415.32,,,,,,,,,,,,,
SHEATH INTRO PINNACLE PRECIS ACCS SYS L 10 CM DIA 48FR BLK,SUP-2385255,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.22,123.64,,,,,,,,,,,,,
KAR HA FEMORAL STEM 16MM,SUP-2823399,CDM,C1776,CPT,0278,RC,,,,both,,,17143.14,11143.04,,,,,,,,,,,,,
BIT DRL DIA3.3MM CANN QUIK CPL FOR SM SCR SYS,SUP-2344066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2278.26,1480.87,,,,,,,,,,,,,
ROD FIXATION 300MM,SUP-2854266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2238.32,1454.91,,,,,,,,,,,,,
TRAY BX SZ 2 BLLN L10MM IBT ADD FRAC KYPHON EXPR KYPHON,SUP-2293624,CDM,C1713,HCPCS,0278,RC,,,,both,,,5331.72,3465.62,,,,,,,,,,,,,
CLIP INT LIG LG CHEVRON SHP TI ORNG STRL DISP,SUP-2757597,CDM,C1889,HCPCS,0278,RC,,,,both,,,16.64,10.82,,,,,,,,,,,,,
COMPONENT HIP CAPPED UPLR,SUP-2365529,CDM,C1776,CPT,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
SCREW BNE COMPR SHT THRD 3.5X18 MM CANN HDLSS TI NS,SUP-2422324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1191.94,774.76,,,,,,,,,,,,,
GUIDEWIRE 14INX.062IN DIA NIT HYPRFLX,SUP-2166838,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.64,49.17,,,,,,,,,,,,,
RING 180MM,SUP-2492232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4657.25,3027.21,,,,,,,,,,,,,
PSN REV TM FEM CENTRAL CONE SZ SM,SUP-2508669,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
LINER ACET ELEV 0 DEG 26MM ID SZ D,SUP-2205870,CDM,C1776,CPT,0278,RC,,,,both,,,4796.35,3117.63,,,,,,,,,,,,,
PLATE BNE TALO NAVICULAR SM TI RIVAL VW,SUP-2645290,CDM,C1713,HCPCS,0278,RC,,,,both,,,5209.26,3386.02,,,,,,,,,,,,,
R3 0 DEGREE +4 28MM XLPE LINER 42MM,SUP-2822957,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
CATHETER GUID R2P SLENGUIDE L 150 CM COAT L 300 MM OD 7 FR,SUP-2519310,CDM,C1887,HCPCS,0272,RC,,,,both,,,947.50,615.87,,,,,,,,,,,,,
BIT DRL DIA2.5MM DISP FOR 3.5MM LOK PROX FEM SCR PEDILOC,SUP-2318877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.06,399.79,,,,,,,,,,,,,
TUNNELER SURG L 450 MM MED RIGID NO RNG MARKING STRL DISP 10/PK,SUP-2928801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.39,283.00,,,,,,,,,,,,,
MESH HERN W10XL15CM THN OXIDIZED REGENERATED CELOS POLYPR,SUP-2219766,CDM,C1781,HCPCS,0278,RC,,,,both,,,1761.13,1144.73,,,,,,,,,,,,,
INSERT ACET OD50MM ID22MM 0DEG HIP UHMWPE CONSTRN OMFIT II,SUP-2370343,CDM,C1776,CPT,0278,RC,,,,both,,,6817.57,4431.42,,,,,,,,,,,,,
GRAFT BNE SUB 5CC SZ 1 5MM MILLED CANC CHIP FRZ DRY FOR,SUP-2307068,CDM,C1713,HCPCS,0278,RC,,,,both,,,603.19,392.07,,,,,,,,,,,,,
SET SCR SPNL AILEVON 5 MM,SUP-2264535,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE 4 HOLE TI NS LC-DCP,SUP-2190802,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.93,152.05,,,,,,,,,,,,,
GRAFT BNE KT 3 CC GENEX,SUP-2866999,CDM,C1713,HCPCS,0278,RC,,,,both,,,4330.06,2814.54,,,,,,,,,,,,,
MESH SURG W6XL8IN RECT FULL REABSORBABLE FOR SFT TISS RECON,SUP-2125870,CDM,C1781,HCPCS,0278,RC,,,,both,,,11916.30,7745.59,,,,,,,,,,,,,
LENS INTOCU 17.0 DIOPT L13MM D6MM 0DEG ANG HAPTIC UV AND,SUP-2112144,CDM,V2787,HCPCS,0276,RC,,,,both,,,895.00,581.75,,,,,,,,,,,,,
WIRE FIX L70MM DIA1MM FOR HALLU-LOCK MTP ARTH SYS K,SUP-2242878,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.59,75.78,,,,,,,,,,,,,
HC Stab Phlebectomy 10-20,PX-3613776500,CDM,37765,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
HC So1 Hepatitis B Core Antibody,PX-3028670467,CDM,86704,CPT,0302,RC,,,,both,,,734.00,477.10,,,,,,,,,,,,,
SHAVER SURG ULTRA MINI 10 MM UTER TISS REMOVING TRUCLEAR,SUP-2172312,CDM,C1782,HCPCS,0272,RC,,,,both,,,2908.43,1890.48,,,,,,,,,,,,,
CATHETER MAP 20 MM ACHVE,SUP-2500842,CDM,C1730,HCPCS,0272,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
MARKER RAD OD10MM COIL FIDUCIAL SUPERLOCK,SUP-2381754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 209X12X3 MM FRZN STRUT,SUP-2717896,CDM,C1762,CPT,0278,RC,,,,both,,,4619.00,3002.35,,,,,,,,,,,,,
SHEARS ENDO L17CM LNG CVD TIP HARM FOCUS,SUP-2219044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1889.71,1228.31,,,,,,,,,,,,,
DEVICE PESSARY DIA2.75IN SIL FLEX GELLHORN FOR 3RD DEG,SUP-2171827,CDM,A4562,HCPCS,0274,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
CATHETER CARD ABLATION BLZR PRIM HTD L 110 CM DIA 7 FR TIP 4,SUP-2141342,CDM,C1731,HCPCS,0278,RC,,,,both,,,3309.56,2151.21,,,,,,,,,,,,,
SCREW BNE PART THRD 5X110 MM PANTA,SUP-2609755,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.78,1220.56,,,,,,,,,,,,,
DEVICE DIL MULT SNUS TOOL XPRESS,SUP-2217796,CDM,C1726,HCPCS,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
MESH HERN REP SOFT-TISSUE RECON ELP W/ POS SYS 7X9INCH,SUP-2125918,CDM,C1781,HCPCS,0278,RC,,,,both,,,3928.14,2553.29,,,,,,,,,,,,,
PHENOBARBITAL 20 MG/5ML PO ELIX,RX-6212,CDM,340b,HCPCS,0637,RC,09999-9911-31,NDC,,both,7.5,ML,2.70,1.75,,,,,,,,,,,,,
COVER BUR H 10MM W/ TAB,SUP-2365222,CDM,C1713,HCPCS,0278,RC,,,,both,,,1000.25,650.16,,,,,,,,,,,,,
CATHETER ETER PERI L90CM STD BA IMPREG OPN END W WALL SLT,SUP-2278359,CDM,C1750,HCPCS,0278,RC,,,,both,,,402.49,261.62,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5 MM 7 HOLE CONTOURED 2 COMPR RECON,SUP-2470716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.84,901.45,,,,,,,,,,,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,0636,RC,55150-0119-30,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
BUR REPROC SURG RND LNG HIP FORMULA 8-FLUT 5.5MM,SUP-2653237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,102.21,66.44,,,,,,,,,,,,,
ALLOGRAFT BNE STRP MED FD IRRADIATED IL CREST,SUP-2867107,CDM,C1762,CPT,0278,RC,,,,both,,,5703.50,3707.27,,,,,,,,,,,,,
SYSTEM IMPL DEL PEC REP FOR FIX OF SFT TISS TO BNE,SUP-2121669,CDM,C1776,CPT,0278,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
TEMPLATE SZ LG GRID 125X125X0.6 MM MXLFCL RESORB-X LF,SUP-2479310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.34,321.97,,,,,,,,,,,,,
TRAY NEO PICC 2 PREFIL SYRINGES PIGGY-BACKED 384825] ARGON MEDICAL DEVICES INC],SUP-2120076,CDM,C1751,HCPCS,0278,RC,,,,both,,,104.31,67.80,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE SM IN-LINE PRIMING ADPT CERTAS +,SUP-2666577,CDM,C1889,HCPCS,0278,RC,,,,both,,,11914.89,7744.68,,,,,,,,,,,,,
ENDOPROBE LRIDEX 10547-120 GA 45 DEGREE,SUP-2885287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
ELIMINATOR H APEX FOR 48-60MM PINN HIP SHELL,SUP-2250733,CDM,C1776,CPT,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
HEAD HUM H17.25MM DIA46MM STD SHLDR CO CHROM REV NECKLESS,SUP-2193859,CDM,C1776,CPT,0278,RC,,,,both,,,7987.03,5191.57,,,,,,,,,,,,,
INFINITY ADAPTIS TALDOME SZ3 INFINITY ADAPTIS,SUP-2822349,CDM,C1776,CPT,0278,RC,,,,both,,,9272.42,6027.07,,,,,,,,,,,,,
BUR SURGICAL L90MM DIAMETER 3MM 120 GRIT DEEP ACCESS DIAMETE,SUP-2843183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,885.70,575.70,,,,,,,,,,,,,
CUTTER BOLT 52MM OUTER TB,SUP-2289763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2292.73,1490.27,,,,,,,,,,,,,
REAMER SURG 11MM GRY FEM FLEX SHFT FIX COMMND,SUP-2362248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1329.16,863.95,,,,,,,,,,,,,
BIT DRILL OD4 MM STERILE LATEX GRIDLOCK SCREW,SUP-2880118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
HC Spinal Puncture Lumbar Diagnos,PX-4506227000,CDM,62270,CPT,0450,RC,,,,inpatient,,,2232.00,1450.80,,,,,,,,,,,,,
ELECTRODE KIT RF 15 CM 3 PRB COOL TIP,SUP-2243995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.4MM MAXILLOMANDIBULAR TI NONLOCKING HI,SUP-2403058,CDM,C1713,HCPCS,0278,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 147 MM DIA28 MM SHTH 20 FR SS,SUP-2171024,CDM,C1874,HCPCS,0278,RC,,,,both,,,20651.78,13423.66,,,,,,,,,,,,,
SCREW BNE L 36 MM DIA 4 MM LNG TI FT ST SD CANN PARTIALLY,SUP-2900638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
PIN FIX 700650002] ZIMMER SPINE],SUP-2415675,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE BNE L49MM -90DEG 2X4 H NONSTERILE L DST DORS RAD R,SUP-2177519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2140.91,1391.59,,,,,,,,,,,,,
"HC So Cortisol,Serum",PX-3018253366,CDM,82533,CPT,0301,RC,,,,both,,,212.00,137.80,,,,,,,,,,,,,
SET THROMCTMY ANGIOJET FETCH 2 L 135 CM DIA 4 FR SHTH 5 FR,SUP-2142037,CDM,C1757,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
RING HALF 130MM FOR TRUELOK FIX SYS,SUP-2316176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.57,906.47,,,,,,,,,,,,,
UNIT COMPR DISTR EXTENDS TO 5CM FOR SM FIX,SUP-2316030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1076.27,699.58,,,,,,,,,,,,,
DRILL SURG KATSUYA 2 MM STRL LTX DISP,SUP-2860992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE",PX-4209711000,CDM,97110,CPT,0420,RC,,,GP|CQ|XU,both,,,195.00,126.75,,,,,,,,,,,,,
COLLAR CERV H3XL22IN 1 SZ FIT MOST ADJ HK AND LOOP CLSR,SUP-2194445,CDM,L0180,HCPCS,0274,RC,,,,both,,,7.47,4.86,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX14 RIGHT MEDIAL DISTAL TIBIAL,SUP-2458801,CDM,C1713,HCPCS,0278,RC,,,,both,,,4429.57,2879.22,,,,,,,,,,,,,
PLATE CRAN W15XL15CM WIRE 0.010IN TI MAL ST FOR,SUP-2243572,CDM,C1713,HCPCS,0278,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
ELECTRODE ELECSURG CUT LOOP 22.5 FR 0.035 IN HF RESECT STRL,SUP-2470805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.19,221.77,,,,,,,,,,,,,
PLATE BNE STR 12X0.6 MM NEURO 2 HOLE TI NS LEVEL 1 ULTRAONE,SUP-2518092,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.41,170.57,,,,,,,,,,,,,
PLATE BONE TUBULAR 49 MM 4 HOLE 1/3 WITH COLLAR STERILE TC10,SUP-2836662,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.74,334.58,,,,,,,,,,,,,
KIT GASTSTMY COMPHSVE INIT PLCMNT,SUP-2119857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL SHLF,SUP-2435544,CDM,L0469,HCPCS,0274,RC,,,,both,,,1346.15,875.00,,,,,,,,,,,,,
TAP SURG DIA65MM CANC CANN,SUP-2412175,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.528,SUP-2860045,CDM,C1713,HCPCS,0278,RC,,,,both,,,42067.52,27343.89,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK02 04MM ACELLULAR DERM MTRX,SUP-2307507,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2143.99,1393.59,,,,,,,,,,,,,
PLATE BNE TI ALLOY LAPIDUS REV NS LEOS,SUP-2933560,CDM,C1713,HCPCS,0278,RC,,,,both,,,4107.12,2669.63,,,,,,,,,,,,,
CATHETER GUID OUTBACK LTD L 120 CM SHTH 6 FR CROSSING PROF,SUP-2155728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM CORT TI ST FULL THRD SM HEX FOR,SUP-2189693,CDM,C1713,HCPCS,0278,RC,,,,both,,,118.44,76.99,,,,,,,,,,,,,
TOBRAMYCIN 0.3 % OP SOLN,RX-7995,CDM,6370000000,HCPCS,0637,RC,62332-0518-05,NDC,,both,5,ML,69.80,45.37,,,,,,,,,,,,,
SHEATH INTRO 6FR L25CM PINN SUP SHTH,SUP-2139615,CDM,C1894,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 1-5MM MILLED CANC CHIP FRZ DRY,SUP-2307069,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
IMPACTOR SURG FIX BEAR TIB ATTUNE,SUP-2454781,CDM,C1776,CPT,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
HC So Smear Complex Stain,PX-3008720966,CDM,87209,CPT,0300,RC,,,,both,,,119.00,77.35,,,,,,,,,,,,,
SHELL BPLR OD51MM ID36MM ACET 1 PC GLADIATOR,SUP-2304608,CDM,C1776,CPT,0278,RC,,,,both,,,7143.50,4643.27,,,,,,,,,,,,,
GUIDEWIRE VASC L 125 CM DIA 0.032 IN TIP L 3 MM SS PTFE J,SUP-2120089,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.41,25.62,,,,,,,,,,,,,
BIT DRL QC 2.8X200 MM 110 MM CALIB STRL,SUP-2563761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.52,317.54,,,,,,,,,,,,,
TRIATHLON CR TIB INSRT TRL NO 3 - 13MM,SUP-2363757,CDM,C1776,CPT,0278,RC,,,,both,,,402.08,261.35,,,,,,,,,,,,,
NAIL INTRAMEDULLARY MEDIUM COMPLETE KNEE SYSTEM STERILE VANG,SUP-2836599,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
IMPLANT OTO L 59 X W 34 MM THK 19.5 MM SM POLYETHYL LT EAR 1,SUP-2883686,CDM,L8699,HCPCS,0278,RC,,,,both,,,5831.73,3790.62,,,,,,,,,,,,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP,RX-11567,CDM,6370000000,HCPCS,0637,RC,61314-0647-25,NDC,,both,2.5,ML,170.70,110.95,,,,,,,,,,,,,
PLATE BNE L65MM STD 3 H L OLECRANON EL TI LO PROF,SUP-2106999,CDM,C1713,HCPCS,0278,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
ASPIRATION NEEDLE 8G X 23CM OPEN TIP,SUP-2765989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF L115CM 8FR F,SUP-2248618,CDM,C1732,HCPCS,0272,RC,,,,both,,,9410.58,6116.88,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH 115CM 8FR D CRV,SUP-2248609,CDM,C1732,HCPCS,0272,RC,,,,both,,,9457.68,6147.49,,,,,,,,,,,,,
STENT URET FLEXIMA L 22 CM DIA 6 FR TECOFLEX GLDEX 2 PIGTL,SUP-2147885,CDM,C2617,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
TRETINOIN 10 MG PO CAPS,RX-16005,CDM,6370000000,HCPCS,0637,RC,00904-6867-04,NDC,,both,1,UN,137.30,89.24,,,,,,,,,,,,,
FOOTRING EXT FIX SHT TENXOR CP49360131,SUP-2530924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11301.17,7345.76,,,,,,,,,,,,,
HC Glucose Post Glucose Dose,PX-3018295000,CDM,82950,CPT,0301,RC,,,,outpatient,,,274.00,178.10,,,,,,,,,,,,,
CANNULA ARTHSCP IRRIGATION 3.2 MMX7 CM OBTURATOR 28146 QO LF,SUP-2768400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.50,369.52,,,,,,,,,,,,,
ENDOPROSTHESIS BILI VIABIL L 8 CM DIA10 MM L 200 CM H L 2CM,SUP-2883727,CDM,C1874,HCPCS,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
HC Deb Skin Bone at Fx Site,PX-4501101200,CDM,11012,CPT,0450,RC,,,,both,,,8335.00,5417.75,,,,,,,,,,,,,
GUIDEWIRE ORTH L220MM DIA1.6MM S STL FULL THRD TRCR PNT,SUP-2184962,CDM,C1769,HCPCS,0272,RC,,,,both,,,92.16,59.90,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 0.086 MM LASER LN SS QUICKFIX DISP,SUP-2122468,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
LEAD PACE L52CM INTRO 9FR SIL INSUL TINES FIX IS-1 BPLR CONN,SUP-2356069,CDM,C1779,HCPCS,0275,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
SET SCREW OCCIPTITAL GIBRALT,SUP-2661347,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE 7 H R PROX TIB TIM STD CRV LOK ALPS,SUP-2413736,CDM,C1713,HCPCS,0278,RC,,,,both,,,3803.80,2472.47,,,,,,,,,,,,,
ALLOGRAFT DRML THICK 20X8 CM READY USE TSSUE MTRX ALLDRM,SUP-2496506,CDM,Q4116,HCPCS,0636,RC,,,,both,,,17335.94,11268.36,,,,,,,,,,,,,
CANNULA VENTRICULAR 9 FR CSF DRN SYS CRANIA ELSBERG,SUP-2666333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.53,883.69,,,,,,,,,,,,,
HC MRI-Abdomen W & WO Contrast,PX-6107418300,CDM,74183,CPT,0610,RC,,,,both,,,4220.00,2743.00,,,,,,,,,,,,,
COIL EMB L5CM DIA5MM 0.035IN FOR ART AND VEN VES MREYE,SUP-2170375,CDM,C1889,HCPCS,0278,RC,,,,both,,,345.37,224.49,,,,,,,,,,,,,
PLATE BNE L27MM 2 H NONSTERILE BILAT TARSOMETATARSAL TI STR,SUP-2181253,CDM,C1713,HCPCS,0278,RC,,,,both,,,2732.93,1776.40,,,,,,,,,,,,,
FIBER LASER HOLMIUM 600 OLYMPUS,SUP-2885280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
CATHETER DIL 10FR L200CM TAPR TIP 7.5-4FR L4CM 0.035IN GRAD,SUP-2169269,CDM,C1726,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
HALF PIN 4X120MM 30MM THR,SUP-2818387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.82,510.78,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 8MM STR STD WALL SLDE GDE,SUP-2525463,CDM,C1768,CPT,0278,RC,,,,both,,,1968.43,1279.48,,,,,,,,,,,,,
AUTOINJECTOR STENT GRFT OVATION PRIM PMA STRL,SUP-2217723,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HC Application of Paste Boot,PX-4502958000,CDM,29580,CPT,0450,RC,,,,both,,,357.00,232.05,,,,,,,,,,,,,
BIT DRL L110MM DIA1.6MM STP 26MM PERC FOR IQ SER,SUP-2136987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
AUGMENT FEM L55MM THK6MM LT MEDL RT LAT DSTL KNEE CONSTRN,SUP-2405614,CDM,C1776,CPT,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
BIT DRL CANN 2.7X145 MM QC STRL,SUP-2563800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1480.95,962.62,,,,,,,,,,,,,
SCREW BNE FUSION LG 7.4X55 MM SS STRL G-BEAM,SUP-2646307,CDM,C1713,HCPCS,0278,RC,,,,both,,,5940.88,3861.57,,,,,,,,,,,,,
GRAFT BNE 2 CC CELLULAR BNE MTRX OSSEOGEN,SUP-2858499,CDM,C1713,HCPCS,0278,RC,,,,both,,,2093.75,1360.94,,,,,,,,,,,,,
KIT LD COILED BLNK STRL,SUP-2905280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CROWN DENT 7 S STL 1ST PRI M LO LT ANTR CUSPID PREFABRICATED,SUP-2238892,CDM,D6783,CPT,0278,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
COMPONENT ULNA DISCOVERY WITH BEARING E+ RIGHT 4.0X155MM,SUP-2879098,CDM,C1776,CPT,0278,RC,,,,both,,,18833.72,12241.92,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN PASV,SUP-2308260,CDM,C1788,HCPCS,0278,RC,,,,both,,,487.39,316.80,,,,,,,,,,,,,
SHEARS ROBOTIC DIA5MM CRV INSRT ENDOSCP DISP FOR HARM ACE,SUP-2246590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
CONNECTOR SHUNT TYP A,SUP-2666433,CDM,C1889,HCPCS,0278,RC,,,,both,,,115.36,74.98,,,,,,,,,,,,,
PLATE BNE L196MM 10 H NONSTERILE L MED DST TIB LOK FOR 35MM,SUP-2348485,CDM,C1713,HCPCS,0278,RC,,,,both,,,13127.40,8532.81,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 80 CM DIA 7 FR HYDRPHLC,SUP-2383410,CDM,C1894,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
KNIFE SURG CIR BLADE 2.2 MM 1 IN ARACH ULTRA THN BAYNT HNDL (MIN QTY 5),SUP-2516359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SET PICC L 1 3/4 IN DIA22 GA SHTH L 1 1/4 IN DIA 3 FR,SUP-2887112,CDM,C1769,HCPCS,0272,RC,,,,both,,,66.57,43.27,,,,,,,,,,,,,
NUT REDUC SPNL VERT BODY THRD POST SCR TSRH 3D,SUP-2289809,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.75,748.64,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET SPIROFLEX VG L 135 CM DIA14 FR,SUP-2277424,CDM,C1757,HCPCS,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
PLATEXSTERNAL 2402541,SUP-2262572,CDM,C1713,HCPCS,0278,RC,,,,both,,,2226.26,1447.07,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT MAGNA MT OD 25 MM ID 24 MM SEW,SUP-2214107,CDM,C1713,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
NAIL IM L320MM DIA11MM 130DEG ST GRN FEM TI LOK UNREAMED AG,SUP-2192564,CDM,C1713,HCPCS,0278,RC,,,,both,,,3888.32,2527.41,,,,,,,,,,,,,
PLATE BONE 4 HOLE TITANIUM GRIDLOCK VLC PLATING SYSTEM FOR 2.4/3/4MM SCREW CUSTOM,SUP-2878334,CDM,C1713,HCPCS,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
COLLAR CERV MULT POST BRAC VISTA,SUP-2388138,CDM,L0190,HCPCS,0274,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 5 MM STR STD WALL REINF,SUP-2462070,CDM,C1768,CPT,0278,RC,,,,both,,,1043.77,678.45,,,,,,,,,,,,,
CATHETER INFUSION 2.4 FRX120 CM EXPANDABLE TIP SYS TRINAV,SUP-2424166,CDM,C1982,HCPCS,0278,RC,,,,both,,,24335.00,15817.75,,,,,,,,,,,,,
GRAFT BONE SUB 1CM MESH CARTIFORM,SUP-2319181,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PIN FIX AXIS 2.5X35 MM ELBW COCR IJS,SUP-2434522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
BLADE SAW L 73 MM L 15 MM THK MATERIAL 0.4 MM CUT 0.6 MM,SUP-2929422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.87,607.67,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 2X12 CMX1-2 MM PROLAYER,SUP-2717796,CDM,C1763,HCPCS,0278,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
PLATE BNE MESHED LG RT CALCANEAL LCK NS A.L.P.S,SUP-2465006,CDM,C1713,HCPCS,0278,RC,,,,both,,,2997.07,1948.10,,,,,,,,,,,,,
BIT DRILL 2.8MM X 165MM STRL SYNTHES 310.288S,SUP-2849040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.11,219.12,,,,,,,,,,,,,
PLATE BNE FIBULAR RT LAT 9-15 HOLE,SUP-2865050,CDM,C1713,HCPCS,0278,RC,,,,both,,,5096.22,3312.54,,,,,,,,,,,,,
REAMER LAPIDUS NAIL CANN 5.5MM,SUP-2321048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
HC Cardiolipin Antibody Each Ig Class,PX-3028614700,CDM,86147,CPT,0302,RC,,,,both,,,138.00,89.70,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LIFT ELEVATION MTL EXTN,SUP-2435717,CDM,L3330,HCPCS,0274,RC,,,,both,,,1602.25,1041.46,,,,,,,,,,,,,
COMPONENT FEM L3CM L DST FEM KNEE RESURF ORTH SALV SYS,SUP-2405702,CDM,C1776,CPT,0278,RC,,,,both,,,17803.80,11572.47,,,,,,,,,,,,,
SHEAR THRM LGTNG VRSTLTY W/PWR CORD CNSTNT VSBLTY CMFRT AUDB,SUP-2693695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
BIT COUNTERSINK 2MM L17MM AO,SUP-2705064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,642.92,417.90,,,,,,,,,,,,,
WALKER ANK L SHT STD BLK COMP SHELL NONSKID HK LO CLSR,SUP-2276717,CDM,L4387,HCPCS,0274,RC,,,,both,,,78.12,50.78,,,,,,,,,,,,,
MESH SURG W15XL20CM OPTIMIZED COMP SKIRTED PARIETEX,SUP-2174718,CDM,C1781,HCPCS,0278,RC,,,,both,,,3985.45,2590.54,,,,,,,,,,,,,
BLADE OSTEO SAW HUB STYL S,SUP-2107137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
COUNTERSINK SURG FT ANK CANN FOR 2/2.4MM QUICKFIX SCR SYS,SUP-2122469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 29.5-32 IN CTR 21-23 IN CALF 22-24 IN 11-1443-7,SUP-2918716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.34,688.57,,,,,,,,,,,,,
BAG VENT ASST L SHWR PERS SUPP,SUP-2282568,CDM,Q0501,HCPCS,0274,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SPLINT SWEDISH AFO M RT WHT,SUP-2324310,CDM,L4350,HCPCS,0274,RC,,,,both,,,67.70,44.00,,,,,,,,,,,,,
PIN EXT FIX L80MM OD3MM THRD L15MM TI NITRIDE HALF CORETRAK,SUP-2399883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
PLATE SPNL UNIV S STL CONN POST COLORADO 2 SACROILIAC FIX,SUP-2290571,CDM,C1713,HCPCS,0278,RC,,,,both,,,3289.78,2138.36,,,,,,,,,,,,,
NAIL IM L340MM DIA115MM LNG UNIV FEM TI ALLY RG,SUP-2208192,CDM,C1713,HCPCS,0278,RC,,,,both,,,6313.16,4103.55,,,,,,,,,,,,,
BASEPLATE TIB HYBRID 63 MM KNEE POLYETH OSS,SUP-2441735,CDM,C1776,CPT,0278,RC,,,,both,,,9566.01,6217.91,,,,,,,,,,,,,
CATHETER CV 3L 6 FRX55 CM ENDEXO NURSING KT 2 NIT BIOFLO,SUP-2734875,CDM,C1751,HCPCS,0278,RC,,,,both,,,148.21,96.34,,,,,,,,,,,,,
CROWN DENT SZ UL1 UP LT CTRL PRI M TRNSPAR SHADE S STL THCK,SUP-2238787,CDM,D6783,CPT,0278,RC,,,,both,,,31.56,20.51,,,,,,,,,,,,,
PROBE KIT ANGLED WRNCH TI COPPER SONICONE OR,SUP-2745916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2343.23,1523.10,,,,,,,,,,,,,
KIT SPNL INSTR MILD DEV W/ INITIATOR ACCS AUGER RONGEUR,SUP-2927440,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
HC So Blood Typing Patient Serum,PX-3008690466,CDM,86904,CPT,0300,RC,,,,inpatient,,,163.00,105.95,,,,,,,,,,,,,
CATHETER CARD ABLATION BLZR II XP L 110 CM DIA 7 FR TIP 8 MM,SUP-2141262,CDM,C1733,HCPCS,0272,RC,,,,both,,,4609.52,2996.19,,,,,,,,,,,,,
SCREW BNE CANN 6.5X80 MM COMPR FT TI STRL 04355780S,SUP-2787796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1182.15,768.40,,,,,,,,,,,,,
PROBE SURG MECHANOMYOGRAPHY LAT RAIL SS NS,SUP-2693684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
INSTRUMENT KIT BLK PROPHECY,SUP-2304850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 18.5MMW X28.5MML 0.4MM THK SM BNE FN TOOT,SUP-2605384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,74.95,48.72,,,,,,,,,,,,,
HC Bedside Swallowing Eval,PX-4449261000,CDM,92610,CPT,0444,RC,,,,both,,,355.00,230.75,,,,,,,,,,,,,
TACROLIMUS ER 0.75 MG PO TB24,RX-151352,CDM,J7503,HCPCS,0636,RC,68992-3075-03,NDC,,both,1,UN,23.90,15.53,,,,,,,,,,,,,
CROWN DENT NOEUL-5 PRI SEC M UP L S STL,SUP-2322203,CDM,D6783,CPT,0278,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL TOE REVERSIBLE,SUP-2328039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM DIA 0.035 IN TIP L 3 MM SS,SUP-2499619,CDM,C1729,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
SCREW BONE L40MM DIA5.7MM CANC S STL SELF DRL ST CANN LCK,SUP-2348911,CDM,C1713,HCPCS,0278,RC,,,,both,,,2311.76,1502.64,,,,,,,,,,,,,
HC Fluoro Guidance Spine,PX-3207700300,CDM,77003,CPT,0320,RC,,,,inpatient,,,987.00,641.55,,,,,,,,,,,,,
SUPPORT ORTH RT BRKT TRAC SPLNT TBL BTTRS FT LEG HLDR,SUP-2197868,CDM,C1713,HCPCS,0278,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
FIBER LASER HOLM 365 M FOR USE W/ H-30 RED SMARTSYNC DISP,SUP-2835944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,999.49,649.67,,,,,,,,,,,,,
PLATE BNE LCK 3.5X78 MM LT MEDL PLNTR CLMN FUSION VA SS,SUP-2178433,CDM,C1713,HCPCS,0278,RC,,,,both,,,5578.49,3626.02,,,,,,,,,,,,,
CATHETER HD STR 15.5X28 CM LT DL STP BASIC SET HEMO-FLOW XF,SUP-2627239,CDM,C1750,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
BIT DRL NANOTACK,SUP-2608553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,605.55,393.61,,,,,,,,,,,,,
KIT INTRO ARW SHTH L 10 CM DIA 6 FR GUIDEWIRE L 45 CM DIA,SUP-2383281,CDM,C1894,HCPCS,0272,RC,,,,both,,,107.07,69.60,,,,,,,,,,,,,
PLATE BNE MINI THK0.5MM 6 H BILAT CRANIOMAXILLOFACIAL BLU,SUP-2181680,CDM,C1713,HCPCS,0278,RC,,,,both,,,1013.28,658.63,,,,,,,,,,,,,
PLATE BONE SM W10XL85MM THK3.4MM 7 H UNIV DSTL HUM RAD ULN,SUP-2343769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1264.01,821.61,,,,,,,,,,,,,
FIBER LASER HOLM 273 M MULTI-USE W/ SMA-905 GRN SMARTSYNC,SUP-2835958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2201.93,1431.25,,,,,,,,,,,,,
GRAFT DURA PTCH 4X5 CM DURAMATER,SUP-2321736,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
BRACE WR CLUTCH DORS STAY VELSTRETCH WRP RT CIRC 6 1/2-8,SUP-2323980,CDM,L3906,HCPCS,0274,RC,,,,both,,,50.84,33.05,,,,,,,,,,,,,
RESERVOIR CSF 1.31ML DIA2.5CM CONV FLAT BTM,SUP-2244287,CDM,C1729,HCPCS,0272,RC,,,,both,,,1027.44,667.84,,,,,,,,,,,,,
PLATE BNE W13.5XL296MM THK4.2MM 16 H BILAT S STL NAR LOK,SUP-2185256,CDM,C1713,HCPCS,0278,RC,,,,both,,,2221.42,1443.92,,,,,,,,,,,,,
PIN DISTRACTOR 2X141 MM TI LEVEL 1 DISP,SUP-2475100,CDM,C1713,HCPCS,0278,RC,,,,both,,,899.52,584.69,,,,,,,,,,,,,
BIT DRL QC 2.8X170 MM 80 MM CALIB NS,SUP-2563758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.27,269.93,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BRUSH CYTO GI W/ 3 RNG HNDL 1.8MMX120MM,SUP-2237071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.08,303.60,,,,,,,,,,,,,
RESERVOIR AUTOTRANSFUSION 225/120 CC GS FILTERED XTRA,SUP-2326361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.92,328.85,,,,,,,,,,,,,
SET LD INTRO EVOLUTION RL L 40.6 CM OD 19 FR ID 11 FR CTRL,SUP-2169470,CDM,C1773,HCPCS,0272,RC,,,,both,,,5466.71,3553.36,,,,,,,,,,,,,
PIN BONE FIX L60MM OD4MM LACTOSORB L15 BIOABSRB ACL,SUP-2212877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1607.68,1044.99,,,,,,,,,,,,,
COMPONENT ARTC SURF KNEE,SUP-2200488,CDM,C1776,CPT,0278,RC,,,,both,,,1886.51,1226.23,,,,,,,,,,,,,
SHEATH INTRO SAFSHTH ULTRA LT L 13 CM DIA10 FR DIL L 18 CM,SUP-2118985,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.25,85.31,,,,,,,,,,,,,
SHUNT SURG STD MINI LO FLO THREE-PIECE CATH W/ORESERVOIR NPH,SUP-2666623,CDM,C1889,HCPCS,0278,RC,,,,both,,,9293.24,6040.61,,,,,,,,,,,,,
GUIDE SURG SFT TISS DRT FOR DVR PLATING SYS,SUP-2137637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.16,626.05,,,,,,,,,,,,,
NAIL IM ELASTIC 1.5X300 MM TI PUR NS,SUP-2192723,CDM,C1713,HCPCS,0278,RC,,,,both,,,720.76,468.49,,,,,,,,,,,,,
ENDCAP SPNL L22MM 0DEG FUS VLIFT,SUP-2380360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SET URET STENT MARD L 26 CM DIA 6 FR PERCFLX HYDROPLUS,SUP-2141632,CDM,C2617,HCPCS,0278,RC,,,,both,,,313.22,203.59,,,,,,,,,,,,,
GRAFT HUM TISS M W11XL20CM THK07 14MM THN ACELLULAR,SUP-2307611,CDM,Q4128,HCPCS,0636,RC,,,,both,,,13442.97,8737.93,,,,,,,,,,,,,
PLATE BNE L PREBENT TI 11 H 10MM ADV 17MM LE FORT I FOR,SUP-2366355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1132.22,735.94,,,,,,,,,,,,,
PLATE BONE CRANIOFACIAL 2X32 MM CRANIOFACIAL 6 HOLE DYNAMIC,SUP-2838376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
GUIDE NDL DISP 16-18GA,SUP-2164618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
GRAFT HUM TISS W4XL16CM THK0.9-1.99MM ACELLULAR DERM MTRX,SUP-2402509,CDM,Q4126,HCPCS,0636,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SHEET ORBIT W50XL50MM THK0.45MM POLYETH POR SQ SYNPOR,SUP-2182841,CDM,C1781,HCPCS,0278,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
HC Treat Dental Ridge Fx,PX-4502144000,CDM,21440,CPT,0450,RC,,,,both,,,9508.00,6180.20,,,,,,,,,,,,,
LOADING SYS AORT VLV SM STRL LF DISP NAVITOR FLEXNAV,SUP-2892359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SCREW BNE L70MM DIA5MM THRD L32MM HD DIA6.2MM CANC FEM TI,SUP-2411476,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
NEEDLE KYPHOPLASTY 13GA L5IN LNG 90 HALF DOSE,SUP-2363252,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
HC So Culture Aerobic Identify,PX-3008707766,CDM,87077,CPT,0300,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
BOOT CAST XSM L17CM TOE W9CM BILAT BLK ETHYL VYN ACETT PRNT,SUP-2196780,CDM,L4387,HCPCS,0272,RC,,,,both,,,14.85,9.65,,,,,,,,,,,,,
"HC So1 Cult,Pathognic Orgnsms,Screen",PX-3008708167,CDM,87081,CPT,0300,RC,,,,both,,,399.00,259.35,,,,,,,,,,,,,
STENT BILI PRECIS L 40 MM DIA 6 MM CATH L 135 CM DIA 8 FR,SUP-2158909,CDM,C1876,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
HC Bx Breast Add Les MR Image,PX-3611908600,CDM,19086,CPT,0361,RC,,,,both,,,5560.00,3614.00,,,,,,,,,,,,,
HC So Hemosiderin Urine,PX-3018307066,CDM,83070,CPT,0301,RC,,,,both,,,71.00,46.15,,,,,,,,,,,,,
GRAFT BONE SUB 7GA 5ML CA PHOS SYR DISPNS GUN CANN STRUCSURE,SUP-2348205,CDM,C1713,HCPCS,0278,RC,,,,both,,,6064.44,3941.89,,,,,,,,,,,,,
SCREW SCHANZ BLUNTED POINT 4.5MM 175MM/HA COATING-STERILE,SUP-2547737,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.52,359.79,,,,,,,,,,,,,
SOUND PROCESSOR KIT FOR NEW RECIP KANSO 2,SUP-2858125,CDM,L8614,HCPCS,0278,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
BACLOFEN 10 MG PO TABS,RX-860,CDM,6370000000,HCPCS,0637,RC,00904-7552-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUTTON FIX L15MM TI CONT LOOP FOR ACL RECON ENDOBTTN CL ULT,SUP-2341701,CDM,C1713,HCPCS,0278,RC,,,,both,,,1066.31,693.10,,,,,,,,,,,,,
PLATE BNE M 5DEG R MT PRI NONBIOABSORBABLE INT FIX SYS,SUP-2321469,CDM,C1713,HCPCS,0278,RC,,,,both,,,4725.70,3071.70,,,,,,,,,,,,,
HC So Chromosome Analysis 20-25,PX-3118826466,CDM,88264,CPT,0311,RC,,,,both,,,636.00,413.40,,,,,,,,,,,,,
SEALANT FBRN 2ML VALUPAK AND DUPLOJECT EZ PREP TISSEEL,SUP-2129970,CDM,C9250,HCPCS,0636,RC,,,,both,,,399.06,259.39,,,,,,,,,,,,,
PLATE BNE L115MM 8 H L LAT DST PERIARTC FIBULAR S STL,SUP-2410567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1531.72,995.62,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL SHELL,SUP-2435546,CDM,L0480,HCPCS,0274,RC,,,,both,,,4276.30,2779.59,,,,,,,,,,,,,
STEM HUM PROX SM 58 MM SHLDR REV SEG W/ BODY COMPHSVE,SUP-2442421,CDM,C1776,CPT,0278,RC,,,,both,,,11360.52,7384.34,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 25CM 5MM 120CM 6FR RADIOPAQUE,SUP-2396643,CDM,C1874,HCPCS,0278,RC,,,,both,,,20658.06,13427.74,,,,,,,,,,,,,
HEAD FEM PRI CERAMIC ON CERAMIC ALUMINA 5 40 36MM DIA +5 NK,SUP-2364460,CDM,C1776,CPT,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
TROCAR SURG 64 MM FOR 2.0/2.7 MM SYS,SUP-2462645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
PORT INFUS 9.5FR PLAS INTMED 2 LUMN PEEL APART PERC INTRO,SUP-2127742,CDM,C1788,HCPCS,0278,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
HC Catheter Stripping Procedure,PX-3207590100,CDM,75901,CPT,0320,RC,,,,both,,,5938.00,3859.70,,,,,,,,,,,,,
IMPLANT HUM TISS L 21-30 CM DIA 3-10 MM SAPH VEIN ALLGRFT,SUP-2933384,CDM,C1762,CPT,0278,RC,,,,both,,,21112.89,13723.38,,,,,,,,,,,,,
HC Cltx Post Ankle Fx W/Mnpj,PX-4502776800,CDM,27768,CPT,0450,RC,,,,both,,,4969.00,3229.85,,,,,,,,,,,,,
KIT TIP NDL PEDCL ACCS PERC SPNL 2 BVL,SUP-2290655,CDM,C1713,HCPCS,0278,RC,,,,both,,,2560.54,1664.35,,,,,,,,,,,,,
WRAP SHLDR L THERMOSKIN,SUP-2324274,CDM,L3650,HCPCS,0274,RC,,,,both,,,139.01,90.36,,,,,,,,,,,,,
IMPLANT TOE JT L16MM DIA3.2MM BLDE W5XL7.85IN 0DEG S STL,SUP-2397821,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED RESURF CORMET,SUP-2365448,CDM,C1776,CPT,0278,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
LEAD NERVE STIM PADDLE SPNL,SUP-2138816,CDM,C1778,HCPCS,0278,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
COUNTERSINK DRL DIA2.4MM CANN DART-FIRE,SUP-2399836,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
SCREW ANT GIC53 BONE SCR 6.5X30MM 8968006,SUP-2291652,CDM,C1713,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
GRAFT BNE MED TIM-GRAFT FIB SEG,SUP-2393043,CDM,C1713,HCPCS,0278,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
RABIES IMMUNE GLOBULIN 1500 UNIT/10ML IJ SOLN,RX-141162,CDM,90377,HCPCS,0636,RC,76125-0150-10,NDC,,both,10,ML,9801.40,6370.91,,,,,,,,,,,,,
SCREW BNE L12MM DIA24MM CORT TAN T8 STARDRV RECESS TB,SUP-2418617,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.70,133.70,,,,,,,,,,,,,
COMPONENT FEM CR 5 RT KNEE COAT,SUP-2314013,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
IBUPROFEN 800 MG PO TABS,RX-3845,CDM,6370000000,HCPCS,0637,RC,60687-0468-11,NDC,,both,1,UN,1.70,1.10,,,,,,,,,,,,,
GRAFT MTRX TISS HUM INJ CYMETRA MICRONIZED ALLDERM,SUP-2113358,CDM,Q4116,HCPCS,0636,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
HC Immunoassay Analyte Qual/Semiquan Multiple Step,PX-3018351600,CDM,83516,CPT,0301,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA LOW BEND 12H 180MM RT STER,SUP-2546872,CDM,C1713,HCPCS,0278,RC,,,,both,,,4969.74,3230.33,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN PTFE BENT FLPY TIP STRL,SUP-2627293,CDM,C1769,HCPCS,0272,RC,,,,both,,,20.22,13.14,,,,,,,,,,,,,
ELECTRODE ELECSURG POWERBALL 24 FR MONOPOLAR FOR ELITE SYS,SUP-2141800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.77,241.00,,,,,,,,,,,,,
SPACER SPNL 6 DEG 60X20X10-7.9 MM TITAN TI STRL ANTERALIGN,SUP-2859352,CDM,C1889,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX16 CNTRD F/3.5MM LOK SCREW ST,SUP-2495380,CDM,C1713,HCPCS,0278,RC,,,,both,,,2076.36,1349.63,,,,,,,,,,,,,
NAIL GAM 3 TI RT 120DEG 11X300MM ST,SUP-2701255,CDM,C1713,HCPCS,0278,RC,,,,both,,,7592.52,4935.14,,,,,,,,,,,,,
COIL DET 3D AXIUM 3MMX8CM,SUP-2471136,CDM,C1889,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
BRACE WALKING ROCKER FT,SUP-2749880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4700.58,3055.38,,,,,,,,,,,,,
SCREW SPNL L6MM OD4.5MM GRY TI CORT CERV VAR ANG,SUP-2286771,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
PLATE BNE VOLAR RT 9 HOLE BEAR,SUP-2389760,CDM,C1713,HCPCS,0278,RC,,,,both,,,4584.40,2979.86,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SZ 50 X 25 X 4 MM 5 CC CER GRAN TYPE-I,SUP-2930814,CDM,C1763,HCPCS,0278,RC,,,,both,,,4678.60,3041.09,,,,,,,,,,,,,
SYRINGE MED SHIELDED 3 CC HI DENS LD GRASS,SUP-2327795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
PLATE BNE TRPL OSTEOTMY 45 DEG 3.5X75 MM LT 6 HOLE SS,SUP-2569188,CDM,C1713,HCPCS,0278,RC,,,,both,,,214.15,139.20,,,,,,,,,,,,,
ANCHOR SUTURE ABSORBABLE 2-0 4.5 MM BLU BLU STRL,SUP-2848958,CDM,C1713,HCPCS,0278,RC,,,,both,,,886.89,576.48,,,,,,,,,,,,,
CATHETER EP DIAG QPLR 6FRX100CM EXPLORER 360 JOSEPHSON FIX,SUP-2140171,CDM,C1730,HCPCS,0272,RC,,,,both,,,649.67,422.29,,,,,,,,,,,,,
GUIDEWIRE SURG L150MM DIA1.2MM NICKEL CHROM SMOOTH SGL END,SUP-2321618,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
VALVE SHUNT LP HYDROCEPHALUS THER STRATA,SUP-2278372,CDM,C1889,HCPCS,0278,RC,,,,both,,,11801.28,7670.83,,,,,,,,,,,,,
COMPONENT FEM A P55MM M L65MM HA POR L HIP OR KNEE CRUCE RET,SUP-2377123,CDM,C1776,CPT,0278,RC,,,,both,,,10426.06,6776.94,,,,,,,,,,,,,
SCREW BNE FT 5X75 MM CANN STRL,SUP-2460082,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.06,348.44,,,,,,,,,,,,,
OLECRANON TRIAL 10 HOLE/LEFT,SUP-2484761,CDM,C1713,HCPCS,0278,RC,,,,both,,,877.44,570.34,,,,,,,,,,,,,
HC Rmv&Rplc Pm Gen Multi Leads,PX-4813322900,CDM,33229,CPT,0481,RC,,,,both,,,65472.00,42556.80,,,,,,,,,,,,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,0636,RC,61703-0309-16,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 2-5-2MM SPC TIP 3.5MM 4 ELECTRD D,SUP-2248839,CDM,C2630,CPT,0272,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
HOFFMANN LRF THUMBWHEEL TELESCOPIC STRUTS,SUP-2488273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
STEM FEM L220MM OD11MM TI 80% POR PLSM SPRY DSTL CALCAR MOD,SUP-2403920,CDM,C1776,CPT,0278,RC,,,,both,,,6694.48,4351.41,,,,,,,,,,,,,
CANNULA VEN SHT 19 FR UNCOATED HLS,SUP-2663484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.13,816.48,,,,,,,,,,,,,
SCREW BNE HDLSS LNG THRD 3X25 MM COMPR,SUP-2183090,CDM,C1713,HCPCS,0278,RC,,,,both,,,994.69,646.55,,,,,,,,,,,,,
HEAD RADIAL 24 MM LT DEMO ANAT SOL 2,SUP-2657749,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
LEVEL CMF PLATE ORTHG TLTS BSSO L SHP WTAB RGHT 10 MM BRG 2,SUP-2668656,CDM,C1713,HCPCS,0278,RC,,,,both,,,1422.99,924.94,,,,,,,,,,,,,
PLATE BNE L 92 MM 10 H SCREW DIA2.7 MM Y SHP NAR LCK MINI,SUP-2902292,CDM,C1713,HCPCS,0278,RC,,,,both,,,5222.45,3394.59,,,,,,,,,,,,,
SCREW BNE LCK 2.3X15 MM SELF RET TI STRL MAXDRIVE,SUP-2457286,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.75,268.29,,,,,,,,,,,,,
CAP SCREW D 3.5 MM DIA 5.93 MM SCREW DIA 4.5 MM WR LCK STRL,SUP-2932965,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.74,346.93,,,,,,,,,,,,,
PLATE BNE L18MM 2X2 H L BILAT S STL T SHP RIG NEUT,SUP-2186160,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.34,110.07,,,,,,,,,,,,,
SPONGE HEMSTAT W3XL4IN WHT CLLGN ABSRB PLIABLE NONFRIABLE,SUP-2243493,CDM,C1713,HCPCS,0278,RC,,,,both,,,771.62,501.55,,,,,,,,,,,,,
Z INACTIVE USE 2717689 FIBER LASER FLEXIVA PULSE 550,SUP-2718712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1307.43,849.83,,,,,,,,,,,,,
SCREW BONE L5MM OD1.5MM SLD CRANIOMAXILLOFACIAL VIT CROSS,SUP-2364634,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.45,82.84,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA24 MM BRANCH SZ 12/10/8/8,SUP-2682221,CDM,C1768,CPT,0278,RC,,,,both,,,5598.43,3638.98,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 30X30 CM RECON TISS MTRX STRATTICE,SUP-2483835,CDM,Q4130,HCPCS,0636,RC,,,,both,,,89110.06,57921.54,,,,,,,,,,,,,
INTRODUCER SHTH 7 FR,SUP-2355532,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
PLATE BNE 40 X 61 MM THK 0.85 MM POLYETHYL EMBEDDED TI MTM,SUP-2883158,CDM,C1713,HCPCS,0278,RC,,,,both,,,3789.10,2462.91,,,,,,,,,,,,,
VALVE AORT TISS ANNULUS OD17MM VLV ORIFICE ID148MM MECH HRT,SUP-2355067,CDM,C1713,HCPCS,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
IMPLANT STAP L4.25MM DIA0.6MM PIST AND WIRE FLROPLAS S STL,SUP-2312791,CDM,L8613,CPT,0278,RC,,,,both,,,427.67,277.99,,,,,,,,,,,,,
STRAP ELBW TENNIS UNIV FOAM D RNG,SUP-2336255,CDM,L3702,HCPCS,0274,RC,,,,both,,,9.70,6.30,,,,,,,,,,,,,
SURFACE ARTC SZ C H26MM W/ SEG HNG POST,SUP-2200517,CDM,C1776,CPT,0278,RC,,,,both,,,5185.71,3370.71,,,,,,,,,,,,,
ANCHOR SUTURE 2-0 2.9 MM WHT COBRAID BLU OSTEORAPTOR,SUP-2434528,CDM,C1713,HCPCS,0278,RC,,,,both,,,943.60,613.34,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ANGLED 3 CM 0.035 INX150 CM GLIDEWIRE,SUP-2141742,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
NERVE STIMULATOR KIT PERIPH NERVE SYS CHANNEL A RECV STIMQ,SUP-2423763,CDM,C1816,LOCAL,0278,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY DBM REFICIO,SUP-2731795,CDM,C1713,HCPCS,0278,RC,,,,both,,,225.30,146.44,,,,,,,,,,,,,
WASHER ORTH DIA5.5MM SPIK,SUP-2184676,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.14,74.19,,,,,,,,,,,,,
CATHETER DEL CARR L 152 CM SM HYDRPHLC 1 LUMEN COMP VAR PK10,SUP-2912343,CDM,C1887,HCPCS,0272,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
KIT CRICOTHYROTOMY SINGLE USE,SUP-2862618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2216.84,1440.95,,,,,,,,,,,,,
HC Eeg Awake and Asleep,PX-7409581900,CDM,95819,CPT,0740,RC,,,,inpatient,,,2577.00,1675.05,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST SWEDISH TYP,SUP-2435617,CDM,L1850,HCPCS,0272,RC,,,,both,,,806.57,524.27,,,,,,,,,,,,,
GUIDEWIRE VASC PNS L 145 CM DIA 0.035 IN TIP L 3 MM PTFE J,SUP-2429610,CDM,C1769,HCPCS,0272,RC,,,,both,,,5.71,3.71,,,,,,,,,,,,,
CABLE EP CATH L 1.5 M 4 PIN DIAG CONN PUSH PUL HNDL,SUP-2676239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
BRACE ANK SPRAIN AND TRAUM AND CHRONIC DISORD 1 SZ FIT MOST,SUP-2319275,CDM,L4350,HCPCS,0272,RC,,,,both,,,41.67,27.09,,,,,,,,,,,,,
COIL EMB L15CM PRI DIA0.020IN 2ND DIA6MM NIT COMPLX STD,SUP-2323360,CDM,C1889,HCPCS,0278,RC,,,,both,,,6644.24,4318.76,,,,,,,,,,,,,
SCREW BNE SD 2X4 MM CRTX T8 STARDRV RECESS TI NS LF,SUP-2189352,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
JOINT SUBTALAR 8 MM TI MBA,SUP-2242696,CDM,C1776,CPT,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5CM 13MM 120CM HEPARIN,SUP-2396586,CDM,C1874,HCPCS,0278,RC,,,,both,,,9715.16,6314.85,,,,,,,,,,,,,
PLATE BNE L MIC MED 100 DEG 1.5X0.6 MM LT TI LEVEL 1,SUP-2462137,CDM,C1713,HCPCS,0278,RC,,,,both,,,597.60,388.44,,,,,,,,,,,,,
CATHETER CV FULL TY 032 8 FRX15 CM 12 GA DL J TIP SPECTRUM,SUP-2759725,CDM,C1751,HCPCS,0278,RC,,,,both,,,508.65,330.62,,,,,,,,,,,,,
SCREW BNE L70MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190370,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.40,79.56,,,,,,,,,,,,,
TROCAR ENDOSCP L 150 MM DIA 5 MM LNG BLDELSS FIX CANN,SUP-2896253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.15,211.35,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN TAPR L 7 CM FLX TIP 6,SUP-2167743,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.35,21.68,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST EXT STL SHANK,SUP-2435661,CDM,L2360,HCPCS,0274,RC,,,,both,,,145.98,94.89,,,,,,,,,,,,,
GUIDEWIRE ORTH L16MM DIA32MM S STL W STP,SUP-2177258,CDM,C1769,HCPCS,0272,RC,,,,both,,,173.14,112.54,,,,,,,,,,,,,
NAIL INTRMDLLRY FMRL TTNM RT 9MM DIA 30CML VRSNL DEPUY,SUP-2587461,CDM,C1713,HCPCS,0278,RC,,,,both,,,6207.47,4034.86,,,,,,,,,,,,,
PLATE BNE CRV 6X1 MM 6 HOLE SAG SPLIT NS MATRIXORTHOGNATHIC,SUP-2431412,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.08,945.80,,,,,,,,,,,,,
CASE STRL ORTHOGNATHIC BNDL VSP,SUP-2366021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4096.29,2662.59,,,,,,,,,,,,,
SCREW BNE L 34 MM DIA 3.2 MM FT COMPR,SUP-2883759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1635.94,1063.36,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 8 MM EPTFE STR TW N RING,SUP-2396353,CDM,C1768,CPT,0278,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
COMPONENT PATELLAR 32 MM KNEE RESURF OVL GEN II,SUP-2450676,CDM,C1776,CPT,0278,RC,,,,both,,,2876.24,1869.56,,,,,,,,,,,,,
BLADE RTRCTR CSPR MED LNGTH SHRT TEETH 55MM X 23MM LTRL BALL,SUP-2668415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.52,270.09,,,,,,,,,,,,,
JOINT TOE STR 0 DEG MED 3.2X21 MM HAMRTOE KT OSSIOFIBER,SUP-2641859,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
STEM TAPER 16X135MM,SUP-2505141,CDM,C1776,CPT,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
GRAFT VASC IMPRA L 35 CM DIA19 MM EPTFE FLEXLG DIAMETER RING,SUP-2761442,CDM,C1768,CPT,0278,RC,,,,both,,,2494.98,1621.74,,,,,,,,,,,,,
SET INTRO FLX L 13 CM OD 5 FR ID 1.9 MM GUIDEWIRE L 40 CM,SUP-2168781,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.06,76.74,,,,,,,,,,,,,
WASHER ORTH PLATE SYS IMPL INSTRUMENT AXIS,SUP-2610214,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 30 CC CANC,SUP-2739091,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
GRAFT BONE L5XW2.5CM DEMIN BONE MTRX MAGNIFUSE II,SUP-2279578,CDM,C1713,HCPCS,0278,RC,,,,both,,,10754.50,6990.42,,,,,,,,,,,,,
SET CATH HEMODIALYSI TRI FLO ACTE BSC 11.5FR DIA 15CM STRGHT,SUP-2610549,CDM,C1752,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
FIGHTER ACT STLTH,SUP-2253541,CDM,C1776,CPT,0278,RC,,,,both,,,4907.19,3189.67,,,,,,,,,,,,,
MESH CRAN L 41 X W 40 MM THK 0.3 MM SCREW DIA1.5 MM TI,SUP-2936705,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PATCH CV GORTX NOM L 15 X W 2.5 CM THK 0.6 MM EPTFE CNFRM,SUP-2395300,CDM,C1768,CPT,0278,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
TRIAL TIB STEM TIB PROV SZ 6 NXGN,SUP-2201513,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
ADAPTER ORTH HUM SHLDR N REVERSED HEMI-PROSTHESIS AEQUALIS,SUP-2715632,CDM,C1776,CPT,0278,RC,,,,both,,,8277.04,5380.08,,,,,,,,,,,,,
COMPONENT ORIG ILIZ EXT FIX CIR FEM ARCHES 90 L SZ,SUP-2342768,CDM,C1776,CPT,0278,RC,,,,both,,,17376.29,11294.59,,,,,,,,,,,,,
PIN EXT FIX THRD L20MM DIA3MM SHANK L65MM DIA4MM SH TI,SUP-2342890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
GRAFT HUM TISS L80-100CM SAPH VEIN A B AB O BLD GRP,SUP-2264307,CDM,C1762,CPT,0278,RC,,,,both,,,36891.86,23979.71,,,,,,,,,,,,,
SELENIOUS ACID 60 MCG/ML IV SOLN,RX-146495,CDM,2500000003,HCPCS,0250,RC,00517-6560-05,NDC,,both,10,ML,2352.00,1528.80,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 80X14 - 18 MM FRZ DRY,SUP-2294104,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
SCREW BONE L90MM DIA6.3MM TI PARTIALLY THRD NAILING SYS,SUP-2412905,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
ADAPTER ORTH TAPR FEM COMP COMPRESS/SRS 178950,SUP-2441883,CDM,C1776,CPT,0278,RC,,,,both,,,2077.11,1350.12,,,,,,,,,,,,,
SNARE VASC L120CM DIA10MM CATH 4FR L100CM G STD PLT RADPQ,SUP-2303141,CDM,C1773,HCPCS,0272,RC,,,,both,,,828.65,538.62,,,,,,,,,,,,,
GRAFT EVAR L82MM DIA10X10MM CATH 14FR NIT HI DENS,SUP-2295235,CDM,C1768,CPT,0278,RC,,,,both,,,14601.00,9490.65,,,,,,,,,,,,,
SYSTEM THROMCTMY CLEANER15 L 135 CM DIA 7 FR SINUSOIDAL WIRE,SUP-2120128,CDM,C1757,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PLATE BNE CVR REMOVER KT SET SOVEREIGN,SUP-2630943,CDM,C1713,HCPCS,0278,RC,,,,both,,,864.38,561.85,,,,,,,,,,,,,
PACEMAKER CARD L 38 MM DIA 6.5 MM 1.1 CU CM 2.4 GM RT,SUP-2895710,CDM,C1786,HCPCS,0275,RC,,,,both,,,34524.30,22440.79,,,,,,,,,,,,,
OBTURATOR ENDO FLEX FOR AC TIGHTROPE TECH,SUP-2121674,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HANDLE SL DRL 4 POS,SUP-2188579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.63,786.91,,,,,,,,,,,,,
BLADE SAW W18.5XL32MM THK0.51MM CRESC OSC,SUP-2367519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.98,222.29,,,,,,,,,,,,,
IMMOBILIZER ORTH ADJ UNIV SHLDR CANVS NAVY NS,SUP-2336314,CDM,L3670,HCPCS,0274,RC,,,,both,,,25.72,16.72,,,,,,,,,,,,,
MOLD CEM SPCR DIA75MM UNIV TIB SIL CRUCE SACRIFICING AGC,SUP-2408628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1833.76,1191.94,,,,,,,,,,,,,
VLP 2.7MM PERC CALC PLT X-LARGE LT 68MM STER,SUP-2820177,CDM,C1713,HCPCS,0278,RC,,,,both,,,7355.61,4781.15,,,,,,,,,,,,,
DEVICE TISS FIX STRL FIBERTAG TIGHTROPE II,SUP-2882184,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
HC Inj Ileal Conduit Ureteropyelo,PX-3615069000,CDM,50690,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
IMPLANT SZ 1 LMH IMPL SYS,SUP-2398601,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
CATHETER CV DL PEDIATRIC 7 FRX65 CM TUNNELED HICKMAN,SUP-2126154,CDM,C1751,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
CATHETER ABLATN XL 2-5-2 MM 4 MM 1304-7-25-XL-TH THER,SUP-2491481,CDM,C1733,HCPCS,0272,RC,,,,both,,,2075.54,1349.10,,,,,,,,,,,,,
CIRCUIT VENTILATOR 2 LIMB AD 6 FTX0.25 IN Y PORTED AIRLFE,SUP-2724361,CDM,C1713,HCPCS,0278,RC,,,,both,,,7.98,5.19,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX50 CM STD WALL SM BEAD EPTFE CARBOFLO,SUP-2761454,CDM,C1768,CPT,0278,RC,,,,both,,,2339.80,1520.87,,,,,,,,,,,,,
PLATE BONE 5 H T SHP BTTRS ECT,SUP-2198571,CDM,C1713,HCPCS,0278,RC,,,,both,,,614.31,399.30,,,,,,,,,,,,,
SPECULUM VAG GRV SM,SUP-2126351,CDM,C1788,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
SCREW BNE L30MM DIA6.28MM S STL CANC CANN LOK FULL THRD,SUP-2370999,CDM,C1713,HCPCS,0278,RC,,,,both,,,699.28,454.53,,,,,,,,,,,,,
PLATE BNE 12 H NONSTERILE BILAT S STL NAR CRV LOK COMPR FOR,SUP-2178043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.76,1260.19,,,,,,,,,,,,,
HC Destruction Mal Lesion Trunk/Arm/Leg > 4.0 Cm,PX-3611726600,CDM,17266,CPT,0361,RC,,,,both,,,1233.00,801.45,,,,,,,,,,,,,
GRAFT 2CMX7CM ACELLULAR DURADERM,SUP-2126452,CDM,C1762,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BONE L29MM THK1.25MM 4 H BILAT MAND ORAL MAXILLOFACIAL,SUP-2191334,CDM,C1713,HCPCS,0278,RC,,,,both,,,1879.29,1221.54,,,,,,,,,,,,,
MESH HERN DIA45IN POLY 4 HYDROXYBUTYRATE SYN FULL RESRB,SUP-2126265,CDM,C1781,HCPCS,0278,RC,,,,both,,,5997.40,3898.31,,,,,,,,,,,,,
PLATE BNE L142MM 10 H L LAT DST PERIARTC TIB S STL LOK COMPR,SUP-2198446,CDM,C1713,HCPCS,0278,RC,,,,both,,,4388.18,2852.32,,,,,,,,,,,,,
CATHETER VENTRICULAR 25 CM HYDROCEPHALUS MGMT MRI SAFE,SUP-2852681,CDM,C1729,HCPCS,0272,RC,,,,both,,,393.41,255.72,,,,,,,,,,,,,
SET CLLR STOUT SORBATEX PD BIOENGINEERED CMFRT ADJ BTTN,SUP-2247595,CDM,L0120,HCPCS,0272,RC,,,,both,,,174.84,113.65,,,,,,,,,,,,,
PLATE BNE L191MM 10 H S STL BROAD WAISTED LOK COMPR FOR 5MM,SUP-2372017,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
GUIDEWIRE VASC CHIKAI BLK 14 L 200 CM DIA 0.014 IN,SUP-2123824,CDM,C1769,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SUTURE MAXON SZ 0 L36IN ABSRB GRN SZ GS-21 L37MM 1/2 CIR 8886626961,SUP-2174617,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.55,393.61,,,,,,,,,,,,,
AM PICC SET: 1-L 4.5FRX55CM 80CM HYDRO,SUP-2827501,CDM,C1751,HCPCS,0278,RC,,,,both,,,422.64,274.72,,,,,,,,,,,,,
PLATE BNE W8XL128MM THK3.3MM 16 H NONSTERILE BILAT PELV S,SUP-2186243,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.65,1504.52,,,,,,,,,,,,,
CLIP INT USE DIA14.6 MM THRD L 165 CM ENDOSCP DIA 8.5-10 MM BLUNT,SUP-2881815,CDM,C1889,HCPCS,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
GUIDEWIRE SUPP L300CM DIA0014IN STR TIP SAVION FLX,SUP-2140936,CDM,C1769,HCPCS,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
CLOBETASOL PROP EMOLLIENT BASE 0.05 % EX CREA,RX-36095,CDM,6370000000,HCPCS,0637,RC,51672-1297-01,NDC,,both,15,GR,112.60,73.19,,,,,,,,,,,,,
KIT FIX DEV TI FOR ANK SYNDESMOSIS W/ ZIPLOOP TECHNOLOGY,SUP-2212940,CDM,C1776,CPT,0278,RC,,,,both,,,3267.11,2123.62,,,,,,,,,,,,,
ALLOGRAFT BNE DBM + CORTICAL 10 CC FD,SUP-2717770,CDM,C1713,HCPCS,0278,RC,,,,both,,,4944.62,3214.00,,,,,,,,,,,,,
FIBER LASER HOLM 940 M FOR USE W/ SMA-905 RED SMARTSYNC,SUP-2835957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1962.78,1275.81,,,,,,,,,,,,,
SET INTRO REMINGTON L 13 CM DIA11 FR GUIDEWIRE 0.038 IN NDL,SUP-2137984,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
RESOLVE BLRY DRNGE CTHTRS LOK 10FR 40CM 038N 17 DRNGE HOLES,SUP-2677279,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 15MM RIGHT ANGLE 201629,SUP-2844592,CDM,C1889,HCPCS,0278,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
SCREW BONE L95MM DIA7.3MM CORT S STL ST CANN LCK PARTIALLY,SUP-2185013,CDM,C1713,HCPCS,0278,RC,,,,both,,,818.22,531.84,,,,,,,,,,,,,
COIL VASC I-ED COIL L 4 CM DIA 0.010 IN SECONDARY 2 MM,SUP-2865296,CDM,C1889,HCPCS,0278,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
PLATE BNE L 81 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 10 H SS 72440310N,SUP-2932737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1725.56,1121.61,,,,,,,,,,,,,
INSERT TIBIAL CRT ULTRA TIB INS SZ3 16MM,SUP-2513011,CDM,C1776,CPT,0278,RC,,,,both,,,6220.97,4043.63,,,,,,,,,,,,,
PLATE BONE 6MM OFFSET 100DEG 3 H PROX FEM LCK FOR 3.5MM SCR,SUP-2318549,CDM,C1713,HCPCS,0278,RC,,,,both,,,7685.31,4995.45,,,,,,,,,,,,,
AXLE TIB PROX KNEE MOD ROT HNG MONOGRAM,SUP-2376369,CDM,C1776,CPT,0278,RC,,,,both,,,2460.03,1599.02,,,,,,,,,,,,,
HC Additional Panel Charge,PX-3028687000,CDM,86870,CPT,0302,RC,,,,both,,,1200.00,780.00,,,,,,,,,,,,,
MESH HERN W10XL15CM SYNTH ABSRB POLY COMP RECT OPN SKRT,SUP-2173619,CDM,C1781,HCPCS,0278,RC,,,,both,,,2915.11,1894.82,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5 FRX28 CM LT DL BASIC SET TITAN HD,SUP-2627352,CDM,C1750,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
PLATE BNE STR NAR 258 MM 18 HOLE FOR PERIPROSTHETIC FRAC NCB,SUP-2478615,CDM,C1713,HCPCS,0278,RC,,,,both,,,1800.82,1170.53,,,,,,,,,,,,,
CLAMP EXT FIX SM DIA4MM FOR BAR CONN,SUP-2188704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.12,569.48,,,,,,,,,,,,,
SCREW BNE L40MM DIA7.5MM ST FULL THRD COMPR HDLSS ACUTRK 2,SUP-2106810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
BLADE CUT MORCELLATOR 15MM,SUP-2261148,CDM,C1782,HCPCS,0272,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT FIB WHL TRAD,SUP-2294140,CDM,C1713,HCPCS,0278,RC,,,,both,,,5551.52,3608.49,,,,,,,,,,,,,
GEM MICROVASCULAR ANAS CPL MAC SYS,SUP-2382615,CDM,C1889,HCPCS,0278,RC,,,,both,,,11024.54,7165.95,,,,,,,,,,,,,
GUIDE SURG CUT TMPLT VSP,SUP-2530173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4231.15,2750.25,,,,,,,,,,,,,
HC Ptt,PX-3058573000,CDM,85730,CPT,0305,RC,,,,both,,,120.00,78.00,,,,,,,,,,,,,
PROBE BRST BX 18GA TI W/ RADPQ CLP W/IN HYDRGEL MAMTOM,SUP-2195599,CDM,A4648,CPT,0278,RC,,,,both,,,24.18,15.72,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10CM 8MM 120CM 7FR RADIOPAQUE,SUP-2396659,CDM,C1874,HCPCS,0278,RC,,,,both,,,11093.62,7210.85,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 X W 3 CM PLCNTA MTRX MEMBRN MINIMALLY,SUP-2905518,CDM,C1762,CPT,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
GRAFT HUM TISS L 220 MM DIA 8 MM POST TIBIALIS TEND FRZN,SUP-2913415,CDM,C1762,CPT,0278,RC,,,,both,,,7272.24,4726.96,,,,,,,,,,,,,
SCREW BNE LOK SELF RET TI L7MM OD2MM MAXDRIVE,SUP-2262887,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.70,243.55,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 5 MM STR REINF SLDE GDS,SUP-2525457,CDM,C1768,CPT,0278,RC,,,,both,,,1488.93,967.80,,,,,,,,,,,,,
KIT EL JT SM REG HUM PIN BUSHING REPL COONRAD/MORREY,SUP-2205911,CDM,C1776,CPT,0278,RC,,,,both,,,2306.33,1499.11,,,,,,,,,,,,,
CEMENT BNE 5 CC DEMINERALIZED BONE MATRIX STRL TRABEXUS LTX,SUP-2855699,CDM,C1713,HCPCS,0278,RC,,,,both,,,16858.66,10958.13,,,,,,,,,,,,,
PROSTHESIS OSS CENTERED 2.00 MM BYTE PART ADJ TI,SUP-2461178,CDM,L8613,CPT,0278,RC,,,,both,,,1194.36,776.33,,,,,,,,,,,,,
HEAD RADIAL H 0.474 IN DIA 0.866 IN SZ 22S COCR ALLOY ELBW,SUP-2933572,CDM,C1776,CPT,0278,RC,,,,both,,,9512.66,6183.23,,,,,,,,,,,,,
FORCEPS SURG AOS PERIMODIOLAR ELECTRD,SUP-2165056,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
KIT INSTR TRANSTIBIAL CRUCE W/O SAW BLDE DISP,SUP-2121486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SHEATH INTRO 0.038 IN 50 DEG 12 FRX67 CM LG CRV BIDIR DIREX,SUP-2424659,CDM,C1766,CPT,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
STENT PERIPH ABS PRO L 80 MM DIA 5 MM CATH L 135 CM DIA 8 FR,SUP-2104808,CDM,C1876,HCPCS,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
FIBER LASER DIA1000UM FLEXSHIELD COAT HOLM HI PWR POLISHED,SUP-2139423,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.11,1375.47,,,,,,,,,,,,,
RETRIEVER THROMCTMY TREVO XP PROVUE L 25 MM 6 MM NIT PROPACK,SUP-2367809,CDM,C1757,HCPCS,0272,RC,,,,both,,,23095.96,15012.37,,,,,,,,,,,,,
HC Echo Exam Uterus,PX-4027683100,CDM,76831,CPT,0402,RC,,,,both,,,959.00,623.35,,,,,,,,,,,,,
SUPPORT ORTH XL 1 8IN NEOPRENE NYL 2 SIDE OPN PAT STBL PAT,SUP-2195472,CDM,L1851,HCPCS,0274,RC,,,,both,,,51.15,33.25,,,,,,,,,,,,,
PLATE BONE BROAD 4.5X375 MM 20 HOLE,SUP-2837424,CDM,C1713,HCPCS,0278,RC,,,,both,,,4660.07,3029.05,,,,,,,,,,,,,
SHEATH RESECTSCP 28FR BLK OBLQ BEAK CONN TUBE FOR INFLO AND,SUP-2261180,CDM,C1894,HCPCS,0272,RC,,,,both,,,2464.74,1602.08,,,,,,,,,,,,,
SLEEVE ANK CLOSED HEEL 8.5-10 IN MED 1/8 IN PROCARE,SUP-2195739,CDM,L1906,HCPCS,0272,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
PUMP KIT FOR PERISTALTIC PMP US STRL LTX,SUP-2875221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
MODAFINIL 200 MG PO TABS,RX-24703,CDM,6370000000,HCPCS,0637,RC,68084-0721-21,NDC,,both,1,UN,76.10,49.46,,,,,,,,,,,,,
COMPONENT FEM SZ 3 L LAT R MED UNI KNEE POLYETH CEM HI PERF,SUP-2249751,CDM,C1776,CPT,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
IMPLANT OSS L8.13MM DIA0.8MM INCUS STAP CRADL HD HA PLAS,SUP-2313677,CDM,L8613,CPT,0278,RC,,,,both,,,1019.87,662.92,,,,,,,,,,,,,
SCREW BNE L50MM DIA3.7MM S STL ST SELF DRL CANN LOK FULL,SUP-2185172,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.31,370.05,,,,,,,,,,,,,
COMPONENT ULN SM L4.5IN LNG LT ELBW TIV PLSM INTERCHANGEABLE,SUP-2205940,CDM,C1776,CPT,0278,RC,,,,both,,,11153.28,7249.63,,,,,,,,,,,,,
GRAFT BNE BLOCK LG 20X20 MM CANC,SUP-2766759,CDM,C1713,HCPCS,0278,RC,,,,both,,,2903.87,1887.52,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC WRST LG LT,SUP-2246904,CDM,L3908,HCPCS,0274,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
KIT ANALGESIC PMP RPS SPIKE CONN CASETTE FILTER TRNSLUC TBNG,SUP-2892645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.95,443.92,,,,,,,,,,,,,
REUTER BOBBIN WHOLES VT 1.14 MM FLPL,SUP-2681459,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.72,21.27,,,,,,,,,,,,,
BROAD PLT STERILIZER 4.5X167 MM 10 HL,SUP-2818117,CDM,C1713,HCPCS,0278,RC,,,,both,,,2071.14,1346.24,,,,,,,,,,,,,
BLADE RETRACTOR MAYO 3.5X2 IN RADLUC ALUM NS GHOSTRACT,SUP-2457893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1326.05,861.93,,,,,,,,,,,,,
NAIL IM CANN LNG 210 MM FOR PELV C-CLAMP II SS NS,SUP-2799343,CDM,C1713,HCPCS,0278,RC,,,,both,,,1414.85,919.65,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 35X20X7MM SM DEMIN BNE CANC N IRRADIATED,SUP-2354398,CDM,C1713,HCPCS,0278,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
CAGE SPNL MESH 33X26X15 MM 6 LOBE,SUP-2602091,CDM,C1889,HCPCS,0278,RC,,,,both,,,11184.68,7270.04,,,,,,,,,,,,,
PLATE BONE W14XL210MM THK3.8MM 90DEG 11 H LT TIB S STL L SHP,SUP-2185792,CDM,C1713,HCPCS,0278,RC,,,,both,,,2391.93,1554.75,,,,,,,,,,,,,
STAPLE BNE 20 MM ANTR BUTTRESS NS BOWTI,SUP-2590315,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CAGE SPNL MESH 28X22X90 MM 6 LOBE,SUP-2602089,CDM,C1889,HCPCS,0278,RC,,,,both,,,20300.10,13195.06,,,,,,,,,,,,,
ALLOGRAFT DERMAL 10X14X2 MM DERMAL MTRX ARTHROFLEX BIOWASHER,SUP-2741915,CDM,Q4125,HCPCS,0636,RC,,,,both,,,881.96,573.27,,,,,,,,,,,,,
BIT DRL DIA2 MM NIT 5TH METATRSL JT FEN NS REUSE UNITE,SUP-2897366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
ELECTRODE ES LAP 5MM DIA 37CML BALL TIP STRGHT HNDLE CGLTNG,SUP-2675721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.32,442.86,,,,,,,,,,,,,
KIT FIX BNE TO BNE TI RND BTTN W 29X35MM SLD DRL,SUP-2136096,CDM,C1713,HCPCS,0278,RC,,,,both,,,2539.73,1650.82,,,,,,,,,,,,,
PLATE BNE 3.5X121 MM 10 HOLE SS DCP,SUP-2569142,CDM,C1713,HCPCS,0278,RC,,,,both,,,302.23,196.45,,,,,,,,,,,,,
GRAFT BNE 11 MM AVITRAC MTP REV,SUP-2423330,CDM,C1713,HCPCS,0278,RC,,,,both,,,4165.21,2707.39,,,,,,,,,,,,,
PLATE BNE L 2X2 H CRANIOMAXILLOFACIAL TI 3D BX LO PROF FOR,SUP-2366202,CDM,C1713,HCPCS,0278,RC,,,,both,,,885.42,575.52,,,,,,,,,,,,,
MESH CRAN L 145 X W 145 MM SCREW DIA2 MM TI PANEL NS DISP,SUP-2936484,CDM,C1713,HCPCS,0278,RC,,,,both,,,4314.36,2804.33,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK.8-1.4MM ACELLULAR DERM MTRX,SUP-2402517,CDM,Q4126,HCPCS,0636,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
GRAFT EVAR 16FR L156MM DIA16X10MM HI DENS MULTIFILAMENT,SUP-2295241,CDM,C1768,CPT,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
CATHETER EMB 3FR L40CM 0.018IN THRU LUMN OVR THE WIRE RADPQ,SUP-2214015,CDM,C1757,HCPCS,0272,RC,,,,both,,,472.29,306.99,,,,,,,,,,,,,
BUR SURG L 13 MM DIA 2 MM SHANNON STR STRL DISP,SUP-2908926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
LID STRL PROX HUM BASE FOR IMPL TY,SUP-2490627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1505.19,978.37,,,,,,,,,,,,,
PLATE BNE W10.1XL94MM 8 H BILAT TI LOK COMPR LO PROF RIG,SUP-2191094,CDM,C1713,HCPCS,0278,RC,,,,both,,,1803.40,1172.21,,,,,,,,,,,,,
PROBE SURG L231CM DIA0.9MM 70DEG FLD OF VW 6000 PIXEL IMAG,SUP-2149605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11890.43,7728.78,,,,,,,,,,,,,
CANNULA X FIX,SUP-2669720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,598.64,389.12,,,,,,,,,,,,,
PLATE BONE L40MM 3 H STRL BILAT 1/4 TBLR COMPR FOR 2.7MM SCR,SUP-2349936,CDM,C1713,HCPCS,0278,RC,,,,both,,,4766.68,3098.34,,,,,,,,,,,,,
PROBE COAG L350CM CHN 2.8MM TIP 7FR SGL PLUG W/ COAX CONN,SUP-2313019,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.90,534.88,,,,,,,,,,,,,
KIT CATH 7FR L16CM CTRL VEN POLYUR 3 LUMN PRSS INJ BLU,SUP-2383382,CDM,C1751,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
DEVICE FIX ARTIFICIAL LIGMNT 7,SUP-2137259,CDM,C1713,HCPCS,0278,RC,,,,both,,,1828.74,1188.68,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE 6 GBQ YTTRIUM-90 GLS DOSE VI,SUP-2135308,CDM,C1889,HCPCS,0278,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
HC So Androstenedione,PX-3018215766,CDM,82157,CPT,0301,RC,,,,outpatient,,,1352.00,878.80,,,,,,,,,,,,,
NEEDLE SUT PASS FOR QUATTRO SHLDR SYS,SUP-2402632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD FJ,SUP-2248500,CDM,C1733,HCPCS,0272,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
FILTER VASC OPT ELITE SHTH L 100 CM DIA 5 FR CAVA DIA 30 MM,SUP-2120060,CDM,C1880,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
BLADE LARYNSCP MACINTOSH AD FBR OPT SZ 3 M 135MMX15MM HEINE,SUP-2238181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC Fna WO Imaging Guidance,PX-4501002100,CDM,10021,CPT,0450,RC,,,,both,,,1531.00,995.15,,,,,,,,,,,,,
ANCHOR SUTURE SFT 1.4 MM 2 IMPL PK GUIDE DRL BIT JUGGERKNOT,SUP-2608797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2278.89,1481.28,,,,,,,,,,,,,
INSERT TIB SZ 2 THK6.5MM KNEE UHMWPE INLAY RESTORIS MCK,SUP-2368680,CDM,C1776,CPT,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
BUR SURG DIAMOND 1.4 MM 98 MM OTO-FLEX GRY WHT SKEETER,SUP-2629051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,619.27,402.53,,,,,,,,,,,,,
COLLAR CERV AD COT LN PD HT ADJ TECHNOLOGY W/ REPL PDS,SUP-2124227,CDM,L0180,HCPCS,0274,RC,,,,both,,,122.59,79.68,,,,,,,,,,,,,
GRAFT BONE 1.7-10MM 90ML CANC CHIP FRZ DRY,SUP-2294033,CDM,C1713,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,0636,RC,63323-0508-30,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
VASCULAR PROS STD WALL STAGGERED CONICA INSIDE DIAM 4MM 7MM,SUP-2395723,CDM,C1768,CPT,0278,RC,,,,both,,,2728.66,1773.63,,,,,,,,,,,,,
PLATE BONE MINI MP PRE BENT CHIN WITH 6MM ADVANCEMENT,SUP-2862614,CDM,C1713,HCPCS,0278,RC,,,,both,,,686.69,446.35,,,,,,,,,,,,,
INTRODUCER SFT ENH COAX ACC SYS 13CM STARBURSTXLL,SUP-2117221,CDM,C1894,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT DURA ABSRB CLLGN BASE ST 5IN 4IN CLLGN DURAMATRIX,SUP-2165122,CDM,C1763,HCPCS,0278,RC,,,,both,,,3891.28,2529.33,,,,,,,,,,,,,
STEM FEM L120MM OD14MM NO CEM MOD,SUP-2265077,CDM,C1776,CPT,0278,RC,,,,both,,,6502.94,4226.91,,,,,,,,,,,,,
CATHETER CRYOABLATION 7FR L108CM TIP L6MM CRV 60MM CARD,SUP-2281874,CDM,C1733,HCPCS,0272,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
PROBE ULTRASONIC W/ OSC BUR TIP,SUP-2261219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
COMPONENT PAT SZ 4 RESURF AUG GMK,SUP-2267457,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SKID BNE MURPHY-LANE 11.75 IN 0.75X1-1/3 DBL END SS NS,SUP-2484771,CDM,C1713,HCPCS,0278,RC,,,,both,,,212.89,138.38,,,,,,,,,,,,,
PLATE BNE L52MM 3X3 H S STL T LOK COMPR OBLQ L ANG FOR,SUP-2186025,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.64,618.57,,,,,,,,,,,,,
ALLOGRAFT TEND SEMITENDINOSUS W GRACILIS FRZN ASEP,SUP-2211505,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
HEAD HUM LT FRZN ALLGRFT,SUP-2335592,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.80,2592.07,,,,,,,,,,,,,
ISOSORBIDE DINITRATE 10 MG PO TABS,RX-4064,CDM,6370000000,HCPCS,0637,RC,63739-0569-10,NDC,,both,1,UN,3.40,2.21,,,,,,,,,,,,,
FOOTPLATE BNE LNG L180MM ALUMINUM MAXFRAME,SUP-2179159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4164.61,2707.00,,,,,,,,,,,,,
GRAFT AMNIOTIC MEMBRANE FLOWERAMNIOPATCH 2CM X 4CM,SUP-2866794,CDM,Q4178,HCPCS,0636,RC,,,,both,,,8036.20,5223.53,,,,,,,,,,,,,
BOLT TIB AUG 5MM KNEE VANGUARD 360,SUP-2408016,CDM,C1776,CPT,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
CATHETER ATR 7FR L46CM OD2.3MM ID1.2MM BA STRP STYL PUDENZ,SUP-2243862,CDM,C1729,HCPCS,0272,RC,,,,both,,,355.54,231.10,,,,,,,,,,,,,
PATCH VASC L75MM DIA6MM HEMACAROTID ULT THN,SUP-2227501,CDM,C1768,CPT,0278,RC,,,,both,,,348.19,226.32,,,,,,,,,,,,,
HC App Skin Sub T/a/L Tot <100 1st 25,PX-3611527100,CDM,15271,CPT,0361,RC,,,,outpatient,,,6021.00,3913.65,,,,,,,,,,,,,
MESH PTCH MK W POSIFLEX OVL 35 IN X 5 IN M,SUP-2126070,CDM,C1781,HCPCS,0278,RC,,,,both,,,412.91,268.39,,,,,,,,,,,,,
HC So Mtb Pcr,PX-3068755668,CDM,87556,CPT,0306,RC,,,,both,,,438.00,284.70,,,,,,,,,,,,,
CATHETER INTVASC OCCL DIA 7 FR BALLOON L 10 MM DIA10 MM SIL,SUP-2365835,CDM,C2628,HCPCS,0272,RC,,,,both,,,3300.77,2145.50,,,,,,,,,,,,,
NECK FEM MOD TI NEUT LNG PROFEMUR,SUP-2400557,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
GRAFT HUM TISS W9XH6XL6MM PARA SPNL ALLGRFT FRZ DRY,SUP-2306947,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
CATHETER CV 3L 5 FR FULL NURSING TY POWERPICC SOLO 2,SUP-2125644,CDM,C1751,HCPCS,0278,RC,,,,both,,,777.90,505.63,,,,,,,,,,,,,
MOULD SPACER SM R/L KNEE TEMP STRL DISP COPAL,SUP-2905409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
PROBE SOUNDING FEELER CD HORZ LEG,SUP-2290334,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.48,413.71,,,,,,,,,,,,,
VALVE AORT CRYOVALVE SZ 21 MM AORT ALLGRFT NONROTATABLE,SUP-2175207,CDM,C1889,HCPCS,0278,RC,,,,both,,,36251.30,23563.34,,,,,,,,,,,,,
EXPANDER LD FOR LCK STR STYL INSRTN STRL,SUP-2169001,CDM,C1789,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 4.5-6.5 MM EPTFE TAPR TW N RING,SUP-2396725,CDM,C1768,CPT,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
TAPESTERY RC BIOINTEGRATIVE 30X20 MM ANTR LF,SUP-2867245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 5 MESH NS FACE ID,SUP-2909575,CDM,C1713,HCPCS,0278,RC,,,,both,,,36913.87,23994.02,,,,,,,,,,,,,
SYSTEM CARD W/ RIATA ST SYS FOR V-196 EPIC CONVERT VR,SUP-2356534,CDM,C1721,HCPCS,0275,RC,,,,both,,,64134.50,41687.42,,,,,,,,,,,,,
PARACENTESIS SET STR 6 FRX10 CM FIX LUER VLV ONESTEP,SUP-2460004,CDM,C1729,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BNE L77MM 6 H TI FIBULAR COMP LOK COMPR LO PROF,SUP-2413681,CDM,C1713,HCPCS,0278,RC,,,,both,,,718.81,467.23,,,,,,,,,,,,,
PLATE BNE W175XL152MM THK52MM 8 H BILAT TI RIG NEUT LOK,SUP-2190845,CDM,C1713,HCPCS,0278,RC,,,,both,,,1602.81,1041.83,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 6 PACK,SUP-2855640,CDM,C2642,HCPCS,0278,RC,,,,both,,,16746.66,10885.33,,,,,,,,,,,,,
NAIL IM L400MM DIA13MM NONSTERILE GRN TIB TI CANN LCK,SUP-2192874,CDM,C1713,HCPCS,0278,RC,,,,both,,,4107.87,2670.12,,,,,,,,,,,,,
EZ BOOTX-L,SUP-2326321,CDM,L4396,HCPCS,0274,RC,,,,both,,,201.53,130.99,,,,,,,,,,,,,
MOST ELLIPTICAL ALL-POLY PATELLA SMALL,SUP-2509222,CDM,C1776,CPT,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
PLATE BNE BAR 8 MM 4 H MINI LT MIDFACE L SHP MALL,SUP-2883165,CDM,C1713,HCPCS,0278,RC,,,,both,,,1545.23,1004.40,,,,,,,,,,,,,
PIN BNE FIX SHRT SHOULDERED CADENCE,SUP-2933745,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.33,227.06,,,,,,,,,,,,,
IMPLANT MENIS L13MM DIA1.1MM PROPRIETARY SELF REINF,SUP-2166737,CDM,C1776,CPT,0278,RC,,,,both,,,1621.31,1053.85,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA2.7 MM TI HI TORQUE XDRV FOR 2.4 MM SYS,SUP-2934722,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
ROD EXT FIX SM L117MM DIA4MM 90DEG UNIV C FBR CRV CONN,SUP-2188717,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.58,355.93,,,,,,,,,,,,,
SLING GYN W1XL60CM MIDURETHRAL RETROPUBIC SYN POLYPR SUPRIS R,SUP-2165382,CDM,C1771,HCPCS,0278,RC,,,,both,,,2954.74,1920.58,,,,,,,,,,,,,
KIT INTRO VSI L 30 CM DIA 4 FR GUIDEWIRE L 80 CM DIA 0.018,SUP-2763441,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.97,63.68,,,,,,,,,,,,,
PLATE BNE M THK0.7MM 12 H ORBIT RIM PNK TI NEUT,SUP-2181697,CDM,C1713,HCPCS,0278,RC,,,,both,,,1378.15,895.80,,,,,,,,,,,,,
PLATE BNE W9.2XL25MM THK1.3MM 100DEG 2 H TI TBLR FOR 3.5MM,SUP-2412032,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
PLATE BNE L 118 SCREW DIA 3.5 MM 10 H SS RECON NS,SUP-2908829,CDM,C1713,HCPCS,0278,RC,,,,both,,,1619.64,1052.77,,,,,,,,,,,,,
SCREW CP LAG 3.6X34MM,SUP-2460800,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
HEPARIN (PORCINE) IN NACL 1000-0.9 UT/500ML-% IV SOLN,RX-145150,CDM,J1644,HCPCS,0636,RC,00409-1005-01,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
HC So Hep C Rna Qual by Pcr,PX-3068752166,CDM,87521,CPT,0306,RC,,,,both,,,386.00,250.90,,,,,,,,,,,,,
MESH SURG L 30 X W 20 CM POLYPRO POLYLACTIC ACD GRP,SUP-2901751,CDM,C1781,HCPCS,0278,RC,,,,both,,,4258.97,2768.33,,,,,,,,,,,,,
PLATE BNE 3 H STD L VOLAR WRST 7 PEG BEAR,SUP-2389746,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
BUR SURG 51X65MM NEURO RND CUT FLUT CARB ST MICROFRANCE,SUP-2278096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.03,356.87,,,,,,,,,,,,,
EXPANDER BRST W14.6XH15.3CM P7.6CM 750CC SIL NACL SHELL RND,SUP-2300642,CDM,C1789,HCPCS,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
DRIVER SURG DIA3.5MM FOR HDLSS COMPR SCR SYS REDUCT,SUP-2340186,CDM,C1713,HCPCS,0278,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
BAND SCLER L125MM DIA2.5MM CIR BCKL LABTICIAN,SUP-2263419,CDM,C1784,HCPCS,0278,RC,,,,both,,,50.87,33.07,,,,,,,,,,,,,
ARTHROSCOPIC FIXATION KIT DELDEV CANN KNOT PUSH FAST-FIX 360,SUP-2341905,CDM,C1713,HCPCS,0278,RC,,,,both,,,1862.02,1210.31,,,,,,,,,,,,,
ARCOS 21X250MM INTLKNG DIST,SUP-2506111,CDM,C1776,CPT,0278,RC,,,,both,,,10562.96,6865.92,,,,,,,,,,,,,
WASHER ORTHOPEDIC LOCKING SURFX ALPHA BONE,SUP-2586519,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.46,347.40,,,,,,,,,,,,,
"HC So2 Quantation of Therapuetic Drug, Nes",PX-3018029968,CDM,80299,CPT,0301,RC,,,,outpatient,,,1562.00,1015.30,,,,,,,,,,,,,
BASEPLATE GLEN L35MM DIA25MM STD POLYETH HA THRD POST,SUP-2388698,CDM,C1776,CPT,0278,RC,,,,both,,,6647.38,4320.80,,,,,,,,,,,,,
GRAFT BONE SUB 7.5CC CORTICOCANCELLOUS PARTICULATE FRZ DRY,SUP-2165565,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PINN GRIP TF REV BUTTRESS 68R,SUP-2512742,CDM,C1776,CPT,0278,RC,,,,both,,,6146.86,3995.46,,,,,,,,,,,,,
DEVICE INFL PRSS G INDIC DISP,SUP-2106379,CDM,C1726,HCPCS,0272,RC,,,,both,,,46.82,30.43,,,,,,,,,,,,,
STRUT EXT FIX XSH NS DISP ACUTE QC,SUP-2933716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4537.80,2949.57,,,,,,,,,,,,,
SCREW BNE L24MM DIA4.5MM S STL CANN FULL THRD LO PROF,SUP-2318702,CDM,C1713,HCPCS,0278,RC,,,,both,,,992.99,645.44,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 8 MM STR STD WALL REINF,SUP-2525431,CDM,C1768,CPT,0278,RC,,,,both,,,345.84,224.80,,,,,,,,,,,,,
BRACE ORTH L ANK FT GTT PRSS RELF CNTRCT 1 SZ FIT MOST AD,SUP-2194768,CDM,L4396,HCPCS,0274,RC,,,,both,,,117.84,76.60,,,,,,,,,,,,,
PLATE BNE L90MM 6 H ST POSTEROLATERAL DST TIB S STL T SHP,SUP-2177709,CDM,C1713,HCPCS,0278,RC,,,,both,,,3195.39,2077.00,,,,,,,,,,,,,
KIT URET INFRAVISION L70CM DIA6FR,SUP-2366514,CDM,C2617,HCPCS,0278,RC,,,,both,,,803.21,522.09,,,,,,,,,,,,,
TAP SURG DIA4MM FOR CANC BONE PLATING SYS TC-100,SUP-2343960,CDM,C1713,HCPCS,0278,RC,,,,both,,,944.20,613.73,,,,,,,,,,,,,
SHELL STPL PWR FOR SIGNIA HNDL STPL SYS,SUP-2283368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.65,883.77,,,,,,,,,,,,,
SCREW BNE 2X15 MM 5 MM THRD BROWLIFT CENTRE DRV DRL FREE,SUP-2457259,CDM,C1713,HCPCS,0278,RC,,,,both,,,267.53,173.89,,,,,,,,,,,,,
SET BNE FIX PIN DIA2.8MM K WIRE DIA1.6MM ECLIPSE UNIVERS II,SUP-2123299,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR DF,SUP-2248608,CDM,C1732,HCPCS,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
LEAD PACE POLYUR SIL ENDOCARD MYOCARDIAL RT ATRIOVENTRICULAR,SUP-2148639,CDM,C1898,HCPCS,0275,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
PACK INSTRUMENTXSM INCLUDE GUID PIN SCR DRVR THIMBLE FOR,SUP-2123611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
BIT DRL CANN 8.5 MM KNEE SINGLE FLUT MTO,SUP-2849083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2442.92,1587.90,,,,,,,,,,,,,
SCREW BONE IMPL CANN HDLSS LAG HPS TI 2.0MMX38MM EXTREMIFIX,SUP-2319465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH SPIRAL-Z L 90 MM DIA11 MM SHTH 14 FR,SUP-2171072,CDM,C1874,HCPCS,0278,RC,,,,both,,,10801.60,7021.04,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 30 X 50 X 0.45 MM POLYETHYL ORBIT FLR,SUP-2935198,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
ALLOGRAFT HUM TISS XL 60X210 MM FD FASC LATA,SUP-2792181,CDM,C1762,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PLATE SPNL SM OCCIPITOCERVICAL LO PROF MIDLN VERTEX SEL,SUP-2289136,CDM,C1713,HCPCS,0278,RC,,,,both,,,5443.98,3538.59,,,,,,,,,,,,,
SPLINT WRST M L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276626,CDM,L3809,HCPCS,0274,RC,,,,both,,,21.38,13.90,,,,,,,,,,,,,
GRAFT HUMAN TISSUE KNEE FEMORAL LEFT LATERAL CONDYLE,SUP-2863727,CDM,C1762,CPT,0278,RC,,,,both,,,36643.80,23818.47,,,,,,,,,,,,,
NAIL IM L28CM OD11MM FEM TROCH ENTRY VERSANAIL,SUP-2412485,CDM,C1713,HCPCS,0278,RC,,,,both,,,7243.76,4708.44,,,,,,,,,,,,,
X LG METAL HEMI IMPLANT METAL HEMI SYSTEM,SUP-2494510,CDM,C1776,CPT,0278,RC,,,,both,,,4587.54,2981.90,,,,,,,,,,,,,
PLATE BNE LG LT LAPIDUS STRATUM,SUP-2607233,CDM,C1713,HCPCS,0278,RC,,,,both,,,4475.91,2909.34,,,,,,,,,,,,,
CATHETER IV L45CM OD5FR ID0.026IN 0.34ML SIL DBL LUMN 3 W,SUP-2125618,CDM,C1751,HCPCS,0278,RC,,,,both,,,593.40,385.71,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 35 CM DIA 6 MM EPTFE CARBON STR,SUP-2761266,CDM,C1768,CPT,0278,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
TUBE GASTROSTMY 18FR L18IN 3 LUMN AUTO XCESS REFLUXING,SUP-2306842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
FIBER LASER G-PROBE SLX,SUP-2225632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
PLATE BNE CRV 15X0.35 MM NEURO 3X2 HOLE LADDER W/ TAB STRL,SUP-2498705,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.69,722.60,,,,,,,,,,,,,
PLATE BNE 3.5X61 MM 5 HOLE SS DCP,SUP-2569137,CDM,C1713,HCPCS,0278,RC,,,,both,,,231.42,150.42,,,,,,,,,,,,,
BASKET STONE RETRV 1.5 FRX90 CMX12 MM TIPLSS NIT,SUP-2336363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,617.32,401.26,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY MED 20 IN KNEE ADJ PERF FOAM,SUP-2194893,CDM,L1830,CPT,0274,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ANGLED 8 CM 0.035 INX150 CM ZIPWIRE,SUP-2862342,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.81,85.03,,,,,,,,,,,,,
CATHETER PERITONEAL L 34.25 CM CURL TO CUF 3 CM PED CURL,SUP-2905031,CDM,C1750,HCPCS,0278,RC,,,,both,,,363.05,235.98,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 20 CC DEMINERALIZED CORT CANC BNE FIBER,SUP-2905191,CDM,C1713,HCPCS,0278,RC,,,,both,,,6176.38,4014.65,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR W73XH14CM THK20CM 02KG SCRN 35IN,SUP-2357680,CDM,C1787,HCPCS,0278,RC,,,,both,,,4827.94,3138.16,,,,,,,,,,,,,
BLADE RESECTION L8CM DIAMETER 2.9MM 35DEG SMALL JOINT STEALT,SUP-2824674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. L 60 MM DIA 8 MM GUIDEWIRE 0.018 IN,SUP-2158926,CDM,C1876,HCPCS,0278,RC,,,,both,,,3755.44,2441.04,,,,,,,,,,,,,
GRAFT BNE STRP 2X6.25X0.8 CM 20 CC CONDUCT,SUP-2599268,CDM,C1713,HCPCS,0278,RC,,,,both,,,8829.68,5739.29,,,,,,,,,,,,,
SHUNT SURG SM PERF LEVEL 1.0 DELT,SUP-2628313,CDM,C1729,HCPCS,0272,RC,,,,both,,,1088.95,707.82,,,,,,,,,,,,,
RING EXT FIX HALF 140 MM CIR SIDEKCK,SUP-2852536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
EXTENSION STEM L60MM DST FEM MOD PC GMRS,SUP-2376558,CDM,C1776,CPT,0278,RC,,,,both,,,7254.34,4715.32,,,,,,,,,,,,,
SCREW SPNL MULTAXL 8.5X60 MM REDUCTION CD HORZ SOLERA 5.5/6,SUP-2629916,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 26-50 MMX0.1 CM FD,SUP-2717855,CDM,C1762,CPT,0278,RC,,,,both,,,2392.24,1554.96,,,,,,,,,,,,,
"HC Platelets,Leuko Red,Cmv-Neg Ea",PX-3900905500,CDM,P9055,CPT,0390,RC,,,,both,,,2239.00,1455.35,,,,,,,,,,,,,
CARPENTER- LO PRSS PORCINE MITRL BIOPROSTHESIS - SZ 27MM,SUP-2214279,CDM,C1713,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
RING EXT FIX DIA180MM HALF FOR RNG FIX SYS TRUELOK,SUP-2316181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1722.86,1119.86,,,,,,,,,,,,,
PLATE BONE L29MM MINI STR,SUP-2364910,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
NEXFIX NCP SCORED GUID  NCPSGW062,SUP-2844032,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
RING EXT FIX L 220 MM ARCH MONK RING,SUP-2899026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2409.17,1565.96,,,,,,,,,,,,,
SCREW BNE L3MM DIA1MM MIC CORT TI ST SELF DRL SELF RET,SUP-2262772,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.00,144.30,,,,,,,,,,,,,
CATHETER GUID MICROGUIDE TOT L 82 CM L 76 CM SHTH 6 FR,SUP-2158735,CDM,C1887,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CROWN FORM DENT STRP U1 PRIMARY ANTR UPPER LT CNTRL PLAS,SUP-2322237,CDM,D6783,CPT,0278,RC,,,,both,,,13.03,8.47,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED 15 MM FRSH PROCHONDRIX CR,SUP-2717805,CDM,C1762,CPT,0278,RC,,,,both,,,23917.38,15546.30,,,,,,,,,,,,,
GAUGE DIAMETER ZIMMER BIOMET,SUP-2488095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
PUMP PAIN MGMT 400ML 5ML/HR N NARC ELASTOMERIC INCIS FIX FLO,SUP-2236776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
MESH HERN 4.5IN VENTRAL POLYPR EPTFE REP LTWT CIR LO PROF L,SUP-2125813,CDM,C1781,HCPCS,0278,RC,,,,both,,,1628.72,1058.67,,,,,,,,,,,,,
LINER ACET OD54MM ID28MM 10DEG MARATHON HIP REV DURALOC,SUP-2250508,CDM,C1776,CPT,0278,RC,,,,both,,,4848.16,3151.30,,,,,,,,,,,,,
ENDOILLUMINATOR OPHTH 25GA STR STIFF SHFT N RFID DISPOSABLE,SUP-2109929,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE L 1.5X0.6 MM 4 MM MIDFACE 2X2 HOLE BRIDGE TI NS,SUP-2518099,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.28,569.58,,,,,,,,,,,,,
TR PN W/CV PT 250X50X5 FP,SUP-2818094,CDM,C1713,HCPCS,0278,RC,,,,both,,,1854.89,1205.68,,,,,,,,,,,,,
PUSHER KNOT 3.5 MMX31 CM EXCORP,SUP-2850204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,953.93,620.05,,,,,,,,,,,,,
SPACER SPNL 30 DEG W 34 X H 15 MM D 26 MM TI ANTR LUMBAR,SUP-2881732,CDM,C1713,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
HC CT Abdomen W/ Cont,PX-3527416000,CDM,74160,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
PLATE BNE L 259 X W 11 MM THK 3.3 MM SCREW DIA 3.5 MM,SUP-2907870,CDM,C1713,HCPCS,0278,RC,,,,both,,,2771.43,1801.43,,,,,,,,,,,,,
ENDCAP ORTH NONSTERILE S STL END FOR OLECRANON OSTEOTMY,SUP-2183156,CDM,C1889,HCPCS,0278,RC,,,,both,,,853.01,554.46,,,,,,,,,,,,,
BIT DRL L280MM DIA4.3MM QUIK CPL W/O STP REUSE,SUP-2187276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1115.89,725.33,,,,,,,,,,,,,
GRAFT HUM TISS PAT TEND BIOCLEANSE,SUP-2361833,CDM,C1713,HCPCS,0278,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
SHUNT CSF 15CM H2O GRAVITATIONAL UNIT PEDIATRIC RESERVOIR VE,SUP-2821854,CDM,C1889,HCPCS,0278,RC,,,,both,,,10002.97,6501.93,,,,,,,,,,,,,
BIT DRL L 175/90 MM DIA2 MM SCREW DIA2.7 MM CALIB AO QC CLR ST,SUP-2913758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,933.05,606.48,,,,,,,,,,,,,
LINER ACET CUP NEUT PRI SNAP IN MTL ON POLY POLYETH 0DEG,SUP-2202228,CDM,C1776,CPT,0278,RC,,,,both,,,2989.28,1943.03,,,,,,,,,,,,,
K WIRE FIX L9IN DIA0.062IN DMND PNT RND END THRD,SUP-2342672,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.22,225.69,,,,,,,,,,,,,
SCREW SPNL L60MM OD6.5MM 0DEG TI CANC PEDCL IL FIX ANG HD,SUP-2287135,CDM,C1713,HCPCS,0278,RC,,,,both,,,3032.93,1971.40,,,,,,,,,,,,,
K-WIRE 2.0MM X 350MM TROCAR TIP,SUP-2931155,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.60,298.74,,,,,,,,,,,,,
CANNULA ROBOTIC DIA85MM BLNT E REUSE DA VINCI SGL SITE,SUP-2246589,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
ALLOGRAFT ADIPOSE EXTRACELLULAR MTRX 3 CC LENEVA,SUP-2636342,CDM,C1762,CPT,0278,RC,,,,both,,,7308.35,4750.43,,,,,,,,,,,,,
TRAMADOL HCL 50 MG PO TABS,RX-14632,CDM,6370000000,HCPCS,0637,RC,00904-7496-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT TMPLT Y SHP DRL ST,SUP-2194193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,190.97,124.13,,,,,,,,,,,,,
SYSTEM CTRL 3772CONTRLSYS,SUP-2615542,CDM,C1767,HCPCS,0278,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
CANNULA ENDOSCP DIA5.8MM HI FLO SPD LOK W/ 2 ROT STPCOCK,SUP-2366614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2044.49,1328.92,,,,,,,,,,,,,
DRESSING BIO 1000 MG TYP I/III BOV CLLGN MTRX FIBRILLAR SHLF,SUP-2905499,CDM,C1763,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA2 MM MANDIBULAR ST LCK NS UNIV AXS,SUP-2909470,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.20,308.23,,,,,,,,,,,,,
CUTTER ENDOSCP DIA9MM USED TO ELIMINATE TRANSOSSEOUS TUNN,SUP-2120853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM 130DEG SHT R PROX TROCHANTERIC FEM,SUP-2192016,CDM,C1713,HCPCS,0278,RC,,,,both,,,5134.03,3337.12,,,,,,,,,,,,,
MESH MXLFCL 126.2X11.2 MM 2 MM SM GRID PDLLA STRL RESORB X,SUP-2476653,CDM,C1713,HCPCS,0278,RC,,,,both,,,2583.00,1678.95,,,,,,,,,,,,,
GRAFT EVAR L13CM AORT DIA31MM IL DIA14.5MM IPSILATERAL LEG,SUP-2396062,CDM,C1768,CPT,0278,RC,,,,both,,,33010.82,21457.03,,,,,,,,,,,,,
PLATE BNE W12XL200MM THK25MM LNG 8 H NONSTERILE BILAT PROX,SUP-2190992,CDM,C1713,HCPCS,0278,RC,,,,both,,,5200.59,3380.38,,,,,,,,,,,,,
STEM FEM L250MM OD11MM TI HA 80% POR DST CALCAR HIP DPHSEAL,SUP-2408335,CDM,C1776,CPT,0278,RC,,,,both,,,8264.48,5371.91,,,,,,,,,,,,,
HC Repair Mouth Laceration,PX-4504083000,CDM,40830,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
POLYMYXIN B SULFATE 500000 UNITS IJ SOLR,RX-6393,CDM,2500000003,HCPCS,0250,RC,72266-0249-01,NDC,,both,1,UN,55.00,35.75,,,,,,,,,,,,,
RETRACTOR ENDOSCP L 2350 MM DIA2.6 MM CLP SZ 16 MM CHANNEL,SUP-2909397,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
DILATOR ENDOSCP L200CM DIA3MM GWIRE 0.035IN GRAD W/O BLLN,SUP-2169260,CDM,C1726,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM 12 MM POLYESTER BOV CLLGN STR,SUP-2265895,CDM,C1768,CPT,0278,RC,,,,both,,,48.61,31.60,,,,,,,,,,,,,
GRAFT HUM TISS DIA 44 MM CORTICAL FEM HD FRZN STRL,SUP-2913410,CDM,C1762,CPT,0278,RC,,,,both,,,4823.04,3134.98,,,,,,,,,,,,,
WIRE FIX L450MM DIA2MM S STL DMND PNT DBL SHRP TIP SMOOTH K,SUP-2372600,CDM,C1713,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
INSERT SURG L61MM SIL FILL RUB DBL HYDRAJAW RIDGED REUSE,SUP-2214536,CDM,C1757,HCPCS,0272,RC,,,,both,,,101.61,66.05,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM 0.035 IN L8CM 3CM HEPARIN AMPLTZ STR,SUP-2169713,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.17,48.86,,,,,,,,,,,,,
GRAFT HUM TISS PERICARD SM 40 MMX4 CM FD,SUP-2307104,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.14,614.99,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SUPRAMALLEOLAR,SUP-2435625,CDM,L1907,HCPCS,0272,RC,,,,both,,,1593.11,1035.52,,,,,,,,,,,,,
HC So1 Immunoassay Quant,PX-3018351967,CDM,83519,CPT,0301,RC,,,,outpatient,,,264.00,171.60,,,,,,,,,,,,,
WEDGE FEM L SZ 4 D5MM P5MM DST POST KNEE SCR ON LEGION,SUP-2346353,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 20 MM DIA2.75 MM SS RX,SUP-2144498,CDM,C1876,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC DEMINERALIZED CORTICAL BNE FIBER,SUP-2932935,CDM,C1762,CPT,0278,RC,,,,both,,,1927.58,1252.93,,,,,,,,,,,,,
STAPLER INTERNAL TITAN SGS LINEAR POWERED ENDOSCOPIC 1.2-2.2MM 23CM JAW,SUP-2902725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
STERILE WATER FOR INJECTION (MIXTURES ONLY),RX-430028,CDM,2500000003,HCPCS,0250,RC,00409-4887-20,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT FEM TOT STBL XS RT KNEE,SUP-2364873,CDM,C1776,CPT,0278,RC,,,,both,,,16417.02,10671.06,,,,,,,,,,,,,
SET SHTH DESTINO L 87 CM L 67 CM DIA12 FR CRV BEND 22 MM,SUP-2616186,CDM,C1766,CPT,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 15 CM DIA 4 MM EPTFE STR TW N RING,SUP-2396329,CDM,C1768,CPT,0278,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|KX|CQ|XU,both,,,191.00,124.15,,,,,,,,,,,,,
NAIL IM L150MM DIA12MM UNIV ANK STR RG NONLOCKING CANN FOR,SUP-2136730,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
SCREW INTRF L 23 MM DIA 6 MM CITREGEN ANK FT TEND FIX RESRB,SUP-2900582,CDM,C1713,HCPCS,0278,RC,,,,both,,,2565.38,1667.50,,,,,,,,,,,,,
STENT CORONARY VERIFLEX L 28 MM DIA 4 MM SS OTW BALLOON,SUP-2144550,CDM,C1876,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
GRAFT BNE FRZ DRY STRUT CORT FEM IMPL ALLGRFT L100MM OD15MM,SUP-2264712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.54,813.50,,,,,,,,,,,,,
ELECTRODE SUCT 90DEG TPLR RF SYS W/ INTEGR HNDPIECE AND HND,SUP-2256714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA BSC 5FR 55CM 3 LUMAN RVS TA,SUP-2613544,CDM,C1751,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
AIRWAY ENDOTRACHEAL ADULT 70-100KG MAX CUFF 40ML LG,SUP-2824582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
KIT HAD CATHETER 12FR L16CM STR EXTN 2 LUMN MAHRK ELITE,SUP-2283958,CDM,C1752,HCPCS,0278,RC,,,,both,,,227.40,147.81,,,,,,,,,,,,,
BOBBIN VT 1.14MM FLPL,SUP-2488688,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.04,14.33,,,,,,,,,,,,,
BLADE RETRACTOR 22 CMX29 MM VES WIDE,SUP-2659976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.54,1502.50,,,,,,,,,,,,,
HC NM Hepatobiliary Imaging WO Pharm,PX-3417822600,CDM,78226,CPT,0341,RC,,,,both,,,3442.00,2237.30,,,,,,,,,,,,,
ANCHOR SUTURE PALADIN 5.0MMX15.3MM WITH TWO NUMBER 2 HI FI S,SUP-2824800,CDM,C1713,HCPCS,0278,RC,,,,both,,,1197.91,778.64,,,,,,,,,,,,,
SCREW SPNL L45MM OD6MM CORT FIX TI POLYAX FEN EXT TAB MIS,SUP-2255030,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
REPAIR 14CM 20CM 5.5IN SYNTHECEL DURA X,SUP-2880392,CDM,C1763,HCPCS,0278,RC,,,,both,,,7526.58,4892.28,,,,,,,,,,,,,
SHEATH INTRO DIA10 FR VLV SET STRL,SUP-2118983,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
DEFIBRILLATOR CARD IS1 CONN 2 CHMBR CARDIOVERTER UPLR AND,SUP-2236351,CDM,C1882,HCPCS,0275,RC,,,,both,,,67120.64,43628.42,,,,,,,,,,,,,
STENT TRACHBRONCH L95CM EXP L60MM DIA14MM TIP DIA4MM CVR,SUP-2141613,CDM,C1874,HCPCS,0278,RC,,,,both,,,9702.60,6306.69,,,,,,,,,,,,,
KIT EXTN L40CM 1X8 NEUROSTIMULATOR FOR SPNL CRD STIM,SUP-2284455,CDM,C1883,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GRAFT HUM TISS THK13 15MM CALCANEUS CRSS SECT FRZ DRY,SUP-2307162,CDM,C1713,HCPCS,0278,RC,,,,both,,,2299.33,1494.56,,,,,,,,,,,,,
COMPONENT FEM MCK RESTORIS,SUP-2407398,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE DORS VOLAR FRAG Y SHP DVR YFP] ZIMMER BIOMET INC],SUP-2137707,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
"HC Compatibility Test, Ahg Test",PX-3008692200,CDM,86922,CPT,0300,RC,,,,both,,,354.00,230.10,,,,,,,,,,,,,
CATHETER TRAY PORT-A-CATH,SUP-2175842,CDM,C1788,HCPCS,0278,RC,,,,both,,,30.93,20.10,,,,,,,,,,,,,
PROSTHESIS OTO L6MM SHFT DIA0.4MM LOOP 0.6MM MID EAR STAP,SUP-2284065,CDM,L8613,CPT,0278,RC,,,,both,,,245.55,159.61,,,,,,,,,,,,,
BUR SURG DR LNG 3.5X19.8 MM FLUT FOR HD/HD-G1,SUP-2848174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.66,335.83,,,,,,,,,,,,,
CLIP ANEUR PERM 9/14.1 MM YASRG,SUP-2108621,CDM,C1889,HCPCS,0278,RC,,,,both,,,989.60,643.24,,,,,,,,,,,,,
BRACE WALKING 14-17 IN XL CUSH LP NYL PROCARE MAXTRAX,SUP-2197143,CDM,L4360,HCPCS,0274,RC,,,,both,,,83.15,54.05,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1173108D5,SUP-2632789,CDM,C1751,HCPCS,0278,RC,,,,both,,,1066.53,693.24,,,,,,,,,,,,,
PLATE BNE VA 90- DEG 2.4X41 MM DSTL RADIAL DORS 3X2 HOLE,SUP-2190204,CDM,C1713,HCPCS,0278,RC,,,,both,,,2272.10,1476.86,,,,,,,,,,,,,
TUBE MYR 102MM DIAM VENT TAB SIL PAPARELLA,SUP-2313720,CDM,L8699,HCPCS,0278,RC,,,,both,,,43.74,28.43,,,,,,,,,,,,,
PIN STRNL CLSR TI EMGCY REL,SUP-2192431,CDM,C1713,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
PLATE BONE W7XL57MM THK1.4MM 7 H RT CNDYL S STL,SUP-2343848,CDM,C1713,HCPCS,0278,RC,,,,both,,,2415.32,1569.96,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 20 MM DIA 4.5 MM SS RX,SUP-2144502,CDM,C1876,HCPCS,0278,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
SCREW OPTILINK VA LCKING SLF -TP T25 SD 5.0X70MM,SUP-2653992,CDM,C1713,HCPCS,0278,RC,,,,both,,,570.13,370.58,,,,,,,,,,,,,
BAND ARM AD UNIV GEL ELAS STRP BILAT,SUP-2324557,CDM,L3702,HCPCS,0272,RC,,,,both,,,48.17,31.31,,,,,,,,,,,,,
SPACER ORTHOPEDIC TIB MED 5 MM 2.5 MM PROX KNEE HEX SOCKET,SUP-2423136,CDM,C1776,CPT,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X180 MM 18 HOLE SS LCP,SUP-2569371,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.88,481.57,,,,,,,,,,,,,
PLATE BONE W8XL26MM THK2MM 0DEG 2 H BILAT TI STR RIG DYN,SUP-2191076,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.30,580.64,,,,,,,,,,,,,
SCISSORS HYSTEROSCOPIC HND ACTUATED STRL DISP OMNI,SUP-2913672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE CLAV CS1 2.7 MM RT VA LCK COMPR TI STRL VALCP,SUP-2789607,CDM,C1713,HCPCS,0278,RC,,,,both,,,3853.41,2504.72,,,,,,,,,,,,,
POTASSIUM CHLORIDE ER 10 MEQ PO TBCR,RX-12184,CDM,6370000000,HCPCS,0637,RC,00574-0275-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DRILL SURG 70 MM FOR 3.5MM SCR SPEEDGUIDE,SUP-2480443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1314.40,854.36,,,,,,,,,,,,,
Z DUP USE 2111353 LENS INTOCU +27.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111354,CDM,V2632,HCPCS,0276,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT VASC GRAD WALL 8 MMX80 CM STR REINF GRAD WALL FLIXENE,SUP-2468087,CDM,C1768,CPT,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-4504908300,CDM,49083,CPT,0450,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
INTRODUCER MIC KT 4FRX40CM WIRE S STL SFT TIP,SUP-2120523,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
DILATOR SHTH OUTER L33CM OD14FR ID11.2FR INNR L43CM OD10.9FR,SUP-2353159,CDM,C1894,HCPCS,0272,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
CATHETER GUID L 100 CM OD 6 FR ID 0.070 IN HYDRPHLC PERIPH,SUP-2154305,CDM,C1887,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
IMPLANT HEARING AID 3 MM PONTO BIOHELIX,SUP-2430348,CDM,L8690,HCPCS,0278,RC,,,,both,,,5224.96,3396.22,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 10X10 CM FOR XENOGRAFT GENTRIX MATRIX PLUS,SUP-2106482,CDM,Q4166,HCPCS,0636,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
COMPONENT FEM MOD LG 65X72.5 MM LT KNEE ENDO-MODEL SL,SUP-2423699,CDM,C1776,CPT,0278,RC,,,,both,,,21644.15,14068.70,,,,,,,,,,,,,
PACEMAKER CARD CYLOS VR TI POLYUR SIL SINGLE CHMBR IS1 CONN,SUP-2138078,CDM,C1786,HCPCS,0275,RC,,,,both,,,14186.52,9221.24,,,,,,,,,,,,,
MESH AUG CUSTOMIZED KT STRL MEDPOR LTX,SUP-2862742,CDM,C1713,HCPCS,0278,RC,,,,both,,,24002.16,15601.40,,,,,,,,,,,,,
PLATE BNE L 167 MM SCREW DIA 4.5 MM 9 H SS NAR COMPR NLCK,SUP-2933779,CDM,C1713,HCPCS,0278,RC,,,,both,,,1939.58,1260.73,,,,,,,,,,,,,
STENT URET POLARIS L 22 CM DIA 6 FR PERCFLX HYDROPLUS 2,SUP-2139074,CDM,C2617,HCPCS,0278,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
BIT DRILL SURG 1.8X110MM W/ 26MM STP IQ SER,SUP-2136988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
HC Exc Tr-Ext B9+Marg 0.5 Cm<,PX-4501140000,CDM,11400,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
KIT PICC 5FR L55CM POLYUR NRS SGL LUMN BASIC PWR INJ N COAT,SUP-2126704,CDM,C1751,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BONE 6 H LCK BILAT STR HND DISP FOR 2MM SCR H DIA,SUP-2267922,CDM,C1713,HCPCS,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
STEMLESS HUMERAL COMP INTEGRIP CAGE SIZE 1,SUP-2512429,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
ROD SPNL 6X300 MM INVICTUS 152705560300,SUP-2724629,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
ETRAVIRINE 100 MG PO TABS,RX-89432,CDM,6370000000,HCPCS,0637,RC,60219-1721-07,NDC,,both,1,UN,48.30,31.39,,,,,,,,,,,,,
PROBE CRYOSURGERY 18IN BALL TIP 8MM ERGO HNDL BEND DST SHFT,SUP-2124445,CDM,C2618,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
BUTTON CERCLAGE CANN 4 MM HEX TI STRL,SUP-2547009,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.19,327.07,,,,,,,,,,,,,
SUTURE FIBERSNARE 2 L26IN NONABSORBABLE GRN L12IN FIBERWIRE AR7209SN,SUP-2122084,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL 3,SUP-2435550,CDM,L0492,HCPCS,0274,RC,,,,both,,,1415.86,920.31,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 55 CM DIA 4-7 MM EPTFE TAPR STD,SUP-2396216,CDM,C1768,CPT,0278,RC,,,,both,,,2398.96,1559.32,,,,,,,,,,,,,
GRAFT DURA 2X7 CM SUTURABLE BIO TISS BOV PERICARD DURAGN,SUP-2468366,CDM,C1763,HCPCS,0278,RC,,,,both,,,1106.72,719.37,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.5-3 MM 30 CC FD CRUSH CORTICAL CANC,SUP-2743408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
SHELL ACET SZ D DIA50MM 3 H OSSEOTI LIMIT H 2 MOBILITY G7,SUP-2403468,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
TRAY GLEN M SHLDR HA POR MOD BIOMOD,SUP-2404646,CDM,C1776,CPT,0278,RC,,,,both,,,4870.14,3165.59,,,,,,,,,,,,,
PLATE BONE LT EPIPHYSIS ECT FX FIX,SUP-2198584,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM NOM THK1.5MM MAXFORC HUM DERM REGEN,SUP-2399062,CDM,Q4107,HCPCS,0636,RC,,,,both,,,8013.28,5208.63,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 60 MM 60 MM 4 HOLE TI NS DCP,SUP-2569036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1396.42,907.67,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 38MM POLYESTER BOV CLLGN STR,SUP-2227241,CDM,C1768,CPT,0278,RC,,,,both,,,2575.18,1673.87,,,,,,,,,,,,,
SCREW IM NAIL L 70 MM DIA 4.5 MM TI LP STRL TRIGEN,SUP-2933850,CDM,C1713,HCPCS,0278,RC,,,,both,,,696.89,452.98,,,,,,,,,,,,,
COIL DETACH 4MM DIA 12CM COIL OUTER DIA 0125IN VOL 950MM,SUP-2173106,CDM,C1889,HCPCS,0278,RC,,,,both,,,6396.18,4157.52,,,,,,,,,,,,,
SEALER TISSUE X1 37CM STRAIGHT JAW,SUP-2749483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
NEEDLE ENDOSCP 25GA L4MM WRK L230CM MIN CHN 28MM UP GI MID,SUP-2313417,CDM,C1713,HCPCS,0278,RC,,,,both,,,138.82,90.23,,,,,,,,,,,,,
WASHER ORTH STP 3.5 MM FOR LAG SCREW IO FRDM DISP,SUP-2864895,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
ELECTRODE ENDO MPLR DISP RL CUT 24FR,SUP-2261188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.61,307.85,,,,,,,,,,,,,
PLATE BNE L135MM 10 H L LAT DST PERIARTC FIBULAR S STL,SUP-2410568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.97,1096.53,,,,,,,,,,,,,
GRAFT HUM TISS 15X15MM PERICARD FRZ DRY READIGRFT,SUP-2264831,CDM,C1768,CPT,0278,RC,,,,both,,,312.78,203.31,,,,,,,,,,,,,
STENT PANCREATIC ZMMN L 40 MM DIA 7 FR CHANNEL 3.2 MM,SUP-2675680,CDM,C2617,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SCREW BNE L40MM DIA5.5MM CORT FT ANK S STL ST SELF DRL CANN,SUP-2398100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
IMPLANT OTO L4.25MM OD.5MM PLAT TI PIST SHT BODY CLR DEPTH,SUP-2284071,CDM,L8613,CPT,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GAUGE DEPTH DISPOSABLE SONOMA CRX,SUP-2431210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC Pre-Pooled Cryoprecipitate,PX-3900901200,CDM,P9012,CPT,0390,RC,,,,outpatient,,,384.00,249.60,,,,,,,,,,,,,
HC Icd New Lead Only,PX-3613321600,CDM,33216,CPT,0361,RC,,,,both,,,27845.00,18099.25,,,,,,,,,,,,,
PLATE 54MM RECON 9 H REAR FT,SUP-2243225,CDM,C1713,HCPCS,0278,RC,,,,both,,,6583.51,4279.28,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID THN 12X2 CM AMNIO PLCNTA PRO3-P,SUP-2742038,CDM,C1762,CPT,0278,RC,,,,both,,,5914.98,3844.74,,,,,,,,,,,,,
HC NM I 131 Thyroid Treatment,PX-3427900500,CDM,79005,CPT,0342,RC,,,,inpatient,,,1313.00,853.45,,,,,,,,,,,,,
CATH ENROUTE ENFLATE TRANSCAROT RX BLLN DILATATION 4X25,SUP-2854415,CDM,C1725,HCPCS,0272,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
PLATE SPNL 60 MM STRL ATLNTS ESSENTIALS,SUP-2632021,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
CATHETER DIAG 2.6X2FR L150CM DST L6CM ID0.019IN MIC,SUP-2367852,CDM,C1887,HCPCS,0272,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
DEXMEDETOMIDINE HCL 400 MCG/4ML IV SOLN,RX-135709,CDM,2500000003,HCPCS,0250,RC,44567-0600-04,NDC,,both,4,ML,454.00,295.10,,,,,,,,,,,,,
SHAFT SCRDRVR SELF RET AO QC T25 STRL DISP FLEX-THREAD,SUP-2900445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GRAFT BONE PRO DENS 15CC,SUP-2399150,CDM,C1713,HCPCS,0278,RC,,,,both,,,11985.29,7790.44,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 16GM THK7MM VAGUS NRV SGL PIN,SUP-2265161,CDM,C1767,HCPCS,0278,RC,,,,both,,,85868.01,55814.21,,,,,,,,,,,,,
RAMUS TRNSPRT DVCE 20MM MDDLE DRVN BODY WTWO PLTS T 6L 4V,SUP-2669790,CDM,C1713,HCPCS,0278,RC,,,,both,,,16971.89,11031.73,,,,,,,,,,,,,
HC Plcmt Interstit Prostate Rx Tx,PX-3615587600,CDM,55876,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
WASHER ORTH STRL FOR 3.5MM SCR EVOS SM PLATING SYS,SUP-2349664,CDM,C1776,CPT,0278,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
SCREW BNE L16MM DIA5MM S STL ST VAR ANG LOK FULL THRD T25,SUP-2178698,CDM,C1713,HCPCS,0278,RC,,,,both,,,573.49,372.77,,,,,,,,,,,,,
GUIDE SURG KNIFE TIP 0.6 MM KNEE WIRE STRUT NOTCH END,SUP-2392436,CDM,C1769,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
DIST HUM LAT RT 15H 142MM STE,SUP-2588821,CDM,C1713,HCPCS,0278,RC,,,,both,,,3001.59,1951.03,,,,,,,,,,,,,
VITAMIN E 450 MG (1000 UT) PO CAPS,RX-155568,CDM,6370000000,HCPCS,0637,RC,00904-0277-60,NDC,,both,1,UN,1.10,0.71,,,,,,,,,,,,,
SCREW BNE 65MMX60MM LO PROF CANC TI ALLY,SUP-2166920,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.59,161.58,,,,,,,,,,,,,
SUPPORT ORTHOT FT HEEL STBL PLAS SIL,SUP-2435713,CDM,L3170,HCPCS,0272,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
SET INTRO SELECTRA STRL,SUP-2418817,CDM,C1893,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
BASKET SPEC RETRV 3 FRX120X11 MM WOVEN NET SUR-CATCH,SUP-2312751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
HC MRI Lower Ext Jnt W/ Cont,PX-6107372200,CDM,73722,CPT,0610,RC,,,,inpatient,,,5019.00,3262.35,,,,,,,,,,,,,
GUIDEWIRE ANKLE ARTHOSCOPY 1.6MM,SUP-2814280,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
GUIDEWIRE ENDO L450CM DIA0.018IN EXCHG SHP STIFF SHFT,SUP-2140156,CDM,C1769,HCPCS,0272,RC,,,,both,,,359.31,233.55,,,,,,,,,,,,,
PLATE BNE L85MM 7 H BILAT S STL COMPR FOR 3.5MM SCR,SUP-2411341,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
SCREW BNE PED L18MM DIA3.5MM L R CORT PROX FEM TIB S STL ST,SUP-2318506,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX20 CM HEPARIN COAT,SUP-2214689,CDM,C1751,HCPCS,0278,RC,,,,both,,,154.55,100.46,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK1.5MM REGEN TISS MTRX HI SUT,SUP-2399109,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
DEVICE TORQ 0009 0018IN GRN PTFE GWIRE ANGIO COAT PIN VISE,SUP-2303056,CDM,C1769,HCPCS,0272,RC,,,,both,,,11.59,7.53,,,,,,,,,,,,,
BLADE RTRCTR BLFR 3 12ND LTRL BLADE SLIDE FNSTRTD,SUP-2672903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.48,234.96,,,,,,,,,,,,,
SCREW CANCELLOUS FULLY THREADED 45MMX40MM LENGTH NCB,SUP-2497247,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
BUTTON SUT L12MM LOOP L15MM TI RETROBTTN,SUP-2121373,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
HC Inject Epidural Blood/Clot Patch,PX-3616227300,CDM,62273,CPT,0361,RC,,,,both,,,1586.00,1030.90,,,,,,,,,,,,,
SPACER SPNL 24 DEG 42X30X18 MM SOVEREIGN,SUP-2424001,CDM,C1821,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
REAMER MTP SPIN GRD CUP M 21MM,SUP-2419180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
SCREW BONE L8MM DIA2MM TI ST GRY MATRIXMANDIBLE,SUP-2181721,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.09,165.16,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM CART ARAGONITE 1PK,SUP-2913427,CDM,C1763,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 30 J STR CURRENT VR,SUP-2356047,CDM,C1722,HCPCS,0275,RC,,,,both,,,71435.00,46432.75,,,,,,,,,,,,,
COMPONENT TIB 6 RT ANK HINTERMANN SER H3,SUP-2751707,CDM,C1776,CPT,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
PLATE BONE ANTR BOW LAT PROX 20 H FOR 3.5 SCR,SUP-2349065,CDM,C1713,HCPCS,0278,RC,,,,both,,,1218.57,792.07,,,,,,,,,,,,,
WASHER ORTH OD13.5MM ID4MM PEEK 6% BASO4 SPIK FOR 3.5/4MM,SUP-2184671,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
GRAFT BONE SUB 10X11X14MM CERV TRIAD,SUP-2310532,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PROSTHESIS TESTICULAR M W2.7XL4CM NACL FIL,SUP-2300764,CDM,C1894,HCPCS,0272,RC,,,,both,,,6267.44,4073.84,,,,,,,,,,,,,
PLATE BNE W11XL216MM THK33MM 16 H BILAT MTPHSEAL TI LOK,SUP-2190768,CDM,C1713,HCPCS,0278,RC,,,,both,,,3887.89,2527.13,,,,,,,,,,,,,
GUIDEWIRE ORTH L46CM DIA3.2MM S STL DISP,SUP-2412675,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BNE TENS BND MINI NAR 1 MM 2X2 HOLE MALL TI NS,SUP-2181762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.95,894.37,,,,,,,,,,,,,
PLATE FRACTURE 6H 2MM PROF,SUP-2740124,CDM,C1713,HCPCS,0278,RC,,,,both,,,2123.17,1380.06,,,,,,,,,,,,,
GUIDE WIRE OBTURATOR PERC PINNING,SUP-2816781,CDM,C1769,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SCREW BONE L26MM D2.7MM CRTCL DST RDL LOK FLLY THRDD SQRE DR,SUP-2496977,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
PLEDGET CV L 9.5 X W 4.8 MM THK 0.65 MM PTFE FELT RECT SHP,SUP-2761354,CDM,C1768,CPT,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
PLATE BONE LOK CMPRSSN 199MML HLX12 TIMAX CRTCL BROAD PRE CN,SUP-2588751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3920.92,2548.60,,,,,,,,,,,,,
RING EXT FIX ROCKER,SUP-2342855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
EXTRACTOR STONE BSKT 0.6 MM 4 WIR HNDL SCP STRL DISP,SUP-2773234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1135.83,738.29,,,,,,,,,,,,,
HC X-Ray Foot Min 3 Views Complete,PX-3207363000,CDM,73630,CPT,0320,RC,,,,both,,,680.00,442.00,,,,,,,,,,,,,
STEM HUM L115MM OD15MM TI IMP BIOMOD,SUP-2404603,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
MICROCATHETER INFUSION PURSUE 150CM DIA 2.9/2FR 45DEG TIP,SUP-2459591,CDM,C1887,HCPCS,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
HC So Erythropoietin,PX-3018266866,CDM,82668,CPT,0301,RC,,,,outpatient,,,373.00,242.45,,,,,,,,,,,,,
BUMETANIDE 2 MG PO TABS,RX-9311,CDM,6370000000,HCPCS,0637,RC,60687-0535-11,NDC,,both,1,UN,7.90,5.13,,,,,,,,,,,,,
PLATE BNE L298MM 16 H ST L LAT PROX TIB S STL LOK COMPR LO,SUP-2185730,CDM,C1713,HCPCS,0278,RC,,,,both,,,4679.67,3041.79,,,,,,,,,,,,,
CATHETER HD DL 15.5 FRX20 CM PRE CRV HEMO-FLOW XF,SUP-2627244,CDM,C1750,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
ALLOGRAFT BNE FD ASEP FEM HD,SUP-2867014,CDM,C1762,CPT,0278,RC,,,,both,,,4429.76,2879.34,,,,,,,,,,,,,
PLATE BONE POST SPNL FUS EXP STATIC AILERON M,SUP-2264539,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
BLADE DERMTOM REG THROW AWAY,SUP-2243522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,158.57,103.07,,,,,,,,,,,,,
HC So Assay of Mercury Quantitative,PX-3018382566,CDM,83825,CPT,0301,RC,,,,outpatient,,,135.00,87.75,,,,,,,,,,,,,
INSTRUMENT EXT FIX REARFOOT SUBTALAR ARTH FOR SIDEKCK FIX,SUP-2400592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9357.20,6082.18,,,,,,,,,,,,,
PLASMAX PLSM CONC SYS PLSMX DISP KT,SUP-2402601,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
BLADE RETRACTOR BALFOUR 2.5 IN ABD FEN LAT 1 PR FOR 50-4503,SUP-2477142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.14,215.24,,,,,,,,,,,,,
SHEATH INTRO PRELUDE SNAP L 13CM DIA10FR HYDRPHLC NO SIDEPRT,SUP-2743277,CDM,C1769,HCPCS,0272,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
GRAFT HUM TISS W3XL7CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2112990,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
SHEET ORBIT W38XL50MM THK1.5MM BIOMATERIAL RECON AUG MEDPOR,SUP-2366443,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CATHETER PRESSURE WEDGE BLLN 6FRX110CM,SUP-2383244,CDM,C1725,HCPCS,0272,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
HOOK SPNL BLDE W6.5MM THRT BILAT PEDCL S STL NEUT OPN NAR,SUP-2257015,CDM,C1713,HCPCS,0278,RC,,,,both,,,3412.24,2217.96,,,,,,,,,,,,,
PLATE CRAN 160X40X40 MM PT SPEC IMPL PEEK,SUP-2860127,CDM,C1713,HCPCS,0278,RC,,,,both,,,27562.92,17915.90,,,,,,,,,,,,,
PLATE BNE L 27.31 X W 5.08 MM THK 0.6 MM SCREW DIA2 MM 4 H,SUP-2936564,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
CATHETER SUPP 3.1FR L90CM DIA0.050X0.063IN 0.035IN GWIRE,SUP-2353128,CDM,C1887,HCPCS,0272,RC,,,,both,,,501.52,325.99,,,,,,,,,,,,,
GRAFT BNE MED 6.25 CC MTRX FIBERGRAFT BG,SUP-2434440,CDM,C1713,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
ADAPTER INTRO 9FR HEMSTAT TEAR AWAY VLV SIDE PRT EXT WNG,SUP-2329878,CDM,C1894,HCPCS,0272,RC,,,,both,,,147.74,96.03,,,,,,,,,,,,,
BURR SURG 8.5MM DIA HD LG BNE BRL FLUTEX6 CTTNG FLFRVSNS SUR,SUP-2605416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.32,366.81,,,,,,,,,,,,,
COMPONENT FEM SZ 1 CO CHROM LT KNEE REV STEMLESS POST STBL,SUP-2346122,CDM,C1776,CPT,0278,RC,,,,both,,,19848.73,12901.67,,,,,,,,,,,,,
BIT DRL L330MM DIA4.2MM CALIB 100MM 3 FLUT QUIK CPL,SUP-2178854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,696.23,452.55,,,,,,,,,,,,,
CATHETER PACE 6FR L110CM 1CM ELECTRD SPACE R HRT CARD VENT,SUP-2355217,CDM,C1730,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
MICRO PLATE H SHAPE REGULAR CP TITANIUM,SUP-2676890,CDM,C1713,HCPCS,0278,RC,,,,both,,,994.09,646.16,,,,,,,,,,,,,
KIT INTRO SHTH 6FR L10CM NDL 22GA L1.25IN 0.021IN NIT FLPY,SUP-2384833,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.27,173.08,,,,,,,,,,,,,
HANDSET INCEPTIV W/COMMUNICATOR KIT,SUP-2891619,CDM,C1787,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BONE 12MM BAR 2 H CRANIOFACIAL FIX LO PROF W/ TAB UNIV,SUP-2365221,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.85,328.15,,,,,,,,,,,,,
PACEMAKER CARD W/ LD ULT VR INSIGNIA,SUP-2236360,CDM,C1786,HCPCS,0275,RC,,,,both,,,18855.70,12256.20,,,,,,,,,,,,,
PLATE BONE L192MM 11 H S STL T SHP BTTRS LO PROF RIG,SUP-2185761,CDM,C1713,HCPCS,0278,RC,,,,both,,,2019.27,1312.53,,,,,,,,,,,,,
ROD SPNL POST SMOOTH TI ALLOY 5.5MM DIA 130MM LEN,SUP-2289287,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
SPACER SPNL 0 DEG 21X9X11 MM POST LUMBAR INTBDY VALEO II,SUP-2577867,CDM,C1889,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
PROBE EXTRACTION FOR SLAPHAMMER NS OSCAR 3 LTX,SUP-2875691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1708.16,1110.30,,,,,,,,,,,,,
PIN FIX L140MM DIA4MM BNE,SUP-2368427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
DISK ARTIFICIAL L H6MM CERV INTERVERTEBRAL CO CHROM 09820046S] CENTINEL SPINE INC],SUP-2163163,CDM,C1889,HCPCS,0278,RC,,,,both,,,16249.50,10562.17,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTEXL 20ML CORT RESRB MOLD MINERALIZED,SUP-2293950,CDM,C1713,HCPCS,0278,RC,,,,both,,,11260.83,7319.54,,,,,,,,,,,,,
HC Biopsy Soft Tissue Neck/T,PX-3612155000,CDM,21550,CPT,0361,RC,,,,inpatient,,,5012.00,3257.80,,,,,,,,,,,,,
PLATE BNE CRV MINI 2-2.5X1 MM 2X6 HOLE LCK LADDER GRID TI,SUP-2468022,CDM,C1713,HCPCS,0278,RC,,,,both,,,1671.45,1086.44,,,,,,,,,,,,,
PIN EXT FIX HALF 6X25 MM HA STRL SALVATION,SUP-2468860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
GRAFT DURA 3X1 IN ONLAY SUTURELESS ENHANCED ABSRB DURAGN XS,SUP-2480909,CDM,C1763,HCPCS,0278,RC,,,,both,,,1442.45,937.59,,,,,,,,,,,,,
GRAFT VASC L40CM DIA8MM STR STRTCH STD WALL N RNGD INTERING,SUP-2395851,CDM,C1768,CPT,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
TRIAL KNEE IMPL SZ 3 TIB BASEPLT NS REUSE NKII,SUP-2209459,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 18 FR 2.7 CM 5 CC EXTN SET LP MIC-KEY,SUP-2764478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.95,354.87,,,,,,,,,,,,,
STENT TRACHBRONCH HANAROSTENT L 60 MM DIA18 MM DEL SYS L 900,SUP-2865673,CDM,C1874,HCPCS,0278,RC,,,,both,,,12638.50,8215.02,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB UNIV R,SUP-2276646,CDM,L3931,HCPCS,0272,RC,,,,both,,,15.89,10.33,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|CQ,both,,,191.00,124.15,,,,,,,,,,,,,
CATHETER HD DL 13.5 FRX70 CM 51 CM ADMIN BASIC KT HICKMAN,SUP-2126593,CDM,C1751,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
CROWN DENT LR6 1ST PRI M INDIV SPACE MAINTAINER,SUP-2176684,CDM,D6783,CPT,0278,RC,,,,both,,,25.91,16.84,,,,,,,,,,,,,
BLADE SCREWDRIVER 15MM DIA 80MML CROSS DRIVE W/SLEEVE,SUP-2681047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1143.09,743.01,,,,,,,,,,,,,
SCREW BONE L70MM OD4.5MM BLU MIDFOOT HINDFOOT ANK CANN SH,SUP-2320935,CDM,C1713,HCPCS,0278,RC,,,,both,,,1263.85,821.50,,,,,,,,,,,,,
WIRE BRST LOC 2 BARB 19 GAX5 CM 15 CM CHESBROUGH,SUP-2759087,CDM,C1819,HCPCS,0278,RC,,,,both,,,78.47,51.01,,,,,,,,,,,,,
SET ID BND FOR STRUT MAXFRAME,SUP-2179162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.46,746.50,,,,,,,,,,,,,
PLATE BNE LCK FT ANAT LAT CLMN W/ SM WDG TIM A.L.P.S,SUP-2463473,CDM,C1713,HCPCS,0278,RC,,,,both,,,2244.75,1459.09,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL GUID 8.5FR L63CM DIL 8.5FR L67CM,SUP-2357264,CDM,C1893,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 70 CM DIA 8 MM POLYESTER BOV CLLGN UTHN,SUP-2681834,CDM,C1768,CPT,0278,RC,,,,both,,,2113.94,1374.06,,,,,,,,,,,,,
PLATE BNE W17.5XL350MM THK5.2MM 16 H NONSTERILE R CNDYL FEM,SUP-2185047,CDM,C1713,HCPCS,0278,RC,,,,both,,,4998.69,3249.15,,,,,,,,,,,,,
CATHETER URETERAL BLLN DILATION 4MM X10CM URO EZDILATE,SUP-2722038,CDM,C1726,HCPCS,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
OBTURATOR ENDOSCP BOAT NOSE NS ECTRA II LTX,SUP-2877787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.13,267.88,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 3",PX-7619921300,CDM,99213,CPT,0761,RC,,,,inpatient,,,257.00,167.05,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM 6 MM POLYESTER BOV CLLGN STR,SUP-2266031,CDM,C1768,CPT,0278,RC,,,,both,,,1212.32,788.01,,,,,,,,,,,,,
TUNNELER MTL MALL TAPR FOR HEMOSPLIT AND HEMOSPLITXK,SUP-2126521,CDM,C1894,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
SCREW SPNL MULTAXL XS 3X22 MM OCCIPITOCERVICAL UPPER THOR,SUP-2631944,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
COMPONENT HIP PRSS FT HI DEMAND BIPOLAR/UNIPOLAR,SUP-2351417,CDM,C1776,CPT,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
SCREW BONE L45MM D6MM HEAD D35MM CRTCL TTNM ALLOY FIXED ANGL,SUP-2463415,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
SCREW BNE ST 1.5X16 MM CRTX W/ FLUT TIP TI GLD NS LF,SUP-2189235,CDM,C1713,HCPCS,0278,RC,,,,both,,,228.59,148.58,,,,,,,,,,,,,
ANCHOR SUT BIOCRYL RAPIDE ORTHOCORD RADLUC BRAID OD4.5MM 222229] DEPUY SYNTHES USA],SUP-2184886,CDM,C1713,HCPCS,0278,RC,,,,both,,,4151.33,2698.36,,,,,,,,,,,,,
POST EXT FIX ANK FT 2 H FOR TRUELOK FRME ASSEMB HEXAPOD SYS,SUP-2316130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.97,310.68,,,,,,,,,,,,,
QUARTER-TUBULAR PLATE 7 HOLE,SUP-2819058,CDM,C1713,HCPCS,0278,RC,,,,both,,,721.85,469.20,,,,,,,,,,,,,
END CAP ORTH STD HINDFOOT NS DUALCOMPRESSION,SUP-2930411,CDM,C1889,HCPCS,0278,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
INTRODUCER ORTHOPEDIC 3 ASST DIR KYPHON,SUP-2432064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 3 MM EPTFE STR TW N RING,SUP-2396325,CDM,C1768,CPT,0278,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
STEM FEM STD C/D 0-5 CM MOD MECH,SUP-2861076,CDM,C1776,CPT,0278,RC,,,,both,,,698.59,454.08,,,,,,,,,,,,,
ANCHOR SUT DIA1.8MM FOR ACET LABRAL REP Q-FIX,SUP-2342828,CDM,C1713,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
HC Evacuation of Hematoma,PX-3611014000,CDM,10140,CPT,0361,RC,,,,inpatient,,,4946.00,3214.90,,,,,,,,,,,,,
MESH HERN W20XL25IN POLYPR EPTFE NONABSORBABLE ELP COMPOSIX,SUP-2125808,CDM,C1781,HCPCS,0278,RC,,,,both,,,3468.13,2254.28,,,,,,,,,,,,,
TI LCP PROX LATERAL TIBIA PL 9 HOLES/220MM/LEFT-STERILE,SUP-2549442,CDM,C1713,HCPCS,0278,RC,,,,both,,,4795.09,3116.81,,,,,,,,,,,,,
HC Veno Renal Bilat Sel S&I,PX-3207583300,CDM,75833,CPT,0320,RC,,,,both,,,3165.00,2057.25,,,,,,,,,,,,,
SET PICC 3L 6FR X 55CM W TEG CHG,SUP-2887058,CDM,C1751,HCPCS,0278,RC,,,,both,,,1849.46,1202.15,,,,,,,,,,,,,
STEM ULN HD 6.5 SM PART MOD REPL 1ST CHOICE,SUP-2610440,CDM,C1776,CPT,0278,RC,,,,both,,,11662.87,7580.87,,,,,,,,,,,,,
CENTRALIZER STEM 16 MM POST HIP SPECTRN EF COBRA,SUP-2434607,CDM,C1776,CPT,0278,RC,,,,both,,,192.17,124.91,,,,,,,,,,,,,
ENVELOP TISS SM 5.4X5 CM SFT SUPPLE CORMATRIX CANGAROO EMC,SUP-2653868,CDM,C1889,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
SHEATH ENDO PROTCT STRL DISP ENF-P4 ENF-GP ENT 3.6FR FOR OLY,SUP-2277925,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.48,35.41,,,,,,,,,,,,,
SYSTEM CLP DEL MITRACLIP XTR L 109.5 CM DIA16 FR BALLOON L,SUP-2102260,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
RING ACET SZ 20 HIP UHMWPE MOD PRI REPL RNGLOC +,SUP-2403376,CDM,C1776,CPT,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
BACLOFEN 10 MG/20ML IT SOLN,RX-104429,CDM,J0475,HCPCS,0636,RC,70121-2501-01,NDC,,both,0.05,ML,68.00,44.20,,,,,,,,,,,,,
SPLINT WR AD SM FOR 5.5-6.5IN STRP L4IN VENT ELAS,SUP-2324483,CDM,L3908,HCPCS,0274,RC,,,,both,,,43.27,28.13,,,,,,,,,,,,,
ALLOGRAFT BNE DEMINERALIZED CORTICAL 125-710 MIC 30 CC FD,SUP-2717751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3647.93,2371.15,,,,,,,,,,,,,
SHAFT HUM TRAD ALLGRFT FRZN,SUP-2294183,CDM,C1713,HCPCS,0278,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
DRILL TWST DIA1.7MM DISP FOR SUTUREFIX ULT SYS,SUP-2341896,CDM,C1713,HCPCS,0278,RC,,,,both,,,708.26,460.37,,,,,,,,,,,,,
PIN FIX L9IN DIA4MM ST S STL 2 SIDE SGL DMND 1 END PNT STYL,SUP-2150480,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.53,12.04,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM PEEK 3 ORTHOCORD SZ 2 L36IN VLT BLU,SUP-2249416,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
SCREW BNE NLCK 3X14 MM DBL STRT THRD SS JPS,SUP-2645433,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
PROCESSOR SND MAG STRENGTH 2 NS BAHA LTX,SUP-2858107,CDM,L8690,HCPCS,0278,RC,,,,both,,,412.38,268.05,,,,,,,,,,,,,
BRACE ORTHOPEDIC FIG 8 SHLDR,SUP-2417064,CDM,L3660,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER ETER DIL 75FR L180CM BLLN L3CM DIA10 11 12MM 0035IN,SUP-2141556,CDM,C1726,HCPCS,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
GRFT CRUSH CANC 1-4MM 60CC PUROS,SUP-2693927,CDM,C1713,HCPCS,0278,RC,,,,both,,,5554.66,3610.53,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 210X13X3 MM FRZN STRUT,SUP-2717901,CDM,C1762,CPT,0278,RC,,,,both,,,4212.78,2738.31,,,,,,,,,,,,,
INSTRUMENT KIT PLN PT SPEC BASIC MAND,SUP-2860254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9945.95,6464.87,,,,,,,,,,,,,
PLATE BONE L46MM THK3.1MM 4 H BILAT S STL LCK COMPR RECON,SUP-2348685,CDM,C1713,HCPCS,0278,RC,,,,both,,,4020.46,2613.30,,,,,,,,,,,,,
DEFIBRILLATOR CARD SGL CHMBR C HD ATLS + VR,SUP-2357746,CDM,C1722,HCPCS,0275,RC,,,,both,,,37366.00,24287.90,,,,,,,,,,,,,
PLATE BONE L231MM 14 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185279,CDM,C1713,HCPCS,0278,RC,,,,both,,,928.81,603.73,,,,,,,,,,,,,
BIT DRL OD2MM CANN FOR MULTIUSE COMPR CHARLOTTE SCR,SUP-2397718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
BUR SURG BALL 2 MM 12 CM TELSCP MIDAS REX LEGEND,SUP-2632194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.54,222.00,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 13 MMX0.4 CM FD CROSS SECT,SUP-2717813,CDM,C1762,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
DEVICE COAG GUID 3 CM W/O CANN EPI-SENSE ST,SUP-2866237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
PLATE BNE W23XL51MM THK18MM 13 H L VOLAR TI WIDE LNG TRILOK,SUP-2423734,CDM,C1713,HCPCS,0278,RC,,,,both,,,5608.35,3645.43,,,,,,,,,,,,,
NAIL IM L180MM DIA11MM 125DEG TROCHANTERIC FEM TI CANN LOK,SUP-2370459,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
BALL TIP PRB DBL END,SUP-2232071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
GRAFT BNE ANTR TIBIALIS 10.5X350 MM ASEP,SUP-2264572,CDM,C1713,HCPCS,0278,RC,,,,both,,,6914.28,4494.28,,,,,,,,,,,,,
ALLOGRAFT BNE WHL ULNA,SUP-2321921,CDM,C1713,HCPCS,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA 30 MM BRANCH SZ,SUP-2695456,CDM,C1768,CPT,0278,RC,,,,both,,,6437.44,4184.34,,,,,,,,,,,,,
PIN SELF DRILL HALF DIA 6MM 150X40MM,SUP-2703127,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.11,516.17,,,,,,,,,,,,,
GRAFT HUM TISS 7X4 CM 4 LAYR CLLGN MTRX BIODESIGN,SUP-2423403,CDM,C1763,HCPCS,0278,RC,,,,both,,,2596.15,1687.50,,,,,,,,,,,,,
ALLOGRAFT BNE DBM + CORTICAL 1 CC FD,SUP-2717768,CDM,C1713,HCPCS,0278,RC,,,,both,,,972.18,631.92,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.545,SUP-2860226,CDM,C1713,HCPCS,0278,RC,,,,both,,,50499.05,32824.38,,,,,,,,,,,,,
COMPONENT PATELLA PERSONA OSSEOTI 3-PEG 29MM,SUP-2935738,CDM,C1776,CPT,0278,RC,,,,both,,,4507.47,2929.86,,,,,,,,,,,,,
MATRIX WND DERM HUM ACELLULAR 6MM MTRX HD 5CMX8CM,SUP-2335295,CDM,Q4345,HCPCS,0636,RC,,,,both,,,14111.16,9172.25,,,,,,,,,,,,,
GUIDEWIRE VASC AGIL 14 L 205 CM DIA 0.014 IN TAPR L 42 CM SS,SUP-2158113,CDM,C1769,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
INSERT TIB M THK11MM AP48MM ML72MM L R ANT POST ARTC KNEE,SUP-2377436,CDM,C1776,CPT,0278,RC,,,,both,,,1975.69,1284.20,,,,,,,,,,,,,
HC Tiss Cul Neo Disorders Bone Marrow Blood Cells,PX-3118823700,CDM,88237,CPT,0311,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
BASKET SPEC RETRV STONE 4.5 FRX85 CM W/O HNDL FLX CYSTOSCOPE,SUP-2772965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.64,266.27,,,,,,,,,,,,,
KIT BSR-1B CONSISTING OFXXX,SUP-2139743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BNE FIBULAR LT 3 HOLE LCK ANAT STRL ALPS LTX,SUP-2861804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2464.46,1601.90,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD 12FR L24CM INSRTN 13.5FR ADMIN,SUP-2125585,CDM,C1752,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
IMPLANT TOE JT DIA21MM THK5MM MT LENGTHENING DISC,SUP-2321674,CDM,C1776,CPT,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0250,RC,00409-7101-02,NDC,,both,250,ML,48.90,31.78,,,,,,,,,,,,,
SPLINT ORTH M LT ANTI SPASMOTIC NEUROLOGIC CONTRACTURES REG,SUP-2324561,CDM,L3906,HCPCS,0272,RC,,,,both,,,77.93,50.65,,,,,,,,,,,,,
CONNECTOR SPNL OFFSET 20 MM PROTEX,SUP-2584143,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
HC Asp Inj Intermediate Joint,PX-4502060500,CDM,20605,CPT,0450,RC,,,,outpatient,,,358.00,232.70,,,,,,,,,,,,,
PLATE BONE W14.9XL74MM THK1.2MM 4 H DSTL TIB S STL SCALLOPED,SUP-2185733,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.13,548.68,,,,,,,,,,,,,
HC So Antibody; Mumps,PX-3028673566,CDM,86735,CPT,0302,RC,,,,inpatient,,,104.00,67.60,,,,,,,,,,,,,
NAIL IM 10X34 CM,SUP-2196674,CDM,C1713,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX5 L SHPD OBLQUE LEFT F/2.7MM SCRE,SUP-2495295,CDM,C1713,HCPCS,0278,RC,,,,both,,,931.45,605.44,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X235 MM LT LAT DSTL 15 HOLE NS VA-LCP,SUP-2758208,CDM,C1713,HCPCS,0278,RC,,,,both,,,3677.07,2390.10,,,,,,,,,,,,,
ANCHOR SUTURE TWST 3.2 MM DRAW TIGHT TWO PEEK WHT BLU,SUP-2761982,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,6370000000,HCPCS,0637,RC,24208-0635-62,NDC,,both,10,ML,377.60,245.44,,,,,,,,,,,,,
PACK INSTR MENIS ROOT REP,SUP-2340964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PLATE BNE L 38 MM SCREW DIA2 MM 7 SHFT H TI STR COMPACT MINI,SUP-2907840,CDM,C1713,HCPCS,0278,RC,,,,both,,,2629.37,1709.09,,,,,,,,,,,,,
STENT COR 15MM 3MM RX MULTLNK VISN,SUP-2104207,CDM,C1876,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
FORCEPS ENDOSCP SPEC RETRV 3.3FR L115CM PTFE S STL ALGTR,SUP-2171258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1089.20,707.98,,,,,,,,,,,,,
INTRODUCER SHTH 5FR L11CM GWIRE 0038IN GRY HUB POLYPR,SUP-2303255,CDM,C1894,HCPCS,0272,RC,,,,both,,,27.66,17.98,,,,,,,,,,,,,
HC Hip Dislocation Reduction,PX-4502725000,CDM,27250,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.504,SUP-2860186,CDM,C1713,HCPCS,0278,RC,,,,both,,,28182.76,18318.79,,,,,,,,,,,,,
CLAMP PIN 5 HOLE,SUP-2678695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.17,274.41,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SZ 100 X 25 X 4 MM 10 CC CER GRAN,SUP-2930821,CDM,C1763,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
CROWN FRM SZ 113 8MM RT CTRL ANTR UP TRNSPAR STRP OFF,SUP-2238376,CDM,D6783,CPT,0278,RC,,,,both,,,5.97,3.88,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB III ROSEN STRL DISP HI-LINE XS,SUP-2929270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.95,243.72,,,,,,,,,,,,,
PLATE BNE L306MM BLDE W48XL25MM 95DEG 18 H ST HIP S STL RIG,SUP-2186765,CDM,C1713,HCPCS,0278,RC,,,,both,,,4611.59,2997.53,,,,,,,,,,,,,
CATHETER ABLATN RF SYS OPN IRRIG INTELLANAV MIFI,SUP-2424674,CDM,C1732,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX20 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761252,CDM,C1768,CPT,0278,RC,,,,both,,,903.66,587.38,,,,,,,,,,,,,
BIT DRL DIA2.9MM FOR SFT ANCHR SHT SHFT PK JUGGERKNOT,SUP-2212783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
PLATE BNE L 145 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 18 H SS 72440318N,SUP-2933070,CDM,C1713,HCPCS,0278,RC,,,,both,,,2142.45,1392.59,,,,,,,,,,,,,
CATHETER PICC L55CM OD5FR ID15.5GA GWIRE L145CM SGL LUMN,SUP-2118961,CDM,C1751,HCPCS,0278,RC,,,,both,,,287.91,187.14,,,,,,,,,,,,,
ROD SPNL STR PRECUT TI OD3.5MM L125MM VAIL,SUP-2415753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
CATHETER NEPHSTMY L35CM DIA20FR W/ 2 FLX STYL DRNGE BG CONN,SUP-2139307,CDM,C1729,HCPCS,0272,RC,,,,both,,,238.67,155.14,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD H1 HD COCR,SUP-2419697,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
PAD THER CRYO L R SHLDR SL AD NONSTERILE W STRP ACCELERATED,SUP-2324440,CDM,L3650,HCPCS,0274,RC,,,,both,,,162.65,105.72,,,,,,,,,,,,,
CATHETER DIAG 2.1-1.6FR L156CM ID0.0165IN STR 2 MRK TIP,SUP-2305458,CDM,C1887,HCPCS,0272,RC,,,,both,,,2869.18,1864.97,,,,,,,,,,,,,
GRAFT BNE 11 MM CUBE Q-PACK CONFORM,SUP-2264596,CDM,C1713,HCPCS,0278,RC,,,,both,,,2091.24,1359.31,,,,,,,,,,,,,
BIT DRL WIRE PASS 1.7X6.7 MM STRL ELITE LTX,SUP-2859477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.55,240.21,,,,,,,,,,,,,
BIT DRL 3.8 MMX6 IN STRL DISP,SUP-2606666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,965.36,627.48,,,,,,,,,,,,,
STRUT EXT FIX L 100 MM STATIC,SUP-2898488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
MESH HERN W3XL6IN OMEGA 3 FATTY ACID COAT POLYPR,SUP-2265981,CDM,C1781,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
PLATE BONE LOK HLX15 TIMAX CNTRD ANTMCL ALPS NON ST LEFT MED,SUP-2588760,CDM,C1713,HCPCS,0278,RC,,,,both,,,4030.28,2619.68,,,,,,,,,,,,,
"HC So Mtb-Rif Naa, Mycobacterium TB",PX-3068755667,CDM,87556,CPT,0306,RC,,,,both,,,155.00,100.75,,,,,,,,,,,,,
KIT K WIRE SM T6 SCRDRVR PLATING DEPTH GA FOR 1.5/2/2.4MM,SUP-2225515,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
TAP SURG UNIV 13 MM BIT HELIX ACP,SUP-2434167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW BNE L76MM OD7MM THRD L17MM PUR HINDFOOT ANK CANN SHT,SUP-2320765,CDM,C1713,HCPCS,0278,RC,,,,both,,,1338.90,870.28,,,,,,,,,,,,,
SCREW INTFR L23MM OD6MM BIOSTEON WDG SHP ROUNDED THRD CRUCE,SUP-2366618,CDM,C1713,HCPCS,0278,RC,,,,both,,,705.15,458.35,,,,,,,,,,,,,
SPLINT WRST COCK UP UNIV R,SUP-2205498,CDM,L3931,HCPCS,0274,RC,,,,both,,,57.15,37.15,,,,,,,,,,,,,
PLATE BNE W11XL86MM THK3.3MM 6 H BILAT MTPHSEAL TI LOK,SUP-2190760,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.43,1708.48,,,,,,,,,,,,,
SPACER SPNL SM 18 DEG 32X23X14 MM SOVEREIGN,SUP-2631362,CDM,C1889,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
PLATE BNE L14MM THK2MM TARSAL TI ISOLATED FUS AFP DARCO MRS,SUP-2399641,CDM,C1713,HCPCS,0278,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
TUBE SUCTION ROSEN 16 GAX2-3/8 IN W/ OBTURATOR,SUP-2484778,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.10,22.16,,,,,,,,,,,,,
GRAFT BNE STRP 12.5X1X0.4 CM 10 CC PLATFORM CM,SUP-2691584,CDM,C1713,HCPCS,0278,RC,,,,both,,,6754.14,4390.19,,,,,,,,,,,,,
SYSTEM DRAINAGE 85-125 MM H2O 325-445 MM H2O TALL AD GRN,SUP-2851476,CDM,C1729,HCPCS,0272,RC,,,,both,,,4289.27,2788.03,,,,,,,,,,,,,
GRAFT HUM TISS L 1 X W 1 CM AMNION PLCNTA MEMBRN SINGLE LAYR,SUP-2913271,CDM,C1762,CPT,0278,RC,,,,both,,,3347.24,2175.71,,,,,,,,,,,,,
PLATE BNE L 113 MM SCREW DIA 4.5 MM 6 H NAR COMPR NLCK NS,SUP-2933279,CDM,C1713,HCPCS,0278,RC,,,,both,,,1794.98,1166.74,,,,,,,,,,,,,
PIN HOLDING PUSH PUSH TEMP FOR ANTR CERV PLATE SYS CERVALIGN,SUP-2713497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ANCHOR SUT LABRUM KNOTLESS LABRALOCK W/INSERTER HNDL,SUP-2342080,CDM,C1776,CPT,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
RESERVOIR PERF BG 800 ML VEN CORTIVA COAT MVR,SUP-2494155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BIT DRL L DIA5MM TI CANN QUIK CPL STD RECON SCR REUSE,SUP-2178896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1302.38,846.55,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 15 CM LOOP DIA 6 MM PRIMARY,SUP-2249270,CDM,C1889,HCPCS,0278,RC,,,,both,,,3929.08,2553.90,,,,,,,,,,,,,
TRAY TIBIALXL SZ 0 SALTO TALARIS,SUP-2244190,CDM,C1776,CPT,0278,RC,,,,both,,,19527.03,12692.57,,,,,,,,,,,,,
TUBE MYR OD1.14MM VENT BVL SIL ARMSTR,SUP-2313719,CDM,L8699,HCPCS,0278,RC,,,,both,,,50.46,32.80,,,,,,,,,,,,,
BIT DRL TIP DIA3.1MM TAPR DIA4.6MM CANN REG DENS BNE ACUTRK,SUP-2107225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX XSMALL 8X16 CM PLASTIC MATRISTEM,SUP-2106511,CDM,Q4166,HCPCS,0636,RC,,,,both,,,10761.41,6994.92,,,,,,,,,,,,,
CATHETER CTRL VEN 24GAX3 1/2IN KT SGL LUMN STR J TIP GWIRE,SUP-2383272,CDM,C1751,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
SIGMOIDOSCOPE FLX RECT DISP,SUP-2800976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1314.09,854.16,,,,,,,,,,,,,
DEVICE FIX HELCL 5 MM FOR LAP FIX OF MESH IN HERN REP TI TRK,SUP-2752179,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.74,236.43,,,,,,,,,,,,,
STEM FEM L155MM DIA17MM DST HIP TI HA STR CONIC CEM MOD REV,SUP-2375812,CDM,C1776,CPT,0278,RC,,,,both,,,7027.32,4567.76,,,,,,,,,,,,,
CATHETER ANGIOPLSTY THRDR L 150 CM BALLOON L 12 MM DIA1.2 MM,SUP-2140839,CDM,C1725,HCPCS,0272,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 14 IN 12-24 IN ADJ FOAM,SUP-2194895,CDM,L1830,CPT,0274,RC,,,,both,,,34.95,22.72,,,,,,,,,,,,,
HC MRI-Pelvis W Contrast,PX-6147219600,CDM,72196,CPT,0614,RC,,,,inpatient,,,4626.00,3006.90,,,,,,,,,,,,,
FIBER LASER HOLM DISP SU555RT] LEONI FIBER OPTICS INC],SUP-2264316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
BIT DRILL NON QUICK COUPLING 4.5X165/180 MM JACOBS CHUCK END,SUP-2837051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.39,665.20,,,,,,,,,,,,,
SCREW BONE LOCKING 4.5X120 MM CORTICAL TIBIAL FEMUR SELFTAPP,SUP-2837315,CDM,C1713,HCPCS,0278,RC,,,,both,,,1559.45,1013.64,,,,,,,,,,,,,
GRAFT BONE TIBIA DISTAL TALUS RIGHT,SUP-2858710,CDM,C1762,CPT,0278,RC,,,,both,,,21509.00,13980.85,,,,,,,,,,,,,
IMMOBILIZER KNEE PREMIER PRO TRI PNL 22INCH FOAM TIETEX PAT,SUP-2336077,CDM,L1830,CPT,0272,RC,,,,both,,,38.78,25.21,,,,,,,,,,,,,
PLATE SPNL 60 MM INVIZIA,SUP-2414425,CDM,C1713,HCPCS,0278,RC,,,,both,,,6964.52,4526.94,,,,,,,,,,,,,
BLADE RETRACTOR BALFOUR STD 3X2.75 IN ABD SWVL SQ SHFT NS,SUP-2477548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1135.46,738.05,,,,,,,,,,,,,
BLADE SURG 6 LT MIDLN MAST MIDLF,SUP-2631588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
STAPE CLSSC PRO 4X1X4 TIT,SUP-2650123,CDM,L8613,CPT,0278,RC,,,,both,,,629.00,408.85,,,,,,,,,,,,,
ROD SPNL 11X250 MM,SUP-2205340,CDM,C1713,HCPCS,0278,RC,,,,both,,,642.92,417.90,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.549,SUP-2860230,CDM,C1713,HCPCS,0278,RC,,,,both,,,51995.89,33797.33,,,,,,,,,,,,,
NAIL IM L350MM OD11MM SUBTROCHANTERIC ROD RT ZCKL II,SUP-2364775,CDM,C1713,HCPCS,0278,RC,,,,both,,,4502.76,2926.79,,,,,,,,,,,,,
PLATE BNE W5XL50MM THK1MM 4X9 H BILAT S STL T SHP RIG NEUT,SUP-2186155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1300.65,845.42,,,,,,,,,,,,,
PERI-LOC VLP 2.7MMX20MM CORTEX SCREW,SUP-2819189,CDM,C1713,HCPCS,0278,RC,,,,both,,,145.29,94.44,,,,,,,,,,,,,
KIT FECAL MGMT 3 FLTR BG 1 SYR 1 SFT SIL CATH TEMP,SUP-2151500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
HC CT Chest W/WO Contrast,PX-3527127000,CDM,71270,CPT,0352,RC,,,,outpatient,,,2630.00,1709.50,,,,,,,,,,,,,
GRAFT BONE SUB 2CC VIABLE BONE MTRX BIOFUSE,SUP-2224015,CDM,C1762,CPT,0278,RC,,,,both,,,3711.48,2412.46,,,,,,,,,,,,,
BUTTON FIX 6MM ENDOBTTN DIR,SUP-2341084,CDM,C1713,HCPCS,0278,RC,,,,both,,,3344.29,2173.79,,,,,,,,,,,,,
STENT CAR PRECIS L 20 MM DIA 5 MM CATH L 135 CM SHTH 6 FR,SUP-2158935,CDM,C1876,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
PLATE BNE L 170 X W 10.9 MM THK 3.4 MM SCREW DIA 3.5 MM 13 H 72463813,SUP-2933023,CDM,C1713,HCPCS,0278,RC,,,,both,,,5885.62,3825.65,,,,,,,,,,,,,
BRACE KNEE HNG WRP M,SUP-2276701,CDM,L1820,HCPCS,0274,RC,,,,both,,,53.73,34.92,,,,,,,,,,,,,
PROBE CHNDLR TRNSLUMN V PACE 2.4X135CM SWAN GANZ,SUP-2214433,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.62,233.10,,,,,,,,,,,,,
LINER FEM OD42MM ID26MM BPLR CENTRAX,SUP-2364422,CDM,C1776,CPT,0278,RC,,,,both,,,2119.97,1377.98,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.018IN TIP L3MM PTFE J TIP FIX,SUP-2421132,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.62,25.10,,,,,,,,,,,,,
INSERT TIB SM DIA4MM KNEE S STL FRAG AXSOS,SUP-2371464,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
OBLONG WASHER 12.7MMX21.7MM,SUP-2818891,CDM,C1713,HCPCS,0278,RC,,,,both,,,371.59,241.53,,,,,,,,,,,,,
SET INTRO L 30 CM DIA 6 FR GUIDEWIRE 0.038 IN PTFE TEARWY,SUP-2226015,CDM,C1892,HCPCS,0272,RC,,,,both,,,143.18,93.07,,,,,,,,,,,,,
SHUNT SUNDT INT AND EXT CAR EAE,SUP-2308228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2350.04,1527.53,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 12 MM SET 8 CHANNEL PR GRN WHT STRL,SUP-2902105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,915.47,595.06,,,,,,,,,,,,,
SCREW BONE SELF TPPNG 2.7X58 MM CRTCL SM HEX STNLSS STEEL,SUP-2491101,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.25,43.06,,,,,,,,,,,,,
IMPLANT CRANIOMAXILLOFACIAL W43XH6XL44MM RT PTERIONAL SMER,SUP-2365351,CDM,C1889,HCPCS,0278,RC,,,,both,,,3659.04,2378.38,,,,,,,,,,,,,
CATHETERIZATION KIT 0.032 IN 7 FRX20 CM BLU FLEXTIP,SUP-2120588,CDM,C1751,HCPCS,0278,RC,,,,both,,,85.41,55.52,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,GP|KX|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
RAIL L300MM AD STD COMP FOR LIMB RECON SYS,SUP-2316078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3826.15,2487.00,,,,,,,,,,,,,
TUBING PMP L50FT DIA05IN FOR 27224P CF 1 2ID 1 16WALL,SUP-2261222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.03,234.02,,,,,,,,,,,,,
IMPL SYS MPFL BIO-COMP WITHOUT INSTRUM,SUP-2812285,CDM,C1713,HCPCS,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
CORTEX SCREW 2.0MMX24MM,SUP-2818645,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.77,147.40,,,,,,,,,,,,,
SHEATH ENH INSRT TS 8FRX11CM,SUP-2294565,CDM,C1894,HCPCS,0272,RC,,,,both,,,28.95,18.82,,,,,,,,,,,,,
FORCEPS 25+ SHARKSKIN ILM,SUP-2431808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.89,443.88,,,,,,,,,,,,,
OSS RS 9CM PROX TIB MOD COCR,SUP-2510703,CDM,C1776,CPT,0278,RC,,,,both,,,17945.10,11664.31,,,,,,,,,,,,,
KIT CVC L 16 CM DIA12 FR TL BIOPATCH DRSG LG BOR FOR HI VOL,SUP-2909932,CDM,C1751,HCPCS,0278,RC,,,,both,,,547.62,355.95,,,,,,,,,,,,,
GRAFT HUM TISS L DST FEM FRZN,SUP-2307309,CDM,C1713,HCPCS,0278,RC,,,,both,,,16760.28,10894.18,,,,,,,,,,,,,
EXTRACTOR STONE TIPLSS 3 FRX115 CM 2 CM MOD BSKT NIT NCIRCLE,SUP-2835765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,663.83,431.49,,,,,,,,,,,,,
SCREW BNE L38MM DIA3.5MM STD CORT TI ST LOK LO PROF FOR,SUP-2376995,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.75,76.54,,,,,,,,,,,,,
STEM FEM REV 24X195 MM MONOBLOC ALTEON,SUP-2432458,CDM,C1776,CPT,0278,RC,,,,both,,,15481.61,10063.05,,,,,,,,,,,,,
PLATE BNE L142MM 6 H NONSTERILE L MED DST TIB S STL LOK,SUP-2185584,CDM,C1713,HCPCS,0278,RC,,,,both,,,4456.23,2896.55,,,,,,,,,,,,,
SYSTEM CHARGING LE EON MINI,SUP-2355972,CDM,C1820,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE 16 H ST BILAT S STL NAR CRV LOK COMPR FOR 3.5MM,SUP-2178048,CDM,C1713,HCPCS,0278,RC,,,,both,,,2666.93,1733.50,,,,,,,,,,,,,
SYSTEM PREPPING PRE-OP SING WRAP 2%CHLORHEXIDINE GLUCO 7.5,SUP-2110449,CDM,V2632,HCPCS,0276,RC,,,,both,,,15.64,10.17,,,,,,,,,,,,,
BUR 45MMX19CM SPHR HPS,SUP-2167161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BNE COMPR NAR 5X97 MM 5 HOLE LCK NS AXSOS,SUP-2424238,CDM,C1713,HCPCS,0278,RC,,,,both,,,6213.75,4038.94,,,,,,,,,,,,,
"HC Amniocentesis,Ther Amniotic Fluid Reduct",PX-3615900100,CDM,59001,CPT,0361,RC,,,,both,,,963.00,625.95,,,,,,,,,,,,,
FERROUS GLUCONATE 324 (37.5 FE) MG PO TABS,RX-110402,CDM,6370000000,HCPCS,0637,RC,20555-0019-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MICROCATHETER DIAG FASTRACKER 325 TRANSEND L 135 CM DIA 3 FR,SUP-2148476,CDM,C1887,HCPCS,0272,RC,,,,both,,,1843.24,1198.11,,,,,,,,,,,,,
HAT EXT FIX COMPR PHOENIX,SUP-2496293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1842.71,1197.76,,,,,,,,,,,,,
SCREW BNE STD 2X6 MM SELF RET TI NS MAXDRIVE LEVEL 1,SUP-2457683,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.24,105.46,,,,,,,,,,,,,
TITANIUM MESH TRAY SYMPHYSIS MANDIBLE CP TITANIUM,SUP-2669724,CDM,C1713,HCPCS,0278,RC,,,,both,,,6533.40,4246.71,,,,,,,,,,,,,
PLATE BNE L104MM THK3.7MM 8 H BILAT S STL STR LO PROF RIG,SUP-2184028,CDM,C1713,HCPCS,0278,RC,,,,both,,,2168.17,1409.31,,,,,,,,,,,,,
HC Trluml Balo Angiop 1st Art,PX-3613724600,CDM,37246,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
SCREW BNE TENTING STYL 1.5X5 MM MOD MAXDRIVE 503380561,SUP-2464339,CDM,C1713,HCPCS,0278,RC,,,,both,,,293.12,190.53,,,,,,,,,,,,,
SCREW BNE L22MM DIA15MM PUR TI ALLY THRD AND ROUNDED HD LOK,SUP-2255843,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.13,226.28,,,,,,,,,,,,,
PIN ANCHR L45MM DIA2MM SMOOTH SHRP TIP,SUP-2249400,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SPACER FEM STD UNIV POST PRI PRESSFIT L 10MM THCK 66326440] STRYKER ORTHOPEDICS HOWM],SUP-2377238,CDM,C1776,CPT,0278,RC,,,,both,,,2347.65,1525.97,,,,,,,,,,,,,
BRACE KNEE POSTOP 1 SZ FITS MOST SH UNIV UNISX FASTEN ON HNG,SUP-2150852,CDM,L1832,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 8X15 MM IL TRICORT CORNERSTONE,SUP-2293822,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
SYSTEM CHARGING FOR DP BAIN STIM VERCISE,SUP-2140424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 8 IN WRST FOREARM RT,SUP-2336336,CDM,L3809,HCPCS,0272,RC,,,,both,,,20.63,13.41,,,,,,,,,,,,,
HC So Cpk (CK),PX-3018255066,CDM,82550,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
PLATE BONE L140MM 7 H RT PROX HUM LCK FOR 3.5MM SCR PERI-LOC,SUP-2348554,CDM,C1713,HCPCS,0278,RC,,,,both,,,13447.21,8740.69,,,,,,,,,,,,,
SCREW BONE L24MM PROX INTERPHALANGEAL JT HDLSS OPP THREADS,SUP-2121840,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
SCREW SPNL L 30 MM DIA 5 MM FIX ANGLE STRL CD HORZ MODULEX,SUP-2926389,CDM,C1713,HCPCS,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
LEAD PACE L78CM DIA5.3FR SIL STEROID CARD ART VENT STR 2 439878] MEDTRONIC CARDIAC RTHYM MGT],SUP-2281934,CDM,C1900,HCPCS,0275,RC,,,,both,,,4909.99,3191.49,,,,,,,,,,,,,
GRAFT BNE SPNG 50X20X5 MM DBM CANC,SUP-2641786,CDM,C1713,HCPCS,0278,RC,,,,both,,,5922.04,3849.33,,,,,,,,,,,,,
TIP SUCTION FRAZIER 4 FRX9 CM 4 FR ESSAR W/ REL HOLE,SUP-2473037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.55,504.76,,,,,,,,,,,,,
K WIRE FIX L5IN DIA1MM S STL SMOOTH BLNT TIP FOR PEDCL SCR,SUP-2289237,CDM,C1769,HCPCS,0272,RC,,,,both,,,366.19,238.02,,,,,,,,,,,,,
KIT ORTH 2 DRL 3 OLV WIRE DISPNSR SYS STRL DISP APOLLOANKLE,SUP-2894238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA2 L 160 MM DIA28 MM SHTH 16 FR,SUP-2911993,CDM,C1768,CPT,0278,RC,,,,both,,,66351.34,43128.37,,,,,,,,,,,,,
GRAFT BIO TISS W10XL25CM FET BOV DERM MESHED PRIMATRIX AG,SUP-2243715,CDM,Q4110,HCPCS,0636,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
DISTRACTOR LIN 150MM FOR TRUELOK FIX SYS,SUP-2316065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1651.95,1073.77,,,,,,,,,,,,,
SCREW BNE L36MM DIA4MM HD DIA8MM TI ST LOK DBL LD THRD HEX,SUP-2192258,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.18,398.57,,,,,,,,,,,,,
CATHETER INTRO 10.06FR UNIV OUTER SLITTABLE RT CRV CPS DIR,SUP-2356377,CDM,C1893,HCPCS,0272,RC,,,,both,,,554.84,360.65,,,,,,,,,,,,,
SYSTEM DEL TRANSSEPTAL 035X135 CM 55 DEG 8.5 FRX79.4 CM TSX,SUP-2424692,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 7.01-8.0 MCI STRL ADVANTAGE 2029HLS2] ISOAID LLC],SUP-2247279,CDM,C2642,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
HC Perq Trluml C Angioplasty 1 Maj C Art&/Branches|RIGHT CORONARY ARTERY|REDUCED SERVICES,PX-4819292000,CDM,92920,CPT,0481,RC,,,RC|52,both,,,15307.00,9949.55,,,,,,,,,,,,,
"HC So Molecular Pathology, Unlisted",PX-3108147966,CDM,81479,CPT,0310,RC,,,,inpatient,,,3280.00,2132.00,,,,,,,,,,,,,
SHUNT VENTRICULOPERI CSF L SNAP ASMBLY CNTOUR REG FLO CTRL,SUP-2277928,CDM,C1889,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X100X0.5 MM RAPID RESORBABLE STE,SUP-2838577,CDM,C1713,HCPCS,0278,RC,,,,both,,,10948.24,7116.36,,,,,,,,,,,,,
SCREW BNE 7X25 MM 8 MM W/ HD STRL BIORCI,SUP-2848552,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.01,417.96,,,,,,,,,,,,,
SCREW SPNL TAPR 5X10 MM OCCIPITOCERVICAL UPPER THOR,SUP-2632009,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
IMPLANT BRST 620 650CC P59CM W145XH15CM SIL STYL 468 FULL HT,SUP-2113355,CDM,C1789,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
BOBBIN VT 127MM ID BLUE TI,SUP-2669488,CDM,L8699,HCPCS,0278,RC,,,,both,,,68.58,44.58,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 15 CC CANC PUROS,SUP-2687381,CDM,C1713,HCPCS,0278,RC,,,,both,,,1739.56,1130.71,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP RT PROX FEM W/ LIGMNT,SUP-2867031,CDM,C1762,CPT,0278,RC,,,,both,,,15437.03,10034.07,,,,,,,,,,,,,
"HC Parananeoplastic Ab Panel, Voltage-Gtd Ca Chnl Antb Ea",PX-3028659667,CDM,86596,CPT,0302,RC,,,,both,,,71.00,46.15,,,,,,,,,,,,,
PATCH CV L 15 X W 10 CM THK 0.6 MM EPTFE RW RECTANGULAR STRL,SUP-2761225,CDM,C1768,CPT,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
TUBE EAR VENT ARMSTRONG GROM 1.14 MM FLUROPLAST BLUE STERILE,SUP-2866539,CDM,L8699,HCPCS,0278,RC,,,,both,,,116.49,75.72,,,,,,,,,,,,,
HC N Block Paravert Thoracic 3+,PX-3606449200,CDM,64492,CPT,0360,RC,,,,both,,,3113.00,2023.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6X3 CM TEND REINF MTRX PURAFORCE,SUP-2716034,CDM,C1765,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
HC Special Med Physics Consult,PX-3337737000,CDM,77370,CPT,0333,RC,,,,outpatient,,,1443.00,937.95,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 CM DIA 5-17 MM SZ 49 CM FEM VEIN,SUP-2933441,CDM,C1762,CPT,0278,RC,,,,both,,,23176.59,15064.78,,,,,,,,,,,,,
RESERVOIR VENT DRNGE NEO 01ML INTCRAN L75CM DIA4CM,SUP-2277914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1006.68,654.34,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 140 CM BALLOON L 15 MM DIA2 MM NC24,SUP-2928715,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PIN FIX L150MM SPNL PERC DISP O ARM,SUP-2280202,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
COIL EMB L10CM DIA0.02IN LOOP DIA4MM COMPLX EXTRA SFT FILL,SUP-2323437,CDM,C1889,HCPCS,0278,RC,,,,both,,,7975.60,5184.14,,,,,,,,,,,,,
BOOT WLK L TALL VECTRA,SUP-2151014,CDM,L4360,HCPCS,0274,RC,,,,both,,,95.14,61.84,,,,,,,,,,,,,
PORT INFUS 96FR TI SIL PWR INJ SGL LUMN FULL SZ PROF ATTCH,SUP-2126316,CDM,C1788,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
EXPANDER BRST W12.3XH12.9CM P6.5CM 450CC SIL NACL SHELL RND,SUP-2300639,CDM,C1789,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
CATHETER REPROC RPRCSS EP INQRY STRBLE DECAP LG CRV 4FRX110CM SP 2 5 2M,SUP-2473227,CDM,C1730,HCPCS,0272,RC,,,,both,,,727.16,472.65,,,,,,,,,,,,,
GUIDEWIRE ORTH 0.94X9.25 IN,SUP-2857702,CDM,C1769,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
DEVICE PESSARY NO4 DIA2.75IN RNG FLD KITTED W/ SUPP PROLAPSE,SUP-2171799,CDM,A4562,HCPCS,0272,RC,,,,both,,,173.30,112.64,,,,,,,,,,,,,
BIT DRILL SURG L 130 MM DIA 4.2 MM FREEHAND STRL LF DISP T2,SUP-2900504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1125.78,731.76,,,,,,,,,,,,,
PLATE BNE SM W11XL202MM THK34MM 15 H BILAT TI RIG NEUT LOK,SUP-2190794,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.18,1240.97,,,,,,,,,,,,,
PLATE BNE RECON 2-2.7X193X3 MM RT MAND 26 HOLE ANGLED STRL,SUP-2482449,CDM,C1713,HCPCS,0278,RC,,,,both,,,6948.38,4516.45,,,,,,,,,,,,,
PLATE BONE ADAPTION 0.5 MM 5 HOLE TITANIUM NON STERILE LOW P,SUP-2838361,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
PLATE BONE L46MM 4 H STRL S STL 1/3 TBLR LCK FOR 3.5MM SCR,SUP-2349627,CDM,C1713,HCPCS,0278,RC,,,,both,,,1407.16,914.65,,,,,,,,,,,,,
STAPLER INT POWDERED 33 MM ECHELON CIR,SUP-2218875,CDM,C1889,HCPCS,0278,RC,,,,both,,,1165.44,757.54,,,,,,,,,,,,,
PLATE BONE 2 CARPAL WRIST FREEDOM,SUP-2586701,CDM,C1713,HCPCS,0278,RC,,,,both,,,12898.96,8384.32,,,,,,,,,,,,,
KIT XLINK W/ XVS MARKERS,SUP-2739163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU DIA 5 FR NYL TUNGSTEN PERIPH BERN SFT,SUP-2117963,CDM,C1887,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA SULF HA INJ BIPHASIC OSTEOCONDUCTIVE,SUP-2402598,CDM,C1713,HCPCS,0278,RC,,,,both,,,5711.66,3712.58,,,,,,,,,,,,,
PORT INFUS 10FR PLAS VLV OPN INTRO 2 LUMN INTERMED,SUP-2127753,CDM,C1788,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BONE THK1.8MM 9 H STRNL TI Y SHP LCK,SUP-2262583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1559.36,1013.58,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM DURAC SCORP,SUP-2365623,CDM,C1776,CPT,0278,RC,,,,both,,,9411.02,6117.16,,,,,,,,,,,,,
SYSTEM CARD ICD SYS 2 CHMBR W/ RIATA ST OPTIM SYS FOR V-24,SUP-2356553,CDM,C1721,HCPCS,0275,RC,,,,both,,,67268.22,43724.34,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA 3.5 MM TI LCK T15 STARDRV TUBE PK STRL,SUP-2905753,CDM,C1713,HCPCS,0278,RC,,,,both,,,862.18,560.42,,,,,,,,,,,,,
BASKET RETRV BILI STONE HELCL 3FR SHTH 16MM OPN DIAM 240CM,SUP-2141354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
HC Assay of Lipoprotein,PX-3018371800,CDM,83718,CPT,0301,RC,,,,outpatient,,,216.00,140.40,,,,,,,,,,,,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) PO TBCR,RX-11083,CDM,6370000000,HCPCS,0637,RC,68084-0850-33,NDC,,both,1,UN,10.90,7.08,,,,,,,,,,,,,
DEFIBRILLATOR LUMAX500 VR T SYS W/ LANDLINE HM,SUP-2138274,CDM,C1722,HCPCS,0275,RC,,,,both,,,49455.00,32145.75,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR 10MM LESS STRAINED SPEAK VLV PROVOX,SUP-2124387,CDM,L8509,HCPCS,0274,RC,,,,both,,,912.70,593.25,,,,,,,,,,,,,
BIT DRL DIA35MM HI SPD,SUP-2187154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.01,503.11,,,,,,,,,,,,,
GRAFT VASC EXCLUDER 23 X 14.5 X 12CM,SUP-2395973,CDM,C1768,CPT,0278,RC,,,,both,,,22915.72,14895.22,,,,,,,,,,,,,
NOZZLE SPRY FOR 2 RNG HNDPC L17 STRL DISP ELAN 4,SUP-2929101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.33,223.81,,,,,,,,,,,,,
DEVICE FIX 7-8 MM TIB BIOSURE SYNC,SUP-2848624,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.64,473.62,,,,,,,,,,,,,
HC Debrid Wound Tis Addl 20 Cm<,PX-7619759800,CDM,97598,CPT,0761,RC,,,,inpatient,,,194.00,126.10,,,,,,,,,,,,,
NAIL FIX L 70 MM DIA 5.5 MM LG THRD TRIM STRL OSSIOFIBER,SUP-2904328,CDM,C1713,HCPCS,0278,RC,,,,both,,,4976.90,3234.98,,,,,,,,,,,,,
SET URET CATH 5FR L130CM PLUG L80CM ILLUMINATING SGL LUMN,SUP-2171299,CDM,C1758,HCPCS,0278,RC,,,,both,,,607.40,394.81,,,,,,,,,,,,,
NEEDLE SUTURE L8.75IN HEAVY CURVED REVERDIN,SUP-2803391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.78,506.21,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 2.5 CC FD CORTICAL PWD ORAGRAFT,SUP-2741027,CDM,C1713,HCPCS,0278,RC,,,,both,,,343.48,223.26,,,,,,,,,,,,,
PLATE BNE STR 1.5X1 MM 4 MM MXLFCL OPN LOOP BRIDGE STP TI NS,SUP-2485770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1093.98,711.09,,,,,,,,,,,,,
GRAFT BNE SUB 15ML GROWTH FACT GRAN OSTEOAMP,SUP-2138499,CDM,C1713,HCPCS,0278,RC,,,,both,,,7755.80,5041.27,,,,,,,,,,,,,
JOINT SACROILIAC 10X50 MM IFUSE-TORQ,SUP-2713924,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
CAP ORTH COMPR,SUP-2406885,CDM,C1776,CPT,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
HC Hands Bone Age Study,PX-3207707200,CDM,77072,CPT,0320,RC,,,,inpatient,,,252.00,163.80,,,,,,,,,,,,,
CATHETER LA6JR405 LA 6F 5PK 100 JR40,SUP-2429762,CDM,C1887,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
TROCAR SURG FOR 2 MM PIN,SUP-2537825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
BIT DRL CANN 6.5 MM KNEE SINGLE FLUT MTO,SUP-2849079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
SIZER SURG 27MM NEUT IMPL TRL,SUP-2400078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
PLATE BONE W24XL24MM THK0.5MM CRAN ORBIT FLR RAP RESRB,SUP-2194077,CDM,C1713,HCPCS,0278,RC,,,,both,,,2868.39,1864.45,,,,,,,,,,,,,
GRAFT BNE 60CC 1 4MM CANC CRUSH CHIP READIGRFT,SUP-2264826,CDM,C1713,HCPCS,0278,RC,,,,both,,,2296.25,1492.56,,,,,,,,,,,,,
INSERT BPLR OD41-44MM ID28MM DURAMER POLY ACET HIP SLR,SUP-2304367,CDM,C1776,CPT,0278,RC,,,,both,,,3367.65,2188.97,,,,,,,,,,,,,
BRACE OPN POPLITEAL 28IN 305IN SZ 3XL FREDDIE,SUP-2196843,CDM,L1810,HCPCS,0274,RC,,,,both,,,66.13,42.98,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 23.5-26.5 IN CTR 17-19 IN CALF 18-20 IN 11-0865-5,SUP-2918712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.76,222.79,,,,,,,,,,,,,
IMPLANT TOE XSM 10DEG ANG PHALINX,SUP-2397783,CDM,C1776,CPT,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
MARKER RAD L3MM DIA1MM W/ 17GA L20CM PLCMNT NDL X THN WALL,SUP-2164649,CDM,A4648,CPT,0278,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
CARTRIDGE GRFT DEL 5 CC DBM INSTAFILL,SUP-2865333,CDM,C1713,HCPCS,0278,RC,,,,both,,,4402.28,2861.48,,,,,,,,,,,,,
GRAFT HUM TISS W13XH14XL11MM CANC CORT FRZ DRY CRNRSTN ASR,SUP-2293790,CDM,C1713,HCPCS,0278,RC,,,,both,,,2662.34,1730.52,,,,,,,,,,,,,
PLATE BNE 1ST METATARSOPHALANGEAL SM RT FT STRL A.L.P.S,SUP-2481927,CDM,C1713,HCPCS,0278,RC,,,,both,,,2278.26,1480.87,,,,,,,,,,,,,
PLATE 1ST MTCRPL 2MM DORS SS STRL VAL,SUP-2546097,CDM,C1713,HCPCS,0278,RC,,,,both,,,2268.74,1474.68,,,,,,,,,,,,,
SEALANT TISS FIBRIN 10 CC HUM 4 PK KT VISTASEAL,SUP-2738901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5660.23,3679.15,,,,,,,,,,,,,
MESH HERN 15X7.5 CM N ABSRB KEYHOLE INGUINAL PARIETENE LF,SUP-2752195,CDM,C1781,HCPCS,0278,RC,,,,both,,,468.30,304.39,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IMPL 2PC SHUNT W/ ANTECHAMBER OSV II,SUP-2666654,CDM,C1889,HCPCS,0278,RC,,,,both,,,9557.47,6212.36,,,,,,,,,,,,,
PLATE BNE ANGLED 2.8 MM LT 7X23 HOLE RECON TI PT SPEC,SUP-2860110,CDM,C1713,HCPCS,0278,RC,,,,both,,,23366.94,15188.51,,,,,,,,,,,,,
PLATE BNE L24MM THK0.4MM 4 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181556,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.27,155.53,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX16 TTNM CNTRD F/2.7MM SCREW UNVRS,SUP-2498034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.19,773.62,,,,,,,,,,,,,
PLATE BNE 3.5X287 MM 22 HOLE SS LCP,SUP-2569332,CDM,C1713,HCPCS,0278,RC,,,,both,,,623.45,405.24,,,,,,,,,,,,,
GRAFT EVAR L10CM DST DIA27MM FEP NIT CONTRALATERAL LEG IL,SUP-2395913,CDM,C1768,CPT,0278,RC,,,,both,,,15630.92,10160.10,,,,,,,,,,,,,
SCREW BONE LOK 5.5MM DIA 100MML TTNM CRTCL FLLY THRDD SOLID,SUP-2587389,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.32,298.56,,,,,,,,,,,,,
HC IV Dop Vel&/Press C/Flo Rsrv Meas 1st Vessel,PX-4819357100,CDM,93571,CPT,0480,RC,,,,both,,,7672.00,4986.80,,,,,,,,,,,,,
ALLOGRAFT HUM TISS WHL BTB FRZN NO-RAD,SUP-2321841,CDM,C1762,CPT,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
KIT BNE CEM ENH TOT HIP W/ CNL BRSH SUCT ABSORBER PRSSZR,SUP-2711612,CDM,C1776,CPT,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0250,RC,00990-7922-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
TI END CAP FOR TROCHANTERIC FIXATION NAILS 0MM EXT,SUP-2549732,CDM,C1889,HCPCS,0278,RC,,,,both,,,539.58,350.73,,,,,,,,,,,,,
BIT DRL CANN 2 IN 1 2 X 65 MM,SUP-2243023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.83,483.49,,,,,,,,,,,,,
HEAD RADIAL 3 FLEXSPAN,SUP-2538174,CDM,C1776,CPT,0278,RC,,,,both,,,10387.12,6751.63,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS TENCK INF 39.25 CM 1 CUF CURL QUINT,SUP-2754740,CDM,C1752,HCPCS,0278,RC,,,,both,,,407.89,265.13,,,,,,,,,,,,,
AUGMENT TIB SZ 6 THK10MM STD UNIV TRABECULAR MTL CEM REV,SUP-2200164,CDM,C1776,CPT,0278,RC,,,,both,,,9294.40,6041.36,,,,,,,,,,,,,
PROBE SURG NERVE STIMULATING DISP,SUP-2517402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC Drug Screen Quantitative Gentamicin,PX-3018017000,CDM,80170,CPT,0301,RC,,,,outpatient,,,147.00,95.55,,,,,,,,,,,,,
COIL NEUROVASCULAR L 6 CM DIA 0.135 IN MICROCATHETER DIA,SUP-2896851,CDM,C1889,HCPCS,0278,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR PRIMARY STEM POROUS,SUP-2257249,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PROFILE COSTAL CARTILAGE ALLOGRAFT SHEET LG,SUP-2727659,CDM,C1762,CPT,0278,RC,,,,both,,,2511.69,1632.60,,,,,,,,,,,,,
GRAFT BONE SUB M 6CC BIOACTIVE GLS PUTTY FIBERGRFT,SUP-2330556,CDM,C1713,HCPCS,0278,RC,,,,both,,,7347.60,4775.94,,,,,,,,,,,,,
KNIFE 3714165 BALLENGER SWIVEL 4MM BAYO,SUP-2706947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1645.45,1069.54,,,,,,,,,,,,,
JIG SURG KNEE PS REPL STRL ITOTAL IDENTITY,SUP-2904460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
INSERT SURG W3MM OP L10MM THK0.35MM MICROSAW MT1S-10 FOR,SUP-2327783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SURFACE ARTC TIB CONSTRN CNDYL KNEE MOD TIV SZ 59 25MM IB II,SUP-2205849,CDM,C1776,CPT,0278,RC,,,,both,,,7767.10,5048.61,,,,,,,,,,,,,
VALVE AORT PORCINE BIOPROSTHESIS 25MM CARPENTIER,SUP-2214049,CDM,C1713,HCPCS,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
BLADE REPROC SHV 4.5MM PLAT INCIS+ SLATE,SUP-2652938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,290.61,188.90,,,,,,,,,,,,,
STEM FEM L250MM DIA13.5MM BEAD 10IN 35MM OFFSET LT HIP CO,SUP-2203192,CDM,C1776,CPT,0278,RC,,,,both,,,22022.39,14314.55,,,,,,,,,,,,,
HC Thrombin Time Plasma,PX-3058567000,CDM,85670,CPT,0305,RC,,,,both,,,122.00,79.30,,,,,,,,,,,,,
FILLER DERMAL JUVEDERM VOLUMA XC 1ML,SUP-2900487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1307.81,850.08,,,,,,,,,,,,,
MANIPULATOR SURG NUCLS KELMAN,SUP-2484800,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.94,289.21,,,,,,,,,,,,,
GRAFT BIO TISS W18XL28MM THK1MM PORCINE DERM CLLGN FOR HERN,SUP-2174698,CDM,C9364,HCPCS,0278,RC,,,,both,,,30856.78,20056.91,,,,,,,,,,,,,
KIT CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 20CM PCED 2LUM,SUP-2613269,CDM,C1752,HCPCS,0278,RC,,,,both,,,715.14,464.84,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 2 ML STR W/ CD-H OSSEOFLEX SB OCP0217,SUP-2463686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10267.80,6674.07,,,,,,,,,,,,,
CHRONOS(TM) BETA-TCP WEDGE 22 DEG/RECTANGULAR-STERILE,SUP-2550434,CDM,C1713,HCPCS,0278,RC,,,,both,,,2181.48,1417.96,,,,,,,,,,,,,
PLATE BURR H DIA22 CTR H 8 MM THK 1.73 MM SCREW DIA1.5 MM TI,SUP-2937007,CDM,C1713,HCPCS,0278,RC,,,,both,,,3742.88,2432.87,,,,,,,,,,,,,
PLATE BNE W10XL96MM THK1.5MM 3X7 H S STL R OBLQ T SHP LOK,SUP-2185839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1126.29,732.09,,,,,,,,,,,,,
PROBE ABLAT L130MM TIP DIA3MM 90DEG CERAMIC ASPIR MPLR LO,SUP-2123445,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI HEM CATH CHRONIC 12.5FR DIA LNG 32CM S,SUP-2610598,CDM,C1750,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321196,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.035IN TIP L3CM PTFE STR FLX,SUP-2139325,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.86,23.96,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT DIA21 MM BOV PERICARD COCR,SUP-2214054,CDM,C1889,HCPCS,0278,RC,,,,both,,,21226.40,13797.16,,,,,,,,,,,,,
CATHETER ATHRCTMY L 135 CM BUR DIA1.75 MM CORONARY ADVANCING,SUP-2140972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
BASEPLATE TIB LIMB SALV LO BODY ELEOS SZ 3 70MM M/L,SUP-2314044,CDM,C1776,CPT,0278,RC,,,,both,,,20918.68,13597.14,,,,,,,,,,,,,
SEALANT HEMOSTATIC POWDER ENDOCLOT 30ML,SUP-2857949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ALLOGRAFT BNE MATCHSTICK SM 60X3-6 MM FD CORTICAL CANC,SUP-2866841,CDM,C1762,CPT,0278,RC,,,,both,,,1011.24,657.31,,,,,,,,,,,,,
PLATE BNE L W10.1XL112MM THK3.5MM 8 H BILAT S STL STR RIG,SUP-2186214,CDM,C1713,HCPCS,0278,RC,,,,both,,,1466.63,953.31,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 8.5 FR SIDEPRT,SUP-2763366,CDM,C1892,HCPCS,0272,RC,,,,both,,,347.91,226.14,,,,,,,,,,,,,
SHELL ACET SZ G DIA64MM HIP TRITANIUM X3 MH HMSPHR MOD 2,SUP-2372558,CDM,C1776,CPT,0278,RC,,,,both,,,7117.75,4626.54,,,,,,,,,,,,,
DILATOR ENDO SZ 54FR POLYVI OVR THE WIRE TAPR MRK SPR TIP,SUP-2166174,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
PLATE BONE MESHED 1X0.3 MM ORBITAL CRANIOFACIAL FLOOR TITANI,SUP-2838340,CDM,C1713,HCPCS,0278,RC,,,,both,,,4903.74,3187.43,,,,,,,,,,,,,
CEMENT KIT CALCIUM PHOSPHATE 8 CC QUICKSET,SUP-2845379,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
HC So Oxcarbazepine Metabolite,PX-3018018366,CDM,80183,CPT,0301,RC,,,,outpatient,,,128.00,83.20,,,,,,,,,,,,,
CATHETER PERICARDCENT 6FR L60CM STR KT,SUP-2303221,CDM,C1729,HCPCS,0272,RC,,,,both,,,313.22,203.59,,,,,,,,,,,,,
DISC INTERVERTEBRAL ARTIFICIAL 1 6 MM CERV SIMPLIFY,SUP-2751656,CDM,C1889,HCPCS,0278,RC,,,,both,,,15662.32,10180.51,,,,,,,,,,,,,
PLATE BNE L 239 X W 12 MM THK 4 MM SCREW DIA2.7/3.5 MM 20 H 72469120,SUP-2933467,CDM,C1713,HCPCS,0278,RC,,,,both,,,6346.57,4125.27,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 4 HOLE ATTCH VA LCK COMPR NS VA-LCP,SUP-2757676,CDM,C1713,HCPCS,0278,RC,,,,both,,,2021.63,1314.06,,,,,,,,,,,,,
SHELL HUM DIA44MM SHLDR CO CHROM BPLR ABS,SUP-2404520,CDM,C1776,CPT,0278,RC,,,,both,,,5878.08,3820.75,,,,,,,,,,,,,
COMPONENT PAT M 3 PEG MTL BK CEM RND REV W/O XR WIRE,SUP-2250822,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC So Bacterium Antibody,PX-3028660966,CDM,86609,CPT,0302,RC,,,,both,,,83.00,53.95,,,,,,,,,,,,,
STENT CORONARY XIENCE PRIM LL L 28 MM DIA2.75 MM SYS L 143,SUP-2104689,CDM,C1874,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
K WIRE FIX L285MM DIA2MM S STL FOR AXSOS SYS,SUP-2377976,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.45,248.59,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ADD ON CERM POLYETH,SUP-2365433,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
COVER BUR H DIA17MM BILAT TI CNTOUR RIG NONCOMPRESSION LO,SUP-2190645,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
SHEATH ENDO DIA4MM 15DEG LENS KARL STORZ DISP ENDO-SCRUB,SUP-2277880,CDM,C1894,HCPCS,0272,RC,,,,both,,,161.58,105.03,,,,,,,,,,,,,
KIT LD TRL 8 CNTRCT 50CM,SUP-2138793,CDM,C1778,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
CATHETER IV SINGLE LEMEN 4 FR DOT KT BIOP PC NG POWERMIDLINE,SUP-2626735,CDM,C1751,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
PIN FIX L9IN DIA24MM ST S STL 3 SIDE SGL TRCR 1 END PNT,SUP-2150506,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.94,16.86,,,,,,,,,,,,,
BIT DRILL 4.5MM 3 FLUTED QC,SUP-2819221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1455.89,946.33,,,,,,,,,,,,,
GII STEP HEMI WDG SZ7-8 {} 10,SUP-2511028,CDM,C1776,CPT,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
OCUVITE-LUTEIN PO TABS,RX-138480,CDM,6370000000,HCPCS,0637,RC,00536-3445-08,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
KIT LASER L65CM 0.035IN NDL 21GA GRP G TIP FRS FBR NEVERTOUCH,SUP-2118073,CDM,C1894,HCPCS,0272,RC,,,,both,,,921.75,599.14,,,,,,,,,,,,,
NAIL INTRAMEDULLARYXL L36CM DIA7MM RT ANTR POST FEM LCK,SUP-2318897,CDM,C1713,HCPCS,0278,RC,,,,both,,,12501.34,8125.87,,,,,,,,,,,,,
PLATE BNE ST 2.4X90 MM RT CORTICAL W/ T8 STARDRV RECESS SS,SUP-2757641,CDM,C1713,HCPCS,0278,RC,,,,both,,,181.05,117.68,,,,,,,,,,,,,
FIBER LASER 550 MH UNSHEATHED SCP SAFE SMA905 STRL DISP,SUP-2768243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3358.54,2183.05,,,,,,,,,,,,,
MATRIX BIO L 1.75 X W 1.75 CM FISH SKIN DERMAL INTACT OMEGA3,SUP-2909329,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
PLATE BONE L40MM SH STRL LT ANTEROLATERAL CALCNL S STL VAR,SUP-2178428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3076.01,1999.41,,,,,,,,,,,,,
SCREW CANN MINI COMP 12MM,SUP-2321406,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.91,490.04,,,,,,,,,,,,,
GRAFT VSCLR L W51XL152CM KNTTD DBLE VLR FBRC HMSHLD,SUP-2467001,CDM,C1768,CPT,0278,RC,,,,both,,,1077.30,700.24,,,,,,,,,,,,,
COVER ACET LNR TAPR H REFLCT,SUP-2351122,CDM,C1776,CPT,0278,RC,,,,both,,,128.58,83.58,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.44/2.16 MM PAPARELLA W/ TAB 510041C,SUP-2460071,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
MARKER XRAY BRST BX F/9 GX10CM SUROS SYST,SUP-2120150,CDM,A4648,CPT,0278,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
DEVICE CRYOTHERAPY W/ CRYO CANSTR CLARIFIX GEN II,SUP-2423335,CDM,C2618,HCPCS,0272,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
STRUT SPNL W10XL200MM THK3-12MM FEM CORT HALVED ALLGRFT,SUP-2307361,CDM,C1713,HCPCS,0278,RC,,,,both,,,3216.93,2091.00,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX16 CM BASIC KT ARROWG+ARD,SUP-2383311,CDM,C1751,HCPCS,0278,RC,,,,both,,,151.10,98.21,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 180 CM DIA 0.018 IN TIP L 3 CM,SUP-2148188,CDM,C1769,HCPCS,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
HC So Hiv-2 Pcr,PX-3068753866,CDM,87538,CPT,0306,RC,,,,both,,,293.00,190.45,,,,,,,,,,,,,
PROBE DOPPLER INTOP FLO CPLR,SUP-2900198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
DRILL 12MMX2.0MM,SUP-2841897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
MESH HERN SM DIA4.3CM VENTRAL POLYPR EPTFE CIR SELF EXP,SUP-2125719,CDM,C1781,HCPCS,0278,RC,,,,both,,,1501.86,976.21,,,,,,,,,,,,,
CATHETER VENTRICULAR STYL LUER CONN CAP ANCHR CLP BACTISEAL,SUP-2666820,CDM,C1729,HCPCS,0272,RC,,,,both,,,1830.65,1189.92,,,,,,,,,,,,,
BLADE RETRACTOR 2 12IND SOLID LATERAL,SUP-2671275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,256.44,166.69,,,,,,,,,,,,,
LOCKING CORTICAL PEG BLUE 2.3MMX36MM,SUP-2841822,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
CEMENT BNE 40GM 2.5% GENT BWL SPAT HND MIX LOW/MEDIUM VISC,SUP-2221996,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SCREW BNE 2.1X5 MM PDLLA STRL RESORB RX 520242504,SUP-2497382,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.29,141.24,,,,,,,,,,,,,
BIT DRL FLX CENTERING SL DISP,SUP-2608596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
GRAFT BNE 10X20X2MM DEMIN CANC SPNG STRP FLEXIGRFT,SUP-2264612,CDM,C9362,HCPCS,0278,RC,,,,both,,,1343.48,873.26,,,,,,,,,,,,,
FENTANYL 0.05 MG/ML SOLN (MIXTURES ONLY),RX-430015,CDM,J3010,HCPCS,0636,RC,00409-9094-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL L195MM DIA2.5MM S STL QUIK CONN NONRADIOLUCENT W/O,SUP-2411441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.57,511.27,,,,,,,,,,,,,
PLATE BNE L 75 MM SCREW DIA2.4 MM 12 SHFT H TI ADPT MINI,SUP-2907587,CDM,C1713,HCPCS,0278,RC,,,,both,,,3069.51,1995.18,,,,,,,,,,,,,
SCREW BNE ST 1.9X5 MM EMGCY PROFYLE,SUP-2364075,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.09,113.81,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12X14X7 MM CERV FD PARL CANC,SUP-2736852,CDM,C1713,HCPCS,0278,RC,,,,both,,,2782.04,1808.33,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN VBX L 15 MM 5/8 MM 80 CM 6 FR,SUP-2892859,CDM,C1874,HCPCS,0278,RC,,,,both,,,8587.90,5582.13,,,,,,,,,,,,,
CATHETER NAVISTAR SFT TIP D CURV,SUP-2248473,CDM,C1730,HCPCS,0272,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
LINER ACET OD40MM ID24MM +3MM OFFSET HIP E1 HI WALL RINGLOC,SUP-2408926,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
FORCEPS BX 2.4FR L115CM BACKLOADING TO OBTAIN SAMP FOR,SUP-2171429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1951.20,1268.28,,,,,,,,,,,,,
CATHETER DRAINAGE WHSTL TIP 4 FRX70 CM URET RT FOR PYELOGRAM,SUP-2168870,CDM,C1758,HCPCS,0278,RC,,,,both,,,166.73,108.37,,,,,,,,,,,,,
LINER ACET NEUT I 5+ MM 28 MM PROV G7,SUP-2441113,CDM,C1776,CPT,0278,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
HC So Assay Myeloperoxidase,PX-3018387666,CDM,83876,CPT,0301,RC,,,,outpatient,,,84.00,54.60,,,,,,,,,,,,,
NEEDLE BX 19GA 155MM UTW TIP TRACKED,SUP-2392617,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BIT DRL N CANN 4 MM TWST,SUP-2389445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
BUR SURG RND 3 MM 93 MM CRV FLUT HI SPD FOR DRL SYS SS VISAO,SUP-2628957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.33,512.41,,,,,,,,,,,,,
GRAFT BNE 5 CC CELLULAR BNE MTRX OSSEOGEN,SUP-2858500,CDM,C1713,HCPCS,0278,RC,,,,both,,,5331.72,3465.62,,,,,,,,,,,,,
HC Endovasc Tempory Vessel Occl,PX-3616162300,CDM,61623,CPT,0361,RC,,,,both,,,11772.00,7651.80,,,,,,,,,,,,,
SHEATH GUID L 10 CM DIA 5 FR GUIDEWIRE 0.035 IN SS HYDRPHLC,SUP-2890403,CDM,C1887,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SET DIL ESOPH 5/7/9/11/12.8/14/15MM STD -,SUP-2126408,CDM,C1726,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
STENT URET 7FR L28CM UROPS OBSTRUCTION,SUP-2312715,CDM,C2617,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
MAGGOT MED,SUP-2306595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
COIL EMB L30CM DIA10MM 360DEG SHP STD DETACH GDC 18,SUP-2365684,CDM,C1889,HCPCS,0278,RC,,,,both,,,6457.72,4197.52,,,,,,,,,,,,,
LEAD EXTENSION BLUE ARIA 72IN,SUP-2867350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
PLATE BNE LG RT DBL LISFRANC STRATUM,SUP-2497793,CDM,C1713,HCPCS,0278,RC,,,,both,,,6675.39,4339.00,,,,,,,,,,,,,
K WIRE FIX L4IN DIA0.045IN DBL TRCR,SUP-2319460,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
IMPLANT FACE W 57 X H 38 MM THK 9 MM PROJCT LG POLYETHYL,SUP-2883417,CDM,C1889,HCPCS,0278,RC,,,,both,,,1447.92,941.15,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STD 4X2 CM REGENERATIVE GRAFTJACKET NOW,SUP-2759443,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6449.47,4192.16,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 40X20 CM BIOLOGIC TISSUE MATRIX STERILE X,SUP-2838620,CDM,C1763,HCPCS,0278,RC,,,,both,,,74241.85,48257.20,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X22 MM,SUP-2343717,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
PATCH CV HEMSHLD L 3 X W 0.2 IN THK 0.76 MM POLYESTER BOV,SUP-2227620,CDM,C1768,CPT,0278,RC,,,,both,,,364.33,236.81,,,,,,,,,,,,,
SCREW SPNL L50MM OD6.5MM 30DEG TI POST ST VAR ANG CANN THRD,SUP-2230544,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA19 GA NDL DIA17 GA CE17TKFN CONT NRFIT,SUP-2936781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.31,59.35,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,PX-3606444600,CDM,64446,CPT,0360,RC,,,XU|LT|PO,both,,,2895.00,1881.75,,,,,,,,,,,,,
GRAFT SHFT FEM STRUCTURAL ALLGRFT FRZN 200MM,SUP-2307349,CDM,C1713,HCPCS,0278,RC,,,,both,,,5699.26,3704.52,,,,,,,,,,,,,
CATHETER GUID 6FR L100CM DIA0.071IN NYL SHFT EBU3.5,SUP-2295685,CDM,C1887,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM 18 MM POLYESTER BOV CLLGN STR,SUP-2227276,CDM,C1768,CPT,0278,RC,,,,both,,,1695.63,1102.16,,,,,,,,,,,,,
AUGMENT FEM BLK 10 MM POST THICKNESS HALF UNIV STD + CEM POS,SUP-2436144,CDM,C1776,CPT,0278,RC,,,,both,,,2540.89,1651.58,,,,,,,,,,,,,
IMPLANT BIO L 7 X W 20 CM FISH SKIN DERMAL SLD INTACT FLAT,SUP-2909270,CDM,Q4158,HCPCS,0636,RC,,,,both,,,17668.15,11484.30,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC IR 6FR 55CM 2 LUMAN RVS TAP 3276335,SUP-2632673,CDM,C1751,HCPCS,0278,RC,,,,both,,,417.93,271.65,,,,,,,,,,,,,
SHUNT SURG SM 120 CM PERF LEVEL 1.0 SNAP DELT,SUP-2628308,CDM,C1729,HCPCS,0272,RC,,,,both,,,4612.72,2998.27,,,,,,,,,,,,,
BRACE ORTHOPEDIC D RNG MED REG AD 8 IN RT ROLYANFIT,SUP-2325902,CDM,L3908,HCPCS,0274,RC,,,,both,,,51.65,33.57,,,,,,,,,,,,,
SCREW BNE L 28 MM DIA 4 MM FT CHMFR MIS HV,SUP-2896781,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SAW SURGICAL 800MM 0.81/0.91MM THK DIAMOND,SUP-2627607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.48,247.96,,,,,,,,,,,,,
SWAN GANZ PACEPORT OXIMETRY TD,SUP-2696592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.11,711.82,,,,,,,,,,,,,
LOCKING END CAP,SUP-2811090,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
COVER SCR HEX DISP FOR TWO STG SURG PROC,SUP-2319870,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SET INTRO ARW SHTH L 4 IN DIA 6 FR GUIDEWIRE L 45 CM DIA,SUP-2384381,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.16,46.90,,,,,,,,,,,,,
STEM FEM SEG 11 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449810,CDM,C1776,CPT,0278,RC,,,,both,,,11424.11,7425.67,,,,,,,,,,,,,
MATRIX BIO L 3 X W 3 CM SZ 16 SQCM FISH SKIN DERMAL 5/BX,SUP-2909362,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
EXTRACTOR STONE 1.7FR L115CM NIT PATENTED DSGN NGAGE,SUP-2171430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.92,495.25,,,,,,,,,,,,,
CURETTE KYPHOPLASTY SZ 3 DIA6.5MM WDG TIP FOR VERTPLSTY,SUP-2293447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.90,395.13,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvic/Le 1st Ord|BILATERAL PROCEDURE,PX-3613624500,CDM,36245,CPT,0361,RC,,,50,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
HC So Calcitionin,PX-3018230866,CDM,82308,CPT,0301,RC,,,,both,,,603.00,391.95,,,,,,,,,,,,,
SCREW SPNL MULTAXL 7.5X80 MM CANC CD HORZ TCS,SUP-2628366,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PIN SURG DRL TRNSVRS XLN 68 MM COMPRESS,SUP-2441835,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
COUNTERSINK SURG DIA3 4MM CANN QUIK REL,SUP-2319461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
SHEATH INTRO DIA 9 FR HEMOSTATIC VLV,SUP-2125359,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.96,45.47,,,,,,,,,,,,,
COLLAR CERV L AD H5XL21.5IN M DENS CNTCT CLSR FOAM W/ STOCK,SUP-2198741,CDM,L0120,HCPCS,0274,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
MESH SURG 25X36 CM FLX PHYSIOMESH DISP,SUP-2219749,CDM,C1781,HCPCS,0278,RC,,,,both,,,7440.54,4836.35,,,,,,,,,,,,,
IMPLANT OPHTH BCKL 2.5X6 MM CONVX TIRE SCLER STYL 286 SIL,SUP-2382004,CDM,C1784,HCPCS,0278,RC,,,,both,,,66.57,43.27,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME RT KNEE PCL L/TH S/CF ADJ OA,SUP-2914958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1467.98,954.19,,,,,,,,,,,,,
SCREW BNE 2.7MMX12MM CORT N CANN FULL THRD N ST DRL N LOK,SUP-2411013,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.96,37.67,,,,,,,,,,,,,
PLATE BONE RT DSTL DORS RAD TI FOR 1.8/2.4/2.7MM SCR,SUP-2191013,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.81,1708.73,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENESTRATED ADULT UNCUFFED ADAPTER STAINLE,SUP-2793417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.68,250.04,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN PC THE FIRM L 145 CM DIA 0.038 IN TAPR,SUP-2168189,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.99,49.39,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.435,SUP-2859999,CDM,C1713,HCPCS,0278,RC,,,,both,,,42511.52,27632.49,,,,,,,,,,,,,
MATRIXNEURO EMER SCR 1.8 MM ST LEN 5 MM TI ALLOY TAN PK OF,SUP-2181602,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.35,22.33,,,,,,,,,,,,,
GRAFT HUM TISS IL 12-14X10-12X7 MM CREST WDG IL STRL LF DISP,SUP-2632287,CDM,C1762,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
MICRO BONE PLATE DOUBLE Y SHAPE 8 HOLE CP TITANIUM,SUP-2677935,CDM,C1713,HCPCS,0278,RC,,,,both,,,537.25,349.21,,,,,,,,,,,,,
FIBER LSWER SINGLE USE 200U SLIMLINE SIS EZ,SUP-2724146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT MAGNA EASE MT OD 19 MM ID 18 MM,SUP-2214116,CDM,C1889,HCPCS,0278,RC,,,,both,,,19678.38,12790.95,,,,,,,,,,,,,
KIT PERFLUOROCARBON LIQ 7ML 23GA BLNT CANN FLTR 20GA 1 1/2IN,SUP-2110014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1206.83,784.44,,,,,,,,,,,,,
COMPONENT FEM SZ 8 R KNEE CO CHROM CEM CONSTRN REV LEGION,SUP-2346845,CDM,C1776,CPT,0278,RC,,,,both,,,18482.04,12013.33,,,,,,,,,,,,,
SCREW SPNL REDUCTION 4.5X25 MM THORLUM PEDCL TRPL LD PREF 2,SUP-2175469,CDM,C1713,HCPCS,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 2.7X46 MM 12/8 MM HIP 2 HOLE LCP,SUP-2799232,CDM,C1713,HCPCS,0278,RC,,,,both,,,2271.76,1476.64,,,,,,,,,,,,,
PLATE BNE 8 H BILAT WRST S STL SHT BEND FUS LO PROF LOK,SUP-2186123,CDM,C1713,HCPCS,0278,RC,,,,both,,,4415.59,2870.13,,,,,,,,,,,,,
PG PRO 18 GAUGE 8CM RT BASIC BIOPATCH,SUP-2613504,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
BRACE ANK OR FT L7-8IN CALF CIRC 15IN SM AD UNISX ACT W/ AMB,SUP-2332640,CDM,L4396,HCPCS,0274,RC,,,,both,,,202.53,131.64,,,,,,,,,,,,,
SYSTEM MIXER BONE CEMENT W/SHORT EXT TUBE PCD VERTAPLEX,SUP-2875968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1731.90,1125.73,,,,,,,,,,,,,
BLADE OSTEOTOM SZ 10 RAD DISP,SUP-2345748,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4X6 H BILAT HND T SHP NONCOMPRESSION,SUP-2267880,CDM,C1713,HCPCS,0278,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
PLATE BONE SM L91MM 7 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348994,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.93,904.75,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 7FRX12CM SHTH W/ LUER LCK 0.032,SUP-2355391,CDM,C1894,HCPCS,0272,RC,,,,both,,,66.73,43.37,,,,,,,,,,,,,
CLIP ENDOSCP 2.6X230 MM HEMSTAT,SUP-2313195,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
IMPLANT PENILE L18CM CYL INFL MINOCYCLINE RIFAMPIN,SUP-2140298,CDM,C1813,HCPCS,0278,RC,,,,both,,,19559.50,12713.67,,,,,,,,,,,,,
BLADE RETRACTOR RICHARDSON 0.75X1 IN BOOKWALTER,SUP-2490716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1596.69,1037.85,,,,,,,,,,,,,
BAR EXT FIX L50MM DIA6MM COMP FOR JET-X FIX SYS,SUP-2342910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,245.89,159.83,,,,,,,,,,,,,
CLAMP EXT FIX PIN UNIV,SUP-2749970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
MESH BIO PORCINE MTRX BRST TISS RECON 14CM LEN 3CM W,SUP-2113067,CDM,Q4130,HCPCS,0636,RC,,,,both,,,3275.02,2128.76,,,,,,,,,,,,,
PLATE 5HL 2.7X65MM,SUP-2464249,CDM,C1713,HCPCS,0278,RC,,,,both,,,962.50,625.62,,,,,,,,,,,,,
PLATE BONE LOK 79MML HLX6 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2588598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1364.33,886.81,,,,,,,,,,,,,
HC I&D Abscess Bartholin Gland,PX-4505642000,CDM,56420,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
VALVE AORT H16MM OD23MM ID23MM PROTRUSION 13MM PORCINE,SUP-2357530,CDM,C1889,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
HC M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb,PX-3128837700,CDM,88377,CPT,0312,RC,,,,outpatient,,,1050.00,682.50,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 6 MM RNG L 7 CM EPTFE STR STD,SUP-2396037,CDM,C1768,CPT,0278,RC,,,,both,,,2304.76,1498.09,,,,,,,,,,,,,
KIT BNE CEMENT SZ 40 44.8 GM PWDR 37.7 GM LIQ 20 ML PMMA MED,SUP-2916857,CDM,C1713,HCPCS,0278,RC,,,,both,,,6622.26,4304.47,,,,,,,,,,,,,
PLATE BNE L100MM 130DEG 4 H PELVIS BILAT S STL STD BRL RIG,SUP-2342580,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.73,2365.82,,,,,,,,,,,,,
FOOTSWITCH ELECSURG BPLR SINGLE FT NS LTX,SUP-2859252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3889.99,2528.49,,,,,,,,,,,,,
BATTERY VENT ASST L PT WAIST PK,SUP-2282573,CDM,Q0498,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X4.25 MM SS MCGEE,SUP-2312492,CDM,L8613,CPT,0278,RC,,,,both,,,283.29,184.14,,,,,,,,,,,,,
PIN FIX ANT CERV STR TEMP 25.4MM SKYLINE,SUP-2255674,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
POST EXT FIX DIA11MM STR OUTRIG MAG RESONANCE CONDITIONAL,SUP-2188506,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.74,211.73,,,,,,,,,,,,,
SCREW BNE L35MM DIA4.7MM CORT TI HDLSS COMPR ACUTRK 2,SUP-2106805,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX20 CM 3L RIFAMPIN SPECTRUM,SUP-2759978,CDM,C1751,HCPCS,0278,RC,,,,both,,,255.88,166.32,,,,,,,,,,,,,
PLATE BONE 4 HOLE 2X24 MM SAGITTAL SPLIT STRAIGHT TITANIUM,SUP-2838397,CDM,C1713,HCPCS,0278,RC,,,,both,,,995.69,647.20,,,,,,,,,,,,,
PLATE B1 CRANIOMAXILLOFACIAL THK1MM 12 H ORBIT TI TI LEV 1,SUP-2262688,CDM,C1713,HCPCS,0278,RC,,,,both,,,820.48,533.31,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE DBL Y SHP NEURO SCRW6 HOLE 16 MM,SUP-2681850,CDM,C1713,HCPCS,0278,RC,,,,both,,,905.95,588.87,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 65 CM 4 FR 0.038 IN BERN NONBRAIDED,SUP-2116850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,176.47,114.71,,,,,,,,,,,,,
SCREW BONE L10MM PAN FIX LUHR,SUP-2364709,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.26,13.82,,,,,,,,,,,,,
POST FIX BI-CORTICAL 4.5X40 MM KNEE,SUP-2431991,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SPLINT ORTHOGNATHIC 2 JAW W/ GENIOPLASTY OPS VSP,SUP-2862844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15693.72,10200.92,,,,,,,,,,,,,
POST GLENOID 20 MM SHOULDER MODULAR CENTRAL STERILE UNIVERS,SUP-2836551,CDM,C1776,CPT,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
KIT STPL BNE FIX BRDG 18MM LEG 18MM SPEEDTITAN BME,SUP-2194269,CDM,C1713,HCPCS,0278,RC,,,,both,,,3215.64,2090.17,,,,,,,,,,,,,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,6370000000,HCPCS,0637,RC,00713-0326-15,NDC,,both,15,GR,80.60,52.39,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO WIDE PLATE 12 PK,SUP-2935261,CDM,C1713,HCPCS,0278,RC,,,,both,,,9134.26,5937.27,,,,,,,,,,,,,
STAPLE INT 6.5 MM,SUP-2435346,CDM,C1713,HCPCS,0278,RC,,,,both,,,4523.96,2940.57,,,,,,,,,,,,,
RING FIX 180MM FULL USED IN STLTH REARFOOT,SUP-2400653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
PLATE BNE CRV MINI 2X1 MM CRANIOMAXILLOFACIAL 7 HOLE TI NS,SUP-2489623,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.90,331.43,,,,,,,,,,,,,
TEMPLATE SURG ANCHR SHT CASPIAN,SUP-2873698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
DRILL TWST L 7 MM DIA1.5 MM STP 5 MM SCREW DIA2 MM CONTRA,SUP-2883878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
FLUCONAZOLE (DIFLUCAN) IVPB,RX-4081084,CDM,J1450,HCPCS,0636,RC,25021-0184-82,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
FIXATOR EXT FIX 40 MM SIDEKCK CORETRAK,SUP-2464291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5677.12,3690.13,,,,,,,,,,,,,
PLATE BNE W12XL232MM THK3.7MM LNG 10 H ST PROX HUM S STL,SUP-2186022,CDM,C1713,HCPCS,0278,RC,,,,both,,,5046.70,3280.35,,,,,,,,,,,,,
MESH HERN SQ 1 20X20 CM MONOFILAMENT 3D TEXTILE VERSATEX,SUP-2752219,CDM,C1781,HCPCS,0278,RC,,,,both,,,749.46,487.15,,,,,,,,,,,,,
CATHETERIZATION KIT 9 FRX115 CM CV DL ARROWG+ARD +,SUP-2383375,CDM,C1751,HCPCS,0278,RC,,,,both,,,467.23,303.70,,,,,,,,,,,,,
GRAFT SFT TISS 20X30 MM BOV PERICARD MEMBRN COPIOS,SUP-2335282,CDM,C1762,CPT,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
APPLICATOR TRAY SPHR 5-6 CM MAMMOSITE,SUP-2239832,CDM,C1728,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT JEJUSTMY TB 18FR BLLN 5ML STOMA L45CM SIL SECURELOK R,SUP-2124608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,535.24,347.91,,,,,,,,,,,,,
CATHETER DRAINAGE TY 7.5 FR LCK INTRO SYS MARKER BND MAK-NV,SUP-2459609,CDM,C1729,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
ROD IM FOREARM TARGETING BASE,SUP-2525750,CDM,C1713,HCPCS,0278,RC,,,,both,,,4496.48,2922.71,,,,,,,,,,,,,
KIT ACCS PRT I 0-10CC W/ 20IN TBNG S STL CONN BND PRIMING,SUP-2119244,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM THK45UM AMNIO MEMBRN DEHYDR OMNI DIR,SUP-2340454,CDM,C1762,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
MESH SURG 10.5 X 20 CM SUTURE SZ 6-0 OVINE PGA REINF TISS,SUP-2914809,CDM,C1781,HCPCS,0278,RC,,,,both,,,11118.74,7227.18,,,,,,,,,,,,,
DISC BIOLOGIC ABSRB SCAFFOLD BIOFIBER 8MM,SUP-2388577,CDM,C1781,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
MESH MXLFCL 52X52 MM 0.6 MM FOIL PLLA-PGA STRL RESORB XG,SUP-2493356,CDM,C1713,HCPCS,0278,RC,,,,both,,,3354.87,2180.67,,,,,,,,,,,,,
PLATE BONE 8 H LT MEDL DSTL TIB S STL,SUP-2123160,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM KNOTLESS PEEK REELX STT,SUP-2366713,CDM,C1713,HCPCS,0278,RC,,,,both,,,1575.68,1024.19,,,,,,,,,,,,,
SHELL ACET SPIK 40 MM HIP REFLECTION,SUP-2434758,CDM,C1776,CPT,0278,RC,,,,both,,,5658.28,3677.88,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR EON RECHRG IPG 16 CHN,SUP-2355970,CDM,C1820,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
INSERT TIB REV KNEE RP BX CUT ATTUNE,SUP-2454416,CDM,C1776,CPT,0278,RC,,,,both,,,3322.12,2159.38,,,,,,,,,,,,,
SCREW BONE L26MM DIA5.5MM THRD L8MM STD CORT S STL PARTIALLY,SUP-2343632,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.52,253.19,,,,,,,,,,,,,
INTRODUCER SHTH MARKER TIP 6 FRX23 CM GRN PRELUDE,SUP-2467843,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
RESTRICTOR CEM DIA13MM INSERTED IN FEM MDLLRY CNL PERM DISPO,SUP-2435986,CDM,C1776,CPT,0278,RC,,,,both,,,115.40,75.01,,,,,,,,,,,,,
TRIAL HD 45MM HUM BPLR,SUP-2372579,CDM,C1713,HCPCS,0278,RC,,,,both,,,1911.38,1242.40,,,,,,,,,,,,,
STERILE WATER FOR INJECTION (MIXTURES ONLY),RX-430028,CDM,2500000003,HCPCS,0250,RC,00487-6105-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
BUR SURG CUT 23MM DIA SIZEIII F AESCULAP HILAN XS,SUP-2108776,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.38,204.35,,,,,,,,,,,,,
CANNULA SURG OD5.5 MM TAPR,SUP-2232076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
DRILL TWST L 50 MM DIA1.15 MM STP 6 MM DENT SHFT STRL DISP,SUP-2883227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.21,339.44,,,,,,,,,,,,,
PLATE BONE 95DEG 8 HOLE SUPRACONDYLAR VERSAFX II,SUP-2490642,CDM,C1713,HCPCS,0278,RC,,,,both,,,1914.65,1244.52,,,,,,,,,,,,,
INTRODUCER SHTH 16FR L37CM SHTH L32CM 2 KNOB GWIRE PEEL AWAY,SUP-2171218,CDM,C1892,HCPCS,0272,RC,,,,both,,,176.34,114.62,,,,,,,,,,,,,
HC Treat Tail Bone Fx,PX-4502720000,CDM,27200,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 3 1/2 IN DIA 3 MM,SUP-2264159,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCREW PIN HI FLX M HXLPE,SUP-2212708,CDM,C1776,CPT,0278,RC,,,,both,,,13073.77,8497.95,,,,,,,,,,,,,
SCREW BNE CAPT 135 DEG SHT BRL 130 MM HIP ANGLED TI,SUP-2472228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
TROCAR ENDOSCP L150MM DIA12MM BLDELSS OBT RADLUC STBL SL,SUP-2218265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
CRADLE BUTTON CORTICAL FEMORAL ADJUSTABLE GRAFTMAX,SUP-2824645,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.43,373.38,,,,,,,,,,,,,
KIT DISPOSABLES BIO-SUTURETAK,SUP-2121596,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
VALVE SHUNT L 13.4 MM PRESSURE SUPINE 10 CM H2O UPR 30 CM,SUP-2928867,CDM,C1889,HCPCS,0278,RC,,,,both,,,6204.42,4032.87,,,,,,,,,,,,,
FIBER LASER OMNIGUIDE ELEV ELITE,SUP-2225690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4251.56,2763.51,,,,,,,,,,,,,
MESH SURG W5XL10CM THK1MM BIOMATERIAL MYCROMESH,SUP-2395359,CDM,C1781,HCPCS,0278,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI 400XL ACTE 14FR DIA 15CM CRV EXTN TAPR,SUP-2610500,CDM,C1752,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BONE W9XL37MM AUG 6MM CO CHROM RIG FOR MAESTRO TOT WR,SUP-2407329,CDM,C1713,HCPCS,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
PIN FIX L40MM SET CBL RDY,SUP-2198052,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.75,514.64,,,,,,,,,,,,,
GRAFT HUM TISS L150MM DIA10MM FEM SHFT FRZN,SUP-2307348,CDM,C1762,CPT,0278,RC,,,,both,,,4627.83,3008.09,,,,,,,,,,,,,
PLATE BNE TI 8 H NONCOMPRESSION ORBIT RIM BILAT 12MM SCR H,SUP-2366227,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.27,428.53,,,,,,,,,,,,,
PLATE 25 ADAPTIVE II TRILOK DST RAD,SUP-2267959,CDM,C1713,HCPCS,0278,RC,,,,both,,,4299.29,2794.54,,,,,,,,,,,,,
SCREW ABSRBBLE 40MM DIA 54MML LOW PRFLE DRCT DRIVE ARTHRTK,SUP-2724044,CDM,C1725,HCPCS,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
TOBRAMYCIN 0.3 % OP OINT,RX-19769,CDM,6370000000,HCPCS,0637,RC,00078-0813-01,NDC,,both,3.5,GR,1260.00,819.00,,,,,,,,,,,,,
HEAD FEM DIA32MM MECTACER BIOLOX OPT SYS,SUP-2267357,CDM,C1776,CPT,0278,RC,,,,both,,,6141.84,3992.20,,,,,,,,,,,,,
ALLOGRAFT BNE RNG 13X14X11 MM,SUP-2787595,CDM,C1713,HCPCS,0278,RC,,,,both,,,2798.53,1819.04,,,,,,,,,,,,,
CATHETER BLLN DIL L17MM DIA6MM FRONTAL EM SKR NUVENT,SUP-2284114,CDM,C1726,HCPCS,0272,RC,,,,both,,,3389.00,2202.85,,,,,,,,,,,,,
PLATE BNE L242MM 12 H R LAT DST PERIARTC FEM S STL,SUP-2410534,CDM,C1713,HCPCS,0278,RC,,,,both,,,2359.68,1533.79,,,,,,,,,,,,,
PLATE BNE Y 3.5X87 MM CALCANEAL FOR SCR SM FRAG SYS SS NS,SUP-2466839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1272.99,827.44,,,,,,,,,,,,,
SPHERE EMBOLIZATION 2ML 100UM MIC MAR INSIDE SYR EMBOZENE,SUP-2855464,CDM,C1889,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
SUPPORT ORTH H8XL13IN D2 1/2IN CUSH MCKENZ SLM LN,SUP-2324239,CDM,L0642,HCPCS,0274,RC,,,,both,,,52.00,33.80,,,,,,,,,,,,,
BIT DRILL SURG CANN 4.7 MM PERC ELBW TRINKLE COMP SS,SUP-2198524,CDM,C1776,CPT,0278,RC,,,,both,,,869.37,565.09,,,,,,,,,,,,,
SCREW SPNL L12MM OD3.5MM TI CERVICOTHORACIC NONCANNULATED ST,SUP-2205770,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 35 CM DIA 4-7 MM EPTFE TRMPT GRAD WALL,SUP-2227244,CDM,C1768,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
ANCHOR SUT L14.7MM DIA6.5MM W/ TWO SZ 2 FIBERWIRE CRKSCR FT,SUP-2121554,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM BAL L15MM OD4MM DIL RX MRAIL,SUP-2140564,CDM,C1725,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
RETRIEVER THROMCTMY L 130 CM DIA 0.044 IN DSTL ACCS STRL,SUP-2365842,CDM,C1887,HCPCS,0272,RC,,,,both,,,3300.77,2145.50,,,,,,,,,,,,,
SPLINT KNEE L20IN FOR 32IN THGH UNIV FOAM 3 PC DSGN TRIMMED,SUP-2196754,CDM,L1830,CPT,0274,RC,,,,both,,,39.19,25.47,,,,,,,,,,,,,
PLATE BNE LCK 51 MM LT RADIAL 5 HOLE STYLOID 00235802805,SUP-2457581,CDM,C1713,HCPCS,0278,RC,,,,both,,,1676.63,1089.81,,,,,,,,,,,,,
URODYNAMICS LOOP CATHETER,SUP-2826944,CDM,C1726,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HC So1 Vdrl / Rpr,PX-3028659267,CDM,86592,CPT,0302,RC,,,,both,,,258.00,167.70,,,,,,,,,,,,,
ENTRADA NEEDLE 15CM 60 IN,SUP-2700479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
STEM RADIAL 9X2 MM DEMO,SUP-2798395,CDM,C1776,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GRAFT CORMATRIX EXTRACELLULAR MATRIX  2CM X 10CM,SUP-2848900,CDM,C1768,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SPLINT WR AD L FOR 7.5-8.5IN STRP L4IN VENT ELAS,SUP-2324481,CDM,L3908,HCPCS,0274,RC,,,,both,,,44.15,28.70,,,,,,,,,,,,,
PUSHER KNOT CVD SUT CUT SLT CANN DISP FAST FIX 360,SUP-2341129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.59,326.68,,,,,,,,,,,,,
K WIRE FIX L8IN DIA1.1MM BVL TIP SMOOTH SPADE PNT SPHERX,SUP-2311267,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 12CM AORTIC/ILIAC 28.5/14.5MM,SUP-2738005,CDM,C1768,CPT,0278,RC,,,,both,,,36279.56,23581.71,,,,,,,,,,,,,
INDOMETHACIN 100 MG RE SUPP,RX-159645,CDM,6370000000,HCPCS,0637,RC,73702-0140-71,NDC,,both,1,UN,1687.50,1096.87,,,,,,,,,,,,,
GRAFT VASC PTCH 10X5 CMX1 MM SFT TISS MESH TRIM GORTX,SUP-2458148,CDM,C1768,CPT,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
SCREW BNE L26MM DIA5MM S STL ST LOK FULL THRD T25 STARDRV,SUP-2184260,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.19,254.92,,,,,,,,,,,,,
COMPONENT TIB SZ 4 RT MEDL LT LAT FIX BEAR CEM PRESERVATION,SUP-2251284,CDM,C1776,CPT,0278,RC,,,,both,,,5856.10,3806.46,,,,,,,,,,,,,
PIN DRL RND END 3.1X76.2 MM FIX TRCR PT,SUP-2760729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.98,375.04,,,,,,,,,,,,,
BAG BLD TRNSFUS CONSOLIDATED VENTRICULAR ASST DEV BLK,SUP-2356005,CDM,Q0508,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM PEDCL REDUCTION UNIAXIAL,SUP-2926519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
ADAPTER HRT ALRM CTRL,SUP-2282559,CDM,Q0508,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
WIRE BRST LESION L10.7CM DIA20GA LOC DUALOK,SUP-2550496,CDM,C1819,HCPCS,0278,RC,,,,both,,,48.48,31.51,,,,,,,,,,,,,
SCREW TAP BIO-CORE INTERFERENCE 7MM,SUP-2633081,CDM,C1713,HCPCS,0278,RC,,,,both,,,1737.30,1129.24,,,,,,,,,,,,,
KNIFE SRGCL 30DG ANGLD RIGHT SCKLE STRGHT SHARP TIP LATEX FR,SUP-2674406,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.02,261.96,,,,,,,,,,,,,
TI MATRIXMANDIBLE 2X2 HOLE,SUP-2823041,CDM,C1713,HCPCS,0278,RC,,,,both,,,2582.65,1678.72,,,,,,,,,,,,,
RIFABUTIN 150 MG PO CAPS,RX-11290,CDM,6370000000,HCPCS,0637,RC,59762-1350-01,NDC,,both,1,UN,63.00,40.95,,,,,,,,,,,,,
PEN ISOLATOR ELECTRD L7MM BPLR TRANSPOLAR UNIDIR LESION MAXI] ATRICURE INC],SUP-2124461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
PLATE BNE L68MM 8 H BILAT S STL LOK COMPR LO PROF FOR 2.4MM,SUP-2186347,CDM,C1713,HCPCS,0278,RC,,,,both,,,1050.77,683.00,,,,,,,,,,,,,
HC Atomic Absrpj Spectroscopy Ea Analyte,PX-3008219066,CDM,82190,CPT,0300,RC,,,,inpatient,,,526.00,341.90,,,,,,,,,,,,,
DISSECTOR SURG US 26 CM CRV JAW CRDLSS STRL SONICISION 7 LF,SUP-2863484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 9 MMX15 CM 9 FRX120 CM HEPARIN VIABAHN,SUP-2396521,CDM,C1874,HCPCS,0278,RC,,,,both,,,10952.32,7119.01,,,,,,,,,,,,,
SCREW BNE SZ 25MMX26MM CANN,SUP-2243603,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.20,652.73,,,,,,,,,,,,,
CAGE SPNL 11 MM BENGAL,SUP-2256188,CDM,C1889,HCPCS,0278,RC,,,,both,,,6867.18,4463.67,,,,,,,,,,,,,
NAIL IM 16 MMX40 CM FEM M/DN,SUP-2198168,CDM,C1713,HCPCS,0278,RC,,,,both,,,1906.61,1239.30,,,,,,,,,,,,,
HC Monkeypox Dna (R),PX-3008759366,CDM,87593,CPT,0300,RC,,,,both,,,113.00,73.45,,,,,,,,,,,,,
IMPLANT HUM TISS L 2 X W 2 CM PLCNTA MEMBRN TRILAYER,SUP-2905510,CDM,Q4278,HCPCS,0636,RC,,,,both,,,4271.40,2776.41,,,,,,,,,,,,,
DRILL TWST OD5MM ADPT TARGETING DEV RADLUC,SUP-2413010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
HC Ivus Each Additional Vessel,PX-4819297900,CDM,92979,CPT,0481,RC,,,,both,,,758.00,492.70,,,,,,,,,,,,,
SPACER TIB H5MM SM PROX ENDO MOD M IMPL,SUP-2265091,CDM,C1776,CPT,0278,RC,,,,both,,,6524.92,4241.20,,,,,,,,,,,,,
COVER KIT 8X2 IN W/ 20 ML GEL FOR ULTRASOUND PRB SHEATHES,SUP-2417988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.97,213.18,,,,,,,,,,,,,
HC So Bile Acids Total,PX-3018223966,CDM,82239,CPT,0301,RC,,,,outpatient,,,65.00,42.25,,,,,,,,,,,,,
GRASPER SURG 3 PRNG 3.2 FRX115 CM CAPT,SUP-2835967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.79,391.81,,,,,,,,,,,,,
PROBE ENDO VW OPT,SUP-2392615,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 77 MM DIA 36 MM SHTH 22 FR SS,SUP-2171023,CDM,C1874,HCPCS,0278,RC,,,,both,,,16321.72,10609.12,,,,,,,,,,,,,
BENDING TEMPLATE FOR LOCKING TROCHANTER STABILIZATION PLATE,SUP-2548476,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.80,346.32,,,,,,,,,,,,,
PROBE ENDOSCP,SUP-2530891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,893.27,580.63,,,,,,,,,,,,,
NAIL INTRMDLLRY 10.5MM DIA 380MML TTNM ALLOY PRXML TBL ANTGR,SUP-2588059,CDM,C1713,HCPCS,0278,RC,,,,both,,,4585.15,2980.35,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD GLIDEPATH L 36 CM INSRTN L 31 CM,SUP-2613290,CDM,C1750,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
GUIDE WIRE SLEEVE PERC PINNING 1.6MM,SUP-2841337,CDM,C1769,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PROSTHESIS VOICE 2 VLV 20 FRX8 MM NS BLOM-SINGER,SUP-2242333,CDM,L8509,HCPCS,0272,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
DRESSING BIO L 7 X W 3 CM SZ 200 UM PORCINE SM INTEST,SUP-2905492,CDM,Q4103,HCPCS,0636,RC,,,,both,,,974.28,633.28,,,,,,,,,,,,,
BUTTON SUTURE CRADLE ADJ LOOP INFIN DISP,SUP-2846781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.03,1228.52,,,,,,,,,,,,,
INSERT TIB SZ 3-4 THK15MM STD LT POST STBL PRI NEUT RENASYS,SUP-2350489,CDM,C1776,CPT,0278,RC,,,,both,,,3358.42,2182.97,,,,,,,,,,,,,
STEM FEM L180MM OD10MM 140DEG TI POR PLSM SPRY CALCAR HIP,SUP-2406823,CDM,C1776,CPT,0278,RC,,,,both,,,16227.52,10547.89,,,,,,,,,,,,,
SPHERE GLEN 6+ MM 40 MM VERSA-DIAL,SUP-2435438,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
COMPONENT FEM SM RT KNEE ZNK LIBRA,SUP-2442387,CDM,C1776,CPT,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
CATHETER HD STR 20 CM 15 CM SINGLE VLV BASIC KT BIOFLO,SUP-2457748,CDM,C1750,HCPCS,0278,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 150 MM DIA 8 MM DEL SYS L 150 CM,SUP-2866193,CDM,C1876,HCPCS,0278,RC,,,,both,,,5704.81,3708.13,,,,,,,,,,,,,
ESTROGENS CONJUGATED 0.625 MG PO TABS,RX-9974,CDM,6370000000,HCPCS,0637,RC,00046-1102-81,NDC,,both,1,UN,31.90,20.73,,,,,,,,,,,,,
PLATE BNE SM W11XL100MM THK15MM 90DEG 4X8 H TI T SHP R ANG,SUP-2190940,CDM,C1713,HCPCS,0278,RC,,,,both,,,1842.55,1197.66,,,,,,,,,,,,,
PLATE BNE W9.2XL121MM THK1.3MM 100DEG 10 H TI TBLR FOR,SUP-2412030,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
PACK PHACO GAMMA STER 0.9MM 45DEG BAL FMS IRR ASPIR CENTURION,SUP-2916666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.26,672.92,,,,,,,,,,,,,
PLATE BONE THK2.8MM 8 H NONSTERILE STRNL TI STR MATRIXRIB,SUP-2181527,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.02,2591.56,,,,,,,,,,,,,
INTRODUCER HEMSTAS ULTIMUM 5FRX23CM SHTH W/ .038IN GWIRE,SUP-2355647,CDM,C1894,HCPCS,0272,RC,,,,both,,,384.65,250.02,,,,,,,,,,,,,
CLAMP EXT FIX PROCALLUS LRS,SUP-2570730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
SLEEVE POS DIA15MM UNIV SHLDR CO CHROM CEM PRI FOR HUM FRAC,SUP-2404537,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SET INTRO 14FR L70CM GWIRE 0038IN STNT POS COOK Z,SUP-2168375,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
MILL BNE MANUAL DISP,SUP-2430784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
CLAMP CRAN TEXT SM 13 MM FLAPFIX FOR EXT FIX TI STRL,SUP-2431408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1232.14,800.89,,,,,,,,,,,,,
SHEATH INTRO PERFRMR CKFLO L 13 CM DIA 5 FR GUIDEWIRE 0.038,SUP-2642108,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.57,81.62,,,,,,,,,,,,,
PIN FIX SKULL RADLUC WNG DSGN W/ FNGR GROOVES STRL DISP,SUP-2243876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.06,548.64,,,,,,,,,,,,,
PLATE BNE W16XL71MM 3 H L PROX HUM SHLDR S STL S3,SUP-2254093,CDM,C1713,HCPCS,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
ATROPINE SULFATE 1 % OP SOLN,RX-736,CDM,6370000000,HCPCS,0637,RC,00065-0817-01,NDC,,both,5,ML,272.10,176.86,,,,,,,,,,,,,
KIT INTRO PEELPRO L 14 CM DIA 7 FR PTFE TEARWY STD,SUP-2118930,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE BNE L180MM ALUMINUM BRDG FOR 5 8 RNG MAXFRAME,SUP-2255813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4358.51,2833.03,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L60CM 8 ELECTRD LAMITRODE,SUP-2356739,CDM,C1778,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
NAIL IM L350MM DIA10.5MM UNIV TIB TI ALLOY CANN LCK,SUP-2412957,CDM,C1713,HCPCS,0278,RC,,,,both,,,5598.62,3639.10,,,,,,,,,,,,,
CATHETER NEPHSTMY 6FR L20CM 0.035IN ALL PURP DRNGE W/ LOK,SUP-2381888,CDM,C1729,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
MATRIX BIO L 12 X W 10 CM FET BOV DERM DERMAL SLD STRL,SUP-2909316,CDM,Q4110,HCPCS,0636,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
BLADE RTRCTR RVL 50MML BLUNT VLT FANTRR CRVCL FSN DISTR TRA,SUP-2673084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.74,313.78,,,,,,,,,,,,,
SPLINT WR AD L 9IN LNG RT COT W/ STAY ELAS SUPP FOR,SUP-2324569,CDM,L3809,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
DEVICE VENT BIPAP AIRWY RESP VPAP III ST,SUP-2331930,CDM,C1713,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
LINER ACET OD48-52MM ID28MM 10DEG TOT UHMWPE PFC,SUP-2253281,CDM,C1776,CPT,0278,RC,,,,both,,,2696.63,1752.81,,,,,,,,,,,,,
CUP ACET CMNTLS FEM HIP PREMIER POROUS,SUP-2379160,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
ANCHOR SUTURE 1.4 MM KT STRL GRAPPLER,SUP-2749836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X17.5 MM WRST LCK CAP STRL FRDM,SUP-2852810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.04,975.03,,,,,,,,,,,,,
SCREW STRNL CLOSURE L 10 MM DIA2.7 MM STRL STERNALOCK XP,SUP-2894391,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.13,63.78,,,,,,,,,,,,,
PERFORATOR SURG 14X11X3 MM CRAN EASYDRILL,SUP-2432050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
PLATE BNE L 206 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 17 H 72466217N,SUP-2933196,CDM,C1713,HCPCS,0278,RC,,,,both,,,6074.02,3948.11,,,,,,,,,,,,,
PLATE BONE L97MM 4 HOLE TTNM LOW PRFLE LOK CMPRSSN,SUP-2476826,CDM,C1776,CPT,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.018 IN TAPR L 7 CM FLX TIP L 2,SUP-2167643,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.66,34.88,,,,,,,,,,,,,
BOLT L80MM DIA65MM PROX L10MM DST L24MM FUS SALVATION,SUP-2400722,CDM,C1713,HCPCS,0278,RC,,,,both,,,5184.14,3369.69,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM FRZN CRUSH CANC 800116,SUP-2743365,CDM,C1713,HCPCS,0278,RC,,,,both,,,6050.78,3933.01,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.7 MM CRANIOMAXILLOFACIAL ST 5PK,SUP-2884113,CDM,C1713,HCPCS,0278,RC,,,,both,,,1276.72,829.87,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ HIP ABDUCTN FLX EXTN CTRL,SUP-2421311,CDM,L2624,HCPCS,0272,RC,,,,both,,,1216.47,790.71,,,,,,,,,,,,,
BAND ANNULPLSTY SIMPLICI-T L 100 MM FLX STRL,SUP-2429903,CDM,C1713,HCPCS,0278,RC,,,,both,,,7755.80,5041.27,,,,,,,,,,,,,
INSERT SHOE ANK JT,SUP-2388172,CDM,L2180,HCPCS,0274,RC,,,,both,,,295.98,192.39,,,,,,,,,,,,,
KETAMINE HCL 10 MG/ML IJ SOLN,RX-4236,CDM,2500000003,HCPCS,0250,RC,65219-0184-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
HC So Aldolase,PX-3078208566,CDM,82085,CPT,0307,RC,,,,both,,,201.00,130.65,,,,,,,,,,,,,
PIN FIX HDLSS MIC 1.6X5 MM POLY-D-L-LACTIC ACID 525192504,SUP-2460985,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.94,174.81,,,,,,,,,,,,,
KIT DRL DIA2MM CONT COMPR IMPL W/O STP SPD,SUP-2194183,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
COMPONENT OP TBL CLARK SOCK,SUP-2360618,CDM,C1776,CPT,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
MESH BONE SM 0.6MM THK TTNM STNDRD PTTRN OUTSDE HOLE LATEX F,SUP-2501123,CDM,C1713,HCPCS,0278,RC,,,,both,,,4053.61,2634.85,,,,,,,,,,,,,
SCREW SET FOR PLATE HOLDER,SUP-2653725,CDM,C1713,HCPCS,0278,RC,,,,both,,,799.16,519.45,,,,,,,,,,,,,
CATHETER FOR ASCITES SHUNT 15.5FR VEN 60CM,SUP-2133691,CDM,C1729,HCPCS,0272,RC,,,,both,,,537.35,349.28,,,,,,,,,,,,,
BRACE SPNL KNGHT TAY HEAT MOLD FOR LO BK STRAIN POST LAM,SUP-2123927,CDM,L0456,HCPCS,0274,RC,,,,both,,,3837.08,2494.10,,,,,,,,,,,,,
DRESSING BIO W5XL5CM CLLGN SH 0.1% POLYHEXMETHYLENEBIGUANIDE,SUP-2314086,CDM,Q4196,HCPCS,0636,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
GUIDE SURG 3IN HUM CNL FINDER,SUP-2372566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1492.88,970.37,,,,,,,,,,,,,
CABLE ABLATION PMP SMARTABLATE COOLFLOW NS,SUP-2737878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 0.3 MM LP CONTOURED TI NS,SUP-2458757,CDM,C1713,HCPCS,0278,RC,,,,both,,,739.56,480.71,,,,,,,,,,,,,
HC Venography Canal Inferior,PX-3207582500,CDM,75825,CPT,0320,RC,,,,inpatient,,,3006.00,1953.90,,,,,,,,,,,,,
IMPLANT BIO TISS W13XL23MM TEND LIGMNT CLLGN STRP ABSRB,SUP-2388569,CDM,C1781,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
RING AND DRL GUID ASSEMB 35 MM PEEK,SUP-2400391,CDM,C1776,CPT,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
IMPLANT NSL L 70 X W 13 MM THK 2 MM SM POLYETHYL ARCH TRIM,SUP-2883445,CDM,C1889,HCPCS,0278,RC,,,,both,,,1300.53,845.34,,,,,,,,,,,,,
HYBRID HIP SYS,SUP-2212074,CDM,C1776,CPT,0278,RC,,,,both,,,12474.69,8108.55,,,,,,,,,,,,,
GRAFT GRAN PRO OSTEON 500 30CC,SUP-2413081,CDM,C1713,HCPCS,0278,RC,,,,both,,,4235.86,2753.31,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 10FR SS HYDRPHLC CORONARY,SUP-2385285,CDM,C1894,HCPCS,0272,RC,,,,both,,,306.15,199.00,,,,,,,,,,,,,
NEEDLE SUT PASS FLX DISP RP360,SUP-2366719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,698.52,454.04,,,,,,,,,,,,,
CANC SCREW STERILIZER 6.5X100 MM 16MM THREAD,SUP-2818178,CDM,C1713,HCPCS,0278,RC,,,,both,,,380.73,247.47,,,,,,,,,,,,,
URETEROSCOPE FLX FLD OF VW 100 DEG SHFT L 670 MM DSTL TIP,SUP-2909606,CDM,C1747,HCPCS,0272,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
PLATE BONE L12MM 12 H MAND TI LCK FOR 2MM SCR,SUP-2191230,CDM,C1713,HCPCS,0278,RC,,,,both,,,2916.75,1895.89,,,,,,,,,,,,,
CORKSCREW SPNL MINI HK CD HORZ M8,SUP-2290029,CDM,C1713,HCPCS,0278,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
ARTISS FROZEN SOLUTION 2ML,SUP-2827667,CDM,C9250,HCPCS,0636,RC,,,,both,,,580.40,377.26,,,,,,,,,,,,,
SCREW BNE L26MM DIA5MM CORT TI SELF DRL LOK FULL THRD HEX HD,SUP-2190330,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.91,412.69,,,,,,,,,,,,,
NAIL IM FEM ADOL 10X240 MM RT LAT ENTRY TI STRL NAIL-EX,SUP-2546423,CDM,C1713,HCPCS,0278,RC,,,,both,,,4308.21,2800.34,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L75CM BAL L40MM OD5MM GWIRE OD0.035IN,SUP-2266001,CDM,C1725,HCPCS,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
CAGE SPNL 14X12X10 MM ANTR CERV INTBDY FUSION PEEK MATISSE,SUP-2578103,CDM,C1889,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
SPLINT WRST FA UNIV L 8 IN,SUP-2276643,CDM,L3809,HCPCS,0272,RC,,,,both,,,14.22,9.24,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ 8IN LOOP LOK W STAY FIRM SUPP,SUP-2276657,CDM,L3808,HCPCS,0274,RC,,,,both,,,16.23,10.55,,,,,,,,,,,,,
PIN FIX 2X30MM COMPR,SUP-2414145,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7 MM STR STD WALL REINF,SUP-2525435,CDM,C1768,CPT,0278,RC,,,,both,,,866.99,563.54,,,,,,,,,,,,,
KIT STYL STEERING CAP PRECIS L70CM,SUP-2141935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 60 MM DIA 7 MM DEL SHTH,SUP-2934241,CDM,C1713,HCPCS,0278,RC,,,,both,,,7828.02,5088.21,,,,,,,,,,,,,
FIBER LASER 400 MH REUSE,SUP-2479649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2131.21,1385.29,,,,,,,,,,,,,
GRAFT BONE CORTICAL STRUT FD IRR,SUP-2875988,CDM,C1713,HCPCS,0278,RC,,,,both,,,2282.00,1483.30,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR STRP W/O JT PREFABRICATED INTFACE,SUP-2435783,CDM,L3924,HCPCS,0274,RC,,,,both,,,248.88,161.77,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 55 CM OD 6 FR GUIDEWIRE 0.038 IN,SUP-2168680,CDM,C1894,HCPCS,0272,RC,,,,both,,,121.83,79.19,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-142361,CDM,Q5106,HCPCS,0636,RC,00069-1305-10,NDC,,both,1,ML,65.10,42.31,,,,,,,,,,,,,
CATHETER ANGIO VEIN SEL 0.046 IN 5 FRX75 CM SIDE PRT IMPRESS,SUP-2798677,CDM,C1887,HCPCS,0272,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
CATHETER ATHRCTMY DIAMONDBACK 360 L 135 CM DIA1.25 MM SHTH 6,SUP-2159495,CDM,C1724,HCPCS,0278,RC,,,,both,,,11916.30,7745.59,,,,,,,,,,,,,
HYDROXYUREA 500 MG PO CAPS,RX-10236,CDM,6370000000,HCPCS,0637,RC,00904-6939-61,NDC,,both,1,UN,4.40,2.86,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST EXT PWR ELECTR FABRICATED,SUP-2435771,CDM,L3904,HCPCS,0274,RC,,,,both,,,8696.98,5653.04,,,,,,,,,,,,,
PROSTHESIS OSS BRACKMAN MOD 0.8X8 MM 3 MM TRIM WIRE TORP,SUP-2638109,CDM,L8613,CPT,0278,RC,,,,both,,,791.12,514.23,,,,,,,,,,,,,
BIT DRILL SURG DIA 3.5 MM MINI PK FOOTPRINT,SUP-2883117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
COIL NEUROVASCULAR L 70 CM DIA10 CM MICROCATHETER DIA,SUP-2898089,CDM,C1889,HCPCS,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X4.5 MM MCGEE SS,SUP-2637756,CDM,L8613,CPT,0278,RC,,,,both,,,275.06,178.79,,,,,,,,,,,,,
STIMULATOR NERVE STRL DISP NSS IB-STIM,SUP-2898795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
GRAFT BNE SUB L W5XH23XL16MM COMPRESSIBLE SPNG PROVIDE,SUP-2138504,CDM,C1713,HCPCS,0278,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
HEAD FEM DIA32MM NK L-3.5MM ALUMINA CERAMIC ON CERAMIC 12/14,SUP-2202657,CDM,C1776,CPT,0278,RC,,,,both,,,6050.78,3933.01,,,,,,,,,,,,,
INTRODUCER STEER 2 REACH 22.4MM CURL BI DIR W/ .032 GWIRE,SUP-2357598,CDM,C1894,HCPCS,0272,RC,,,,both,,,2656.13,1726.48,,,,,,,,,,,,,
PLATE BNE THK13MM 6 H LOK COMPR BILAT NEUT MAL ROTATIONAL,SUP-2107088,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BLADE RETRACTOR ABH 5X1 IN RENAL ALUM,SUP-2472281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1374.72,893.57,,,,,,,,,,,,,
DRILL TWST L83MM DIA1MM STRYKR END PROFYLE,SUP-2364171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.93,254.10,,,,,,,,,,,,,
MESH SYN ABD BIOMATERIAL N ABSRB EXP POLYTETRAFLUROETHYLENE 1DLMCP203] WL GORE AND ASSOCIATES INC],SUP-2395347,CDM,C1781,HCPCS,0278,RC,,,,both,,,8098.06,5263.74,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0258,RC,00990-7984-20,NDC,,both,250,ML,291.20,189.28,,,,,,,,,,,,,
EXPANDER TISS 12X17CM P12CM 1600CC RECT SMOOTH 2 STG INTEGRA,SUP-2328139,CDM,C1789,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
ALLOGRAFT BNE LG FRZN ASEP TIB SHFT,SUP-2867007,CDM,C1762,CPT,0278,RC,,,,both,,,5611.02,3647.16,,,,,,,,,,,,,
STEM HUM PRSS FT 125 DEG 7X115 MM SHLDR AEQUALIS,SUP-2715567,CDM,C1776,CPT,0278,RC,,,,both,,,10622.62,6904.70,,,,,,,,,,,,,
MESH SURG MXLFCL 85X50 MM SM GRID FOR 1.5 MM SCREW TI,SUP-2461550,CDM,C1713,HCPCS,0278,RC,,,,both,,,2694.06,1751.14,,,,,,,,,,,,,
FOIL DENTAL 25MMW X 25MML 01MM THK RESORB X LATEX FREE,SUP-2694436,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.43,683.43,,,,,,,,,,,,,
PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN,RX-145108,CDM,J0780,HCPCS,0636,RC,25021-0790-02,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER ANGIO 7FR L60CM 130DEG PLCMNT CUT AWAY COR SNUS,SUP-2420680,CDM,C1887,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PPICC PROVENA SOLO 3F SLEEVE TL,SUP-2613553,CDM,C1751,HCPCS,0278,RC,,,,both,,,630.48,409.81,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP SEMITENDINOSUS 920780,SUP-2867085,CDM,C1762,CPT,0278,RC,,,,both,,,4581.89,2978.23,,,,,,,,,,,,,
TALQUETAMAB-TGVS 40 MG/ML SC SOLN,RX-165051,CDM,J3055,HCPCS,0636,RC,57894-0470-01,NDC,,both,1,ML,33272.80,21627.32,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X50X3-6 MM SPNG FD 2 CANC,SUP-2717785,CDM,C1713,HCPCS,0278,RC,,,,both,,,9725.58,6321.63,,,,,,,,,,,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,0636,RC,60505-6157-00,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
OXYTOCIN 30 UNITS IN 500 ML INFUSION,RX-40850002,CDM,J2590,HCPCS,0636,RC,71285-6044-01,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
PUTTY 10.0CC DBM W/ RPM,SUP-2415795,CDM,C9359,HCPCS,0278,RC,,,,both,,,6515.50,4235.07,,,,,,,,,,,,,
PLATE BONE LCK L CRV LT 13 H TI PROX TIB PLATING SYS ALPS,SUP-2413718,CDM,C1713,HCPCS,0278,RC,,,,both,,,4163.64,2706.37,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZN CANC STRL 1-10MM 30CC,SUP-2165556,CDM,C1762,CPT,0278,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
LENS INTOCU +14.0 DIOPT L13.5MM DIA6MM AC D5.2MM 5DEG UV,SUP-2247675,CDM,V2632,HCPCS,0276,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 25X20 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838618,CDM,C1763,HCPCS,0278,RC,,,,both,,,46401.98,30161.29,,,,,,,,,,,,,
PLATE BONE 1.5MM BAR 16MM UNIV 2 H W/ TAB DOG NEURO III,SUP-2363623,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.44,310.99,,,,,,,,,,,,,
PLATE BNE 110 DEG PEDIATRIC 5X90 MM 23/15 MM HIP 3 HOLE LCP,SUP-2799110,CDM,C1713,HCPCS,0278,RC,,,,both,,,2459.72,1598.82,,,,,,,,,,,,,
ARM EXT FIX SHT REAR FT ARTC 3 ARTH SIDEKCK,SUP-2400622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 4-7 MM RNG L 5 CM EPTFE TAPR,SUP-2396103,CDM,C1768,CPT,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
PARTICLE EMB DIA 500-710 UM 1 CC PVA FOAM NONRADIOACTIVE FOR,SUP-2168482,CDM,C1889,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 40 CM DIA 4-7 MM SZ 5 CM EPTFE SFT,SUP-2266064,CDM,C1768,CPT,0278,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
DEXAMETHASONE 4 MG/ML IJ SOLN (MIXTURES ONLY),RX-4081237,CDM,J1100,HCPCS,0636,RC,67457-0423-12,NDC,,both,.5,ML,54.10,35.16,,,,,,,,,,,,,
PIN DRL L LNG DISP FOR 4.5/8.5MM BEAMING SYS,SUP-2223925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THN AMNIO PLCNTAL MEM PRO3 PLCNTA,SUP-2320321,CDM,C1713,HCPCS,0278,RC,,,,both,,,5000.45,3250.29,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 6 FRX22-30 CM 6 FR STRTCH VL,SUP-2491343,CDM,C2617,HCPCS,0278,RC,,,,both,,,507.99,330.19,,,,,,,,,,,,,
BOLT EXT FIX LNG CONN MR CONDITIONAL FOR DISTR OSTEOGENESIS,SUP-2179134,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.54,23.10,,,,,,,,,,,,,
PLATE BNE L69MM 3 H ST R SUP ANT CLAV TI LOK COMPR W LAT,SUP-2180853,CDM,C1713,HCPCS,0278,RC,,,,both,,,3063.51,1991.28,,,,,,,,,,,,,
SCREW INTFR L25MM OD9MM LACTOSORB POLYMER CORT KNEE CANN,SUP-2212862,CDM,C1713,HCPCS,0278,RC,,,,both,,,865.13,562.33,,,,,,,,,,,,,
BIT DRILL OD4MM CANNULATED,SUP-2878352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
CAGE SPNL 25X15X13 MM SABER,SUP-2256339,CDM,C1889,HCPCS,0278,RC,,,,both,,,10468.76,6804.69,,,,,,,,,,,,,
SLING GYN L 12 X W 1.1 CM POLYPRO MONOFILAMENT SHRT CAL-DS01BSL,SUP-2929667,CDM,C1771,HCPCS,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
INSERT ACET TAPR HIP M2A-MAGNUM,SUP-2137413,CDM,C1776,CPT,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.032 IN TAPR L 7 CM TIP L 2.5,SUP-2638698,CDM,C1769,HCPCS,0272,RC,,,,both,,,152.70,99.25,,,,,,,,,,,,,
SET SUPRPUB CATH 14FR L30CM NDL 15GA W/ MCOT CONN TUBE 1 W,SUP-2171109,CDM,C2627,HCPCS,0272,RC,,,,both,,,268.16,174.30,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM D CRV UNIDIR,SUP-2475051,CDM,C1732,HCPCS,0272,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
HC Cv Cath Plac WO Port>5yr (Tun),PX-3613655800,CDM,36558,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BONE L130MM 6 H LT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348222,CDM,C1713,HCPCS,0278,RC,,,,both,,,12640.07,8216.05,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.550,SUP-2860231,CDM,C1713,HCPCS,0278,RC,,,,both,,,53919.14,35047.44,,,,,,,,,,,,,
BASEPLATE TIB SZ 4+ UNIV TI ALLOY NP REV CEM STEM MOD SCR H,SUP-2304815,CDM,C1776,CPT,0278,RC,,,,both,,,7485.76,4865.74,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X9 MM 6 LOBE,SUP-2602068,CDM,C1889,HCPCS,0278,RC,,,,both,,,6458.98,4198.34,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 71 CM DIA13.8 FR CRV BEND 39 MM DIL,SUP-2616241,CDM,C1766,CPT,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
MESH SURG W9XL15CM ABSRB BIO-A,SUP-2395751,CDM,C1781,HCPCS,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
BOLT SPNL L30MM OD8MM TI CANC ANT THORLUM PEDCL ST FIX ANG,SUP-2292732,CDM,C1713,HCPCS,0278,RC,,,,both,,,4736.69,3078.85,,,,,,,,,,,,,
PLATE BONE W5.1XL30MM THK1MM 6 H RT HND T LO PROF FOR,SUP-2417077,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.65,700.47,,,,,,,,,,,,,
BIT DRL SLD 3.5 MM ALIGNX,SUP-2433775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
PLATE BNE LCK 217 MM RT DSTL LAT HUM PERIARTICULAR 15 HOLE,SUP-2525156,CDM,C1713,HCPCS,0278,RC,,,,both,,,3146.25,2045.06,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L15MM IBT 1 STP OSTEO INTRO,SUP-2293661,CDM,C1894,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
PLATE BNE STR MINI REG 2X0.6 MM 8 HOLE LP FOR SCR TI STRL,SUP-2497344,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.26,231.57,,,,,,,,,,,,,
HC X-Ray Femur 1 View,PX-3207355100,CDM,73551,CPT,0320,RC,,,,outpatient,,,267.00,173.55,,,,,,,,,,,,,
MAXCESS MAS TLIF 2 KT ACC,SUP-2310439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
PLATE BNE L 2-2.5X34X1 MM 18 MM LT 2X2 HOLE TLTS BSSO TI,SUP-2467215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.88,718.82,,,,,,,,,,,,,
BUTTON SUT DIA12MM TI FOR PRI BKUP FIBERWIRE FIX OF ACL PCL,SUP-2122820,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SCREW BNE CANN 7X115 MM FT SS NS,SUP-2183895,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
GRAFT DERM HYDRATED THCK ACELLULAR DERM IMPL ALLGRFT L7XW2CM,SUP-2307457,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1674.00,1088.10,,,,,,,,,,,,,
GRAFT DURA PTCH 12X12 CM DURAMATER,SUP-2321735,CDM,C1713,HCPCS,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA10 MM EPTFE STR TW N RING,SUP-2396359,CDM,C1768,CPT,0278,RC,,,,both,,,3702.06,2406.34,,,,,,,,,,,,,
KIT MICROPUNCTURE MINISTICK MAX  4FR X 10CM STIFF .018 NITINOL ECHOGENIC NEEDLE 2.75IN,SUP-2849609,CDM,C1894,HCPCS,0272,RC,,,,both,,,71.91,46.74,,,,,,,,,,,,,
SUPPORT WRST PUL LACE CLOSURE UNIV LT PROCARE QUICK-FIT,SUP-2195780,CDM,L3931,HCPCS,0274,RC,,,,both,,,34.32,22.31,,,,,,,,,,,,,
ALLOGRAFT BNE PARTICULATE 250-1000 MH 0.5 CC CANC ORAGRAFT,SUP-2740778,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.93,142.95,,,,,,,,,,,,,
RING EXT FIX 2/3 220 MM CARBON DFS DYNAFIX,SUP-2534572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
BASEPLATE GLEN HD DIA44MM REG BILAT UHMWPE PEGGED PRESSFIT,SUP-2193839,CDM,C1776,CPT,0278,RC,,,,both,,,3899.06,2534.39,,,,,,,,,,,,,
PASSER SUTURE SIDE LOAD QUATTRO GTS,SUP-2745503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
INSERT TIB RP FEM KNEE CEM,SUP-2249577,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
HC US Fetal Evaluation-Limited,PX-4027681500,CDM,76815,CPT,0402,RC,,,,both,,,744.00,483.60,,,,,,,,,,,,,
GRAFT VASC VLV 27 MM AORT ROTATABLE STENT MSTR SER,SUP-2356715,CDM,C1889,HCPCS,0278,RC,,,,both,,,20045.76,13029.74,,,,,,,,,,,,,
PLATE SPNL OD 32MM L100MM UNIV TI ANT OCCIPITAL 3 H TEMPLT,SUP-2286686,CDM,C1713,HCPCS,0278,RC,,,,both,,,7220.43,4693.28,,,,,,,,,,,,,
CATHETER ABLATN RF SYS OPN IRRIG INTELLANAV MIFI,SUP-2424674,CDM,C1732,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SUMMIT 6/7 STD NK SEG W/COLLAR,SUP-2515382,CDM,C1776,CPT,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
BIT DRILL SURG L 296 MM DIA 3.2 MM PANGEA SPNL SYS STRL,SUP-2900803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,877.63,570.46,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 45 CM DIA 6 MM STR TW STRL,SUP-2396307,CDM,C1768,CPT,0278,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
CATH REPROC EP STRBL DECAPLR 2-5-2MM MED CRV 5FR 110CM,SUP-2526275,CDM,C1730,HCPCS,0272,RC,,,,both,,,865.67,562.69,,,,,,,,,,,,,
CATHETER GUID AMPLATZER TREVISIO L 80 CM DIA 8 FR SHTH OD,SUP-2558646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2408.38,1565.45,,,,,,,,,,,,,
CATHETER CTRL VEN AD 7FR L60CM POLYUR 3 LUMN N TUNNELED,SUP-2383988,CDM,C1751,HCPCS,0278,RC,,,,both,,,925.23,601.40,,,,,,,,,,,,,
BLADE SURG SAW SAG S STL 750MM LEN 75MM CUT DEPTH 250MM W,SUP-2364340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,168.18,109.32,,,,,,,,,,,,,
TRAY HEMO DYLS OR HD 12FR L20CM STR CATH VEN STYL KINK,SUP-2126525,CDM,C1752,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
STAPLE STR ASSEMB 25MM X 20MM,SUP-2321574,CDM,C1713,HCPCS,0278,RC,,,,both,,,4318.60,2807.09,,,,,,,,,,,,,
BRACE LUMBAR TLSO BODY JACKET,SUP-2388144,CDM,L0486,HCPCS,0274,RC,,,,both,,,5013.48,3258.76,,,,,,,,,,,,,
HC Debride Skin and Subcu|PBB CHARGE,PX-4501104200,CDM,11042,CPT,0450,RC,,,PBB,both,,,1247.00,810.55,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X14 MM SS NS,SUP-2183908,CDM,C1713,HCPCS,0278,RC,,,,both,,,804.56,522.96,,,,,,,,,,,,,
SYSTEM TKR SZ 2-5 HNG LINK ASMBLY LEGION,SUP-2346313,CDM,C1776,CPT,0278,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
GUIDEWIRE VASC SPLASHWIRE L 180 CM DIA 0.018 IN STD STR,SUP-2665480,CDM,C1769,HCPCS,0272,RC,,,,both,,,160.45,104.29,,,,,,,,,,,,,
PLATE BNE L 48 X W 8 MM THK 3.3 MM SCREW DIA2.7 MM DISTANCE,SUP-2908131,CDM,C1713,HCPCS,0278,RC,,,,both,,,1031.99,670.79,,,,,,,,,,,,,
SNARE ENDO L350CM DIA2.4MM STD OVL POLYP DISP SH THROW,SUP-2360309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
INSERT TIB SZ 2-3 THK11MM KNEE HNG ROT PLATFRM LEGION,SUP-2346655,CDM,C1776,CPT,0278,RC,,,,both,,,6493.52,4220.79,,,,,,,,,,,,,
SCREW BNE L9MM DIA2.3MM CORT HND TI HEXALOBE MULTISCR,SUP-2106772,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
STAPLER INT CIR MED THCK 25 MM 3/3.5/4 MM TRI-STAPLE PUR EEA,SUP-2858011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3328.56,2163.56,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0258,RC,00409-7101-66,NDC,,both,50,ML,38.30,24.89,,,,,,,,,,,,,
BAR EXT FIX 6MM OFFSET FOR JET-X EXT FIX,SUP-2342917,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1385.84,900.80,,,,,,,,,,,,,
SCREW BNE L 80 MM DIA2.4 MM TI ST LCK T7 DRV NS VLP,SUP-2931896,CDM,C1713,HCPCS,0278,RC,,,,both,,,394.76,256.59,,,,,,,,,,,,,
CLAMP EXT FIX HLD FOR 1.6MM K WIRE MINI FIX,SUP-2188693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2052.71,1334.26,,,,,,,,,,,,,
GRAFT VASC L80CM ID8MM STRTCH THN WALLED INTERING,SUP-2395853,CDM,C1768,CPT,0278,RC,,,,both,,,5089.94,3308.46,,,,,,,,,,,,,
CATHETER CV KT 12 FRX16 CM 3L LG BOR FOR HI VOL INFUSION,SUP-2763356,CDM,C1751,HCPCS,0278,RC,,,,both,,,413.22,268.59,,,,,,,,,,,,,
BUTTON FIX L14MM RND TWO PC FOR ACL RECON TIGHTROPE ABS,SUP-2121394,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
GRAFT HUM TISS L 1 X W 1 CM XS AMNIO MEMBRN RESRB AIR DRY,SUP-2913446,CDM,Q4173,HCPCS,0636,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX8 CM DL J TIP RIFAMPIN SPECTRUM,SUP-2759965,CDM,C1751,HCPCS,0278,RC,,,,both,,,348.04,226.23,,,,,,,,,,,,,
"HC Tolerance Test, Addit.",PX-3018295200,CDM,82952,CPT,0301,RC,,,,inpatient,,,72.00,46.80,,,,,,,,,,,,,
INBONE  POLY SZ 6 11MM SULCUS,SUP-2470049,CDM,C1776,CPT,0278,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
BASEPLATE TIB XSM SZ 2 AP39MM ML64MM UNIV KNEE CEM NONBEADED,SUP-2377183,CDM,C1776,CPT,0278,RC,,,,both,,,4376.53,2844.74,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK-X L 100 CM DIA 6 FR 2 CM 8 MM,SUP-2659818,CDM,C1725,HCPCS,0272,RC,,,,both,,,1841.77,1197.15,,,,,,,,,,,,,
INTRODUCER TUBE SET 28 FR PERC SET CIAGLIA BLU RHINO,SUP-2760021,CDM,C1769,HCPCS,0272,RC,,,,both,,,938.80,610.22,,,,,,,,,,,,,
GRAFT HUM TISS AMNION PTCH 10X10 CM AMNIO TISS MEMBRN CYGNUS,SUP-2422823,CDM,Q4170,HCPCS,0636,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PLATE BONE TRAPEZOIDAL SMALL 1 MM RIGHT SUBCONDYLAR 4 HOLE M,SUP-2837776,CDM,C1713,HCPCS,0278,RC,,,,both,,,3129.95,2034.47,,,,,,,,,,,,,
MESH TISS L 20 X W 25 MM HYAFF-11 P100 TBA MULTIFILAMENT PET,SUP-2901902,CDM,C1781,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
IMPLANT OP RM UNIV PLT 10MM DOGB,SUP-2321540,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
PIN FIX L40MM DIA2.5MM ELBW CO CHROM AXIS FOR STBL SYS IJS,SUP-2340230,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
CANNULA SURG LAG SCREW SHT CEPHALOMEDULLARY,SUP-2471456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1055.67,686.19,,,,,,,,,,,,,
CAGE SPNL L12XW12XH11MM 4 LOBE MESH L ANAT FOOTPRINT MOD,SUP-2317731,CDM,C1889,HCPCS,0278,RC,,,,both,,,5658.28,3677.88,,,,,,,,,,,,,
WIRE FIX DIA1.4MM BLNT FOR MIS SPINE TELLURIDE K,SUP-2137004,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SUPPORT ORTHOT MTCRPL HND ADJ FIT PREFABRICATED,SUP-2435778,CDM,L3917,HCPCS,0272,RC,,,,both,,,272.08,176.85,,,,,,,,,,,,,
PLATE BNE L 132 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 12 H 72440612,SUP-2933388,CDM,C1713,HCPCS,0278,RC,,,,both,,,2641.84,1717.20,,,,,,,,,,,,,
ROD IM DIA5MM COMPR FOR ARTH NAIL SYS PANTA 2,SUP-2417301,CDM,C1713,HCPCS,0278,RC,,,,both,,,3423.98,2225.59,,,,,,,,,,,,,
BIT DRL 4.5X35 MM ALLOFIT,SUP-2448646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
ROD REPROC EXT FIX 11X650 MM MR CARBON FIBER NS,SUP-2188678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
WALKER PT L DIAB,SUP-2276715,CDM,L4387,HCPCS,0274,RC,,,,both,,,257.67,167.49,,,,,,,,,,,,,
SNARE ENDOSCP HELCL LOOP 0.014 INX180 CM 4 MM MIC ELITE,SUP-2606013,CDM,C1773,HCPCS,0272,RC,,,,both,,,6179.52,4016.69,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX2 CM BLLN BUTTON SIL CLR MINI 1,SUP-2754575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,702.17,456.41,,,,,,,,,,,,,
CATHETER PICC AD 4FR L55CM SGL LUMN NRS PWR INJ N COAT CT,SUP-2125634,CDM,C1751,HCPCS,0278,RC,,,,both,,,624.55,405.96,,,,,,,,,,,,,
BAND SCLER W2.5XL125MM THK0.6MM SIL CIR CERCLAGE PERM BCKL,SUP-2213473,CDM,C1784,HCPCS,0278,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
WASHER FOR NUT 17.5/11.8MM STERILE,SUP-2761699,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.04,132.63,,,,,,,,,,,,,
BUR SURG CARB DMND RND N FLUT STRL 3.0MM 39MML,SUP-2361984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
DEVICE PRESSURE MONITOR INT ABD STRL LF,SUP-2427953,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.80,249.47,,,,,,,,,,,,,
PLATE BNE T 4.5X199 MM 10 HOLE LCP,SUP-2569412,CDM,C1713,HCPCS,0278,RC,,,,both,,,694.25,451.26,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME 120CM 5FR DAMATO QPLR,SUP-2700029,CDM,C1730,HCPCS,0272,RC,,,,both,,,245.64,159.67,,,,,,,,,,,,,
PLATE SPNL L8-14MM 4 H LAT FULL CVR FOR MOD FIX SYS,SUP-2415816,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA 5 MM EPTFE FLX STD WALL SM BEAD,SUP-2761500,CDM,C1768,CPT,0278,RC,,,,both,,,3368.22,2189.34,,,,,,,,,,,,,
SCREW CORT 3.5MM DIAX28MM LNG,SUP-2198416,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.36,49.63,,,,,,,,,,,,,
PLATE BNE L 38 MM SCREW DIA 4.5 MM ST LCK NS EVOS,SUP-2931229,CDM,C1713,HCPCS,0278,RC,,,,both,,,851.41,553.42,,,,,,,,,,,,,
PLATE BNE THK 1 MM ADV 7 MM SCREW DIA2 MM MINI RT,SUP-2883213,CDM,C1713,HCPCS,0278,RC,,,,both,,,1815.33,1179.96,,,,,,,,,,,,,
SCREW BONE CNNLTD 45MM DIA W/INSTRMNT CASE NON ST,SUP-2721263,CDM,C1713,HCPCS,0278,RC,,,,both,,,7596.51,4937.73,,,,,,,,,,,,,
HC Insert Impella Device,PX-3613399900,CDM,33999,CPT,0361,RC,,,,both,,,668.00,434.20,,,,,,,,,,,,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,0636,RC,71288-0409-05,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
TIGHTROPE II RT RECON IB,SUP-2718075,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
TRIAL TIB 11MM ANTR POST LIP,SUP-2364861,CDM,C1776,CPT,0278,RC,,,,both,,,463.31,301.15,,,,,,,,,,,,,
KIT INSRT DIA2.4MM PERC INCL DISP 17GA SPNL NDL 1.1MM NIT,SUP-2121599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
RONGEUR SURG KERRISON 40 DEG 2 MM,SUP-2115015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SMASH L 80 CM DIA 5 FR BALLOON L 2 CM,SUP-2118776,CDM,C1725,HCPCS,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 2X3 HOLE TITANIUM LIGHT GREEN MATRIX,SUP-2842242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1445.03,939.27,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 250-125 MG PO TABS,RX-22992,CDM,6370000000,HCPCS,0637,RC,16714-0476-01,NDC,,both,1,UN,21.40,13.91,,,,,,,,,,,,,
VEST PT SURG ASST CERV HALO,SUP-2265013,CDM,L0810,HCPCS,0274,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
RXG FOIL52X52MM T06MM SM HOLES,SUP-2669331,CDM,C1713,HCPCS,0278,RC,,,,both,,,3591.91,2334.74,,,,,,,,,,,,,
CATHETER DIL 6FR L180CM BLLN INFLATED 36-40.5-45FR L8CM ES,SUP-2149683,CDM,C1726,HCPCS,0272,RC,,,,both,,,539.42,350.62,,,,,,,,,,,,,
SUPPORT KNEE HALF RND,SUP-2324295,CDM,L1810,HCPCS,0272,RC,,,,both,,,113.20,73.58,,,,,,,,,,,,,
KIT TMPLT STRL DISP MOTOBAND CP DYNAMET,SUP-2893259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
TUBE GASTSTMY 18FR L3.4CM 1 STP BTTN,SUP-2149754,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SHEATH INTRO SAFSHTH DIA 9.5 FR STRL,SUP-2458215,CDM,C1894,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SCREW BONE L7MM DIA1.5MM CORT CRANIOMAXILLOFACIAL TI ST FULL,SUP-2188927,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
CAP PROTCT FOR 2.5MM K WIRE,SUP-2188573,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.35,102.93,,,,,,,,,,,,,
DEVICE THROMCTMY ALPHAVAC 20 DEG CANN L 77 CM DIA22 FR ACCS,SUP-2862979,CDM,C1757,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
BUR SURG OD8.0MM LNG DMND ECOURSE RND N FLUT STRL FOR TPS,SUP-2363384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,256.35,166.63,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB III BRL STD STRL DISP HI-LINE XS,SUP-2929291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.90,237.83,,,,,,,,,,,,,
SPATULA SURG L32CM FOR SUCT IRRIG,SUP-2361198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.94,302.86,,,,,,,,,,,,,
BRACE FT HEEL FTDROP AND PRSS REL CNTRCT REG AD UNIV UNISX,SUP-2326319,CDM,L4396,HCPCS,0274,RC,,,,both,,,200.52,130.34,,,,,,,,,,,,,
PLATE BNE ROT CORRECTION 1.5/2X32 MM 2X5 HOLE SS STRL,SUP-2568764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2457.43,1597.33,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1.5 CC ADIPOSE MTRX RENUVA HD,SUP-2761880,CDM,C1762,CPT,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
PLATE BONE CURVED 3.5X190 MM 16 HOLE RECONSTRUCTION FOR SCRE,SUP-2836673,CDM,C1713,HCPCS,0278,RC,,,,both,,,4523.01,2939.96,,,,,,,,,,,,,
HC CT Chest W/O Contrast,PX-3527125000,CDM,71250,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
SEALANT SURG 13 YR DURA AUTOSPRAY ADHERUS,SUP-2381862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2437.64,1584.47,,,,,,,,,,,,,
CHECKMATE VALVE ADJUSTMENT SYSTEM PROSA,SUP-2821806,CDM,C1889,HCPCS,0278,RC,,,,both,,,1254.62,815.50,,,,,,,,,,,,,
SPACER SPNL TI IMPL H33 TO 39MM 0DEG M XPAND,SUP-2229150,CDM,C1821,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
GRAFT HUM TISS 2ML 160MG AMNIO MEM PARTICULATE INJ AMNIOFIX,SUP-2305721,CDM,V2790,HCPCS,0278,RC,,,,both,,,6265.87,4072.82,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,PX-3616449000,CDM,64490,CPT,0361,RC,,,50,both,,,4864.00,3161.60,,,,,,,,,,,,,
KIT RELF CRPL TUNN SURG,SUP-2166902,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.14,299.74,,,,,,,,,,,,,
NAIL IM SHT 130 DEG 10 MM HIP FRAC SYS STRL CHIMAERA,SUP-2646593,CDM,C1713,HCPCS,0278,RC,,,,both,,,5353.48,3479.76,,,,,,,,,,,,,
BASKET STONE RETRV L120CM DIA12MM SHTH 1.9FR NIT POLYAMIDE,SUP-2139280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,695.16,451.85,,,,,,,,,,,,,
STENT COR OTW 0.014 IN 3X28 MM 135 CM TAXUS,SUP-2140724,CDM,C1874,HCPCS,0278,RC,,,,both,,,8258.20,5367.83,,,,,,,,,,,,,
BLADE SAW 54.6MMW X 40MML F/REPEAT STERNOTOMY HALL STERILE,SUP-2586285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.28,54.78,,,,,,,,,,,,,
LEAD NERVE STIM 50 CM 3-4 TRL LINEAR,SUP-2765577,CDM,C1778,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
HC Special Doses Verification,PX-3337733100,CDM,77331,CPT,0333,RC,,,,both,,,672.00,436.80,,,,,,,,,,,,,
BIT DRL L125MM OD3.6MM GRY TIP W/O STP NONRADIOLUCENT BI,SUP-2373944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
AUGMENT ACET OD50MM ID52MM THK15MM GRIPTION TF REV PINN,SUP-2250126,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
STENT CORONARY L 14 MM DIA 4 MM SS OTW STRL,SUP-2140495,CDM,C1876,HCPCS,0278,RC,,,,both,,,4107.12,2669.63,,,,,,,,,,,,,
SCREW BNE CANN 2X6 MM LAG PARTIALLY THRD TI DK BLU,SUP-2392831,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
KIT VERSACOSS ACCESS  LARGE,SUP-2740412,CDM,C1769,HCPCS,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
SUTURE DURASTAT DURAL REPAIR,SUP-2601077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
BUR SURG DIA 4 MM DIAMOND COARSE 2 RNG STRL DISP ELAN 4,SUP-2929478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.31,258.90,,,,,,,,,,,,,
HARVESTING SET 6.5 MM MOSAICPLASTY DISP,SUP-2849112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
HC So Cystatin C,PX-3018261066,CDM,82610,CPT,0301,RC,,,,outpatient,,,80.00,52.00,,,,,,,,,,,,,
PLATE BNE STR NAR 4.5X215 MM 13 HOLE 2 COMPR FOR SCR SS NS,SUP-2479158,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.33,410.36,,,,,,,,,,,,,
TISSUE FRZ DRY IL CREST WDG 10-12MM THCK 6-9MMW 14-20MML,SUP-2307520,CDM,C1713,HCPCS,0278,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 90 CM DIA 0.035 IN TAPR L 15 CM,SUP-2638728,CDM,C1769,HCPCS,0272,RC,,,,both,,,176.03,114.42,,,,,,,,,,,,,
CATHETER DRAINAGE 13X25 MMX120 CM ANTIBIO IMPREG ARES,SUP-2280104,CDM,C1729,HCPCS,0278,RC,,,,both,,,1336.23,868.55,,,,,,,,,,,,,
SET IMPL PELV INT FIX W/ ST SCR,SUP-2183094,CDM,C1713,HCPCS,0278,RC,,,,both,,,175289.21,113937.99,,,,,,,,,,,,,
STEM RADIAL ELBW KATALYST,SUP-2610316,CDM,C1776,CPT,0278,RC,,,,both,,,9239.61,6005.75,,,,,,,,,,,,,
BLADE SURG ULTRA AGGRESSIVE MINI 2.7 MM + FMS VUE,SUP-2624807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,234.87,152.67,,,,,,,,,,,,,
SCREW BNE L10MM OD2MM THRD L5MM TI BRK OFF MONSTER BITE,SUP-2320987,CDM,C1713,HCPCS,0278,RC,,,,both,,,977.33,635.26,,,,,,,,,,,,,
PLATE BNE 1ST METATARSOPHALANGEAL 7 DEG STD RT STRATUM,SUP-2499410,CDM,C1713,HCPCS,0278,RC,,,,both,,,5438.48,3535.01,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 BLLN L15MM IBT 1ST FRAC OSTEO INTRO,SUP-2293626,CDM,C1894,HCPCS,0272,RC,,,,both,,,8415.20,5469.88,,,,,,,,,,,,,
ORTHOSES THERMOPLASTIC ACROMIOCLAVICULAR SHLDR PREFABRICATED,SUP-2319133,CDM,L3670,HCPCS,0274,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
INTRODUCER VASC 4FR L6CM DIL L2.5CM RADPQ W/O CRV HEMSTAT,SUP-2385179,CDM,C1894,HCPCS,0272,RC,,,,both,,,67.51,43.88,,,,,,,,,,,,,
GRAFT NRV REP L3CM DIA1.5MM TYP 1 CLLGN ABSRB SEMIPERMEABLE,SUP-2244347,CDM,C9352,HCPCS,0278,RC,,,,both,,,4337.69,2819.50,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 30 CC FD CANC,SUP-2205399,CDM,C1889,HCPCS,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
INTRODUCER TUBE SET 80 FR PERC ADV SET CIAGLIA BLU RHINO,SUP-2759757,CDM,C1769,HCPCS,0272,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
COMPONENT TIB SZ 2 CO CHROM FOR CEM USE SALTO TALARIS,SUP-2123857,CDM,C1776,CPT,0278,RC,,,,both,,,21925.05,14251.28,,,,,,,,,,,,,
AMMONIUM LACTATE 12 % EX CREA,RX-17997,CDM,6370000000,HCPCS,0637,RC,00904-5983-48,NDC,,both,140,GR,21.50,13.97,,,,,,,,,,,,,
SCREW BONE L10MM DIA1.5MM STD CORT TI NCANNULATED N ST N,SUP-2188915,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.92,61.70,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00264-7510-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
IMPLANT ORBIT INFERIOR 2/3 LT MEDPOR,SUP-2366499,CDM,C1713,HCPCS,0278,RC,,,,both,,,11802.88,7671.87,,,,,,,,,,,,,
ADAPTER ASPRTN ENDSCPC ULTRSND NDLE RX LOK DVCE CMPTBLE FPL,SUP-2676537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,54.92,35.70,,,,,,,,,,,,,
PLATE FOOT LK L PLT LT,SUP-2701953,CDM,C1713,HCPCS,0278,RC,,,,both,,,1688.06,1097.24,,,,,,,,,,,,,
LEVEL NEURO ST MESH SPCLTY PTTSBRGH SMCRCLE NEURO SCRW54 X 3,SUP-2707411,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.20,1060.93,,,,,,,,,,,,,
MICROCATHETER INFUSION PROWLER 27 L 150 CM OD 3/2.6 FR ID,SUP-2257682,CDM,C1887,HCPCS,0272,RC,,,,both,,,3172.59,2062.18,,,,,,,,,,,,,
ROD DISTR 120MML CRBN WGRVE FRGD EXTRNL DISTR RED III,SUP-2669817,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.77,904.65,,,,,,,,,,,,,
TAP SURG CANN 3.5 MM STRL,SUP-2194152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
BIT DRL TWST 1.5X20 MM 6 MM W/ STP DENT LATCH LEVEL 1 DISP,SUP-2475244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.24,318.01,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM OD0035IN 3MM TIP CRV RAD PTFE MOVABLE,SUP-2167917,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
BLADE SURG 62MM ACET REV SYS EZOUT,SUP-2365141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
ARMSTRONG R VENT TUBE 114MM BLUE FLPL,SUP-2669498,CDM,L8699,HCPCS,0278,RC,,,,both,,,45.88,29.82,,,,,,,,,,,,,
BIT DRL OD1.5MM DENT FGS,SUP-2365168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
PLATE BNE H0.6MM 6X2 H UP FACE G TI 3D LEIBINGER UNIV 2,SUP-2366269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1211.57,787.52,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.516,SUP-2860033,CDM,C1713,HCPCS,0278,RC,,,,both,,,39414.54,25619.45,,,,,,,,,,,,,
GRAFT BIO TISS W8XL12CM THK08 17MM THCK STRUCTURAL,SUP-2307478,CDM,Q4128,HCPCS,0636,RC,,,,both,,,9281.59,6033.03,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 28 HOLE-STERILE,SUP-2546109,CDM,C1713,HCPCS,0278,RC,,,,both,,,3924.91,2551.19,,,,,,,,,,,,,
HC US Extrem Limited Nonvasc,PX-4027688200,CDM,76882,CPT,0402,RC,,,,both,,,1227.00,797.55,,,,,,,,,,,,,
BLADE CVD 4.5MM INCIS + ELITE PLAT,SUP-2349223,CDM,C1713,HCPCS,0278,RC,,,,both,,,460.54,299.35,,,,,,,,,,,,,
STEM FEM L150MM OD10.5MM TI POR IM STR CEM LNG BODY MOD,SUP-2405799,CDM,C1776,CPT,0278,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
CROSSBAR SPNL FIX 3 MM SET SCR REPL OZAT DAYTONA,SUP-2709431,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 7/20 MM 6 FRX195 CM PUL TYP,SUP-2475924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1116.96,726.02,,,,,,,,,,,,,
PLATE BONE L301MM 16 H LCK COMPR FOR 4.5MM SCR PERI-LOC L,SUP-2348445,CDM,C1713,HCPCS,0278,RC,,,,both,,,7812.48,5078.11,,,,,,,,,,,,,
CATHETER ANGIO AD L80CM DIA5FR 0.038IN HYDRPHLC SOS OMNI 2,SUP-2117797,CDM,C1887,HCPCS,0272,RC,,,,both,,,47.73,31.02,,,,,,,,,,,,,
HANDPIECE SUCTION IRRIGATION PULSED TRMPT SURGFLX WAVE XP,SUP-2313619,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VISIA AF MRI VR SURESCAN W 51 X H 64 MM D,SUP-2282425,CDM,C1722,HCPCS,0275,RC,,,,both,,,32046.84,20830.45,,,,,,,,,,,,,
SCREW BNE ST 3.5X26 MM LCK W/ STARDRV RECESS,SUP-2569717,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.44,63.99,,,,,,,,,,,,,
RISPERIDONE 1 MG PO TABS,RX-18313,CDM,6370000000,HCPCS,0637,RC,68084-0272-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CLAMP EXT FIX OPT FASTFRAME,SUP-2498315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER GUID FUBUKI L 120 CM DIA 0.043 IN COAT L 105 CM,SUP-2858325,CDM,C1887,HCPCS,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRAFT HUM TISS XSM W9XL15CM THK07 14MM THN ACELLULAR,SUP-2307600,CDM,Q4128,HCPCS,0636,RC,,,,both,,,15751.97,10238.78,,,,,,,,,,,,,
PLATE BNE MESHED LG 0.6 MM MXLFCL NEURO 250065309,SUP-2525644,CDM,C1713,HCPCS,0278,RC,,,,both,,,4469.60,2905.24,,,,,,,,,,,,,
PLATE BONE STRL BARBELL FOR 2.7MM SCR VLP,SUP-2349944,CDM,C1713,HCPCS,0278,RC,,,,both,,,3380.84,2197.55,,,,,,,,,,,,,
CUBE EXT FIX 120 MM UBER,SUP-2898471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
BIT DRL DIA2.5MM FLUT SH NAVIGATED,SUP-2364163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1806.63,1174.31,,,,,,,,,,,,,
PROBE SRGCL SKLLRN 65NL SINUS BDD GRDTD W/MRKR,SUP-2706954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,458.66,298.13,,,,,,,,,,,,,
STEM FEM SZ 20 L190MM 131DEG HIP CO CHROM POR STD CLLR STR,SUP-2345222,CDM,C1776,CPT,0278,RC,,,,both,,,19389.50,12603.17,,,,,,,,,,,,,
WASHER ORTH 4 MM FOR PROV TISS TRABECULAR MTL,SUP-2437273,CDM,C1713,HCPCS,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
PLATE FOOT CRV 4 HL RT,SUP-2473511,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
GRAFT VASC IMPRA L 15 CM DIA 3-6 MM EPTFE STP STD WALL N,SUP-2761527,CDM,C1768,CPT,0278,RC,,,,both,,,814.36,529.33,,,,,,,,,,,,,
"HC So Aldosterone, Serum|REPEAT CLINICAL DIAGNOSTIC LABORATORY TEST",PX-3018208866,CDM,82088,CPT,0301,RC,,,91,both,,,341.00,221.65,,,,,,,,,,,,,
BRACE ANK FT M AD WOM SHOE 7-9 STRP 2IN LT UNISX,SUP-2324848,CDM,L4350,HCPCS,0272,RC,,,,both,,,98.22,63.84,,,,,,,,,,,,,
GRAFT VASC BOR SZ 28MM MAX SKRT L28MM DIA36MM BODY 15CM,SUP-2384986,CDM,C1768,CPT,0278,RC,,,,both,,,6157.54,4002.40,,,,,,,,,,,,,
WIRE FIX L450MM OD3.2MM S STL DBL END SMOOTH DBL SHRP TIP K,SUP-2371037,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
BIT DRL HALF PIN DIA 6 MM NONSTEP NS DISP,SUP-2933689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1562.50,1015.62,,,,,,,,,,,,,
STENT ENDOPROS L15CM DIA6MM CATH 7FR L75CM BAL DIA6MM,SUP-2396551,CDM,C1874,HCPCS,0278,RC,,,,both,,,11523.80,7490.47,,,,,,,,,,,,,
WALKER POSTOP SM AD F ANK BILAT FIX UNISX TRAUM MAXTRAX,SUP-2197140,CDM,L4350,HCPCS,0274,RC,,,,both,,,83.15,54.05,,,,,,,,,,,,,
FIBER LSR HOLM 1000 DISP,SUP-2225592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
INSERT TIB PS 1 10 MM KNEE PROVEN GEN-FLEX,SUP-2359100,CDM,C1776,CPT,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
WAND ARTHSCP WRK L3IN SHFT DIA0.8MM TIP DIA1MM 0DEG SLIM LN,SUP-2341981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
PLATE BNE W14XL85MM THK3.8MM 4 H R TIB L SHP BTTRS L ANG S,SUP-2185775,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
TIP ASPIR THRD ADPT ULTRAFLOW STTL,SUP-2110009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
CATHETER GUID ANGLED 0.018 IN 150 CM SUPP 3 MARKER NAVICROSS,SUP-2435371,CDM,C1887,HCPCS,0272,RC,,,,both,,,700.53,455.34,,,,,,,,,,,,,
HC L-Spine Min 4 Views,PX-3207211000,CDM,72110,CPT,0320,RC,,,,both,,,825.00,536.25,,,,,,,,,,,,,
WASHER ORTHOPEDIC LIGMNT ANCHR W/ SCR,SUP-2449901,CDM,C1713,HCPCS,0278,RC,,,,both,,,3080.34,2002.22,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 10 CM DIA 6 MM EPTFE CARBON STR N,SUP-2761535,CDM,C1768,CPT,0278,RC,,,,both,,,1469.61,955.25,,,,,,,,,,,,,
CAP PRICE,SUP-2212308,CDM,C1713,HCPCS,0278,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
COLLAR CERV L H3XL18IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335995,CDM,L0120,HCPCS,0272,RC,,,,both,,,17.68,11.49,,,,,,,,,,,,,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,6370000000,HCPCS,0637,RC,50742-0515-30,NDC,,both,1,UN,238.50,155.02,,,,,,,,,,,,,
CATHETER DRAIN 14F 25CM STD LOOP W/ RADIOPAQUE MRKR BND PG,SUP-2659162,CDM,C1729,HCPCS,0272,RC,,,,both,,,224.20,145.73,,,,,,,,,,,,,
IMPLANT OSS L6.6MM HD DIA4X3MM 1.15MM CANN BLK MID EAR HA,SUP-2312563,CDM,L8613,CPT,0278,RC,,,,both,,,1440.69,936.45,,,,,,,,,,,,,
CLAMP PIN 2-BAR 45MMXTRAFIX,SUP-2205436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3867.70,2514.00,,,,,,,,,,,,,
REAMER SURG OD41MM S STL ACET SPHR CUTTINGEDGE,SUP-2361869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,677.61,440.45,,,,,,,,,,,,,
SCREW BNE L75MM DIA4MM CORT S STL ST NONCANNULATED,SUP-2183709,CDM,C1713,HCPCS,0278,RC,,,,both,,,137.66,89.48,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.7 MM PATELLAR STAGGERED STRL EVOS,SUP-2932873,CDM,C1713,HCPCS,0278,RC,,,,both,,,8835.96,5743.37,,,,,,,,,,,,,
BIT DRL L380MM DIA35MM W O STP CALIB JCBS CHK,SUP-2188816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.31,1040.85,,,,,,,,,,,,,
SIGMA HP UNI FEM DEFCT SHM 1MM,SUP-2513393,CDM,C1776,CPT,0278,RC,,,,both,,,3871.62,2516.55,,,,,,,,,,,,,
SPLINT WR INSTABILITY INJ LT PED COCK UP SM,SUP-2211572,CDM,C1821,HCPCS,0278,RC,,,,both,,,22.80,14.82,,,,,,,,,,,,,
PLUG MESH M ANCHR 4CM RIM 5CM 3D THERMOFORMED FLAT,SUP-2220111,CDM,C1781,HCPCS,0278,RC,,,,both,,,704.87,458.17,,,,,,,,,,,,,
CATHETER HD INT ACCS JUG,SUP-2269565,CDM,C1750,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
PLATE BNE SET FOR SM LOWER EXTREMITY PERI-LOC,SUP-2351409,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
PLATE BNE L 77 MM SCREW DIA 4.5 MM 4 H SS NAR COMPR NLCK,SUP-2933822,CDM,C1713,HCPCS,0278,RC,,,,both,,,1543.94,1003.56,,,,,,,,,,,,,
PLATE BONE L40MM 3 HOLE RCNSTRCTN 35MM SCREW UNVRSL LOK SSTM,SUP-2498369,CDM,C1713,HCPCS,0278,RC,,,,both,,,1159.16,753.45,,,,,,,,,,,,,
SCREW SPNL L40MM DIA7MM CANC POST PEDCL THORLUM TI SIDE OPN,SUP-2193575,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
ELECTRODE ELECSURG ENDOTHERMAL ARTHSCP TACS,SUP-2314078,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PIN BNE SM NON-THREADED BB-TAK,SUP-2423858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
MGII KNEE TIB ART SURF A/P LIP GHJK/ BLU 9MM,SUP-2501963,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
BIT DRL 11 MM NS 7080610,SUP-2730588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.26,481.82,,,,,,,,,,,,,
IMMOBILIZER KNEE L20IN AD 1 SZ FIT MOST UNIV WRP ARND OPN,SUP-2196742,CDM,L1830,CPT,0272,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
INTRODUCER LD L14CM OD8FR GWIRE OD0038IN PACEMKR DI LOCK DIL,SUP-2357074,CDM,C1894,HCPCS,0272,RC,,,,both,,,27.63,17.96,,,,,,,,,,,,,
HC Prog Eval Dual Lead Icd,PX-4809328300,CDM,93283,CPT,0480,RC,,,,both,,,132.00,85.80,,,,,,,,,,,,,
RETRACTOR SURG W12XH8MMXL3CM SELF RET MEDL OR LAT BLNT,SUP-2393985,CDM,C1894,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
BLOCK I/B II CCK TIB 54X10MM,SUP-2205965,CDM,C1776,CPT,0278,RC,,,,both,,,5875.57,3819.12,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 15CM 5MM 120CM 7FR HEPARIN,SUP-2719622,CDM,C1768,HCPCS,0278,RC,,,,both,,,11818.96,7682.32,,,,,,,,,,,,,
DEVICE COMPR PLASMAFLOW,SUP-2787593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BNE CRV NAR 4.5 MM 20 HOLE SS NS LCP,SUP-2178065,CDM,C1713,HCPCS,0278,RC,,,,both,,,4209.04,2735.88,,,,,,,,,,,,,
LENGTHENER EXT FIX L 50 MM MINI KT,SUP-2885172,CDM,C1713,HCPCS,0278,RC,,,,both,,,6850.04,4452.53,,,,,,,,,,,,,
VALVE SHUNT LUMBAR PERITONEAL TALL CHLD AD 91 CM YEL,SUP-2257215,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
SLEEVE KNEE SM L13IN FOR 155 18IN NEOPRENE OPN PAT EXTRA LEN,SUP-2196828,CDM,L1820,HCPCS,0274,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
PLATE TI VA-LCKNG CALCANEAL W/TABS LG 2.7MM 70MM LEFT-STER,SUP-2547008,CDM,C1713,HCPCS,0278,RC,,,,both,,,3873.16,2517.55,,,,,,,,,,,,,
ANCHOR SUTURE BIOCOMP SWIVELOCK STRL DISP FIBERTAK,SUP-2882190,CDM,C1713,HCPCS,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
STENT COLON Z-STENT L 8 CM FLARED END 35 MM SHFT 25 MM INTRO,SUP-2169504,CDM,C1877,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE COMPRSS CRV VARIAX 11HL,SUP-2695728,CDM,C1713,HCPCS,0278,RC,,,,both,,,3082.70,2003.75,,,,,,,,,,,,,
SUPPORT NEW EDGE CLAVICLEXL,SUP-2324200,CDM,L3670,HCPCS,0272,RC,,,,both,,,115.96,75.37,,,,,,,,,,,,,
INTRODUCER ENGAGE TR 4FRX12CM SHTH W/ SS STD 0.025 IN GWIRE,SUP-2355809,CDM,C1894,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
HEAD FEM MOD 3+ MM 12/14 32 MM CONSTRN TAPR COCR FRDM,SUP-2441358,CDM,C1776,CPT,0278,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
CATHETER GUID AL3 7 FR VKG OPTMA,SUP-2103949,CDM,C1887,HCPCS,0272,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
KIT IMPLANT XPRESS CITRELOCK 5MM X 15MM,SUP-2787791,CDM,C1713,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
STENT BILI COMPASS BDS L 5 CM DIA 7 FR GUIDEWIRE 0.035 IN,SUP-2863655,CDM,C2625,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
GUIDEWIRE SURG L410MM DIA1.6MM S STL FULL THRD SGL END,SUP-2186891,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.97,98.13,,,,,,,,,,,,,
COMPONENT FEM CR 67.5 MM RT KNEE POROUS COCR AGC,SUP-2406027,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PUNCH ARTHSCP OD34MM 90DEG L STR SHFT ROTARY TIP SER 1,SUP-2120932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
GRAFT BNE 10ML SIL SOD CA PHOS OXIDE RECTANG CONT RESRB,SUP-2368192,CDM,C1713,HCPCS,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
VALVE SHUNT REG ADJ MAG RESONANCE CONDITIONAL STRL STRATAMR,SUP-2910697,CDM,C1889,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
SET CATH 5FR L10CM NDL 21GA L7CM GWIRE L40CM DIA0.018IN NIT,SUP-2170559,CDM,C1894,HCPCS,0272,RC,,,,both,,,79.60,51.74,,,,,,,,,,,,,
DRILL SURG 4.5/5.5 MM SUTURE ANCHR,SUP-2857744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
CUP ACET OD54MM ID24MM HIP UHMWPE TPLR REV FOR TOT,SUP-2404276,CDM,C1776,CPT,0278,RC,,,,both,,,6468.40,4204.46,,,,,,,,,,,,,
PLATE BONE THK2MM 12 H MAND BLU TI STR FOR 2/2.3MM SCR,SUP-2136806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
HEAD FEM PRSS FT HIP OXINUM R3,SUP-2351418,CDM,C1776,CPT,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
MARKER BX BRST F/ULTRASOUND GUID W/ 14 G SYS V-MARK 15 GX10,SUP-2120152,CDM,A4648,CPT,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,6370000000,HCPCS,0637,RC,45802-0730-32,NDC,,both,1,UN,2.40,1.56,,,,,,,,,,,,,
HC Bx Breast Add Lesion Strtctc,PX-3611908200,CDM,19082,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW BNE 4.5X30 MM,SUP-2243199,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.26,379.77,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM XK CHRONIC STD 16FR DIA 24CM,SUP-2613303,CDM,C1750,HCPCS,0278,RC,,,,both,,,1526.51,992.23,,,,,,,,,,,,,
HC So Hla II Typing 1 Locus Lr,PX-3108137666,CDM,81376,CPT,0310,RC,,,,inpatient,,,143.00,92.95,,,,,,,,,,,,,
PLATE BNE L 130 MM SCREW DIA 3.5 MM 10 SHFT H SS MTPHSEAL VA,SUP-2907571,CDM,C1713,HCPCS,0278,RC,,,,both,,,3382.72,2198.77,,,,,,,,,,,,,
IMPLANT CRANIOMAXILLOFACIAL W58XL56MM THICKNESS 15MM POLYETH,SUP-2366486,CDM,C1713,HCPCS,0278,RC,,,,both,,,3625.76,2356.74,,,,,,,,,,,,,
BIT DRL L14MM OD2MM W/O STP NONRADIOLUCENT,SUP-2353296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
MESH SURG W12XL14IN UNCOATED MFIL POLYPR ABSRB HYDRGEL LO,SUP-2125904,CDM,C1781,HCPCS,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
MESH HERN DIA8IN CIR W/ PRE ATTCH LO PROF BLLN AND ECHO PS,SUP-2125919,CDM,C1781,HCPCS,0278,RC,,,,both,,,3937.56,2559.41,,,,,,,,,,,,,
BLADE SAW W12.5MM D70MM CUT THK0.94MM BRASSELER HUB RECIP,SUP-2244432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,272.55,177.16,,,,,,,,,,,,,
PSN REV STRAIGHT SMOOTH STEM EXT 12X175MM,SUP-2508769,CDM,C1776,CPT,0278,RC,,,,both,,,4044.32,2628.81,,,,,,,,,,,,,
RING EXT FIX HALF 80 MM ALUM RINGFIX,SUP-2365295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 30X10MM,SUP-2461400,CDM,C1713,HCPCS,0278,RC,,,,both,,,5601.76,3641.14,,,,,,,,,,,,,
SCREWDRIVER SURG SD2 FOR BCI 602 IMPL STRL DISP,SUP-2905148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GRAFT EVAR L124MM DIA16X13MM CATH 14FR LIMB DST DSGN C DEL,SUP-2295245,CDM,C1768,CPT,0278,RC,,,,both,,,15621.50,10153.97,,,,,,,,,,,,,
SCREW SET REPL FOR KATALYST BPLR RADIAL HD,SUP-2852034,CDM,C1776,CPT,0278,RC,,,,both,,,1104.90,718.18,,,,,,,,,,,,,
VALVE CSF STD AD FIN CATH STAINLESS STL CONN WHT DP,SUP-2852665,CDM,C1889,HCPCS,0278,RC,,,,both,,,3591.88,2334.72,,,,,,,,,,,,,
PLATE BNE W10.1XL70MM 6 H BILAT TI LO PROF RIG LOK COMPR,SUP-2191091,CDM,C1713,HCPCS,0278,RC,,,,both,,,1657.04,1077.08,,,,,,,,,,,,,
PLATE BNE PED W23XL159MM 90DEG 7 H ST DST CNDYL FEM S STL LO,SUP-2177214,CDM,C1713,HCPCS,0278,RC,,,,both,,,3082.79,2003.81,,,,,,,,,,,,,
ANCHOR SUT OD2.9MM ABSRB 1 SZ 2 PRELD ULTRABRAID STRL STR,SUP-2341671,CDM,C1713,HCPCS,0278,RC,,,,both,,,762.49,495.62,,,,,,,,,,,,,
SHELL ACET OD58MM PRESSFIT PRI UNIV MLRY HD,SUP-2408828,CDM,C1776,CPT,0278,RC,,,,both,,,6336.52,4118.74,,,,,,,,,,,,,
PIN EXT FIX L 230 MM DIA 4 MM OAL AO CONN SMTH DRL TIP NS,SUP-2899256,CDM,C1713,HCPCS,0278,RC,,,,both,,,682.17,443.41,,,,,,,,,,,,,
IMPLANT HUM TISS L 7 X W 7 CM AMNIO MEMBRN LYOPRESERVED,SUP-2905520,CDM,Q4133,HCPCS,0636,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
BIT DRL W/ CENTERING SL FOR 2.2 MM SURELOCK ALL SUTURE ANCHR,SUP-2608903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.49,475.47,,,,,,,,,,,,,
MESH HERN ELLIPSE 10X8 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855265,CDM,C1781,HCPCS,0278,RC,,,,both,,,25371.20,16491.28,,,,,,,,,,,,,
PLATE BNE 8 H NONSTERILE L TI EXT H SHP LOK COMPR W SHT THRD,SUP-2180915,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.40,892.71,,,,,,,,,,,,,
PLATE BNE THK0.6MM 6 H MAND TI T LO PROF FOR 2MM SCR MINI,SUP-2262942,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.38,166.65,,,,,,,,,,,,,
GUIDEWIRE VASC H2O L 150 CM DIA 0.018 IN NIT COR HYDRPHLC,SUP-2302582,CDM,C1769,HCPCS,0272,RC,,,,both,,,147.42,95.82,,,,,,,,,,,,,
CATHETER HD DL 11.5 FRX20 CM RAULERSON INT JUG DUOFLO,SUP-2269578,CDM,C1752,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BNE L 306 MM SCREW DIA 4.5 MM 15 H RT DSTL FEM STRL,SUP-2931181,CDM,C1713,HCPCS,0278,RC,,,,both,,,12348.05,8026.23,,,,,,,,,,,,,
GRAFT DURA W1XL1IN REABSORBABLE MTRX SUB FOR SFT TISS REP ID1101] INTEGRA LIFESCIENCES CORP],SUP-2244077,CDM,C1763,HCPCS,0278,RC,,,,both,,,648.91,421.79,,,,,,,,,,,,,
CANNULA ART 1/4 IN 10 CM PEDIATRIC 10 FRX22.9 CM BIO-MEDICUS,SUP-2473526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
GUIDE WIRE 5/1.6MM,SUP-2548457,CDM,C1769,HCPCS,0272,RC,,,,both,,,2215.52,1440.09,,,,,,,,,,,,,
BUR SURG CRAN 7 MM CORNERSTONE,SUP-2363390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.68,283.19,,,,,,,,,,,,,
PLATE BNE T SM 45 MM LT DSTL DORS RADIAL 3 HOLE SS STRL,SUP-2468376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1790.46,1163.80,,,,,,,,,,,,,
SHELL ACET BPLR 22X64 MM HIP COCR UHMWPE TNDM,SUP-2344596,CDM,C1776,CPT,0278,RC,,,,both,,,2912.35,1893.03,,,,,,,,,,,,,
FELT SURG L15X15CM DIA6X6IN THK1.85MM PTFE POLY SQ LO,SUP-2126650,CDM,C1781,HCPCS,0278,RC,,,,both,,,550.60,357.89,,,,,,,,,,,,,
KIT IMPL HUM CONDYLE HEXALOBULAR ELBW SYS DISCVR,SUP-2196663,CDM,C1776,CPT,0278,RC,,,,both,,,6041.36,3926.88,,,,,,,,,,,,,
PLATE BONE 5X22X5 H BILAT TI DBL ANG RIG NONCOMPRESSION,SUP-2191423,CDM,C1713,HCPCS,0278,RC,,,,both,,,11724.76,7621.09,,,,,,,,,,,,,
INTRODUCER PEELWY 5FRX14CM 038IN ENDHOLE,SUP-2357091,CDM,C1892,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
PLATE BNE RECTANGULAR MIC 1X0.6 MM CRANIOMAXILLOFACIAL 4X2,SUP-2472521,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.95,545.32,,,,,,,,,,,,,
IMPLANT BLGCL TSSUE SHEET 107SQCM 8CMW X 15CML PRCNE TSSUE M,SUP-2675731,CDM,Q4130,HCPCS,0636,RC,,,,both,,,8091.78,5259.66,,,,,,,,,,,,,
HOLDER INSTRUMENT HK FORCEP STYL CERTEX,SUP-2401548,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
EXTRACTOR SURG FEM PROS ADPT,SUP-2252759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1007.94,655.16,,,,,,,,,,,,,
PLATE BONE 5 HOLE COMPRESSION VARIABLE ANGLE LOCKING TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878130,CDM,C1713,HCPCS,0278,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
LENS INTOCU +6.0 DIOPT L13.5MM DIA6MM AC D5.2MM 5DEG UV BLK,SUP-2247662,CDM,V2632,HCPCS,0276,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
FILTER VASC GRNFLD L 28 MM DIA12 FR SS VENA CAVA OTW N MRI,SUP-2142721,CDM,C1880,HCPCS,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
COMPONENT TALAR SZ 2 COCR POROUS TI LT ANK FLAT CUT STRL,SUP-2933408,CDM,C1776,CPT,0278,RC,,,,both,,,35781.24,23257.81,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC CORTICOCANCELLOUS ALLGRFT FRZN,SUP-2933867,CDM,C1762,CPT,0278,RC,,,,both,,,13683.34,8894.17,,,,,,,,,,,,,
LINER ACET 38X28 MM SCR IN +5 HI WALL RINGLOC+,SUP-2447221,CDM,C1776,CPT,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
PROTECTOR NAV2017 SOLERA TISS SM,SUP-2281196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
TRIAL HD 32MM -4MM OFFSET SH FEM TAPR LFIT HMSPHR V40,SUP-2364471,CDM,C1776,CPT,0278,RC,,,,both,,,295.95,192.37,,,,,,,,,,,,,
IMPLANT STPE PSTN SM 6MM WRE FLROPLAS,SUP-2650109,CDM,L8613,CPT,0278,RC,,,,both,,,363.99,236.59,,,,,,,,,,,,,
BRACE ORTH L8IN FOR 10IN WRST UNIV R NYL QUICK FIT,SUP-2197071,CDM,L3908,HCPCS,0274,RC,,,,both,,,30.30,19.69,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT L 27 CM 4 FR 9 MM PLIABLE,SUP-2589474,CDM,C2628,HCPCS,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
POTASSIUM BICARB-CITRIC ACID 20 MEQ PO TBEF,RX-87912,CDM,6370000000,HCPCS,0637,RC,51801-0011-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE BSSO MINI 2X28 MM 13 MM 14 MM DBL Y CRV FOR SCR TI,SUP-2471824,CDM,C1713,HCPCS,0278,RC,,,,both,,,1729.61,1124.25,,,,,,,,,,,,,
PLATE BNE ANGLED 2.5 MM LT 7X23 HOLE RECON PT SPEC,SUP-2860091,CDM,C1713,HCPCS,0278,RC,,,,both,,,24448.35,15891.43,,,,,,,,,,,,,
TIRE SCLER OD7MM ID3.5MM SIL CONVX SYMMETRICAL STYL,SUP-2213482,CDM,L8610,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
GUIDE SURG R PT SPEC,SUP-2379229,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
VERAPAMIL HCL ER 240 MG PO TBCR,RX-13073,CDM,6370000000,HCPCS,0637,RC,68462-0260-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 25 CM 8FR SS HYDRPHLC CORONARY,SUP-2385683,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
RIBBON RETR 4 X 13,SUP-2244673,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.17,44.31,,,,,,,,,,,,,
ROD SPNL PRECRV 100 MM TI,SUP-2415238,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
IMPLANT NSL DORSUM POLYETH SMOOTH RECT,SUP-2242097,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SPHERE STRL PASSIVE MARKER 30,SUP-2430172,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BNE 2.7X45 MM FOR SCR MULT FRAG SYS SS NS,SUP-2467227,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.73,129.17,,,,,,,,,,,,,
BLADE SURG EXTRACTOR SPACER,SUP-2653712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1642.85,1067.85,,,,,,,,,,,,,
CEFTRIAXONE SODIUM-DEXTROSE 1-3.74 GM-%(50ML) IV SOLR,RX-143617,CDM,J0696,HCPCS,0636,RC,00264-3153-11,NDC,,both,1,UN,113.20,73.58,,,,,,,,,,,,,
BUR SURG DIA3MM RND PRECIS RIM GLDE TECHNOLOGY RAP SMOOTH,SUP-2363784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,762.27,495.48,,,,,,,,,,,,,
GRAFT BIO TISS W4XL8CM THK1 2MM PROLAYER,SUP-2362231,CDM,C1763,HCPCS,0278,RC,,,,both,,,8694.03,5651.12,,,,,,,,,,,,,
CATHETER ATHRCTMY 0.058 INX135 MM 2.25 MM PRECONN ROTLNK,SUP-2143725,CDM,C1724,HCPCS,0278,RC,,,,both,,,4849.73,3152.32,,,,,,,,,,,,,
PLATE BONE REG L12MM 2X2 H MIDFACE SLV TI RT L SHP FOR 1.5MM,SUP-2402877,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
HC So Acetone Assay,PX-3078201066,CDM,82010,CPT,0307,RC,,,,outpatient,,,116.00,75.40,,,,,,,,,,,,,
CATHETER CV 3L 12 FRX23 CM OTW HICKMAN TRIFUSION,SUP-2126183,CDM,C1751,HCPCS,0278,RC,,,,both,,,2764.61,1797.00,,,,,,,,,,,,,
FIBER LASER 200UM 2J 80HZ 60W D F L FOR LITHO MOSES,SUP-2417489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1646.99,1070.54,,,,,,,,,,,,,
MESH SURG L 40 X W 30 CM POLYPRO POLYLACTIC ACD GRP,SUP-2901811,CDM,C1781,HCPCS,0278,RC,,,,both,,,7594.09,4936.16,,,,,,,,,,,,,
PROSTHESIS OSS SCHEER PISTON SHT 0.6X4.33 MM SLIM SS,SUP-2637783,CDM,L8613,CPT,0278,RC,,,,both,,,317.27,206.23,,,,,,,,,,,,,
PLATE EXT FIX L 45 MM 3 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
CATHETER GUID SOFIA L 115 CM DIA 5 FR ID 0.55 IN OD 0.067 IN,SUP-2305413,CDM,C1887,HCPCS,0272,RC,,,,both,,,4407.30,2864.74,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X16 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851923,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.69,434.65,,,,,,,,,,,,,
CURETTE SURG 7X5 MM CUP JT PREP LAPIDUS SYS IO FRDM,SUP-2865099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
VALVE AORT FREESTYLE H 9 MM DIA19 MM PORCINE PRESTYLED,SUP-2429932,CDM,C1713,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
BLOCK FEM AUG REV UNIV 55X10 MM POST KNEE POLYETH,SUP-2408077,CDM,C1776,CPT,0278,RC,,,,both,,,2549.68,1657.29,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM KNOTLESS MULTIFLEX S-ULTRA,SUP-2341942,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
SCREW BNE L24MM DIA35MM STD ANK S STL LOK FIX ANG SYS SURFIX,SUP-2243356,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.02,734.51,,,,,,,,,,,,,
SET SPEC RETRV CATH 6.3FR L80CM 11FR SHTH L60CM VENA CAVA,SUP-2168835,CDM,C1880,HCPCS,0278,RC,,,,both,,,846.64,550.32,,,,,,,,,,,,,
STAPLE BNE 15X18X18 MM OSSTAPLE,SUP-2194218,CDM,C1713,HCPCS,0278,RC,,,,both,,,2849.55,1852.21,,,,,,,,,,,,,
HC Sacroplasty Bilat,PX-3610201000,CDM,0201T,CPT,0361,RC,,,,outpatient,,,15457.00,10047.05,,,,,,,,,,,,,
SYSTEM EXT DRNGE AND MON BLUECORE W VENT CATHETER DUET,SUP-2284566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.67,728.44,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA 8 MM EPTFE STR TW N RING,SUP-2396351,CDM,C1768,CPT,0278,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
CEMENT BONE 40GM W/ GENTMYCN PCH HI VISC CO,SUP-2196557,CDM,C1713,HCPCS,0278,RC,,,,both,,,1602.34,1041.52,,,,,,,,,,,,,
SUPPORT ORTHOT CUST FURNISHING INIT ORTHOSIS ONLY,SUP-2435584,CDM,L1200,HCPCS,0272,RC,,,,both,,,5066.39,3293.15,,,,,,,,,,,,,
SCREW BNE L60MM DIA6.5MM THRD L16MM CORT S STL CANN ST SELF,SUP-2185086,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.81,561.48,,,,,,,,,,,,,
IMPLANT BRST 545CC P6.2CM DIA13CM COHESIVE SIL GEL SMOOTH SCX545] ALLERGAN USA INC],SUP-2113671,CDM,C1789,HCPCS,0278,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
TEMPLATE SPNL 14MM LUM TAPR FUS L CAGE DISCECTOMY,SUP-2291602,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
CATHETER EXTR BAL DASH BILI INFL TO 8.5MM 12MM AND,SUP-2169555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
COIL EMB L10CM DIA6MM 0.018IN PERIPH HYDRGEL DETACH 18 SYS,SUP-2385415,CDM,C1889,HCPCS,0278,RC,,,,both,,,2847.82,1851.08,,,,,,,,,,,,,
CATHETER CV STD SET 018 3 FRX40 CM 1 LUMEN NIT TURBO-JECT,SUP-2760084,CDM,C1751,HCPCS,0278,RC,,,,both,,,410.49,266.82,,,,,,,,,,,,,
BIT DRL 3.5X40 MM,SUP-2322485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,848.93,551.80,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 60 CM EPTFE STR STD,SUP-2396095,CDM,C1768,CPT,0278,RC,,,,both,,,2885.66,1875.68,,,,,,,,,,,,,
NERVE STIMULATOR KIT IPG CHARGER KT WAVEWRITER,SUP-2141894,CDM,C1820,HCPCS,0278,RC,,,,both,,,57462.00,37350.30,,,,,,,,,,,,,
CATHETER IVL SHOCKWAVE  4.0MM 135CM,SUP-2850094,CDM,C1725,HCPCS,0272,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
IMPLANT TOE JT HEMI 1ST MPJ BASE OF PHALANX REPL CANN CHI TI,SUP-2392715,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SCREW BNE L20MM OD45MM S STL HINDFOOT LOK ADVANSYS SURFIX,SUP-2243405,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.45,750.39,,,,,,,,,,,,,
SPACER TIB MOD 00 MED 4 MM CEM BPLR N-K II,SUP-2449251,CDM,C1776,CPT,0278,RC,,,,both,,,3026.96,1967.52,,,,,,,,,,,,,
PLATE BN DR 2.4/2.7 VA LCP 2C STD 6H HD 13HSFT 186MM RT STER,SUP-2546049,CDM,C1713,HCPCS,0278,RC,,,,both,,,5128.47,3333.51,,,,,,,,,,,,,
SHELL ACET OD46MM FF UNIV TI HIP PRESSFIT CEMENTLESS,SUP-2206146,CDM,C1776,CPT,0278,RC,,,,both,,,5245.37,3409.49,,,,,,,,,,,,,
PLATE BNE SM LT LAPIDUS STRATUM,SUP-2607234,CDM,C1713,HCPCS,0278,RC,,,,both,,,4155.63,2701.16,,,,,,,,,,,,,
ONDANSETRON 8 MG PO TBDP,RX-27698,CDM,Q0162,HCPCS,0637,RC,65862-0391-10,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM 5CM INTMED SEGMENTS 4CM RADPQ TIP,SUP-2103572,CDM,C1769,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
SCREW DYNA PIP IMPLANT W/14MM BENT,SUP-2665177,CDM,C1776,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
WEDGE FEM L20MM HTO,SUP-2307175,CDM,C1713,HCPCS,0278,RC,,,,both,,,2600.55,1690.36,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X8 MM 6 LOBE,SUP-2602067,CDM,C1889,HCPCS,0278,RC,,,,both,,,6305.12,4098.33,,,,,,,,,,,,,
SCREW BNE ST 1.7X7 MM NS AXS LTX,SUP-2862786,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.86,181.26,,,,,,,,,,,,,
PLATE BNE BUTTRESS 30 MM ATLS,SUP-2391495,CDM,C1713,HCPCS,0278,RC,,,,both,,,8785.41,5710.52,,,,,,,,,,,,,
BIT DRILL - LG (HAND),SUP-2374050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.54,387.75,,,,,,,,,,,,,
WIRE FIX 0.7X127 MM SS KIRSCHNER,SUP-2412972,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.61,23.15,,,,,,,,,,,,,
OSSEOFLEX SN STRBLE NDLE 10 G INCL CNNLSSTLTSBPSY NDLE,SUP-2701996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4279.98,2781.99,,,,,,,,,,,,,
SURFACE ARTC 1-2 AB THK10MM AP40MM ML58MM UNIV PUR UHMWPE,SUP-2201438,CDM,C1776,CPT,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
SNARE VASC CLOVER SNR L 90 CM DIA 6 FR SHTH OUTER L 80 CM,SUP-2171012,CDM,C1773,HCPCS,0272,RC,,,,both,,,1957.44,1272.34,,,,,,,,,,,,,
GRAFT HUM TISS 3X7CM ACELLULAR HYDRATED DERMA MTRX,SUP-2306893,CDM,C1762,CPT,0278,RC,,,,both,,,1603.25,1042.11,,,,,,,,,,,,,
MESH HERN 4X6 IN O3FA COAT POLYPR C-QUR TACSHIELD,SUP-2227256,CDM,C1781,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SCREW BNE L10MM DIA2MM STD TI NONLOCKING FULL THRD FOR HND,SUP-2319649,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
PLATE BNE L121MM THK3.3MM 10 H BILAT S STL RIG STR DYN,SUP-2186334,CDM,C1713,HCPCS,0278,RC,,,,both,,,1097.18,713.17,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 59 MM DIA 6 MM CATH L 80 CM,SUP-2884907,CDM,C1874,HCPCS,0278,RC,,,,both,,,9800.25,6370.16,,,,,,,,,,,,,
HC Drainage Ext Ear Abscess,PX-4506900000,CDM,69000,CPT,0450,RC,,,,both,,,730.00,474.50,,,,,,,,,,,,,
ENDCAP ORTH STRL S STL END FOR OLECRANON OSTEOTMY NAIL,SUP-2177096,CDM,C1889,HCPCS,0278,RC,,,,both,,,838.66,545.13,,,,,,,,,,,,,
HC Bil Niv Arterial Low Ext Duplex,PX-9219392500,CDM,93925,CPT,0921,RC,,,,both,,,1577.00,1025.05,,,,,,,,,,,,,
PORT INFUS CATH 9.5FR POLYUR 2 LUMN ATTCH VEN CATH X-PRT,SUP-2127755,CDM,C1788,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
EXTENSION GUIDEWIRE L 165 CM DIA 0.014 IN STR TIP FOR PTCA,SUP-2123749,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
KIT CATH 5.5FR L13CM MULTILUMEN INDWL SPR WIRE GUID INTRO,SUP-2383300,CDM,C1751,HCPCS,0278,RC,,,,both,,,173.96,113.07,,,,,,,,,,,,,
PLATE BNE THK0.6MM 5 H CRAN TI MESH MIC RECT FOR 1.5MM SCR,SUP-2262704,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.84,169.55,,,,,,,,,,,,,
GRAFT AMNIOFIX AMNIOTIC MEMBRANE 40MG,SUP-2866797,CDM,C1762,CPT,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
SCREW BNE PART THRD 4.5X42 MM CANN W/ LG HEX SOCKET SD ST,SUP-2190416,CDM,C1713,HCPCS,0278,RC,,,,both,,,544.04,353.63,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM CORT DST TIB TYP II ANODIZED TI ST,SUP-2411682,CDM,C1713,HCPCS,0278,RC,,,,both,,,165.79,107.76,,,,,,,,,,,,,
STENT PANCREATIC SINGLE PGTL 0.035 IN 5 FRX5 CM ADVANIX,SUP-2149519,CDM,C2617,HCPCS,0278,RC,,,,both,,,247.81,161.08,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZN 5CMX10CM M HMTRX,SUP-2125443,CDM,Q4134,HCPCS,0636,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
NEEDLE LAP 140 MM FOR FACE CLOSURE,SUP-2748429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1559.45,1013.64,,,,,,,,,,,,,
KIT RF 4MM ACT TIP 17GA 75MM MULT PRB PROC COMPONENTS MULT,SUP-2236771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
ALUMINUM RENAL ABH BLADE 1 X 4,SUP-2703358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1419.31,922.55,,,,,,,,,,,,,
SET IMPL SCR DISK SELF DRL 1.5MM DIA 5MML,SUP-2362179,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM DIA1MM 5MM SPC 4 ELECTRD PERC FLX,SUP-2357677,CDM,C1778,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 15 CC FD ASEP CANC,SUP-2867066,CDM,C1762,CPT,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
HC Pt Neuro Facilitation Ea 15 Min,PX-4209711200,CDM,97112,CPT,0420,RC,,,,both,,,159.00,103.35,,,,,,,,,,,,,
PLATE BNE LCK 3.5X53 MM 4 HOLE CNTOUR 2 COMPR SS STRL,SUP-2476210,CDM,C1713,HCPCS,0278,RC,,,,both,,,807.26,524.72,,,,,,,,,,,,,
CATHETER HD DL 13.5 FRX13.5 CM ADMIN BASIC KT MAHRK,SUP-2174223,CDM,C1751,HCPCS,0278,RC,,,,both,,,233.62,151.85,,,,,,,,,,,,,
PORT 8FR PWR INJ MID SIZED TI DIGNITY W/ ATTACH CATH,SUP-2268425,CDM,C1788,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
BASEPLATE TIB L85XW60MM SZ 2 XL DURAC KNEE CEM,SUP-2377174,CDM,C1776,CPT,0278,RC,,,,both,,,3350.00,2177.50,,,,,,,,,,,,,
BIT DRL DIA2.1MM CANN ADD ON CPL DISP FOR ASNS MIC SCR SYS,SUP-2372170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
ANCHOR SUTURE UHMWPE POLYESTER TI BTTN WASHER EXTRATHORACIC,SUP-2905458,CDM,C1713,HCPCS,0278,RC,,,,both,,,11178.40,7265.96,,,,,,,,,,,,,
ANCHOR SUT DIA3.5MM SZ 2 ETHBND PANALOK ABSRB,SUP-2249321,CDM,C1713,HCPCS,0278,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
SHELL ACET MH 40 MM HIP LEGEND,SUP-2434196,CDM,C1776,CPT,0278,RC,,,,both,,,6145.61,3994.65,,,,,,,,,,,,,
HINGE EXT FIX ROTATING F FEM SVC PART,SUP-2437346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
DRILL SURG DIA1.5MM MNL NONRADIOLUCENT W/O STP HPS,SUP-2319570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
PLATE BNE W12XL114MM THK25MM 5 H BILAT PROX HUM TI RIG LOK,SUP-2190989,CDM,C1713,HCPCS,0278,RC,,,,both,,,4769.94,3100.46,,,,,,,,,,,,,
GRAFT BNE CRUSH FRZN CANC 1MM 8MM RANG 80CC READIGRFT,SUP-2264729,CDM,C1713,HCPCS,0278,RC,,,,both,,,2917.72,1896.52,,,,,,,,,,,,,
STAPLE 20MM X 20MM X 20MM STPLS,SUP-2401355,CDM,C1713,HCPCS,0278,RC,,,,both,,,5058.54,3288.05,,,,,,,,,,,,,
NAIL 12MMX210MM,SUP-2244339,CDM,C1713,HCPCS,0278,RC,,,,both,,,16396.99,10658.04,,,,,,,,,,,,,
SCREW BNE CANN 1.7X60 MM COMPR,SUP-2389377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
HC Holter Scan Analysis,PX-7319322600,CDM,93226,CPT,0731,RC,,,,both,,,1348.00,876.20,,,,,,,,,,,,,
GRAFT HUM TISS DIA 45 MM FEM HD NK FD STERIGRAFT,SUP-2913177,CDM,C1762,CPT,0278,RC,,,,both,,,8817.12,5731.13,,,,,,,,,,,,,
WIRE FIX L229MM DIA1.7MM S STL PARTIALLY THRD TWO END SHRP,SUP-2409762,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.39,26.90,,,,,,,,,,,,,
COIL VASC AZUR L 34 CM DIA14 MM MICROCATHETER 0.018 IN LOOP,SUP-2385436,CDM,C1889,HCPCS,0278,RC,,,,both,,,2893.51,1880.78,,,,,,,,,,,,,
CATHETER DIAG L20.25IN OD2.54MM ID1.14MM CUF OD11/32IN COR,SUP-2384405,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.07,213.90,,,,,,,,,,,,,
PAD ORTHOT ABD CUST,SUP-2435590,CDM,L1270,HCPCS,0274,RC,,,,both,,,234.65,152.52,,,,,,,,,,,,,
COVER BUR H DIA22MM TI SHUNT FOR CRAN CLSR SYS,SUP-2243980,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.46,296.05,,,,,,,,,,,,,
STEM FEM TAPR PRI STD OFFSET CEM CLLRD CO CHROM IMP 12/14,SUP-2344495,CDM,C1776,CPT,0278,RC,,,,both,,,11633.70,7561.90,,,,,,,,,,,,,
MESH SURG W20XL30CM SKIRTED FOR OPN VENTRAL PCOX,SUP-2752147,CDM,C1781,HCPCS,0278,RC,,,,both,,,7244.77,4709.10,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS AK HIP ALIGNABLE SYS,SUP-2388220,CDM,L5920,HCPCS,0272,RC,,,,both,,,1394.63,906.51,,,,,,,,,,,,,
GUIDEWIRE VASC SAFE-T-J L 15 CM DIA 0.018 IN SS STR FIX COR,SUP-2759998,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.70,47.90,,,,,,,,,,,,,
KIT CATH DLYS 2LUMEN STR SHORT-TERM 12FRENCH 24CENTIMETER,SUP-2126491,CDM,C1752,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
SUTURE PASSER CAPFIX 45 DEG,SUP-2801014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1390.20,903.63,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 2X50X1.2 MM RAPID RESORBABLE STERIL,SUP-2838599,CDM,C1713,HCPCS,0278,RC,,,,both,,,5769.75,3750.34,,,,,,,,,,,,,
PLATE BNE JAW FACE 4 ORTHOGNATHIC,SUP-2883355,CDM,C1713,HCPCS,0278,RC,,,,both,,,28651.31,18623.35,,,,,,,,,,,,,
ROD SPNL POST SMOOTH 5.5MM DIA 190MM LEN,SUP-2289293,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
PLATE BONE 3X16 HOLE LEFT RECONSTRUCTION WITH CONDYLAR HEAD,SUP-2838420,CDM,C1713,HCPCS,0278,RC,,,,both,,,16779.53,10906.69,,,,,,,,,,,,,
PLATE BNE LOK L CRV L 7 H TI PROX TIB PLATING SYS ALPS,SUP-2413715,CDM,C1713,HCPCS,0278,RC,,,,both,,,3884.18,2524.72,,,,,,,,,,,,,
"HC So Compatibility Test, Immed.Spin",PX-3008692066,CDM,86920,CPT,0300,RC,,,,inpatient,,,359.00,233.35,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 45 CM DIA 0.025 IN SS PERIPH SFT,SUP-2383359,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
COIL NEUROVASCULAR MICRUSPHERE XL 10 L 14 CM DIA 5 MM,SUP-2249286,CDM,C1889,HCPCS,0278,RC,,,,both,,,4248.89,2761.78,,,,,,,,,,,,,
MAXLOCK EXTRM WSHR,SUP-2401260,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.49,406.57,,,,,,,,,,,,,
SCREW BNE N CANN 2 INX12 MM BOLD,SUP-2608941,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.40,483.21,,,,,,,,,,,,,
SHEATH INTRO STEADYSHEATH EVOLUTION L 36.5 CM OD 17.2 FR ID,SUP-2638739,CDM,C1893,HCPCS,0272,RC,,,,both,,,866.83,563.44,,,,,,,,,,,,,
PATCH VASC HEMGRD L 75 X W 75 MM THK 0.65 MM POLYESTER BOV,SUP-2535430,CDM,C1768,CPT,0278,RC,,,,both,,,532.48,346.11,,,,,,,,,,,,,
DRESSING WND 3 LAYR 7X10 CM MTRX CYTAL,SUP-2106529,CDM,Q4166,HCPCS,0636,RC,,,,both,,,6744.72,4384.07,,,,,,,,,,,,,
KIT INSRTN SMRT PICC 5 FR SGL LUMN STD TAPR 65 CM CATH STYL,SUP-2118466,CDM,C1751,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PROBE SURG 35MM 7DEG UNIV THORLUM TI SGL END ANG BALL HNDL,SUP-2287388,CDM,C1713,HCPCS,0278,RC,,,,both,,,1098.97,714.33,,,,,,,,,,,,,
PLATE BNE L142MM BLDE W5.8XL38MM 140DEG 8 H ST BILAT PELV,SUP-2186650,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.27,1499.73,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTEROLATERAL DISTAL HUMERUS 5H RIGHT,SUP-2549678,CDM,C1713,HCPCS,0278,RC,,,,both,,,3284.06,2134.64,,,,,,,,,,,,,
STAPLE BNE FIX 25X7MM BRDG 4 20MM LEG Y SHP IMPL,SUP-2194191,CDM,C1713,HCPCS,0278,RC,,,,both,,,5420.24,3523.16,,,,,,,,,,,,,
PORT IMP TI SIL CATH 8FR W/ 8 INTRO SHTH VAXCEL,SUP-2308262,CDM,C1788,HCPCS,0278,RC,,,,both,,,1553.30,1009.64,,,,,,,,,,,,,
HC Vasc Embolize Occlude Venous,PX-3613724100,CDM,37241,CPT,0361,RC,,,,both,,,12876.00,8369.40,,,,,,,,,,,,,
CAGE SPNL W10XH18XL55MM 0DEG CLYDESDALE PTC,SUP-2285761,CDM,C1889,HCPCS,0278,RC,,,,both,,,17599.70,11439.80,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLUENCY + L 40 MM DIA10 MM CATH L 80 CM,SUP-2128267,CDM,C1874,HCPCS,0278,RC,,,,both,,,23747.82,15436.08,,,,,,,,,,,,,
ESTROGENS CONJUGATED 0.3 MG PO TABS,RX-9973,CDM,6370000000,HCPCS,0637,RC,00046-1100-81,NDC,,both,1,UN,31.90,20.73,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 60 CM DIA 4 FR SPC,SUP-2357647,CDM,C1730,HCPCS,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7MM STR TW HELIX SLDE GDS,SUP-2227379,CDM,C1768,CPT,0278,RC,,,,both,,,2758.36,1792.93,,,,,,,,,,,,,
STAPLER INT EXTRA THICK 80 MM W/ TRI-STAPLE BLK GIA,SUP-2787701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.64,406.02,,,,,,,,,,,,,
SCREW BNE CRTX 2.7X90 MM ST T8 STARDRV RECESS TI NS,SUP-2758224,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.42,112.07,,,,,,,,,,,,,
PLATE BNE L STD 2.4/2.7X44 MM RT 1ST MTP 2X2 HOLE VA LP LCK,SUP-2181249,CDM,C1713,HCPCS,0278,RC,,,,both,,,3224.00,2095.60,,,,,,,,,,,,,
COMPONENT TIB UNI 8 MM KNEE,SUP-2205996,CDM,C1776,CPT,0278,RC,,,,both,,,4477.64,2910.47,,,,,,,,,,,,,
NEXGEN AC ART SURF 5-6/ GREEN 12MM,SUP-2503015,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT BNE SUB 2.5ML PTTY DEMIN BNE MTRX JR GRFTON,SUP-2294015,CDM,C9359,HCPCS,0278,RC,,,,both,,,1427.13,927.63,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5 MM RT PROX PERIPROSTHETIC NS VA-LCP,SUP-2757656,CDM,C1713,HCPCS,0278,RC,,,,both,,,4889.80,3178.37,,,,,,,,,,,,,
CATH GUIDE CPS LOCATOR MEDIUM 3D,SUP-2873674,CDM,C1887,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
MESH SURG DIA4.5IN CIR SEPRA TECHNOLOGY VENTRALIGHT,SUP-2125905,CDM,C1781,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
PLATE-SBF LONG 5 HOLE,SUP-2818118,CDM,C1713,HCPCS,0278,RC,,,,both,,,1766.56,1148.26,,,,,,,,,,,,,
SCREW BONE 5X80MM THRD LO PROF TI,SUP-2316512,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.60,438.49,,,,,,,,,,,,,
IMPLANT SUBTALAR TRUARCH 8 MM,SUP-2586648,CDM,C1776,CPT,0278,RC,,,,both,,,7689.39,4998.10,,,,,,,,,,,,,
STENT NEURO FRED L 31/23 MM WORKING L 26/17 MM DIA 4 MM SYS,SUP-2739136,CDM,C1876,HCPCS,0278,RC,,,,both,,,39901.55,25936.01,,,,,,,,,,,,,
GRAFT BNE SUB 1.5ML VOID FILL RESRB PTTY MASTERGRFT,SUP-2288540,CDM,C9359,HCPCS,0278,RC,,,,both,,,450.56,292.86,,,,,,,,,,,,,
JIG SURG RT KNEE AREF PT SPEC DISP PERSONA,SUP-2205587,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER HAD KT DIAL CHRONIC DBL LUMN 15FRX28 CANNON II,SUP-2383439,CDM,C1750,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
CANNULA SET 25 GA W/ HI FLO INFUSION LN STRL AVETA LTX DISP,SUP-2864523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,765.28,497.43,,,,,,,,,,,,,
CATHETER ATHRCTMY DIA2.3MM 0.018IN OVR THE WIRE LSR MNL,SUP-2353098,CDM,C1885,CPT,0278,RC,,,,both,,,11035.53,7173.09,,,,,,,,,,,,,
FIBER LASER FLAT TIP 1000 MH ASMBLY HOLM,SUP-2225997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
PLATE TI BROAD LCP 4.5MM 18 HOLES 332MM,SUP-2549494,CDM,C1713,HCPCS,0278,RC,,,,both,,,3467.56,2253.91,,,,,,,,,,,,,
IMPLANT BRST W14.9XH12.5CM P5.6CM 525-575CC SIL NACL FILL,SUP-2300566,CDM,C1789,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
HC So Leukocyte Alka Phosphat Stain,PX-3058554066,CDM,85540,CPT,0305,RC,,,,both,,,463.00,300.95,,,,,,,,,,,,,
GRAFT HUM TISS L18CM GRACILIS FRZN SGL STRND,SUP-2113927,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
NAIL IM TROCH ENTRY 130 DEG 11 MMX46 CM LT FEM TI STRL,SUP-2412494,CDM,C1713,HCPCS,0278,RC,,,,both,,,7243.76,4708.44,,,,,,,,,,,,,
BLADE SCREWDRIVER 2X84.5 MM CMF MMF INSIDE TIP SS LEVEL 1,SUP-2469114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.12,305.58,,,,,,,,,,,,,
CATHETER PICC ARROW TAPERFREE 4FR 55CM 1-LUMEN,SUP-2887041,CDM,C1751,HCPCS,0278,RC,,,,both,,,520.20,338.13,,,,,,,,,,,,,
HC Clsd Tx Trimall Fx W Manip,PX-4502781800,CDM,27818,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
SCREW BNE OD35MM L26MM 27MM HD CORT PERIARTC ST ST,SUP-2207948,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.93,75.35,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE ROTARY MIX PTTY VOID FILL INJ,SUP-2194289,CDM,C9359,HCPCS,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
WASHER ORTH DIA14MM 1.3MM TI RND LO PROF,SUP-2166861,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.96,147.52,,,,,,,,,,,,,
CAP NAIL FEM RETRGRD,SUP-2467182,CDM,C1889,HCPCS,0278,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
HEAD FEM 12/14 TAPR ZIRCONIA 28MM +0 NOVATION ELEMENT,SUP-2222106,CDM,C1776,CPT,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
COMPONENT FEM M R KNEE REV CEM CRUCE RET STEM BEAD VIT AND,SUP-2377065,CDM,C1776,CPT,0278,RC,,,,both,,,6191.58,4024.53,,,,,,,,,,,,,
VALVE SHUNT OD 2.5 MM ID 1.14 MM CATH 120/14 CM PRESSURE 40,SUP-2883449,CDM,C1729,HCPCS,0272,RC,,,,both,,,3171.71,2061.61,,,,,,,,,,,,,
TROCAR DIA3.2MM TIP TRIGEN,SUP-2348120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.27,746.38,,,,,,,,,,,,,
CUP HUM BEAR 3+ MM STD 40 MM COMPHSVE VIVACIT-E,SUP-2441526,CDM,C1776,CPT,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
SPACER ORTH HUM 9X20 MM ADJ REVERSED AEQUALIS,SUP-2715380,CDM,C1776,CPT,0278,RC,,,,both,,,7364.87,4787.17,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X320 MM RT PROX 10 HOLE NS VA-LCP,SUP-2757664,CDM,C1713,HCPCS,0278,RC,,,,both,,,7849.75,5102.34,,,,,,,,,,,,,
PLATE BONE 2X2 HOLE 90 DEGREE 2X17 MM LEFT L TYPE LOW PROFIL,SUP-2838400,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.83,547.19,,,,,,,,,,,,,
"HC So1 Quantation of Therapuetic Drug, Nes",PX-3018029967,CDM,80299,CPT,0301,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
INTRODUCER SHTH 0.038 IN 8 FRX23 CM GUIDEWIRE BLU PRELUDE,SUP-2303305,CDM,C1893,HCPCS,0272,RC,,,,both,,,37.93,24.65,,,,,,,,,,,,,
IMPLANT ANTIREFLX SZ 14 LAPSCP FUNDIC SPRNG MRI COMPATIBLE,SUP-2219560,CDM,C1889,HCPCS,0278,RC,,,,both,,,20375.46,13244.05,,,,,,,,,,,,,
SHEATH INTRO SOLOPATH WORKING L 25 CM EXPANDABLE L 20CM 18FR,SUP-2385696,CDM,C1894,HCPCS,0272,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
RX BURR HOLE COVER 12MM X 1MM,SUP-2669321,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.03,612.32,,,,,,,,,,,,,
"HC So Hiv-1, Amplified Probe Tech|UNUSUAL NON-OVERLAPPING SERVICE",PX-3068753566,CDM,87535,CPT,0306,RC,,,XU,both,,,293.00,190.45,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 90 DEG L 150 CM OD,SUP-2383137,CDM,C1887,HCPCS,0272,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
GUIDEWIRE VASC L175CM DIA0.014IN 5 SENS STR TIP PRESSUREWIRE,SUP-2331129,CDM,C1769,HCPCS,0272,RC,,,,both,,,5301.89,3446.23,,,,,,,,,,,,,
CLIP EXT FIX ROTATIONAL CTRL,SUP-2459899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5553.03,3609.47,,,,,,,,,,,,,
SPLINT DORSAL AFO SPLNT S LF W STRP,SUP-2163833,CDM,L4396,HCPCS,0274,RC,,,,both,,,86.13,55.98,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 2XL L 75 CM BALLOON L 40 MM DIA14 MM,SUP-2142058,CDM,C1725,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L15CM 13.5FR AD ADMIN ACUTE BASIC,SUP-2125586,CDM,C1752,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
BLADE FLAT 10MM 11CM STER DISP,SUP-2801000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CA SULF HI STRENGTH INJ RESRB MIIG X3,SUP-2399047,CDM,C1713,HCPCS,0278,RC,,,,both,,,7930.89,5155.08,,,,,,,,,,,,,
GRAFT BTM THK 20X16CM NO CL SCAF NAT OCC PRCN STRL GNTRX DSP,SUP-2106500,CDM,Q4166,HCPCS,0636,RC,,,,both,,,25953.98,16870.09,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5.5X13.5 MM DWL FD THRD FACET,SUP-2736760,CDM,C1713,HCPCS,0278,RC,,,,both,,,6661.82,4330.18,,,,,,,,,,,,,
PLATE CRAN 180X100X40 MM PT SPEC IMPL PEEK,SUP-2860149,CDM,C1713,HCPCS,0278,RC,,,,both,,,42768.68,27799.64,,,,,,,,,,,,,
"HC So Porphyrins,Quantitive",PX-3018412066,CDM,84120,CPT,0301,RC,,,,inpatient,,,1044.00,678.60,,,,,,,,,,,,,
CATHETER VASC 7FR L100CM FEM GUID VODA LT 3 COR W/O HYDRPHLC,SUP-2144029,CDM,C1887,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
SLEEVE CNTR L6MM FOR ANG PIN CONNECTOR/ILIZAROV TAY SPAT,SUP-2340791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,874.14,568.19,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 8 MM RNG L 20 CM STR TW,SUP-2396163,CDM,C1768,CPT,0278,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
HC Ventilator Initial Day,PX-4109400200,CDM,94002,CPT,0410,RC,,,,outpatient,,,1570.00,1020.50,,,,,,,,,,,,,
CG+ PICC SET: THREE LUMEN 6FRX55CM W/130CM SWG,SUP-2827504,CDM,C1751,HCPCS,0278,RC,,,,both,,,590.95,384.12,,,,,,,,,,,,,
BUR SHV L13CM DIA4MM 15DEG TAPR DMND CHOANAL ATRESIA 30K HI,SUP-2277872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.65,976.72,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM 1-2MM STD REGENERATIVE TISS MTRX,SUP-2399084,CDM,Q4107,HCPCS,0636,RC,,,,both,,,7917.10,5146.11,,,,,,,,,,,,,
CATHETER DIALYSIS 19CM DUAL LUMEN PERMCATH,SUP-2718755,CDM,C1750,HCPCS,0278,RC,,,,both,,,813.29,528.64,,,,,,,,,,,,,
HANDLE BLU LT ERGO TI REUSE GRIESHABER RENAISSANCE NG,SUP-2109713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
SCREW BNE CANN 10.35X70 MM TI GLD NS TFN-ADVANCED 04038070,SUP-2799596,CDM,C1713,HCPCS,0278,RC,,,,both,,,1772.91,1152.39,,,,,,,,,,,,,
CEMENT BNE PMMA FOR FEN SCR HV R,SUP-2279567,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO BASIC 22GA 8CM WNG 1 F322087T,SUP-2632774,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.58,163.53,,,,,,,,,,,,,
PLATE BNE W13.5XL286MM THK4.2MM 16 H BILAT S STL NAR LIMIT,SUP-2185255,CDM,C1713,HCPCS,0278,RC,,,,both,,,2285.42,1485.52,,,,,,,,,,,,,
PLATE BNE L 80 MM SCREW DIA2 MM 5 HD 10 SHFT H SS Y SHP VA NS,SUP-2909161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2830.49,1839.82,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN L4CM DIA1.5MM J TIP PTFE S,SUP-2148286,CDM,C1769,HCPCS,0272,RC,,,,both,,,24.81,16.13,,,,,,,,,,,,,
PLATE BONE 37MML HLX7 1.5MM STNLSS STEEL F/2MM SCREW MINI FR,SUP-2493892,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE W 4.45 X H 4.81 CM THK 0.75 CM 13.2,SUP-2149248,CDM,C1786,HCPCS,0275,RC,,,,both,,,9938.10,6459.76,,,,,,,,,,,,,
CAGE SPNL 10 DEG 31X24X10 MM MERID,SUP-2710944,CDM,C1889,HCPCS,0278,RC,,,,both,,,18290.50,11888.82,,,,,,,,,,,,,
PPICC PROVENA 4F DL BASIC TL,SUP-2613557,CDM,C1751,HCPCS,0278,RC,,,,both,,,615.50,400.07,,,,,,,,,,,,,
MESH HERN RECT 6.3X2.4 IN MONOFILAMENT SCAFFOLD PHASIX,SUP-2736740,CDM,C1781,HCPCS,0278,RC,,,,both,,,4885.84,3175.80,,,,,,,,,,,,,
LEVETIRACETAM 750 MG PO TABS,RX-26818,CDM,6370000000,HCPCS,0637,RC,68084-0882-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CAGE SPNL W15XH15XL25MM C FBR REINF POLYMER POST LUM INTBDY,SUP-2252405,CDM,C1889,HCPCS,0278,RC,,,,both,,,9737.14,6329.14,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L 115CM 7FR 20 POLE,SUP-2460618,CDM,C1731,HCPCS,0278,RC,,,,both,,,2816.27,1830.58,,,,,,,,,,,,,
FIBER LASER DIA200UM FLEXSHIELD COAT HOLM HI PWR TRAC TIP,SUP-2141781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1298.83,844.24,,,,,,,,,,,,,
FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN,RX-88010,CDM,Q2009,HCPCS,0636,RC,00069-6001-21,NDC,,both,2,ML,139.50,90.67,,,,,,,,,,,,,
GUIDEWIRE UROLOGY L150CM OD.035IN 3CM TIP NIT HYDRPHLC TAPR,SUP-2385304,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.51,112.13,,,,,,,,,,,,,
PLATE BNE XLN L VOLAR DST RAD WRST LOK ACU LOC,SUP-2107774,CDM,C1713,HCPCS,0278,RC,,,,both,,,2970.44,1930.79,,,,,,,,,,,,,
PLATE BNE RECON 3.5X142 MM 12 HOLE SS,SUP-2569087,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.93,284.00,,,,,,,,,,,,,
AWL SURG UNIV SPNL REUSE ATLNTS,SUP-2279317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,296.35,192.63,,,,,,,,,,,,,
KIT PAINBUSTER W/ SILVERSOAK SOAK CATH 10IN 400ML X4ML PER,SUP-2420882,CDM,C9804,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
TUBE VENT DIA1.27MM SHEEHY TYP,SUP-2277603,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.52,45.84,,,,,,,,,,,,,
STAPLE STR ASSEMB 10MM X 10MM,SUP-2321572,CDM,C1713,HCPCS,0278,RC,,,,both,,,4824.61,3136.00,,,,,,,,,,,,,
SET LD INTRO DIA12 FR PTFE PEELABLE GUIDEWIRE STRL,SUP-2133597,CDM,C1769,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 70 CM EPTFE STR STD,SUP-2396097,CDM,C1768,CPT,0278,RC,,,,both,,,2816.58,1830.78,,,,,,,,,,,,,
LENS IOL 16.0 DIOPT CYL 2.25 DIOPT L 13 MM DIA 6,SUP-2881476,CDM,V2787,HCPCS,0276,RC,,,,both,,,515.00,334.75,,,,,,,,,,,,,
FIBER LASER KIT OMNIGUIDE,SUP-2225640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
SET KNOT PUSH SUT CUT SLT CANN STR DISP FOR FAST FIX MENIS,SUP-2341853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,554.96,360.72,,,,,,,,,,,,,
HC So Flow Cytometry,PX-3118818466,CDM,88184,CPT,0311,RC,,,,both,,,246.00,159.90,,,,,,,,,,,,,
PLATE BNE L 267 MM SCREW DIA 4.5 MM 16 H COMPR LCK NS EVOS,SUP-2933212,CDM,C1713,HCPCS,0278,RC,,,,both,,,3410.83,2217.04,,,,,,,,,,,,,
GRAFT HUM TISS 100MG PARTICULATE INJ MICRONIZED AMNIO MEM,SUP-2305720,CDM,V2790,HCPCS,0274,RC,,,,both,,,4381.87,2848.22,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK FLX INNR SOCKET,SUP-2388208,CDM,L5645,HCPCS,0272,RC,,,,both,,,2097.24,1363.21,,,,,,,,,,,,,
CATHETER ETER IV POLY MIDLN SGL LUMN MAX BARR OD3FR,SUP-2125577,CDM,C1751,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
RELOAD STPL L100MM REG TISS GRN TI LOR PROX LIN CUT DST SER,SUP-2283276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.69,209.10,,,,,,,,,,,,,
PLATE BNE L210MM 13 H NAR 2 COMPR FOR 45MM SCR L FRAG SYS,SUP-2411428,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
PLATE BNE L 261 X W 11.4 MM THK 3.4 MM SCREW DIA2.7/3.5 MM 72464021N,SUP-2933312,CDM,C1713,HCPCS,0278,RC,,,,both,,,8861.87,5760.22,,,,,,,,,,,,,
SURGICAL LEAD KIT 70 CM 32 ELECTRD COVE EDGE 32,SUP-2141959,CDM,C1778,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
DRILL SURG 3.5 MM STRL LINEUM OCT,SUP-2683055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
COMPONENT FEM SZ 9 L POST KNEE NP PRI BICRUCIATE CEM STBL,SUP-2350310,CDM,C1776,CPT,0278,RC,,,,both,,,14411.82,9367.68,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE STD MINI W/O ANTECHAMBER IMPL SYS,SUP-2666621,CDM,C1889,HCPCS,0278,RC,,,,both,,,9286.05,6035.93,,,,,,,,,,,,,
CABLE NEUROSTIMULATOR W45XL57MM 50GM MULT LD TRIALING,SUP-2284448,CDM,C1778,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
MESH HERN W4XL6IN ELLIPSE W/ ECHO PS POS SYS VENTRALIGHT ST,SUP-2125914,CDM,C1781,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
BIT DRILL TROCAR LONG F/ NAILS 8-11 SILE,SUP-2737586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,323.29,210.14,,,,,,,,,,,,,
IMMOBILIZER ORTH SHLDR SUPP UNIV UNISX STD CUFED AD LN WR,SUP-2306067,CDM,L3650,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
LIOTHYRONINE SODIUM 5 MCG PO TABS,RX-10443,CDM,6370000000,HCPCS,0637,RC,70377-0114-12,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIT DRL TWST 1.5X100 MM MORRISON W/ NOTCH LEVEL 1 DISP,SUP-2463124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
SCREW SPNL EMGCY 3.1X11 MM LCK MAXDRIVE 258891191,SUP-2472435,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.71,321.56,,,,,,,,,,,,,
EXTENSION DBS LD L 50 CM 8 CHANNEL FLX MR UNSAFE FOR MED,SUP-2637200,CDM,C1883,HCPCS,0278,RC,,,,both,,,3113.94,2024.06,,,,,,,,,,,,,
HC So1 Lipid Panel,PX-3018006167,CDM,80061,CPT,0301,RC,,,,both,,,55.00,35.75,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 60 CM DIA 6 MM AX COMPLIANCE,SUP-2477406,CDM,C1768,CPT,0278,RC,,,,both,,,4814.56,3129.46,,,,,,,,,,,,,
CATHETER HAD ADMIN FULL KT DBL LUMN POLYUR STR HYDR TIP CUF,SUP-2266965,CDM,C1752,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
VALSARTAN 80 MG PO TABS,RX-31209,CDM,6370000000,HCPCS,0637,RC,31722-0152-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT EXP NDL L8IN SOAK CATH L10IN T PEEL ON-Q PAINBUSTER,SUP-2236845,CDM,C1751,HCPCS,0278,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
SPLINT ORTHOPEDICXSM FNGR DYN WIRE FOAM PIP EXTN ASST AA,SUP-2324550,CDM,L3933,HCPCS,0272,RC,,,,both,,,63.02,40.96,,,,,,,,,,,,,
DEVICE THROMCTMY CLN XT L 135 CM DIA 6 FR SINUSOIDAL WIRE,SUP-2120126,CDM,C1724,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
STENT NEPHURET EXPEL L 22 CM DIA10 FR FLEXITHANE HYDRPHLC 2,SUP-2146911,CDM,C2617,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
GRAFT DERMAL N FEN 8X4 CMX0.4-0.8 MM DERMAL MTRX PARADERM,SUP-2742062,CDM,C1763,HCPCS,0278,RC,,,,both,,,5845.90,3799.83,,,,,,,,,,,,,
FIBER LASER 272UM DUST THULIUM,SUP-2885341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
KNIFE SURG SCHUCKNECHT 2 ROLLER,SUP-2459172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.23,405.75,,,,,,,,,,,,,
SCREW BNE L20MM DIA27MM DST LAT CORT PERIARTC S STL ST,SUP-2198483,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.31,102.25,,,,,,,,,,,,,
PLATE BONE THK1.8MM 7 H STRNL TI J SHP LCK,SUP-2262577,CDM,C1713,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
EXTENSION EXT FIX MONOAX SHT OPN BODY PHOENIX,SUP-2657927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HOOK SPNL 55MM DIA 8MML STNLSS STEEL LMNR THRCC CLSD F/475,SUP-2720444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1210.91,787.09,,,,,,,,,,,,,
HC Repair Enteroctaneous Fistula Small Intestine or Colon,PX-3610979600,CDM,C9796,CPT,0361,RC,,,,both,,,8689.00,5647.85,,,,,,,,,,,,,
CATHETER KIT HYBRID PICC 6 FRX55 CM 145 CM WIRE W/ ENDEXO,SUP-2117130,CDM,C1751,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
KIT CATH VENT STR RT ANG 2.7MM DIA 15CM LEN,SUP-2308190,CDM,C1713,HCPCS,0278,RC,,,,both,,,399.31,259.55,,,,,,,,,,,,,
NEEDLE SURG BVL VITAL JAMSH,SUP-2693463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
RESORB XG ST MESH LG GRID 51 X 51 MM T10 MM PLLA PGA,SUP-2694979,CDM,C1713,HCPCS,0278,RC,,,,both,,,3135.51,2038.08,,,,,,,,,,,,,
TIP ASPIR KNIFE 0.83X12.5 MM 11 CM FOR BNE CUT SONOPET IQ,SUP-2791053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2980.49,1937.32,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 7X7 CM CRYOPRESERVED AMNIOX CLARIX 100,SUP-2648670,CDM,Q4156,HCPCS,0636,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
NUT EXT FIX DIA10MM ANK DC COUNT SQ RINGFIX,SUP-2378778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.19,230.22,,,,,,,,,,,,,
SPLINT FNGR OVL 8 11,SUP-2100002,CDM,L3933,HCPCS,0272,RC,,,,both,,,28.51,18.53,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 23CM 5FR 80CM NDL 4CM NIT PLAT,SUP-2740551,CDM,C1894,HCPCS,0272,RC,,,,both,,,151.66,98.58,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO SPLIT ACTE 13FR DIA 20CM INTRNL JU,SUP-2610514,CDM,C1752,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
SCREW BONE L12MM OD2.4MM TI CORT VOLAR ST T7 SET D RAD,SUP-2351124,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.33,189.36,,,,,,,,,,,,,
GRAFT HUM TISS M THN CNTOUR RDY TO USE ALLDERM,SUP-2113054,CDM,Q4116,HCPCS,0636,RC,,,,both,,,15429.96,10029.47,,,,,,,,,,,,,
SCREW 5.0MM PERIPR VA LCKNG SLF TPNG STRDRV 8MM STER,SUP-2546195,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.23,617.65,,,,,,,,,,,,,
STEM FEM L150MM DIA13.5MM TI POR IM REV BOW NEUT MOD LNG,SUP-2405743,CDM,C1776,CPT,0278,RC,,,,both,,,5298.75,3444.19,,,,,,,,,,,,,
BLADE SURG SAW SAG 90 MM LEN 1.2 MM BLDE THICKNESS 25.4 MM W,SUP-2166684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,118.06,76.74,,,,,,,,,,,,,
GRAFT BNE CRUSH 90 CC,SUP-2321772,CDM,C1762,CPT,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
NEEDLE BX DIA22GA FN ENDOSCP SHARKCORE,SUP-2174334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1103.40,717.21,,,,,,,,,,,,,
BLADE DERMTOM W25MM,SUP-2319878,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE BNE THK 0.5 MM SCREW DIA1.7 MM PLL POLYGLYCOLIDE POLY,SUP-2883265,CDM,C1713,HCPCS,0278,RC,,,,both,,,11668.99,7584.84,,,,,,,,,,,,,
HC Mammo Dgx Unilateral Incl Cad if Perf,PX-4017706500,CDM,77065,CPT,0401,RC,,,,outpatient,,,629.00,408.85,,,,,,,,,,,,,
SCREW BNE COMPR LNG THRD 3.2X10 MM,SUP-2399955,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
BLADE SAW OSCILLATING CLASSIC 19MM/13MMW X90MML 1.37MM THK I,SUP-2605832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,81.99,53.29,,,,,,,,,,,,,
ALLOGRAFT BNE SHFT FIB,SUP-2321802,CDM,C1713,HCPCS,0278,RC,,,,both,,,2439.78,1585.86,,,,,,,,,,,,,
SLEEVE FEM L9MM PROX HIP PMMA MOD CNTR GENERATION 4,SUP-2406629,CDM,C1776,CPT,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
CATHETER HD SET 0.035 INX60 CM 12 FRX13 CM DL ACUTE YOU-BEND,SUP-2763037,CDM,C1752,HCPCS,0278,RC,,,,both,,,192.73,125.27,,,,,,,,,,,,,
CATHETER ETER CTRL VEN PED 42FR L71CM SGL LUMN TISS INGROWTH,SUP-2126553,CDM,C1751,HCPCS,0278,RC,,,,both,,,841.30,546.84,,,,,,,,,,,,,
ALLOGRAFT TISS DEHYDR 2X3 CM AMNIO MEMBRN AMBIO2,SUP-2242545,CDM,V2790,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE BONE 2 H STR RIG GRD 1/3 COMMERCIALLY PURE TI CRAN,SUP-2277530,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.71,96.01,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-15863,CDM,J3490,HCPCS,0258,RC,00338-0077-04,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
BLOCK CUT RT FEM TIB GUID LCK OUT KT JBCS VISIONAIRE JOURNEY,SUP-2351442,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
VALVE AORT CRYOVALVE SZ 25 MM AORT ALLGRFT CONDUIT NS,SUP-2175240,CDM,C1889,HCPCS,0278,RC,,,,both,,,36251.30,23563.34,,,,,,,,,,,,,
NAIL IM L240MM OD8.5MM HUM PICCOLO,SUP-2152630,CDM,C1713,HCPCS,0278,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP L25MM OD6-5FR 0.035IN BRAID TRCE,SUP-2169216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
SPACER SPNL CRV 0 DEG 27X11X6 MM TRANSFORAMINAL PLATEAU,SUP-2430683,CDM,C1889,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
PROBE LASER CYCLOPHOTOCOAGULATION FOR GLAUCOMA PROC MICROPULSE,SUP-2247220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SLING UROLOGICAL MID-URETHRAL TRNSVAG 1 ADVANTAGE FIT ULTRA,SUP-2876040,CDM,C1771,HCPCS,0278,RC,,,,both,,,6126.14,3981.99,,,,,,,,,,,,,
STEM FEM CEM 9 HIP EXT ALPINE,SUP-2315834,CDM,C1776,CPT,0278,RC,,,,both,,,6079.04,3951.38,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 9/64X9 IN 4 PT STYL SMOOTH PLN STRL,SUP-2150500,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.23,9.90,,,,,,,,,,,,,
PLATE BNE W17.5XL142MM THK5.2MM 8 H BILAT S STL BROAD LIMIT,SUP-2185289,CDM,C1713,HCPCS,0278,RC,,,,both,,,1400.28,910.18,,,,,,,,,,,,,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-40840058,CDM,2580000003,HCPCS,0258,RC,00264-7751-00,NDC,,both,250,ML,6.40,4.16,,,,,,,,,,,,,
MATRIX WOUND SM AMNIOTIC FLUID COVER NUCEL,SUP-2715851,CDM,C1765,HCPCS,0278,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
CATHETER ETER UNIT VENT INTODUCING ROD ACCURACY 15CM,SUP-2243868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10100.94,6565.61,,,,,,,,,,,,,
GRAFT BNE SUB 7GA 8CC CA PHSPTE SYR DISPENSER GUN CANN,SUP-2348206,CDM,C1713,HCPCS,0278,RC,,,,both,,,7762.49,5045.62,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DECATHLON DF CHRONIC STD 16FR DIA 36CM,SUP-2613311,CDM,C1750,HCPCS,0278,RC,,,,both,,,1134.17,737.21,,,,,,,,,,,,,
BLADE ARTHSCP SHV L8CM DIA2.5MM AGG SERR,SUP-2363530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.89,261.23,,,,,,,,,,,,,
HC Abd Paracentesis W Guide|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3614908300,CDM,49083,CPT,0361,RC,,,73,both,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW BNE 3X28 MM,SUP-2365612,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.64,53.72,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER SHT 25X9X9 MM PLIF BIO AVS UNILIF,SUP-2632328,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
K-WIRE THR DMD PT .045X9,SUP-2818085,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.22,225.69,,,,,,,,,,,,,
PUMP VENT ASST BLD L PERICARD MINIATURIZED FULL OUTPT LESS,SUP-2282536,CDM,C1713,HCPCS,0278,RC,,,,both,,,234401.00,152360.65,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 80 CM DIA 5 FR TIP 3 MM SPC YEL,SUP-2248650,CDM,C1730,HCPCS,0272,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
CATHETER URODYN 5FR L30CM 2 LUMN,SUP-2168936,CDM,C1726,HCPCS,0272,RC,,,,both,,,70.68,45.94,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 117290] ORTHOFIX INC],SUP-2315988,CDM,C1769,HCPCS,0272,RC,,,,both,,,441.48,286.96,,,,,,,,,,,,,
SCREW BONE CORTEX 1.5X6 MM RAPID RESORBABLE STERILE RAPIDSOR,SUP-2838540,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
WIRE STRL K,SUP-2361764,CDM,C1713,HCPCS,0278,RC,,,,both,,,440.86,286.56,,,,,,,,,,,,,
SCREW BNE PART THRD MINI 3.5X36 MM CANN TI,SUP-2316482,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
STEM FEM L300MM OD9MM RT HIP POR NONCOATED TYP 1 TAPR PRI,SUP-2406682,CDM,C1776,CPT,0278,RC,,,,both,,,19932.72,12956.27,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 7CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2462361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.13,536.33,,,,,,,,,,,,,
GUIDEPIN SURG DIA1/8IN ARTHSCP SCR GUID ASNS 2,SUP-2362448,CDM,C1769,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
PLATE BNE L60MM THK1.2MM DISTANCE BTWN H 9MM CALCNL TI FOR,SUP-2190978,CDM,C1713,HCPCS,0278,RC,,,,both,,,1811.12,1177.23,,,,,,,,,,,,,
GRAFT MTRX DERM PTCH SFT TISS REP 10X10CM,SUP-2335294,CDM,Q4128,HCPCS,0636,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
NEEDLE ENDOSCP INJ 23 GAX5 MM 28 MMX230 CM W/CHANNEL SM BWL,SUP-2313414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,86.76,56.39,,,,,,,,,,,,,
SHOE ORTHOT ADDITION TOE TAP STD,SUP-2435739,CDM,L3550,HCPCS,0274,RC,,,,both,,,25.31,16.45,,,,,,,,,,,,,
ISOSORB DINITRATE-HYDRALAZINE 20-37.5 MG PO TABS,RX-41893,CDM,6370000000,HCPCS,0637,RC,72319-0012-03,NDC,,both,1,UN,7.60,4.94,,,,,,,,,,,,,
CAGE SPNL 16X20MM TI ANT LUM THRD REDUC PROF INTERFIX,SUP-2291788,CDM,C1889,HCPCS,0278,RC,,,,both,,,16029.26,10419.02,,,,,,,,,,,,,
SCREW BNE L26MM DIA3.5MM PROX HUM NONLOCKING T15 LO PROF 110017726] ZIMMER BIOMET TRAUMA],SUP-2411565,CDM,C1713,HCPCS,0278,RC,,,,both,,,145.95,94.87,,,,,,,,,,,,,
BUTTON SEPTAL 2 PC DEV 3X25X0.64 MM PLASTI PORE,SUP-2637860,CDM,C1889,HCPCS,0278,RC,,,,both,,,723.17,470.06,,,,,,,,,,,,,
GRAFT HUM TISS 0.75CC CART EXTRACELLULAR MTRX FOR SCAFFOLD,SUP-2120735,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
SAMPLER SET BRONCHSCP LG 85 DEG CLOSED LOOP ORNG ASCOPE 4,SUP-2752995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
ALLOGRAFT BNE SM 3.1-3.4X0.7-0.9 CMX 1.8-2.2 MM FD NAR PROF,SUP-2472010,CDM,C1889,HCPCS,0278,RC,,,,both,,,1694.34,1101.32,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.5MM CORT TI ST NONCANNULATED,SUP-2190465,CDM,C1713,HCPCS,0278,RC,,,,both,,,71.03,46.17,,,,,,,,,,,,,
OVITEX PRS PERMANENT RECTANGLE 16.5X20 CM,SUP-2914683,CDM,C1781,HCPCS,0278,RC,,,,both,,,18532.28,12045.98,,,,,,,,,,,,,
GUIDEWIRE ENDO L260CM DIA0.018IN HI PERF NOVAGOLD,SUP-2141517,CDM,C1769,HCPCS,0272,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
COCHLEAR IMPL FOR OSI300 IMPL STRL OSIA,SUP-2882743,CDM,L8690,HCPCS,0278,RC,,,,both,,,14601.31,9490.85,,,,,,,,,,,,,
BLADE RETRACTOR DISTRACTOR OLIF,SUP-2629253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1939.77,1260.85,,,,,,,,,,,,,
CATHETER HD DL 14 FRX24 CM STR TAPR TIP SLX,SUP-2269526,CDM,C1752,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
CURETTE SRGCL BRUN SIZE 0000 CUP 22.9CML 2.6MMW X 3MML CUP S,SUP-2494962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 60 CM DIA 6 MM EXTERNALLY SUPP,SUP-2266009,CDM,L8670,HCPCS,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
HC So Hemoglobin,PX-3058501866,CDM,85018,CPT,0305,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
BLADE RETRCT PED WIRE HND MAL DENIS BROWNE,SUP-2162011,CDM,C1713,HCPCS,0278,RC,,,,both,,,616.16,400.50,,,,,,,,,,,,,
BUTTON GASTRIC KIT 24 FRX35 CM ADJ APPLE SHP BLLN MINIONE,SUP-2119902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.12,331.58,,,,,,,,,,,,,
PROBESAPHYRE ALBLATION-S 60DE,SUP-2341622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
HEAD HUM SEG 48X19 MM SHLDR REV SUPER EAS COMPHSVE,SUP-2442441,CDM,C1776,CPT,0278,RC,,,,both,,,5736.78,3728.91,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 40 CM DIA 6 MM EPTFE STR TW STRL,SUP-2227653,CDM,C1768,CPT,0278,RC,,,,both,,,1251.04,813.18,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CALF SPRING WIRE DORSIFLEXION BND,SUP-2435621,CDM,L1900,HCPCS,0274,RC,,,,both,,,807.73,525.02,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 160 MM PROX/DSTL 37/20 MM,SUP-2913632,CDM,C1768,CPT,0278,RC,,,,both,,,91060.00,59189.00,,,,,,,,,,,,,
KIT CATH NEPHRO STENT,SUP-2312713,CDM,C2617,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
VALVE MITRL BIOPROS PORCINE SZ 29MM,SUP-2214278,CDM,C1889,HCPCS,0278,RC,,,,both,,,17292.77,11240.30,,,,,,,,,,,,,
SCREW BNE FT 3.2X30 MM SELF COMPR,SUP-2433779,CDM,C1713,HCPCS,0278,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
PIN PROV 27MM TARGETER,SUP-2343984,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.11,406.32,,,,,,,,,,,,,
SCREW BNE CANN SHRT THRD 4.5X68 MM 23 MM MIDFOOT HD COMPR SS,SUP-2609326,CDM,C1713,HCPCS,0278,RC,,,,both,,,1184.44,769.89,,,,,,,,,,,,,
GRAFT BNE SUB 1CC DBM GEL FRZ DRY OPTIUM,SUP-2264856,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.65,220.77,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE UNIV ECON BUCK,SUP-2336324,CDM,L4398,HCPCS,0272,RC,,,,both,,,93.38,60.70,,,,,,,,,,,,,
CANNULA SUCTION UMIDIFYING MOIST AIR STRL DISP,SUP-2471273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,909.44,591.14,,,,,,,,,,,,,
PIN BNE FIX TEMP L110MM DIA4MM MAKO,SUP-2368494,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.96,284.02,,,,,,,,,,,,,
GRAFT VASC L 50 CM DIA 8 MM PVC GEL EPTFE CARDPULM BYPS STRL,SUP-2385090,CDM,C1768,CPT,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
NAIL IM L420MM DIA9MM 130DEG STRL GRN FEM TI LCK UNREAMED,SUP-2192546,CDM,C1713,HCPCS,0278,RC,,,,both,,,3463.92,2251.55,,,,,,,,,,,,,
PLATE BNE L199MM 12 H BROAD CNTOUR 2 COMPR FOR 45MM SCR L,SUP-2411427,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.08,444.00,,,,,,,,,,,,,
SCREW SPNL ST 11.5X25 MM FIREBIRD,SUP-2658661,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
FOOTSWITCH ELECSURG BPLR GENRTR CUT/COAG 2 NS LTX,SUP-2859251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4545.68,2954.69,,,,,,,,,,,,,
SYSTEM TKR FEM PAT TIB STD GENDER SOL,SUP-2212276,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 180 CM DIA 0.035 IN TAPR L 11,SUP-2170522,CDM,C1769,HCPCS,0272,RC,,,,both,,,204.92,133.20,,,,,,,,,,,,,
COMPONENT HUM SZ 2 SHLDR NUCLS SIMPLICITI,SUP-2388772,CDM,C1776,CPT,0278,RC,,,,both,,,15304.36,9947.83,,,,,,,,,,,,,
HC Fresh Plasma 24hrs,PX-3900905900,CDM,P9059,HCPCS,0390,RC,,,,inpatient,,,491.00,319.15,,,,,,,,,,,,,
KIT PMP FILL VOL 100ML FLO RATE 2ML/HR ELASTOMERIC FIX FLO,SUP-2236817,CDM,C2626,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
PLATE BONE L30MM 14 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1049.61,682.25,,,,,,,,,,,,,
PLATE BNE L148MM 8 H S STL T SHP LOK COMPR FOR 4.5/5MM SCR,SUP-2185758,CDM,C1713,HCPCS,0278,RC,,,,both,,,2153.38,1399.70,,,,,,,,,,,,,
HC MRI - Tmj Unilat or Bilat,PX-6107033600,CDM,70336,CPT,0610,RC,,,,inpatient,,,4365.00,2837.25,,,,,,,,,,,,,
"HC So Selenium, Serum",PX-3018425566,CDM,84255,CPT,0301,RC,,,,both,,,744.00,483.60,,,,,,,,,,,,,
PROBE ELECSURG CHSL MIC ANGLED VULCAN,SUP-2848572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.10,388.11,,,,,,,,,,,,,
FRACTURE KIT 7 ML BNE CEMENT SATURATE MIXING SYS STABILIT ER,SUP-2470253,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE NAR 4.5X199 MM 12 HOLE SS DCP,SUP-2569170,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.22,233.49,,,,,,,,,,,,,
IRINOTECAN HCL 100 MG/5ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-91054,CDM,J9206,HCPCS,0636,RC,60505-6128-01,NDC,JW,both,5,ML,54.10,35.16,,,,,,,,,,,,,
SPLINT ORTHOPEDIC NT LG 10.5 IN RT HND FOREARM COLLES PADDED,SUP-2306271,CDM,L3906,HCPCS,0274,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
HC So1 Immunofluoresc per Spec 1st Ab,PX-3128834667,CDM,88346,CPT,0312,RC,,,,both,,,12.00,7.80,,,,,,,,,,,,,
CATHETER IABP AD 8FR L174MM DIA14.7MM 25ML NONFIBEROPTIC,SUP-2227415,CDM,C1725,HCPCS,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
KIT THR R 3 TIB 4 FEM KNEE RESECT GUID SPEC 2 TRUMATCH,SUP-2252932,CDM,C1713,HCPCS,0278,RC,,,,both,,,4052.48,2634.11,,,,,,,,,,,,,
PLATE BNE W10.1XL190MM THK3.5MM 18 H S STL CRV LOK COMPR,SUP-2186267,CDM,C1713,HCPCS,0278,RC,,,,both,,,2958.51,1923.03,,,,,,,,,,,,,
SET VENT EXT DRNGE HERM KT 2.7MM DIA 35CM CATH W/ STYL CRV,SUP-2244102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.19,238.67,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.4MM FOR MAXTORQUE CANN SCR SYS,SUP-2399450,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
GRAFT VASC BYPS 6 MMX60 CM STD WALL MINI CUF EPTFE DISTAFLO,SUP-2761424,CDM,C1768,CPT,0278,RC,,,,both,,,12667.07,8233.60,,,,,,,,,,,,,
INSERT TIB CNDYL STABILIZING MED 11 MM LIP X3 STRL DURAC LTX,SUP-2869662,CDM,C1776,CPT,0278,RC,,,,both,,,5177.23,3365.20,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED COSTAL CART,SUP-2867161,CDM,C1762,CPT,0278,RC,,,,both,,,2789.11,1812.92,,,,,,,,,,,,,
PIN FIX TRCR PT 5/64X9 IN PLN STEINMANN,SUP-2362521,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.81,21.33,,,,,,,,,,,,,
CATHETER VENTRICULAR EXT 1.5X28 MMX35 CM ANGLED ADPT STRIPE,SUP-2631751,CDM,C1729,HCPCS,0272,RC,,,,both,,,599.11,389.42,,,,,,,,,,,,,
DILATOR SURG DIA65MM PRB SPNL SYS DISPOSABLE ARIA,SUP-2381019,CDM,C1713,HCPCS,0278,RC,,,,both,,,2186.32,1421.11,,,,,,,,,,,,,
SYSTEM KNEE FLX CEM,SUP-2212147,CDM,C1776,CPT,0278,RC,,,,both,,,10343.16,6723.05,,,,,,,,,,,,,
HC Lactate Dehydrogenase Ldh,PX-3018361500,CDM,83615,CPT,0301,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
SUPPORT ORTHOT RIB CUST GUSSET ELASTIC,SUP-2435591,CDM,L1280,HCPCS,0272,RC,,,,both,,,247.37,160.79,,,,,,,,,,,,,
AFFINITY 2.5CMX2.5CM 7SQ CM,SUP-2314093,CDM,Q4159,HCPCS,0636,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.542,SUP-2860223,CDM,C1713,HCPCS,0278,RC,,,,both,,,49061.56,31890.01,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + XL PRIORITY STRL MEDPOR,SUP-2862760,CDM,C1713,HCPCS,0278,RC,,,,both,,,75264.45,48921.89,,,,,,,,,,,,,
SYSTEM STENT DEL SFT 14X7 MMX5X4 CM 4.5 CM NUDEL CP,SUP-2257078,CDM,C1769,HCPCS,0272,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X240 MM FRZN GAM ANTR TIBIALIS TEND,SUP-2866911,CDM,C1762,CPT,0278,RC,,,,both,,,3624.35,2355.83,,,,,,,,,,,,,
HC NM Sest. Rest Stress Single,PX-3417845100,CDM,78451,CPT,0341,RC,,,,both,,,3905.00,2538.25,,,,,,,,,,,,,
SPACER SPNL L 42X30X16MM 18DEG CP SOVEREIGN,SUP-2419572,CDM,C1821,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
PROBE LITHO 12FR L3.76MM DISP SHOCKPULSE,SUP-2421174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2247.30,1460.74,,,,,,,,,,,,,
CALCAR C BODY 40X55MM STANDARD OFFSET,SUP-2505271,CDM,C1776,CPT,0278,RC,,,,both,,,11228.64,7298.62,,,,,,,,,,,,,
ETHYL CHLORIDE EX AERO,RX-2951,CDM,6370000000,HCPCS,0637,RC,00386-0001-03,NDC,,both,116,ML,69.00,44.85,,,,,,,,,,,,,
ANCHOR SUT OD5.5MM LACTOSORB L15 COPOLYMER 2 TWO MAXBRAID 905942] ZIMMER BIOMET SPORTS MEDICINE],SUP-2212878,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SPLINT WRST FA Y L W O FOAM PD ALUMINUM PERF PREMOLDED DSGN,SUP-2195056,CDM,L3908,HCPCS,0272,RC,,,,both,,,13.75,8.94,,,,,,,,,,,,,
GUIDEWIRE VASC TAPR STD 0.014 INX205 CM 42 CM STEER AGIL,SUP-2459138,CDM,C1769,HCPCS,0272,RC,,,,both,,,1888.21,1227.34,,,,,,,,,,,,,
CEMENT BNE ARTHRPLSTY HI VISC ORTHOPEDIC N MEDICATED,SUP-2156015,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
PLATE BNE L 59 MM SCREW DIA 3.5 MM 4 SHFT H SS STR VA,SUP-2907589,CDM,C1713,HCPCS,0278,RC,,,,both,,,2472.75,1607.29,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S3173108PD,SUP-2632833,CDM,C1751,HCPCS,0278,RC,,,,both,,,675.70,439.20,,,,,,,,,,,,,
CATHETER DRNGE 24FR 4 WNG DISP FOR NEPHSTMY MALECOTS,SUP-2128993,CDM,C1729,HCPCS,0272,RC,,,,both,,,96.02,62.41,,,,,,,,,,,,,
SPLINT FNGR M W075XL18IN ALUMINUM MAL,SUP-2276739,CDM,L3933,HCPCS,0272,RC,,,,both,,,3.01,1.96,,,,,,,,,,,,,
HC Sel Cath Pulmonary Art,PX-3613601400,CDM,36014,CPT,0361,RC,,,,inpatient,,,13613.00,8848.45,,,,,,,,,,,,,
HC So Hsv IP Stain,PX-3008725366,CDM,87253,CPT,0300,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
TOOL BORING MED 9.5X10.4 MM M18 FOR TPS SYS,SUP-2363347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.75,318.34,,,,,,,,,,,,,
GRAFT BONE SUB 10CC DEMIN BONE MTRX PLUSXEMPLIFI,SUP-2417199,CDM,C9359,HCPCS,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W7MM LEG L5X5MM WIRE DIA1.5X1.5MM NIT,SUP-2194210,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
CANNULA SUCTION DIAMETER 2MM 0DEG STRAIGHT TIP BLUNT FOR MIN,SUP-2825704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,977.26,635.22,,,,,,,,,,,,,
PIN FIXATION 4.5MM THREADED CANCELLOUS,SUP-2498971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.27,227.68,,,,,,,,,,,,,
IMPLANT TIGHTROPE II ABS,SUP-2749481,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
SHEARS ENDOSCP L36CM DIA5MM ULTRASONIC CRV TIP ADAPTIVE,SUP-2219101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4208.82,2735.73,,,,,,,,,,,,,
GRAFT BNE 25CC DBM SHP,SUP-2364717,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PASSER SUT PERC W/18G SPNL NDL,SUP-2121828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
LINER WLK BOOT VENTURE TALL M,SUP-2151035,CDM,L4386,HCPCS,0274,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
KIT HAD CATH L24CM DIA15FR TIP TO CUF 19CM TWO LUMN LNG,SUP-2383437,CDM,C1750,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
CATHETER HAD AD OVERALL L72CM L55CM DIA14.5FR CARBOTHANE,SUP-2283953,CDM,C1881,HCPCS,0278,RC,,,,both,,,1331.05,865.18,,,,,,,,,,,,,
EXTRACTOR SURG FEM,SUP-2361690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.30,410.99,,,,,,,,,,,,,
GRAFT BNE SUB W25XL100MM THK3MM B TCP SYN TISS STRP CHRONOS,SUP-2182832,CDM,C1713,HCPCS,0278,RC,,,,both,,,3845.72,2499.72,,,,,,,,,,,,,
SCREW SHT TRCR FOR AG FEM NAT NAIL SYS 80MM,SUP-2198682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.37,565.09,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX19 CM PALINDROMIC EMERALD,SUP-2174236,CDM,C1750,HCPCS,0278,RC,,,,both,,,1786.03,1160.92,,,,,,,,,,,,,
DEVICE ENDSCPC FXTN 1650MML RTTBLE OPNCLSE FNCTNLTY QCKCLPP,SUP-2675479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.98,421.84,,,,,,,,,,,,,
BLADE SAW SM HUB STYL FOR OSTEOTMY,SUP-2107136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ATLS + HF SZ 5 CM 36 J 40 CC TI POLYUR,SUP-2357757,CDM,C1882,HCPCS,0275,RC,,,,both,,,63742.00,41432.30,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZ DRY ALLGRFT CANC CORT DWL BONE 12MM,SUP-2307025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
RETRACTOR SYS DP SCROT,SUP-2140289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
CARTRIDGE BNE TUNN L12MM L CURVTEK,SUP-2212882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
CATHETER DRAINAGE SINGLE LUMEN 0.035 IN 6 FRX25 CM UTHANE,SUP-2168611,CDM,C1729,HCPCS,0272,RC,,,,both,,,186.58,121.28,,,,,,,,,,,,,
CATHETER THROMCTMY L 65 CM DIA 6 FR GUIDEWIRE 0.018 IN STRL,SUP-2140133,CDM,C1757,HCPCS,0272,RC,,,,both,,,1818.06,1181.74,,,,,,,,,,,,,
PIN FIX L14MM DIA2.7MM PROV FOR VAR ANG PLATING SYS,SUP-2343967,CDM,C1713,HCPCS,0278,RC,,,,both,,,1227.46,797.85,,,,,,,,,,,,,
PLATE BNE 2X5 H CRANIOMAXILLOFACIAL TI Y SHP FOR 1MM SCR,SUP-2190608,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.49,652.92,,,,,,,,,,,,,
SLEEVE KNEE RIGID SUPP ADJ JT,SUP-2388160,CDM,L1832,HCPCS,0272,RC,,,,both,,,2659.58,1728.73,,,,,,,,,,,,,
GRAFT HUM TISSUE 200 SQ CM XL THK2.4MM +/-0.4MM CNTOUR PERF RDY TO USE,SUP-2113446,CDM,Q4116,HCPCS,0636,RC,,,,both,,,24077.52,15650.39,,,,,,,,,,,,,
PLATE BONE L35MM BLDE W9.2XL80MM 90DEG 6 H BILAT S STL LCK,SUP-2185368,CDM,C1713,HCPCS,0278,RC,,,,both,,,2974.93,1933.70,,,,,,,,,,,,,
JOINT WRST 3 STD CRPL UHMWPE FRDM,SUP-2852881,CDM,C1776,CPT,0278,RC,,,,both,,,4387.46,2851.85,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.7MM LOK FOR R3CON TECHNOLOGY GORILLA,SUP-2321280,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
PLATE BNE W13.5XL214MM THK4.2MM 12 H BILAT S STL NAR LIMIT,SUP-2185248,CDM,C1713,HCPCS,0278,RC,,,,both,,,1743.23,1133.10,,,,,,,,,,,,,
IMPLANT BIO L 7 X W 10 CM FISH SKIN DERMAL FEN 11 INTACT,SUP-2909299,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9815.64,6380.17,,,,,,,,,,,,,
BIT DRILL 4.8MM DIA 11INL JACOBS CHUCK END DISPOSABLE,SUP-2588690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.42,359.07,,,,,,,,,,,,,
PIN FIX L229MM OD2.4MM S STL SMOOTH DMND PT SGL END BAYNT,SUP-2304040,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.45,10.69,,,,,,,,,,,,,
PLATE BNE 3D PRNT SM MIDFACE MAND TI TRUMATCH,SUP-2860366,CDM,C1713,HCPCS,0278,RC,,,,both,,,19313.83,12553.99,,,,,,,,,,,,,
STEM FEM SZ 1 STD OFFSET TAPR HIP REV CLP,SUP-2216934,CDM,C1776,CPT,0278,RC,,,,both,,,11822.10,7684.36,,,,,,,,,,,,,
MESH HERN W30XL26CM FLAT BG VCRL,SUP-2220334,CDM,C1781,HCPCS,0278,RC,,,,both,,,2407.38,1564.80,,,,,,,,,,,,,
KIT INTRO VSI L 12 CM DIA 6 FR NIT MANDREL SS TIP SIL,SUP-2763485,CDM,C1892,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
NAIL IM L38CM DIA10MM 135DEG L TROCHANTERIC LIME TI CANN,SUP-2347220,CDM,C1713,HCPCS,0278,RC,,,,both,,,15152.86,9849.36,,,,,,,,,,,,,
SHEETS NON-WOVEN WEB 35MMX35MM 1.4X1.4,SUP-2826683,CDM,C1763,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
COLLAR CERV L13-16IN H3.25IN M TRACH OPN W/ CHIN SUPP ADJ,SUP-2197923,CDM,L0120,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
KIT JEJUSTMY TB 22FR L45CM SIL INFL SECUR-LOK TAPR DST TIP,SUP-2124612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
BIT DRL CALIB 4.8X180 MM QC,SUP-2315869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.14,282.84,,,,,,,,,,,,,
NAIL IM CANN 130 DEG 12X340 MM RT DSTL TI STRL TFN- ADV,SUP-2180616,CDM,C1713,HCPCS,0278,RC,,,,both,,,8292.65,5390.22,,,,,,,,,,,,,
TEMPLATE SURG PLATE 11 STD RT CRAN MESHED,SUP-2482598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1060.85,689.55,,,,,,,,,,,,,
BASEPLATE TIB CEM SM UNIV 15 MM HIP PS NP PRIMARY STEM REV,SUP-2253234,CDM,C1776,CPT,0278,RC,,,,both,,,4384.70,2850.05,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 8 PACK,SUP-2855642,CDM,C2642,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
CATHETER VASC DIAG SIM 1 PERIPH W/ HYDRPHLC COAT AD RADPQ,SUP-2141099,CDM,C1887,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
PLATE SPNL L27.5MM ANT CERV BILAT TI VAR ANG LO PROF ZEPHIR,SUP-2291218,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SCREW BNE LAG 4.1X36 MM T10 TI,SUP-2364509,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
PLATE BONE 7 H TI LCK 3RD TBLR,SUP-2419536,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
GUIDEWIRE VASC PULSE SPRY L 60 CM DIA 0.035 IN FLPY TIP L 2,SUP-2118467,CDM,C1769,HCPCS,0272,RC,,,,both,,,241.15,156.75,,,,,,,,,,,,,
INSERT TIB ONLAY KNEE 30453659S] MAKO],SUP-2265745,CDM,C1776,CPT,0278,RC,,,,both,,,1660.56,1079.36,,,,,,,,,,,,,
COMPONENT FEM KNEE CRUC RET MIC LT UNISX REV CEM STEM PC,SUP-2201426,CDM,C1776,CPT,0278,RC,,,,both,,,18532.28,12045.98,,,,,,,,,,,,,
PACEMAKER CARD PHILOS SR-B SINGLE CHMBR 6 CONN UPLR SSIR,SUP-2137962,CDM,C1786,HCPCS,0275,RC,,,,both,,,8647.56,5620.91,,,,,,,,,,,,,
KIT EXT FIX WRST SELF DRL RADLUC LO PROF,SUP-2316309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3826.15,2487.00,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.018IN TIP L5CM L1MM RADPQ 1MM,SUP-2385553,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.66,56.33,,,,,,,,,,,,,
ALLOGRAFT BNE 1-4 MM 15 CC FD IRRADIATED CORTICAL CANC,SUP-2866827,CDM,C1762,CPT,0278,RC,,,,both,,,671.18,436.27,,,,,,,,,,,,,
VALVE VENT DRNGE RT ANG PROGRAMMABLE W/ INTEGR PLAS CONN,SUP-2243809,CDM,C1729,HCPCS,0272,RC,,,,both,,,14668.20,9534.33,,,,,,,,,,,,,
STEM FEM SZ 2 L124MM NK L30MM 132DEG ANG CEM ACCOLADE C,SUP-2364227,CDM,C1776,CPT,0278,RC,,,,both,,,8977.89,5835.63,,,,,,,,,,,,,
SPACER SPNL W18XH8-11XL45MM LUM INTBDY FUS EXP CTRL DISC HT,SUP-2230738,CDM,C1821,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
SLEEVE WIRE 1.4MM SGL CHAMBER,SUP-2905212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
PROSTHESIS OSS SANNA PISTON 0.5X6 MM TRIM FLROPLAS PLAT,SUP-2638117,CDM,L8613,CPT,0278,RC,,,,both,,,631.83,410.69,,,,,,,,,,,,,
WASHER ORTHPDC 65MM DIA FLAT SPDR COUNTSINK NON ST,SUP-2722546,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
BEARING HUM DIA36-44MM STD E1 FOR COMPHSVE REV SHLDR SYS,SUP-2408946,CDM,C1776,CPT,0278,RC,,,,both,,,4841.88,3147.22,,,,,,,,,,,,,
TRIAL SHLDR 36MM -4MM YEL TI GLEN HD,SUP-2197202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PROBE OPHTH VITRECTOMY 20 GA ACTIVE ASPIR ENDOPROBE,SUP-2225676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
DILATOR BAL ESOPH QNT TTC INFLATED DIAM 20MM 60FR BAL LEN,SUP-2170068,CDM,C1726,HCPCS,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209753000,CDM,97530,CPT,0420,RC,,,KX|CQ|XU,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE COMPRSS BROAD CRVD 9 HL 115MM,SUP-2705336,CDM,C1713,HCPCS,0278,RC,,,,both,,,2591.60,1684.54,,,,,,,,,,,,,
SCREW BONE PROX LCK S STL CONQ FN 7.5MMX95MM,SUP-2341201,CDM,C1713,HCPCS,0278,RC,,,,both,,,2165.56,1407.61,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5 MM 4 HOLE CONTOURED 2 COMPR FOR SCR,SUP-2479199,CDM,C1713,HCPCS,0278,RC,,,,both,,,1148.80,746.72,,,,,,,,,,,,,
NEEDLE INJ LL 18 GA 5 MMX43 CM,SUP-2767580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.95,422.47,,,,,,,,,,,,,
SCREW BNE LAG 2.4X12 MM CARNIO MXLFCL HPS,SUP-2319410,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
NAIL IM L300MM DIA16MM R LAT FEM AQUA TI CANN LOK CRV ENTRY,SUP-2179787,CDM,C1713,HCPCS,0278,RC,,,,both,,,5361.99,3485.29,,,,,,,,,,,,,
HC Gases Blood Ph Only,PX-3018280000,CDM,82800,CPT,0301,RC,,,,both,,,246.00,159.90,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2.3 MM MANDIBULAR ST NS AXS,SUP-2909484,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.70,210.40,,,,,,,,,,,,,
PLATE BNE STRIKE,SUP-2589504,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
ELECTRODE SUCTION SPATULA 5X330 MM,SUP-2850570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,826.76,537.39,,,,,,,,,,,,,
TUBE ENDOTRACHEAL L 34 CM OD 7.9 MM ID 5 MM SIL DUALCUFF BLU,SUP-2891630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.84,517.95,,,,,,,,,,,,,
DRILL SURG PATELLO FEM JT PEG TAIL GENDER SOL,SUP-2437891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
PLATE BNE ANAT RT HND 7 HOLE EXT NS DVR,SUP-2414029,CDM,C1713,HCPCS,0278,RC,,,,both,,,2295.34,1491.97,,,,,,,,,,,,,
KIT HDSET COMM SMRT PRGMR GU PROX US INTERSTIM,SUP-2281684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN TAPR 3CM HYDRPHLC NIT STR,SUP-2148167,CDM,C1769,HCPCS,0272,RC,,,,both,,,112.41,73.07,,,,,,,,,,,,,
TUBE GASTMY W/LMA TUBE 7X70 MM F/LIPPGOLECKI AIRWY SET,SUP-2775409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.63,595.81,,,,,,,,,,,,,
ROD SPNL CRV 75 MM,SUP-2211122,CDM,C1713,HCPCS,0278,RC,,,,both,,,1238.16,804.80,,,,,,,,,,,,,
SCREW BNE LAG 12.7X130 MM CANN THRD 1 STP SS NS DHS DCS,SUP-2547618,CDM,C1713,HCPCS,0278,RC,,,,both,,,988.63,642.61,,,,,,,,,,,,,
COMPONENT ARTC SURF PS 12 MM KNEE,SUP-2208666,CDM,C1776,CPT,0278,RC,,,,both,,,1965.77,1277.75,,,,,,,,,,,,,
BLADE ENDO L10CM DIA5MM HK TIP ELECTRD SCALP OPN DISECT,SUP-2218961,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.34,275.82,,,,,,,,,,,,,
CATHETER CV BEDSIDE SET 018 4 FRX60 CM SPECTRUM TURBO-JECT,SUP-2759827,CDM,C1751,HCPCS,0278,RC,,,,both,,,351.84,228.70,,,,,,,,,,,,,
PROBE ELECSURG CHSL STR INTEGR VULCAN,SUP-2848574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,526.83,342.44,,,,,,,,,,,,,
PROSTHESIS OTO L5MM OD4MM HA MID EAR OSS PART OFFSET HD FULL,SUP-2284003,CDM,L8613,CPT,0278,RC,,,,both,,,1564.03,1016.62,,,,,,,,,,,,,
HC Place Cath Subclavian Art,PX-3613622500,CDM,36225,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 20 CM DIA12 MM POLYESTER BOV CLLGN STR,SUP-2227541,CDM,C1768,CPT,0278,RC,,,,both,,,1401.29,910.84,,,,,,,,,,,,,
CANNULA BNE CEMENT END-DELIVERY 11 GA 200 MM DRL ACCUPORT,SUP-2866861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
HC Debrid Wound Tis 20 Cm/<,PX-4209759700,CDM,97597,CPT,0420,RC,,,,both,,,583.00,378.95,,,,,,,,,,,,,
SUTURE ANCHR L15.5MM DIA6.5MM TI TWO 2 FIBERWIRE CRKSCR,SUP-2121529,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
BIPOLAR SHELL 43MM OD,SUP-2501841,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CLIP INT LIG MED TI BLU,SUP-2757592,CDM,C1889,HCPCS,0278,RC,,,,both,,,8.07,5.25,,,,,,,,,,,,,
BAR EXT FIX L200MM DIA6MM SACR S STL THRD,SUP-2187004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1851.44,1203.44,,,,,,,,,,,,,
STENT BILI AD L120MM DIA7MM CATH 6FR L80CM SHTH 0.035IN,SUP-2170734,CDM,C1876,HCPCS,0278,RC,,,,both,,,3026.80,1967.42,,,,,,,,,,,,,
BLADE 2MM DIA TURBINATOR ELONG TIP IRRIG DIEGO SYS SMOOTH,SUP-2313837,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.94,251.51,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 23 CM DIA 5 FR 80CM 0.021IN STR,SUP-2740594,CDM,C1892,HCPCS,0272,RC,,,,both,,,154.96,100.72,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 18 MM 4 CHANNEL PRASS PR SM HUB STRL,SUP-2901991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.85,383.40,,,,,,,,,,,,,
PLATE BNE L L57MM 5DEG 7 H NONSTERILE L 1ST MTP FUS TI VAR,SUP-2181236,CDM,C1713,HCPCS,0278,RC,,,,both,,,4021.15,2613.75,,,,,,,,,,,,,
HC Placement of J-Tube,PX-3614401500,CDM,44015,CPT,0361,RC,,,,outpatient,,,10303.00,6696.95,,,,,,,,,,,,,
CATHETER SET 3 FRX55 CM PRO-PICC,SUP-2269766,CDM,C1751,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
"HC Creatinine,Serum",PX-3018256500,CDM,82565,CPT,0301,RC,,,,both,,,103.00,66.95,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO CRV PLATE 12 PK,SUP-2935575,CDM,C1713,HCPCS,0278,RC,,,,both,,,23367.88,15189.12,,,,,,,,,,,,,
STENT 2 PIGTAIL 28CM 8FR URETERAL NITINOL HYDROPHILIC,SUP-2655872,CDM,C2625,HCPCS,0278,RC,,,,both,,,325.90,211.83,,,,,,,,,,,,,
MATRIX BIO L 7 X W 20 CM SZ 252 SQCM FISH SKIN DERMAL MESHED,SUP-2909277,CDM,Q4158,HCPCS,0636,RC,,,,both,,,14867.90,9664.13,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR QAUDRI LAT BRIM,SUP-2435673,CDM,L2510,HCPCS,0274,RC,,,,both,,,2283.35,1484.18,,,,,,,,,,,,,
SCREW SPNL LCK 4.5 MM SS SHILLA,SUP-2630595,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CATHETER ABLAT 8FR L115CM 2-5-2MM SPC TIP 3.5MM 6 ELECTRD D,SUP-2248601,CDM,C1732,HCPCS,0278,RC,,,,both,,,4374.02,2843.11,,,,,,,,,,,,,
MESH SURG 20X16 CM BIOMATERIAL INTRAPERITONEAL ENFORM,SUP-2435396,CDM,C1781,HCPCS,0278,RC,,,,both,,,18582.52,12078.64,,,,,,,,,,,,,
IMPLANT TOE L16MM D2MM LCTSRB CPLMR THRDD RSRBBLE HMMRTOE WE,SUP-2477252,CDM,C1776,CPT,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
CATHETER GUID RAPIDO L 75 CM WORKING L 69 CM OD 6 FR ID 4.9,SUP-2148899,CDM,C1887,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
JOINT TOE HAMRTOE 10 DEG 3.3 MM TOE-LEGIT,SUP-2749828,CDM,C1776,CPT,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP APRON,SUP-2435539,CDM,L0457,HCPCS,0274,RC,,,,both,,,2815.80,1830.27,,,,,,,,,,,,,
CATHETER PERIPHERAL ENTENDED DWELL ENDURNC SYSTEM 22GAX8,SUP-2744558,CDM,C1751,HCPCS,0278,RC,,,,both,,,169.25,110.01,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0250,RC,00990-7984-20,NDC,,both,1000,ML,1164.50,756.92,,,,,,,,,,,,,
HC So Drug Scrn Quan Levetiracetam,PX-3018017766,CDM,80177,CPT,0301,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
DM-GUAIFENESIN ER 30-600 MG PO TB12,RX-27543,CDM,6370000000,HCPCS,0637,RC,63824-0056-32,NDC,,both,1,UN,2.90,1.88,,,,,,,,,,,,,
TRIAL BONE PLT 7 H TI SEMI TBLR TC-100 L FRAG SYS,SUP-2343743,CDM,C1713,HCPCS,0278,RC,,,,both,,,752.31,489.00,,,,,,,,,,,,,
MESH HERN L15XW15CM POLY OVL W O HYDRGEL BARR IMPL PARIETEX,SUP-2174804,CDM,C1781,HCPCS,0278,RC,,,,both,,,652.34,424.02,,,,,,,,,,,,,
SHUNT CAR W/O RESVR N PROGRAMMABLE 9FR 15CM,SUP-2264205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ LG AD PEDIATRIC LT HND WRST FNGR SEP,SUP-2264311,CDM,L3807,HCPCS,0274,RC,,,,both,,,171.92,111.75,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MINI GHST L 40CM DIA 3.5FR 3CM 4.5MM,SUP-2659698,CDM,C1725,HCPCS,0272,RC,,,,both,,,1405.02,913.26,,,,,,,,,,,,,
BRACE UNIV WRST UNI L 8IN 45IN 95IN FRM FIT,SUP-2319285,CDM,L3809,HCPCS,0272,RC,,,,both,,,28.32,18.41,,,,,,,,,,,,,
DEFIBRILLATOR CARD W/ HM LUMAX 740 DX,SUP-2138277,CDM,C1722,HCPCS,0275,RC,,,,both,,,43018.00,27961.70,,,,,,,,,,,,,
MOD DMND KNEE SYS W/O PAT,SUP-2212167,CDM,C1776,CPT,0278,RC,,,,both,,,9971.23,6481.30,,,,,,,,,,,,,
PATCH CV HEMACAROTID L 75XW 8MM THK0.65MM POLYESTER BOV PK1,SUP-2540303,CDM,C1768,CPT,0278,RC,,,,both,,,381.04,247.68,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 3.9X0.25X20 MM JAGWIRE TRUETOME,SUP-2417749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1238.95,805.32,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 18 CM DIA 6 FR POLYUR AQ BRAIDED,SUP-2836071,CDM,C2617,HCPCS,0278,RC,,,,both,,,270.45,175.79,,,,,,,,,,,,,
GRAFT HUM TISS W3XL6CM MTRX CRD AMNION,SUP-2418326,CDM,C1762,CPT,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
PLUG ARTHROSCOPIC 2.4MM TIBIAL ACL/PCL TUNNEL,SUP-2370388,CDM,C1713,HCPCS,0278,RC,,,,both,,,140.17,91.11,,,,,,,,,,,,,
NAIL IM L360MM OD10MM TIB INTERCOMPRESSION,SUP-2362519,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
HC Allo Cryo Infusion,PX-3623824001,CDM,38240,CPT,0362,RC,,,,both,,,1411.00,917.15,,,,,,,,,,,,,
SCREW BONE 7X30MM INTRF BIOABSRB 1.5MM CANN TI LTX STRL,SUP-2341646,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.76,387.89,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC ALLGRFT FLOWABLE OSTEOAMP SEL,SUP-2931046,CDM,C1762,CPT,0278,RC,,,,both,,,1921.62,1249.05,,,,,,,,,,,,,
CATHETER US 8FR L90CM 4 W STEERING PRECIS FOR SIEMENS,SUP-2248453,CDM,C1759,HCPCS,0272,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
PLATE BNE MESH PANEL 1/1.5X85X54X0.2 MM SCRN TI NS LEVEL 1,SUP-2496233,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.94,1072.46,,,,,,,,,,,,,
CATHETER TRAY PWR INJ 7 FRX20 CM CV 3L,SUP-2120603,CDM,C1751,HCPCS,0278,RC,,,,both,,,544.48,353.91,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 45 X 44 X 7 X 3 MM POLYETHYL RT,SUP-2935970,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
HC So Ca 125,PX-3028630466,CDM,86304,CPT,0302,RC,,,,outpatient,,,221.00,143.65,,,,,,,,,,,,,
TIBIAL INSRT CR SZ 1 11MM,SUP-2221132,CDM,C1776,CPT,0278,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
SAW SURG CAPTURE 0.040 IN W/ HNDL N-K II,SUP-2449162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
WASHER EXT FIX CPL HOFFMANN,SUP-2457050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
PROBE SURG MENIS 10-3/8 IN 1.8 MM TIP STR SS,SUP-2488622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.62,322.80,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7118,SUP-2525311,CDM,C1769,HCPCS,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
SHUNT VLV FLSH RESERVOIR 14X14.7X600 MMX10 CM 15 CM H2O ADJ,SUP-2846931,CDM,C1889,HCPCS,0278,RC,,,,both,,,13038.60,8475.09,,,,,,,,,,,,,
HC So Sgpt (Alt),PX-3018446066,CDM,84460,CPT,0301,RC,,,,inpatient,,,37.00,24.05,,,,,,,,,,,,,
STEM FEM L100MM OD16MM UNIV STD TI KNEE REV CEM FLUT STR,SUP-2406965,CDM,C1776,CPT,0278,RC,,,,both,,,3553.38,2309.70,,,,,,,,,,,,,
ALBUTEROL SULFATE (5 MG/ML) 0.5% IN NEBU|DISCARDED DRUG NOT ADMINISTE,RX-251,CDM,J7611,HCPCS,0636,RC,00487-9901-30,NDC,JW,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE SM BNE SYS TCP SYS,SUP-2457686,CDM,C1713,HCPCS,0278,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
HC Niv Venous Duplex Uni/Ltd Study,PX-9219397100,CDM,93971,CPT,0921,RC,,,,both,,,1625.00,1056.25,,,,,,,,,,,,,
TITANIUM FIXATION SCREW 45MM RED DEVICE,SUP-2679222,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.72,336.52,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM SCREW DIA1.5 MM TI RT,SUP-2935836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
DEROTATOR TB 55MM SPNL APCL LEG INSTR CDH,SUP-2287752,CDM,C1713,HCPCS,0278,RC,,,,both,,,1838.75,1195.19,,,,,,,,,,,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,0250,RC,00338-0117-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
HEPARIN NA (PORK) LOCK FLSH PF 10 UNIT/ML IV SOLN,RX-162827,CDM,J1642,HCPCS,0636,RC,64253-0222-35,NDC,,both,3,ML,54.10,35.16,,,,,,,,,,,,,
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-102330,CDM,J3480,HCPCS,0636,RC,00338-0695-04,NDC,,both,1000,ML,69.00,44.85,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 260 MM DIA22/13 MM DEL,SUP-2934213,CDM,C1713,HCPCS,0278,RC,,,,both,,,22144.72,14394.07,,,,,,,,,,,,,
SCREW BNE L 145 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931838,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.30,134.09,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.025IN TAPR 7 CM FLPY TIP 2 CM,SUP-2167651,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.26,22.27,,,,,,,,,,,,,
PLATE BNE L98MM 6 H NONSTERILE L LAT PROX TIB LOK FOR 3.5MM,SUP-2348470,CDM,C1713,HCPCS,0278,RC,,,,both,,,9944.54,6463.95,,,,,,,,,,,,,
BRACE ORTHOPEDIC LBR AFO ADJ,SUP-2265018,CDM,L4205,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SET INTRO 12FR L15CM DIA4MM CYSTIC DUCT ACCS PRT INTO PERI,SUP-2168313,CDM,C1894,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
WIRE FIX L100MM OD.9MM SM FOR 2-2.5MM SCR 1 END TRCR PIN K,SUP-2392808,CDM,C1713,HCPCS,0278,RC,,,,both,,,29.05,18.88,,,,,,,,,,,,,
SET URET STENT SOFFLX L 26 CM DIA10 FR INSRTR L 40 CM DIA10,SUP-2171244,CDM,C2617,HCPCS,0278,RC,,,,both,,,350.93,228.10,,,,,,,,,,,,,
BIT DRL L230MM DIA3.2MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.77,538.70,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 10FR L300CM WRK CHN 3.7MM STD PLUG,SUP-2149700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.38,256.35,,,,,,,,,,,,,
GUIDEWIRE ORTH METATRSL GRP LAPIDUS CLMP SYS NS LF,SUP-2881091,CDM,C1769,HCPCS,0272,RC,,,,both,,,3178.78,2066.21,,,,,,,,,,,,,
CATHETER EP CRD 10 MM 6 FRX120 CM BPLR RESPON,SUP-2356821,CDM,C1730,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
MONITOR CRD IMPL CNFRM,SUP-2356336,CDM,C1764,HCPCS,0278,RC,,,,both,,,8832.82,5741.33,,,,,,,,,,,,,
PLATE DERMTOM W4IN STD BLDE GRD AIR ACCURATE ARTC SIMP,SUP-2204023,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X50 MM 6.35 MM PEDCL FOR ROD RED LEG,SUP-2288978,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 5 CM DIA 5 MM CATH DIA 0.018 IN,SUP-2638547,CDM,C1889,HCPCS,0278,RC,,,,both,,,326.53,212.24,,,,,,,,,,,,,
KIT SHUNT W CLS TIP LUM CATHETER STRATA,SUP-2278370,CDM,C1729,HCPCS,0272,RC,,,,both,,,15707.60,10209.94,,,,,,,,,,,,,
HC Aaa Screening Ultrasound,PX-4027670600,CDM,76706,CPT,0402,RC,,,,outpatient,,,881.00,572.65,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 5 MM EPTFE STR TW N RING,SUP-2396333,CDM,C1768,CPT,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND SHLDR ADJ AIRPLANE DESIGN,SUP-2435791,CDM,L3960,HCPCS,0274,RC,,,,both,,,2055.04,1335.78,,,,,,,,,,,,,
STEM TIB SMOOTH MID 12 MM TOT ANK COAT INBONE II,SUP-2472121,CDM,C1776,CPT,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
HC Porphobolinogen Urine Qual,PX-3008410666,CDM,84106,CPT,0300,RC,,,,both,,,396.00,257.40,,,,,,,,,,,,,
PROBE ES TEMP HOT AND CLD FAST ACCURATE SFT FLX CIRCA S CATH,SUP-2164521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
PLATE BONE 5 H TI STR LO PROF FOR 2.4MM SCR,SUP-2123113,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
ANCHOR SUT BIOCRYL RAPIDE PUSH IN W/ 2 ETHBND GRYPHON,SUP-2249332,CDM,C1713,HCPCS,0278,RC,,,,both,,,2389.54,1553.20,,,,,,,,,,,,,
NEEDLE ENDOSCP STR 18 CM SHRT CRV F/660530 HNDL,SUP-2773876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.63,243.51,,,,,,,,,,,,,
HC Bil Duct Dila W/ W/O Stent S&I,PX-3207436300,CDM,74363,CPT,0320,RC,,,,both,,,2584.00,1679.60,,,,,,,,,,,,,
PLATE BONE W17.4XL79.8MM THK1.65MM TI LCK WEB FOR 2.5MM SCR,SUP-2411749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
CANNULA ENDOSCP LL 11 MMX6.5 CM STOPCOCK ANGLED N THRD GRN,SUP-2771889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1125.34,731.47,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT THERMOCOOL L 130 CM DIA,SUP-2248934,CDM,C1732,HCPCS,0272,RC,,,,both,,,7831.16,5090.25,,,,,,,,,,,,,
CATHETER HD STR 28 CM 23 CM SINGLE VLV VASCPAK BIOFLO,SUP-2459559,CDM,C1750,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TAPR L 4.5 CM FLX TIP L,SUP-2167752,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.46,20.45,,,,,,,,,,,,,
KIT PEG 20FR SFTY PUSH METHD MIC,SUP-2236710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,295.32,191.96,,,,,,,,,,,,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2151,HCPCS,0636,RC,63323-0024-25,NDC,,both,25,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT FEM M H10MM DSTL SPCR RNG ENDO MOD TILASTAN,SUP-2265088,CDM,C1776,CPT,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
STEM FEM SZ 2 L115MM NK L32MM 36MM OFFSET 132DEG HIP FORGED,SUP-2375349,CDM,C1776,CPT,0278,RC,,,,both,,,6256.14,4066.49,,,,,,,,,,,,,
PACEMAKER CRD 2 CHMBR AFFIN DR,SUP-2357334,CDM,C1785,HCPCS,0275,RC,,,,both,,,16799.00,10919.35,,,,,,,,,,,,,
PLATE BNE STD UNIV TALONAVICULAR STRATUM,SUP-2607271,CDM,C1713,HCPCS,0278,RC,,,,both,,,3995.49,2597.07,,,,,,,,,,,,,
GRAFT DURA W1XL3IN WHT CLLGN POR MTRX ABSRB PLIABLE,SUP-2244079,CDM,C1763,HCPCS,0278,RC,,,,both,,,800.64,520.42,,,,,,,,,,,,,
FIBER LASER FLEXIVA PULSE TRACTIP 242 EACH,SUP-2716207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1533.36,996.68,,,,,,,,,,,,,
BLADE SHAVER RESECT 4.5X120 MM FULL RAD LIGHT GRN UNIDRIVE,SUP-2585907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.94,243.06,,,,,,,,,,,,,
PLATE CRAN L 45.7 X W 45.7 MM THK 0.5 MM SCREW DIA1.5 MM SM,SUP-2936881,CDM,C1713,HCPCS,0278,RC,,,,both,,,2719.24,1767.51,,,,,,,,,,,,,
CATHETER URET WVN OLV TIP 6 FR 70 CM,SUP-2126411,CDM,C1729,HCPCS,0272,RC,,,,both,,,227.56,147.91,,,,,,,,,,,,,
KIT ABLATION RF MULTI-COOLED 17GA 5CM,SUP-2236770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
BIT DRL 2.4MM S STL DISP CINCHLOCK,SUP-2378804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HC So Prolactin,PX-3018414666,CDM,84146,CPT,0301,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
DRILL SURG 6 MM GENDER SOL N-K FLX,SUP-2438081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 131MML HLX10 STNLSS STEEL CNTRD,SUP-2588605,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.93,662.30,,,,,,,,,,,,,
DILTIAZEM HCL 125 MG/25ML IV SOLN,RX-97167,CDM,J1163,HCPCS,0636,RC,00641-6015-10,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SCREW COMPR 2.4X11MM HEADLESS TI SHRT THRD STRL,SUP-2547016,CDM,C1713,HCPCS,0278,RC,,,,both,,,850.50,552.82,,,,,,,,,,,,,
AGENT HEMSTAT 10ML MTRX W/ MALL TRIM TIP FLOSEAL,SUP-2129982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1062.64,690.72,,,,,,,,,,,,,
PLATE BNE H1.5MM 6 H 140DEG MAND G TI FULL AND HALF FRAC,SUP-2366369,CDM,C1713,HCPCS,0278,RC,,,,both,,,2023.38,1315.20,,,,,,,,,,,,,
REPAIR KIT CRUC BUTTON PK,SUP-2121320,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT HUM TISS W3-10MMX26-38CM SEMITENDINOSUS TEND FRZN,SUP-2307285,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
HC So1 Assay of Psa Total,PX-3018415367,CDM,84153,CPT,0301,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GAX12.5 CM MAMMO,SUP-2120047,CDM,C1819,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
COLLAR CERV ADJ SM AD 10-20 IN 2 IN W/ PD MIAMI J,SUP-2196886,CDM,L0174,HCPCS,0274,RC,,,,both,,,143.56,93.31,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS PAT W/ EXT MECHANISM ASP,SUP-2875981,CDM,C1762,CPT,0278,RC,,,,both,,,15869.56,10315.21,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.4MM HD DIA3.5MM CORT TI ST FULL THRD,SUP-2189554,CDM,C1713,HCPCS,0278,RC,,,,both,,,223.57,145.32,,,,,,,,,,,,,
HC Arthrogram Wrist S&I,PX-3227311500,CDM,73115,CPT,0322,RC,,,,both,,,601.00,390.65,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.505,SUP-2860022,CDM,C1713,HCPCS,0278,RC,,,,both,,,34831.71,22640.61,,,,,,,,,,,,,
GRAFT BNE EVANS WDG 18X15X7 MM STRL RIPTIDE LTX,SUP-2866951,CDM,C1713,HCPCS,0278,RC,,,,both,,,6298.53,4094.04,,,,,,,,,,,,,
PLATE BONE SHAFT 258MML HLX18 STRGHT NRRW NON CNTCT BRDGE PO,SUP-2459815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1759.40,1143.61,,,,,,,,,,,,,
LENS INTOCU +24.0D L13MM OD6MM 0DEG A CONSTANT 119.1 CYL,SUP-2112172,CDM,V2788,HCPCS,0276,RC,,,,both,,,895.00,581.75,,,,,,,,,,,,,
HC Washed Red Blood Cells Each,PX-3900902200,CDM,P9022,CPT,0390,RC,,,,both,,,1536.00,998.40,,,,,,,,,,,,,
FORCEPS SURG 25GA FN TIP ECKARDT INT LIMITING MEMBRN PINN,SUP-2129184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.53,275.94,,,,,,,,,,,,,
BIT DRL DIA4MM GLEN CNTR H QUIK CONN MOD,SUP-2408541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
MOLD FEM STEM L135MM DIA11MM HIP SIL W/ S STL REINF,SUP-2408610,CDM,C1776,CPT,0278,RC,,,,both,,,2876.24,1869.56,,,,,,,,,,,,,
CATHETER SPEC RETRV 2 MM SINGLE LUMEN W/O VOL CAP,SUP-2312956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.13,327.68,,,,,,,,,,,,,
BOLT EXT FIX CANN FOR WIRE ILIZ,SUP-2342270,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.15,997.85,,,,,,,,,,,,,
CATHETER DRAINAGE STD LOOP 10 FRX25 CM MULTPURP EXODUS ARRY,SUP-2752492,CDM,C1729,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
INSERT HUM +12 MM HT STD 36 MM DIAM RVS POLYETH AEQUALIS,SUP-2388642,CDM,C1776,CPT,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
ENDPLATE SPNL SZ 3 H28MM DIA22MM TI MESH FOR THOR AND LUM,SUP-2254374,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
HEAD RADL SZ2 LAT STEM,SUP-2705945,CDM,C1776,CPT,0278,RC,,,,both,,,6869.85,4465.40,,,,,,,,,,,,,
PLATE BNE THK 0.75 MM SCREW DIA1.7 MM 49 H PLL POLYGLYCOLIDE,SUP-2883152,CDM,C1713,HCPCS,0278,RC,,,,both,,,11940.98,7761.64,,,,,,,,,,,,,
CATHETER CRICO L7.5CM DIA6MM UNCUF AIRWY RADPQ ACCS,SUP-2168034,CDM,C1769,HCPCS,0272,RC,,,,both,,,777.46,505.35,,,,,,,,,,,,,
ELECTRODE ENDOSCP 24-28FR 12DEG AND 30DEG HI FREQ RESECT,SUP-2314006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1954.65,1270.52,,,,,,,,,,,,,
ALLODERM SELECT RESTORE EXTRA LARGE - THICK 2.4 0.4MM,SUP-2826665,CDM,Q4116,HCPCS,0636,RC,,,,both,,,44182.94,28718.91,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT W/ NDL SUTX2 TI W/ DIL DURABRAID 3.5MM,SUP-2341043,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
PIN FIX L229MM OD2.8MM S STL SMOOTH SGL SHRP TIP TRCR PT 1,SUP-2304042,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.70,10.85,,,,,,,,,,,,,
SCREW BONE L24MM DIA5.5MM CANC BLNT ARW,SUP-2224548,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL STD M W90XL90MM THK0.6MM UPGRADED,SUP-2419458,CDM,C1713,HCPCS,0278,RC,,,,both,,,5556.10,3611.46,,,,,,,,,,,,,
WIRE ORTH SURG L280MM DIA1.25MM S STL CERCLAGE PRECUT,SUP-2186837,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.41,149.12,,,,,,,,,,,,,
SET URET STENT SOFFLX L 10 CM DIA 4.7 FR POS L 50 CM DIA 4.7,SUP-2168905,CDM,C2617,HCPCS,0278,RC,,,,both,,,419.10,272.41,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 6.5FRX45CM 30 DEG CRV 0.038 IN,SUP-2355582,CDM,C1894,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
ROD EXT FIX L60MM THRD SALVATION,SUP-2401128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.014IN COR STR SHARPEABLE TIP,SUP-2385226,CDM,C1769,HCPCS,0272,RC,,,,both,,,331.27,215.33,,,,,,,,,,,,,
KNIFE SRGCL YASRGL MICRO 7 14NL 2 14NL WRKNG 3MMW TIP ARCH,SUP-2669630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,304.33,197.81,,,,,,,,,,,,,
CARTRIDGE BLADE PRECIS,SUP-2364807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
PLATE BONE W24XL24MM THK0.5MM CRAN ORBIT FLR RAP RESRB W/,SUP-2194080,CDM,C1713,HCPCS,0278,RC,,,,both,,,2890.37,1878.74,,,,,,,,,,,,,
DEVICE FIX OD9-10MM LNG FEM ANCHR SFT TISS FOR ABV 50MM,SUP-2212830,CDM,C1776,CPT,0278,RC,,,,both,,,2240.20,1456.13,,,,,,,,,,,,,
SHEATH INTRO SWARTZ L 81 CM DIA 8 FR TRANSSEPTAL LAMP CRV,SUP-2357234,CDM,C1893,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PORT IMPL INFUSION BVL 2.2X90 MM MIS SS,SUP-2419687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZN ALLGRFT TIB CORT STRUT BONE,SUP-2294186,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
SLING ORTHOT LUMBAR CUST,SUP-2435580,CDM,L1090,HCPCS,0274,RC,,,,both,,,284.89,185.18,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 PLU MAXBARR 4FR 55C 1194108D3,SUP-2632631,CDM,C1751,HCPCS,0278,RC,,,,both,,,983.45,639.24,,,,,,,,,,,,,
DEVICE EMBOLIC COMANECI NON-OCCL 0.5-3MM 22MM BRAIDED,SUP-2854062,CDM,C1889,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
CYCLOSPORINE 25 MG PO CAPS,RX-9707,CDM,J7515,HCPCS,0636,RC,68084-0879-95,NDC,,both,1,UN,21.60,14.04,,,,,,,,,,,,,
PATCH CV PERI-GUARD SZ 6 X 8 CM BOV PERICARD FOR SFT TISS,SUP-2129887,CDM,C1763,HCPCS,0278,RC,,,,both,,,2067.85,1344.10,,,,,,,,,,,,,
CATHETER PTCA L130CM BLLN L20MM DIA6MM 0.035IN PERIPH,SUP-2294968,CDM,C2623,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.421,SUP-2859985,CDM,C1713,HCPCS,0278,RC,,,,both,,,36482.40,23713.56,,,,,,,,,,,,,
GRAFT HUM TISS 1CC CART EXTRACELLULAR MTRX INJ BIOCART,SUP-2120736,CDM,C1713,HCPCS,0278,RC,,,,both,,,2769.48,1800.16,,,,,,,,,,,,,
GUIDEWIRE ARTHSCP L10IN DIA2.4MM NIT DRL TIP SMOOTH FLX W/O,SUP-2341319,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SCREW BNE COMPR 3X8 MM LP HD BITE,SUP-2645005,CDM,C1713,HCPCS,0278,RC,,,,both,,,821.58,534.03,,,,,,,,,,,,,
GUIDEWIRE ORTH SUPER STIFF 2.2X500 MM SHLDR MARKER AEQUALIS,SUP-2715408,CDM,C1769,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PEEK CANN A,SUP-2417906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
DEVICE BLOWER/MISTER AXIUS,SUP-2717309,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.05,113.13,,,,,,,,,,,,,
GRAFT BNE SPNL SPCR PARA CERV IMPL ALLGRFT L12XW145XH10MM,SUP-2264900,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.63,1608.51,,,,,,,,,,,,,
PUNCH OPHTH DIA9MM DONOR CORNEAL CYL DEL SHRP NONVACUUM,SUP-2261438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,190.91,124.09,,,,,,,,,,,,,
BLADE SAW MIC OSC AND SAG CUT EDGE .347IN THICKNESS .020IN,SUP-2367315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
PLATE BONE L4MM THK0.5MM 90DEG SH 3X3 H BILAT MAXILLOFACIAL,SUP-2181818,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.41,710.07,,,,,,,,,,,,,
LEAD PACE SELUTE PICOTIP L 45 CM POLYUR SIL ENDOCARD RT,SUP-2148629,CDM,C1898,HCPCS,0275,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
GRAFT BNE SUB 5ML 1.7-10MM CANC CHIP MORSELIZED FRZ DRY,SUP-2307076,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CATHETER GUID CROSSCATH L 150 MM DIA PROX/DSTL 4.8/3.7,SUP-2170841,CDM,C1887,HCPCS,0272,RC,,,,both,,,441.39,286.90,,,,,,,,,,,,,
TRIAL PIN L25MM DIA2MM PROV FOR TEMP FIX,SUP-2344024,CDM,C1713,HCPCS,0278,RC,,,,both,,,865.01,562.26,,,,,,,,,,,,,
CAGE SPINL EXCEED INTERBODY DEVICE 25 MM L X 10 MM W X 13 MM H,SUP-2934655,CDM,C1889,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
RETRACTOR SURG L40MM OPENER CLOSER INSTR EXP MTRX X TUBE,SUP-2293012,CDM,C1713,HCPCS,0278,RC,,,,both,,,2562.77,1665.80,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA LOW BEND 16H 232MM RT STER,SUP-2546876,CDM,C1713,HCPCS,0278,RC,,,,both,,,5197.67,3378.49,,,,,,,,,,,,,
LINER ACET DUR 0 DEG 28MM ID 50-52MM OD,SUP-2376137,CDM,C1776,CPT,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SET DRNGE CATH 14FR L29CM SIDEPRT 19 NDL L9CM CONN TUBE,SUP-2171162,CDM,C1729,HCPCS,0272,RC,,,,both,,,815.77,530.25,,,,,,,,,,,,,
HOLDER NDLE TRTMN 4 3/4NL 9MML JAW CRVD ROUND HNDLE DLCTE W/,SUP-2476573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,780.76,507.49,,,,,,,,,,,,,
GRAFT DERMAL N FEN 4X4 CMX2.2-3.5 MM DERMAL MTRX PARADERM,SUP-2742065,CDM,C1763,HCPCS,0278,RC,,,,both,,,5863.17,3811.06,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO CRV PLATE 1 PK STRL,SUP-2935385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-120973,CDM,2500000003,HCPCS,0250,RC,63323-0417-01,NDC,,both,10,ML,132.30,85.99,,,,,,,,,,,,,
PLATE BNE L25MM THK33MM 2 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185123,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.32,489.66,,,,,,,,,,,,,
PLATE BONE L166MM THK4.5MM 7 H LT LAT TIB HD BTTRS TI RIG,SUP-2190895,CDM,C1713,HCPCS,0278,RC,,,,both,,,2685.27,1745.43,,,,,,,,,,,,,
BASEPLATE TIB SZ 2 L MEDIAL/RIGHT LAT UNI KNEE TI ONLAY FOR,SUP-2368580,CDM,C1776,CPT,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,0636,RC,00409-9735-01,NDC,,both,1,UN,57.80,37.57,,,,,,,,,,,,,
SCREW BONE L85MM DIA4MM CANC T20 FULL THRD SM FRAG PLATING,SUP-2350007,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.65,330.62,,,,,,,,,,,,,
STAPLER INT EXTRA THICK 60 MM W/ TRI-STAPLE BLK GIA,SUP-2787697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1525.76,991.74,,,,,,,,,,,,,
COLLAR CERV AD H25XL22IN UNIV FIRM DENS CNTOUR HK LOOP CLSR,SUP-2276585,CDM,L0120,HCPCS,0272,RC,,,,both,,,8.07,5.25,,,,,,,,,,,,,
CLAMP AD MULTIPLANAR FOR LIMB RECON SYS,SUP-2316079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4760.81,3094.53,,,,,,,,,,,,,
CATHETER GUIDE EXTN 7 FRX150 CM HYDRPHLC COAT TELSCP,SUP-2416548,CDM,C1887,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
CEMENT BNE 2GM HA CA PHSPTE MID EAR RESRB OTOMIMIX,SUP-2313856,CDM,C1713,HCPCS,0278,RC,,,,both,,,1345.96,874.87,,,,,,,,,,,,,
NEEDLE INJ LL 21 GA 5 MMX36 CM,SUP-2767266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
TRIAL BONE PLT 3 H T SHP OBLQ TC-100 SM FRAG SYS,SUP-2343729,CDM,C1713,HCPCS,0278,RC,,,,both,,,1952.36,1269.03,,,,,,,,,,,,,
BRACE KNEE HNG WRP SM,SUP-2276702,CDM,L1820,HCPCS,0274,RC,,,,both,,,56.05,36.43,,,,,,,,,,,,,
HC Dest Botox-Ea Add Ext 1-4 Musc,PX-5106464300,CDM,64643,CPT,0510,RC,,,,inpatient,,,2154.00,1400.10,,,,,,,,,,,,,
PLATE BNE LP LG LT SUP CLAV 8 HOLE MIDSHAFT ACU-SINCH,SUP-2106985,CDM,C1713,HCPCS,0278,RC,,,,both,,,3362.94,2185.91,,,,,,,,,,,,,
HC So Gram Stain Smear,PX-3008720566,CDM,87205,CPT,0300,RC,,,,both,,,22.00,14.30,,,,,,,,,,,,,
BLADE 24X45MM S STL MEDL SLD CERV RETRCT SYS,SUP-2108277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.81,586.18,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND CUST ADJ FIT W/O JT FABRICATED,SUP-2435762,CDM,L3762,HCPCS,0272,RC,,,,both,,,1928.18,1253.32,,,,,,,,,,,,,
STRAP CLAV M BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194671,CDM,L3670,HCPCS,0272,RC,,,,both,,,14.73,9.57,,,,,,,,,,,,,
CATHETER VENTRICULAR STR 1.3X2.5X23 CM LG HOLE SLT TIP,SUP-2851432,CDM,C1729,HCPCS,0272,RC,,,,both,,,510.56,331.86,,,,,,,,,,,,,
COIL EMB 2MMX4CM HELI MIC NEUROVASC XSFT MIC NEUROVASC,SUP-2249161,CDM,C1889,HCPCS,0278,RC,,,,both,,,5700.26,3705.17,,,,,,,,,,,,,
KIT CATH HEMODIALYSI PWR TRIALYSI ACUTE 13FR DIA 20CML INSER,SUP-2613245,CDM,C1752,HCPCS,0278,RC,,,,both,,,896.78,582.91,,,,,,,,,,,,,
DRILL SRGCL TWIST HAND 11MM DIA 85MML F/BTTRY OPRTD SCRWDRV,SUP-2668855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.74,504.23,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DECANAV L 115 CM DIA 7 FR 10,SUP-2764134,CDM,C1732,HCPCS,0278,RC,,,,both,,,2417.49,1571.37,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF SHORT 3X15 MM RADIAL DISTAL TITAN,SUP-2836764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,843.69,548.40,,,,,,,,,,,,,
CONNECTOR SPNL DIA5.5X5.5MM TI OPN SIDE LD ROD TO ROD ARMDA,SUP-2311885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
EXTERNAL FIXATION SET MINI CALCANEAL FIX FIX SYS CALCFIX +,SUP-2875652,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.45,520.29,,,,,,,,,,,,,
PLATE BNE L36MM THK1MM 2X6 H NONSTERILE CNDYL HND TI LOK VAR,SUP-2181007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.15,1071.30,,,,,,,,,,,,,
KIT SZR SZ 1-4 INSTR,SUP-2242118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PLATE RAD INTMD CLMN 2.4MM +90DEG 2H HD 4H SHFT TI STRL,SUP-2546764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2569.78,1670.36,,,,,,,,,,,,,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,6370000000,HCPCS,0637,RC,00378-3352-16,NDC,,both,1,UN,83.60,54.34,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.7MM CORT S STL ST LOK FULL THRD T8,SUP-2183363,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.21,206.84,,,,,,,,,,,,,
CATHETER ANGIOPLASTY OTW 0.018 IN 130CM 5X120MM  018 DCB,SUP-2757488,CDM,C1725,HCPCS,0272,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 16X8 CM HYDRATED BIOLOGIC TISSUE MA,SUP-2838611,CDM,C1763,HCPCS,0278,RC,,,,both,,,11877.99,7720.69,,,,,,,,,,,,,
SCREW BNE L50MM DIA4MM S STL CANN LNG HALF THRD SM HEX SOCK,SUP-2183792,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.32,303.11,,,,,,,,,,,,,
PLATE 3.5 MM TI LCP POSTEROMEDIAL PROX TIBIA 8 H/157 MM STER,SUP-2546840,CDM,C1713,HCPCS,0278,RC,,,,both,,,3914.51,2544.43,,,,,,,,,,,,,
BRACE ANK 2 X SM M SHOE 3-5 WOMEN SHOE 4-6 AD SWEDE O X8,SUP-2325306,CDM,L1930,HCPCS,0272,RC,,,,both,,,68.42,44.47,,,,,,,,,,,,,
PLATE BNE L 202 MM 6 H SCREW DIA 3.5/4.5 MM LT TROCHANTERIC,SUP-2931428,CDM,C1713,HCPCS,0278,RC,,,,both,,,20637.65,13414.47,,,,,,,,,,,,,
HC L-Spine Bend Only 2-3 Views,PX-3207212000,CDM,72120,CPT,0320,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
KIT SPNL IMPL FIX SHIM MAXCESS,SUP-2310425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
TRIAL KNEE SZ 2 AP56MM ML60MM R FEM HI PERF CRUCE RET FOR PR,SUP-2436185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
DUAL-LUMEN URETERAL CATHETER,SUP-2827461,CDM,C1758,HCPCS,0278,RC,,,,both,,,106.82,69.43,,,,,,,,,,,,,
HC Alkaline Phosphatase,PX-3018407500,CDM,84075,CPT,0301,RC,,,,inpatient,,,161.00,104.65,,,,,,,,,,,,,
RING ACET SZ 21 HIP UHMWPE MOD PRI REPL RNGLOC +,SUP-2403377,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT DURA ABSRB STRL 7IN 4IN PORCINE SURGISIS BIODESIGN,SUP-2169998,CDM,C1763,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CONNECTOR SPINE SACR AND SACR IL S STL 6.35MM COLORADO 2,SUP-2290621,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE PRECIS 100 H2O MED HI RANG HAKIM,SUP-2666824,CDM,C1889,HCPCS,0278,RC,,,,both,,,5851.61,3803.55,,,,,,,,,,,,,
BIT DRILL J LATCH 1.8X88 MM 20 MM WITH STOP TITANIUM NON STE,SUP-2837619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.46,530.05,,,,,,,,,,,,,
ELEVATOR SURG W066XL12IN S STL SATIN FINISH PERIOST CRV COBB,SUP-2161314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.47,340.26,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SUPRAMALLEOLAR,SUP-2435625,CDM,L1907,HCPCS,0274,RC,,,,both,,,1593.11,1035.52,,,,,,,,,,,,,
ANCHOR BONE W/ ARTHSCP DEL SYS ADV,SUP-2334700,CDM,C1713,HCPCS,0278,RC,,,,both,,,1813.35,1178.68,,,,,,,,,,,,,
GRAFT BONE PRIMAGEN 5CC,SUP-2402836,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
NXSTAGE PUREFLOW B RFP-400,RX-4082402,CDM,2580000003,HCPCS,0250,RC,40861-0102-77,NDC,,both,5000,ML,136.60,88.79,,,,,,,,,,,,,
SYNPOR SMOOTH SQUARE SHEET,SUP-2823308,CDM,C1713,HCPCS,0278,RC,,,,both,,,1784.78,1160.11,,,,,,,,,,,,,
BLADE RETRACTOR MALL UNIV 2X8 IN ABD RNG W/ LIP,SUP-2465270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,895.25,581.91,,,,,,,,,,,,,
LOCKING SCREW TKA TIBIAL AUGMENT 5MM,SUP-2813238,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
GRAFT BNE STRP 12 CC ISOTIS PURE,SUP-2644343,CDM,C1713,HCPCS,0278,RC,,,,both,,,6729.02,4373.86,,,,,,,,,,,,,
COMPONENT HUM SHLDR CONSTRUCT COMPHSVE,SUP-2212467,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
NAIL INTRAMEDULLARY MINI 7X140MM FOR MEDIAL COLUMN FUSION,SUP-2878226,CDM,C1713,HCPCS,0278,RC,,,,both,,,23722.70,15419.75,,,,,,,,,,,,,
SEGMENT FEM COMP M SZ 3 W65XH50MM LT DSTL TILASTAN,SUP-2265083,CDM,C1776,CPT,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
GUIDEWIRE ORTH OD5MM 3 3.5 4 4 M KT CANN SCRDRVR 2IN 1 DRL,SUP-2225502,CDM,C1769,HCPCS,0272,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
NAIL IM 11X300 MM TIB TI LIGHT GRN NS,SUP-2179844,CDM,C1713,HCPCS,0278,RC,,,,both,,,4935.08,3207.80,,,,,,,,,,,,,
STENT PERIPH INNOVA L 150 MM DIA 5 MM CATH L 160 CM WORKING,SUP-2146844,CDM,C1876,HCPCS,0278,RC,,,,both,,,5573.50,3622.77,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L6MM INDWL 2 VLV BLOM-SINGER,SUP-2242331,CDM,L8509,HCPCS,0272,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
HC Electro Cerebral Silence,PX-7409582400,CDM,95824,CPT,0740,RC,,,,both,,,4157.00,2702.05,,,,,,,,,,,,,
GRAFT HUM TISS SZ 12 MM BICORTICAL FT WDG PRESHAPED EVANS,SUP-2913204,CDM,C1713,HCPCS,0278,RC,,,,both,,,8182.84,5318.85,,,,,,,,,,,,,
BLADE RETRACTOR KOCHER 9 IN 38X20 MM SLIGHTLY CRV,SUP-2458460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.39,227.10,,,,,,,,,,,,,
GRAFT HUM TISS DIA21MM THK10MM MT LENGTHENING DISC,SUP-2321681,CDM,C1776,CPT,0278,RC,,,,both,,,8077.65,5250.47,,,,,,,,,,,,,
PLATE BONE HLX16 TTNM STRGHT PRPLE FNRO SSTM CRNFCL,SUP-2676832,CDM,C1713,HCPCS,0278,RC,,,,both,,,661.63,430.06,,,,,,,,,,,,,
HC Iaad Ia Hepatitis B Surface Antigen,PX-3068734000,CDM,87340,CPT,0306,RC,,,,both,,,554.00,360.10,,,,,,,,,,,,,
SPACER PREFRM FEM L 74 MM TIB L 74 MM GENTAMICIN KNEE STRL,SUP-2905381,CDM,C1776,CPT,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
NECK FEM 2XL L65MM 126DEG TAPR 12/14MM OFFSET 40MM TILASTAN,SUP-2265100,CDM,C1776,CPT,0278,RC,,,,both,,,12886.56,8376.26,,,,,,,,,,,,,
BIT DRL L94MM OD2.5MM FOR 3.5MM SCR,SUP-2243614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.92,397.10,,,,,,,,,,,,,
GUIDEWIRE INTRO L 230 MM DIA1.6 MM ENTRY TROCAR FOR FIBULAR,SUP-2909115,CDM,C1769,HCPCS,0272,RC,,,,both,,,129.53,84.19,,,,,,,,,,,,,
SHELL ACET DIA40MM F/M TI ALLOY POR UNIHOLED PRI REV UNIV,SUP-2202331,CDM,C1776,CPT,0278,RC,,,,both,,,4837.17,3144.16,,,,,,,,,,,,,
ANCHOR SUT Y KNOT RC 3 LD W 3 NUMBER 2 HI FI SUTS W NDL,SUP-2418757,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.85,1374.00,,,,,,,,,,,,,
STEM FEM STD OFFSET 6-10 W/ TRUNNION GLD MALLORY-HEAD EXACT,SUP-2442625,CDM,C1776,CPT,0278,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
PLATE BNE L107MM THK1.5MM 3X8 H L S STL OBLQ T SHP LOK,SUP-2186030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1225.42,796.52,,,,,,,,,,,,,
BLADE SCREWDRIVER CANN MINI 3.5 MM HEX AO,SUP-2321269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CATHETER PERIPHERALLY INSERTED CTRL VEN 28GA W/ 24GA INTRO,SUP-2394006,CDM,C1751,HCPCS,0278,RC,,,,both,,,134.39,87.35,,,,,,,,,,,,,
PLATE BNE 5 H TI L DST CORONOID FIBULAR MOD FOR 2.5MM SCR,SUP-2411727,CDM,C1713,HCPCS,0278,RC,,,,both,,,3053.34,1984.67,,,,,,,,,,,,,
PLATE BONE DIA70MM THK1.5MM NONSTERILE CRANIOMAXILLOFACIAL,SUP-2191127,CDM,C1713,HCPCS,0278,RC,,,,both,,,5226.22,3397.04,,,,,,,,,,,,,
CATHETER PICC 4FR NIT GWIRE L135CM SGL LUMN BASIC TY,SUP-2125532,CDM,C1751,HCPCS,0278,RC,,,,both,,,384.15,249.70,,,,,,,,,,,,,
CHOLANGIOGRAPHY SET FRANK 0.025 IN 4 FRX60 CM,SUP-2737155,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CATHETER HD SET 15 FRX19 CM 21 GA DL AG MIC PUNC INTRO,SUP-2762999,CDM,C1750,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
BIT DRL L160MM DIA2.7MM CANN QUIK CPL ADJ STP REUSE FOR,SUP-2187336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1021.47,663.96,,,,,,,,,,,,,
PIN REDUC L180MM OD6MM TRAUM,SUP-2362538,CDM,C1713,HCPCS,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
BIT DRL DIA3MM CLAV STP SCR 2 TRAK,SUP-2107141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
PLATE TI 13 TUBULAR 10 HL,SUP-2704881,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.86,244.31,,,,,,,,,,,,,
ACL INTERNALBRACE LIGAMENT AUGMEN BUTTON,SUP-2811993,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
TOE IMPL INSRTN KT SIZE: 0 TO 7 CONTENTS: SH INSTR SET SZ,SUP-2397010,CDM,C1776,CPT,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
SCREW BNE L45MM DIA4X5MM CORT CANN HDLSS TAPR PROF ACUTRK,SUP-2107222,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
PLATE BONE L W13.5XL250MM THK4.2MM 14 H BILAT TI STR RIG,SUP-2190827,CDM,C1713,HCPCS,0278,RC,,,,both,,,2010.76,1306.99,,,,,,,,,,,,,
COMPONENT FEM STANDARD+ R KNEE CRUCE RET CEM REV NP NONBEADE,SUP-2436145,CDM,C1776,CPT,0278,RC,,,,both,,,12938.06,8409.74,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-2 MM 5 CC PRESERVON CANC READIGRAFT,SUP-2740887,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.08,334.15,,,,,,,,,,,,,
HC CT Abd/Pelvis W/O Contrast,PX-3527417600,CDM,74176,CPT,0352,RC,,,,both,,,4901.00,3185.65,,,,,,,,,,,,,
VALVE VOICE 4.5MM TRACH LT PROVOX ACTIVLV,SUP-2124317,CDM,L8509,HCPCS,0274,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
HC So Hcg Quantitative,PX-3018470266,CDM,84702,CPT,0301,RC,,,,outpatient,,,64.00,41.60,,,,,,,,,,,,,
VENLAFAXINE HCL ER 37.5 MG PO CP24,RX-27857,CDM,6370000000,HCPCS,0637,RC,00904-7487-61,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
SET INTRO SAFSHTH L 13 CM DIA 9 FR GUIDEWIRE 0.038 IN NDL 18,SUP-2137993,CDM,C1892,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5MM 9MM 120CM 8FR HEPARIN,SUP-2558722,CDM,C1768,CPT,0278,RC,,,,both,,,9391.74,6104.63,,,,,,,,,,,,,
MESH HERN CIR 4.5 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855268,CDM,C1781,HCPCS,0278,RC,,,,both,,,6876.60,4469.79,,,,,,,,,,,,,
FIBER LASER 200UM TFL EXCALIBUR TRUE THULIUM DISPOSABLE,SUP-2885345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 8 MM RNG L 10 CM EPTFE,SUP-2396299,CDM,C1768,CPT,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
SPHERE EMB EMBOZENE DIA1300 UM 2 ML PREFIL SYR HYDRGEL,SUP-2139492,CDM,C1889,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7166,SUP-2525318,CDM,C1769,HCPCS,0272,RC,,,,both,,,708.29,460.39,,,,,,,,,,,,,
KIT PLT RICH PLSM AUTOLGS REGENKT,SUP-2366727,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SCREW ATTCH POLY INSRT INFIN,SUP-2397264,CDM,C1713,HCPCS,0278,RC,,,,both,,,1576.28,1024.58,,,,,,,,,,,,,
PLATE BNE W17.5XL206MM THK5.2MM 8 H L CNDYL FEM S STL LOK,SUP-2185020,CDM,C1713,HCPCS,0278,RC,,,,both,,,4179.43,2716.63,,,,,,,,,,,,,
PLATE BNE CRV 2-2.5X29X1.5 MM 4 HOLE FRAC TI STRL LEVEL 1,SUP-2480937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1967.40,1278.81,,,,,,,,,,,,,
COIL VASC AZUR HYDROPACK L 60 CM SZ 18 MICROCATHETER 2.4/2.8,SUP-2896816,CDM,C1889,HCPCS,0278,RC,,,,both,,,5077.38,3300.30,,,,,,,,,,,,,
KIT BNE PIN L 50 MM DIA1.5 MM K WIRE DIA1.5 MM,SUP-2913324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
PLATE BNE L107MM 6 H NONSTERILE L LAT PROX TIB S STL LOK,SUP-2185608,CDM,C1713,HCPCS,0278,RC,,,,both,,,3836.08,2493.45,,,,,,,,,,,,,
GUIDEWIRE SURG L1000MM DIA3MM S STL IM SMOOTH TIP,SUP-2362246,CDM,C1769,HCPCS,0272,RC,,,,both,,,667.25,433.71,,,,,,,,,,,,,
SUTURE TIGERTAPE CERCLAGE W/O NEEDLE,SUP-2761686,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE BNE L 96 X W 10.9 MM THK 1.5 MM SCREW DIA 3.5 MM 6 H 72454506N,SUP-2932983,CDM,C1713,HCPCS,0278,RC,,,,both,,,2887.07,1876.60,,,,,,,,,,,,,
GUIDEWIRE VASC R350 L 350 CM DIA 0.013 IN RADIOPAQUE TIP L 5,SUP-2120534,CDM,C1769,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
DEVICE EXTR CATH 7-5FR L200CM GWIRE 0.035IN BAL 12MM 2.8MM,SUP-2169382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
BUR SURG 57X40MM RND DMND STD NONFLUTED ST POWERFORMA,SUP-2284213,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.18,317.97,,,,,,,,,,,,,
CONNECTOR SPNL L12MM DIA45MM LAT TI CDH LEG,SUP-2279260,CDM,C1713,HCPCS,0278,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
HEAD FEM OD32MM +0 NK LEN 12/14 TAPR CO CHROM MTL ON POLY,SUP-2205555,CDM,C1776,CPT,0278,RC,,,,both,,,3229.18,2098.97,,,,,,,,,,,,,
SCREW EMER ABSRB 2.5MMDIA 4MML,SUP-2364995,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.13,115.78,,,,,,,,,,,,,
COLLAR CERV M AD H225XL13 16IN TRACH CLS 2 PC RIG POLYETH,SUP-2196882,CDM,L0120,HCPCS,0274,RC,,,,both,,,42.01,27.31,,,,,,,,,,,,,
SET URET STENT CNTOUR L 20 CM DIA 7 FR PTFE GUIDEWIRE 0.038,SUP-2479830,CDM,C2617,HCPCS,0278,RC,,,,both,,,451.88,293.72,,,,,,,,,,,,,
SCREW CORT NON-LOCKING 90 DEG 3.8 MMX38.0 MM S3 PROX HUM,SUP-2137573,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.34,4.12,,,,,,,,,,,,,
PLATE BNE W25.5XL77MM WIDE 7X5 H NONSTERILE R DST RAD VOLAR,SUP-2184126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2368.22,1539.34,,,,,,,,,,,,,
CORE 13MM E+ SLIDING STAR TOTAL ANKLE,SUP-2878205,CDM,C1776,CPT,0278,RC,,,,both,,,8304.33,5397.81,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 8/21 ATM 75 CM 3 MMX40 CM ULTRAVERSE,SUP-2128498,CDM,C1725,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BONE L86MM 2 H RT OLECRANON TI FOR 3.5MM SCR LOQTEQ,SUP-2101273,CDM,C1713,HCPCS,0278,RC,,,,both,,,2725.52,1771.59,,,,,,,,,,,,,
BUR SURG L42MM LNG ABRAD FIT,SUP-2364284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1042.79,677.81,,,,,,,,,,,,,
HC Perc Transhep Port W/Hemo Eval,PX-3207588500,CDM,75885,CPT,0320,RC,,,,inpatient,,,7130.00,4634.50,,,,,,,,,,,,,
BIT DRL L 7.4 IN DIA2.7 MM TROCR TIP AO CONN NS DISP RIBFIX,SUP-2905463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
KIT INSTR DIA15MM CRV GUID W DRL CNTR SL FOR SFT ANCHR SYS,SUP-2212963,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
GRAFT TISS FEM CRSS SECT FRZ DRY ALLGRFT 28MM,SUP-2307160,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.61,1775.55,,,,,,,,,,,,,
METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR,RX-162819,CDM,J2919,HCPCS,0636,RC,00009-0039-28,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE ORTH 32X475 MM FOR NAILING SYS STRL TFN ADV,SUP-2183041,CDM,C1769,HCPCS,0272,RC,,,,both,,,341.41,221.92,,,,,,,,,,,,,
SCREW SPNL L14MM DIA3.5MM MINI CANC POST OCCIPITAL CERV THOR,SUP-2254389,CDM,C1713,HCPCS,0278,RC,,,,both,,,2869.96,1865.47,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BAL PERIPH OVR THE WIRE SEMI COMPLIANT,SUP-2156284,CDM,C1725,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
PLATE BNE 3.5X25 MM 2 HOLE SS DCP,SUP-2569134,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.15,114.50,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC BSC 4FR 55CM 1 LUMAN RVS TAPR PWR I,SUP-2613383,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.86,286.56,,,,,,,,,,,,,
PLATE BNE HK SM 3.5/4.5X285 MM RT FEM PROX 8 STRL VALCP,SUP-2789194,CDM,C1713,HCPCS,0278,RC,,,,both,,,8576.41,5574.67,,,,,,,,,,,,,
COIL FIL COMPLX SFT .020IN W DIA 13MM SEC DIA 48CM PENUMBRA,SUP-2323417,CDM,C1889,HCPCS,0278,RC,,,,both,,,8176.56,5314.76,,,,,,,,,,,,,
BURR SURG 10MM DIA HD LG BNE BRL FLUTEX6 FLFRVSNS SURG CEBOT,SUP-2605417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
HC Egd Diagnostic Brush Wash,PX-4504323500,CDM,43235,CPT,0450,RC,,,,both,,,2447.00,1590.55,,,,,,,,,,,,,
STEM HUM L125MM DIA10MM UNIV SHLDR CO CHROM REV CEM ANAT,SUP-2193876,CDM,C1776,CPT,0278,RC,,,,both,,,9946.48,6465.21,,,,,,,,,,,,,
COLLAR CERV M AD MIAMI J,SUP-2151872,CDM,L0172,HCPCS,0274,RC,,,,both,,,133.89,87.03,,,,,,,,,,,,,
SCREW BONE L7MM OD2.7MM DSTL TIB S STL ST LCK FULL THRD,SUP-2183360,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.42,260.92,,,,,,,,,,,,,
COMPONENT FEM SZ 4 NP RT KNEE PRI CRUC RET CEM STEMLESS,SUP-2349033,CDM,C1776,CPT,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
DRILL SURG QR 2.8 MM STRL LTX,SUP-2857677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
SCREW BNE L7MM OD23MM TI CRANIOMAXILLOFACIAL CROSSDRIVE SELF,SUP-2262805,CDM,C1713,HCPCS,0278,RC,,,,both,,,187.65,121.97,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 9 MM 2 HOLE TITANIUM LIGHT GREEN MAT,SUP-2842241,CDM,C1713,HCPCS,0278,RC,,,,both,,,220.43,143.28,,,,,,,,,,,,,
POST TAPR L31MM DIA8.5MM HEMICAP,SUP-2123529,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CANNULA OPHTH VLV 500 CPM CONSTELLATION VITRECTOMY TOT + PK,SUP-2109965,CDM,C1713,HCPCS,0278,RC,,,,both,,,2069.26,1345.02,,,,,,,,,,,,,
HC CT Colonography Screening,PX-3507426300,CDM,74263,CPT,0350,RC,,,,both,,,2769.00,1799.85,,,,,,,,,,,,,
KIT DRL BIT DIA2MM DRL GUID HNDL LOC PIN TAMP CORRESPONDING,SUP-2194161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.35,511.13,,,,,,,,,,,,,
PLATE BONE L54MM THK3.4MM 3 H BILAT NONLOCKING COMPR FOR,SUP-2348946,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.18,785.97,,,,,,,,,,,,,
PLATE BONE COMPR 4 H 20 MM,SUP-2243487,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
ELECTRODE ELECSURG LOOP CUT 90 DEG PEDIATRIC 10 FR HI FREQ,SUP-2430222,CDM,C1713,HCPCS,0278,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
SCREW BNE SM L10MM DIA1.2MM CANC CORT HND TI ST NONLOCKING,SUP-2366388,CDM,C1713,HCPCS,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
KIT COR DCOMPR 15CC FOR INJ INDUCTIVE GRFT PRO STIM,SUP-2399133,CDM,C1713,HCPCS,0278,RC,,,,both,,,23628.50,15358.52,,,,,,,,,,,,,
SCREW INTRF L28MM OD6MM BIOSTEON WDG SHP ROUNDED THRD CRUC,SUP-2366625,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.09,462.86,,,,,,,,,,,,,
IMPLANT DERM W100XL150MM CLLGN SQ SHT ALLOMAX,SUP-2125858,CDM,C1781,HCPCS,0278,RC,,,,both,,,14883.60,9674.34,,,,,,,,,,,,,
PLATE BNE 3X8 H S STL T SHP LOK COMPR LO PROF FOR 15MM MOD,SUP-2177464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.75,757.09,,,,,,,,,,,,,
RESERVOIR CSF BRDN 20 MM 1.2X2.2 MM 1.2X2.2 MM DBL DOME BTM,SUP-2852579,CDM,C1889,HCPCS,0278,RC,,,,both,,,1067.54,693.90,,,,,,,,,,,,,
SHOE ORTHOT ADDITION INSOLE RUBBER,SUP-2435738,CDM,L3510,HCPCS,0272,RC,,,,both,,,82.77,53.80,,,,,,,,,,,,,
COIL EMB L4CM PRI DIA0.020IN 2ND DIA4MM NIT COMPLX SFT FILL,SUP-2323392,CDM,C1889,HCPCS,0278,RC,,,,both,,,6904.86,4488.16,,,,,,,,,,,,,
GRAFT BNE SUB 5ML CANC CORT DBM CHIP RM TEMP FRZ DRY,SUP-2223562,CDM,C1762,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE L151MM THK3MM 8 H BILAT S STL STR LOK COMPR RECON,SUP-2185339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1524.38,990.85,,,,,,,,,,,,,
PEG BNE FIX L26MM DIA2.5MM DST VOLAR RAD PARTIALLY THRD FOR,SUP-2414247,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SCREW SPNL L50MM DIA6.5MM HA CANC PEDCL MULTIAXIAL,SUP-2287274,CDM,C1713,HCPCS,0278,RC,,,,both,,,4304.47,2797.91,,,,,,,,,,,,,
CUP ACET OD49MM ID32MM 0DEG LONGEVITY HXLPE SNAP IN SPCR,SUP-2203800,CDM,C1776,CPT,0278,RC,,,,both,,,8551.79,5558.66,,,,,,,,,,,,,
SCREW PED GIC52 6.35-6.35MM CLS LAT CON 30MM SS7021430,SUP-2286996,CDM,C1713,HCPCS,0278,RC,,,,both,,,2343.07,1523.00,,,,,,,,,,,,,
MESH HERN W10XL15CM POLYPR FLAT L PORE MFIL SFT KNIT LTWT,SUP-2125779,CDM,C1781,HCPCS,0278,RC,,,,both,,,212.89,138.38,,,,,,,,,,,,,
PIN FIX 3.1MM STNMN,SUP-2277485,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
STENT BILI ZILVER 518 L 40 MM DIA 4 MM DEL SYS L 125 CM SHTH,SUP-2170061,CDM,C1876,HCPCS,0278,RC,,,,both,,,2868.39,1864.45,,,,,,,,,,,,,
LEVEL TWIST DRILL J NOTCH MRRSN 20 MM STOP USE W/25 471 05 0,SUP-2497037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.97,310.68,,,,,,,,,,,,,
STEM FEM 12X220MM BOW LEGION,SUP-2349118,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
CAGE FUSION SPINAL MODULUS ALIF 8X34X24MM 10 DEG,SUP-2719500,CDM,C1889,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 20 CM DIA26 MM SIDE BRANCH L 15 MM DIA,SUP-2384999,CDM,C1768,CPT,0278,RC,,,,both,,,2535.80,1648.27,,,,,,,,,,,,,
PLATE BNE HK SM 3.5/4.5X354 MM RT FEM PROX 10 STRL VA-LCP,SUP-2750915,CDM,C1713,HCPCS,0278,RC,,,,both,,,9273.49,6027.77,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 10X1 CM TAPR BOV PERICARD PHOTOFIX LTX,SUP-2859713,CDM,C1768,CPT,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
WIRE FIX SMOOTH 1.1X102 MM TRCR PT KIRSCHNER,SUP-2247471,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE MESHED 2X2CM,SUP-2905482,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PIN GUIDE PARTIALLY THRD,SUP-2137364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BLADE IM L110MM DIA11MM ST G TI HNDL HELI FOR TROCHANTERIC,SUP-2191909,CDM,C1713,HCPCS,0278,RC,,,,both,,,1900.30,1235.19,,,,,,,,,,,,,
NEEDLE CIRCLE 1/2 IN SUTURE TAPER L1.950IN DIA0.056IN ABD S STL,SUP-2387188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9.36,6.08,,,,,,,,,,,,,
IMPLANT TOE JT CANN HEMI AND METATRSL HD IMPL SYS LESSER JT,SUP-2392820,CDM,C1776,CPT,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 24 IN 12-24 IN PERF FOAM,SUP-2194891,CDM,L1830,CPT,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
SCREW SPNL ROD DIA 5.5/6 MM SS REDUCTION UNIAXIAL STRL CD 2PK,SUP-2928048,CDM,C1713,HCPCS,0278,RC,,,,both,,,5683.40,3694.21,,,,,,,,,,,,,
SHOE CAST SM AD W4.25XL9.25IN W/ ROCK OPN TOE AND OPN HEEL,SUP-2203830,CDM,L4387,HCPCS,0272,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
STABILIZER ORTH CHST CIRC 48-52 IN 3XL SZ 7 POLYESTER LYCRA,SUP-2915153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.37,237.49,,,,,,,,,,,,,
BRACE WRST M FOR 17.1-19.1CM L PROTCT PD ADJ BAR D RNG CLSR,SUP-2326112,CDM,L3931,HCPCS,0274,RC,,,,both,,,50.77,33.00,,,,,,,,,,,,,
STAPLE BNE FIX SZ 45 X 14 X 11 MM LG TI ALLOY RAPID COMPR,SUP-2908955,CDM,C1713,HCPCS,0278,RC,,,,both,,,11671.38,7586.40,,,,,,,,,,,,,
COUPLER ANAS VES DIA2MM TI PURE STR MALL MICROCLIP,SUP-2382618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SHUNT SURG SM 16 GA SNAP ASMBLY BLNT NDL VLV BA STRATA NSC,SUP-2628578,CDM,C1729,HCPCS,0272,RC,,,,both,,,13667.29,8883.74,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 025 PEDIATRIC 5 FRX5 CM 3L,SUP-2760000,CDM,C1751,HCPCS,0278,RC,,,,both,,,382.73,248.77,,,,,,,,,,,,,
SPLINT WRIST FA RIGHT 7,SUP-2136568,CDM,L3809,HCPCS,0272,RC,,,,both,,,37.40,24.31,,,,,,,,,,,,,
SYSTEM IMPL MENIS ROOT REP W/ PEEK SWIVELOCK,SUP-2121865,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
CATHETER ARTERIAL 20 GAX12 CM ARTERIAL KIT WITH NEEDLE LOCKI,SUP-2838742,CDM,C1751,HCPCS,0278,RC,,,,both,,,353.56,229.81,,,,,,,,,,,,,
WIRE FIX THRD BLNT K,SUP-2232046,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BIT DRL SFT BNE 3 MM FOR 4.5/5.5 MM QUATTRO LINK ANCHR REUSE,SUP-2608883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,478.28,310.88,,,,,,,,,,,,,
ANCHOR SUT 2 DIA2.5MM BLU PLLA NONABSORBABLE ULTBRAID DBL,SUP-2341846,CDM,C1713,HCPCS,0278,RC,,,,both,,,983.67,639.39,,,,,,,,,,,,,
CATHETER VENT L35CM OD2.8MM ID1.5MM BA IMPREG EXT DRNGE AND,SUP-2284540,CDM,C1729,HCPCS,0272,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
TRAY CATH PICC GROSH BASIC 3FR 0.022IN 60CM 1 LUMAN 7755305,SUP-2632683,CDM,C1751,HCPCS,0278,RC,,,,both,,,331.58,215.53,,,,,,,,,,,,,
RETRACTOR SPINE FOR MTRX SYS,SUP-2292926,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.52,402.04,,,,,,,,,,,,,
ALLOGRAFT HUM TISS TEND FLX,SUP-2321806,CDM,C1762,CPT,0278,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
STAPLE INT WHT BLU GRN REINF FOR ENDOPATH ETS45 SEAMGRD,SUP-2395317,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE BNE RECON MAND 8 HOLE TI LEVEL 1 THREADLOCK,SUP-2497967,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.56,1267.21,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 6MM STR STD WALL SLDE GDS,SUP-2485219,CDM,C1768,CPT,0278,RC,,,,both,,,1810.52,1176.84,,,,,,,,,,,,,
GUIDEPIN FIX L9IN DIA2.4MM TRCR TIP SMOOTH SHFT,SUP-2410083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,70.37,45.74,,,,,,,,,,,,,
SHAFT DRVR L50MM DIA15MM NONCANNULATED HEX QUIK CONN,SUP-2199219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.06,578.54,,,,,,,,,,,,,
BIT DRL SELF CNTR SL ANGLED TIP FOR 4MM SCR ELLIPSE,SUP-2598932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE PROF H 0.6 MM DIA2 MM 2 H BAR 12 MM SCREW DIA2 MM,SUP-2883313,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.44,162.14,,,,,,,,,,,,,
IMPLANT COAT HA 12MM,SUP-2319778,CDM,C1776,CPT,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
MESH SYNTH ABD N ABSRB BIOMATERIAL EXP,SUP-2395365,CDM,C1781,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
MICROPOWER OSCILLATING SAW,SUP-2605738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8906.11,5788.97,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336039,CDM,L3809,HCPCS,0272,RC,,,,both,,,18.46,12.00,,,,,,,,,,,,,
CATHETER IV 4FR POLYUR SGL LUMN PWR INJ DST TRIM MAX BARR,SUP-2125693,CDM,C1751,HCPCS,0278,RC,,,,both,,,470.18,305.62,,,,,,,,,,,,,
BURR 5.5MMX19CM POLISHING HIP PRESERVATION SYSTEM,SUP-2824500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
HC Ribs Bilat 3 Vw W/O Chest,PX-3207111000,CDM,71110,CPT,0320,RC,,,,outpatient,,,732.00,475.80,,,,,,,,,,,,,
STAPLE KIT 8X8 MM INDIV ASMBLY STRL ARCUS,SUP-2482189,CDM,C1713,HCPCS,0278,RC,,,,both,,,2384.86,1550.16,,,,,,,,,,,,,
FORCEP ELECSURG BPLR 1.2 MM 22 CM IRRIGATING SILVERGLIDE,SUP-2859627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3600.20,2340.13,,,,,,,,,,,,,
DEVICE INT FIX SM 11 MM THOR SINGLE FT STRNL TALON LEVEL 1,SUP-2869145,CDM,C1713,HCPCS,0278,RC,,,,both,,,3464.96,2252.22,,,,,,,,,,,,,
PACEMAKER CARD AZURE XT SR MRI SURESCAN W 50.8 X H 42.6 MM D,SUP-2282506,CDM,C1786,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
GUIDEWIRE SOLO PLUS  .038IN STIFF  STRAIGHT,SUP-2655883,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
DART SURG L10MM FOR ARTHSCP MENIS REP DARTSTICK,SUP-2121765,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
PLEDGET SURG W1XL6IN THK1.65MM PTFE FELT RECT,SUP-2126028,CDM,C1768,CPT,0278,RC,,,,both,,,291.99,189.79,,,,,,,,,,,,,
HC So Parathyroid Hormone,PX-3018397066,CDM,83970,CPT,0301,RC,,,,both,,,308.00,200.20,,,,,,,,,,,,,
INSTRUMENT FIX MINI FIX HNG,SUP-2316470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5851.39,3803.40,,,,,,,,,,,,,
KIT NAIL INSTR CHT STICKER TENFUSE,SUP-2401377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
TUBE CHST 40FR L20IN POLYVI CHL OPN TIP STR FIRM RADPQ ARGY,SUP-2154971,CDM,C1729,HCPCS,0272,RC,,,,both,,,35.04,22.78,,,,,,,,,,,,,
PACEMAKER CARD ADAPTA W 47.9 X H 44.7 MM D 7.5 MM 12.1 CC,SUP-2282306,CDM,C1785,HCPCS,0275,RC,,,,both,,,9322.31,6059.50,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6X3 CM CRYOPRESERVED UMB CRD NEOX CRD 1K,SUP-2648688,CDM,Q4148,HCPCS,0636,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
GLIPIZIDE 5 MG PO TABS,RX-10117,CDM,6370000000,HCPCS,0637,RC,00904-6637-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE 16 H ANTR LAT PROX FOR 4.5MM SCR,SUP-2349069,CDM,C1713,HCPCS,0278,RC,,,,both,,,1777.08,1155.10,,,,,,,,,,,,,
BASKET RETRV HELI BGLY 10MM BSKT 1.9 FR X 90 CM,SUP-2139260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.68,296.84,,,,,,,,,,,,,
SCREW TUBE ORTH LAT COMMON NS REUSE PRECIS MIS,SUP-2899000,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SCREW BNE L42MM DIA3.5MM CORT ST NONCANNULATED NONLOCKING,SUP-2413376,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.76,103.19,,,,,,,,,,,,,
GRAFT VASC GELSFT + ERS 90 DEG L 100 CM DIA10 MM SIDE BRANCH,SUP-2894819,CDM,C1768,CPT,0278,RC,,,,both,,,6641.10,4316.71,,,,,,,,,,,,,
CATHETER BLLN DIL L7MM DIA7MM MAX EM SKR NUVENT,SUP-2284351,CDM,C1726,HCPCS,0272,RC,,,,both,,,1647.24,1070.71,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR PROTEGE,SUP-2615543,CDM,C1820,HCPCS,0278,RC,,,,both,,,47559.76,30913.84,,,,,,,,,,,,,
COMPONENT PAT L RESURFACE POR GEN,SUP-2344077,CDM,C1776,CPT,0278,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
PLATE BONE SM LT ANTEROLATERAL,SUP-2398500,CDM,C1713,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
SCREW SPNL L25MM OD6.5MM THORLUM REDUC LO PROF TOP LD REVERE,SUP-2231890,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
IMMOBILIZER SHLDR W ABD SM,SUP-2276608,CDM,L3670,HCPCS,0274,RC,,,,both,,,75.74,49.23,,,,,,,,,,,,,
SCREW BNE AD PED L11MM DIA2MM STD CRANIOMAXILLOFACIAL TI ST 256721191] KLS MARTIN LP],SUP-2262796,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.24,105.46,,,,,,,,,,,,,
GAUGE DEPTH FOR 27X35X4MM SCR TO 60MM,SUP-2199215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1045.31,679.45,,,,,,,,,,,,,
IMPL SPNE SN VG-VLAG-0051,SUP-2431581,CDM,C1889,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
PLATE SLIM Y 6 SHAFT HL,SUP-2695695,CDM,C1713,HCPCS,0278,RC,,,,both,,,3683.85,2394.50,,,,,,,,,,,,,
CATHETER ETER DRNGE 12FR L25CM 0038IN MCOT SFT SHFT,SUP-2168854,CDM,C1729,HCPCS,0272,RC,,,,both,,,204.16,132.70,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM S STL THRD TRCR PNT,SUP-2186897,CDM,C1713,HCPCS,0278,RC,,,,both,,,45.72,29.72,,,,,,,,,,,,,
G7 DUAL MOBILITY LINER 44MM F,SUP-2505827,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE SYNDESMOSIS 2 H BUTTRESS NS,SUP-2897149,CDM,C1713,HCPCS,0278,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
MESH CRANIAL STRAIGHT 1.5X50X50X0.5 MM RAPID RESORBABLE STER,SUP-2838582,CDM,C1713,HCPCS,0278,RC,,,,both,,,4642.18,3017.42,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 38 MM DIA 8 MM CATH L 80 CM,SUP-2884883,CDM,C1874,HCPCS,0278,RC,,,,both,,,8106.22,5269.04,,,,,,,,,,,,,
MATERIAL RESTORATIVE 38GM PWD 14ML LIQ IVRY POLYMER REINF ZN,SUP-2238586,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.59,255.18,,,,,,,,,,,,,
GRAFT BONE 0 DEGREE 6X11X11 MM ASSEMBLED PUROS-S,SUP-2414403,CDM,C1762,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CONNECTOR SPNL MULTIAXIAL SCR XLNK CLP VERTEX,SUP-2279733,CDM,C1713,HCPCS,0278,RC,,,,both,,,984.39,639.85,,,,,,,,,,,,,
PROBE PALPATION 5MM 33CM DEPTH MRK,SUP-2361235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.28,262.78,,,,,,,,,,,,,
PLATE BONE L35MM AQUA LT TOT COMPR L,SUP-2396854,CDM,C1713,HCPCS,0278,RC,,,,both,,,3133.72,2036.92,,,,,,,,,,,,,
PLATE BONE L123MM 8 H LT ANTEROLATERAL MEDL DSTL TIB LCK FOR,SUP-2348478,CDM,C1713,HCPCS,0278,RC,,,,both,,,16949.88,11017.42,,,,,,,,,,,,,
PLATE BNE L174MM 14 H L POSTEROLATERAL DST PERIARTC HUM,SUP-2198398,CDM,C1713,HCPCS,0278,RC,,,,both,,,2608.08,1695.25,,,,,,,,,,,,,
SCREW VPC 4.0X38MM,SUP-2587630,CDM,C1713,HCPCS,0278,RC,,,,both,,,937.26,609.22,,,,,,,,,,,,,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-3613240800,CDM,32408,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
STENT GRFT VASC RELAYPRO L 250 MM CVR L 259 MM DIA 26 MM,SUP-2894603,CDM,C1768,CPT,0278,RC,,,,both,,,68923.00,44799.95,,,,,,,,,,,,,
PROSTHESIS OSS L 5 MM SHFT DIA1.14 MM HD DIA 3 MM HA FLX H/A,SUP-2902123,CDM,L8613,CPT,0278,RC,,,,both,,,1445.03,939.27,,,,,,,,,,,,,
PLATE BNE THK1MM 3X2 H UNIV CRANIOMAXILLOFACIAL TI 3D,SUP-2366346,CDM,C1713,HCPCS,0278,RC,,,,both,,,991.86,644.71,,,,,,,,,,,,,
STAPLER INT CIR XL MED THCK 28 MM 3-4 MM PUR EEA,SUP-2787718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4865.81,3162.78,,,,,,,,,,,,,
SPLINT ORTH L3IN STD PLAS FNGR MLLT W/O PD STAX,SUP-2198709,CDM,L3913,HCPCS,0274,RC,,,,both,,,5.18,3.37,,,,,,,,,,,,,
TRACKER NAVIGATION EM ENT STLTH,SUP-2280208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ TAB 2.03 MM ID SIL BLU,SUP-2312637,CDM,L8699,HCPCS,0278,RC,,,,both,,,45.06,29.29,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 2.5CM X 7.5CM,SUP-2874119,CDM,A2007,HCPCS,0636,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
BUR SURG RND 2.3 MM 66 MM FLUT FOR DRL SYS SS INDIGO,SUP-2628952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,174.33,113.31,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR 16 CHANNEL OCTRODE ETERNA,SUP-2858400,CDM,C1822,CPT,0278,RC,,,,both,,,59346.00,38574.90,,,,,,,,,,,,,
BRACE ORTH 2X UPR KNEE FREE KAFO,SUP-2388169,CDM,L2036,HCPCS,0274,RC,,,,both,,,4743.47,3083.26,,,,,,,,,,,,,
BLADE CAST CUT CRD HEX 115 V 1.5 A 5060 HZ 10 FTX2.5 IN DRV,SUP-2599495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3166.22,2058.04,,,,,,,,,,,,,
BLADE SAW SAG 9.5MMW X7.5MML 0.4MM THK 0.6MM THK CUT SM BNE,SUP-2605377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,83.93,54.55,,,,,,,,,,,,,
SAW SURG STRGHT OSCLLTNG REMOVABLE LEVER FLFSMLL BNE MICROPO,SUP-2605589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9083.05,5903.98,,,,,,,,,,,,,
IMPLANT BIOINDUCTIVE M BOV ACHILLES TEND W/ ARTHSCP DEL SYS,SUP-2419470,CDM,C1763,HCPCS,0278,RC,,,,both,,,8341.41,5421.92,,,,,,,,,,,,,
HEAD HUM H17MM DIA44MM 4MM OFFSET SHLDR CO CHROM PRI TOT,SUP-2404660,CDM,C1776,CPT,0278,RC,,,,both,,,5256.36,3416.63,,,,,,,,,,,,,
GUIDEWIRE UROLOGY DBL FLX 0.035 INX145 CM 5 CM RDRUN PC,SUP-2835783,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.48,99.76,,,,,,,,,,,,,
GUIDEWIRE VASC CHIKAI L 300 CM 0.014IN L 5CM STR DURABLE TIP,SUP-2123856,CDM,C1769,HCPCS,0272,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
SPACER SPNL W11XH5XL11MM PEEK OPTMA ANT CERV INTBDY FUS,SUP-2286332,CDM,C1889,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
GUIDEWIRE TORQUABLE ANG TIP STD .035INX450CM FX WIRE,SUP-2166275,CDM,C1769,HCPCS,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
ENDCAP ORTHOPEDIC PANTA,SUP-2423079,CDM,C1713,HCPCS,0278,RC,,,,both,,,3105.37,2018.49,,,,,,,,,,,,,
ASSEMBLY KYPHOPLASTY BI PEDICULAR 15 MM W/ OUT CEMENT STRL,SUP-2846419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
STIMULATOR BNE DISP,SUP-2316220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
GRAFT BNE 20 MM DISC HA,SUP-2651597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2423.89,1575.53,,,,,,,,,,,,,
GUIDEWIRE ORTH BALL TIP 3X800 MM,SUP-2760195,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
MESH CRAN DIA23MM PROF 06MM CRANIOMAXILLOFACIAL RESORB X,SUP-2263014,CDM,C1713,HCPCS,0278,RC,,,,both,,,2215.30,1439.94,,,,,,,,,,,,,
TRAY CATH PICC LUMENX2 6FR DIA 60CML POLYURETHANE 0.69ML PRI,SUP-2613393,CDM,C1751,HCPCS,0278,RC,,,,both,,,252.14,163.89,,,,,,,,,,,,,
WASHER ORTH DIA18MM SPIK FOR CANC SCR,SUP-2121106,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
IMPLANT SYS BIOCOMP 2.9MM PUSHLOCK SHRT,SUP-2812591,CDM,C1713,HCPCS,0278,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
LIDOCAINE (CARDIAC) 100 MG/5ML IV SOLN (MIXTURES ONLY),RX-430054,CDM,J2003,HCPCS,0636,RC,00409-1323-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE LOK 158MML HLX10 STNLSS STEEL ST RIGHT LTRL DST F,SUP-2588181,CDM,C1713,HCPCS,0278,RC,,,,both,,,2218.22,1441.84,,,,,,,,,,,,,
STENT COR 18MM 2MM 0.014IN HYDRPHLC RX LO PROF,SUP-2103672,CDM,C1876,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
STENT PERIPH L28MM DIA4.5MM INTCRAN ENTERPRISE,SUP-2249134,CDM,C1874,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
HC Allergen Spec Ige Recombinant/Purified Compnt Ea,PX-3058600800,CDM,86008,CPT,0305,RC,,,,both,,,98.00,63.70,,,,,,,,,,,,,
CATHETER DRAINAGE OTW 40 CM 6 MMX4 CM GLDEX,SUP-2140998,CDM,C1725,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
STENT BILI ZILVER 518 L 20 MM DIA 4 MM DEL SYS L 125 CM SHTH,SUP-2170059,CDM,C1876,HCPCS,0278,RC,,,,both,,,2924.91,1901.19,,,,,,,,,,,,,
OBTURATOR SURG FOR 1.4 MM SURELOCK REUSE,SUP-2664017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.47,608.06,,,,,,,,,,,,,
BIT DRL L150MM DIA2MM CANN QUIK CPL W/O STP REUSE FOR 3MM,SUP-2187217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.64,619.22,,,,,,,,,,,,,
SCREW BNE ANAT TIGHT REV,SUP-2440686,CDM,C1713,HCPCS,0278,RC,,,,both,,,2091.24,1359.31,,,,,,,,,,,,,
NAIL IM L360MM DIA12MM ST AQUA L/R DST FEM TI LOK SLD DYN,SUP-2191785,CDM,C1713,HCPCS,0278,RC,,,,both,,,4330.06,2814.54,,,,,,,,,,,,,
RELOAD STPLR ARTICULATING 4.8 MM UNIV STR SULU DUET TRS 45,SUP-2174660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1345.24,874.41,,,,,,,,,,,,,
COMPONENT ARTC SURF UNI 4 8 MM KNEE,SUP-2340775,CDM,C1776,CPT,0278,RC,,,,both,,,5746.20,3735.03,,,,,,,,,,,,,
PI PICC KIT: 1L 4.5FR 55CM AGBA TIPTRACK,SUP-2826699,CDM,C1751,HCPCS,0278,RC,,,,both,,,861.40,559.91,,,,,,,,,,,,,
PLATE SPNL L10MM TI POST CERV LO PROF OPN DOOR BILAT,SUP-2290211,CDM,C1713,HCPCS,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
NEEDLE SPNL CRD STIM FOR PAIN RELF ENTRADA SC4200,SUP-2138847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BIT DRL DIA3MM RND SHFT REUSE FOR ODONTID FIX APFELBAUM,SUP-2108503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1467.95,954.17,,,,,,,,,,,,,
TUBE ET OD8.5MM ID6MM NSL ORAL LSR RESIST 2 CUF MURPHY EYE,SUP-2283785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,74.95,48.72,,,,,,,,,,,,,
REPAIR KIT CATH 9 FR DL TISS INGROWTH CUF HICKMAN,SUP-2126561,CDM,C1751,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
SPLINT KNEE L16IN FOR 29IN THGH UNIV NYL FBR LAM ALUM FOAM,SUP-2196753,CDM,L1830,CPT,0274,RC,,,,both,,,43.08,28.00,,,,,,,,,,,,,
PIN FIX DIA12MM TEMP COMPR FOR CERV PLT,SUP-2255611,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
APPLICATOR ELECSURG 5X350 MM RIGID PLASMA COAG FILTER NDL AR,SUP-2762600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.68,420.34,,,,,,,,,,,,,
SUPPORT ORTHOT CUST FURNISHING INIT ORTHOSIS ONLY,SUP-2435584,CDM,L1200,HCPCS,0274,RC,,,,both,,,5066.39,3293.15,,,,,,,,,,,,,
SHANK SPNL SCREW L 30 MM DIA 4.5 MM OSTEOGRIP STRL CD HORZ 5PK,SUP-2928659,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 80 CM BALLOON L 60 MM DIA 4,SUP-2141203,CDM,C1725,HCPCS,0272,RC,,,,both,,,1790.93,1164.10,,,,,,,,,,,,,
GUIDEWIRE ENDO L145CM 0.038IN INJ LUMENATOR,SUP-2141748,CDM,C1769,HCPCS,0272,RC,,,,both,,,177.19,115.17,,,,,,,,,,,,,
SET PICC 2L 5FR X 55CM W TEGADERM,SUP-2887045,CDM,C1751,HCPCS,0278,RC,,,,both,,,723.24,470.11,,,,,,,,,,,,,
ODH 32MM S/+0 12/14 FEM HEAD,SUP-2830379,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PROSTHESIS PENILE L12CM MALL CYL AMS 650,SUP-2140266,CDM,C1813,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE BNE L182MM THK37MM 14 H BILAT S STL STR LO PROF RIG,SUP-2177146,CDM,C1713,HCPCS,0278,RC,,,,both,,,2656.53,1726.74,,,,,,,,,,,,,
STENT PERIPH PALMAZ GEN L 25 MM DIA10 MM SHTH 8 FR GUIDE 10,SUP-2159235,CDM,C1877,HCPCS,0278,RC,,,,both,,,2150.90,1398.08,,,,,,,,,,,,,
PLATE BNE MEDL STD 17 HOLE SYS IMPL INSTRUMENT AXIS,SUP-2610176,CDM,C1713,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
CUTTER SURG OD46MM PAT KNEE DISP FOR RM SYS XCELERATE,SUP-2378569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.99,776.09,,,,,,,,,,,,,
MESH SURG 40X25 CM BIOMATERIAL INTRAPERITONEAL ENFORM,SUP-2435398,CDM,C1781,HCPCS,0278,RC,,,,both,,,58068.02,37744.21,,,,,,,,,,,,,
CD BONE SCR 2.3X18MM,SUP-2494495,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.92,133.20,,,,,,,,,,,,,
MESH GYN POLYPRO OR PPL Y SHP CNTOUR VPS PORE SACR TAIL,SUP-2896111,CDM,C1781,HCPCS,0278,RC,,,,both,,,4138.52,2690.04,,,,,,,,,,,,,
HANDLE BLDE FOR PLNTR FASCTMY ENDOTRAC,SUP-2362194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1729.83,1124.39,,,,,,,,,,,,,
STEM HUM L125MM DIA11MM UNIV DST SHLDR TI PRI REV CEM FOR,SUP-2372854,CDM,C1776,CPT,0278,RC,,,,both,,,10252.73,6664.27,,,,,,,,,,,,,
KIT LD L70CM 4X8 32 SURG COVEREDGE,SUP-2141956,CDM,C1778,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
PLATE BNE NAR 3.5X251 MM 14 HOLE SS LCP,SUP-2569357,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.99,427.69,,,,,,,,,,,,,
GRAFT HUM TISS XL W15XL24CM THK07 14MM THN ACELLULAR,SUP-2307617,CDM,Q4128,HCPCS,0636,RC,,,,both,,,40928.52,26603.54,,,,,,,,,,,,,
BLADE SAW OSCILLATING CLSSC 13MMW X90MML 1.37MM THK INNVTVE,SUP-2605814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,139.32,90.56,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CC DBM BONUS TRIAD,SUP-2607049,CDM,C1889,HCPCS,0278,RC,,,,both,,,1530.75,994.99,,,,,,,,,,,,,
TM COLUMN BUTTRESS AUGMENT RT POST LT ANT,SUP-2501831,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 1.3MM WITH 1.3MM WHITE/BLACK HI-FI RI,SUP-2825062,CDM,C1713,HCPCS,0278,RC,,,,both,,,1541.74,1002.13,,,,,,,,,,,,,
GRAFT BIO TISS W24XL63IN RECT XENMATRIX,SUP-2126238,CDM,C1781,HCPCS,0278,RC,,,,both,,,9172.25,5961.96,,,,,,,,,,,,,
SYSTEM DIL BLLN DIA6MM MULTISINUS,SUP-2217802,CDM,C1726,HCPCS,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SYSTEM BNE GRFT L MIX N-FORCE,SUP-2421383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
TOOL APPLIER RAPIDPORT EZ,SUP-2119254,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
ALLODERM DERMAL X THICK 16CM X 20CM MATRIX,SUP-2866786,CDM,Q4116,HCPCS,0636,RC,,,,both,,,33225.91,21596.84,,,,,,,,,,,,,
HC Central Ven Cath 5+ Yrs,PX-4503655600,CDM,36556,CPT,0450,RC,,,,inpatient,,,9955.00,6470.75,,,,,,,,,,,,,
PROBE ARC STRAIGHT FIRE 23 MM OD X 220 CM 10/BX,SUP-2720130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,620.31,403.20,,,,,,,,,,,,,
VANCOMYCIN HCL 125 MG PO CAPS,RX-11628,CDM,6370000000,HCPCS,0637,RC,42494-0450-20,NDC,,both,1,UN,112.80,73.32,,,,,,,,,,,,,
GUIDEWIRE ORTH DRL TIP 1.6X200 MM SS NS KIRSCHNER,SUP-2863372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.59,67.33,,,,,,,,,,,,,
SET INTRO L 45 CM DIA 4 FR SS WIRE MIC SHRT B BVL ECHOGENIC,SUP-2117204,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
KIT CATH CATH 12FR L8IN GWIRE 0.035IN,SUP-2383316,CDM,C1752,HCPCS,0278,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
WIRE FIX L150MM DIA0.9MM SMOOTH SGL END TRCR TIP K,SUP-2321614,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ENTEER L 135 CM BALLOON L 20 X W 3.75 X,SUP-2280836,CDM,C1887,HCPCS,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
GRAFT BNE L16-40MM OD16MM UNICORTICAL DWL FRZ DRY IMPL,SUP-2307089,CDM,C1762,CPT,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1294108D4,SUP-2632812,CDM,C1751,HCPCS,0278,RC,,,,both,,,884.70,575.05,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 0 DEG 5 MM LORDTC TRICORT STRL BIO DISP,SUP-2637024,CDM,C1713,HCPCS,0278,RC,,,,both,,,3026.96,1967.52,,,,,,,,,,,,,
VON GRAEFE KNIFE 2,SUP-2672833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.74,249.43,,,,,,,,,,,,,
SULFASALAZINE 500 MG PO TABS,RX-7562,CDM,6370000000,HCPCS,0637,RC,59762-5000-05,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BONE L36MM CORT S STL ST NONCANNULATED NONLOCKING FULL,SUP-2186583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1670.17,1085.61,,,,,,,,,,,,,
AGENT HEMSTAT 2GM ABSRB SYNTH BONE PUTTY W/ SPAT,SUP-2106297,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
MIDAZOLAM HCL (PF) 5 MG/5ML IJ SOLN,RX-147446,CDM,J2250,HCPCS,0636,RC,00409-2305-50,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE VASC AQUALINER 150CM 0.035IN TIP 3CM ANGLED STIFF,SUP-2118698,CDM,C1769,HCPCS,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
STEM HUM INTERCALARY 60 MM SHLDR REV SEG W/ SCREW COMPHSVE,SUP-2442426,CDM,C1776,CPT,0278,RC,,,,both,,,17266.86,11223.46,,,,,,,,,,,,,
PROSTHESIS OSS 3 MM 0.8X37 MM INTEGR SHOE TI CENTERED ALTO,SUP-2232496,CDM,L8613,CPT,0278,RC,,,,both,,,1218.60,792.09,,,,,,,,,,,,,
BLADE RETRACTOR BALFOUR 2.75X4 IN CENTER BLADE,SUP-2460867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,487.11,316.62,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0018,SUP-2759903,CDM,C1751,HCPCS,0278,RC,,,,both,,,478.25,310.86,,,,,,,,,,,,,
SCREW BNE STD L14MM DIA4MM ANTLAT DST CANC TIB S STL FULL,SUP-2348826,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.52,134.24,,,,,,,,,,,,,
LIGATOR ENDOSCP DIA8.6-11.5MM MULT DISP SPDBND LIGATOR SUP,SUP-2149563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.98,294.44,,,,,,,,,,,,,
NAIL IM TIB 7.5X360 MM PROX AG TARGETING ARM CLR CODE TI,SUP-2460210,CDM,C1713,HCPCS,0278,RC,,,,both,,,1871.44,1216.44,,,,,,,,,,,,,
PLATE BNE L207MM 12 H NONSTERILE R PROX TIB S STL VAR ANG,SUP-2177920,CDM,C1713,HCPCS,0278,RC,,,,both,,,6005.66,3903.68,,,,,,,,,,,,,
TROCAR SURG MULT HOLE T2 RECON,SUP-2467457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
PROSTHESIS EAR INCUS EXTENSIBLE 2.5-5 MM POR,SUP-2247167,CDM,L8613,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,J2804,HCPCS,0636,RC,00068-0597-01,NDC,,both,1,UN,1026.80,667.42,,,,,,,,,,,,,
AUGMENT TIB L75MM THK5MM UNIV KNEE REV VANGUARD 360,SUP-2408011,CDM,C1776,CPT,0278,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
TRAY CATH PICC CUST SUBCLAV POWERPICC SOLO 2 LTXFRDM,SUP-2613404,CDM,C1751,HCPCS,0278,RC,,,,both,,,572.61,372.20,,,,,,,,,,,,,
ROD EXT FIX L499MM DIA11MM 135DEG UNIV C FBR SEMI CIR CRV,SUP-2188645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1871.03,1216.17,,,,,,,,,,,,,
INSERT TIB THK 7 MM SZ 4 UHMWPE LT ANK POST BIASED STRL,SUP-2933180,CDM,C1776,CPT,0278,RC,,,,both,,,11976.75,7784.89,,,,,,,,,,,,,
DEVICE NEUROSTIMULATOR W2.9XL3.1IN THK0.8IN 71GM,SUP-2284639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
"HC So Surg Path, Consult, Slides",PX-3128832566,CDM,88325,CPT,0312,RC,,,,both,,,795.00,516.75,,,,,,,,,,,,,
PIN GUIDE L 450 MM DIA 3.2 MM DRL TIP STRL DISP,SUP-2932833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,260.27,169.18,,,,,,,,,,,,,
LUMBAR BLD SACRAL WTEETH TITN 30X40MM LEFT,SUP-2676794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,594.15,386.20,,,,,,,,,,,,,
IMPLANT JOINT PYROSPHERE PCS SZ 30,SUP-2852828,CDM,C1776,CPT,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
KIT CATH 1.9FR X 6 CM EPIV W STYLET AND 27GA INTRODUCER,SUP-2874165,CDM,C1751,HCPCS,0278,RC,,,,both,,,144.75,94.09,,,,,,,,,,,,,
IMPLANT STRNL CLSR SM FT PLT D17MM DBL VERSION TALON,SUP-2262542,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
TAP SURG DIA4.5MM BNE SCR CANN QUIK CONN,SUP-2409919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1366.15,888.00,,,,,,,,,,,,,
HC Tcat Insj Perm 1chmbr Ldls Pacemaker R Atrial,PX-4810823000,CDM,0823T,CPT,0481,RC,,,,both,,,56457.00,36697.05,,,,,,,,,,,,,
CATHETER ETER GUID 5FR MP2 JB2 CHAPERON,SUP-2305420,CDM,C1887,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 1.5X85 MM 1.5 MM WITHOUT STOP FOR C,SUP-2837899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.50,212.87,,,,,,,,,,,,,
OSELTAMIVIR PHOSPHATE 30 MG PO CAPS,RX-88704,CDM,6370000000,HCPCS,0637,RC,33342-0256-66,NDC,,both,1,UN,8.70,5.65,,,,,,,,,,,,,
HC So Clot Factor Fletcher Fac,PX-3058529266,CDM,85292,CPT,0305,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
PLATE BONE L14MM 4 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413741,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.04,592.83,,,,,,,,,,,,,
PLATE BNE C MED 2X0.7 MM 9 MM CRANIOMAXILLOFACIAL 4 LEFORT,SUP-2460649,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.97,412.73,,,,,,,,,,,,,
BIT TWST DRL L81MM DIA1.2MM STP 25MM ADD ON QUIK CPL SHFT,SUP-2267830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.23,303.70,,,,,,,,,,,,,
CATHETER DIL 6FR 12CC L70CM BLLN L3.5CM DEFCT SZ 20MM,SUP-2355748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,986.21,641.04,,,,,,,,,,,,,
OVERTUBE ENDOSCP L50CM ID16.7MM SCP DIA8.6-10MM GAST INSUF,SUP-2360646,CDM,C1713,HCPCS,0278,RC,,,,both,,,708.86,460.76,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 7 MM STR STD WALL HELIX,SUP-2461259,CDM,C1768,CPT,0278,RC,,,,both,,,583.95,379.57,,,,,,,,,,,,,
STENT GRFT VASC AFX L 88 MM DIA PROX/DSTL 20/13 MM,SUP-2217716,CDM,C1768,CPT,0278,RC,,,,both,,,10346.30,6725.09,,,,,,,,,,,,,
PLATE BNE L W10.1XL168MM THK3.5MM 12 H BILAT S STL STR LOK,SUP-2186220,CDM,C1713,HCPCS,0278,RC,,,,both,,,1682.73,1093.77,,,,,,,,,,,,,
PLATE BONE REG L16MM THK0.6MM 5 H MIDFACE TI Y SHP FOR 1.5MM,SUP-2402882,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
CANNULA CURVED CROSSBOW MANUAL FIXATION SET WITHOUT CHANNELS,SUP-2824676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1567.17,1018.66,,,,,,,,,,,,,
KIT PEG 20FR NONSAFETY PUSH GWIRE PLCMNT TECH DLX,SUP-2127679,CDM,C1769,HCPCS,0272,RC,,,,both,,,548.09,356.26,,,,,,,,,,,,,
INSERT TIB ARTC SURF CRUC RET MOLD PUR LT RT 9MM THCK 58MM,SUP-2201263,CDM,C1776,CPT,0278,RC,,,,both,,,4127.22,2682.69,,,,,,,,,,,,,
PLATE BNE H0.5MM 10X10 H CRANIOMAXILLOFACIAL BLU TI 3D MAL,SUP-2366235,CDM,C1713,HCPCS,0278,RC,,,,both,,,4062.03,2640.32,,,,,,,,,,,,,
SPHERE ORBIT DIA18MM PMMA FOR RET EYE SOCK CNTOUR,SUP-2236376,CDM,L8610,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6-7X170-220 MM TIBIALIS TEND FLEXIGRAFT,SUP-2740858,CDM,C1762,CPT,0278,RC,,,,both,,,5618.56,3652.06,,,,,,,,,,,,,
KIT FEED TB 18FR L45CM STOMA L2CM TRANSGASTRIC JEJU SIL LO,SUP-2236573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.27,716.48,,,,,,,,,,,,,
PLATE BNE L183MM 11 H SEMI TBLR FOR 45MM SCR L FRAG SYS,SUP-2411421,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.41,161.47,,,,,,,,,,,,,
CAGE SPNL MESH 17X13X13 MM 6 LOBE,SUP-2602079,CDM,C1889,HCPCS,0278,RC,,,,both,,,9228.46,5998.50,,,,,,,,,,,,,
ANCHOR SUTURE 4.75X20 MM BIO-SWIVELOCK,SUP-2121701,CDM,C1713,HCPCS,0278,RC,,,,both,,,1705.02,1108.26,,,,,,,,,,,,,
NAIL IM L200MM OD11.5MM FEM RG TRIGEN META-NAIL,SUP-2347402,CDM,C1713,HCPCS,0278,RC,,,,both,,,10888.74,7077.68,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 9H /70MM/152MM,SUP-2547722,CDM,C1713,HCPCS,0278,RC,,,,both,,,2241.52,1456.99,,,,,,,,,,,,,
ROD EXT FIX L400MM THRD STR SIDEKCK FREE CIR FIX,SUP-2400600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
POWDER HAEMOSTATIC MICFIB CLLGN 5GM ABSRB WHT AVIT,SUP-2125828,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
COUNTERSINK SURG CANN FOR 65 73MM SCR,SUP-2187344,CDM,C1713,HCPCS,0278,RC,,,,both,,,1132.50,736.12,,,,,,,,,,,,,
DRESSING BIO L 2 X W 2IN CLLGN CHONDROITIN-6-SULFATE MESHED,SUP-2909180,CDM,Q4105,HCPCS,0636,RC,,,,both,,,9959.42,6473.62,,,,,,,,,,,,,
SHEATH RENAL L17CM ID24 30FR AMPLATZ SET PTFE,SUP-2141696,CDM,C1894,HCPCS,0272,RC,,,,both,,,89.84,58.40,,,,,,,,,,,,,
NEEDLE SUT PASS FOR ROT CUF LABRAL REP SUREFIRE SCORPION,SUP-2121199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA 3 MM SHRT TI CANN COMPR STRL DARTFIRE,SUP-2900526,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
CATHETER ABLATN F-J CRV 7 FR EZ STEER CS,SUP-2257362,CDM,C1730,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
RING EXT FIX DIA180MM TAY 2/3 SPAT FRME ILIZ,SUP-2342977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6182.97,4018.93,,,,,,,,,,,,,
GRAFT BNE SUB W14XH6MM D12 4DEG PLUG LORD BIO AVS,SUP-2381462,CDM,C1713,HCPCS,0278,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
ELECTRODE LOOP CUTTING 12 DEG LARGE,SUP-2866522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
GRAFT NRV L30MM DIA1-2MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124847,CDM,C1763,HCPCS,0278,RC,,,,both,,,14035.80,9123.27,,,,,,,,,,,,,
KIT REP OD135FR RED LEG 2 LUMN CATHETER ETERS HCKMN,SUP-2126565,CDM,C1751,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
ANTERIOR ANKLE FUSION PLATE STANDARD LEFT,SUP-2586672,CDM,C1713,HCPCS,0278,RC,,,,both,,,9118.56,5927.06,,,,,,,,,,,,,
BRACE ORTH SZ 1 RT THMB CMC PUSH METAGRIP,SUP-2324629,CDM,L3924,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
PLATE STRNL 4 H TI ANGLED NS MATRIXSTERNUM,SUP-2904236,CDM,C1713,HCPCS,0278,RC,,,,both,,,1639.11,1065.42,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450395505,SUP-2844122,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.76,56.39,,,,,,,,,,,,,
HC Transcath Therapy Emboliz S&,PX-3207589400,CDM,75894,CPT,0320,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
HC Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq,PX-3068763700,CDM,87637,CPT,0306,RC,,,,outpatient,,,300.00,195.00,,,,,,,,,,,,,
KIT BAL DISECT KII LO PROF OVL 5MMX55MM,SUP-2418457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
ANKLE FUSION PLATE POSTERIOR TTC LEFT,SUP-2815099,CDM,C1713,HCPCS,0278,RC,,,,both,,,7143.50,4643.27,,,,,,,,,,,,,
GUIDEPIN ORTH L150MM DIA1.2MM SCR FOR DELT XTEND REV SHLDR,SUP-2252750,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BRACE WRST R INSTABILITY INJ LOOP LOK W/ STAY COCK UP E,SUP-2197948,CDM,L3931,HCPCS,0272,RC,,,,both,,,25.37,16.49,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S9274108D,SUP-2632875,CDM,C1751,HCPCS,0278,RC,,,,both,,,639.96,415.97,,,,,,,,,,,,,
CANNULA LAP AUTO VLV 22 MMX12 CM,SUP-2767793,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1970.48,1280.81,,,,,,,,,,,,,
PLATE STRNL SM 8 H TI H SHP NS MATRIXSTERNUM,SUP-2904214,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.70,1260.15,,,,,,,,,,,,,
CONNECTOR SPNL L35MM IL TI LO PROF OFFSET FOR DEFORMITY CORR,SUP-2317341,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
KIT CATH HEMODIALYSI SFT CELL CHRONIC STD 12.5FR DIA 38CM 19,SUP-2613294,CDM,C1750,HCPCS,0278,RC,,,,both,,,629.73,409.32,,,,,,,,,,,,,
PLATE BNE L142MM BLDE W5.8XL38MM 145DEG 8 H NONSTERILE,SUP-2186651,CDM,C1713,HCPCS,0278,RC,,,,both,,,2098.62,1364.10,,,,,,,,,,,,,
HC Chemo IV Push Initial Drug,PX-3319640900,CDM,96409,CPT,0331,RC,,,,inpatient,,,673.00,437.45,,,,,,,,,,,,,
PLATE BNE BAR L 4 MM 4 H SAG SPLIT CRV LCK NS SMARTLOCK,SUP-2909478,CDM,C1713,HCPCS,0278,RC,,,,both,,,2777.33,1805.26,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONFIENT RF HE TI 1 LD W/O ATR LD PASS,SUP-2149144,CDM,C1722,HCPCS,0275,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
MESH HERN SQ 19.5X19.5 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855259,CDM,C1781,HCPCS,0278,RC,,,,both,,,102207.00,66434.55,,,,,,,,,,,,,
GUIDE WIRE CNTR SL,SUP-2290627,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.85,421.75,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 10X2.5 CM DBM FIBERFUSE,SUP-2736953,CDM,C1713,HCPCS,0278,RC,,,,both,,,12236.58,7953.78,,,,,,,,,,,,,
GRAFT BNE DWL 13X12 MM PATELLAR,SUP-2860933,CDM,C1713,HCPCS,0278,RC,,,,both,,,3871.62,2516.55,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE SLD STIRRUP W/O JT,SUP-2435633,CDM,L2010,HCPCS,0272,RC,,,,both,,,2470.33,1605.71,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvic/Le 1st Ord|LEFT SIDE,PX-3613624500,CDM,36245,CPT,0361,RC,,,LT,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BONE L48MM THK0.6MM LNG 2X2 H LT CRANIOMAXILLOFACIAL,SUP-2191294,CDM,C1713,HCPCS,0278,RC,,,,both,,,789.08,512.90,,,,,,,,,,,,,
"HC So Transferrin, Carbohydrate Dfct",PX-3018237366,CDM,82373,CPT,0301,RC,,,,inpatient,,,146.00,94.90,,,,,,,,,,,,,
SCISSORS SURG MALIS BAY NEURO DEL MIC TIP SERR TI CVD 9,SUP-2382548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1571.32,1021.36,,,,,,,,,,,,,
CATHETER INFUSION FASTRACKER 325 L 140 CM OD PROX/DSTL,SUP-2147319,CDM,C1887,HCPCS,0272,RC,,,,both,,,1270.88,826.07,,,,,,,,,,,,,
AWL SURG 25 MM FOR ALIF SYS CHESAPEAKE,SUP-2855056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
MICROCATHETER NAVIGATION 2.8FR L150CM GWIRE L160CM 0.021IN MCPE28151YV] TERUMO MEDICAL CORP],SUP-2385609,CDM,C1887,HCPCS,0272,RC,,,,both,,,1863.90,1211.53,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM IM FIX SELF DRL,SUP-2183326,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.00,288.60,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 13 CM DIA15 FR PTFE PERC NO CRV,SUP-2127712,CDM,C1894,HCPCS,0272,RC,,,,both,,,265.33,172.46,,,,,,,,,,,,,
GRAFT BNE PAT LIGMNT 9-10 MM,SUP-2361834,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
SUPPORT ANK TRICOT 7.75-8.5 IN SM VLY PROCARE DLX,SUP-2195733,CDM,L4350,HCPCS,0274,RC,,,,both,,,33.54,21.80,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X211 MM 16 HOLE SS LC-DCP,SUP-2569250,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.66,260.43,,,,,,,,,,,,,
DEVICE INT FIX DIA29MM W NDL TOGGLELOC,SUP-2136123,CDM,C1713,HCPCS,0278,RC,,,,both,,,1920.17,1248.11,,,,,,,,,,,,,
MATRIX DERM ACELLULAR HYDRATED DERMAMTRX 0.4-0,SUP-2306894,CDM,C1762,CPT,0278,RC,,,,both,,,2140.29,1391.19,,,,,,,,,,,,,
SCREW 4.0MMX40MM  HEADED DART-FIRE,SUP-2857926,CDM,C1713,HCPCS,0278,RC,,,,both,,,2295.34,1491.97,,,,,,,,,,,,,
GRAFT BNE 85X11 MM DBM BLLST,SUP-2641772,CDM,C1713,HCPCS,0278,RC,,,,both,,,9608.40,6245.46,,,,,,,,,,,,,
IMPLANT OTO 37 X 62 MM LT HELCL EAR RIM 2PC RECON POROUS,SUP-2883474,CDM,L8699,HCPCS,0278,RC,,,,both,,,1999.43,1299.63,,,,,,,,,,,,,
MESH CRAN L 80.1 X W 50.8 MM THK 0.8 MM SCREW DIA1.5 MM MED,SUP-2936163,CDM,C1713,HCPCS,0278,RC,,,,both,,,5560.94,3614.61,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CHARGER L 75 CM BALLOON L 20 MM DIA 6 MM,SUP-2145898,CDM,C1725,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS AXIOFILL 250MG,SUP-2865148,CDM,C1762,CPT,0278,RC,,,,both,,,2050.42,1332.77,,,,,,,,,,,,,
SCREW BNE L12MM DIA27MM TI ALLY NONLOCKING CRSS DRV,SUP-2262817,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.74,207.18,,,,,,,,,,,,,
INSERT HUM DIA39MM THK+6MM B-12.5DEG SHLDR REVERSED AEQUALIS,SUP-2388717,CDM,C1776,CPT,0278,RC,,,,both,,,3524.65,2291.02,,,,,,,,,,,,,
INSERT TIB 1 9MM CONSTRN CNDYL,SUP-2221225,CDM,C1776,CPT,0278,RC,,,,both,,,5341.14,3471.74,,,,,,,,,,,,,
ALLOGRAFT BNE FILL 1-8 MM 5 CC FD SPNG CANC READIGRAFT BLX,SUP-2740977,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.33,904.36,,,,,,,,,,,,,
PLATE BONE L24MM THK.3MM 5 H L TI CRAN MAXILLOFACIAL BILAT,SUP-2137626,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
RECON PLATE 15X178MM 3.5MM,SUP-2818783,CDM,C1713,HCPCS,0278,RC,,,,both,,,5558.59,3613.08,,,,,,,,,,,,,
SYSTEM LD CATH TIP GUIDE BACKPLATE OUTFLO ENVEO R,SUP-2281142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
SYSTEM DRAINAGE 15 MM CATH SHUNT FOR EDS III,SUP-2308157,CDM,C1729,HCPCS,0272,RC,,,,both,,,441.99,287.29,,,,,,,,,,,,,
BRACE WLK M M 7 10 WOM 8 11 EXTRA PNEUMAT LTWT DURABLE SEMI,SUP-2196364,CDM,L4361,HCPCS,0272,RC,,,,both,,,184.22,119.74,,,,,,,,,,,,,
CLIP SURG MECHANOMYOGRAPHY STIM ALLIGATOR SS NS,SUP-2693682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ALLOGRAFT BNE SHT 45X20X5 MM CANC CONFORM Q-PACK,SUP-2737085,CDM,C1713,HCPCS,0278,RC,,,,both,,,5671.63,3686.56,,,,,,,,,,,,,
PLATE BURR H L 14 MM THK 0.6 MM 5 H SCREW DIA1 MM TI CRAN NS,SUP-2883275,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
OBTURATOR LATCHING BLNT REUSE LNG DA VINCI,SUP-2246608,CDM,C1713,HCPCS,0278,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
COMPONENT PAT 28MM INSET SAMP PFC SIG,SUP-2253515,CDM,C1776,CPT,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
CLAMP EXT FIX PEDIATRIC SHEFFIELD,SUP-2645884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2194.48,1426.41,,,,,,,,,,,,,
HC Comlex Drainage Wound,PX-4501018000,CDM,10180,CPT,0450,RC,,,,both,,,8335.00,5417.75,,,,,,,,,,,,,
STENT UTER BALLOON L 3 X W 2.8 CM SIL FOR INTRAUTERINE SURG,SUP-2168925,CDM,C2628,HCPCS,0272,RC,,,,both,,,104.41,67.87,,,,,,,,,,,,,
SHELL ACET OD62MM ID56MM UNIV HIP TI POR PRI PRESSFIT DUROM,SUP-2204676,CDM,C1776,CPT,0278,RC,,,,both,,,11699.64,7604.77,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE 5X2 HOLES CRVD W2 HOLE TABS CP TTNM,SUP-2681098,CDM,C1713,HCPCS,0278,RC,,,,both,,,1326.08,861.95,,,,,,,,,,,,,
MOLINA ORBTL MALAR DSTRCTR 25MM DISTR T 6L 4V SNGLE USE,SUP-2694390,CDM,C1713,HCPCS,0278,RC,,,,both,,,12775.25,8303.91,,,,,,,,,,,,,
DRILL SURG LNG STRL ACUTRK 2 LTX DISP,SUP-2857810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
PLATE BNE L50MM S STL 4 H T SHP FOR 2MM SCR MINI FRAG SYS,SUP-2199357,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
GRAFT VASC STR 7 MMX70 CM TW N RING HD ACCS EPTFE CARBOFLO,SUP-2761329,CDM,C1768,CPT,0278,RC,,,,both,,,2790.11,1813.57,,,,,,,,,,,,,
SUPPORT ORTH LO SPINE ADJ VISTA 464 TLSO,SUP-2123918,CDM,L0464,HCPCS,0272,RC,,,,both,,,993.81,645.98,,,,,,,,,,,,,
CLIP ANEUR BLDE L8.4MM MAX OPN 6.8MM 70GM STD TEMP PHYNOX,SUP-2108379,CDM,C1889,HCPCS,0278,RC,,,,both,,,1273.05,827.48,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 80 CM DIA 0.035 IN PTFE PERIPH,SUP-2301915,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.64,40.72,,,,,,,,,,,,,
HC Infectious Agent Dna/Rna Vancomycin Resistance,PX-3068750000,CDM,87500,CPT,0306,RC,,,,both,,,91.00,59.15,,,,,,,,,,,,,
SCREW BNE UNICORTICAL 5X10 MM FEM POLYAX TI NS NCB,SUP-2459660,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
TACROLIMUS ER 4 MG PO TB24,RX-151353,CDM,J7503,HCPCS,0636,RC,68992-3040-03,NDC,,both,1,UN,127.40,82.81,,,,,,,,,,,,,
CATHETER PTCA 4FR L150CM QUADFLEX BLLN L15CM DIA2.5MM SHTH,SUP-2156486,CDM,C1725,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
KIT PROS HEXALOBULAR CONDYLE,SUP-2215506,CDM,C1776,CPT,0278,RC,,,,both,,,4612.66,2998.23,,,,,,,,,,,,,
SYSTEM VLV REP MITRACLIP G4 EDGE TO EDGE BNDL SGC0701 STEER,SUP-2660820,CDM,C1725,HCPCS,0272,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
PUMP PENILE PROS INFL DEFL AMS 700,SUP-2138918,CDM,C1813,HCPCS,0278,RC,,,,both,,,856.59,556.78,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN WHL HUM,SUP-2321818,CDM,C1713,HCPCS,0278,RC,,,,both,,,4226.44,2747.19,,,,,,,,,,,,,
PLATE 3.5MM TI LCP OLECRANON 4 HOLES LEFT 112MM-STERILE,SUP-2549522,CDM,C1713,HCPCS,0278,RC,,,,both,,,3606.70,2344.35,,,,,,,,,,,,,
SCREW BNE OD1.5MM L4MM CORT TI ST MIC N LOK NSTERILE CRANIO,SUP-2262609,CDM,C1713,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA 3.7 MM LISFRANC JT SLD,SUP-2896834,CDM,C1713,HCPCS,0278,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
GRAFT VASC IMPRA L 20 CM DIA 6 MM EPTFE FLEXS BEAD RING HEMO,SUP-2761432,CDM,C1768,CPT,0278,RC,,,,both,,,1293.15,840.55,,,,,,,,,,,,,
CATHETER GUID .098IN CBL MOD BURKE VASC COR W/O HYDRPHLC,SUP-2158070,CDM,C1887,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
NUT SPNL W55MM TI ACROS FLAT USS,SUP-2193639,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
STEM FEM L225MM OD11MM POR LT REV PRESSFIT INTEGR,SUP-2406833,CDM,C1776,CPT,0278,RC,,,,both,,,19053.52,12384.79,,,,,,,,,,,,,
SYSTEM RADAR LOC DEL 7.5 CM NDL MINI REFLCT 16 GA HND SCOUT,SUP-2864536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
PROSTHESIS OSS CENTERED 3 MM 4 2 3 TOT HA TI WILDCAT,SUP-2458139,CDM,L8613,CPT,0278,RC,,,,both,,,1144.72,744.07,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 2X100/125 MM STERILE TC100 DISPOSAB,SUP-2837027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,865.01,562.26,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS AXIOFILL 2000MG,SUP-2865151,CDM,C1762,CPT,0278,RC,,,,both,,,16387.66,10651.98,,,,,,,,,,,,,
RING EXT FIX STRUT TMPLT TRUELOK EVO,SUP-2875224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
HC So Estrogens Total,PX-3018267266,CDM,82672,CPT,0301,RC,,,,inpatient,,,366.00,237.90,,,,,,,,,,,,,
PLATE BNE L 87 X W 8 MM THK 2.4 MM SCREW DIA2.7 MM 13 H SS 72468913N,SUP-2933399,CDM,C1713,HCPCS,0278,RC,,,,both,,,2676.85,1739.95,,,,,,,,,,,,,
HC So Endomysial Antibody Each Immunoglobulin Class,PX-3028623166,CDM,86231,CPT,0302,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
PLATE BNE L120MM 10 H TIB S STL LOK RECON FOR 4MM SCR AXSOS,SUP-2362717,CDM,C1713,HCPCS,0278,RC,,,,both,,,2622.21,1704.44,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA18MM HALF PNT TIP REDUC,SUP-2179131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
NAIL IM L405MM DIA8MM UNIV DK BLU PROX TIB TI BEND CANN LOK,SUP-2180391,CDM,C1713,HCPCS,0278,RC,,,,both,,,4576.36,2974.63,,,,,,,,,,,,,
DYNANITE STAPLE BIT DRILL CAL 1.6,SUP-2814456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
NEEDLE BRST LOC 20GA L9CM L20CM N REPOSITIONAL DISP BEAD,SUP-2126462,CDM,C1819,HCPCS,0278,RC,,,,both,,,517.79,336.56,,,,,,,,,,,,,
BUR SURG L14CM DIA3MM MTCH HD FLUT L BOR MIDAS REX LEGEND,SUP-2284085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.59,220.73,,,,,,,,,,,,,
IMPLANT SPHR EYE SST POLYETH W/ NOVABONE 20MM MEDPOR +,SUP-2328482,CDM,L8610,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 9MM FENESTRATED 90 DEG 201719,SUP-2844604,CDM,C1889,HCPCS,0278,RC,,,,both,,,828.74,538.68,,,,,,,,,,,,,
NAIL IM CANN 12X390 MM TIB TI LIGHT GRN NS EXPERT,SUP-2179864,CDM,C1713,HCPCS,0278,RC,,,,both,,,4446.24,2890.06,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 6.5 FR CANN L 23 CM DIL 30 CM POLYUR,SUP-2157399,CDM,C1894,HCPCS,0272,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
HC Rep Lac Floor Mouth 0-2.5cm,PX-4504125000,CDM,41250,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
BAR EXT FIX DIA 6 MM OFFSET NS DISP MAV MINI,SUP-2932789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1 CC AMNIO TISS MEMBRN AMNIFLO CRYOPRES,SUP-2423434,CDM,C1762,CPT,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
LEAD DEFIB ENDOTK ENDUR RX L 64 CM SIL STEROID ENDOCARD,SUP-2148549,CDM,C1895,HCPCS,0275,RC,,,,both,,,21116.50,13725.72,,,,,,,,,,,,,
IMPLANT BRST 560CC DIA13.5CM P5.7CM SIL RESPON GEL FULL,SUP-2113694,CDM,C1789,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
CATHETER ANGIOPLSTY METACROSS 135 CM 3.9/5.7 FR 80 MM 5 MM,SUP-2384778,CDM,C1725,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
RESERVOIR EXT DRNGE NEO L10MM DIA4MM FLD 01ML BTM INLET CONN,SUP-2277916,CDM,C1889,HCPCS,0278,RC,,,,both,,,853.14,554.54,,,,,,,,,,,,,
SCREW BNE L26MM OD4MM GRN FOREFOOT MIDFOOT HINDFOOT ANK,SUP-2320540,CDM,C1713,HCPCS,0278,RC,,,,both,,,620.15,403.10,,,,,,,,,,,,,
PLATE BNE 4 H CRANIOMAXILLOFACIAL TI LO PROF X FOR UNIV,SUP-2366211,CDM,C1713,HCPCS,0278,RC,,,,both,,,752.82,489.33,,,,,,,,,,,,,
UNIT THER COMB CRYO W PD KNEE W TB PWR OPERATED W OUT BD,SUP-2150931,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.13,213.93,,,,,,,,,,,,,
STENT BILI PRECIS L 20 MM DIA 5 MM CATH L 135 CM DIA 8 FR,SUP-2158901,CDM,C1876,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
CATHETER CARD ABLATION QDOT MIC L 115 CM 8 FR 3.5 MM D-F TYP,SUP-2880099,CDM,C1732,HCPCS,0272,RC,,,,both,,,12365.32,8037.46,,,,,,,,,,,,,
SEED BRACHYTHERAPY CESIUM STRND LD IN NDL,SUP-2247309,CDM,C2642,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
PLATE BNE L116MM 6 H ST R POSTEROLATERAL DST FIBULAR S STL,SUP-2176957,CDM,C1713,HCPCS,0278,RC,,,,both,,,2020.15,1313.10,,,,,,,,,,,,,
SCREW BONE L85MM DIA4.5MM THRD L38MM MALL S STL ST SELF DRL,SUP-2184560,CDM,C1713,HCPCS,0278,RC,,,,both,,,108.33,70.41,,,,,,,,,,,,,
TUBE VENT LT,SUP-2468998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,418.56,272.06,,,,,,,,,,,,,
PLATE BNE L282MM 15 H S STL LOK COMPR BROAD CRV FOR 4.5/5MM,SUP-2185307,CDM,C1713,HCPCS,0278,RC,,,,both,,,2366.49,1538.22,,,,,,,,,,,,,
IMPLANT HUM TISS L 1 CM AORT DIA10 MM ABD AORT ALLGRFT,SUP-2933873,CDM,C1762,CPT,0278,RC,,,,both,,,71267.95,46324.17,,,,,,,,,,,,,
BIOTIN 3 MG PO TABS,RX-1070,CDM,6370000000,HCPCS,0637,RC,54022-1098-01,NDC,,both,1,UN,1.20,0.78,,,,,,,,,,,,,
PLATE BNE L 270 MM SCREW DIA 4.5 MM 13 H SS LT DSTL FEM NS,SUP-2931187,CDM,C1713,HCPCS,0278,RC,,,,both,,,11916.30,7745.59,,,,,,,,,,,,,
BLADE SHV OD4MM 60DEG ROT SERR CLOSE DS ELITE COMPATIBLE,SUP-2313528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.91,438.04,,,,,,,,,,,,,
SPLINT THMB AD M L BGE L MCP CMC JT PREFRM PERF FLX BASE LAM,SUP-2326182,CDM,L3908,HCPCS,0274,RC,,,,both,,,70.21,45.64,,,,,,,,,,,,,
IMPLANT OP RM UNIV PLT TED BEAR,SUP-2321555,CDM,C1713,HCPCS,0278,RC,,,,both,,,4591.62,2984.55,,,,,,,,,,,,,
STEM RADIAL L 1.842 IN DIA 0.322 IN SZ 4 COCR ALLOY ELBW MOD,SUP-2933675,CDM,C1776,CPT,0278,RC,,,,both,,,10039.02,6525.36,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 1.5X85/110 MM STERILE TC100 DISPOSA,SUP-2837025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.24,572.16,,,,,,,,,,,,,
BUR SURG L 8 MM DIA2 MM SCULPTING CYL FOR SM JT ARTH STRL,SUP-2881781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2490.02,1618.51,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD BLU,SUP-2248512,CDM,C1732,HCPCS,0272,RC,,,,both,,,6220.34,4043.22,,,,,,,,,,,,,
ENDCAP SPINE EXTND 25X30MM 0 DEG,SUP-2662877,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER ABLAT 4MM OD7.5FR STD OPN IRRIG INTELLANAV,SUP-2141345,CDM,C1732,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PATCH CV XENOSURE L 14 X W 8 CM BOV PERICARD BIOLOGIC UNIF,SUP-2264302,CDM,C1713,HCPCS,0278,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
CATHETER EP D 2-5-2 MM 7 FRX95 CM ORBITER ST,SUP-2142352,CDM,C1731,HCPCS,0278,RC,,,,both,,,2405.24,1563.41,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX12 CM DL J TIP POLYETH,SUP-2760052,CDM,C1751,HCPCS,0278,RC,,,,both,,,233.08,151.50,,,,,,,,,,,,,
KIT SHOULDR IMPL CAPPED S4 HEMI S4ZIMMERBIOMET,SUP-2431800,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
CATHETER INFUSION 2.4 FRX150 CM STD FLX STR EXCELSIOR XT 17,SUP-2368069,CDM,C1887,HCPCS,0272,RC,,,,both,,,2874.36,1868.33,,,,,,,,,,,,,
HEAD REAMER 2 11.5 MM RETROCUTTER,SUP-2120871,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
JOINT SUBTALAR 10.5 MM ANK,SUP-2318977,CDM,C1776,CPT,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
DRESSING BIO 500 MG PORCINE EXTRACELLULAR MTRX PWDR WND STRL,SUP-2911946,CDM,A2004,HCPCS,0278,RC,,,,both,,,3169.83,2060.39,,,,,,,,,,,,,
GRAFT DURA W5XL7IN THK0.6MM CLLGN MEMBRN DURAMATRIX-ONLAY +,SUP-2365457,CDM,C1763,HCPCS,0278,RC,,,,both,,,3687.27,2396.73,,,,,,,,,,,,,
GRAFT VASC PERIPH BYPS STR THN WALL N RING EPTFE 7MM DIA,SUP-2127826,CDM,C1768,CPT,0278,RC,,,,both,,,2272.86,1477.36,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 10MM THREADED DISPOSABLE WITH,SUP-2804744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.74,436.63,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA1.8MM CORT TI BAYNT PT ILIZ,SUP-2342845,CDM,C1769,HCPCS,0272,RC,,,,both,,,4824.55,3135.96,,,,,,,,,,,,,
CUP ACET DIA56MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH 124556000] JNJ DEPUY SYNTHES ORTHOPEDICS],SUP-2250722,CDM,C1776,CPT,0278,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
BIT DRL CANN 4.8X300 MM W/ ZH,SUP-2606141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,594.46,386.40,,,,,,,,,,,,,
ABLATOR ASPIRATING RF H50 APOLLO,SUP-2711654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
KIT INTRO ONESTIC L 5.75 CM DIA 8 FR GUIDEWIRE L 45 CM DIA,SUP-2876553,CDM,C1894,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
POST EXT FIX WIRE HYBRID RNG FOR 1.5/2MM HOFFMANN II,SUP-2372246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
CATHETER DRNGE 10FR L35CM GWIRE 0.038IN FLEXIMA BILI SFT 5,SUP-2147860,CDM,C1729,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM BIOCRYL RAPIDE ABSRB 3 DYNACORD SZ 2,SUP-2256648,CDM,C1713,HCPCS,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
HC Spirometry / Tvc / Mvv,PX-4609401000,CDM,94010,CPT,0460,RC,,,,both,,,347.00,225.55,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CORTICOCANCELLOUS ALLGRFT FRZN,SUP-2933459,CDM,C1762,CPT,0278,RC,,,,both,,,10513.19,6833.57,,,,,,,,,,,,,
MARKER BRST BX L12CM 18GA NIT Q SHP INTRO FREE HND TUMARK,SUP-2239915,CDM,A4648,CPT,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
BLADE IM NAIL HELCL 75 MM STR FEN IMPL,SUP-2417919,CDM,C1713,HCPCS,0278,RC,,,,both,,,6550.86,4258.06,,,,,,,,,,,,,
ROD SPNL 3X45 MM,SUP-2564513,CDM,C1713,HCPCS,0278,RC,,,,both,,,50.08,32.55,,,,,,,,,,,,,
COIL VASC I-ED COIL L 20 CM DIA 0.012 IN SECONDARY 3-5 MM,SUP-2865321,CDM,C1889,HCPCS,0278,RC,,,,both,,,5667.70,3684.00,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7MM STR TW REINF SLDE GDE,SUP-2525467,CDM,C1768,CPT,0278,RC,,,,both,,,1694.38,1101.35,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR PT GEN,SUP-2356762,CDM,C1767,HCPCS,0278,RC,,,,both,,,3114.41,2024.37,,,,,,,,,,,,,
DRESSING POST OPERATIVE RIGID BULK N WET BEAR,SUP-2388204,CDM,L5460,HCPCS,0272,RC,,,,both,,,1662.85,1080.85,,,,,,,,,,,,,
STAPLER INT CRV TIP 30 MM ENDOWRIST,SUP-2246773,CDM,C1713,HCPCS,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
BENDING TEMPLATE 5 HOLES FOR 2.7MM,SUP-2548477,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.69,63.50,,,,,,,,,,,,,
SUPPORT ORTHOT SACROILIAC PELV CUST W/PANEL STRP PENDULOUS,SUP-2435553,CDM,L0623,HCPCS,0272,RC,,,,both,,,501.05,325.68,,,,,,,,,,,,,
SET SHTH DESTINO REACH L 71 CM DIA12 FR CRV BEND L 22 MM DIL,SUP-2616166,CDM,C1766,CPT,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SPLINT WRIST EXTRA SMALL 8 IN THUMB LEFT,SUP-2428142,CDM,L3908,HCPCS,0274,RC,,,,both,,,96.30,62.59,,,,,,,,,,,,,
CATHETER PICC L55CM OD6FR GWIRE L80CM .018IN 3 LUMN N COAT,SUP-2117004,CDM,C1751,HCPCS,0278,RC,,,,both,,,236.13,153.48,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 5 FR POLYPRO TBNG SS,SUP-2740710,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.28,42.43,,,,,,,,,,,,,
COIL NEUROVASCULAR WEB SL W 10-11 X H 5 MM DIA10 MM,SUP-2418962,CDM,C1889,HCPCS,0278,RC,,,,both,,,46943.00,30512.95,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 5 MM EPTFE STR STD WALL,SUP-2396180,CDM,C1768,CPT,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
TRAY CATHETER 4FR SGL LUMN MAXIMAL BARR GROSH,SUP-2126718,CDM,C1751,HCPCS,0278,RC,,,,both,,,697.80,453.57,,,,,,,,,,,,,
SET CERV PD4 FOR 35 45IN 2 5YRS PED L89 114CM W REPL PD,SUP-2123894,CDM,L0190,HCPCS,0274,RC,,,,both,,,219.08,142.40,,,,,,,,,,,,,
SYSTEM SLNG SGL INCIS W/ INTRO ANCHR TENSIONING SUT ALTIS,SUP-2165319,CDM,C1781,HCPCS,0278,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
KIT INT FIX FEM ACL GUID PIN BNE PLUG GUIDWIRE DISP EZLOC,SUP-2212937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2078.43,1350.98,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE 16X8 CMX1-1.7 MM BRST KT FEN FLEXHD,SUP-2307571,CDM,Q4128,HCPCS,0636,RC,,,,both,,,22772.85,14802.35,,,,,,,,,,,,,
GRAFT HUM TISS FRZN DBL STRND SEMITENDINOSUS,SUP-2113905,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
PLATE BNE L90MM STD 3 H PROX HUM S STL LOK COMPR FOR 3.5MM,SUP-2186012,CDM,C1713,HCPCS,0278,RC,,,,both,,,4204.59,2732.98,,,,,,,,,,,,,
CATHETER BAL DIL L65CM OD12FR FULL OCCL FOR AORT STENT GRFT,SUP-2395997,CDM,C2628,HCPCS,0272,RC,,,,both,,,1425.56,926.61,,,,,,,,,,,,,
MESH HERN REP W15XL20CM RECT LAP,SUP-2717686,CDM,C1781,HCPCS,0278,RC,,,,both,,,3345.10,2174.31,,,,,,,,,,,,,
IMPLANT OTO L5MM HD DIA2.87MM PLASTIPORE FULL CANN PORP,SUP-2313844,CDM,L8613,CPT,0278,RC,,,,both,,,1308.97,850.83,,,,,,,,,,,,,
BIT DRL L30MM DIA2.6MM ADD ON FIT SPEEDGUIDE,SUP-2378003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HALF RING-SBF 100MM,SUP-2818185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4446.87,2890.47,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BUTTON SUT DIA11MM KNEE RND CONCV ABS 2 PC TIGHTROPE,SUP-2121395,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
DRILL CANN 19MM TRUVIEW,SUP-2400036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
PLATE FIXATION BOX STERNAL 4 HOLES,SUP-2719527,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
PACK TDC POSTERIOR 25G EVA NEXUSTM,SUP-2863707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1156.56,751.76,,,,,,,,,,,,,
SCREW BONE DIA1.7MM L4MM CRANIOMAXILLOFACIAL LCK CROSS PIN,SUP-2363334,CDM,C1713,HCPCS,0278,RC,,,,both,,,146.76,95.39,,,,,,,,,,,,,
CATHETER BLLN DIL ADVANTAGE 180 CM 12X80 MM PK,SUP-2126434,CDM,C1726,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
CLIP SURG SZ 1 CLS TB DISP FOR GAM 3,SUP-2368479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,6370000000,HCPCS,0637,RC,43598-0326-75,NDC,,both,7.5,ML,519.20,337.48,,,,,,,,,,,,,
CATHETER ETER ABLAT 6FR L120CM HEXAPOLAR SPEC WIRE COR SUP,SUP-2356847,CDM,C1730,HCPCS,0272,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
STEM FEM SEG 9 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449809,CDM,C1776,CPT,0278,RC,,,,both,,,11251.72,7313.62,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 55CM 6 FR 0.018/0.038 IN AQ RENAL,SUP-2169822,CDM,C1894,HCPCS,0272,RC,,,,both,,,165.29,107.44,,,,,,,,,,,,,
COMPONENT FEM SZ 3 L REV POST STBL GMK,SUP-2267609,CDM,C1776,CPT,0278,RC,,,,both,,,19866.78,12913.41,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND FNGR CUST W/OUT JT FABRICATED,SUP-2435764,CDM,L3765,HCPCS,0274,RC,,,,both,,,3303.85,2147.50,,,,,,,,,,,,,
HC Lung Volumes Airway Resist,PX-4609472600,CDM,94726,CPT,0460,RC,,,,both,,,584.00,379.60,,,,,,,,,,,,,
BRA SURG 2XL WHT POST SURG MAMM COMPR DSG W/ REM STRP FR HK,SUP-2276929,CDM,L8000,HCPCS,0274,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
STEM FEM KNEE CONSTRN SCR SUPLMNT,SUP-2210610,CDM,C1713,HCPCS,0278,RC,,,,both,,,2172.88,1412.37,,,,,,,,,,,,,
MICRO PLATE TRIANGULAR 6MM 15MM SYSTEM CP TITANIUM,SUP-2707394,CDM,C1713,HCPCS,0278,RC,,,,both,,,427.13,277.63,,,,,,,,,,,,,
GRAFT VASC IMPRA L 60 CM DIA 6 MM EPTFE STR TW N RING HEMO,SUP-2761313,CDM,C1768,CPT,0278,RC,,,,both,,,2504.12,1627.68,,,,,,,,,,,,,
BLADE OSTEO FLAT TIP 11X50 MM PNEUMATIC VERSADRIVER,SUP-2877744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.93,1125.10,,,,,,,,,,,,,
SCREW BNE L34MM DIA2MM STD CORT S STL NONCANNULATED FULL,SUP-2183189,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.85,73.35,,,,,,,,,,,,,
MATRIX BIO SZ 19 SQCM FISH SKIN DERMAL MIC INTACT STRL,SUP-2909234,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 25 X 50 X 3 MM POLYETHYL BLOCK STRL DISP,SUP-2935429,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 50 CM DIA 6 MM EPTFE STR GRAD REINF 3,SUP-2227388,CDM,C1768,CPT,0278,RC,,,,both,,,3898.25,2533.86,,,,,,,,,,,,,
COLLAR CERV PADDED LG TALL COMFORT ADJ MIAMI J,SUP-2434343,CDM,L0174,HCPCS,0274,RC,,,,both,,,155.46,101.05,,,,,,,,,,,,,
GRAFT TISS SPCR CERV CANC FRZ DRY ALLGRFT 5MM,SUP-2307220,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
CONNECTOR SPNL XLNK ASMBLY FIX TRNSVRS CONN TI 4.75MM ROD,SUP-2415716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
LEVEL CMF ST PLATE RECON TLTS ANGLE ANGLE BENT 20 25 MM SC,SUP-2669750,CDM,C1713,HCPCS,0278,RC,,,,both,,,7303.51,4747.28,,,,,,,,,,,,,
OVERDRILL SURG 2.8MM SM SCR FIX SYS LACTOSORB REUNITE,SUP-2137301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
TIP ENDO SUCT STR 10 MM DIAM 33 CM LEN QUIK DC N COAG W/ H,SUP-2125888,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
NEEDLE NAVIGATION SYS 22GA L15MM DIA1.8MM NIT FLXIBLE SPIN,SUP-2392618,CDM,C1713,HCPCS,0278,RC,,,,both,,,2670.57,1735.87,,,,,,,,,,,,,
PRESSURIZER BNE CEM SM PROX FEM CNL HI VAC W/O HUB DISP,SUP-2366765,CDM,C1713,HCPCS,0278,RC,,,,both,,,48.83,31.74,,,,,,,,,,,,,
PIN DISTRACTOR 16 MM TI STRL 0460002902S,SUP-2591709,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN 7.5MM TIP PTFE S STL COR,SUP-2355723,CDM,C1769,HCPCS,0272,RC,,,,both,,,182.87,118.87,,,,,,,,,,,,,
STEM FEM REV PRSS FIT CALCAR RESTR 237MML SZ 2 12 L BOW,SUP-2375188,CDM,C1776,CPT,0278,RC,,,,both,,,17042.66,11077.73,,,,,,,,,,,,,
SCREW BONE L5MM DIA2MM BLU CRANIOMAXILLOFACIAL TI SELF DRL,SUP-2137243,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
HC Blood Draw per Picc/Cl,PX-7613659200,CDM,36592,CPT,0761,RC,,,,both,,,218.00,141.70,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.432,SUP-2859996,CDM,C1713,HCPCS,0278,RC,,,,both,,,43735.80,28428.27,,,,,,,,,,,,,
KIT CATHETER 7FR L20CM 2 TIP STR J DIL GWIRE INTRO,SUP-2383326,CDM,C1751,HCPCS,0278,RC,,,,both,,,135.27,87.93,,,,,,,,,,,,,
SEALANT TISS 4ML FIBRIN PREFIL SYR PRIMA FRZN W/ 1 DUPLOJET,SUP-2130407,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.25,586.46,,,,,,,,,,,,,
ROD SPNL L200MM DIA35MM OCCIPITOCERVICAL UP THOR CO CHROME,SUP-2285380,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC SYR DBM ACCELL EVO3,SUP-2641760,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
SCREW BONE DART-FIRE SHORT HEADLESS 3.0MMX14MM,SUP-2854124,CDM,C1713,HCPCS,0278,RC,,,,both,,,2179.16,1416.45,,,,,,,,,,,,,
HEAD REAMER DIA 9.5 MM FLX,SUP-2898466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE L189MM THK3.4MM 14 H BILAT S STL STR LOK COMPR,SUP-2185151,CDM,C1713,HCPCS,0278,RC,,,,both,,,1624.98,1056.24,,,,,,,,,,,,,
SPACER SPNL H8MM SM PEEK THORLUM INTBDY FUS FLAT ADD ON STK,SUP-2291491,CDM,C1713,HCPCS,0278,RC,,,,both,,,13056.12,8486.48,,,,,,,,,,,,,
CABLE EP CATH WOVEN L 125 CM 4 PIN FOR FIX CRV CATH STRL,SUP-2885501,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 75 MCG PO TABS,RX-4422,CDM,6370000000,HCPCS,0637,RC,51079-0441-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L112MM 4 H R MED DST TIB S STL VAR ANG LOK COMPR,SUP-2177629,CDM,C1713,HCPCS,0278,RC,,,,both,,,4769.53,3100.19,,,,,,,,,,,,,
SCREW SET 8-32X0.25 MM,SUP-2846273,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
CATHETER SNUS BLLN L24MM DIA7MM HI PERF DIL INT SNUS IRRIG,SUP-2106327,CDM,C1729,HCPCS,0272,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
BUTTON CERCLAGE DIA2.5MM STRL S STL HEX STARDRV T25 USS,SUP-2187034,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
CATHETER HD SHT TERM 14 FRX24 CM ADMIN BASIC SET PRECRV,SUP-2269515,CDM,C1752,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
CATHETER NEPHROSTOMY BLLN 10 MMX15 CM W/ SHTH ULTRAXX,SUP-2835968,CDM,C1726,HCPCS,0272,RC,,,,both,,,727.00,472.55,,,,,,,,,,,,,
HC IV 1st Hour Init Drug,PX-2609636500,CDM,96365,CPT,0260,RC,,,,both,,,370.00,240.50,,,,,,,,,,,,,
HC Anterior Nose Bleed Comp,PX-4503090300,CDM,30903,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
KIT TRL AXIUM INCL 2 AXIUM 50CM TRL LD KTS AND 1 CONN CBL KT,SUP-2356722,CDM,C1897,HCPCS,0278,RC,,,,both,,,8529.12,5543.93,,,,,,,,,,,,,
KIT LD ADPT BLV BIS 40,SUP-2282320,CDM,C1883,HCPCS,0278,RC,,,,both,,,1384.30,899.79,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.7X14 MM CORTICAL CRUCIFORM RECESS TIT,SUP-2838297,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
MESH CRAN L 77.52 X W 38.1 MM THK 0.61 MM SZ 80 MM XW TI,SUP-2936194,CDM,C1713,HCPCS,0278,RC,,,,both,,,8145.16,5294.35,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 16 MM,SUP-2741812,CDM,C1762,CPT,0278,RC,,,,both,,,13996.24,9097.56,,,,,,,,,,,,,
PLATE BONE THK1MM 12 H CRANIOMAXILLOFACIAL ORAL SLV TI ADPT,SUP-2181764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2459.56,1598.71,,,,,,,,,,,,,
PLATE BNE L114MM 5 H STD PROX HUM S STL LOK COMPR FOR 3.5MM,SUP-2186013,CDM,C1713,HCPCS,0278,RC,,,,both,,,4336.34,2818.62,,,,,,,,,,,,,
INSERT TIB ARTC POST STBL HI POST 10MM THCK 71-75MM MEDL LAT,SUP-2409156,CDM,C1776,CPT,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
STRAP SPLNT NYL WHT 2INX14IN ROLYAN D RNG,SUP-2324780,CDM,L3908,HCPCS,0274,RC,,,,both,,,9.11,5.92,,,,,,,,,,,,,
LEAD PACE MYOPORE L 54 CM TI SIL PTIR ATRIOVENTRICULAR IS1,SUP-2356207,CDM,C1898,HCPCS,0275,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE SPINE IMPL NARROW LCK 2X34MM 6HL,SUP-2661360,CDM,C1713,HCPCS,0278,RC,,,,both,,,3519.94,2287.96,,,,,,,,,,,,,
ELECTRODE ELECSURG 24-28 FR BRL,SUP-2312910,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.68,552.29,,,,,,,,,,,,,
SCREW BNE L36MM DIA3.5MM CORT DST TIB TI ST NONCANNULATED,SUP-2411695,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.87,152.67,,,,,,,,,,,,,
SYSTEM SINUPLASTY BAL L16MM DIA6MM SPINPLUS NAV RELIEVA,SUP-2106370,CDM,C1726,HCPCS,0272,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESHED THN 25X13 CM MTRX SOMAGEN,SUP-2434142,CDM,C1762,CPT,0278,RC,,,,both,,,56909.74,36991.33,,,,,,,,,,,,,
SPLINT SPNL SM CHILD W5XL60CM BCKL STRP CNTCT CLSR PD MCLEOD,SUP-2197368,CDM,L3650,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP OCCUPATIONAL THERAPY SERV,PX-4309712900,CDM,97129,CPT,0430,RC,,,GO,outpatient,,,186.00,120.90,,,,,,,,,,,,,
ADAPTER CBL 6MM PACEMKR UPLR,SUP-2357323,CDM,C1883,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE EXOSEAL DIA 6 FR FEM ART 2 UNIQUE,SUP-2158725,CDM,C1760,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BNE 2.7X145 MM 16 HOLE SS LC-DCP,SUP-2569223,CDM,C1713,HCPCS,0278,RC,,,,both,,,416.21,270.54,,,,,,,,,,,,,
ALLOGRAFT BNE SHT 25X20X5 MM CANC CONFORM Q-PACK,SUP-2737083,CDM,C1713,HCPCS,0278,RC,,,,both,,,3296.22,2142.54,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT WDG FIB RND COR IRRADIATED 18MM,SUP-2264757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1562.34,1015.52,,,,,,,,,,,,,
PLATE BNE 110 DEG LNG BAR MINI RT CRANIOMAXILLOFACIAL L SHP,SUP-2883176,CDM,C1713,HCPCS,0278,RC,,,,both,,,1402.17,911.41,,,,,,,,,,,,,
GUIDEWIRE VASC DURAFLO ANGIO,SUP-2130898,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
SYSTEM PHACO OD9MM BASIC FLUIDICS MGMT SYS OZIL TORSIONAL,SUP-2109969,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
PLATE BNE L61MM 5 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT DYN,SUP-2185927,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.79,298.21,,,,,,,,,,,,,
ANCHOR SUT W 3 NO 2 HI FI SUTS 17MM LEN 55MM CROSSFT,SUP-2167100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1471.72,956.62,,,,,,,,,,,,,
KIT INTRO TSX 55 DEG L 60 CM DIA 8.5 FR GUIDEWIRE L 135 CM,SUP-2148497,CDM,C1894,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,0636,RC,61703-0319-22,NDC,,both,20,ML,58.60,38.09,,,,,,,,,,,,,
INTRODUCER PACE LD L 14 CM DIA 7 FR DI-LOCK DIL L 19 CM DIA,SUP-2357093,CDM,C1892,HCPCS,0272,RC,,,,both,,,16.96,11.02,,,,,,,,,,,,,
IMPLANT BRST W11.5-11.1XH9.5-9.4CM P5.1-6.3CM 275-330CC,SUP-2300536,CDM,C1789,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
HC Intro Catheter Aorta,PX-3613620000,CDM,36200,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
STAPLE CARTRIDGE STR 16X10 MM TI,SUP-2166812,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
ALLOGRAFT BNE 1.2 ML BIOACTIVE FOAM PK VITOSS BA BIMODAL,SUP-2637053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
HC Rsf Lab Ecmc - Special Stain,PX-9900000128,CDM,9900000128,LOCAL,0990,RC,,,,both,,,19.00,12.35,,,,,,,,,,,,,
COMPONENT ARTC 25X3X3MM OFFSET,SUP-2123539,CDM,C1776,CPT,0278,RC,,,,both,,,12625.94,8206.86,,,,,,,,,,,,,
PROSTHESIS OSS 4X4X6 MM 3.67 MM RICHARDS CENTERED HA TORP,SUP-2637875,CDM,L8613,CPT,0278,RC,,,,both,,,1225.54,796.60,,,,,,,,,,,,,
HC So2 Immunoglobulin,PX-3018278468,CDM,82784,CPT,0301,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
BLADE SAW THK0.38MM MIC LT IBO RECIP COR TPS,SUP-2363315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.95,209.92,,,,,,,,,,,,,
SCREW STRNL CLOSURE L 14 MM DIA2.7 MM TI STRL STERNALOCK XP,SUP-2895211,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.08,201.55,,,,,,,,,,,,,
CATHETER DIL PTA P3 9MM X 2CM PWRFLX,SUP-2156167,CDM,C1725,HCPCS,0272,RC,,,,both,,,797.50,518.37,,,,,,,,,,,,,
PLATE BNE W11.7XL45.3MM 8 H WRST TI L ANG LOK COMPR HI,SUP-2411671,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.66,1479.83,,,,,,,,,,,,,
CATHETER DRAINAGE DUROMETER LOOP REG 10 FRX25 CM FLEXIMA,SUP-2147823,CDM,C1729,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
INTRODUCER SHTH L45CM OD4FR TIP L7CM OD0.018IN S STL WIRE S,SUP-2117379,CDM,C1894,HCPCS,0272,RC,,,,both,,,61.14,39.74,,,,,,,,,,,,,
SLEEVE TROCAR L60MM DIAMETER 5MM SMOOTH WITH TAP DISPOSABLE,SUP-2804743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.63,294.21,,,,,,,,,,,,,
DAPSONE 25 MG PO TABS,RX-2132,CDM,6370000000,HCPCS,0637,RC,70954-0135-10,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
IMPLANT HUM TISS TEND L 180 X W 10 MM BNE L 25-30 X W 14 X H,SUP-2913408,CDM,C1762,CPT,0278,RC,,,,both,,,8182.84,5318.85,,,,,,,,,,,,,
SET CHOLANGIOGRAPHY ENDO CATH 3FR L43CM NDL 16GA L12CM,SUP-2168107,CDM,C1894,HCPCS,0272,RC,,,,both,,,249.63,162.26,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L40CM ADMIN CHRONIC BASIC KT 14.5,SUP-2266984,CDM,C1750,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
GRAFT VASC GORTX L 15 CM DIA 6 MM RNG L 5 CM EPTFE STR TW,SUP-2396149,CDM,C1768,CPT,0278,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
HEAD FEM DIA50MM HIP ULT UPLR HLLW,SUP-2253258,CDM,C1776,CPT,0278,RC,,,,both,,,1051.27,683.33,,,,,,,,,,,,,
HEAD HUM H15MM DIA40MM CO CHROME ECC PRI GLOB AP,SUP-2249979,CDM,C1776,CPT,0278,RC,,,,both,,,5522.00,3589.30,,,,,,,,,,,,,
BURR ARTHSCP 5.5MM DIA 120MML BONE ROUND DARK GRAY ORNG F/PW,SUP-2574097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
ROD SPNL L20MM 2 BALL SPHERX DBR,SUP-2311186,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
HC Car-T Therapy Hrvg Bld Drv T Lmphcyt PR Day,PX-8713822500,CDM,38225,CPT,0871,RC,,,,inpatient,,,2291.00,1489.15,,,,,,,,,,,,,
CATHETER GUID L 95 CM OD 9 FR ID 0.098 IN CORONARY HNCK HH1,SUP-2158072,CDM,C1887,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
GUIDEWIRE SPNL SYM OCT DIA 0.95 MM NS,SUP-2591518,CDM,C1769,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
SCREW BONE L46MM OD5.5MM THRD L32MM STD TI CORT ST SELF DRL,SUP-2343149,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.13,1259.13,,,,,,,,,,,,,
IMPLANT HUM TISS L 70 X W 40 MM THK 4 MM ACHILLES TEND RC,SUP-2932924,CDM,C1762,CPT,0278,RC,,,,both,,,12964.93,8427.20,,,,,,,,,,,,,
HC Debrid Wound Tis 20 Cm/<,PX-4309759700,CDM,97597,CPT,0430,RC,,,,both,,,583.00,378.95,,,,,,,,,,,,,
HC Laryngoscopy Flexible Fiberoptic Diagnostic,PX-4503157500,CDM,31575,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
FORCEP OPHTH ASYM 23 GA STRL GRIESHABER REVOLUTION DSP DISP,SUP-2109704,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
CAGE SPNL E 13 MM EXPANDABLE CORPECTOMY STRL STRATOSPHERE,SUP-2423887,CDM,C1889,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
BIT DRILL STOP MINI 1.25X44.5 MM 8 MM QUICK COUPLING NON STE,SUP-2842021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,595.66,387.18,,,,,,,,,,,,,
POROUS FEM W/ COCR HD ANDXLPE ALL POLY CUP,SUP-2347943,CDM,C1776,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 135 CM BALLOON L 100 MM,SUP-2141226,CDM,C1725,HCPCS,0272,RC,,,,both,,,2885.66,1875.68,,,,,,,,,,,,,
NAIL LEFT LONG 10 X 120MM,SUP-2854414,CDM,C1713,HCPCS,0278,RC,,,,both,,,8888.02,5777.21,,,,,,,,,,,,,
COOLCUT 90 ABLATOR,SUP-2816012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SYSTEM IMPL IB FIBERLINK DRL STRL DISP TIGHTROPE II RT,SUP-2882328,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SHEATH INTRO AD 7FR L59CM DIL L67CM 0.032IN PTFE FIX CRV,SUP-2284369,CDM,C1894,HCPCS,0272,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
STENT BILI ZILVER 635 L 60 MM DIA12 MM DEL SYS L 40 CM SHTH,SUP-2647170,CDM,C1876,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRAFIX PRIME 16MM DISC CYROPRESERVED,SUP-2319187,CDM,Q4133,HCPCS,0636,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
BUR SURG DIA 3 MM HUB I NEURO 1 RNG CUT STRL DISP ELAN 4,SUP-2929199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.97,233.98,,,,,,,,,,,,,
BIT DRL 3.2MM LNG GLEN LATARJET,SUP-2256874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4942.36,3212.53,,,,,,,,,,,,,
TRAY CHST TB CATH 18FR 41CM GWIRE L80CM 3 MRK DIL 8X14X20FR,SUP-2168083,CDM,C1729,HCPCS,0272,RC,,,,both,,,750.15,487.60,,,,,,,,,,,,,
CATHETER GUID TYP 3DRC USED IN COR ANGIOPLSTY VASC PERIPH,SUP-2158732,CDM,C1887,HCPCS,0272,RC,,,,both,,,419.98,272.99,,,,,,,,,,,,,
DEVICE FLO CPLR OD3MM 20MHZ DOPP,SUP-2382625,CDM,C1889,HCPCS,0278,RC,,,,both,,,3444.58,2238.98,,,,,,,,,,,,,
STABILIZATION KIT LG WRST,SUP-2384731,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.52,147.89,,,,,,,,,,,,,
PLATE BNE L 220 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 20 HL,SUP-2936833,CDM,C1713,HCPCS,0278,RC,,,,both,,,3444.42,2238.87,,,,,,,,,,,,,
ANCHOR SUTURE 4.5MM WITH 3 NO 2 SUTURES HI-FI NEEDLE CROSSFT,SUP-2824425,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
DEVICE FIX FEM W/ ZIPLOOP TECHNOLOGY SYS TOGGLELOC,SUP-2212939,CDM,C1713,HCPCS,0278,RC,,,,both,,,4571.84,2971.70,,,,,,,,,,,,,
PROSTHESIS VOICE SIL L6 MM OD16 FR TRACHEOESOPHAGEAL 1W SLT,SUP-2242327,CDM,L8507,HCPCS,0274,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
TM FEM METAPHYSEAL CONE 35 MEDIUM RIGHT,SUP-2502267,CDM,C1776,CPT,0278,RC,,,,both,,,12882.79,8373.81,,,,,,,,,,,,,
SYSTEM DRAINAGE NON-PRESSURE TBNG BLU STRP,SUP-2666732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.31,331.70,,,,,,,,,,,,,
KIT PLEUR DRNGE COMPLT INSRT TY CATHETER 5 DRNGE 5 DSG KT,SUP-2301575,CDM,C1729,HCPCS,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
DRILL SURG STEM 13 MM FEM W/ HUDSON END SPEC 2,SUP-2456532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCISSORS LAPSCP 5MM L45CM BPLR CUT AND COAG DISP,SUP-2312663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR 6MM LESS STRAINED SPEAK VLV PROVOX,SUP-2124379,CDM,L8509,HCPCS,0274,RC,,,,both,,,940.08,611.05,,,,,,,,,,,,,
HC Irrigation of Vad - Only,PX-4509652300,CDM,96523,CPT,0450,RC,,,,both,,,265.00,172.25,,,,,,,,,,,,,
SPIKE CBL HIP S STL ACCORD,SUP-2345199,CDM,C1776,CPT,0278,RC,,,,both,,,469.74,305.33,,,,,,,,,,,,,
SURFACE ARTC SZ 1-2 THK23MM AP40MM ML58MM UNIV ANTR UHMWPE,SUP-2208695,CDM,C1776,CPT,0278,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
PLATE BNE L L114MM 2X4 H L MT TI POLYAX LOK COMPR LO PROF,SUP-2398498,CDM,C1713,HCPCS,0278,RC,,,,both,,,6955.10,4520.81,,,,,,,,,,,,,
KIT INTRO ONESTIC L 5.75 CM DIA 7FR 7CM 21GA NIT WIRE PD TIP,SUP-2876557,CDM,C1894,HCPCS,0272,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
CLAMP EXT FIX FOR 10.5MM BAR 4MM PIN JET-X,SUP-2342948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3990.00,2593.50,,,,,,,,,,,,,
CATHETER CHOLGM L18IN OD18GA LAP DISP,SUP-2331300,CDM,C1726,HCPCS,0272,RC,,,,both,,,207.33,134.76,,,,,,,,,,,,,
MESH HERN OVL 8X6 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855271,CDM,C1781,HCPCS,0278,RC,,,,both,,,17348.50,11276.52,,,,,,,,,,,,,
SCREW BONE L42MM OD4.5MM S STL CORT ST NONLOCKING FULL THRD,SUP-2344161,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.55,125.81,,,,,,,,,,,,,
CATHETER HD STR 12 FRX15 CM SHT TERM 3L TY SLIM-CATH,SUP-2424484,CDM,C1752,HCPCS,0278,RC,,,,both,,,979.96,636.97,,,,,,,,,,,,,
LONG DRILL COMPATIBLE WITH KDPDKBP 1110 13 G,SUP-2702558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CEFAZOLIN SODIUM 2 G SOLR (MIXTURES ONLY),RX-430073,CDM,J0690,HCPCS,0636,RC,60505-6231-05,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
STEM HUM PROX 142 DEG 6/8 SHLDR ANAT W/ BODY GLOB UNITE,SUP-2452214,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER DRAINAGE TIGHT LOOP TIP 8 FRX25 CM EXODUS ARRY,SUP-2118771,CDM,C1729,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
FOOTPLATE EXT FIX DIA150MM FOR RNG FIX SYS TRUELOK,SUP-2316189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
PLATE BNE W10.2XL39MM THK2.7MM 3 H BILAT S STL STR LO PROF,SUP-2186190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1087.76,707.04,,,,,,,,,,,,,
PLATE BNE L64MM THK2MM 11 H L MED FT TIM LOK COMPR FOR,SUP-2413837,CDM,C1713,HCPCS,0278,RC,,,,both,,,2452.53,1594.14,,,,,,,,,,,,,
BIT DRILL HIP FIBERTAK 1.6MM,SUP-2841347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SPLINT FRARM AD SM/M RT NEOPRNE TERRY LNR BASE CVA/TBI DGT,SUP-2324472,CDM,L3809,HCPCS,0272,RC,,,,both,,,375.98,244.39,,,,,,,,,,,,,
HC Closed Tx Ulnar Shaft Frac Man,PX-4502553500,CDM,25535,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SUPPORT ORTHOT CUST SOLE WDG OUTSIDE,SUP-2435722,CDM,L3360,HCPCS,0274,RC,,,,both,,,100.79,65.51,,,,,,,,,,,,,
TEMPLATE SURG XL DST RAD SZ SET LCP,SUP-2178987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,592.05,384.83,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 100X100X0.6 MM RIGID TI SLV STRL,SUP-2859898,CDM,C1713,HCPCS,0278,RC,,,,both,,,6722.11,4369.37,,,,,,,,,,,,,
PAD ORTHOT STRNL CUST,SUP-2435575,CDM,L1050,HCPCS,0272,RC,,,,both,,,284.08,184.65,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 4X44 MM HD 10004044] EXACTECH INC],SUP-2221521,CDM,C1713,HCPCS,0278,RC,,,,both,,,1265.42,822.52,,,,,,,,,,,,,
GRAFT VASC 6 MMX40 CMX0.35 MM STR ULTRA THN WALL HEMGRD,SUP-2471676,CDM,C1768,CPT,0278,RC,,,,both,,,1612.17,1047.91,,,,,,,,,,,,,
STABILIZER 045MMX25IN OLV CROSSCHECK,SUP-2401429,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
HC Pain Combination,PX-3600007517,CDM,3600007517,LOCAL,0360,RC,,,,inpatient,,,3954.00,2570.10,,,,,,,,,,,,,
BIT DRL QC MINI 0.76X44.5 MM 8 MM SS STRL,SUP-2187633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.62,378.05,,,,,,,,,,,,,
LCKNG PL CVD2X816 H GRID T1.5MM CP TI,SUP-2500129,CDM,C1713,HCPCS,0278,RC,,,,both,,,2830.68,1839.94,,,,,,,,,,,,,
BONE HOLDING FORCEPS-SOFT RATCHET F/PLATES TO 19MM WIDE,SUP-2548933,CDM,C1713,HCPCS,0278,RC,,,,both,,,2221.42,1443.92,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 30CML INSER 400,SUP-2613240,CDM,C1752,HCPCS,0278,RC,,,,both,,,706.37,459.14,,,,,,,,,,,,,
PLUG MESH SM ANCHR 5CM RIM 5CM 3D THERMOFORMED FLAT,SUP-2220109,CDM,C1781,HCPCS,0278,RC,,,,both,,,711.84,462.70,,,,,,,,,,,,,
DEVICE SEALER TISSUE REPROC LIGASURE 44CM MARYLAND,SUP-2717600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,877.06,570.09,,,,,,,,,,,,,
CATHETER HD STR 9 FRX15 CM CATH INTRO NDL DUOFLO,SUP-2627101,CDM,C1752,HCPCS,0278,RC,,,,both,,,269.57,175.22,,,,,,,,,,,,,
FILLER BNE GRFT 10 ML GENTAMICIN SULF HA CALCIUM SULF INJ,SUP-2893106,CDM,C1602,HCPCS,0278,RC,,,,both,,,23352.18,15178.92,,,,,,,,,,,,,
STENT BILI SOLUS L 7 CM DIA10 FR CATH L 210 CM 10 FR PUR,SUP-2169567,CDM,C2625,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GEL EMB TORPEDO L 10 MM HYDRATED 5 MM CATH ID 0.040 IN 3 CC,SUP-2516671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
ENDOPROSTHESIS TRACHBRONCH VIABAHN L 10 CM DIA10 MM NIT,SUP-2396463,CDM,C1874,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 5 FR HYDRPHLC,SUP-2383978,CDM,C1894,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
PATCH DURA L 1.6 X W 1.6 IN SURF AREA2.6 SQ IN BOV PERICARD,SUP-2884038,CDM,C1763,HCPCS,0278,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
ANCHOR N SUT FIX 1.1 MM SZ 16 MM LEN MENIS BIONX,SUP-2166727,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE L69MM THK2MM R CALCNL S STL LOK COMPR FOR 3.5MM,SUP-2185988,CDM,C1713,HCPCS,0278,RC,,,,both,,,1975.75,1284.24,,,,,,,,,,,,,
BUR REPROC SHV 5.5MMX18CM ABRAD HI VISIBILITY,SUP-2652939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,112.38,73.05,,,,,,,,,,,,,
BIT REPROC DRL CANN QUICK CPL 3.2X170MM,SUP-2653188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.87,441.92,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL LT 8 HOLE,SUP-2609043,CDM,C1713,HCPCS,0278,RC,,,,both,,,6492.33,4220.01,,,,,,,,,,,,,
COLLAR CERV SFT 375X21IN XL,SUP-2276588,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.19,4.02,,,,,,,,,,,,,
CONNECTOR SPNL L CDH DOMINO,SUP-2279960,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
GRAFT HUM TISS 6MM CERV F6183 4 007,SUP-2364362,CDM,C1713,HCPCS,0278,RC,,,,both,,,4504.33,2927.81,,,,,,,,,,,,,
BONE SCREW 6.5X30 SELF-TAP,SUP-2503712,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CATH BLLN SCORING 6X40MM X 90CM OTW PTA ANGIOSCULPT,SUP-2353203,CDM,C1725,HCPCS,0272,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
HC Ot Ultrasound 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309703500,CDM,97035,CPT,0430,RC,,,GP|CQ,both,,,194.00,126.10,,,,,,,,,,,,,
CATHETER HEMODLYS 13FR L20CM STR SHT TERM 3 LUMN DLYS,SUP-2125590,CDM,C1752,HCPCS,0278,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
GUIDE PIN ORTH 3.2X330 MM AOS,SUP-2766025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CATHETER VENT DRNGE L84CM OD1.5MM ID0.7MM CSF LP BA IMPREG,SUP-2284530,CDM,C1729,HCPCS,0272,RC,,,,both,,,1653.18,1074.57,,,,,,,,,,,,,
BOLT FUSION MIDFOOT 6.5X115MM TI STRL,SUP-2546677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1796.68,1167.84,,,,,,,,,,,,,
HC Med Nut Therapy Ind Init 15 Min,PX-9429780200,CDM,97802,CPT,0940,RC,,,,both,,,95.00,61.75,,,,,,,,,,,,,
PLATE BNE L200MM HIP TI 5 CBL FOR ACCORD SYS,SUP-2345379,CDM,C1713,HCPCS,0278,RC,,,,both,,,2442.92,1587.90,,,,,,,,,,,,,
HC Insert Cath Pleura W/ Image,PX-3613255700,CDM,32557,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SUTURE MORPHIX 3.5MM ANCHR W/ 2 USP NO0 DBL ARMED 100004235,SUP-2277451,CDM,C1776,CPT,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
LINER ACET HIP,SUP-2366760,CDM,C1776,CPT,0278,RC,,,,both,,,1.07,0.70,,,,,,,,,,,,,
SIGMA HP UNI DISTAL SHIM 8MM,SUP-2513353,CDM,C1776,CPT,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
UNIT BRST BX L14CM L20MM OD9GA HNDPC ATEC,SUP-2239993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA 6 MM RNG L 10 CM EPTFE,SUP-2396264,CDM,C1768,CPT,0278,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 4 MM STR STD WALL HELIX,SUP-2491640,CDM,C1768,CPT,0278,RC,,,,both,,,928.50,603.52,,,,,,,,,,,,,
PROSTHESIS OSS 0.6 MM 1.4X0.86X1.14 MM K-HELIX FTPLT SHOE TI,SUP-2465347,CDM,L8613,CPT,0278,RC,,,,both,,,417.59,271.43,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 304CUCM H219XL195IN THK053IN,SUP-2356746,CDM,C1767,HCPCS,0278,RC,,,,both,,,48670.00,31635.50,,,,,,,,,,,,,
DEFIBRILLATOR CARD W/ RIATA ATLS II DR,SUP-2356569,CDM,C1721,HCPCS,0275,RC,,,,both,,,71435.00,46432.75,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAG CTRL OFF THE SHLF,SUP-2435542,CDM,L0467,HCPCS,0274,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
BEARING TIB 12 MM POLYETH OSS AVL,SUP-2441785,CDM,C1776,CPT,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
SET VASC SNR MULTI-SNARE L 125 CM DIA20 MM INTRO L 105 CM,SUP-2125282,CDM,C1773,HCPCS,0272,RC,,,,both,,,829.78,539.36,,,,,,,,,,,,,
ANCHOR SUT ETHBND 4-0 DRL BIT OD1.3MM NDL C-1 TAPERPOINT WHT,SUP-2256608,CDM,C1713,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
KIT CATH 14.5FR L40CM INSRT L23CM POLYUR DBL LUMN STD FLO,SUP-2283941,CDM,C1881,HCPCS,0278,RC,,,,both,,,1089.05,707.88,,,,,,,,,,,,,
CINACALCET HCL 30 MG PO TABS,RX-38100,CDM,6370000000,HCPCS,0637,RC,69097-0410-02,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PASSER SUTURE 155MM DIAMETER 3.5MM LEFT RC SEAHAWK,SUP-2828616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3275.05,2128.78,,,,,,,,,,,,,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG PO TB24,RX-28643,CDM,6370000000,HCPCS,0637,RC,00904-7208-06,NDC,,both,1,UN,4.40,2.86,,,,,,,,,,,,,
CATHETER INTVASC LITHO E8 WORKING L 150 CM L 80 MM DIA 5 MM,SUP-2894715,CDM,C1768,CPT,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
SPLINT REST HND ADL R S DRBLUE BROAD,SUP-2165487,CDM,L3807,HCPCS,0272,RC,,,,both,,,123.25,80.11,,,,,,,,,,,,,
SYRINGE EAR ALL MTL 2 TIP,SUP-2159688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.65,394.32,,,,,,,,,,,,,
HC So1 Hexagonal Phospholipid,PX-3058559867,CDM,85598,CPT,0305,RC,,,,both,,,22.00,14.30,,,,,,,,,,,,,
COUNTERSINK SURG FOR 7MM CANN SCR,SUP-2187345,CDM,C1713,HCPCS,0278,RC,,,,both,,,1285.74,835.73,,,,,,,,,,,,,
BUR SURG MATCHSTICK LNG 3 MM FLUT LESS AGGRESSIVE CARBIDE,SUP-2848157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.00,416.65,,,,,,,,,,,,,
HC So N Gonorrhoeae Dna Amp Prob,PX-3068759166,CDM,87591,CPT,0306,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
BRACE ANK FT M AD WOM SHOE 7-9 STRP 2IN LT UNISX,SUP-2324848,CDM,L4350,HCPCS,0274,RC,,,,both,,,98.22,63.84,,,,,,,,,,,,,
DEVICE TRAC 19-23IN SM CRWN W/ SKULL PIN FOR BREMER HALO SYS,SUP-2255771,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
ANCHOR SUTURE PRE LD 2 2.9 MM W/ FORC FIBER QUATTRO GL,SUP-2608892,CDM,C1713,HCPCS,0278,RC,,,,both,,,1118.34,726.92,,,,,,,,,,,,,
COMPONENT FEM 00 LT KNEE CSTI POROUS N-K II,SUP-2210458,CDM,C1776,CPT,0278,RC,,,,both,,,12062.31,7840.50,,,,,,,,,,,,,
IMPLANT BIO TISS L25CM ID5MM PERIPH NRV CLLGN CONDUIT,SUP-2378815,CDM,C9353,HCPCS,0278,RC,,,,both,,,5051.00,3283.15,,,,,,,,,,,,,
STAPLER ENDO SKIN FIRING REINF W/ DRY CLLGN MTRX BOV,SUP-2130285,CDM,C9354,HCPCS,0278,RC,,,,both,,,671.90,436.73,,,,,,,,,,,,,
FORCEP ELECSURG BPLR 1.2 MM 15.5 CM PRECIS BAYNT SILVERGLIDE,SUP-2859573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2779.78,1806.86,,,,,,,,,,,,,
DEVICE FIXTN PROCINCH ADJ LOOP,SUP-2361152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.11,1146.67,,,,,,,,,,,,,
PROBE ELECSURG L ANGLED HK 5 MMX42 CM PREATTACH TBNG EPIX,SUP-2422366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BAG TISS RETRV 1850ML L10.4IN MOUTH DIA6IN INTRO TRCR 15MM,SUP-2166308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,498.44,323.99,,,,,,,,,,,,,
STENT BILI PALMAZ BLU L 19 MM DIA10-12 MM BALLOON EXPANDABLE,SUP-2102308,CDM,C1877,HCPCS,0278,RC,,,,both,,,4099.58,2664.73,,,,,,,,,,,,,
PLATE EXT FIX L180MM LNG ALUM FT RNG FOR ILIZ TAY SPAT FRME,SUP-2342981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8969.88,5830.42,,,,,,,,,,,,,
PLATE BNE L 257 MM SCREW DIA 4.5 MM 14 H SS NAR COMPR NLCK,SUP-2933469,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.14,1418.39,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 15.5 CM DIA 8 FR GUIDEWIRE 0.035 IN,SUP-2167816,CDM,C1894,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
STENT URET EXPEL L 24 CM DIA 6 FR FLEXITHANE HYDRPHLC 2,SUP-2652789,CDM,C2617,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM DIA1MM 5MM SPC 4 ELECTRD PERC TRL,SUP-2357675,CDM,C1778,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
INSERT TALAR SZ 4 THK9MM L R ANK POLYETH SADL PROPHECY,SUP-2397102,CDM,C1776,CPT,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
IBUPROFEN 100 MG/5ML PO SUSP,RX-10246,CDM,340b,HCPCS,0637,RC,00121-0914-05,NDC,,both,10,ML,12.60,8.19,,,,,,,,,,,,,
PLATE SPNL SM 2 H FOR OBLQ LAT LUM INTBDY FUS OLIF25 PIVOX,SUP-2284942,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 80 CM DIA 7 MM EPTFE CARBON PERIPH,SUP-2128082,CDM,C1768,CPT,0278,RC,,,,both,,,16413.31,10668.65,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 5MM TIP 2-5-2MM SPC M CURL QPLR,SUP-2421255,CDM,C1733,HCPCS,0272,RC,,,,both,,,2230.97,1450.13,,,,,,,,,,,,,
GRAFT HUMAN TSSUE SHEET 2CMW X 4CML ALLGRFT CNCLLS BONE RCTN,SUP-2726034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.49,1066.32,,,,,,,,,,,,,
WASHER ORTH SZ 12.7MM S STL BTRFLY FOR FIX,SUP-2343056,CDM,C1713,HCPCS,0278,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
SUTURE PROL 7 0 L8MM NONABSORBABLE BLU BV175 7 CTRL REL 3 8 M8764,SUP-2219653,CDM,C1713,HCPCS,0278,RC,,,,both,,,250.35,162.73,,,,,,,,,,,,,
CATHETER ENDO ACC DEL SPYSCOPE,SUP-2149612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2491.15,1619.25,,,,,,,,,,,,,
COMPONENT KNEE LOWER EXTREMITIES. ANCIL ZIRCONIUM NAVIO DISP,SUP-2348002,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BAG SHWR PROTECT DISP,SUP-2356015,CDM,Q0501,HCPCS,0274,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
GRAFT BONE MEDIOLATERAL W14.5MM H11.22X9.75MM,SUP-2264951,CDM,C1713,HCPCS,0278,RC,,,,both,,,4093.74,2660.93,,,,,,,,,,,,,
HINGE EXT FIX B FEM SVC PART,SUP-2437342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
BLADE RETRACTOR 7 CM MEDL LAT WIDE BLADE MAST QUAD,SUP-2631646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1751.18,1138.27,,,,,,,,,,,,,
HANDPIECE LASER STR 60 MM STR TIP FIBERLASE HP-R,SUP-2713725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SEGMENT FEM SZ 1 H20MM LT MEDL TILASTAN FOR W60MM COMP,SUP-2265081,CDM,C1776,CPT,0278,RC,,,,both,,,2838.56,1845.06,,,,,,,,,,,,,
TOWER SPNL REDUC ADDITION REVERE,SUP-2232140,CDM,2780000010,LOCAL,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
REAMER SURG 16MM MT JT CUP GEN 2,SUP-2398414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
PLATE BONE SM 8 H LT CLAV LCK,SUP-2107757,CDM,C1713,HCPCS,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 11 HOLE 2 COMPR LCK FOR SCR TI STRL,SUP-2473515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 70 MM DIA 7 MM DEL SHTH,SUP-2934216,CDM,C1713,HCPCS,0278,RC,,,,both,,,8785.72,5710.72,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8MM STR REINF SLDE GDS,SUP-2525459,CDM,C1768,CPT,0278,RC,,,,both,,,1885.76,1225.74,,,,,,,,,,,,,
STEM FEM PRESS FIT DUAL MORSE 65001105] ENCORE MEDICAL - DJO SURGICAL],SUP-2217406,CDM,C1776,CPT,0278,RC,,,,both,,,8578.48,5576.01,,,,,,,,,,,,,
CLIP INT LIG MED TI BLU VESOCCLUDE,SUP-2757594,CDM,C1889,HCPCS,0278,RC,,,,both,,,33.91,22.04,,,,,,,,,,,,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,0636,RC,00409-5820-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
MESH BONE 287MMW X 287MML 03MM THK RSRB X LG GRID LATEX F,SUP-2669263,CDM,C1713,HCPCS,0278,RC,,,,both,,,1291.51,839.48,,,,,,,,,,,,,
FORCEPS OPHTH 25GA END GRSP REVOLUTION DISPOSABLE GRIESHABER,SUP-2109693,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.51,307.78,,,,,,,,,,,,,
CATHETER CV 2 LUMEN 8 FR DISP,SUP-2384677,CDM,C1751,HCPCS,0278,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
MESH MXLFCL 157X134 MM 0.2 MM STD SCRN BNE 1.0 1.5 MM CP TI,SUP-2468553,CDM,C1713,HCPCS,0278,RC,,,,both,,,14000.51,9100.33,,,,,,,,,,,,,
TAP SURG DIA35MM CORT ST REUSE FOR BNE SCR POLARUS,SUP-2107699,CDM,C1713,HCPCS,0278,RC,,,,both,,,3896.74,2532.88,,,,,,,,,,,,,
BIT DRL QC 2.5X240 MM 150 MM CALIB NS,SUP-2563752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.74,292.33,,,,,,,,,,,,,
CATHETER ANGIO L135CM OD5FR 5CM INFUS PERIPH PAT PULSE SPRY,SUP-2118497,CDM,C1757,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
CATHETER PTCA L135CM BLLN L20MM DIA4MM XCELON HYDROPHOBIC,SUP-2104226,CDM,C1725,HCPCS,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
CONNECTOR SPNL L15MM OD5.5MM S STL THORLUM LO PROF CLOSE,SUP-2230992,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
GRAFT BNE SUB 30CC SZ 01 4MM CRUSH CANC CHIP FRZN,SUP-2307400,CDM,C1713,HCPCS,0278,RC,,,,both,,,2028.69,1318.65,,,,,,,,,,,,,
SCREW BNE L16MM DIA4.5MM PUR TI CORT ST CANN FULL THRD FOR,SUP-2316383,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.64,316.32,,,,,,,,,,,,,
CONNECTOR SPNL L30MM STD ANT TI FIX OPN TRNSVRS BAR AX USS,SUP-2181871,CDM,C1713,HCPCS,0278,RC,,,,both,,,1701.88,1106.22,,,,,,,,,,,,,
IMMOBILIZER KNEE PERF-VINYL FOAM MEDL LAT POST STAY LOOP LCK,SUP-2197967,CDM,L1830,CPT,0274,RC,,,,both,,,98.78,64.21,,,,,,,,,,,,,
HARVESTER BONE W/ FILTER INSERT 8MM,SUP-2715942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
FIXATION KIT SELFDRILLING LARGE 12 MM STERNAL H TYPE PRECONT,SUP-2838436,CDM,C1713,HCPCS,0278,RC,,,,both,,,6158.80,4003.22,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 2X4CM,SUP-2907550,CDM,Q4151,HCPCS,0636,RC,,,,both,,,2875.74,1869.23,,,,,,,,,,,,,
DEVICE GLAUCOMA DRNGE 1/4IN CLR CORNEA W/ SCLER,SUP-2247189,CDM,V2785,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
SYSTEM DELIVERY 34 MM  EVOLUT FX,SUP-2854100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9765.40,6347.51,,,,,,,,,,,,,
AUGMENT FEM THK 5 MM SZ 2 DSTL HINGE REV STRL TRIATHLON,SUP-2889784,CDM,C1776,CPT,0278,RC,,,,both,,,5000.45,3250.29,,,,,,,,,,,,,
PIN FIX L200MM OD1.8MM TRCR PNT ST DISP,SUP-2405549,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.91,302.84,,,,,,,,,,,,,
CAGE SPNL 10 DEG 12X22X60 MM LAT COROENT XL-W+ LF,SUP-2560504,CDM,C1889,HCPCS,0278,RC,,,,both,,,13979.28,9086.53,,,,,,,,,,,,,
TREPHINE ORTH SZ 65MM STR SCR REM CRWN DRL,SUP-2368627,CDM,C1713,HCPCS,0278,RC,,,,both,,,2240.39,1456.25,,,,,,,,,,,,,
BUTTON SUTURE TIB STD INFIN DISP,SUP-2846787,CDM,C1713,HCPCS,0278,RC,,,,both,,,1195.71,777.21,,,,,,,,,,,,,
ANCHOR SUT MIC W/ SZ 4/0 C1 TAPR PT ORTHOCORD AND DRL BIT,SUP-2256600,CDM,C1713,HCPCS,0278,RC,,,,both,,,1761.54,1145.00,,,,,,,,,,,,,
SCREW BONE CORT LCK S STL HUM 3.8MMX20MM EQUINOXE,SUP-2223440,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BEARING TIB L63/67MM THK24MM KNEE SUP STBL POST STBL CNDYL 183834] ZIMMER BIOMET ORTHOPEDICS],SUP-2407713,CDM,C1776,CPT,0278,RC,,,,both,,,5695.96,3702.37,,,,,,,,,,,,,
PLATE BNE L96MM 5 H T SHP BTTRS FOR 45MM SCR L FRAG SYS,SUP-2411393,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.01,558.36,,,,,,,,,,,,,
CEFPODOXIME PROXETIL 100 MG PO TABS,RX-9468,CDM,6370000000,HCPCS,0637,RC,65862-0095-20,NDC,,both,1,UN,9.50,6.17,,,,,,,,,,,,,
SCALPEL HNDPC DISECT HK VAR SZ REPROC HARM,SUP-2219117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
CATHETER GUIDE EXTN 6 FRX150 CM HYDRPHLC COAT TELSCP,SUP-2416547,CDM,C1887,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
STENT CORONARY JOSTENT GRAFTMASTER L 19 MM DIA 3.5 MM GUIDE,SUP-2106199,CDM,C1874,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
SCREW BONE L33MM OD28MM LCTSRB CPLMR SHLDR SOLID FLLY THRDD,SUP-2724042,CDM,C1725,HCPCS,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
TUBE FEEDING 10FR 36 IRIS ENFIT,SUP-2878018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.94,446.51,,,,,,,,,,,,,
WAND ABLAT FOR LARYN PROCISE LW COBLATION,SUP-2342045,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3112.34,2023.02,,,,,,,,,,,,,
ELECTRODE UROLOGY 3MM 24FR RL BALL STRL DISP,SUP-2361447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.81,208.53,,,,,,,,,,,,,
CATHETER THROMCTMY FOGARTY L 50 CM DIA 5 FR SPRL DIA,SUP-2214036,CDM,C1757,HCPCS,0272,RC,,,,both,,,1263.13,821.03,,,,,,,,,,,,,
"HC New Pt, E/M Level 2",PX-5109920200,CDM,99202,CPT,0510,RC,,,,inpatient,,,296.00,192.40,,,,,,,,,,,,,
STEM FEM L240MM OD16MM POR DST CALCAR MOD RLER HARDENED,SUP-2403944,CDM,C1776,CPT,0278,RC,,,,both,,,9794.76,6366.59,,,,,,,,,,,,,
PLATE BNE BAR 12 MM 4 H L SHP SMARTLOCK LCK NS,SUP-2883193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1056.74,686.88,,,,,,,,,,,,,
CATHETER INFUSION BRAIDED 3 FRX150 CM RENEGADE HYDR PASS,SUP-2147587,CDM,C1887,HCPCS,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
WASHER ORTH 7 MM FOR PROV TISS TRABECULAR MTL,SUP-2437275,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
ANCHOR N SUT FIX 1.1 MM SZ 13 MM LEN W/O LOOP MENIS CNTOUR,SUP-2166729,CDM,C1776,CPT,0278,RC,,,,both,,,441.61,287.05,,,,,,,,,,,,,
SPACER HUM +9MM W TIGHT SCR,SUP-2399863,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.6X5.25 MM ECLIPSE PISTON NIT FLROPLAS,SUP-2486984,CDM,L8613,CPT,0278,RC,,,,both,,,975.35,633.98,,,,,,,,,,,,,
MARKER BRST BX L13CM SHP 2 SITE IDENTIFIER FOR EVIVA,SUP-2239978,CDM,A4648,CPT,0278,RC,,,,both,,,113.20,73.58,,,,,,,,,,,,,
PLIER DENT TWEED 4-7/8 INX12.5 CM WIRE BEND SS LEVEL 1,SUP-2473783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.76,421.69,,,,,,,,,,,,,
ANGEL BLOOD PROCESSING SET US,SUP-2816344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
HC So Calr Gene Analysis,PX-3108121966,CDM,81219,CPT,0310,RC,,,,inpatient,,,395.00,256.75,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB UNIV L,SUP-2276645,CDM,L3931,HCPCS,0274,RC,,,,both,,,15.92,10.35,,,,,,,,,,,,,
LINER ACET ID32MM +3MM 10DEG L SER S-ROM,SUP-2253366,CDM,C1776,CPT,0278,RC,,,,both,,,4571.84,2971.70,,,,,,,,,,,,,
SEALANT TISS CLOSURE ABSORB SYNTHESIZER KT,SUP-2227098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
MESH HERN FLAT SHT 10X14 IN RECT OVL KNITTED PROLITE ULTRA,SUP-2227249,CDM,C1781,HCPCS,0278,RC,,,,both,,,317.08,206.10,,,,,,,,,,,,,
PLATE BONE L156MM THK3MM 9 H TI TIM RT DSTL ANTEROLATERAL,SUP-2413680,CDM,C1713,HCPCS,0278,RC,,,,both,,,4956.49,3221.72,,,,,,,,,,,,,
TUBE FEED NG RADPQ POLYUR PED W OUT CO2 CONN SGL LUMN,SUP-2308298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,25.06,16.29,,,,,,,,,,,,,
CAGE SPNL W10XH9XL27MM 10-15DEG LUM PEEK INTBDY SELF EXP,SUP-2353369,CDM,C1889,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
SPLINT ORTHOPEDIC BOUTONNIERE 10 FNGR BEAUTY STRENGTH,SUP-2325010,CDM,L3927,HCPCS,0272,RC,,,,both,,,253.27,164.63,,,,,,,,,,,,,
GRAFT BONE GRAN FRZ DRY DEMIN CRUSH CANC CORT 0.5MM-3MM RANG,SUP-2307254,CDM,C1713,HCPCS,0278,RC,,,,both,,,1997.39,1298.30,,,,,,,,,,,,,
LCK MAND ANG PL3X3NON COM T25MM CP,SUP-2679064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1870.53,1215.84,,,,,,,,,,,,,
VALVE ENDOBRONCHIAL ZEPHYR DIA 5.5-8.5 MM NIT IMPL LP,SUP-2930255,CDM,C1889,HCPCS,0278,RC,,,,both,,,8179.70,5316.80,,,,,,,,,,,,,
BIT DRL L230MM DIA2.5MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,698.56,454.06,,,,,,,,,,,,,
TISSUE EPICORD 1X2CM,SUP-2716335,CDM,Q4187,HCPCS,0636,RC,,,,both,,,3083.48,2004.26,,,,,,,,,,,,,
PLATE BNE CRV 0.8 MM 8 HOLE CONTOURED SM GRID PLLA-PGA STRL,SUP-2489900,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.83,551.09,,,,,,,,,,,,,
STENT URET FLX 0.035 IN 3 CM 7 FRX20 CM 6 FR POLARIS ULTRA,SUP-2467805,CDM,C2617,HCPCS,0278,RC,,,,both,,,614.97,399.73,,,,,,,,,,,,,
HC So Malaria Prep,PX-3008720766,CDM,87207,CPT,0300,RC,,,,both,,,43.00,27.95,,,,,,,,,,,,,
CARTRIDGE SUT FOR SPEEDSTITCH MINI BLK COBRAID MAG WIRE,SUP-2342095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1569.56,1020.21,,,,,,,,,,,,,
SCREW IM L 67.5 MM DIA 5 MM TI LCK STRL TRIGEN MAX,SUP-2931487,CDM,C1713,HCPCS,0278,RC,,,,both,,,783.74,509.43,,,,,,,,,,,,,
BIT DRILL QUICK DISCONNECT DISPOSABLE FOR 1.5MM WIRE,SUP-2431395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
PLATE BONE 8 H BILAT CRANIOMAXILLOFACIAL TI STRUT LO PROF,SUP-2191330,CDM,C1713,HCPCS,0278,RC,,,,both,,,2233.17,1451.56,,,,,,,,,,,,,
ANCHOR SUT 5MM NO 2 W/ TWO BRAID POLY AND NDL SFT TISS,SUP-2362553,CDM,C1713,HCPCS,0278,RC,,,,both,,,632.40,411.06,,,,,,,,,,,,,
VORTIOXETINE HBR 5 MG PO TABS,RX-124079,CDM,6370000000,HCPCS,0637,RC,64764-0720-30,NDC,,both,1,UN,77.20,50.18,,,,,,,,,,,,,
KIT SPNL CEM 11CC PMMA NDLLESS HI VISC W/ RESVR MIX HYDRLC,SUP-2255658,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BONE THK1MM 3X2 H LT HND TRAPEZOIDAL LCK TRILOK FOR,SUP-2267930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
TRIAL ANK TALUS PT SPEC,SUP-2899085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
GRAFT SFT TISS W/O DWL CART,SUP-2307007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
STAPLE CARTRIDGE STR 20X16 MM TI,SUP-2166814,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.19,281.57,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER 2 CHMBR 40 J BPLR STD VVED 20 SEC,SUP-2138117,CDM,C1721,HCPCS,0275,RC,,,,both,,,52567.78,34169.06,,,,,,,,,,,,,
PLATE BONE L128MM 9 H LT LAT DSTL HUM LCK FOR 2.7/3.5MM SCR,SUP-2348657,CDM,C1713,HCPCS,0278,RC,,,,both,,,12320.26,8008.17,,,,,,,,,,,,,
ROD SPNL ANTR RT CVD SMOOTH S STL 5.0MM DIA 300MM LEN,SUP-2290515,CDM,C1713,HCPCS,0278,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
SPACER SPNL L20XW11XH11MM 4DEG PEEK POST THORLUM INTBDY FUS,SUP-2380616,CDM,C1821,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
MATRIX BIO L 10 X W 18 CM SZ 180 SQCM FISH SKIN SIL DERMAL,SUP-2909215,CDM,Q4158,HCPCS,0636,RC,,,,both,,,19116.32,12425.61,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 5 CM DIA 4 MM MICROCATHETER 0.035,SUP-2385395,CDM,C1889,HCPCS,0278,RC,,,,both,,,3425.11,2226.32,,,,,,,,,,,,,
PACEMAKER CARD PHILOS DR 2 CHMBR,SUP-2137964,CDM,C1785,HCPCS,0275,RC,,,,both,,,12456.38,8096.65,,,,,,,,,,,,,
HC Pain Minor,PX-3600007514,CDM,3600007514,LOCAL,0360,RC,,,,outpatient,,,2101.00,1365.65,,,,,,,,,,,,,
PATCH CV XENOSURE L 10 X W 1.5 CM BOV PERICARD BIOLOGIC UNIF,SUP-2217970,CDM,C1762,CPT,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BNE 6 H LT PREBENT NS DISP TRAUMAONE CHAMPY,SUP-2934687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
TROCAR ARTHSCP N THRD N OPT VW BLDELSS SHRP TIP W O HNDL W O,SUP-2166823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.54,443.00,,,,,,,,,,,,,
SCREW BONE FINE PITCH 2X5 MM MANDIBULAR SELFTAPPING 5/PK TIT,SUP-2842318,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.20,171.73,,,,,,,,,,,,,
CLIP MED 8 MM ABSORBABLE,SUP-2787681,CDM,C1889,HCPCS,0278,RC,,,,both,,,292.55,190.16,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.2 MM 5PK CRANIOFACIAL SD AXS 5PK,SUP-2883346,CDM,C1713,HCPCS,0278,RC,,,,both,,,1586.96,1031.52,,,,,,,,,,,,,
FLUOROPLASTIC VENT TUBE SHPRD GRMMT TYPE WITHOUT TAB WTH WIR,SUP-2681462,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.53,17.24,,,,,,,,,,,,,
HC Rp Loclzj Tumor/Dstrbj Agent Tomog Spect,PX-3417883100,CDM,78831,CPT,0341,RC,,,,both,,,2681.00,1742.65,,,,,,,,,,,,,
GUIDEWIRE VASC L40CM DIA0018IN S STL PLAT TIP MAK NV,SUP-2302990,CDM,C1769,HCPCS,0272,RC,,,,both,,,70.96,46.12,,,,,,,,,,,,,
GRAFT SYNTH L100XW75MM THICK4MM FOAM COMPR RESIST PREFRM,SUP-2368178,CDM,C1713,HCPCS,0278,RC,,,,both,,,11049.66,7182.28,,,,,,,,,,,,,
NAIL FIX L 70 MM DIA 4.5 MM HND WR THRD TRIM STRL OSSIOFIBER,SUP-2904326,CDM,C1713,HCPCS,0278,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
WIRE EXT FIX L385MM DIA1.8MM S STL DRL TIP FOR ILIZ TAY,SUP-2343003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.29,617.69,,,,,,,,,,,,,
SENSOR KT BLD GAS VIA AD,SUP-2246393,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
HEAD HUM DIA44MM SHT SHLDR FOR HEMIARTHROPLASTY EQUINOXE,SUP-2223316,CDM,C1776,CPT,0278,RC,,,,both,,,4266.63,2773.31,,,,,,,,,,,,,
BRACE ORTH SH UNIV KNEE FAST HNG ROM STRP CLSR FOAM AD UNISX,SUP-2196518,CDM,L1810,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
ROD THRD 400MM,SUP-2499725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY AVT TI 2 CHMBR 2 LD REMOT,SUP-2140362,CDM,C1721,HCPCS,0275,RC,,,,both,,,90651.80,58923.67,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2.8 MM 9 HOLE TITANIUM STERILE MATRIXRIB,SUP-2837691,CDM,C1713,HCPCS,0278,RC,,,,both,,,3725.61,2421.65,,,,,,,,,,,,,
ADAPTER PACEMKR LD L47CM DIA32MM BPLR IS 1 CONN SIL INSUL LO,SUP-2355668,CDM,C1883,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PACK FIX CL SZ CALC W CANN ENDOSCP DRL BIT GWIRE PASS PIN,SUP-2341011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 90 CM DIA 8 MM EPTFE STR TW,SUP-2681783,CDM,C1768,CPT,0278,RC,,,,both,,,2684.04,1744.63,,,,,,,,,,,,,
SHEATH GUID 11.5X8.5FR L72CM BI DIR SM CRV MOBICATH,SUP-2248640,CDM,C1766,CPT,0272,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY HT 225IN CIRC 13 16IN M PHIL,SUP-2319292,CDM,L0172,HCPCS,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
"HC So Infectious Agent,Nos",PX-3068789966,CDM,87899,CPT,0306,RC,,,,outpatient,,,141.00,91.65,,,,,,,,,,,,,
ANCHOR SPNL L25MM ANTR LUM TI FOR INTBDY FUS,SUP-2228832,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
LOW PRFLE NEURO TI MESH PANEL SML GRID 85X50MM .3MM1.5MM SYS,SUP-2500492,CDM,C1713,HCPCS,0278,RC,,,,both,,,2973.23,1932.60,,,,,,,,,,,,,
SCREW BNE SCHNZ 2.5/4 MM 12 MM THRD TI NS,SUP-2860071,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.77,1737.30,,,,,,,,,,,,,
ELECTRODE ELECSURG BPLR 0 DEG 4 MM VAPORIZING TIP VERSAPOINT,SUP-2218059,CDM,C1713,HCPCS,0278,RC,,,,both,,,1178.94,766.31,,,,,,,,,,,,,
MESH SURG 30CM LEN 20CM W THK2MM SYN ABD N ABSRB RECT EXP,SUP-2126082,CDM,C1781,HCPCS,0278,RC,,,,both,,,6477.82,4210.58,,,,,,,,,,,,,
STEM TAPER 22X235MM,SUP-2505155,CDM,C1776,CPT,0278,RC,,,,both,,,8452.88,5494.37,,,,,,,,,,,,,
TI NUT 45MM CORTEX SCREWS,SUP-2704873,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
WASHER ORTHOPAEDIC 7 MM STAINLESS STEEL,SUP-2836676,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.75,132.44,,,,,,,,,,,,,
ARH SLIDE-LOC NECK +1MM,SUP-2822968,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
RING ACET GANZ ROOF W/ HK 38MM,SUP-2212026,CDM,C1776,CPT,0278,RC,,,,both,,,5592.34,3635.02,,,,,,,,,,,,,
KIT CATH AD 12.5FR L90CM 3 LUMN CTRL VEN TUNNELED NONCOATED,SUP-2127693,CDM,C1751,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 12H 271MM RT STRL,SUP-2546851,CDM,C1713,HCPCS,0278,RC,,,,both,,,6757.53,4392.39,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 45 CM 5FR SLT 20CM 0.035IN BALL,SUP-2117040,CDM,C1887,HCPCS,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
HEAD RAD H10MM DIA22MM ANT DST EL CO CHROM STR MOD BILAT,SUP-2404365,CDM,C1776,CPT,0278,RC,,,,both,,,6207.78,4035.06,,,,,,,,,,,,,
RING EXT FIX DIA275 MM FULL NS DISP TAY SPAT FRME,SUP-2932783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7891.32,5129.36,,,,,,,,,,,,,
PLATE BONE SH THK1.8MM 4 H FOR 2.4MM SCR LORENZ,SUP-2136637,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
STEM FEM L180MM OD18MM 10MM BUILDUP CO CHROM HIP CALCAR REV,SUP-2203254,CDM,C1776,CPT,0278,RC,,,,both,,,21577.48,14025.36,,,,,,,,,,,,,
SET PROC L125CM OD12FR OPN END HYPOTONIC DUODENOGRAPHY,SUP-2167943,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.67,244.19,,,,,,,,,,,,,
FIBER LSR FLEXIVA PULSE 550,SUP-2717689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1361.66,885.08,,,,,,,,,,,,,
HC Rh Immune Globulin,PX-6360279000,CDM,J2790,CPT,0636,RC,,,,outpatient,,,543.00,352.95,,,,,,,,,,,,,
GRAFT BNE SUB 2.5ML PTTY SYR IRRADIATED DEMIN MTRX GRFTON,SUP-2294010,CDM,C1713,HCPCS,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
EPINEPHRINE 1 MG/ML IJ SOLN (MIXTURES ONLY),RX-430031,CDM,J0169,HCPCS,0636,RC,42023-0168-01,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7050,HCPCS,0250,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
FILLER BNE VOID LG CELLULAR BNE LYOGRAFT SHLF STBL VIRTUOS,SUP-2927231,CDM,C1713,HCPCS,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
NAIL FIX L26MM OD2MM LACTOSORB COPOLYMER ABSRB SGL USE FOR,SUP-2212971,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
OXYGENATOR PERFSN TUBE 3/8 X 3/32 IN AD 0.5-7 L/MIN 600/273,SUP-2908604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,42583.24,27679.11,,,,,,,,,,,,,
BUTTERFLY WASHER LENGTH 21.7MM,SUP-2818892,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
STAPLE INT W6XL20MM LIG SPIK,SUP-2120784,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 12 H TI LADDER NAR LP NS,SUP-2894504,CDM,C1713,HCPCS,0278,RC,,,,both,,,3523.08,2290.00,,,,,,,,,,,,,
SPINDLE TOT FEM 12MM DIA INTFACE MED FORC SM POR COAT COMPR,SUP-2406895,CDM,C1776,CPT,0278,RC,,,,both,,,11143.86,7243.51,,,,,,,,,,,,,
ACT ARM RIGID RMTE DTCH CNCLD TIP 33 MM T 6L 4V,SUP-2680297,CDM,C1713,HCPCS,0278,RC,,,,both,,,3257.06,2117.09,,,,,,,,,,,,,
PLATE PHLANG BASE 1.5MM RT TI STRL VAL,SUP-2546894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1878.57,1221.07,,,,,,,,,,,,,
INSERTER SURG CAP FOR AG FEM NAT NAIL SYS,SUP-2198679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1241.93,807.25,,,,,,,,,,,,,
CATHETER ETER ANGIO 5FR GUID EMB COIL MP2 CHAPERON,SUP-2305419,CDM,C1887,HCPCS,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
KIT DSG M W DEHP ST DISPOSABLE VAC VERAFLO CLEANSE,SUP-2262379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.08,274.35,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESHED THN 8X4 CMX0.4-0.7 MM ALLOPATCH HD,SUP-2480052,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4900.28,3185.18,,,,,,,,,,,,,
CATHETER ATHRCTMY PREDATOR 360 L 325 CM DIA1.25 MM DIAMOND,SUP-2159521,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE L 100 DEG 1.7X12 MM RT 6 HOLE BAR TI GLD NS,SUP-2366311,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.67,444.39,,,,,,,,,,,,,
CATHETER KIT AGBA PI PICC 2L 5.5 FR X 55CM,SUP-2655672,CDM,C1751,HCPCS,0278,RC,,,,both,,,614.44,399.39,,,,,,,,,,,,,
PLATE BONE PT SPEC SPLNT ORTHOGNATHIC INTERMED,SUP-2257767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3182.70,2068.75,,,,,,,,,,,,,
SEALER TISS L45CM DIA5MM ARTC ADV BPLR CRV TIP LAP APPRCH,SUP-2219731,CDM,C1713,HCPCS,0278,RC,,,,both,,,8293.62,5390.85,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-2 MM 15 CC PRESERVON CANC READIGRAFT,SUP-2740888,CDM,C1713,HCPCS,0278,RC,,,,both,,,845.38,549.50,,,,,,,,,,,,,
"HC So Antibody,Hiv 1 & Hiv 2, Assay",PX-3028670366,CDM,86703,CPT,0302,RC,,,,both,,,187.00,121.55,,,,,,,,,,,,,
CEMENT BONE 20GM RADPQ FOR KYPHOPLASTY STRL CONCORD HP,SUP-2231423,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
HC Surgery Level 2 Addtl 15min,PX-3600000012,CDM,3600000012,LOCAL,0360,RC,,,,both,,,1930.00,1254.50,,,,,,,,,,,,,
BLADE SCRWDRVR 2MM/2.3MM DIA 94MML CROSS DRIVE RTCHTD F/2.0/,SUP-2494974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.96,300.92,,,,,,,,,,,,,
PLATE BNE FEM 3.5X182 MM LT DSTL PROX 6 HOLE STRL VALCP,SUP-2789593,CDM,C1713,HCPCS,0278,RC,,,,both,,,4433.99,2882.09,,,,,,,,,,,,,
KYPHOPLASTY TRAY 20/3 OSTEO INTRO W/ CDS KYPHOPAK XPANDER II,SUP-2632080,CDM,C1713,HCPCS,0278,RC,,,,both,,,12898.49,8384.02,,,,,,,,,,,,,
PLATE BNE THK1.5MM 6 H CRANIOMAXILLOFACIAL ORAL SIL TI STR,SUP-2181769,CDM,C1713,HCPCS,0278,RC,,,,both,,,2661.78,1730.16,,,,,,,,,,,,,
PLATE BNE HUM 88 MM LT DSTL 9 HOLE STRL LTX,SUP-2861613,CDM,C1713,HCPCS,0278,RC,,,,both,,,3318.29,2156.89,,,,,,,,,,,,,
GUIDE SURG U SHP,SUP-2212872,CDM,C1713,HCPCS,0278,RC,,,,both,,,3058.36,1987.93,,,,,,,,,,,,,
SCREW BNE 3.0MM DIA 14MM BNE CORT SHFT 1/3 THRD CANN ST,SUP-2409808,CDM,C1713,HCPCS,0278,RC,,,,both,,,512.45,333.09,,,,,,,,,,,,,
SCLERA FRESH,SUP-2855185,CDM,C1762,CPT,0278,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
SCREW INTFR L30MM DIA9MM KNEE PLLA CANN ABSRB RND HD,SUP-2249518,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
SCREW BNE L45MM DIA6MM CORT ST NONCANNULATED NONLOCKING,SUP-2377555,CDM,C1713,HCPCS,0278,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
TRAY HEMO DYLS OR HD CATH AD L45CM INSRTN L28CM POLYUR ADMIN,SUP-2174220,CDM,C1750,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SUPPORT ANK L PUL ON WHT PROCARE,SUP-2196786,CDM,L1906,HCPCS,0272,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
STRUT EXT FIX W81MM RAD LNG ASSEMB TRAUM FOR TRUELOK RNG,SUP-2316071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3804.93,2473.20,,,,,,,,,,,,,
MESH SURGICAL 3.8CM X 5CM MATRIX RESTRATA,SUP-2874118,CDM,A2007,HCPCS,0636,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
IMPLANT HUM TISS L 3 X W 3 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905530,CDM,Q4184,HCPCS,0636,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
PLATE BNE W8XL84MM THK2MM 0DEG 10 H BILAT S STL STR RIG DYN,SUP-2186182,CDM,C1713,HCPCS,0278,RC,,,,both,,,889.28,578.03,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.025IN TIP DIA3MM L7MM INTVASC S,SUP-2355272,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
CONFORMER EYE 28 X 24 X 10 MM SZ 5 LG STEEPER ANTR CRV VLT,SUP-2883205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,789.80,513.37,,,,,,,,,,,,,
CATHETER EP DIAG MAP L CRV OCTAPOLAR 2-2-2MM SPC 2MM TIP,SUP-2356931,CDM,C1730,HCPCS,0272,RC,,,,both,,,1549.59,1007.23,,,,,,,,,,,,,
HC Drain Peri/Prevesical Space Ab,PX-3615108000,CDM,51080,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PIN EXT FIX L160MM DIA5MM THRD L30MM LNG S STL TI NITRIDE,SUP-2342921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1206.14,783.99,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT PELVIS ACETABULUM STRUCTURAL R,SUP-2307424,CDM,C1713,HCPCS,0278,RC,,,,both,,,8304.45,5397.89,,,,,,,,,,,,,
ANCHOR SUTURE 5.5MM WITH WITH 3 HI FI NUMBER 2 SUTURES GENES,SUP-2824877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
BASEPLATE TIB A UNIV STD PUR PC KNEE PRI CEM STEM NP STRL,SUP-2199597,CDM,C1776,CPT,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
HC Rp Loclzj Tum Plnr Whole Body Single Day Imaging,PX-3417880200,CDM,78802,CPT,0341,RC,,,,both,,,2681.00,1742.65,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|DOCUMENTATION ON FILE,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|CQ|KX,both,,,191.00,124.15,,,,,,,,,,,,,
SYSTEM ACCS WATCHMAN TRUSTEER OD 17 FR ID 12 FR LT ATR DBL,SUP-2895305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
RING ANNULPLSTY 24MM RIG FOR MI VALVULOPLASTY CARPENTIER,SUP-2214129,CDM,C1713,HCPCS,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
HC Lymphangiogram Uni S&I Rt,PX-3207580100,CDM,75801,CPT,0320,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 14 28MM 5CC B TRICALCIUM PHSPTE SYN,SUP-2194009,CDM,C1713,HCPCS,0278,RC,,,,both,,,1076.24,699.56,,,,,,,,,,,,,
GUIDEWIRE ORTH L1.1MM INTRO,SUP-2121824,CDM,C1769,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
GUIDEWIRE VASC CRV 4 CM 0.035 INX300 CM 11 CM LUNDERQUIST,SUP-2422124,CDM,C1769,HCPCS,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
SCREW BNE L65MM DIA5MM TIB KNEE G TI FULL THRD HEX DRV INT,SUP-2347248,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.85,944.35,,,,,,,,,,,,,
RING RADLUC 1 3 190MM,SUP-2316274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1037.64,674.47,,,,,,,,,,,,,
DRESSING COMPR CONTOURED ADH FREE FLX STRP W/ COOL CLR,SUP-2880995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 33 CM DIA24 FR BODY DIA 8.8 MM,SUP-2395736,CDM,C1894,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
HC Mra Lower Ext W/O Contrast,PX-6107372501,CDM,C8913,CPT,0610,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
PLATE BNE L 50.67 X W 5.72 MM THK 1.6 MM 7 H GRD III TI MOD,SUP-2936910,CDM,C1713,HCPCS,0278,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40 MM DIA14 X 8 MM POLYESTER BOV,SUP-2266030,CDM,C1768,CPT,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
BUR SURG RND 8 MM SS TEAL UPWR,SUP-2607633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PUNCH ENDOSCP DISP FOR SWIVELOCK CRKSCR FULL THRD,SUP-2121561,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
BLADE SAW KNEE 12.7MM CUT EDGE 86MM CUT DEPTH 1.19MM CUT THC,SUP-2586349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,212.26,137.97,,,,,,,,,,,,,
SHUNT PERI W O RESVR PROGRAMMABLE 7FR 120CM M SM,SUP-2278388,CDM,C1889,HCPCS,0278,RC,,,,both,,,12476.13,8109.48,,,,,,,,,,,,,
COMPONENT ULNA L75MM DIA3MM LEFT WITH BEARING E+ DISCOVERY,SUP-2879097,CDM,C1776,CPT,0278,RC,,,,both,,,16525.82,10741.78,,,,,,,,,,,,,
BOLT ORTHOPEDIC 26 MM LAT TROCHANTERIC HIP ACROS MOD REV SYS,SUP-2435440,CDM,C1776,CPT,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM 6 FR 1MM 2MM F DECAPOLAR,SUP-2248885,CDM,C1730,HCPCS,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
TRIAL KNEE 29MM UNIV PAT RESURF GEN II,SUP-2346854,CDM,C1776,CPT,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SCREW BONE 35 MM ACCESS LIF-PTP,SUP-2721712,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT BIO TISS W6XL6CM MESHED FET BOV ACELLULAR DERM MTRX,SUP-2243705,CDM,Q4110,HCPCS,0636,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
INTRODUCER 4FRX7CM S STEELNITINOL MICPUNC ECHO STIFF,SUP-2267050,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
PLATE BNE FEM 3.5X182 MM RT DSTL PROX 5 HOLE NS VA-LCP,SUP-2757674,CDM,C1713,HCPCS,0278,RC,,,,both,,,4029.94,2619.46,,,,,,,,,,,,,
COUPLER SURG USED EXT SVC 1 YR SM PWR,SUP-2761004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3379.43,2196.63,,,,,,,,,,,,,
DEVICE FIX ARTC RELDABLE W/ 1 HNDL 3 10 TACK STD PURCH RELD,SUP-2283329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1485.72,965.72,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PROX PEEK EYELET KNOTLESS REELX STT,SUP-2366712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1515.08,984.80,,,,,,,,,,,,,
DISTRACTION EXTRNL HRZNTL CROSS BAR ASSEMB RED 2 CMPLTE BLCK,SUP-2681287,CDM,C1713,HCPCS,0278,RC,,,,both,,,5132.58,3336.18,,,,,,,,,,,,,
PLATE BNE L40MM 4 H NONSTERILE BILAT TARSOMETATARSAL TI STR,SUP-2181254,CDM,C1713,HCPCS,0278,RC,,,,both,,,2892.66,1880.23,,,,,,,,,,,,,
PLATE BNE HK 2.7X15 MM RT CLAV BUTTON LCK COMPR NS VA-LCP,SUP-2750828,CDM,C1713,HCPCS,0278,RC,,,,both,,,3809.32,2476.06,,,,,,,,,,,,,
PACK SUT PERC ACHILLES REP SYS,SUP-2122781,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER SUPRPUB DIA12FR PLAS DISP RUSCH,SUP-2383925,CDM,C2627,HCPCS,0272,RC,,,,both,,,50.59,32.88,,,,,,,,,,,,,
SHEATH GUID 8FR L62CM ID011IN ANT CRV LO FRIC OBLQ CUT VLV,SUP-2248482,CDM,C1892,HCPCS,0272,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP TIP 4.4FR L5MM CUT WIRE L20MM GWIRE,SUP-2149854,CDM,C1769,HCPCS,0272,RC,,,,both,,,1303.07,847.00,,,,,,,,,,,,,
COMPONENT FEM SM RT KNEE LIBRA,SUP-2442352,CDM,C1776,CPT,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
KIT INTRO SHTH 5 CM GUIDEWIRE L 30 CM DIA 3 FR NDL L 1.5 IN,SUP-2734923,CDM,C1894,HCPCS,0272,RC,,,,both,,,13.19,8.57,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2.8 MM LG CP TI MANDIBULAR FULL,SUP-2883715,CDM,C1713,HCPCS,0278,RC,,,,both,,,19437.79,12634.56,,,,,,,,,,,,,
SET FEM SZ 4 GMK SPHR,SUP-2417435,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC ER Level 2,PX-4509928200,CDM,99282,CPT,0450,RC,,,,inpatient,,,987.00,641.55,,,,,,,,,,,,,
INSTRUMENT ORTH GUID RELEASE CUT EDGE STRL DISP SPEEDRELEASE,SUP-2893044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
STENT ESOPH ALIMAXX-ES L 100 MM DIA22 MM DEL DEV L 64 MM,SUP-2461216,CDM,C1874,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ACUSON ACUNAV L 90 CM DIA10 FR,SUP-2481454,CDM,C1753,HCPCS,0278,RC,,,,both,,,2348.41,1526.47,,,,,,,,,,,,,
INSERT HUM OD36MM STD ARW,SUP-2224533,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
STENT CORONARY MULTLNK TRI L 8 MM DIA2.5 MM GUIDE CATH 0.064,SUP-2101447,CDM,C1876,HCPCS,0278,RC,,,,both,,,4254.70,2765.55,,,,,,,,,,,,,
STEM HUM L140MM DIA10MM UNIV SHLDR CO CHROM PORCOAT CEM PRI,SUP-2249922,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GRAFT VASC TW 8 MMX50 CM STR REINF RNG SLDE GDS ADVANTA VXT,SUP-2468689,CDM,C1768,CPT,0278,RC,,,,both,,,2116.33,1375.61,,,,,,,,,,,,,
PLATE BNE L99MM 5 H L DST LAT FIBULAR S STL LOK COMPR FOR,SUP-2184158,CDM,C1713,HCPCS,0278,RC,,,,both,,,1672.36,1087.03,,,,,,,,,,,,,
SUPPORT ANK XL FOR 14 15IN UNIV NYL STBL NONSTRETCH LACE UP,SUP-2196816,CDM,L4350,HCPCS,0272,RC,,,,both,,,33.03,21.47,,,,,,,,,,,,,
SYMBOTEX COMP MESH STEX SKRT 8CM(3.1INCH),SUP-2174766,CDM,C1781,HCPCS,0278,RC,,,,both,,,2179.10,1416.41,,,,,,,,,,,,,
WASHER SPNL 2 INNIE SPLIT TI NS EXPEDIUM,SUP-2590388,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H LNG TI NEURO STR PLT 1 PK,SUP-2935383,CDM,C1713,HCPCS,0278,RC,,,,both,,,1755.26,1140.92,,,,,,,,,,,,,
SPHINCTEROTOME ENDO L30MM OD7FR 0.035IN 3 LUMN MFIL CUT,SUP-2169395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
GRAFT BONE SUB 45CC 2-5MM CORT CANC MORSELIZED FN CHIP FRZN,SUP-2307428,CDM,C1713,HCPCS,0278,RC,,,,both,,,4465.99,2902.89,,,,,,,,,,,,,
GRAFT BNE PASTE 0.5 CC SYR DBM ORTHOBLAST II,SUP-2641745,CDM,C1713,HCPCS,0278,RC,,,,both,,,429.77,279.35,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 3FR 20CM 1 LUMAN R S4153108D,SUP-2632859,CDM,C1751,HCPCS,0278,RC,,,,both,,,509.40,331.11,,,,,,,,,,,,,
KIT PATELLA TEMPLATE ANTERIOR / STERILE,SUP-2739167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.11,372.52,,,,,,,,,,,,,
CATHETER CTRL VEN 0.61ML 6FR CUF POS 5CM POLYUR GRAV FLO,SUP-2127766,CDM,C1751,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 7 CM DIA 4 MM STD SFT HELCL,SUP-2604641,CDM,C1889,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
HC Platelets Hla-M Lr,PX-3900905200,CDM,P9052,CPT,0390,RC,,,,both,,,2460.00,1599.00,,,,,,,,,,,,,
HC So Drg Scrn Class List A,PX-3018030766,CDM,80307,CPT,0301,RC,,,,outpatient,,,79.00,51.35,,,,,,,,,,,,,
TUBE NG M 16FR BLLN L1.5-6IN SPEC BLAKMR DISP TO CTRL BLEED,SUP-2127132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1030.96,670.12,,,,,,,,,,,,,
SHEATH GUID 7FR L45CM DIA2.5MM 0.018/0.038IN RENAL DBL CLS,SUP-2169818,CDM,C1894,HCPCS,0272,RC,,,,both,,,316.76,205.89,,,,,,,,,,,,,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,2500000003,HCPCS,0250,RC,55150-0439-01,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
ANCHOR SUT W/ TWO NO 2 SUT COBRAID BLU COBRAID BLK 5.5MM,SUP-2341859,CDM,C1713,HCPCS,0278,RC,,,,both,,,892.67,580.24,,,,,,,,,,,,,
ELECTRODE ELECSURG RL BALL RESECTSCP CLASS SER 28 FR BLU,SUP-2312670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.38,268.05,,,,,,,,,,,,,
PIN FIX L2.25IN DIA0.125IN TRCR QUIK CONN JOURNEY,SUP-2347043,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.63,149.91,,,,,,,,,,,,,
OBTURATOR 8FR 33CM LEN F/9.5-14FR INTRO SNAP LCK - 8FR 33CM,SUP-2355509,CDM,C1894,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
SET URET STENT MARD L 22 CM DIA 6 FR ZIPWIRE 0.035 IN,SUP-2461119,CDM,C2617,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
HC Stimulation Pacing Heart,PX-4809362300,CDM,93623,CPT,0480,RC,,,,both,,,7361.00,4784.65,,,,,,,,,,,,,
BRONCHOSCOPE RIGID INTUB 4 LG 5.8/2.8 MM 23.6 IN ASCOPE DISP,SUP-2389099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
BASEPLATE TIB L67XW42MM UNIV DURAC KNEE CRUCFRM BEAD IMPL,SUP-2377159,CDM,C1776,CPT,0278,RC,,,,both,,,8911.32,5792.36,,,,,,,,,,,,,
CORD BPLR FTSWCH NONSTERILE REUSE,SUP-2292933,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.27,283.58,,,,,,,,,,,,,
SET CATH HEMODIALYSI FRDM FLO CHRNC BSC 15.5FR DIA 40CM STRG,SUP-2610621,CDM,C1752,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
TAP SURG L180MM D80MM FOR 4.5MM CANN SCR,SUP-2187417,CDM,C1713,HCPCS,0278,RC,,,,both,,,2012.99,1308.44,,,,,,,,,,,,,
CLIP ANEURYSM SUGITA TEMPORARY 15MM STRAIGHT 07-939-15,SUP-2848786,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
LIGATOR ENDO L122CM DIA9.5-11.5MM 6 BND RECESS 6 SHOT SAEED,SUP-2169499,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA 8 FR HYDRPHLC,SUP-2383413,CDM,C1894,HCPCS,0272,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
PLATE VOLAR DISTAL RADIUS L NRW,SUP-2466349,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
STAPLER INT CUT LN 40MM STPL 51MM GRN CRV HD B FRM,SUP-2716240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1582.03,1028.32,,,,,,,,,,,,,
STRUT EXT FIX L 126193 MM MED HEXAPOD STRL DISP MAXFRAME,SUP-2907863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 7-4 MM EPTFE TAPR TW N RING,SUP-2761337,CDM,C1768,CPT,0278,RC,,,,both,,,2665.36,1732.48,,,,,,,,,,,,,
HC So Stem Cells Total Count,PX-3028636766,CDM,86367,CPT,0302,RC,,,,both,,,246.00,159.90,,,,,,,,,,,,,
STABILIT VP FRACTURE KIT WITHOUT NEEDLES,SUP-2699829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
COLLAR CERV MED DENS 2XS PEDIATRIC 14X2 IN FRM FIT PROCARE,SUP-2195744,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.83,7.04,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ SM LG AD PEDIATRIC RT HND WRST FNGR,SUP-2264312,CDM,L3807,HCPCS,0272,RC,,,,both,,,159.36,103.58,,,,,,,,,,,,,
PLATE BNE W33XL147MM 10 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185113,CDM,C1713,HCPCS,0278,RC,,,,both,,,3879.00,2521.35,,,,,,,,,,,,,
BAR EXT FIX CRV 11X210 MM CARBON XTRAFIX,SUP-2534564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1645.58,1069.63,,,,,,,,,,,,,
RESERVOIR 20MM BURR HOLE WITHOUT SHUNT ASSISTANT HYDRO PROGA,SUP-2825796,CDM,C1889,HCPCS,0278,RC,,,,both,,,7388.26,4802.37,,,,,,,,,,,,,
BEARING TOE L PHLANG MTL BK IMP,SUP-2404752,CDM,C1776,CPT,0278,RC,,,,both,,,2879.38,1871.60,,,,,,,,,,,,,
CATHETER CV CHRONIC 14 FRX19 CM 15 MM,SUP-2308263,CDM,C1751,HCPCS,0278,RC,,,,both,,,1175.96,764.37,,,,,,,,,,,,,
SD BLADE 2.7MM MD,SUP-2678834,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.44,314.89,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA20 GA NDL DIA18 GA CE18TKN ACCU BLOC,SUP-2936706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,74.76,48.59,,,,,,,,,,,,,
STENT PANCREATIC GEENEN L 5 CM DIA10 FR GUIDEWIRE 0.035 IN,SUP-2169326,CDM,C2617,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BNE FIBULAR 6 HOLE COMP LCK STRL ALPS LTX,SUP-2861799,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.75,365.79,,,,,,,,,,,,,
PLATE BNE L235MM 15 H ST R DST LAT FIBULAR S STL VAR ANG,SUP-2177742,CDM,C1713,HCPCS,0278,RC,,,,both,,,3590.62,2333.90,,,,,,,,,,,,,
PLATE BNE W22XL54MM STD 9 H R DST RAD VOLAR S STL VAR ANG,SUP-2177296,CDM,C1713,HCPCS,0278,RC,,,,both,,,2163.62,1406.35,,,,,,,,,,,,,
CROWN DENT LL7 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176706,CDM,D6783,CPT,0278,RC,,,,both,,,21.51,13.98,,,,,,,,,,,,,
MIDAZOLAM HCL 2 MG/ML PO SYRP,RX-24176,CDM,340b,HCPCS,0637,RC,60687-0576-86,NDC,,both,1,ML,5.60,3.64,,,,,,,,,,,,,
SCREW BNE L90MM DIA6.5MM THRD L16MM CANC S STL ST,SUP-2411274,CDM,C1713,HCPCS,0278,RC,,,,both,,,111.78,72.66,,,,,,,,,,,,,
ANCHOR SPNL LUMBAR 30 MM INDEPENDENCE MIS,SUP-2663501,CDM,C1889,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE BNE L 178 X W 13.5 MM THK 4.2 MM SCREW DIA 4.5 MM,SUP-2908483,CDM,C1713,HCPCS,0278,RC,,,,both,,,1793.82,1165.98,,,,,,,,,,,,,
PROSTHESIS OSS OVL TOP 4X3X6.6 MM 1.15 MM TRIM CANN HA PORP,SUP-2637863,CDM,L8613,CPT,0278,RC,,,,both,,,1402.58,911.68,,,,,,,,,,,,,
GRAFT DURA REP L 5 X W 5 CM THK 0.4 MM ELECTROSPUN FIBER,SUP-2904023,CDM,C1763,HCPCS,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
INSTRUMENT 9560180 18MM MTRXND ATCH STRL,SUP-2292890,CDM,C1713,HCPCS,0278,RC,,,,both,,,987.62,641.95,,,,,,,,,,,,,
IONOMER GLASS VITREBOND POWDER 9GM,SUP-2714084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.51,430.63,,,,,,,,,,,,,
NEEDLE ENDOSCP U SHP CUETO FOR SUBQ LIG OF TROCAR INCISION,SUP-2767439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.47,595.71,,,,,,,,,,,,,
SCREW INTFR L30MM DIA7MM KNEE PLLA CANN ABSRB RND HD,SUP-2249502,CDM,C1713,HCPCS,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
GRAFT BNE 1ML DEMIN BNE MTRX GEL,SUP-2362219,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
HYDROMORPHONE 1 MG/ML PCA (DISCRETE DOSING),RX-4081982,CDM,J1171,HCPCS,0636,RC,09999-9915-73,NDC,,both,30,ML,92.30,59.99,,,,,,,,,,,,,
PLATE BONE L42MM THK1.4MM SHFT W7.5MM HD 21.5MM 3X5 H STRL T,SUP-2349691,CDM,C1713,HCPCS,0278,RC,,,,both,,,4538.24,2949.86,,,,,,,,,,,,,
NAIL IM L205MM DIA7.5MM 120DEG STRL BLU L/R HUM TI CANN LCK,SUP-2192485,CDM,C1713,HCPCS,0278,RC,,,,both,,,5324.06,3460.64,,,,,,,,,,,,,
BLADE DISP LARYNSCP FBR OPT 195MMX14MM SZ 3 M AD MILLER GRN,SUP-2393649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
FIBER LASER 550 MH SOLTIVE DISP,SUP-2540084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1860.48,1209.31,,,,,,,,,,,,,
LINER ACET NEUT H 28 MM PROV G7,SUP-2440200,CDM,C1776,CPT,0278,RC,,,,both,,,240.21,156.14,,,,,,,,,,,,,
BIT DRL 3.8X10 MM DURALOC,SUP-2453983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.29,387.59,,,,,,,,,,,,,
CATHETER ABLATN F-J 4 MM 1-4-1 MM 8 FRX115 CM FLEXABILITY,SUP-2357520,CDM,C2630,CPT,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 0.035 IN 10 FRX100 CM 18 MMX6 CM ZMED II,SUP-2309679,CDM,C1725,HCPCS,0272,RC,,,,both,,,1686.34,1096.12,,,,,,,,,,,,,
BUR SURG 4MM PRECIS RND,SUP-2365195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.41,505.97,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 40 CM OD 5 FR ID 1.7 MM GUIDEWIRE,SUP-2168402,CDM,C1894,HCPCS,0272,RC,,,,both,,,272.24,176.96,,,,,,,,,,,,,
PLATE BNE L106MM 6 H L LAT DST PERIARTC FIBULAR LOK,SUP-2413023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1987.12,1291.63,,,,,,,,,,,,,
SCREW BNE CANN 7.3X50 MM PERI ARTC CONCL FT SS NS LCP,SUP-2184772,CDM,C1713,HCPCS,0278,RC,,,,both,,,685.40,445.51,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 1.7-10MM CHIP CANC FRZ,SUP-2307535,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
ROD SPNL 5.5-6.3X500 MM COCRMOLY + APEX,SUP-2627781,CDM,C1713,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
ACCOLADE CEM HIP STEMNO 7,SUP-2364226,CDM,C1776,HCPCS,0278,RC,,,,both,,,7099.54,4614.70,,,,,,,,,,,,,
PLATE BNE W255XL47MM WIDE 7X2 H ST R DST RAD VOLAR S STL VAR,SUP-2177310,CDM,C1713,HCPCS,0278,RC,,,,both,,,2327.05,1512.58,,,,,,,,,,,,,
FILTER VASC GRNFLD L 28 MM DIA12 FR TI VENA CAVA FEM SHTH N,SUP-2148340,CDM,C1880,HCPCS,0278,RC,,,,both,,,3450.86,2243.06,,,,,,,,,,,,,
NEEDLE NERVE STIM TROCAR PEDCL ACCS NAV PK,SUP-2764368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,875.59,569.13,,,,,,,,,,,,,
"HC Insert Aortic Circulation Assist Device ,Open Approach",PX-4813397000,CDM,33970,CPT,0481,RC,,,,inpatient,,,8382.00,5448.30,,,,,,,,,,,,,
STAPLE BNE RELIABLE 3 18X18X20 MM COMPR STRL EXPRESS XL,SUP-2223982,CDM,C1713,HCPCS,0278,RC,,,,both,,,4314.36,2804.33,,,,,,,,,,,,,
CONNECTOR SPNL PARL VAR SIDE LD NORTHSTAR,SUP-2710723,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
PLATE BNE Z SM 1.7 MM LT MIDFACE 4 HOLE GSP GLD NS LTX,SUP-2862761,CDM,C1713,HCPCS,0278,RC,,,,both,,,717.24,466.21,,,,,,,,,,,,,
ROD SPNL L90MM DIA5.5MM LORDOSED,SUP-2353319,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ANCHOR SUT DIA45MM BIOCRYL RAPIDE ABSRB 3 DYNACORD SZ 2,SUP-2256646,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.82,1659.33,,,,,,,,,,,,,
SYSTEM THROMCTMY POUNCE L 135 CM DIA 7 FR GUIDEWIRE 0.018 IN,SUP-2913918,CDM,C1757,HCPCS,0272,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
GRAFT BNE SUB 25X50X4MM 5ML STRP,SUP-2416974,CDM,C1713,HCPCS,0278,RC,,,,both,,,5767.49,3748.87,,,,,,,,,,,,,
IMPLANT HUM TISS SZ 3 X 4 CM THK 2000 UM PLCNTA MEMBRN FRSH,SUP-2913444,CDM,C1762,CPT,0278,RC,,,,both,,,19741.18,12831.77,,,,,,,,,,,,,
PROBE NERVE STIM FLSH TIP 0.2 MM 130-270 MM SLIDESHAFT,SUP-2871474,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
TUBE SET SONICONE SHARPVAC DISP (MIN ORDER 5),SUP-2423014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1825.13,1186.33,,,,,,,,,,,,,
GUIDEWIRE VASC IMAG STR TIP 0018 IN DIA 135 CM LEN 2 CM TIP,SUP-2141241,CDM,C1769,HCPCS,0272,RC,,,,both,,,691.27,449.33,,,,,,,,,,,,,
RING EXT FIX DIA105 MM U SHP NS DISP SMRT TSF,SUP-2933115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5771.85,3751.70,,,,,,,,,,,,,
PLATE EXT FIX SHT 160 MM FT RNG CARBON FIBER NS,SUP-2799575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2221.42,1443.92,,,,,,,,,,,,,
HC Plmt Xtn Prosth Evasc Rpr,PX-3603470900,CDM,34709,CPT,0360,RC,,,,both,,,20612.00,13397.80,,,,,,,,,,,,,
FIBER SURG LASER CO2 BEAMPATH,SUP-2225708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BNE L 147 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 11 72466611,SUP-2933305,CDM,C1713,HCPCS,0278,RC,,,,both,,,6005.88,3903.82,,,,,,,,,,,,,
SLING GYN MESH CONTINENCE SYS POLYPR BLU DESARA,SUP-2152276,CDM,C1771,HCPCS,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THN 4CMX12CM,SUP-2306896,CDM,C1762,CPT,0278,RC,,,,both,,,2486.10,1615.96,,,,,,,,,,,,,
SHEATH URO 30FR L17CM CLR NEPHSTMY RADPQ MRK G PRB,SUP-2139237,CDM,C1894,HCPCS,0272,RC,,,,both,,,202.12,131.38,,,,,,,,,,,,,
SCREW BNE L40MM DIA7MM THRD L16MM S STL CANN,SUP-2183808,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.74,521.78,,,,,,,,,,,,,
HC Inj Neurolytic Epi Cerv/Dor,PX-3616228100,CDM,62281,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT BNE 1 CC CELLULAR BNE MTRX V92 FC+,SUP-2742067,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.93,1431.25,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 13 CM DIA11 GA,SUP-2930215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46531.79,30245.66,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB UNIV R,SUP-2276646,CDM,L3931,HCPCS,0274,RC,,,,both,,,15.89,10.33,,,,,,,,,,,,,
ELECTRODE ELECTROTHERAPY L10CM CBL L3M ADPT CBL L20CM RF,SUP-2357694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
HC ER Level 4,PX-4509928400,CDM,99284,CPT,0450,RC,,,,outpatient,,,2334.00,1517.10,,,,,,,,,,,,,
SPLINT WRST SM L THMB SPICA COT POLY FAB LTHR WRKHRD ORIG,SUP-2326129,CDM,L3908,HCPCS,0272,RC,,,,both,,,74.26,48.27,,,,,,,,,,,,,
STEM ULN 50MM L STR PRSS FIT TI SOLAR,SUP-2372329,CDM,C1776,CPT,0278,RC,,,,both,,,12139.62,7890.75,,,,,,,,,,,,,
HC Inj Stelat Gangl Cerv Sym,PX-3616451000,CDM,64510,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
OXYCODONE HCL ER 40 MG PO T12A,RX-123653,CDM,6370000000,HCPCS,0637,RC,59011-0440-20,NDC,,both,1,UN,83.50,54.27,,,,,,,,,,,,,
RING EXT FIX DIA160MM FREE CIR FULL SIDEKCK FREE CIR FIX,SUP-2400650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2618.76,1702.19,,,,,,,,,,,,,
GRAFT BNE L40MM FIBULAR SHFT SEG FRZ DRY MATRIGRFT,SUP-2264768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1555.18,1010.87,,,,,,,,,,,,,
CATHETER EP CRD 2 MM SPC 6 FRX110 CM INQUIRY,SUP-2357413,CDM,C1730,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CAPSULE ENDOSCP L26.2MM DIA11.4MM BIOCOMPATIBLE PLAS SB 3,SUP-2173699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1635.63,1063.16,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CORTICOCANCELLOUS ALLGRFT FRZN,SUP-2933017,CDM,C1762,CPT,0278,RC,,,,both,,,5822.69,3784.75,,,,,,,,,,,,,
KIT CATH 12FR L4CM TIP L2CM NONCOMPLIANT BLLN LO PROF,SUP-2139184,CDM,C1726,HCPCS,0272,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
SHELL ACET DIA48MM HIP PORCOAT LOK PRI SECT PRESSFIT PINN,SUP-2250176,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
WIRE FIX 2X450MM HYBRID CTRL OLV K,SUP-2316254,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.87,287.87,,,,,,,,,,,,,
STEM HUM CEM 8B LNG 132.5 DEG 120 MM SHLDR AEQUALIS ASCEND,SUP-2715777,CDM,C1776,CPT,0278,RC,,,,both,,,13164.45,8556.89,,,,,,,,,,,,,
WEDGE ILIUM CREST SPEC TRAD ALLGRFT 6 MM FRZ DRY,SUP-2294055,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
TRAY PICC 6FR POLYUR FULL TRIM LEN DBL LUMN PWR INJ PASV VLV,SUP-2126389,CDM,C1751,HCPCS,0278,RC,,,,both,,,646.97,420.53,,,,,,,,,,,,,
CATHETER NEPHROSTOMY 8 FRX30 CM LCK PGTL GEN TOT ABSCESSION,SUP-2424173,CDM,C1729,HCPCS,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
SCREW BONE FT COPOLYMER RESRB ORTH PLATING SYS ABSRB,SUP-2412907,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.19,434.32,,,,,,,,,,,,,
CABLE ORTHOT HIP KNEE ANK PELV CUST TORSION,SUP-2435641,CDM,L2050,LOCAL,0274,RC,,,,both,,,1379.62,896.75,,,,,,,,,,,,,
PIN FXTN L229MM D48MM STNLSS STEEL 5 TRCR POINT SNGLE SHARP,SUP-2499238,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.82,34.98,,,,,,,,,,,,,
SCREW BONE L6MM DIA2.7MM BRN LCK RIBLOC,SUP-2107911,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 8 FRX61.7 CM 14 GA 1.5 CC POWERHICKMAN,SUP-2424091,CDM,C1751,HCPCS,0278,RC,,,,both,,,2210.34,1436.72,,,,,,,,,,,,,
COUNTERSINK SURG CANN REUSE FOR 4.5MM TI SCR SYS,SUP-2187348,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.05,759.23,,,,,,,,,,,,,
SHEATH URET ACC FORTE 10 FR DIL 12 FRX45CM SHTH SZ 1 HD,SUP-2119497,CDM,C1894,HCPCS,0272,RC,,,,both,,,277.04,180.08,,,,,,,,,,,,,
SLEEVE TIB L30MM PROX KNEE ORTH SALV SYS,SUP-2406463,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
HOOK SPNL L PEDCL S STL NEUT BILAT FOR 5.5MM ROD CDH LEG,SUP-2288176,CDM,C1713,HCPCS,0278,RC,,,,both,,,2341.03,1521.67,,,,,,,,,,,,,
PLATE BONE SM W11XL142MM THK3.3MM 0DEG 11 H BILAT TI STR RIG,SUP-2190786,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.53,387.09,,,,,,,,,,,,,
EXPANDER TISS NACL 7.8 CM PROJCT 15.5 CM 1000 CC VERSAFIL,SUP-2300334,CDM,C1789,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SYSTEM ASPIR CVAC INTRACORPOREAL LITHO SUCTION STRL LF,SUP-2863726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
PLATE BNE BX 1.3 MM TI NS,SUP-2190699,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y PLT XDRV 1 PK STRL,SUP-2935513,CDM,C1713,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
SCREW BONE L22MM OD3.5MM CRUCFRM,SUP-2362294,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.10,13.71,,,,,,,,,,,,,
PIN EXT FIX 6MM DIA 120MM OVERALL LEN 50MM THRD LEN,SUP-2372367,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY DIA 7 FR SPC 1-3 MM TIP 1,SUP-2357673,CDM,C1730,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
COLLAR CERV SERP SM XLN 23 X 3.5 IN CONTOURED,SUP-2276599,CDM,L0120,HCPCS,0272,RC,,,,both,,,7.76,5.04,,,,,,,,,,,,,
BURR SURG 2MMX25MM TAPR ROUTER FOR TPS MIDAS REX UPWR,SUP-2367455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,241.53,156.99,,,,,,,,,,,,,
CAGE SPNL H9XL10MM TI ANT THORLUM INTBDY FUS RND PYRAMESH,SUP-2291991,CDM,C1889,HCPCS,0278,RC,,,,both,,,3176.30,2064.59,,,,,,,,,,,,,
VALVE MITRL CARP EDW TISS ANNULUS 33 MM SEW RNG DIA 42 MM,SUP-2214276,CDM,C1889,HCPCS,0278,RC,,,,both,,,17992.20,11694.93,,,,,,,,,,,,,
PLATE BONE L119MM 20 H BILAT MAND ORAL MAXILLOFACIAL TI LO,SUP-2191331,CDM,C1713,HCPCS,0278,RC,,,,both,,,2529.90,1644.43,,,,,,,,,,,,,
RELOAD STPLR CRV TIP SM LNG VASC THN 45 MM WHT,SUP-2787710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.93,1125.10,,,,,,,,,,,,,
GRAFT HUM TISS CORNEAL,SUP-2427794,CDM,V2785,HCPCS,0810,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
LINER KT WLK BOOT VENTURE AIR TALL SM,SUP-2151041,CDM,L4386,HCPCS,0274,RC,,,,both,,,54.01,35.11,,,,,,,,,,,,,
CUP ACET PATELLAR 3 1 STP CUT,SUP-2441709,CDM,C1776,CPT,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
CATHETER DIGITAL DISCOVER SPYGLASS,SUP-2713871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8894.05,5781.13,,,,,,,,,,,,,
SPACER SPNL W55XH8-15MM D20MM 6DEG ELSA,SUP-2228775,CDM,C1821,HCPCS,0278,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
GRAFT HUM TISS DIA18MM AMNIO MEMBRN DISK AMNIOEXCEL,SUP-2194317,CDM,Q4137,HCPCS,0636,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
PLATE BNE L CLAV CTRL 3RD S STL FOR FACTURE,SUP-2121731,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
BIT DRL DIA10MM HLLW FOR MULTILOC HUM NAILING SYS,SUP-2178934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1079.16,701.45,,,,,,,,,,,,,
CATHETER THROMCTMY ESPERANCE L 115 CM DIA 5 FR SHFT,SUP-2892528,CDM,C1757,HCPCS,0272,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
BOLT SPNL GRFT 8X40 MM CANN ALIF STANDALONE IDENTITI,SUP-2800082,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
CATHETER INFUSION SWAN NK 014 2.8/2.1 FRX130 CM FIX MAESTRO,SUP-2466817,CDM,C1887,HCPCS,0272,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
SPLINT THMB AD L4IN UNIV R FOAM LAM INSTABILITY LOOP LOK E,SUP-2197017,CDM,L3809,HCPCS,0272,RC,,,,both,,,19.78,12.86,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 100 X 10 X 5 MM 5 CC DEMINERALIZED,SUP-2881963,CDM,C1713,HCPCS,0278,RC,,,,both,,,7002.20,4551.43,,,,,,,,,,,,,
SYSTEM THROMCTMY CLEANER15 L 65 CM DIA 7 FR SINUSOIDAL WIRE,SUP-2120125,CDM,C1757,HCPCS,0272,RC,,,,both,,,3320.08,2158.05,,,,,,,,,,,,,
PLUG HERN L W1.6XL1.9IN INGUINAL POLYPR REP PRESHAPED ONLAY,SUP-2125756,CDM,C1781,HCPCS,0278,RC,,,,both,,,653.43,424.73,,,,,,,,,,,,,
PLATE BNE 90 DEG 1X4 MM RINGFIX SYS,SUP-2365337,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
KWIRE DRILL TIP RECON 32X400MM,SUP-2701538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,696.77,452.90,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.7MM LOK FOR TUFFNEK TECHNOLOGY GORILLA,SUP-2321096,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.87,351.57,,,,,,,,,,,,,
STAPLER INT MED THCK 80 MM W/ TRI-STAPLE TECHNOLOGY PUR GIA,SUP-2787699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2336.88,1518.97,,,,,,,,,,,,,
HC Joint Survey Single View 2 or More Joints,PX-3207707700,CDM,77077,CPT,0320,RC,,,,both,,,809.00,525.85,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA14 FR GUIDEWIRE 0.038 IN,SUP-2168410,CDM,C1894,HCPCS,0272,RC,,,,both,,,307.25,199.71,,,,,,,,,,,,,
PROBE LASER OD20GA 45DEG RETIN STD TAPR TIP ANG ENDOPRB,SUP-2247211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,460.54,299.35,,,,,,,,,,,,,
TI LOW PROFILE NEURO MACHINE,SUP-2828048,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.13,195.73,,,,,,,,,,,,,
CLIP ENDOSCP 235 CM 2.8 MM STRL MANTIS LTX 1 PER BX,SUP-2862928,CDM,C1889,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
BLADE SAW 85X10X1.27MM OSCIL HALL SS,SUP-2586312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.97,42.88,,,,,,,,,,,,,
GRAFT HUM TISS W10XL19MM MT LENGTHENING DISC,SUP-2321676,CDM,C1776,CPT,0278,RC,,,,both,,,7473.20,4857.58,,,,,,,,,,,,,
GUAIFENESIN ER 600 MG PO TB12,RX-37651,CDM,6370000000,HCPCS,0637,RC,68084-0572-11,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
PLATE BNE LCK 363 MM RT PROX FEM 18 HOLE BRIDGE N CONTACT,SUP-2483555,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.75,2959.94,,,,,,,,,,,,,
CHEEK RETRACTOR RING/THREADED,SUP-2823396,CDM,C1713,HCPCS,0278,RC,,,,both,,,1059.44,688.64,,,,,,,,,,,,,
NEEDLE BRST LOC L5CM OD20GA N REPOSITIONABLE W/ FLEXSTRAND,SUP-2381876,CDM,C1819,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
BLADE BREAKER HOLDER STRAIGHT LOCK,SUP-2473494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2347.15,1525.65,,,,,,,,,,,,,
DRILL TWST L 60 MM DIA1.2 MM STP 4 MM LAG NS DISP LEIBINGER,SUP-2883192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.72,357.32,,,,,,,,,,,,,
RELOAD STPLR RADIAL MED 2 MM VASC TRI-STAPLE,SUP-2787707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2151.12,1398.23,,,,,,,,,,,,,
AUGMENT FEM SZ E THK5MM STD UNIV DST KNEE TRABECULAR MTL,SUP-2200238,CDM,C1776,CPT,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
HC Mech Rem Intracath,PX-3613659600,CDM,36596,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
COVER IMPL IMPL 10 MM PEEK ZUMA,SUP-2245578,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SLEEVE DRL 6+ MM PIN APEX,SUP-2465611,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CATHETER BLLN DIL SET 5-15 MM ESOPH GAST SAVARY-GILLIARD,SUP-2759280,CDM,C1769,HCPCS,0272,RC,,,,both,,,5118.20,3326.83,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK XL INTUITRAK L 80 MM DIA 34 MM,SUP-2217584,CDM,C1768,CPT,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
CATHETER HD LT 16 FRX32 CM SPLIT TIP STR SET SPLIT STRM,SUP-2267089,CDM,C1750,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
SPLINT WRST BLK XS 8 IN L,SUP-2336048,CDM,L3809,HCPCS,0272,RC,,,,both,,,18.68,12.14,,,,,,,,,,,,,
SYSTEM INTRO SHTH 7FR L25CM ORNG HUB W O SIDEPRT SPLITTABLE,SUP-2303231,CDM,C1892,HCPCS,0272,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
GUIDEPIN ORTH FLX VERSITOMIC,SUP-2366528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
SCREW INTRF 10X35 MM ROUNDED EDGE FT PEEK OPTMA,SUP-2762239,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
COMPONENT FEM SZ 3 NAR L KNEE CO CHROM CEM POST STBL CRUCE,SUP-2206157,CDM,C1776,CPT,0278,RC,,,,both,,,25559.60,16613.74,,,,,,,,,,,,,
HC Unlisted Procedure Nervous System,PX-3616499900,CDM,64999,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
BUTTON GAST 20FR STOMA L35CM ADJUSTABLE APPLE SHP BLLN TAPR,SUP-2119900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.32,332.36,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0.038IN S STL STR COAT FLX DST,SUP-2172400,CDM,C1769,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
BOX CTRL COIL DETACH ENPOWER,SUP-2467544,CDM,C1889,HCPCS,0278,RC,,,,both,,,5905.15,3838.35,,,,,,,,,,,,,
DILATOR ENDO L180CM BAL L3CM OD6MM GWIRE OD0.035IN,SUP-2169412,CDM,C1725,HCPCS,0272,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
PLATE BNE CRV 310X11X1 MM MESH STRP SM GRID PDLLA STRL LF,SUP-2457108,CDM,C1713,HCPCS,0278,RC,,,,both,,,12556.45,8161.69,,,,,,,,,,,,,
SYSTEM SUT DEL SGL INCIS CVD HNDL TRIG DISP FLEXISHAFT,SUP-2165321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 10 CM DIA 8 MM EPTFE CARBON STR STD,SUP-2127042,CDM,C1768,CPT,0278,RC,,,,both,,,1559.48,1013.66,,,,,,,,,,,,,
METHYLPREDNISOLONE NA SUC (PF) 500 MG IJ SOLR,RX-162821,CDM,J2919,HCPCS,0636,RC,00009-0003-02,NDC,,both,1,UN,272.50,177.12,,,,,,,,,,,,,
STENT BILI L 7 CM DIA 7 FR PERCFLX DUODENAL BEND INTRO KT W/,SUP-2149469,CDM,C2625,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
PLATE BNE L 243 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 20 HL,SUP-2937096,CDM,C1713,HCPCS,0278,RC,,,,both,,,7669.14,4984.94,,,,,,,,,,,,,
GRAFT VASC L40CM DIA26MM STR STD WALL N RING WVN VASCUTEK,SUP-2385009,CDM,C1768,CPT,0278,RC,,,,both,,,4093.27,2660.63,,,,,,,,,,,,,
PLATE BNE SKULL BASE LG 0.4 MM RND MESH MALL UNIV NEURO III,SUP-2862737,CDM,C1713,HCPCS,0278,RC,,,,both,,,3154.82,2050.63,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM CORT S STL ST NONCANNULATED LOK,SUP-2183575,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.60,43.29,,,,,,,,,,,,,
PLATE BONE SYS UTIL STR 5 H IMP L33MM,SUP-2365886,CDM,C1713,HCPCS,0278,RC,,,,both,,,4929.80,3204.37,,,,,,,,,,,,,
DEVICE FIX STRND 5 MM ARTICULATING RELD 30 STD ABSORBABLE,SUP-2913727,CDM,C1713,HCPCS,0278,RC,,,,both,,,2959.67,1923.79,,,,,,,,,,,,,
MESH SURG W40XL60MM MIC LUHR,SUP-2364691,CDM,C1781,HCPCS,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
GRAFT EVAR L75MM DIA25MM SUPRARENAL EXTN INTUITRAK POWERFIT,SUP-2217570,CDM,C1768,CPT,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
GRAFT HUM TISS L 35-48 MM TIB BLOCK L 23 MM THK 9 MM QUAD L,SUP-2913273,CDM,C1762,CPT,0278,RC,,,,both,,,15053.16,9784.55,,,,,,,,,,,,,
HC Treat Fibula Fx,PX-4502778100,CDM,27781,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 11 CM SEG FD FIB,SUP-2321800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2094.38,1361.35,,,,,,,,,,,,,
BIT DRL DIA4MM 4 FLUT CANN FOR 4.5MM HDLSS COMPR SCR,SUP-2179107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.10,707.26,,,,,,,,,,,,,
PLATE BONE 10 H ANK S STL 3RD TBLR LCK FOR FX MGMT SYS,SUP-2123040,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CATHETERIZATION KIT ART 018 20 GAX4.5 CM 25 GA 3 CC LF,SUP-2865585,CDM,C1751,HCPCS,0278,RC,,,,both,,,162.65,105.72,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,J7060,HCPCS,0250,RC,00264-7510-10,NDC,,both,250,ML,17.00,11.05,,,,,,,,,,,,,
PLATE BNE 8 H TI ALLOY RT 1ST-2ND TMT NS LEOS,SUP-2933214,CDM,C1713,HCPCS,0278,RC,,,,both,,,5666.13,3682.98,,,,,,,,,,,,,
STENT COLON SELF EXPND 0.035 IN 25 MMX12 CM HANAROSTENT,SUP-2469989,CDM,C1876,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
PLATE BNE BAR L12MM 2 H CRANIOMAXILLOFACIAL TI LO PROF W/,SUP-2366199,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.82,213.08,,,,,,,,,,,,,
PLATE BNE L59MM THK3.4MM 4 H BILAT S STL STR LOK COMPR FOR,SUP-2185128,CDM,C1713,HCPCS,0278,RC,,,,both,,,765.12,497.33,,,,,,,,,,,,,
NEXGEN LPS ART SURF EF 7-10/STR BLU 23MM,SUP-2201983,CDM,C1776,CPT,0278,RC,,,,both,,,2413.09,1568.51,,,,,,,,,,,,,
FLEXI-TIP DUAL-LUMEN URETERAL ACCESS CATHETER,SUP-2826630,CDM,C1758,HCPCS,0278,RC,,,,both,,,115.74,75.23,,,,,,,,,,,,,
HANDPIECE LASER BENT 140 MM STR TIP FIBERLASE HP-R,SUP-2713737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.78,565.36,,,,,,,,,,,,,
DRESSING BIO L 20 X W 10 CM PORCINE CLLGN PHMB PURAPLY SX,SUP-2913696,CDM,C1763,HCPCS,0278,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
OCCLUDER CV AMPLATZER PI MUSCULAR VSD WAIST L 10 MM DIA20 MM,SUP-2737595,CDM,C1817,HCPCS,0278,RC,,,,both,,,20535.60,13348.14,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 15 CC FRZN CRUSH CANC,SUP-2743354,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
HYDROCHLOROTHIAZIDE 50 MG PO TABS,RX-3721,CDM,6370000000,HCPCS,0637,RC,00172-2089-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT POS CUSH FOAM HEAL PROTCT THGH STRP AND SEAT CVR,SUP-2306276,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
CATHETER HD LT 14 FRX36 CM DBL D INT LUMEN BASIC SPLIT STRM,SUP-2627430,CDM,C1750,HCPCS,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 4X4 CMX2-3.3 MM MTRX PROLAYER,SUP-2717808,CDM,C1763,HCPCS,0278,RC,,,,both,,,5275.45,3429.04,,,,,,,,,,,,,
CATH ABLATION TACTIFLEX SE UNID CURVE F,SUP-2874131,CDM,C2630,CPT,0272,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
BIT DRL L 370 MM DIA 3.2 MM STRL DISP PANGEA,SUP-2900602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1420.85,923.55,,,,,,,,,,,,,
ANCHOR SUTURE SFT JUGGERKNOT,SUP-2608806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2186.04,1420.93,,,,,,,,,,,,,
BUTAMBEN-TETRACAINE-BENZOCAINE 2-2-14 % EX AERO,RX-9328,CDM,6370000000,HCPCS,0637,RC,10223-0201-03,NDC,,both,0.2,GR,6.40,4.16,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 65 CM SHTH 7 FR GUIDEWIRE,SUP-2155676,CDM,C1887,HCPCS,0272,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
GRAFT BNE SUB 1ML DEMIN BNE MTRX PSTE SYR FRZ DRY DBX,SUP-2306990,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.45,393.54,,,,,,,,,,,,,
CARTRIDGE SEED MICK CESIUM 131 DISP,SUP-2247307,CDM,C2643,HCPCS,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
GUIDEWIRE VASC HYBRID L 220 CM 0.012/0.007 IN D CRV STR TIP,SUP-2895591,CDM,C1769,HCPCS,0272,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
BASE TY TAG LIBRA ST,SUP-2442362,CDM,C1776,CPT,0278,RC,,,,both,,,2501.01,1625.66,,,,,,,,,,,,,
GRAFT TIMS  AFT STRAIGHT TUBE,SUP-2740169,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
BRACE KNEE HNG WRP SM,SUP-2276702,CDM,L1820,HCPCS,0272,RC,,,,both,,,56.05,36.43,,,,,,,,,,,,,
BIOPSY SET 19 GAX70 CM 7 FR STRT NDL SHTH,SUP-2168817,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.27,1036.28,,,,,,,,,,,,,
BLADE RETRACTOR RICHARDSON UNIV PEDIATRIC 1X1.25 IN RNG SYS,SUP-2460488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.22,600.09,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 8 MM EPTFE STR STD WALL N RING,SUP-2126228,CDM,C1768,CPT,0278,RC,,,,both,,,447.48,290.86,,,,,,,,,,,,,
GRAFT BNE PTTY 1-2 MM 7.5 CC SYNTH KT APPL ACTIFUSE MIS,SUP-2130294,CDM,C1713,HCPCS,0278,RC,,,,both,,,7805.91,5073.84,,,,,,,,,,,,,
PLATE BONE LT DSTL RAD VOLAR TI FOR 1.8/2.4/2.7MM SCR,SUP-2191017,CDM,C1713,HCPCS,0278,RC,,,,both,,,2172.38,1412.05,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 30 CM DIA 9.5 FR GUIDEWIRE 0.038 IN,SUP-2355546,CDM,C1894,HCPCS,0272,RC,,,,both,,,58.88,38.27,,,,,,,,,,,,,
CLORAZEPATE DIPOTASSIUM 3.75 MG PO TABS,RX-1759,CDM,6370000000,HCPCS,0637,RC,13107-0319-01,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
PLATE BNE L92MM 7 H LOK 2 COMPR FOR 35MM SCR UNIV LOK SYS,SUP-2199387,CDM,C1713,HCPCS,0278,RC,,,,both,,,941.81,612.18,,,,,,,,,,,,,
ECLIPSE TI HUMERAL HEAD SIZE 51/21,SUP-2815509,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SHEATH UROLOGICAL 1 STP TROCAR L 20 CM L 17 CM CATH 12 FR,SUP-2835963,CDM,C1894,HCPCS,0272,RC,,,,both,,,248.69,161.65,,,,,,,,,,,,,
WIRE BRST LESION L7.7CM DIA20GA LOC DUALOK,SUP-2126946,CDM,C1819,HCPCS,0278,RC,,,,both,,,484.82,315.13,,,,,,,,,,,,,
STAPLE KIT 15X15/17 MM STRL INSTAFIX LTX DISP,SUP-2857581,CDM,C1713,HCPCS,0278,RC,,,,both,,,3654.96,2375.72,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA2 L 147 MM DIA 40 MM SHTH 20 FR,SUP-2912013,CDM,C1768,CPT,0278,RC,,,,both,,,66894.56,43481.46,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W1XL4CM THK1.04 2.28MM THICK RGNRTVE TSSUE,SUP-2487772,CDM,Q4116,HCPCS,0636,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
TI MATRIXMANDIBLE 3X3H ANGLE,SUP-2823040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1973.80,1282.97,,,,,,,,,,,,,
HC Chem Cautery Granulatn Tissue,PX-4501725000,CDM,17250,CPT,0450,RC,,,,both,,,280.00,182.00,,,,,,,,,,,,,
COMPONENT TIB SZ 1 THICKNESS 10MM POLYETH NP LT LAT RT MEDL,SUP-2200429,CDM,C1776,CPT,0278,RC,,,,both,,,4551.43,2958.43,,,,,,,,,,,,,
PLATE BNE MESHED XL LT CALCANEAL LCK NS A.L.P.S,SUP-2497770,CDM,C1713,HCPCS,0278,RC,,,,both,,,3097.58,2013.43,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 10X20X2 MM FD SPNG CANC READIGRAFT BLX,SUP-2741064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.23,779.50,,,,,,,,,,,,,
CONNECTOR SPNL 6.35MM M CORONAL SPINNER TI,SUP-2293328,CDM,C1713,HCPCS,0278,RC,,,,both,,,3290.72,2138.97,,,,,,,,,,,,,
POSTLAT DIST HUM LCK PL RIGHT SMPL,SUP-2820939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1824.43,1185.88,,,,,,,,,,,,,
CATHETER SURG L16MM OD7FR SINUS RELIEVA SOLO,SUP-2106321,CDM,C1725,HCPCS,0272,RC,,,,both,,,2430.36,1579.73,,,,,,,,,,,,,
GRAFT HUM TISS W13XL15CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2125859,CDM,C1781,HCPCS,0278,RC,,,,both,,,19342.40,12572.56,,,,,,,,,,,,,
PLATE SPNL BURR HOLE CVR 5 MM CRAN GRDIAN,SUP-2637197,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.62,242.20,,,,,,,,,,,,,
OSS 7CM OSSEOTI PROX TIB SLV,SUP-2506334,CDM,C1776,CPT,0278,RC,,,,both,,,11934.20,7757.23,,,,,,,,,,,,,
SCREW SPNL L40MM DIA6MM PEDCL TI FULL THRD FOR 5.5MM ROD,SUP-2182693,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH XP L 150 CM DIA 5 FR SHFT DIA1.22,SUP-2761863,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.52,112.79,,,,,,,,,,,,,
PLATE BNE LCK 77 MM LT DORS PROXIMAL ULNAR 3 HOLE STRL,SUP-2468301,CDM,C1713,HCPCS,0278,RC,,,,both,,,2214.80,1439.62,,,,,,,,,,,,,
SET VASC ACCS PEELWY L 13 CM INTRO L 20 CM DIA20 FR,SUP-2168025,CDM,C1892,HCPCS,0272,RC,,,,both,,,183.66,119.38,,,,,,,,,,,,,
SHUNT DRAINAGE BURR HOLE RESERVOIR PEDIATRIC 15 CM PROGAV,SUP-2108726,CDM,C1889,HCPCS,0278,RC,,,,both,,,7918.42,5146.97,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR ADJ CUST FIT STRP W/OUT JT FABRICATED,SUP-2435751,CDM,L3671,HCPCS,0272,RC,,,,both,,,2321.65,1509.07,,,,,,,,,,,,,
CATHETER DIAG L150CM OD0.059X0.052IN TIP OD3.2FR 50MM SPC,SUP-2353142,CDM,C1887,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PROBE ENDOSCP L135MM TIP DIA35MM DIR SERFAS ENERGY PROVIDE,SUP-2366832,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.91,272.29,,,,,,,,,,,,,
KIT DLYS .038 IN PEEL AWAY SHTH FLEX STIFFENER GWIRE SCALP,SUP-2120055,CDM,C1881,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SPHERE GLEN DIA36MM TI REV SCR LOK DELT CTA,SUP-2254051,CDM,C1776,CPT,0278,RC,,,,both,,,3786.84,2461.45,,,,,,,,,,,,,
PACER S ZEPHYR SR 5620,SUP-2356213,CDM,C1786,HCPCS,0275,RC,,,,both,,,18080.12,11752.08,,,,,,,,,,,,,
TISSUE ACHILLES TENDON PRE-SHAPED 10X260MM,SUP-2718660,CDM,C1762,CPT,0278,RC,,,,both,,,7510.19,4881.62,,,,,,,,,,,,,
GRAFT BIO TISS W2XL3CM 1 LAYR PORCINE MTRX ABD HERN SURGISIS,SUP-2168830,CDM,C1763,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
FIBER LASER HOLM 550 M MULTI-USE W/ H-30 PUR SMARTSYNC,SUP-2835947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1614.75,1049.59,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 3 FR SHERLOCK STYL GROSH,SUP-2126719,CDM,C1751,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
PROBE ABLAT 17GA L20CM CBL L1.4M STD PERC ACT ZONE DISPLAY 3,SUP-2219810,CDM,C1886,HCPCS,0278,RC,,,,both,,,12484.64,8115.02,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES ORTHOSIS TORONTO TYP,SUP-2435603,CDM,L1700,HCPCS,0274,RC,,,,both,,,4404.76,2863.09,,,,,,,,,,,,,
STRUT EXT FIX SM 14 MM INFIX,SUP-2683731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
HC So Gastrin,PX-3018294166,CDM,82941,CPT,0301,RC,,,,inpatient,,,341.00,221.65,,,,,,,,,,,,,
PLATE BNE L94MM THK3.1MM 8 H BILAT S STL LOK COMPR RECON,SUP-2348691,CDM,C1713,HCPCS,0278,RC,,,,both,,,5162.63,3355.71,,,,,,,,,,,,,
GUIDEWIRE HYDRPHLC ANG REG TIP 0038INX150CM ZIPWIRE,SUP-2139335,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.56,109.56,,,,,,,,,,,,,
ROD SPNL 11X300 MM,SUP-2205341,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.33,431.16,,,,,,,,,,,,,
DEVICE EXT FIX DYN JT DISTRACTOR BODY HNG,SUP-2372640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
CATHETER GUID FLOWGATE 2 L 85 CM OD 8 FR ID 0.084 IN BALLOON,SUP-2884389,CDM,C1887,HCPCS,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
RESERVOIR CEREBROSPINAL 14MM FLUID FLUSHING BOTTOM INLET CON,SUP-2830492,CDM,C1889,HCPCS,0278,RC,,,,both,,,1344.80,874.12,,,,,,,,,,,,,
IMMOBOLIZER SHLDR SUPP UNIV UNISX M,SUP-2136721,CDM,L3660,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
PLATE STRNL SM 4 H TI SQ NS MATRIXSTERNUM,SUP-2904245,CDM,C1713,HCPCS,0278,RC,,,,both,,,1719.28,1117.53,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT CANC OR CORT DWL 16MMX16MM,SUP-2307027,CDM,C1762,CPT,0278,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
BOLT EXT FIX M6 L18MM W HEX 10MM S STL,SUP-2242956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,44.05,28.63,,,,,,,,,,,,,
GRAFT BNE SUB W1.75XL10CM POSTEROLATERAL MAGNIFUSE,SUP-2293961,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 10 MM INFRASPINATUS CORTICAL,SUP-2787781,CDM,C1713,HCPCS,0278,RC,,,,both,,,8883.97,5774.58,,,,,,,,,,,,,
PIN FIX FLUT 3.2X150 MM KNEE FIX NS ROSA DISP,SUP-2656951,CDM,C1713,HCPCS,0278,RC,,,,both,,,149.15,96.95,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7030,HCPCS,0250,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq 1st 30 Minutes,PX-4309755000,CDM,97550,CPT,0430,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
HC Ult Guide Perc Drain Abscess,PX-4027598900,CDM,75989,CPT,0402,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD 15.5FR L24CM BASIC DBL LUMN W/,SUP-2116516,CDM,C1881,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX55 CM W/ ECHOGENIC TIP XCELA,SUP-2118960,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SPACER SPNL W9XH7XL22MM LORDTC SELF EXP TANT MRK LO PROF,SUP-2354690,CDM,C1821,HCPCS,0278,RC,,,,both,,,17332.80,11266.32,,,,,,,,,,,,,
LINER ACET C NEUT 32 MM HIP VIVACIT-E G7,SUP-2423974,CDM,C1776,CPT,0278,RC,,,,both,,,6148.12,3996.28,,,,,,,,,,,,,
CATHETER KIT INSRTN TY PLEURAL DRAINAGE ASPIRA,SUP-2487165,CDM,C1729,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
WASHER ORTHOPEDIC LCK 3.5 MM,SUP-2243054,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.22,263.39,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL 109X10 MM FD STRUT,SUP-2717906,CDM,C1762,CPT,0278,RC,,,,both,,,3916.87,2545.97,,,,,,,,,,,,,
RHINOLARYNGOSCOPE SLIM 4 ASCOPE SGL USE FLEX,SUP-2865123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 5FR 0.034IN 60CM 2 LUMAN RVRSE TA,SUP-2613388,CDM,C1751,HCPCS,0278,RC,,,,both,,,388.10,252.26,,,,,,,,,,,,,
ALLOGRAFT BNE COR FRZN HEMI PAT,SUP-2736963,CDM,C1762,CPT,0278,RC,,,,both,,,3377.67,2195.49,,,,,,,,,,,,,
PLATE B1 STP 0 MM CROSSCHECK NS ORTHOLOC 3DI,SUP-2900547,CDM,C1713,HCPCS,0278,RC,,,,both,,,10657.16,6927.15,,,,,,,,,,,,,
EXPANDER BRST TISS 650CC W13XH13CM P8.2CM SIL SMOOTH ULT HI,SUP-2301019,CDM,C1789,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
PLATE BONE L82MM 6 H LT PROX MEDL PERIARTC TIB S STL,SUP-2205631,CDM,C1713,HCPCS,0278,RC,,,,both,,,2004.42,1302.87,,,,,,,,,,,,,
GRAFT VASC L60CM DIA6MM STR STRTCH THN WALLED INTERING,SUP-2395845,CDM,C1768,CPT,0278,RC,,,,both,,,4088.28,2657.38,,,,,,,,,,,,,
NEEDLE NUCLEOPLASTY DLR PK CONTAINS DLR SPINEWAND AND,SUP-2342060,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SOLUTION IV 500ML 20% D,SUP-2106281,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
LEAD CARD PACE PERM ATR VENT LD PACE BPLR ACT FIX IS 1 CONN,SUP-2356665,CDM,C1898,HCPCS,0275,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PUMP INFUSION ELASTOMERIC 400 CC 4 ML/HR FIX FLO STRL ON-Q,SUP-2424461,CDM,C9804,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SCREW BONE L18MM DIA2.7MM CORT S STL ST LCK FULL THRD LO,SUP-2349852,CDM,C1713,HCPCS,0278,RC,,,,both,,,801.05,520.68,,,,,,,,,,,,,
RELOAD STPL SZ 2.5MM L45MM 0DEG UNIV WHT TI ROTICULATING,SUP-2283058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.09,369.26,,,,,,,,,,,,,
CANNULA CEMENT STRL DISP,SUP-2917071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PIN BNE FIX DIA 5 MM CANC THRD REDUCTION STRL VARIAX,SUP-2900652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1281.87,833.22,,,,,,,,,,,,,
SCREW SPNL MULTAXL 7.5X45 MM ESSENCE KT,SUP-2631917,CDM,C1713,HCPCS,0278,RC,,,,both,,,8102.77,5266.80,,,,,,,,,,,,,
STEM FEM HIP PRI NEUT POR STR 40MM OFFSET TIV 11.0MM DIA,SUP-2203129,CDM,C1776,CPT,0278,RC,,,,both,,,15237.79,9904.56,,,,,,,,,,,,,
GRAFT BLGCL TSSUE W10XL16CM RCNSTRCTVE MTRX FIRM STRTTCE,SUP-2458367,CDM,Q4130,HCPCS,0636,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
SCREW BNE SCHNZ 3 MM,SUP-2150262,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
PROBE OPHTH 23GA LASER CVD FLEX NIT TAPR TIP,SUP-2129220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.65,266.92,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN AXOGRFT,SUP-2125453,CDM,C1762,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
COMPONENT TIB AUG 47X51X20 MM LM/RL KNEE OSS RS RD122163,SUP-2450002,CDM,C1776,CPT,0278,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
SCREW BNE L85MM DIA14MM THRD L22MM NONSTERILE CANC S STL ST,SUP-2186517,CDM,C1713,HCPCS,0278,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
PLATE BNE CRV 0.8 MM MEDL LAT HND STRL,SUP-2518384,CDM,C1713,HCPCS,0278,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
TROCAR ARTHSCP W/ PYR TIP 3.7MM,SUP-2332821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.41,217.37,,,,,,,,,,,,,
CATHETER BLLN 18 FR 16X34 MM TRI LOBE,SUP-2395625,CDM,C1725,HCPCS,0272,RC,,,,both,,,2050.42,1332.77,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA 5 MM STD OPT 2 FIX CANN DOLPHIN,SUP-2896330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.52,249.29,,,,,,,,,,,,,
SLEEVE DRL SZ 5MM CODE GRN DISP TRUKOR,SUP-2341081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
PLATE BNE W15XL104MM THK2MM 4 H BILAT S STL COVERLEAF RIG,SUP-2186006,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
BIT DRL DIA2.4MM S STL LABRUM FLUT NONCANNULATED CINCHLOCK,SUP-2366747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ANCHOR SUT 5 MM DIA NO 2 SUT ABSRB TWINFIX,SUP-2341597,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.45,512.49,,,,,,,,,,,,,
CATHETER US 5FR L150CM 0.056IN PLAT GLYDX HYDRPHLC INTVASC,SUP-2327229,CDM,C1753,HCPCS,0278,RC,,,,both,,,2504.15,1627.70,,,,,,,,,,,,,
CATHETER URET 6FR L70CM POLYUR WHSTL TIP W/ ADPT DISP,SUP-2129007,CDM,C1758,HCPCS,0278,RC,,,,both,,,20.98,13.64,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST RIGID W/O JT,SUP-2435611,CDM,L1836,HCPCS,0274,RC,,,,both,,,377.71,245.51,,,,,,,,,,,,,
SPLINT HND AD UNIV L W STAY WLK,SUP-2112604,CDM,L3807,HCPCS,0274,RC,,,,both,,,148.43,96.48,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 6 MM EPTFE FLX TW SM BEAD RING,SUP-2761456,CDM,C1768,CPT,0278,RC,,,,both,,,3033.52,1971.79,,,,,,,,,,,,,
SPACER SPNL MED 73-88 MM CNTRL BODY STRL XLR,SUP-2592014,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
SCREW BONE STAINLESS STEEL ST CORTICAL 3.5X50MM,SUP-2721584,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.02,87.11,,,,,,,,,,,,,
COLLAR EXTRIC FR 2.5IN FOR 11-23IN NK SHT 1 PC,SUP-2194421,CDM,L0172,HCPCS,0272,RC,,,,both,,,24.46,15.90,,,,,,,,,,,,,
HC Assay of Volatiles,PX-3018460000,CDM,84600,CPT,0301,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
STEM FEM SZ 10 L130MM HIP CO CHROM POR HI OFFSET 12/14 TAPR,SUP-2345298,CDM,C1776,CPT,0278,RC,,,,both,,,14266.59,9273.28,,,,,,,,,,,,,
ROD EXT FIX L382MM DIA11MM 90DEG UNIV C FBR SEMI CIR CRV,SUP-2188643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1713.31,1113.65,,,,,,,,,,,,,
HC So Jak2 Gene Analysis,PX-3108127066,CDM,81270,CPT,0310,RC,,,,both,,,529.00,343.85,,,,,,,,,,,,,
"HC So Quantation of Therapuetic Drug, Nes",PX-3018029966,CDM,80299,CPT,0301,RC,,,,outpatient,,,63.00,40.95,,,,,,,,,,,,,
PLATE BNE HK 3 HOLE,SUP-2518429,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
CONNECTOR SPNL DOMINO 4.5-5.5 MM,SUP-2631252,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
VALVE SHUNT HEYSCHLT HI PRESSURE MULTPURP ON-OFF FLSH,SUP-2244285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4109.38,2671.10,,,,,,,,,,,,,
GRAFT HUM TISS 3X8CM THCK AMNION,SUP-2419167,CDM,C1762,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
PLATE BNE CRV MINI XLN 2-2.5X1 MM MAND 6 HOLE LCK SAG TI,SUP-2487350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.52,823.89,,,,,,,,,,,,,
FIXATOR SURG L200MM DSTL RAD S STL W/ SELF DRL SCHNZ C FBR,SUP-2188754,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC VIABLE BNE MTRX BIO4 PS51010,SUP-2637052,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 14 CM DIA 0.018 IN PERIPH POS PLCMNT TB,SUP-2383493,CDM,C1769,HCPCS,0272,RC,,,,both,,,19.47,12.66,,,,,,,,,,,,,
CLAMP PIN YELLOW,SUP-2700561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,575.88,374.32,,,,,,,,,,,,,
INTRODUCER SHTH 8.5FR L63CM DIL 8.5FR L67CM GWIRE L180CM 407362,SUP-2357235,CDM,C1893,HCPCS,0272,RC,,,,both,,,507.74,330.03,,,,,,,,,,,,,
PLATE BONE L52XW25MM STD RT DSTL VOLAR RAD TI CNTOUR LO PROF,SUP-2361546,CDM,C1713,HCPCS,0278,RC,,,,both,,,2954.46,1920.40,,,,,,,,,,,,,
LINER ACET SZ C DIA32MM UHMWPE FLAT HIGHCROSS MPACT,SUP-2267403,CDM,C1776,CPT,0278,RC,,,,both,,,4022.84,2614.85,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 30 CC PRESERVON CANC READIGRAFT,SUP-2740811,CDM,C1713,HCPCS,0278,RC,,,,both,,,1210.97,787.13,,,,,,,,,,,,,
BLADE ARTHSCP SHV L11CM DIA4MM 12DEG AGG IRR ANG FOR SM JT,SUP-2363537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.16,277.00,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.546,SUP-2860227,CDM,C1713,HCPCS,0278,RC,,,,both,,,53378.43,34695.98,,,,,,,,,,,,,
GRAFT BNE SUB W1XL20CM SPNL DEFORMITY MAGNIFUSE,SUP-2293964,CDM,C1713,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
GRAFT DERM DECELLULARIZED RM TEMP ALLGRFT 0.75MM-1.50MM,SUP-2264719,CDM,Q4122,HCPCS,0636,RC,,,,both,,,11195.67,7277.19,,,,,,,,,,,,,
PROBE STEREOTACTIC DIA11GA DISP MAMTOM,SUP-2195657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
FIBER LASER HPS] PURCHASE SVCS INVOICED SVCS],SUP-2330638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
CUP HUM H+0MM DIA42MM REV SHLDR POLYETH METALIZED RETENTIVE,SUP-2252983,CDM,C1776,CPT,0278,RC,,,,both,,,5178.02,3365.71,,,,,,,,,,,,,
CATHETER VLV DEL BRONCH DIA 4-7 MM J CONFIGURATION STRL DISP,SUP-2930258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
INSERT TIB SZ 2 THK12MM UNIV UNI KNEE POLYETH UNI PRI NEUT,SUP-2251233,CDM,C1776,CPT,0278,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
STENT PANCREATIC JOHLIN L 8 CM DIA10 FR GUIDEWIRE 0.035 IN,SUP-2737534,CDM,C2625,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
PLATE BNE L79MM THK34MM 6 H BILAT PUBIC S STL LO PROF RIG,SUP-2184020,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.41,1612.27,,,,,,,,,,,,,
PLATE BONE L195MM 11 H RT PROX HUM LCK FOR 4.5MM SCR,SUP-2348278,CDM,C1713,HCPCS,0278,RC,,,,both,,,16325.49,10611.57,,,,,,,,,,,,,
ALLOGRAFT GRAFTLINK: D=8.5 L=65 MM,SUP-2815859,CDM,C1762,CPT,0278,RC,,,,both,,,7033.91,4572.04,,,,,,,,,,,,,
PIN FIX OD4MM THRD L50MM OD5MM TRANSFIXING PREFIX 92000 SER,SUP-2316290,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.59,327.33,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L45CM DIA13MM PERC 4 ELECTRD IN LN CONN,SUP-2278192,CDM,C1767,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAG CTRL PANEL STRP STAY,SUP-2435557,CDM,L0643,HCPCS,0272,RC,,,,both,,,458.57,298.07,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7040,HCPCS,0258,RC,00264-7800-10,NDC,,both,250,ML,14.90,9.68,,,,,,,,,,,,,
MATRIX HUM TISS L 4 X W 8 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909228,CDM,Q4122,HCPCS,0636,RC,,,,both,,,7022.61,4564.70,,,,,,,,,,,,,
PLATE BNE BADIE 7X13X0.6 MM RESORB X STRL,SUP-2461165,CDM,C1713,HCPCS,0278,RC,,,,both,,,1163.87,756.52,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED FEM ADV HD POROUS OXIN XLPE R3,SUP-2348014,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
KIT SURG ACC L VENT ASST DEV HEARTMATE III,SUP-2355986,CDM,C1713,HCPCS,0278,RC,,,,both,,,5228.10,3398.26,,,,,,,,,,,,,
HC CT Facial Bones W/WO Contrast,PX-3517048800,CDM,70488,CPT,0351,RC,,,,inpatient,,,2630.00,1709.50,,,,,,,,,,,,,
CLAMP INDEPENDENT WIRE FOR SHEFFIELD STERILISATION TY SYS,SUP-2316251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.41,344.77,,,,,,,,,,,,,
CYCLOPHOSPHAMIDE 2 G IJ SOLR,RX-38280,CDM,J9076,HCPCS,0636,RC,10019-0957-01,NDC,,both,1,UN,1685.70,1095.70,,,,,,,,,,,,,
POST MODULAR F/AUNMENTED MGS BASEPLATE,SUP-2749343,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER ABLATN MED LG CURL 2-5-2 MM 4 MM 7 FRX115 CM,SUP-2356995,CDM,C1733,HCPCS,0272,RC,,,,both,,,2348.69,1526.65,,,,,,,,,,,,,
SPHERE GLEN SM 40 MM SHLDR GLENOSPHERE RVS EXP EQUINOXE,SUP-2451437,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
KIT CANN 19FR TIP L18CM VENT CONN 3/8IN ART POLYUR PERC,SUP-2282864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.97,493.98,,,,,,,,,,,,,
MAGNESIUM OXIDE -MG SUPPLEMENT 400 (240 MG) MG PO TABS,RX-118293,CDM,6370000000,HCPCS,0637,RC,10006-0700-28,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIT DRL TWST 1.6X50 MM 8 MM W/ STP SONICWELD RX DISP,SUP-2458397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.30,270.59,,,,,,,,,,,,,
PLATE BNE W22XL45MM STD 6X2 H NONSTERILE L DST RAD VOLAR TI,SUP-2180845,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.49,1504.42,,,,,,,,,,,,,
SHEATH INTRO CHANNEL L 67 CM DIA 9 FR OD 12.6 FR ID 9.8 FR,SUP-2424650,CDM,C1766,CPT,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
STRAP CLAV XS STD MTL TOOTH BCKL,SUP-2428779,CDM,L3650,HCPCS,0272,RC,,,,both,,,23.17,15.06,,,,,,,,,,,,,
LASER SURG W/ SCANNER ULTRAPULSE DUO,SUP-2713805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500045.00,325029.25,,,,,,,,,,,,,
SEGMENTAL STR FLUTED STEM 12X130MM,SUP-2502462,CDM,C1776,CPT,0278,RC,,,,both,,,10286.64,6686.32,,,,,,,,,,,,,
TUBE TRACH CUF AD 9X12.9X140 MM SIL BIVONA TTS HYPRFLX,SUP-2352025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.58,351.38,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.6MM TIP DRL SGL PERC,SUP-2410862,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.44,123.79,,,,,,,,,,,,,
FIBER LASER HOLM 940 M MULTI-USE W/ H-30 ORNG SMARTSYNC,SUP-2835946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3082.70,2003.75,,,,,,,,,,,,,
CASE GRFT ENDURANT II NIT POLYESTER 3 PC STRL,SUP-2873746,CDM,C1768,CPT,0278,RC,,,,both,,,59660.00,38779.00,,,,,,,,,,,,,
CENTRALIZER VERSYS DISTAL 10MM,SUP-2504427,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE L 10 CM DIA 5 FR GUIDEWIRE L 40 CM,SUP-2633291,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.03,38.37,,,,,,,,,,,,,
DISTRACTION EXTRNL HLDR RED 2 HRZNTL CROSS BAR BLACK ALMNM Q,SUP-2680464,CDM,C1713,HCPCS,0278,RC,,,,both,,,742.30,482.49,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY OPTMA 110CM 7 FR TIP 2 MM,SUP-2489594,CDM,C1730,HCPCS,0272,RC,,,,both,,,1617.73,1051.52,,,,,,,,,,,,,
LEAD PACE L50CM EPICARD SIL PTCH DF-1,SUP-2282236,CDM,C1896,HCPCS,0275,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT ACF SPCR CERV SPNL IMPL 7X4MM,SUP-2414384,CDM,C1762,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
SCREW SPNL L60MM OD7.5MM S STL PEDCL IL CDH LEG,SUP-2286974,CDM,C1713,HCPCS,0278,RC,,,,both,,,2847.20,1850.68,,,,,,,,,,,,,
PLATE BNE 6 H R STD LO PROF NONCOMPRESSION S STL MTP FUS,SUP-2397483,CDM,C1713,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
CATHETER URET PGTL 10 FRX56 CM SOFFLX AQ,SUP-2835786,CDM,C1758,HCPCS,0278,RC,,,,both,,,139.26,90.52,,,,,,,,,,,,,
RETRACTOR SURG WND ALEXIS LAPAROSCOPIC SM,SUP-2855490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE BNE SM THK0.3MM STD UNIV CRANIOMAXILLOFACIAL TI,SUP-2366223,CDM,C1713,HCPCS,0278,RC,,,,both,,,2465.25,1602.41,,,,,,,,,,,,,
STRAP ORTH W3XL4IN STD M FOAM COT MTL TOOTH CLAV BCKL CLSR,SUP-2276601,CDM,L3650,HCPCS,0272,RC,,,,both,,,22.26,14.47,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER L 115 CM 8 FR 4 MM D-F CRV,SUP-2248504,CDM,C1732,HCPCS,0272,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
TRAY CATH MIDLN Q CATH INTERMED 5FR 20CM 2 LUMAN W/15GA EXCA,SUP-2613419,CDM,C1751,HCPCS,0278,RC,,,,both,,,224.51,145.93,,,,,,,,,,,,,
FOOTPLATE EXT FIX 140 MM,SUP-2197248,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
ADAPTER STEM POR TIB KNEE REV STRL IMP,SUP-2208315,CDM,C1776,CPT,0278,RC,,,,both,,,8562.78,5565.81,,,,,,,,,,,,,
CLIP BONE SCR CRANIOMAXILLOFACIAL W/ 1.5X4MM TI SELF DRL HI,SUP-2403079,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
BLADE KEL 2INX4IN BKWALT,SUP-2382392,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1266.05,822.93,,,,,,,,,,,,,
PROSTHESIS OSS L425MM SHFT OD05MM PLAT OR TI STAP PIST MEITI,SUP-2232478,CDM,L8613,CPT,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
PLATE BNE W16XL221MM THK5MM 11 H R CNDYL FEM S STL BTTRS,SUP-2185797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2506.57,1629.27,,,,,,,,,,,,,
ANCHOR SUT DIA5MM TENODESIS W 1 NUMBER 2 HI FI SUT TENOLOK,SUP-2167247,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
BRACE KNEE 2XL FOR 255 28IN NEOPRENE OPN POPLITEAL WRP ARND,SUP-2196842,CDM,L1810,HCPCS,0274,RC,,,,both,,,65.56,42.61,,,,,,,,,,,,,
SAW BLDE W13XL70MM D70MM CUT THK1.27MM UNIV S STL OSC,SUP-2253190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,402.08,261.35,,,,,,,,,,,,,
HEAD RAD DIA22MM RT ELBW CO CHROM ANAT,SUP-2107856,CDM,C1776,CPT,0278,RC,,,,both,,,8437.18,5484.17,,,,,,,,,,,,,
RANOLAZINE ER 500 MG PO TB12,RX-70434,CDM,6370000000,HCPCS,0637,RC,00904-7506-04,NDC,,both,1,UN,7.20,4.68,,,,,,,,,,,,,
PROBE ENDOSCP DISECT 90 DEG 19.7 CM SHFT FOR NEUROENDOSCOPE,SUP-2665082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1131.66,735.58,,,,,,,,,,,,,
BONE CEMENT KIT 900 DEG LNG 11 GA PCD PRECIS SYS SPINEPLEX,SUP-2367021,CDM,C1713,HCPCS,0278,RC,,,,both,,,1888.05,1227.23,,,,,,,,,,,,,
GRAFT DURA W4XL5IN THK0.6MM CLLGN MEM DURAMATRIX-ONLAY +,SUP-2165127,CDM,C1763,HCPCS,0278,RC,,,,both,,,2872.88,1867.37,,,,,,,,,,,,,
ANCHOR SUTURE 3.5 MM SUTURETAK,SUP-2198349,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.63,348.81,,,,,,,,,,,,,
TIBIAL COMP SINGLE COATED/US VERSION SMALL,SUP-2878755,CDM,C1776,CPT,0278,RC,,,,both,,,18197.24,11828.21,,,,,,,,,,,,,
HOOK SPNL ANGLED 6X7.5 MM LT MARINER,SUP-2737717,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK LAPAROSCOPIC/CHOLECYSTECTOMY ESFDA61] JNJ HEALTHCARE],SUP-2257565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,537.85,349.60,,,,,,,,,,,,,
CATHETER PERI DLYS AD 15FR L57CM 2 CUF SWAN NK CURL RADPQ,SUP-2283893,CDM,C1750,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
MORPHINE SULFATE ER 30 MG PO TBCR,RX-120941,CDM,6370000000,HCPCS,0637,RC,00406-8330-62,NDC,,both,1,UN,7.90,5.13,,,,,,,,,,,,,
JOINT FNGR HINGED 5 16.5X2.1/5X3.2 MM 9.9 MM PROX MP,SUP-2852848,CDM,C1776,CPT,0278,RC,,,,both,,,10797.68,7018.49,,,,,,,,,,,,,
ANCHOR SUTURE DIA2.3 MM SUTURE 1.8 MM HA COAT 2 STRND XBRAID,SUP-2908768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
GRAFT HUM TISS L 220 FOLDED DIA 7 MM PERONEUS LONGUS TEND,SUP-2913401,CDM,C1762,CPT,0278,RC,,,,both,,,6936.26,4508.57,,,,,,,,,,,,,
DEVICE LAPSCP M DIA4-7CM HND ASST LAP-DISC,SUP-2257667,CDM,C1788,HCPCS,0278,RC,,,,both,,,4920.66,3198.43,,,,,,,,,,,,,
TRAY HUM DIA44MM +10MM TI OFFSET SHLDR REV SYS COMPHSVE,SUP-2404728,CDM,C1776,CPT,0278,RC,,,,both,,,5435.34,3532.97,,,,,,,,,,,,,
ELECTRODE LAP MNPLR OLSEN 5MM DIA SHAFT 12 12NL BTTN TIP SC,SUP-2675666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,982.54,638.65,,,,,,,,,,,,,
ANCHOR SUTURE L8.5MM OD2.7MM WHITE WITH BLUE STRIPS PRE THRE,SUP-2824806,CDM,C1713,HCPCS,0278,RC,,,,both,,,716.17,465.51,,,,,,,,,,,,,
STENT URET 0.038 IN 5 FRX26 CM SET 2 DUROMETER POLARIS ULTRA,SUP-2537712,CDM,C2617,HCPCS,0278,RC,,,,both,,,629.98,409.49,,,,,,,,,,,,,
IMPLANT CRAN L CUST PEEK,SUP-2365129,CDM,C1713,HCPCS,0278,RC,,,,both,,,51707.70,33610.00,,,,,,,,,,,,,
PERIOTOME SET INCLUDES BLADES 1 2 3 HANDLE,SUP-2497938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.23,494.15,,,,,,,,,,,,,
ALLOGRAFT BNE OSTEOTMY WDG FRZN ASEP,SUP-2867123,CDM,C1762,CPT,0278,RC,,,,both,,,2434.13,1582.18,,,,,,,,,,,,,
BONE MARROW TRAY STD 8 GAX4 IN W/ BX NDL STRL T-LOK LTX,SUP-2876731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC VI DBM DYNAGRAFT II,SUP-2641742,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
CATHETER ANGIO SARAH DIA 5 FR RADIAL ART STRL,SUP-2385633,CDM,C1725,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
MATRIX BIO L 25 X W 20 CM FET BOV DERM DERMAL SLD STRL,SUP-2909326,CDM,Q4110,HCPCS,0636,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
PLATE BONE 2 H CRANIOMAXILLOFACIAL PURE TI STR FOR 1.3MM SCR,SUP-2190643,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.34,80.82,,,,,,,,,,,,,
INSERTER TACK DART DEL TISS REINF SHFT SINGLE EXIT PT STRL,SUP-2901972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1683.04,1093.98,,,,,,,,,,,,,
SET CATH L4.2CM OD5.9MM ID4MM W/ INTRO NDL 6ML SYR NO15,SUP-2168129,CDM,C1769,HCPCS,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
ADAPTER SL +0MM OFFSET UNIV HIP TI V40 TAPR ACCOLADE II,SUP-2376607,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
MINERAL OIL LIGHT OIL,RX-27386,CDM,6370000000,HCPCS,0637,RC,63323-0254-10,NDC,,both,10,ML,196.00,127.40,,,,,,,,,,,,,
SCREW BONE L85MM DIA5MM FT ANK TI ALLOY CANN FT HDLSS SHRP,SUP-2321009,CDM,C1713,HCPCS,0278,RC,,,,both,,,4088.28,2657.38,,,,,,,,,,,,,
STAPLE SURG 10X8MM ARCUS,SUP-2417438,CDM,C1713,HCPCS,0278,RC,,,,both,,,3263.59,2121.33,,,,,,,,,,,,,
NAIL INTRAMEDULLARY 3MM DIA 210MML TITANIUM ULNAR,SUP-2640104,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
SPREADER SURG L6 1 2IN S STL MATTE FINISH LAM INGE,SUP-2161220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.90,326.88,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2 MM 4 HOLE RAPID RESORBABLE STERILE RAP,SUP-2838588,CDM,C1713,HCPCS,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
STENT BILI WALLFLEX L 60 MM DIA10 MM CATH L 75 CM SHTH 9 FR,SUP-2149822,CDM,C1874,HCPCS,0278,RC,,,,both,,,11376.22,7394.54,,,,,,,,,,,,,
HC Trigeminal Nerve Block,PX-4506440000,CDM,64400,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE LCK 5.5X128 MM LT PROX LAT TIB 6 HOLE SS STRL,SUP-2469856,CDM,C1713,HCPCS,0278,RC,,,,both,,,3870.71,2515.96,,,,,,,,,,,,,
PLATE BNE L103MM 5 H R POSTEROLATERAL DST FIBULAR S STL LOK,SUP-2184151,CDM,C1713,HCPCS,0278,RC,,,,both,,,1731.55,1125.51,,,,,,,,,,,,,
ALLOGRAFT BNE 60 MM FEM SHFT STRL BIO LF DISP,SUP-2632312,CDM,C1762,CPT,0278,RC,,,,both,,,3165.12,2057.33,,,,,,,,,,,,,
SHEATH INTFR SCR SM TIB TCP/PLA BIOABSRB BIO-INTRAFIX,SUP-2249563,CDM,C1776,CPT,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
CHLORDIAZEPOXIDE-CLIDINIUM 5-2.5 MG PO CAPS,RX-1738,CDM,6370000000,HCPCS,0637,RC,60687-0639-11,NDC,,both,1,UN,24.30,15.79,,,,,,,,,,,,,
CUTTER ENDO L45MM GRN TI LIN ARTC DISP,SUP-2257552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,877.03,570.07,,,,,,,,,,,,,
CATHETER GUID L55CM OD6FR ID.070IN J INTRO,SUP-2158224,CDM,C1887,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
BUR SURG TAPR 1.7X15.8 MM 8 CM SM BOR MIDAS REX LEGEND,SUP-2631335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,275.57,179.12,,,,,,,,,,,,,
CABLE NERVE STIM ELECTRD MIC 3 IN LEADPOINT,SUP-2661733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
GRAFT BNE SUB MINI CA SULF INJ MIIG 115,SUP-2399044,CDM,C1713,HCPCS,0278,RC,,,,both,,,2654.12,1725.18,,,,,,,,,,,,,
MESH MXLFCL 26.2X26.2 MM 0.6 MM FOIL LG GRID PDLLA RESORB XG,SUP-2475635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1364.46,886.90,,,,,,,,,,,,,
IMPLANT SUBTALAR 75MM BLU ANK SPCR CSTS STS,SUP-2396775,CDM,C1713,HCPCS,0278,RC,,,,both,,,4606.38,2994.15,,,,,,,,,,,,,
HC Pathogen Test for Platelets,PX-3020910000,CDM,P9100,CPT,0302,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 7 FRX20 CM BASIC KT ARROWG+ARD,SUP-2383339,CDM,C1751,HCPCS,0278,RC,,,,both,,,177.57,115.42,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC SYR DBM ACCELL EVO3,SUP-2641761,CDM,C1713,HCPCS,0278,RC,,,,both,,,3179.25,2066.51,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 10 FRX15 CM 5 LUMEN QUINT,SUP-2759872,CDM,C1751,HCPCS,0278,RC,,,,both,,,742.64,482.72,,,,,,,,,,,,,
SHEATH INTRO MORPHEUS CT DIA 5 FR SPLITTABLE DIL ASMBLY STRL,SUP-2117209,CDM,C1894,HCPCS,0272,RC,,,,both,,,68.14,44.29,,,,,,,,,,,,,
HC Inj Proc Shoulder Arthro,PX-3612335000,CDM,23350,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SLING SUT PASS AND SPCR VESICA,SUP-2141755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
LINER ACET CUP PRI SNAP IN MTL ON POLY POLYETH 50MM-54MM OD 00612005032] ZIMMER BIOMET INC],SUP-2202175,CDM,C1776,CPT,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
HEAD FEM DIA28MM +5MM OFFSET 12 14 TAPR HIP MTL BIOLOX FORTE,SUP-2251172,CDM,C1776,CPT,0278,RC,,,,both,,,4623.34,3005.17,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 120 CC FD IRRADIATED CANC,SUP-2867181,CDM,C1762,CPT,0278,RC,,,,both,,,4698.23,3053.85,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SABER L 200 CM BALLOON L 250 MM DIA2 MM,SUP-2909702,CDM,C1725,HCPCS,0272,RC,,,,both,,,821.80,534.17,,,,,,,,,,,,,
TAPE MEAS IMPL 550MM W/ GUID STENT VASC,SUP-2264172,CDM,C1876,HCPCS,0278,RC,,,,both,,,281.03,182.67,,,,,,,,,,,,,
SCREW BONE SM L50MM DIA3.5MM HD DIA6MM CORT TI NONCANNULATED,SUP-2189879,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.72,38.17,,,,,,,,,,,,,
BODY EXT FIX CTRL STD M COMP PVC FREE STRL PROCALLUS,SUP-2645893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.63,595.81,,,,,,,,,,,,,
IMPL EYE OCCULAR HYDROXYAPPETITE NO 20MM,SUP-2525521,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
ANCHOR SUTURE 2 3.5 MM 2 DURABRAID PK W/ NDL TI TWINFIX,SUP-2849121,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
MESH SURG W4XL7CM THK1.1MM ACELLULAR DERM MATRIXXENOGRAFT,SUP-2362225,CDM,C1763,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
ACYCLOVIR 400 MG PO TABS,RX-8971,CDM,6370000000,HCPCS,0637,RC,00904-7507-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE L 40 MM DIA 7 MM LNG TI CANN HD NS LEOS,SUP-2931583,CDM,C1713,HCPCS,0278,RC,,,,both,,,999.15,649.45,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 90 CM DIA 5 MM EPTFE STR STD WALL,SUP-2489517,CDM,C1768,CPT,0278,RC,,,,both,,,1097.56,713.41,,,,,,,,,,,,,
CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN,RX-144832,CDM,J0613,HCPCS,0636,RC,44567-0620-01,NDC,,both,50,ML,113.60,73.84,,,,,,,,,,,,,
SLEEVE FEM 45MM LATERAL/MEDIAL FULL COAT REV PORCOAT ATTUNE,SUP-2251469,CDM,C1776,CPT,0278,RC,,,,both,,,8297.14,5393.14,,,,,,,,,,,,,
SCREW BNE L28MM DIA4.5MM THRD L12MM S STL PARTIALLY THRDED,SUP-2184427,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.61,40.70,,,,,,,,,,,,,
IMPLANT BRST SMOOTH 4.8 CM PROJCT 13.3 CM 545 CC MOD HI HSC,SUP-2264568,CDM,C1789,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
BRACE ANK XL FOR 14 15IN BLK W O STAY GAMEDAY,SUP-2319318,CDM,L4350,HCPCS,0272,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
DILTIAZEM HCL 50 MG/10ML IV SOLN,RX-97168,CDM,J1163,HCPCS,0636,RC,00641-9218-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SCREW SPNL L25MM OD10MM CANN THRD TI IL SI LOK,SUP-2229754,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
HOLE SAW 25MM WITH 9.5MM DRILL CANNUL.,SUP-2817900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2722.38,1769.55,,,,,,,,,,,,,
PLATE STRNL CLOSURE 13 MM TI JL WIDE GAP NS STERNALOCK BLU,SUP-2894491,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
SLING INCONT TENS FRE SUPP FOR OBT SYS GYNECARE TVT,SUP-2257138,CDM,C1771,HCPCS,0278,RC,,,,both,,,7043.55,4578.31,,,,,,,,,,,,,
CATHETER BAL 5.3FR 3MM BAL DIAM 4MM BAL LEN .035IN WIRE SZ,SUP-2141045,CDM,C1725,HCPCS,0272,RC,,,,both,,,563.13,366.03,,,,,,,,,,,,,
SCREW SPNL L35MM OD5.5MM TI CANC ANT THOR PEDCL ST,SUP-2292718,CDM,C1713,HCPCS,0278,RC,,,,both,,,1775.67,1154.19,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1X4 MM CORTEX CRANIOMAXILLOFACIAL WIT,SUP-2838138,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.08,231.45,,,,,,,,,,,,,
ALLOGRAFT BNE DBM + CORTICAL 5 CC FD,SUP-2717769,CDM,C1713,HCPCS,0278,RC,,,,both,,,3168.73,2059.67,,,,,,,,,,,,,
SODIUM CHLORIDE (PF) 0.9 % IJ SOLN,RX-147478,CDM,A4216,HCPCS,0250,RC,63323-0186-10,NDC,,both,10,ML,9.90,6.43,,,,,,,,,,,,,
BOOT LEG TRAC CONVOLUTED FOAM LNR W/ STAY UNIV AD BUCK,SUP-2194992,CDM,L4360,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 47 CM DIA26 MM BRANCH SZ 10/10/8/8,SUP-2459829,CDM,C1768,CPT,0278,RC,,,,both,,,8329.51,5414.18,,,,,,,,,,,,,
CONNECTOR LASER FIBER LITHO SUREFLEX 200,SUP-2263900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
STEM TIB SMOOTH TOP 16 MM R/L TOT ANK COAT INBONE II,SUP-2475073,CDM,C1776,CPT,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
PLATE BNE STR SM 1.5X0.6 MM MIDFACE 4 HOLE TI GLD NS LEVEL 1,SUP-2499690,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.97,280.13,,,,,,,,,,,,,
SCREW CP LAG 4.1X48 MM T10,SUP-2703201,CDM,C1713,HCPCS,0278,RC,,,,both,,,1138.88,740.27,,,,,,,,,,,,,
STENT PERIPHERAL L50MM DIAMETER 6MM VASCULAR ARTERIOVENOUS STRAIGHT FLAIR,SUP-2128226,CDM,C1874,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
CONNECTOR SPNL L40MM STD TI XLNK ASMBLY FIX TRNSVRS W/ CLOSE,SUP-2254508,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
IMPLANT CAPPED SHOULDER S9 CONVERTIBLE GLENOID BASEPLATE SCREWS,SUP-2903941,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
NUT ORTH CORT S STL FOR 4.5MM SCR,SUP-2411298,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.89,113.03,,,,,,,,,,,,,
COLLAR CERVICALXSM H2.75XL22.5IN EXTRIC EMS 1 PC PLAS FOAM,SUP-2197905,CDM,L0120,HCPCS,0272,RC,,,,both,,,89.80,58.37,,,,,,,,,,,,,
PLATE BNE HUM 3.5X266 MM RT DSTL 12 HOLE LCK LP RIGID STRL,SUP-2177171,CDM,C1713,HCPCS,0278,RC,,,,both,,,5265.75,3422.74,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED RT FEM HD,SUP-2740783,CDM,C1762,CPT,0278,RC,,,,both,,,24572.51,15972.13,,,,,,,,,,,,,
HC Eval of Speech Production|OP SPEECH LANGUAGE SERVICE,PX-4449252200,CDM,92522,CPT,0444,RC,,,GN,outpatient,,,693.00,450.45,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3 CM 0.014 INX300 CM MOD RAIL SUPP CHOICE,SUP-2143060,CDM,C1769,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT REMOVABLE UCB TYP BERK SHELL,SUP-2435700,CDM,L3000,HCPCS,0274,RC,,,,both,,,889.37,578.09,,,,,,,,,,,,,
GRAFT VASC STD WALL 5-8 MMX45 CM SHT TAPR STR ADVANTA VXT,SUP-2464340,CDM,C1768,CPT,0278,RC,,,,both,,,1496.43,972.68,,,,,,,,,,,,,
ANCHOR 4.75MM HEALIX ADVANCE KNOTLESS BR,SUP-2184947,CDM,C1713,HCPCS,0278,RC,,,,both,,,415.86,270.31,,,,,,,,,,,,,
KIT VEIN HARV VASOVIEW UNIPORT + W/ BPLR BISECTOR,SUP-2227754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SET INT FIX BURR H PLATE DIA18.5 MM SCREW DIA1.5 MM 15-7382-12,SUP-2936402,CDM,C1713,HCPCS,0278,RC,,,,both,,,27588.04,17932.23,,,,,,,,,,,,,
COMPONENT PAT DIA38MM THK9.5MM KNEE POLY CEM CONVENTIONAL,SUP-2207286,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
INTRODUCER SHTH SET 0.18 IN 6 FRX20 CM HYDRPHLC COAT M DRN,SUP-2303568,CDM,C1894,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 17 10MM CANC CRUSH CHIP READIGRFT,SUP-2264821,CDM,C1713,HCPCS,0278,RC,,,,both,,,1064.27,691.78,,,,,,,,,,,,,
RING ANAS 2 MM 31 MM GAP VALTRAC,SUP-2174532,CDM,C1889,HCPCS,0278,RC,,,,both,,,1321.03,858.67,,,,,,,,,,,,,
STENT BILI AD 85FR L50MM MIN WRK CHN 32MM ETHYLENE VYN,SUP-2313490,CDM,C2617,HCPCS,0278,RC,,,,both,,,182.40,118.56,,,,,,,,,,,,,
STIMULATOR NERVE QPLR 60X55X11.4 MM 28 CC 45 GM ENTERRA II,SUP-2866565,CDM,C1767,HCPCS,0278,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
CATHETER ETER DRNGE MP SIMP LOC 85FRX25CM HYDRPHLC,SUP-2168322,CDM,C1729,HCPCS,0272,RC,,,,both,,,345.75,224.74,,,,,,,,,,,,,
PLATE DISTL ANTERO TIB RT 8HL 153MM,SUP-2702943,CDM,C1713,HCPCS,0278,RC,,,,both,,,7018.21,4561.84,,,,,,,,,,,,,
PARTICLE EMB SZ 250-500UM POLYVI ALC N RADIOACTIVE CNTOUR 2,SUP-2148441,CDM,C1889,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
MESH HERN L DIA45IN POLYPR MFIL DBL LAYR CIR NONABSORBABLE,SUP-2125978,CDM,C1781,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
GRAFT VASC HEMGRD BODY/BRANCH L 100/60 CM DIA10 X 10 MM,SUP-2227557,CDM,C1768,CPT,0278,RC,,,,both,,,3015.34,1959.97,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X354 MM RT PROX 11 HOLE NS VA-LCP,SUP-2757666,CDM,C1713,HCPCS,0278,RC,,,,both,,,8271.55,5376.51,,,,,,,,,,,,,
TRAY MIDLN BASIC POWERGLIDE ST 20G X 8CM ST020080,SUP-2125704,CDM,C1751,HCPCS,0278,RC,,,,both,,,340.56,221.36,,,,,,,,,,,,,
SYSTEM ENDO INSTR ANTEROLATERAL LIGMNT RECON,SUP-2121948,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN (ADD-VANTAGE),RX-40860021,CDM,J7060,HCPCS,0250,RC,00409-7100-66,NDC,,both,50,ML,37.00,24.05,,,,,,,,,,,,,
VALVE WITH MCLANAHAN RESERVOIR AND MININAV 0 PROSA,SUP-2826814,CDM,C1889,HCPCS,0278,RC,,,,both,,,10665.20,6932.38,,,,,,,,,,,,,
SET DRNGE L41CM OD24FR ODSEC.038IN J 3 SIDE PRT ENDOSCP,SUP-2168143,CDM,C1729,HCPCS,0272,RC,,,,both,,,303.86,197.51,,,,,,,,,,,,,
GRAFT BNE SHFT SM 100-125 MM FD CORTICAL,SUP-2264581,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
OSTEOTOME SURG OD20MM BLDE THN CVD END FLEX,SUP-2408598,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED SH2] STELKAST CO],SUP-2359391,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
PLATE BONE L154MM 7 H TI LT DSTL DORSOLATERAL HUM FOR 3.5MM,SUP-2101271,CDM,C1713,HCPCS,0278,RC,,,,both,,,2758.18,1792.82,,,,,,,,,,,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,0636,RC,25021-0191-10,NDC,,both,1,UN,133.40,86.71,,,,,,,,,,,,,
HOLDER NDL 4 1/2IN SMOOTH TUNGSTEN CARB WEBST,SUP-2129710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
CATHETER CV 3L 6 FRX135 CM BASIC KT PWR INJ POWERPICC,SUP-2126401,CDM,C1751,HCPCS,0278,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 22 MM DIA 6 MM CATH L 80 CM,SUP-2884894,CDM,C1874,HCPCS,0278,RC,,,,both,,,9429.73,6129.32,,,,,,,,,,,,,
PIN LOCATING DIA2.5MM,SUP-2878313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
HC So Hepatitis Be Antibody,PX-3028670766,CDM,86707,CPT,0302,RC,,,,both,,,106.00,68.90,,,,,,,,,,,,,
IMPL KNEE FEM NAIL CEPHALOMEDULLARY SHRT BL LFT,SUP-2489869,CDM,C1776,CPT,0278,RC,,,,both,,,4450.26,2892.67,,,,,,,,,,,,,
CEMENT BNE 10 CC STRL FORTERA LTX,SUP-2855703,CDM,C1713,HCPCS,0278,RC,,,,both,,,17879.16,11621.45,,,,,,,,,,,,,
SET TB INTRO 8-14FR W/ 15CM PEEL AWAY SHTH NDL GWIRE 3 DIL,SUP-2168912,CDM,C1894,HCPCS,0272,RC,,,,both,,,336.77,218.90,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM FULL TY PWR INJ POWERPICC,SUP-2126386,CDM,C1751,HCPCS,0278,RC,,,,both,,,633.46,411.75,,,,,,,,,,,,,
GRAFT HUM TISS L 30-53 X W 14 MM BNE BLOCK L 25-30 X W 14 X,SUP-2913405,CDM,C1762,CPT,0278,RC,,,,both,,,18111.52,11772.49,,,,,,,,,,,,,
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,0636,RC,68817-0134-50,NDC,,both,1,UN,4550.60,2957.89,,,,,,,,,,,,,
IMPLANT OSS L4.5MM PIST DIA0.5MM STAP PLAT S STL RBBN LOOP,SUP-2313662,CDM,L8613,CPT,0278,RC,,,,both,,,473.86,308.01,,,,,,,,,,,,,
HC Assay of Progesterone,PX-3018414400,CDM,84144,CPT,0301,RC,,,,inpatient,,,332.00,215.80,,,,,,,,,,,,,
PROSTHESIS PENILE 18 CM INFPUB APPRCH PRECONN AMS 700 CXR MS,SUP-2139002,CDM,C1813,HCPCS,0278,RC,,,,both,,,27446.74,17840.38,,,,,,,,,,,,,
DISC BNE SCREW DIA 5.5 MM NIT DYN REFLX,SUP-2897281,CDM,C1713,HCPCS,0278,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
PLATE BNE VOLAR HK FOR DST RAD SYS GEMINUS,SUP-2340194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.01,707.21,,,,,,,,,,,,,
CAGE SPNL MESH 22X17X10 MM 6 LOBE,SUP-2602082,CDM,C1889,HCPCS,0278,RC,,,,both,,,8110.62,5271.90,,,,,,,,,,,,,
COLLAR CERV 3 1/4X10-12IN SM TRACH OPN ADJ PHIL,SUP-2195259,CDM,L0120,HCPCS,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
CATHETER ETER MIDLN FULL NRS TY 2 LUMN 5FRX20 CM,SUP-2267039,CDM,C1751,HCPCS,0278,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
HC Replace Atrial and Vent Lead,PX-4813321700,CDM,33217,CPT,0481,RC,,,,both,,,9016.00,5860.40,,,,,,,,,,,,,
PLATE KNEE MG II OPT STEM TIB C/YELLOW,SUP-2199657,CDM,C1776,CPT,0278,RC,,,,both,,,10691.07,6949.20,,,,,,,,,,,,,
HC 3d Rendering Requiring Sep Wor,PX-3507637700,CDM,76377,CPT,0350,RC,,,,inpatient,,,1344.00,873.60,,,,,,,,,,,,,
HC So CKMB,PX-3018255366,CDM,82553,CPT,0301,RC,,,,both,,,41.00,26.65,,,,,,,,,,,,,
SCREW BNE LCK 2.7X60 MM ST PERI-LOC,SUP-2348654,CDM,C1713,HCPCS,0278,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
GUIDEPIN ORTHOPAEDIC 2.8 MM NON STERILE LATEXFREE REUSABLE,SUP-2836578,CDM,C1769,HCPCS,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
SCREW SPNL L40MM DIA65MM AWL TAP HI STRENGTH LO PROF,SUP-2278778,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
COIL EMB L35CM PRI DIA0.020IN 2ND DIA11MM NIT COMPLX SFT,SUP-2323412,CDM,C1889,HCPCS,0278,RC,,,,both,,,7799.76,5069.84,,,,,,,,,,,,,
EXTRACTOR SCR CENTRONAIL FEM GEN INSTRMT BX LCK,SUP-2315999,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.71,138.91,,,,,,,,,,,,,
PLATE BONE 107MML HLX8 STNLSS STEEL BTTRSS F/3.5MM/4MM CRTCL,SUP-2478773,CDM,C1713,HCPCS,0278,RC,,,,both,,,2318.29,1506.89,,,,,,,,,,,,,
BOLT ORTH 25 MM LAT TROCHANTERIC ARCOS,SUP-2441646,CDM,C1776,CPT,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
CATHETER URET OPN END 038 5 FRX70 CM SOFFLX,SUP-2835722,CDM,C1758,HCPCS,0278,RC,,,,both,,,40.19,26.12,,,,,,,,,,,,,
KIT PAIN PMP 270ML 4ML/HR ELASTOMERIC NONNARCOTIC 2 ON-Q,SUP-2236816,CDM,C9804,HCPCS,0272,RC,,,,both,,,413.44,268.74,,,,,,,,,,,,,
SCREW FEM UNIV STD TI KNEE REV PRESSFIT IMP ASCNT,SUP-2407027,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
CATHETER CARD ABLATION RF MARINR MC L 110 CM DIA 7 FR TIP L,SUP-2749540,CDM,C1732,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SEALANT HEMSTATIC HUM 4 CC KT FIBRIN VISTASEAL,SUP-2432427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.25,399.91,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED REVERSED S4FHORTHO] FH ORTHO INC],SUP-2224562,CDM,C1776,CPT,0278,RC,,,,both,,,21038.00,13674.70,,,,,,,,,,,,,
SET ORTH GRPHC CA W/ DRL BIT GUID CONCL SCR WRNCH BEND FE,SUP-2177073,CDM,C1713,HCPCS,0278,RC,,,,both,,,85952.10,55868.86,,,,,,,,,,,,,
PARTICLE EMB SZ 250-500UM POLYVI ALC N RADIOACTIVE CNTOUR 5,SUP-2148442,CDM,C1889,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
DIST TIB ANTLAT PLATE LEFT NARROW 12H,SUP-2588758,CDM,C1713,HCPCS,0278,RC,,,,both,,,3920.92,2548.60,,,,,,,,,,,,,
VALVE MITRL OPN PVT DIA 33 MM ORIFICE 26.8 MM TISS ANNULUS,SUP-2282658,CDM,C1889,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
ANCHOR STRE 1.4MML PRLDD IMPLNT W/ NDLE/1.4MM DRILL SHRT SRL,SUP-2589288,CDM,C1713,HCPCS,0278,RC,,,,both,,,1301.22,845.79,,,,,,,,,,,,,
PLATE BNE W5XL50MM THK1-1.2MM 3X9 H BILAT TI T SHP RIG,SUP-2191057,CDM,C1713,HCPCS,0278,RC,,,,both,,,798.75,519.19,,,,,,,,,,,,,
PLATE BNE L 54 MM 4 H ANODIZATION TYP II RT VOLAR DSTL,SUP-2902220,CDM,C1713,HCPCS,0278,RC,,,,both,,,4851.83,3153.69,,,,,,,,,,,,,
HEXAMINOLEVULINATE HCL 100 MG IS SOLR,RX-106546,CDM,A9589,HCPCS,0636,RC,10511-3001-02,NDC,,both,1,UN,690.10,448.56,,,,,,,,,,,,,
SCREW BNE 35MMX65MM CORT N CANN FULL THRD N ST DRL N LOK HEX,SUP-2199293,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.73,52.47,,,,,,,,,,,,,
RAIL EXT FIX SM 250 MM,SUP-2467791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3557.62,2312.45,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 50 MM DIA 7 MM CATH TOT L 116 CM,SUP-2141192,CDM,C1874,HCPCS,0278,RC,,,,both,,,6446.42,4190.17,,,,,,,,,,,,,
BOLT EXT FIX LP SHT UNIV WIRE TRUELOK +,SUP-2875033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.74,330.03,,,,,,,,,,,,,
CATHETER INT AORT BLLN 9.5FX340,SUP-2227308,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
HEAD FEM EXT 5+ MM 10/12 26 MM HIP TAPR OXIN,SUP-2434569,CDM,C1776,CPT,0278,RC,,,,both,,,4854.44,3155.39,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR THCK FRZ DRY 8CMX16CM,SUP-2306917,CDM,C1762,CPT,0278,RC,,,,both,,,12516.95,8136.02,,,,,,,,,,,,,
HC So Genotype Dna/Rna Hiv,PX-3068790666,CDM,87906,CPT,0306,RC,,,,both,,,362.00,235.30,,,,,,,,,,,,,
ALLOGRAFT BNE RAD DSTL,SUP-2321879,CDM,C1713,HCPCS,0278,RC,,,,both,,,3234.20,2102.23,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X43X1.5 MM 6 HOLE FRAC TI STRL LEVEL 1,SUP-2539576,CDM,C1713,HCPCS,0278,RC,,,,both,,,1738.30,1129.89,,,,,,,,,,,,,
WSHR ORTH 8MM POLARUS 3 LOCK STRL,SUP-2639524,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
HALF PIN EXT FIX L50MM DIA5MM TI TRAC FOR JET-X EXT FIX,SUP-2342937,CDM,C1713,HCPCS,0278,RC,,,,both,,,2235.62,1453.15,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD KT CHRONIC INTRO MTL L37CM L13CM,SUP-2117118,CDM,C1750,HCPCS,0278,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 6 MM RND UPWR,SUP-2166789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,228.59,148.58,,,,,,,,,,,,,
COMPONENT FEM L105MM KNEE SEG IMP MOST OPTIONS,SUP-2208265,CDM,C1776,CPT,0278,RC,,,,both,,,9495.36,6171.98,,,,,,,,,,,,,
SPHERE GLEN CRV DIA36MM STD TI FOR COMPHSVE REV SHLDR SYS,SUP-2409235,CDM,C1776,CPT,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
WIRE FIX TRCAR PT 1 END 1.5 MMX9 IN SMTH/PLAIN KIRSCHNER 6PK,SUP-2476700,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 21 CM ART SINGLE SET BIOFLX TESIO,SUP-2627158,CDM,C1750,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
BIT DRL L100MM DIA1.7MM CANN QUIK CPL NONRADIOLUCENT W/O,SUP-2187212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1106.98,719.54,,,,,,,,,,,,,
DEFIBRILLATOR CARD 30.5CC W6.17XH6.90CM D0.99CM VR CONN DF4,SUP-2149196,CDM,C1722,HCPCS,0275,RC,,,,both,,,37234.12,24202.18,,,,,,,,,,,,,
WRAP WR UNIV LT COMPR GEL,SUP-2324362,CDM,L3931,HCPCS,0272,RC,,,,both,,,99.91,64.94,,,,,,,,,,,,,
MESH HERN COMP 15 CM MONOFILAMENT EZ TO USE PARIETENE DS,SUP-2752202,CDM,C1781,HCPCS,0278,RC,,,,both,,,9007.03,5854.57,,,,,,,,,,,,,
GUIDEPIN ORTH L14IN OD3.6MM CNL PREP DISP,SUP-2412706,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX8 TTNM 1/3 TBLR F/3.5MM LOK SCREW,SUP-2588615,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
POST FIX L30MM OD4.5MM TI KNEE SUT STRL FOR ACL PCL FIX SYS,SUP-2342261,CDM,C1713,HCPCS,0278,RC,,,,both,,,277.04,180.08,,,,,,,,,,,,,
HC Ins Cd Gen Only Dual,PX-4813323000,CDM,33230,CPT,0481,RC,,,,inpatient,,,81065.00,52692.25,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN 115CM 4-4-4 D,SUP-2485389,CDM,C1732,HCPCS,0278,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
CLONAZEPAM 0.5 MG PO TABS,RX-9637,CDM,6370000000,HCPCS,0637,RC,00093-0832-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ANCHOR SUT STR FOR SFT TISS MENIS REP SYS ULT FAST-FIX,SUP-2341773,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
CANNULA RF 100MM 20GA VENOM,SUP-2366962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,229.35,149.08,,,,,,,,,,,,,
SPACER SPNL W14XH7XL16MM PEEK CERV INTBDY FUS SET TYP 2096,SUP-2278331,CDM,C1889,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
LINER TIB KNEE HYBIRD XLPE PREMIER STRYK3] STRYKER ORTHOPEDICS HOWM],SUP-2379180,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
INSERT TIB ONLAY KNEE 30550130S] MAKO],SUP-2265749,CDM,C1776,CPT,0278,RC,,,,both,,,1515.74,985.23,,,,,,,,,,,,,
PLATE BNE L194MM 8 H L DST HUM EXTRA ARTC TI LOK COMPR LO,SUP-2180808,CDM,C1713,HCPCS,0278,RC,,,,both,,,4749.22,3086.99,,,,,,,,,,,,,
PROBE LASER 23 GA CRV ENDO OCU SMA906 W/ ALCO,SUP-2713795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.70,333.90,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE REG RT ANGLE W/ SIPHONGUARD HAKIM,SUP-2666511,CDM,C1889,HCPCS,0278,RC,,,,both,,,16468.70,10704.65,,,,,,,,,,,,,
MESH SURG W3.5XL6IN POLY SELF FIXATING RECT W/ RESRB PLA,SUP-2174793,CDM,C1781,HCPCS,0278,RC,,,,both,,,739.25,480.51,,,,,,,,,,,,,
VALVE HEMOSTAS GRDIAN POLYCARB GUIDEWIRE INSRTN TOOL STRL,SUP-2383195,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
KIT OPHTH 5ML PERFLUOROCARBON LIQ PROC PERFLUORON,SUP-2110015,CDM,C1784,HCPCS,0278,RC,,,,both,,,1862.65,1210.72,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HYBRID HD CERM,SUP-2212725,CDM,C1776,CPT,0278,RC,,,,both,,,13046.17,8480.01,,,,,,,,,,,,,
BIT DRL SHT 2.8 MM BLNT SHFT POLARUS 3 SURGIBIT,SUP-2518565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
CATHETER ANGIOPLASTY OTW 0.018 IN 130CM 5X150MM  018 DCB,SUP-2757489,CDM,C1725,HCPCS,0272,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
SCREW SET CANN 3.5 MM,SUP-2183052,CDM,C1713,HCPCS,0278,RC,,,,both,,,41626.10,27056.96,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ 8IN IMMOB LOOP LOK ABDUCTED,SUP-2276632,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.33,14.51,,,,,,,,,,,,,
KIT HEMO DYLS OR HD L50CM L33CM OD14.5FR ODSEC16FR,SUP-2174222,CDM,C1750,HCPCS,0278,RC,,,,both,,,1229.28,799.03,,,,,,,,,,,,,
PLATE BNE W24.4XL89.5MM STD L DST VOLAR RAD EXT ANAT FAST,SUP-2414030,CDM,C1713,HCPCS,0278,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
BURR SURG 2.1MM DIA HD 5MML HD CARBIDE TAPR FISS MICROPOWER,SUP-2605539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,114.20,74.23,,,,,,,,,,,,,
SHELL ACET CMNTLS 46 MM MULT HOLE STRL EMPHASYS LTX,SUP-2874345,CDM,C1776,CPT,0278,RC,,,,both,,,10708.66,6960.63,,,,,,,,,,,,,
NALOXONE HCL 4 MG/10ML IJ SOLN,RX-135455,CDM,J2312,HCPCS,0636,RC,00409-1219-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER DIAG 5FR 100CM LEN 5MM SPC 5MM TIP MAP EP ABLAT,SUP-2141289,CDM,C1730,HCPCS,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
"HC Dest Botox-1 Extrm,5 or > Musc",PX-7616464400,CDM,64644,CPT,0761,RC,,,,inpatient,,,2138.00,1389.70,,,,,,,,,,,,,
DEVICE FIX 5MM TI HELI 5 MESH ASSEMB DISP FOR HERN REP TCKR,SUP-2283316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.49,559.97,,,,,,,,,,,,,
KIT SURG SEAL 4ML W/ DEL HSNG APPL TIP DISP COSEAL,SUP-2130350,CDM,C2615,HCPCS,0278,RC,,,,both,,,2460.72,1599.47,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-JEJUNAL 22 FRX45 CM 7-10 CC FOR SURG,SUP-2764470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1080.69,702.45,,,,,,,,,,,,,
PUTTY BONE HEMSTAT ABSORB MTRX 2.0GRAM,SUP-2106298,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
HC Needle Bx Abd/Retroper Mass,PX-3614918000,CDM,49180,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
CEMENT PERM GLS IONOMER LUTING REFIL PK MAXICAP KETAC,SUP-2100207,CDM,C1713,HCPCS,0278,RC,,,,both,,,49.46,32.15,,,,,,,,,,,,,
PLATE BONE L127MM 15 H STRL S STL COMPR FOR 2.7MM SCR EVOS,SUP-2349625,CDM,C1713,HCPCS,0278,RC,,,,both,,,2537.15,1649.15,,,,,,,,,,,,,
GRAFT BONE SUB W10XH10XL10MM CUBE SHP DEMIN CANC FIL MTRX,SUP-2307019,CDM,C1713,HCPCS,0278,RC,,,,both,,,1635.00,1062.75,,,,,,,,,,,,,
PLATE BNE STR MINI 2X1 MM 5 HOLE COMPR FOR SCR TI LEVEL 1,SUP-2500999,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.55,550.91,,,,,,,,,,,,,
COIL EMB L40CM OD0.020IN LOOP OD10MM STD NIT COMPLX FRME,SUP-2323372,CDM,C1889,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
SEED BRACHYTHERAPY I-125 MICK DISP,SUP-2247284,CDM,C2638,HCPCS,0278,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
CATHETER NEPHROSTOMY X-FORCE N30 L 15 CM DIA 8 MM DULA LUMEN,SUP-2655876,CDM,C1729,HCPCS,0272,RC,,,,both,,,609.47,396.16,,,,,,,,,,,,,
PLATE BONE LOK HLX34 HDSHFT T SHPD OBLQUE 47494603405,SUP-2722672,CDM,C1713,HCPCS,0278,RC,,,,both,,,1144.91,744.19,,,,,,,,,,,,,
SCREW BNE LCK 2.5X5 MM TI MAXDRIVE 258850591,SUP-2460110,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.23,308.25,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC WRST LG LT,SUP-2246904,CDM,L3908,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
HC Inject Sacroiliac Joint,PX-3612709600,CDM,27096,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE SCREW DIA 3/3.5/4 MM LG TI ALLOY LT 1ST SEC,SUP-2907560,CDM,C1713,HCPCS,0278,RC,,,,both,,,6804.60,4422.99,,,,,,,,,,,,,
SET SCR SPNL L3.17MM DIA0.25IN S STL DEV ISOLA,SUP-2255702,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
DEVICE DEFCT CLOSURE PRELD SELF GRASPING FOR GI TRACT PDLOK,SUP-2913711,CDM,C1889,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
BIT DRL L50MM DIA19MM TWST J NOTCH ARNETT STYL INSRT W O,SUP-2262754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.78,280.01,,,,,,,,,,,,,
SET PRSS MON 3FR L8CM 0.018IN POLYETH SGL LUMN STR TIP NDL,SUP-2167821,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP,RX-70693,CDM,J1815,HCPCS,0637,RC,00002-7511-01,NDC,,both,10,ML,68.40,44.46,,,,,,,,,,,,,
CATHETER KIT HYSTEROSALPINGOGRAM 5 FR,SUP-2360916,CDM,C1894,HCPCS,0272,RC,,,,both,,,71.28,46.33,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY D OCTAPOLAR DEFLECTABLE REPROC,SUP-2535612,CDM,C1730,HCPCS,0272,RC,,,,both,,,347.88,226.12,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING BOLT INDIGO 7 L 130 CM ASPIR,SUP-2874863,CDM,C1757,HCPCS,0272,RC,,,,both,,,25182.80,16368.82,,,,,,,,,,,,,
WASHER ORTH STR FOR DARCO 7MM HDLSS COMPR SCR,SUP-2399606,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
DRILL SURG RESECT 3.5 MM TIB ARC TOT ANK REPL SYS SS APEX 3D,SUP-2742292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.71,411.26,,,,,,,,,,,,,
WEDGE ACET AUG 50 MM,SUP-2363288,CDM,C1713,HCPCS,0278,RC,,,,both,,,8845.38,5749.50,,,,,,,,,,,,,
BOLT ORTHOPEDIC FUSION 6.5X90 MM MIDFOOT SS NS,SUP-2184093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.81,969.68,,,,,,,,,,,,,
PLATE BONE L265MM 14 H S STL LCK COMPR FOR 4.5MM SCR,SUP-2348945,CDM,C1713,HCPCS,0278,RC,,,,both,,,7233.78,4701.96,,,,,,,,,,,,,
NUT SPNL DIA5/16IN S STL TAPR LCK VSP,SUP-2255575,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
STENT COR 23MM 2.25MM 0.014IN HYDRPHLC RX LO,SUP-2103677,CDM,C1876,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
FOOTRING EXT FIX SHT TENXOR CP49360128,SUP-2530922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6800.61,4420.40,,,,,,,,,,,,,
TRAY PICC 5FR L55CM SIL NRS SGL LUMN FULL PWR INJ N COAT CT,SUP-2126723,CDM,C1751,HCPCS,0278,RC,,,,both,,,790.65,513.92,,,,,,,,,,,,,
GRAFT ALLGRFT TEND TIBIALIS ANT FRZN AESEPTIC 920332] ZIMMER BIOMET INC],SUP-2137246,CDM,C1762,CPT,0278,RC,,,,both,,,5273.94,3428.06,,,,,,,,,,,,,
DRIVER SURG CANN PARTIALLY THRD T15 AO QC,SUP-2898130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
ROD SPNL L300MM DIA5.5MM THORLUM CO CHROM HEX END CREO,SUP-2420851,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Splint Appl Long Arm,PX-4502910500,CDM,29105,CPT,0450,RC,,,,both,,,867.00,563.55,,,,,,,,,,,,,
PLATE BNE THK 0.75 MM SCREW DIA1.7 MM 3 X 21 H PLL,SUP-2883171,CDM,C1713,HCPCS,0278,RC,,,,both,,,14565.52,9467.59,,,,,,,,,,,,,
CATHETER REPERFUSION L190CM WRK L155CM DIA0.022IN SEP FLX,SUP-2323626,CDM,C1757,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
HC Renal Function Panel,PX-3018006900,CDM,80069,CPT,0301,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
HC Repr Smp Not Face 2.6-7.5cm,PX-4501200200,CDM,12002,CPT,0450,RC,,,,inpatient,,,632.00,410.80,,,,,,,,,,,,,
BRACE KNEE ACL PLC MCL ICL SIZED TO FIT UNIV UNISX FASTEN ON,SUP-2150832,CDM,L1810,HCPCS,0274,RC,,,,both,,,1375.57,894.12,,,,,,,,,,,,,
SPHINCTEROTOME RAP EXCHG CANN WIRE STD 20MM 5MM,SUP-2149565,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.74,356.03,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED MOM CHIPBIOM2M] ZIMMER BIOMET INC],SUP-2137374,CDM,C1776,CPT,0278,RC,,,,both,,,20745.98,13484.89,,,,,,,,,,,,,
CLAMP SURG L9IN S STL MATTE FINISH ANG NONCRUSHING GLSMN,SUP-2162099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.76,294.29,,,,,,,,,,,,,
CANNULA SURG ID15MM SACROILIAC SPNL MINIMAL ACC RETRCT SYS,SUP-2232174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 INX150 CM 3 CM 6 FRX20 CM POLARIS,SUP-2470105,CDM,C1758,HCPCS,0278,RC,,,,both,,,681.82,443.18,,,,,,,,,,,,,
OPTIMIZER SMART MINI IPG 10-B501-2-XX,SUP-2854408,CDM,C1824,HCPCS,0278,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
KNIFE ARTHSCP 5MM HK SERR REUSE STR S STL STRL,SUP-2340708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
CATHETER INNR CPS AIM SL N022-59,SUP-2356607,CDM,C1887,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 5 MM 4.4 FRX20 MM TRUTOME 8310,SUP-2500225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,917.16,596.15,,,,,,,,,,,,,
ELECTRODE ES URLGY 4MM DIA BLACK FVPRZTN ELITE SSTM USA SRS,SUP-2722878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.66,348.83,,,,,,,,,,,,,
PLATE BNE W10XL57MM THK1.5MM 4X5 H BILAT S STL T SHP R ANG,SUP-2185871,CDM,C1713,HCPCS,0278,RC,,,,both,,,991.58,644.53,,,,,,,,,,,,,
PLATE BNE L247MM 8 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186044,CDM,C1713,HCPCS,0278,RC,,,,both,,,4462.13,2900.38,,,,,,,,,,,,,
MARKER FIDUCIAL 0.75 MMX1 CM 18 GA PRELD GLD VISICOIL,SUP-2430921,CDM,A4648,CPT,0278,RC,,,,both,,,381.51,247.98,,,,,,,,,,,,,
PLATE BNE LCK NAR 2.4X41 MM 6 HOLE VARIAX,SUP-2435315,CDM,C1713,HCPCS,0278,RC,,,,both,,,3755.75,2441.24,,,,,,,,,,,,,
STAPLER INT CARTRIDGE MED THCK 60 MM W/ TRI-STAPLE PUR GIA,SUP-2787694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.88,519.27,,,,,,,,,,,,,
HANDPIECE 430 SER AND SOLARA SER HIGH-SPEED LUBEFREE CERAMIC,SUP-2322265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1196.34,777.62,,,,,,,,,,,,,
GRAFT BNE 2.5 CC OSTEOSURGE 300,SUP-2641800,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
ADAPTER EXTRCTN CNNLTD CPHLMDLLRY ASIA NAT NAIL SSTM,SUP-2479183,CDM,C1713,HCPCS,0278,RC,,,,both,,,890.06,578.54,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS TEND 16-19.9X3 CM FRZN,SUP-2423852,CDM,C1762,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PLATE BNE L180MM BRL L15IN 130DEG PELVIS BILAT S STL STD 8,SUP-2342434,CDM,C1713,HCPCS,0278,RC,,,,both,,,4781.91,3108.24,,,,,,,,,,,,,
CATHETER HD SPRT PK 14.5 FRX23 CM SYMMETRICAL TIP PALINDROME,SUP-2754729,CDM,C1750,HCPCS,0278,RC,,,,both,,,1229.28,799.03,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 6 MM EPTFE GRAD REINF 3 LAYR,SUP-2474583,CDM,C1768,CPT,0278,RC,,,,both,,,3448.44,2241.49,,,,,,,,,,,,,
ANCHOR SUT TI WDG W TWO STRANDS OF FORCEFIBER AND NDL 5MM,SUP-2362551,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.04,532.38,,,,,,,,,,,,,
GRAFT DURA CLLGN MTRX 2X2 IN ABSORBABLE,SUP-2383006,CDM,C1763,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BIT DRL 3 MM LF,SUP-2608415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
LENS IOL ASPHERIC 17+ DIOPT ANTR CHMBR MONO FOC 1 PC,SUP-2112424,CDM,V2632,HCPCS,0276,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
IMPLANT HUM TISS L 30-80 X W 25-50 MM PA PTCH TRUNK THCK,SUP-2932767,CDM,C1762,CPT,0278,RC,,,,both,,,21457.10,13947.11,,,,,,,,,,,,,
PLATE BNE LEFORT 2X7 MM RT LINDORF TI,SUP-2466454,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.68,563.99,,,,,,,,,,,,,
PLATE BNE NAR 4.5X167 MM 10 HOLE SS DCP,SUP-2569168,CDM,C1713,HCPCS,0278,RC,,,,both,,,324.68,211.04,,,,,,,,,,,,,
SCREW BNE L12MM OD2MM THRD L6MM TI BRK OFF MONSTER BITE,SUP-2320991,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.02,550.56,,,,,,,,,,,,,
GRAFT ALLGRFT TEND TIBIALIS ANTR FRZN,SUP-2165551,CDM,C1713,HCPCS,0278,RC,,,,both,,,5014.58,3259.48,,,,,,,,,,,,,
GRAFT VASC L15CM BOR 24MM MAX SKRT L24MM DIA32MM PROX CLLR,SUP-2384984,CDM,C1768,CPT,0278,RC,,,,both,,,8917.60,5796.44,,,,,,,,,,,,,
PLATE BNE SM W11XL72MM THK34MM 5 H BILAT TI RIG NEUT LOK,SUP-2190777,CDM,C1713,HCPCS,0278,RC,,,,both,,,865.76,562.74,,,,,,,,,,,,,
PARTICLE EMB BNDL S220PRO MIV-20500 SWIFTNINJA EMBOSPHEREPRO,SUP-2798603,CDM,C1889,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
TISSUE HUM IMPL W5XL5CM AMNIO MEMBRN ALLGRFT BIOVANCE,SUP-2113888,CDM,Q4154,HCPCS,0636,RC,,,,both,,,8901.90,5786.23,,,,,,,,,,,,,
SUPPORT KNEE HALF RND,SUP-2324295,CDM,L1810,HCPCS,0274,RC,,,,both,,,113.20,73.58,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 1 MM 6 HOLE TITANIUM MATRIXMANDIBLE,SUP-2842350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1510.03,981.52,,,,,,,,,,,,,
PLATE BNE 12 H TI STR FOR 1.3MM SCR,SUP-2190688,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.78,731.11,,,,,,,,,,,,,
STENT URET ENDOPYLTMY 14/7 FRX22 CM HYDROPLUS COAT RETROMX +,SUP-2141648,CDM,C2617,HCPCS,0278,RC,,,,both,,,622.88,404.87,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 20GA 8CM WNG 1 LUMAN F120081T,SUP-2632733,CDM,C1751,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
HC Dexa Appendicular Skeleton,PX-3207708100,CDM,77081,CPT,0320,RC,,,,inpatient,,,649.00,421.85,,,,,,,,,,,,,
SET URET STENT MARD L 22 CM DIA 6 FR PERCFLX HYDROPLUS TEMP,SUP-2141627,CDM,C1876,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
FOOTSWITCH ELECSURG 10 MM FOR LAP,SUP-2225600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
VALVE SHUNT SINGLE OPENING PRESSURE 20CM H2O WITH PREATTACHE,SUP-2821787,CDM,C1889,HCPCS,0278,RC,,,,both,,,4472.74,2907.28,,,,,,,,,,,,,
TUBING SET VERSICON FOR JOIMAX SPINE PUMP,SUP-2848823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SCREW DISTRCTN QUICK START 14 MM PRE-PACKAGED STRL TSI DISP,SUP-2732066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1953.77,1269.95,,,,,,,,,,,,,
ALLOGRAFT AXIS 6CM X 8CM TUTOPLAST PROCESSED DERMIS,SUP-2165390,CDM,C1762,CPT,0278,RC,,,,both,,,6985.87,4540.82,,,,,,,,,,,,,
PLATE BNE ADV 7 MM LT CRANIOMAXILLOFACIAL LEFORT I,SUP-2883263,CDM,C1713,HCPCS,0278,RC,,,,both,,,1912.35,1243.03,,,,,,,,,,,,,
GUIDEWIRE URO L145CM DIA0038IN PTFE S STL SGL END FIX COR J,SUP-2126213,CDM,C1769,HCPCS,0272,RC,,,,both,,,55.33,35.96,,,,,,,,,,,,,
PLATE BONE THK2.6MM 7 H MAND TI CVD FOR 2/2.3MM SCR SYS,SUP-2137629,CDM,C1713,HCPCS,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X118 MM LT LAT DSTL 6 HOLE STRL VALCP,SUP-2789397,CDM,C1713,HCPCS,0278,RC,,,,both,,,3110.48,2021.81,,,,,,,,,,,,,
GUIDEWIRE ORTH PARL 2.8 MM,SUP-2657789,CDM,C1769,HCPCS,0272,RC,,,,both,,,3118.02,2026.71,,,,,,,,,,,,,
PLATE BNE L90MM 5 H L DST POSTEROLATERAL HUM S STL LOK,SUP-2185894,CDM,C1713,HCPCS,0278,RC,,,,both,,,2555.93,1661.35,,,,,,,,,,,,,
PLATE CRAN 120X40X40 MM PT SPEC IMPL PEEK,SUP-2860125,CDM,C1713,HCPCS,0278,RC,,,,both,,,28804.79,18723.11,,,,,,,,,,,,,
PLATE BNE L 114 MM SCREW DIA2.7/3.5 MM 8 H SS RT OLECRANON,SUP-2931273,CDM,C1713,HCPCS,0278,RC,,,,both,,,5801.46,3770.95,,,,,,,,,,,,,
CATHETER INFUSION 4 FRX90 CM 40 CM OCCL WIRE FOUNTAIN,SUP-2302768,CDM,C1751,HCPCS,0278,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
PLATE BNE 14 H NONSTERILE STRNL TI DBL T SHP LOK FOR 3MM,SUP-2192442,CDM,C1713,HCPCS,0278,RC,,,,both,,,3050.20,1982.63,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 6.25X2X0.8 CM 20 CC CRBNT APATITE VENADO,SUP-2718022,CDM,C1713,HCPCS,0278,RC,,,,both,,,4842.32,3147.51,,,,,,,,,,,,,
STRIPS ILIUM TRICORT TRAD ALLGRFT 22X45 MM FRZ DRY,SUP-2294071,CDM,C1713,HCPCS,0278,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
BIT DRILL 2.4MM DIAMETER FOR ULTRA FIX MINIMITE ANCHOR,SUP-2824090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
HC Skull Complete Min 4 Views,PX-3207026000,CDM,70260,CPT,0320,RC,,,,both,,,996.00,647.40,,,,,,,,,,,,,
HC So Thiocyanate,PX-3018443066,CDM,84430,CPT,0301,RC,,,,both,,,417.00,271.05,,,,,,,,,,,,,
MICROCATHETER GUID MAMBA L 135 CM CROSSING PROF 2.4 FR PROX,SUP-2715873,CDM,C1887,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 16 MM DIA 6 MM CATH L 120 CM,SUP-2884912,CDM,C1874,HCPCS,0278,RC,,,,both,,,7586.81,4931.43,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM CORT RAP RESRB FOR 1.5MM PLT RECON,SUP-2194051,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
STERI-TAMP SEALS BOTTLES/VIALS MISC,RX-38012,CDM,2500000003,HCPCS,0250,RC,63323-0111-02,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PLATE SPNL L39MM SACR TI 1 LEV,SUP-2180806,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
HC Perq Trluml C Athrc Angiop 1 Maj C Art&/Branches,PX-4819292400,CDM,92924,CPT,0481,RC,,,,both,,,16980.00,11037.00,,,,,,,,,,,,,
COMPONENT FEM MOD BX 55 MM LT KNEE VANGUARD 360,SUP-2444786,CDM,C1776,CPT,0278,RC,,,,both,,,1540.17,1001.11,,,,,,,,,,,,,
CATHETER BAL DIL L17MM DIA7MM 70DEG ELECTROMAGNETIC FRONTAL,SUP-2284117,CDM,C1713,HCPCS,0278,RC,,,,both,,,3389.00,2202.85,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST W/O JT MULT AXIS PLAS,SUP-2435639,CDM,L2308,HCPCS,0274,RC,,,,both,,,5155.88,3351.32,,,,,,,,,,,,,
STAPLER INT 5MM POLY COPOLYMER TACK FIX DEV PNT AND SHOOT,SUP-2283222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.56,608.11,,,,,,,,,,,,,
IMPL CAP END NAIL 12MM 10,SUP-2704173,CDM,C1889,HCPCS,0278,RC,,,,both,,,611.83,397.69,,,,,,,,,,,,,
HC So2 Thrombin Time Plasma,PX-3058567068,CDM,85670,CPT,0305,RC,,,,both,,,8.00,5.20,,,,,,,,,,,,,
DEVICE FIX SGL SUT CVD INTRO FOR MENIS REP SYS FAST-FIX,SUP-2341342,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.34,255.02,,,,,,,,,,,,,
SEED IODINE LOOSE IN VIAL K,SUP-2129116,CDM,C2639,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
PLATE SPNL 37 MM ANTR LUMBAR 4 HOLE PYRAMID +4,SUP-2631825,CDM,C1713,HCPCS,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
CATHETER THORACENTESIS STR 20 FRX20 IN THROMBO RESIST ARGY,SUP-2428068,CDM,C1729,HCPCS,0272,RC,,,,both,,,55.26,35.92,,,,,,,,,,,,,
SET CATH HEMODIALYSI ARW CANNON II PLU CHRONIC 15FR DIA 24CM,SUP-2613330,CDM,C1750,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
INTRODUCER TUBE SET 7.5/8.5/9 MM MULTI PERC W/O PHAR 8.5 MM,SUP-2759717,CDM,C1769,HCPCS,0272,RC,,,,both,,,1561.37,1014.89,,,,,,,,,,,,,
FIBER LASER SINGLE W/ WALL PLATE,SUP-2798103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1041.98,677.29,,,,,,,,,,,,,
BUR SURG L78MM DIA3MM XLN FN DMND RND,SUP-2284192,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.79,319.66,,,,,,,,,,,,,
PLATE BONE L142MM THK3.7MM 6 H RT DSTL MEDL TIB TI LCK COMPR,SUP-2190881,CDM,C1713,HCPCS,0278,RC,,,,both,,,4519.81,2937.88,,,,,,,,,,,,,
SCREW SPNL OCT 6 MM POST ASCNT,SUP-2589729,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT MAGNA SZ 19 SEW RNG DIA24 MM PROF,SUP-2214088,CDM,C1889,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
TRAY DRAINAGE CATH DIA15.5 FR NDL DIA25 GA SIL CUF POLYESTER,SUP-2881432,CDM,C1729,HCPCS,0272,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
GROMMET VENT ID1.14MM INNR FLNG OD2.4MM INTERFLNG DISTANCE,SUP-2284033,CDM,L8699,HCPCS,0278,RC,,,,both,,,126.95,82.52,,,,,,,,,,,,,
LEVEL CMF PLATE MDFCE Y SHP WTAB 1.5 MM SCRW7 HOLE T0.4 MM,SUP-2707484,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
STENT PERIPH ABS PRO L 100 MM DIA 5 MM CATH L 80 CM DIA 8 FR,SUP-2104773,CDM,C1876,HCPCS,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
HEAD HUM DIA45MM THK15MM SHLDR CO CHROM PRI STD OFFSET NK 53504515] STRYKER ORTHOPEDICS HOWM],SUP-2372836,CDM,C1776,CPT,0278,RC,,,,both,,,4645.94,3019.86,,,,,,,,,,,,,
SET ORTH IMPL 3.5MM MEDL PROX TIB S STL PLT LCP,SUP-2177071,CDM,C1713,HCPCS,0278,RC,,,,both,,,111033.29,72171.64,,,,,,,,,,,,,
TAMP BNE SZ 3 BLLN L20MM INFL FRAC REDUC SYS KYPHON XPANDER,SUP-2281106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,J7060,HCPCS,0250,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
HEPARIN (PORCINE) IN D5W 100-5 UNIT/ML-% IV SOLN RATE BASED DOSING,RX-104329,CDM,J1644,HCPCS,0636,RC,00264-9587-20,NDC,,both,250,ML,90.60,58.89,,,,,,,,,,,,,
RIVAROXABAN 2.5 MG PO TABS,RX-143788,CDM,6370000000,HCPCS,0637,RC,50458-0577-10,NDC,,both,1,UN,44.90,29.18,,,,,,,,,,,,,
TIP ULTRASONIC EXT MACR CVD CUSA 23KHZ,SUP-2243957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
PLATE BNE SM L93MM 3X6X2 H POST TIBIOTALOCALCANEAL ANK TI,SUP-2398511,CDM,C1713,HCPCS,0278,RC,,,,both,,,6794.96,4416.72,,,,,,,,,,,,,
ROD 3600100 OC ADJUSTABLE TI 35 X 100,SUP-2285375,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
SAW SURG JOS 19 CM RT NSL BAYNT SS,SUP-2465021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.82,276.78,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 45X15MM,SUP-2466732,CDM,C1713,HCPCS,0278,RC,,,,both,,,6402.46,4161.60,,,,,,,,,,,,,
BLADE SAW OSCILLATING 9.5MMW X18.5MML FLUORIDEFSTRYKER MICRO,SUP-2605446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63.62,41.35,,,,,,,,,,,,,
GUIDEWIRE VASC NEOMAGIC L 60 CM DIA 0.010 IN HYDRPHLC REPOS,SUP-2874179,CDM,C1769,HCPCS,0272,RC,,,,both,,,119.95,77.97,,,,,,,,,,,,,
CATHETER PICC 5FR L20CM MIDLN W/ STYL INTMED TY PER-Q-CATH,SUP-2125575,CDM,C1894,HCPCS,0272,RC,,,,both,,,198.13,128.78,,,,,,,,,,,,,
PLATE BONE W30XL30MM THK0.5MM CRAN ORBIT FLR RAP RESRB W/,SUP-2194081,CDM,C1713,HCPCS,0278,RC,,,,both,,,3004.67,1953.04,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 X W 5 CM PLCNTA MTRX MEMBRN MINIMALLY,SUP-2905497,CDM,C1762,CPT,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SEMITENDINOSUS TEND FRZN NO-RAD,SUP-2321842,CDM,C1762,CPT,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 11CM 4FR 40 CM NDL 4 CM SS WIRE,SUP-2491270,CDM,C1894,HCPCS,0272,RC,,,,both,,,126.60,82.29,,,,,,,,,,,,,
HC So Factor VIII,PX-3058524066,CDM,85240,CPT,0305,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
SCREW SPNL L25MM DIA4.2MM CANC POST PEDCL THORLUM TI SIDE,SUP-2193512,CDM,C1713,HCPCS,0278,RC,,,,both,,,2209.93,1436.45,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR NAR M-L BRIM,SUP-2435675,CDM,L2525,HCPCS,0272,RC,,,,both,,,3226.92,2097.50,,,,,,,,,,,,,
GRAFT BNE SUB 3ML CA PHSPTE FAST SET PTTY DRILLABLE NORIAN,SUP-2420786,CDM,C1713,HCPCS,0278,RC,,,,both,,,2252.51,1464.13,,,,,,,,,,,,,
GRAFT BNE 5 CC OSTEOCURRENT,SUP-2644333,CDM,C1713,HCPCS,0278,RC,,,,both,,,6876.60,4469.79,,,,,,,,,,,,,
INTRODUCER SHTH 4FR L10CM DIL L2.5CM RADPQ MRK KINK RESIST,SUP-2385177,CDM,C1894,HCPCS,0272,RC,,,,both,,,45.53,29.59,,,,,,,,,,,,,
X FUSE IMPLANT STANDARD 0 DEGREE,SUP-2704846,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7030,HCPCS,0258,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
INVOTEC TYMPANOSTOMY TUBE SHEEHY GROMMET ID 1.27MM FLPL,SUP-2930250,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.20,18.98,,,,,,,,,,,,,
IMPLANT MAXILLOFACIAL 79X32X10X4X10X5MM RT ES ANG,SUP-2328481,CDM,L8610,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PLATE BNE W10XL94MM THK3.6MM 8 H BILAT S STL CRV RIG CLLR,SUP-2186254,CDM,C1713,HCPCS,0278,RC,,,,both,,,2169.65,1410.27,,,,,,,,,,,,,
COLLAR CERV L H4.25IN FOR 16-19IN PLASTAZOTE FOAM 2 PC L,SUP-2336006,CDM,L0140,HCPCS,0272,RC,,,,both,,,30.87,20.07,,,,,,,,,,,,,
STAPLE SPNL ANTR ANTR SYS S STL COLORADO 2,SUP-2290569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1661.06,1079.69,,,,,,,,,,,,,
SCREW BNE MAXILLOFACIAL CORT CENTRE-DRIVE 2.3 25085091] KLS MARTIN LP],SUP-2262627,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
HC So Glucose CSF,PX-3018294568,CDM,82945,CPT,0301,RC,,,,both,,,33.00,21.45,,,,,,,,,,,,,
SPONGE 5.5MMX7.5MMX80MM OVL SIL,SUP-2213491,CDM,L8610,HCPCS,0278,RC,,,,both,,,223.57,145.32,,,,,,,,,,,,,
PIN IMPL POS N THRD NS BB-TAK,SUP-2930402,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.25,182.16,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 8 FR VLV PLAS X-PORT ISP,SUP-2126610,CDM,C1788,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
INSTRUMENT KIT ORTHOPEDIC KNEE NAVITRACK,SUP-2422962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
BRACE WR CLUTCH DORS STAY VELSTRETCH WRP LT CIRC 6 1/2-8,SUP-2323979,CDM,L3931,HCPCS,0274,RC,,,,both,,,50.84,33.05,,,,,,,,,,,,,
SPACER SPNL W10XH8XL25MM 4DEG PEEK POST LUM INTBDY FUS LORD,SUP-2380591,CDM,C1821,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SCREW BNE MAXILLOMANDIBULAR 2X16 MM 12 MM X DRV DRILL-FREE,SUP-2457030,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.40,203.06,,,,,,,,,,,,,
DRAWER TAG 70 MM IMPLANTS 60X28X4MM,SUP-2696076,CDM,C1713,HCPCS,0278,RC,,,,both,,,93.20,60.58,,,,,,,,,,,,,
GRAFT AMNIOTIC MEMBRANE FLOWERAMNIOPATCH 12MM DISC SIZE,SUP-2866791,CDM,Q4178,HCPCS,0636,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PACK ORTHOPEDIC STRL DARTFIRE EDGE,SUP-2900821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LIFT ELEVATION INSIDE SHOE UP TO 1 HALF,SUP-2435718,CDM,L3332,HCPCS,0274,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
KIT SHTH CONVOY 55 DEG L 79.4 CM DIA 8.5 FR SFT TIP ADV DEL,SUP-2141300,CDM,C1894,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
ROD DISTRACTOR MAXILLOFCL SHRT ACTIVATION FLX NS,SUP-2883555,CDM,C1713,HCPCS,0278,RC,,,,both,,,2415.16,1569.85,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 12 MM BLB DIA2 MM SIL RUBBER CORONARY,SUP-2130327,CDM,C1760,HCPCS,0278,RC,,,,both,,,236.54,153.75,,,,,,,,,,,,,
PERI LOC 4.5 FEM MID SHAFT LOCK PL 14 H,SUP-2819766,CDM,C1713,HCPCS,0278,RC,,,,both,,,9396.29,6107.59,,,,,,,,,,,,,
BUR SURG DIA35MM DMND RND NONFLUTED SABER SHANK ELITE TPS,SUP-2367571,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.17,295.21,,,,,,,,,,,,,
HC Lipid Panel,PX-3018006100,CDM,80061,CPT,0301,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
GRAFT BONE OSTEOARTICULAR STRUCTURAL CUF L SEG RECON TISS,SUP-2307435,CDM,C1762,CPT,0278,RC,,,,both,,,16908.90,10990.78,,,,,,,,,,,,,
INSERT TIB PROX KNEE IMP MOST OPTIONS,SUP-2208304,CDM,C1776,CPT,0278,RC,,,,both,,,29136.06,18938.44,,,,,,,,,,,,,
COMPONENT TIB BASE CEM LT/RT 63MM MEDL LAT FINN - L/R 63MM,SUP-2406092,CDM,C1776,CPT,0278,RC,,,,both,,,8556.50,5561.72,,,,,,,,,,,,,
INTRODUCER SHTH L11CM OD5FR DIL L17CM 0.038IN GRY SIL,SUP-2294510,CDM,C1894,HCPCS,0272,RC,,,,both,,,91.19,59.27,,,,,,,,,,,,,
PROCESSOR HEARING AID BLK KT SND LT INCL ABUTMENT CVR BTTRY,SUP-2164945,CDM,L8614,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RETRO CHRONIC STD 16FR DIA 32CM 27CML I,SUP-2613316,CDM,C1750,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
CONE XSMALL/SMALL 37X30X28.5 MM KNEE 2 ZONE TI TRABECULINK,SUP-2636330,CDM,C1776,CPT,0278,RC,,,,both,,,16437.37,10684.29,,,,,,,,,,,,,
NEEDLE SPNL TUOHY 14 GAX15.2 CM STRL,SUP-2851434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.69,226.00,,,,,,,,,,,,,
CATHETER DIAG L150CM OD2.9X2.7FR ID0.027IN DST L18CM,SUP-2368150,CDM,C1887,HCPCS,0272,RC,,,,both,,,3163.24,2056.11,,,,,,,,,,,,,
SPLINT WRST COCK UP UNIV R,SUP-2205498,CDM,L3931,HCPCS,0272,RC,,,,both,,,57.15,37.15,,,,,,,,,,,,,
HC Chem Cautery Granulatn Tissue|UNUSUAL NON-OVERLAPPING SERVICE,PX-4501725000,CDM,17250,CPT,0450,RC,,,XU,both,,,280.00,182.00,,,,,,,,,,,,,
SPACER SPNL W10XH7XL27MM 6DEG TRANSFORAMINAL INTBDY FUS TI,SUP-2415043,CDM,C1821,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
GUIDEWIRE UROLOGY STR 0.035 INX150 CM STANDARD-BODY BIWIRE,SUP-2836010,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.95,100.07,,,,,,,,,,,,,
PLATE BNE FEM 120 DEG 180 MM ARCHED MR SAFE NS,SUP-2863458,CDM,C1713,HCPCS,0278,RC,,,,both,,,2937.72,1909.52,,,,,,,,,,,,,
IMPLANT BIO TISS SZ 4 X 5 CM NOM THK 0.15-0.25 MM BOV,SUP-2894046,CDM,C1768,CPT,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
PLATE BNE SM 8 H NONSTERILE MANUBRIUM STRNL TI H SHP RIG,SUP-2192435,CDM,C1713,HCPCS,0278,RC,,,,both,,,2998.07,1948.75,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM CORT TI ST NONCANNULATED FULL THRD,SUP-2189648,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.41,221.27,,,,,,,,,,,,,
SPLINT RNG PIP FLX EXTN FNGR 3/4IN SM,SUP-2324608,CDM,L3808,HCPCS,0272,RC,,,,both,,,45.81,29.78,,,,,,,,,,,,,
HEAD HUM H12MM OD40MM THK12MM CONCENTRIC TOT SHLDR SOLAR,SUP-2378990,CDM,C1776,CPT,0278,RC,,,,both,,,6048.90,3931.78,,,,,,,,,,,,,
FIXATOR EXT W224MM HORZ ARTICULATED DBL SIDE MINIRAIL,SUP-2316471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9853.76,6404.94,,,,,,,,,,,,,
PLATE BONE THK1.5MM TI MAND 11 H PRI STR,SUP-2363731,CDM,C1713,HCPCS,0278,RC,,,,both,,,1889.59,1228.23,,,,,,,,,,,,,
GRAFT HUM TISS DIA19MM THK15MM MT RESTORING DISC,SUP-2321677,CDM,C1776,CPT,0278,RC,,,,both,,,8352.40,5429.06,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED STD ANAT,SUP-2267727,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PLATE BNE 1 H PELV ACET POST RIM BROAD STRL PRO,SUP-2902162,CDM,C1713,HCPCS,0278,RC,,,,both,,,2441.98,1587.29,,,,,,,,,,,,,
CLIP ANEUR W8XL7.5MM CO CHROM ALLOY FEN L TYP L SHP M BLDE,SUP-2306022,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
KIT BNE GRFT HARVESTING SZ 10 MM PER PASS 1.7 CC TREPHINE,SUP-2913165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3739.74,2430.83,,,,,,,,,,,,,
PROBE SURG PEDIATRIC DSTL RAD,SUP-2535371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
CABLE ORTH 2X600 MM ASMBLY FLIP ANCHR STRL,SUP-2563689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1379.34,896.57,,,,,,,,,,,,,
BIT DRL DIA2.2MM CROSSLOCK MOD TY DVR ANAT VOLAR PLATING,SUP-2412639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,248.41,161.47,,,,,,,,,,,,,
SUPPORT FACE L FOR 27IN EAR CHEEK CHIN E FOR FACIOPLASTY,SUP-2151622,CDM,L0150,HCPCS,0272,RC,,,,both,,,61.80,40.17,,,,,,,,,,,,,
WIRE FIX TROCAR TIP 1.6 MM A.L.P.S KIRSCHNER,SUP-2461813,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 40CM 3,SUP-2613281,CDM,C1750,HCPCS,0278,RC,,,,both,,,7418.25,4821.86,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 10 CM DIA 7 MM EPTFE CARBON STR STD,SUP-2128668,CDM,L8670,HCPCS,0278,RC,,,,both,,,1124.37,730.84,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO FLO ACTE 11.5FR DIA 20C MCDLT118IJ,SUP-2633019,CDM,C1750,HCPCS,0278,RC,,,,both,,,271.92,176.75,,,,,,,,,,,,,
TORSEMIDE 100 MG PO TABS,RX-18294,CDM,6370000000,HCPCS,0637,RC,50111-0918-01,NDC,,both,1,UN,8.80,5.72,,,,,,,,,,,,,
STEM FEM L120MM OD10MM KNEE STR UNCEMENTED SPLINED VANGUARD,SUP-2405461,CDM,C1776,CPT,0278,RC,,,,both,,,3661.24,2379.81,,,,,,,,,,,,,
DEVICE PESSARY RNG W/ SUPP FLD 3IN SZ 5,SUP-2171738,CDM,A4562,HCPCS,0274,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
PLATE BONE MINI L29MM 4 H STR ECT,SUP-2198560,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.49,78.97,,,,,,,,,,,,,
INFINITY ADAPTIS TIB SZ4LNG INFINITY ADAPTIS,SUP-2822271,CDM,C1776,CPT,0278,RC,,,,both,,,14823.94,9635.56,,,,,,,,,,,,,
CLINIMIX E/DEXTROSE (5/20) 5 % IV SOLN,RX-23214,CDM,2500000003,HCPCS,0250,RC,00338-1125-04,NDC,,both,2000,ML,506.00,328.90,,,,,,,,,,,,,
STENT URET OPN END 7 FRX28 CM KID CURL TAPR SIL MULTI-FLEX,SUP-2313771,CDM,C2617,HCPCS,0278,RC,,,,both,,,388.10,252.26,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 8X8X8 MM SPNG FD CANC,SUP-2717778,CDM,C1713,HCPCS,0278,RC,,,,both,,,1442.26,937.47,,,,,,,,,,,,,
PLATE BNE ST 2.4/2.7X90 MM VA LCK COMPR TI VA-LCP,SUP-2758286,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.74,129.83,,,,,,,,,,,,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD,RX-12556,CDM,340b,HCPCS,0637,RC,58657-0528-16,NDC,,both,2.5,ML,0.60,0.39,,,,,,,,,,,,,
SPACER SPNL ANGLED 4 DEG 23X14X10 MM SLT RECTANGULAR PARL,SUP-2416074,CDM,C1889,HCPCS,0278,RC,,,,both,,,11037.10,7174.11,,,,,,,,,,,,,
COMPONENT FEM CR 3 UNISX LT KNEE NP PRIMARY STEMLESS CEM,SUP-2377956,CDM,C1776,CPT,0278,RC,,,,both,,,6053.29,3934.64,,,,,,,,,,,,,
GRAFT BNE SUB W11XH7XL14MM CORT INTBDY FUS FRZ DRY BLK SPCR,SUP-2293779,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
PLATE BNE L 1.5X0.6 MM 10 MM MIDFACE 3X3 HOLE W/ TAB TI NS,SUP-2497480,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.28,569.58,,,,,,,,,,,,,
HC So1 Creatine Kinase (CK) Mb,PX-3018255367,CDM,82553,CPT,0301,RC,,,,both,,,41.00,26.65,,,,,,,,,,,,,
CATHETER PERI DLYS L13.5CM PRESTRNL POLYUR PRECRV SHFT KT,SUP-2283917,CDM,C1750,HCPCS,0278,RC,,,,both,,,1629.60,1059.24,,,,,,,,,,,,,
COMPONENT FNGR JT SZ 40 PROX MP PYROCARBON SIL SPCR,SUP-2244240,CDM,C1776,CPT,0278,RC,,,,both,,,7023.27,4565.13,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA4MM THRD L30MM S STL HA SELF DRL MR,SUP-2186978,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.42,507.92,,,,,,,,,,,,,
SCREW BNE L50MM DIA6.5MM THRD L16MM CALCNL TI CANN HD COMPR,SUP-2398985,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
CONNECTOR SPNL L SZ 10 L51-59MM STD POST LUM THOR TI SCR,SUP-2254365,CDM,C1713,HCPCS,0278,RC,,,,both,,,4223.30,2745.14,,,,,,,,,,,,,
CATHETER INFUSION ANGLED 3 FRX150 CM 20 CM RENEGADE HIFLO,SUP-2147584,CDM,C1887,HCPCS,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 2.5X220 MM GLEN AEQUALIS PERFORM,SUP-2390579,CDM,C1769,HCPCS,0272,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
FOSCARNET SODIUM 6000 MG/250ML IV SOLN,RX-133082,CDM,J1455,HCPCS,0636,RC,00143-9192-01,NDC,,both,250,ML,1255.30,815.94,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1.7-10 MM 15 CC FD CANC,SUP-2743407,CDM,C1713,HCPCS,0278,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
LENS INTRAOCULAR 24.0 DIOPT POST CHMBR BCNVX 1 PC ULTRA,SUP-2885208,CDM,V2632,HCPCS,0276,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,0636,RC,44567-0236-10,NDC,,both,1,UN,57.50,37.37,,,,,,,,,,,,,
PROCESSOR HEARING AID MOCCA BRN LT EAR SND PROC CHAN WIND,SUP-2319860,CDM,L8690,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
PLATE BNE L118MM 6 H ST L DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177724,CDM,C1713,HCPCS,0278,RC,,,,both,,,2788.38,1812.45,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA 34 MM SIDE BRANCH L 15 CM,SUP-2894590,CDM,C1768,CPT,0278,RC,,,,both,,,7319.34,4757.57,,,,,,,,,,,,,
PACK VITRCTMY 25GA 5000CPM STR ENDOILLUMINATOR W/ VLV CANN,SUP-2109966,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
MESH CRAN W90XL90MM PROF H0.3MM MIC MID FACE,SUP-2366217,CDM,C1713,HCPCS,0278,RC,,,,both,,,4579.69,2976.80,,,,,,,,,,,,,
HC Debrid Wound Tis 20 Cm/<,PX-7619759700,CDM,97597,CPT,0761,RC,,,,both,,,583.00,378.95,,,,,,,,,,,,,
BREXUCABTAGENE AUTOLEUCEL 200000000 CELLS IV SUSP,RX-151536,CDM,Q2053,HCPCS,0891,RC,71287-0219-01,NDC,,both,1,UN,3234000.00,2102100.00,,,,,,,,,,,,,
SCREW SPNL L30MM OD5.5MM TI CORT PEDCL NONCANNULATED TOP LD,SUP-2288109,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
CLAMP EXT FIX L 75 MM MLTI PIN UNILAT NS DISP MAV,SUP-2931159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
ROD EXT FIX BIPHASE SYS,SUP-2136046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY REFLEXION SPRL L 99 CM 7FR 1-4-1,SUP-2496760,CDM,C1730,HCPCS,0272,RC,,,,both,,,746.91,485.49,,,,,,,,,,,,,
COMPONENT FEM DIA18MM CANN FUS NAIL NONLOCKING WICH,SUP-2377548,CDM,C1776,CPT,0278,RC,,,,both,,,11532.44,7496.09,,,,,,,,,,,,,
SCREW BONE L28MM OD4MM SELF DRL CANN LNG THRD MAXTORQUE,SUP-2315917,CDM,C1713,HCPCS,0278,RC,,,,both,,,708.86,460.76,,,,,,,,,,,,,
STENT URET STR 0.038 IN 3 CM 7 FRX20 CM 6 FR POLARIS ULTRA,SUP-2478060,CDM,C2617,HCPCS,0278,RC,,,,both,,,427.64,277.97,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 170 MM DIA 5 MM CATH L 80 CM DIA 5,SUP-2541393,CDM,C1876,HCPCS,0278,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
ALLOGRAFT BNE HD FD HUM,SUP-2321813,CDM,C1713,HCPCS,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
TUBE TRACH L112MM OD12X11MM CLR THOR CANN AIRWY SIL 2 PLUG,SUP-2138750,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
WIRE EXT FIX L360MM DIA2MM OLV,SUP-2197298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC So Iadna Sars-Cov-2-19 Amp Probe Tq,PX-3068763566,CDM,87635,CPT,0306,RC,,,,both,,,176.00,114.40,,,,,,,,,,,,,
PLATE BNE 0.8 MM HND OFFSET STRL,SUP-2518382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CC DEMINERALIZED BNE MTRX FIBER ALLOFIBER,SUP-2759528,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.50,892.77,,,,,,,,,,,,,
STEM FEM SZ 0 TI PREMIER NATURAL-HIP,SUP-2210717,CDM,C1776,CPT,0278,RC,,,,both,,,13941.60,9062.04,,,,,,,,,,,,,
ROD SPNL STR 5.5X25 MM TI NS CD HORZ MODULEX,SUP-2854493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
DRSG BIO PRCN MTRX RS STRL DISP REINF STW MATRISTEM 15X10CM,SUP-2106517,CDM,Q4166,HCPCS,0636,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
SCREW CONN 4MM W COCHLEAR PREMOUNTED PONTO,SUP-2319890,CDM,C1713,HCPCS,0278,RC,,,,both,,,5228.10,3398.26,,,,,,,,,,,,,
SLING GYN POLYPR MFIL WRP KNIT MESH T FOR GENUINE STRESS,SUP-2152275,CDM,C1771,HCPCS,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
CATHETER HD 14.5 FRX28 CM TUNN PLAS VAXCEL,SUP-2308265,CDM,C1881,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
AUGMENT FLNG ANTR FEM 3CM RESURF TI FINN,SUP-2406083,CDM,C1776,CPT,0278,RC,,,,both,,,2270.22,1475.64,,,,,,,,,,,,,
HC Allergen Spec Ige Crude Allergen Extract Each,PX-3058600300,CDM,86003,CPT,0305,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST FULL CORSET,SUP-2435565,CDM,L0976,HCPCS,0272,RC,,,,both,,,423.30,275.14,,,,,,,,,,,,,
HC Sel Cath Plcmt 2nd Order Brach|RIGHT SIDE,PX-3613621600,CDM,36216,CPT,0361,RC,,,RT,both,,,6875.00,4468.75,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 7 MM THK 0.49 MM POLYESTER,SUP-2459343,CDM,C1768,CPT,0278,RC,,,,both,,,1785.12,1160.33,,,,,,,,,,,,,
AGENT HEMSTAT SURG 2 VITAGEL RT,SUP-2361944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BONE LT KNEE TI L SHP FOR HI OSTEOTMY SYS N-K,SUP-2210171,CDM,C1713,HCPCS,0278,RC,,,,both,,,3039.52,1975.69,,,,,,,,,,,,,
MARKER BRST BX XR 8 GA MAMTOM IDENTIFIER PRB TISS MICROMARK,SUP-2195655,CDM,A4648,CPT,0278,RC,,,,both,,,341.10,221.71,,,,,,,,,,,,,
PROTECTOR NERVE L 2 X W 1 CM PORCINE SODIUM HYALURONATE,SUP-2890372,CDM,C1763,HCPCS,0278,RC,,,,both,,,8066.66,5243.33,,,,,,,,,,,,,
CLAMP TBL FOR ACUFEX NONINVASIVE ANK DISTRACTOR SYS,SUP-2340723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2304.76,1498.09,,,,,,,,,,,,,
WILLIAMS MAND DIST 25MM LFT END DRVN BODY 3DX ELBOW T 6L 4V,SUP-2494932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16971.89,11031.73,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 104 MM 50 MM 6 HOLE TI NS DCP,SUP-2569046,CDM,C1713,HCPCS,0278,RC,,,,both,,,1493.98,971.09,,,,,,,,,,,,,
RING PESSARY SZ 4 275IN SIL W SUPP,SUP-2273826,CDM,A4562,HCPCS,0272,RC,,,,both,,,102.27,66.48,,,,,,,,,,,,,
FIBER LASER 270UM DISP FLAT TIP HOLM SINGLEFLEX,SUP-2213046,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SET ARTHRO CNNLA BLUNT OBTRTR FLOW PORT ACTRK STNDRD,SUP-2639872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6904.86,4488.16,,,,,,,,,,,,,
PLATE BENDING PLIERS 10MM SYSTEM,SUP-2678833,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.92,328.85,,,,,,,,,,,,,
PLATE BNE L 46 MM 3 H ANODIZATION TYP II RT VOLAR DSTL,SUP-2902161,CDM,C1713,HCPCS,0278,RC,,,,both,,,4765.20,3097.38,,,,,,,,,,,,,
STEM FEM L127MM DIA15MM PROX HIP STR CEM W/O POR BODY GMRS,SUP-2376429,CDM,C1776,CPT,0278,RC,,,,both,,,6699.03,4354.37,,,,,,,,,,,,,
COMPONENT FEM INTERCALARY 55 MM KNEE SEG,SUP-2437245,CDM,C1776,CPT,0278,RC,,,,both,,,8944.29,5813.79,,,,,,,,,,,,,
PLATE BNE L226MM 12 H ST R LAT PROX TIB S STL LOK COMPR LO,SUP-2185723,CDM,C1713,HCPCS,0278,RC,,,,both,,,4752.20,3088.93,,,,,,,,,,,,,
CATH REPROC EP FIXED JSN 4POL 2-5-2 5FR,SUP-2526068,CDM,C1730,HCPCS,0272,RC,,,,both,,,185.29,120.44,,,,,,,,,,,,,
WASHER ORTH IMP F MAXICAN 4.5 MM SCR,SUP-2321037,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.48,82.86,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3 CC ADIPOSE MTRX RENUVA,SUP-2465397,CDM,C1762,CPT,0278,RC,,,,both,,,3040.15,1976.10,,,,,,,,,,,,,
CLAMP SURG ADJ FOR SCHNZ SCREW NS,SUP-2863404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1315.69,855.20,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430078,CDM,Q5135,HCPCS,0636,RC,65219-0592-10,NDC,,both,10,ML,2888.70,1877.65,,,,,,,,,,,,,
SOLUTION HEMOSTATIC NDL L 4 MM DIA25 GA WORKING L 230 CM 15,SUP-2912511,CDM,C1889,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC So Hepatitis C Virus Genotyping,PX-3068790266,CDM,87902,CPT,0306,RC,,,,outpatient,,,1147.00,745.55,,,,,,,,,,,,,
SCREW BNE 1.5X13 MM 5 MM X DRV DRILL-FREE TI LEVEL1 10771391,SUP-2478720,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.69,123.95,,,,,,,,,,,,,
BRACE KNEE L FOR 205 23IN NEOPRENE OPN POPLITEAL WRP ARND,SUP-2196840,CDM,L1810,HCPCS,0274,RC,,,,both,,,64.87,42.17,,,,,,,,,,,,,
PLATE BNE L114MM 6 H R LAT PROX PERIARTC HUM LOK COMPR,SUP-2410727,CDM,C1713,HCPCS,0278,RC,,,,both,,,4305.38,2798.50,,,,,,,,,,,,,
COMPONENT FEM KNEE REV THRD SHFT LCS COMPLETE,SUP-2453523,CDM,C1776,CPT,0278,RC,,,,both,,,2562.24,1665.46,,,,,,,,,,,,,
NEEDLE PLCMNT 18 GAX20 CM FUSIONCOIL MARKER STRL,SUP-2164570,CDM,A4648,CPT,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
EXPANDER BRST W11.7XH10CM P6.6CM 350CC SIL NACL SHELL RND M,SUP-2300632,CDM,C1789,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ 0.6X4.25 MM PISTON NIT SMRT,SUP-2651569,CDM,L8613,CPT,0278,RC,,,,both,,,1141.11,741.72,,,,,,,,,,,,,
STEM FEM CEMENTLESS MOD R HIP HA COAT IMPL SZ 1 ABG II,SUP-2372187,CDM,C1776,CPT,0278,RC,,,,both,,,13553.50,8809.77,,,,,,,,,,,,,
HC Chem Cautery Gran Tissue,PX-5101725000,CDM,17250,CPT,0510,RC,,,,outpatient,,,280.00,182.00,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST THMS EXT TO BALL,SUP-2435735,CDM,L3470,HCPCS,0272,RC,,,,both,,,176.41,114.67,,,,,,,,,,,,,
SET SCR SPNL OD6.35MM STD TI POST THORACOLUMBOSACRAL CANN,SUP-2290653,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.96,419.22,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UPCHARGE HI FLX,SUP-2212681,CDM,C1776,CPT,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
BRACE ORTH CUST ANK FT,SUP-2388163,CDM,L1940,HCPCS,0274,RC,,,,both,,,1220.14,793.09,,,,,,,,,,,,,
GRAFT VASC TW 6 MMX80 CM STR SFT WRP TUNN ATTCH ADVANTA VXT,SUP-2464366,CDM,C1768,CPT,0278,RC,,,,both,,,1061.29,689.84,,,,,,,,,,,,,
SCREW BNE 14 MM TIP 2-3/4 IN DISTRCTN RUGGLES REDMOND STRL,SUP-2481257,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.71,147.36,,,,,,,,,,,,,
CATHETER EP D 2 MM 1 MM 6 FRX92 CM BLU,SUP-2248655,CDM,C1730,HCPCS,0272,RC,,,,both,,,1331.36,865.38,,,,,,,,,,,,,
K WIRE FIX L152MM DIA2MM S STL SGL END SMOOTH BAYNT TIP 3PK,SUP-2251209,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.98,230.74,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 24 CM DIA 6 FR POLYUR AQ BRAIDED,SUP-2171437,CDM,C2617,HCPCS,0278,RC,,,,both,,,389.61,253.25,,,,,,,,,,,,,
HC Pain Combination,PX-3600007517,CDM,3600007517,LOCAL,0360,RC,,,,outpatient,,,3954.00,2570.10,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.177X9 IN SS NS STEINMANN,SUP-2791346,CDM,C1713,HCPCS,0278,RC,,,,both,,,38.12,24.78,,,,,,,,,,,,,
CATHETER EPI 19GA L14IN G SGL STYL RND ATRAUM TIP RADPQ,SUP-2217832,CDM,C1725,HCPCS,0272,RC,,,,both,,,240.12,156.08,,,,,,,,,,,,,
COUNTERSINK SURG DIA 5.5 MM CANN HDLSS AO QC,SUP-2898154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
PLATE BNE L 126 MM SCREW DIA 4.5 MM 7 H NAR COMPR LCK STRL,SUP-2932786,CDM,C1713,HCPCS,0278,RC,,,,both,,,1994.69,1296.55,,,,,,,,,,,,,
RETRACTOR SURG TBLR 20 MMX4 CM SPINE ANGLED COAT METRX REUSE,SUP-2292989,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
MINI L PLATE 2.0 OBLIQUE L 4 HOLES,SUP-2496554,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.97,165.73,,,,,,,,,,,,,
COPELAND SHLDR W/ POLY GLD,SUP-2212469,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BUR SURG OVL 4 MMX10 CM SM BOR MIDAS REX LEGEND,SUP-2627641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,333.78,216.96,,,,,,,,,,,,,
PIN FXTN RSRBBLE 16MM DIA 4MML POLY DL LCTC ACID FLAT HEAD,SUP-2681198,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.38,175.10,,,,,,,,,,,,,
CATHETER HD DL 12 FRX16 CM ARROWG+ARD BLU BLU FLEXTIP,SUP-2763039,CDM,C1752,HCPCS,0278,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
SHEET CRAN W50XL50MM THK0.5MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194075,CDM,C1781,HCPCS,0278,RC,,,,both,,,3426.68,2227.34,,,,,,,,,,,,,
CLIP HEMSTAS 135 DEG 4 MM LNG ARM ROTATABLE SHT TAIL EZ CLP,SUP-2865653,CDM,C1889,HCPCS,0278,RC,,,,both,,,648.98,421.84,,,,,,,,,,,,,
CATHETER PICC L55CM OD4FR SGL LUMN N COAT N CT COMPATIBLE N,SUP-2118829,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
SCREW BNE 9X35 MM SAMBASCREW,SUP-2601128,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
INSERT TIB ROTATING HINGE 10 MM,SUP-2452028,CDM,C1776,CPT,0278,RC,,,,both,,,1535.93,998.35,,,,,,,,,,,,,
SET ORTH GRPHC CA W/ IMPL AND INSTR FOR PERIPROSTHETIC SYS,SUP-2177074,CDM,C1713,HCPCS,0278,RC,,,,both,,,18047.31,11730.75,,,,,,,,,,,,,
SCREW BONE L35MM COMPR META-TAN,SUP-2340870,CDM,C1713,HCPCS,0278,RC,,,,both,,,1809.21,1175.99,,,,,,,,,,,,,
"HC So Factor Xa, Lmwh",PX-3058552066,CDM,85520,CPT,0305,RC,,,,both,,,879.00,571.35,,,,,,,,,,,,,
PLATE BNE FUSION 2 MM NS LTX,SUP-2856946,CDM,C1713,HCPCS,0278,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
SYSTEM DRAINAGE 20 CC BG,SUP-2666736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1262.85,820.85,,,,,,,,,,,,,
RETAINER NSL L 19 X W 26 MM DIA 9 MM SZ 4 SIL NOSTRIL ARCH,SUP-2883404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.06,348.44,,,,,,,,,,,,,
BOLT ORTH L75MM LOK FOR MOD REV HIP SYS RECLAIM,SUP-2252536,CDM,C1776,CPT,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
DRILL SURG BUSHING 1.8 MM NC,SUP-2487599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
PLATE BNE COMPR 3 H 3D 25MM,SUP-2321434,CDM,C1713,HCPCS,0278,RC,,,,both,,,3979.95,2586.97,,,,,,,,,,,,,
GRIP CBL SM L185MM TROCHANTERIC HIP 3 CBL ACCORD,SUP-2345202,CDM,C1776,CPT,0278,RC,,,,both,,,6738.44,4379.99,,,,,,,,,,,,,
BRACE ORTH FRAC FEM CAST MOLD KAFO L2128] TIDEWATER PROSTHETICS],SUP-2388171,CDM,L2128,HCPCS,0274,RC,,,,both,,,4592.53,2985.14,,,,,,,,,,,,,
BLADE SHV 4.5MM DIA ENDO ANG CVD DBL SERR ULT SER DISP,SUP-2341007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.03,211.92,,,,,,,,,,,,,
INSTRUMENT KIT PLN PT SPEC MIDFACE RECON SD900056,SUP-2860262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8712.87,5663.37,,,,,,,,,,,,,
INSTRUMENT ENDOSCP CRPL TUNN RELEASE SX-ONE MICROKNIFE DISP,SUP-2874141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
PLATE BNE L 49 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 6 H SS 72440306N,SUP-2932862,CDM,C1713,HCPCS,0278,RC,,,,both,,,1431.06,930.19,,,,,,,,,,,,,
COMP FEM AUG BTN STD/LG+ 10DTL,SUP-2513645,CDM,C1776,CPT,0278,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN BASIC INSRTN KT DBL LUMN,SUP-2126482,CDM,C1752,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
CATHETER PTCA 5FR L130CM BLLN L100MM DIA4MM GWIRE 0.035IN,SUP-2128356,CDM,C2623,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.035IN L 7CM 2.5CM SAFE-T-J HVY DTY,SUP-2638691,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.76,35.59,,,,,,,,,,,,,
MESH PREPERITONEAL BIOMATERIAL 9CM CIRCULAR SYNECOR,SUP-2752386,CDM,C1781,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
SYSTEM INTRO ACUSTK II GUIDEWIRE 0.038/0.018 IN SS WIRE STR,SUP-2147740,CDM,C1894,HCPCS,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
LINER ACET OD68MM ID28MM +4MM OFFSET 10DEG HIP MARATHON,SUP-2250366,CDM,C1776,CPT,0278,RC,,,,both,,,4722.56,3069.66,,,,,,,,,,,,,
PIN DRL 13MM ACL PCL KNEE ALL IN 1 GUID RG RMR DISP,SUP-2120835,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
ANCHOR SUT DIA2.9MM NO2 MAXBRAID DBL LD JUGGERKNOT,SUP-2212947,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
SHUNT NEUROSURGICAL ADJ PROSA,SUP-2108730,CDM,C1889,HCPCS,0278,RC,,,,both,,,15433.10,10031.51,,,,,,,,,,,,,
SYSTEM DEL 11 GA W/ NDL,SUP-2308558,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
CUTTER ENDOSCP DIA8.5MM USED TO ELIMINATE TRANSOSSEOUS TUNN AR1204R085S] ARTHREX INC],SUP-2120850,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS II AVG 6.3X5.2X2.5 MM SINGLE NOTCH HA,SUP-2638123,CDM,L8613,CPT,0278,RC,,,,both,,,1165.63,757.66,,,,,,,,,,,,,
CANNULA BIO MEDICUS 23FR,SUP-2720545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1033.34,671.67,,,,,,,,,,,,,
STEM FEM REV PRSS FIT L BOW TI POR PLSM COAT RESTR 254MML,SUP-2375433,CDM,C1776,CPT,0278,RC,,,,both,,,18097.70,11763.50,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.5X4.5 MM 0.6 MM PISTON FLROPLAS,SUP-2459454,CDM,L8613,CPT,0278,RC,,,,both,,,286.18,186.02,,,,,,,,,,,,,
EXPEL NEPH 12/25 K,SUP-2652778,CDM,C1729,HCPCS,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
STENT URO DBL PGTL FIRM SUT HYDRPHLC POLYMER COAT POS THRD,SUP-2141667,CDM,C2617,HCPCS,0278,RC,,,,both,,,457.81,297.58,,,,,,,,,,,,,
STRUT EXTERNAL FIXATION L163300MM LONG RAPID,SUP-2874152,CDM,C1713,HCPCS,0278,RC,,,,both,,,3191.34,2074.37,,,,,,,,,,,,,
LINER ACET OD57-60MM ID28MM UNIV,SUP-2342600,CDM,C1776,CPT,0278,RC,,,,both,,,236.60,153.79,,,,,,,,,,,,,
D-RAD VOLAR PLATE 10H RIGHT STANDARD TI,SUP-2818922,CDM,C1713,HCPCS,0278,RC,,,,both,,,13690.87,8899.07,,,,,,,,,,,,,
SPLINT HND AD SM L5.75IN LT HEADLINER CVR FIVE STRP CLSR ADJ,SUP-2324297,CDM,L3807,HCPCS,0274,RC,,,,both,,,180.93,117.60,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 5 MM STR STD WALL REINF,SUP-2525432,CDM,C1768,CPT,0278,RC,,,,both,,,209.72,136.32,,,,,,,,,,,,,
SHUNT KIT 1 PC 80 CM LUMPERITON SPETZLER,SUP-2851454,CDM,C1889,HCPCS,0278,RC,,,,both,,,2382.66,1548.73,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 90 CM OD 8 FR GUIDEWIRE 0.038 IN,SUP-2168691,CDM,C1894,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
IMPLANT HUM TISS DIA22 MM MONO CUSP PTCH SINGLE LEAFLET,SUP-2933362,CDM,C1762,CPT,0278,RC,,,,both,,,22293.87,14491.02,,,,,,,,,,,,,
INSTRUMENT TRAY 3X15 MM 11 GA INFLATABLE TAMP KYPHON XPANDER,SUP-2293648,CDM,C1894,HCPCS,0272,RC,,,,both,,,10846.82,7050.43,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL HVY DTY,SUP-2435684,CDM,L2620,HCPCS,0272,RC,,,,both,,,707.79,460.06,,,,,,,,,,,,,
CATHETER EP JSN 10 MM 6 FRX120 CM SUPREME,SUP-2492236,CDM,C1730,HCPCS,0272,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
SCREW BNE CANN 6.5X45 MM 20 MM THRD NS LTX,SUP-2856354,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
GRAFT HUM TISS 15ML VIABLE CELL MORSELIZED IMPL TRINITY,SUP-2307246,CDM,C1713,HCPCS,0278,RC,,,,both,,,18007.90,11705.13,,,,,,,,,,,,,
MIXER BNE CEM 40GM SGL MIX OPTVAC VAC SYS,SUP-2216855,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
STEM HUM H130MM DIA9MM GRN CO CHROM ALLY HA CEM FOR,SUP-2388687,CDM,C1776,CPT,0278,RC,,,,both,,,15707.85,10210.10,,,,,,,,,,,,,
PLATE MESH TI CONTOURABLE 38X45MM RIGID LPROF SYNTHES,SUP-2848979,CDM,C1713,HCPCS,0278,RC,,,,both,,,4214.51,2739.43,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.437,SUP-2860001,CDM,C1713,HCPCS,0278,RC,,,,both,,,45322.76,29459.79,,,,,,,,,,,,,
SHOE ORTHOT MAR BAR ADDITION,SUP-2435744,CDM,L3595,HCPCS,0272,RC,,,,both,,,118.75,77.19,,,,,,,,,,,,,
PLATE BNE STR MINI XL 2-2.5X1 MM 22 MM 4 HOLE LCK TLTS TI,SUP-2481118,CDM,C1713,HCPCS,0278,RC,,,,both,,,1712.46,1113.10,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 10 WITH SHUNT ASSISTANT AND CONTROL RESE,SUP-2826125,CDM,C1889,HCPCS,0278,RC,,,,both,,,8777.12,5705.13,,,,,,,,,,,,,
SCREW BNE EMGCY 12 MM TI NS MATRIXMIDFACE,SUP-2191595,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PROSTHESIS FEN NAR STR 1 PC HIP 38MM ASTN MOORE,SUP-2377813,CDM,C1776,CPT,0278,RC,,,,both,,,2466.16,1603.00,,,,,,,,,,,,,
CLAMP REPROC FIX EXT MULTI PIN 6 POS LG,SUP-2471393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.66,357.93,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM NONLOCKING TI 2 PK,SUP-2399692,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 8 FRX15 CM 3L SPECTRUM,SUP-2759803,CDM,C1751,HCPCS,0278,RC,,,,both,,,489.90,318.43,,,,,,,,,,,,,
MESH HERN W10XL13CM POLYPR POLYDIOXANONE POLYMER OVL THN,SUP-2219768,CDM,C1781,HCPCS,0278,RC,,,,both,,,7378.69,4796.15,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN TAPR L7CM FLPY TIP L3CM,SUP-2167947,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.64,35.52,,,,,,,,,,,,,
BLADE TNG SM F/10 PDGTT LATEX FREE PVC FREE DEHP FREE MRCRY,SUP-2457515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.68,530.19,,,,,,,,,,,,,
RING EXT FIX ID205MM ALUM FULL FOR TAY SPAT FRME ILIZ,SUP-2342966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6624.62,4306.00,,,,,,,,,,,,,
COVER US PRB L11.8IN DIA1.18IN ISOPRENE SEAMLESS STR RL X,SUP-2337625,CDM,C1894,HCPCS,0272,RC,,,,both,,,7.28,4.73,,,,,,,,,,,,,
PLATE BNE 2X6 H NONSTERILE CNDYL S STL LOK COMPR W/ SHT,SUP-2177485,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.97,986.03,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.529,SUP-2860210,CDM,C1713,HCPCS,0278,RC,,,,both,,,38271.58,24876.53,,,,,,,,,,,,,
SCREW BNE 2.1X4 MM PDLLA STRL RESORB RX,SUP-2457766,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.00,131.95,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 24 IN BLNT CD HORZ,SUP-2628256,CDM,C1769,HCPCS,0272,RC,,,,both,,,221.94,144.26,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC OSTEOSURGE 300C,SUP-2644324,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5 CM DIA 6 MM CATH L 75 CM NIT,SUP-2396475,CDM,C1876,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
GUIDEWIRE ORTH L24IN CANN THRD,SUP-2290861,CDM,C1769,HCPCS,0272,RC,,,,both,,,221.94,144.26,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 4 FR MAXIMAL BARR TY POWERPICC SOLO 2,SUP-2126373,CDM,C1751,HCPCS,0278,RC,,,,both,,,555.69,361.20,,,,,,,,,,,,,
DEVICE ENDART L44CM OD5MM TRANSECTION MOLLRING CUT,SUP-2264256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6144.98,3994.24,,,,,,,,,,,,,
ASPIRIN 16.2 MG/ML PO SUSP (FOR DESENSITIZATION),RX-4081285,CDM,6370000000,HCPCS,0637,RC,09999-9909-83,NDC,,both,0.6172839506172839506,ML,2.70,1.75,,,,,,,,,,,,,
THERAPEUTIC MULTIVIT/MINERAL PO TABS,RX-7856,CDM,6370000000,HCPCS,0637,RC,00536-3445-08,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM OD0038IN OD14FR INTRO 3MM J TIP MOV,SUP-2141740,CDM,C1769,HCPCS,0272,RC,,,,both,,,60.54,39.35,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CORTICAL FIBER,SUP-2899230,CDM,C1713,HCPCS,0278,RC,,,,both,,,5569.58,3620.23,,,,,,,,,,,,,
IMPLANT FNGR JT SZ 1 PROX INTERPHALANGEAL FUS,SUP-2243141,CDM,C1776,CPT,0278,RC,,,,both,,,3775.28,2453.93,,,,,,,,,,,,,
STRUT FIX XSH QUIK ADJ MAXFRAME,SUP-2179160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3399.49,2209.67,,,,,,,,,,,,,
PASSOR SUTURE MEDIUM,SUP-2749339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GRAFT BIO TISS W5.9XL7.9IN PORCINE DERM RIFAMPIN,SUP-2125838,CDM,C1781,HCPCS,0278,RC,,,,both,,,22498.10,14623.76,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST THOR CTRL LAT SUPP UPR,SUP-2435693,CDM,L2680,HCPCS,0272,RC,,,,both,,,414.26,269.27,,,,,,,,,,,,,
PLATE BNE CRV 2X39 MM 15 MM ORTHOGNATHIC 6 HOLE BSSO TI,SUP-2480755,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.20,384.93,,,,,,,,,,,,,
BUR SURG 3.1 MM STRT ORTHOSPHERE CMC,SUP-2521577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
PAD ORTHOT CERV THOR LUMBAR SACR CUST KYPHOSIS FLOATING,SUP-2435572,CDM,L1025,HCPCS,0274,RC,,,,both,,,440.17,286.11,,,,,,,,,,,,,
COMPONENT TALAR SZ 0 COCR ALLOY TI PLASMA SPRY LT ANK DOME,SUP-2933126,CDM,C1776,CPT,0278,RC,,,,both,,,16605.89,10793.83,,,,,,,,,,,,,
STAPLE BNE FIX BRIDGE L 8 X 8 X W 1.5 MM MINI NIT LP NS,SUP-2897019,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
PLATE BNE L65MM THK1.2MM 3X10 H S STL T SHP ADPT FOR 2MM,SUP-2186154,CDM,C1713,HCPCS,0278,RC,,,,both,,,1352.68,879.24,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 4CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2667616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.70,231.20,,,,,,,,,,,,,
UNISPACER KNEE SYS FEM RASP,SUP-2208947,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.4X150 MM FOR CANN SCREW NS 03333012,SUP-2789101,CDM,C1769,HCPCS,0272,RC,,,,both,,,297.17,193.16,,,,,,,,,,,,,
ANCHOR SUT DIA5MM DRL 28MM BLK HNDL SELF PUNCHING W TWO,SUP-2167268,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
DILATOR SURG L21.5CM TEF SMOOTH MALL FOR INTRACERVICAL DIL,SUP-2421469,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.40,7.41,,,,,,,,,,,,,
BLADE RETRACTOR CLOWARD 7.5X20 MM W/ LIP ULTRA,SUP-2496149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.86,222.86,,,,,,,,,,,,,
HC Njx Px Cntrst Kne Arthg Cntrst Enhncd CT/MRI Kne,PX-3612736900,CDM,27369,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
FORCEPS SURG 23GA FN TIP ECKARDT INT LIMITING MEMBRN PINN,SUP-2129183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.53,275.94,,,,,,,,,,,,,
PERFORATOR SURGICAL L14MM OD11MM CRANIAL HIGH PERFORMANCE DISPOSABLE KIT ACRA CUT DGR II,SUP-2106553,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
STRAIGHT PLATE VARIAX FIBULA 4 HOLE L60MM STERILE,SUP-2703555,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.27,1193.58,,,,,,,,,,,,,
STAPLE SPNL OD14MM SM THORLUM RSTRL CROSS CONN FOR 2 ROD SYS,SUP-2229601,CDM,C1713,HCPCS,0278,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
HC Aerobic ID,PX-3008707700,CDM,87077,CPT,0300,RC,,,,both,,,83.00,53.95,,,,,,,,,,,,,
MATRIX BIO L 20 X W 7 CM FISH SKIN DERMAL INTACT MARIGEN 10/BX,SUP-2909388,CDM,Q4158,HCPCS,0636,RC,,,,both,,,21983.14,14289.04,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 300CM 0.014IN SEG 35CM EXCHANGE STD,SUP-2717705,CDM,C1769,HCPCS,0272,RC,,,,both,,,2716.10,1765.46,,,,,,,,,,,,,
ROPIV-EPI-CLONIDINE-KETOROLAC 123-0.25-0.04- 15 MG/50ML PA SOSY,RX-143529,CDM,2500000003,HCPCS,0250,RC,70092-1433-50,NDC,,both,50,ML,282.70,183.75,,,,,,,,,,,,,
SIZER GRFT L7-15MM ORNG DISP CHONDROFIX,SUP-2200251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MESH SYN Y SHP FLAT SUT SURF MULTDIR POS FOR VAG COLPASSIST,SUP-2139037,CDM,C1781,HCPCS,0278,RC,,,,both,,,4361.65,2835.07,,,,,,,,,,,,,
LEAD PACE 6FR L58CM VENT SIL INSUL BPLR TI NITRIDE STEROID,SUP-2281981,CDM,C1898,HCPCS,0275,RC,,,,both,,,1332.87,866.37,,,,,,,,,,,,,
SCREW BNE CANN 3.2X33 MM TWINFIX,SUP-2364038,CDM,C1713,HCPCS,0278,RC,,,,both,,,896.78,582.91,,,,,,,,,,,,,
PLATE BNE L 192 X W 10 MM THK 2 MM SCREW DIA2.7/3.5 MM 14 H,SUP-2936263,CDM,C1713,HCPCS,0278,RC,,,,both,,,5707.26,3709.72,,,,,,,,,,,,,
MESH BONE SIZE 11 0.6MM THK TTNM CNTRD STNDRD LATEX FREE ST,SUP-2496702,CDM,C1713,HCPCS,0278,RC,,,,both,,,16876.12,10969.48,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 4 FRX55 CM FULL TY POWERPICC,SUP-2126368,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.96,321.72,,,,,,,,,,,,,
COMPONENT FEM CEM UNISX LT ANTR POST PRIMARY STEMLESS N BEAD,SUP-2376273,CDM,C1776,CPT,0278,RC,,,,both,,,12129.19,7883.97,,,,,,,,,,,,,
SCREW BONE L11MM D2MM FOOT TTNM SELF TPPNG SELF DRLLNG FRS,SUP-2469771,CDM,C1713,HCPCS,0278,RC,,,,both,,,651.80,423.67,,,,,,,,,,,,,
PLATE BONE 8MM ADV MINI TI CHIN CRANIOMAXILLOFACIAL FOR 2MM,SUP-2319367,CDM,C1713,HCPCS,0278,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
PIN FIX BUTTRESS 24/14 MM SFC COMBINATION,SUP-2389691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
TUBE GASTMY W/LMA 75 MM LIPPGOLECKI DIFFICULT AIRWY SET,SUP-2775169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.31,518.90,,,,,,,,,,,,,
HALF RING WITH CVD EXT120,SUP-2818048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8650.07,5622.55,,,,,,,,,,,,,
PLATE BNE 130 DEG SHFT L 104 MM BLADE L 50 MM SCREW DIA 4.5,SUP-2908023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1744.84,1134.15,,,,,,,,,,,,,
NAIL IM 3X400 MM TI STRL MJ-FLEX,SUP-2646410,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.54,1051.40,,,,,,,,,,,,,
FENOFIBRATE 54 MG PO TABS,RX-31336,CDM,6370000000,HCPCS,0637,RC,00115-5511-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE L184MM BLDE W11.7XL30MM 90DEG 10 H STRL BILAT TI,SUP-2190868,CDM,C1713,HCPCS,0278,RC,,,,both,,,3838.18,2494.82,,,,,,,,,,,,,
KIT ACCESS PORT 010CC RAPIDPORT EZ,SUP-2430924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
"HC So Cryoglobulin,Qualitative",PX-3018259566,CDM,82595,CPT,0301,RC,,,,inpatient,,,214.00,139.10,,,,,,,,,,,,,
SLEEVE FEM 61MM LATERAL MEDIAL FULL COAT REV PORCOAT ATTUNE,SUP-2251471,CDM,C1776,CPT,0278,RC,,,,both,,,8297.14,5393.14,,,,,,,,,,,,,
BOLT TROCH MEDALLION 24MM,SUP-2408757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1331.36,865.38,,,,,,,,,,,,,
INTRODUCER SHTH 8.5FR L63CM DIL 8.5FR L67CM GWIRE L180CM,SUP-2357169,CDM,C1893,HCPCS,0272,RC,,,,both,,,476.97,310.03,,,,,,,,,,,,,
SEALER TISS L20CM DIA13MM ADV BPLR L CRV JAW OPN APPRCH,SUP-2219738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4488.82,2917.73,,,,,,,,,,,,,
CATHETER HD STR EXTN 15.5 FRX15 CM 3L SHT TERM TY T-3,SUP-2266994,CDM,C1752,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE SHTH L 7 CM DIA 4 FR GUIDEWIRE L 40,SUP-2167895,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.23,77.50,,,,,,,,,,,,,
PORT IMPL INFUSION 7.2 FR VORT,SUP-2165210,CDM,C1788,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
INSERT FEM NK +6MM HIP CO CHROM MOLYBDENUM ALLY TAPR 1 ENDO,SUP-2405243,CDM,C1776,CPT,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
PLATE SPNL L45MM CEPHALIC TO CAUD 37MM 8 H GLD ANTR BILAT,SUP-2193039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
BIT DRL DIA2MM FT FOR CHARLOTTE CLAW PLT,SUP-2397354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
DRESSING BIO SZ 8 X 15 CM OVINE MTRX 3 LAYR CNTOUR LT RESRB,SUP-2914594,CDM,C1781,HCPCS,0278,RC,,,,both,,,6327.10,4112.61,,,,,,,,,,,,,
CATHETER GUID LUMAX L 90 CM DIA 7 FR GUIDEWIRE 0.038 IN,SUP-2638654,CDM,C1887,HCPCS,0272,RC,,,,both,,,1058.97,688.33,,,,,,,,,,,,,
PATCH BIO L 15 X W 2.5 CM BOV PERICARD XENOSURE,SUP-2884014,CDM,C1768,CPT,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,6370000000,HCPCS,0637,RC,69918-0560-30,NDC,,both,1,UN,27.90,18.13,,,,,,,,,,,,,
STRAP FNGR W5/8IN BGE BUDDY HK LOOP CLSR ROLYAN,SUP-2324809,CDM,L3933,HCPCS,0272,RC,,,,both,,,4.24,2.76,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM ENDEXO NURSING KT BIOFLO 75034,SUP-2734874,CDM,C1751,HCPCS,0278,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
PROSTHESIS INDWL VOICE L FLNG T AND E 20F 14MM,SUP-2242419,CDM,L8509,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT L 125 CM DIA 8 FR SHTH,SUP-2248931,CDM,C1732,HCPCS,0272,RC,,,,both,,,6575.16,4273.85,,,,,,,,,,,,,
COVER BURR HOLE 17MM DIA 1MM THK RESORB X,SUP-2494600,CDM,C1713,HCPCS,0278,RC,,,,both,,,1014.97,659.73,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.526,SUP-2860043,CDM,C1713,HCPCS,0278,RC,,,,both,,,39196.93,25478.00,,,,,,,,,,,,,
PLATE BNE L127MM 13 H L MED DST HUM TIM LO PROF ALPS,SUP-2411736,CDM,C1713,HCPCS,0278,RC,,,,both,,,4259.72,2768.82,,,,,,,,,,,,,
STEM RADIAL MORSE TAPR LNG 8 MM,SUP-2424148,CDM,C1776,CPT,0278,RC,,,,both,,,5692.82,3700.33,,,,,,,,,,,,,
PSN REV TM TIB CENTRAL CONE SZ MED,SUP-2508667,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
PLATE BNE L208MM THK3MM 11 H BILAT S STL STR LOK COMPR RECON,SUP-2185345,CDM,C1713,HCPCS,0278,RC,,,,both,,,1768.54,1149.55,,,,,,,,,,,,,
HC MRI-Myocardium W/WO Contrast,PX-6107556100,CDM,75561,CPT,0610,RC,,,,both,,,4647.00,3020.55,,,,,,,,,,,,,
SCREW WDG FEM L5MM DSTL KNEE HNG LEGION,SUP-2346315,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.38,323.30,,,,,,,,,,,,,
SCREW SPNL L25MM OD6.5MM 5.5MM ROD MONOAX LO PROF DBL LD,SUP-2229329,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PHENYLEPHRINE HCL 10 % OP SOLN,RX-19636,CDM,6370000000,HCPCS,0637,RC,70756-0614-30,NDC,,both,5,ML,180.00,117.00,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX4 LEFT LATERAL PROXIMAL TIBIAL,SUP-2588167,CDM,C1713,HCPCS,0278,RC,,,,both,,,3808.60,2475.59,,,,,,,,,,,,,
BLADE REPROC BUR BARREL FORMULA 12-FLUT 4MM,SUP-2653134,CDM,2720000010,LOCAL,0272,RC,,,,both,,,77.62,50.45,,,,,,,,,,,,,
CATHETER CV 3L 12 FRX27 CM OTW HICKMAN TRIFUSION,SUP-2126184,CDM,C1751,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
STAPLE BONE FIX OFFSET 5MM FOR OSTEOTMY,SUP-2342734,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.45,1532.34,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.5MM S STL ST LOK FULL THRD SM HEX HD,SUP-2348661,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.64,546.42,,,,,,,,,,,,,
COMPONENT TIB L MOD NEUT ROTATIONAL KNEE ENDO MOD,SUP-2265074,CDM,C1776,CPT,0278,RC,,,,both,,,9539.32,6200.56,,,,,,,,,,,,,
CATHETER NEPHROSTOMY MCOT 8 FRX20 CM SIL,SUP-2835735,CDM,C1729,HCPCS,0272,RC,,,,both,,,266.27,173.08,,,,,,,,,,,,,
SET ORTH FOR INT BRAC TECH STRL DISP AUTOGRFT GRAFTLINK,SUP-2882291,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
PIN FIX TEMP,SUP-2379520,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
BAR EXT FIX L 150 MM DIA11 MM NS MAV,SUP-2931172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1810.52,1176.84,,,,,,,,,,,,,
AZITHROMYCIN 200 MG/5ML PO SUSR,RX-15797,CDM,340b,HCPCS,0637,RC,09999-9903-76,NDC,,both,5,ML,39.30,25.54,,,,,,,,,,,,,
BUTTON SUTURE DIA14 MM OUTER THK 1.6 MM TUNN SZ 7-9 MM TI,SUP-2905794,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE 2X32X1 MM 6 HOLE SS DCP,SUP-2569121,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.50,182.97,,,,,,,,,,,,,
PLATE BNE EVANS W/ 10 MM SPACER TI RIVAL VW REDUC,SUP-2645297,CDM,C1713,HCPCS,0278,RC,,,,both,,,5333.29,3466.64,,,,,,,,,,,,,
STEM CPT 2 HIP,SUP-2205951,CDM,C1776,CPT,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
BLADE SAW 296 37 133S4 W TPS RECIP NOTCH,SUP-2363310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
CAP NAIL RET SHFT FOR RG FEM NAT NAIL,SUP-2198680,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.37,565.09,,,,,,,,,,,,,
STAPLER INT L75MM CUT LN L73MM STPL LN L77MM BLU B FRM 8,SUP-2220040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.89,278.13,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-40840053,CDM,J3490,HCPCS,0258,RC,00338-0043-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
PLATE BONE 12 H STOUT STR FOR 2.4MM SCR VLP MINI-MOD SM BONE,SUP-2351102,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.47,2959.76,,,,,,,,,,,,,
CLAMP REPROC FIX EXT PIN 4 POS MR SAFE LG,SUP-2467409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.94,272.96,,,,,,,,,,,,,
DEVICE SUT L53IN DIA5MM THE RUNNING DEV RD 180,SUP-2265295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
ANCHOR SUTURE STRL CITREFIX XPRESS,SUP-2883465,CDM,C1713,HCPCS,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
GRAFT HUM TISS BNE TEND BNE HEMI W/ QUADRICEPS W10-13MM,SUP-2307265,CDM,C1713,HCPCS,0278,RC,,,,both,,,7330.08,4764.55,,,,,,,,,,,,,
SAW SURG JOS 190 RT BAYNT SHP CRV,SUP-2649606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.71,220.16,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X183 MM RT LAT DSTL 11 HOLE STRL VALCP,SUP-2789399,CDM,C1713,HCPCS,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 60 MG MICROMATRIX,SUP-2106470,CDM,Q4118,HCPCS,0636,RC,,,,both,,,716.67,465.84,,,,,,,,,,,,,
PLATE BNE 90 DEG THK 0.6 MM 7 X 7 H SCREW DIA1.5 MM TI,SUP-2883846,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
KNIFE SCKL STR BLNT TIP,SUP-2261344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.75,344.99,,,,,,,,,,,,,
PLATE BNE STR METATARSOPHALANGEAL LATTICE LCK,SUP-2107934,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
HC Catheterize for Urine Spec,PX-4500961200,CDM,P9612,CPT,0450,RC,,,,inpatient,,,76.00,49.40,,,,,,,,,,,,,
SPACER SPNL W11XH7XL14MM 0DEG LORDTC CORT CANC LIFEGRAFT,SUP-2353351,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
CANN DRIVER BIT HEX 25MM AO,SUP-2724774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.06,348.44,,,,,,,,,,,,,
PLATE BONE METATARSOPHALANGEAL LEFT STANDARD TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878468,CDM,C1713,HCPCS,0278,RC,,,,both,,,7237.70,4704.50,,,,,,,,,,,,,
PLATE BONE LOW PROFILE 17 MM PRECONTOURED FOR SHUNT TITANIUM,SUP-2842240,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.99,559.64,,,,,,,,,,,,,
GRAFT VASC L70CM DIA8MM CLLGN POLY STR KNIT ULTRATHIN SM,SUP-2227536,CDM,C1768,CPT,0278,RC,,,,both,,,1839.04,1195.38,,,,,,,,,,,,,
PLATE BNE L 225 MM SCREW DIA 3.5 MM 15 H SS PROX HUM STR,SUP-2932923,CDM,C1713,HCPCS,0278,RC,,,,both,,,9247.30,6010.74,,,,,,,,,,,,,
BRACE KNEE SM FOR 115 13IN UNIV BUTTERESS NEOPRENE W STBL,SUP-2319243,CDM,L1810,HCPCS,0272,RC,,,,both,,,54.13,35.18,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT CRANIOMAXILLOFACIAL TI EMER W/,SUP-2189253,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.98,158.59,,,,,,,,,,,,,
GUIDEROD ORTH L600MM DIA2MM GRAD BALL TIP TRIGEN,SUP-2348121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
PLATE LK POLYAXIAL LT SHRT T10,SUP-2704905,CDM,C1713,HCPCS,0278,RC,,,,both,,,5171.89,3361.73,,,,,,,,,,,,,
COIL EMB L15CM DIA8MM 3D NEUROVASC DETACH FRME PRIM,SUP-2280961,CDM,C1889,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
SCREW BNE LCK 3.5X24 MM 311351] DEPUY SYNTHES USA],SUP-2187399,CDM,C1713,HCPCS,0278,RC,,,,both,,,1435.61,933.15,,,,,,,,,,,,,
NEEDLE INTRO TRANSSEPTAL 19GA 56CM LEN BRK 2 CRV STYL,SUP-2357225,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBM PRO-DENSE INJ INDUCTIVE PRO-STIM,SUP-2399131,CDM,C1713,HCPCS,0278,RC,,,,both,,,8854.80,5755.62,,,,,,,,,,,,,
BASKET STONE RETRV L3.2MM DIA2.5CM GWIRE 0.035IN BILI DUCT,SUP-2149356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,852.79,554.31,,,,,,,,,,,,,
PIN ALIGN KNEE HOWMED PCA UNIV LNG,SUP-2364946,CDM,C1713,HCPCS,0278,RC,,,,both,,,253.08,164.50,,,,,,,,,,,,,
KIT 210CM TBNG 1 TRNSDUC MON PRSS TRUWAVE,SUP-2214652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,120.86,78.56,,,,,,,,,,,,,
INTRODUCER MIC KT VSI 5FR NIT MANDREL TUNGSTEN SFT TIP,SUP-2383174,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.36,36.63,,,,,,,,,,,,,
LOCKING CAP MOD,SUP-2232361,CDM,C1713,HCPCS,0278,RC,,,,both,,,4402.28,2861.48,,,,,,,,,,,,,
SCREW BNE L22MM DIA35MM RAREFT LOK PLT FOR TOT FT SYS 2,SUP-2243296,CDM,C1713,HCPCS,0278,RC,,,,both,,,812.76,528.29,,,,,,,,,,,,,
BIT DRL OD4MM CANN FOR SFT TISS FIX,SUP-2399125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1321.94,859.26,,,,,,,,,,,,,
COMPONENT FEM SM RT KNEE ZPU LIBRA,SUP-2442381,CDM,C1776,CPT,0278,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
WASHER SUTURE 2 TITANIUM CURVED NEEDLE FIBERWIRE,SUP-2765948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
LEAD DEFIB 7FR L52/58/65CM SIL SGL COIL TRUE BPLR ACT,SUP-2357378,CDM,C1777,HCPCS,0275,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
SPACER SPNL L8MM PEEK TI SPINOUS PROC FUS AXLE,SUP-2401502,CDM,C1889,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
GRAFT SKIN L 20 X W 8 CM THK 1.25-2 MM HUM ACELLULAR DERMAL,SUP-2890354,CDM,Q4122,HCPCS,0636,RC,,,,both,,,14221.09,9243.71,,,,,,,,,,,,,
PLATE BNE L 31.1 X W 3.2 MM THK 0.6 MM SCREW DIA1.65 MM 8 H,SUP-2936647,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
PLATE BONE 1MM DIA XL HLX6 CP TTNM STRGHT RIGHT SIDED WTAB,SUP-2677937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1132.91,736.39,,,,,,,,,,,,,
SCREW BNE L32MM DIA6.5MM SHLDR CNTR FOR RSA REUNION,SUP-2373752,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
VALVE SPEAK PMV 2000,SUP-2433847,CDM,L8501,HCPCS,0272,RC,,,,both,,,324.08,210.65,,,,,,,,,,,,,
SHELL ACET SZ F DIA56MM LNR POR REFLCT I,SUP-2350897,CDM,C1776,CPT,0278,RC,,,,both,,,6563.86,4266.51,,,,,,,,,,,,,
COMPONENT TIB AUG 360 DEG 10 MM W/ BOLT,SUP-2441915,CDM,C1776,CPT,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
STENT ENDOPROS L15CM DIA6MM CATH 7FR L120CM 0.035IN VES,SUP-2396535,CDM,C1874,HCPCS,0278,RC,,,,both,,,10952.32,7119.01,,,,,,,,,,,,,
COLLAR CERV SFT 375X17IN M,SUP-2276589,CDM,L0120,HCPCS,0272,RC,,,,both,,,5.97,3.88,,,,,,,,,,,,,
VALVULOTOME LEMAITRE 3MM 3 1/2IN 051481D30] LEMAITRE VASCULAR INC],SUP-2264155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BIT DRL DIA4.3MM LNG FOR VALOR HINDFOOT FUS SYS,SUP-2397590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
HC ED Clsd Tx Shdr W Fx WO Anes,PX-4502366500,CDM,23665,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
COIL NEUROVASCULAR ULTIPAQ 10 CERECYTE L 8 CM DIA 4 MM,SUP-2458404,CDM,C1889,HCPCS,0278,RC,,,,both,,,4434.25,2882.26,,,,,,,,,,,,,
HC So Adalimumab Level,PX-3018014566,CDM,80145,CPT,0301,RC,,,,inpatient,,,197.00,128.05,,,,,,,,,,,,,
INSERT TIB SZ 4 POLYETH NONCOATED CEM REV COMP PRI NEUT FOR,SUP-2252064,CDM,C1776,CPT,0278,RC,,,,both,,,2800.25,1820.16,,,,,,,,,,,,,
HC Injection Shunt,PX-3614942700,CDM,49427,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC Fat Stain Feces Urine/Respir Secretions,PX-3008912500,CDM,89125,CPT,0300,RC,,,,both,,,246.00,159.90,,,,,,,,,,,,,
GUIDEWIRE VASC L335CM DIA0.014IN IMAG SPR COIL TIP INTVENT,SUP-2159528,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STENT NEPHURET RESOLV CONVERTX L 26 CM 10.3/8.3FR SUTURE LCK,SUP-2516567,CDM,C2617,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
HC MRI Face Neck Eye W Contrast,PX-6107054200,CDM,70542,CPT,0610,RC,,,,both,,,4451.00,2893.15,,,,,,,,,,,,,
IMPLANT BRST DIA14.3CM P4.4CM 475-570CC NACL RND SMOOTH,SUP-2300244,CDM,C1789,HCPCS,0278,RC,,,,both,,,3344.10,2173.66,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FOX SV L 150 CM BALLOON L 100 MM DIA2.5,SUP-2105995,CDM,C1725,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SCREW BNE L32MM DIA4.7MM S STL CORT N ST DRL NCANNULATED,SUP-2412997,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.99,134.54,,,,,,,,,,,,,
BEARING TIB L67MM THK24MM KNEE ANTR STBL VANGUARD,SUP-2408110,CDM,C1776,CPT,0278,RC,,,,both,,,7168.62,4659.60,,,,,,,,,,,,,
CATHETER EP 6FR L115CM 5MM SPC 4 ELECTRD A CRV NYL PROTCT,SUP-2248898,CDM,C1730,HCPCS,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
SPACER SPNL 12 MM COR 0 DEG H15-19 MM VERT BODY REPL PARA NO,SUP-2229948,CDM,C1821,HCPCS,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.7MM STD SM FRAG FT PLATING SYS,SUP-2319591,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
TORSEMIDE 20 MG PO TABS,RX-18293,CDM,6370000000,HCPCS,0637,RC,00904-7283-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DRILL CANN 4MM,SUP-2417468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
STEREOTACTIC SET KNEE ROBOTIC-ASSISTED SOLUTION ARRY VELYS,SUP-2749617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
COIL NEUROVASCULAR WEB SL W 3-7 X H 3 MM DIA 5 MM,SUP-2836311,CDM,C1889,HCPCS,0278,RC,,,,both,,,51794.30,33666.29,,,,,,,,,,,,,
GRAFT BONE STRP 2.5CMX5CM GRFTON,SUP-2293900,CDM,C1713,HCPCS,0278,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
PROCEDURE PACK GRFT DEL,SUP-2384786,CDM,C1713,HCPCS,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
PACK ARTHSCP B DRL TIP GWIRE PASS PIN BONE TUNN PLUG,SUP-2341854,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM OD.038IN NIT HYDRPHLC ANG STIFF TAPR,SUP-2139350,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.60,107.64,,,,,,,,,,,,,
CATHETER THROMCTMY 5MAX L 132 CM PROX/DSTL OD 6/5.75,SUP-2323547,CDM,C1725,HCPCS,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
INSTRUMENT KIT,SUP-2119914,CDM,C1776,CPT,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
PIN EXT FIX CLMP ARTC TOMAHAWK MINI FIX,SUP-2400712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1673.62,1087.85,,,,,,,,,,,,,
LEAD NERVE STIM 33 CM MRI INTERSTIM SURESCAN,SUP-2641996,CDM,C1778,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
PLATE BNE HK ANK 8 HOLE,SUP-2389479,CDM,C1713,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
GRAFT BNE H100MM ANT POST DIA23 27MM FEM SHFT FRZ DRY TEXT,SUP-2264865,CDM,C1713,HCPCS,0278,RC,,,,both,,,4534.41,2947.37,,,,,,,,,,,,,
KIT CAST SZ 3 IN TOT CONTACT SYS W/O BOOT SAW TCC-EZ,SUP-2909201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
PLATE BNE L 208 MM SCREW DIA 3.5 MM 18 H SS HUM FEM TIB,SUP-2931234,CDM,C1713,HCPCS,0278,RC,,,,both,,,3277.22,2130.19,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LORDTC 7 DEG 12X14.5X7.22X5.75 MM,SUP-2264943,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.35,1892.38,,,,,,,,,,,,,
HC So Bordetella,PX-3028661566,CDM,86615,CPT,0302,RC,,,,both,,,24.00,15.60,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT SHELL TRAB MEL,SUP-2212734,CDM,C1776,CPT,0278,RC,,,,both,,,13459.61,8748.75,,,,,,,,,,,,,
EXTENSION STEM L180MM OD13MM HIP FEM MOD PLSM SPRY IMP,SUP-2217204,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE STROPP SGL TUNN REP STRL PACKAGED KT THAT INCLUDE PEEK,SUP-2175158,CDM,C1776,CPT,0278,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
BUR ENDOSCP BRL 6.5X120 MM FINISH DK BLK PUR UNIDRIVE,SUP-2585889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,121.68,79.09,,,,,,,,,,,,,
HALF PIN 4MMX45MM,SUP-2818302,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1002.07,651.35,,,,,,,,,,,,,
PLATE BNE LCK 233 MM LT DORS PROXIMAL ULNAR 15 HOLE STRL,SUP-2470065,CDM,C1713,HCPCS,0278,RC,,,,both,,,3001.34,1950.87,,,,,,,,,,,,,
ANCHOR 6.8MM PEEK,SUP-2589139,CDM,C1713,HCPCS,0278,RC,,,,both,,,1223.85,795.50,,,,,,,,,,,,,
BENZONATATE 100 MG PO CAPS,RX-988,CDM,6370000000,HCPCS,0637,RC,68084-0214-01,NDC,,both,1,UN,4.00,2.60,,,,,,,,,,,,,
CATHETER ABLATN LG 2-5-2 MM 8 MM TIP 8 FRX110 CM THER 2 8,SUP-2102286,CDM,C1733,HCPCS,0272,RC,,,,both,,,2844.84,1849.15,,,,,,,,,,,,,
BB-TAK MTP THREADED,SUP-2811921,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 15 CM DIA 8 MM STD,SUP-2323364,CDM,C1889,HCPCS,0278,RC,,,,both,,,7115.24,4624.91,,,,,,,,,,,,,
GUIDEWIRE VASC STR 182 FLPY CHOICE,SUP-2139580,CDM,C1769,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3373,HCPCS,0636,RC,67457-0339-50,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
VALVE ANGIO Y VLV HEMSTAT 75FR W INSRT TOOL PASS,SUP-2303030,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.43,28.23,,,,,,,,,,,,,
ISOSORBIDE DINITRATE 20 MG PO TABS,RX-4065,CDM,6370000000,HCPCS,0637,RC,00904-6620-61,NDC,,both,1,UN,3.30,2.14,,,,,,,,,,,,,
SHEATH INTRO FLX L 40 CM OD 12 FR GUIDEWIRE 0.038 IN LG,SUP-2170116,CDM,C1894,HCPCS,0272,RC,,,,both,,,176.66,114.83,,,,,,,,,,,,,
ALLOGRAFT BNE GRAN STRP 2 CC HA/TCP CLLGN VENADO 4815T5022,SUP-2718007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1595.12,1036.83,,,,,,,,,,,,,
HC Reposition a/V Lead,PX-4813321500,CDM,33215,CPT,0481,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
TRIAL SPNL L17MM ANTR PLT,SUP-2291671,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
PLATE BNE RECON MED 2-2.3X2.8 MM LT PRESHAPED SMRT TI NS,SUP-2487421,CDM,C1713,HCPCS,0278,RC,,,,both,,,9908.84,6440.75,,,,,,,,,,,,,
COMPONENT TALAR FIN SWEEPER FIN SWEEPER TOT ANK REPL APEX 3D,SUP-2742290,CDM,C1776,CPT,0278,RC,,,,both,,,632.71,411.26,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4X2 H BILAT HND TRAPEZOIDAL,SUP-2267893,CDM,C1713,HCPCS,0278,RC,,,,both,,,811.38,527.40,,,,,,,,,,,,,
PROBE LSR ANG ILLUMINATING STP OPTIMAL BRIGHTNESS 20DEG,SUP-2247217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,862.46,560.60,,,,,,,,,,,,,
ANCHOR SUT DIA14MM 1 SFT SGL LD MB JUGGERKNOT,SUP-2137224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1241.56,807.01,,,,,,,,,,,,,
SHEARS SEAL L45CM DIA5MM CRV BLDE W ERGO GRP HNDL HARM ACE,SUP-2257349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1700.15,1105.10,,,,,,,,,,,,,
SHEATH INTRO 8FR L63CM TRANSSEPTAL SL2 CRV BRAID HEMSTAS,SUP-2357254,CDM,C1893,HCPCS,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
TUBING ASPIR FOR REPERFUSION CATH PMP CANSTR MAX PTS3,SUP-2849700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
GRAFT VASC INTERGARD BODY/BRANCH L 100/60 CM DIA10 X 10 MM,SUP-2914832,CDM,C1762,CPT,0278,RC,,,,both,,,3015.34,1959.97,,,,,,,,,,,,,
PUSHER KNOT L12.9IN FOR EXCORP TYNG HEARTPORT,SUP-2219525,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
BLADE SURG OPENER MAST QUAD,SUP-2631644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1576.06,1024.44,,,,,,,,,,,,,
SCREW BNE INTRF 7X25 MM FT COMPOSITCP 30,SUP-2608575,CDM,C1713,HCPCS,0278,RC,,,,both,,,1244.95,809.22,,,,,,,,,,,,,
PIN POS S STL CERCLAGE,SUP-2187032,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PLATE BNE L 131 X W 11.4 MM THK 3.5 MM SCREW DIA 3.5 MM 9 H 72464509,SUP-2933336,CDM,C1713,HCPCS,0278,RC,,,,both,,,3366.39,2188.15,,,,,,,,,,,,,
TRIAL FIX PIN MOB BEAR TIB TY,SUP-2252717,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SUTURE ACHOR PUSHLOCK,SUP-2812464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
HC Ventilator Subsequent Day,PX-4109400300,CDM,94003,CPT,0410,RC,,,,outpatient,,,1569.00,1019.85,,,,,,,,,,,,,
PIN FIX L30MM OD2MM NONLOCKING RESRB SELF REINF PLLA ST,SUP-2166476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.38,303.15,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 10 PED W/ SHUNT ASST AND BUR H RESVR,SUP-2108747,CDM,C1729,HCPCS,0272,RC,,,,both,,,8990.95,5844.12,,,,,,,,,,,,,
ANCHOR SUT ST COBRAID BLK BLU OD4.5MM SZ 2 TWINFIX ULT HA,SUP-2341851,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
PLATE VA-LOCKING CALCANEAL 2.7MM SMALL 58MM LEFT-STERILE,SUP-2546124,CDM,C1713,HCPCS,0278,RC,,,,both,,,3313.11,2153.52,,,,,,,,,,,,,
NAIL INTRMDLLRY 2MM DIA 440MML TTNM FLXBLE UNVRSL SOLID GREE,SUP-2734263,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
HANDPIECE ULTRSNC SYS 11 MM CEMENT REMOVAL HELIX TIP STRL,SUP-2883822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1329.35,864.08,,,,,,,,,,,,,
DARBEPOETIN ALFA 300 MCG/0.6ML IJ SOSY,RX-131233,CDM,J0881,HCPCS,0636,RC,55513-0111-01,NDC,,both,0.6,ML,6849.90,4452.43,,,,,,,,,,,,,
PLATE BNE L137MM THK3.4MM 10 H BILAT S STL STR LOK COMPR,SUP-2185142,CDM,C1713,HCPCS,0278,RC,,,,both,,,981.22,637.79,,,,,,,,,,,,,
SLEEVE COMPR SCR FIX DRL FRAG LOC,SUP-2106752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
SET INTRO L 60 CM DIA 5 FR SS WIRE SHRT B BVL ECHOGENIC TIP,SUP-2116527,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
SPLINT HND ANTIMICROBIAL LG 8 IN WRST LT ROLYAN HANZ WHFO,SUP-2326334,CDM,L3906,HCPCS,0272,RC,,,,both,,,138.03,89.72,,,,,,,,,,,,,
IMPLANT TOE HEMI,SUP-2397200,CDM,C1776,CPT,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
SYSTEM BRACHYTHERAPY DEL W THE PALLADIUM 103 SEED READYLINK,SUP-2129128,CDM,C2640,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
STEM FEM TAPR 12/14 UNCEMENTED TI ALLOY SM MAYO,SUP-2203725,CDM,C1776,CPT,0278,RC,,,,both,,,15532.01,10095.81,,,,,,,,,,,,,
BIT DRL QC 2.4X100 MM FOR VAR ANGLE NS LCP,SUP-2424151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.76,243.59,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 67X50X14 MM 38 CC 78 GM ATLS + DR V243ROPT] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356552,CDM,C1721,HCPCS,0275,RC,,,,both,,,51904.20,33737.73,,,,,,,,,,,,,
TAN {} ROSE {} 10X32 RT,SUP-2818884,CDM,C1713,HCPCS,0278,RC,,,,both,,,15899.08,10334.40,,,,,,,,,,,,,
KIT INTRO DIA 6 FR TUOHY BORST ADPT STRL,SUP-2877845,CDM,C1894,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
STRAP SPLNT 2INX18IN WHT NYL D RNG HK AND LOOP ROLYAN,SUP-2324781,CDM,L3908,HCPCS,0274,RC,,,,both,,,9.73,6.32,,,,,,,,,,,,,
CONNECTOR SHUNT 0.78X1.35 MM TYP C SS HOLTER,SUP-2666818,CDM,C1889,HCPCS,0278,RC,,,,both,,,1136.08,738.45,,,,,,,,,,,,,
RESORB X BURR HOLE COVER CONTOURED 10MM 17MM DIA,SUP-2681138,CDM,C1713,HCPCS,0278,RC,,,,both,,,1014.97,659.73,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC STRP LG ELBW TENNNIS NEOPRNE,SUP-2136949,CDM,L3702,HCPCS,0274,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
GUIDEWIRE ORTH OD1.1MM FOR INTROSSEOUS FIX SYS,SUP-2315894,CDM,C1769,HCPCS,0272,RC,,,,both,,,52.75,34.29,,,,,,,,,,,,,
NAIL IM L270MM DIA9MM TIB DK BLU TI SLD LOK BEND,SUP-2192771,CDM,C1713,HCPCS,0278,RC,,,,both,,,4215.70,2740.20,,,,,,,,,,,,,
POST GLEN 15.6X32 MM 2 MM TAPR W/ SHT PIN GUIDEWIRE CLN OVO,SUP-2776723,CDM,C1713,HCPCS,0278,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
HC NM Acute GI Bleed Study,PX-3417827800,CDM,78278,CPT,0341,RC,,,,inpatient,,,2106.00,1368.90,,,,,,,,,,,,,
BRACE ORTH UNIV FABRIC MESH SHLDR UNISX AD BCKL CLOSURE HK,SUP-2915222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.45,223.24,,,,,,,,,,,,,
PLATE BNE L118MM 9 H RECON FOR 35MM SCR UNIV LOK SYS,SUP-2199389,CDM,C1713,HCPCS,0278,RC,,,,both,,,1542.09,1002.36,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE STR WTAB 1.5 MM SCRW6 HOLE T0.6 MM,SUP-2681872,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.24,356.36,,,,,,,,,,,,,
IMPLANT W/ HIFOCUS HELIX ELECTRD DIAM 0.66MM-1.16MM OR,SUP-2140410,CDM,L8614,HCPCS,0278,RC,,,,both,,,80855.00,52555.75,,,,,,,,,,,,,
STYLET SURG VIPER PRIM,SUP-2255668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 7 MM EPTFE STR STD WALL,SUP-2525430,CDM,C1768,CPT,0278,RC,,,,both,,,345.84,224.80,,,,,,,,,,,,,
SYSTEM DRAINAGE MONITORR SP0042,SUP-2666839,CDM,C1729,HCPCS,0272,RC,,,,both,,,634.25,412.26,,,,,,,,,,,,,
PLUG ACET SCR H CONTINUUM,SUP-2203895,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
NAIL IM L180MM OD11MM 125DEG S STL TROCHANTERIC LOK CANN,SUP-2371033,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
PLATE BONE SM 5 H PROX RAD TI LCK COMPR FOR 2.5MM SCR ALPS,SUP-2411725,CDM,C1713,HCPCS,0278,RC,,,,both,,,2647.02,1720.56,,,,,,,,,,,,,
MESH SURG DIA86CM POLY PGLA CLLGN FLM RIG ABSRB EXP SEMI,SUP-2283995,CDM,C1781,HCPCS,0278,RC,,,,both,,,1649.94,1072.46,,,,,,,,,,,,,
GRAFT BNE SUB W10 30MM SPL L50 130MM THK1 20MM RIB SEGMENTS,SUP-2307187,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.43,577.48,,,,,,,,,,,,,
ORTHO ANCHRGE C TUBE PLATE RIGHT HOOK STRGHT 4 HOLE 6MM BRG,SUP-2676797,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.77,750.60,,,,,,,,,,,,,
RHINOLARYNGOSCOPE VID INTERVENTION 130 DEG 5X350 MM ASCOPE 4,SUP-2752985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
PROCESSOR SND HEARING MAIN MOD NEUT BGE NUCLS FRDM,SUP-2165042,CDM,L8690,HCPCS,0278,RC,,,,both,,,14280.72,9282.47,,,,,,,,,,,,,
IMPLANT BIO TISS W18 25XL450MM THCK CLLGN DERM MTRX XENMTRX,SUP-2126246,CDM,C1781,HCPCS,0278,RC,,,,both,,,125690.12,81698.58,,,,,,,,,,,,,
SCREW BNE L65MM DIA7.3MM PROX FEM S STL SELF DRL ST CONIC,SUP-2184760,CDM,C1713,HCPCS,0278,RC,,,,both,,,768.73,499.67,,,,,,,,,,,,,
HC Rm Private,PX-1100000000,CDM,1100000000,LOCAL,0110,RC,,,,inpatient,,,2515.00,1634.75,,,,,,,,,,,,,
SPACER FEM SZ 0 THK4MM LT LAT CONSTRN REV CEM NP N-K II,SUP-2209189,CDM,C1776,CPT,0278,RC,,,,both,,,3224.78,2096.11,,,,,,,,,,,,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,0636,RC,00338-0703-41,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
PASSER SUTURE STRL DISP GRAPPLER KIT 5/BX,SUP-2900171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
BOOT ORTHOT M SMOOTH IN BD AFO SOFTPRO,SUP-2324237,CDM,L4387,HCPCS,0272,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
SCREW BNE FOR TOT HIP POSTEROLATERAL APPRCH MAKO,SUP-2368442,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.33,418.81,,,,,,,,,,,,,
CATHETER DRNGE 8.5FR CANN 18GA L15CM DIA0.038IN UTHANE,SUP-2168646,CDM,C1729,HCPCS,0272,RC,,,,both,,,200.46,130.30,,,,,,,,,,,,,
WIRE BNE FIX REDUCTION NS DISP PRECIS MIS,SUP-2899213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 50 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120665,CDM,C1768,CPT,0278,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
TIP MACRO SHORT 2.6MM,SUP-2741123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
BALLOON PRSS REG 61-70CM H2O W/O INHIBZN FOR PENILE PROS,SUP-2138914,CDM,C1815,HCPCS,0278,RC,,,,both,,,10540.98,6851.64,,,,,,,,,,,,,
PEG BNE FIX L10MM DIA2.5MM VOLAR PARTIALLY THRD FOR ANAT,SUP-2414240,CDM,C1776,CPT,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
PIN DRL SM SH DISP FOR 4.5/8.5MM BEAMING SYS,SUP-2223921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
TREPHINE SURG OD12MM CRWN DRL,SUP-2368638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2017.45,1311.34,,,,,,,,,,,,,
SHEATH INTRO VASCU-SHEATH L 14 CM DIA17 FR PTFE VLV PEELABLE,SUP-2905036,CDM,C1892,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
CATHETER INFUSION L 40 CM DIA 5 FR SEG L 7 CM GUIDEWIRE,SUP-2168146,CDM,C1751,HCPCS,0278,RC,,,,both,,,277.54,180.40,,,,,,,,,,,,,
TISSUETAK TENDON ANCHOR,SUP-2812415,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
CATHETER PA L 75 CM DIA 4 FR INTRO DIA 5 FR BALLOON DIA 8 MM,SUP-2894093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
PLATE BNE L 201 X W 10.9 MM THK 3.4 MM SCREW DIA 3.5 MM 16 H 72463716,SUP-2933029,CDM,C1713,HCPCS,0278,RC,,,,both,,,6063.97,3941.58,,,,,,,,,,,,,
COMPONENT TOE 15MM 2.5X3.5MM OFFSET ARTC DF,SUP-2123614,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
PLATE VARIAX COMP NAR STRAIGHT 9HL,SUP-2703713,CDM,C1713,HCPCS,0278,RC,,,,both,,,2670.57,1735.87,,,,,,,,,,,,,
HC Insert Ivc Filter,PX-3613719100,CDM,37191,CPT,0361,RC,,,,inpatient,,,16763.00,10895.95,,,,,,,,,,,,,
SCREW BNE L 65 MM DIA 6.5 MM SS CANN LCK NS EVOS,SUP-2931536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1385.05,900.28,,,,,,,,,,,,,
KIT CATHETER AD 7FR L30CM CTRL VEN POLYUR NONCOATED 3 LUMN,SUP-2120585,CDM,C1751,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,0636,RC,10019-0055-61,NDC,,both,250,ML,744.70,484.05,,,,,,,,,,,,,
SYSTEM CARD PACEMKR LEADLESS SINGLE CHMBR SURESCAN,SUP-2882758,CDM,C1786,HCPCS,0275,RC,,,,both,,,29547.40,19205.81,,,,,,,,,,,,,
GRAFT BNE MTRX 2.5 CC CELLULAR BNE MTRX V92,SUP-2434350,CDM,C1713,HCPCS,0278,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
GRAFT HUM TISS 4X12CM THK0.8-1.8MM DERM NEOFORM,SUP-2300709,CDM,C1762,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SUTURE ANCHR BIORAPTOR 2.9 SUT ANCHR W/ 2 ULTRABRAID NO 2,SUP-2341672,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.42,550.82,,,,,,,,,,,,,
COLLAR CERV M H3XL17IN HK AND LOOP CLSR W/ STOCK,SUP-2194569,CDM,L0180,HCPCS,0272,RC,,,,both,,,45.50,29.57,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 2 CM DIA2 MM CATH DIA 0.018 IN LOOP,SUP-2647205,CDM,C1889,HCPCS,0278,RC,,,,both,,,326.53,212.24,,,,,,,,,,,,,
HC Assay of Prostate Specific Antigen Free,PX-3018415400,CDM,84154,CPT,0301,RC,,,,both,,,267.00,173.55,,,,,,,,,,,,,
"HC So Chloride, Urine Spot",PX-3018243666,CDM,82436,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
CATHETER TRAY 10 FRX90 CM CV PASV 2,SUP-2308259,CDM,C1751,HCPCS,0278,RC,,,,both,,,1018.77,662.20,,,,,,,,,,,,,
COIL EMB L35CM OD0.020IN LOOP OD9MM STD NIT COMPLX FRME,SUP-2323369,CDM,C1889,HCPCS,0278,RC,,,,both,,,7149.78,4647.36,,,,,,,,,,,,,
PLATE BNE Y MIC XLN 1.5 MM TI LEVEL 1,SUP-2461681,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
PLATE BNE NAR 3.5X287 MM 16 HOLE SS LCP,SUP-2569358,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.80,461.37,,,,,,,,,,,,,
LACTATED RINGERS IV BOLUS,RX-40840057,CDM,J7120,HCPCS,0250,RC,00338-0117-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
DEVICE PESSARY CUBE 4 DRN,SUP-2119333,CDM,A4562,HCPCS,0272,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
"HC So Encephalitis, California",PX-3028665166,CDM,86651,CPT,0302,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1010,HCPCS,0636,RC,70121-1574-01,NDC,,both,1,ML,93.90,61.03,,,,,,,,,,,,,
BIT DRL 2.7 MM,SUP-2365029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
HAEMOPHILUS B POLYSAC CONJ VAC 10 MCG IJ SOLR,RX-127387,CDM,2500000003,HCPCS,0250,RC,58160-0726-15,NDC,,both,1,UN,59.30,38.54,,,,,,,,,,,,,
HC Intro Need/Cath Car/Ver Art,PX-3613610000,CDM,36100,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SHOE ORTHOT MAR BAR ADDITION,SUP-2435744,CDM,L3595,HCPCS,0274,RC,,,,both,,,118.75,77.19,,,,,,,,,,,,,
PIN EXT FIX L150MM DIA6MM THRD L60MM S STL HA HALF FOR ILIZ,SUP-2343021,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
SIMVASTATIN 10 MG PO TABS,RX-11364,CDM,6370000000,HCPCS,0637,RC,16714-0682-02,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE 1.5MM MESH NEURO SCR DIA7.5X7.5CM ISOGRID TI,SUP-2277536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 10X13X39 MM 8 FRX135 CM VIABAHN VBX,SUP-2395692,CDM,C1874,HCPCS,0278,RC,,,,both,,,9715.16,6314.85,,,,,,,,,,,,,
KIT INFSN 5FR CATH 135CML LNGTH 20CM CHECK RELF VLV HEMSTAS,SUP-2676954,CDM,C1751,HCPCS,0278,RC,,,,both,,,333.31,216.65,,,,,,,,,,,,,
HC Glucose Post Glucose Dose,PX-3018295000,CDM,82950,CPT,0301,RC,,,,inpatient,,,274.00,178.10,,,,,,,,,,,,,
STAPLE INT CARTRIDGE 10X10 MM TI SS DISP,SUP-2166759,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SIZER SURG BRST SMOOTH HI PROF X SILTEX MEMORYGEL,SUP-2748644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CALF SPRING WIRE DORSIFLEXION BND,SUP-2435621,CDM,L1900,HCPCS,0272,RC,,,,both,,,807.73,525.02,,,,,,,,,,,,,
SHEATH INTRO OPTISEAL L 25 CM OD 12 FR ID 4.1 MM DIL DIA 4.2,SUP-2281856,CDM,C1892,HCPCS,0272,RC,,,,both,,,202.12,131.38,,,,,,,,,,,,,
CONNECTOR SPNL L200MM POST LAT TI OFFSET SACR EXT FIX XLNK,SUP-2254757,CDM,C1713,HCPCS,0278,RC,,,,both,,,2395.82,1557.28,,,,,,,,,,,,,
HEAD FEM MED 36 MM HIP CERM,SUP-2322502,CDM,C1776,CPT,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
GRAFT TEND ACHILLES W CALCANEUS ALLGRFT FRZ DRY 195 38CM L,SUP-2307083,CDM,C1762,CPT,0278,RC,,,,both,,,6446.04,4189.93,,,,,,,,,,,,,
SYSTEM GLAUCOMA TREAT INCLUDES XEN 45 PORCINE DERM GEL STENT,SUP-2113356,CDM,L8612,HCPCS,0278,RC,,,,both,,,8013.28,5208.63,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 440 MM NEWPORT MIS,SUP-2245926,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMOS DR-T TI EPOXY RESIN SIL 2 CHMBR DF1,SUP-2138085,CDM,C1721,HCPCS,0275,RC,,,,both,,,57590.74,37433.98,,,,,,,,,,,,,
KIT BNE CEMENT MIXING SYS MIS FEM BRKWY NOZ ADV FEM CNL,SUP-2884228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.44,264.19,,,,,,,,,,,,,
OXYCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS,RX-31863,CDM,6370000000,HCPCS,0637,RC,00904-7094-61,NDC,,both,1,UN,3.70,2.40,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED RESURF H20] STRYKER CORP],SUP-2365526,CDM,C1776,CPT,0278,RC,,,,both,,,30772.00,20001.80,,,,,,,,,,,,,
WASHER ORTH FIX OLECRANON NUT SPCR SZ 1.0MM,SUP-2106886,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SPACER FEM 5 MM DSTL RT LAT,SUP-2364851,CDM,C1776,CPT,0278,RC,,,,both,,,2922.56,1899.66,,,,,,,,,,,,,
HC Drug Screen Quantitative Phenytoin Total,PX-3018018500,CDM,80185,CPT,0301,RC,,,,both,,,319.00,207.35,,,,,,,,,,,,,
CLAMP ABLAT JAW L53MM L CRV 2 ELECTRD BPLR,SUP-2124465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 THK10MM KNEE FULL STP HNG REV LEGION,SUP-2346599,CDM,C1776,CPT,0278,RC,,,,both,,,5695.96,3702.37,,,,,,,,,,,,,
PLATE SPNL OCC SM EL CAPITAN NORTHSTAR,SUP-2710863,CDM,C1713,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM 7 FR 35MM 1-1 MM D,SUP-2248480,CDM,C1731,HCPCS,0278,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
RING EXT FIX HALF 140 MM CARBON FIBER NS,SUP-2799574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1434.10,932.16,,,,,,,,,,,,,
PEG IM NAIL L 26 MM DIA2.7 MM TI FIBULAR DSTL THRD HDLSS NS,SUP-2909006,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
COMPONENT FEM 5 CO CHROM LT KNEE UNISX PRI CEM,SUP-2346571,CDM,C1776,CPT,0278,RC,,,,both,,,10000.90,6500.58,,,,,,,,,,,,,
ENDCAP ORTH L15MM DIA3.5MM ST HUM TI NAIL EXTN HEX RECESS,SUP-2192535,CDM,C1713,HCPCS,0278,RC,,,,both,,,949.88,617.42,,,,,,,,,,,,,
PLATE BNE METATARSAL PHYLANGEAL FUS FOR 35MM SCR,SUP-2243231,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
STEM FEM PRSS FT 12X100 MM REV N SLT GEN II,SUP-2435042,CDM,C1776,CPT,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
MESH HERN L W1.5XL1.9IN SYN POLY-4-HYDROXYBUTYRATE PLUG AND,SUP-2125875,CDM,C1781,HCPCS,0278,RC,,,,both,,,1412.84,918.35,,,,,,,,,,,,,
JIG TIBIAL LOCKING NAIL,SUP-2588064,CDM,C1713,HCPCS,0278,RC,,,,both,,,46795.86,30417.31,,,,,,,,,,,,,
PERI-LOC 3.5MM S-T LOCK SCREW 16MM,SUP-2819136,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.39,665.20,,,,,,,,,,,,,
GRAFT TENDON SEMITENDINOSUS SGL STRAND,SUP-2855505,CDM,C1762,CPT,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
PLATE BONE THK0.5MM 4 H BILAT CRAN TI STR LO PROF RIG NEUT,SUP-2190695,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.96,181.32,,,,,,,,,,,,,
SHEATH INTRO DIA 4 FR GUIDEWIRE L 40 CM DIA 0.018 IN NDL L 7,SUP-2120521,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.39,48.35,,,,,,,,,,,,,
AMK TIB TY SZ 2,SUP-2251227,CDM,C1776,CPT,0278,RC,,,,both,,,7240.84,4706.55,,,,,,,,,,,,,
HC So1 Chylmd Trach Dna Amp Probe,PX-3068749167,CDM,87491,CPT,0306,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
BUR SURG L75CM DIA5MM DMND LEGEND MIDAS REX,SUP-2279702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.11,262.02,,,,,,,,,,,,,
SLING INCONT RETROPUBIC CONTINENCE SYS GYNECARE TVT EXACT,SUP-2220077,CDM,C1771,HCPCS,0278,RC,,,,both,,,6069.62,3945.25,,,,,,,,,,,,,
MESH BONE 126MMW X 126MML 1MM THK RSRB XG SM GRID LATEX FREE,SUP-2487541,CDM,C1713,HCPCS,0278,RC,,,,both,,,8438.81,5485.23,,,,,,,,,,,,,
COMPONENT TIB CR 0 13 MM RT KNEE PRIMARY STEM CEM NP UCONG,SUP-2209406,CDM,C1776,CPT,0278,RC,,,,both,,,4143.23,2693.10,,,,,,,,,,,,,
HC Special Med Physics Consult,PX-3337737000,CDM,77370,CPT,0333,RC,,,,inpatient,,,1443.00,937.95,,,,,,,,,,,,,
KIT INTRO ELITE HV L 7 CM DIA 3 FR GUIDEWIRE L 40 CM DIA,SUP-2615941,CDM,C1894,HCPCS,0272,RC,,,,both,,,143.62,93.35,,,,,,,,,,,,,
HC So1 Testosterone Free,PX-3018440267,CDM,84402,CPT,0301,RC,,,,both,,,312.00,202.80,,,,,,,,,,,,,
CLAMP REPROC EXT FIX L DIA11MM C FBR CLP ON SELF HLD MRI COMPATIBLE,SUP-2188496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.48,303.21,,,,,,,,,,,,,
SCREW BNE L16MM DIA1.3MM CORT TI ST FULL THRD W/ CRUCFRM,SUP-2189219,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.90,148.13,,,,,,,,,,,,,
PIN TENS BND DIA15MM L50MM S STL SMOOTH,SUP-2107849,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
GRAFT PLCNTA MEMBRN 14MM DISC ECM GRAFIX,SUP-2319159,CDM,Q4133,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BONE CRANIAL SQUARE 12X12MM TITANIUM NEURO PLATING SYS,SUP-2827186,CDM,C1713,HCPCS,0278,RC,,,,both,,,209.75,136.34,,,,,,,,,,,,,
KIT INTRO VSI L 10CM 4FR NIT MANDREL TUNGSTEN TIP SIL ANGLED,SUP-2763490,CDM,C1892,HCPCS,0272,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
HC Cbc (Hemogram)|NOT REASONABLE AND NECESSARY,PX-3058502700,CDM,85027,CPT,0305,RC,,,GZ,both,,,116.00,75.40,,,,,,,,,,,,,
HC Pt Ultrasound Each 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209703500,CDM,97035,CPT,0420,RC,,,GP|CQ,outpatient,,,194.00,126.10,,,,,,,,,,,,,
ANCHOR SUT DIA1.45MM 2 SHT RIG DRL BIT JUGGERKNOT,SUP-2212785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.72,722.62,,,,,,,,,,,,,
"HC So Chlamydia, Ab, Igm",PX-3028663266,CDM,86632,CPT,0302,RC,,,,outpatient,,,225.00,146.25,,,,,,,,,,,,,
CLIP SURG VES .196INX6X1MM BLDE KLEINERT KUTZ FN CVD PILLING,SUP-2384441,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 2X3CM,SUP-2905486,CDM,Q4151,HCPCS,0636,RC,,,,both,,,2694.87,1751.67,,,,,,,,,,,,,
SCREW BNE L13MM DIA2.4MM HD DIA4.5MM STD CORT S STL ST,SUP-2183245,CDM,C1713,HCPCS,0278,RC,,,,both,,,136.15,88.50,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.025 IN TAPR L 7 CM FLX TIP 2.5,SUP-2167793,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.16,22.20,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK45UM AMNIO MEMBRN DEHYDR OMNI DIR,SUP-2340452,CDM,C1762,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
FIBER LASER 550 MH 0.58 MM SIDE FIRING HOLM SLM LN EZ DISP,SUP-2141789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3811.71,2477.61,,,,,,,,,,,,,
DEVICE EMBOLIC 0.36MM WIRE DIA 190CM 5FR INTRO 7MM TEMP NIT S,SUP-2173566,CDM,C1884,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CANNULA IRRIGATION 7X85 MM HEX-FLEX,SUP-2167092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
SET CARDPLG PERF 4:1 W/ HEAT EXCHG W/ RIDGE BUB TRAP FLTR,SUP-2384917,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.63,216.86,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEM H3SN] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351358,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
TADALAFIL 20 MG PO TABS,RX-36986,CDM,6370000000,HCPCS,0637,RC,29300-0289-13,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE FIX ANGLE 4X14 MM,SUP-2391497,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.73,745.37,,,,,,,,,,,,,
SCREW BONE L80MM DIA13MM THRD L22MM STRL CANC S STL ST CANN,SUP-2186573,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.01,554.46,,,,,,,,,,,,,
ELECTRODE COAG PT 22FR,SUP-2261119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
KIT INFUS PMP 270ML 2M/HR SOAK CATH L5IN N NARC ON-Q,SUP-2420884,CDM,C9804,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
PLATE BNE 3.5X265 MM 22 HOLE SS DCP,SUP-2569148,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
PLATE BNE LCK 155 MM RT DORS PROXIMAL ULNAR 9 HOLE STRL,SUP-2462364,CDM,C1713,HCPCS,0278,RC,,,,both,,,2504.59,1627.98,,,,,,,,,,,,,
PLATE BNE L68MM 5 H 1 3RD TBLR LOK FOR 3.5MM SCR UNIV LOK,SUP-2411367,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
CATHETER GUID SOFIA + L 131 CM DIA 6 FR ID 0.070 IN OD,SUP-2538141,CDM,C1887,HCPCS,0272,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
SPACER SPNL W26XH10MM SM PEEK THORLUM INTBDY FUS CNTR STK,SUP-2291507,CDM,C1889,HCPCS,0278,RC,,,,both,,,4421.12,2873.73,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED MED 8 IN RT WRST FOREARM THMB,SUP-2276638,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.61,14.70,,,,,,,,,,,,,
COMPONENT FEM 5 CM RT KNEE RESURF OSS,SUP-2441729,CDM,C1776,CPT,0278,RC,,,,both,,,18905.94,12288.86,,,,,,,,,,,,,
SET INTRO S-MAK L 15 CM DIA 5 FR GUIDEWIRE L 60 CM DIA 0.018,SUP-2474699,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.8MM S STL W/ TRCR PNT,SUP-2184072,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.92,14.25,,,,,,,,,,,,,
STENT OPHTH MINI SIL FOR CANALICULAR LAC MONOKA,SUP-2224378,CDM,C1783,HCPCS,0278,RC,,,,both,,,272.11,176.87,,,,,,,,,,,,,
BRACE ORTHOPEDIC PUL ON 1 XS 12-15 IN KNEE FULL CIR STRP,SUP-2150965,CDM,L1810,HCPCS,0274,RC,,,,both,,,299.09,194.41,,,,,,,,,,,,,
AGENT EMB OBSIDIO CATH ID 0.024 IN RVD 3 MM 1 ML SHR,SUP-2874851,CDM,C1889,HCPCS,0278,RC,,,,both,,,20001.80,13001.17,,,,,,,,,,,,,
BUR SURG L98MM DIA1MM S STL CRV FLUT CUT VISAO,SUP-2284225,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.16,481.10,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 80 MM DIA22 MM LIMB 40 MM 20 MM,SUP-2541371,CDM,C1768,CPT,0278,RC,,,,both,,,37441.36,24336.88,,,,,,,,,,,,,
DRILL SURG PEGGED 1/8 IN KNEE TRIATHLON,SUP-2663081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,683.89,444.53,,,,,,,,,,,,,
HC Ptt|NOT REASONABLE AND NECESSARY,PX-3058573000,CDM,85730,CPT,0305,RC,,,GZ,both,,,120.00,78.00,,,,,,,,,,,,,
OXYCODONE HCL 5 MG/5ML PO SOLN,RX-10813,CDM,6370000000,HCPCS,0637,RC,60687-0406-40,NDC,,both,5,ML,31.50,20.47,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK MINI L 65 CM 2.5 FR 1 CM 6 MM,SUP-2659647,CDM,C1725,HCPCS,0272,RC,,,,both,,,2352.86,1529.36,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5 FR GUIDEWIRE L 40CM DIA 0.018 IN,SUP-2120526,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.505,SUP-2860187,CDM,C1713,HCPCS,0278,RC,,,,both,,,25477.02,16560.06,,,,,,,,,,,,,
"HC So Infectious Agent,Nos",PX-3068789966,CDM,87899,CPT,0306,RC,,,,inpatient,,,141.00,91.65,,,,,,,,,,,,,
MATRIX BIO L 6 X W 6 CM FET BOV DERM IONIC SLV DERMAL SLD,SUP-2909265,CDM,Q4110,HCPCS,0636,RC,,,,both,,,4874.85,3168.65,,,,,,,,,,,,,
BUR SURG CYL 3X11.3 MM 10 CM BRL SM BOR MIDAS REX 8 LEGEND,SUP-2664508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.01,307.46,,,,,,,,,,,,,
PLATE BNE SM W11XL64MM THK3.3MM 0DEG 5 H BILAT TI STR RIG,SUP-2190776,CDM,C1713,HCPCS,0278,RC,,,,both,,,513.48,333.76,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN XL 24X15 CMX0.7-1.4 MM KT FLEXHD,SUP-2307609,CDM,C1713,HCPCS,0278,RC,,,,both,,,37233.49,24201.77,,,,,,,,,,,,,
PLATE BNE STR 2.7X3 MM 20 HOLE RECON LCK FOR SCR TI GLD,SUP-2499142,CDM,C1713,HCPCS,0278,RC,,,,both,,,4004.54,2602.95,,,,,,,,,,,,,
HC Debrid Wound Tis Addl 20 Cm<,PX-4209759800,CDM,97598,CPT,0420,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
POST EXT FIX ANK FT 1 H FOR TRUELOK FRME ASSEMB HEXAPOD SYS,SUP-2316129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.96,283.37,,,,,,,,,,,,,
STEM HUM DSTL 19X170 MM SHLDR AEQUALIS FLX REVIVE PTC,SUP-2715477,CDM,C1776,CPT,0278,RC,,,,both,,,24335.00,15817.75,,,,,,,,,,,,,
INTRO SAFESHEATH 7FR 25CM W/SIDEPORT,SUP-2478232,CDM,C1892,HCPCS,0272,RC,,,,both,,,148.52,96.54,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 80 CM SUPP L 80 CM DIA 6 MM EPTFE,SUP-2227659,CDM,C1768,CPT,0278,RC,,,,both,,,3097.99,2013.69,,,,,,,,,,,,,
TOOL TUNN L 35.5 CM DIA 9 FR INTRO L 19.13 CM DIA 9 FR SS,SUP-2891549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CATHETER PERI DLYS 15FR L46CM UNIV STR LIN RADPQ STRP TENCK,SUP-2283895,CDM,C1750,HCPCS,0278,RC,,,,both,,,131.50,85.47,,,,,,,,,,,,,
BLADE SAW W13XL76MM THK089MM DBL SIDE RECIP,SUP-2205421,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
FLUCONAZOLE 100 MG PO TABS,RX-10044,CDM,6370000000,HCPCS,0637,RC,00904-6500-61,NDC,,both,1,UN,6.40,4.16,,,,,,,,,,,,,
GRAFT BONE 5ML MTRX,SUP-2136829,CDM,C1713,HCPCS,0278,RC,,,,both,,,4622.08,3004.35,,,,,,,,,,,,,
MESH SURG DIA6IN UNCOATED M WT MFIL PROPYLENE CIR HYDRGEL,SUP-2126542,CDM,C1781,HCPCS,0278,RC,,,,both,,,1613.96,1049.07,,,,,,,,,,,,,
"HC Debrid,Bone,1st 20sqcm or Less|UNUSUAL NON-OVERLAPPING SERVICE",PX-3611104400,CDM,11044,CPT,0361,RC,,,XU,both,,,4946.00,3214.90,,,,,,,,,,,,,
ERYTHROMYCIN BASE 250 MG PO TBEC,RX-2891,CDM,6370000000,HCPCS,0637,RC,13668-0586-30,NDC,,both,1,UN,22.50,14.62,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY DIA26 MM TI ALLOY POLYESTER SIL,SUP-2214261,CDM,C1889,HCPCS,0278,RC,,,,both,,,7677.30,4990.24,,,,,,,,,,,,,
PLATE SPNL L42MM CEPHALIC TO CAUD 34MM 8 H GLD ANTR BILAT,SUP-2193038,CDM,C1713,HCPCS,0278,RC,,,,both,,,1739.56,1130.71,,,,,,,,,,,,,
HC Icu R&B,PX-2000000000,CDM,2000000000,LOCAL,0200,RC,,,,inpatient,,,4935.00,3207.75,,,,,,,,,,,,,
KRANIOS 1.6 MM CRAN CLSR SYS BUR H CVR M 18 MM,SUP-2244074,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SCREW BNE L14MM DIA4MM CORT S STL ST FIX ANG NONCANNULATED,SUP-2184697,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.78,250.11,,,,,,,,,,,,,
HC Layer Closure Face <2.5 Cm,PX-4501205100,CDM,12051,CPT,0450,RC,,,,both,,,810.00,526.50,,,,,,,,,,,,,
KIT ROBOTIC SPINE DISP MAZORX,SUP-2266519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
MOMETASONE FUROATE 50 MCG/ACT NA SUSP,RX-21905,CDM,6370000000,HCPCS,0637,RC,65162-0891-29,NDC,,both,17,GR,540.10,351.06,,,,,,,,,,,,,
GUIDEWIRE VASC STR 0.035 INX50 CM STD FIX COR TAPR PTFE SS,SUP-2167661,CDM,C1769,HCPCS,0272,RC,,,,both,,,27.10,17.61,,,,,,,,,,,,,
WEDGE TIB SZ 7-8 10MM L MED R LAT KNEE HEMI STP LEGION,SUP-2346578,CDM,C1776,CPT,0278,RC,,,,both,,,4226.44,2747.19,,,,,,,,,,,,,
CANNULA SUCTION CURVED RUGGLES REDMOND,SUP-2702224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4491.20,2919.28,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7040,HCPCS,0250,RC,00264-7800-10,NDC,,both,500,ML,29.80,19.37,,,,,,,,,,,,,
HC So Osteocalcin,PX-3018393766,CDM,83937,CPT,0301,RC,,,,both,,,469.00,304.85,,,,,,,,,,,,,
KNIFE ULTRASND SONOPET 12CM IQ APEX 360,SUP-2719504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3069.92,1995.45,,,,,,,,,,,,,
WIRE FIX NIT K,SUP-2353339,CDM,C1713,HCPCS,0278,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
COMPONENT TIB CR ALL POLY 13MM SZ 1,SUP-2222625,CDM,C1776,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
BUR SURG HUDSON END 14 MMX4 IN CRAN BRAC CUSHING,SUP-2499470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1031.52,670.49,,,,,,,,,,,,,
KIT INTRO ELITE HV SHTH L 7 CM DIA 5 FR GUIDEWIRE L 45 CM,SUP-2615932,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.96,41.57,,,,,,,,,,,,,
GRAFT VASC L80CM OD6MM PTFE NONRINGED THN WALL SM BEAD STR,SUP-2126888,CDM,C1768,CPT,0278,RC,,,,both,,,4468.22,2904.34,,,,,,,,,,,,,
CATHETER MAP 4 MM 8 FRX120 CM 48 MM 64 ELECTRD CONSTELLATION,SUP-2424696,CDM,C1732,HCPCS,0278,RC,,,,both,,,14626.12,9506.98,,,,,,,,,,,,,
CATHETER INFUSION STR 200 CM 2.7/2.4 FRX155 CM FATHOM-16,SUP-2653477,CDM,C1887,HCPCS,0272,RC,,,,both,,,2499.44,1624.64,,,,,,,,,,,,,
SPLINT FNGR AD M JT EXTN TUBE DGT DYN,SUP-2325054,CDM,L3933,HCPCS,0272,RC,,,,both,,,46.91,30.49,,,,,,,,,,,,,
FILLER DERMAL JUVEDERM VOLLURE XC 1ML,SUP-2901641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
PLATE BNE L90MM 20 H TI ADPT FOR 1.5MM SCR,SUP-2191135,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS 35 L 105 CM DIA 8 FR,SUP-2738597,CDM,C1753,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
HC So Oxcarbazepine Metabolite,PX-3018018366,CDM,80183,CPT,0301,RC,,,,inpatient,,,128.00,83.20,,,,,,,,,,,,,
SCREW BONE 4.5X20MM ACET CANC TI SELF TAP HGP II,SUP-2202665,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.53,275.94,,,,,,,,,,,,,
SCREW BNE LO PROF CANN SYS 25MMX16MM CAPTURE,SUP-2243886,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.60,535.99,,,,,,,,,,,,,
SHUNT CV OD11.5FR DBL VLV RETAINS NUTRIENTS DIURESIS DENV,SUP-2133688,CDM,C1889,HCPCS,0278,RC,,,,both,,,6045.91,3929.84,,,,,,,,,,,,,
KIT RECHRG SPNL CRD PULSE GENRTR STIM SYS SURG EQUIP PRECIS,SUP-2141891,CDM,C1820,HCPCS,0278,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
STEM FEM SPLINED KNEE TAPR MICROPLASTY,SUP-2446370,CDM,C1776,CPT,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
IMPLANT BIO L 7 X W 10 CM FISH SKIN DERMAL SLD INTACT FLAT,SUP-2909240,CDM,Q4158,HCPCS,0636,RC,,,,both,,,7363.30,4786.14,,,,,,,,,,,,,
PIN EXT FIX THRD L25MM DIA3MM SHANK L65MM DIA4MM SH TI,SUP-2342891,CDM,C1713,HCPCS,0278,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
SCREW BNE 35MM THRD 4 3X80MM EXT FIX HA XCALIBER OSTEOTITE,SUP-2316321,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.39,266.10,,,,,,,,,,,,,
STENT PERIPH L50MM OD9MM CATH L75CM OD11FR VIABAHN,SUP-2396459,CDM,C1874,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COMPRESSOR EXT FIX OPN,SUP-2188620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1747.85,1136.10,,,,,,,,,,,,,
MESH HERN RECT 16X8 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855255,CDM,C1781,HCPCS,0278,RC,,,,both,,,33786.40,21961.16,,,,,,,,,,,,,
HC Inj Thrombin for Aneurysm,PX-3613600200,CDM,36002,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
SEGMENTAL ART SURF SZ C 12MM,SUP-2502388,CDM,C1776,CPT,0278,RC,,,,both,,,5185.71,3370.71,,,,,,,,,,,,,
BUR REVERSED TAPERED CUTTING 30K,SUP-2653407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.65,976.72,,,,,,,,,,,,,
MINI PLATE CUTTER DISTRACTORS,SUP-2680280,CDM,C1713,HCPCS,0278,RC,,,,both,,,4081.15,2652.75,,,,,,,,,,,,,
HEAD HUM ANAT 1.5 MM 37X13.5 MM SHLDR LOW OFFSET COCR,SUP-2715707,CDM,C1776,CPT,0278,RC,,,,both,,,9928.68,6453.64,,,,,,,,,,,,,
HC So Urine Cult/Colony Count,PX-3008708666,CDM,87086,CPT,0300,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
STRIP TST 10X40 CM 35 GM FOR HERN TILENE,SUP-2402502,CDM,C1781,HCPCS,0278,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
TIP ASPIR 23GA ADV BACKFLUSH SFT PASS OR ACT DISP,SUP-2109650,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.49,207.02,,,,,,,,,,,,,
SYSTEM LD DEL SELECTRA CORONARY SINUS STRL,SUP-2138088,CDM,C1893,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
SCREW BNE L115MM DIA9MM THRD L21MM DIA14.3MM SUP LAG CLASS,SUP-2342460,CDM,C1713,HCPCS,0278,RC,,,,both,,,2464.05,1601.63,,,,,,,,,,,,,
PROSTHESIS OSS 3-7 MM 3 MM 0.8 MM LT ALTO TOT W/ BND HA TI,SUP-2470841,CDM,L8613,CPT,0278,RC,,,,both,,,1314.09,854.16,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 80 MM DIA 9 MM DEL SYS L 150 CM,SUP-2866208,CDM,C1725,HCPCS,0272,RC,,,,both,,,3949.49,2567.17,,,,,,,,,,,,,
PLATE BNE 5DEG SHT L MTPHSEAL,SUP-2321451,CDM,C1713,HCPCS,0278,RC,,,,both,,,5196.70,3377.85,,,,,,,,,,,,,
GRAFT BONE PRO DENS 40CC,SUP-2399151,CDM,C1713,HCPCS,0278,RC,,,,both,,,16921.55,10999.01,,,,,,,,,,,,,
GRAFT DISC BIOFIBER BIOLOGIC SCAFFOLD BIOFIBER 8MM,SUP-2388568,CDM,C1781,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
PATCH VASC VASCU-GUARD L 6 X W 1 CM BOV PERICARD FOR CARTOID,SUP-2130382,CDM,C1768,CPT,0278,RC,,,,both,,,469.74,305.33,,,,,,,,,,,,,
STEM RADIAL 2 ELBW EXT RECON RHEAD,SUP-2463697,CDM,C1776,CPT,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT DIA25 MM BOV PERICARD COCR,SUP-2214056,CDM,C1889,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
ANCHOR SUT L16.3MM DIA5.5MM TI W/ TWO SZ 2 FIBERWIRE CRKSCR,SUP-2121570,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
LACOSAMIDE 50 MG PO TABS,RX-96882,CDM,6370000000,HCPCS,0637,RC,00131-2477-35,NDC,,both,1,UN,54.40,35.36,,,,,,,,,,,,,
BRACE WLK M M 5.5-10 FEM 6.5-11 SFT NYL FOAM LNR LO PROF,SUP-2197141,CDM,L4350,HCPCS,0274,RC,,,,both,,,84.62,55.00,,,,,,,,,,,,,
NEEDLE BRAIN BX DIM A 8MM DIMINLIN 24C,SUP-2107928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
PIN FIX TROCAR PT 1 END 4.8X229 MM STYL 5 THRD PLN SHANK SS,SUP-2466827,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.80,53.82,,,,,,,,,,,,,
HC Chemo Admin Subq/Intramusc,PX-3319640100,CDM,96401,CPT,0331,RC,,,,both,,,254.00,165.10,,,,,,,,,,,,,
HC So Aluminum,PX-3018210866,CDM,82108,CPT,0301,RC,,,,outpatient,,,497.00,323.05,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED RT WHL DSTL CONDYLE,SUP-2740771,CDM,C1762,CPT,0278,RC,,,,both,,,62964.82,40927.13,,,,,,,,,,,,,
AGENT HEMSTAT 3GM PURIFIED PLNT STARCH ABSRB BIOCOMPATIBLE,SUP-2379553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 3.01-4.0 MCI NS ADVANTAGE,SUP-2247268,CDM,C2643,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SLEEVE FEM L31MM UNIV MTPHSEAL TI PORCOAT DST POR LPS,SUP-2250938,CDM,C1776,CPT,0278,RC,,,,both,,,6703.27,4357.13,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM 14 MM POLYESTER BOV CLLGN STR,SUP-2265892,CDM,C1768,CPT,0278,RC,,,,both,,,1490.24,968.66,,,,,,,,,,,,,
GRAFT HUM TISS W10XL200MM THK3-12MM CORT FEM STRUT 3RD FRZN,SUP-2307354,CDM,C1713,HCPCS,0278,RC,,,,both,,,2530.06,1644.54,,,,,,,,,,,,,
STEM FEM SZ 6 SH TAPR HIP TI POR PLSM SPRY STD OFFSET,SUP-2349072,CDM,C1776,CPT,0278,RC,,,,both,,,20700.45,13455.29,,,,,,,,,,,,,
PLATE SPNL SZ 10 2 H ANT LAT LUM XLP,SUP-2311329,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PROBE VASC STERILIZABLE 8MHZ,SUP-2381493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1165.94,757.86,,,,,,,,,,,,,
GUIDEROD ORTH L1000MM DIA3MM PROX TIB BALL TIP FOR TRIGEN,SUP-2347059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1388.88,902.77,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLE 30 CM BA ACCU-FLO,SUP-2666402,CDM,C1729,HCPCS,0272,RC,,,,both,,,832.16,540.90,,,,,,,,,,,,,
LAG SCREW GUIDE SLEEVE,SUP-2678030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1005.80,653.77,,,,,,,,,,,,,
HC Pt Eval High Complex,PX-4249716300,CDM,97163,CPT,0424,RC,,,,both,,,326.00,211.90,,,,,,,,,,,,,
HYDROMORPHONE HCL PF 50 MG/5ML IJ SOLN,RX-118275,CDM,J1171,HCPCS,0636,RC,00409-2634-05,NDC,,both,5,ML,87.70,57.00,,,,,,,,,,,,,
PIN SURG FOR 0.078-0.126IN DRL CHK CLLT,SUP-2362644,CDM,C1713,HCPCS,0278,RC,,,,both,,,2466.72,1603.37,,,,,,,,,,,,,
RELOAD STPL H2X0.75MM DIA45MM GRY MESENTERY/THIN TISS NAT,SUP-2218988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.83,384.69,,,,,,,,,,,,,
PLATE BNE L 91 MM SHFT THK 2 MM HD 1.8 MM SCREW DIA 3.5 MM 6,SUP-2931289,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.77,2847.50,,,,,,,,,,,,,
GRAFT BONE SUB 2CC DEMIN BONE MTRX PASTE STAGRFT,SUP-2137252,CDM,C1713,HCPCS,0278,RC,,,,both,,,1584.76,1030.09,,,,,,,,,,,,,
PASSER SUT DIA2.3MM BAN SUTLASSO,SUP-2121807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
DRILL SLEEVE DOUBLE 2.7/2.0MM F/KMEDIC,SUP-2466477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,683.08,444.00,,,,,,,,,,,,,
HC Drain Cyst/Absces Dentoaveolar,PX-4504180000,CDM,41800,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
SCREW ACET CANC 6.5X15 MM HIP,SUP-2390373,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
FIBER LSR FLEXIVA PULSE 365,SUP-2717688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1033.00,671.45,,,,,,,,,,,,,
CATHETER ANGIO AD L130CM DIA5FR 0.038IN NONBRAIDED PGTL W/O(MIN ORDER 2 BX),SUP-2116597,CDM,C1887,HCPCS,0272,RC,,,,both,,,432.06,280.84,,,,,,,,,,,,,
CAGE SPNL L10XW10XH10MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317725,CDM,C1889,HCPCS,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
HC So Neuro CSF Prion Prtn Qual,PX-3100035066,CDM,0035U,CPT,0310,RC,,,,both,,,630.00,409.50,,,,,,,,,,,,,
STAPLER INT L21MM 48MM STPL GI TI CIR CUT LN 2 ROW,SUP-2283253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1028.13,668.28,,,,,,,,,,,,,
NAIL IM 5.5 MM DSTL DRL GAMMA,SUP-2538267,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HUNTER ACTIVE TENDON IMPLANT PC 4MMX22CM,SUP-2822403,CDM,C1763,HCPCS,0278,RC,,,,both,,,4267.26,2773.72,,,,,,,,,,,,,
DRESSING BIO 38 SQ CM INTACT FISH SKIN MIC STRL KERECIS,SUP-2883566,CDM,Q4158,HCPCS,0636,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
ROD SPNL L110MM DIA5.5MM POST R STR SMOOTH TI ALLY SEXTANT,SUP-2288459,CDM,C1713,HCPCS,0278,RC,,,,both,,,2016.51,1310.73,,,,,,,,,,,,,
SCREW BNE 3X50 MM MICA MIS,SUP-2417204,CDM,C1713,HCPCS,0278,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
BUR SURG BALL 4 MMX10 CM SPEC MIDAS REX LEGEND,SUP-2627617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.62,262.35,,,,,,,,,,,,,
GRAFT BNE SUB W10XH35XL25MM 10DEG B TRICALCIUM PHSPTE GRAN,SUP-2194025,CDM,C1713,HCPCS,0278,RC,,,,both,,,2258.41,1467.97,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR SS SHFT GLD TIP STD DIL MIC,SUP-2615952,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.81,59.03,,,,,,,,,,,,,
FASTTHREAD INTERFERENCE SCREW INST SET,SUP-2841330,CDM,C1713,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
BLADE SAW L 31 X W 9 MM THK 0.51 MM ORTHOCIRCLE STRL DISP,SUP-2881142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.04,230.13,,,,,,,,,,,,,
SPACER CORT ADCF 8MM,SUP-2137562,CDM,C1821,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE W255XL55MM WIDE 7X3 H NONSTERILE L DST RAD VOLAR,SUP-2180851,CDM,C1713,HCPCS,0278,RC,,,,both,,,2410.52,1566.84,,,,,,,,,,,,,
GRAFT ILIAC CREST WEDGE 10 X 15 FD,SUP-2863671,CDM,C1762,CPT,0278,RC,,,,both,,,5761.90,3745.23,,,,,,,,,,,,,
ELEVEST PROC KT KT INCL E-Z PASS SUT PASS METRAPASS SUT,SUP-2171702,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
UNIVERSAL RING RETRACTOR BLADE MALLEABLE 4X12,SUP-2672838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1809.17,1175.96,,,,,,,,,,,,,
SHEATH INTRO ARW L 10 CM DIA 6 FR GUIDEWIRE 0.018 IN PTFE,SUP-2120536,CDM,C1892,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 50 CM DIA 7 MM EPTFE CARBON PERIPH,SUP-2761420,CDM,C1768,CPT,0278,RC,,,,both,,,5014.30,3259.29,,,,,,,,,,,,,
HC Basic Metabolic Panel Calcium Total,PX-3018004800,CDM,80048,CPT,0301,RC,,,,both,,,330.00,214.50,,,,,,,,,,,,,
LUG FEM PRI GEN II,SUP-2346154,CDM,C1776,CPT,0278,RC,,,,both,,,117.75,76.54,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 30 CM DIA12 MM MICROCATHETER,SUP-2385406,CDM,C1889,HCPCS,0278,RC,,,,both,,,4566.85,2968.45,,,,,,,,,,,,,
MICROSPONGE DRUG DELIVERY VECTRA F,SUP-2848998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TAP SURG L 43 MM DIA2.2 MM SCREW DIA 8/10 MM SD HEX NS DISP,SUP-2909588,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.63,812.26,,,,,,,,,,,,,
INTRODUCER SHTH STEER SM CURL 164MM 85F 74CM HEARTSPAN,SUP-2302675,CDM,C1766,CPT,0272,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
BRACE ORTH POST LUMBAR BK PREFABRICATED LSO,SUP-2388149,CDM,L0630,HCPCS,0274,RC,,,,both,,,417.09,271.11,,,,,,,,,,,,,
PLATE 1.0MM THCK 20 H STRNL LCK STR CP TI,SUP-2262566,CDM,C1713,HCPCS,0278,RC,,,,both,,,2735.63,1778.16,,,,,,,,,,,,,
MATRIX BIO SZ 250 SQCM FISH SKIN DERMAL SLD INTACT STRL 10/BX,SUP-2909457,CDM,Q4158,HCPCS,0636,RC,,,,both,,,23314.50,15154.42,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED RT PROX TIB W/ PATELLAR,SUP-2867177,CDM,C1762,CPT,0278,RC,,,,both,,,15302.79,9946.81,,,,,,,,,,,,,
HC Iadna Mycobacteria Tuberculosis Amp Prb,PX-3068755600,CDM,87556,CPT,0306,RC,,,,both,,,151.00,98.15,,,,,,,,,,,,,
MESH SYN 10X15CM HERN RECT PARIETEX,SUP-2174803,CDM,C1781,HCPCS,0278,RC,,,,both,,,617.45,401.34,,,,,,,,,,,,,
PLATE BNE IMPL SM R CHARLOTTE MTP FUS SYS S STL,SUP-2397487,CDM,C1713,HCPCS,0278,RC,,,,both,,,3366.08,2187.95,,,,,,,,,,,,,
PLATE BNE W9XL145MM THK1MM 12 H TI 1/3 TBLR W/ CLLR LIMIT,SUP-2190958,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.57,379.97,,,,,,,,,,,,,
EXTENSION STEM REV 175X6X14 MM TIB KNEE OFFSET OFFSET,SUP-2508656,CDM,C1776,CPT,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
MESH HERN W10XL15CM VENTRAL OVL COMPOSIX E/X,SUP-2125805,CDM,C1781,HCPCS,0278,RC,,,,both,,,992.87,645.37,,,,,,,,,,,,,
HC Proc Xr Fluoro Unlistd,PX-3207649600,CDM,76496,CPT,0320,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.4X6 MM CORTICAL CRUCIFORM RECESS S,SUP-2837810,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.48,82.86,,,,,,,,,,,,,
BUR SURG 9 MM RND FLUT STRL LTX,SUP-2862507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,534.52,347.44,,,,,,,,,,,,,
BUR SURG WIRE PASS MED 2X19 MM SS MICROPOWER MIC 100,SUP-2166419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
CEMENT BONE 70GM FULL DOSE POLYMETHYLMETHACRYLATE W/O,SUP-2222197,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 4.75 X19.1 MM TIGERTAPE LOOP BIOCOMP,SUP-2615623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
SPLINT WRIST EXTRA SMALL 8 IN THUMB LEFT,SUP-2428142,CDM,L3908,HCPCS,0272,RC,,,,both,,,96.30,62.59,,,,,,,,,,,,,
SYSTEM BRACHYTHERAPY DEL W/ THE I-125 SEED 3 DIFF LD OPTIONS,SUP-2129120,CDM,C2638,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
SCREW BNE CANC UNIV 4X36 MM ST PART THRD ULS,SUP-2459904,CDM,C1713,HCPCS,0278,RC,,,,both,,,74.54,48.45,,,,,,,,,,,,,
STEM FEM SZ 5 L125MM NK L37MM 47MM OFFSET 132DEG HIP FORGED,SUP-2375352,CDM,C1776,CPT,0278,RC,,,,both,,,6133.55,3986.81,,,,,,,,,,,,,
HC Iron Binding Capacity,PX-3018355000,CDM,83550,CPT,0301,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
DELIVERY NEEDLE 8GX11CM OPEN TIP,SUP-2816333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
AMANTADINE HCL 50 MG/5ML PO SOLN,RX-155560,CDM,340b,HCPCS,0637,RC,00121-0646-10,NDC,,both,5,ML,8.90,5.78,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM LG 36X20MM TI,SUP-2549728,CDM,C1713,HCPCS,0278,RC,,,,both,,,2600.30,1690.19,,,,,,,,,,,,,
NAIL IM FEM N LCK LT RECON STRL FOR VECT SYS 11MM 320MM,SUP-2136668,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT BNE CHIP 2-5 MM 60 CC FRZN FN CORTICAL CANC,SUP-2307427,CDM,C1713,HCPCS,0278,RC,,,,both,,,5724.60,3720.99,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 180 CM DIA 0.038 IN NIT HYDRPHLC,SUP-2141145,CDM,C1769,HCPCS,0272,RC,,,,both,,,132.88,86.37,,,,,,,,,,,,,
PLATE BONE L100MM 12 HOLE STNLSS STEEL CMPRSSN 27MM SCREW MI,SUP-2477821,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.44,450.74,,,,,,,,,,,,,
GUIDEWIRE VASC L200CM OD0.012IN ID0.014IN TIP L3CM HYDRPHLC,SUP-2305454,CDM,C1769,HCPCS,0272,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
HC So Cytomegalovirus Pcr,PX-3068749666,CDM,87496,CPT,0306,RC,,,,outpatient,,,254.00,165.10,,,,,,,,,,,,,
COIL NEUROVASCULAR L 12 CM DIA2 MM BARE PLAT LG VOL COIL,SUP-2895596,CDM,C1889,HCPCS,0278,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
MESH SURG L ARC THK0.4MM SLV CRANIOFACIAL TI MALL CNTOUR LO,SUP-2181575,CDM,C1781,HCPCS,0278,RC,,,,both,,,3990.31,2593.70,,,,,,,,,,,,,
INTRODUCER TUBE 21/24/27 FR ADV SET DIL CIAGLIA BLU RHINO G2,SUP-2759772,CDM,C1769,HCPCS,0272,RC,,,,both,,,1077.02,700.06,,,,,,,,,,,,,
EVACUATOR SURG GLS BODY M CONN TBNG AND BLB ELLIK,SUP-2312602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,808.55,525.56,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN STATIC PLAS,SUP-2435601,CDM,L1660,HCPCS,0274,RC,,,,both,,,511.63,332.56,,,,,,,,,,,,,
BLADE SURG VES 29 MMX10 CM WIDE,SUP-2629240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.57,1020.87,,,,,,,,,,,,,
BLADE SHV DIA4MM STR AGG DISECT FOR DIEGO SYS,SUP-2313840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.53,234.34,,,,,,,,,,,,,
PLATE BNE L 126 MM 16 H SCREW DIA2.4 MM TI ALLOY MINI FRAG,SUP-2902340,CDM,C1713,HCPCS,0278,RC,,,,both,,,3827.47,2487.86,,,,,,,,,,,,,
BUR DENT 1.8 MM CARBIDE BRN STRL OSSEO STAP,SUP-2134835,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE MESH PANEL 2X10X1 MM MENARD SPEC SM GRID FOR SCR,SUP-2539594,CDM,C1713,HCPCS,0278,RC,,,,both,,,2008.28,1305.38,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRP ILIUM TRICORT TRAD 22X50MM,SUP-2294072,CDM,C1713,HCPCS,0278,RC,,,,both,,,5187.28,3371.73,,,,,,,,,,,,,
NEEDLE NERVE BLOCK ASPIRATION 13 GA INTRAOSSEOUS BIOPLASTY,SUP-2836588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,664.11,431.67,,,,,,,,,,,,,
PROBE ENDOSCP BICOAGULATION 10 FRX3500 MM 3.7 MM FIX PI,SUP-2475166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.90,534.88,,,,,,,,,,,,,
CATHETER ATHRCTMY DIAMONDBACK PREDATOR 360 L 145 CM DIA1.75,SUP-2159496,CDM,C1724,HCPCS,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
TUBE TRACH AD L130MM OD12.9MM ID9MM SIL UNCUF EXTRA LEN FIX,SUP-2352036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,299.27,194.53,,,,,,,,,,,,,
CATHETER CV SET 018 PEDIATRIC 4 FRX5 CM DL J TIP SPECTRUM,SUP-2759964,CDM,C1751,HCPCS,0278,RC,,,,both,,,337.93,219.65,,,,,,,,,,,,,
TROCAR DLYS STYL PERI TUNN FALLER ARGY,SUP-2172340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,625.17,406.36,,,,,,,,,,,,,
CATHETER HAD AD 14.5FR L27CM POLYUR STR TAPR TIP NO CUF,SUP-2127859,CDM,C1750,HCPCS,0278,RC,,,,both,,,1430.90,930.08,,,,,,,,,,,,,
NEEDLE INTRO L98CM OD18GA 30DEG BRK-1 XS S STL TRANSSEPTAL,SUP-2357594,CDM,C1893,HCPCS,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
HAND CONTROL ELECSURG SINGLE FUNC,SUP-2225598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
SPLINT WR FRARM SM AD L11IN BLU L FOAM FOR INSTABILITY INJ,SUP-2195162,CDM,L3908,HCPCS,0272,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
TALQUETAMAB-TGVS 40 MG/ML SC SOLN|DISCARDED DRUG NOT ADMINISTE,RX-165051,CDM,J3055,HCPCS,0636,RC,57894-0470-01,NDC,JW,both,1,ML,33272.80,21627.32,,,,,,,,,,,,,
HC Pelvis Min 3 Views,PX-3207219000,CDM,72190,CPT,0320,RC,,,,outpatient,,,513.00,333.45,,,,,,,,,,,,,
PLATE BONE 6 H TI STR FOR 1.5MM SCR VLP MINI-MOD SM BONE SYS,SUP-2341192,CDM,C1713,HCPCS,0278,RC,,,,both,,,2351.36,1528.38,,,,,,,,,,,,,
PATCH VASC W5XL15CM THK1MM SFT TISS GORTX,SUP-2395295,CDM,C1781,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
TITANIUM MESH PANEL ROUND CNTRD 100MM DIA 6MM 15MM SSTM CP,SUP-2681384,CDM,C1713,HCPCS,0278,RC,,,,both,,,5711.97,3712.78,,,,,,,,,,,,,
BLADE SURG FOR SM CUT T2,SUP-2467160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
ENDCAP ORTH DIA12MM 0MM EXTN ST TI SPRL BLDE LOK T40,SUP-2180033,CDM,C1713,HCPCS,0278,RC,,,,both,,,732.37,476.04,,,,,,,,,,,,,
PLATE BNE OSTEOTMY 2.4/2.7 MM LCK VA OPENING WDG W/O SPACER,SUP-2184805,CDM,C1713,HCPCS,0278,RC,,,,both,,,3079.37,2001.59,,,,,,,,,,,,,
PLATE PROMO RT SZ 3,SUP-2321423,CDM,C1713,HCPCS,0278,RC,,,,both,,,6352.22,4128.94,,,,,,,,,,,,,
CATHETER HD STR 14 FRX32 CM LT BASIC SET SPLIT CATH III,SUP-2627121,CDM,C1750,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BNE CRV 4.5X370 MM RT CNDYL 18 HOLE VA LCK STRL VALCP,SUP-2789388,CDM,C1713,HCPCS,0278,RC,,,,both,,,7549.53,4907.19,,,,,,,,,,,,,
INJECTOR EYEJET TYPE 15 RIGHT PRELOADED,SUP-2859239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SET SUPRPUB CATH 10FR L30CM NDL 18GA INCL MCOT LOK CONN TB,SUP-2171108,CDM,C2627,HCPCS,0272,RC,,,,both,,,252.14,163.89,,,,,,,,,,,,,
GRAFT FEM CORT STRUT THIRDS 20CM,SUP-2307356,CDM,C1713,HCPCS,0278,RC,,,,both,,,4391.79,2854.66,,,,,,,,,,,,,
NAIL IM L360MM DIA13MM FEM TIB KNEE G TI CANN LOK AG RG,SUP-2347118,CDM,C1713,HCPCS,0278,RC,,,,both,,,2877.34,1870.27,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX24 CM SHT TERM DL BASIC SET DUOFLO,SUP-2627396,CDM,C1752,HCPCS,0278,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 10X10X10 MM SPNG FD CANC,SUP-2717779,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
INSERT TIB SM SZ 1-2 THK9MM RT KNEE POLYETH PRI NEUT,SUP-2350388,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
TOOL TUNN ROD 12 IN,SUP-2496412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED INCRD MOTN ADD ON,SUP-2365442,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SCREW BONE L90MM DIA3.5MM S STL CORT ST VAR ANG,SUP-2348269,CDM,C1713,HCPCS,0278,RC,,,,both,,,250.35,162.73,,,,,,,,,,,,,
PLATE BENDING PLIERS TRACK 10MM 23CM JAWS,SUP-2680413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1049.26,682.02,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.8 MM THOR 14 HOLE LCK BODY NS LEVEL 1,SUP-2869269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1968.43,1279.48,,,,,,,,,,,,,
"HC Inj Proc for Myelogram/CT, Lumbar",PX-3616228400,CDM,62284,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN 115CM 4-4-4 D,SUP-2485389,CDM,C1732,HCPCS,0272,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
CYSTOTOME ENDOSCP ELECTROCAUTERY L 185 CM DIA 8.5 FR ELECTRD,SUP-2900079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
STEM HUM COMP BODY SECT IMPL CO CHROM PRI CEM TOT 8.0MM DIA,SUP-2344293,CDM,C1776,CPT,0278,RC,,,,both,,,7528.15,4893.30,,,,,,,,,,,,,
PLATE BNE L82MM 4 H NONSTERILE L ANTLAT DST TIB S STL VAR,SUP-2177668,CDM,C1713,HCPCS,0278,RC,,,,both,,,5075.62,3299.15,,,,,,,,,,,,,
SEED BRACHYTHERAPY CESIUM LD IN NDL,SUP-2247308,CDM,C2643,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
TOE JOINT KIT CANN 10 DEG 3.5 MM STRL HAMMERTUBE,SUP-2749751,CDM,C1776,CPT,0278,RC,,,,both,,,4700.58,3055.38,,,,,,,,,,,,,
CATHETER CV DL 7 FRX30 CM N TUNNELED BASIC KT,SUP-2120591,CDM,C1751,HCPCS,0278,RC,,,,both,,,96.71,62.86,,,,,,,,,,,,,
CANNULA INJ 8.5 CM F/POS PRESSURE VENT LARYNGOSCOPE 8587K,SUP-2775140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.82,320.33,,,,,,,,,,,,,
HC Blood Culture Multiplex Pcr 2|NOT REASONABLE AND NECESSARY,PX-3008715400,CDM,87154,CPT,0300,RC,,,GZ,both,,,524.00,340.60,,,,,,,,,,,,,
PLATE BNE L 31 MM SCREW DIA2.4 MM 4 SHFT H SS COMPACT STR VA NS,SUP-2910644,CDM,C1713,HCPCS,0278,RC,,,,both,,,2790.93,1814.10,,,,,,,,,,,,,
ANCHOR SUT SUP REVO PRE LD ON A DISP DRVR 5.0MMX14MM W/ TWO,SUP-2166968,CDM,C1713,HCPCS,0278,RC,,,,both,,,576.44,374.69,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS II SHT 5.3X4.1X2.5 MM SINGLE NOTCH HA,SUP-2638122,CDM,L8613,CPT,0278,RC,,,,both,,,1176.53,764.74,,,,,,,,,,,,,
COUNTERSINK CANN 4.0MM,SUP-2315874,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.85,383.40,,,,,,,,,,,,,
ALTEPLASE (ACTIVASE) 100 MG VIAL IV INFUSION,RX-4081202,CDM,J2997,HCPCS,0636,RC,50242-0085-27,NDC,,both,1,UN,50602.10,32891.36,,,,,,,,,,,,,
GRAFT BONE 1.7-10MM 15ML CANC CRUSH CHIP FRZN,SUP-2294132,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
PLATE BNE L169MM THK3.3MM 14 H BILAT S STL RIG STR DYN,SUP-2186336,CDM,C1713,HCPCS,0278,RC,,,,both,,,1817.24,1181.21,,,,,,,,,,,,,
"HC So Detect, Agnt Mult, Dna Ampli",PX-3068780166,CDM,87801,CPT,0306,RC,,,,both,,,179.00,116.35,,,,,,,,,,,,,
CONFORMER OPHTH M W21XL24MM BILAT CLR VENT ACRYL CUP,SUP-2366502,CDM,L8610,HCPCS,0278,RC,,,,both,,,157.50,102.37,,,,,,,,,,,,,
SCREW BNE CANN 10.35X115 MM TI GLD NS TFN-ADVANCED 04038115,SUP-2799599,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.60,1136.59,,,,,,,,,,,,,
TRAY ART LN CATH 3FR L8CM 0.018IN NDL 20GA POLYETH BASEPLT,SUP-2167868,CDM,C1751,HCPCS,0278,RC,,,,both,,,166.73,108.37,,,,,,,,,,,,,
HEAD FEM LG 60 MM HIP REMEDY SPECTRM GV,SUP-2424211,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
HEAD HUM DXTEND CTA D48 X 26MM,SUP-2512996,CDM,C1776,CPT,0278,RC,,,,both,,,7105.82,4618.78,,,,,,,,,,,,,
BIT DRILL 1.5 QCURVE 85/60,SUP-2819035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.27,530.58,,,,,,,,,,,,,
HC Replac Central Tun Cath W/Port,PX-3613658200,CDM,36582,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE L350MM 16 H ST R CNDYL S STL LOK COMPR CRV FOR,SUP-2177091,CDM,C1713,HCPCS,0278,RC,,,,both,,,5113.30,3323.64,,,,,,,,,,,,,
GUIDEWIRE NDL FRE TRANSSEPTAL SAFESEPT,SUP-2329875,CDM,C1769,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Transcatheter Biopsy,PX-3613720000,CDM,37200,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
GRAFT BNE SUB 30ML 4-9.5MM CHIP CANC FRZ DRY ALLGRFT 27615030] ALLOSOURCE],SUP-2113908,CDM,C1713,HCPCS,0278,RC,,,,both,,,1634.50,1062.42,,,,,,,,,,,,,
SCREW BNE LCK 2.4X10 MM T8 DRV FT STRL VARIAX,SUP-2485634,CDM,C1713,HCPCS,0278,RC,,,,both,,,793.48,515.76,,,,,,,,,,,,,
GUIDEWIRE VASC COPE L 60 CM DIA 0.018 IN TAPR L 7 CM FLPY,SUP-2168063,CDM,C1769,HCPCS,0272,RC,,,,both,,,76.27,49.58,,,,,,,,,,,,,
SHEATH GUID 8FR L77CM DIA0.11IN MP CRV LO FRIC OBLQ CUT VLV,SUP-2248483,CDM,C1892,HCPCS,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
CAGE SPNL INTBDY 7 DEG 14X13X12 MM NS SHORELINE ACS,SUP-2245736,CDM,C1889,HCPCS,0278,RC,,,,both,,,2048.85,1331.75,,,,,,,,,,,,,
PLATE BONE L150MM 90DEG 2 H SUPCNDYL TUBE FRELOK,SUP-2197716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1771.87,1151.72,,,,,,,,,,,,,
CERAMENT BEAD TRAY,SUP-2893103,CDM,C1602,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
COMPONENT FEM POST STBL LEGION OXINIUM,SUP-2348026,CDM,C1776,CPT,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
HC So1 Microbe Susceptible Mic,PX-3008718667,CDM,87186,CPT,0300,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
PROSTHESIS OSS 0.6X4.5 MM MAZZAWI PISTON TAB PLAT RIBBON TI,SUP-2482389,CDM,L8613,CPT,0278,RC,,,,both,,,604.48,392.91,,,,,,,,,,,,,
STAPLER INT L45IN S STL AUTO PLCMNT 2-0 SUT SURGDAC DISP,SUP-2283035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.51,244.08,,,,,,,,,,,,,
HEAD HUM OD22.2MM +4MM SHLDR BPLR INNR IMP FOR SHLDR,SUP-2404518,CDM,C1776,CPT,0278,RC,,,,both,,,5146.46,3345.20,,,,,,,,,,,,,
BLADE SCREWDRIVER 1.7MM DIA CROSS-FIT,SUP-2695622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
ASSEMBLY FEM KNEE SZ 4 OXIN LT KNEE STRL LEGION HK,SUP-2909998,CDM,C1776,CPT,0278,RC,,,,both,,,47470.52,30855.84,,,,,,,,,,,,,
SCREW BNE EMGCY 2X4 MM TI NS,SUP-2188961,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.41,115.32,,,,,,,,,,,,,
BIT DRL L44.5MM DIA0.7MM STP 6MM L14MM STRL MAXILLOFACIAL S,SUP-2187622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.63,281.86,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL SWARTZ SL 62CM SP,SUP-2357197,CDM,C1893,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
FORCEPS ENDO L45CM TIP L23MM DIA10MM DEBAKEY TEETH PRSS LCK,SUP-2382314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KIT CONVENIENCE HND WRST INTERNALBRACE LIG AUG IMPL REP SYS,SUP-2123211,CDM,C1776,CPT,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
FOOTPLATE EXT FIX 140 MM ALUM,SUP-2162657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5144.58,3343.98,,,,,,,,,,,,,
BALLOON EXTRCTN 1900MML X 15MM DIA 28MM MNMM CHNNL SIZE 3 L,SUP-2679325,CDM,C1726,HCPCS,0272,RC,,,,both,,,714.76,464.59,,,,,,,,,,,,,
HC MRI Face Neck Eye WO Contrast,PX-6107054000,CDM,70540,CPT,0610,RC,,,,outpatient,,,4451.00,2893.15,,,,,,,,,,,,,
GRAFT BNE SUB 5CC 25X25X8MM DEMIN BNE MTRX 3D SCFLD STRP,SUP-2335644,CDM,C9362,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
KIT INTRO MINI STK II L 7 CM DIA 5 FR GUIDEWIRE L 60 CM DIA,SUP-2118837,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.95,48.72,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0258,RC,00338-0023-02,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
PROBE SURG GROOVER 90 MM 2 LOBE NS OSCAR 3 LTX,SUP-2875720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM UNIV TIB LT GRN TI CANN LOK FLUT,SUP-2179849,CDM,C1713,HCPCS,0278,RC,,,,both,,,4441.12,2886.73,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19MMW X95MML 1.37MM/1.37MM THK CUT BRAZOL,SUP-2605499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,212.26,137.97,,,,,,,,,,,,,
CATHETER ABLATN F-J CRV 1-7-4 MM 8 MM 7 FRX115 CM EZ STEER,SUP-2248517,CDM,C1732,HCPCS,0278,RC,,,,both,,,7762.08,5045.35,,,,,,,,,,,,,
CATHETER EP MED SWP 4 MM 2-5-2 MM 7 FRX115 CM,SUP-2356860,CDM,C1730,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GRAFT BNE SUB 1CC H5MM DIA16MM DBM SHP BIO,SUP-2364716,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BEARING ANK JT H9MM TIB TALAR UHMWPE SLDE COR STAR,SUP-2340544,CDM,C1776,CPT,0278,RC,,,,both,,,4406.99,2864.54,,,,,,,,,,,,,
PLATE BNE VOLAR STD 26 MM RT DSTL RADIAL 7 HOLE OPTILOCK,SUP-2474415,CDM,C1713,HCPCS,0278,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
KIT RF MULT COOLED INCL PRB INTRO BURET DISP COOLIEF ADV,SUP-2719766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
ELECTRODE SPATULA WITH MOVABLE SHEATH LAPAROSCOPIC REUSABLE,SUP-2843214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.39,461.10,,,,,,,,,,,,,
HC So1 Thyroxine Total,PX-3018443667,CDM,84436,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
SCREW BNE SNAP OFF 2X13 MM,SUP-2175087,CDM,C1713,HCPCS,0278,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
TRIAL KNEE SZ 2 THK8MM DST FEM AUG REV WDG FOR MOB BEAR TIB,SUP-2436186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
SHUTTLE SUT 90DEG UP CHIA IDEAL,SUP-2256804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
PLATE BNE MEDL STD 94 MM R/L 11 HOLE EVOLVE EPS ORTHOLOC,SUP-2535935,CDM,C1713,HCPCS,0278,RC,,,,both,,,3300.14,2145.09,,,,,,,,,,,,,
CATHETER ATHRCTMY OCELOT MVRX L 110 CM DIA 6 FR GUIDEWIRE,SUP-2124794,CDM,C2628,HCPCS,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
HC Inj/Asp Maj Jnt or Bursa,PX-7612061000,CDM,20610,CPT,0761,RC,,,,both,,,1092.00,709.80,,,,,,,,,,,,,
COMPONENT FEM SZ 1 LT KNEE CONV MOD TAPR GEN II,SUP-2345982,CDM,C1776,CPT,0278,RC,,,,both,,,5929.11,3853.92,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 100 MM H2O MED HI BACTISEAL,SUP-2666829,CDM,C1889,HCPCS,0278,RC,,,,both,,,4513.00,2933.45,,,,,,,,,,,,,
TRIFECTA VIABLE CELL ALLGRFT 1CC,SUP-2232315,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HOOP EXT FIX 1/4 MED,SUP-2459039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1000.09,650.06,,,,,,,,,,,,,
HC Incis/Drain Scrotum/Testis Epididym,PX-4505470000,CDM,54700,CPT,0450,RC,,,,both,,,2099.00,1364.35,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE STRYKERHIPUP] STRYKER CORP],SUP-2365978,CDM,C1776,CPT,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BRACE ORTH CUST FABRICATED RIGID W/O INTFACE LNR TLSO,SUP-2388143,CDM,L0450,HCPCS,0272,RC,,,,both,,,4930.40,3204.76,,,,,,,,,,,,,
ROD STBL SIL REUSE LMA FASTRACH,SUP-2383608,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.55,41.31,,,,,,,,,,,,,
SHELL ACET TOT HIP PRI PRESSFIT SLD UNIV POR TI 42MM OD,SUP-2403407,CDM,C1776,CPT,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE MRI W 4.45 X H 5.88 CM THK 0.75 CM,SUP-2149253,CDM,C1785,HCPCS,0275,RC,,,,both,,,8854.80,5755.62,,,,,,,,,,,,,
BLADE LARYN L22CM DIA4MM 360DEG ROT ANG TIP DBL CVD LO PROF,SUP-2854044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1894.05,1231.13,,,,,,,,,,,,,
SHEATH INTRO SUPER SHTH L 11 CM DIA 6 FR GUIDEWIRE 0.035 IN,SUP-2147280,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.46,19.80,,,,,,,,,,,,,
SCREW CONN CANN FOR HUM NAILING SYS MULTILOC,SUP-2178938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.62,1139.20,,,,,,,,,,,,,
SET IMPL W/ DEPTH GA DRL BIT FOR 3.5MM PROX TIB LCK SCR,SUP-2183065,CDM,C1713,HCPCS,0278,RC,,,,both,,,72395.15,47056.85,,,,,,,,,,,,,
CATHETER INFUSION 0.038 IN 5 FRX65 CM 5 CM 10 SH MEWISSEN,SUP-2141150,CDM,C1751,HCPCS,0278,RC,,,,both,,,237.16,154.15,,,,,,,,,,,,,
ANCHOR SUTURE ZIP 5-0 4.5X38 MM BRAIDED POLYESTER,SUP-2608407,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.58,359.18,,,,,,,,,,,,,
TEMPLATE SURG SM M FOR CRANIOMAXILLOFACIAL ORBIT FLR PLT,SUP-2366220,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.35,93.83,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL FRAME,SUP-2435559,CDM,L0650,HCPCS,0272,RC,,,,both,,,3667.77,2384.05,,,,,,,,,,,,,
DISC ARTIFICIAL SZ 3 7.5DEG UNIV INTERVERTEBRAL LUM MTL ON,SUP-2257119,CDM,C1889,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
Z DISCONTINUED CATHETER IABP 7FR 40CC SHTH LAIN FBROPT DATASCP SYS,SUP-2227313,CDM,C1725,HCPCS,0272,RC,,,,both,,,2976.06,1934.44,,,,,,,,,,,,,
SENSOR SPO2 AD FNGR PULSE DURA SENS REUSE,SUP-2394647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
PLATE BNE L74MM 4 H R POSTEROLATERAL DST PERIARTC FIBULAR S,SUP-2410554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
GRAFT SFT TISS 30X40 MM PERICARD MEMBRN COPIOS,SUP-2390690,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
GRAFT WDG EVANS ALLGRFT ADDUCTION 30DEG 12MM TX20MM H X 23MM,SUP-2321722,CDM,C1713,HCPCS,0278,RC,,,,both,,,6966.09,4527.96,,,,,,,,,,,,,
STEM TALAR 2 L14MM ANK PROPHECY INBONE,SUP-2397139,CDM,C1776,CPT,0278,RC,,,,both,,,2744.36,1783.83,,,,,,,,,,,,,
BIT DRL 2.5 MM FOR TOT WRST FUSION DISP,SUP-2852116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.82,566.68,,,,,,,,,,,,,
KNIFE OPHTH 0.5MM STR DISECT USHRP GRIESHABER,SUP-2109684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.42,278.47,,,,,,,,,,,,,
TORQUE COUNT FINAL TIGHT,SUP-2232121,CDM,C1713,HCPCS,0278,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
PIN CNTR SPARE FOR HLLW RMR EXT FIX,SUP-2187149,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.67,231.84,,,,,,,,,,,,,
CATHETER CTRL VEN L12CM OD7FR .030IN GWIRE KT SGL LUMN N,SUP-2120595,CDM,C1751,HCPCS,0278,RC,,,,both,,,161.40,104.91,,,,,,,,,,,,,
SYSTEM SURG HEMSTAT PWD 5 GM POLYSACCHARIDE HEMOSPHERES,SUP-2175235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
HC So1 Islet Cell Antibody,PX-3028634167,CDM,86341,CPT,0302,RC,,,,both,,,187.00,121.55,,,,,,,,,,,,,
IMPLANT LARYN L8MM DIA16FR INDWL RADPQ RNG CLASS BLOM-SINGER,SUP-2242359,CDM,L8509,HCPCS,0274,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
ALLOGRAFT DERMAL 25X30X2 MM ACELLULAR DERMAL MTRX ARTHROFLEX,SUP-2740935,CDM,Q4125,HCPCS,0636,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
IMPLANT HUM TISS CARDIOGRAFT DIA23 MM LG AORT VLV,SUP-2866796,CDM,C1762,CPT,0278,RC,,,,both,,,31846.51,20700.23,,,,,,,,,,,,,
CATHETER GUID TIG3.5 6 FRX100 CM SM ATRAUM SFT CONVEY,SUP-2146313,CDM,C1887,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
CATHETER PERI DLYS L90CM OD2.5MM ID1.3MM,SUP-2284523,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.79,264.41,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND FNGR CUST W/OUT JT FABRICATED,SUP-2435764,CDM,L3765,HCPCS,0272,RC,,,,both,,,3303.85,2147.50,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL III HE W 2.48 X H 3.25 IN,SUP-2149225,CDM,C1722,HCPCS,0275,RC,,,,both,,,77558.00,50412.70,,,,,,,,,,,,,
INSERT TIB SZ 7 THK13MM KNEE X3 CNDYL STBL BEAR TECHNOLOGY,SUP-2373230,CDM,C1776,CPT,0278,RC,,,,both,,,6918.05,4496.73,,,,,,,,,,,,,
SCREW BNE L6MM DIA2.4MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189484,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
ELECTRODE SURG MECHANOMYOGRAPHY TRAIN SS NS,SUP-2693685,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CAP PROTCT OD4MM PIN BAR EXT FIX SYS JETX,SUP-2342868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1425.43,926.53,,,,,,,,,,,,,
PIN FIX TI EMER REL,SUP-2192432,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.58,214.88,,,,,,,,,,,,,
SCREW BONE L26MM DIA2.5MM HEX DRVR DIA1.5MM MAG ST CANN FULL,SUP-2205623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
ANCHOR SUT NO2 DIA2.9MM MAXBRAID DBL LD SFT W/ TAPR NDL,SUP-2212781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.078X9 IN SS NS STEINMANN,SUP-2791590,CDM,C1713,HCPCS,0278,RC,,,,both,,,10.30,6.69,,,,,,,,,,,,,
PORT IMPL INFUS LO PROF SGL CHMBR TI DEV OPN SUT PLG ATTCH,SUP-2126175,CDM,C1788,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
PIN FIX L15IN DIA2.7MM PASS DRL TIP,SUP-2341327,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2360.09,1534.06,,,,,,,,,,,,,
GRAFT BIO TISS W5XL16CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2112972,CDM,Q4130,HCPCS,0636,RC,,,,both,,,7689.86,4998.41,,,,,,,,,,,,,
CATHETER BLLN DIL FIX WIRE 7-8-9-10-11 MM 8 CM ELATION 5,SUP-2468470,CDM,C1726,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
ROD SPNL CVD MULT ANG PERC IMP L30MM OD5.5MM SNIPER,SUP-2354845,CDM,C1713,HCPCS,0278,RC,,,,both,,,2499.44,1624.64,,,,,,,,,,,,,
CATHETER DRNGE PERI L120CM VENT L14CM ENDOMYOCARD RT ANG,SUP-2243807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2894.70,1881.55,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 5 MM EPTFE STR STD WALL,SUP-2496964,CDM,C1768,CPT,0278,RC,,,,both,,,466.48,303.21,,,,,,,,,,,,,
PLATE BNE L96MM 0DEG 8 H TI ANK BILAT 1 3 TBLR STR LOK COMPR,SUP-2398346,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
CONNECTOR CSF T 1.2X1.8 MM FOR NEUROSURGERY SS STRL,SUP-2851467,CDM,C1889,HCPCS,0278,RC,,,,both,,,3246.85,2110.45,,,,,,,,,,,,,
GUIDE SURG FOR ATLNTS VISN SCR,SUP-2293186,CDM,C1713,HCPCS,0278,RC,,,,both,,,3204.62,2083.00,,,,,,,,,,,,,
STEM FEM 46MM LNG WDG HIP INTERSPACE,SUP-2223683,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
BIT DRL L200MM DIA2.8MM CALIB L100MM FOR 3.5MM VA LCP PROX,SUP-2187853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.56,309.76,,,,,,,,,,,,,
MESH HERN M 45X10CM ONLAY 7CM UNDERLAY 19X13CM CONN,SUP-2219792,CDM,C1781,HCPCS,0278,RC,,,,both,,,984.30,639.79,,,,,,,,,,,,,
ADAPTER EXT FIX MCREYNOLDS,SUP-2495532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1861.39,1209.90,,,,,,,,,,,,,
SET INT FIX BURR H PLATE DIA18.5 MM SCREW DIA1.5 MM 15-7379X,SUP-2936398,CDM,C1713,HCPCS,0278,RC,,,,both,,,3400.62,2210.40,,,,,,,,,,,,,
PLATE BONE W14.9XL184MM THK1.2MM 11 H DSTL TIB S STL,SUP-2185740,CDM,C1713,HCPCS,0278,RC,,,,both,,,1283.95,834.57,,,,,,,,,,,,,
VALVE CSF MULTPURP HI PRESSURE ON-OFF FLSH ANTISIPH DEV,SUP-2852567,CDM,C1889,HCPCS,0278,RC,,,,both,,,5226.22,3397.04,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 6 MM EPTFE STR STD WALL,SUP-2396184,CDM,C1768,CPT,0278,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC STD 14.5FR DIA 29CM,SUP-2613300,CDM,C1750,HCPCS,0278,RC,,,,both,,,1658.39,1077.95,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 70CM 5FR ID 1.9MM 0.035IN AQ MULTPURP,SUP-2171140,CDM,C1894,HCPCS,0272,RC,,,,both,,,197.98,128.69,,,,,,,,,,,,,
LENS INTOCU +6.5 DIOPT L13MM DIA6MM A CONSTANT 118.4 10DEG,SUP-2110484,CDM,V2632,HCPCS,0276,RC,,,,both,,,260.87,169.57,,,,,,,,,,,,,
PLATE BNE W5XL27MM THK1MM 0DEG 5 H BILAT S STL STR RIG DYN,SUP-2186163,CDM,C1713,HCPCS,0278,RC,,,,both,,,572.74,372.28,,,,,,,,,,,,,
TRABECULAR METALTM TECHNOLOGY VBR 11X14X21.5MM,SUP-2415528,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
FLUTICASONE PROPIONATE 0.005 % EX OINT,RX-10083,CDM,6370000000,HCPCS,0637,RC,00713-0632-15,NDC,,both,15,GR,83.10,54.01,,,,,,,,,,,,,
ROD SPNL Z 5.5X300 MM TI MARINER OUTRIG,SUP-2709861,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
GRAFT HUM TISS 10X10MM PAT TEND PRESHAPED BIOCLEANSE,SUP-2335534,CDM,C1762,CPT,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA18 FR GUIDEWIRE 0.038 IN,SUP-2168684,CDM,C1894,HCPCS,0272,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
STENT URET LUBRICIOUS COAT,SUP-2126177,CDM,C2617,HCPCS,0278,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
COLLAR CERV ADJ MED 20X3 IN COTTON FOAM PREMIERPRO REUSE,SUP-2424885,CDM,L0120,HCPCS,0274,RC,,,,both,,,12.78,8.31,,,,,,,,,,,,,
CATHETER ETER HAD STD KT 145FRX42CM GLIDEPATH,SUP-2126476,CDM,C1881,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
PLATE BNE W22XL41MM 12 H L DST RAD TI LOK COMPR LO PROF NAR,SUP-2411819,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
PLATE BONE L125MM 9 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349758,CDM,C1713,HCPCS,0278,RC,,,,both,,,5330.15,3464.60,,,,,,,,,,,,,
CATHETER MAP DF CRV 1-4-1 MM SPC 8 FRX117 CM CIR ADVISOR VL,SUP-2867392,CDM,C1730,HCPCS,0272,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM DIA 0.035 IN PTFE PERIPH STR,SUP-2301931,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
MESH SPNL H30XL10MM TI RND,SUP-2254463,CDM,C1713,HCPCS,0278,RC,,,,both,,,8748.04,5686.23,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1295108FD5,SUP-2632818,CDM,C1751,HCPCS,0278,RC,,,,both,,,1044.49,678.92,,,,,,,,,,,,,
PATCH VASC W1XL9CM THK0.5MM FLUOROPOLYMER ACCUSEAL,SUP-2395322,CDM,C1768,CPT,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
HEAD FEM DIA22MM +3.5MM NK BPLR CO CHROM 12/14 TAPR,SUP-2210662,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
NEEDLE PUNC AUTO SPRING MECHANISM 15 MMX30 CM,SUP-2767360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2849.49,1852.17,,,,,,,,,,,,,
PLATE BNE 7 X 5 H CRANIOMAXILLOFACIAL REG DISTRCTN NS,SUP-2883330,CDM,C1713,HCPCS,0278,RC,,,,both,,,6458.67,4198.14,,,,,,,,,,,,,
PLATE BNE L 134 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 11 H 72466011,SUP-2932754,CDM,C1713,HCPCS,0278,RC,,,,both,,,5616.52,3650.74,,,,,,,,,,,,,
CATHETER GUID DIA 7 FR AL1 STRL,SUP-2154503,CDM,C1769,HCPCS,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
CATHETER DRNGE 12FR L25CM 0.038IN 9 H POLYUR HYDRPHLC YEL,SUP-2303337,CDM,C1729,HCPCS,0272,RC,,,,both,,,189.81,123.38,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA 3 MM BALL TIP,SUP-2898625,CDM,C1769,HCPCS,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
SEALANT TISS FIBRIN 1 CC HUM W/ AIRLESS SPRY ACCSRY EVICEL,SUP-2738903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3321.34,2158.87,,,,,,,,,,,,,
PIN FIX L229MM DIA2.8MM S STL 6 DMND PNT STYL UNTHREADED,SUP-2409676,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.47,34.76,,,,,,,,,,,,,
PLATE BNE L115MM 8 H L SUP CLAV S STL LOK COMPR FOR 3.5MM,SUP-2177369,CDM,C1713,HCPCS,0278,RC,,,,both,,,2808.98,1825.84,,,,,,,,,,,,,
DRILL TWST 90 DEG L 21 MM DIA1.5 MM STP 8 MM DENT SHFT NS,SUP-2883271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.86,235.86,,,,,,,,,,,,,
BAR EXTERNAL FIXATION L250MM DIA11MM XTRAFIX SYSTEM,SUP-2459552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.02,423.81,,,,,,,,,,,,,
HC Anterior Epitaxis Simple,PX-4503090100,CDM,30901,CPT,0450,RC,,,,outpatient,,,214.00,139.10,,,,,,,,,,,,,
GRAFT BONE SUB 5CC CA PHOS SYNTH PUTTY FIL IMPACTION FRMLA,SUP-2319790,CDM,C1713,HCPCS,0278,RC,,,,both,,,4011.51,2607.48,,,,,,,,,,,,,
GUIDEWIRE VASC L260 DIA0035IN TAPR 105CM TIP L3CM 2MM CRV,SUP-2168683,CDM,C1769,HCPCS,0272,RC,,,,both,,,117.15,76.15,,,,,,,,,,,,,
BRACE W/ STRNL PD KT COMPLT BLK M CNTOUR TLSO,SUP-2123919,CDM,L0462,HCPCS,0272,RC,,,,both,,,1020.19,663.12,,,,,,,,,,,,,
PLATE 4.5MM TI LCP T 8 HOLES 147MM,SUP-2549654,CDM,C1713,HCPCS,0278,RC,,,,both,,,2369.41,1540.12,,,,,,,,,,,,,
COMPONENT FEM H LT KNEE OPT NXGN LPS-FLEX,SUP-2201161,CDM,C1776,CPT,0278,RC,,,,both,,,17596.56,11437.76,,,,,,,,,,,,,
PLATE BONE L33MM THK0.7MM 4 H CRANIOMAXILLOFACIAL TI SAG SPL,SUP-2191237,CDM,C1713,HCPCS,0278,RC,,,,both,,,1718.84,1117.25,,,,,,,,,,,,,
VALVE CSF SM PERF LEVEL 1.5 W/ BIOGLDE DELT,SUP-2631427,CDM,C1889,HCPCS,0278,RC,,,,both,,,4188.73,2722.67,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0250,RC,00264-1510-32,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
PLATE BNE 3X3 H 2 23X365MM LOK GRID TRILOK,SUP-2267952,CDM,C1713,HCPCS,0278,RC,,,,both,,,2801.63,1821.06,,,,,,,,,,,,,
SCREW BNE L28MM DIA5MM TIB TI DBL LD FOR PHOENIX NAIL SYS,SUP-2412117,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.78,577.71,,,,,,,,,,,,,
HC So Anti Nuclear Antibody,PX-3028603866,CDM,86038,CPT,0302,RC,,,,both,,,505.00,328.25,,,,,,,,,,,,,
BIT DRL DIA3.2MM CANN FOR JONE FRAC SYS CHARLOTTE CAROLINA,SUP-2398089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
MESH HERN W6XL6IN SFT POLYPR OPN WV PROL SURGPRO,SUP-2219917,CDM,C1781,HCPCS,0278,RC,,,,both,,,5732.01,3725.81,,,,,,,,,,,,,
PLATE BNE CHAMPY 2/2.5X41X9X1 MM LT 6 HOLE SMART3D TRAUM NS,SUP-2484068,CDM,C1713,HCPCS,0278,RC,,,,both,,,1258.89,818.28,,,,,,,,,,,,,
PLATE BNE LCK SHT 178 MM LT DSTL MEDL HUM 11 HOLE PUR STRL,SUP-2469482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3104.83,2018.14,,,,,,,,,,,,,
BIT DRL OD2.7MM CALCLOCK,SUP-2399236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
SCREW BNE CANN 2.5X30 MM LAG SS,SUP-2392884,CDM,C1713,HCPCS,0278,RC,,,,both,,,601.31,390.85,,,,,,,,,,,,,
BIT DRL L 295 MM DIA 7.5 MM LG LNG CANN AO QC FOR CSS NS,SUP-2907919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3643.31,2368.15,,,,,,,,,,,,,
CAP END 5X12MM,SUP-2494165,CDM,C1889,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
ALLOGRAFT TEND TIBIALIS ANT 23ML FRZN,SUP-2421704,CDM,C1762,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
INSERT SHOE PART FT,SUP-2388200,CDM,L5000,HCPCS,0274,RC,,,,both,,,1465.03,952.27,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305761,CDM,V2790,HCPCS,0274,RC,,,,both,,,7824.88,5086.17,,,,,,,,,,,,,
"HC So Concentratn ,Any, Infect Agent",PX-3008701566,CDM,87015,CPT,0300,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
EXPANDER TISS L6XW4XH3.5CM 70CC FIL VOL STD PLAS BRST SIL,SUP-2113723,CDM,C1789,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SPACER SPNL W11XH4XL11MM PEEK CERV INTBDY FUS TANT MRK,SUP-2279511,CDM,C1821,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
CATHETER CV 3L AD 6 FRX55 CM PWR INJ N COAT POWERPICC,SUP-2125554,CDM,C1751,HCPCS,0278,RC,,,,both,,,575.56,374.11,,,,,,,,,,,,,
CATHETER BRACHYTHERAPY BRST SAVI PREP,SUP-2164406,CDM,C1728,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CATHETER EP JSN 10 MM SPC 6 FRX125 CM WOVEN,SUP-2142181,CDM,C1733,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM RT MAND 26 HOLE ANGLED NS LEVEL 1,SUP-2489282,CDM,C1713,HCPCS,0278,RC,,,,both,,,5134.47,3337.41,,,,,,,,,,,,,
BUR SURG DIA 4 MM RVS TAPR 2 RNG STRL DISP ELAN 4,SUP-2928881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.13,255.53,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY L20CM OD18GA APPL BRACHYSTAR,SUP-2129080,CDM,C1715,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X0.4 MM LT CONTOURED FOR SCREW STRL,SUP-2462516,CDM,C1713,HCPCS,0278,RC,,,,both,,,3304.03,2147.62,,,,,,,,,,,,,
APPLIER CLP XL 10 MMX45 CM MANUAL LOAD HEM-O-LOK ENDO10,SUP-2656815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
CAP PROTCT FOR 18 2MM K WIRE,SUP-2188572,CDM,C1713,HCPCS,0278,RC,,,,both,,,88.80,57.72,,,,,,,,,,,,,
HC Suture Tongue > 2.6 Cm,PX-4504125200,CDM,41252,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
LIDOCAINE 4 % EX PTCH,RX-129559,CDM,6370000000,HCPCS,0637,RC,70512-0812-01,NDC,,both,1,UN,31.20,20.28,,,,,,,,,,,,,
NEEDLE BRST LOC TAG 7 CM,SUP-2433839,CDM,A4648,CPT,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
SPLINT WRST LOOP LCK CLOSURE SM 10 IN RT VELCRO PROCARE,SUP-2196996,CDM,L3809,HCPCS,0272,RC,,,,both,,,19.44,12.64,,,,,,,,,,,,,
HC Insert Peritoneal Venous Shunt,PX-3614942500,CDM,49425,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
MOLESKIN 2INX5YD 6RLS/BX,SUP-2525988,CDM,C1776,CPT,0278,RC,,,,both,,,36.58,23.78,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM 2X8 SPNL CRD PERC 16 ACT CNTCT,SUP-2141953,CDM,C1778,HCPCS,0278,RC,,,,both,,,17507.07,11379.60,,,,,,,,,,,,,
BANDAGE SUPP ANK AK PELV,SUP-2388214,CDM,L5697,HCPCS,0274,RC,,,,both,,,222.03,144.32,,,,,,,,,,,,,
SYSTEM PHACO L09MM 45DEG TIPLSS ULT FMS ACT CENTURION,SUP-2109973,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 4 CM FLPY TIP L,SUP-2638704,CDM,C1769,HCPCS,0272,RC,,,,both,,,284.11,184.67,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.032 IN TAPR L 6 CM FLPY TIP L,SUP-2167850,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.05,27.98,,,,,,,,,,,,,
GRAFT BNE W20XL100MM THK3-12MM CORT FEM STRUT FRZ DRY,SUP-2307184,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.31,632.65,,,,,,,,,,,,,
STENT URTRL 7FR DIA 30CML TCFLX DBLE PGTL OPEN END CLSSC SNG,SUP-2721959,CDM,C2617,HCPCS,0278,RC,,,,both,,,176.15,114.50,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED LT CLAV,SUP-2740853,CDM,C1762,CPT,0278,RC,,,,both,,,15105.91,9818.84,,,,,,,,,,,,,
ANCHOR SUTURE KT ULTRABRACE,SUP-2882976,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
HC Assay of Sodium Other Source,PX-3018430200,CDM,84302,CPT,0301,RC,,,,both,,,203.00,131.95,,,,,,,,,,,,,
CLAMP EXT FIX ADJ MR CONDITIONAL FOR SCHNZ SCR,SUP-2188597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1069.80,695.37,,,,,,,,,,,,,
CONNECTOR CSF STR 1X2 MM RADIOPAQUE POLYPR STRL,SUP-2851297,CDM,C1889,HCPCS,0278,RC,,,,both,,,1242.75,807.79,,,,,,,,,,,,,
CATHETER HD DL 14.5 FRX19 CM 36 CM STR SYMTRC TIP PALINDROME,SUP-2283935,CDM,C1750,HCPCS,0278,RC,,,,both,,,805.76,523.74,,,,,,,,,,,,,
LENS IOL 16.5 DIOPT DIA12.5 MM A CONSTANT BLK,SUP-2882613,CDM,V2787,HCPCS,0276,RC,,,,both,,,950.00,617.50,,,,,,,,,,,,,
COMPONENT FEM M L RT KNEE POST STABILIZING REV PRI STEMLESS,SUP-2364857,CDM,C1776,CPT,0278,RC,,,,both,,,13349.43,8677.13,,,,,,,,,,,,,
BOLT ARCOS LATERAL TROCH 24MM,SUP-2506130,CDM,C1776,CPT,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
VALVE AORT SZ 27MM STD CUF PERICARD BIOPROSTHESIS IMPL,SUP-2214058,CDM,C1713,HCPCS,0278,RC,,,,both,,,16312.30,10602.99,,,,,,,,,,,,,
CONNECTOR TBNG NYL FOR DENV SHUNT REV SYS,SUP-2133694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
HC Plc Brst Dvc 1st Lesion Mam,PX-3201928100,CDM,19281,CPT,0320,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 8 MM RNG L 15 CM UTHN,SUP-2914831,CDM,C1762,CPT,0278,RC,,,,both,,,3149.58,2047.23,,,,,,,,,,,,,
SHEET HEMSTAT W7XL7CM CLLGN MICFIB ABSRB NONWOVEN AVIT,SUP-2125826,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER GUID BNCHMRK BMX96 L 80 CM OD 8 FR 0.096 IN DEL,SUP-2653461,CDM,C1887,HCPCS,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
CATHETER PLCMNT KT,SUP-2126777,CDM,C1751,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PIN DRL DIA3MM W/ SPADE TIP FOR KNEE LIG RECON RETROBUTTON,SUP-2121403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SZ 50 X 20 X 7 MM DBM CANC SPNG STRP,SUP-2913397,CDM,C1713,HCPCS,0278,RC,,,,both,,,12267.98,7974.19,,,,,,,,,,,,,
CATHETER EP L125CM OD6FR TEMP BPLR PACE SFT TIP GOETZ,SUP-2126151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,127.45,82.84,,,,,,,,,,,,,
CATHETER EP 6FR L120CM 2-5-2 SPC 1MM BND DECAPOLAR TORQ,SUP-2356813,CDM,C1730,HCPCS,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
OSSEOFLEX SN STRBLE NDLE 8 G INCL CNNLSSTLTSBPSY NDLE,SUP-2677171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-157711,CDM,J1836,HCPCS,0636,RC,00338-1055-48,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
EYELET ORTH FOR 2 MM CABLE STRL,SUP-2563693,CDM,C1713,HCPCS,0278,RC,,,,both,,,495.77,322.25,,,,,,,,,,,,,
MESH CRANIAL 2X78X78X1.2 MM RAPID RESORBABLE STERILE RAPIDSO,SUP-2838598,CDM,C1713,HCPCS,0278,RC,,,,both,,,8257.89,5367.63,,,,,,,,,,,,,
PLATE BNE W135XL62MM THK42MM 3 H BILAT S STL NAR LOK COMPR,SUP-2185229,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.06,573.34,,,,,,,,,,,,,
PLATE BNE L46MM 7 H DST ULN TI LOK COMPR FOR 2MM SCR,SUP-2191038,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.80,1426.62,,,,,,,,,,,,,
EPINEPHRINE 5 MG IN NS 250 ML INFUSION,RX-4082235,CDM,2500000003,HCPCS,0250,RC,99999-9916-43,NDC,,both,250,ML,431.30,280.34,,,,,,,,,,,,,
CATHETER DRNGE 6.5FR L30CM TOT ABSCESSION,SUP-2117065,CDM,C1729,HCPCS,0272,RC,,,,both,,,212.80,138.32,,,,,,,,,,,,,
ROD SPNL TAPR 3.5-5.5X420 MM TI VERTEX,SUP-2630726,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
BUTTON SUT L45MM DIA12MM LOOP RETROBTTN,SUP-2121380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SET SCR SPNL TI FLSH BRK OFFSET TSRH-3DX,SUP-2289708,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
SET SCR SPNL L9MM DIA1.5MM STD LUM TI OPTMA,SUP-2212644,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
KIT PT PRGM FOR SPNL CRD STIM SYS PRECIS SPECTR,SUP-2138827,CDM,C1787,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
COMPONENT MAND CNDYL RT TLTS FOR LCK SYS TI NS LEVEL 1,SUP-2460292,CDM,C1889,HCPCS,0278,RC,,,,both,,,3301.99,2146.29,,,,,,,,,,,,,
SYSTEM INCISION MINI LAPIPLASTY,SUP-2652626,CDM,C1713,HCPCS,0278,RC,,,,both,,,16312.30,10602.99,,,,,,,,,,,,,
GRAFT SURG HUM CLLGN ACELLULAR RECT 6CMX12CM,SUP-2126258,CDM,C1781,HCPCS,0278,RC,,,,both,,,5046.29,3280.09,,,,,,,,,,,,,
TIP ELECSURG 5MM STD 14CM ENSEAL,SUP-2257686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1101.70,716.10,,,,,,,,,,,,,
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,0636,RC,00270-1411-11,NDC,,both,10,ML,35.60,23.14,,,,,,,,,,,,,
TRAY CATH MIDLN GROSH INTERMED 3FR 25CM 1 LUMAN W/16GA INTRO,SUP-2613422,CDM,C1751,HCPCS,0278,RC,,,,both,,,202.84,131.85,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 4 FR SPC 5 MM D CRV,SUP-2248642,CDM,C1730,HCPCS,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
GRAFT HUM TISS L23CM PERONEUS LONGUS FRZN DBL STRND,SUP-2257906,CDM,C1762,CPT,0278,RC,,,,both,,,7855.56,5106.11,,,,,,,,,,,,,
IMPLANT ANK JT SZ 9 SNUS TARSI HYPROCURE,SUP-2236088,CDM,C1776,CPT,0278,RC,,,,both,,,4217.02,2741.06,,,,,,,,,,,,,
PIN GUID L229MM OD2MM FOR FUTURA CSI SYS,SUP-2388544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
KIT ABLATION RF MULTI-COOLED 17GA 5CM ADV,SUP-2719768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PATCH CV IVENA L 30 X W 20 MM PTFE PLLW SHP,SUP-2763170,CDM,C1768,CPT,0278,RC,,,,both,,,853.11,554.52,,,,,,,,,,,,,
PLATE 60MM INTERPEDICULAR GIC59,SUP-2293978,CDM,C1713,HCPCS,0278,RC,,,,both,,,6361.64,4135.07,,,,,,,,,,,,,
BIT DRILL 3.5MM DIA WRIST LATEXFREEDOM,SUP-2605907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,830.78,540.01,,,,,,,,,,,,,
APPLIER CLP SM L54.5CM JAW L1.1CM VERY HI CLS VERY LO OPN,SUP-2246602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
COMPONENT PATELLAR CEM 3 LT KNEE GENDER SOL,SUP-2437876,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
GRAFT DERMAL RECT 3.1X6.3 IN ANTIBACT XENMATRIX AB,SUP-2855241,CDM,C1781,HCPCS,0278,RC,,,,both,,,13700.45,8905.29,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PROMOTE L 8 X W 5 X H 1.3 CM 30 J TI,SUP-2356732,CDM,C1882,HCPCS,0275,RC,,,,both,,,59660.00,38779.00,,,,,,,,,,,,,
HC Thromb Mech 2nd Vssl,PX-3613718500,CDM,37185,CPT,0361,RC,,,,inpatient,,,4295.00,2791.75,,,,,,,,,,,,,
COMPOUND CEM GLS IONOMER LUTING GC FUJI I,SUP-2226108,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.68,147.34,,,,,,,,,,,,,
SHELL ACET MOLD PRE TIB HIP,SUP-2388179,CDM,L2340,LOCAL,0274,RC,,,,both,,,1420.22,923.14,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT DIA29 MM BOV PERICARD COCR WOVEN,SUP-2214766,CDM,C1889,HCPCS,0278,RC,,,,both,,,27632.00,17960.80,,,,,,,,,,,,,
BLADE FULL RAD BYONICS BONECUTTER 3.5 MM,SUP-2340786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.76,387.89,,,,,,,,,,,,,
IMPLANT CRANIAL M CUSTOMIZED MEDPOR,SUP-2862613,CDM,C1713,HCPCS,0278,RC,,,,both,,,45661.69,29680.10,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0258,RC,00990-7984-20,NDC,,both,25,ML,29.20,18.98,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ADD ON CERM BIOLOX,SUP-2365430,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PIN FIX PROV SM FRAG SYS 2.7MMX18MM,SUP-2343972,CDM,C1713,HCPCS,0278,RC,,,,both,,,1245.73,809.72,,,,,,,,,,,,,
ROD SPNL ANTR SMOOTH TI ALLOY 5.5MM DIA 120MM LEN,SUP-2289286,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
HEAD FEM TYP 1 3+ MM 44 MM HIP CERM,SUP-2449641,CDM,C1776,CPT,0278,RC,,,,both,,,6966.09,4527.96,,,,,,,,,,,,,
CATHETER GUID HEARTRAIL III L 100 CM DIA 6 FR IR1.5 2 SIDE H,SUP-2522837,CDM,C1887,HCPCS,0272,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE HYALURONIC ACID CEM VOID FILL,SUP-2378761,CDM,C1713,HCPCS,0278,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
GRAFT BNE CHIP 30 CC FD CORTICAL CANC,SUP-2321738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
KIT TMPLT W/ WIRE GWIRE GUIDEPIN FOR MINIRAIL FIX SYS,SUP-2316445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,149.34,97.07,,,,,,,,,,,,,
HC Unlisted Chemistry Procedure,PX-3018499900,CDM,84999,CPT,0301,RC,,,,both,,,213.00,138.45,,,,,,,,,,,,,
VITAMIN B-6 50 MG PO TABS,RX-8667,CDM,6370000000,HCPCS,0637,RC,50268-0858-11,NDC,,both,1,UN,2.10,1.36,,,,,,,,,,,,,
CUTTER LOOP DISPOSABLE 230CM,SUP-2665296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
ADJUST MAXILLARY DISTRACTOR BODY 15MM,SUP-2694294,CDM,C1713,HCPCS,0278,RC,,,,both,,,13275.92,8629.35,,,,,,,,,,,,,
ADAPTER KIT 55 CM M8 TORQUE WRENCH VERCISE,SUP-2836336,CDM,C1883,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
HC N Block Paravert Lumbar 1st|BILATERAL PROCEDURE,PX-3606449300,CDM,64493,CPT,0360,RC,,,50,both,,,4864.00,3161.60,,,,,,,,,,,,,
SPACER RECTAL STERILE BARRIGEL BIODEGRADEABLE,SUP-2930568,CDM,C1889,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
BOOT CAST W/ CUF SM BLK,SUP-2277488,CDM,L4386,HCPCS,0274,RC,,,,both,,,238.45,154.99,,,,,,,,,,,,,
ANCHOR SUT ARTHSCP HNDL INSRT NO 2 SUT TI DURABRAID 2.8MM,SUP-2341741,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
PLATE BNE OFFSET SYNDESMOSIS ANK ORTHOLOC 3DI,SUP-2398374,CDM,C1713,HCPCS,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
POST EXT FIX 4 HOLE W/O THRD ATTCH,SUP-2749943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
GRAFT VASC GORTX L 100 CM DIA10 MM EPTFE STR STD WALL N RING,SUP-2396441,CDM,C1768,CPT,0278,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
MESH SURG SHT 19X15 CMX2 MM AORT GRFT VASC OVL DUALMESH,SUP-2469741,CDM,C1781,HCPCS,0278,RC,,,,both,,,4823.04,3134.98,,,,,,,,,,,,,
IMMOBILIZER SHLDR L L9X19.5IN R/L CANVS W/ WAIST STRP THMB,SUP-2336104,CDM,L3660,HCPCS,0274,RC,,,,both,,,20.88,13.57,,,,,,,,,,,,,
NEEDLE SUTURE L8.25IN BLUNT LIGATURE FOR LEFT HAND DESCHAMPS,SUP-2802481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.31,204.30,,,,,,,,,,,,,
GRAFT BIO TISS 20X20CM LAPSCP STRATTICE,SUP-2113220,CDM,Q4130,HCPCS,0636,RC,,,,both,,,38458.72,24998.17,,,,,,,,,,,,,
TAPESTRY RC BIOINTEGRATIVE 30X30 MM LAT TAPESTRY LF,SUP-2867250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
GRAFT HUM TISS W3XL3CM COMP AMNIO MEM MTRX SHT AMNIOFIX,SUP-2305707,CDM,V2790,HCPCS,0274,RC,,,,both,,,4600.10,2990.06,,,,,,,,,,,,,
CATHETER EP L120CM OD6FR 2-5-2MM SPC CRD QPLR ELECTRD,SUP-2355183,CDM,C1730,HCPCS,0272,RC,,,,both,,,401.70,261.10,,,,,,,,,,,,,
GRAFT BNE 2.5 CC ACTIFUSE ABX,SUP-2208431,CDM,C1713,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL 20 ML MONOMER VI PCH STRL,SUP-2934646,CDM,C1713,HCPCS,0278,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.5MM DST RAD VOLAR CO CHROM POLYAX LOK,SUP-2340265,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.08,303.60,,,,,,,,,,,,,
LINER ACET W/ VIT E TRABECULAR MTL,SUP-2212340,CDM,C1776,CPT,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
AIRWAY LARYNGEAL CHILDREN 30-50KG MASK SIZE 3 OROGASTRIC TUB,SUP-2824818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
PICC AGBA NAVICURVE 3L 6FR X 55CM TCG,SUP-2867377,CDM,C1751,HCPCS,0278,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ LOOP LOK W STAY E SUPP COT,SUP-2276650,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.64,6.27,,,,,,,,,,,,,
WASHER OD7MM BLU FLAT MAXTORQUE,SUP-2399471,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
GUIDEWIRE VASC ROTAWIRE L 330 CM DIA 0.009 IN SS STR TIP,SUP-2147252,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.02,228.16,,,,,,,,,,,,,
PLATE BNE RECON 3.5X166 MM 14 HOLE SS,SUP-2569089,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.56,301.96,,,,,,,,,,,,,
ELECTRODE ELECSURG 24FR LOOP WNG VAPORTRODE,SUP-2332858,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
COOLCUT 90 ABLATOR MENISCECTOM,SUP-2816011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
HC Catheterize for Urine Spec,PX-4500961200,CDM,P9612,CPT,0300,RC,,,,outpatient,,,76.00,49.40,,,,,,,,,,,,,
PLATE BNE FEM LG 0.2 CM,SUP-2321786,CDM,C1713,HCPCS,0278,RC,,,,both,,,2854.26,1855.27,,,,,,,,,,,,,
CATHETER GUID 3DRC 0.078 INX7 FRX100 CM 2 SH,SUP-2155866,CDM,C1887,HCPCS,0272,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
HC Fetal Eval 1st Trim @ Addl Ges,PX-4027680200,CDM,76802,CPT,0402,RC,,,,both,,,793.00,515.45,,,,,,,,,,,,,
WASHER ORTH DIA2.5MM RND THRD LO PROF ALPS,SUP-2411738,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
CATHETER PTCA 5FR L80CM BLLN L100MM DIA6MM SHTH 6FR 0.035IN,SUP-2156359,CDM,C1725,HCPCS,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
GRAFT BIO TISS W4XL4CM FET BOV ANTIMIC DERM REP SCAFFOLD,SUP-2243703,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
HC Pt Eval Mod Complex,PX-4249716200,CDM,97162,CPT,0424,RC,,,,both,,,227.00,147.55,,,,,,,,,,,,,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK,RX-143096,CDM,6370000000,HCPCS,0637,RC,00310-1110-30,NDC,,both,1,UN,129.30,84.04,,,,,,,,,,,,,
EXTRACTOR SURG END CAP EZ OUT FOR HINDFOOT TTC/TC NAIL SYS,SUP-2909078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
BIT DRL HEX 3.2 MM TSRH 3DX,SUP-2631142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.46,240.80,,,,,,,,,,,,,
KIT EXT REAR TIP NAR BASE TI,SUP-2165317,CDM,C1813,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
STENT BILI HANAROSTENT L 80 MM DIA 8 MM L 1800 MM LNG WIRE,SUP-2679934,CDM,C1874,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
HC So Chimerism Anal No Cell Selec,PX-3018126766,CDM,81267,CPT,0301,RC,,,,both,,,258.00,167.70,,,,,,,,,,,,,
ICE ROD KIT,SUP-2314035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10.68,6.94,,,,,,,,,,,,,
PROSTHESIS OSS 4.5 MM 0.2 MM 1.45 MM PRECIS OWENS ASSURE TI,SUP-2468524,CDM,L8613,CPT,0278,RC,,,,both,,,1287.81,837.08,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM S STL DBL END SMOOTH DBL SHRP,SUP-2316403,CDM,C1769,HCPCS,0272,RC,,,,both,,,102.99,66.94,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S3274108PD,SUP-2632842,CDM,C1751,HCPCS,0278,RC,,,,both,,,693.50,450.77,,,,,,,,,,,,,
CATHETERIZATION KIT ART 021 22 GAX5 CM 25 GA 3 CC LF,SUP-2865596,CDM,C1751,HCPCS,0278,RC,,,,both,,,156.37,101.64,,,,,,,,,,,,,
HANDPIECE IRRIGATION COAX STR LUER LCK SS CAPSULEGUARD IA,SUP-2476374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,56.14,36.49,,,,,,,,,,,,,
MESH HERN ANAT MED 13X9 CM RT PRESHAPED MONOFILAMENT DEXTILE,SUP-2752173,CDM,C1781,HCPCS,0278,RC,,,,both,,,766.00,497.90,,,,,,,,,,,,,
CATHETER EP CSL 2-4-5 MM 6 FRX120 CM SUPREME,SUP-2356973,CDM,C1730,HCPCS,0272,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
OBTURATOR ENDOSCP 0.057 INX11 MM CORONARY INTRO SHTH GRY,SUP-2294579,CDM,C1894,HCPCS,0272,RC,,,,both,,,17.27,11.23,,,,,,,,,,,,,
GRAFT BONE SUB 10CC DEMIN BONE MTRX GEL GRFTON,SUP-2293897,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
TOOL INSRTN TRANSVALVULAR,SUP-2139581,CDM,C1725,HCPCS,0272,RC,,,,both,,,18824.30,12235.79,,,,,,,,,,,,,
CLAMP SPNL C 4.75 MM TI POLARIS,SUP-2663623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PROBE ABLATN 2 20 MM OPTABLATE,SUP-2864574,CDM,C1886,HCPCS,0278,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
SPLINT KNEE UNIV FOR LESS THAN 36IN L24IN FOAM LAM ELAS CNTCT,SUP-2197156,CDM,L3650,HCPCS,0272,RC,,,,both,,,45.34,29.47,,,,,,,,,,,,,
HC Repl Duo/Jeju Tube Under Fluor,PX-4504945100,CDM,49451,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
GRAFT FEM PROX W/ HD FRZN ALLGRFT,SUP-2165579,CDM,C1713,HCPCS,0278,RC,,,,both,,,6876.60,4469.79,,,,,,,,,,,,,
PLATE BNE W38XL50MM THK09MM 3X9 H BILAT S STL T SHP RIG,SUP-2186289,CDM,C1713,HCPCS,0278,RC,,,,both,,,1226.67,797.34,,,,,,,,,,,,,
FRACTURE ADAPTER SZ 5,SUP-2817839,CDM,C1776,CPT,0278,RC,,,,both,,,8682.10,5643.36,,,,,,,,,,,,,
SCREW BONE THOR STD 6MMX22MM,SUP-2362800,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.84,1147.15,,,,,,,,,,,,,
SEALER BPLR MINI MINIMALLY INVASIVE FLX BPLR W/ SALN FLD DEL,SUP-2277932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
SIZER SURG GEL 6 CM 15.5 CM 770 CC MSZF NATRELLE INSPIRA,SUP-2475363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
WASHER ORTH OD7MM ID3.7MM STRL S STL RND TC-100,SUP-2343819,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.57,154.42,,,,,,,,,,,,,
GRAFT HUM TISS 20X6.5MM WDG COT FOR ANAT RECON ALLOSYNC,SUP-2120759,CDM,C1713,HCPCS,0278,RC,,,,both,,,4733.55,3076.81,,,,,,,,,,,,,
GRAFT TISS MATRIX REGEN 4X8CM GRAFTJACKET,SUP-2262294,CDM,Q4107,HCPCS,0636,RC,,,,both,,,9508.17,6180.31,,,,,,,,,,,,,
COMPONENT FEM SM UNIV W1XL3MM OFFSET CO CHROM ARTC UNI,SUP-2123715,CDM,C1776,CPT,0278,RC,,,,both,,,21267.22,13823.69,,,,,,,,,,,,,
COLLAR CERV COT DIAL HT ADJ XL PT ACCS WIND VISTA,SUP-2123900,CDM,L0190,HCPCS,0272,RC,,,,both,,,102.71,66.76,,,,,,,,,,,,,
HC So Hemochromatosis Gene Analysis,PX-3108125666,CDM,81256,CPT,0310,RC,,,,inpatient,,,349.00,226.85,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 4 H TI BRIDGE BX LP BLU NS,SUP-2894448,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM GRAVITATIONAL L 12 MM CATH DSTL L FX624T,SUP-2931041,CDM,C1729,HCPCS,0272,RC,,,,both,,,15818.35,10281.93,,,,,,,,,,,,,
BURR SURG 1.6MM DIA HD LNG MIC 3.8MML HD SM BNE TAPR CROS CT,SUP-2605573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,97.03,63.07,,,,,,,,,,,,,
RING EXT FIX HALF 130 MM CARBON FIBER RINGFIX,SUP-2365276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3080.34,2002.22,,,,,,,,,,,,,
PLUG MESH L ANCHR 5CM RIM 5CM SYN POLYPR POLIGLECAPRONE 25,SUP-2220110,CDM,C1781,HCPCS,0278,RC,,,,both,,,637.67,414.49,,,,,,,,,,,,,
ENDCAP ORTH L20MM DIA15MM ST FEM TI NAIL SPRL BLDE EXTN LOK,SUP-2192144,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.70,528.90,,,,,,,,,,,,,
PLATE BNE L155MM THK3MM 6 H MAND TI FOR RECON SYS,SUP-2262976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2313.83,1503.99,,,,,,,,,,,,,
BASEPLATE TIB LIMB SALV LO BODY ELEOS SZ 4 75MM M/L,SUP-2314045,CDM,C1776,CPT,0278,RC,,,,both,,,18456.92,11997.00,,,,,,,,,,,,,
NAIL IM L240MM DIA9MM HUM TI NONLOCKING CANN AIM,SUP-2252403,CDM,C1713,HCPCS,0278,RC,,,,both,,,3912.44,2543.09,,,,,,,,,,,,,
CONTOURED PLATE 12 HOLE LEFT,SUP-2722550,CDM,C1713,HCPCS,0278,RC,,,,both,,,3903.02,2536.96,,,,,,,,,,,,,
HC So Deoxycorticosterone,PX-3018263366,CDM,82633,CPT,0301,RC,,,,both,,,160.00,104.00,,,,,,,,,,,,,
PLATE BNE W13.5XL98MM THK4.2MM 5 H BILAT S STL NAR LOK,SUP-2185234,CDM,C1713,HCPCS,0278,RC,,,,both,,,994.53,646.44,,,,,,,,,,,,,
PLATE BONE 8 H S STL 1/3 TBLR ECT,SUP-2198534,CDM,C1713,HCPCS,0278,RC,,,,both,,,139.82,90.88,,,,,,,,,,,,,
BUR SURG 3500-5000RPM COARSE GRIT HYDROBRADER,SUP-2284174,CDM,C1713,HCPCS,0278,RC,,,,both,,,831.47,540.46,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN PTFE N CRV TAPR LL TIP,SUP-2301907,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.24,20.31,,,,,,,,,,,,,
HEAD 22MM BPLR MOD NK,SUP-2372633,CDM,C1776,CPT,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
PLATE BNE PERIPROSTHETIC TROCHANTERIC NCB,SUP-2474541,CDM,C1713,HCPCS,0278,RC,,,,both,,,4595.17,2986.86,,,,,,,,,,,,,
KIT ARTHSCP 7X15MM DISP BICEPTOR FOR BICEPS TENODESIS REP,SUP-2341824,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
SUPPORT ORTH LO SPINE ADJ VISTA 464 TLSO,SUP-2123918,CDM,L0464,HCPCS,0274,RC,,,,both,,,993.81,645.98,,,,,,,,,,,,,
BEAD MAT ORTH SIL FOR MAG BVF MIXING DEL SYS,SUP-2899246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
STRUT EXT FIX SHRT STD NS DISP SMRT TSF,SUP-2933052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4183.61,2719.35,,,,,,,,,,,,,
ROD ORTH THRD COMPR OLECRANON IMP STRL L89.5MM OD4.5MM,SUP-2106883,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
PLATE BNE L 235.6 X W 8.3 MM THK 2.6 MM SCREW DIA2/2.3 MM,SUP-2936852,CDM,C1713,HCPCS,0278,RC,,,,both,,,8364.96,5437.22,,,,,,,,,,,,,
STENT PANCREATIC ZMMN L 15 CM DIA 4 FR GUIDEWIRE 0.021 IN,SUP-2738124,CDM,C2617,HCPCS,0278,RC,,,,both,,,245.71,159.71,,,,,,,,,,,,,
CEMENT DENT 25GM 35GM SELF CURED LUTING BONDS CHEMICALLY LT,SUP-2238616,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.32,73.66,,,,,,,,,,,,,
SCREW BNE L32.5MM HIP S STL COMPR DISP,SUP-2370967,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT WDG ACF FIB TRAD 10X9-13MM,SUP-2294097,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.44,706.19,,,,,,,,,,,,,
SUPPORT ANKLE HAMMER SPLINT BREMER HALO SYSTEM,SUP-2431399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,210.63,136.91,,,,,,,,,,,,,
SCULPT FLOW DELIVERY SYSTEM,SUP-2682265,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
PLATE BNE HK UNIV 5 HOLE NS LTX,SUP-2857096,CDM,C1713,HCPCS,0278,RC,,,,both,,,6110.44,3971.79,,,,,,,,,,,,,
PLATE BNE L300MM 13 H NONSTERILE R PROX LAT TIB S STL LOK,SUP-2184885,CDM,C1713,HCPCS,0278,RC,,,,both,,,4151.33,2698.36,,,,,,,,,,,,,
CLINIMIX E/DEXTROSE (4.25/5) 4.25 % IV SOLN,RX-23162,CDM,2500000003,HCPCS,0250,RC,00338-7022-06,NDC,,both,1000,ML,247.30,160.74,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 3 MESH KT NS FACE ID,SUP-2909584,CDM,C1713,HCPCS,0278,RC,,,,both,,,39439.09,25635.41,,,,,,,,,,,,,
CATHETER ENDOBRONCHIAL BLK SET PEDIATRIC 5 FRX65 CM 4.5 MM,SUP-2759866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.31,463.00,,,,,,,,,,,,,
SCREW BNE BIPLANAR ANAT FOR LAPIPLASTY SYS 2,SUP-2421328,CDM,C1713,HCPCS,0278,RC,,,,both,,,15056.30,9786.59,,,,,,,,,,,,,
HC Xray Cystogram Voiding,PX-3207445500,CDM,74455,CPT,0320,RC,,,,both,,,950.00,617.50,,,,,,,,,,,,,
BRIVARACETAM 50 MG PO TABS,RX-133983,CDM,6370000000,HCPCS,0637,RC,50474-0570-09,NDC,,both,1,UN,110.50,71.82,,,,,,,,,,,,,
DIANEAL PD-2/2.5% DEXTROSE 396 MOSM/L IP SOLN,RX-15435,CDM,2580000003,HCPCS,0258,RC,00941-0413-01,NDC,,both,6000,ML,379.50,246.67,,,,,,,,,,,,,
TILENE GRD LT 20CMX14 3PK,SUP-2402563,CDM,C1781,HCPCS,0278,RC,,,,both,,,1579.42,1026.62,,,,,,,,,,,,,
BIT DRL BI CORT BIO-POST,SUP-2121144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
IMMOBILIZER SHLDR L W8XL18IN COT ADJUSTABLE  SHLDR STRP W  A,SUP-2431841,CDM,L3670,HCPCS,0272,RC,,,,both,,,53.51,34.78,,,,,,,,,,,,,
PLATE BNE L 62 MM SCREW DIA2.7 MM 8 SHFT H TI STR COMPACT NS,SUP-2927308,CDM,C1713,HCPCS,0278,RC,,,,both,,,4788.91,3112.79,,,,,,,,,,,,,
PLATE BNE L36MM 4 H MAXILLOFACIAL ORAL TI STR LIMIT CNTCT,SUP-2191396,CDM,C1713,HCPCS,0278,RC,,,,both,,,2349.66,1527.28,,,,,,,,,,,,,
PLATE BONE 4 H LT MINI PREBENT FOR ANG FX,SUP-2365249,CDM,C1713,HCPCS,0278,RC,,,,both,,,1008.00,655.20,,,,,,,,,,,,,
SCREW BONE FINE PITCH 2X4 MM MANDIBULAR SELFTAPPING 5/PK TIT,SUP-2842316,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.55,151.16,,,,,,,,,,,,,
WAND ELECSURG INTEGR CABLE COVAC 70,SUP-2848690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 20MMW X 40MML SPNL MSCLE NRRW RGGLS RDM,SUP-2467343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1610.54,1046.85,,,,,,,,,,,,,
CLIP EASY FIX DEV 18X12X12,SUP-2696123,CDM,C1713,HCPCS,0278,RC,,,,both,,,3172.37,2062.04,,,,,,,,,,,,,
BIT DRL DIA2.4MM CANN W/ DEPTH STP TWINFIX,SUP-2368330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
NEEDLE BX CHIBA 22 GAX9 CM,SUP-2120158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CATHETER DLYS AD L62.5CM SWAN NK CURL DBL CUF R COILED ARGY,SUP-2283990,CDM,C1750,HCPCS,0278,RC,,,,both,,,595.41,387.02,,,,,,,,,,,,,
TROCAR SURGICAL 60MML TRANSBUCCAL,SUP-2695259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.89,240.43,,,,,,,,,,,,,
WAND ABLAT FOR ADENOTONSILLECTOMY EVAC 70XTRA HP COBLATION,SUP-2342043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1167.14,758.64,,,,,,,,,,,,,
CATHETER THOR 28FR L20IN PVC R ANG RADPQ SENTNL LN SENTNL,SUP-2154972,CDM,C1729,HCPCS,0272,RC,,,,both,,,34.73,22.57,,,,,,,,,,,,,
PLATE BNE L123MM 8 H NONSTERILE R LAT PROX TIB LOK FOR 35MM,SUP-2348475,CDM,C1713,HCPCS,0278,RC,,,,both,,,11589.27,7533.03,,,,,,,,,,,,,
COIL EMB L2CM LOOP DIA3MM 0.018IN PERIPH PLAT HYDRGEL,SUP-2385380,CDM,C1889,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT BNE SHFT HUM IMPL ALLGRFT L120MM MATRIGRFT,SUP-2264765,CDM,C1713,HCPCS,0278,RC,,,,both,,,2374.59,1543.48,,,,,,,,,,,,,
VALVE ANGIO HEMSTAS TORQ DEV GWIRE INTRO TUOHY BORST HONOR,SUP-2303049,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.64,40.72,,,,,,,,,,,,,
PLATE BNE TBLR 100 DEG 5 HOLE STRL LTX,SUP-2861630,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.08,189.20,,,,,,,,,,,,,
WALKER SM SHT LEG NONSKID,SUP-2276712,CDM,L4387,HCPCS,0274,RC,,,,both,,,80.60,52.39,,,,,,,,,,,,,
K WIRE FIX L9IN DIA1.1MM NS S STL 2 SIDE SGL DMND 6PK,SUP-2150680,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.08,78.70,,,,,,,,,,,,,
EXTERNAL FIXATION SET BAR PIN CLMP ASMBLY TEMPFIX,SUP-2484777,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.03,174.22,,,,,,,,,,,,,
COMPONENT FEM W11XL21.5MM TAPR POST DISP FOR RESURF SYS,SUP-2123692,CDM,C1776,CPT,0278,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
ALLODERM SELECT RESTORE X-LARGE PERFORATED - MEDIUM 1.6 0.4M,SUP-2827047,CDM,Q4116,HCPCS,0636,RC,,,,both,,,55336.22,35968.54,,,,,,,,,,,,,
BLADE SAW 25X2-86 MM MICS ATTCH STRL,SUP-2869283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.80,466.57,,,,,,,,,,,,,
LINER ACET 52-54 MM NEUT XL 36 MM HIP UHMWPE TRYON,SUP-2322435,CDM,C1776,CPT,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
GUIDEWIRE ORTH L100CM DIA3MM S STL TEAR GTT,SUP-2413041,CDM,C1769,HCPCS,0272,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
CATHETER VENTRICULAR 23 CM RT ANGLE CLP INTEGR PLUG IMPREG,SUP-2628450,CDM,C1729,HCPCS,0272,RC,,,,both,,,381.57,248.02,,,,,,,,,,,,,
GUIDE SURG PLN TI LP RECON CUSTOMIZABLE VSP,SUP-2883951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9020.59,5863.38,,,,,,,,,,,,,
SPLINT THMB UNIV NEOPRENE PERF W DORS RAD PALMAR STAY PKT,SUP-2196849,CDM,L3923,HCPCS,0272,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
HC Blood Occult Peroxidase Actv Qual Feces 1 Deter,PX-3018227000,CDM,82270,CPT,0301,RC,,,,both,,,87.00,56.55,,,,,,,,,,,,,
"HC So Dna Quantification, Each",PX-3068779966,CDM,87799,CPT,0306,RC,,,,both,,,267.00,173.55,,,,,,,,,,,,,
GUIDE NAVIGATION DT NAVIGATED INFIN,SUP-2293671,CDM,C1713,HCPCS,0278,RC,,,,both,,,12372.89,8042.38,,,,,,,,,,,,,
RING SPNL SM STAT 5.5X50 MM CLOSED MESA,SUP-2531762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW BONE L85MM LAG OMEGA + SUP,SUP-2370966,CDM,C1713,HCPCS,0278,RC,,,,both,,,969.98,630.49,,,,,,,,,,,,,
BLADE RTRCTR 4MM DIA HEAD MED CRVCL PEAR F/MDS REX ZMMR ULTR,SUP-2461602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.87,275.52,,,,,,,,,,,,,
BIT DRL 4.75/5.5 MM ARGO KNOTLESS DISP,SUP-2846776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,864.10,561.66,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED TUBE JEJUSTMY L66CM DIA12FR GWIRE L200CM 0.035IN JEJU PEG,SUP-2169407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PUMP CNTRFUG CONN SZ 3/8 IN BIOLINE COAT FLOWPR STRL DISP,SUP-2908663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1147.36,745.78,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN PC NIMB L 180 CM DIA 0.035 IN TAPR L,SUP-2168472,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.45,61.39,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X50X3-6 MM DBM PUROS 61615205,SUP-2684572,CDM,C1713,HCPCS,0278,RC,,,,both,,,16306.02,10598.91,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN UNVRSL 3.5X157 MM 12 HOLE LOK,SUP-2488500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1138.44,739.99,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 1CC DBM W/ RPM PASTE CANC,SUP-2415802,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SCREW BONE 2.5MMX17MM REG EMER CROSS DRV,SUP-2262632,CDM,C1713,HCPCS,0278,RC,,,,both,,,91.41,59.42,,,,,,,,,,,,,
WASHER SPNL 6 MM SFS,SUP-2582940,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
RELOAD STPLR RADIAL EXTRA THICK 2 MM INTELLIGENT BLK,SUP-2787708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2537.43,1649.33,,,,,,,,,,,,,
ANCHOR SUTURE NO2 L16.5MM OD6MM 3.5MM DISPOSABLE BONE PUNCH,SUP-2842790,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.69,573.75,,,,,,,,,,,,,
LEAD PACE SIL ENDOCARD RT VENTRICULAR PASS FIX IS1 BPLR CONN,SUP-2148540,CDM,C1898,HCPCS,0275,RC,,,,both,,,2835.42,1843.02,,,,,,,,,,,,,
SCREW SCHANZ SD 5X200MM HA COAT TI STRL,SUP-2549742,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.45,626.24,,,,,,,,,,,,,
VALVE SHUNT ADJUSTABLE UNIT 0-20CM H2O WITHOUT GRAVITATIONAL,SUP-2821851,CDM,C1889,HCPCS,0278,RC,,,,both,,,8007.03,5204.57,,,,,,,,,,,,,
GUIDEWIRE VASC XCELA L 70 CM DIA 0.018 IN NIT TUNGSTEN,SUP-2118820,CDM,C1769,HCPCS,0272,RC,,,,both,,,227.56,147.91,,,,,,,,,,,,,
IMPLANT FACE L 42 X H 20 MM THK 0.35 MM POLYETHYL LOWER,SUP-2883475,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.20,1073.28,,,,,,,,,,,,,
FORCEPS ENDOMYOCARDIAMETERL BX 2.2MM JAW PRECRV 7FRX50CM,SUP-2120027,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
CONNECTOR SPNL L26-28MM STD TI POST XLNK ADJ TRNSVRS CONN,SUP-2229236,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN L 115CM 2-6-2,SUP-2248593,CDM,C1732,HCPCS,0272,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CANC CRUSH,SUP-2899239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1467.95,954.17,,,,,,,,,,,,,
SCREW BNE L 110 MM DIA 4.7 MM SS PARTIALLY THRD OSTEOPENIA,SUP-2931541,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.59,186.93,,,,,,,,,,,,,
SET PICC CONV FOR 5FR CATH SELD,SUP-2384043,CDM,C1751,HCPCS,0278,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.7MM S STL CORT MIDFOOT FOREFOOT ST VAR,SUP-2348710,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.13,128.78,,,,,,,,,,,,,
INDOMETHACIN 50 MG RE SUPP,RX-3901,CDM,6370000000,HCPCS,0637,RC,69344-0102-33,NDC,,both,1,UN,1628.60,1058.59,,,,,,,,,,,,,
FIXATOR EXT MINI CALCNL,SUP-2316441,CDM,C1713,HCPCS,0278,RC,,,,both,,,9749.45,6337.14,,,,,,,,,,,,,
BLADE SURG BLACKLINE 47X26.5 MM BLNT 2 LEVEL SS TI LF,SUP-2763777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.75,373.59,,,,,,,,,,,,,
NEEDLE CYTO 21GA L137MM DIA1.9MM PULM BRAID TAPR SHTH OPT 5PK,SUP-2281030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
STAPLE SPNL L24MM ANT MTL ALLY CRV BTTRS BOWTI,SUP-2254344,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
DILATOR ENDOSCP 53 FRX70 CM ESOPH SET,SUP-2737151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE L246MM THK3MM 13 H BILAT S STL STR LOK COMPR RECON,SUP-2185349,CDM,C1713,HCPCS,0278,RC,,,,both,,,1971.32,1281.36,,,,,,,,,,,,,
PLATE BNE W12XL268MM THK37MM LNG 12 H PROX HUM S STL LOK,SUP-2186024,CDM,C1713,HCPCS,0278,RC,,,,both,,,5212.46,3388.10,,,,,,,,,,,,,
RELOAD STPL H38XL60MM G REG THCK B FORM NAT ARTC ECHELON,SUP-2218990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.73,261.12,,,,,,,,,,,,,
PLATE BNE L151MM 9 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185276,CDM,C1713,HCPCS,0278,RC,,,,both,,,1515.55,985.11,,,,,,,,,,,,,
CUFF URETH 6.5CM INHIBIZONE OCCL SPHIN FOR URIN CTRL SYS AMS,SUP-2138954,CDM,C1815,HCPCS,0278,RC,,,,both,,,17185.22,11170.39,,,,,,,,,,,,,
SCREW BONE L16MM OD2.3MM TI CORT ST CROSS PIN NONLOCKING,SUP-2363448,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.60,86.19,,,,,,,,,,,,,
SLEEVE FEM THK35MM KNEE TI ALLY FULL POR COAT REV ATTUNE,SUP-2251455,CDM,C1776,CPT,0278,RC,,,,both,,,7350.11,4777.57,,,,,,,,,,,,,
TRAY PERICARDCENT CATH 5FR L20CM 0.025IN 7 SIDEPRT TO,SUP-2168549,CDM,C1769,HCPCS,0272,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
INSTRUMENT EXT FIX REARFOOT ANK ARTH FOR SIDEKCK FIX,SUP-2400593,CDM,C1713,HCPCS,0278,RC,,,,both,,,19047.24,12380.71,,,,,,,,,,,,,
SHEATH URET ACC 14FR L45CM HYDRPHLC FOR ENDO URO PROC FLX,SUP-2170511,CDM,C1894,HCPCS,0272,RC,,,,both,,,463.87,301.52,,,,,,,,,,,,,
STAPLE BNE COMPR 20 MM LG NOTCH STR STRL UNICLIP,SUP-2397150,CDM,C1713,HCPCS,0278,RC,,,,both,,,1533.76,996.94,,,,,,,,,,,,,
PROBE ABLAT 17GA L15CM CBL L1.4M STD PERC ACT ZONE DISPLAY 3,SUP-2219809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12484.64,8115.02,,,,,,,,,,,,,
PLATE BNE L63MM 3 LOK 1 3 TBLR PLT 5 H,SUP-2371991,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
PROBE BRST BX TROCAR TIP 7 GA FOR MRI ENCOR,SUP-2128177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GRAFT BONE SUB 10ML CANC CORT DEMIN BONE MTRX FRZ DRY,SUP-2212980,CDM,C1713,HCPCS,0278,RC,,,,both,,,14158.26,9202.87,,,,,,,,,,,,,
LITHOTRIPTER SURG L195CM DIA3.2MM BSKT 30MM BULL TIP ROT,SUP-2312979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1344.61,874.00,,,,,,,,,,,,,
IMPLANT OSS L4.5MM PIST DIA0.4MM WELL DIA1MM STAP S STL BCKT,SUP-2312586,CDM,L8613,CPT,0278,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
WAND ABLATN 70 MM PLASMA COBLATOR,SUP-2342040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
PLATE BONE LOCKING 4.5X336 MM 18 HOLE COMPRESSION,SUP-2837369,CDM,C1713,HCPCS,0278,RC,,,,both,,,9137.40,5939.31,,,,,,,,,,,,,
HC Treat Radius/Ulna Fx,PX-4502560000,CDM,25600,CPT,0450,RC,,,,both,,,729.00,473.85,,,,,,,,,,,,,
ALLOGRAFT BNE PARTICULATE 250-1000 MH 2 CC CANC ORAGRAFT,SUP-2741030,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.10,280.86,,,,,,,,,,,,,
CONNECTOR SPNL SM TI FOR 6.35MM ROD TSRH-3D,SUP-2290003,CDM,C1713,HCPCS,0278,RC,,,,both,,,2877.81,1870.58,,,,,,,,,,,,,
SYSTEM POS STD 36X55 IN PREVALON GLIDE SHT REPOS AIRTAP,SUP-2336480,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.91,676.59,,,,,,,,,,,,,
GRAFT BIO TISS W6XL8CM CVR 48SQCM PLIABLE PORCINE REGEN,SUP-2112974,CDM,Q4130,HCPCS,0636,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
KIT EEG ELECTRD L 54.5 MM 16 CONTACT RF PRB STRL DISP EVO,SUP-2936420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
INSERTION KIT PKGD SENSATION PLUS 40CC,SUP-2850007,CDM,C1894,HCPCS,0272,RC,,,,both,,,449.40,292.11,,,,,,,,,,,,,
SCREW BNE L 8 MM DIA1.7 MM TI CRANIOMAXILLOFACIAL ANCHR ST,SUP-2883602,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.50,208.32,,,,,,,,,,,,,
DA VINCI TIBIAL NAIL 12MMX31.5CM,SUP-2828941,CDM,C1713,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
PLATE BNE RECON 2.8 MM 20 HOLE PT SPEC,SUP-2860106,CDM,C1713,HCPCS,0278,RC,,,,both,,,20157.86,13102.61,,,,,,,,,,,,,
CATHETER NPHRSTMY DLTN 30FR OD 55CML 15CML BLLN PRCTNS FADER,SUP-2721797,CDM,C1729,HCPCS,0272,RC,,,,both,,,842.24,547.46,,,,,,,,,,,,,
SPACER SPNL 10X26MM 8 TO 12MM 8DEG ALTERA,SUP-2228780,CDM,C1821,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
EVOS WASHER - 3.5MM SCREWS,SUP-2819677,CDM,C1713,HCPCS,0278,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
LENS INTOCU +24.00 DIOPT L13MM DIA6MM HAPTIC REFRACTIVE,SUP-2129529,CDM,V2632,HCPCS,0276,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CATHETER IV NEOMAGIC L 25 CM DIA1.9 FR SIL PICC 1 LUMEN STYL,SUP-2874155,CDM,C1751,HCPCS,0278,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
HC So Hcg Quantitative,PX-3018470266,CDM,84702,CPT,0301,RC,,,,inpatient,,,64.00,41.60,,,,,,,,,,,,,
GENTEAL TEARS NIGHT-TIME OP OINT,RX-138583,CDM,6370000000,HCPCS,0637,RC,00065-0518-01,NDC,,both,3.5,GR,32.20,20.93,,,,,,,,,,,,,
SEED BRACHYTHERAPY I-125 IMPL STRANDS LD RND HUB NDL,SUP-2247256,CDM,C2638,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
SYSTEM BNE CEM MIX VAC 3 DOSE COMP,SUP-2199465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
KIT KYPHOPLASTY BALLOON L 25 MM DIA10 GA PRESSURE 700 PSI 7,SUP-2930381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5821.56,3784.01,,,,,,,,,,,,,
RELOAD STPL H1-2.5X45MM VASC THN TISS WHT 6 ROW B FRM SGL,SUP-2220066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.82,251.43,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CATHETER ANGIOPLSTY L40CM DIA5FR 0.035IN BAL INFLATED DIA4CM,SUP-2170365,CDM,C1725,HCPCS,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
ANCHOR SUTURE 4MM KNOTLESS CROSSFT,SUP-2824383,CDM,C1713,HCPCS,0278,RC,,,,both,,,2031.89,1320.73,,,,,,,,,,,,,
IMPLANT SZ 2 ULN HD ST PK,SUP-2379271,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
TAP SURG L180MM D110MM FOR 4.5MM CORT AND SHFT SCR,SUP-2187416,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.68,470.39,,,,,,,,,,,,,
TETRACYCLINE HCL 250 MG PO CAPS,RX-7796,CDM,6370000000,HCPCS,0637,RC,51991-0906-01,NDC,,both,1,UN,7.50,4.87,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 7.5 FR B-B CRV,SUP-2248522,CDM,C1732,HCPCS,0278,RC,,,,both,,,7583.10,4929.01,,,,,,,,,,,,,
PUTTY BONE GRAFT 5ML DBM,SUP-2632265,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT HUM TISS L230MM MIN DIA75MM PERONEUS LONGUS TEND FRZN,SUP-2264785,CDM,C1762,CPT,0278,RC,,,,both,,,5422.75,3524.79,,,,,,,,,,,,,
GRAFT BIO W8XL12CM SFT REGEN TISS MTRX PELV FLR REP BOV,SUP-2139397,CDM,C1763,HCPCS,0278,RC,,,,both,,,5353.57,3479.82,,,,,,,,,,,,,
GRAFT BNE FIBER LG 10 CC SYR DBM,SUP-2431098,CDM,C1889,HCPCS,0278,RC,,,,both,,,6688.20,4347.33,,,,,,,,,,,,,
PIN FIX L9IN DIA32MM ST S STL 3 SIDE SGL TRCR 1 END PNT,SUP-2150502,CDM,C1713,HCPCS,0278,RC,,,,both,,,26.31,17.10,,,,,,,,,,,,,
STEM HUM OD7MM HYDROXYAPETITE SHLDR IMPL REUNION,SUP-2379009,CDM,C1776,CPT,0278,RC,,,,both,,,13056.12,8486.48,,,,,,,,,,,,,
ROD IM L 120 MM DIA22 MM PHOTODYNAMIC BNE STBL PROC PK STRL,SUP-2934113,CDM,C1713,HCPCS,0278,RC,,,,both,,,13740.64,8931.42,,,,,,,,,,,,,
NAIL IM PROX RT HUM LCK CANN T2,SUP-2361807,CDM,C1713,HCPCS,0278,RC,,,,both,,,4459.59,2898.73,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL KT AND STYL 18GA 71CM 50 DEG CRV ANG,SUP-2302570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.13,267.88,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.14 MM INNR FLANGE DIA1.58 MM FLROPLAS,SUP-2901961,CDM,L8699,HCPCS,0278,RC,,,,both,,,66.47,43.21,,,,,,,,,,,,,
DEVICE SUTURING 2 PK LD FIX KNOT PUSH FIXATE,SUP-2765584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC Diskography Cerv/Thorac S&I,PX-3207228500,CDM,72285,CPT,0320,RC,,,,both,,,3509.00,2280.85,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 6X6 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651379,CDM,Q4154,HCPCS,0636,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
OXYCODONE HCL 5 MG PO TABS,RX-10814,CDM,6370000000,HCPCS,0637,RC,00406-0552-23,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PIN FIX 50MM TRANSFIX QUIK CPL,SUP-2316016,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
COMPONENT PATELLAR DOMED 38 MM KNEE UHMWPE S-ROM NOILES,SUP-2455923,CDM,C1776,CPT,0278,RC,,,,both,,,2395.19,1556.87,,,,,,,,,,,,,
PATCH CV GORTX NOM L 7.5 X W 5 CM THK 0.6 MM EPTFE CNFRM,SUP-2395301,CDM,C1768,CPT,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-15861,CDM,J3490,HCPCS,0250,RC,00338-0085-04,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA 8 MM STD BLDELSS FIX CANN,SUP-2896251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.26,213.37,,,,,,,,,,,,,
CLIP ASSURANCE 16MM,SUP-2862314,CDM,C1889,HCPCS,0278,RC,,,,both,,,278.36,180.93,,,,,,,,,,,,,
GRAFT VASC L40CM DIA8MM PTFE CBAS HEP SURF THN WALLED REM,SUP-2395822,CDM,C1768,CPT,0278,RC,,,,both,,,4540.44,2951.29,,,,,,,,,,,,,
INTRODUCER PACE LD APEEL CS 60 DEG L 47 CM DIA 8 FR CATH DEL,SUP-2357275,CDM,C1894,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SCREW BNE 34 MM FA4634] ACUMED LLC],SUP-2107618,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
FIBER LASER WAVEGUIDE CARBON DIOX,SUP-2352852,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2812.40,1828.06,,,,,,,,,,,,,
ROD IM UNIV 5 DEG PFC,SUP-2456051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
TUBING IRRGTN 0.125N ID 0.25N OD 19FR DIA 50FTL SLSTC SLCNE,SUP-2492891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.40,368.81,,,,,,,,,,,,,
GRAFT HUM TISS 40MG AMNIO MEM PARTICULATE DEHYDR AMNIOFIX,SUP-2305719,CDM,V2790,HCPCS,0278,RC,,,,both,,,2278.07,1480.75,,,,,,,,,,,,,
SCREW INTFR 10MM 25MM KNEE CANN ABSRB POLY L LACTIC ACID RND,SUP-2166999,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.37,292.74,,,,,,,,,,,,,
SET KNEE REPL POLY MOST OPTIONS,SUP-2208301,CDM,C1776,CPT,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
IMPLANT TOE JT STD METATRSL,SUP-2319765,CDM,C1776,CPT,0278,RC,,,,both,,,3538.78,2300.21,,,,,,,,,,,,,
SPLINT WRST FA AD L11IN UNIV BLU CANVS TRICOT LNR STRP ON,SUP-2194375,CDM,L3908,HCPCS,0274,RC,,,,both,,,20.79,13.51,,,,,,,,,,,,,
SET URET STENT SOFFLX L 8 CM DIA 3.0 FR GUIDEWIRE L 60 CM,SUP-2707491,CDM,C2617,HCPCS,0278,RC,,,,both,,,573.05,372.48,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY PRO L 90 CM DIA 4 FR SLT PAT L,SUP-2117022,CDM,C1757,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
PUMP PAIN 100ML 2ML/HR FIX INCIS FOR MED DEL ON-Q,SUP-2236773,CDM,C9804,HCPCS,0272,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
SPLINT ORTHOPEDIC ANTIMICROBIAL WHFO LG RT HND,SUP-2325146,CDM,L3809,HCPCS,0272,RC,,,,both,,,142.65,92.72,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM OVL,SUP-2521576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
CONTROLLER COIL XCEL DETACH HNDHLD 60 CYCLE STRL,SUP-2743577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
PROVENTM POST STBL KNEE SYS M/L 55 MM A/P 53 MM,SUP-2359094,CDM,C1776,CPT,0278,RC,,,,both,,,6939.40,4510.61,,,,,,,,,,,,,
HC So Ferritin,PX-3018272866,CDM,82728,CPT,0301,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
SYSTEM FIX STD FEM W/ SHTH 7MM SCR L23MM DIA7-7.5MM INTRAFIX,SUP-2256824,CDM,C1713,HCPCS,0278,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
SCREW BONE L60MM DIA5MM TI CANN PARTIALLY THRD,SUP-2402711,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 18 IN KNEE ADJ PERF FOAM,SUP-2194899,CDM,L1830,CPT,0274,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 2 X 21 H PLL,SUP-2883320,CDM,C1713,HCPCS,0278,RC,,,,both,,,16061.10,10439.71,,,,,,,,,,,,,
METHYLNALTREXONE BROMIDE 8 MG/0.4ML SC SOSY,RX-173411,CDM,2500000003,HCPCS,0250,RC,65649-0552-04,NDC,,both,.4,ML,977.10,635.11,,,,,,,,,,,,,
PLUG VASC AMPLATZER UNCONSTRAINED L 8 MM DIA14 MM DEL SYS L,SUP-2116332,CDM,C1889,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
SCREW BNE L 150 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931632,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.96,152.07,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 MAXBARR 6FR 55CM 3 LUMAN RVS,SUP-2613401,CDM,C1751,HCPCS,0278,RC,,,,both,,,815.46,530.05,,,,,,,,,,,,,
GUIDEWIRE ORTHPDC 2MM DIA 20NL NTNL HMRL F/ROD SSTM PLRS NON,SUP-2640112,CDM,C1769,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
SCREW BNE STD 2.7X9 MM CRANIOMAXILLOFACIAL MAXDRIVE LEVEL 1,SUP-2467771,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.51,221.98,,,,,,,,,,,,,
PACK PHACO 09MM 30DEG RND ABS LEG,SUP-2109846,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
AML/TL ENDR REP LINER 32X44SP,SUP-2513025,CDM,C1776,CPT,0278,RC,,,,both,,,4588.17,2982.31,,,,,,,,,,,,,
ENDPLATE SPNL 14MM UP 15X18MM FOOTPRINT 7DEG PEEK INTEGR TI,SUP-2231208,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BIT DRL L 115 MM DIA1.5 MM STP 26 MM NS DISP,SUP-2936992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
ROD EXT FIX L300MM DIA11MM C FBR MR CONDITIONAL,SUP-2188659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.77,414.55,,,,,,,,,,,,,
BUR SURG DIA 5 MM HUB II BRL SOFTCUT STRL DISP HI-LINE XS,SUP-2929121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,726.06,471.94,,,,,,,,,,,,,
FRACTURE ADAPTER SZ 6- 9 WIDE,SUP-2815879,CDM,C1776,CPT,0278,RC,,,,both,,,7112.10,4622.86,,,,,,,,,,,,,
PLATE LCK NAVICULAR 2.4/2.7MM TI STRL,SUP-2546616,CDM,C1713,HCPCS,0278,RC,,,,both,,,2835.61,1843.15,,,,,,,,,,,,,
KIT CEM MIXING/DELIVERY 10CC RADPQ NDL 11GA L5IN W/O CEM PCD,SUP-2367027,CDM,C1713,HCPCS,0278,RC,,,,both,,,1457.84,947.60,,,,,,,,,,,,,
PLATE BNE L 2.7 MM LT 2X3 HOLE SS NS,SUP-2186365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.84,828.65,,,,,,,,,,,,,
PI PICC KIT 2-L 5 FR X 55 CM VPS G4 PRELOADED,SUP-2565192,CDM,C1751,HCPCS,0278,RC,,,,both,,,678.37,440.94,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6MM L 70CM STR STD WALL,SUP-2396270,CDM,C1768,CPT,0278,RC,,,,both,,,4603.24,2992.11,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX 5X300 MM W/ WIRE HOLE TIP SIDEKCK,SUP-2483147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
CATH BLLN SCORING 2X10MM X 139CM OTW PTCA ANGIOSCULPT,SUP-2353175,CDM,C1725,HCPCS,0272,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
DRESSING WND 6 LAYR 7X10 CM MTRX CYTAL,SUP-2106532,CDM,Q4166,HCPCS,0636,RC,,,,both,,,8983.54,5839.30,,,,,,,,,,,,,
IMPLANT GYN W4XL12CM FASC LATA TUTOPLAST PROC ALLGRFT TISS,SUP-2300760,CDM,C1762,CPT,0278,RC,,,,both,,,3158.84,2053.25,,,,,,,,,,,,,
ELECTRODE RT ANG 3.0MMX90DEG ARTHWAND,SUP-2341955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SHELL ACET UNIV DIA40MM NO H HA PRI PRESSFIT SECUR FIT PSL,SUP-2370221,CDM,C1776,CPT,0278,RC,,,,both,,,4696.81,3052.93,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 4 CM DIA 6 FR GUIDEWIRE L 40 CM DIA,SUP-2303309,CDM,C1894,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
GRAFT BNE 14 MM DISC HA,SUP-2651596,CDM,C1713,HCPCS,0278,RC,,,,both,,,2497.40,1623.31,,,,,,,,,,,,,
COLLAR CERV SEMI RIGID BRAC ADJ,SUP-2265009,CDM,L0140,HCPCS,0272,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
HC Potassium 24hr Urine,PX-3018413300,CDM,84133,CPT,0301,RC,,,,outpatient,,,119.00,77.35,,,,,,,,,,,,,
SCREW BNE 5X44 MM,SUP-2205580,CDM,C1713,HCPCS,0278,RC,,,,both,,,472.26,306.97,,,,,,,,,,,,,
GRAFT SURG REGEN PORCINE CLLGN XENMATRIX RECT 20CM X 20CM,SUP-2125850,CDM,C1781,HCPCS,0278,RC,,,,both,,,38335.32,24917.96,,,,,,,,,,,,,
PLATE BNE SM L27MM 4 H NONSTERILE BILAT FOREFOOT S STL X,SUP-2184802,CDM,C1713,HCPCS,0278,RC,,,,both,,,3069.29,1995.04,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 FT MAXBARR 5FR 55CM 3295108FD,SUP-2632676,CDM,C1751,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
FIBER LASER 365 MH SIDE FIRING FOR LUMENIS HOLM SLM LN EZ,SUP-2140361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.89,588.18,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 60 CM DIA 8.5 FR NDL L 71 CM MP28,SUP-2516626,CDM,C1893,HCPCS,0272,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
SHEATH INTRO ACCEL L 20 CM DIA 6 FR L 60 CM DIA 22 GA NIT,SUP-2659244,CDM,C1894,HCPCS,0272,RC,,,,both,,,230.29,149.69,,,,,,,,,,,,,
CAGE SPNL 3D 7 DEG 15X5X20 MM WAVEFORM C,SUP-2710166,CDM,C1889,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
CONNECTOR TBNG DISMANTLING W/ STPCOCK LUERLOCK,SUP-2261235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.00,289.25,,,,,,,,,,,,,
PLATE BONE BAR L8MM 6 H MIC DBL Y,SUP-2365224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1140.07,741.05,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 8 MM STR STD WALL REINF,SUP-2525436,CDM,C1768,CPT,0278,RC,,,,both,,,671.65,436.57,,,,,,,,,,,,,
BOLT 8 MM,SUP-2696096,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
VEST PT CERV HALO,SUP-2322423,CDM,L0112,HCPCS,0274,RC,,,,both,,,19625.00,12756.25,,,,,,,,,,,,,
SPACER JT CARPOMETACARPAL SPHR INTERPOSITI,SUP-2399054,CDM,C1776,CPT,0278,RC,,,,both,,,7787.20,5061.68,,,,,,,,,,,,,
COMPONENT PAT SZ 1 10MM POLYETH N-K FLX,SUP-2200040,CDM,C1776,CPT,0278,RC,,,,both,,,2408.38,1565.45,,,,,,,,,,,,,
COMPONENT FEM DSTL E 8.5 CM RT KNEE POROUS MAK OSS,SUP-2449875,CDM,C1776,CPT,0278,RC,,,,both,,,18917.24,12296.21,,,,,,,,,,,,,
PLATE BNE LCK 5X196 MM RT DSTL FEM 7 HOLE COMPR SS NS LCP,SUP-2184891,CDM,C1713,HCPCS,0278,RC,,,,both,,,4392.55,2855.16,,,,,,,,,,,,,
CATHETER CTRL VEN 4.2FR 0.3ML L71CM OD1.4MM ID0.7MM SIL SGL,SUP-2127697,CDM,C1751,HCPCS,0278,RC,,,,both,,,1111.94,722.76,,,,,,,,,,,,,
STEM HUM L160MM DIA6MM UNIV SHLDR CO CHROME NONCOATED CEM,SUP-2249918,CDM,C1776,CPT,0278,RC,,,,both,,,13794.02,8966.11,,,,,,,,,,,,,
SET DIL DIA4 5 6 7FR SALIVARY ACC OTOLARYN,SUP-2169479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
OBTURATOR ARTHSCP SPEAR TRCR TIP DISP FOR 3MM SUTURETAK,SUP-2121621,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
CUP ACET 10 DEG 32X70 MM FEM HIP,SUP-2202591,CDM,C1776,CPT,0278,RC,,,,both,,,2139.28,1390.53,,,,,,,,,,,,,
SYSTEM CARD PACEMKR SGL CHMBR MICRONY II SR PULSE RATE,SUP-2356133,CDM,C1786,HCPCS,0275,RC,,,,both,,,11410.76,7416.99,,,,,,,,,,,,,
PIN GIC64 15X50MM RESRB NEXFIX RFS,SUP-2388884,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BURR BALL FLUTED 3.0MM W/ MED ATTACHMENT,SUP-2843301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,402.36,261.53,,,,,,,,,,,,,
MESH SPNL W26XH50XL33MM TI OVL,SUP-2256179,CDM,C1781,HCPCS,0278,RC,,,,both,,,12289.96,7988.47,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT BLK ILIUM TRICORT TRAD 15-18MM M,SUP-2294069,CDM,C1713,HCPCS,0278,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
PROSTHESIS PENILE 12CM SNAP FIT RT CX MS INHIBIZONE,SUP-2138965,CDM,C1813,HCPCS,0278,RC,,,,both,,,24774.60,16103.49,,,,,,,,,,,,,
CATHETER CNTSS 5FR DIA 19GA INTRDCR NDLE 7CML TPRD TIP LOW P,SUP-2473617,CDM,C1729,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN LG 22X13 CMX0.7-1.4 MM BRST FLEXHD,SUP-2307607,CDM,C1768,CPT,0278,RC,,,,both,,,27813.49,18078.77,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ SM LG AD PEDIATRIC RT HND WRST FNGR,SUP-2264312,CDM,L3807,HCPCS,0274,RC,,,,both,,,159.36,103.58,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.538,SUP-2860219,CDM,C1713,HCPCS,0278,RC,,,,both,,,42390.63,27553.91,,,,,,,,,,,,,
PLATE BNE PROX RAD TRL,SUP-2606623,CDM,C1713,HCPCS,0278,RC,,,,both,,,937.23,609.20,,,,,,,,,,,,,
BIT DRILL 2.1MM,SUP-2468680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.43,466.33,,,,,,,,,,,,,
PLATE BONE L96MM 6 H RT FEM CNTOUR LCK COMPR FOR 4.5MM SCR,SUP-2318706,CDM,C1713,HCPCS,0278,RC,,,,both,,,12927.44,8402.84,,,,,,,,,,,,,
DRILL SURG 3.4X160 MM FOR 5 MM HALF PIN,SUP-2749965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SPHERE GLEN CENTERED 39 MM 25 MM SHLDR COCR AEQUALIS,SUP-2715793,CDM,C1776,CPT,0278,RC,,,,both,,,9160.95,5954.62,,,,,,,,,,,,,
HC Intrapx Coronary Ffr W/3d Funcjl Map,PX-4810523000,CDM,0523T,HCPCS,0360,RC,,,,both,,,17689.00,11497.85,,,,,,,,,,,,,
PACK SAW BLDE 42MM D302MM CUT EDGE 10MM THK12MM FOR PWR,SUP-2365131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
GRAFT BONE SUB 16ML HA SYNTH TISS CLLGN MTRX STRP RESRB,SUP-2256854,CDM,C9362,HCPCS,0278,RC,,,,both,,,7764.72,5047.07,,,,,,,,,,,,,
APPLIER CLIP 90/225MM DOUBLE BAYONET STANDARD PHYNOX,SUP-2826144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7748.04,5036.23,,,,,,,,,,,,,
LACOSAMIDE 10 MG/ML PO SOLN,RX-105342,CDM,340b,HCPCS,0637,RC,66689-0109-01,NDC,,both,5,ML,88.30,57.39,,,,,,,,,,,,,
STIMULATOR NERVE 4.95X5.55X1.34 CM 30.4 CC 48.9 GM PROCLAIM,SUP-2421702,CDM,C1767,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
CANNULA ENDOSCOPIC OD6.7MM LOW PROFILE SLOTTED,SUP-2825163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1837.59,1194.43,,,,,,,,,,,,,
GUIDEWIRE VASC VIPERWIRE ADV L 335 CM DIA 0.014 IN SS PERIPH,SUP-2159533,CDM,C1769,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CROSSTELLA 150CM 80 MM 4 MM PERIPH RX,SUP-2384772,CDM,C1725,HCPCS,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
SCREW BONE L28MM DIA4MM CORT SLD,SUP-2123643,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
BIT DRILL CROSSPIN PINN-ACL,SUP-2825126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.46,887.55,,,,,,,,,,,,,
CATHETER CTRL VEN OD5FR PICC TRIM LEN 2 LUMN INTMED TY NRS,SUP-2125537,CDM,C1894,HCPCS,0272,RC,,,,both,,,483.87,314.52,,,,,,,,,,,,,
STENT URET 45FR L8CM NYL COAT DBL PGTL BRAID HYDRPHLC OPN,SUP-2313796,CDM,C2617,HCPCS,0278,RC,,,,both,,,245.80,159.77,,,,,,,,,,,,,
SCREW BNE SET STD 7.5 MM 32 MM CANN THRD,SUP-2861010,CDM,C1713,HCPCS,0278,RC,,,,both,,,25226.76,16397.39,,,,,,,,,,,,,
COIL NEUROVASCULAR TRUFILL L 5 MM MICROCATHETER 0.021 IN,SUP-2482185,CDM,C1768,CPT,0278,RC,,,,both,,,1523.21,990.09,,,,,,,,,,,,,
GRAFT HUM TISS DIA44MM FEM HD FRZN,SUP-2307304,CDM,C1713,HCPCS,0278,RC,,,,both,,,3959.51,2573.68,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L145CM OD0038IN 35CM TIP PTFE AMPLATZ SUP,SUP-2139357,CDM,C1769,HCPCS,0272,RC,,,,both,,,88.14,57.29,,,,,,,,,,,,,
HC Lymph Vessel X-Ray Trunk,PX-3207580700,CDM,75807,CPT,0320,RC,,,,inpatient,,,2864.00,1861.60,,,,,,,,,,,,,
MESH HERN W2XL4IN VENTRAL INGUINAL POLYPR REP MFIL,SUP-2125744,CDM,C1781,HCPCS,0278,RC,,,,both,,,121.46,78.95,,,,,,,,,,,,,
APPLIER CLP ENDOSAPHENOUS MED 5/7 MMX13 IN HORZ MTL LIG SYS,SUP-2656772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
PLATE BONE 6X17 H LT MAND HMSPHR TI RECON LEIBINGER,SUP-2363751,CDM,C1713,HCPCS,0278,RC,,,,both,,,4361.15,2834.75,,,,,,,,,,,,,
SPLINT THMB M L5IN SH LT 1 STRP THERMOPLASTIC INSRT,SUP-2324195,CDM,L3931,HCPCS,0272,RC,,,,both,,,42.26,27.47,,,,,,,,,,,,,
COMPONENT KNEE FOR PK 3900 LEG,SUP-2212671,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
KIT SUTURE ANCHR SZ 2 KNOTLESS IMPL NDL STRL DX FIBERTAK,SUP-2882188,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 6.25X6.25 IN FNGR W/ BLB RADLUC,SUP-2276775,CDM,L3933,HCPCS,0272,RC,,,,both,,,5.78,3.76,,,,,,,,,,,,,
SYSTEM DRAINAGE INTRAVENTRICULAR CATH,SUP-2666768,CDM,C1729,HCPCS,0272,RC,,,,both,,,391.43,254.43,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 5 CC OSTEOINDUCTIVE DBM REFICIO,SUP-2731793,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM 10 MM POLYESTER BOV CLLGN STR,SUP-2266032,CDM,L8670,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
EXTERNAL FIXATION KIT MILITARY LG STRL,SUP-2546227,CDM,C1713,HCPCS,0278,RC,,,,both,,,11817.55,7681.41,,,,,,,,,,,,,
TRAP SPEC CUSA CLARITY,SUP-2604370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3442.04,2237.33,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X183 MM RT LAT DSTL 11 HOLE NS VA-LCP,SUP-2758203,CDM,C1713,HCPCS,0278,RC,,,,both,,,3273.76,2127.94,,,,,,,,,,,,,
BIT DRL L125MM DIA2.7MM QUIK CPL 3 FLUT,SUP-2187589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.21,206.84,,,,,,,,,,,,,
CATHETER ATHRCTMY ELCA LASER 130CM DIA 0.9MM TIP DIA 0.038IN SHFT,SUP-2353044,CDM,C1885,CPT,0278,RC,,,,both,,,10344.73,6724.07,,,,,,,,,,,,,
BIT DRILL STOP 90 DEGREE 2.2 MM 8 MM FOR SCREWDRIVER NON STE,SUP-2837623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1028.66,668.63,,,,,,,,,,,,,
KIT INTRO INTDYN TEARWY DIA16 FR PTFE,SUP-2125219,CDM,C1894,HCPCS,0272,RC,,,,both,,,853.58,554.83,,,,,,,,,,,,,
COLLAR CERV CHILD SZ PD1 1 18MON 21 33IN FOR 075IN NK UP EXT,SUP-2123899,CDM,L0190,HCPCS,0272,RC,,,,both,,,89.46,58.15,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 18 MM CABLE L 2 M 4 CHANNEL PRASS PR,SUP-2902062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1030.23,669.65,,,,,,,,,,,,,
MIXER BNE CEM ROTARY ELECTR PWR FOR MAXILLOFACIAL SURG,SUP-2194208,CDM,C1713,HCPCS,0278,RC,,,,both,,,6045.66,3929.68,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W25MM LEG L22X22MM NIT NONBIOABSORBABLE,SUP-2194229,CDM,C1713,HCPCS,0278,RC,,,,both,,,4600.10,2990.06,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SABER L 200 CM BALLOON L 250 MM DIA 3 MM,SUP-2909685,CDM,C1725,HCPCS,0272,RC,,,,both,,,847.33,550.76,,,,,,,,,,,,,
SPLINT WRST UNIV L11IN R CUTAWAY PERF FOAM CONSTR MAL,SUP-2194859,CDM,L3931,HCPCS,0274,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
AGENT HEMSTAT 5ML BOV DERIVD GEL MTRX THROM COMP W NDL FREE,SUP-2130316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.81,377.53,,,,,,,,,,,,,
BIT DRL DIA3.3MM EQUINOXE FX,SUP-2223460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
HC So Erythropoietin,PX-3018266866,CDM,82668,CPT,0301,RC,,,,inpatient,,,373.00,242.45,,,,,,,,,,,,,
GUN DEPLOYMENT ANCHR AND INSTR VERSA-LOK,SUP-2249391,CDM,C1713,HCPCS,0278,RC,,,,both,,,2668.84,1734.75,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN 20X8 CMX0.7-1.4 MM PERF FLEXHD,SUP-2307573,CDM,Q4128,HCPCS,0636,RC,,,,both,,,635.19,412.87,,,,,,,,,,,,,
CATHETER PD COILED INF 42 CM 4.5 CM CLASSIC 1 CUF,SUP-2469784,CDM,C1750,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
SPLINT WR AD SM FOR 2.5-3IN LT MCP REG FIRM OUTER FAB HND,SUP-2324878,CDM,L3809,HCPCS,0272,RC,,,,both,,,46.19,30.02,,,,,,,,,,,,,
ANCHOR SUT ETHBND SZ 2 L36IN GRN POLY BRAID CP-2 DBL ARMED,SUP-2249346,CDM,C1713,HCPCS,0278,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
CATHETER DRNGE 10FR L25CM FLEXIMA KT ALL PURP LOOP REG,SUP-2147853,CDM,C1729,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-40840052,CDM,J7040,HCPCS,0258,RC,00264-7800-10,NDC,,both,250,ML,14.90,9.68,,,,,,,,,,,,,
SUPPORT ANK XL FOR 14-15IN BLK BALLISTIC NYL L R FT STBL LO,SUP-2269721,CDM,L1930,HCPCS,0274,RC,,,,both,,,64.87,42.17,,,,,,,,,,,,,
TUNNELER SURG FLUID SHTH 11 GAX10 IN REMOVABLE WNG STRL ON Q,SUP-2424463,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
DRILL SL 4.3 MM FOR RG FEM NAT NAIL SYS,SUP-2198659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
PIN BONE L89MM DIA4MM NAVIO,SUP-2341231,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE BNE 2 HOLE ORTHOLINK,SUP-2315902,CDM,C1713,HCPCS,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL PREFABRICATED FLEXION,SUP-2388150,CDM,L0633,HCPCS,0272,RC,,,,both,,,738.50,480.02,,,,,,,,,,,,,
SCREW BNE CANC FULL THRD N CANN N LOK 4.0MM DIA 20MM LEN,SUP-2198337,CDM,C1713,HCPCS,0278,RC,,,,both,,,48.23,31.35,,,,,,,,,,,,,
Z DISCONTINUED 2/27/25 MASS INACTIVE JR PORT PERITONEAL TI W/ 14.3FR,SUP-2845005,CDM,C1788,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
STEM FEM L150MM OD9MM STR CLLRD TI IM OSS,SUP-2405835,CDM,C1776,CPT,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TAPR L 15 CM X FLPY TIP,SUP-2167668,CDM,C1769,HCPCS,0272,RC,,,,both,,,40.60,26.39,,,,,,,,,,,,,
INTRODUCER SHTH 0.038 IN 7 FRX12 CM HEMOSTATIC FAST-CATH,SUP-2357126,CDM,C1894,HCPCS,0272,RC,,,,both,,,39.69,25.80,,,,,,,,,,,,,
BRACE WLK XL 13+ M 15+ WOM ANK FOAM PNEUMAT SEMI RIG SHELL,SUP-2196362,CDM,L4361,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
HC 2d Echo W Contrast - WO Dop/Color Flow,PX-4839330700,CDM,C8923,CPT,0483,RC,,,,both,,,1075.00,698.75,,,,,,,,,,,,,
HC N Block Paravert Thoracic 2nd,PX-3606449100,CDM,64491,CPT,0360,RC,,,,both,,,3892.00,2529.80,,,,,,,,,,,,,
GRAFT DURAL 2INW X 2NL ULTRPRE CLLGN ONLAY STRLSS CLSRE ENHN,SUP-2493464,CDM,C1763,HCPCS,0278,RC,,,,both,,,1482.39,963.55,,,,,,,,,,,,,
KNIFE OPHTH WEINSTOCK BIMANUAL 19 GA DIAMOND BVL LF,SUP-2491683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5302.52,3446.64,,,,,,,,,,,,,
NEEDLE CRYOABLATION 90DEG ANG GRY HNDL ICEFORCE 2.1 CX,SUP-2225995,CDM,C2618,HCPCS,0272,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
PLATE BONE 1X3 H CRANIOMAXILLOFACIAL TI Y SHP MALL FOR 1.5MM,SUP-2191689,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
GRAFT VSCLR STRGHT WOVEN DBLE VLR 28MM DX15CM L HMSHLD PLTNM,SUP-2464174,CDM,C1768,CPT,0278,RC,,,,both,,,1418.28,921.88,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM TWO ULTRABRAID SUT FOR ROT CUF SFT TISS,SUP-2341134,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
IMPLANT FEM L24MM DIA10MM INSRT APERFIX AM,SUP-2402619,CDM,C1776,CPT,0278,RC,,,,both,,,4163.64,2706.37,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING BOLT INDIGO L 132 CM SHTH 6 FR,SUP-2930520,CDM,C1757,HCPCS,0272,RC,,,,both,,,24240.80,15756.52,,,,,,,,,,,,,
GRAFT BNE WDG LG 6X19 MM EVANS TITAN 3-D,SUP-2423120,CDM,C1713,HCPCS,0278,RC,,,,both,,,6867.18,4463.67,,,,,,,,,,,,,
PACEMAKER CARD ALTURA20 TI 2 CHMBR 1 LD BATTERY PWR EXT,SUP-2149114,CDM,C1882,HCPCS,0275,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
PATCH HEMSTAT W1.5XL1.5IN FOR THE EXT BLEED CTRL,SUP-2238296,CDM,C1768,CPT,0278,RC,,,,both,,,91.81,59.68,,,,,,,,,,,,,
BLADE ES SPAT TIP W4MM TELSCP INTEGR SUCT 3.0S PLASMABLDE,SUP-2281811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
CATHETER ABLATN D 1-4-1 MM 4 MM TIP 8 FRX115 CM FLEXABILITY,SUP-2357515,CDM,C2630,CPT,0272,RC,,,,both,,,7928.50,5153.52,,,,,,,,,,,,,
CAGE SPNL 13X20MM INTBDY FUS RADLUC BAK VISTA,SUP-2414373,CDM,C1889,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
INTERTAN NAIL CAP 0.0MM,SUP-2821024,CDM,C1889,HCPCS,0278,RC,,,,both,,,928.97,603.83,,,,,,,,,,,,,
INSTRUMENT PACK PIN,SUP-2878039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1341.88,872.22,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50CM DIA28MM L 15CM 10MM 12/8MM PLEXUS,SUP-2894604,CDM,C1768,CPT,0278,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 15 CM DIA10 MM POLYESTER GEL,SUP-2384994,CDM,C1768,CPT,0278,RC,,,,both,,,3877.90,2520.63,,,,,,,,,,,,,
PACK PIP FUS ID2.7X4MM PROX MID PHALANX IMPL PEEK HAT-TRICK,SUP-2349219,CDM,C1713,HCPCS,0278,RC,,,,both,,,4995.11,3246.82,,,,,,,,,,,,,
PACK ARTHSCP ACL PCL RAP PAC C,SUP-2341855,CDM,C1769,HCPCS,0272,RC,,,,both,,,869.34,565.07,,,,,,,,,,,,,
KIT IMPL SYS PROX TENODESIS W/ BICEPSBUTTON INSRT FIBERLOOP,SUP-2121681,CDM,C1776,CPT,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
TUBE SUCT L7IN OD6FR TAPR TEARDROP MAL T FUKUSHIMA,SUP-2436395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.00,263.25,,,,,,,,,,,,,
PLATE BNE 4 H 130DEG HIP S STL LOK BILAT COMPR RIG STD BRL,SUP-2370872,CDM,C1713,HCPCS,0278,RC,,,,both,,,2258.45,1467.99,,,,,,,,,,,,,
EXPEL APD 16/30,SUP-2652769,CDM,C1729,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.7MM SELF DRL LO PROF HD HT AXS 5PK,SUP-2363866,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.74,203.28,,,,,,,,,,,,,
BLADE ARTHROSCOPY CAP-FIX STRAIGHT,SUP-2822789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED TOT STBL BASEPLT X3 TRIATHLON,SUP-2365631,CDM,C1776,CPT,0278,RC,,,,both,,,16092.50,10460.12,,,,,,,,,,,,,
KIT CATH 7FR L12IN NDL 18GA L2.5IN SYR 3ML 0.032IN POLYUR,SUP-2383315,CDM,C1751,HCPCS,0278,RC,,,,both,,,157.63,102.46,,,,,,,,,,,,,
SYSTEM TARGETING 6MM PRECIS W/ PERPENDICULARITY ROD FOR GRFT,SUP-2256809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6352.22,4128.94,,,,,,,,,,,,,
WASHER ORTHOPEDIC SPC 4 MM FOR MR SAFE TI NS,SUP-2179143,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
INSERT TIB RP 5 10 MM KNEE CRUC RETAINING STBL REV ATTUNE,SUP-2136396,CDM,C1776,CPT,0278,RC,,,,both,,,9256.72,6016.87,,,,,,,,,,,,,
HC Continous Inhale Tx 1st Hour,PX-4109464400,CDM,94644,CPT,0410,RC,,,,outpatient,,,660.00,429.00,,,,,,,,,,,,,
STEM FEM L200MM CO CHROM MOLYBDENUM POREX CEM MOD ENDO MOD,SUP-2265095,CDM,C1776,CPT,0278,RC,,,,both,,,19986.10,12990.96,,,,,,,,,,,,,
SCREW BNE L90MM DIA7.3MM CORT S STL ST CANN LOK FULL THRD,SUP-2184942,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
TRUMATCH TRAY FEM 2.0,SUP-2513273,CDM,C1776,CPT,0278,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
DEVICE GRAFT DELIVERY WITH CUSTOM CANNULA,SUP-2731950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.141X9 IN THRD SS NS STEINMANN,SUP-2791295,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.67,53.09,,,,,,,,,,,,,
COMPONENT GLEN L THK4MM SHLDR POLY PEGGED MOD CONSTRN CEM,SUP-2404650,CDM,C1776,CPT,0278,RC,,,,both,,,5127.62,3332.95,,,,,,,,,,,,,
STEM FEM L210MM OD22.5MM 005 TI HX COAT HIP CEMENTLESS 03,SUP-2397013,CDM,C1776,CPT,0278,RC,,,,both,,,14287.00,9286.55,,,,,,,,,,,,,
SYSTEM RETRV 20 MM NIT 2 SHTH SNR KINK RESIST RADIOPAQUE,SUP-2128488,CDM,C1773,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BIT DRL N CANN 2.7 MM FOR LAG TECH SMRTSCR II,SUP-2167109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
BIT DRL TWST 1X40 MM 8 MM W/ STP BOS ATTCH SS SONICWELD RX,SUP-2467335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.14,363.44,,,,,,,,,,,,,
HC Thrmbc/Nfs Dialysis W Pta|UNUSUAL NON-OVERLAPPING SERVICE,PX-3613690500,CDM,36905,CPT,0361,RC,,,XU,both,,,11772.00,7651.80,,,,,,,,,,,,,
MATRIX BIO SZ 300-540 SQCM FISH SKIN DERMAL MESHED 21,SUP-2909213,CDM,Q4158,HCPCS,0636,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
GRAFT RECT XENMATRIX 4 IN X 8 IN,SUP-2126240,CDM,C1781,HCPCS,0278,RC,,,,both,,,19889.07,12927.90,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMOS DR-T W 67 X H 55 MM D 12 MM 32 CC,SUP-2138067,CDM,C1721,HCPCS,0275,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
BAR EXT FIX L L250MM DIA10.5MM C FBR JET-X,SUP-2342875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1681.28,1092.83,,,,,,,,,,,,,
SCREW BNE L24MM DIA3MM LOK PLATING SYS MOTOBAND CP,SUP-2175142,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
CABLE EP L150CM BLK 24K GLD PLT PINS EXTN CONN DUO DECAPOLAR,SUP-2356880,CDM,C1730,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 7 CM DIA 5 FR GUIDEWIRE L 40 CM DIA,SUP-2461396,CDM,C1894,HCPCS,0272,RC,,,,both,,,100.92,65.60,,,,,,,,,,,,,
PLATE BONE 3D PRNT LG MIDFACE MAND TI TRUMATCH SD980.109,SUP-2860373,CDM,C1713,HCPCS,0278,RC,,,,both,,,51499.14,33474.44,,,,,,,,,,,,,
TRAY EPIDURAL HUSTEAD NDL L 3.5 IN DIA18 GA SD LIDO HCL 5 ML,SUP-2936649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,50.77,33.00,,,,,,,,,,,,,
MEMBRANE AMNIOTIC DS 4X8CM,SUP-2880402,CDM,C1762,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
HC Dil Ure Strc Fil/Fol Male Init,PX-4505362000,CDM,53620,CPT,0450,RC,,,,both,,,706.00,458.90,,,,,,,,,,,,,
FENOFIBRATE 145 MG PO TABS,RX-40010,CDM,6370000000,HCPCS,0637,RC,00378-3066-77,NDC,,both,1,UN,3.00,1.95,,,,,,,,,,,,,
BLADE RETRCT D4IN FOR CHARNLEY TYP FRME,SUP-2242483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,990.04,643.53,,,,,,,,,,,,,
STEM HUM L125MM L9.5MM UNIV TI POR SHLDR PRI CEM IMP,SUP-2404705,CDM,C1776,CPT,0278,RC,,,,both,,,12503.48,8127.26,,,,,,,,,,,,,
PUTTY BONE 3 CC REINFORCED FAST SET STERILE CRANIOS,SUP-2838511,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
PLATE BNE L 130 X W 11.2 MM THK 3.5 MM 8 H SS RT PROX RADIAL,SUP-2933120,CDM,C1713,HCPCS,0278,RC,,,,both,,,3066.21,1993.04,,,,,,,,,,,,,
CLAMP SURG STD LEN JAW STRL ISOLATOR SYNERGY ENCOMPASS DISP,SUP-2866238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
HC Revasc Intravasc Lithotripsy,PX-4810976400,CDM,C9764,CPT,0481,RC,,,,outpatient,,,57405.00,37313.25,,,,,,,,,,,,,
NUT ORTH 47 MM OLECRANON SLED,SUP-2389621,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
BRACE W/ STRNL PD KT COMPLT BLK M CNTOUR TLSO,SUP-2123919,CDM,L0462,HCPCS,0274,RC,,,,both,,,1020.19,663.12,,,,,,,,,,,,,
SHEATH INTRO MP SHT CRV 8 FRX77 CM GUID LD DBL WIRE PREFACE,SUP-2248486,CDM,C1892,HCPCS,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
BLADE SHAVER BPLR STD 40 DEG 4 MM SERRATED STRL DISP,SUP-2638395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
GAUGE DEPTH STANDALONE FOR 5 MM SCREW STRL DISP PROSTEP MIS,SUP-2902371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1430.74,929.98,,,,,,,,,,,,,
ANCHOR SUT SZ 2 DIA3.5MM BNE ABSRB DBL ARMED CP-2 NDL,SUP-2249330,CDM,C1713,HCPCS,0278,RC,,,,both,,,1331.36,865.38,,,,,,,,,,,,,
INTRODUCER LD 0.032 IN 8.5 FRX40 CM SINUS ACCS VLV AGILIS,SUP-2357589,CDM,C1894,HCPCS,0272,RC,,,,both,,,4348.90,2826.78,,,,,,,,,,,,,
SHORT RADIAL OSTEOTOME BLADE,SUP-2514518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BONE L82MM 6 H BILAT ELBW 1/3 TBLR LCK COMPR FOR 3.5MM,SUP-2348936,CDM,C1713,HCPCS,0278,RC,,,,both,,,1541.17,1001.76,,,,,,,,,,,,,
NAIL IM 11.5X200 MM PHANTOM ACTIVCORE P312152000S,SUP-2743184,CDM,C1713,HCPCS,0278,RC,,,,both,,,21666.00,14082.90,,,,,,,,,,,,,
SCREW BNE LCK 2.3X9 MM THOR STRNL DRL FREE LEVEL 1 MAXDRIVE,SUP-2869240,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.26,56.72,,,,,,,,,,,,,
RING EXT FIX L120MM DBL H FT FOR SIDEKCK FREE CIR FIX,SUP-2400633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
PLATE BNE L169MM THK37MM 13 H BILAT S STL STR LO PROF RIG,SUP-2177145,CDM,C1713,HCPCS,0278,RC,,,,both,,,2572.19,1671.92,,,,,,,,,,,,,
LINER ACET CONSTRN 32/36 MM JUMBO INSTRUMENT TY CONTINUUM,SUP-2439844,CDM,C1776,CPT,0278,RC,,,,both,,,1455.39,946.00,,,,,,,,,,,,,
PLATE BNE L194MM 8 H ST R DST HUM EXTRA ARTC S STL LOK,SUP-2177169,CDM,C1713,HCPCS,0278,RC,,,,both,,,4352.57,2829.17,,,,,,,,,,,,,
CANNULA SUCTION MONOPOLAR 3 MMX30 CM COAG INSUL,SUP-2767475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.30,529.94,,,,,,,,,,,,,
ADAPTER FEM DIA6MM KNEE TOT STBL OFFSET REV TRIATHLON,SUP-2373735,CDM,C1776,CPT,0278,RC,,,,both,,,2684.04,1744.63,,,,,,,,,,,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,0636,RC,00024-2792-10,NDC,,both,5,ML,182.90,118.88,,,,,,,,,,,,,
BUR 1883070HSE RAD FRNTL FINESSE 3MM 40D,SUP-2277862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X251 MM 14 HOLE SS LCP,SUP-2569367,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.88,506.27,,,,,,,,,,,,,
PLATE BNE LCK 118 MM RT DSTL RADIAL VOLAR 10 HOLE LAT CLMN,SUP-2459511,CDM,C1713,HCPCS,0278,RC,,,,both,,,2690.85,1749.05,,,,,,,,,,,,,
GRAFT DELIVERY SYSTEM SET 3 CC GRFT DBF CANN ACCELERATE BG,SUP-2766771,CDM,C1713,HCPCS,0278,RC,,,,both,,,2451.12,1593.23,,,,,,,,,,,,,
SIZER SURG GEL 5.3 CM PROJCT 10.5X10.9 CM 290 CC MEMORYSHAPE,SUP-2758644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STIMULATOR NERVE 5.55X4.95X1.34 CM,SUP-2637205,CDM,C1767,HCPCS,0278,RC,,,,both,,,34372.67,22342.24,,,,,,,,,,,,,
KIT CATH URTHRL DLTR 4MM OD BLLN 12FR DIA INFLTD 3FR DIA SHA,SUP-2727094,CDM,C2617,HCPCS,0278,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
ECLIPSE CAGE SCREW L 40MM,SUP-2815662,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
DRILL TWST L19MM DIA1.6MM WRK L8MM FOR 2/2.3MM SCR,SUP-2364189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,866.70,563.35,,,,,,,,,,,,,
INTRODUCER HEMSTAS MAXIMUMXTRA 5.5FRX12CM SHTH W/ 0.038 IN,SUP-2355575,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
KIT BNE MAR ASPIR 60ML 15GA SYR,SUP-2163070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PROBE RF STR 22 GAX100 MM NIT DISP,SUP-2753309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
STAPLE BNE ORTHOPEDIC 12 MM STRENGTH,SUP-2392828,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
TAP SURG L196MM QUIK CONN FOR 6.5MM SCR,SUP-2410966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,0258,RC,00409-7418-03,NDC,,both,500,ML,382.40,248.56,,,,,,,,,,,,,
CATHETER GUID L100CM OD5FR AD MPC COR W/O SIDE H W/O,SUP-2249315,CDM,C1887,HCPCS,0272,RC,,,,both,,,1388.88,902.77,,,,,,,,,,,,,
IMPLANT HUM TISS H 10 MM CALC-CUBOID PRO-SPEC WDG,SUP-2932788,CDM,C1762,CPT,0278,RC,,,,both,,,4328.49,2813.52,,,,,,,,,,,,,
GRAFT VASC IMPRA L 60 CM DIA10 MM EPTFE FLX STD WALL RING,SUP-2126882,CDM,C1768,CPT,0278,RC,,,,both,,,2559.70,1663.80,,,,,,,,,,,,,
ORTHOPAEDIC KIT 12X3.2 MM TI SYND-EZ,SUP-2761960,CDM,C1713,HCPCS,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
SENNOSIDES 8.8 MG/5ML PO SYRP,RX-15168,CDM,340b,HCPCS,0637,RC,00536-1266-59,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 8 MM RNG L 20 CM UTHN,SUP-2227616,CDM,C1768,CPT,0278,RC,,,,both,,,3149.58,2047.23,,,,,,,,,,,,,
PLATE BNE BSSO MINI 2X24 MM 9 MM 10 MM DBL Y CRV FOR SCR TI,SUP-2461312,CDM,C1713,HCPCS,0278,RC,,,,both,,,1729.61,1124.25,,,,,,,,,,,,,
STENT BILI ZILVER L 4 CM DIA 8 MM INTRO L 208 CM DIA 7 FR,SUP-2169573,CDM,C1876,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CLIP SURG JAW L25MM 350GM CLS FORC ENDO VES SHORT STRAIGHT,SUP-2108996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2098.62,1364.10,,,,,,,,,,,,,
SCREW BNE L40MM DIA4.5MM THRD L12MM S STL PARTIALLY THRDED,SUP-2184433,CDM,C1713,HCPCS,0278,RC,,,,both,,,71.34,46.37,,,,,,,,,,,,,
NEEDLE BRST LOC 7GA ENCOR,SUP-2126866,CDM,C1819,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SUPPORT ANK UNIV AIR FOAM STRRP,SUP-2276705,CDM,L4350,HCPCS,0272,RC,,,,both,,,33.28,21.63,,,,,,,,,,,,,
PIN GUID DIA2MM GLEN SYS HEMICAP,SUP-2123637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
ROSUVASTATIN CALCIUM 5 MG PO TABS,RX-36612,CDM,6370000000,HCPCS,0637,RC,60687-0234-01,NDC,,both,1,UN,6.30,4.09,,,,,,,,,,,,,
PLATE BNE 24 DEG L 76 X W 8.5 MM THK 1.6 MM 5 H SS LT DSTL,SUP-2933580,CDM,C1713,HCPCS,0278,RC,,,,both,,,7957.86,5172.61,,,,,,,,,,,,,
TOLTERODINE TARTRATE ER 2 MG PO CP24,RX-29434,CDM,6370000000,HCPCS,0637,RC,60687-0319-11,NDC,,both,1,UN,45.20,29.38,,,,,,,,,,,,,
KIT SYR 1ML 2ML TRAUM TRAUMCEM V+,SUP-2179485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.90,246.28,,,,,,,,,,,,,
CATHETER INFUSION,SUP-2305457,CDM,C1887,HCPCS,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
COIL EMB L2CM DIA0.02IN LOOP DIA2MM CRV EXTRA SFT FILL,SUP-2323439,CDM,C1889,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
BUR SHV OD55MM HPS PREBENT SPHR,SUP-2167163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 018 IN 4 FRX55 CM 135 CM POWERPICC,SUP-2126369,CDM,C1751,HCPCS,0278,RC,,,,both,,,330.80,215.02,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FEN 10X4 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871304,CDM,C1762,CPT,0278,RC,,,,both,,,9250.44,6012.79,,,,,,,,,,,,,
PROMETHAZINE HCL 6.25 MG/5ML PO SOLN,RX-6620,CDM,Q0169,HCPCS,0637,RC,17856-0608-05,NDC,,both,5,ML,4.70,3.05,,,,,,,,,,,,,
GRAFT HUM TISS,SUP-2213682,CDM,V2785,HCPCS,0810,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
BENZTROPINE MESYLATE 0.5 MG PO TABS,RX-998,CDM,6370000000,HCPCS,0637,RC,00904-7288-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SPACER 11X13 MM PLIF TRAP VERTIGRAFT VG2,SUP-2264968,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.79,5307.11,,,,,,,,,,,,,
STEM TIB I-BEAM MED SHT KNEE,SUP-2846150,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE CLAV SET PERI-LOC,SUP-2351348,CDM,C1713,HCPCS,0278,RC,,,,both,,,26187.60,17021.94,,,,,,,,,,,,,
COMPONENT HUM DIA48MM STD SUT CLLR GLOB UNITE,SUP-2249863,CDM,C1776,CPT,0278,RC,,,,both,,,1245.95,809.87,,,,,,,,,,,,,
BAR EXT FIX CROSS 120 MM HORIZONTAL FOR RED DEV,SUP-2462232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1385.71,900.71,,,,,,,,,,,,,
SCREW LAG GAMMA 10.5X95MM,SUP-2854215,CDM,C1713,HCPCS,0278,RC,,,,both,,,2124.87,1381.17,,,,,,,,,,,,,
GRAFT HUM TISS M W60MMX10CM FASC LATA FRZN,SUP-2307272,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.90,1211.53,,,,,,,,,,,,,
HC So Varicella Igg Igm,PX-3028678766,CDM,86787,CPT,0302,RC,,,,both,,,80.00,52.00,,,,,,,,,,,,,
SAW SURG PNEUMATIC FOR REPEAT STERNOTOMY,SUP-2607457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7366.85,4788.45,,,,,,,,,,,,,
CANNULA 5MM NDL 100MM 20GA PREM SL RF STR ACT TIP,SUP-2357719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
PLATE BONE MEDIAL COLUMN RIGHT LONG TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878139,CDM,C1713,HCPCS,0278,RC,,,,both,,,7991.30,5194.34,,,,,,,,,,,,,
STENT URET L 24 CM DIA 6 FR TIP L 3 CM STIFF SHFT PTFE,SUP-2522131,CDM,C2617,HCPCS,0278,RC,,,,both,,,410.34,266.72,,,,,,,,,,,,,
NEXGEN TIBIAL WEDGE ATTACHING SCREW,SUP-2503253,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BONE TUBULAR BROAD 4.5 MM 14 HOLE PROVISIONAL FIXATION,SUP-2836968,CDM,C1713,HCPCS,0278,RC,,,,both,,,2863.05,1860.98,,,,,,,,,,,,,
PLATE BNE LCK 2 MM STRNL 10 HOLE BODY,SUP-2262564,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
CATHETER IAB 0.025 IN 8 FRX26 IN 6 IN 50 CC INTRO STOPCOCK,SUP-2877609,CDM,C1894,HCPCS,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
RING EXT FIX 105MM 2/3 TAY SPAT FRME,SUP-2342974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
PLATE BNE CRV 10 MM 4 HOLE SAG,SUP-2417588,CDM,C1713,HCPCS,0278,RC,,,,both,,,1568.90,1019.78,,,,,,,,,,,,,
ANCHOR SUT ABSRB W/ NDL QUICKANCHR + PANALOK RC,SUP-2249365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 8 MM EPTFE STR STD WALL N RING,SUP-2761305,CDM,C1768,CPT,0278,RC,,,,both,,,1773.88,1153.02,,,,,,,,,,,,,
CUTTER LOOP L 145 CM DIA2.8 MM STRL DISP,SUP-2912523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BONE CEMENT SURG PMMA GENTAMICIN VANCO STD SET HI VISC,SUP-2905405,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SET INTRO 5F COAX MICRO STICK STIFF W NIT WIRE RADPQ DST,SUP-2267054,CDM,C1894,HCPCS,0272,RC,,,,both,,,8.16,5.30,,,,,,,,,,,,,
EXTERNAL FIXATION KIT WRST STRL GALAXY,SUP-2646386,CDM,C1713,HCPCS,0278,RC,,,,both,,,9011.80,5857.67,,,,,,,,,,,,,
STAPLE INT L3.85XH3MM OD.24MM 60MM CUT LEN BLU TI RELD 2,SUP-2283065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
STEM MOD REMEDY LNG SM 227MM,SUP-2319836,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SCREW BNE L65MM DIA5MM TIB TI DBL LD FOR PHOENIX NAIL SYS,SUP-2412134,CDM,C1713,HCPCS,0278,RC,,,,both,,,627.37,407.79,,,,,,,,,,,,,
HC So Immunodiffusion Nes,PX-3028632966,CDM,86329,CPT,0302,RC,,,,both,,,330.00,214.50,,,,,,,,,,,,,
KIT STRNL CLOSURE SS LADDER CABLE PLATE SCREW STRL THORECON,SUP-2894486,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
DRESSING BIO 1000 MG PORCINE EXTRACELLULAR MTRX PWDR WND,SUP-2911929,CDM,A2004,HCPCS,0278,RC,,,,both,,,6323.96,4110.57,,,,,,,,,,,,,
COIL VASC EMBOLD L 15 CM DIA 5 MM CATH LUMEN DIA 0.021 IN,SUP-2753948,CDM,C1889,HCPCS,0278,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
HC Place Cath Carotd Art,PX-3613622400,CDM,36224,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
K WIRE FIXATION L400MM STAINLESS STEEL SMOOTH,SUP-2586483,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.38,413.00,,,,,,,,,,,,,
ALLOGRAFT BNE DBM 2 CC FIBER VESUVIUS,SUP-2717976,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.83,673.94,,,,,,,,,,,,,
SCREW BNE L24MM DIA4.5MM GLEN SHLDR METAGLENE LOK FOR DELT,SUP-2251020,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 8 FR B CRV RED,SUP-2492474,CDM,C1732,HCPCS,0278,RC,,,,both,,,7762.08,5045.35,,,,,,,,,,,,,
INSERT TIB SM THK16MM KNEE DUR CEM POST STBL LIP DURAC,SUP-2377660,CDM,C1776,CPT,0278,RC,,,,both,,,2297.22,1493.19,,,,,,,,,,,,,
GRAFT SYNTH TISS 5MMX12MMX40MM BLK BONE IMPL CA PHOS HA PRO,SUP-2413072,CDM,C1713,HCPCS,0278,RC,,,,both,,,1673.46,1087.75,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MUSTANG L 75 CM BALLOON L 20 MM DIA 7 MM,SUP-2142564,CDM,C1725,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
BRONCHOSCOPE L600MM DIA22MM FLX VID REG DISPOSABLE ASCOPE 3,SUP-2115186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
STAPLE BONE FIX 18X18X18MM NIT SUPERELASTIC OSTEOTMY FIX AND,SUP-2175183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
ALLOGRAFT BNE DEMINERALIZED CORTICAL 125-710 MIC 5 CC FD,SUP-2717748,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
HC So Body Fluid Culture,PX-3008707066,CDM,87070,CPT,0300,RC,,,,both,,,43.00,27.95,,,,,,,,,,,,,
SPACER SPNL W40XH12MM 6DEG WIDE TI ANT INTBDY FUS LORD,SUP-2414751,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
GUIDE WIRE PERC 2.5MM F/5MM LCK SCR,SUP-2548437,CDM,C1769,HCPCS,0272,RC,,,,both,,,1901.74,1236.13,,,,,,,,,,,,,
NAIL R 11MMX380MM LNG GAM,SUP-2370055,CDM,C1713,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
MESH COMPOSIX LP W ECHO PS ELP 72 IN X 92 IN,SUP-2125821,CDM,C1781,HCPCS,0278,RC,,,,both,,,3809.45,2476.14,,,,,,,,,,,,,
PLATE BONE W16XL158MM THK5MM 7 H LT CNDYL FEM S STL BTTRS,SUP-2185803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2308.37,1500.44,,,,,,,,,,,,,
STEM FEM CEM 11 120 MM HIP PROS N V-LIGN STD OFFSET VERSYS,SUP-2439201,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
SPHERE GLEN DIA36MM THK11MM STD SHLDR POLY TRABECULAR MTL,SUP-2199137,CDM,C1776,CPT,0278,RC,,,,both,,,4521.29,2938.84,,,,,,,,,,,,,
CAGE SPNL BULLETED 10 DEG 60X18X9 MM COROENT XL,SUP-2557524,CDM,C1889,HCPCS,0278,RC,,,,both,,,13244.52,8608.94,,,,,,,,,,,,,
KIT INTRO 5FR L30CM NDL 21GA L15CM GWIRE L70CM MIC MRK,SUP-2120544,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CATHETER CARD ABLATION PULSESELECT PFA170 DEG TOT L 145 CM,SUP-2882558,CDM,C1733,HCPCS,0272,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
"HC New Pt, E/M Level 5|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-5109920500,CDM,99205,CPT,0510,RC,,,27,both,,,387.00,251.55,,,,,,,,,,,,,
RASP SURG 16MM CUP DISP FOR MTP FUS PLATING SYS OMNI,SUP-2223755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
LINER ACET SZ DML OD60MM ID28MM BRN DBL MOBILITY HIGHCROSS,SUP-2267323,CDM,C1776,CPT,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 74X50X14 MM VENTRIC CSYS ATLAS+ VR,SUP-2356525,CDM,C1722,HCPCS,0275,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
POST EXT FIX 6 HOLE SIDEKCK EZ FRAME,SUP-2850663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
LUBIPROSTONE 24 MCG PO CAPS,RX-70472,CDM,6370000000,HCPCS,0637,RC,00480-4138-06,NDC,,both,1,UN,8.00,5.20,,,,,,,,,,,,,
SPACER SPNL W20XH8XL50MM 6DEG PEEK LUM INTBDY FUS LORDTC,SUP-2231319,CDM,C1821,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
ENDCAP SPNL W/ LCK SCR TI X-CORE MINI,SUP-2567546,CDM,C1889,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SHELL ACET OFFSET SM HYBRID,SUP-2439118,CDM,C1776,CPT,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
STENT BILI L40MM 10MM DIAM AD PRECIS,SUP-2158896,CDM,C1876,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
HANDLE ADV RENAISSANCE,SUP-2109715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
SURGICAL PROCEDURE SET SINGLE STRL GENESYS HTA PROCERVE LTX,SUP-2864515,CDM,C1886,HCPCS,0278,RC,,,,both,,,6232.90,4051.38,,,,,,,,,,,,,
LEAD STIMULATION UPPER AIRWAY INSPIRE,SUP-2664096,CDM,C1778,HCPCS,0278,RC,,,,both,,,6308.26,4100.37,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.093X9 IN SS NS STEINMANN,SUP-2791606,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.06,7.84,,,,,,,,,,,,,
STENT COR 28MM 2.5MM DEL SYS 145CM 0.014IN CO CHROM,SUP-2105440,CDM,C1874,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
LINER ACET F HIP DBL MOBILITY CONV FOR DME MPACT,SUP-2420198,CDM,C1776,CPT,0278,RC,,,,both,,,5375.68,3494.19,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 90 MM DIA22 MM LIMB 30 MM 20 MM,SUP-2217624,CDM,C1874,HCPCS,0278,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
PLATE BNE THK07MM TI BILAT ORAL MAXILLOFACIAL NONCOMPRESSION,SUP-2262951,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.45,342.19,,,,,,,,,,,,,
GUIDEWIRE ORTH 2 HOLE 3.2X12 MM NS,SUP-2799385,CDM,C1769,HCPCS,0272,RC,,,,both,,,2131.53,1385.49,,,,,,,,,,,,,
GUIDEWIRE VASC L50CM OD0035IN S STL PTFE HEP FIX COR AD,SUP-2167662,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.77,20.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ADV MIC 14 L 150 CM BALLOON L 3 CM DIA2,SUP-2633245,CDM,C1725,HCPCS,0272,RC,,,,both,,,1103.55,717.31,,,,,,,,,,,,,
HC Rem/Rep Ex/in N-U Stent,PX-3615038700,CDM,50387,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GLYCOPYRROLATE 1 MG PO TABS,RX-10130,CDM,6370000000,HCPCS,0637,RC,00904-6709-61,NDC,,both,1,UN,4.90,3.18,,,,,,,,,,,,,
PROBE BRST BX 11GA TI SHP 3 FLX DEL SYS MAMTOM HYDROMARK,SUP-2195593,CDM,A4648,CPT,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
SIZER BRST DIA12.6CM P3.8CM 350CC GEL RND SMOOTH MOD + PROF,SUP-2300855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
GRAFT BONE 2.5 CC OSTEOAMP,SUP-2424594,CDM,C1713,HCPCS,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 25GM 14ML THK7MM L VAGUS NRV SGL,SUP-2265163,CDM,C1767,HCPCS,0278,RC,,,,both,,,77124.68,50131.04,,,,,,,,,,,,,
COMPONENT FEM 1 LT CONSTRN CNDYL,SUP-2220849,CDM,C1776,CPT,0278,RC,,,,both,,,16466.16,10703.00,,,,,,,,,,,,,
ELECTRODE ES WIDE FRONTLOADING SURF LOOP SUPERSECT,SUP-2313935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1796.99,1168.04,,,,,,,,,,,,,
CONNECTOR SPINE DEV CLS,SUP-2289281,CDM,C1713,HCPCS,0278,RC,,,,both,,,1457.78,947.56,,,,,,,,,,,,,
REAMER SURG 12MM CONCAVE MTP FOR SM JT RMR MOD HND SYS,SUP-2107732,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
COMPONENT PATELLAR PEGGED SM STD 35 MM KNEE OVL MOD CEM REV,SUP-2253517,CDM,C1776,CPT,0278,RC,,,,both,,,2238.19,1454.82,,,,,,,,,,,,,
COMPONENT TOE JT PHLANG M L18MM TI UNIV POR COAT PRI PRSS,SUP-2319772,CDM,C1776,CPT,0278,RC,,,,both,,,5862.38,3810.55,,,,,,,,,,,,,
BATTERY CHARGER DBS NS ACTIVA RC,SUP-2882956,CDM,C1820,HCPCS,0278,RC,,,,both,,,8650.70,5622.95,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND SHLDR ADJ AIRPLANE DESIGN,SUP-2435791,CDM,L3960,HCPCS,0272,RC,,,,both,,,2055.04,1335.78,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CATH 6FR 0.035IN PUR TAPR TO 5FR W/,SUP-2169288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
PLATE BNE 130DEG 4 H S STL HIP LOK BILAT COMPR RIG SHT BRL,SUP-2370860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.89,1218.68,,,,,,,,,,,,,
GRAFT BIO TISS W15XL10CM THK1MM NONDENATURED CLLGN BOV,SUP-2383080,CDM,C1781,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
GRAFT BNE SUB 10CC INJ FOR BNE AUG CORTOSS,SUP-2379532,CDM,C1713,HCPCS,0278,RC,,,,both,,,6056.18,3936.52,,,,,,,,,,,,,
PLATE BONE L17MM 2 H LT S STL L SHP RIG NEUT NONCOMPRESSION,SUP-2186156,CDM,C1713,HCPCS,0278,RC,,,,both,,,184.38,119.85,,,,,,,,,,,,,
GRAFT BNE CUBE 10X10X10 MM DBM ALLOSYNC,SUP-2845373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1851.03,1203.17,,,,,,,,,,,,,
WASHER 7MM RED,SUP-2474534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,139.82,90.88,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN PTFE MOVABLE COR,SUP-2147064,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
GRANULES BONE GRAFT OSTEOSOURCE 1-4MM ALLOGRAFT 30ML,SUP-2137586,CDM,C1734,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
INTRODUCER SHTH J TIP 0.038 IN 10 FRX13 CM 18 GA HYDRPHLC,SUP-2740669,CDM,C1892,HCPCS,0272,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
HC Thoracentesis WO Imaging,PX-4503255400,CDM,32554,CPT,0450,RC,,,,both,,,1901.00,1235.65,,,,,,,,,,,,,
ROD SPNL L480MM DIA5.5MM RT POST S STL SMOOTH STR PRE CUT,SUP-2256373,CDM,C1713,HCPCS,0278,RC,,,,both,,,2340.87,1521.57,,,,,,,,,,,,,
PROCESSOR HEARING AID CHROMA BGE RT EAR SND PROC CHAN WIND,SUP-2319863,CDM,L8690,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SYSTEM MIXING AND DELIVERY BONE CEMENT MEDIUM VISCOSITY,SUP-2766615,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BONE 17DEG 6X17 H LT MAND SEC HMSPHR TI RECON,SUP-2363752,CDM,C1713,HCPCS,0278,RC,,,,both,,,3661.43,2379.93,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 0.1-4MM CRUSH CANC CHIP MORSELIZED FRZ,SUP-2307065,CDM,C1713,HCPCS,0278,RC,,,,both,,,1405.15,913.35,,,,,,,,,,,,,
ANCHOR SUT 2.8 MM DIA NO 2 SUT TI TWINFIX,SUP-2318502,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
COIL NEUROVASCULAR CEREPAK HELIFORM XTRASOFT XL L 4 CM DIA2,SUP-2865277,CDM,C1889,HCPCS,0278,RC,,,,both,,,6057.56,3937.41,,,,,,,,,,,,,
GUIDEWIRE VASC COMBOWIRE L 300 CM DIA 0.014 IN OFFSET 1.5 CM,SUP-2393126,CDM,C1769,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE CONN 90 DEG 4 HOLE OFFSET NS,SUP-2800151,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
PLATE BONE THK1.8MM 10 H STRNL BODY TI LCK,SUP-2262574,CDM,C1713,HCPCS,0278,RC,,,,both,,,1985.99,1290.89,,,,,,,,,,,,,
SCREW PIN PROV FIX 23MMDIA 61MMLENGTH LNG THRD,SUP-2343746,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.82,510.78,,,,,,,,,,,,,
BALLOON RETRV BILI DBL LUMN 11.5MM,SUP-2149637,CDM,C1726,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST ADJ FIT STRP W/NONTORSION JT,SUP-2435772,CDM,L3905,HCPCS,0272,RC,,,,both,,,2555.14,1660.84,,,,,,,,,,,,,
SPLINT ANKLE FOOT ORTHOSIS MALE 8-10 RT LG,SUP-2326060,CDM,L4350,HCPCS,0272,RC,,,,both,,,98.56,64.06,,,,,,,,,,,,,
AUGMENT FEM THK5MM BX CUT GUID S-ROM NOILES,SUP-2253243,CDM,C1776,CPT,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SYSTEM GRFT PREP FOR GPS III PLT CONC,SUP-2402583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
STEM FEM REV 0+ MM SHT 17 MM HIP POLISHED EMPERION,SUP-2434539,CDM,C1776,CPT,0278,RC,,,,both,,,12490.92,8119.10,,,,,,,,,,,,,
ADAPTER HD +0MM OFFSET 12/14 TAPR HIP TI BIOLOX OPT,SUP-2222438,CDM,C1776,CPT,0278,RC,,,,both,,,650.61,422.90,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM DIA 0.018 IN PTFE PERIPH STR,SUP-2301901,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
IMPLANT HEARING 6MM THK3MM HA ABUTMENT IMPL HEARINGABLE,SUP-2164980,CDM,L8614,HCPCS,0278,RC,,,,both,,,10487.60,6816.94,,,,,,,,,,,,,
METOPROLOL TARTRATE 50 MG PO TABS,RX-5009,CDM,6370000000,HCPCS,0637,RC,51079-0801-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ANCHOR SUTURE DBL LD W/ NDL 5MM DRL Y-KNOT RC 2 HI-FI,SUP-2422968,CDM,C1713,HCPCS,0278,RC,,,,both,,,2054.50,1335.42,,,,,,,,,,,,,
PLATE BNE ORBIT FLR SM 1.5X0.4 MM LT SMRT 3D TI NS LEVEL 1,SUP-2488954,CDM,C1713,HCPCS,0278,RC,,,,both,,,3341.40,2171.91,,,,,,,,,,,,,
CATHETER CV SET 032 8 FRX15 CM DL J TIP RIFAMPIN SPECTRUM,SUP-2759760,CDM,C1751,HCPCS,0278,RC,,,,both,,,111.91,72.74,,,,,,,,,,,,,
SCREW BNE NC 4.5X44 MM CORTICAL HIP POLARCUP,SUP-2418620,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.15,151.55,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 50 CM DIA 6 MM EPTFE STR STD WALL,SUP-2227644,CDM,L8670,HCPCS,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
BOLT EXT FIX MR SAFE SCR POST MT SCHNZ FOR DISTR,SUP-2417127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.32,489.66,,,,,,,,,,,,,
DRESSING 10X10CM WND HEALING PTCH TALYMED,SUP-2266130,CDM,Q4127,HCPCS,0636,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BNE L112MM 6 H ST R LAT DST FIBULAR S STL LOK COMPR,SUP-2177418,CDM,C1713,HCPCS,0278,RC,,,,both,,,1953.55,1269.81,,,,,,,,,,,,,
NEEDLE LOC 21GA L7CM FOR PREOPERATIVE MRK OF NONPALPABLE,SUP-2167949,CDM,C1819,HCPCS,0278,RC,,,,both,,,77.56,50.41,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.4MM MAXILLOMANDIBULAR TI NONLOCKING HI,SUP-2403056,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
GRAFT BNE 3 CC AUG,SUP-2759480,CDM,C1734,HCPCS,0278,RC,,,,both,,,10424.80,6776.12,,,,,,,,,,,,,
SCREW BONE LOCKING 2.4X14 MM MANDIBULAR SELFTAPPING 20/PK TI,SUP-2842339,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.22,335.54,,,,,,,,,,,,,
PLATE BNE STR 63X0.6 MM NEURO 16 HOLE TI NS LEVEL 1 ULTRAONE,SUP-2481557,CDM,C1713,HCPCS,0278,RC,,,,both,,,827.14,537.64,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 1-4 MM 5 CC FD IRRADIATED CANC,SUP-2866923,CDM,C1762,CPT,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 14X12X10 MM PARL DENS CANC STERIGRAFT,SUP-2430765,CDM,C1889,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 162 MM DIA 42 MM SHTH 22 FR RVD,SUP-2171022,CDM,C1713,HCPCS,0278,RC,,,,both,,,37975.16,24683.85,,,,,,,,,,,,,
ROD REPROC SEMI CIR CRVD SS,SUP-2472209,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.54,86.15,,,,,,,,,,,,,
HC Perq Plmt Bile Duct Stent,PX-3614753800,CDM,47538,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
GRAFT BNE 150X11 MM BLLST 021000000,SUP-2644294,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
BLADE RTRCTR 2INW X 4 12NL ALMNM SPLNCHNC ABDMNL ABH STYLE,SUP-2703360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1512.48,983.11,,,,,,,,,,,,,
SPLINT FNGR BASEBL 425IN M,SUP-2276752,CDM,L3933,HCPCS,0274,RC,,,,both,,,3.11,2.02,,,,,,,,,,,,,
BUR SURG DIAMOND WHL 25.4 MM FOR LOWER MED SPD DRL TEAL UPWR,SUP-2607632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,674.16,438.20,,,,,,,,,,,,,
DRESSING BIO L 5 X W 5 CM PORCINE CLLGN SINGLE LAYR FEN SHT,SUP-2909417,CDM,Q4195,HCPCS,0636,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
PLATE BONE L215MM RIB RIBLOC,SUP-2107920,CDM,C1713,HCPCS,0278,RC,,,,both,,,6747.86,4386.11,,,,,,,,,,,,,
NAIL IM RETROGRADE 5 DEG 12X280 MM FEM TI STRL RFNADVANCED,SUP-2789410,CDM,C1713,HCPCS,0278,RC,,,,both,,,5404.03,3512.62,,,,,,,,,,,,,
SPLINT CLAV L AD W2.75XL34.5IN BCKL CLSR PD MCLEOD,SUP-2197365,CDM,L3650,HCPCS,0274,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
GRAFT DERM HYDRATED THCK ACELLULAR DERM IMPL ALLGRFT,SUP-2307466,CDM,Q4128,HCPCS,0636,RC,,,,both,,,3282.49,2133.62,,,,,,,,,,,,,
GRAFT BNE STRP LG 100X25X6 MM 30 CC SCAFFOLD ATTRAX,SUP-2736498,CDM,C1713,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
GRAFT BONE SUB 43ML W2XL36MM B TRICALCIUM PHOS CLLGN HA RECT,SUP-2289163,CDM,C1713,HCPCS,0278,RC,,,,both,,,13539.68,8800.79,,,,,,,,,,,,,
"HC Peripheral Art Disease Rehab, Ea",PX-9409366800,CDM,93668,CPT,0940,RC,,,,inpatient,,,336.00,218.40,,,,,,,,,,,,,
NAIL IM L 210 MM DIA10.5 MM HINDFOOT STRL DUALCOMPRESSION,SUP-2930406,CDM,C1713,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
GRAFT HUM TISS 2X6CM AMNIOFIX,SUP-2305725,CDM,V2790,HCPCS,0274,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
TUNNELER SURG L 8 IN DIA11 GA STRL DISP ON-Q,SUP-2917152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
MULTIGEN 70 MG PO TABS,RX-93008,CDM,6370000000,HCPCS,0637,RC,51991-0543-90,NDC,,both,1,UN,4.30,2.79,,,,,,,,,,,,,
OSSEOFLEX 10GA4ML SB CONVENIENCE PACK,SUP-2702606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7186.68,4671.34,,,,,,,,,,,,,
WEDGE ALLGRFT FIBULAR STRUT 40MM,SUP-2293969,CDM,C1713,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
BATTERY SET 14 V CLP HEARTMATE,SUP-2356044,CDM,C1713,HCPCS,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
CATHETER KIT 3L 7 FRX6 IN PRESSURE INJ FLX ARROWG+ARD BLU +,SUP-2383381,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.75,220.84,,,,,,,,,,,,,
GLIMEPIRIDE 1 MG PO TABS,RX-16355,CDM,6370000000,HCPCS,0637,RC,55111-0320-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
AUGMENT FEM SZ 2 THK5MM POST KNEE REV SPCR BLK FOUNDATION,SUP-2215550,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PURAPLY 2X4CM 8SQ CM,SUP-2314121,CDM,Q4195,HCPCS,0636,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X6 MM 0.6 MM FLROPLAS,SUP-2637727,CDM,L8613,CPT,0278,RC,,,,both,,,280.50,182.32,,,,,,,,,,,,,
CONNECTOR SPNL SCREW RNG,SUP-2316270,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.51,112.13,,,,,,,,,,,,,
GRAFT BNE L PROX TIB BNE TEND BNE FRZN IMPL,SUP-2307300,CDM,C1713,HCPCS,0278,RC,,,,both,,,17772.87,11552.37,,,,,,,,,,,,,
CAGE SPNL W13XH6XL15MM 5DEG ANTR CERV PEEK DISCECTOMY FUS,SUP-2137095,CDM,C1889,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
HC So Assay of Albumin,PX-3078204067,CDM,82040,CPT,0307,RC,,,,both,,,17.00,11.05,,,,,,,,,,,,,
BASKET EXTR STONE THE WEB II 4 WIR 7 FR X 220 CM SHTH 2 CM,SUP-2169437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
RESERVOIR PERF VEN BG W/ RECIRC LN AFFIN RV,SUP-2473177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
STEM FEM L250MM OD12MM 80% POR PLSM SPRY DSTL HIP BOW RL,SUP-2408822,CDM,C1776,CPT,0278,RC,,,,both,,,7887.68,5126.99,,,,,,,,,,,,,
BIT DRL CANN 3.5 MM AO FIT,SUP-2691432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1250.66,812.93,,,,,,,,,,,,,
SCREW SYS PARTIALLY THRD LAG SCRS 316 L VM S THRD 2.5MM,SUP-2392876,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
HC Repair Lip,PX-4504065200,CDM,40652,CPT,0450,RC,,,,both,,,1337.00,869.05,,,,,,,,,,,,,
CROWN DENT NOELR6 SEC M PRI LO R S STL,SUP-2322213,CDM,D6783,CPT,0278,RC,,,,both,,,36.05,23.43,,,,,,,,,,,,,
GRAFT BNE PTTY 47 MM 5 CC CHIP CANC DBM ALLMTRX,SUP-2399140,CDM,C9359,HCPCS,0278,RC,,,,both,,,3208.30,2085.39,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.5MM CANN SHANK SPHERX PPS,SUP-2311488,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GRAFT VASC L30CM ID10MM RNGD SECT L30CM STD WALLED STR GOR,SUP-2396023,CDM,C1768,CPT,0278,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
BASEPLATE TIB N MOD LNG 67 MM KNEE OSS AVL,SUP-2441801,CDM,C1776,CPT,0278,RC,,,,both,,,9170.37,5960.74,,,,,,,,,,,,,
PLUG VASC AMPLATZER II L 6 MM DIA 4 MM DEL SYS L 135 CM CATH,SUP-2116304,CDM,C1889,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BLADE SURG 70 MM POST MARS 3V,SUP-2599079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
STEM FEM L225MM DIA15X20MM NK L36+8MM LNG HIP NEUT STR BOW,SUP-2253203,CDM,C1776,CPT,0278,RC,,,,both,,,12091.51,7859.48,,,,,,,,,,,,,
PUMP PROS PENILE TCH ASMBLY TI,SUP-2165315,CDM,C1813,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
SET SCR THRESHOLD PEDICULAR FIX,SUP-2354658,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PROSTHESIS 9MM PENILE MAL GEN,SUP-2165394,CDM,C1813,HCPCS,0278,RC,,,,both,,,22438.44,14584.99,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X133 MM 10 HOLE SS LCP,SUP-2569336,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.74,305.33,,,,,,,,,,,,,
PLATE BONE SIZE 3 SHOULDER NAIL,SUP-2458648,CDM,C1713,HCPCS,0278,RC,,,,both,,,5768.18,3749.32,,,,,,,,,,,,,
CRYOPROBE 2.1MM (14G) ISOLIS 20CM SPHR,SUP-2885471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FR FULL TY NURSING PER-Q-CATH,SUP-2126364,CDM,C1894,HCPCS,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
HC US Duplex Abd/Pelvis/Scrotum Ltd,PX-9219397600,CDM,93976,CPT,0921,RC,,,,both,,,1152.00,748.80,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK 25 MM SCAPHOLUNATE INT CRPL SLIC,SUP-2106425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3896.74,2532.88,,,,,,,,,,,,,
BOLT ORTHOPEDIC LCK 3.9X52 MM TI NS,SUP-2192160,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
T8 HLD SL,SUP-2344041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X20 MM PRESERVON STRUCTURAL ORAGRAFT,SUP-2740968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1119.72,727.82,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn,PX-3606441500,CDM,64415,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
PLATE BNE TI TALONAVICULOCUNEIFORM EXT REV NS UNITE,SUP-2897094,CDM,C1713,HCPCS,0278,RC,,,,both,,,5805.86,3773.81,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 38 X 50 X 1 MM POLYETHYL ORBIT FLR SMTH,SUP-2935214,CDM,C1713,HCPCS,0278,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
TC-100 6.5MMX16MM P-T CANC SCREW 55MM,SUP-2818831,CDM,C1713,HCPCS,0278,RC,,,,both,,,358.81,233.23,,,,,,,,,,,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-128726,CDM,90620,HCPCS,0636,RC,58160-0976-20,NDC,,both,.5,ML,1067.10,693.61,,,,,,,,,,,,,
PLATE BONE THK0.8MM 12 H LCK COMPR BILAT NEUT MALL OFFSET,SUP-2107081,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
MESH HERN M W4.3XL5.5IN POLYPR EPTFE OVL SELF EXP PTCH,SUP-2125714,CDM,C1781,HCPCS,0278,RC,,,,both,,,2192.98,1425.44,,,,,,,,,,,,,
MESH C-QUR EDGEXL OBLONG OVL 7 INX9 IN,SUP-2265968,CDM,C1781,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
LINER ACET CONSTRN 28 MM EPSILON,SUP-2448626,CDM,C1776,CPT,0278,RC,,,,both,,,124428.78,80878.71,,,,,,,,,,,,,
LIDO-EPINEPHRINE-TETRACAINE 4-0.18-0.5 % EX GEL,RX-153363,CDM,6370000000,HCPCS,0637,RC,71266-6290-01,NDC,,both,3,ML,79.20,51.48,,,,,,,,,,,,,
TOPIRAMATE 100 MG PO TABS,RX-18922,CDM,6370000000,HCPCS,0637,RC,00904-6929-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 100 MM DIA 9 MM DEL SHTH 4.5MM,SUP-2936837,CDM,C1713,HCPCS,0278,RC,,,,both,,,11661.96,7580.27,,,,,,,,,,,,,
BOOT WALKING HI TOP SM FT ANK LIFESTRIDE,SUP-2108144,CDM,L4386,HCPCS,0272,RC,,,,both,,,109.59,71.23,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 5FR 55CM 3 LUMAN R S3395108,SUP-2632852,CDM,C1751,HCPCS,0278,RC,,,,both,,,682.76,443.79,,,,,,,,,,,,,
CONNECTOR SPNL L40MM STD POST TI XLNK FIX ASMBLY TRNSVRS,SUP-2254569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SHOE ORTHOT EXISTING SLD STIRRUP TRANSFER,SUP-2435747,CDM,L3620,HCPCS,0274,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
GRAFT ENDOVASC L 18FR L14CM OD23MM ID18.5-21.5MM,SUP-2395960,CDM,C1768,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
HC Cv Cath Plac Nontun <5yr,PX-3613655500,CDM,36555,CPT,0361,RC,,,,both,,,10064.00,6541.60,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 240 MM DIA22/13 MM DEL,SUP-2934280,CDM,C1713,HCPCS,0278,RC,,,,both,,,21929.51,14254.18,,,,,,,,,,,,,
SCREW BONE L90MM DIA6.5MM CANC PARTIALLY THRD S STL,SUP-2348932,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.50,237.57,,,,,,,,,,,,,
Z INACTIVE SUPPLIER LINER ACET OD38MM ID28MM +5MM HIP E1 MAX ROM RINGLOC,SUP-2408959,CDM,C1776,CPT,0278,RC,,,,both,,,10895.80,7082.27,,,,,,,,,,,,,
PROSTHESIS OSS MCGEE 1.22X4.5 MM 4.75 MM STAPE MALL SS,SUP-2637817,CDM,L8613,CPT,0278,RC,,,,both,,,495.65,322.17,,,,,,,,,,,,,
COLLAR CERV SFT 375X21IN XL,SUP-2276588,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.19,4.02,,,,,,,,,,,,,
HC Cath Urethra Complicated,PX-4505170300,CDM,51703,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX10 MM KT IMPL CLASSIC BLOM-SINGER,SUP-2238270,CDM,L8509,HCPCS,0274,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
KIT STRNL CLOSURE SS BX CABLE PLATE SCREW STRL THORECON,SUP-2894495,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HC Rehab R&B,PX-1180000000,CDM,1180000000,LOCAL,0118,RC,,,,inpatient,,,2515.00,1634.75,,,,,,,,,,,,,
URETEROSCOPE (see item comments) DIGITAL URS FLX SU MODEL E NORM DEFL AXIS II,SUP-2882439,CDM,C1747,HCPCS,0272,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
SCREW BNE L8MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI SELF,SUP-2189351,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.34,182.87,,,,,,,,,,,,,
"HC Plmt Nephrostomy Catheter,Perc|SEPARATE PRACTITIONER|RIGHT SIDE",PX-3615043200,CDM,50432,CPT,0361,RC,,,XP|RT,both,,,6875.00,4468.75,,,,,,,,,,,,,
PROBE BRST BX 12 GA BLU ELEVATION,SUP-2624837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PUTTY BONE GRAFT FACTOR 5ML PEPTIDE ENHANCED W/SYRINGE,SUP-2693634,CDM,C1713,HCPCS,0278,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 8 CM PRIMARY DIA,SUP-2323355,CDM,C1889,HCPCS,0278,RC,,,,both,,,6443.28,4188.13,,,,,,,,,,,,,
REAMER SURG DIA46MM ACET BSKT,SUP-2368443,CDM,C1713,HCPCS,0278,RC,,,,both,,,862.78,560.81,,,,,,,,,,,,,
CATHETER CTRL VEN L145CM OD5FR ID17.5GA 2 LUMN PASV VLV,SUP-2118817,CDM,C1751,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
MESH SURG DIA20 30CM WHT POLY CLLGN FLM RECT MFIL BIOABSRB,SUP-2283403,CDM,C1781,HCPCS,0278,RC,,,,both,,,7298.46,4744.00,,,,,,,,,,,,,
SPACER SPNL SPIKLS 14X14 MM 14 MM UPPER ENDPLATE FORTIFY I-R,SUP-2594929,CDM,C1821,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 20MMW X 70MML SPNL MSCLE NRRW RGGLS RDM,SUP-2668606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1627.71,1058.01,,,,,,,,,,,,,
DRIVER CAP THRD REDUC,SUP-2232114,CDM,2780000010,LOCAL,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT FEM WHL STRUCTURAL L,SUP-2307312,CDM,C1713,HCPCS,0278,RC,,,,both,,,29046.66,18880.33,,,,,,,,,,,,,
BRACE ORTHOPEDIC LSO BK POST OPERATIVE RIGID PANEL,SUP-2138675,CDM,L0630,HCPCS,0274,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
PACEMAKER CARD ALTRUA 40 W 42 X H 42 MM THK 8 MM 23.4 GM,SUP-2149273,CDM,C1786,HCPCS,0275,RC,,,,both,,,16007.72,10405.02,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM ACHILLES MIDSUBSTANCE SYS STRL DISP,SUP-2882225,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
HEAD FEM 12/14 TAPR PRI CERAMIC ON CERAMIC 28MM DIA -3.5 NK,SUP-2202658,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
GRAFT HUM TISS W22XL45MM ILIUM BICORT STRP FRZ DRY,SUP-2307120,CDM,C1713,HCPCS,0278,RC,,,,both,,,1954.56,1270.46,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST N CORROSIVE FINISH,SUP-2435696,CDM,L2780,HCPCS,0272,RC,,,,both,,,179.17,116.46,,,,,,,,,,,,,
EXTRACTOR STONE 2.5FR L115CM 2.8FR SHTH TIP 4W URIN TRACT,SUP-2170136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,611.92,397.75,,,,,,,,,,,,,
SPLINT DENT OCCLUSAL IPS,SUP-2263024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3030.57,1969.87,,,,,,,,,,,,,
WIRE FIX L30CM DIA1.2MM BEAD LOOP LUQ,SUP-2410236,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.97,76.03,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAG CTRL SFT ANTR APRON,SUP-2435541,CDM,L0466,HCPCS,0274,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
PLATE BNE L81MM 4 H ST L SUP ANT CLAV S STL LOK COMPR W/,SUP-2177331,CDM,C1713,HCPCS,0278,RC,,,,both,,,2851.91,1853.74,,,,,,,,,,,,,
TRIAL SURG 6MM MIDFOOT BIOFOAM,SUP-2397845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
KIT IR FULL SMRT CT PICC 6 FR 2 LUMN STD TAPR .018 X 130 CM,SUP-2118452,CDM,C1751,HCPCS,0278,RC,,,,both,,,258.74,168.18,,,,,,,,,,,,,
PLATE BNE HUM XLN LT PROX TI NS POLARUS,SUP-2525800,CDM,C1713,HCPCS,0278,RC,,,,both,,,8176.56,5314.76,,,,,,,,,,,,,
CATHETER EP DIAG MAPPINGXLARGE CRV QPLR 2 -5 -2MM SPC 4MM,SUP-2357661,CDM,C2630,CPT,0272,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
HC So Serum Hgb Quantitative,PX-3018305166,CDM,83051,CPT,0301,RC,,,,outpatient,,,75.00,48.75,,,,,,,,,,,,,
SHELL ACET SLD BK COCR ALLOY 46MM VITALOCK,SUP-2364624,CDM,C1776,CPT,0278,RC,,,,both,,,3264.69,2122.05,,,,,,,,,,,,,
BOUGIE ESOPH 34FR TUNGSTEN FIL SIL HURST,SUP-2383703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.46,253.80,,,,,,,,,,,,,
CATHETER VENTRICULAR STYL 35X38 CM SS,SUP-2666713,CDM,C1729,HCPCS,0272,RC,,,,both,,,414.64,269.52,,,,,,,,,,,,,
PROPRANOLOL HCL 40 MG PO TABS,RX-6658,CDM,6370000000,HCPCS,0637,RC,60687-0609-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
LEAD DEFIB LINOXSMART S DX L 65 CM TIP DISTANCE 17 CM PTIR,SUP-2138196,CDM,C1777,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
NEEDLE SUTURE KNOTLESS SWIVELOCK C SCORPION AR2600SBS10,SUP-2845508,CDM,C1713,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
PLATE BONE 135DEG 8 H SUPCNDYL S STL COMPR FRELOK,SUP-2197729,CDM,C1713,HCPCS,0278,RC,,,,both,,,1721.44,1118.94,,,,,,,,,,,,,
SCREW BNE L32MM DIA3.5MM STD CORT TIM ST CANN NONLOCKING,SUP-2413371,CDM,C1713,HCPCS,0278,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
"HC Debrid,Subq Ea Addt'l 20sqcm",PX-3611104500,CDM,11045,CPT,0361,RC,,,,inpatient,,,207.00,134.55,,,,,,,,,,,,,
PLATE BNE THK 0.3 MM SCREW DIA1.5 MM XS TRNS NS DISP,SUP-2936892,CDM,C1713,HCPCS,0278,RC,,,,both,,,3457.14,2247.14,,,,,,,,,,,,,
HC Drain Perirenal/Renal Abscess,PX-3615002000,CDM,50020,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
POSTERIOR FEMORAL AUGMENT - UNIVERSAL SZ 4/5 5MM,SUP-2890722,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CATHETER CV 3L UNIV 5 FR W/ MAXIMAL BARR POWERPICC,SUP-2126713,CDM,C1751,HCPCS,0278,RC,,,,both,,,789.14,512.94,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 6 MM RNG L 50 CM EPTFE STR TW,SUP-2396159,CDM,C1768,CPT,0278,RC,,,,both,,,3903.02,2536.96,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 7 FRX20 CM 3L DRY POLYURETHANE,SUP-2759878,CDM,C1751,HCPCS,0278,RC,,,,both,,,341.95,222.27,,,,,,,,,,,,,
PLATE BNE LCK SHT 126 MM RT DSTL MEDL HUM 7 HOLE SS PUR NS,SUP-2492939,CDM,C1713,HCPCS,0278,RC,,,,both,,,2877.15,1870.15,,,,,,,,,,,,,
BOOT CAST 4IN TCC-EZ,SUP-2194354,CDM,L4386,HCPCS,0274,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
NEEDLE SPNL FIX 11 GA BVL FOR PEDCL ACCS SERENGETI,SUP-2869133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.36,500.08,,,,,,,,,,,,,
HC So F2 Gene Analysis,PX-3108124066,CDM,81240,CPT,0310,RC,,,,outpatient,,,330.00,214.50,,,,,,,,,,,,,
SPACER SPNL W37XH14MM D28MM 12DEG GRFT 3.3ML PEEK CERV,SUP-2317133,CDM,C1821,HCPCS,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
STEM FEM 13.5X170 MM HIP,SUP-2204191,CDM,C1776,CPT,0278,RC,,,,both,,,10423.01,6774.96,,,,,,,,,,,,,
SCREW SPNL L10MM DIA4MM ANT CANC,SUP-2291051,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.84,534.85,,,,,,,,,,,,,
TITANIUM MESH TRAY HEMI MANDIBLE RIGHT CP TITANIUM,SUP-2679029,CDM,C1713,HCPCS,0278,RC,,,,both,,,10268.40,6674.46,,,,,,,,,,,,,
ARTHREX MENISCAL DART 14MM 5-BOX,SUP-2812806,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
STENT URET 45FR L10CM POLYMER HYDRPHLC OPN TIP RADPQ MRK,SUP-2313775,CDM,C2617,HCPCS,0278,RC,,,,both,,,255.50,166.07,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 67 MM DIA 7 MM CATH TOT L 160,SUP-2148406,CDM,C1876,HCPCS,0278,RC,,,,both,,,6063.34,3941.17,,,,,,,,,,,,,
PLATE BONE 3D PRNT MIDFACE MAND TI TRUMATCH,SUP-2860374,CDM,C1713,HCPCS,0278,RC,,,,both,,,36785.73,23910.72,,,,,,,,,,,,,
COLLAR CERV SUPP X TALL AD COMFORT,SUP-2269629,CDM,L0180,HCPCS,0274,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
SHELL ACET RIM FLARED UNIV 41 MM PRIMARY PRSS FT SPIK TI,SUP-2210135,CDM,C1776,CPT,0278,RC,,,,both,,,5245.37,3409.49,,,,,,,,,,,,,
DEVICE FEED G-JET 16F X 2.0CM X 22CM LP TRANSGASTRIC-JEJUNAL,SUP-2849687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.14,1124.59,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB W/ SP0004 SYS INS4500 CATH,SUP-2883570,CDM,C1729,HCPCS,0272,RC,,,,both,,,724.15,470.70,,,,,,,,,,,,,
POR ST/OSS CP/E1 LN/STD HD,SUP-2212420,CDM,C1776,CPT,0278,RC,,,,both,,,19665.82,12782.78,,,,,,,,,,,,,
GRAFT BNE PELLET INJ 5 CC OSTEOSET XR,SUP-2759439,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB XLII ROSEN STRL REUSE HI-LINE,SUP-2929086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.09,483.66,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM 36X20 LG STRL,SUP-2547592,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.72,1526.67,,,,,,,,,,,,,
HC X-Ray Exam Chest 3 Views,PX-3247104700,CDM,71047,CPT,0324,RC,,,,outpatient,,,827.00,537.55,,,,,,,,,,,,,
STRUT EXT FIX 80-120 MM C/D SALVATION,SUP-2463765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
DVR VOLAR RIM NRW L ST,SUP-2587122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2607.77,1695.05,,,,,,,,,,,,,
CATHETER PERIPH DIA3.2MM WC 2MM VW SPINPERC,SUP-2392608,CDM,C1751,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
HINGE EXT FIX LCK UNIV JT,SUP-2749936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 8-5 MM EPTFE TAPR STD WALL N,SUP-2761339,CDM,C1768,CPT,0278,RC,,,,both,,,2319.83,1507.89,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID THN 3X2 CM AMNIO PLCNTA PRO3-P,SUP-2742037,CDM,C1762,CPT,0278,RC,,,,both,,,2676.85,1739.95,,,,,,,,,,,,,
ANG BLDE PL 130 6H {} 70/104,SUP-2818826,CDM,C1713,HCPCS,0278,RC,,,,both,,,5116.94,3326.01,,,,,,,,,,,,,
ROD EXT FIX L200MM LNG THRD MR CONDITIONAL FOR DISTR,SUP-2179147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,207.21,134.69,,,,,,,,,,,,,
CATHETER DRAINAGE 8.5 FRX40 CM BILI MAC LOC LOOP UTHANE,SUP-2168530,CDM,C1729,HCPCS,0272,RC,,,,both,,,523.60,340.34,,,,,,,,,,,,,
SET INTRO TRIFORCE CATH L 65 CM DIA 4 FR SHTH L 55 CM ID 5,SUP-2171151,CDM,C1894,HCPCS,0272,RC,,,,both,,,1117.84,726.60,,,,,,,,,,,,,
PLATE BONE L23MM 100DEG 7 H RT CRANIOMAXILLOFACIAL TI L FOR,SUP-2136527,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
APPLIER INT CLP MULT FIRE MED LG 10X370 MM CHALLENGER REUSE,SUP-2850165,CDM,C1889,HCPCS,0278,RC,,,,both,,,5265.59,3422.63,,,,,,,,,,,,,
PLATE BONE W17.5XL322MM THK5.2MM 18 H BILAT S STL BROAD,SUP-2185316,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.07,847.00,,,,,,,,,,,,,
COMPONENT PAT OD32MM THK8MM SGL PEG POLYETH ONLAY RM SYS ADV,SUP-2304732,CDM,C1776,CPT,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 5 PACK,SUP-2855639,CDM,C2642,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
INTRODUCER SHTH 0.038 IN 6 FRX14 CM DILOCK DIL PEELWY,SUP-2357092,CDM,C1892,HCPCS,0272,RC,,,,both,,,16.96,11.02,,,,,,,,,,,,,
PACK PROC 3.5MM W/ DRL GUID AND BIT DISP MORPHIX,SUP-2277454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
HC Level III Surg Pathology Gross&Microscopic Exam,PX-3128830400,CDM,88304,CPT,0312,RC,,,,both,,,433.00,281.45,,,,,,,,,,,,,
BIT DRL L210MM DIA32MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.86,414.61,,,,,,,,,,,,,
PLATE BONE W8XL60MM THK2MM 0DEG 7 H BILAT TI STR RIG DYN,SUP-2191071,CDM,C1713,HCPCS,0278,RC,,,,both,,,1442.39,937.55,,,,,,,,,,,,,
GRAFT DURA W3XH3CM ULTRAPURE CLLGN ADH BARR MTRX DURAGN +,SUP-2244007,CDM,C1763,HCPCS,0278,RC,,,,both,,,2926.92,1902.50,,,,,,,,,,,,,
IMPLANT CRPL SZ 2 PYROCARBON LUNATE,SUP-2244198,CDM,C1776,CPT,0278,RC,,,,both,,,11750.01,7637.51,,,,,,,,,,,,,
ROD EXT FIX L250MM DIA6MM THRD FOR HOFFMANN LRF SYS,SUP-2418164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,259.99,168.99,,,,,,,,,,,,,
PLATE BNE STR 2.3X45X1.5 MM 6 HOLE COMPR FRAC TI LEVEL 1,SUP-2469290,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.04,558.38,,,,,,,,,,,,,
INSERT TIB 1 8 MM CONSTRN REV BKS,SUP-2434222,CDM,C1776,CPT,0278,RC,,,,both,,,2763.83,1796.49,,,,,,,,,,,,,
SPLINT WRST WRP ARND UNIV 8 IN FOREARM RT COOL BLU,SUP-2336238,CDM,L3908,HCPCS,0272,RC,,,,both,,,15.57,10.12,,,,,,,,,,,,,
DRILL TWST 1X18X8MM,SUP-2364175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,578.55,376.06,,,,,,,,,,,,,
DEVICE EMB L25MM OD4MM 55DEG SFT DST TIP BRAID 4 FLX,SUP-2296740,CDM,C1884,HCPCS,0278,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
LEAD SENSING RESPIRATORY INSPIRE,SUP-2664097,CDM,C1778,HCPCS,0278,RC,,,,both,,,10914.64,7094.52,,,,,,,,,,,,,
GRAFT DERMAL RECT 2.4X3.1 IN ANTIBACT XENMATRIX AB,SUP-2855240,CDM,C1781,HCPCS,0278,RC,,,,both,,,5120.71,3328.46,,,,,,,,,,,,,
SCREW SPNL L 90 MM DIA11.5 MM PEDCL SLD NS MARINER,SUP-2884749,CDM,C1889,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH PREMOLDED LONGITUDINAL,SUP-2435706,CDM,L3060,HCPCS,0272,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
PLATE BNE L90MM 2 H R OLECRANON S STL VAR ANG LOK COMPR LO,SUP-2177184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3239.13,2105.43,,,,,,,,,,,,,
MATRIX BIO SZ 8 SQCM FISH SKIN DERMAL INTACT STRL OMEGA3,SUP-2909239,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
DOUBLE BARREL CANNULA SM,SUP-2720854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22086.76,14356.39,,,,,,,,,,,,,
GUIDE DRL CERV SPNL PLT ANG LOK SGL W TISS PROTCT SL,SUP-2187796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5519.18,3587.47,,,,,,,,,,,,,
LOW PRFLE TTNM MESH PANEL REG GRID 100MM X 100MM 0.6MM 1.5 S,SUP-2488973,CDM,C1713,HCPCS,0278,RC,,,,both,,,9857.50,6407.37,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PERICARD 30X40 MM PUROS,SUP-2335277,CDM,C1762,CPT,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
AMPICILLIN-SULBACTAM 1500 (1000-500) MG IJ (MIXTURES ONLY),RX-430056,CDM,J0295,HCPCS,0636,RC,00049-0013-83,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CEMENT BNE 20ML 40GM PCH M VISC CO,SUP-2216771,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
STENT COR 0.014 IN 4.5X20 MM 6 FRX140 CM CVR PK PAPYRUS,SUP-2422138,CDM,C1874,HCPCS,0278,RC,,,,both,,,11398.20,7408.83,,,,,,,,,,,,,
SHEATH INTRO 8FR L10CM 0.35IN TIP PERIPH PINN TIF,SUP-2384797,CDM,C1894,HCPCS,0272,RC,,,,both,,,427.67,277.99,,,,,,,,,,,,,
HC X-Ray Knee 3 Views,PX-3207356200,CDM,73562,CPT,0320,RC,,,,both,,,374.00,243.10,,,,,,,,,,,,,
SCREW PEDCL POLYAX CANC TOP LD CANN TI 5.5MM ROD 5.5MM DIA,SUP-2414588,CDM,C1713,HCPCS,0278,RC,,,,both,,,5122.13,3329.38,,,,,,,,,,,,,
BUR SURG DIA 5 MM R FLUT UL FOR STD ATTACH STRL DISP,SUP-2937200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX5 CM HEMO DYLS or HD ACCS EPTFE IMPRA,SUP-2126470,CDM,C1768,CPT,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
PLATE SPINAL 38X45X0.4 MM CONTOURABLE MESH MALLEABLE LOW PRO,SUP-2838370,CDM,C1713,HCPCS,0278,RC,,,,both,,,4214.51,2739.43,,,,,,,,,,,,,
SROM MARATHON LINER M 28 10DEG,SUP-2512779,CDM,C1776,CPT,0278,RC,,,,both,,,4129.73,2684.32,,,,,,,,,,,,,
BOLT ORTHOPEDIC 12 MM,SUP-2316057,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
ALLOGRAFT BNE 1000-2000 MH 2 CC FD CANC PWD ORAGRAFT,SUP-2740886,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.66,311.13,,,,,,,,,,,,,
FIBER LASER HOLM 365 M MULTI-USE W/ SMA-905 BLU SMARTSYNC,SUP-2835959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.57,906.47,,,,,,,,,,,,,
CATHETER ANGIO 5FR L125CM DIA0.047IN FEM L 3.5 IMPLS,SUP-2142085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29.52,19.19,,,,,,,,,,,,,
SHEATH INTRO CLASSICSHEATH L 25 CM DIA 7 FR NDL 18 GA ROBUST,SUP-2302505,CDM,C1894,HCPCS,0272,RC,,,,both,,,117.94,76.66,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 7 FRX25 CM 13 GA 3L SPECTRUM,SUP-2759869,CDM,C1751,HCPCS,0278,RC,,,,both,,,474.64,308.52,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX3 TTNM L SHPD OBLQUE F2.7MM LOK,SUP-2721019,CDM,C1713,HCPCS,0278,RC,,,,both,,,1028.48,668.51,,,,,,,,,,,,,
BIT PERF L14/11MM CRAN DISP ZYPHR,SUP-2367385,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.91,357.44,,,,,,,,,,,,,
TROCAR ENDOSCP L 150 MM DIA12 MM LNG LAPSCP BLADED SMTH CANN,SUP-2896379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.67,273.44,,,,,,,,,,,,,
CLIP LIG L235CM RESOL 360 BX/20,SUP-2149430,CDM,C1889,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-139548,CDM,J0166,HCPCS,0636,RC,54288-0103-10,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
CANNULATED IMPLANTS FOR FOREFOOT JOINTS CO CHROM MET HD SZ,SUP-2392728,CDM,L8642,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
FILTER VASC OPT ELITE SHTH L 70 CM DIA 5 FR CAVA DIA 30 MM,SUP-2120059,CDM,C1880,HCPCS,0278,RC,,,,both,,,5392.01,3504.81,,,,,,,,,,,,,
SCREW BNE CANN TI FIX 40MMX46MM TI6,SUP-2244446,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.34,730.82,,,,,,,,,,,,,
PLATE BNE L 238 MM SCREW DIA 3.5 MM 20 H SS RECON NS,SUP-2908372,CDM,C1713,HCPCS,0278,RC,,,,both,,,2776.83,1804.94,,,,,,,,,,,,,
CATHETER HD STR 13.5 FRX15 CM 3L BASIC SET TRIO-CT,SUP-2433953,CDM,C1752,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
WALKER L SHT LEG NONSKID,SUP-2276710,CDM,L4387,HCPCS,0272,RC,,,,both,,,83.56,54.31,,,,,,,,,,,,,
TUBE ENDOTRACHEAL LASER 6.5 MM SAFETY,SUP-2225686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,506.33,329.11,,,,,,,,,,,,,
PLATE BONE DOUBLE Y MINI 2 MM MANDIBULAR LOCKING MALLEABLE T,SUP-2838415,CDM,C1713,HCPCS,0278,RC,,,,both,,,1228.68,798.64,,,,,,,,,,,,,
COLLAR TRACHEOTOMY M H3.25IN FOR 13-16IN NK POLY FOAM TWO,SUP-2196876,CDM,L0120,HCPCS,0272,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
PACK VITRCTMY 25GA 5000CPM STR ENDOILLUMINATOR NONVALVED,SUP-2109942,CDM,C1713,HCPCS,0278,RC,,,,both,,,1818.06,1181.74,,,,,,,,,,,,,
EXPANDER TISS GEL 7.8 CM PROJCT 15.5X15.5 CM 850 CC ARTOURA,SUP-2301025,CDM,C1789,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
LEVOFLOXACIN 5 MG/ML IVPB (PED) >/= 50 ML,RX-4090161,CDM,2500000003,HCPCS,0250,RC,00143-9316-24,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
GUIDE SURG FRONTAL SINUS DEPLOYMENT RELIEVA STRATUS,SUP-2106352,CDM,C1887,HCPCS,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
ELECTRODE ELECSURG NDL 16.5 GA 0.9X18 CM RF SOLOIST LEVEEN,SUP-2149346,CDM,C1713,HCPCS,0278,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
NAIL IM TIBIOTALOCALCANEL 11MMX15CM REV,SUP-2343699,CDM,C1713,HCPCS,0278,RC,,,,both,,,6019.38,3912.60,,,,,,,,,,,,,
BLADE IM L42MM TAN TI ALLY SPRL LOK FOR UHN/PHN HUM NAIL,SUP-2192460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1492.88,970.37,,,,,,,,,,,,,
PLATE BONE 9 H RT FIB ANAT FOR ANK FX GORILLA,SUP-2321566,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
STENT COR 8MM 2.25MM CO ALLY ZOTAROLIMUS ELUT OTW,SUP-2296909,CDM,C1874,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
HC CT Chest W/ Contrast,PX-3527126000,CDM,71260,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
CROWN DENT 4 S STL PRI ANTR UP CUSPID PREFABRICATED,SUP-2100371,CDM,D6783,CPT,0278,RC,,,,both,,,17.58,11.43,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST CORSET FRONT,SUP-2435563,CDM,L0970,HCPCS,0272,RC,,,,both,,,302.54,196.65,,,,,,,,,,,,,
HC So Flt3 Gene Analysis,PX-3108124566,CDM,81245,CPT,0310,RC,,,,both,,,209.00,135.85,,,,,,,,,,,,,
HYDROMORPHONE 5 MG/ML HIGH DOSE PCA (DISCRETE DOSING),RX-4081415,CDM,J1171,HCPCS,0636,RC,99999-9908-70,NDC,,both,30,ML,457.20,297.18,,,,,,,,,,,,,
BOLT FIX L125MM DIA65MM MIDFOOT S STL LOK CANN SHT THRD,SUP-2177275,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.25,1092.81,,,,,,,,,,,,,
SCREW BONE L20MM OD3MM LCK GRIDLOCK,SUP-2390561,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT PERICARD PROC TUTOPLAST 6X6CM,SUP-2165388,CDM,C1762,CPT,0278,RC,,,,both,,,8449.74,5492.33,,,,,,,,,,,,,
PLATE BNE W5XL37MM THK1.5MM 0DEG 7 H BILAT S STL STR RIG,SUP-2186165,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.07,408.90,,,,,,,,,,,,,
PLATE BNE L60MM BRL L1.5IN 130DEG PELVIS BILAT S STL STD 2,SUP-2342409,CDM,C1713,HCPCS,0278,RC,,,,both,,,3426.53,2227.24,,,,,,,,,,,,,
WASHER ORTH SCREW DIA 5.5 MM HD NS,SUP-2896692,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
CATHETER GUID MP 9 FRX45 CM SP ACUITY PRO CUT-AWAY,SUP-2149041,CDM,C1887,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
NEEDLE EPIDRL COUDE RX AND INTRODUCERS TW 16GAX3.5IN,SUP-2217821,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.62,37.45,,,,,,,,,,,,,
SCREW BONE L85MM DIA3.5MM S STL ST VAR ANG NONCANNULATED LCK,SUP-2348261,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.40,752.31,,,,,,,,,,,,,
SCREW SPNL L30MM DIA4.75MM PEDCL TI POLYAX MNRCH SYS,SUP-2254485,CDM,C1713,HCPCS,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
BIT DRL L44.5MM DIA1.4MM L8MM STP J LATCH NONRADIOPAQUE,SUP-2179239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.25,391.46,,,,,,,,,,,,,
SHELL ACET 48 MM HIP CERM REFLECTION,SUP-2434646,CDM,C1776,CPT,0278,RC,,,,both,,,6914.28,4494.28,,,,,,,,,,,,,
WRENCH SURG STEM PLUG MONOGRAM DURAC,SUP-2364826,CDM,C1776,CPT,0278,RC,,,,both,,,804.15,522.70,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY EL TI RELIANCE PASS FIX EXT,SUP-2149068,CDM,C1722,HCPCS,0275,RC,,,,both,,,52438.00,34084.70,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X30X40X0.25 MM RAPID RESORBABLE,SUP-2838570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1556.18,1011.52,,,,,,,,,,,,,
K WIRE 0.045X6IN STANDARD STAINLESS STEEL,SUP-2878434,CDM,C1713,HCPCS,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
CYCLOPHOSPHAMIDE 25 MG PO CAPS,RX-126700,CDM,J8530,HCPCS,0636,RC,62332-0618-31,NDC,,both,1,UN,7.60,4.94,,,,,,,,,,,,,
DEVICE INT FIX 30 MM ACL/PCL ENDOBUTTON CL,SUP-2341548,CDM,C1713,HCPCS,0278,RC,,,,both,,,1094.60,711.49,,,,,,,,,,,,,
SHELL ACET OD54MM CLUS H CERAMIC POR REFLCT FSO,SUP-2344700,CDM,C1776,CPT,0278,RC,,,,both,,,4278.25,2780.86,,,,,,,,,,,,,
SYSTEM TOT SHLDR REPL REV + PROMOS,SUP-2348003,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
PLATE BNE L 213 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 15 H SS,SUP-2933516,CDM,C1713,HCPCS,0278,RC,,,,both,,,6589.92,4283.45,,,,,,,,,,,,,
STAPLER INT L28CM DIA29MM CLS STPL H10-2.5MM OPN LEG L5.5MM,SUP-2218995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.69,536.05,,,,,,,,,,,,,
GUIDEWIRE VASC BLNT 350 MM NIT,SUP-2630450,CDM,C1769,HCPCS,0272,RC,,,,both,,,221.94,144.26,,,,,,,,,,,,,
PLATE DIST ANT TIB RT 4HL 102MM,SUP-2705013,CDM,C1713,HCPCS,0278,RC,,,,both,,,6714.89,4364.68,,,,,,,,,,,,,
LEAD PACE 9FR L58CM QPLR IS 1 CONN A SENSE V PACE SENSE R,SUP-2421028,CDM,C1779,HCPCS,0275,RC,,,,both,,,1305.39,848.50,,,,,,,,,,,,,
SINUS SCTN BURR ANGLD 70 DMNDBRR D3.6MM SHFT4MMX12CM 5/PK ST,SUP-2574164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.51,477.43,,,,,,,,,,,,,
CATHETER VENTRICULAR STR SM 2.2 MMX18 CM TANTALUM PUDENZ,SUP-2852593,CDM,C1729,HCPCS,0272,RC,,,,both,,,477.41,310.32,,,,,,,,,,,,,
STEM TIB DIA14MM BILAT ANK PLSM TOP CEM PROPHECY INBONE,SUP-2397070,CDM,C1776,CPT,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
PLATE BNE L81MM 6 H 1 3RD TBLR LOK FOR 3.5MM SCR UNIV LOK,SUP-2411369,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
LINER ACET OD52MM ID28MM 0DEG MARATHON HIP REV NEUT DURALOC,SUP-2250497,CDM,C1776,CPT,0278,RC,,,,both,,,3887.32,2526.76,,,,,,,,,,,,,
SCREW BNE CANN MED THRD 7.2X80 MM HDLSS SHRP TIP BEAM JOUSTA,SUP-2742955,CDM,C1713,HCPCS,0278,RC,,,,both,,,3739.74,2430.83,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 5 FR GUIDEWIRE L 45 CM DIA 0.018 IN,SUP-2116538,CDM,C1894,HCPCS,0272,RC,,,,both,,,82.90,53.88,,,,,,,,,,,,,
HC Mra Pelvis With Contrast,PX-6100891800,CDM,C8918,CPT,0610,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX4 TTNM CNTRD F/2.7MM SCREW UNVRSL,SUP-2494025,CDM,C1713,HCPCS,0278,RC,,,,both,,,765.88,497.82,,,,,,,,,,,,,
PLATE BNE L 138 X W 10.9 MM THK 3.4 MM SCREW DIA 3.5 MM 10 H 72463810N,SUP-2933425,CDM,C1713,HCPCS,0278,RC,,,,both,,,5584.65,3630.02,,,,,,,,,,,,,
BLADE SHV 3.5MM L11CM SINUS TAPR TIP CVD SHFT NONROTATABLE,SUP-2277865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1050.86,683.06,,,,,,,,,,,,,
PLATE SPNL L22MM UNIV TI ANTR CERV BILAT CNVGNT KT ZEPHIR,SUP-2291236,CDM,C1713,HCPCS,0278,RC,,,,both,,,7331.90,4765.73,,,,,,,,,,,,,
PLATE BONE L216MM 13 H RT PROX HUM LCK FOR 3.5MM SCR,SUP-2348560,CDM,C1713,HCPCS,0278,RC,,,,both,,,14741.67,9582.09,,,,,,,,,,,,,
SPINDLE ORTH XS 30 MM 400 LB ANTI ROT W/ PIN COMPRESS,SUP-2441810,CDM,C1776,CPT,0278,RC,,,,both,,,9311.67,6052.59,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE UNIV ECON BUCK,SUP-2336324,CDM,L4398,HCPCS,0274,RC,,,,both,,,93.38,60.70,,,,,,,,,,,,,
ALLODERM SELECT 2X12CM XTHICK 2.8-4.0,SUP-2822078,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
CATHETER ASPIR 6FR L140CM GWIRE 0.014IN OPTIMIZED TIP DSGN,SUP-2295344,CDM,C1757,HCPCS,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
PLATE 3.5MM TI LCP OLECRANON 6 HOLES LEFT 138MM-STERILE,SUP-2549526,CDM,C1713,HCPCS,0278,RC,,,,both,,,3717.70,2416.50,,,,,,,,,,,,,
BUR SURG L15CM DIA3MM CYL COARSE DMND SM BOR MIDAS REX,SUP-2277787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,698.59,454.08,,,,,,,,,,,,,
BUR SURG ACROMIONIZER 3.5X130 MM W/ LAT PROTCT VIO STRL DISP,SUP-2599845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.05,287.98,,,,,,,,,,,,,
CONNECTOR SPNL CLOSED 30 MM AX MARINER OUTRIG,SUP-2709766,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.018 IN TIP CRV RAD 3 MM HVY DBL,SUP-2759994,CDM,C1769,HCPCS,0272,RC,,,,both,,,133.67,86.89,,,,,,,,,,,,,
"HC So Lipoprotein,Bld,by Nmr",PX-3018370466,CDM,83704,CPT,0301,RC,,,,outpatient,,,76.00,49.40,,,,,,,,,,,,,
CATHETER INT THCL 0.5X12 MMX13.97 CM CLOSED TIP PMP ASCENDA,SUP-2280044,CDM,C1755,HCPCS,0278,RC,,,,both,,,3519.94,2287.96,,,,,,,,,,,,,
GRAFT BONE LT PROX HUM W/ CUF TRAD FRZN,SUP-2294178,CDM,C1713,HCPCS,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
CATHETER HD SET 15 FRX27 CM DL RETROGRADE STP TIP NEXTSTEP,SUP-2762966,CDM,C1750,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SHOE ORTHOT ADDITION INSOLE LTHR,SUP-2435737,CDM,L3500,HCPCS,0274,RC,,,,both,,,82.77,53.80,,,,,,,,,,,,,
SET BX NDL 19GA SHTH 7FR L60CM CATH STR 5FR L65CM CRV 5FR,SUP-2120184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
FIBER LASER HOLM 1000 MIC,SUP-2430214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10939.76,7110.84,,,,,,,,,,,,,
PLATE BNE L168MM 8 H NONSTERILE R MED DST TIB S STL LOK,SUP-2185586,CDM,C1713,HCPCS,0278,RC,,,,both,,,4498.99,2924.34,,,,,,,,,,,,,
SYSTEM EXT DRNGE LSR ACCURACY L RED CAP YEL TAG MRI SAFE W O,SUP-2308154,CDM,C1729,HCPCS,0272,RC,,,,both,,,683.89,444.53,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6X3 CM TERMINALLY STRL WND NEOX CRD RT,SUP-2648699,CDM,Q4148,HCPCS,0636,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
ANCHOR SUT BIOCRYL RAPIDE W/ PROKNOT TECHNOLOGY FOR JT RECON,SUP-2256594,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
TUBE VENT 1.27 MM 1.5 MM 2.75 MM SHEEHY CLLR BUTTON SIL STRL,SUP-2458252,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.39,19.10,,,,,,,,,,,,,
CATHETER PERITONEAL DIALYSI V SER 15FR DIA 43CM S MC20VS43RC,SUP-2633015,CDM,C1752,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
LEAD PACE 8.6FR L55CM SGL COIL PERM ACT FIX DF4 CONN SPRNT,SUP-2282265,CDM,C1895,HCPCS,0275,RC,,,,both,,,8769.83,5700.39,,,,,,,,,,,,,
BLADE RETRACTOR SCOVILLE 1X3.5 IN SLD PRNG SHRP LAMINECTOMY,SUP-2484769,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.01,171.61,,,,,,,,,,,,,
COLLAR CERV CNTOUR SM 18.5X3 IN 11-16 IN MED FOAM PROCARE,SUP-2196858,CDM,L0180,HCPCS,0274,RC,,,,both,,,10.71,6.96,,,,,,,,,,,,,
KIT DRL BIT DIA2MM DRL GUID HNDL TMPLT LOC PIN TAMP,SUP-2194162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1037.71,674.51,,,,,,,,,,,,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,0636,RC,00338-0709-48,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 5X20 MM ARROW STAINLESS STEEL NON,SUP-2836751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,243.98,158.59,,,,,,,,,,,,,
HC So Testosterone Total|NOT REASONABLE AND NECESSARY,PX-3018440366,CDM,84403,CPT,0301,RC,,,GZ,both,,,118.00,76.70,,,,,,,,,,,,,
STENT PERIPH L100MM DIA13MM CATH L120CM DIA12FR 0.035IN NIT,SUP-2396589,CDM,C1874,HCPCS,0278,RC,,,,both,,,10654.02,6925.11,,,,,,,,,,,,,
GRAFT ENDOVASC L100MM DIA34MM SUPRARENAL AORT AFX VELA,SUP-2217608,CDM,C1768,CPT,0278,RC,,,,both,,,13420.36,8723.23,,,,,,,,,,,,,
ROD DISTRACTOR 120 MM FOR RIGID EXT FIX CARBON RED II,SUP-2472689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.53,586.64,,,,,,,,,,,,,
BUR SURG DIAMOND 2 MM 12 CM BALL TELSCP MIDAS REX LEGEND,SUP-2632195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.86,278.76,,,,,,,,,,,,,
HC So1 Factor VIII,PX-3058524067,CDM,85240,CPT,0305,RC,,,,outpatient,,,637.00,414.05,,,,,,,,,,,,,
HC Intmd Wnd Repair N-Hg/Gen,PX-4501204700,CDM,12047,CPT,0450,RC,,,,both,,,6021.00,3913.65,,,,,,,,,,,,,
PROSTHESIS OSS L 9 MM SHFT DIA1 MM HD DIA 3.25 MM TI HA FLX,SUP-2902032,CDM,L8613,CPT,0278,RC,,,,both,,,1700.15,1105.10,,,,,,,,,,,,,
K WIRE FIX L285MM DIA2.5MM S STL W/ TRCR PNT,SUP-2186866,CDM,C1713,HCPCS,0278,RC,,,,both,,,306.34,199.12,,,,,,,,,,,,,
Z DISCONTINUED SEALER TISS L14CM DIA5MM ADV BPLR CRV TIP OPN APPRCH ENSEAL,SUP-2219726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1205.89,783.83,,,,,,,,,,,,,
PIN BONE FIX L150MM DIA4MM,SUP-2368498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.96,284.02,,,,,,,,,,,,,
HOOK SPNL RT LAM S STL OPN ANG FOR 4MM ROD MOSS MIAMI SYS,SUP-2254425,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
CATHETER SPEC RETRV BELOW 9-12 MM EXTRACTOR PRO RX-S,SUP-2484405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.96,304.82,,,,,,,,,,,,,
SYSTEM MENIS REP W/ 12DEG ORTHOCORD VLT BRAID COMP 2-0 SUT,SUP-2249481,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SCREW BNE L4MM DIA2.3MM MAND CRANIOMAXILLOFACIAL SIL LOK 5PK,SUP-2366161,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.13,225.63,,,,,,,,,,,,,
PUSHER SURG FOR AC JT RECON TOGGLELOC DISP,SUP-2137214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.82,384.03,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 100 CM DIA 0.038 IN TAPR L 15 CM FLPY,SUP-2167859,CDM,C1769,HCPCS,0272,RC,,,,both,,,65.41,42.52,,,,,,,,,,,,,
GRAFT ALLGRFT TYP ANTIMIGRATION CORT DWL,SUP-2309707,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
BOLT BNE FIX L80MM DIA5MM PROX L10MM DST L22MM MIDFOOT FUS,SUP-2400718,CDM,C1713,HCPCS,0278,RC,,,,both,,,4826.18,3137.02,,,,,,,,,,,,,
BUR SURG L115MM DIA1MM S STL RND CUT FLUT CRV VISAO,SUP-2284228,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.60,524.29,,,,,,,,,,,,,
CATHETER CV FULL TY 018 4 FRX5 CM DL J TIP STR NDL SPECTRUM,SUP-2759854,CDM,C1751,HCPCS,0278,RC,,,,both,,,512.89,333.38,,,,,,,,,,,,,
NEEDLE ENDOSCP INJ 16 GA 55 16 MMX43 CM LL PUNC,SUP-2767362,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.19,438.87,,,,,,,,,,,,,
GRAFT PERICARDIAL PERI-GUARD 8CM X 14CM REPAIR PATCH,SUP-2845105,CDM,C1781,HCPCS,0278,RC,,,,both,,,2373.40,1542.71,,,,,,,,,,,,,
PLATE BNE 18MM UNIV FOREFOOT,SUP-2243215,CDM,C1776,CPT,0278,RC,,,,both,,,3976.78,2584.91,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FLSH L 135 CM BALLOON L 12 MM DIA 5 MM,SUP-2319857,CDM,C1725,HCPCS,0272,RC,,,,both,,,3921.86,2549.21,,,,,,,,,,,,,
GRAFT BONE SUB 10ML PUTTY BIOLOGIC SPINE SURG BIOACTIVE,SUP-2232313,CDM,C9359,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
SYSTEM ASPIR BNE MAR 11 GAX11 CM W/ PREP MAXX CELL,SUP-2740205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CLAMP SURG PIN 8 MM 16 MM BEND BUTTRESS PIN,SUP-2389688,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
IMPLANT HUM TISS L 70 X W 40 MM THK 5 MM DECELL DERM,SUP-2931224,CDM,C1762,CPT,0278,RC,,,,both,,,14438.22,9384.84,,,,,,,,,,,,,
INTRODUCER SHTH STR 0.021 IN 6 FRX11 CM 21 GAX4 CM PRELUDE,SUP-2303223,CDM,C1893,HCPCS,0272,RC,,,,both,,,126.60,82.29,,,,,,,,,,,,,
PROBE SURG 0.028 IN ACUTRK,SUP-2535350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2144.62,1394.00,,,,,,,,,,,,,
KIT SPNL CRD STIM L70CM 16 LD PRECIS NEUROMODULATION,SUP-2138789,CDM,C1778,HCPCS,0278,RC,,,,both,,,9539.32,6200.56,,,,,,,,,,,,,
STENT BILI ST-2 SOEH TANNENBAUM L 14 CM DIA11.5 FR GUIDEWIRE,SUP-2738198,CDM,C2617,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
ADAPTER PACE LD OSCOR L 10 CM SIL INSUL UPLR IS 1 CONN,SUP-2356430,CDM,C1883,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
HC Cortisol Total,PX-3018253300,CDM,82533,CPT,0301,RC,,,,both,,,212.00,137.80,,,,,,,,,,,,,
KIT INTRO FLUENT L 10 CM DIA 5 FR GUIDEWIRE L 40 CM NDL L 7,SUP-2164807,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
NUSHIELD 3X4CM 12SQ CM,SUP-2314110,CDM,Q4160,HCPCS,0636,RC,,,,both,,,3661.24,2379.81,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 12X12X12 MM DEMINERALIZED CANC LIFEFLEX,SUP-2866838,CDM,C1762,CPT,0278,RC,,,,both,,,1407.98,915.19,,,,,,,,,,,,,
PLATE BNE W10.1XL58MM 5 H BILAT TI LO PROF RIG LOK COMPR,SUP-2191090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1436.27,933.58,,,,,,,,,,,,,
SEVELAMER CARBONATE 0.8 G PO PACK,RX-98615,CDM,J0602,HCPCS,0637,RC,65862-0930-90,NDC,,both,1,UN,8.60,5.59,,,,,,,,,,,,,
HC Cytp Eval Fine Needle Aspirate Interp & Report,PX-3118817300,CDM,88173,CPT,0311,RC,,,,both,,,453.00,294.45,,,,,,,,,,,,,
LEVEL NEURO MESH 3D NEURO SCRW170 X 138 MM T10 MM CP TTNM Q,SUP-2681434,CDM,C1713,HCPCS,0278,RC,,,,both,,,12870.55,8365.86,,,,,,,,,,,,,
CATHETER HD SET 035 12 FRX15 CM 60 CM ACUTE DL TURBO-FLO HD,SUP-2759833,CDM,C1752,HCPCS,0278,RC,,,,both,,,435.30,282.94,,,,,,,,,,,,,
VALVE SHUNT PED CONTROL RESERVOIR,SUP-2711649,CDM,C1729,HCPCS,0272,RC,,,,both,,,1069.80,695.37,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 70 CM DIA 6 MM EPTFE STR STD WALL,SUP-2227646,CDM,C1768,CPT,0278,RC,,,,both,,,1744.93,1134.20,,,,,,,,,,,,,
STENT THOR L100MM DIA26X26MM W CAPTIVIA DEL SYS VALIANT,SUP-2603421,CDM,C1768,CPT,0278,RC,,,,both,,,53364.30,34686.79,,,,,,,,,,,,,
WIRE FIX L150MM OD0.9MM FOR FT RECON MIDFT FUS PLT K DARCO,SUP-2398609,CDM,C1776,CPT,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
TUBE IRRIGATION HI FLO ANSPACH EMAX2,SUP-2265795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.59,245.43,,,,,,,,,,,,,
BLADE SURGICAL L65MM TONGUE PLAIN FOR MOUTH GAG DAVIS-BOYLE,SUP-2808624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.27,206.23,,,,,,,,,,,,,
GUIDEWIRE SURG L900MM OD3MM BALL NOSE DISP PRECICE UNYTE,SUP-2309746,CDM,C1769,HCPCS,0272,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
PLATE EXT FIX SHT 100 MM FT RNG TI NS,SUP-2799578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2526.29,1642.09,,,,,,,,,,,,,
RECON PLATE 22X263MM 3.5MM,SUP-2818797,CDM,C1713,HCPCS,0278,RC,,,,both,,,7675.42,4989.02,,,,,,,,,,,,,
SCREW BNE SELF RET MINI 2X6 MM MAND X DRV TI,SUP-2466032,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.40,101.01,,,,,,,,,,,,,
NAIL IM L320MM OD13MM UNIV TI FEM CANN LCK VERSANAIL,SUP-2412450,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
DRILL SURG 12 MM FOR ANCHORAGE HOLE,SUP-2449524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
KNIFE ENDOSCP SLIM SHTH 2X1650 MM 2.8 MM 2 KNOB SHP ITKNIFE2,SUP-2491063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2208.21,1435.34,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM DIA1 MM 2 H BAR 8 MM SCREW DIA2 MM TI,SUP-2883196,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.59,182.38,,,,,,,,,,,,,
SPLINT WRST UNIV L11IN L CUTAWAY PERF FOAM CONSTR MAL,SUP-2194860,CDM,L3809,HCPCS,0272,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
PROBE ENDOSCP 90 DEG HI PROF SAPHYRE,SUP-2848576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.07,383.55,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 100 CM DIA 4 FR 0.038 IN JB2 SEL,SUP-2116864,CDM,C1887,HCPCS,0272,RC,,,,both,,,138.79,90.21,,,,,,,,,,,,,
BARRIER ADH L 4 X W 2 CM AMNIO MEMBRN DBL SIDE LAYR PROTCT,SUP-2904080,CDM,C1762,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE 3D PRNT MED MIDFACE MAND TI TRUMATCH,SUP-2860367,CDM,C1713,HCPCS,0278,RC,,,,both,,,23175.71,15064.21,,,,,,,,,,,,,
HC Fna Bx W/US Gdn 1st Les,PX-3611000500,CDM,10005,CPT,0361,RC,,,,both,,,3993.00,2595.45,,,,,,,,,,,,,
IMPLANT GYN L 24 X W 2 CM ALLGRFT FASC LATA PROC UNI DIR,SUP-2896113,CDM,C1762,CPT,0278,RC,,,,both,,,5881.22,3822.79,,,,,,,,,,,,,
TESTER VENTILATOR CIRC LUNG 0.05 LT BABI +,SUP-2352862,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BONE SM THK2.5MM 4X20X4 H BILAT MAXILLOFACIAL ORAL LT,SUP-2181776,CDM,C1713,HCPCS,0278,RC,,,,both,,,9062.35,5890.53,,,,,,,,,,,,,
BEARING TIB THK12MM KNEE CONSTRN REDUC SZ OSS,SUP-2406490,CDM,C1776,CPT,0278,RC,,,,both,,,2345.58,1524.63,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-4 MM 60 CC FRZN CANC,SUP-2792184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3744.45,2433.89,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.025IN TAPR L7CM FLPY TIP L2.5CM,SUP-2167882,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
CLAMP EXT FIX M DSTL RAD S STL SELF HLD CLP ON COMB REPROC,SUP-2188522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1673.65,1087.87,,,,,,,,,,,,,
BRACE ELBW TENNIS 1 SZ BLK INT FOAM PD LTWT HG80,SUP-2324093,CDM,L3702,HCPCS,0272,RC,,,,both,,,37.93,24.65,,,,,,,,,,,,,
BRACE WR CLUTCH DORS STAY VELSTRETCH WRP LT CIRC 6 1/2-8,SUP-2323979,CDM,L3931,HCPCS,0272,RC,,,,both,,,50.84,33.05,,,,,,,,,,,,,
POST EXT FIX MIAMI FOR HOFFMANN II SYS,SUP-2372206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
STEM RAD H42MM DIA7MM TI ALLOY CVD FOR PRI AND REV REPL,SUP-2181499,CDM,C1776,CPT,0278,RC,,,,both,,,7322.92,4759.90,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION LARGE 2 MM DOUBLE ANGLE TITANIUM M,SUP-2837758,CDM,C1713,HCPCS,0278,RC,,,,both,,,9365.68,6087.69,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.519,SUP-2860036,CDM,C1713,HCPCS,0278,RC,,,,both,,,35943.89,23363.53,,,,,,,,,,,,,
SPLINT HND AD SM L5.75IN LT HEADLINER CVR FIVE STRP CLSR ADJ,SUP-2324297,CDM,L3807,HCPCS,0272,RC,,,,both,,,180.93,117.60,,,,,,,,,,,,,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-151970,CDM,2500000003,HCPCS,0250,RC,00338-0206-04,NDC,,both,2000,ML,690.00,448.50,,,,,,,,,,,,,
CATHETER EP SM 2-5-2 MM 8 FR110 CM BPLR STEER,SUP-2357036,CDM,C1733,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HC ED Avulsion Nail Plate Single,PX-4501173000,CDM,11730,CPT,0450,RC,,,,both,,,632.00,410.80,,,,,,,,,,,,,
COMPONENT FEM SZ 8 CO CHROM NP L KNEE CRUCE RET PRI,SUP-2345812,CDM,C1776,CPT,0278,RC,,,,both,,,10249.75,6662.34,,,,,,,,,,,,,
PLATE BONE T TYPE 1.5 MM 4 HOLE STAINLESS STEEL STERILE TC10,SUP-2836680,CDM,C1713,HCPCS,0278,RC,,,,both,,,1626.46,1057.20,,,,,,,,,,,,,
PLATE BNE L49MM 4 H BILAT S STL 1/3 TBLR FOR 3.5MM SCR,SUP-2411333,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.59,126.48,,,,,,,,,,,,,
LINER KT WLK BOOT VENTURE AIR TALL SM,SUP-2151041,CDM,L4386,HCPCS,0272,RC,,,,both,,,54.01,35.11,,,,,,,,,,,,,
SCREW BNE SHT THRD 9 MM,SUP-2315914,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
FIBER LASER HOLM SUREFLEX 10812] FORTEC MEDICAL INC],SUP-2225689,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CLOVERLEAF PL 5H 120MM,SUP-2818807,CDM,C1713,HCPCS,0278,RC,,,,both,,,3411.30,2217.34,,,,,,,,,,,,,
BRACE KNEE SM FOR 15-18IN LT PAT PREFABRICATED AIRTECH FRME,SUP-2151021,CDM,L3660,HCPCS,0272,RC,,,,both,,,931.29,605.34,,,,,,,,,,,,,
KIT SCOPE NANO 1.9MM DISP,SUP-2713884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2069.26,1345.02,,,,,,,,,,,,,
PLATE SPNL L35MM SPINOUS PROC AFFIX II,SUP-2311358,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
AGENT HEMSTAT 3GM PURIFIED PLNT STARCH PWD ABSRB ARISTA AH,SUP-2125941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
TAP SURG 4.5 MM OCPTL VERTEX SEL,SUP-2432048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.46,240.80,,,,,,,,,,,,,
KIT ABLATION ACESSA LAPAROSCOPIC RADIOFREQUENCY,SUP-2665165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10173.60,6612.84,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 38 X 50 X 3 MM POLYETHYL ORBIT FLR SHT,SUP-2936087,CDM,C1713,HCPCS,0278,RC,,,,both,,,4578.12,2975.78,,,,,,,,,,,,,
INSERT TIB SZ 9 THK12MM UNIV CO CHROM UHMWPE KNEE ARTC PRI,SUP-2378284,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
MICROCATHETER GUID TREVO PRO 18 L 157 CM PROX/DSTL OD,SUP-2367795,CDM,C1725,HCPCS,0272,RC,,,,both,,,2195.49,1427.07,,,,,,,,,,,,,
BUR SURG MED,SUP-2585528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
KIT BNE CEM PREP UNIV W/ RESTRIC INSRT 2 CEM SCULP FEM CNL,SUP-2366770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION MEDIUM 2.5 MM DOUBLE ANGLE TITANIU,SUP-2837761,CDM,C1713,HCPCS,0278,RC,,,,both,,,9563.50,6216.27,,,,,,,,,,,,,
RING EXTERNAL FIXATION DIA160MM ALUMINUM HALF,SUP-2586493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3903.87,2537.52,,,,,,,,,,,,,
HC Assay of Urea Nitrogen Quantitative,PX-3018452000,CDM,84520,CPT,0301,RC,,,,inpatient,,,92.00,59.80,,,,,,,,,,,,,
AGENT HEMSTAT HUM FBRN SEAL EVICEL KT,SUP-2256934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14360.32,9334.21,,,,,,,,,,,,,
GRIP IT SHOES FRACTURE,SUP-2366437,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.53,272.04,,,,,,,,,,,,,
GRAFT BONE PUTTY DEMINERLIZED BONE MTRX 1CC ALLOFUSE,SUP-2113944,CDM,C9359,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 155 MM 25/16 MM,SUP-2217567,CDM,C1768,CPT,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
PROBE SURG STR BALL HNDL CD HORZ ENGAGE,SUP-2293399,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.22,1373.59,,,,,,,,,,,,,
SCREW SPNL L40MM DIA6.5MM CANC PEDCL TI MULTIAXIAL SEXTANT,SUP-2288501,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 12 HOLE SS NS LCP,SUP-2799220,CDM,C1713,HCPCS,0278,RC,,,,both,,,2092.65,1360.22,,,,,,,,,,,,,
ROPIVACAINE ELASTOMERIC INFUSION 0.2%,RX-4081819201,CDM,J2795,HCPCS,0636,RC,63323-0285-23,NDC,,both,100,ML,317.40,206.31,,,,,,,,,,,,,
INTRODUCER PACE LD SHTH L 14.2 CM DIL L 17.7 CM DIA 9 FR STD,SUP-2148967,CDM,C1894,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CATHETER GUID 6FR INSIDE DIA0.07IN AL Q4 PTFE LNR RND BRAID,SUP-2144699,CDM,C1887,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
KIT DRNGE PERI CONTAIN CATH AND STRT 4 1000ML BTL PLEURX,SUP-2133749,CDM,C1729,HCPCS,0272,RC,,,,both,,,2766.34,1798.12,,,,,,,,,,,,,
KIT INTRO ACCS 5FR L10CM GWIRE 0018IN NDL 21GA L7CM MINI S,SUP-2303010,CDM,C1894,HCPCS,0272,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
PLATE BNE L33MM THK3.4MM 2 H BILAT S STL STR LOK COMPR FOR,SUP-2185124,CDM,C1713,HCPCS,0278,RC,,,,both,,,704.46,457.90,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .035 WORKING L 90 CM SHTH 8.5 FR,SUP-2898458,CDM,C1753,HCPCS,0278,RC,,,,both,,,1783.36,1159.18,,,,,,,,,,,,,
PLATE SPNL L57MM ANT BILAT THORLUM TI LOK,SUP-2193093,CDM,C1713,HCPCS,0278,RC,,,,both,,,7174.90,4663.68,,,,,,,,,,,,,
BIT DRILL ARTHROSCOPIC 2.4 MM DIAMETER FLUTED NON CANNULATED,SUP-2824795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.69,454.80,,,,,,,,,,,,,
PLATE BNE L132MM BLDE W9.2XL30MM 90DEG 10 H BILAT S STL LOK,SUP-2185355,CDM,C1713,HCPCS,0278,RC,,,,both,,,3981.36,2587.88,,,,,,,,,,,,,
BODY FEM L75MM DIA20MM 135DEG 40MM OFFSET PROX TI ALLY,SUP-2252540,CDM,C1776,CPT,0278,RC,,,,both,,,11006.33,7154.11,,,,,,,,,,,,,
BOLT ORTH FUSION 6.5X115 MM MIDFOOT TI NS,SUP-2799617,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.66,1071.63,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 35 X 53 MM POLYETHYL RT EAR BASE EXT,SUP-2935177,CDM,C1713,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
VALVE AORT CARP EDW TISS ANNULUS 31 MM SEW RNG DIA 37 MM,SUP-2214052,CDM,C1889,HCPCS,0278,RC,,,,both,,,12638.50,8215.02,,,,,,,,,,,,,
LENS INTOCU L13MM DIA6MM HYDROPHOBIC ACRYL POST CHMBR,SUP-2102344,CDM,V2632,HCPCS,0276,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
COMPONENT TIBIAL LG W33XL40MM SINGLE COATED US VERSION STAR,SUP-2878521,CDM,C1776,CPT,0278,RC,,,,both,,,18197.24,11828.21,,,,,,,,,,,,,
INTRODUCER PACE LD WORLEY ADV CSG L 40 CM DIA 9 FR GUIDEWIRE,SUP-2357564,CDM,C1892,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
RECON TS LCK DBL ANG36 H,SUP-2669751,CDM,C1713,HCPCS,0278,RC,,,,both,,,8723.30,5670.14,,,,,,,,,,,,,
PLUG ACET MET CTRL H MPACT,SUP-2267359,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
"HC New Pt, E/M Level 3",PX-5109920300,CDM,99203,CPT,0510,RC,,,,inpatient,,,321.00,208.65,,,,,,,,,,,,,
ANCHOR SUT DIA4.75MM BIOCRYL RAPIDE ABSRB KNOTLESS HEALIX,SUP-2249438,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.88,1922.62,,,,,,,,,,,,,
GUIDE SURG 3D PRNT MIDFACE MAND TI TRUMATCH SD980.017,SUP-2860364,CDM,C1713,HCPCS,0278,RC,,,,both,,,9655.81,6276.28,,,,,,,,,,,,,
HC Stent Plmt Ctr Dialysis Seg,PX-3613690800,CDM,36908,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
TITLE CAP SCR EXTR TIP,SUP-2212567,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
CATHETER CRYOABLATION C2 CRYOBALLOON L 105 CM CHANNEL 3.7 MM,SUP-2422295,CDM,C2618,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
Elite H Drill Template Kit,SUP-2550451,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.97,124.13,,,,,,,,,,,,,
CAGE SPNL 25X11MM LUM CONVX FUSELOX,SUP-2152495,CDM,C1889,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRAFT VASC STP 4-7 MMX50 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761532,CDM,C1768,CPT,0278,RC,,,,both,,,2020.34,1313.22,,,,,,,,,,,,,
SYSTEM THROMCTMY CLN XT L 65 CM DIA 6 FR GUIDEWIRE 0.035 IN,SUP-2120124,CDM,C1724,HCPCS,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 202 MM DIA 30 MM SHTH 20 FR RVD,SUP-2423375,CDM,C1768,CPT,0278,RC,,,,both,,,55829.20,36288.98,,,,,,,,,,,,,
BIT DRL OD3.2MM FOR RADLUC TARGET SYS SIDEWNDR,SUP-2371638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
SCREW BNE LCK 10X2 MM VARIAX,SUP-2550585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
CATHETER THROMCTMY SOLITAIRE X L 31 MM DIA 6 MM USABLE L 20,SUP-2432063,CDM,C1757,HCPCS,0272,RC,,,,both,,,21125.92,13731.85,,,,,,,,,,,,,
PLATE BNE L56MM THK2MM 9 H NAR L DST RAD VOLAR ANAT TI FOR,SUP-2372937,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
DILATOR TRANSSEPTAL L 67 CM GUIDEWIRE L 230 CM HDPE HYPOTUBE PIGTAIL,SUP-2913475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
BUR SURG L 125 MM DIA2.35 MM HD DIA1.4 MM DIAMOND NS REUSE,SUP-2929333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.18,266.62,,,,,,,,,,,,,
PUMP BLD CNTRFUG BAL BIOSURFACE AFFIN CP,SUP-2467203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.98,380.24,,,,,,,,,,,,,
HC X-Ray Knee Rout Inc Tun Pat Min 4 View,PX-3207356400,CDM,73564,CPT,0320,RC,,,,inpatient,,,616.00,400.40,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309711000,CDM,97110,CPT,0430,RC,,,GO|KX|CO|XU,both,,,195.00,126.75,,,,,,,,,,,,,
SPLINT ORTH SPICA THMB,SUP-2388192,CDM,L3807,HCPCS,0274,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
GRAFT DERM L8CMXW4CM MTRX FLOWABLE FOR INTEGUMENTARY AUG,SUP-2321664,CDM,Q4126,HCPCS,0636,RC,,,,both,,,8970.35,5830.73,,,,,,,,,,,,,
BLADE SAW OSCILLATING 90X19X1 MM,SUP-2607491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,73.98,48.09,,,,,,,,,,,,,
ADAPTER TBNG W/ STPCOCK AND LUERLOCK FOR CUT CANN,SUP-2361364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1150.65,747.92,,,,,,,,,,,,,
RELOAD STPLR L 5 MM ARTICULATING RELD FIX DEV 10 STD VIO,SUP-2913726,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.11,521.37,,,,,,,,,,,,,
MESH SURG W15XL19CM THK1MM EPTFE CORDUROY SURF CNFRM TEXT,SUP-2395331,CDM,C1781,HCPCS,0278,RC,,,,both,,,3008.12,1955.28,,,,,,,,,,,,,
OCCLUDER CV AMPLATZER AMULET IDE LOBE DIA28 MM NIT LAA PERC,SUP-2866213,CDM,C1889,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
PREM ST/RGX CP/LGXL/LG HD,SUP-2212378,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PLATE BNE TIBIOTALAR ANTR AXSOS 3 630101,SUP-2613575,CDM,C1713,HCPCS,0278,RC,,,,both,,,9608.40,6245.46,,,,,,,,,,,,,
THYROID 15 MG PO TABS,RX-7940,CDM,6370000000,HCPCS,0637,RC,62559-0740-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT LAP BND DISECT ADJ,SUP-2257755,CDM,2780000010,LOCAL,0278,RC,,,,both,,,9071.46,5896.45,,,,,,,,,,,,,
MESH HERN ELLIPSE 8X6IN W/ POS SYS PHASIX ST ECHO 2,SUP-2855262,CDM,C1781,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 260 CM DIA 0.035 IN TIP,SUP-2385544,CDM,C1769,HCPCS,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
CATHETER ANGIO IMPRESS L 100 CM 4 FR 0.04 IN L 40 CM SIM2,SUP-2301493,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
DISTRACTION INTRNL DIST SMPHSS ZRCH 1 RTTRDM 20 23 MM SCRW,SUP-2680370,CDM,C1713,HCPCS,0278,RC,,,,both,,,9424.90,6126.18,,,,,,,,,,,,,
BIT DRL DIA2MM SHT CALIB W/ AO QUIK CONN PERI-LOC,SUP-2344005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,858.92,558.30,,,,,,,,,,,,,
GRAFT BNE 10MM CERV CORT,SUP-2364366,CDM,C1762,CPT,0278,RC,,,,both,,,4504.33,2927.81,,,,,,,,,,,,,
PLATE BNE 9 HOLE 0.5 MM ORBIT 1.3 MM SCR TI NS MATRIXMIDFACE,SUP-2776726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.37,1241.09,,,,,,,,,,,,,
HC CT Facial Bones W/O Contrast,PX-3517048600,CDM,70486,CPT,0351,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
GRAFT BNE CRUSH 1-10 MM 5 CC CANC,SUP-2766760,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
FORCEPS BPLR L33CM DISECT TWO TIER JAW DSGN W/ SERR SURF,SUP-2313946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
GRAFT BONE RADLUC DEMIN CORT STRL 30MMX30MM L OSTEOWRAP,SUP-2125429,CDM,C1713,HCPCS,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
SPACER SPNL 30X12X8-12 MM CALIB,SUP-2231981,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BIT DRILL MINI AO 2.0MM,SUP-2745252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC Direct Ldl Cholesterol,PX-3018372100,CDM,83721,CPT,0301,RC,,,,both,,,81.00,52.65,,,,,,,,,,,,,
ANCHOR SUT 15MM PRELD W 2 0 AND NDL MICROMITE STITCHPAK,SUP-2166461,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.16,442.75,,,,,,,,,,,,,
PACEMAKER CRD UPLR/BPLR SINGLE CHMBR IS-1 CONN LEGEND SR,SUP-2236359,CDM,C1721,HCPCS,0275,RC,,,,both,,,92221.80,59944.17,,,,,,,,,,,,,
PROBE ARTHSCP HIP BLK INTEGR CBL EFLEX ABLAT,SUP-2341733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1840.51,1196.33,,,,,,,,,,,,,
KIT BLD PMP 17FR ART CANN 62CM VEN TANDEMHEART,SUP-2152645,CDM,C1889,HCPCS,0278,RC,,,,both,,,61230.00,39799.50,,,,,,,,,,,,,
IMPLANT BIO TISS W5XL10CM PORCINE DERM MTRX RECON THINNER BCP051010] TORNIER INC],SUP-2388574,CDM,C1763,HCPCS,0278,RC,,,,both,,,9417.49,6121.37,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED INCRD MOTN CKNEEBIOINCMOT] ZIMMER BIOMET INC],SUP-2137377,CDM,C1776,CPT,0278,RC,,,,both,,,14801.96,9621.27,,,,,,,,,,,,,
SCREW INTRF L25MM OD7MM CANN N ABSRB TI ADVNTG,SUP-2249493,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
KIT MRK DEL NAVIGATION CATH L125CM OD0.070IN ID0.040IN,SUP-2381771,CDM,C1769,HCPCS,0272,RC,,,,both,,,435.20,282.88,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION LARGE 2.5 MM DOUBLE ANGLE TITANIUM,SUP-2837762,CDM,C1713,HCPCS,0278,RC,,,,both,,,10095.41,6562.02,,,,,,,,,,,,,
PLATE BNE THK2.3MM LNG CRV NONCOMPRESSION FRAC,SUP-2263004,CDM,C1713,HCPCS,0278,RC,,,,both,,,903.03,586.97,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUET CHRONIC STD 10FR DIA 28/31CMLAV IN,SUP-2613276,CDM,C1750,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY,RX-147640,CDM,6370000000,HCPCS,0637,RC,25021-0673-76,NDC,,both,6,ML,26.80,17.42,,,,,,,,,,,,,
PLATE BONE 10 H RT SCAPULA LAT BORD,SUP-2107833,CDM,C1713,HCPCS,0278,RC,,,,both,,,5837.26,3794.22,,,,,,,,,,,,,
ASSEMBLY SHUNT CATH DSTL L 120 CM REG STRL STRATAMR II,SUP-2929975,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PLATE BNE L250MM 12 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185682,CDM,C1713,HCPCS,0278,RC,,,,both,,,4468.03,2904.22,,,,,,,,,,,,,
COMPONENT HIP CEM UPLR HA LD/FX,SUP-2212771,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
ROD SPNL PRE-BENT 5.5X35 MM TI STRL CD HORZ ESSENTIALS,SUP-2629471,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.13,651.38,,,,,,,,,,,,,
CONNECTOR SPNL EXT AX 3X90 MM 2 SCREW DAYTONA OZAT,SUP-2709258,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW FIX FASTENING THREADLOCK TAPR CROSS DRV 50-174-03-75,SUP-2493744,CDM,C1889,HCPCS,0278,RC,,,,both,,,267.56,173.91,,,,,,,,,,,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,0636,RC,00641-6046-10,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
PROPRANOLOL HCL ER 80 MG PO CP24,RX-38225,CDM,6370000000,HCPCS,0637,RC,00228-2779-11,NDC,,both,1,UN,8.90,5.78,,,,,,,,,,,,,
PLEDGET 3X3MM TEFLON FIRM,SUP-2425484,CDM,C1768,CPT,0278,RC,,,,both,,,69.17,44.96,,,,,,,,,,,,,
PLATE BNE 180 MM FT TRULOK,SUP-2316140,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
HC So Macroscopic Exam Arthropod,PX-3008716866,CDM,87168,CPT,0300,RC,,,,both,,,75.00,48.75,,,,,,,,,,,,,
PROSTHESIS OSS 2.5X3.5 MM 0.8X37 MM DSTL TI SILVERSTEIN ALTO,SUP-2232495,CDM,L8613,CPT,0278,RC,,,,both,,,1151.12,748.23,,,,,,,,,,,,,
ROD X MEDULLARY DSTL TIB UP ATTUNE,SUP-2454749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
CATHETER GUID EASYTRAK L 54 CM OD 8 FR ID 0.87 IN CORONARY,SUP-2148999,CDM,C1887,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
GRAFT HUM TISS L 100 MM DIA10 MM FIB SHFT LYOPH STRL,SUP-2913150,CDM,C1762,CPT,0278,RC,,,,both,,,3598.44,2338.99,,,,,,,,,,,,,
WEDGE ACF ILIUM CREST TRADITION ALLGRFT 10 - 12 MM FRZ DRY,SUP-2294064,CDM,C1713,HCPCS,0278,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
PLATE BNE 1/3 TBLR 23 MM 3 HOLE NS LTX,SUP-2861927,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.84,88.30,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THN MTRX ANAT BARR FOR ORTH APPL,SUP-2120774,CDM,C1762,CPT,0278,RC,,,,both,,,5239.88,3405.92,,,,,,,,,,,,,
SCREW BNE L30MM DIA6.5MM CANC LO PROF,SUP-2121115,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
PUMP INFUSION ELASTOMERIC 400 CC 6 ML/HR TRPL FIX FLO ON-Q,SUP-2424462,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
HC Cltx Gr Hmrl Tbrs Fx WO Mnpj,PX-4502362000,CDM,23620,CPT,0450,RC,,,,both,,,630.00,409.50,,,,,,,,,,,,,
CATHETER EP 5FR L115CM ELECTRD SPC 2-5-2MM TIP 2MM BND,SUP-2356878,CDM,C1730,HCPCS,0272,RC,,,,both,,,1657.92,1077.65,,,,,,,,,,,,,
NARROW PLATE 4.5MM 24X390MM,SUP-2818526,CDM,C1713,HCPCS,0278,RC,,,,both,,,5086.49,3306.22,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.1 MMX6 IN,SUP-2663620,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.28,29.43,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,KX|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
CAGE SPNL 7 MM BENGAL,SUP-2256273,CDM,C1889,HCPCS,0278,RC,,,,both,,,5341.14,3471.74,,,,,,,,,,,,,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,6370000000,HCPCS,0637,RC,24208-0580-60,NDC,,both,5,ML,160.70,104.45,,,,,,,,,,,,,
CATHETER ABLATN B 2-5-2 MM 3.5 MM 7 FRX115 CM THERMOCOOL LF,SUP-2248838,CDM,C2630,CPT,0272,RC,,,,both,,,3793.12,2465.53,,,,,,,,,,,,,
SUPPORT ORTHOT FT LOWER EXTREMITY INSERT/PLATE PREPREG COMP,SUP-2435704,CDM,L3031,HCPCS,0274,RC,,,,both,,,346.72,225.37,,,,,,,,,,,,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,0636,RC,00469-3051-30,NDC,,both,1,UN,938.50,610.02,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THN 1CMX2CM,SUP-2306888,CDM,C1762,CPT,0278,RC,,,,both,,,356.26,231.57,,,,,,,,,,,,,
SCREW BONE L83MM OD3.5MM 6 CRUCFRM COARSE THRD WDRUFF,SUP-2362308,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
IMMOBILIZER SHLDR L FOR 40-44IN RIB FOAM WRST NYL HUM CUF E,SUP-2196922,CDM,L3650,HCPCS,0274,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
CATHETER ETER HAD 12FR L13CM STR EXTN 2 LUMN MAHRK ELITE,SUP-2613223,CDM,C1752,HCPCS,0278,RC,,,,both,,,125.35,81.48,,,,,,,,,,,,,
RING EXT FIX HALF 210 MM 6 TAB ALUM RINGFIX,SUP-2530905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4510.30,2931.69,,,,,,,,,,,,,
PLATE BNE MESHED 51X51X1.5 MM SM GRID PLLA-PGA STRL,SUP-2480459,CDM,C1713,HCPCS,0278,RC,,,,both,,,3591.91,2334.74,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN 103MML HLX6 STNLSS STEEL STRGHT NRRW,SUP-2495950,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ANGIOSCULPT L 155 CM 100 MM 2 MM,SUP-2353226,CDM,C1725,HCPCS,0272,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 30X20 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838619,CDM,C1763,HCPCS,0278,RC,,,,both,,,55681.93,36193.25,,,,,,,,,,,,,
STAPLE BONE FIX 8MM WIRE 1.6X1.3MM ASMBLY SNIPER,SUP-2390573,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SCREW GLEN FIX SHLDR LCK RVS CNTRL BASEPLT EQUINOXE,SUP-2908865,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
FORCEPS BX STD 7FR L50CM SHFT 2.3MM OVL CUP SERR INT JUG,SUP-2157335,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
CATHETER REPROC BW HALO XP DIAP EP 7FR,SUP-2473832,CDM,C1731,HCPCS,0278,RC,,,,both,,,1092.78,710.31,,,,,,,,,,,,,
CANNULA SRGCL PRCTNS 4.5/5.5MM SCREW NON ST,SUP-2484113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,994.75,646.59,,,,,,,,,,,,,
BIT DRL 29X140 MM,SUP-2644591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,283.23,184.10,,,,,,,,,,,,,
GRAFT HUM TISS TEND GRACILIS,SUP-2165546,CDM,C1713,HCPCS,0278,RC,,,,both,,,4044.32,2628.81,,,,,,,,,,,,,
HC Treat Lower Leg Fx,PX-4502782500,CDM,27825,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
ALUM SULFATE-CA ACETATE EX PACK,RX-9020,CDM,6370000000,HCPCS,0637,RC,57074-0001-77,NDC,,both,1,UN,3.00,1.95,,,,,,,,,,,,,
INSERTER SURG STR IN 28 CM SHFT,SUP-2140253,CDM,C2631,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR (MIXTURES ONLY),RX-430071,CDM,J2919,HCPCS,0636,RC,00009-0039-28,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
COMPONENT HUM REG DIA35MM W7XL7MM OFFSET CO CHROM ARTC,SUP-2123553,CDM,C1776,CPT,0278,RC,,,,both,,,13611.90,8847.73,,,,,,,,,,,,,
KIT GUID NDL C95,SUP-2164587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
ODH 56MM ACETABULAR LINER,SUP-2830375,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SET DILATOR DIA4 5 6 6FR SALIVARY ACCESS OTOLARYNGOLOGY,SUP-2874849,CDM,C1894,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
INSERT TIB XSM 8MM DST FEM ALL POLY ROT HNG KNEE KINEMATIC,SUP-2376391,CDM,C1776,CPT,0278,RC,,,,both,,,3642.71,2367.76,,,,,,,,,,,,,
BIT DRL GRAD 10-12 MM 177665] ORTHOFIX INC],SUP-2316013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
MICRO PLATE 4 X 4 HOLES RCTNGLR SGMNTS 6MM 15MM SSTM CP TT,SUP-2677442,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.59,786.23,,,,,,,,,,,,,
ROCKER SPNL FOR OD4.5MM SCR ROD REDUC CD HORZ LEG,SUP-2290304,CDM,C1713,HCPCS,0278,RC,,,,both,,,3155.86,2051.31,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 4.5 CM FLX TIP L,SUP-2167749,CDM,C1769,HCPCS,0272,RC,,,,both,,,70.68,45.94,,,,,,,,,,,,,
KIT THR R 15 TIB 15 FEM KNEE RESECT GUID SPEC 2 TRUMATCH,SUP-2252922,CDM,C1713,HCPCS,0278,RC,,,,both,,,4052.48,2634.11,,,,,,,,,,,,,
HC Venous Sampling Through Cath,PX-3207589300,CDM,75893,CPT,0320,RC,,,,both,,,7130.00,4634.50,,,,,,,,,,,,,
SCREW BNE L 130 MM DIA 7 MM LG CANN HDLSS STRL,SUP-2931454,CDM,C1713,HCPCS,0278,RC,,,,both,,,1131.22,735.29,,,,,,,,,,,,,
MARKER FIDUCIAL IMPLT G SFT TISS 12MM 1 NDL W 2 MRK SPC,SUP-2418128,CDM,A4648,CPT,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR,RX-10581,CDM,J2919,HCPCS,0636,RC,00009-0758-01,NDC,,both,1,UN,139.70,90.80,,,,,,,,,,,,,
AID HEARING BONE ANCHORED 6 MAX BRN,SUP-2823403,CDM,L8690,HCPCS,0278,RC,,,,both,,,13282.20,8633.43,,,,,,,,,,,,,
DEVICE OCCL CLP L45MM PLUNG GRP FLX SHFT FOR GILLINOV,SUP-2540328,CDM,C1889,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
MESH HERN W30.5XL35.6CM POLYPR PTFE NONABSORBABLE RECTANG,SUP-2125912,CDM,C1781,HCPCS,0278,RC,,,,both,,,6562.60,4265.69,,,,,,,,,,,,,
ROD 350MM LNG FOR ORTHOFIX PREFIX FIX,SUP-2316293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.23,396.65,,,,,,,,,,,,,
DILATOR ENDOSCP ADV L 80 CM DIA 5 FR BALLOON L 4 CM DIA 8 MM,SUP-2880206,CDM,C1726,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CHOLECALCIFEROL 10 MCG/ML PO LIQD,RX-147756,CDM,340b,HCPCS,0637,RC,99992-0510-01,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
WASHER SLT FOR SHEFFIELD STERILISATION TY SYS,SUP-2316260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.16,574.05,,,,,,,,,,,,,
RESIN VERTEBROPLASTY ACRYL SECOUR,SUP-2342138,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CHLORPROMAZINE HCL 25 MG PO TABS,RX-1656,CDM,6370000000,HCPCS,0637,RC,50268-0163-11,NDC,,both,1,UN,10.10,6.56,,,,,,,,,,,,,
ANCHOR SUTURE L12MM OD4MM ID1.8MM PRE THREADED WITH SINGLE N,SUP-2828526,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.99,393.89,,,,,,,,,,,,,
SYSTEM THROMCTMY CLN XT L 135 CM DIA 6 FR GUIDEWIRE 0.035 IN,SUP-2120127,CDM,C1724,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST POS LCK,SUP-2435609,CDM,L1831,HCPCS,0272,RC,,,,both,,,833.23,541.60,,,,,,,,,,,,,
PLATE BNE SM W11XL124MM THK34MM 9 H BILAT TI RIG NEUT LOK,SUP-2190783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1047.82,681.08,,,,,,,,,,,,,
ANCHOR SUT L14.7MM DIA5.5MM BIOCOMPOSITE W/ 3 SZ 2,SUP-2121541,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
WIRE FIX TRCR PT 1.2X150 MM KIRSCHNER,SUP-2267993,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
RING EXT FIX LNG 180 MM SET HEX RX STRUT TRUELOK EVO LTX,SUP-2875595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30964.17,20126.71,,,,,,,,,,,,,
BIT DRL L 135 MM DIA2.7 MM SCREW DIA2.7 MM AO QC DBL CLR BND,SUP-2908230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,766.54,498.25,,,,,,,,,,,,,
EXPANDER TISS GEL 7.1 CM PROJCT 14X13 CM 600 CC MOD HT X,SUP-2418551,CDM,C1789,HCPCS,0278,RC,,,,both,,,5099.36,3314.58,,,,,,,,,,,,,
EYE WASH OP SOLN,RX-3000,CDM,6370000000,HCPCS,0637,RC,00536-1224-97,NDC,,both,118,ML,13.90,9.03,,,,,,,,,,,,,
IMPLANT SUBTALAR L12MM DIA7MM ANK JT FOR ARTHROERESIS,SUP-2121852,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
TUBE EXT FIX 20X640 MM MONOTUBE TRIAX,SUP-2480847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9091.24,5909.31,,,,,,,,,,,,,
CATHETER ART DL 0.025 IN 7 FRX110 CM PULM HEPCOAT LTX,SUP-2662680,CDM,C1751,HCPCS,0278,RC,,,,both,,,118.69,77.15,,,,,,,,,,,,,
FORCEPS ELECSURG CUT L33CM OD5MM EVEREST,SUP-2312646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CATHETER HD CRV EXTN 11 FRX12 CM CATH NDL DUOFLO,SUP-2627068,CDM,C1752,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-ENTERIC 24 FRX57.9 CM SECUR-LOK MIC,SUP-2764445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.34,365.52,,,,,,,,,,,,,
SET DRNGE L41CM OD18FR ABCESS MP LOOP SGL LUMN RADPQ,SUP-2168141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,303.86,197.51,,,,,,,,,,,,,
GRAFT BNE L60MM FEM SHFT FRZ DRY MATRIGRFT,SUP-2264750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2312.48,1503.11,,,,,,,,,,,,,
GRAFT VASC DURAGN SECUR L 1 X W 1 IN DURA REGEN MTRX STRL,SUP-2500914,CDM,C1763,HCPCS,0278,RC,,,,both,,,1021.10,663.71,,,,,,,,,,,,,
LEAD PACE QPLR 2.6 FRX95 CM 3D SPRL TINES IS4-LLLL ACUITY X4,SUP-2148717,CDM,C1900,HCPCS,0275,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
SCREW BNE L90MM DIA5MM CANN LOK,SUP-2184922,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 12X3X1.5 MM LP CONTOURED TI STRL,SUP-2472581,CDM,C1713,HCPCS,0278,RC,,,,both,,,768.55,499.56,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV IR 4FR 55CM 2 LUMAN RVS 3274355,SUP-2632666,CDM,C1751,HCPCS,0278,RC,,,,both,,,461.20,299.78,,,,,,,,,,,,,
SLING SHLDR PCH 13X19IN SWTH 5X54IN UNIV FOAM ADJ STRP,SUP-2195491,CDM,L3660,HCPCS,0272,RC,,,,both,,,30.33,19.71,,,,,,,,,,,,,
PLATE BONE THK0.8MM 3 H HND ROT TRILOK FOR 1.5MM SCR APTUS,SUP-2267905,CDM,C1713,HCPCS,0278,RC,,,,both,,,1732.24,1125.96,,,,,,,,,,,,,
SHEATH INTRO CHARIOT L 45 CM DIA 5 FR STR TIP XCUT LG LUMEN,SUP-2140841,CDM,C1725,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE BNE INTERCARPAL 2.4X15 MM 6 HOLE VA LCK FUSION SS NS,SUP-2799113,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.74,2031.08,,,,,,,,,,,,,
HEAD FEM MOD 0+ MM STD 32 MM 9/10 MM HIP TAPR ELITE,SUP-2456454,CDM,C1776,CPT,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
ALLOGRAFT SKIN MESHED HUM TISS,SUP-2165585,CDM,C1762,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 6.6 FRX90 CM 0.7 CC PEEL APART BRVC,SUP-2127878,CDM,C1751,HCPCS,0278,RC,,,,both,,,976.76,634.89,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L480CM 0.018IN TIP L3CM PLAT SPR COIL TIP,SUP-2169364,CDM,C1769,HCPCS,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
SPLINT TRAC 12IN UNIV 3 PNL KNEE,SUP-2196752,CDM,L1830,CPT,0272,RC,,,,both,,,56.58,36.78,,,,,,,,,,,,,
SCREW BNE L30MM OD6.5MM TI BICORT ACL PCL POST ST CANN,SUP-2121132,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SCREW BNE ST 2X11 MM LCK W/ STARDRV RECESS SS NS LCP,SUP-2183311,CDM,C1713,HCPCS,0278,RC,,,,both,,,308.91,200.79,,,,,,,,,,,,,
SEED BRACHYTHERAPY FOR LOAD,SUP-2247275,CDM,C2642,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
DEFIBRILLATOR IMPL TELIGEN VR TI SINGLE CHMBR RF HI ENERGY,SUP-2149135,CDM,C1722,HCPCS,0275,RC,,,,both,,,51025.00,33166.25,,,,,,,,,,,,,
PLATE BNE W10.2XL182MM THK2.7MM 14 H BILAT S STL STR LO,SUP-2186201,CDM,C1713,HCPCS,0278,RC,,,,both,,,1762.64,1145.72,,,,,,,,,,,,,
PLATE BNE W6XL30MM 16 H CRANIOMAXILLOFACIAL TI STRUT FOR,SUP-2190566,CDM,C1713,HCPCS,0278,RC,,,,both,,,2024.36,1315.83,,,,,,,,,,,,,
BUR ORTH L 13 MM DIA2.9 MM WDG 3 STRL DISP,SUP-2896776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT FASC LATA 15CMX3MM,SUP-2307103,CDM,C1762,CPT,0278,RC,,,,both,,,778.28,505.88,,,,,,,,,,,,,
PATCH CV VASCU-GUARD L 9 X W 2 CM BOV PERICARD PERIPH STRL,SUP-2129977,CDM,C1768,CPT,0278,RC,,,,both,,,752.85,489.35,,,,,,,,,,,,,
KIT INTRO MAC SHTH L 11.5 CM DIA 9 FR POLYUR LIDO CV 3 LUMEN,SUP-2763402,CDM,C1892,HCPCS,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
SCREW EXT FIX L260MM SHFT DIA6MM THRD L50MM DIA6 56MM HA,SUP-2316319,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.84,276.15,,,,,,,,,,,,,
SET IRR ARTHSCP FLD PMP,SUP-2166212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
SCREW BNE NLCK 2.7X24 MM SQ DRVR DVR,SUP-2470347,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
SET INTRO FLX L 38.5 CM OD 10 FR GUIDEWIRE 0.035 IN CKFLO,SUP-2168822,CDM,C1894,HCPCS,0272,RC,,,,both,,,284.14,184.69,,,,,,,,,,,,,
CUBE EXT FIX TWO HOLE SS,SUP-2162666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,592.83,385.34,,,,,,,,,,,,,
NAIL IM L420MM DIA8MM UNIV DK BLU PROX TIB TI BEND CANN LOK,SUP-2180392,CDM,C1713,HCPCS,0278,RC,,,,both,,,4731.67,3075.59,,,,,,,,,,,,,
BRA SURG LG 40-42IN WHT LYCRA FR HK AND LOOP CLSR WIDE ADJ,SUP-2336338,CDM,L8000,HCPCS,0274,RC,,,,both,,,107.61,69.95,,,,,,,,,,,,,
GRAFT VASC ALBOGRAFT L 100 CM DIA 8 MM POLYESTER STR KNITTED,SUP-2601079,CDM,C1768,CPT,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA10 MM STR STD WALL HELIX,SUP-2476734,CDM,C1768,CPT,0278,RC,,,,both,,,2791.99,1814.79,,,,,,,,,,,,,
SCREW INTRF L25MM OD7MM TI ACL CANN BLNT THRD NONABSORBABLE,SUP-2362041,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SCREW BNE L 70 MM DIA 7 MM LG CANN HDLSS STRL,SUP-2931688,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.17,622.16,,,,,,,,,,,,,
CATHETER GUID AMPLATZER TREVISIO L 80 CM DIA12 FR SHTH OD,SUP-2574332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2069.26,1345.02,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF PEDIATRIC 5X200 MM 50 MM ANKLE FO,SUP-2836746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6685.53,4345.59,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5 MM UNIV LCK,SUP-2861482,CDM,C1713,HCPCS,0278,RC,,,,both,,,23053.38,14984.70,,,,,,,,,,,,,
GRAFT BNE SUB 25CC 1 4MM DEMIN CANC SPNG CHIP FLEXIGRFT,SUP-2264610,CDM,C1713,HCPCS,0278,RC,,,,both,,,940.46,611.30,,,,,,,,,,,,,
HEAD HUM RESURF 47 MM SHLDR EQUINOXE,SUP-2451410,CDM,C1776,CPT,0278,RC,,,,both,,,9404.93,6113.20,,,,,,,,,,,,,
PLATE BONE ADAPTION 1.6X0.5 MM 20 HOLE STRAIGHT FOR SCREW LO,SUP-2838363,CDM,C1713,HCPCS,0278,RC,,,,both,,,1998.92,1299.30,,,,,,,,,,,,,
PACEMAKER CARD W 8.6 X H 20.3 CM D 4.45 CM 680 GM 2 CHMBR,SUP-2278429,CDM,C1785,HCPCS,0275,RC,,,,both,,,17013.84,11059.00,,,,,,,,,,,,,
SCREW BNE ST 2X5 MM EMGCY W/ PLUSDRIVE RECESS TI MTRX TEAL,SUP-2188976,CDM,C1713,HCPCS,0278,RC,,,,both,,,246.18,160.02,,,,,,,,,,,,,
BIT DRL L50MM DIA1.8MM STP 22MM FOR LORENZ MAND PLATING SYS,SUP-2136818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
RING EXT FIX DIA180 MM SPEEDWIRE FULL,SUP-2898417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
BEAM FIX L75MM DIA7.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223953,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SCREW BNE CANN 7.3X35 MM LCK,SUP-2340731,CDM,C1713,HCPCS,0278,RC,,,,both,,,1807.04,1174.58,,,,,,,,,,,,,
FIBER LASER 940 MICRON 3/PKG STERILE INCLUDES 1,SUP-2574065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1484.12,964.68,,,,,,,,,,,,,
PLATE BNE L 118 SCREW DIA 3.5 MM 10 H TI RECON NS,SUP-2908832,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.10,1157.71,,,,,,,,,,,,,
PLATE BNE CALCANEOCUBOID SM RT STRATUM,SUP-2474069,CDM,C1713,HCPCS,0278,RC,,,,both,,,4430.54,2879.85,,,,,,,,,,,,,
STAPLER INT CIR XL EXTRA THICK 31 MM 4-5 MM BLK EEA,SUP-2787721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5211.33,3387.36,,,,,,,,,,,,,
HC ED Clsd Manip Tibial Shaft Fx,PX-4502775200,CDM,27752,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
BIT DRL L145MM DIA3.2MM ST QUIK CPL W/O STP REUSE,SUP-2187256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.15,232.80,,,,,,,,,,,,,
KIT TKR HYBRID TRABECULAR MTL FEM CEM TIB VIT E SURF AND STD,SUP-2212235,CDM,C1776,CPT,0278,RC,,,,both,,,16682.82,10843.83,,,,,,,,,,,,,
GRAFT BONE VIABLE CELL BONE MTRX 15CC CELLENTRA,SUP-2402616,CDM,C1713,HCPCS,0278,RC,,,,both,,,17687.62,11496.95,,,,,,,,,,,,,
SCREW BNE L110MM OD3.5MM S STL CORT ST NONLOK FULL THRD LO,SUP-2348357,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.55,190.16,,,,,,,,,,,,,
CATHETER ABLAT IRRIG 4MM TIP THRMCPL 7FR QPLR,SUP-2357657,CDM,C1730,HCPCS,0272,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
COIL EMB L10CM OD2MM 360DEG HELCL USFT STRTCH RESIST BIG,SUP-2365766,CDM,C1889,HCPCS,0278,RC,,,,both,,,6464.00,4201.60,,,,,,,,,,,,,
GUN BNE CEM DEL SZ 2 W/ BNE FILL DEV FOR KYPHOPAK TY KYPHON,SUP-2293482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COIL NEUROVASCULAR L 6 CM DIA 3 MM PLAT TUNGSTEN STD,SUP-2884370,CDM,C1889,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
HC Basic Radiation Dosimetry Calc,PX-3337730000,CDM,77300,CPT,0333,RC,,,,both,,,586.00,380.90,,,,,,,,,,,,,
BLADE ENDO SHV DIA4MM 30DEG ANG SINUS CVD SERR CONCV WIND,SUP-2312774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.79,226.06,,,,,,,,,,,,,
COMPONENT FEM SZ 3 L KNEE CO CHROM CRUCE RET NP PRI CEM,SUP-2346615,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SEMI-TUBULAR PLATE 10X167MM,SUP-2820878,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
BLADE SAW OSCILLATING 63X49X0.6 MM 0.6 MM FOR LG BNE HALL,SUP-2607472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
SCREW BNE L55MM DIA4MM CANC TI NONLOCKING FOR SM FRAG,SUP-2412088,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
ROD REPROC EXT FIX HYBRID 8X240 MM CARBON FIBER,SUP-2188745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CLIP INT USE THRD L 165 CM ENDOSCP DIA 8.5-11 MM CAP D 7 MM,SUP-2881908,CDM,C1889,HCPCS,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
BROACH SURG LESSER ENCOMPASS,SUP-2319783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
PLATE BNE L55MM 7X3 H R VOLAR DST RAD S STL VAR ANG LOK,SUP-2184123,CDM,C1713,HCPCS,0278,RC,,,,both,,,2191.06,1424.19,,,,,,,,,,,,,
PROSTHESIS OSS FISCH TYP PISTON 0.4X6 MM PLAT RIBBON,SUP-2637813,CDM,L8613,CPT,0278,RC,,,,both,,,491.57,319.52,,,,,,,,,,,,,
SPACER SPNL LUM 12MMX26MMX9-13MM CALIB,SUP-2231995,CDM,C1821,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 38 X 50 X 1.5 MM POLYETHYL ORBIT FLR SHT,SUP-2935201,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS 3X200 MM FRZN GRACILIS TEND,SUP-2264583,CDM,C1713,HCPCS,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
SYSTEM BLLN DIL L16MM DIA6MM FOR EUSTACHIAN TB,SUP-2106342,CDM,C1726,HCPCS,0272,RC,,,,both,,,8280.81,5382.53,,,,,,,,,,,,,
SCREW CANN COMPR 22MM 10MM,SUP-2268244,CDM,C1713,HCPCS,0278,RC,,,,both,,,1033.63,671.86,,,,,,,,,,,,,
STEM HUM STD 9 MM SHLDR NP AFFINITI,SUP-2715299,CDM,C1776,CPT,0278,RC,,,,both,,,15440.95,10036.62,,,,,,,,,,,,,
CATHETER KT CTRL VEN PICC DBL LUMN,SUP-2164394,CDM,C1751,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL PREFABRICATED FLEXION,SUP-2388150,CDM,L0633,HCPCS,0274,RC,,,,both,,,738.50,480.02,,,,,,,,,,,,,
GRAFT SFT TISS 2CC SCAFFOLD FLOWABLE CLLGN FOR HRD TO ACC DP,SUP-2399102,CDM,Q4113,HCPCS,0636,RC,,,,both,,,4668.49,3034.52,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM,SUP-2749879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2816.58,1830.78,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RANG L 150 CM BALLOON L 120 MM DIA 5 MM,SUP-2754437,CDM,C2623,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
BASKET STONE REM 1.5FR L120CM SHTH DIA12MM NIT POLYIMIDE,SUP-2336364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.50,501.47,,,,,,,,,,,,,
CONNECTOR ROD LG CROSSBAR AX SS,SUP-2245533,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
HC Pain Major,PX-3600007516,CDM,3600007516,LOCAL,0360,RC,,,,inpatient,,,2879.00,1871.35,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L480CM DIA0.021IN TIP L5CM HYDRPHLC COAT,SUP-2169615,CDM,C1769,HCPCS,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
BONE GRAFTING KIT UNILAT CELLULAR BNE MTRX VIVIGEN MIS,SUP-2740944,CDM,C1713,HCPCS,0278,RC,,,,both,,,11099.02,7214.36,,,,,,,,,,,,,
GRAFT DURA L 1 X W 1 IN TYP I CLLGN BOV ACHILLES TEND RESRB,SUP-2889750,CDM,C1763,HCPCS,0278,RC,,,,both,,,882.53,573.64,,,,,,,,,,,,,
STEM FEM L160MM DIA13.5MM 12/14 TAPR HIP 5/8 POR TRIANG STD,SUP-2252067,CDM,C1776,CPT,0278,RC,,,,both,,,11008.84,7155.75,,,,,,,,,,,,,
PIN FIX 2X50 MM STRL INION FREEDOMPIN LTX DISP,SUP-2857895,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
BALLOON KYPHOPLASTY AUG SYS SZ 2 L15MM W/ 10GA NDL IVAS,SUP-2367064,CDM,C1727,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
HEAD FEM REV +8 MM 26 MM HIP PRIMARY INCREASED TAPR COCR,SUP-2375218,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER GUID NAVICROSS L 150 CM DIA 1.39 MM L 40 CM ANGLED,SUP-2385616,CDM,C1887,HCPCS,0272,RC,,,,both,,,717.49,466.37,,,,,,,,,,,,,
PROSTHESIS PENILE L 21 CM X W 12 MM PMP INFLATABLE,SUP-2930692,CDM,C1813,HCPCS,0278,RC,,,,both,,,42481.85,27613.20,,,,,,,,,,,,,
SET URET STENT SOFFLX L 12 CM DIA 4.7 FR POS L 50 CM DIA 4.7,SUP-2168902,CDM,C2617,HCPCS,0278,RC,,,,both,,,317.77,206.55,,,,,,,,,,,,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,2500000003,HCPCS,0250,RC,70069-0271-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % PO SOLN,RX-9828,CDM,Q9963,HCPCS,0636,RC,00270-0445-40,NDC,,both,5,ML,0.50,0.32,,,,,,,,,,,,,
IMPLANT BIO TISS W25XL40CM 1000SQCM PORCINE RECON PERF MTRX,SUP-2113247,CDM,C1781,HCPCS,0278,RC,,,,both,,,99016.76,64360.89,,,,,,,,,,,,,
BLADE SHAVER CLOSED 40 DEG 4 MM MALL STRL DISP,SUP-2648977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.12,304.93,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC DBM FIBER INTERGRO,SUP-2691578,CDM,C1713,HCPCS,0278,RC,,,,both,,,4917.24,3196.21,,,,,,,,,,,,,
HC Assay of Parathormone,PX-3018397000,CDM,83970,CPT,0301,RC,,,,both,,,308.00,200.20,,,,,,,,,,,,,
PILOCARPINE HCL 1 % OP SOLN,RX-6279,CDM,6370000000,HCPCS,0637,RC,69238-1745-08,NDC,,both,15,ML,283.80,184.47,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST + DRV,SUP-2189323,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.96,172.87,,,,,,,,,,,,,
GRAFT SFT TISS W5XL19.2CM SPNL HUM FRZN FASC LATA,SUP-2113899,CDM,C1762,CPT,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
PLATE BNE RIGID 4.5X138 MM BILATERAL 4X6 HOLE NC STBL STRL,SUP-2186750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2453.82,1594.98,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 20 MM DIA 6 MM CATH L 130 CM DIA 6,SUP-2420389,CDM,C1876,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
DEVICE TORQUE GUIDEWIRE 0.009-0.18 IN FOR CORONARY STRL,SUP-2105882,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.177X9 IN THRD RND END NS STEINMANN,SUP-2791403,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.21,53.44,,,,,,,,,,,,,
CATHETER SPHINTOM DBL LUMN SIZE: 6F,SUP-2169383,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
BIT DRL L20MM DIA5 73MM THRD STP W O STP NONRADIOLUCENT,SUP-2179057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1496.27,972.58,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 INX150 CM 3 CM 6 FRX30 CM POLARIS,SUP-2465195,CDM,C2617,HCPCS,0278,RC,,,,both,,,681.82,443.18,,,,,,,,,,,,,
SPLINT 31 TIB FIB PD PERF COAT ALUM FOAM LNR HIP AD,SUP-2210446,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
CONNECTOR SPNL SZ 5 L55MM STD POST S STL FIX TRNSVRS CONN,SUP-2254368,CDM,C1713,HCPCS,0278,RC,,,,both,,,3475.98,2259.39,,,,,,,,,,,,,
SPHERE GLEN DIA38MM REG STD SHLDR CO CHROM LOK SCR PRI REV,SUP-2223371,CDM,C1776,CPT,0278,RC,,,,both,,,4266.63,2773.31,,,,,,,,,,,,,
CATHETER INTVASC OCCL ASCNT L 150 CM 2.9 FR 0.0170 IN 7 MM,SUP-2458036,CDM,C2628,HCPCS,0272,RC,,,,both,,,6208.72,4035.67,,,,,,,,,,,,,
MESH HERN PTCH 3.5X1.8 IN PRESHAPE ONLAY KNITTED PROLITE,SUP-2227233,CDM,C1781,HCPCS,0278,RC,,,,both,,,126.10,81.96,,,,,,,,,,,,,
STENT ES L12CM DIA18MM PROX FLARE DIA23MM CVR L9CM DST REL,SUP-2149380,CDM,C1874,HCPCS,0278,RC,,,,both,,,5352.60,3479.19,,,,,,,,,,,,,
BIT DRL L23X3MM STP TUNGSTEN CARB CANN RELF DISPOSABLE,SUP-2243910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.43,381.83,,,,,,,,,,,,,
PLATE BNE L85MM 6 H NONSTERILE L PROX TIB S STL LO PROF,SUP-2185812,CDM,C1713,HCPCS,0278,RC,,,,both,,,3722.91,2419.89,,,,,,,,,,,,,
SET PUNC L12.5MM DIA20FR PHARYNX PROTCT NDL GWIRE DIL DISP,SUP-2124377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1260.68,819.44,,,,,,,,,,,,,
SUPPORT SHLDR M L36-40IN UNIV CHST NEOPRENE BLK HUM CUF 61460601] PERFORMANCE HEALTH INC],SUP-2324516,CDM,L3675,HCPCS,0274,RC,,,,both,,,160.45,104.29,,,,,,,,,,,,,
PROSTHESIS OSS MIC 3X3 MM 1 MM MONOLITHIC CENTERED TI PORP,SUP-2638135,CDM,L8613,CPT,0278,RC,,,,both,,,1078.50,701.02,,,,,,,,,,,,,
SURFACE ARTC 3-4 CH THK10MM AP42MM ML66MM REG YEL UHMWPE,SUP-2201354,CDM,C1776,CPT,0278,RC,,,,both,,,3683.22,2394.09,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X33X1.5 MM 4 HOLE FRAC TI STRL LEVEL 1,SUP-2475303,CDM,C1713,HCPCS,0278,RC,,,,both,,,1503.18,977.07,,,,,,,,,,,,,
NEEDLE BRST LOC REPOSITIONABLE 20GA X 10CM HOMER,SUP-2120046,CDM,C1819,HCPCS,0278,RC,,,,both,,,105.19,68.37,,,,,,,,,,,,,
NAIL IM HD LNG VANGUARD 360,SUP-2445060,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
SLEEVE TIB SZ 29 H40MM AP26MM ML29MM MTPHSEAL TI PORCOAT,SUP-2250947,CDM,C1776,CPT,0278,RC,,,,both,,,6886.65,4476.32,,,,,,,,,,,,,
GRAFT EVAR L82MM DIA20X20MM IL C DSGN ENDURANT II,SUP-2295237,CDM,C1768,CPT,0278,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
BIT DRL L190MM DIA11MM ST TI CANN QUIK CPL W/O STP,SUP-2188297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1823.30,1185.14,,,,,,,,,,,,,
MULTIPLE VITAMINS PO TABS,RX-5225,CDM,6370000000,HCPCS,0637,RC,00904-0539-61,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
WIRE FIX UNIV 23 MM FOR BOLT SS,SUP-2162664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.65,292.27,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 5 FRX130 CM 4X120 MM LUTONIX BSLX3513041205F] BARD PERIPHERAL VASCULAR],SUP-2127968,CDM,C2623,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
IMPLANT BIO TISS W7XL10CM WND MTRX FEN MATRISTEM,SUP-2106523,CDM,Q4166,HCPCS,0636,RC,,,,both,,,827.70,538.00,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.078X9 IN 3 SHANK END SS NS STEINMANN,SUP-2791828,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.84,20.70,,,,,,,,,,,,,
BODY FEM SZ 16.5 LNG L HA DST TEXT APR,SUP-2211011,CDM,C1776,CPT,0278,RC,,,,both,,,29170.60,18960.89,,,,,,,,,,,,,
LINER ACET OD50MM ID28MM 10DEG NEUT MARATHON CEMENTLESS,SUP-2250506,CDM,C1776,CPT,0278,RC,,,,both,,,3636.12,2363.48,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0258,RC,00990-7984-20,NDC,,both,1000,ML,1164.50,756.92,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 30 CM DIA24 MM THK 0.38 MM POLYESTER,SUP-2695249,CDM,C1768,CPT,0278,RC,,,,both,,,1570.13,1020.58,,,,,,,,,,,,,
TREPHINE BONE RMR 14X8MM,SUP-2136783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1508.77,980.70,,,,,,,,,,,,,
MESH CRAN W100XL100MM THK0.5MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194072,CDM,C1781,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
LENS INTOCU +10.5 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111162,CDM,V2632,HCPCS,0276,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
IMPLANT ANK JT BRL PATENTED SLT DSGN SUBTALAR MBA TI,SUP-2242695,CDM,C1776,CPT,0278,RC,,,,both,,,6938.36,4509.93,,,,,,,,,,,,,
IMPLANT HUM TISS RT MEDL MENIS BNE BLOCK GLD STD,SUP-2881311,CDM,C1762,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
HC I&D Abscess Vulva Perineum,PX-4505640500,CDM,56405,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SPACER SPNL W10XH7XL27MM 0DEG PEEK PARA LAT THORLUM INTBDY,SUP-2194086,CDM,C1821,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
ROD EXT FIX L30MM DIA3MM MINI C CONN FOR MIC SYS HOFFMANN,SUP-2372513,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
NAIL IM L360MM DIA10MM 130DEG NONSTERILE GRN FEM TI CANN,SUP-2192596,CDM,C1713,HCPCS,0278,RC,,,,both,,,3974.99,2583.74,,,,,,,,,,,,,
BUR SURG STD MED 60 K 4 MM HI SPD STRL UNIDRIVE DISP,SUP-2599308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.90,394.48,,,,,,,,,,,,,
STENT URET 6FR L28CM PERCFLX HYDR+ SFT LOOP 2 DUROMETER,SUP-2139608,CDM,C2617,HCPCS,0278,RC,,,,both,,,494.61,321.50,,,,,,,,,,,,,
INSERT TIB SZ 2-3 THK11MM LT KNEE HNG GUID MOTN LEGION,SUP-2346670,CDM,C1776,CPT,0278,RC,,,,both,,,7529.72,4894.32,,,,,,,,,,,,,
HC So Giardia Antigen,PX-3068732966,CDM,87329,CPT,0306,RC,,,,both,,,423.00,274.95,,,,,,,,,,,,,
MESH BONE 50MMW X 50MML 03MM THK TTNM 3D LATEX FREE MXLFCL,SUP-2681428,CDM,C1713,HCPCS,0278,RC,,,,both,,,4279.76,2781.84,,,,,,,,,,,,,
ORTHOSIS ADDITION TO LO EXT VARUS VALGUS CORR PLAS MOD,SUP-2237271,CDM,L2275,HCPCS,0274,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
PLATELET CONCENTRATION KIT ERYTHROCYTE MAR STRL DISP,SUP-2417287,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
DRILL SURG PNEUMATIC 6000 RPM ELEC RT HND NS SABER,SUP-2898898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.87,633.02,,,,,,,,,,,,,
COLLAR PREMIER PRO CERV UNIV ADJ CLS CELL FOAM LNR L TRACH,SUP-2336010,CDM,L0140,HCPCS,0274,RC,,,,both,,,14.10,9.16,,,,,,,,,,,,,
STENT BILI C FLX L 15 CM DIA10 FR PLAS DBL PIGTL AD GRA STRL,SUP-2141398,CDM,C2617,HCPCS,0278,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
DEVICE LASER DEL LNG ENT ANGLED OTOPROBE 10706] FORTEC MEDICAL INC],SUP-2225657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
HC Fibrinogen Activity,PX-3058538400,CDM,85384,CPT,0305,RC,,,,both,,,272.00,176.80,,,,,,,,,,,,,
SHEARS SEAL L17CM LNG ULTRASONIC CRV TIP HARM FOCS,SUP-2219098,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.01,971.11,,,,,,,,,,,,,
EXTRACTOR ENDOSCP SM 11X35 MM VAG BALL SPHR AUTO CLICKLINE,SUP-2776255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2439.00,1585.35,,,,,,,,,,,,,
NAIL IM 8X285 MM TIB TI STRL EXPERT,SUP-2179811,CDM,C1713,HCPCS,0278,RC,,,,both,,,4001.62,2601.05,,,,,,,,,,,,,
KIT PRSS MON L84IN DBL VAMP +,SUP-2214664,CDM,C1713,HCPCS,0278,RC,,,,both,,,146.95,95.52,,,,,,,,,,,,,
SCREW INTFR 5X10MM IORT TEND TENSIONING SUP FIX STRENGTH,SUP-2399118,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
GUIDEWIRE VASC MIC KT ACCS STRL,SUP-2117208,CDM,C1769,HCPCS,0272,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 4FR 55CM 2 LUMAN R S3274108,SUP-2632840,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.52,321.44,,,,,,,,,,,,,
INSTRUMENT SET EXTN ON DEMAND SET,SUP-2267690,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SUPPORT ANK UNIV AIR FOAM STRRP,SUP-2276705,CDM,L4350,HCPCS,0274,RC,,,,both,,,33.28,21.63,,,,,,,,,,,,,
CATHETER INTVASC OCCL ER-REBOA L 72 CM DIA 32 MM BALLOON,SUP-2417425,CDM,C2628,HCPCS,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
SCREW BNE L40MM DIA6MM CORT TI ST CANN LOK FULL THRD HEX HD,SUP-2191862,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.02,427.71,,,,,,,,,,,,,
APPLICATOR HEMOSTATIC CLLGN 2 CMX16.5 CM PRE LD ENDOAVITENE,SUP-2846978,CDM,C1763,HCPCS,0278,RC,,,,both,,,411.97,267.78,,,,,,,,,,,,,
HC Ins Ppm Only Exist Mult Leads,PX-4813322100,CDM,33221,CPT,0481,RC,,,,inpatient,,,65472.00,42556.80,,,,,,,,,,,,,
CUP ACET OD38MM ID22MM UHMWPE COMPR MOLD PVT BPLR,SUP-2314493,CDM,C1776,CPT,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
PLATE BNE TIB LG 0.2 CM,SUP-2321910,CDM,C1713,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
SCREW BNE LCK 14 MM AIRLOCK,SUP-2309315,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.99,343.19,,,,,,,,,,,,,
KIT CATH HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 12.5CML IN,SUP-2613232,CDM,C1752,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
DEVICE INFUS PERIPH EMER,SUP-2120632,CDM,C1751,HCPCS,0278,RC,,,,both,,,55.26,35.92,,,,,,,,,,,,,
SPLINT WRST FA Y L W O FOAM PD ALUMINUM PERF PREMOLDED DSGN,SUP-2195056,CDM,L3908,HCPCS,0274,RC,,,,both,,,13.75,8.94,,,,,,,,,,,,,
INDWELLING VOICE PROS L FLNG T,SUP-2242343,CDM,L8509,HCPCS,0272,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
SUPPORT ORTHOT CUST OUTRIG,SUP-2435578,CDM,L1080,HCPCS,0274,RC,,,,both,,,148.15,96.30,,,,,,,,,,,,,
ENDRING SPNL DIA10MM 0DEG TI RND PRESSFIT SYNMESH,SUP-2193237,CDM,C1889,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
HC CT Chest W/WO Contrast,PX-3527127000,CDM,71270,CPT,0352,RC,,,,inpatient,,,2630.00,1709.50,,,,,,,,,,,,,
SET INTRO L 7 CM DIA 5 FR MIC ACCS PEELWY STRL,SUP-2117377,CDM,C1892,HCPCS,0272,RC,,,,both,,,93.89,61.03,,,,,,,,,,,,,
PLATE BNE MIDFACE 40 MM DORA PLLA-PGA STRL RESORB XG,SUP-2479401,CDM,C1713,HCPCS,0278,RC,,,,both,,,4938.12,3209.78,,,,,,,,,,,,,
BUR SURG OD2 MM RND COARSE DMND F MOTORIZED RHINOSCOPIC,SUP-2363796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.65,284.47,,,,,,,,,,,,,
SLEEVE IM 100DEG LT BLU TI FOR SPRL BLDE FEM NAIL,SUP-2192712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1370.70,890.95,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.423,SUP-2859987,CDM,C1713,HCPCS,0278,RC,,,,both,,,37598.99,24439.34,,,,,,,,,,,,,
SK SLM CP ENC 4X7MM GRFT,SUP-2243077,CDM,C1713,HCPCS,0278,RC,,,,both,,,3545.06,2304.29,,,,,,,,,,,,,
SHAFT FEM TRAD ALLGRFT 200 MM FRZN,SUP-2294170,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
PLATE BONE L109MM 6 H RT SUP DSTL CLAV LCK FOR 3.5MM SCR,SUP-2348749,CDM,C1713,HCPCS,0278,RC,,,,both,,,6685.53,4345.59,,,,,,,,,,,,,
SHEATH THROMCTMY CATH INTHRILL L 6 CM DIA 8 FR STRL,SUP-2862338,CDM,C1894,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE 2 X 32 H MINI MIDFACE DBL STRP MALL,SUP-2883291,CDM,C1713,HCPCS,0278,RC,,,,both,,,5012.98,3258.44,,,,,,,,,,,,,
ROSUVASTATIN CALCIUM 40 MG PO TABS,RX-35136,CDM,6370000000,HCPCS,0637,RC,50268-0711-11,NDC,,both,1,UN,6.00,3.90,,,,,,,,,,,,,
WIRE FIX BNE TO BNE ANTR CERV LIGMNT KIRSCHNER,SUP-2362046,CDM,C1713,HCPCS,0278,RC,,,,both,,,1041.60,677.04,,,,,,,,,,,,,
PLATE BNE L239MM 15 H BILAT S STL STR NONCOMPRESSION RECON,SUP-2410186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.39,988.90,,,,,,,,,,,,,
BAG TISS CLSR DIA5CM TRNSPAR SIL SILO SPR LD PROX OPN SFT,SUP-2134673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
BIT SCRDRVR L24MM DIA2X2.4MM CANN DISP,SUP-2390534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KIT PROC W DRP AND DRUG COMP FOR PRTBL HANDHELD IMAGER,SUP-2419056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2028.47,1318.51,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZ DRY ALLGRFT HUM SHFT BNE 60MM LEN,SUP-2307199,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.83,1630.74,,,,,,,,,,,,,
INBONE  POLY SZ 5 20MM SULCUS TOTAL ANKLE,SUP-2492608,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
BUR SURG PRECIS 15 DEG 3 MMX12.5 CM RND DSTL BEND ORNG IBUR,SUP-2859500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
IMMOBILIZER SHLDR L L9X19.5IN R/L CANVS W/ WAIST STRP THMB,SUP-2336104,CDM,L3660,HCPCS,0272,RC,,,,both,,,20.88,13.57,,,,,,,,,,,,,
FIBER LASER E6783898] FORTEC MEDICAL INC],SUP-2225706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2804.02,1822.61,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.4MM S STL DISP PK FOR MINIMAL INVASIVE,SUP-2259523,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
HC Ot Electricl Stim Attended 15,PX-4309703200,CDM,97032,CPT,0430,RC,,,,outpatient,,,206.00,133.90,,,,,,,,,,,,,
PLATE BNE Y,SUP-2315932,CDM,C1713,HCPCS,0278,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
IMMOBILIZER ORTH T BAR UNIV 19 IN KNEE CANVS BLU REUSE,SUP-2336063,CDM,L1830,CPT,0272,RC,,,,both,,,38.12,24.78,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 4 FRX45 CM MAXIMAL BARR POWERPICC,SUP-2126367,CDM,C1751,HCPCS,0278,RC,,,,both,,,607.87,395.12,,,,,,,,,,,,,
PLATE BNE 1ST MTP 10 DEG 2.7 MM RT NS LTX,SUP-2857041,CDM,C1713,HCPCS,0278,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
KIT INTRO L 14 CM DIA10 FR GUIDEWIRE L 50 CM DIA 0.038 IN,SUP-2125278,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.34,67.17,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5CM 13MM 120CM 8FR HEPARIN,SUP-2610471,CDM,C1768,CPT,0278,RC,,,,both,,,9391.74,6104.63,,,,,,,,,,,,,
MARKER BREAST VISION TUMARK FOR BREVERA STD,SUP-2662949,CDM,A4648,CPT,0278,RC,,,,both,,,326.40,212.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.441,SUP-2860005,CDM,C1713,HCPCS,0278,RC,,,,both,,,48749.44,31687.14,,,,,,,,,,,,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,2500000003,HCPCS,0250,RC,00409-7299-73,NDC,,both,20,ML,64.40,41.86,,,,,,,,,,,,,
PRESSURE MONITORING TRAY 0.015 IN 25 FRX25 CM CATH NDL SYR,SUP-2167884,CDM,C1751,HCPCS,0278,RC,,,,both,,,193.49,125.77,,,,,,,,,,,,,
PLATE BONE THK1.5MM 2X2 H CRANIOMAXILLOFACIAL ORAL SLV TI,SUP-2181771,CDM,C1713,HCPCS,0278,RC,,,,both,,,2371.64,1541.57,,,,,,,,,,,,,
SCREW BNE 5.5X120 MM FIX BEAM FOR CHARCOT FIX SYS AXIS,SUP-2433772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
"HC RBC, Frz/Deg/Wsh, L/R. Irrad",PX-3900905700,CDM,P9057,CPT,0390,RC,,,,both,,,2154.00,1400.10,,,,,,,,,,,,,
SCREW BONE L14MM DIA3.5MM CORT ANK FT TI ST NONLOCKING FULL,SUP-2362632,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.17,167.16,,,,,,,,,,,,,
BUR SURG CYL 5 MMX14 CM LG BOR MIDAS REX LEGEND,SUP-2627693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.86,278.76,,,,,,,,,,,,,
GUIDE SURG ANT CERV FIX ANG VENTURE,SUP-2293245,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.09,828.16,,,,,,,,,,,,,
DRAIN PACK,SUP-2302898,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.51,183.63,,,,,,,,,,,,,
CLIP INT LIG ALLIGATOR,SUP-2266677,CDM,C1889,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
BAG BLD TRNSFUS CONSOLIDATED RT VENTRICULAR ASST DEV,SUP-2356016,CDM,Q0508,HCPCS,0274,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 1 MESH NS FACE ID,SUP-2909646,CDM,C1713,HCPCS,0278,RC,,,,both,,,27516.26,17885.57,,,,,,,,,,,,,
COIL EMB 2MMX15CM MIC NEUROVASC XSFT MIC NEUROVASC GALAXY,SUP-2249159,CDM,C1889,HCPCS,0278,RC,,,,both,,,4087.90,2657.13,,,,,,,,,,,,,
GRAFT EVAR L12CM DIA14.5MM CONTRALATERAL LEG EXCLUDER,SUP-2395946,CDM,C1768,CPT,0278,RC,,,,both,,,13260.22,8619.14,,,,,,,,,,,,,
COIL VASC I-ED COIL PRIMARY L 20 CM DIA 0.010 IN SECONDARY,SUP-2865283,CDM,C1889,HCPCS,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
DEVICE LASER DEL LNG ENT ANGLED OTOPROBE 10775] FORTEC MEDICAL INC],SUP-2225683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
COMPONENT GLEN PEGGED 5 4 MM SHLDR KEELED FIX UHMWPE STRL,SUP-2372870,CDM,C1776,CPT,0278,RC,,,,both,,,3355.40,2181.01,,,,,,,,,,,,,
PROBE NSL STR W/ SMK EVAC,SUP-2713681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,852.29,553.99,,,,,,,,,,,,,
CEMENT BONE 13.8GM FULL DOSE M VISC RADPQ LNG SET TIME PMMA,SUP-2155334,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.32,239.41,,,,,,,,,,,,,
BINDER ABD 12 IN HK,SUP-2691242,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.67,23.19,,,,,,,,,,,,,
CODMAN HAKIM PROGRAMMABLE VLV IN-LINE VLV W/ SIPHONGUARD,SUP-2243810,CDM,C1729,HCPCS,0272,RC,,,,both,,,16468.70,10704.65,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 240 MM DIA22/13 MM DEL 58ML,SUP-2937089,CDM,C1713,HCPCS,0278,RC,,,,both,,,16761.32,10894.86,,,,,,,,,,,,,
PLATE BNE TIB LT DSTL POSTEROMEDIAL ANK 3 HOLE NS,SUP-2518425,CDM,C1713,HCPCS,0278,RC,,,,both,,,5005.16,3253.35,,,,,,,,,,,,,
DEVICE CAPT NDL,SUP-2876934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,557.19,362.17,,,,,,,,,,,,,
PLATE BNE 24 DEG L 209 X W 8.5 MM THK 1.6 MM 16 H SS RT DSTL,SUP-2932864,CDM,C1713,HCPCS,0278,RC,,,,both,,,8253.80,5364.97,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END MULTIPLE NS,SUP-2789119,CDM,C1769,HCPCS,0272,RC,,,,both,,,610.67,396.94,,,,,,,,,,,,,
HC Njx Aa&/Strd Ntrcost Nrv 1|RIGHT SIDE|PO,PX-3616442000,CDM,64420,CPT,0361,RC,,,RT|PO,both,,,2230.00,1449.50,,,,,,,,,,,,,
HC Surgery Ohs Base,PX-3600000008,CDM,3600000008,LOCAL,0360,RC,,,,inpatient,,,9658.00,6277.70,,,,,,,,,,,,,
STEM HUM L110MM DIA12MM 135DEG CO CHROM MOLYBDENUM CEM STD,SUP-2204826,CDM,C1776,CPT,0278,RC,,,,both,,,8025.84,5216.80,,,,,,,,,,,,,
PLATE BNE L 221 MM SCREW DIA 4.5 MM 12 H SS NAR COMPR NLCK,SUP-2933812,CDM,C1713,HCPCS,0278,RC,,,,both,,,2244.13,1458.68,,,,,,,,,,,,,
MESH SURG W20XL30CM THK1MM EPTFE CORDUROY SURF CNFRM TEXT,SUP-2395335,CDM,C1781,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
PLATE BONE STR CRANIOMAXILLOFACIAL 2X34 H 2 STRP NONSTERILE,SUP-2363721,CDM,C1713,HCPCS,0278,RC,,,,both,,,2654.40,1725.36,,,,,,,,,,,,,
SCREW BNE ST 2X5 MM CRTX MAND TI GLD NS PLUSDRIVE,SUP-2189324,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.64,172.02,,,,,,,,,,,,,
SPLINT WRST SM L7IN AD R FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276655,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.36,6.08,,,,,,,,,,,,,
BIT DRL CANN LNG 12 MM STRL,SUP-2789946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2699.87,1754.92,,,,,,,,,,,,,
LEAD DEFIB SPRNT QUATTRO SECUR S MRI SURESCAN L 72 CM DIA,SUP-2282267,CDM,C1895,HCPCS,0275,RC,,,,both,,,8258.20,5367.83,,,,,,,,,,,,,
LINER ACET SZ 21 ID28MM 10DEG POLY HIP NONCONSTRAINED COMP,SUP-2403362,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
IMPLANT KNEE TOT SYS VANGUARD,SUP-2212592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
TROCAR ENDOSCP BLNT TIP W/ RND DISECT BLLN DISP ACCS AND,SUP-2421063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1275.03,828.77,,,,,,,,,,,,,
LEAD DEFIB ENDOTK ENDUR EZ L 70 CM SIL PTIR STEROID ENDOCARD,SUP-2148553,CDM,C1899,HCPCS,0275,RC,,,,both,,,21116.50,13725.72,,,,,,,,,,,,,
BIT DRL TWST 1.1X61 MM 12 MM W/ STP O-SHANK CYL SS LEVEL 1,SUP-2457787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.08,308.15,,,,,,,,,,,,,
PLATE BNE RECON 3.5X117 MM PELV 9 HOLE LP WA SS NS,SUP-2863438,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.18,904.27,,,,,,,,,,,,,
EXCHANGER PERF CRDPLGIA 6LPM FLOW RATE 135ML CPCTY W38N CN,SUP-2722919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.69,549.05,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZN ALLGRFT FEM CORT STRUT BNE 200MM,SUP-2307362,CDM,C1713,HCPCS,0278,RC,,,,both,,,5736.37,3728.64,,,,,,,,,,,,,
PIN FIX ABSORBABLE 2X2 MM STRL,SUP-2462146,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
PLATE BNE W175XL296MM THK52MM 16 H BILAT TI RIG NEUT LOK,SUP-2256970,CDM,C1713,HCPCS,0278,RC,,,,both,,,2739.37,1780.59,,,,,,,,,,,,,
SCREW 12MM 22MM PLT LOK,SUP-2243262,CDM,C1713,HCPCS,0278,RC,,,,both,,,903.13,587.03,,,,,,,,,,,,,
PLATE BONE L204MM 12 H S STL BROAD SELF COMPR,SUP-2198610,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.36,312.88,,,,,,,,,,,,,
BUR SURG DIA3MM DMND RND 5 STP NOTCH EXPOSE MRK ELITE 5820012030] STRYKER INSTRUMENT DIV],SUP-2367570,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.23,234.80,,,,,,,,,,,,,
RING EXT FIX LNG 180 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29668.98,19284.84,,,,,,,,,,,,,
BUR DENT L70MM DIA5MM 80000RPM VOLLKARBID DISP PM2 BOHRER,SUP-2134830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST-RING L 145 CM DIA 0.035 IN SS,SUP-2169712,CDM,C1769,HCPCS,0272,RC,,,,both,,,89.87,58.42,,,,,,,,,,,,,
LINER ACET 24 10 DEG 36 MM FEM HIP POLYETH RINGLOK,SUP-2136080,CDM,C1776,CPT,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
HC Finger Splint Application,PX-4502913000,CDM,29130,CPT,0450,RC,,,,both,,,363.00,235.95,,,,,,,,,,,,,
CATHETER BILI DRN CATH SET CONTENTS CATH PROX LOOP 2 INTRO,SUP-2168183,CDM,C1729,HCPCS,0272,RC,,,,both,,,412.34,268.02,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 29 MM EXPANSION DIA 5-10 MM SHTH,SUP-2159246,CDM,C1877,HCPCS,0278,RC,,,,both,,,3560.76,2314.49,,,,,,,,,,,,,
SCREW BNE STD MINI TI NONSTERILE 23MMX13MM MAXDRIVE,SUP-2262860,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.85,133.15,,,,,,,,,,,,,
PLANER SURG M PAT BLDE BIT PFC SIG SPEC 2,SUP-2253953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
MATRIX BIO L 3.2 X W 2.4 IN SZ 49.2 SQCM PORCINE TEND,SUP-2909311,CDM,A2008,HCPCS,0636,RC,,,,both,,,7385.28,4800.43,,,,,,,,,,,,,
VALVE SHUNT L23.7MM 25CM H2O PRSS TI 2 CONN GRAVITATIONAL,SUP-2108717,CDM,C1729,HCPCS,0272,RC,,,,both,,,4341.65,2822.07,,,,,,,,,,,,,
NAIL INTRAMEDULLARY TIBIOTALOCALCANEAL 12MM X 30CM NITINOL DYNANAIL XL,SUP-2878955,CDM,C1713,HCPCS,0278,RC,,,,both,,,58859.30,38258.54,,,,,,,,,,,,,
REAMER SURG 12MM FEM FULL FLUT,SUP-2249544,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA24 MM EPTFE STR STD WALL,SUP-2396234,CDM,C1768,CPT,0278,RC,,,,both,,,1981.34,1287.87,,,,,,,,,,,,,
SCREW BNE 2X2 MM,SUP-2262854,CDM,C1713,HCPCS,0278,RC,,,,both,,,148.55,96.56,,,,,,,,,,,,,
HC Add Vessel Pa Valvulaplas,PX-4819299800,CDM,92998,CPT,0481,RC,,,,both,,,35312.00,22952.80,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA12MM DIL TIP OBT RADLUC STBL SL,SUP-2218274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.38,413.00,,,,,,,,,,,,,
BIT DRL REMOVABLE STRL INCORE LAPIDUS REUSE,SUP-2465811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,578.70,376.15,,,,,,,,,,,,,
LENS INTOCU +13.0 DIOPT L13.5MM D5.37MM OD6.5MM 5DEG HAPTIC,SUP-2110501,CDM,V2632,HCPCS,0276,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
INSERT TIB THK 13 MM SZ 3 ACTIVIT-E KNEE CR CONSTRND STRL,SUP-2893916,CDM,C1776,CPT,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
DEVICE FIX OPN ABSRB STRP SECURESTRP,SUP-2219750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1844.88,1199.17,,,,,,,,,,,,,
BUR SURG DIA4MM RND PRECIS S2 F MOTORIZED RHINOSCOPIC SURG,SUP-2363778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
HC Pt Adl Training 15min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4409753500,CDM,97535,CPT,0440,RC,,,GO|CO,both,,,174.00,113.10,,,,,,,,,,,,,
EXPANDER BRST TISS 750CC W15XH15CM P7.7CM SIL SMOOTH HI,SUP-2301024,CDM,C1789,HCPCS,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
WIRE FIX FOR L QWIX SCR L250MM OD2.5MM K,SUP-2243648,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.12,144.38,,,,,,,,,,,,,
RESERVOIR DRAINAGE NEONATAL 75X3 CM VENTRICULAR FLAT DOME,SUP-2277913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1006.68,654.34,,,,,,,,,,,,,
PLATE BONE LOK 97MML HLX12 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2720493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1630.04,1059.53,,,,,,,,,,,,,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN,RX-11394,CDM,340b,HCPCS,0637,RC,00121-1190-00,NDC,,both,15,ML,11.50,7.47,,,,,,,,,,,,,
BLADE SCRWDRVR 40MML STNLSS STEEL WIDE ULTRA LOW PRFLE FBOS,SUP-2682156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.81,432.78,,,,,,,,,,,,,
MESH CRAN W41XL42MM D0.5MM THK1MM L ORBIT TIIUM BARR SURF,SUP-2366482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3978.38,2585.95,,,,,,,,,,,,,
SPLINT WR AD L GREATER THAN W4IN LT MCP DLX KAY-SPLNT III,SUP-2324563,CDM,L3906,HCPCS,0274,RC,,,,both,,,87.95,57.17,,,,,,,,,,,,,
RESTRICTOR CEMENT 12/13 MM PFC,SUP-2253283,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SUPPORT ORTHOT CUST HEEL WDG SACH,SUP-2435720,CDM,L3340,HCPCS,0272,RC,,,,both,,,241.31,156.85,,,,,,,,,,,,,
STAPLE BNE SUPER ELASTIC 20X20X20 MM RELD HIMAX DYNAFORCE,SUP-2175189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
SCREW BONE L17MM OD2.8MM LACTOSORB COPOLYMER SHLDR SLD FULL,SUP-2137289,CDM,C1713,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 4 ML STR W/ BFD OSSEOFLEX SB OCP0114,SUP-2500037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
NEEDLE SUTURE L8.25IN SHARP LIGATURE FOR RIGHT HAND HURD,SUP-2802482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.12,233.43,,,,,,,,,,,,,
MESH HERN VENTRAL SM 1.7X1.7 IN O3FA POLYPR C-QUR V-PATCH,SUP-2227251,CDM,C1781,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
CATHETER HD STR 13.5 FRX24 CM DL SHT TERM NIAG,SUP-2126504,CDM,C1752,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
AMBI SUP PL 10SL 204MM 95,SUP-2820661,CDM,C1713,HCPCS,0278,RC,,,,both,,,5360.61,3484.40,,,,,,,,,,,,,
CATHETER THORACENTESIS SET 8.5 FRX22 CM 4 SIDEPRT,SUP-2760151,CDM,C1729,HCPCS,0272,RC,,,,both,,,439.07,285.40,,,,,,,,,,,,,
GUIDE DISTRCTN LAPIDUS SYS IO FRDM,SUP-2865097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
NUT EXT FIX SPD NS DISP,SUP-2932766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.23,163.30,,,,,,,,,,,,,
UGW 0038 150CM RER ANG 3CM,SUP-2725839,CDM,C1769,HCPCS,0272,RC,,,,both,,,183.44,119.24,,,,,,,,,,,,,
HC Perq Trluml C Athrc St Angiop 1 Maj C Art&/Brnch,PX-4819293300,CDM,92933,CPT,0481,RC,,,,both,,,21763.00,14145.95,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 2 Y SHP XLN PLATE 1 PK,SUP-2936670,CDM,C1713,HCPCS,0278,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
SPACER SPNL ALLGRFT 9X16X14 MM CERV ANAT CORNERSTONE,SUP-2423141,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 18 FRX45 CM 3.5 CM 7-10 CC LP MIC-KEY,SUP-2764874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1054.79,685.61,,,,,,,,,,,,,
KIT HAD CATHETER 12FR L24CM STR EXTN 2 LUMN MAHRK ELITE,SUP-2283959,CDM,C1750,HCPCS,0278,RC,,,,both,,,227.40,147.81,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.502,SUP-2860184,CDM,C1713,HCPCS,0278,RC,,,,both,,,26747.46,17385.85,,,,,,,,,,,,,
BEARING HUM DIA36-44MM STD ARCOMXL FOR COMPHSVE REV SHLDR,SUP-2409553,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 6 MM RNG L 20 CM EPTFE STR TW,SUP-2396113,CDM,C1768,CPT,0278,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
BIT DRL PROF FOR 4.7MM SCR ACUTRK 2,SUP-2107152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
PLATE BNE L 8 H R MIDSHAFT CLAV LO PROF,SUP-2106986,CDM,C1713,HCPCS,0278,RC,,,,both,,,2791.46,1814.45,,,,,,,,,,,,,
CAGE SPNL LORDTC 17X14X6 MM MP DIVERGENCE,SUP-2603526,CDM,C1889,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SCREW BNE CANN 3X32 MM CAPTURE HIGH-TORQUE,SUP-2609498,CDM,C1713,HCPCS,0278,RC,,,,both,,,1079.47,701.66,,,,,,,,,,,,,
SCREW BNE L 52 MM DIA 4 MM SHRT TI CANN HDLSS NS LEOS,SUP-2931484,CDM,C1713,HCPCS,0278,RC,,,,both,,,1076.99,700.04,,,,,,,,,,,,,
PLATE BONE W12XL183MM THK1MM 11 H BILAT TI SEMI TBLR LO PROF,SUP-2190709,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.99,245.04,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 4FR 0.024/0.032IN 60CM 2 LUMAN RV,SUP-2613432,CDM,C1751,HCPCS,0278,RC,,,,both,,,609.47,396.16,,,,,,,,,,,,,
GRAFT ENDOVASC L10CM DIA27MM CONTRALATERAL LEG ENDOPROS USED,SUP-2395961,CDM,C1768,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
BLADE ENDO STD CRPL TUNN REL DISP SMARTREL,SUP-2304074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
STEM FEM 0 STD HIP SS QUDRA-C,SUP-2267297,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
PLATE BNE L 88 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 8 H 72440608,SUP-2932925,CDM,C1713,HCPCS,0278,RC,,,,both,,,2363.16,1536.05,,,,,,,,,,,,,
EXTENSION STEM L23MM DIA12.7MM KNEE TIV ALLOY FLUT M/G,SUP-2200365,CDM,C1776,CPT,0278,RC,,,,both,,,4755.53,3091.09,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1.6 MM 2.3 MM SHEP GRMMT W/ TAB SIL 510022,SUP-2535077,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.25,20.96,,,,,,,,,,,,,
KIT BAR SACRAL THRD 6X260MM STRL,SUP-2547194,CDM,C1713,HCPCS,0278,RC,,,,both,,,3529.74,2294.33,,,,,,,,,,,,,
ALLOGRAFT BNE RAD SHFT 101-159X2 MM FRZN,SUP-2717879,CDM,C1762,CPT,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
NEEDLE SUTURE L7.75IN HEAVY CURVED REVERDIN,SUP-2802449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,720.25,468.16,,,,,,,,,,,,,
BLOCK CORTICAL 11X11X9 IN CORNERSTONE,SUP-2277892,CDM,C1713,HCPCS,0278,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
AUGMENT TIB SM CONE SYMM STRL EMPOWR,SUP-2929661,CDM,C1776,CPT,0278,RC,,,,both,,,18515.95,12035.37,,,,,,,,,,,,,
SCREW BNE MULT DIR 2.7X28 MM STRL DVR,SUP-2606227,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.83,325.54,,,,,,,,,,,,,
CAP SPNL 2 H LCK ANTR CERV PLT SNOWCAP,SUP-2207860,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PROBE SURG 45 CONTRALATERAL ACC DISP IO-FLEX,SUP-2115826,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
TILENE STRP 4CMX40CM LT 3PK,SUP-2402554,CDM,C1781,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
SCREW BONE L20MM DIA4.5MM CORT STRNL S STL CANN NONLOCKING,SUP-2184374,CDM,C1713,HCPCS,0278,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
EXTRACTOR STONE 1.5FR L115CM BSKT DIA1CM NIT TIPLSS UNIDEX,SUP-2170513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1144.22,743.74,,,,,,,,,,,,,
KIT BPH W/ 90FR X 30MM DCB 90FR X 30MM BASIC BALL INFL DEV,SUP-2915375,CDM,C1889,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
STAPLE INT BIOABSRB REINF FOR ETHICON FLX ENDOPATH 60 PWR +,SUP-2395316,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
BLADE SHAVER CRV 15 DEG 4 MM SERRATED CONVX WINDOW DIEGO,SUP-2638087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.77,275.45,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE SINGLE UPR PREFABRICATED OFF THE SHLF,SUP-2435618,CDM,L1851,HCPCS,0274,RC,,,,both,,,2540.29,1651.19,,,,,,,,,,,,,
SHEATH ACCESS SHORT 12FR 10FR 25CM PROXIS URETERAL,SUP-2655863,CDM,C1894,HCPCS,0272,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
"HC New Pt, E/M Level 5",PX-5109920500,CDM,99205,CPT,0510,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
HC Immunization Administration,PX-7719047100,CDM,90471,CPT,0771,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
RING EXT FIX OPEN ALUMINIUM DIA180 MM,SUP-2472823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3762.98,2445.94,,,,,,,,,,,,,
PLATE BNE RADIAL SM 43 MM RT DSTL VOLAR PERIARTICULAR 3 HOLE,SUP-2460887,CDM,C1713,HCPCS,0278,RC,,,,both,,,1790.46,1163.80,,,,,,,,,,,,,
HC Vasc Embolize Occlude Organ|BILATERAL PROCEDURE,PX-3613724300,CDM,37243,CPT,0361,RC,,,50,both,,,11772.00,7651.80,,,,,,,,,,,,,
NEEDLE BX 22GA FN ENDOSCP US FNB ACQUIRE,SUP-2149649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.51,830.38,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.5 MM FOR 7.3 MM CANN LCK SCREW NS,SUP-2799487,CDM,C1769,HCPCS,0272,RC,,,,both,,,473.57,307.82,,,,,,,,,,,,,
INSERT TIBIAL PROLONG SIZE 3 0,SUP-2493171,CDM,C1776,CPT,0278,RC,,,,both,,,4281.39,2782.90,,,,,,,,,,,,,
CATH BLLN ANGIO 2X8MM NC EUPHORIA RX,SUP-2281201,CDM,C1725,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
BIT DRL L195MM DIA3.3MM S STL FOR NCB SYS,SUP-2411440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
"HC So Blood Typing, Abo",PX-3008690066,CDM,86900,CPT,0300,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
WASHER ORTHPDC TTNM FLAT F4.5 5MM CNNLTD SCREW SSTM TMX,SUP-2723556,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
COMPONENT FEM SZ 1 KNEE POST STABILIZING UNIV UNISX PRI CEM,SUP-2223013,CDM,C1776,CPT,0278,RC,,,,both,,,18891.81,12279.68,,,,,,,,,,,,,
HC So Detect Agent Nos Dna Amp,PX-3068779866,CDM,87798,CPT,0306,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
SCREW INTRF L14MM OD9MM SUBTALAR FOR ARTHROEREISIS PROSTOP +,SUP-2121856,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
BOLT EXT FIX HALF 8 MM PIN FIX STRL TRUELOK EVO LTX,SUP-2875626,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.37,219.94,,,,,,,,,,,,,
KNIFE SURG OPT RND URETHROTM,SUP-2463253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1395108D1,SUP-2632826,CDM,C1751,HCPCS,0278,RC,,,,both,,,911.23,592.30,,,,,,,,,,,,,
ALLOGRAFT BNE FLOWABLE 10 CC OSTEOAMP,SUP-2731799,CDM,C1776,CPT,0278,RC,,,,both,,,8471.09,5506.21,,,,,,,,,,,,,
PROBE US AD DIA3/8IN STD FLAT PNCL,SUP-2321984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 5 FR L 7 CM NIT PLAT,SUP-2170488,CDM,C1894,HCPCS,0272,RC,,,,both,,,58.22,37.84,,,,,,,,,,,,,
CABLE ORTH 2X600 MM ASMBLY STRL,SUP-2563688,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.54,911.00,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X240 MM FRZN ASEP PERONEUS LONGUS TEND,SUP-2866983,CDM,C1762,CPT,0278,RC,,,,both,,,3346.93,2175.50,,,,,,,,,,,,,
STENT URET L 90 CM DIA 8 FR SIL BRAIDED DIV HYDRO-GLIDE,SUP-2126217,CDM,C2617,HCPCS,0278,RC,,,,both,,,544.48,353.91,,,,,,,,,,,,,
INSERT TIB SZ 3 THK9.5MM RT MEDL LT LAT KNEE FIX BEAR,SUP-2251272,CDM,C1776,CPT,0278,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
COMPONENT HIP HYBRID,SUP-2212667,CDM,C1776,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
STENT BILI EXP L26MM BLLN L30MM DIA7MM SHFT L80CM 0.035IN,SUP-2159253,CDM,C1876,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
BASEPLATE GLEN MED SHLDR POROUS COAT REVERS,SUP-2422328,CDM,C1776,CPT,0278,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 45CM 7FR COAT 5CM HS XCUT,SUP-2385267,CDM,C1894,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
STENT NEURO SURPS STREAMLINE L 25 MM DIA 4 MM COCR INTCRAN,SUP-2884355,CDM,C1876,HCPCS,0278,RC,,,,both,,,45530.00,29594.50,,,,,,,,,,,,,
WASHER FIX DIA65MM TI FOR ORTHOLOC 3DI ANK FUS PLATING SYS,SUP-2398621,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
CATHETER EP 2-18-2-8-2 MM 7 FRX110 CM HALO XP,SUP-2248466,CDM,C1731,HCPCS,0278,RC,,,,both,,,3033.24,1971.61,,,,,,,,,,,,,
GRAFT HUM TISS W20XL20CM THK18 4MM ACELLULAR DERM MTRX,SUP-2307482,CDM,Q4128,HCPCS,0636,RC,,,,both,,,35617.46,23151.35,,,,,,,,,,,,,
PROBE APC DIAM 2.3MM 7FR LEN 9FT10IN 300CM,SUP-2217942,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.77,470.45,,,,,,,,,,,,,
DARBEPOETIN ALFA 200 MCG/0.4ML IJ SOSY,RX-131232,CDM,J0881,HCPCS,0636,RC,55513-0028-01,NDC,,both,0.4,ML,4566.60,2968.29,,,,,,,,,,,,,
CATHETER DIL BAL L24MM DIA5MM FOR INTRASINUS IRR RELIEVA,SUP-2106314,CDM,C1729,HCPCS,0272,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
PLATE BNE L46MM 5 H ST DST DORS RAD S STL CLMN LOK COMPR,SUP-2420768,CDM,C1713,HCPCS,0278,RC,,,,both,,,2070.30,1345.69,,,,,,,,,,,,,
DEVICE LASER DEL 10 DEG ENT ANGLED OTOPROBE,SUP-2225639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HC So Collagen Cross-Link N-Telopep,PX-3018252366,CDM,82523,CPT,0301,RC,,,,outpatient,,,139.00,90.35,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM AMNION PTCH CYGNUS SOLO,SUP-2393056,CDM,Q4170,HCPCS,0636,RC,,,,both,,,4785.36,3110.48,,,,,,,,,,,,,
SCREW BONE CNNLTD 5MM DIA 32MML TIMAX PRTLLY THRDD NON ST,SUP-2586811,CDM,C1713,HCPCS,0278,RC,,,,both,,,484.25,314.76,,,,,,,,,,,,,
HC Pain Intermediate,PX-3600007515,CDM,3600007515,LOCAL,0360,RC,,,,both,,,2485.00,1615.25,,,,,,,,,,,,,
SCREW BNE HALLUX VALGUS 3X14 MM PROSTEP,SUP-2400016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
TRAY VEN ACCS DIA9FR 3 LUMN ADV HF DEV,SUP-2272951,CDM,C1751,HCPCS,0278,RC,,,,both,,,304.05,197.63,,,,,,,,,,,,,
BRACE WRST LEN 6 1 4IN CIRC UP TO 5 3 4IN XSM L REG D RNG W,SUP-2326020,CDM,L3908,HCPCS,0274,RC,,,,both,,,79.54,51.70,,,,,,,,,,,,,
BLADE RETRACTOR KOROS 2 IN SELF RET,SUP-2444063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
BRACE KNEE LG W/ FAN STBL,SUP-2337058,CDM,L1810,HCPCS,0272,RC,,,,both,,,133.48,86.76,,,,,,,,,,,,,
MESH ORBIT THK0.6MM MIC 22 H CRANIOMAXILLOFACIAL TI PROF,SUP-2262587,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.91,413.34,,,,,,,,,,,,,
GRAFT BNE L100MM FRZN TIB SEG IMPL ALLGRFT MATRIGRFT,SUP-2264791,CDM,C1713,HCPCS,0278,RC,,,,both,,,2422.35,1574.53,,,,,,,,,,,,,
BIT DRL L50MM DIA1.2MM WRK L6MM J NOTCH FOR UNIV NEURO 2 LO,SUP-2365217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
PLATE BNE L 100 DEG STD 1.7X2X0.55 MM RT 5 HOLE BAR MALL,SUP-2366243,CDM,C1713,HCPCS,0278,RC,,,,both,,,616.57,400.77,,,,,,,,,,,,,
CATHETER PICC AD 5FR L55CM GWIRE L135CM SGL LUMN BASIC KT,SUP-2125528,CDM,C1894,HCPCS,0272,RC,,,,both,,,293.02,190.46,,,,,,,,,,,,,
HYDROCORT-PRAMOXINE (PERIANAL) 1-1 % EX FOAM,RX-150023,CDM,6370000000,HCPCS,0637,RC,00037-6822-10,NDC,,both,10,GR,874.80,568.62,,,,,,,,,,,,,
BASEPLATE GLEN 20 DEG OD 27 MM ID 20 MM FULL WDG RECON STRL,SUP-2888638,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW INTFR L25MM DIA9MM KNEE TI GWIRE FIX CANN,SUP-2341647,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
HC NM Kidney Imag Vasc Flow Funct Ph,PX-3417870800,CDM,78708,CPT,0341,RC,,,,both,,,2771.00,1801.15,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,GP|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
SHEATH INTCARD STEER 8.5FR DIREX 71CM L 50MM CRV 50DEG DIL,SUP-2140432,CDM,C1894,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BNE ANTR TIBIAXYS,SUP-2609014,CDM,C1713,HCPCS,0278,RC,,,,both,,,6001.14,3900.74,,,,,,,,,,,,,
TROCAR EXT FIX LNG ORNG,SUP-2465961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
COVER BUR H DIA7MM CRANIOMAXILLOFACIAL PLT LO PROF W/ TAB,SUP-2366204,CDM,C1713,HCPCS,0278,RC,,,,both,,,507.30,329.74,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM STD LOK FOR HALLU-LOCK MTP ARTH,SUP-2243341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1039.78,675.86,,,,,,,,,,,,,
LINER ACET SZ Q OD70MM ID32MM HIP HGP II CUP ELEV RIM,SUP-2202761,CDM,C1776,CPT,0278,RC,,,,both,,,2306.33,1499.11,,,,,,,,,,,,,
STENT TRACHBRONCH COOK-Z GIANTURCO-ROSCH L 5 CM DIA25 MM,SUP-2693658,CDM,C1877,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STEM AUG WDG K4MEDACTA] MEDACTA USA],SUP-2267794,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
TROCAR 67MM LENGTH 2.0/2.7MM SYSTEM,SUP-2487850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.49,559.97,,,,,,,,,,,,,
SET SCR SPNL S STL BRK OFF FOR 5.5MM ROD CDH LEG,SUP-2288171,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SPACER ORTH HUM 9+ MM 42 MM,SUP-2715590,CDM,C1776,CPT,0278,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0258,RC,00338-0049-11,NDC,,both,250,ML,123.30,80.14,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ATLS II VR 36 J TI POLYUR SINGLE CHMBR,SUP-2357739,CDM,C1722,HCPCS,0275,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
DRILL SURG 3.5X200 MM AO ATTCH 6.5 MM SCREW ADVANSYS,SUP-2243133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
IMPLANT MANDIBULAR SZ 50 MM TI ALLOY LT TEMPOROMANDIBULAR JT,SUP-2934178,CDM,C1713,HCPCS,0278,RC,,,,both,,,20639.22,13415.49,,,,,,,,,,,,,
SCREW BONE L90MM DIA11MM CANC SUBTROCHANTERIC TI CANN LAG,SUP-2347861,CDM,C1713,HCPCS,0278,RC,,,,both,,,3792.02,2464.81,,,,,,,,,,,,,
GRAFT BNE SUB W10XH125XL125MM B TRICALCIUM PHSPTE GRAN SYN,SUP-2194020,CDM,C1713,HCPCS,0278,RC,,,,both,,,930.88,605.07,,,,,,,,,,,,,
HC Wound Debridement Tis 20 Cm/<|PBB CHARGE,PX-4509759700,CDM,97597,CPT,0450,RC,,,PBB,both,,,413.00,268.45,,,,,,,,,,,,,
SCREW 65 L90 FT CANN,SUP-2243588,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.37,867.34,,,,,,,,,,,,,
DEVICE BNE FILL BX 10 GA OSSEOFLEX BFD,SUP-2496250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1009.29,656.04,,,,,,,,,,,,,
STENT BILI ABS L 100 MM UNCONSTRAINED DIA 6 MM CATH L 135 CM,SUP-2101747,CDM,C1876,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SET CATH HEMODIALYSI BIOFLXTESIO CHRONIC BSC 10FR DIA 70CM 4,SUP-2610496,CDM,C1750,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
HC Replace Icd Mult Lead System,PX-3613326400,CDM,33264,CPT,0361,RC,,,,both,,,7823.00,5084.95,,,,,,,,,,,,,
SHOE ORTHOT ADDITION TOE TAP HRS,SUP-2435740,CDM,L3560,HCPCS,0272,RC,,,,both,,,64.75,42.09,,,,,,,,,,,,,
SYSTEM AUTOTRNS 3/16IN 600ML DBL TRCR W/ PVC DRN HEMVAC,SUP-2198715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,451.56,293.51,,,,,,,,,,,,,
INTRODUCER STEERABLE SHEATH MED CVD 8.5FR,SUP-2858169,CDM,C1766,CPT,0272,RC,,,,both,,,2804.02,1822.61,,,,,,,,,,,,,
KIT PICC 5FR L55CM GWIRE L80CM CARBOTHANE NIT 2 LUMN INSRT,SUP-2116977,CDM,C1751,HCPCS,0278,RC,,,,both,,,468.96,304.82,,,,,,,,,,,,,
TROCAR ENDOPATH BLADELESS 10/12MM 100MM W/ STABILITY SLV,SUP-2855496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.05,338.03,,,,,,,,,,,,,
RING PESSARY RNG 5 KNOB SIL,SUP-2171733,CDM,A4562,HCPCS,0274,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
MESH HERN W10XL15CM PET PLA 70% CLLGN 30% GLYC LAP SELF,SUP-2174686,CDM,C1781,HCPCS,0278,RC,,,,both,,,953.90,620.03,,,,,,,,,,,,,
KIT LUM DRNGE EDM SYS EXT DRNGE AND MON CATHETER BG W TBNG,SUP-2284406,CDM,C1729,HCPCS,0272,RC,,,,both,,,751.21,488.29,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX10 CM 51IN SAFETY SPIN-LOCK ACCEL,SUP-2659272,CDM,C1729,HCPCS,0272,RC,,,,both,,,134.33,87.31,,,,,,,,,,,,,
MATRIX TISS PELV FLR REP BOV 4CMX7CM XENFORM,SUP-2139395,CDM,C1763,HCPCS,0278,RC,,,,both,,,2466.85,1603.45,,,,,,,,,,,,,
TRAVASOL 10 % IV SOLN,RX-8074,CDM,2500000003,HCPCS,0250,RC,00338-0644-03,NDC,,both,2000,ML,460.00,299.00,,,,,,,,,,,,,
GRAFT BNE L150 250MM L PROX FEM W HD FRZN,SUP-2335567,CDM,C1713,HCPCS,0278,RC,,,,both,,,10801.60,7021.04,,,,,,,,,,,,,
SHEATH INTRO PERITONEAL 31 CM POLYPR TRNSLUC STRL DISP,SUP-2243866,CDM,C1894,HCPCS,0272,RC,,,,both,,,109.18,70.97,,,,,,,,,,,,,
HC Endo Level 2 Addl 15 Min,PX-3600007512,CDM,3600007512,LOCAL,0360,RC,,,,both,,,2137.00,1389.05,,,,,,,,,,,,,
PLATE BNE L57MM 6X5 H NONSTERILE L DST RAD VOLAR RIM S STL,SUP-2177523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.13,1744.68,,,,,,,,,,,,,
HC NM Peritoneal Venous Shunt Paten,PX-3407829100,CDM,78291,CPT,0340,RC,,,,outpatient,,,2204.00,1432.60,,,,,,,,,,,,,
CATHETER THROMCTMY SOCRATES 38 L 156 CM DIA 4 FR COAT L 90,SUP-2909581,CDM,C1757,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CLAMP EXT FIX PENNING MINIFIX FOR 3MM SCR FIX SYS,SUP-2316504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2265.82,1472.78,,,,,,,,,,,,,
CONNECTOR ROD OD35X35MM POST CERV PARA DBL SIERRA,SUP-2245451,CDM,C1713,HCPCS,0278,RC,,,,both,,,163.47,106.26,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 9MMW X12MML 0.4MM THK 0.6MM THK CUT INTRA,SUP-2605374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,487.17,316.66,,,,,,,,,,,,,
SET CNNLAOBTRTR LAP 12MM DIA THRCC THRDD BLUNT TIP JARIT RS,SUP-2675722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,719.19,467.47,,,,,,,,,,,,,
MEDIA TRACER CONTRAST LIQ 1MG MAGTRACE,SUP-2427295,CDM,A4648,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 7 MM CERV VIKOS,SUP-2538547,CDM,C1889,HCPCS,0278,RC,,,,both,,,2490.02,1618.51,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA100 UM SM 3 ML PREFIL SYR HYDRGEL WHT,SUP-2717592,CDM,C1889,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
SCREW BONE L90MM DIA4.5MM ST CRTX LCK L FRAG SET,SUP-2348904,CDM,C1713,HCPCS,0278,RC,,,,both,,,1172.63,762.21,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED LO DEMAND CEM POLYETH STRYKERKLCEM] STRYKER CORP],SUP-2365985,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
SCREW BNE L 80 MM DIA 6.5 MM CANN STRL EVOS,SUP-2931302,CDM,C1713,HCPCS,0278,RC,,,,both,,,1364.33,886.81,,,,,,,,,,,,,
IMPLANT DENT W4XL4CM THK0.4MM NYL SMOOTH SUPRAFOIL,SUP-2335973,CDM,C1781,HCPCS,0278,RC,,,,both,,,14.92,9.70,,,,,,,,,,,,,
"HC Debridement, Skin, Sub-Q Tissue,Each Add 20 Sq Cm",PX-4501104500,CDM,11045,CPT,0450,RC,,,,both,,,207.00,134.55,,,,,,,,,,,,,
COMPONENT FEM PS 1 LT KNEE,SUP-2391440,CDM,C1776,CPT,0278,RC,,,,both,,,7652.18,4973.92,,,,,,,,,,,,,
SCREW BONE L24MM OD4MM HEADLESS,SUP-2431345,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTMA L 20 CM DIA 6 MM SZ 0.018 IN PLAT,SUP-2753873,CDM,C1889,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
PIN DISTRACTOR L14MM CERV S STL W UNIV FIT,SUP-2194307,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
HEAD RADIAL 2 FLEXSPAN,SUP-2538173,CDM,C1776,CPT,0278,RC,,,,both,,,9052.62,5884.20,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP BONE-PATELLAR TENDON-BONE TRU-ARC,SUP-2867219,CDM,C1762,CPT,0278,RC,,,,both,,,12298.91,7994.29,,,,,,,,,,,,,
HC So Assay of Manganese,PX-3018378566,CDM,83785,CPT,0301,RC,,,,both,,,108.00,70.20,,,,,,,,,,,,,
CPS SHRT CENTERING SLEEVE 26MM,SUP-2506438,CDM,C1776,CPT,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
BLADE OSTEOTOM L15MM CVD FLEX W/ BLDE AND DETACH HNDL,SUP-2364283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,444.94,289.21,,,,,,,,,,,,,
SHEATH INTRO L28CM DIA16FR POLYETH HYDRPHLC W/O CRV HEMSTAT,SUP-2396256,CDM,C1894,HCPCS,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
CEMENT BNE 10 CC DRILLABLE CALCIUM PHOSPHATE BONESYNC,SUP-2845381,CDM,C1713,HCPCS,0278,RC,,,,both,,,7050.87,4583.07,,,,,,,,,,,,,
GRAFT BNE L12CMXW2CM REGEN MTRX 2 REPLFRM,SUP-2139391,CDM,C1762,CPT,0278,RC,,,,both,,,2956.62,1921.80,,,,,,,,,,,,,
PROSTHESIS 4MM DIAM 7MM LEN TORP FLROPLAS SHEA,SUP-2313655,CDM,L8613,CPT,0278,RC,,,,both,,,694.51,451.43,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.045X12 IN SS NS KIRSCHNER,SUP-2791815,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.25,8.61,,,,,,,,,,,,,
SCREW BRAKE OFF SOLERA G5 4.75MM TI NS,SUP-2285819,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.74,113.58,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 4 FR DIA 9 MM FLAT PK RED,SUP-2214589,CDM,C1757,HCPCS,0272,RC,,,,both,,,160.45,104.29,,,,,,,,,,,,,
STEM TAPER 18X185MM,SUP-2505147,CDM,C1776,CPT,0278,RC,,,,both,,,7724.40,5020.86,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 21 MMX0.4 CM FD CROSS SECT,SUP-2717821,CDM,C1762,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PROSTHESIS OSS L 3.75 MM SHFT DIA1.1 MM HA INCUS PART,SUP-2901957,CDM,L8613,CPT,0278,RC,,,,both,,,1348.44,876.49,,,,,,,,,,,,,
STEM FEM 28 MM HIP MOD NK PROFEMUR,SUP-2400560,CDM,C1776,CPT,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
PASSER SUT DISP NOVOSTITCH,SUP-2163491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
MEMBRANE CLLGN DURA REP DURAMATRIX SUTURABLE 1IN X 3IN,SUP-2165129,CDM,C1763,HCPCS,0278,RC,,,,both,,,952.30,618.99,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA 6 MM POLYESTER GEL,SUP-2385051,CDM,C1768,CPT,0278,RC,,,,both,,,1193.04,775.48,,,,,,,,,,,,,
SCREW BNE L75MM DIA6.5MM THRD L32MM TAN CANN SELF DRL HDLSS,SUP-2181471,CDM,C1713,HCPCS,0278,RC,,,,both,,,954.87,620.67,,,,,,,,,,,,,
STAPLE INT STR 20X20 MM JAWS ASMBLY NIT,SUP-2751541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4318.60,2807.09,,,,,,,,,,,,,
BIT DRL DIA2.4MM FOR JT STBL AND TEND INJ REP GLL QANCHR,SUP-2249340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1276.72,829.87,,,,,,,,,,,,,
DILATOR ENDOSCP CATHETER  L18MM DIA6FR BLLN L40MM DIA6MM PRS,SUP-2436488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,899.08,584.40,,,,,,,,,,,,,
KIT INTRO MAK-NV L 20 CM DIA 6 FR CHIBA NDL L 15 CM DIA21 GA,SUP-2499825,CDM,C1894,HCPCS,0272,RC,,,,both,,,143.44,93.24,,,,,,,,,,,,,
CROSSLINK MECH GIC55 TRNSVRS LINK W/ 100MM BAR806LT55L100T,SUP-2289276,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.14,1736.89,,,,,,,,,,,,,
COIL EMB L45CM PRI DIA0.020IN 2ND DIA11MM NIT COMPLX STD,SUP-2323374,CDM,C1889,HCPCS,0278,RC,,,,both,,,7294.22,4741.24,,,,,,,,,,,,,
CUP ACET CONSTRN STD 32X48 MM HIP SNAP IN ALL POLYETH ZCA,SUP-2203662,CDM,C1776,CPT,0278,RC,,,,both,,,5044.10,3278.66,,,,,,,,,,,,,
GRAFT BNE STRUT 50X19X3 MM FRZN FEM CORTICAL,SUP-2294172,CDM,C1713,HCPCS,0278,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
CATHETER EP CRD 5-5-5 MM SPC 6 FRX120 CM QPLR,SUP-2357016,CDM,C1730,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MM 7.5 CM FLUT FOR TOOL MIDAS REX LEGEND,SUP-2630558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.08,244.45,,,,,,,,,,,,,
CAGE SPNL L14XW14XH13MM 4 LOBE MESH L ANAT FOOTPRINT MOD,SUP-2317736,CDM,C1889,HCPCS,0278,RC,,,,both,,,6732.16,4375.90,,,,,,,,,,,,,
VARENICLINE TARTRATE 1 MG PO TABS,RX-76445,CDM,6370000000,HCPCS,0637,RC,43598-0908-56,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
SYSTEM BONE CEM MX VAC M LO VISC W/ CLR CART CHAR FLTR SUCT,SUP-2199462,CDM,C1713,HCPCS,0278,RC,,,,both,,,440.39,286.25,,,,,,,,,,,,,
HYOSCYAMINE SULFATE 0.125 MG/5ML PO ELIX,RX-3781,CDM,6370000000,HCPCS,0637,RC,54838-0511-80,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.513,SUP-2860195,CDM,C1713,HCPCS,0278,RC,,,,both,,,27657.43,17977.33,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 31 X 22 X 6.5 MM POLYETHYL LT REG,SUP-2935890,CDM,C1713,HCPCS,0278,RC,,,,both,,,2298.48,1494.01,,,,,,,,,,,,,
PLATE BNE L 2.19 IN MED TI ALLOY RT 2ND/3RD DORS FT LP,SUP-2912926,CDM,C1713,HCPCS,0278,RC,,,,both,,,7856.28,5106.58,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION SM 12-30 DEG WA22705S,SUP-2482278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.10,1038.76,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA IR 5FR 55CM 3 LUMA S3385355,SUP-2632851,CDM,C1751,HCPCS,0278,RC,,,,both,,,462.33,300.51,,,,,,,,,,,,,
DRILL SURG CANN 3/16 IN 3.8X150 MM SQ CONN SS MONSTER,SUP-2751470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SHOE ORTHOT CALIP PLATE NEW TRANSFER,SUP-2435746,CDM,L3610,HCPCS,0272,RC,,,,both,,,284.45,184.89,,,,,,,,,,,,,
COMPONENT FEM SZ C LT KNEE POST STBL COMPATIBLE W/ LPS-FLEX,SUP-2201145,CDM,C1776,CPT,0278,RC,,,,both,,,14801.96,9621.27,,,,,,,,,,,,,
INTRODUCER SET MICPUNC PUSH + 5FR STIFF CANN NIT WIRE,SUP-2170560,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.46,58.80,,,,,,,,,,,,,
MIRTAZAPINE 30 MG PO TABS,RX-17465,CDM,6370000000,HCPCS,0637,RC,68084-0120-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ADAPTER PACE LD OSCOR L 17 CM SIL INSUL LV1 BPLR IS1 CONN,SUP-2356255,CDM,C1883,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
GRAFT BNE SUB 5CC SPNG DEMIN CORT FBR FLEXIGRFT,SUP-2264607,CDM,C1713,HCPCS,0278,RC,,,,both,,,1979.42,1286.62,,,,,,,,,,,,,
PLATE PL DSTL HUM LAT SUPP 3.5MM 14H RT 208MM LCP STRL,SUP-2547578,CDM,C1713,HCPCS,0278,RC,,,,both,,,3627.39,2357.80,,,,,,,,,,,,,
CATHETER VENTRICULAR FEN,SUP-2666776,CDM,C1729,HCPCS,0272,RC,,,,both,,,961.25,624.81,,,,,,,,,,,,,
PLUG CEMENT MEDULLARY ALLEN,SUP-2205607,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.73,133.72,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2MM DIA 230MM SMOOTH SHRP TIP S STL W/ LEN,SUP-2412995,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.25,43.06,,,,,,,,,,,,,
ELECTRODE VPR FOR 12/30 LENS CBL PLASMABUTTON,SUP-2313585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1474.86,958.66,,,,,,,,,,,,,
GRAFT HUM TISS FLOWABLE 0.6 CC CONNECTIVE TISS MTRX INTERFYL,SUP-2845979,CDM,Q4171,HCPCS,0636,RC,,,,both,,,3603.15,2342.05,,,,,,,,,,,,,
"HC So Sodium,Urine Spot",PX-3018430066,CDM,84300,CPT,0301,RC,,,,both,,,25.00,16.25,,,,,,,,,,,,,
SPACER ORTH TALAR PT SPEC PK,SUP-2742003,CDM,C1776,CPT,0278,RC,,,,both,,,41369.50,26890.17,,,,,,,,,,,,,
SLING GYN L33CM CONTINENCE PP SUT SLNG TRANSURETHRAL M,SUP-2140328,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CONNECTOR SPNL THORLUM THRD POLYAX FOR 5.5MM ROD TULIP CREO,SUP-2228674,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GRAFT EVAR IL BRANCH COMP L7CM DIA14.5MM NIT EPTFE FEP INT,SUP-2395802,CDM,C1768,CPT,0278,RC,,,,both,,,8638.14,5614.79,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 47CM 4,SUP-2613282,CDM,C1750,HCPCS,0278,RC,,,,both,,,7418.25,4821.86,,,,,,,,,,,,,
GRAFT VASC PTCH 7.6X0.8 CMX0.76 MM AORT TAPR END HEMSHLD GLD,SUP-2468641,CDM,C1768,CPT,0278,RC,,,,both,,,359.12,233.43,,,,,,,,,,,,,
INTRODUCER EP 10 FR 63 CM LEN HEMSTATIC VLV AD TRIO HEM,SUP-2357212,CDM,C1893,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB III DIAMOND NEURO CUT COARSE STRL,SUP-2929450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.69,341.05,,,,,,,,,,,,,
MARKER RAD 1X3 MM W/ PLCMNT NDL STRL POLYMARK,SUP-2164574,CDM,A4648,CPT,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
SPLINT WRST XL AD L8IN FOR 85 95IN L NYL LN FOAM PUL ON,SUP-2276660,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.83,10.94,,,,,,,,,,,,,
EPIFIX 2X3CM 6SQ CM MESH,SUP-2305740,CDM,Q4186,HCPCS,0636,RC,,,,both,,,3702.06,2406.34,,,,,,,,,,,,,
NIPPER NAIL 5IN S STL,SUP-2227916,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.05,224.28,,,,,,,,,,,,,
NAIL IM 12X170 MM SUPCNDYL FEM T2,SUP-2361803,CDM,C1713,HCPCS,0278,RC,,,,both,,,9026.56,5867.26,,,,,,,,,,,,,
ISOSORBIDE MONONITRATE ER 60 MG PO TB24,RX-24268,CDM,6370000000,HCPCS,0637,RC,23155-0178-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ADAPTER EXT FIX DRV W/ QUIK CPL FOR 5MM SCHNZ SCR,SUP-2188584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.13,617.58,,,,,,,,,,,,,
PLATE BONE 3.5X230MM LCP X ARTC DSTL HUM 10 H RT TI,SUP-2419610,CDM,C1713,HCPCS,0278,RC,,,,both,,,4542.64,2952.72,,,,,,,,,,,,,
ALLODERM SELECT RESTORE LARGE - MEDIUM 1.6 0.4MM,SUP-2826662,CDM,Q4116,HCPCS,0636,RC,,,,both,,,44145.26,28694.42,,,,,,,,,,,,,
STENT URET 4.5FR L24CM OPN END LUB FLX,SUP-2313777,CDM,C2617,HCPCS,0278,RC,,,,both,,,214.31,139.30,,,,,,,,,,,,,
PLATE BONE ANGLED BROAD 2 MM 3X3 HOLE PRECONTOURED TITANIUM,SUP-2837753,CDM,C1713,HCPCS,0278,RC,,,,both,,,3804.74,2473.08,,,,,,,,,,,,,
CAP K WIRE HLDR TELLURIDE FOR MIS SPNL FIX SYS,SUP-2211173,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMOS W67XH55MM D12MM 32CC 80 GM 2 CHMBR,SUP-2138081,CDM,C1721,HCPCS,0275,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
BUTTON NSL SEPTAL DIA 3 MM SZ 11 X 13 MM OVL 2PC,SUP-2889375,CDM,C1889,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
GRAFT BNE L201 270MM L PROX HUM FRZN,SUP-2335591,CDM,C1713,HCPCS,0278,RC,,,,both,,,8289.60,5388.24,,,,,,,,,,,,,
HEAD FEM ROTARY BALL MED 32 MM HIP WEBER,SUP-2440883,CDM,C1776,CPT,0278,RC,,,,both,,,1144.53,743.94,,,,,,,,,,,,,
SCREW BONE LOK 3.5MM DIA 34MML STNLSS STEEL SRFX STE ST,SUP-2586536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1025.27,666.43,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg,PX-3616449000,CDM,64490,CPT,0361,RC,,,,both,,,4864.00,3161.60,,,,,,,,,,,,,
PLATE BONE L116MM 6 H T SHP FOR 4.5MM CORTEX/MALLEOLAR/SHAFT,SUP-2343817,CDM,C1713,HCPCS,0278,RC,,,,both,,,2494.51,1621.43,,,,,,,,,,,,,
NAIL IM LNG 130 DEG 15X320 MM RT HIP AFFIXUS,SUP-2460703,CDM,C1713,HCPCS,0278,RC,,,,both,,,7771.50,5051.47,,,,,,,,,,,,,
VALVE SHUNT FLO CTRL SM CONTOURED W/ BIOGLDE MED PRESSURE,SUP-2631414,CDM,C1889,HCPCS,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
WASHER ORTH DIA10MM DBL FOR 2MM SCR,SUP-2349665,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.86,253.41,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT 5FR 55CM 2 LUMAN RVS TA 9275108F,SUP-2632700,CDM,C1751,HCPCS,0278,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
GRAFT BONE SUB 2.5CC ALLOSYNC PURE,SUP-2120753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
ROD IM L150MM DIA11MM HUM LOK POLARUS,SUP-2107702,CDM,C1713,HCPCS,0278,RC,,,,both,,,6173.24,4012.61,,,,,,,,,,,,,
HC Change G to Gj Tube,PX-3614944600,CDM,49446,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
CATHETER EP 5FR L110CM ELECTRD TIP L1MM SPC 2-5-2MM M CRV,SUP-2357630,CDM,C1730,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
BRACE ORTH BILATERAL SM AD ANK WALKING MAXTRAX AIR,SUP-2427326,CDM,L4360,HCPCS,0274,RC,,,,both,,,93.76,60.94,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 68 CM DIA 0.032 IN SS PERIPH MARKED,SUP-2383971,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.52,19.19,,,,,,,,,,,,,
BEAM FIX 7.5X70 MM,SUP-2422264,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
LENS INTOCU +0.0-30.0 DIOPT DIA6MM BCNVX ASPHERIC 10DEG A,SUP-2129258,CDM,V2632,HCPCS,0276,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE 5 H TARSALIS T SHP,SUP-2243240,CDM,C1713,HCPCS,0278,RC,,,,both,,,4013.74,2608.93,,,,,,,,,,,,,
RXG PLATE STR 4 HLE 40MM 24MM BRG RDCD HOLE SPCNG T06MM,SUP-2679389,CDM,C1713,HCPCS,0278,RC,,,,both,,,2658.98,1728.34,,,,,,,,,,,,,
WASHER 55MM 75MM CANN SCREWS 12MM THICK,SUP-2720255,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.46,138.75,,,,,,,,,,,,,
DRIVER SURG SNAP OFF STRL DISP STROPP,SUP-2913521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.99,414.69,,,,,,,,,,,,,
REAMER SURG DIA 8.5 MM STP NS DISP,SUP-2930409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
JOINT TOE 10 DEG 3.7 MM 5 MM INTER-PHALANGEAL FUSION PK,SUP-2423827,CDM,C1713,HCPCS,0278,RC,,,,both,,,4995.11,3246.82,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL GUID 8FR L63CM DIL 8FR L67CM GWIRE,SUP-2357162,CDM,C1893,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
NEEDLE NAVIGATION BX,SUP-2900080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2766.31,1798.10,,,,,,,,,,,,,
PIN FIX DIA11MM GUID CERCLAGE POS,SUP-2193589,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.88,289.17,,,,,,,,,,,,,
STAPLER INT REG RELD LD UNIT SM DISP,SUP-2787673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.24,211.41,,,,,,,,,,,,,
BRACE SHLDR L RT UNILAT LYCRA SPANDEX ORTHOSIS MFC II ROLYAN,SUP-2324867,CDM,L3660,HCPCS,0272,RC,,,,both,,,114.74,74.58,,,,,,,,,,,,,
HOOK SPNL PEDCL NEUT OPN BILAT 5.5MM ROD DIA M THRT,SUP-2290617,CDM,C1713,HCPCS,0278,RC,,,,both,,,9398.02,6108.71,,,,,,,,,,,,,
DISTRACTOR EXT FIX 30 MM 1.5 - 1.8 MM TELSCP W/O ACTIVATOR,SUP-2492291,CDM,C1713,HCPCS,0278,RC,,,,both,,,17506.69,11379.35,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 2X2 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651373,CDM,Q4154,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CABLE EP CATH QUAD TWST TO S PIN,SUP-2141308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BIT DRL L 175/90 MM DIA2 MM SCREW DIA2.7 MM CALIB AO QC CLR,SUP-2907958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,852.26,553.97,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRACILIS TEND FRZN COLL-E-STRONG,SUP-2321811,CDM,C1762,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SYSTEM SEAL 5ML SPINE DURA FOR CRAN SURG DURASEAL,SUP-2243096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2553.57,1659.82,,,,,,,,,,,,,
CATHETER CARD ABLATION BLZR PRIM XP L 110 CM DIA 7 FR TIP L,SUP-2141339,CDM,C1731,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
CABLE ADPT CARRG ADAPTOR LT VENTRICULAR ASST DEV,SUP-2356042,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
POROUS TOT CNDYL FEM COMP MED R,SUP-2397049,CDM,C1776,CPT,0278,RC,,,,both,,,16390.80,10654.02,,,,,,,,,,,,,
KIT INTRO VSI L 15 CM DIA 4 FR NIT TUNGSTEN TIP SIL STIFFEN,SUP-2763487,CDM,C1892,HCPCS,0272,RC,,,,both,,,199.70,129.80,,,,,,,,,,,,,
STENT NEURO LVIS L 19 MM DIA 3.5 MM MICROCATHETER 0.021 IN,SUP-2305225,CDM,C1876,HCPCS,0278,RC,,,,both,,,20205.90,13133.83,,,,,,,,,,,,,
SYSTEM INTRO SHTH 9FR L13CM BLK HUB W O SIDEPRT SPLITTABLE,SUP-2303230,CDM,C1892,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
TUBING SUCT L244CM L61CM DIR CTRL HD DISP FOR OLY FUJINON,SUP-2360654,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
CROWN DENT 6 UP LT PRI CTRL INCIS PED PREFABRICATED UNITEK,SUP-2100350,CDM,D6783,CPT,0278,RC,,,,both,,,19.59,12.73,,,,,,,,,,,,,
ANCHOR SUT L14.5MM DIA3MM W/ SZ 2 FIBERWIRE BIO-SUTTAK(ORDER MULTIPLES OF 5EA),SUP-2121590,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
LG OATS HARVSTR 14,SUP-2812478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1410.17,916.61,,,,,,,,,,,,,
PUTTY T50106 GRFT DBF 6CC,SUP-2281670,CDM,C1713,HCPCS,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
PLATE BONE L112MM PROX HUM LCK FOR ORTH FIX SYS,SUP-2167418,CDM,C1713,HCPCS,0278,RC,,,,both,,,3384.92,2200.20,,,,,,,,,,,,,
CATHETER ATHRCTMY JETSTREAM XC L 135 CM TIP DIA2.1-3 MM,SUP-2148530,CDM,C1724,HCPCS,0278,RC,,,,both,,,20253.00,13164.45,,,,,,,,,,,,,
COIL EMB COMPLX 2 MMX4 CM ORBIT GALAXY XTRASOFT,SUP-2427735,CDM,C1713,HCPCS,0278,RC,,,,both,,,4994.30,3246.29,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 7-4 MM EPTFE TAPR FLX TW SM,SUP-2761495,CDM,C1768,CPT,0278,RC,,,,both,,,3730.29,2424.69,,,,,,,,,,,,,
PLATE BONE 8 H LT CLAV LCK J,SUP-2107751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP FIXED 60MM,SUP-2749356,CDM,C1713,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
DRSG BIO L 7 X W 20 CM DECELL INTACT FISH SKIN SKIN MESHED 2,SUP-2909179,CDM,Q4158,HCPCS,0636,RC,,,,both,,,22501.24,14625.81,,,,,,,,,,,,,
ULNAR COLUMN SMARTLOCK PLATE LNG LEFT,SUP-2484508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
HC Blood Patch,PX-4506227300,CDM,62273,CPT,0450,RC,,,,both,,,1586.00,1030.90,,,,,,,,,,,,,
CATHETER EMB 4FR 0.50ML L40CM BLLN DIA9MM 0.025IN S STL BA,SUP-2214016,CDM,C1757,HCPCS,0272,RC,,,,both,,,421.07,273.70,,,,,,,,,,,,,
GUIDEWIRE VASC L 300 CM DIA 0.038 IN TAPR L 9.5 CM FLPY TIP,SUP-2167956,CDM,C1769,HCPCS,0272,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
SPLINT WRST FOAM PADDING YTH FOREARM RT PERF DESIGN ALUM,SUP-2336021,CDM,L3908,HCPCS,0274,RC,,,,both,,,11.43,7.43,,,,,,,,,,,,,
FIXED ANGLE GUIDE 135 DEG,SUP-2704816,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.29,481.19,,,,,,,,,,,,,
TAMP KYPHOPLASTY SZ 3 BLLN L10MM INFL BNE KYPHON XPANDER II,SUP-2293665,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PLATE FUS INTCARP 2.4MM 7H 17MM TI VAL STRL,SUP-2546688,CDM,C1713,HCPCS,0278,RC,,,,both,,,3750.38,2437.75,,,,,,,,,,,,,
ANCHOR SUTURE 5.5MM WITH 2 SUTURES HI-FI NEEDLE GENESYS CROS,SUP-2824354,CDM,C1713,HCPCS,0278,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
NAIL INTRMDLLRY 9.3MM DIA 360MML TTNM ALLOY PRFRMS FOSSA FMR,SUP-2588307,CDM,C1713,HCPCS,0278,RC,,,,both,,,5112.64,3323.22,,,,,,,,,,,,,
INDWELLING VOICE PROS LEF,SUP-2242341,CDM,L8509,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
INTRODUCER RF 17 GAX150 MM COOLIEF,SUP-2237171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.98,230.74,,,,,,,,,,,,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,0636,RC,70710-1478-01,NDC,,both,1.5,ML,2666.20,1733.03,,,,,,,,,,,,,
COMPONENT FEM KNEE POST STABILIZING UNI UNISX PRI PRESSFIT,SUP-2208911,CDM,C1776,CPT,0278,RC,,,,both,,,9327.37,6062.79,,,,,,,,,,,,,
DILATOR ENDOSCP CATHETER  L2400MM BLLN L55MM DIA18 20MM ES P,SUP-2436500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
OXYBUTYNIN CHLORIDE 5 MG/5ML PO SOLN,RX-161504,CDM,340b,HCPCS,0637,RC,54838-0510-80,NDC,,both,2.5,ML,2.70,1.75,,,,,,,,,,,,,
GRAFT HUM TISS L 49-51 X W 4-6 MM THK 4-8 MM SZ 50 MM,SUP-2913233,CDM,C1762,CPT,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
HOOK SUT PREASSEMBLED FOR RETRCT FISH,SUP-2194668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,37.46,24.35,,,,,,,,,,,,,
PLATE BONE FRDM WR IMPL CRPL SIZE2,SUP-2243495,CDM,C1713,HCPCS,0278,RC,,,,both,,,14189.25,9223.01,,,,,,,,,,,,,
SYSTEM PACEMKR PHILOS SINGLE CHMBR,SUP-2137965,CDM,C1786,HCPCS,0275,RC,,,,both,,,10060.56,6539.36,,,,,,,,,,,,,
CATHETER ETER VEN EXTN SET W INJ CAP 10FR TESIO,SUP-2269529,CDM,C1881,HCPCS,0278,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
CATHETER EP L120CM DIA6FR ELECTRD SPC 2-2-2MM JSN CRV MAP,SUP-2356819,CDM,C1730,HCPCS,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
ANCHOR SUT 2 ORTHOCORD BRAID GRSP SET BIOKNOTLESS,SUP-2249362,CDM,C1713,HCPCS,0278,RC,,,,both,,,1372.18,891.92,,,,,,,,,,,,,
GRAFT BNE PASTE 8 CC SYR DBM ORTHOBLAST II,SUP-2641748,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE FEM 90 5 DEG 5 MM DSTL 4 HOLE FLARE SS STRL JPS,SUP-2645619,CDM,C1713,HCPCS,0278,RC,,,,both,,,16755.04,10890.78,,,,,,,,,,,,,
CENTRALIZER VERSYS HERITAGE PROX 15MM EXT,SUP-2504424,CDM,C1776,CPT,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SHEATH ENDOSCP DIA4MM 30DEG LENS CLN DISP ENDO-SCRUB 2,SUP-2284170,CDM,C1894,HCPCS,0272,RC,,,,both,,,161.58,105.03,,,,,,,,,,,,,
ORTHODONTIC ANCHRGE PLATE 14MM WTH FLAT 5MM AREA T10MM CP T,SUP-2680878,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.23,367.40,,,,,,,,,,,,,
CLAMP EXT FIX RNG TO ROD,SUP-2188590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2594.39,1686.35,,,,,,,,,,,,,
HC So Ihc Ea Addl Single Ab Stain,PX-3128834166,CDM,88341,CPT,0312,RC,,,,both,,,495.00,321.75,,,,,,,,,,,,,
PLATE BNE L 114 MM 5 H SS PROX HUM STR STRL EVOS,SUP-2931130,CDM,C1713,HCPCS,0278,RC,,,,both,,,5462.03,3550.32,,,,,,,,,,,,,
PLATE BONE L68MM 3 H BILAT S STL T SHP LO PROF NEUT,SUP-2185751,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.79,557.56,,,,,,,,,,,,,
SET PICC 3L 6FR X 55CM TCG,SUP-2887073,CDM,C1751,HCPCS,0278,RC,,,,both,,,1097.96,713.67,,,,,,,,,,,,,
BIT DRL DIA 4.15 MM RT ANGLE FOR TOT ANK REPL SYS NS DISP,SUP-2899211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
SPACER SPNL LORDTC 50X14 MM DUO,SUP-2423847,CDM,C1821,HCPCS,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
STENT BILI L20MM 6FR 135CM CATH LEN 10MM DIAM AD,SUP-2158931,CDM,C2625,HCPCS,0278,RC,,,,both,,,5928.32,3853.41,,,,,,,,,,,,,
PLATE BNE OSTEOTMY 110 DEG AD 4.5X116 MM TI NS DCP,SUP-2569053,CDM,C1713,HCPCS,0278,RC,,,,both,,,3381.53,2197.99,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 12X12X12 MM FD SPNG CANC READIGRAFT BLX,SUP-2740971,CDM,C1713,HCPCS,0278,RC,,,,both,,,1671.92,1086.75,,,,,,,,,,,,,
MESH SURG W5XL15CM SILK BIOABSRB MULTIFILAMENT KNIT,SUP-2113412,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
GRAFT BNE SUB 25CC 50X10X5MM STRP STRATOFUSE,SUP-2164171,CDM,C1713,HCPCS,0278,RC,,,,both,,,981.25,637.81,,,,,,,,,,,,,
SCREW AUTO DRIVE 13.6X4MM,SUP-2719502,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.93,104.60,,,,,,,,,,,,,
"HC So Antidiuretic Hormone, Plasma",PX-3018458866,CDM,84588,CPT,0301,RC,,,,outpatient,,,74.00,48.10,,,,,,,,,,,,,
LENS INTOCU 21.5 DIOPT 118.7 A CONSTANT L13MM DIA6MM 0DEG,SUP-2110230,CDM,V2632,HCPCS,0276,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
DRILL ENDOSCP 2.5 MM 4 5,SUP-2877962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
HC So Myelin Basic Protein,PX-3018387366,CDM,83873,CPT,0301,RC,,,,outpatient,,,992.00,644.80,,,,,,,,,,,,,
SPACER FEM -2 MM MULTI-REFERENCE 4-IN-1 MICRO-MILL NXGN,SUP-2438070,CDM,C1776,CPT,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR (MIXTURES ONLY),RX-430070,CDM,J2919,HCPCS,0636,RC,00009-0698-01,NDC,,both,1,UN,252.90,164.38,,,,,,,,,,,,,
STEM FEM L L60MM NK L35MM SH CEMEX GENTMYCN HI REL IMPREG,SUP-2223679,CDM,C1776,CPT,0278,RC,,,,both,,,9693.18,6300.57,,,,,,,,,,,,,
SCALPEL ELECSURG 85MM PLSM PADDLE BLDE CANADY HYBRID,SUP-2391728,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
KIT TRL ANK FT STRL DISP APOLLOANKLE,SUP-2894237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KNIFE OPHTHLMC 4.5NL 2MMW 0.2MM THK DMND TRFCT BLADE PUSH PU,SUP-2499879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2465.53,1602.59,,,,,,,,,,,,,
PLATE BNE W11XL246MM THK3.7MM 14 H NONSTERILE L MED DST TIB,SUP-2185600,CDM,C1713,HCPCS,0278,RC,,,,both,,,4656.43,3026.68,,,,,,,,,,,,,
REPLACEMENT PD F VISTA CERV CLLR ADLT,SUP-2196894,CDM,L0120,HCPCS,0272,RC,,,,both,,,52.19,33.92,,,,,,,,,,,,,
KIT RETRCT SHIM DISP FOR MINIMAL ACCS SYS MAXCESS 4,SUP-2310431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CATHETER INTVASC OCCL EQL L 100 CM DIA 7 FR BALLOON DIA20 MM,SUP-2147468,CDM,C2628,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
STEM HUM L205MM OD8MM TI POR SHLDR REV UNCEMENTED IMP,SUP-2404710,CDM,C1776,CPT,0278,RC,,,,both,,,11533.22,7496.59,,,,,,,,,,,,,
KIT PUMP BLOOD CANNULA BYPS TANDEMHEART LIFESPARC V24/A17,SUP-2717605,CDM,C1889,HCPCS,0278,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
NEEDLE BX 19 GAX155 MM ALWAYS-ON TIP TRACKED,SUP-2797899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2246.67,1460.34,,,,,,,,,,,,,
SYSTEM MIC ACCS GLIDEACCESS DIA 4 FR L 40 CM PLAT NIT WIRE,SUP-2385205,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.038 IN TAPR L 9 CM FLPY TIP L 4,SUP-2638705,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.35,22.33,,,,,,,,,,,,,
OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR,RX-110204,CDM,340b,HCPCS,0637,RC,72205-0060-78,NDC,,both,5,ML,3.80,2.47,,,,,,,,,,,,,
MESH SPNL W17XH50XL22MM TI OVL,SUP-2254371,CDM,2780000010,LOCAL,0278,RC,,,,both,,,12289.96,7988.47,,,,,,,,,,,,,
WASHER ORTH L L13MM DIA6.6MM BONE FIX RND,SUP-2198347,CDM,C1713,HCPCS,0278,RC,,,,both,,,45.84,29.80,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE UPR W/O KA PLAS,SUP-2435636,CDM,L2034,HCPCS,0274,RC,,,,both,,,5751.38,3738.40,,,,,,,,,,,,,
GUIDEPIN ORTH DIA3MM FOR OPN WDG OSTEOTMY,SUP-2121036,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
QUARTEX OCCIPITAL PLT SM,SUP-2229108,CDM,C1713,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
WIRE FIX 1X70 MM DBL END TRCR PT STRL KIRSCHNER,SUP-2860990,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
PLATE BNE TIB TUBEROSITY ADV 2.4/2.7X53 MM RT 2 HOLE LCP,SUP-2569433,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.98,74.09,,,,,,,,,,,,,
TAP SURG L 65 MM DIA1.7 MM SD HEX FOR 3 MM SCREW DELT,SUP-2883333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1690.67,1098.94,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUMERUS 14H 307MM RT STER,SUP-2546853,CDM,C1713,HCPCS,0278,RC,,,,both,,,6773.83,4402.99,,,,,,,,,,,,,
PLATE BONE LOCKING LARGE 3.5X68 MM LEFT CALCANEAL FOR SCREW,SUP-2837156,CDM,C1713,HCPCS,0278,RC,,,,both,,,6959.65,4523.77,,,,,,,,,,,,,
SCREW INTRF L30MM DIA8-10MM TIB PEEK TAPR INTRAFIX,SUP-2256822,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
ARTHROSCOPE VID L 180 MM PASSPRT CANN L 5 CM DIA 8 MM,SUP-2930477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1763.90,1146.53,,,,,,,,,,,,,
IMPL WRIST HEAD STEM 6MM COLLAR SZ 2,SUP-2703130,CDM,C1776,CPT,0278,RC,,,,both,,,9679.84,6291.90,,,,,,,,,,,,,
MOLD CEM SPCR DIA70MM UNIV TIB SIL CRUCE SACRIFICING AGC,SUP-2408627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
BUR SURG CYL 7.6 MMX14 CM FLUT LG BOR MIDAS REX LEGEND,SUP-2627698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.62,262.35,,,,,,,,,,,,,
STYLET PACE L 80 CM DIA 0.016 IN SFT STIFFNESS STRL,SUP-2148857,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BONE L20MM THK1MM 12 H TI LCK COMPR ADPT MINI FRAG FOR,SUP-2191209,CDM,C1713,HCPCS,0278,RC,,,,both,,,2710.13,1761.58,,,,,,,,,,,,,
"HC So Gel Diffusion, Qualitative",PX-3028633166,CDM,86331,CPT,0302,RC,,,,both,,,41.00,26.65,,,,,,,,,,,,,
SCREW BNE L6MM DIA2.3MM MAND CRANIOMAXILLOFACIAL G ST CRSS 5PK,SUP-2366152,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.74,130.48,,,,,,,,,,,,,
CATH REBAR MICRO 027,SUP-2469113,CDM,C1887,HCPCS,0272,RC,,,,both,,,888.62,577.60,,,,,,,,,,,,,
CATHETER GUID L100CM OD7FR ID0.081IN NYL COR EXTRA BK UP,SUP-2296064,CDM,C1887,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
DISP KIT DX SWIVELOCK CANN 4.75 MM,SUP-2815107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SEALER TISS L14CM ADV BPLR STR RND TIP OPN APPRCH ENSEAL,SUP-2257688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5743.00,3732.95,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L105CM BAL L20MM DIA2MM 14ATM BURST RATE,SUP-2101442,CDM,C1725,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
KIT REPAIR SYNDESMOSIS SS STRL FIBULINK,SUP-2605957,CDM,C1713,HCPCS,0278,RC,,,,both,,,3678.38,2390.95,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 6-8 MM EPTFE TAPR TW N RING,SUP-2396729,CDM,C1768,CPT,0278,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
COMPONENT PATELLAR F 12 MM ARTC KNEE,SUP-2200799,CDM,C1776,CPT,0278,RC,,,,both,,,9200.20,5980.13,,,,,,,,,,,,,
HC Insert Picc Cath,PX-4503656900,CDM,36569,CPT,0450,RC,,,,both,,,4942.00,3212.30,,,,,,,,,,,,,
PROSTHESIS URETH L6CM OCCL CUF W/O INHIBZN AMS 800,SUP-2138923,CDM,C1815,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
GRAFT VASC L50CM DIA16X8MM UNIV POLY KNIT BIFUR STD WALL,SUP-2395628,CDM,C1768,CPT,0278,RC,,,,both,,,1673.62,1087.85,,,,,,,,,,,,,
HC Lyr Clos Nk Hnd Ft <2.6cm,PX-4501204100,CDM,12041,CPT,0450,RC,,,,both,,,810.00,526.50,,,,,,,,,,,,,
GRAFT BNE L210MM SHFT FEM FEM FRZN BISECTED MATRIGRFT,SUP-2264726,CDM,C1713,HCPCS,0278,RC,,,,both,,,2883.43,1874.23,,,,,,,,,,,,,
LINER ACET OD68MM ID32MM THK12.4MM 10DEG LONGEVITY,SUP-2202590,CDM,C1776,CPT,0278,RC,,,,both,,,2139.28,1390.53,,,,,,,,,,,,,
OCCLUDER CV AMULET 2 DIA 34 MM NIT POLYESTER LAA STRL,SUP-2909498,CDM,C1817,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
VALVE VENT PUR TRACH TBNG SWALLOING LO PROF DISP PASSY MUIR,SUP-2322024,CDM,L8501,HCPCS,0272,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
PLATE QUIKFLAP 1X20 BURR 2X2 PLT,SUP-2718048,CDM,C1713,HCPCS,0278,RC,,,,both,,,5287.45,3436.84,,,,,,,,,,,,,
STAPLE BNE SUPER ELASTIC 20X20X20 MM RELD HIMAX DYNA,SUP-2748446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
STENT BILI XCEED L 120 MM DIA 6 MM DEL CATH L 120 CM INTRO 6,SUP-2105750,CDM,C1876,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CICLOPIROX OLAMINE 0.77 % EX SUSP,RX-38962,CDM,6370000000,HCPCS,0637,RC,45802-0400-49,NDC,,both,30,ML,270.00,175.50,,,,,,,,,,,,,
BRACE ORTH L 11.5 X W 3 X H 18.5 IN THORACOLUMBOSACRAL MODEL,SUP-2902070,CDM,L0456,HCPCS,0274,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
MESH SURG W6XL13.7CM DIA5MM POLYPR L PRESHAPED H FLAT FOR,SUP-2219798,CDM,C1781,HCPCS,0278,RC,,,,both,,,342.07,222.35,,,,,,,,,,,,,
SCREW BONE L44MM DIA4.5MM CORT S STL ST NONCANNULATED,SUP-2363886,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.54,52.35,,,,,,,,,,,,,
STEM HUM CEM STD UNIV 6X115 MM REV W/ ALIGN HOLE TI PLASMA,SUP-2431672,CDM,C1776,CPT,0278,RC,,,,both,,,12195.76,7927.24,,,,,,,,,,,,,
SHUNT CAR OUTLYING 9FX31CM,SUP-2264211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
BIT DRL OD2MM LNG PILOT QUIK REL,SUP-2319579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
CANNULA SUC IRR 5X350 MM 2 TRMPT VLV LASER GUIDE SEAL SS,SUP-2490633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,808.36,525.43,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 0.038 IN 8.5 FRX25 CM 7 HOLE UTHANE,SUP-2168244,CDM,C1729,HCPCS,0272,RC,,,,both,,,593.49,385.77,,,,,,,,,,,,,
STEM FEM PRSS FT 10X150 MM REV SLT GEN II,SUP-2435045,CDM,C1776,CPT,0278,RC,,,,both,,,4220.16,2743.10,,,,,,,,,,,,,
HC Iaadiadoo Not Otherwise Specified,PX-3068789900,CDM,87899,CPT,0306,RC,,,,both,,,689.00,447.85,,,,,,,,,,,,,
PLATE FT 200MM FOR TRUELOK FIX SYS,SUP-2316197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1951.35,1268.38,,,,,,,,,,,,,
PLATE PHLANG HD 1.5MM RT STRL VAL,SUP-2546075,CDM,C1713,HCPCS,0278,RC,,,,both,,,1619.58,1052.73,,,,,,,,,,,,,
FIXATOR EXT FIX LNG HND N BRDG FRACTR STRL DISP NBX,SUP-2909398,CDM,C1713,HCPCS,0278,RC,,,,both,,,9624.10,6255.66,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA10 FR HYDRPHLC,SUP-2383397,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.06,102.09,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST SUPCNDYL SOCKET MOLD,SUP-2435620,CDM,L1860,HCPCS,0274,RC,,,,both,,,3530.36,2294.73,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DYN TIP L 110 CM DIA 6 FR SPC,SUP-2141316,CDM,C1730,HCPCS,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
HC So Trb@ Gene Rearrange Amp,PX-3108134066,CDM,81340,CPT,0310,RC,,,,both,,,698.00,453.70,,,,,,,,,,,,,
CAGE SPNL 4 DEG 10X18X55 MM EXPANDABLE PEEK COROENT XLCT,SUP-2560176,CDM,C1889,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
CATHETER DIAG 3FR ID0.027IN L150CM HYDRPHLC COAT MICCATH STR,SUP-2305467,CDM,C1887,HCPCS,0272,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
NUT SPNL OUTERING 4.5 MM TI EXPEDIUM,SUP-2590813,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PROSTHESIS OSS SHEA HA/FP 3X10 MM TRIM HA FLROPLAS TORP,SUP-2637895,CDM,L8613,CPT,0278,RC,,,,both,,,1356.29,881.59,,,,,,,,,,,,,
TUBE TYMPLSTY PED L2MM DIA0.76MM TI VENT MORETZ TAB GRMMT,SUP-2284039,CDM,L8614,HCPCS,0278,RC,,,,both,,,117.12,76.13,,,,,,,,,,,,,
SCREW BNE PICK-UP,SUP-2467990,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.06,212.59,,,,,,,,,,,,,
PATCH CV HEMSHLD L 6 X W 2 IN THK 0.46 MM POLYESTER BOV,SUP-2484252,CDM,C1768,CPT,0278,RC,,,,both,,,1115.83,725.29,,,,,,,,,,,,,
SHUTTLE SUT 45DEG R W CHIA IDEAL,SUP-2256803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX32 CM 27 CM STR W/ SH,SUP-2267101,CDM,C1750,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
SIZER BRST DIA161CM P5CM 750CC GEL RND MOD + PROF,SUP-2300922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
PLATE BONE L12MM THK0.3MM 2 H TI STR ULT LO PROF MATRIXNEURO,SUP-2255851,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.96,148.17,,,,,,,,,,,,,
ALLOGRAFT OATS DISPOSABLE KIT 20MM,SUP-2811232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0258,RC,00264-1800-32,NDC,,both,250,ML,57.40,37.31,,,,,,,,,,,,,
GRAFT STENT IL 0.035 IN 10 MMX2.5 CM 11 FRX120 CM VIABAHN,SUP-2396573,CDM,C1874,HCPCS,0278,RC,,,,both,,,9200.20,5980.13,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H LNG TI NEURO STR PLT 1 PK,SUP-2935613,CDM,C1713,HCPCS,0278,RC,,,,both,,,1265.42,822.52,,,,,,,,,,,,,
COIL VASC AZUR CX L 28 CM DIA 9 MM MICROCATHETER 0.018 IN,SUP-2385238,CDM,C1889,HCPCS,0278,RC,,,,both,,,1412.22,917.94,,,,,,,,,,,,,
PLATE PERIARTICULAR PROX HUM 3.5MM 12H 271MM RT SS LCP STRL,SUP-2546056,CDM,C1713,HCPCS,0278,RC,,,,both,,,6193.68,4025.89,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO 2 SQ PLATE 1 PK,SUP-2936742,CDM,C1713,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
TRIAL WEDGEXXL 5MM FEM POST,SUP-2364867,CDM,C1776,CPT,0278,RC,,,,both,,,1310.32,851.71,,,,,,,,,,,,,
PLATE BONE L25MM THK0.6MM 3X4 H BILAT CRANIOMAXILLOFACIAL TI,SUP-2191245,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
NAIL IM TIB 7.5X240 MM PHOENIX,SUP-2534688,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
CATHETER VENTRICULAR ANTIMICROBIAL BACTISEAL BA STRP NS0340,SUP-2666790,CDM,C1729,HCPCS,0272,RC,,,,both,,,3088.41,2007.47,,,,,,,,,,,,,
BIT DRL L75MM DIA2MM STRL J LATCH NONRADIOPAQUE W/O STP,SUP-2187208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.38,255.70,,,,,,,,,,,,,
TAMP BNE GRFT SPNL STR,SUP-2292627,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.98,898.94,,,,,,,,,,,,,
BASEPLATE TIB UNI LT MEDL PRI PEG CEM JOURNEY SZ 1,SUP-2346435,CDM,C1776,CPT,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
ENFIT BUTTON G TUBE 182.4,SUP-2674508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CATHETER ETER HAD ADMIN LNG TERM STR 145FRX28CM HEMO FLOW,SUP-2266974,CDM,C1750,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
ESG PLASMALOOP LG 30,SUP-2720994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1593.55,1035.81,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE RATCH LCK FOR ACTIVE,SUP-2435670,CDM,L2430,HCPCS,0274,RC,,,,both,,,405.85,263.80,,,,,,,,,,,,,
GRAFT NRV REP L3CM DIA2MM TYP 1 CLLGN ABSRB SEMIPERMEABLE,SUP-2244349,CDM,C9352,HCPCS,0278,RC,,,,both,,,4600.26,2990.17,,,,,,,,,,,,,
STEM HUM L122MM DIA12MM STD CO CHROM POR PRI PRESSFIT CEM,SUP-2404594,CDM,C1776,CPT,0278,RC,,,,both,,,9831.34,6390.37,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 2.8 MM 12 HOLE TITANIUM MATRIXMAND,SUP-2837765,CDM,C1713,HCPCS,0278,RC,,,,both,,,4415.78,2870.26,,,,,,,,,,,,,
STAPLER INT L100MM THK38MM TI RELD TWO DBL STAGGERED ROW,SUP-2283275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.82,400.28,,,,,,,,,,,,,
PLATE BNE 1.5/2X48X1.2 MM 7 HOLE SS LCP,SUP-2569287,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.95,222.27,,,,,,,,,,,,,
POST EXT FIX 4 H WIRE,SUP-2255810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.68,470.39,,,,,,,,,,,,,
BLADE SAW RECIP,SUP-2418566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
COMPONENT FEM RESURF CODE D MTL ON MTL CEM CO CHROM 38MM HD,SUP-2204655,CDM,C1776,CPT,0278,RC,,,,both,,,18573.10,12072.51,,,,,,,,,,,,,
GRAFT BNE STD W55 60XL55 60MM PERICARD TISS BIO SCFLD FRZ,SUP-2307106,CDM,C1713,HCPCS,0278,RC,,,,both,,,1492.98,970.44,,,,,,,,,,,,,
CATHETER VENTILATOR L 40 CM DIA 4 MM PTFE LASER JET DL ENT,SUP-2662067,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
BIOTENE PBF DRY MOUTH MT LIQD,RX-82596,CDM,A9154,HCPCS,0636,RC,09999-9917-32,NDC,,both,15,ML,2.70,1.75,,,,,,,,,,,,,
SCREW BNE L34MM DIA3.5MM NONLOCKING FOR R3CON PLATING SYS,SUP-2321371,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.62,289.00,,,,,,,,,,,,,
STYLET SPNL 45 MM FOR RELINE K WIRELESS MAS,SUP-2421827,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PLATE BNE RECON UNIV 2.7 MM 8 HOLE 2 COMPR LCK FOR SCR TI NS,SUP-2478271,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.69,706.35,,,,,,,,,,,,,
STAPLER INT RELD LD UNIT SM DISP,SUP-2787674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.33,210.81,,,,,,,,,,,,,
METOCLOPRAMIDE HCL 10 MG PO TABS,RX-5005,CDM,6370000000,HCPCS,0637,RC,60687-0631-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 4.01-5.0 MCI NS ADVANTAGE,SUP-2247271,CDM,C2643,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
ELECTRODE ENDOSCP 24FR MPLR DISP BALL UROLOGY COAG 1 STEM,SUP-2261112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VISIA AF MRI VR SURESCAN W 51 X H 66 MM D,SUP-2282424,CDM,C1722,HCPCS,0275,RC,,,,both,,,36743.59,23883.33,,,,,,,,,,,,,
HC So Rubella Latex Test,PX-3028676266,CDM,86762,CPT,0302,RC,,,,inpatient,,,165.00,107.25,,,,,,,,,,,,,
GRAFT VASC GORTX L 110 CM DIA 8 MM RNG L 70 CM EPTFE STR TW,SUP-2396139,CDM,C1768,CPT,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
BRACE ORTH CUST FABRICATED RIGID W/O INTFACE LNR PLAS,SUP-2388142,CDM,L0482,HCPCS,0274,RC,,,,both,,,4080.59,2652.38,,,,,,,,,,,,,
PLATE BNE TBLR 49 MM 4 HOLE 1/3 STRL,SUP-2518435,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
LIDOCAINE HCL 1% INJ (MIXTURES ONLY),RX-430017,CDM,J2003,HCPCS,0636,RC,63323-0492-57,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
HC So Hematology Procedure,PX-3058599966,CDM,85999,CPT,0305,RC,,,,both,,,237.00,154.05,,,,,,,,,,,,,
RESERVOIR SHUNT 14MM SMALL TITANIUM RADIOPAQUE INTEGRATED CA,SUP-2830498,CDM,C1729,HCPCS,0272,RC,,,,both,,,1536.43,998.68,,,,,,,,,,,,,
GRAFT HUM TISS W8-17XH10-17XL14-20MM THK7MM IL CREST,SUP-2307137,CDM,C1762,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
GRAFT BONE SUB L13.5MM OD6.5MM FACET DWL FLX HD THRD,SUP-2306918,CDM,C1713,HCPCS,0278,RC,,,,both,,,6661.82,4330.18,,,,,,,,,,,,,
INTRODUCER VASC 8 FR 98 CM LEN AD,SUP-2355589,CDM,C1894,HCPCS,0272,RC,,,,both,,,82.43,53.58,,,,,,,,,,,,,
SHEATH GUID 5FR L45CM HOCK STK HYDRPHLC XCUT W/ DIL PINN,SUP-2384891,CDM,C1894,HCPCS,0272,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
GRAFT BNE SUB 3ML VOID FILL RESRB PTTY MASTERGRFT,SUP-2288541,CDM,C9359,HCPCS,0278,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
INSERT HUM CONSTRN 6+ MM 36 MM SHLDR AEQUALIS REVERSED FX,SUP-2715647,CDM,C1776,CPT,0278,RC,,,,both,,,4890.55,3178.86,,,,,,,,,,,,,
VALVE PULM HOMOGRAFT SZ 23 MM CONDUIT STRL,SUP-2175243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
PLATE BONE SM W11XL233MM THK3.3MM 0DEG 18 H BILAT TI STR RIG,SUP-2190798,CDM,C1713,HCPCS,0278,RC,,,,both,,,1518.88,987.27,,,,,,,,,,,,,
SPLINT HND RT REG FUNC POS ABDUCTN OPPOS THMB FIRM SUPP,SUP-2324560,CDM,L3906,HCPCS,0274,RC,,,,both,,,81.33,52.86,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 6 MM CUBE,SUP-2547185,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.99,265.84,,,,,,,,,,,,,
WIRE BRST LOC BEAD 20 GAX14 CM 35 CM BARB GHIATAS,SUP-2759084,CDM,C1819,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
SHEATH LASER L50CM OD12FR LD OD7.5FR TIP OD12.5FR ID8.3FR,SUP-2353106,CDM,C2629,CPT,0272,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP J 0.038 INX145 CM SUPER STIFF PTFE AMPLATZ,SUP-2139355,CDM,C1769,HCPCS,0272,RC,,,,both,,,99.13,64.43,,,,,,,,,,,,,
PLATE LOK 10MM THCK PEREZ MINI T SHP EXT BASE LNG WIDE BAR,SUP-2262971,CDM,C1713,HCPCS,0278,RC,,,,both,,,1552.26,1008.97,,,,,,,,,,,,,
SYSTEM PLT PREP FOR CASCADE AUTOLGS MEMBRN,SUP-2307545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
GUIDEWIRE SURG PARL 6.5-8 MM SCR RIVAL,SUP-2644850,CDM,C1769,HCPCS,0272,RC,,,,both,,,2408.19,1565.32,,,,,,,,,,,,,
PLEDGET CV L 2.5 X W 2.5 CM THK 1.85 MM PTFE FELT LO,SUP-2761316,CDM,C1768,CPT,0278,RC,,,,both,,,54.76,35.59,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX XSMALL 5X5 CM PLASTIC MATRISTEM,SUP-2106508,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2156.55,1401.76,,,,,,,,,,,,,
BOLT EXT FIX SHLDR NS DISP SMRT TSF,SUP-2932922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,195.90,127.33,,,,,,,,,,,,,
STRAP ELBW TENNIS UNIV FOAM D RNG,SUP-2336255,CDM,L3702,HCPCS,0272,RC,,,,both,,,9.70,6.30,,,,,,,,,,,,,
HEAD FEM SZ 2 DIA48MM FEM HIP M SPECIFICATION MTL 12 14 ARTC,SUP-2251167,CDM,C1776,CPT,0278,RC,,,,both,,,5635.04,3662.78,,,,,,,,,,,,,
STENT ESOPH HANAROSTENT L 100 MM DIA22 MM DEL SYS L 700 MM,SUP-2498307,CDM,C1874,HCPCS,0278,RC,,,,both,,,6860.90,4459.58,,,,,,,,,,,,,
PLATE BNE U FT 4 H INTERAXIS COMPR UNIV CP FOR FIX OF BNE,SUP-2243478,CDM,C1713,HCPCS,0278,RC,,,,both,,,12098.42,7863.97,,,,,,,,,,,,,
SCREW SPNL L4MM DIA2MM CORT TI SELF DRL FULL THRD STARDRV,SUP-2189353,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
ROD EXT FIX CRV 180 DEG 8X540 MM SPAN CARBON FIBER,SUP-2188574,CDM,C1713,HCPCS,0278,RC,,,,both,,,1213.11,788.52,,,,,,,,,,,,,
PEG FIX LCK 2.5X12 MM PART THRD STRL,SUP-2457660,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
TAP SURG L 50 MM DIA1.7 MM SCREW DIA 5/6 MM SD DENT NS DISP,SUP-2909582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1038.46,675.00,,,,,,,,,,,,,
PLATE BONE L99MM 5 H S STL T SHP,SUP-2198573,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.69,289.05,,,,,,,,,,,,,
GUIDEWIRE ORTH SKYHAWK,SUP-2658910,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
STENT PERIPH S.M.A.R.T. CTRL L 150 MM DIA 7 MM DEL SYS L 120,SUP-2158593,CDM,C1876,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
KIT VENT ASST ACC SUPP L HEARTWARE,SUP-2282538,CDM,C1713,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX30 RCNSTRCTN F/2.7MM LOK SCREW ST,SUP-2461645,CDM,C1713,HCPCS,0278,RC,,,,both,,,2028.50,1318.52,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1395108D5,SUP-2632830,CDM,C1751,HCPCS,0278,RC,,,,both,,,1207.27,784.73,,,,,,,,,,,,,
VALVE VENTRICULAR SHUNT L90CM OD1.9MM 40CM VERTICAL WATER PR,SUP-2821785,CDM,C1889,HCPCS,0278,RC,,,,both,,,7154.90,4650.68,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM FLX GENDER SOL N-K,SUP-2212608,CDM,C1776,CPT,0278,RC,,,,both,,,15219.99,9892.99,,,,,,,,,,,,,
PACEMAKER CARD 12.8GM 5.9CC W33XH33IN THK6MM SGL CHMBR IS1,SUP-2356132,CDM,C1786,HCPCS,0275,RC,,,,both,,,7138.16,4639.80,,,,,,,,,,,,,
SCREW CANN VA LCK OPTILINK  5.0X30MM,SUP-2657208,CDM,C1713,HCPCS,0278,RC,,,,both,,,771.97,501.78,,,,,,,,,,,,,
PLATE BONE MESH 1.3X100X100 MM 5X5 MM TITANIUM,SUP-2838346,CDM,C1713,HCPCS,0278,RC,,,,both,,,6904.86,4488.16,,,,,,,,,,,,,
CONE FEM AUG 6 LT KNEE CTRL TRITANIUM TRIATHLON,SUP-2422247,CDM,C1776,CPT,0278,RC,,,,both,,,10847.98,7051.19,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA 34 MM BRANCH SZ,SUP-2695457,CDM,C1768,CPT,0278,RC,,,,both,,,5383.78,3499.46,,,,,,,,,,,,,
GRAFT BNE 20MM LEN 8 15MM W IMPL HUM TISS FIB SHFT BNE FRZN,SUP-2264879,CDM,C1713,HCPCS,0278,RC,,,,both,,,3236.46,2103.70,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL SHELL,SUP-2435548,CDM,L0490,HCPCS,0274,RC,,,,both,,,800.86,520.56,,,,,,,,,,,,,
PACK 23 KHZ ST STD TIP,SUP-2243954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
NEEDLE CRYOABLATION 90 DEG ICEEDGE,SUP-2225666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4698.23,3053.85,,,,,,,,,,,,,
COMPONENT HIP BPLR HA PART LO DEMAND,SUP-2249605,CDM,C1776,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0X40MM HDLSS CANN LNG THRD SCR,SUP-2320928,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.79,510.76,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 2",PX-7619921200,CDM,99212,CPT,0761,RC,,,,both,,,302.00,196.30,,,,,,,,,,,,,
IMPLANT OPHTH RETIN TIRE SIL,SUP-2213508,CDM,L8610,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
SCREW BONE L6MM THRD DIA2.7MM HD DIA4.3MM COR DIA2MM PITCH,SUP-2349433,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.21,441.49,,,,,,,,,,,,,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-159345,CDM,J1720,HCPCS,0636,RC,00009-0013-05,NDC,,both,1,UN,256.10,166.46,,,,,,,,,,,,,
ROD SPNL ANTR RT SMOOTH 5.5MM DIA 110MM LEN LEG,SUP-2289285,CDM,C1713,HCPCS,0278,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
FUSION WCARMEDA 26L,SUP-2725865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
AUGMENT FEM L70MM THK10MM R LAT L MED DST UNIV KNEE STD TI,SUP-2407799,CDM,C1776,CPT,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
CATHETER HD STR EXTN 13.5 FRX13 CM DL HI FLO KT MAHRK ELITE,SUP-2626880,CDM,C1752,HCPCS,0278,RC,,,,both,,,223.82,145.48,,,,,,,,,,,,,
SYSTEM TISS GLUE 4 ML KT BIOLOGIC FBRN SEAL TISSEEL VALUPAK,SUP-2129971,CDM,C9250,HCPCS,0636,RC,,,,both,,,677.67,440.49,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 8 IN WRST FOREARM LT,SUP-2336337,CDM,L3809,HCPCS,0274,RC,,,,both,,,24.55,15.96,,,,,,,,,,,,,
IMPLANT THMB 75MM MOD STEM,SUP-2137791,CDM,C1776,CPT,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SLEEVE DRL SPEC BLADE GUIDE FOR TROCHANTERIC FIX NAIL,SUP-2188248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4392.55,2855.16,,,,,,,,,,,,,
PLATE BNE TI ORTHOGNATHIC 7 PLATE CUSTOMIZED FACE ID,SUP-2883699,CDM,C1713,HCPCS,0278,RC,,,,both,,,34382.69,22348.75,,,,,,,,,,,,,
MINIMAL INVASIVE CALCANEAL PLATE L S,SUP-2829383,CDM,C1713,HCPCS,0278,RC,,,,both,,,5133.90,3337.03,,,,,,,,,,,,,
SET DIL PROTEK DUO DIA14/18/22/26 FR VEN STRL,SUP-2929862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SHEARS ROBOTIC DIA8MM CRV FOR ULTRASONIC ENERGY HARM ACE,SUP-2246795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1797.12,1168.13,,,,,,,,,,,,,
KIT SUBCHONDROPLASTY PROC SIDE TARGETED ACCUPORT,SUP-2414255,CDM,C1713,HCPCS,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
PLATE BNE OLECRANON 2.7/3.5X169 MM RT ELBW 8 HOLE LP VA LCK,SUP-2180816,CDM,C1713,HCPCS,0278,RC,,,,both,,,3738.61,2430.10,,,,,,,,,,,,,
PLATE BONE W23XL68MM THK2MM LNG 15 H LT DSTL RAD TI ADAPTIVE,SUP-2267976,CDM,C1713,HCPCS,0278,RC,,,,both,,,4111.05,2672.18,,,,,,,,,,,,,
MARKER SURG FIDUCIAL 2X3X1 CM SPACER CLP SFT TISS BIOZORB,SUP-2716283,CDM,A4648,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ TAB 1.02 MM ID TYTAN TI STRL,SUP-2277596,CDM,L8699,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
PLATE BNE THK06MM 4 H MIDFACE TI STR LO PROF LEV 1 SIL FOR,SUP-2262715,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.45,154.99,,,,,,,,,,,,,
STENT CORONARY MAGIC WSTNT DIA 6 MM LNG STRL,SUP-2141825,CDM,C1876,HCPCS,0278,RC,,,,both,,,6511.58,4232.53,,,,,,,,,,,,,
PLATE BNE 2.4X72X2 MM 9 HOLE SS LCP,SUP-2569301,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.93,271.65,,,,,,,,,,,,,
PLATE BNE L 95 MM DIA2.7 MM 10 SHFT 5 HD H SS T SHP HG NS V,SUP-2905622,CDM,C1713,HCPCS,0278,RC,,,,both,,,3394.28,2206.28,,,,,,,,,,,,,
APPLIER CLIP HEM-O-LOK ML ENDO 5,SUP-2747678,CDM,C1889,HCPCS,0278,RC,,,,both,,,3256.18,2116.52,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA 5 FR HYDRPHLC,SUP-2383400,CDM,C1894,HCPCS,0272,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
BUR SURGICAL TRABECULAR METAL TOTAL ANKLE ALTERNATE,SUP-2478397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1052.09,683.86,,,,,,,,,,,,,
SHEETING SIL 6X8IN THK.020IN SILAS N REINF,SUP-2134687,CDM,C1781,HCPCS,0278,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
PIN EXT FIX HALF 6X110 MM 40 MM THRD SS RINGFIX,SUP-2483167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE TROCH PERIPROSTHETIC STRL NCB,SUP-2862095,CDM,C1713,HCPCS,0278,RC,,,,both,,,15174.87,9863.67,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE THGH CALF CUST SINGLE FREE STIRRUP,SUP-2435631,CDM,L2000,HCPCS,0272,RC,,,,both,,,3167.13,2058.63,,,,,,,,,,,,,
SHELL ACET PRESSFIT REV 54 MM OD UNIV CLUS H FLR PLSM SPRY,SUP-2359356,CDM,C1776,CPT,0278,RC,,,,both,,,4728.84,3073.75,,,,,,,,,,,,,
BURR SURG L72MM OD1MM LNG RND CUT TOOL S STL NONFLUTED,SUP-2284256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
TUBE VENT ID1.14MM BLU SIL DONALDSON,SUP-2312635,CDM,L8699,HCPCS,0278,RC,,,,both,,,27.95,18.17,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.109X9 IN 3 SHANK END NS STEINMANN,SUP-2791601,CDM,C1713,HCPCS,0278,RC,,,,both,,,22.23,14.45,,,,,,,,,,,,,
BLADE US CRV LNG 20 MM RIGID SHTH TISS REMOVAL BONESCALPEL,SUP-2305945,CDM,C1713,HCPCS,0278,RC,,,,both,,,1964.07,1276.65,,,,,,,,,,,,,
SET SCR SPNL S STL PEDCL W/O BRK OFF FOR 6.35MM ROD CDH LEG,SUP-2288808,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.10,294.51,,,,,,,,,,,,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-7322,CDM,J7131,HCPCS,0258,RC,63323-0093-30,NDC,JW,both,30,ML,54.10,35.16,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 5ML DBM PUTTY IMP DYNAGRFT D,SUP-2242678,CDM,C9359,HCPCS,0278,RC,,,,both,,,1844.81,1199.13,,,,,,,,,,,,,
BLADE SAW KNEE 13MM CUT EDGE 2039710] EXACTECH INC],SUP-2222814,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
BASEPLATE GLEN 29 MM SHLDR W/ LNG POST AEQUALIS REVERSED II,SUP-2715609,CDM,C1776,CPT,0278,RC,,,,both,,,6030.37,3919.74,,,,,,,,,,,,,
HC So1 Ptt,PX-3058573067,CDM,85730,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD 12.5FRX24CM 3 MAHRK ELITE,SUP-2174267,CDM,C1752,HCPCS,0278,RC,,,,both,,,403.36,262.18,,,,,,,,,,,,,
SCREW CONN HUM TI NAIL CANN EXPERT SYS,SUP-2178847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1528.83,993.74,,,,,,,,,,,,,
FIBER LASER ORTHOPEDIC 0 DEG HOLM DISP,SUP-2225604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH L 100 CM BER TIP S SEP12,SUP-2865162,CDM,C1757,HCPCS,0272,RC,,,,both,,,31368.60,20389.59,,,,,,,,,,,,,
HC Group Caregiver Training Strategies & Technique,PX-4309755200,CDM,97552,CPT,0430,RC,,,,both,,,56.00,36.40,,,,,,,,,,,,,
RING EXT FIX DIA210MM C FULL FOR HOFFMANN LRF SYS,SUP-2363154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5000.14,3250.09,,,,,,,,,,,,,
STEM FEM L200MM OD11MM CVD MOD SEG FORGED HIP TI ACUMATCH,SUP-2222150,CDM,C1776,CPT,0278,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
PLATE BNE THK06MM 4 H REG TI R L LO PROF LEV 1 FIX FOR 2MM,SUP-2262933,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
HEAD ULN 17.5 WRST MOD COCR 1ST CHOICE,SUP-2852954,CDM,C1776,CPT,0278,RC,,,,both,,,5750.72,3737.97,,,,,,,,,,,,,
HC Remove Aortic Assist Device,PX-3603396800,CDM,33968,CPT,0360,RC,,,,outpatient,,,5920.00,3848.00,,,,,,,,,,,,,
BRACE ANK SM AD FOR 7-8.5IN UNIV VLY CNTOUR STL STAY CNTCT,SUP-2197932,CDM,L4350,HCPCS,0272,RC,,,,both,,,110.21,71.64,,,,,,,,,,,,,
PLATE BNE SM W10XL97MM THK15MM 90DEG 3X8 H TI T SHP R ANG,SUP-2190939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1849.96,1202.47,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y PLT XDRV 12 PK STRL,SUP-2935624,CDM,C1713,HCPCS,0278,RC,,,,both,,,26887.82,17477.08,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X18 MM FUSION HEX DRV YEL WRST SS NS,SUP-2852117,CDM,C1713,HCPCS,0278,RC,,,,both,,,710.93,462.10,,,,,,,,,,,,,
ALLOGRAFT BTB WHOLE LT FZ ASP,SUP-2875971,CDM,C1762,CPT,0278,RC,,,,both,,,11839.53,7695.69,,,,,,,,,,,,,
SPLINT THMB AD FOR 4.5-9.5IN REG KUHL PERF NEOPRNE WRP ARND,SUP-2324315,CDM,L3931,HCPCS,0272,RC,,,,both,,,73.70,47.90,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED STD S3 MOD TURON,SUP-2197233,CDM,C1776,CPT,0278,RC,,,,both,,,14601.00,9490.65,,,,,,,,,,,,,
SET URET STENT PROX L 30 CM DIA24 FR DSTL L 20 CM DIA12-7 FR,SUP-2171266,CDM,C2617,HCPCS,0278,RC,,,,both,,,327.50,212.87,,,,,,,,,,,,,
SUPPORT ORTHOT CUST MILWAUKEE TYP SUPERSTRUCTURE,SUP-2435586,CDM,L1230,HCPCS,0274,RC,,,,both,,,1888.71,1227.66,,,,,,,,,,,,,
SCREW INTRF BIOSURE REGENESORB 9MMX35MM,SUP-2341924,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.90,662.93,,,,,,,,,,,,,
MAXDRIVE BLADE ANGULUS 20/23MM,SUP-2679093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.99,304.19,,,,,,,,,,,,,
STAPLER INT USE DIA21 MM STPL H 4/4.5/5 MM XL X THCK CIR BLK,SUP-2896440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4688.52,3047.54,,,,,,,,,,,,,
EPICORD EXPANDABLE 2x3cm 6SQ CM,SUP-2660776,CDM,Q4187,HCPCS,0636,RC,,,,both,,,4753.96,3090.07,,,,,,,,,,,,,
PLATE BNE CRV R108 58.5 MM PELV 4 HOLE SS MATTA,SUP-2362681,CDM,C1713,HCPCS,0278,RC,,,,both,,,2395.82,1557.28,,,,,,,,,,,,,
HC Myelogram Lumbar,PX-3616230400,CDM,62304,CPT,0361,RC,,,,outpatient,,,3892.00,2529.80,,,,,,,,,,,,,
PLATE BNE CONN 6 HOLE,SUP-2468568,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER SET TWO LUMEN 0.035 IN 12 FRX20 CM YOU-BEND LG BOR,SUP-2627065,CDM,C1752,HCPCS,0278,RC,,,,both,,,230.04,149.53,,,,,,,,,,,,,
CONNECTOR SPNL TRNSVRS STD 15 MM CROSSLINK AX FOR 6MM ROD TI,SUP-2193734,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 50 CM DIA 6 MM EPTFE STR STD WALL REINF,SUP-2480088,CDM,C1768,CPT,0278,RC,,,,both,,,3298.51,2144.03,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 22 MM 8 CHANNEL TWISTED PR GRN WHT,SUP-2901949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.14,601.99,,,,,,,,,,,,,
TUBE CHST 24FR L20IN POLYVI CHL OPN TIP STR FIRM RADPQ ARGY,SUP-2154967,CDM,C1729,HCPCS,0272,RC,,,,both,,,26.25,17.06,,,,,,,,,,,,,
BIT DRL QC 2.8X200 MM 110 MM CALIB NS,SUP-2563760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,444.00,288.60,,,,,,,,,,,,,
BUR SURG STD MED 60 K 3 MM HI SPD STRL UNIDRIVE DISP,SUP-2599309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.04,421.88,,,,,,,,,,,,,
SET HEMO DYLS OR HD ADMIN ST100 HI PERM HEMDLYZR EXCORP CIRC,SUP-2885238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4873.78,3167.96,,,,,,,,,,,,,
ACETAMINOPHEN 325 MG PO TABS,RX-101,CDM,6370000000,HCPCS,0637,RC,49483-0340-10,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
TIP ASPIR L4.92IN DIA0.05IN ULTRASONIC CRV EXT FLUE DISP,SUP-2243958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1844.75,1199.09,,,,,,,,,,,,,
DRESSING BIO COVERAGE AREA170 SQ CM 1000 MG PORCINE SM,SUP-2905498,CDM,Q4102,HCPCS,0636,RC,,,,both,,,6867.18,4463.67,,,,,,,,,,,,,
KIT IMPL L450MM DIA3MM TIM IM AND ENDCAP THE NANCY NAIL,SUP-2253251,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SHAFT SCRDRVR SELF RET AO QC T8 STRL DISP FLEX-THREAD,SUP-2900417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
GRAFT BNE L16MM OD27MM PARTIALLY DEMIN TENFUSE NAIL,SUP-2401374,CDM,C1713,HCPCS,0278,RC,,,,both,,,4229.58,2749.23,,,,,,,,,,,,,
BIT DRL L190MM DIA12MM STRL TI CANN QUIK CPL W/O STP,SUP-2188299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2171.78,1411.66,,,,,,,,,,,,,
ROD EXT FIX END CAP INSRTN,SUP-2478677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
FIBER LASER FLEXIVA ID 550 SINGLE,SUP-2721827,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1189.87,773.42,,,,,,,,,,,,,
HC NM Bone Marrow Imaging-Ltd,PX-3417810200,CDM,78102,CPT,0341,RC,,,,both,,,1348.00,876.20,,,,,,,,,,,,,
KIT FIX DRL 2 GWIRE PAC STRL SURTAC,SUP-2341331,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
CATHETER EXT LUM L80CM OD1.5MM ID0.7MM CLS TIP BA IMPREG,SUP-2284544,CDM,C1729,HCPCS,0272,RC,,,,both,,,564.16,366.70,,,,,,,,,,,,,
CATHETER THOR 12FR 25CM VAN SONN,SUP-2141068,CDM,C1729,HCPCS,0272,RC,,,,both,,,205.83,133.79,,,,,,,,,,,,,
AGENT HEMSTAT W2XL4IN FIBRIN SEAL PTCH DSG EVARREST,SUP-2257603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
NAVIGATION SET CRAN PASS BX NAVIGUS,SUP-2432049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4374.65,2843.52,,,,,,,,,,,,,
ANCHOR SUTURE 2 4.5 MM TI WHT BLU STRL TWINFIX ULTRA,SUP-2848954,CDM,C1713,HCPCS,0278,RC,,,,both,,,892.67,580.24,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SONICATH ULTRA L 95 CM DIA 6 FR,SUP-2139882,CDM,C1753,HCPCS,0278,RC,,,,both,,,982.04,638.33,,,,,,,,,,,,,
MESH SURG PORCINE COLLGN MTRX W/ PHMB 0.1% PURAPLYAM,SUP-2423145,CDM,Q4195,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
STEM FEM CEM 12 125 MM HIP PROS EXT OFFSET VERSYS ADVOCATE,SUP-2439206,CDM,C1776,CPT,0278,RC,,,,both,,,16799.00,10919.35,,,,,,,,,,,,,
PLATE BNE L314MM 14 H ST R CNDYL S STL LOK COMPR CRV FOR,SUP-2177090,CDM,C1713,HCPCS,0278,RC,,,,both,,,5018.57,3262.07,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT ULNA WHL STRUCTURAL L,SUP-2307317,CDM,C1713,HCPCS,0278,RC,,,,both,,,7937.70,5159.50,,,,,,,,,,,,,
TUBE VENT L12MM ID1.14MM SIL GOODE T,SUP-2284010,CDM,L8699,HCPCS,0278,RC,,,,both,,,109.21,70.99,,,,,,,,,,,,,
PLATE BNE L94MM 5 H ST R SUP ANT CLAV S STL LOK COMPR W/,SUP-2177332,CDM,C1713,HCPCS,0278,RC,,,,both,,,2902.24,1886.46,,,,,,,,,,,,,
ALLOGRAFT BNE W/ HD FRZN WHL FEM,SUP-2321809,CDM,C1713,HCPCS,0278,RC,,,,both,,,14327.82,9313.08,,,,,,,,,,,,,
HC L-Spine Comp Inc Bend Min 6 Views,PX-3207211400,CDM,72114,CPT,0320,RC,,,,outpatient,,,1420.00,923.00,,,,,,,,,,,,,
CABLE EP BPLR EXTN FOR USE W CPS LUMINARY,SUP-2357044,CDM,C1887,HCPCS,0272,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
CATHETER HAD L28CM OD14.5FR POLYUR 2 LUMN SPL TIP CUF 5685230] BARD PERIPHERAL VASCULAR],SUP-2127838,CDM,C1750,HCPCS,0278,RC,,,,both,,,1496.84,972.95,,,,,,,,,,,,,
SCREW BONE 35MM 4MM DIA SLEEVE HOLDING,SUP-2720253,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.55,780.36,,,,,,,,,,,,,
IMPLANT OTO L4.5MM PIST DIA0.6MM WELL DIA1MM FLROPLAS,SUP-2312590,CDM,L8613,CPT,0278,RC,,,,both,,,409.86,266.41,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L 33 CM DIA15.5 FR INSRTN L 28 CM,SUP-2896199,CDM,C1750,HCPCS,0278,RC,,,,both,,,1704.55,1107.96,,,,,,,,,,,,,
ELECTRODE ES 24FR R ANG NDL 12 30DEG HF RESECT PLSM NDL ESG,SUP-2313591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1678.02,1090.71,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ 8IN IMMOB LOOP LOK ABDUCTED,SUP-2276632,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.33,14.51,,,,,,,,,,,,,
HC So Targeted Genomic Seq Analys,PX-3108145566,CDM,81455,CPT,0310,RC,,,,inpatient,,,3287.00,2136.55,,,,,,,,,,,,,
HANDLE INSTR ZONE NAVIGATOR SYS,SUP-2417073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
IMPLANT PENILE L21CM CYL INFL MINOCYCLINE RIFAMPIN,SUP-2140284,CDM,C1813,HCPCS,0278,RC,,,,both,,,7893.02,5130.46,,,,,,,,,,,,,
SCREW SPNL L14MM DIA3.5MM ANODIZED BLU POST PEDCL,SUP-2380761,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
HC Rep Lac Smp Face 2.6-5.0 Cm,PX-4501201300,CDM,12013,CPT,0450,RC,,,,both,,,632.00,410.80,,,,,,,,,,,,,
HC Psa Screening|NOT REASONABLE AND NECESSARY,PX-3010010300,CDM,G0103,HCPCS,0301,RC,,,GZ,both,,,343.00,222.95,,,,,,,,,,,,,
SET NEPHSTMY 14FR L25CM BLLN L15CM DIA12MM FOR URET DRNGE,SUP-2171214,CDM,C1729,HCPCS,0272,RC,,,,both,,,861.93,560.25,,,,,,,,,,,,,
ELECTRODE ELECSURG 20 MM LINEAR,SUP-2866312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
HC Additional Vessel Selection,PX-3237577400,CDM,75774,CPT,0323,RC,,,,both,,,7130.00,4634.50,,,,,,,,,,,,,
KIT CHOLGM PROC W SPHINTOM GWIRE JAGWIRE RX,SUP-2148976,CDM,C1769,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 24 IN 12-24 IN PERF FOAM,SUP-2194891,CDM,L1830,CPT,0274,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA XT DR 34 CC 71.4 GM TI POLYUR SIL,SUP-2282396,CDM,C1721,HCPCS,0275,RC,,,,both,,,40348.31,26226.40,,,,,,,,,,,,,
PLATE BNE L 60 MM RT DORS DSTL RADIAL WIDE LNG NS VARIAX 2,SUP-2902285,CDM,C1713,HCPCS,0278,RC,,,,both,,,4838.55,3145.06,,,,,,,,,,,,,
COIL VASC RETRACTA CATH 0.035 IN PLAT INCONEL DETACHABLE,SUP-2570697,CDM,C1889,HCPCS,0278,RC,,,,both,,,2097.27,1363.23,,,,,,,,,,,,,
MARKER BX SITE TI PLA/PGA MINI CORK SHP W/ INTRO DEPLOYMENT,SUP-2240056,CDM,A4648,CPT,0278,RC,,,,both,,,184.35,119.83,,,,,,,,,,,,,
MONITOR CARD MNL AUTOACTIVATED TRIG CLS BOR CYL MAG MR,SUP-2356337,CDM,C1764,HCPCS,0278,RC,,,,both,,,8923.88,5800.52,,,,,,,,,,,,,
SCREW SPNL L10MM DIA4MM MINI CANC POST OCCIPITAL CERV THOR,SUP-2256184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3344.10,2173.66,,,,,,,,,,,,,
DEVICE TISS REM L32CM DIA3MM S STL ULT HRD HI WR RESISTANCE,SUP-2436359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3039.52,1975.69,,,,,,,,,,,,,
CATHETER ENDOBRONCHIAL BLK SET PEDIATRIC 5 FRX50 CM 4.5 MM,SUP-2759865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,614.62,399.50,,,,,,,,,,,,,
FENTANYL 0.05 MG/ML SOLN (MIXTURES ONLY),RX-430015,CDM,J3010,HCPCS,0636,RC,00641-6030-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
HC Perc Drug-El Cor Stent Bran,PX-4810960100,CDM,C9601,CPT,0481,RC,,,,both,,,9327.00,6062.55,,,,,,,,,,,,,
KNIFE SURG BAYNT 193 CM 1 PC ANNULOTOMY SS TRANSCONTINENTAL,SUP-2232207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
CATHETER ANGIOPLSTY WORKHORSE II 75 CM 5 FR 4 CM 7 MM,SUP-2117096,CDM,C1725,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PLATE BNE FIBULAR 61 MM EXT DSTL ANK 5 HOLE TI,SUP-2525763,CDM,C1713,HCPCS,0278,RC,,,,both,,,3777.42,2455.32,,,,,,,,,,,,,
STIMULATOR BONE GROWTH EXT ELECTROMAGNETIC CLAV SHLDR PRTBL,SUP-2316217,CDM,E0749,HCPCS,0278,RC,,,,both,,,11602.30,7541.49,,,,,,,,,,,,,
SCREW BONE L10MM DIA1.5MM EMER PAN FIX LUHR,SUP-2364710,CDM,C1713,HCPCS,0278,RC,,,,both,,,111.47,72.46,,,,,,,,,,,,,
PLATE BNE CRESCENT BROAD 2 MM 3X3 HOLE TI NS MATRIXMANDIBLE,SUP-2181772,CDM,C1713,HCPCS,0278,RC,,,,both,,,2776.07,1804.45,,,,,,,,,,,,,
SUPPORT ORTHOT TRILATERAL CUST LEGG PERTHES ORTHOSIS,SUP-2435604,CDM,L1720,HCPCS,0272,RC,,,,both,,,4176.42,2714.67,,,,,,,,,,,,,
SCREW ACET 6.5X30 MM HIP,SUP-2308990,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
OCCLUDER CV WAIST L7MM DIA4MM 45X180DEG SHTH 5X6FR NIT,SUP-2357483,CDM,C1817,HCPCS,0278,RC,,,,both,,,26036.63,16923.81,,,,,,,,,,,,,
FILLER BNE VOID 5 CC CORT CANC BNE SODIUM HYALURONATE,SUP-2927228,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
HC Creatinine Clearance,PX-3018257500,CDM,82575,CPT,0301,RC,,,,outpatient,,,265.00,172.25,,,,,,,,,,,,,
EYELET SPNL LP VUEPOINT II,SUP-2563644,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 8MM STR TW REMOVABLE RNG,SUP-2396300,CDM,C1768,CPT,0278,RC,,,,both,,,1912.26,1242.97,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 3.0 X 10MM H,SUP-2320440,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.10,391.36,,,,,,,,,,,,,
WIRE ORTH SMOOTH S STL 1.6MM DIA 150MM,SUP-2397719,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
EPIDURAL TRAY CATH THERACATH,SUP-2383961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SINUS SCTN BURR ANGLD 40DGRS OBLONG BURR D3MM SHFT4MMX12CM5/,SUP-2574174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.53,471.59,,,,,,,,,,,,,
SPACER SPNL W11XH8XL14MM 0DEG PEEK TI MRK PARA ANT THORLUM,SUP-2286240,CDM,C1821,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE FEM LNG 3.5X152 MM RT DSTL PROX 4 HOLE STRL VALCP,SUP-2789586,CDM,C1713,HCPCS,0278,RC,,,,both,,,4157.23,2702.20,,,,,,,,,,,,,
BIT DRL L122MM DIA2.7MM ADD ON FIT FOR VARIAX 2 EL LOK PLT,SUP-2377985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,529.72,344.32,,,,,,,,,,,,,
SCREW SPNL MULTAXL 3.5X36 MM PART THRD INFIN,SUP-2631995,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
HC So Gabapentin Neurontin,PX-3018017166,CDM,80171,CPT,0301,RC,,,,both,,,49.00,31.85,,,,,,,,,,,,,
BODY HUM PROXIMAGE 62 MM COMPHSVE SEG REV SYSTEML LAR,SUP-2136571,CDM,L3809,HCPCS,0274,RC,,,,both,,,11360.52,7384.34,,,,,,,,,,,,,
FIBER LASER ACCUSTAT,SUP-2225641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM OD16FR TRACHEOESOPHAGEAL INDWL CLASS,SUP-2242366,CDM,L8509,HCPCS,0274,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SPACER SPNL BLK CT XIA,SUP-2381173,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE FUSION RT ANTR ANK 7 HOLE CONSTRUCT,SUP-2609568,CDM,C1713,HCPCS,0278,RC,,,,both,,,6595.19,4286.87,,,,,,,,,,,,,
DEVICE DCOMPR 16MM BLU ALUM TI VANADIUM INTERLAMINAR,SUP-2320314,CDM,C1889,HCPCS,0278,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
BIT DRL CANN 70-85 MM DENS QR NS ACUTRK 6/7 LF DISP,SUP-2518488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
BIT DRL SM DIA2MM SH W/ AO QUIK CONN DISP FOR EVOS SM,SUP-2344043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.02,390.01,,,,,,,,,,,,,
HANDPIECE BX INTRO 9GA NDL L14CM APER L20MM FOR MRI GUID,SUP-2239994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
ANCHOR SUT NO2 DIA3MM GLEN SFT TISS TI WDG NDL PRELD W 1,SUP-2362549,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.79,384.01,,,,,,,,,,,,,
INSERT TIB ARTC SURF NEUT UNIV PRI CONSTRN POLYETH MOLD CRUC,SUP-2201340,CDM,C1776,CPT,0278,RC,,,,both,,,3682.59,2393.68,,,,,,,,,,,,,
STAPLER INT AD L25MM DIA5MM STD GI WHT RED BLK TI CIR CUT 2,SUP-2283242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,851.88,553.72,,,,,,,,,,,,,
PORT VASC ACC 10.5FRXCELA POWERPRT,SUP-2116580,CDM,C1892,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
AUGMENT FEM L54MM THICKNESS 5MM UNIV STD DSTL KNEE PRI CEM,SUP-2199916,CDM,C1776,CPT,0278,RC,,,,both,,,5935.86,3858.31,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA28 MM BRANCH SZ 12/10/8/8,SUP-2499699,CDM,C1768,CPT,0278,RC,,,,both,,,5563.36,3616.18,,,,,,,,,,,,,
VEST ORTHOPEDIC HALO XL 42-58 IN CLASS II,SUP-2255768,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
BASEPLATE TIB STD STEM CEM LT MEDL RT LAT PRI MOD REPICCI II,SUP-2136600,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
FIBER LASER 550 MH 2 WVLNGTH SIDE FIRING FOR BPH XPEEDA HOLM,SUP-2417492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3673.55,2387.81,,,,,,,,,,,,,
GLUTH ALTO TOTAL,SUP-2669516,CDM,L8613,CPT,0278,RC,,,,both,,,1176.84,764.95,,,,,,,,,,,,,
SCREW BNE L10MM OD4MM STD TI CANC CORT ST SELF DRL CANN,SUP-2374501,CDM,C1713,HCPCS,0278,RC,,,,both,,,811.38,527.40,,,,,,,,,,,,,
PLATE BNE L 89 MM 5 H SCREW DIA2.7/3.5 MM SS LT SUP DSTL,SUP-2931287,CDM,C1713,HCPCS,0278,RC,,,,both,,,3134.35,2037.33,,,,,,,,,,,,,
DRILL SURG 1.1MM QUIK CONN VLP MINI MOD,SUP-2351106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,688.35,447.43,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY DS DR TI 2 CHMBR STD BPLR REMOT,SUP-2149064,CDM,C1721,HCPCS,0275,RC,,,,both,,,52438.00,34084.70,,,,,,,,,,,,,
SHUNT VLV PROGAV 2.0 W/SPRNG RSVR,SUP-2737584,CDM,C1889,HCPCS,0278,RC,,,,both,,,13766.26,8948.07,,,,,,,,,,,,,
DEVICE PESSARY NO4 DIA2.75IN RNG FLD KITTED W/ SUPP PROLAPSE,SUP-2171799,CDM,A4562,HCPCS,0274,RC,,,,both,,,173.30,112.64,,,,,,,,,,,,,
HC Behavral Qualit Analys Voice,PX-4449252400,CDM,92524,CPT,0444,RC,,,,both,,,719.00,467.35,,,,,,,,,,,,,
PLATE BNE ORBIT FLR LG 1.5X40X35X0.5 MM RT SMRT TI STRL,SUP-2484584,CDM,C1713,HCPCS,0278,RC,,,,both,,,4579.34,2976.57,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL SHELL,SUP-2435546,CDM,L0480,HCPCS,0272,RC,,,,both,,,4276.30,2779.59,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL RECIP CABLE,SUP-2435687,CDM,L2628,HCPCS,0274,RC,,,,both,,,4435.12,2882.83,,,,,,,,,,,,,
BASEPLATE TIB UNI UNIV PRI PEG CEM NP SZ 1 NAT KNEE II,SUP-2208934,CDM,C1776,CPT,0278,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
PLATE BNE W12XL160MM THK3.7MM LNG 6 H NONSTERILE PROX HUM S,SUP-2186017,CDM,C1713,HCPCS,0278,RC,,,,both,,,4552.37,2959.04,,,,,,,,,,,,,
GRAFT BONE SPCR FRZ DRY CORT H 5MM SM GRFTECH,SUP-2294202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
SCREW PERIIPR VA LCK OPTILINK 5.0X10MM,SUP-2720093,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.98,529.09,,,,,,,,,,,,,
GENERATOR EXT PULSE DRG W/ 2 PRT HD,SUP-2357373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC NM Myocard Infarct Spect Scan,PX-3417846900,CDM,78469,CPT,0341,RC,,,,both,,,2886.00,1875.90,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 8 MM RNG L 12 CM EPTFE,SUP-2396317,CDM,C1768,CPT,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
STENT BILI L 30 MM DIA2 MM CATH L 80 CM DIA 7 FR AD STRL,SUP-2155739,CDM,C1876,HCPCS,0278,RC,,,,both,,,3187.10,2071.61,,,,,,,,,,,,,
HC X-Ray Exam Chest 1 View,PX-3247104500,CDM,71045,CPT,0324,RC,,,,both,,,270.00,175.50,,,,,,,,,,,,,
NAIL IM FEM PEDIATRIC 6.5 MMX24 CM TI,SUP-2861972,CDM,C1713,HCPCS,0278,RC,,,,both,,,3997.47,2598.36,,,,,,,,,,,,,
OXYCODONE HCL 15 MG PO TABS,RX-28899,CDM,6370000000,HCPCS,0637,RC,68084-0975-11,NDC,,both,1,UN,4.30,2.79,,,,,,,,,,,,,
DEVICE SUCT 70DEG CRV,SUP-2364158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,804.22,522.74,,,,,,,,,,,,,
HC NM Shuntogram,PX-3417864500,CDM,78645,CPT,0341,RC,,,,both,,,2031.00,1320.15,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 18 ATM 4 FRX190 CM 2X300 MM SABERX,SUP-2866052,CDM,C1725,HCPCS,0272,RC,,,,both,,,1261.90,820.23,,,,,,,,,,,,,
SPLINT ANK WOM SHOE SZ 7-9 IN MED POLYPRO PLAS RT FT,SUP-2930193,CDM,L1930,HCPCS,0274,RC,,,,both,,,251.70,163.60,,,,,,,,,,,,,
PLATE BNE RADIAL SM 116 MM LT DSTL VOLAR PERIARTICULAR 10,SUP-2472488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2111.30,1372.34,,,,,,,,,,,,,
CAP PROTCT L4.5MM EXT FIX FOR SCHNZ SCR STNMN PIN,SUP-2188587,CDM,C1776,CPT,0278,RC,,,,both,,,2752.21,1788.94,,,,,,,,,,,,,
WEDGE BNE W 20 X H 4.5 MM MED EVANS OSTEOTOM 3D PRNT TRUSS,SUP-2900964,CDM,C1713,HCPCS,0278,RC,,,,both,,,12350.09,8027.56,,,,,,,,,,,,,
RESERVOIR SHUNT BURR HOLE 6.4X0.8 MM RADIOPAQUE POLYPR,SUP-2851296,CDM,C1889,HCPCS,0278,RC,,,,both,,,473.01,307.46,,,,,,,,,,,,,
ANCHOR SUT SZ 2 3MM HI STRENGTH BIOABSRB XCEL,SUP-2362556,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
STEM FEM L135MM OD11MM STR MOD SEG FORGED HIP TI ACUMATCH,SUP-2222137,CDM,C1776,CPT,0278,RC,,,,both,,,4314.67,2804.54,,,,,,,,,,,,,
STENT URETH 7FR L24MM SIL CLS END DBL J,SUP-2313759,CDM,C2617,HCPCS,0278,RC,,,,both,,,391.34,254.37,,,,,,,,,,,,,
FIBERTAPE STERNAL CLOSURE WITH BLUNT NDL,SUP-2814067,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CLAMP REPROC PIN CPL ROD FIXATOR 575IN,SUP-2700104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.33,223.81,,,,,,,,,,,,,
CATHETER DRAINAGE 0.038 IN 8 FRX35 CM FIRM 5 HOLE FLEXIMA,SUP-2147836,CDM,C1729,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
KIT SURG BNE CEMENT 120 GM SYR MIXING DEL SYS DISP PICOMIX,SUP-2898586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
TRAY TIB SZ 74 AP60MM ML81MM KNEE IB2,SUP-2199757,CDM,C1776,CPT,0278,RC,,,,both,,,10388.69,6752.65,,,,,,,,,,,,,
CYGNUS ANTR CERV 32MM PLTE MTI LVL,SUP-2664167,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
RECON PLATE 15X237MM 4.5MM,SUP-2820870,CDM,C1713,HCPCS,0278,RC,,,,both,,,6061.14,3939.74,,,,,,,,,,,,,
ROD SPNL ANTR SMOOTH TI ALLOY 5.5MM DIA 100MM LEN,SUP-2289284,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
SYSTEM DEL 1 CLP MITRACLP,SUP-2106212,CDM,C1889,HCPCS,0278,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
DANTROLENE SODIUM 25 MG PO CAPS,RX-9718,CDM,6370000000,HCPCS,0637,RC,68084-0300-11,NDC,,both,1,UN,7.40,4.81,,,,,,,,,,,,,
PLATE BONE L87MM THK1.2MM CALCNL BEND W/ TEMPLT FOR 3.5/4MM,SUP-2343825,CDM,C1713,HCPCS,0278,RC,,,,both,,,5254.01,3415.11,,,,,,,,,,,,,
BUTTON GASTRONOMY 18FR L17CM LO PROF ENDOVIVE,SUP-2149740,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.74,236.43,,,,,,,,,,,,,
CROWN DENT PRI M S STL,SUP-2238885,CDM,D6783,CPT,0278,RC,,,,both,,,1700.28,1105.18,,,,,,,,,,,,,
CATHETER DRNGE 12FR UNIV NIT LOK PGTL NAVARRE,SUP-2128419,CDM,C1729,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PASSER SUTURE 210X3.5MM HIP SLIM RAVEN,SUP-2828617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4590.30,2983.69,,,,,,,,,,,,,
CATHETER DIL 5.8FR L75CM BLLN L4CM INFLATED DIA5MM 0.038IN,SUP-2139198,CDM,C1726,HCPCS,0272,RC,,,,both,,,919.08,597.40,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.018IN TIP L3IN SM VES NIT COR,SUP-2385559,CDM,C1769,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
FORCEP RETRV ALLIGATOR 5.2 FRX65 CM TOOTH DBL JAW,SUP-2835710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,984.30,639.79,,,,,,,,,,,,,
AGENT HEMSTAT 1GM CLLGN MICFIB ACT ABSRB FLOUR AVIT,SUP-2125824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.97,267.78,,,,,,,,,,,,,
COMPONENT TOT KNEE MAKO,SUP-2378880,CDM,C1776,CPT,0278,RC,,,,both,,,1980.18,1287.12,,,,,,,,,,,,,
NERVE STIMULATOR KIT N RECHRG FULL IMPL PKG,SUP-2857914,CDM,C1767,HCPCS,0278,RC,,,,both,,,48575.80,31574.27,,,,,,,,,,,,,
HC Surgery Level 6 Base,PX-3600000006,CDM,3600000006,LOCAL,0360,RC,,,,both,,,9199.00,5979.35,,,,,,,,,,,,,
HC Cardioversion,PX-4509296000,CDM,92960,CPT,0450,RC,,,,both,,,1401.00,910.65,,,,,,,,,,,,,
SCREW BONE L10MM OD2.7MM S STL CORT ST NONCANNULATED LCK,SUP-2348300,CDM,C1713,HCPCS,0278,RC,,,,both,,,999.02,649.36,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM OD 11 FR ID 3.6 MM GUIDEWIRE 0.038,SUP-2168232,CDM,C1894,HCPCS,0272,RC,,,,both,,,127.92,83.15,,,,,,,,,,,,,
MICROCATHETER DIAG RENEGADE HI FLO L 80 CM OD,SUP-2653472,CDM,C1887,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS,SUP-2859965,CDM,C1713,HCPCS,0278,RC,,,,both,,,29662.01,19280.31,,,,,,,,,,,,,
SCREW BNE L130MM 140DEG HIP CAPT ASSEMB,SUP-2251194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
KIT FRACTURE OMNICURVE 11GA 15 MM,SUP-2864548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8087.07,5256.60,,,,,,,,,,,,,
CRICOTHYROTOMY KIT 4 MM AD QUICKTRACH,SUP-2384062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
PLATE BNE 12 H ST BILAT S STL NAR CRV LOK COMPR FOR 35MM SCR,SUP-2178044,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.63,1386.21,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.4MM CORT TI ST FOR MOD HND SYS PRO-PAK,SUP-2189511,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.43,147.18,,,,,,,,,,,,,
PLATE BNE TBLR 55 MM 4 HOLE 1/3 LCK SS STRL,SUP-2480564,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.09,309.46,,,,,,,,,,,,,
ROD SPNL 6.35 MM DIA 120 MM LEN POST R SMOOTH LEG,SUP-2289200,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
CATHETER CARD ABLATION QDOT MIC L 115 CM 8 FR 3.5 MM D-F TYP,SUP-2880099,CDM,C1732,HCPCS,0278,RC,,,,both,,,12365.32,8037.46,,,,,,,,,,,,,
OSSEOFLEX SB STEERABLE BLLN 10GA2ML,SUP-2702607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2999.20,1949.48,,,,,,,,,,,,,
ENVELOPE PLSE GENRTR M W2.7XL2.5IN NEURO ANTIBACT ABSRB,SUP-2281260,CDM,C1889,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL III HE W 6.3 X H 8.26 CM,SUP-2149226,CDM,C1895,HCPCS,0275,RC,,,,both,,,85332.64,55466.22,,,,,,,,,,,,,
DILATOR ENDO BAL L4CM DIA10MM CATH L230CM PYL COLON PET DISP,SUP-2166057,CDM,C1726,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 7 MM EPTFE STR TW N RING,SUP-2396347,CDM,C1768,CPT,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
SLEEVE FEM L SZ 18D UNIV PROX HIP ZTT MOD CONE SPOUT PRI,SUP-2253119,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PRAVASTATIN SODIUM 20 MG PO TABS,RX-11111,CDM,6370000000,HCPCS,0637,RC,50268-0666-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET CATH 8.5FR L25CM DIL 9FR GWIRE 0.038IN 6 SIDEPRT NIT,SUP-2168531,CDM,C1729,HCPCS,0272,RC,,,,both,,,432.13,280.88,,,,,,,,,,,,,
GRAFT BIO TISS W4XL4CM THK1 2MM PROLAYER,SUP-2362230,CDM,C1763,HCPCS,0278,RC,,,,both,,,4890.86,3179.06,,,,,,,,,,,,,
GRAFT EVAR L9.5CM DIA16MM IL LIMB EXCLUDER,SUP-2395948,CDM,C1768,CPT,0278,RC,,,,both,,,11294.58,7341.48,,,,,,,,,,,,,
PIN TEMP FIX ASSURE,SUP-2232043,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK0.23-0.51MM THN REGENERATIVE TISS,SUP-2113074,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
BIT DRL L136MM OD2MM PILOT W/O STP J LATCH N RADLUC REUSE,SUP-2319401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
STEM HUM 14X170 MM SHLDR RVS TRABECULAR MTL,SUP-2436913,CDM,C1776,CPT,0278,RC,,,,both,,,18533.85,12047.00,,,,,,,,,,,,,
CLAMP PIN 105MMXTRAFIX,SUP-2205435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2030.80,1320.02,,,,,,,,,,,,,
STENT BILI 7FR L5CM PLAS CNTR BEND SGL ADVANIX,SUP-2141416,CDM,C2617,HCPCS,0278,RC,,,,both,,,173.64,112.87,,,,,,,,,,,,,
COLLAR CERV M H3.25IN FOR 13-16IN PLASTAZOTE FOAM 2 PC L,SUP-2336004,CDM,L0140,HCPCS,0274,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
KIT TISS CLOSURE SUTURE USP 2-0 L 66 CM TENS CTRL L 2.6 X W,SUP-2930521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
BUMPER ORTH MAK OSS,SUP-2449865,CDM,C1776,CPT,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
DISTRACTOR SURG MIC 25 MM 1 MM TOP RATCH ZURICH II,SUP-2473898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19582.20,12728.43,,,,,,,,,,,,,
SCREW BNE LCK 6.5X35 MM SS STRL SURFIX ADVANSYS,SUP-2243417,CDM,C1713,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
TUBE TRACH MONTGOMERY 14 MM SAFE T STD CLR,SUP-2140098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
VALVE CSF FLO BURR HOLE 12 MM CTRL VENTRICULOSTOMY DELT,SUP-2629162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2084.65,1355.02,,,,,,,,,,,,,
NEEDLE EPI 22GA L2IN N STIMULATING ULTRAPLEX,SUP-2125036,CDM,C1713,HCPCS,0278,RC,,,,both,,,30.77,20.00,,,,,,,,,,,,,
TUBE TYMPANOSTOMY L 6 MM DIA1.14 MM FLANGE L 6 MM SIL FIRM,SUP-2902088,CDM,L8699,HCPCS,0278,RC,,,,both,,,77.06,50.09,,,,,,,,,,,,,
WIRE FIX L6IN DIA0.08IN K,SUP-2167370,CDM,C1713,HCPCS,0278,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
PIN EXT FIX L250MM DIA5MM THRD L60MM S STL TRANSFIXING APEX,SUP-2372471,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE LAPIDUS RT 5 HOLE OMNI,SUP-2610160,CDM,C1713,HCPCS,0278,RC,,,,both,,,4399.14,2859.44,,,,,,,,,,,,,
COIL VASC INTERLOCK-35 L 20 CM DIA15 MM GUIDEWIRE 0.035 IN,SUP-2148117,CDM,C1889,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
TELMISARTAN 40 MG PO TABS,RX-24335,CDM,6370000000,HCPCS,0637,RC,00378-2921-93,NDC,,both,1,UN,4.90,3.18,,,,,,,,,,,,,
GRAFT VASC SZ 26 MM SPEC SINGLE BRANCH,SUP-2535441,CDM,C1768,CPT,0278,RC,,,,both,,,5553.12,3609.53,,,,,,,,,,,,,
MODEL PT SPEC GLEN VIP 3D,SUP-2123500,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY LP 0.018 IN 100 CM 5X150 MM LUTONIX 018,SUP-2128354,CDM,C2623,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
LENS IOL 23.0 DIOPT L 13 MM DIA 6 MM HAPTIC 10 DEG,SUP-2881372,CDM,V2787,HCPCS,0276,RC,,,,both,,,1000.00,650.00,,,,,,,,,,,,,
DEXMEDETOMIDINE HCL 120 MCG SL FILM,RX-158220,CDM,J1105,HCPCS,0636,RC,81092-1120-00,NDC,,both,1,UN,472.50,307.12,,,,,,,,,,,,,
BIT DRL OD2.9MM STBL NONSTERILE REUSE FOR COMPHSVE DEL SYS,SUP-2249337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1077.02,700.06,,,,,,,,,,,,,
COIL DETACH 2MM DIA 2CM RESTRAINED NEXUS HELIX SUPERSOFT,SUP-2173644,CDM,C1889,HCPCS,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
ROD SPNL L240MM DIA3.5MM POST CERVICOTHORACIC TI RECON,SUP-2289081,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
LEAD PACE SIL ENDOCARD RT ATRIOVENTRICULAR SCREW FIX SWEET,SUP-2148541,CDM,C1895,HCPCS,0275,RC,,,,both,,,7049.30,4582.04,,,,,,,,,,,,,
GUIDEPIN ORTH DIA3MM CANN FOR ACL RECON RETRODRILL,SUP-2120914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
CATHETER HD CRV EXTN 9 FRX7.5 CM CATH NDL DUOFLO,SUP-2627076,CDM,C1752,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
SOTALOL HCL AF 80 MG PO TABS,RX-38966,CDM,2500000003,HCPCS,0250,RC,76385-0125-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
KIT PRSS TRNSDUC TBNG L48X12IN STD TWO FLSH DEV BIFUR IV,SUP-2214624,CDM,C1713,HCPCS,0278,RC,,,,both,,,41.17,26.76,,,,,,,,,,,,,
CATHETER GUID ENVOY DA L 95 CM OD 6 FR ID 0.071 IN STR,SUP-2458143,CDM,C1887,HCPCS,0272,RC,,,,both,,,2957.00,1922.05,,,,,,,,,,,,,
HC So Hepatitis Delta Agent Ab,PX-3028669266,CDM,86692,CPT,0302,RC,,,,both,,,108.00,70.20,,,,,,,,,,,,,
SCREW BNE LCK 2.3X18 MM MAND SELF RET X DRV TI LEVEL 1,SUP-2468567,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.64,265.62,,,,,,,,,,,,,
SCREW BNE L28MM DIA3.5MM PROX HUM NONLOCKING T15 LO PROF,SUP-2411566,CDM,C1713,HCPCS,0278,RC,,,,both,,,221.53,143.99,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA PLU 3FR 20CM 1 LUMAN RVRSE TAPR PWR,SUP-2613547,CDM,C1751,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
PLATE BNE L194MM 12 H NAR 2 COMPR FOR 4.5MM SCR L FRAG SYS,SUP-2411426,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 209MML HLX16 STNLSS STEEL CNTRD,SUP-2588609,CDM,C1713,HCPCS,0278,RC,,,,both,,,1744.27,1133.78,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 18 FR 7-10 CC SECUR-LOK EXT ENFIT MIC,SUP-2764436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.55,278.56,,,,,,,,,,,,,
ROD SPNL L120MM DIA3MM POST BILAT TI SMOOTH SYNERGY SUMMIT,SUP-2254415,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
PLATE BNE CRV 1.5X0.8 MM MIDFACE 12 HOLE W/ TAB TI STRL,SUP-2474849,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.28,598.83,,,,,,,,,,,,,
NAIL IM FOR PROX FEM FRAC PICCOLO COMP,SUP-2422370,CDM,C1713,HCPCS,0278,RC,,,,both,,,4749.56,3087.21,,,,,,,,,,,,,
MESH SURG DIA 3.2 IN LG POLY-4-HYDROXYBUTYRATE POLYGLY ACD,SUP-2937422,CDM,C1781,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
DISSECTOR LAP BLLN VEIN,SUP-2329903,CDM,C1727,CPT,0278,RC,,,,both,,,949.85,617.40,,,,,,,,,,,,,
PLATE SPNL L118MM ANT BILAT THORLUM TI LOK,SUP-2193105,CDM,C1713,HCPCS,0278,RC,,,,both,,,7595.66,4937.18,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 4 MM DEL SHTH,SUP-2934391,CDM,C1713,HCPCS,0278,RC,,,,both,,,6374.07,4143.15,,,,,,,,,,,,,
PORT IMPL INFUSION 2 L LUMEN 10 FR SIL CATH X-PORTDUO MRI,SUP-2126179,CDM,C1788,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
IMPLANT TOE JT DIA19MM THK8MM MT LENGTHENING DISC,SUP-2321675,CDM,C1776,CPT,0278,RC,,,,both,,,7473.20,4857.58,,,,,,,,,,,,,
PLATE BONE CMPRSSN 8.7MM ID 12.19MM OD TUBE 246MML HLX14 38.,SUP-2492487,CDM,C1713,HCPCS,0278,RC,,,,both,,,2421.79,1574.16,,,,,,,,,,,,,
SCREW SLF DRLG SCHANZ 4.0MM 3.0MM TI 80MM HA COATING STERILE,SUP-2549740,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.45,554.09,,,,,,,,,,,,,
HC Burn Dress/Debrid >10%,PX-3611603000,CDM,16030,CPT,0361,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
HC So Hsv Amplified Probe,PX-3068752966,CDM,87529,CPT,0306,RC,,,,both,,,498.00,323.70,,,,,,,,,,,,,
PUMP BRST DBL ELECTR STAND NS PMP IN STYL MAXFLOW LF,SUP-2858135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
STIMULATOR NERVE CHARGING SYSTEM VERCISE,SUP-2836334,CDM,C1820,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ W STAY COCK UP FIRM SUPP,SUP-2276617,CDM,L3809,HCPCS,0272,RC,,,,both,,,15.95,10.37,,,,,,,,,,,,,
STAPLER INT SHFT L 20 CM DIA 5 MM LEG L 2 MM LN L 25 MM CUT,SUP-2903963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ENSITE L 110 CM MAP ARRY,SUP-2516514,CDM,C1731,HCPCS,0278,RC,,,,both,,,10462.48,6800.61,,,,,,,,,,,,,
TOOL SZ DISSECTION/TRANSECTION DEV MULTITASC,SUP-2264264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TIP ASPIR L11CM APEX KNF FOR SURG HNDPC SONOPET IQ,SUP-2419488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3256.87,2116.97,,,,,,,,,,,,,
PLATE BNE W11XL220MM THK3.7MM 12 H L MED DST TIB S STL LOK,SUP-2185596,CDM,C1713,HCPCS,0278,RC,,,,both,,,4598.25,2988.86,,,,,,,,,,,,,
PATCH MEMBRN CRAN SPNL,SUP-2365424,CDM,C1763,HCPCS,0278,RC,,,,both,,,5052.98,3284.44,,,,,,,,,,,,,
STEM HUM SZ 7 L170MM 135DEG TI ALLOY LNG CEM PRESSFIT UNIV,SUP-2204848,CDM,C1776,CPT,0278,RC,,,,both,,,11699.64,7604.77,,,,,,,,,,,,,
SHELL ACET MOD 74 MM HIP REDAPT,SUP-2434873,CDM,C1776,CPT,0278,RC,,,,both,,,7807.30,5074.74,,,,,,,,,,,,,
KIT PT PRGMR FOR RESTORE NEUROSTIMULATOR MYSTIM,SUP-2278227,CDM,C1787,HCPCS,0278,RC,,,,both,,,3623.56,2355.31,,,,,,,,,,,,,
DEVICE FIX DIA7-8MM LNG FEM ANCHR SFT TISS FOR 35-50MM TUNN,SUP-2212829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2240.20,1456.13,,,,,,,,,,,,,
LEAD PACE CAPSUR SENSE MRI SURESCAN L 53 CM DIA 5.3 FR,SUP-2281943,CDM,C1898,HCPCS,0275,RC,,,,both,,,1174.86,763.66,,,,,,,,,,,,,
BUR SURG OD5.5MM BLK SHTH BRL HI VISIBILITY DYONICS,SUP-2341869,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.34,255.02,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY HALO XP L 110 CM 7 FR 2-8-2 MM,SUP-2699999,CDM,C1730,HCPCS,0272,RC,,,,both,,,1092.78,710.31,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2X400 MM W/ DRL TIP NS,SUP-2757722,CDM,C1769,HCPCS,0272,RC,,,,both,,,287.37,186.79,,,,,,,,,,,,,
SUPPORT ORTHOT CUST SOLE WDG OUTSIDE,SUP-2435722,CDM,L3360,HCPCS,0272,RC,,,,both,,,100.79,65.51,,,,,,,,,,,,,
BUR SURG IRR BULL DMND DIEGO PRECIS DIAM 3 MM BIT DIAM 40,SUP-2312828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
SLEEVE SM KNEE W/ PD,SUP-2351387,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
BIT DRL L12MM SZ 2MM GUID COUNT SINK AO CANN STP FIXOS,SUP-2379286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
KIT DRL DIA7MM PROX BICEPS REP ACC,SUP-2417351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1209.78,786.36,,,,,,,,,,,,,
LEAD PACE BPLR ACT DEFIB OPTIM INSUL INTEGRATEDDURATA L21MM,SUP-2356241,CDM,C1895,HCPCS,0275,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
COMPONENT HIP CMNTLS,SUP-2351396,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
CONNECTOR SPNL M TI FOR 635MM ROD TSRH 3D,SUP-2290004,CDM,C1713,HCPCS,0278,RC,,,,both,,,3008.12,1955.28,,,,,,,,,,,,,
BURR SIDE CUTTING CARBIDE 3.2MM MHD15CG1,SUP-2843306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,588.31,382.40,,,,,,,,,,,,,
CANNULA LAP SMOOTH 13.5 MMX15 CM N THRD STOPCOCK BLU RED,SUP-2776627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,992.11,644.87,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSOSTAR NAV L 115 CM DIA 4 FR,SUP-2530193,CDM,C1732,HCPCS,0272,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
MESH SURG PRESHAPED LG 2.4X5.4 IN,SUP-2126289,CDM,C1781,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
STAPLE EASYCLIP 20 16 16,SUP-2696124,CDM,C1713,HCPCS,0278,RC,,,,both,,,5385.73,3500.72,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FIFTH DIGIT",CASE-26951,LOCAL,26951,CPT,,,,,F4,outpatient,,,22434.18,13460.51,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,LOCAL,64491,CPT,,,,,,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,LOCAL,64495,CPT,,,,,,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>|LEFT SIDE,CASE-23073,LOCAL,23073,CPT,,,,,LT,outpatient,,,33501.53,20100.92,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,LOCAL,43239,CPT,,,,,XU,outpatient,,,11938.77,7163.26,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THUMB|PO",CASE-26765,LOCAL,26765,CPT,0360,RC,,,FA|PO,outpatient,,,17714.68,10628.81,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|SEPARATE STRUCTURE|PO",CASE-26055,LOCAL,26055,CPT,,,,,F2|XS|PO,outpatient,,,12880.15,7728.09,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,LOCAL,64721,CPT,,,,,RT,outpatient,,,13016.33,7809.80,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,LOCAL,29828,CPT,,,,,,outpatient,,,50375.35,30225.21,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL ADJ FLX,SUP-2435685,CDM,L2622,HCPCS,0272,RC,,,,both,,,900.87,585.57,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,0636,RC,81298-5785-03,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
STEM FEM L200MM L30MM OD12MM SZ 5 L HIP REV CEM BOW IMPL,SUP-2374698,CDM,C1776,CPT,0278,RC,,,,both,,,10620.11,6903.07,,,,,,,,,,,,,
CHEEK RETRACTOR RING FOR WIRE,SUP-2823422,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.55,610.06,,,,,,,,,,,,,
SCREW SPNL L15MM DIA4MM FIX ANG ANT CERV CANC TI ST,SUP-2293230,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.96,581.07,,,,,,,,,,,,,
INSERT HUM DIA36MM THK+9MM B 125DEG ANG RETENTIVE REVERSED,SUP-2399871,CDM,C1776,CPT,0278,RC,,,,both,,,6149.69,3997.30,,,,,,,,,,,,,
PLATE BONE W9XL145MM THK1.1MM 12 H DSTL ULN FIBULAR S STL,SUP-2343781,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
TUNNELER MAINSTAY,SUP-2877974,CDM,C1730,HCPCS,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE,CASE-27570,LOCAL,27570,CPT,,,,,LT,outpatient,,,13456.40,8073.84,,,,,,,,,,,,,
Carpectomy All Bones Proximal Row,CASE-25215,LOCAL,25215,CPT,0360,RC,,,,outpatient,,,21219.00,12731.40,,,,,,,,,,,,,
Mastectomy Partial|RIGHT SIDE,CASE-19301,LOCAL,19301,CPT,0360,RC,,,RT,outpatient,,,35850.68,21510.41,,,,,,,,,,,,,
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE|PO,CASE-27680,LOCAL,27680,CPT,0360,RC,,,LT|PO,outpatient,,,23884.05,14330.43,,,,,,,,,,,,,
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,LOCAL,45171,CPT,0360,RC,,,,outpatient,,,19474.53,11684.72,,,,,,,,,,,,,
Cysto W/Destruction of Lesions,CASE-52214,LOCAL,52214,CPT,0360,RC,,,,outpatient,,,26107.60,15664.56,,,,,,,,,,,,,
Realignment Extensor Tendon Hand Each Tendon|RIGHT SIDE|PO,CASE-26437,LOCAL,26437,CPT,0360,RC,,,RT|PO,outpatient,,,15589.47,9353.68,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, THIRD DIGIT|PO",CASE-28270,LOCAL,28270,CPT,,,,,T2|PO,outpatient,,,23884.05,14330.43,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,LOCAL,64490,CPT,0361,RC,,,50,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT",CASE-28285,LOCAL,28285,CPT,,,,,T3,outpatient,,,27397.82,16438.69,,,,,,,,,,,,,
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE|PO,CASE-27685,LOCAL,27685,CPT,0360,RC,,,LT|PO,outpatient,,,34429.60,20657.76,,,,,,,,,,,,,
Ligj Divj & Stripping Short Saphenous Vein,CASE-37718,LOCAL,37718,CPT,,,,,,outpatient,,,32297.85,19378.71,,,,,,,,,,,,,
Osteotomy Tarsal Bones Oth/Thn Calcaneus/Talus|LEFT SIDE|PO,CASE-28304,LOCAL,28304,CPT,0360,RC,,,LT|PO,outpatient,,,16375.20,9825.12,,,,,,,,,,,,,
SCREW BNE LCK 2.4X8 MM METATRSL STRL MSP,SUP-2472408,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.22,225.69,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 217 MM DIA 38 MM SHTH 18 FR,SUP-2170244,CDM,C1874,HCPCS,0278,RC,,,,both,,,48670.00,31635.50,,,,,,,,,,,,,
PLATE BNE L207MM 12 H ST R PROX TIB S STL VAR ANG LOK COMPR,SUP-2177921,CDM,C1713,HCPCS,0278,RC,,,,both,,,6607.75,4295.04,,,,,,,,,,,,,
PLATE BONE LOK 287MML HLX22 STRGHT RCNSTRCTN ST,SUP-2588611,CDM,C1713,HCPCS,0278,RC,,,,both,,,2538.69,1650.15,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 30 CM DIA 6 MM EPTFE STR STD WALL,SUP-2477545,CDM,C1768,CPT,0278,RC,,,,both,,,974.75,633.59,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X5.5 MM MCGEE SS,SUP-2637760,CDM,L8613,CPT,0278,RC,,,,both,,,264.17,171.71,,,,,,,,,,,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,0636,RC,70436-0019-82,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
DEVICE TISS REMOVING 17OZ L25.25IN DIA3MM INTUTER CTRL UNIT,SUP-2239905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
LINER ACET NEUT LONGEVITY,SUP-2448627,CDM,C1776,CPT,0278,RC,,,,both,,,98556.75,64061.89,,,,,,,,,,,,,
BUR SURG L125MM DIA2.7MM RND CUT NONFLUTED DMND END STR,SUP-2108950,CDM,C1713,HCPCS,0278,RC,,,,both,,,544.63,354.01,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct Ea Addl 15 Mins,PX-4309713000,CDM,97130,CPT,0430,RC,,,,inpatient,,,186.00,120.90,,,,,,,,,,,,,
PLATE BNE THK1MM 9 H 100DEG L CRANIOMAXILLOFACIAL TI MINI L,SUP-2366332,CDM,C1713,HCPCS,0278,RC,,,,both,,,798.69,519.15,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj 1st Metar|LEFT SIDE|PO,CASE-28306,LOCAL,28306,CPT,,,,,LT|PO,outpatient,,,19110.08,11466.05,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|PO,CASE-28122,LOCAL,28122,CPT,0360,RC,,,LT|PO,outpatient,,,13527.90,8116.74,,,,,,,,,,,,,
Tx Tibl Shft Fx Imed Implt W/WO Screws&/Cercla,CASE-27759,LOCAL,27759,CPT,,,,,,outpatient,,,47131.20,28278.72,,,,,,,,,,,,,
Mastectomy Partial|LEFT SIDE,CASE-19301,LOCAL,19301,CPT,,,,,LT,outpatient,,,34335.15,20601.09,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|PO,CASE-29881,LOCAL,29881,CPT,0360,RC,,,RT|PO,outpatient,,,21247.73,12748.64,,,,,,,,,,,,,
Bone Graft Any Donor Area Major/Large|PO,CASE-20902,LOCAL,20902,CPT,,,,,PO,outpatient,,,61983.88,37190.33,,,,,,,,,,,,,
Tendon Sheath Incision|PO,CASE-26055,LOCAL,26055,CPT,,,,,PO,outpatient,,,8480.43,5088.26,,,,,,,,,,,,,
Cystourethroscopy With Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52204,LOCAL,52204,CPT,,,,,XU,outpatient,,,30801.07,18480.64,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,LOCAL,G0260,CPT,,,,,LT,outpatient,,,4422.92,2653.75,,,,,,,,,,,,,
Revascularization Iliac Artery Angiop 1st Vsl|LEFT SIDE,CASE-37220,LOCAL,37220,CPT,0360,RC,,,LT,outpatient,,,56908.88,34145.33,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|LEFT SIDE|PO,CASE-28309,LOCAL,28309,CPT,,,,,LT|PO,outpatient,,,53463.60,32078.16,,,,,,,,,,,,,
"Sesamoidectomy First Toe Spx|RIGHT FOOT, GREAT TOE|PO",CASE-28315,LOCAL,28315,CPT,0360,RC,,,T5|PO,outpatient,,,18082.22,10849.33,,,,,,,,,,,,,
Mastectomy Simple Complete|RIGHT SIDE,CASE-19303,LOCAL,19303,CPT,,,,,RT,outpatient,,,51426.98,30856.19,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,LOCAL,64634,CPT,0360,RC,,,LT,outpatient,,,11775.07,7065.04,,,,,,,,,,,,,
Bx Anorectal Wall Anal Approach,CASE-45100,LOCAL,45100,CPT,0360,RC,,,,outpatient,,,36343.98,21806.39,,,,,,,,,,,,,
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE,CASE-28200,LOCAL,28200,CPT,0360,RC,,,RT,outpatient,,,36459.58,21875.75,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,LOCAL,49505,CPT,,,,,LT,outpatient,,,29999.58,17999.75,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE|PO,CASE-64633,LOCAL,64633,CPT,0360,RC,,,RT|PO,outpatient,,,4471.57,2682.94,,,,,,,,,,,,,
COMPONENT FEM SM LT KNEE ZPU LIBRA,SUP-2442382,CDM,C1776,CPT,0278,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
SLEEVE FEM +4MM OFFSET MOD REV 12/14 TAPR REDAPT,SUP-2350890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
RETRACTOR SURG BRST ABD LT CRDLSS MULTIPLE BLADE RADIALUX,SUP-2278408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
STEM FEM XSM L115MM STD CO CHROMIUM KNEE EXTN CEM BILAT,SUP-2376291,CDM,C1776,CPT,0278,RC,,,,both,,,2428.48,1578.51,,,,,,,,,,,,,
PLATE BNE CLAV 3.5X86 MM LT SUP MIDSHAFT 8 HOLE EVOS,SUP-2424108,CDM,C1713,HCPCS,0278,RC,,,,both,,,2959.14,1923.44,,,,,,,,,,,,,
PLATE BNE L151MM 9 H L DST LAT FIBULAR S STL LOK COMPR FOR,SUP-2184164,CDM,C1713,HCPCS,0278,RC,,,,both,,,1807.04,1174.58,,,,,,,,,,,,,
SCREW BONE FEM HIP CANN SET,SUP-2347912,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.59,267.53,,,,,,,,,,,,,
KIT OLV WIRE M FOR BONE FIX,SUP-2225526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
KIT REP TI FOR RECON OF ACUTE AC JT SEP AC TIGHTROPE,SUP-2121657,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,LOCAL,11424,CPT,0360,RC,,,,outpatient,,,16266.03,9759.62,,,,,,,,,,,,,
Tenotomy Open Extensor Foot/Toe Each Tendon,CASE-28234,LOCAL,28234,CPT,,,,,,outpatient,,,11454.52,6872.71,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE|PO,CASE-23515,LOCAL,23515,CPT,0360,RC,,,LT|PO,outpatient,,,47339.70,28403.82,,,,,,,,,,,,,
Unlisted Laps Px Hrnap Herniorrhaphy Herniotomy,CASE-49659,LOCAL,49659,CPT,,,,,,outpatient,,,49022.45,29413.47,,,,,,,,,,,,,
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|RIGHT SIDE,CASE-27680,LOCAL,27680,CPT,0360,RC,,,RT,outpatient,,,36064.92,21638.95,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE,CASE-29806,LOCAL,29806,CPT,0360,RC,,,RT,outpatient,,,44989.63,26993.78,,,,,,,,,,,,,
Unlisted Procedure Pelvis/Hip Joint,CASE-27299,LOCAL,27299,CPT,0360,RC,,,,outpatient,,,53130.23,31878.14,,,,,,,,,,,,,
Suture Quadriceps/Hamstring Rupture Primary|RIGHT SIDE|PO,CASE-27385,LOCAL,27385,CPT,,,,,RT|PO,outpatient,,,45972.65,27583.59,,,,,,,,,,,,,
Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt,CASE-26531,LOCAL,26531,CPT,0360,RC,,,,outpatient,,,24951.15,14970.69,,,,,,,,,,,,,
Rmvl/Revj Sling Stress Incontinence,CASE-57287,LOCAL,57287,CPT,,,,,,outpatient,,,22306.70,13384.02,,,,,,,,,,,,,
Lengthening Tendon Extensor Hand/Finger Each,CASE-26476,LOCAL,26476,CPT,0360,RC,,,,outpatient,,,8193.55,4916.13,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,LOCAL,29823,CPT,0360,RC,,,LT,outpatient,,,42560.58,25536.35,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,LOCAL,28820,CPT,,,,,TA,outpatient,,,19818.07,11890.84,,,,,,,,,,,,,
Capsular Contracture Release|RIGHT SIDE,CASE-23020,LOCAL,23020,CPT,0360,RC,,,RT,outpatient,,,48673.63,29204.18,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT",CASE-28270,LOCAL,28270,CPT,0360,RC,,,XS|T6,outpatient,,,40956.73,24574.04,,,,,,,,,,,,,
Open Repair of Rotator Cuff Chronic,CASE-23412,LOCAL,23412,CPT,0360,RC,,,,outpatient,,,52273.90,31364.34,,,,,,,,,,,,,
Rpr Aa Hernia Recr < 3 Cm Ncrc8/Strangulated,CASE-49614,LOCAL,49614,CPT,,,,,,outpatient,,,24573.08,14743.85,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-23430,LOCAL,23430,CPT,,,,,XU|LT,outpatient,,,71027.33,42616.40,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB|PO",CASE-26540,LOCAL,26540,CPT,0360,RC,,,F5|PO,outpatient,,,18309.60,10985.76,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28285,LOCAL,28285,CPT,,,,,T4|PO,outpatient,,,21355.03,12813.02,,,,,,,,,,,,,
STENT URET L 24 CM DIA 4.8 FR TIP L 3 CM STIFF SHFT PTFE,SUP-2141639,CDM,C2617,HCPCS,0278,RC,,,,both,,,374.82,243.63,,,,,,,,,,,,,
MESH MXLFCL 251X16 MM 0.8 MM SM GRID PDLLA STRL RESORB X,SUP-2473843,CDM,C1713,HCPCS,0278,RC,,,,both,,,8122.80,5279.82,,,,,,,,,,,,,
TUBING INSUF STRL DISP PMP INSTR SYS COMB TEM,SUP-2332797,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
NAIL IM FEM 15X240 MM RT PROX PIRIFORMIS FOSSA STRL DISP,SUP-2463969,CDM,C1713,HCPCS,0278,RC,,,,both,,,5403.94,3512.56,,,,,,,,,,,,,
COMPONENT FEM PS E 61.5X72 MM RT KNEE PC NXGN,SUP-2201496,CDM,C1776,CPT,0278,RC,,,,both,,,5557.33,3612.26,,,,,,,,,,,,,
PLATE BONE W41XL41MM THK0.6MM MESH ORBIT FLR PDLLA SONICWELD,SUP-2263015,CDM,C1713,HCPCS,0278,RC,,,,both,,,2398.96,1559.32,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR ATLS DR V242ROPTSYS] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356548,CDM,C1721,HCPCS,0275,RC,,,,both,,,58319.22,37907.49,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 5 MM EPTFE STR STD WALL,SUP-2396181,CDM,C1768,CPT,0278,RC,,,,both,,,3224.78,2096.11,,,,,,,,,,,,,
K WIRE FIX DIA1.4MM FOR CANN GREAT TOE LPT,SUP-2397197,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
INTRODUCER SHTH 18FRX30CM GORE,SUP-2395872,CDM,C1894,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT HUM TISS 1ML AMNIO FLD ORTHOFLO,SUP-2305758,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FD IRRADIATED PERICARD,SUP-2866900,CDM,C1762,CPT,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
Fasciectomy Plantar Fascia Radical Spx|RIGHT SIDE,CASE-28062,LOCAL,28062,CPT,0360,RC,,,RT,outpatient,,,16549.10,9929.46,,,,,,,,,,,,,
Blepharoplasty Lower Eyelid Herniated Fat Pad,CASE-15821,LOCAL,15821,CPT,0360,RC,,,,outpatient,,,43856.37,26313.82,,,,,,,,,,,,,
HC Thromb Mech 1st Vssl,CASE-37184,LOCAL,37184,CPT,0361,RC,,,,outpatient,,,77948.65,46769.19,,,,,,,,,,,,,
Synovectomy Tendon Sheath Foot Extensor,CASE-28088,LOCAL,28088,CPT,0360,RC,,,,outpatient,,,22918.45,13751.07,,,,,,,,,,,,,
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,LOCAL,58542,CPT,,,,,,outpatient,,,65620.70,39372.42,,,,,,,,,,,,,
Transoral Lower Esophageal Myotomy,CASE-43497,LOCAL,43497,CPT,0360,RC,,,,outpatient,,,47585.13,28551.08,,,,,,,,,,,,,
Exc Tumor Soft Tiss Shoulder Subfasc <5cm|LEFT SIDE,CASE-23076,LOCAL,23076,CPT,0360,RC,,,LT,outpatient,,,13966.12,8379.67,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<,CASE-11420,LOCAL,11420,CPT,,,,,,outpatient,,,16220.85,9732.51,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE|PO,CASE-29846,LOCAL,29846,CPT,,,,,LT|PO,outpatient,,,28093.25,16855.95,,,,,,,,,,,,,
LOCKING FRACTURE PLATE 6 HOLE 43MM 2.0MM THICK TI 6AL 4V,SUP-2500729,CDM,C1713,HCPCS,0278,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
IMPLANT INTBDY FUS LUM LORDTC ALIF OR PLIF 19X24MM BAK VISTA,SUP-2414391,CDM,C1776,CPT,0278,RC,,,,both,,,18106.81,11769.43,,,,,,,,,,,,,
CATHETER ANGIO STR PIG AD 4 FRX65 CM SH TEF,SUP-2301519,CDM,C1713,HCPCS,0278,RC,,,,both,,,33.76,21.94,,,,,,,,,,,,,
HC Cart-T Therapy Receipt & Prep Car-T Cells F/Admin,PX-8723822700,CDM,38227,CPT,0873,RC,,,,both,,,4194.00,2726.10,,,,,,,,,,,,,
PLATE BNE T SM 2X0.7 MM 9 MM CRANIOMAXILLOFACIAL 4 LEFORT,SUP-2479068,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.97,412.73,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM ANK S STL LOK LO PROF FOR FRAC,SUP-2122625,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
COVER BUR H DIA22MM TI FOR CRAN CLSR SYS,SUP-2243979,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.27,351.18,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EXPLORER ST L 100 CM DIA 6 FR TIP,SUP-2141294,CDM,C1730,HCPCS,0272,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|LEFT FOOT, GREAT TOE|PO",CASE-28291,LOCAL,28291,CPT,,,,,TA|PO,outpatient,,,25713.85,15428.31,,,,,,,,,,,,,
Open Treatment Bimalleolar Ankle Fracture|RIGHT SIDE,CASE-27814,LOCAL,27814,CPT,,,,,RT,outpatient,,,36212.23,21727.34,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,LOCAL,52351,CPT,0360,RC,,,,outpatient,,,37858.80,22715.28,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,LOCAL,45380,CPT,,,,,PT|XU,outpatient,,,15043.82,9026.29,,,,,,,,,,,,,
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,LOCAL,43266,CPT,,,,,,outpatient,,,17099.42,10259.65,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening|RIGHT SIDE|PO,CASE-25390,LOCAL,25390,CPT,,,,,RT|PO,outpatient,,,37299.03,22379.42,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 1.1-2.0 Cm|PO,CASE-11402,LOCAL,11402,CPT,0360,RC,,,PO,outpatient,,,31671.87,19003.12,,,,,,,,,,,,,
Cptr-Asst Surgical Navigation Image-Less,CASE-20985,LOCAL,20985,CPT,0360,RC,,,,outpatient,,,78524.87,47114.92,,,,,,,,,,,,,
Bladder Instillation Anticarcinogenic Agent,CASE-51720,LOCAL,51720,CPT,0360,RC,,,,outpatient,,,19649.38,11789.63,,,,,,,,,,,,,
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,LOCAL,43238,CPT,0360,RC,,,,outpatient,,,22030.83,13218.50,,,,,,,,,,,,,
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr,CASE-28238,LOCAL,28238,CPT,,,,,,outpatient,,,34347.48,20608.49,,,,,,,,,,,,,
CATHETER 24FR RIGHT ANGLE SILICONE THO,SUP-2825232,CDM,C1729,HCPCS,0272,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 90 CM DIA 5 FR SLT PAT L 20,SUP-2118493,CDM,C1757,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
ARH SLIDE-LOC LONG STEM 6MM RIGHT,SUP-2830413,CDM,C1776,CPT,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
SCREW SET BREAK-OFF INSTRUMENT IPC,SUP-2628257,CDM,C1713,HCPCS,0278,RC,,,,both,,,7112.48,4623.11,,,,,,,,,,,,,
PLATE STRNL LG 10 H TI LADDER NS MATRIXSTERNUM,SUP-2904259,CDM,C1713,HCPCS,0278,RC,,,,both,,,2936.69,1908.85,,,,,,,,,,,,,
KIT INFL 18IN FOR SNUS DIL SYS NUVENT,SUP-2284167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,702.10,456.36,,,,,,,,,,,,,
GRAFT VASC IMPRA L 20 CM DIA 6 MM EPTFE FLX STD WALL RING,SUP-2761431,CDM,C1768,CPT,0278,RC,,,,both,,,1259.67,818.79,,,,,,,,,,,,,
HYDROMORPHONE HCL 2 MG PO TABS,RX-3760,CDM,6370000000,HCPCS,0637,RC,60687-0579-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE SPNL 10MM GRFT CONTAINMENT MLX,SUP-2310441,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BRACE ORTHOPEDIC D RNG MED REG AD 8 IN RT ROLYANFIT,SUP-2325902,CDM,L3908,HCPCS,0272,RC,,,,both,,,51.65,33.57,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE|PO,CASE-29883,LOCAL,29883,CPT,,,,,LT|PO,outpatient,,,81502.78,48901.67,,,,,,,,,,,,,
Arthroscopy Knee Removal Loose/Foreign Body|LEFT SIDE,CASE-29874,LOCAL,29874,CPT,0360,RC,,,LT,outpatient,,,18525.75,11115.45,,,,,,,,,,,,,
Arthrs Knee Drill Osteochondritis Dissecans Grfg|LEFT SIDE,CASE-29885,LOCAL,29885,CPT,0360,RC,,,LT,outpatient,,,37993.68,22796.21,,,,,,,,,,,,,
"HC Debrid,Bone,1st 20sqcm or Less",CASE-11044,LOCAL,11044,CPT,0361,RC,,,,outpatient,,,19365.23,11619.14,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,LOCAL,45380,CPT,0360,RC,,,74,outpatient,,,9765.48,5859.29,,,,,,,,,,,,,
Open Tx Radial&Ulnar Shaft Fx W/Fixj Radius&Ulna,CASE-25575,LOCAL,25575,CPT,0360,RC,,,,outpatient,,,46185.27,27711.16,,,,,,,,,,,,,
NAIL IM LENGTHENING 11X225 MM FITBONE 60001468000,SUP-2645845,CDM,C1713,HCPCS,0278,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,J7060,HCPCS,0250,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
PLATE STRNL CLOSURE 6 H TI H CONCV NS STERNALOCK EZ,SUP-2894445,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
AXIUM HELIX 9MM X 20CM COIL,SUP-2499308,CDM,C1889,HCPCS,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
KIT INSTR OSTEOPRECISE CUT GUIDE REDUCER JOYSTICK FREEHAND,SUP-2893268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PATCH DURA REP W6XL8CM BOV PERICARD GTA NONPYROGENIC,SUP-2130352,CDM,C1763,HCPCS,0278,RC,,,,both,,,2200.70,1430.45,,,,,,,,,,,,,
PLATE BNE L 42 MM SCREW DIA 3.5/4 MM 30 H H SHP FOR FRAG FT,SUP-2912940,CDM,C1713,HCPCS,0278,RC,,,,both,,,2662.72,1730.77,,,,,,,,,,,,,
NAIL IM L33CM OD11MM TIB CANN LCK DELT RUSS TAY,SUP-2342520,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
NAIL IM TIB 8X390 MM TI STRL TNADVANCED,SUP-2789173,CDM,C1713,HCPCS,0278,RC,,,,both,,,4781.87,3108.22,,,,,,,,,,,,,
BLADE HANDLE 2050,SUP-2853239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt|LEFT SIDE|PO,CASE-25020,LOCAL,25020,CPT,,,,,LT|PO,outpatient,,,12738.37,7643.02,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE,CASE-28090,LOCAL,28090,CPT,,,,,LT,outpatient,,,19625.32,11775.19,,,,,,,,,,,,,
Trurl Rescj Residual/Regrowth Obstr Prstate Tiss,CASE-52630,LOCAL,52630,CPT,0360,RC,,,,outpatient,,,24336.97,14602.18,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,LOCAL,38900,CPT,,,,,,outpatient,,,43563.10,26137.86,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,LOCAL,28285,CPT,,,,,T1,outpatient,,,25077.23,15046.34,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T4,outpatient,,,15667.47,9400.48,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit W Pta|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36902,LOCAL,36902,CPT,0361,RC,,,XU,outpatient,,,33843.10,20305.86,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO,CASE-27691,LOCAL,27691,CPT,0360,RC,,,LT|PO,outpatient,,,47905.90,28743.54,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|PO,CASE-64721,LOCAL,64721,CPT,0360,RC,,,LT|PO,outpatient,,,10392.50,6235.50,,,,,,,,,,,,,
Open Treatment of Ulnar Shaft Fracture,CASE-25545,LOCAL,25545,CPT,0360,RC,,,,outpatient,,,33527.12,20116.27,,,,,,,,,,,,,
Laps Bi Tot Pel Lmphadec & Pri-Aortic Lymph Bx 1,CASE-38572,LOCAL,38572,CPT,0360,RC,,,,outpatient,,,66908.52,40145.11,,,,,,,,,,,,,
Mediastinoscopy With Lymph Node Biopsy/Ies,CASE-39402,LOCAL,39402,CPT,,,,,,outpatient,,,32619.55,19571.73,,,,,,,,,,,,,
Open Treatment Metatarsal Fracture Each|RIGHT SIDE,CASE-28485,LOCAL,28485,CPT,0360,RC,,,RT,outpatient,,,34208.55,20525.13,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,LOCAL,28820,CPT,0360,RC,,,TA,outpatient,,,19818.07,11890.84,,,,,,,,,,,,,
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,LOCAL,38531,CPT,,,,,RT,outpatient,,,32455.47,19473.28,,,,,,,,,,,,,
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt|LEFT SIDE|PO,CASE-27602,LOCAL,27602,CPT,0360,RC,,,LT|PO,outpatient,,,20916.57,12549.94,,,,,,,,,,,,,
Open Treatment Fracture Distal Tibia & Fibula,CASE-27828,LOCAL,27828,CPT,0360,RC,,,,outpatient,,,44947.28,26968.37,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THUMB|SEPARATE STRUCTURE|PO",CASE-26055,LOCAL,26055,CPT,0360,RC,,,FA|XS|PO,outpatient,,,10914.55,6548.73,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE,CASE-27524,LOCAL,27524,CPT,0360,RC,,,RT,outpatient,,,31014.30,18608.58,,,,,,,,,,,,,
Patellectomy/Hemipatellectomy|RIGHT SIDE,CASE-27350,LOCAL,27350,CPT,,,,,RT,outpatient,,,21647.35,12988.41,,,,,,,,,,,,,
CATHETER GUID SHEATHLESS EAUCATH L 100 CM DIA 7.5 FR JR4,SUP-2517609,CDM,C1887,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 3.5X32 MM HD MINI-MONSTER,SUP-2320506,CDM,C1713,HCPCS,0278,RC,,,,both,,,670.39,435.75,,,,,,,,,,,,,
ROD EXT FIX LNG 500 MM NS PREFIX FIX LTX,SUP-2875766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.51,316.23,,,,,,,,,,,,,
HC So B Burgdorferi Amplified Probe,PX-3068747666,CDM,87476,CPT,0306,RC,,,,both,,,201.00,130.65,,,,,,,,,,,,,
CATHETER PICC SGL LUMN COMP ONLY NRS N PWR INJ SIL N COAT N,SUP-2120073,CDM,C1751,HCPCS,0278,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
SPLINT WRST SM R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG,SUP-2326135,CDM,L3908,HCPCS,0272,RC,,,,both,,,72.06,46.84,,,,,,,,,,,,,
GRAFT BONE ILIUM HEMI TRAD FRZN,SUP-2294150,CDM,C1713,HCPCS,0278,RC,,,,both,,,3968.96,2579.82,,,,,,,,,,,,,
VALVE AORT L12CM DIA28MM TISS ANNULUS DIA25MM CLLGN MSTR LO,SUP-2355124,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
ENDCAP SPNL OD13MM 0DEG TI RND DISTRACTIBLE MESH INTBDY FUS,SUP-2291985,CDM,C1889,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
DRAIN SURG 10 FRX250 CM NASOBILIARY KT,SUP-2167502,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
ANCHOR SUT DIA5MM W/ VLT BLU ABSRB ORTHOCORD NDL SPIRALOK,SUP-2249449,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
PLATE BNE L51MM THK1.2MM 0DEG 8 H BILAT S STL STR RIG LIMIT,SUP-2186171,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.43,844.63,,,,,,,,,,,,,
SHUNT SURG L 8.9 MM VENTRICULAR CATH L 180 MM PRESSURE 0 CM,SUP-2931062,CDM,C1729,HCPCS,0272,RC,,,,both,,,2853.98,1855.09,,,,,,,,,,,,,
SHELL ACET SZ E OD50MM ID22X26X28X32MM TI ALLOY POR MH,SUP-2344961,CDM,C1776,CPT,0278,RC,,,,both,,,7163.91,4656.54,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC VIABLE BNE MTRX BIO4 PS51001,SUP-2637049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2111.96,1372.77,,,,,,,,,,,,,
GUIDEWIRE ORTH BLNT TIP 1.4X510 MM DISP,SUP-2684359,CDM,C1769,HCPCS,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,LOCAL,31654,CPT,,,,,,outpatient,,,23524.62,14114.77,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, SECOND DIGIT|SEPARATE STRUCTURE|PO",CASE-28124,LOCAL,28124,CPT,0360,RC,,,T6|XS|PO,outpatient,,,27151.63,16290.98,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE|PO,CASE-29875,LOCAL,29875,CPT,,,,,LT|PO,outpatient,,,18319.27,10991.56,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26123,LOCAL,26123,CPT,0360,RC,,,F8,outpatient,,,16206.85,9724.11,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT|PO",CASE-28820,LOCAL,28820,CPT,,,,,T1|PO,outpatient,,,10961.68,6577.01,,,,,,,,,,,,,
Cysto W/Simple Removal Stone & Stent,CASE-52310,LOCAL,52310,CPT,,,,,,outpatient,,,21743.25,13045.95,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv,CASE-64418,LOCAL,64418,CPT,0360,RC,,,,outpatient,,,92837.65,55702.59,,,,,,,,,,,,,
Fasciectomy Plantar Fascia Partial Spx|RIGHT SIDE|PO,CASE-28060,LOCAL,28060,CPT,0360,RC,,,RT|PO,outpatient,,,10652.72,6391.63,,,,,,,,,,,,,
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64448,LOCAL,64448,CPT,0360,RC,,,XU|LT,outpatient,,,59606.47,35763.88,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE|PO,CASE-29876,LOCAL,29876,CPT,,,,,LT|PO,outpatient,,,18100.22,10860.13,,,,,,,,,,,,,
Laps Surg Gastrostomy W/O Constj Gstr Tube Spx,CASE-43653,LOCAL,43653,CPT,,,,,,outpatient,,,36779.38,22067.63,,,,,,,,,,,,,
HC N Block Inj Intercost Sng|RIGHT SIDE|PO,CASE-64420,LOCAL,64420,CPT,0360,RC,,,RT|PO,outpatient,,,5424.57,3254.74,,,,,,,,,,,,,
HC Stent Place Initial Artery Ang,CASE-37236,LOCAL,37236,CPT,0360,RC,,,,outpatient,,,67648.42,40589.05,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|BILATERAL PROCEDURE|PO,CASE-28308,LOCAL,28308,CPT,0360,RC,,,50|PO,outpatient,,,21352.17,12811.30,,,,,,,,,,,,,
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|BILATERAL PROCEDURE,CASE-37722,LOCAL,37722,CPT,0360,RC,,,50,outpatient,,,39797.12,23878.27,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Recurrent|LEFT SIDE|PO,CASE-25112,LOCAL,25112,CPT,0360,RC,,,LT|PO,outpatient,,,13513.90,8108.34,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-29881,LOCAL,29881,CPT,,,,,XS|LT|PO,outpatient,,,48468.53,29081.12,,,,,,,,,,,,,
Litholapaxy Smpl/Sm <2.5 Cm|SEPARATE STRUCTURE,CASE-52317,LOCAL,52317,CPT,,,,,XS,outpatient,,,37159.03,22295.42,,,,,,,,,,,,,
SHEATH INTRO 8.5FR L72CM TIP L22.4MM 0.032IN BIDIR M CRV,SUP-2148501,CDM,C1894,HCPCS,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
ANCHOR SUT OD55MM 2 TWO PEEK OPTMA POLYMER FOR ROT CUF REP,SUP-2212838,CDM,C1713,HCPCS,0278,RC,,,,both,,,1488.36,967.43,,,,,,,,,,,,,
TUBE SET MICRO-HOOK BONESCALPEL MIS,SUP-2748600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
NAIL IM L150MM DIA10MM ANK TI COR LOK TECHNOLOGY 2 STG ARTH,SUP-2412146,CDM,C1713,HCPCS,0278,RC,,,,both,,,8107.92,5270.15,,,,,,,,,,,,,
PRESSURE MONITORING KIT INTCRAN PARENCHYMA HEX WRNCH CAMINO,SUP-2851494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2752.02,1788.81,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 35X15 CM RECON TISS MTRX STRATTICE,SUP-2488678,CDM,Q4130,HCPCS,0636,RC,,,,both,,,51976.42,33784.67,,,,,,,,,,,,,
POUCH MESH GRFT DEL OPTIMESH 23X2MM YELLO,SUP-2354628,CDM,C1781,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SCREW BONE L9MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2188967,CDM,C1713,HCPCS,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 4 FRX15 CM DL J TIP STRL,SUP-2759909,CDM,C1751,HCPCS,0278,RC,,,,both,,,436.30,283.59,,,,,,,,,,,,,
"HC So Cult,Pathognic Orgnsms,Screen",PX-3008708166,CDM,87081,CPT,0300,RC,,,,both,,,173.00,112.45,,,,,,,,,,,,,
SCREW SPNL 14 MM DISTRCTN,SUP-2354558,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE BNE STR 2.3X105 MM 16 HOLE FRAC FOR SCR TI LEVEL 1,SUP-2481100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.99,853.44,,,,,,,,,,,,,
CONT MESH F TEMPOROPARIETAL PED L06MM,SUP-2681438,CDM,C1713,HCPCS,0278,RC,,,,both,,,16354.12,10630.18,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,LOCAL,28270,CPT,0360,RC,,,T6|PO,outpatient,,,15248.78,9149.27,,,,,,,,,,,,,
Unlisted Procedure Femur/Knee|LEFT SIDE,CASE-27599,LOCAL,27599,CPT,0360,RC,,,LT,outpatient,,,20260.72,12156.43,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,LOCAL,28122,CPT,0360,RC,,,RT,outpatient,,,30270.30,18162.18,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,LOCAL,29880,CPT,,,,,RT,outpatient,,,22355.77,13413.46,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, THIRD DIGIT",CASE-28270,LOCAL,28270,CPT,,,,,T7,outpatient,,,39850.62,23910.37,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F8|PO,outpatient,,,6433.13,3859.88,,,,,,,,,,,,,
Arthrs Knee Drill Osteochondritis Dissecans Grfg|LEFT SIDE,CASE-29885,LOCAL,29885,CPT,,,,,LT,outpatient,,,37993.68,22796.21,,,,,,,,,,,,,
Unlisted Procedure Pelvis/Hip Joint,CASE-27299,LOCAL,27299,CPT,,,,,,outpatient,,,53130.23,31878.14,,,,,,,,,,,,,
Revj Total Knee Arthrp W/WO Algrft 1 Component|LEFT SIDE,CASE-27486,LOCAL,27486,CPT,0360,RC,,,LT,outpatient,,,35968.07,21580.84,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 7.6-12cm|SEPARATE STRUCTURE,CASE-12034,LOCAL,12034,CPT,0450,RC,,,XS,outpatient,,,35367.78,21220.67,,,,,,,,,,,,,
Arteriovenous Anastomosis Open Direct|LEFT SIDE,CASE-36821,LOCAL,36821,CPT,0360,RC,,,LT,outpatient,,,30015.05,18009.03,,,,,,,,,,,,,
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,LOCAL,45331,CPT,,,,,,outpatient,,,11428.40,6857.04,,,,,,,,,,,,,
Arthrotomy W/Meniscus Repair Knee,CASE-27403,LOCAL,27403,CPT,0360,RC,,,,outpatient,,,63869.23,38321.54,,,,,,,,,,,,,
Laps Surg Prst8ect Smpl Stot Robotic Assistance,CASE-55867,LOCAL,55867,CPT,0360,RC,,,,outpatient,,,83240.22,49944.13,,,,,,,,,,,,,
Rhinp Prim Complete Xtrnl Parts|PO,CASE-30410,LOCAL,30410,CPT,0360,RC,,,PO,outpatient,,,36725.65,22035.39,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|PO,CASE-64721,LOCAL,64721,CPT,,,,,LT|PO,outpatient,,,10392.50,6235.50,,,,,,,,,,,,,
SOUND URETH L7IN OD10FR CRV TIP MTL FEM MCCREA,SUP-2126575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.99,411.44,,,,,,,,,,,,,
HC Antibody Elution RBC Each Elution,PX-3028686000,CDM,86860,CPT,0302,RC,,,,both,,,656.00,426.40,,,,,,,,,,,,,
CAST ORTH 4 IN KIT W/O BOOT EZ,SUP-2427662,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.31,263.45,,,,,,,,,,,,,
CATHETER INFUS 6-8FR PROXIS,SUP-2355065,CDM,C1751,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Platelet Aggregation in Vitro Each Agent,PX-3058557600,CDM,85576,CPT,0305,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,6370000000,HCPCS,0637,RC,00904-7478-35,NDC,,both,15,ML,8.60,5.59,,,,,,,,,,,,,
INFUVITE ADULT IV SOLN,RX-169304,CDM,2500000003,HCPCS,0250,RC,54643-9007-01,NDC,,both,10,ML,88.50,57.52,,,,,,,,,,,,,
CATHETER URETH 14FR L25CM UTHANE NDL OBT CANN ASSEMB CONN,SUP-2171361,CDM,C2627,HCPCS,0272,RC,,,,both,,,165.32,107.46,,,,,,,,,,,,,
KIT DSG 1.3X5.9X10CM STD SZ BLK NEG PRSS ABD SYS,SUP-2262323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,958.39,622.95,,,,,,,,,,,,,
KIT EXT FIX MULTAXL CORRECTION SYS HEXAPOD FULL AUTO NS,SUP-2905693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.29,384.34,,,,,,,,,,,,,
PIN EXT FIX L80MM DIA25MM THRD L20MM HALF SELF DRL,SUP-2199721,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
SET INSTR IMPL SCR DIA6.5/7.3MM COMBINED CANN,SUP-2183060,CDM,C1713,HCPCS,0278,RC,,,,both,,,141088.05,91707.23,,,,,,,,,,,,,
PLATE BONE L35MM THK0.9MM 8 H BILAT TI STRUT RIG NEUT SAG,SUP-2191224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1532.01,995.81,,,,,,,,,,,,,
FIBER LASER FLEXIVA PULSE 242,SUP-2718710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1258.98,818.34,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 2.3MM STAINLESS STEEL KNOTLESS PRE LO,SUP-2824591,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.89,402.28,,,,,,,,,,,,,
Litholapaxy Comp/Lg > 2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52318,LOCAL,52318,CPT,0360,RC,,,XU,outpatient,,,36113.70,21668.22,,,,,,,,,,,,,
Bone Surgery Using Computer,CASE-0055T,LOCAL,0055T,CPT,0360,RC,,,,outpatient,,,61203.52,36722.11,,,,,,,,,,,,,
Mastectomy Simple Complete,CASE-19303,LOCAL,19303,CPT,,,,,,outpatient,,,56000.47,33600.28,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26123,LOCAL,26123,CPT,,,,,F8,outpatient,,,16206.85,9724.11,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28308,LOCAL,28308,CPT,0360,RC,,,RT|XS,outpatient,,,39850.62,23910.37,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64721,LOCAL,64721,CPT,0360,RC,,,RT|XS|PO,outpatient,,,27264.38,16358.63,,,,,,,,,,,,,
Adjnt Tis Trnsfr/Reargmt Any Area 30.1-60 Sq Cm,CASE-14301,LOCAL,14301,CPT,,,,,,outpatient,,,78411.37,47046.82,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE|PO,CASE-29806,LOCAL,29806,CPT,0360,RC,,,LT|PO,outpatient,,,37838.58,22703.15,,,,,,,,,,,,,
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|RIGHT SIDE,CASE-27130,LOCAL,27130,CPT,,,,,RT,outpatient,,,53800.60,32280.36,,,,,,,,,,,,,
Excision Lesion Tendon Sheath/Capsule Leg&/Ank,CASE-27630,LOCAL,27630,CPT,,,,,,outpatient,,,24787.32,14872.39,,,,,,,,,,,,,
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE,CASE-27339,LOCAL,27339,CPT,0360,RC,,,LT,outpatient,,,17545.02,10527.01,,,,,,,,,,,,,
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE,CASE-24685,LOCAL,24685,CPT,,,,,LT,outpatient,,,28602.35,17161.41,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FOURTH DIGIT|PO",CASE-26951,LOCAL,26951,CPT,0360,RC,,,F3|PO,outpatient,,,15455.88,9273.53,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM CRANIOMAXILOFACIAL MED DOG BNE,SUP-2935199,CDM,C1713,HCPCS,0278,RC,,,,both,,,8945.86,5814.81,,,,,,,,,,,,,
CLIP INT LIG SM WIDE TI RED VESOCCLUDE DISP,SUP-2757589,CDM,C1889,HCPCS,0278,RC,,,,both,,,7.22,4.69,,,,,,,,,,,,,
HC Veeg by Tech 2-12 Hr Cont R-T Monitoring,PX-7409571300,CDM,95713,CPT,0740,RC,,,,inpatient,,,4222.00,2744.30,,,,,,,,,,,,,
NEOSTIGMINE METHYLSULFATE 5 MG/5ML IV SOSY,RX-131329,CDM,J2710,HCPCS,0636,RC,71266-2003-02,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
HC NM Liver Scan/Spleen Scan,PX-3417821500,CDM,78215,CPT,0341,RC,,,,both,,,2195.00,1426.75,,,,,,,,,,,,,
CATHETER CARD ABLATION CELSIUS DIA 7 FR TIP 4 MM SPC 2-5-2,SUP-2257449,CDM,C1733,HCPCS,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
DA VINCI TIBIAL NAIL SCREW CASE,SUP-2816347,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
MARKER BRST BX 14GA TI FOR PRB CORMARK,SUP-2195641,CDM,A4648,CPT,0278,RC,,,,both,,,333.15,216.55,,,,,,,,,,,,,
MESH SURG 30CM LEN 5CM W 0.5MM THICKNESS STD SH SYNTH ABD,SUP-2265903,CDM,C1781,HCPCS,0278,RC,,,,both,,,117.22,76.19,,,,,,,,,,,,,
TITAN INFL PENILE PROS CYL SET 14 CM,SUP-2165372,CDM,C1813,HCPCS,0278,RC,,,,both,,,10892.66,7080.23,,,,,,,,,,,,,
SIGMA HP UNI FEM FIN BLK SZ 1,SUP-2513377,CDM,C1776,CPT,0278,RC,,,,both,,,5353.70,3479.90,,,,,,,,,,,,,
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,LOCAL,49593,CPT,0360,RC,,,,outpatient,,,41189.45,24713.67,,,,,,,,,,,,,
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26536,LOCAL,26536,CPT,,,,,F2|PO,outpatient,,,28192.65,16915.59,,,,,,,,,,,,,
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,LOCAL,55040,CPT,0360,RC,,,RT,outpatient,,,20812.13,12487.28,,,,,,,,,,,,,
HC Open/Perq Place Stent Ea Add A,CASE-37237,LOCAL,37237,CPT,0360,RC,,,,outpatient,,,67648.42,40589.05,,,,,,,,,,,,,
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE|SEPARATE STRUCTURE,CASE-27339,LOCAL,27339,CPT,,,,,LT|XS,outpatient,,,30349.03,18209.42,,,,,,,,,,,,,
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26080,LOCAL,26080,CPT,,,,,F1|PO,outpatient,,,12053.35,7232.01,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26735,LOCAL,26735,CPT,,,,,F9|PO,outpatient,,,19472.57,11683.54,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE|PO,CASE-29823,LOCAL,29823,CPT,0360,RC,,,LT|PO,outpatient,,,34593.22,20755.93,,,,,,,,,,,,,
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>|LEFT SIDE,CASE-23071,LOCAL,23071,CPT,0360,RC,,,LT,outpatient,,,17042.67,10225.60,,,,,,,,,,,,,
Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,CASE-49616,LOCAL,49616,CPT,,,,,,outpatient,,,68432.20,41059.32,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Capsulorrhaphy|PO,CASE-29806,LOCAL,29806,CPT,,,,,PO,outpatient,,,43306.68,25984.01,,,,,,,,,,,,,
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, THIRD DIGIT",CASE-28234,LOCAL,28234,CPT,0360,RC,,,T2,outpatient,,,11454.52,6872.71,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT HAND, FIFTH DIGIT",CASE-28308,LOCAL,28308,CPT,,,,,F9,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, FIFTH DIGIT",CASE-28234,LOCAL,28234,CPT,,,,,T4,outpatient,,,11454.52,6872.71,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,LOCAL,28270,CPT,,,,,T1|PO,outpatient,,,19110.18,11466.11,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE,CASE-29827,LOCAL,29827,CPT,,,,,RT,outpatient,,,50274.85,30164.91,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE|PO,CASE-24359,LOCAL,24359,CPT,,,,,LT|PO,outpatient,,,13245.50,7947.30,,,,,,,,,,,,,
SYSTEM CTRL 3664CONTRLSYS,SUP-2615537,CDM,C1767,HCPCS,0278,RC,,,,both,,,66083.28,42954.13,,,,,,,,,,,,,
PLATE BNE RECON 3.5X156 MM 12 HOLE LCK LP SS NS,SUP-2184032,CDM,C1713,HCPCS,0278,RC,,,,both,,,2490.81,1619.03,,,,,,,,,,,,,
SCREW BNE L14MM OD27MM STD TI TARSALIS FULL THRD NONLOCKING,SUP-2243282,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.25,306.31,,,,,,,,,,,,,
SHEATH INTRO L 43 CM CATH 7 FR FCPS SZ 5.5/7 FR STR AD W/O,SUP-2157190,CDM,C1894,HCPCS,0272,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL VIT 2.0MM DIA 20MML,SUP-2364643,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.84,63.60,,,,,,,,,,,,,
GRAFT BNE SUB 1.2CC FOAM PK STBL COMPR RESIST VITOSS BA2X,SUP-2368193,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
NAIL IM L210MM OD12MM 130DEG S STL PROX MEDIOLATERAL FEM,SUP-2351367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1931.48,1255.46,,,,,,,,,,,,,
GII STEP HEMI WDG SZ1-2 {} 15,SUP-2511029,CDM,C1776,CPT,0278,RC,,,,both,,,2650.16,1722.60,,,,,,,,,,,,,
SCREW BONE L70MM DIA4MM STD CORT NONCANNULATED LCK PARTIALLY,SUP-2348844,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.05,177.48,,,,,,,,,,,,,
COMPONENT ARTC SURF CR 1-2 AB 9 MM TIB KNEE PUR NXGN,SUP-2201339,CDM,C1776,CPT,0278,RC,,,,both,,,3682.59,2393.68,,,,,,,,,,,,,
CATHETER SNUS BLLN L16MM DIA6MM HI PERF DIL INT SNUS IRRIG,SUP-2106319,CDM,C1729,HCPCS,0272,RC,,,,both,,,2452.34,1594.02,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ANK MED,SUP-2330426,CDM,L4350,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
HC So Iadna Mycoplasma Genitalium Amplified Probe Tech,PX-3068756366,CDM,87563,CPT,0306,RC,,,,both,,,53.00,34.45,,,,,,,,,,,,,
SCREW BNE L 8 MM DIA2.2 MM SM CANN STRL QFX,SUP-2932889,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.04,405.63,,,,,,,,,,,,,
NEEDLE BRST LOC BLNT 20 GAX5 CM STRL HAWK3 LTX,SUP-2876181,CDM,C1819,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
HC Revasc Intra Lithotrip-Stent,PX-4810976500,CDM,C9765,CPT,0481,RC,,,,outpatient,,,57405.00,37313.25,,,,,,,,,,,,,
PLATE BNE SM W10.1XL106MM THK3.5MM 8 H BILAT S STL CRV RIG,SUP-2186262,CDM,C1713,HCPCS,0278,RC,,,,both,,,2086.18,1356.02,,,,,,,,,,,,,
Prq Skeletal Fix Carpo/Metacarpal Fx Dislc Thumb,CASE-26650,LOCAL,26650,CPT,,,,,,outpatient,,,10640.50,6384.30,,,,,,,,,,,,,
HC Inj Trigger Pt 1-2 Musc Grps|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,LOCAL,20552,CPT,0510,RC,,,XU,outpatient,,,5662.15,3397.29,,,,,,,,,,,,,
Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated,CASE-49596,LOCAL,49596,CPT,0360,RC,,,,outpatient,,,61194.60,36716.76,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,LOCAL,29846,CPT,0360,RC,,,,outpatient,,,29451.92,17671.15,,,,,,,,,,,,,
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE|PO,CASE-28200,LOCAL,28200,CPT,0360,RC,,,LT|PO,outpatient,,,40088.18,24052.91,,,,,,,,,,,,,
Lateral Retinacular Release Open,CASE-27425,LOCAL,27425,CPT,0360,RC,,,,outpatient,,,21598.42,12959.05,,,,,,,,,,,,,
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE,CASE-27685,LOCAL,27685,CPT,,,,,RT,outpatient,,,87970.43,52782.26,,,,,,,,,,,,,
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|RIGHT SIDE,CASE-37232,LOCAL,37232,CPT,,,,,RT,outpatient,,,72153.18,43291.91,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE|PO,CASE-64493,LOCAL,64493,CPT,0360,RC,,,50|PO,outpatient,,,4412.95,2647.77,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F7|XU,outpatient,,,14409.52,8645.71,,,,,,,,,,,,,
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB|PO",CASE-64831,LOCAL,64831,CPT,,,,,F5|PO,outpatient,,,18985.28,11391.17,,,,,,,,,,,,,
Colorectal Scrn; Hi Risk Ind,CASE-G0105,LOCAL,G0105,CPT,,,,,,outpatient,,,9888.12,5932.87,,,,,,,,,,,,,
Revis Shoulder Arthrplsty Humeral&Glenoid Compnt|RIGHT SIDE,CASE-23474,LOCAL,23474,CPT,0360,RC,,,RT,outpatient,,,104345.23,62607.14,,,,,,,,,,,,,
HC Strapping of Toes,PX-4502955000,CDM,29550,CPT,0450,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
LABETALOL HCL 200 MG PO TABS,RX-10374,CDM,6370000000,HCPCS,0637,RC,00904-7452-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT SELF REINFORCED CROSSPIN STERILE 45MM,SUP-2824428,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.84,543.30,,,,,,,,,,,,,
GRAFT HUM TISS XSM W9XL15CM THK15 22MM THCK PERF FLEXHD,SUP-2436520,CDM,Q4128,HCPCS,0636,RC,,,,both,,,7431.75,4830.64,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 15MM BAYONET 201659,SUP-2844598,CDM,C1889,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
CATHETER THROMCTMY SYNTEL L 80 CM 5FR 11MM 1.5CC 3CC FLX TIP,SUP-2119457,CDM,C1757,HCPCS,0272,RC,,,,both,,,19.56,12.71,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EMBLEM W 83.1 X H 69.1 MM D 12.7 MM 59.5,SUP-2149156,CDM,C1722,HCPCS,0275,RC,,,,both,,,64370.00,41840.50,,,,,,,,,,,,,
SCREW SPINAL POLYAXIAL MODULAR TULIP INVICTUS,SUP-2553710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1532.32,996.01,,,,,,,,,,,,,
CATHETER MULTI-PURPOSE DRAIN 8FR L25CM GWIRE DIA0.038IN POLYUR MTL,SUP-2381889,CDM,C1729,HCPCS,0272,RC,,,,both,,,233.62,151.85,,,,,,,,,,,,,
GUIDE NDL FOR ULTRASOUND PRB STRL MULTI-PRO 2000 DISP,SUP-2165784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 12MM REINFORCING 30 DEG 201746,SUP-2844626,CDM,C1889,HCPCS,0278,RC,,,,both,,,1182.30,768.49,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L31CM OD9FR REG W/O RESVR T PRT,SUP-2264215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS,RX-34505,CDM,6370000000,HCPCS,0637,RC,60687-0396-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DEVICE SUT SPNL CRD STIM SYS SURG EQUIP FIXATE,SUP-2138772,CDM,C1713,HCPCS,0278,RC,,,,both,,,5620.60,3653.39,,,,,,,,,,,,,
SLING UROLOGICAL MID-URETHRAL TRNSVAG 1 DEL ADVANTAGE ULTRA,SUP-2876039,CDM,C1771,HCPCS,0278,RC,,,,both,,,5301.48,3445.96,,,,,,,,,,,,,
HC Injection Small Joint/Bursa,PX-3612060000,CDM,20600,CPT,0361,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
GRAFT HUM TISS 100MM FRZN ALLGRFT HUM W O ROT CUF PROX,SUP-2307324,CDM,C1713,HCPCS,0278,RC,,,,both,,,15938.64,10360.12,,,,,,,,,,,,,
Patellectomy/Hemipatellectomy|RIGHT SIDE,CASE-27350,LOCAL,27350,CPT,0360,RC,,,RT,outpatient,,,21647.35,12988.41,,,,,,,,,,,,,
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,LOCAL,67900,CPT,0360,RC,,,50,outpatient,,,64260.53,38556.32,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea,CASE-28092,LOCAL,28092,CPT,,,,,,outpatient,,,12964.35,7778.61,,,,,,,,,,,,,
Removal Implant Deep|SEPARATE STRUCTURE|PO,CASE-20680,LOCAL,20680,CPT,,,,,XS|PO,outpatient,,,35793.97,21476.38,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, FOURTH DIGIT",CASE-28308,LOCAL,28308,CPT,0360,RC,,,T3,outpatient,,,19207.23,11524.34,,,,,,,,,,,,,
Revis Shoulder Arthrplsty Humeral&Glenoid Compnt,CASE-23474,LOCAL,23474,CPT,,,,,,outpatient,,,104345.23,62607.14,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE|PO,CASE-29846,LOCAL,29846,CPT,,,,,RT|PO,outpatient,,,31695.40,19017.24,,,,,,,,,,,,,
HC Debride Subq First 20 Sq Cm|SEPARATE STRUCTURE,CASE-11042,LOCAL,11042,CPT,0361,RC,,,XS,outpatient,,,53245.60,31947.36,,,,,,,,,,,,,
Fasciotomy Foot&/Toe|BILATERAL PROCEDURE|PO,CASE-28008,LOCAL,28008,CPT,0360,RC,,,50|PO,outpatient,,,13586.57,8151.94,,,,,,,,,,,,,
PLATE BONE L110MM BLDE W5.8XL38MM 145DEG 6 H STRL BILAT PELV,SUP-2186672,CDM,C1713,HCPCS,0278,RC,,,,both,,,2498.18,1623.82,,,,,,,,,,,,,
CATHETER GUID ADV EH 52CM,SUP-2149008,CDM,C1887,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SCREW BNE L90MM DIA13MM THRD L22MM STD HIP S STL LAG CANN,SUP-2370957,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
GRAFT BONE SUB 10CC W25XH8XL50MM NANOSTRUCTURED HA GRAN POR,SUP-2335285,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SHEATH INTRO ACCEL L 20CM DIA 6 FR L 60/145 CM DIA 21 GA NIT,SUP-2659242,CDM,C1894,HCPCS,0272,RC,,,,both,,,257.01,167.06,,,,,,,,,,,,,
ANCHOR SUT DIA2.9MM SFT JUGGERKNOT,SUP-2212955,CDM,C1713,HCPCS,0278,RC,,,,both,,,1202.75,781.79,,,,,,,,,,,,,
PLATE BNE XSM W14XL22MM 4 H NONSTERILE BILAT S STL X SHP LO,SUP-2186325,CDM,C1713,HCPCS,0278,RC,,,,both,,,2338.36,1519.93,,,,,,,,,,,,,
BASEPLATE NEXGEN ROTATING HINGE STEM TIBIAL PLATE SIZE 6,SUP-2502529,CDM,C1776,CPT,0278,RC,,,,both,,,10781.19,7007.77,,,,,,,,,,,,,
HC Needle Biopsy Muscle,CASE-20206,LOCAL,20206,CPT,0361,RC,,,,outpatient,,,9142.25,5485.35,,,,,,,,,,,,,
Cysto/Pyeloscopy Rescj Pelvic Tumor|LEFT SIDE,CASE-52355,LOCAL,52355,CPT,0360,RC,,,LT,outpatient,,,25111.83,15067.10,,,,,,,,,,,,,
Arthrs Knee Drill Osteochondritis Dissecans Grfg,CASE-29885,LOCAL,29885,CPT,,,,,,outpatient,,,37993.68,22796.21,,,,,,,,,,,,,
Nerve Repair W/Nerve Allograft First Strand|PO,CASE-64912,LOCAL,64912,CPT,0360,RC,,,PO,outpatient,,,29029.73,17417.84,,,,,,,,,,,,,
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE,CASE-27654,LOCAL,27654,CPT,0360,RC,,,RT,outpatient,,,38377.33,23026.40,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|PO",CASE-26055,LOCAL,26055,CPT,,,,,F6|PO,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
Destruction Mal Lesion Trunk/Arm/Leg > 4.0 Cm|RIGHT SIDE,CASE-17266,LOCAL,17266,CPT,,,,,RT,outpatient,,,15776.15,9465.69,,,,,,,,,,,,,
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, FOURTH DIGIT|PO",CASE-26080,LOCAL,26080,CPT,,,,,F3|PO,outpatient,,,14915.00,8949.00,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26123,LOCAL,26123,CPT,0360,RC,,,F8|PO,outpatient,,,10730.72,6438.43,,,,,,,,,,,,,
Esophagogastroduodenoscopy US Scope W/Adj Strxrs|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43237,LOCAL,43237,CPT,,,,,74,outpatient,,,11511.00,6906.60,,,,,,,,,,,,,
"Ostc Prtl Exostc/Condylc Metar Head|LEFT FOOT, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28288,LOCAL,28288,CPT,0360,RC,,,T1|XU,outpatient,,,22918.45,13751.07,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, THIRD DIGIT|PO",CASE-26123,LOCAL,26123,CPT,,,,,F2|PO,outpatient,,,13228.23,7936.94,,,,,,,,,,,,,
Laps Supracervical Hysterectomy >250,CASE-58543,LOCAL,58543,CPT,0360,RC,,,,outpatient,,,67907.53,40744.52,,,,,,,,,,,,,
Tenolysis Extensor Foot Single Tendon|LEFT SIDE|PO,CASE-28225,LOCAL,28225,CPT,,,,,LT|PO,outpatient,,,21325.52,12795.31,,,,,,,,,,,,,
Laparoscopy Surg Cholecystectomy,CASE-47562,LOCAL,47562,CPT,,,,,,outpatient,,,25449.88,15269.93,,,,,,,,,,,,,
Destruction Mal Lesion Trunk/Arm/Leg > 4.0 Cm|RIGHT SIDE,CASE-17266,LOCAL,17266,CPT,0360,RC,,,RT,outpatient,,,15776.15,9465.69,,,,,,,,,,,,,
Ligation/Biopsy Temporal Artery|RIGHT SIDE,CASE-37609,LOCAL,37609,CPT,,,,,RT,outpatient,,,21730.68,13038.41,,,,,,,,,,,,,
Debridement Nail Any Method 1-5,CASE-11720,LOCAL,11720,CPT,0360,RC,,,,outpatient,,,120565.82,72339.49,,,,,,,,,,,,,
Laparoscopy Surg Ablation Renal Cysts|RIGHT SIDE,CASE-50541,LOCAL,50541,CPT,0360,RC,,,RT,outpatient,,,102769.62,61661.77,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|PO",CASE-26055,LOCAL,26055,CPT,,,,,F9|PO,outpatient,,,8208.63,4925.18,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2X400 MM W/ DRL TIP STRL,SUP-2789594,CDM,C1769,HCPCS,0272,RC,,,,both,,,402.33,261.51,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX LNG 5X300 MM TIN SIDEKCK,SUP-2850838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
SCREW BNE L50MM OD4MM CANN LO PROF IMPL CAPTURE,SUP-2243895,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.52,652.94,,,,,,,,,,,,,
HC So1 Special Stain Grp 2,PX-3128831367,CDM,88313,CPT,0312,RC,,,,both,,,297.00,193.05,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.9MM PUR TI ST NONLOCKING MATRIXRIB,SUP-2181526,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.71,309.21,,,,,,,,,,,,,
PROBE LASER 23GA 40DEG NIT TIP EZ INSRTN DISP,SUP-2109925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.05,445.28,,,,,,,,,,,,,
SCREW BONE STD CORT FULL THRD FLX CANN N LCK NSTERILE 5.5MM,SUP-2341063,CDM,C1713,HCPCS,0278,RC,,,,both,,,110.53,71.84,,,,,,,,,,,,,
GRAFT HUM TISS POST TIBIALIS TEND FRZN,SUP-2165552,CDM,C1762,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
NAIL IM L255MM DIA8MM NONSTERILE DK BLU TIB TI LCK UNREAMED,SUP-2192746,CDM,C1713,HCPCS,0278,RC,,,,both,,,4211.87,2737.72,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THCK 4CMX16CM,SUP-2306913,CDM,C1762,CPT,0278,RC,,,,both,,,5776.44,3754.69,,,,,,,,,,,,,
BUR SURG M DIA5MM RND FLUT,SUP-2367420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,296.86,192.96,,,,,,,,,,,,,
COIL VASC AZUR L 26 CM DIA10 MM MICROCATHETER 0.018 IN LOOP,SUP-2385435,CDM,C1889,HCPCS,0278,RC,,,,both,,,2568.90,1669.78,,,,,,,,,,,,,
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE,CASE-27405,LOCAL,27405,CPT,0360,RC,,,LT,outpatient,,,31537.33,18922.40,,,,,,,,,,,,,
"Open Tx Fracture Phalanx/Phalanges Not Great Toe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28525,LOCAL,28525,CPT,,,,,T9|PO,outpatient,,,15785.70,9471.42,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT|PO",CASE-26160,LOCAL,26160,CPT,,,,,F2|PO,outpatient,,,8824.37,5294.62,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT",CASE-28285,LOCAL,28285,CPT,,,,,T4,outpatient,,,15667.47,9400.48,,,,,,,,,,,,,
Injection Intralesional Up to & Includ 7 Lesions,CASE-11900,LOCAL,11900,CPT,0360,RC,,,,outpatient,,,33259.95,19955.97,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,LOCAL,11404,CPT,0360,RC,,,,outpatient,,,22448.28,13468.97,,,,,,,,,,,,,
Exc Tumor Soft Tiss Back/Flank Subfascial 5 Cm/>,CASE-21933,LOCAL,21933,CPT,,,,,,outpatient,,,22592.27,13555.36,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FIFTH DIGIT|PO",CASE-28232,LOCAL,28232,CPT,,,,,T4|PO,outpatient,,,21238.90,12743.34,,,,,,,,,,,,,
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,LOCAL,52601,CPT,,,,,,outpatient,,,26789.72,16073.83,,,,,,,,,,,,,
Laps Surg Prst8ect Smpl Stot Robotic Assistance,CASE-55867,LOCAL,55867,CPT,,,,,,outpatient,,,83240.22,49944.13,,,,,,,,,,,,,
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,LOCAL,58120,CPT,0360,RC,,,,outpatient,,,24392.00,14635.20,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27691,LOCAL,27691,CPT,0360,RC,,,LT|PO|CG,outpatient,,,25385.63,15231.38,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64418,LOCAL,64418,CPT,0360,RC,,,XU|LT,outpatient,,,32272.38,19363.43,,,,,,,,,,,,,
Excision Local Lesion Epididymis|RIGHT SIDE,CASE-54830,LOCAL,54830,CPT,0360,RC,,,RT,outpatient,,,21664.60,12998.76,,,,,,,,,,,,,
Colonoscopy Stoma Dx Including Collj Spec Spx,CASE-44388,LOCAL,44388,CPT,0360,RC,,,,outpatient,,,9519.78,5711.87,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28289,LOCAL,28289,CPT,0360,RC,,,T5|PO,outpatient,,,21771.18,13062.71,,,,,,,,,,,,,
Excision Tumor Soft Tiss Face/Scalp Subq 2 Cm/>,CASE-21012,LOCAL,21012,CPT,,,,,,outpatient,,,13868.62,8321.17,,,,,,,,,,,,,
Arthroplasty Glenohumeral Joint Total Shoulder|RIGHT SIDE,CASE-23472,LOCAL,23472,CPT,,,,,RT,outpatient,,,77824.52,46694.71,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|LEFT FOOT, SECOND DIGIT|PO",CASE-28124,LOCAL,28124,CPT,,,,,T1|PO,outpatient,,,56989.27,34193.56,,,,,,,,,,,,,
Chemodenervation Muscle Neck Unilat for Dystonia|RIGHT SIDE|PO,CASE-64616,LOCAL,64616,CPT,0360,RC,,,RT|PO,outpatient,,,7170.37,4302.22,,,,,,,,,,,,,
HC Rmvl Perm Intraperitneal Cath,CASE-49422,LOCAL,49422,CPT,0361,RC,,,,outpatient,,,17503.73,10502.24,,,,,,,,,,,,,
BRACE ORTHOPEDIC ANK FT PLAS,SUP-2388162,CDM,L1930,HCPCS,0274,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
WEDGE TIB L59MM 10DEG MEDL LAT KNEE TI HALF PRI CEM 2 SCR,SUP-2405475,CDM,C1776,CPT,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
BLOCK TIB AUG 8 10 MM PROX FULL CEM BOTH SIDE UHMWPE RT-PLUS,SUP-2450903,CDM,C1776,CPT,0278,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
FIBER LASER HI PWR END FIRE EVOLVE,SUP-2225587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
HC Chem Cautery Granulatn Tissue|PBB CHARGE,PX-4501725000,CDM,17250,CPT,0450,RC,,,PBB,both,,,280.00,182.00,,,,,,,,,,,,,
HC Daily Hospital at Home,PX-1610000000,CDM,1610000000,LOCAL,0161,RC,,,,inpatient,,,2441.00,1586.65,,,,,,,,,,,,,
NAIL 8.0 MM STP DRL SALVATION MIDFOOT,SUP-2417603,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
DRILL SURG L30MM DIA3MM SH,SUP-2266526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
TUBE CHST SET 32 FRX41 CM 1 LUMEN 4 SIDEPRT THAL-QUICK,SUP-2760008,CDM,C1729,HCPCS,0272,RC,,,,both,,,522.46,339.60,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + MED PRIORITY STRL MEDPOR,SUP-2862758,CDM,C1713,HCPCS,0278,RC,,,,both,,,56400.77,36660.50,,,,,,,,,,,,,
RELOAD REPROC STPLR REINF ENDO GIA,SUP-2365470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,878.26,570.87,,,,,,,,,,,,,
HC US Duplex Scan of Aorta Complt,PX-9219397800,CDM,93978,CPT,0921,RC,,,,inpatient,,,2518.00,1636.70,,,,,,,,,,,,,
SYSTEM CALIB 36FR SL GASTRECTOMY NS W/O BLB VISIGI 3D,SUP-2138631,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
Trluml Balo Angiop Ctr Dialysis Seg W/Img S&I,CASE-36907,LOCAL,36907,CPT,0360,RC,,,,outpatient,,,35016.12,21009.67,,,,,,,,,,,,,
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,LOCAL,43253,CPT,0360,RC,,,,outpatient,,,37023.45,22214.07,,,,,,,,,,,,,
HC Lyr Clos Nk Hnd Ft <2.6cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-12041,LOCAL,12041,CPT,0450,RC,,,XU,outpatient,,,26980.57,16188.34,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE|PO,CASE-64484,LOCAL,64484,CPT,,,,,RT|PO,outpatient,,,3914.52,2348.71,,,,,,,,,,,,,
"Correction Hammertoe|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,LOCAL,28285,CPT,0360,RC,,,XU|T6|PO,outpatient,,,47230.27,28338.16,,,,,,,,,,,,,
"Prq Skeletal Fix Carpo/Metacarpal Fx Dislc Thumb|RIGHT HAND, THUMB|PO",CASE-26650,LOCAL,26650,CPT,,,,,F5|PO,outpatient,,,10640.50,6384.30,,,,,,,,,,,,,
Repair Primary Open/Prq Ruptured Achilles Tendon|PO,CASE-27650,LOCAL,27650,CPT,,,,,PO,outpatient,,,19709.95,11825.97,,,,,,,,,,,,,
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|PO,CASE-26080,LOCAL,26080,CPT,0360,RC,,,PO,outpatient,,,18820.85,11292.51,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT|PO",CASE-26727,LOCAL,26727,CPT,0360,RC,,,F4|PO,outpatient,,,6212.92,3727.75,,,,,,,,,,,,,
Revsc Opn/Prq Tib/Pero W/Athrc/Angiop Uni Ea Vsl|RIGHT SIDE,CASE-37233,LOCAL,37233,CPT,0360,RC,,,RT,outpatient,,,53548.50,32129.10,,,,,,,,,,,,,
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,LOCAL,49321,CPT,0360,RC,,,,outpatient,,,29224.60,17534.76,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,XS|LT,outpatient,,,17623.45,10574.07,,,,,,,,,,,,,
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO,CASE-14040,LOCAL,14040,CPT,,,,,PO,outpatient,,,15739.18,9443.51,,,,,,,,,,,,,
Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT SIDE|PO,CASE-28750,LOCAL,28750,CPT,0360,RC,,,RT|PO,outpatient,,,46277.97,27766.78,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid|BILATERAL PROCEDURE|PO,CASE-15822,LOCAL,15822,CPT,,,,,50|PO,outpatient,,,36460.77,21876.46,,,,,,,,,,,,,
HC Assay of Osmolality Blood,PX-3018393000,CDM,83930,CPT,0301,RC,,,,inpatient,,,216.00,140.40,,,,,,,,,,,,,
CONNECTOR SPNL ROD 5.5X110 MM STR SS CD HORZ,SUP-2631080,CDM,C1713,HCPCS,0278,RC,,,,both,,,4713.14,3063.54,,,,,,,,,,,,,
WEDGE TIB L 12DEG/XL 11DEG PEEK IBALANCE HTO,SUP-2121060,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
TROCAR ENDOSCP L 70 MM DIA12 MM LAPSCP SHRT BLDELSS DOLPHIN,SUP-2896205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.64,278.62,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC DBM,SUP-2430248,CDM,C1713,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
STENT URET L24CM DIA7FR TECOFLEX LITHOSTNT,SUP-2312743,CDM,C2617,HCPCS,0278,RC,,,,both,,,290.20,188.63,,,,,,,,,,,,,
KIT FIX 2.4MM DRL TIP GWIRE CANN BNE TUNN PLUG DRL BIT DISP,SUP-2341339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1650.42,1072.77,,,,,,,,,,,,,
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,LOCAL,31653,CPT,,,,,,outpatient,,,23138.48,13883.09,,,,,,,,,,,,,
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, FOURTH DIGIT",CASE-28234,LOCAL,28234,CPT,0360,RC,,,T3,outpatient,,,11454.52,6872.71,,,,,,,,,,,,,
Open Treatment Fracture Distal Tibia & Fibula|LEFT SIDE|PO,CASE-27828,LOCAL,27828,CPT,0360,RC,,,LT|PO,outpatient,,,42721.33,25632.80,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,LOCAL,64490,CPT,0361,RC,,,RT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Recurrent,CASE-25112,LOCAL,25112,CPT,,,,,,outpatient,,,13513.90,8108.34,,,,,,,,,,,,,
Carpectomy 1 Bone|LEFT SIDE|PO,CASE-25210,LOCAL,25210,CPT,0360,RC,,,LT|PO,outpatient,,,15735.82,9441.49,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,LOCAL,64634,CPT,0360,RC,,,RT,outpatient,,,12105.48,7263.29,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,LOCAL,45380,CPT,,,,,74,outpatient,,,9765.48,5859.29,,,,,,,,,,,,,
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE|PO,CASE-25607,LOCAL,25607,CPT,0360,RC,,,LT|PO,outpatient,,,27790.10,16674.06,,,,,,,,,,,,,
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs,CASE-25116,LOCAL,25116,CPT,,,,,,outpatient,,,31099.67,18659.80,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|PO,CASE-28122,LOCAL,28122,CPT,,,,,LT|PO,outpatient,,,13527.90,8116.74,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6 MM STR TW HELIX,SUP-2525455,CDM,C1768,CPT,0278,RC,,,,both,,,2011.36,1307.38,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.7X10 MM TITANIUM MATRIXMANDIBLE,SUP-2837730,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
SCREW BONE L6MM DIA1.5MM STD CORT S STL ST FULL THRD HEX HD,SUP-2343856,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.43,169.28,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 22-25 CM ART CUF SET STYL TESIO,SUP-2627151,CDM,C1750,HCPCS,0278,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
GRAFT BNE STRP 30X20X5 MM CANC INDUX,SUP-2684160,CDM,C1713,HCPCS,0278,RC,,,,both,,,3818.24,2481.86,,,,,,,,,,,,,
GRAFT NRV L2CM ID3MM CLLGN PERIPH NEURAWRAP,SUP-2244316,CDM,C9361,HCPCS,0278,RC,,,,both,,,3390.32,2203.71,,,,,,,,,,,,,
HC Intrvasc US Noncoronary 1st|RIGHT SIDE,CASE-37252,LOCAL,37252,CPT,0361,RC,,,RT,outpatient,,,27259.98,16355.99,,,,,,,,,,,,,
Fasciotomy Foot&/Toe|RIGHT SIDE|PO,CASE-28008,LOCAL,28008,CPT,0360,RC,,,RT|PO,outpatient,,,10617.18,6370.31,,,,,,,,,,,,,
Prostate Needle Biopsy Any Approach,CASE-55700,LOCAL,55700,CPT,,,,,,outpatient,,,19624.37,11774.62,,,,,,,,,,,,,
Sling Operation Stress Incontinence,CASE-57288,LOCAL,57288,CPT,0360,RC,,,,outpatient,,,51931.27,31158.76,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE|PO,CASE-27695,LOCAL,27695,CPT,0360,RC,,,RT|PO,outpatient,,,32164.05,19298.43,,,,,,,,,,,,,
Synovectomy Tendon Sheath Foot Extensor|RIGHT SIDE|PO,CASE-28088,LOCAL,28088,CPT,,,,,RT|PO,outpatient,,,35678.48,21407.09,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28820,LOCAL,28820,CPT,,,,,T7,outpatient,,,45726.50,27435.90,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-25111,LOCAL,25111,CPT,,,,,XS|LT|PO,outpatient,,,13095.20,7857.12,,,,,,,,,,,,,
HC Inj Tendon Sheath/Ligament|LEFT SIDE|PO,CASE-20550,LOCAL,20550,CPT,0510,RC,,,LT|PO,outpatient,,,15271.40,9162.84,,,,,,,,,,,,,
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,LOCAL,64585,CPT,,,,,,outpatient,,,14001.53,8400.92,,,,,,,,,,,,,
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|LEFT SIDE|PO,CASE-27675,LOCAL,27675,CPT,,,,,LT|PO,outpatient,,,68579.72,41147.83,,,,,,,,,,,,,
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|RIGHT SIDE|PO,CASE-27675,LOCAL,27675,CPT,,,,,RT|PO,outpatient,,,38224.85,22934.91,,,,,,,,,,,,,
Unlisted Laparoscopy Procedure Stomach,CASE-43659,LOCAL,43659,CPT,,,,,,outpatient,,,128435.58,77061.35,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28299,LOCAL,28299,CPT,,,,,T5|PO,outpatient,,,21750.43,13050.26,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,LOCAL,52353,CPT,,,,,LT,outpatient,,,24393.20,14635.92,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE|PO,CASE-27427,LOCAL,27427,CPT,,,,,LT|PO,outpatient,,,47575.93,28545.56,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|PREVENTIVE SERVICES,CASE-45385,LOCAL,45385,CPT,0360,RC,,,33,outpatient,,,10944.37,6566.62,,,,,,,,,,,,,
HC Treat Kneecap Fx,PX-4502752000,CDM,27520,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 2.5ML 100 DEMIN BONE MTRX PUTTY,SUP-2319808,CDM,C9359,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
CEMENT BONE INJ TRAUMACEM V+ STERILE,SUP-2547171,CDM,C1713,HCPCS,0278,RC,,,,both,,,1134.04,737.13,,,,,,,,,,,,,
ASSEMBLY PMP TI AND TI OTR,SUP-2165352,CDM,C1813,HCPCS,0278,RC,,,,both,,,12355.90,8031.33,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 180 CM DIA 0.035 IN TIP,SUP-2385543,CDM,C1769,HCPCS,0272,RC,,,,both,,,670.39,435.75,,,,,,,,,,,,,
GUIDEWIRE ORTH MULT HOLE 13 MM PROTCT SL FOR ALFN NS EXPERT,SUP-2799294,CDM,C1769,HCPCS,0272,RC,,,,both,,,2288.06,1487.24,,,,,,,,,,,,,
HC Repair Complex Trunk 2.6-7.5 Cm,PX-4501310100,CDM,13101,CPT,0450,RC,,,,both,,,1227.00,797.55,,,,,,,,,,,,,
SLEEVE FEM SLT 1 LG STD UNIV 13 MM PROX REV PRSS FT CMNTLS,SUP-2344360,CDM,C1776,CPT,0278,RC,,,,both,,,6381.27,4147.83,,,,,,,,,,,,,
ROD ORTHOPEDIC 2 MM W/ SPACER KT ORTHOFLEX,SUP-2396951,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
GRAFT BIO TISS W2.4XL6.3IN PORCINE DERM RIFAMPIN,SUP-2125832,CDM,C1781,HCPCS,0278,RC,,,,both,,,10173.60,6612.84,,,,,,,,,,,,,
DISC ARTIFICIAL SZ 4 7.5DEG UNIV INTERVERTEBRAL LUM MTL ON,SUP-2255736,CDM,C1889,HCPCS,0278,RC,,,,both,,,16108.20,10470.33,,,,,,,,,,,,,
SEGMENT HUM TOT REPL 100MM MOSAIC,SUP-2136205,CDM,C1776,CPT,0278,RC,,,,both,,,25311.54,16452.50,,,,,,,,,,,,,
PLATE BNE STR 1.7X119 MM FIBULAR 10 HOLE LCK,SUP-2520875,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.89,2365.93,,,,,,,,,,,,,
DEVICE GREATER TROCHANT REATTACHMENT EXT,SUP-2469176,CDM,C1713,HCPCS,0278,RC,,,,both,,,11405.11,7413.32,,,,,,,,,,,,,
DEVICE FIX STERNALOCK BLU,SUP-2691303,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Cervical Node,CASE-38510,LOCAL,38510,CPT,0360,RC,,,,outpatient,,,23761.63,14256.98,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT|PO",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F6|PO,outpatient,,,9121.97,5473.18,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64415,LOCAL,64415,CPT,0360,RC,,,XU|RT,outpatient,,,46259.20,27755.52,,,,,,,,,,,,,
Arthro/shoul surg; w/spacer|PO,CASE-C9781,LOCAL,C9781,CPT,0360,RC,,,PO,outpatient,,,73584.70,44150.82,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,LOCAL,G0121,CPT,,,,,KX|74,outpatient,,,7006.23,4203.74,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,LOCAL,50081,CPT,,,,,RT,outpatient,,,43049.00,25829.40,,,,,,,,,,,,,
Laparoscopy Surg Pyeloplasty|RIGHT SIDE,CASE-50544,LOCAL,50544,CPT,0360,RC,,,RT,outpatient,,,102769.62,61661.77,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE|PO,CASE-64454,LOCAL,64454,CPT,,,,,50|PO,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs|LEFT SIDE|PO,CASE-25116,LOCAL,25116,CPT,0360,RC,,,LT|PO,outpatient,,,31099.67,18659.80,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26735,LOCAL,26735,CPT,0360,RC,,,F1|PO,outpatient,,,23370.45,14022.27,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28296,LOCAL,28296,CPT,0360,RC,,,T5|PO,outpatient,,,26155.97,15693.58,,,,,,,,,,,,,
HC Daily Hospital at Home,PX-1610000000,CDM,1610000000,LOCAL,,,,,,outpatient,,,2644.42,1586.65,,,,,,,,,,,,,
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,LOCAL,43246,CPT,0360,RC,,,,outpatient,,,37983.45,22790.07,,,,,,,,,,,,,
Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,CASE-58571,LOCAL,58571,CPT,,,,,,outpatient,,,65813.80,39488.28,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-28270,LOCAL,28270,CPT,,,,,XS|TA|PO,outpatient,,,19110.18,11466.11,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T3,outpatient,,,27397.82,16438.69,,,,,,,,,,,,,
PLATE BNE L266MM 12 H ST L CNDYL S STL CRV LOK COMPR VAR,SUP-2177858,CDM,C1713,HCPCS,0278,RC,,,,both,,,6446.29,4190.09,,,,,,,,,,,,,
SHEATH INTRO FLEXCATH ADV TOT L 81 CM L 65 CM OD 15 FR ID 12,SUP-2281956,CDM,C1766,CPT,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,0636,RC,63323-0229-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L 140 MM SCREW DIA2.7 MM 20 SHFT H SS ADPT VA SLV,SUP-2907644,CDM,C1713,HCPCS,0278,RC,,,,both,,,4788.88,3112.77,,,,,,,,,,,,,
HC Trluml Balo Angiop Addl Vein,PX-3613724900,CDM,37249,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
BIOPSY PROCEDURE KIT UNIV SHT BLDELSS PRB MARKER MAMTOM,SUP-2195660,CDM,C1713,HCPCS,0278,RC,,,,both,,,1848.20,1201.33,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED LT LAT PART CONDYLE,SUP-2740800,CDM,C1762,CPT,0278,RC,,,,both,,,23985.30,15590.44,,,,,,,,,,,,,
GRAFT HUM TISS W3XL6CM CRYOPRESERVED PLCNTA TISS UMB AMNION,SUP-2319186,CDM,Q4133,HCPCS,0636,RC,,,,both,,,9325.80,6061.77,,,,,,,,,,,,,
PASSER SUT 45DEG L W/ SM PUNC FOOTPRINT SGL PORTAL PVT,SUP-2366736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,LOCAL,25608,CPT,,,,,RT,outpatient,,,39858.32,23914.99,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,LOCAL,28270,CPT,0360,RC,,,XS|T1|PO,outpatient,,,48283.90,28970.34,,,,,,,,,,,,,
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE,CASE-27654,LOCAL,27654,CPT,,,,,RT,outpatient,,,38377.33,23026.40,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 1.1-2.0 Cm|PO,CASE-11402,LOCAL,11402,CPT,,,,,PO,outpatient,,,31671.87,19003.12,,,,,,,,,,,,,
HC Tib per Territory Ather|LEFT SIDE,CASE-37229,LOCAL,37229,CPT,0361,RC,,,LT,outpatient,,,49148.80,29489.28,,,,,,,,,,,,,
"HC Debrid,Subq Ea Addt'l 20sqcm|PBB CHARGE",CASE-11045,LOCAL,11045,CPT,0361,RC,,,PBB,outpatient,,,1500.42,900.25,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization,CASE-52005,LOCAL,52005,CPT,0360,RC,,,,outpatient,,,15930.88,9558.53,,,,,,,,,,,,,
HC Add 2nd/3rd Order Abd/Le|RIGHT SIDE,CASE-36248,LOCAL,36248,CPT,0361,RC,,,RT,outpatient,,,38609.35,23165.61,,,,,,,,,,,,,
Inject Platelet Rich Plasma W/Img Harvest/Preparatoin,CASE-0232T,LOCAL,0232T,CPT,,,,,,outpatient,,,28755.95,17253.57,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE|PO,CASE-27601,LOCAL,27601,CPT,0360,RC,,,RT|PO,outpatient,,,32616.33,19569.80,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy 2/>Compartments|RIGHT SIDE|PO,CASE-29876,LOCAL,29876,CPT,,,,,RT|PO,outpatient,,,25814.42,15488.65,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 8.01-9.0 MCI STRL ADVANTAGE 2029ILS2] ISOAID LLC],SUP-2247282,CDM,C2642,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BONE L252MM 20 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349644,CDM,C1713,HCPCS,0278,RC,,,,both,,,3609.27,2346.03,,,,,,,,,,,,,
TUBE MYR 1MM DIAM VENT TAB SIL SHEA,SUP-2312640,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
CLARITHROMYCIN 250 MG PO TABS,RX-9616,CDM,6370000000,HCPCS,0637,RC,50268-0178-11,NDC,,both,1,UN,12.90,8.38,,,,,,,,,,,,,
SHEATH INTRO L 98 CM CATH 8 FR STR AD W/O HYDRPHLC COAT,SUP-2157192,CDM,C1894,HCPCS,0272,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
SHEAR HARMONIC 700 VES SEAL 360 DEG SHFT L 36 MM DIA 5 MM JAW L,SUP-2889526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1599.96,1039.97,,,,,,,,,,,,,
INBONE  POLY SZ 4 15MM SULCUS,SUP-2493374,CDM,C1776,CPT,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
BUPIVACAINE HCL 0.5 % IJ SOLN (MIXTURES ONLY),RX-430038,CDM,J0665,HCPCS,0636,RC,00409-1162-02,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
COLLAR CERV CNTOUR SM 18.5X3 IN 11-16 IN MED FOAM PROCARE,SUP-2196858,CDM,L0180,HCPCS,0272,RC,,,,both,,,10.71,6.96,,,,,,,,,,,,,
NEEDLE ASPRTN ENDBRNCHL 052MM DIA ULTRSND TRNSBRNCHL ST SNG,SUP-2676540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.18,441.47,,,,,,,,,,,,,
SCREW BONE L8MM DIA2.4MM CORT MAND VIO TI ST FOR LCK RECON,SUP-2193356,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
VALVE HYDROCEPHALUS SYS W/ SPRUNG RESVR PROGAV 2.0,SUP-2108744,CDM,C1729,HCPCS,0272,RC,,,,both,,,8478.47,5511.01,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 8 MM EPTFE STR TW N RING STRL,SUP-2396712,CDM,C1768,CPT,0278,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
TAP ST 2.5 MM REUNITE SM SCR FIX SYS,SUP-2212975,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
BRACE ORTHOPEDIC FOAM SHT SM UNIV 8.5 IN CONFOR FLEX-N-FIT,SUP-2428146,CDM,L1930,HCPCS,0272,RC,,,,both,,,50.27,32.68,,,,,,,,,,,,,
DEFIBRILLATOR CARD 76GM 35CC W40XH73MM THK14MM DF1 IS1 CONN,SUP-2356259,CDM,C1722,HCPCS,0275,RC,,,,both,,,31400.82,20410.53,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE|PO,CASE-25609,LOCAL,25609,CPT,0360,RC,,,LT|PO,outpatient,,,29507.75,17704.65,,,,,,,,,,,,,
Rhinoplasty Secondary Intermediate Revision,CASE-30435,LOCAL,30435,CPT,,,,,,outpatient,,,28608.23,17164.94,,,,,,,,,,,,,
Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT SIDE,CASE-28297,LOCAL,28297,CPT,0360,RC,,,LT,outpatient,,,102832.62,61699.57,,,,,,,,,,,,,
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs|LEFT SIDE|PO,CASE-25116,LOCAL,25116,CPT,,,,,LT|PO,outpatient,,,31099.67,18659.80,,,,,,,,,,,,,
Removal Non-Biodegradable Drug Delivery Implant,CASE-11982,LOCAL,11982,CPT,0360,RC,,,,outpatient,,,31968.40,19181.04,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,LOCAL,29881,CPT,,,,,RT,outpatient,,,21012.33,12607.40,,,,,,,,,,,,,
Ant Vesicourethropexy/Urethropexy Smpl,CASE-51840,LOCAL,51840,CPT,0360,RC,,,,outpatient,,,92091.05,55254.63,,,,,,,,,,,,,
Circumcision Age >28 Days,CASE-54161,LOCAL,54161,CPT,0360,RC,,,,outpatient,,,21219.90,12731.94,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28296,LOCAL,28296,CPT,,,,,TA|PO,outpatient,,,19493.02,11695.81,,,,,,,,,,,,,
BIT DRL LNG 1.1X60 MM 4 MM W/ STP STRYKR QUIK CPL,SUP-2653745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,780.35,507.23,,,,,,,,,,,,,
GUIDEWIRE VASC MORPHEUS L 80 CM DIA 0.018 IN SS PERIPH STRL,SUP-2734842,CDM,C1769,HCPCS,0272,RC,,,,both,,,12.72,8.27,,,,,,,,,,,,,
HC Insertion of Chest Tube,PX-4503255100,CDM,32551,CPT,0450,RC,,,,inpatient,,,4942.00,3212.30,,,,,,,,,,,,,
HOOK SPNL 90DEG RT TI TYP S VEPTR II,SUP-2181852,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
CATHETER ELECHEMSTAS STRL ENDOSTAT II LF DISP,SUP-2125961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CATHETER ETER THOR 12FR L16IN POLYVI CHL 4 EYELET STR ATRAUM,SUP-2266021,CDM,C1729,HCPCS,0272,RC,,,,both,,,233.33,151.66,,,,,,,,,,,,,
SROM*ST XL36+8LNK22X17X275L,SUP-2540392,CDM,C1776,CPT,0278,RC,,,,both,,,14501.78,9426.16,,,,,,,,,,,,,
SYSTEM BX NDL 18GA SHTH W/ MTL STIFFENER 7FR L60CM CATH STR,SUP-2120183,CDM,C1894,HCPCS,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
CATHETER CV 4 FRX55 CM SINGLE LUMEN PWR INJ XCELA,SUP-2117122,CDM,C1751,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT PASTE SYNTH CLLGN COPIOS BVF 10CC,SUP-2197453,CDM,C1713,HCPCS,0278,RC,,,,both,,,4465.08,2902.30,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 16 CM OD 5 FR ID 0.074 IN TIP DIA,SUP-2385327,CDM,C1894,HCPCS,0272,RC,,,,both,,,133.14,86.54,,,,,,,,,,,,,
CRANIO SCULPT FLOW BONE VOID FILLER10CC QTY001 EA,SUP-2669410,CDM,C1713,HCPCS,0278,RC,,,,both,,,10876.18,7069.52,,,,,,,,,,,,,
GRAFT BNE PARTICULATE 250-1000 M UM 2 CC CANC PUROS,SUP-2860955,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
DRESSING WND MULTLYR CLLGN MTRX 10X15 CM SHT MATRISTEM,SUP-2106527,CDM,Q4166,HCPCS,0636,RC,,,,both,,,6942.54,4512.65,,,,,,,,,,,,,
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE|PO,CASE-27822,LOCAL,27822,CPT,,,,,RT|PO,outpatient,,,38444.12,23066.47,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE|PO",CASE-28750,LOCAL,28750,CPT,0360,RC,,,T5|PO,outpatient,,,42596.50,25557.90,,,,,,,,,,,,,
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT SIDE|PO,CASE-26356,LOCAL,26356,CPT,0360,RC,,,RT|PO,outpatient,,,15124.93,9074.96,,,,,,,,,,,,,
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,LOCAL,13160,CPT,,,,,,outpatient,,,29271.23,17562.74,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,LOCAL,23515,CPT,0360,RC,,,LT,outpatient,,,37933.70,22760.22,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,LOCAL,58662,CPT,,,,,LT,outpatient,,,45159.50,27095.70,,,,,,,,,,,,,
Excision Malignant Lesion S/N/H/F/G 1.1-2.0 Cm,CASE-11622,LOCAL,11622,CPT,,,,,,outpatient,,,35089.77,21053.86,,,,,,,,,,,,,
Carpectomy 1 Bone|RIGHT SIDE|PO,CASE-25210,LOCAL,25210,CPT,0360,RC,,,RT|PO,outpatient,,,16093.22,9655.93,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE|PO,CASE-28306,LOCAL,28306,CPT,,,,,RT|PO,outpatient,,,24033.37,14420.02,,,,,,,,,,,,,
HC Intrvasc US Noncoronary Addl,CASE-37253,LOCAL,37253,CPT,0361,RC,,,,outpatient,,,55057.63,33034.58,,,,,,,,,,,,,
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,LOCAL,45390,CPT,,,,,XU|PT,outpatient,,,11886.77,7132.06,,,,,,,,,,,,,
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn|RIGHT SIDE|PO,CASE-26480,LOCAL,26480,CPT,,,,,RT|PO,outpatient,,,15327.97,9196.78,,,,,,,,,,,,,
RATCHETING COMPRESSION PLATE 15X14,SUP-2823111,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SCREW BNE L11MM OD2MM T6 LOK ST TI VLP,SUP-2350979,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
HC So Hiv Genotype for Retrov Resist,PX-3068790166,CDM,87901,CPT,0306,RC,,,,outpatient,,,1147.00,745.55,,,,,,,,,,,,,
COIL VASC TORNADO EMBOLUS L 14.2 CM DIA10-5 MM CATH DIA,SUP-2168427,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
IMPLANT OPHTH 1.25X4.5X100MM SIL STRP,SUP-2213510,CDM,L8610,HCPCS,0278,RC,,,,both,,,44.59,28.98,,,,,,,,,,,,,
MESH HERN W3XL6IN POLYPR MFIL RECTANG,SUP-2125747,CDM,C1781,HCPCS,0278,RC,,,,both,,,161.08,104.70,,,,,,,,,,,,,
HEAD FEM 28MM +0 CO CHROM,SUP-2359067,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
NAIL IM L180MM DIA11MM 130DEG LNG HIP TIM CANN LOK FOR AG,SUP-2413331,CDM,C1713,HCPCS,0278,RC,,,,both,,,3127.44,2032.84,,,,,,,,,,,,,
NEEDLE BRST LOC REPOSITIONAL DISP 20GA 5CM KOP,SUP-2331831,CDM,C1819,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
PLATE SPNL W37MM CVR PILLAR SA,SUP-2317122,CDM,C1821,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
"Exc Tum/Vas Mal Sft Tis Hand/Fngr Subfasc<1.5cm|LEFT HAND, THUMB|PO",CASE-26116,LOCAL,26116,CPT,0360,RC,,,FA|PO,outpatient,,,9764.70,5858.82,,,,,,,,,,,,,
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26125,LOCAL,26125,CPT,0360,RC,,,F8|PO,outpatient,,,13286.83,7972.10,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp,CASE-27691,LOCAL,27691,CPT,,,,,,outpatient,,,102832.62,61699.57,,,,,,,,,,,,,
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,CASE-36556,LOCAL,36556,CPT,0761,RC,,,,outpatient,,,29884.57,17930.74,,,,,,,,,,,,,
HC Fem Pop Terr Plasty and Stent,CASE-37226,LOCAL,37226,CPT,0361,RC,,,,outpatient,,,60596.37,36357.82,,,,,,,,,,,,,
Tx Tibl Shft Fx Imed Implt W/WO Screws&/Cercla,CASE-27759,LOCAL,27759,CPT,0360,RC,,,,outpatient,,,47131.20,28278.72,,,,,,,,,,,,,
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,LOCAL,54405,CPT,0360,RC,,,,outpatient,,,89454.92,53672.95,,,,,,,,,,,,,
Open Treatment Bimalleolar Ankle Fracture,CASE-27814,LOCAL,27814,CPT,0360,RC,,,,outpatient,,,36212.23,21727.34,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26735,LOCAL,26735,CPT,0360,RC,,,F2|PO,outpatient,,,23370.45,14022.27,,,,,,,,,,,,,
PORT IMPL INFUSION LIFEPORT 11.4 FR TI,SUP-2332934,CDM,C1788,HCPCS,0278,RC,,,,both,,,2562.24,1665.46,,,,,,,,,,,,,
PLATE BNE L86MM 2 H NONSTERILE L OLECRANON S STL LOK COMPR,SUP-2185422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2880.04,1872.03,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM LT WRST LTHR,SUP-2194370,CDM,L3809,HCPCS,0274,RC,,,,both,,,25.94,16.86,,,,,,,,,,,,,
ROD SURG ROCK SILVERTON,SUP-2211164,CDM,C1713,HCPCS,0278,RC,,,,both,,,1239.67,805.79,,,,,,,,,,,,,
BUR SURG L21CM HD L79MM DIA9MM CYL FLUT L BOR MIDAS REX,SUP-2277908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00264-1510-32,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.025 IN TAPR L 7 CM FLX TIP L,SUP-2167591,CDM,C1769,HCPCS,0272,RC,,,,both,,,35.26,22.92,,,,,,,,,,,,,
PLATE BONE L RT 1ST MTP FUS TI ALPS,SUP-2211519,CDM,C1713,HCPCS,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
BRACE ORTH BILATERAL SM AD ANK WALKING MAXTRAX AIR,SUP-2427326,CDM,L4360,HCPCS,0272,RC,,,,both,,,93.76,60.94,,,,,,,,,,,,,
STEM FEM SZ 002 PROX STEM DIA 16MM DIST STEM DIA 14MM,SUP-2265098,CDM,C1776,CPT,0278,RC,,,,both,,,11018.26,7161.87,,,,,,,,,,,,,
STEM HUM SZ 1 DIA20MM R SHLDR HA CEMENTLESS MOD ECC,SUP-2250997,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.018IN TIP L3CM STD NIT HYDRPHLC,SUP-2385561,CDM,C1769,HCPCS,0272,RC,,,,both,,,263.54,171.30,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,LOCAL,29879,CPT,,,,,LT,outpatient,,,35525.72,21315.43,,,,,,,,,,,,,
Rpr Tdn/Musc Xtnsr F/Arm&/Wrist Prim 1 Ea Tdn|LEFT SIDE|PO,CASE-25270,LOCAL,25270,CPT,0360,RC,,,LT|PO,outpatient,,,28009.37,16805.62,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THUMB|PO",CASE-26735,LOCAL,26735,CPT,0360,RC,,,FA|PO,outpatient,,,19615.57,11769.34,,,,,,,,,,,,,
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE,CASE-27685,LOCAL,27685,CPT,,,,,LT,outpatient,,,52734.25,31640.55,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G > 4.0cm,CASE-11426,LOCAL,11426,CPT,0360,RC,,,,outpatient,,,16326.80,9796.08,,,,,,,,,,,,,
Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea,CASE-25290,LOCAL,25290,CPT,0360,RC,,,,outpatient,,,12902.80,7741.68,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm|PO,CASE-11421,LOCAL,11421,CPT,0360,RC,,,PO,outpatient,,,10680.12,6408.07,,,,,,,,,,,,,
Tnols Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|LEFT SIDE|PO,CASE-25295,LOCAL,25295,CPT,,,,,LT|PO,outpatient,,,10124.93,6074.96,,,,,,,,,,,,,
Removal Implant Deep|BILATERAL PROCEDURE,CASE-20680,LOCAL,20680,CPT,,,,,50,outpatient,,,15889.57,9533.74,,,,,,,,,,,,,
Exc Tumor Soft Tissue Abdominal Wall Subq <3cm,CASE-22902,LOCAL,22902,CPT,,,,,,outpatient,,,45200.57,27120.34,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,LOCAL,64718,CPT,,,,,RT,outpatient,,,13016.33,7809.80,,,,,,,,,,,,,
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE|PO,CASE-27685,LOCAL,27685,CPT,0360,RC,,,RT|PO,outpatient,,,33874.72,20324.83,,,,,,,,,,,,,
Biopsy Urethra,CASE-53200,LOCAL,53200,CPT,,,,,,outpatient,,,19746.45,11847.87,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-29881,LOCAL,29881,CPT,0360,RC,,,LT|PO|XS,outpatient,,,60209.02,36125.41,,,,,,,,,,,,,
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE,CASE-28200,LOCAL,28200,CPT,,,,,LT,outpatient,,,16535.67,9921.40,,,,,,,,,,,,,
HC Revasc Intra Lithotrip-Stent,CASE-C9765,LOCAL,C9765,CPT,0481,RC,,,,outpatient,,,120727.70,72436.62,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12X12X8 MM CERV LORDTC FORTIS,SUP-2135931,CDM,C1889,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
ANCHOR SUT S STL OD29MM ULTRAFIX RC,SUP-2166457,CDM,C1713,HCPCS,0278,RC,,,,both,,,608.81,395.73,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB XLII DIAMOND STRL REUSE HI-LINE,SUP-2928897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.07,503.15,,,,,,,,,,,,,
LEAD PACE SWEET TIP L 52 CM SIL STEROID ENDOCARD RT,SUP-2148648,CDM,C1898,HCPCS,0275,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
RING EXT FIX RADLUC 1/3 D 190 MM CE MARKED,SUP-2875118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1016.89,660.98,,,,,,,,,,,,,
LINER ACET DUR 15 DEG 28MM ID 58-60MM OD,SUP-2376155,CDM,C1776,CPT,0278,RC,,,,both,,,1701.31,1105.85,,,,,,,,,,,,,
TEMPLATE SZ PATELLAR NXGN,SUP-2437565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
PLATE BNE L 130 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 12 H SS 72469512,SUP-2933125,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.61,2031.00,,,,,,,,,,,,,
HC Add 2nd/3rd Order Abd/Le|LEFT SIDE,CASE-36248,LOCAL,36248,CPT,0361,RC,,,LT,outpatient,,,68098.97,40859.38,,,,,,,,,,,,,
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|LEFT SIDE,CASE-37765,LOCAL,37765,CPT,0360,RC,,,LT,outpatient,,,38612.17,23167.30,,,,,,,,,,,,,
Arthro/shoul surg; w/spacer|PO,CASE-C9781,LOCAL,C9781,CPT,,,,,PO,outpatient,,,73584.70,44150.82,,,,,,,,,,,,,
Repair Non/Malunion Humerus W/O Graft|LEFT SIDE,CASE-24430,LOCAL,24430,CPT,,,,,LT,outpatient,,,47199.98,28319.99,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,LOCAL,G0121,CPT,0360,RC,,,KX|74,outpatient,,,7006.23,4203.74,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,LOCAL,28750,CPT,,,,,T5,outpatient,,,62578.70,37547.22,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|PO,CASE-25111,LOCAL,25111,CPT,0360,RC,,,PO,outpatient,,,11520.57,6912.34,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,LOCAL,24342,CPT,,,,,RT,outpatient,,,27644.07,16586.44,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F7,outpatient,,,13875.43,8325.26,,,,,,,,,,,,,
Repair Non/Malunion Humerus W/Iliac/Oth Agrft|LEFT SIDE,CASE-24435,LOCAL,24435,CPT,,,,,LT,outpatient,,,52858.08,31714.85,,,,,,,,,,,,,
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43277,LOCAL,43277,CPT,,,,,XU,outpatient,,,31284.85,18770.91,,,,,,,,,,,,,
Open Treatment Proximal Fibula/Shaft Fracture|RIGHT SIDE|PO,CASE-27784,LOCAL,27784,CPT,0360,RC,,,RT|PO,outpatient,,,48649.82,29189.89,,,,,,,,,,,,,
HC Trluml Balo Angiop 1st Vein,CASE-37248,LOCAL,37248,CPT,0361,RC,,,,outpatient,,,32571.30,19542.78,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .014P L 150 CM GLYDX HYDRPHLC,SUP-2900240,CDM,C1753,HCPCS,0278,RC,,,,both,,,1675.13,1088.83,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 IN 3 CM 6 FRX20 CM 6 FR POLARIS,SUP-2465265,CDM,C2617,HCPCS,0278,RC,,,,both,,,655.07,425.80,,,,,,,,,,,,,
BUR SURG MED 9.5 MM BORING TOOL FOR HD-G1,SUP-2848313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.72,430.12,,,,,,,,,,,,,
HC So Mog-Igg1 Antibody Cell-Based Imfluor Assay Each,PX-3028636266,CDM,86362,CPT,0302,RC,,,,both,,,780.00,507.00,,,,,,,,,,,,,
DEVICE URIN SPHIN CTRL W/O INHIBZN AMS 800,SUP-2138917,CDM,C1815,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
CATHETER ART 7 FRX110 CM FEM ART,SUP-2214679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.03,305.52,,,,,,,,,,,,,
MENISCAL CINCH II,SUP-2121860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PI PICC 3-LUMEN: 6FRX50CM WITH 130CM SS,SUP-2827498,CDM,C1751,HCPCS,0278,RC,,,,both,,,412.60,268.19,,,,,,,,,,,,,
RELOAD STPLR X THN 45 MM REINF SIGNIA LD GRY TRI-STAPLE 2.0,SUP-2858002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1405.21,913.39,,,,,,,,,,,,,
BAND LIGATOR LAPAROSCOPY SM SYS LAP-BAND,SUP-2113472,CDM,C1713,HCPCS,0278,RC,,,,both,,,8556.50,5561.72,,,,,,,,,,,,,
COIL EMB L12CM DIA4MM 0.0115IN INTCRAN 3D MICROFILAMENT,SUP-2295050,CDM,C1889,HCPCS,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
SHOE ORTHOT MEN CUST OXFORD INTEGR PART OF BRAC,SUP-2435715,CDM,L3225,HCPCS,0272,RC,,,,both,,,208.97,135.83,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 8 FR D-D CRV,SUP-2516525,CDM,C2630,CPT,0272,RC,,,,both,,,4920.38,3198.25,,,,,,,,,,,,,
WIRE EXT FIX L400MM OD1.8MM BAYNT FOR SIDEKCK FREE CIR FIX,SUP-2400661,CDM,C1776,CPT,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
MESH CRAN L 81.28 X W 72.39 MM THK 0.3 MM SCREW DIA1.5 MM SZ,SUP-2936145,CDM,C1713,HCPCS,0278,RC,,,,both,,,15725.12,10221.33,,,,,,,,,,,,,
COMPONENT ARTC SURF CR 7 KNEE FIX BEAR ATTUNE,SUP-2454890,CDM,C1776,CPT,0278,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,LOCAL,28270,CPT,0360,RC,,,,outpatient,,,27750.93,16650.56,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, SECOND DIGIT|PO",CASE-26440,LOCAL,26440,CPT,0360,RC,,,F6|PO,outpatient,,,10622.82,6373.69,,,,,,,,,,,,,
Rhinoplasty Primary W/Major Septal Repair|PO,CASE-30420,LOCAL,30420,CPT,,,,,PO,outpatient,,,39029.90,23417.94,,,,,,,,,,,,,
Rectal Tumor Excision Transanal Endoscopic,CASE-0184T,LOCAL,0184T,CPT,,,,,,outpatient,,,62500.27,37500.16,,,,,,,,,,,,,
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE,CASE-29891,LOCAL,29891,CPT,0360,RC,,,LT,outpatient,,,42163.30,25297.98,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE,CASE-29880,LOCAL,29880,CPT,0360,RC,,,50,outpatient,,,25491.58,15294.95,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-29881,LOCAL,29881,CPT,0360,RC,,,XS|LT|PO,outpatient,,,48468.53,29081.12,,,,,,,,,,,,,
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf,CASE-36825,LOCAL,36825,CPT,0360,RC,,,,outpatient,,,47193.40,28316.04,,,,,,,,,,,,,
Partial Excision Bone Metacarpal|LEFT SIDE|PO,CASE-26230,LOCAL,26230,CPT,0360,RC,,,LT|PO,outpatient,,,10847.07,6508.24,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,LOCAL,23430,CPT,0360,RC,,,RT|XU,outpatient,,,75667.90,45400.74,,,,,,,,,,,,,
Bone Graft Any Donor Area Major/Large|SEPARATE STRUCTURE,CASE-20902,LOCAL,20902,CPT,,,,,XS,outpatient,,,119772.13,71863.28,,,,,,,,,,,,,
Cysto/Pyeloscopy Rescj Pelvic Tumor,CASE-52355,LOCAL,52355,CPT,,,,,,outpatient,,,23927.88,14356.73,,,,,,,,,,,,,
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE|PO,CASE-27792,LOCAL,27792,CPT,0360,RC,,,LT|PO,outpatient,,,32104.32,19262.59,,,,,,,,,,,,,
HC Remove Tun Cath Vad W/Port,CASE-36590,LOCAL,36590,CPT,0361,RC,,,,outpatient,,,7383.13,4429.88,,,,,,,,,,,,,
PLATE BNE H1MM 6 H MAND BLU TI MINI STR LOK LEIBINGER,SUP-2366342,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.14,232.14,,,,,,,,,,,,,
COLLAR CERV LG BLK,SUP-2414450,CDM,L0120,HCPCS,0272,RC,,,,both,,,34.85,22.65,,,,,,,,,,,,,
GUIDEWIRE ORTH FACETLINX,SUP-2293749,CDM,C1769,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
MIS LOCK CALC PLT LG EXD 2H RT,SUP-2586881,CDM,C1713,HCPCS,0278,RC,,,,both,,,2780.56,1807.36,,,,,,,,,,,,,
SCREW BNE L10MM DIA4MM CANC BIODUR ALLY ST SELF DRL CANN,SUP-2409799,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.69,365.75,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 1 MM 4 HOLE ADAPTION TITANIUM MATRIX,SUP-2842349,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.54,898.65,,,,,,,,,,,,,
FIBER LASER 0.6MM BALL TIP KTP/YAG LP,SUP-2885373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,LOCAL,64418,CPT,0360,RC,,,RT|XU,outpatient,,,29907.15,17944.29,,,,,,,,,,,,,
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,LOCAL,26080,CPT,0360,RC,,,,outpatient,,,14915.00,8949.00,,,,,,,,,,,,,
HC Sleep Study Unattended,CASE-95800,LOCAL,95800,CPT,0920,RC,,,,outpatient,,,972.83,583.70,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28825,LOCAL,28825,CPT,,,,,T5,outpatient,,,18774.05,11264.43,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,LOCAL,29828,CPT,0360,RC,,,,outpatient,,,50375.35,30225.21,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,LOCAL,23430,CPT,0360,RC,,,XU,outpatient,,,78467.23,47080.34,,,,,,,,,,,,,
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE|PO,CASE-28740,LOCAL,28740,CPT,0360,RC,,,LT|PO,outpatient,,,39959.50,23975.70,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<,CASE-11420,LOCAL,11420,CPT,0360,RC,,,,outpatient,,,16220.85,9732.51,,,,,,,,,,,,,
Excision Hidradenitis Axillary Smpl/Intrm Rpr,CASE-11450,LOCAL,11450,CPT,,,,,,outpatient,,,11221.82,6733.09,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT L180CM DIA6MM 0014IN 8 NIT STRUT GWIRE,SUP-2158106,CDM,C1884,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
HOOK SPNL L PEDCL TI FOR 5.5MM ROD CDH LEG,SUP-2287857,CDM,C1713,HCPCS,0278,RC,,,,both,,,2863.52,1861.29,,,,,,,,,,,,,
PLATE BNE THK1MM REG 8 H TI FOR 2MM MINI MOD,SUP-2262766,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.76,86.94,,,,,,,,,,,,,
GUIDEPIN ORTH JT SEEKING PIN RM WIRE KT STRL DISP VIRTUGUIDE,SUP-2908142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1460.82,949.53,,,,,,,,,,,,,
SCREW BNE L32MM OD42MM NONLOCKING COMPR,SUP-2321255,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
INDOCYANINE GREEN 25 MG IJ SOLR,RX-164944,CDM,2500000003,HCPCS,0250,RC,66259-0146-01,NDC,,both,1,UN,403.60,262.34,,,,,,,,,,,,,
POTASSIUM CHLORIDE 20 MEQ PO PACK,RX-6434,CDM,6370000000,HCPCS,0637,RC,00603-1554-10,NDC,,both,1,UN,34.20,22.23,,,,,,,,,,,,,
VALVE SPEAK SZ 6 SIL CANN MONT,SUP-2138745,CDM,L8501,HCPCS,0274,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
RING EXT FIX DIA105MM FULL TAY SPAT FRME,SUP-2342959,CDM,C1713,HCPCS,0278,RC,,,,both,,,6198.20,4028.83,,,,,,,,,,,,,
BUR SURG 10.7 MM TREPHINE FOR OTO SPINE,SUP-2607577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.83,363.89,,,,,,,,,,,,,
SUPPORT ORTHOT METATRSL CUST BAR WDG BTWN SOLE,SUP-2435727,CDM,L3410,HCPCS,0272,RC,,,,both,,,262.82,170.83,,,,,,,,,,,,,
HC Fem Pop Terr Plasty and Stent|RIGHT SIDE,CASE-37226,LOCAL,37226,CPT,0361,RC,,,RT,outpatient,,,52787.82,31672.69,,,,,,,,,,,,,
Tenolysis Extensor Tendon Hand/Finger Each,CASE-26445,LOCAL,26445,CPT,,,,,,outpatient,,,13068.78,7841.27,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT|PO",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T1|PO,outpatient,,,21700.38,13020.23,,,,,,,,,,,,,
I&D Ischiorct/Intramural Absc W/WO Seton,CASE-46060,LOCAL,46060,CPT,0360,RC,,,,outpatient,,,16704.02,10022.41,,,,,,,,,,,,,
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE,CASE-28238,LOCAL,28238,CPT,,,,,LT,outpatient,,,42614.05,25568.43,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|RIGHT SIDE|PO,CASE-28090,LOCAL,28090,CPT,0360,RC,,,RT|PO,outpatient,,,16398.72,9839.23,,,,,,,,,,,,,
Synovectomy Tendon Sheath Foot Extensor,CASE-28088,LOCAL,28088,CPT,,,,,,outpatient,,,22918.45,13751.07,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,LOCAL,52332,CPT,,,,,RT,outpatient,,,18153.38,10892.03,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T8|PO,outpatient,,,22059.40,13235.64,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|PO,CASE-64494,LOCAL,64494,CPT,0360,RC,,,PO,outpatient,,,4412.95,2647.77,,,,,,,,,,,,,
IMPLANT SYNTH L 91 X W 56 MM THK 4 MM POLYETHYL CRANIOFACIAL,SUP-2883679,CDM,C1713,HCPCS,0278,RC,,,,both,,,5084.35,3304.83,,,,,,,,,,,,,
PLATE BNE THK1MM 6 H TI FOREFOOT MIDFOOT BILAT POLYAX LOK,SUP-2398224,CDM,C1713,HCPCS,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
DOXYLAMINE SUCCINATE (SLEEP) 25 MG PO TABS,RX-14847,CDM,6370000000,HCPCS,0637,RC,41167-0006-23,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Nerve Neurolysis,PX-3600007520,CDM,3600007520,LOCAL,0360,RC,,,,both,,,6487.00,4216.55,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE MATERIAL 3 CC PREFILL STRL ACCUFILL LF,SUP-2866847,CDM,C1713,HCPCS,0278,RC,,,,both,,,8000.41,5200.27,,,,,,,,,,,,,
RIZATRIPTAN BENZOATE 10 MG PO TABS,RX-23377,CDM,6370000000,HCPCS,0637,RC,33342-0088-41,NDC,,both,1,UN,2.90,1.88,,,,,,,,,,,,,
BASEPLATE TIB L54MM THICKNESS 8MM UNIV POLYETH KNEE PRI CEM,SUP-2199769,CDM,C1776,CPT,0278,RC,,,,both,,,7531.29,4895.34,,,,,,,,,,,,,
BLADE SHV OD3.5MM 15DEG FULL RAD RESECT CUT PREBENT DISP,SUP-2341388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA2 MM TI CANN HDLSS NS LEOS,SUP-2932618,CDM,C1713,HCPCS,0278,RC,,,,both,,,817.91,531.64,,,,,,,,,,,,,
PLATE BNE W12XL199MM THK1MM 11 H BILAT S STL SEMI TBLR LO,SUP-2184873,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.00,203.45,,,,,,,,,,,,,
Insertion Intrauterine Device Iud,CASE-58300,LOCAL,58300,CPT,,,,,,outpatient,,,18809.37,11285.62,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,LOCAL,60500,CPT,0360,RC,,,LT,outpatient,,,55607.13,33364.28,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-20605,LOCAL,20605,CPT,0510,RC,,,XS|LT|PO,outpatient,,,46071.70,27643.02,,,,,,,,,,,,,
Carpectomy All Bones Proximal Row|RIGHT SIDE|PO,CASE-25215,LOCAL,25215,CPT,0360,RC,,,RT|PO,outpatient,,,16481.05,9888.63,,,,,,,,,,,,,
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,LOCAL,45381,CPT,0360,RC,,,PT,outpatient,,,15686.23,9411.74,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,LOCAL,58661,CPT,,,,,LT,outpatient,,,28426.55,17055.93,,,,,,,,,,,,,
Arthroplasty Glenohumeral Joint Total Shoulder,CASE-23472,LOCAL,23472,CPT,0360,RC,,,,outpatient,,,70589.23,42353.54,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,LOCAL,64633,CPT,,,,,LT,outpatient,,,11775.07,7065.04,,,,,,,,,,,,,
HC 3rd Order Sel Abd/Lower Ext,CASE-36247,LOCAL,36247,CPT,0361,RC,,,,outpatient,,,51730.18,31038.11,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Recurrent,CASE-25112,LOCAL,25112,CPT,0360,RC,,,,outpatient,,,13513.90,8108.34,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg,CASE-29881,LOCAL,29881,CPT,,,,,,outpatient,,,24656.93,14794.16,,,,,,,,,,,,,
STEM HUM L175MM SZ 8 REV MONOBLOCK,SUP-2217387,CDM,C1776,CPT,0278,RC,,,,both,,,19979.38,12986.60,,,,,,,,,,,,,
TREPHINE SURG DIA8MM CRWN DRL,SUP-2368636,CDM,C1713,HCPCS,0278,RC,,,,both,,,2014.31,1309.30,,,,,,,,,,,,,
ALLOGRAFT HUM TISS DISC 15 MM AMNIO WND MTRX BIOSKIN,SUP-2759608,CDM,C1762,CPT,0278,RC,,,,both,,,2006.30,1304.09,,,,,,,,,,,,,
PERI-LOC 4.5MM S-T LOCK SCREW 90MM,SUP-2819187,CDM,C1713,HCPCS,0278,RC,,,,both,,,1181.77,768.15,,,,,,,,,,,,,
SET INTRO SUPER SHTH L 5 CM DIA 5 FR NIT WIRE TEARWY SUPER,SUP-2627263,CDM,C1894,HCPCS,0272,RC,,,,both,,,10.80,7.02,,,,,,,,,,,,,
PLATE BNE 7 H MED EL LOK CONG,SUP-2107808,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
SCREW BNE L18MM DOA2.7MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321180,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
RING EXT FIX 180MM 5 8 TL HEX,SUP-2316204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3382.16,2198.40,,,,,,,,,,,,,
BIT DRL OLECRANON CANN ROD,SUP-2107106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
INSERT TIB STD NEUT UNIV PRI UNCONSTRAINED 12MM THCK M,SUP-2397052,CDM,C1776,CPT,0278,RC,,,,both,,,8650.70,5622.95,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE|PO,CASE-29827,LOCAL,29827,CPT,,,,,LT|PO,outpatient,,,52895.18,31737.11,,,,,,,,,,,,,
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,LOCAL,64448,CPT,0360,RC,,,XU,outpatient,,,58228.68,34937.21,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,LOCAL,45385,CPT,0360,RC,,,PT,outpatient,,,11059.10,6635.46,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE,CASE-29828,LOCAL,29828,CPT,,,,,RT,outpatient,,,47018.13,28210.88,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg F/E/E/N/L/M 0.5cm/<|PO,CASE-11440,LOCAL,11440,CPT,0360,RC,,,PO,outpatient,,,39029.90,23417.94,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THIRD DIGIT|PO",CASE-26727,LOCAL,26727,CPT,,,,,F7|PO,outpatient,,,13035.73,7821.44,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|PO,CASE-64718,LOCAL,64718,CPT,,,,,RT|PO,outpatient,,,13112.32,7867.39,,,,,,,,,,,,,
"HC Debrid,Bone,1st 20sqcm or Less|UNUSUAL NON-OVERLAPPING SERVICE",CASE-11044,LOCAL,11044,CPT,0361,RC,,,XU,outpatient,,,29271.23,17562.74,,,,,,,,,,,,,
HC Debride Subq First 20 Sq Cm|PBB CHARGE,CASE-11042,LOCAL,11042,CPT,0361,RC,,,PBB,outpatient,,,1500.42,900.25,,,,,,,,,,,,,
Repair Fibula Nonunion/Malunion W/Int Fixation|LEFT SIDE,CASE-27726,LOCAL,27726,CPT,0360,RC,,,LT,outpatient,,,40869.75,24521.85,,,,,,,,,,,,,
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE|PO,CASE-29877,LOCAL,29877,CPT,,,,,RT|PO,outpatient,,,17946.17,10767.70,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,LOCAL,64493,CPT,0360,RC,,,50,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,LOCAL,52235,CPT,0360,RC,,,,outpatient,,,18822.92,11293.75,,,,,,,,,,,,,
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, GREAT TOE|PO",CASE-28160,LOCAL,28160,CPT,0360,RC,,,TA|PO,outpatient,,,22178.83,13307.30,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,LOCAL,52332,CPT,,,,,50,outpatient,,,21502.90,12901.74,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|SEPARATE STRUCTURE|RIGHT SIDE|PO",CASE-64708,LOCAL,64708,CPT,,,,,XS|RT|PO,outpatient,,,20179.65,12107.79,,,,,,,,,,,,,
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc,CASE-24341,LOCAL,24341,CPT,,,,,,outpatient,,,33273.60,19964.16,,,,,,,,,,,,,
Syndactylization Toes|LEFT SIDE,CASE-28280,LOCAL,28280,CPT,0360,RC,,,LT,outpatient,,,26726.37,16035.82,,,,,,,,,,,,,
PLATE SPINE L65MM ANT CERV TI ALLY CNVGNT ATLNTS,SUP-2291088,CDM,C1713,HCPCS,0278,RC,,,,both,,,3977.50,2585.37,,,,,,,,,,,,,
DRILL SURG PREMIER AFFIRM,SUP-2598515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BNE THK0.6MM BAR L5MM 100DEG 5 H L,SUP-2366297,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.51,324.03,,,,,,,,,,,,,
HC So Assay of Mercury Quantitative,PX-3018382566,CDM,83825,CPT,0301,RC,,,,inpatient,,,135.00,87.75,,,,,,,,,,,,,
PLATE BNE L 234 MM SCREW DIA 4.5 MM 14 H COMPR LCK STRL EVOS,SUP-2933227,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.57,2144.07,,,,,,,,,,,,,
MGII KNEE POR STEM TIB.E+/GRE BLK LT/M RT/L,SUP-2199639,CDM,C1776,CPT,0278,RC,,,,both,,,15659.81,10178.88,,,,,,,,,,,,,
PLATE BONE L23MM LNG DBL Y SPEC LORENZ,SUP-2137628,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
HC Perc Balloon Valvuloplasty; Aortic Valve,PX-4819298600,CDM,92986,CPT,0481,RC,,,,inpatient,,,15337.00,9969.05,,,,,,,,,,,,,
GUIDEWIRE VASC L 70 CM DIA 0.018 IN NIT MARKED RADIOPAQUE,SUP-2269549,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
BIT DRILL STOP 1.8X16 MM 82 MM HEXAGONAL COUPLING TITANIUM N,SUP-2841982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.22,412.89,,,,,,,,,,,,,
"Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn|RIGHT HAND, THIRD DIGIT|PO",CASE-26145,LOCAL,26145,CPT,0360,RC,,,F7|PO,outpatient,,,23079.30,13847.58,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26735,LOCAL,26735,CPT,,,,,F2|PO,outpatient,,,23370.45,14022.27,,,,,,,,,,,,,
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE,CASE-28120,LOCAL,28120,CPT,,,,,RT,outpatient,,,33279.22,19967.53,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26525,LOCAL,26525,CPT,0360,RC,,,F7|PO,outpatient,,,15631.72,9379.03,,,,,,,,,,,,,
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,LOCAL,46261,CPT,,,,,,outpatient,,,22140.22,13284.13,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,LT|XU,outpatient,,,5976.53,3585.92,,,,,,,,,,,,,
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,LOCAL,31652,CPT,0360,RC,,,,outpatient,,,26164.02,15698.41,,,,,,,,,,,,,
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,LOCAL,64561,CPT,,,,,,outpatient,,,48818.20,29290.92,,,,,,,,,,,,,
Dcmprn Fasct Leg Ant&/Lat Compartments Only|RIGHT SIDE|PO,CASE-27600,LOCAL,27600,CPT,0360,RC,,,RT|PO,outpatient,,,20812.13,12487.28,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|RIGHT SIDE|PO,CASE-25609,LOCAL,25609,CPT,0360,RC,,,RT|PO,outpatient,,,38150.23,22890.14,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,LOCAL,64484,CPT,,,,,LT,outpatient,,,3990.02,2394.01,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-23430,LOCAL,23430,CPT,0360,RC,,,XU|LT,outpatient,,,71027.33,42616.40,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE,CASE-27691,LOCAL,27691,CPT,,,,,RT,outpatient,,,47822.53,28693.52,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE|PO,CASE-64493,LOCAL,64493,CPT,,,,,LT|PO,outpatient,,,4102.47,2461.48,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 6.5 MM TWST W/ TAPE 1 WHT 11083T,SUP-2762109,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
CANNULA SUCTION WORKING L140MM OD2.7MM MICRO GREEN OBTURATOR,SUP-2805826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.20,724.23,,,,,,,,,,,,,
PLATE BNE L109MM 9 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT DYN,SUP-2185935,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.12,330.93,,,,,,,,,,,,,
PLATE BNE RECON UNIV 3.5 MM 10 HOLE 2 COMPR FOR SCR TI NS,SUP-2478918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1490.34,968.72,,,,,,,,,,,,,
BUR SURG CYL 4X11.3 MM 10 CM BRL SM BOR MIDAS REX 8 LEGEND,SUP-2664510,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.57,281.17,,,,,,,,,,,,,
BAR EXT FIX L225MM DIA6MM COMP FOR JET-X FIX SYS,SUP-2342916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
SLING ORTH ADJ STRP UNIV 5.4X5 IN 19X13 IN SHLDR DLX,SUP-2195027,CDM,L3660,HCPCS,0274,RC,,,,both,,,31.43,20.43,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK0.23-0.51MM GRFTABLE REGEN TISS,SUP-2112985,CDM,Q4116,HCPCS,0636,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
KIT REMOT CTRL 3 FOR DP BRAIN STIM VERCISE,SUP-2140423,CDM,C1787,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
TIP ASPIR L11.9CM DIA1.57MM FOR ULTRASONIC SURG ASPIR CUSA,SUP-2243961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3088.19,2007.32,,,,,,,,,,,,,
SEALER MPLR HK DSGN TRANSCOLLATION DISP ENDOSH2.0,SUP-2281801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3020.68,1963.44,,,,,,,,,,,,,
GRAFT HUM TISS W5XL110MM FIB STRUT FRZN,SUP-2307387,CDM,C1713,HCPCS,0278,RC,,,,both,,,2999.45,1949.64,,,,,,,,,,,,,
PLATE BNE RECON LG 2-2.3X176X2.8 MM RT 24 HOLE SMRT TI STRL,SUP-2460372,CDM,C1713,HCPCS,0278,RC,,,,both,,,10543.65,6853.37,,,,,,,,,,,,,
KIT PNEUMOTHOR CATH 8FR L6.44IN NDL 18GA INJ SYR APPL PCH,SUP-2383256,CDM,C1729,HCPCS,0272,RC,,,,both,,,497.28,323.23,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,LOCAL,49505,CPT,,,,,RT,outpatient,,,26451.93,15871.16,,,,,,,,,,,,,
HC Repr Smp Not Face 2.6-7.5cm|SEPARATE STRUCTURE,CASE-12002,LOCAL,12002,CPT,0450,RC,,,XS,outpatient,,,28679.87,17207.92,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,50|XU,outpatient,,,5708.52,3425.11,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE|PO,CASE-29880,LOCAL,29880,CPT,0360,RC,,,LT|PO,outpatient,,,21272.87,12763.72,,,,,,,,,,,,,
Rpr Component Inflatable Penile Prosthesis,CASE-54408,LOCAL,54408,CPT,,,,,,outpatient,,,67309.77,40385.86,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,LOCAL,23430,CPT,,,,,XU,outpatient,,,78467.23,47080.34,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|LEFT SIDE,CASE-50081,LOCAL,50081,CPT,0360,RC,,,LT,outpatient,,,70093.62,42056.17,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE|PO,CASE-25609,LOCAL,25609,CPT,,,,,LT|PO,outpatient,,,29507.75,17704.65,,,,,,,,,,,,,
Surg Tx Anal Fistula Intersphincteric,CASE-46275,LOCAL,46275,CPT,0360,RC,,,,outpatient,,,18372.90,11023.74,,,,,,,,,,,,,
Partical Excision Bone Phalanx Toe|LEFT SIDE|PO,CASE-28124,LOCAL,28124,CPT,0360,RC,,,LT|PO,outpatient,,,21983.18,13189.91,,,,,,,,,,,,,
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, THIRD DIGIT",CASE-28645,LOCAL,28645,CPT,0360,RC,,,T7,outpatient,,,34797.97,20878.78,,,,,,,,,,,,,
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE,CASE-28300,LOCAL,28300,CPT,,,,,LT,outpatient,,,52734.25,31640.55,,,,,,,,,,,,,
Dir Rpr Aneurysm Axil-Brachial Arm Incision,CASE-35011,LOCAL,35011,CPT,,,,,,outpatient,,,51788.87,31073.32,,,,,,,,,,,,,
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-24341,LOCAL,24341,CPT,0360,RC,,,74,outpatient,,,10923.90,6554.34,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|RIGHT SIDE|PO,CASE-28090,LOCAL,28090,CPT,,,,,RT|PO,outpatient,,,16398.72,9839.23,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,LOCAL,45380,CPT,0360,RC,,,,outpatient,,,12669.70,7601.82,,,,,,,,,,,,,
Unlisted Procedure Male Genital System,CASE-55899,LOCAL,55899,CPT,,,,,,outpatient,,,22192.30,13315.38,,,,,,,,,,,,,
COMPONENT HIP CMNTLS P3,SUP-2351398,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE L230MM 10 H ST L CNDYL S STL CRV LOK COMPR VAR,SUP-2177854,CDM,C1713,HCPCS,0278,RC,,,,both,,,6315.11,4104.82,,,,,,,,,,,,,
TOOL INSRTN STRL FURLOW LTX DISP,SUP-2862194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1644.10,1068.66,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-15882,CDM,J7042,HCPCS,0250,RC,00338-0089-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL L 3.5 IN DIA17 GA SGL SHT LIDO NACL,SUP-2936441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,47.60,30.94,,,,,,,,,,,,,
IMPLANT BIO TISS W15XL25CM REGEN PORCINE CLLGN RECT,SUP-2125847,CDM,C1781,HCPCS,0278,RC,,,,both,,,24617.60,16001.44,,,,,,,,,,,,,
DEVICE GRFT DEL ANGLED 15 CM VENTED BIOXPRESS,SUP-2431986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
COMPONENT FEM MOD SM 8.5 CM LT CNDYL DSTL KNEE REV RECON,SUP-2376389,CDM,C1776,CPT,0278,RC,,,,both,,,18510.30,12031.69,,,,,,,,,,,,,
SCREW BNE HDLSS TH SER 3 X 16 MM TI,SUP-2244461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.73,665.42,,,,,,,,,,,,,
SEGMENTAL SHIELD HINGE SVC KIT SIZE E,SUP-2502436,CDM,C1776,CPT,0278,RC,,,,both,,,4775.94,3104.36,,,,,,,,,,,,,
IMPLANT BIO TISS L25CM ID2MM PERIPH NRV CLLGN CONDUIT,SUP-2378811,CDM,C9353,HCPCS,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
KNIFE BROAD 10CM IQ,SUP-2717564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3387.12,2201.63,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,LOCAL,49507,CPT,0360,RC,,,RT,outpatient,,,24997.20,14998.32,,,,,,,,,,,,,
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE,CASE-24073,LOCAL,24073,CPT,0360,RC,,,LT,outpatient,,,35681.82,21409.09,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,LOCAL,58661,CPT,,,,,50,outpatient,,,27943.17,16765.90,,,,,,,,,,,,,
Arthrodesis Subtalar|RIGHT SIDE,CASE-28725,LOCAL,28725,CPT,0360,RC,,,RT,outpatient,,,71276.72,42766.03,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THIRD DIGIT|PO",CASE-26765,LOCAL,26765,CPT,0360,RC,,,F2|PO,outpatient,,,6199.00,3719.40,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|SEPARATE STRUCTURE,CASE-23430,LOCAL,23430,CPT,0360,RC,,,XS,outpatient,,,75254.82,45152.89,,,,,,,,,,,,,
HC Remove Retrievable Filter,CASE-37193,LOCAL,37193,CPT,0361,RC,,,,outpatient,,,27177.22,16306.33,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,LOCAL,64415,CPT,0360,RC,,,LT|XU,outpatient,,,46203.17,27721.90,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,LOCAL,28289,CPT,,,,,TA,outpatient,,,19476.55,11685.93,,,,,,,,,,,,,
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE,CASE-27822,LOCAL,27822,CPT,0360,RC,,,RT,outpatient,,,36422.03,21853.22,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,LOCAL,64634,CPT,,,,,RT,outpatient,,,12105.48,7263.29,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE|PO,CASE-29879,LOCAL,29879,CPT,0360,RC,,,LT|PO,outpatient,,,48468.53,29081.12,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm,CASE-11422,LOCAL,11422,CPT,0360,RC,,,,outpatient,,,25293.23,15175.94,,,,,,,,,,,,,
HC Extremity Venogram|LEFT SIDE,CASE-36005,LOCAL,36005,CPT,0361,RC,,,LT,outpatient,,,41623.45,24974.07,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE|PO,CASE-64484,LOCAL,64484,CPT,0360,RC,,,LT|PO,outpatient,,,3914.52,2348.71,,,,,,,,,,,,,
Rhinoplasty Secondary Intermediate Revision|PO,CASE-30435,LOCAL,30435,CPT,,,,,PO,outpatient,,,28608.23,17164.94,,,,,,,,,,,,,
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt,CASE-27602,LOCAL,27602,CPT,0360,RC,,,,outpatient,,,20832.28,12499.37,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA19 GA NDL DIA17 GA CE17TKFSN NRFIT,SUP-2936422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,93.16,60.55,,,,,,,,,,,,,
ORTHOPEDIC KIT LNG 4.5X17.5 MM ARTHRPLSTY SCREW W/ LCK CAP,SUP-2243513,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.94,608.36,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 45X25 CM BIOLOGIC TISSUE MATRIX STERILE X,SUP-2838623,CDM,C1763,HCPCS,0278,RC,,,,both,,,104405.00,67863.25,,,,,,,,,,,,,
NUT EXT FIX MRI SAFE FOR DISTR OSTEOGENESIS RNG SYS 10 PER,SUP-2179140,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.30,82.74,,,,,,,,,,,,,
PLATE BNE L45-55MM TROCHANTERIC HIP MALLORY-HEAD TI POR,SUP-2403612,CDM,C1776,CPT,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
COMPONENT FMRL LG TBL RTTNG PLTFRMFLXN GSB LATEX FREE ST SN,SUP-2720917,CDM,C1776,CPT,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L120CM BAL L80MM DIA6MM SHTH 7FR 0.035IN,SUP-2141211,CDM,C1725,HCPCS,0272,RC,,,,both,,,2248.24,1461.36,,,,,,,,,,,,,
PIN FIX L215MM OD2.5MM SMOOTH SGL SHRP TIP S STL,SUP-2342381,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
FORCEP ELECSURG BPLR 1.5 MM 14.5 CM PRO SER SILVERGLIDE,SUP-2859593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3775.41,2454.02,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK INNR SOCKET CUSH LNR,SUP-2388210,CDM,L5679,HCPCS,0274,RC,,,,both,,,1538.82,1000.23,,,,,,,,,,,,,
PLATE BNE L53MM 3 H BILAT S STL T SHP LO PROF RIG NEUT,SUP-2186301,CDM,C1713,HCPCS,0278,RC,,,,both,,,1468.11,954.27,,,,,,,,,,,,,
HOOK 3714111 SISSON NERVE 6MM 90DG BLUNT,SUP-2705132,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.72,416.47,,,,,,,,,,,,,
MESH HERN DIA9CM UMB RND PARIETEX,SUP-2752148,CDM,C1781,HCPCS,0278,RC,,,,both,,,1520.51,988.33,,,,,,,,,,,,,
CANNULA ARTHSCP L72MM DIA6.5MM SMOOTH 3 SEAL DSGN FLEX OBT,SUP-2341062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,217.70,141.50,,,,,,,,,,,,,
BUSHING FEM KNEE ARCM POLY LO FRIC INTFACE AXLE AND REINF,SUP-2405828,CDM,C1776,CPT,0278,RC,,,,both,,,522.81,339.83,,,,,,,,,,,,,
HC Therapeutic Plasma Pheresis,PX-7613651400,CDM,36514,CPT,0761,RC,,,,both,,,3809.00,2475.85,,,,,,,,,,,,,
IMPLANT SZ 10 HEMI PHLANG GREAT TOE MOV,SUP-2244246,CDM,C1776,CPT,0278,RC,,,,both,,,7441.89,4837.23,,,,,,,,,,,,,
GUIDEWIRE K PARTIAL-THRD 2.2MM DIA 4.73INL 30MM THRD LEN NS,SUP-2316518,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.12,58.58,,,,,,,,,,,,,
PLATE BONE 7 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413751,CDM,C1713,HCPCS,0278,RC,,,,both,,,1140.13,741.08,,,,,,,,,,,,,
COMPONENT TOE DIA12MM 1X1.2MM OFFSET MT CE ARTC HEMICAP,SUP-2123596,CDM,C1776,CPT,0278,RC,,,,both,,,8207.96,5335.17,,,,,,,,,,,,,
GRAFT STENT BIFUR 12-13.5X14.5 MMX7 CM 12 FR AAA IL EXT,SUP-2395918,CDM,C1768,CPT,0278,RC,,,,both,,,9432.56,6131.16,,,,,,,,,,,,,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,6370000000,HCPCS,0637,RC,51672-2116-02,NDC,,both,1,UN,8.80,5.72,,,,,,,,,,,,,
STENT URET L 22 CM DIA 8 FR FLEXIMA GLDEX DBL PIGTL THRD,SUP-2147878,CDM,C2617,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
NEEDLE BX L16CM DIA18GA DISPOSABLE CM MRK BIOPTY CUT,SUP-2127818,CDM,C1713,HCPCS,0278,RC,,,,both,,,74.42,48.37,,,,,,,,,,,,,
BIT SURG DRL FOR POLY LNR REMOVAL STRL DISP G7,SUP-2887667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE GT L 180CM 0.018IN 90/60 DEG,SUP-2385632,CDM,C1769,HCPCS,0272,RC,,,,both,,,619.08,402.40,,,,,,,,,,,,,
KNEE ORTHOLOC II PAT POLYETH 35MM MED-LRG-XLG,SUP-2397043,CDM,C1776,CPT,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
BLADE RMR PERC SELF EXP X-REAM,SUP-2397142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1731.55,1125.51,,,,,,,,,,,,,
BASKET STONE SEGR 16MM,SUP-2141355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
QUARTEX LAT CONNECTOR4.0MM ROD,SUP-2229090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
STEM FEM L200MM DIA16MM LNG PROX KNEE TI PPS PUREFIX BOW,SUP-2376538,CDM,C1776,CPT,0278,RC,,,,both,,,11547.04,7505.58,,,,,,,,,,,,,
DRILL SURG CALIB 3.5X130 MM STP,SUP-2766123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
HC CT Orbit/Ear/Fossa W/ Contrast,PX-3517048100,CDM,70481,CPT,0351,RC,,,,inpatient,,,1973.00,1282.45,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .018 WORKING L 135 CM SHTH 6 FR,SUP-2898500,CDM,C1753,HCPCS,0278,RC,,,,both,,,1329.04,863.88,,,,,,,,,,,,,
PLATE BNE STD SM MEDL LT CLMN FUSION SS STRL SOLE MCF LTX,SUP-2875505,CDM,C1713,HCPCS,0278,RC,,,,both,,,12799.27,8319.53,,,,,,,,,,,,,
INTRODUCER GWIRE L50CM L3MM 0.038IN S STL PTFE STR CRV FIX,SUP-2355266,CDM,C1769,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
MATRIX BIO LG SZ 196 SQCM FISH SKIN LT DORSUM RT PALMAR MANO,SUP-2909252,CDM,Q4158,HCPCS,0636,RC,,,,both,,,26441.94,17187.26,,,,,,,,,,,,,
PACK IMPL 3.2MM PROXIMAL/ PHALANX PEEK PIP FUS HAT-TRICK,SUP-2349220,CDM,C1776,CPT,0278,RC,,,,both,,,4995.11,3246.82,,,,,,,,,,,,,
PLATE BNE L316MM 13 H NONSTERILE R DST FEM TI LOK COMPR FOR,SUP-2190729,CDM,C1713,HCPCS,0278,RC,,,,both,,,5128.09,3333.26,,,,,,,,,,,,,
PLATE BNE L W7XL32MM THK1MM 3 H R TI RIG OBLQ,SUP-2191009,CDM,C1713,HCPCS,0278,RC,,,,both,,,231.92,150.75,,,,,,,,,,,,,
GRAFT BNE PTTY 20 CC BIOACTIVE MTRX STRL BONESYNC LTX,SUP-2859808,CDM,C1713,HCPCS,0278,RC,,,,both,,,8760.60,5694.39,,,,,,,,,,,,,
GRAFT HUM TISS 4.5SQCM AMNION AND CHORION MEMBRN EPIFIX,SUP-2305745,CDM,Q4186,HCPCS,0636,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
PUMP MS 700 LGX PRECONNECT,SUP-2139020,CDM,C1813,HCPCS,0278,RC,,,,both,,,26523.58,17240.33,,,,,,,,,,,,,
PLATE BNE W9XL25MM THK1MM 2 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190944,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.75,276.09,,,,,,,,,,,,,
DAPSONE 100 MG PO TABS,RX-2131,CDM,6370000000,HCPCS,0637,RC,70954-0136-10,NDC,,both,1,UN,5.50,3.57,,,,,,,,,,,,,
BUTTON GAST ACCS L44CM DIA24FR LO PROF PUL PEG KT 1 STP,SUP-2149749,CDM,C1733,HCPCS,0272,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
CANNULA OPHTH KRATZ 30 GA LENS MANIP,SUP-2484860,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.96,75.37,,,,,,,,,,,,,
SET LOC INTRO 9GA NDL L14CM APER L20MM FOR ATEC MRI GUID,SUP-2240023,CDM,C1894,HCPCS,0272,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
HC Mra Pelvis Without Contrast,PX-6100891900,CDM,C8919,CPT,0610,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
BIT DRL L 195 MM DIA 6 MM FOR QC NS REUSE,SUP-2908022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.16,340.70,,,,,,,,,,,,,
PLATE BNE FIBULAR RT LAT ANK 6 HOLE NS,SUP-2518402,CDM,C1713,HCPCS,0278,RC,,,,both,,,5388.24,3502.36,,,,,,,,,,,,,
CATHETER GUID CXI L 65 CM DIA 2.6 FR 0.018IN SS ANGLED 2 TIP,SUP-2638648,CDM,C1887,HCPCS,0272,RC,,,,both,,,638.77,415.20,,,,,,,,,,,,,
STERILE WATER FOR INJECTION (MIXTURES ONLY),RX-430028,CDM,2500000003,HCPCS,0250,RC,63323-0185-10,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
POST SURG ANK INTOSS FIX L18MM OD4.6MM 60DEG IOFIX,SUP-2223852,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PIN BNE FIX L 1 1/4 IN DIA 0.062 IN SMILLIE,SUP-2933912,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.55,79.01,,,,,,,,,,,,,
RETRACTABLE SCR IN J,SUP-2236353,CDM,C1883,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CATHETER EP QPLR 2-5-2 MM 7 FRX115 CM TC,SUP-2356974,CDM,C1733,HCPCS,0272,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
SCREW BONE L100MM DIA6.5MM UNIV CORT FEM ST FT DRV END,SUP-2411524,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
MESH HERN RECTANGULAR 3 11X6 CM MONOFILAMENT VERSATEX,SUP-2752213,CDM,C1781,HCPCS,0278,RC,,,,both,,,269.98,175.49,,,,,,,,,,,,,
GRAFT BNE 5CC DBM SHP,SUP-2364718,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT BONE SUB 30CC CANC CUBE,SUP-2212020,CDM,C1713,HCPCS,0278,RC,,,,both,,,1485.22,965.39,,,,,,,,,,,,,
BIT DRL L190MM DIA6MM STRL TI CANN QUIK CPL W/O STP,SUP-2188288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2073.44,1347.74,,,,,,,,,,,,,
URETEROSCOPE FLX 105 DEG L 70 CM SHTH OD 9FR 6PC/BX,SUP-2889752,CDM,C1747,HCPCS,0272,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
SCREW BNE L25MM DIA6.5MM CANC HIP TI NONLOCKING TORX DRV,SUP-2370277,CDM,C1713,HCPCS,0278,RC,,,,both,,,297.67,193.49,,,,,,,,,,,,,
GUIDEWIRE VASC RUNTHROUGH NS L 150 CM DIA 0.014 IN NIT SS,SUP-2384827,CDM,C1769,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
CATHETER ENDOBRONCH DIA2.6MM LOADER DEPLOYMENT HUD,SUP-2313514,CDM,C1887,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
NAIL IM L160MM DIA9MM GRN FEM TI CANN LOK RG BEND RND FOR,SUP-2180052,CDM,C1713,HCPCS,0278,RC,,,,both,,,4938.75,3210.19,,,,,,,,,,,,,
IMPLANT HUM TISSSUE 1X4CM THK2.31-3.30MM ALLDERM,SUP-2113415,CDM,Q4116,HCPCS,0636,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
COMPONENT PAT DIA38MM THK9.5MM 3 PEG POLYETH CEM RND REV,SUP-2251242,CDM,C1776,CPT,0278,RC,,,,both,,,3259.32,2118.56,,,,,,,,,,,,,
HC So Rubella Latex Test,PX-3028676266,CDM,86762,CPT,0302,RC,,,,outpatient,,,165.00,107.25,,,,,,,,,,,,,
CATHETER COR LSR ATHRCTMY OVR THE WIRE 0.9 MMX130 CM ELCA,SUP-2353041,CDM,C1885,CPT,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
MESH HERN W1.8XL4.0IN POLYPR INGUINAL NONABSORBABLE,SUP-2125781,CDM,C1781,HCPCS,0278,RC,,,,both,,,173.01,112.46,,,,,,,,,,,,,
STAPLE BNE 15X15 MM FOREFOOT PK NIT DYNAFORCE MOTOCLIP MAX,SUP-2175169,CDM,C1713,HCPCS,0278,RC,,,,both,,,2471.18,1606.27,,,,,,,,,,,,,
SCREW BONE CANCELLOUS 6.5X65 MM TIBIAL PARTIAL THREADED LOCK,SUP-2837342,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.53,195.99,,,,,,,,,,,,,
COVER BUR H DIA10MM UNIV CRANIOMAXILLOFACIAL TI MAL LO PROF,SUP-2366285,CDM,C1713,HCPCS,0278,RC,,,,both,,,883.60,574.34,,,,,,,,,,,,,
HC Fna Bx W/US Gdn Ea Addl,PX-3611000600,CDM,10006,CPT,0361,RC,,,,inpatient,,,2124.00,1380.60,,,,,,,,,,,,,
ROD SPNL 5.5X110MM CVD TI CREO MIS,SUP-2417908,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP GLIDEWIRE L 260 CM DIA 0.035 IN TIP L 3 CM,SUP-2385258,CDM,C1769,HCPCS,0272,RC,,,,both,,,382.45,248.59,,,,,,,,,,,,,
RING EXT FIX BUTTRESS 5.5 MM,SUP-2517368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PACEMAKER CARD ALTRUA 60 W 42 X H 42 MM THK 8 MM 23.4 GM,SUP-2149277,CDM,C1786,HCPCS,0275,RC,,,,both,,,9655.50,6276.07,,,,,,,,,,,,,
CATHETER ANGIOPLSTY AGNT L 144 MM BALLOON L 30 MM DIA2 MM,SUP-2892813,CDM,C9610,HCPCS,0272,RC,,,,both,,,17741.00,11531.65,,,,,,,,,,,,,
PLATE BNE L350MM 16 H NONSTERILE L CNDYL S STL LOK COMPR,SUP-2183118,CDM,C1713,HCPCS,0278,RC,,,,both,,,4650.06,3022.54,,,,,,,,,,,,,
HC So1 Fluor Anti Titer,PX-3028625667,CDM,86256,CPT,0302,RC,,,,both,,,196.00,127.40,,,,,,,,,,,,,
PLATE BNE 2.7 MM W/ 1 MM STP NS LTX,SUP-2857022,CDM,C1713,HCPCS,0278,RC,,,,both,,,3158.84,2053.25,,,,,,,,,,,,,
PLATE BONE W16XL190MM THK5MM 9 H LT CNDYL FEM S STL BTTRS,SUP-2185804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2499.60,1624.74,,,,,,,,,,,,,
SCREW BNE L45MM DIA6.5MM HD FOR FRAC REP AND FIX OSTEOTMY,SUP-2175054,CDM,C1713,HCPCS,0278,RC,,,,both,,,1907.55,1239.91,,,,,,,,,,,,,
PLATE SPNL W9XL112MM 7 H ANTR BILAT TI CHANNELED SUMMIT FIX,SUP-2254412,CDM,C1713,HCPCS,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
PIN FIX L9IN DIA28MM ST S STL 3 SIDE DBL TRCR BOTH END PNT,SUP-2150526,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.78,16.76,,,,,,,,,,,,,
PLATE BONE LOK NON CMPRSSN HLX12 1MM THK TTNM LATEX FREE MND,SUP-2680146,CDM,C1713,HCPCS,0278,RC,,,,both,,,1592.45,1035.09,,,,,,,,,,,,,
DRESSING BIO CORNEAL BNDG PROKERA SLIM,SUP-2135267,CDM,V2790,HCPCS,0274,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 105 CM OD 0.07 IN ID 0.058 IN FLX,SUP-2522807,CDM,C1887,HCPCS,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
BAG TISS CLSR DIA4CM TRNSPAR SIL SILO SPR LD PROX OPN SFT,SUP-2134678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
SPLINT WRST R INSTABILITY INJ LOOP LOK W STAY FIRM SUPP,SUP-2276663,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.36,10.63,,,,,,,,,,,,,
TUBING EXPANSION FLX 1 ACCULIF,SUP-2381474,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PRODENSE 15CC BONE GRFT SUB,SUP-2400572,CDM,C1713,HCPCS,0278,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
SCREW BONE L6MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST FULL,SUP-2189425,CDM,C1713,HCPCS,0278,RC,,,,both,,,180.55,117.36,,,,,,,,,,,,,
TUBE MYR 127MM DIAM VENT SIL DURAVENT,SUP-2313728,CDM,L8699,HCPCS,0278,RC,,,,both,,,51.03,33.17,,,,,,,,,,,,,
PLATE BNE STR 20X0.6 MM NEURO 4 HOLE TI STRL LEVEL 1,SUP-2500874,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.42,321.37,,,,,,,,,,,,,
TUNNELER SURG TRANSOSSEOUS FOR RC REP STRL DISP,SUP-2908689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
STEM FEM L127X203MM DIA11MM LNG DST KNEE TI POR BODY CRV,SUP-2364663,CDM,C1776,CPT,0278,RC,,,,both,,,12089.63,7858.26,,,,,,,,,,,,,
GRAFT BNE SUB W3-6XL60MM CORT STRUTS FRZ DRY STRUCTURAL,SUP-2307179,CDM,C1713,HCPCS,0278,RC,,,,both,,,2564.53,1666.94,,,,,,,,,,,,,
SCREW STRM MDS 2.4X14MM RS ST,SUP-2653985,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.28,364.83,,,,,,,,,,,,,
EMBOLIZATION KIT SPHR M100 YEL LC BEAD,SUP-2835336,CDM,C1889,HCPCS,0278,RC,,,,both,,,7300.50,4745.32,,,,,,,,,,,,,
BIT DRILL 2.1MM HIP INSTRUMENT SYSTEM PRESSFT,SUP-2842813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1470.62,955.90,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 40X30X10 MM FD IRRADIATED CALCANEUS,SUP-2866901,CDM,C1762,CPT,0278,RC,,,,both,,,1983.70,1289.40,,,,,,,,,,,,,
GRAFT BNE SYR 1 CC GRFT 945001] MUSCULOSKELETAL TRANSPLANT FOUNDATION],SUP-2307548,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
MESH TISS L 30 X W 23 MM TYP 1 CLLGN MTRX PLLA MICROFILAMENT,SUP-2895933,CDM,C1781,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
HEAD HUM DIA50MM THK28MM SHLDR CO CHROM PRI STD OFFSET NK,SUP-2372844,CDM,C1776,CPT,0278,RC,,,,both,,,4287.04,2786.58,,,,,,,,,,,,,
GUIDEWIRE EMBOLIC PROTCT EMBOSHIELD DIA 6 FR FILTER DIA 4 MM,SUP-2102270,CDM,C1884,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
COLLAR EXTRIC AD L H2XL235IN NAR BRTH M DENS FOAM CNTOUR W,SUP-2194383,CDM,L0120,HCPCS,0272,RC,,,,both,,,20.38,13.25,,,,,,,,,,,,,
SYSTEM IMPL L24MM DIA5.5MM BIOCOMP INCL 2 SWIVELOCK SP FOR,SUP-2121718,CDM,C1713,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
KIT OXGNTR W/ ACCSRY TANDEMLUNG,SUP-2152643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1193108D5,SUP-2632796,CDM,C1751,HCPCS,0278,RC,,,,both,,,893.83,580.99,,,,,,,,,,,,,
PROSTHESIS VOICE LO PRSS BLOM-SINGER 16 FRX28 MM,SUP-2242315,CDM,L8507,HCPCS,0274,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
REAMER MTCRPL FOR IMPLATE SYS 3.4MM,SUP-2340242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ALLOGRAFT DERMAL 2X12 CMX2.31-3.30 MM TISS MTRX ALLDERM,SUP-2113046,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
CROSSLINK SPNL RVS 29-34 MM,SUP-2232299,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE W10.2XL156MM THK2.7MM 12 H BILAT S STL STR LO,SUP-2186199,CDM,C1713,HCPCS,0278,RC,,,,both,,,1620.55,1053.36,,,,,,,,,,,,,
MESH CRAN W38XL50MM THK1MM TIIUM POLYETH POR MTRX 1 SIDE,SUP-2366477,CDM,C1713,HCPCS,0278,RC,,,,both,,,3675.75,2389.24,,,,,,,,,,,,,
SUPPORT ORTHOT PIP FNGR DSTL INTERPHALANGEAL SPRING W/JT,SUP-2435784,CDM,L3925,HCPCS,0274,RC,,,,both,,,169.25,110.01,,,,,,,,,,,,,
MAXFRAME RING MOUNT FOR 5-6MM,SUP-2752092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,512.95,333.42,,,,,,,,,,,,,
COMPONENT FEM SZ 4 LT CO CHROM CRUC RET CEM PRI NP UNISX,SUP-2350332,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
STEM FEM CMNTLS 24/20X130 MM MOD W/ M TAPR FOR 6 MM NOSE,SUP-2423702,CDM,C1776,CPT,0278,RC,,,,both,,,7051.91,4583.74,,,,,,,,,,,,,
NEUROPATH GUID CATH TIP SHP MOD CEREB WRK LEN 90CM INNR,SUP-2257606,CDM,C1887,HCPCS,0272,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
HC Intrvasc US Noncoronary Addl,PX-4023725300,CDM,37253,CPT,0402,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
HC Prog Eval Impl Loop Recorder,PX-4809328500,CDM,93285,CPT,0480,RC,,,,both,,,132.00,85.80,,,,,,,,,,,,,
HC MRI-Angio Head WO& W Contras,PX-6157054600,CDM,70546,CPT,0615,RC,,,,both,,,4794.00,3116.10,,,,,,,,,,,,,
BIT DRL QC 2.8X135 MM 45 MM CALIB NS,SUP-2563756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.17,226.96,,,,,,,,,,,,,
DRILL SURG ZM ATTCH FOR LG BNE PWR SYS BUSA BSPMAX II,SUP-2745861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
SPLINT WR L AD W3.5-4IN BGE LT FAB GEL CRPL TUNN REG INSRT,SUP-2324880,CDM,L3809,HCPCS,0274,RC,,,,both,,,48.54,31.55,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL L71CM FIX CRV C1 INSUL W/ RF ENERGY NRG,SUP-2131507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
CATHETER ATHRCTMY CROSSER L 146 CM DIA1.67 MM PERIPH,SUP-2126795,CDM,C1714,HCPCS,0272,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RADIA L 95 CM DIA 7 FR SPC 2 MM,SUP-2142363,CDM,C1731,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
KIT CATH FOR CARD MAP REF LOCATION,SUP-2141347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCREW INTRF KT PROC IFIX DISP,SUP-2402617,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
SCREW PEDCL SPNL CLOSE TI 6MMDIA 35MMLGTH 4.75MM THCK,SUP-2415696,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.07,1608.15,,,,,,,,,,,,,
PRECISION CONNECTOR M1 55 CM,SUP-2679262,CDM,C1883,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
VALVE DRAINAGE 0CM H2O SINGLE WITH 1200MM DISTAL CATHETER M,SUP-2821868,CDM,C1729,HCPCS,0272,RC,,,,both,,,13432.01,8730.81,,,,,,,,,,,,,
DRESSING BIO W4XL10IN THN CLLGN GLYCOSAMINOGLYCAN WND MTRX,SUP-2243651,CDM,Q4108,HCPCS,0636,RC,,,,both,,,27020.27,17563.18,,,,,,,,,,,,,
CAP END DIA15MM 10MM EXTN LT BLU TI FOR SPRL BLDE,SUP-2192141,CDM,C1713,HCPCS,0278,RC,,,,both,,,691.65,449.57,,,,,,,,,,,,,
PLATE BNE TIBIOTALAR STD RT LAT BABY GORILLA,SUP-2751228,CDM,C1713,HCPCS,0278,RC,,,,both,,,5172.37,3362.04,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT SHELL HD TRAB MEL CERM,SUP-2212735,CDM,C1776,CPT,0278,RC,,,,both,,,13773.61,8952.85,,,,,,,,,,,,,
NAIL IM L320MM DIA10MM FEM TIB KNEE G TI CANN LOK AG RG,SUP-2347084,CDM,C1713,HCPCS,0278,RC,,,,both,,,5083.60,3304.34,,,,,,,,,,,,,
BLADE ENDOSCP CRV HIP TEXT HNDL SHRP TIP W/ PAC CAP-FIX DISP,SUP-2849166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1675.19,1088.87,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.547,SUP-2860064,CDM,C1713,HCPCS,0278,RC,,,,both,,,58695.39,38152.00,,,,,,,,,,,,,
PLATE BONE W10.3XL85.6MM THK3.7MM 6 H TI LOK COMPR LO PROF,SUP-2413706,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
SCREW BNE L95MM DIA7.3MM CORT S STL ST CANN LOK FULL THRD,SUP-2184943,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.84,309.30,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 17 10MM CANC CHIP FRZN MORSELIZED,SUP-2307398,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.48,617.81,,,,,,,,,,,,,
KIT INSTR SZ 3-4 RAP TRANSLATION SYS,SUP-2242119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
I/B II PSCK TIB ART SURF 59/54X12MM,SUP-2502042,CDM,C1776,CPT,0278,RC,,,,both,,,6568.88,4269.77,,,,,,,,,,,,,
FIXED MODIFIED HALL REAMER 10.0MM,SUP-2823792,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX16 TTNM RCNSTRCTN F2.7MM LOK SCR,SUP-2721057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1552.42,1009.07,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM ADV 8 MM SCREW DIA2 MM 4 H MINI CHIN,SUP-2883232,CDM,C1713,HCPCS,0278,RC,,,,both,,,1359.37,883.59,,,,,,,,,,,,,
DEVICE ELECSURG TIPTOOL SONICFUSION 19101020,SUP-2499743,CDM,C1776,CPT,0278,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS 15 FRX64 CM UPPER ABD SET X-SERIES,SUP-2267007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
TRAY TIB SZ 1 NEUT MOD BAL REV SYS,SUP-2315544,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
BUR SURG DMND RND N FLUT COARSE 2.0MM ELITE TPS,SUP-2364025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,217.60,141.44,,,,,,,,,,,,,
SHELL ACET MOD 66 MM HIP REDAPT,SUP-2419731,CDM,C1776,CPT,0278,RC,,,,both,,,17395.60,11307.14,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI 400XL ACTE 14FR DIA 15CM INTRNL JUG PC,SUP-2610525,CDM,C1752,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
PLATE BONE W8XL64MM THK3.3MM 8 H STRL BILAT PELV S STL,SUP-2186235,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.60,770.64,,,,,,,,,,,,,
TROCAR ENDOSCP L 150 MM DIA 5 MM LNG OPT BLDELSS FIX CANN,SUP-2896306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,363.74,236.43,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 4-7 MM EPTFE STP STD WALL N,SUP-2127039,CDM,C1768,CPT,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
PLATE BONE UNIV RT MAXLOCK EXTRM,SUP-2400154,CDM,C1713,HCPCS,0278,RC,,,,both,,,4947.38,3215.80,,,,,,,,,,,,,
BIT DRL L145MM DIA3.2MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.32,273.21,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED GLEN TOT STBL PERFORM +,SUP-2388596,CDM,C1776,CPT,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
PLATE BONE THK0.6MM ORAL MAXILLOFACIAL N COMPR STR BILAT 20,SUP-2262703,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.43,275.23,,,,,,,,,,,,,
CONNECTOR SPNL EXT LAT TI ADJ FOR 6.35MM ROD,SUP-2415612,CDM,C1713,HCPCS,0278,RC,,,,both,,,1851.60,1203.54,,,,,,,,,,,,,
HC So Microbe Suscept,PX-3008718666,CDM,87186,CPT,0300,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
SET NEPHSTMY BAL L15CM DIA10MM SHTH 30FR L17CM NYL RADPQ,SUP-2171358,CDM,C1726,HCPCS,0272,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
STENT VASC L 38 MM DIA 5 MM ULTRA STRL,SUP-2101472,CDM,C1876,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
ANCHOR SUT W TWO NO 2 HI FI SUTS W NDL 17MM LEN 65MM,SUP-2167097,CDM,C1713,HCPCS,0278,RC,,,,both,,,1526.73,992.37,,,,,,,,,,,,,
COLLAR CERV AD PLAS FOAM EXTRIC ADJ SET TRACH OPN VELC,SUP-2115114,CDM,L0180,HCPCS,0274,RC,,,,both,,,33.35,21.68,,,,,,,,,,,,,
HC Ot Vasopneumatic Device Therapy|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309701600,CDM,97016,CPT,0430,RC,,,GP|CQ,both,,,206.00,133.90,,,,,,,,,,,,,
PLATE BNE STR 1 MM 4 HOLE CONTOURED SM GRID PLLA-PGA STRL LF,SUP-2479437,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.03,357.52,,,,,,,,,,,,,
STAPLE BNE FIX NO1 BRDG W20MM LEG L20X20MM WIRE DIA2X2MM OS,SUP-2194226,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
METOPROLOL TARTRATE 100 MG PO TABS,RX-5008,CDM,6370000000,HCPCS,0637,RC,65862-0064-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
WASHER ORTH OD12.7MM ID6.5MM S STL FOR 6.5MM CANN SCR,SUP-2342487,CDM,C1713,HCPCS,0278,RC,,,,both,,,2083.33,1354.16,,,,,,,,,,,,,
GRAFT DERM PLIABLE FLD HYDRATED THCK ACELLULAR DERM IMPL,SUP-2307559,CDM,Q4128,HCPCS,0636,RC,,,,both,,,6472.95,4207.42,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X22 MM,SUP-2458998,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.51,65.33,,,,,,,,,,,,,
HC X-Ray Exam Bil Hips 5/> Views,PX-3207352300,CDM,73523,CPT,0320,RC,,,,inpatient,,,128.00,83.20,,,,,,,,,,,,,
SCREW BNE LCK 4X55 MM 6 MM CORTICAL TI STRL,SUP-2243005,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 7 FRX15 CM 3L RIFAMPIN SPECTRUM,SUP-2759702,CDM,C1751,HCPCS,0278,RC,,,,both,,,544.01,353.61,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 80 CM DIA 0.018 IN NIT HYDRPHLC PERIPH,SUP-2610465,CDM,C1769,HCPCS,0272,RC,,,,both,,,124.97,81.23,,,,,,,,,,,,,
PLATE BNE MINI CRV BAR NS,SUP-2883294,CDM,C1713,HCPCS,0278,RC,,,,both,,,1725.34,1121.47,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX 6X15 CM PLASTIC MATRISTEM,SUP-2106491,CDM,Q4166,HCPCS,0636,RC,,,,both,,,5663.62,3681.35,,,,,,,,,,,,,
GUIDEWIRE VASC SAVION DLVR L 182 CM DIA 0.014 IN NIT POLYMER,SUP-2652811,CDM,C1769,HCPCS,0272,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG PO TABS,RX-18291,CDM,6370000000,HCPCS,0637,RC,42799-0920-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
FIXATION K WIRE SPI 3X285 MM WCH COATED,SUP-2701033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
BUR SURG DR LNG 4.7X20 MM FLUT FOR HD/HD-G1,SUP-2848175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.60,294.19,,,,,,,,,,,,,
COUNTERSINK SND PROC 4MM W DISP FOR PONTO SYS,SUP-2319886,CDM,C1713,HCPCS,0278,RC,,,,both,,,653.91,425.04,,,,,,,,,,,,,
PIN FIX BUTTRESS 1.8X18 MM TI NS,SUP-2189682,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.40,127.01,,,,,,,,,,,,,
STENT BILI FLEXXUS L 8 CM DIA10 MM CATH L 190 CM DIA 7.5 FR,SUP-2166292,CDM,C1876,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
STENT PERIPH L150MM DIAM 6MM CATH L120CM VASC,SUP-2396486,CDM,C1874,HCPCS,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
SPACER SPNL 37X16X8MM 6DEG LORDTC LO PROF PEEK CERV BCNVX,SUP-2354683,CDM,C1821,HCPCS,0278,RC,,,,both,,,22356.80,14531.92,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 3.5X140 MM 19/12 MM 9 HOLE LCP,SUP-2799200,CDM,C1713,HCPCS,0278,RC,,,,both,,,2752.74,1789.28,,,,,,,,,,,,,
JOINT FNGR 20 PROX INTERPHALANGEAL FOR PYROCARBON PIP,SUP-2852864,CDM,C1776,CPT,0278,RC,,,,both,,,8301.38,5395.90,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC DBM,SUP-2391506,CDM,C9359,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
VALVE AORT SZ 25 MM ANNULUS DIA21-23 MM AREA 338-415 SQ MM,SUP-2892457,CDM,C1889,HCPCS,0278,RC,,,,both,,,75360.00,48984.00,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS AXIOFILL 1000MG,SUP-2865150,CDM,C1762,CPT,0278,RC,,,,both,,,8192.26,5324.97,,,,,,,,,,,,,
ALLOGRAFT HUM TISS DISK 18 MM AMNION CHORION MEMBRN EPIFIX,SUP-2871320,CDM,Q4186,HCPCS,0636,RC,,,,both,,,2109.77,1371.35,,,,,,,,,,,,,
SCREW BNE L65MM DIA8MM THRD L22MM DIA12.7MM CANC CNDYL S,SUP-2186549,CDM,C1713,HCPCS,0278,RC,,,,both,,,939.77,610.85,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE LUMBAR LO FLO SHUNT W/O ANTECHAMBER,SUP-2666631,CDM,C1889,HCPCS,0278,RC,,,,both,,,9712.74,6313.28,,,,,,,,,,,,,
WIRE FIX L70MM OD8MM HDLSS SMOOTH TI K TH SERIES,SUP-2244121,CDM,C1713,HCPCS,0278,RC,,,,both,,,50.59,32.88,,,,,,,,,,,,,
STARTER PLUG/NUT FOR M8 MULTAXL SCR SPNL SYS CD HORZ,SUP-2290033,CDM,C1713,HCPCS,0278,RC,,,,both,,,2490.02,1618.51,,,,,,,,,,,,,
NUT SPINE DEV BRK OFF,SUP-2290608,CDM,C1713,HCPCS,0278,RC,,,,both,,,5363.12,3486.03,,,,,,,,,,,,,
DISTRACTOR SURG WOOD 15X10 MM RT MAND BIDIR TI ZURICH II,SUP-2470961,CDM,C1776,CPT,0278,RC,,,,both,,,12763.10,8296.01,,,,,,,,,,,,,
EVOS 3.5/4.5 PP DIS FEM PLATE L 14 HOLE 297MM,SUP-2931221,CDM,C1713,HCPCS,0278,RC,,,,both,,,19256.05,12516.43,,,,,,,,,,,,,
DOME TALAR SZ 1 CO CHROM MO RT ANK TOT ANAT STRL CADENCE,SUP-2931374,CDM,C1776,CPT,0278,RC,,,,both,,,23391.90,15204.73,,,,,,,,,,,,,
INTRODUCER TUBE SET PERC CIAGLIA BLU RHINO G2,SUP-2759773,CDM,C1769,HCPCS,0272,RC,,,,both,,,444.53,288.94,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE MED FD IRRADIATED TIB,SUP-2867176,CDM,C1762,CPT,0278,RC,,,,both,,,2818.94,1832.31,,,,,,,,,,,,,
CATHETER DIAG L135CM DST L10CM MIC NEURO RENEGADE HI FLO,SUP-2367867,CDM,C1887,HCPCS,0272,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
NEEDLE BRST LOC 20GAX5CM REPOSITIONAL MRK SYS BARB DISP HAWK,SUP-2120048,CDM,C1819,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
MESH SURG W6XL8IN OMEGA 3 FATTY ACIDS NAT BIORESORBABLE,SUP-2265966,CDM,C1781,HCPCS,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
PLEDGET CV SAUVAGE L 15.2 X W 15.2 CM THK 0.61 MM POLYESTER,SUP-2761342,CDM,C1768,CPT,0278,RC,,,,both,,,456.40,296.66,,,,,,,,,,,,,
HC Dx Breast Tomo Bil,PX-4017706200,CDM,G0279,HCPCS,0401,RC,,,,outpatient,,,99.00,64.35,,,,,,,,,,,,,
COLLAR CERV SFT DENS UNIV 24X4.5 IN HK LOOP CLOSURE,SUP-2336316,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.46,6.80,,,,,,,,,,,,,
RESERVOIR SHUNT OD14MM THK4.8MM SM TI BUR H RADPQ,SUP-2108709,CDM,C1729,HCPCS,0272,RC,,,,both,,,929.03,603.87,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7030,HCPCS,0250,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
HC Ult Guide Perc Drain Abscess,PX-4027598900,CDM,75989,CPT,0402,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
HC Nonselect Debride WO Anes,PX-3619760200,CDM,97602,CPT,0361,RC,,,,both,,,253.00,164.45,,,,,,,,,,,,,
GRAFT BNE 1X1MM 30ML CANC CUBE FRZ DRY,SUP-2264690,CDM,C1713,HCPCS,0278,RC,,,,both,,,1311.48,852.46,,,,,,,,,,,,,
PLATE VOLAR UNIV RADIUS STD XLONG,SUP-2695482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3394.97,2206.73,,,,,,,,,,,,,
PLATE BNE LCK 5X236 MM RT DSTL FEM 9 HOLE COMPR SS NS LCP,SUP-2184895,CDM,C1713,HCPCS,0278,RC,,,,both,,,4488.76,2917.69,,,,,,,,,,,,,
HEAD FEM SZ +3.5 NK L32MM CERAMIC ON MTL,SUP-2359354,CDM,C1776,CPT,0278,RC,,,,both,,,4433.68,2881.89,,,,,,,,,,,,,
VALVE AORT MECH ROT MSTR SER HRT VLV PTFE CUF 19MM,SUP-2355078,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
GRAFT VASC FLX 7 MMX70 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761481,CDM,C1768,CPT,0278,RC,,,,both,,,3416.92,2221.00,,,,,,,,,,,,,
PLATE BNE W13.5XL80MM THK4.2MM 4 H BILAT S STL NAR LOK,SUP-2185231,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.41,604.12,,,,,,,,,,,,,
PLATE BONE CONTOUR MESH 200X200X0.6 MM RIGID TITANIUM BLUE S,SUP-2837707,CDM,C1713,HCPCS,0278,RC,,,,both,,,26713.24,17363.61,,,,,,,,,,,,,
GENERATOR PULSE IMPLABLE RECHRG FLEX LD CONN TO THE IMPL,SUP-2141895,CDM,C1820,HCPCS,0278,RC,,,,both,,,43449.75,28242.34,,,,,,,,,,,,,
STEM FEM L170MM OD34MM ID9MM CALCAR HIP 1 PC H MLRY HD,SUP-2403604,CDM,C1776,CPT,0278,RC,,,,both,,,20334.64,13217.52,,,,,,,,,,,,,
GUIDEWIRE ORTH NO EYELET 2.4 MMX10 IN SMOOTH STRL DISP,SUP-2848551,CDM,C1769,HCPCS,0272,RC,,,,both,,,491.25,319.31,,,,,,,,,,,,,
SCREW BNE L 90 MM DIA2.4 MM SS LCK T8 STARDRV AQUA HD NS V,SUP-2905776,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.25,752.21,,,,,,,,,,,,,
SET CATH L3.8CM OD5.1MM ID3.5MM W/ INTRO NDL 6ML SYR NO15,SUP-2168128,CDM,C1769,HCPCS,0272,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
HC Debride Skin and Subcu|SEPARATE STRUCTURE,PX-4501104200,CDM,11042,CPT,0450,RC,,,XS,both,,,1247.00,810.55,,,,,,,,,,,,,
GRAFT BONE 7.5 DEG SUB RESRB WDG POLYGRFT CA SULF OSTEOCURE,SUP-2400548,CDM,C1776,CPT,0278,RC,,,,both,,,2001.75,1301.14,,,,,,,,,,,,,
PIN HOLDING HD SHT NXGN,SUP-2438146,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.59,41.33,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM DIA20 MM POLYESTER BOV CLLGN,SUP-2227695,CDM,C1768,CPT,0278,RC,,,,both,,,1446.03,939.92,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN RT DSTL TIB,SUP-2740914,CDM,C1762,CPT,0278,RC,,,,both,,,14029.05,9118.88,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00338-0017-31,NDC,,both,50,ML,21.70,14.10,,,,,,,,,,,,,
"HC Post.Drain/Percussion,Initial",PX-4109466700,CDM,94667,CPT,0410,RC,,,,outpatient,,,247.00,160.55,,,,,,,,,,,,,
KIT INTRO L 11 CM DIA 4 FR GUIDEWIRE L 45 CM DIA 0.025 IN SS,SUP-2876486,CDM,C1894,HCPCS,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
STAPLE BNE FIX 8X8MM STR ASSEMB,SUP-2321571,CDM,C1776,CPT,0278,RC,,,,both,,,4824.61,3136.00,,,,,,,,,,,,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,6370000000,HCPCS,0637,RC,00378-9122-16,NDC,,both,1,UN,57.10,37.11,,,,,,,,,,,,,
TRAY PICC MAXIMAL BARR 5FR 2 LUMN CATHETER W BIOPATCH PROTCT,SUP-2125698,CDM,C1751,HCPCS,0278,RC,,,,both,,,1015.66,660.18,,,,,,,,,,,,,
PLATE OLECRANON LCK 17 H LT,SUP-2107799,CDM,C1713,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
SYSTEM INJECT ISTENT TRABECULAR MICRO-BYPASS,SUP-2854046,CDM,C1783,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
HC T-Spine Routine W/ Swimmer 3 Views,PX-3207207200,CDM,72072,CPT,0320,RC,,,,both,,,596.00,387.40,,,,,,,,,,,,,
DRILL CANN 2.75MM,SUP-2321075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 5-8 MM SHRT TAPR SLDE GDS,SUP-2525447,CDM,C1768,CPT,0278,RC,,,,both,,,1124.94,731.21,,,,,,,,,,,,,
"HC Laryngoscopy,Indirect,Dx",PX-4503150500,CDM,31505,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
BIT DRL L110MM OD43MM W O STP N RADLUC CENTRONAIL,SUP-2316002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.81,331.38,,,,,,,,,,,,,
COMPONENT TIB SZ 2 RT MEDL LT LAT FIX BEAR CEM PRESERVATION,SUP-2251282,CDM,C1776,CPT,0278,RC,,,,both,,,5268.92,3424.80,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO FLO ACTE 11.5FR DIA 15CM STRGHT TA,SUP-2610535,CDM,C1752,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 6X20 MM ARROW STAINLESS STEEL JET,SUP-2836754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1766.56,1148.26,,,,,,,,,,,,,
HC Ultrasound Elastography Parenchyma,PX-4027698100,CDM,76981,CPT,0402,RC,,,,both,,,1276.00,829.40,,,,,,,,,,,,,
CLIP ANEUR W5XL6MM CO CHROM ALLY TEMP STD TYP STR SUGITA,SUP-2305976,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PIN BNE FIX MED SHOULDERED CADENCE,SUP-2933381,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.83,248.84,,,,,,,,,,,,,
LEAD PACE AD 8.6FR L65CM VENT SIL EPTFE DF1 CONN ACT FIX,SUP-2282248,CDM,C1777,HCPCS,0275,RC,,,,both,,,8769.83,5700.39,,,,,,,,,,,,,
MARKER BRST BX 7 CM NDL MAGSEED,SUP-2427296,CDM,A4648,CPT,0278,RC,,,,both,,,1786.97,1161.53,,,,,,,,,,,,,
TIP DRVR AO SHFT 1.5 MM SLD HEX NS ACU-LOC 2 LF DISP,SUP-2518463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
RIBAVIRIN 200 MG PO CAPS,RX-11286,CDM,6370000000,HCPCS,0637,RC,65862-0290-84,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
GRAFT BNE L16MM DIA8MM CANC PLUG W CART FRZN FLEXIGRFT,SUP-2264633,CDM,C1762,CPT,0278,RC,,,,both,,,1265.58,822.63,,,,,,,,,,,,,
TUBE SCTN 6FR DIA 8INL TRDRP TPRD STRGHT MAL,SUP-2484865,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.42,295.37,,,,,,,,,,,,,
SCREW BONE L80MM DIA6.5MM STD S STL CORT ST SELF DRL CANN,SUP-2343239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1501.58,976.03,,,,,,,,,,,,,
PLATE BONE SM LT CALCNL FX BTTRS SINUS TARSI APPRCH GORILLA,SUP-2321442,CDM,C1713,HCPCS,0278,RC,,,,both,,,4780.65,3107.42,,,,,,,,,,,,,
SPACER SPNL H7XL25MM PEEK MET FUS CRESC,SUP-2292797,CDM,C1713,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
TROCAR SURG DBL SL 5X150 MM ASMBLY,SUP-2517249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SCREW BNE CANN 4.5X44 MM SS,SUP-2183091,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.31,484.45,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 4X12 CMX1-2 MM PROLAYER,SUP-2717797,CDM,C1763,HCPCS,0278,RC,,,,both,,,15233.90,9902.03,,,,,,,,,,,,,
CATHETER PICC ARROWG+ARD BLUE ADVANCE 6FR 55CM 3-LUMEN,SUP-2887070,CDM,C1751,HCPCS,0278,RC,,,,both,,,730.58,474.88,,,,,,,,,,,,,
PLATE BONE L175MM 4 H STRL LT PROX FEM S STL LO PROF LCK,SUP-2186040,CDM,C1713,HCPCS,0278,RC,,,,both,,,4170.55,2710.86,,,,,,,,,,,,,
ADAPTER FEM L+0MM UPLR NEUT NK,SUP-2207892,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min|OP PT SERVICES,PX-4209711600,CDM,97116,CPT,0420,RC,,,GP,both,,,164.00,106.60,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 3.0 X 30MM H,SUP-2320887,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.93,512.80,,,,,,,,,,,,,
WASHER ORTH LCK RESRB HALF CLOVER CENTRALOC RESRB TIB FIX SZ,SUP-2212869,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PACEMAKER CRD 52X44X6 MM 11 CC 2 CHMBR GENRTR IDENTITY DR,SUP-2357344,CDM,C1785,HCPCS,0275,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
FIBER LASER 300 MH UNSHEATHED SCP SAFE SMA905 STRL DISP,SUP-2768241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2503.52,1627.29,,,,,,,,,,,,,
CLAMP EXT FIX SZ 11-5/6 MM COMB NS DISP MAV,SUP-2931171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3513.66,2283.88,,,,,,,,,,,,,
MESH GYN W3XL24CM POLYPR UNIDIR Y CNTOUR FOR TRANSABDOMINAL,SUP-2165313,CDM,C1781,HCPCS,0278,RC,,,,both,,,3719.33,2417.56,,,,,,,,,,,,,
APPLICATOR SURG FARRELL 5.5 IN 18 MM TRIANG END SS,SUP-2501259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,58.75,38.19,,,,,,,,,,,,,
PLATE DSTL RAD DRSL 2.4MM RAD CLMN 5H SHFT TI STRL VA LCP,SUP-2546760,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.97,1467.03,,,,,,,,,,,,,
DEVICE DRIVE ROTAWIRE EXTRA SUPPORT,SUP-2743276,CDM,C1769,HCPCS,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ LOOP LOK FIRM SUPP VYN STRP,SUP-2276619,CDM,L3908,HCPCS,0272,RC,,,,both,,,15.86,10.31,,,,,,,,,,,,,
BLADE SAW LAPIPLASTY 11X40MM,SUP-2389094,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
HC Assay of Iron,PX-3018354000,CDM,83540,CPT,0301,RC,,,,both,,,105.00,68.25,,,,,,,,,,,,,
HC So Complement C-3/C-4,PX-3028616066,CDM,86160,CPT,0302,RC,,,,both,,,148.00,96.20,,,,,,,,,,,,,
SCREW BNE L70MM DIA3.5MM STD CORT TI ST LOK LO PROF AXSOS 3,SUP-2704637,CDM,C1713,HCPCS,0278,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
PLATE BNE CONN 90 DEG 2 HOLE OFFSET NS,SUP-2799518,CDM,C1713,HCPCS,0278,RC,,,,both,,,306.34,199.12,,,,,,,,,,,,,
CATHETER THROMCTMY ZELANTEDVT CLOTHUNTER L 105 CM DIA 8 FR,SUP-2867276,CDM,C1757,HCPCS,0272,RC,,,,both,,,19562.20,12715.43,,,,,,,,,,,,,
PROBE ABLATION L130MM TIP DIA4MM 90DEG CERAMIC ASPIRATING MONOPOLAR LOW PROFILE OPES,SUP-2123441,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ENVELOPE PULSE GENRTR TYRX L 2.9 X W 3.3 IN LG NEURO,SUP-2281262,CDM,C1889,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
GRAFT HUM TISS 100MG AMNIO MEM UMB CRD PARTICULATE MTRX FOR,SUP-2116293,CDM,Q4155,HCPCS,0636,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CROWN DENT SZ DLR3 LO RT 1ST M S STL REFIL PRI,SUP-2322186,CDM,D6783,CPT,0278,RC,,,,both,,,28.13,18.28,,,,,,,,,,,,,
PLATE LOQTEQ VA VOLAR DISTAL RADIUS 2.5 BORAD 4 HL RT,SUP-2713862,CDM,C1713,HCPCS,0278,RC,,,,both,,,5290.27,3438.68,,,,,,,,,,,,,
TROCAR SURG L150MM DIA12MM DIL TIP STBL SL FOR WRK PRT,SUP-2218907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,770.37,500.74,,,,,,,,,,,,,
HC Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std,PX-9219398500,CDM,93985,CPT,0921,RC,,,,both,,,1222.00,794.30,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC CELLULAR BNE MTRX SYGNACEL CBM,SUP-2929817,CDM,C1713,HCPCS,0278,RC,,,,both,,,21571.80,14021.67,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-15882,CDM,J7042,HCPCS,0258,RC,00264-7610-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
ANCHOR SUT FOR PERCANNULA SYS,SUP-2256655,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
RX MESH 50 X 50 X 10MM LG GRID,SUP-2669320,CDM,C1713,HCPCS,0278,RC,,,,both,,,2841.32,1846.86,,,,,,,,,,,,,
SHEATH DIL SM 12FR L43CM OD0.215IN ID0.168IN STR TORQ DEL,SUP-2353109,CDM,C1894,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
GRAFT BNE 20 CC CRUSH FD CANC,SUP-2684089,CDM,C1713,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
STEM FEM SZ 0 L115MM DIA10MM NK L31MM 4MM OFFSET 132DEG HIP,SUP-2375322,CDM,C1776,CPT,0278,RC,,,,both,,,11581.80,7528.17,,,,,,,,,,,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,0636,RC,63323-0665-00,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
SET BILI DRNGE CATH 7FR 0.035IN 5 SIDE H NSL PGTL,SUP-2169092,CDM,C1729,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2 MM TI LCK VA BLU NS PRO-PAK TRILEAP,SUP-2905566,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.06,450.49,,,,,,,,,,,,,
PLATE BNE 3.5X131 MM 10 HOLE SS LCP,SUP-2569323,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.48,281.76,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IMPL DP,SUP-2666619,CDM,C1889,HCPCS,0278,RC,,,,both,,,2919.57,1897.72,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 152 MM 50 MM 9 HOLE SS NS,SUP-2905686,CDM,C1713,HCPCS,0278,RC,,,,both,,,1886.29,1226.09,,,,,,,,,,,,,
CENTESIS CATH 5F 12CM PGTL FIXED LUER 20GA INTRDCR NDLE 4 HO,SUP-2481965,CDM,C1729,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 33MMW X71MML 1.2MM THK 1.5MM THK CUT LG B,SUP-2605509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,75.33,48.96,,,,,,,,,,,,,
CUTTER SHAVER COUGAR END ARTHSCP 4MM DIA STD MENISCU ACL/PCL,SUP-2605865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,169.62,110.25,,,,,,,,,,,,,
"HC So1 Antibody Virus, Nos",PX-3028679067,CDM,86790,CPT,0302,RC,,,,outpatient,,,473.00,307.45,,,,,,,,,,,,,
ALLODERM SELECT 1X4 THIN 0.8-1.2,SUP-2822069,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.93 MM 2.8 MM REUT BOB W/ HOLE 520181,SUP-2535144,CDM,L8699,HCPCS,0278,RC,,,,both,,,35.11,22.82,,,,,,,,,,,,,
PLATE BNE L 40 MM RT TCP,SUP-2535869,CDM,C1713,HCPCS,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
BLADE RTRCTR BLFR 241MMD ARM STNLSS STEEL ADLT ABDMNL SELF R,SUP-2703309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
BIT DRL QC 2.8X200 MM W/ SCALE 3 FLUT NS,SUP-2863396,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.79,418.46,,,,,,,,,,,,,
HANDPIECE STEREOTACTIC 12GA L12CM BRST BX LNG GUID,SUP-2239996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.91,514.74,,,,,,,,,,,,,
COMPONENT GLEN SHLDR CAPPED REVERSED,SUP-2417151,CDM,C1776,CPT,0278,RC,,,,both,,,18400.40,11960.26,,,,,,,,,,,,,
BIT DRL L445MM DIA07MM STP 6MM L6MM ST MAXILLOFACIAL S,SUP-2187631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,506.14,328.99,,,,,,,,,,,,,
JEJUNOSTOMY SET JEJU 12 FR 0.035 INX200 CM PEG24,SUP-2738116,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
KIT PD 5.8FT-6.3FT M STRNL BRAC PT TLSO,SUP-2123924,CDM,L0462,HCPCS,0274,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GRAFT TISS FRZ DRY CORT BLK 9X11 X 11MM CRNRSTN SR,SUP-2293783,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
COMPONENT FEM SZ 2.5 AP59MM ML63MM R KNEE CO CHROM CRUCE,SUP-2253501,CDM,C1776,CPT,0278,RC,,,,both,,,13750.69,8937.95,,,,,,,,,,,,,
PLATE SPNL W16XL54MM STD DBL HALF H XLNK POST LUM S STL FIX,SUP-2255570,CDM,C1713,HCPCS,0278,RC,,,,both,,,4165.21,2707.39,,,,,,,,,,,,,
GRAFT WND BURN 10X15 CM EXTRACELLULAR MTRX MATRISTEM,SUP-2106464,CDM,Q4166,HCPCS,0636,RC,,,,both,,,6641.10,4316.71,,,,,,,,,,,,,
CUP 32MM ID/44MM OD MUELLER FULL PROF ALL POLY,SUP-2209462,CDM,C1776,CPT,0278,RC,,,,both,,,2265.82,1472.78,,,,,,,,,,,,,
N S BIPOLAR BAYONET FCPS 20MM TIP,SUP-2703458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1997.20,1298.18,,,,,,,,,,,,,
COMPONENT PATELLAR PS 38X10 MM KNEE RND PEG CEM,SUP-2359099,CDM,C1776,CPT,0278,RC,,,,both,,,6939.40,4510.61,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X1 MM 20 HOLE TI LEVEL 1 THREADLOCK TS,SUP-2474570,CDM,C1713,HCPCS,0278,RC,,,,both,,,2505.75,1628.74,,,,,,,,,,,,,
BIT DRL CANN 3 MM RESRB,SUP-2608845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
RETRACTOR CEM 24MM FOR SHLDR SYS AEQUALIS REVERSED II,SUP-2388809,CDM,C1776,CPT,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
GRAFT VASC GELSFT L 45 CM DIA12 MM BRANCH DIA 6 MM POLYESTER,SUP-2384919,CDM,C1768,CPT,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
SUPPORT OBESITY BARIATRIC L FOR 65-75IN HIP W/ LUM SHLDR,SUP-2324542,CDM,L0642,HCPCS,0274,RC,,,,both,,,215.94,140.36,,,,,,,,,,,,,
MESH SURG 120X120X1 MM 3D TI STRL LEVEL 1 NEURO,SUP-2482027,CDM,C1713,HCPCS,0278,RC,,,,both,,,8660.91,5629.59,,,,,,,,,,,,,
SLEEVE LIG SZ 1.8 MM STRL,SUP-2616249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46.32,30.11,,,,,,,,,,,,,
HC Thyroid Stimulating Hormone|NOT REASONABLE AND NECESSARY,PX-3018444300,CDM,84443,CPT,0301,RC,,,GZ,both,,,293.00,190.45,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 2 G SOLR (MIXTURES ONLY),RX-430030,CDM,J0696,HCPCS,0636,RC,00409-7336-04,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
GRAFT BNE W8XL110MM FIB FRZN STRUT,SUP-2307389,CDM,C1762,CPT,0278,RC,,,,both,,,3376.07,2194.45,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X3.75 MM RICHARD PLAT FLROPLAS,SUP-2637849,CDM,L8613,CPT,0278,RC,,,,both,,,546.01,354.91,,,,,,,,,,,,,
INSERT TIB CR 1 STD 10 MM HI FLX POLYETH PROVEN GEN-FLEX,SUP-2390381,CDM,C1776,CPT,0278,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC SYR DBM ACCELL EVO3,SUP-2641762,CDM,C1713,HCPCS,0278,RC,,,,both,,,5722.65,3719.72,,,,,,,,,,,,,
ASSEMBLY BLADE ENDOSCP CRPL TUNN RELEASE STRL LTX DISP,SUP-2877768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE BNE L157MM 8 H S STL LOK COMPR FOR 4.5MM SCR PERI-LOC,SUP-2348942,CDM,C1713,HCPCS,0278,RC,,,,both,,,4888.51,3177.53,,,,,,,,,,,,,
SCREW INTFR L25MM DIA9MM OPN ARCHITECTURE DSGN BIOSURE,SUP-2341922,CDM,C1713,HCPCS,0278,RC,,,,both,,,1171.88,761.72,,,,,,,,,,,,,
PLEDGET SUT SFT OVL 3 8X5 16IN,SUP-2384386,CDM,C1768,CPT,0278,RC,,,,both,,,76.68,49.84,,,,,,,,,,,,,
CATHETER THOR 32FR L23IN PVC 6 EYELET STR ATRAUM,SUP-2227433,CDM,C1729,HCPCS,0272,RC,,,,both,,,20.79,13.51,,,,,,,,,,,,,
PPICC PROV SOLO PED 4F DL MAXDELTA,SUP-2613528,CDM,C1751,HCPCS,0278,RC,,,,both,,,1078.59,701.08,,,,,,,,,,,,,
SHOE ORTHOT ADDITION CONVERT FIRM SFT COUNT,SUP-2435743,CDM,L3590,HCPCS,0272,RC,,,,both,,,151.25,98.31,,,,,,,,,,,,,
HC So Elastase Pancreatic Fecal Qt,PX-3018265366,CDM,82653,CPT,0300,RC,,,,both,,,1605.00,1043.25,,,,,,,,,,,,,
PATCH DURA W4XL4CM ELASTOMERIC INNR LAYR PRECL MVP,SUP-2395358,CDM,C1763,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 12.5CML I,SUP-2613234,CDM,C1752,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
ALLOGRAFT BNE ULN SHFT 51-100 MM FRZN,SUP-2717872,CDM,C1762,CPT,0278,RC,,,,both,,,2984.04,1939.63,,,,,,,,,,,,,
BEAM FIX L75MM DIA5.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223938,CDM,C1776,CPT,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
SCREW SPNL L6MM DIA4MM CORT POST OCCIPITAL THRD VERTEX MAX,SUP-2286764,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.11,618.22,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EZ STEER WEBST CS L 115 CM DIA 5,SUP-2458534,CDM,C1730,HCPCS,0272,RC,,,,both,,,792.91,515.39,,,,,,,,,,,,,
PLATE BNE SM 10 DEG 2.4/2.7X42 MM RT 1ST MTP FUSION VA-LCP,SUP-2432252,CDM,C1713,HCPCS,0278,RC,,,,both,,,3856.36,2506.63,,,,,,,,,,,,,
METRONIDAZOLE 0.75 % EX GEL,RX-19741,CDM,6370000000,HCPCS,0637,RC,00713-0637-37,NDC,,both,45,GR,441.10,286.71,,,,,,,,,,,,,
BUR SURG DIA22 MM HUB I DIAMOND CUT DISK STRL DISP HI-LINE,SUP-2929561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.65,636.77,,,,,,,,,,,,,
REAMER SURGICAL DIA2.7MM CANNULATED,SUP-2123474,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X20 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851924,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.85,422.40,,,,,,,,,,,,,
SEED BRACHYTHERAPY PROST PALLADIUM-103 VI CALIB SGL,SUP-2129126,CDM,C2640,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
BEARING TIB 51MM AXLE PED MRS,SUP-2376473,CDM,C1776,CPT,0278,RC,,,,both,,,7097.50,4613.37,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 7 MM STR STD WALL REINF,SUP-2681082,CDM,C1768,CPT,0278,RC,,,,both,,,408.39,265.45,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.018 IN TAPR L 5 CM FLX TIP 2 CM,SUP-2167573,CDM,C1769,HCPCS,0272,RC,,,,both,,,23.24,15.11,,,,,,,,,,,,,
PLATE EXT FIX DIA140MM ANK FT FOR TRUELOK FRME ASSEMB,SUP-2316188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.24,976.46,,,,,,,,,,,,,
SCREW FIX L190MM DIA6MM S STL SPADE PNT MR CONDITIONAL FOR,SUP-2186962,CDM,C1713,HCPCS,0278,RC,,,,both,,,242.31,157.50,,,,,,,,,,,,,
INTRODUCER NEUROSTIMULATOR REACTIV8 PERC STRL,SUP-2877972,CDM,C1730,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
HC Wound Debridement Tis 20 Cm/<|UNUSUAL NON-OVERLAPPING SERVICE,PX-4509759700,CDM,97597,CPT,0450,RC,,,XU,both,,,413.00,268.45,,,,,,,,,,,,,
COMPONENT TIB TY REV 5 KNEE OFFSET BKRS,SUP-2434219,CDM,C1776,CPT,0278,RC,,,,both,,,5809.31,3776.05,,,,,,,,,,,,,
VEST PT HOLSTER SM 14 IN VENTRICULAR THORATEC HEARTMATE,SUP-2356007,CDM,Q0499,HCPCS,0274,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
STEM FEM DIA13.5MM LT HIP SM STAT LNG REPLICA,SUP-2251975,CDM,C1776,CPT,0278,RC,,,,both,,,17489.80,11368.37,,,,,,,,,,,,,
INOTUZUMAB OZOGAMICIN 0.9 MG IV SOLR,RX-139756,CDM,J9229,HCPCS,0636,RC,00008-0100-01,NDC,,both,1,UN,68878.00,44770.70,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 180 CM DIA 0.014 IN TIP,SUP-2385539,CDM,C1769,HCPCS,0272,RC,,,,both,,,907.77,590.05,,,,,,,,,,,,,
COIL EMB L26CM OD6MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305178,CDM,C1889,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PIN FIX L18MM DIA1.8MM TI BTTRS FOR MOD HND SYS,SUP-2189683,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.40,127.01,,,,,,,,,,,,,
PLATE BNE L 424 MM SCREW DIA 3.5/4.5 MM 21 H SS RT DSTL FEM 72585221N,SUP-2932884,CDM,C1713,HCPCS,0278,RC,,,,both,,,22442.37,14587.54,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR CUST VEST TYP ABDUCTN RESTRAINER,SUP-2435755,CDM,L3675,HCPCS,0272,RC,,,,both,,,452.25,293.96,,,,,,,,,,,,,
SCREW IM L 32 MM DIA 3.5 MM TI CORTICAL T15 DRVR GLD STRL,SUP-2900381,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
GRAFT HUM TISS 1000MG PLCNTA TISS AMNIOFILL,SUP-2305715,CDM,C1762,CPT,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
COUNTERSINK SURG DIA5.5MM HDLSS DISP MONSTER,SUP-2320974,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
SYSTEM LOADING VALVE EVOLUT 26/29MM,SUP-2501425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
PLATE BONE LOK CMPRSSN 114MML HLX6 TIMAX CRTCL NRRW PRE CNTR,SUP-2494121,CDM,C1713,HCPCS,0278,RC,,,,both,,,4370.72,2840.97,,,,,,,,,,,,,
DRILL ENDOSCP FLX 10 MM CLANCY,SUP-2849120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3497.80,2273.57,,,,,,,,,,,,,
JOINT TOE 0 DEG 3.1X15 MM PRO-TOE X-FLEX,SUP-2468529,CDM,C1776,CPT,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
CABLE SPNL FLANGE W/ CRMP TI SONGER,SUP-2713124,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
BALL CARPAL LG NEUT,SUP-2471154,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CEMENT BONE FAST SETTING 3 CC DRILLABLE CALCIUM PHOSPHATE BO,SUP-2836349,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 85 CM OD 10 FR ID 3.3 MM GUIDEWIRE,SUP-2168404,CDM,C1894,HCPCS,0272,RC,,,,both,,,264.98,172.24,,,,,,,,,,,,,
DRIVER SURG BALL TIP LOK SPNL ATLNTS NONSTERILE REUSE,SUP-2279321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.98,303.54,,,,,,,,,,,,,
RING SPNL STD 6 LOBE SCREW,SUP-2602104,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,0636,RC,00409-5082-16,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
STIRRUP POS H10IN STD UNIV ANK AIR BLDR RIG MED LAT SHELLS,SUP-2195184,CDM,L4350,HCPCS,0274,RC,,,,both,,,41.86,27.21,,,,,,,,,,,,,
PLATE BNE L145MM 8 H NONSTERILE L PROX TIB S STL,SUP-2185701,CDM,C1713,HCPCS,0278,RC,,,,both,,,3734.09,2427.16,,,,,,,,,,,,,
PLATE BONE L132MM 10 H LT OLECRANON S STL LCK FOR 2.7/3.5MM,SUP-2348708,CDM,C1713,HCPCS,0278,RC,,,,both,,,13584.27,8829.78,,,,,,,,,,,,,
CUTTER SPNL OD9MM D12.8CM-11MM PWR BURR MIDAS CLASS AM,SUP-2290933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.50,229.12,,,,,,,,,,,,,
BIO MEDICUS 17FR,SUP-2726347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.58,665.33,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.109X9 IN RND END SS NS STEINMANN,SUP-2791829,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.77,10.90,,,,,,,,,,,,,
BIT DRL 3.5MM TWST INSTR GIC94,SUP-2415758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
ENDCAP ORTH DIA11MM 5MM EXTN GRN TI FOR TROCHANTERIC FIX,SUP-2191917,CDM,C1713,HCPCS,0278,RC,,,,both,,,539.58,350.73,,,,,,,,,,,,,
NAIL IM L380MM DIA11MM UNIV FEM GRN TI AG RG CANN LOK SLOT,SUP-2192619,CDM,C1713,HCPCS,0278,RC,,,,both,,,5278.97,3431.33,,,,,,,,,,,,,
CANNULA SUCTION BPLR 5 MMX25 CM COAG TUBE DSTL ANGLED SHTH,SUP-2775798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3077.77,2000.55,,,,,,,,,,,,,
IMPLANT LOOP KNOTILLUS 25MM,SUP-2366686,CDM,C1713,HCPCS,0278,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
CATHETER DRNGE 12FR L35CM FLEXIMA LOOP REG DUROMETER TRCR,SUP-2147864,CDM,C1729,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
BIT DRL L180MM DIA4.3MM QUIK CPL W/O STP REUSE,SUP-2187279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
IMPLANT OP RM TISS 10 X 5MM CALCANEO CUBOID JT WDG,SUP-2321656,CDM,C1776,CPT,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
GRAFT HUM TISS 2X2 CM AMNIO MEMBRN MTRX,SUP-2225380,CDM,2780000010,LOCAL,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
PLATE BNE 1.5/2X49X1.5 MM 8 HOLE SS LC-DCP,SUP-2569198,CDM,C1713,HCPCS,0278,RC,,,,both,,,283.23,184.10,,,,,,,,,,,,,
DEVICE VENTRICULAR ASST LT KT SHWR BG HEARTMATE II,SUP-2356004,CDM,Q0501,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PAIN PUMP KIT 10 IN 400 CC SILVERSOAKER CATH ON-Q PAINBUSTER,SUP-2236850,CDM,C2626,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X6 MM SCHKNT MALL ATTCH SS FLROPLAS,SUP-2637750,CDM,L8613,CPT,0278,RC,,,,both,,,351.30,228.34,,,,,,,,,,,,,
PLATE BNE STR 9 HOLE LCK PRECONTOURED DYN COMPR TOT WRST NS,SUP-2851920,CDM,C1713,HCPCS,0278,RC,,,,both,,,3772.33,2452.01,,,,,,,,,,,,,
DEVICE PESSARY SZ 2 RNG W KNOB AND SUPP,SUP-2305664,CDM,A4562,HCPCS,0272,RC,,,,both,,,200.05,130.03,,,,,,,,,,,,,
PLATE BNE L 400 MM SCREW DIA 3.5/4.5 MM 20 H SS RT PROX FEM 72582220,SUP-2933062,CDM,C1713,HCPCS,0278,RC,,,,both,,,20853.53,13554.79,,,,,,,,,,,,,
SET TRACH PERC,SUP-2168327,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.078X9 IN THRD RND END NS STEINMANN,SUP-2791380,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.07,43.60,,,,,,,,,,,,,
WAND ABLAT FOR TNSLCTMY ADENOIDECTOMY PROCISE EZ,SUP-2342047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1058.97,688.33,,,,,,,,,,,,,
WASHER SPNL LAT OCCIPITOCERVICOTHORACIC TI ALLY MOUNTAINEER,SUP-2255364,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER ABLAT 8FR L115CM TIP ELECTRD L4MM D-F CRV 1-4-1,SUP-2357505,CDM,C2630,CPT,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CODMAN SCOTT VENT CANN DISP 8FR. 1.3MM I DX2.5MM O DX80MM,SUP-2243025,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.27,169.18,,,,,,,,,,,,,
THREADED GUIDE WIRE 32MM X 230MM,SUP-2705142,CDM,C1769,HCPCS,0272,RC,,,,both,,,503.34,327.17,,,,,,,,,,,,,
HC X-Ray Knee Standing Ap,PX-3207356500,CDM,73565,CPT,0320,RC,,,,inpatient,,,599.00,389.35,,,,,,,,,,,,,
PLATE BNE THK15MM 4X4 H MAND ANG LOK,SUP-2262970,CDM,C1713,HCPCS,0278,RC,,,,both,,,2614.08,1699.15,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 5.5 FR BALLOON DIA,SUP-2214021,CDM,C1757,HCPCS,0272,RC,,,,both,,,332.21,215.94,,,,,,,,,,,,,
LEVEL NEURO ST MESH 3D NEURO SCRW80 X 80 MM T06 MM CP TTNM,SUP-2681436,CDM,C1713,HCPCS,0278,RC,,,,both,,,5536.29,3598.59,,,,,,,,,,,,,
IMPLANT HUM TISS LT PROX ULN OSTEOARTICULAR CUST MATCHED,SUP-2932973,CDM,C1762,CPT,0278,RC,,,,both,,,10342.06,6722.34,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X136 MM LT PL 10 HOLE BUTTRESS SS,SUP-2462496,CDM,C1713,HCPCS,0278,RC,,,,both,,,1530.88,995.07,,,,,,,,,,,,,
GRAFT BNE 2-10 MM CRUSH FD CANC,SUP-2684149,CDM,C1713,HCPCS,0278,RC,,,,both,,,8054.10,5235.16,,,,,,,,,,,,,
SPLINT HND M ULN DEVIATION RT NEOPRNE WRP ARND W/ THMB H ADJ,SUP-2324909,CDM,L3906,HCPCS,0272,RC,,,,both,,,28.01,18.21,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED PART,SUP-2365902,CDM,C1876,HCPCS,0278,RC,,,,both,,,11397.57,7408.42,,,,,,,,,,,,,
RXG FOIL 512X512 T10MM,SUP-2669332,CDM,C1713,HCPCS,0278,RC,,,,both,,,2959.83,1923.89,,,,,,,,,,,,,
IMPLANT ZIM UNI TIB SZ 3 LFT MED/RT LAT,SUP-2340774,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SHOE ORTHOT ADDITION INSOLE LTHR,SUP-2435737,CDM,L3500,HCPCS,0272,RC,,,,both,,,82.77,53.80,,,,,,,,,,,,,
FIBER LASER DIA1000UM HOLM 2 WVLNGTH DEL SYS REUSE SLM LN,SUP-2139443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2900.67,1885.44,,,,,,,,,,,,,
BIT DRILL 2.9 MM INLINE SPADE W/ DEPTH STP FOR 2.7 MM,SUP-2849140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP WRK L4500MM COAT L70MM DIA0025IN FLUORINE,SUP-2313170,CDM,C1769,HCPCS,0272,RC,,,,both,,,537.03,349.07,,,,,,,,,,,,,
ANCHOR SUTURE WITH THREE NO 2 HI FI SUTURES 17MM LENGTH 4.5M,SUP-2825103,CDM,C1713,HCPCS,0278,RC,,,,both,,,1528.55,993.56,,,,,,,,,,,,,
HC So Ethylene Glycol,PX-3018269366,CDM,82693,CPT,0301,RC,,,,both,,,106.00,68.90,,,,,,,,,,,,,
HEAD FEM ADV MTL W/BFH TECHNOLOGY 52MM LNG A CLASS,SUP-2304512,CDM,C1776,CPT,0278,RC,,,,both,,,9694.75,6301.59,,,,,,,,,,,,,
PLATE CRAN W38XL45MM TI RECTANG MALL CNTOUR MESH FOR 1.3MM,SUP-2190619,CDM,C1713,HCPCS,0278,RC,,,,both,,,4598.84,2989.25,,,,,,,,,,,,,
PLATE BONE L25MM 4 H MAND ORAL MAXILLOFACIAL TI STR TENS BND,SUP-2191344,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.12,1054.38,,,,,,,,,,,,,
PLATE BNE L8MM N COMPR CHIN BILAT 4 H RIG FOR 2MM SCR H DIA,SUP-2421257,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.77,542.60,,,,,,,,,,,,,
GRAFT VASC DIA22MM GREATER AORT HRT VLV CARDIOGRFT,SUP-2264800,CDM,C1762,CPT,0278,RC,,,,both,,,43374.01,28193.11,,,,,,,,,,,,,
SNARE RETRV L286CM WRK CHN 1.2MM CBL DIA1MM DIR VIS DISP,SUP-2418488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1641.53,1066.99,,,,,,,,,,,,,
PIN SURG DRL TRNSVRS XLN 64 MM COMPRESS,SUP-2441834,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
CATHETER GUID MP1 8 FR CORONARY LAUNCHER,SUP-2281133,CDM,C1887,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
BLADE RETRACTOR SHT TEETH 65X15X MM SPNL SELF RET BLK,SUP-2457184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,773.95,503.07,,,,,,,,,,,,,
GRAFT BNE CRUSH 1-10 MM 30 CC CANC,SUP-2766762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
PLATE BNE TIB 166 MM LAT 7 HOLE BUTTRESS HD TI NS LC-DCP,SUP-2569060,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.47,1581.76,,,,,,,,,,,,,
KIT HEMDIALYSIS L24CM BASIC ACUTE CATH 0.035INX70CM J/FLEX,SUP-2118060,CDM,C1752,HCPCS,0278,RC,,,,both,,,438.22,284.84,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WOVEN L 105 CM DIA 7 FR SPC,SUP-2142016,CDM,C1730,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SET INTRO VSI L 10 CM DIA 4 FR NIT MANDREL TIP SMTH STIFF,SUP-2120520,CDM,C1894,HCPCS,0272,RC,,,,both,,,171.13,111.23,,,,,,,,,,,,,
CATHETER GUID MOD CBL PERIPH VASC COR W/O HYDRPHLC COAT AD,SUP-2157939,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.64,112.87,,,,,,,,,,,,,
PLATE BNE L109MM THK3MM 7 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185336,CDM,C1713,HCPCS,0278,RC,,,,both,,,1659.58,1078.73,,,,,,,,,,,,,
MESH HERN W10XL15CM POLY POLYLACTIC ACID 70% CLLGN 30% GLYC,SUP-2174683,CDM,C1781,HCPCS,0278,RC,,,,both,,,1113.32,723.66,,,,,,,,,,,,,
GRAFT HUM TISS L 120 MM FIB SHFT LYOPH,SUP-2913297,CDM,C1762,CPT,0278,RC,,,,both,,,4226.44,2747.19,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 109 MM DIA 30 MM SHTH 16 FR,SUP-2170230,CDM,C1874,HCPCS,0278,RC,,,,both,,,53182.18,34568.42,,,,,,,,,,,,,
STRAP CLAV SM BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194669,CDM,L3670,HCPCS,0274,RC,,,,both,,,14.82,9.63,,,,,,,,,,,,,
CATHETER EP XL 2-5-2 MM 6 FRX115 CM LIVEWIRE,SUP-2355234,CDM,C1730,HCPCS,0272,RC,,,,both,,,1778.90,1156.28,,,,,,,,,,,,,
SCREW BN WSHR CAP 0 MM F/THR STRL,SUP-2639515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
PARTICLE EMB BEAR NSPVA DIA 500-710 UM 100 MG PVA HYDRPHLC,SUP-2677312,CDM,C1889,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
STEM FEM SZ 3 STD SHT NK HIP HA QUADRA H,SUP-2267226,CDM,C1776,CPT,0278,RC,,,,both,,,9325.80,6061.77,,,,,,,,,,,,,
MROM ARCOMXL ALLPOLY 32IDX48OD,SUP-2510896,CDM,C1776,CPT,0278,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
BUR SURG L750MM DIA4MM LNG BALL FLUT MIDAS REX LEGEND,SUP-2279700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.53,246.04,,,,,,,,,,,,,
HEAD FEM BPLR 62 HIP UHMWP,SUP-2216840,CDM,C1776,CPT,0278,RC,,,,both,,,3102.32,2016.51,,,,,,,,,,,,,
IMMOBILIZER KIT ABDUCTN UNIV SHLDR NYL PROCARE 45-70DEG,SUP-2196974,CDM,L3660,HCPCS,0274,RC,,,,both,,,78.88,51.27,,,,,,,,,,,,,
PROBE SURG TARGETING 3.5 MM DEPTH MARKING,SUP-2535358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
WAND ARTHSCP DIA3.75MM TIP DIA5.25MM 90DEG W/ INTEGR FNGR,SUP-2342010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC Strapping of Hip,PX-4502952000,CDM,29520,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
STENT BILI PGTL 2.3 MM AD 7 FRX50 MM ETHYLENE VLY ACETT,SUP-2421727,CDM,C1876,HCPCS,0278,RC,,,,both,,,182.40,118.56,,,,,,,,,,,,,
HC Clsd Tx Hum Shaft Fx Manip,PX-4502450500,CDM,24505,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
LEAD NERVE STIM 70 CM 16 CONTACT KT ARTISAN,SUP-2138833,CDM,C1778,HCPCS,0278,RC,,,,both,,,11671.38,7586.40,,,,,,,,,,,,,
PLATE BNE MESHED 0.6 MM 3X20 HOLE SPECIALITY PLLA-PGA STRL,SUP-2472274,CDM,C1713,HCPCS,0278,RC,,,,both,,,3169.52,2060.19,,,,,,,,,,,,,
TOTAL ELBW,SUP-2212312,CDM,C1776,CPT,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
SET IMPL GRPHC CA INSTR W/ DRL BIT COUNTSINK SCR HNDL SL,SUP-2183070,CDM,C1713,HCPCS,0278,RC,,,,both,,,113747.44,73935.84,,,,,,,,,,,,,
VALVE AORT KONECT RESILIA TISS ANNULUS 19 MM SEW RNG DIA 31,SUP-2624859,CDM,C1889,HCPCS,0278,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
STAPLE SPNL OVL VERT HOLEX1 W/ ROD TI XIA II,SUP-2379332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.035IN 6MM SFT FIX COR FLX J TIP,SUP-2355725,CDM,C1769,HCPCS,0272,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
SLING UROLOGICAL MID-URETHRAL SUPRAPUBIC 2 DEL LYNX ULTRA,SUP-2876041,CDM,C1771,HCPCS,0278,RC,,,,both,,,5251.96,3413.77,,,,,,,,,,,,,
ADENOSINE 12 MG/4ML IV SOLN,RX-39477,CDM,J0153,HCPCS,0636,RC,63323-0651-04,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
KIT CATH HEMODIALYSI SPLIT CATH III CHRONIC 14FR DIA 40CM 35,SUP-2610494,CDM,C1750,HCPCS,0278,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
SCREW SPNL SHANK 5.5X30 MM POST LUMBAR INTBDY FUSION SYS MAS,SUP-2311080,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
HC Repair of Wound or Lesion,PX-4501315200,CDM,13152,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
STENT URET 14/7FR L26CM PERCFLX HYDR+ TAPR TIP SMOOTH,SUP-2139061,CDM,C2617,HCPCS,0278,RC,,,,both,,,641.69,417.10,,,,,,,,,,,,,
BOLT BNE FIX L85MM DIA5MM PROX L10MM DST L22MM MIDFOOT FUS,SUP-2400719,CDM,C1713,HCPCS,0278,RC,,,,both,,,4826.18,3137.02,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 35X60 MM PRESERVON TRICORT MATRIGRAFT,SUP-2740792,CDM,C1713,HCPCS,0278,RC,,,,both,,,7687.32,4996.76,,,,,,,,,,,,,
NAIL INTRMDLLRY CNNLTD 35MM DIA 150MML FBLR SST ST,SUP-2721290,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
SIZER SURG DIA9.5MM MALL,SUP-2165380,CDM,C1813,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SUPPORT ORTHOT FNGR W/NONTORSION JT FABRICATED SFT INTFACE,SUP-2435790,CDM,L3935,HCPCS,0274,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
CATH REPROC EP SUPREME FIX JSN 4POL 5MM 6FR,SUP-2526066,CDM,C1730,HCPCS,0272,RC,,,,both,,,120.64,78.42,,,,,,,,,,,,,
PLATE BNE L W10.1XL182MM THK3.5MM 13 H BILAT S STL STR RIG,SUP-2186221,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.86,1184.21,,,,,,,,,,,,,
CATHETER HD DL 11.5 FRX15 CM RAULERSON INT JUG DUOFLO,SUP-2269577,CDM,C1751,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
STEM FEM DSTL MOD W/ SLOT POR RL HARDENED OD17MM L 250MM,SUP-2404200,CDM,C1776,CPT,0278,RC,,,,both,,,10107.66,6569.98,,,,,,,,,,,,,
DEVICE OCCL CLP L35MM 60DEG HD ARTC DEPLOYMENT LAA EXCLUSION,SUP-2124467,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
HEAD HUM H18XL35MM DIA48MM STD SHLDR TI HA STEM PRESSFIT,SUP-2399859,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER CV 5 FRX55 CM ENDEXO NURSING KT 2 NIT WIRE BIOFLO,SUP-2734872,CDM,C1751,HCPCS,0278,RC,,,,both,,,135.65,88.17,,,,,,,,,,,,,
PASSER SUT 70DEG UP RETRV SGL PORTAL CAP RESTR SLINGSHOT,SUP-2366749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1153.86,750.01,,,,,,,,,,,,,
COMPONENT TALAR SZ 1 RT CO CHROM CEM USE SALTO TALARIS,SUP-2417001,CDM,C1776,CPT,0278,RC,,,,both,,,16605.89,10793.83,,,,,,,,,,,,,
MICROSTENT LACR HYDRUS L 8 MM NIT GLAUCOMA NONBIOABSORBABLE,SUP-2714092,CDM,C1783,HCPCS,0278,RC,,,,both,,,5264.15,3421.70,,,,,,,,,,,,,
SPACER HIP 275MM LNG 54MM DIA 2.1GA XL ANTIBIO,SUP-2223684,CDM,C1776,CPT,0278,RC,,,,both,,,9388.60,6102.59,,,,,,,,,,,,,
SUTURE MAGNUMWIRE L48IN NONABSORBABLE COBRAID BLU OM9043,SUP-2342106,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.85,42.80,,,,,,,,,,,,,
TRANEXAMIC ACID 650 MG PO TABS,RX-103146,CDM,6370000000,HCPCS,0637,RC,60687-0750-11,NDC,,both,1,UN,19.40,12.61,,,,,,,,,,,,,
SHEATH URET 14FR L55CM HYDRPHLC RADPQ 2 LUERLOCK STP COCK,SUP-2169835,CDM,C1894,HCPCS,0272,RC,,,,both,,,644.01,418.61,,,,,,,,,,,,,
PRESSURIZER BONE CEM ACET 1 EA,SUP-2408532,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
CROWN DENT 1 S STL SEC PRI M UP RT ANTR CUSPID PREFABRICATED,SUP-2238932,CDM,D6783,CPT,0278,RC,,,,both,,,27.04,17.58,,,,,,,,,,,,,
FIBRIN KIT SYS,SUP-2130788,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
EXTENSION STEM L100MM OD13MM FEM HIP CEMENTLESS CNL FILL,SUP-2304761,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ANCHOR SUT L14MM OD3MM TWO 2-0 TIGERTAIL IMP BIO-SUTTAK,SUP-2121593,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
GRAFT VASC W5XL75CM THK05MM CV PTCH GOR TX,SUP-2395326,CDM,C1768,CPT,0278,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
GRAFT BNE MORSL LG 11 CC FIBERGRAFT BG,SUP-2736516,CDM,C1713,HCPCS,0278,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
DISSECTOR ARTHSCP LUMITIP 27 CM,SUP-2691376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
ACL REPAIR TIGHTROPE WITH INTERNALBRACE,SUP-2816616,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
GABAPENTIN 100 MG PO CAPS,RX-18309,CDM,6370000000,HCPCS,0637,RC,60687-0580-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK18 39MM DERM ULT THCK ACELLULAR,SUP-2307492,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5975.89,3884.33,,,,,,,,,,,,,
PLATE BONE FUSION 3.5X79 MM RIGHT ANKLE HINDFOOT 3 HOLE UTIL,SUP-2837550,CDM,C1713,HCPCS,0278,RC,,,,both,,,7340.38,4771.25,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 60 MM ANTR LUMBAR TI CITADEL,SUP-2584592,CDM,C1713,HCPCS,0278,RC,,,,both,,,10405.96,6763.87,,,,,,,,,,,,,
SPLINT FNGR OVL-8 RNG SZ 4 5PK,SUP-2112610,CDM,L3927,HCPCS,0272,RC,,,,both,,,60.82,39.53,,,,,,,,,,,,,
NADOLOL 40 MG PO TABS,RX-5331,CDM,6370000000,HCPCS,0637,RC,62332-0403-31,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MESH BIO PORCINE HERN 8 LAYR TISS MTRX ABD 20CM LEN 7CM W,SUP-2168853,CDM,C1763,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
SHUNT CSF CONNECTOR 1.9MM CATHETER ID1.2MM OD2.5MM DIFFERENT,SUP-2825721,CDM,C1889,HCPCS,0278,RC,,,,both,,,13038.60,8475.09,,,,,,,,,,,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-22473,CDM,J1885,HCPCS,0636,RC,63323-0162-00,NDC,JW,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT SPCR SPNL IMPL C RNG 5MM ALLOCRAFT,SUP-2364344,CDM,C1713,HCPCS,0278,RC,,,,both,,,3903.74,2537.43,,,,,,,,,,,,,
CUP ACET DIA52MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH 124552000] JNJ DEPUY SYNTHES ORTHOPEDICS],SUP-2250720,CDM,C1776,CPT,0278,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
RAIL INT FIX NEW AD 250 MM,SUP-2517843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
HC Cbc,PX-3058502500,CDM,85025,CPT,0305,RC,,,,both,,,180.00,117.00,,,,,,,,,,,,,
VALVE SHUNT ADJ W/ BURR HOLE RESERVOIR POLARIS SPVA] KIRWAN SURGICAL PRODUCTS],SUP-2262474,CDM,C1889,HCPCS,0278,RC,,,,both,,,7284.80,4735.12,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION SM LNG 12-30 DEG PLASMALOOP,SUP-2466262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1627.12,1057.63,,,,,,,,,,,,,
CATHETER BLLN CHN SZ 2.8MM L350CM DIA13MM 0.035IN ABV INJ,SUP-2312957,CDM,C1751,HCPCS,0278,RC,,,,both,,,573.74,372.93,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 4 CM PLCNTA MEMBRN ALLGRFT CROSS,SUP-2909414,CDM,Q4109,HCPCS,0636,RC,,,,both,,,43551.80,28308.67,,,,,,,,,,,,,
SNARE SHT THROW STIFF JUMBO,SUP-2148788,CDM,C1892,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PROSTHESIS TESTICULAR IMPL 5,SUP-2340094,CDM,C1889,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HC Sacroplasty Bilat,PX-3610201000,CDM,0201T,CPT,0361,RC,,,,inpatient,,,15457.00,10047.05,,,,,,,,,,,,,
CYCLOSPORINE 0.05 % OP EMUL,RX-35209,CDM,6370000000,HCPCS,0637,RC,00023-9163-30,NDC,,both,1,UN,48.50,31.52,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X4 CM AMNIO WND MTRX BIOSKIN,SUP-2759454,CDM,Q4163,HCPCS,0636,RC,,,,both,,,7456.90,4846.98,,,,,,,,,,,,,
GRAFT VASC STR 7 MMX80 CM TW N RING HD ACCS EPTFE CARBOFLO,SUP-2761366,CDM,C1768,CPT,0278,RC,,,,both,,,7629.67,4959.29,,,,,,,,,,,,,
IMMOBILIZER KNEE PREMIER PRO TRI PNL 24INCH FOAM TIETEX PAT,SUP-2336078,CDM,L1830,CPT,0272,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM TIP 1 MM DIA 7 FR SPC 5,SUP-2248701,CDM,C1730,HCPCS,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
HC Pt Ultrasound Each 15 Min,PX-4209703500,CDM,97035,CPT,0420,RC,,,,outpatient,,,194.00,126.10,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 0.018 IN 5 FRX60 CM 65 CM SIL,SUP-2168371,CDM,C1751,HCPCS,0278,RC,,,,both,,,271.55,176.51,,,,,,,,,,,,,
COIL EMB L5CM DIA0.02IN LOOP DIA3MM CRV EXTRA SFT FILL,SUP-2323445,CDM,C1889,HCPCS,0278,RC,,,,both,,,6170.10,4010.56,,,,,,,,,,,,,
STEM HUM L90MM 7A 127.5DEG ANG STD PTC AEQUALIS ASCEND FLX,SUP-2388742,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
TRAY TIB SZ 3 AP47MM ML71MM STD UNIV KNEE NP MOD + STEM PRI,SUP-2253289,CDM,C1776,CPT,0278,RC,,,,both,,,7302.38,4746.55,,,,,,,,,,,,,
SUPPORT KNEE CLS PAT M,SUP-2276695,CDM,L1810,HCPCS,0274,RC,,,,both,,,11.46,7.45,,,,,,,,,,,,,
GRAFT BONE SUB 20CC HIGHLY PURIFIED TYP I CLLGN HA B,SUP-2310444,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
PLATE BONE L169MM 8 H TI TIM RT DSTL FIBULAR LCK COMPR ANAT,SUP-2413695,CDM,C1713,HCPCS,0278,RC,,,,both,,,2969.50,1930.17,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI HEM CATH STRL ACTE 11.5FR DI MCDLTSL27,SUP-2633021,CDM,C1750,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN ALLGRFT AMBIO5,SUP-2247197,CDM,V2790,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
ETHAMBUTOL HCL 100 MG PO TABS,RX-9982,CDM,6370000000,HCPCS,0637,RC,54879-0001-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L 162 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 13 H 72466113N,SUP-2933010,CDM,C1713,HCPCS,0278,RC,,,,both,,,5567.85,3619.10,,,,,,,,,,,,,
PLATE BONE LT TIB HI OSTEOTMY OSTEOTRAC,SUP-2223273,CDM,C1713,HCPCS,0278,RC,,,,both,,,4119.68,2677.79,,,,,,,,,,,,,
HC US Fetal Anatomic Eval,PX-4027681100,CDM,76811,CPT,0402,RC,,,,both,,,1366.00,887.90,,,,,,,,,,,,,
GUIDEWIRE VASC CLOSUREFAST L 260 CM DIA 0.025 IN TIP L 1.5,SUP-2172403,CDM,C1769,HCPCS,0272,RC,,,,both,,,59.22,38.49,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX2.5 CM BLLN BUTTON SIL MINI 1,SUP-2754576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,586.96,381.52,,,,,,,,,,,,,
HC Inj Methylpred Acetate 1 Mg,PX-6360101000,CDM,J1010,HCPCS,0636,RC,,,,both,,,1.00,0.65,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI 400XL ACTE 14FR DIA 24CM STRGHT TAPR T,SUP-2610528,CDM,C1752,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
MESH HERN 7.6CM POLY 4 HYDROXYBUTYRATE RND FULL RESRB SYN,SUP-2125868,CDM,C1781,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
PLATE BONE W17.5XL282MM THK5.2MM 15 H STRL BILAT S STL BROAD,SUP-2185308,CDM,C1713,HCPCS,0278,RC,,,,both,,,2603.28,1692.13,,,,,,,,,,,,,
PACLITAXEL 300 MG/50ML IV CONC,RX-31097,CDM,J9267,HCPCS,0636,RC,25021-0255-50,NDC,,both,50,ML,172.80,112.32,,,,,,,,,,,,,
GRAFT BONE SUB W5XL2.5CM DEMIN MTRX FLX GRFTON,SUP-2281663,CDM,C1713,HCPCS,0278,RC,,,,both,,,3384.92,2200.20,,,,,,,,,,,,,
FILTER GRFT 100ML GRAD FOR RMR IRRIG ASPIR,SUP-2188149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2237.72,1454.52,,,,,,,,,,,,,
TUBE ENTRL FEED PUSH METHOD 035 20 FRX4.47 MM PHAR FLO 20,SUP-2737403,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KIT ABLAT PRB 17GA L10MM 2 OSTEOCOOL RF,SUP-2293686,CDM,C1886,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
OSSEOFLEX SN STEERABLE NEEDLE 10 G NEEDLE,SUP-2701997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L480CM DIA0018IN TIP L6CM TRITON STR RADPQ,SUP-2141519,CDM,C1769,HCPCS,0272,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
HC Inj Sinus Tract Therapeutic,PX-3612050000,CDM,20500,CPT,0361,RC,,,,both,,,1586.00,1030.90,,,,,,,,,,,,,
HOLDER IMPL L1.6MM THRD TAK EXTREMILOCK,SUP-2319689,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
IMPLANT OSI200 OTOLOGIC,SUP-2858184,CDM,L8690,HCPCS,0278,RC,,,,both,,,13643.30,8868.14,,,,,,,,,,,,,
CLAMP REPROC JETX 6 HL PIN,SUP-2700485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.48,353.91,,,,,,,,,,,,,
KIT CHOLANGIOGM SPHINTOM BILI EXT STR 44FR 20MM 0035IN,SUP-2149815,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
CONE TIB M H25MM ECC 3 D MTL,SUP-2267617,CDM,C1776,CPT,0278,RC,,,,both,,,12385.73,8050.72,,,,,,,,,,,,,
MESH C-QUR EDGEXL OBLONG OVL 14 INX14 IN,SUP-2265975,CDM,C1781,HCPCS,0278,RC,,,,both,,,7121.52,4628.99,,,,,,,,,,,,,
CATHETER ANGIOPLSTY AVTR L 142 CM BALLOON L 20 MM DIA 4 MM,SUP-2156427,CDM,C1725,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
MATRIX WOUND THERAGENESIS MESHED 4X6CM,SUP-2738095,CDM,A2008,HCPCS,0636,RC,,,,both,,,7173.17,4662.56,,,,,,,,,,,,,
SCREW ORTH FOR POLY LNR REMOVAL STRL DISP G7,SUP-2887697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
GRAFT HUM TISS W7.5XL15CM PLCNTA MEM CRYOPRESERVED AMNION,SUP-2319179,CDM,Q4133,HCPCS,0636,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 240 MM NEWPORT MIS,SUP-2245925,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
NAIL INTRMDLLRY 9MM DIA 270MML TTNM ALLOY PRXML TBL ANTGRDE,SUP-2588053,CDM,C1713,HCPCS,0278,RC,,,,both,,,4585.15,2980.35,,,,,,,,,,,,,
HC Sp Ther Svs Use of Non Spc Gen De,PX-4409260600,CDM,92606,CPT,0440,RC,,,,both,,,410.00,266.50,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 3 LUMEN GUIDEWIRE CLEVERCUT DISP,SUP-2313226,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
CATHETER ANGIO 90CML AD AAA STNT GRFT DBL LUMN DBL CHRONIC,SUP-2217696,CDM,C1887,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PUSH BLADE,SUP-2700938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.76,341.74,,,,,,,,,,,,,
HC Pt Re-Eval Est Plan Care,PX-4249716400,CDM,97164,CPT,0424,RC,,,,outpatient,,,153.00,99.45,,,,,,,,,,,,,
STRAP CLAV L BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194673,CDM,L3670,HCPCS,0272,RC,,,,both,,,13.47,8.76,,,,,,,,,,,,,
PLATE BONE L135MM STD 9 H LT DSTL VOLAR RAD S STL LCK FOR,SUP-2348325,CDM,C1713,HCPCS,0278,RC,,,,both,,,17711.33,11512.36,,,,,,,,,,,,,
HC So West Nile Ab,PX-3028678966,CDM,86789,CPT,0302,RC,,,,inpatient,,,49.00,31.85,,,,,,,,,,,,,
PLATE BNE SM L MID FT TI POLYAX LO PROF FUS RECON SALVATION,SUP-2401168,CDM,C1713,HCPCS,0278,RC,,,,both,,,8434.04,5482.13,,,,,,,,,,,,,
SLING ORTH CHST CIRC 32-36IN SM BLK UNIV HUM CUF SHLDR SUPP,SUP-2324515,CDM,L3675,HCPCS,0272,RC,,,,both,,,79.47,51.66,,,,,,,,,,,,,
CAST ORTH L53X54IN NO BOOT TOT CNTCT TCC EZ,SUP-2244457,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.36,215.38,,,,,,,,,,,,,
GRAFT PIP STRL ALLGRFT 2MM WX15MM L TENFUSE,SUP-2401369,CDM,C1776,CPT,0278,RC,,,,both,,,4229.58,2749.23,,,,,,,,,,,,,
OFFSET ALTO CONCISE PARTIAL,SUP-2680309,CDM,L8613,CPT,0278,RC,,,,both,,,1234.21,802.24,,,,,,,,,,,,,
PLATE BNE T 6 HOLE,SUP-2205647,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.60,358.54,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 20X25-29 MM PRESERVON CANN CANC FLEXIGRAFT,SUP-2740896,CDM,C1713,HCPCS,0278,RC,,,,both,,,3222.83,2094.84,,,,,,,,,,,,,
KIT ACCESS VASCULAR 21030,SUP-2853473,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE H1MM BAR L4MM 4 H R CRANIOMAXILLOFACIAL TI L,SUP-2366321,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.22,442.79,,,,,,,,,,,,,
HEAD FEM SZ M DIA28MM FOR QUADRA HIP SYS BIOLOX DELT,SUP-2267343,CDM,C1776,CPT,0278,RC,,,,both,,,5213.53,3388.79,,,,,,,,,,,,,
WASHER ORTH DIA 7.5 MM ANK FIT ALL SCREW STRL APOLLOANKLE,SUP-2894179,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STEM FEM SZ 15 RT HIP CO CHROM NP 12/14 APR,SUP-2210901,CDM,C1776,CPT,0278,RC,,,,both,,,9960.08,6474.05,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 45 CM OD 9 FR GUIDEWIRE 0.018/0.038,SUP-2170665,CDM,C1894,HCPCS,0272,RC,,,,both,,,174.21,113.24,,,,,,,,,,,,,
BONE VOID FILLERS MORSELIZED ALLOGRAFTS CORT CANC SPIERINGS,SUP-2307432,CDM,C1713,HCPCS,0278,RC,,,,both,,,3265.13,2122.33,,,,,,,,,,,,,
DRILL SURG STR 55 MM INTERCONTINENTAL,SUP-2585621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
MATRIX WOUND THERAGENESIS MESHED 8.2X12CM,SUP-2740183,CDM,A2008,HCPCS,0636,RC,,,,both,,,10751.36,6988.38,,,,,,,,,,,,,
TRAY CHST TB CATH 12FR L22CM 3 SIDEPRT THAL-QUICK,SUP-2168086,CDM,C1729,HCPCS,0272,RC,,,,both,,,691.74,449.63,,,,,,,,,,,,,
SCREW BNE FUSION 2X40 MM DIGITAL CAPTURE,SUP-2419201,CDM,C1713,HCPCS,0278,RC,,,,both,,,997.30,648.24,,,,,,,,,,,,,
SCREW SPNL L14MM DIA3.5MM POST CERVICOTHORACIC TI ST,SUP-2286842,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
PROBE SURG 6.4FR L2.13CM 1.5CM ESOPH IMPED SPC PH 1 CHAN,SUP-2336773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ELECTRODE TAB DISPOSABLE SANIBEL,SUP-2719742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
PLATE BNE OSTEOTMY 130 DEG AD 4.5X100 MM TI NS DCP,SUP-2569054,CDM,C1713,HCPCS,0278,RC,,,,both,,,1690.76,1098.99,,,,,,,,,,,,,
NAIL IM L300MM DIA11MM 125DEG RAD OF CURVATURE 1.5M LNG L,SUP-2371386,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
FILTER PERF ART PED AFFIN PIXIE,SUP-2500380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,306.15,199.00,,,,,,,,,,,,,
COVER BUR H DIA17MM 6 H TI FOR 1.3MM PLUSDRIVE SCR,SUP-2190678,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.45,554.74,,,,,,,,,,,,,
NEEDLE BNE MAR ASPIR 6 GAX11 IN AUTOLGS CELL 60S EXTRACTOR,SUP-2138520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.18,372.57,,,,,,,,,,,,,
MICRO ACC SET 5F SS WIRE SH B BVL,SUP-2116523,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
CATHETER CV KT 0.032 IN AD 5 FR X 6 CM 16 GA SINGLE LUMEN,SUP-2763317,CDM,C1751,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
PLATE BNE CONN 5 HOLE NS,SUP-2799567,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.42,219.32,,,,,,,,,,,,,
CATHETER SET 3 LUMEN 9 FR CV KT HI FLO DEV BASIC,SUP-2214566,CDM,C1751,HCPCS,0278,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
BLADE SAW CUT EDGE L135MM D255MM THK051MM INTRAORAL S STL,SUP-2363657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.31,212.10,,,,,,,,,,,,,
SET URET STENT SOFFLX L 75 CM CATH 7.2 FR GUIDEWIRE L 100 CM,SUP-2168950,CDM,C2617,HCPCS,0278,RC,,,,both,,,493.29,320.64,,,,,,,,,,,,,
SCREW HEADED 25X10MM,SUP-2696128,CDM,C1713,HCPCS,0278,RC,,,,both,,,1090.84,709.05,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|ADJ,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|KX|CQ|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
PIN EXT FIX ROT CONN FOR CALCNL FRAC REAR FT FIX SIDEKCK,SUP-2400621,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
TIP CATH 110DEG MAX COMP SNUS GUID FOR BLLN SINUPLASTY SYS,SUP-2106367,CDM,C1887,HCPCS,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
BOLT ORTHOPEDIC 90 MM FOR FEM NK SYS TI,SUP-2181055,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.54,788.15,,,,,,,,,,,,,
SHELL ACET 62 MM HIP 3 HOLE HA REFLECTION INTERFIT,SUP-2434631,CDM,C1776,CPT,0278,RC,,,,both,,,6518.64,4237.12,,,,,,,,,,,,,
PLATE BNE 2 H COMPR,SUP-2321439,CDM,C1713,HCPCS,0278,RC,,,,both,,,3520.73,2288.47,,,,,,,,,,,,,
BUR SURG CYL 6.4 MM FOR XL-HD-G1/XL-HD CARBIDE,SUP-2848479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.52,368.89,,,,,,,,,,,,,
INSERTER BTTN DISP FOR TENS SLDE TECH DSTL BICEPS REP,SUP-2121664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CONNECTOR SHUNT 1X1.9X11 MM RT ANGLE SS STRL ACCU-FLO,SUP-2666413,CDM,C1889,HCPCS,0278,RC,,,,both,,,335.07,217.80,,,,,,,,,,,,,
SCREW BNE HIP 6.5X105 MM RECON THRD STRL TUBE FRNADVANCED,SUP-2789376,CDM,C1713,HCPCS,0278,RC,,,,both,,,620.46,403.30,,,,,,,,,,,,,
GRAFT BNE SUB 1CC PTTY PREHYDRATED CRUSH MIX TENSIX,SUP-2400562,CDM,C9359,HCPCS,0278,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 90 DEG L 130 CM OD,SUP-2120493,CDM,C1887,HCPCS,0272,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
PROBE SURG L400MM OD4MM,SUP-2261218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.82,281.98,,,,,,,,,,,,,
STENT GRFT VASC BIFURCATE 1 AORT LIMB EXT,SUP-2777589,CDM,C1768,CPT,0278,RC,,,,both,,,31525.60,20491.64,,,,,,,,,,,,,
NEEDLE OPHTH ILIFF-WRIGHT FASC 127 MM CRV SHFT RNG HNDL SS,SUP-2470743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
LINER ACET CUP 28 MM ID 0 DEG MTL AND POLY ON POLY SZ P5,SUP-2364629,CDM,C1776,CPT,0278,RC,,,,both,,,6572.30,4271.99,,,,,,,,,,,,,
OCCLUDER CV 14X33 MM STENT GRFT LP W/ DEL SYS TALENT,SUP-2429838,CDM,C1768,CPT,0278,RC,,,,both,,,7771.50,5051.47,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 15 CM DIA 6 MM EPTFE STR TW N RING,SUP-2396337,CDM,C1768,CPT,0278,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
PLATE T PROFYLE SHP 90DEG NAR 23MM,SUP-2695490,CDM,C1713,HCPCS,0278,RC,,,,both,,,1062.26,690.47,,,,,,,,,,,,,
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS,RX-34544,CDM,6370000000,HCPCS,0637,RC,00406-0124-62,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
PREDNISONE 5 MG/5ML PO SOLN,RX-6492,CDM,J7512,HCPCS,0637,RC,00054-3722-50,NDC,,both,5,ML,15.10,9.81,,,,,,,,,,,,,
SET INTRO MICRO-STICK SHTH L 9 CM DIA 4 FR NIT COAX STIFF,SUP-2627259,CDM,C1894,HCPCS,0272,RC,,,,both,,,33.28,21.63,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH SM 0.4 MM CRESCENT BLU STRL,SUP-2859902,CDM,C1713,HCPCS,0278,RC,,,,both,,,2383.26,1549.12,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE SM SHT ANK ROCKER BTM INLINE,SUP-2336131,CDM,L4361,HCPCS,0272,RC,,,,both,,,78.75,51.19,,,,,,,,,,,,,
SYSTEM BULKING PRC BULKAMID URETHRAL,SUP-2717685,CDM,L8606,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SHUNT SURG VENTRICULAR CATH L 180 MM PRESSURE DIFF 5 CM H2O FX846T,SUP-2928932,CDM,C1889,HCPCS,0278,RC,,,,both,,,16745.37,10884.49,,,,,,,,,,,,,
PATCH HERN W15.5XL20.5CM 28-35MM STOMA OPN POLYPR W/ EXP,SUP-2126078,CDM,C1781,HCPCS,0278,RC,,,,both,,,3600.48,2340.31,,,,,,,,,,,,,
SCREW SET POST EXPANDABLE AILERON,SUP-2430745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
ELECTRODE ELECSURG OD5MM YEL STRL DISP FOR 24/26FR RESECTSCP,SUP-2261199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
BUR HIP L19CM DIAMETER 4.2MM PREBENT STRAIGHT STYLES UNIQUE,SUP-2828619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
HC Thromblytic Art/Ven Therapy,PX-3613721300,CDM,37213,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SYSTEM BLLN DISECT ACCS OVL KII,SUP-2420137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
IMPLANT SPNL H26-36MM 0DEG LUM W/ L ENDPLATE RATCH MECHANISM,SUP-2194240,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ROD EXT FIX 25X250 MM CARBON LIGHTWEIGHT RADLUC,SUP-2372614,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CATHETER DEL AMPLATZER TORQVUE LP TIP 90 DEG L 80 CM DIA 4,SUP-2904230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
MATRIX BIO L 25 X W 20 CM FET BOV DERM IONIC SLV DERMAL SLD,SUP-2909307,CDM,Q4110,HCPCS,0636,RC,,,,both,,,27624.15,17955.70,,,,,,,,,,,,,
VALVE SHUNT AD 14GA NDL LUM BLU S STL MIN VENT ENLMENT HORZ,SUP-2243840,CDM,C1729,HCPCS,0272,RC,,,,both,,,3051.51,1983.48,,,,,,,,,,,,,
LINER ACET ECC 32X66 MM HIP,SUP-2202296,CDM,C1776,CPT,0278,RC,,,,both,,,3486.78,2266.41,,,,,,,,,,,,,
STRM LOCKING SCREW 3.5X14MM ST,SUP-2483503,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
ROD SPNL DIA4.5MM 90MM ACTUATOR STD FOR BRACING AND,SUP-2312244,CDM,C1713,HCPCS,0278,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
COMPONENT PATELLAR 29 MM KNEE E-VITALIZE BKS TRIMAX,SUP-2314929,CDM,C1776,CPT,0278,RC,,,,both,,,1708.16,1110.30,,,,,,,,,,,,,
DRILL ENDOSCP XL 9 MM,SUP-2849146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
SCREW HD 6.5MMX35MMX16 DARCO,SUP-2401066,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
STENT COR 8MM 2.25MM RADPQ MRK RX MICROTRAC DEL,SUP-2296908,CDM,C1874,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
IMPLANT HUM TISS LT HUM HD OSTEOCHNDRL,SUP-2902057,CDM,C1762,CPT,0278,RC,,,,both,,,24570.50,15970.82,,,,,,,,,,,,,
JUGGERKNOT SHRT RIGID SZ 1 IMPLANT PK 10,SUP-2589030,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.99,593.44,,,,,,,,,,,,,
DRESSING WND BIO FISH SKIN FENESTRATED 3CM X 7CM RSFH ONLY,SUP-2859690,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3951.38,2568.40,,,,,,,,,,,,,
SCREW SPNL MULTAXL 11.5X110 MM CANN CD HORZ,SUP-2628411,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
SCREW BNE 2X12 MM 8 MM X DRV DRILL-FREE TI LEVEL 1,SUP-2464760,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.04,205.43,,,,,,,,,,,,,
CONDYLAR PLATE RIGHT 15X285MM,SUP-2819050,CDM,C1713,HCPCS,0278,RC,,,,both,,,8177.97,5315.68,,,,,,,,,,,,,
WIRE BRST LOC L35CM NDL L14CM OD20GA BEAD BARB GHIATAS,SUP-2126438,CDM,C1819,HCPCS,0278,RC,,,,both,,,97.03,63.07,,,,,,,,,,,,,
BLADE SAW L 7.3 MM D 30 MM THK MATERIAL 0.6 MM CUT 0.7 MM,SUP-2928829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,385.40,250.51,,,,,,,,,,,,,
MESH HERN W10XL15CM OVL ABSRB MACROPOROUS KNIT LO PROF,SUP-2395763,CDM,C1781,HCPCS,0278,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
PLATE BNE FEM 146 MM LT DSTL LAT CNDYL 6 HOLE BUTTRESS SS,SUP-2461627,CDM,C1713,HCPCS,0278,RC,,,,both,,,2235.49,1453.07,,,,,,,,,,,,,
COLLAR EXTRIC FR 1 3/4IN CIRC 8IN-18IN PED AQUA CERV,SUP-2194419,CDM,L0172,HCPCS,0272,RC,,,,both,,,22.67,14.74,,,,,,,,,,,,,
PLATE BNE L195MM THK3.7MM 15 H BILAT S STL STR LO PROF RIG,SUP-2177147,CDM,C1713,HCPCS,0278,RC,,,,both,,,2737.95,1779.67,,,,,,,,,,,,,
PLUG VASC AMPLATZER II L 7 MM DIA10 MM DEL SYS L 135 CM CATH,SUP-2116307,CDM,C1889,HCPCS,0278,RC,,,,both,,,2876.24,1869.56,,,,,,,,,,,,,
CATHETER CV DL 0.018 IN 5 FRX60 CM 150 CM OTW TURBO FLO,SUP-2170005,CDM,C1751,HCPCS,0278,RC,,,,both,,,312.96,203.42,,,,,,,,,,,,,
SCREW SPNL L50MM DIA6.5MM CANC PEDCL THORLUM TI NTHRD LOK,SUP-2229413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK NUCLS L 100 CM 5.5 FR 2 CM 4MM,SUP-2659671,CDM,C1725,HCPCS,0272,RC,,,,both,,,2339.43,1520.63,,,,,,,,,,,,,
HC Icd Generator Removal,PX-3613324100,CDM,33241,CPT,0361,RC,,,,both,,,7401.00,4810.65,,,,,,,,,,,,,
COMPONENT FEM CR POR COAT SYMMETRICAL SZ 0,SUP-2222761,CDM,C1776,CPT,0278,RC,,,,both,,,11643.12,7568.03,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR HELIX SLDE GDS,SUP-2482765,CDM,C1768,CPT,0278,RC,,,,both,,,2529.84,1644.40,,,,,,,,,,,,,
PLATE BNE L171MM 10 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185643,CDM,C1713,HCPCS,0278,RC,,,,both,,,4308.21,2800.34,,,,,,,,,,,,,
PROBE NSL 20 DEG,SUP-2713684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.14,351.09,,,,,,,,,,,,,
HC Myelogram Thoracic,PX-3616230300,CDM,62303,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BONE 130DEG 5 H SUPCNDYL S STL COMPR FRELOK,SUP-2197724,CDM,C1713,HCPCS,0278,RC,,,,both,,,1537.34,999.27,,,,,,,,,,,,,
GRAFT BNE SPNG 10X10X10 MM DBM CANC,SUP-2641779,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PIN OCCL W10MM STD W/ APPL DISP FOR HEMORRHAGE,SUP-2381977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1405.15,913.35,,,,,,,,,,,,,
ANCHOR SUT 5.5MM W/ NDL,SUP-2366676,CDM,C1713,HCPCS,0278,RC,,,,both,,,721.51,468.98,,,,,,,,,,,,,
PLATE BNE Y 46X1.6 MM WRST 7 HOLE APTUS TRILOK,SUP-2423732,CDM,C1713,HCPCS,0278,RC,,,,both,,,3358.54,2183.05,,,,,,,,,,,,,
CATHETER HD STR 16 FRX28 CM 23 CM SPLIT TIP LT EQUISTREAM XK,SUP-2126537,CDM,C1750,HCPCS,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
SCREW SPNL TRANSITION RAIL 4.5X500 MM COCR MESA RAIL 4D,SUP-2538578,CDM,C1713,HCPCS,0278,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
REFL ACET FIXATION PEG 25MM,SUP-2827843,CDM,C1776,CPT,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
KIT HARV VES VASOVIEW HEMOPRO 2 W VASOSHIELD PRSS,SUP-2227761,CDM,C1713,HCPCS,0278,RC,,,,both,,,4021.15,2613.75,,,,,,,,,,,,,
LOOP OPHTH 25+GA FLX RETRCT TIP FOR POST SEG SURG DISP,SUP-2109656,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
GRAFT VASC L 45 MM ID 5 MM CLLGN BOV CAR ART WOVEN,SUP-2880946,CDM,C1768,CPT,0278,RC,,,,both,,,13593.06,8835.49,,,,,,,,,,,,,
CATHETER BLLN OCCL L150CM TIP L5MM BLLN L10MM OD4MM COR,SUP-2305408,CDM,C2628,HCPCS,0272,RC,,,,both,,,4592.25,2984.96,,,,,,,,,,,,,
PLATE 7MM DIAM M ATTIC DEFCT HA,SUP-2312564,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.63,315.66,,,,,,,,,,,,,
STEM FEM 0 HIP NP APOLLO,SUP-2210878,CDM,C1776,CPT,0278,RC,,,,both,,,4473.87,2908.02,,,,,,,,,,,,,
INSERT TIB FLX ULT CONG PROLONG NAT KNEE RT 22 MM SZ 3/4/5,SUP-2200122,CDM,C1776,CPT,0278,RC,,,,both,,,7316.20,4755.53,,,,,,,,,,,,,
HEAD FEM DIA32MM 5 OFFSET 10 12 TAPR HIP CO CHROME MTL ON,SUP-2253279,CDM,C1776,CPT,0278,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.7MM CORT TI ST NONCANNULATED LOK FULL,SUP-2189716,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.21,228.94,,,,,,,,,,,,,
SET SCR SPNL FAST ANTR THORLUM TI FOR CVR PLT EPIC,SUP-2136836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GUIDEWIRE VASC APPRCH CTO L190CM 0.014IN L18CM 12GM STR SHRT,SUP-2170828,CDM,C1769,HCPCS,0272,RC,,,,both,,,401.89,261.23,,,,,,,,,,,,,
GRAFT HUM TISS L 25-30 X W 18 MM THK T1 10 MM T2 7 MM IL,SUP-2913212,CDM,C1713,HCPCS,0278,RC,,,,both,,,5626.88,3657.47,,,,,,,,,,,,,
PLATE BONE L210MM 21 H RT LAT DSTL POST HUM LCK ALPS,SUP-2205425,CDM,C1713,HCPCS,0278,RC,,,,both,,,5371.28,3491.33,,,,,,,,,,,,,
COIL VASC AZUR CX L 7 CM DIA 4 MM MICROCATHETER 0.035 IN,SUP-2385438,CDM,C1889,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
OXYGENATOR PERFSN BIOLINE COAT PED STRL DISP QUADROX-ID,SUP-2908774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6919.74,4497.83,,,,,,,,,,,,,
PLATE BONE L396MM 18 H LT PROX FEM LCK FOR 4.5MM SCR,SUP-2351130,CDM,C1713,HCPCS,0278,RC,,,,both,,,15899.08,10334.40,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC DBM FLOWABLE FIBER AMBIENT STOR,SUP-2933207,CDM,C1762,CPT,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
COLLAR CERV M H3XL17IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335996,CDM,L0180,HCPCS,0272,RC,,,,both,,,12.21,7.94,,,,,,,,,,,,,
PLATE BONE 4 H CRANIOMAXILLOFACIAL NONCOMPRESSIONXSHAPED,SUP-2363641,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.71,590.01,,,,,,,,,,,,,
LINER ACET OD60MM ID40MM 0DEG XLPE HIP CEM REDAPT,SUP-2345567,CDM,C1776,CPT,0278,RC,,,,both,,,2844.84,1849.15,,,,,,,,,,,,,
PLATE BONE L21MM 3X3 H S STL RAD NK ELBW POLYAX LCK LO PROF,SUP-2397935,CDM,C1713,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X1 CMX1.27-3.30 MM TISS MTRX ALLDERM,SUP-2113045,CDM,Q4116,HCPCS,0636,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SCREW BNE L 75 MM DIA 3.5 MM TI LCK T15 STARDRV NS V,SUP-2905977,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.36,763.98,,,,,,,,,,,,,
PLATE BNE LCK 2.7/3.5X237 MM RT DSTL MEDL 18 HOLE FIX ANGLE,SUP-2525036,CDM,C1713,HCPCS,0278,RC,,,,both,,,4615.86,3000.31,,,,,,,,,,,,,
BRACE QXXLG,SUP-2174973,CDM,L1820,HCPCS,0274,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
CLIP ANEUR CRAN RT ANGLE W/ TABS,SUP-2666515,CDM,C1889,HCPCS,0278,RC,,,,both,,,177.16,115.15,,,,,,,,,,,,,
HC Iaad Ia Shiga-Like Toxin,PX-3068742700,CDM,87427,CPT,0306,RC,,,,both,,,71.00,46.15,,,,,,,,,,,,,
HC Joint Bursa Inj Med Arm,PX-7612060500,CDM,20605,CPT,0761,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
SCREW BONE LOK 6.5MM DIA 75MML TIMAX CNCLLS HXGNL DRIVE HEAD,SUP-2588749,CDM,C1713,HCPCS,0278,RC,,,,both,,,140.70,91.45,,,,,,,,,,,,,
BOLT EXT FIX L10MM S STL CONN FOR ILIZ TAY SPAT FRME EXT,SUP-2342323,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
HEAD FEM DIA32MM +5MM OFFSET 14/16 TAPR CO CHROM MTL ON,SUP-2249718,CDM,C1776,CPT,0278,RC,,,,both,,,2113.85,1374.00,,,,,,,,,,,,,
HOLDER SPNL PLT FOR FIX,SUP-2287267,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
PACEMAKER CARD REOCOR D 2 CHMBR EXT TEMP NS,SUP-2138198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
LEAD DEFIB 7FR L60CM TIP TO PROX COIL 17CM SIL OPTIM EXT,SUP-2356222,CDM,C1777,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
HC Mammo Dgx Unilateral Incl Cad if Perf,PX-4017706500,CDM,77065,CPT,0401,RC,,,,inpatient,,,629.00,408.85,,,,,,,,,,,,,
SCREW BNE EMGCY 2X5 MM TI NS,SUP-2188963,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.72,115.52,,,,,,,,,,,,,
INTRODUCER TUBE SET 8.5/9/10 MM MULTI PERC TY W/ PHAR,SUP-2759711,CDM,C1769,HCPCS,0272,RC,,,,both,,,1738.93,1130.30,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 0.5 CC FD MINERALIZED ORAGRAFT,SUP-2740794,CDM,C1713,HCPCS,0278,RC,,,,both,,,148.11,96.27,,,,,,,,,,,,,
HEAD RAD H16.5MM DIA22MM +4MM OFFSET BILAT ELBW CO CHROM,SUP-2183051,CDM,C1776,CPT,0278,RC,,,,both,,,6074.61,3948.50,,,,,,,,,,,,,
HC So Platelet Neutralization,PX-3058559766,CDM,85597,CPT,0305,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
BLADE RETRACTOR 6 IN HIP STD T BAR HNDL SELF RET,SUP-2242482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1145.75,744.74,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC MICROINTRODU 5904310,SUP-2632976,CDM,C1750,HCPCS,0278,RC,,,,both,,,1717.58,1116.43,,,,,,,,,,,,,
INLAY IM POLYMER STRL RFN-ADVANCED,SUP-2913527,CDM,C1713,HCPCS,0278,RC,,,,both,,,962.72,625.77,,,,,,,,,,,,,
GUIDE SURG SZ 04-02 MOD SET FOR TOT KNEE ARTHROPLASTY SIGN,SUP-2408585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
DRILL SURG TWST 0.25 IN MRI,SUP-2439953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2 MM W/ STP NS,SUP-2757692,CDM,C1769,HCPCS,0272,RC,,,,both,,,489.97,318.48,,,,,,,,,,,,,
BAR EXT FIX L110MM DIA6MM C FOR JET-X MINI EXT FIX,SUP-2342912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1062.98,690.94,,,,,,,,,,,,,
SPLINT ORTHOPEDICXSM FNGR DYN WIRE FOAM PIP EXTN ASST AA,SUP-2324550,CDM,L3933,HCPCS,0274,RC,,,,both,,,63.02,40.96,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH LG 0.4 MM MASTOID TI BLU STRL,SUP-2859918,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
STEM FEM 98MM LEN 12/14 TAPR L HIP PRI NEUT PRESSFIT HA,SUP-2210417,CDM,C1776,CPT,0278,RC,,,,both,,,27475.00,17858.75,,,,,,,,,,,,,
COMPONENT ACET TRIFLANGED 25 MM RT HIP CUST,SUP-2137600,CDM,C1776,CPT,0278,RC,,,,both,,,34854.00,22655.10,,,,,,,,,,,,,
CATHETER PICC 5FR GWIRE L70CM POLYUR NIT GWIRE,SUP-2127466,CDM,C1751,HCPCS,0278,RC,,,,both,,,396.27,257.58,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.406,SUP-2859970,CDM,C1713,HCPCS,0278,RC,,,,both,,,31851.22,20703.29,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE ZRCH 2 WLLMS RIGHT ANGLE RGHT,SUP-2694396,CDM,C1713,HCPCS,0278,RC,,,,both,,,17316.94,11256.01,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-142363,CDM,Q5106,HCPCS,0636,RC,00069-1307-10,NDC,,both,1,ML,130.20,84.63,,,,,,,,,,,,,
PLATE BNE L300MM 13 H L PROX TIB TI NONCOMPRESSION FOR,SUP-2190737,CDM,C1713,HCPCS,0278,RC,,,,both,,,4152.46,2699.10,,,,,,,,,,,,,
STEM HUM SZ 4 L100MM CEM CONSTRN NEXEL,SUP-2135760,CDM,C1776,CPT,0278,RC,,,,both,,,17784.96,11560.22,,,,,,,,,,,,,
SHEATH INTRO 8FR L25CM 0.038IN SIL TRICSP VLV W/O GWIRE,SUP-2139634,CDM,C1894,HCPCS,0272,RC,,,,both,,,595.03,386.77,,,,,,,,,,,,,
ROD SPNL L240MM OD4MM 115DEG OCCIPITAL QUARTEX,SUP-2229111,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE SM L106MM 9 H BILAT S STL LO PROF RIG LIMIT CNTCT,SUP-2186230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1545.10,1004.31,,,,,,,,,,,,,
GUIDEWIRE ORTH L 16 IN DIA2.5 MM LG TROCAR TIP STRL DISP,SUP-2934627,CDM,C1769,HCPCS,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
HEAD RAD DIA22MM CO CHROM W/ LOK SCR ALIGN,SUP-2340138,CDM,C1776,CPT,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
CATHETER VENT DRNGE L15CM DOTTED ROUNDEDXRAY DTECT TANT TIP,SUP-2243778,CDM,C1729,HCPCS,0272,RC,,,,both,,,1022.95,664.92,,,,,,,,,,,,,
PIN EXT FIX CASE 3-6 MM APEX,SUP-2494304,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5521.38,3588.90,,,,,,,,,,,,,
IMPLANT FACE 33 X 38 MM THK 0.8 MM POLYETHYL RT ORBIT ZYG,SUP-2883153,CDM,C1713,HCPCS,0278,RC,,,,both,,,3310.31,2151.70,,,,,,,,,,,,,
CROWN DENT 3U REFIL S STL UP BICUSPID PRI PREFRM UNITEK,SUP-2322229,CDM,D6783,CPT,0278,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
MATRIX DEMIN BONE 10CC STERIFUSE CRUNCH,SUP-2138661,CDM,C1713,HCPCS,0278,RC,,,,both,,,7598.80,4939.22,,,,,,,,,,,,,
DOME TALUS LT ARTC FT BNE,SUP-2257910,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 8 HOLE,SUP-2518363,CDM,C1713,HCPCS,0278,RC,,,,both,,,3212.22,2087.94,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,0636,RC,00781-3288-91,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
KIT INTRO SHTH MICROEZ L 50 CM CATH 6 FR NDL L 7 CM FLEXURA,SUP-2125504,CDM,C1769,HCPCS,0272,RC,,,,both,,,120.48,78.31,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 30 CM FEM ART BLD TYP A B AB O,SUP-2417672,CDM,C1768,CPT,0278,RC,,,,both,,,24551.66,15958.58,,,,,,,,,,,,,
AML SM STATURE 12.0MM,SUP-2513034,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SYSTEM IMPL BICEPS INCL 5.5MM PEEK SWIVELOCK FIBERLINK +,SUP-2121440,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
STEM FEM SZ 5 L140MM DIA15MM NK L37MM 47MM OFFSET 132DEG 62651011] STRYKER ORTHOPEDICS HOWM],SUP-2375330,CDM,C1776,CPT,0278,RC,,,,both,,,12654.83,8225.64,,,,,,,,,,,,,
SCREW INTERFERENCE DIAMETER 11MM L40MM CANNULATED ABSORBABLE,SUP-2824845,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.35,316.13,,,,,,,,,,,,,
ANCHOR SUT L14.7MM DIA5.5MM PEEK W/ TWO SZ 2 FIBERWIRE,SUP-2121565,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
COLLAR CERV M DENS AD CNTOUR CNTCT CLSR FOAM W/ STOCK SERP,SUP-2210884,CDM,L0120,HCPCS,0272,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
GRAFT BIO TISS W30XL30CM RECON TISS MTRX FIRM STRATTICE,SUP-2113043,CDM,Q4130,HCPCS,0636,RC,,,,both,,,86528.98,56243.84,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X3.75 MM SCHKNT SS FLROPLAS,SUP-2637745,CDM,L8613,CPT,0278,RC,,,,both,,,330.86,215.06,,,,,,,,,,,,,
HC Ot Eval High Complex,PX-4349716700,CDM,97167,CPT,0434,RC,,,,both,,,341.00,221.65,,,,,,,,,,,,,
PLATE BONE L84MM 10 H STRL S STL COMPR FOR 2.7MM SCR EVOS,SUP-2349624,CDM,C1713,HCPCS,0278,RC,,,,both,,,2293.49,1490.77,,,,,,,,,,,,,
GUIDEWIRE 6CM X 16CM RECTANG,SUP-2418078,CDM,C1769,HCPCS,0272,RC,,,,both,,,4009.78,2606.36,,,,,,,,,,,,,
STEM FEM SEG 10 CM LT KNEE REDUC RESECT TAPR COMPRESS,SUP-2441850,CDM,C1776,CPT,0278,RC,,,,both,,,19753.74,12839.93,,,,,,,,,,,,,
NAIL TIBIA TI6AL4V ALLOY 10MMX38CM,SUP-2491309,CDM,C1776,CPT,0278,RC,,,,both,,,4864.24,3161.76,,,,,,,,,,,,,
GRAFT HUM TISS 3X3CM THCK CYGNUS MAX,SUP-2393050,CDM,Q4170,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 10 CC DBM,SUP-2632266,CDM,C1713,HCPCS,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
KIT ARTHSCP INSTR INCLUDE CRV SPEAR W/ CIRCUMFERENTIAL,SUP-2121773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CATHETER CTRL VEN PED 4FR L8CM 0.021IN DBL LUMN,SUP-2383319,CDM,C1751,HCPCS,0278,RC,,,,both,,,227.96,148.17,,,,,,,,,,,,,
LINER ACET CEM HIP HYBIRD XLPE,SUP-2379163,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
PLATE LK COMPRSS BROAD 9HL 173MM,SUP-2702815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1096.49,712.72,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC MAXBARR 5FR 55CM 1 LUMAN R 9175108D,SUP-2632695,CDM,C1751,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
CATHETER INTERMED REVIVE IC L 115 CM OD 5 FR ID 0.056 IN,SUP-2460546,CDM,C1887,HCPCS,0272,RC,,,,both,,,4509.54,2931.20,,,,,,,,,,,,,
CATHETER CV 3L 12 FRX20 CM N TUNNELED FULL KT,SUP-2120610,CDM,C1751,HCPCS,0278,RC,,,,both,,,448.39,291.45,,,,,,,,,,,,,
SCREW SZ 30MMX26MM CANN,SUP-2243601,CDM,C1713,HCPCS,0278,RC,,,,both,,,1079.50,701.67,,,,,,,,,,,,,
WIRE FIX BLNT TIP CORRIDOR L500MM OD1.05MM K,SUP-2232177,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
CATHETER URETH 18 FR 5 CM BLLN W/ INFLATION DRUG OPTILUME,SUP-2863021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
PROBE RF L75MM OD17GA 4MM PAIN MGMT SINERGY,SUP-2237202,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
NOZZLE BONE CEM REV,SUP-2216852,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
GUIDEWIRE ORTH TRCR PT 1 END 0.8X100 MM STRL,SUP-2789088,CDM,C1769,HCPCS,0272,RC,,,,both,,,966.62,628.30,,,,,,,,,,,,,
FENTANYL 50 MCG/ML PCA,RX-40851003,CDM,J3010,HCPCS,0636,RC,09999-9901-20,NDC,,both,30,ML,126.50,82.22,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM DIA 7 MM POLYESTER BOV CLLGN,SUP-2491622,CDM,C1768,CPT,0278,RC,,,,both,,,1877.75,1220.54,,,,,,,,,,,,,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech (Addon),PX-4839335600,CDM,93356,CPT,0483,RC,,,,both,,,818.00,531.70,,,,,,,,,,,,,
INSERT TIB SZ 9 THICKNESS 10MM UHMWPE KNEE PRI NEUT UNIV,SUP-2365106,CDM,C1776,CPT,0278,RC,,,,both,,,1997.42,1298.32,,,,,,,,,,,,,
EVOS 3.5MM CVD PROX HUM PL 6H R 114,SUP-2931193,CDM,C1713,HCPCS,0278,RC,,,,both,,,5606.94,3644.51,,,,,,,,,,,,,
CATHETER VENTRICULAR STYL 6 CM 14 CM STYL RT ANGLE BACTISEAL,SUP-2666815,CDM,C1729,HCPCS,0272,RC,,,,both,,,1498.41,973.97,,,,,,,,,,,,,
CROWN DRILL 010X195 M,SUP-2701846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,931.01,605.16,,,,,,,,,,,,,
CORE SLIDING UHMPWE 11MM REVISION,SUP-2878125,CDM,C1776,CPT,0278,RC,,,,both,,,7297.05,4743.08,,,,,,,,,,,,,
BUR SURG L48MM DIA2MM 150 200 GRIT DMND RND FOR OTO OSTEON,SUP-2166382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,311.08,202.20,,,,,,,,,,,,,
ROD EXT FIX L250MM DIA11MM C CONN FOR HOFFMANN III MRI SYS,SUP-2372228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1112.19,722.92,,,,,,,,,,,,,
GRAFT DERMAL MESH 12X10 CM FEN CLLGN MTRX,SUP-2243699,CDM,Q4110,HCPCS,0636,RC,,,,both,,,12811.20,8327.28,,,,,,,,,,,,,
PLATE BONE L14MM THK0.6MM 3 H REG MIDFACE TI TRIANG FOR,SUP-2402890,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CATHETER EP VAR LOOP 5 MM SPC 7 FRX105 CM,SUP-2142370,CDM,C1731,HCPCS,0278,RC,,,,both,,,5036.56,3273.76,,,,,,,,,,,,,
SYRINGE (DISPOSABLE) 20 ML MISC,RX-11478,CDM,2500000003,HCPCS,0250,RC,08881-5206-57,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CAGE SPNL 15 DEG 40X30X15X8 MM ALIF CASCADIA,SUP-2732271,CDM,C1889,HCPCS,0278,RC,,,,both,,,12999.60,8449.74,,,,,,,,,,,,,
GEMCITABINE HCL 2 GM/52.6ML IV SOLN,RX-111498,CDM,J9184,HCPCS,0636,RC,00409-0182-25,NDC,,both,52.6,ML,81.70,53.10,,,,,,,,,,,,,
SCREW BNE L 52 MM DIA 3 MM THRD L 21 MM TI CANN COMPR HDLSS,SUP-2905726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1671.61,1086.55,,,,,,,,,,,,,
KIT CONVENIENCE STD FT ANK BONE GRFT BIOCUE ASPIR NDL DISP,SUP-2402590,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SPACER SPNL H14MM ST TRANSITION,SUP-2231431,CDM,C1821,HCPCS,0278,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
RACK INSTR RETRCT WIREFIX,SUP-2399615,CDM,C1776,CPT,0278,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
PIN FIX L2IN W/ HNDL STNMN P.F.C.,SUP-2253358,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
DEVICE FIX HELCL MULT USE HNDL 5 TUBE TI,SUP-2752180,CDM,C1713,HCPCS,0278,RC,,,,both,,,4879.91,3171.94,,,,,,,,,,,,,
VITAMIN D (ERGOCALCIFEROL) 1.25 MG (50000 UT) PO CAPS,RX-100998,CDM,6370000000,HCPCS,0637,RC,64380-0737-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min|OP PT SERVICES|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209711600,CDM,97116,CPT,0420,RC,,,GP|XU,both,,,164.00,106.60,,,,,,,,,,,,,
BURR HOLE COVER LOW PRFLE Q STYLE W4 HLE ARMS.4MM 21MM D11M,SUP-2676795,CDM,C1713,HCPCS,0278,RC,,,,both,,,2992.99,1945.44,,,,,,,,,,,,,
DEVICE OCCL CLP L40MM LAA EXCLUSION SYS ATRICLP PRO V,SUP-2124475,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
KIT CVC INJ PRES ARROW G +ARD BLUE PLUS 3 LUMEN 7 FRX20CM,SUP-2743279,CDM,C1751,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SHELL ACET OD41MM ID28MM THK5.3MM HIP TI 3PLR FOR TOT,SUP-2404294,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
TUNNELER SURG L 600 MM LG STD RNG MARKING STRL DISP,SUP-2929221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.80,300.82,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 6H RT 142MM STER,SUP-2549605,CDM,C1713,HCPCS,0278,RC,,,,both,,,5011.19,3257.27,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SPICA MED LG LT THMB HK LOOP CLOSURE VLY 0005785000000] ALIMED INC],SUP-2112560,CDM,L3924,HCPCS,0272,RC,,,,both,,,96.56,62.76,,,,,,,,,,,,,
STABILIZER PECTUS BAR TI NS PECTUS BLU,SUP-2895745,CDM,C1713,HCPCS,0278,RC,,,,both,,,10299.20,6694.48,,,,,,,,,,,,,
COLLAR CERV 9-24 MO PEDIATRIC 29-37 IN FLEXTABS HK,SUP-2427924,CDM,L0172,HCPCS,0272,RC,,,,both,,,103.87,67.52,,,,,,,,,,,,,
HC Trach Change,PX-7613150200,CDM,31502,CPT,0761,RC,,,,inpatient,,,694.00,451.10,,,,,,,,,,,,,
BLADE SEAL L31CM DIA5MM ULTRASONIC BALL TIP HARM,SUP-2219113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,575.09,373.81,,,,,,,,,,,,,
PLATE BONE PREBENT 2MM STP RT MAX 1.6MM SCR OSA SYS,SUP-2319382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1133.54,736.80,,,,,,,,,,,,,
CHANLDRY 10 COLONODUODENOSIFGASTRO CONN,SUP-2728887,CDM,C1713,HCPCS,0278,RC,,,,both,,,18473.75,12007.94,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST MULTILIGAMENTOUS PREFABRICATED,SUP-2435624,CDM,L1906,HCPCS,0272,RC,,,,both,,,318.33,206.91,,,,,,,,,,,,,
CATHETER HD PASS TY 13.5 FRX16 CM 1.8/1.9 CC PRE CRV MAHRK,SUP-2754730,CDM,C1750,HCPCS,0278,RC,,,,both,,,537.82,349.58,,,,,,,,,,,,,
PACEMAKER CARD REVO MRI SURESCAN W 51 X H 45 MM D 8 MM 12.7,SUP-2282478,CDM,C1785,HCPCS,0275,RC,,,,both,,,11779.87,7656.92,,,,,,,,,,,,,
PLATE BNE SQ MINI 2X0.6 MM 3X2 HOLE FOR SCREW TI NS LEVEL 1,SUP-2472563,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.04,455.68,,,,,,,,,,,,,
CABLE SPNL TI W/ INTEGR CRMP DBL ATLS,SUP-2289632,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GUIDEWIRE L12IN SUBTALAR HORZ,SUP-2137795,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
ALUMINUM RENAL ABH BLADE 1 X 7 25CM X 178CM,SUP-2702015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1423.39,925.20,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX15 CM DL J TIP RIFAMPIN SPECTRUM,SUP-2759966,CDM,C1751,HCPCS,0278,RC,,,,both,,,348.48,226.51,,,,,,,,,,,,,
PLATE BONE HOLEX8 TITANIUM BLUE CRANIOMAXILLOFACIAL,SUP-2694730,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.60,255.84,,,,,,,,,,,,,
STEM FEM L115MM OD10MM 12/14 131DEG CEM + STD OFFSET PRI,SUP-2222334,CDM,C1776,CPT,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
KIT REVISION GRAFT BONE DOWEL 11 MM,SUP-2836343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
GLYCOPYRROLATE 1 MG/5ML IV SOSY,RX-134290,CDM,J7999,HCPCS,0636,RC,71266-9015-05,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER ANGIOPLSTY METACROSS L 90 DIA PROX/DSTL,SUP-2385500,CDM,C1725,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
GUIDE DRILL COMP/POLYAX 2.6MM T10,SUP-2472245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
ASSEMBLY SURG SAW SZ 15 MM IM CAM STRL DISP,SUP-2887640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2557.53,1662.39,,,,,,,,,,,,,
WIRE ORTH SMOOTH SGL SHRP TIP TRCR PLN S STL ST 16MM DIA,SUP-2304030,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.77,11.55,,,,,,,,,,,,,
DRILL CANN 4.5X90MM A/O SHFT,SUP-2321241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR,RX-25005,CDM,J7528,HCPCS,0636,RC,99999-0272-05,NDC,,both,1.25,ML,23.10,15.01,,,,,,,,,,,,,
TROCAR SURG 4.3 MM ANK INTLOK,SUP-2457905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2177.75,1415.54,,,,,,,,,,,,,
STEM FEM ROTATIONAL ENDOMODEL L 145X195,SUP-2418363,CDM,C1776,CPT,0278,RC,,,,both,,,27324.28,17760.78,,,,,,,,,,,,,
SEALER LAP SM L18.8CM OPN JAW HAND/FOOT SWCH FORCETRIAD,SUP-2283557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1209.25,786.01,,,,,,,,,,,,,
BUR SURG L48MM DIA1.5MM 150-200 GRIT DMND RND FOR OTO,SUP-2166383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.60,212.94,,,,,,,,,,,,,
CATHETER HD STR 14 FRX40 CM DL LT BASIC SET SPLIT CATH III,SUP-2269502,CDM,C1881,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
BLADE SAW 54X10 MM STRNM FOR PRIMARY,SUP-2607459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3353.52,2179.79,,,,,,,,,,,,,
VANCOMYCIN HCL 1.75 G IV SOLR,RX-168630,CDM,J3374,HCPCS,0636,RC,72078-0065-50,NDC,,both,1,UN,215.40,140.01,,,,,,,,,,,,,
STENT COR CATH 5FR L19MM 2.5MM 0.014IN 8ATM CO CHROM,SUP-2155971,CDM,C1876,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
LOCKING DLVRY CNNLA 11 G WTH DMND TPPD STLT SHRT,SUP-2475596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,736.80,478.92,,,,,,,,,,,,,
RELOAD STPL H1-2.5XL35MM VASC THN TISS WHT B FRM NAT ARTC,SUP-2220356,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.36,392.83,,,,,,,,,,,,,
GRAFT VASC L80CM L20CM OD6MM STD WALL RING STRL STR GORTX,SUP-2396004,CDM,C1768,CPT,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
COMPONENT FNGR JT SZ 30 PROX MP PYROCARBON SIL SPCR,SUP-2244238,CDM,C1776,CPT,0278,RC,,,,both,,,7319.34,4757.57,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 65321] CONVENTUS ORTHOPAEDICS],SUP-2167403,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
KIT STEERABLE LG VERSACROSS WIRE AND SHEATH,SUP-2525908,CDM,C1766,CPT,0272,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
AIRWAY LARYNGEAL 2,SUP-2312344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STEM FEM CMNTLS 14X240 MM KNEE MOD IMPL,SUP-2433945,CDM,C1776,CPT,0278,RC,,,,both,,,7768.36,5049.43,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CUP HD LNR ST TRAB MTL XLPE CERM,SUP-2212327,CDM,C1776,CPT,0278,RC,,,,both,,,17838.37,11594.94,,,,,,,,,,,,,
INSERT TIBIAL CR IDENTITY ITOTAL 10MM,SUP-2719733,CDM,C1776,CPT,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
DILTIAZEM HCL 25 MG/5ML IV SOLN,RX-97166,CDM,J1163,HCPCS,0636,RC,00641-6013-10,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
DRILL SURG PILOT FOR NAVIGATED SI FUSION SYS RIALTO,SUP-2632154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1646.77,1070.40,,,,,,,,,,,,,
FEEDING TUBE KIT LP 18 FRX2.3 CM BLLN BUTTON SIL MINI 1,SUP-2754578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,691.71,449.61,,,,,,,,,,,,,
EXTENSION LD DBS L 95 CM STRL DISP SENSIGHT,SUP-2883016,CDM,C1883,HCPCS,0278,RC,,,,both,,,2965.10,1927.31,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.078X9 IN 3 SHANK END NS STEINMANN,SUP-2791279,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.57,10.12,,,,,,,,,,,,,
VALVE VENTRICULAR SHUNT L1.5CM OD2.8MM 0CM WATER PRESSURE VE,SUP-2821800,CDM,C1889,HCPCS,0278,RC,,,,both,,,2098.24,1363.86,,,,,,,,,,,,,
COIL EMB 10 L2CM OD2MM HELCL STRTCH RESIST HYDRGEL V-TRAK,SUP-2305135,CDM,C1889,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST W/ADJ STP SINGLE UPR,SUP-2435627,CDM,L1920,HCPCS,0272,RC,,,,both,,,1163.06,755.99,,,,,,,,,,,,,
COMPONENT FEM UNI LM/RL X SM EIUS,SUP-2364875,CDM,C1776,CPT,0278,RC,,,,both,,,3856.55,2506.76,,,,,,,,,,,,,
CATHETER BILI L40CM DIA5FR 0.4ML BLLN PRB FGRTY ORDER MULT OF 5 EA,SUP-2214137,CDM,C1726,HCPCS,0272,RC,,,,both,,,270.86,176.06,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .035 L 90 CM COAT L 30 CM SHTH 8.5,SUP-2327233,CDM,C1753,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLUG SYN HERN W4CM D4.5CM POLYPR NONABSORBABLE PRESHAPED,SUP-2227399,CDM,C1781,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
PANCRELIPASE (LIP-PROT-AMYL) 20000-63000 UNITS PO CPEP,RX-140364,CDM,6370000000,HCPCS,0637,RC,73562-0112-01,NDC,,both,1,UN,37.20,24.18,,,,,,,,,,,,,
BIT DRL DIA5MM CANN FOR 7MM HDLSS COMPR SCR,SUP-2397749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL LNR,SUP-2435547,CDM,L0488,HCPCS,0274,RC,,,,both,,,2842.01,1847.31,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT GRAN MIC CA PHSPTE RESRB ST 15CC VITOSS,SUP-2368165,CDM,C1713,HCPCS,0278,RC,,,,both,,,3226.04,2096.93,,,,,,,,,,,,,
ANCHOR SUT SZ 2-0 OD2.3MM RB-1 TAPR NDL 2.0MM DRL BIT ABSRB,SUP-2249372,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
DISTRACTOR SURG WOOD 30 MM 1.5-1.8 MM 36 HOLE TI ZURICH TELE,SUP-2473748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17857.21,11607.19,,,,,,,,,,,,,
COLLAR CERV ADJ FOAM 2 PC THERMOPLASTIC,SUP-2388134,CDM,L0172,HCPCS,0274,RC,,,,both,,,431.62,280.55,,,,,,,,,,,,,
HANDLE LARYNSCP 3.5V STD FBROPT NT RECHRG NIMH LI ION BTTRY,SUP-2238186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
SLEEVE FEM 30MM CEM REV ATTUNE,SUP-2251447,CDM,C1776,CPT,0278,RC,,,,both,,,7350.11,4777.57,,,,,,,,,,,,,
PASSER SUTURE 3MM LIGATURE SHARP STRAIGHT REUSABLE,SUP-2824869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.73,268.92,,,,,,,,,,,,,
SCREW SPNL REDUCTION 5.5X30 MM TRPL LD,SUP-2175728,CDM,C1713,HCPCS,0278,RC,,,,both,,,6053.92,3935.05,,,,,,,,,,,,,
POST EXT FIX 3/5 2 CLMP IMPL,SUP-2136334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SIZER BRST 175CC DIA10CM P31CM SIL GEL MOD + PROF RND SMOOTH,SUP-2300840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
SCREW BONE LOK 4MM DIA UNVRSL 45MML TTNM CNCLLS FLLY THRDD S,SUP-2588579,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.66,51.13,,,,,,,,,,,,,
SET URET STENT SOFFLX L 70 CM DIA 7.2FR GUIDEWIRE L 145CM LT,SUP-2835687,CDM,C2617,HCPCS,0278,RC,,,,both,,,192.39,125.05,,,,,,,,,,,,,
CUTTER ENDO L35MM DIA12MM WHT TI LIN ARTC DISP,SUP-2218778,CDM,C1713,HCPCS,0278,RC,,,,both,,,2447.82,1591.08,,,,,,,,,,,,,
HC So Brucella Antibody,PX-3028662266,CDM,86622,CPT,0302,RC,,,,inpatient,,,253.00,164.45,,,,,,,,,,,,,
TUBE ORTHOPEDIC MEDULLARY INSTR STRL,SUP-2188169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
BROAD PLATE 4.5MM 26X423MM,SUP-2818486,CDM,C1713,HCPCS,0278,RC,,,,both,,,6076.37,3949.64,,,,,,,,,,,,,
GUIDEWIRE ORTH CRV SM 230 MM ERGO HNDL NS SQ LN REUSE,SUP-2846802,CDM,C1769,HCPCS,0272,RC,,,,both,,,632.40,411.06,,,,,,,,,,,,,
HC Remove Retrievable Filter,PX-3613719300,CDM,37193,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
POSTOP APP NON WGT BEAR DSG,SUP-2388203,CDM,L5450,HCPCS,0274,RC,,,,both,,,715.67,465.19,,,,,,,,,,,,,
CLIP SURG MECHANOMYOGRAPHY STIM MULT STG SS NS,SUP-2693683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SCREW BNE ST 1.5X4 MM CRTX W/ T4 STARDRV RECESS SS NS,SUP-2178443,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.30,82.74,,,,,,,,,,,,,
GRAFT BNE 10X20X8MM DEMIN CANC SPNG STRP FLEXIGRFT,SUP-2264613,CDM,C9362,HCPCS,0278,RC,,,,both,,,2283.97,1484.58,,,,,,,,,,,,,
REAMER SURG 3 MM,SUP-2175004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
PLATE BNE W17.5XL286MM THK5.2MM 16 H BILAT S STL BROAD,SUP-2185309,CDM,C1713,HCPCS,0278,RC,,,,both,,,2488.92,1617.80,,,,,,,,,,,,,
PLATE BNE RT DSTL HUM LAT TRL,SUP-2606622,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.33,589.76,,,,,,,,,,,,,
BAND STRUT ID STD FOR ILIZ TAY SPAT FRME EXT FIX,SUP-2342996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1614.27,1049.28,,,,,,,,,,,,,
MOLINA UNDRCTNL MNDBLR DISTR LNGTH 43MM T 6L 4V SNGLE USE,SUP-2669818,CDM,C1713,HCPCS,0278,RC,,,,both,,,10791.33,7014.36,,,,,,,,,,,,,
PIN BNE FIX L 150 MM DIA 5 MM SS FOR LG EXT FIX NS STEINMANN,SUP-2908443,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.15,169.75,,,,,,,,,,,,,
PROSTHESIS PENILE 22 CM SCROT PMP SET NAR BASE TITAN ESZ922] COLOPLAST CORP],SUP-2165451,CDM,C1813,HCPCS,0278,RC,,,,both,,,29795.46,19367.05,,,,,,,,,,,,,
CUP HIP PT SPEC,SUP-2165898,CDM,C1776,CPT,0278,RC,,,,both,,,3708.34,2410.42,,,,,,,,,,,,,
LOCKING PLATE STRGHT 2X12 24 HLE GRID 10MM THICK T 6L 4V,SUP-2680145,CDM,C1713,HCPCS,0278,RC,,,,both,,,2013.96,1309.07,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ITREVIA HF-T W 58.5 X H 65 MM D 11 MM 36,SUP-2138440,CDM,C1882,HCPCS,0275,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
GUIDEWIRE VASC NIT HYDRPHLC STR HYBRID TORQ TRNSMIT,SUP-2305456,CDM,C1769,HCPCS,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
SCREW BNE L26MM DIA2.7MM ANK S STL ST VAR ANG LOK FULL THRD,SUP-2178355,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.89,282.03,,,,,,,,,,,,,
POST FIX X 20 MM LAPIDUS SYS FOR 4.5 MM SCREW IO FRDM,SUP-2864925,CDM,C1713,HCPCS,0278,RC,,,,both,,,5557.80,3612.57,,,,,,,,,,,,,
CLIP INT LIG XL N ABSRB SMOOTH V SHPD TIP TI,SUP-2757599,CDM,C1889,HCPCS,0278,RC,,,,both,,,110.84,72.05,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE SM IN-LINE UNITZ BACTISEAL CERTAS +,SUP-2666579,CDM,C1889,HCPCS,0278,RC,,,,both,,,14067.80,9144.07,,,,,,,,,,,,,
MESH HERN W20XL30CM VENTRAL COMP SMRT DSGN HANDLING REP,SUP-2173623,CDM,C1781,HCPCS,0278,RC,,,,both,,,7969.26,5180.02,,,,,,,,,,,,,
IMPLANT HYB HP-CEM ST/POR CUP/LGXLPE LN/ LG DELT CER HD,SUP-2212062,CDM,C1776,CPT,0278,RC,,,,both,,,13102.69,8516.75,,,,,,,,,,,,,
PUNCH SURG SKIN COR STRL DISP HEARTMATE II,SUP-2895109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
MESH HERN REP W10XL17CM ELP SYN COMP POLY ABSRB SYMBOTEX,SUP-2174764,CDM,C1781,HCPCS,0278,RC,,,,both,,,2293.83,1490.99,,,,,,,,,,,,,
PATELLA POLY LP 28MM,SUP-2397053,CDM,C1776,CPT,0278,RC,,,,both,,,5045.98,3279.89,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X10 MM TOT WR SS NS,SUP-2610354,CDM,C1713,HCPCS,0278,RC,,,,both,,,308.88,200.77,,,,,,,,,,,,,
BIT DRL L300MM DIA7.3MM QUIK CPL W/O STP REUSE FOR,SUP-2187291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.29,728.19,,,,,,,,,,,,,
BONE STIM SPEC PURCH,SUP-2316213,CDM,E0749,HCPCS,0278,RC,,,,both,,,11602.30,7541.49,,,,,,,,,,,,,
HC Dress or Debride Burn Small,PX-4501602000,CDM,16020,CPT,0450,RC,,,,outpatient,,,421.00,273.65,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE TORSION CTRL STRL,SUP-2388181,CDM,L2380,HCPCS,0274,RC,,,,both,,,303.73,197.42,,,,,,,,,,,,,
SCREW BNE HD 3.5X48 MM HEX PERSONA (NOT IMPLANTED),SUP-2437521,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
CONNECTOR 2 MM 22.5 DEG BLU TI FOR IMPLATE SYS,SUP-2340249,CDM,C1713,HCPCS,0278,RC,,,,both,,,868.21,564.34,,,,,,,,,,,,,
DRILL SURG PEG UNI TIB PART KNEE HI PERF SIG,SUP-2453109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SCREW BNE SET 4.5 MM CANN 1/3 THRD EXT TAB,SUP-2861014,CDM,C1713,HCPCS,0278,RC,,,,both,,,24838.66,16145.13,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 500-700 UM 2 ML PVA STRL,SUP-2142756,CDM,C1889,HCPCS,0278,RC,,,,both,,,794.73,516.57,,,,,,,,,,,,,
PLATE BNE CALCANEAL FRAC MED TAB ORTHOLOC,SUP-2476704,CDM,C1713,HCPCS,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ACUNAV DIA10 FR POLYMER CORONARY,SUP-2535567,CDM,C1759,HCPCS,0272,RC,,,,both,,,2348.41,1526.47,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE,PX-4209711600,CDM,97116,CPT,0420,RC,,,GP|KX,both,,,164.00,106.60,,,,,,,,,,,,,
SCREW BNE L 3.5 MM DIA1.5 MM STRL DISP LORENZ STRL TRAC,SUP-2934950,CDM,C1713,HCPCS,0278,RC,,,,both,,,3111.74,2022.63,,,,,,,,,,,,,
PLATE BONE 13 H LT OLECRANON S STL LCK PERI-LOC,SUP-2350886,CDM,C1713,HCPCS,0278,RC,,,,both,,,1957.16,1272.15,,,,,,,,,,,,,
SCREW SPNL L25MM DIA6.5MM ANT CANC LUM TI PYRAMID,SUP-2291653,CDM,C1713,HCPCS,0278,RC,,,,both,,,1642.09,1067.36,,,,,,,,,,,,,
CATHETER HD SWAN NK 112.8 CM PRESTRNL PERITONEAL 2 CUF ARGY,SUP-2626974,CDM,C1750,HCPCS,0278,RC,,,,both,,,1314.94,854.71,,,,,,,,,,,,,
HC So Microsatellite Instability,PX-3108130166,CDM,81301,CPT,0310,RC,,,,both,,,506.00,328.90,,,,,,,,,,,,,
GRAFT DURA L 4 X W 5 IN THK 0.6 MM TYP I CLLGN BOV ACHILLES,SUP-2889754,CDM,C1763,HCPCS,0278,RC,,,,both,,,3870.30,2515.69,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 2 FRX30 CM INTERMED TY PER-Q-CATH,SUP-2125570,CDM,C1751,HCPCS,0278,RC,,,,both,,,177.41,115.32,,,,,,,,,,,,,
PIN EXT FIX L 25 MM DIA 3 MM SS HALF NS DISP JET-X,SUP-2933746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.48,290.21,,,,,,,,,,,,,
PLATE BNE LCK 94 MM LT DSTL LAT TIB PERIARTICULAR 6 HOLE,SUP-2468662,CDM,C1713,HCPCS,0278,RC,,,,both,,,4263.99,2771.59,,,,,,,,,,,,,
EXTENSION STEM FEM 11X30 MM KNEE PRIMARY CMNTLS GMK,SUP-2571080,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BONE W12XL87MM 5 H SEMI TBLR ECT,SUP-2198537,CDM,C1713,HCPCS,0278,RC,,,,both,,,151.29,98.34,,,,,,,,,,,,,
PLATE BONE 1.8MM THICKNESS STRNL LCK 6 H CP TI,SUP-2262573,CDM,C1713,HCPCS,0278,RC,,,,both,,,1828.05,1188.23,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST DBL SLD STIRRUP W/O JT,SUP-2435635,CDM,L2030,HCPCS,0274,RC,,,,both,,,3066.65,1993.32,,,,,,,,,,,,,
COMPONENT FEM SZ 9 R KNEE CO CHROM NAR POST STBL CEM,SUP-2206173,CDM,C1776,CPT,0278,RC,,,,both,,,17379.59,11296.73,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM 0.035IN TIP 1.5 MM J FIX COR,SUP-2701663,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.63,22.51,,,,,,,,,,,,,
FIBER LASER CO2 PWR PK FIBERLASE,SUP-2713719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,33158.40,21552.96,,,,,,,,,,,,,
GRAFT BNE 18X18X6.5 MM EVANS WDG ALLOSYNC,SUP-2570696,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM TIP L8MM 2.5MM SPC QPLR L CRV,SUP-2141344,CDM,C1732,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
"HC Exchange Nephrostomy Cath, Perc|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE",PX-3615043500,CDM,50435,CPT,0361,RC,,,50|XU,both,,,6875.00,4468.75,,,,,,,,,,,,,
MICONAZOLE NITRATE 2 % VA CREA,RX-5040,CDM,6370000000,HCPCS,0637,RC,61269-0730-63,NDC,,both,45,GR,26.80,17.42,,,,,,,,,,,,,
BOLT L25MM SHEFFIELD RNG EXT FIX SYS,SUP-2316261,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.38,8.70,,,,,,,,,,,,,
EPOETIN ALFA 3000 UNIT/ML IJ SOLN,RX-9940,CDM,J0885,HCPCS,0636,RC,59676-0303-01,NDC,,both,1,ML,236.60,153.79,,,,,,,,,,,,,
HEMOSTAT ENDOSCP CATHETER 7FR L220CM ACC CHN 28MM FOR,SUP-2171165,CDM,C1052,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
GRAFT BNE W12XL100MM CORT CANC STRUT FRZ DRY,SUP-2307183,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.90,406.83,,,,,,,,,,,,,
INSERT TIB THICKNESS 10MM UNIV STRP YEL POLYETH PRI NEUT,SUP-2201278,CDM,C1776,CPT,0278,RC,,,,both,,,2541.42,1651.92,,,,,,,,,,,,,
BIT DRL L230MM OD2.5MM 3 FLUT QUIK CPL REUSE,SUP-2343965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1937.13,1259.13,,,,,,,,,,,,,
GRAFT VASC GELSFT L 45 CM DIA22 MM BRANCH DIA11 MM POLYESTER,SUP-2384941,CDM,C1768,CPT,0278,RC,,,,both,,,1504.81,978.13,,,,,,,,,,,,,
SCREW INTRF CANN 7X20 MM 2 MM RND HD TI SOFTSILK CLEAR-TRAC,SUP-2877888,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.65,394.32,,,,,,,,,,,,,
ENDCAP ORTH 15 MM STRL VERSANAIL,SUP-2483523,CDM,C1889,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
TROCAR TIP PLN GUIDWIRE,SUP-2243875,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
RING ACET DIA48MM FOR MOD CUP REPL LCK,SUP-2209081,CDM,C1776,CPT,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
STEM FEM 10X400 MM LT HIP META 400 BIMTRC,SUP-2449902,CDM,C1776,CPT,0278,RC,,,,both,,,16758.18,10892.82,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM OD0.035IN TIP L9CM STR PTFE HEP EXTRA,SUP-2157303,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.94,85.11,,,,,,,,,,,,,
PIN DRL L75MM DIA3.2MM HEX 2.5MM TRCR TIP DISP FOR PERSONA,SUP-2342258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
BASEPLATE TIB SZ 1 L LAT MOD CEM NTRL KN II,SUP-2210157,CDM,C1776,CPT,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
PLATE BNE W175XL336MM THK52MM 18 H ST BILAT S STL BROAD CRV,SUP-2185319,CDM,C1713,HCPCS,0278,RC,,,,both,,,3252.98,2114.44,,,,,,,,,,,,,
SHOE ORTHOT ADDITION INSOLE RUBBER,SUP-2435738,CDM,L3510,HCPCS,0274,RC,,,,both,,,82.77,53.80,,,,,,,,,,,,,
RONGEUR SURG CLEVELAND 4 5.5 IN AUTOCLV SS HIS,SUP-2238355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.13,293.88,,,,,,,,,,,,,
SPLINT WR UNIV PED LT HND COCKUP ALUM STAY INSTABILITY INJ,SUP-2203821,CDM,L3908,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BASKET EXTR L4CM DIA2CM CATH L208CM SHTH 10FR ACC CHN 4.2MM,SUP-2170589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 12MM SMOOTH DISPOSABLE WITH TA,SUP-2809464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,711.27,462.33,,,,,,,,,,,,,
NEEDLE VENTRICULAR POPPEN 12 GAX3-3/8 IN 2 HOLE LUER LCK HUB,SUP-2666375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1301.31,845.85,,,,,,,,,,,,,
LEAD PACE L90CM ENDO LV UNI/BIPOLAR IS-1 SGL ELECTRD PASS,SUP-2148689,CDM,C1786,HCPCS,0275,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
PLATE OLECRANON 3.5MM 8H RT 164MM SS LCP STRL,SUP-2547485,CDM,C1713,HCPCS,0278,RC,,,,both,,,3513.47,2283.76,,,,,,,,,,,,,
IMPLANT FACE L 76 X W 50 MM THK 1.5 MM POLYETHYL EMBEDDED TI,SUP-2883505,CDM,C1713,HCPCS,0278,RC,,,,both,,,4023.88,2615.52,,,,,,,,,,,,,
WIRE PL REDUCTION WIRE 1.25MM /THRDD TIP W/SM STOP/150MM-ST,SUP-2546046,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
CLIP SURG L155CM CHN DIA2.8MM OPN W11IN RESOL 360 20/BX,SUP-2679024,CDM,C1889,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
IMMOBILIZER SHLDR XL L9X22.5IN R/L CANVS W/ WAIST STRP THMB,SUP-2336107,CDM,L3660,HCPCS,0272,RC,,,,both,,,14.60,9.49,,,,,,,,,,,,,
HC MRI-Upper Ext Jnt W Cont,PX-6107322200,CDM,73222,CPT,0610,RC,,,,inpatient,,,3764.00,2446.60,,,,,,,,,,,,,
HEAD HUM ECC 40X18 MM SHLDR AFFINITI,SUP-2715308,CDM,C1776,CPT,0278,RC,,,,both,,,7603.51,4942.28,,,,,,,,,,,,,
BUNDLE CASE ORTHOGNATHIC POSTOP VSP,SUP-2862840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11952.03,7768.82,,,,,,,,,,,,,
LABETALOL HCL 100 MG PO TABS,RX-10373,CDM,6370000000,HCPCS,0637,RC,00904-7451-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE HK SHT 2.7X12 MM RT CLAV VA LCK COMPR STRL VA-LCP,SUP-2750824,CDM,C1713,HCPCS,0278,RC,,,,both,,,3802.79,2471.81,,,,,,,,,,,,,
PROBE NERVE STIM STIMULATING BALL TIP STRL SAFEOP,SUP-2725219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,2500000003,HCPCS,0250,RC,09999-9919-84,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
MATRIX VERIT CLLGN 6X18CM,SUP-2130300,CDM,C9354,HCPCS,0278,RC,,,,both,,,9486.82,6166.43,,,,,,,,,,,,,
STEM FEM L200MM L30MM OD12MM SZ 5 R HIP REV CEM BOW IMPL,SUP-2374699,CDM,C1776,CPT,0278,RC,,,,both,,,12920.47,8398.31,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.021 IN CRV RAD 2 MM STR CRV DBL,SUP-2760070,CDM,C1769,HCPCS,0272,RC,,,,both,,,134.67,87.54,,,,,,,,,,,,,
HC MRI-Angio Neck WO Contrast,PX-6157054700,CDM,70547,CPT,0615,RC,,,,both,,,4844.00,3148.60,,,,,,,,,,,,,
PAD ORTHOT SCOLIOSIS CUST TENS BASE FIT ADJ,SUP-2435569,CDM,L1005,HCPCS,0272,RC,,,,both,,,9061.47,5889.96,,,,,,,,,,,,,
INSERT TIB L54MM THICKNESS 10MM POLYETH CNDYL KNEE REV MOD,SUP-2199886,CDM,C1776,CPT,0278,RC,,,,both,,,9327.37,6062.79,,,,,,,,,,,,,
NAIL IM ARTH 13X540 MM RT T2,SUP-2458403,CDM,C1713,HCPCS,0278,RC,,,,both,,,14907.15,9689.65,,,,,,,,,,,,,
HC Airway Insertion Emergent,PX-3703150000,CDM,31500,CPT,0370,RC,,,,inpatient,,,403.00,261.95,,,,,,,,,,,,,
CLAMP EXT FIX 90DEG PIN ADJ LOK HNG FOR ACUTE TRAUM ILIZ,SUP-2340787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2013.27,1308.63,,,,,,,,,,,,,
INSERT TALAR SZ 1 THK15MM LT UHMWPE SALTO TALARIS,SUP-2244153,CDM,C1776,CPT,0278,RC,,,,both,,,8271.07,5376.20,,,,,,,,,,,,,
IMPLANT TOE JT LESSER MT CANN CO CHROME 1175MM,SUP-2137786,CDM,C1776,CPT,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
GRAFT ENDOVASC L14CM DIA27MM IL LIMB EXCLUDER,SUP-2395963,CDM,C1876,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
PLATE BNE L117MM THK3.7MM 9 H BILAT S STL STR LO PROF RIG,SUP-2184029,CDM,C1713,HCPCS,0278,RC,,,,both,,,2249.53,1462.19,,,,,,,,,,,,,
ADAPTER FEM STEM CC REV TAPR W/ SCR 5DEG EXACTECH,SUP-2223074,CDM,C1776,CPT,0278,RC,,,,both,,,763.81,496.48,,,,,,,,,,,,,
HC Echo Cong. Anom - Lmt W/Ctrst,PX-4839330401,CDM,C8922,HCPCS,0483,RC,,,,both,,,870.00,565.50,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TAPR L 8 CM TIP L 3 CM,SUP-2169795,CDM,C1769,HCPCS,0272,RC,,,,both,,,84.53,54.94,,,,,,,,,,,,,
CONNECTOR SPNL THORLUM LO PROF WIDE PARA FOR 5.5/5.5MM ROD,SUP-2229568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
NEEDLE BONE CEMENT DELIVERY 10 GAX10 CM STERILE,SUP-2838509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.06,245.74,,,,,,,,,,,,,
HC Apply Long Arm Cast,PX-4502906500,CDM,29065,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SCREW BNE ST 4.3X46 MM CANN SD PART THRD TI NS PROPELLER HD,SUP-2474003,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.58,457.33,,,,,,,,,,,,,
PLATE BONE 80MMW X 80MML 06MM THK CP TTNM 3D F/15MM SCREW,SUP-2681435,CDM,C1713,HCPCS,0278,RC,,,,both,,,4919.06,3197.39,,,,,,,,,,,,,
FIBER LASER HOLMIUM 1000 OLYMPUS,SUP-2885433,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
HC Removal Duct Glbldr Calculi,PX-3614754400,CDM,47544,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
CATHETER THROMCTMY XPRESS-WAY DIA 7 FR RX,SUP-2227362,CDM,C1757,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
CATHETER ABLAT SPC M SWP DSTL REACH L4MM BIDIR QPLR THRMCPL,SUP-2357501,CDM,C1730,HCPCS,0272,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC L70CM DIA3MM TEAR DROP,SUP-2480450,CDM,C1769,HCPCS,0272,RC,,,,both,,,424.34,275.82,,,,,,,,,,,,,
INSERT SCRDRVR TORX STARDRV T10 FOR SCREW STRL DISP OPERACE,SUP-2913519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2199.10,1429.41,,,,,,,,,,,,,
CATHETER ANGIO L49CM OD8FR PLCMNT CUT AWAY COR SNUS ACCS,SUP-2148934,CDM,C1887,HCPCS,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
CATHETER URET 4FR L70CM 0.028IN OPN END FLEXITIP FOR DRNGE,SUP-2171268,CDM,C1758,HCPCS,0278,RC,,,,both,,,55.95,36.37,,,,,,,,,,,,,
DRILL ARTHSCP CORACOID,SUP-2418031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
BAR EXT FIX 11X500 MM CARBON XTRAFIX,SUP-2475116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,817.62,531.45,,,,,,,,,,,,,
SCREW INTRF L23MM DIA8MM NONABSORBABLE ADV PEEK MILAGRO,SUP-2419571,CDM,C1713,HCPCS,0278,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
PLIER SURG FOR 2 MM ADPT PLATE LEVEL 1 015101207,SUP-2473376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,980.81,637.53,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC EXCHANGE 14.5 5397190 - ORDER UOM CA,SUP-2632952,CDM,C1750,HCPCS,0278,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
BIT DRL TWST LNG 1.9X105 MM TRANSBUCCAL CYL ATTCH SS LEVEL 1,SUP-2478798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.09,263.31,,,,,,,,,,,,,
CATHETER DLYS L28CM DIA14.5FR SHTH L13CM PLAS TUNN VAXCEL +,SUP-2117117,CDM,C1881,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR CUST SAG CTRL STRP PADDING STAY,SUP-2435556,CDM,L0641,HCPCS,0272,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
BIT DRL TWST 1.9X5 MM ANGLED SCREWDRIVER ANGULUS 2,SUP-2464465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.90,317.78,,,,,,,,,,,,,
ULTRABAG/DIANEAL/2.5% DEXTROSE 395 MOSM/L IP SOLN,RX-21546,CDM,2580000003,HCPCS,0250,RC,00941-0430-53,NDC,,both,1000,ML,69.00,44.85,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 40 X 9 X 1.1 MM POLYETHYL NSL SHT STRL,SUP-2936094,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
COMPONENT ARTC BUTTON 30X7 MM PATELLAR,SUP-2123681,CDM,C1776,CPT,0278,RC,,,,both,,,2160.32,1404.21,,,,,,,,,,,,,
BELL CIRC 3.2 CM REUSE,SUP-2470960,CDM,C1776,CPT,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
CATHETER VASC 6 FR GUID JUDKINS LT 4 COR 90CM LEN W/O,SUP-2143737,CDM,C1887,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
DEVICE STRNL CLSR M D14MM SGL FT TALON PLT BONE,SUP-2262521,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
TUBE FEED 16FR SIL GAST DCOMPR PRT SECUR LOK RETEN RNG MIC,SUP-2124613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1074.95,698.72,,,,,,,,,,,,,
GUIDEWIRE BALL TIP ST PACKAGED INSTR 2.5MMX800MM CENTRONAIL,SUP-2316306,CDM,C1769,HCPCS,0272,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
PLATE BNE INFRAPECTINEAL LG RT QUADRILATERAL SURF STRL PRO,SUP-2470893,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-40840052,CDM,J7050,HCPCS,0250,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
SUTURE ANCHR TWINFIX TI 5MM W/ TWO NO 2 DURABRAID SUT,SUP-2341072,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.40,543.01,,,,,,,,,,,,,
HFN RH 130 DEG 11MM X 400MM,SUP-2488052,CDM,C1713,HCPCS,0278,RC,,,,both,,,6752.38,4389.05,,,,,,,,,,,,,
SCREW BNE LAG 120 MM SLD SLIDING,SUP-2415891,CDM,C1713,HCPCS,0278,RC,,,,both,,,2446.06,1589.94,,,,,,,,,,,,,
SPLINT ORTH L3IN STD PLAS FNGR MLLT W/O PD STAX,SUP-2198709,CDM,L3913,HCPCS,0272,RC,,,,both,,,5.18,3.37,,,,,,,,,,,,,
KIT PICC 5FR L55CM GWIRE L80CM CARBOTHANE S STL 2 LUMN FULL,SUP-2116960,CDM,C1751,HCPCS,0278,RC,,,,both,,,346.34,225.12,,,,,,,,,,,,,
STEM FEM SZ 3 L145MM CALCAR HIP 12/14 TAPR ENDUR,SUP-2420928,CDM,C1776,CPT,0278,RC,,,,both,,,13715.52,8915.09,,,,,,,,,,,,,
SCREW BNE LAG 12.7X90 MM HIP COMPR TALON,SUP-2391518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1948.37,1266.44,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 70 MM DIA12 MM CATH TOT L 116 CM,SUP-2424707,CDM,C1874,HCPCS,0278,RC,,,,both,,,8069.80,5245.37,,,,,,,,,,,,,
NUT TDWRIRE RS,SUP-2653989,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.59,220.73,,,,,,,,,,,,,
EXTENSION STEM CEM 14X110 MM KNEE REV BKS,SUP-2434286,CDM,C1776,CPT,0278,RC,,,,both,,,2273.99,1478.09,,,,,,,,,,,,,
BUR SURG DIA2MM RND TAPR EXT NONFLUTED CUT FOR ELITE SABER,SUP-2363980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.45,273.29,,,,,,,,,,,,,
STEM FEM L200MM OD19MM POR DST CALCAR MOD RLER HARDENED,SUP-2403940,CDM,C1776,CPT,0278,RC,,,,both,,,9455.95,6146.37,,,,,,,,,,,,,
CONTROLLER TRUVIC HOTSHOT,SUP-2855179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE L23MM 4 H NONSTERILE S STL STR LOK COMPR FOR,SUP-2177460,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.30,393.44,,,,,,,,,,,,,
TUBE MYR ID1.27MM WHT FLROPLAS CLLR BTTN FOR OTITIS MEDIA,SUP-2312594,CDM,L8699,HCPCS,0278,RC,,,,both,,,23.33,15.16,,,,,,,,,,,,,
RING EXT FIX SLT 1/8 UNIV SALVATION,SUP-2851105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
GUIDE SURG FOR 2.3MM ICONIX TY,SUP-2366691,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
PLATE SPNL 5.5X30-34 MM SS CROSSLINK MULTI-SPAN,SUP-2630569,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
PLATE SPNL CERV 20 MM ANTR INVIZIA,SUP-2414396,CDM,C1713,HCPCS,0278,RC,,,,both,,,4777.35,3105.28,,,,,,,,,,,,,
PLATE STRNL CLOSURE 8 H TI X WIDE NS STERNALOCK BLU,SUP-2894439,CDM,C1713,HCPCS,0278,RC,,,,both,,,1971.92,1281.75,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE OXIN XLPE,SUP-2351338,CDM,C1776,CPT,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
PLATE BONE 1.2MM TI CRANIOFACIAL 6 H STR MCPLUS,SUP-2363682,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.04,222.33,,,,,,,,,,,,,
CYTAL WOUND MATRIX 3 LAYER LAWD 16X35CM,SUP-2909167,CDM,Q4166,HCPCS,0636,RC,,,,both,,,24190.56,15723.86,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA4MM THRD L30MM CORT S STL SELF DRL,SUP-2186977,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.41,293.42,,,,,,,,,,,,,
GUIDEWIRE VASC ADX L 260 CM DIA 0.025 IN TIP L 3 MM PTFE,SUP-2752481,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.45,26.94,,,,,,,,,,,,,
FIBER SURG LASER DIA272UM OPT DISPOSABLE COMPATIBLE,SUP-2313072,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.91,901.49,,,,,,,,,,,,,
KNIFE SURG BALLENGER 8.25 IN 4X3 MM SWVL BAYNT SHP,SUP-2853086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.62,228.55,,,,,,,,,,,,,
PLATE BNE L 1.2 CM THK 0.5 MM SCREW DIA1.5 MM 2 H SHRT,SUP-2936843,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
OSTEOTOME SURG L67MM DIA6MM FLX HARRIS,SUP-2375015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.03,518.72,,,,,,,,,,,,,
CATHETER OPHTH BLLN L15MM DIA3MM BILAT DCP LACRICATH,SUP-2330966,CDM,C1726,HCPCS,0272,RC,,,,both,,,914.93,594.70,,,,,,,,,,,,,
SLEEVE TROCAR L60MM DIAMETER 5MM THREADED DISPOSABLE WITHOUT,SUP-2803689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.38,238.15,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0025IN HYDRPHLC STD ANG FIX COR,SUP-2302957,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
INSERT TIB L L75MM THK15MM AP46MM L MED LAT ARTC CRUCE RET,SUP-2344101,CDM,C1776,CPT,0278,RC,,,,both,,,3436.73,2233.87,,,,,,,,,,,,,
PLATE BNE W13.5XL250MM THK4.2MM 14 H BILAT S STL NAR LIMIT,SUP-2185252,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.80,546.52,,,,,,,,,,,,,
SCREW BONE CANNULATED 4MM DIA 38MML HIGH TORQUE,SUP-2586597,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.43,760.13,,,,,,,,,,,,,
SPHERE EMB EMBOZENE DIA 40 UM 2 ML PREFIL SYR HYDRGEL BLK,SUP-2139483,CDM,C1889,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SURFACE ARTC TIB CONSTRN SZ 59 30MM I/B II CCK,SUP-2205850,CDM,C1776,CPT,0278,RC,,,,both,,,7000.63,4550.41,,,,,,,,,,,,,
DIGOXIN 125 MCG PO TABS,RX-2444,CDM,6370000000,HCPCS,0637,RC,00904-5921-61,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
GRAFT BNE FIBER 10 CC DBM CORTICAL PUREBONE,SUP-2424608,CDM,C1713,HCPCS,0278,RC,,,,both,,,3470.05,2255.53,,,,,,,,,,,,,
PATCH CV W25XL15CM THK05MM FOR RECON ACUSEAL,SUP-2395324,CDM,C1768,CPT,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
WALKER BOOT HI PRESSURE MED ANK AIR TRIO,SUP-2227874,CDM,L4386,HCPCS,0274,RC,,,,both,,,187.93,122.15,,,,,,,,,,,,,
CATHETER CTRL VEN L8IN OD12FR POLYUR FOR HI VOL INFUS,SUP-2120627,CDM,C1751,HCPCS,0278,RC,,,,both,,,327.19,212.67,,,,,,,,,,,,,
IMPLANT LARYN 24GA 1ML TRNSOR CA HA FILL PERC INJ NONCORING,SUP-2303665,CDM,C1878,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 40 CM DIA 7 FR GUIDEWIRE 0.038 IN,SUP-2355553,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
LEVEL ST TWIST DRILL J NOTCH 21 MM STP15 X 50 MM QT001 EA,SUP-2677985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.92,286.60,,,,,,,,,,,,,
GRAFT BNE CHIP FRZ DRY CANC CORT 1MM 8MM RANG 40CC READIGRFT,SUP-2264693,CDM,C1713,HCPCS,0278,RC,,,,both,,,1317.67,856.49,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.6X4 MM DE LA CRUZ PISTON FLROPLAS,SUP-2458913,CDM,L8613,CPT,0278,RC,,,,both,,,575.28,373.93,,,,,,,,,,,,,
TIBIAL FIXATION KIT 14MM BUTTON,SUP-2811994,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
TRAVASOL 10 % IV SOLN,RX-8074,CDM,2500000003,HCPCS,0250,RC,00338-0644-06,NDC,,both,2000,ML,322.00,209.30,,,,,,,,,,,,,
STAPLE MENIS ABSRB 13MM,SUP-2212870,CDM,C1713,HCPCS,0278,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 150 CM DIA 0.035 IN TIP L 8 CM,SUP-2140130,CDM,C1769,HCPCS,0272,RC,,,,both,,,108.14,70.29,,,,,,,,,,,,,
ANCHOR SUT 93CM 5MM WHT 2 QUICKDRAW MINI BELAY,SUP-2399088,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
CATHETER NERVE BLOCK 19 GAX60 CM 17 GAX8 CM CPNB KT,SUP-2383238,CDM,C1755,HCPCS,0278,RC,,,,both,,,272.52,177.14,,,,,,,,,,,,,
GRAFT BNE FEM HD 4.5 CM W/O CART 6578411730] ZIMMER BIOMET INC],SUP-2210354,CDM,C1776,CPT,0278,RC,,,,both,,,8732.34,5676.02,,,,,,,,,,,,,
STEM FEM L140MM DIA12MM HIP FBR MTL MIDCOAT L MTPHSEAL BODY 78411250] ZIMMER BIOMET INC],SUP-2211306,CDM,C1776,CPT,0278,RC,,,,both,,,9314.50,6054.42,,,,,,,,,,,,,
GRAFT BNE LG GRAN 5-9 MM 30 CC SYNTH W/VI HA PRO OSTEON 500R,SUP-2413087,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-102329,CDM,J3480,HCPCS,0636,RC,00264-7865-00,NDC,JW,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
MESH SURG L 15 X W 15 CM POLYPRO POLYLACTIC ACD GRP,SUP-2901690,CDM,C1781,HCPCS,0278,RC,,,,both,,,2128.42,1383.47,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 6 MM EPTFE STR TW N RING STRL,SUP-2396693,CDM,C1768,CPT,0278,RC,,,,both,,,1494.64,971.52,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 10FR L210CM NDL 25GA OD0.51MM ID0.24MM,SUP-2149312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.37,441.59,,,,,,,,,,,,,
OVERDRILL SURG DIA3.5MM SH W/ AO QUIK CONN DISP FOR SM,SUP-2344048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.41,536.52,,,,,,,,,,,,,
BOLT REPROC CANN WIRE FIX,SUP-2482606,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.40,37.96,,,,,,,,,,,,,
VALVE AORT ATS OPN PVT AP360 DIA18 MM ORIFICE 16.8 MM TISS,SUP-2282691,CDM,C1889,HCPCS,0278,RC,,,,both,,,9840.76,6396.49,,,,,,,,,,,,,
BIT DRL L105MM DIA2MM W/O STP N RADPQ DISP,SUP-2243615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.87,378.22,,,,,,,,,,,,,
SYSTEM AUTOGRFT TRNSF 6MM SM JT OSTEOCHNDRL DISP,SUP-2123216,CDM,C1776,CPT,0278,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR MTL HD SELF CNTR,SUP-2257247,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
STRM CC PLATE LG RT,SUP-2471503,CDM,C1713,HCPCS,0278,RC,,,,both,,,4793.08,3115.50,,,,,,,,,,,,,
ORTHOPAEDIC INSTRUMENT KIT 1 PLNTR PLATE 2 DISTRACTOR STROPP,SUP-2866374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2424.08,1575.65,,,,,,,,,,,,,
HC US Breast Comp,PX-4027664100,CDM,76641,CPT,0402,RC,,,,outpatient,,,1082.00,703.30,,,,,,,,,,,,,
STENT BILI ZILVER FLX 35 L 120 MM DIA 6 MM CATH L 125 CM DIA,SUP-2170731,CDM,C1876,HCPCS,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
INTRODUCER SHTH L62CM DIA55FR HOCK STK TELSCP WORLEY ADV LVI,SUP-2303513,CDM,C1892,HCPCS,0272,RC,,,,both,,,1205.54,783.60,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE MANTA DIA14 FR CLLGN FEM ART FOR VASC,SUP-2740190,CDM,C1760,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
HC Med Nut Therapy Ind Fu 15 Min,PX-9429780300,CDM,97803,CPT,0940,RC,,,,both,,,42.00,27.30,,,,,,,,,,,,,
DEFIBRILLATOR CARD 82GM 43CC W50XH81MM THK14MM IS1 DF1 CONN,SUP-2356310,CDM,C1882,HCPCS,0275,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 40 CM DIA10 MM POLYESTER BOV CLLGN,SUP-2682169,CDM,C1768,CPT,0278,RC,,,,both,,,1877.75,1220.54,,,,,,,,,,,,,
GUIDE SURG SZ 03-05 CT MOD SET FOR TOT KNEE ARTHROPLASTY,SUP-2136776,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HINGE EXT FIX UNIV,SUP-2432233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.64,857.12,,,,,,,,,,,,,
NAIL IM L 200 MM DIA10 MM CARBON FIBER POLYMER ANK ARTH CANN,SUP-2930815,CDM,C1713,HCPCS,0278,RC,,,,both,,,6325.31,4111.45,,,,,,,,,,,,,
BEARING TIB OD65MM THK10MM KNEE ARCM MEDL LAT ARTC POST STBL,SUP-2404969,CDM,C1776,CPT,0278,RC,,,,both,,,2524.56,1640.96,,,,,,,,,,,,,
MESH HERN W15XL25CM OPN TISS SEPARATING PHYSIOMESH,SUP-2219747,CDM,C1781,HCPCS,0278,RC,,,,both,,,5305.97,3448.88,,,,,,,,,,,,,
KIT INTRO L 11 CM DIA 8 FR PERC NO SIDEPRT CRV HEMOSTATIC,SUP-2120107,CDM,C1751,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
CHRONOS TM BETA-TCP BLOCK,SUP-2823512,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.61,567.20,,,,,,,,,,,,,
BLADE ENDO SINUS SERR CONCV ANG TIP CVD IRR 2.9MM DIA 60DEG,SUP-2312775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1.5X12 MM CORTEX CRANIOMAXILLOFACIAL,SUP-2838125,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.19,152.87,,,,,,,,,,,,,
AIRWAY KIT SZ ENDOBRONCHIAL FOR SPIRATION VLV SYS STRL LTX,SUP-2865659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
CAGE SPNL OFFSET 1 PRNG TIP TOP THORLUM PEEK IMP STRL DISP,SUP-2291707,CDM,C1889,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7164,SUP-2525317,CDM,C1769,HCPCS,0272,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
CAGE SPNL 10X12MM ANTR CERV INTBDY FUS BAK/C,SUP-2208743,CDM,C1889,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
VALVE TRACH SPEAK CLR,SUP-2322025,CDM,L8501,HCPCS,0272,RC,,,,both,,,198.61,129.10,,,,,,,,,,,,,
SUTURE POLYPR SZ 2 0 NONABSORBABLE W NDL 520270,SUP-2165324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
INTRODUCER PACE LD CPS DIR SL II L 47 CM DIA10.06 FR SS,SUP-2357577,CDM,C1893,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HEAD FEM CEM 47 MM HIP RESURF RECAP,SUP-2441777,CDM,C1776,CPT,0278,RC,,,,both,,,10126.50,6582.22,,,,,,,,,,,,,
BOOT AMBULTNG BOOT ADL DKBLU,SUP-2272967,CDM,L4397,HCPCS,0272,RC,,,,both,,,170.50,110.82,,,,,,,,,,,,,
HC Nasopharyngoscopy Endoscope,PX-4509251100,CDM,92511,CPT,0450,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
PLATE BNE L103MM 6 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185272,CDM,C1713,HCPCS,0278,RC,,,,both,,,1081.51,702.98,,,,,,,,,,,,,
PASSER SUTURE ERGO DESIGN 150 MM LT SS NS REUSE,SUP-2762075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
DRIVER PLT ASMBLY SNOWCAP ANTR CERV LANX,SUP-2136802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
STENT CORONARY ORSIRO L 15 MM DIA 3.5 MM DEL SYS L 140 CM,SUP-2501377,CDM,C1874,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
OPHTHALMOLOGY EQUIP CRWFRD/BELLAN PGTL PRB THE CRWFRD/BELLAN,SUP-2247575,CDM,C1784,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
STAPLER INT SZ 23MM H1.5-2.2MM OPN LEG L5.2MM PWR ADJ HT W/,SUP-2218868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1430.62,929.90,,,,,,,,,,,,,
CATHETER HD 14 FRX24 CM ASH SPLIT CATH,SUP-2269497,CDM,C1750,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
SLING GYN POLYPR TRNSVAG MID URETH SYS DESARA BLU TV,SUP-2152277,CDM,C1771,HCPCS,0278,RC,,,,both,,,3378.64,2196.12,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED XL AB GLEN COMPHSVE REVERSED,SUP-2417334,CDM,C1776,CPT,0278,RC,,,,both,,,26206.44,17034.19,,,,,,,,,,,,,
PLATE BNE LADDER MED 1.5X0.8 MM MIDFACE 16 HOLE W/ TAB NS,SUP-2498095,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.17,571.46,,,,,,,,,,,,,
HC Iadna Sarscov2& Inf a&B Mult Amp Probe,PX-3068763600,CDM,87636,CPT,0306,RC,,,,both,,,170.00,110.50,,,,,,,,,,,,,
COMPONENT HNG TIB LIMB SALV LO BODY W/ ROTATIONAL STP,SUP-2314041,CDM,C1776,CPT,0278,RC,,,,both,,,10622.62,6904.70,,,,,,,,,,,,,
PI PICC KIT 2-L 5 FR X 55 CM AGBA/TIPTRACKER,SUP-2565196,CDM,C1751,HCPCS,0278,RC,,,,both,,,664.52,431.94,,,,,,,,,,,,,
CATHETER GUID MP OUTER CPS DIR SL,SUP-2357293,CDM,C1887,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
STEM FEM PRSS FT 2 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267796,CDM,C1776,CPT,0278,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
SPACER FEM SZ 0 LT MEDL CONSTRN REV CEM NP N-K II,SUP-2209254,CDM,C1776,CPT,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
HEAD RAD H26MM DIA15.5MM +2MM OFFSET BILAT ELBW CO CHROM,SUP-2183049,CDM,C1776,CPT,0278,RC,,,,both,,,6585.99,4280.89,,,,,,,,,,,,,
SYSTEM THERMOABLATION COBRA FUSION MAG RETRV W/ CAP TBNG,SUP-2124419,CDM,C1713,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
CROTALIDAE POLYVAL IMMUNE FAB IV SOLR,RX-29313,CDM,J0840,HCPCS,0636,RC,50633-0110-12,NDC,,both,1,UN,9434.10,6132.16,,,,,,,,,,,,,
BIT DRL L 2.09 IN DIA1.1 MM STP 5 MM SS NS DISP TRAUMAONE IQ,SUP-2935223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.4MM S STL CANC SELF DRL CANN,SUP-2184192,CDM,C1713,HCPCS,0278,RC,,,,both,,,487.42,316.82,,,,,,,,,,,,,
DEVICE BIOPSY KYPHOPLASTY,SUP-2823540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FOX + L 135 CM BALLOON L 120 MM DIA 4 MM,SUP-2102230,CDM,C1725,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SPACER SPNL SPIKLS 0 DEG 14X14X25-29 MM 14 MM TI FORTIFY I-R,SUP-2594895,CDM,C1821,HCPCS,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
BRACE THMB AD SM FOR 6-6.875IN LT MCP BLK ALIDRY FAB BRTH,SUP-2323970,CDM,L3931,HCPCS,0272,RC,,,,both,,,92.50,60.12,,,,,,,,,,,,,
GUIDEWIRE VASC PIGGYBACK L 145 CM DIA 0.014 IN PERIPH WIRE,SUP-2383210,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.77,14.80,,,,,,,,,,,,,
HC Adult Sleep Study (Polysomnogram),PX-9209581000,CDM,95810,CPT,0920,RC,,,,outpatient,,,5628.00,3658.20,,,,,,,,,,,,,
LINER ACET NEUT J 36 MM PROV G7,SUP-2440215,CDM,C1776,CPT,0278,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
SCREW BNE CANC 6.5X30 MM NO-PROFILE,SUP-2608692,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.82,384.03,,,,,,,,,,,,,
WEDGE TIB M SZ 1 THK10MM KNEE PRI PRESSFIT FULL FLAT BLK,SUP-2377113,CDM,C1776,CPT,0278,RC,,,,both,,,3244.25,2108.76,,,,,,,,,,,,,
GRAFT BNE SPNG 50X10X7 MM DBM CANC,SUP-2641785,CDM,C1713,HCPCS,0278,RC,,,,both,,,4621.77,3004.15,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1275108FD4,SUP-2632807,CDM,C1751,HCPCS,0278,RC,,,,both,,,745.44,484.54,,,,,,,,,,,,,
STAPLE INT BRDG W30MM LEG L30XL30MM WIRE DIA2X3MM NIT,SUP-2194230,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
DEVICE VASC CLOSURE ANGIO-SEAL EVOLUTION DIA 6 FR GUIDEWIRE,SUP-2385256,CDM,C1760,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.125X9 IN RND END SS NS STEINMANN,SUP-2791376,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
HC Pump Refill,PX-5109599000,CDM,95990,CPT,0510,RC,,,,both,,,1112.00,722.80,,,,,,,,,,,,,
IMPLANT TOE L16MM 0DEG PROX INTERPHALANGEAL NIT NEUT 1 PC IM,SUP-2365954,CDM,C1713,HCPCS,0278,RC,,,,both,,,2583.12,1679.03,,,,,,,,,,,,,
TM TIBIAL CONE LARGE 55 X 36 LEFT,SUP-2502241,CDM,C1776,CPT,0278,RC,,,,both,,,9558.16,6212.80,,,,,,,,,,,,,
CHEEK RETRACTOR RING,SUP-2827971,CDM,C1713,HCPCS,0278,RC,,,,both,,,934.15,607.20,,,,,,,,,,,,,
SCREW BNE OP LOK 55 X 36MM,SUP-2401214,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM W/O PAT POROUS HA,SUP-2365948,CDM,C1776,CPT,0278,RC,,,,both,,,11897.46,7733.35,,,,,,,,,,,,,
NEXGEN LPS ART SURF EF 3-4/STR YEL 17MM,SUP-2208733,CDM,C1776,CPT,0278,RC,,,,both,,,2413.40,1568.71,,,,,,,,,,,,,
BRACE ORTHOPEDIC ABDUCTN HIP,SUP-2388159,CDM,L1686,HCPCS,0274,RC,,,,both,,,4779.08,3106.40,,,,,,,,,,,,,
UPCHARGE KNEE TRITANIUM X3 PATELLA STRYKER,SUP-2501353,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CLASSIC COILED 3 CM DISTANCE CUFFS 42 CM INFANT,SUP-2700449,CDM,C1750,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
PROBE NERVE STIM BALL TIP STRL DISP,SUP-2517604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER THROMCTMY SYM L 85 CM SHTH 24 FR GUIDEWIRE 0.035 IN,SUP-2887256,CDM,C1757,HCPCS,0272,RC,,,,both,,,28244.30,18358.79,,,,,,,,,,,,,
PLATE BNE L 55 MM SCREW DIA2.4/2.7 MM 6 HD 3 SHFT H RT DSTL,SUP-2913635,CDM,C1713,HCPCS,0278,RC,,,,both,,,4373.49,2842.77,,,,,,,,,,,,,
KIT DBS CONN PLUG STRL DISP SENSIGHT,SUP-2883136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SET TRACH 26-28FR LD DIL EXCHG WEINMANN,SUP-2170062,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
CAGE SPNL LORDTC 10-30 DEG 22X50X16 MM STAND-ALONE SAHARA,SUP-2520312,CDM,C1889,HCPCS,0278,RC,,,,both,,,44854.90,29155.68,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL LNG RT LAT STRADDLE,SUP-2751254,CDM,C1713,HCPCS,0278,RC,,,,both,,,6899.37,4484.59,,,,,,,,,,,,,
HC So1 Immunoglobulinige,PX-3018278567,CDM,82785,CPT,0301,RC,,,,both,,,48.00,31.20,,,,,,,,,,,,,
COIL EMB L40CM DIA8MM 0.02IN PERIPH COMPLX STD FRME,SUP-2323669,CDM,C1889,HCPCS,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
WIRE ORTH TROCHANTERIC S STL L24IN OD.048IN,SUP-2342789,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.57,154.42,,,,,,,,,,,,,
COLLAR CERV SM FOAM LF,SUP-2330406,CDM,L0120,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE L 51 X W 19.94 MM THK 0.6 MM SCREW DIA1.5 MM SM TI,SUP-2936520,CDM,C1713,HCPCS,0278,RC,,,,both,,,2609.34,1696.07,,,,,,,,,,,,,
PACEMAKER CARD PHILOS SR TI POLYUR SIL SINGLE CHMBR IS1 UPLR,SUP-2138488,CDM,C1786,HCPCS,0275,RC,,,,both,,,8333.56,5416.81,,,,,,,,,,,,,
TIP ASPIR L4.5IN OD1.92MM ID1.5MM SFT TISS SPETZLER,SUP-2367532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1966.61,1278.30,,,,,,,,,,,,,
Needle Biopsy Craig Vertebral Body 24-2507,SUP-2853279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.94,306.76,,,,,,,,,,,,,
PROSTHESIS VOICE LO PRSS 16FR SZ 18MM BLOM SINGER,SUP-2242312,CDM,L8509,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
CATHETER PERF L154CM OD4.1 3.4FR ID.032IN PROX WRK POS CONT,SUP-2323622,CDM,C1757,HCPCS,0272,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
SCREW INTRF L23MM DIA7MM BIO-TENODESIS,SUP-2121350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
PLATE BONE L85MM 7 H S STL SELF COMPR FOR 3.5MM SCR ECT,SUP-2198565,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.63,222.06,,,,,,,,,,,,,
CATHETER ETER MIC OD 21 AND 17 TIP 90 DEG ECHELON 10,SUP-2172499,CDM,C1887,HCPCS,0272,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
NUT SPINE LCK FIX TI FOR OMEGA 21 SYS,SUP-2414724,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.91,123.44,,,,,,,,,,,,,
BRACE WLK SM SHOE MAN 4 7 WOMAN 5 8 SHT PNEUMAT SEMI RIG,SUP-2196357,CDM,L4361,HCPCS,0274,RC,,,,both,,,113.35,73.68,,,,,,,,,,,,,
SPLINT ORTH PNEUMATIC ANK FT CTRL,SUP-2388196,CDM,L4350,HCPCS,0274,RC,,,,both,,,246.96,160.52,,,,,,,,,,,,,
COMPONENT FEM 54MM R MED L LAT CO CHROM MOLYBDENUM REPICCI,SUP-2403265,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PLATE BNE L150MM THK3.4MM 11 H BILAT S STL STR LOK COMPR,SUP-2185144,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.11,665.67,,,,,,,,,,,,,
LIDOCAINE HCL 1% INJ (MIXTURES ONLY),RX-430017,CDM,J2003,HCPCS,0636,RC,63323-0485-27,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,0250,RC,00409-7418-03,NDC,,both,500,ML,382.40,248.56,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC DBM FLOWABLE FIBER AMBIENT STOR,SUP-2933199,CDM,C1762,CPT,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
COMPONENT TIB SZ 1 KNEE TY ROT HNG IMP MOST OPTIONS,SUP-2208384,CDM,C1776,CPT,0278,RC,,,,both,,,12688.74,8247.68,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 1MM 4MM RANG 40CC READIGRFT,SUP-2264741,CDM,C1713,HCPCS,0278,RC,,,,both,,,3822.54,2484.65,,,,,,,,,,,,,
WRAP SHLDR L THERMOSKIN,SUP-2324274,CDM,L3650,HCPCS,0272,RC,,,,both,,,139.01,90.36,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA11 FR CANN L 11 CM POLYUR PLAS SS STD,SUP-2157384,CDM,C1894,HCPCS,0272,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 62 CM DIA10 FR DIL L 67 CM,SUP-2357190,CDM,C1894,HCPCS,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - 12 Visits,PX-9900000059,CDM,9900000059,LOCAL,0990,RC,,,,both,,,60.00,39.00,,,,,,,,,,,,,
GUIDE GRFT ANCHR HELI-FX WORKING L 62 CM DIA16 FR DEFLECTED,SUP-2749556,CDM,C1768,CPT,0278,RC,,,,both,,,5529.54,3594.20,,,,,,,,,,,,,
K WIRE FIX L152MM DIA0.9MM DST VOLAR RAD STD TIP GEMINUS,SUP-2340261,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.07,52.05,,,,,,,,,,,,,
HC So Hiv1 Probe|UNUSUAL NON-OVERLAPPING SERVICE,PX-3068753568,CDM,87535,CPT,0306,RC,,,XU,outpatient,,,118.00,76.70,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA2 L 204 MM DIA 42 MM SHTH 20 FR,SUP-2911980,CDM,C1768,CPT,0278,RC,,,,both,,,67535.12,43897.83,,,,,,,,,,,,,
TRIAL BONE PLT 7 H RT LAT TIB BTTRS TC-100 L FRAG SYS,SUP-2343736,CDM,C1713,HCPCS,0278,RC,,,,both,,,6015.46,3910.05,,,,,,,,,,,,,
PLATE BNE LG TI ORBIT 3D PRNT NS DISP ACCUPLATE,SUP-2934779,CDM,C1713,HCPCS,0278,RC,,,,both,,,34926.22,22702.04,,,,,,,,,,,,,
SHEATH PROTCT FOR G27 AND M3 TELESCOPES SCOPEGUARD,SUP-2313552,CDM,C1894,HCPCS,0272,RC,,,,both,,,155.59,101.13,,,,,,,,,,,,,
CAGE SPINAL CERVICAL CAVUX 4MM SPINAL-X TITANIUM,SUP-2859207,CDM,C1889,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
ROCURONIUM BROMIDE 50 MG/5ML IV SOLN,RX-95811,CDM,2500000003,HCPCS,0250,RC,00143-9250-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
AMIODARONE HCL 900 MG/18ML IV SOLN,RX-97605,CDM,J0282,HCPCS,0636,RC,67457-0153-18,NDC,,both,3,ML,54.10,35.16,,,,,,,,,,,,,
ANCHOR SUT 3.5MM NO 0 TI DBL STRND NDL FORC FBR INSITE FT,SUP-2388905,CDM,C1713,HCPCS,0278,RC,,,,both,,,1424.30,925.79,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL THCK 7X3 CMX0.8-1.7 MM FLEXHD,SUP-2307465,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2140.29,1391.19,,,,,,,,,,,,,
DHHS HELIX BLADE 100MM-STERILE,SUP-2547631,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.44,770.54,,,,,,,,,,,,,
PIN GUIDE TILINK-P,SUP-2937175,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM DIA2MM S STL NTHRD SPADE PNT,SUP-2186892,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.39,61.35,,,,,,,,,,,,,
GRAFT BONE 100X20MM FEM CORT STRUT,SUP-2281642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3747.28,2435.73,,,,,,,,,,,,,
ROD SPNL L50MM DIA6.35MM R POST TI ALLY CRV SMOOTH LEG,SUP-2289186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
PLATE BONE COMPRESSION SMALL 195 MM PELVIC 15 HOLE CONTOURED,SUP-2837526,CDM,C1713,HCPCS,0278,RC,,,,both,,,4142.29,2692.49,,,,,,,,,,,,,
"HC So Htlv or Hiv Ab, Western Blot",PX-3028668966,CDM,86689,CPT,0302,RC,,,,both,,,183.00,118.95,,,,,,,,,,,,,
TERAZOSIN HCL 1 MG PO CAPS,RX-14550,CDM,6370000000,HCPCS,0637,RC,59746-0383-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HEAD FEM SZ 38MM CO CHROM ALLOY HIP RESURF CEM RECAP,SUP-2409290,CDM,C1776,CPT,0278,RC,,,,both,,,10126.50,6582.22,,,,,,,,,,,,,
CATHETER INFUSION 3X2.8 FRX130 CM 0.027 IN STR HIFLO,SUP-2141056,CDM,C1887,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
HC Perc Balloon Valvuloplasty; Mitral Valve,PX-4819298700,CDM,92987,CPT,0481,RC,,,,both,,,35312.00,22952.80,,,,,,,,,,,,,
DEVICE SPNL FIX TOP ANTR CERV TI 12MM LEN SPINELINK,SUP-2165649,CDM,C1894,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
PLATE BNE TIB NEUT 2.7/3.5X172 MM RT DSTL 10 HOLE VA LCK LP,SUP-2177679,CDM,C1713,HCPCS,0278,RC,,,,both,,,5760.14,3744.09,,,,,,,,,,,,,
SHEATH CATH 11.5FR L72CM ID8.5FR CRV L30MM SM SFT TIP,SUP-2248641,CDM,C1766,CPT,0272,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
APPLIER PORT GASTRIC BAND DISPOSABLE RAPIDPORT EZ,SUP-2119242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 80 MM DIA14 MM DEL SYS L 80 CM,SUP-2158669,CDM,C1876,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
RESERVOIR CSF 1.26ML FLSH 2.5CM STD DOME FLAT BTM W/ SM,SUP-2239246,CDM,C1889,HCPCS,0278,RC,,,,both,,,2285.92,1485.85,,,,,,,,,,,,,
KNIFE SURG BALLENGER SWVL 5 MM BAYNT MICROFRANCE,SUP-2485370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2380.65,1547.42,,,,,,,,,,,,,
ROD EXT FIX L400MM DIA11MM C FBR MR CONDITIONAL 39487] DEPUY SYNTHES USA],SUP-2188665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.50,454.67,,,,,,,,,,,,,
TUBE VENT W98XL12MM DIA114MM BLU ULTRASIL SIL T RICHARD,SUP-2313875,CDM,L8699,HCPCS,0278,RC,,,,both,,,63.96,41.57,,,,,,,,,,,,,
STEM ULN HD 6.5 MED PART MOD REPL 1ST CHOICE,SUP-2610439,CDM,C1776,CPT,0278,RC,,,,both,,,12501.34,8125.87,,,,,,,,,,,,,
SCREW BNE CANC 5X80 MM 32 MM FEM ST THRD TI STRL NCB,SUP-2458223,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.34,275.82,,,,,,,,,,,,,
GRAFT DERM ALLGRFT DERM 1MM 16X20CM CORTIVA,SUP-2335287,CDM,C1762,CPT,0278,RC,,,,both,,,24598.13,15988.78,,,,,,,,,,,,,
PLATE EXT FIX 115MM 10 H SH FOR ILIZ,SUP-2340711,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.66,892.88,,,,,,,,,,,,,
PLATE BNE PERIARTICULAR 2.7/3.5X220 MM LT DSTL PL 18 HOLE SS,SUP-2410561,CDM,C1713,HCPCS,0278,RC,,,,both,,,2297.60,1493.44,,,,,,,,,,,,,
OSS 9CM ELLIPT PROX TIB BODY,SUP-2506415,CDM,C1776,CPT,0278,RC,,,,both,,,19739.61,12830.75,,,,,,,,,,,,,
PLATE BONE LOCKING SMALL 3.5X243X11X3.4 MM 16 HOLE COMPRESSI,SUP-2837438,CDM,C1713,HCPCS,0278,RC,,,,both,,,6350.49,4127.82,,,,,,,,,,,,,
IMMOBILIZER ORTH 2 AXIS LNG 26 IN 36 IN KNEERANGER II,SUP-2197134,CDM,L3702,HCPCS,0274,RC,,,,both,,,122.62,79.70,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 80 MM FRZN,SUP-2294143,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
BIT DRL TAPR 4.3X16 MM GUID TWST REG PLATFORM,SUP-2430147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.76,430.14,,,,,,,,,,,,,
COLLAR CERV M W4XL21IN FIRM FOAM SERP STYL WSH,SUP-2276597,CDM,L0120,HCPCS,0272,RC,,,,both,,,7.38,4.80,,,,,,,,,,,,,
GRAFT BNE H11XL21MM PARA PLIF FRZN TEXT VERTIGRFT VG 2,SUP-2264963,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.79,5307.11,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 4 FRX11 CM W/O GUIDEWIRE SUPER SHTH,SUP-2464025,CDM,C1894,HCPCS,0272,RC,,,,both,,,29.83,19.39,,,,,,,,,,,,,
DRILL SURG PERIPH REV PINNACLE,SUP-2454006,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
STEM FEM 34-B MAG NK W/ TRUNNION SIRIUS,SUP-2442945,CDM,C1776,CPT,0278,RC,,,,both,,,946.71,615.36,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON SM 8 IN LT WRST PLUSH FOAM LNR NYL,SUP-2276659,CDM,L3908,HCPCS,0274,RC,,,,both,,,17.05,11.08,,,,,,,,,,,,,
HEAD FEM OD32MM -5MM NK OFFSET C TAPR CO CHROM MTL ON POLY,SUP-2408736,CDM,C1776,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
GUIDEWIRE VASC ARISTOTLE 14 L 200 CM DIA 0.014 IN SFT,SUP-2656731,CDM,C1769,HCPCS,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
KIT PICC CATH L 50 CM DIA 6 FR GUIDEWIRE 0.018 IN NDL L 7 CM,SUP-2884237,CDM,C1751,HCPCS,0278,RC,,,,both,,,947.24,615.71,,,,,,,,,,,,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-106538,CDM,J0670,HCPCS,0636,RC,63323-0294-27,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
STRIP SCLER L125MMXW5MM THICKNESS 1MM SIL SLD TRAP DOOR,SUP-2213472,CDM,C1784,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
PROBE LITHO OD3.3FR REINF ST DISP,SUP-2332792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
DISTRACTION INTRNL DIST LFRT 3MNO MESH MDFCE END DRV BODY 1,SUP-2681267,CDM,C1713,HCPCS,0278,RC,,,,both,,,12532.34,8146.02,,,,,,,,,,,,,
KIT HEMO DYLS OR HD CATH 15.5FR L28CM STD CHRONIC PEEL AWAY,SUP-2120053,CDM,C1751,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DECANAV L 115 CM DIA 7 FR 10,SUP-2764134,CDM,C1732,HCPCS,0272,RC,,,,both,,,2417.49,1571.37,,,,,,,,,,,,,
POST EXT FIX 1 H M,SUP-2898407,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CROWN FORM DENT STRP U3 PRIMARY ANTR UPPER RT LAT PLAS,SUP-2322250,CDM,D6783,CPT,0278,RC,,,,both,,,40.76,26.49,,,,,,,,,,,,,
BAND GAST W/ CALIB TUBE,SUP-2257756,CDM,C1889,HCPCS,0278,RC,,,,both,,,9949.88,6467.42,,,,,,,,,,,,,
GRAFT VASC HEMSHLD VANTAGE L 40 CM DIA 7 MM POLYESTER BOV,SUP-2266060,CDM,C1768,CPT,0278,RC,,,,both,,,1291.11,839.22,,,,,,,,,,,,,
CATHETER DEL CARR L 152 CM MED HYDRPHLC 1 LUMEN COMP VAR PK5,SUP-2912310,CDM,C1887,HCPCS,0272,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 10/50CM WATER WITH BURR HOLE RESERVIOR N,SUP-2821795,CDM,C1889,HCPCS,0278,RC,,,,both,,,6900.18,4485.12,,,,,,,,,,,,,
PLATE BNE T 3.5X75 MM 5 HOLE OBLQ FOR SM FRAG SS,SUP-2431715,CDM,C1713,HCPCS,0278,RC,,,,both,,,391.97,254.78,,,,,,,,,,,,,
ROD SPNL L120MM DIA3.5MM RT POST OCCIPITAL CERV THOR TI,SUP-2256391,CDM,C1713,HCPCS,0278,RC,,,,both,,,3631.41,2360.42,,,,,,,,,,,,,
PLATE BONE L102MM 3 H TI RT DSTL DORSOLATERAL HUM FOR 3.5MM,SUP-2418397,CDM,C1713,HCPCS,0278,RC,,,,both,,,2815.95,1830.37,,,,,,,,,,,,,
BLADE KEL 2INX3IN BKWALT,SUP-2382391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.25,812.01,,,,,,,,,,,,,
BETAXOLOL HCL 0.25 % OP SUSP,RX-19703,CDM,6370000000,HCPCS,0637,RC,00078-0729-10,NDC,,both,10,ML,1825.40,1186.51,,,,,,,,,,,,,
EXTENDER BONE GRFT 15ML CUBE CANC,SUP-2165575,CDM,C1762,CPT,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
STEM FEM REV CEM LT SZ 13 300MM LEN MALLORY-HEAD - LT SZ 13,SUP-2403331,CDM,C1776,CPT,0278,RC,,,,both,,,18227.70,11848.00,,,,,,,,,,,,,
COLLAR CERV SFT BABY FIRM DENS NO NK STFFNK SN6] PENNCARE],SUP-2323344,CDM,L0140,HCPCS,0274,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
PIN FIX L200MM DIA5MM S STL W/ CTRL THRD STNMN,SUP-2186935,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.73,227.32,,,,,,,,,,,,,
CASSETTE EXPIRATORY SERVO-N,SUP-2747090,CDM,C1713,HCPCS,0278,RC,,,,both,,,2743.58,1783.33,,,,,,,,,,,,,
CATHETER ART DL 0.025 IN 7 FRX110 CM MONITORING,SUP-2798491,CDM,C1727,CPT,0278,RC,,,,both,,,88.36,57.43,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.035IN TAPR L6CM FLPY TIP L2.5CM,SUP-2167613,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.96,19.47,,,,,,,,,,,,,
SET INTRO PED 4FR L10CM GWIRE L40CM DIA0018IN NDL 21GA,SUP-2170552,CDM,C1894,HCPCS,0272,RC,,,,both,,,73.98,48.09,,,,,,,,,,,,,
INTRODUCER LD L14CM OD9FR 0.038IN STD PLCMNT PEEL AWAY COR,SUP-2357076,CDM,C1892,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 70X0.6 MM RIGID TI SLV STRL,SUP-2859914,CDM,C1713,HCPCS,0278,RC,,,,both,,,4764.64,3097.02,,,,,,,,,,,,,
CATHETER VENTRICULAR DRAINAGE PEDIATRIC SMALL L180MM WITH ST,SUP-2825902,CDM,C1729,HCPCS,0272,RC,,,,both,,,977.70,635.50,,,,,,,,,,,,,
BUR NEUROSURGICAL L10CM DIA5MM S STL CUT RND BALL FLUT,SUP-2277615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,310.48,201.81,,,,,,,,,,,,,
ALLOGRAFT BNE INJ 2.5 CC FD DBM DBX,SUP-2737040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.31,926.45,,,,,,,,,,,,,
ANCHOR SUT BLU ORTHOCORD BIOKNOTLESS +,SUP-2249364,CDM,C1713,HCPCS,0278,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
PLATE BNE W10.2XL234MM THK2.7MM 18 H BILAT S STL STR LO,SUP-2186204,CDM,C1713,HCPCS,0278,RC,,,,both,,,2014.25,1309.26,,,,,,,,,,,,,
INSERT TIB L59MM THK20MM UNIV KNEE PRI CRUC RET NEUT LIP,SUP-2407111,CDM,C1776,CPT,0278,RC,,,,both,,,2898.22,1883.84,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BIB L 110 CM DIA 8 FR BALLOON L 3.5 CM,SUP-2309671,CDM,C1725,HCPCS,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
HC So Assay Thiopurine S-Methyltransferase,PX-3018443366,CDM,84433,CPT,0301,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
PLATE BONE L25X10MM 100DEG 2X3 H RT CRANIOMAXILLOFACIAL TI L,SUP-2191280,CDM,C1713,HCPCS,0278,RC,,,,both,,,817.66,531.48,,,,,,,,,,,,,
PLATE SPNL L14MM ANT CERV LOK BILAT LEV 1 PROVIDENCE,SUP-2229837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
BLADE RTRCTR BLFR 2 1/2ND ABDMNL WIRE LTRL JARIT NON ST,SUP-2499447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.47,225.21,,,,,,,,,,,,,
CATHETER ABLATION SHFT L 110 CM DIA 7.5 FR TIP L 4 MM QD,SUP-2890503,CDM,C2630,CPT,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SHANK SPNL SCREW L 55 MM DIA 7.5 MM OSTEOGRIP STRL CD HORZ 2PK,SUP-2928492,CDM,C1713,HCPCS,0278,RC,,,,both,,,2686.58,1746.28,,,,,,,,,,,,,
GRAFT BNE 5 CC SUBSTITUTE VITOSS FOAM,SUP-2361122,CDM,C1713,HCPCS,0278,RC,,,,both,,,4816.76,3130.89,,,,,,,,,,,,,
TUBE TRACH NEO L86MM OD53MM ID35MM SIL CUF STR NK FLNG W,SUP-2352027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,629.76,409.34,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|ADJ,PX-4209753000,CDM,97530,CPT,0420,RC,,,KX|CQ|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
GRAFT BNE PTTY 8 CC MOLD DBM XEMPLIFI +,SUP-2423035,CDM,C9359,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
PLATE FOOT 140MM,SUP-2696086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5013.32,3258.66,,,,,,,,,,,,,
IMPLANT ORBIT SM W32XH13XL35MM THK1.2MM RT 3D FLR W/,SUP-2365170,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
VANICREAM EX CREA,RX-12863,CDM,6370000000,HCPCS,0637,RC,00299-3917-56,NDC,,both,453,GR,60.30,39.19,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 58 MM DIA22 MM SHTH 18 FR SS,SUP-2750387,CDM,C1768,CPT,0278,RC,,,,both,,,6258.02,4067.71,,,,,,,,,,,,,
SCREW SPNL L16MM DIA4.2MM ANT CERV SELF DRL VAR ANG LOK ADV,SUP-2229911,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE MEDL SLIM 15 HOLE SYS IMPL INSTRUMENT AXIS,SUP-2610175,CDM,C1713,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 15MM KNEE REV FULL STP LEGION,SUP-2346596,CDM,C1776,CPT,0278,RC,,,,both,,,5474.59,3558.48,,,,,,,,,,,,,
ENDCAP SPNL OD13MM 4DEG TI CO CHROM NIT T2 ALTITUDE,SUP-2292807,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
STAPLER INT CARTRIDGE MED THCK 80 MM W/ TRI-STAPLE PUR GIA,SUP-2787698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.89,788.38,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN (ADD-VANTAGE)|DISCARDED DRUG NOT ADMINISTE,RX-40860021,CDM,J7060,HCPCS,0250,RC,00409-7100-02,NDC,JW,both,250,ML,48.90,31.78,,,,,,,,,,,,,
SLEEVE FIX L 30 MM DIA2.1 MM BND 2 X 0.75 MM SIL TYP 70 STRL,SUP-2930290,CDM,C1784,HCPCS,0278,RC,,,,both,,,41.86,27.21,,,,,,,,,,,,,
INSERT TIBIAL LCS COMP VVC INS STD+ 20MM,SUP-2512984,CDM,C1776,CPT,0278,RC,,,,both,,,5851.70,3803.60,,,,,,,,,,,,,
SPACER SPNL 3 MM SFS,SUP-2601816,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
HC Inj/Asp Maj Jnt or Bursa|BILATERAL PROCEDURE,PX-7612061000,CDM,20610,CPT,0761,RC,,,50,both,,,1092.00,709.80,,,,,,,,,,,,,
SCREW SPNL SACR AND SACROILIAC S STL 6.5MMX30MM COLORADO 2,SUP-2290490,CDM,C1713,HCPCS,0278,RC,,,,both,,,2913.92,1894.05,,,,,,,,,,,,,
BLADE RETRACTOR HARRINGTON UNIV PEDIATRIC 2X8 IN ABD RNG,SUP-2459816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,892.14,579.89,,,,,,,,,,,,,
BIT DRL L110X85MM DIA2MM 2 FLUT MRK FOR QUIK CPL,SUP-2187312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.91,196.24,,,,,,,,,,,,,
SCREW BONE L6MM PAN FIX LUHR,SUP-2364707,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.13,85.88,,,,,,,,,,,,,
TROCAR OPHTH OD23GA CANN STD ALONE PRB FOR CONSTELLATION,SUP-2109938,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
GRAFT BNE INJ 4 CC INDUCTIVE EXTREMITY PRO-STIM,SUP-2759538,CDM,C1713,HCPCS,0278,RC,,,,both,,,4741.40,3081.91,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 6 H SCREW DIA2 MM MED TI MIDFACE GLD,SUP-2883838,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
MESH HERN W20XL30CM THN OXIDIZED REGENERATED CELOS POLYPR,SUP-2219763,CDM,C1781,HCPCS,0278,RC,,,,both,,,5209.35,3386.08,,,,,,,,,,,,,
PLATE POLYAX LK LAT COL LENGTHING 0MM,SUP-2462335,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CATHETER TEMP PACE DIA 5 FR TRNSVEN BPLR BALLOON,SUP-2126032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
ASPIRIN 325 MG PO TBEC,RX-685,CDM,6370000000,HCPCS,0637,RC,57896-0921-01,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
ALLOGRAFT BNE CERV 4.75X6.22 MM LORDTC VERTIGRAFT VG2,SUP-2264651,CDM,C1889,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
GRAFT VASC GELSFT L 25 CM DIA22 MM POLYESTER GEL ABD PERIPH,SUP-2384949,CDM,C1768,CPT,0278,RC,,,,both,,,1228.24,798.36,,,,,,,,,,,,,
HINGE EXT FIX UNIV KNEE COMPASS,SUP-2342861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,58723.02,38169.96,,,,,,,,,,,,,
BIT DRL L102MM OD1.6MM 10-20MM STP SAG SPL SHFT END,SUP-2366425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,826.10,536.96,,,,,,,,,,,,,
SCREW SPNL L9MM DIA2.6MM TI ST FOR PLT FIX SYS CENTERPIECE,SUP-2290250,CDM,C1713,HCPCS,0278,RC,,,,both,,,149.15,96.95,,,,,,,,,,,,,
SET FIX DSTL RAD VOLAR DSTL RAD D-RAD,SUP-2347937,CDM,C1713,HCPCS,0278,RC,,,,both,,,5192.78,3375.31,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC DEPTH GZ LG 3.2 MM REUSE,SUP-2223920,CDM,C1769,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
GRAFT HUM TISS AMBIENT 0.5 CC FLOWABLE PLCNTA TISS VIAFLOW,SUP-2759453,CDM,C1762,CPT,0278,RC,,,,both,,,2343.44,1523.24,,,,,,,,,,,,,
MATRIX WND CELLULAR REP GRAFIX PRIM 5 X 5CM,SUP-2319177,CDM,Q4132,HCPCS,0636,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
CATHETER SET TRAUM CATH BA STRP,SUP-2666767,CDM,C1729,HCPCS,0272,RC,,,,both,,,394.32,256.31,,,,,,,,,,,,,
SLEEVE SMIT ENDOCERV BRACHYTHERAPY F/INTRAUTERINE TUBE 6X40,SUP-2214858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,209.12,135.93,,,,,,,,,,,,,
BIT DRL LNG 4X150 MM S3 FAST GUIDE,SUP-2606605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1473.95,958.07,,,,,,,,,,,,,
FREECLIMB 70 132CM REPERFUSION SYSTEMFC70 TENZING 7,SUP-2878099,CDM,C1887,HCPCS,0272,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
HC Uni/Ltd Niv Arterial Upp Ext Duplex,PX-9219393100,CDM,93931,CPT,0921,RC,,,,both,,,1484.00,964.60,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ABDUCTN ROT BAR W/O SHOE,SUP-2435712,CDM,L3150,HCPCS,0272,RC,,,,both,,,230.48,149.81,,,,,,,,,,,,,
LOCATOR PINPT BONE PELV,SUP-2141756,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
LEAD ICD PASS FIX 2 COIL RIATA ST OPTIM,SUP-2356221,CDM,C1895,HCPCS,0275,RC,,,,both,,,15643.48,10168.26,,,,,,,,,,,,,
PLATE BNE M L200MM VIT TROCHANTERIC GRP 2 2MM CBL DALL-MILE,SUP-2377572,CDM,C1713,HCPCS,0278,RC,,,,both,,,4389.72,2853.32,,,,,,,,,,,,,
PIN FIX L25MM DIA2MM PROV FOR EVOS SM PLATING SYS,SUP-2344053,CDM,C1713,HCPCS,0278,RC,,,,both,,,874.14,568.19,,,,,,,,,,,,,
STENT URET UROGUIDE L 24 CM DIA 7 FR SIL NYL TETH HYDRPHLC,SUP-2495689,CDM,C2617,HCPCS,0278,RC,,,,both,,,378.31,245.90,,,,,,,,,,,,,
COUNTERSINK ORTH L37MM DIA2.7MM DENT SHFT END FOR 1.2/1.5MM,SUP-2267832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.05,618.83,,,,,,,,,,,,,
SPLINT ORTHOGNATHIC 1 JAW W/ GUIDANCE OPS VSP,SUP-2862841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9231.60,6000.54,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2113001,CDM,Q4116,HCPCS,0636,RC,,,,both,,,11015.12,7159.83,,,,,,,,,,,,,
BASEPLATE TIB SZ 6 RT CEM PRI STEM NP PROFIX,SUP-2347035,CDM,C1776,CPT,0278,RC,,,,both,,,5337.22,3469.19,,,,,,,,,,,,,
BIT DRL DIA2.7MM CANN QUIK CPL,SUP-2409860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1593.83,1035.99,,,,,,,,,,,,,
COMPONENT GLEN NO 9 THK4MM SHLDR UHMWPE REG CONSTRN CEM W/ 2,SUP-2372872,CDM,C1776,CPT,0278,RC,,,,both,,,4451.89,2893.73,,,,,,,,,,,,,
PAD ORTHOT STRNL CUST,SUP-2435575,CDM,L1050,HCPCS,0274,RC,,,,both,,,284.08,184.65,,,,,,,,,,,,,
PROSTHESIS OSS CENTERED 0.2X1.45X1.5 MM PART TI PRECIS,SUP-2458236,CDM,L8613,CPT,0278,RC,,,,both,,,1115.52,725.09,,,,,,,,,,,,,
HC Intrvasc US Noncoronary Addl,PX-3613725300,CDM,37253,CPT,0361,RC,,,,inpatient,,,1485.00,965.25,,,,,,,,,,,,,
MESH HERN L W4.1XL6.2IN R POLYPR L PORE KNIT LT 3DMAX,SUP-2125797,CDM,C1781,HCPCS,0278,RC,,,,both,,,598.80,389.22,,,,,,,,,,,,,
CATHETER GUID ANGLE 110 DEG SINUS FLX RELIEVA,SUP-2106354,CDM,C1887,HCPCS,0272,RC,,,,both,,,1254.74,815.58,,,,,,,,,,,,,
GRAFT BONE SUB 10CC FIL BONE VOID SOLUM IV,SUP-2163078,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
GRASPER ENDOSCP L 30 CM DIA2.4 MM SLIM MINIGRIP HNDL INTEGR,SUP-2901844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
BIT DRL DIA2MM ULN SHORTNG GENERATION II LO PROF LOK SYS,SUP-2397325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
ESTROGENS CONJUGATED 0.45 MG PO TABS,RX-36198,CDM,6370000000,HCPCS,0637,RC,00046-1101-81,NDC,,both,1,UN,31.90,20.73,,,,,,,,,,,,,
WIRE FIXATION L30CM OD122MM LOOP LUQUE,SUP-2494541,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.93,76.00,,,,,,,,,,,,,
WAND ABLAT FOR TNSLCTMY ADENOIDECTOMY COBLATION PROCISE XP,SUP-2342048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.77,729.80,,,,,,,,,,,,,
GRAFT HUM TISS L50MM DIA10MM FEM SHFT FRZN,SUP-2307345,CDM,C1713,HCPCS,0278,RC,,,,both,,,2333.81,1516.98,,,,,,,,,,,,,
ROD IM LNG 4.5X200 MM FEM CANN OXFORD,SUP-2445146,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
STEM HUM FRAC IMPL R 9.5MM EQUINOXE,SUP-2223295,CDM,C1776,CPT,0278,RC,,,,both,,,9580.14,6227.09,,,,,,,,,,,,,
TUBE VENT ID1.27MM BLU FLROPLAS IMP SHEEHY,SUP-2277569,CDM,L8699,HCPCS,0278,RC,,,,both,,,51.21,33.29,,,,,,,,,,,,,
DEVICE RESECTING SZ 2.9 MM STRL DISP AVETA AUTO,SUP-2914493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0250,RC,00409-7101-66,NDC,,both,50,ML,38.30,24.89,,,,,,,,,,,,,
BIT DRL CANN 4X180 MM AUTOFIX 6,SUP-2538440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
DEVICE REPROC VES SEAL JAW SEAL 23 CM JAW LIGASURE LF,SUP-2763774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.63,545.11,,,,,,,,,,,,,
OBTURATOR TROCAR CONCL SHRP 10X110 MM REUSE,SUP-2850121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.96,224.22,,,,,,,,,,,,,
SYSTEM KNEE N POR CO CHROM FEM COMP N POR TIB JOURNEY,SUP-2347990,CDM,C1776,CPT,0278,RC,,,,both,,,25079.18,16301.47,,,,,,,,,,,,,
SET VASC ACCS PEELWY L 15.5 CM INTRO L 20 CM DIA12 FR,SUP-2168019,CDM,C1892,HCPCS,0272,RC,,,,both,,,127.80,83.07,,,,,,,,,,,,,
INSERT TOE IMPLANTXSM PHLANG IMP,SUP-2404755,CDM,C1776,CPT,0278,RC,,,,both,,,2160.32,1404.21,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR LUMAX 540 VR-T,SUP-2138266,CDM,C1722,HCPCS,0275,RC,,,,both,,,47633.80,30961.97,,,,,,,,,,,,,
SEMI-TUB PLT STERILIZER 87 MM LENGTH 5 HL,SUP-2818126,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.65,330.62,,,,,,,,,,,,,
RELOAD STPLR CRV TIP SM LNG 30 MM INTELLIGENT WHT,SUP-2787712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2556.43,1661.68,,,,,,,,,,,,,
FLUDARABINE PHOSPHATE 50 MG IV SOLR,RX-10053,CDM,J9185,HCPCS,0636,RC,45963-0609-55,NDC,,both,1,UN,272.20,176.93,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 18 CM DIA 8 FR POLYUR AQ,SUP-2826996,CDM,C2617,HCPCS,0278,RC,,,,both,,,188.90,122.78,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN W/ GROWTH PLATE RT FEM DSTL,SUP-2740860,CDM,C1762,CPT,0278,RC,,,,both,,,25453.94,16545.06,,,,,,,,,,,,,
SHEATH FLD TUNN L8IN DIA11GA DISP ON-Q,SUP-2236758,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
CAGE SPNL H46-80MM OD22MM 8DEG TI THORLUM INTBDY FUS LORDTC,SUP-2390799,CDM,C1889,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
HEAD FEM CERAMIC ON CERAMIC +4 MM NK LEN ALUMINA 32 MM DIA,SUP-2364459,CDM,C1776,CPT,0278,RC,,,,both,,,4041.18,2626.77,,,,,,,,,,,,,
CONFORMER OPHTH STR SM,SUP-2236371,CDM,L8610,HCPCS,0278,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
CLIP INT USE DIA17.5 MM THRD L 165 CM ENDOSCP DIA10.5-12 MM 12/3T,SUP-2881862,CDM,C1889,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
HC Thrombectomy Graft Not Dialysi,PX-3613587500,CDM,35875,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
REAMER SURG 3 MM STRL,SUP-2175008,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
AGENT SUBMUCOSAL LIFTING 5 ML SODIUM HYALURONATE PREFIL SYR,SUP-2913655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
HC NM Tumor Localization Mult,PX-3417880100,CDM,78801,CPT,0341,RC,,,,both,,,2681.00,1742.65,,,,,,,,,,,,,
STEM HIP SZ 8 OMFLX HA,SUP-2364206,CDM,C1776,CPT,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID 0.5 CC AMNIO PLCNTA MEMBRN PRO3-F,SUP-2742031,CDM,C1762,CPT,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
STEM HUM PRI REV CEM IMPL SHLDR 1 PC 15.0MM DIA 8MM HD HT,SUP-2342767,CDM,C1776,CPT,0278,RC,,,,both,,,8898.76,5784.19,,,,,,,,,,,,,
DRILL SURG 2.4X9 MM CALCANEAL INBONE,SUP-2850353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
PROBE OPHTH VITRECTOMY 20 GA STD TAPR TIP ENDOPROBE,SUP-2225636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
MESH HERN W10XL15CM L INGUINAL POLY ANAT PARIETEX,SUP-2174781,CDM,C1781,HCPCS,0278,RC,,,,both,,,411.47,267.46,,,,,,,,,,,,,
PLATE BNE L73MM 3 H R DST LAT FIBULAR S STL LOK COMPR FOR,SUP-2184154,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.06,1054.34,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2.4X12 MM MANDIBULAR 20/PK TITANIUM N,SUP-2842290,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.10,235.36,,,,,,,,,,,,,
PROSTHESIS OSS PORE DISC 1X54 MM EAR PLAS,SUP-2312558,CDM,L8613,CPT,0278,RC,,,,both,,,152.01,98.81,,,,,,,,,,,,,
HEAD FEM HIP UPLR CEM HI DEMAND KT,SUP-2347957,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
INTRODUCER PACE LD SCOUTPRO L 45 CM DIA 7 FR MULTPURP HK W/O,SUP-2138044,CDM,C1894,HCPCS,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
SPLINT ORTHOPEDIC COLLES SM WRST FOREARM LF,SUP-2330386,CDM,L3808,HCPCS,0274,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
DIFFUSER GAS CO2 DISP DEV CARBONAID,SUP-2175227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
RING EXT FIX DIA220 MM SS 5/8 NS DISP ILIZ,SUP-2932832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4685.54,3045.60,,,,,,,,,,,,,
NAIL 13MMX180MM,SUP-2244340,CDM,C1713,HCPCS,0278,RC,,,,both,,,13703.49,8907.27,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 260CM 0.035IN TIP L 1 CM ANGLED,SUP-2385108,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.23,94.40,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONFIENT W 6.7 X H 8.25 CM D 1.45 CM 41 J,SUP-2149191,CDM,C1882,HCPCS,0275,RC,,,,both,,,44588.00,28982.20,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 0.035 IN 7 FRX205 CM DOME FUSION OMNI,SUP-2737414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PLATE THK1.7MM 2X2 H BX RESRB STRL DELT SYS,SUP-2364982,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.45,295.39,,,,,,,,,,,,,
STENT PERIPH L140MM DIA10MM CATH L120CM GWIRE 0.035IN SHTH,SUP-2416735,CDM,C1876,HCPCS,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
PROCESSOR HEARING AID CHESTNUT BRN BAHA 3 BP100,SUP-2164959,CDM,L8690,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PLATE BONE W203XL127MM THK0.2MM MH TI SH FOR 1.5MM SCR,SUP-2135906,CDM,C1713,HCPCS,0278,RC,,,,both,,,4383.44,2849.24,,,,,,,,,,,,,
GRAFT VASC L30CM ID12MM RNGD SECT L30CM STD WALLED STR GOR,SUP-2396027,CDM,C1768,CPT,0278,RC,,,,both,,,3410.04,2216.53,,,,,,,,,,,,,
PLATE EXT FIX RETENTION 1.8 MM LEIPZIG COMPLETE FOR RED II,SUP-2491541,CDM,C1713,HCPCS,0278,RC,,,,both,,,2470.58,1605.88,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PERCIVA W 5.23 X H 7.03 CM D 0.99 CM 28,SUP-2149183,CDM,C1721,HCPCS,0275,RC,,,,both,,,39388.16,25602.30,,,,,,,,,,,,,
PERI-LOC TGR 4.5MM PF PIN 80MM,SUP-2819223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.99,734.49,,,,,,,,,,,,,
PLATE BNE L THK0.3MM STD UNIV CRANIOMAXILLOFACIAL TI COMPLX,SUP-2366221,CDM,C1713,HCPCS,0278,RC,,,,both,,,2751.30,1788.34,,,,,,,,,,,,,
SET URET STENT UTHANE MAC-LOC L 25 CM DIA12 FR GUIDEWIRE L,SUP-2835752,CDM,C2627,HCPCS,0278,RC,,,,both,,,722.14,469.39,,,,,,,,,,,,,
GUIDEWIRE VASC H2O L 150 CM DIA 0.035 IN NIT COR HYDRPHLC,SUP-2302581,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
CLAMP EXT FIX XSM DIA3MM C FBR 1 H PIN TO ROD,SUP-2188694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1907.68,1239.99,,,,,,,,,,,,,
INTRODUCER SHTH SPLITTABLE 5 FRX13 CM N VLV PRELUDE PRESTIGE,SUP-2798469,CDM,C1892,HCPCS,0272,RC,,,,both,,,46.16,30.00,,,,,,,,,,,,,
SET URET ACC SHTH SPLNT PEEL AWAY FINLAYSON,SUP-2171220,CDM,C1892,HCPCS,0272,RC,,,,both,,,586.30,381.09,,,,,,,,,,,,,
BIT DRL L27MM DIA1.4MM ADD ON END W/O STP FOR VARIAX HND,SUP-2374211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STAPLE BONE MIDFOOT COMPR UNI CLP L 2 H 17 MM S STL,SUP-2243481,CDM,C1713,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
STENT PERIPH ABRE L 150 MM DIA10 MM CATH WORKING L 90 CM,SUP-2665375,CDM,C1876,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
TRIAL KNEE DIA35MM THK10MM ASYM TOT STBL TRIATHLON,SUP-2363807,CDM,C1776,CPT,0278,RC,,,,both,,,400.04,260.03,,,,,,,,,,,,,
TUBE LACR DUCT 3MM M NASOLACR MONO CRWFRD,SUP-2224383,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
ROD ORTH RT PELV TI NS,SUP-2718778,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
OMEGA-3-ACID ETHYL ESTERS 1 G PO CAPS,RX-41822,CDM,6370000000,HCPCS,0637,RC,70756-0423-22,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUR SURG DIA 8 MM HUB III ROSEN STRL REUSE HI-LINE,SUP-2928997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,705.93,458.85,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.518,SUP-2860035,CDM,C1713,HCPCS,0278,RC,,,,both,,,36957.17,24022.16,,,,,,,,,,,,,
BIT DRL DIA3MM CANN W/O STP NONRADIOLUCENT FOR ORTHOLOC 3DI,SUP-2398329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
SHEATH INTRO MORPHEUS DIA 6 FR PEELWY SPLITTABLE DIL ASMBLY,SUP-2117376,CDM,C1892,HCPCS,0272,RC,,,,both,,,7.82,5.08,,,,,,,,,,,,,
HDLS CMPN SCR 3.0X12 NS,SUP-2493444,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.83,487.39,,,,,,,,,,,,,
GRAFT BNE SUB W20XL15MM TRICORT ILIUM CREST BLK FRZ DRY,SUP-2293831,CDM,C1713,HCPCS,0278,RC,,,,both,,,3158.84,2053.25,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTMA L 20 CM DIA 6 MM SZ 0.010 IN SFT,SUP-2753874,CDM,C1889,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
WASHER ORTH LCK CLOVER RESRB CENTRALOC RESRB TIB FIX,SUP-2212866,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE ANGLED 2.8 MM LT 7X23 HOLE RECON PT SPEC,SUP-2860108,CDM,C1713,HCPCS,0278,RC,,,,both,,,28659.72,18628.82,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,KX|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct Ea Addl 15 Mins,PX-4409713000,CDM,97130,CPT,0440,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
MESH SURG STD 84X53X0.3 MM TI LEVEL 1 NEURO ULTRAONE,SUP-2477789,CDM,C1713,HCPCS,0278,RC,,,,both,,,3062.57,1990.67,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5CM 7MM 120CM 7FR RADIOPAQUE,SUP-2396652,CDM,C1874,HCPCS,0278,RC,,,,both,,,9869.02,6414.86,,,,,,,,,,,,,
ANKLE FUSION PLATE LATERAL TT 4H,SUP-2815340,CDM,C1713,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD L50CM INSRTN L33CM DIA14.5FR,SUP-2174235,CDM,C1881,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
BIT DRILL L320MM OD5MM CLBRTD ANKLE ARTHRDSS NAIL SSTM PHNX,SUP-2493318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
PLATE CNDYL 6H SHFT W/GUIDES STRL TI LCP,SUP-2546745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1818.88,1182.27,,,,,,,,,,,,,
TUBE FEEDING 8FR 55 IRIS ENFIT,SUP-2878017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.94,459.51,,,,,,,,,,,,,
HC Special Treatment Procedure,PX-3337747000,CDM,77470,CPT,0333,RC,,,,both,,,3782.00,2458.30,,,,,,,,,,,,,
MESH HERN L6XW3IN DISP TRELEX NAT,SUP-2227625,CDM,C1781,HCPCS,0278,RC,,,,both,,,252.39,164.05,,,,,,,,,,,,,
SHEATH INTRO PRELUDE PRESTIGE L 13 CM DIA14 FR ADV NDL L 7,SUP-2677193,CDM,C1892,HCPCS,0272,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
PASSER SUTURE EXT 45 DEG RT STRL SPECTRUM MVP DISP,SUP-2765727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,867.68,563.99,,,,,,,,,,,,,
HC So Lipid Panel|NOT REASONABLE AND NECESSARY,PX-3018006166,CDM,80061,CPT,0301,RC,,,GZ,outpatient,,,43.00,27.95,,,,,,,,,,,,,
STRUT EXT FIX LNG STD MAXFRAME,SUP-2432235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
ALLOGRAFT BNE SPNG 50X20X7 MM CANC DBM,SUP-2135425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3422.60,2224.69,,,,,,,,,,,,,
SCREW BNE L55MM DIA6.5MM THRD L16MM CANC TI ST SELF DRL,SUP-2190504,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.43,75.03,,,,,,,,,,,,,
TOCILIZUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430062,CDM,J3262,HCPCS,0636,RC,50242-0135-01,NDC,,both,4,ML,1567.00,1018.55,,,,,,,,,,,,,
PLATE BONE 6 H TI Y SHP FOR 1.5MM SCR VLP MINI-MOD SM BONE,SUP-2351067,CDM,C1713,HCPCS,0278,RC,,,,both,,,3944.31,2563.80,,,,,,,,,,,,,
GRAFT HUM TISS 1000MG AMNIOFILL,SUP-2305716,CDM,C1762,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
HC Prothrombin Time|NOT REASONABLE AND NECESSARY,PX-3058561000,CDM,85610,CPT,0305,RC,,,GZ,both,,,106.00,68.90,,,,,,,,,,,,,
CAGE SPNL ALIF 10 DEG 31X24X10 MM PRIM NM,SUP-2245130,CDM,C1889,HCPCS,0278,RC,,,,both,,,18902.80,12286.82,,,,,,,,,,,,,
CATHETER VALVULOPLASTY PED 2.5FR L65CM BAL L2CM DIA4MM INTRO,SUP-2125275,CDM,C1725,HCPCS,0272,RC,,,,both,,,1668.88,1084.77,,,,,,,,,,,,,
NAIL IM L34CM OD10MM 130DEG S STL HIP LT LCK CANN,SUP-2343922,CDM,C1713,HCPCS,0278,RC,,,,both,,,5064.82,3292.13,,,,,,,,,,,,,
ELECTRODE ENDO 500ML NRML NACL COBLATION PROCISE EZ VW,SUP-2342049,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
SAWBLADE STERNUM OFFSET 31.4X6X64MM,SUP-2646900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78.28,50.88,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 1 CC OSTEOINDUCTIVE DBM REFICIO,SUP-2731792,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.5 % EX CREA,RX-8114,CDM,6370000000,HCPCS,0637,RC,45802-0065-35,NDC,,both,15,GR,36.90,23.98,,,,,,,,,,,,,
LINER HUM CUPXLPE TM,SUP-2212339,CDM,C1776,CPT,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
KIT SUT ENDO 2 DEV 12 FASTENERS COR-KNOT MIS COMB,SUP-2265304,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
BLADE REPROC SAW OSC LG BONE 1.27X13X90MM,SUP-2652873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,92.88,60.37,,,,,,,,,,,,,
GRAFT BNE MORSL MED 6 CC FIBERGRAFT BG,SUP-2736515,CDM,C1713,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
HC Ot Orthotic Fit/Train per 15 Min,PX-4309776000,CDM,97760,CPT,0430,RC,,,,outpatient,,,206.00,133.90,,,,,,,,,,,,,
HC So Collagen Cross-Link N-Telopep,PX-3018252366,CDM,82523,CPT,0301,RC,,,,inpatient,,,139.00,90.35,,,,,,,,,,,,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,0636,RC,00517-0031-25,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
PPICC PROV SOLO 5F TL BASIC,SUP-2613545,CDM,C1751,HCPCS,0278,RC,,,,both,,,619.77,402.85,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L12CM DIA0.038IN STD HEMSTAS CLOSE TOL,SUP-2355392,CDM,C1894,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
TUBE VENTILIATION DIA114MM L12MM BLU T SHP SIL RICHARDS,SUP-2313721,CDM,L8699,HCPCS,0278,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
INSERT TIB SZ 7 8 THK15MM STD L KNEE POLYETH PRI NEUT,SUP-2350485,CDM,C1776,CPT,0278,RC,,,,both,,,5353.70,3479.90,,,,,,,,,,,,,
COLLAR CERV 4.25IN 12IN SM TRACH OPN AD PHIL,SUP-2195257,CDM,L0180,HCPCS,0272,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
SET INJ SYR 10ML TB 08ML L15CM FOR PLACING BNE CEM FOR,SUP-2168823,CDM,C1713,HCPCS,0278,RC,,,,both,,,355.51,231.08,,,,,,,,,,,,,
SCREWDRIVER BLADE 1.5 MM CROSS DRV SS,SUP-2479318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.10,285.41,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 50 CM DIA 8 MM EPTFE STR GRAD REINF 3,SUP-2265948,CDM,C1768,CPT,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
KIT TKR TRABECULAR MTL FEM TIB PROLONG NXGN SURF AND STD PAT,SUP-2212237,CDM,C1776,CPT,0278,RC,,,,both,,,16682.82,10843.83,,,,,,,,,,,,,
PROSTHESIS RAD 8MM SZ 1 RT MAESTRO FX,SUP-2407359,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 L 6 CM DIA 4 MM SFT 2D HELCL STRL,SUP-2365667,CDM,C1889,HCPCS,0278,RC,,,,both,,,2999.33,1949.56,,,,,,,,,,,,,
GUIDEWIRE AR896320,SUP-2843934,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM OD20FR TRACHEOESOPHAGEAL INDWL L FLNG,SUP-2242406,CDM,L8509,HCPCS,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
MESH HERN W6XL6IN POLYPR SQ L PORE MFIL SFT KNIT,SUP-2125780,CDM,C1781,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
MESH 15X20CM OPN FLX COMP PHYSIOMESH,SUP-2219746,CDM,C1781,HCPCS,0278,RC,,,,both,,,3236.02,2103.41,,,,,,,,,,,,,
BLADE SAW 10 MM HIGH-TORQUE SAG DBL GRFT HARVESTING TRITON,SUP-2628168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
GRAFT BNE VOID FILL 15 CC MG,SUP-2742077,CDM,C1713,HCPCS,0278,RC,,,,both,,,16202.40,10531.56,,,,,,,,,,,,,
KIT INTRO ARW FLX SHTH L 10 CM DIA 9 FR POLYUR INTEGR,SUP-2763350,CDM,C1892,HCPCS,0272,RC,,,,both,,,228.59,148.58,,,,,,,,,,,,,
PLATE CRAN 100X20X40 MM PT SPEC IMPL PEEK,SUP-2860116,CDM,C1713,HCPCS,0278,RC,,,,both,,,23072.41,14997.07,,,,,,,,,,,,,
HC Event Monitor - Hookup,PX-7319327000,CDM,93270,CPT,0731,RC,,,,both,,,117.00,76.05,,,,,,,,,,,,,
PROBENECID 500 MG PO TABS,RX-6561,CDM,6370000000,HCPCS,0637,RC,00591-5347-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE SUB W40XH10XL50MM BOV CANC CANCELLO-PURE,SUP-2399158,CDM,C1713,HCPCS,0278,RC,,,,both,,,5372.54,3492.15,,,,,,,,,,,,,
ASSEMBLY BLDE DISP FOR SMARTREL ENDOSCP CRPL TUNN REL SYS,SUP-2303823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.62,577.60,,,,,,,,,,,,,
SCREW SET HEX M4.5X0.75 MM RND TIP 3.5 MM HEX PROTEX CT,SUP-2593223,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
PATCH VASC HEMAPATCH L 50 X W 25 MM THK 0.65 MM POLYESTER,SUP-2914824,CDM,C1768,CPT,0278,RC,,,,both,,,533.55,346.81,,,,,,,,,,,,,
AUTOTRANSFUSION PACK 1 SOURC 120 MU M AUTOLOG ATLS21,SUP-2470905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.36,205.63,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S3294108D,SUP-2632846,CDM,C1751,HCPCS,0278,RC,,,,both,,,609.35,396.08,,,,,,,,,,,,,
CATHETER IV DL 4 FR MAX BARR NURSING TY PWR INJ POWERMIDLINE,SUP-2125694,CDM,C1751,HCPCS,0278,RC,,,,both,,,561.75,365.14,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 40 CC 81 GM ATR IS-1 ATLAS+ HF,SUP-2356581,CDM,C1882,HCPCS,0275,RC,,,,both,,,63525.34,41291.47,,,,,,,,,,,,,
GRAFT ALLGRFT STRP DBM PLF 2.5CMX10CM GRFTON,SUP-2293903,CDM,C1713,HCPCS,0278,RC,,,,both,,,6296.11,4092.47,,,,,,,,,,,,,
CANNULA ENDOSCP W/O VLV 11 MMX15 CM LL W/45 STOPCOCK GRN WHT,SUP-2768024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.62,607.50,,,,,,,,,,,,,
STENT BILI L26MM DIA4.5MM SELF EXP UNMOUNTED FLEXIBILITY,SUP-2172553,CDM,C1877,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC EXCHANGE 14.5 5397270,SUP-2632954,CDM,C1750,HCPCS,0278,RC,,,,both,,,1341.88,872.22,,,,,,,,,,,,,
KIT LD L60CM 8 ELECTRD PERC COMP CONTAIN LD ANCHR GWIRE NDL,SUP-2284647,CDM,C1778,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
HC So Additional Panel Charge,PX-3028687066,CDM,86870,CPT,0302,RC,,,,inpatient,,,381.00,247.65,,,,,,,,,,,,,
ALPRAZOLAM 0.25 MG PO TABS,RX-324,CDM,6370000000,HCPCS,0637,RC,60687-0377-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BLADE SHAVER SERRATED STD 40 DEG 4 MM N DSTL SUCTION STRL,SUP-2648979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,707.63,459.96,,,,,,,,,,,,,
PLATE BNE HK SHT 2.7X12 MM RT CLAV VA LCK STRL VALCP,SUP-2789387,CDM,C1713,HCPCS,0278,RC,,,,both,,,4183.23,2719.10,,,,,,,,,,,,,
CATHETER HD DL 14 FRX40 CM STR STP TIP HEMO-FLOW,SUP-2266983,CDM,C1750,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
BODY RAD W15XH7MM 7.5MM LT WR MAESTRO,SUP-2407292,CDM,C1776,CPT,0278,RC,,,,both,,,6116.72,3975.87,,,,,,,,,,,,,
CATHETER URET 5FR L70CM RT PVC WHSTL TIP USED FOR DRNGE RG,SUP-2168871,CDM,C1758,HCPCS,0278,RC,,,,both,,,52.94,34.41,,,,,,,,,,,,,
DISSECTOR ENDOSCP BLNT TIP TRCR W OVL BLLN SPCMKR +,SUP-2283390,CDM,C1727,CPT,0278,RC,,,,both,,,1750.24,1137.66,,,,,,,,,,,,,
PROBE PEDICLEXSM TRI TIP L40MM DIA2.5MM STR GRAD SGL PC MOD,SUP-2354603,CDM,C1776,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ELECTRODE ES 27X28FR DIA3MM BRN COAG BALL SHP FOR 24 28FR,SUP-2360974,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.81,280.68,,,,,,,,,,,,,
PASSER SUTURE 155MM DIAMETER 3.5MM RIGHT RC SEAHAWK,SUP-2824492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3753.74,2439.93,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2.5MM THRD L15MM S STL TRCR PNT,SUP-2186904,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.66,328.03,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 4FR 0.034IN 60CM 1 LUMAN 9154108,SUP-2632691,CDM,C1751,HCPCS,0278,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
PACEMAKER CARD ADAPTA W 52.3 X H 45.4 MM D 7.5 MM 13.1 CC 2,SUP-2282310,CDM,C1785,HCPCS,0275,RC,,,,both,,,8222.28,5344.48,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRACILIS TEND 5X230 MM FRZN GRAFTLINK,SUP-2264761,CDM,C1762,CPT,0278,RC,,,,both,,,3586.67,2331.34,,,,,,,,,,,,,
CATHETER INFUSION ENDOVASC DEV 30 FRX135 CM US COR EKOSONIC,SUP-2214805,CDM,C1887,HCPCS,0272,RC,,,,both,,,18887.10,12276.61,,,,,,,,,,,,,
CATHETER HD STR 14.5 FRX36 CM LT DL STP BASIC SET HEMO-FLOW,SUP-2627204,CDM,C1750,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
RETRACTOR SURG W12XH8MMXL5CM SELF RET MEDL OR LAT BLNT,SUP-2393986,CDM,C1894,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE BONE L157MM 12 H LT OLECRANON S STL LCK FOR 2.7/3.5MM,SUP-2348709,CDM,C1713,HCPCS,0278,RC,,,,both,,,13751.79,8938.66,,,,,,,,,,,,,
SPLINT WRST M R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326137,CDM,L3908,HCPCS,0272,RC,,,,both,,,73.51,47.78,,,,,,,,,,,,,
KIT PICC IR 4FR SGL LUMEN6 FR RVS TAPR DIA17G INNR DIA W/,SUP-2118777,CDM,C1751,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
CATHETER DRNGE 14FR L35CM CHST NONVASCULAR INTERVENTIONS,SUP-2147733,CDM,C1729,HCPCS,0272,RC,,,,both,,,313.75,203.94,,,,,,,,,,,,,
RING EXT FIX 160 MM 5/8 CARBON FIBER NS,SUP-2799526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1750.83,1138.04,,,,,,,,,,,,,
CATHETER BAL OCCL L100CM OD7FR OD34FR,SUP-2141681,CDM,C2628,HCPCS,0272,RC,,,,both,,,432.57,281.17,,,,,,,,,,,,,
WRIST RADIAL RIGHT MED,SUP-2479890,CDM,C1776,CPT,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING 6MM DIA 100CM LEN 50CM GORTX,SUP-2396008,CDM,C1768,CPT,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
INSERT TIB SM DIA5MM KNEE S STL FRAG AXSOS,SUP-2371465,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
HC Icd Generator Insert Sgl/Dual,PX-3613324000,CDM,33240,CPT,0361,RC,,,,both,,,76255.00,49565.75,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.0X38MM H,SUP-2320871,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.58,558.73,,,,,,,,,,,,,
CATHETER HEMODILAYSIS KT DIAL CHRONIC DBL LUMN LNG TERM,SUP-2383442,CDM,C1752,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
FIDAXOMICIN 200 MG PO TABS,RX-108906,CDM,6370000000,HCPCS,0637,RC,52015-0080-01,NDC,,both,1,UN,1171.20,761.28,,,,,,,,,,,,,
BRACE ANK L H10IN RIG THERMOPLASTIC SHELL ADJ HEEL STRP W/,SUP-2197171,CDM,L4350,HCPCS,0274,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
MARKER RAD MRI FIDUCIAL PAT,SUP-2264512,CDM,A4648,CPT,0278,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
CANNULA ATRIAL/VENTRICULAR 32FR L10.7MM INFLO BVS5000,SUP-2106279,CDM,C1713,HCPCS,0278,RC,,,,both,,,3422.60,2224.69,,,,,,,,,,,,,
KIT NERVE STIM BARORECEPTOR NEUROMODULATION GENRTR CSL LD,SUP-2894037,CDM,C1825,HCPCS,0278,RC,,,,both,,,109900.00,71435.00,,,,,,,,,,,,,
BEARING TIB 20 MM OSS RS LS,SUP-2441806,CDM,C1776,CPT,0278,RC,,,,both,,,2359.71,1533.81,,,,,,,,,,,,,
CAGE SPNL W28XH12XL38MM 8DEG FOR ANT LUM INTBDY FUS BRIGADE,SUP-2310967,CDM,C1889,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
WEDGE ANK D16MM THK7.5MM COT TECH TI PORUS ANAT 3D OPN,SUP-2123094,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
SCREW BNE L5MM DIA1.5MM MIC CORT CRANIOMAXILLOFACIAL TI LEV 256780591] KLS MARTIN LP],SUP-2262821,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.01,120.26,,,,,,,,,,,,,
CONNECTOR VENT 15MM DIA 2CM LEN 3 W Y SHP,SUP-2277889,CDM,C1889,HCPCS,0278,RC,,,,both,,,547.80,356.07,,,,,,,,,,,,,
GRAFT VASC TW 8 MMX70 CM STR SFT WRP TUNN ATTCH ADVANTA VXT,SUP-2468029,CDM,C1768,CPT,0278,RC,,,,both,,,1453.32,944.66,,,,,,,,,,,,,
FIBER LASER FLEXIVA PULSE 365,SUP-2718711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1053.53,684.79,,,,,,,,,,,,,
SPLINT WRST SM L THMB SPICA COT POLY FAB LTHR WRKHRD ORIG,SUP-2326129,CDM,L3908,HCPCS,0274,RC,,,,both,,,74.26,48.27,,,,,,,,,,,,,
BLADE SAW W25XL90MM D90MM CUT THK119MM S STL OSC STABLECUT,SUP-2253182,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.35,217.98,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.038 IN TAPR L 6 CM RAD 3 MM,SUP-2167619,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.34,21.02,,,,,,,,,,,,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,J7131,HCPCS,0250,RC,63323-0093-30,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L 86 MM LT 4 HOLE BUTTRESS TI NS,SUP-2569059,CDM,C1713,HCPCS,0278,RC,,,,both,,,4028.65,2618.62,,,,,,,,,,,,,
SCREW BNE L40MM DIA5MM HEX HD DIA3.5MM CORT TIB TI ALLY FIX,SUP-2413027,CDM,C1713,HCPCS,0278,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.025IN L 7CM 2.5CM SAFE-T-J HVY DTY,SUP-2638696,CDM,C1769,HCPCS,0272,RC,,,,both,,,55.64,36.17,,,,,,,,,,,,,
STAPLE KIT 10X15/17 MM STRL INSTAFIX LTX DISP,SUP-2857580,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.14,1736.89,,,,,,,,,,,,,
INTRODUCER KIT VASCULAR SPLIT SHEATH 8FR X 25CM,SUP-2424648,CDM,C1894,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 40 CM BALLOON L 60 MM DIA10 MM COAT L,SUP-2909764,CDM,C1725,HCPCS,0272,RC,,,,both,,,441.80,287.17,,,,,,,,,,,,,
GRAFT VASC TW 6 MMX40 CM AORT STR REINF SLDE GDS ADVANTA VXT,SUP-2467687,CDM,C1768,CPT,0278,RC,,,,both,,,1402.92,911.90,,,,,,,,,,,,,
COMPONENT FEM SM L KNEE PRI CEM STEMLESS POST STABILIZING,SUP-2406880,CDM,C1776,CPT,0278,RC,,,,both,,,14956.45,9721.69,,,,,,,,,,,,,
CEMENT DENT 1LB LT YEL ZN PWD,SUP-2238331,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.83,74.64,,,,,,,,,,,,,
CATHETER EP L105CM OD6FR 2-5-2MM SPC DECAPOLAR STEER BIDIR,SUP-2357020,CDM,C1730,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW SPNL CERV TEMP FOR PLATE,SUP-2430804,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
HC US Gd Tiss Parench Ablation,PX-4027694000,CDM,76940,CPT,0402,RC,,,,both,,,1295.00,841.75,,,,,,,,,,,,,
PLATE BNE L 176 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 16 H,SUP-2936246,CDM,C1713,HCPCS,0278,RC,,,,both,,,3087.72,2007.02,,,,,,,,,,,,,
IMPLANT FEM STR SHT NK HIP MOD IMPLABLE GRY ABG II V40,SUP-2372195,CDM,C1776,CPT,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
NEEDLE PROC AD 18GA L71CM 50DEG S STL TRANSSEPTAL POINTER,SUP-2357221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
SCREW CONN FOR HELI BLDE TFN,SUP-2188217,CDM,C1713,HCPCS,0278,RC,,,,both,,,2844.49,1848.92,,,,,,,,,,,,,
SODIUM PHOSPHATES 15 MMOLE/5ML IV SOLN,RX-137338,CDM,2500000003,HCPCS,0250,RC,63323-0884-06,NDC,,both,5,ML,111.70,72.60,,,,,,,,,,,,,
DELIVERY SYS STENT NAVIFLEX RX DIA10 FR PLAS PANCREATIC,SUP-2149500,CDM,C2625,HCPCS,0278,RC,,,,both,,,258.64,168.12,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV BASIC 3FR 45CM 1 LUMAN R 9173118,SUP-2632694,CDM,C1751,HCPCS,0278,RC,,,,both,,,579.90,376.93,,,,,,,,,,,,,
PLATE BNE SM L92MM 2X3 H LAT TIBIOTALOCALCANEAL ANK TI,SUP-2398501,CDM,C1713,HCPCS,0278,RC,,,,both,,,5403.94,3512.56,,,,,,,,,,,,,
BLADE TONGUE RUSSEL DAVIS 29MMW 67MML,SUP-2676000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.61,235.70,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST RIGID W/O JT PREFABRICATED,SUP-2435761,CDM,L3762,HCPCS,0272,RC,,,,both,,,277.01,180.06,,,,,,,,,,,,,
IMPLANT OSS L8.2MM HD 4.2MM THK2.3MM INCUS STAP HA HD HAPEX,SUP-2312819,CDM,L8613,CPT,0278,RC,,,,both,,,1178.50,766.02,,,,,,,,,,,,,
SHEATH INTRO D'VILL L 30 CM DIA14 FR GUIDEWIRE 0.035 IN LNG,SUP-2615936,CDM,C1894,HCPCS,0272,RC,,,,both,,,651.71,423.61,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY HT 225IN CIRC 13 16IN M PHIL,SUP-2319292,CDM,L0172,HCPCS,0274,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN WHL FIB,SUP-2321808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2866.82,1863.43,,,,,,,,,,,,,
TUBE VENT BVL 1.14 MM ARMSTR V GRMMT PC COAT 70140396,SUP-2638108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,42.86,27.86,,,,,,,,,,,,,
CATHETER EMB PYTHON L 80 CM DIA 5 FR INFLATED DIA 5 MM SHTH,SUP-2761878,CDM,C1757,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 40 CM DIA 7 MM POLYESTER BOV CLLGN UTHN,SUP-2763174,CDM,C1768,CPT,0278,RC,,,,both,,,1226.74,797.38,,,,,,,,,,,,,
IMPLANT MALAR SUP PET 50X19X3MM LT DSGN RZ MEDPOR,SUP-2365272,CDM,C1776,CPT,0278,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX16 RIGHT LATERAL PROXIMAL HUMERAL,SUP-2588189,CDM,C1713,HCPCS,0278,RC,,,,both,,,4636.56,3013.76,,,,,,,,,,,,,
SCREW BNE NLCK 3.2X10 MM VW REDUC,SUP-2645223,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.33,346.66,,,,,,,,,,,,,
PATCH HERN W12.5XL15.5CM 28-35MM STOMA OPN POLYPR W/ EXP,SUP-2126076,CDM,C1781,HCPCS,0278,RC,,,,both,,,3534.86,2297.66,,,,,,,,,,,,,
PLATE BNE L98MM THK3.4MM 7 H BILAT S STL STR LOK COMPR FOR,SUP-2185135,CDM,C1713,HCPCS,0278,RC,,,,both,,,871.70,566.60,,,,,,,,,,,,,
IMP SYS T-ROPE BTB-J W/8.5MM FLPCTR IIS,SUP-2811462,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
TOOL LEGEND 75CM 15MM BALL DMND,SUP-2279689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.11,262.02,,,,,,,,,,,,,
NAIL IM LNG 13X340 MM RT TI,SUP-2362241,CDM,C1713,HCPCS,0278,RC,,,,both,,,9831.97,6390.78,,,,,,,,,,,,,
LITHOTRIPTER SURG FIBER SUREFLEX REUSE RLLF910] LASER VENTURES],SUP-2263899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PATCH DURAL 4X5CM NEURO PATCH,SUP-2826139,CDM,C1763,HCPCS,0278,RC,,,,both,,,641.25,416.81,,,,,,,,,,,,,
AUGMENT FEM SZ 4 THK4MM DST KNEE CO CHROM MOLYBDENUM CEM,SUP-2251999,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
SCREW LANX MINI-INVAS 6.5X50,SUP-2137019,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
HANDPIECE VITRECTOMY 23 GA 225 + ESA VITESSE,SUP-2537895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5991.12,3894.23,,,,,,,,,,,,,
PACK VITRECTOMY POSTERIOR 25GA BL5225V,SUP-2844715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1833.76,1191.94,,,,,,,,,,,,,
CLIP INT L235CM WRK CHN DIA2.8MM OPN 11MM BRAID CATH ROT BX/10,SUP-2149429,CDM,C1889,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
GRAFT VASC VEN KT OUTFLO ADPT SUPER HERO,SUP-2302611,CDM,C1768,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SCREW BNE L85MM OD3.5MM S STL CORT ST LOK FULL THRD LO PROF,SUP-2348382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.68,764.19,,,,,,,,,,,,,
NAIL DIAM 13MM LEN 240MM PANTSA XL,SUP-2243621,CDM,C1713,HCPCS,0278,RC,,,,both,,,14094.71,9161.56,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT MAXBARR 5FR 0.026IN 55CM 2 9927508D,SUP-2632714,CDM,C1751,HCPCS,0278,RC,,,,both,,,829.31,539.05,,,,,,,,,,,,,
PROXIMAL HUMERAL PLATE 5 HOLE,SUP-2829258,CDM,C1713,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
TEMPLATE SURG ROD 150 MM FLX,SUP-2864129,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L140CM BAL L100MM DIA10MM 7ATM COR FIX,SUP-2140452,CDM,C1725,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
RING EXT FIX L140MM FT DBL H FOR SIDEKCK FREE CIR FIX,SUP-2400643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-9.5 MM 15 CC FD DEMINERALIZED CANC,SUP-2717752,CDM,C1713,HCPCS,0278,RC,,,,both,,,1082.11,703.37,,,,,,,,,,,,,
SPLINT FNGR W1 2IN 3PP BUDDY LOOP,SUP-2112615,CDM,L3933,HCPCS,0274,RC,,,,both,,,8.35,5.43,,,,,,,,,,,,,
COLLAR CERV ADJ FLX THERMOPLASTIC,SUP-2388132,CDM,L0130,HCPCS,0274,RC,,,,both,,,487.64,316.97,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 10 FRX15 CM 10 GA 5 LUMEN,SUP-2759736,CDM,C1751,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
TRANDOLAPRIL 1 MG PO TABS,RX-17017,CDM,6370000000,HCPCS,0637,RC,68180-0566-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CAGE SPNL 12X20MM TI ANTR LUM THRD REDUC PROF INTERFIX,SUP-2291782,CDM,C1889,HCPCS,0278,RC,,,,both,,,16356.26,10631.57,,,,,,,,,,,,,
SCREW BNE L 95 MM DIA2.4 MM 10 SHFT H SS Y SHP HD NS V,SUP-2905671,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.97,1810.88,,,,,,,,,,,,,
LEAD PACE 100CM STEROID ELUTION ACT FIX IMP TENDRIL SDX,SUP-2356678,CDM,C1898,HCPCS,0275,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
DEVICE SUT CAPT 38.2GM SHFT DIA3MM HD W6.3MM CARR DIA1.2MM,SUP-2139404,CDM,C2631,HCPCS,0278,RC,,,,both,,,2326.52,1512.24,,,,,,,,,,,,,
PROBE BRST BX DIA10GA PRB US MAMTOM ELITE,SUP-2195607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1204.57,782.97,,,,,,,,,,,,,
SPLINT KNEE L26IN CIRC 36IN UNIV AD IMMOB FIT MOST WRP ARND,SUP-2197157,CDM,L1830,CPT,0272,RC,,,,both,,,51.90,33.73,,,,,,,,,,,,,
WEDGE ACF ILIUM CREST TRADITION ALLGRFT 6 MM FRZ DRY,SUP-2294061,CDM,C1713,HCPCS,0278,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
COMPONENT FEM POLYMER MTL R LAT KNEE TIB BICOMPARTMENTAL,SUP-2165963,CDM,C1776,CPT,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
HC Exchange Biliary Drng Cath,PX-3614753600,CDM,47536,CPT,0361,RC,,,,both,,,11207.00,7284.55,,,,,,,,,,,,,
GRAFT HUM TISS L 10 X W 10 CM SZ 100 SQCM AMNIO,SUP-2909297,CDM,Q4137,HCPCS,0636,RC,,,,both,,,17327.96,11263.17,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 CM DIA 4-10 MM SZ 54 CM FEM ART,SUP-2932971,CDM,C1762,CPT,0278,RC,,,,both,,,38936.00,25308.40,,,,,,,,,,,,,
GRAFT SPNG CANC 1.4,SUP-2415401,CDM,C1713,HCPCS,0278,RC,,,,both,,,3585.88,2330.82,,,,,,,,,,,,,
ARTHROFLEX 40X70X1.0 MM,SUP-2811355,CDM,Q4125,HCPCS,0636,RC,,,,both,,,7726.28,5022.08,,,,,,,,,,,,,
GUIDEWIRE ENDO L150CM DIA0.038IN TIP L3CM NIT COR HYDRPHLC,SUP-2169840,CDM,C1769,HCPCS,0272,RC,,,,both,,,105.41,68.52,,,,,,,,,,,,,
BINDER ABD UNIV H9IN WAIST 45-62IN E SFT COT PREM 3 PNL,SUP-2197075,CDM,L0450,HCPCS,0274,RC,,,,both,,,20.72,13.47,,,,,,,,,,,,,
KIT PLT CONC SYS MINI BNE MAR NDL MARROWSTIM BIOCUE,SUP-2402591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
PLATE BONE L38MM THK1.25MM 10 H BILAT TI CVD RIG NEUT SAG,SUP-2191225,CDM,C1713,HCPCS,0278,RC,,,,both,,,1342.98,872.94,,,,,,,,,,,,,
CRANIO SCULPT FLOW BONE VOID FILLER5CC QTY001 EA,SUP-2457216,CDM,C1713,HCPCS,0278,RC,,,,both,,,5538.18,3599.82,,,,,,,,,,,,,
BIT DRL L130MM DIA2.7MM FOR VLP VAR ANG LOCKED PLATING SYS,SUP-2344020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,560.43,364.28,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN BASIC KT DBL LUMN POLYUR,SUP-2174119,CDM,C1751,HCPCS,0278,RC,,,,both,,,249.69,162.30,,,,,,,,,,,,,
PLATE BONE W24XL85MM 12 H RT DSTL RAD TI LCK COMPR LO PROF,SUP-2136264,CDM,C1713,HCPCS,0278,RC,,,,both,,,3494.82,2271.63,,,,,,,,,,,,,
SPACER SPNL ZERO-P IMPL 10MM CONVEX STERILE,SUP-2182393,CDM,C1821,HCPCS,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THCK 6CMX12CM,SUP-2306915,CDM,C1762,CPT,0278,RC,,,,both,,,6667.13,4333.63,,,,,,,,,,,,,
PLATE BONE 4 H RT GLEN SCAPULAR LCK,SUP-2107832,CDM,C1713,HCPCS,0278,RC,,,,both,,,3256.18,2116.52,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 30X13X15 MM FD IRRADIATED PATELLAR,SUP-2866891,CDM,C1762,CPT,0278,RC,,,,both,,,2034.41,1322.37,,,,,,,,,,,,,
HANDPIECE SCIS SUP CTRL ACTUATION THRU FOOTPEDAL,SUP-2109720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
IMPLANT BIO TISS M CLLGN SCFLD FOR ARTHSCP REGENETEN,SUP-2334693,CDM,C1763,HCPCS,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
CATHETER INFUSION MINI 40 CM BENEPHIT PV,SUP-2117134,CDM,C1751,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
GRAFT HUM TISS 6X4 CM MEMBRN REGENERATIVE AMNIO STRATOGEN,SUP-2164202,CDM,Q4139,HCPCS,0636,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 3 or More Muscles,PX-4202056100,CDM,20561,CPT,0420,RC,,,,both,,,42.00,27.30,,,,,,,,,,,,,
CATHETER EP MAP SUPREME 6FR HEXAPOLAR W/ UPLR RCRD,SUP-2356898,CDM,C1730,HCPCS,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
PLATE BONE GENIOPLASTY 5MM,SUP-2262916,CDM,C1713,HCPCS,0278,RC,,,,both,,,10126.50,6582.22,,,,,,,,,,,,,
SHEATH URO L35CM ID14FR AQ PARA RAP REL FLX,SUP-2171159,CDM,C1894,HCPCS,0272,RC,,,,both,,,544.95,354.22,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM LT MAND 26 HOLE ANGLED LCK TI STRL,SUP-2498438,CDM,C1713,HCPCS,0278,RC,,,,both,,,6575.73,4274.22,,,,,,,,,,,,,
CATHETER URET PIG 0.038 IN 4.8 FRX70 CM C FLX LF,SUP-2478296,CDM,C1758,HCPCS,0278,RC,,,,both,,,193.71,125.91,,,,,,,,,,,,,
INTRODUCER TUBE TY 8 FR PERC CIAGLIA BLU RHINO SHILEY,SUP-2760025,CDM,C1769,HCPCS,0272,RC,,,,both,,,1336.70,868.85,,,,,,,,,,,,,
TRAY CATH 5FR DUAL LUMEN NONCOATED VLV COMPATIBLE TRIM LEN,SUP-2125641,CDM,C1751,HCPCS,0278,RC,,,,both,,,732.50,476.12,,,,,,,,,,,,,
PLATE BNE L99MM 7 H BILAT MTPHSEAL S STL LOK COMPR LO PROF,SUP-2185100,CDM,C1713,HCPCS,0278,RC,,,,both,,,2437.52,1584.39,,,,,,,,,,,,,
COIL VASC I-ED COIL L 50 CM DIA 0.014 IN SECONDARY 14 MM,SUP-2865316,CDM,C1889,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
ROD SPNL 5.5X510MM RT POST TI SMOOTH STR HRD,SUP-2137260,CDM,C1713,HCPCS,0278,RC,,,,both,,,807.11,524.62,,,,,,,,,,,,,
PACEMAKER CARD SERENA QUAD CRT-P MRI SURESCAN W 46.5 X H 59,SUP-2282511,CDM,C2621,HCPCS,0275,RC,,,,both,,,18880.91,12272.59,,,,,,,,,,,,,
COIL EMB L2CM DIA1MM DETAIL FINISH RNDM COMPLX 10 SYS,SUP-2249142,CDM,C1889,HCPCS,0278,RC,,,,both,,,4741.97,3082.28,,,,,,,,,,,,,
RING RETRCT SM/M SHTH L14CM INCIS RANG 2.5-8CM RIG ORTH,SUP-2119767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT BIO TISS 3CC BOV FLOWABLE,SUP-2244049,CDM,Q4114,HCPCS,0636,RC,,,,both,,,16475.61,10709.15,,,,,,,,,,,,,
INTRODUCER CARD LD PLCMNT 9FRX47CM W/O HEMSTAT VLV COR SINUS,SUP-2357297,CDM,C1887,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT VASC STR 8 MMX40 CM COAT W/ RNG SUPP FUSION BIOLINE,SUP-2464469,CDM,C1768,CPT,0278,RC,,,,both,,,3023.98,1965.59,,,,,,,,,,,,,
HC So Assay of Protein Other,PX-3018415766,CDM,84157,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
CUFF VENTRICULAR ASST DEV APCL SLD STRL HEARTMATE 3,SUP-2895266,CDM,C1889,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
COMPONENT FEM L THCK UNI GEN,SUP-2344260,CDM,C1776,CPT,0278,RC,,,,both,,,7512.45,4883.09,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X259X2.8 MM 36 HOLE ANGLED-ANGLED STRL,SUP-2479746,CDM,C1713,HCPCS,0278,RC,,,,both,,,8893.05,5780.48,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.018 IN TIP LOAD 30,SUP-2909245,CDM,C1769,HCPCS,0272,RC,,,,both,,,115.46,75.05,,,,,,,,,,,,,
PLATE BNE L100MM BRL L1.5IN 135DEG PELVIS BILAT S STL STD 4,SUP-2342420,CDM,C1713,HCPCS,0278,RC,,,,both,,,3533.13,2296.53,,,,,,,,,,,,,
ENDCAP ORTH L0MM DIA15MM NONSTERILE FEM TI NAIL EXTN LCK HD,SUP-2192154,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.78,411.96,,,,,,,,,,,,,
PROSTHESIS OSS 9.14 MM 1 MM WEHRS SINGLE NOTCH INCUS STAP HA,SUP-2464412,CDM,L8613,CPT,0278,RC,,,,both,,,1533.11,996.52,,,,,,,,,,,,,
CATHETER INTVASC OCCL EQL L 65 CM DIA 7 FR BALLOON DIA27 MM,SUP-2147469,CDM,C2628,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SET URET DIL 6-18FR L60CM POLY W/ GWIRE,SUP-2171202,CDM,C2627,HCPCS,0272,RC,,,,both,,,530.28,344.68,,,,,,,,,,,,,
PLATE BNE SPCR 0MM 4 H ST MIDFOOT TI VAR ANG LOK OPN WDG FOR,SUP-2181213,CDM,C1713,HCPCS,0278,RC,,,,both,,,3694.90,2401.68,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.035IN TIP L3CM NIT HYDRPHLC STIFF,SUP-2385587,CDM,C1769,HCPCS,0272,RC,,,,both,,,159.95,103.97,,,,,,,,,,,,,
GRAFT BONE PRO DENS CDK,SUP-2399155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14093.36,9160.68,,,,,,,,,,,,,
HC So Acetylcholn Rcptr Modlg Antb,PX-3028604366,CDM,86043,CPT,0302,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
MATRIX BONE 2ML DEMIN PASTE SYR INTERGRO,SUP-2414009,CDM,C1713,HCPCS,0278,RC,,,,both,,,1237.16,804.15,,,,,,,,,,,,,
CANNULA DELIVERY INJECTABLE BONE SUBSTITUTE 11 GA ANIKA,SUP-2850036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
TAP SURG JONES SCR 5.5 MM,SUP-2691278,CDM,C1889,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
COMPONENT RND PRI STD CEM NP WITHOUTXRAY WIRE SZ 0 NAT KNEE,SUP-2208959,CDM,C1776,CPT,0278,RC,,,,both,,,14336.30,9318.59,,,,,,,,,,,,,
SLEEVE FEM STD OFFSET HIP TYP 1 TAPR FOR CERAMIC BIOLOX,SUP-2408753,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
COLLAR PREMIER PRO UNIV ADJ CLS CELL FOAM LNR L TRACH OPN,SUP-2336009,CDM,L0140,HCPCS,0272,RC,,,,both,,,14.32,9.31,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 7 FR D CRV HEXAPOLAR,SUP-2248755,CDM,C1730,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
TRIAL PLATE STR 1.3 MM 10 HOLE,SUP-2525721,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
KIT VASC FILTER TRAPEASE L 90 CM DIA 6 FR CAVA DIA 30 MM NIT,SUP-2157009,CDM,C1880,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
COLLAR CERV L H4.25IN FOR 16-19IN PLASTAZOTE FOAM 2 PC L,SUP-2336006,CDM,L0140,HCPCS,0274,RC,,,,both,,,30.87,20.07,,,,,,,,,,,,,
BUR SHV L13CM DIA4MM 12000RPM DMND CVD SHFT TAPR SUCT TIP,SUP-2277867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.86,729.86,,,,,,,,,,,,,
PIN FIX TIB BASE ATTUNE,SUP-2252815,CDM,C1713,HCPCS,0278,RC,,,,both,,,139.89,90.93,,,,,,,,,,,,,
MESH HERN 6X4IN 2D POLY RECT PARTIALLY ABSRB KNIT MFIL,SUP-2174774,CDM,C1781,HCPCS,0278,RC,,,,both,,,257.32,167.26,,,,,,,,,,,,,
PLATE STRNL CLOSURE 4 H TI V CONCV NS STERNALOCK EZ,SUP-2894428,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
SPACER SPNL 24X15 MM ADAPTIX,SUP-2731000,CDM,C1889,HCPCS,0278,RC,,,,both,,,32798.09,21318.76,,,,,,,,,,,,,
KNEE IMMOB 20 IN SM,SUP-2195246,CDM,L1830,CPT,0272,RC,,,,both,,,36.71,23.86,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 150 CM DIA 0.038 IN NIT HYDRPHLC,SUP-2141157,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.78,98.01,,,,,,,,,,,,,
PLATE BNE L 95 MM SCREW DIA 3.5 MM 8 SHFT H SS 1/3 TUBLR VA,SUP-2907785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1834.76,1192.59,,,,,,,,,,,,,
ENDCAP SPNL COLOSSEUM 0 DEG 14MMX16MMX3MM,SUP-2417972,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC NM Peritoneal Venous Shunt Paten,PX-3407829100,CDM,78291,CPT,0340,RC,,,,inpatient,,,2204.00,1432.60,,,,,,,,,,,,,
SHEATH INTRO L 44 CM DIA12 FR GUIDEWIRE 0.038 IN LNG PTFE X,SUP-2615916,CDM,C1894,HCPCS,0272,RC,,,,both,,,190.57,123.87,,,,,,,,,,,,,
CATHETER EP 6FR L92CM 2-8-2MM SPC TIP 1MM 10 ELECTRD D CRV,SUP-2248659,CDM,C1730,HCPCS,0272,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED S4 HA,SUP-2419704,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,2500000003,HCPCS,0250,RC,61570-0131-40,NDC,,both,400,GR,221.40,143.91,,,,,,,,,,,,,
VIPER PRIM CFXFEN XTAB 7X55MM,SUP-2177023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SCREW BNE L20MM DIA4.75MM CORT FIX ANG NONCANNULATED,SUP-2407395,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.08,261.35,,,,,,,,,,,,,
CATHETER HAD 11.5FR L20CM STR POLYUR 3 LUMN FULL KT TR FL,SUP-2267014,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BNE SCAPULA RT MEDL 13 HOLE BORDER,SUP-2846284,CDM,C1713,HCPCS,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME 120CM 6FR 5MM FIX TORQUE,SUP-2526073,CDM,C1730,HCPCS,0272,RC,,,,both,,,112.26,72.97,,,,,,,,,,,,,
BIT DRL L 115/30 MM DIA2 MM SCREW DIA2.7 MM CALIB AO QC STRL,SUP-2907646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.80,503.62,,,,,,,,,,,,,
CATHETER DIAG L135CM SHFT DIA0.026X0.039IN SPC L15MM TIP,SUP-2353124,CDM,C1887,HCPCS,0272,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
PROSTHESIS PENILE 12CM SNAP FIT RT CX,SUP-2139003,CDM,C1813,HCPCS,0278,RC,,,,both,,,24256.50,15766.72,,,,,,,,,,,,,
IMMOBILIZER ORTH 30-36IN M SHLDR UNIV ELAS M,SUP-2197391,CDM,L1830,CPT,0274,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 260 CM DIA 0.038 IN TAPR L 15 CM FLPY,SUP-2167858,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.97,51.33,,,,,,,,,,,,,
PLATE SPNL LAT 20 MM 4 HOLE REGATTA,SUP-2711122,CDM,C1713,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
ANCHOR SUT MINILOK QUIK ANCHR W/ 2-0 ORTHOCORD RB-1 NDL AND,SUP-2249374,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.07,55.95,,,,,,,,,,,,,
CATHETER THROMCTMY QUICKCLEAR L 85 CM DIA10 FR NOM DIA 0.130,SUP-2823591,CDM,C1757,HCPCS,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
TUBE JEJUNOSTOMY 9 FRX27 IN SIL 319] BARD PERIPHERAL VASCULAR],SUP-2127814,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
SPACER DST CNTRLZR HIP 8MM OD RELIANCE,SUP-2375169,CDM,C1776,CPT,0278,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
ANCHOR SUT OD4.5MM BIOCOMP W/ 1 STRND O INSITE FT,SUP-2315931,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT-KEES 12MM FENESTRATED 90 DEG 20-1699,SUP-2849027,CDM,C1889,HCPCS,0278,RC,,,,both,,,932.36,606.03,,,,,,,,,,,,,
SCREW SPNL L35MM DIA4.35MM CANC PEDCL THORACOLUMBOSACRAL TI,SUP-2254680,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SCREW BNE L110MM DIA7.3MM S STL ST CANN NONLOCKING,SUP-2184792,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.45,481.94,,,,,,,,,,,,,
COLLAR CERV XL H3XL20IN AD CLS TRACH HK AND LOOP CLSR CNTOUR,SUP-2194433,CDM,L0120,HCPCS,0274,RC,,,,both,,,17.87,11.62,,,,,,,,,,,,,
BIT DRL TWST 1.9X50 MM W/ NOTCH DISP,SUP-2460310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,330.42,214.77,,,,,,,,,,,,,
BROACH SM/M 3S HEMI,SUP-2390489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
BLADE SAW SAG 202534] STRYKER CORP],SUP-2361842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,186.05,120.93,,,,,,,,,,,,,
WASHER 30 MM CANNULATED SCREWS,SUP-2484531,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.93,75.35,,,,,,,,,,,,,
KIT VENT CATH MICROSENSOR,SUP-2243822,CDM,C1729,HCPCS,0272,RC,,,,both,,,2212.48,1438.11,,,,,,,,,,,,,
PLATE BNE BRIM W 10.5 MM DELT H 40 MM THK 2.5 MM H SPC 12 MM,SUP-2902351,CDM,C1713,HCPCS,0278,RC,,,,both,,,9604.95,6243.22,,,,,,,,,,,,,
PLATE BNE L242MM 10 H ST R CNDYL S STL LOK COMPR CRV FOR,SUP-2177088,CDM,C1713,HCPCS,0278,RC,,,,both,,,4814.34,3129.32,,,,,,,,,,,,,
BROMOCRIPTINE MESYLATE 2.5 MG PO TABS,RX-9297,CDM,6370000000,HCPCS,0637,RC,00574-0106-03,NDC,,both,1,UN,14.90,9.68,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR PHILOSIIDR,SUP-2137974,CDM,C1786,HCPCS,0275,RC,,,,both,,,12726.42,8272.17,,,,,,,,,,,,,
PIN FIX STD ANTR LUM TEMP TRINICA,SUP-2205179,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
METHOTREXATE ECTOPIC PREGNANCY SYRINGE,RX-4081729,CDM,J9260,HCPCS,0636,RC,00143-9519-10,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
POROUS FEM /POR TIBIA/ PRLNG SURF/ NO PAT,SUP-2212153,CDM,C1776,CPT,0278,RC,,,,both,,,11595.02,7536.76,,,,,,,,,,,,,
EXTENSION STEM REV 175X6X14 MM KNEE PERSONA,SUP-2508839,CDM,C1776,CPT,0278,RC,,,,both,,,8980.40,5837.26,,,,,,,,,,,,,
CATHETER URET WHSTL TIP 4 FRX70 CM SINGLE LUMEN FLEXIMA,SUP-2424629,CDM,C1758,HCPCS,0278,RC,,,,both,,,30.40,19.76,,,,,,,,,,,,,
SCREW BNE ST 2X7 MM LP TI GLD LEIBINGER UNIV 2 5PK,SUP-2431317,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.25,106.76,,,,,,,,,,,,,
ALLOGRAFT BNE 60 MM PRESERVON FEM SHFT MATRIGRAFT,SUP-2740820,CDM,C1762,CPT,0278,RC,,,,both,,,2381.85,1548.20,,,,,,,,,,,,,
SALINE 0.65 % NA SOLN,RX-18225,CDM,6370000000,HCPCS,0637,RC,00225-0382-80,NDC,,both,50,ML,9.50,6.17,,,,,,,,,,,,,
DEVICE VENTRICULAR ASST LT KT SHWR BG HEARTMATE II,SUP-2356004,CDM,Q0501,HCPCS,0274,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
LINER ACET CUP THCK PRI CEM MTL ON POLYETH STD NEUT HI WALL,SUP-2406711,CDM,C1776,CPT,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
GRAFT HUM TISS L 180 X W 10 MM CALCANEAL BNE BLOCK L 23 X W,SUP-2913170,CDM,C1762,CPT,0278,RC,,,,both,,,10223.84,6645.50,,,,,,,,,,,,,
SCREW BNE COMPR 2.7 MM SS KREULOCK,SUP-2845739,CDM,C1713,HCPCS,0278,RC,,,,both,,,10613.20,6898.58,,,,,,,,,,,,,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97253,CDM,6370000000,HCPCS,0637,RC,63323-0273-01,NDC,,both,0.5,ML,281.80,183.17,,,,,,,,,,,,,
COMPONENT PART KNEE CAPPED UNI TRIATHLON,SUP-2365443,CDM,C1776,CPT,0278,RC,,,,both,,,14679.50,9541.67,,,,,,,,,,,,,
BIT DRL CANN LG 5X215 MM QC FOR 6.5-7.5 MM SCREW PUR GRN NS,SUP-2423427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1329.10,863.91,,,,,,,,,,,,,
GRAFT HUM TISS 0.5CC PLCNTA MTRX FLOWABLE IMMUNOSUPPRESSIVE,SUP-2340459,CDM,C1762,CPT,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
IMPLANT OPHTH NORTH CAROLINA EYE BNK,SUP-2309109,CDM,V2785,HCPCS,0810,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
SPLINT HND M PALM W3-3.5IN RT DORS CRPL TUNN HEAT MOLD,SUP-2332646,CDM,L3808,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
MARKER FIDUCIAL 17 GA GLD,SUP-2247291,CDM,A4648,CPT,0278,RC,,,,both,,,96.30,62.59,,,,,,,,,,,,,
ECH STRAIGHT 190MM +15 CALCAR SZ 11,SUP-2822848,CDM,C1776,CPT,0278,RC,,,,both,,,18507.16,12029.65,,,,,,,,,,,,,
PAROXETINE HCL 20 MG PO TABS,RX-10855,CDM,6370000000,HCPCS,0637,RC,00904-5677-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT HUM TISS W10 20MMXL165 25CM ALLGRFT TEND QUADRICEPS,SUP-2307294,CDM,C1762,CPT,0278,RC,,,,both,,,5697.22,3703.19,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTLAT DISTAL HUMERUS LAT SUPPORT 5H RT,SUP-2549686,CDM,C1713,HCPCS,0278,RC,,,,both,,,3701.40,2405.91,,,,,,,,,,,,,
HC Rmvl FB Conjunctival Sprfcl,PX-4506520500,CDM,65205,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
CANNULA SURG 23GA SUTURELESS NONVALVED 1 STP DISP,SUP-2129243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.73,294.92,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM KINSA RC,SUP-2341077,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
GUIDEWIRE THRD 3.2X230MM,SUP-2704858,CDM,C1769,HCPCS,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
KIT ANALGESIC PMP BASIC FILTER CASETTE M LUER CONN TRNSLUC,SUP-2892643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
GRAFT HUM TISS L 6 X W 2 CM AMNIO MEMBRN RESRB STRL PALINGEN,SUP-2913455,CDM,Q4173,HCPCS,0636,RC,,,,both,,,7601.94,4941.26,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA2 MM TI SNAP OFF STRL,SUP-2913555,CDM,C1713,HCPCS,0278,RC,,,,both,,,1048.45,681.49,,,,,,,,,,,,,
CEMENT BNE GENTAMICIN 40 GM SMARTSET GMV,SUP-2253085,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.125X9 IN THRD RND END NS STEINMANN,SUP-2791296,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.58,58.23,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 2.7 FRX71 CM LO PROF ADPT BRVC,SUP-2127877,CDM,C1751,HCPCS,0278,RC,,,,both,,,718.62,467.10,,,,,,,,,,,,,
LINER ACET K OD70-76MM ID22MM THK19MM 20DEG +4MM XLPE HIP,SUP-2344885,CDM,C1776,CPT,0278,RC,,,,both,,,4622.87,3004.87,,,,,,,,,,,,,
PLATE BNE CNDYL 90 DEG PEDIATRIC 5X159 MM 23/15 MM LCP,SUP-2799202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2803.05,1821.98,,,,,,,,,,,,,
COMPONENT GLEN FIX SZ 48 PEGGED AFFINITI,SUP-2396771,CDM,C1776,CPT,0278,RC,,,,both,,,5353.70,3479.90,,,,,,,,,,,,,
PLATE BONE L35MM 4 H MAND TI STR ECC LIMIT CNTCT DYN COMPR,SUP-2191399,CDM,C1713,HCPCS,0278,RC,,,,both,,,2452.97,1594.43,,,,,,,,,,,,,
GRAFT DERM HUM TISS THCK KT MTRX ACELLULAR DERM IMPL ALLGRFT,SUP-2307511,CDM,Q4128,HCPCS,0636,RC,,,,both,,,21866.65,14213.32,,,,,,,,,,,,,
COIL EMB L8CM OD4MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305162,CDM,C1889,HCPCS,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
SET CATH BILI DRN DSTL LOOP 12FR HYDRPHLC COAT W/ STD LCK,SUP-2141085,CDM,C1729,HCPCS,0272,RC,,,,both,,,230.70,149.95,,,,,,,,,,,,,
CAGE SPNL W10XH8XL28MM 5DEG ANTR THORLUM C FBR REINF,SUP-2254812,CDM,C1889,HCPCS,0278,RC,,,,both,,,12528.60,8143.59,,,,,,,,,,,,,
WAND ABLAT DIA1.4MM TIP 0.9MM 30DEG INTEGR CBL MICROBLATOR,SUP-2341983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.91,387.99,,,,,,,,,,,,,
IMPLANT HEARING 3MM TI W/ ABUTMENT ST BAHA BA300,SUP-2164961,CDM,L8614,HCPCS,0278,RC,,,,both,,,5086.80,3306.42,,,,,,,,,,,,,
PROTECTOR NRV L40MM DIA3.5MM PORCINE EXTRACELLULAR MTRX WRP,SUP-2124857,CDM,C1763,HCPCS,0278,RC,,,,both,,,9627.24,6257.71,,,,,,,,,,,,,
DILATOR ENDO BAL L8CM OD20MM CATH L180CM ESOPH REUSE FOR SM,SUP-2166038,CDM,C1725,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
TOOL INSERTION FOR S-ICD ELECTRODE EMBLEM,SUP-2424812,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SET SCR BNE L17.5MM DIA8MM TI FOR TROCHANTERIC NAILING SYS,SUP-2370393,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
BASEPLATE GLEN DIA28MM UNIV HA FOR COMPHSVE REV SHLDR SYS,SUP-2404725,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2X9 MM WITH FLUTED TIP TITANIUM,SUP-2838218,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.60,141.44,,,,,,,,,,,,,
NEXGEN PROV A/P WEDGED TIB PLT SZ 5,SUP-2201706,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
WASHER ORTH SPIK 10 MM BOLT OSS,SUP-2441747,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
SUPPORT ORTHOT CUST RNG FLANGE PLAS LTHR,SUP-2435581,CDM,L1100,HCPCS,0272,RC,,,,both,,,537.66,349.48,,,,,,,,,,,,,
CATHETER ETER VENT L120CM ANTIBIO IMPREG,SUP-2280158,CDM,C1729,HCPCS,0272,RC,,,,both,,,1676.63,1089.81,,,,,,,,,,,,,
CATHETER ABLATN D-D 2-5-2 MM 2MM 7 FRX115 CM EZ STEER LF,SUP-2248510,CDM,C1732,HCPCS,0272,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
GRAFT HUM TISS W40XL40MM THK1MM ACELLULAR DERM RM TEMP,SUP-2264665,CDM,C1762,CPT,0278,RC,,,,both,,,5170.51,3360.83,,,,,,,,,,,,,
CATHETER ETER EP ABLAT D CRV QPLR 1 7 4MM SPC 4MM TIP DEFL TEMP SENS,SUP-2248467,CDM,C1732,HCPCS,0278,RC,,,,both,,,5567.22,3618.69,,,,,,,,,,,,,
CATHETER EP CSL 2-8-2 MM 7 FRX120 CM RESPON,SUP-2464391,CDM,C1730,HCPCS,0272,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
SCREW GLEN L 40 MM DIA 8 MM REV MOD CNTRL STRL ALTIVATE RVS,SUP-2904156,CDM,C1776,CPT,0278,RC,,,,both,,,6250.17,4062.61,,,,,,,,,,,,,
TRIAL HD 26MM -3MM OFFSET SH FEM CO CHROM TAPR LFIT,SUP-2364469,CDM,C1776,CPT,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
CUP ACET FLNG E RT HIP,SUP-2417196,CDM,C1776,CPT,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
PUSHER KNOT SGL H W/ THMB RNG FOR SHLDR AND EL,SUP-2120937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 10X6 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871496,CDM,C1762,CPT,0278,RC,,,,both,,,14569.60,9470.24,,,,,,,,,,,,,
NEEDLE STIM L5IN STR INSRT NEUROMODULATION,SUP-2138807,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
PLATE FOOT LK H PLT SM,SUP-2701550,CDM,C1713,HCPCS,0278,RC,,,,both,,,1989.50,1293.17,,,,,,,,,,,,,
HC So1 Ptt|NOT REASONABLE AND NECESSARY,PX-3058573067,CDM,85730,CPT,0305,RC,,,GZ,both,,,36.00,23.40,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 8 MM RNG L 20 CM EPTFE STR TW,SUP-2396166,CDM,C1768,CPT,0278,RC,,,,both,,,3212.22,2087.94,,,,,,,,,,,,,
CATHETER ETER HAD ADMIN SET STR 115FRX24CM TRI FLO,SUP-2269581,CDM,C1752,HCPCS,0278,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
KIT OPTHACATH 3MM UNILAT,SUP-2224387,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
SYSTEM RETRACTOR VIEWLINE,SUP-2415684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GRAFT BONE 15ML CANC CHIP FRZ DRY,SUP-2165606,CDM,C1762,CPT,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SET PROST SEEDING L20CM OD18GA NDL FLEX UTW,SUP-2381879,CDM,C1715,HCPCS,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
STEM FEM SZ 00 L110MM DIA9MM NK L26MM 28MM OFFSET 132DEG,SUP-2375321,CDM,C1776,CPT,0278,RC,,,,both,,,13325.53,8661.59,,,,,,,,,,,,,
PLATE BNE L274MM BLDE W4.8XL25MM 95DEG 16 H NONSTERILE HIP,SUP-2186762,CDM,C1713,HCPCS,0278,RC,,,,both,,,3288.49,2137.52,,,,,,,,,,,,,
STEM FEM L130MM OD9MM 12/14 131DEG PRSS FIT STD OFFSET,SUP-2222288,CDM,C1776,CPT,0278,RC,,,,both,,,16202.40,10531.56,,,,,,,,,,,,,
DEVICE REATTACHMENT W23XL53MM SHT GREATER TROCHANTERIC TIV,SUP-2410263,CDM,C1713,HCPCS,0278,RC,,,,both,,,4512.37,2933.04,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PLU MAXBARR 4FR 55CM 1 LU 1174108D3,SUP-2632627,CDM,C1751,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST W/NONTORSION JT,SUP-2435788,CDM,L3931,HCPCS,0272,RC,,,,both,,,537.22,349.19,,,,,,,,,,,,,
PACEMAKER CARD ITREVIA HF-T TI HSNG EPOXY RESIN HEADER SIL,SUP-2138467,CDM,C1882,HCPCS,0275,RC,,,,both,,,77950.50,50667.82,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2.5 MM RECON MAXILLA PT SPEC,SUP-2860098,CDM,C1713,HCPCS,0278,RC,,,,both,,,27765.14,18047.34,,,,,,,,,,,,,
WASHER ORTH OLECRANON SLED,SUP-2389623,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BAR RETRACTOR JANETTA SINGLE RND LUMBARTRAK RUGGLES-REDMOND,SUP-2472807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.46,466.35,,,,,,,,,,,,,
SCREW BNE MALL 4.5X70 MM,SUP-2530686,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.30,74.29,,,,,,,,,,,,,
COMPONENT FEM CRUC RET POR RT SZ 7 OXINIUM PROFIX,SUP-2347007,CDM,C1776,CPT,0278,RC,,,,both,,,8759.03,5693.37,,,,,,,,,,,,,
IMPLANT UNI TIB IMPL KT ZM,SUP-2200486,CDM,C1776,CPT,0278,RC,,,,both,,,4446.24,2890.06,,,,,,,,,,,,,
GRAFT BNE H18MM IL CREST WDG PRESERVON MATRIGRFT,SUP-2264843,CDM,C1713,HCPCS,0278,RC,,,,both,,,2595.93,1687.35,,,,,,,,,,,,,
BRACE WRISTXSM FOR 14.6CM LT PROTCT PD ADJ BAR D RNG CLSR,SUP-2324887,CDM,L3931,HCPCS,0274,RC,,,,both,,,41.07,26.70,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 11.5MMW X12MML 0.4MM THK 0.6MM THK CUT IN,SUP-2605373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.43,220.63,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX15 CM DL J TIP POLYURETHANE,SUP-2759959,CDM,C1751,HCPCS,0278,RC,,,,both,,,230.04,149.53,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH TRIO L 12 CM DIA10 FR CATH 4/5 FR,SUP-2357117,CDM,C1894,HCPCS,0272,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
SCAFFOLD WOUND 8X8 PRIMATRIX,SUP-2653423,CDM,Q4110,HCPCS,0636,RC,,,,both,,,7149.78,4647.36,,,,,,,,,,,,,
SYSTEM CLSR L SZ 1.7MM SHFT L8CM VASC TI DURA ANAS 35 CLP,SUP-2264250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
SPINAL KIT 17 MM BUR HOLE COVER TITANIUM STERILE MATRIXNEURO,SUP-2837711,CDM,C1713,HCPCS,0278,RC,,,,both,,,3174.54,2063.45,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CERM VIVACIT-E,SUP-2212494,CDM,C1776,CPT,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
REAMER SURG 22MM MT JT CUP GEN 2,SUP-2398417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
CAP END FEM UNIV 10 MM NAIL EXTN TI,SUP-2480497,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
EVOS VOL PLATE 5H RIGHT STD TI 81MM NS,SUP-2819172,CDM,C1713,HCPCS,0278,RC,,,,both,,,7782.02,5058.31,,,,,,,,,,,,,
DRESSING BIO L 8 X W 6 CM FISH SKIN 21 PRE MESHED STRL,SUP-2909173,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9137.40,5939.31,,,,,,,,,,,,,
K WIRE FIX L6IN DIA0.045IN 1600645] MICROAIRE SURGICAL INSTRUMENTS INC],SUP-2304023,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.70,10.85,,,,,,,,,,,,,
COLLAR CERV H325XL19IN M TRACH CLS VELC CLSR CNTOUR LO DENS,SUP-2196900,CDM,L0120,HCPCS,0272,RC,,,,both,,,8.54,5.55,,,,,,,,,,,,,
STEM FEM SZ 1 L115MM DIA11MM NK L31MM 34MM OFFSET 132DEG 62650003] STRYKER CORP],SUP-2364473,CDM,C1776,CPT,0278,RC,,,,both,,,8220.52,5343.34,,,,,,,,,,,,,
HC NM 3 Phase Bone Scan,PX-3417831500,CDM,78315,CPT,0341,RC,,,,outpatient,,,3524.00,2290.60,,,,,,,,,,,,,
PLATE BNE L52MM THK3.7MM 4 H BILAT S STL STR LO PROF RIG,SUP-2177144,CDM,C1713,HCPCS,0278,RC,,,,both,,,1848.49,1201.52,,,,,,,,,,,,,
HC Arthrogram Hip S&I,PX-3227352500,CDM,73525,CPT,0322,RC,,,,both,,,1013.00,658.45,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSOSTAR NAV L 115 CM DIA 4 FR,SUP-2530193,CDM,C1732,HCPCS,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
GUIDEWIRE UROLOGY ANGLED 0.025 INX150 CM STIFF-BODY HIWIRE,SUP-2835975,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.67,107.69,,,,,,,,,,,,,
GUIDEWIRE ORTH FLX TIP 2.5X620 MM CALIB,SUP-2563948,CDM,C1769,HCPCS,0272,RC,,,,both,,,267.78,174.06,,,,,,,,,,,,,
COUPLER SURG USED EXT SVC 1 YR LG PWR,SUP-2760997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1401.23,910.80,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT HEMI PAT WDG 16 18MM THICKNESS,SUP-2307176,CDM,C1713,HCPCS,0278,RC,,,,both,,,2569.84,1670.40,,,,,,,,,,,,,
METFORMIN HCL ER 500 MG PO TB24,RX-28995,CDM,6370000000,HCPCS,0637,RC,67877-0159-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE W6.3XL47MM THK1.6MM 3X4 H RT DSTL VOLAR RAD TI,SUP-2191012,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.96,824.17,,,,,,,,,,,,,
HEAD FEM OD26MM NK -6MM OFFSET TYP 2 CO CHROM TAPR,SUP-2406792,CDM,C1776,CPT,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
UNIVERS II GLENOID INSTRUMENTATION SET,SUP-2815582,CDM,C1713,HCPCS,0278,RC,,,,both,,,109900.00,71435.00,,,,,,,,,,,,,
SET IMPL UNIV NONSTERILE GRPHC CA W/ SCR PLT FOR DYN HIP,SUP-2183069,CDM,C1713,HCPCS,0278,RC,,,,both,,,46250.85,30063.05,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 30 MM DIA16 MM SS POLYPRO,SUP-2170449,CDM,C1713,HCPCS,0278,RC,,,,both,,,5752.48,3739.11,,,,,,,,,,,,,
KIT CARD PACE ARW L 110 CM DIA 5 FR BALLOON DIA 7 MM INTRO 6,SUP-2383248,CDM,C1887,HCPCS,0272,RC,,,,both,,,773.70,502.90,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 3.9 FRX30X5 MM JAGWIRE CANN TRUTOME,SUP-2498332,CDM,C1769,HCPCS,0272,RC,,,,both,,,1238.95,805.32,,,,,,,,,,,,,
RING STEM SUPP 18X10 MM TILASTAN,SUP-2423133,CDM,C1776,CPT,0278,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
HANDLE SUT PASS SGL USE FOR MENIS REP SHRP SHOT,SUP-2362796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
LINER ACET 38X27 MM SCR IN +5 HI WALL RINGLOC+,SUP-2447220,CDM,C1776,CPT,0278,RC,,,,both,,,2585.79,1680.76,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 6 FR SPC 2-8-2 MM,SUP-2894348,CDM,C1730,HCPCS,0272,RC,,,,both,,,615.31,399.95,,,,,,,,,,,,,
HC Ot Wheelchair Mngment Training,PX-4309754200,CDM,97542,CPT,0430,RC,,,,outpatient,,,154.00,100.10,,,,,,,,,,,,,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,6370000000,HCPCS,0637,RC,61314-0227-05,NDC,,both,5,ML,43.50,28.27,,,,,,,,,,,,,
PLATE BNE MEDL CLMN SM 2.7/3.5 MM MIDFOOT 9 HOLE COMPR TI,SUP-2398186,CDM,C1713,HCPCS,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
IMPLANTABLE PULSE GENRTR,SUP-2418030,CDM,C1767,HCPCS,0278,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305760,CDM,V2790,HCPCS,0278,RC,,,,both,,,4606.38,2994.15,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BREAST BIOPSY TRAY FOR US BX NDL LOC,SUP-2175843,CDM,C1819,HCPCS,0278,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX 5X35 MM YEL,SUP-2205301,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.82,285.23,,,,,,,,,,,,,
PUTTY W/ CHIP 10.0CC DBM W/ RPM,SUP-2415804,CDM,C9359,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,0636,RC,00517-2340-10,NDC,,both,2.5,ML,95.90,62.33,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 200 MM DIA 7 MM DEL SHTH,SUP-2934381,CDM,C1713,HCPCS,0278,RC,,,,both,,,15603.54,10142.30,,,,,,,,,,,,,
MARKER BRST BX PET DIA8GA BARBELL CLP MAMMOSTAR,SUP-2195621,CDM,A4648,CPT,0278,RC,,,,both,,,318.40,206.96,,,,,,,,,,,,,
ALLOGRAFT OSTEOTOMY WDG FD IRR,SUP-2875976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2738.39,1779.95,,,,,,,,,,,,,
HC Bilirubin Direct,PX-3018224800,CDM,82248,CPT,0301,RC,,,,both,,,359.00,233.35,,,,,,,,,,,,,
PATCH CV HEMGRD L 75 X W 14 MM THK 0.41 MM POLYESTER BOV,SUP-2535422,CDM,C1768,CPT,0278,RC,,,,both,,,454.01,295.11,,,,,,,,,,,,,
CAP HEALING DIA30MM FOR STD USE BAHA,SUP-2164979,CDM,L8614,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
GRAFT HUM TISS 15X140X1.5MM DECELLULARIZED DERM W/ MATRACELL,SUP-2120779,CDM,Q4125,HCPCS,0636,RC,,,,both,,,6180.46,4017.30,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 8 MM EPTFE CENTERFLEX RING HEMO,SUP-2761397,CDM,C1768,CPT,0278,RC,,,,both,,,2132.91,1386.39,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST CLASP ATTCH SHOE BAR SINGLE,SUP-2435626,CDM,L1910,HCPCS,0274,RC,,,,both,,,793.98,516.09,,,,,,,,,,,,,
PLATE BNE LCK 210 MM RT DSTL LAT FIBULAR 14 HOLE SS STRL,SUP-2469509,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.78,1708.71,,,,,,,,,,,,,
PLATE BNE STR NAR STRL NCB,SUP-2862094,CDM,C1713,HCPCS,0278,RC,,,,both,,,9159.25,5953.51,,,,,,,,,,,,,
INDAPAMIDE 2.5 MG PO TABS,RX-3879,CDM,6370000000,HCPCS,0637,RC,00228-2571-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L154MM 8 H L LAT PROX TIB S STL LOK COMPR LO PROF,SUP-2185716,CDM,C1713,HCPCS,0278,RC,,,,both,,,4225.34,2746.47,,,,,,,,,,,,,
PIN GUIDE L 300 MM DIA1.9 MM NTHRD FOR CANN SCREW BX OF 6,SUP-2933258,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.66,306.58,,,,,,,,,,,,,
INTRODUCER BNE CEMENT STABILIT VP DIA10-11 GA10 CC,SUP-2421786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
BIT DRL 3.2X40 MM DURALOC,SUP-2453984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,285.43,185.53,,,,,,,,,,,,,
COLLAR CERV AD M H4.25IN FOR 13-16IN NK FOAM TRACH OPN,SUP-2195537,CDM,L0172,HCPCS,0272,RC,,,,both,,,45.28,29.43,,,,,,,,,,,,,
SPACER SPNL TI INTBDY FUS C RNG FOR 635MM ROD,SUP-2280179,CDM,C1889,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
MESH BONE SIZE 7 TTNM STNDRD LATEX FREE PSTRR PRSGTTL CRNL,SUP-2707385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1060.85,689.55,,,,,,,,,,,,,
RING EXT FIX HALF 210 MM ALUM NS MAXFRAME,SUP-2757975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
CATHETER SHUNT L900MM OD2.5MM ID1.2MM SILICONE PERITONEAL RA,SUP-2821783,CDM,C1729,HCPCS,0272,RC,,,,both,,,801.01,520.66,,,,,,,,,,,,,
FIBER LASER HOLM 550 MIC,SUP-2430217,CDM,C1713,HCPCS,0278,RC,,,,both,,,4925.56,3201.61,,,,,,,,,,,,,
HYDRALAZINE HCL 50 MG PO TABS,RX-3701,CDM,6370000000,HCPCS,0637,RC,00904-7449-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MESH MXLFCL PALE ADJ FOR 3DX GEAR 1.5 - 1.8 MM SS TI RED II,SUP-2482896,CDM,C1713,HCPCS,0278,RC,,,,both,,,9040.53,5876.34,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2.8 MM SM CP TI RT MANDIBULAR,SUP-2883703,CDM,C1713,HCPCS,0278,RC,,,,both,,,15550.22,10107.64,,,,,,,,,,,,,
BIT DRL JCBS 3.5 MM,SUP-2205611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
SET URET STENT UTHANE L 24 CM POS L 46 CM DIA 7.0 FR SLV L,SUP-2168928,CDM,C2617,HCPCS,0278,RC,,,,both,,,441.58,287.03,,,,,,,,,,,,,
GRAFT DURA STRP 3X1 IN DURA REGEN MTRX DURAGN +,SUP-2427678,CDM,C1763,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
COMPONENT FEM PS CEM SYMMETRICAL SZ 2,SUP-2222820,CDM,C1776,CPT,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.520,SUP-2860037,CDM,C1713,HCPCS,0278,RC,,,,both,,,36970.36,24030.73,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L52 MM DIA 9 MM CATH TOT L 160,SUP-2148419,CDM,C1876,HCPCS,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
IMPLANT OTO L4MM DIA0.84MM DENS HA OFF CNTR,SUP-2312570,CDM,2780000010,LOCAL,0278,RC,,,,both,,,926.49,602.22,,,,,,,,,,,,,
PLATE BNE STR MINI REG 2 MM 4 HOLE FOR SCR TI RIGID BLU,SUP-2461589,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.79,209.16,,,,,,,,,,,,,
MARKER FIDUCIAL SYS TISS GLD 18 G BIOMARC,SUP-2152634,CDM,A4648,CPT,0278,RC,,,,both,,,79.54,51.70,,,,,,,,,,,,,
PLATE BONE THK1MM 4X2 H BILAT HND TRAPEZOIDAL LCK TRILOK FOR,SUP-2267932,CDM,C1713,HCPCS,0278,RC,,,,both,,,2238.82,1455.23,,,,,,,,,,,,,
BONE MATRIX CELLULAR ORIOS 10CC,SUP-2653968,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
DRILL SURG VAR 35 MM,SUP-2417120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TAP 5MM MOD CT XIA,SUP-2381176,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
IMPLANT BRST 235CC DIA95CM P49CM SIL GEL SMOOTH RND HI PROF,SUP-2300975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
ALLOGRAFT BNE CHIPS 1-8 MM 10 CC CANC DEMINERALIZED BNE BIO,SUP-2637036,CDM,C1713,HCPCS,0278,RC,,,,both,,,3506.09,2278.96,,,,,,,,,,,,,
CAP LCK S STL REVERE,SUP-2230742,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED RT TALUS NO CART,SUP-2867173,CDM,C1762,CPT,0278,RC,,,,both,,,8188.34,5322.42,,,,,,,,,,,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-110967,CDM,J0884,HCPCS,0636,RC,65145-0126-01,NDC,,both,50,ML,805.00,523.25,,,,,,,,,,,,,
LEAD NERVE STIM 60 CM 16 ELECTRD PENTA,SUP-2421248,CDM,C1778,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILIVIA NEO 7 VR-T PROMRI TI POLYUR SIL,SUP-2739242,CDM,C1722,HCPCS,0275,RC,,,,both,,,55590.56,36133.86,,,,,,,,,,,,,
ANCHOR SUTURE L11MM DIAMETER 3.5MM PEEK DEPLOYED POPLOK,SUP-2825123,CDM,C1713,HCPCS,0278,RC,,,,both,,,1608.65,1045.62,,,,,,,,,,,,,
PLATE BONE TIBIAL 4.5 MM LEFT PROXIMAL LATERAL 8 HOLE LOCKIN,SUP-2836980,CDM,C1713,HCPCS,0278,RC,,,,both,,,8375.95,5444.37,,,,,,,,,,,,,
GRAFT BNE SUB 5ML HA CLLGN INJ FILL RESRB HEALOS FX,SUP-2255629,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.75,1892.64,,,,,,,,,,,,,
BLADE SHV DIA3.5MM BGE FULL RAD BONECUTTER DISP,SUP-2341659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.28,160.73,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 79 MM EXPANSION DIA 5-10 MM SHTH,SUP-2159303,CDM,C1877,HCPCS,0278,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
GRAFT BNE 10 CC OSTEOCURRENT,SUP-2644334,CDM,C1713,HCPCS,0278,RC,,,,both,,,13376.40,8694.66,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 3 PLATE CUSTOMIZED FACE ID,SUP-2883366,CDM,C1713,HCPCS,0278,RC,,,,both,,,36204.26,23532.77,,,,,,,,,,,,,
CONNECTOR SPNL M LAT TOP ANT FIX TI XLNK,SUP-2415884,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SET INSERTION ACCESS TRAY,SUP-2855519,CDM,C1751,HCPCS,0278,RC,,,,both,,,43.65,28.37,,,,,,,,,,,,,
CAP NAIL H10MM CEPHALOMEDULLARY,SUP-2208069,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
CATHETER CTRL VEN L70CM OD6FR 3 LUMN NIT GWIRE BLU INTRO,SUP-2125562,CDM,C1751,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
HC Baclofen 10 Mg Injection,PX-6360047500,CDM,J0475,CPT,0636,RC,,,,both,,,608.00,395.20,,,,,,,,,,,,,
PLEDGET SURG PTFE RECT FELT 3/16X.025IN 1.65MM THK STRL 10PK,SUP-2913772,CDM,C1781,HCPCS,0278,RC,,,,both,,,399.09,259.41,,,,,,,,,,,,,
MESH HERN DIA12CM CIR BIOMATERIAL PTFE KNIT DURABLE SGL STG,SUP-2395755,CDM,C1781,HCPCS,0278,RC,,,,both,,,1849.46,1202.15,,,,,,,,,,,,,
SAW SURG OSCLLTNG W/O HOSE FLFORTHPDC ORLORALMXLLFCL OTOLARY,SUP-2605430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7937.35,5159.28,,,,,,,,,,,,,
CATHETER GUID 6FR L55CM BLU PTFE RDC I TRUELUMEN HYBRID,SUP-2158222,CDM,C1887,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
PLATE BNE DBL Y NEURO ULTRA LO PROF W/ TAB TI LEVEL 1 LF,SUP-2457627,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.59,535.33,,,,,,,,,,,,,
HC Motion Fluor Eval Swlng Funcj C/V Rec,PX-4449261100,CDM,92611,CPT,0444,RC,,,,both,,,510.00,331.50,,,,,,,,,,,,,
HFN RH 130 DEG 15MM X 440MM,SUP-2588706,CDM,C1713,HCPCS,0278,RC,,,,both,,,7503.03,4876.97,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135CM 4FR SLT 5CM 0.035 IN BALL,SUP-2117047,CDM,C1725,HCPCS,0272,RC,,,,both,,,443.09,288.01,,,,,,,,,,,,,
SCREW BNE ST 5X30 MM TI NS NCB MOTIONLOC,SUP-2423586,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.89,363.28,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-9 MM 50 CC FD CANC,SUP-2717763,CDM,C1713,HCPCS,0278,RC,,,,both,,,1699.31,1104.55,,,,,,,,,,,,,
SCREW CORTEX ST 2.4X50MM W/3.5MM HD,SUP-2547212,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.66,111.58,,,,,,,,,,,,,
STRYKER REPLACEMENT BLADE 19X90X0.89MM,SUP-2605752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,179.89,116.93,,,,,,,,,,,,,
SCREW SPNL MULTAXL 8.5X50 MM CANC CD HORZ TCS,SUP-2628371,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
CATHETER CTRL VEN 8.5FR L20CM QUAD LUMN INDWL RADPQ POLYUR,SUP-2383393,CDM,C1751,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
GRAFT VASC L40CM OD26MM SIDE BRANCH L15CM OD10MM ARCH BRANCH,SUP-2385008,CDM,C1768,CPT,0278,RC,,,,both,,,6719.60,4367.74,,,,,,,,,,,,,
PATCH CV HEMSHLD PLAT FINESSE L 152 X W 8 MM THK 0.36 MM,SUP-2461651,CDM,C1768,CPT,0278,RC,,,,both,,,451.59,293.53,,,,,,,,,,,,,
GRAFT BNE FEM HD FD,SUP-2684083,CDM,C1762,CPT,0278,RC,,,,both,,,10949.18,7116.97,,,,,,,,,,,,,
KIT MAINT VENT SERVO I,SUP-2227264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.15,360.85,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED FEM HIP MED DEMAND CEMNETED,SUP-2365980,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
CANNULA VENT ASST L ART SEAL OUTFLOW BEND RELF HEARTMATE III,SUP-2356019,CDM,L8670,HCPCS,0278,RC,,,,both,,,16277.76,10580.54,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INVENTRA PROMRI UHE DX TI EPOXY RESIN SIL,SUP-2138431,CDM,C1722,HCPCS,0275,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.507,SUP-2860189,CDM,C1713,HCPCS,0278,RC,,,,both,,,26241.92,17057.25,,,,,,,,,,,,,
CATHETER DRAINAGE 4 FRX10 CM 20 GA ECHOGENIC NDL TIP ACCEL,SUP-2659261,CDM,C1729,HCPCS,0272,RC,,,,both,,,66.13,42.98,,,,,,,,,,,,,
SCREW BONE L5MM DIA2MM CRANIOMAXILLOFACIAL TI ST LCK FULL,SUP-2189379,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.40,242.06,,,,,,,,,,,,,
SET TBNG EXT FLTR DISP FOR ULTRASONIC ASPIR SONOPET,SUP-2367534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1010.14,656.59,,,,,,,,,,,,,
CEMENT BNE HI VISC 80 GM PALACOS R PRO,SUP-2738875,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
ALLOGRAFT BNE 2 CC FIBER VIABLE MTRX FIBERCEL,SUP-2541276,CDM,C1713,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
PLATE BNE L193MM 8 H L DST LAT FEM S STL LOK FOR 4.5MM SCR,SUP-2348210,CDM,C1713,HCPCS,0278,RC,,,,both,,,13706.10,8908.96,,,,,,,,,,,,,
CAP SCR IM NAIL ST GAM NAIL,SUP-2370987,CDM,C1713,HCPCS,0278,RC,,,,both,,,699.28,454.53,,,,,,,,,,,,,
COMPONENT PAT OD26MM THICKNESS 10MM STD TI POLYETH POR PRI,SUP-2370401,CDM,C1776,CPT,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
KNIFE OPHTHLMC 1MM DIA UNVRSL 4 1/2NL 0.2MM THK DMND TRFCT B,SUP-2469955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3357.45,2182.34,,,,,,,,,,,,,
PIN EXT FIX SD 4X180 MM 50 MM ST THRD SS STRL APEX,SUP-2460782,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL MOD,SUP-2435540,CDM,L0458,HCPCS,0272,RC,,,,both,,,2524.97,1641.23,,,,,,,,,,,,,
STAPLER INT TRNSOR CIR ANVIL W/ ADVANCING 21MM PROX GUID,SUP-2283247,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1078.90,701.28,,,,,,,,,,,,,
MESH HERN CIR 8 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855261,CDM,C1781,HCPCS,0278,RC,,,,both,,,21992.56,14295.16,,,,,,,,,,,,,
SHEATH INTRO BRT TIP L 11 CM DIA 5 FR DIL TIP L 25 MM GRA,SUP-2156024,CDM,C1894,HCPCS,0272,RC,,,,both,,,73.48,47.76,,,,,,,,,,,,,
"HC Removal of Embedded Foreign Body, Vestible of Mouth, Simple",PX-4504080400,CDM,40804,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
PLATE BNE L129MM 7 H ST L POSTEROLATERAL DST FIBULAR S STL,SUP-2177394,CDM,C1713,HCPCS,0278,RC,,,,both,,,2048.28,1331.38,,,,,,,,,,,,,
INTRODUCER TUBE SET 7.5/8.5/9 MM MULTI PERC TY PHAR 7.5 MM,SUP-2759714,CDM,C1769,HCPCS,0272,RC,,,,both,,,1607.30,1044.74,,,,,,,,,,,,,
PLATE BONE THK0.8MM 6 H LCK COMPR BILAT NEUT MALL FOR,SUP-2107082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
TW DRL F/COLE RAD DRILL 4.8MM,SUP-2818201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2052.87,1334.37,,,,,,,,,,,,,
COVER BUR H L10MM W/ SHUNT PASS,SUP-2365226,CDM,C1713,HCPCS,0278,RC,,,,both,,,889.78,578.36,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM OD 5 FR ID 1.7 MM GUIDEWIRE,SUP-2168351,CDM,C1894,HCPCS,0272,RC,,,,both,,,77.81,50.58,,,,,,,,,,,,,
"HC So RBC, Automated",PX-3058504166,CDM,85041,CPT,0305,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
PLATE BNE L118MM 9 H CNTOUR LOK 2 COMPR FOR 3.5MM SCR UNIV,SUP-2411376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1003.92,652.55,,,,,,,,,,,,,
SET CTRL VEN CATH 5FR L25CM STR J TIP 3MM GWIRE DIA0.035IN,SUP-2167826,CDM,C1751,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
ELECTRODE KNF 26-28FR WHT BRANCHES RED STEM COLLINS,SUP-2332861,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
SPACER HUM +12MM OFFSET 12DEG TRABECULAR MTL,SUP-2199141,CDM,C1776,CPT,0278,RC,,,,both,,,2428.79,1578.71,,,,,,,,,,,,,
PROBE LITHO US 35X400 MM OSCILLATING TIP CALCUSON DISP,SUP-2261225,CDM,C1713,HCPCS,0278,RC,,,,both,,,1006.62,654.30,,,,,,,,,,,,,
ENDCAP ORTH 0 MM HIP FRAC SYS STRL CHIMAERA,SUP-2646588,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.22,158.09,,,,,,,,,,,,,
SCREW BNE CANN 2X10X25 MM AP CRUC LIGMNT BLNT THRD RCI,SUP-2691285,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.69,293.60,,,,,,,,,,,,,
SUPPORT KNEE CLS PAT M,SUP-2276695,CDM,L1810,HCPCS,0272,RC,,,,both,,,11.46,7.45,,,,,,,,,,,,,
KIT LD L70CM SPNL CRD STIM PADDLE 32 CNTCT TIGHT COVEREDGE,SUP-2138839,CDM,C1778,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
PIN FIX L 40 MM DIA2.5 MM PROV SM TARGETER SYS STRL EVOS,SUP-2933910,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
GRAFT HUM TISS 250MG AMNIOFILL,SUP-2305712,CDM,C1762,CPT,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
CATHETER HD DL 14.5 FRX27 CM MICROINTRODUCER KT HEMOSPLIT,SUP-2127856,CDM,C1750,HCPCS,0278,RC,,,,both,,,1694.66,1101.53,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI T 3 CT ACTE 15.5FR DIA 15CM STRGHT EXT,SUP-2610561,CDM,C1752,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 5X30 MM ARROW STAINLESS STEEL NON,SUP-2836753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1690.42,1098.77,,,,,,,,,,,,,
SLEEVE ANK CLOSED HEEL 8.5-10 IN MED 1/8 IN PROCARE,SUP-2195739,CDM,L1906,HCPCS,0274,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
PLATE SPNL 41 MM ANTR LUMBAR 4 HOLE PYRAMID +4,SUP-2631827,CDM,C1713,HCPCS,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
BIT DRL L125MM DIA3.2MM GRY ATTCH W/O STP NONRADIOLUCENT BI,SUP-2373943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.36,307.68,,,,,,,,,,,,,
PLATE BNE L 45 MM SCREW DIA2 MM HD 2 SHFT 6 H SS CNDYL SLV,SUP-2905540,CDM,C1713,HCPCS,0278,RC,,,,both,,,2428.22,1578.34,,,,,,,,,,,,,
SUPPORT ORTHOT CERV THOR LUMBAR SACR CUST ANTR POST LAT,SUP-2435562,CDM,L0710,HCPCS,0274,RC,,,,both,,,6195.63,4027.16,,,,,,,,,,,,,
HC Ep Study,PX-4809362000,CDM,93620,CPT,0480,RC,,,,both,,,10416.00,6770.40,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.4X150 MM FOR CANN SCREW NS 0333301204,SUP-2789098,CDM,C1769,HCPCS,0272,RC,,,,both,,,1196.84,777.95,,,,,,,,,,,,,
FORCEPS BX L 1150 MM DIA1.15 MM CHANNEL DIA1.2 MM LUNG RAT,SUP-2912537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1495.43,972.03,,,,,,,,,,,,,
COLLAR EXT FIX CENTERING CUBE FOR 6 MM HALF PIN RANCHO,SUP-2749953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
T PLATE OBLIQUE SMALL,SUP-2820885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1967.59,1278.93,,,,,,,,,,,,,
PLATE BNE STD IMPL R CALCLOCK,SUP-2399208,CDM,C1713,HCPCS,0278,RC,,,,both,,,2203.02,1431.96,,,,,,,,,,,,,
ROD REPROC EXT FIX 11X200 MM MR CARBON FIBER NS,SUP-2188655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.05,577.23,,,,,,,,,,,,,
BLADE SCREWDRIVER 2/2.3X27 MM RT ANGLED CROSS DRV LEVEL 1,SUP-2474845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.34,373.32,,,,,,,,,,,,,
SHEATH INTRO D'VILL L 65 CM DIA14 FR GUIDEWIRE 0.035 IN LNG,SUP-2615939,CDM,C1894,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE BNE L336MM 16 H NONSTERILE R CNDYL S STL CRV LOK,SUP-2177863,CDM,C1713,HCPCS,0278,RC,,,,both,,,6377.34,4145.27,,,,,,,,,,,,,
MESH SYNTH ABD ABSRB COAT RECT POLYPR O3FA OVL FLAT SH 10CM,SUP-2265954,CDM,C1781,HCPCS,0278,RC,,,,both,,,93.10,60.51,,,,,,,,,,,,,
CAGE APR REINF RT 50MM,SUP-2137268,CDM,C1889,HCPCS,0278,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
DECOMPRESSION CANNULA,SUP-2811424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GRAFT BIO TISS W2.4XL3.9IN PORCINE DERM RIFAMPIN,SUP-2125831,CDM,C1781,HCPCS,0278,RC,,,,both,,,4499.62,2924.75,,,,,,,,,,,,,
COMPONENT FEM XSM R KNEE MOD ROT HNG REV CEM MONOGRAM,SUP-2421282,CDM,C1776,CPT,0278,RC,,,,both,,,20771.10,13501.21,,,,,,,,,,,,,
KNIFE SURG MCCABE CNL 6-1/8 IN 2.5 MM EAR CNL SHRP TIP LF,SUP-2460860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,300.00,195.00,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 1 G IV SOLR,RX-27308,CDM,J0696,HCPCS,0636,RC,00409-7333-04,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CATHETER JEJUNOSTOMY 12 FRX72 CM 20 SP UTHANE,SUP-2168465,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.24,266.01,,,,,,,,,,,,,
SET CATH HEMODIALYSI ARWGRD BLU BEND ACUTE 12FR DIA 16CM 2LM,SUP-2613340,CDM,C1752,HCPCS,0278,RC,,,,both,,,230.04,149.53,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6X2 CM TEND REINF MTRX PURAFORCE,SUP-2716033,CDM,C1765,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
BLADE SHV L11CM OD4MM 40DEG ANG AGG MICRODEBRIDER ESSX,SUP-2363536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.89,261.23,,,,,,,,,,,,,
ALLOGRAFT DERMAL ACELLULAR MTRX 5X10 CMX1.1-0.5 MM XENOGRAFT,SUP-2717794,CDM,C1763,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
HC X-Ray Bile Duct Endoscopy,PX-3207432800,CDM,74328,CPT,0320,RC,,,,outpatient,,,859.00,558.35,,,,,,,,,,,,,
PEG GLENOIDXL DIA56MM SHLDR UHMWPE 1020XLK ANCHR FOR,SUP-2250038,CDM,C1776,CPT,0278,RC,,,,both,,,5855.63,3806.16,,,,,,,,,,,,,
MESH CRAN L 119.89 X W 65.02 MM THK 0.8 MM SCREW DIA1.5 MM,SUP-2935773,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
CANCL BONE SCW Ti 6.5MMX30MM FULLY THREADED,SUP-2508850,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CATHETER ETER BRACHYTHERAPY L5 6CM MULT LUMN BLLN CONTURA,SUP-2239951,CDM,C1728,HCPCS,0272,RC,,,,both,,,8223.66,5345.38,,,,,,,,,,,,,
UNISPACER 50MM X 2MM MED RT,SUP-2202428,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
PLATE CRNL LOW PRFLE LNG HLX4 TTNM CRNFCL DBLE Y SHPD CNTRD,SUP-2677802,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.40,440.96,,,,,,,,,,,,,
BIT DRL L270MM DIA3.8MM 3 FLUT QUIK CPL NONRADIOLUCENT W/O,SUP-2178939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.41,429.92,,,,,,,,,,,,,
BLADE RTRCTR BLFR STNDRD 3 5/8NW X 10 3/4NL X 1 3/4ND ABDMNL,SUP-2494033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.18,321.87,,,,,,,,,,,,,
WEDGE FEM SZ 7 THK20MM DSTL KNEE FOR HNG SYS LEGION,SUP-2346409,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L20CM OD15FR ADMIN CHRONIC BASIC KT,SUP-2116554,CDM,C1750,HCPCS,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
ADAPTER LD 5MM UPLR,SUP-2355666,CDM,C1883,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
SET URET STENT L 22 CM DIA 4.8 FR PERCFLX + HYDROPLUS 2,SUP-2139089,CDM,C2617,HCPCS,0278,RC,,,,both,,,382.86,248.86,,,,,,,,,,,,,
DAPAGLIFLOZIN PROPANEDIOL 10 MG PO TABS,RX-124903,CDM,6370000000,HCPCS,0637,RC,00310-6210-30,NDC,,both,1,UN,90.00,58.50,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO LUMBAR S/C SHELL/PANEL PREFABRICATED,SUP-2265012,CDM,L0450,HCPCS,0274,RC,,,,both,,,4998.88,3249.27,,,,,,,,,,,,,
PLATE BNE THK0.6MM 16 H MAND TI STR LO PROF FOR 2MM SCR,SUP-2262931,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.79,137.66,,,,,,,,,,,,,
KNEE WEDGE UPCHARGE AUGMENT ZIMMER,SUP-2501337,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SLEEK L 150 CM BALLOON L 40 MM DIA2 MM,SUP-2156514,CDM,C1725,HCPCS,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
K WIRE FIX L200MM DIA1.6MM FULL THRD,SUP-2362787,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
HC Ribs Bilateral 1 View Cvr Min 4 Views,PX-3207111100,CDM,71111,CPT,0320,RC,,,,both,,,786.00,510.90,,,,,,,,,,,,,
"HC Glucose, Fasting",PX-3018294700,CDM,82947,CPT,0301,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
GRAFT VASC PTCH 6 MMX40 CM BIOPROSTHESIS PROCOL,SUP-2237244,CDM,C1768,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
LINER ACET HIP A-SERIES,SUP-2221814,CDM,C1776,CPT,0278,RC,,,,both,,,7.54,4.90,,,,,,,,,,,,,
ALLOGRAFT DERMAL 4X6 CM DECELL DERMAL MTRX DERMAPURE,SUP-2388445,CDM,Q4152,HCPCS,0636,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
IMPLANT OSS L0.5MM DIA0.8MM STAP HA DENS FTPLT PARTIALLY,SUP-2312577,CDM,L8613,CPT,0278,RC,,,,both,,,631.93,410.75,,,,,,,,,,,,,
SCREW BONE L32MM DIA5.5MM THRD L16MM STD CORT S STL ST SELF,SUP-2343635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1857.94,1207.66,,,,,,,,,,,,,
CATHETER TRAY PICC 5 FR 3 LT MAX BARR,SUP-2126402,CDM,C1751,HCPCS,0278,RC,,,,both,,,713.50,463.77,,,,,,,,,,,,,
ROD RM L1150MM DIA2.5MM TI W/ EXTN BALL TIP FOR IM NAIL,SUP-2188108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.43,267.43,,,,,,,,,,,,,
MESH HERN SQ 18X18 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855258,CDM,C1781,HCPCS,0278,RC,,,,both,,,82896.00,53882.40,,,,,,,,,,,,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,0636,RC,63323-0523-01,NDC,,both,250,ML,61.90,40.23,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 45 DEG 0.035 INX350 CM STIFF GLIDEWIRE,SUP-2422176,CDM,C1769,HCPCS,0272,RC,,,,both,,,261.56,170.01,,,,,,,,,,,,,
STIMULATOR NERVE CHECKPOINT GAURDIAN DISP,SUP-2736213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
ALLOGRAFT FEM HD W/O CART FRZ DRY IRRAD ALL SZ,SUP-2165538,CDM,C1713,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC DEMINERALIZED CORT CANC BNE FIBER,SUP-2905185,CDM,C1713,HCPCS,0278,RC,,,,both,,,3088.19,2007.32,,,,,,,,,,,,,
PLATE SPNL SLAP SPCR CAPSTONE,SUP-2285080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.51,294.78,,,,,,,,,,,,,
REAMER SPNL 14MM DIA HLLW ADJUSTABLE TAPR,SUP-2292333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1385.24,900.41,,,,,,,,,,,,,
PLATE BNE L116MM 7 H ANT ANK S STL LOK COMPR FOR ARTH,SUP-2177143,CDM,C1713,HCPCS,0278,RC,,,,both,,,4518.77,2937.20,,,,,,,,,,,,,
KIT TOOL INSERTABLE ACC REVEAL LINQ,SUP-2281140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SYSTEM MENIS REP RVS CRV ASMBLY FAST-FIX,SUP-2341589,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.87,552.42,,,,,,,,,,,,,
PROSTHESIS VOICE 22.5FR 4MM PRELD W/ SMRT INSRTR AND BRSH,SUP-2124407,CDM,L8509,HCPCS,0272,RC,,,,both,,,1029.35,669.08,,,,,,,,,,,,,
MARKER BRST BX L13CM OD14GA RBBN TI SENOMARK ULTRACOR,SUP-2127030,CDM,A4648,CPT,0278,RC,,,,both,,,191.89,124.73,,,,,,,,,,,,,
BIT DRL DIA4MM FORXTRACT-ALL V.2 SCR REM SYS,SUP-2337691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PLATE BONE SHFT L19MM BLDE L15MM THK0.9MM 2X2 H SH RT,SUP-2191180,CDM,C1713,HCPCS,0278,RC,,,,both,,,1063.83,691.49,,,,,,,,,,,,,
HALF RING 110MM INT DIA,SUP-2818148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5832.71,3791.26,,,,,,,,,,,,,
SHELL ACET DP 58 MM FEM HIP,SUP-2101360,CDM,C1776,CPT,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SCREW BONE SCHANZ 2.5 MM 4X70 MM SELFDRILLING TITANIUM NONST,SUP-2842152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1369.35,890.08,,,,,,,,,,,,,
SPLINT ORTH 10IN KNEE BASIC,SUP-2197150,CDM,L1830,CPT,0272,RC,,,,both,,,30.52,19.84,,,,,,,,,,,,,
CUBE EXT FIX 4 H S STL RANCHO FOR ILIZ TAY SPAT FRME EXT,SUP-2342335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1471.12,956.23,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.2MM CORT CRANIOMAXILLOFACIAL G S STL ST 5PK,SUP-2366076,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.79,132.46,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM 0.018 IN L 5 CM SS MANDREL PLAT COIL,SUP-2823947,CDM,C1769,HCPCS,0272,RC,,,,both,,,110.15,71.60,,,,,,,,,,,,,
PLATE BNE W5.6XL50MM 8 H STR HI STRENGTH FOR FLX FRAG FIX,SUP-2411672,CDM,C1713,HCPCS,0278,RC,,,,both,,,1502.84,976.85,,,,,,,,,,,,,
BIT DRL DIA10MM COUNTERBORE,SUP-2162882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
PLEDGET VASCULAR 3X6MM OVAL SOFT,SUP-2427113,CDM,C1768,CPT,0278,RC,,,,both,,,106.48,69.21,,,,,,,,,,,,,
GRAFT BNE SUB 13ML W11XH11XL11MM DEMIN CANC CUBOID CNFRM,SUP-2306903,CDM,C1713,HCPCS,0278,RC,,,,both,,,2282.06,1483.34,,,,,,,,,,,,,
HC Emergent/Unsched Dialysis,PX-8290025700,CDM,G0257,CPT,0829,RC,,,,both,,,810.00,526.50,,,,,,,,,,,,,
CANNULA SUCTION KAHN 13.25 IN UTER TRIGGER W/ SPARE TIP,SUP-2464035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.58,389.73,,,,,,,,,,,,,
LEAD PACE L100CM L VENT POLYUR SIL PLAT IRIDIUM PACE SENSE,SUP-2148684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
BASEPLATE TIB RESURF LT REV STEM CEM SZ 2 FOUNDATION,SUP-2215744,CDM,C1776,CPT,0278,RC,,,,both,,,7033.60,4571.84,,,,,,,,,,,,,
GRAFT PUTTY SYNTH OSTEOVATIONEX IMPACTION FRMLA 3CC,SUP-2319788,CDM,C1713,HCPCS,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
GRAFT VASC STD WALL 4-7 MMX40 CM SHT TAPR REINF ADVANTA VXT,SUP-2468444,CDM,C1768,CPT,0278,RC,,,,both,,,844.69,549.05,,,,,,,,,,,,,
CAGE SPNL H7MM 7DEG STD CERV THORLUM C FBR REINF POLYMER,SUP-2256327,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BRACE ORTH AD XSM L6.5IN FOR 7.25-8IN HND L WRST BLK BOA LOK,SUP-2196532,CDM,L3931,HCPCS,0272,RC,,,,both,,,193.55,125.81,,,,,,,,,,,,,
STENT PANCREATIC 7 FRX7 CM ADVANIX,SUP-2141441,CDM,C2625,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
TROLAMINE SALICYLATE 10 % EX CREA,RX-27680,CDM,6370000000,HCPCS,0637,RC,41167-0057-23,NDC,,both,85,GR,21.50,13.97,,,,,,,,,,,,,
ELECTRODE 5CM 1M AUTOCLV THRMCPL SENS W/ LEADER CBL RF,SUP-2172176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
BURR HOLE KIT W/ SKULL MT SMARTFRAME XG,SUP-2328068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14519.36,9437.58,,,,,,,,,,,,,
GUIDEWIRE ENDOVASC L260CM DIA0.025IN TIP L3CM STD REG PERIPH,SUP-2385564,CDM,C1769,HCPCS,0272,RC,,,,both,,,207.77,135.05,,,,,,,,,,,,,
PLATE BONE LOCKING STERNAL PRECONTOURED TITANIUM STERILE STE,SUP-2838431,CDM,C1713,HCPCS,0278,RC,,,,both,,,2874.98,1868.74,,,,,,,,,,,,,
PHYTONADIONE 1 MG/ML ORAL SOLUTION,RX-4082399,CDM,6370000000,HCPCS,0637,RC,09999-9158-10,NDC,,both,2.5,ML,35.40,23.01,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 12 H TI STR LP NS STERNALOCK,SUP-2894522,CDM,C1713,HCPCS,0278,RC,,,,both,,,4088.28,2657.38,,,,,,,,,,,,,
GUIDEWIRE VASC STR 15 CM 0.038 INX145 CM FLX TIP TAPR N LLT,SUP-2167678,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.53,25.04,,,,,,,,,,,,,
STENT ENDOPROS L10CM DIA5MM CATH 7FR L120CM BAL DIA5MM,SUP-2396493,CDM,C1874,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
SCREW BNE EMGCY MIC 1.8X7 MM TI CENTRE-DRIVE,SUP-2459925,CDM,C1713,HCPCS,0278,RC,,,,both,,,170.75,110.99,,,,,,,,,,,,,
BRACE WR LEN 9 1/8IN CIRC OVR 8 3/4INXL BGE D RNG LNG LEN LT,SUP-2324967,CDM,L3931,HCPCS,0272,RC,,,,both,,,44.49,28.92,,,,,,,,,,,,,
COLLAR CERV DEFINITIVE PEDIATRIC 8-11X2 IN 2 PC,SUP-2428148,CDM,L0172,HCPCS,0274,RC,,,,both,,,173.83,112.99,,,,,,,,,,,,,
OLECRANON PLATE LT 21HOLE 194MM,SUP-2587101,CDM,C1713,HCPCS,0278,RC,,,,both,,,3580.10,2327.06,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT REUT BOB W/O FLNG H 1.14 MM ID TYTAN,SUP-2277597,CDM,L8699,HCPCS,0278,RC,,,,both,,,161.40,104.91,,,,,,,,,,,,,
AXLE TIB STD COMP KINEMATIC,SUP-2376288,CDM,C1776,CPT,0278,RC,,,,both,,,2395.04,1556.78,,,,,,,,,,,,,
CLAMP SURG TRPL OCPTL LNG PROTEX CT,SUP-2584536,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
EVOS 2.7/3.5MM L-D HUM PL 13H RIGHT 156MM,SUP-2820154,CDM,C1713,HCPCS,0278,RC,,,,both,,,8908.97,5790.83,,,,,,,,,,,,,
GUIDEWIRE UROLOGY DBL FLX 0.035 INX145 CM X STIFF AMPLATZ,SUP-2836140,CDM,C1769,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
HC So Tissue Thromboplastin Inhib,PX-3058570566,CDM,85705,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
HC Inj Cvad W/Fluoro,PX-3613659800,CDM,36598,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE 4 H STR FOR SM BNES ORTHOLOC 3DI,SUP-2398060,CDM,C1713,HCPCS,0278,RC,,,,both,,,1654.78,1075.61,,,,,,,,,,,,,
HC Transcatheter Renal Sympath Denervation Unilat,PX-3610338000,CDM,0338T,CPT,0361,RC,,,,inpatient,,,14967.00,9728.55,,,,,,,,,,,,,
COMPONENT FEM KNEE CRUC RET LT UNISX PRI CEM STEM MOD PC,SUP-2200373,CDM,C1776,CPT,0278,RC,,,,both,,,15612.08,10147.85,,,,,,,,,,,,,
SCREW BNE L5MM OD1.5MM CRANIO MAXILLOFACIAL HD SELF DRL TI,SUP-2262615,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.00,84.50,,,,,,,,,,,,,
CATHETER GUID SOFIA L 115 CM DIA 6 FR ID 0.070 IN OD 0.082,SUP-2305417,CDM,C1887,HCPCS,0272,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
ADAPTER LD L 13 CM A1 MBP 32 MM TO IS1 CONN BPLR PACE,SUP-2137917,CDM,C1883,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
ELECTRODE ES LAP MNPLR 5MM DIA 45CML J HOOK TIP CGLTNG PRTLL,SUP-2668367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,754.89,490.68,,,,,,,,,,,,,
PLATE BNE CRANIOMAXILLOFACIAL THK06MM 7 H Y SHP PROF MIDFACE,SUP-2262679,CDM,C1713,HCPCS,0278,RC,,,,both,,,815.93,530.35,,,,,,,,,,,,,
STIMULATOR FUS SPNL PK,SUP-2414475,CDM,E0749,HCPCS,0278,RC,,,,both,,,16547.80,10756.07,,,,,,,,,,,,,
COVER BURR HOLE CONTOURED 18X0.6 MM W/ 3.2 MM DRN LO PROF,SUP-2463299,CDM,C1713,HCPCS,0278,RC,,,,both,,,783.05,508.98,,,,,,,,,,,,,
ROD SPNL 50X9X12MM 3D AX LIF,SUP-2389066,CDM,C1713,HCPCS,0278,RC,,,,both,,,25104.30,16317.79,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM 30MM POLYESTER BOV CLLGN STR,SUP-2265919,CDM,C1768,CPT,0278,RC,,,,both,,,1296.32,842.61,,,,,,,,,,,,,
CUP VAC EXTR DIA60MM STD BELL W 4IN TBNG FLTR PEARL EDGE,SUP-2171488,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.05,53.98,,,,,,,,,,,,,
ALLOGRAFT BNE 80 MM FD IRRADIATED WHL RIB,SUP-2866914,CDM,C1762,CPT,0278,RC,,,,both,,,1404.99,913.24,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM CRANIOMAXILLOFACIAL S STL SELF DRL,SUP-2183325,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.36,286.88,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S1193108PD,SUP-2632797,CDM,C1751,HCPCS,0278,RC,,,,both,,,856.15,556.50,,,,,,,,,,,,,
STEM TIBIAL ENDO MODEL MOD CMNTLS 16X120MM,SUP-2657210,CDM,C1776,CPT,0278,RC,,,,both,,,6995.92,4547.35,,,,,,,,,,,,,
FAMOTIDINE 20 MG PO TABS,RX-10011,CDM,6370000000,HCPCS,0637,RC,50268-0299-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L W135XL260MM THK42MM 14 H BILAT TI NAR RIG NEUT,SUP-2190828,CDM,C1713,HCPCS,0278,RC,,,,both,,,2091.18,1359.27,,,,,,,,,,,,,
SCREW BONE L12MM DIA4.5MM STD CORT S STL ST NONCANNULATED,SUP-2371085,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
TIP ASPIR NAKAGAWA UNIV 0.8X3 MMX4.3 IN BNE SERRATED SONOPET,SUP-2791037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1837.31,1194.25,,,,,,,,,,,,,
CLIP ENDOSCP L165CM NIT PT PRELD HND WHL MOD 11/6T,SUP-2319929,CDM,C1889,HCPCS,0278,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
GRAFT BNE FRZN STRUCTURAL L WHL FIB IMPL,SUP-2307385,CDM,C1713,HCPCS,0278,RC,,,,both,,,7914.40,5144.36,,,,,,,,,,,,,
LINER ACET L60MM NEUT LO PROF CANC ESCALADE,SUP-2315279,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
LO-PRO SCRW INSTRU-MENT CS 4.5/6.7MM,SUP-2814868,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
HC So Lamotrigine,PX-3018017566,CDM,80175,CPT,0301,RC,,,,inpatient,,,96.00,62.40,,,,,,,,,,,,,
FORCEPS BX L115CM DIA1.1MM ELONG TEETH RNG HNDL DISP,SUP-2139315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1098.40,713.96,,,,,,,,,,,,,
LINEZOLID 600 MG PO TABS,RX-28224,CDM,6370000000,HCPCS,0637,RC,67877-0419-01,NDC,,both,1,UN,51.80,33.67,,,,,,,,,,,,,
CANDESARTAN CILEXETIL 4 MG PO TABS,RX-23229,CDM,6370000000,HCPCS,0637,RC,33342-0114-07,NDC,,both,1,UN,5.80,3.77,,,,,,,,,,,,,
RETRACTOR SURG BLNT 25 MMX5 CM SPNL MEDL LAT DIL HLLW SS,SUP-2293010,CDM,C1713,HCPCS,0278,RC,,,,both,,,5135.66,3338.18,,,,,,,,,,,,,
GRAFT BNE GRAN 5 CC VI RESRB CERM MASTERGRAFT,SUP-2743386,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO CRV PLATE XDRV 12,SUP-2935601,CDM,C1713,HCPCS,0278,RC,,,,both,,,26322.62,17109.70,,,,,,,,,,,,,
GRAFT BNE 25CC DBM PTTY PREHYDRATED TENSIX,SUP-2400564,CDM,C9359,HCPCS,0278,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
PLATE BONE L103MM 5 H LT POSTEROLATERAL DSTL HUM LIMIT CNTCT,SUP-2107056,CDM,C1713,HCPCS,0278,RC,,,,both,,,4085.14,2655.34,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL SHTH 8.5FR L63CM DIL L67CM 0.032IN,SUP-2357268,CDM,C1894,HCPCS,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
SCREW BNE L35MM DIA4.5MM THRD L18MM HD DIA8MM MALL S STL,SUP-2184551,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.18,76.17,,,,,,,,,,,,,
CABLE NRV STIM L9FT DISECT KARTUSH,SUP-2277646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SPACER SPNL W22XH8XL45MM LORD 6DEG LAT INTBDY FUS SYS VEO,SUP-2164087,CDM,C1821,HCPCS,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
POST EXT FIX PIN MT MULTIPARALLEL 5 HI NS MAXFRAME,SUP-2758002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.84,416.55,,,,,,,,,,,,,
HC Myelogram 2 or More Regions,PX-3616230500,CDM,62305,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BONE CRANIAL 20 HOLE STRAIGHT 88.9X3.4MM TITANIUM NEUR,SUP-2827189,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
TM STEM/TM CUP/LG HD/XLPE LNR,SUP-2212130,CDM,C1776,CPT,0278,RC,,,,both,,,19094.37,12411.34,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR W495XH61CM THK134CM 32CC DORS,SUP-2356748,CDM,C1767,HCPCS,0278,RC,,,,both,,,61486.51,39966.23,,,,,,,,,,,,,
PROBE SURG ACET NS OSCAR 3 LTX,SUP-2875713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
SPLINT FNGR 9CM L 3.5IN 4 PRNG PROTCT ALUMINIUM NONPADDED,SUP-2197320,CDM,L3933,HCPCS,0274,RC,,,,both,,,126.35,82.13,,,,,,,,,,,,,
MESH SURG DIA100MM THK0.6MM PNK CRANIOFACIAL TI RIG CNTOUR,SUP-2181605,CDM,C1781,HCPCS,0278,RC,,,,both,,,6609.07,4295.90,,,,,,,,,,,,,
LPS XX-SM HINGE PIN,SUP-2513219,CDM,C1776,CPT,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
GRAFT VASC GELSFT L 45 CM DIA14 MM BRANCH DIA 7 MM POLYESTER,SUP-2384926,CDM,C1768,CPT,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
TRAY TIB SZ 1 NP A BAL SYS,SUP-2314673,CDM,C1776,CPT,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,0636,RC,00270-1315-30,NDC,,both,50,ML,12.90,8.38,,,,,,,,,,,,,
K WIRE FIX L6IN DIA0.035IN DBL END SMOOTH TRCR PNT 6PK,SUP-2412236,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.25,140.56,,,,,,,,,,,,,
DRAIN SURG L0.375IN SIL CHN FLAT FULL FLOATED RADPQ CLS WND,SUP-2127327,CDM,C1729,HCPCS,0272,RC,,,,both,,,42.61,27.70,,,,,,,,,,,,,
TIP SUCT PRB 5MM QUIK DC W/ IRRIG H NEZHAT-DORSEY REPROC,SUP-2125886,CDM,C1713,HCPCS,0278,RC,,,,both,,,704.62,458.00,,,,,,,,,,,,,
PLATE BNE ADV 10 MM SCREW DIA2 MM MINI LT,SUP-2883160,CDM,C1713,HCPCS,0278,RC,,,,both,,,2040.78,1326.51,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 500 DR-T W 55 X H 66 MM D 12 MM 30,SUP-2138273,CDM,C1721,HCPCS,0275,RC,,,,both,,,55735.00,36227.75,,,,,,,,,,,,,
DRILL SURG 3.5X130 MM FOR NAILING SYS STRL T2,SUP-2361774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,757.37,492.29,,,,,,,,,,,,,
STENT INTRAOCULAR ISTENT INFINITE H 360 UM DIA 360 UM CNTRL,SUP-2866316,CDM,C1783,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
BRACE LS M 15DEG BK HK RECV MAT SFT BRTH LNR RIG TAPR PLAS,SUP-2195545,CDM,L0625,HCPCS,0272,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
APPLICATOR BRACHYTHERAPY SZ 5 POLYUR SPHR MAMMOSITE 2256] HOLOGIC INC],SUP-2239909,CDM,C1729,HCPCS,0272,RC,,,,both,,,8901.90,5786.23,,,,,,,,,,,,,
STENT BILI WALLFLEX L 80 MM DIA10 MM CATH L 75 CM SHTH 9 FR,SUP-2149823,CDM,C1874,HCPCS,0278,RC,,,,both,,,9231.60,6000.54,,,,,,,,,,,,,
NOREPINEPHRINE-SODIUM CHLORIDE 32-0.9 MG/250ML-% IV SOLN,RX-144802,CDM,2500000003,HCPCS,0250,RC,69194-0117-01,NDC,,both,250,ML,237.20,154.18,,,,,,,,,,,,,
SYSTEM ACUCISE 6 ACCESSORIES,SUP-2119502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5035.65,3273.17,,,,,,,,,,,,,
CONNECTOR SPNL TI SIDE BY SIDE ROD TO ROD FOR 5.5MM ROD,SUP-2254576,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER DRAINAGE AMPLATZ 0.038 IN 12 FRX50 CM 6 SP UTHANE,SUP-2168698,CDM,C1729,HCPCS,0272,RC,,,,both,,,198.23,128.85,,,,,,,,,,,,,
FORCEPS BPLR L33CM DIA5MM 360DEG TAPR JAW CVD FN ROUNDED TIP,SUP-2312661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STEM FEM L135MM DIA14MM EXT OFFSET HIP ZMLY CT POLISHED CEM,SUP-2203459,CDM,C1776,CPT,0278,RC,,,,both,,,9978.92,6486.30,,,,,,,,,,,,,
HALF PIN EXT FIX L 130 MM DIA 6 MM THRD L 30 MM HA COAT SD,SUP-2899011,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
PLATE BONE L111MM THK3.4MM 7 H BILAT S STL LCK COMPR NEUT,SUP-2348982,CDM,C1713,HCPCS,0278,RC,,,,both,,,2838.69,1845.15,,,,,,,,,,,,,
PLATE BONE FIXATOR 1MM DIA SM WWEDGE,SUP-2669820,CDM,C1713,HCPCS,0278,RC,,,,both,,,16971.89,11031.73,,,,,,,,,,,,,
BALLOON CERV RIPENING 80ML L40CM PREINDUCTION FOR MECH DIL,SUP-2170568,CDM,C1726,HCPCS,0272,RC,,,,both,,,177.85,115.60,,,,,,,,,,,,,
POST EXTERNAL FIXATION L STAINLESS STEEL SLOTTED,SUP-2586505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.98,413.39,,,,,,,,,,,,,
WASHER EX FIX 1MM,SUP-2467313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,139.82,90.88,,,,,,,,,,,,,
SET URET STENT SOFFLX BANDER L 75 CM DIA 6 FR 0.038 IN,SUP-2835755,CDM,C2617,HCPCS,0278,RC,,,,both,,,325.37,211.49,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 5.5 FRX6 CM CHECK- FLO CLMP PERFRMR,SUP-2168846,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.80,45.37,,,,,,,,,,,,,
COLLAR CERV SERP CNTOUR L235XH5IN L,SUP-2276596,CDM,L0120,HCPCS,0272,RC,,,,both,,,8.51,5.53,,,,,,,,,,,,,
PATCH CV CARDIOCEL L 4 X W 4 CM THK 0.5 MM BOV PERICARD,SUP-2433943,CDM,C1768,CPT,0278,RC,,,,both,,,5240.66,3406.43,,,,,,,,,,,,,
WASHER ORTHOPEDIC 54X70 MM TROCH S-ROM,SUP-2455874,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.30,619.64,,,,,,,,,,,,,
BIT DRL L260MM DIA4MM CALIB L60MM 3 FLUT QUIK CPL FOR TFN,SUP-2188238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.80,384.67,,,,,,,,,,,,,
AMIODARONE HCL 150 MG/3ML IV SOLN,RX-93084,CDM,J0282,HCPCS,0636,RC,63323-0616-03,NDC,,both,3,ML,54.10,35.16,,,,,,,,,,,,,
STENT URTRL 48FR DIA 22 30CML FLXMA STRGHT TIP STIFF W/003,SUP-2724821,CDM,C2617,HCPCS,0278,RC,,,,both,,,585.04,380.28,,,,,,,,,,,,,
PPICC PROVENA SOLO 4F DL 3CG,SUP-2613530,CDM,C1751,HCPCS,0278,RC,,,,both,,,757.96,492.67,,,,,,,,,,,,,
ELECTRODE ES L DIA4MM SUCT LO PROF INTEGR HNDL VAPR,SUP-2249476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
HINGE EXT FIX FEMALE,SUP-2898468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
TUBE ENDOSCP 25 CM LEN 19.5 MM OD 16.7 MM ID W/ TAPR TIP,SUP-2416284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
COIL EMB L20MM UNRESTRAINED L4MM DIA4MM GWIRE 0.018IN FBR,SUP-2141086,CDM,C1889,HCPCS,0278,RC,,,,both,,,227.81,148.08,,,,,,,,,,,,,
SUPPORT ORTH XL 1 8IN NEOPRENE NYL 2 SIDE OPN PAT STBL PAT,SUP-2195472,CDM,L1851,HCPCS,0272,RC,,,,both,,,51.15,33.25,,,,,,,,,,,,,
PLATE BNE W10.2XL143MM THK2.7MM 11 H BILAT S STL STR LO,SUP-2186198,CDM,C1713,HCPCS,0278,RC,,,,both,,,1559.89,1013.93,,,,,,,,,,,,,
KIT NEPHSTMY CATH 30FR L12CM SHTH L17CM PTFE NONCOMPLIANT,SUP-2139180,CDM,C1726,HCPCS,0272,RC,,,,both,,,920.84,598.55,,,,,,,,,,,,,
SCREW BNE CANN 4X38 MM CAPT SS,SUP-2848543,CDM,C1713,HCPCS,0278,RC,,,,both,,,1285.55,835.61,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZ DRY ALLGRFT UNICORTICAL DWL W/O CART,SUP-2113897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE L292MM 18 H NONSTERILE R ANTLAT DST TIB S STL VAR,SUP-2177694,CDM,C1713,HCPCS,0278,RC,,,,both,,,7134.14,4637.19,,,,,,,,,,,,,
RING ANNULPLSTY SZ 40 OD46MM ID39MM MI VLV SEMI RIG 3D POST,SUP-2355861,CDM,C1889,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
HC NM Inject for Neoprobe Study,PX-3407880800,CDM,78808,CPT,0340,RC,,,,both,,,338.00,219.70,,,,,,,,,,,,,
BIT DRILL CANN TH SER RELF,SUP-2244048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.21,479.19,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.553,SUP-2860234,CDM,C1713,HCPCS,0278,RC,,,,both,,,61605.54,40043.60,,,,,,,,,,,,,
MILRINONE LACTATE IN DEXTROSE 20-5 MG/100ML-% IV SOLN,RX-137857,CDM,J2260,HCPCS,0636,RC,25021-0313-82,NDC,,both,100,ML,54.70,35.55,,,,,,,,,,,,,
DRIVER SURG HEX 2 MM ACTUATION FOR FIBULAR NAIL STRL DISP,SUP-2909093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
COLLAR CERV EXTRIC COMB PK PERFIT ACE,SUP-2115130,CDM,L0120,HCPCS,0272,RC,,,,both,,,45.81,29.78,,,,,,,,,,,,,
FIBER LASER 295 MH 40 W LNG 0.5X1.04 MMX2 MR FIBERLASE,SUP-2574321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4123.54,2680.30,,,,,,,,,,,,,
STENT BILI ZILVER 635 L 40 MM DIA14 MM DEL SYS L 80 CM SHTH,SUP-2170320,CDM,C1876,HCPCS,0278,RC,,,,both,,,1972.83,1282.34,,,,,,,,,,,,,
LEGION FEM CONE ID 20MM L,SUP-2349186,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
GRAFT BNE SPNG 16X16X16 MM DBM CANC,SUP-2641781,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
CLINDAMYCIN (CLEOCIN) 6 MG/ML IVPB (PED) >/=50 ML,RX-4090064,CDM,J0737,HCPCS,0636,RC,00338-3410-24,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
NAIL IM TIB UNIV 8 MMX39 CM LCK CANN TI STRL VERSANAIL,SUP-2463411,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.80,2592.07,,,,,,,,,,,,,
SYSTEM IV INFUSION 4 FRX135 CM 10 CM 1 CC,SUP-2740490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE ANTR CRUC LIGMNT CUST DEROTATION,SUP-2435612,CDM,L1840,HCPCS,0274,RC,,,,both,,,2662.44,1730.59,,,,,,,,,,,,,
SCREW BNE L28MM DIA4MM CORT TI ST LOK FULL THRD TRIGEN,SUP-2348129,CDM,C1713,HCPCS,0278,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
STYLET PACE L52CM REACH L40MM RAD 14MM 0.016IN DEFL ENABLES,SUP-2356062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
DEVICE VENTRICULAR ASST SHT 3 IN,SUP-2355997,CDM,L8670,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SCREW SPNL L 50 MM DIA 6.5 MM BLACKARMOR CARBON PEEK TI-IT,SUP-2917081,CDM,C1713,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
CATHETER HD STR 7 FRX7 CM SHT TERM DL BASIC SET SOFT-LINE,SUP-2627337,CDM,C1752,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
SET INSTR DISP SGL USE DUAFIT 17/10/0,SUP-2242114,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
BIT DRL L115MM DIA1.8MM STP 26MM FOR LORENZ MAND PLATING,SUP-2136817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
GRAFT VASC L80CM OD6MM EPTFE STD WALL NONRINGED MINI CUF,SUP-2128085,CDM,C1768,CPT,0278,RC,,,,both,,,8050.87,5233.07,,,,,,,,,,,,,
INSERT TIB 1/2 9MM L CONG NAT KNEE II,SUP-2202426,CDM,C1776,CPT,0278,RC,,,,both,,,3224.78,2096.11,,,,,,,,,,,,,
PERCUTANEOUS ENTRY SET,SUP-2826995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.14,244.49,,,,,,,,,,,,,
IMPLANT CRAN M CUST PEEK,SUP-2365128,CDM,C1713,HCPCS,0278,RC,,,,both,,,43306.25,28149.06,,,,,,,,,,,,,
COIL VASC INTERLOCK-35 L 4.5 CM DIA 4 MM GUIDEWIRE 0.035 IN,SUP-2148130,CDM,C1889,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
BUR DENT 35 INVRT CONE FRIC GRP CARBIDE,SUP-2322355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.56,339.66,,,,,,,,,,,,,
PLATE BONE L12MM THK0.3MM 4 H TI STR ULT LO PROF MATRIXNEURO,SUP-2181542,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.88,170.22,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X211 MM 16 HOLE SS LCP,SUP-2569342,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.00,365.95,,,,,,,,,,,,,
HC So Sgpt (Alt),PX-3018446066,CDM,84460,CPT,0301,RC,,,,outpatient,,,37.00,24.05,,,,,,,,,,,,,
RALTEGRAVIR POTASSIUM 400 MG PO TABS,RX-88608,CDM,6370000000,HCPCS,0637,RC,00006-0227-61,NDC,,both,1,UN,156.30,101.59,,,,,,,,,,,,,
HF RES SML LOOP 24FR 1216DEG,SUP-2722416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1414.41,919.37,,,,,,,,,,,,,
RING ACET SZ 23 HIP LOK REPL RNGLOC,SUP-2403338,CDM,C1776,CPT,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
"HC X-Ray, Thoracic Spine/4 V",PX-3207207400,CDM,72074,CPT,0320,RC,,,,outpatient,,,795.00,516.75,,,,,,,,,,,,,
HC Injection for Cholangiogram,PX-3614753100,CDM,47531,CPT,0361,RC,,,,outpatient,,,12375.00,8043.75,,,,,,,,,,,,,
CUTTER WIRE DBL ACT 7 IN SIDE CUT SAW EDGE TUNGSTEN CARBIDE,SUP-2273737,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.54,481.35,,,,,,,,,,,,,
BUR ENDOSCP AUGER MED 5.5X120 MM GRY LIGHT PUR UNIDRIVE,SUP-2585891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,257.86,167.61,,,,,,,,,,,,,
PLATE BNE W29XL40MM 4.5X5MM H SPC CRAN TI MESH FOR 1MM SCR,SUP-2190565,CDM,C1713,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
CATHETER GUID DAC L 125 CM OD 3.9 FR ID 0.038 IN DSTL ACCS,SUP-2367799,CDM,C1887,HCPCS,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
IMPLANT BIO TISS W10XL20MM THK1MM BRST BOV CLLGN RECT FEN,SUP-2243671,CDM,C9360,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
NCB PP DF PLATE PROVISION15/18 H,SUP-2478953,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
SPACER SPNL LORDTC 7 DEG 18X15X8 MM HEDRON C,SUP-2732375,CDM,C1889,HCPCS,0278,RC,,,,both,,,5620.60,3653.39,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 6 FR SPC 10 MM LG 4,SUP-2526002,CDM,C1730,HCPCS,0272,RC,,,,both,,,517.38,336.30,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L115CM 7/20FR 6MM D,SUP-2248627,CDM,C1732,HCPCS,0272,RC,,,,both,,,3990.94,2594.11,,,,,,,,,,,,,
PAD CLLR CERV UNIV AD REPL,SUP-2124221,CDM,L0172,HCPCS,0274,RC,,,,both,,,31.78,20.66,,,,,,,,,,,,,
CAP PROTCT WIRE CLMP,SUP-2898976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
COMPONENT ARTC 3X2MM OFFSET PATELLOFEMORAL HEMICAP,SUP-2123661,CDM,C1776,CPT,0278,RC,,,,both,,,14973.72,9732.92,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB PATELLAR FLX SURF POROUS,SUP-2212269,CDM,C1776,CPT,0278,RC,,,,both,,,15567.40,10118.81,,,,,,,,,,,,,
VALVE AORT FREESTYLE H 32 MM DIA21 MM PORCINE FULL ROOT,SUP-2282937,CDM,C1889,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM 30X20 MED STRL,SUP-2547591,CDM,C1713,HCPCS,0278,RC,,,,both,,,2566.26,1668.07,,,,,,,,,,,,,
PLATE BNE L81MM 12 H S STL LO PROF LOK COMPR FOR 2MM SCR,SUP-2186311,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.43,722.43,,,,,,,,,,,,,
STEM EXTN 10MMX80MM NMC,SUP-2222908,CDM,C1776,CPT,0278,RC,,,,both,,,3589.02,2332.86,,,,,,,,,,,,,
NEEDLE PROC PED 5FR L10CM PLAT NIT GWIRE L40CM 0018IN,SUP-2170541,CDM,C1894,HCPCS,0272,RC,,,,both,,,113.64,73.87,,,,,,,,,,,,,
HC So1 Complement C-3/C-4,PX-3028616067,CDM,86160,CPT,0302,RC,,,,both,,,315.00,204.75,,,,,,,,,,,,,
GRAFT BONE SUB 7.5CC L1-10MM CANC CRUSH FRZ DRY,SUP-2165594,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
IMPLANT MAMM NACL ANT DIAPHM VLV RND SMOOTH 390ML - 390ML,SUP-2113258,CDM,C1789,HCPCS,0278,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
CANNULA ENDOSCOPIC OD6.7MM SLOTTED,SUP-2842811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1689.41,1098.12,,,,,,,,,,,,,
LINER ACET OD38MM ID24MM +5MM HIP E1 MAX ROM RINGLOC,SUP-2408955,CDM,C1776,CPT,0278,RC,,,,both,,,5402.53,3511.64,,,,,,,,,,,,,
SPLINT RST PAN MIT SP M LF,SUP-2163832,CDM,L3807,HCPCS,0272,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
ELECTRODE VPR M LOOP FOR 30DEG TELESCOPES PLASMABUTTON,SUP-2313582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1416.83,920.94,,,,,,,,,,,,,
NAIL IM L22CM DIA12MM TIBIOTALOCALCANEAL NIT DYNANAIL,SUP-2277457,CDM,C1713,HCPCS,0278,RC,,,,both,,,52909.00,34390.85,,,,,,,,,,,,,
BRACE ANK L M 115 13 WOM 13 145 L FOAM FILL SEMI RIG SHELL,SUP-2196376,CDM,L4350,HCPCS,0272,RC,,,,both,,,72.38,47.05,,,,,,,,,,,,,
BAR BENT 11X175MM,SUP-2477709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1707.66,1109.98,,,,,,,,,,,,,
OBTURATOR ROBOTIC 8 MM 14X5.5 IN BLNT ENDOWRIST DA VINCI XI,SUP-2246720,CDM,C1713,HCPCS,0278,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
SCREW BONE 1ST 2.5X14 MM,SUP-2137589,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.85,618.05,,,,,,,,,,,,,
BIT DRL TWST 1.1X50 MM CYL ATTCH SS LEVEL 1 DISP,SUP-2460571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.34,271.27,,,,,,,,,,,,,
CATHETER PICC 6FR L55CM 16.5/19/19GA PEELABLE SHEATH/DILATOR,SUP-2117123,CDM,C1751,HCPCS,0278,RC,,,,both,,,622.60,404.69,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM DIA3MM ELECTRD PLAT IRIDIUM SGL,SUP-2175907,CDM,C1778,HCPCS,0278,RC,,,,both,,,14393.76,9355.94,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 20-29 CM FEM ART BLD TYP A B AB O,SUP-2884011,CDM,C1768,CPT,0278,RC,,,,both,,,22290.86,14489.06,,,,,,,,,,,,,
PROSTHESIS OTOLARYN L3.5MM WELL DIA1MM PIST DIA0.4MM TI BCKT,SUP-2312800,CDM,L8613,CPT,0278,RC,,,,both,,,622.10,404.36,,,,,,,,,,,,,
COIL EMB L4CM OD2MM 0.018IN SFT HELCL STRTCH DETACH GDC-18,SUP-2365700,CDM,C1889,HCPCS,0278,RC,,,,both,,,3069.66,1995.28,,,,,,,,,,,,,
FILIFORM URO 3FR L18IN WVN STR TIP REUSE,SUP-2128948,CDM,C1726,HCPCS,0272,RC,,,,both,,,105.66,68.68,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX80 CM STD WALL SM BEAD EPTFE CARBOFLO,SUP-2761503,CDM,C1768,CPT,0278,RC,,,,both,,,3705.95,2408.87,,,,,,,,,,,,,
HC Ot Orthotic Fit/Train per 15 Min,PX-4309776000,CDM,97760,CPT,0430,RC,,,,inpatient,,,206.00,133.90,,,,,,,,,,,,,
GRAFT BONE SUB 14MM CANC BLK OSTEOSPONGE,SUP-2125418,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
INSERT TIB SZ 4 THK11MM KNEE CONVENTIONAL POLYETH CNDYL,SUP-2421265,CDM,C1776,CPT,0278,RC,,,,both,,,2238.47,1455.01,,,,,,,,,,,,,
ROD ORTH THRD 50 MM PILLAR,SUP-2749916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
VITAMIN B-12 250 MCG PO TABS,RX-8655,CDM,6370000000,HCPCS,0637,RC,50268-0853-15,NDC,,both,1,UN,1.70,1.10,,,,,,,,,,,,,
CATHETER HAD AD 14FR L15CM ADMIN BASIC KT DBL LUMN POLYUR,SUP-2266963,CDM,C1752,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
PACEMAKER CARD LEGEND II SR TI SINGLE CHMBR IS1 CONN UPLR,SUP-2149060,CDM,C1786,HCPCS,0275,RC,,,,both,,,52438.00,34084.70,,,,,,,,,,,,,
GENERATOR PULSE IMPLANTABLE INSPIRE,SUP-2664095,CDM,C1767,HCPCS,0278,RC,,,,both,,,58944.08,38313.65,,,,,,,,,,,,,
CATHETER ABLATN B CRV 4 MM 7 FR SFT TIP THRMCPL NAVISTAR,SUP-2248470,CDM,C1732,HCPCS,0272,RC,,,,both,,,5802.72,3771.77,,,,,,,,,,,,,
MICROCATHETER GUID CANTATA L 150 CM OD 2.9 FR ID 0.027 IN,SUP-2638531,CDM,C1887,HCPCS,0272,RC,,,,both,,,982.07,638.35,,,,,,,,,,,,,
NAIL INTRMDLLRY L200MM OD9MM UNVRSL HMRL CNNLTD LOK END CAP,SUP-2484515,CDM,C1713,HCPCS,0278,RC,,,,both,,,4644.06,3018.64,,,,,,,,,,,,,
SPLINT WRST HK LOOP CLOSURE MED 6 IN RT ELASTIC COTTON,SUP-2336321,CDM,L3809,HCPCS,0274,RC,,,,both,,,11.15,7.25,,,,,,,,,,,,,
SHUNT CAR 9 FR OUTLYING W/O T PRT EIFU PRUITT F3,SUP-2589472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3607.86,2345.11,,,,,,,,,,,,,
BIT DRL L215MM DIA4MM CALIB L80MM 3 FLUT QUIK CPL,SUP-2188200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.45,486.49,,,,,,,,,,,,,
FAMOTIDINE 200 MG/20ML IV SOLN,RX-125407,CDM,J1308,HCPCS,0636,RC,63323-0738-20,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE SPNL L23MM 15DEG ANTR CERV TI CNVGNT,SUP-2280006,CDM,C1713,HCPCS,0278,RC,,,,both,,,3580.70,2327.45,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 4-10 MM 30 CC CANC PROX DSTL END LNG,SUP-2913264,CDM,C1713,HCPCS,0278,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 6 MM RNG L 10 CM EPTFE STR STD,SUP-2396091,CDM,C1768,CPT,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
SHOE CAST WALKING XS PEDIATRIC,SUP-2306064,CDM,L4387,HCPCS,0274,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
PROSTHESIS 4MM DIAM 8MM LEN TORP PLASTIPORE SHEA,SUP-2312575,CDM,L8613,CPT,0278,RC,,,,both,,,516.75,335.89,,,,,,,,,,,,,
BRACE BK ASPN QUICKDRAW PRO BLK M,SUP-2123910,CDM,L0628,HCPCS,0274,RC,,,,both,,,264.67,172.04,,,,,,,,,,,,,
RETRACTOR SINGLE USE CORDLESS ONETRAC LX 135MMX30MM,SUP-2740194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
ANCHOR SUTURE SLIDING 4.5 MM DBL SIDE ROW X2 WHT COMPOSITCP,SUP-2745438,CDM,C1776,CPT,0278,RC,,,,both,,,1264.16,821.70,,,,,,,,,,,,,
KIT ORTH INCL CLLRD BRKWY AND TUBEROSITY PIN CUT BLK DISP,SUP-2121006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
PEEK SWIVELOCK BICEPS TENO 8X23 KIT,SUP-2812049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
MESH CRAN W120XL120MM PROF H0.3MM MIC MID FACE,SUP-2363670,CDM,C1713,HCPCS,0278,RC,,,,both,,,5458.11,3547.77,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 30 CM DIA13 FR GUIDEWIRE 0.038 IN,SUP-2167891,CDM,C1892,HCPCS,0272,RC,,,,both,,,162.84,105.85,,,,,,,,,,,,,
SET URET STENT C FLX L 6 CM CATH L 70 CM DIA 3.7 FR,SUP-2171309,CDM,C2617,HCPCS,0278,RC,,,,both,,,453.67,294.89,,,,,,,,,,,,,
SHELL ACET DIA58MM LNR SZ DMI ORNG VERSAFITCUP DM,SUP-2267332,CDM,C1776,CPT,0278,RC,,,,both,,,4613.16,2998.55,,,,,,,,,,,,,
IMPLANT SYNTH L 76 X W 50 MM THK 1.5 MM POLYETHYL,SUP-2883545,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.28,1228.68,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LNR POLYETH H2STRYKER] STRYKER CORP],SUP-2365527,CDM,C1776,CPT,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
DEFIBRILLATOR IMPL DYNAGEN W 5.37 X H 7.36 CM D 0.99 CM 29.5,SUP-2149174,CDM,C1722,HCPCS,0275,RC,,,,both,,,30071.78,19546.66,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.417,SUP-2859981,CDM,C1713,HCPCS,0278,RC,,,,both,,,36871.45,23966.44,,,,,,,,,,,,,
GRAFT DERM HUM TISS HYDRATED ULT THCK ACELLULAR DERM IMPL,SUP-2307499,CDM,Q4128,HCPCS,0636,RC,,,,both,,,8891.26,5779.32,,,,,,,,,,,,,
PICC AGBA NAVICURVE 2L 5.5FR X 55CM TCG,SUP-2867376,CDM,C1751,HCPCS,0278,RC,,,,both,,,846.76,550.39,,,,,,,,,,,,,
STRAP CLAV XL PD W3XL4IN STD FOAM PD STOCKINET MTL TOOTH,SUP-2276603,CDM,L3650,HCPCS,0272,RC,,,,both,,,15.32,9.96,,,,,,,,,,,,,
SHEATH URO 11/13FR L36CM URETRAL NAVIGATOR ACCS,SUP-2139216,CDM,C1894,HCPCS,0272,RC,,,,both,,,383.74,249.43,,,,,,,,,,,,,
KIT HAD CATHETER L40CM DIA145FR INSRT L35CM POLYUR NONCOATED,SUP-2126534,CDM,C1750,HCPCS,0278,RC,,,,both,,,1615.53,1050.09,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 5.8FR L40CM BAL L30MM DIA8MM 0.035IN,SUP-2141000,CDM,C1725,HCPCS,0272,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
GRAFT BNE 100X25X4 MM 10 CC GRAN BI-OSTETIC FOAM,SUP-2134722,CDM,C1713,HCPCS,0278,RC,,,,both,,,7743.24,5033.11,,,,,,,,,,,,,
PARTICLE EMB BNDL S220PRO MIV20500 28MC24150SN EMBOSPHEREPRO,SUP-2798607,CDM,C1889,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
SCREW BNE SET 4.5 MM CANN FT EXT TAB,SUP-2861022,CDM,C1713,HCPCS,0278,RC,,,,both,,,19405.20,12613.38,,,,,,,,,,,,,
SPLINT FINGER SIZE 5.5 STAX,SUP-2895961,CDM,L3933,HCPCS,0274,RC,,,,both,,,5.50,3.57,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX60 CM TW SM BEAD N RING EPTFE CARBOFLO,SUP-2761470,CDM,C1768,CPT,0278,RC,,,,both,,,3395.60,2207.14,,,,,,,,,,,,,
BUR SURG DIA13MM WIRE PASS DRL COR REUSE ELITE TPS,SUP-2367595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.85,263.80,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 30H TI STRL,SUP-2546942,CDM,C1713,HCPCS,0278,RC,,,,both,,,3805.02,2473.26,,,,,,,,,,,,,
CAP HIP APEX,SUP-2165826,CDM,C1776,CPT,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
CATHETER THOR 24FR L22IN PVC 4 EYELET R ANG ATRAUM,SUP-2227437,CDM,C1729,HCPCS,0272,RC,,,,both,,,36.49,23.72,,,,,,,,,,,,,
HC Treat Clavicle Disloc,PX-4502354500,CDM,23545,CPT,0450,RC,,,,both,,,725.00,471.25,,,,,,,,,,,,,
BURR SURG LINDE 4MM DIA HD MED MIC 50MML CARBIDE SM BNE RND,SUP-2605557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,192.11,124.87,,,,,,,,,,,,,
VALVE MITRL MECH 23 MM OPTIFIRM,SUP-2265203,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE NARROW 10 HOLE RIGHT,SUP-2718087,CDM,C1713,HCPCS,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
MATRIX PARTICULATE AMNIOBAND 160MG,SUP-2719487,CDM,Q4168,HCPCS,0636,RC,,,,both,,,8275.94,5379.36,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst W/Indwelling Cath Intrlmnr Crv/Thrc W/Img Gdn,PX-3606232500,CDM,62325,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 3 CM 0.038 INX150 CM DUAL-FLEX,SUP-2139370,CDM,C1769,HCPCS,0272,RC,,,,both,,,735.29,477.94,,,,,,,,,,,,,
AIRWAY LARYNGEAL ADULT SIZE 5 SOFT SILICONE REUSABLE LMA CLA,SUP-2824584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
GRAFT SYNTHETIC TISSUE GRANULE 1.42.8 MM 5 CC BETA TRICALCIU,SUP-2838534,CDM,C1713,HCPCS,0278,RC,,,,both,,,1611.13,1047.23,,,,,,,,,,,,,
CATHETER KIT 7 FRX16 CM CV 3L HEPARIN N LIDO,SUP-2214564,CDM,C1751,HCPCS,0278,RC,,,,both,,,117.94,76.66,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.5 X 11MM HD CANN SHT THRD SCR,SUP-2320390,CDM,C1713,HCPCS,0278,RC,,,,both,,,591.89,384.73,,,,,,,,,,,,,
DEVICE RESECT 4X LAP BPLR HABIB,SUP-2118728,CDM,C1713,HCPCS,0278,RC,,,,both,,,9875.30,6418.94,,,,,,,,,,,,,
PLATE BONE 9 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1290.10,838.56,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM COARSE EXT STRL ELITE LTX,SUP-2859313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1003.54,652.30,,,,,,,,,,,,,
PLATE BNE 7 HOLE SS NS,SUP-2186087,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.42,516.37,,,,,,,,,,,,,
PLATE S PROFYLE HAND T PLT WD 1.7MM,SUP-2464985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
ANCHOR SUTURE BIO ABSORBABLE 3 MM 3 BRAIDED POLYESTER XCEL,SUP-2608443,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.27,381.73,,,,,,,,,,,,,
PLATE BNE L116MM 4 H NONSTERILE L MED DST TIB S STL LOK,SUP-2185580,CDM,C1713,HCPCS,0278,RC,,,,both,,,4411.73,2867.62,,,,,,,,,,,,,
ROD FOR GALAXY FIXATION SYSTEM 9MM 100MM,SUP-2633890,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.92,358.75,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0036,SUP-2759808,CDM,C1751,HCPCS,0278,RC,,,,both,,,429.14,278.94,,,,,,,,,,,,,
SCREW INTRF KNEE EZSTART,SUP-2423002,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CABLE ELECTRD L3M MIC TARGETING ACT SHLD DISPOSABLE,SUP-2284685,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
JANNETTA SCRN MESH TRNGLR 2MM 15MM SSTM CP TTNM,SUP-2676689,CDM,C1713,HCPCS,0278,RC,,,,both,,,999.43,649.63,,,,,,,,,,,,,
KIT FEED TB 18FR STOMA L2CM JEJU SIL LO PROF TRIM DST TIP,SUP-2236561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.33,363.56,,,,,,,,,,,,,
NAIL IM FEM PEDIATRIC 5.5 MMX20 CM TI,SUP-2861971,CDM,C1713,HCPCS,0278,RC,,,,both,,,4715.46,3065.05,,,,,,,,,,,,,
VENLAFAXINE HCL 50 MG PO TABS,RX-12204,CDM,6370000000,HCPCS,0637,RC,57237-0174-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT HUM TISS RT DSTL HUM OSTEOARTICULAR CUST MATCHED,SUP-2932895,CDM,C1762,CPT,0278,RC,,,,both,,,21389.37,13903.09,,,,,,,,,,,,,
CENTRALIZER STEM OD8MM ALPINE,SUP-2315811,CDM,C1776,CPT,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN TAPR L 6 CM FLX TIP L 2,SUP-2167658,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.74,19.33,,,,,,,,,,,,,
SPLINT WRST FA UNIV R 8 IN,SUP-2276644,CDM,L3809,HCPCS,0272,RC,,,,both,,,14.63,9.51,,,,,,,,,,,,,
PAIN PMP2 250 CC PMP W/ STD 2.5 IN AND 5.0 IN EXFEN,SUP-2363507,CDM,C1772,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
GRAFT BNE 15 CC DEMINERALIZED BNE FIBER PROGRAFT,SUP-2858507,CDM,C1713,HCPCS,0278,RC,,,,both,,,3935.36,2557.98,,,,,,,,,,,,,
GUIDEWIRE PRESSURE VERRATA + L 300 CM DIA 0.014 IN TIP L 3,SUP-2327201,CDM,C1769,HCPCS,0272,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
SCREW TIB BASEPLT OD6MM THICKNESS 6MM UNIV STD PRI CEM IMP,SUP-2208415,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC FIBER VIABLE MTRX FIBERCEL,SUP-2541277,CDM,C1713,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
RING EXT FIX LNG 200 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30265.33,19672.46,,,,,,,,,,,,,
KIT SURG BNE CEMENT MX DEL SYS CEMENT CTRL CLUTCH FLX EXT,SUP-2885587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4160.94,2704.61,,,,,,,,,,,,,
SCREW 2.0X10MM CORT HEXADRIVE 6,SUP-2268100,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
SEALER TISS L37CM SHFT DIA5MM 360DEG ROT CVD JAW TAPR TIP,SUP-2219740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4774.90,3103.68,,,,,,,,,,,,,
PLATE BONE L112MM 6 H S STL T SHP BTTRS LO PROF RIG,SUP-2185765,CDM,C1713,HCPCS,0278,RC,,,,both,,,1916.84,1245.95,,,,,,,,,,,,,
GRAFT HUM TISS W8XL3CM 12SQCM UMB CRD AMNIO MEM,SUP-2116292,CDM,Q4148,HCPCS,0636,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
HC So Tissue Culture Skin/Biopsy,PX-3118823366,CDM,88233,CPT,0311,RC,,,,both,,,512.00,332.80,,,,,,,,,,,,,
PLATE BNE L 203 MM SCREW DIA 4.5 MM 11 H SS NAR COMPR NLCK,SUP-2933496,CDM,C1713,HCPCS,0278,RC,,,,both,,,2138.72,1390.17,,,,,,,,,,,,,
PLATE BONE 12 H STRL STRNL TI ANG LCK FOR 3MM SCR,SUP-2192444,CDM,C1713,HCPCS,0278,RC,,,,both,,,4306.82,2799.43,,,,,,,,,,,,,
SCREW BONE PLLA CORT FULL THRD N CANN N LCK RESRB NSTERILE,SUP-2166518,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.20,286.78,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE 23 GA CUST,SUP-2110950,CDM,C1713,HCPCS,0278,RC,,,,both,,,1802.20,1171.43,,,,,,,,,,,,,
PROBE LASER 23GA 78DEG NIT TIP PLAS FBR ILLUMINATED FLX CRV,SUP-2109954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
WIRE FIX L9IN DIA0.035IN S STL SHRP TIP DBL END K,SUP-2342696,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.47,106.91,,,,,,,,,,,,,
KNIFE NDL 6 FR 7 FRX200 CM 0.035 IN 4.2 MM ACTIVE CRD FUSION,SUP-2737416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
RING FIX MODULAR EXTERNAL FIXATION KIT SET 1 2,SUP-2473119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC Chemo IV Push Initial Drug,PX-3319640900,CDM,96409,CPT,0331,RC,,,,outpatient,,,673.00,437.45,,,,,,,,,,,,,
HC Perc D-E Cor Revasc T Cabg B,PX-4810960500,CDM,C9605,CPT,0481,RC,,,,outpatient,,,9327.00,6062.55,,,,,,,,,,,,,
PLATE BNE L36MM 6 H TI DYN LOK COMPR FOR 2MM SCR MOD HND,SUP-2191480,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.27,780.18,,,,,,,,,,,,,
STEM FEM PRSS FT 5 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267799,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SYSTEM OCCL DEL SHTH 9FR L80CM OD3.81MM ID3MM TIP 45DEG S,SUP-2355737,CDM,C1894,HCPCS,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
PLATE BNE DSTL 20X1 MM RT MAX 12 HOLE MOD TI,SUP-2487460,CDM,C1713,HCPCS,0278,RC,,,,both,,,13145.99,8544.89,,,,,,,,,,,,,
HC Split Blood or Products,PX-3008698500,CDM,86985,CPT,0300,RC,,,,both,,,380.00,247.00,,,,,,,,,,,,,
CATHETER ANGIO L100CM OD6FR 0.038IN TEMPO BERN,SUP-2249319,CDM,C1730,HCPCS,0272,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
CANNULA SUCTION 4 MMX30 CM 9 MM BENT FLARED MERCED TIP PAL,SUP-2760861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,912.17,592.91,,,,,,,,,,,,,
CUTTER SPNL OD7MM D12.8CM-11MM PWR BLDE MIDAS CLASS AM,SUP-2290931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,319.93,207.95,,,,,,,,,,,,,
GRAFT HUM TISS NRML THK230-320UM CLR PRE HYDRATION CORNEA W/,SUP-2261409,CDM,V2785,HCPCS,0810,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
ENDCAP ORTH L10MM FOR FEM IM NAIL SYS TRIGEN,SUP-2347070,CDM,C1776,CPT,0278,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL ANTEROLATERAL AXSOS 3 630114,SUP-2613581,CDM,C1713,HCPCS,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
HC Pacu Recovery - Addtl 15 Min,PX-7100000001,CDM,7100000001,LOCAL,0710,RC,,,,both,,,616.00,400.40,,,,,,,,,,,,,
BAR EXT FIX 11X600 MM XTRAFIX,SUP-2534563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,900.43,585.28,,,,,,,,,,,,,
RING HALF 140MM FOR TRUELOK FIX SYS,SUP-2316177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1486.48,966.21,,,,,,,,,,,,,
CATHETER THOR 20FR L20IN PVC STR RADPQ SENTNL LN TBNG,SUP-2154966,CDM,C1729,HCPCS,0272,RC,,,,both,,,19.06,12.39,,,,,,,,,,,,,
HC So Hemochromatosis Gene Analysis,PX-3108125666,CDM,81256,CPT,0310,RC,,,,outpatient,,,349.00,226.85,,,,,,,,,,,,,
METOPROLOL TARTRATE 25 MG PO TABS,RX-37637,CDM,6370000000,HCPCS,0637,RC,51079-0255-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BLADE RTRCTR 45MMW X 60MML TTNM LEFT SCRL PRNGX5 GREEN LMBRT,SUP-2460573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.40,577.46,,,,,,,,,,,,,
CATHETER HD PRECRV 12.5 FRX28 CM LT DL STP BASIC SET HEMCATH,SUP-2627316,CDM,C1750,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
PIN PROV FIX L40MM DIA3.5MM PERI-LOC INSTR,SUP-2343975,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.07,910.70,,,,,,,,,,,,,
CLIP ANEUR L W9XL10MM STD CO CHROM ALLY STR DBL COILED SPR,SUP-2305971,CDM,C1889,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
PLATE BNE 2 H SM TI ALLOY STR LCK NS LEOS,SUP-2933246,CDM,C1713,HCPCS,0278,RC,,,,both,,,3023.82,1965.48,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO STR REG PLATE SD HI 1PK,SUP-2937266,CDM,C1713,HCPCS,0278,RC,,,,both,,,1488.36,967.43,,,,,,,,,,,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,0636,RC,00338-1049-02,NDC,,both,250,ML,129.40,84.11,,,,,,,,,,,,,
IMMOBILIZER KNEE XL L19IN FOR 20 22IN BLU CANVS T BAR STAY,SUP-2336066,CDM,L1830,CPT,0274,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
INTRODUCER TUBE TY PERC ADV FLX CIAGLIA BLU RHINO,SUP-2759812,CDM,C1769,HCPCS,0272,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
GRAFT BNE L100MM SHFT FIB STRUCTURAL ALLGRFT FRZN,SUP-2307380,CDM,C1762,CPT,0278,RC,,,,both,,,2349.72,1527.32,,,,,,,,,,,,,
ROD SPNL L70MM DIA5.5MM THORACOLUMBOSACRAL CP TI PREBENT,SUP-2290745,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
CATHETER URET 11/13 FRX24 CM UROPS AS,SUP-2458910,CDM,C1758,HCPCS,0278,RC,,,,both,,,448.77,291.70,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 6X12 CMX1-2 MM PRE HYDRATED DERM,SUP-2632333,CDM,C1763,HCPCS,0278,RC,,,,both,,,16249.50,10562.17,,,,,,,,,,,,,
HC So Hla Class II Typing Ea,PX-3108138266,CDM,81382,CPT,0310,RC,,,,both,,,203.00,131.95,,,,,,,,,,,,,
CABLE SPNL DIA1MM S STL SGL W/ LEADER 1 CINCH AND TIGHTENER,SUP-2257003,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|ADJ|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,ADJ|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
ELECTRODE CORTICAL 2 X 6 KT STRL DISP EVO,SUP-2934977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3567.04,2318.58,,,,,,,,,,,,,
FELT SURG W4XL4IN THK1.65MM POLY PTFE,SUP-2127684,CDM,C1768,CPT,0278,RC,,,,both,,,771.75,501.64,,,,,,,,,,,,,
PLATE BNE ACTIVE COMPR BROAD 4.5 MM 14 HOLE NS,SUP-2525138,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
NEEDLE BIOPSY ION 19G IF1000 (CM),SUP-2844580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE 5 H CRANIO FACE N COMPR L R RIG FOR 2MM SCR H,SUP-2366323,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.81,471.78,,,,,,,,,,,,,
SCREW BNE CAPT 135 DEG SHT BRL 100 MM HIP ANGLED TI,SUP-2469332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 45 DEG L 450 CM DIA 0.035 IN STIFF,SUP-2535565,CDM,C1769,HCPCS,0272,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ PO TBCR,RX-35943,CDM,6370000000,HCPCS,0637,RC,00832-5325-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE L5MM DIA2MM MAND CRANIOMAXILLOFACIAL SIL LOK CRSS 5PK,SUP-2366126,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.06,195.69,,,,,,,,,,,,,
NAIL IM L180MM DIA11.5MM NK ANG 130DEG SHT,SUP-2347582,CDM,C1713,HCPCS,0278,RC,,,,both,,,11041.03,7176.67,,,,,,,,,,,,,
PLATE BNE L83MM 5 H L DST LAT FIBULAR VAR ANG LOK FOR 3.5MM,SUP-2349828,CDM,C1713,HCPCS,0278,RC,,,,both,,,5863.17,3811.06,,,,,,,,,,,,,
NEEDLE BX 19GA L60CM THROW L2CM SHTH 7FR LIV ACCS QUIK COR,SUP-2168312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.49,976.62,,,,,,,,,,,,,
LINER ACET 50-52 0 DEG 38X54 MM FEM HIP,SUP-2202561,CDM,C1776,CPT,0278,RC,,,,both,,,3848.07,2501.25,,,,,,,,,,,,,
GRAFT VASC ALBOGRAFT L 40 CM DIA 6 MM POLYESTER STR KNITTED,SUP-2264284,CDM,C1768,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00338-0017-31,NDC,,both,50,ML,21.70,14.10,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LG UPCHARGE HD LNR,SUP-2212680,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SEGMENT EXT FIX MOD RT FOR RED II ALUM 515830204,SUP-2499038,CDM,C1713,HCPCS,0278,RC,,,,both,,,9146.88,5945.47,,,,,,,,,,,,,
ICP KIT PEDIATRIC PLAS DISP,SUP-2666390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1199.70,779.80,,,,,,,,,,,,,
BRACE WR RT INSTABILITY INJ LACE AD SM,SUP-2197946,CDM,L3809,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
HC I&D Abcess Complic Multiple,PX-4501006100,CDM,10061,CPT,0450,RC,,,,outpatient,,,405.00,263.25,,,,,,,,,,,,,
PUSHER KNOT CRV,SUP-2341940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
BOLT SPNL L55MM DIA5.5MM ANT LAT LUM PLT SYS XLP,SUP-2311339,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
STRAP ORTH W3XL4IN STD M FOAM COT MTL TOOTH CLAV BCKL CLSR,SUP-2276601,CDM,L3650,HCPCS,0274,RC,,,,both,,,22.26,14.47,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC LG HI TOP AIR LIFESTRIDE,SUP-2108147,CDM,L4386,HCPCS,0274,RC,,,,both,,,112.73,73.27,,,,,,,,,,,,,
SCREW BONE L20MM DIA2.5MM LCK ST T7 PERI-LOC,SUP-2350054,CDM,C1713,HCPCS,0278,RC,,,,both,,,807.14,524.64,,,,,,,,,,,,,
GRAFT BNE M TRICORT BLK FOR OSTEOTMY ALLOPURE,SUP-2400550,CDM,C1762,CPT,0278,RC,,,,both,,,5683.40,3694.21,,,,,,,,,,,,,
PUNCH SURG OD4MM ETHM BONE RELIEVA CIRCA,SUP-2106341,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
SPACER SPNL H23XL32MM L10MM 8DEG LUM TI ALLY FOR SCR STBL,SUP-2279873,CDM,C1889,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
ANCHOR BNE 3 W/ ARTHSCP DEL SYS REGENETEN,SUP-2341376,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
STENT URET L 24 CM DIA 7 FR PERCFLX SFT TEMP W/O DEL SYS,SUP-2141646,CDM,C2617,HCPCS,0278,RC,,,,both,,,442.11,287.37,,,,,,,,,,,,,
CLIP EXT FIX SPNG SALVATION,SUP-2401152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
BIT DRILL 2.6 WHITE/BLACK WITH ONE NO2 5 METRIC HI FI SUTURE,SUP-2824683,CDM,C1713,HCPCS,0278,RC,,,,both,,,1977.13,1285.13,,,,,,,,,,,,,
GUIDEWIRE SMOOTH ALTA 3.2X100,SUP-2363487,CDM,C1769,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
BLADE SURG FULL 56 MM HMSPHR EXPLANT,SUP-2202988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0258,RC,00338-0023-02,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
MESH HERN W6XL137CM L G POLYPR SYN INGUINAL ABD FLAT,SUP-2126060,CDM,C1781,HCPCS,0278,RC,,,,both,,,239.90,155.93,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 100 CM DIA 6 MM POLYESTER BOV CLLGN,SUP-2265896,CDM,C1768,CPT,0278,RC,,,,both,,,1817.12,1181.13,,,,,,,,,,,,,
BIT DRL DIA3.5MM CALIB FOR PEDILOC PLT L FRAG SYS,SUP-2318880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,944.83,614.14,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00338-0017-31,NDC,,both,250,ML,108.40,70.46,,,,,,,,,,,,,
NAIL IM L250MM OD13MM MULT H SUPCNDYL RG LCK CANN ANTR BEND,SUP-2343601,CDM,C1713,HCPCS,0278,RC,,,,both,,,2741.22,1781.79,,,,,,,,,,,,,
GRAFT BONE SUB W14XH6XL11MM CANC CERV TISS UNICORTICAL DWL,SUP-2277987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
DRAINAGE KIT LL CONN 80 CM 120 CC LUMBAR GRAD CHMBR FIX TAB,SUP-2664454,CDM,C1729,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
DIANEAL PD-2/1.5% DEXTROSE 346 MOSM/L IP SOLN,RX-15434,CDM,A4722,HCPCS,0258,RC,00941-0426-52,NDC,,both,1000,ML,74.80,48.62,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT THEON DIA29 MM SEW RNG DIA 40 MM,SUP-2214065,CDM,C1889,HCPCS,0278,RC,,,,both,,,17882.30,11623.49,,,,,,,,,,,,,
PIN FIX L305MM DIA3MM TEMP THRD,SUP-2198628,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA11 MM STD LAPSCP BLADED FIX CANN,SUP-2896386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,454.14,295.19,,,,,,,,,,,,,
COUNTERSINK DRL L 205 MM DIA 5.5 MM HDLSS,SUP-2899184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.17,443.41,,,,,,,,,,,,,
BUR SURG DIAMOND COARSE 2 MM 5 CM BALL MIDAS REX 8 CLRVW LP,SUP-2664910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1052.69,684.25,,,,,,,,,,,,,
SET INTRO MICRO-STICK SHTH L 9 CM DIA 4 FR SS COAX STIFF,SUP-2627260,CDM,C1894,HCPCS,0272,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
STEM FEM PRSS FIT R POR W/ SLOT TI BAL 19.0MM DIA 180MML,SUP-2406869,CDM,C1776,CPT,0278,RC,,,,both,,,28197.20,18328.18,,,,,,,,,,,,,
BIT DRL L170MM DIA3.2MM ST CANN QUIK CPL NONRADIOLUCENT ADJ,SUP-2187333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1220.24,793.16,,,,,,,,,,,,,
BRACE KNEE AD UNIV FOAM POSTOP UNISX WRP ARND HNG T SCP,SUP-2150860,CDM,L1810,HCPCS,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
ENDCAP ORTH FOR CANN TIB IM NAIL,SUP-2192166,CDM,C1713,HCPCS,0278,RC,,,,both,,,669.45,435.14,,,,,,,,,,,,,
THIAMINE HCL 200 MG/2ML IJ SOLN,RX-163114,CDM,2500000003,HCPCS,0250,RC,72485-0507-01,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
LACTATED RINGERS IR SOLN,RX-4319,CDM,2500000003,HCPCS,0250,RC,00338-0137-27,NDC,,both,3000,ML,103.50,67.27,,,,,,,,,,,,,
KIT LASER TREAT L65CM NDL 21GA 0.035IN GLD TIP FBR LNG ACC,SUP-2116798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
KIT PICC INTERMED SAFT 5FR 2 LUMN VAXCEL M001455980,SUP-2117120,CDM,C1751,HCPCS,0278,RC,,,,both,,,498.07,323.75,,,,,,,,,,,,,
HC So2 Ptt|NOT REASONABLE AND NECESSARY,PX-3058573068,CDM,85730,CPT,0305,RC,,,GZ,both,,,9.00,5.85,,,,,,,,,,,,,
SHELL ACET CLUS HOLE 48 MM HIP HA POROUS TRIL,SUP-2210226,CDM,C1776,CPT,0278,RC,,,,both,,,5755.62,3741.15,,,,,,,,,,,,,
ROD EXT FIX L250MM DIA11MM UNIV C FBR RADLUC CONN,SUP-2188658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SUTURE ANCHR HITCH 1 NO 2 MAXBRAID SUTS,SUP-2137202,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
FILTER VASC EMBOL-X ID 32-35 MM LG POLYESTER MESH DURAFLO,SUP-2214503,CDM,C1884,HCPCS,0278,RC,,,,both,,,1065.87,692.82,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC PREFABRIC,SUP-2388197,CDM,L4360,HCPCS,0274,RC,,,,both,,,759.16,493.45,,,,,,,,,,,,,
ADAPTER EARTIP SANIBEL INFANT,SUP-2719738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,116.49,75.72,,,,,,,,,,,,,
HC ER Level 4,PX-4509928400,CDM,99284,CPT,0450,RC,,,,inpatient,,,2334.00,1517.10,,,,,,,,,,,,,
BIT DRL DIA2 25MM OVERDRL FOR TC CANN SCR SYS CAPTURE,SUP-2243905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.75,455.49,,,,,,,,,,,,,
PIN NAVIGATION L150MM DIA3MM ANCHR MRK IMAG GUID ORTHOMAP,SUP-2720251,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.63,22.51,,,,,,,,,,,,,
"HC So Coombs,Direct",PX-3028688066,CDM,86880,CPT,0302,RC,,,,inpatient,,,218.00,141.70,,,,,,,,,,,,,
BOOT AMBULTNG BOOT ADL DKBLU,SUP-2272967,CDM,L4397,HCPCS,0274,RC,,,,both,,,170.50,110.82,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 4-7 MM EPTFE TAPR STD WALL N,SUP-2396451,CDM,C1768,CPT,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
RATCHETING COMPRESSION PLATE 15X17,SUP-2822964,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 100 MM DIA 9 MM DEL SHTH,SUP-2934246,CDM,C1713,HCPCS,0278,RC,,,,both,,,15258.99,9918.34,,,,,,,,,,,,,
BIT DRL UNIV MIC FX DISP,SUP-2366674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
CATHETER HD SHT TERM 13 FRX24 CM STR SPLIT TIP DUO-SPLIT,SUP-2269521,CDM,C1752,HCPCS,0278,RC,,,,both,,,225.39,146.50,,,,,,,,,,,,,
SPLINT WRST M L7IN AD L FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276649,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.51,6.18,,,,,,,,,,,,,
SPACER NSL CATH W/ PRECIS FRM MICPOR RESVR RADPQ MRK BND,SUP-2106329,CDM,C2625,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
METATARSAL DCOMPR IMPL SZ 1 163MM W 126MM HT HD,SUP-2400139,CDM,C1776,CPT,0278,RC,,,,both,,,10104.52,6567.94,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL SPENCO,SUP-2435701,CDM,L3001,HCPCS,0272,RC,,,,both,,,374.48,243.41,,,,,,,,,,,,,
MESH SURG W15XL12CM SEPRA TECHNOLOGY RECT PHASIX,SUP-2125883,CDM,C1781,HCPCS,0278,RC,,,,both,,,14993.50,9745.77,,,,,,,,,,,,,
HC N Block Inj Intercost Sng,PX-3606442000,CDM,64420,CPT,0360,RC,,,,outpatient,,,2230.00,1449.50,,,,,,,,,,,,,
ALLOGRAFT BNE DBM 2.5 CC VESUVIUS 4104K0825DC,SUP-2717986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.72,662.82,,,,,,,,,,,,,
SCREW BONE L40MM DIA4.5MM CORT S STL ST NONCANNULATED,SUP-2363884,CDM,C1713,HCPCS,0278,RC,,,,both,,,56.68,36.84,,,,,,,,,,,,,
CATHETER THROMCTMY QUICKCLEAR L 85 CM DIA10 FR NOM DIA 0.107,SUP-2823724,CDM,C1757,HCPCS,0272,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
MAGNESIUM SULFATE 50 % IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-4720,CDM,J3475,HCPCS,0636,RC,63323-0642-20,NDC,JW,both,2,ML,54.10,35.16,,,,,,,,,,,,,
HC So Q Fever Antibody,PX-3028663866,CDM,86638,CPT,0302,RC,,,,inpatient,,,423.00,274.95,,,,,,,,,,,,,
SPHERE FINGER JOINT SIZE 10 CMC SYSTEM PYROSPHERE,SUP-2586709,CDM,C1776,CPT,0278,RC,,,,both,,,7700.07,5005.05,,,,,,,,,,,,,
CATHETER CTRL VEN OD6FR POLYUR 2 LUMN PEEL APART INTRO PWR,SUP-2127765,CDM,C1751,HCPCS,0278,RC,,,,both,,,4455.31,2895.95,,,,,,,,,,,,,
PLATE BNE L 248 MM SCREW DIA 4.5 MM 15 H PROX HUM NS EVOS,SUP-2931249,CDM,C1713,HCPCS,0278,RC,,,,both,,,11173.69,7262.90,,,,,,,,,,,,,
BIT DRL ARTHSCP 8 MM NS SURTAC 2000,SUP-2217552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.16,255.55,,,,,,,,,,,,,
HC Arthrocent/Aspiration Maj Jnt|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,PX-3612061000,CDM,20610,CPT,0361,RC,,,50|XU,both,,,1245.00,809.25,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 13 X 38 X 6 MM POLYETHYL BLOCK STRL DISP,SUP-2935315,CDM,C1713,HCPCS,0278,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 9.6 FRX76 CM LP DOME,SUP-2126168,CDM,C1788,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
GRAFT EVAR L7CM DIA14.5MM FEP NIT IL EXT W/ C3 DEL SYS FOR,SUP-2395967,CDM,C1768,CPT,0278,RC,,,,both,,,9335.22,6067.89,,,,,,,,,,,,,
FIBER LASER 197 FT KRA-CPAOCHXL HDMI,SUP-2798094,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1742.73,1132.77,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X89X19 MM THOR 30 HOLE LCK LADDER LEVEL 1,SUP-2869222,CDM,C1713,HCPCS,0278,RC,,,,both,,,3083.64,2004.37,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE XLN 5 CC DBM FIBER INFLUENCER -RSFH,SUP-2881440,CDM,C1713,HCPCS,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
DRAWER PLATE COMPR,SUP-2474207,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ PISTON 0.6X5 MM SS FLROPLAS,SUP-2638116,CDM,L8613,CPT,0278,RC,,,,both,,,486.10,315.96,,,,,,,,,,,,,
PIN PREFIXATION VENTURE ANT CERV PLT SYS,SUP-2293244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.68,262.39,,,,,,,,,,,,,
SPLINT CLAV XL W3XL41IN SHLDR PD STRP MCLEOD,SUP-2197366,CDM,L3650,HCPCS,0272,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
DEVICE FIX MENIS LD NONABSORBABLE STR FAST-FIX,SUP-2341567,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.27,555.28,,,,,,,,,,,,,
SHEATH INTRO 30FR L18CM W/ SIL PINCH VLV GORE,SUP-2396404,CDM,C1894,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
HC Assay of Osmolality Urine,PX-3018393500,CDM,83935,CPT,0301,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
KIT SUT ANCHR DIA21MM HIP SFT LO PROF FOR LABRAL REP,SUP-2136085,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.02,614.91,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 1 92X22 MM ENG PROF GRNLN,SUP-2381515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,125.13,81.33,,,,,,,,,,,,,
STAPLE INT 12MMX10MMX10MM MS MEMOFIX,SUP-2244264,CDM,C1713,HCPCS,0278,RC,,,,both,,,3436.35,2233.63,,,,,,,,,,,,,
SPACER SPNL W11XH9XL14MM 4DEG PEEK ANT CERV INTBDY FUS LORD,SUP-2286353,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
SCREW INTFR BIOSURE REGENESORB 12MM X 35MM,SUP-2341932,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.74,704.43,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA 9 MM DEL SHTH 13ML,SUP-2936819,CDM,C1713,HCPCS,0278,RC,,,,both,,,16514.45,10734.39,,,,,,,,,,,,,
PLATE 8 H RECON 3.5MM INA,SUP-2186268,CDM,C1713,HCPCS,0278,RC,,,,both,,,3789.67,2463.29,,,,,,,,,,,,,
PILLAR EXT FIX L 300 MM THRD MONK RING,SUP-2899088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.10,1105.71,,,,,,,,,,,,,
DRILL SONIC ANCHOR 2.8,SUP-2465292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
PEDIATRIC LCP CONDYLAR PLATE 3.5MM/90/5 HOLES-STERILE,SUP-2546041,CDM,C1713,HCPCS,0278,RC,,,,both,,,2742.38,1782.55,,,,,,,,,,,,,
BRACE UNIV WRST UNI L 8IN 45IN 95IN FRM FIT,SUP-2319285,CDM,L3809,HCPCS,0274,RC,,,,both,,,28.32,18.41,,,,,,,,,,,,,
STAPLES INT L60MM M THCK REINF INTELLIGENT RELD FOR SIGNIA,SUP-2283376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2368.35,1539.43,,,,,,,,,,,,,
CAP END DIA12MM EXTN 20MM TI CANN LOK HD FOR 9-12MM FEM,SUP-2192366,CDM,C1713,HCPCS,0278,RC,,,,both,,,870.69,565.95,,,,,,,,,,,,,
HEAD FEM COMP ACET RESURF CO CHROM 50MM CONSERVE +,SUP-2397309,CDM,C1776,CPT,0278,RC,,,,both,,,12143.95,7893.57,,,,,,,,,,,,,
CONNECTOR SPNL DOMINO OPN POST ANT 2 ROD SPNL SYS 45MM TO,SUP-2631251,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
PLATE BNE L35MM THK1.3MM 6 H NONSTERILE HND S STL STR LOK,SUP-2178033,CDM,C1713,HCPCS,0278,RC,,,,both,,,1553.95,1010.07,,,,,,,,,,,,,
KNEE VNGD TI FEM SSK 65MM RT,SUP-2510698,CDM,C1776,CPT,0278,RC,,,,both,,,17671.92,11486.75,,,,,,,,,,,,,
SUPPORT ORTHOT PIP FNGR DSTL INTERPHALANGEAL CUST W/O JT,SUP-2435785,CDM,L3927,HCPCS,0272,RC,,,,both,,,90.21,58.64,,,,,,,,,,,,,
CATHETER CV SET 12 FRX16 CM 3L LG BOR ARW HWS,SUP-2763395,CDM,C1751,HCPCS,0278,RC,,,,both,,,280.72,182.47,,,,,,,,,,,,,
GRAFT BNE PTTY DEMIN BNE MTRX 3CC TREL-XC,SUP-2244467,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
DRILL SURG OFFSET KNEE FOR REV SYS ATTUNE,SUP-2454562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1510.34,981.72,,,,,,,,,,,,,
SNARE VASC ENSNARE L 120 CM DIA18-30 MM CATH L 100 CM DIA 7,SUP-2217698,CDM,C1773,HCPCS,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
RESERVOIR 20MM 15 WITH UND SHUNT ASSISTANT HYDRO SPRUNG PROG,SUP-2821839,CDM,C1889,HCPCS,0278,RC,,,,both,,,8912.76,5793.29,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI T 3 CT ACTE 15.5FR DIA 24CM MC013523MB,SUP-2633010,CDM,C1752,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
WALKER LEG DLX BLK SHT L,SUP-2276713,CDM,L4387,HCPCS,0272,RC,,,,both,,,87.64,56.97,,,,,,,,,,,,,
BRACE WALKING LP MED 5.5-10 IN 6.5-11 IN WOMEN MAXTRAX AIR,SUP-2428155,CDM,L4360,HCPCS,0274,RC,,,,both,,,97.50,63.37,,,,,,,,,,,,,
SLEEVE HUM DIA7MM PMMA COMPHSVE,SUP-2404529,CDM,C1776,CPT,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
BUR SURG MTCH HD FLUT SM BOR MIDAS REX LEGEND,SUP-2627637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,287.18,186.67,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 386CUCM H198XL263IN THK053IN,SUP-2356747,CDM,C1767,HCPCS,0278,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
SPLINT ORTH 3 1 2 4 1 4 M L L WRST THMB LTWT SFT INNR LINING,SUP-2194733,CDM,L3931,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
LINER KT WLK BOOT VENTURE AIR TALL M,SUP-2151042,CDM,L4386,HCPCS,0274,RC,,,,both,,,67.51,43.88,,,,,,,,,,,,,
CATHETER DRAINAGE PUDENZ,SUP-2666771,CDM,C1729,HCPCS,0272,RC,,,,both,,,449.81,292.38,,,,,,,,,,,,,
GRAFT TISS SZ 2X3CM SINONASAL REP MR SAFE BIODESIGN,SUP-2170296,CDM,C1763,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 6 MM STR DBL SLDE GDS,SUP-2494318,CDM,C1768,CPT,0278,RC,,,,both,,,1387.25,901.71,,,,,,,,,,,,,
SHAFT SCRDRVR SELF RET T15 FRAG PLATING SYS 120MM SM,SUP-2344016,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.43,364.93,,,,,,,,,,,,,
PIN EXT FIX HALF M5 200 MM 30 MM SS,SUP-2162651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 6 MM RNG L 20 CM EPTFE STR TW,SUP-2396155,CDM,C1768,CPT,0278,RC,,,,both,,,3551.34,2308.37,,,,,,,,,,,,,
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-118012,CDM,J1100,HCPCS,0636,RC,72485-0118-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER KIT 25 MMX15 CM VENTRICULAR RESERVOIR BUR HOLE,SUP-2278368,CDM,C1729,HCPCS,0272,RC,,,,both,,,693.06,450.49,,,,,,,,,,,,,
SHEATH INTRO INPUT SSV L 13 CM DIA12 FR DIL L 20 CM,SUP-2294836,CDM,C1892,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
ASSY SHIP GAMMA STER A 0.9 MM,SUP-2916662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,264.51,171.93,,,,,,,,,,,,,
SCREW BNE 2X27 MM 7 MM TI,SUP-2484022,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.18,262.72,,,,,,,,,,,,,
HEAD HUM DIA40MM THK18MM SHLDR CO CHROM PRI STD OFFSET NK 53504018] STRYKER ORTHOPEDICS HOWM],SUP-2372833,CDM,C1776,CPT,0278,RC,,,,both,,,7418.25,4821.86,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-40840056,CDM,J3490,HCPCS,0250,RC,00338-0085-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
APPLIER CLP 8.75IN ANEUR VARIO STD BAYNT SWVL REUSE,SUP-2108607,CDM,C1889,HCPCS,0278,RC,,,,both,,,6032.41,3921.07,,,,,,,,,,,,,
UPCHARGE KNEE TRITANIUM TIBIAL COMPONET STRYKER,SUP-2501354,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER DIAG L150CM ID0.0175IN SHTH OD5FR 0.014IN STD S,SUP-2173631,CDM,C1887,HCPCS,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
BIT DRL L300MM DIA5MM CANN L QUIK CPL FOR 6.5/7.3MM CANN,SUP-2187330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1225.76,796.74,,,,,,,,,,,,,
SET VITRCTMY 25GA PRB STANDALONE ACCURUS,SUP-2109888,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SYSTEM WND DRAINAGE FOR CLOSED INCISION,SUP-2354966,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
SEALANT HEMSTAT 4 CC TISSEEL,SUP-2430137,CDM,C1713,HCPCS,0278,RC,,,,both,,,3849.64,2502.27,,,,,,,,,,,,,
PLATE BNE MESHED 126X126X1 MM LG GRID PLLA-PGA STRL,SUP-2458840,CDM,C1713,HCPCS,0278,RC,,,,both,,,10456.33,6796.61,,,,,,,,,,,,,
PLATE BNE CONN 1 HOLE FOR CARBON FIBER RNG NS,SUP-2799519,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.99,168.34,,,,,,,,,,,,,
GUIDEPIN ORTH DIA2.5MM TRABECULAR MTL RVS SHLDR SYS,SUP-2208229,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SHEATH GUID 7FR L45CM HYDRPHLC COAT L35CM S STL COIL STR,SUP-2385456,CDM,C1894,HCPCS,0272,RC,,,,both,,,347.82,226.08,,,,,,,,,,,,,
CATHETER DLYS ADOL 15FR L59CM TWO CUF SWAN NK RADPQ STRP,SUP-2174279,CDM,C1751,HCPCS,0278,RC,,,,both,,,321.44,208.94,,,,,,,,,,,,,
ANCHOR SUT OD6.5MM BIOCRYL RAPIDE ORTHOCORD HEALIX ADV BR,SUP-2256660,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2 MM MANDIBULAR ST NS AXS,SUP-2909500,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.55,184.96,,,,,,,,,,,,,
GRAFT HUM TISS W3XL3CM CRYOPRESERVED AMNIO MEM LO PROF FOR,SUP-2116285,CDM,Q4148,HCPCS,0636,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
PLATE BNE THK0.5MM 10 H CRANIOMAXILLOFACIAL BLU TI ORBIT,SUP-2366237,CDM,C1713,HCPCS,0278,RC,,,,both,,,695.82,452.28,,,,,,,,,,,,,
BUR SURG L 125 MM DIA2.35 MM HD DIA 4.5 MM DIAMOND NS REUSE,SUP-2929414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.06,234.04,,,,,,,,,,,,,
BIT DRILL DIAMETER 1.4MM SUTURE PASSING CMC MICROLINK,SUP-2825007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.83,1502.69,,,,,,,,,,,,,
SYSTEM BRST BX STD STEREOTACTIC NDL BREVERA,SUP-2572372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
BIT DRL DIA3.2MM CTRL SCR DISP FOR COMPHSVE REV SHLDR SYS,SUP-2408539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
PROSTHESIS VOICE RAPID EXCHANGE 20 FRX10 MM NS BLOM-SINGER,SUP-2242337,CDM,L8509,HCPCS,0274,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
STENT COR 30MM OD3MM BARE MTL OTW S STL S670,SUP-2281443,CDM,C1876,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
SCREW BNE FOR GALAXY FIX SYS 35MMX80MM 4MM,SUP-2316042,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.13,204.18,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6 MM 30 CM STR STD WALL,SUP-2396267,CDM,C1768,CPT,0278,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
GRAFT VASC PROPATEN L 15 CM DIA 6 MM EPTFE CBAS HEPARIN TW,SUP-2655628,CDM,C1768,CPT,0278,RC,,,,both,,,3475.98,2259.39,,,,,,,,,,,,,
DRL BIT SURG DIA 4 MM BRAD PT NONSTERILE ADVANTAGERIB,SUP-2908969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
CATH IVUS VISIONS PV .018 OTW,SUP-2849671,CDM,C1753,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.537,SUP-2860054,CDM,C1713,HCPCS,0278,RC,,,,both,,,48778.02,31705.71,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X200 MM FRZN GAM SEMITENDINOSUS GRACILIS,SUP-2866910,CDM,C1762,CPT,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
LORATADINE 5 MG/5ML PO SOLN,RX-107392,CDM,340b,HCPCS,0637,RC,00904-6767-20,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
MESH SURG W15XL15CM POLYPR SYN ABD NONABSORBABLE SQ 3 INDIV,SUP-2165384,CDM,C1781,HCPCS,0278,RC,,,,both,,,1360.66,884.43,,,,,,,,,,,,,
PLATE BNE RECON UNIV 2.7 MM 6 HOLE 2 COMPR LCK FOR SCR TI NS,SUP-2462930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1045.31,679.45,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 45 CM DIA 6 FR HYDRPHLC RENAL,SUP-2383430,CDM,C1894,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE DIA 7.5 MM SZ 3 CART ARAGONITE POROUS,SUP-2913149,CDM,C1763,HCPCS,0278,RC,,,,both,,,21666.00,14082.90,,,,,,,,,,,,,
ANCHOR SUTXL DIA1.7MM W/ SZ 2 BLU COBRAID ULTBRAID POLY SUT,SUP-2341891,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.33,767.21,,,,,,,,,,,,,
TUBE LARYNGECTOMY MARTIN 8 EXTN STERLING SLV LF,SUP-2489764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.81,283.93,,,,,,,,,,,,,
PLATE BNE W23XL44MM THK1.6MM 10 H SHT L DST RAD VOLAR TI,SUP-2267967,CDM,C1713,HCPCS,0278,RC,,,,both,,,3058.36,1987.93,,,,,,,,,,,,,
CATHETER ANGIO JACKY RADIAL 3.5 6 FRX110 CM 2 SH OPTITORQUE,SUP-2385356,CDM,C1725,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PIN EXTRNL FXTN CLCNS TRBCLR METAL TOTAL ANKLE SSTM,SUP-2720892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,719.85,467.90,,,,,,,,,,,,,
POST EXT FIX 2 HOLE STRL TRUELOK EVO LTX,SUP-2875628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1453.19,944.57,,,,,,,,,,,,,
CANNULA SPNL CVD 1.5 MM,SUP-2366996,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
PLATE BNE L266MM 12 H L CNDYL S STL VAR ANG LOK COMPR CRV,SUP-2177857,CDM,C1713,HCPCS,0278,RC,,,,both,,,5861.03,3809.67,,,,,,,,,,,,,
APPLIER CLP SHFT L33CM W/ 20 M L SUP INTLOK TI CLP PSTL GRP,SUP-2283165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.36,707.43,,,,,,,,,,,,,
PLATE BNE 2.7X129 MM 16 HOLE,SUP-2199265,CDM,C1713,HCPCS,0278,RC,,,,both,,,1396.67,907.84,,,,,,,,,,,,,
ELECTRODE ES 24X26FR DIA3MM YEL COAG BRL SHP FOR 24/28FR,SUP-2261198,CDM,C1713,HCPCS,0278,RC,,,,both,,,440.45,286.29,,,,,,,,,,,,,
"HC Insert Picc Cath, 5/> Yrs - Anes",PX-3613656901,CDM,36569,CPT,0361,RC,,,,both,,,4942.00,3212.30,,,,,,,,,,,,,
ANCHOR SUT DIA2.9MM WHT COBRAID BLK W/ TWO COBRAID SUT,SUP-2341807,CDM,C1713,HCPCS,0278,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
SLING TRNSVAG IN FAST ULT SYS INTEXEN,SUP-2140293,CDM,C1771,HCPCS,0278,RC,,,,both,,,5294.83,3441.64,,,,,,,,,,,,,
BLOCK ILIUM TRICORT TRAD ALLGRFT SM 20 - 30 MM LX8 - 14 MM W,SUP-2294060,CDM,C1713,HCPCS,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
SYSTEM SEAL 5ML SPINE DURA HYDRGEL POLYETH GLYCOL,SUP-2243116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2744.93,1784.20,,,,,,,,,,,,,
KIT ENDO VEIN HARV VASOVIEW,SUP-2227755,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
VALVE HEMSTAS ADJ ROT,SUP-2282186,CDM,C1887,HCPCS,0272,RC,,,,both,,,83.59,54.33,,,,,,,,,,,,,
HC CT L-Spine W/O Contrast,PX-3527213100,CDM,72131,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
INSULIN REGULAR(HUMAN) IN NACL 100-0.9 UT/100ML-% IV SOLN,RX-147180,CDM,J1815,HCPCS,0637,RC,00338-0126-12,NDC,,both,100,ML,28.00,18.20,,,,,,,,,,,,,
SLING GYN L 45 X W 1.1 CM POLYPRO MONOFILAMENT DIL,SUP-2929642,CDM,C1771,HCPCS,0278,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
INTRODUCER ORTHOPEDIC BLNT,SUP-2265698,CDM,C1894,HCPCS,0272,RC,,,,both,,,807.92,525.15,,,,,,,,,,,,,
PLATE BONE NONSTERILE LT VOLAR RIM CROSSLOCK DVR,SUP-2136268,CDM,C1713,HCPCS,0278,RC,,,,both,,,2711.39,1762.40,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA10 FR GUIDEWIRE 0.038 IN,SUP-2168377,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.36,65.88,,,,,,,,,,,,,
MESH DERM MTRX PORCINE 2X7CM INTEXEN LP,SUP-2140303,CDM,C1763,HCPCS,0278,RC,,,,both,,,1327.44,862.84,,,,,,,,,,,,,
CATHETER EP MED SWP 2-5-2 DECAPOLAR LIVEWIRE,SUP-2465588,CDM,C1730,HCPCS,0272,RC,,,,both,,,1673.62,1087.85,,,,,,,,,,,,,
VEST PT HOLSTER SM 14 IN VENTRICULAR THORATEC HEARTMATE,SUP-2356007,CDM,Q0499,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
STEM FEM L152MM OD11MM FINN L8.5CM HIP SEGMENTED COMP,SUP-2406095,CDM,C1776,CPT,0278,RC,,,,both,,,12914.82,8394.63,,,,,,,,,,,,,
LENS INTOCU +16.5 DIOPT A CONSTANT 118.8 L13MM DIA6MM 0DEG,SUP-2247750,CDM,V2632,HCPCS,0276,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
KIT TRACH TB AD L80MM OD10MM ID7MM SIL W/ OBT SIDEPRT,SUP-2352053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,310.01,201.51,,,,,,,,,,,,,
CATHETER CV TY 018 PEDIATRIC 5 FRX5 CM DL J TIP POLYETH,SUP-2760003,CDM,C1751,HCPCS,0278,RC,,,,both,,,287.56,186.91,,,,,,,,,,,,,
INSERT REDUC SCR BLK,SUP-2289268,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
PLATE BNE OPN WDG 3.5 MM FORE FT W/ STEM,SUP-2609147,CDM,C1713,HCPCS,0278,RC,,,,both,,,6027.04,3917.58,,,,,,,,,,,,,
TUBE SALIVARY BYPS N ADH 12 191X38X12 MM ESOPH MONTGOMERY,SUP-2138740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
CATHETER CV KT 8.5 FRX20 CM 4 LUMEN PRESSURE INJ ARROWG+ARD,SUP-2763388,CDM,C1751,HCPCS,0278,RC,,,,both,,,526.89,342.48,,,,,,,,,,,,,
CHLORHEXIDINE GLUCONATE 4 % EX SOLN,RX-104334,CDM,6370000000,HCPCS,0637,RC,00234-0575-04,NDC,,both,118,ML,17.60,11.44,,,,,,,,,,,,,
STIMULATOR NERVE REMOTE CONTROL,SUP-2568749,CDM,C1787,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
TIP CRYOSURGERY L 90 MM DIA1 MM GEN 2 STRL DISP IOVERA SMRT,SUP-2882200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1481.17,962.76,,,,,,,,,,,,,
CLAMP EXT FIX 2 H BODY COMPLT RAIL,SUP-2197295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
HC Ventilator Subsequent Day,PX-4109400300,CDM,94003,CPT,0410,RC,,,,inpatient,,,1569.00,1019.85,,,,,,,,,,,,,
STAPLE SPNL 1 H ANTR THORLUM TI EXPEDIUM,SUP-2256340,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CABLE INTCONN L15FT REUSE FOR CIRCA S CATH AND S CATH M TO,SUP-2164519,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
DEVICE VENTRICULAR ASST KT,SUP-2356020,CDM,C1713,HCPCS,0278,RC,,,,both,,,274750.00,178587.50,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM B CRV UNIDIR,SUP-2248936,CDM,C1732,HCPCS,0272,RC,,,,both,,,5567.22,3618.69,,,,,,,,,,,,,
BAR EXT FIX L350MM DIA11MM FBR GLS FOR XTRAFIX SYS,SUP-2199713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
CATHETER EMB NOVASIL L 80 CM DIA 4 FR BALLOON DIA 9 MM 0.60,SUP-2264197,CDM,C1757,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
RHS SHORT RADIAMETERL STEM DIAMETER 6MM NECK 13MM,SUP-2830222,CDM,C1776,CPT,0278,RC,,,,both,,,8939.58,5810.73,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 4X35 MM TITANIUM NITRIDE STERILE,SUP-2836772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.60,587.99,,,,,,,,,,,,,
KIT PAIN PMP 400ML 4ML PER HR L25IN W ANTIMIC SIL CATHETER,SUP-2236830,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
NEEDLE SPNL LASER 25 CM SIDEFIRE ORTH HOLM,SUP-2225668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
NEEDLE BONE CEMENT DELIVERY 12 GAX10 CM STERILE,SUP-2838510,CDM,2720000010,LOCAL,0272,RC,,,,both,,,270.35,175.73,,,,,,,,,,,,,
PLATE BNE L47MM 6 H TI RIG DYN LOK COMPR FOR 2.4MM SCR MOD,SUP-2191477,CDM,C1713,HCPCS,0278,RC,,,,both,,,1846.98,1200.54,,,,,,,,,,,,,
PLATE BNE L39MM THK3.8MM 2 H BILAT S STL NAR DYN COMPR FOR,SUP-2185180,CDM,C1713,HCPCS,0278,RC,,,,both,,,1013.78,658.96,,,,,,,,,,,,,
DRILL SURG DIA11MM DISK DISP FOR ULTRASONIC REV SYS UDRV 3,SUP-2408564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.80,798.07,,,,,,,,,,,,,
PROBE NRV STIM DIA0.5MM STD PRASS PR DISP,SUP-2284319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.86,231.96,,,,,,,,,,,,,
SLEEVE CNTR L9MM DIA1.5MM PMMA FOR OUTSIDE STEM RX90,SUP-2405679,CDM,C1776,CPT,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
REAMER SURG DIA2.7MM HLLW FOR 2.4/3MM SCR,SUP-2187143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.70,566.60,,,,,,,,,,,,,
QUARTEX INLINE HK,SUP-2228836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
TUBING SET SUC IRR W/ EXCHG TIP FOR ROSI SYS STRL LTX,SUP-2865325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2584.22,1679.74,,,,,,,,,,,,,
SCREW BNE L82MM OD7MM THRD L21MM PUR HINDFOOT ANK CANN M,SUP-2320776,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.75,892.94,,,,,,,,,,,,,
DILATOR URETH 8-20FR L37CM W/ SIDEPRT SET S-CURVE,SUP-2171366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
POST EXT FIX CIR FEMALE 3 HOLE,SUP-2400677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.95,257.37,,,,,,,,,,,,,
GRAFT STENT 6X15 MM HEPARIN,SUP-2396648,CDM,C1874,HCPCS,0278,RC,,,,both,,,11837.80,7694.57,,,,,,,,,,,,,
CATHETER HD SET 15 FRX42 CM DL AG ACCS CENTER VECTORFLOW,SUP-2762980,CDM,C1750,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
HC Mlc Device(S) for Imrt,PX-3337733800,CDM,77338,CPT,0333,RC,,,,both,,,1593.00,1035.45,,,,,,,,,,,,,
MATRIX BIO L 7 X W 10 CM FISH SKIN DERMAL STD INTACT STRL SINGLE,SUP-2909432,CDM,Q4158,HCPCS,0636,RC,,,,both,,,10776.48,7004.71,,,,,,,,,,,,,
STEM FEM L178MM DIA108MM JUNCTION BX LOK BOLT BAL KNEE,SUP-2431847,CDM,C1776,CPT,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BNE L78MM THK3.7MM 6 H BILAT S STL STR LO PROF RIG,SUP-2184026,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.82,1306.38,,,,,,,,,,,,,
PLATE BNE SHT BRL 130 DEG 3 HOLE,SUP-2861269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1688.25,1097.36,,,,,,,,,,,,,
PAD CERV CLLR REPL FOR VISTA,SUP-2123902,CDM,L0190,HCPCS,0272,RC,,,,both,,,23.20,15.08,,,,,,,,,,,,,
HC Nephrostogram/Urography Antegrade,PX-3207442500,CDM,74425,CPT,0320,RC,,,,outpatient,,,1485.00,965.25,,,,,,,,,,,,,
COVER BUR H DIA15MM TI FOR CRAN CLSR SYS,SUP-2243977,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.83,224.14,,,,,,,,,,,,,
ELECTRODE ELECSURG CUT LOOP 30 DEG 24 FR 0.2 IN MONOPOLAR,SUP-2485688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.33,245.26,,,,,,,,,,,,,
SEALANT TISS 4 CC TISSEEL KT,SUP-2129851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,689.07,447.90,,,,,,,,,,,,,
SHELL TRI + SHELL CLUS 46MM,SUP-2267696,CDM,C1776,CPT,0278,RC,,,,both,,,3170.77,2061.00,,,,,,,,,,,,,
CATHETER HD ALPHACURVE 14.5 FRX28 CM CHRONIC KT GLIDEPATH,SUP-2126480,CDM,C1881,HCPCS,0278,RC,,,,both,,,1374.85,893.65,,,,,,,,,,,,,
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3613850500,CDM,38505,CPT,0361,RC,,,TC|73,both,,,5560.00,3614.00,,,,,,,,,,,,,
PLATE BNE 6 H L HINDFOOT IMPL ADVANSYS TTC,SUP-2243041,CDM,C1713,HCPCS,0278,RC,,,,both,,,6491.92,4219.75,,,,,,,,,,,,,
VALVE AORT ORIFICE DIA21.4MM TISS ANNULUS DIA23MM 85DEG,SUP-2355104,CDM,C1889,HCPCS,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
DRILL SURG LUG FEM HI PERF LCS,SUP-2454042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
NKII +4MM MOD NP TIBIAL BASEPLATE-CONST RT SIZE 2,SUP-2510148,CDM,C1776,CPT,0278,RC,,,,both,,,7988.16,5192.30,,,,,,,,,,,,,
SCREW BONE 3.5MM DIA 10MML CORTICAL,SUP-2588529,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.87,55.17,,,,,,,,,,,,,
WAND ENDOSCP ELECTROCAUTERY WEREWOLF FASTSEAL 6.0 HEMOSTAS,SUP-2716212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM DIA 8 MM POLYESTER BOV CLLGN,SUP-2484046,CDM,C1768,CPT,0278,RC,,,,both,,,1737.61,1129.45,,,,,,,,,,,,,
SLING TVEZ 2.7MM TROCAL DESARA BLUE,SUP-2740343,CDM,C1771,HCPCS,0278,RC,,,,both,,,3604.72,2343.07,,,,,,,,,,,,,
CATHETER ANGIO ARW BERMAN L 80 CM DIA 5 FR BALLOON DIA12 MM,SUP-2383927,CDM,C1725,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
BRACE Q LG,SUP-2174971,CDM,L1820,HCPCS,0272,RC,,,,both,,,188.24,122.36,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB CEM SURF TIV PROLONG,SUP-2212333,CDM,C1776,CPT,0278,RC,,,,both,,,11070.23,7195.65,,,,,,,,,,,,,
GRAFT BNE 1-4 MM 90 CC CORTICAL CANC,SUP-2766767,CDM,C1713,HCPCS,0278,RC,,,,both,,,3724.67,2421.04,,,,,,,,,,,,,
SCREW BONE L12MM OD3.5MM STD S STL CORT ST NONCANNULATED,SUP-2348771,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.28,30.08,,,,,,,,,,,,,
PIN FIX L14IN DIA0.094IN SMOOTH W/ EYELET BEATH FOR ANT,SUP-2249397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
COMPONENT TIB CR SM UNIV 11 MM DSTL STEM NP MONOBLOCK CEM,SUP-2376396,CDM,C1776,CPT,0278,RC,,,,both,,,3935.68,2558.19,,,,,,,,,,,,,
PLATE BONE 12 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413755,CDM,C1713,HCPCS,0278,RC,,,,both,,,1471.15,956.25,,,,,,,,,,,,,
GUIDEWIRE SURG L355MM DIA2.4MM S STL SMOOTH BALL TIP,SUP-2256598,CDM,C1769,HCPCS,0272,RC,,,,both,,,269.41,175.12,,,,,,,,,,,,,
DRESSING BIO W8XL10IN MESHED BILAYER WND MTRX,SUP-2244275,CDM,C9363,HCPCS,0636,RC,,,,both,,,34906.00,22688.90,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM RT WRST LTHR,SUP-2194875,CDM,L3931,HCPCS,0274,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
BIT DRL CANN LNG 12 MM FLX STRL,SUP-2789625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3274.61,2128.50,,,,,,,,,,,,,
IMP SYS T-ROPE RT-J W/8.0MM FLPCTR IIS,SUP-2811810,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE SYNDESMOTIC 2 H 1/3 TUBLR STRL GORILLA,SUP-2898997,CDM,C1713,HCPCS,0278,RC,,,,both,,,2504.15,1627.70,,,,,,,,,,,,,
CATHETER PICC ARROW TAPERFREE 5FR 55CM 2-LUMEN,SUP-2887046,CDM,C1751,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
BRACE ORTHOPEDIC PRO XL 24-27 IN RT KNEE TRK ORTHOSIS PTO,SUP-2150972,CDM,L1810,HCPCS,0274,RC,,,,both,,,158.82,103.23,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN AMBRIO2,SUP-2247194,CDM,V2790,HCPCS,0278,RC,,,,both,,,1983.32,1289.16,,,,,,,,,,,,,
SHEATH URO 11 13FRX38CM UROPS,SUP-2312756,CDM,C1894,HCPCS,0272,RC,,,,both,,,2243.78,1458.46,,,,,,,,,,,,,
GRAFT BONE LT TIB WHL TRAD FRZN,SUP-2294146,CDM,C1713,HCPCS,0278,RC,,,,both,,,15046.88,9780.47,,,,,,,,,,,,,
WASHER ORTHPDC CNNLTD STNLSS STEEL SPHRCL F3.5MM SCREW NON,SUP-2727190,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.36,83.43,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 0.035 IN 24 ATM 5 FRX135 CM 3X20 MM,SUP-2865912,CDM,C1725,HCPCS,0272,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
GRAFT BNE CAP ADAPT MIS,SUP-2430777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC DBM TENSIX,SUP-2759548,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
PATCH CV IMPRA L 75 X W 50 MM THK 0.6 MM EPTFE RECTANGULAR,SUP-2761295,CDM,C1768,CPT,0278,RC,,,,both,,,909.75,591.34,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED LT LAT FEM CONDYLE,SUP-2867082,CDM,C1762,CPT,0278,RC,,,,both,,,10723.89,6970.53,,,,,,,,,,,,,
KIT BONE CEM HNDL W/ 11GA L12CM NDL N BVL AVATEX,SUP-2155333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BAR XTRAFIX 11MM CRBN 600,SUP-2720467,CDM,2720000010,LOCAL,0272,RC,,,,both,,,900.43,585.28,,,,,,,,,,,,,
SHEATH INTRO FLX L 45 CM OD 6 FR GUIDEWIRE 0.038 IN SM CKFLO,SUP-2168513,CDM,C1894,HCPCS,0272,RC,,,,both,,,173.61,112.85,,,,,,,,,,,,,
FIBER LASER 550 MH 100 W FLEXSHIELD OUTPT TIP ETFE SIL,SUP-2141812,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1285.05,835.28,,,,,,,,,,,,,
STENT PANCREATIC FREEMAN L 5 CM DIA 5 FR GUIDEWIRE 0.035 IN,SUP-2319809,CDM,C2617,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 8 MM RNG L 20 CM EPTFE,SUP-2396273,CDM,C1768,CPT,0278,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
STEM FEM L27MM OD14MM UNIV CSTI POR KNEE PRI CEM FLUT IMP,SUP-2208274,CDM,C1776,CPT,0278,RC,,,,both,,,13621.32,8853.86,,,,,,,,,,,,,
IMMOBILIZER KNEE 1 SZ FITS MOST WRP ARND ABV KNEE OPN PAT,SUP-2324216,CDM,L1830,CPT,0274,RC,,,,both,,,76.08,49.45,,,,,,,,,,,,,
PLATE 95 DEG CONDYLAR 9 HOLES 40MM 156MM,SUP-2547716,CDM,C1713,HCPCS,0278,RC,,,,both,,,3559.13,2313.43,,,,,,,,,,,,,
HC Mandible Panorex,PX-3207035500,CDM,70355,CPT,0320,RC,,,,both,,,770.00,500.50,,,,,,,,,,,,,
SCREW BONE LOCKING 2.9X14 MM SELFTAPPING TITANIUM NON STERIL,SUP-2837689,CDM,C1713,HCPCS,0278,RC,,,,both,,,754.07,490.15,,,,,,,,,,,,,
INSERT TIB SZ 1 L10MM LT MEDL RT LAT ALL POLY UNI,SUP-2342208,CDM,C1776,CPT,0278,RC,,,,both,,,4918.81,3197.23,,,,,,,,,,,,,
BRACE WRISTXL L8IN RT FOAM LOOP LCK CLSR W/ THMB SPICA,SUP-2324354,CDM,L3931,HCPCS,0274,RC,,,,both,,,70.68,45.94,,,,,,,,,,,,,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG PO TABS,RX-21288,CDM,6370000000,HCPCS,0637,RC,60687-0592-11,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
BRACE KNEE UNIV RIGID CUSTOMIZABLE ROM HINGE TRIM DONJOY,SUP-2914882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.60,218.14,,,,,,,,,,,,,
HC Dexa Appendicular Skeleton,PX-3207708100,CDM,77081,CPT,0320,RC,,,,outpatient,,,649.00,421.85,,,,,,,,,,,,,
STENT URETH 8.5FR L90CM PTFE DIV SGL J OPN END,SUP-2313761,CDM,C2617,HCPCS,0278,RC,,,,both,,,1089.89,708.43,,,,,,,,,,,,,
SCREW SPNL L12MM DIA32MM CORT TI STR NONCANNULATED ST,SUP-2189827,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
SET SCR SPNL CLOSE VLS TI,SUP-2415638,CDM,C1713,HCPCS,0278,RC,,,,both,,,572.36,372.03,,,,,,,,,,,,,
HC So Immunofixation Serum,PX-3028633466,CDM,86334,CPT,0302,RC,,,,both,,,71.00,46.15,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 X W 20 MM THK 3 MM ACHILLES TEND RC,SUP-2933146,CDM,C1762,CPT,0278,RC,,,,both,,,3241.23,2106.80,,,,,,,,,,,,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-10734,CDM,2500000003,HCPCS,0250,RC,72078-0002-00,NDC,,both,4,ML,100.40,65.26,,,,,,,,,,,,,
SPLINT UP EXTRM MTL SPLNTS MTCRPL,SUP-2124890,CDM,L3913,HCPCS,0272,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
RASP SURG STD SGL END CRV HANDHELD,SUP-2372588,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.85,1647.00,,,,,,,,,,,,,
LIP-GUARD EX OINT,RX-82160,CDM,6370000000,HCPCS,0637,RC,41388-0210-41,NDC,,both,10,GR,6.50,4.22,,,,,,,,,,,,,
PASTE BONE GRAFT GRAFTON PLUS ALLOGRAFT 1ML MOLDABLE SYRINGE DBM,SUP-2293916,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.06,280.84,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN 37MML HLX3 11MM THK STNLSS STEEL F/,SUP-2721568,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
LEVOFLOXACIN 750 MG PO TABS,RX-28964,CDM,6370000000,HCPCS,0637,RC,00904-6353-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STEM HUM L145MM DIA10MM STD SHLDR CO CHROM COFIELD2,SUP-2344289,CDM,C1776,CPT,0278,RC,,,,both,,,6790.25,4413.66,,,,,,,,,,,,,
BAND CIR L125MM 2X0.75MM 4.0,SUP-2129433,CDM,C1784,HCPCS,0278,RC,,,,both,,,200.18,130.12,,,,,,,,,,,,,
SLEEVE CNTR DIA9MM SHLDR PMMA BIOMOD,SUP-2404625,CDM,C1776,CPT,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
HC Cta Head W & W/O Cont,PX-3517049600,CDM,70496,CPT,0351,RC,,,,both,,,3184.00,2069.60,,,,,,,,,,,,,
PLATE BNE W101XL154MM THK35MM 11 H BILAT TI STR RIG LOK,SUP-2191086,CDM,C1713,HCPCS,0278,RC,,,,both,,,1809.99,1176.49,,,,,,,,,,,,,
SET HAD CATHETER 10FR L52CM SGL W CUF L22X25CM TWO FREE,SUP-2269510,CDM,C1881,HCPCS,0278,RC,,,,both,,,460.95,299.62,,,,,,,,,,,,,
GUIDEWIRE VASC L 45 CM DIA 0.018 IN NIT TUNGSTEN TIP PERIPH,SUP-2752623,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.31,41.80,,,,,,,,,,,,,
POST FIX TAPR,SUP-2123530,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE ANGLED 2.5 MM LT 7X23 HOLE RECON PT SPEC TI,SUP-2860093,CDM,C1713,HCPCS,0278,RC,,,,both,,,19076.44,12399.69,,,,,,,,,,,,,
CATHETER INFUSION PMP 4 ML/HR 2X10 IN 275 CC,SUP-2361463,CDM,C1751,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
GRAFT BONE SUB L9MM CORT FIBULAR WDG FRZ DRY CORNERSTONE SEL,SUP-2293786,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PLATE BNE L421MM 18 H ST PROX FEM S STL HK LO PROF LOK COMPR,SUP-2186069,CDM,C1713,HCPCS,0278,RC,,,,both,,,5925.78,3851.76,,,,,,,,,,,,,
PIN FIX 2.1X5 MM POLY-L-LACTIC ACID POLY GLYCOLIC ACID STRL,SUP-2470755,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.47,186.86,,,,,,,,,,,,,
TRIAL BONE PLT 4 H T SHP OBLQ TC-100 SM FRAG SYS,SUP-2343730,CDM,C1713,HCPCS,0278,RC,,,,both,,,2110.74,1371.98,,,,,,,,,,,,,
TRUMATCH MIDFACE/MANDIBLE TI 3D PRNT IMPLANT/ ORBIT,SUP-2194246,CDM,C1713,HCPCS,0278,RC,,,,both,,,25749.57,16737.22,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.5X14 MM SELFTAPPING PLUSDRIVE RECESS T,SUP-2838126,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.19,152.87,,,,,,,,,,,,,
CAGE SPCR CORPECTOMY SM 12X143.5 29 TO 36MM S XPAND,SUP-2229141,CDM,C1889,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
PLATE BNE 45MM R NONBIOABSORBABLE DISPOSABLE TCP,SUP-2396861,CDM,C1713,HCPCS,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
HC So Hepatitis B Core Igm Antibody,PX-3028670566,CDM,86705,CPT,0302,RC,,,,both,,,45.00,29.25,,,,,,,,,,,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,0636,RC,43598-0901-11,NDC,,both,1,UN,159.30,103.54,,,,,,,,,,,,,
ADAPTER LD FOR ILINK-BIS-10 PULSE GENRTR,SUP-2138033,CDM,C1883,HCPCS,0278,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
PACK BONE MAR ASPIR 30ML CONC,SUP-2384781,CDM,C1713,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
STENT URET L22-28CM DIA4.5FR HYDRPHLC QUADRA COIL TECOFLEX,SUP-2313748,CDM,C2617,HCPCS,0278,RC,,,,both,,,252.27,163.98,,,,,,,,,,,,,
DRILL SET HUDSON CRAN BRAC COMPLETE,SUP-2470555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1795.17,1166.86,,,,,,,,,,,,,
CATHETER EP ABLAT B CRV QPLR 2-5-2MM SPC 4MM TIP UNI DIR,SUP-2248688,CDM,C1733,HCPCS,0272,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
SHELL ACET 60 MM HIP 9 HOLE REFLECTION FSO,SUP-2434637,CDM,C1776,CPT,0278,RC,,,,both,,,5005.16,3253.35,,,,,,,,,,,,,
SPIRATION DEPLOYMENT CATHETER,SUP-2679936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
BRACE KNEE T SCP POSTOP MEAS TAKEN 6IN ABV MID PAT 27-35IN,SUP-2150859,CDM,L1810,HCPCS,0274,RC,,,,both,,,303.95,197.57,,,,,,,,,,,,,
SHELL ACET DIA36MM TI ALLOY POR HA CALCICOAT CERAMIC MH PRI,SUP-2210210,CDM,C1776,CPT,0278,RC,,,,both,,,6592.43,4285.08,,,,,,,,,,,,,
SEED BRACHYTHERAPY I-125 LOOSE PROST BRACHYSOURCE,SUP-2129115,CDM,C2638,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GAUGE WIRE 0.045,SUP-2480299,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
PLATE BONE LOK HLX46 HDSHFT TTNM T SHPD OBLQUE ST,SUP-2724423,CDM,C1713,HCPCS,0278,RC,,,,both,,,1261.34,819.87,,,,,,,,,,,,,
CYSTOSCOPE ASCOPE 4 CYSTO REVERSE SINGLE USE,SUP-2884333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SPACER INTBDY 24X13MM 0 DEG AP LUM CYL NONSCREW TI BAK,SUP-2205735,CDM,C1889,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
MESH HERN OBLONG 3X6 IN O3FA COAT POLYPR C-QUR TACSHIELD,SUP-2227255,CDM,C1781,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
SCREW BNE CRTX 2.4X65 MM ST T8 STARDRV RECESS TI NS,SUP-2758281,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.10,124.21,,,,,,,,,,,,,
VALVE SHUNT INLINE PROGRAMMABLE CODMAN CERTAS +,SUP-2243823,CDM,C1729,HCPCS,0272,RC,,,,both,,,12086.77,7856.40,,,,,,,,,,,,,
HC Cessj Therapy Cath Removal,PX-3613721400,CDM,37214,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
WASHER 3.5/4.5MM STRL,SUP-2547540,CDM,C1713,HCPCS,0278,RC,,,,both,,,303.42,197.22,,,,,,,,,,,,,
PLATE BNE L236MM 9 H NONSTERILE R DST FEM TI LOK COMPR FOR,SUP-2190725,CDM,C1713,HCPCS,0278,RC,,,,both,,,4937.21,3209.19,,,,,,,,,,,,,
TUBE VENT FOR SH TERM APPLICATIONS LIKE AIRPLANE TRAVEL,SUP-2277599,CDM,L8699,HCPCS,0278,RC,,,,both,,,53.57,34.82,,,,,,,,,,,,,
GII C/R DEEP TIB SZ5 11MM LF,SUP-2822559,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PROBE BRST BX DIA10GA ENCOR,SUP-2126858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
COUNTERSINK SURG 3.5MM W/ AO QUIK CPL EVOS,SUP-2344050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
DRILL SURG ULTRA AFFIRM,SUP-2598516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HEAD FEM OD28MM -3.5MM OFFSET CERAMIC ON CERAMIC ALUMINA PRI,SUP-2216740,CDM,C1776,CPT,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 7.01-8.0 MCI NS ADVANTAGE,SUP-2247280,CDM,C2643,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BASKET STONE RETRV L120CM SHTH 1.3FR NIT THMB WHL DSGN RACK,SUP-2139283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,764.72,497.07,,,,,,,,,,,,,
BIT DRL DIA4X45MM CANN BITE COMPR SCR QUIK CONN,SUP-2315943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1232.95,801.42,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.525,SUP-2860206,CDM,C1713,HCPCS,0278,RC,,,,both,,,34697.63,22553.46,,,,,,,,,,,,,
PLATE BNE L385MM 16 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186066,CDM,C1713,HCPCS,0278,RC,,,,both,,,5221.35,3393.88,,,,,,,,,,,,,
PLATE BNE L W13.5XL142MM THK4.2MM 8 H BILAT TI STR RIG,SUP-2190815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1363.29,886.14,,,,,,,,,,,,,
MESALAMINE 4 G RE ENEM,RX-10535,CDM,6370000000,HCPCS,0637,RC,45802-0098-51,NDC,,both,60,ML,45.10,29.31,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY STEEROCATH DX L 110 CM DIA 7 FR,SUP-2141248,CDM,C1730,HCPCS,0272,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
LEVEL NEURO PLATE ULTRNE STR NEURO SCRW2 HOLE 12 MM T06 MM,SUP-2677496,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.33,193.91,,,,,,,,,,,,,
KIT TRACH AD TB L98MM OD12.3MM ID9MM SIL W/ OBT SIDEPRT,SUP-2352055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.18,215.27,,,,,,,,,,,,,
TUBE MYRINGOTOMY 1.27 MM 1 MM RUBE TAB SIL STRL,SUP-2535113,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.04,27.33,,,,,,,,,,,,,
BIT DRILL SURG 4.3X152.5 MM FREE HND NAT NAIL,SUP-2198676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,291.39,189.40,,,,,,,,,,,,,
HEAD PAT STD LG LAT LCS MILESTONE,SUP-2454059,CDM,C1776,CPT,0278,RC,,,,both,,,2304.76,1498.09,,,,,,,,,,,,,
MESH HERN W15XL15CM POLYGLACTIN 910 WVN FLAT VCRL,SUP-2220358,CDM,C1781,HCPCS,0278,RC,,,,both,,,1539.60,1000.74,,,,,,,,,,,,,
GUIDE SURG PT SPEC BNE GRFT HARVESTING,SUP-2860263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3182.70,2068.75,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 7 FR 0.025IN PLAS,SUP-2420179,CDM,C1894,HCPCS,0272,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
PIN FIX L120MM DIA35MM S STL SGL END SMOOTH SHRP TIP FOR,SUP-2186908,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
MARKER BX SITE FOR CELERO-12 DEV,SUP-2240010,CDM,A4648,CPT,0278,RC,,,,both,,,205.98,133.89,,,,,,,,,,,,,
BLADE PUSH DISP ST,SUP-2370238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
SET ENDOBRONCH BLK AD L78CM BAL 9FR W/ SPHR MULTPURP ADPT,SUP-2168834,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.41,412.37,,,,,,,,,,,,,
STENT PERIPH ZILVER 518 L 20 MM DIA10 MM DEL SYS L 125 CM,SUP-2170480,CDM,C1876,HCPCS,0278,RC,,,,both,,,2868.39,1864.45,,,,,,,,,,,,,
GRAFT BIO TISS W8XL16CM THK1MM CLLGN MTRX FEN SEMI OVL FOR,SUP-2243672,CDM,C9360,HCPCS,0278,RC,,,,both,,,8440.32,5486.21,,,,,,,,,,,,,
HEAD HUM RESURF SHLDR,SUP-2304827,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BONE DELTA 1X21-HOLE 0.5MM THK PLLA PDLA PGA,SUP-2883363,CDM,C1713,HCPCS,0278,RC,,,,both,,,8926.83,5802.44,,,,,,,,,,,,,
HC CT Abd/Pelvis W W/O Contrast,PX-3527417800,CDM,74178,CPT,0352,RC,,,,both,,,3757.00,2442.05,,,,,,,,,,,,,
PLATE BONE L47MM SH 2X2 H RT OBLQ TI L SHP MALL FOR 2MM SCR,SUP-2191291,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
COLLAR CERV SUPP X TALL AD COMFORT,SUP-2269629,CDM,L0180,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CANNULA PERF 17FR L17CM FEM ART W/ 12FR INTRO TANDEMHEART,SUP-2152641,CDM,C1889,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
WALKER ANK L SHT STD BLK COMP SHELL NONSKID HK LO CLSR,SUP-2276717,CDM,L4387,HCPCS,0272,RC,,,,both,,,78.12,50.78,,,,,,,,,,,,,
SCREW DISTRCTN L14MM QUIK STRT CASPR,SUP-2390670,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SHEATH INTRO 17GA L8IN TUNN DISP ON-Q,SUP-2236802,CDM,C1892,HCPCS,0272,RC,,,,both,,,85.09,55.31,,,,,,,,,,,,,
RING EXT FIX HALF 80 MM CARBON FIBER RINGFIX,SUP-2365281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2662.72,1730.77,,,,,,,,,,,,,
TOOL VENT ASST PMP L COR TORQ WRNCH TUNN HEX DRVR AND CVR,SUP-2282551,CDM,C1713,HCPCS,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
NAIL IM L360MM DIA10MM R FEM PIRIFORMIS FOSSA ENTRY LT GRN,SUP-2180374,CDM,C1713,HCPCS,0278,RC,,,,both,,,5684.44,3694.89,,,,,,,,,,,,,
GRAFT BNE 85X17.5 MM DBM BLLST,SUP-2641774,CDM,C1713,HCPCS,0278,RC,,,,both,,,13753.20,8939.58,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 7 MM EPTFE STR TW N RING,SUP-2396345,CDM,C1768,CPT,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
HC Endoluminal Bx Biliary Tree,PX-3614754300,CDM,47543,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SLEEVE DRL L200MM DIA8/5MM FOR LAT ENTRY FEM NAIL RECON-EX,SUP-2178860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.33,559.86,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM LAP 16 GAX76 CM,SUP-2330477,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
CATHETERIZATION KIT 8 FRX20 CM DL PRB ARROWG+ARD BLU +,SUP-2383109,CDM,C1751,HCPCS,0278,RC,,,,both,,,183.38,119.20,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM DIA 45/45 MM THOR AORT,SUP-2719572,CDM,C1768,HCPCS,0278,RC,,,,both,,,57885.90,37625.83,,,,,,,,,,,,,
SPLINT WRST AND THMB UNIV,SUP-2336035,CDM,L3809,HCPCS,0274,RC,,,,both,,,37.55,24.41,,,,,,,,,,,,,
SPLINT CLAV M AD BCKL CLSR PD MCLEOD,SUP-2197364,CDM,L3660,HCPCS,0272,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 18 MM PA COMPETENT VLV STRL,SUP-2884025,CDM,C1768,CPT,0278,RC,,,,both,,,73001.86,47451.21,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS STD 13X25 MMX90CM BA IMPREG TRNSLUC,SUP-2277946,CDM,C1729,HCPCS,0272,RC,,,,both,,,394.26,256.27,,,,,,,,,,,,,
GRAFT VASC STR 10 MMX100 CM AORT ARCH 1 LAYR SFT HEMSHLD GLD,SUP-2457107,CDM,C1768,CPT,0278,RC,,,,both,,,1928.15,1253.30,,,,,,,,,,,,,
CATHETER CV FULL TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0004,SUP-2760038,CDM,C1751,HCPCS,0278,RC,,,,both,,,455.27,295.93,,,,,,,,,,,,,
WARFARIN SODIUM 2.5 MG PO TABS,RX-8750,CDM,6370000000,HCPCS,0637,RC,68084-0027-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET INT FIX LAPIDUS SYS,SUP-2900640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 15CM 9MM 120CM 8FR RADIOPAQUE,SUP-2719612,CDM,C1768,HCPCS,0278,RC,,,,both,,,10754.50,6990.42,,,,,,,,,,,,,
IMPLANT KNEE JOINT OSTEOCHONDRAL MATRIX SYNTHETIC BONE STERILE,SUP-2913426,CDM,C1763,HCPCS,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
COMPONENT TALAR DOMED 4 3+ MM ANK INVISION,SUP-2850489,CDM,C1776,CPT,0278,RC,,,,both,,,17213.48,11188.76,,,,,,,,,,,,,
DEFIBRILLATOR CARD 38CC W41XH76MM THK14MM L VENT DF-4 IS-4,SUP-2356330,CDM,C1882,HCPCS,0275,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
HC So Elution Procedure,PX-3028686066,CDM,86860,CPT,0302,RC,,,,inpatient,,,282.00,183.30,,,,,,,,,,,,,
PROBE LAP 10 MM W/ HANDSWITCH,SUP-2225601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
CROWN DENT SZ LL2 LO LT 1ST PERM M S STL THCK OCCLUSAL SURF,SUP-2238798,CDM,D6783,CPT,0278,RC,,,,both,,,109.87,71.42,,,,,,,,,,,,,
SHUNT PERI W OUT RESVR PROGRAMMABLE SYS ASSEMB STRATA VLV,SUP-2277981,CDM,C1889,HCPCS,0278,RC,,,,both,,,13135.91,8538.34,,,,,,,,,,,,,
CAGE ACET CUP DIA52MM THK2MM LT COMMERCIALLY PURE TI MOD,SUP-2405114,CDM,C1776,CPT,0278,RC,,,,both,,,13564.80,8817.12,,,,,,,,,,,,,
STEM RADIAL STD 4X8 MM ELBW,SUP-2106428,CDM,C1776,CPT,0278,RC,,,,both,,,5608.04,3645.23,,,,,,,,,,,,,
CUTTER SUTURE ARTHROSCOPY DISPOSABLE,SUP-2828668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.66,205.18,,,,,,,,,,,,,
NEEDLE ASPIR INJ 15 GAX32 CM NS ENDOLAP LTX REUSE,SUP-2868232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.00,297.05,,,,,,,,,,,,,
IMPLANT HUM TISS L 230-330 MM DIA 4-8.5 MM TIBIALIS TEND,SUP-2881937,CDM,C1762,CPT,0278,RC,,,,both,,,4014.40,2609.36,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH II L 13 CM DIA 9.5 FR GUIDEWIRE L,SUP-2418816,CDM,C1892,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
PLATE BNE L183MM 10 H ST POST MED PROX TIB S STL LOK COMPR,SUP-2177801,CDM,C1713,HCPCS,0278,RC,,,,both,,,3625.92,2356.85,,,,,,,,,,,,,
IMPRESSION MATERIAL DENT ULT PK ACCSRY CINCH PLUS,SUP-2355846,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
HC Ot Rmvl Devital Tiss N-Slctv Dbrdmt W/O Anes 1 Sess,PX-4309760200,CDM,97602,CPT,0430,RC,,,,both,,,253.00,164.45,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L NP CRUCE RET BAL SYS,SUP-2314641,CDM,C1776,CPT,0278,RC,,,,both,,,6141.84,3992.20,,,,,,,,,,,,,
GRAFT HUM TISS 9SQCM EPIFIX AMNIO MEM ALLGRFT DEHYDR N VIABLE,SUP-2305752,CDM,Q4186,HCPCS,0636,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
CENTRALIZER STEM L120MM DIA13.5MM DSTL FEM HIP CEM MOLD FOR,SUP-2251179,CDM,C1776,CPT,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
PROSTHESIS OSS 0.6X6 MM MID EAR MALL PISTON FLROPLAS SMRT,SUP-2313852,CDM,L8613,CPT,0278,RC,,,,both,,,1054.82,685.63,,,,,,,,,,,,,
DRILL TWST L 1.9 IN DIA 0.8 MM STP 6 MM CHK NS DISP,SUP-2883250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.90,245.63,,,,,,,,,,,,,
STABILIZER TISS BEAT HRT OCTPS NUVO,SUP-2284350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
CATHETER DIAG TRK EXCEL-14 L 150 CM DSTL L 7.5 CM OD,SUP-2361687,CDM,C1887,HCPCS,0272,RC,,,,both,,,2682.82,1743.83,,,,,,,,,,,,,
CATHETER PICC AD 5FR L55CM 2 LUMN NRS PWR INJ N COAT CT,SUP-2125548,CDM,C1751,HCPCS,0278,RC,,,,both,,,507.52,329.89,,,,,,,,,,,,,
SCREW BNE LAG 80 MM SLD FIX STRL PHOENIX LTX DISP,SUP-2861385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1804.68,1173.04,,,,,,,,,,,,,
DEXAMETHASONE 4 MG/ML IJ SOLN (MIXTURES ONLY),RX-4081237,CDM,J1100,HCPCS,0636,RC,67457-0422-54,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
STEM HUM L75MM OD7MM UNIV CO CHROME SHLDR MOD PRI W O BODY,SUP-2376490,CDM,C1776,CPT,0278,RC,,,,both,,,6280.79,4082.51,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-40840052,CDM,J7030,HCPCS,0258,RC,00264-7800-09,NDC,,both,250,ML,6.40,4.16,,,,,,,,,,,,,
SLEEVE SURG DRL 2.5-3.5X130 MM DBL,SUP-2319110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
EXPANDER TISS 450CC P7.1CM W14XH10.2CM BRST SIL RND TEXT,SUP-2300627,CDM,C1789,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
SHEATH INTRO FLX L 30 CM OD 6 FR GUIDEWIRE 0.038 IN SM CKFLO,SUP-2168401,CDM,C1894,HCPCS,0272,RC,,,,both,,,143.15,93.05,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPLR AUSTIN-MOORE,SUP-2351341,CDM,C1776,CPT,0278,RC,,,,both,,,4204.46,2732.90,,,,,,,,,,,,,
CATHETER THROMCTMY L 80 MM BALLOON L 10 MM DIA 8 MM PTFE,SUP-2227485,CDM,C1725,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BONE L41MM 10 H ORBIT RIM CRANIOMAXILLOFACIAL TI FOR,SUP-2191139,CDM,C1713,HCPCS,0278,RC,,,,both,,,1294.62,841.50,,,,,,,,,,,,,
CATHETER HD DL 11.5 FRX12 CM ADMIN FULL KT HYDR TIP DURAFLO,SUP-2267008,CDM,C1750,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
COMPONENT PAT L+ 3PEG RND REV ROT CEM POR WITHOUTXRAY WIRE,SUP-2252417,CDM,C1776,CPT,0278,RC,,,,both,,,5542.10,3602.36,,,,,,,,,,,,,
BIT DRL TRI FLAT STRL DISP CENTERPIECE,SUP-2926468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.81,237.78,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE INJ DRILLABLE VOID FILL NORIAN,SUP-2182827,CDM,C1713,HCPCS,0278,RC,,,,both,,,3695.50,2402.07,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EPSTAR L 130 CM DIA2 FR SPC 5-5-5,SUP-2641907,CDM,C1730,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
HC Pericardiocentesis Including Imag Guid When Performed,PX-3613301600,CDM,33016,CPT,0361,RC,,,,outpatient,,,3477.00,2260.05,,,,,,,,,,,,,
NAIL IM L350MM OD13MM SUBTROCHANTERIC ROD LT ZCKL II,SUP-2364772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4354.40,2830.36,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN ADJ,SUP-2435599,CDM,L1650,HCPCS,0274,RC,,,,both,,,698.18,453.82,,,,,,,,,,,,,
ANCHOR SUT OD5.5MM TI 3 NO 2 SUT WHT COBRAID BLU COBRAID BLK,SUP-2341860,CDM,C1713,HCPCS,0278,RC,,,,both,,,933.37,606.69,,,,,,,,,,,,,
PIN FIX HABAL TYP 2X8 MM 5 MM RED II,SUP-2463190,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.63,235.06,,,,,,,,,,,,,
VALVE SHUNT SINGLE OPENING PRESSURE 30CM H2O WITH NO CONNECT,SUP-2825629,CDM,C1889,HCPCS,0278,RC,,,,both,,,4341.65,2822.07,,,,,,,,,,,,,
SCREW BONE CORT HEX HD,SUP-2198413,CDM,C1713,HCPCS,0278,RC,,,,both,,,38.56,25.06,,,,,,,,,,,,,
PLATE BNE 3.5X85 MM 7 HOLE SS DCP,SUP-2569139,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.50,170.62,,,,,,,,,,,,,
CATHETER THROMCTMY PRODIGY L 160 CM OD 0.067 IN ID 0.055 IN,SUP-2864587,CDM,C1757,HCPCS,0272,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
INSERT TIB SZ 1-2 THK18MM R KNEE BI CRUCE STBL CONSTRN ARTC,SUP-2350781,CDM,C1776,CPT,0278,RC,,,,both,,,8547.08,5555.60,,,,,,,,,,,,,
PLATE BONE L191MM 11 H LT PROX HUM LCK FOR 3.5MM SCR,SUP-2348594,CDM,C1713,HCPCS,0278,RC,,,,both,,,14345.72,9324.72,,,,,,,,,,,,,
SCREW BNE L50MM DIA6.5MM THRD L32MM TAN CANN SELF DRL HDLSS,SUP-2177013,CDM,C1889,HCPCS,0278,RC,,,,both,,,954.87,620.67,,,,,,,,,,,,,
INBONE  POLY SZ 5 10MM SULCUS,SUP-2471108,CDM,C1776,CPT,0278,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
STEM FEM L160MM OD10MM TIB KNEE UNCEMENTED SPLINED STR IMP,SUP-2405468,CDM,C1776,CPT,0278,RC,,,,both,,,4298.66,2794.13,,,,,,,,,,,,,
SET CHOLANGIOGRAPHY 4FR L60CM W/ ARW KARLAN BLLN CATH CRV,SUP-2383432,CDM,C1726,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE 3 HL TWST RINGFIX SYS,SUP-2704820,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
COUNTERSINK SURG DIA3/2.4MM CANN SCR,SUP-2390540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
POWDER SURG CELLERATE RX 1 GM HYDROL COLLEGEN,SUP-2737594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE L52MM 3X3 H T SHP FOR 3.5MM SCR,SUP-2411362,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
TUBE VENTILATION 1.02MM ID 2.4MM SHEPARD GROMMET,SUP-2902750,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.35,26.23,,,,,,,,,,,,,
CATHETER DRNGE 8.5FR L25CM 0.038IN 8 H POLYUR HYDRPHLC BLU,SUP-2303364,CDM,C1729,HCPCS,0272,RC,,,,both,,,187.93,122.15,,,,,,,,,,,,,
CENTRALIZER STEM DIA11MM UNIV DST HIP,SUP-2210693,CDM,C1776,CPT,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BONE L48MM 3 H T SHP LCK 2 HD FOR 3.5MM SCR,SUP-2318679,CDM,C1713,HCPCS,0278,RC,,,,both,,,1737.74,1129.53,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM RT MAND 26 HOLE ANGLED TI NS,SUP-2470840,CDM,C1713,HCPCS,0278,RC,,,,both,,,6041.93,3927.25,,,,,,,,,,,,,
ASSEMBLY KIT PENILE PROS,SUP-2300751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
NAIL IM L180MM DIA11MM UNIV ANK TI SIL STR RG NONLOCKING,SUP-2412891,CDM,C1713,HCPCS,0278,RC,,,,both,,,4467.91,2904.14,,,,,,,,,,,,,
ANCHOR SUTURE 5.5 MM KNOTLESS HEALICOIL,SUP-2516501,CDM,C1713,HCPCS,0278,RC,,,,both,,,1532.85,996.35,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 15 MM EXPANSION DIA 5-8 MM SHTH 6 FR,SUP-2159109,CDM,C1877,HCPCS,0278,RC,,,,both,,,3334.68,2167.54,,,,,,,,,,,,,
PLATE BONE 18 H S STL BILAT NONCOMPRESSION RIG CLLR 1/3 TBLR,SUP-2372062,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.00,288.60,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5 FR SS MANDREL TUNGSTEN TIP SIL,SUP-2763433,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
PLATE BNE RECON 3.5X169 MM 13 HOLE W/ WIDE ANGLE STR LP NS,SUP-2799193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1688.63,1097.61,,,,,,,,,,,,,
PLATE BNE L 30.5 MM THK 1 MM SCREW DIA2 MM 6 H SHRT TI,SUP-2936955,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.74,695.98,,,,,,,,,,,,,
SCREW BNE L4MM DIA15MM CRANIOMAXILLOFACIAL TI ALLY ULT LO,SUP-2262842,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.23,128.85,,,,,,,,,,,,,
CATHETER PERFSN PRUITT L 24 CM DIA12 FR BALLOON DIA20 MM,SUP-2884050,CDM,C2628,HCPCS,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
ENDOPROSTHESIS VASC GRAFTMASTER L 19 MM DIA 3.5 MM THK 0.52,SUP-2105202,CDM,C1874,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
KIT STYL L70CM FOR CATHETER,SUP-2416952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
DEVICE COMPR SM 1CM DIA38MM HI F SPINDLE,SUP-2406894,CDM,C1776,CPT,0278,RC,,,,both,,,11143.86,7243.51,,,,,,,,,,,,,
CAGE SPNL W10XH12XL22MM SELF EXP,SUP-2354933,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
HC Rmvl Transvns Pm Eltrd Dual Lead Sys,PX-4803323500,CDM,33235,CPT,0480,RC,,,,outpatient,,,5391.00,3504.15,,,,,,,,,,,,,
SCREW BNE CANN LNG THRD 6.5X45 MM 32 MM HDLSS COMPR TI PUR,SUP-2564298,CDM,C1713,HCPCS,0278,RC,,,,both,,,2209.18,1435.97,,,,,,,,,,,,,
GUIDEWIRE NOSE BALL 100CM,SUP-2478134,CDM,C1769,HCPCS,0272,RC,,,,both,,,6685.75,4345.74,,,,,,,,,,,,,
TRAY KYPHOPLASTY BLLN 4ML L20MM DIA16.1MM NDL 11GA SYR 20ML,SUP-2367078,CDM,C1713,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT FILTERWIRE EZ L 300 CM RVD 2.25-3.5 MM,SUP-2145069,CDM,C1769,HCPCS,0272,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
ROD EXT FIX LNG 11X220 MM NS BRDG,SUP-2421792,CDM,C1713,HCPCS,0278,RC,,,,both,,,2154.83,1400.64,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 130 CM DIA 5 FR 0.035 IN H1 BRAIDED,SUP-2118115,CDM,C1887,HCPCS,0272,RC,,,,both,,,254.72,165.57,,,,,,,,,,,,,
GRAFT BIO TISS W15XL10CM THK0.6MM NONDENATURED CLLGN BOV OVL,SUP-2383081,CDM,C9356,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
NERVE STIMULATOR KIT IMPL PULSE KT,SUP-2141900,CDM,C1820,HCPCS,0278,RC,,,,both,,,54322.00,35309.30,,,,,,,,,,,,,
KYPHOPLASTY KIT BLLN 11 GAX10 MM FRAC IVAS ELITE DISP,SUP-2423878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8607.02,5594.56,,,,,,,,,,,,,
DEVICE FIX LP MINI 3 MM FOREHEAD ENDOTINE,SUP-2760653,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.92,555.05,,,,,,,,,,,,,
WRX DISTAL RADIUS NAIL 6X70MM STERILE,SUP-2818038,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
ELEVATOR SURG TIP 3.5 MM MOD OBWEGESER,SUP-2936983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
BIT DRL SHT 2.8 MM POLARUS 3,SUP-2431926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
LEFLUNOMIDE 20 MG PO TABS,RX-23873,CDM,6370000000,HCPCS,0637,RC,00088-2161-30,NDC,,both,1,UN,224.20,145.73,,,,,,,,,,,,,
PLATE BONE L31MM 2 HOLE BLTRL STNLSS STEEL STRGHT NNCMPRSSN,SUP-2492489,CDM,C1713,HCPCS,0278,RC,,,,both,,,765.88,497.82,,,,,,,,,,,,,
BODY HUM L30MM STD PROX SHLDR MOD FOR FX PROMOS +,SUP-2351245,CDM,C1776,CPT,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
VALVE CSF MINI 15 CM TWO PC SYS ANTECHAMBER VENTRICULAR CATH,SUP-2666633,CDM,C1889,HCPCS,0278,RC,,,,both,,,9770.24,6350.66,,,,,,,,,,,,,
SCREW BNE NLCK 5X65 MM OSTEOPENIA PARTIALLY THRD NS PERI-LOC,SUP-2348508,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.36,163.38,,,,,,,,,,,,,
MATRIX BIO DIA15 MM FISH SKIN SIL DERMAL ADH CIR FEN INTACT,SUP-2909289,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
CATHETER KT BIO-STABLE NON-VALVED,SUP-2118833,CDM,C1751,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
CATHETER HD PRECRV 14 FRX12 CM SHT TERM SET DUOFLO 400XL,SUP-2627165,CDM,C1752,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
CATHETER INTRO KT 14F DIAM,SUP-2327257,CDM,C1894,HCPCS,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB FLX CEM TAP PLUG SURF,SUP-2212253,CDM,C1776,CPT,0278,RC,,,,both,,,15022.23,9764.45,,,,,,,,,,,,,
LINER ACET CUP 28 MM ID 48 MM TO 54 MM OD 0 DEG CERAMIC ON,SUP-2202650,CDM,C1776,CPT,0278,RC,,,,both,,,5857.67,3807.49,,,,,,,,,,,,,
PLATE BONE 12X3 H MESH FOR 2.4MM SCR VLP MINI-MOD SM BONE,SUP-2351099,CDM,C1713,HCPCS,0278,RC,,,,both,,,6198.20,4028.83,,,,,,,,,,,,,
LEAD PACE SENTUS PROMRI L 85 CM DIA16 MM TIP 49 CM L85/49,SUP-2138463,CDM,C1900,HCPCS,0275,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4X20 MM OCCIPITOCERVICAL UPPER THOR,SUP-2631997,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 7 MM EPTFE GRAD REINF 3 LAYR,SUP-2669712,CDM,C1768,CPT,0278,RC,,,,both,,,3448.44,2241.49,,,,,,,,,,,,,
PROBE E ENDOSCP J 5MMX45CM DISPOSABLE ST 0250070555,SUP-2361229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.58,436.53,,,,,,,,,,,,,
BASEPLATE TIB MOD 71 MM KNEE POROUS OSS,SUP-2449767,CDM,C1776,CPT,0278,RC,,,,both,,,8435.61,5483.15,,,,,,,,,,,,,
SYSTEM REPAIR MENISCAL AIR+ CURVED DOWN,SUP-2749431,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.19,884.77,,,,,,,,,,,,,
HEAD FEM 9X30X140 MM NK BIMTRC,SUP-2791016,CDM,C1776,CPT,0278,RC,,,,both,,,8942.72,5812.77,,,,,,,,,,,,,
GUIDE NDL BX 0 DEG 1.6 MM BOR E13C2 TRANSDUCER STRL DISP,SUP-2835414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
CONNECTOR SPNL SZ A5 L41-49MM MED TI CRSS FOR 5.5MM ROD,SUP-2255518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
TACROLIMUS 5 MG PO CAPS,RX-12934,CDM,J7507,HCPCS,0636,RC,16729-0043-01,NDC,,both,1,UN,13.20,8.58,,,,,,,,,,,,,
NUT ORTH LCK NS,SUP-2902572,CDM,C1713,HCPCS,0278,RC,,,,both,,,2441.66,1587.08,,,,,,,,,,,,,
HEAD PAT MED LARGE+ MEDL LCS MILESTONE,SUP-2454058,CDM,C1776,CPT,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
BIN STRL COMPR WIRE FRCP MOD,SUP-2193970,CDM,C1713,HCPCS,0278,RC,,,,both,,,1106.60,719.29,,,,,,,,,,,,,
SROM NRH REPLC HINGE BRG QTY2,SUP-2515641,CDM,C1776,CPT,0278,RC,,,,both,,,1051.27,683.33,,,,,,,,,,,,,
PLATE BNE L 203 MM SCREW DIA 4.5 MM 11 H NAR COMPR NLCK NS,SUP-2933315,CDM,C1713,HCPCS,0278,RC,,,,both,,,1902.34,1236.52,,,,,,,,,,,,,
KIT SGL LUMN PICC CATH 45CM NRS FULL TY W/ MICEZ SFTY MIC,SUP-2125617,CDM,C1751,HCPCS,0278,RC,,,,both,,,780.92,507.60,,,,,,,,,,,,,
EXTRACTOR SALIVARY STONE CATH 1.5FR L115CM BSKT DIA10MM,SUP-2169475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
SPONGE SCLER BCKL L80MM DIA3MM RND STYL 503,SUP-2213492,CDM,C1784,HCPCS,0278,RC,,,,both,,,146.32,95.11,,,,,,,,,,,,,
BIT DRL DIA3.5MM CLR FT PLATING SYS DISP FPS,SUP-2319605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SCREW BONE L15MM OD6.5MM MTL ON POLYETH CANC HIP RESTORIS Z,SUP-2371460,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.60,383.24,,,,,,,,,,,,,
DRILL SURG PISTON 2 MM PERC NS INION OTPS LTX REUSE,SUP-2857870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
PLATE EXT FIX 1 H CIR FIX SIDEKCK FREE,SUP-2400607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
SPACER SPNL PARL 0 DEG 21X15X9 MM VALEO PL,SUP-2175328,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE BNE 2.5X49X1.6 MM LAT DSTL RADIAL WRST 6 HOLE TI,SUP-2423733,CDM,C1713,HCPCS,0278,RC,,,,both,,,3164.18,2056.72,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA 8 HOLES 133MM RIGHT,SUP-2549545,CDM,C1713,HCPCS,0278,RC,,,,both,,,3624.47,2355.91,,,,,,,,,,,,,
PROFILE CSTL CRTLGE SHEET XS 2PK L 2.5 3 CM W 1 2 CM T 1.8,SUP-2722654,CDM,C1762,CPT,0278,RC,,,,both,,,1506.42,979.17,,,,,,,,,,,,,
SHEATH INTRO L 36 IN DIA12 FR SS NIT WIRE FEM CRV INNR LD,SUP-2169590,CDM,C1725,HCPCS,0272,RC,,,,both,,,769.27,500.03,,,,,,,,,,,,,
KWIRE THRD RECON 3.2X400MM,SUP-2465619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
IMPLANT FACE L 95 X H 98 MM THK 18 MM LG POLYETHYL TEMPORAL,SUP-2883655,CDM,C1713,HCPCS,0278,RC,,,,both,,,5200.97,3380.63,,,,,,,,,,,,,
KIT ORTH STBL IMPL ON INSRTR SLD DRL ANGLED GUIDE STRL DISP,SUP-2899045,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
RING FIX 180MM HALF CIR FIX FRDM,SUP-2400656,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
KNIFE SURG BLDE L220MM DBL CUT FOR AMPUTATION LISTON,SUP-2108449,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.87,356.77,,,,,,,,,,,,,
SCREW BNE L 15 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2932403,CDM,C1713,HCPCS,0278,RC,,,,both,,,136.06,88.44,,,,,,,,,,,,,
STAPLER EXT 65MM S STL AUTO DISP PURSTRING,SUP-2283033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.51,244.08,,,,,,,,,,,,,
SYSTEM DISTR UPPER MDFD WSLDR ATTCH FRGD EXTRNL DISTR RED,SUP-2669815,CDM,C1713,HCPCS,0278,RC,,,,both,,,6837.38,4444.30,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + M,SUP-2195532,CDM,L1830,CPT,0272,RC,,,,both,,,60.92,39.60,,,,,,,,,,,,,
PLATE CNDYL 2MM 2H HD 6H SHFT TI STRL VAL,SUP-2546912,CDM,C1713,HCPCS,0278,RC,,,,both,,,2110.65,1371.92,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7040,HCPCS,0250,RC,00264-7800-10,NDC,,both,250,ML,14.90,9.68,,,,,,,,,,,,,
BIT DRL DIA2.6MM PILOT H CANN FOR 4MM SCR FLOWERCUBE,SUP-2225308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.23,438.90,,,,,,,,,,,,,
HC Icu Intermediate R&B,PX-2060000000,CDM,2060000000,LOCAL,0206,RC,,,,inpatient,,,3713.00,2413.45,,,,,,,,,,,,,
HC So Glucose 6 Phos Dehydro Quant,PX-3018295566,CDM,82955,CPT,0301,RC,,,,both,,,111.00,72.15,,,,,,,,,,,,,
BIT DRL OD1.3MM S STL FOR EVOLVE TRIAD FIX SYS,SUP-2397954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
COMPONENT TIB CR XS UNIV 11 MM DSTL STEM NP MONOBLOCK CEM,SUP-2376392,CDM,C1776,CPT,0278,RC,,,,both,,,3935.68,2558.19,,,,,,,,,,,,,
IMMOBILIZER SHLDR W ABD SM,SUP-2276608,CDM,L3670,HCPCS,0272,RC,,,,both,,,75.74,49.23,,,,,,,,,,,,,
BARRIER ADH L 2 X W 2 CM AMNIO MEMBRN DBL SIDE LAYR PROTCT,SUP-2904076,CDM,C1762,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCISSOR SURG 1619 MM 2.8 MM STRL LF DISP,SUP-2865651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1927.02,1252.56,,,,,,,,,,,,,
IMPL TOE JT 0 DEG SM CANN STR STRL PHALINX,SUP-2883987,CDM,C1776,CPT,0278,RC,,,,both,,,5099.36,3314.58,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST DBL SLD STIRRUP BND,SUP-2435634,CDM,L2020,HCPCS,0274,RC,,,,both,,,3119.94,2027.96,,,,,,,,,,,,,
SCREW SPNL L50MM PEEK EXT HEX FOR 6.35MM ROD CDH,SUP-2287301,CDM,C1713,HCPCS,0278,RC,,,,both,,,669.45,435.14,,,,,,,,,,,,,
NEEDLE VENTRICULAR MIXTER 16 GAX3-5/8 IN 2 HOLE SLV,SUP-2666378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1126.63,732.31,,,,,,,,,,,,,
HEAD FEM OD32MM +7MM XLN NK CO CHROM HIP SLOT TAPR N,SUP-2304434,CDM,C1776,CPT,0278,RC,,,,both,,,4624.91,3006.19,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT RIB SEG 50 300MM LX5 30MM W,SUP-2307297,CDM,C1713,HCPCS,0278,RC,,,,both,,,1787.48,1161.86,,,,,,,,,,,,,
NAIL IM CANN 135 DEG 10 MM FIX TI STRL,SUP-2192104,CDM,C1713,HCPCS,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
STEM FEM REV 0+ MM SHT 19 MM HIP POLISHED EMPERION,SUP-2434542,CDM,C1776,CPT,0278,RC,,,,both,,,13238.24,8604.86,,,,,,,,,,,,,
ENDCAP ORTH L20MM DIA15MM STRL GRN FEM TI NAIL EXTN LCK HD,SUP-2192718,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.93,500.45,,,,,,,,,,,,,
HC Sedimentation Rate RBC Non-Automated,PX-3058565100,CDM,85651,CPT,0305,RC,,,,both,,,166.00,107.90,,,,,,,,,,,,,
SCREW BNE L18MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413564,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
PLATE BNE CRV 6 HOLE TI,SUP-2402951,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
HC Egd Flexible Foreign Body Removal,PX-4504324700,CDM,43247,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
PLATE BNE FEM LNG 3.5X152 MM LT DSTL PROX 4 HOLE NS VA-LCP,SUP-2757673,CDM,C1713,HCPCS,0278,RC,,,,both,,,3779.84,2456.90,,,,,,,,,,,,,
SHUNT SURG L 13.4 MM CATH L DSTL 600 MM VENTRICULAR 180 MM,SUP-2929354,CDM,C1889,HCPCS,0278,RC,,,,both,,,7237.29,4704.24,,,,,,,,,,,,,
SPACER TIB MED 15 MM PROX KNEE TILASTAN,SUP-2433948,CDM,C1776,CPT,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
SCREW BONE L30MM DIA6MM STRL CORT TI ST CANN LCK FULL THRD,SUP-2191859,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.29,507.84,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 60 MM 85 MM 4 HOLE TI NS DCP,SUP-2569043,CDM,C1713,HCPCS,0278,RC,,,,both,,,2770.61,1800.90,,,,,,,,,,,,,
SPACER SPNL W10XH7X32MM LUM SACR PEEK INTBDY FUS W TANT MRK,SUP-2289141,CDM,C1821,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
HC Nasal Bones Min 3 Views,PX-3207016000,CDM,70160,CPT,0320,RC,,,,both,,,693.00,450.45,,,,,,,,,,,,,
NKII R/C FEMUR NP REV ADAPTER SPCR RT SIZE 0 LAT,SUP-2509751,CDM,C1776,CPT,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
SUPPORT OBESITY BARIATRIC L FOR 65-75IN HIP W/ LUM SHLDR,SUP-2324542,CDM,L0642,HCPCS,0272,RC,,,,both,,,215.94,140.36,,,,,,,,,,,,,
COUPLER ANAS DIA5MM POLYETH S STL GEM,SUP-2382628,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SCREW BONE LOCKING 3.5MM DIA 12MML,SUP-2588211,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
KIT TKR CEM FEM CEM TIB STD SURF AND NO PAT PERSONA,SUP-2212215,CDM,C1776,CPT,0278,RC,,,,both,,,11972.82,7782.33,,,,,,,,,,,,,
BIT DRL DIA13 MM CANN REMOVAL NS REUSE,SUP-2905317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5397.66,3508.48,,,,,,,,,,,,,
CANNULA LAP W/O VLV 6 MMX8.5 CM W/ INSUFFLATION STOPCOCK BLK,SUP-2767864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.72,607.57,,,,,,,,,,,,,
PLATE SPNL L5.5MM UNIV S STL ILLIOSACRAL POST LCK BILAT,SUP-2290568,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 5 MM RNG L 60 CM EPTFE,SUP-2396286,CDM,C1768,CPT,0278,RC,,,,both,,,4100.84,2665.55,,,,,,,,,,,,,
BUPROPION HCL ER (SR) 100 MG PO TB12,RX-18385,CDM,6370000000,HCPCS,0637,RC,50228-0174-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ORTHOSIS ANK FT SM SZ M 6-7.5 WOM 7.5-9 LT CLOSE HEEL DLX,SUP-2195193,CDM,L1930,HCPCS,0274,RC,,,,both,,,104.72,68.07,,,,,,,,,,,,,
LENS IOL ASPHERIC 10+ DIOPT 5 MM MLPC CYL PWR 1.25,SUP-2392072,CDM,V2787,HCPCS,0276,RC,,,,both,,,499.00,324.35,,,,,,,,,,,,,
PLATE BNE 3X8 H NONSTERILE S STL Y SHP LOK COMPR W/ SHT,SUP-2177483,CDM,C1713,HCPCS,0278,RC,,,,both,,,1247.62,810.95,,,,,,,,,,,,,
COUNTERSINK SURG DIA 4 MM CANN FT AO QC MIS,SUP-2898209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
GUIDEWIRE ORTH L 100 MM DIA 0.8 MM SCREW DIA2 MM TROCAR TIP,SUP-2908181,CDM,C1769,HCPCS,0272,RC,,,,both,,,242.60,157.69,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7030,HCPCS,0250,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
COLLAR CERV L H3.25X23IN M DENS FOAM COT STOCK CVR LO,SUP-2196890,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.96,7.12,,,,,,,,,,,,,
MESH SURGICAL A TYPE 1.5 MM FOOT FOR CMF DISTRACTOR MANDIBLE,SUP-2842166,CDM,C1713,HCPCS,0278,RC,,,,both,,,3286.01,2135.91,,,,,,,,,,,,,
SUPPORT ANK TRICOT 7.75-8.5 IN SM VLY PROCARE DLX,SUP-2195733,CDM,L4350,HCPCS,0272,RC,,,,both,,,33.54,21.80,,,,,,,,,,,,,
BEARING TOE SM PHLANG MTL BK IMPL,SUP-2404750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
NAIL IM 11X250 MM ANK HINDFOOT REV ARTH W/ GUIDE JIG TI LTX,SUP-2875680,CDM,C1713,HCPCS,0278,RC,,,,both,,,8616.16,5600.50,,,,,,,,,,,,,
NUT ORTH DIA5MM RESIST SCR BK OUT STBL LOK,SUP-2347061,CDM,C1713,HCPCS,0278,RC,,,,both,,,1891.44,1229.44,,,,,,,,,,,,,
S/D BLADE94MMX2.0MM USR DRIVER LCKING,SUP-2499119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.39,342.80,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM TI NS,SUP-2863453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1479.98,961.99,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS REDUCTION UNIAXIAL STRL CD 559200023,SUP-2927813,CDM,C1713,HCPCS,0278,RC,,,,both,,,2.83,1.84,,,,,,,,,,,,,
CATHETER CV 3 LUMEN MED 7 FRX16 CM MULT MED,SUP-2214688,CDM,C1751,HCPCS,0278,RC,,,,both,,,137.66,89.48,,,,,,,,,,,,,
SET PIN MOD GLEN SYS,SUP-2418458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
DRILL SURG STEM SHT TIB KNEE ROTATING HINGE N MOD NXGN,SUP-2437384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.93,560.25,,,,,,,,,,,,,
BASEPLATE GLEN DIA29MM 15MM POST PRESSFIT AEQUALIS REVERSED,SUP-2388656,CDM,C1713,HCPCS,0278,RC,,,,both,,,6398.54,4159.05,,,,,,,,,,,,,
BIT DRILL L200MM OD4.8MM CANNULATED,SUP-2493566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
COMPONENT FEM PS 3 UNISX LT KNEE CEM STEMLESS SINGLE AXIS,SUP-2378102,CDM,C1776,CPT,0278,RC,,,,both,,,7245.86,4709.81,,,,,,,,,,,,,
PLATE BNE MESHED 26X26X1 MM SM GRID PLLA-PGA STRL RESORB XG,SUP-2461689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1561.96,1015.27,,,,,,,,,,,,,
ANCHOR FIX 60 MM AERO-LL,SUP-2732358,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.522,SUP-2860039,CDM,C1713,HCPCS,0278,RC,,,,both,,,39174.95,25463.72,,,,,,,,,,,,,
KIT FIX DIA10 MM ALL INSIDE STRL QUADLINK,SUP-2930405,CDM,C1713,HCPCS,0278,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
PLATE BNE L31MM 4 H S STL 1/4 TBLR CLLRD FOR 2.7MM SCR,SUP-2411321,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.99,134.54,,,,,,,,,,,,,
PLATE BNE,SUP-2499640,CDM,C1713,HCPCS,0278,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
VANCOMYCIN HCL 5 G IV SOLR,RX-143506,CDM,J3373,HCPCS,0636,RC,67457-0341-05,NDC,,both,1,UN,511.40,332.41,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM 0.035IN BENT PTFE FIX COR INQWIRE,SUP-2302700,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
SHEATH INTRO L81CM DIA8FR 0.032IN SL1 CRV TRANSSEPTAL BRAID,SUP-2357253,CDM,C1893,HCPCS,0272,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM CRANIOMAXILOFACIAL 3 LNG DOG BNE 15-7378X-12,SUP-2936397,CDM,C1713,HCPCS,0278,RC,,,,both,,,24190.56,15723.86,,,,,,,,,,,,,
WASHER ORTH L25MM FOR SIDEKCK EZ FRME EXT FIX,SUP-2400674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
MANIFOLD IV 2 PRT 200PSI BLOCK BODY RT ORIENTATION DISP,SUP-2301354,CDM,C1713,HCPCS,0278,RC,,,,both,,,14.70,9.55,,,,,,,,,,,,,
THUMB SCREW FOR WIRE GUIDE/,SUP-2828031,CDM,C1713,HCPCS,0278,RC,,,,both,,,661.60,430.04,,,,,,,,,,,,,
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-149780,CDM,J9155,HCPCS,0636,RC,55566-8403-01,NDC,,both,1,UN,2194.90,1426.68,,,,,,,,,,,,,
STEM FEM L200MM OD16MM NO CEM MOD,SUP-2265080,CDM,C1776,CPT,0278,RC,,,,both,,,8179.89,5316.93,,,,,,,,,,,,,
SPLINT WRIST FA RIGHT 7,SUP-2136568,CDM,L3809,HCPCS,0274,RC,,,,both,,,37.40,24.31,,,,,,,,,,,,,
SPHERE GLEN DIA 40 MM OFFSET 4 MM SHLDR RETAINING SCREW,SUP-2904146,CDM,C1776,CPT,0278,RC,,,,both,,,6488.81,4217.73,,,,,,,,,,,,,
POST HUM L32MM DIA12MM SHLDR TAPR HEMICAPOVO,SUP-2123537,CDM,C1776,CPT,0278,RC,,,,both,,,2841.70,1847.10,,,,,,,,,,,,,
KIT IMPL L CUST CRAN CMF,SUP-2363697,CDM,C1713,HCPCS,0278,RC,,,,both,,,40119.78,26077.86,,,,,,,,,,,,,
CATHETER EP ASYM 2-5 MM 5 MM 8 FRX110 CM HTD,SUP-2424670,CDM,C1733,HCPCS,0272,RC,,,,both,,,3309.56,2151.21,,,,,,,,,,,,,
PLATE BNE CALCANEAL 2.4/2.7/3.5 MM LT,SUP-2653733,CDM,C1713,HCPCS,0278,RC,,,,both,,,2385.55,1550.61,,,,,,,,,,,,,
GUIDEWIRE ENDO L250CM SAVARY-GILLIARD,SUP-2417513,CDM,C1769,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
RESERVOIR 100ML PC,SUP-2138964,CDM,C1813,HCPCS,0278,RC,,,,both,,,6462.12,4200.38,,,,,,,,,,,,,
HC Cta Neck/Carotid W & W/O Cont,PX-3517049800,CDM,70498,CPT,0351,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
FIBER LASER DVDF-200 DVI-SC CONV,SUP-2798104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3414.50,2219.42,,,,,,,,,,,,,
SYSTEM MIX BNE CEM ACCUMIX,SUP-2414254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
GRAFT VASC L45CM DIA4-7MM PTFE CBAS HEP SURF STD WALLED,SUP-2395785,CDM,C1768,CPT,0278,RC,,,,both,,,4060.02,2639.01,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY + 10 CC DBM,SUP-2632267,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
COIL EMB L4CM LOOP OD2MM OD0.020IN NIT STRTCH RESIST CRV,SUP-2323441,CDM,C1889,HCPCS,0278,RC,,,,both,,,5865.52,3812.59,,,,,,,,,,,,,
PLATE BNE 3.5X235 MM 18 HOLE SS LCP,SUP-2569330,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.28,364.83,,,,,,,,,,,,,
CATHETER PTCA L130CM BLLN L220MM DIA5MM SHTH 5FR GWIRE,SUP-2128365,CDM,C2623,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
ANCHOR SUT OD65MM 2 TWO MAXBRAID TI SCR SP CUT NDL PERM DBL,SUP-2212812,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
PLATE BONE L220MM THK3.7MM 12 H LT DSTL MEDL TIB TI LCK,SUP-2190884,CDM,C1713,HCPCS,0278,RC,,,,both,,,4488.00,2917.20,,,,,,,,,,,,,
LINER ACETABULARXL OD68MM ID32MM THK12.4MM 0DEG STD,SUP-2209703,CDM,C1776,CPT,0278,RC,,,,both,,,2024.83,1316.14,,,,,,,,,,,,,
SCREW BNE NLCK 2.7X9 MM NS DVR,SUP-2459031,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
HC X-Ray Os Calcis Min 2 Views,PX-3207365000,CDM,73650,CPT,0320,RC,,,,both,,,376.00,244.40,,,,,,,,,,,,,
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106760,CDM,J2003,HCPCS,0636,RC,63323-0491-57,NDC,,both,50,ML,83.40,54.21,,,,,,,,,,,,,
KIT TKR TIB POR CRUC RET FEM TIB HI DEMAND LEGION GEN II,SUP-2348038,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
GRAFT BNE 12MM WDG,SUP-2244475,CDM,C1713,HCPCS,0278,RC,,,,both,,,6006.73,3904.37,,,,,,,,,,,,,
PLATE BNE L 185 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 16 H,SUP-2933363,CDM,C1713,HCPCS,0278,RC,,,,both,,,3037.01,1974.06,,,,,,,,,,,,,
BUR SURG MED WAVED SPRL FOR CRANIOTOME HNDPC STRL DISP,SUP-2937167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
FILLER BONE VOID 3ML PUTTY HA NORIAN SRS,SUP-2341402,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
SCREW SET HD 1.5/2/2.5 MM,SUP-2607262,CDM,C1713,HCPCS,0278,RC,,,,both,,,9970.66,6480.93,,,,,,,,,,,,,
COIL L10CM OD5MM HELCL DETACH 18D SYS AZUR,SUP-2385414,CDM,C1889,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
NAIL IM L330MM DIA11MM STD TIB TI CANN LOK CEPHALOMEDULLARY,SUP-2368787,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PROSTHESIS OSS SHEEHY 0.13X5.5 MM INCUS REPL STRUT SS,SUP-2637815,CDM,L8613,CPT,0278,RC,,,,both,,,281.85,183.20,,,,,,,,,,,,,
KIT FILL 14ML FOR STNT GRFT SYS STNT OVATION PRIM,SUP-2217724,CDM,C1768,CPT,0278,RC,,,,both,,,2326.74,1512.38,,,,,,,,,,,,,
SET LD INTRO EVOLUTION RL L 40.6 CM OD 21 FR ID 13 FR CTRL,SUP-2169471,CDM,C1773,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
CATHETER GUID HEARTRAIL III L 100 CM DIA 6 FR 700 PSI IL4.5,SUP-2384864,CDM,C1887,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
NAIL IM TROCHANTERIC 9X265 MM STRL FITBONE,SUP-2875397,CDM,C1713,HCPCS,0278,RC,,,,both,,,105538.07,68599.75,,,,,,,,,,,,,
PROBE LASER 20GA STD STR TAPR TIP DISP ENDOPRB,SUP-2247212,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.86,274.86,,,,,,,,,,,,,
PLATE BNE LCK REG 1.5 MM 18 HOLE TI,SUP-2462150,CDM,C1713,HCPCS,0278,RC,,,,both,,,1674.41,1088.37,,,,,,,,,,,,,
BIT DRL CANN 2X120MM,SUP-2321601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
INSTRUMENT REPROC SEAL/DIVIDE LIGASURE SM JAW CRV TIP 7.4IN,SUP-2527601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.93,572.60,,,,,,,,,,,,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG PO TABS,RX-24216,CDM,6370000000,HCPCS,0637,RC,00904-7440-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE THK0.75MM 6 H RESRB POLYMER CRANIOMAXILLOFACIAL,SUP-2364978,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.55,330.56,,,,,,,,,,,,,
MESH SYNTH INGUINAL N ABSRB RECT POLYPR OVL FLAT SH 18CM,SUP-2265905,CDM,C1781,HCPCS,0278,RC,,,,both,,,135.52,88.09,,,,,,,,,,,,,
HINGE OUTBOARD FOR TRUELOK FIX SYS,SUP-2316081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1935.59,1258.13,,,,,,,,,,,,,
ELECTRODE LOOP 27FR WIRE DIA0.35MM BRN CUT ANG 1 STEM W/,SUP-2261182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,629.04,408.88,,,,,,,,,,,,,
PLATE BONE 3X2 H LCK BILAT GRID TRAPEOID HND DISP FOR 2MM,SUP-2267929,CDM,C1713,HCPCS,0278,RC,,,,both,,,1343.92,873.55,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 4-7 MM EPTFE LNG TAPR TW,SUP-2461570,CDM,C1768,CPT,0278,RC,,,,both,,,3177.77,2065.55,,,,,,,,,,,,,
PEG BONE FIXATION 2MM DIA 10MML COBALT CHROMIUM,SUP-2862336,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
SCREW BNE STD 2.7X16 MM STRL HALLU SNAP-OFF,SUP-2608917,CDM,C1713,HCPCS,0278,RC,,,,both,,,564.70,367.05,,,,,,,,,,,,,
KIT SPEC CART BX TRNSPRT CARTICEL 80006] VERICEL CORP],SUP-2392682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1934.24,1257.26,,,,,,,,,,,,,
NUT EXT FIX SPD NS,SUP-2863415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.56,309.76,,,,,,,,,,,,,
NAIL IM 8.25X225MM TIB HUM N LCK SLD TI ALTA,SUP-2363488,CDM,C1713,HCPCS,0278,RC,,,,both,,,1992.17,1294.91,,,,,,,,,,,,,
CATHETER DIAG STEER L CRV 2 5 2MM ELECTRD SPC OCTAPOLAR,SUP-2142291,CDM,C1730,HCPCS,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
DIVALPROEX SODIUM 125 MG PO CSDR,RX-27631,CDM,6370000000,HCPCS,0637,RC,55111-0532-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
RING FIX HRT MITRL 24 MM,SUP-2214189,CDM,C1889,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PLATE BNE L163MM 6 H NONSTERILE L PERIARTC PROX HUM S STL,SUP-2177808,CDM,C1713,HCPCS,0278,RC,,,,both,,,5067.43,3293.83,,,,,,,,,,,,,
CATHETER PICC 6FR L55CM GWIRE 80CM 3 LUMN PERIPH NIT WIRE CT,SUP-2117003,CDM,C1894,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC CLLGN MOZAIK,SUP-2431103,CDM,C9359,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
KIT BONE GRFT SUB SIDE DEL CANN COMPLT KNEE FOR,SUP-2207870,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
STEM HUM L55MM DIA11MM MIC SHLDR CO CHROM POR CEM PRESSFIT,SUP-2404547,CDM,C1776,CPT,0278,RC,,,,both,,,16773.88,10903.02,,,,,,,,,,,,,
ANCHOR SUT MINI SZ 2-0 BRAID COMP SUT W/ V5 L18IN DBL ARMED,SUP-2249349,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
RING EXT FIX DIA120 MM FULL TAB MONK RING,SUP-2898981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4654.27,3025.28,,,,,,,,,,,,,
IMPLANT OSS NOTCH 3X0.5 MM CENTER SHFT BEND FLANGE TI,SUP-2232512,CDM,L8613,CPT,0278,RC,,,,both,,,889.37,578.09,,,,,,,,,,,,,
PLATE BNE ULN TI RAYHACK,SUP-2535896,CDM,C1713,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
CATHETER DRAINAGE 8 FRX40 CM BILI,SUP-2303541,CDM,C1729,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
REVERS CA HUM HD 50/19,SUP-2123387,CDM,C1776,CPT,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 5MMW X12MML 0.4MM THK 0.6MM THK CUT INTRA,SUP-2605375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.64,244.82,,,,,,,,,,,,,
MESH SURG 19CM LEN 15CM W THK1MM SYN ABD N ABSRB OVL EXP,SUP-2125769,CDM,C1781,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
SCREW SPINAL LOCKING 3X14 MM FOR STERNAL PLATE TITANIUM,SUP-2838334,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.22,412.89,,,,,,,,,,,,,
SCREW BNE 35X16MM CORT TI G HEXADRIVE 15,SUP-2268361,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.84,187.10,,,,,,,,,,,,,
KNIFE 3722151 MYRINGOPLASTY 2545 DEG,SUP-2667295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,978.61,636.10,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA2.2 MM SM CANN STRL QFX,SUP-2932858,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.52,478.74,,,,,,,,,,,,,
INSERT TIB REV KNEE SYS POLYETH SZ 2 17MM PROVEN,SUP-2359242,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE L48MM 4X3 H L DST RAD VOLAR EXTRA ARTC S STL VAR,SUP-2184070,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.35,1514.08,,,,,,,,,,,,,
HC Endo Swallow Tst (Fees),PX-4449261200,CDM,92612,CPT,0444,RC,,,,both,,,437.00,284.05,,,,,,,,,,,,,
SPLINT IM M W4MM TI ALLOY MATRIXRIB,SUP-2181513,CDM,C1713,HCPCS,0278,RC,,,,both,,,2220.77,1443.50,,,,,,,,,,,,,
PLATE BNE L 75.2 X W 31 MM THK 1 MM SCREW DIA2 MM TI,SUP-2936170,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
KIT INFUS 6FR POLYUR CATH FOOTPRINT PEEL APART INTRO SIL FIL,SUP-2127759,CDM,C1788,HCPCS,0278,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
GRAFT VASC W1XL10CM THK6 PLY SYNTH CROSSLINKED ELAS FOR VASC - ORDER UOM BX,SUP-2172044,CDM,C1768,CPT,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
RING EXT FIX ID180MM ALUM HALF FOR TAY SPAT FRME ILIZ,SUP-2342970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7584.04,4929.63,,,,,,,,,,,,,
PLATE BNE TI ORTHOGNATHIC 5 PLATE CUSTOMIZED FACE ID,SUP-2883698,CDM,C1713,HCPCS,0278,RC,,,,both,,,30561.78,19865.16,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 4.25X4.25 IN FNGR W/ BLB RADLUC,SUP-2276773,CDM,L3933,HCPCS,0272,RC,,,,both,,,4.33,2.81,,,,,,,,,,,,,
PLATE BNE MESHED SM 0.6 MM MXLFCL NEURO STD PAT OUSIDE HOLE,SUP-2525645,CDM,C1713,HCPCS,0278,RC,,,,both,,,5094.96,3311.72,,,,,,,,,,,,,
PLATE BNE W12XL71MM THK1MM 4 H BILAT S STL SEMI TBLR LO,SUP-2184865,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7040,HCPCS,0250,RC,00264-7800-10,NDC,,both,500,ML,29.80,19.37,,,,,,,,,,,,,
DRILL TWST L 54 MM DIA1 MM STP 12 MM CHK NS DISP LEIBINGER,SUP-2883217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.90,250.18,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY AFOCUS II L 110 CM DIA 5,SUP-2491785,CDM,C1730,HCPCS,0272,RC,,,,both,,,734.41,477.37,,,,,,,,,,,,,
PLATE BNE LAPIDUS 3.5/4 MM DORS MEDL NS LTX,SUP-2857063,CDM,C1713,HCPCS,0278,RC,,,,both,,,7583.10,4929.01,,,,,,,,,,,,,
NEEDLE ENDO NON STRL ELITE REUSE,SUP-2747578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,905.54,588.60,,,,,,,,,,,,,
SEALANT TISS FIBRIN 5 CC W/ CTRL TIP EVICEL,SUP-2738904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14149.31,9197.05,,,,,,,,,,,,,
BIT DRILL TWST L43MM DIA1.1MM 5MM STP IQ SER FOR SYS,SUP-2136985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
KIT TROCHLEOPLASTY W/ 2.9MM BUR SL,SUP-2419177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SCREW BNE L10MM DIA42MM NONLOCKING GORILLA PLATING SYS R3CON,SUP-2321380,CDM,C1713,HCPCS,0278,RC,,,,both,,,463.15,301.05,,,,,,,,,,,,,
HC Repair Mouth Laceration,PX-4504083100,CDM,40831,CPT,0450,RC,,,,both,,,706.00,458.90,,,,,,,,,,,,,
PROBE ABLAT 90DEG ASPIR MULTIPORT BPLR RF 1 PC ELECTRD ERGO,SUP-2123447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BNE CRV 4.5X301 MM RT CNDYL 14 HOLE VA LCK STRL VALCP,SUP-2789867,CDM,C1713,HCPCS,0278,RC,,,,both,,,6950.83,4518.04,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 40 MM DIA20 MM SHTH 11 FR CATH L,SUP-2147042,CDM,C1876,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
SPLINT WRST XSM AD L8IN FOR 5 65IN L NYL LN FOAM PUL ON,SUP-2276661,CDM,L3908,HCPCS,0272,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
WASHER ORTH FOR 3.5MM SCR,SUP-2609149,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.61,367.65,,,,,,,,,,,,,
CEMENT BONE 40GM HI VISC PALACOS R,SUP-2239056,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CATHETER HAD L20CM OD14FR ACUTE VES INSRT KINK RESIST REM,SUP-2118063,CDM,C1752,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HC Intrvasc US Noncoronary 1st,PX-4023725200,CDM,37252,CPT,0402,RC,,,,outpatient,,,1485.00,965.25,,,,,,,,,,,,,
KIT PLT CONCENTRATOR DISP CAPTION,SUP-2344073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
NEEDLE ASPIR 22GA L2.4MM SHTH DIA1.52MM ENDO US EXPECT SLM,SUP-2418158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2546.54,1655.25,,,,,,,,,,,,,
ASPIRIN 81 MG PO CHEW,RX-680,CDM,6370000000,HCPCS,0637,RC,77333-0049-25,NDC,,both,1,UN,1.30,0.84,,,,,,,,,,,,,
DEVICE PESSARY SZ 6 83MM RNG W KNOB AND SUPP GEHRUNG,SUP-2417157,CDM,A4562,HCPCS,0274,RC,,,,both,,,112.66,73.23,,,,,,,,,,,,,
ST REPL BLADE/STRYKER 5071-201 19.5X86X1.27M,SUP-2199481,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
BASKET STONE RTRVL 24FR L120CM D11MM 3 WIRE O TIP PRD HELI,SUP-2730107,CDM,C1889,HCPCS,0278,RC,,,,both,,,634.00,412.10,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 9 FR GUIDEWIRE PERIPHERAL,SUP-2385684,CDM,C1894,HCPCS,0272,RC,,,,both,,,18.06,11.74,,,,,,,,,,,,,
BLADE REPROC SHV SERRAT STR SHAFT 11CM W/O TUBE 4MM,SUP-2653215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.51,171.28,,,,,,,,,,,,,
STAPLE BNE W10XL10MM NIT SHP MEM COMPRESSIVE FORC DISP,SUP-2399892,CDM,C1713,HCPCS,0278,RC,,,,both,,,3598.44,2338.99,,,,,,,,,,,,,
MESH HERN W7.5XL15CM POLYPR SYN FLAT L PORE MFIL,SUP-2125778,CDM,C1781,HCPCS,0278,RC,,,,both,,,126.67,82.34,,,,,,,,,,,,,
BEAM FIX L130MM DIA4.5MM ARTH,SUP-2223933,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L75CM DIA13MM CYL SPNL CRD 8 ELECTRD,SUP-2280218,CDM,C1778,HCPCS,0278,RC,,,,both,,,7529.72,4894.32,,,,,,,,,,,,,
SHEATH INTRO SILHOUETTE PEELWY L 30 CM DIA 9 FR GUIDEWIRE,SUP-2168315,CDM,C1892,HCPCS,0272,RC,,,,both,,,156.97,102.03,,,,,,,,,,,,,
PASSER SUT L162MM MIN CANN DIA6MM BITE D18MM STD PRELD,SUP-2340735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 180 MM FRZN,SUP-2294145,CDM,C1713,HCPCS,0278,RC,,,,both,,,3165.12,2057.33,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN CTRL SEMI FLX,SUP-2435597,CDM,L1630,HCPCS,0272,RC,,,,both,,,598.11,388.77,,,,,,,,,,,,,
GUIDEWIRE MOVABLE COR DSGN 0.038 INX150CM W/ J TIP 3MM,SUP-2355316,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
IMPLANT BRST 450CC DIA13.6CM P4.2CM SIL GEL SMOOTH RND MOD,SUP-2300347,CDM,C1789,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COGNIS W 6.17 X H 7.95 CM D 0.99 CM 72 GM,SUP-2149260,CDM,C1882,HCPCS,0275,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
HC Perc D-E Cor Revasc Chro Sin,PX-4810960700,CDM,C9607,CPT,0481,RC,,,,both,,,23915.00,15544.75,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),RX-40850049,CDM,2580000003,HCPCS,0258,RC,00338-0553-18,NDC,,both,100,ML,62.10,40.36,,,,,,,,,,,,,
FEMORAL STEM,SUP-2364225,CDM,C1776,CPT,0278,RC,,,,both,,,8978.83,5836.24,,,,,,,,,,,,,
BUR ENDOSCP SHAVER L 10 CM DIA2.9 MM SPD 5000 RPM RND STR,SUP-2901992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.78,446.41,,,,,,,,,,,,,
ALLOGRAFT BNE DEMINERALIZED CORTICAL 125-710 MIC 15 CC FD,SUP-2717750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.31,1479.60,,,,,,,,,,,,,
KIT CATH REPERFUSION 6FR L132CM 0.072IN W/ HI FLO ASPIR,SUP-2323555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SYSTEM HEARING AID 1 STG BAHA,SUP-2165027,CDM,L8614,HCPCS,0278,RC,,,,both,,,18563.68,12066.39,,,,,,,,,,,,,
GRAFT VASC STD WALL 5-8 MMX70 CM LNG TAPR REINF ADVANTA VXT,SUP-2470202,CDM,C1768,CPT,0278,RC,,,,both,,,1056.39,686.65,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC 5FR 55CM 1 LUMAN RVS TAPR PWR INJ W,SUP-2613366,CDM,C1751,HCPCS,0278,RC,,,,both,,,587.75,382.04,,,,,,,,,,,,,
BIT DRILL ARTHROSCOPIC 8MM DIA F/MENISCAL TRANSPLANTATION,SUP-2589297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2106.94,1369.51,,,,,,,,,,,,,
PROSTHESIS KNEE 7.5X18.5MM L STUD UNI FEM CE,SUP-2123697,CDM,C1776,CPT,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
SUPPORT ORTH SM NYL LEG LTWT XCELTRAX AIR,SUP-2197147,CDM,L4370,HCPCS,0272,RC,,,,both,,,78.06,50.74,,,,,,,,,,,,,
HEAD FEM C TAPR 0+ MM 36 MM OFFSET PRIMARY ALUMINA CERM,SUP-2368527,CDM,C1776,CPT,0278,RC,,,,both,,,4410.44,2866.79,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP DOME 5.5 FR 0.021 IN 2.8 MM OMNI,SUP-2737409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
GUIDEWIRE ORTH FLUT 2.8X450 MM SLIPPED EPIPHYSIS SS NS LCP,SUP-2863441,CDM,C1769,HCPCS,0272,RC,,,,both,,,247.15,160.65,,,,,,,,,,,,,
COUNTERSINK SURG OD5.5MM HD SGL USE MONSTER,SUP-2320966,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
CATHETER CV KT 7 FRX16 CM 20 GA 3L PRESSURE INJ RW INTRO,SUP-2763403,CDM,C1751,HCPCS,0278,RC,,,,both,,,219.17,142.46,,,,,,,,,,,,,
HYPERFORM 7X15 MM BLLN SYSTEM,SUP-2676312,CDM,C2628,HCPCS,0272,RC,,,,both,,,5630.02,3659.51,,,,,,,,,,,,,
APEX BLUNT HALF PIN 5MM 180 X 20MM,SUP-2703151,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.98,506.99,,,,,,,,,,,,,
SET ART LN CATH 4FR L15CM STR BASEPLT W/ GWIRE INTRO AND,SUP-2167823,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
CAP KNEE W/ VE SURF AND PAT PERSONA,SUP-2212228,CDM,C1776,CPT,0278,RC,,,,both,,,15112.82,9823.33,,,,,,,,,,,,,
"HC So Herpes Simplex, Type 2",PX-3028669666,CDM,86696,CPT,0302,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
IMPLANT THYROPLASTY VOCAL CRD 12 M STRL MONTGOMERY,SUP-2141839,CDM,L8509,HCPCS,0274,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC TIB,SUP-2366800,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MESH HERN W20XL30CM OPN TISS SEPARATING PHYSIOMESH,SUP-2219748,CDM,C1781,HCPCS,0278,RC,,,,both,,,5652.63,3674.21,,,,,,,,,,,,,
KIT IR PWR INJ PICC SGL LUMN PASV VLV W/ 145CM WIRE 5 FRX7,SUP-2117125,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 12X12X12 MM DBM PUROS,SUP-2684559,CDM,C1713,HCPCS,0278,RC,,,,both,,,5030.28,3269.68,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 7MM SUPER BAYONET 201676,SUP-2848939,CDM,C1889,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
GUIDEWIRE ORTH L6IN DIA1.6MM PART THRD TIP FOR CANN SCR,SUP-2410065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,51.75,33.64,,,,,,,,,,,,,
CANNULA OPHTH COURT X BINKHORST,SUP-2113485,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BNE LCK 1.5X33X1 MM HND 14 HOLE WEB VA TI NS,SUP-2181013,CDM,C1713,HCPCS,0278,RC,,,,both,,,1342.07,872.35,,,,,,,,,,,,,
CATHETER THROMCTMY 7FR L145CM STD ALONE EXPORT,SUP-2295351,CDM,C1769,HCPCS,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
NAIL INTRMDLLRY CNNLTD 20MM DIA 100 POLY L LCTC ACID HELI RS,SUP-2639522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
BRACE KNEE MCL LCL EC HNG NEOPRENE W POPLITEAL PAT UNIV,SUP-2196414,CDM,L1810,HCPCS,0272,RC,,,,both,,,119.48,77.66,,,,,,,,,,,,,
COLLAR CERV ADJ MED 20X3 IN COTTON FOAM PREMIERPRO REUSE,SUP-2424885,CDM,L0120,HCPCS,0272,RC,,,,both,,,12.78,8.31,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 8 MM EPTFE FLX STD WALL RING,SUP-2761484,CDM,C1768,CPT,0278,RC,,,,both,,,3228.27,2098.38,,,,,,,,,,,,,
COUNTERSINK SURG DIA3.5/4MM,SUP-2123101,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
L CONN PL 17 HLS 335MM LG,SUP-2853456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2537.15,1649.15,,,,,,,,,,,,,
OSTEOTOME ACET 46MM,SUP-2364386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1089.89,708.43,,,,,,,,,,,,,
PLATE EXT FIX 4 H THRD CONN MRI CONDITIONAL FOR DISTR,SUP-2179152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,293.02,190.46,,,,,,,,,,,,,
ANCHOR SUT NO 2-0 V-5 DRL BIT QUICKANCHR + MINILOK,SUP-2249373,CDM,C1713,HCPCS,0278,RC,,,,both,,,3055.22,1985.89,,,,,,,,,,,,,
FILLER BNE GRFT L 45 X W 20 X H 7 MM DEMINERALIZED CANC SHT,SUP-2894878,CDM,C1713,HCPCS,0278,RC,,,,both,,,7269.10,4724.91,,,,,,,,,,,,,
RESERVOIR SHUNT OD14MM THK4.8MM SM TI FLSH LO PROF RADPQ,SUP-2108708,CDM,C1729,HCPCS,0272,RC,,,,both,,,887.84,577.10,,,,,,,,,,,,,
HC Chng Perc Tube/Cath With Cont,PX-3207598400,CDM,75984,CPT,0320,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
HC So 17-Hydroxyprogesterone,PX-3018349866,CDM,83498,CPT,0301,RC,,,,inpatient,,,553.00,359.45,,,,,,,,,,,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,0636,RC,10019-0120-39,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L50MM DIA3.5MM PROX FEM CANN T15 HEXALOBE PEDILOC,SUP-2318568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1548.02,1006.21,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP LG 8 IN LT WRST COCK UP ELASTIC,SUP-2108133,CDM,L3809,HCPCS,0274,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
HC Myelogram Lumbar,PX-3616230400,CDM,62304,CPT,0361,RC,,,,inpatient,,,3892.00,2529.80,,,,,,,,,,,,,
KETOCONAZOLE 200 MG PO TABS,RX-10369,CDM,6370000000,HCPCS,0637,RC,64380-0827-06,NDC,,both,1,UN,4.80,3.12,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX8 MM INDWL ESOPH FLANGE BLOM-SINGER,SUP-2242399,CDM,L8509,HCPCS,0274,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
GRAFT HUM TISS DISC 16 MM REP AMNIO TISS MEMBRN,SUP-2423432,CDM,C1762,CPT,0278,RC,,,,both,,,1557.44,1012.34,,,,,,,,,,,,,
PLATE SPNL Z 8 MM CLUTCH,SUP-2762333,CDM,C1713,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
SCREW VA LCK 2.4X8MM STARDRIVE STRL,SUP-2546111,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.09,284.76,,,,,,,,,,,,,
REAMER SURG DIA9MM PAT FLEX INTERCHANGEABLE HD W/ END CUT,SUP-2343580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,841.39,546.90,,,,,,,,,,,,,
ZIPRASIDONE HCL 80 MG PO CAPS,RX-29781,CDM,6370000000,HCPCS,0637,RC,68084-0106-09,NDC,,both,1,UN,12.50,8.12,,,,,,,,,,,,,
TUNNELER NEUROSTIMULATOR L28CM FOR SPNL CRD STIM SYS,SUP-2138849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SCREW SPNL 2PK ST 3.5X15 MM MINIP DIVERGENCE,SUP-2632042,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
INTRODUCER SHTH KT 018 5 FRX10 CM 40 CM 21 GAX7 CM NIT VSI,SUP-2763444,CDM,C1894,HCPCS,0272,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
PROBE ENDOSCP BPLR 7 FR 2 GENRTR PLUG QUICKSILVER,SUP-2737102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
STRAP SELF ADH BGE 1X18IN D RNG,SUP-2324798,CDM,L3908,HCPCS,0274,RC,,,,both,,,10.86,7.06,,,,,,,,,,,,,
COVER DOPP SHTH W/ 20ML US GEL STRL 3 1/2INX12IN,SUP-2308232,CDM,C1894,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
BLADE SHV L L13CM DIA42MM 15DEG FULL RAD RESECT PREBENT,SUP-2167049,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.79,149.36,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA 7 MM EPTFE STR STD WALL,SUP-2396192,CDM,C1768,CPT,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
PLATE BNE THK0.8MM UNIV 6X2 H CRANIOMAXILLOFACIAL TI 3D LOK,SUP-2366256,CDM,C1713,HCPCS,0278,RC,,,,both,,,1883.00,1223.95,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.512,SUP-2860194,CDM,C1713,HCPCS,0278,RC,,,,both,,,30349.98,19727.49,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 30 HOLE SS NS LCP,SUP-2799226,CDM,C1713,HCPCS,0278,RC,,,,both,,,3890.84,2529.05,,,,,,,,,,,,,
MESH HERN 20CM WHT COMP RND MFIL POLY W/ ABSRB CLLGN FLM,SUP-2173620,CDM,C1781,HCPCS,0278,RC,,,,both,,,4415.53,2870.09,,,,,,,,,,,,,
ROD SPNL ANTR RT SMOOTH S STL 5.0MM DIA 440MM LEN,SUP-2290520,CDM,C1713,HCPCS,0278,RC,,,,both,,,2697.26,1753.22,,,,,,,,,,,,,
SPACING 115CM LEN 7 F DEFL CRISTA CATH 20 POLE 1-3-1 PR,SUP-2248715,CDM,C1733,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLUG ACET DOME H CONTINUUM,SUP-2203894,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CANNULA ARTHSCP L75MM OD8.5MM RIG DISP AQUALOC,SUP-2212793,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
INFUSION PUMP KIT PAIN 1 IN CTRL CATH PAINBUSTER ON-Q PM032] HALYARD SALES LLC FKA I-FLOW],SUP-2236841,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY GLUTEAL ISCHIAL WT BEAR,SUP-2435672,CDM,L2500,HCPCS,0272,RC,,,,both,,,885.95,575.87,,,,,,,,,,,,,
GRAFT HUM TISS BNE BLOCK 65-95 MM 20X10-12 MM FLEXIGRAFT,SUP-2740877,CDM,C1762,CPT,0278,RC,,,,both,,,6165.39,4007.50,,,,,,,,,,,,,
ALLOGRAFT HUM TISS POST TIBIALIS ASEP DBL STRND,SUP-2422330,CDM,C1762,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
STEM HUM CEM STD UNIV 15X115 MM REV W/ ALIGN HOLE TI PLASMA,SUP-2431683,CDM,C1776,CPT,0278,RC,,,,both,,,5972.28,3881.98,,,,,,,,,,,,,
ELECTRODE ES 24FR L LOOP 12 16DEG PLSM LOOP HF RESECTION,SUP-2436281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.83,1040.54,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.544,SUP-2860061,CDM,C1713,HCPCS,0278,RC,,,,both,,,48841.76,31747.14,,,,,,,,,,,,,
PLATE BNE RADIAL DSTL SET PERI-LOC,SUP-2351351,CDM,C1713,HCPCS,0278,RC,,,,both,,,25193.38,16375.70,,,,,,,,,,,,,
HC Ribs Unilateral 2 Views,PX-3207110000,CDM,71100,CPT,0320,RC,,,,both,,,497.00,323.05,,,,,,,,,,,,,
NAIL IM L300MM DIA9MM NONSTERILE DK BLU TIB TI LCK UNREAMED,SUP-2192774,CDM,C1713,HCPCS,0278,RC,,,,both,,,3778.55,2456.06,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.141X9 IN THRD SS NS STEINMANN,SUP-2791388,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.14,52.74,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 45 CM DIA 7 FR CRV BEND 22 MM DIL L,SUP-2616225,CDM,C1766,CPT,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X200 MM FRZN GAM GRACILIS TEND,SUP-2866908,CDM,C1762,CPT,0278,RC,,,,both,,,1959.36,1273.58,,,,,,,,,,,,,
RETRACTOR ENDOSCOPIC HAND FREE INTRACORPOREAL TRIO,SUP-2880420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct Ea Addl 15 Mins|OP SPEECH LANGUAGE SERVICE|DOCUMENTATION ON FILE,PX-4309713000,CDM,97130,CPT,0430,RC,,,GN|KX,outpatient,,,186.00,120.90,,,,,,,,,,,,,
KIT NEUROSTIMULATOR PT PRGMR INCLUDE REMOT CTRL HOLSTER,SUP-2141948,CDM,C1787,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
AZACITIDINE 100 MG IJ SUSR (MIXTURES ONLY),RX-1150427,CDM,J9025,HCPCS,0636,RC,71288-0115-30,NDC,,both,1,UN,129.60,84.24,,,,,,,,,,,,,
PLANER SURG FACE IO FIX SYS,SUP-2400072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
BIT DRL DIA 4.3 MM LNG AO QC STRL DISP TRIGEN MAX,SUP-2932881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,851.57,553.52,,,,,,,,,,,,,
FIBER LASER HOLM 273 M FOR USE W/ SMA-905 RED SMARTSYNC,SUP-2835954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.82,592.03,,,,,,,,,,,,,
CATHETER DRNGE 10.2FR L50CM DIA0.038IN HYDRPHLC RADPQ BND,SUP-2168696,CDM,C1729,HCPCS,0272,RC,,,,both,,,250.76,162.99,,,,,,,,,,,,,
PLATE BNE L73MM 10 H BILAT S STL LOK COMPR LO PROF FOR 2MM,SUP-2186310,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.58,428.08,,,,,,,,,,,,,
HC Chloride Bld,PX-3018243500,CDM,82435,CPT,0301,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
GRAFT STENT 18X33 MM ABD AORT TALENT XCELERANT,SUP-2429839,CDM,C1768,CPT,0278,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
GUIDE PIN ORTH 2.4X450 MM,SUP-2766035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 X W 4 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881925,CDM,C1762,CPT,0278,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
TRIAL KNEE SPACER SM MED LG SZ SET STRL DISP COPAL EXCHANGE,SUP-2905435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY AFOCUS L 110 CM DIA 5 FR TIP L 20,SUP-2141326,CDM,C1730,HCPCS,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
PLATE BNE THK06MM 16 H TI CRAN MESH MIC RECT FOR 15MM SCR,SUP-2262702,CDM,C1713,HCPCS,0278,RC,,,,both,,,666.03,432.92,,,,,,,,,,,,,
NAIL IM L340MM OD15MM FEM N LCK CANN,SUP-2205961,CDM,C1713,HCPCS,0278,RC,,,,both,,,15743.96,10233.57,,,,,,,,,,,,,
SET ORTH INSTR STRL DISP ULTRABRIDGE,SUP-2883091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
ALLOGRAFT BNE 1-4 MM 15 CC FD CORTICAL CANC,SUP-2867102,CDM,C1762,CPT,0278,RC,,,,both,,,850.16,552.60,,,,,,,,,,,,,
BASEPLATE TIB 2 R MED L LAT PC UNI HI FLX NXGN,SUP-2342146,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
RELOAD STPL 4.8MM L60MM 0DEG UNIV TISS GRN TI NONCUTTING,SUP-2283419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.01,380.26,,,,,,,,,,,,,
PLATE BONE L199MM 12 H BILAT COMPR STR BROAD FOR 4.5MM SCR,SUP-2343800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2464.05,1601.63,,,,,,,,,,,,,
DEVICE DEL H2O VPR THER W/CABLE SYR SPIKE ADAPTOR VI REZUM,SUP-2432115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4033.02,2621.46,,,,,,,,,,,,,
PLATE BONE 32MML STNLSS STEEL L SHPD RIGHT F/2.7MM SCREW MIN,SUP-2493338,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.89,113.03,,,,,,,,,,,,,
PLATE BNE STR 1.5X0.6 MM MIDFACE 24 HOLE W/ TAB TI STRL,SUP-2486413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1141.70,742.10,,,,,,,,,,,,,
PLATE BONE STRUT 2 MM 2X18 HOLE RAPID RESORBABLE STERILE RAP,SUP-2838596,CDM,C1713,HCPCS,0278,RC,,,,both,,,2428.79,1578.71,,,,,,,,,,,,,
HC Bladder Scan,PX-4505179800,CDM,51798,CPT,0450,RC,,,,outpatient,,,191.00,124.15,,,,,,,,,,,,,
NITROGLYCERIN IV BOLUS,RX-4081329,CDM,J2305,HCPCS,0636,RC,00338-1049-02,NDC,,both,250,ML,129.40,84.11,,,,,,,,,,,,,
SYSTEM CLOSURE VASC KNOT TYNG PER CLOSE CLINCH,SUP-2241108,CDM,C1760,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
CONNECTOR SPNL SM TI OFFSET LOK SCR FOR 5.5MM ROD TSRH-3D,SUP-2289993,CDM,C1713,HCPCS,0278,RC,,,,both,,,2875.77,1869.25,,,,,,,,,,,,,
KIT CTRL VEN 2 LUMN W/ ARWGRD + BLU ACCS DEV INTEGR HEMSTAS,SUP-2383304,CDM,C1751,HCPCS,0278,RC,,,,both,,,435.83,283.29,,,,,,,,,,,,,
CATHETER THOR 24FR L22IN PVC 5 EYELET STR ATRAUM,SUP-2227431,CDM,C1729,HCPCS,0272,RC,,,,both,,,22.95,14.92,,,,,,,,,,,,,
SHOE ORTHOT EXISTING SLD STIRRUP TRANSFER,SUP-2435747,CDM,L3620,HCPCS,0272,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
GRAFT BNE SUB 30ML TRICALCIUM PHSPTE GRAN CONT RESRB,SUP-2255617,CDM,C1763,HCPCS,0278,RC,,,,both,,,4060.02,2639.01,,,,,,,,,,,,,
MATRIX BIO SZ 300-540 SQCM FISH SKIN DERMAL MESHED 21 SINGLE,SUP-2909392,CDM,Q4158,HCPCS,0636,RC,,,,both,,,32499.00,21124.35,,,,,,,,,,,,,
TEMPLATE SZ TRIANG MESH 30 MM ORBIT FLR ALUM RESORB-X LF,SUP-2466263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1030.17,669.61,,,,,,,,,,,,,
ROD ORTH ALIGN FOR BIOARCH SUBTALAR IMPL SYS,SUP-2401366,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.543,SUP-2860060,CDM,C1713,HCPCS,0278,RC,,,,both,,,57750.25,37537.66,,,,,,,,,,,,,
COIL DETACH SFT SR 2MM HELI COIL DIA 1CM INTRO GDC 10,SUP-2365650,CDM,C1889,HCPCS,0278,RC,,,,both,,,2128.76,1383.69,,,,,,,,,,,,,
LIFT OTOLOGICAL H 1 MM BCI 602 STRL DISP BONEBRIDGE,SUP-2905147,CDM,L8690,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER INTVASC OCCL Q50 + L 65 CM L 40 MM 10-50 mm 3-60cc,SUP-2691406,CDM,C2628,HCPCS,0272,RC,,,,both,,,2125.78,1381.76,,,,,,,,,,,,,
IMPLANT L9MM OD4MM ABUTMENT FIX CONN SCR BONE ANCHORED,SUP-2319881,CDM,L8690,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 150 MCG PO TABS,RX-4425,CDM,6370000000,HCPCS,0637,RC,51079-0445-01,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
INSERT TIB PS 3 13 MM KNEE,SUP-2391470,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST COUNT REINF PLAS,SUP-2435729,CDM,L3430,HCPCS,0272,RC,,,,both,,,453.70,294.90,,,,,,,,,,,,,
PLATE BONE L90MM NONCOMPRESSION FRAG,SUP-2364908,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.07,310.75,,,,,,,,,,,,,
CATHETER ABLATN D-F CRV N NAVIGATIONAL EZ STEER THERMOCOOL,SUP-2257365,CDM,C1732,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2.5 MM RECON PT SPEC TI,SUP-2860105,CDM,C1713,HCPCS,0278,RC,,,,both,,,24600.02,15990.01,,,,,,,,,,,,,
CATHETER VLV MAPPER STD CRV EXT DSTL SHFT QPLR 2.5MM SPC 8MM,SUP-2139726,CDM,C1733,HCPCS,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
CATHETER ETER PICC 19FR 2 LUMN ARGY,SUP-2173951,CDM,C1751,HCPCS,0278,RC,,,,both,,,334.57,217.47,,,,,,,,,,,,,
PLATE BNE 3.5X97 MM 8 HOLE SS DCP,SUP-2569140,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.59,178.48,,,,,,,,,,,,,
STENT ENDOPROS W/ HOLES L8CM DIA10MM CATH L40CM BILI PERC NIT EPTFE,SUP-2396666,CDM,C1874,HCPCS,0278,RC,,,,both,,,9639.80,6265.87,,,,,,,,,,,,,
CAPLACIZUMAB-YHDP 11 MG IJ KIT,RX-145241,CDM,C9047,HCPCS,0636,RC,58468-0225-01,NDC,,both,1,UN,25286.50,16436.22,,,,,,,,,,,,,
ANCHOR SUTURE WITH THREE NO 2 HI FI SUTURES WITH NEEDLES 5.0,SUP-2828569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.03,752.07,,,,,,,,,,,,,
SET INTRO OD7GA VISILOC FOR ENCOR MRI PRB,SUP-2126857,CDM,C1894,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PACEMAKER CARD AD PERM SGL CHMBR NOT MRI COMPATIBLE STD,SUP-2356708,CDM,C1786,HCPCS,0275,RC,,,,both,,,8996.10,5847.46,,,,,,,,,,,,,
COUPLER ANAS 4 MM DOPPLER 20 MHZ WHT DISP FLO CPLR,SUP-2900202,CDM,C1889,HCPCS,0278,RC,,,,both,,,3444.58,2238.98,,,,,,,,,,,,,
BUR SURG HUB III CRANIOTOME CUT SPRL STRL DISP HI-LINE XS,SUP-2929046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.97,255.43,,,,,,,,,,,,,
ENDCAP SPNL DIA6.35MM TI TYPHOON MNRCH,SUP-2254528,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
FORCEP ELECSURG SPETZLER MALIS 0.5 MM 20 CM 2IRRIGATING BPLR,SUP-2859775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1370.23,890.65,,,,,,,,,,,,,
MESH HERN RECTANGULAR 25X40 CM PREPERITONEAL ENFORM,SUP-2539550,CDM,C1781,HCPCS,0278,RC,,,,both,,,41780.84,27157.55,,,,,,,,,,,,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,0636,RC,00169-7202-01,NDC,,both,1,UN,16579.00,10776.35,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X5 H BILAT HND T SHP NONCOMPRESSION,SUP-2267878,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.31,450.65,,,,,,,,,,,,,
ANCHOR SUTURE HI STRENGTH 2/1/2000 W/ NDL ORTHOCORD,SUP-2176892,CDM,C1713,HCPCS,0278,RC,,,,both,,,591.45,384.44,,,,,,,,,,,,,
ENDCAP SPNL 4- DEG 30X16X16 MM TI X-CORE 2,SUP-2559806,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 15 CM DIA 30 MM CATH DIA 0.038 IN,SUP-2749446,CDM,C1889,HCPCS,0278,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
COIL EMB L30CM DIA0.034IN LOOP DIA15MM DETACH 18 AZUR,SUP-2385427,CDM,C1889,HCPCS,0278,RC,,,,both,,,3328.40,2163.46,,,,,,,,,,,,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-27696,CDM,6370000000,HCPCS,0637,RC,50742-0505-01,NDC,,both,1,UN,72.80,47.32,,,,,,,,,,,,,
PROSTHESIS OSS TOT L 7 MM PART L 3.65 MM DIA1.14 MM HD DIA 3,SUP-2902042,CDM,L8613,CPT,0278,RC,,,,both,,,1602.19,1041.42,,,,,,,,,,,,,
GRAFT BNE SUB 15ML 100X25X6MM MTRX OSTEOCONDUCTIVE MOZAIK,SUP-2244489,CDM,C9362,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
"HC Aerosol, Hhn, Mdi, Ippb",PX-4109464000,CDM,94640,CPT,0410,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
KIT INTRO 14FR SHTH DIL GWIRE PUNC NDL IMPELLA CP,SUP-2106268,CDM,C1894,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW BNE ST 1.9X5 MM EMGCY AXS 5PK,SUP-2421797,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.53,199.89,,,,,,,,,,,,,
WASHER LCK M6 INBONE,SUP-2494978,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
CHIPS BNE GRFT 15CC 1-4MM ALLGRFT CANC FRZ DRY PRESERVATION,SUP-2293747,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.96,760.47,,,,,,,,,,,,,
BELT RIB ELAS FOAM FEM UNIV 6IN,SUP-2194538,CDM,L0220,HCPCS,0274,RC,,,,both,,,30.21,19.64,,,,,,,,,,,,,
SCREW BONE LOCKING 2X12 MM MANDIBULAR SELFTAPPING 20/PK TITA,SUP-2842331,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.52,309.09,,,,,,,,,,,,,
HC Treat Hip Dislocation,PX-4502726600,CDM,27266,CPT,0450,RC,,,,both,,,4794.00,3116.10,,,,,,,,,,,,,
ALLOGRAFT BNE INJ 20 CC IGNITE PWR MIX,SUP-2759597,CDM,C1713,HCPCS,0278,RC,,,,both,,,7910.13,5141.58,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X3 H L HND L SHP NONCOMPRESSION GRID,SUP-2267882,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ELECTRODE ABLAT TUMOR RF RITA UNIBLATE CT COMPATIBLE 17 GA 5,SUP-2118725,CDM,C1713,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
WASHER ORTH DIA13MM TI FOR 6.7MM SCR,SUP-2123199,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PIN EXT FIX HALF 3X70 MM 12 MM SD ST NS LTX,SUP-2862039,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.67,176.59,,,,,,,,,,,,,
KIT SONIC ANCHOR FORCE FIB 2.5X10MM 2 0,SUP-2488013,CDM,C1713,HCPCS,0278,RC,,,,both,,,1016.36,660.63,,,,,,,,,,,,,
HC Perq Transcath Cls Paravalvr Leak Each Occls Dev,PX-4819359200,CDM,93592,CPT,0481,RC,,,,outpatient,,,4113.00,2673.45,,,,,,,,,,,,,
SCREW BNE L11MM DIA2MM CORT HND FT TI TRILOK APTUS,SUP-2268147,CDM,C1713,HCPCS,0278,RC,,,,both,,,570.85,371.05,,,,,,,,,,,,,
PLATE BNE L135MM THK3.8MM 8 H BILAT S STL NAR DYN COMPR FOR,SUP-2185208,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.65,147.97,,,,,,,,,,,,,
PROSTHESIS OSS GROTE INCUS 1.5X1.5X6 MM 0.83 MM STAIR STP HA,SUP-2637867,CDM,L8613,CPT,0278,RC,,,,both,,,1304.54,847.95,,,,,,,,,,,,,
CONNECTOR SPNL PARL 10 MM TOP LOADING/CLOSED MARINER OUTRIG,SUP-2709832,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
HC Surgery Level 4 Addtl 15min,PX-3600000014,CDM,3600000014,LOCAL,0360,RC,,,,both,,,3551.00,2308.15,,,,,,,,,,,,,
CATHETER GUID ANGLED 018IN 5 FRX135 CM TRAILBLAZER,SUP-2280517,CDM,C1887,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
TUBE TRACH CUF AD 7X10.6X120 MM SIL BIVONA TTS HYPRFLX,SUP-2352023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,542.72,352.77,,,,,,,,,,,,,
CABLE SPNL DBL LOOP,SUP-2327660,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
CEFAZOLIN SODIUM-DEXTROSE 2-3 GM-%(50ML) IV SOLR,RX-143625,CDM,J0690,HCPCS,0636,RC,00264-3105-11,NDC,,both,1,UN,84.90,55.18,,,,,,,,,,,,,
"HC Ventricular Puncture,Prev Burr Hole",PX-3616102600,CDM,61026,CPT,0361,RC,,,,both,,,744.00,483.60,,,,,,,,,,,,,
INSERT TIB REPL HD N-K II,SUP-2449214,CDM,C1776,CPT,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
BLADE SCREWDRIVER T7 AO,SUP-2691425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.98,542.09,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.125X9 IN SS NS STEINMANN,SUP-2791821,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.88,18.12,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA 3.5 MM LCK FOR PLATE NS ORTHOLOC 3DI,SUP-2900505,CDM,C1713,HCPCS,0278,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
SYSTEM TRAC L ADJ OPN BK HALO RNG COMPLT C GRAPHITE TI SKULL,SUP-2328131,CDM,L0810,HCPCS,0274,RC,,,,both,,,7837.44,5094.34,,,,,,,,,,,,,
HC MRI Face Neck Eye WO Contrast,PX-6107054000,CDM,70540,CPT,0610,RC,,,,inpatient,,,4451.00,2893.15,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 6MM STR STD WALL SLDE GDS,SUP-2669690,CDM,C1768,CPT,0278,RC,,,,both,,,1286.21,836.04,,,,,,,,,,,,,
ANCHOR SUTURE MORPHIX XT 3.5MM W/2-USP #2 DOUBLE-ARMED,SUP-2878657,CDM,C1713,HCPCS,0278,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7519,SUP-2525324,CDM,C1769,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
GRAFT BNE 2.5 CC CURRENT,SUP-2644309,CDM,C1713,HCPCS,0278,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
MASK CPAP LG VITERA,SUP-2423088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
BUR SURG OD20MM M DMND RND N FLUT ST TPS,SUP-2367429,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.35,209.53,,,,,,,,,,,,,
EXTRACTOR STONE BSKT 0.4 MM 4 WIR HNDL ENDOSCP STRL DISP,SUP-2773255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1060.10,689.06,,,,,,,,,,,,,
KIT INTCRAN PRSS MON AD DISP,SUP-2243739,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
NEEDLE CENTESIS 19GA CATH 5FR 10CM 4 SIDEPRT FOR,SUP-2168453,CDM,C1729,HCPCS,0272,RC,,,,both,,,46.41,30.17,,,,,,,,,,,,,
GRAFT BNE WDG 5 MM COTTON TITAN 3-D,SUP-2421813,CDM,C1713,HCPCS,0278,RC,,,,both,,,6539.05,4250.38,,,,,,,,,,,,,
SCREWDRIVER SURG DISPOSABLE N CANN NAVIGUS,SUP-2284447,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
MESH DERM REP W10XL20CM SURGIMEND PRS,SUP-2243678,CDM,C9360,HCPCS,0278,RC,,,,both,,,22294.00,14491.10,,,,,,,,,,,,,
SIZER BRST 325CC DIA115CM P48CM COHESIVE I SIL GEL SMOOTH,SUP-2300854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
FOOTPLATE SHOE W109XH114XL140MM ID08MM TI DORNHOFFER,SUP-2232503,CDM,L8613,CPT,0278,RC,,,,both,,,417.59,271.43,,,,,,,,,,,,,
SCREW BONE L26MM DIA4.5MM CORT ST FULL THRD HEX HD,SUP-2342652,CDM,C1713,HCPCS,0278,RC,,,,both,,,26.22,17.04,,,,,,,,,,,,,
GUIDEWIRE VASC SAFESEPT L 135 CM DIA 0.014 IN NIT,SUP-2159466,CDM,C1769,HCPCS,0272,RC,,,,both,,,692.68,450.24,,,,,,,,,,,,,
HC MRI-Pelvis WO & W Contrast,PX-6147219700,CDM,72197,CPT,0614,RC,,,,both,,,5187.00,3371.55,,,,,,,,,,,,,
BLADE SURG L80MM DIA105MM NONSTERILE TI CANN FEN HELI G,SUP-2180771,CDM,C1713,HCPCS,0278,RC,,,,both,,,1839.63,1195.76,,,,,,,,,,,,,
CATHETER KIT 3L 7 FRX16 CM CV MULT LUMEN SPRING WIRE LL,SUP-2435362,CDM,C1751,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
BIT DRL L16MM OD8MM BIOABSRB SURTAC,SUP-2341293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
STENT PERIPH EVERFLEX L 20 MM DIA 6 MM CATH L 80 CM SHTH 5,SUP-2172884,CDM,C1725,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
LINER ACET HIP IPOLYSE GRP D 36MM +0 FC,SUP-2165913,CDM,C1776,CPT,0278,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
GRAFT BNE SPACER 5X3.4 MM MATRISPINE,SUP-2264618,CDM,2780000010,LOCAL,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM SZ 2-0 CRV 26 MM STR 89 MM SS WHT,SUP-2101191,CDM,2720000010,LOCAL,0272,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
SHEATH INTFR SCR L TIB TCP/PLA BIOABSRB BIO-INTRAFIX,SUP-2249562,CDM,C1776,CPT,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
HC So1 Fluorescent Antibody Screen,PX-3028625567,CDM,86255,CPT,0302,RC,,,,outpatient,,,588.00,382.20,,,,,,,,,,,,,
HC Removal Aortic Assist Device,PX-7613396800,CDM,33968,CPT,0761,RC,,,,both,,,5920.00,3848.00,,,,,,,,,,,,,
ROD EXT FIX L100MM GRAD TELSCP FOR ILIZ SYS,SUP-2342266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6715.99,4365.39,,,,,,,,,,,,,
DRILL HND OD4MM BONE CANN OVR QUIK REL,SUP-2319582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE EXT FIX L 95 MM 8 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.85,511.45,,,,,,,,,,,,,
GUIDEWIRE VASC HYDR JAGWIRE L 260 CM DIA 0.035 IN SS NIT,SUP-2436462,CDM,C1769,HCPCS,0272,RC,,,,both,,,551.38,358.40,,,,,,,,,,,,,
PLATE BNE THK1MM 4 H CRANIOMAXILLOFACIAL TI MINI REG STR,SUP-2366313,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.30,283.59,,,,,,,,,,,,,
IMPLANT HUM TISS DIA22 MM LG ASCEND AORT CONDUIT NONVALVED,SUP-2933481,CDM,C1762,CPT,0278,RC,,,,both,,,25616.59,16650.78,,,,,,,,,,,,,
FIBER LASER 940 MH UNSHEATHED SCP SAFE SMA905 STRL DISP,SUP-2768497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4200.38,2730.25,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO CRV PLATE XDRV 1 PK,SUP-2935492,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
TIP SURG HARD TISS BONESCAPEL ULTRASONIC,SUP-2141638,CDM,C2617,HCPCS,0278,RC,,,,both,,,1753.88,1140.02,,,,,,,,,,,,,
SPONGE SCLER W3XL80MM SIL BCKL STYL 503,SUP-2213486,CDM,L8610,HCPCS,0278,RC,,,,both,,,146.32,95.11,,,,,,,,,,,,,
GRAFT DERMAL RECT 7.9X15.7 IN ANTIBACT XENMATRIX AB,SUP-2855243,CDM,C1781,HCPCS,0278,RC,,,,both,,,84780.00,55107.00,,,,,,,,,,,,,
WIRE EXT FIX L 500 MM DIA2 MM SS SMTH HALF PT NS DISP MONK,SUP-2899106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.17,443.41,,,,,,,,,,,,,
KIT INJ CEILING FUSIONARY GRFT DEL SPINESMITH,SUP-2163073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BASEPLATE TIB CRUC RET STD UNIV PRI PEG PRESSFIT POR SZ 1,SUP-2201351,CDM,C1776,CPT,0278,RC,,,,both,,,8760.60,5694.39,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 55 CM OD 4 FR GUIDEWIRE 0.035 IN,SUP-2633282,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.47,81.56,,,,,,,,,,,,,
HC Duplex Scan Artl Infl&Ven O/F Hemo Compl Uni Std,PX-9219398600,CDM,93986,CPT,0921,RC,,,,outpatient,,,920.00,598.00,,,,,,,,,,,,,
GRAFT BONE SUB W20XH20XL10MM B TRICALCIUM PHOS GRAN SYNTH,SUP-2194021,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.63,1981.61,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK08 17MM ACELLULAR HYDRATED DERM,SUP-2307549,CDM,Q4128,HCPCS,0636,RC,,,,both,,,12910.11,8391.57,,,,,,,,,,,,,
DEVICE FIX STPL 12MM S STL DISP FOR FT AND ANK PLAPLE SYS,SUP-2122332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BONE W24XL24MM CRAN ORBIT FLR RESRB FOR 1.5MM SCR,SUP-2194053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
BIT DRL CANN 3.7 MM,SUP-2468175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
MESH CRAN L 85 X W 53 MM THK 0.6 MM SCREW DIA1.5 MM SM TI,SUP-2936498,CDM,C1713,HCPCS,0278,RC,,,,both,,,3146.28,2045.08,,,,,,,,,,,,,
TRIAL GREAT TOE HEMI MED MTL,SUP-2319051,CDM,C1776,CPT,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
ROD EXT FIX W239XL190MM DIA11MM LNG C FBR BRDG,SUP-2420186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2154.83,1400.64,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED STD HA,SUP-2197231,CDM,C1776,CPT,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
PLATE BNE ANGLED 2.5 MM RT 7X23 HOLE RECON MAXILLA PT SPEC,SUP-2860095,CDM,C1713,HCPCS,0278,RC,,,,both,,,26250.71,17062.96,,,,,,,,,,,,,
GRAFT BNE GEL 0.5 CC INJ DBM GRFT 41110A] MEDTRONIC USA INC],SUP-2278316,CDM,C1713,HCPCS,0278,RC,,,,both,,,236.13,153.48,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV 18-20 IN 2XS PEDIATRIC PROCARE,SUP-2196975,CDM,L3670,HCPCS,0272,RC,,,,both,,,14.57,9.47,,,,,,,,,,,,,
SET ORTH EXT FIX FOR SELF DRL SCHNZ SCR,SUP-2177077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,56329.34,36614.07,,,,,,,,,,,,,
PS TIBIAL BEARING SIZE 10 16MM VIT E,SUP-2813227,CDM,C1776,CPT,0278,RC,,,,both,,,6386.76,4151.39,,,,,,,,,,,,,
KIT CATH PICC CATH 5FR L50CM GWIRE L17.75IN 0.018IN POLYUR,SUP-2383379,CDM,C1751,HCPCS,0278,RC,,,,both,,,554.52,360.44,,,,,,,,,,,,,
MESH SURG DIA15CM OPTIMIZED COMP W O FIX SUT RND PARIETEX,SUP-2174709,CDM,C1781,HCPCS,0278,RC,,,,both,,,1771.62,1151.55,,,,,,,,,,,,,
HEAD FEM ADPT 0+ MM 12/14 HIP TAPR SEL,SUP-2449647,CDM,C1776,CPT,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MESHED 16X8 CMX0.3 MM PERITONEUM MESO,SUP-2486980,CDM,C1763,HCPCS,0278,RC,,,,both,,,5802.72,3771.77,,,,,,,,,,,,,
CANNULA SUCTION SIMMEN 3.5 MMX12 CM NOSE EPISTAXIS ANGULAR,SUP-2776831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.83,465.29,,,,,,,,,,,,,
GUIDEWIRE VASC .012 .014IN DIA 175CM LEN STR TIP SUPERSOFT,SUP-2157200,CDM,C1769,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
CAGE SPNL W13XH11XL21MM 10DEG C FBR REINF POLYMER POST LUM,SUP-2256323,CDM,C1889,HCPCS,0278,RC,,,,both,,,10500.16,6825.10,,,,,,,,,,,,,
AMIODARONE HCL 200 MG PO TABS,RX-9066,CDM,6370000000,HCPCS,0637,RC,65862-0732-05,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA17 MM DEL SHTH,SUP-2934269,CDM,C1713,HCPCS,0278,RC,,,,both,,,20642.11,13417.37,,,,,,,,,,,,,
SPHINCTEROTOME ENDO L480CM 0.021IN DOME TIP DBL LUMN HOWELL,SUP-2169580,CDM,C1769,HCPCS,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC THRD 1.4X150 MM,SUP-2377914,CDM,C1769,HCPCS,0272,RC,,,,both,,,257.17,167.16,,,,,,,,,,,,,
SCREW BNE CORTICAL 2X8 MM 4 MM ST TI NS,SUP-2460180,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
INTRODUCER HEMSTAS 6FRX5CM SHTH W/ .035IN GWIRE ULTIMUM EV 407649] ST JUDE MED CARDIOVASCULAR DIV],SUP-2355603,CDM,C1894,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
CATHETER ART PRESSURE MONITORING TY 021 4 FRX12 CM FEM,SUP-2760101,CDM,C1751,HCPCS,0278,RC,,,,both,,,220.55,143.36,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 5 MM STR STD WALL HELIX,SUP-2695232,CDM,C1768,CPT,0278,RC,,,,both,,,905.26,588.42,,,,,,,,,,,,,
PLATE EXT FIX SHT 180 MM FT ALUM NS MAXFRAME,SUP-2799583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4164.61,2707.00,,,,,,,,,,,,,
PLATE BNE ANGLED 2 MM LT 7X23 HOLE RECON PT SPEC TI,SUP-2860076,CDM,C1713,HCPCS,0278,RC,,,,both,,,17726.87,11522.47,,,,,,,,,,,,,
HC L-Spine Comp Inc Bend Min 6 Views,PX-3207211400,CDM,72114,CPT,0320,RC,,,,inpatient,,,1420.00,923.00,,,,,,,,,,,,,
MEDROXYPROGESTERONE ACETATE 10 MG PO TABS,RX-4854,CDM,6370000000,HCPCS,0637,RC,60687-0105-11,NDC,,both,1,UN,6.30,4.09,,,,,,,,,,,,,
INSERT TIB SZ 2 L11MM UHMWPE ANK INBONE,SUP-2397096,CDM,C1776,CPT,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
WASHER ORTH L5.5MM TI POST SCR,SUP-2269748,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
BIT DRL DIA4MM S STL CANN,SUP-2290857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1456.46,946.70,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX 10X15 CM PLASTIC MATRISTEM,SUP-2106494,CDM,Q4166,HCPCS,0636,RC,,,,both,,,10435.82,6783.28,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA PHSPTE FAST SET INJ DRILLABLE VOID,SUP-2182830,CDM,C1713,HCPCS,0278,RC,,,,both,,,7263.70,4721.40,,,,,,,,,,,,,
BUR ROBOT SURG DIA 5 MM CYL STRL DISP REAL INTELLIGENCE CORI,SUP-2927270,CDM,C1776,CPT,0278,RC,,,,both,,,299.02,194.36,,,,,,,,,,,,,
PLATE BONE L242MM BLDE W4.8XL25MM 95DEG 14 H STRL HIP S STL,SUP-2186761,CDM,C1713,HCPCS,0278,RC,,,,both,,,4679.86,3041.91,,,,,,,,,,,,,
FIBER LASER 365 MH 100 W FLEXSHIELD OUTPT TIP ETFE SIL,SUP-2141811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,974.84,633.65,,,,,,,,,,,,,
SCREW SPNL POLYAX 10X100 MM POST IL 2 COR REDUCTION STRL,SUP-2566431,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
WASHER ORTH DIA 9 MM THK 2 MM TI NS RIBFIX TITAN,SUP-2905461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1343.92,873.55,,,,,,,,,,,,,
SCREW BNE L 8 MM DIA 4.5 MM LCK BLNT TIP STRL EVOS,SUP-2931131,CDM,C1713,HCPCS,0278,RC,,,,both,,,1488.67,967.64,,,,,,,,,,,,,
GRAFT PULM VLV ALLGRFT,SUP-2175267,CDM,2720000006,LOCAL,0272,RC,,,,both,,,34524.30,22440.79,,,,,,,,,,,,,
GUIDEWIRE VASC ADX L 150 CM DIA 0.035 IN TIP L 3.5 CM PTFE,SUP-2118916,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.86,18.76,,,,,,,,,,,,,
PORT INFUS 9.5FR ATTCH CHRONOFLEX POLYUR CATH SIL FILL SUT,SUP-2127805,CDM,C1788,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
LOCK DISTAL FIBULA PLT SS LT 14H STRL,SUP-2814836,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
BRACE ORTH MOLD ANK FT,SUP-2388164,CDM,L1945,HCPCS,0272,RC,,,,both,,,2917.09,1896.11,,,,,,,,,,,,,
HC Blood Count Hematocrit|NOT REASONABLE AND NECESSARY,PX-3058501400,CDM,85014,CPT,0305,RC,,,GZ,both,,,66.00,42.90,,,,,,,,,,,,,
TUBE ENDOTRACHEAL L 34 CM OD 11 MM ID 7.5 MM SIL DUALCUFF,SUP-2891629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.84,517.95,,,,,,,,,,,,,
CUP ACET PROFORM POR BEAD ACET CUP NO H 46,SUP-2359082,CDM,C1776,CPT,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 740 VR-T DX 55 X 66MM 13MM BPLR GSM,SUP-2138424,CDM,C1722,HCPCS,0275,RC,,,,both,,,46158.00,30002.70,,,,,,,,,,,,,
PLATE BNE LCK 5X156 MM RT DSTL FEM 5 HOLE COMPR SS NS LCP,SUP-2184887,CDM,C1713,HCPCS,0278,RC,,,,both,,,4306.70,2799.35,,,,,,,,,,,,,
PLATE SPNL L22MM LEV 1 ANTR BILAT CERV TI LCK LO PROF,SUP-2254578,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
BIT DRL L333MM DIA4MM LNG ADD ON PILOT DISP FOR TRIGEN,SUP-2347048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1519.85,987.90,,,,,,,,,,,,,
REAMER SURG DIA10MM CANN HD FOR BIO-TENODESIS SCR SYS,SUP-2121251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
PLATE BNE ACROMION RT SCAPULA 7 HOLE,SUP-2106427,CDM,C1713,HCPCS,0278,RC,,,,both,,,10208.14,6635.29,,,,,,,,,,,,,
CATHETER ETER EP MAP RESPON 6FR HEXAPOLAR 2 2 2MM ELECTRD SPC CRD,SUP-2356804,CDM,C1730,HCPCS,0272,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
HC Cryoprecipitate Reduced Plasma,PX-3900904400,CDM,P9044,HCPCS,0390,RC,,,,both,,,526.00,341.90,,,,,,,,,,,,,
HC So2 Anti Striated Antibody,PX-3028625568,CDM,86255,CPT,0302,RC,,,,both,,,55.00,35.75,,,,,,,,,,,,,
HEAD FEM DIA36MM +1MM OFFSET CERAMIC DELT U-MOTION II,SUP-2391366,CDM,C1776,CPT,0278,RC,,,,both,,,4282.96,2783.92,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN FRIC SINGLE AXIS ULT,SUP-2388217,CDM,L5811,HCPCS,0274,RC,,,,both,,,1916.97,1246.03,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST FT PLATE STIRRUP ATTCH,SUP-2435655,CDM,L2250,HCPCS,0274,RC,,,,both,,,945.67,614.69,,,,,,,,,,,,,
HOLDER NDL MCPHER 3-7/8 IN CRV FLAT HNDL W/CTCH MICROSURGERY,SUP-2494986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1257.76,817.54,,,,,,,,,,,,,
CATHETER EP 6FR L65CM 2-5-2MM SPC STABILENE DECAPOLAR,SUP-2141259,CDM,C1730,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KIT BNE GRFT M RHBMP-2 4.2MG INJ 5ML CONTAIN NDL 20GA,SUP-2287849,CDM,C1713,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
CATHETER GUID GUIDER XF SFTIP 40 DEG L 90 CM DIA 6 FR DSTL,SUP-2367813,CDM,C1887,HCPCS,0272,RC,,,,both,,,924.42,600.87,,,,,,,,,,,,,
CATHETER PICC 5FR L55CM GWIRE L70CM 0.018IN POLYUR S STL,SUP-2125529,CDM,C1751,HCPCS,0278,RC,,,,both,,,293.02,190.46,,,,,,,,,,,,,
HALF RNG 120MM FRDM CIR FIX,SUP-2400630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1372.18,891.92,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 6 FRX45 CM 17 GA INTERMED XCELA,SUP-2118814,CDM,C1751,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
PLATE BONE W10XL75MM THK1.5MM 3X5 H NEUT BILAT S STL,SUP-2185889,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.81,561.48,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC SYR VIABLE MTRX OSTEOCONDUCTIVE,SUP-2916780,CDM,C1713,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
GRAFT VASC STR 32 MMX30 CMX0.038 MM AORT CV BOV INTERGARD,SUP-2472279,CDM,C1768,CPT,0278,RC,,,,both,,,1429.01,928.86,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENESTRATED ADULT 7  UNCUFFED ADAPTER OBTU,SUP-2793425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,146.92,95.50,,,,,,,,,,,,,
PLATE BNE L233MM 15 H NONSTERILE L POSTEROLATERAL DST,SUP-2177408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BUR SURG LINDE 1.6X31 MM FOR OTO SPINE NEURO STRL,SUP-2607649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.60,422.24,,,,,,,,,,,,,
PUMP PENILE PROS W/ INHIBIZONE AMS 700,SUP-2138970,CDM,C1813,HCPCS,0278,RC,,,,both,,,13652.72,8874.27,,,,,,,,,,,,,
NEEDLE PHACO 30 DEG 20/21 GA ANGLED VORT STRL LF DISP,SUP-2464271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.16,830.15,,,,,,,,,,,,,
GRAFT SFT TISS 13X6 CM PLIABLE PORCINE TISS MTRX STRATTICE,SUP-2488520,CDM,Q4130,HCPCS,0636,RC,,,,both,,,4650.34,3022.72,,,,,,,,,,,,,
BLADE SCRWDRVR 2MM2.3MM DIA 80MML QUICK CPLNG CNTRE DRIVE,SUP-2676901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.71,215.61,,,,,,,,,,,,,
STENT BILI 0.035 IN 6X150 MM 6 FRX80 CM LIFESTENT,SUP-2126871,CDM,C1876,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
BLOCK EXT FIX 50MM RIG COMPRESSION/DISTRACTION STRUT,SUP-2197299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
RING EXT FIX MED 200 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30569.38,19870.10,,,,,,,,,,,,,
BRACE ORTH 2 MOD BK PRE CUST TLSO,SUP-2388139,CDM,L0460,HCPCS,0272,RC,,,,both,,,2585.10,1680.31,,,,,,,,,,,,,
HC Assay of Triiodothyronine T3 Free,PX-3018448100,CDM,84481,CPT,0301,RC,,,,both,,,181.00,117.65,,,,,,,,,,,,,
TACROLIMUS 0.2 MG PO PACK,RX-145114,CDM,J7507,HCPCS,0636,RC,00469-1230-50,NDC,,both,1,UN,23.40,15.21,,,,,,,,,,,,,
PLATE BONE L 4 H BX FOR STERNALOCK BLU SYS,SUP-2418021,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
PLATE BONE LOK CMPRSSN HLX15 TIMAX CRTCL WIDE PRE CNTRD ANTM,SUP-2588752,CDM,C1713,HCPCS,0278,RC,,,,both,,,4030.28,2619.68,,,,,,,,,,,,,
SUPPORT VAG W/ CAPIO SLIM PELV FLR MESH ASSEMB OPN ACCS DEV,SUP-2139401,CDM,C1781,HCPCS,0278,RC,,,,both,,,7244.51,4708.93,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 13X13X13 MM 2.2 CC CANC CONFORM Q-PACK,SUP-2737082,CDM,C1713,HCPCS,0278,RC,,,,both,,,2129.86,1384.41,,,,,,,,,,,,,
HC Blood Count Platelet Automated,PX-3058504900,CDM,85049,CPT,0305,RC,,,,both,,,139.00,90.35,,,,,,,,,,,,,
KNIFE SURG BALLENGER SWVL 8.5 INX4 MM STR MICROFRANCE LF,SUP-2467298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.81,441.23,,,,,,,,,,,,,
INSERT TIB SZ 9 THK18MM UNIV CO CHROM UHMWPE KNEE REV NEUT,SUP-2378391,CDM,C1776,CPT,0278,RC,,,,both,,,3597.75,2338.54,,,,,,,,,,,,,
ENDCAP IM NAIL 0MM OFFSET FEM LO PROF FOR PHOENIX SYS,SUP-2412152,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK.9-1.99MM ACELLULAR DERM MTRX,SUP-2402516,CDM,Q4126,HCPCS,0636,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
IMPLANT SPNG SIL OBLONG,SUP-2213503,CDM,L8610,HCPCS,0278,RC,,,,both,,,170.19,110.62,,,,,,,,,,,,,
ALLOGRAFT BNE PASTE 3 CC DEMINERALIZED BNE MTRX + CANC,SUP-2717766,CDM,C1713,HCPCS,0278,RC,,,,both,,,2472.31,1607.00,,,,,,,,,,,,,
COMPONENT FEM SZ 5 R KNEE POST STBL CEM SIG,SUP-2252517,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM STD ANK S STL LOK FIX ANG SYS,SUP-2243360,CDM,C1713,HCPCS,0278,RC,,,,both,,,927.96,603.17,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 0.062X12 IN RND END SS NS KIRSCHNER,SUP-2791265,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.85,5.75,,,,,,,,,,,,,
MILRINONE LACTATE IN DEXTROSE 40-5 MG/200ML-% IV SOLN,RX-123635,CDM,J2260,HCPCS,0636,RC,00338-6011-37,NDC,,both,200,ML,393.30,255.64,,,,,,,,,,,,,
BIT DRL L155MM DIA2.7MM SHT CANN CALIB QUIK CONN FOR,SUP-2344006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.92,278.15,,,,,,,,,,,,,
PLATE BNE L53MM THK1.5MM 3X3 H BILAT S STL T SHP OBLQ ANG,SUP-2185882,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
PENICILLIN V POTASSIUM 250 MG/5ML PO SOLR,RX-6091,CDM,340b,HCPCS,0637,RC,09999-9914-33,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
OPIUM 10 MG/ML (1%) PO TINC,RX-99771,CDM,6370000000,HCPCS,0637,RC,99999-9908-22,NDC,,both,0.6,ML,9.00,5.85,,,,,,,,,,,,,
GRAFT BNE SUB 1.5CC RHPDGF-BB/-TCP FOR ANK HINDFOOT ARTH,SUP-2400114,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
Z DUP USE 2759589 GRAFT HUM TISS 4X8CM STD ACELLULAR HUM DERM MTRX STD,SUP-2399085,CDM,Q4107,HCPCS,0636,RC,,,,both,,,8939.77,5810.85,,,,,,,,,,,,,
PIN FIX L9IN DIA32MM ST S STL 2 SIDE DBL DMND BOTH END PNT,SUP-2150543,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.62,16.65,,,,,,,,,,,,,
PROCESSOR SND SLV GRY BAHA INTENSO,SUP-2164953,CDM,L8691,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
EVOS 1.8MMX26MM LOCKING PEG T7,SUP-2819366,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.25,399.91,,,,,,,,,,,,,
VALVE ENDOSCP EMPHYSEMA 9 MM SPIRATION,SUP-2457293,CDM,C1889,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
PROBE CRYOABLATION L 11 IN OD 8 MM BALL TIP STRL DISP,SUP-2889680,CDM,C9808,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
COLLAR EXTRIC AD REG HI DENS POLYETH PD SET XTW,SUP-2194470,CDM,L0172,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
SPACER SPNL 10X26MM H11 TO 15MM CALIB,SUP-2230719,CDM,C1821,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
SET SCR HEXALOBE 25 ARRY SYS,SUP-2415866,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
CATHETER GUID AD L120CM BAL L15CM DIA4FR 0.038IN POLYUR,SUP-2141102,CDM,C1887,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
IMPLANT HUM TISS W6XL16CM THK1MM PROC DERM CLLGN RECTANG,SUP-2125863,CDM,C1781,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
CATHETER EP 7FR L115CM TIP 15-25MM 2-6-2MM SPC 20 ELECTRD D,SUP-2248774,CDM,C1731,HCPCS,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
PLATE BNE FOR SCREW STRL LEVEL 1,SUP-2499890,CDM,C1713,HCPCS,0278,RC,,,,both,,,1680.03,1092.02,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 2.6-7 Cm,PX-4501203200,CDM,12032,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
ALLOGRAFT DERMAL THN 4X4 CM MTRX MIAMI,SUP-2321687,CDM,C1713,HCPCS,0278,RC,,,,both,,,5731.13,3725.23,,,,,,,,,,,,,
CAGE SPNL 22X9X45MM 0DEG PARA LAT INTBDY FUS VEO,SUP-2164083,CDM,C1889,HCPCS,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
STEM HUM L125MM DIA10MM UNIV DST SHLDR TI PRI REV CEM FOR,SUP-2372853,CDM,C1776,CPT,0278,RC,,,,both,,,12971.34,8431.37,,,,,,,,,,,,,
CLADRIBINE 10 MG/10ML IV SOLN,RX-133071,CDM,J9065,HCPCS,0636,RC,00143-9871-01,NDC,,both,10,ML,278.30,180.89,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN L 115CM 2-6-2,SUP-2248593,CDM,C1732,HCPCS,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
PLATE BNE L301MM 14 H ST R CNDYL S STL CRV LOK COMPR VAR,SUP-2177860,CDM,C1713,HCPCS,0278,RC,,,,both,,,6878.48,4471.01,,,,,,,,,,,,,
SCREW INTFR L25MM DIA7MM CANN 1.5MM BIOABSRB PLLA RND THRD,SUP-2341553,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.78,450.31,,,,,,,,,,,,,
HC Rem Int Ureteral Stent,PX-3615038400,CDM,50384,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
SYSTEM GRFT DEL MOD MAS,SUP-2904122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.6 MM LG TI RT CRANIOMAXILLOFACIAL STD,SUP-2936494,CDM,C1713,HCPCS,0278,RC,,,,both,,,6732.16,4375.90,,,,,,,,,,,,,
INSERT TIB L79/83MM THK10MM UNIV KNEE PRI CRUCE RET NEUT,SUP-2407124,CDM,C1776,CPT,0278,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
CATHETER CTRL VEN SET DBL LUMN W/ + 7FR 20CM LEN ARROWGUARD,SUP-2383446,CDM,C1751,HCPCS,0278,RC,,,,both,,,174.33,113.31,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 20 HOLE SS NS LCP,SUP-2799222,CDM,C1713,HCPCS,0278,RC,,,,both,,,2906.64,1889.32,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 40 CM DIA2 MM SHTH TEF OTW SELF,SUP-2884029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11300.86,7345.56,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM TRCR PNT 1 END FOR SM FRAG UNIV,SUP-2411305,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.84,16.15,,,,,,,,,,,,,
CANNULA ENDO L90MM OD7MM HIP COMPLT THRD DISP CLEAR-TRAC,SUP-2341064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
BUR SURG HD L19.1MM DIA3.1MMXLONG STR ROUTER ELITE TPS,SUP-2363412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.24,223.76,,,,,,,,,,,,,
STENT URET L80CM DIA6FR STR FIRM OPN PERCFLX LUERLOCK ADPT,SUP-2139080,CDM,C2617,HCPCS,0278,RC,,,,both,,,65.28,42.43,,,,,,,,,,,,,
CATHETER URET OPN END 038 5 FRX10 CM MOD FLEXI-TIP,SUP-2835746,CDM,C1758,HCPCS,0278,RC,,,,both,,,38.59,25.08,,,,,,,,,,,,,
PLATE BONE SM THK1.6MM 7 H MAND TI ANG FOR 2/2.3MM SCR,SUP-2136788,CDM,C1713,HCPCS,0278,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
IMPLANT BRST SIL 440CC SMOOTH RND NATRELLE SIL SHELL,SUP-2113265,CDM,C1789,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
BURR HOLE COVER CNTRD 3MM 12MM DIA 15MM SSTM T 6L 4V,SUP-2707249,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.84,437.35,,,,,,,,,,,,,
SCREW ACET LP UNIV 6.5X45 MM HIP DOMED 2 MOBILITY STRL G7,SUP-2403205,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
BRACE ORTHOPEDIC FOAM SHT SM UNIV 8.5 IN CONFOR FLEX-N-FIT,SUP-2428146,CDM,L1930,HCPCS,0274,RC,,,,both,,,50.27,32.68,,,,,,,,,,,,,
SUPPORT ORTHOT FT HEEL STBL PLAS SIL,SUP-2435713,CDM,L3170,HCPCS,0274,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
PIN EXT FIX HALF 3X80 MM 20 MM BLNT TIP BRN XTRAFIX,SUP-2466340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
TROCAR SURG TRANSBUCCAL 71 MM MOD,SUP-2477313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.12,442.08,,,,,,,,,,,,,
SCREW BNE L14MM DIA4MM PERIARTC S STL ST LOK FULL THRD FOR,SUP-2184945,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.11,389.42,,,,,,,,,,,,,
ANCHOR SUT 4.5MM NO 2 W/ NDL MORPHIX,SUP-2277452,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
ANCHOR SUT MINI MAG KNOTLESS W/ INSRT HNDL,SUP-2342078,CDM,C1776,CPT,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
STEM FEM L200MMXOD14MM LIMB SALV LO BODY CYL CEMENTLESS,SUP-2265079,CDM,C1776,CPT,0278,RC,,,,both,,,8179.89,5316.93,,,,,,,,,,,,,
PLATE BNE L140MM 13 H OLECRANON TIM LO PROF MULTIPLANAR ARM,SUP-2411729,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.49,2591.87,,,,,,,,,,,,,
FIBER LASER EVOLVE SIDE FIRE,SUP-2885289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
COLLAR VENTRICULAR ASST DEV SEAL OUTFLO GRFT BEND REL STRL,SUP-2894740,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BRONCHOSCOPE RIGID THE GALAXY SYS,SUP-2885099,CDM,C1601,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
WASHER FOR SCREW 14/7MM STERILE,SUP-2761697,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.04,132.63,,,,,,,,,,,,,
ANCHOR SUTURE LIGMNT 2 W/ TAPE WHT BLU LABRALTAPE DISP,SUP-2422112,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BUTTON SUTURE DST CLAV PLT KNOTLESS PRELD ON INSRT TIGHTROPE,SUP-2121740,CDM,C1713,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
INSERT ACET SZ D OD58-61MM ID32MM 10DEG HIP DUR PCA HOOD,SUP-2376063,CDM,C1776,CPT,0278,RC,,,,both,,,936.19,608.52,,,,,,,,,,,,,
CATHETER EP D 6 MM 20 MMX7 FRX115 CM CARTO,SUP-2467701,CDM,C1732,HCPCS,0278,RC,,,,both,,,7262.82,4720.83,,,,,,,,,,,,,
PLATE BNE MESH PANEL STD 1.5X160X135X0.6 MM NEURO 750 HOLE,SUP-2474776,CDM,C1713,HCPCS,0278,RC,,,,both,,,9531.09,6195.21,,,,,,,,,,,,,
COMPONENT FEM C- KNEE FEMALE NXGN LPS-FLEX GENDER SOL 00592401351] ZIMMER BIOMET INC],SUP-2200806,CDM,C1776,CPT,0278,RC,,,,both,,,16554.08,10760.15,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 6MM 120CM 7FR HEPARIN,SUP-2396598,CDM,C1876,HCPCS,0278,RC,,,,both,,,12318.22,8006.84,,,,,,,,,,,,,
IMPLANT BRST SIL GEL LO HT MOD + PROF ANAT MEMORYSHAPE,SUP-2748608,CDM,C1789,HCPCS,0278,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
HC MRI-Brain WO & W Contrast,PX-6117055300,CDM,70553,CPT,0611,RC,,,,both,,,3486.00,2265.90,,,,,,,,,,,,,
ELECTRODE ENDOSCP VES SEAL SPR DISPOSABLE PK SUPERPULSE,SUP-2312848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,792.22,514.94,,,,,,,,,,,,,
FILTER SMK EVAC NEPTUNE 2 NEPTUNE 3 3-PORT,SUP-2151926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1216.03,790.42,,,,,,,,,,,,,
PACK BTTRY FOR PWR SCRDRVR QUICKDRIVE MINI,SUP-2366439,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.52,418.94,,,,,,,,,,,,,
SHEET THERMOPLASTIC SPLNT 1/16X12X18IN 4 PER CA SLD BLUSH,SUP-2324644,CDM,L4350,HCPCS,0274,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
DRESSING BIO W2XL2IN THN CLLGN GLYCOSAMINOGLYCAN WND MTRX,SUP-2243646,CDM,Q4108,HCPCS,0636,RC,,,,both,,,10057.23,6537.20,,,,,,,,,,,,,
ORTHOSIS LUMSACR PREFABRICATED SAG CTRL SACROCOCCYGEAL,SUP-2237268,CDM,L0648,HCPCS,0272,RC,,,,both,,,3128.51,2033.53,,,,,,,,,,,,,
AQUAPHOR EX OINT,RX-612,CDM,6370000000,HCPCS,0637,RC,72140-0633-86,NDC,,both,396,GR,66.00,42.90,,,,,,,,,,,,,
RESERVOIR VENTRICULAR L18CM OD60FR ODSEC2.5MM D.56CM 20MM L,SUP-2825885,CDM,C1729,HCPCS,0272,RC,,,,both,,,1393.53,905.79,,,,,,,,,,,,,
PLATE BNE L20MM 2 H LOK FOR 15MM SCR,SUP-2321432,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT L 27 CM 4 FR 9 MM STR PLIABLE,SUP-2264225,CDM,C2628,HCPCS,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
EXTENSION STEM L140MM OD21MM FEM HIP CEMENTLESS CNL FILL,SUP-2304776,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STENT BILI WALLFLEX L 60 MM DIA 8 MM CVR L 48 MM CATH L 75,SUP-2149821,CDM,C1874,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
HC X-Ray Specimen,PX-3207609800,CDM,76098,CPT,0320,RC,,,,inpatient,,,566.00,367.90,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM TI SELF DRL FULL THRD CRSS PIN COR,SUP-2366090,CDM,C1713,HCPCS,0278,RC,,,,both,,,223.07,145.00,,,,,,,,,,,,,
PLATE BONE W8XL192MM THK3.3MM 24 H STRL BILAT PELV S STL,SUP-2186252,CDM,C1713,HCPCS,0278,RC,,,,both,,,2827.41,1837.82,,,,,,,,,,,,,
WIRE FIX L10MM DIA1MM CERCLAGE S STL PRECUT SMOOTH W/,SUP-2186840,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.86,126.01,,,,,,,,,,,,,
PLATE BNE 100DEG 4 H L SHP STERNALOCK BLU PRI CLSR SYS,SUP-2403029,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
CATHETER HD KT 15 FRX27 CM DL RETROGRADE SHTH CANNON II +,SUP-2763032,CDM,C1750,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP J 0.035 INX150 CM FIX COR RADIOPAQUE,SUP-2141739,CDM,C1769,HCPCS,0272,RC,,,,both,,,42.67,27.74,,,,,,,,,,,,,
PACEMAKER CARD ALTURA 40 TI 2 CHMBR 1 LD BATTERY PWR STRL,SUP-2149116,CDM,C1785,HCPCS,0275,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
MARKER BRST BX TI SHP 2 TOP HAT FOR CELERO 12 DEV SECURMARK,SUP-2240048,CDM,A4648,CPT,0278,RC,,,,both,,,258.89,168.28,,,,,,,,,,,,,
PLATE BNE L42MM THK1.3MM 6 H MTCRPL TI STR COMPR FOR,SUP-2267914,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 70-74 CM SAPH VEIN BLD TYP A B AB,SUP-2264306,CDM,C1768,CPT,0278,RC,,,,both,,,31239.86,20305.91,,,,,,,,,,,,,
MARKER BRST BX 18 GAX13.3 CM VISION NIT TUMARK EVIVA,SUP-2716299,CDM,A4648,CPT,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC FIBER KORE,SUP-2736956,CDM,C1713,HCPCS,0278,RC,,,,both,,,3508.95,2280.82,,,,,,,,,,,,,
PLATE BNE CNDYL 1.5X37 MM LT 7 HOLE,SUP-2861497,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.85,618.05,,,,,,,,,,,,,
MOLD CEMENT SPACER STEM DIA10 MM HD DIA 48 MM OFFSET 18 MM,SUP-2898430,CDM,C1713,HCPCS,0278,RC,,,,both,,,11570.90,7521.08,,,,,,,,,,,,,
BUR SURG DIA 4.5 MM HUB II DIAMOND EXCEPT LG STRL REUSE,SUP-2929541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.84,262.50,,,,,,,,,,,,,
SCREW BNE EMGCY 2.4X9 MM T8 TI NS,SUP-2189474,CDM,C1713,HCPCS,0278,RC,,,,both,,,949.85,617.40,,,,,,,,,,,,,
SYSTEM RECHARGING NEUROSTIMULATOR RECHRG BTTRY PK PWR SUPL,SUP-2284644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3388.06,2202.24,,,,,,,,,,,,,
KIT KYPHOPLASTY FULL DOSE PMMA RADPQ HI VISC W/O ANTIBIO,SUP-2293484,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE W8XL36MM THK2MM 0DEG 4 H BILAT S STL STR RIG DYN,SUP-2186175,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.02,282.76,,,,,,,,,,,,,
FORCEPS OPHTH 23GA SERR DISP GRIESHABER REVOLUTION DSP,SUP-2109705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.06,224.94,,,,,,,,,,,,,
CATHETER IV DL 5 FR DOT KT MBP POWERMIDLINE,SUP-2626738,CDM,C1751,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
SYRINGE MED 1 CC DEFLUX PREFIL 159034] OCEANA THERAPEUTICS INC],SUP-2312331,CDM,L8604,HCPCS,0278,RC,,,,both,,,5964.27,3876.78,,,,,,,,,,,,,
STAPLER INT 48MM W21MMXL22CM AQUA STD CUT EDGE TECHNOLOGY,SUP-2283240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1132.06,735.84,,,,,,,,,,,,,
STEM RADIAL SM 4.5 ULN WRST MOD COCR 1ST CHOICE,SUP-2852861,CDM,C1776,CPT,0278,RC,,,,both,,,13295.36,8641.98,,,,,,,,,,,,,
BIT DRL DIA 3.2 MM PIN DIA 4 MM STP NS DISP MAV MINI,SUP-2933152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1170.44,760.79,,,,,,,,,,,,,
PLATE BNE L 150.62 X W 8.25 MM THK 2.8 MM 20 H TI STR NS,SUP-2936949,CDM,C1713,HCPCS,0278,RC,,,,both,,,6135.56,3988.11,,,,,,,,,,,,,
KIT COMP PK VAR-A-PULSE,SUP-2199698,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.86,724.66,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 9-13 MM FRZN ILIUM TRICORT,SUP-2717919,CDM,C1762,CPT,0278,RC,,,,both,,,3570.84,2321.05,,,,,,,,,,,,,
ANCHOR SUTURE XL 2-0 1.7 MM BLU SUTUREFIX ULTRA ULTRABRAID,SUP-2848639,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.33,767.21,,,,,,,,,,,,,
ZINC OXIDE 40 % EX PSTE,RX-110359,CDM,6370000000,HCPCS,0637,RC,69968-0848-09,NDC,,both,28,GR,13.50,8.77,,,,,,,,,,,,,
CATHETER DRAINAGE MCL COPE 0.038 IN 14 FRX60 CM MP UTHANE,SUP-2168391,CDM,C1729,HCPCS,0272,RC,,,,both,,,379.66,246.78,,,,,,,,,,,,,
CATHETER CARD ABLATION CELSIUS RMT THERMOCOOL L 130 CM DIA 8,SUP-2248583,CDM,C2630,CPT,0272,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 120 CM,SUP-2666784,CDM,C1889,HCPCS,0278,RC,,,,both,,,11315.78,7355.26,,,,,,,,,,,,,
ALLOGRAFT BNE LORDTC 7 DEG 12 MM CERV PRESERVON VG2,SUP-2740923,CDM,C1713,HCPCS,0278,RC,,,,both,,,3435.16,2232.85,,,,,,,,,,,,,
PLATE SPNL 16MM 10MM H COALITION AGX,SUP-2228803,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ITREVIA DX W 55 X H 65 MM D 11 MM 33 CC,SUP-2138373,CDM,C1722,HCPCS,0275,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
RING ANNULPLSTY 27MM FLX ADJ ATTUNE,SUP-2355754,CDM,C1889,HCPCS,0278,RC,,,,both,,,3344.10,2173.66,,,,,,,,,,,,,
COLLAR CERV AD COT LN PD HT ADJ TECHNOLOGY W/ REPL PDS,SUP-2124227,CDM,L0180,HCPCS,0272,RC,,,,both,,,122.59,79.68,,,,,,,,,,,,,
COMPONENT PAT RESURF IMP GEN II,SUP-2349043,CDM,C1776,CPT,0278,RC,,,,both,,,1861.77,1210.15,,,,,,,,,,,,,
SCREW BNE LCK 3.5X36 MM PERIARTICULAR STRL,SUP-2459159,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
BLADE L SERR SONICONE,SUP-2305950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
GRAFT BNE MORSELS MINI 1.5 CC MOLD GRAN CUBE ISOTIS MOZAIK,SUP-2427675,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
MESH SURG 60X53X0.3 MM TI LEVEL 1 NEURO,SUP-2497077,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.96,614.87,,,,,,,,,,,,,
IMPLANT BIO SZ 250 SQCM FISH SKIN DERMAL FEN 11 INTACT FLAT,SUP-2909233,CDM,Q4158,HCPCS,0636,RC,,,,both,,,25905.00,16838.25,,,,,,,,,,,,,
TUBE MYR ID114MM SFT SIL FLNG ST DONALDSON,SUP-2312638,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.66,21.23,,,,,,,,,,,,,
PLATE BNE N COMPR Y BILAT 5 H RIG FOR 2MM SCR H DIA,SUP-2366326,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.46,394.20,,,,,,,,,,,,,
STEM FEM SZ 1 TI PPS PROX HIP REV MOD CLLRD BIPLANAR TAPR,SUP-2403437,CDM,C1776,CPT,0278,RC,,,,both,,,14795.68,9617.19,,,,,,,,,,,,,
TRANSDUCER 15 MM 2 MHZ MON,SUP-2162528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
WASHER ORTH FOR 6.2 MM BNE SCR VIT STRL LTX,SUP-2869884,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
PROSTHESIS OSS L 8 MM SHFT DIA1 MM HD DIA 3.25 MM TI HA FLX,SUP-2902106,CDM,L8613,CPT,0278,RC,,,,both,,,1685.87,1095.82,,,,,,,,,,,,,
SLEEVE FEM ADPT 11/13 TAPR +0MM OFFSET HD ASR,SUP-2254024,CDM,C1776,CPT,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
ENDCAP NAIL L6.85MM HD L2.5MM 3MM HEX TIBIOTALOCALCANEAL,SUP-2277472,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
BUR SURG DIAMOND LNG 1.2 MM 7.5 CM BALL MIDAS REX LEGEND,SUP-2630503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.11,262.02,,,,,,,,,,,,,
PLATE BONE LOCKING STERNAL 8 HOLE PRECONTOURED TITANIUM STER,SUP-2838433,CDM,C1713,HCPCS,0278,RC,,,,both,,,3123.67,2030.39,,,,,,,,,,,,,
PLATE BNE VA NEUT 2.7/3.5X232 MM RT DSTL TIB 14 HOLE LCK LP,SUP-2177686,CDM,C1713,HCPCS,0278,RC,,,,both,,,6632.97,4311.43,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK HEMORRHOID TRANSANAL,SUP-2385924,CDM,C1713,HCPCS,0278,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
HC Assay of Glutamyltrase Gamma,PX-3018297700,CDM,82977,CPT,0301,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 8 MM EPTFE STR STD WALL,SUP-2396199,CDM,C1768,CPT,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GRAFT BNE SM 2.5 CC DBM STRND +,SUP-2641767,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
APPLIER CLIP 8.75IN ANEURYSM VARIO MINI BAYONET SWIVEL REUSA,SUP-2821710,CDM,C1889,HCPCS,0278,RC,,,,both,,,6032.41,3921.07,,,,,,,,,,,,,
BENDAMUSTINE HCL (UNBRANDED) 100 MG/4ML IV SOLN,RX-132213,CDM,J9036,HCPCS,0636,RC,10019-0079-01,NDC,,both,4,ML,6739.20,4380.48,,,,,,,,,,,,,
LOWER EXTREMITY KIT DISP,SUP-2365639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
COIL EMB L5CM PRI DIA0.02IN 2ND DIA3MM COMPLX STD FRME L,SUP-2323652,CDM,C1889,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
BEAM FIX L135MM DIA4.5MM ARTH,SUP-2223934,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GRAFT BNE FRZN LAT MED FEM HEMICONDYLE IMPL ALLGRFT L50 TO,SUP-2264763,CDM,C1713,HCPCS,0278,RC,,,,both,,,4424.29,2875.79,,,,,,,,,,,,,
INSERT ACET SZ E DIA44.4MM HD OD36MM ID22MM THK7.9MM 10DEG,SUP-2377727,CDM,C1776,CPT,0278,RC,,,,both,,,6860.27,4459.18,,,,,,,,,,,,,
STEM FEM SZ 13 L195MM HIP TI HA STD OFFSET CEMENTLESS REV,SUP-2257652,CDM,C1776,CPT,0278,RC,,,,both,,,19061.06,12389.69,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA SOLENT OMNI L 120 CM DIA 6,SUP-2142039,CDM,C1757,HCPCS,0272,RC,,,,both,,,13140.90,8541.58,,,,,,,,,,,,,
BIT DRL DIA25MM STP 12MM SHT VECTRA,SUP-2179381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
BUR SURG RND LNG 1.5X1.5 MM 48 MM 6 FLUT OTO SS,SUP-2761063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.67,226.64,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK FD IRRADIATED CANC,SUP-2867101,CDM,C1762,CPT,0278,RC,,,,both,,,1783.83,1159.49,,,,,,,,,,,,,
PIN EXT FIX FT 7X125 MM BEAM SALVATION,SUP-2852135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
WIRE FIX 1.2X150 MM KIRSCHNER,SUP-2316473,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
MESH HERN CIR 15 CM W/ ECHO 2 POS SYS POLYPR VENTRALIGHT ST,SUP-2126500,CDM,C1781,HCPCS,0278,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
INTRO CANN W/STYLET 5PK 6IN 17G,SUP-2366995,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
CATHETER EMB L 110 CM DIA16 FR GUIDEWIRE 0.035 IN CRV 1 TIME,SUP-2891721,CDM,C1757,HCPCS,0272,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
COIL NEUROVASCULAR AXIUM MICROFX L 40 CM SECONDARY DIA12 MM,SUP-2459512,CDM,C1889,HCPCS,0278,RC,,,,both,,,5918.90,3847.28,,,,,,,,,,,,,
MONITOR CRD 1.4 CC 3.4 GM INSERTABLE LINQ,SUP-2665248,CDM,C1764,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 80 CM DIA 0.035 IN TAPR L 15 CM TIP,SUP-2168716,CDM,C1769,HCPCS,0272,RC,,,,both,,,101.99,66.29,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 35 CM DIA 0.021 IN SS PERIPH,SUP-2383969,CDM,C1769,HCPCS,0272,RC,,,,both,,,26.38,17.15,,,,,,,,,,,,,
SYSTEM CAST 3IN W/ 1 REG BOOT TCC-EZ 5 CAST,SUP-2244453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
CANNULA ENDOSCP W/ STOPCOCK,SUP-2747296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.06,450.49,,,,,,,,,,,,,
BUR SURG L9CM DIA254MM MTL WHL MIDAS REX LEGEND,SUP-2280239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,479.73,311.82,,,,,,,,,,,,,
FILTER VASC 4 MM EMBOLC PROTCT FLPY TIP MED NIT ANGIOGUARD,SUP-2865935,CDM,C1725,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
"HC Unlisted Procedure, Nervous System",PX-3606499900,CDM,64999,CPT,0360,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW BNE DRILL-FREE 1.5X13 MM 5 MM TI MAXDRIVE,SUP-2540260,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.07,128.75,,,,,,,,,,,,,
DISC INTERVERTEBRAL 5X12 MM CERV PRESTIGE LP,SUP-2630296,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
GRAFT BNE 10 CC DEMINERALIZED BNE FIBER PROGRAFT,SUP-2858506,CDM,C1713,HCPCS,0278,RC,,,,both,,,3282.24,2133.46,,,,,,,,,,,,,
NEPHRON FA PO TABS,RX-5497,CDM,6370000000,HCPCS,0637,RC,59528-4456-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE W10XL142MM THK2.8MM 12 H S STL STR NONCOMPRESSION,SUP-2343767,CDM,C1713,HCPCS,0278,RC,,,,both,,,4248.89,2761.78,,,,,,,,,,,,,
HC So Assay of Psa Total,PX-3018415366,CDM,84153,CPT,0301,RC,,,,outpatient,,,338.00,219.70,,,,,,,,,,,,,
HC Perq Dilation Xst Trc Endourologic Px W/Img,PX-3615043600,CDM,50436,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
COMPONENT FEM LIP 59X60 MM LT MEDL LAT CNDYL CONSTRN COCR,SUP-2199878,CDM,C1776,CPT,0278,RC,,,,both,,,30737.46,19979.35,,,,,,,,,,,,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,2500000003,HCPCS,0250,RC,00409-3299-26,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
STEM FEM L167MM OD11MM BOW FLUT TI ALLY HA DST HIP REV MOD,SUP-2375745,CDM,C1776,CPT,0278,RC,,,,both,,,8140.14,5291.09,,,,,,,,,,,,,
ROD EXT FIX ALIGN FEM SIG LCS HP,SUP-2456161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2430.36,1579.73,,,,,,,,,,,,,
PIN FIX L25MM DIA2.7MM PROV FOR VAR ANG PLATING SYS,SUP-2343968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1331.01,865.16,,,,,,,,,,,,,
CATHETER THOR STR 32F FIRM PVC,SUP-2227341,CDM,C1729,HCPCS,0272,RC,,,,both,,,24.46,15.90,,,,,,,,,,,,,
MESH HERN L W6XL12CM ULTRAPRO SYS,SUP-2220100,CDM,C1781,HCPCS,0278,RC,,,,both,,,984.30,639.79,,,,,,,,,,,,,
EXTRACTOR SURG SCR 4.5/5.5 MM NS EXTRIMIFIX LTX,SUP-2856029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
T-PLT OBLQ 73MM STER HEAD 5HL SHAFT 4HL,SUP-2818408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1854.89,1205.68,,,,,,,,,,,,,
AMITRIPTYLINE HCL 50 MG PO TABS,RX-436,CDM,6370000000,HCPCS,0637,RC,60687-0444-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BAR REDUCER EXTN SHT STRL OSCAR 3 LTX DISP,SUP-2875733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1145.79,744.76,,,,,,,,,,,,,
SCREW SPNL 2PK L13MM OD4MM SELF DRL VAR ANG 2P,SUP-2418612,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
TAP SURG DIA65MM CANN QUIK CONN,SUP-2409939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1366.15,888.00,,,,,,,,,,,,,
MINI CMPRSSN PLATE STRGHT 8 HOLE 20MM CP TTNM,SUP-2681042,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.68,563.99,,,,,,,,,,,,,
BIT DRILL RECON LAG SCREW,SUP-2701128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2833.22,1841.59,,,,,,,,,,,,,
NEEDLE SUTURE L8IN HEAVY CURVED LIGATURE KOCHER,SUP-2809005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.97,238.53,,,,,,,,,,,,,
PLATE BONE THK1MM 16 H MINI STR FOR 2/2.3MM SCR,SUP-2418321,CDM,C1713,HCPCS,0278,RC,,,,both,,,2774.72,1803.57,,,,,,,,,,,,,
STEM FEM KNEE HIP EXTN DST N MOD CONSTRN W/ LOK SCR IMPACT,SUP-2222918,CDM,C1776,CPT,0278,RC,,,,both,,,2420.00,1573.00,,,,,,,,,,,,,
PIN EXT FIX L 50 MM DIA 5 MM SHRT TIN TRACTION STRL DISP,SUP-2932905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.27,806.18,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X0.2 MM MESHED BOWLE SHP TI GLD NS,SUP-2494182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.74,695.98,,,,,,,,,,,,,
PLATE BNE L166MM 14 H BILAT S STL LO PROF RIG LIMIT CNTCT,SUP-2186206,CDM,C1713,HCPCS,0278,RC,,,,both,,,1891.41,1229.42,,,,,,,,,,,,,
DRILL SURG STEM TIB KNEE ROTATING HINGE BASE NXGN,SUP-2437383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
ENDCAP ORTH L0MM DIA11MM ST GRN TI NAIL EXTN TROCHANTERIC,SUP-2191916,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.28,462.98,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 40 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120669,CDM,C1768,CPT,0278,RC,,,,both,,,8098.06,5263.74,,,,,,,,,,,,,
WASHER ORTH 4.5-8 MM 430290,SUP-2609253,CDM,C1713,HCPCS,0278,RC,,,,both,,,434.80,282.62,,,,,,,,,,,,,
HC Sacroiliac Joints Less Than 3,PX-3207220000,CDM,72200,CPT,0320,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
ANCHOR SUT HEALIX BRAID 6.5MM W/ ORTHOCORD,SUP-2249425,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.50,170.62,,,,,,,,,,,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,0636,RC,25021-0400-10,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SCREW DISTRCTN CASPR 16MM 2 3/4IN - 16MM,SUP-2106568,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
CATHETER GUID CELLO TOT L 103 CM EFFECTIVE L 95 CM OD 0.102,SUP-2277832,CDM,C1887,HCPCS,0272,RC,,,,both,,,4097.70,2663.50,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR KT PRECIS MONTAGE MRI,SUP-2138778,CDM,C1820,HCPCS,0278,RC,,,,both,,,66863.16,43461.05,,,,,,,,,,,,,
ANCHOR SUT BRAID 2 SUT W/ ORTHOCORD GRYPHON T,SUP-2256591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
STEM FEM L125MM DIA14MM CLLR H20MM 38MM OFFSET 135DEG NEUT,SUP-2252660,CDM,C1776,CPT,0278,RC,,,,both,,,10385.55,6750.61,,,,,,,,,,,,,
CANNULA INSUL B,SUP-2417905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
CABLE ORTH L L50MM DIA1MM HIP TI ALLY SURG SMOOTH TROCH,SUP-2193592,CDM,C1713,HCPCS,0278,RC,,,,both,,,7608.53,4945.54,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0.014IN EXTN ADDWIRE 5 PK,SUP-2143722,CDM,C1769,HCPCS,0272,RC,,,,both,,,229.85,149.40,,,,,,,,,,,,,
DEXAMETHASONE 4 MG PO TABS,RX-2327,CDM,J8540,HCPCS,0636,RC,00904-7266-61,NDC,,both,1,UN,4.70,3.05,,,,,,,,,,,,,
SYSTEM CRAN FIX SM 12 MM STRL LOOP,SUP-2430763,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
SCREW BNE CANN 4X26 MM FT TIM NS,SUP-2460927,CDM,C1713,HCPCS,0278,RC,,,,both,,,484.28,314.78,,,,,,,,,,,,,
COMPONENT FEM CR NAR LT KNEE REV NP LEGION,SUP-2346229,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 81 CM DIA 8.5 FR NDL L 89 CM ML1,SUP-2497458,CDM,C1893,HCPCS,0272,RC,,,,both,,,28.04,18.23,,,,,,,,,,,,,
GRAFT BNE 10 CC CELLULAR BNE MTRX V92 FC,SUP-2742073,CDM,C1713,HCPCS,0278,RC,,,,both,,,16579.20,10776.48,,,,,,,,,,,,,
STEM HUM SZ 9 DIA9MM PROX SHLDR TI HYDROXYAPETITE REUNION,SUP-2379011,CDM,C1776,CPT,0278,RC,,,,both,,,17237.34,11204.27,,,,,,,,,,,,,
HC So1 Infliximab Level,PX-3018023067,CDM,80230,CPT,0301,RC,,,,both,,,1477.00,960.05,,,,,,,,,,,,,
PROBE VITRCTMY 23GA ANT CHMBR CENTURION ULTRAVIT,SUP-2109971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.58,448.88,,,,,,,,,,,,,
PLATE BNE L44MM THK13MM 2X6 H NONSTERILE PHLANG BASE HND TI,SUP-2176871,CDM,C1713,HCPCS,0278,RC,,,,both,,,1984.51,1289.93,,,,,,,,,,,,,
HC Renal Arteriogram,PX-3233625100,CDM,36251,CPT,0323,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
COMPONENT TALAR SZ 2 RT ANK DOME SLOPED XT REV STRL,SUP-2933030,CDM,C1776,CPT,0278,RC,,,,both,,,33252.60,21614.19,,,,,,,,,,,,,
PLATE BONEXL THK2MM 6X24X6 H MAND TI DBL ANG LCKING FOR 2MM,SUP-2191277,CDM,C1713,HCPCS,0278,RC,,,,both,,,9912.98,6443.44,,,,,,,,,,,,,
NIPPER SURG THN LN 5 IN SS,SUP-2305687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.07,273.70,,,,,,,,,,,,,
GRAFT HUM TISS TEND 10.5X80 MM FRZN TERMINALLY GRAFTLINK,SUP-2123476,CDM,C1713,HCPCS,0278,RC,,,,both,,,7300.50,4745.32,,,,,,,,,,,,,
MICROCATHETER INFUSION PROWLER SEL LP-ES L 150CM L 5CM J TIP,SUP-2460415,CDM,C1887,HCPCS,0272,RC,,,,both,,,4203.96,2732.57,,,,,,,,,,,,,
BLADE RETRCT W2XL7CM NAR MUSC MCCULLOCH,SUP-2161019,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.96,394.52,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK WAIST BELT WEB,SUP-2388212,CDM,L5688,HCPCS,0274,RC,,,,both,,,160.55,104.36,,,,,,,,,,,,,
PLATE BNE L94MM 5 H ST R SUP ANT CLAV TI LOK COMPR W LAT,SUP-2180865,CDM,C1713,HCPCS,0278,RC,,,,both,,,3165.65,2057.67,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE DERMACELL AWM 4CM X 8CM 0.2-1MM,SUP-2909513,CDM,Q4122,HCPCS,0636,RC,,,,both,,,7006.13,4553.98,,,,,,,,,,,,,
GRAFT BNE SM CYL 5 BETA-TRICALCIUM PHOSPHATE STRL CHRONOS L,SUP-2194032,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.60,748.54,,,,,,,,,,,,,
HC Abd Aortogram With Runoffs,PX-3237563000,CDM,75630,CPT,0323,RC,,,,both,,,6621.00,4303.65,,,,,,,,,,,,,
HC Extremity Venogram,PX-3613600500,CDM,36005,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L POST STBL NP HI FLX TRIMAX,SUP-2314934,CDM,C1776,CPT,0278,RC,,,,both,,,8327.28,5412.73,,,,,,,,,,,,,
PLATE TIBIA DISTAL 3.5MM TI LCP LOW BEND MEDIAL 14H LEFT 239MM,SUP-2549692,CDM,C1713,HCPCS,0278,RC,,,,both,,,3313.64,2153.87,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 20-5-0.225 MEQ/L-%-% IV SOLN,RX-102364,CDM,2500000003,HCPCS,0250,RC,65219-0153-02,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN TIP L3MM PTFE J CRV FIX,SUP-2302704,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.20,14.43,,,,,,,,,,,,,
WIRE OD15MM L250MM X FIX W O OLV,SUP-2315980,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.19,93.72,,,,,,,,,,,,,
PLATE BONE CMPRSSN 25MML HLX2 1.1MM THK STNLSS STEEL F/3.5MM,SUP-2494112,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
GRAFT ENDOVASC L12CM AORT IL DIA28.5X14.5MM TRUNK,SUP-2396084,CDM,C1768,CPT,0278,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
ELECTRODE ES 24X26FR YEL COAG PT FOR 24/28FR RESECTSCP,SUP-2261190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.11,240.57,,,,,,,,,,,,,
MARKER IDENTIFIER BX SITE MAMMOSTAR 14 G BARBELL SHP,SUP-2195625,CDM,A4648,CPT,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
IMPLANT OP RM 28 PLTS 28 PLT 20MM,SUP-2321429,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
GRAFT HUM TISS 11MM TEND PAT BNE FRZN,SUP-2335535,CDM,C1762,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK VITRECTOMY 23 GA CPM ULTRAVIT,SUP-2431932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.49,593.77,,,,,,,,,,,,,
KIT CRANIAL ACCESS SUBDURAL EVACUATING PORT SYSTEM STRL,SUP-2927884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6647.38,4320.80,,,,,,,,,,,,,
CATHETER EP MED 2 MM 1 MM 5 FRX110 CM INQUIRY,SUP-2357430,CDM,C1730,HCPCS,0272,RC,,,,both,,,823.34,535.17,,,,,,,,,,,,,
HC Sel Cath Plcmt 2nd Order Brach,PX-3613621600,CDM,36216,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW BNE L24MM DIA3.5MM CORT DST TIB TYP II ANODIZED TI ST,SUP-2411689,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
VALVE SHUNT DIA16MM SIL FLSH INTEGR CONN M PRSS SPHR FOR,SUP-2244292,CDM,C1729,HCPCS,0272,RC,,,,both,,,2248.84,1461.75,,,,,,,,,,,,,
HC Cardiopulm Resuscitation,PX-4509295000,CDM,92950,CPT,0450,RC,,,,outpatient,,,424.00,275.60,,,,,,,,,,,,,
CLOSURE SPNL GLD TI ALLOY FOR EXTN BAR RIB SUPP VEPTR,SUP-2193299,CDM,C1713,HCPCS,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
CUP ACET PROFORM POR BEAD ACET CUP NO H 56,SUP-2359087,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
BIT DRL DIA2MM DISP FOR PLT CLAW,SUP-2397355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
THORACENTESIS PRCNTSS SET 8F X 17 CM VLVD STEP FIXED LUER PG,SUP-2699822,CDM,C1729,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
CATHETER EP JSN 2-5-2 MM 6 FRX120 CM RESPON,SUP-2356802,CDM,C1730,HCPCS,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4409712900,CDM,97129,CPT,0440,RC,,,GO|CO,both,,,186.00,120.90,,,,,,,,,,,,,
PIN FIX L40MM DIA2.5MM PROV FOR EVOS SM PLATING SYS,SUP-2344057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
BUR SURG HD DIA2.1MM HELICOIDAL RASP 5 EXPOSE MARK/STEP,SUP-2367593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.96,249.57,,,,,,,,,,,,,
STAPLE BNE L 12 X W 12 X H 12 MM STRL MOTOCLIP MAX,SUP-2908414,CDM,C1713,HCPCS,0278,RC,,,,both,,,3620.42,2353.27,,,,,,,,,,,,,
MODULE EMG STRL DISP KT MAXCESS,SUP-2311772,CDM,C1713,HCPCS,0278,RC,,,,both,,,6553.18,4259.57,,,,,,,,,,,,,
PROSTHESIS OSS VENT TUBE 1.02X0.040X1 MM W/ TAB SHEA PARASOL,SUP-2312829,CDM,L8699,HCPCS,0278,RC,,,,both,,,46.85,30.45,,,,,,,,,,,,,
TUBE JEJUSTMY ENTAKE PUSH GW 9FR 35IN,SUP-2166297,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.70,409.95,,,,,,,,,,,,,
HC So Assay Myeloperoxidase,PX-3018387666,CDM,83876,CPT,0301,RC,,,,inpatient,,,84.00,54.60,,,,,,,,,,,,,
SCREW BONE L76MM OD7MM THRD L21MM PUR HINDFOOT ANK CANN M,SUP-2320952,CDM,C1713,HCPCS,0278,RC,,,,both,,,2187.01,1421.56,,,,,,,,,,,,,
ALLOGRAFT BNE FILL 1-8 MM 10 CC FD SPNG CANC READIGRAFT BLX,SUP-2740972,CDM,C1713,HCPCS,0278,RC,,,,both,,,2550.78,1658.01,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|ADJ,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|KX|CQ|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE BNE FEM 236 MM RT DSTL 9 HOLE TI STRL LCP,SUP-2549451,CDM,C1713,HCPCS,0278,RC,,,,both,,,5385.60,3500.64,,,,,,,,,,,,,
PLATE BNE STR MIC SHT 2 HOLE RIGID BLU,SUP-2462806,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.37,126.99,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X4.75 MM SHEA CUP PLAT FLROPLAS,SUP-2637821,CDM,L8613,CPT,0278,RC,,,,both,,,418.03,271.72,,,,,,,,,,,,,
HC Assay of Prolactin,PX-3018414600,CDM,84146,CPT,0301,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
HC 2 Cv Cath Plac Tesio,PX-3613656500,CDM,36565,CPT,0361,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
HC Asp Injection Major Joint|BILATERAL PROCEDURE|PO,PX-4502061000,CDM,20610,CPT,0450,RC,,,50|PO,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
BUR SURG FLUT 3 MM 2 MM RND CYL SS CARBIDE TEAL UPWR,SUP-2607630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.29,243.94,,,,,,,,,,,,,
SYRINGE MED CONE TIP 100 CC 3 RNG CTRL AUTOCLV FOR UROLOGY,SUP-2747410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1286.18,836.02,,,,,,,,,,,,,
KIT PICC DIA 6 FR GUIDEWIRE L 80 CM GUIDEWIRE NIT HYDRPHLC,SUP-2909919,CDM,C1751,HCPCS,0278,RC,,,,both,,,769.93,500.45,,,,,,,,,,,,,
BIT DRL 3.8X40 MM DURALOC,SUP-2252735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.36,223.18,,,,,,,,,,,,,
BIT DRL 4.8X280 MM,SUP-2644555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,267.78,174.06,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 10 CM DIA 7 MM EPTFE STR STD WALL REINF,SUP-2669709,CDM,C1768,CPT,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
KIT NEUROSTIMULATOR ANCHRING SYS W/ BUMPY ANCHR INJEX,SUP-2284645,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
DRIVER SURG MULTPURP N CANN FOR TRIGEN PERC SYS,SUP-2347051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1022.38,664.55,,,,,,,,,,,,,
GRAFT VASC 6MMX70CM THN WALL STRTCH PROPATEN,SUP-2395811,CDM,C1768,CPT,0278,RC,,,,both,,,7196.88,4677.97,,,,,,,,,,,,,
COIL NEUROVASCULAR AXIUM MICROFX L 20 CM SECONDARY DIA 7 MM,SUP-2430041,CDM,C1713,HCPCS,0278,RC,,,,both,,,5947.16,3865.65,,,,,,,,,,,,,
PLATE BNE W17.5XL170MM THK5.2MM 9 H BILAT S STL BROAD LOK,SUP-2185292,CDM,C1713,HCPCS,0278,RC,,,,both,,,1576.19,1024.52,,,,,,,,,,,,,
CYTAL WOUND MATRIX 3 LAYER LAWD 16X25CM,SUP-2909172,CDM,Q4166,HCPCS,0636,RC,,,,both,,,19221.32,12493.86,,,,,,,,,,,,,
SCREW INT FIX L16MM DIA1.1MM L 80L/20D COPOLYMER MENIS ARW,SUP-2166738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.11,920.47,,,,,,,,,,,,,
PLATE BNE L190MM 10 H NONSTERILE L LAT PROX TIB S STL LOK,SUP-2185720,CDM,C1713,HCPCS,0278,RC,,,,both,,,4269.71,2775.31,,,,,,,,,,,,,
KIT PLT CONC SYS BLD BNE MAR ASPIRATE RESVR AUTOTRNS BIOCUE,SUP-2402592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
OBTURATOR ENDOSCP FOR RC REP ARTHROTUNNELER,SUP-2908726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2 MM RECON PT SPEC TI,SUP-2860085,CDM,C1713,HCPCS,0278,RC,,,,both,,,21665.69,14082.70,,,,,,,,,,,,,
NEEDLE BX COR 16 GAX16 CM SEMI AUTO COAX PUR COR MISSION,SUP-2127780,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
STENT CORONARY SYNERGY L 8 MM DIA2.25 MM CATH L 144 CM DIA,SUP-2146136,CDM,C1874,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
BODY FEM SZ A W21XH60MM DIA18.5MM PROX HIP TI PPS STD,SUP-2404446,CDM,C1776,CPT,0278,RC,,,,both,,,14330.96,9315.12,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 51-100 MMX0.1 CM FD,SUP-2717856,CDM,C1762,CPT,0278,RC,,,,both,,,3049.25,1982.01,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST W/O JT PREFABRICATED,SUP-2435768,CDM,L3809,HCPCS,0272,RC,,,,both,,,644.23,418.75,,,,,,,,,,,,,
PLATE BNE L 1.71 IN MED TI ALLOY LT FT STBL LP LISFRANC NS,SUP-2912912,CDM,C1713,HCPCS,0278,RC,,,,both,,,6236.04,4053.43,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7192,SUP-2525321,CDM,C1769,HCPCS,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y DBL PLATE 1 PK STRL,SUP-2935637,CDM,C1713,HCPCS,0278,RC,,,,both,,,2078.68,1351.14,,,,,,,,,,,,,
CANNULA ART L10MM HEMSHLD,SUP-2106278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
GRAFT BNE SUB 5CC FOAM PK VERSATILE COMPR RESIST VITOSS 21021905] STRYKER CORP],SUP-2361882,CDM,C1713,HCPCS,0278,RC,,,,both,,,3692.64,2400.22,,,,,,,,,,,,,
HOOK SPNL BLDE W5.5MM BILAT TI TRNSVRS PROC OFFSET OPN REDUC,SUP-2254442,CDM,C1713,HCPCS,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
PLATE BNE 3.5X37 MM 3 HOLE SS DCP,SUP-2569135,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.42,125.72,,,,,,,,,,,,,
"HC So Enzyme Activity,Cells/Tissue",PX-3018265766,CDM,82657,CPT,0301,RC,,,,both,,,223.00,144.95,,,,,,,,,,,,,
BIT DRL NANO PROF NS ACUTRK 3,SUP-2912742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1623.38,1055.20,,,,,,,,,,,,,
TROCAR SURG CALCANEUS,SUP-2468313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BONE 1.7MM SCR H DIA N COMPR L PLT BILAT 7 H RIG RESRB,SUP-2364974,CDM,C1713,HCPCS,0278,RC,,,,both,,,470.69,305.95,,,,,,,,,,,,,
MESH HERN W25.4XL33CM POLYPR PTFE NONABSORBABLE ELLIPSE EXP,SUP-2125911,CDM,C1781,HCPCS,0278,RC,,,,both,,,6188.94,4022.81,,,,,,,,,,,,,
HINGE EXT FIX UNIV ANK FT TRUELOK FRAME ASMBLY HEXAPOD SYS,SUP-2316166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1202.84,781.85,,,,,,,,,,,,,
KIT ACC PROLAPSE,SUP-2140329,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
SCREW BNE L5MM DIA1.4MM CORT CRANIOMAXILLOFACIAL PUR S STL 5PK,SUP-2366086,CDM,C1713,HCPCS,0278,RC,,,,both,,,212.92,138.40,,,,,,,,,,,,,
ALLOGRAFT DERMAL MED 12X20 CMX1.6/0.4 MM RDY TO USE ALLDERM,SUP-2474881,CDM,Q4116,HCPCS,0636,RC,,,,both,,,28049.62,18232.25,,,,,,,,,,,,,
PLATE BONE 6 H STR FOR 2MM SCR VLP MINI-MOD SM BONE SYS,SUP-2351085,CDM,C1713,HCPCS,0278,RC,,,,both,,,2479.28,1611.53,,,,,,,,,,,,,
COLLAR CERV CNTOUR UNIV 3 IN MED DENS FOAM PROCARE,SUP-2196897,CDM,L0180,HCPCS,0274,RC,,,,both,,,7.82,5.08,,,,,,,,,,,,,
PAD ORTHOT ANTR CUST ASIS,SUP-2435588,CDM,L1250,HCPCS,0272,RC,,,,both,,,223.91,145.54,,,,,,,,,,,,,
HEADLESS SCREW SZ 3.0MM X 30MM,SUP-2586636,CDM,C1713,HCPCS,0278,RC,,,,both,,,1073.16,697.55,,,,,,,,,,,,,
HC Peripheral Block - Axillary W/Img Gdn,PX-3606441700,CDM,64417,CPT,0360,RC,,,,outpatient,,,2895.00,1881.75,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 15 CM DIA13 FR PTFE PERC NO CRV,SUP-2127884,CDM,C1894,HCPCS,0272,RC,,,,both,,,228.44,148.49,,,,,,,,,,,,,
ROD ORTHOPEDIC STBL 4.5 MM INTER-PHALANGEAL INTERPHLEX,SUP-2266337,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
CABLE STRNL TAPR 3 BLNT 1 CUT EDGE NDL SS,SUP-2754810,CDM,C1713,HCPCS,0278,RC,,,,both,,,845.29,549.44,,,,,,,,,,,,,
STENT TRACHBRONCH 8MMX80MMX117CM FLUENCY +,SUP-2129092,CDM,C1874,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
COUNTERSINK DRL SCREW DIA 3 MM NS DISP PRECIS MIS,SUP-2899150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
MONITOR CARD ASSERT-IQ EL L 9.4 X H 49 MM THK 4.4 MM 1.2 ML,SUP-2877891,CDM,C1833,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
PLATE BONE W15XL152MM THK2MM 7 H BILAT TI THN BLDE RIG,SUP-2190985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1576.25,1024.56,,,,,,,,,,,,,
BIT DRL TAPR 3.2 MM OCCIPITOCERVICAL INFIN,SUP-2632003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1387.10,901.61,,,,,,,,,,,,,
POSACONAZOLE 300 MG/16.7ML IV SOLN,RX-125559,CDM,J1837,HCPCS,0636,RC,00085-4331-01,NDC,,both,16.7,ML,3050.10,1982.56,,,,,,,,,,,,,
PORT IMPL INFUSION PWR INJ 9.6 FR PLAS POWERPORT MRI,SUP-2427949,CDM,C1788,HCPCS,0278,RC,,,,both,,,11839.84,7695.90,,,,,,,,,,,,,
STENT URET 035 6 FRX26 CM SET SENSOR POLARIS ULTRA,SUP-2754258,CDM,C2617,HCPCS,0278,RC,,,,both,,,516.59,335.78,,,,,,,,,,,,,
RING EXT FIX HALF 100 MM CARBON FIBER NS,SUP-2800122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1275.75,829.24,,,,,,,,,,,,,
HC ED Clsd Tx Shoulder WO Anes,PX-4502365000,CDM,23650,CPT,0450,RC,,,,outpatient,,,383.00,248.95,,,,,,,,,,,,,
PLUG BONE CEM 5X18MM GRN GRFT SYNTH CANC COMP RESRB TRUFIT,SUP-2341080,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
FLUCONAZOLE (DIFLUCAN) IVPB,RX-4081084,CDM,J1450,HCPCS,0636,RC,70655-0088-06,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT VASC WOVN DBL VELR STR 20MMX30CM,SUP-2469691,CDM,C1768,CPT,0278,RC,,,,both,,,2009.44,1306.14,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7050,HCPCS,0250,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
HC ER Level 3,PX-4509928300,CDM,99283,CPT,0450,RC,,,,inpatient,,,1556.00,1011.40,,,,,,,,,,,,,
PROSTHESIS 3.25MM DIAM 8.25MM LEN TORP W/ LINK DORNHOFFER,SUP-2312810,CDM,L8613,CPT,0278,RC,,,,both,,,1112.53,723.14,,,,,,,,,,,,,
SET PUNCTURE PROVOX VEGA 22.5FR X 8MM,SUP-2741941,CDM,L8501,HCPCS,0278,RC,,,,both,,,1260.68,819.44,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RANG L 150 CM BALLOON L 200 MM DIA 4 MM,SUP-2754424,CDM,C2623,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
WASHER 1.3X20MM RND SFT TISS FIX SPIK POST HT LO PROF TI ST,SUP-2166924,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.49,398.12,,,,,,,,,,,,,
IMPLANT FACE 47 X 28 MM THK 3 MM POLYETHYL LT INFERIOR MEDL,SUP-2883146,CDM,C1713,HCPCS,0278,RC,,,,both,,,1555.68,1011.19,,,,,,,,,,,,,
Access Instruments,SUP-2757214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5903.20,3837.08,,,,,,,,,,,,,
CATHETER ANGIOPASTY 137CM 40MM OD5FR ODSEC3MM .014IN OTW,SUP-2353068,CDM,C1725,HCPCS,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
MESH HERN W20.3XL25.4CM POLY 4 HYDROXYBUTYRATE SYN RECTANG,SUP-2125871,CDM,C1781,HCPCS,0278,RC,,,,both,,,19923.30,12950.14,,,,,,,,,,,,,
PROSTHESIS OSS L 2 MM DIA1.1 MM HD DIA2.5 MM TI PART FULL,SUP-2902036,CDM,L8613,CPT,0278,RC,,,,both,,,1398.68,909.14,,,,,,,,,,,,,
KIT ART LN L 15 CM DIA18 GA GUIDEWIRE L 40 CM DIA 0.028 IN,SUP-2120113,CDM,C1751,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW BONE L22MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189340,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.91,149.44,,,,,,,,,,,,,
BONE MATRIX CELLULAR ORIOS 5CC,SUP-2653967,CDM,C1713,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
TROCAR ENDOSCP DIA10 MM SZ 5/ 7/8 MM BLNT TIP SHRT BLT IN,SUP-2896288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.18,410.92,,,,,,,,,,,,,
PLATE BNE THK0MM 4 H TI BILAT LOK COMPR FOR 27 35MM SCR COT,SUP-2398182,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SCREW BNE IMPL CORT ANT CERV BLU 40MMX12MM REFLX,SUP-2380887,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.093X9 IN 3 SHANK END SS NS STEINMANN,SUP-2791272,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.13,9.83,,,,,,,,,,,,,
HC Ins Cath Ren Art 2nd+ Unilat,PX-3613625300,CDM,36253,CPT,0361,RC,,,,outpatient,,,16763.00,10895.95,,,,,,,,,,,,,
HOLDER NDLE MAYO HEGAR 7NL STRGHT STBBY JAW LATEX FREE,SUP-2484870,CDM,C1713,HCPCS,0278,RC,,,,both,,,150.00,97.50,,,,,,,,,,,,,
GRAFT BNE FEN 15X150 MM DEMINERALIZED CORTICAL FENFLEX,SUP-2742007,CDM,C1713,HCPCS,0278,RC,,,,both,,,4058.45,2637.99,,,,,,,,,,,,,
PLATE BNE 3.5X109 MM 9 HOLE SS DCP,SUP-2569141,CDM,C1713,HCPCS,0278,RC,,,,both,,,286.68,186.34,,,,,,,,,,,,,
PLATE BNE 3 H PELV ACET SPRING STRL PRO,SUP-2902627,CDM,C1713,HCPCS,0278,RC,,,,both,,,1320.53,858.34,,,,,,,,,,,,,
GRAFT SKIN 2X3 IN PURAPLY AM,SUP-2314116,CDM,Q4196,HCPCS,0636,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
INTRODUCER PACE LD FLOWGUARD DIA 8 FR ART VLV PEELABLE STRL,SUP-2281859,CDM,C1894,HCPCS,0272,RC,,,,both,,,187.65,121.97,,,,,,,,,,,,,
CANNULA SUCTION INSUL 3.5 MMX30 CM COAG W/ STYL,SUP-2773549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1625.70,1056.70,,,,,,,,,,,,,
IMPLANT TOE SM DIA22MM WIRE DIA08MM FOR IO FIX SYS CANNULINK,SUP-2400043,CDM,C1776,CPT,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 20X6 CMX1.8-4 MM FLEXHD,SUP-2307483,CDM,Q4128,HCPCS,0636,RC,,,,both,,,10688.37,6947.44,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE LG XL 28 IN BLK LTX,SUP-2421706,CDM,L1833,HCPCS,0272,RC,,,,both,,,228.18,148.32,,,,,,,,,,,,,
BIT DRL TWST 1.5X15 MM ANGLED SCREWDRIVER ANGULUS 2,SUP-2458010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.90,317.78,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 8 MM EPTFE STR TW N RING STRL,SUP-2396708,CDM,C1768,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER RENAL ACC 6FR L65CM TORC W/ INNR S STL BRAID COBRA,SUP-2171213,CDM,C1758,HCPCS,0278,RC,,,,both,,,113.67,73.89,,,,,,,,,,,,,
PLATE BNE 2X9 MM TI,SUP-2262918,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
PROBE QUIK CONN SPNL LUM CDH SEXTANT,SUP-2290626,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.27,852.98,,,,,,,,,,,,,
CATHETER SYS DRNGE UNIV CRV AQ HYDRPHLC COAT,SUP-2168612,CDM,C1729,HCPCS,0272,RC,,,,both,,,225.42,146.52,,,,,,,,,,,,,
PLATE BNE FIBULAR ANK 4 HOLE TIBIAXYS,SUP-2609016,CDM,C1713,HCPCS,0278,RC,,,,both,,,3558.03,2312.72,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX60 CM TURBO-JECT UPICDS40CT40NT1110,SUP-2759934,CDM,C1751,HCPCS,0278,RC,,,,both,,,375.51,244.08,,,,,,,,,,,,,
UNISPACER 54MM X 4MM MED LT,SUP-2202427,CDM,C1776,CPT,0278,RC,,,,both,,,10126.50,6582.22,,,,,,,,,,,,,
CATHETER NEPHROSTOMY MCOT 24 FRX25 CM SIL,SUP-2835743,CDM,C1729,HCPCS,0272,RC,,,,both,,,294.53,191.44,,,,,,,,,,,,,
SUPPORT KNEE XSM FOR 12 15IN THGH NEOPRENE,SUP-2150840,CDM,L1812,HCPCS,0272,RC,,,,both,,,32.03,20.82,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC DEMINERALIZED BNE MTRX FIBER ALLOFIBER,SUP-2759430,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
CANNULA PERF AD 17FR L762IN 3 8 CONN FEM ART NVENT PERC,SUP-2282872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.77,470.45,,,,,,,,,,,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,0636,RC,00409-2723-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER URET L69CM DIA6FR 0.038IN POLYUR OPN TIP ADPT,SUP-2129003,CDM,C1758,HCPCS,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
BLADE SCALP 85MM TIP AND HNDL CANADY HYBRID PLSM,SUP-2391727,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
PLATE BNE L187MM 10 H NONSTERILE L MED DST TIB S STL LOK,SUP-2184175,CDM,C1713,HCPCS,0278,RC,,,,both,,,3815.35,2479.98,,,,,,,,,,,,,
KIT HARV BONE GRFT,SUP-2353381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY CUST OFFSET HVY DTY,SUP-2435667,CDM,L2395,HCPCS,0274,RC,,,,both,,,414.17,269.21,,,,,,,,,,,,,
SCREW 6.5MM TI CANCELLOUS BONE WITH 4.0MM CORE DIA 60MM,SUP-2549368,CDM,C1713,HCPCS,0278,RC,,,,both,,,343.36,223.18,,,,,,,,,,,,,
COMPONENT FEM L65MM STD R DST HIP GMRS,SUP-2376513,CDM,C1776,CPT,0278,RC,,,,both,,,17141.10,11141.71,,,,,,,,,,,,,
SCREW BONE L40MM OD3.2MM FULL THRD COMPR,SUP-2418850,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
PLATE BNE W63XL40MM THK16MM 90DEG 2X3 H DST RAD TI L SHP,SUP-2191023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1801.10,1170.71,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 120 DEG L 130 CM OD,SUP-2605998,CDM,C1887,HCPCS,0272,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
BIT DRL 3.2X140 MM QC TIN COAT,SUP-2644587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,399.09,259.41,,,,,,,,,,,,,
BRACE SHLDR SM FA L115 13IN UNIV AIRMESH BRTH SLNG 15DEG,SUP-2150867,CDM,L3650,HCPCS,0274,RC,,,,both,,,171.16,111.25,,,,,,,,,,,,,
SEXUAL ASSAULT KIT EVIDENCE COLLCTN,SUP-2390655,CDM,2720000011,LOCAL,0272,RC,,,,both,,,59.50,38.67,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL CROSS PIN SELF DRL MID FACE TI,SUP-2363335,CDM,C1713,HCPCS,0278,RC,,,,both,,,126.17,82.01,,,,,,,,,,,,,
PLATE BNE VOLAR CLMN RT DSTL RADIAL 9 HOLE SS NS LCP,SUP-2183197,CDM,C1713,HCPCS,0278,RC,,,,both,,,2405.55,1563.61,,,,,,,,,,,,,
PATCH EP CATH REFSTAR QWIKPATCH DIA 6 FR EXT REF HYPR NS,SUP-2248956,CDM,C1730,HCPCS,0272,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
BUR SURG FLUT 11.1 MM ROUTER FOR ATTCH ORNG,SUP-2848327,CDM,2720000010,LOCAL,0272,RC,,,,both,,,526.08,341.95,,,,,,,,,,,,,
CUP ACET OD56MM ID50MM CO CHROM HA POR HIP PRI CEMENTLESS,SUP-2350848,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
PATCH HERN L DIA4.5IN UNCOATED MFIL PROPYLENE CIR ABSRB,SUP-2125895,CDM,C1781,HCPCS,0278,RC,,,,both,,,1791.06,1164.19,,,,,,,,,,,,,
NAIL FEM RG 10.5MM 260MM,SUP-2405537,CDM,C1713,HCPCS,0278,RC,,,,both,,,9325.80,6061.77,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 6.01-7.0 MCI STRL ADVANTAGE,SUP-2247276,CDM,C2642,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SPLINT WR PED M THK1/8IN LT WRP ARND DSGN D RNG STRP ROLYAN,SUP-2324210,CDM,L3809,HCPCS,0272,RC,,,,both,,,51.68,33.59,,,,,,,,,,,,,
BLADE SURG BRACKET O/R TBL,SUP-2479549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1732.53,1126.14,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X263 MM 20 HOLE SS LCP,SUP-2569345,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.17,406.36,,,,,,,,,,,,,
MESH HERN OPN SKRT 20X15 CM COMP PARIETEX,SUP-2174714,CDM,C1781,HCPCS,0278,RC,,,,both,,,3024.45,1965.89,,,,,,,,,,,,,
SCREW COMPR 4.5X40MM HEADLESS TI SHRT THRD STRL,SUP-2547070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1038.15,674.80,,,,,,,,,,,,,
"HC Hla a,B,C,Dr1,3,4,5, Dq Intermediate Resolution",PX-3108137066,CDM,81370,CPT,0310,RC,,,,both,,,477.00,310.05,,,,,,,,,,,,,
PLATE BNE L132MM 8 H ST POST DST TIB S STL T LOK COMPR FOR,SUP-2177437,CDM,C1713,HCPCS,0278,RC,,,,both,,,4413.27,2868.63,,,,,,,,,,,,,
ABUTMENT HEALING 17 DEG 3.5 MM CONCL REG PLATFORM MULTI-UNIT,SUP-2430164,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.69,378.10,,,,,,,,,,,,,
PLATE BONE SM L85MM 7 HOLE RIGHT DST VOLAR PRRTCLR RDL ULNAR,SUP-2720786,CDM,C1713,HCPCS,0278,RC,,,,both,,,2503.27,1627.13,,,,,,,,,,,,,
SCREW BNE L 8 MM DIA 3.2 MM MANDIBULAR XDRV EMER DISP,SUP-2935135,CDM,C1713,HCPCS,0278,RC,,,,both,,,3733.46,2426.75,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 38 X 63 X 3 MM POLYETHYL BLOCK STRL DISP,SUP-2935415,CDM,C1713,HCPCS,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
PLATE BNE L 1.5X24X22X0.6 MM RT CRANIOMAXILLOFACIAL 9 NS,SUP-2462863,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.39,656.75,,,,,,,,,,,,,
PLATE BNE LCK NAR 4.5 MM 6 HOLE COMPR STRL ALPS LTX,SUP-2861820,CDM,C1713,HCPCS,0278,RC,,,,both,,,1377.77,895.55,,,,,,,,,,,,,
WASHER ORTH DIA19 MM TI FOR 6.5/8 MM SCREW STRL ASNS,SUP-2902143,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.19,225.02,,,,,,,,,,,,,
IMMOBILIZER SHLDR BASIC ABD SLNG SM,SUP-2150926,CDM,L3650,HCPCS,0274,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
HC N Block Lumbar/Thoracic|BILATERAL PROCEDURE|PO,PX-3606452000,CDM,64520,CPT,0360,RC,,,50|PO,both,,,2895.00,1881.75,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS WORKING L 135 MM,SUP-2146960,CDM,C1753,HCPCS,0278,RC,,,,both,,,2442.42,1587.57,,,,,,,,,,,,,
GRAFT HUM TISS W2XL5CM THK08 17MM DERM ACELLULAR THCK HUM,SUP-2307455,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1580.05,1027.03,,,,,,,,,,,,,
SHEATH INTRO 9FR L40CM NDL 18GA GWIRE 0.035IN SYR 10ML COR,SUP-2282362,CDM,C1892,HCPCS,0272,RC,,,,both,,,873.08,567.50,,,,,,,,,,,,,
PLATE BNE R TROCHANTERIC FEM TI ALLY PERIPROSTHETIC NCB,SUP-2411446,CDM,C1713,HCPCS,0278,RC,,,,both,,,2815.07,1829.80,,,,,,,,,,,,,
TROCAR SURGICAL 5MM DIA SINUS WCANNULA NON STERILE,SUP-2705632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,472.66,307.23,,,,,,,,,,,,,
CATHETER ART PRESSURE MONITORING TY 018 3 FRX5 CM CPMSY300RA,SUP-2760100,CDM,C1751,HCPCS,0278,RC,,,,both,,,190.38,123.75,,,,,,,,,,,,,
SCREW BNE LCK 1.7X12 MM T5 VARIAX,SUP-2695757,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.94,331.46,,,,,,,,,,,,,
MESH HERN W5.5XL4.3IN OMEGA 3 FATTY ACID COAT POLYPR,SUP-2265982,CDM,C1781,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SYSTEM PAIN PMP 2.5 IN 270 CC QN-Q PAIN BUST SILVERSOAKER,SUP-2236826,CDM,C2626,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
VITAFOL-OB PO TABS,RX-34527,CDM,6370000000,HCPCS,0637,RC,00642-0079-12,NDC,,both,1,UN,19.20,12.48,,,,,,,,,,,,,
CATHETER ABLATN F-F CRV 2-5-2 MM 3.5 MM 8 FRX115 CM EZ STEER,SUP-2248507,CDM,C2630,CPT,0272,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
STEM FEM L150MM OD24MM UNIV STD TI KNEE REV CEM FLUT STR,SUP-2406977,CDM,C1776,CPT,0278,RC,,,,both,,,3331.85,2165.70,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE|DISCARDED DRUG NOT ADMINISTE,RX-40840076,CDM,2580000003,HCPCS,0258,RC,00264-7510-20,NDC,JW,both,250,ML,31.90,20.73,,,,,,,,,,,,,
GRAFT DERM PLIABLE FLD BRST RECON ALLGRFT L12XW4CM THICKNESS,SUP-2307550,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2369.13,1539.93,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 10 H TI V JUNCTION LP NS,SUP-2894552,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
HC So Factor X,PX-3058526066,CDM,85260,CPT,0305,RC,,,,both,,,842.00,547.30,,,,,,,,,,,,,
GUIDEWIRE ORTH VAR ANG,SUP-2187444,CDM,C1769,HCPCS,0272,RC,,,,both,,,2575.90,1674.33,,,,,,,,,,,,,
PIN DISTR AD AND PED L12MM ANT CERV R OR L,SUP-2290991,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.66,234.43,,,,,,,,,,,,,
CATHETER DRAINAGE SINGLE LUMEN 14 FRX30 CM MP UTHANE,SUP-2168201,CDM,C1729,HCPCS,0272,RC,,,,both,,,550.38,357.75,,,,,,,,,,,,,
GRAFT BONE THICKNESS 10MM PAT TEND PRESHAPED,SUP-2335260,CDM,C1713,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
TESTER VENTILATOR CIRC LUNG 1 LT VENTI +,SUP-2352860,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
RING EXT FIX PART 5/8 200 MM SLT SALVATION,SUP-2458987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB I ROSEN STRL REUSE HI-LINE,SUP-2928935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
PLATE BNE L82MM 4 H ST R ANTEROMEDIAL DST TIB S STL VAR ANG,SUP-2177667,CDM,C1713,HCPCS,0278,RC,,,,both,,,5583.52,3629.29,,,,,,,,,,,,,
PLATE BNE L112MM 4 H ST L MED DST TIB S STL VAR ANG LOK,SUP-2177632,CDM,C1713,HCPCS,0278,RC,,,,both,,,5247.16,3410.65,,,,,,,,,,,,,
BOLT INSRT FOR TI SLD TIB NAIL,SUP-2188190,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.57,307.82,,,,,,,,,,,,,
HC Percut Ablate Liver Rf,PX-3524738200,CDM,47382,CPT,0352,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
HYDROMORPHONE HCL 0.2 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-151804,CDM,J1171,HCPCS,0636,RC,71266-5035-01,NDC,JW,both,100,ML,177.10,115.11,,,,,,,,,,,,,
VALVE 40019 AORT MMX U30 1Y,SUP-2278288,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PLATE BNE L275MM 18 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185659,CDM,C1713,HCPCS,0278,RC,,,,both,,,4885.37,3175.49,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 180 CM DIA 0.035 IN SS COR STRL,SUP-2148183,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.44,43.19,,,,,,,,,,,,,
PLATE BONE L48MM STD 3 H RT DSTL VOLAR RAD S STL LO PROF,SUP-2341163,CDM,C1713,HCPCS,0278,RC,,,,both,,,2458.24,1597.86,,,,,,,,,,,,,
PIN FIX L9IN DIA32MM ST S STL 2 SIDE SGL DMND 1 END PNT,SUP-2150474,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.83,10.29,,,,,,,,,,,,,
NAIL IM L400MM OD11MM 135DEG 2MM RAD TI L TROCHANTERIC,SUP-2370335,CDM,C1713,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
PROSTHESIS PENILE 20CM CYL MALL MINOCYCLINE RIFAMPIN,SUP-2140254,CDM,C1813,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
PLATE BNE W101XL252MM 18 H BILAT TI STR LO PROF RIG LOK,SUP-2191095,CDM,C1713,HCPCS,0278,RC,,,,both,,,2362.03,1535.32,,,,,,,,,,,,,
TOTAL KNEE REPLACEMENT KIT END-DELIVERY 11 GAX120 MM 5 CC,SUP-2866890,CDM,C1713,HCPCS,0278,RC,,,,both,,,8716.64,5665.82,,,,,,,,,,,,,
PIN APEX HALF 5X120 30 C THRD,SUP-2705299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,638.68,415.14,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA SULF CA PHSPTE INJ REGEN PRO-DENSE,SUP-2399153,CDM,C1713,HCPCS,0278,RC,,,,both,,,10707.40,6959.81,,,,,,,,,,,,,
NAIL IM TIB LNG W/ HNDL OXFORD,SUP-2445267,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
PLATE CRAN 160X60X40 MM PT SPEC IMPL PEEK,SUP-2860135,CDM,C1713,HCPCS,0278,RC,,,,both,,,30123.59,19580.33,,,,,,,,,,,,,
SPACER CEMENT HD TIB DIA 54 MM FEM DIA 54 MM PMMA INNR SS,SUP-2905420,CDM,C1776,CPT,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
CATHETER ETER OCCL 24 34FR L135CM COR CTO CROSSING CROSSBOSS,SUP-2140965,CDM,C1725,HCPCS,0272,RC,,,,both,,,3782.44,2458.59,,,,,,,,,,,,,
PORT INFUS CATH DIA6.6FR TI ATTCH SIL PEEL APART INTRO SGL,SUP-2126176,CDM,C1788,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
BLADE SHAVER CRV 40 DEG 4 MM SERRATED CONVX WINDOW DIEGO,SUP-2638086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.77,275.45,,,,,,,,,,,,,
COLLECTOR TISS AUTOLGS,SUP-2418776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.01,707.21,,,,,,,,,,,,,
IMPLANT UROLOGICAL BULK AGNT 3 CC INJ DURASPHERE EXP,SUP-2165454,CDM,L8606,HCPCS,0278,RC,,,,both,,,2100.66,1365.43,,,,,,,,,,,,,
RING EXT FIX 160 MM SALVATION,SUP-2461405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3937.56,2559.41,,,,,,,,,,,,,
HC Sel Cath Plcmt Add 2/3 Brach,PX-3613621800,CDM,36218,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X40 MM PRESERVON STRUCTURAL ORAGRAFT,SUP-2745099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1765.87,1147.82,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.035IN TIP L15CM BENT PTFE,SUP-2139326,CDM,C1769,HCPCS,0272,RC,,,,both,,,50.96,33.12,,,,,,,,,,,,,
DILTIAZEM HCL ER COATED BEADS 300 MG PO CP24,RX-29276,CDM,6370000000,HCPCS,0637,RC,60687-0228-11,NDC,,both,1,UN,7.20,4.68,,,,,,,,,,,,,
PLATE BNE 19 H 2.5MM DORS WRST FUS LNG BEND TRILOK,SUP-2267978,CDM,C1713,HCPCS,0278,RC,,,,both,,,6857.76,4457.54,,,,,,,,,,,,,
VALVE AORT SZ 25 ID234MM GRFT L11CM DIA26MM SEW RNG DIA34MM,SUP-2175252,CDM,C1889,HCPCS,0278,RC,,,,both,,,24802.86,16121.86,,,,,,,,,,,,,
DEVICE DCOMPR M COR BONE POST FUS EXP STATIC AILERON,SUP-2264538,CDM,2780000010,LOCAL,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
CATHETER ABLAT L160CM DIA4MM BPLR ELECTRD W13XL40MM ULT LNG,SUP-2172350,CDM,C1888,HCPCS,0272,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,0636,RC,14789-0116-07,NDC,,both,1,UN,511.10,332.21,,,,,,,,,,,,,
HC So1 Allergen Specific,PX-3058600367,CDM,86003,CPT,0305,RC,,,,both,,,17.00,11.05,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 7 FR TIP 4 MM SPC 2,SUP-2248699,CDM,C1730,HCPCS,0272,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
HC Subsequent Immun Admin,PX-7719047200,CDM,90472,CPT,0771,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
KNOWLES PIN 5.32X3 1.2,SUP-2818102,CDM,C1713,HCPCS,0278,RC,,,,both,,,1288.37,837.44,,,,,,,,,,,,,
HC Coronaries With Graft,PX-4819345500,CDM,93455,CPT,0481,RC,,,,both,,,17157.00,11152.05,,,,,,,,,,,,,
HC Assay of Phosphorus Inorganic Urine,PX-3018410500,CDM,84105,CPT,0301,RC,,,,inpatient,,,193.00,125.45,,,,,,,,,,,,,
SCREW LAG FRE LCK 15.8 MM DIAMETERX75 MM L THRD,SUP-2197712,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.09,612.36,,,,,,,,,,,,,
CATHETER EP HISSER 5 MM SPC 5 FRX110 CM STEER,SUP-2357440,CDM,C1730,HCPCS,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
HC Balloon Dilate Urtrl Strx,PX-3615070600,CDM,50706,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
ADAPTER PACE LD OSCOR L 10 CM SIL INSUL 2 BPLR IS1 CONN,SUP-2356411,CDM,C1883,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
INTRODUCER SHTH GRY HUB 5FRX23CM PRELUDE,SUP-2303275,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.93,24.65,,,,,,,,,,,,,
HC So1 Immunoglob G Subclasses Each,PX-3018278767,CDM,82787,CPT,0301,RC,,,,both,,,5.00,3.25,,,,,,,,,,,,,
MESH MAND CUSTOMIZED PRIORITY AUG MEDPOR,SUP-2862755,CDM,C1713,HCPCS,0278,RC,,,,both,,,26288.74,17087.68,,,,,,,,,,,,,
STEM HIP SZ 2 FX,SUP-2364954,CDM,C1776,CPT,0278,RC,,,,both,,,1556.62,1011.80,,,,,,,,,,,,,
PACK TISS REM 1IN TX1 MICROTIP ULTRASONIC SURG ASPIR TISS,SUP-2384732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
SHEATH URET ACCS 9.5 FRX28 CM DIL FLX,SUP-2835790,CDM,C1894,HCPCS,0272,RC,,,,both,,,418.19,271.82,,,,,,,,,,,,,
CHANNEL WORKING L 185 CM INSRTN L 160-170 CM ENDOSCP DIA,SUP-2881889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX8 TTNM CNTRD F3.5MM LOK SCREW ST,SUP-2722262,CDM,C1713,HCPCS,0278,RC,,,,both,,,1765.87,1147.82,,,,,,,,,,,,,
PLATE BONE 45MML 23MM THK HLX8 TTNM 60DG ANGLD F/23MM SCRE,SUP-2680279,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.78,812.36,,,,,,,,,,,,,
NEEDLE SUTURE L11IN BLUNT LIGATURE FOR LEFT HAND DESCHAMPS,SUP-2803432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.44,251.19,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 4 HOLE BOX CAR 10MM TITANIUM,SUP-2826365,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.04,158.63,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 4 FR L 7 CM SS PLAT,SUP-2170553,CDM,C1894,HCPCS,0272,RC,,,,both,,,77.72,50.52,,,,,,,,,,,,,
EPIFIX 2X3CM 6SQ CM SHEET,SUP-2305750,CDM,Q4186,HCPCS,0636,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
CLAMP REPROC COMBO MR SAFE LG,SUP-2537966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.66,357.93,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 25X9X8 MM FRSH IN NACL STRL TRIAD LF,SUP-2565347,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
JOINT TOE HINGED 1 FLX,SUP-2399030,CDM,C1776,CPT,0278,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
PLATE BNE LCK NAR 4.5 MM 12 HOLE COMPR STRL ALPS LTX,SUP-2861825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.44,1072.14,,,,,,,,,,,,,
ASPIRIN 325 MG PO TABS,RX-681,CDM,6370000000,HCPCS,0637,RC,00536-1054-29,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
MESH CRAN L 55 X W 38 MM THK 0.6 MM SCREW DIA1.5 MM LG TI,SUP-2936919,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CATHETER IRRIGATION L 80 CM DIA 4 FR DSTL,SUP-2264230,CDM,C1757,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
KIT THROMCTMY 3MAX WORKING L 160 CM PROX/DSTL OD 4.7,SUP-2323351,CDM,C1887,HCPCS,0272,RC,,,,both,,,6028.80,3918.72,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2 MM MAXILLOMANDIBULAR SD NS AXS,SUP-2909475,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.25,505.86,,,,,,,,,,,,,
BASEPLATE TIB ROT TOT ANK INVISION,SUP-2850836,CDM,C1776,CPT,0278,RC,,,,both,,,5410.22,3516.64,,,,,,,,,,,,,
EVOS 3.5/4.5 PP TROC RING PL R 12H 295,SUP-2931254,CDM,C1713,HCPCS,0278,RC,,,,both,,,21337.09,13869.11,,,,,,,,,,,,,
RAIL EXT FIX 2.75IN MINI RX-FIX,SUP-2396840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8107.48,5269.86,,,,,,,,,,,,,
PROSTHESIS OSS L5MM HD OD3MM CANN OD117MM HA PART CNTR,SUP-2436524,CDM,L8613,CPT,0278,RC,,,,both,,,966.59,628.28,,,,,,,,,,,,,
PLATE BNE THK0.6MM MIC 4 H TI L FOR 1.5MM SCR OSTEOSYN LEV,SUP-2262689,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
PLATE STR 2MM 12H TI STRL VAL,SUP-2546908,CDM,C1713,HCPCS,0278,RC,,,,both,,,1972.74,1282.28,,,,,,,,,,,,,
GRAFT BNE STRP 12.5X1X0.4 CM 5 CC PLATFORM CM,SUP-2691583,CDM,C1713,HCPCS,0278,RC,,,,both,,,4823.04,3134.98,,,,,,,,,,,,,
VALVE MITRL MSTR SER CUF DIA20 MM TISS ANNULUS DIA15 MM,SUP-2894019,CDM,C1889,HCPCS,0278,RC,,,,both,,,29651.02,19273.16,,,,,,,,,,,,,
STENT URET POLARIS L 10 CM DIA 5 FR SENSOR GUIDEWIRE L 150,SUP-2461922,CDM,C2617,HCPCS,0278,RC,,,,both,,,561.49,364.97,,,,,,,,,,,,,
ROD EXT FIX GRAD 60 MM,SUP-2464594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CANCELLOUS SCREW STERILIZER 4.0X30 MM P-T,SUP-2818174,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.60,69.29,,,,,,,,,,,,,
BUR SURG DIA0.6MM BLK DRL TIP OTO-FLEX SKEETER,SUP-2284272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.39,453.30,,,,,,,,,,,,,
PLATE BNE THK08MM ORBIT PUR TI REINF FAN SMOOTH W EXPOSED,SUP-2182845,CDM,C1713,HCPCS,0278,RC,,,,both,,,4763.07,3096.00,,,,,,,,,,,,,
WEDGE TIB 28X12 MM TUBEROSITY ADV,SUP-2564492,CDM,C1776,CPT,0278,RC,,,,both,,,191.70,124.60,,,,,,,,,,,,,
PLATE BNE L145MM 8 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185638,CDM,C1713,HCPCS,0278,RC,,,,both,,,3873.06,2517.49,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM 6 H TI ALLOY T SHP NS TRILEAP,SUP-2907914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.86,1639.21,,,,,,,,,,,,,
SCREW PEDCL 6.5X50MM 2105-6550,SUP-2415320,CDM,C1713,HCPCS,0278,RC,,,,both,,,5451.04,3543.18,,,,,,,,,,,,,
HC Apply Short Leg Cast,PX-4502942500,CDM,29425,CPT,0450,RC,,,,both,,,848.00,551.20,,,,,,,,,,,,,
SCREW BNE 40X120MM SELF DRL QUIK CONN CYL SHFT AO XCALIBER,SUP-2316302,CDM,C1713,HCPCS,0278,RC,,,,both,,,463.46,301.25,,,,,,,,,,,,,
DISTRACTION INTRNL ST SIZER 51 423 21 7120 MM 36 HOLE T 6L 4,SUP-2669792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
GRAFT SFT TISS FRZN BONE BRDG LT LAT BIOCLEANSE MENIS IMP,SUP-2335262,CDM,C1713,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
SUPPORT ORTHOT CUST CLUBFOOT WDG,SUP-2435724,CDM,L3380,HCPCS,0274,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
DRILL SURGICAL 2MM DIA 2.5MML TITANIUM CANNULATED,SUP-2586645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,836.81,543.93,,,,,,,,,,,,,
TRANSDUCER W WNG HSNG 12IN CBL,SUP-2303073,CDM,C1713,HCPCS,0278,RC,,,,both,,,30.36,19.73,,,,,,,,,,,,,
PROBE NERVE STIM CONCENTRIC 100 MM,SUP-2631487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
PLATE BNE SIDE 135 DEG STD BRL 38 MM HIP 4 HOLE TALON,SUP-2391522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.12,811.93,,,,,,,,,,,,,
CONNECTOR SPNL TI PARA SM STAT FOR 6MM ROD USS VENTROFIX,SUP-2193435,CDM,C1713,HCPCS,0278,RC,,,,both,,,1588.84,1032.75,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.109X9 IN THRD SS NS STEINMANN,SUP-2791389,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.11,48.82,,,,,,,,,,,,,
STEM FEM CLLRD 13 MM KNEE REV LCS COMPLETE,SUP-2453516,CDM,C1776,CPT,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
STENT BILI HERCLNK + L 18 MM DIA 6 MM CATH L 80 CM GUIDEWIRE,SUP-2101563,CDM,C1876,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
PERC NCOMPASS NITINOL TIPLESS STONE EXTRACTOR,SUP-2827000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,799.76,519.84,,,,,,,,,,,,,
HC Percut Ablate Liver Rf,PX-3524738200,CDM,47382,CPT,0352,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PANCRELIPASE (LIP-PROT-AMYL) 5000-24000 UNITS PO CPEP,RX-141346,CDM,6370000000,HCPCS,0637,RC,73562-0115-01,NDC,,both,1,UN,9.60,6.24,,,,,,,,,,,,,
PLATE BONE W14.9XL104MM THK1.2MM 6 H DSTL TIB S STL,SUP-2185735,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.40,619.71,,,,,,,,,,,,,
TRAY INTRO L 11 CM 8 FR TUOHY BORST STR J DIL NDL SIDEPRT,SUP-2120109,CDM,C1894,HCPCS,0272,RC,,,,both,,,107.58,69.93,,,,,,,,,,,,,
PLATE BNE L 58.85 MM THK 2.59 MM TI SUBMENTAL MANDIBULAR NS,SUP-2936185,CDM,C1713,HCPCS,0278,RC,,,,both,,,4565.56,2967.61,,,,,,,,,,,,,
RETRACTOR SURG BLDE W155MM RHINOPLASTY SGL END W/O PRNG HND,SUP-2244334,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.46,288.25,,,,,,,,,,,,,
STEM FEM SZ 1 STD HIP TI PLSM SPR OVATION,SUP-2314387,CDM,C1776,CPT,0278,RC,,,,both,,,9696.32,6302.61,,,,,,,,,,,,,
DRILL 30MM,SUP-2841577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1133.54,736.80,,,,,,,,,,,,,
GRAFT HUM TISS L 250 MM DIA 7 MM PERONEUS LONGUS TEND FRZN,SUP-2913198,CDM,C1762,CPT,0278,RC,,,,both,,,6575.16,4273.85,,,,,,,,,,,,,
GRAFT HUM TISS W3-10MMX20-38CM GRACILIS TEND FRZN,SUP-2307278,CDM,C1713,HCPCS,0278,RC,,,,both,,,3568.39,2319.45,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA2MM UNTHREADED NS FOR FIXOS  ORDER MULLTIPLES OF 10,SUP-2378064,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
INSERT TIB M THK11MM UNIV DUR TOT STBL REV NEUT DURAC,SUP-2377484,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
RING FIX SZ 5 8 180MM ALUMINUM MAXFRAME,SUP-2255814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3378.80,2196.22,,,,,,,,,,,,,
"HC So1 Cytomegalovirus, Igg Antibody",PX-3028664467,CDM,86644,CPT,0302,RC,,,,both,,,49.00,31.85,,,,,,,,,,,,,
KIT RESIN AND CEM CUST,SUP-2341408,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
SLING ORTHOT LUMBAR CUST,SUP-2435580,CDM,L1090,HCPCS,0272,RC,,,,both,,,284.89,185.18,,,,,,,,,,,,,
HC N Block Inj Intercost Sng,PX-3606442000,CDM,64420,CPT,0360,RC,,,,inpatient,,,2230.00,1449.50,,,,,,,,,,,,,
IMPLANT MIDFACE PT SPEC CUSTOMIZED MEDPOR,SUP-2363698,CDM,C1713,HCPCS,0278,RC,,,,both,,,50090.88,32559.07,,,,,,,,,,,,,
SET INTRO 16FR PERC W/ GWIRE,SUP-2133598,CDM,C1892,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
SCREW BONE L30MM DIA5MM TAPR LCK FOR INTOSS FIX IOFIX 2.0,SUP-2223857,CDM,C1713,HCPCS,0278,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
PLATE BNE RECTANGULAR 1.5X38X45X0.6 MM MESH RIGID TI NS,SUP-2191100,CDM,C1713,HCPCS,0278,RC,,,,both,,,4384.07,2849.65,,,,,,,,,,,,,
STENT URET ILLUMINATOR,SUP-2242456,CDM,C2617,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
TRIAL ORTH 2.2 MM SZR TRUVIEW,SUP-2400031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1635.94,1063.36,,,,,,,,,,,,,
STEM HUM 6MM MINI SHLDR CO CHROM COMPHSVE REV PRI CEM,SUP-2404559,CDM,C1776,CPT,0278,RC,,,,both,,,14952.68,9719.24,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED STAPLER INT DIA33MM STPL L4MM KNF DIA24.4MM 2 ROW,SUP-2219808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.15,811.30,,,,,,,,,,,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1938,HCPCS,0636,RC,71288-0203-02,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL DIA 9.5 MM CANN REMOVAL NS REUSE,SUP-2905286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2044.14,1328.69,,,,,,,,,,,,,
PLATE BNE L137MM 10 H NONSTERILE R PROX TIB S STL LO PROF,SUP-2185815,CDM,C1713,HCPCS,0278,RC,,,,both,,,3659.86,2378.91,,,,,,,,,,,,,
SCREW BONE L90MM DIA6.4MM BLU TI ALLOY ANTIROTATION T25,SUP-2181060,CDM,C1713,HCPCS,0278,RC,,,,both,,,748.42,486.47,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BLU MAX 20 L 75 CM DIA 4 FR BALLOON L 10,SUP-2140995,CDM,C1725,HCPCS,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN,RX-127963,CDM,J2371,HCPCS,0636,RC,71288-0807-01,NDC,,both,0.01,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL 6 MM,SUP-2602158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
ELECTRODE NDL L15CM DIA4CM PATENTED LEVEEN UMBRELLA SHP,SUP-2149342,CDM,C1713,HCPCS,0278,RC,,,,both,,,6845.20,4449.38,,,,,,,,,,,,,
EPIFIX 2X2CM 4SQ CM,SUP-2305748,CDM,Q4186,HCPCS,0636,RC,,,,both,,,3340.96,2171.62,,,,,,,,,,,,,
SYSTEM FIX 16X14X6 MM CERV SPINE UNISON-C,SUP-2419602,CDM,C1889,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
CATHETER EP STD 2-5 MM 8 FRX110 CM STR BLZR,SUP-2424664,CDM,C1733,HCPCS,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
PTFE LINER LNG TERM VENT TUBE,SUP-2680303,CDM,L8699,HCPCS,0278,RC,,,,both,,,83.71,54.41,,,,,,,,,,,,,
PLATE BNE 59 MM,SUP-2136811,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM ROSEN XSH STRL REUSE HI-LINE,SUP-2929340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,397.24,258.21,,,,,,,,,,,,,
SPLINT WRST L L10IN R FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276629,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.29,14.49,,,,,,,,,,,,,
PLATE SPNL L5CM STD ANT THORLUM TI VANTAGE,SUP-2292691,CDM,C1713,HCPCS,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
KIT PERI DRNGE CATHETER 155FR SIL CUF 1 INSRT TY ASPIRA,SUP-2301569,CDM,C1729,HCPCS,0272,RC,,,,both,,,3293.33,2140.66,,,,,,,,,,,,,
PLATE BNE 76X50X06MM MESH CRANIOFACIAL DBL BARR TI MEDPOR,SUP-2366476,CDM,C1713,HCPCS,0278,RC,,,,both,,,4455.22,2895.89,,,,,,,,,,,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,J2470,HCPCS,0636,RC,00008-0923-51,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
COMPONENT TALAR FLAT CUT 0 RT ANK DOMED SALTO TALARIS,SUP-2423987,CDM,C1776,CPT,0278,RC,,,,both,,,24408.79,15865.71,,,,,,,,,,,,,
HC ED Clsd Tx Mcp Disl WO Anesth,PX-4502670000,CDM,26700,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SAW SURG OSCILLATING DISP,SUP-2391436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
BIT DRL L125MM DIA2MM STRYKR SHFT END OVR FOR 2X50MM,SUP-2366436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.58,384.53,,,,,,,,,,,,,
CATHETER UROLOGICAL INFUSION 5 FR 3 CC UTER GYNECATH CNTRST,SUP-2428126,CDM,C1713,HCPCS,0278,RC,,,,both,,,96.59,62.78,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 30 CC DEMINERALIZED CORT CANC BNE FIBER,SUP-2905203,CDM,C1713,HCPCS,0278,RC,,,,both,,,9264.57,6021.97,,,,,,,,,,,,,
BIT DRILL 1X75 MM 12 MM J LATCH,SUP-2841946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.81,280.03,,,,,,,,,,,,,
HC So Mgmt Methylation Analysis,PX-3108128766,CDM,81287,CPT,0310,RC,,,,both,,,418.00,271.70,,,,,,,,,,,,,
CATH DIAG PERI 5FR IMAGER II C1 65CM 5 FR,SUP-2652849,CDM,C1758,HCPCS,0278,RC,,,,both,,,45.84,29.80,,,,,,,,,,,,,
DEVICE OCCL CLP L50MM PLUNG GRP FLX SHFT FOR GILLINOV,SUP-2540327,CDM,C1889,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
OCCLUDER CV TIGERPAW SYS II LAA,SUP-2227753,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
GRAFT BONE SUB 5CC L1-10MM CANC CRUSH FRZ DRY,SUP-2165595,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
COLLAR CERV MOTN CTRL STOUT W/ REPL PD MIAMI J XTRA,SUP-2270252,CDM,L0174,HCPCS,0272,RC,,,,both,,,120.23,78.15,,,,,,,,,,,,,
D-RAD VOLAR PLATE 5H LEFT STANDARD TI,SUP-2819154,CDM,C1713,HCPCS,0278,RC,,,,both,,,3746.33,2435.11,,,,,,,,,,,,,
BIT DRL CANN 8 MM KNEE SINGLE FLUT MTO,SUP-2849082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2301.62,1496.05,,,,,,,,,,,,,
RING EXT FIX DIA120 MM HALF MONK RING,SUP-2899039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2927.27,1902.73,,,,,,,,,,,,,
ANCHOR SUT NO2 DIA65MM UP EXT TI WDG NDL PRELD W 2 STRND,SUP-2362552,CDM,C1713,HCPCS,0278,RC,,,,both,,,818.03,531.72,,,,,,,,,,,,,
GRAFT HUM TISS 50MG AMNIO MEM UMB CRD PARTICULATE MTRX FOR,SUP-2116294,CDM,Q4155,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SET SCR SPNL L40MM DIA6.4MM PEDCL TI ALLOY FUS FOR DYN STBL,SUP-2414266,CDM,C1713,HCPCS,0278,RC,,,,both,,,8778.97,5706.33,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 7X2 CM PROC SUSPEND FASC LATA TUTOPLAST,SUP-2165387,CDM,C1762,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
HANDLE SCREWDRIVER TORQUE LIMITING 2 NM STRL DISP,SUP-2435492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PROBE CIRCUMFERENTIAL 2.3MMX6.9FR LENGTH 7 FT 2 IN,SUP-2719875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.34,459.12,,,,,,,,,,,,,
SHELL ACET DIA48MM LNR SZ C 2 H MPACT,SUP-2267362,CDM,C1776,CPT,0278,RC,,,,both,,,5912.62,3843.20,,,,,,,,,,,,,
GRAFT HUM TISS W22XL50MM ILIUM BICORT STRP FRZ DRY,SUP-2307122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2437.24,1584.21,,,,,,,,,,,,,
SHELL ACET DIA42MM NO H TI ALLY PLSM SPR ESCALADE,SUP-2315199,CDM,C1776,CPT,0278,RC,,,,both,,,3755.44,2441.04,,,,,,,,,,,,,
BLOCK SURG CARVING IMPL TESTICULAR SIL ELASTMR OVL SHP 2 VOL,SUP-2340090,CDM,C1889,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HC Anesthesia Attended Care,PX-3700000000,CDM,3700000000,LOCAL,0370,RC,,,,both,,,1048.00,681.20,,,,,,,,,,,,,
NAIL IM L130MM DIA8MM MIDFOOT CANN SALVATION 2,SUP-2417598,CDM,C1713,HCPCS,0278,RC,,,,both,,,5717.94,3716.66,,,,,,,,,,,,,
LACOSAMIDE 200 MG PO TABS,RX-96885,CDM,6370000000,HCPCS,0637,RC,00131-2480-60,NDC,,both,1,UN,99.00,64.35,,,,,,,,,,,,,
SHUNT CAR 2 SWCH W/O RESVR N PROGRAMMABLE 9FR 15CM,SUP-2264207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
COMPLETION REV FM SHIM MD/STD+,SUP-2513631,CDM,C1776,CPT,0278,RC,,,,both,,,3582.74,2328.78,,,,,,,,,,,,,
SUPPORT KNEE GEL FORC L PRO-TEC,SUP-2324031,CDM,L1810,HCPCS,0274,RC,,,,both,,,75.71,49.21,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM 1.5 MM 3 MM FLROPLAS 525016,SUP-2473983,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.11,14.37,,,,,,,,,,,,,
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,2500000003,HCPCS,0250,RC,60793-0205-05,NDC,,both,1,UN,508.80,330.72,,,,,,,,,,,,,
GRAFT BONE DISC AND CHIP DEMIN BONE MTRX FRZN CANC CORT 32CC,SUP-2223556,CDM,C1762,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5 DEG 8X22X10 MM LORDTC PLIF,SUP-2632323,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
PLATE BONE L396MM 18 H RT PROX FEM LCK FOR 4.5MM SCR,SUP-2351132,CDM,C1713,HCPCS,0278,RC,,,,both,,,15746.79,10235.41,,,,,,,,,,,,,
TRIAL NERVE STIM EXT REFURB SPECTR WAVEWRITER,SUP-2141941,CDM,C1820,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CLAMP EXT FIX BAR 11 MM PIN 5 MM COMBINATION NS DISP MONK,SUP-2909040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2806.38,1824.15,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 6X6X6MM DEMIN CANC CNFRM FLX,SUP-2307024,CDM,C1713,HCPCS,0278,RC,,,,both,,,1477.94,960.66,,,,,,,,,,,,,
BIT DRILL QC 3.8X180MM,SUP-2749486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,622.63,404.71,,,,,,,,,,,,,
TUBE TRACH AD L100MM OD9.2MM ID6MM SIL UNCUF EXTRA LEN FIX,SUP-2352033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,852.64,554.22,,,,,,,,,,,,,
LENS IOL CNA0T0.205,SUP-2876998,CDM,V2632,HCPCS,0276,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA11 MM STD OPT BLDELSS FIX CANN,SUP-2896437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.84,314.50,,,,,,,,,,,,,
DRESSING BIO W4XL5IN BOV CLLGN GLYCOSAMINOGLYCAN,SUP-2243932,CDM,Q4104,HCPCS,0636,RC,,,,both,,,25873.60,16817.84,,,,,,,,,,,,,
GUIDEWIRE VASC SHORTY L 180 CM DIA 0.016 IN TAPR L 6 CM FLPY,SUP-2168622,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.40,109.46,,,,,,,,,,,,,
CATHETER DIAG ID.0170IN MIC STR COURIER,SUP-2249257,CDM,C1889,HCPCS,0278,RC,,,,both,,,2040.69,1326.45,,,,,,,,,,,,,
COMPONENT HIP P5 ENDO PROS,SUP-2351400,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 26-50 MMX0.3 CM FRZN,SUP-2717851,CDM,C1762,CPT,0278,RC,,,,both,,,3590.90,2334.08,,,,,,,,,,,,,
CATHETER CV SET 035 9 FRX15 CM 3L POLYETH,SUP-2760028,CDM,C1751,HCPCS,0278,RC,,,,both,,,308.69,200.65,,,,,,,,,,,,,
FIBER LASER 200 MH HOLM 10493] FORTEC MEDICAL INC],SUP-2225589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SCREW BNE L11MM DIA1MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189088,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
PROBE BRST BX STEREOTACTIC W/ TBNG SET TISS MGMT SYS L9CM,SUP-2420811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.73,643.32,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4X40 MM OCCIPITOCERVICAL UPPER THOR,SUP-2632002,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
GRAFT BNE 1-2 MM 10 CC SYNTH CALCIUM PHOSPHATE ACTIFUSE ABX,SUP-2130291,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
PLATE BNE L90MM 2 H ST L OLECRANON S STL LO PROF VAR ANG,SUP-2177192,CDM,C1713,HCPCS,0278,RC,,,,both,,,3563.71,2316.41,,,,,,,,,,,,,
BAG VENT ASST L SHWR PERS SUPP,SUP-2282568,CDM,Q0501,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
IMPLANT OTO 3.3X1.6X4.5MM LNG INCUS HA DBL NOTCH WEHRS,SUP-2312569,CDM,L8613,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HC So Hiv-1 & Hiv-2 Ab,PX-3068738966,CDM,87389,CPT,0306,RC,,,,outpatient,,,121.00,78.65,,,,,,,,,,,,,
BIT DRL 3.5 MM UPEX,SUP-2330464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.02,206.71,,,,,,,,,,,,,
CLIP ANEURYSM L13MM 90DEG STANDARD TITANIUM PERMANENT YASARG,SUP-2826616,CDM,C1889,HCPCS,0278,RC,,,,both,,,7451.91,4843.74,,,,,,,,,,,,,
CATHETER HD STR 24 CM 19 CM 2 VLV VASCPAK BIOFLO DURAMAX,SUP-2486139,CDM,C1750,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM 7 FR 6 MM DACRON D,SUP-2538040,CDM,C1730,HCPCS,0272,RC,,,,both,,,1225.54,796.60,,,,,,,,,,,,,
SCREW BONE MONOAXIAL 3.5 MM OVAL HEAD FOR MAXILLARY DISTRACT,SUP-2837832,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.82,272.88,,,,,,,,,,,,,
BUR SURG DIA5MM RND TWO FLUT RIM GLDE TECHNOLOGY PRECIS,SUP-2367542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
"HC Culture, Afb",PX-3008711600,CDM,87116,CPT,0300,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
MONITOR CO INSERTABLE LUXDX,SUP-2640130,CDM,C1764,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
PLATE BNE 1.5/2X27X1.2 MM 4 HOLE SS LCP,SUP-2569284,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.41,199.82,,,,,,,,,,,,,
PROGRAMMER PT FOR NEUROSTIM SYS,SUP-2284641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 25 CM DIA 0.018 IN SS PERIPH,SUP-2383358,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.01,18.86,,,,,,,,,,,,,
PLATE BNE THK0.6MM 7 H CRANIOMAXILLOFACIAL G DBL Y UNIV 2,SUP-2366252,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.86,414.61,,,,,,,,,,,,,
DILATOR SURG L24MM OD7MM INTVENT SNUS BLLN DIL CATH SYS,SUP-2106325,CDM,C1726,HCPCS,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
BRACE BK M FOR 35 40IN WAIST BLK ALUMINUM NYL STRNL BAR POLY,SUP-2196478,CDM,L0464,HCPCS,0274,RC,,,,both,,,599.83,389.89,,,,,,,,,,,,,
FENTANYL (SUBLIMAZE) 0.05 MG/ML INFUSION (PED) UNDILUTED,RX-4090323,CDM,J3010,HCPCS,0636,RC,00641-6030-01,NDC,,both,50,ML,143.80,93.47,,,,,,,,,,,,,
ROD SPNL L150MM N HANCE,SUP-2181851,CDM,C1713,HCPCS,0278,RC,,,,both,,,19478.99,12661.34,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 15 HOLES 284MM,SUP-2549515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1775.95,1154.37,,,,,,,,,,,,,
SCREW BNE 2X11 MM SELF COMPRESSIVE DYNAFIT,SUP-2610274,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.74,695.98,,,,,,,,,,,,,
SYSTEM HARVESTING GRAFT BONE 8MM OSTEOAUGER,SUP-2748438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1596.69,1037.85,,,,,,,,,,,,,
MICROCATHETER DIAG 45DEG L115CM ID0.025IN HI FLO FULL,SUP-2323641,CDM,C1887,HCPCS,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
SYSTEM ANCHR 2 ANCHR ANCHRURE,SUP-2308303,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.43,296.68,,,,,,,,,,,,,
CATHETER DRAINAGE SLIP FIT 4 FRX7 CM 20 GA 4 SH 1 STP,SUP-2303166,CDM,C1729,HCPCS,0272,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
KIT PICC 4FR L55CM DBL LUMN INDWL BLU FLEXTIP W GLIDETHRU,SUP-2383373,CDM,C1751,HCPCS,0278,RC,,,,both,,,313.37,203.69,,,,,,,,,,,,,
COMPONENT PART KNEE CEM FEM TIB KNEE UNI,SUP-2379206,CDM,C1776,CPT,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
DEVICE SUTURING N ABSRB 2-0 6 IN LD UNIT ENDOSTCH DISP,SUP-2787730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.62,224.65,,,,,,,,,,,,,
THUMBWHEEL EXT FIX UPPER LT DISP 49221002,SUP-2517240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
STENT BILI PALMAZ XL L 50 MM DIA10 MM SHTH 10 FR SS TRNSHEP,SUP-2158993,CDM,C1877,HCPCS,0278,RC,,,,both,,,5633.16,3661.55,,,,,,,,,,,,,
GUIDEWIRE HYDROPHILIC ZIP WIRE 0.025IN X 150CM,SUP-2646888,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.25,21.61,,,,,,,,,,,,,
HC Mech-Mv-Vc-Tv-Rr-Neg If,PX-4609479900,CDM,94799,CPT,0460,RC,,,,inpatient,,,491.00,319.15,,,,,,,,,,,,,
HC Mt Massage Ea 15 Min,PX-4209712401,CDM,97124,CPT,0420,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
STAPLER 45 SUREFORM CURVED TIP,SUP-2738091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.27,1060.98,,,,,,,,,,,,,
KIT LD L50CM 5MM SPC BLU FOR NEUROSTIM,SUP-2308588,CDM,C1778,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HEAD PAT SM SMALL+ LAT LCS MILESTONE,SUP-2454057,CDM,C1776,CPT,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
PLATE BONE L67MM 5 H RT ANG T SHP PERI-LOC SM FRAG SYS,SUP-2348449,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.51,843.38,,,,,,,,,,,,,
BLADE LARYN L22.5CM DIA3.5MM 60-500RPM DBL CRV ANG TIP LO,SUP-2284138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1747.50,1135.87,,,,,,,,,,,,,
GUIDE TARGET INVISION REPORT PROPHECY PS,SUP-2481858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2568.52,1669.54,,,,,,,,,,,,,
SCREW BNE LCK 3.5X10 MM DBL STRT THRD SS JPS,SUP-2645521,CDM,C1713,HCPCS,0278,RC,,,,both,,,1097.74,713.53,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 20 CM SZ 2-0 CRV NDL 28 MM SS TEMP ORN,SUP-2101197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,48.92,31.80,,,,,,,,,,,,,
STENT ES L12CM DIA18MM CATH 18.5FR L120CM MTL FULL CVR SELF,SUP-2149298,CDM,C1874,HCPCS,0278,RC,,,,both,,,7661.85,4980.20,,,,,,,,,,,,,
SCREWDRIVER BLADE 2.7 MM QUIK CPL CENTRE DRV SS 500189807,SUP-2525661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.94,280.76,,,,,,,,,,,,,
METAPHYSEAL FEMORAL CONE LARGE H52MM,SUP-2511512,CDM,C1776,CPT,0278,RC,,,,both,,,10143.77,6593.45,,,,,,,,,,,,,
STENT URET POLARIS L 26 CM DIA 5 FR SENSOR GUIDEWIRE L 150,SUP-2537597,CDM,C2617,HCPCS,0278,RC,,,,both,,,497.25,323.21,,,,,,,,,,,,,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-3729915200,CDM,99152,CPT,0372,RC,,,,both,,,297.00,193.05,,,,,,,,,,,,,
SCREW BNE L18MM DIA4.2MM NONLOCKING COMPR FOR TUFFNEK,SUP-2321248,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.49,364.32,,,,,,,,,,,,,
CATHETER CV KT 7 FRX30 CM 3L INTRO NDL SHRP SAFETY,SUP-2763325,CDM,C1751,HCPCS,0278,RC,,,,both,,,305.21,198.39,,,,,,,,,,,,,
IMMOBILIZER SHLDR SWTH UNIV DEV BLK P.A.D. III,SUP-2336074,CDM,L3650,HCPCS,0272,RC,,,,both,,,167.86,109.11,,,,,,,,,,,,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,0636,RC,55150-0259-30,NDC,,both,3,ML,54.10,35.16,,,,,,,,,,,,,
BRACE ORTH L 30 CM CIRC THGH 15.5-18.5 IN CTR 13-14 IN CALF,SUP-2914947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,841.02,546.66,,,,,,,,,,,,,
PLATE BONE 12 H ANTR LAT PROX FOR 4.5MM SCR,SUP-2349067,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.48,686.06,,,,,,,,,,,,,
MOUNT EXT FIX BEAC NS DISP SMRT TSF,SUP-2933057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3536.14,2298.49,,,,,,,,,,,,,
GRAFT BONE SUB 10ML CA PHOS FIL VOID CEM NORIAN CRS,SUP-2193981,CDM,C1713,HCPCS,0278,RC,,,,both,,,10179.88,6616.92,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X68 MM 8 HOLE TI,SUP-2536117,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
CATHETERIZATION KIT 3 L 6FRX55CM VPS,SUP-2641814,CDM,C1751,HCPCS,0278,RC,,,,both,,,1066.56,693.26,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM 10 CM BALL SM BOR MIDAS REX 8 LEGEND,SUP-2664489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.22,268.59,,,,,,,,,,,,,
LEAD PACE L86CM CRV H16MM INTRO 5FR L HRT LO PROF STEER TIP,SUP-2356059,CDM,C1900,HCPCS,0275,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CATHETER MAP 3 MM 7 FRX110 CM 15 MM INQUIRY AFOCUS II EB,SUP-2516512,CDM,C1731,HCPCS,0278,RC,,,,both,,,3227.92,2098.15,,,,,,,,,,,,,
GRAFT BONE ALLGRFT TEND SEMITENDINOSUS N GAM FRZN MAXXEUS,SUP-2165610,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
CUP ACET DIA62MM UNIV HIP PORCOAT MH STD PROF REV PINN,SUP-2250122,CDM,C1776,CPT,0278,RC,,,,both,,,5042.84,3277.85,,,,,,,,,,,,,
PLATE BNE W5XL39MM THK1.2MM 7 H L CNDYL TI RIG LOK FOR 2MM,SUP-2191063,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.67,733.64,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA LOW BEND 14H 206MM RT STER,SUP-2546874,CDM,C1713,HCPCS,0278,RC,,,,both,,,5023.03,3264.97,,,,,,,,,,,,,
PLATE BNE W195XL42MM NAR 6X2 H ST R DST VOLAR RAD TI VAR ANG,SUP-2180831,CDM,C1713,HCPCS,0278,RC,,,,both,,,2523.65,1640.37,,,,,,,,,,,,,
CATHETER VASC ELLIPSYS SHTH 6 FR GUIDEWIRE 0.014 IN RVD 2 MM,SUP-2859466,CDM,C1889,HCPCS,0278,RC,,,,both,,,28103.00,18266.95,,,,,,,,,,,,,
SHUNT ARTOTMY 27 F 89 CM LEN TAPR VLV LO FLO W/O RESVR BVL,SUP-2174291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.70,494.45,,,,,,,,,,,,,
RING HALF FRDM CIR FIX 160MM,SUP-2400647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
PROBE LITHO L500MM DIA1.6MM PNEUMAT HANDHELD DISP LMA,SUP-2171446,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.49,406.57,,,,,,,,,,,,,
CATHETER INFUS 4FR L135CM TIP L10CM 0.035IN VLV SGL LUMN,SUP-2172513,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
MESH SURG 35CM LEN 25CM W THK07MM INGUINAL SYN N ABSRB,SUP-2126051,CDM,C1781,HCPCS,0278,RC,,,,both,,,899.30,584.54,,,,,,,,,,,,,
SCREW CORT 5.0MMX34MM ALTA,SUP-2363416,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.22,166.54,,,,,,,,,,,,,
PLATE BNE TIB 4.5/6.5X165 MM LT PROX LAT 8 HOLE SS EPI UNION,SUP-2472819,CDM,C1713,HCPCS,0278,RC,,,,both,,,1321.00,858.65,,,,,,,,,,,,,
COLLAR EXTRIC FR 2.5IN FOR 11-23IN NK SHT 1 PC,SUP-2194421,CDM,L0172,HCPCS,0274,RC,,,,both,,,24.46,15.90,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 15CC ALLO ADIPOSE MATRIX AP0001,SUP-2676578,CDM,C1762,CPT,0278,RC,,,,both,,,1534.83,997.64,,,,,,,,,,,,,
COMPONENT PAT STD 3PEG RND REV ROT NP CEM WITHOUTXRAY WIRE,SUP-2252418,CDM,C1776,CPT,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
HALF RING 140 MM INT DIAM,SUP-2818047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7020.57,4563.37,,,,,,,,,,,,,
BIT DRILL TWIST 16MM DIA 295MML STNLSS STEEL DNTL ATTCH W/,SUP-2681195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.30,270.59,,,,,,,,,,,,,
HC 3d Plan,PX-3337729500,CDM,77295,CPT,0333,RC,,,,both,,,6474.00,4208.10,,,,,,,,,,,,,
INSERT ACET 42X50X9 MM HIP HD NK MAG,SUP-2137412,CDM,C1776,CPT,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.428,SUP-2859992,CDM,C1713,HCPCS,0278,RC,,,,both,,,38421.04,24973.68,,,,,,,,,,,,,
CATHETER KIT SINGLE LUMEN 3 FR PICC,SUP-2118362,CDM,C1751,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
CATHETER CV SET 018 6 FRX60 CM 3L SPECTRUM TURBO-JECT,SUP-2759764,CDM,C1751,HCPCS,0278,RC,,,,both,,,375.61,244.15,,,,,,,,,,,,,
KIT STPL W20XL20MM BNE FIX BRDG 2 LEG CONT COMPR BME ELITE,SUP-2254042,CDM,C1713,HCPCS,0278,RC,,,,both,,,4490.67,2918.94,,,,,,,,,,,,,
BLADE ENDOSCP CAPSLTMY 4 MM CRV HNDL CAPSULECUT DISP,SUP-2121994,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413562,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.68,246.14,,,,,,,,,,,,,
HC NM Thyroid Uptake Sgl/Multi,PX-3417801400,CDM,78014,CPT,0341,RC,,,,both,,,4685.00,3045.25,,,,,,,,,,,,,
PLATE BNE L28MM THK1MM 6 H NONSTERILE HND TI STR LOK VAR ANG,SUP-2181003,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.68,939.04,,,,,,,,,,,,,
PASSER SUTURE CAPSULESTITCH,SUP-2859832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
"HC Neuromuscular Re-Education, Ot|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS",PX-4309711200,CDM,97112,CPT,0430,RC,,,GO|CO,both,,,159.00,103.35,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 9 FR GUIDEWIRE L,SUP-2763327,CDM,C1892,HCPCS,0272,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
COLLAR CERV SFT 4X22IN UNIV,SUP-2276584,CDM,L0120,HCPCS,0274,RC,,,,both,,,7.79,5.06,,,,,,,,,,,,,
HC Cholecystostomy,PX-3614749000,CDM,47490,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
HC So1 Factor IX,PX-3058525067,CDM,85250,CPT,0305,RC,,,,both,,,53.00,34.45,,,,,,,,,,,,,
HC So Bile Acids Total,PX-3018223966,CDM,82239,CPT,0301,RC,,,,inpatient,,,65.00,42.25,,,,,,,,,,,,,
BOOT WALKING PREFORTED FT GTT,SUP-2265019,CDM,L4387,HCPCS,0274,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
LEAD DEFIB LINOXSMART SD L 65 CM DIA2.6 MM TIP DISTANCE 18,SUP-2138095,CDM,C1895,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
WIRE ORTH POLYETHYL KT CERCLAGE FOR GLEN BNE LOSS IMPL STRL,SUP-2882281,CDM,C1713,HCPCS,0278,RC,,,,both,,,2530.84,1645.05,,,,,,,,,,,,,
GRAFT BNE L160 180MM DIA4 6MM SEMITENDINOSUS TEND HAMSTRING,SUP-2264639,CDM,C1713,HCPCS,0278,RC,,,,both,,,2525.78,1641.76,,,,,,,,,,,,,
PLATE BNE L56MM 4 H R RAD HD RIM S STL RIG LOK COMPR FOR,SUP-2186000,CDM,C1713,HCPCS,0278,RC,,,,both,,,1833.67,1191.89,,,,,,,,,,,,,
STEM FEM 3X6IN TI PROX HIP MOD 1 PC FIN,SUP-2407279,CDM,C1776,CPT,0278,RC,,,,both,,,14871.04,9666.18,,,,,,,,,,,,,
CATHETER ANGIO IMPRESS L 110 CM 5 FR 0.046 IN 0.038 IN IM,SUP-2665520,CDM,C1887,HCPCS,0272,RC,,,,both,,,75.11,48.82,,,,,,,,,,,,,
MESH HERN W15XL10CM TEXTILE MFIL POLYETH TEREPHTHALATE,SUP-2174685,CDM,C1781,HCPCS,0278,RC,,,,both,,,1330.79,865.01,,,,,,,,,,,,,
GUIDEWIRE ORTH L450MM DIA2.8MM CALIB L300MM TRCR PNT THRD,SUP-2194147,CDM,C1769,HCPCS,0272,RC,,,,both,,,193.20,125.58,,,,,,,,,,,,,
BRACE KNEE 2XL POPLITEAL FAB W ADV STRTCH POLYCENTRIC HNG,SUP-2276698,CDM,L1810,HCPCS,0274,RC,,,,both,,,391.34,254.37,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 20 X 20 X 2.45 X 0.45 MM POLYETHYL SELLA,SUP-2935353,CDM,C1713,HCPCS,0278,RC,,,,both,,,2455.48,1596.06,,,,,,,,,,,,,
PROSTHESIS OSS 06X4MM TI PIST,SUP-2232482,CDM,L8613,CPT,0278,RC,,,,both,,,567.24,368.71,,,,,,,,,,,,,
TRIGEN 4.0 DIAPHYSEAL DRILL,SUP-2818908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,727.95,473.17,,,,,,,,,,,,,
COMPONENT TIB STEMMABLE 1 KNEE FLUT STEM MOB PC NEGEN,SUP-2200827,CDM,C1776,CPT,0278,RC,,,,both,,,8886.20,5776.03,,,,,,,,,,,,,
HALF RNG 140MM FRDM CIR FIX,SUP-2400640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
INSERT TIB SZ 1.5 THK8MM UNIV KNEE POLYETH CRUC RET POST LIP,SUP-2253778,CDM,C1776,CPT,0278,RC,,,,both,,,3214.10,2089.16,,,,,,,,,,,,,
COIL NEUROVASCULAR HYPERSOFT 3D L 2 CM LOOP DIA2 MM,SUP-2305365,CDM,C1889,HCPCS,0278,RC,,,,both,,,5388.24,3502.36,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED ANTR TIBIALIS,SUP-2867111,CDM,C1762,CPT,0278,RC,,,,both,,,4614.70,2999.55,,,,,,,,,,,,,
LEAD NERVE STIM 60 CM PERC PADDLE 8 CHANNEL TRIPOLE,SUP-2355938,CDM,C1778,HCPCS,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 4 FR SM VEIN BASIC W/ TCS POWERPICC,SUP-2759201,CDM,C1751,HCPCS,0278,RC,,,,both,,,1045.78,679.76,,,,,,,,,,,,,
HC C-Spine Complete W/ Flex/Ext,PX-3207205200,CDM,72052,CPT,0320,RC,,,,outpatient,,,1157.00,752.05,,,,,,,,,,,,,
PROSTHESIS OSS COIL L275MM DST END DIA145MM TI KRAUS K HELIX,SUP-2232514,CDM,L8613,CPT,0278,RC,,,,both,,,1561.05,1014.68,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 8H 199MM LT STRL,SUP-2546848,CDM,C1713,HCPCS,0278,RC,,,,both,,,6312.09,4102.86,,,,,,,,,,,,,
"HC So Aldosterone, Serum",PX-3078208866,CDM,82088,CPT,0307,RC,,,,both,,,341.00,221.65,,,,,,,,,,,,,
GRAFT BNE 3X3 TISSUEMEND PTCH,SUP-2366723,CDM,C1781,HCPCS,0278,RC,,,,both,,,13649.58,8872.23,,,,,,,,,,,,,
KIT NAVIGATION W/ BX NDL 19GA L105MM FNA NDL 20GA L15CM BX,SUP-2392619,CDM,C1713,HCPCS,0278,RC,,,,both,,,2246.67,1460.34,,,,,,,,,,,,,
BIT DRL DIA1.5MM STP D6MM MINI QUIK CPL FOR ST SCR,SUP-2188360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
ROD SPNL L 100 DIA 6 MM CARBON FIBER PEDCL IL CREST STRL,SUP-2883099,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
SHUNT CV L10CM DIA3.5X5MM SIL STR FULL SPR REINF SUNDT,SUP-2308221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1890.31,1228.70,,,,,,,,,,,,,
CATHETER ATHRCTMY LSR CLIRPATH,SUP-2353077,CDM,C1885,CPT,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
PLATE BONE MAND HEMI PRI RECON RT 5 + 17 H,SUP-2363733,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.83,2255.39,,,,,,,,,,,,,
GUIDEWIRE VASC L 100 CM DIA 0.038 IN TIP L 3 MM NDL 18 GA 5,SUP-2214398,CDM,C1769,HCPCS,0272,RC,,,,both,,,96.77,62.90,,,,,,,,,,,,,
BIT DRL L190MM DIA2MM LNG QUIK CONN DISP FOR PERI-LOC L,SUP-2343993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,807.14,524.64,,,,,,,,,,,,,
SCREW BNE L32MM DIA4MM PROX HUM S STL ST NONCANNULATED LOK,SUP-2371531,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.73,337.17,,,,,,,,,,,,,
KIT INTRO PK L 10 CM DIA 4 FR 7 CM 21 GA 7 CM 21 GA HYDRPHLC,SUP-2703689,CDM,C1894,HCPCS,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
ORTHO ANCHRGE C TUBE PLATE CROSS SHPD 17MM BRDGE 10MM THICK,SUP-2707481,CDM,C1713,HCPCS,0278,RC,,,,both,,,632.05,410.83,,,,,,,,,,,,,
SCREW KIT TRAD EQUINOXE,SUP-2451372,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
PLATE BNE L115MM THK3.5-4.5MM 4X4 H MED TIB TI LOK FOR,SUP-2190906,CDM,C1713,HCPCS,0278,RC,,,,both,,,3480.91,2262.59,,,,,,,,,,,,,
BIT DRL L157MM DIA2MM SH FOR VAR ANG LOCKED PLATING SYS,SUP-2344012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.69,591.95,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED ARTC SURF KNEE UPCHARGE HXLPE,SUP-2212682,CDM,C1776,CPT,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
KIT ANGIO XCELA DIA 4 FR STRL,SUP-2117195,CDM,C1751,HCPCS,0278,RC,,,,both,,,519.61,337.75,,,,,,,,,,,,,
SHORT CALCNL DRL 4.1MM,SUP-2244336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.69,786.95,,,,,,,,,,,,,
DEFIBRILLATOR IMPL KRONOS W 55 X H 55 MM D 13 MM 30 J VVED,SUP-2138089,CDM,C1721,HCPCS,0275,RC,,,,both,,,63537.90,41299.63,,,,,,,,,,,,,
SPACER SHLDR 11X20 MM AEQUALIS FLX REVIVE,SUP-2421705,CDM,C1776,CPT,0278,RC,,,,both,,,8093.35,5260.68,,,,,,,,,,,,,
SEGMENT FEM L26CM INTERCALARY FINN CPS,SUP-2406907,CDM,C1776,CPT,0278,RC,,,,both,,,16968.56,11029.56,,,,,,,,,,,,,
CATHETER NEPHSTMY 8FR L25CM PERCFLX GLDEX KT PGTL TIP RADPQ,SUP-2147789,CDM,C1729,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
MICROCATHETER GUID MARATHON TOT L 170 CM L 165 CM,SUP-2172482,CDM,C1887,HCPCS,0272,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
TRIUNE VENT TUBE 135MM ID X 5MM LENGTH 80 DUROMETER 5 PACK,SUP-2669495,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.46,32.15,,,,,,,,,,,,,
RELOAD STPL 45MM THCK TISS GRN W/ GRIPPING SURF TECHNOLOGY,SUP-2283261,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.18,466.82,,,,,,,,,,,,,
BOWL BNE CEM MIX UNIV W/ SPAT SGL VAC ROTOR W/OUT NOZ,SUP-2199458,CDM,C1763,HCPCS,0278,RC,,,,both,,,273.49,177.77,,,,,,,,,,,,,
FOUNDATION CONSTRN PS INSRT SZ 2 11 MM,SUP-2216428,CDM,C1776,CPT,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
CUTTER PIN HRCLS 3MM MAX CPCTY LG 8 1/2NL TNGSTN CRBDE BLADE,SUP-2484805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2875.83,1869.29,,,,,,,,,,,,,
DUAL OUTER DIAM SCR REVERE SCR MOD,SUP-2232365,CDM,C1713,HCPCS,0278,RC,,,,both,,,2603.06,1691.99,,,,,,,,,,,,,
CATHETER BILI DRNAGE 12FR L40CM POLYUR HYDRPHLC COAT SFT AND,SUP-2303562,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
SHEATH URET ACCS AQUAGUIDE 10 FR 12 14 FR 55 CM,SUP-2126283,CDM,C1894,HCPCS,0272,RC,,,,both,,,2684.10,1744.66,,,,,,,,,,,,,
GRAFT BONE SUB 5CC 1CM DEMIN MTRX PUTTY FRZ DRY OSTEOFIL,SUP-2293736,CDM,C1713,HCPCS,0278,RC,,,,both,,,2359.40,1533.61,,,,,,,,,,,,,
RELOAD STPLR LD UNIT 25 USE SS TI WHT EEA DISP,SUP-2787748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,985.39,640.50,,,,,,,,,,,,,
PIN FIX SZ 2MM PROV DISP,SUP-2344037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.60,587.99,,,,,,,,,,,,,
GRAFT BNE CANC 60 CC 80-20% CORTICAL,SUP-2321771,CDM,C1762,CPT,0278,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
LONG CALI DRILL 4.9MM CANN,SUP-2496893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2173.38,1412.70,,,,,,,,,,,,,
CATHETER EP SFT TIP DECAPOLAR STEER INQUIRY,SUP-2516508,CDM,C1730,HCPCS,0272,RC,,,,both,,,1307.81,850.08,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL 19GA L56CM 50DEG BVL ANG S STL BRK CRV SM,SUP-2357224,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
COMPONENT TIB SM L80MM DIA16MM PROX MOD GMRS,SUP-2376521,CDM,C1776,CPT,0278,RC,,,,both,,,17264.03,11221.62,,,,,,,,,,,,,
HC Splint Appl Long Arm,PX-4302910500,CDM,29105,CPT,0430,RC,,,,both,,,867.00,563.55,,,,,,,,,,,,,
GRAFT BNE XS,SUP-2424568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.11,695.57,,,,,,,,,,,,,
BIT DRILL CALIB RF 4.9MM,SUP-2474906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.24,793.81,,,,,,,,,,,,,
CATHETER URODYN 3L 7.4 FRX30 CM POLYURETHANE,SUP-2835716,CDM,C1726,HCPCS,0272,RC,,,,both,,,66.35,43.13,,,,,,,,,,,,,
SCREW SPNL TAPR 4.5X12 MM OCCIPITOCERVICAL,SUP-2632005,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
NEEDLE NRV STIM BVL TIP INSUL PEDCL ACCS SYS FOR EMG MON,SUP-2310407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SYSTEM OCCL DEL L60CM SHTH 6FR 45DEG CRV CBL DIL HEMSTAS,SUP-2355729,CDM,C1894,HCPCS,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 50 CM EPTFE STR TW,SUP-2396158,CDM,C1768,CPT,0278,RC,,,,both,,,1840.04,1196.03,,,,,,,,,,,,,
CATHETER THROMBS RETRV ERIC L 30 MM DIA 4 MM DSTL TIP L 5 MM,SUP-2898697,CDM,C1757,HCPCS,0272,RC,,,,both,,,20017.50,13011.37,,,,,,,,,,,,,
CATHETER IVUS REFINITY WORKING L 135 MM TIP TO TRANSDUCER L,SUP-2430604,CDM,C1753,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
PLATE BNE L118MM 6 H ST L LAT PROX TIB S STL LOK COMPR LO,SUP-2185714,CDM,C1713,HCPCS,0278,RC,,,,both,,,4593.82,2985.98,,,,,,,,,,,,,
EXTERNAL FIXATION KIT DPHSEAL TIB STRL GALAXY UNYCO LTX,SUP-2875637,CDM,C1713,HCPCS,0278,RC,,,,both,,,8308.44,5400.49,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA10 MM EPTFE FLX STD WALL SM BEAD,SUP-2761491,CDM,C1768,CPT,0278,RC,,,,both,,,3118.74,2027.18,,,,,,,,,,,,,
CATHETER THOR HTS CTD SIL MEDIA 11MM10CS,SUP-2265911,CDM,C1729,HCPCS,0272,RC,,,,both,,,62.17,40.41,,,,,,,,,,,,,
SHELL ACET OD56MM ID23MM UNIV TI PPS HIP MH LCK RNG PRI IMP,SUP-2403458,CDM,C1776,CPT,0278,RC,,,,both,,,12255.42,7966.02,,,,,,,,,,,,,
PLATE BNE W11XL226MM THK4.2MM 14 H MTPHSEAL S STL LOK COMPR,SUP-2185267,CDM,C1713,HCPCS,0278,RC,,,,both,,,3460.15,2249.10,,,,,,,,,,,,,
TRANS1 FACET SCR SYS,SUP-2389071,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
COLLAR CERV PADDED SM SHT 2X10X20 IN COMFORT ADJ MIAMI J,SUP-2434341,CDM,L0174,HCPCS,0272,RC,,,,both,,,150.66,97.93,,,,,,,,,,,,,
SCREW SPNL POLYAX 6X30 MM POST THORLUM SELF RET TI PRECEPT,SUP-2568255,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SET URET STENT MARD L 28 CM DIA 7 FR ZIPWIRE 0.038 IN,SUP-2721280,CDM,C2617,HCPCS,0278,RC,,,,both,,,520.08,338.05,,,,,,,,,,,,,
AGENT VISCOELASTIC 0.85 CC COHESIVE HEALON GV PRO,SUP-2753859,CDM,C1814,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
BENEFIBER ON THE GO PO POWD,RX-132196,CDM,6370000000,HCPCS,0637,RC,86790-0162-80,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE GLDEWIRE .018INX150CM,SUP-2140128,CDM,C1769,HCPCS,0272,RC,,,,both,,,879.70,571.80,,,,,,,,,,,,,
TOOL SURG DIA9.5MM KNEE CRUCIAL GORE SMOOTH,SUP-2341335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1137.62,739.45,,,,,,,,,,,,,
LINER ACET OD44MM ID28MM 0DEG HIP ULTAMET REV LOK RNG,SUP-2250321,CDM,C1776,CPT,0278,RC,,,,both,,,5537.08,3599.10,,,,,,,,,,,,,
PLATE BNE L 1 MM RT LCK TI,SUP-2459892,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.17,597.46,,,,,,,,,,,,,
FOIL DENTAL 262MMW X 262MML 03MM THK RESORB X LATEX FREE,SUP-2669264,CDM,C1713,HCPCS,0278,RC,,,,both,,,1327.97,863.18,,,,,,,,,,,,,
Z INACTIVATING USE 2718717 LASER FIBER FLEXIVA PULSE ID 365,SUP-2718716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1000.78,650.51,,,,,,,,,,,,,
CATHETER CV KT PEDIATRIC 5.5 FRX8 CM 3L STR SFT TIP,SUP-2763364,CDM,C1751,HCPCS,0278,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
DEVICE ULTRASOUND IMAGING SYS FLUID DOCK FOR ULTRA ICE CATH,SUP-2141336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CASSETTE IRR SUCT SONOPET IQ,SUP-2419516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1504.44,977.89,,,,,,,,,,,,,
GRAFT HUM TISS W14-18XL40MM FIB SHFT STRUCTURAL ALLGRFT FRZ,SUP-2307190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1795.42,1167.02,,,,,,,,,,,,,
SETSCREW SPNL DIA6.35MM TI NONBREAK OFF CDH LEG,SUP-2288548,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
PLATE BONE L94MM 6 HOLE RIGHT LTRL DST PRRTCLR TBL STNLSS ST,SUP-2483830,CDM,C1713,HCPCS,0278,RC,,,,both,,,4263.99,2771.59,,,,,,,,,,,,,
PLATE EXT FIX BRDG 210 MM FOR 5/8 RNG ALUM NS MAXFRAME,SUP-2800254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4358.51,2833.03,,,,,,,,,,,,,
PLATE BNE THK 0.75 MM PANEL 1.7 MM 1 X 21 H MAXILLOFCL PART,SUP-2909605,CDM,C1713,HCPCS,0278,RC,,,,both,,,7925.17,5151.36,,,,,,,,,,,,,
CATHETER BLLN OCCL L150CM OD2.95X2.6FR ID0.025IN STR MIC,SUP-2323649,CDM,C1887,HCPCS,0272,RC,,,,both,,,2775.76,1804.24,,,,,,,,,,,,,
FIBER LASER DIA550UM FLEXSHIELD HOLM HI PWR POLISHED OUTPT,SUP-2139420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1272.39,827.05,,,,,,,,,,,,,
DEFIBRILLATOR CARD 76GM 35CC W40XH73MM THK14MM PARYLENE,SUP-2356268,CDM,C1722,HCPCS,0275,RC,,,,both,,,35168.00,22859.20,,,,,,,,,,,,,
HC Pvb Thoracic Single Inj Site,PX-3606446100,CDM,64461,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
FLOTUFOLASTAT F 18 GALLIUM 296-5846 MBQ/ML IV SOLN,RX-163890,CDM,A9608,HCPCS,0343,RC,69932-0002-01,NDC,,both,1,UN,21374.80,13893.62,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 40 CM DIA28 MM L 15 CM 10 MM AG FLO,SUP-2385036,CDM,C1768,CPT,0278,RC,,,,both,,,5228.10,3398.26,,,,,,,,,,,,,
BRACE KNEE AD UNIV FOAM POSTOP UNISX WRP ARND HNG T SCP,SUP-2150860,CDM,L1810,HCPCS,0274,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX1.5 CM BLLN BUTTON SIL MINI 1,SUP-2754573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.73,332.62,,,,,,,,,,,,,
ALLOGRAFT BNE FD IRRADIATED FEM SEG,SUP-2867055,CDM,C1762,CPT,0278,RC,,,,both,,,2416.23,1570.55,,,,,,,,,,,,,
SYSTEM KNEE FLEX CEM GSF MIS,SUP-2212261,CDM,C1776,CPT,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
BUR SURG HOLE MAKER 12.6X10.4 MM 14 CM LG BOR MIDAS REX 8,SUP-2664603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.69,332.60,,,,,,,,,,,,,
BLADE SCREWDRIVER 2MM2.3MM DIA 94MML CROSS DRIVE WSLEEVE,SUP-2707273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1610.82,1047.03,,,,,,,,,,,,,
GRAFT VASC L 35 MM ID 5 MM CLLGN BOV CAR ART WOVEN,SUP-2880947,CDM,C1768,CPT,0278,RC,,,,both,,,8474.86,5508.66,,,,,,,,,,,,,
PLATE BNE CLMN RT DSTL DORS ULN STRL,SUP-2463657,CDM,C1713,HCPCS,0278,RC,,,,both,,,2445.06,1589.29,,,,,,,,,,,,,
SPLINT WRST XL AD L8IN FOR 85 95IN L NYL LN FOAM PUL ON,SUP-2276660,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.83,10.94,,,,,,,,,,,,,
ADJUSTER SPNL 14MM STR,SUP-2292678,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.60,944.19,,,,,,,,,,,,,
SCREW BNE LCK 4.5X26 MM ANK FUSION CONSTRUCT,SUP-2609769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.04,656.53,,,,,,,,,,,,,
BASKET STONE RETRV L70CM DIA4.5FR SEGR,SUP-2141083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TROCAR ARTHSCP 5MM CANN SPEED-LOCK,SUP-2361387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.02,304.21,,,,,,,,,,,,,
PLATE BNE L W135XL188MM THK42MM 10 H BILAT TI NAR RIG NEUT,SUP-2190820,CDM,C1713,HCPCS,0278,RC,,,,both,,,1610.19,1046.62,,,,,,,,,,,,,
CAP PROTCT GRN FOR 6MM EXT FIX PIN,SUP-2188686,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.24,108.71,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 6 MM EPTFE STD WALL REINF 3,SUP-2481904,CDM,C1768,CPT,0278,RC,,,,both,,,6923.70,4500.40,,,,,,,,,,,,,
COMPONENT HUM DSTL MRS L45MM,SUP-2364665,CDM,C1776,CPT,0278,RC,,,,both,,,14506.80,9429.42,,,,,,,,,,,,,
AGENT VISCOELASTIC REG 0.55 CC COHESIVE HEALON PRO,SUP-2753858,CDM,C1814,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
PLATE BNE 11 H ORBIT RIM TI FOR PLUSDRIVE SCR,SUP-2190575,CDM,C1713,HCPCS,0278,RC,,,,both,,,1103.40,717.21,,,,,,,,,,,,,
ROD EXT FIX L335MM DIA16MM S STL THRD CANN BLNT TIP,SUP-2187862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.87,989.87,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM HA TWO NO2 WHT COBRAID BLU TWINFIX ULT,SUP-2341840,CDM,C1713,HCPCS,0278,RC,,,,both,,,988.13,642.28,,,,,,,,,,,,,
GUIDEPIN ORTH DIA2.5MM BRK AWAY FOR ANCHR PEG GLEN GLOB,SUP-2252720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
FILTER VASC OPTEASE L 90 CM DIA 6 FR NIT AC JUG ACCS,SUP-2865605,CDM,C1880,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
ENDOTRACHEAL TUBE KIT 35 FR LT DL BLT IN VID CAM VIVASIGHT 2,SUP-2752982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
TUBE CONN OUTER MID TELLURIDE FOR MIS SPNL FIX SYS,SUP-2211191,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2115.73,1375.22,,,,,,,,,,,,,
SCREW BONE CORT ST,SUP-2184533,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.95,44.17,,,,,,,,,,,,,
STENT BILI ZILVER 635 L 40 MM DIA 8 MM DEL SYS L 40 CM SHTH,SUP-2647163,CDM,C1876,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN STATIC PLAS,SUP-2435601,CDM,L1660,HCPCS,0272,RC,,,,both,,,511.63,332.56,,,,,,,,,,,,,
PLATE BONE L 3X3 H MAND TI CRESC SHP FOR 2MM SCR FIX LCKING,SUP-2191239,CDM,C1713,HCPCS,0278,RC,,,,both,,,4035.53,2623.09,,,,,,,,,,,,,
CANNULA PERF AD 23FR L30IN TIP L197IN 3 8 CONN FEM ART NVENT,SUP-2282875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1021.91,664.24,,,,,,,,,,,,,
PLATE BONE ADAPTION 2 MM 8 HOLE RAPID RESORBABLE STERILE RAP,SUP-2838589,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
HC Biopsy/Exc Lymph Node Needle,PX-3613850500,CDM,38505,CPT,0361,RC,,,,both,,,5560.00,3614.00,,,,,,,,,,,,,
TRIAL SCREW TALAR,SUP-2223541,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE BNE W10XL63MM THK15MM 3X4 H R TI T SHP OBLQ LO PROF,SUP-2190918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1090.74,708.98,,,,,,,,,,,,,
SET URET STENT SOFFLX BANDER L 8-12 CM DIA 3 FR POS L 25 CM,SUP-2826945,CDM,C2617,HCPCS,0278,RC,,,,both,,,398.59,259.08,,,,,,,,,,,,,
SPATULA SURG,SUP-2291544,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.68,483.39,,,,,,,,,,,,,
COLLAR CERV SERP SM XLN 23 X 3.5 IN CONTOURED,SUP-2276599,CDM,L0120,HCPCS,0274,RC,,,,both,,,7.76,5.04,,,,,,,,,,,,,
PLATE BNE L125MM 7 H R DST LAT FIBULAR S STL LOK COMPR FOR,SUP-2184161,CDM,C1713,HCPCS,0278,RC,,,,both,,,1721.19,1118.77,,,,,,,,,,,,,
PLATE BNE L142MM 6 H L MED DST TIB S STL VAR ANG LOK COMPR,SUP-2177635,CDM,C1713,HCPCS,0278,RC,,,,both,,,4823.35,3135.18,,,,,,,,,,,,,
HC M/Phmtrc Alys Ish Quant/Semiq Mnl per Spec Each,PX-3128836900,CDM,88369,CPT,0312,RC,,,,both,,,360.00,234.00,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 3 CM DIA 3 MM CATH DIA 0.035 IN,SUP-2170417,CDM,C1889,HCPCS,0278,RC,,,,both,,,313.47,203.76,,,,,,,,,,,,,
DRESSING WND SURG MTRX 4X12 CM THCK MATRISTEM,SUP-2106495,CDM,Q4166,HCPCS,0636,RC,,,,both,,,4080.74,2652.48,,,,,,,,,,,,,
GRAFT BIO TISS W7.9XL9.8IN PORCINE DERM RIFAMPIN,SUP-2125843,CDM,C1781,HCPCS,0278,RC,,,,both,,,38210.66,24836.93,,,,,,,,,,,,,
COMPONENT FEM L130MM KNEE SEG IMP MOST OPTIONS,SUP-2208266,CDM,C1776,CPT,0278,RC,,,,both,,,9495.36,6171.98,,,,,,,,,,,,,
STAPLE INT M SZ 30MM RELD VASC FOR SIGNIA STPL SYS TRI STPL,SUP-2283352,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.64,371.57,,,,,,,,,,,,,
STEM FEM L167MM OD13MM BOW TRI SLOT PLSM SPRAYED HA DST HIP,SUP-2375870,CDM,C1776,CPT,0278,RC,,,,both,,,8596.06,5587.44,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 1X150 MM SS NS KIRSCHNER,SUP-2905611,CDM,C1713,HCPCS,0278,RC,,,,both,,,33.19,21.57,,,,,,,,,,,,,
PLATE BNE L SHT 4X0.7 MM 3X3 HOLE REVERSIBLE OBLQ TI NS LF,SUP-2181815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.25,680.06,,,,,,,,,,,,,
PACK VITRCTMY PRB 25+GA CASS EXTRUSION LN INFUS CANN PLUG,SUP-2109944,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
TORSEMIDE 10 MG PO TABS,RX-18292,CDM,6370000000,HCPCS,0637,RC,50111-0916-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHUNT SURG L 8.9 MM VENTRICULAR CATH L 250 MM PRESSURE 10 CM,SUP-2931051,CDM,C1729,HCPCS,0272,RC,,,,both,,,4178.74,2716.18,,,,,,,,,,,,,
CATHETER INFUS 27FR L31CM 0.375IN CONN 2 LUMN BI CAVAL 701063537] GETINGE USA MAQUET MED SYS],SUP-2227419,CDM,C1713,HCPCS,0278,RC,,,,both,,,7903.69,5137.40,,,,,,,,,,,,,
PLATE BONE L2MM THK0.8MM LT MAX GLD TI PREBENT OFFSET,SUP-2181827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1672.68,1087.24,,,,,,,,,,,,,
POST EXT FIX SHT WIRE PREASSEMBLED FOR SALVATION EXT FIX,SUP-2401120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
RELOAD STPL 3.5MM L60MM 0DEG UNIV TISS PUR TI 6 ROW LIN,SUP-2283264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1238.13,804.78,,,,,,,,,,,,,
INSTRUMENT STBL L25IN OD0045MM OLV,SUP-2398629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
NEEDLE BX LIV ACCS 19 GAX20 CM,SUP-2432216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
KYPHOPLASTY TRAY 10/3 ADV OSTEO INTRO SYS KYPHOPAK XPANDERII,SUP-2665119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11340.17,7371.11,,,,,,,,,,,,,
FOUNDATION NP STEM TIB SZ 3 LT **SPECIAL ORD ONLY,SUP-2215824,CDM,C1776,CPT,0278,RC,,,,both,,,5846.68,3800.34,,,,,,,,,,,,,
BLADE SHV L13CM DIA4MM 360DEG STR SHFT ROT DISP FOR,SUP-2284160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.66,786.93,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE MRI W 4.45 X H 4.81 CM THK 0.75 CM,SUP-2149250,CDM,C1786,HCPCS,0275,RC,,,,both,,,8650.70,5622.95,,,,,,,,,,,,,
CONFORMER EYE DIA25 X 22 MM THK 5.6 MM LG ACRYL NVENT CUP,SUP-2883164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,192.54,125.15,,,,,,,,,,,,,
CATHETER HD DL 15.5 FRX36 CM LT FULL SET W/O SIDE H TITAN HD,SUP-2627358,CDM,C1750,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
PLATE BONE NARROW 4.5X412 MM 22 HOLE,SUP-2837413,CDM,C1713,HCPCS,0278,RC,,,,both,,,4492.56,2920.16,,,,,,,,,,,,,
AGENT HEMOSTATIC POLYSACCHARIDE 230 CM 2.8 MM 5 GM ENDOCLOT,SUP-2865643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
BLADE SHAVER DIA5MM SLOTTED WHISKER BLUE HUB,SUP-2589354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,183.75,119.44,,,,,,,,,,,,,
CONTOURED MESH GRDNR STYLE 10MM STNDRD STYLE T 6L 4V ST,SUP-2681258,CDM,C1713,HCPCS,0278,RC,,,,both,,,9743.23,6333.10,,,,,,,,,,,,,
BRACE ORTHPDC D RING SM ADLT 21.6 CM 14.6 16.5 CM RIGHT WRIS,SUP-2457443,CDM,L3931,HCPCS,0272,RC,,,,both,,,40.95,26.62,,,,,,,,,,,,,
PLATE BONE THK1.25MM 3X3 H CRANIOMAXILLOFACIAL ORAL SLV TI,SUP-2181768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1567.17,1018.66,,,,,,,,,,,,,
SHUNT SURG SM ASSY LO,SUP-2628145,CDM,C1729,HCPCS,0272,RC,,,,both,,,3130.74,2034.98,,,,,,,,,,,,,
STIMULATOR NEUROMUSCULAR TRL PRECIS SPECTR,SUP-2148535,CDM,C1897,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TRAY TIB SZ 3 KNEE CEM KEELED MOB BEAR REV LCS COMPLT,SUP-2250907,CDM,C1776,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
PLATE SPINE L42.5MM ANT CERV TI ALLY CNVGNT ATLNTS,SUP-2291079,CDM,C1713,HCPCS,0278,RC,,,,both,,,3100.31,2015.20,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6MM STR STD WALL SLDE GDS,SUP-2479677,CDM,C1768,CPT,0278,RC,,,,both,,,1385.68,900.69,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|ADJ,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|CO|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE BNE L59MM THK2.4MM 18 H LOK COMPR WRST FUS SHT BEND,SUP-2267979,CDM,C1713,HCPCS,0278,RC,,,,both,,,7560.81,4914.53,,,,,,,,,,,,,
NAIL IM L255MM DIA8.5MM L HUM TAN STR CANN BLU MULTILOC,SUP-2180253,CDM,C1713,HCPCS,0278,RC,,,,both,,,6077.25,3950.21,,,,,,,,,,,,,
SCREW BNE LAG SHT THRD 12.7X155 MM STRL VERSAFX LTX,SUP-2861093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.31,756.80,,,,,,,,,,,,,
PLATE BONE L92MM 5 H STRL RT ANK FUS ANTR PRI COMPR SLOT FOR,SUP-2349833,CDM,C1713,HCPCS,0278,RC,,,,both,,,6898.74,4484.18,,,,,,,,,,,,,
GRAFT BNE 4X4 CM REGENERATIVE TISS MTRX,SUP-2399157,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
LASER ENDOSCP 20 W HOLM,SUP-2540076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,142741.26,92781.82,,,,,,,,,,,,,
PLATE BNE NAR 3.5X215 MM 12 HOLE SS LCP,SUP-2569356,CDM,C1713,HCPCS,0278,RC,,,,both,,,607.90,395.13,,,,,,,,,,,,,
PEG FIX LCK 2X26 MM T8 STARDRV NS VARIAX 2,SUP-2473001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SHEATH DIL SZ B INNR 12.1FR/10FR OUTER 15.2FR/13.1FR,SUP-2169011,CDM,C1893,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
PLATE BNE L253MM 16 H R DST ANTLAT TIB S STL LOK FOR 35 4MM,SUP-2362749,CDM,C1713,HCPCS,0278,RC,,,,both,,,6440.14,4186.09,,,,,,,,,,,,,
CAGE GLEN SM STD POLYETH ALPHA CEM OR PRSS FIT BILAT,SUP-2223363,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.4MM DST RAD VOLAR S STL ST VAR ANG LOK,SUP-2178312,CDM,C1713,HCPCS,0278,RC,,,,both,,,415.42,270.02,,,,,,,,,,,,,
TUBING CT L60IN Y W DUAL CK VLV FOR OPTIVANTAGE 2,SUP-2858154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5.43,3.53,,,,,,,,,,,,,
STENT BILI PRECIS L 30 MM DIA 9 MM CATH L 135 CM DIA 8 FR,SUP-2158970,CDM,C1876,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SZ 1-4 MM 30 CC CANC CRUSH,SUP-2913354,CDM,C1713,HCPCS,0278,RC,,,,both,,,3196.52,2077.74,,,,,,,,,,,,,
MESH SURG W62XL82IN POLYPR EXP PTFE SYN ABD NONABSORBABLE,SUP-2125820,CDM,C1781,HCPCS,0278,RC,,,,both,,,2793.66,1815.88,,,,,,,,,,,,,
KIT INTRO AVNT + DIA 5 FR CANN L 11 CM MINI GUIDEWIRE L 70,SUP-2157388,CDM,C1894,HCPCS,0272,RC,,,,both,,,58.09,37.76,,,,,,,,,,,,,
SCREW BNE L26 MM OD55 MM FULL THRD MONSTER IMPL,SUP-2320644,CDM,C1713,HCPCS,0278,RC,,,,both,,,915.31,594.95,,,,,,,,,,,,,
ALLOGRAFT BNE 14 MM BIO AVS AL 77701404,SUP-2637012,CDM,C1713,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
PLATE BNE L W12XL87MM THK1MM 5 H BILAT TI SEMI TBLR LO PROF,SUP-2190703,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.52,206.39,,,,,,,,,,,,,
REAMER SURG DIA16MM NONSTERILE CANN HLLW FOR QUIK CPL DH DC,SUP-2255807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2707.25,1759.71,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 18 IN KNEE ADJ PERF FOAM,SUP-2194899,CDM,L1830,CPT,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
"HC Exchange Nephrostomy Cath, Perc|BILATERAL PROCEDURE",PX-3615043500,CDM,50435,CPT,0361,RC,,,50,both,,,6875.00,4468.75,,,,,,,,,,,,,
TRIAL CV OCCL AMPLATZER AMULET LOBE DIA25 MM LAA PERC SELF,SUP-2905205,CDM,C1817,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
GRAFT BNE SUB 30ML 4-9.5MM CHIP CANC FRZ DRY ALLGRFT CHIPS30CC] US TISSUE AND CELL],SUP-2391734,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
STEM FEM L25MM OD12MM UNIV CSTI POR KNEE PRI CEM FLUT STR,SUP-2208273,CDM,C1776,CPT,0278,RC,,,,both,,,13621.32,8853.86,,,,,,,,,,,,,
ROD SPNL L90MM OD5.5MM POST LUM SMOOTH PRE CUT REVOLVE,SUP-2230518,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SAW HAND STTRLEE 11 12NL 8NL BLADE BONE JARIT NON ST,SUP-2702377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.72,395.02,,,,,,,,,,,,,
SPLINT WRST SM L8IN L BLK FOAM D RNG CLSR LO PROF MAL,SUP-2336046,CDM,L3809,HCPCS,0272,RC,,,,both,,,19.19,12.47,,,,,,,,,,,,,
WIRE FIX OD1.6MM K,SUP-2152541,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.17,22.86,,,,,,,,,,,,,
BUTTON SUT L50MM TI ACL RECON LOOP ULT ENDOBTTN,SUP-2341708,CDM,C1713,HCPCS,0278,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
GUIDEWIRE SURG L150MM DIA2.3MM NICKEL CHROM SMOOTH SGL END,SUP-2321624,CDM,C1713,HCPCS,0278,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
PLATE BONE L96MM 8 HOLE RIGHT DST PRRTCLR RDL VOLAR STNLSS S,SUP-2457982,CDM,C1713,HCPCS,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
PLATE BONE 12 H STOUT STR FOR 2MM SCR VLP MINI-MOD SM BONE,SUP-2351089,CDM,C1713,HCPCS,0278,RC,,,,both,,,5345.38,3474.50,,,,,,,,,,,,,
IMPLANT OPHTH SCLER TISS WHL,SUP-2303761,CDM,C1762,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SCREW BONE L85MM OD3.5MM STD TI CORT DSTL TIB ST LCK FULL,SUP-2413591,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.80,287.17,,,,,,,,,,,,,
CATHETER IV OD4FR POLY MIDLN 1 LUMN MAX BARR,SUP-2125579,CDM,C1751,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
COUNTERSINK SURG DIA3-4MM FOR CANN SCR SYS,SUP-2319430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
HC Debride Assoc Open Fx/Disloc Skin/Subq,PX-7611101000,CDM,11010,CPT,0761,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 15 CM DIA 5 MM EPTFE STR TW N RING,SUP-2396334,CDM,C1768,CPT,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
GRAFT BNE SUB W15 18XL60MM RAD ULN SHFT FRZ DRY,SUP-2307201,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.69,1373.90,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 2X6 MM MANDIBULAR LOCKING 5/PK TITAN,SUP-2842313,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.84,317.75,,,,,,,,,,,,,
NAIL IM L440MM DIA12MM FEM TI CANN LCK AG RG T2,SUP-2361800,CDM,C1713,HCPCS,0278,RC,,,,both,,,6893.71,4480.91,,,,,,,,,,,,,
"HC So Platelet,Automated",PX-3058504966,CDM,85049,CPT,0305,RC,,,,both,,,15.00,9.75,,,,,,,,,,,,,
CATHETER HD STR 14 FRX15 CM SHT TERM 400 XL FULL TY TAPR TIP,SUP-2266959,CDM,C1752,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
COMPONENT FEM SZ 1 CO CHROM NP LT KNEE CRUC RET PRI STEMLESS,SUP-2345805,CDM,C1776,CPT,0278,RC,,,,both,,,9388.60,6102.59,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 45 CM DIA 5 MM CLLGN BOV CAR ART,SUP-2120664,CDM,C1768,CPT,0278,RC,,,,both,,,3953.26,2569.62,,,,,,,,,,,,,
PLATE BNE L36MM THK1MM 2X6 H NONSTERILE PHLANG BASE HND TI,SUP-2181006,CDM,C1713,HCPCS,0278,RC,,,,both,,,1722.13,1119.38,,,,,,,,,,,,,
DEVICE CLSR 6FR VASC SUT FOR FEM ART PERCLOSE AT,SUP-2105662,CDM,C1760,HCPCS,0278,RC,,,,both,,,6060.20,3939.13,,,,,,,,,,,,,
NUT EXT FIX SQ FOR SIDEKCK FREE CIR FIX,SUP-2400608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
KIT ASMBLY TI PENILE IMPL,SUP-2165316,CDM,C1713,HCPCS,0278,RC,,,,both,,,1485.22,965.39,,,,,,,,,,,,,
MESH GORE SYNECOR 30CM X 40CM RECTANGLE,SUP-2763180,CDM,C1781,HCPCS,0278,RC,,,,both,,,29107.80,18920.07,,,,,,,,,,,,,
PLATE BNE COMPR 0.8 MM HND 6 HOLE STRL,SUP-2518383,CDM,C1713,HCPCS,0278,RC,,,,both,,,1325.08,861.30,,,,,,,,,,,,,
HC Mra Chest W&W/O Contrast,PX-6107155502,CDM,C8911,CPT,0610,RC,,,,both,,,4146.00,2694.90,,,,,,,,,,,,,
PLATE BNE MINI THK0.5MM 3X4 H BILAT CRANIOMAXILLOFACIAL SIL,SUP-2181672,CDM,C1713,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
PLATE BNE L85MM THK1.5MM 3X6 H L S STL OBLQ T SHP LOK COMPR,SUP-2186028,CDM,C1713,HCPCS,0278,RC,,,,both,,,1112.94,723.41,,,,,,,,,,,,,
BAR EXT FIX L 300 MM DIA 6 MM NS DISP MAV MINI,SUP-2932852,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.81,424.33,,,,,,,,,,,,,
BLADE SURG CUT EDGE 13.5MM D25.5MM THK0.51MM SAW CRESC S STL,SUP-2361978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.09,215.86,,,,,,,,,,,,,
TUBE ET 34FR OD11.5MM ID8MM CUF EMG MON ACT REINF FULL ROT,SUP-2284331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1247.58,810.93,,,,,,,,,,,,,
GRAFT BNE 1 4MM 40ML CANC CHIP DEMIN,SUP-2264715,CDM,C1713,HCPCS,0278,RC,,,,both,,,1930.66,1254.93,,,,,,,,,,,,,
CATHETER BLLN DIL 7.5 FRX180 CM 10-12 MMX5.5 CM CRE RX,SUP-2417342,CDM,C1726,HCPCS,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
SCREW BNE CANN 3X20 MM TC-SERIES LP TI TI6,SUP-2609870,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.85,663.55,,,,,,,,,,,,,
CROWN DENT PED SZ DUR2 RT UP 1ST PRI M S STL REPL PRETRIMMED,SUP-2238870,CDM,D6783,CPT,0278,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
IMPLANT UROLOGICAL 8 CM SCREW INSRT,SUP-2140252,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SHEET THERMOPLASTIC SPLNT 1/16X12X18IN 4 PER CA SLD BLUSH,SUP-2324644,CDM,L4350,HCPCS,0272,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
ANCHOR SPNL LUMBAR 27 MM INDEPENDENCE MIS,SUP-2663500,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
STAPLE BONE FIX BRDG W11MM LEG L7X15MM WIRE DIA1.5MM NIT,SUP-2135431,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN LT ANK TALUS,SUP-2740764,CDM,C1762,CPT,0278,RC,,,,both,,,9381.54,6098.00,,,,,,,,,,,,,
SHEATH INTRO L 14 CM DIA10 FR GUIDEWIRE 0.038 IN PTFE X TW,SUP-2615901,CDM,C1894,HCPCS,0272,RC,,,,both,,,85.06,55.29,,,,,,,,,,,,,
STENT URET L 24 CM DIA 6 FR TIP L 3 CM STIFF SHFT ZIPWIRE,SUP-2754250,CDM,C2617,HCPCS,0278,RC,,,,both,,,566.86,368.46,,,,,,,,,,,,,
FORCEP ELECSURG BPLR 15 DEG UP 0.7 MM 22 CM PRO SER BAYNT,SUP-2859608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3922.65,2549.72,,,,,,,,,,,,,
HYDROCORTISONE 2.5 % EX LOTN,RX-3729,CDM,6370000000,HCPCS,0637,RC,45802-0937-26,NDC,,both,118,ML,145.50,94.57,,,,,,,,,,,,,
SCREW CANN 6.5X4.5MM,SUP-2211455,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
CATHETER BLLN DIL 10 MMX15 CM NEPHROSTOMY X-FORCE N30,SUP-2126727,CDM,C1726,HCPCS,0272,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
COMPONENT FEM L21MM KNEE HNG BOLT W/ SL LEGION,SUP-2346263,CDM,C1776,CPT,0278,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
PLATE SPINE FIX 10MM 1 LEV AMBASSADOR,SUP-2163960,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
HOOK RETRCT RHOTON 2 MM SEMI SHRP STYL 9 NS RUGGLES-REDMOND,SUP-2473847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219.42,142.62,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W12MM LEG L12X15MM WIRE DIA2X2MM NIT,SUP-2194217,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
COMPONENT PAT DIA37MM THK10MM STD REV CEM SUT H BTTN W/O XR,SUP-2404199,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
FOIL DENT 50X20X0.1 MM MEMBRN N PERF RESORB X LF,SUP-2470848,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.12,922.43,,,,,,,,,,,,,
BLANK RST PAN POS SP 1 8 INFIN M,SUP-2163841,CDM,L3807,HCPCS,0272,RC,,,,both,,,39.00,25.35,,,,,,,,,,,,,
HC US Retroperitoneal Complete,PX-4027677000,CDM,76770,CPT,0402,RC,,,,both,,,1764.00,1146.60,,,,,,,,,,,,,
PLATE SPNL W16XL44MM STD 1 H XLNK POST LUM S STL FIX CONN,SUP-2255569,CDM,C1713,HCPCS,0278,RC,,,,both,,,4165.21,2707.39,,,,,,,,,,,,,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,6370000000,HCPCS,0637,RC,78112-0011-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT ORTH SZ 25 MM STPL PREP STRL DISP DYNAFORCE,SUP-2893291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
BURR SURG SWNSN REAMER 5MM DIA HD MED MIC 62MML STL SM BNE M,SUP-2605556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,134.45,87.39,,,,,,,,,,,,,
PROBE LITHO ELEC HYDRLC RIWOLITH STRL DISP L770MM OD5FR,SUP-2332791,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.094MM DIA 9INL,SUP-2640114,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 35 CM DIA 7 FR HYDRPHLC,SUP-2383981,CDM,C1894,HCPCS,0272,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
HC Asp Injection Major Joint|LEFT SIDE,PX-4502061000,CDM,20610,CPT,0450,RC,,,LT,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L81CM DIL 8FR L85CM 0032IN SL4 CRV,SUP-2357244,CDM,C1893,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PACEMAKER CARD VISIONIST X4 W 4.45 X H 6.17 MM THK 0.75 MM,SUP-2432111,CDM,C2621,HCPCS,0275,RC,,,,both,,,19766.30,12848.09,,,,,,,,,,,,,
SHEATH INTRO FUBUKI L 90 CM OD 7 FR ID 2.05 MM COAT L 15 CM,SUP-2530224,CDM,C1887,HCPCS,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
PIN EXT FIX HALF 6X45 MM 160 MM BLNT SHANK P451966045,SUP-2749895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
DEVICE EMB PIPELINE 3.00X35MM,SUP-2466480,CDM,C1889,HCPCS,0278,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
COMPONENT SUBTALAR L4MM SZ 8MM BILAT ANK JT PLLA,SUP-2242684,CDM,C1713,HCPCS,0278,RC,,,,both,,,8089.90,5258.43,,,,,,,,,,,,,
CATHETER SUPP SIDEKCK L 110 CM SS ANGLED TAPR TIP BRAIDED,SUP-2127015,CDM,C1887,HCPCS,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FEN 9X9 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871494,CDM,C1762,CPT,0278,RC,,,,both,,,18730.10,12174.56,,,,,,,,,,,,,
ROD EXT FIX 8MM 90DEG ADPT ACE-FISCHER,SUP-2414054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
DILATOR COAX 4FR 0.018X40CM MICPUNC ACC,SUP-2385654,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
RHINO-LARYNGOSCOPE FLX L 350 MM OD 5 MM ID 2 MM INTERVENTION,SUP-2882909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SCREW INTRF L28MM DIA10MM KNEE PLLA CANN BIOABSRB THRD WDG,SUP-2362045,CDM,C1713,HCPCS,0278,RC,,,,both,,,463.15,301.05,,,,,,,,,,,,,
CATHETER DRNGE 20FR L25CM GWIRE 0.038IN NDL 18GA 6 SIDEPRT,SUP-2168307,CDM,C1729,HCPCS,0272,RC,,,,both,,,278.89,181.28,,,,,,,,,,,,,
CLAMP THRCSCPC DUVAL 10MM/11MM DIA 13 1/2NL TRNGLR RING LEFT,SUP-2484902,CDM,C1713,HCPCS,0278,RC,,,,both,,,2407.81,1565.08,,,,,,,,,,,,,
PLATE BNE T 100 MM 5 HOLE SS,SUP-2569107,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.58,227.88,,,,,,,,,,,,,
HANDPIECE SURG LAP 5 MMX28 CM PRECIS CUT COAG PLASMAJET DISP,SUP-2328049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BONE L35MM THK0.3MM 6 H CRANIOMAXILLOFACIAL TI GAP RIG,SUP-2136518,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
BUR SURGICAL DIAMETER 22MM SPHERICAL FOR SKULL OPENING NEURO,SUP-2804671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.69,264.35,,,,,,,,,,,,,
PLATE SPNL L14MM ASMBLY SPINOUS PROC ASPN,SUP-2209278,CDM,C1713,HCPCS,0278,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
COMPONENT GLEN FIX M DIA40MM BACKSIDE RAD CORTILOC PEGGED,SUP-2388693,CDM,C1776,CPT,0278,RC,,,,both,,,7107.39,4619.80,,,,,,,,,,,,,
BRACE ORTH 30 150DEG SHLDR UNIV MOTN CTRL CHST STRP WAIST,SUP-2196399,CDM,L3650,HCPCS,0274,RC,,,,both,,,716.83,465.94,,,,,,,,,,,,,
PLATE BNE LG NON-BIOASORB STRL X-PLATE STRATUM,SUP-2656715,CDM,C1713,HCPCS,0278,RC,,,,both,,,3221.26,2093.82,,,,,,,,,,,,,
HC MRI-Myocardium WO Contrast,PX-6107555700,CDM,75557,CPT,0610,RC,,,,inpatient,,,4146.00,2694.90,,,,,,,,,,,,,
SHUNT SURG L 8.9 MM VENTRICULAR CATH L 180 MM PRESSURE 15 CM FV681T,SUP-2929034,CDM,C1889,HCPCS,0278,RC,,,,both,,,2853.98,1855.09,,,,,,,,,,,,,
FIBER LASER 200 MH FLEXSHIELD FLX HOLM ACCUTRAC DISP,SUP-2139425,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.52,921.39,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2.8 MM MED CP TI MANDIBULAR FULL,SUP-2883713,CDM,C1713,HCPCS,0278,RC,,,,both,,,18882.42,12273.57,,,,,,,,,,,,,
HC Potassium Serum Plasma/Whole Blood,PX-3018413200,CDM,84132,CPT,0301,RC,,,,both,,,80.00,52.00,,,,,,,,,,,,,
PEG BNE FIX L16MM DIA2.5MM DST VOLAR RAD PARTIALLY THRD FOR,SUP-2414242,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.76,188.99,,,,,,,,,,,,,
TUBE SCTN 7FR DIA 8INL TRDRP TPRD STRGHT MAL,SUP-2472928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.35,281.03,,,,,,,,,,,,,
COMPONENT TIB CR 5 UNIV 12 MM NP PRIMARY CEM STEM MONOBLOCK,SUP-2378462,CDM,C1776,CPT,0278,RC,,,,both,,,2859.91,1858.94,,,,,,,,,,,,,
NICARDIPINE HCL IN NACL 20-0.9 MG/200ML-% IV SOLN,RX-150326,CDM,J2404,HCPCS,0636,RC,00143-9634-10,NDC,,both,200,ML,468.10,304.26,,,,,,,,,,,,,
GUIDEWIRE ORTH SMOOTH 22X800 MM FOR HUM NAILING SYS T2,SUP-2368576,CDM,C1769,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 11 CM DIA 4 FR W/O GUIDEWIRE STRL,SUP-2141019,CDM,C1894,HCPCS,0272,RC,,,,both,,,359.53,233.69,,,,,,,,,,,,,
IMPLANT SYNTH L 124 X W 170 MM THK 6 MM POLYETHYL LT CRAN,SUP-2883412,CDM,C1713,HCPCS,0278,RC,,,,both,,,15308.13,9950.28,,,,,,,,,,,,,
KIT PRCTNS NPHRSTMY 10FR CATH PGTL C FLEX GDWRE 038X150CM D,SUP-2727446,CDM,C1729,HCPCS,0272,RC,,,,both,,,350.96,228.12,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 9 FRX15 CM 11 GA 3L SPECTRUM,SUP-2759741,CDM,C1751,HCPCS,0278,RC,,,,both,,,605.58,393.63,,,,,,,,,,,,,
STRAP CLAV SELF-ADJSTBLE L,SUP-2195528,CDM,L3650,HCPCS,0274,RC,,,,both,,,21.38,13.90,,,,,,,,,,,,,
INSERT TIB SZ 6 THK10MM LT CNFRM + NEUT PRI PROFIX,SUP-2419451,CDM,C1776,CPT,0278,RC,,,,both,,,4110.26,2671.67,,,,,,,,,,,,,
CANNULA ENDOSCP 10 MM FOR STEINER MORCELLATOR HNDL,SUP-2360968,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BUR SURG MTCH HD 4 MMX16 CM BRN MIS PRECIS,SUP-2365197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.77,406.10,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA 7 FR HYDRPHLC,SUP-2383409,CDM,C1894,HCPCS,0272,RC,,,,both,,,254.97,165.73,,,,,,,,,,,,,
RING EXT FIX FULL 140 MM CIR SIDEKCK,SUP-2850515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2282.78,1483.81,,,,,,,,,,,,,
IMPLANT BRST DIA5.4CM 800ML P16.5CM NACL SIL SHELL TEXT RND,SUP-2300231,CDM,C1789,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SPECULUM VAG PETERSON,SUP-2155550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1575.50,1024.07,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0035IN TIP L23CM PTFE HEP BENT STR,SUP-2302738,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.38,22.35,,,,,,,,,,,,,
ROD 275MM LNG FOR ORTHOFIX PREFIX FIX,SUP-2316292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.13,349.78,,,,,,,,,,,,,
HC G Tube Plcmt,PX-3614944000,CDM,49440,CPT,0361,RC,,,,both,,,17165.00,11157.25,,,,,,,,,,,,,
COMPONENT FEM MOD REV POR COAT CO CHROM SZ 5 75MM PROVEN,SUP-2359208,CDM,C1776,CPT,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
PLATE BONE W13.5XL34MM THK4.2MM 2 H BILAT S STL NAR LIMIT,SUP-2185226,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.90,351.58,,,,,,,,,,,,,
COMPONENT BEAR TIB DSTL FEM KNEE MRH,SUP-2452041,CDM,C1776,CPT,0278,RC,,,,both,,,6498.39,4223.95,,,,,,,,,,,,,
PLATE BNE L157MM 8 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177798,CDM,C1713,HCPCS,0278,RC,,,,both,,,3261.83,2120.19,,,,,,,,,,,,,
MATRIX BIO L 20 X W 7 CM FISH SKIN DERMAL INTACT MARIGEN,SUP-2909236,CDM,Q4158,HCPCS,0636,RC,,,,both,,,24181.14,15717.74,,,,,,,,,,,,,
GUIDEWIRE VASC DBL END,SUP-2264476,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.18,28.07,,,,,,,,,,,,,
MARKER BRST BX COIL 12 GA FOR ATEC BIODUR 108 SENOMARK ULTRA,SUP-2759147,CDM,A4648,CPT,0278,RC,,,,both,,,197.98,128.69,,,,,,,,,,,,,
GRAFT DURAL SUBSTITUTE CRANIAL TUMOR TRAUMA NON ABSORBABLE P,SUP-2825291,CDM,C1763,HCPCS,0278,RC,,,,both,,,641.25,416.81,,,,,,,,,,,,,
SYSTEM ENDOSCP VES HARV VASOVIEW 6 PRO,SUP-2266079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2402.63,1561.71,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN BASIC KT DBL LUMN POLYUR STR,SUP-2116540,CDM,C1752,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT BNE DIA10MM PAT LIG PRESHAPED DWL FLEXIGRFT,SUP-2264637,CDM,C1776,CPT,0278,RC,,,,both,,,9122.39,5929.55,,,,,,,,,,,,,
BIT DRL CHK END 12 MM TIB FOR ACL COMBINATION,SUP-2608126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1042.70,677.75,,,,,,,,,,,,,
COMPONENT TOE DIA15MM 1.5X3.5MM OFFSET MT CE ARTC TOE2,SUP-2123612,CDM,C1776,CPT,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
GRAFT HUM TISS  164 SQ CM THK0.8-1.2MM THN L PERF CNTOUR ACELLULAR DERM,SUP-2113434,CDM,Q4116,HCPCS,0636,RC,,,,both,,,19744.32,12833.81,,,,,,,,,,,,,
TUBE AERATION L12MM FLNG L3.5MM ID1.14MM FLROPLAS SIL STYL,SUP-2284027,CDM,L8699,HCPCS,0278,RC,,,,both,,,257.04,167.08,,,,,,,,,,,,,
PEG BNE FIX FEM REPL DURAC,SUP-2377156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.65,700.47,,,,,,,,,,,,,
GUIDEWIRE ORTH OLV THRD MAXLOCK EXTRM,SUP-2400238,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
GUIDEWIRE SURG PARL 1.1 MM 3-3.5 MM FOR BITE COMPR SCR RIVAL,SUP-2644831,CDM,C1769,HCPCS,0272,RC,,,,both,,,214.56,139.46,,,,,,,,,,,,,
ADAPTER ORTH 5+ MM FEM KNEE REV SL LIMB PRESERVATION ATTUNE,SUP-2744026,CDM,C1776,CPT,0278,RC,,,,both,,,1544.41,1003.87,,,,,,,,,,,,,
PLATE BNE M L64MM NONSTERILE R CALCNL S STL VAR ANG LOK FOR,SUP-2178421,CDM,C1713,HCPCS,0278,RC,,,,both,,,3035.63,1973.16,,,,,,,,,,,,,
STRAP TRAC L6FT UP ARM W PD TRAC TWR,SUP-2166901,CDM,L3660,HCPCS,0274,RC,,,,both,,,415.23,269.90,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 450 CM DIA 0.035 IN TIP 1.5 MM,SUP-2761855,CDM,C1769,HCPCS,0272,RC,,,,both,,,356.08,231.45,,,,,,,,,,,,,
GUIDEWIRE GLDEWIRE G 011IN,SUP-2305437,CDM,C1769,HCPCS,0272,RC,,,,both,,,865.07,562.30,,,,,,,,,,,,,
PIN DISTR L12MM SELF DRL CASPR,SUP-2108444,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.91,64.29,,,,,,,,,,,,,
CATHETER THROMCTMY EMBOVAC L 125 CM PROX/DSTL OD,SUP-2707591,CDM,C1757,HCPCS,0272,RC,,,,both,,,9619.20,6252.48,,,,,,,,,,,,,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,6370000000,HCPCS,0637,RC,65162-0826-34,NDC,,both,1,UN,19.20,12.48,,,,,,,,,,,,,
CUP ACET SZ 6 DIA54MM HIP CO CHROM RESURF CORMET PRECIS,SUP-2363892,CDM,C1776,CPT,0278,RC,,,,both,,,10472.90,6807.38,,,,,,,,,,,,,
KIT HEMODLYS L40CM BASIC DLYS CATH 16FR VLV BRKWY INTRO,SUP-2117393,CDM,C1750,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PLATE BNE THK 1 MM SCREW DIA2.2 MM 49 H PLL POLYGLYCOLIDE,SUP-2883339,CDM,C1713,HCPCS,0278,RC,,,,both,,,8476.21,5509.54,,,,,,,,,,,,,
WEDGE EVANS ADDUCTION STRUCTURAL ALLGRFT 20 DEG 8 MM,SUP-2321672,CDM,C1713,HCPCS,0278,RC,,,,both,,,6099.45,3964.64,,,,,,,,,,,,,
KIT ACCS INTRO L10CM DIA4FR GWIRE L40CM DIA0.018IN NDL L7CM,SUP-2302993,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.46,49.70,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 12 HOLE-STERILE,SUP-2546101,CDM,C1713,HCPCS,0278,RC,,,,both,,,2301.37,1495.89,,,,,,,,,,,,,
CATHETER CV RAD SET 018 3 FRX40 CM 1 LUMEN OTW SS TURBO-JECT,SUP-2759782,CDM,C1751,HCPCS,0278,RC,,,,both,,,375.29,243.94,,,,,,,,,,,,,
GRAFT VASC 8 MMX35/15X70 CMX0.35 MM 20 CM STR HEMGRD,SUP-2471001,CDM,C1768,CPT,0278,RC,,,,both,,,3149.58,2047.23,,,,,,,,,,,,,
INTRODUCER SUPRPUB SHTH 18FR L17CM TRCR STYL L20CM REM DISP,SUP-2169600,CDM,C1725,HCPCS,0272,RC,,,,both,,,379.31,246.55,,,,,,,,,,,,,
ACCESSORY NEUROSTIMULATOR 2XL PERIPH HORIZONTAL FOR WEARABLE,SUP-2917123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
COMPONENT FEM SZ C L DST KNEE SEG,SUP-2200502,CDM,C1776,CPT,0278,RC,,,,both,,,31029.48,20169.16,,,,,,,,,,,,,
PLATE BONE L22MM 2 H STRL S STL 1/3 TBLR FOR 3.5MM SCR EVOS,SUP-2349634,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM 0.035 IN TIP 3 MM N CRV LNG,SUP-2301909,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.50,21.12,,,,,,,,,,,,,
HC CT-Guided Aspiration,PX-3507598900,CDM,75989,CPT,0350,RC,,,,inpatient,,,7563.00,4915.95,,,,,,,,,,,,,
PROBE ELECSURG SUCTION REG 133 MM 50-S SWP RF N BEND SERFAS,SUP-2435284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1194.64,776.52,,,,,,,,,,,,,
PLATE BNE L213MM 13 H L DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177225,CDM,C1713,HCPCS,0278,RC,,,,both,,,4894.26,3181.27,,,,,,,,,,,,,
LEAD DEFIB L65/18CM SD PLEXA PROMRI,SUP-2138441,CDM,C1895,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
HC Insertion Swan-Ganz Catheter,PX-4819350300,CDM,93503,CPT,0481,RC,,,,inpatient,,,6214.00,4039.10,,,,,,,,,,,,,
DISTRACTION INTRNL TUBE ADJ MDFCE BTTRSS ADJ LNGTH16 MM T 6L,SUP-2495471,CDM,C1713,HCPCS,0278,RC,,,,both,,,6497.01,4223.06,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON XL 7 IN LT WRST ELASTIC LTX,SUP-2276651,CDM,L3809,HCPCS,0272,RC,,,,both,,,10.77,7.00,,,,,,,,,,,,,
GRAFT HUM TISS DIA12MM AMNIO MEMBRN DISK AMNIOEXCEL,SUP-2194314,CDM,Q4137,HCPCS,0636,RC,,,,both,,,846.23,550.05,,,,,,,,,,,,,
PLATE BNE X 35 MM TCP,SUP-2535867,CDM,C1713,HCPCS,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
HEAD FEM PLANAR 46 MM CALCAR HIP,SUP-2441559,CDM,C1776,CPT,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
PLATE BNE W10.2XL117MM THK2.7MM 9 H BILAT S STL STR LO PROF,SUP-2186196,CDM,C1713,HCPCS,0278,RC,,,,both,,,1472.57,957.17,,,,,,,,,,,,,
ADAPTOR TAPER NEURTRAL LONG 0MM TITANIUM,SUP-2863710,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STENT BILI AD 10FR L80MM MIN WRK CHN 37MM POLYETH DUODENAL,SUP-2313493,CDM,C1877,HCPCS,0278,RC,,,,both,,,677.93,440.65,,,,,,,,,,,,,
CATHETER ABLATN EP 7 FR MED MAP COOL PATH,SUP-2102236,CDM,C2630,CPT,0272,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
SHAVER BNE SONIC 1 OR 360,SUP-2305933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1399.03,909.37,,,,,,,,,,,,,
REAMER SURG DIA18MM METATRSL FOR COMPHSVE FT SYS,SUP-2123055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
MATRIX SURGICAL WOUND 0.030OZ CONNEXT,SUP-2758896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
PIN ORTH SMOOTH DBL SHRP TIP TRCR S STL NONSTERILE 2.8MM,SUP-2363713,CDM,C1713,HCPCS,0278,RC,,,,both,,,38.47,25.01,,,,,,,,,,,,,
GRAFT NRV L50MM DIA2-3MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124850,CDM,C1763,HCPCS,0278,RC,,,,both,,,21160.46,13754.30,,,,,,,,,,,,,
ELECTRODE ES OD24 28FR 12 30DEG BRL MPLR DISPOSABLE,SUP-2312911,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.05,295.78,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO LP L 138 CM DIA 5 FR RX SECT 25,SUP-2763424,CDM,C1757,HCPCS,0272,RC,,,,both,,,1896.56,1232.76,,,,,,,,,,,,,
PROSTHESIS OTO L5MM SHFT OD0.4MM S STL MID EAR STAP OFFSET,SUP-2284063,CDM,L8613,CPT,0278,RC,,,,both,,,668.32,434.41,,,,,,,,,,,,,
SET INTRO KOLENDA SHTH L 5.5 CM INTRO DIA1.88 MM GUIDEWIRE,SUP-2169480,CDM,C1894,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CROWN DENT E2 2ND PRIMARY M UPPER LT SS,SUP-2100308,CDM,D6783,CPT,0278,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX10 MM KT IMPL CLASSIC BLOM-SINGER,SUP-2238270,CDM,L8509,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CONNECTOR ROD OFFSET,SUP-2381437,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
HC Repair Tun or Non Cath W/Port,PX-3613657600,CDM,36576,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PROBE CRYOSURGERY L 1.1 MM W/ OVERSHEATH SLIM LIGHT STRL (MUST ORDER MULTIPLES OF 5 EACH),SUP-2890320,CDM,C2618,HCPCS,0272,RC,,,,both,,,1470.15,955.60,,,,,,,,,,,,,
BLADE SHV L8CM DIA3.5MM ENT ARTHSCP PRECIS CUT AGG SERR,SUP-2363531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.36,308.33,,,,,,,,,,,,,
KNIFE ELECSURG 3 MM ORISE PROKNIFE,SUP-2754410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2668.22,1734.34,,,,,,,,,,,,,
CYLINDER DOSE OF SF6,SUP-2865712,CDM,C1814,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
AMOXICILLIN 500 MG PO CAPS,RX-451,CDM,6370000000,HCPCS,0637,RC,16714-0299-04,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUR SURG RND XL 4 MM TORNADO + STRL FMS VUE DISP,SUP-2624804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
FIBER LASER HOLM 940 M FOR USE W/ H-30 RED SMARTSYNC DISP,SUP-2835951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2180.86,1417.56,,,,,,,,,,,,,
FIBER LASER 200 MICRON 3/PKG STERILE INCLUDES 1,SUP-2574061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.12,586.38,,,,,,,,,,,,,
PLATE BNE L178MM 8 H ST L MED PROX TIB S STL LOK COMPR LO,SUP-2185677,CDM,C1713,HCPCS,0278,RC,,,,both,,,4642.68,3017.74,,,,,,,,,,,,,
SLEEVE LAPSCP 6MM DEPTH,SUP-2232028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
PLATE BONE 13 H RT DSTL MEDL TIB LCK W/O TAB FOR 3.5MM SCR,SUP-2349087,CDM,C1713,HCPCS,0278,RC,,,,both,,,3128.98,2033.84,,,,,,,,,,,,,
STAPLE BNE W18XL16MM NIT SHP MEM COMPRESSIVE FORC DISP,SUP-2399897,CDM,C1713,HCPCS,0278,RC,,,,both,,,4970.62,3230.90,,,,,,,,,,,,,
EXPANDER TISS 5.2-6 CM 12X9.8 CM 225-280 CC MID ALLOX2,SUP-2471207,CDM,C1889,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SCREW SET RIGID ASSURE,SUP-2592868,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
SCREW BNE SM L45MM DIA3.5MM HD DIA6MM CORT TI NONCANNULATED,SUP-2189878,CDM,C1713,HCPCS,0278,RC,,,,both,,,61.04,39.68,,,,,,,,,,,,,
CALCIUM CITRATE 950 (200 CA) MG PO TABS,RX-1308,CDM,6370000000,HCPCS,0637,RC,80681-0140-00,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
CATHETER ABLAT 7FR TIP L5MM 2.5MM SPC QPLR STD CRV AND LEN,SUP-2141281,CDM,C1733,HCPCS,0272,RC,,,,both,,,3011.26,1957.32,,,,,,,,,,,,,
PLATE BNE 3X6 H 2 23MM LOK GRID T SHP TRILOK,SUP-2267940,CDM,C1713,HCPCS,0278,RC,,,,both,,,2762.57,1795.67,,,,,,,,,,,,,
GRAFT BONE SUB 2.5CC DEMIN BONE MTRX PRIM HD,SUP-2307262,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
MATRIX 1.4MM BIT DRILL W/6MM,SUP-2823023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1483.30,964.14,,,,,,,,,,,,,
SYSTEM VASC FILTER XS INTAORT FILTRATION STRL,SUP-2214491,CDM,C1884,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PIN TEMP FIX L11.5IN GUID SUBTALAR,SUP-2390490,CDM,C1776,CPT,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BRACE THMB AD SM FOR 6-6.875IN LT MCP BLK ALIDRY FAB BRTH,SUP-2323970,CDM,L3931,HCPCS,0274,RC,,,,both,,,92.50,60.12,,,,,,,,,,,,,
RING EXT FIX ID205MM TI C FBR HYBRID 3 4 FOR DST TIB FRME,SUP-2188606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1607.27,1044.73,,,,,,,,,,,,,
BIT DRL L50MM DIA1.6MM 5MM STP FOR 2/2.3MM SCR LEIBINGER,SUP-2366415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,385.94,250.86,,,,,,,,,,,,,
SUTURE SURG PRE MEASURED LOOP 2-0 12 MM 18 MM CHORD-X,SUP-2799090,CDM,C1889,HCPCS,0278,RC,,,,both,,,8474.86,5508.66,,,,,,,,,,,,,
PLATE BONE SM L156MM 12 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348999,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.24,1134.41,,,,,,,,,,,,,
GRAFT BNE CLOWARD DWL FRZN OD 10MM MATRIGRFT,SUP-2264705,CDM,C1713,HCPCS,0278,RC,,,,both,,,1712.59,1113.18,,,,,,,,,,,,,
HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS,RX-28384,CDM,6370000000,HCPCS,0637,RC,00406-0125-62,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1395108D4,SUP-2632829,CDM,C1751,HCPCS,0278,RC,,,,both,,,1173.36,762.68,,,,,,,,,,,,,
ADAPTER TIB OFFSET SZ 2.5MM KNEE REV VANGUARD 360,SUP-2408002,CDM,C1776,CPT,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
SCREW BONE LOCKING 3X16 MM STERNAL SELFDRILLING TITANIUM STE,SUP-2837701,CDM,C1713,HCPCS,0278,RC,,,,both,,,742.30,482.49,,,,,,,,,,,,,
HC Doppler Velocimetry Fetal Umb,PX-4027682000,CDM,76820,CPT,0402,RC,,,,both,,,607.00,394.55,,,,,,,,,,,,,
STEM FEM L270MM OD14MM 135DEG HIP TI REV PRESSFIT MOD TAPR,SUP-2404205,CDM,C1776,CPT,0278,RC,,,,both,,,21942.32,14262.51,,,,,,,,,,,,,
INSERT TIB SZ 3 H14MM POLYETH PRI NEUT UNI NET SHP MOLD HI,SUP-2208541,CDM,C1776,CPT,0278,RC,,,,both,,,2428.79,1578.71,,,,,,,,,,,,,
CATHETER TRAY DL 6 FR PERIPH,SUP-2116965,CDM,C1751,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CLARIA MRI SURESCAN W 51 X H 73 MM D 13,SUP-2282410,CDM,C1882,HCPCS,0275,RC,,,,both,,,51012.44,33158.09,,,,,,,,,,,,,
STENT URET INLAY L 16 CM DIA 6 FR POLYUR HYDRPHLC LUBRICIOUS,SUP-2126624,CDM,C2625,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CMNTLS CERM X3,SUP-2365523,CDM,C1776,CPT,0278,RC,,,,both,,,15623.82,10155.48,,,,,,,,,,,,,
SCREW BNE L 150 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2932525,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.42,167.97,,,,,,,,,,,,,
KIT CA 5.8MM SPINEJACK,SUP-2417100,CDM,C1062,HCPCS,0278,RC,,,,both,,,13078.10,8500.76,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 60 CM DIA 6 MM EPTFE STR STD WALL,SUP-2396188,CDM,C1768,CPT,0278,RC,,,,both,,,2172.88,1412.37,,,,,,,,,,,,,
RING ID190MM 2 3 RADLUC,SUP-2316273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2770.48,1800.81,,,,,,,,,,,,,
PLATE BNE L MINI 2X29 MM OBLQ ANGLED SS,SUP-2479038,CDM,C1713,HCPCS,0278,RC,,,,both,,,272.55,177.16,,,,,,,,,,,,,
CANNULA CHOPPER 23GA VISCO PAREKH LATEX FREE,SUP-2493345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.10,391.36,,,,,,,,,,,,,
ENDCAP ORTH 10 MM EXTN FOR TIB NAIL ADV TI STRL,SUP-2789370,CDM,C1889,HCPCS,0278,RC,,,,both,,,590.54,383.85,,,,,,,,,,,,,
TRAY HEMO DYLS OR HD CATH AD L72CM SLV ION ANTIMIC SL COILED,SUP-2174245,CDM,C1881,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
GRAFT STRUT CORT FEM QTR FRZN ALLGRFT 210MM MATRIGRFT,SUP-2264747,CDM,C1713,HCPCS,0278,RC,,,,both,,,1376.01,894.41,,,,,,,,,,,,,
SHEATH INTRO PRELUDE ROADSTER L 45 CM DIA 5 FR COAT L 35 CM,SUP-2900367,CDM,C1894,HCPCS,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
COIL MICRUSFRAME 6MMX122CM,SUP-2249237,CDM,C1889,HCPCS,0278,RC,,,,both,,,6409.81,4166.38,,,,,,,,,,,,,
HEAD RAD DIA20MM +4MM OFFSET 2499KITA EVOLVE PROLINE,SUP-2397970,CDM,C1776,CPT,0278,RC,,,,both,,,5915.76,3845.24,,,,,,,,,,,,,
TRACTION KIT PINNING,SUP-2165215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
PLATE BNE LAT 70 MM LT 8 HOLE EVOLVE EPS ORTHOLOC,SUP-2535915,CDM,C1713,HCPCS,0278,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
LINER ACET OD54MM ID40MM CO CHROM BIOFOAM HIP GRP E DYNASTY,SUP-2304540,CDM,C1776,CPT,0278,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X33 MM 4 HOLE 1/4 TI,SUP-2536104,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
ALLOPURINOL 300 MG PO TABS,RX-311,CDM,6370000000,HCPCS,0637,RC,00904-6572-61,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
BLADE LARYNGEAL SUPERFICIAL STD 2.9X22 MM STRL DISP,SUP-2638402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PACK INSTR DARTFIRE EDGE D1040000,SUP-2849008,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
SCREW BONE L30MM DIA4MM STD FT ANK TI SELF DRL ST CANN FULL,SUP-2122496,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BNE LCK WIDE RT TROCHANTERIC BRIDGE N CONTACT POLYAX,SUP-2492625,CDM,C1713,HCPCS,0278,RC,,,,both,,,3022.06,1964.34,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 4 FRX10 CM 20 GA SAFETY ACCEL,SUP-2659266,CDM,C1729,HCPCS,0272,RC,,,,both,,,66.76,43.39,,,,,,,,,,,,,
LASER URETERAL CATHETER,SUP-2826994,CDM,C1758,HCPCS,0278,RC,,,,both,,,99.22,64.49,,,,,,,,,,,,,
PIN FIX L16MM DIA1.8MM S STL BTTRS,SUP-2183329,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.72,114.87,,,,,,,,,,,,,
ROPIVACAINE HCL 2 MG/ML IJ SOLN,RX-18192,CDM,C9804,HCPCS,0636,RC,09999-9917-29,NDC,,both,500,ML,376.70,244.85,,,,,,,,,,,,,
CAGE SPNL MESH 22X17X90 MM 6 LOBE,SUP-2602085,CDM,C1889,HCPCS,0278,RC,,,,both,,,19628.14,12758.29,,,,,,,,,,,,,
BIT DRL STR 1.4 MM ICONIX REUSE,SUP-2608470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1360.94,884.61,,,,,,,,,,,,,
ROD SPNL REDUCER OCPTL CERV THOR STRL INFIN,SUP-2660092,CDM,C1713,HCPCS,0278,RC,,,,both,,,7420.95,4823.62,,,,,,,,,,,,,
KIT CVC L 16 CM DIA12 FR TL TEGDERM DRSG LG BOR FOR HI VOL,SUP-2909918,CDM,C1751,HCPCS,0278,RC,,,,both,,,533.17,346.56,,,,,,,,,,,,,
DISTRACTION INTRNL DIST PLTL RTTRDM SNDRMC19 MM T 6L 4V QT00,SUP-2493438,CDM,C1713,HCPCS,0278,RC,,,,both,,,7262.79,4720.81,,,,,,,,,,,,,
BODY EXT FIX CTRL SHT FOR METADIAPHYSEAL PVC FREE PROCALLUS,SUP-2645898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3087.19,2006.67,,,,,,,,,,,,,
FILTER VASC DENALI SHTH L 55 CM VENA CAVA KT EMB FEM DEL ADV,SUP-2126818,CDM,C1880,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
PLATE BONE 2.4MM SUBCONDYLAR TI TIA HND PLATING,SUP-2319671,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.22,1373.59,,,,,,,,,,,,,
SHEET CMF 38X50X0.85MM POR HI DENS MEDPOR TI,SUP-2328483,CDM,C1713,HCPCS,0278,RC,,,,both,,,3218.53,2092.04,,,,,,,,,,,,,
PLATE BNE ROT CORRECTION 2X42 MM VA LCK FRAC SS NS,SUP-2799219,CDM,C1713,HCPCS,0278,RC,,,,both,,,2312.48,1503.11,,,,,,,,,,,,,
GRAFT BONE 5 CC,SUP-2424592,CDM,C1713,HCPCS,0278,RC,,,,both,,,4671.38,3036.40,,,,,,,,,,,,,
IMPLANT CRAN SM CUST PEEK,SUP-2365127,CDM,C1713,HCPCS,0278,RC,,,,both,,,36270.64,23575.92,,,,,,,,,,,,,
GRAFT HUM TISS ANT TIBIALIS TEND >22CM FRZN (FOLDED DIAM,SUP-2307279,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
PLATE BNE L39MM 5 H S STL 1/4 TBLR CLLRD FOR 2.7MM SCR,SUP-2411323,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.04,154.73,,,,,,,,,,,,,
SET INSTR W/ GWIRE DRL BIT COUNTSINK SL SCRDRIVER SHFT MEAS,SUP-2183057,CDM,C1713,HCPCS,0278,RC,,,,both,,,39611.01,25747.16,,,,,,,,,,,,,
DRILL TWST 1.7X10 MM FOR DISTRACTION SCREW,SUP-2732065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
"HC So Sodium, Other Source",PX-3018430266,CDM,84302,CPT,0301,RC,,,,both,,,32.00,20.80,,,,,,,,,,,,,
ORTHOPAEDIC KIT HIP STEM CUP SCREW APEX POROUS,SUP-2254035,CDM,C1776,CPT,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
HC Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX-3068748300,CDM,87483,CPT,0306,RC,,,,outpatient,,,907.00,589.55,,,,,,,,,,,,,
HC Ecmo/Ecls Initiation Artery,PX-3603394700,CDM,33947,CPT,0360,RC,,,,both,,,37949.00,24666.85,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 0 DEG 18 MM LORDTC ILLIAC CREST BIO,SUP-2637034,CDM,C1713,HCPCS,0278,RC,,,,both,,,4100.46,2665.30,,,,,,,,,,,,,
KIT INTRO MINI STK II L 7 CM DIA 4 FR GUIDEWIRE L 45 CM DIA,SUP-2734845,CDM,C1894,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 8 MM STR TW SLDE GDS,SUP-2669694,CDM,C1768,CPT,0278,RC,,,,both,,,1886.70,1226.35,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11CM DIA 5FR 7CM 18GA SS POLYPRO TBNG,SUP-2458347,CDM,C1894,HCPCS,0272,RC,,,,both,,,38.37,24.94,,,,,,,,,,,,,
PLATE BNE SHT RT PLNTR SYS IMPL INSTRUMENT AXIS,SUP-2610219,CDM,C1713,HCPCS,0278,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
SCREW BNE L 60 MM DIA 3.5 MM TI LCK T15 STARDRV NS V,SUP-2905772,CDM,C1713,HCPCS,0278,RC,,,,both,,,784.69,510.05,,,,,,,,,,,,,
GRAFT BONE 3-6MM 15ML CANC CHIP FRZ DRY,SUP-2294035,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
GRAFT VASC HEMSHLD L 60 CM DIA 6 MM POLYESTER BOV CLLGN STR,SUP-2266061,CDM,C1768,CPT,0278,RC,,,,both,,,1842.36,1197.53,,,,,,,,,,,,,
BUR SURG ACORN MED 3.7 MM 67 MM ENT FLUT HI SPD SS,SUP-2628876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,179.55,116.71,,,,,,,,,,,,,
JGRLC 2.3MM SFT TIS PULL W/NDL,SUP-2589032,CDM,C1713,HCPCS,0278,RC,,,,both,,,1965.89,1277.83,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 12.5CML 5565120,SUP-2632902,CDM,C1752,HCPCS,0278,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
SYSTEM FIXATION SCREOPTILINK 5.0 VAL SLF TPNG SD 80,SUP-2718041,CDM,C1776,CPT,0278,RC,,,,both,,,570.13,370.58,,,,,,,,,,,,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-104435,CDM,J1956,HCPCS,0636,RC,25021-0132-83,NDC,,both,150,ML,63.00,40.95,,,,,,,,,,,,,
RITUXIMAB-ABBS 100 MG/10ML IV SOLN,RX-148009,CDM,Q5115,HCPCS,0636,RC,63459-0103-10,NDC,,both,10,ML,2435.20,1582.88,,,,,,,,,,,,,
SCREW SPNL MONOAX 4.5X25 MM TRPL LD,SUP-2175459,CDM,C1713,HCPCS,0278,RC,,,,both,,,3601.58,2341.03,,,,,,,,,,,,,
CANNULA ENDOSCP OBLQ THRD 6 MMX10.5 CM W/ INSUFFLATION MTL,SUP-2767615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1109.27,721.03,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.407,SUP-2859971,CDM,C1713,HCPCS,0278,RC,,,,both,,,32758.99,21293.34,,,,,,,,,,,,,
HC ER Level 5,PX-4509928500,CDM,99285,CPT,0450,RC,,,,outpatient,,,3911.00,2542.15,,,,,,,,,,,,,
COVER SCR FOR 5MM 6MM HALF PIN STERILIZABLE,SUP-2315964,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.31,4.10,,,,,,,,,,,,,
APPLICATOR THERMOABLATION L14CM OD1.8MM STANDARD COOLED PMTA FOR ACCULIS MICROWAVE TISSUE ABLATION SYSTEM ACCU2I,SUP-2117255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
TWIST DRILL 15MM DIA X 80MM H SHANK BOD/BOS SNGLE USE,SUP-2676843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,528.65,343.62,,,,,,,,,,,,,
LP PLATE STRAIGHT 2 HOLE MED 06MM CP TITANIUM,SUP-2694753,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.78,76.56,,,,,,,,,,,,,
STIMULATOR NRV SPNL CRD NEUROMODULATION PRECIS,SUP-2141950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6896.70,4482.85,,,,,,,,,,,,,
LEAD DEFIB RELIANCE SG L 64 CM SIL EPTFE STEROID ENDOCARD RT,SUP-2459476,CDM,C1777,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 4 FR BASIC MI TY ORNG POWERPICC SOLO 2,SUP-2126374,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.86,286.56,,,,,,,,,,,,,
KIT SURG PWR MINIMALLY INVASIVE IRRIGATION STRL LF DISP,SUP-2881112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
BRACE KNEE AD ALUM FOAM FULL UNIV HNG STRP CLSR ADJ X-ACT,SUP-2196492,CDM,L1833,HCPCS,0274,RC,,,,both,,,315.07,204.80,,,,,,,,,,,,,
PLATE BNE L235MM 15 H NONSTERILE R DST LAT FIBULAR S STL VAR,SUP-2177741,CDM,C1713,HCPCS,0278,RC,,,,both,,,3271.10,2126.21,,,,,,,,,,,,,
PLATE BNE L32MM THK1.3MM 2X4 H HND TI T SHP TRILOK FOR 2MM,SUP-2267938,CDM,C1713,HCPCS,0278,RC,,,,both,,,3025.70,1966.70,,,,,,,,,,,,,
CROWN 6 2ND PERM M LO LT S STL UNITEK,SUP-2238853,CDM,D6783,CPT,0278,RC,,,,both,,,116.31,75.60,,,,,,,,,,,,,
CATHETER ANGIO 9 ARRY L12CM 4-7CMXL STARBURST,SUP-2117215,CDM,C1819,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
PLATE SPNL L26MM ANT CERV 1 LEV COMPR HELIX MINI ACP,SUP-2311444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
AMIODARONE 450 MG IN DEXTROSE 5% 250 ML INFUSION,RX-4081292,CDM,2500000003,HCPCS,0250,RC,09999-9910-08,NDC,,both,250,ML,314.90,204.68,,,,,,,,,,,,,
SCREW CORT FT L HEX 45MMX150MM,SUP-2411235,CDM,C1713,HCPCS,0278,RC,,,,both,,,120.07,78.05,,,,,,,,,,,,,
PLATE BNE L 115 MM SCREW DIA 3.5 MM 5 H MEDL DSTL FEM CNDYL,SUP-2931192,CDM,C1713,HCPCS,0278,RC,,,,both,,,7823.31,5085.15,,,,,,,,,,,,,
NEEDLE NERVE STIM BVL PEDCL ACCS KT INTEGRITY MONITOR PK NIM,SUP-2792154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1886.45,1226.19,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL HVY DTY,SUP-2435684,CDM,L2620,HCPCS,0274,RC,,,,both,,,707.79,460.06,,,,,,,,,,,,,
"HC Sodium,Urine Spot",PX-3018430000,CDM,84300,CPT,0301,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|ADJ|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|ADJ|CO,both,,,144.00,93.60,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CEM KT INJ CA PHSPTE LIQ PWD BWL SPAT SYR,SUP-2366470,CDM,C1713,HCPCS,0278,RC,,,,both,,,4741.93,3082.25,,,,,,,,,,,,,
SHUNT COR L18MM DIA225MM NONPROGRAMMABLE GUIDANT W/O RESVR,SUP-2582817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.67,1034.59,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 IJ SOLN (MIXTURES ONLY),RX-430034,CDM,2500000003,HCPCS,0250,RC,00409-1541-01,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
INFUSION PUMP KIT PAIN 10 IN CTRL CATH PAINBUSTER SOAK ON-Q,SUP-2236848,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
KIT GRFT SUB 2XSM 0.7ML 1.05MG RHBMP-2 FRZ DRY ST H2O CLLGN,SUP-2287846,CDM,C1713,HCPCS,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
HC I & D Simple,PX-4501006000,CDM,10060,CPT,0450,RC,,,,inpatient,,,632.00,410.80,,,,,,,,,,,,,
HEAD HUM H18MM DIA48MM SHLDR CO CHROM STD OFFSET PRI FOR,SUP-2249953,CDM,C1776,CPT,0278,RC,,,,both,,,5893.78,3830.96,,,,,,,,,,,,,
PLATE BONE L22MM MINI T SHP,SUP-2364915,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.24,189.96,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 5 MM RNG L 70 CM EPTFE,SUP-2396288,CDM,C1768,CPT,0278,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
APPLIER CLP L6IN 28MM WRK CHN 11MM OPN TISS HEMSTAT REUSE,SUP-2141394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.18,321.87,,,,,,,,,,,,,
CONNECTOR SPNL L40MM TRNSVRS LO PROF CLP ON DSGN OASYS,SUP-2362942,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
STEM HUM L 125 MM DIA11.5/8/6 MM COCR LNG CEM 4 FLUT TOT,SUP-2910015,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE EXT FIX LNG REAR FT FOR SIDEKCK STLTH,SUP-2400639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
FOOT PLATE EXT FIX DIA200 MM SHRT NS DISP MONK RING,SUP-2881090,CDM,C1769,HCPCS,0272,RC,,,,both,,,4999.67,3249.79,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE STR WTAB 1.5 MM SCRW24 HOLE 108 MM,SUP-2677639,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE,PX-4409753000,CDM,97530,CPT,0440,RC,,,GO|CO|XU|KX,both,,,191.00,124.15,,,,,,,,,,,,,
PLATE BNE MESHED 126X126X0.3 MM SM GRID PDLLA STRL RESORB XG,SUP-2477456,CDM,C1713,HCPCS,0278,RC,,,,both,,,10848.61,7051.60,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 56 MM DIA24 MM SHTH 16 FR SS,SUP-2170654,CDM,C1768,CPT,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
SPONGE GRV SIL 4.0MMX12.0MMX80MM,SUP-2213498,CDM,C1784,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
STEM FEM CONE 125 DEG 135 DEG HIP WAGNER,SUP-2448641,CDM,C1776,CPT,0278,RC,,,,both,,,210932.64,137106.22,,,,,,,,,,,,,
PLATE BNE SZ 2 R TIB FIX BEAR CEM,SUP-2420824,CDM,C1713,HCPCS,0278,RC,,,,both,,,16102.55,10466.66,,,,,,,,,,,,,
SCREW SHRT CANN 10.0MM OD 8.0MM ID,SUP-2491072,CDM,C1713,HCPCS,0278,RC,,,,both,,,2214.80,1439.62,,,,,,,,,,,,,
PLATE BNE L217MM THK3.3MM 18 H BILAT S STL RIG STR DYN,SUP-2186338,CDM,C1713,HCPCS,0278,RC,,,,both,,,2281.15,1482.75,,,,,,,,,,,,,
FELT PTFE LO POROSITY NOM THICKNESS 1.85MM 4INX4IN DIAM,SUP-2127685,CDM,C1768,CPT,0278,RC,,,,both,,,355.98,231.39,,,,,,,,,,,,,
GUIDEWIRE VASC FLPY 0.035 INX260 CM PERIPH HI TORQ VERSACORE – ORDER MULTIPLES OF 5EACH,SUP-2104848,CDM,C1769,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
CUP ACET DIA64MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH,SUP-2250731,CDM,C1776,CPT,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
BIT DRL 3 FLUT 3.2X145 MM MOD W/ QUIK CPL,SUP-2653738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.19,361.52,,,,,,,,,,,,,
PLATE BNE XSM L BRDG MID FUS,SUP-2401174,CDM,C1713,HCPCS,0278,RC,,,,both,,,8810.84,5727.05,,,,,,,,,,,,,
MESH HERN W1.3XL1.6IN M POLYPR INGUINAL NONABSORBABLE,SUP-2125787,CDM,C1781,HCPCS,0278,RC,,,,both,,,486.39,316.15,,,,,,,,,,,,,
RESONANCE POSITIONER,SUP-2822058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,441.01,286.66,,,,,,,,,,,,,
PROGRAMMER SLEEP STUDY UPPER AIRWAY,SUP-2865143,CDM,C1787,HCPCS,0278,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
BIT DRILL STOP 90 DEGREE 1.8X21 MM 14 MM FOR SCREWDRIVER NON,SUP-2842089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,953.93,620.05,,,,,,,,,,,,,
PLATE BONE 3X3 H BILAT MAND ORAL MAXILLOFACIAL TI CRESC LO,SUP-2191434,CDM,C1713,HCPCS,0278,RC,,,,both,,,4771.86,3101.71,,,,,,,,,,,,,
ROD IM KNEE AGC,SUP-2445374,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
ANCHOR FIX OCPTL SHT 11 MM SPINAL SYSTEM CASPIAN,SUP-2734710,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
GUIDEWIRE VASC L205CM OD0.014IN TIP L2CM HYDRPHLC,SUP-2362792,CDM,C1769,HCPCS,0272,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
CATHETER THROMCTMY AXS VECTA 46 L 125 CM PROX/DSTL OD,SUP-2878077,CDM,C1757,HCPCS,0272,RC,,,,both,,,4882.07,3173.35,,,,,,,,,,,,,
SHEATH INTRO AXS INFIN LS + L 80 CM OD 8 FR ID 0.091 IN LNG,SUP-2551064,CDM,C1766,CPT,0272,RC,,,,both,,,1574.40,1023.36,,,,,,,,,,,,,
SCREW BNE EXTRACTION FOR HUM NAILING SYS NS MULTILOC,SUP-2799297,CDM,C1713,HCPCS,0278,RC,,,,both,,,1767.35,1148.78,,,,,,,,,,,,,
PLATE BNE L63MM 3X4 H OBLQ T SHP FOR 35MM SCR,SUP-2199382,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.89,363.28,,,,,,,,,,,,,
EXPANDER TISS NACL 5.3 CM PROJCT 12X12.5 CM 400 CC 133FV,SUP-2113117,CDM,C1789,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SPACER SPNL 4 MM MONOTUBE,SUP-2476623,CDM,C1821,HCPCS,0278,RC,,,,both,,,50.55,32.86,,,,,,,,,,,,,
BRACE KNEE AD L23 17IN UNIV COOL FOAM UNISX TRANSITION,SUP-2195291,CDM,L1810,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
COMPONENT HUM ELBW CONN PC M TO M TAPR MRS L35MM,SUP-2364664,CDM,C1776,CPT,0278,RC,,,,both,,,10418.52,6772.04,,,,,,,,,,,,,
STEM FEM 2 125 MM MOLD PROSTALAC,SUP-2454727,CDM,C1776,CPT,0278,RC,,,,both,,,23427.54,15227.90,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0.035IN TIP L4CM PTFE S STL SHT,SUP-2148227,CDM,C1769,HCPCS,0272,RC,,,,both,,,99.22,64.49,,,,,,,,,,,,,
BUTTON SUTURE CLOSURE,SUP-2936918,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
POST EXT FIX 2 HOLE W/ THRD ATTCH,SUP-2749944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
CATHETER ART PRESSURE MONITORING SET 018 3 FRX5 CM CPMS300RA,SUP-2760096,CDM,C1751,HCPCS,0278,RC,,,,both,,,146.64,95.32,,,,,,,,,,,,,
PATCH BIO TISS W10PATCH BIO TISS W10XL16CM BOV PERICARD,SUP-2130368,CDM,C1768,CPT,0278,RC,,,,both,,,1937.66,1259.48,,,,,,,,,,,,,
RETRIEVER THROMCTMY MERCI L4 DIA2 MM NIT STRL,SUP-2367770,CDM,C1773,HCPCS,0272,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
COIL HELI MICROPLEX SFT SZ 18 LOOP 2MM X 4CM,SUP-2305199,CDM,C1889,HCPCS,0278,RC,,,,both,,,1654.78,1075.61,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UPCHARGE ZIMMERKNEUP] ZIMMER BIOMET INC],SUP-2212750,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE H 3.5/4X30 MM NS LTX,SUP-2857048,CDM,C1713,HCPCS,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
WIRE OLIVE 1.8MM X 400MM,SUP-2498241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
IMPLANT FACE L 50 X W 38 MM THK 0.25 MM POLYETHYL,SUP-2883424,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.81,926.78,,,,,,,,,,,,,
PAROXETINE HCL ER 12.5 MG PO TB24,RX-32631,CDM,6370000000,HCPCS,0637,RC,60505-1316-03,NDC,,both,1,UN,9.00,5.85,,,,,,,,,,,,,
COMPONENT FEM SLED PROSTHESES LINK ENDO-MODEL IMP L46XW17MM,SUP-2397005,CDM,C1776,CPT,0278,RC,,,,both,,,10770.20,7000.63,,,,,,,,,,,,,
BLADE LARYNGOSCOPE PHILIPS SZ1 EQIV 2 MILLER1.5,SUP-2665191,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.65,335.17,,,,,,,,,,,,,
GRAFT BNE CRUSH 1-10 MM 15 CC CANC,SUP-2766761,CDM,C1713,HCPCS,0278,RC,,,,both,,,966.49,628.22,,,,,,,,,,,,,
TM FEM METAPHYSEAL CONE 35 SMALL LEFT,SUP-2502264,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,6370000000,HCPCS,0637,RC,70752-0130-05,NDC,,both,60,ML,127.50,82.87,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 4 FR NIT MANDREL TUNGSTEN TIP SMTH,SUP-2739178,CDM,C1892,HCPCS,0272,RC,,,,both,,,56.36,36.63,,,,,,,,,,,,,
LEAD NERVE STIM 50 CM 3-6 TRL LINEAR,SUP-2765586,CDM,C1883,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
BURR SURG 3MM DIA HD XLN 95MML SM BNE RND DIAMOND FLUTEX8 MI,SUP-2605840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
HEAD HUM 56X24 MM SHLDR COCR BIO MOD,SUP-2449915,CDM,C1776,CPT,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
BIT DRL L110MM DIA2.5MM 3 FLUT QUIK CPL NONRADIOPAQUE W/O,SUP-2187584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.52,215.49,,,,,,,,,,,,,
SCREW BNE L25MM DIA6MM CORT ST NONCANNULATED NONLOCKING FULL,SUP-2377551,CDM,C1713,HCPCS,0278,RC,,,,both,,,608.53,395.54,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.0 X 12MM H,SUP-2320339,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.18,436.27,,,,,,,,,,,,,
SHEATH TG0854522 85F 22MM 45CM,SUP-2298503,CDM,C1887,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR AIRPLANE DESIGN W/W O NONTORSION JT,SUP-2435754,CDM,L3674,HCPCS,0274,RC,,,,both,,,3045.61,1979.65,,,,,,,,,,,,,
SYSTEM EMB 36 FR SZ 20 CM LEN PERIPH HYDRGEL HYDROLYSER,SUP-2385405,CDM,C1889,HCPCS,0278,RC,,,,both,,,4281.39,2782.90,,,,,,,,,,,,,
KNIFE SURG CLD STR DISP SACHSE,SUP-2717639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
SHOE ORTHOT CUST SLD STIRRUP TRANSFER NEW,SUP-2435748,CDM,L3630,HCPCS,0272,RC,,,,both,,,284.45,184.89,,,,,,,,,,,,,
HC So F5 Factor V Leiden Mutation,PX-3108124166,CDM,81241,CPT,0310,RC,,,,both,,,211.00,137.15,,,,,,,,,,,,,
PLATE BNE L117MM 6 H NONSTERILE L PROX TIB S STL VAR ANG,SUP-2177912,CDM,C1713,HCPCS,0278,RC,,,,both,,,4677.06,3040.09,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM PEEK OPTMA LINK KNOTLESS CLEAT EYELET,SUP-2402633,CDM,C1713,HCPCS,0278,RC,,,,both,,,1484.09,964.66,,,,,,,,,,,,,
GUIDEPIN ORTH L343MM DIA3.2MM BRAD PNT TIP INSTR FOR OPN,SUP-2347574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.28,574.13,,,,,,,,,,,,,
PLATE BNE 130 DEG SHFT L 104 MM BLADE L 50 MM 6 H SS PROX,SUP-2908090,CDM,C1713,HCPCS,0278,RC,,,,both,,,2869.36,1865.08,,,,,,,,,,,,,
COMPONENT FEM CO CHROM POR HD BPLR CEM TNDM KT,SUP-2347986,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.541,SUP-2860222,CDM,C1713,HCPCS,0278,RC,,,,both,,,45894.24,29831.26,,,,,,,,,,,,,
DRESSING WND 6 LAYR 10X15 CM MTRX CYTAL,SUP-2106533,CDM,Q4166,HCPCS,0636,RC,,,,both,,,15417.40,10021.31,,,,,,,,,,,,,
CATHETER GUID 16FR L62CM DEFLECTED TIP REACH 22MM NK,SUP-2298365,CDM,C1894,HCPCS,0272,RC,,,,both,,,5529.54,3594.20,,,,,,,,,,,,,
SET DEVICE SPINAL W/CANNULA BLADE ST DISP,SUP-2354636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 0.018 IN 3 FRX50 CM 55 CM SIL,SUP-2168330,CDM,C1751,HCPCS,0278,RC,,,,both,,,248.44,161.49,,,,,,,,,,,,,
BRACE ORTH ADJACENT FIT ELBW CUST FIT,SUP-2388191,CDM,L3760,HCPCS,0272,RC,,,,both,,,1755.26,1140.92,,,,,,,,,,,,,
CLINDAMYCIN HCL 300 MG PO CAPS,RX-9621,CDM,6370000000,HCPCS,0637,RC,68084-0244-01,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
LENS INTOCU 20.0 DIOPT 118.7 A CONSTANT L13MM DIA6MM 0DEG,SUP-2110224,CDM,V2632,HCPCS,0276,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM SM CP TI MANDIBULAR FULL,SUP-2883710,CDM,C1713,HCPCS,0278,RC,,,,both,,,16660.97,10829.63,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X40 MM OCCIPITOCERVICAL UPPER THOR,SUP-2631976,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
SET HAD CATH 12.5FR L28CM W/ INJ CAP SCALP SHTH NDL GWIRE,SUP-2267082,CDM,C1752,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SCREW BNE HD 4X26 MM,SUP-2365613,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.13,51.43,,,,,,,,,,,,,
TRAY KYPHOPLASTY BLLN 2ML L15MM DIA10.9MM NDL 10GA W/ LOK,SUP-2367063,CDM,C1726,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SHEATH INTRO AXCESS L 45 CM DIA 5 FR GUIDEWIRE 0.035-0.038,SUP-2876098,CDM,C1894,HCPCS,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY II DIA 36 MM COCR POLYESTER SIL,SUP-2214251,CDM,C1889,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
PLATE BONE CONTOUR MESH 70X0.6 MM RECONSTRUCTION TITANIUM GO,SUP-2837715,CDM,C1713,HCPCS,0278,RC,,,,both,,,6064.60,3941.99,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY SM AD 4.25 IN 10-13 IN PHILADELPHIA,SUP-2319297,CDM,L0172,HCPCS,0272,RC,,,,both,,,30.52,19.84,,,,,,,,,,,,,
SCREW INTFR L8MM DIA3MM BIOCOMPOSITE W/ HNDL INSRT,SUP-2121327,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
TRAY CTRL VEN AD 9.5FR L5CM 0.018IN NDL 19GA DIL C5 SYR DBL,SUP-2127768,CDM,C1751,HCPCS,0278,RC,,,,both,,,2430.05,1579.53,,,,,,,,,,,,,
HC Treat Ulna Fx,PX-4502553000,CDM,25530,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
DRESSING WND THERAGENESIS MESHED BILYR MATRIX 20X24CM,SUP-2737951,CDM,A2008,HCPCS,0636,RC,,,,both,,,30618.14,19901.79,,,,,,,,,,,,,
PLATE BNE W13XL13MM 4 H CRANIOMAXILLOFACIAL TI BX SHP FOR,SUP-2190682,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.79,413.91,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MARSH L 75 CM BALLOON L 40 MM DIA 9 MM,SUP-2141029,CDM,C1725,HCPCS,0272,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
JOINT TALAR ANK TOT SYS SALTO TALARIS XL,SUP-2244040,CDM,C1713,HCPCS,0278,RC,,,,both,,,25512.50,16583.12,,,,,,,,,,,,,
GRAFT BONE SUB W8XH4.6-7XL22MM POST LUM INTBDY FUS SPCR FRZN,SUP-2306878,CDM,C1713,HCPCS,0278,RC,,,,both,,,8193.92,5326.05,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX19 CM SET W/ SIDE H STYL SYMETREX,SUP-2627447,CDM,C1750,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
ALLOGRAFT BNE FD ASEP WHL RIB,SUP-2867057,CDM,C1762,CPT,0278,RC,,,,both,,,1825.60,1186.64,,,,,,,,,,,,,
HC CT Rf Ablation Pulm Tumor(S),PX-3613299800,CDM,32998,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
BRACE THORACOLUMBOSACRAL M 15DEG LORDOSIS HK RECV MAT BK,SUP-2195550,CDM,L0650,HCPCS,0274,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
CATHETER ART 0.025 IN 7 FRX110 CM STD 4 LUMEN HEPCOAT LTX,SUP-2662679,CDM,C1751,HCPCS,0278,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
CATHETER DIL PASSPRT L 150 CM DIA 3 FR BALLOON 4 CM DIA 4 MM,SUP-2139182,CDM,C1726,HCPCS,0272,RC,,,,both,,,849.68,552.29,,,,,,,,,,,,,
PLATE BNE L65MM THK385MM 5 H BILAT S STL STR WIDE ANG LO,SUP-2177152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1188.43,772.48,,,,,,,,,,,,,
APPLIER CLP L9.75IN STD BLU TI STR BAYNT FOR ANEUR CLP REUSE,SUP-2108608,CDM,C1889,HCPCS,0278,RC,,,,both,,,5071.60,3296.54,,,,,,,,,,,,,
ROD RMR L950MM DIA2.5MM W/ EXTN BALL TIP,SUP-2188106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.41,221.27,,,,,,,,,,,,,
COIL EMB L40CM DIA10MM 360DEG SFT DETACH TARGET XL,SUP-2367752,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BNE 2.4X80X2 MM 10 HOLE SS LCP,SUP-2569302,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.66,285.13,,,,,,,,,,,,,
CATHETER HEMODIALYSI NIAG ACUTE 13.5FR DIA 20CML INSER 400ML,SUP-2613253,CDM,C1752,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
INSERT TIB SZ 4 THK12MM RT FLX GMK SPHR,SUP-2267672,CDM,C1776,CPT,0278,RC,,,,both,,,1890.59,1228.88,,,,,,,,,,,,,
GRAFT BONE VOID FIL 20CC NANOSS,SUP-2335283,CDM,C1713,HCPCS,0278,RC,,,,both,,,11435.88,7433.32,,,,,,,,,,,,,
PLATE BNE L10MM N COMPR CHIN BILAT 20MM SCR H DIA 4 H RIG,SUP-2366338,CDM,C1713,HCPCS,0278,RC,,,,both,,,871.57,566.52,,,,,,,,,,,,,
ATTACHMENT HNDPC TELSCP MIDAS REX LEGEND,SUP-2284671,CDM,C1713,HCPCS,0278,RC,,,,both,,,4833.72,3141.92,,,,,,,,,,,,,
AUGMENT TIB L63/67MM THK20MM R LAT L MED KNEE UHMWPE PRI,SUP-2405781,CDM,C1776,CPT,0278,RC,,,,both,,,2783.61,1809.35,,,,,,,,,,,,,
NEEDLE 25GA ASPIRATION VIZISHOT 2,SUP-2659180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.30,517.59,,,,,,,,,,,,,
PLATE BONE MINI MTP PKT,SUP-2400414,CDM,C1713,HCPCS,0278,RC,,,,both,,,5827.84,3788.10,,,,,,,,,,,,,
WASHER SPNL 7X18 MM FOR SCREW TI NS USS,SUP-2423057,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
HC CT Upper Extremity W/WO Cont,PX-3527320200,CDM,73202,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
SYSTEM INT FIX GFS BTB LINK,SUP-2762120,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
GRAFT HUM TISS W20-24XL60MM THK5-30MM ILIUM TRICORT STRP,SUP-2307167,CDM,C1713,HCPCS,0278,RC,,,,both,,,6653.66,4324.88,,,,,,,,,,,,,
EXTENSION ORTHOT LAT THOR CUST,SUP-2435585,CDM,L1210,HCPCS,0272,RC,,,,both,,,692.68,450.24,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLUENCY + L 80 MM DIA10 MM CATH L 80 CM,SUP-2128269,CDM,C1874,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
PLATE BNE NAR 4.5X151 MM 9 HOLE SS DCP,SUP-2569167,CDM,C1713,HCPCS,0278,RC,,,,both,,,303.95,197.57,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO SEP L 175 CM DSTL DIA 0.055 IN,SUP-2323712,CDM,C1757,HCPCS,0272,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
SCREW INTRF L20MM DIA7MM TI CANN SOFTSILK FOR 1MM GWIRE,SUP-2340726,CDM,C1713,HCPCS,0278,RC,,,,both,,,638.42,414.97,,,,,,,,,,,,,
CATHETER HD 3L 11.5 FRX20 CM ADMIN FULL KT PRECRV TRIFLO,SUP-2269543,CDM,C1752,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
HC Electrophysiology Evaluation,PX-4819362200,CDM,93622,CPT,0481,RC,,,,both,,,3541.00,2301.65,,,,,,,,,,,,,
BRACE ORTHOPEDIC AFO ANK PREFABRICATED SPRL,SUP-2265016,CDM,L1951,HCPCS,0274,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
OXYGENATOR PERF CARDOTMY RESERVOIR PMP MT AFFIN NT,SUP-2463204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,855.78,556.26,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 3 MM RND UPWR,SUP-2166786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,140.11,91.07,,,,,,,,,,,,,
CATHETER TRROMBECTORY TRUVIC PRODIGY 6F,SUP-2855181,CDM,C1751,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL HEEL PD,SUP-2435736,CDM,L3480,HCPCS,0272,RC,,,,both,,,176.41,114.67,,,,,,,,,,,,,
GRAFT BNE SUB 20CC SYN TISS MTRX EXT BLK MASTERGRFT,SUP-2288546,CDM,C9362,HCPCS,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
BASKET STONE 31 MM 2Q MECH LITHO,SUP-2492310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,721.32,468.86,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.02 MM 1.6 MM 2.3 MM W/ TAB FLROPLAS,SUP-2535128,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.30,15.79,,,,,,,,,,,,,
GRAFT BNE SUB XL W10-20MMXL19.5-38CM VIABLE CELL TRINITY,SUP-2307242,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
BIT DRL 2X130 MM PENNIG DYN WRST FIX,SUP-2644602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,272.93,177.40,,,,,,,,,,,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,0636,RC,00781-3408-80,NDC,,both,1,UN,77.10,50.11,,,,,,,,,,,,,
NAIL RFNA 10MMX 360MM 10 DEG BEND/ ST,SUP-2720091,CDM,C1713,HCPCS,0278,RC,,,,both,,,5751.76,3738.64,,,,,,,,,,,,,
SCREW STRNL CLOSURE L 10 MM DIA2.7 MM TI STRL STERNALOCK XP,SUP-2895210,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
BRACE ORTHOPEDIC LUMBAR MIAMI,SUP-2319301,CDM,L0642,HCPCS,0274,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 TI LCK SCREW 48MM S-T,SUP-2819594,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
CATH BLLN INTRA AORTIC MEGA 8FRX50CC,SUP-2468489,CDM,C1725,HCPCS,0272,RC,,,,both,,,2857.87,1857.62,,,,,,,,,,,,,
SCREW BNE ST 1.3X17 MM CRTX SS NS,SUP-2177965,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.44,102.99,,,,,,,,,,,,,
CATHETER EP K 5-5-5-42-5-5-5 MM 6 FRX110 CM,SUP-2461809,CDM,C1730,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SCREW BONE L55MM D55MM THRD L16MM CNCLLS SELF DRLLNG SELF TP,SUP-2482922,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.83,385.34,,,,,,,,,,,,,
SPLINT WRST M L10IN FOR 6 7IN R FA VYN FLANNEL LN SLIP ON,SUP-2276623,CDM,L3908,HCPCS,0274,RC,,,,both,,,18.27,11.88,,,,,,,,,,,,,
T2 PROX HUM NAIL 8MMX150MM LT STRL,SUP-2361808,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
SCREW BNE 5.5X40 MM 5TH METATRSL,SUP-2223987,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2.8 MM SM CP TI MANDIBULAR FULL,SUP-2883711,CDM,C1713,HCPCS,0278,RC,,,,both,,,18327.05,11912.58,,,,,,,,,,,,,
SYSTEM INTRO SAFSHTH II L 23 CM DIA 7 FR DIL 28.5 CM ORN,SUP-2281630,CDM,C1892,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BASE PHLANG 2H HD 6H SHFT TI STRL VAL,SUP-2546911,CDM,C1713,HCPCS,0278,RC,,,,both,,,1843.24,1198.11,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC FIBER STAGRAFT,SUP-2661731,CDM,C1713,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX50 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761452,CDM,C1768,CPT,0278,RC,,,,both,,,2491.94,1619.76,,,,,,,,,,,,,
BOLT SPNL L40MM OD9MM TI CANC ANT THORLUM PEDCL ST FIX ANG,SUP-2292742,CDM,C1713,HCPCS,0278,RC,,,,both,,,5856.10,3806.46,,,,,,,,,,,,,
DRILL SURG L122MM DIA2.7MM ADD ON OVERDRL FOR VARIAX SYS,SUP-2378005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
BIT DRILL 10.2MM CANN LEN 251MM,SUP-2417043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1849.96,1202.47,,,,,,,,,,,,,
MASK CPAP FULL FACE W/ SIL SEAL FLEXIFOAM CUSH AND HDGEAR,SUP-2224714,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
ANCHOR SUT SHLDR JUGGERKNOT SZ 1 BLACK WHITE,SUP-2212951,CDM,C1713,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 150 CM DIA 4 FR DIA1.05 MM IMA,SUP-2615634,CDM,C1887,HCPCS,0272,RC,,,,both,,,164.54,106.95,,,,,,,,,,,,,
STENT URET 5FR L28CM HYDRPHLC SET SFT PGTL STRAIGHTENER POS,SUP-2170695,CDM,C2617,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
LINER ACET NON-HOODED 36X54-56 MM HIP CLUS XLPE POLYETH EXP,SUP-2390423,CDM,C1776,CPT,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
SET PICC L 55 CM DIA 5.5 FR SHTH L 7 CM DIA 5.5 FR,SUP-2887067,CDM,C1751,HCPCS,0278,RC,,,,both,,,679.28,441.53,,,,,,,,,,,,,
IMPLANT HEARING 8.5MM ABUTMENT SNAP CPL,SUP-2164933,CDM,C1713,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
TRAY DIAG X LEV RADPQ W/ BONE CEM DEL AVATEX AVAMAX,SUP-2367084,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GRAFT DERMACELL DERMAL MATRIX 20CM X 20MM THICK,SUP-2854468,CDM,Q4122,HCPCS,0636,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
PLATE BNE 1.5/2X37X1.5 MM 6 HOLE SS LC-DCP,SUP-2569196,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.23,171.75,,,,,,,,,,,,,
WIRE FIX THRD 1.25 MM 80 MM SS KIRSCHNER,SUP-2653535,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.87,182.57,,,,,,,,,,,,,
BLADE SAW D64MM CUT EDGE 34.5MM,SUP-2659188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
SCREW BNE ST 2X10 MM MAND LCK TI SLV NS MATRIXMANDIBLE LF,SUP-2181745,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT SEG FD RAD,SUP-2321898,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209753000,CDM,97530,CPT,0420,RC,,,CO|XU,both,,,144.00,93.60,,,,,,,,,,,,,
GRAFT BNE H15XL25MM TRICORT PAT WDG FRZ DRY MATRIGRFT,SUP-2264809,CDM,C1713,HCPCS,0278,RC,,,,both,,,2183.46,1419.25,,,,,,,,,,,,,
NEEDLE NRV STIM INSRT NDL 65IN PAIN MGMT,SUP-2138808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEM XLPE CHIPSNEPHCEMXLPE] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351334,CDM,C1776,CPT,0278,RC,,,,both,,,11319.70,7357.80,,,,,,,,,,,,,
WIRE FIX 1.6X150 MM W/STP KIRSCHNER VARIAX,SUP-2435340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.27,257.58,,,,,,,,,,,,,
SCREW 5.0MM TI DUAL CORE LCKNG T25 STRDRV 28MM F IM NAIL STE,SUP-2546343,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.55,453.41,,,,,,,,,,,,,
KYPHOPLASTY KIT BLLN 11 GAX20 MM,SUP-2864564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8329.70,5414.30,,,,,,,,,,,,,
HC Pulmonary Arteriogram Bil,PX-3237574300,CDM,75743,CPT,0323,RC,,,,both,,,7211.00,4687.15,,,,,,,,,,,,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,0636,RC,63323-0173-02,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L 55 MM 4 H LT VOLAR DSTL RADIAL WIDE NS VARIAX,SUP-2902150,CDM,C1713,HCPCS,0278,RC,,,,both,,,4332.01,2815.81,,,,,,,,,,,,,
DIGIFUSE IMPLANT 2.0MM 0 DEGREE ANGLE SHRT,SUP-2586637,CDM,C1713,HCPCS,0278,RC,,,,both,,,5736.84,3728.95,,,,,,,,,,,,,
REAMER SURG 11 MM FEM,SUP-2121313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE BNE GRP MED 200 MM TROCHANTERIC SS DALL-M,SUP-2451635,CDM,C1713,HCPCS,0278,RC,,,,both,,,4856.95,3157.02,,,,,,,,,,,,,
GRAFT VASC GRAD WALL 8 MMX40 CM STR REINF SLDE GDS FLIXENE,SUP-2471417,CDM,C1768,CPT,0278,RC,,,,both,,,2357.29,1532.24,,,,,,,,,,,,,
PIN FIX L25MM DIA2.5MM PROV FOR EVOS SM PLATING SYS,SUP-2344056,CDM,C1713,HCPCS,0278,RC,,,,both,,,1066.03,692.92,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL FRAME,SUP-2435559,CDM,L0650,HCPCS,0274,RC,,,,both,,,3667.77,2384.05,,,,,,,,,,,,,
PLATE BNE 4 H L SLNT STR COMPR LISFRANC GORILLA,SUP-2321514,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
ABLYSINOL IA SOLN,RX-145355,CDM,2500000003,HCPCS,0250,RC,54288-0105-15,NDC,,both,1,ML,1144.30,743.79,,,,,,,,,,,,,
BIT DRL L91MM DIA2MM STP 40MM AO QUIK CPL TWST,SUP-2267864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 MO-6 6.5 MM NDL TI WHT BLU V-LOX,SUP-2762303,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.62,577.60,,,,,,,,,,,,,
CATHETER DRAINAGE 25 MMX6CM UNITZ SNAP ASMBLY RESERVOIR BASE,SUP-2278322,CDM,C1729,HCPCS,0272,RC,,,,both,,,485.54,315.60,,,,,,,,,,,,,
GRAFT VASC INTERGARD BODY/BRANCH L 100/55 CM RNG L 60/30 CM,SUP-2462110,CDM,C1768,CPT,0278,RC,,,,both,,,2494.64,1621.52,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 5 FR 5 MM 10 POLE,SUP-2493971,CDM,C1730,HCPCS,0272,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
TC-100 4.5M S-T CRTX SCREW 76MM,SUP-2818935,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.67,236.39,,,,,,,,,,,,,
VPAP III BI-LEVEL DEV,SUP-2331929,CDM,C1713,HCPCS,0278,RC,,,,both,,,3296.97,2143.03,,,,,,,,,,,,,
PLATE BNE L 246 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 18 H SS 72467118,SUP-2933409,CDM,C1713,HCPCS,0278,RC,,,,both,,,7245.55,4709.61,,,,,,,,,,,,,
REAMER SURG 10MM STRL FOR HAMRTOE HTR IMPL SYS,SUP-2390550,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
DEVICE CLOSURE 10 FR PERC VASC SURG SYS PROSTAR XL,SUP-2846208,CDM,C1760,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
BOLT EXT FIX LNG WIRE COMB NS DISP SMRT TSF,SUP-2933200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
COMPONENT HUM CMNTLS 42 MM SHLDR HA AEQUALIS REVERSED,SUP-2715658,CDM,C1776,CPT,0278,RC,,,,both,,,9146.82,5945.43,,,,,,,,,,,,,
PIN ARTHSCP FLEX FOR FLEX RMR,SUP-2121218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE BNE LCK NAR RT DSTL ANTEROLATERAL CORTICAL TIB 15 HOLE,SUP-2475112,CDM,C1713,HCPCS,0278,RC,,,,both,,,4590.02,2983.51,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP DOME 7 FR 035X480 CM TRCE METRO DIR,SUP-2737413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
PLATE BONE STD 3 H LT ANK FT COMPR FOR LAPIDUS PROC PRECIS,SUP-2321489,CDM,C1713,HCPCS,0278,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
CLAMP REPROC SM COMBINATION MR SAFE,SUP-2461875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.64,231.82,,,,,,,,,,,,,
STRUT EXT FIX SHRT MULTAXL CORRECTION SYS HEXAPOD FULL AUTO,SUP-2905657,CDM,C1713,HCPCS,0278,RC,,,,both,,,6720.60,4368.39,,,,,,,,,,,,,
CLAMP MULT SCR FOR ORTHOFIX PREFIX FIX,SUP-2316289,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.33,589.11,,,,,,,,,,,,,
PIN FIX REDUCTION SM 15 MM TCP,SUP-2530500,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 7 FR GUIDEWIRE PERIPHERAL,SUP-2385674,CDM,C1894,HCPCS,0272,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
BIT DRL DIA3.5MM METATARSAL CANN FOR FRAC SYS,SUP-2123145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SPACER ALLGRFT 7 DEG L 11 X W 14 X H 5 MM CORT CANC BNE CERV,SUP-2916804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
PLATE BNE 3X8 H NONSTERILE TI T SHP LOK COMPR W SHT THRD DRL,SUP-2180913,CDM,C1713,HCPCS,0278,RC,,,,both,,,1434.10,932.16,,,,,,,,,,,,,
INTERNAL FIXATION KIT 1X4 MM STRL SPEEDBUTTON LTX,SUP-2866392,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
PLEDGET CV SAUVAGE L 15.2 X W 1 CM THK 0.61 MM POLYESTER,SUP-2761349,CDM,C1768,CPT,0278,RC,,,,both,,,511.16,332.25,,,,,,,,,,,,,
SCREW SPNL MULT ANGLE 90 DEG 6.75X40 MM SPRL ROD,SUP-2381435,CDM,C1713,HCPCS,0278,RC,,,,both,,,4330.06,2814.54,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 15.5-18.5 IN CTR 13-14 IN CALF 12-14 IN 11-3504,SUP-2916999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.93,280.10,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM NOM THK1.1MM STD HUM DERM REGEN TISS,SUP-2399063,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6116.72,3975.87,,,,,,,,,,,,,
HC Insert Bladder Catheter Non-Indwelling|UNUSUAL NON-OVERLAPPING SERVICE,PX-4505170100,CDM,51701,CPT,0450,RC,,,XU,both,,,204.00,132.60,,,,,,,,,,,,,
AUGMENT TIB SZ 4 LT KNEE UNIV SGL USE LEGION,SUP-2349124,CDM,C1776,CPT,0278,RC,,,,both,,,5344.28,3473.78,,,,,,,,,,,,,
PLATE BNE L276MM 11 H NONSTERILE R DST FEM TI LOK COMPR FOR,SUP-2190727,CDM,C1713,HCPCS,0278,RC,,,,both,,,5031.91,3270.74,,,,,,,,,,,,,
CATHETER HEMODIALYSI HEM FLO CHRONIC 14.5FR DIA 40CM 35CML C,SUP-2610555,CDM,C1750,HCPCS,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
GRAFT BNE FIBER MED 5 CC SYR DBM,SUP-2431097,CDM,C1889,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CATHETERIZATION KIT 7 FRX16 CM 3L,SUP-2383966,CDM,C1751,HCPCS,0278,RC,,,,both,,,448.02,291.21,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.035X5 IN SS NS KIRSCHNER,SUP-2791811,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.48,5.51,,,,,,,,,,,,,
PLATE BNE L125MM 7 H ST L DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177222,CDM,C1713,HCPCS,0278,RC,,,,both,,,4682.62,3043.70,,,,,,,,,,,,,
PLATE BNE W10XL87MM THK1.5MM 90DEG 3X7 H BILAT S STL T SHP,SUP-2185876,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.01,911.96,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 40 CM DIA14 MM THK 0.49 MM POLYESTER,SUP-2227585,CDM,C1768,CPT,0278,RC,,,,both,,,1737.61,1129.45,,,,,,,,,,,,,
HC Clsd Tx Patella Disloc W Anes,PX-4502756200,CDM,27562,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE TOD BLDE L44MM DISPLC 4MM 100DEG NONSTERILE S STL,SUP-2185408,CDM,C1713,HCPCS,0278,RC,,,,both,,,2151.87,1398.72,,,,,,,,,,,,,
MESH HERN L W10.8XL16CM L INGUINAL WHT POLYPR MFIL,SUP-2125772,CDM,C1781,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SCREW BNE SCHNZ 6X100 MM SD HA STRL,SUP-2563698,CDM,C1713,HCPCS,0278,RC,,,,both,,,472.10,306.86,,,,,,,,,,,,,
PUMP PAIN 400ML 2 PART,SUP-2236774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
LO-PRO SCRW SYS 2.0/2.3/3.0MM SET,SUP-2814795,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
BUR SURG DIA1.2 MM TWST DRL STRL DISP HI-LINE XS,SUP-2929619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,267.09,173.61,,,,,,,,,,,,,
STOPPER EXT FIX WIRE PIN STRL DISP SMRT TSF,SUP-2932927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,88.14,57.29,,,,,,,,,,,,,
ALLOGRAFT BNE IRRADIATED COSTAL CART NACL,SUP-2867210,CDM,C1762,CPT,0278,RC,,,,both,,,2762.26,1795.47,,,,,,,,,,,,,
HC CT Heart No Contrast Quant Eval Coronry Calcium,PX-3507557100,CDM,75571,CPT,0350,RC,,,,both,,,362.00,362.00,,,,,,,,,,,,,
PLATE BNE STR MINI REG 2 HOLE TI NS LEVEL 1,SUP-2465858,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.75,412.59,,,,,,,,,,,,,
OCCLUDER DUCT L5MM DIA5X4MM RETEN SKRT DIA9MM SHTH 5FR,SUP-2355740,CDM,C1817,HCPCS,0278,RC,,,,both,,,14058.41,9137.97,,,,,,,,,,,,,
KIT EEG ELECTRD L 40.5 MM 12 CONTACT STRL DISP EVO,SUP-2936767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3388.06,2202.24,,,,,,,,,,,,,
PLATE BONE REG L36MM THK1MM 4 H MIDFACE SLV TI STR FOR 2MM,SUP-2402947,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTLAT DISTAL HUMERUS LAT SUPPORT 7H RT,SUP-2549688,CDM,C1713,HCPCS,0278,RC,,,,both,,,4010.72,2606.97,,,,,,,,,,,,,
CATHETER HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 24 5432240,SUP-2632890,CDM,C1752,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
GUIDEWIRE VASC AXIS L 90 CM DIA 0.035 IN TIP L 9 CM PTFE STR,SUP-2120533,CDM,C1769,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
BOOT TRAC M L20IN FOR 15.5IN CALF CONVOLUTED FOAM LNR STAY,SUP-2196869,CDM,L4387,HCPCS,0272,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
PLATE BNE ACET LT PELV POST WALL,SUP-2518346,CDM,C1713,HCPCS,0278,RC,,,,both,,,5893.78,3830.96,,,,,,,,,,,,,
ARH SLIDE-LOC NECK +3MM,SUP-2830410,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 5-8 MM EPTFE SHRT TAPR,SUP-2476212,CDM,C1768,CPT,0278,RC,,,,both,,,872.64,567.22,,,,,,,,,,,,,
IMMOBILIZER ORTH 2 AXIS SHT 17 IN 36 IN KNEERANGER II,SUP-2197133,CDM,L3702,HCPCS,0274,RC,,,,both,,,105.28,68.43,,,,,,,,,,,,,
PLATE BNE L81MM 4 H ST R SUP ANT CLAV TI LOK COMPR W LAT,SUP-2180861,CDM,C1713,HCPCS,0278,RC,,,,both,,,3110.92,2022.10,,,,,,,,,,,,,
ROUTER PWR,SUP-2304059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM SPNL CRD PERC W/ ENH STYL IMAG,SUP-2141904,CDM,C1778,HCPCS,0278,RC,,,,both,,,5702.24,3706.46,,,,,,,,,,,,,
COMPONENT SHLDR RESURF HUM,SUP-2217516,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
ROD SPNL SZ 6 RAD 220MM LUM GLD TI ALLOY EXTN VEPTR,SUP-2193303,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER HD SHT TERM 11.5 FRX24 CM STR TRI-FLOW,SUP-2627432,CDM,C1752,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
LEAD PACE ATTAIN ABIL MRI SURESCAN L 88 CM DIA 6 FR SIL,SUP-2281923,CDM,C1900,HCPCS,0275,RC,,,,both,,,4450.10,2892.56,,,,,,,,,,,,,
CATHETER HD KT 12 FRX25 CM 3L PRESSURE INJ HI VOL INFUSION,SUP-2762988,CDM,C1752,HCPCS,0278,RC,,,,both,,,401.01,260.66,,,,,,,,,,,,,
"HC So Quantation of Therapuetic Drug, Nes",PX-3018029966,CDM,80299,CPT,0301,RC,,,,inpatient,,,63.00,40.95,,,,,,,,,,,,,
ALLODERM SELECT RESTORE LARGEPERFORATED - MEDIUM 1.6 0.4MM,SUP-2827484,CDM,Q4116,HCPCS,0636,RC,,,,both,,,45470.34,29555.72,,,,,,,,,,,,,
BEARING TIB L63/67MM THK24MM KNEE SUP STBL POST STBL CNDYL 183874] ZIMMER BIOMET ORTHOPEDICS],SUP-2407728,CDM,C1776,CPT,0278,RC,,,,both,,,6510.79,4232.01,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY DIA24 MM TI ALLOY POLYESTER SIL,SUP-2214260,CDM,C1889,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
PEG BNE FIX L11MM DIA2.5MM LOK FULL THRD FOR HND FRAC SYS,SUP-2414058,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.97,225.53,,,,,,,,,,,,,
HC Transcath Closure of Vsd,PX-4819358100,CDM,93581,CPT,0481,RC,,,,both,,,41135.00,26737.75,,,,,,,,,,,,,
INSERT TIB CD 1-2 ARTC SURF KNEE,SUP-2198760,CDM,C1776,CPT,0278,RC,,,,both,,,3576.46,2324.70,,,,,,,,,,,,,
LOCKING MNDBLR ANGLE PLATE 3X3 NON CMPRSSN 20MM THICK T 6L,SUP-2694218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1630.48,1059.81,,,,,,,,,,,,,
TUNNELER SURG PLAS FOR HCKMN BRVC LNRD CATH,SUP-2127721,CDM,C1894,HCPCS,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
SUPPORT ORTH H8XL13IN D2 1/2IN CUSH MCKENZ SLM LN,SUP-2324239,CDM,L0642,HCPCS,0272,RC,,,,both,,,52.00,33.80,,,,,,,,,,,,,
DIGOXIN 250 MCG PO TABS,RX-2445,CDM,6370000000,HCPCS,0637,RC,00904-5922-61,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
CUP ACET OD40MM ID22MM ALL POLYPR XLPE CEM REFLCT,SUP-2345690,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BNE W9XL37MM THK1MM 3 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190945,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.59,283.78,,,,,,,,,,,,,
PACEMAKER CARD 10.4ML W50XH47MM THK6MM IS-1 CONN SGL CHMBR,SUP-2356454,CDM,C1786,HCPCS,0275,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SHEATH ENDO 25.6FR YEL INNR RND TIP RESECTOSCOPIC CONT FLO,SUP-2313068,CDM,C1894,HCPCS,0272,RC,,,,both,,,4191.49,2724.47,,,,,,,,,,,,,
HC Tcat Impl Wrls P-Art Prs Snr L-T Hemodyn|INVESTIGATIONAL RESEARCH STUDY,PX-4803328900,CDM,33289,CPT,0480,RC,,,Q0,both,,,89941.00,58461.65,,,,,,,,,,,,,
BIT DRL FOR 4.75MM SUTURE ANCHR STRL REUSE ALPHAVENT OMEGA,SUP-2905791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
MESH HERN W10XL10IN SQ SFT POLYPR FOR ABD WALL FASCIAL,SUP-2219919,CDM,C1781,HCPCS,0278,RC,,,,both,,,5203.11,3382.02,,,,,,,,,,,,,
NKII REV CONSTRAINED TIBIA INS LT SZ 1/2 9MM,SUP-2510385,CDM,C1776,CPT,0278,RC,,,,both,,,5576.64,3624.82,,,,,,,,,,,,,
GUIDEWIRE VASC L 190 CM DIA 0.035 IN SS PERIPH AMPLTZ X,SUP-2170312,CDM,C1769,HCPCS,0272,RC,,,,both,,,167.99,109.19,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X198 MM 15 HOLE SS LCP,SUP-2569341,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.73,354.72,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 5FR 55CML PU PWR INJ RADPQ PEEL 9295110,SUP-2632703,CDM,C1751,HCPCS,0278,RC,,,,both,,,558.17,362.81,,,,,,,,,,,,,
SCREW INTRF CANN 8X35 MM 2 MM GUIDEWIRE BLNT THRD STD TI RCI,SUP-2878047,CDM,C1713,HCPCS,0278,RC,,,,both,,,520.93,338.60,,,,,,,,,,,,,
EXPANDER TISS 700CC SMTH UHP ARTOURA PLUS,SUP-2740160,CDM,C1889,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
TRAY SURG PROC UMBILICAL W/3.5,SUP-2864586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.79,264.41,,,,,,,,,,,,,
HC CT Pelvis W/O Contrast,PX-3527219200,CDM,72192,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
NAIL IM L26CM DIA8.5MM TIB KNEE GRY TI CANN LCK RG BEND,SUP-2347073,CDM,C1713,HCPCS,0278,RC,,,,both,,,3906.95,2539.52,,,,,,,,,,,,,
BRACE ORTH SHELL ADJ 2XS AD 9-10 IN BILATERAL REUSE,SUP-2319320,CDM,L4350,HCPCS,0272,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
SEALER LAP L20CM SHFT DIA10MM TISS FUS OPN INSTR STR BILAT,SUP-2283571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1072.84,697.35,,,,,,,,,,,,,
IMPLANT OTO L4MM PIST DIA06MM NIT FLROPLAS SMRT,SUP-2313866,CDM,L8613,CPT,0278,RC,,,,both,,,861.18,559.77,,,,,,,,,,,,,
GRAFT HUM TISS 5ML STERIFUSE DEMIN BNE MTRX,SUP-2138658,CDM,C9359,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X110 MM 9 HOLE SS DCP,SUP-2569151,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.22,208.79,,,,,,,,,,,,,
SCREW INTRF KNEE CANN N ABSRB TI 9MM 25MM,SUP-2256756,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
PLATE BONE CH BLDE L45MM 6MM OFFSET 100DEG 3 H LT RT S STL,SUP-2318746,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
HC Myelography 2+ Regions S&I,PX-3207227000,CDM,72270,CPT,0320,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
NEEDLE BX DIA11GA DISP TELLURIDE JAMSH,SUP-2137005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
NEEDLE BX 22GA SHTH 4.1FR ADJ EXTN 0-5CM ENDOBRONCH HD US,SUP-2170150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
CATHETER HD STR 22 CM BASIC KT ROBUST DURAFLO 2,SUP-2117400,CDM,C1750,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
DERMATOME BLDE 6IN STRL 10/BOX,SUP-2243525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
COVER BURR H L 25.9 X W 20 MM SCREW DIA1.5 MM SM TI OBLNG,SUP-2936555,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
INTRODUCER KYPHOPLASTY SZ 2 10GA 3.4MM TRCR RADPQ KYPHON T34B] MEDTRONIC SOFAMOR DANEK],SUP-2293708,CDM,C1894,HCPCS,0272,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
GRAFT DERMAL N FEN 8X4 CMX2.2-3.5 MM DERMAL MTRX PARADERM,SUP-2742066,CDM,C1763,HCPCS,0278,RC,,,,both,,,7814.68,5079.54,,,,,,,,,,,,,
PLATE BNE L94MM 8 H BILAT S STL STR RECON NONLOCKING,SUP-2197673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.69,706.35,,,,,,,,,,,,,
DISK ARTIFICIAL W15XH5XL17MM CERV CO CHROM MOLYBDENUM TI HA,SUP-2415962,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
CLAMP EXT FIX L6IN TI ALLY MULTIPIN 6 POS,SUP-2188486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1977.32,1285.26,,,,,,,,,,,,,
PROSTHESIS TESTICULAR NACL MED AD CHLD TOROSA,SUP-2165399,CDM,C1889,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
PROSTHESIS OSS 4 MM GTR STAPE,SUP-2232476,CDM,L8613,CPT,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
KIT BNE GRFT L RHBMP-2 12MG INJ 10ML CONTAIN NDL 20GA,SUP-2287851,CDM,C1713,HCPCS,0278,RC,,,,both,,,18557.40,12062.31,,,,,,,,,,,,,
STEM SPLINE 15.0X115MM STRAIGHT,SUP-2505076,CDM,C1776,CPT,0278,RC,,,,both,,,8126.32,5282.11,,,,,,,,,,,,,
ELECTRODE RF 90DEG SUCT DISPOSABLE VAPR PREMIERE 90,SUP-2256732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SOL SYS 8/16.5 L LRG STAT,SUP-2513056,CDM,C1776,CPT,0278,RC,,,,both,,,19354.96,12580.72,,,,,,,,,,,,,
CANNULA RF STR 22 GAX100 MM 2 MM SHRP ACTIVE TIP,SUP-2753127,CDM,C1887,HCPCS,0272,RC,,,,both,,,48.67,31.64,,,,,,,,,,,,,
GRAFT VASC 4-6MM DIA 45CM LEN STR STRTCH STD WALL N RNGD,SUP-2395842,CDM,C1768,CPT,0278,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
MESH HERN 14X6IN COMP STOMY,SUP-2752149,CDM,C1781,HCPCS,0278,RC,,,,both,,,3109.23,2021.00,,,,,,,,,,,,,
PLATE CRAN 80X40X20 MM PT SPEC IMPL PEEK,SUP-2860176,CDM,C1713,HCPCS,0278,RC,,,,both,,,24228.55,15748.56,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 12 IN RETROGRADE NS,SUP-2476610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.74,215.63,,,,,,,,,,,,,
NAIL ANKLE ARTHRODESIS RT T2 10X620MM,SUP-2701150,CDM,C1713,HCPCS,0278,RC,,,,both,,,24812.28,16127.98,,,,,,,,,,,,,
PLATE BNE L 120 X W 12 MM THK 2.4 MM SCREW DIA2.7 MM 18 H SS 72469718,SUP-2932773,CDM,C1713,HCPCS,0278,RC,,,,both,,,2852.06,1853.84,,,,,,,,,,,,,
SCREW BONE L100MM OD10.5MM TI U-BLADE LAG SET FOR IM NAIL,SUP-2362207,CDM,C1713,HCPCS,0278,RC,,,,both,,,2861.17,1859.76,,,,,,,,,,,,,
CATHETER INFUSION CLEARWAY L 80 CM BALLOON L 10 MM DIA 4 MM,SUP-2227479,CDM,C1725,HCPCS,0272,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
SEEKER BAL L17MM DIA7MM FRONTAL SINUS FOR ENT,SUP-2284116,CDM,C1713,HCPCS,0278,RC,,,,both,,,3389.00,2202.85,,,,,,,,,,,,,
TM REV ST/ TM GLENOID/ STD HD,SUP-2212304,CDM,C1776,CPT,0278,RC,,,,both,,,38260.46,24869.30,,,,,,,,,,,,,
KIT POWERPRT CLEARVUE ISP IMPL PRT 6FRENCH ATTCH POLYUR,SUP-2126305,CDM,C1788,HCPCS,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
PLATE BONE W20.4XL56.3MM THK1.1MM TI T LCK LO PROF FOR 1.5MM,SUP-2411740,CDM,C1713,HCPCS,0278,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
UNIT DRNGE PLEUR CAV 2 COLL WET SUCT WET SEAL REGULATED STR,SUP-2384315,CDM,C1729,HCPCS,0272,RC,,,,both,,,132.29,85.99,,,,,,,,,,,,,
PLATE BNE STR 1.5X100 MM 20 HOLE FOR MINI FRAG SYS SS NS,SUP-2478771,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
IMPLANT TOE JT 20 METATARSAL HEMI GREAT TOE SYS MOV IMPLABLE,SUP-2244248,CDM,C1776,CPT,0278,RC,,,,both,,,8793.60,5715.84,,,,,,,,,,,,,
HIP UPCHARGE LINER ZIMMER,SUP-2501340,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
IMPLANT OSS L4.5MM PIST DIA0.4MM WELL DIA1MM STAP S STL,SUP-2312799,CDM,L8613,CPT,0278,RC,,,,both,,,556.13,361.48,,,,,,,,,,,,,
MARKER BRST TISS SPRING 17 GA SS ULTRACOR,SUP-2759178,CDM,A4648,CPT,0278,RC,,,,both,,,206.96,134.52,,,,,,,,,,,,,
BUNDLE GRFT ENDURANT II NIT POLYESTER 4 PC HELI-FX,SUP-2873749,CDM,C1768,CPT,0278,RC,,,,both,,,87920.00,57148.00,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 20CM 14 MM 15/15CM 10/10MM DEBRANCHING,SUP-2894550,CDM,C1768,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 90 XT DEG L 130 CM OD,SUP-2763426,CDM,C1887,HCPCS,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
ALLOGRAFT BNE PATELLAR TEND TISS,SUP-2165535,CDM,C1889,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
MATRIX BIO L 12 X W 10 CM FET BOV DERM IONIC SLV DERMAL SLD,SUP-2909235,CDM,Q4110,HCPCS,0636,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
CATHETER ANGIOPLSTY NC RANG L 135 CM BALLOON L 9 MM DIA 3 MM,SUP-2140522,CDM,C1725,HCPCS,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
PLATE BNE 4X8 H BILAT HND S STL T SHP LO PROF RIG NEUT,SUP-2184853,CDM,C1713,HCPCS,0278,RC,,,,both,,,1043.39,678.20,,,,,,,,,,,,,
SPLINT WRST XL AD L8IN FOR 85 95IN R NYL LN FOAM PUL ON,SUP-2276665,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.42,10.67,,,,,,,,,,,,,
CATH BLLN SCORING 5X20MM X 137CM OTW PTA ANGIOSCULPT,SUP-2353196,CDM,C1725,HCPCS,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
STENT URET 8.5FR L90CM SGL J SILITEK,SUP-2313762,CDM,C2617,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
SCREW SPNL L14MM DIA4.5MM CANC ANTR CERV TI ST LCK VAR ANG,SUP-2254602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
ROUND WASHER 12.7MM O.D TI,SUP-2820845,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.52,173.24,,,,,,,,,,,,,
PERFORATOR CRAN DGR-II MINI 1.57 MM DISP,SUP-2106559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
COIL EMB L8CM DIA4MM 0.0115IN INTCRAN 3D MICROFILAMENT,SUP-2295052,CDM,C1889,HCPCS,0278,RC,,,,both,,,5143.32,3343.16,,,,,,,,,,,,,
CLIP ENDO L220CM CAP D6MM DIA11.5-14MM NIT HANDWHEEL THRD,SUP-2319931,CDM,C1889,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
CATHETER CV SET 018 5 FRX12 CM DL J TIP POLYETH,SUP-2760168,CDM,C1751,HCPCS,0278,RC,,,,both,,,234.43,152.38,,,,,,,,,,,,,
STAPLE BNE FIX BRIDGE W 30 MM NIT METATARSOPHALANGEAL FUSION,SUP-2897012,CDM,C1713,HCPCS,0278,RC,,,,both,,,5962.86,3875.86,,,,,,,,,,,,,
BAND SCLER L 120 MM SZ 2.5 X 0.6 MM SIL TYP 240 SFT ELAS,SUP-2930310,CDM,C1784,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
BEARING HUM DIA44MM STD TI FOR REV SHLDR SYS COMPHSVE,SUP-2404729,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM KNOTLESS MULTIFIX S-ULTRA,SUP-2341941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.84,726.60,,,,,,,,,,,,,
PLATE BNE L ADVANSYS R DORS FT LISFRANC ADVANSYS,SUP-2243043,CDM,C1713,HCPCS,0278,RC,,,,both,,,5112.58,3323.18,,,,,,,,,,,,,
ALLOGRAFT HUM TISS HEMI BTB FRZN PRESHAPED COLL-E-STRONG,SUP-2321873,CDM,C1762,CPT,0278,RC,,,,both,,,11602.30,7541.49,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 3.5X125 MM CORTICAL DISTAL VOLAR RADI,SUP-2837009,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.72,203.92,,,,,,,,,,,,,
MESH HERN W12XL14IN MFIL RESRB RECT W/ HYDRGEL BARR SCFLD,SUP-2125885,CDM,C1781,HCPCS,0278,RC,,,,both,,,49455.00,32145.75,,,,,,,,,,,,,
SCREW BNE LCK 4.5X66 MM T25 PERI-LOC,SUP-2349968,CDM,C1713,HCPCS,0278,RC,,,,both,,,487.01,316.56,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1 CC CELLENTRA ADV,SUP-2866897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1503.43,977.23,,,,,,,,,,,,,
SCREW BNE SCHNZ 5X150 MM SD HA TI STRL,SUP-2424237,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.45,626.24,,,,,,,,,,,,,
HANDLE KNIFE BAYO CERVICAL LATEX FREE NON STERILE,SUP-2672128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.85,281.35,,,,,,,,,,,,,
STENT GRFT VASC AFX2 L 55 MM DIA PROX/DSTL 16 MM COCR,SUP-2217704,CDM,C1768,CPT,0278,RC,,,,both,,,10481.32,6812.86,,,,,,,,,,,,,
GUIDEWIRE URO L150CM 0038IN TAPR 5CM ANG TIP STIFF SHFT BENT,SUP-2139352,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.56,109.56,,,,,,,,,,,,,
GRAFT BNE CRUNCH 5 CC JR SUBSTITUTE DBM GRFT,SUP-2293912,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.62,581.50,,,,,,,,,,,,,
STRAP SPLNT NYL WHT 1INX14IN ROLYAN D RNG,SUP-2324779,CDM,L3908,HCPCS,0272,RC,,,,both,,,5.56,3.61,,,,,,,,,,,,,
IMPL ELBOW RECON RAD HEAD SZ 3,SUP-2706512,CDM,C1776,CPT,0278,RC,,,,both,,,6675.95,4339.37,,,,,,,,,,,,,
BLADE SURG L19CM THK42MM WHT PREBENT HPS GREAT CONCAVE,SUP-2167160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.83,427.59,,,,,,,,,,,,,
PLATE BNE L 61 MM SCREW DIA2.7 MM 2 HD 6 SHFT H SS TINE VA,SUP-2907563,CDM,C1713,HCPCS,0278,RC,,,,both,,,3732.20,2425.93,,,,,,,,,,,,,
ROD EXT FIX L 60 MM DIA 4 MM CARBON FIBRE CONN NS DISP,SUP-2908262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,126.92,82.50,,,,,,,,,,,,,
SCREW BNE L28MM DIA4.5MM S STL CORT FEM ST LOK FULL THRD,SUP-2348886,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.18,742.42,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.125X9 IN THRD SS NS STEINMANN,SUP-2791304,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.64,52.42,,,,,,,,,,,,,
SCREW IM L75MM DIA105MM TI ALLY LAG NAT NAIL,SUP-2208053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1614.53,1049.44,,,,,,,,,,,,,
SCREW SPNL 45X6.5MM PEDCL MULT AX CORT NONCANNULATED S STL,SUP-2415296,CDM,C1713,HCPCS,0278,RC,,,,both,,,1885.88,1225.82,,,,,,,,,,,,,
VALVE AORT MOSAIC H 13.5 MM DIA19 MM ORIFICE 17.5 MM SUTURE,SUP-2278064,CDM,C1889,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
PLATE BNE CALCANEAL 65 MM NS FPS LTX,SUP-2856890,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
GENERATOR PACEMKR STRATOS TI POLYUR SIL 3 CHMBR ADV DDDRV,SUP-2137971,CDM,C2621,HCPCS,0275,RC,,,,both,,,23274.15,15128.20,,,,,,,,,,,,,
TROCAR SURG HURWITZ 22 FRX8 IN NS,SUP-2458848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.61,253.25,,,,,,,,,,,,,
CLIP HEMOSTATIC REPOSITIONABLE 235 CMX16 MM SHTH DURACLIP,SUP-2428104,CDM,C1713,HCPCS,0278,RC,,,,both,,,1296.22,842.54,,,,,,,,,,,,,
STENT CAR L40MM DIA9MM CATH 7FR L135CM GWIRE 0.014IN NIT,SUP-2158973,CDM,C1876,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
PROBE SURG PIERCER 10X175 MM NS OSCAR 3 LTX,SUP-2875724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
CROWN FORM DENT STRP U4 PRIMARY ANTR UPPER LT CNTRL PLAS,SUP-2322240,CDM,D6783,CPT,0278,RC,,,,both,,,33.10,21.51,,,,,,,,,,,,,
HALF PIN 6MMX70MM,SUP-2818081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,670.08,435.55,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE CYL 30MM H2O TO 200MM H2O HAKIM,SUP-2666796,CDM,C1889,HCPCS,0278,RC,,,,both,,,18930.46,12304.80,,,,,,,,,,,,,
HC Adrenal Arteriogram Bilateral,PX-3237573300,CDM,75733,CPT,0323,RC,,,,both,,,2932.00,1905.80,,,,,,,,,,,,,
WARFARIN SODIUM 2 MG PO TABS,RX-8749,CDM,6370000000,HCPCS,0637,RC,00093-1713-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIT DRL L5.5IN DIA3.5MM OVR QUIK CONN DISP FOR SM FRAG,SUP-2413872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
STE COMPRESSION FUSION PLT,SUP-2488096,CDM,C1713,HCPCS,0278,RC,,,,both,,,2494.51,1621.43,,,,,,,,,,,,,
PLATE BNE L44MM 10DEG L 1ST MTP FT TI FUS FOR 27MM SCR,SUP-2319678,CDM,C1713,HCPCS,0278,RC,,,,both,,,6923.70,4500.40,,,,,,,,,,,,,
MESH SURG SHT 24X18 CMX2 MM AORT GRFT VASC DUALMESH,SUP-2496403,CDM,C1781,HCPCS,0278,RC,,,,both,,,6691.34,4349.37,,,,,,,,,,,,,
VANCOMYCIN 500 MG/100 ML RECTAL ENEMA,RX-4082497,CDM,6370000000,HCPCS,0637,RC,99999-0550-10,NDC,,both,100,ML,41.20,26.78,,,,,,,,,,,,,
ENDCAP ORTH L15MM DIA3MM NONSTERILE HUM TI NAIL EXTN,SUP-2192719,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.15,467.45,,,,,,,,,,,,,
ELECTRODE RESECTION ROLLER BALL 12,SUP-2848834,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.63,318.91,,,,,,,,,,,,,
KIT PICC CATH L 55 CM DIA 6 FR SHTH L 7 CM DIA 6 FR,SUP-2884240,CDM,C1751,HCPCS,0278,RC,,,,both,,,604.98,393.24,,,,,,,,,,,,,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-4839331900,CDM,93319,CPT,0483,RC,,,,both,,,1225.00,796.25,,,,,,,,,,,,,
STRIP SUTURE STRL DISP ZIPSEAL 16,SUP-2904104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1799.31,1169.55,,,,,,,,,,,,,
PROSTHESIS 16F 5MM SPEC LEN LG ESOPH FLNG INDWL VOICE,SUP-2242345,CDM,L8509,HCPCS,0274,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 5 FRX13 CM 20 CM CK FLO PERFRMR,SUP-2168767,CDM,C1894,HCPCS,0272,RC,,,,both,,,108.90,70.78,,,,,,,,,,,,,
BUR SURG BALL 5 MM 14 CM FLUT LG BOR MIDAS REX 8 LEGEND,SUP-2664564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.12,288.03,,,,,,,,,,,,,
ANCHOR SUT L11.7MM DIA2.8MM W/ INSRTR FASTAK LL,SUP-2121023,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BUR SURG OD5.0MM LNG CUT ACORN N FLUT FOR TPS MIDAS REX,SUP-2363479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.27,206.88,,,,,,,,,,,,,
BIT DRL DIA2.8MM FOR 3.5MM SCR SALVATION 2 MIDFOOT NAIL SYS,SUP-2417601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 30 CM DIA13 FR GUIDEWIRE 0.038 IN,SUP-2355551,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.59,41.33,,,,,,,,,,,,,
BRACE ORTHOPEDIC LUMBAR MIAMI,SUP-2319301,CDM,L0642,HCPCS,0272,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
CURETTE KYPHOPLASTY W/ 11GA NDL SPNL IVAS,SUP-2362212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1312.77,853.30,,,,,,,,,,,,,
GUIDEWIRE VASC 0.035 INX275 CM X SM CRV LUBRIGREEN SS SAFARI,SUP-2140933,CDM,C1769,HCPCS,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
GRAFT HUM TISS W13XL30MM THK13MM FRZ DRY ALLGRFT BLK CANC,SUP-2307114,CDM,C1713,HCPCS,0278,RC,,,,both,,,2771.40,1801.41,,,,,,,,,,,,,
SCREW SPNL LAG 25 MM CAPTURE FACET,SUP-2538839,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
ORBIT GALAXY DETACH COIL SYS 175CM 35MM 5CM CONTENTS 1,SUP-2249002,CDM,C1713,HCPCS,0278,RC,,,,both,,,7481.58,4863.03,,,,,,,,,,,,,
PLATE BONE W8XL26MM THK2.5MM 0DEG 2 H BILAT S STL STR RIG,SUP-2186184,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.67,300.09,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD,SUP-2248516,CDM,C1732,HCPCS,0272,RC,,,,both,,,6669.36,4335.08,,,,,,,,,,,,,
ROD EXT FIX L250MM DIA8MM C CONN HOFF III,SUP-2372457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SLEEVE PROTEC E51 V52 FLEX LG FOR NL 8-11 ST,SUP-2718100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.43,466.98,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 180 CM TIP L 9 CM DIA 0.035 IN SS,SUP-2148179,CDM,C1769,HCPCS,0272,RC,,,,both,,,564.79,367.11,,,,,,,,,,,,,
ADAPTER FEM STEM REV TAPR 7DEG W/SCREW F/EXACTECH,SUP-2223075,CDM,C1776,CPT,0278,RC,,,,both,,,763.81,496.48,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 1MM 8MM RANG 30CC READIGRFT,SUP-2264735,CDM,C1713,HCPCS,0278,RC,,,,both,,,1316.07,855.45,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 151 MM DIA 44 MM NIT POLYPRO,SUP-2750378,CDM,C1768,CPT,0278,RC,,,,both,,,33073.81,21497.98,,,,,,,,,,,,,
BASEPLATE TIB SM SZ 1 MOD ROT HNG MONOGRAM,SUP-2376374,CDM,C1776,CPT,0278,RC,,,,both,,,7939.65,5160.77,,,,,,,,,,,,,
HC Endo Level 3 Base 15 Min,PX-3600007503,CDM,3600007503,LOCAL,0360,RC,,,,both,,,4659.00,3028.35,,,,,,,,,,,,,
STEM FEM L110MM OD11MM 115DEG CO CHROM COMP FULL COAT HIP,SUP-2198926,CDM,C1776,CPT,0278,RC,,,,both,,,17226.04,11196.93,,,,,,,,,,,,,
BOLT EXT FIX 12 MM RR1200,SUP-2486094,CDM,2720000010,LOCAL,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM DL 4 FRX50 CM SCOOP TIP SCOOP REDDICK,SUP-2264232,CDM,C1713,HCPCS,0278,RC,,,,both,,,507.74,330.03,,,,,,,,,,,,,
CATHETER EP CRD 2 2-2 MM 4 FRX120 CM SUPREME,SUP-2356937,CDM,C1730,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
SCREW LAG TAP INTERTROCHANTERIC AG NAIL SYS INTERTAN TRIGEN,SUP-2418076,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
OFFSET END CAP 12X1MM,SUP-2722210,CDM,C1889,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
PIN FIX 1ST GENERATION FOR RETRCT CASPR,SUP-2415893,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE CNDYL 2/2.5X31X26X1 MM RT 9 HOLE SMART3D TRAUM NS,SUP-2499063,CDM,C1713,HCPCS,0278,RC,,,,both,,,3223.15,2095.05,,,,,,,,,,,,,
CATHETER ANGIO LANGSTON L 102 CM WORKING L 95 CM DIA 6 FR,SUP-2120498,CDM,C1751,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GRAFT HUM TISS L 6 X W 3 CM AMNION-CHORION-AMNION LAYR,SUP-2909308,CDM,Q4140,HCPCS,0636,RC,,,,both,,,12040.17,7826.11,,,,,,,,,,,,,
CURVED BAR 500MM,SUP-2720980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1956.06,1271.44,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 45X24 MM TRICORT,SUP-2743389,CDM,C1713,HCPCS,0278,RC,,,,both,,,7043.02,4577.96,,,,,,,,,,,,,
SCREW 28MM SCAPHOLUNATE INTERCARPAL RT PK,SUP-2106902,CDM,C1713,HCPCS,0278,RC,,,,both,,,3896.74,2532.88,,,,,,,,,,,,,
SPACER SPNL TRAP 20X10 MM HULL STT,SUP-2120680,CDM,C1821,HCPCS,0278,RC,,,,both,,,5482.44,3563.59,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA12.5 MM CART ARAGONITE,SUP-2913199,CDM,C1763,HCPCS,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
SET TBNG L3.8M IRR DISP,SUP-2164957,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BIT DRL DIA1.4MM SHT DISP FOR SFT ANCHR SYS JUGGERKNOT,SUP-2212958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.75,237.74,,,,,,,,,,,,,
RING EXT FIX HALF 120 MM TI NS,SUP-2800190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1197.31,778.25,,,,,,,,,,,,,
PLATE BNE SM CALCANEUS RAREFT FOR TOT FT SYS 2,SUP-2243251,CDM,C1713,HCPCS,0278,RC,,,,both,,,6191.23,4024.30,,,,,,,,,,,,,
GUIDE SURG L PROX TIB INSRT LISS,SUP-2187789,CDM,C1776,CPT,0278,RC,,,,both,,,10016.44,6510.69,,,,,,,,,,,,,
SYSTEM EXCHG 12FR L80CM OD0.19IN ID0.16IN 45DEG TIP,SUP-2355722,CDM,C1773,HCPCS,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
SYSTEM SKIN CLSR 22CM DERMBND PRINEO,SUP-2218876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,274.84,178.65,,,,,,,,,,,,,
GRAFT VASC GORTX L 100 CM DIA 6 MM RNG L 60 CM EPTFE STR TW,SUP-2396124,CDM,C1768,CPT,0278,RC,,,,both,,,3680.08,2392.05,,,,,,,,,,,,,
STENT PERIPH L5CM DIA6MM CATH L120CM FEM IL AV ACC EPTFE,SUP-2396548,CDM,C1874,HCPCS,0278,RC,,,,both,,,9969.50,6480.17,,,,,,,,,,,,,
STENT PERIPH XPERT L 80 MM DIA 4 MM DEL SYS L 90 CM INTRO 4,SUP-2105969,CDM,C1725,HCPCS,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CABLE EP CATH L 1.5 M 14 PIN MODEL 1914-SA DIAG CONN SHROUD,SUP-2676240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
BLADE RTRCTR BLFR STNDRD 2 5/8NW X 10 3/4NL X 1 5/8ND ABDMNL,SUP-2487735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.99,300.29,,,,,,,,,,,,,
ANCHOR SUT FOR SPNL CRD STIM SWIFT LOCK,SUP-2356643,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.67,264.99,,,,,,,,,,,,,
NAIL INTRMDLLRY L380MM OD13MM 125DG LNG TIMAX RIGHT HIP ANTG,SUP-2475386,CDM,C1776,CPT,0278,RC,,,,both,,,6992.78,4545.31,,,,,,,,,,,,,
PLATE CRAN THK 0.4 MM SCREW DIA1.5 MM 4 X 2 H SM TI BX LP 3D,SUP-2883642,CDM,C1713,HCPCS,0278,RC,,,,both,,,1233.14,801.54,,,,,,,,,,,,,
GRAFT BNE SUB 90CC 4 10MM PARTIC CANC FRZ DRY,SUP-2264682,CDM,C1713,HCPCS,0278,RC,,,,both,,,3027.40,1967.81,,,,,,,,,,,,,
THREAD LOCK MNDBLR RCNSTRCTN PLATE ANGLD RGHT 13 HOLE CP TTN,SUP-2681352,CDM,C1713,HCPCS,0278,RC,,,,both,,,3621.05,2353.68,,,,,,,,,,,,,
RING EXT FIX CIR 5/8 180 MM SIDEKCK,SUP-2851274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
PLATE BNE L 137 MM SHFT THK 2 MM HD 1.8 MM SCREW DIA2.7/3.5,SUP-2931248,CDM,C1713,HCPCS,0278,RC,,,,both,,,4759.77,3093.85,,,,,,,,,,,,,
NEXGEN PRECOAT STEMMED TIBIAL PLATE SZ 7,SUP-2503045,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
ENDCAP ORTH L5MM ANK COMPR NAIL LOK,SUP-2316328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,688.10,447.26,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 30 J OPTIM INSUL CURRENT VR,SUP-2356049,CDM,C1722,HCPCS,0275,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
INSERT TIB 1 2+ MM ANK TRABECULAR MTL PROLONG POLYETH,SUP-2470148,CDM,C1776,CPT,0278,RC,,,,both,,,4281.39,2782.90,,,,,,,,,,,,,
PORT INFUS CATH 6.6FR TI SGL LUMN PEEL APART PERC INTRO SYS,SUP-2126165,CDM,C1788,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
GRFT CRUSH CANC 1-4MM 5CC PUROS,SUP-2693924,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
PLATE BNE K MINI 2/2.5X1 MM RT SUBCONDYLAR 9 HOLE LCK TI NS,SUP-2463650,CDM,C1713,HCPCS,0278,RC,,,,both,,,2707.75,1760.04,,,,,,,,,,,,,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG PO TBCR,RX-27181,CDM,6370000000,HCPCS,0637,RC,50268-0584-11,NDC,,both,1,UN,7.60,4.94,,,,,,,,,,,,,
CLASSIC CHS PL 12 SLOT 135 DEG,SUP-2818264,CDM,C1713,HCPCS,0278,RC,,,,both,,,6137.29,3989.24,,,,,,,,,,,,,
SET PICC L 20 CM DIA 5 FR SHTH L 7 CM DIA 5 FR,SUP-2887011,CDM,C1751,HCPCS,0278,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
STENT BILI AD L40MM DIA6MM CATH 6FR L135CM GWIRE 0.035IN,SUP-2420538,CDM,C1876,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
KIT PROCEDURE CANN BNDR INSRTR FASTFIX CRVD,SUP-2717591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
CATHETER VASC L135CM OD5FR INFUS L5CM 0.038IN LNG VLV CRAGG,SUP-2172527,CDM,C1751,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
RING EXT FIX FT EZ FRAME,SUP-2486112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5633.16,3661.55,,,,,,,,,,,,,
LEAD NERVE STIM 41 MM MRI INTERSTIM SURESCAN,SUP-2641995,CDM,C1778,HCPCS,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
BIT DRL L6MM DIA2.7MM REUSE FOR ILIZ AND TAY SPAT FRME EXT,SUP-2342319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2180.79,1417.51,,,,,,,,,,,,,
HEAD HUM ECC 26X48 MM 5 MM SHLDR COFEILD 2,SUP-2346846,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
DRILL SURG SPNL JACOB CHK TWST DISPOSABLE TRIMLINE,SUP-2290999,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.62,586.05,,,,,,,,,,,,,
PLATE BNE L 55 X W 55 MM THK 1.4 MM SCREW DIA2.2 MM PLL,SUP-2883190,CDM,C1713,HCPCS,0278,RC,,,,both,,,4911.87,3192.72,,,,,,,,,,,,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0688,HCPCS,0636,RC,00143-9983-91,NDC,,both,1,UN,63.60,41.34,,,,,,,,,,,,,
IMMOBILIZER ORTH SHLDR SUPP UNIV UNISX STD CUFED AD LN WR,SUP-2306067,CDM,L3650,HCPCS,0274,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
PLATE BNE W175XL408MM THK52MM 22 H BILAT S STL BROAD CRV,SUP-2185325,CDM,C1713,HCPCS,0278,RC,,,,both,,,3923.40,2550.21,,,,,,,,,,,,,
PLATE BONE L168MM THK3.7MM 8 H STRL RT DSTL MEDL TIB S STL,SUP-2185530,CDM,C1713,HCPCS,0278,RC,,,,both,,,4813.43,3128.73,,,,,,,,,,,,,
SLING URETH PRECIS MINIARC 900261,SUP-2140381,CDM,C1771,HCPCS,0278,RC,,,,both,,,4044.32,2628.81,,,,,,,,,,,,,
PLATE BONE L104MM 4 H S STL CLVRLF,SUP-2198577,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.08,347.15,,,,,,,,,,,,,
GRAFT HUM TISS TEND SEMITENDINOSUS,SUP-2165549,CDM,C1713,HCPCS,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 25MM SUPER BAYONET 201681,SUP-2848944,CDM,C1889,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
MATRIX BIO DIA16 MM FISH SKIN DERMAL CIR INTACT OMEGA3 BX/10,SUP-2909378,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1205.76,783.74,,,,,,,,,,,,,
EXTENDER SURG L60MM DISP FOR ULTSONIC REV SYS ULT DRV 3,SUP-2408554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
PROBE OPHTH LASER STR STRL 23GA,SUP-2129218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.52,223.94,,,,,,,,,,,,,
BLADE SAW L 95 X W 11 MM D 12 MM THK MATERIAL 0.4 MM CUT 0.5,SUP-2929439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.02,282.76,,,,,,,,,,,,,
SCREW SPNL ST 6X35 MM SOVEREIGN,SUP-2630892,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
STENT COLONIC/DUODENAL WSTNT L 90 MM DIA20 MM WORKING L 230,SUP-2149765,CDM,C1876,HCPCS,0278,RC,,,,both,,,5530.48,3594.81,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 7 MM RNG L 20 CM,SUP-2227612,CDM,C1768,CPT,0278,RC,,,,both,,,3244.09,2108.66,,,,,,,,,,,,,
CATHETER DRNGE 22FR 2 EYE PROPORTIONATE HD DISP FOR,SUP-2128979,CDM,C1729,HCPCS,0272,RC,,,,both,,,323.86,210.51,,,,,,,,,,,,,
FELODIPINE ER 2.5 MG PO TB24,RX-27489,CDM,6370000000,HCPCS,0637,RC,23155-0048-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT OPHTH W50XL76MM THK16MM MTB MEDPOR TI,SUP-2366480,CDM,C1713,HCPCS,0278,RC,,,,both,,,4455.22,2895.89,,,,,,,,,,,,,
STENT BILI 10FR L7CM 0.035IN ACC CHN 3.7MM PLAS FOR,SUP-2169042,CDM,C2617,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
ANCHOR SUT DIA2.3MM W/ NDL 2 STRND NO2 FORC FBR,SUP-2366690,CDM,C1713,HCPCS,0278,RC,,,,both,,,1364.68,887.04,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM S STL TRCR TIP APTUS,SUP-2267989,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.20,78.78,,,,,,,,,,,,,
GRAFT BONE SUB 10CC MTRX DEMIN PASTE INTERGRO +,SUP-2414015,CDM,C1713,HCPCS,0278,RC,,,,both,,,5510.70,3581.95,,,,,,,,,,,,,
BLADE SURG BRAGA-MELE 19 GA CHOP BLNT TIP OFFSET,SUP-2467236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1259.30,818.54,,,,,,,,,,,,,
BUR SURG 5 MM STRT ORTHOSPHERE CMC,SUP-2521578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
DRESSING BIO COVERAGE AREA 85 SQ CM 500 MG PORCINE SM INTEST,SUP-2905489,CDM,Q4102,HCPCS,0636,RC,,,,both,,,3751.52,2438.49,,,,,,,,,,,,,
GRAFT DERM HUM TISS THCK KT BRST ACELLULAR DERM IMPL ALLGRFT,SUP-2307509,CDM,Q4128,HCPCS,0636,RC,,,,both,,,12294.26,7991.27,,,,,,,,,,,,,
BRACE KNEE SM FOR 115 13IN UNIV BUTTERESS NEOPRENE W STBL,SUP-2319243,CDM,L1810,HCPCS,0274,RC,,,,both,,,54.13,35.18,,,,,,,,,,,,,
GRAFT VASC ALBOGRAFT L 15 CM DIA16 MM POLYESTER STR KNITTED,SUP-2601082,CDM,C1768,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
LACTATED RINGERS IV BOLUS,RX-40840057,CDM,J7120,HCPCS,0258,RC,00338-0117-04,NDC,,both,250,ML,10.70,6.95,,,,,,,,,,,,,
PLATE BNE CRAN SM PEEK,SUP-2435345,CDM,C1713,HCPCS,0278,RC,,,,both,,,39410.67,25616.94,,,,,,,,,,,,,
COMPONENT ARTC SURF CD 17 MM KNEE YEL NXGN LEG,SUP-2201853,CDM,C1776,CPT,0278,RC,,,,both,,,5407.39,3514.80,,,,,,,,,,,,,
BLADE SCREWDRIVER 1MM DIA CENTRE DRIVE,SUP-2667828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
KIT INSRT W/ 6IN INTRO FOR USE W/ FIDELITY 8FR 34 AND 40CC,SUP-2227323,CDM,C1894,HCPCS,0272,RC,,,,both,,,333.63,216.86,,,,,,,,,,,,,
HANDPIECE LASER 0.2 MM FOC INCIS ACUPULSE,SUP-2713657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
GRAFT BONE PATELLA LEFT OC AMBIENT MOPS,SUP-2570514,CDM,C1762,CPT,0278,RC,,,,both,,,20601.54,13391.00,,,,,,,,,,,,,
HC Dna/Rna Amplified Probe,PX-3008715000,CDM,87150,CPT,0300,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
STENT CAR 7X30 MM ENROUTE,SUP-2431178,CDM,C1884,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
FOOTPLATE EXT FIX RAD ALUM RINGFIX 9501601,SUP-2471011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SET URET STENT L 26 CM DIA 4.8 FR GUIDEWIRE 0.035 IN CATH,SUP-2141659,CDM,C2617,HCPCS,0278,RC,,,,both,,,579.33,376.56,,,,,,,,,,,,,
HC Iliac Angiogram Nonselective,PX-4810027800,CDM,G0278,CPT,0481,RC,,,,outpatient,,,391.00,254.15,,,,,,,,,,,,,
IMPLANT GYN L 7 X W 4 CM ALLGRFT FASC LATA PROC UNI DIR STRL,SUP-2896107,CDM,C1762,CPT,0278,RC,,,,both,,,3771.14,2451.24,,,,,,,,,,,,,
CATHETER CARD ABLATION FREEZOR L 108 CM 7 FR L 4 MM MED BLU,SUP-2175198,CDM,C1733,HCPCS,0272,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
LINER ACET OD74MM ID28MM HIP MARATHON NEUT SNAP IN REV PINN,SUP-2250352,CDM,C1776,CPT,0278,RC,,,,both,,,3786.84,2461.45,,,,,,,,,,,,,
CATHETER VASC DIAG SIM 2 PERIPH W/ HYDRPHLC COAT AD RADPQ,SUP-2141095,CDM,C1887,HCPCS,0272,RC,,,,both,,,158.10,102.76,,,,,,,,,,,,,
BROAD PLT STERILIZER 4.5X231 MM 14 HL,SUP-2818455,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.53,1449.19,,,,,,,,,,,,,
SUPPORT ORTHOT CERV THOR LUMBAR SACR CUST ANTR POST LAT CTRL,SUP-2435561,CDM,L0700,HCPCS,0272,RC,,,,both,,,5636.11,3663.47,,,,,,,,,,,,,
CLAMP CRAN DIA18MM TI FLAP TUBE,SUP-2192429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1530.12,994.58,,,,,,,,,,,,,
KIT DEL PWR PULSE ADMIN Y SPIKE 1W STOPCOCK CATH 3000 SER,SUP-2142028,CDM,C1757,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
HC Bone Marrow Aspiration,PX-3613822000,CDM,38220,CPT,0361,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
SET CATHETER L65CM OD4FR GWIRE OD0035IN CRV TIP SHTH L55CN,SUP-2171154,CDM,C1894,HCPCS,0272,RC,,,,both,,,1310.92,852.10,,,,,,,,,,,,,
GRIP CBL L85MM STD TROCHANTERIC HIP 3 CBL ACCORD,SUP-2345206,CDM,C1776,CPT,0278,RC,,,,both,,,4628.36,3008.43,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM DIL L 20 CM OD 5.5 FR ID 1.8 MM,SUP-2168254,CDM,C1894,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
FIXATOR EXT HING RINGFIX SYS LPROF 90DEG,SUP-2459740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,663.17,431.06,,,,,,,,,,,,,
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-157663,CDM,J1650,HCPCS,0636,RC,63323-0531-90,NDC,,both,0.8,ML,91.50,59.47,,,,,,,,,,,,,
SHUNT SURG CORONARY 2X12 MM ATRAUM VES TAPR TIP SOF-FLO,SUP-2261622,CDM,L8612,HCPCS,0278,RC,,,,both,,,230.79,150.01,,,,,,,,,,,,,
ELECTRODE RF DIA4MM 90DEG SUCT W/ INTEGR HNDPC VAPR S90,SUP-2249477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1343.92,873.55,,,,,,,,,,,,,
EXPANDER TISS W14XH15CM 600CC PROJCT L5.5CM RND FULL HT NACL,SUP-2113321,CDM,C1789,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
PLATE BNE VA 2.7X3.5 MM LT ANTR LAT 14 HOLE SS STRL VA-LCP,SUP-2177233,CDM,C1713,HCPCS,0278,RC,,,,both,,,7278.96,4731.32,,,,,,,,,,,,,
MESH SURG L 30 X W 30 CM POLYPRO VENTRAL MONOFILAMENT,SUP-2901704,CDM,C1781,HCPCS,0278,RC,,,,both,,,401.04,260.68,,,,,,,,,,,,,
PROSTHESIS OSS 0.4X3.75 MM SHFT TI STAP NOTCH HNDL LIPPY,SUP-2232479,CDM,L8613,CPT,0278,RC,,,,both,,,718.37,466.94,,,,,,,,,,,,,
ANCHOR SFT TISS REV CRV FOR MENIS REP SYS ULT FAST-FIX,SUP-2341775,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
PLATE BNE L92MM 4 H R LAT DST FIBULAR S STL VAR ANG LOK,SUP-2177714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2302.37,1496.54,,,,,,,,,,,,,
ARMSTRONG X BVLD GRMMT 114MM ID BLUE FLRPLSTC 30 PACK,SUP-2680304,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.90,24.63,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.519,SUP-2860200,CDM,C1713,HCPCS,0278,RC,,,,both,,,31075.32,20198.96,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 500 HF-T 59 X 66MM 12MM 30J BPLR,SUP-2138128,CDM,C1721,HCPCS,0275,RC,,,,both,,,58875.00,38268.75,,,,,,,,,,,,,
IMPLANT TOE JT HAMR RMR NONSTERILE FEATURING HTR SYS,SUP-2390552,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
TUBE OPHTH IMPL 350 MM DIAM 32 MM TUBE LEN STRL SIL,SUP-2326685,CDM,C1783,HCPCS,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
SCREW EXT FIX L 175 MM THRD L 40 MM DIA 6 MM TI BLNT PT STRL,SUP-2913618,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.56,577.56,,,,,,,,,,,,,
PLATE BNE LADDER WIDE 12 HOLE,SUP-2136993,CDM,C1713,HCPCS,0278,RC,,,,both,,,2270.22,1475.64,,,,,,,,,,,,,
SET LD EXTRACTION EVOLUTION SHORTIE RL L 13.6 CM OD 17 FR ID,SUP-2169472,CDM,C1773,HCPCS,0272,RC,,,,both,,,4395.97,2857.38,,,,,,,,,,,,,
PLATE BONE L22MM BLDE L13MM 3X3 H RT ORAL MAXILLOFACIAL TI L,SUP-2191150,CDM,C1713,HCPCS,0278,RC,,,,both,,,969.32,630.06,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 5FR 55CM 2 LUMAN RVS TAPR PWR,SUP-2613370,CDM,C1751,HCPCS,0278,RC,,,,both,,,800.32,520.21,,,,,,,,,,,,,
CATHETER DRAIN 10F 25CM TGHT LOOP W/ RADIOPAQUE MRKR BND PG,SUP-2659160,CDM,C1729,HCPCS,0272,RC,,,,both,,,247.18,160.67,,,,,,,,,,,,,
KIT LAPSCP UTER PROLAPSE SUT PASS LIGMNT GRSP KNOT PUSH,SUP-2171753,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SCREW BNE L36MM DIA4MM CORT TI ST LAG CANN FULL THRD UCSS,SUP-2290879,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5 CM DIA 5 MM CATH L 75 CM,SUP-2396491,CDM,C1874,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
PLATE BNE 3 X 2 H 3D SQ SEG NS,SUP-2883292,CDM,C1713,HCPCS,0278,RC,,,,both,,,1098.37,713.94,,,,,,,,,,,,,
COMPONENT TOE GREAT TOE METATARSAL NEUT TI SM SZ 1 SWNSN,SUP-2397899,CDM,C1776,CPT,0278,RC,,,,both,,,4537.30,2949.24,,,,,,,,,,,,,
GRAFT HUM TISS W9XL22 30MM PAT WDG FRZ DRY,SUP-2307178,CDM,C1713,HCPCS,0278,RC,,,,both,,,3238.16,2104.80,,,,,,,,,,,,,
PLATE BNE L73MM 6 H S STL 1/3 TBLR LIMIT CNTCT DYN COMPR W/,SUP-2185929,CDM,C1713,HCPCS,0278,RC,,,,both,,,472.10,306.86,,,,,,,,,,,,,
NEEDLE SUT L2.087IN DIA0.043IN S STL REG SURG 1/2 CIR RVS,SUP-2124112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.07,336.75,,,,,,,,,,,,,
PATCH DURA W10XL12CM NONBIOLOGICAL MEMBRN FOR MINIMIZING CSF,SUP-2395375,CDM,C1713,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
SCREW BNE L70MM DIA5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412135,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
PLATE BNE L118MM WRST S STL SHT BEND LOK COMPR FOR FUS LCP,SUP-2177229,CDM,C1713,HCPCS,0278,RC,,,,both,,,5060.02,3289.01,,,,,,,,,,,,,
SODIUM CHLORIDE (PF) 0.9 % IJ SOLN,RX-147478,CDM,A4216,HCPCS,0250,RC,63323-0186-20,NDC,,both,10,ML,9.00,5.85,,,,,,,,,,,,,
MEDROXYPROGESTERONE ACETATE 2.5 MG PO TABS,RX-4855,CDM,6370000000,HCPCS,0637,RC,00555-0872-02,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.7MM ULN SHORTNG GENERATION II LO PROF,SUP-2397333,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
BODY HUM SZ 12 135DEG PROX SHLDR PORCOAT FOR ANAT PLATFRM,SUP-2249873,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SCREW SQ FIT 1.2X6MM,SUP-2366197,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.78,114.26,,,,,,,,,,,,,
PLATE BNE 24 DEG L 141 X W 8.5 MM THK 1.6 MM 10 H TI LT DSTL,SUP-2933647,CDM,C1713,HCPCS,0278,RC,,,,both,,,5853.59,3804.83,,,,,,,,,,,,,
SUPPORT ORTHOT HIP KNEE ANK CUST UNILAT TORSON BALL BEAR,SUP-2435645,CDM,L2090,HCPCS,0272,RC,,,,both,,,1407.69,915.00,,,,,,,,,,,,,
MESH SURG 0.5 MM ORBIT FLR FOR 1.5 MM SCREW TI GLD,SUP-2478744,CDM,C1713,HCPCS,0278,RC,,,,both,,,1917.60,1246.44,,,,,,,,,,,,,
HC Veeg by Tech 2-12 Hr Intmt Monitoring,PX-7409571200,CDM,95712,CPT,0740,RC,,,,both,,,2592.00,1684.80,,,,,,,,,,,,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,0636,RC,00143-9744-10,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L 43.2 X W 5 MM THK 1 MM 7 H GRD IV TI STR NS DISP,SUP-2937016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
STEM HUM 10MM FX COMPHSVE,SUP-2404526,CDM,C1776,CPT,0278,RC,,,,both,,,10795.32,7016.96,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|DOCUMENTATION ON FILE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|CO|KX,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE BONE L38MM 135DEG 3 H TALON S STL STD BRL SIDE COMPR,SUP-2318970,CDM,C1713,HCPCS,0278,RC,,,,both,,,1217.06,791.09,,,,,,,,,,,,,
PLATE BNE L 43 MM SCREW DIA2 MM 8 SHFT H SS COMPACT STR VA,SUP-2908106,CDM,C1713,HCPCS,0278,RC,,,,both,,,4338.85,2820.25,,,,,,,,,,,,,
GAUGE DEPTH PERIARTICULAR CANNULATED 35MM LOCKING SCREW,SUP-2494810,CDM,C1713,HCPCS,0278,RC,,,,both,,,652.02,423.81,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM 4 FR NIT TUNGSTEN TIP SIL ANGLED SMTH,SUP-2765617,CDM,C1894,HCPCS,0272,RC,,,,both,,,88.23,57.35,,,,,,,,,,,,,
HC So Hepatitis a Antibody (Total),PX-3028670866,CDM,86708,CPT,0302,RC,,,,both,,,106.00,68.90,,,,,,,,,,,,,
TEMPLATE BEND DIA35MM ALUMINUM FOR COMPR PLT W 7 H,SUP-2199237,CDM,C1713,HCPCS,0278,RC,,,,both,,,755.52,491.09,,,,,,,,,,,,,
HC App Skin Sub T/a/L Tot <100 1st 25,PX-3611527100,CDM,15271,CPT,0361,RC,,,,inpatient,,,6021.00,3913.65,,,,,,,,,,,,,
COLLAR EXTRIC AD L H2XL235IN NAR BRTH M DENS FOAM CNTOUR W,SUP-2194383,CDM,L0120,HCPCS,0274,RC,,,,both,,,20.38,13.25,,,,,,,,,,,,,
PLATE BNE SM W10.1XL166MM THK3.5MM 14 H BILAT S STL CRV RIG,SUP-2186265,CDM,C1713,HCPCS,0278,RC,,,,both,,,2567.17,1668.66,,,,,,,,,,,,,
STENT COR 15MM 2.5MM CO CHROM ALLOY EVEROLIMUS DRUG,SUP-2139513,CDM,C1874,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
DISTRACTOR EXT FIX RAMUS 20 MM TRNSPRT END DRIVEN BODY ONLY,SUP-2495903,CDM,C1713,HCPCS,0278,RC,,,,both,,,16971.89,11031.73,,,,,,,,,,,,,
PLATE BNE L107MM 7 H ST R DST LAT FIBULAR VAR ANG LOK FOR,SUP-2349840,CDM,C1713,HCPCS,0278,RC,,,,both,,,6152.52,3999.14,,,,,,,,,,,,,
BIT DRILL DIA2MM HEX ADD CANNULATED DRIVER,SUP-2481556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.06,348.44,,,,,,,,,,,,,
DIVERTED TUBE 1/2,SUP-2307039,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
CEPHALEXIN 500 MG PO CAPS,RX-9500,CDM,6370000000,HCPCS,0637,RC,00904-7337-35,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET UROLOGY DIL 8-24FR L37CM POLY SFTY GWIRE,SUP-2171193,CDM,C1769,HCPCS,0272,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
PLATE BNE FRACTR ANGLED W/ TMPLT NS,SUP-2883244,CDM,C1713,HCPCS,0278,RC,,,,both,,,3833.97,2492.08,,,,,,,,,,,,,
BOOT WLK N PNEUMAT,SUP-2319135,CDM,L4386,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SCREW BNE L85MM LAG SLDE FOR HIP FRAC SYS CHIMAERA,SUP-2316375,CDM,C1713,HCPCS,0278,RC,,,,both,,,2458.53,1598.04,,,,,,,,,,,,,
CUBE EXT FIX 2 H RANCHO W/ POST FOR ILIZ TAY SPAT FRME SYS,SUP-2342988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
SARGRAMOSTIM 250 MCG IJ SOLR,RX-146022,CDM,J2820,HCPCS,0636,RC,71837-5843-01,NDC,,both,1,UN,906.20,589.03,,,,,,,,,,,,,
TOURNIQUET SURG 2XL TURQ HEMACLEAR,SUP-2918234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM DIA0.014IN NIT HYDRPHLC ANG TIP,SUP-2148153,CDM,C1769,HCPCS,0272,RC,,,,both,,,532.36,346.03,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO 2515 L115CM 7FR D DECAPOLAR,SUP-2248767,CDM,C1730,HCPCS,0272,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
BIT DRL DIA2.4MM SHLDR CANN FOR ACROMIOCLAVICULAR REP,SUP-2121658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRP ILIUM TRICORT STRUCTURAL,SUP-2307029,CDM,C1713,HCPCS,0278,RC,,,,both,,,5361.64,3485.07,,,,,,,,,,,,,
FILLER BNE 10ML SCFLD COLLAGE,SUP-2316224,CDM,C1713,HCPCS,0278,RC,,,,both,,,6421.30,4173.84,,,,,,,,,,,,,
SET EMB TRUFILL 10 ML 2 GM 1 GM N-BCA TANTALUM ETHIODIZED,SUP-2913676,CDM,C1889,HCPCS,0278,RC,,,,both,,,23707.00,15409.55,,,,,,,,,,,,,
PLATE BNE W19.5XL51MM NAR 6X3 H ST R DST RAD VOLAR TI VAR,SUP-2180835,CDM,C1713,HCPCS,0278,RC,,,,both,,,2596.81,1687.93,,,,,,,,,,,,,
BLADE SHAVER RESECT 4.5X130 MM CRV CONCV DISP,SUP-2661226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.07,252.25,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 025 5 FRX12 CM 16 GA 3L SPECTRUM,SUP-2759898,CDM,C1751,HCPCS,0278,RC,,,,both,,,583.38,379.20,,,,,,,,,,,,,
FERRIC SUBSULFATE 259 MG/GM EX SOLN,RX-28357,CDM,6370000000,HCPCS,0637,RC,59365-6065-00,NDC,,both,8,GR,73.70,47.90,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK15 22MM THCK ACELLULAR,SUP-2307569,CDM,Q4128,HCPCS,0636,RC,,,,both,,,28288.26,18387.37,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 2.5CC DEMINERALIZED BONE MATRIX PUTTY REVERSE PHASE M STIMUBLAST,SUP-2120745,CDM,C9359,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
CATHETER INTVASC OCCL CODA L 120 CM DIA10 FR BALLOON DIA 40,SUP-2750349,CDM,C2628,HCPCS,0272,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
BIT DRL L80MM OD1.9MM NONSTERILE REUSE,SUP-2242919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.06,429.69,,,,,,,,,,,,,
BIT DRL FLUT 0.8X148 MM 15 MM HOUGH STAPEDIAL SS MICROFRANCE,SUP-2464810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.85,273.55,,,,,,,,,,,,,
SHEATH INTRO MEDIKIT SUPERSHEATH RO L 11 CM DIA 6 FR BLU,SUP-2147309,CDM,C1894,HCPCS,0272,RC,,,,both,,,58.72,38.17,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK SZ 4 X 20 MM PEBAX PTFE COIL SS,SUP-2367918,CDM,C1757,HCPCS,0272,RC,,,,both,,,28873.56,18767.81,,,,,,,,,,,,,
TROCAR SURG DIA2MM FOR DST RAD FIX,SUP-2187735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.56,381.91,,,,,,,,,,,,,
CATHETER URET OPN END 040 5 FRX70 CM SOFFLX,SUP-2835723,CDM,C1758,HCPCS,0278,RC,,,,both,,,32.94,21.41,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA2.7 MM TI MAND ST LCK EMER AXS NS UNIV,SUP-2909542,CDM,C1713,HCPCS,0278,RC,,,,both,,,566.08,367.95,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSPLIT XK CHRONIC MICROINTRO 5693270,SUP-2632961,CDM,C1750,HCPCS,0278,RC,,,,both,,,1694.66,1101.53,,,,,,,,,,,,,
SCREW INTRF 8X25 MM ROUNDED EDGE FT PEEK OPTMA,SUP-2762241,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
COIL EMB L2CM DIA1MM EXTRA SFT HELIX DETACH AXIUM PRIM,SUP-2295013,CDM,C1889,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
SYSTEM PLAQ EXCISION 7/8FR L113CM TIP L9CM VES DIA3.5-7MM,SUP-2173625,CDM,C1714,HCPCS,0272,RC,,,,both,,,9577.00,6225.05,,,,,,,,,,,,,
IRRIGATION SET CTRL DISTENTION,SUP-2208441,CDM,C1894,HCPCS,0272,RC,,,,both,,,2900.64,1885.42,,,,,,,,,,,,,
COLLAR CERV SM H4.25IN FOR 10-13IN PLASTAZOTE FOAM 2 PC L,SUP-2336008,CDM,L0140,HCPCS,0272,RC,,,,both,,,30.33,19.71,,,,,,,,,,,,,
SPLINT FNGR M 3IN WIRE FOAM EXTN ASST BROAD CRV DORS CNTR PD,SUP-2194873,CDM,L3933,HCPCS,0272,RC,,,,both,,,60.26,39.17,,,,,,,,,,,,,
GRAFT HUM TISS W6XL12CM BLDR TISS REGEN MTRX REPLFRM,SUP-2139393,CDM,C1762,CPT,0278,RC,,,,both,,,6613.22,4298.59,,,,,,,,,,,,,
SLEEVE NAIL INSRT DIA8-13MM E SPI,SUP-2368597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
PLATE BNE W33XL251MM 18 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185121,CDM,C1713,HCPCS,0278,RC,,,,both,,,5974.64,3883.52,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT TI ST NONLOCKING COARSE PITCH,SUP-2189624,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
PRISMASATE B22GK 4/0 DIALYSIS SOLUTION,RX-40840083,CDM,2580000003,HCPCS,0258,RC,09999-9999-45,NDC,,both,5000,ML,103.50,67.27,,,,,,,,,,,,,
MATRIX TISS 2X7CM BOV SKIN SFT TISS REPAIRXENOFORM,SUP-2140341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1998.23,1298.85,,,,,,,,,,,,,
LENS INTOCU SGL PC LENSES OPT DSGN EQCNVX OPT STYL MOD S,SUP-2129720,CDM,V2630,CPT,0276,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BONE L112MM BLDE W11.7XL40MM 90DEG 6 H STRL BILAT TI,SUP-2190863,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.42,1910.62,,,,,,,,,,,,,
COMPONENT FEM M PART KNEE TWIN PEGGED UNI OXFORD,SUP-2406561,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ W STAY COCK UP FIRM SUPP,SUP-2276618,CDM,L3809,HCPCS,0274,RC,,,,both,,,16.14,10.49,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB III NEURO CUT STRL DISP HI-LINE XS,SUP-2929255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.68,287.74,,,,,,,,,,,,,
CAGE SPNL W10XH8XL22MM 8DEG MTL POLYMER COMP LORD EXP CART,SUP-2354723,CDM,C1889,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
STEM FEM SZ 14 L165X145MM ML36MM 135DEG TI PLSM SPRAYED HIP,SUP-2304847,CDM,C1776,CPT,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
DRAIN SURG 24FR BLAK SIL HUBLESS 4 CHANNELED RADPQ EXTN TB,SUP-2218225,CDM,C1729,HCPCS,0272,RC,,,,both,,,348.23,226.35,,,,,,,,,,,,,
SCREW BNE SELF DRILLING 2.3X14 MM LCK,SUP-2435293,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.07,106.65,,,,,,,,,,,,,
LINER ACET OD50MM ID28MM POLY MTL ON POLY REV NEUT OBLQ MOD,SUP-2202305,CDM,C1776,CPT,0278,RC,,,,both,,,3551.34,2308.37,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST THMS W/WDG,SUP-2435734,CDM,L3465,HCPCS,0274,RC,,,,both,,,165.73,107.72,,,,,,,,,,,,,
ELECTRODE NDL CANN L15CM ARRY DIA4CM FOR OPN AND PERC RF,SUP-2149339,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
"HC So Heavy Metals,Quant Ea",PX-3018301866,CDM,83018,CPT,0301,RC,,,,outpatient,,,70.00,45.50,,,,,,,,,,,,,
STENT GI CATH 10.8FR L138CM TOT L146CM FLNG DIA24MM LUMN,SUP-2149641,CDM,C1874,HCPCS,0278,RC,,,,both,,,14230.48,9249.81,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.7MM CORT DST FIBULAR TI ST,SUP-2413246,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.84,131.85,,,,,,,,,,,,,
SCREW BONE CORTEX 1.5X4 MM RAPID RESORBABLE STERILE RAPIDSOR,SUP-2838539,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.14,206.79,,,,,,,,,,,,,
PLATE STRUT 1.5MM 8H OBLQ LT STRL VAL,SUP-2546078,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.75,969.64,,,,,,,,,,,,,
SCREW BNE L12MM OD2.7MM NONLOCKING TUFFNEK TECHNOLOGY FOR,SUP-2321174,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.82,285.23,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS BK ALIGNABLE SYS,SUP-2388219,CDM,L5910,HCPCS,0272,RC,,,,both,,,958.74,623.18,,,,,,,,,,,,,
PLATE BNE L 17.86 X W 9.35 MM THK 0.6 MM SCREW DIA1.5 MM 6 H,SUP-2937031,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
CANNULA VITRECTOMY 25 GA 1 STP STRL DISP,SUP-2424170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.46,811.50,,,,,,,,,,,,,
ALLOGRAFT BNE DURA MATER LG ETO,SUP-2867003,CDM,C1763,HCPCS,0278,RC,,,,both,,,5602.07,3641.35,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-102351,CDM,2500000003,HCPCS,0250,RC,00264-7652-00,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BNE SUB 20CC OSTEOINDUCTIVE DBM OSTEOGENIC AUTOLGS,SUP-2399144,CDM,C1713,HCPCS,0278,RC,,,,both,,,8940.43,5811.28,,,,,,,,,,,,,
GUIDEWIRE 16CMX20CM RECTANG,SUP-2420227,CDM,C1769,HCPCS,0272,RC,,,,both,,,13370.12,8690.58,,,,,,,,,,,,,
PLATE BNE W12XL103MM THK1MM 6 H BILAT S STL SEMI TBLR LO,SUP-2184867,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
DEVICE SPEC RETRV L175CM OD.4MM ODSEC5MMX5IN 5MM ARD INTCRAN,SUP-2280936,CDM,C1773,HCPCS,0272,RC,,,,both,,,8251.92,5363.75,,,,,,,,,,,,,
SET URET STENT C FLX L 20 CM CATH L 70 CM DIA 3.7 FR,SUP-2171230,CDM,C2617,HCPCS,0278,RC,,,,both,,,632.71,411.26,,,,,,,,,,,,,
LEAD PACE AROX L 60 CM SIL INSUL PLATINIZED PLAT TIP STEROID,SUP-2137967,CDM,C1898,HCPCS,0275,RC,,,,both,,,1986.80,1291.42,,,,,,,,,,,,,
GABAPENTIN 250 MG/5ML PO SOLN,RX-29169,CDM,340b,HCPCS,0637,RC,42192-0608-06,NDC,,both,2.5,ML,7.10,4.61,,,,,,,,,,,,,
CATHETER GUID L125CM OD5FR GWIRE OD0.056IN LIMA VISTA BRT,SUP-2155876,CDM,C1887,HCPCS,0272,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
BIT SURG CANN 2.4 MM MAX VPC,SUP-2459317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,636.57,413.77,,,,,,,,,,,,,
GUIDEWIRE ORTH L450MM OD1.2MM SMOOTH BLNT TIP NIT,SUP-2341497,CDM,C1769,HCPCS,0272,RC,,,,both,,,231.01,150.16,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.24 MM INNR FLANGE DIA2.65 MM BLU,SUP-2901985,CDM,L8699,HCPCS,0278,RC,,,,both,,,94.55,61.46,,,,,,,,,,,,,
PLATE BNE L27MM THK1.3MM 4 H HND TI STR TRILOK COMPR FOR,SUP-2267934,CDM,C1713,HCPCS,0278,RC,,,,both,,,1657.92,1077.65,,,,,,,,,,,,,
BIT DRL 2.5 MM PERC FOR UNIV LCK SYS,SUP-2199256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
CATHETER PD STR AD 52 CM 6 CM 15.5 CM CLASSIC STD,SUP-2490127,CDM,C1750,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
ANCHOR SUTURE 2-0 LNG 1.5 MM SINGLE LD BLK WHT JUGGERKNOT,SUP-2745520,CDM,C1776,CPT,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
CATHETER IU 10FR BLLN 5ML L5CM DISP FOR FEM WORD BARTH,SUP-2384667,CDM,C1729,HCPCS,0272,RC,,,,both,,,64.90,42.18,,,,,,,,,,,,,
PACKING NSL CHITOSAN ENT SINUS GEL POSTOP STRL DISP CHITOGEL,SUP-2902121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1149.24,747.01,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT MAGNA EASE MT OD 21 MM ID 20 MM,SUP-2214117,CDM,C1889,HCPCS,0278,RC,,,,both,,,20253.00,13164.45,,,,,,,,,,,,,
BASEPLATE TIB M + STD UNIV KNEE CEM STEM PRI MOD N POR W/O,SUP-2397048,CDM,C1776,CPT,0278,RC,,,,both,,,10431.08,6780.20,,,,,,,,,,,,,
GLYCERIN (LAXATIVE) 2 G RE SUPP,RX-41003,CDM,6370000000,HCPCS,0637,RC,00132-0079-12,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ARCUS 16X13 STAPLE ASSEMBLY STERILE,SUP-2477081,CDM,C1713,HCPCS,0278,RC,,,,both,,,2384.86,1550.16,,,,,,,,,,,,,
HC Rep Lac Smp Face 7.6-12.5cm,PX-4501201500,CDM,12015,CPT,0450,RC,,,,both,,,1090.00,708.50,,,,,,,,,,,,,
SCREW BNE L17MM DIA2.4MM LNG THRD L6MM CANC TI CANN ST SELF,SUP-2181373,CDM,C1713,HCPCS,0278,RC,,,,both,,,880.46,572.30,,,,,,,,,,,,,
GRAFT VASC GORTX L 5 CM DIA 3.5 MM EPTFE TW PED SHUNT STRL,SUP-2396722,CDM,C1768,CPT,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
CEMENT KIT CALCIUM PHOSPHATE 16 CC QUICKSET,SUP-2845380,CDM,C1713,HCPCS,0278,RC,,,,both,,,7418.25,4821.86,,,,,,,,,,,,,
FASTRAC BONE SCREW 2.7X12MM,SUP-2841623,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS MAXXEUS ACHILLES PRESHAPE 10MM,SUP-2875994,CDM,C1762,CPT,0278,RC,,,,both,,,6242.32,4057.51,,,,,,,,,,,,,
BOOT CAST L TOT CNTCT SYS TCC-EZ,SUP-2244448,CDM,L4387,HCPCS,0274,RC,,,,both,,,355.39,231.00,,,,,,,,,,,,,
NEEDLE BX BONE MAR ASPIR NS,SUP-2415887,CDM,C1713,HCPCS,0278,RC,,,,both,,,730.84,475.05,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|ADJ|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|ADJ|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
SHEATH INTRO 24FR L28CM HYDRPHLC DRYSEAL,SUP-2395743,CDM,C1894,HCPCS,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
CENTRALIZER STEM DIA12MM UNIV DSTL HIP,SUP-2210694,CDM,C1776,CPT,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
BIT DRL 2.9X150 MM STRL VERSANAIL,SUP-2606673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,962.41,625.57,,,,,,,,,,,,,
SCREW BNE LCK 1.7X6 MM NS AXS LTX 5PK,SUP-2862788,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.26,235.47,,,,,,,,,,,,,
GRAFT BNE SUB W9XL15MM TRICORT ILIUM CREST BLK FRZ DRY MECH,SUP-2293823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
KIT VASC DIL 4FR L10CM MINI ACCS STIFF COAX S MAK,SUP-2303435,CDM,C1894,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
PLATE BNE L16MM BLU QUAD FOR GUID GROWTH SYS,SUP-2316409,CDM,C1713,HCPCS,0278,RC,,,,both,,,1188.68,772.64,,,,,,,,,,,,,
PIN RETRCT L10MM DOCKING FOR MARS 3V MINIMAL ACC SYS,SUP-2232226,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
WIRE BNE FIX L 229 MM DIA2.8 MM FLUT TIP NS LEOS KIRSCHNER,SUP-2933710,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.89,172.18,,,,,,,,,,,,,
GRAFT HUM TISS W14XH7MM D11MM CANC CORT LORD SPNL SPCR BLK,SUP-2293881,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
PLATE VARIAX COMP NAR STRAIGHT 4HL,SUP-2703372,CDM,C1713,HCPCS,0278,RC,,,,both,,,1371.55,891.51,,,,,,,,,,,,,
HANDPIECE SURG 3 IN BEND-A-BEAM ABC,SUP-2225594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,694.73,451.57,,,,,,,,,,,,,
CAPECITABINE 150 MG PO TABS,RX-22993,CDM,J8522,HCPCS,0637,RC,16729-0072-12,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT CATHETER PUMP INSERTION INTRACARDIAC IMPELLA CP,SUP-2652612,CDM,C1889,HCPCS,0278,RC,,,,both,,,87920.00,57148.00,,,,,,,,,,,,,
CATHETER PA L 110 CM DIA 7 FR INTRO DIA 7 FR BALLOON DIA11 1.25CC,SUP-2894137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
KIT ACCS INTRO L10CM DIA5FR GWIRE L40CM DIA0018IN NDL L7CM,SUP-2303007,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.04,61.13,,,,,,,,,,,,,
PLATE BNE 10 H STRNL TI X LOK FOR 3MM SCR,SUP-2192441,CDM,C1713,HCPCS,0278,RC,,,,both,,,2690.35,1748.73,,,,,,,,,,,,,
CATHETER VENTRICULAR ANTIMICROBIAL VENTRICULAR CATH,SUP-2666788,CDM,C1729,HCPCS,0272,RC,,,,both,,,18930.46,12304.80,,,,,,,,,,,,,
STRIP DENT 2 FOR CRWN FRM REPL UNITEK,SUP-2238917,CDM,D6783,CPT,0278,RC,,,,both,,,25.87,16.82,,,,,,,,,,,,,
TUBE VENT MORETZ 1.27MM 6/BXPC COAT FLROPLAS,SUP-2312795,CDM,L8699,HCPCS,0278,RC,,,,both,,,41.17,26.76,,,,,,,,,,,,,
BLOCK SPRD CERV INTBDY 14MM CATLYST C,SUP-2291048,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.84,534.85,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ HIP ABDUCTN FLX EXTN CTRL,SUP-2421311,CDM,L2624,HCPCS,0274,RC,,,,both,,,1216.47,790.71,,,,,,,,,,,,,
SET BILI STENT COTTON-HUIBREGTSE L 5 CM DIA10 FR PUSH L 170,SUP-2169034,CDM,C2617,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.25MM CO K 6PK,SUP-2136103,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM HYDRPHLC AMNIO MEMBRN PROTCT,SUP-2894615,CDM,C1762,CPT,0278,RC,,,,both,,,3557.62,2312.45,,,,,,,,,,,,,
GRAFT HUM TISS W20-24XL45MM THK5-30MM ILIUM TRICORT STRP,SUP-2307164,CDM,C1713,HCPCS,0278,RC,,,,both,,,4358.32,2832.91,,,,,,,,,,,,,
GRAFT PTTY SYN STIMULAN RAP CURE 5CC,SUP-2135331,CDM,C1713,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
BUR SURG L72MM DIA4MM LNG RND FN DMND VISAO,SUP-2278122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,491.79,319.66,,,,,,,,,,,,,
SYSTEM KNEE NP PS FEM COMP W/ CEM TIB GEN II,SUP-2347966,CDM,C1776,CPT,0278,RC,,,,both,,,11643.12,7568.03,,,,,,,,,,,,,
DRILL TWST L115MM OD19MM MORRISON ST,SUP-2436521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.60,388.44,,,,,,,,,,,,,
SCREW SPNL POST LNG 5.5X40 MM TSRH-3D MPA,SUP-2631234,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
HC So1 Albumin Other Source Quan Ea,PX-3078204267,CDM,82042,CPT,0307,RC,,,,both,,,17.00,11.05,,,,,,,,,,,,,
NAIL IM L300MM DIA10MM NK ANG 130DEG LT FEM TI CANN LCK,SUP-2347145,CDM,C1713,HCPCS,0278,RC,,,,both,,,13051.25,8483.31,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL FIX COR 15 CM 0.035 INX145 CM BENT,SUP-2835678,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.67,49.19,,,,,,,,,,,,,
KIT LD INTRO SAFSHTH L 13 CM DIA 9 FR NDL 18 GA GUIDEWIRE,SUP-2148862,CDM,C1892,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
WIRE FIX PILOT NIT,SUP-2423034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
INTRODUCER TUBE SET PERC FLX CIAGLIA BLU RHINO,SUP-2759811,CDM,C1769,HCPCS,0272,RC,,,,both,,,982.82,638.83,,,,,,,,,,,,,
LGN PRESSFIT STEM 18X220 STRT GRT BLST,SUP-2822668,CDM,C1776,CPT,0278,RC,,,,both,,,6506.08,4228.95,,,,,,,,,,,,,
MATRIX BIO SZ 250-540 SQCM FISH SKIN DERMAL MESHED 21,SUP-2909274,CDM,Q4158,HCPCS,0636,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
ACTIVATION ARM RIGID CARDANIC 25MM DISTRACTOR,SUP-2493313,CDM,C1713,HCPCS,0278,RC,,,,both,,,2248.74,1461.68,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 3X4 CM UMB CRD RESTORIGIN,SUP-2321893,CDM,Q4191,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GUIDE WIRE 1 MMX95 MM STRL,SUP-2814251,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
COLLAR CERV ADJ FOAM 2 PC THERMOPLASTIC,SUP-2388134,CDM,L0172,HCPCS,0272,RC,,,,both,,,431.62,280.55,,,,,,,,,,,,,
HC Radiologic Exam Small Int Single Contrast Study,PX-3207425000,CDM,74250,CPT,0320,RC,,,,inpatient,,,1702.00,1106.30,,,,,,,,,,,,,
PLATE BONE 5 HOLE TITANIUM GRIDLOCK VLC PLATING SYSTEM FOR 2.4/3/4MM SCREW CUSTOM,SUP-2878771,CDM,C1713,HCPCS,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
SURESPACE FEM SPACER MOLD MED,SUP-2540678,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Single W/Img,PX-3606444500,CDM,64445,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
CATHETER HAD SET LNG TERM PRECRV W/ SIDE H 15.5FRX24CM TI,SUP-2268416,CDM,C1881,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BNE STR 1.5X0.6 MM 6 MM 4 HOLE C-TUBE BRIDGE TI NS,SUP-2486399,CDM,C1713,HCPCS,0278,RC,,,,both,,,495.34,321.97,,,,,,,,,,,,,
IMPLANT H11MM SCR 1 5.5X30MM AND TWO 5.5X25MM INTERVERTEBRAL,SUP-2163228,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CUP ACET CEM 10 DEG 22 MM HIP W/ PLATE,SUP-2447858,CDM,C1776,CPT,0278,RC,,,,both,,,946.71,615.36,,,,,,,,,,,,,
ALLODERM SELECT 3X7 MEDIUM 1.2-2.0,SUP-2822072,CDM,Q4116,HCPCS,0636,RC,,,,both,,,3001.84,1951.20,,,,,,,,,,,,,
CATHETER GUID WINGMAN 18 L 90 CM OD 0.05 IN TIP DIA 0.032 IN,SUP-2227765,CDM,C1887,HCPCS,0272,RC,,,,both,,,2028.44,1318.49,,,,,,,,,,,,,
HC Brachytx Isodose Complex,PX-3337731800,CDM,77318,CPT,0333,RC,,,,both,,,1200.00,780.00,,,,,,,,,,,,,
HC So1 Platelet Aggr(Invitro) Ea Agnt,PX-3058557667,CDM,85576,CPT,0305,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 26 HOLE-STERILE,SUP-2546108,CDM,C1713,HCPCS,0278,RC,,,,both,,,3569.68,2320.29,,,,,,,,,,,,,
PLATE BONE L56MM LNG STRL RT ANTEROLATERAL CALCNL S STL VAR,SUP-2178429,CDM,C1713,HCPCS,0278,RC,,,,both,,,3197.09,2078.11,,,,,,,,,,,,,
CANNULA SUCTION INSUL 5 MMX30 CM CRV DST ANGLED HNDL UPLR,SUP-2773025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1905.85,1238.80,,,,,,,,,,,,,
ASSEMBLY ADPT 39MM TOT RVS SHLDR PROS CA REVERS,SUP-2123338,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 5 CM DIA 5 MM EPTFE STR TW N RING,SUP-2396332,CDM,C1768,CPT,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GUIDEWIRE VASC STR 0.035 INX180 CM SHT STEER PTFE COAT JINDO,SUP-2157315,CDM,C1769,HCPCS,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
WASHER ORTH OD8MM ID3.2MM SPIK FOR 2.7MM SCR,SUP-2184669,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.34,126.97,,,,,,,,,,,,,
NAIL IM L240MM DIA7.5MM 120DEG UNIV NONSTERILE DK BLU L/R,SUP-2192488,CDM,C1713,HCPCS,0278,RC,,,,both,,,5832.49,3791.12,,,,,,,,,,,,,
MODIFIED BURR HOLE COVER DR BAJWA CNTRD3MM17MM D15 SSTM CP,SUP-2680899,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.13,412.83,,,,,,,,,,,,,
SCREW BNE L5MM DIA2.7MM MAND CRANIOMAXILLOFACIAL SIL LOK 5PK,SUP-2366184,CDM,C1713,HCPCS,0278,RC,,,,both,,,387.10,251.61,,,,,,,,,,,,,
NUT ORTH BTTRS COMPR,SUP-2188215,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.68,279.94,,,,,,,,,,,,,
BASKET STONE REM 3 4 90 SEGR DRETLER,SUP-2141706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
TI LOW PROFILE NEURO ORBITAL,SUP-2823241,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
MATRIX BIO L 7 X W 7 CM SZ 300 SQCM ACELLULAR FISH SKIN SINGLE,SUP-2909434,CDM,Q4158,HCPCS,0636,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
PIN FIX L420MM DIA3.2MM TIB THRD PRECICE UNYTE STNMN,SUP-2312266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
CANNULA ART SHT 23 FR UNCOATED HLS,SUP-2663479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1006.59,654.28,,,,,,,,,,,,,
CEMENT BNE MAX VISC,SUP-2736290,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
FUROSEMIDE 80 MG PO TABS,RX-3296,CDM,6370000000,HCPCS,0637,RC,43547-0403-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLEDGET VASC W3/16XL3/8IN THK1/16IN PTFE SFT,SUP-2384372,CDM,C1768,CPT,0278,RC,,,,both,,,26.44,17.19,,,,,,,,,,,,,
BAR EXTERNAL FIXATION L500MM DIA11MM XTRAFIX SYSTEM,SUP-2478417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,817.62,531.45,,,,,,,,,,,,,
EVOS VOL PLATE 5H LEFT WDE TI 83MM NS,SUP-2818938,CDM,C1713,HCPCS,0278,RC,,,,both,,,7995.23,5196.90,,,,,,,,,,,,,
DEVICE THROMBOLYTIC 7FR L65CM SHTH 2/7FR L2IN 3000RPM PERC,SUP-2239969,CDM,C1757,HCPCS,0272,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
SPACER SPNL 20-25MM COR DIA22MM TI FOR SELF EXP VBR,SUP-2311166,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESH 12X8 CMX2.31-3.30 MM TISS MTRX ALLDERM,SUP-2113049,CDM,Q4116,HCPCS,0636,RC,,,,both,,,11250.62,7312.90,,,,,,,,,,,,,
BIT DRL 3.5 MM STP KNOTILUS,SUP-2608460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,622.79,404.81,,,,,,,,,,,,,
FELT SURG W0.5XL4IN THK1.65MM POLY PTFE,SUP-2127687,CDM,C1768,CPT,0278,RC,,,,both,,,235.19,152.87,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB,SUP-2883563,CDM,C1729,HCPCS,0272,RC,,,,both,,,772.16,501.90,,,,,,,,,,,,,
HC Hepatic Function Panel,PX-3018007600,CDM,80076,CPT,0301,RC,,,,both,,,317.00,206.05,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI TRI FLO ACTE 11.5FR DIA 12CM PCED TAPR,SUP-2610593,CDM,C1752,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM PEEK 2 ORTHOCORD SZ 2 L36IN VLT BLU,SUP-2249411,CDM,C1713,HCPCS,0278,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
STEM HUM 10X130 MM SHLDR RVS NP,SUP-2436920,CDM,C1776,CPT,0278,RC,,,,both,,,13013.73,8458.92,,,,,,,,,,,,,
ALLOGRAFT GRAFTLINK: D=7.5 L=68 MM,SUP-2815811,CDM,C1762,CPT,0278,RC,,,,both,,,6963.26,4526.12,,,,,,,,,,,,,
BIT DRL L17MM WRK L6MM OD1.6MM FOR 2/2.3MM SCR,SUP-2364188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.99,508.29,,,,,,,,,,,,,
SCREW BNE L32MM DIA3.5MM CORT DST TIB TYP II ANODIZED TI ST,SUP-2411693,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.40,101.66,,,,,,,,,,,,,
ANCHOR SUT LOOP W/ ORTHOCORD LUPINE +,SUP-2249327,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
PLATE CRAN 80X40X40 MM PT SPEC IMPL PEEK,SUP-2860123,CDM,C1713,HCPCS,0278,RC,,,,both,,,27220.03,17693.02,,,,,,,,,,,,,
PACEMAKER CARD EVIA DR-T TI 2 CHMBR PREM DDDR IS1 UPLR BPLR,SUP-2138284,CDM,C1785,HCPCS,0275,RC,,,,both,,,14412.60,9368.19,,,,,,,,,,,,,
ALLOPATCH HD MESHED THIN 04 07MM 4CM X 4CM HYDRATED,SUP-2726037,CDM,Q4128,HCPCS,0636,RC,,,,both,,,3200.13,2080.08,,,,,,,,,,,,,
HC Plcmt Prostate Radioelem Ndl/C,PX-3615587500,CDM,55875,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
MESH HERN RND 12X12 CMX1MM BIOMATERIAL TRIM DUALMESH LF DISP,SUP-2474291,CDM,C1781,HCPCS,0278,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
PLATE 14MM DIAM 1MM THICKNESS ATTIC DEFCT KARTUSH HA KARTUSH,SUP-2312566,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.69,281.25,,,,,,,,,,,,,
ACET RECONSTRUCTION ROOF RING 58MM OD X54MM ID,SUP-2504600,CDM,C1776,CPT,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,J2004,HCPCS,0636,RC,00409-3178-03,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
PLATE SPNL L16MM UNIV CERV ANT 1 LEV TI STD REFLX,SUP-2380854,CDM,C1713,HCPCS,0278,RC,,,,both,,,5089.94,3308.46,,,,,,,,,,,,,
GRAFT VASC GORTX L 60 CM DIA 4-7 MM OFFSET RNG L 30 CM EPTFE,SUP-2396107,CDM,C1768,CPT,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
Z DISCONTINUED BIT DRL OD3.8MM CALIB REUSE POLYAX,SUP-2412622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,528.46,343.50,,,,,,,,,,,,,
LAWSON RETROGRADE NEPHROSTOMY WIRE PUNCTURE SET,SUP-2826624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,808.24,525.36,,,,,,,,,,,,,
PLATE BONE MAXILLOFACIAL LT W/O BRDG,SUP-2372895,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
SPLINT CLAVICLEXSM INF W4XL52CM BCKL STRP CNTCT CLSR PD,SUP-2197367,CDM,L3650,HCPCS,0274,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
HC Injection for Cholangiogram,PX-3614753100,CDM,47531,CPT,0361,RC,,,,inpatient,,,12375.00,8043.75,,,,,,,,,,,,,
PLATE BNE L W135XL98MM THK42MM 5 H BILAT TI NAR RIG NEUT,SUP-2190810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1093.69,710.90,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.1MM NICKEL CHROM SMOOTH SGL END,SUP-2321616,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 6 MM STR TW CTR HELIX,SUP-2525456,CDM,C1768,CPT,0278,RC,,,,both,,,1279.36,831.58,,,,,,,,,,,,,
STRIP FNGR ALUM W/ FOAM 1INX18IN XL,SUP-2194457,CDM,L3933,HCPCS,0272,RC,,,,both,,,3.86,2.51,,,,,,,,,,,,,
COUNTERSINK SURG FOR 2/2.4MM SCR,SUP-2187360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.01,358.81,,,,,,,,,,,,,
CAGE SPNL W12XH22XL14MM 6DEG STD CERV THORLUM C FBR POLYMER,SUP-2254531,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
DEVICE RESECTING 3.6MM SYMPHION,SUP-2865687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2822.86,1834.86,,,,,,,,,,,,,
NAIL IM L340MM DIA9MM 130DEG LNG GRN L PROX FEM TI,SUP-2180696,CDM,C1713,HCPCS,0278,RC,,,,both,,,6805.60,4423.64,,,,,,,,,,,,,
SCREW BNE LCK 5X30 MM W/ T25 STARDRV FOR IM NAIL TI STRL,SUP-2179927,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.03,421.22,,,,,,,,,,,,,
FORCEP TISS BISH HARMON 0.3 MM STR TIP,SUP-2246240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.01,248.31,,,,,,,,,,,,,
GRAFT SYNTHECEL DURA MATER 2 X2 IN (5.0 CM X 5.0 CM),SUP-2719496,CDM,C1763,HCPCS,0278,RC,,,,both,,,1737.99,1129.69,,,,,,,,,,,,,
INTRODUCER VASC AD 6FR L25CM W/ DIA0.038IN GWIRE PINN,SUP-2141022,CDM,C1894,HCPCS,0272,RC,,,,both,,,1084.40,704.86,,,,,,,,,,,,,
CLAMP XTRAFIX KROD MULTI PIN,SUP-2721918,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4139.78,2690.86,,,,,,,,,,,,,
WIRE FIX DIAMOND PT 2 END 0.054X5 IN SS NS KIRSCHNER,SUP-2791280,CDM,C1713,HCPCS,0278,RC,,,,both,,,7.82,5.08,,,,,,,,,,,,,
HC Clsd Tx Bimall Fx W Manip,PX-4502781000,CDM,27810,CPT,0450,RC,,,,outpatient,,,1633.00,1061.45,,,,,,,,,,,,,
PLATE BNE TI LT NAVICULOCUNEIFORM FUSION NS UNITE,SUP-2897212,CDM,C1713,HCPCS,0278,RC,,,,both,,,4895.26,3181.92,,,,,,,,,,,,,
MESH CRAN L 57.2 X W 21.2 MM THK 0.3 MM SCREW DIA1.5 MM SM,SUP-2936727,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.14,1430.74,,,,,,,,,,,,,
COLLAR CERV TRACH OPN ADJ AD 3.25IN 13-16IN M PHIL,SUP-2195170,CDM,L0172,HCPCS,0274,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
TRACHEOSTOMY KIT PEDIATRIC 17 GA 3.5 MMX4 CM SPL NDL UNCUF,SUP-2846609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.10,358.21,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY 24MM 28.7MM 22.9MM 274SQMM FLX2,SUP-2214156,CDM,C1889,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
IMPLANT FACE L 65 X H 35 MM LAT PROJCT 11 MM LG POLYETHYL RT,SUP-2883502,CDM,C1713,HCPCS,0278,RC,,,,both,,,2067.63,1343.96,,,,,,,,,,,,,
OXYGENATOR PERFSN POLYMETHYLPENTENE FIBER KT PED AMG,SUP-2895169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29987.00,19491.55,,,,,,,,,,,,,
SET SUT OD5MM STD ENDOSCP,SUP-2245602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
NEUROSTIMULATOR EXT SM LTWT SGL BTTN H2O RESIST WIRELESS,SUP-2284422,CDM,C1897,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
NARROW PLT STERILIZER 4.5X135 MM 8 HL,SUP-2818128,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.82,813.68,,,,,,,,,,,,,
CLIP SM STIM DYN,SUP-2310408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 20 MM DIA 6 MM DEL SYS L 120 CM,SUP-2155348,CDM,C1876,HCPCS,0278,RC,,,,both,,,3543.80,2303.47,,,,,,,,,,,,,
RESERVOIR CSF VENTRICULAR ON-OFF FLSH ANTISIPH DEV,SUP-2852570,CDM,C1889,HCPCS,0278,RC,,,,both,,,3823.74,2485.43,,,,,,,,,,,,,
BASEPLATE TIB 5 R MED PRI CEM UNI JOURNEY DEUCE,SUP-2346445,CDM,C1776,CPT,0278,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
CATHETER IV DL 5 FR DOT KT MBP GIVA PC NG POWERMIDLINE,SUP-2626742,CDM,C1751,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PLATE BONE CRANIAL MEDIUM 6 HOLE GAP 38.8X15.3X0.4MM TITANIU,SUP-2826279,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
PROBE SURG DIA8MM PIERCER DISP OSCAR3,SUP-2319122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,0636,RC,72603-0139-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE CANC STD 6.5X30 MM HIP ST PART THRD CANN NLCK TORX,SUP-2370032,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SUPPORT ORTHOT FT LOWER EXTREMITY INSERT/PLATE PREPREG COMP,SUP-2435704,CDM,L3031,HCPCS,0272,RC,,,,both,,,346.72,225.37,,,,,,,,,,,,,
PROBE SUCT L45CM DIA5MM OUTER SHTH REPL REPOSABLE DISPOSABLE,SUP-2361203,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.92,77.95,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X193X2.8 MM LT 26 HOLE ANGLED LCK STRL,SUP-2539588,CDM,C1713,HCPCS,0278,RC,,,,both,,,7636.61,4963.80,,,,,,,,,,,,,
SPLINT WRST L R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326139,CDM,L3908,HCPCS,0272,RC,,,,both,,,63.71,41.41,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min",PX-4209711000,CDM,97110,CPT,0420,RC,,,,both,,,195.00,126.75,,,,,,,,,,,,,
DEVICE FIX 35MM AC JT FEM 2 ZIPLOOP TECHNOLOGY ZIPTIGHT,SUP-2212833,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
COMPONENT INNR 24/10 MM SFC,SUP-2389696,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLEDGET CV EDW L 10.2 X W 5.1 CM THK 0.91 MM PTFE FABRIC,SUP-2761358,CDM,C1768,CPT,0278,RC,,,,both,,,298.17,193.81,,,,,,,,,,,,,
VALVE VENT DRNGE PRECIS FIX INLINE W/ STR CONN INTRO,SUP-2243817,CDM,C1729,HCPCS,0272,RC,,,,both,,,2860.54,1859.35,,,,,,,,,,,,,
BIT DRL 2.5 MM 00430004901],SUP-2199000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
FIBERTAG TIGHTROPE WITH FLIPCUTTER III,SUP-2811464,CDM,C1713,HCPCS,0278,RC,,,,both,,,3187.10,2071.61,,,,,,,,,,,,,
STENT PERIPH L15CM DIA7MM CATH 7FR L120CM BLLN DIA7MM,SUP-2396632,CDM,C1874,HCPCS,0278,RC,,,,both,,,11837.80,7694.57,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 76 MM LEG L 45 MM IPSILATERAL DIA20,SUP-2170132,CDM,C1768,CPT,0278,RC,,,,both,,,12132.96,7886.42,,,,,,,,,,,,,
BLADE SCALPEL CART MENEZES MST STRL,SUP-2481832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.86,350.26,,,,,,,,,,,,,
FIXATOR ORTH WRST LO PROF W 4 25MM SCHNZ SCR 200MM C FBR ROD,SUP-2179121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2980.65,1937.42,,,,,,,,,,,,,
NEEDLE NERVE STIM BLNT ACCS KT INTEGRITY MONITOR XPAK NIM,SUP-2792158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.71,649.16,,,,,,,,,,,,,
SPLINT WR UNIV PED LT HND COCKUP ALUM STAY INSTABILITY INJ,SUP-2203821,CDM,L3908,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE CAPTURE FOREFT SELF DRL ST CANN HDLSS 2 THRD L22MM,SUP-2243903,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.54,643.20,,,,,,,,,,,,,
SPACER SPNL W20XH10XL55MM 12DEG LORD OBLQ LAT LUM INTBDY,SUP-2284878,CDM,C1821,HCPCS,0278,RC,,,,both,,,16365.68,10637.69,,,,,,,,,,,,,
SURFACE ARTC 1-2 AB THK9MM AP40MM ML58MM PUR POLYETH KNEE,SUP-2211970,CDM,C1776,CPT,0278,RC,,,,both,,,3877.90,2520.63,,,,,,,,,,,,,
ADAPTER LD DF1 TO IS1 CONN EXT PPM,SUP-2148913,CDM,C1883,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 8 MM EPTFE FLX TW RING HEMO,SUP-2761450,CDM,C1768,CPT,0278,RC,,,,both,,,2160.29,1404.19,,,,,,,,,,,,,
PLATE BNE L 33 X W 6.6 MM THK 0.6 MM SCREW DIA2 MM 4 H TI,SUP-2936864,CDM,C1713,HCPCS,0278,RC,,,,both,,,1673.62,1087.85,,,,,,,,,,,,,
PATCH SYNTH ABD N ABSRB RECT EXP POLYTETRAFLUROETHYLENE 6CM,SUP-2395377,CDM,C1781,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
INTRODUCER SHTH W51XH73XL557MM D13MM DIA7.8MM HYDRPHLC,SUP-2281174,CDM,C1894,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SEED BRACHYTHERAPY STD STRND,SUP-2135323,CDM,C2638,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
HEAD HUM 17MM HT 41MM DIA INTEGR - 17MM HT 41MM DIAM,SUP-2408633,CDM,C1776,CPT,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
CEMENT BNE 20ML 41GM FULL DOSE PMMA W/ TOBRA M VISC RADPQ,SUP-2374949,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM 7MM EXTRA SUPP ANGIOGAURD,SUP-2158277,CDM,C1769,HCPCS,0272,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
GRAFT HUM TISS XL 9X9CM DEHYDR AMNION CHORION MEM EPIFIX,SUP-2305765,CDM,Q4186,HCPCS,0636,RC,,,,both,,,19546.53,12705.24,,,,,,,,,,,,,
SHEATH INTRO SUPER SHTH RO L 25 CM DIA 8 FR GUIDEWIRE 0.038,SUP-2147313,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.43,58.78,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4 H STD CRANIOMAXILLOFACIAL G TI STR,SUP-2366288,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.08,232.10,,,,,,,,,,,,,
SCREW BONE 2.3MM DIAM 10MM LEN CORT ST STD NONLOCKING HDED,SUP-2363447,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.73,99.92,,,,,,,,,,,,,
COLLAR CERV AD H25XL22IN UNIV FIRM DENS CNTOUR HK LOOP CLSR,SUP-2276585,CDM,L0120,HCPCS,0274,RC,,,,both,,,8.07,5.25,,,,,,,,,,,,,
SCREW BONE L17MM DIA2.3MM CRANIOMAXILLOFACIAL TI CROSSDRIVE,SUP-2262622,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.18,57.97,,,,,,,,,,,,,
CATHETER US 8FR L90CM FOR SIEMENS SEQUOIA CYPRESS ACUSON,SUP-2248455,CDM,C1759,HCPCS,0272,RC,,,,both,,,7843.72,5098.42,,,,,,,,,,,,,
SCREW BNE L 140 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2931605,CDM,C1713,HCPCS,0278,RC,,,,both,,,214.05,139.13,,,,,,,,,,,,,
PORT KIT 9.5FR MICROINTRODUCER POWERPORT DUO,SUP-2126330,CDM,C1788,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE R MT SLIM FUS OMNI,SUP-2223994,CDM,C1713,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
VESSEL HARVESTING KIT ENDOSCP ACCS,SUP-2140984,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 7 MM RNG L 30 CM EPTFE STR TW,SUP-2396127,CDM,C1768,CPT,0278,RC,,,,both,,,3020.68,1963.44,,,,,,,,,,,,,
CUP ACET 54MM 38 N FLR M2A,SUP-2136395,CDM,C1776,CPT,0278,RC,,,,both,,,17993.46,11695.75,,,,,,,,,,,,,
"HC Growth Hormone, Serum (5 Spec)",PX-3018300367,CDM,83003,CPT,0301,RC,,,,both,,,46.00,29.90,,,,,,,,,,,,,
URSODIOL 300 MG PO CAPS,RX-11624,CDM,6370000000,HCPCS,0637,RC,00591-3159-01,NDC,,both,1,UN,4.60,2.99,,,,,,,,,,,,,
BIT DRL CANN 9 MM KNEE SINGLE FLUT MTO,SUP-2849084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
GRAFT HUM TISS R FEM FRZN,SUP-2307326,CDM,C1713,HCPCS,0278,RC,,,,both,,,16942.81,11012.83,,,,,,,,,,,,,
PLATE BNE RECON 2.5 MM 20 HOLE RECON PT SPEC TI,SUP-2860090,CDM,C1713,HCPCS,0278,RC,,,,both,,,12671.47,8236.46,,,,,,,,,,,,,
SPLINT WR COLLES ALUM W/ FOAM LT M,SUP-2195268,CDM,L3906,HCPCS,0274,RC,,,,both,,,28.54,18.55,,,,,,,,,,,,,
GRAFT BNE L20XW14 18MM FIB SHFT FRZ DRY IMPL,SUP-2307188,CDM,C1713,HCPCS,0278,RC,,,,both,,,1662.82,1080.83,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X65 MM CANN EXT TAB VOYAGER 4.75,SUP-2629433,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 7MM STR STD WALL SLDE GDS,SUP-2695233,CDM,C1768,CPT,0278,RC,,,,both,,,2852.47,1854.11,,,,,,,,,,,,,
HC So Enterovirus,PX-3028665866,CDM,86658,CPT,0302,RC,,,,outpatient,,,158.00,102.70,,,,,,,,,,,,,
PLATE BNE COMPR SM 2.7X68 MM 8 HOLE DYN NS DCP LTX,SUP-2861901,CDM,C1713,HCPCS,0278,RC,,,,both,,,426.91,277.49,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0258,RC,00338-0017-31,NDC,,both,50,ML,21.70,14.10,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 12H 226MM RIGHT STERILE,SUP-2549645,CDM,C1713,HCPCS,0278,RC,,,,both,,,5185.80,3370.77,,,,,,,,,,,,,
MARKER TISS W2XL3CM RADIOGRAPHIC BIOABSRB SPCR HLD RADPQ,SUP-2225558,CDM,A4648,CPT,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
SPHERE EYE MEDPOR POLYETH POR OD20 MM RND BIOCOMPATIBLE ST,SUP-2366440,CDM,L8610,HCPCS,0278,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
PLATE BONE 2 H 130DEG CCD ANG GLD TI ALLOY FOR FEM NK SYS,SUP-2181487,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.19,1459.37,,,,,,,,,,,,,
GRAFT BNE BLOCK SM TRICORT,SUP-2759546,CDM,C1713,HCPCS,0278,RC,,,,both,,,5662.21,3680.44,,,,,,,,,,,,,
GUIDEWIRE PIN PRECISION TM 3.9 X 450 MM,SUP-2855151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.03,493.37,,,,,,,,,,,,,
TITANIUM 3D MESH 120MM X 120MM 3MM 15MM SSTM CP TTNM,SUP-2681401,CDM,C1713,HCPCS,0278,RC,,,,both,,,7699.66,5004.78,,,,,,,,,,,,,
SCREW INTRF L20MM DIA9MM TIB RETROSCR,SUP-2121347,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
PLEDGET CV SZ 6 MM THK 2.87 MM PTFE FELT RND SHP THCK STRL,SUP-2761356,CDM,C1768,CPT,0278,RC,,,,both,,,3.45,2.24,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 7 MM EPTFE CENTERFLEX RING HEMO,SUP-2761403,CDM,C1768,CPT,0278,RC,,,,both,,,2282.00,1483.30,,,,,,,,,,,,,
PLATE BONE 8 H STR FOR SM BONES ORTHOLOC 3DI,SUP-2398062,CDM,C1713,HCPCS,0278,RC,,,,both,,,2483.74,1614.43,,,,,,,,,,,,,
PROPRANOLOL 0.1 MG/ML INJ SOLN (PED-NEO),RX-4090139,CDM,J1800,HCPCS,0636,RC,09999-9906-60,NDC,,both,1,UN,11.00,7.15,,,,,,,,,,,,,
SEGMENT FEM L13CM INTERCALARY FINN CPS,SUP-2406903,CDM,C1776,CPT,0278,RC,,,,both,,,16284.04,10584.63,,,,,,,,,,,,,
ANGLE S/D BLADE 2.0/2.3MM XD SCRWS DNTL LATCH 12MM 1/2N,SUP-2498129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.54,282.45,,,,,,,,,,,,,
TRAY BNE CEMENT BEAD CERAMENT,SUP-2893105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
BASEPLATE TIB SZ 4 UNIV LT MEDL RT LAT SAMP JOURNEY,SUP-2346857,CDM,C1776,CPT,0278,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
BUR SURG 1.5X15 MM FOR PILOT DRL,SUP-2361339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.035IN TIP 2CM PTFE HEPARIN STR,SUP-2167657,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.46,19.80,,,,,,,,,,,,,
REAMER 17X8MM TREPH CHG,SUP-2207343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2802.45,1821.59,,,,,,,,,,,,,
PLATE BNE STR 1.5X18X0.8 MM MIDFACE 4 HOLE W/ TAB TI STRL,SUP-2518104,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE L140MM 5 H NONSTERILE R PROX LAT TIB S STL LOK,SUP-2184877,CDM,C1713,HCPCS,0278,RC,,,,both,,,3834.60,2492.49,,,,,,,,,,,,,
HC So Alkaline Phosphatase,PX-3018407566,CDM,84075,CPT,0301,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
BRACE KNEE ADULTXL UNIV FOAM POSTOP UNISX WRP ARND HNG T SCP,SUP-2150861,CDM,L1810,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
PLUG HIP FIX FEN SIZE2,SUP-2377823,CDM,C1776,CPT,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
STAPLE INT 8X8X8MM THK1.5X1.2MM DRL DIA2MM COMPR FOR,SUP-2378850,CDM,C1776,CPT,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
CAGE SPNL W9XH10XL25MM WDG 0DEG C FBR REINF POLYMER POST,SUP-2255157,CDM,C1889,HCPCS,0278,RC,,,,both,,,9187.64,5971.97,,,,,,,,,,,,,
CATHETER ABLAT OD7.5FR 2-5-2MM SPC 4 POLE DEFL C THRMSTER,SUP-2248929,CDM,C1732,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SHEATH GUID 6FR L45CM ID2.2MM GWIRE 0.018X0.038IN RENAL DBL,SUP-2169815,CDM,C1894,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
CATHETER HD STR EXTN 11.5 FRX24 CM SHT TERM DL HEMCATH,SUP-2627310,CDM,C1752,HCPCS,0278,RC,,,,both,,,20.22,13.14,,,,,,,,,,,,,
ANCHOR SUTURE 2.8MM SELF PUNCHING WITH TWO 1.3MM WHITE/BLUE,SUP-2825066,CDM,C1713,HCPCS,0278,RC,,,,both,,,1502.18,976.42,,,,,,,,,,,,,
HC Ercp Biliary and Pancreatic,PX-3207433000,CDM,74330,CPT,0320,RC,,,,both,,,2384.00,1549.60,,,,,,,,,,,,,
PLATE LK POLYAXIAL ST,SUP-2495321,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
OCCLUDER DUCT L7MM DIA6X4MM RETEN SKRT DIA10MM SHTH 6FR,SUP-2355741,CDM,C1889,HCPCS,0278,RC,,,,both,,,14058.41,9137.97,,,,,,,,,,,,,
KIT DRL PIN L100MM DIA2MM ABSRB W/ MTL TIP K WIRE GUID SL,SUP-2121832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
GRAFT HUM TISS L23CM FLD DIA6MM FRZN DBL STRND POST,SUP-2113923,CDM,C1713,HCPCS,0278,RC,,,,both,,,9326.74,6062.38,,,,,,,,,,,,,
TRIAL SPNL 0DEG IL REUSE,SUP-2287101,CDM,C1713,HCPCS,0278,RC,,,,both,,,554.56,360.46,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 22-25 CM ART CUF BASIC SET TESIO,SUP-2627149,CDM,C1750,HCPCS,0278,RC,,,,both,,,1070.11,695.57,,,,,,,,,,,,,
FIBER LASER FLEXIVA PULSE TRACTIP 242 BOX,SUP-2716208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.36,976.53,,,,,,,,,,,,,
HC Pt Elec Stim Unattended,PX-4209701400,CDM,G0283,HCPCS,0420,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CANN 4.4 FRX20 MM DREAMWIRE TRUETOME,SUP-2141619,CDM,C1769,HCPCS,0272,RC,,,,both,,,1238.95,805.32,,,,,,,,,,,,,
TRIAL PLATE HK 0.8 MM AVULSION,SUP-2525711,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
RIFAMPIN 300 MG PO CAPS,RX-11293,CDM,6370000000,HCPCS,0637,RC,00904-7315-61,NDC,,both,1,UN,5.60,3.64,,,,,,,,,,,,,
PROBE SURGICAL MCCULLOCH 9 12INL 8MML TIP ANGLED BALL TIP,SUP-2676450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.88,233.92,,,,,,,,,,,,,
KIT SPNL CEM 5CC FULL DOSE PMMA RADPQ HI VISC W O SYR AND,SUP-2255656,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HC X-Ray Foot 2 Views,PX-3207362000,CDM,73620,CPT,0320,RC,,,,both,,,606.00,393.90,,,,,,,,,,,,,
IMPLANT BRST NACL TEXT RND SIL SHELL MOD PROF ANT DIAPH VLV,SUP-2113280,CDM,C1789,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA 5 FR HYDRPHLC,SUP-2383398,CDM,C1894,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST ADJ POS RIGID SUPP PREFABRICATED,SUP-2435610,CDM,L1833,HCPCS,0274,RC,,,,both,,,1950.10,1267.56,,,,,,,,,,,,,
SUPPORT ORTHOT CERV THOR LUMBAR SACR CUST MILWAUKEE INIT,SUP-2435568,CDM,L1000,HCPCS,0274,RC,,,,both,,,5740.92,3731.60,,,,,,,,,,,,,
CEMENT BONE FULL DOSE 40 GM TWIN PK SPINPLEX STRL,SUP-2366941,CDM,C1713,HCPCS,0278,RC,,,,both,,,991.52,644.49,,,,,,,,,,,,,
BIT DRL DIA6.5MM GLIDING H CANN FOR 6.5MM SCR FLOWERCUBE,SUP-2225314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.63,493.76,,,,,,,,,,,,,
PPICC PROVENA SOLO SP 3F SLEEVE MAX TL,SUP-2613555,CDM,C1751,HCPCS,0278,RC,,,,both,,,744.12,483.68,,,,,,,,,,,,,
BLADE SHAVER 3.5 MM ULTRAGATOR,SUP-2765776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.32,268.66,,,,,,,,,,,,,
SHEATH GUID 6FR L45CM GWIRE 0.018-0.038IN POLYUR COBRA TIP,SUP-2169816,CDM,C1894,HCPCS,0272,RC,,,,both,,,137.06,89.09,,,,,,,,,,,,,
INSERT TIB CR 4 12 MM KNEE BEAR TECHNOLOGY X3 TRIATHLON,SUP-2431365,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BIT DRILL EXTRACTION SZ 4 MM SCREW DIA 7-7.5 MM STRL DISP,SUP-2913563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2611.22,1697.29,,,,,,,,,,,,,
HC So Pretreatment for RBC Ab ID,PX-3028697766,CDM,86977,CPT,0302,RC,,,,both,,,239.00,155.35,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.8X100 MM TROCAR PT 1 END,SUP-2422315,CDM,C1769,HCPCS,0272,RC,,,,both,,,176.34,114.62,,,,,,,,,,,,,
PLATE BONE CALCNL,SUP-2247331,CDM,C1713,HCPCS,0278,RC,,,,both,,,3011.26,1957.32,,,,,,,,,,,,,
METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN,RX-117354,CDM,J9260,HCPCS,0636,RC,00143-9519-10,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CLONAZEPAM 1 MG PO TABS,RX-9638,CDM,6370000000,HCPCS,0637,RC,50268-0174-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRIP CBL L125MM STD TROCHANTERIC HIP 5 CBL ACCORD,SUP-2345207,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
SET SPEC RETRV L 220 CM OD 2.2 MM ID 1.9 MM CAP OD 21 MM ID,SUP-2881911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
PLATE SPNL L17MM UNIV ANTR LUMSACR CVR FIX UNITY 51,SUP-2316768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1645.36,1069.48,,,,,,,,,,,,,
KIT INFUS PRT CATH L50CM DIA8FR TI SGL LUMN ATTCH GROSH VLV,SUP-2127744,CDM,C1788,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
ANCHOR ENDO L220CM STD GAST RIG FOR 3.2MM WRK CHAN GASTSCP,SUP-2319935,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
CATHETER CV FULL TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0052,SUP-2759804,CDM,C1751,HCPCS,0278,RC,,,,both,,,554.46,360.40,,,,,,,,,,,,,
INSERT TIB THK 8 MM SZ 1 POLYETHYL LT ANK FIX XT REV STRL LJV310T,SUP-2932741,CDM,C1776,CPT,0278,RC,,,,both,,,9385.46,6100.55,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X4 CM CRYOPRESERVED AMNIOX CLARIX 100,SUP-2648669,CDM,Q4156,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
TEMPLATE SURG L45MM STR RECON PLT,SUP-2197685,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
PLATE BONE 4X10 H CRANIOMAXILLOFACIAL TI Y SHP FOR SCR,SUP-2190610,CDM,C1713,HCPCS,0278,RC,,,,both,,,925.36,601.48,,,,,,,,,,,,,
"HC Post.Drain/Percussion,Initial",PX-4109466700,CDM,94667,CPT,0410,RC,,,,inpatient,,,247.00,160.55,,,,,,,,,,,,,
PACEMAKER CARD 23GM 12.8CC W52XH52MM THK6MM 2 CHMBR IS-1,SUP-2356462,CDM,C1785,HCPCS,0275,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
TEMPLATE SURG LEV 1 THOR RIB KEYRING,SUP-2262536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SEALER VES DIA8MM EXT ENDOWRIST,SUP-2246798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.88,1339.57,,,,,,,,,,,,,
TUBE VENT 1.27 MM 1.17 MM 4.5/2.72 MM TAPR VENT SIL STRL,SUP-2535110,CDM,L8699,HCPCS,0278,RC,,,,both,,,59.60,38.74,,,,,,,,,,,,,
ROD SPNL L40MM DIA4.75MM CO CHROM PREBENT CDH SOLERA,SUP-2284759,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SPACER SPNL W26XH9MM PEEK-OPTIMA 1 LEV NONTAPERED ADJ VU,SUP-2385987,CDM,C1889,HCPCS,0278,RC,,,,both,,,10701.12,6955.73,,,,,,,,,,,,,
CLAV SUP NRW LT 10H 100MM NS,SUP-2467892,CDM,C1713,HCPCS,0278,RC,,,,both,,,4248.42,2761.47,,,,,,,,,,,,,
FIBER LASER 230 FT KRA-CPAOCHXL HDMI,SUP-2798105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2015.88,1310.32,,,,,,,,,,,,,
ANCHR SUT 2.3 MM ULTRABRAID BIORAPTOR,SUP-2848600,CDM,C1713,HCPCS,0278,RC,,,,both,,,952.83,619.34,,,,,,,,,,,,,
HC So Copper,PX-3018252566,CDM,82525,CPT,0301,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
CATHETER INFUS 32FR INSRTN L34CM CONN 3/8IN JUG 2 LUMN RADPQ,SUP-2279233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RADIA L 95 CM DIA 7 FR SPC 2-10-2,SUP-2142362,CDM,C1731,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL METATRSL CUST LIFT ELEVATION PER INCH,SUP-2435716,CDM,L3300,HCPCS,0274,RC,,,,both,,,147.64,95.97,,,,,,,,,,,,,
SCREW BONE TI HEX NUT BIPHASE SYS,SUP-2135875,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
SEGMENT FEM L30CM INTERCALARY FINN CPS,SUP-2406909,CDM,C1776,CPT,0278,RC,,,,both,,,16968.56,11029.56,,,,,,,,,,,,,
COMPONENT GLEN MOD HYBRID POST FOR COMPHSVE SHLDR SYS,SUP-2409121,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
KYPHOPLASTY TRAY 2 10 MM CEMENT DEL INTRO KYPHON EXPRESS II,SUP-2429555,CDM,C1713,HCPCS,0278,RC,,,,both,,,8031.08,5220.20,,,,,,,,,,,,,
PURAPLYAM FENESTRATED 4.0X4.0 16 SQ CM,SUP-2635405,CDM,Q4196,HCPCS,0636,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 58 MM DIA 30 MM SHTH 20 FR SS,SUP-2750813,CDM,C1874,HCPCS,0278,RC,,,,both,,,6258.02,4067.71,,,,,,,,,,,,,
PLATE BNE MESHED 126.2X11.2X2 MM SM GRID TI PDLLA STRL LF,SUP-2464804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2765.34,1797.47,,,,,,,,,,,,,
MESH SYN W20XL30CM 67% POLYGLY ACID 33% TRIMETHYLENE CRBNT,SUP-2395754,CDM,C1781,HCPCS,0278,RC,,,,both,,,12660.48,8229.31,,,,,,,,,,,,,
GUIDEWIRE ORTH L 150 MM DIA1.4 MM SCREW DIA 3.5/4 MM THRD,SUP-2908509,CDM,C1769,HCPCS,0272,RC,,,,both,,,448.64,291.62,,,,,,,,,,,,,
BRACE WR L LT COT FOAM LAM INSTABILITY INJ REG EXTN D RNG W/,SUP-2326132,CDM,L3908,HCPCS,0272,RC,,,,both,,,47.57,30.92,,,,,,,,,,,,,
PLATE BNE TIB RT DSTL MEDL 8 HOLE TS,SUP-2362736,CDM,C1713,HCPCS,0278,RC,,,,both,,,3534.86,2297.66,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 75 X W 11 MM MYRIAD HNDPC L 13 CM,SUP-2930228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22169.69,14410.30,,,,,,,,,,,,,
STEM FEM SZ 5 L140MM DIA15MM NK L37MM 47MM OFFSET 132DEG 62650011] STRYKER CORP],SUP-2364476,CDM,C1776,CPT,0278,RC,,,,both,,,8903.78,5787.46,,,,,,,,,,,,,
IMPLANT TOE JT SZ 30 1ST MTP FLEX W/ GRMMT,SUP-2242120,CDM,C1776,CPT,0278,RC,,,,both,,,7523.44,4890.24,,,,,,,,,,,,,
KIT SHUNT CSF LP STRATA NCS,SUP-2278371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15362.64,9985.72,,,,,,,,,,,,,
CANNULA INJ STR 0.8 MM TIP 5 MMX37 CM,SUP-2850979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
PLATE LO PROF 4 H MINI 20 MOD TI 06MM LNG,SUP-2262930,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.31,186.75,,,,,,,,,,,,,
SEALER/DIVIDER LAP SHFT L44CM DIA5MM STR BLNT TIP JAW HND,SUP-2283562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1474.70,958.55,,,,,,,,,,,,,
SCREW BNE EMGCY 2.5X13 MM TI MAXDRIVE LEVEL 1 258741361,SUP-2461407,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.43,138.73,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 3 HOLE 109MM RT STRL,SUP-2546855,CDM,C1713,HCPCS,0278,RC,,,,both,,,5681.58,3693.03,,,,,,,,,,,,,
PLATE BNE W5XL23MM THK1.5MM 4 H 1ST METATARSAL FOREFOOT,SUP-2398017,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
HC Shoulder/Clavicle Strap/Splint,PX-4502924000,CDM,29240,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
LEAD PACE 5.3FR L88CM CARD VENT SIL STEROID STR 2 ELECTRD,SUP-2281935,CDM,C1900,HCPCS,0275,RC,,,,both,,,4903.71,3187.41,,,,,,,,,,,,,
PLATE BNE L169MM 4 H ST PROX FEM S STL HK LO PROF LOK COMPR,SUP-2186055,CDM,C1713,HCPCS,0278,RC,,,,both,,,4803.98,3122.59,,,,,,,,,,,,,
CATHETER THROMCTMY SYM PROHELIX L 102 CM DIA24 FR AUXILIARY,SUP-2887295,CDM,C1757,HCPCS,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SPACER SPNL W12XH8XL12MM 5DEG INTBDY FUS LORDTC FOOTPRINT,SUP-2206003,CDM,C1889,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SET PICC 2L 5.5FR X 55CM BP,SUP-2887069,CDM,C1751,HCPCS,0278,RC,,,,both,,,1052.94,684.41,,,,,,,,,,,,,
KIT SHTH Z FLX 270 DIA12 FR STEER SFT TIP STRL,SUP-2141320,CDM,C1894,HCPCS,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
GRAFT BONE SUB 30ML CANC CUBE FRZ DRY,SUP-2165553,CDM,C1713,HCPCS,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
CAGE SPNL LORDTC 16X13X7 MM PEEK,SUP-2401533,CDM,C1889,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
BOOT WALKING SURG,SUP-2265017,CDM,L3260,HCPCS,0274,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HYSTEROSCOPIC SET OUTFLO TUBE FOR FLUID MGMT SYS TRUCLEAR,SUP-2172306,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.85,264.45,,,,,,,,,,,,,
TWIST DRILL MRRSNKLS MRTN1.5MM X 117 X 25MM STOP CYL 01 100,SUP-2707268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.39,465.00,,,,,,,,,,,,,
WIRE ORTH L500MM DIA0.3MM TI SMOOTH W/ NDL CANTHAL,SUP-2193155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.37,738.64,,,,,,,,,,,,,
CATHETER CV 3L 6 FR PWR INJ N COAT CT COMPATIBLE POWERPICC,SUP-2126714,CDM,C1751,HCPCS,0278,RC,,,,both,,,739.47,480.66,,,,,,,,,,,,,
IMMOBILIZER SHLDR BASIC ABD SLNG SM,SUP-2150926,CDM,L3650,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SOCK PROSTHETIC LNG FRAC,SUP-2388188,CDM,L2850,HCPCS,0272,RC,,,,both,,,152.76,99.29,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 2.9MM STAINLESS STEEL PRETHREADED WIT,SUP-2824091,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.12,449.88,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 12 MM BLB DIA2.5 MM SIL RUBBER,SUP-2130329,CDM,C1760,HCPCS,0278,RC,,,,both,,,248.19,161.32,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA100 UM 2 ML HYDRGEL POLYZENE MIC WHT,SUP-2139574,CDM,C1889,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
BURR SURG 2MM DIA HD LNG MIC 72MML 10MML HD CARBIDE SM BNE B,SUP-2605566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.49,45.17,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN MICRO 19SQCM,SUP-2909379,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SCREW BNE ST 2.7X12 MM CORTICAL HEX HD,SUP-2196671,CDM,C1713,HCPCS,0278,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W4 10XH0.009 0.13XL33MM NON MSHD DRMS TSSU,SUP-2460373,CDM,Q4116,HCPCS,0636,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT FEM SHFT 30MM,SUP-2307344,CDM,C1713,HCPCS,0278,RC,,,,both,,,2158.75,1403.19,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7526,SUP-2482989,CDM,C1769,HCPCS,0272,RC,,,,both,,,870.00,565.50,,,,,,,,,,,,,
PLATE BNE MINI W5XL10MM THK0.5MM 4 H BILAT,SUP-2181691,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.39,724.35,,,,,,,,,,,,,
GUIDEWIRE ORTH RETICLE NEUROVISION M5 SYS,SUP-2310422,CDM,C1769,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SCREW BONE L100MM D105MM CRTCL TTNM ALLOY NNCNNLTD LAG NNLCK,SUP-2495133,CDM,C1713,HCPCS,0278,RC,,,,both,,,1614.53,1049.44,,,,,,,,,,,,,
PLATE ARSENAL ANKLE 7 HOLE ANTEROLATERAL TIBIA R,SUP-2878318,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
SYSTEM TISS GLUE 5ML CONTAIN SYR PLUNG STD SYR TIP 12MM 5PKS/EA,SUP-2175219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
TI LCP DIA-META VOLAR DISTAL RADIUS PL 5H SHAFT/LT-STERILE,SUP-2546643,CDM,C1713,HCPCS,0278,RC,,,,both,,,4984.56,3239.96,,,,,,,,,,,,,
PIN FIX SM REPL AXLE,SUP-2372335,CDM,C1713,HCPCS,0278,RC,,,,both,,,3305.16,2148.35,,,,,,,,,,,,,
SIDEPLATE STD BARL 140 DEG 16H STRL LCP DHHS,SUP-2547668,CDM,C1713,HCPCS,0278,RC,,,,both,,,2968.49,1929.52,,,,,,,,,,,,,
MESH MIDFACIAL CUSTOMIZED + STRL MEDPOR LTX,SUP-2862748,CDM,C1713,HCPCS,0278,RC,,,,both,,,53291.17,34639.26,,,,,,,,,,,,,
GRAFT BNE H12MM IL CREST WDG PRESERVON MATRIGRFT,SUP-2264840,CDM,C1713,HCPCS,0278,RC,,,,both,,,2061.98,1340.29,,,,,,,,,,,,,
RESERVOIR CSF STD MINI 0.14 CC W/O VENTRICULAR CATH,SUP-2852700,CDM,C1729,HCPCS,0272,RC,,,,both,,,1635.59,1063.13,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA2.7 MM TI NLCK T15 DRV NS LEOS,SUP-2931540,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.53,216.14,,,,,,,,,,,,,
PLATE BONE L227MM 18 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349643,CDM,C1713,HCPCS,0278,RC,,,,both,,,3213.32,2088.66,,,,,,,,,,,,,
GRAFT HUM TISS CARTIFORM CELL CLLGN TYP II,SUP-2319182,CDM,C1713,HCPCS,0278,RC,,,,both,,,25355.50,16481.07,,,,,,,,,,,,,
SCREW BNE L6MM DIA2MM CORT TI ST NONCANNULATED FULL THRD 0450340601] DEPUY SYNTHES USA],SUP-2181719,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.97,165.73,,,,,,,,,,,,,
HC Sclerotherapy Single Vein,PX-3613647000,CDM,36470,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
SCREW CORTICAL LOQTEQ 2.5 L12,SUP-2713866,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE RADIAL LNG WIDE LT VOLAR DSTL,SUP-2646873,CDM,C1713,HCPCS,0278,RC,,,,both,,,2410.01,1566.51,,,,,,,,,,,,,
SCREW BONE L18MM DIA3.5MM MIDFOOT VAR ANG COMPR 1ST RAY,SUP-2225406,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
WIRE BRST LOC BEAD BARB MR NDL 15CM 20GAX5CM GHIATAS,SUP-2126439,CDM,C1819,HCPCS,0278,RC,,,,both,,,118.79,77.21,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 8H RT 178MM STER,SUP-2549609,CDM,C1713,HCPCS,0278,RC,,,,both,,,5065.92,3292.85,,,,,,,,,,,,,
PLATE BNE L242MM 10 H NONSTERILE L CNDYL S STL LOK COMPR,SUP-2183115,CDM,C1713,HCPCS,0278,RC,,,,both,,,4376.25,2844.56,,,,,,,,,,,,,
DRILL ARTHSCP GLEN LATERJET,SUP-2256897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
SLEEVE HUM DIA13MM PMMA CNTR AUX MINI COMPR,SUP-2406921,CDM,C1776,CPT,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
NAIL INTRAMEDULLARY 135 DEGREE 8.5 MMX28 CM RIGHT ROSE TRIGE,SUP-2837094,CDM,C1713,HCPCS,0278,RC,,,,both,,,9167.86,5959.11,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - 10 Visits (Spouse),PX-9900000060,CDM,9900000060,LOCAL,0990,RC,,,,both,,,50.00,32.50,,,,,,,,,,,,,
BAR EXT FIX L200MM DIA6MM C FBR FOR XTRAFIX SYS,SUP-2199718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.82,477.63,,,,,,,,,,,,,
PLATE BONE L170MM 8 H BILAT S STL COBRA HD LO PROF RIG NEUT,SUP-2185807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1860.36,1209.23,,,,,,,,,,,,,
CATHETER THROMCTMY CLOTTRIEVER BOLD L 80 CM DIA 3.9 MM,SUP-2751577,CDM,C1757,HCPCS,0272,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
NAIL IM L19.5CM DIA14MM 130DEG LT FEM HIP GRN TI CANN LCK,SUP-2347889,CDM,C1713,HCPCS,0278,RC,,,,both,,,2877.50,1870.37,,,,,,,,,,,,,
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY,RX-155574,CDM,90715,HCPCS,0636,RC,58160-0842-52,NDC,,both,.5,ML,219.40,142.61,,,,,,,,,,,,,
IMPLANT VG POR FEM RGX TIB/E1/PAT,SUP-2212443,CDM,C1776,CPT,0278,RC,,,,both,,,16171.00,10511.15,,,,,,,,,,,,,
PATCH CV HEMGRD L 120 X W 8 MM THK 0.41 MM POLYESTER BOV,SUP-2535435,CDM,C1768,CPT,0278,RC,,,,both,,,847.77,551.05,,,,,,,,,,,,,
CATHETER NSL L3.25CM DIA0.265IN SIL 2 CUF EDISTAT,SUP-2284101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.45,248.59,,,,,,,,,,,,,
CATHETER HAD 11.5FR L24CM STR SIL DBL LUMN HEM CATH ST,SUP-2267081,CDM,C1751,HCPCS,0278,RC,,,,both,,,173.96,113.07,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO MEMBRN 4X4 CM DRY ALLOWRAP DRY,SUP-2717792,CDM,Q4150,HCPCS,0636,RC,,,,both,,,12265.63,7972.66,,,,,,,,,,,,,
KIT NEG PRSS FOR NONLIN OR UPTO 90CM LIN INCIS PREVENA +,SUP-2262374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
HC Ot Vasopneumatic Device Therapy|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309701600,CDM,97016,CPT,0430,RC,,,KX|CQ,both,,,206.00,133.90,,,,,,,,,,,,,
GRAFT BNE STRP 25X20X7 MM COMPRESSIBLE BNE MTRX,SUP-2644320,CDM,C1713,HCPCS,0278,RC,,,,both,,,4364.29,2836.79,,,,,,,,,,,,,
SET PICC L 55 CM DIA 5 FR SHTH L 7 CM DIA 5 FR,SUP-2886978,CDM,C1751,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
CATHETER GUID MIDWAY62 L 115 CM COAT L 30 CM DIA1.93 MM,SUP-2896795,CDM,C1887,HCPCS,0272,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
MOLD KNEE SPACER FEM ML DIA 70 MM TIB ML DIA 75 MM MED TEMP,SUP-2905382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
PLATE CRAN 160X100X40 MM PT SPEC IMPL PEEK,SUP-2860148,CDM,C1713,HCPCS,0278,RC,,,,both,,,41034.46,26672.40,,,,,,,,,,,,,
COIL EMB L48CM OD0.020IN LOOP OD13MM STD NIT COMPLX FRME,SUP-2323378,CDM,C1889,HCPCS,0278,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
BLADE SAW SAG 70X13X1.47 MM SYS 6 STRL PERF SER LTX,SUP-2862543,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.92,243.70,,,,,,,,,,,,,
BONE BIOPSY KIT HUNTINGTON GUID 18 GAX15 CM MADISON MINI,SUP-2476026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
ADAPTER EXT FIX LNG FOR 3 4 5 6MM APEX PIN HOFFMANN LRF,SUP-2363126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.83,878.04,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 9H /50MM/152MM STRL,SUP-2547719,CDM,C1713,HCPCS,0278,RC,,,,both,,,2465.65,1602.67,,,,,,,,,,,,,
MESH SURG W4XL4CM THK1.1MM ACELLULAR DERM MATRIXXENOGRAFT,SUP-2362224,CDM,C1763,HCPCS,0278,RC,,,,both,,,8258.20,5367.83,,,,,,,,,,,,,
HC Remv & Replc Pm Gen Dual,PX-4813322800,CDM,33228,CPT,0481,RC,,,,inpatient,,,36553.00,23759.45,,,,,,,,,,,,,
SONICPIN RX 16 X 5MM 2/CTG STERILE,SUP-2679385,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.79,166.91,,,,,,,,,,,,,
PLATE BNE L 56 MM SCREW DIA2.4/2.7 MM 7 HD 3 SHFT H RT DSTL,SUP-2913587,CDM,C1713,HCPCS,0278,RC,,,,both,,,5143.32,3343.16,,,,,,,,,,,,,
NEUROPEN 15.5 CM SHAFT,SUP-2854428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3177.68,2065.49,,,,,,,,,,,,,
PLATE BNE L44MM STD 2X2 H NONSTERILE R BILAT 1ST MTP FUS S,SUP-2184836,CDM,C1713,HCPCS,0278,RC,,,,both,,,2929.68,1904.29,,,,,,,,,,,,,
TACROLIMUS 5 MG/ML IV SOLN,RX-12935,CDM,J7525,HCPCS,0636,RC,00469-3016-01,NDC,,both,1,ML,1466.50,953.22,,,,,,,,,,,,,
DEXAMETHASONE 6 MG PO TABS,RX-2328,CDM,6370000000,HCPCS,0637,RC,60687-0729-11,NDC,,both,1,UN,7.20,4.68,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 2 ML W/O CEMENT DEL SYS OSSEOLFEX SB,SUP-2460443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6389.90,4153.43,,,,,,,,,,,,,
GRAFT HUM TISS L60-80MM DIA7.5-10.5MM FRZN FLEXIGRFT,SUP-2264760,CDM,C1713,HCPCS,0278,RC,,,,both,,,7567.27,4918.73,,,,,,,,,,,,,
WASHER ORTHOPEDIC FOR 4.5 MM SCR STRL EVOS,SUP-2931352,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.57,103.72,,,,,,,,,,,,,
DEVICE ABLAT BPLR LO PROF STD ALONE ELECTRD CARDIOBLATE,SUP-2278866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
NAIL IM FEM RT LCK CANN MEDIOLATERAL BEND 12MMX38CM 130DEG,SUP-2343946,CDM,C1713,HCPCS,0278,RC,,,,both,,,4932.94,3206.41,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 27MMW X 50MML SPNL MSCLE WIDE RGGLS RDM,SUP-2670371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.89,1034.73,,,,,,,,,,,,,
CEPHALEXIN 250 MG/5ML PO SUSR,RX-9502,CDM,340b,HCPCS,0637,RC,09999-9903-69,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
SHEATH TUNN L12IN DIA11GA ON-Q,SUP-2236803,CDM,C1894,HCPCS,0272,RC,,,,both,,,85.09,55.31,,,,,,,,,,,,,
INSERT TIB ROTATING HINGED 4 14 MM RT-PLUS,SUP-2450894,CDM,C1776,CPT,0278,RC,,,,both,,,2932.76,1906.29,,,,,,,,,,,,,
REAMER SURG OD21 MM SPIN GRD CUP CONE FEM,SUP-2320319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
HC Destruct Lesions Up to 14,PX-3611711000,CDM,17110,CPT,0361,RC,,,,both,,,604.00,392.60,,,,,,,,,,,,,
RASP SPINE SM INTBDY PYRAMETRIX,SUP-2292094,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.42,1324.32,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID THCK 3X2 CM AMNIO PLCNTA PRO3-C,SUP-2742029,CDM,C1762,CPT,0278,RC,,,,both,,,5517.77,3586.55,,,,,,,,,,,,,
PROBE ARTHROSCOPIC 70DEG MEASUREMENT FOR SUTURE PASSING,SUP-2766022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
SCREW BNE L9MM DIA2.3MM THOR STRNL TI LOK DRL FREE LEV 1,SUP-2262553,CDM,C1713,HCPCS,0278,RC,,,,both,,,170.00,110.50,,,,,,,,,,,,,
STENT GRFT VASC OVATION IX L 45 MM DIA PROX/DSTL 12/12,SUP-2217726,CDM,C1874,HCPCS,0278,RC,,,,both,,,13275.92,8629.35,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ LACE W STAY COCK UP FIRM SUPP,SUP-2197063,CDM,L3908,HCPCS,0274,RC,,,,both,,,27.41,17.82,,,,,,,,,,,,,
CATHETER URET 3 FRX65 CM WHSTL TIP LUER FIT ADPT,SUP-2384602,CDM,C1758,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SPLINT WRST M L7IN AD R FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276653,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.80,6.37,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED SPHINCTEROTOME WIRE GUID SGL LUMN SH NOSE 20MM CUT WIRE LEN,SUP-2141402,CDM,C1769,HCPCS,0272,RC,,,,both,,,532.36,346.03,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 20 CM EPTFE STR TW,SUP-2396153,CDM,C1768,CPT,0278,RC,,,,both,,,3246.76,2110.39,,,,,,,,,,,,,
PLATE PL DSTL HUM 2.7/3.5MM 13H LT 205MM STRL TI VA LCP,SUP-2546793,CDM,C1713,HCPCS,0278,RC,,,,both,,,4310.44,2801.79,,,,,,,,,,,,,
BUR SURG TAPR 14 CM TELE ANGLED MIDAS REX LEGEND,SUP-2281701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3037.20,1974.18,,,,,,,,,,,,,
HC Inject Trigger Point 3/> Muscle,PX-4502055300,CDM,20553,CPT,0450,RC,,,,both,,,920.00,598.00,,,,,,,,,,,,,
HC So2 Collagen Cross-Link N-Telopep,PX-3018252368,CDM,82523,CPT,0301,RC,,,,inpatient,,,254.00,165.10,,,,,,,,,,,,,
CLIP ANEUR MIC M CVD 9MM - 9MM,SUP-2243942,CDM,C1889,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
HC NM Rx IV Admin,PX-3427910100,CDM,79101,CPT,0342,RC,,,,both,,,1865.00,1212.25,,,,,,,,,,,,,
SCREW BNE L34MM DIA3.5MM SHT THRD HD MINI-MONSTER,SUP-2320508,CDM,C1713,HCPCS,0278,RC,,,,both,,,622.51,404.63,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,GP|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
SCREW BNE MYOMA 10X320 MM LAP FOR MANIPULATION,SUP-2475554,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.94,323.66,,,,,,,,,,,,,
STEM RAD L26MM DIA7MM TAN STR FOR PRI AND REV JT REPL,SUP-2181496,CDM,C1776,CPT,0278,RC,,,,both,,,8920.74,5798.48,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 22X3X1.5 MM LP CONTOURED TI SLV NS,SUP-2461351,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.17,469.41,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 3-6 MM 30 CC PRESERVON CANC READIGRAFT,SUP-2740970,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.81,812.38,,,,,,,,,,,,,
HC Ot Eval Low Complex,PX-4349716500,CDM,97165,CPT,0434,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
BUR SURG DIAMOND 2.5 MM 9 CM MTCH HD TELSCP MIDAS REX LEGEND,SUP-2632224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.69,289.70,,,,,,,,,,,,,
GRAFT SFT TISS FLOWABLE 0.3 CC 50 MG TISS MTRX INTERFYL,SUP-2651382,CDM,Q4171,HCPCS,0636,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
"HC So1 Detect Agent Nos, Dna, Amp",PX-3068779867,CDM,87798,CPT,0306,RC,,,,both,,,609.00,395.85,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ IMMOB LOOP LOK ABDUCTED,SUP-2276637,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.17,14.41,,,,,,,,,,,,,
CATHETER ANGIOPLSTY VASCUTRAK L 140 CM BALLOON L 15 CM,SUP-2128680,CDM,C1725,HCPCS,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
CLAMP CRAN L 16 MM NEURO BURR H STRL DISP LORENZ RAPIDFLAP,SUP-2935197,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
CONNECTOR ROD S STL OD55 635 MM SDLD,SUP-2279834,CDM,C1713,HCPCS,0278,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
GRAFT HUM TISS W4XL12CM THK0.9-1.99MM ACELLULAR DERM MTRX,SUP-2402508,CDM,Q4126,HCPCS,0636,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON SM 8 IN RT WRST PLUSH FOAM LNR NYL,SUP-2276664,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.86,10.96,,,,,,,,,,,,,
COMPONENT PAT RND PRI STD CEM N POR UHMWPE WITHOUTXRAY WIRE,SUP-2199556,CDM,C1776,CPT,0278,RC,,,,both,,,4245.28,2759.43,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1275108FD2,SUP-2632805,CDM,C1751,HCPCS,0278,RC,,,,both,,,739.16,480.45,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE 5X2 HOLES CRVD SQRE SGMNTS 06MM 15MM,SUP-2707407,CDM,C1713,HCPCS,0278,RC,,,,both,,,988.28,642.38,,,,,,,,,,,,,
HC So Carbohydrate Antigen 19-9|NOT REASONABLE AND NECESSARY,PX-3028630166,CDM,86301,CPT,0302,RC,,,GZ,both,,,306.00,198.90,,,,,,,,,,,,,
CATHETER PTCA L142CM BLLN L20MM DIA2MM 0.022IN 14ATM,SUP-2298377,CDM,C1725,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
KNIFE BLADE BAN 3.5 MM,SUP-2399091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
SCREW BONE CRANIO MAXILLOFACIAL CROSS FIT ST TI 2MM DIA 14MM,SUP-2363431,CDM,C1713,HCPCS,0278,RC,,,,both,,,294.44,191.39,,,,,,,,,,,,,
PLATE BNE 11 H ST L CUBOID S STL MAL LO PROF FOR 24 27MM,SUP-2177138,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.55,1630.56,,,,,,,,,,,,,
CATHETER HD STR 0.038 IN 16 FRX120 CM 19 CM DL HEMOSPLIT XK,SUP-2126520,CDM,C1881,HCPCS,0278,RC,,,,both,,,1486.95,966.52,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 17 HOLE/396MM RIGHT-STERILE,SUP-2546861,CDM,C1713,HCPCS,0278,RC,,,,both,,,5625.34,3656.47,,,,,,,,,,,,,
BUTTON SUTURE STRL FIBERTAK,SUP-2882214,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
CANNULA SHRT MULTI TIP ROTATABLE FIXATED LEVEL 1,SUP-2498540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1857.09,1207.11,,,,,,,,,,,,,
KIT PERC DILATIONAL TRACH TUBE DIA 7 MM DIL DIA14 FR SYR 5,SUP-2887178,CDM,C1769,HCPCS,0272,RC,,,,both,,,1243.00,807.95,,,,,,,,,,,,,
COMPONENT TALAR SZ 4 POLYETH L R ANK PRI CEM DOME SADL,SUP-2397093,CDM,C1776,CPT,0278,RC,,,,both,,,8503.12,5527.03,,,,,,,,,,,,,
SPACER FEM M H10MM DSTL RNG TERM SEG ENDO-MODEL-M,SUP-2265089,CDM,C1776,CPT,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
LENS IOL BCNVX 22+ DIOPT 12.5 MM PMMA PLEXIGLAS,SUP-2129725,CDM,C1780,HCPCS,0276,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY SM AD 4.25 IN 10-13 IN PHILADELPHIA,SUP-2319297,CDM,L0172,HCPCS,0274,RC,,,,both,,,30.52,19.84,,,,,,,,,,,,,
ANCHOR SUTURE NO2 LNG HIP SOFT SINGLE LOADED JUGGERKNOT,SUP-2589014,CDM,C1713,HCPCS,0278,RC,,,,both,,,1160.54,754.35,,,,,,,,,,,,,
DEVICE THROMCTMY L200CM L155CM OD.028IN REPERFUSION CATH,SUP-2323632,CDM,C1757,HCPCS,0272,RC,,,,both,,,7190.60,4673.89,,,,,,,,,,,,,
SPLINT FNGR L L3.25IN ALUM PD LTWT COT,SUP-2196692,CDM,L3809,HCPCS,0272,RC,,,,both,,,2.32,1.51,,,,,,,,,,,,,
PLATE BNE 5DEG THK1.6MM M R MT REV GORILLA,SUP-2321477,CDM,C1713,HCPCS,0278,RC,,,,both,,,6648.95,4321.82,,,,,,,,,,,,,
OSS 3CM RESURFACING RT,SUP-2506331,CDM,C1776,CPT,0278,RC,,,,both,,,18510.30,12031.69,,,,,,,,,,,,,
BLADE ELECSURG 4.5 MM RESECT FULL RAD ELECTROBLADE,SUP-2848578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
COUNTERSINK SURG OD3MM HD SGL USE MONSTER,SUP-2320962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
DEVICE ASPIRATION ALPHAVAC MULTIPURPOSE,SUP-2855524,CDM,C1757,HCPCS,0272,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
PLATE BNE L286MM 14 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185687,CDM,C1713,HCPCS,0278,RC,,,,both,,,4966.79,3228.41,,,,,,,,,,,,,
CATHETER VALVULOPLASTY SHFT L110CM SHTH DIA11FR BLLN L3.5CM,SUP-2128491,CDM,C1725,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC STD 14.5FR DIA 36CM,SUP-2613302,CDM,C1750,HCPCS,0278,RC,,,,both,,,1658.39,1077.95,,,,,,,,,,,,,
HC Drain Pilonidal Cyst,PX-4501008100,CDM,10081,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
STAPLE ENDOSCP BIOABSORB LN REINF ENDOPATH SEAMGUARD BLK,SUP-2716235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.34,340.17,,,,,,,,,,,,,
VALVE AORT CARBOMEDICS DIA20.5 MM TAD 20.5 MM OH 7.7 MM SZ,SUP-2265217,CDM,C1889,HCPCS,0278,RC,,,,both,,,14990.36,9743.73,,,,,,,,,,,,,
SHEATH DIL EVOLUTION L 40.6 CM OD 19 FR ID 11 FR SS MECH SET,SUP-2170519,CDM,C1773,HCPCS,0272,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
SHEATH DEL AMULET L 75 CM DIA14 FR LAA STEER STRL,SUP-2893216,CDM,C1766,CPT,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
STENT EVAR L80MM DIA8MM DST TRNSJUG BARE MTL INTRAHEPATIC,SUP-2395924,CDM,C1874,HCPCS,0278,RC,,,,both,,,12867.72,8364.02,,,,,,,,,,,,,
GRAFT BNE SM DIA20-43MM FEM FRZ DRY,SUP-2307305,CDM,C1713,HCPCS,0278,RC,,,,both,,,3914.42,2544.37,,,,,,,,,,,,,
PLATE BONE 10 H ANTR BOW LAT PROX FOR 4.5 SCR,SUP-2349066,CDM,C1713,HCPCS,0278,RC,,,,both,,,995.47,647.06,,,,,,,,,,,,,
STAPLER INT L34CM 60MM LNG ENDOSCP ARTC PWR + ECHELON FLX,SUP-2219817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1134.54,737.45,,,,,,,,,,,,,
BIT DRL DIA4MM DISP FOR TIBIOTALOCALCANEAL FUS SYS DYNANAIL,SUP-2277481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
DEVICE INFUS 8.5FR L3.5IN EMGCY RADPQ FEP SHTH 17GAX5.5IN,SUP-2383450,CDM,C1894,HCPCS,0272,RC,,,,both,,,96.40,62.66,,,,,,,,,,,,,
PROVEN REV TIB INSRT SZ 3 14 MM,SUP-2359249,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SMALL PLATE 20X242MM 3.5MM,SUP-2818810,CDM,C1713,HCPCS,0278,RC,,,,both,,,4279.35,2781.58,,,,,,,,,,,,,
KIT ARTHRO HIP W/ BAN BLDE DISP,SUP-2121998,CDM,C1769,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
ROD SPNL POST R CRV SMOOTH TI ALLY PREBENT 5.5MM DIA 55MM,SUP-2415857,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SLING ORTH FNGR 3 IN DYN REINF EYELET SUP-R-SOFT LF,SUP-2477659,CDM,L3933,HCPCS,0274,RC,,,,both,,,2.70,1.75,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA18MM ANK FT BAYNT W O STPR ELEMENT,SUP-2316138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.81,233.88,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 30X0.6 MM RIGID TI SLV NS,SUP-2859911,CDM,C1713,HCPCS,0278,RC,,,,both,,,2426.59,1577.28,,,,,,,,,,,,,
COVER BURR HOLE 03MM 22MM DIA CMMRCLLY PURE TTNM C3 LOW PRF,SUP-2669084,CDM,C1713,HCPCS,0278,RC,,,,both,,,1656.00,1076.40,,,,,,,,,,,,,
"HC Insert Picc Cath, 5/> Yrs",PX-3613656900,CDM,36569,CPT,0361,RC,,,,both,,,1231.00,800.15,,,,,,,,,,,,,
DEFIBRILLATOR CARD 31.5CC W2.43XH2.69-2.89IN THK0.39IN 72GM,SUP-2149198,CDM,C1721,HCPCS,0275,RC,,,,both,,,38772.72,25202.27,,,,,,,,,,,,,
EYE STREAM OP SOLN,RX-2999,CDM,6370000000,HCPCS,0637,RC,00065-0530-01,NDC,,both,30,ML,89.80,58.37,,,,,,,,,,,,,
HC So Acetone Assay,PX-3078201066,CDM,82010,CPT,0307,RC,,,,inpatient,,,116.00,75.40,,,,,,,,,,,,,
FIBER LASER 1000UM HOLM SMRT ID SYS REUSE FOR ALL LUMENIS LASER,SUP-2141792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3123.45,2030.24,,,,,,,,,,,,,
CONNECTOR SPNL CROSS SM 39-46MM,SUP-2354726,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
SCREW BNE L70MM DIA5MM CORT G TI ST LOK FULL THRD T25,SUP-2189537,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.03,369.87,,,,,,,,,,,,,
PISTON OTO KRAUS 0.6X4.7 MM 2.75 MM K-HELIX TI,SUP-2485850,CDM,L8613,CPT,0278,RC,,,,both,,,1480.54,962.35,,,,,,,,,,,,,
TRAY HEMODIALYSI W/O CATH FEN DRP GLOVEX1PR PROVIDONE SWBX3S,SUP-2613238,CDM,C1752,HCPCS,0278,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
SCREW BNE 1.5 MM TI NS,SUP-2189273,CDM,C1713,HCPCS,0278,RC,,,,both,,,161.43,104.93,,,,,,,,,,,,,
MESH HERN 13.2X10.2 IN ABD W/ ECHO PS POS SYS COMPOSIX L/P,SUP-2126097,CDM,C1781,HCPCS,0278,RC,,,,both,,,5815.28,3779.93,,,,,,,,,,,,,
ROD IM LNG DSTL LCS HP,SUP-2453499,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
PLATE BONE L59MM 5 H FIB TI STR LCK FOR 2.7/3/3.5/4MM SCR,SUP-2420143,CDM,C1713,HCPCS,0278,RC,,,,both,,,4282.80,2783.82,,,,,,,,,,,,,
SHELL ACET SZ B OD42MM ID22MM TI ALLOY POR NO H REFLCT,SUP-2344928,CDM,C1776,CPT,0278,RC,,,,both,,,6704.69,4358.05,,,,,,,,,,,,,
SET SCR SPNL HEX G4 CDH SEXTANT II,SUP-2288456,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.20,427.18,,,,,,,,,,,,,
MOLD KNEE SPACER FEM ML DIA 70 MM AP DIA 48 MM TIB ML DIA 75,SUP-2905380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER HAD L15CM OD11.5FR POLYUR ACUTE 2 LUMN STR TAPR,SUP-2267104,CDM,C1752,HCPCS,0278,RC,,,,both,,,111.53,72.49,,,,,,,,,,,,,
SHOE ORTHOT CALIP PLATE NEW TRANSFER,SUP-2435746,CDM,L3610,HCPCS,0274,RC,,,,both,,,284.45,184.89,,,,,,,,,,,,,
STAR TUMOR ABLATION KIT 1015 WITH POWERCURVE SHRT,SUP-2677281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
PLATE BONE L213MM 11 H S STL BROAD NONLOCKING COMPR CNTOUR,SUP-2348974,CDM,C1713,HCPCS,0278,RC,,,,both,,,2610.25,1696.66,,,,,,,,,,,,,
CONNECTOR SPNL PARA ROD 35 635 DBL SIERRA,SUP-2245453,CDM,C1713,HCPCS,0278,RC,,,,both,,,108.27,70.38,,,,,,,,,,,,,
GRAFT BNE STRP 100X20X5 MM DBM FIBER,SUP-2860952,CDM,C1713,HCPCS,0278,RC,,,,both,,,10409.10,6765.91,,,,,,,,,,,,,
SEGMENT EXT FIX MOD RT FOR RED II ALUM 515800204,SUP-2463039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7770.28,5050.68,,,,,,,,,,,,,
HC Place Cath Vertebral Art,PX-3613622600,CDM,36226,CPT,0361,RC,,,,both,,,5589.00,3632.85,,,,,,,,,,,,,
DRILL TWST DENT 1.0MM W/ STP,SUP-2419547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SET INTRO V-STICK DIA 4 FR 7 CM NIT COAX NONECHOGENIC STD,SUP-2269622,CDM,C1769,HCPCS,0272,RC,,,,both,,,120.89,78.58,,,,,,,,,,,,,
HC Heparin Assay,PX-3058552000,CDM,85520,CPT,0305,RC,,,,outpatient,,,200.00,130.00,,,,,,,,,,,,,
FOSINOPRIL SODIUM 10 MG PO TABS,RX-10094,CDM,6370000000,HCPCS,0637,RC,69097-0856-05,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIT DRL L195MM DIA4.3MM S STL FOR NCB SYS,SUP-2411439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
LEAD PACE CAPSUR L 53 CM DIA 6.6 FR SIL PLAT INSUL STEROID,SUP-2281967,CDM,C1898,HCPCS,0275,RC,,,,both,,,1024.71,666.06,,,,,,,,,,,,,
PLATE BNE L293MM THK3.4MM 22 H BILAT S STL STR LOK COMPR,SUP-2185159,CDM,C1713,HCPCS,0278,RC,,,,both,,,2265.82,1472.78,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBX MIX FRZ DRY FOR VOID FILL,SUP-2307003,CDM,C1713,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
CEFAZOLIN SODIUM 3 G IV SOLR,RX-162907,CDM,J0688,HCPCS,0636,RC,00143-9140-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
COMPONENT CARPOMETACARPAL 40 MED NUGRIP,SUP-2610448,CDM,C1776,CPT,0278,RC,,,,both,,,7501.37,4875.89,,,,,,,,,,,,,
PLATE CRAN 140X100X40 MM PT SPEC IMPL PEEK,SUP-2860147,CDM,C1713,HCPCS,0278,RC,,,,both,,,38882.62,25273.70,,,,,,,,,,,,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,2500000003,HCPCS,0250,RC,00409-6695-11,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE SM W38XL50MM THK0.6MM R CRANIOFACIAL TIIUM MESH,SUP-2366475,CDM,C1713,HCPCS,0278,RC,,,,both,,,3866.94,2513.51,,,,,,,,,,,,,
PLATE BNE 3.5X69 MM POSTEROMEDIAL PROX TIB STRL LCP,SUP-2432242,CDM,C1713,HCPCS,0278,RC,,,,both,,,3648.15,2371.30,,,,,,,,,,,,,
DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % EX CREA,RX-16299,CDM,6370000000,HCPCS,0637,RC,45802-0358-03,NDC,,both,28,GR,9.80,6.37,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA3.2MM THRD TIP FOR FEM NAIL PEDINAIL,SUP-2318959,CDM,C1769,HCPCS,0272,RC,,,,both,,,1016.42,660.67,,,,,,,,,,,,,
SET TRAC L SPINE EXT BRACING PROD ADJ CRWN BREMER HALO SYS,SUP-2255769,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT HUM TISS L 50 MM DIA 4 CM CORTICAL FIB SHFT SEG FD,SUP-2913399,CDM,C1762,CPT,0278,RC,,,,both,,,2267.08,1473.60,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL APRON,SUP-2435545,CDM,L0470,HCPCS,0274,RC,,,,both,,,1862.77,1210.80,,,,,,,,,,,,,
AMOXICILLIN 400 MG/5ML PO SUSR,RX-25246,CDM,340b,HCPCS,0637,RC,00143-9887-75,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
SCREW BNE L7MM OD2MM TI CRANIOMAXILLOFACIAL SELF DRLING SELF,SUP-2262792,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.44,114.69,,,,,,,,,,,,,
SCREW BONE L70MM DIA6.5MM CANC PARTIALLY THRD S STL,SUP-2348928,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.25,170.46,,,,,,,,,,,,,
KIT PICC DIA1.9 FR POLYUR COMPLETE 2 LUMEN CATH PEELWY INTRO,SUP-2911900,CDM,C1751,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SYSTEM DRNAGE 1 4IN ORTH REINFUS W PVC DRN AND 2 TROCARS,SUP-2125935,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.93,364.60,,,,,,,,,,,,,
KIT SUTURE ANCHR DIA 4.5 MM PEEK KNOTLESS BRIDGELINE TAPE,SUP-2899051,CDM,C1713,HCPCS,0278,RC,,,,both,,,3099.97,2014.98,,,,,,,,,,,,,
GUIDEWIRE ORTH 15MMX14IN NIT,SUP-2137207,CDM,C1769,HCPCS,0272,RC,,,,both,,,203.97,132.58,,,,,,,,,,,,,
MESH DERM IMPL SFT TISS MTRX PORCINE 6X8CM INTEXEN LP,SUP-2140305,CDM,C1781,HCPCS,0278,RC,,,,both,,,2669.79,1735.36,,,,,,,,,,,,,
CRYOABLATION KIT PROST ICESEED,SUP-2225658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11480.63,7462.41,,,,,,,,,,,,,
FOOTPLATE EXT FIX ROT TOT ANK INVISION,SUP-2481355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5601.76,3641.14,,,,,,,,,,,,,
"HC So Ca 15-3, (27.29)",PX-3028630066,CDM,86300,CPT,0302,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
REPAIR KIT 3.5 MM KNOTLESS SYS W/ INSRTR W/O DRL ACU-SINCH,SUP-2857597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.88,1922.62,,,,,,,,,,,,,
CATHETER MNOMTR AIR CHARGED ANORECT,SUP-2265006,CDM,C1713,HCPCS,0278,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
VALVE MI H19MM DIA27MM ORIFICE DIA24MM SUT RNG DIA35MM,SUP-2282629,CDM,C1889,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
PLATE BONE CRANIAL 6 HOLE DOUBLE SQUARE 24X14MM TITANIUM NEU,SUP-2821911,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.68,168.79,,,,,,,,,,,,,
CATHETER DRAINAGE INTRO 27 FRX61 CM MULTI XL BIO-MEDICUS LS,SUP-2745341,CDM,C1729,HCPCS,0272,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
CATHETER CV KT 7 FRX16 CM DL PRESSURE INJ INTRO INJ NDL,SUP-2763324,CDM,C1751,HCPCS,0278,RC,,,,both,,,328.44,213.49,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED 3 PART CEM TRAB MEL,SUP-2212529,CDM,C1776,CPT,0278,RC,,,,both,,,16009.29,10406.04,,,,,,,,,,,,,
WIRE EXT FIX REDUCTION LNG 2X400 MM MR SAFE,SUP-2176963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS SET 035X30 CM PEDIATRIC 8.5 FRX8 CM,SUP-2760088,CDM,C1752,HCPCS,0278,RC,,,,both,,,435.30,282.94,,,,,,,,,,,,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-118040,CDM,J1171,HCPCS,0636,RC,00703-0110-01,NDC,,both,0.2,ML,54.10,35.16,,,,,,,,,,,,,
TUBE VENT MOD ARMSTR 1.14 MM 1.14 MM 2.54 MM FLROPLAS 525181,SUP-2478107,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.15,24.80,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 10H 159MM RIGHT-STER,SUP-2549550,CDM,C1713,HCPCS,0278,RC,,,,both,,,3543.05,2302.98,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED XL PRIORITY + PEEK NS LTX,SUP-2862818,CDM,C1713,HCPCS,0278,RC,,,,both,,,68949.88,44817.42,,,,,,,,,,,,,
PROSTHESIS PENILE L18CM MINOCYCLINE RIFAMPIN INHIBIZONE,SUP-2140258,CDM,C1813,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
GRAFT ENDOVASC L142MM DIA32MM INTRO SHTH OD7.7MM ID6.7MM,SUP-2419732,CDM,C1768,CPT,0278,RC,,,,both,,,54202.68,35231.74,,,,,,,,,,,,,
CATHETER DIAG SZ 7FRX115CM 20 ELECTRD 2-6-2 SPC D CRV MAP HI,SUP-2248709,CDM,C1730,HCPCS,0272,RC,,,,both,,,5639.44,3665.64,,,,,,,,,,,,,
COIL NEUROVASCULAR COSMOS 10 L 2 CM LOOP DIA2 MM,SUP-2305321,CDM,C1889,HCPCS,0278,RC,,,,both,,,4998.88,3249.27,,,,,,,,,,,,,
GUIDEWIRE ORTH 0.9 MMX6 IN,SUP-2663619,CDM,C1769,HCPCS,0272,RC,,,,both,,,44.84,29.15,,,,,,,,,,,,,
"HC US Transvaginal, Non OB",PX-4027683000,CDM,76830,CPT,0402,RC,,,,both,,,1439.00,935.35,,,,,,,,,,,,,
HC Asp Inj Intermediate Joint,PX-4502060500,CDM,20605,CPT,0450,RC,,,,inpatient,,,358.00,232.70,,,,,,,,,,,,,
GRAFT BNE PASTE 5 CC SYR DBM GRFT + 45005P] MEDTRONIC USA INC],SUP-2278375,CDM,C9359,HCPCS,0278,RC,,,,both,,,1782.26,1158.47,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 10FR GUIDEWIRE CORONARY,SUP-2385283,CDM,C1894,HCPCS,0272,RC,,,,both,,,35.58,23.13,,,,,,,,,,,,,
COLLAR CERV UNIV AD L13-19IN TRACH OPN TWO PC RIG POLYETH,SUP-2124202,CDM,L0120,HCPCS,0274,RC,,,,both,,,115.05,74.78,,,,,,,,,,,,,
TOOL PACE ACUITY X4 PSA TO IS4 CONN STRL,SUP-2140129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TOOL IMPL FASTAC FLX LD,SUP-2138084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
MESH PLUG PERFIX LT 1 IN X 1.4 IN SM,SUP-2125786,CDM,C1781,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
SET INSTR FOR SCR REM,SUP-2183079,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TRIAL PLATE COMPR 0.8 MM 6 HOLE,SUP-2525714,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
PLATE BNE W17.5XL106MM THK5.2MM 6 H BILAT S STL BROAD LIMIT,SUP-2185285,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.36,656.73,,,,,,,,,,,,,
HC So Thrombin Clotting Level,PX-3058567066,CDM,85670,CPT,0305,RC,,,,outpatient,,,122.00,79.30,,,,,,,,,,,,,
KIT TRACH PERC DIL FULL COMP LOC ANES W O TB PORTEX,SUP-2351756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.00,455.00,,,,,,,,,,,,,
PLATE SPNL SM L35MM TI POST OFFSET BILAT CD HORZ,SUP-2291780,CDM,C1713,HCPCS,0278,RC,,,,both,,,24570.50,15970.82,,,,,,,,,,,,,
STRIPPER 365 MU SLM LN,SUP-2140359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
DRESSING BIO W4XL10IN BOV CLLGN AND GLYCOSAMINOGLYCAN,SUP-2243933,CDM,Q4104,HCPCS,0636,RC,,,,both,,,9624.10,6255.66,,,,,,,,,,,,,
COMPRESSOR GRP FOR INSTR SYS TENOR,SUP-2289253,CDM,C1713,HCPCS,0278,RC,,,,both,,,6587.72,4282.02,,,,,,,,,,,,,
KIT HAMRTOE CORR STP DRL 16 28 35MM PROX MID PHALANX RMR,SUP-2137575,CDM,C1713,HCPCS,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
PLATE BNE STD EXT LG MEDL LT CLMN FUSION SS STRL SOLE MCF,SUP-2875507,CDM,C1713,HCPCS,0278,RC,,,,both,,,13260.38,8619.25,,,,,,,,,,,,,
DUAL POCKETLOCK COUNTSINK,SUP-2400569,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
JOINT SUBTALAR 9 MM TI MBA,SUP-2244067,CDM,C1776,CPT,0278,RC,,,,both,,,7473.20,4857.58,,,,,,,,,,,,,
CARBAMAZEPINE 100 MG PO CHEW,RX-1355,CDM,6370000000,HCPCS,0637,RC,00904-3854-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER DEL SYS 8 FRX47 CM APEEL CS,SUP-2357688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SCREW BNE COMPR FOR MULT LCK HUM NAILING SYS NAIL NS,SUP-2799397,CDM,C1713,HCPCS,0278,RC,,,,both,,,1887.83,1227.09,,,,,,,,,,,,,
VALGANCICLOVIR HCL 50 MG/ML PO SOLR,RX-101365,CDM,340b,HCPCS,0637,RC,27241-0159-19,NDC,,both,9,ML,368.40,239.46,,,,,,,,,,,,,
WIRE ORTH THRD SGL SHRP TIP TRCR S STL NONSTERILE 1.4MM DIA,SUP-2363709,CDM,C1713,HCPCS,0278,RC,,,,both,,,29.83,19.39,,,,,,,,,,,,,
ICP KIT AD PLAS DISP,SUP-2666389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1110.37,721.74,,,,,,,,,,,,,
SCREW BNE RESRB,SUP-2608838,CDM,C1713,HCPCS,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
HC Asp Injection Major Joint|BILATERAL PROCEDURE,PX-4502061000,CDM,20610,CPT,0450,RC,,,50,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
HC So1 T-3 Uptake,PX-3018447967,CDM,84479,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
AUGMENT FEM L59MM THICKNESS 5MM UNIV STD DSTL KNEE PRI CEM,SUP-2199922,CDM,C1776,CPT,0278,RC,,,,both,,,5735.21,3727.89,,,,,,,,,,,,,
MESH HERN OVL 10X8 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855273,CDM,C1781,HCPCS,0278,RC,,,,both,,,27867.50,18113.87,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST W/NONTORSION JT PREFABRICATED,SUP-2435776,CDM,L3915,HCPCS,0272,RC,,,,both,,,1369.64,890.27,,,,,,,,,,,,,
MESH HERN W8XL9CM POLY ABSRB CLLGN FLM COMP HRSHOE SHP FOR,SUP-2174721,CDM,C1781,HCPCS,0278,RC,,,,both,,,2215.65,1440.17,,,,,,,,,,,,,
GRAFT VASC L20CM ID12MM STR RING STD WALL STR IMP GORTX,SUP-2396026,CDM,C1768,CPT,0278,RC,,,,both,,,2100.66,1365.43,,,,,,,,,,,,,
CAP ORTHOPEDIC LCK STRL NCB,SUP-2470569,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
CAGE SPNL 45X22X10 MM MODULUS XLW,SUP-2559259,CDM,C1889,HCPCS,0278,RC,,,,both,,,16579.20,10776.48,,,,,,,,,,,,,
COMPONENT PAT L+ 3PEG RND REV ROT NP CEM WITHOUTXRAY WIRE,SUP-2252425,CDM,C1776,CPT,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BNE TARGETING GUIDE PROX HUM B LBL SYS CASE AFFIXUS,SUP-2606196,CDM,C1713,HCPCS,0278,RC,,,,both,,,17144.40,11143.86,,,,,,,,,,,,,
DRAINAGE SET LUMBAR INTEGR 1 PC ASMBLY M LL CONN EXAFLOW,SUP-2666670,CDM,C1729,HCPCS,0272,RC,,,,both,,,643.67,418.39,,,,,,,,,,,,,
VALVE AORT SZ 19MM BOV PERICARD TRANSCATHETER STENTED N ROT,SUP-2214330,CDM,C1889,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
BLADE RTRCTR 14MMW X 35MML SPNL BALL SNAP CNTR FMCRO LMBR D,SUP-2667434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1040.50,676.32,,,,,,,,,,,,,
SCREW BONE L150MM DIA6.5MM THRD L24MM HD DIA8MM CANC S STL,SUP-2184599,CDM,C1713,HCPCS,0278,RC,,,,both,,,143.40,93.21,,,,,,,,,,,,,
GRAFT STENT IL LIMB EXTN 4X14X100 MM 13 FR OVATION IX AAA,SUP-2427395,CDM,C1874,HCPCS,0278,RC,,,,both,,,13275.92,8629.35,,,,,,,,,,,,,
SHEATH INTRO BAN PEEL L 30 CM DIA12 FR STRL,SUP-2141073,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.08,104.05,,,,,,,,,,,,,
NAIL INTRMDLLRY LOK CNNLTD UNVRSL 9MM DIA 300MML TTNM ALLOY,SUP-2587505,CDM,C1713,HCPCS,0278,RC,,,,both,,,4384.48,2849.91,,,,,,,,,,,,,
SHELL ACET SZ F DIA56MM MH OSSEOTI 2 MOBILITY G7,SUP-2403479,CDM,C1713,HCPCS,0278,RC,,,,both,,,7950.48,5167.81,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST W/NONTORSION JT PREFABRICATED,SUP-2435786,CDM,L3929,HCPCS,0272,RC,,,,both,,,235.31,152.95,,,,,,,,,,,,,
TAP SURG DIA5MM 2 LD,SUP-2256858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
PSN REV 3MM OFFSET STEM EXT 24X135MM,SUP-2508810,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
CHLORDIAZEPOXIDE HCL 25 MG PO CAPS,RX-1623,CDM,6370000000,HCPCS,0637,RC,51079-0141-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT PERIPH L200MM DIA6MM CATH L120CM 6FR 0.035IN,SUP-2173214,CDM,C1876,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PLATE BNE W10.1XL112MM THK3.5MM 8 H BILAT TI STR RIG LOK,SUP-2191083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1611.67,1047.59,,,,,,,,,,,,,
KIT TKR TRABECULAR MTL FEM TIB PAT AND PROLONG SURF PERSONA,SUP-2212238,CDM,C1776,CPT,0278,RC,,,,both,,,18252.82,11864.33,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INCEPTA VR W 6.9 X H 6.17 CM D 0.99 CM TI,SUP-2149200,CDM,C1722,HCPCS,0275,RC,,,,both,,,38003.42,24702.22,,,,,,,,,,,,,
DILATOR SURG PRB 14.5 MM AVS ARIA,SUP-2524283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2186.32,1421.11,,,,,,,,,,,,,
HC CT Soft Tissue Neck W/ Contrast,PX-3517049100,CDM,70491,CPT,0351,RC,,,,both,,,2388.00,1552.20,,,,,,,,,,,,,
HC So Phosphatase Isoenzymes,PX-3018408066,CDM,84080,CPT,0301,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
STRATOGEN MEM 4 X 4 CM,SUP-2164201,CDM,Q4139,HCPCS,0636,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SPLINT KNEE L26IN CIRC 36IN UNIV AD IMMOB FIT MOST WRP ARND,SUP-2197157,CDM,L1830,CPT,0274,RC,,,,both,,,51.90,33.73,,,,,,,,,,,,,
CATHETER DRNGE 6.5FR 15CM GEN TOT ABSCESSION,SUP-2118556,CDM,C1729,HCPCS,0272,RC,,,,both,,,213.96,139.07,,,,,,,,,,,,,
NEEDLE BX RAMEL PLEURAL PNCH,SUP-2772934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1127.67,732.99,,,,,,,,,,,,,
TUBE TRACH AD L130MM OD11.7MM ID8MM SIL CUF ADJ NK FLNG,SUP-2352038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.41,387.67,,,,,,,,,,,,,
GUIDE WIRE PLUNGER,SUP-2814356,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BONE COMPRESSION BROAD 324 MM PELVIC 18 HOLE CONTOURED,SUP-2837531,CDM,C1713,HCPCS,0278,RC,,,,both,,,3822.48,2484.61,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X2 CM BLOCKADE AMNIO PROTCT BARR,SUP-2538793,CDM,C1762,CPT,0278,RC,,,,both,,,7699.28,5004.53,,,,,,,,,,,,,
MESH RESTRATA 10.0CM X 12.5CM,SUP-2874127,CDM,A2007,HCPCS,0636,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|ADJ|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|ADJ|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
COMPONENT PAT RND PRI STD PRESSFIT POR WITHOUT XRAY WIRE,SUP-2199554,CDM,C1776,CPT,0278,RC,,,,both,,,8706.59,5659.28,,,,,,,,,,,,,
MICROCATHETER GUID L153CM OD2.8X2.3FR ID0.021IN GWIRE,SUP-2172488,CDM,C1887,HCPCS,0272,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
PLATE BNE L349MM 14 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186064,CDM,C1713,HCPCS,0278,RC,,,,both,,,5052.61,3284.20,,,,,,,,,,,,,
NUT FIX 13.8MM MULT AX HEX,SUP-2415295,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.66,413.18,,,,,,,,,,,,,
WIRE K 1.4MM DISP,SUP-2152540,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
LEVEL CMF PLATE MDFCE CVD WTAB 1.5 MM SCRW12 HOLE T0.4 MM C,SUP-2681870,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
GRAFT BNE 5 CC DEMINERALIZED CORTICAL SUBSTITUTE FIBERS FD,SUP-2931240,CDM,C1762,CPT,0278,RC,,,,both,,,3428.66,2228.63,,,,,,,,,,,,,
SCREW MULTIDIRECTION 3.8X30MM,SUP-2414103,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
LINER CAST PADDING 6 PEDIATRIC HIP WTRPRF EPTFE SPICA SKINZ,SUP-2315939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
STEM FEM L217MM OD13MM BOW TRI SLOT PLSM SPRAYED HA DST HIP,SUP-2375884,CDM,C1776,CPT,0278,RC,,,,both,,,8991.70,5844.60,,,,,,,,,,,,,
SCREW BNE 4.5X28 MM MOTIONLOC,SUP-2606804,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
HC Cul Bact Quan Aerobic Isol Xcpt UR Blood/Stool,PX-3068707100,CDM,87071,CPT,0306,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|CO|XU,both,,,144.00,93.60,,,,,,,,,,,,,
LEVEL NEURO MESH SPCLTY KSSM SCRN MESH PANEL RGLR 3MM CP TT,SUP-2681097,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.69,604.30,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 10%,RX-430005,CDM,J1459,HCPCS,0636,RC,44206-0437-10,NDC,,both,100,ML,5659.90,3678.93,,,,,,,,,,,,,
RELOAD STPL L45MM M THCK REINF FOR SIGNIA STPLR TRI-STPL,SUP-2174748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2468.57,1604.57,,,,,,,,,,,,,
STENT COR 28MM 3.5MM S STL PACLITAXEL DRUG ELUT RAP,SUP-2140748,CDM,C1874,HCPCS,0278,RC,,,,both,,,8267.62,5373.95,,,,,,,,,,,,,
CAP PROTCT EXT FIX 5X4.5 MM TRANSFX,SUP-2362753,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
PIN FIX L102MM OD32MM TOT ANK SYS INFIN,SUP-2397265,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
VALVE SHUNT W/ PRECHAMBER 4/19 PAEDIGAV,SUP-2846936,CDM,C1889,HCPCS,0278,RC,,,,both,,,5141.91,3342.24,,,,,,,,,,,,,
TRIAL TIB 11MM SM S1 A/P LIP CONSTRN DURAC,SUP-2364860,CDM,C1776,CPT,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PATCH CV HEMGRD L 150 X W 25 MM THK 0.41 MM POLYESTER BOV,SUP-2535423,CDM,C1768,CPT,0278,RC,,,,both,,,563.32,366.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.553,SUP-2860070,CDM,C1713,HCPCS,0278,RC,,,,both,,,70944.85,46114.15,,,,,,,,,,,,,
SCREW BNE 3X16 MM,SUP-2321703,CDM,C1713,HCPCS,0278,RC,,,,both,,,762.71,495.76,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC DEMINERALIZED CORT CANC BNE FIBER,SUP-2905181,CDM,C1713,HCPCS,0278,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
KIT PMP 100ML 2ML/HR CATH L1IN ANTIMIC SIL COAT ON-Q,SUP-2236842,CDM,C9804,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SHEATH INTRO VASCU-SHEATH II L 14 CM DIA11 FR PTFE VLV,SUP-2905226,CDM,C1892,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
PLATE BNE W35XL35MM THK05MM ST R ORBIT FLR CP TI GRID SMRT,SUP-2262596,CDM,C1713,HCPCS,0278,RC,,,,both,,,4197.33,2728.26,,,,,,,,,,,,,
TRAY CATH PICC LUMENX3 6FR DIA 60CML PRPHRL W/0.018IN STRGHT,SUP-2613395,CDM,C1751,HCPCS,0278,RC,,,,both,,,360.47,234.31,,,,,,,,,,,,,
CATHETER URET OPN END FLEXI-TIP,SUP-2836004,CDM,C1758,HCPCS,0278,RC,,,,both,,,167.77,109.05,,,,,,,,,,,,,
BIT DRILL JLATCH 2.2X135 MM 20 MM,SUP-2841965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2942.81,1912.83,,,,,,,,,,,,,
HC Autolog Prp Diab Wound Ulcer,PX-3610046500,CDM,G0465,CPT,0361,RC,,,,outpatient,,,4802.00,3121.30,,,,,,,,,,,,,
SYRINGE (DISPOSABLE) 5 ML MISC,RX-11482,CDM,2500000003,HCPCS,0250,RC,08290-3096-46,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PROSTHESIS PENILE L4CM DIA12MM CYL POSITIONABLE MALL DURA II,SUP-2140242,CDM,C1813,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SUTURE NONABSORBABLE MONOFILAMENT CV-6 TT-09 36 IN DA 6N02B,SUP-2395546,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.20,542.23,,,,,,,,,,,,,
MATRIX BIO L 10 X W 7 CM FISH SKIN DERMAL FEN INTACT STRL,SUP-2909285,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12974.48,8433.41,,,,,,,,,,,,,
IMPLANT PHLANG 10 FOREFOOT GREAT TOE SYS MOV,SUP-2244247,CDM,C1776,CPT,0278,RC,,,,both,,,7768.64,5049.62,,,,,,,,,,,,,
PLATE BNE 8 H ANK TI UNIV STR BILAT LOK COMPR FOR 35 4MM SCR,SUP-2398386,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
BIT DRILL 1.5X82 MM 10 MM WITH STOP FOR J LATCH TITANIUM NON,SUP-2837610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.82,417.18,,,,,,,,,,,,,
STEM HUM 13 MM SHLDR REUNION RFX,SUP-2451924,CDM,C1776,CPT,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
HFN A/R SCREW 60MM STER,SUP-2588685,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.79,486.06,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 2 END 0.035X6 IN STRL,SUP-2846262,CDM,C1769,HCPCS,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
CONNECTOR SPNL L13MM CROSS 1 STP GTT LCK DSGN FOR STPL SYS,SUP-2229612,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
STENT PERIPH L100MM DIAM 6MM CATH L120CM VASC W/ RADPQ MRK,SUP-2396600,CDM,C1874,HCPCS,0278,RC,,,,both,,,10748.22,6986.34,,,,,,,,,,,,,
PLATE BNE RECON 3.5X156 MM 12 HOLE W/ WIDE ANGLE STR LP NS,SUP-2799215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1607.27,1044.73,,,,,,,,,,,,,
HC So Hba1/Ahb2 Alpha Globulin,PX-3108125766,CDM,81257,CPT,0310,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
CATHETER EP 7FR L115CM 2-8-2MM SPC TIP 2MM 10 ELECTRD FJ,SUP-2248492,CDM,C1730,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 16 HOLES,SUP-2549478,CDM,C1713,HCPCS,0278,RC,,,,both,,,3159.72,2053.82,,,,,,,,,,,,,
HOOK SPNL DIA8MM PEDCL TI CLOSE W BLDE FOR 5.5MM ROD MNRCH,SUP-2254575,CDM,C1713,HCPCS,0278,RC,,,,both,,,3001.84,1951.20,,,,,,,,,,,,,
DISTAL VOLAR PLATE STANDARD LEFT,SUP-2678016,CDM,C1713,HCPCS,0278,RC,,,,both,,,3147.07,2045.60,,,,,,,,,,,,,
LIDOCAINE HCL (CARDIAC) PF 100 MG/5ML IV SOSY,RX-145137,CDM,J2003,HCPCS,0636,RC,00409-1323-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR CARDIOVERTER W/ 1 ACT FIX LD NOT,SUP-2236356,CDM,C1721,HCPCS,0275,RC,,,,both,,,91750.80,59638.02,,,,,,,,,,,,,
RESERVOIR PENILE PROS 125CC CLVRLF W/ LOK OUT VLV TI,SUP-2165444,CDM,C1813,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
HC Drug Screen Quantitative Vancomycin,PX-3018020200,CDM,80202,CPT,0301,RC,,,,both,,,170.00,110.50,,,,,,,,,,,,,
LEVEL CMF PLATE SMRT3D TRMA ZMC BTTRSS LFT 15 MM SCRW11 HOL,SUP-2667284,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.20,767.13,,,,,,,,,,,,,
GUIDEWIRE VASC PRIMEWIRE L 185 CM 0.014 IN L 3 CM SS STR AD,SUP-2327219,CDM,C1769,HCPCS,0272,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
LINER ACET 24 10 DEG 32 MM FEM HIP ARCOMXL RINGLOK,SUP-2136079,CDM,C1776,CPT,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
SCREW BONE L85MM DIA3.5MM S STL ST LCK T20 DRV PERI-LOC,SUP-2349997,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.07,910.70,,,,,,,,,,,,,
PLATE BNE L62MM 2X5 H NONSTERILE T SHP FOR 27MM SCR UNIV LOK,SUP-2199365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1034.94,672.71,,,,,,,,,,,,,
STENT URIN DIV SUBQ CLS TIP 2 DIL 0.038IN STR GWIRE 8FR,SUP-2139083,CDM,C2617,HCPCS,0278,RC,,,,both,,,652.71,424.26,,,,,,,,,,,,,
HC Inj Proc Shoulder Arthro,PX-3612335000,CDM,23350,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC CELLULAR BNE MTRX SYGNACEL CBM,SUP-2929810,CDM,C1713,HCPCS,0278,RC,,,,both,,,4348.90,2826.78,,,,,,,,,,,,,
INSERT ACET OD56MM ID40MM HIP ULTAMET COBAL CHROME ARTC MOD,SUP-2250307,CDM,C1776,CPT,0278,RC,,,,both,,,9045.08,5879.30,,,,,,,,,,,,,
ANCHOR SUTURE L8.5MM DIAMETER 2.7MM PRETHREADED WITH SIZE 2,SUP-2824805,CDM,C1713,HCPCS,0278,RC,,,,both,,,487.70,317.00,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.536,SUP-2860217,CDM,C1713,HCPCS,0278,RC,,,,both,,,43305.00,28148.25,,,,,,,,,,,,,
PLATE SPINAL RIGHT 3X4 HOLE LOW PROFILE L OBLIQUE NEURO TITA,SUP-2838355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
SHELL ACET K 70 MM HIP POROUS REFLECTION,SUP-2435184,CDM,C1776,CPT,0278,RC,,,,both,,,5915.76,3845.24,,,,,,,,,,,,,
DRILL HND OD1.5MM SH QUIK REL HPS,SUP-2319573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
SUTURE SYNETURE CHROMIC GUT SZ 2 0 L30IN ABSRB UD V 20 L26MM GG123,SUP-2174673,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING EPTFE 6MM DIA 40CM LEN,SUP-2126766,CDM,C1768,CPT,0278,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
ROD SPNL POST CRV SMOOTH TI ALLY PREBENT 5.5MM DIA 50MM LEN,SUP-2415856,CDM,C1713,HCPCS,0278,RC,,,,both,,,1307.03,849.57,,,,,,,,,,,,,
STENT ESOPH HANAROSTENT L 80MM 20MM L 1800MM 0.035IN,SUP-2912524,CDM,C1874,HCPCS,0278,RC,,,,both,,,8737.05,5679.08,,,,,,,,,,,,,
STENT BILI L80MM DIA10MM CATH L194CM 8FR 0.035IN MTL,SUP-2149794,CDM,C1876,HCPCS,0278,RC,,,,both,,,4473.06,2907.49,,,,,,,,,,,,,
KIT TRACH TB L70MM OD105MM ID7MM PERC DIL FULL COMP BLU LN,SUP-2351757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.70,566.60,,,,,,,,,,,,,
GRAFT DERMAL MESH 7X10 CM FEN WND MTRX MIRODERM,SUP-2431549,CDM,Q4175,HCPCS,0636,RC,,,,both,,,12924.24,8400.76,,,,,,,,,,,,,
PLATE BONE W12XL199MM THK1MM 12 H BILAT TI SEMI TBLR LO PROF,SUP-2190710,CDM,C1713,HCPCS,0278,RC,,,,both,,,385.18,250.37,,,,,,,,,,,,,
SHEATH INTRO SUREFLEX L 72 CM DIA 8.5 FR DSTL CRV DIA22 MM,SUP-2420621,CDM,C1766,CPT,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HC So Ish Ea Addl Single Probe Stain,PX-3128836966,CDM,88369,CPT,0312,RC,,,,both,,,122.00,79.30,,,,,,,,,,,,,
KIT HAD CATHETER L23CM DIA155FR STD LNG TERM POLYUR STR,SUP-2269556,CDM,C1750,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SCREW BNE L14MM DIA5MM CNDYL S STL ST VAR ANG LOK COMPR T25,SUP-2178693,CDM,C1713,HCPCS,0278,RC,,,,both,,,792.13,514.88,,,,,,,,,,,,,
VALVE AORT INSPIRIS RESILIA TISS ANNULUS 19 MM SEW RNG DIA25,SUP-2213990,CDM,C1889,HCPCS,0278,RC,,,,both,,,24963.00,16225.95,,,,,,,,,,,,,
PLATE EXT FIX L130MM ALUM U FOR SPAT FRME TAY,SUP-2340796,CDM,C1713,HCPCS,0278,RC,,,,both,,,10081.60,6553.04,,,,,,,,,,,,,
PROBE RF L150MM ACT TIPL4MM OD17GA DISP COOLIEF ADV,SUP-2719765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
NEXGEN ROTATING HINGE ARTICULAR SURFACE D 17MM,SUP-2502560,CDM,C1776,CPT,0278,RC,,,,both,,,4775.94,3104.36,,,,,,,,,,,,,
HC Facial Bones Min 3 Views,PX-3207015000,CDM,70150,CPT,0320,RC,,,,outpatient,,,552.00,358.80,,,,,,,,,,,,,
HC Perq Trluml Coronry Lithotrp,PX-4819297200,CDM,92972,CPT,0481,RC,,,,both,,,14803.00,9621.95,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0258,RC,00338-0049-11,NDC,,both,250,ML,123.30,80.14,,,,,,,,,,,,,
PLATE BNE SM TI R CALCNL LOK,SUP-2106921,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.97,183.28,,,,,,,,,,,,,
PROBE ABLAT XL 90DEG ASPIR BPLR RF 1 PC ELECTRD ERGO HNDL,SUP-2123449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC JGWRE RVLTN 0025N TIP 450CML ANG BX2,SUP-2676535,CDM,C1729,HCPCS,0272,RC,,,,both,,,549.81,357.38,,,,,,,,,,,,,
SCREW BNE L25MM DIA5MM CORT CONIC S STL ST CANN LOK FULL,SUP-2184909,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
HC So Pdgfra Gene,PX-3018131466,CDM,81314,CPT,0301,RC,,,,both,,,429.00,278.85,,,,,,,,,,,,,
BRACE ANK SWVL STRP STD 10 IN AIR/GEL BLDR LP BLK STIRRUP,SUP-2336325,CDM,L4350,HCPCS,0274,RC,,,,both,,,28.79,18.71,,,,,,,,,,,,,
BLADE ENDO UDIN AM,SUP-2399181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1986.36,1291.13,,,,,,,,,,,,,
SET NEPHSTMY CATHETER 83FR L30CM 0038IN 6 SIDEPRT PERC FOR,SUP-2167941,CDM,C1769,HCPCS,0272,RC,,,,both,,,418.12,271.78,,,,,,,,,,,,,
KIT EXT FIX TWO RAIL W UNDERNEATH SURF CVR BY RUB FOR,SUP-2316207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5512.58,3583.18,,,,,,,,,,,,,
GUIDEWIRE ORTH L 285 MM DIA2.5 MM THRD NS DISP,SUP-2900653,CDM,C1769,HCPCS,0272,RC,,,,both,,,528.46,343.50,,,,,,,,,,,,,
ARNAUD MRCHC CRNL MNBLC DIST BODY ONL20MM3MM PRNGS,SUP-2669825,CDM,C1713,HCPCS,0278,RC,,,,both,,,8447.95,5491.17,,,,,,,,,,,,,
CONNECTOR SPNL GTT ENTRY X25 6.35 MM J-HOOK CLOSED BODY,SUP-2718835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV MAXBARR 3FR 45CM 1 LUMAN RVRSE T,SUP-2613430,CDM,C1751,HCPCS,0278,RC,,,,both,,,709.61,461.25,,,,,,,,,,,,,
ALLOGRAFT BNE PWD 15 CC FD IRRADIATED CANC,SUP-2867088,CDM,C1762,CPT,0278,RC,,,,both,,,885.95,575.87,,,,,,,,,,,,,
PLATE BNE L 213 MM SCREW DIA 3.5/4.5 MM H 8 UTIL NS EVOS,SUP-2931151,CDM,C1713,HCPCS,0278,RC,,,,both,,,16389.23,10653.00,,,,,,,,,,,,,
DRESSING BIO L 3.5 X W 3 CM SZ 200 UM PORCINE SM INTEST,SUP-2905496,CDM,Q4103,HCPCS,0636,RC,,,,both,,,487.14,316.64,,,,,,,,,,,,,
PADDLE GRFT REMOVAL ASMBLY,SUP-2421819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 14 MM FD ASEP,SUP-2867009,CDM,C1762,CPT,0278,RC,,,,both,,,1798.75,1169.19,,,,,,,,,,,,,
GRAFT BNE SUB 60CC SZ 01 4MM CRUSH CANC CHIP FRZN,SUP-2307397,CDM,C1713,HCPCS,0278,RC,,,,both,,,3929.62,2554.25,,,,,,,,,,,,,
IMMUNE GLOBULIN (FLEBOGAMMA) 10%,RX-4081761,CDM,J1459,HCPCS,0636,RC,44206-0436-05,NDC,,both,50,ML,2830.00,1839.50,,,,,,,,,,,,,
SET EMER 8.5FR L6CM NDL 15GA PNEUMOTHOR CATH,SUP-2169802,CDM,C1729,HCPCS,0272,RC,,,,both,,,178.92,116.30,,,,,,,,,,,,,
BIT DRL 2.4 MM VERTEX SEL,SUP-2630739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.23,333.60,,,,,,,,,,,,,
GRAFT TISS 2CMX10CM CORMATRIX ECM VASC CAR REP,SUP-2172042,CDM,C1768,CPT,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
PLATE BNE 24 HOLE 0.5 MM ADAPTATION 1.3 MM SCR MATRIXMIDFACE,SUP-2776725,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.08,249.65,,,,,,,,,,,,,
BIT DRL DIA4.5MM CANN FOR TARGETER PLATING SYS PERI-LOC,SUP-2343991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1489.40,968.11,,,,,,,,,,,,,
HC So Lactoferrin Fecal (Quant),PX-3018363166,CDM,83631,CPT,0301,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
PLATE BNE SM L75MM 3X5 H BILAT TI T OBLQ LIMIT CNTCT DYN,SUP-2190943,CDM,C1713,HCPCS,0278,RC,,,,both,,,897.98,583.69,,,,,,,,,,,,,
CEMENT BNE 10CC CA PHSPTE INJ LIQ PWD HYDROSET,SUP-2366471,CDM,C1713,HCPCS,0278,RC,,,,both,,,9024.61,5866.00,,,,,,,,,,,,,
FILLER DERMAL JUVEDERM VOLUX XC 1ML,SUP-2900489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
SHUNT SURG CORONARY 1.5X12 MM ATRAUM VES TAPR TIP SOF-FLO,SUP-2261620,CDM,L8612,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BONE ADOL BLDE L40MM 6MM OFFSET 90DEG 4 H LT RT S STL,SUP-2318747,CDM,C1713,HCPCS,0278,RC,,,,both,,,5154.75,3350.59,,,,,,,,,,,,,
UNIVERSAL GRP,SUP-2289258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
WAND ABLAT PLSM EVAC T AND A COBLATOR II,SUP-2342034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.70,651.75,,,,,,,,,,,,,
FIXATOR EXT FIX 16X80 MM 25 MM COMPR DISTRCTN RANG CORETRAK,SUP-2399885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5677.12,3690.13,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LG 10 CC DEMINERALIZED CORTICAL NUCEL,SUP-2314103,CDM,C1713,HCPCS,0278,RC,,,,both,,,10754.50,6990.42,,,,,,,,,,,,,
SCREW BNE LCK 4X27.5 MM STRL IMN,SUP-2467277,CDM,C1713,HCPCS,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
CATHETER SUPP TRAILBLAZER L 90 CM DIA 0.03 IN SHTH 4 FR,SUP-2716003,CDM,C1887,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
CRYOABLATION KIT CLARIFIX DISP,SUP-2419520,CDM,C2618,HCPCS,0272,RC,,,,both,,,6036.02,3923.41,,,,,,,,,,,,,
IMPLANT FNGR JT M L15MM SCR OD3.4MM BARB L6.8MM OD4.5MM THRD,SUP-2223970,CDM,C1776,CPT,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
COMPONENT KNEE CEM PRIMARY SCORP,SUP-2379190,CDM,C1776,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
PLATE BNE STR 3.5X235 MM 18 HOLE RECON LCK SS STRL,SUP-2474971,CDM,C1713,HCPCS,0278,RC,,,,both,,,2059.56,1338.71,,,,,,,,,,,,,
NUT EXT FIX WIRE SIDEKCK EZ FRAME EF1600PK,SUP-2851085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5067.96,3294.17,,,,,,,,,,,,,
PIN FIX THRD TRINICA SYS STRL,SUP-2205137,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
FIBER LSR 365MH BLU SUREFLEX,SUP-2141885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
HEAD FEM DIA28MM +1.5MM OFFSET 12/14 TAPR HIP CERAMIC TI SL,SUP-2251087,CDM,C1776,CPT,0278,RC,,,,both,,,5363.12,3486.03,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0250,RC,00338-0049-11,NDC,,both,50,ML,24.70,16.05,,,,,,,,,,,,,
HC Echo Cong. Anom - Lmt,PX-4839330400,CDM,93304,CPT,0483,RC,,,,both,,,927.00,602.55,,,,,,,,,,,,,
HC So John Cunningham Antibody,PX-3028671166,CDM,86711,CPT,0302,RC,,,,both,,,1756.00,1141.40,,,,,,,,,,,,,
PACEMAKER CARD 10MM OUTFLOW IDE PMP VENT ASST DEV HEARTWARE,SUP-2282537,CDM,C1768,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SCISSORS SURG 23GA CVD,SUP-2304864,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
HOOK SPNL THORLUM TI NEUT BILAT OPN TOP LD FOR 4.5MM ROD,SUP-2287447,CDM,C1713,HCPCS,0278,RC,,,,both,,,3466.03,2252.92,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 5CC POLYMER HYALURONIC ACID CONT PSTE,SUP-2247321,CDM,C1713,HCPCS,0278,RC,,,,both,,,3855.92,2506.35,,,,,,,,,,,,,
CUP ACET OD64MM ID22MM ALL POLYPROPYLENEXLPE CEM REFLCT,SUP-2345698,CDM,C1776,CPT,0278,RC,,,,both,,,2990.07,1943.55,,,,,,,,,,,,,
PLATE BNE THK0.6MM 3X2 H BILAT HND RECTANG NONCOMPRESSION,SUP-2267887,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
CABLE SURG DIA1.7MM S STL HA CERCLAGE W/ CRMP 29880101S] DEPUY SYNTHES USA],SUP-2187030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.94,867.71,,,,,,,,,,,,,
PROBE RF 17 GAX75 MM PMP THORACOOL,SUP-2753314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
KIT HIP ARTHROSCOPY DISTENTION NEEDLE GUIDEWIRE SWITCHING ST,SUP-2828618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.71,798.01,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.6MM,SUP-2412112,CDM,C1769,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
IMPLANT FACE W20XH2.5XL20MM THK0.45MM POLYETH SH FLR EASILY,SUP-2365179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1974.75,1283.59,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X199 MM LT PL 16 HOLE BUTTRESS SS,SUP-2499496,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.00,1385.80,,,,,,,,,,,,,
HC So Alkaloids Nos,PX-3018032366,CDM,G0480,CPT,0301,RC,,,,inpatient,,,64.00,41.60,,,,,,,,,,,,,
PLATE BNE L72MM BRL L38MM 135DEG 3 H ST BILAT PELV HIP S STL,SUP-2186805,CDM,C1713,HCPCS,0278,RC,,,,both,,,1984.64,1290.02,,,,,,,,,,,,,
HC Dna Antibody Native/Double Stranded,PX-3028622500,CDM,86225,CPT,0302,RC,,,,both,,,75.00,48.75,,,,,,,,,,,,,
CLOPIDOGREL BISULFATE 75 MG PO TABS,RX-22142,CDM,6370000000,HCPCS,0637,RC,55111-0196-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP HEMI BONE-PATELLAR TENDON-BONE,SUP-2867006,CDM,C1762,CPT,0278,RC,,,,both,,,7558.92,4913.30,,,,,,,,,,,,,
PROSTHESIS OTO L5MM OD4MM HA AND TI MID EAR OSS W/ MAL LINK,SUP-2284004,CDM,L8613,CPT,0278,RC,,,,both,,,1622.60,1054.69,,,,,,,,,,,,,
CEMENT DENT SELF CURED LUTING ENH CAP FUJI I,SUP-2226110,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.02,11.06,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.422,SUP-2859986,CDM,C1713,HCPCS,0278,RC,,,,both,,,35706.51,23209.23,,,,,,,,,,,,,
PLATE SPNL OCPTL SM MIDLN KEEL,SUP-2630219,CDM,C1713,HCPCS,0278,RC,,,,both,,,5443.98,3538.59,,,,,,,,,,,,,
ROCKER PLATE EXT FIX SIDEKCK EZ FRAME DISP,SUP-2399880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5633.16,3661.55,,,,,,,,,,,,,
"HC So Culture, Chlamydia, Any Source",PX-3008711066,CDM,87110,CPT,0300,RC,,,,outpatient,,,185.00,120.25,,,,,,,,,,,,,
WASHER EXT FIX CPL HOFFMANN 49221007,SUP-2517241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
MESH BIO PORCINE MTRX ABD 20CM LEN 20CM W SURGISIS,SUP-2170304,CDM,C1713,HCPCS,0278,RC,,,,both,,,21477.60,13960.44,,,,,,,,,,,,,
SCREW BNE L 45 MM DIA 7.5 MM SHANK OSTEOGRIP NS CD HORZ,SUP-2925413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
CATHETER HAD L40CM L19CM OD14.5FR CHRONIC AD DBL LUMN STR,SUP-2283936,CDM,C1881,HCPCS,0278,RC,,,,both,,,1037.20,674.18,,,,,,,,,,,,,
CONNECTOR SHUNT DIAMETER 1.9MM TITANIUM FOR HYDROCEPHALUS,SUP-2825617,CDM,C1889,HCPCS,0278,RC,,,,both,,,653.31,424.65,,,,,,,,,,,,,
GRAFT BIO TISS W2.4XL2.4IN PORCINE DERM RIFAMPIN,SUP-2125830,CDM,C1713,HCPCS,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
DILATOR TRANSSEPTAL L 85 CM OD 12 FR ID 0.035 IN GUIDEWIRE L,SUP-2913166,CDM,C1889,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SCREW BNE SELF DRL CANN COMPR TI L36MM L13MM OD3MM APTUS,SUP-2268358,CDM,C1713,HCPCS,0278,RC,,,,both,,,1509.08,980.90,,,,,,,,,,,,,
COMPONENT FEM POST STBL L MED LAT 70MM ANT POST 67MM PROVEN,SUP-2390421,CDM,C1776,CPT,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
CATHETER KT MST PICC W/ PASV VLV TECHNOLOGY W/ 145CM WIRE 3,SUP-2118915,CDM,C1751,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
PLATE BNE L205MM 6 H ST PROX FEM S STL HK LO PROF LOK COMPR,SUP-2186057,CDM,C1713,HCPCS,0278,RC,,,,both,,,4882.42,3173.57,,,,,,,,,,,,,
BUR SURG MTL CUT 1.6X6.4 MM 14 CM LG BOR MIDAS REX 8 LEGEND,SUP-2664605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.96,369.17,,,,,,,,,,,,,
GUIDEWIRE ORTH L 450 MM DIA 3.2 MM SMTH W/O THRD NS DISP,SUP-2902247,CDM,C1769,HCPCS,0272,RC,,,,both,,,237.07,154.10,,,,,,,,,,,,,
PLATE BNE SQ MINI 2X0.6 MM 6X4 HOLE FOR SCREW TI NS LEVEL 1,SUP-2476725,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.35,612.53,,,,,,,,,,,,,
ALLOGRAFT DERMAL THN 16X8 CM RDY TO USE TISS MTRX ALLDERM,SUP-2113004,CDM,Q4116,HCPCS,0636,RC,,,,both,,,14962.10,9725.36,,,,,,,,,,,,,
STENT ENDOPROS L25CM DIA8MM CATH 8FR L120CM 0.035IN VES,SUP-2396624,CDM,C1874,HCPCS,0278,RC,,,,both,,,19753.74,12839.93,,,,,,,,,,,,,
STENT BILI FLEXIMA L 15 CM DIA 7 FR GUIDEWIRE 0.035 IN PLAS,SUP-2149546,CDM,C2625,HCPCS,0278,RC,,,,both,,,292.77,190.30,,,,,,,,,,,,,
BUR ARTHRO ROUND RPRCSSD 3.5MM DIA FLTX6 HLLW ST,SUP-2589365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,164.07,106.65,,,,,,,,,,,,,
BIT DRL L165MM DIA2.8MM 2 FLUT QUIK CPL NONRADIOLUCENT STP,SUP-2187241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,267.87,174.12,,,,,,,,,,,,,
PLATE SPNL 26 MM,SUP-2415397,CDM,C1713,HCPCS,0278,RC,,,,both,,,3271.88,2126.72,,,,,,,,,,,,,
NCB SPACER 3,SUP-2722205,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE DERMACELL AWM 6CM X 7CM 0.2-1MM,SUP-2909514,CDM,Q4122,HCPCS,0636,RC,,,,both,,,9215.12,5989.83,,,,,,,,,,,,,
HC Ot Electricl Stim Attended 15,PX-4309703200,CDM,97032,CPT,0430,RC,,,,inpatient,,,206.00,133.90,,,,,,,,,,,,,
SHEATH URET PROXIS L 45 CM OD 12 FR ID 10 FR ACCS SHRT DIL,SUP-2655865,CDM,C1894,HCPCS,0272,RC,,,,both,,,507.74,330.03,,,,,,,,,,,,,
IMPLANT FACE W 40 X H 25 MM THK 4 MM SM POLYETHYL CHIN BTTN,SUP-2883599,CDM,C1713,HCPCS,0278,RC,,,,both,,,1300.53,845.34,,,,,,,,,,,,,
CATHETER KIT 2 LUMEN 5 FR POWERPICC SOLO,SUP-2126781,CDM,C1751,HCPCS,0278,RC,,,,both,,,350.11,227.57,,,,,,,,,,,,,
SLING M SYS W/ INHIBIZONE INVANCE,SUP-2140286,CDM,C1771,HCPCS,0278,RC,,,,both,,,14601.00,9490.65,,,,,,,,,,,,,
GRAFT VASC L50CM DIA18X9MM UNIV POLY KNIT BIFUR STD WALL,SUP-2395629,CDM,C1768,CPT,0278,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
HC So1 Chromosome Anal 15-20,PX-3118826267,CDM,88262,CPT,0311,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
ZINC GLUCONATE 50 MG PO TABS,RX-8872,CDM,6370000000,HCPCS,0637,RC,80681-0002-00,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
CLAMP CRAN TEXT 18 MM FLAPFIX FOR EXT FIX TI STRL LF,SUP-2431409,CDM,C1713,HCPCS,0278,RC,,,,both,,,1277.35,830.28,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X30 MM FD STRUCTURAL ILIUM ORAGRAFT,SUP-2741058,CDM,C1713,HCPCS,0278,RC,,,,both,,,1307.28,849.73,,,,,,,,,,,,,
HC Retrograde,PX-3207442000,CDM,74420,CPT,0320,RC,,,,both,,,1188.00,772.20,,,,,,,,,,,,,
CATHETER EP D CRV 2-2-2 MM 6 FRX120 CM RESPON,SUP-2356772,CDM,C1730,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
CANC SC 95MM FULLY TH 4.0,SUP-2819088,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.97,178.08,,,,,,,,,,,,,
SCREW CRAN L 4 MM DIA1.5 MM ST PRELD DISC NS UNIV NEURO III,SUP-2883981,CDM,C1713,HCPCS,0278,RC,,,,both,,,18274.64,11878.52,,,,,,,,,,,,,
BLADE EXPLANT TRUNCATED 52MM,SUP-2202804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
BLADE SCRDRVR W2.4MM STD PRI CLSR SYS STERNALOCK BLU,SUP-2136992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-10181,CDM,J1644,HCPCS,0636,RC,00409-2723-01,NDC,JW,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
WALKER PNEUMAT DLX L,SUP-2276721,CDM,L4361,HCPCS,0272,RC,,,,both,,,101.30,65.84,,,,,,,,,,,,,
SCREW BONE L65MM OD4MM S STL CANC CORT ST FULL THRD SELF DRL,SUP-2370612,CDM,C1713,HCPCS,0278,RC,,,,both,,,760.51,494.33,,,,,,,,,,,,,
DRAINAGE SET CATH 2.7X1.4 MM 20-35 CM 8 FR TBNG CLMP STRL,SUP-2666665,CDM,C1729,HCPCS,0272,RC,,,,both,,,490.00,318.50,,,,,,,,,,,,,
HC US Abdomen Complete,PX-4027670000,CDM,76700,CPT,0402,RC,,,,both,,,1432.00,930.80,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE,PX-4309712900,CDM,97129,CPT,0430,RC,,,GN|XU|KX,outpatient,,,186.00,120.90,,,,,,,,,,,,,
SCHON TRAY WCUT TROCAR PG,SUP-2723661,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
GRAFT HUM TISS W/O SCLER RIM,SUP-2388444,CDM,V2785,HCPCS,0810,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
PACEMAKER CARD INTUA W 1.75 X H 2.4 IN THK 0.76 CM 34 GM TI,SUP-2149294,CDM,C2621,HCPCS,0275,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
MESH CRAN W100XL100MM TEAL TI CNTOUR MAL FOR 1.5MM CRUCFRM,SUP-2191101,CDM,C1713,HCPCS,0278,RC,,,,both,,,6844.57,4448.97,,,,,,,,,,,,,
CANNULA FOR USE WITH AR-8911G,SUP-2814594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BOLT ORTHOPEDIC 85 MM FOR FEM NK SYS TI,SUP-2181053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1616.47,1050.71,,,,,,,,,,,,,
STEM TIB CEM 16/13X100 MM MOD W/ FEMALE TAPR FOR 6 MM NOSE,SUP-2423137,CDM,C1776,CPT,0278,RC,,,,both,,,4534.16,2947.20,,,,,,,,,,,,,
PERI SCR  65MM X 95MM,SUP-2725999,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.24,100.91,,,,,,,,,,,,,
SET TRAP SM PED UNIV FNGR S STL TRAC,SUP-2197344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,996.29,647.59,,,,,,,,,,,,,
DILATOR SURG MINI 1-3.5 MM CERV SS LF,SUP-2735312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.38,243.35,,,,,,,,,,,,,
STUD FIX L17MM DIA8.5MM PATELLOFEMORAL JT UHMWPE TAPR POST,SUP-2123654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
TUBE ET L40CM DIA4MM FOAM SURROUND MAGILL CUF LSR RESIST,SUP-2383546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,290.45,188.79,,,,,,,,,,,,,
CAGE SPNL 15X20MM INTBDY FUS BAK,SUP-2414386,CDM,C1889,HCPCS,0278,RC,,,,both,,,18106.81,11769.43,,,,,,,,,,,,,
GRAFT VASC W1XL3IN THK0.36MM CLLGN ULT THN KNIT PTCH N TAPR,SUP-2227662,CDM,C1768,CPT,0278,RC,,,,both,,,465.22,302.39,,,,,,,,,,,,,
PLATE BONE L214MM 6X23 H LT MAND TI ANG LCK COMPR FOR 2.4MM,SUP-2191429,CDM,C1713,HCPCS,0278,RC,,,,both,,,8299.65,5394.77,,,,,,,,,,,,,
FORCEP ENDOSCP W SHP 14X1650 MM 2 MM GRASPING W/ CHANNEL,SUP-2865650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.39,405.85,,,,,,,,,,,,,
SET PRSS MON 5FR L15CM 0.035IN POLYETH SGL LUMN STR TIP NDL,SUP-2167829,CDM,C1751,HCPCS,0278,RC,,,,both,,,113.39,73.70,,,,,,,,,,,,,
TRIAL KNEE SZ 3 L FEM TRIATHLON PS,SUP-2363725,CDM,C1776,CPT,0278,RC,,,,both,,,1908.34,1240.42,,,,,,,,,,,,,
BASKET STONE REMV W1.5XL3.5CM SHTH 7FR 4 WIR ROT PIN VISE,SUP-2169281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
REAMER SURG 10MM CONCAVE MTP FOR SM JT RMR MOD HND SYS,SUP-2107731,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
PLATE BNE L119MM 6 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185634,CDM,C1713,HCPCS,0278,RC,,,,both,,,3827.22,2487.69,,,,,,,,,,,,,
GUIDEPIN FIX DIA1.5MM TOEMOTION HEMICAP,SUP-2123617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
VALVE MITRL OPN PVT AP360 DIA22 MM ORIFICE 20.8 MM TISS,SUP-2429923,CDM,C1713,HCPCS,0278,RC,,,,both,,,9840.76,6396.49,,,,,,,,,,,,,
DEVICE REVASCULARIZATION EMBOTRAP III L 196 MM STENT RETRV L,SUP-2716211,CDM,C1757,HCPCS,0272,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
TIP ASPIR L03MM BENT MIC COAX INTREPID,SUP-2109920,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X2 CM TERMINALLY STRL WND NEOX CRD RT,SUP-2648695,CDM,Q4148,HCPCS,0636,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
FIBER LASER 365 MH SOLTIVE DISP,SUP-2540083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.42,775.72,,,,,,,,,,,,,
SPLINT WRST L L10IN R FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276629,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.29,14.49,,,,,,,,,,,,,
CATHETER CTRL VEN L55CM L60CM OD5FR PWR INJ 2 LUMN GWIRE,SUP-2118962,CDM,C1751,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
NKII POROUS TIBIAL SPACER SIZE 4 4MM LAT,SUP-2509807,CDM,C1776,CPT,0278,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1295108FD3,SUP-2632816,CDM,C1751,HCPCS,0278,RC,,,,both,,,1037.71,674.51,,,,,,,,,,,,,
GRAFT EVAR L11.5CM DIA18MM CONTRALATERAL LEG FOR AAA,SUP-2395905,CDM,C1768,CPT,0278,RC,,,,both,,,13451.76,8743.64,,,,,,,,,,,,,
HC So Assay of Volatiles,PX-3018460066,CDM,84600,CPT,0301,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY POLARIS X 270DEG L 110 CM DIA 6,SUP-2700079,CDM,C1732,HCPCS,0278,RC,,,,both,,,380.10,247.06,,,,,,,,,,,,,
SCREW BNE L40MM DIA5MM CORT CONIC S STL ST CANN LOK FULL,SUP-2184912,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.76,366.44,,,,,,,,,,,,,
COMPRESSION SCREW 40MM,SUP-2819501,CDM,C1713,HCPCS,0278,RC,,,,both,,,1532.04,995.83,,,,,,,,,,,,,
KYPHOPLASTY TRAY 15/3 OSTEO INTRO CDS SYS KYPHOPAK XPANDER,SUP-2665114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11617.00,7551.05,,,,,,,,,,,,,
SCREW ACET LP 6.5X100 MM HIP SYS TI RINGLOK,SUP-2449907,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
BIT DRL DIA65MM CONIC W STP FOR MULTILOC PROX HUM NAIL,SUP-2178942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1147.42,745.82,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 14 FRX45 CM 5 CM STOMA LP AMT G-JET,SUP-2424369,CDM,C1713,HCPCS,0278,RC,,,,both,,,1527.61,992.95,,,,,,,,,,,,,
GUIDE DRL AND 2MM PIN GLENOJET,SUP-2123641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
LEAD DEFIB SIL ENDOCARD ICD SGL COIL RIATA,SUP-2356671,CDM,C1777,HCPCS,0275,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
SUPPORT ORTH L8IN M NEOPRENE EL CNTCT CLSR STRP D RNG GOLFER,SUP-2196836,CDM,L3702,HCPCS,0272,RC,,,,both,,,20.85,13.55,,,,,,,,,,,,,
HC So Chromosome Analysis Tissue,PX-3118826166,CDM,88261,CPT,0311,RC,,,,both,,,331.00,215.15,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.7MM BOB TI BLU STRL 500002,SUP-2535061,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.62,45.90,,,,,,,,,,,,,
PLATE BNE STR 127 MM R/L 13 HOLE EVOLVE EPS ORTHOLOC,SUP-2535934,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
ATTACHMENT PWR TOOL L5CM SH FOR HI PERF INSTR SYS ANSPACH,SUP-2176948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC So Drug or Substance Nos 7 or Mor,PX-3018037766,CDM,G0480,CPT,0301,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
"HC So Encephalitis, St.Louis",PX-3028665366,CDM,86653,CPT,0302,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
CATHETER THORACENTESIS DRY SET 8.5 FRX8.7 CM 15 GA EMGCY,SUP-2759771,CDM,C1729,HCPCS,0272,RC,,,,both,,,356.01,231.41,,,,,,,,,,,,,
ELECTRODE KIT EMG SSEP NDL SAFEOP,SUP-2736620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
BUPIVACAINE HCL 0.25 % IJ SOLN (MIXTURES ONLY),RX-430037,CDM,J0665,HCPCS,0636,RC,00409-1159-01,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
SCREW SPNL L50MM DIA4MM CORT PEDCL TI CANN DISCVR,SUP-2256187,CDM,C1713,HCPCS,0278,RC,,,,both,,,2388.57,1552.57,,,,,,,,,,,,,
HOOK SUT L25MM DIA6MM LARE CRV CRESC SPECTRM,SUP-2167030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SHAFT FEM TRAD ALLGRFT 150 MM FRZN,SUP-2294169,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE NEURO T 6L 4V TTNM ALLOY ULTRA LOW PRFLE BOX STYLE WT,SUP-2677364,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.91,506.29,,,,,,,,,,,,,
NEEDLE PROC L56CM OD19-22GA TRANSSEPTAL PERC STYL PED L HRT,SUP-2167853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESHED THN 15X10 CM MTRX SOMAGEN,SUP-2434141,CDM,C1762,CPT,0278,RC,,,,both,,,32676.79,21239.91,,,,,,,,,,,,,
HC Pt Vasopneumatic Device Therapy|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701600,CDM,97016,CPT,0420,RC,,,KX|CQ,outpatient,,,206.00,133.90,,,,,,,,,,,,,
SHUNT CAR OUTLYING PRUITT 8 FR,SUP-2264221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4298.66,2794.13,,,,,,,,,,,,,
SET INTRO PERFRMR L 45 CM OD 5 MM ID 1.7 MM TIP 3 MM,SUP-2169774,CDM,C1894,HCPCS,0272,RC,,,,both,,,61.20,39.78,,,,,,,,,,,,,
SCREW SPNL L13MM DIA4.5MM CANC ANTR CERV TI SELF DRL VAR ANG,SUP-2254607,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
ILLUMINATOR OPHTH DIA35GA RFID STR SMOOTH ROUNDED DSTL TIP,SUP-2109914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.75,242.94,,,,,,,,,,,,,
HC Bx Soft Tissue Pelvis/Hip Deep,PX-3612704100,CDM,27041,CPT,0361,RC,,,,both,,,5012.00,3257.80,,,,,,,,,,,,,
LAMOTRIGINE 100 MG PO TABS,RX-13982,CDM,6370000000,HCPCS,0637,RC,00904-7008-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TRIAL BONE PLT 3 H T SHP TC-100 SM FRAG SYS,SUP-2343726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1184.82,770.13,,,,,,,,,,,,,
PLATE EXT FIX L30MM ANK FT FOR TRUELOK FRME ASSEMB HEXAPOD,SUP-2316155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.93,228.75,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 CM DIA16 X 8 MM THK 0.49 MM,SUP-2227598,CDM,L8670,HCPCS,0278,RC,,,,both,,,2567.70,1669.00,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1274108D4,SUP-2632802,CDM,C1751,HCPCS,0278,RC,,,,both,,,821.90,534.23,,,,,,,,,,,,,
CATHETER ETER HAD KT LNG TERM ACCS 32 15FRX27CM CANNON II +,SUP-2762958,CDM,C1750,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
LINER WLK BOOT VENTURE TALL SM,SUP-2151034,CDM,L4386,HCPCS,0272,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
ALLOGRAFT BNE FLOWABLE 2.5 CC OSTEOAMP,SUP-2731797,CDM,C1776,CPT,0278,RC,,,,both,,,3430.92,2230.10,,,,,,,,,,,,,
SCREW BNE THRD 6X180 MM 40 MM,SUP-2315870,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
SHOE ORTHOT ADDITION CONVERT FIRM SFT COUNT,SUP-2435743,CDM,L3590,HCPCS,0274,RC,,,,both,,,151.25,98.31,,,,,,,,,,,,,
INSERT ACET MOB BEAR HIP,SUP-2365998,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 25 CM 5FR SS HYDRPHLC CORONARY,SUP-2385666,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.76,48.59,,,,,,,,,,,,,
IMPLANT LARYN 1ML GEL INJ VOCAL CRD MEDIALIZATION PROLARYN,SUP-2303664,CDM,L8607,HCPCS,0274,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
CABLE SURG L229MM DIA18MM HIP S STL BNE PLT SMOOTH SL,SUP-2252406,CDM,C1713,HCPCS,0278,RC,,,,both,,,1360.25,884.16,,,,,,,,,,,,,
PLATE BONE L115MM 5 H RT PROX HUM LCK FOR 3.5MM SCR PERI-LOC,SUP-2348552,CDM,C1713,HCPCS,0278,RC,,,,both,,,13036.02,8473.41,,,,,,,,,,,,,
COMPONENT FEM SZ 6 KNEE HNG AXLE LEGION,SUP-2346403,CDM,C1776,CPT,0278,RC,,,,both,,,1540.96,1001.62,,,,,,,,,,,,,
PLATE BNE W13.5XL170MM THK4.2MM 9 H BILAT S STL NAR LOK,SUP-2185242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1348.25,876.36,,,,,,,,,,,,,
TUBE VENT 0.76 MM 3.81 MM 1.6 MM PHOSPHORYLCHOLINE COAT SIL,SUP-2479469,CDM,L8699,HCPCS,0278,RC,,,,both,,,60.82,39.53,,,,,,,,,,,,,
PLEDGET CV L 5/16 X W 5/16 IN PTFE STRL,SUP-2761293,CDM,C1768,CPT,0278,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
EVOS VOL PLATE 7H LEFT STD TI 105MM NS,SUP-2818636,CDM,C1713,HCPCS,0278,RC,,,,both,,,8223.66,5345.38,,,,,,,,,,,,,
IMPLANT BRST W15 145XH127 125CM P66 82CM 650 780CC NACL,SUP-2300540,CDM,C1789,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L260CM 0.035IN 11CM 7.5/7.5MM DBL,SUP-2170507,CDM,C1769,HCPCS,0272,RC,,,,both,,,368.01,239.21,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO STR REG PLATE SD HI,SUP-2936065,CDM,C1713,HCPCS,0278,RC,,,,both,,,17835.20,11592.88,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node,PX-3613879200,CDM,38792,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW BNE L 4.6 MM DIA2.5 MM TI MAND CNDYL PROS FIX AXS NS,SUP-2909586,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.99,419.24,,,,,,,,,,,,,
IMPLANT WRST JT THK1.7X1.5MM L18MM L12-13MM QUADRIPODAL 4,SUP-2378989,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
COVER BURR H DIA13 MM THK 0.5 MM PROF THK 0.6 MM SCREW DIA1,SUP-2883821,CDM,C1713,HCPCS,0278,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
CABLE SPNL TI DBL LOOP W/ 2 INTEGR CRMP,SUP-2206117,CDM,C1713,HCPCS,0278,RC,,,,both,,,2103.80,1367.47,,,,,,,,,,,,,
PROBE COAG L330CM DIA2.3MM STR FIRE ARC SMRT,SUP-2360708,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
HC So Lyme Disease Total Anitbodies,PX-3028661866,CDM,86618,CPT,0302,RC,,,,both,,,200.00,130.00,,,,,,,,,,,,,
BIT DRL DIA2.7MM FOR ANTR CERV PLT SYS,SUP-2108490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
INSERT TIB L59MM THK11MM KNEE CRUC RET LIP VANGUARD,SUP-2137389,CDM,C1776,CPT,0278,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING BOLT HTORQ + L 115 CM DIA12 FR,SUP-2930561,CDM,C1757,HCPCS,0272,RC,,,,both,,,30520.80,19838.52,,,,,,,,,,,,,
SENSOR SHUNT HEP TREAT DISP FOR CDI SYS 500,SUP-2385082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.35,316.13,,,,,,,,,,,,,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,6370000000,HCPCS,0637,RC,00713-0536-06,NDC,,both,1,UN,83.90,54.53,,,,,,,,,,,,,
EXTENSION STEM L100MM DIA14MM FEM HIP CEMENTLESS CNL FILL,SUP-2304763,CDM,C1776,CPT,0278,RC,,,,both,,,3089.76,2008.34,,,,,,,,,,,,,
SPLINT WRST XSM AD L8IN FOR 5 65IN L NYL LN FOAM PUL ON,SUP-2276661,CDM,L3908,HCPCS,0274,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
NEEDLE VENTRICULAR SCOVILLE 14 GAX3-3/8 IN TWO HOLE,SUP-2666373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1167.55,758.91,,,,,,,,,,,,,
PLATE BNE SM RT CALCANEAL PERIMETER NS,SUP-2896942,CDM,C1713,HCPCS,0278,RC,,,,both,,,2822.86,1834.86,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY PRO L 90 CM 5 FR SLT 5 CM FLX Y,SUP-2117005,CDM,C1751,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
ADAPTER PACE ADAP-2RL REMINGTON NS,SUP-2538009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER SZ PTS-X L 110 CM BALLOON L 3 CM DIA25 MM INTRO 8,SUP-2659789,CDM,C1725,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
SYSTEM OCCL DEL AMPLATZER 180 DEG L 80 CM SHTH 6 FR NIT MESH,SUP-2116315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
BRACE ORTHOPEDIC LBR AFO ADJ,SUP-2265018,CDM,L4205,HCPCS,0274,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
JOINT FNGR MP 10 SIL PREFLEX STRL,SUP-2536094,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PLATE BNE W5XL100MM THK1MM 20 H TI STR FOR 2MM SCR,SUP-2191056,CDM,C1713,HCPCS,0278,RC,,,,both,,,940.15,611.10,,,,,,,,,,,,,
BOOT CAST XL VELC OPN TOE FOR TOT CNTCT SYS TCC-EZ,SUP-2244449,CDM,L4370,HCPCS,0272,RC,,,,both,,,370.33,240.71,,,,,,,,,,,,,
PLATE BONE UNIV L50MM RIB NONCOMPRESSION RIBLOC,SUP-2107916,CDM,C1713,HCPCS,0278,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
SENSOR CARD OUTPT L60IN VAMP AD SYS FLOTRAC,SUP-2214570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1071.12,696.23,,,,,,,,,,,,,
SCREW BONE L17MM OD3MM 0DEG CROSSTIE,SUP-2175108,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
LIGATOR HEMORRHOID VARICEAL NAT RUB TAMP MULT BND UNIV,SUP-2170088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
CATHETER ANGIO L135CM DIA0.044X.038IN DIA2.1FR GWIRE,SUP-2353151,CDM,C1887,HCPCS,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
BIT DRL OD3MM JCBS CHK END FOR CHARLOTTE COMPR STPL,SUP-2397623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS INCUS SHT 2.1X0.9X2.5 MM SINGLE NOTCH,SUP-2637872,CDM,L8613,CPT,0278,RC,,,,both,,,1206.48,784.21,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 3.5X82 MM 7 HOLE FOR SCREW STERILE,SUP-2836652,CDM,C1713,HCPCS,0278,RC,,,,both,,,2966.61,1928.30,,,,,,,,,,,,,
SCREW BNE 45X66MM LO PROF CORT TI ALLY CORT,SUP-2166944,CDM,C1713,HCPCS,0278,RC,,,,both,,,302.66,196.73,,,,,,,,,,,,,
PATCH LD TEMP TRNSVEN UPLR ACT FIX DF-1 CONN,SUP-2282237,CDM,C1896,HCPCS,0275,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PIN EXT FIX L35X18MM FOR RX FX MINI RAIL FIX,SUP-2396844,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
CATHETER URET 6FR L75CM SIL BLLN OCCL URETEROPELVIC,SUP-2171205,CDM,C1726,HCPCS,0272,RC,,,,both,,,727.54,472.90,,,,,,,,,,,,,
TRAY TIB REV MOD 4T4F PROVEN,SUP-2359299,CDM,C1776,CPT,0278,RC,,,,both,,,4749.25,3087.01,,,,,,,,,,,,,
BIT DRL DIA 3.7 MM CORTICAL FAR AO QC LG SYS STRL DISP EVOS,SUP-2933920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
BIT DRL GRAD 10-12 MM 177651] ORTHOFIX INC],SUP-2316012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCREW BNE XL L75MM DIA7MM HDLSS COMPR FULL THRD,SUP-2122591,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.419,SUP-2859983,CDM,C1713,HCPCS,0278,RC,,,,both,,,32486.44,21116.19,,,,,,,,,,,,,
SEGMENT FEM COMP M SZ 3 W65XH50MM RT DSTL TILASTAN,SUP-2419629,CDM,C1776,CPT,0278,RC,,,,both,,,4311.22,2802.29,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN COMP ONLY DBL LUMN POLYUR STR,SUP-2116547,CDM,C1750,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
TM SHIM 5 DEGREE,SUP-2501805,CDM,C1776,CPT,0278,RC,,,,both,,,2059.84,1338.90,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 40 CM DIA20 X 11 MM POLYESTER BOV,SUP-2694286,CDM,C1768,CPT,0278,RC,,,,both,,,2582.21,1678.44,,,,,,,,,,,,,
SCREW SPNL POLYAX 50 MM,SUP-2175448,CDM,C1713,HCPCS,0278,RC,,,,both,,,5968.51,3879.53,,,,,,,,,,,,,
DEVICE URETER COMPR,SUP-2129159,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SET INTRO LIVERTY L 43.6 CM WORKING L 40 CM OD 4 MM ID 3.4,SUP-2877230,CDM,C1894,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HC Carbon Dioxide Bicarbonate,PX-3018237400,CDM,82374,CPT,0301,RC,,,,both,,,121.00,78.65,,,,,,,,,,,,,
IMPLANT OTO PART POLYCEL CLASS DSGN SHEEHY,SUP-2284067,CDM,L8613,CPT,0278,RC,,,,both,,,715.42,465.02,,,,,,,,,,,,,
ALLOGRAFT BNE 10X10X13 MM BIOEXPAND,SUP-2637001,CDM,C1713,HCPCS,0278,RC,,,,both,,,3651.76,2373.64,,,,,,,,,,,,,
HC So1 Alcohol Biomarkers,PX-3018032167,CDM,80321,CPT,0301,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
STEM HUM UNIV SHLDR TI PORCOAT BALL TAPR ADJ NK ASSEMB GLOB,SUP-2249959,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 47 CM DIA28 MM BRANCH SZ 10/10/8/8,SUP-2694287,CDM,C1768,CPT,0278,RC,,,,both,,,7638.11,4964.77,,,,,,,,,,,,,
BRACE WRST M L7IN FOR 65 75IN R COT E CNTOUR ALUMINUM STAY,SUP-2197008,CDM,L3931,HCPCS,0272,RC,,,,both,,,11.21,7.29,,,,,,,,,,,,,
GRAFT BONE SUB 10GM CA PHOS CLASS BONESOURCE,SUP-2365153,CDM,C1713,HCPCS,0278,RC,,,,both,,,3213.48,2088.76,,,,,,,,,,,,,
CLAMP EXT FIX TUBE TO TUBE MED LG 20/25 MM BLU RED TRIAX,SUP-2501292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3149.73,2047.32,,,,,,,,,,,,,
PROBE DIL 180 MM MOLD LUCENT L,SUP-2740272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
PLEDGET CV L 1 X W 15.2 CM THK 2.87 MM PTFE FELT LO POROSITY,SUP-2761314,CDM,C1768,CPT,0278,RC,,,,both,,,88.23,57.35,,,,,,,,,,,,,
CANNULATED HIP PIN 30MM,SUP-2818073,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.57,1710.52,,,,,,,,,,,,,
CATHETER GUID TWIN-PASS L 135 CM DIA 3.5 FR GUIDEWIRE 0.014,SUP-2435361,CDM,C1887,HCPCS,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
BLADE ELECSURG SHV 4.5MM RESECT ELECTROSHV ELITE VULCAN,SUP-2341031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.66,476.23,,,,,,,,,,,,,
TWIST DRILL 15MM DIA X 28MM STOP DNTL LATCH SNGLE USE,SUP-2679092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.70,290.35,,,,,,,,,,,,,
CATHETER ETER EP OD7FR 2 20 2MM SPC L 6 POLE 10 PIN G DR FIX,SUP-2248462,CDM,C1730,HCPCS,0272,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
GRAFT BNE GRAN 4 CC CORTICAL CANC,SUP-2307035,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
IMPLANT BIO TISS W8XL16CM BOV PERICARD CLLGN MTRX MESH SGL,SUP-2130301,CDM,C9354,HCPCS,0278,RC,,,,both,,,11243.62,7308.35,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8 MM STR STD WALL REINF,SUP-2695225,CDM,C1768,CPT,0278,RC,,,,both,,,1236.25,803.56,,,,,,,,,,,,,
SCREW SPNL L20MM DIA3.5MM CANC POST CERVICOTHORACIC TI FIX,SUP-2254385,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
PLATE BONE FACIAL ID TITANIUM 3D RECONST CUSTOM,SUP-2883354,CDM,C1713,HCPCS,0278,RC,,,,both,,,26743.63,17383.36,,,,,,,,,,,,,
PROSTHESIS OSS MCGEE 0.8X52X7 MM 3 MM MALL WIRE REINF SHFT,SUP-2637881,CDM,L8613,CPT,0278,RC,,,,both,,,1369.89,890.43,,,,,,,,,,,,,
CATHETER INFSN 4FR DIA 90CML 5CML PEBAX OCCLDNG WIRE HEMSTAS,SUP-2677058,CDM,C1751,HCPCS,0278,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
GRAFT BONE PASTE DEMIN BONE MTRX 1CC GRFTON +,SUP-2281283,CDM,C9359,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
BURR SURG 5MM DIA HD LNG MIC 70MML SM BNE RND DIAMOND MICROP,SUP-2605569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,67.64,43.97,,,,,,,,,,,,,
PIN FIX L65MM DIA1.2MM ANK FT SMOOTH TRCR TIP OLV DISP FOR,SUP-2379280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
INTRODUCER THERMOABLATION STARBURST XL L 11 CM HRD COAX ACCS,SUP-2117218,CDM,C1894,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
GUIDEPIN ORTH L343MM DIA3.2MM FULL THRD BLNT TIP DISP,SUP-2347570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.37,534.54,,,,,,,,,,,,,
HC 6-Minute Walk Test/Pulm Stress Test,PX-4609461800,CDM,94618,CPT,0460,RC,,,,outpatient,,,387.00,251.55,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 CM DIA16 X 8 MM THK 0.38 MM,SUP-2461153,CDM,C1768,CPT,0278,RC,,,,both,,,1898.48,1234.01,,,,,,,,,,,,,
BIT DRL L100MM DIA2MM ST 3 FLUT QUIK CPL NONRADIOPAQUE W O,SUP-2187579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,451.41,293.42,,,,,,,,,,,,,
DRESSING NSL L4CM SYN PROPRIETARY POLYMER FOAM STD,SUP-2367516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.28,242.63,,,,,,,,,,,,,
RING EXT FIX DIA180MM TI HALF MR CONDITIONAL FOR DISTR,SUP-2179156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1589.50,1033.17,,,,,,,,,,,,,
PIN EXT FIX SELF TAPPING 5X300 MM THRD TRANSFIX,SUP-2362754,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,0636,RC,67457-0177-50,NDC,,both,50,ML,4196.10,2727.46,,,,,,,,,,,,,
SCREW BNE CONN CANN W/ INT THRD FOR PERC INSRTN HNDL NS,SUP-2799750,CDM,C1713,HCPCS,0278,RC,,,,both,,,1420.76,923.49,,,,,,,,,,,,,
ELECTRODE ELECSURG HK 5 MX33 CM MONOPOLAR PARTIALLY INSUL,SUP-2496707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,582.60,378.69,,,,,,,,,,,,,
BAR SPNL SZ 12 L116.5MM RAD 220MM SUP INFERIOR CRAN GLD TI,SUP-2193298,CDM,C1713,HCPCS,0278,RC,,,,both,,,7501.46,4875.95,,,,,,,,,,,,,
PLATE BONEXL STRL LT CALCNL FOR 3.5MM SCR VLP,SUP-2349963,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.16,4286.20,,,,,,,,,,,,,
KIT INTRO L 10 CM 45 CM SS WIRE/TIP MIC B BVL STIFF,SUP-2752615,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.86,66.21,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L120CM L150MM ODSEC5MM .035IN PERIPH OVR,SUP-2141205,CDM,C1725,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT DERMAL SQ 11.8X11.8 IN ANTIBACT XENMATRIX AB,SUP-2855246,CDM,C1781,HCPCS,0278,RC,,,,both,,,93766.68,60948.34,,,,,,,,,,,,,
IMPLANT BRST W13.2-12.7XH11CM P6.1-7.5CM 450-540CC NACL,SUP-2300538,CDM,C1789,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
MESH HERN 50X20 CMX1.5 MM HYDRATED PORCINE CLLGN PERMACOL,SUP-2174704,CDM,C1781,HCPCS,0278,RC,,,,both,,,75662.38,49180.55,,,,,,,,,,,,,
INSERT TIB 10X75 MM BASE AXIOM,SUP-2397003,CDM,C1776,CPT,0278,RC,,,,both,,,10091.96,6559.77,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL TR W 4.50 X H 5.40 CM D,SUP-2149119,CDM,C1882,HCPCS,0275,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT MAXBARR 5FR 55CM 2 LUM 3275108FD,SUP-2632668,CDM,C1751,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
BURR DIAMOND BALL 4.0MM S4DG1,SUP-2843315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.68,245.49,,,,,,,,,,,,,
HC Stent Place Initial Venous Ang,PX-3603723800,CDM,37238,CPT,0360,RC,,,,both,,,11772.00,7651.80,,,,,,,,,,,,,
BRACE ELBW TENNIS 1 SZ BLK INT FOAM PD LTWT HG80,SUP-2324093,CDM,L3702,HCPCS,0274,RC,,,,both,,,37.93,24.65,,,,,,,,,,,,,
DEFIBRILLATOR IMPL RIVACOR 7 DR-T PROMRI W 60 X H 66.5 MM D,SUP-2739234,CDM,C1898,HCPCS,0275,RC,,,,both,,,58278.40,37880.96,,,,,,,,,,,,,
PORT IMPL INFUSION 9.6 FR PRE ATTCH SIL CATH POWERPORT MRI,SUP-2126333,CDM,C1788,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
HC Injection Onabotulinumtoxin a 1 Unit,PX-6360058500,CDM,J0585,HCPCS,0636,RC,,,,inpatient,,,16.00,10.40,,,,,,,,,,,,,
ALLOGRAFT BNE GEL 10 CC DBM,SUP-2636992,CDM,C1713,HCPCS,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
PLATE BONE SHFT L366MM BLDE L60MM THK4.8MM 95DEG 22 H BILAT,SUP-2185462,CDM,C1713,HCPCS,0278,RC,,,,both,,,3567.67,2318.99,,,,,,,,,,,,,
SET URET STENT STRTCH VL L 22-30 CM DIA 6 FR TIP L 3 CM PTFE,SUP-2481642,CDM,C2617,HCPCS,0278,RC,,,,both,,,440.64,286.42,,,,,,,,,,,,,
SP PLASMANEEDLE LNG RIGHT ANGLED,SUP-2722602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.10,1038.76,,,,,,,,,,,,,
PLATE BONE EPICONDYLARXLATERAL LE X LNG,SUP-2107781,CDM,C1713,HCPCS,0278,RC,,,,both,,,3953.26,2569.62,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 11X25-29 MM PRESERVON CANN CANC FLEXIGRAFT,SUP-2264644,CDM,C1762,CPT,0278,RC,,,,both,,,3222.83,2094.84,,,,,,,,,,,,,
MESH SURG DIA15CM WHT POLY CLLGN FLM RND MFIL BIOABSRB,SUP-2283398,CDM,C1781,HCPCS,0278,RC,,,,both,,,1719.90,1117.93,,,,,,,,,,,,,
UNIT THER COMB CRYO W/ PD SHLDR W/ TUBE PWR OPERATED W/ BD,SUP-2150877,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
PLATE BNE UNIV 4 H STR MAXLOCK EXTRM,SUP-2400385,CDM,C1713,HCPCS,0278,RC,,,,both,,,3403.76,2212.44,,,,,,,,,,,,,
CEMENT BNE 20GM HALF DOSE RADPQ ST VERTAPLEX,SUP-2366943,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.08,750.15,,,,,,,,,,,,,
SCREW BONE L20MM OD3.5MM TI CORT T15 ST LOQTEQ,SUP-2101294,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.31,246.55,,,,,,,,,,,,,
CATHETER CTRL VEN L28CM OD12FR TIP L23CM POLYUR 3 LUMN HCKMN,SUP-2127762,CDM,C1751,HCPCS,0278,RC,,,,both,,,1824.34,1185.82,,,,,,,,,,,,,
ELECTRODE LOOP BPLR CUT LONGITUDINAL 24/26FR,SUP-2261170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1493.07,970.50,,,,,,,,,,,,,
CATHETER GUID L110CM L CURL BIDEFLECTABLE SFT ATRAUM TIP,SUP-2357042,CDM,C1887,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PATCH DURA W10XL16CM BOV PERICARD DURA-GUARD,SUP-2130236,CDM,C1763,HCPCS,0278,RC,,,,both,,,3161.98,2055.29,,,,,,,,,,,,,
"HC So Epstein-Barr Virus,Ebna",PX-3028666466,CDM,86664,CPT,0302,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
BASKET EXTR L6CM DIA3CM CATH L208CM SHTH 10FR ACC CHN 4.2MM,SUP-2170590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
GRAFT BNE H12XL25MM TRICORT PAT WDG FRZ DRY MATRIGRFT,SUP-2264808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2075.98,1349.39,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM NOM THK1.5MM MAXFORC HUM DERM REGEN,SUP-2399110,CDM,Q4107,HCPCS,0636,RC,,,,both,,,7209.44,4686.14,,,,,,,,,,,,,
BIT DRL 3 FLUT 2.5 MMX9 IN CALIB,SUP-2795898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.07,218.45,,,,,,,,,,,,,
STENT URET STR 0.038 IN 7 FRX28 CM 6 FR DBL PGTL SFT CNTOUR,SUP-2465699,CDM,C2617,HCPCS,0278,RC,,,,both,,,564.57,366.97,,,,,,,,,,,,,
NAIL IM HUM 9.5X200 MM AG RETROGRADE AFFIXUS NAT NAIL,SUP-2606981,CDM,C1713,HCPCS,0278,RC,,,,both,,,5504.42,3577.87,,,,,,,,,,,,,
PIN FIX CRSS CANN KT DISP AXL,SUP-2212892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
"HC Acetone, Serum",PX-3078200900,CDM,82009,CPT,0307,RC,,,,outpatient,,,275.00,178.75,,,,,,,,,,,,,
SHELL ACET L41-44MM 44MM LIMIT H POR RINGLOK RX 90,SUP-2406297,CDM,C1776,CPT,0278,RC,,,,both,,,8892.48,5780.11,,,,,,,,,,,,,
HC Inj/Asp Maj Jnt or Bursa|RIGHT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-7612061000,CDM,20610,CPT,0761,RC,,,RT|73,both,,,1092.00,709.80,,,,,,,,,,,,,
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-127408,CDM,J1071,HCPCS,0636,RC,00009-0086-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER GUID L132CM STR X SUPP MIC ELITECROSS,SUP-2155670,CDM,C1887,HCPCS,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST EXT PWR ELECTR FABRICATED,SUP-2435771,CDM,L3904,HCPCS,0272,RC,,,,both,,,8696.98,5653.04,,,,,,,,,,,,,
CONTROL REMOT QUIK GUIDE SIM FOR SENZA,SUP-2308596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SPLINT ANK WOM SHOE SZ 7-9 IN MED POLYPRO PLAS RT FT,SUP-2930193,CDM,L1930,HCPCS,0272,RC,,,,both,,,251.70,163.60,,,,,,,,,,,,,
BASKET STONE REM L350CM OD2.5MM 3X6CM DISP ROTH NET,SUP-2391610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
FOIL DNTL 25MMW X 7MML 01MM THK RSRB X LATEX FREE ALVLR,SUP-2669845,CDM,C1713,HCPCS,0278,RC,,,,both,,,1081.82,703.18,,,,,,,,,,,,,
CANNULA INJ BENJAMIN 2 MMX13.5 CM F/POS PRESSURE ASST VENT,SUP-2774794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.51,545.03,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA 6 FR HYDRPHLC,SUP-2383405,CDM,C1894,HCPCS,0272,RC,,,,both,,,307.88,200.12,,,,,,,,,,,,,
"HC Repair Trnscath Mitral Valve, Initial Prosthesis",PX-3603341800,CDM,33418,CPT,0360,RC,,,,outpatient,,,44486.00,28915.90,,,,,,,,,,,,,
INSERT TIB + + 9MM SZ 3 OPTETRAK CR SLOPE,SUP-2222737,CDM,C1776,CPT,0278,RC,,,,both,,,4088.28,2657.38,,,,,,,,,,,,,
HC Removal FB Skin,PX-3611012000,CDM,10120,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
DEVICE FIX 5MM SHFT ENDO W/ 20 ANCHR STPLR HERN TACK MULTFI,SUP-2257514,CDM,C1713,HCPCS,0278,RC,,,,both,,,931.70,605.60,,,,,,,,,,,,,
LIFT HEEL LG ADJLFT,SUP-2394116,CDM,L3334,HCPCS,0272,RC,,,,both,,,40.66,26.43,,,,,,,,,,,,,
BLADE SHAVER STR 4 MM SMOOTH RND TIP DIEGO,SUP-2638085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.72,276.72,,,,,,,,,,,,,
SET LD EXTRACTION BYRD SHTH L 41/46CM 12.3FR 10 FR SZ AA BLU,SUP-2169594,CDM,C1894,HCPCS,0272,RC,,,,both,,,460.01,299.01,,,,,,,,,,,,,
LINER ACET OBLQ POLYETH 22MMX38MM TRIL LONGEVITY,SUP-2202299,CDM,C1776,CPT,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
BUR SURG RND CUT NONFLUTED CARB L54.0MM OD3.0MM,SUP-2284205,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
PIN GUID 3.2MM ORTH LNG FULL THRD FOR SUBTROCHANTERIC,SUP-2410484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
PROCESSOR SND SUPERPOWER LT DIAMOND BLK PONTO 3,SUP-2430354,CDM,L8690,HCPCS,0278,RC,,,,both,,,12858.30,8357.89,,,,,,,,,,,,,
CANNULA KYPHOPLASTY NDL 10GA 0.8ML SYR L5IN W/ CEM RADPQ,SUP-2366872,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.66,149.93,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 18.5-21 IN CTR 14-15 IN CALF 14-16 IN,SUP-2914942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.04,226.88,,,,,,,,,,,,,
DEVICE ANTI SIPHON W/ PUDENZ STR CONN,SUP-2244286,CDM,C1729,HCPCS,0272,RC,,,,both,,,1275.00,828.75,,,,,,,,,,,,,
CONNECTOR SPNL OFFSET 15 MM PROTEX,SUP-2584142,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
NAIL IM L380MM DIA10MM FEM TIB KNEE G TI CANN LOK AG RG,SUP-2347087,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.16,2593.60,,,,,,,,,,,,,
PLATE BNE W10XL90MM THK1.2MM 90DEG 4X6 H BILAT S STL T SHP,SUP-2185875,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.45,554.74,,,,,,,,,,,,,
DISTRACTION INTRNL DIST CRNL MICRO ZRCH 2 ARND END DRV 20 2,SUP-2681381,CDM,C1713,HCPCS,0278,RC,,,,both,,,12475.16,8108.85,,,,,,,,,,,,,
SCREW BONE 9MM THRD 45MM ANK ARTH LCK RETRONAIL,SUP-2316238,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
STEM HUM L122MM DIA6MM SHLDR PPS FOR FRAC SYS COMPHSVE,SUP-2404912,CDM,C1776,CPT,0278,RC,,,,both,,,7787.20,5061.68,,,,,,,,,,,,,
PLASMA-LYTE A IV SOLN,RX-6331,CDM,2580000003,HCPCS,0250,RC,00338-0221-04,NDC,,both,1000,ML,97.80,63.57,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 40 CM DIA18 FR GUIDEWIRE 0.038 IN,SUP-2168592,CDM,C1894,HCPCS,0272,RC,,,,both,,,295.44,192.04,,,,,,,,,,,,,
COMPONENT ULN SM L3IN L EL TIV PLSM INTERCHANGEABLE CEM,SUP-2205934,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
PLATE BNE L9MM 4 H S STL H SHP FOR 1.5MM SCR MINI FRAG SYS,SUP-2411307,CDM,C1713,HCPCS,0278,RC,,,,both,,,434.70,282.55,,,,,,,,,,,,,
STEM FEM SZ 11 L200MM NK L40MM DST DIA155MM LNG L HIP CEM,SUP-2374745,CDM,C1776,CPT,0278,RC,,,,both,,,12453.24,8094.61,,,,,,,,,,,,,
LEVEL CMF ST PLATE ORTHG TLTS BSSO STR 4 MM BRG 20 25 MM S,SUP-2682287,CDM,C1713,HCPCS,0278,RC,,,,both,,,1093.22,710.59,,,,,,,,,,,,,
NEEDLE PUNC 21 MMX213 CM,SUP-2768432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.70,274.10,,,,,,,,,,,,,
GRAFT HUM TISS 2X4CM PLCNTA MEMBRN BIODFENCE G3,SUP-2243998,CDM,Q4140,HCPCS,0636,RC,,,,both,,,6934.69,4507.55,,,,,,,,,,,,,
PLATE BNE MIC THK06MM 5X7 H BILAT CRANIOMAXILLOFACIAL TI,SUP-2262729,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.00,352.95,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1MM S STL TRCR PNT,SUP-2186857,CDM,C1713,HCPCS,0278,RC,,,,both,,,245.67,159.69,,,,,,,,,,,,,
MESH CRAN THK 0.2 MM SCREW DIA1/1.5 MM SM TRAP NS DISP,SUP-2937011,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
WIRE GUIDE.BALL END 3FR PKG 10,SUP-2574027,CDM,C1769,HCPCS,0272,RC,,,,both,,,241.84,157.20,,,,,,,,,,,,,
TUBE TRACH 7MM REPL PERC CUF W OBT DIL AND INNR CANN PER FIT,SUP-2351977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.17,243.86,,,,,,,,,,,,,
PROCHLORPERAZINE 25 MG RE SUPP,RX-11138,CDM,6370000000,HCPCS,0637,RC,00713-0135-12,NDC,,both,1,UN,75.00,48.75,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM DIA12 FR TIP 3 MM GUIDEWIRE 0.038,SUP-2168216,CDM,C1894,HCPCS,0272,RC,,,,both,,,132.41,86.07,,,,,,,,,,,,,
HC Clsed Tx Radial W Manipulation,PX-4502550500,CDM,25505,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
BAR INSTR BARMESH ARCH 14.5CM,SUP-2135881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
WIRE FIX OLV 400 MM KIRSCHNER,SUP-2162650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,856.59,556.78,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK FLX INNR SOCKET,SUP-2388208,CDM,L5645,HCPCS,0274,RC,,,,both,,,2097.24,1363.21,,,,,,,,,,,,,
PLATE BONE 5 H LCK GLDE ANK IMP,SUP-2107793,CDM,C1713,HCPCS,0278,RC,,,,both,,,2879.38,1871.60,,,,,,,,,,,,,
IMPLANT FOSSA MED UHMWPE LT TEMPOROMANDIBULAR JT STRL DISP,SUP-2934203,CDM,C1713,HCPCS,0278,RC,,,,both,,,17304.54,11247.95,,,,,,,,,,,,,
SCREW BNE L20MM OD3.5MM STD TI REARFT NONLOCKING TOT FT SYS,SUP-2243259,CDM,C1713,HCPCS,0278,RC,,,,both,,,519.61,337.75,,,,,,,,,,,,,
SCREW CANNULATED 7.3X135MM SS FULL THRD STRL,SUP-2547277,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.46,487.15,,,,,,,,,,,,,
SET CATH RAD C-PMS-400-RA,SUP-2167838,CDM,C1751,HCPCS,0278,RC,,,,both,,,114.45,74.39,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 1.4X150 MM TROCAR PT 1 END,SUP-2422325,CDM,C1769,HCPCS,0272,RC,,,,both,,,226.96,147.52,,,,,,,,,,,,,
GUIDE WIRE 1.2 MMX100 MM STRL,SUP-2814085,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
GRAFT BONE SUB 1-10MM 10ML CRUSH CANC FRZ DRY,SUP-2165597,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
CATHETER BLLN 7.5FR 25ML LIN INT AORT DATASCP SYS D68400047801] GETINGE USA MAQUET MED SYS],SUP-2227496,CDM,C1725,HCPCS,0272,RC,,,,both,,,2644.98,1719.24,,,,,,,,,,,,,
COMPONENT FEM KNEE CR KT STRL ITOTAL,SUP-2904534,CDM,C1776,CPT,0278,RC,,,,both,,,7339.75,4770.84,,,,,,,,,,,,,
RELOAD FIX DEV ARTC 5 TACK STD PURCH FOR RELIATACK,SUP-2283331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.48,298.66,,,,,,,,,,,,,
MESH HERN MED 3.5X5.7 IN ANAT O3FA FIL COAT C-QUR CENTRIFX,SUP-2227253,CDM,C1781,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
MARKER BRST BX 17GA L10CM NIT RNG SHP ULTRACOR TWIRL,SUP-2128631,CDM,A4648,CPT,0278,RC,,,,both,,,204.07,132.65,,,,,,,,,,,,,
SUPPORT ORTHOT MTCRPL HND OFF-THE-SHELF PREFABRICATED,SUP-2435779,CDM,L3918,HCPCS,0274,RC,,,,both,,,272.08,176.85,,,,,,,,,,,,,
SPACER CERV SPNL GRFT CANC FRZ DRY 5MM ALLOFUSE,SUP-2113928,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
KIT CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 20CM STRGHT 2L,SUP-2613263,CDM,C1752,HCPCS,0278,RC,,,,both,,,672.75,437.29,,,,,,,,,,,,,
CATHETER HF 3 LUMN BASIC KT 70CM NIT GWIRE W/ RADSTIC,SUP-2125558,CDM,C1751,HCPCS,0278,RC,,,,both,,,603.82,392.48,,,,,,,,,,,,,
KIT PROC W/ 180DEG FIRM TIP EXT WRK CHAN TELE FOR BRONCHSCP,SUP-2381761,CDM,C1887,HCPCS,0272,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
ANCHOR SUT 1.4MM W/ FLX INSRT HI STRENGTH FLXIBLE DEL FOR,SUP-2366741,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
CATHETER URET L70CM DIA5FR POLYUR SPRL OLV TIP W/ ADPT,SUP-2129012,CDM,C1758,HCPCS,0278,RC,,,,both,,,41.01,26.66,,,,,,,,,,,,,
HANDPIECE FIX WASHER ASMBLY FACETGUN DISP,SUP-2175706,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
DRAINAGE SET PGTL 0.25 INX15 CM 5 FRX6 MM CATH NDL,SUP-2638579,CDM,C1729,HCPCS,0272,RC,,,,both,,,152.23,98.95,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 8MM STR STD WALL SLDE GDS,SUP-2681786,CDM,C1768,CPT,0278,RC,,,,both,,,2372.77,1542.30,,,,,,,,,,,,,
HC So Clot Factor XIII Fibrin Scrn,PX-3058529166,CDM,85291,CPT,0305,RC,,,,both,,,456.00,296.40,,,,,,,,,,,,,
BLADE RETRACTOR CASPR 50X23 MM CERV BALL SNAP MEDL ULTRA,SUP-2458700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.47,374.71,,,,,,,,,,,,,
PLATE BNE CRV 4.5X370 MM LT CNDYL 18 HOLE VA LCK NS VA-LCP,SUP-2758218,CDM,C1713,HCPCS,0278,RC,,,,both,,,6863.38,4461.20,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT VOID FIL 3D LD SYR DEL 5CC NANOSS,SUP-2335284,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER ENDO DIA15MM MICROVASIVE RAP EXCHG 3 LUMN RETRV BAL,SUP-2140119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO WIDE PLATE XDRV 12,SUP-2935390,CDM,C1713,HCPCS,0278,RC,,,,both,,,10117.08,6576.10,,,,,,,,,,,,,
SCREW INTRF L20MM DIA9MM UNIV TI CANN BLNT NONABSORBABLE,SUP-2362042,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.70,209.75,,,,,,,,,,,,,
PLATE SPINE IMPL 3 LEV VUELOCK CERV TI 46 MM,SUP-2415779,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
MESH C-QUR EDGEXL OBLONG OVL 12 INX18 IN,SUP-2265972,CDM,C1781,HCPCS,0278,RC,,,,both,,,7856.28,5106.58,,,,,,,,,,,,,
CATHETER INFUSION PMP 4ML/HR 2X5 IN 550 CC,SUP-2361469,CDM,C1751,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CATHETER DRAINAGE SINGLE LUMEN 10 FRX25 CM MP UTHANE,SUP-2168324,CDM,C1729,HCPCS,0272,RC,,,,both,,,291.45,189.44,,,,,,,,,,,,,
BOLT GUIDE VOLAR DST RDL LOK F/GDE PLTNG SSTM ACU LOC 2,SUP-2639632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
NAIL RG SH 10MMX140MM,SUP-2316242,CDM,C1713,HCPCS,0278,RC,,,,both,,,3728.75,2423.69,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 300 CM DIA 0.014 IN TIP,SUP-2385540,CDM,C1769,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
HC L Hrt Cath Trnsptl Puncture,PX-4819346200,CDM,93462,CPT,0481,RC,,,,inpatient,,,27322.00,17759.30,,,,,,,,,,,,,
SCREW BNE L 28 MM DIA2 MM TI CANN HD NS LEOS,SUP-2932596,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.08,401.75,,,,,,,,,,,,,
SENSOR PPG YELLOW RSFH ONLY,SUP-2862969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PIN FIX TROCAR PT 1 END 3/32X9 IN 1 PT STYL SMOOTH PLN STRL,SUP-2150450,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.35,8.68,,,,,,,,,,,,,
PLATE SPNL L23MM 5 H CERV VERT,SUP-2185978,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SHUNT LUMPERITON HI W/ CTRL RESVR N PROGRAMMABLE 15FR 3CM,SUP-2308230,CDM,C1713,HCPCS,0278,RC,,,,both,,,2138.87,1390.27,,,,,,,,,,,,,
STEM FEM L150MM DIA13MM KNEE CO CHROME BOW CEM MOD M TAPR,SUP-2252630,CDM,C1776,CPT,0278,RC,,,,both,,,10386.96,6751.52,,,,,,,,,,,,,
DRILL SURG FLX 10.5 MM CANN ANAT CRUCIATED GUIDE SYS CLANCY,SUP-2849156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L22IN FOR UP TO 27IN THGH UNIV FOAM NYL,SUP-2197966,CDM,L1830,CPT,0272,RC,,,,both,,,179.61,116.75,,,,,,,,,,,,,
ROD SPNL EXTN TENOR,SUP-2289259,CDM,C1713,HCPCS,0278,RC,,,,both,,,3300.14,2145.09,,,,,,,,,,,,,
SUTURE V-LOC 180 3-0 L18IN ABSRB GRN V-20 L26MM 1/2 CIR VLOCL0624,SUP-2174830,CDM,C1760,HCPCS,0278,RC,,,,both,,,81.99,53.29,,,,,,,,,,,,,
CATHETER CV FULL TY 025 5 FRX5 CM 16 GA 3L STR NDL SPECTRUM,SUP-2759862,CDM,C1751,HCPCS,0278,RC,,,,both,,,522.34,339.52,,,,,,,,,,,,,
INTRODUCER ORTH FOR STEM EXETER V40,SUP-2368333,CDM,C1713,HCPCS,0278,RC,,,,both,,,9817.52,6381.39,,,,,,,,,,,,,
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn,PX-3606444700,CDM,64447,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
INTRODUCER VASC AD 7FRX14CM,SUP-2357077,CDM,C1892,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
TRANSDUCER PRESSURE MONITOR SET W/ VENT TRUWAVE DISP,SUP-2214636,CDM,C1713,HCPCS,0278,RC,,,,both,,,39.19,25.47,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED RT ANK TALUS,SUP-2740840,CDM,C1762,CPT,0278,RC,,,,both,,,20671.84,13436.70,,,,,,,,,,,,,
CEMENT KIT CALCIUM PHOSPHATE 5 CC QUICKSET,SUP-2845378,CDM,C1713,HCPCS,0278,RC,,,,both,,,3857.49,2507.37,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 9/11X26X11 MM FD T-PLIF,SUP-2736785,CDM,C1713,HCPCS,0278,RC,,,,both,,,13903.17,9037.06,,,,,,,,,,,,,
STEM FEM L195MM DIA18MM DST HIP TI HA STR CONIC CEM MOD REV,SUP-2375829,CDM,C1776,CPT,0278,RC,,,,both,,,7441.80,4837.17,,,,,,,,,,,,,
PLATE BNE 24 DEG L 174 X W 8.5 MM THK 1.6 MM 13 H SS RT DSTL,SUP-2933532,CDM,C1713,HCPCS,0278,RC,,,,both,,,6031.16,3920.25,,,,,,,,,,,,,
ANCHOR SUTURE 5.5X15 MM PEEK KT STRL GRAPPLER,SUP-2749833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
BUTTON CERCLAGE 25MM TI HEX T15 STARDRV FOR ORTH CBL SYS,SUP-2181296,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.28,323.23,,,,,,,,,,,,,
HC Pt Manual Therapy Ea 15|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209714000,CDM,97140,CPT,0420,RC,,,GO|CO,both,,,194.00,126.10,,,,,,,,,,,,,
STENT ENDOVASCULAR L50MM DIA9MM CATHETER 9FR L80CM GUIDEWIRE 0.035IN EPTFE GRAFT FLARED OUTFLOW CONFIGURATION ENCAPSULATED CARBON IMPREGNATION FLAIR,SUP-2128224,CDM,C1874,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
CLAMP EXT FIX SM ADJ NONSPANNING MAG RESONANCE SAFE FOR,SUP-2188537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2266.45,1473.19,,,,,,,,,,,,,
DRILL SURG TRINKLE TORQUE LIMITING ATTCH,SUP-2475270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3498.12,2273.78,,,,,,,,,,,,,
SCREW BNE SZ 4/3.7 MM TAPR,SUP-2896673,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
PLATE BNE SIDE 145 DEG STD BRL 6 SLOT OMEGA +,SUP-2464268,CDM,C1713,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
ROD SPNL Z 5.5X260 MM TI MARINER OUTRIG,SUP-2709857,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
INTRODUCER HEMSTAS TEAR AWAY 9.5FR,SUP-2148789,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BLADE SURG L110MM S STL HELIX FOR LCP DHHS SYS,SUP-2186786,CDM,C1713,HCPCS,0278,RC,,,,both,,,1050.77,683.00,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ACROBAT 2 L 450 CM DIA 0.025 IN RADIOPAQUE,SUP-2170531,CDM,C1769,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
STENT NEPHURETSTMY L24CM OD10.2FR .038IN UTHANE COPE,SUP-2170573,CDM,C2617,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
FEM OPENG WEDG OSTEOTOME PLT 9MM,SUP-2811471,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
HC US Dup Scn Aorta Ivc Ltd,PX-9219397900,CDM,93979,CPT,0921,RC,,,,outpatient,,,1888.00,1227.20,,,,,,,,,,,,,
GRAFT DURA REP L 4 X W 3 CM THK 0.4 MM ELECTROSPUN FIBER ART3401,SUP-2904065,CDM,C1763,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
TUBE VENT 1.27 MM 1.3 MM 2.75 MM SHEEHY CLLR BUTTON SIL,SUP-2473009,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.94,25.31,,,,,,,,,,,,,
TUBE VENT L7MM ID0.89MM WHT FLROPLAS PLN STR SHANK,SUP-2284046,CDM,L8699,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
SPLINT ORTHOPEDIC PADDED LG 9X4.5 IN LT PRE MOLD PROCARE,SUP-2196717,CDM,L3809,HCPCS,0272,RC,,,,both,,,13.69,8.90,,,,,,,,,,,,,
GRAFT DURA W3XL3IN REGEN MTRX CLLGN BILAYER SUTURABLE,SUP-2244025,CDM,C1763,HCPCS,0278,RC,,,,both,,,3061.75,1990.14,,,,,,,,,,,,,
MARKER ENDO TISS 5ML BLK C LUERLOCK TIP PREFIL SYR SPOT,SUP-2227804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
SCREW BONE L30MM DIA2.5MM CRTX ST T7 PERI-LOC,SUP-2350070,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.48,116.01,,,,,,,,,,,,,
DRILL SH COUNTSINK COMB 3-4MM,SUP-2319462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
SCREW BONE L17MM OD2MM SLV TI CORT CRANIOMAXILLOFACIAL,SUP-2403116,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.014IN COR STR SHP TIP HYPERCOAT,SUP-2385315,CDM,C1769,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PULLER PLUG DIA6MM DISP FOR ULTSONIC REV SYS ULT DRV 3,SUP-2408561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1345.02,874.26,,,,,,,,,,,,,
PLATE STRAIGHT 24 HOLE,SUP-2719535,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
TUBING ASPIR MILLIPEDE 070 FLX BRAIDED ROTATING M LL CONN,SUP-2929966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
KIT BNE FIX STPL BRIDGE L 10 X 10 MM MINI NIT ANK FT ULTRA,SUP-2897558,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
ATTUNE SOLO PINNING SYSTEM,SUP-2514810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
CATHETER HD CRV EXTN 12 FRX16 CM ACUTE DL TY MAHRK ELITE,SUP-2283963,CDM,C1752,HCPCS,0278,RC,,,,both,,,301.06,195.69,,,,,,,,,,,,,
BLADE SHAVER RESECT 2X45 MM SERRATED DISP,SUP-2661212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.18,237.37,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 7X4 CM HYDRATED BIOLOGIC TISSUE MAT,SUP-2838607,CDM,C1763,HCPCS,0278,RC,,,,both,,,2598.04,1688.73,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.014 IN TIP LOAD 3,SUP-2909314,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.48,61.41,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 3.01-4.0 MCI STRL ADVANTAGE 2029DLS2] ISOAID LLC],SUP-2247267,CDM,C2642,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2MM TI TRCR PNT,SUP-2193149,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.14,184.69,,,,,,,,,,,,,
CONNECTOR EXT FIX L35MM ANG PIN FOR TAY SPAT FRME SYS,SUP-2342989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2390.95,1554.12,,,,,,,,,,,,,
CAP END 5MM ANKLE ARTHRODESIS NAIL SYSTEM PHOENIX,SUP-2500913,CDM,C1889,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
CABLE SPNL DBL LOOP TI,SUP-2430775,CDM,C1713,HCPCS,0278,RC,,,,both,,,4691.16,3049.25,,,,,,,,,,,,,
PROBE LAP L28CM DIA10MM W/ CRD L10FT ABC,SUP-2166156,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
COLLAR CERV LG MED 4.5X24 IN POLY CVR FOAM,SUP-2194442,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.93,7.10,,,,,,,,,,,,,
SYSTEM CORT IMPL STD ADJUSTABLE 1 W SLDE LOK KNOT DSGN 1 HND,SUP-2256783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1840.04,1196.03,,,,,,,,,,,,,
DRILL TWST RM 5/16 IN LNG,SUP-2436179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
VALVE MITRL ATS OPN PVT AP DIA24 MM ORIFICE 22.8 MM TISS,SUP-2282676,CDM,C1889,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PURAPLYAM (Fenestrated 3.0x4.0) 12 sq. cm,SUP-2635404,CDM,Q4196,HCPCS,0636,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
SHELL BPLR DIA42MM ACET HIP HMSPHR SLR,SUP-2304365,CDM,C1776,CPT,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
TOOL REMOVAL ANNULAR CLOSURE DEV STRL BARRICAID LTX DISP,SUP-2858411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
TM MODULAR CUP 80MM CLUSTER-HOLE,SUP-2503667,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BRUSH CYTO L200CM SHTH 75FR NIT DRV WIRE SFT STIFF BRIST,SUP-2391638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 035X260 STD COR CANALIZER,SUP-2120020,CDM,C1769,HCPCS,0272,RC,,,,both,,,143.18,93.07,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VIVA QUAD XT TI POLYUR SIL RUBBER 2 CHMBR,SUP-2282404,CDM,C1882,HCPCS,0275,RC,,,,both,,,54904.28,35687.78,,,,,,,,,,,,,
INSERT TIB THK6MM S STL UHMWPE KNEE PRI MOB SLDE COR STAR,SUP-2362575,CDM,C1776,CPT,0278,RC,,,,both,,,5821.56,3784.01,,,,,,,,,,,,,
GRAFT BNE 5CC DBM PTTY PREHYDRATED TENSIX,SUP-2400566,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.82,2883.93,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,0636,RC,00409-7335-03,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
IMPLANT WR JT CRPL POLY INSRT SZ 1 STD,SUP-2243503,CDM,C1776,CPT,0278,RC,,,,both,,,3617.78,2351.56,,,,,,,,,,,,,
ELECTRODE ENDSCPC URLGY 24 28FR DIA ANGLD CTTNG LOOP HIGH FR,SUP-2730096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,391.21,254.29,,,,,,,,,,,,,
PROG VLV RT ANG W SG,SUP-2194059,CDM,C1729,HCPCS,0272,RC,,,,both,,,15737.68,10229.49,,,,,,,,,,,,,
HC NM Bone Scan Whole Body,PX-3417830600,CDM,78306,CPT,0341,RC,,,,both,,,2813.00,1828.45,,,,,,,,,,,,,
IMPLANT BIO 250 SQ CM OMEGA 3 21 PRE-MESHED FISH STRL DISP,SUP-2909178,CDM,Q4158,HCPCS,0636,RC,,,,both,,,29792.32,19365.01,,,,,,,,,,,,,
BLADE IM L85MM DIA12.5MM FEM G TI CANN SPRL FR CUT EDGE FOR,SUP-2189404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1557.13,1012.13,,,,,,,,,,,,,
PLATE CRAN THK 0.5 MM SCREW DIA1.7 MM 4 H PLLA PDLA PGA STR,SUP-2883500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1279.11,831.42,,,,,,,,,,,,,
TISSUE T00247 ILIUMTRICORTSTRIP22MMX55MM,SUP-2281641,CDM,C1762,CPT,0278,RC,,,,both,,,7824.88,5086.17,,,,,,,,,,,,,
CATHETER CV BEDSIDE SET 018 6 FRX60 CM 3L NIT TURBO-JECT,SUP-2759935,CDM,C1751,HCPCS,0278,RC,,,,both,,,358.78,233.21,,,,,,,,,,,,,
DRILL SURGICAL PERFORATING  FLAT CUSHING,SUP-2793113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.30,231.59,,,,,,,,,,,,,
MESH CRAN L 84.33 X W 34.7 MM THK 0.3 MM SCREW DIA1.5 MM LG,SUP-2936583,CDM,C1713,HCPCS,0278,RC,,,,both,,,4289.24,2788.01,,,,,,,,,,,,,
NUT ORTH SCR 5 MM FOR PERIARTICULAR PLATING SYS TI,SUP-2563978,CDM,C1713,HCPCS,0278,RC,,,,both,,,479.51,311.68,,,,,,,,,,,,,
KIT BONE GRFT SUB KNEE INSTR FOR SUBCHONDROPLASTY ACCUPORT,SUP-2206118,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
AIRWAY LARYN MASK AD SZ 4 CUF 30ML SIL SFT INFL PILOT BAL LN,SUP-2383543,CDM,2720000010,LOCAL,0272,RC,,,,both,,,708.07,460.25,,,,,,,,,,,,,
RING EXT FIX 5/8 150 MM NS TRUELOK LTX,SUP-2875077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,958.55,623.06,,,,,,,,,,,,,
GRAFT HUM TISS W7.3XL14.7CM CNTOUR ALLDERM,SUP-2113060,CDM,Q4116,HCPCS,0636,RC,,,,both,,,8342.98,5422.94,,,,,,,,,,,,,
SYSTEM MONITOR HEARTMATE II,SUP-2356045,CDM,C1713,HCPCS,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
DEVICE SUCTION DIR BIOVAC,SUP-2736674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.54,230.45,,,,,,,,,,,,,
CUP ACET OD56MM ID36MM 0DEG HIP UHMWPE CONSTRN STD FACE,SUP-2403895,CDM,C1776,CPT,0278,RC,,,,both,,,5400.80,3510.52,,,,,,,,,,,,,
SHELL ACET SZ I DIA70MM HIP TRITANIUMX3 BEAR TECHNOLOGY,SUP-2363284,CDM,C1776,CPT,0278,RC,,,,both,,,9870.28,6415.68,,,,,,,,,,,,,
HEAD FEM OD36MM +0 NK CERAMIC ALUMINA V40,SUP-2364458,CDM,C1776,CPT,0278,RC,,,,both,,,4592.25,2984.96,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 30 J CURRENT VR,SUP-2356048,CDM,C1722,HCPCS,0275,RC,,,,both,,,70336.00,45718.40,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 45 CM OD 5 FR ID 1.7 MM GUIDEWIRE,SUP-2168666,CDM,C1894,HCPCS,0272,RC,,,,both,,,234.53,152.44,,,,,,,,,,,,,
CATHETER DRNGE VSC LOOP FIRM DUROMETER 12FRX35CM FLEXIMA VS,SUP-2147871,CDM,C1729,HCPCS,0272,RC,,,,both,,,329.98,214.49,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2MM S STL BALL NOSE DISP,SUP-2412815,CDM,C1769,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD L72CM INSRTN L55CM DIA14.5FR,SUP-2174154,CDM,C1750,HCPCS,0278,RC,,,,both,,,1780.88,1157.57,,,,,,,,,,,,,
SCREW BNE 5512003] STRYKER CORP],SUP-2363726,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.64,86.87,,,,,,,,,,,,,
NAIL INTRMDLLRY FMRL TTNM 14MM DIA 44CML VRSNL DEPUY,SUP-2587460,CDM,C1713,HCPCS,0278,RC,,,,both,,,4712.42,3063.07,,,,,,,,,,,,,
HEAD HUM RESURF 1 SHLDR,SUP-2267804,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
SUPPORT ORTHOT TRILATERAL CUST LEGG PERTHES ORTHOSIS,SUP-2435604,CDM,L1720,HCPCS,0274,RC,,,,both,,,4176.42,2714.67,,,,,,,,,,,,,
FIBER LASER CO2 2 MM ENDURE,SUP-2713745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
PLATE BNE CRV 4.5X336 MM LT CNDYL 16 HOLE VA LCK STRL VALCP,SUP-2789644,CDM,C1713,HCPCS,0278,RC,,,,both,,,7090.40,4608.76,,,,,,,,,,,,,
ALLOGRAFT BNE LORDTC 0 DEGREE 12X14X6 MM OPTIO-C,SUP-2402681,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
CANNULA ORTH SHFT DRV PATH SUPERPATH,SUP-2304387,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L6MM L FLNG INDWL 2 VLV BLOM-SINGER,SUP-2242330,CDM,L8509,HCPCS,0272,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
PLATE BNE HUM 127 MM RT DSTL MEDL 13 HOLE STRL A.L.P.S,SUP-2463649,CDM,C1713,HCPCS,0278,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
GRAFT BNE W10XL250MM THK3 12MM CORT FEM FRZN HALVED STRUT 2,SUP-2307352,CDM,C1713,HCPCS,0278,RC,,,,both,,,3837.52,2494.39,,,,,,,,,,,,,
HC Assay of Hemosiderin Qualitative,PX-3018307000,CDM,83070,CPT,0301,RC,,,,both,,,294.00,191.10,,,,,,,,,,,,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,0636,RC,13533-0602-50,NDC,,both,1,UN,6578.50,4276.02,,,,,,,,,,,,,
PACEMAKER CARD ADVANTIO W 4.45 X H 4.57 CM THK 0.75 CM 23.5,SUP-2149238,CDM,C1786,HCPCS,0275,RC,,,,both,,,9354.06,6080.14,,,,,,,,,,,,,
PLATE BONE W3.8XL100MM THK0.9MM 20 H S STL STR,SUP-2343826,CDM,C1713,HCPCS,0278,RC,,,,both,,,1918.85,1247.25,,,,,,,,,,,,,
CATHETER ABLAT OD7.5FR 2-5-2MM SPC 4 POLE DEFL C THRMSTER,SUP-2248929,CDM,C1732,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE 2.7 MM W/ 5 MM STP NS LTX,SUP-2857025,CDM,C1713,HCPCS,0278,RC,,,,both,,,3378.64,2196.12,,,,,,,,,,,,,
STENT VASC L150MM DIA7MM CATH L130CM SHTH 6FR DRUG ELUT,SUP-2853969,CDM,C1874,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
DAUNORUBICIN-CYTARABINE LIPO 44-100 MG IV SUSR,RX-139664,CDM,J9153,HCPCS,0636,RC,68727-0745-02,NDC,,both,1,UN,31622.40,20554.56,,,,,,,,,,,,,
INSERT TIB L THK9MM AP55MM ML80MM STD L R KNEE ARTC CONSTRN,SUP-2377541,CDM,C1776,CPT,0278,RC,,,,both,,,5233.50,3401.77,,,,,,,,,,,,,
GRAFT BONE SUB BONE GRFT 5ML GEL TRANZGRFT,SUP-2353938,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCREW BONE ANTR PLT 5.5MM 25MM,SUP-2229631,CDM,C1713,HCPCS,0278,RC,,,,both,,,3036.38,1973.65,,,,,,,,,,,,,
CAP ORAL SYR LT BLU EXACTAMED,SUP-2130331,CDM,C1760,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
ANCHOR SFT TISS W/ DEPLOYING SUT BTB TIGHTROPE,SUP-2121386,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
STENT PANCREAS 7FR L12CM PLAS STR LD BARB TRAILING RADPQ,SUP-2149510,CDM,C2617,HCPCS,0278,RC,,,,both,,,279.99,181.99,,,,,,,,,,,,,
KIT INTRO L 10 CM SS WIRE/TIP MIC B BVL CLR HUB ECHOGENIC,SUP-2117380,CDM,C1894,HCPCS,0272,RC,,,,both,,,61.14,39.74,,,,,,,,,,,,,
PLATE BNE L70MM THK1.2MM BILAT CALCNL S STL LOK COMPR FOR,SUP-2185987,CDM,C1713,HCPCS,0278,RC,,,,both,,,2885.94,1875.86,,,,,,,,,,,,,
ANCHOR SUTURE LOOPED CRV NDL BLU,SUP-2848967,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
STENT URET L 20 CM DIA 6 FR GUIDEWIRE 0.038 IN SIL FILIFORM,SUP-2836025,CDM,C2617,HCPCS,0278,RC,,,,both,,,594.40,386.36,,,,,,,,,,,,,
BLADE SAW SAG 96 MM CLMN STRL LTX,SUP-2862419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.21,223.74,,,,,,,,,,,,,
CATHETER CV TY 7 FRX15 CM 3L CUTLMY701JABRMCUSTOM0001,SUP-2759793,CDM,C1751,HCPCS,0278,RC,,,,both,,,449.65,292.27,,,,,,,,,,,,,
SCREW BNE L30MM OD10.5MM DISP ACL MULCH,SUP-2212890,CDM,C1713,HCPCS,0278,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
TUBING IRRIG HI FLO RIO SYS ANSPACH EMAX 2,SUP-2368423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
SCREW BNE L 105 MM DIA 7 MM LNG TI CANN HDLSS NS LEOS,SUP-2931456,CDM,C1713,HCPCS,0278,RC,,,,both,,,1118.81,727.23,,,,,,,,,,,,,
ALLOGRAFT PROVENDA-FLO 2.0ML,SUP-2653995,CDM,C1762,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
HC Repr Smp Not Face 2.6-7.5cm,PX-4501200200,CDM,12002,CPT,0450,RC,,,,outpatient,,,632.00,410.80,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 180 CM 0.035 IN TAPR L 22 CM ANGLED,SUP-2170347,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.21,75.54,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZ DRY CANC 1MM 4MM RANG 20CC,SUP-2264675,CDM,C1713,HCPCS,0278,RC,,,,both,,,939.08,610.40,,,,,,,,,,,,,
SLEEVE CBL SM OD16MM VIT DALL M,SUP-2377577,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.42,294.72,,,,,,,,,,,,,
PLATE BNE 2 COMPR 3.5X217X1.1 MM 18 HOLE FOR SCR SM FRAG SYS,SUP-2457213,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.11,733.27,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 3CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2672365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.05,224.28,,,,,,,,,,,,,
SCREW BNE L90MM DIA10.5MM ST LAG SQ DRVR SOCK FOR AFFIXUS,SUP-2413329,CDM,C1713,HCPCS,0278,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
HEAD RADIAL DIA20 MM MED COCR LATITUDE EV,SUP-2902144,CDM,C1776,CPT,0278,RC,,,,both,,,7386.38,4801.15,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THCK 20X6 CMX0.8-1.7 MM BRST KT FLEXHD,SUP-2307580,CDM,Q4128,HCPCS,0636,RC,,,,both,,,18995.43,12347.03,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 2X8 MM MANDIBULAR 5/PK TITANIUM NONS,SUP-2842312,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.46,182.30,,,,,,,,,,,,,
SCREW BNE L10MM OD27MM TI CORT DST RAD LOK FULL THRD CRSS,SUP-2372700,CDM,C1713,HCPCS,0278,RC,,,,both,,,567.08,368.60,,,,,,,,,,,,,
GRAFT BONE SUB 7.5CC W25XH12XL25MM HA POR BLK PRO OSTEON 500,SUP-2413074,CDM,C1713,HCPCS,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
PLATE BNE MESHED 1.5X120X120X0.6 MM NEURO 3D FOR SCR LEVEL 1,SUP-2464359,CDM,C1713,HCPCS,0278,RC,,,,both,,,7699.66,5004.78,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 60 MM DIA 6 MM CATH TOT L 100,SUP-2142745,CDM,C1876,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
SPLINT ORTH W4IN RT HND BASE THMB SPICA ROLYAN,SUP-2324965,CDM,L3931,HCPCS,0274,RC,,,,both,,,102.74,66.78,,,,,,,,,,,,,
LENS IOL TECNIS 1-PIECE ACRYLIC DCB0000220,SUP-2853105,CDM,V2632,HCPCS,0276,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,6370000000,HCPCS,0637,RC,00378-9102-93,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0035IN STR TIP REG BODY ULTRATRACK,SUP-2313185,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.24,83.36,,,,,,,,,,,,,
INSTRUMENT KIT 3.9 MM KNOTLESS CRKSCR INCL SPEAR PNCH DISP,SUP-2421793,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
BUR SURG HOLE MAKER 9.5 MMX14 CM LG BOR MIDAS REX LEGEND,SUP-2627700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.51,286.33,,,,,,,,,,,,,
CATHETER ETER URET TORQUEABLE C2 TIP 5FRX65CM IMAGER II,SUP-2139302,CDM,C1758,HCPCS,0278,RC,,,,both,,,54.38,35.35,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 150CM 0.018IN TIP L 3 CM STR,SUP-2385545,CDM,C1769,HCPCS,0272,RC,,,,both,,,174.65,113.52,,,,,,,,,,,,,
CATHETER LD DEL CPS AIM 90 DEG STD CRV SUBSELECTOR STRL,SUP-2357302,CDM,C1887,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SPLINT ARM SM L7IN L ALUMINUM FOAM PD MAL COLLES,SUP-2276768,CDM,L3809,HCPCS,0272,RC,,,,both,,,17.80,11.57,,,,,,,,,,,,,
MODULAR CUP NEUTRAL LINER LONGEVITY 44X28,SUP-2503727,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PACEMAKER CARD 9.7CUCM W42.9XH40.2MM D7.5MM IS-1 B OR UNI,SUP-2282313,CDM,C1786,HCPCS,0275,RC,,,,both,,,8241.09,5356.71,,,,,,,,,,,,,
CATHETER THRMDIL 7.5FR L110CM PROXIMAL/DISTAL PRT L30CM STD,SUP-2214335,CDM,C1751,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
STEM FEM CONCL 20X195 MM DSTL HIP STR,SUP-2364560,CDM,C1776,CPT,0278,RC,,,,both,,,9185.44,5970.54,,,,,,,,,,,,,
SCREW INTFR L30MM DIA10MM BIOCRYL RAPIDE ABSRB MILAGRO ADV,SUP-2249516,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
HEAD FEM 26 MM HIP COCR,SUP-2449387,CDM,C1776,CPT,0278,RC,,,,both,,,2303.19,1497.07,,,,,,,,,,,,,
CARBOXYMETHYLCELLULOSE SOD PF 1 % OP GEL,RX-138278,CDM,6370000000,HCPCS,0637,RC,00023-4554-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 35 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120668,CDM,C1768,CPT,0278,RC,,,,both,,,7878.26,5120.87,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT 400 MH PERF,SUP-2752490,CDM,C1888,HCPCS,0272,RC,,,,both,,,889.41,578.12,,,,,,,,,,,,,
PLATE BONE L164MM 12 H BILAT FIBULAR TIM LCK COMPR FOR,SUP-2413685,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.47,667.21,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 14X1 CM TAPR BOV PERICARD PHOTOFIX LTX,SUP-2859714,CDM,C1768,CPT,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
PLATE BNE THK0.6MM 12MM BAR 6 H 100DEG UNIV,SUP-2366310,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.67,444.39,,,,,,,,,,,,,
STENT NEURO NEUROFORM ATLS L 21 MM DIA 4.5 MM DEL WIRE L 185,SUP-2431334,CDM,C1877,HCPCS,0278,RC,,,,both,,,25748.00,16736.20,,,,,,,,,,,,,
SPACER FEM M/L THK5MM POST HALF DURAC,SUP-2377251,CDM,C1776,CPT,0278,RC,,,,both,,,182.31,118.50,,,,,,,,,,,,,
KIT HAD L45CM CATH SYMMETRIC TIP 2 LUMN CATH SFTY SHTH TISS,SUP-2283924,CDM,C1881,HCPCS,0278,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
SUTURE FIBERTAPE W2MMXL17IN BLU STR NDL BRAID POLYBLEND AR723717LN (ORDER MULTIPLES OF 6  EACH),SUP-2122113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CATHETER ETER CVC DBL LUMN KT BASIC L 9FRX90CM,SUP-2268422,CDM,C1751,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ROD SPNL POST BILAT SMOOTH TI ALLOY 4.5MM DIA 16MM LEN,SUP-2290272,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE 8 H CRANIOMAXILLOFACIAL TI LO PROF STR FOR UNIV,SUP-2366212,CDM,C1713,HCPCS,0278,RC,,,,both,,,519.73,337.82,,,,,,,,,,,,,
BLADE SURG SAW SAG S STL 85MM LEN 19.5MM W 1.27MM THCK 85MM,SUP-2150770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,642.76,417.79,,,,,,,,,,,,,
BIT DRL 4.2X270 MM,SUP-2496114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,647.63,420.96,,,,,,,,,,,,,
BOLT SURG 3.5X30 MM ANTI-DRIFT,SUP-2610689,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 PLU MAXBARR 4FR 55C 1194108D5,SUP-2632633,CDM,C1751,HCPCS,0278,RC,,,,both,,,990.23,643.65,,,,,,,,,,,,,
BIT DRL DIA4MM CARB DISP FOR 3.5/5MM SCR,SUP-2187124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,812.51,528.13,,,,,,,,,,,,,
COMPONENT TOT ANK NEUT 4 18 MM POLYETH VIT E APEX 3D,SUP-2742203,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
GRAFT HUM TISS FIRM 25X20 CM RECON TISS MTRX STRATTICE,SUP-2113038,CDM,Q4130,HCPCS,0636,RC,,,,both,,,49508.38,32180.45,,,,,,,,,,,,,
CUSHION RAD 100X70 35L FIL VAC BG,SUP-2137738,CDM,L1830,CPT,0272,RC,,,,both,,,907.08,589.60,,,,,,,,,,,,,
PIN FIX L9IN ODSEC4.8MM BONE THRD SGL TRCR STNMN,SUP-2304055,CDM,C1713,HCPCS,0278,RC,,,,both,,,22.64,14.72,,,,,,,,,,,,,
GUIDE BLOCK FOR LCP(TM) DISTAL FEMUR PLATES-RIGHT,SUP-2548289,CDM,C1713,HCPCS,0278,RC,,,,both,,,1530.28,994.68,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.014IN TIP L2CM S STL HYDRPHLC,SUP-2367926,CDM,C1769,HCPCS,0272,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
WASHER ORTH 2.5MM SPIK CRTX SCR,SUP-2184670,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.21,215.94,,,,,,,,,,,,,
GRAFT VASC IMPRA L 90 CM DIA 6 MM EPTFE FLX STD WALL RING,SUP-2126890,CDM,C1768,CPT,0278,RC,,,,both,,,2567.30,1668.74,,,,,,,,,,,,,
POVIDONE-IODINE 10 % EX OINT,RX-6455,CDM,6370000000,HCPCS,0637,RC,00536-1271-80,NDC,,both,28.4,GR,8.20,5.33,,,,,,,,,,,,,
TRAY KYPHOPLASTY BLLN 4ML L10MM DIA15.5MM NDL 11GA SYR 20ML,SUP-2367067,CDM,C1726,HCPCS,0272,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
SHEATH INTRO DIA 8 FR STRL,SUP-2393093,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
SET SCR SPNL LOK N BRK OFF TI 4MM DIA TSRH 3D SPNL SYS,SUP-2289648,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CLAMP MED 6 POSITION MULTI PIN MR SAFE,SUP-2679120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.32,366.81,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27X3 MM 1.52 MM FLANGE CLLR BUTTON WHT,SUP-2284075,CDM,L8699,HCPCS,0278,RC,,,,both,,,28.83,18.74,,,,,,,,,,,,,
SCREW BNE L52MM DIA3.5MM CORT FULL FOR ANK FRAC LP PLT SYS,SUP-2398443,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
SET INTRO PERFRMR L 6 CM OD 3 FR ID 1 MM GUIDEWIRE 0.018 IN,SUP-2169798,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.80,45.37,,,,,,,,,,,,,
SCREW INTRF 7X25 MM NS SOFTSILK,SUP-2877782,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.58,83.58,,,,,,,,,,,,,
CATHETER CECOSTOMY 10.2FR TRACT L0-6CM 3 SIDE PRT PERC,SUP-2168674,CDM,C1729,HCPCS,0272,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZN 2CMX4CM M HMTRX,SUP-2125440,CDM,Q4134,HCPCS,0636,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
HC Drug Admin & Hemodynmic Meas,PX-4819346300,CDM,93463,CPT,0481,RC,,,,both,,,285.00,185.25,,,,,,,,,,,,,
SCREW BNE L10MM DIA3MM NONBIOABSORBABLE HV,SUP-2399784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
DRESSING WND FEN 7X10 CM SHT EXTRACELLULAR MTRX MATRISTEM,SUP-2106522,CDM,Q4166,HCPCS,0636,RC,,,,both,,,1198.35,778.93,,,,,,,,,,,,,
ANCHOR SUT MICRORAPTOR KNOTLESS RG,SUP-2418766,CDM,C1713,HCPCS,0278,RC,,,,both,,,2649.85,1722.40,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 135 CM DIA 4 FR SLT PAT L 10,SUP-2118501,CDM,C1751,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BNE OSTEOTMY MAND SLIDING SAG MALL NS LTX,SUP-2862766,CDM,C1713,HCPCS,0278,RC,,,,both,,,1015.26,659.92,,,,,,,,,,,,,
STENT BILI L 10 CM DIA 7 FR GUIDEWIRE 0.035 IN PLAS RX,SUP-2149576,CDM,C2625,HCPCS,0278,RC,,,,both,,,330.58,214.88,,,,,,,,,,,,,
CLAMP EXT FIX BAR TO PIN COMBINATION,SUP-2749991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
PLATE BONE L16MM 5 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413742,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.74,487.33,,,,,,,,,,,,,
SPACER SPNL PARL SM 5 MM COLONIAL,SUP-2598657,CDM,C1889,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
PUMP PAIN 400X10ML/HR ON Q C BLOC,SUP-2236808,CDM,C9804,HCPCS,0272,RC,,,,both,,,616.88,400.97,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X40X35X0.4 MM LT SMRT TI NS LEVEL 1,SUP-2480291,CDM,C1713,HCPCS,0278,RC,,,,both,,,4120.21,2678.14,,,,,,,,,,,,,
ROD EXT FIX L185MM DIA6MM BAR JET-X,SUP-2342915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.41,536.52,,,,,,,,,,,,,
NEEDLE ENDO 22GA US FOR SAMP GI LESIONS DISP ECHO-TIP,SUP-2169550,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
CATHETER EP MED CRV 2-5-2 MM 5 FRX110 CM,SUP-2102175,CDM,C1730,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BUTTON SUTURE DIA11 MM ABS 3 H BUTTON RND CONCV FOR INT BRAC,SUP-2882170,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
RING EXT FIX DIA130 MM 2/3 PNK NS DISP SPAT FRME TSF,SUP-2932820,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4582.08,2978.35,,,,,,,,,,,,,
WAND ABLAT BVL 30DEG 3MM,SUP-2341966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
LETERMOVIR 480 MG PO TABS,RX-140596,CDM,6370000000,HCPCS,0637,RC,00006-3076-03,NDC,,both,1,UN,1234.80,802.62,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDIC 3 PNL UNIV 14-29 IN DURABLE TIETEX,SUP-2428152,CDM,L1830,CPT,0274,RC,,,,both,,,31.62,20.55,,,,,,,,,,,,,
HEAD RADIAL STD 28X14 MM ELBW COCR STRL,SUP-2564450,CDM,C1776,CPT,0278,RC,,,,both,,,4861.82,3160.18,,,,,,,,,,,,,
BIT DRL CANN 6.5 MM SPRL UNDERCUT W/ ACORN TIP,SUP-2767127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1544.72,1004.07,,,,,,,,,,,,,
HC Sclerotx Fluid Collection,PX-3614918500,CDM,49185,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SPACER SPNL W20XH12XL55MM 18DEG LORD OBLQ LAT LUM INTBDY FUS,SUP-2421108,CDM,C1889,HCPCS,0278,RC,,,,both,,,16365.68,10637.69,,,,,,,,,,,,,
COIL EMB 3 DIM 4 MMX8 CM TARGET 3D,SUP-2368051,CDM,C1889,HCPCS,0278,RC,,,,both,,,5533.47,3596.76,,,,,,,,,,,,,
PLATE BNE CNDYL 1.5 MM FRAC TI,SUP-2462853,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.99,500.49,,,,,,,,,,,,,
WASHER EXT FIX 2.5 MM,SUP-2457738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
KIT BNE SCR TORQ DEFINING SHLDR PRI FIX ANG REV EQUINOXE,SUP-2223386,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT BONE SUB W5XL5CM GRFTON,SUP-2293901,CDM,C1713,HCPCS,0278,RC,,,,both,,,3054.59,1985.48,,,,,,,,,,,,,
DRILL SURG MOD AO DETACHABLE FIT,SUP-2449172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,664.11,431.67,,,,,,,,,,,,,
SCREW BNE ST 1.3X7 MM CRTX W/ FLUT TIP TI MTRX GLD NS LF,SUP-2189178,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.23,209.45,,,,,,,,,,,,,
BIT DRILL STOP 90 DEGREE 1.1X13 MM 6 MM FOR SCREWDRIVER NON,SUP-2842079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1068.23,694.35,,,,,,,,,,,,,
PLATE BNE 5 DEG SM TI ALLOY RT MTP NS LEOS,SUP-2932841,CDM,C1713,HCPCS,0278,RC,,,,both,,,3518.37,2286.94,,,,,,,,,,,,,
ELECTRODE ELECTROTHERAPY L10CM RF REUSE,SUP-2357706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 8 CM LOOP DIA 4 MM PRIMARY,SUP-2249265,CDM,C1889,HCPCS,0278,RC,,,,both,,,3852.94,2504.41,,,,,,,,,,,,,
ANCHOR SUTURE SFT 2.9 MM REUSE PNCH JUGGERKNOT,SUP-2608807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1645.86,1069.81,,,,,,,,,,,,,
STEM CEMENTED 18MM X 80MM TITANIUM,SUP-2863708,CDM,C1776,CPT,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
PLATE BONE L201MM 10 H LT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348224,CDM,C1713,HCPCS,0278,RC,,,,both,,,12929.42,8404.12,,,,,,,,,,,,,
HC Renal Venogram Unilateral,PX-3207583100,CDM,75831,CPT,0320,RC,,,,both,,,3165.00,2057.25,,,,,,,,,,,,,
NEEDLE KIT SR061123,SUP-2737858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
DOCETAXEL 80 MG/4ML IV CONC,RX-104437,CDM,J9171,HCPCS,0636,RC,00955-1021-04,NDC,,both,4,ML,1252.80,814.32,,,,,,,,,,,,,
BRACE BACKXSM FOR 25-30IN WAIST HK RECV MAT SFT BRTH LNR ABD,SUP-2194511,CDM,L0625,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER ETER HAD 145FR L32CM INSRT L27CM POLYUR BIOBLOC SIL,SUP-2127840,CDM,C1750,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
PLATE BONE 6X21 H RT MAND TI LCK FOR 2MM SCR,SUP-2191235,CDM,C1713,HCPCS,0278,RC,,,,both,,,7644.64,4969.02,,,,,,,,,,,,,
ANCHOR SUT DIA6.8MM SUT SZ 2 MAXBRAID LACTOSORB L15,SUP-2137200,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
STEM FEM HIP PRESSFIT LT PRI 35 MM OFFSET 11 MM DIA 130 MM,SUP-2198910,CDM,C1776,CPT,0278,RC,,,,both,,,20632.63,13411.21,,,,,,,,,,,,,
TAP SURG FOR 6.5/7.3MM CANN SCR,SUP-2187432,CDM,C1713,HCPCS,0278,RC,,,,both,,,2171.75,1411.64,,,,,,,,,,,,,
BOLT BNE FIX L185MM DIA65MM PROX L10MM DST L24MM MIDFOOT,SUP-2400776,CDM,C1713,HCPCS,0278,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
SHELL HUM DIA40MM SHLDR CO CHROM BPLR ABS,SUP-2404519,CDM,C1776,CPT,0278,RC,,,,both,,,3808.82,2475.73,,,,,,,,,,,,,
GUIDE SURGICAL VSP NYLON F/ORTHOGNATHIC,SUP-2883356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5593.13,3635.53,,,,,,,,,,,,,
PLATE BNE L63MM 8 H TI RIG DYN LOK COMPR FOR 2.4MM SCR MOD,SUP-2191478,CDM,C1713,HCPCS,0278,RC,,,,both,,,1996.47,1297.71,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.014 IN TIP LOAD 1,SUP-2909310,CDM,C1769,HCPCS,0272,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
PLATE BNE L 16.6 X W 17 MM THK 0.6 MM SCREW DIA2 MM SHRT TI,SUP-2936492,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
STENT NEURO NEUROFORM EZ L 20 MM DIA 4.5 MM MICROCATHETER,SUP-2368089,CDM,C1876,HCPCS,0278,RC,,,,both,,,20943.80,13613.47,,,,,,,,,,,,,
COIL EMB L2CM 2ND DIA1MM HELI SFT NEUROVASC SMRT WAVE,SUP-2323454,CDM,C1889,HCPCS,0278,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
GUIDEWIRE ORTH L460CM DIA3.2MM CO CHROM THRD TIP FOR,SUP-2412148,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CATHETER THOR 20FR L15.75IN PVC SHRP TRCR TIP RADPQ SENTNL,SUP-2154956,CDM,C1729,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
MATRIX SURGICAL WOUND 0.045OZ CONNEXT,SUP-2863796,CDM,C1763,HCPCS,0278,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 12X12X12 MM FUSIONFLEX,SUP-2759431,CDM,C1713,HCPCS,0278,RC,,,,both,,,2203.28,1432.13,,,,,,,,,,,,,
NEEDLE SCLERO L4MM L200CM OD25GA ODSEC18MM 038IN LOK CLR HUB,SUP-2141385,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.43,317.48,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM TIP L10MM 2.5MM SPC QPLR STD CRV,SUP-2148480,CDM,C1733,HCPCS,0272,RC,,,,both,,,4794.78,3116.61,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED SIGN VANGUARD,SUP-2137381,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
STEM XL TAPER 18X185MM,SUP-2505009,CDM,C1776,CPT,0278,RC,,,,both,,,8025.84,5216.80,,,,,,,,,,,,,
BLADE SAW SAG 18.5X10X0.4 MM 0.6 MM FN TOOTH MICROPOWER,SUP-2607449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,79.50,51.67,,,,,,,,,,,,,
"HC Trans, Esb, L/S, Single|BILATERAL PROCEDURE",PX-3606448300,CDM,64483,CPT,0360,RC,,,50,both,,,2817.00,1831.05,,,,,,,,,,,,,
PLATE BNE L37MM 3 H BILAT S STL 1/3 TBLR FOR 3.5MM SCR,SUP-2411330,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.15,118.40,,,,,,,,,,,,,
PATCH HERN M W4.3XL5.5IN UNCOATED MFIL PROPYLENE OVL SELF,SUP-2125897,CDM,C1781,HCPCS,0278,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
PLATE BONE L208MM 12 H S STL T SHP BTTRS LO PROF RIG,SUP-2185762,CDM,C1713,HCPCS,0278,RC,,,,both,,,2091.49,1359.47,,,,,,,,,,,,,
HC Perq Tcat Plmt Ntrac St 1 Les 1+C Segments,PX-4819292800,CDM,92928,CPT,0481,RC,,,,both,,,20807.00,13524.55,,,,,,,,,,,,,
SPACER SHLDR W46XH11XL125MM CERV GENTMYCN INTERSPACE,SUP-2223699,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1294108D3,SUP-2632811,CDM,C1751,HCPCS,0278,RC,,,,both,,,1127.57,732.92,,,,,,,,,,,,,
SAW SURG RECIP DEDICATED HND OP LCK BLADE CLLT KLS VAR SPD T,SUP-2605725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14329.33,9314.06,,,,,,,,,,,,,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,6370000000,HCPCS,0637,RC,00065-0741-14,NDC,,both,4,ML,62.50,40.62,,,,,,,,,,,,,
CATHETER IAB 0.025 IN 0.027 INX8 FRX26 IN 6 IN 50 CC SHTH,SUP-2877608,CDM,C1894,HCPCS,0272,RC,,,,both,,,4254.70,2765.55,,,,,,,,,,,,,
PLATE BNE SM L79MM 12 H MED DST PERIARTC HUM,SUP-2410659,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.23,928.35,,,,,,,,,,,,,
WIRE SURG FLX INSTR NIT,SUP-2608587,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.99,406.89,,,,,,,,,,,,,
STABILIZER SURG S STL STR ELONG FOR PECTUS BAR EXCAVATUM,SUP-2135889,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.82,1659.33,,,,,,,,,,,,,
COIL EMB L40CM DIA002IN LOOP DIA7MM COMPLX STD FRME RUBY,SUP-2323667,CDM,C1889,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
PLATE BNE 4 H R T SLNT COMPR FOR LISFRANC INJ GORILLA,SUP-2321527,CDM,C1713,HCPCS,0278,RC,,,,both,,,3814.63,2479.51,,,,,,,,,,,,,
CAP ORTH,SUP-2388584,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BONE L334MM 18 H LT PROX TIB S STL LCK COMPR LO PROF,SUP-2419194,CDM,C1713,HCPCS,0278,RC,,,,both,,,4768.47,3099.51,,,,,,,,,,,,,
SET DRNGE DBL LUMN SUMP W WIRE GUID AND CONN TB COOK COPE,SUP-2168259,CDM,C1729,HCPCS,0272,RC,,,,both,,,503.19,327.07,,,,,,,,,,,,,
SPLINT THMB AD M L BGE R MCP CMC JT PREFRM PERF FLX BASE LAM,SUP-2326183,CDM,L3908,HCPCS,0274,RC,,,,both,,,65.81,42.78,,,,,,,,,,,,,
ALLOGRAFT BNE WDG LG 25-30X10X15-25 MM FD IL CREST,SUP-2866875,CDM,C1762,CPT,0278,RC,,,,both,,,2296.91,1492.99,,,,,,,,,,,,,
SHUNT VENTRICULOPERITONEAL 120CM L VLV CEREB SPNL FLD,SUP-2244313,CDM,C1889,HCPCS,0278,RC,,,,both,,,16069.58,10445.23,,,,,,,,,,,,,
PACEMAKER CARD ENTOVIS PROMRI SR-T SINGLE CHMBR CELLULAR HM,SUP-2138453,CDM,C1786,HCPCS,0275,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
LINER ACET OD68MM ID32MM HIP MARATHON NEUT SNAP IN REV PINN,SUP-2250409,CDM,C1776,CPT,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
CEMENT BONE POLYMETHYLMETHACRYLATE W/ TOBRA M VISC RADPQ LNG,SUP-2364374,CDM,C1713,HCPCS,0278,RC,,,,both,,,924.73,601.07,,,,,,,,,,,,,
BODY FEM MOD SPOUT UNIV PROX STD OFFSET REV TI 16.6MM 35MM,SUP-2204252,CDM,C1776,CPT,0278,RC,,,,both,,,12470.51,8105.83,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO STR PLT XDRV 12 PK,SUP-2935648,CDM,C1713,HCPCS,0278,RC,,,,both,,,8883.06,5773.99,,,,,,,,,,,,,
SYSTEM DELIVERY MEDICATION CATHETER MACY,SUP-2240139,CDM,C1751,HCPCS,0278,RC,,,,both,,,174.62,113.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 14 ATM 4/6 FRX150 CM 3X220 MM COYOTE,SUP-2145622,CDM,C1725,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 90 CM DIA 5 FR SLT PAT L 10,SUP-2118492,CDM,C1751,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
TRAY APPL BLLN 3.5-5CM TARGETED BRST RAD THER TRCR INTRO,SUP-2239889,CDM,C1751,HCPCS,0278,RC,,,,both,,,8954.65,5820.52,,,,,,,,,,,,,
STEM FEM H35MM 5DEG OFFSET JUNCTION BX TAPR BAL KNEE REV,SUP-2431848,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BLADE RTRCTR RVL 60MMW X 60MML TTNM LMBR 15DG ANGLD TTHD ULT,SUP-2674276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.84,373.65,,,,,,,,,,,,,
MESH SURG W30XL45CM POLY MACROPOROUS FOR EXTRAPERITONEAL,SUP-2172438,CDM,C1781,HCPCS,0278,RC,,,,both,,,1018.74,662.18,,,,,,,,,,,,,
NAIL INTRMDLLRY LOK CNNLTD UNVRSL 8MM DIA 345MML TTNM ALLOY,SUP-2587452,CDM,C1713,HCPCS,0278,RC,,,,both,,,3716.94,2416.01,,,,,,,,,,,,,
CATHETER ABLAT 7FR L60CM ENDOVENOUS RF HEAT ELEMENT,SUP-2393076,CDM,C1888,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
RETRACTOR SINGLE USE CORDLESS ONETRAC LX 135MMX20MM,SUP-2740196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
HEAD FEM DIA36MM OFFSET +5MM 12 14 TAPR HIP ASPHERE M SPEC,SUP-2251145,CDM,C1776,CPT,0278,RC,,,,both,,,5130.13,3334.58,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.442,SUP-2860006,CDM,C1713,HCPCS,0278,RC,,,,both,,,48716.47,31665.71,,,,,,,,,,,,,
PLATE BNE L26MM THK1MM NONSTERILE R PHLANG HD HND TI LOK VAR,SUP-2181008,CDM,C1713,HCPCS,0278,RC,,,,both,,,1471.59,956.53,,,,,,,,,,,,,
OVITEX PRS PERMANENT POLYMER 11.5X22CM 3 LAYERS,SUP-2914475,CDM,C1781,HCPCS,0278,RC,,,,both,,,13285.34,8635.47,,,,,,,,,,,,,
DEVICE PESSARY OD2 1/2IN GELLHORN FLEX IMP,SUP-2171735,CDM,A4562,HCPCS,0274,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
CATHETER CARD ABLATION RF MARINR L 80 CM DIA 5 FR TIP L 65,SUP-2749546,CDM,C1732,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SHUNT KIT EDW BARBARO SYRINGO LUMPERITON T TUBE FOLTZ CSF,SUP-2838800,CDM,C1889,HCPCS,0278,RC,,,,both,,,3686.71,2396.36,,,,,,,,,,,,,
NORETHINDRONE ACETATE 5 MG PO TABS,RX-10747,CDM,6370000000,HCPCS,0637,RC,68462-0304-50,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SYSTEM HIP UPLR CEMTD FEM W/ LRG MET HD,SUP-2347955,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
RING EXT FIX HALF 140 MM CARBON FIBER RINGFIX,SUP-2365277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3161.98,2055.29,,,,,,,,,,,,,
SCREW BNE FIX L48MM UNICORTICAL THRD N CANN N LOK S STL HD,SUP-2200478,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
BUR SURG RND CUT SHT 3 MM ROSEN N FLUT HI-LINE XS DISP,SUP-2108764,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.49,223.92,,,,,,,,,,,,,
SCREW BONE L44MM OD5.5MM PNK MIDFOOT HINDFOOT ANK CANN SH,SUP-2320939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1747.41,1135.82,,,,,,,,,,,,,
CATHETER CV DL 7 FRX20 CM KT BLU FLEXTIP,SUP-2383472,CDM,C1751,HCPCS,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
BIT DRL OD15MM LT GRN W AO,SUP-2244014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.61,367.65,,,,,,,,,,,,,
PORT HND ACCS INJ INTRO LAP DISP TRIPRT,SUP-2313599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1054.26,685.27,,,,,,,,,,,,,
PLATE BNE L69MM 6 H S STL 1/3 TBLR LOK COMPR W/ CLLR FOR,SUP-2185930,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.36,295.33,,,,,,,,,,,,,
PLATE BNE W5XL23MM THK1MM 4 H S STL STR FOR 2MM SCR,SUP-2186148,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.87,500.42,,,,,,,,,,,,,
NEEDLE BRONCH TREE BRONCH INTACT HLTH NAKHOSTEEN BRONCHSCP,SUP-2772833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2348.22,1526.34,,,,,,,,,,,,,
SCREW COMPR 1.5X14MM HEADLESS TI STRL,SUP-2547164,CDM,C1713,HCPCS,0278,RC,,,,both,,,699.50,454.67,,,,,,,,,,,,,
TUBE CHST 16FR L9 8 10IN OPN TIP STR FIRM RADPQ POLYVI CHL,SUP-2174292,CDM,C1729,HCPCS,0272,RC,,,,both,,,37.62,24.45,,,,,,,,,,,,,
BLADE SURG SERRATED 20 MM UNILAT TUBESET NEXUS BONESCALPEL,SUP-2745898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1638.04,1064.73,,,,,,,,,,,,,
SYSTEM BRST LOC 75CM DEL NDL SAVI SCOUT,SUP-2164411,CDM,C1819,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
CATHETER EP D 2-5-2 MM SPC 7 FRX95 CM RADIA,SUP-2142360,CDM,C1731,HCPCS,0278,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 24CML IN 5565240,SUP-2632903,CDM,C1752,HCPCS,0278,RC,,,,both,,,538.07,349.75,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM DIA 6 FR DIAG QPLR D-TYPE,SUP-2495465,CDM,C1730,HCPCS,0272,RC,,,,both,,,379.06,246.39,,,,,,,,,,,,,
INBONE EVERLAST SZ 2 6MM TOTAL ANKLE,SUP-2822304,CDM,C1776,CPT,0278,RC,,,,both,,,4637.78,3014.56,,,,,,,,,,,,,
FIBER LASER 200 MH SOLTIVE DISP,SUP-2540082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.67,775.89,,,,,,,,,,,,,
MIXOR VAC SYS.W/SYRINGE,SUP-2822522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BONE L189MM 14 H NONSTERILE RT PROX TIB S STL LO PROF,SUP-2185819,CDM,C1713,HCPCS,0278,RC,,,,both,,,3746.90,2435.48,,,,,,,,,,,,,
STIMULATOR NERVE PT PRGMR EON,SUP-2355981,CDM,C1787,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 7 FRX15 CM 3L RIFAMPIN SPECTRUM,SUP-2759874,CDM,C1751,HCPCS,0278,RC,,,,both,,,478.35,310.93,,,,,,,,,,,,,
PLATE BNE H1.5MM 14 H MAND G TI LO PROF FRAC FOR 2/2.3MM,SUP-2366366,CDM,C1713,HCPCS,0278,RC,,,,both,,,2102.80,1366.82,,,,,,,,,,,,,
BREXUCABTAGENE AUTOLEUCEL 100000000 CELLS IV SUSP,RX-156489,CDM,Q2053,HCPCS,0891,RC,71287-0220-01,NDC,,both,1,UN,3234000.00,2102100.00,,,,,,,,,,,,,
BLADESTERILEABRADER BURR,SUP-2574153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,302.92,196.90,,,,,,,,,,,,,
IMPLANT BLGCL TSSUE SHEET 100SQCM 10CMW X 10CML PRCNE TSSUE,SUP-2707153,CDM,Q4130,HCPCS,0636,RC,,,,both,,,9614.68,6249.54,,,,,,,,,,,,,
ELECTRODE STARBURST XLI ENH 9 ARRY + ACT TRCR TIP,SUP-2118723,CDM,C1894,HCPCS,0272,RC,,,,both,,,9332.08,6065.85,,,,,,,,,,,,,
PLATE STD BRL OMEGA SS 8 HL 145DEG,SUP-2487853,CDM,C1713,HCPCS,0278,RC,,,,both,,,2774.19,1803.22,,,,,,,,,,,,,
FRAME EXT FIX L155MM ASSEMB FT ILIZ,SUP-2343004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36595.29,23786.94,,,,,,,,,,,,,
KIT HEMTLGY 30ML PLT RICH PLSM DISP PEAK,SUP-2256856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
CENTRALIZER FEM L135MM DIA11MM HIP CO CHROM PMMA FORGED,SUP-2405078,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
SCREW TIB FIX MOD ROD CAP,SUP-2363497,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
HC Perc D-E Cor Revasc Chro Add,PX-4810960800,CDM,C9608,CPT,0481,RC,,,,both,,,9327.00,6062.55,,,,,,,,,,,,,
PLATE BNE L322MM 16 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185691,CDM,C1713,HCPCS,0278,RC,,,,both,,,5017.09,3261.11,,,,,,,,,,,,,
TIP SONOPET BARRACUDA 12CM IQ,SUP-2844703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2977.72,1935.52,,,,,,,,,,,,,
COMPONENT SUBTALAR L15MM DIA9MM RESRB SFT THRD CYL BIOBLOCK,SUP-2242685,CDM,C1713,HCPCS,0278,RC,,,,both,,,6643.39,4318.20,,,,,,,,,,,,,
STEM FEM SZ 12 R IMAG,SUP-2344438,CDM,C1776,CPT,0278,RC,,,,both,,,15409.55,10016.21,,,,,,,,,,,,,
CONTROLLER INTELLIS PTM NONTRAIL,SUP-2750022,CDM,C1787,HCPCS,0278,RC,,,,both,,,3011.26,1957.32,,,,,,,,,,,,,
GRAFT FRZ DRY ALLGRFT 100-150CM2,SUP-2165570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
HC Mammo Screening Incl Cad if Perf,PX-4037706700,CDM,77067,CPT,0403,RC,,,,inpatient,,,480.00,312.00,,,,,,,,,,,,,
SPINAL KIT STANDARD 4 MM STANDARD TITANIUM STERILE MATRIXNEU,SUP-2837710,CDM,C1713,HCPCS,0278,RC,,,,both,,,2104.43,1367.88,,,,,,,,,,,,,
POST EXT FIX DIA11MM 90DEG OUTRIG MAG RESONANCE CONDITIONAL,SUP-2188510,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.90,233.28,,,,,,,,,,,,,
EXTENSION LD D4 25 CM DSTL SPL,SUP-2539657,CDM,C1883,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X25X6 MM FD SPNG CANC READIGRAFT BLX,SUP-2740890,CDM,C1713,HCPCS,0278,RC,,,,both,,,3821.54,2484.00,,,,,,,,,,,,,
HC Thrombolytic Ther Stroke,PX-4503719500,CDM,37195,CPT,0450,RC,,,,both,,,1088.00,707.20,,,,,,,,,,,,,
SLEEVE TIB L7CM TI POR PROX KNEE REDUC SZ OSS MARTI VIERZON,SUP-2406487,CDM,C1776,CPT,0278,RC,,,,both,,,11770.29,7650.69,,,,,,,,,,,,,
PLATE BONE SM 116MML HLX10 STNLSS STEEL BTTRSS ST RIGHT DST,SUP-2471023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2111.30,1372.34,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT MENIS W/ HEMI PLATEAU MED HUM,SUP-2307290,CDM,C1762,CPT,0278,RC,,,,both,,,18103.83,11767.49,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,J7060,HCPCS,0258,RC,00264-7510-10,NDC,,both,500,ML,34.00,22.10,,,,,,,,,,,,,
GUIDEWIRE VASC STR 10 CM 0.035 INX150 CM BENT FIX INQWIRE,SUP-2302701,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.47,21.76,,,,,,,,,,,,,
LEAD PACE SIL MYOCARDIAL RT VENTRICULAR SCREW FIX IS1 UPLR,SUP-2148632,CDM,C1898,HCPCS,0275,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER EP H 2-7-1 MM 7 FRX110 CM INQUIRY,SUP-2357628,CDM,C1730,HCPCS,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SYSTEM VLV SHUNT ADJ DIFF PRSS 0-20CM H2O W/O GRAVITATIONAL,SUP-2108724,CDM,C1729,HCPCS,0272,RC,,,,both,,,10263.09,6671.01,,,,,,,,,,,,,
PLATE BNE L50MM 3X3 H T SHP FOR 3.5MM SCR,SUP-2411361,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
WASHER ORTH 9 H RECON PLT LISFRANC CHARLOTTE,SUP-2397630,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
HEAD HUM H21MM OD64MM ID54MM SHLDR CO CHROM MOD NECKLESS,SUP-2404506,CDM,C1776,CPT,0278,RC,,,,both,,,4684.88,3045.17,,,,,,,,,,,,,
BLADE SHV DIA3MM STR AGG TURB HEMSTAT W/ PK TECHNOLOGY FOR,SUP-2313841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3326.01,2161.91,,,,,,,,,,,,,
LEAD DEFIB 59 CM ENDOCARD 2 COIL PASS FIX RELIANCE ENDOTK,SUP-2148612,CDM,C1895,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA10 MM EPTFE STR TW N RING HEMO,SUP-2126598,CDM,C1768,CPT,0278,RC,,,,both,,,1641.37,1066.89,,,,,,,,,,,,,
DEVICE EXTR BLLN OD85MM 115 15MM DST TIP OD45FR ERCP MULT,SUP-2312989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.61,324.75,,,,,,,,,,,,,
ROD EXT FIX THRD 150 MM UNIV HINGE,SUP-2517346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1939.26,1260.52,,,,,,,,,,,,,
BUR SURG MED 6.7 MM COR TOOL FOR HD-G1,SUP-2848301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,985.77,640.75,,,,,,,,,,,,,
HC OP Traction Intermittent,PX-4209701200,CDM,97012,CPT,0420,RC,,,,outpatient,,,292.00,189.80,,,,,,,,,,,,,
PACEMAKER CARD ADVANTIO W 4.45 X H 4.70 CM THK 0.75 CM 24.5,SUP-2149239,CDM,C1785,HCPCS,0275,RC,,,,both,,,10462.48,6800.61,,,,,,,,,,,,,
CATHETER INFUSION 2.7 FRX165 CM 20 CM MAGIC SPIF FLO COIL,SUP-2424286,CDM,C1887,HCPCS,0272,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
SCREW BONE L32MM DIA4MM FEMORAL DEEP THREADED NCB,SUP-2472330,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
CEMENT LNR BASE STD DYCAL PRISMA VLC,SUP-2238603,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.76,380.09,,,,,,,,,,,,,
NAIL IM L165MM DIA3.175MM FEM HIP S STL CANN NONLOCKING,SUP-2371422,CDM,C1713,HCPCS,0278,RC,,,,both,,,1204.50,782.92,,,,,,,,,,,,,
HARVESTER MORSELIZING BONE GRAFT AO 6MM,SUP-2740174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2187.01,1421.56,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL SM W40XL40MM THK0.3MM MALL,SUP-2419457,CDM,C1713,HCPCS,0278,RC,,,,both,,,3740.18,2431.12,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.8 MM THOR 4 HOLE LCK ANGLE NS LEVEL 1,SUP-2869248,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.05,299.68,,,,,,,,,,,,,
SHELL ACET 64 MM HIP 3 HOLE HA REFLECTION INTERFIT,SUP-2434632,CDM,C1776,CPT,0278,RC,,,,both,,,6663.08,4331.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FOX SV L 135 CM BALLOON L 100 MM DIA10,SUP-2106194,CDM,C1874,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT ARTHSCP HIP MSTR DISP W/ KNF BLDE,SUP-2121991,CDM,C1769,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ORTHOSIS ANK FT SM SZ M 6-7.5 WOM 7.5-9 LT CLOSE HEEL DLX,SUP-2195193,CDM,L1930,HCPCS,0272,RC,,,,both,,,104.72,68.07,,,,,,,,,,,,,
ACETIC ACID 3 % SOLN,RX-15091,CDM,6370000000,HCPCS,0637,RC,09999-9917-50,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 20 CM DIA 6 MM THK 0.49 MM POLYESTER,SUP-2227563,CDM,C1768,CPT,0278,RC,,,,both,,,1401.29,910.84,,,,,,,,,,,,,
PLATE OLECRANON 3.5MM 12H LT 216MM SS LCP STRL,SUP-2547490,CDM,C1713,HCPCS,0278,RC,,,,both,,,3674.77,2388.60,,,,,,,,,,,,,
HC Surgery Robot Addtl 15min,PX-3600000019,CDM,3600000019,LOCAL,0360,RC,,,,both,,,5209.00,3385.85,,,,,,,,,,,,,
CYCLOPENTOLATE HCL 2 % OP SOLN,RX-9700,CDM,6370000000,HCPCS,0637,RC,00065-0397-02,NDC,,both,2,ML,208.70,135.65,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE STRL SELD BASIC 18GA 10CM 1 LUMAN ST018100,SUP-2613565,CDM,C1751,HCPCS,0278,RC,,,,both,,,340.56,221.36,,,,,,,,,,,,,
HC Ph Body Fluid Not Elsewhere Specified,PX-3018398600,CDM,83986,CPT,0301,RC,,,,both,,,86.00,55.90,,,,,,,,,,,,,
HC So Hep B Core Ab - Ref,PX-3028670468,CDM,86704,CPT,0302,RC,,,,both,,,21.00,13.65,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X116 MM LT POSTEROLATERAL DSTL 6,SUP-2424163,CDM,C1713,HCPCS,0278,RC,,,,both,,,2020.15,1313.10,,,,,,,,,,,,,
PLATE BNE STR 3.5X213 MM 18 HOLE RECON FOR SCR SS NS,SUP-2458666,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.67,975.44,,,,,,,,,,,,,
PLATE BONE FAN 35X1.5 MM POROUS POLYETHYLENE STERILE SYNPOR,SUP-2837801,CDM,C1713,HCPCS,0278,RC,,,,both,,,2325.48,1511.56,,,,,,,,,,,,,
GRAFT HUM TISS W6XL12CM THK0.9-1.99MM ACELLULAR DERM MTRX,SUP-2402511,CDM,Q4126,HCPCS,0636,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
STEM FEM SEG 3 150/200/240 MM HIP REV NK ENDUR,SUP-2454655,CDM,C1776,CPT,0278,RC,,,,both,,,3859.06,2508.39,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO SQ PLATE XDRV 1 PK,SUP-2935486,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
LARYNGECTOMY KIT PULM 9/36 9/55 STD W/ PROVOX LARYTUBE,SUP-2424442,CDM,C1713,HCPCS,0278,RC,,,,both,,,2228.58,1448.58,,,,,,,,,,,,,
GUIDEWIRE URLGCL 0032N DIA 150CML 18CML TIP CTD STRGHT TIP,SUP-2729842,CDM,C1769,HCPCS,0272,RC,,,,both,,,97.59,63.43,,,,,,,,,,,,,
CAP NAIL L4.7MM FEM HEX SET SCR META-NAIL TRIGEN,SUP-2347544,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.68,764.19,,,,,,,,,,,,,
METHOTREXATE SODIUM 1 G IJ SOLR,RX-4975,CDM,J9260,HCPCS,0636,RC,00143-9367-01,NDC,,both,1,UN,129.60,84.24,,,,,,,,,,,,,
ATTACHMENT HNDPC ANG TELSCP TUBE T12 MIDAS REX LEGEND,SUP-2284705,CDM,C1713,HCPCS,0278,RC,,,,both,,,2616.69,1700.85,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-9.5 MM 15 CC FD CORTICAL CANC,SUP-2717788,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.63,420.96,,,,,,,,,,,,,
CURVED RECON 3.5MM 6X70MM,SUP-2818480,CDM,C1713,HCPCS,0278,RC,,,,both,,,3487.44,2266.84,,,,,,,,,,,,,
PLATE BNE L226MM 12 H NONSTERILE R LAT PROX TIB S STL LOK,SUP-2185722,CDM,C1713,HCPCS,0278,RC,,,,both,,,4320.04,2808.03,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 50 CM DIA20 X 11 MM THK 0.49 MM,SUP-2669753,CDM,C1768,CPT,0278,RC,,,,both,,,2567.70,1669.00,,,,,,,,,,,,,
APPLIER TKR SYS W/ MAL GRFT RETRCT FOR OMNISPAN MENISCI REP,SUP-2252748,CDM,C1769,HCPCS,0272,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
SHAVER SURG SIL SLV MACR HK STRL DISP BONESCALPEL,SUP-2887851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1280.62,832.40,,,,,,,,,,,,,
LINER ACET OD49MM ID28MM STD DURASUL HIP PRI NEUT SNAP IN,SUP-2207461,CDM,C1776,CPT,0278,RC,,,,both,,,2326.74,1512.38,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 63 X 31 X 17 MM POLYETHYL LT EAR BASE,SUP-2935586,CDM,C1713,HCPCS,0278,RC,,,,both,,,7278.52,4731.04,,,,,,,,,,,,,
PSN REV TIB FIXED KEEL CMT SZ D L,SUP-2508652,CDM,C1776,CPT,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 8 DEG 23-27X24-32X13 MM FD ANGLED FRA,SUP-2736752,CDM,C1713,HCPCS,0278,RC,,,,both,,,12317.91,8006.64,,,,,,,,,,,,,
CATHETER CTRL VEN AD 5FR L16CM POLYUR SGL LUMN N TUNNELED,SUP-2120605,CDM,C1751,HCPCS,0278,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST GTT LCK RETAINER,SUP-2435697,CDM,L2785,HCPCS,0274,RC,,,,both,,,83.90,54.53,,,,,,,,,,,,,
HARNESS CERV VIS PD33600] PROVIDENCE MEDICAL TECHNOLOGY],SUP-2330585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 300 CM DIA 0.018 IN TIP,SUP-2385542,CDM,C1769,HCPCS,0272,RC,,,,both,,,974.97,633.73,,,,,,,,,,,,,
PLATE BNE L141MM THK3MM 9 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185340,CDM,C1713,HCPCS,0278,RC,,,,both,,,1872.23,1216.95,,,,,,,,,,,,,
NUT ORTH CO CHROM MOLYBDENUM ALLOY AUX MINI COMPR,SUP-2406902,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
DX KNOTLESS SWIVELOCK PEEK 4.75 MM,SUP-2815360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
HC Creatine Kinase Total,PX-3018255000,CDM,82550,CPT,0301,RC,,,,both,,,160.00,104.00,,,,,,,,,,,,,
COMPONENT FEM SZ 1 R KNEE OXINIUM POST STBL PRI CEM,SUP-2346169,CDM,C1776,CPT,0278,RC,,,,both,,,12041.90,7827.23,,,,,,,,,,,,,
PROBE MICROWAVE ABLATION L 15 CM DIA15 GA STRL DISP NEUWAVE,SUP-2908862,CDM,C1886,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 7 CM DIA 4 FR 0.018 IN 4 CM 21 GA NIT,SUP-2677274,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.84,59.05,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK1.04-2.28MM THCK REGEN TISS,SUP-2113002,CDM,Q4116,HCPCS,0636,RC,,,,both,,,36716.02,23865.41,,,,,,,,,,,,,
SET AUTOTRNS 10L 120UM ATF FAST COLLCTN RESVR SUCT LN W/,SUP-2385070,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SCREW BNE CANN 13-16 MM SUBTALAR TI DP VARIO,SUP-2861391,CDM,C1713,HCPCS,0278,RC,,,,both,,,4909.52,3191.19,,,,,,,,,,,,,
SPLINT REST HND ADL L S DRBLUE BROAD,SUP-2165486,CDM,L3807,HCPCS,0272,RC,,,,both,,,140.26,91.17,,,,,,,,,,,,,
SHEATH URO L35CM OD3FR ID12FR 2 LUMN FLX DL,SUP-2171425,CDM,C1894,HCPCS,0272,RC,,,,both,,,580.27,377.18,,,,,,,,,,,,,
SPACER SPNL 45X10X10 MM INTBDY FUSION DEV CRESCENT,SUP-2281752,CDM,C1889,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
EXTENSION LD 25 CM SPNL CRD PRECIS,SUP-2138800,CDM,C1883,HCPCS,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
NAIL IM L 120 MM DIA 8 MM COMPR SCREW STRL T2,SUP-2900534,CDM,C1713,HCPCS,0278,RC,,,,both,,,10738.80,6980.22,,,,,,,,,,,,,
SPACER HUM L9MM TRABECULAR MTL,SUP-2199140,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BIT DRILL 2.6MM AO SHANK,SUP-2858751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
GRAFT HUM TISS M W60MMXL10CM FRZ DRY,SUP-2307105,CDM,C1762,CPT,0278,RC,,,,both,,,1958.42,1272.97,,,,,,,,,,,,,
BIT DRL DIA5.2MM FOR 7MM CANN SCR,SUP-2343599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3259.01,2118.36,,,,,,,,,,,,,
TUBE VENT L5MM FLNG L2MM LUMN DIA135MM INNR EAR PC SIL FOR,SUP-2232492,CDM,L8699,HCPCS,0278,RC,,,,both,,,93.57,60.82,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CHARGER L 135 CM BALLOON L 60 MM DIA 5,SUP-2140812,CDM,C1725,HCPCS,0272,RC,,,,both,,,276.95,180.02,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X2 CM CRYOPRESERVED UMB CRD NEOX CRD 1K,SUP-2648684,CDM,Q4148,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HEAD HUM ANAT 3.5 MM 37X13.5 MM SHLDR HIGH OFFSET COCR,SUP-2715717,CDM,C1776,CPT,0278,RC,,,,both,,,10484.46,6814.90,,,,,,,,,,,,,
PLATE BONE FIXATION 2 MM CONDYLAR TITANIUM,SUP-2837684,CDM,C1713,HCPCS,0278,RC,,,,both,,,1191.32,774.36,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CER GRAN TYPE-I BOV CLLGN RPM CARR,SUP-2930803,CDM,C1763,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
BALL TIP NRV STIM PRB 160MM,SUP-2415717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GRAFT BNE VOID FILL MIXING DEL SYS MG,SUP-2742078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.531,SUP-2860048,CDM,C1713,HCPCS,0278,RC,,,,both,,,45470.03,29555.52,,,,,,,,,,,,,
BIT DRL TWST TIP FOR 2.3MM BIORAPTOR ANCHR,SUP-2341800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
BUR SURG 3MM COARSE DMND MTCH HD,SUP-2365196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,639.15,415.45,,,,,,,,,,,,,
SCREW SPNL 6.5X40 MM PEDCL,SUP-2211275,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
WASHER ORTH OD7MM OLV WIRE S STL,SUP-2343821,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.43,926.53,,,,,,,,,,,,,
SPONGE SCLER BCKL 3X5MM STYL 506 OVL,SUP-2213490,CDM,C1784,HCPCS,0278,RC,,,,both,,,201.59,131.03,,,,,,,,,,,,,
CATHETER LD RETRV AVEIR VR L 105 CM DIA25 FR TRI LOOP 2,SUP-2880903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GRAFT VASC PTCH 7.5X8 MM POLYESTER DBL VELOUR ULTRAMAX,SUP-2469104,CDM,C1768,CPT,0278,RC,,,,both,,,386.82,251.43,,,,,,,,,,,,,
NAIL IM L440MM DIA4MM PROX TIB PUR TI ALLY,SUP-2192733,CDM,C1713,HCPCS,0278,RC,,,,both,,,987.12,641.63,,,,,,,,,,,,,
COMPONENT TOE L13MM DIA7MM MT CE TAPR POST HEMICAP,SUP-2123592,CDM,C1776,CPT,0278,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
PLATE BNE L26MM THK075MM 2X5 H NONSTERILE PHLANG BASE HND TI,SUP-2180989,CDM,C1713,HCPCS,0278,RC,,,,both,,,1607.77,1045.05,,,,,,,,,,,,,
PLATE SPNL CERV 4.5X12 MM SEMI-CONSTRN ST PYRENEES,SUP-2732263,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
CLIP EXT FIX DYNAMIZATION FOR LG COMBINATION CLMP,SUP-2188497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.32,282.31,,,,,,,,,,,,,
PLATE SPNL 16 H THOR PRE CNTOUR RIBFIX BLU,SUP-2137002,CDM,C1713,HCPCS,0278,RC,,,,both,,,5793.30,3765.64,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 25X25MM,SUP-2473271,CDM,C1713,HCPCS,0278,RC,,,,both,,,6644.24,4318.76,,,,,,,,,,,,,
SHEARS ENDO L20CM DIA10MM HARM SCALP HNDPC ULTRASONIC UCIS,SUP-2257412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.22,710.59,,,,,,,,,,,,,
IMPLANT BIO L 3 X W 12 CM FISH SKIN DERMAL FEN 11 INTACT,SUP-2909225,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
CONNECTOR SPNL SZ 7 L37-45MM STD POST S STL FIX TRNSVRS CONN,SUP-2254369,CDM,C1713,HCPCS,0278,RC,,,,both,,,3912.44,2543.09,,,,,,,,,,,,,
PLATE BNE L119MM 7 H SEMI TBLR FOR 4.5MM SCR L FRAG SYS,SUP-2411404,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.73,129.17,,,,,,,,,,,,,
SPACER SPNL LORDTC 360 DEG STD 14X13X8 MM STRL ACIS PROTI,SUP-2590288,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 4 FR GUIDEWIRE PERIPHERAL,SUP-2385661,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.18,24.17,,,,,,,,,,,,,
SCREW BNE 3.5X14 MM TI,SUP-2321690,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
CATHETER THRMDIL 6FR 110CM BAL TORQ CTRL,SUP-2383251,CDM,C1751,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
BLADE SHAVER RESECT 3.5X130 MM SMOOTH DISP,SUP-2661215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.30,232.24,,,,,,,,,,,,,
ALLOGRAFT BNE PARL MED 14X13X6X6 MM CANC VERTIGRAFT VG2,SUP-2740763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2721.38,1768.90,,,,,,,,,,,,,
PLATE BNE L212MM THK3.4MM 16 H BILAT S STL STR LOK COMPR,SUP-2185155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1817.40,1181.31,,,,,,,,,,,,,
COMPONENT TALAR SINGLE COATED/US VERS LARGE RIGHT,SUP-2878211,CDM,C1776,CPT,0278,RC,,,,both,,,20158.96,13103.32,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME RT KNEE COMBINED INSTABILITY,SUP-2914917,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1031.30,670.34,,,,,,,,,,,,,
SPHINCTEROTOME ENDO OD5.5FR 0.021IN DOME TIP BLK CONN DASH,SUP-2169612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
BUR SURG L3.8MM DIA3MM NEURO DMND SABER SHANK ELITE TPS,SUP-2367600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.12,215.88,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvic/Le 1st Ord,PX-3613624500,CDM,36245,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PIFLUFOLASTAT F 18 9 MCI IV SOSY,RX-155146,CDM,A9595,HCPCS,0343,RC,71258-0022-00,NDC,,both,.1,UN,1363.00,885.95,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM ALUM,SUP-2162655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3562.02,2315.31,,,,,,,,,,,,,
SCREW BONE L44MM DIA4.5MM THRD L13MM CORT TI ST SELF DRL,SUP-2190385,CDM,C1713,HCPCS,0278,RC,,,,both,,,61.45,39.94,,,,,,,,,,,,,
TRAY DRNGE CATH 5FR THORA-PARA,SUP-2133921,CDM,C1729,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
PLATE BNE LT 6 HOLE,SUP-2321648,CDM,C1713,HCPCS,0278,RC,,,,both,,,4341.05,2821.68,,,,,,,,,,,,,
BUR SURG 13.5 MM TREPHINE FOR OTO SPINE,SUP-2607578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.61,324.75,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1.25 CC CER GRAN TYPE-I BOV CLLGN RPM,SUP-2930798,CDM,C1763,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
CATHETER COR L20.25IN OD3.45MM ID1.73MM CUF DIA13/32IN SIL,SUP-2384406,CDM,C1751,HCPCS,0278,RC,,,,both,,,381.86,248.21,,,,,,,,,,,,,
CURETTE SURG CUP STR AQ/AC,SUP-2897555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
INTRODUCER SHTH J 10 FRX11 CM ENHANCED DIL DBL DSTL INPUT TS,SUP-2294413,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND SHLDR CUST CAP DESIGN W/O JT,SUP-2435792,CDM,L3961,HCPCS,0274,RC,,,,both,,,4329.02,2813.86,,,,,,,,,,,,,
KNIFE ELECSURG 1.5 MM TWIN PK ORISE GEL CATH ORISE PROKNIFE,SUP-2754409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
SHEATH INTRO L 80 CM DIA 6 FR STRL,SUP-2383980,CDM,C1894,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
HC So Acetylcholn Rcptr Bndng Antb,PX-3028604166,CDM,86041,CPT,0302,RC,,,,both,,,207.00,134.55,,,,,,,,,,,,,
ELECTRODE CORTICAL 2 X 8 T TAIL KT STRL DISP EVO,SUP-2934766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
KIT CATH 7FR L20CM CTRL VEN POLYUR 3 LUMN BLU FLEXTIP ARWGRD,SUP-2120598,CDM,C1751,HCPCS,0278,RC,,,,both,,,227.34,147.77,,,,,,,,,,,,,
WIRE FIX 1.6 MM ASNS KIRSCHNER,SUP-2362518,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
PLATE BNE L132MM 8 H L LAT DST PERIARTC FIBULAR S STL LOK,SUP-2410717,CDM,C1713,HCPCS,0278,RC,,,,both,,,2235.49,1453.07,,,,,,,,,,,,,
PLATE BNE L80MM 4 H R LAT DST PERIARTC FIBULAR S STL LOK,SUP-2410713,CDM,C1713,HCPCS,0278,RC,,,,both,,,1812.06,1177.84,,,,,,,,,,,,,
CONNECTOR SPNL OD5.5X5.5MM TI THORLUM SACR PARA DOMINO FOR,SUP-2205439,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
GRAFT DURA W3XL3IN CLLGN BASE CSF LEAK RESISTANCE DURAFORM,SUP-2243766,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE 9HL 2.7X107MM,SUP-2477304,CDM,C1713,HCPCS,0278,RC,,,,both,,,952.17,618.91,,,,,,,,,,,,,
STIMULATOR NERVE REMOT CTRL PRGMR KT FREELINK,SUP-2139754,CDM,C1787,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SPHERE GLEN DIA36MM STD REVERSED AEQUALIS PERFORM,SUP-2388775,CDM,C1776,CPT,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
PROSTHESIS OSS L8MM TRIM L57MM HD W4MM FLNG DIA4MM SHFT,SUP-2312571,CDM,L8613,CPT,0278,RC,,,,both,,,1209.21,785.99,,,,,,,,,,,,,
PLATE BNE RADIAL C1 LNG LT VOLAR DSTL SCR ANGLE MOD TI,SUP-2646866,CDM,C1713,HCPCS,0278,RC,,,,both,,,2142.23,1392.45,,,,,,,,,,,,,
PLATE BNE THK15MM M 4 H TI LOK FOR 27MM SCR 2MM MINI SYS,SUP-2262961,CDM,C1713,HCPCS,0278,RC,,,,both,,,1346.53,875.24,,,,,,,,,,,,,
SNARE VASC 1 SNR L 200 CM LOOP DIA 4 MM CATH L 175 CM,SUP-2702000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
SHEATH INTRO L 5.5 CM DIA 5 FR STRL,SUP-2153790,CDM,C1894,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
KIT INTRO INTROFLEX L 10 CM DIA 7 FR DETACHABLE AUTO VLV,SUP-2214540,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
SCREW SPNL STR RAIL 4.5X500 MM DEFORMITY TI MESA RAIL 4D,SUP-2538575,CDM,C1713,HCPCS,0278,RC,,,,both,,,5770.32,3750.71,,,,,,,,,,,,,
HC Clsd Tx MC Fx Manipulation,PX-4502660500,CDM,26605,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE ADPT NEUT 2X81 MM 12 HOLE LP RIGID LCK COMPR TI,SUP-2191259,CDM,C1713,HCPCS,0278,RC,,,,both,,,1222.43,794.58,,,,,,,,,,,,,
MESH CRAN 105X60 MM 0.6 MM PLATE PROF PANEL OBLONG CP TI,SUP-2493671,CDM,C1713,HCPCS,0278,RC,,,,both,,,3645.95,2369.87,,,,,,,,,,,,,
SIROLIMUS 0.5 MG PO TABS,RX-102547,CDM,J7520,HCPCS,0636,RC,68382-0520-01,NDC,,both,1,UN,24.60,15.99,,,,,,,,,,,,,
OCCLUDER CV L12MM BLB DIA3.5MM SIL RUB COR VES RADPQ DISP,SUP-2129864,CDM,C1760,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
SCREW BONE L20MM DIA2MM STD CORT TI NCANNULATED FULL THRD N,SUP-2189312,CDM,C1713,HCPCS,0278,RC,,,,both,,,93.54,60.80,,,,,,,,,,,,,
GRAFT BONE PUTTY W/ CHIP DEMIN BONE MTRX 2CC PUROS,SUP-2197454,CDM,C9359,HCPCS,0278,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
LEVEL NEURO MESH 3D NEURO SCRW75 X 75 MM T08 MM CP TTNM QT0,SUP-2681431,CDM,C1713,HCPCS,0278,RC,,,,both,,,3044.36,1978.83,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.035 IN CRV RAD 3 MM STR FIX COR,SUP-2167844,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.44,56.19,,,,,,,,,,,,,
PLATE SPNL FIX 75 ANTR LAT THORLUM TI TRAVERSE,SUP-2561610,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
DEVICE BNE BX SZ 3 8GA FOR INTVENT THER KYPHON,SUP-2293564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
FOOTSWITCH LASER H65W H100W HOLM EMPOWER,SUP-2489928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2710.95,1762.12,,,,,,,,,,,,,
PLATE BNE L 119 MM SCREW DIA 3.5 MM 10 SHFT H TI 1/3 TUBLR,SUP-2907866,CDM,C1713,HCPCS,0278,RC,,,,both,,,2753.00,1789.45,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SM 1.3 CC CORTICOCANCELLOUS VIABLE 4PK,SUP-2936803,CDM,C1762,CPT,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
HC Pvb Thoracic 2 or More Inj Site,PX-3606446200,CDM,64462,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
GRAFT BONE 1ML MULT POTENT CELLULAR SUSP TISS OVATION REP,SUP-2319176,CDM,C1762,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CATHETER ETER FULL TY STR RADPQ TIP POLYUR 11 FR 15 CM,SUP-2269566,CDM,C1750,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
GRAFT BNE MTRX XL 20 CC FIBERGRAFT BG,SUP-2736522,CDM,C1713,HCPCS,0278,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
SHAFT RAD TRADTIONAL ALLGRFT 40 MM FRZ DRY,SUP-2294109,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
BOUGIE ESOPH HURST TUNGSTEN FIL 32FR SIL,SUP-2383702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.82,231.28,,,,,,,,,,,,,
ROD SPNL SZ 12 RAD 220MM LUM GLD TI ALLOY EXTN VEPTR,SUP-2193330,CDM,C1713,HCPCS,0278,RC,,,,both,,,7501.46,4875.95,,,,,,,,,,,,,
HC US Spinal Canal and Contents,PX-4027680000,CDM,76800,CPT,0402,RC,,,,both,,,693.00,450.45,,,,,,,,,,,,,
FIBER LASER FLAT TIP 800 MH ASMBLY HOLM,SUP-2300072,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
BIT DRL L45MM DIA1.1MM ST TI JCBS CHK NONRADIOPAQUE W/O STP,SUP-2187169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,363.30,236.14,,,,,,,,,,,,,
CATHETER EP MED CRV 2-5-2 MM 6 FRX110 CM QPLR,SUP-2357433,CDM,C1730,HCPCS,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
SCREW BNE ST 2.7X18 MM CORTICAL W/ T8 SS NS,SUP-2183600,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.08,41.00,,,,,,,,,,,,,
LINER ACET NEUT 28X66 MM HIP ENDRN,SUP-2342576,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.73,2365.82,,,,,,,,,,,,,
HC Perq Dev Breast 1st MR Guide,PX-3611928700,CDM,19287,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
KIT EEG ELECTRD L 16 MM 5 CONTACT STRL DISP EVO,SUP-2936756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2854.26,1855.27,,,,,,,,,,,,,
SCREW BNE L65MM DIA14MM THRD L22MM ST CANC S STL ST CANN LAG,SUP-2186554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1192.85,775.35,,,,,,,,,,,,,
IO FIX TRIO PLATE 10,SUP-2586666,CDM,C1713,HCPCS,0278,RC,,,,both,,,4766.52,3098.24,,,,,,,,,,,,,
HC Implant Spinal Cord Stim,PX-3600007518,CDM,3600007518,LOCAL,0360,RC,,,,inpatient,,,6232.00,4050.80,,,,,,,,,,,,,
SPACER EXT FIX 80 MM RNG SALVATION,SUP-2463567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
NEEDLE HURD CLEFT PALATE TONSIL 21CM 8 14IN LEFT,SUP-2681809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.64,218.82,,,,,,,,,,,,,
DRILL SURG RESECT TOT ANK,SUP-2742330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP JAGWIRE REVOLUTION L 500 CM TIP L 5 CM,SUP-2419661,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.81,357.38,,,,,,,,,,,,,
ALLOGRAFT BNE PASTE 8 CC CANC PUROS,SUP-2692418,CDM,C1713,HCPCS,0278,RC,,,,both,,,2640.74,1716.48,,,,,,,,,,,,,
BUTTON FIXATION ENDOBUTTON CL BTB 45MM,SUP-2845208,CDM,C1730,HCPCS,0272,RC,,,,both,,,985.80,640.77,,,,,,,,,,,,,
FORM CRWN 30 UP 18UP LAT AND 12 STRP OFF,SUP-2238329,CDM,D6783,CPT,0278,RC,,,,both,,,4.11,2.67,,,,,,,,,,,,,
BONE MARROW KIT MED BIO ART BMC,SUP-2163082,CDM,C1830,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
HC Fresh Frozen Plasma Thawing,PX-3008692700,CDM,86927,CPT,0300,RC,,,,inpatient,,,247.00,160.55,,,,,,,,,,,,,
AUTOINJECTOR STENT GRFT ALTO 2 CUSTOMSEAL KT SYR PLUNG AAA,SUP-2691413,CDM,C1768,CPT,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
SYSTEM PMP CANSTR TBNG AND LID FLTR KT,SUP-2323588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.515,SUP-2860197,CDM,C1713,HCPCS,0278,RC,,,,both,,,29578.49,19226.02,,,,,,,,,,,,,
GRAFT STRUT CORT STRUCTURAL ALLGRFT FRZ DRY 40 80MM LX1MM,SUP-2307180,CDM,C1713,HCPCS,0278,RC,,,,both,,,2938.47,1910.01,,,,,,,,,,,,,
FIBER LASER 550 MH HD YAG,SUP-2835044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BNE R DST VOLAR RAD ANAT FAST GUID DNP,SUP-2414017,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.56,1743.01,,,,,,,,,,,,,
SLEEVE DRL 9MM BLU DISP OSTEOCURE,SUP-2400544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST ANTR SWNG BND,SUP-2435660,CDM,L2335,HCPCS,0274,RC,,,,both,,,795.86,517.31,,,,,,,,,,,,,
BOOT WLK LO XS NOAIR EA,SUP-2319305,CDM,L4386,HCPCS,0274,RC,,,,both,,,72.97,47.43,,,,,,,,,,,,,
GRAFT BONE LT FEM WHL TRAD FRZN,SUP-2294155,CDM,C1713,HCPCS,0278,RC,,,,both,,,18934.20,12307.23,,,,,,,,,,,,,
VALVE SHUNT SYSTEM WITH NO DIFFERENTIAL PRESSURE UNIT WITH F,SUP-2825719,CDM,C1889,HCPCS,0278,RC,,,,both,,,11337.91,7369.64,,,,,,,,,,,,,
STAPLE BONE FIX BRDG W11MM LEG L14X13MM WIRE DIA1.5X1.5MM,SUP-2135430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PENTAFLUOROPROP-TETRAFLUOROETH EX AERO,RX-39802,CDM,6370000000,HCPCS,0637,RC,00386-0008-04,NDC,,both,30,ML,48.00,31.20,,,,,,,,,,,,,
PACK PROC S AND N PART SHLDR H COFLD,SUP-2347983,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
FOOTPLATE EXT FIX L 180 MM LNG GRN NS DISP SPAT FRME TSF,SUP-2933241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4914.10,3194.16,,,,,,,,,,,,,
CATHETER HD STR 12 FRX20 CM SHT TERM 3L TY SLIM-CATH,SUP-2427950,CDM,C1752,HCPCS,0278,RC,,,,both,,,2818.12,1831.78,,,,,,,,,,,,,
IRINOTECAN HCL 40 MG/2ML IV SOLN,RX-91055,CDM,J9206,HCPCS,0636,RC,70700-0169-22,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
PROSTHESIS OSS VENT TUBE 1.52X0.060 MM W/TAB SHEA PARASOL,SUP-2312830,CDM,L8699,HCPCS,0278,RC,,,,both,,,258.30,167.89,,,,,,,,,,,,,
BASKET HELCL STONE 3FR SHTH L110CM 4W DISP,SUP-2261077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SHEARS ENDOSCP L14CM DIA5MM CRV VES SCIS HNDL RELIABLE,SUP-2218770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1100.92,715.60,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 3.2 MM 351399] DEPUY SYNTHES USA],SUP-2188082,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE L6MM DIA1.3MM HND 316L S STL ST LOK T4 STARDRV,SUP-2177969,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.33,215.36,,,,,,,,,,,,,
BOLD SCREW DIAM 3MM LG 10MM,SUP-2586427,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.48,750.41,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X51 MM LT PL 2 HOLE BUTTRESS SS,SUP-2522056,CDM,C1713,HCPCS,0278,RC,,,,both,,,1503.90,977.53,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 120 CC FRZN IRRADIATED CANC,SUP-2867149,CDM,C1762,CPT,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
IOBP HIP OPEN TIP PROCEDURE KIT,SUP-2811227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
FORCEPS BPLR L7IN TIP 1MM STD DISPOSABLE SPETZLER MALIS,SUP-2364925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1191.44,774.44,,,,,,,,,,,,,
SCREW BNE L12MM DIA5MM ST UNICORTICAL TI ST NONCANNULATED,SUP-2255847,CDM,C1713,HCPCS,0278,RC,,,,both,,,771.06,501.19,,,,,,,,,,,,,
SCREW SPNL MULTAXL STD 5.5X40 MM FIREBIRD,SUP-2658646,CDM,C1889,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SHELL ACET MOLD PRE TIB HIP,SUP-2388179,CDM,L2340,LOCAL,0272,RC,,,,both,,,1420.22,923.14,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 45 CM OD 4 FR GUIDEWIRE 0.018/0.035,SUP-2170582,CDM,C1894,HCPCS,0272,RC,,,,both,,,147.01,95.56,,,,,,,,,,,,,
BIT DRL CANN LG 13X465 MM QC FLX TI NS EXPERT,SUP-2863378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2051.17,1333.26,,,,,,,,,,,,,
STEM HUM L125MM OD13MM 140DEG NK ANG UNIV CO CHROME SHLDR,SUP-2399848,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 14X11X6 MM LORDTC DENS CANC,SUP-2743372,CDM,C1713,HCPCS,0278,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
HEAD FEM DIA28 MM CERAMYS CHOICE HIP REV STRL,SUP-2929704,CDM,C1776,CPT,0278,RC,,,,both,,,6247.47,4060.86,,,,,,,,,,,,,
GRAFT AORTIC VALVED SZ 21MM L12CM DIA21.5MM,SUP-2282679,CDM,C1889,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
GRAFT BNE SUB 10ML DEMIN MTRX STERIFUSE,SUP-2138660,CDM,C9359,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
WASHER ORTHOPAEDIC ROUND 2.2X4.5 MM STAINLESS STEEL NON STER,SUP-2837002,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.61,133.65,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED SM PRIORITY STRL MEDPOR,SUP-2862750,CDM,C1713,HCPCS,0278,RC,,,,both,,,44597.29,28988.24,,,,,,,,,,,,,
CATHETER INFUSION BENEPHIT XT L 105 CM SHTH 5 FR TARGETED,SUP-2117251,CDM,C1751,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE W11XL220MM THK37MM 12 H ST R MED DST TIB S STL LOK,SUP-2185595,CDM,C1713,HCPCS,0278,RC,,,,both,,,5143.98,3343.59,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA PHSPTE HA PTTY INJ HYDROSET,SUP-2366072,CDM,C1713,HCPCS,0278,RC,,,,both,,,10077.52,6550.39,,,,,,,,,,,,,
CEFDINIR 300 MG PO CAPS,RX-22289,CDM,6370000000,HCPCS,0637,RC,60687-0699-21,NDC,,both,1,UN,15.20,9.88,,,,,,,,,,,,,
PLATE BNE LCK LG RT CALCANEAL FOR MINIMALLY INVASIVE SURG NS,SUP-2525058,CDM,C1713,HCPCS,0278,RC,,,,both,,,2881.33,1872.86,,,,,,,,,,,,,
PLATE BONE W5XL100MM THK1.2MM 20 H MINI S STL STR,SUP-2343835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1903.63,1237.36,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC STD 14.5FR DIA 39CM 3,SUP-2613291,CDM,C1750,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
RIGHT RADIAL STYLOID PLATE STERILE,SUP-2722441,CDM,C1713,HCPCS,0278,RC,,,,both,,,2445.06,1589.29,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 23CM 7FR 80CM NDL 4CM NIT PLAT,SUP-2740568,CDM,C1894,HCPCS,0272,RC,,,,both,,,187.93,122.15,,,,,,,,,,,,,
GUIDE PIN FIX 12X225MM SMOOTH SHRP TIP BRKWY,SUP-2208446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
KIT CAST TOT CONTACT SYS DUST VAC TCC-EZ,SUP-2909278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2007.25,1304.71,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THN AMNIO BARR MEM CHORION FREE,SUP-2399185,CDM,C1762,CPT,0278,RC,,,,both,,,4355.18,2830.87,,,,,,,,,,,,,
PROBE LASER PRECIS 20 GA FIBER HND PC STR PLAS EYELITE,SUP-2109738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2509.49,1631.17,,,,,,,,,,,,,
PLATE BNE 100 DEG L 2.48 CM THK 1 MM SCREW DIA2 MM 2X2 H LNG,SUP-2936779,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
PEG BNE FIX 15MM HD LOK REFLCT,SUP-2344766,CDM,C1776,CPT,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
HANDPIECE ELECSURG L140MM SHFT L100MM ELECTRD DIA1.1MM CONCL,SUP-2313606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
PLATE LK COMPRSS 18 HOLE,SUP-2704416,CDM,C1713,HCPCS,0278,RC,,,,both,,,1650.38,1072.75,,,,,,,,,,,,,
ANCHOR SUTURE FIBER 5.5/6 MM FOR SCR THERAFUZE DBF,SUP-2744195,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
REFL ACET FLEX DR W/TRKL END,SUP-2822561,CDM,C1776,CPT,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ELECTRODE ELECSURG VPR 24 FR 2 STEM BALL SHP YEL HALF MOON,SUP-2423435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1316.45,855.69,,,,,,,,,,,,,
CANNULA DRNGE 20DEG W/ DIL ANGIOVAC,SUP-2420159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
HC Lrbc-Red Cross,PX-3900901600,CDM,P9016,CPT,0390,RC,,,,both,,,966.00,627.90,,,,,,,,,,,,,
COMPONENT FEM SZ 5 BILAT KNEE NP NONBEADED UNI CEM SIG,SUP-2253898,CDM,C1776,CPT,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
POROUS FINN STEM 89MMX12.5MM,SUP-2510726,CDM,C1776,CPT,0278,RC,,,,both,,,5393.42,3505.72,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 15 CM RND POLYESTER PARIETEX,SUP-2752190,CDM,C1781,HCPCS,0278,RC,,,,both,,,3029.88,1969.42,,,,,,,,,,,,,
CONNECTOR SHUNT OD1.9MM YOUTH SHAPED TITANIUM 3 WAYOUTH MIET,SUP-2825579,CDM,C1889,HCPCS,0278,RC,,,,both,,,737.99,479.69,,,,,,,,,,,,,
BONE CEMENT SURG 40 GM PMMA GENTAMICIN SULPHATE LO VISC,SUP-2898408,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SCREW BNE CANN 5X100 MM PERI ARTC LCK SS NS LCP,SUP-2184733,CDM,C1713,HCPCS,0278,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.7X10 MM TITANIUM,SUP-2838295,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
SPRONE OBLONG 3.5X7.5X80MM,SUP-2213497,CDM,C1784,HCPCS,0278,RC,,,,both,,,156.37,101.64,,,,,,,,,,,,,
GUIDEWIRE HYBRID .008 DOUBLE ANGLE,SUP-2854078,CDM,C1769,HCPCS,0272,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
PROSTHESES BTTN SEPT OD.06MM 20FR OESOPHAGUS TRACH LARYN,SUP-2242394,CDM,L8509,HCPCS,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
HC Rep Lac Smp Not Face <2.5cm,PX-4501200100,CDM,12001,CPT,0450,RC,,,,outpatient,,,421.00,273.65,,,,,,,,,,,,,
TUBE TRACHEOSTOMY STAINLES ADULT RIGID ORIGINAL NECK FLANGE,SUP-2793422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.64,163.57,,,,,,,,,,,,,
HC So Von Wille Brand Factor,PX-3058524566,CDM,85245,CPT,0305,RC,,,,both,,,204.00,132.60,,,,,,,,,,,,,
PORT ACCS BVL 26 MM,SUP-2433828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
SNARE ENDOSCP OD25MM SHTH L50CM OD55FR DUCK BILL INSUL S STL,SUP-2171039,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.02,245.71,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE L 90 CM OD 8 FR GUIDEWIRE 0.038 IN,SUP-2168797,CDM,C1894,HCPCS,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
PIN HALF THRD 4X180 MM 55 MM CIR FIX,SUP-2400697,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
PLATE BONE 12MM OFFSET 90DEG 3 H PROX FEM LCK FOR 3.5MM SCR,SUP-2318552,CDM,C1713,HCPCS,0278,RC,,,,both,,,7045.69,4579.70,,,,,,,,,,,,,
CASE MODULE F/ HAND 1.5MM,SUP-2547986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2592.79,1685.31,,,,,,,,,,,,,
ANCHOR SUT W 1 SZ 2 HIFI SUT DRVR BIO MINI REVO,SUP-2166969,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.49,580.77,,,,,,,,,,,,,
PLATE BNE PED W23XL127MM 90DEG 5 H ST DST CNDYL FEM S STL LO,SUP-2177213,CDM,C1713,HCPCS,0278,RC,,,,both,,,2887.42,1876.82,,,,,,,,,,,,,
GRASPER SURG 3 PRNG 2.8 FRX115 CM CAPT,SUP-2835969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.22,450.59,,,,,,,,,,,,,
GRAFT DURA W2XL2IN CLLGN DURAFOAM 1 PER CA,SUP-2243765,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
STENT GRFT VASC OVATION IX L 140 MM 185 MM 14/14 MM 10/12 FR,SUP-2217744,CDM,C1876,HCPCS,0278,RC,,,,both,,,13275.92,8629.35,,,,,,,,,,,,,
STENT EVAR L60MM DIA8MM DST TRNSJUG EPTFE NYL INTRAHEPATIC,SUP-2395922,CDM,C1874,HCPCS,0278,RC,,,,both,,,13856.82,9006.93,,,,,,,,,,,,,
SLEEVE TIB 29MM KNEE PORCOAT PARTIALLY REV SYS ATTUNE,SUP-2251461,CDM,C1776,CPT,0278,RC,,,,both,,,8297.14,5393.14,,,,,,,,,,,,,
STAPLER INT MULTFI 30-V3 MM DST SER TA,SUP-2174498,CDM,C1713,HCPCS,0278,RC,,,,both,,,2424.08,1575.65,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 10 CM OD 4 FR ID 0.061 IN TIP DIA,SUP-2384846,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
GRAFT VASC XENOSURE L 8 X W 0.8 CM BOV PERICARD RECTANGULAR,SUP-2264287,CDM,C1768,CPT,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG PO TABS,RX-21287,CDM,6370000000,HCPCS,0637,RC,13668-0091-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT GRFT VASC DETOUR CAP FOR ANY NUMBER OF TORUS/ENDOCROSS,SUP-2898716,CDM,C1604,HCPCS,0278,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
PLATE BONE L139MM 12 H STRL S STL LCK COMPR FOR 3.5MM SCR,SUP-2349632,CDM,C1713,HCPCS,0278,RC,,,,both,,,2860.01,1859.01,,,,,,,,,,,,,
CLAMP SURG ROD TO ROD 7.5 MM 4.75 TO 5.5-6.5 MM CREO,SUP-2584159,CDM,C1713,HCPCS,0278,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
COMPONENT TROCHLEAR SZ 1 RT PATELLOFEMORAL CEM IBALANCE,SUP-2121884,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
CATHETER GUID TURNPIKE LP L 150 CM SHFT DIA PROX/DSTL,SUP-2383148,CDM,C1887,HCPCS,0272,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
DANTROLENE SODIUM 20 MG IV SOLR,RX-9716,CDM,2500000003,HCPCS,0250,RC,78670-0003-67,NDC,,both,1,UN,402.50,261.62,,,,,,,,,,,,,
PIN EXT FIX L 100 MM DIA 35 MM THRD DIA 4 MM SS NS DISP MAV,SUP-2931204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.20,589.03,,,,,,,,,,,,,
SHUNT SURG L 28 MM RESERVOIR 20 MM CATH L DSTL 600 MM FV172T,SUP-2929167,CDM,C1889,HCPCS,0278,RC,,,,both,,,8431.28,5480.33,,,,,,,,,,,,,
SET INT FIX BURR H PLATE DIA18.5 MM SCREW DIA1.5 MM,SUP-2935209,CDM,C1713,HCPCS,0278,RC,,,,both,,,40804.30,26522.79,,,,,,,,,,,,,
COMPONENT FEM L3CM RT KNEE RESURF REDUC SZ OSS,SUP-2406467,CDM,C1776,CPT,0278,RC,,,,both,,,17351.64,11278.57,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM MAND 34 HOLE FULL MAND TI NS,SUP-2472861,CDM,C1713,HCPCS,0278,RC,,,,both,,,6481.02,4212.66,,,,,,,,,,,,,
BRACE KNEE CUST W/ ADJ HNG FUSIONXT OA,SUP-2150833,CDM,L1810,HCPCS,0274,RC,,,,both,,,1709.73,1111.32,,,,,,,,,,,,,
ALLOGRAFT DISC DBM AND CORT CANC BONE CHIP FRZN OPTEFORM 8CC,SUP-2223555,CDM,C1762,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 20 CM DIA 8 MM EPTFE STR TW ULTRA,SUP-2266065,CDM,C1768,CPT,0278,RC,,,,both,,,914.24,594.26,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvic/Le 1st Ord,PX-3613624500,CDM,36245,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,0636,RC,00409-3815-12,NDC,,both,10,ML,120.70,78.45,,,,,,,,,,,,,
NEEDLE BRST LOC L7.5CM OD20GA REPOSIT H STYL,SUP-2174909,CDM,C1819,HCPCS,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
DEVICE VENTRICULAR EMGCY PWR PK,SUP-2356040,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
RETRACTOR SPNL L6CM DIA22MM D2.36IN S STL TB MED LAT DIL,SUP-2292984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.97,429.63,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 3 FRX20 CM 19 GA SIL PER-Q-CATH,SUP-2125573,CDM,C1751,HCPCS,0278,RC,,,,both,,,198.13,128.78,,,,,,,,,,,,,
PLATE BNE W15XL88MM THK2MM 3 H BILAT S STL COVERLEAF RIG,SUP-2186005,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
SCREW BNE ST 5X48 MM LCK T25 STARDRV RECESS TI STRL,SUP-2569912,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.62,79.70,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0035IN S STL PTFE HEP STR AMPLATZ,SUP-2167927,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.63,55.66,,,,,,,,,,,,,
CATHETER ETER EP DIAG MAP M CRV QPLR 2 5 2MM SPC 5MM TIP BI DIR,SUP-2356986,CDM,C1733,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
NAIL IM FEM 130 DEG UNIV 13 MMX44 CM RT LCK CANN VERSANAIL,SUP-2460878,CDM,C1713,HCPCS,0278,RC,,,,both,,,6889.16,4477.95,,,,,,,,,,,,,
CALIBRATOR BRACHYTHERAPY SEED CESIUM-131,SUP-2247302,CDM,C2643,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
KIT BNE ACCS PRB 13GA L100CM W/O SPCR DISP FOR VERTPLSTY,SUP-2293681,CDM,C1894,HCPCS,0272,RC,,,,both,,,1424.30,925.79,,,,,,,,,,,,,
SHEATH INTRO L10CM ID7FR 2.5CM DIL .038IN MINI GWIRE MRK,SUP-2385191,CDM,C1894,HCPCS,0272,RC,,,,both,,,100.32,65.21,,,,,,,,,,,,,
MESH BONE KSSM 06MM THK TTNM LATEX FREE RIGHT PTRNL MXLFCL,SUP-2707391,CDM,C1713,HCPCS,0278,RC,,,,both,,,6373.60,4142.84,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.018IN TAPR L3CM NIT HYDRPHLC STR,SUP-2139328,CDM,C1769,HCPCS,0272,RC,,,,both,,,181.77,118.15,,,,,,,,,,,,,
IMPLANT BRST 755CC DIA15.7CM P5.4CM GEL RND EXTRA SMOOTH,SUP-2301014,CDM,C1789,HCPCS,0278,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
FIBER LASER L12IN DIA0.4MM SMARTCONNECTOR TECHNOLOGY FOR FLEX,SUP-2138859,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SCREW PEDCL L25XOD5.5MM S STL CANN REVERE,SUP-2230811,CDM,C1713,HCPCS,0278,RC,,,,both,,,5846.68,3800.34,,,,,,,,,,,,,
TAP VITALITY 7.5MM IL,SUP-2402707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
BLADE SHAVER SERRATED STD 2.9 MM STR DSTL SUCTION STRL DISP,SUP-2638418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
BIT DRL DIA2.7MM TWST FOR INTMED OSTEOTMY SYS,SUP-2343752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,303.51,197.28,,,,,,,,,,,,,
STEM FEM SZ 3 8DEG STR HIP CLASS PROFEMUR PRESERVE,SUP-2304851,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
ALLOGRAFT CHIP CANC CRUSH FRZN 1.7MM - 10MM RANG 60CC,SUP-2307395,CDM,C1713,HCPCS,0278,RC,,,,both,,,3365.45,2187.54,,,,,,,,,,,,,
COUNTERSINK 4MM FOR IMP BONE CONDUCTION SYS,SUP-2319872,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
HEAD HUM DIA40MM STEM H15MM STD SHLDR CO CHROME PORCOAT,SUP-2250655,CDM,C1776,CPT,0278,RC,,,,both,,,11550.80,7508.02,,,,,,,,,,,,,
STAPLE INT CARTRIDGE 16X15 MM TI SS DISP,SUP-2100301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
KIT SUTURE STRP WND CLOSURE DEV ZIP PRELOC 2,SUP-2904097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,859.01,558.36,,,,,,,,,,,,,
GRAFT BNE FRZN TIB SEG IMPL ALLGRFT L200MM MATRIGRFT,SUP-2264790,CDM,C1713,HCPCS,0278,RC,,,,both,,,3332.54,2166.15,,,,,,,,,,,,,
SPLINT KNEE L12IN UNIV PERF FOAM HK AND LOOP CLSR QUICK-FIT,SUP-2197151,CDM,L1851,HCPCS,0274,RC,,,,both,,,31.34,20.37,,,,,,,,,,,,,
"HC Hbo,W/Press,Fullbdy Chmb,30min",PX-4130027700,CDM,G0277,CPT,0413,RC,,,,both,,,1870.00,1215.50,,,,,,,,,,,,,
IMPLANT HUM TISS L 2 X W 1 CM PLCNTA MEMBRN TRILAYER,SUP-2905503,CDM,Q4278,HCPCS,0636,RC,,,,both,,,3176.17,2064.51,,,,,,,,,,,,,
PLATE BONE L104MM 5 H ANTR PRI COMPR SLOT RT ANK FUS L FRAG,SUP-2349835,CDM,C1713,HCPCS,0278,RC,,,,both,,,7416.52,4820.74,,,,,,,,,,,,,
RAIL EXT FIX MINI BODY,SUP-2197292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
ENDCAP ORTH RESRB C STEM,SUP-2253662,CDM,C1776,CPT,0278,RC,,,,both,,,258.74,168.18,,,,,,,,,,,,,
PLATE BONE L62MM 6 H LCK COMPR FOR 2.7MM SCR PEDIFRAG,SUP-2318663,CDM,C1713,HCPCS,0278,RC,,,,both,,,2252.76,1464.29,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE L 90 CM OD 7 FR GUIDEWIRE 0.038 IN,SUP-2168796,CDM,C1894,HCPCS,0272,RC,,,,both,,,315.26,204.92,,,,,,,,,,,,,
SET SPR SNAP LOK 40CM 360DEG ENDOSCP APPL FLX W DUPLOSPR,SUP-2130381,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.63,319.56,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X50X3-6 MM DBM PUROS 61615251,SUP-2684573,CDM,C1713,HCPCS,0278,RC,,,,both,,,8889.34,5778.07,,,,,,,,,,,,,
DRILL TWST 1.8MM DS FOR 4MM SCR,SUP-2365070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.67,206.49,,,,,,,,,,,,,
GRAFT STRP DEMIN CANC IRRADIATED ALLGRFT 26MM C 19MMX7MM,SUP-2125427,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
PLATE BONE L71MM 5 H T SHP LCK 2 HD FOR 3.5MM SCR,SUP-2318680,CDM,C1713,HCPCS,0278,RC,,,,both,,,1860.01,1209.01,,,,,,,,,,,,,
COVER BUR H DIA24MM 6 H TI BENT W/O TAB NONCOMPRESSION LO,SUP-2136517,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
SET URET STENT UNIVERSA L 20 CM DIA 5 FR HYDRPHLC SFT,SUP-2169453,CDM,C2617,HCPCS,0278,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
HC Level I Surg Pathology Gross Examination Only,PX-3128830000,CDM,88300,CPT,0312,RC,,,,both,,,219.00,142.35,,,,,,,,,,,,,
HINGE EXT FIX LCK,SUP-2749935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
PLATE BNE H0.6MM 7 H UP FACE G TI T LEIBINGER UNIV 2,SUP-2366277,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.34,357.07,,,,,,,,,,,,,
CATHETER HD LT 14 FRX28 CM ADMIN BASIC SET SPLIT STRM,SUP-2267086,CDM,C1750,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 31CM 3,SUP-2613287,CDM,C1750,HCPCS,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
PLATE BONE L300MM 130DEG 14 H PELVIS BILAT S STL STD BRL RIG,SUP-2342589,CDM,C1713,HCPCS,0278,RC,,,,both,,,1613.96,1049.07,,,,,,,,,,,,,
LONG CALI DRILL 49 MM CANN,SUP-2726665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1780.13,1157.08,,,,,,,,,,,,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,0636,RC,63323-0322-94,NDC,,both,1,UN,64.50,41.92,,,,,,,,,,,,,
SCREW BNE LCK 5X75 MM COR 2 W/ STARDRV TI NS,SUP-2181843,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
IMPLANT BEDROCK GRANITE INFUSE,SUP-2858214,CDM,C1737,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
WIRE GUID TRANSRADIAL HYDRPHLC REG STIFFNESS SHT TAPR STR,SUP-2158672,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.00,84.50,,,,,,,,,,,,,
INSERT TIBIALXSM THK16MM UNIV KNEE HNG POST STBL BEAR PRI,SUP-2252652,CDM,C1776,CPT,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
COMPONENT TIB SZ G R MED CEM FOR PART KNEE SYS PERSONA,SUP-2402770,CDM,C1776,CPT,0278,RC,,,,both,,,11586.60,7531.29,,,,,,,,,,,,,
ALLOGRAFT BNE FIBER SM CORTICAL INCITE,SUP-2538794,CDM,C1889,HCPCS,0278,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
CANNULA SUCTION 4 MMX15 CM NASOPHARYNX CRV UPWARDS MALL,SUP-2776832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.61,300.05,,,,,,,,,,,,,
IMPLANT ANK JT OD8MM YEL TI CONCL FOR ARTHROEREISIS,SUP-2365932,CDM,C1776,CPT,0278,RC,,,,both,,,4091.42,2659.42,,,,,,,,,,,,,
PROSTHESIS OSS UNIV TI,SUP-2277634,CDM,L8613,CPT,0278,RC,,,,both,,,525.01,341.26,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV ECO 115CM 7FR4-4-4 D,SUP-2880938,CDM,C1732,HCPCS,0272,RC,,,,both,,,4279.82,2781.88,,,,,,,,,,,,,
SEEKER BALLOON L 17 MM DIA 5 MM FRONTAL FOR ENT,SUP-2901984,CDM,C1726,HCPCS,0272,RC,,,,both,,,3389.00,2202.85,,,,,,,,,,,,,
CANNULA INJ 3.5 MMX30 CM KOH ULTRAMICRO NDL,SUP-2766999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1127.64,732.97,,,,,,,,,,,,,
GRAFT NRV L5CM DIA12MM NEURO CONDUIT CLLGN WRP,SUP-2378818,CDM,C9353,HCPCS,0278,RC,,,,both,,,4179.34,2716.57,,,,,,,,,,,,,
CATHETER US GE COMPATIBILITY SOUNDSTAR ECO 10FR,SUP-2248456,CDM,C1759,HCPCS,0272,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
ARM EXTN 5MM VAR ANG W/ 4MM BLIND SCR AXSOS 3,SUP-2365358,CDM,C1713,HCPCS,0278,RC,,,,both,,,1429.96,929.47,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 74X50X14 MM VENTRIC ATLAS+ VR,SUP-2356530,CDM,C1722,HCPCS,0275,RC,,,,both,,,66568.00,43269.20,,,,,,,,,,,,,
PHYTONADIONE 1 MG/ML ORAL SOLUTION,RX-4082399,CDM,6370000000,HCPCS,0637,RC,09999-9158-25,NDC,,both,2.5,ML,35.40,23.01,,,,,,,,,,,,,
PLATE BNE Z CRANIOFACIAL 4 HOLE REVERSIBLE TI GRY NS UNIV II,SUP-2422996,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.57,557.42,,,,,,,,,,,,,
COMPONENT ULN SM L3IN R EL TIV PLSM INTERCHANGEABLE CEM,SUP-2205936,CDM,C1776,CPT,0278,RC,,,,both,,,14219.27,9242.53,,,,,,,,,,,,,
TAP SURG DIA2.3 MM CRANIOMAXILLOFACIAL NS DISP LORENZ,SUP-2936869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1588.84,1032.75,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 025X260 GLIDEWIRE,SUP-2385607,CDM,C1769,HCPCS,0272,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO FLO ACTE 11.5FR DIA 15C MCDLT116IJ,SUP-2633018,CDM,C1750,HCPCS,0278,RC,,,,both,,,271.92,176.75,,,,,,,,,,,,,
PLATE BNE L37MM SHT 2X2 H NONSTERILE R BILAT 1ST MTP FUS TI,SUP-2177010,CDM,C1713,HCPCS,0278,RC,,,,both,,,3141.57,2042.02,,,,,,,,,,,,,
MORCELLATOR ENDO OD2.9MM ROTARY DISP TRUCLEAR INCIS +,SUP-2341839,CDM,C1782,HCPCS,0272,RC,,,,both,,,2227.83,1448.09,,,,,,,,,,,,,
BLADE LARYNGOSCOPE SIZE 4 L207MM M GREENLINE MILLER FIBEROPT,SUP-2828246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.26,213.37,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 6 MM OFFSET RNG L 30 CM,SUP-2396311,CDM,C1768,CPT,0278,RC,,,,both,,,2948.46,1916.50,,,,,,,,,,,,,
PLATE BNE BAR L6MM 4 H CRANIOMAXILLOFACIAL TI LO PROF FOR,SUP-2366203,CDM,C1713,HCPCS,0278,RC,,,,both,,,309.01,200.86,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.557,SUP-2860238,CDM,C1713,HCPCS,0278,RC,,,,both,,,25085.77,16305.75,,,,,,,,,,,,,
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,0636,RC,00270-1315-25,NDC,,both,30,ML,12.20,7.93,,,,,,,,,,,,,
PLATE BNE 24 DEG L 174 X W 8.5 MM THK 1.6 MM 13 H SS LT DSTL,SUP-2933044,CDM,C1713,HCPCS,0278,RC,,,,both,,,5198.43,3378.98,,,,,,,,,,,,,
PLATE BNE W175XL368MM THK52MM 20 H BILAT S STL BROAD LOK,SUP-2185321,CDM,C1713,HCPCS,0278,RC,,,,both,,,3479.40,2261.61,,,,,,,,,,,,,
MICROCATHETER DIAG SWIFTNINJA L 125 CM DIA PROX/DSTL,SUP-2303080,CDM,C1887,HCPCS,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
BOLT LOCKING RADIUS ULNA ROD F / IM ROD SYSTEM,SUP-2639989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
MIDLINE CATHETERIZATION KIT: 3 FRX8,SUP-2827494,CDM,C1751,HCPCS,0278,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
HC So Factor IX,PX-3058525066,CDM,85250,CPT,0305,RC,,,,both,,,301.00,195.65,,,,,,,,,,,,,
LEAD NERVE STIM 90 CM SPEC SURESCAN MRI 5-6-5,SUP-2659105,CDM,C1778,HCPCS,0278,RC,,,,both,,,19954.70,12970.55,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 8X8X8 MM FD DEMINERALIZED CANC FLEXIGRAFT,SUP-2740768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1276.35,829.63,,,,,,,,,,,,,
NECK FEM 12/14 TAPR 8 DEG 32MM MOD CERASIV,SUP-2216772,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
VEST HOLSTER POCKET SM CTRL,SUP-2356012,CDM,Q0499,HCPCS,0274,RC,,,,both,,,1339.52,870.69,,,,,,,,,,,,,
PLATE BONE L22MM 6 H CRANIOMAXILLOFACIAL TI DBL Y SHP FOR,SUP-2190657,CDM,C1713,HCPCS,0278,RC,,,,both,,,1022.07,664.35,,,,,,,,,,,,,
WASHER ORTH PIN CONN FOR SIDEKCK STLTH REARFOOT FIX,SUP-2400620,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
SYSTEM UROLIFT2 W/ IMPL DEL DEV FOR TREAT OF URIN OUTFLO,SUP-2743298,CDM,C1889,HCPCS,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
HC Iadna Enterovirus Amplif Probe & Revrse Trnscrip,PX-3068749800,CDM,87498,CPT,0306,RC,,,,both,,,89.00,57.85,,,,,,,,,,,,,
DARBEPOETIN ALFA 60 MCG/0.3ML IJ SOSY,RX-131225,CDM,J0881,HCPCS,0636,RC,55513-0023-04,NDC,,both,0.3,ML,1370.00,890.50,,,,,,,,,,,,,
STEM FEM 17 MM LT KNEE ANAT,SUP-2204193,CDM,C1776,CPT,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
STAPLER INT SHFT L55MM STPL H1.5X1.8X2MM 6 ROW ENDO-SURGERY,SUP-2219742,CDM,C1713,HCPCS,0278,RC,,,,both,,,108.39,70.45,,,,,,,,,,,,,
PLATE BNE MEDL RT PLNTR W/ TALAR WRP AXIS,SUP-2610178,CDM,C1713,HCPCS,0278,RC,,,,both,,,8383.80,5449.47,,,,,,,,,,,,,
HC I&D Hematoma Seroma Fluid,PX-4501014000,CDM,10140,CPT,0450,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
PLATE BNE LCK SM RT CALCANEAL MESH STRL ALPS LTX,SUP-2860964,CDM,C1713,HCPCS,0278,RC,,,,both,,,3784.01,2459.61,,,,,,,,,,,,,
SLING URETH MONOARC,SUP-2140379,CDM,C1771,HCPCS,0278,RC,,,,both,,,3721.81,2419.18,,,,,,,,,,,,,
CANNULA SUCT 5FR L230MM DIA70MM WRK L165MM MIC TAPR TEARDROP,SUP-2108796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,674.25,438.26,,,,,,,,,,,,,
MATRIX 1.4MM BIT DRILL W/14MM,SUP-2823234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1361.22,884.79,,,,,,,,,,,,,
CUP ACET MULT H 44MM ACUMATCH A SER,SUP-2221815,CDM,C1776,CPT,0278,RC,,,,both,,,6028.80,3918.72,,,,,,,,,,,,,
GRAFT SCFLD W3XL3CM DERM REP MESHED PRIMATRIX,SUP-2243702,CDM,Q4110,HCPCS,0636,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
ROD EXT FIX L200MM THRD STR SIDEKCK FREE CIR FIX,SUP-2400599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
PLATE BONE W38XL53MM THK0.4MM 5X5MM SPC 8X11 H TI BILAT CRAN,SUP-2190618,CDM,C1713,HCPCS,0278,RC,,,,both,,,4453.78,2894.96,,,,,,,,,,,,,
SPACER HUM +9MM OFFSET SHLDR POLYETH FOR DELT XTEND REV SYS,SUP-2251001,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
HC Closed Tx of Ankle Dislocation,PX-4502784000,CDM,27840,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
VITAMIN B-12 100 MCG PO TABS,RX-8653,CDM,6370000000,HCPCS,0637,RC,50268-0852-15,NDC,,both,1,UN,1.60,1.04,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM TAP IN DSGN FOR SFT TISS FIX FOOTPRINT,SUP-2341861,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.78,757.11,,,,,,,,,,,,,
BIT DRL DIA2MM CANN FOR CSS SYS,SUP-2396783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
CATHETER URET 13/15 FRX24 CM UROPS AS,SUP-2465467,CDM,C1758,HCPCS,0278,RC,,,,both,,,327.16,212.65,,,,,,,,,,,,,
BLADE RETRACTOR ABH 6X1 IN RENAL ALUM,SUP-2483688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.51,847.28,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VISIA AF MRI S VR SURESCAN W 51 X H 66 MM,SUP-2421054,CDM,C1722,HCPCS,0275,RC,,,,both,,,38264.32,24871.81,,,,,,,,,,,,,
WIRE FIX BLNT 1.5X350 MM TSI KIRSCHNER DISP,SUP-2536922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
HC Joint Bursa Inj Small Joint,PX-7612060000,CDM,20600,CPT,0761,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
CATHETER NEPHSTMY L15CM BAL DIA10MM PTFE BURST RATE SHTH BAL,SUP-2169833,CDM,C1726,HCPCS,0272,RC,,,,both,,,860.52,559.34,,,,,,,,,,,,,
CONTOURED MESH UNIV CENTER06MM PROFILE STERILE,SUP-2707382,CDM,C1713,HCPCS,0278,RC,,,,both,,,15619.93,10152.95,,,,,,,,,,,,,
HC So Plasminogen,PX-3058542066,CDM,85420,CPT,0305,RC,,,,both,,,515.00,334.75,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.021 IN TAPR L 7 CM FLPY TIP L,SUP-2167590,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.10,22.16,,,,,,,,,,,,,
PLATE BNE STR LG 1.5X28X1 MM MIDFACE 6 HOLE W/ TAB NS,SUP-2493927,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.81,326.83,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM THK100UM AMNIO MEMBRN AMBIO5,SUP-2247196,CDM,V2790,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
HC Debride Skin Sub Musc Bone,PX-4501104400,CDM,11044,CPT,0450,RC,,,,both,,,1677.00,1090.05,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SAPPHIRE II PRO L 150 CM BALLOON L 10 MM,SUP-2636322,CDM,C1725,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC X-Ray Exam Bil Hips 5/> Views,PX-3207352300,CDM,73523,CPT,0320,RC,,,,outpatient,,,128.00,83.20,,,,,,,,,,,,,
FORCEPS OPHTH 25+GA ILM DISP GRIESHABER REVOLUTION DSP,SUP-2109695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.28,241.98,,,,,,,,,,,,,
SCREW BONE L25MM DIA5MM CANC S STL PERIPH REFLCT,SUP-2344769,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.24,266.66,,,,,,,,,,,,,
KIT NEUROSTIM PLSE GENRTR ANALGESIC SPNL CRD ELECTRC SYS,SUP-2148512,CDM,C1820,HCPCS,0278,RC,,,,both,,,65048.24,42281.36,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE XLN 2.5 CC DBM FIBER INFLUENCER -RSFH,SUP-2881441,CDM,C1713,HCPCS,0278,RC,,,,both,,,3253.04,2114.48,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - 1 Visit,PX-9900000065,CDM,9900000065,LOCAL,0990,RC,,,,both,,,75.00,48.75,,,,,,,,,,,,,
CATHETER URODYN DBL LUMN W/ EXTN DISP 8FR,SUP-2355029,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 100 CM DIA 0.035 IN PTFE PERIPH J,SUP-2383973,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.91,38.29,,,,,,,,,,,,,
GRAFT BONE 10ML DEMIN BONE MTRX PUTTY PROC STRL IMP ACCELL,SUP-2247313,CDM,C9359,HCPCS,0278,RC,,,,both,,,4348.90,2826.78,,,,,,,,,,,,,
PLATE BNE L32MM 2X3 H R S STL L LO PROF LOK COMPR FOR 2.7MM,SUP-2186357,CDM,C1713,HCPCS,0278,RC,,,,both,,,1053.75,684.94,,,,,,,,,,,,,
PLATE BONE 12 HOLE LEFT LTRL PRXML PRRTCLR TBL TTNM LOK CMPR,SUP-2494701,CDM,C1713,HCPCS,0278,RC,,,,both,,,4036.28,2623.58,,,,,,,,,,,,,
GRAFT BNE L200MM SHFT FEM FEM FRZN MATRIGRFT,SUP-2264758,CDM,C1713,HCPCS,0278,RC,,,,both,,,3182.04,2068.33,,,,,,,,,,,,,
SCREW CORTEX 4.5MM 120MM,SUP-2547355,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.64,137.57,,,,,,,,,,,,,
PLATE BNE L 48 MM 3 H RT DSTL VOLAR RADIAL WIDE STRL VARIAX,SUP-2902226,CDM,C1713,HCPCS,0278,RC,,,,both,,,4981.83,3238.19,,,,,,,,,,,,,
BLADE RTRCTR BLFR 3 14NW X 10 34NL X 2 38ND SPRPBC CNTR J,SUP-2703311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.47,285.66,,,,,,,,,,,,,
CATHETER EXT WRK CHAN 45 EDGE,SUP-2381746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1526.86,992.46,,,,,,,,,,,,,
HEAD FEMORAL COCR 12/14 40MM +0,SUP-2504658,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
COUNTERSINK BNE L37MM DIA3.5MM FOR 2.0/2.3 LAG SCR,SUP-2267854,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
CONTROLLER VENT ASST W EMGCY BK BTTRY HEARTMATE 3,SUP-2356029,CDM,C1713,HCPCS,0278,RC,,,,both,,,18651.60,12123.54,,,,,,,,,,,,,
PLATE BNE NAR 4.5X71 MM 4 HOLE SS DCP,SUP-2569162,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.33,142.56,,,,,,,,,,,,,
CATHETER HD SET 16 FRX28 CM 23 CM 2 TRINIFLEX SPLIT CATH III,SUP-2863689,CDM,C1750,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
STENT CORONARY MULTLNK TRI L 13 MM DIA 3.5 MM GUIDE CATH,SUP-2101463,CDM,C1876,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
CATHETER ARTHERECTOMY LASER 5 FRX1.7 MM OTW,SUP-2353090,CDM,C1885,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
MARKER TISS PLCMNT NDL 18GA ETWX12CM W/ 0.9X3MM GLD,SUP-2164655,CDM,A4648,CPT,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
RETRIEVER GWIRE TIP 8MM CATH L100CM OD5.9FR ANGIO QUIK CRSS,SUP-2353172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
"HC So Antidiuretic Hormone, Plasma",PX-3018458866,CDM,84588,CPT,0301,RC,,,,inpatient,,,74.00,48.10,,,,,,,,,,,,,
CLAMP EXT FIX DIA 4/5/6 MM UNIV HALF PIN,SUP-2898426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.021 IN TAPR L 7 CM FLPY TIP,SUP-2167812,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.84,24.60,,,,,,,,,,,,,
NUT ORTH L17MM DIA5MM TI FOR CNDYL SCR T2,SUP-2369862,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN 115CM 4-4-4 F,SUP-2492016,CDM,C1731,HCPCS,0278,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
COVER BURR H DIA17 MM THK 0.5 MM PROF THK 0.6 MM SCREW DIA1,SUP-2883894,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
GUIDEWIRE VASC L 80CM 0.035IN L7CM L 3CM AMPLTZ STR X STIFF,SUP-2167977,CDM,C1769,HCPCS,0272,RC,,,,both,,,57.96,37.67,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM SZ 2-0 CRV 26 MM STR 89 MM SS ORN,SUP-2101190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,50.37,32.74,,,,,,,,,,,,,
WASHER ORTH OD13.5MM ID5.5MM SPIK FOR 4.5/6.5MM CANC SCR,SUP-2184673,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.64,209.72,,,,,,,,,,,,,
PLATE BNE 1/4 TBLR 6 HOLE W/ CLLRD NS LTX,SUP-2861936,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-103555,CDM,2580000003,HCPCS,0258,RC,00338-0049-04,NDC,JW,both,250,ML,10.70,6.95,,,,,,,,,,,,,
NAIL FEMORAL RETROGRADE 105MM 380MM,SUP-2587158,CDM,C1713,HCPCS,0278,RC,,,,both,,,5446.74,3540.38,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE 3 PNL CANVS 16INCH LTX FREE,SUP-2336075,CDM,L1830,CPT,0272,RC,,,,both,,,45.44,29.54,,,,,,,,,,,,,
KNIFE SURG BLITZER 10 IN GRAD ANGLED TIP MICROFRANCE DISP,SUP-2470951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,155.87,101.32,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK0.1-0.2MM AMNIO MEM 2 LAYR,SUP-2370450,CDM,Q4150,HCPCS,0636,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 150 CM DIA 0.038 IN FLX TIP L 3 CM,SUP-2157323,CDM,C1769,HCPCS,0272,RC,,,,both,,,17.27,11.23,,,,,,,,,,,,,
PLATE BNE 2.7/3.5X184 MM LT PROX ULN X ARTC 10 HOLE LP VA,SUP-2180824,CDM,C1713,HCPCS,0278,RC,,,,both,,,4471.89,2906.73,,,,,,,,,,,,,
FIBER LASER 262 FT KRA-CPAOCHXL HDMI,SUP-2798097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2212.60,1438.19,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC DEMINERALIZED CORTICAL BNE FIBER,SUP-2932784,CDM,C1762,CPT,0278,RC,,,,both,,,5086.11,3305.97,,,,,,,,,,,,,
FEMORAL HD COCR 22MM +0,SUP-2359091,CDM,C1776,CPT,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
CUSHION RAD 100X70 35L FIL VAC BG,SUP-2137738,CDM,L1830,CPT,0274,RC,,,,both,,,907.08,589.60,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 4 CM DIA 4 MM MICROCATHETER 0.035,SUP-2385370,CDM,C1889,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-4 MM 15 CC FRZN CANC,SUP-2792182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1407.35,914.78,,,,,,,,,,,,,
SCREW CANN COMPR HDLSS 2 THRD TI 3.0MMX20MM,SUP-2392761,CDM,C1713,HCPCS,0278,RC,,,,both,,,782.65,508.72,,,,,,,,,,,,,
BIT DRL DIA1.4MM DISP FOR ICONIX,SUP-2366696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
HC Spectrophotometry Analyt Not Elsewhere Specified,PX-3018431100,CDM,84311,CPT,0301,RC,,,,both,,,203.00,131.95,,,,,,,,,,,,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,0636,RC,00517-0791-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
FILLER BNE VOID 3CC CA PHSPTE FBR REINF DRILLABLE FAST SET,SUP-2182826,CDM,C9359,HCPCS,0278,RC,,,,both,,,2252.51,1464.13,,,,,,,,,,,,,
PLATE BNE DORS SM RT MID FT,SUP-2609048,CDM,C1713,HCPCS,0278,RC,,,,both,,,5112.30,3322.99,,,,,,,,,,,,,
FLUCONAZOLE 200 MG PO TABS,RX-10045,CDM,6370000000,HCPCS,0637,RC,68084-0735-01,NDC,,both,1,UN,12.20,7.93,,,,,,,,,,,,,
LISINOPRIL 5 MG PO TABS,RX-10451,CDM,6370000000,HCPCS,0637,RC,00904-6797-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
RING 5/8 180MM FOR TRUELOK FIX SYS,SUP-2316185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2056.39,1336.65,,,,,,,,,,,,,
SPLINT REST HND ADL R DRBLUE BROAD,SUP-2165489,CDM,L3807,HCPCS,0274,RC,,,,both,,,124.82,81.13,,,,,,,,,,,,,
SYSTEM POS STD BLDE VAC OFF PMP RIG FT DEV XPOSE 3 AXIUS,SUP-2142005,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
MATRIX BONE 5ML GRFT SUB DEMIN PASTE INTERGRO +,SUP-2414014,CDM,C1713,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
PLATE BNE L37MM THK1.3MM 2X4 H L MTCRPL TI L SHP COMPR FOR,SUP-2267918,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.22,437.59,,,,,,,,,,,,,
IMPLANT STAPE PISTON WIRE SCHKNT 0.8MM PISTON 6.25MML SSSFLR,SUP-2638215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.26,213.37,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 90 CC FD IRRADIATED CANC,SUP-2867147,CDM,C1762,CPT,0278,RC,,,,both,,,3221.64,2094.07,,,,,,,,,,,,,
LINER ACET POR HIP ANTEVERTED W/ OXINIUM HD R3,SUP-2348015,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 8 HOLES 151MM,SUP-2549508,CDM,C1713,HCPCS,0278,RC,,,,both,,,1678.30,1090.89,,,,,,,,,,,,,
PLATE BNE W10XL118MM THK3.6MM 10 H BILAT S STL CRV RIG CLLR,SUP-2186255,CDM,C1713,HCPCS,0278,RC,,,,both,,,2270.28,1475.68,,,,,,,,,,,,,
HC Bone Marrow Biopsy-CT,PX-3613822100,CDM,38221,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
KIT SURG PROC UPSYLON Y SHP MESH FLAT SUT SURF MULT DIR,SUP-2140347,CDM,C1781,HCPCS,0278,RC,,,,both,,,5402.94,3511.91,,,,,,,,,,,,,
SCREW BNE CANN CONN INSRT TFN-ADVANCED,SUP-2178962,CDM,C1713,HCPCS,0278,RC,,,,both,,,1735.20,1127.88,,,,,,,,,,,,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,0258,RC,00264-7751-00,NDC,,both,1000,ML,25.50,16.57,,,,,,,,,,,,,
HC Repair Blood Vessel Low Ext,PX-4503522600,CDM,35226,CPT,0450,RC,,,,both,,,730.00,474.50,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 70CM 7FR ID 2.5MM 0.035IN AQ MULTPURP,SUP-2171142,CDM,C1894,HCPCS,0272,RC,,,,both,,,209.85,136.40,,,,,,,,,,,,,
SCREW BNE L 22 MM DIA 3.5 MM TI CANN HDLSS NS LEOS,SUP-2932592,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.77,657.00,,,,,,,,,,,,,
SROM MILLER SHELL SZ 25,SUP-2515426,CDM,C1776,CPT,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
RESERVOIR VENTCULSTMY S STL W/ BASE FOR 6MM BUR H,SUP-2243790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
GRAFT DERM L12CM W3CM THK.8-1.7MM THCK DERMAMATRIX ACELLULAR,SUP-2306910,CDM,C1762,CPT,0278,RC,,,,both,,,3282.49,2133.62,,,,,,,,,,,,,
PORT INFUS CATH DIA8FR PLAS POLYUR PEEL APART PERC INTRO,SUP-2127738,CDM,C1788,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
KIT EEG ELECTRD L 16 MM 5 CONTACT RF PRB STRL DISP EVO,SUP-2936747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3017.54,1961.40,,,,,,,,,,,,,
NAIL IM L170MM DIA12MM 125DEG SHT TROCHANTERIC FEM GRN TI,SUP-2191927,CDM,C1713,HCPCS,0278,RC,,,,both,,,3637.78,2364.56,,,,,,,,,,,,,
CABLE TRNSDUC FOR INTELJET CTRL UNIT,SUP-2340762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
FIBER LASER 600UM HOLM LT GUID,SUP-2313982,CDM,C1713,HCPCS,0278,RC,,,,both,,,1305.52,848.59,,,,,,,,,,,,,
NAIL IM L180MM DIA10MM R HINDFOOT TI CANN LOK LAT BEND RND,SUP-2180015,CDM,C1713,HCPCS,0278,RC,,,,both,,,5449.31,3542.05,,,,,,,,,,,,,
SCREW BNE L 14 MM DAI 3.5 MM COCR ELBW LCK HEXALOBE,SUP-2912775,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
SCREW BNE ST 2X12 MM CORTICAL COARSE PITCH TI NS,SUP-2189632,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 16X6 CM HYDRATED BIOLOGIC TISSUE MA,SUP-2838609,CDM,C1763,HCPCS,0278,RC,,,,both,,,8908.49,5790.52,,,,,,,,,,,,,
DUODENOSCOPE RIGID CTRL STRL EXALT D DISP M00542423,SUP-2480888,CDM,C1748,HCPCS,0278,RC,,,,both,,,12010.50,7806.82,,,,,,,,,,,,,
TEMPORARY CNDLR IMPLNT RGHT 2.7MM LOK SSTM CP TTNM ST,SUP-2500417,CDM,C1889,HCPCS,0278,RC,,,,both,,,3972.32,2582.01,,,,,,,,,,,,,
POSACONAZOLE 100 MG PO TBEC,RX-124366,CDM,6370000000,HCPCS,0637,RC,43598-0470-60,NDC,,both,1,UN,72.80,47.32,,,,,,,,,,,,,
FUSEFORCE STRL SZR KT,SUP-2399890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
SCREW ABSORBABLE CANNULATED 40MM DIA 34MML ARTHROTEK,SUP-2724045,CDM,C1725,HCPCS,0272,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 5 MM EPTFE STR TW N RING STRL,SUP-2396687,CDM,C1768,CPT,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
DILATOR ENDOSCP 54FR L180CM BLLN L8CM ES DISP ELIM PET,SUP-2166036,CDM,C1726,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
RING EXT FIX DIA220 MM FULL SINGLE ROW MONK RING,SUP-2899177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4308.87,2800.77,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 40X20 CM RECON TISS MTRX STRATTICE,SUP-2496346,CDM,Q4130,HCPCS,0636,RC,,,,both,,,79203.36,51482.18,,,,,,,,,,,,,
PLATE BNE 1.8MM THICKNESS TI 18 H LADDER STRNL,SUP-2262578,CDM,C1713,HCPCS,0278,RC,,,,both,,,2140.54,1391.35,,,,,,,,,,,,,
SCREW BNE L 95 MM DIA 4.5 MM ST LCK STRL EVOS,SUP-2931253,CDM,C1713,HCPCS,0278,RC,,,,both,,,958.49,623.02,,,,,,,,,,,,,
DEVICE TARGETING DIAM 2.8MM LEN 195MM SIDEWNDR RADLUC,SUP-2371637,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
BUR REPROC SHV 4MMX18CM ABRAD HI VISIBILITY,SUP-2652940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,74.67,48.54,,,,,,,,,,,,,
CAGE SPNL L14XW14XH50MM SPNL 4 LOBE IMP NGAGE,SUP-2317740,CDM,C1889,HCPCS,0278,RC,,,,both,,,15712.56,10213.16,,,,,,,,,,,,,
PLATE BNE CALCANEAL LG 2.7X70 MM LT LCK VA TAB SS NS VA-LCP,SUP-2799245,CDM,C1713,HCPCS,0278,RC,,,,both,,,3227.35,2097.78,,,,,,,,,,,,,
PLATE BNE L57MM THK1MM 12 H ST HND S STL STR LOK VAR ANG FOR,SUP-2255804,CDM,C1713,HCPCS,0278,RC,,,,both,,,1585.95,1030.87,,,,,,,,,,,,,
SET EXPLORATION COMMON BILE DUCT W/ GWIRE INTRO BLLN CATH,SUP-2169659,CDM,C1726,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
CENTRALIZER STEM 8 MM DSTL FEM HIP MTRX,SUP-2450934,CDM,C1776,CPT,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
GUIDEWIRE VASC CONFIANZA PRO 9 L 300 CM DIA 0.014 IN,SUP-2123737,CDM,C1769,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 80 MM PROX/DSTL 24/12 MM,SUP-2171045,CDM,C1874,HCPCS,0278,RC,,,,both,,,7743.24,5033.11,,,,,,,,,,,,,
MARKER BRST BX 9 GA SHP 1 STEREOTACTIC GUID SYS TRIMARK ATEC,SUP-2240072,CDM,A4648,CPT,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
PLATE BNE 2.7X76 MM 9 HOLE SS DCP,SUP-2569131,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.77,206.55,,,,,,,,,,,,,
TRAY CATH CNTRL VENOU LUMENX2 7FR DIA 36CML SIL 0.2/0.3ML PR,SUP-2613072,CDM,C1751,HCPCS,0278,RC,,,,both,,,497.69,323.50,,,,,,,,,,,,,
BLADE MONOPOLAR SERRATED STD 4 MM STR SUCTION EDGE FRM MALL,SUP-2638409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.14,325.74,,,,,,,,,,,,,
CATHETER EP D 6 MM 20 MMX7 FRX115 CM CARTO,SUP-2467701,CDM,C1732,HCPCS,0272,RC,,,,both,,,7262.82,4720.83,,,,,,,,,,,,,
CONNECTOR SET SCR EXTN LOK MULT AX MAS XLNK MAS EXTN VERTEX,SUP-2289102,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
CLIP LIG M BLU TI HRT SHP WIRE HORZ 6 CLIPS PER PK,SUP-2855136,CDM,C1889,HCPCS,0278,RC,,,,both,,,9.11,5.92,,,,,,,,,,,,,
SET INTRO PEELWY L 9 CM DIA 5.5 FR GUIDEWIRE 0.018 IN NIT,SUP-2168419,CDM,C1894,HCPCS,0272,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
SCREW SPNL MULTAXL 7.5X40 MM ESSENCE TI CD HORZ ESSENTIALS,SUP-2631916,CDM,C1713,HCPCS,0278,RC,,,,both,,,8102.77,5266.80,,,,,,,,,,,,,
SCR DF ZURICH HEXMD1.2X7MM5MM THD,SUP-2678357,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
TRAY HUM ADPT +5MM OFFSET STD POLY FOR REV SHLDR SYS,SUP-2223377,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
KYPHOPLASTY KIT BLLN 8 GAX15 MM SINGLE FRAC IVAS ELITE DISP,SUP-2424040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4211.96,2737.77,,,,,,,,,,,,,
PLATE BNE LP 1.5X0.6 MM NEURO 3X2 HOLE LADDER SQ SEG STRL,SUP-2475785,CDM,C1713,HCPCS,0278,RC,,,,both,,,739.82,480.88,,,,,,,,,,,,,
HC Peripheral Block - Axillary W/Img Gdn,PX-3606441700,CDM,64417,CPT,0360,RC,,,,inpatient,,,2895.00,1881.75,,,,,,,,,,,,,
PLATE BONE L31MM 4 H STRL S STL LCK COMPR FOR 2.7MM SCR EVOS,SUP-2349615,CDM,C1713,HCPCS,0278,RC,,,,both,,,1842.71,1197.76,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX THICK 10X20 CM MATRISTEM,SUP-2106499,CDM,Q4166,HCPCS,0636,RC,,,,both,,,16814.70,10929.55,,,,,,,,,,,,,
PLATE BONE L15MM THK0.9MM 3MM OFFSET 0DEG 4 H BILAT CHIN,SUP-2191214,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
PLATE BONE CMPRSSN 204MML HLX11 STNLSS STEEL 90DG ANGLD TUBE,SUP-2720626,CDM,C1713,HCPCS,0278,RC,,,,both,,,1718.02,1116.71,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 3 or More Muscles,PX-4202056100,CDM,20561,CPT,0940,RC,,,,both,,,42.00,27.30,,,,,,,,,,,,,
DEXTROSE 70 % IV SOLN,RX-2367,CDM,2580000003,HCPCS,0250,RC,00338-0719-06,NDC,,both,2000,ML,170.00,110.50,,,,,,,,,,,,,
PLATE BNE L292MM 16 H ST R MED DST TIB S STL VAR ANG LOK,SUP-2177653,CDM,C1713,HCPCS,0278,RC,,,,both,,,7223.29,4695.14,,,,,,,,,,,,,
STENT URET STR 0.038 IN 3 CM 5 FRX24 CM 6 FR POLARIS ULTRA,SUP-2458928,CDM,C2617,HCPCS,0278,RC,,,,both,,,494.64,321.52,,,,,,,,,,,,,
STAPLER INT L30MM DIA3.5MM BLU ROTIC USE W/ TI STPL DISP,SUP-2283030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2013.12,1308.53,,,,,,,,,,,,,
SPLINT WR FRARM PED L4IN LT TIETEX COCK UP LOOP LCK W/ STAY,SUP-2195514,CDM,L3931,HCPCS,0274,RC,,,,both,,,24.43,15.88,,,,,,,,,,,,,
NAIL FEM CHILD RIGHT 8MMX 360MM,SUP-2750026,CDM,C1713,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 300CM 0.014IN SEG 35CM STD PRESHAPED,SUP-2866244,CDM,C1769,HCPCS,0272,RC,,,,both,,,2906.23,1889.05,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING 6MM DIA 50CM LEN 8CM GORTX,SUP-2395999,CDM,C1768,CPT,0278,RC,,,,both,,,2411.52,1567.49,,,,,,,,,,,,,
CANNULA PROTEKDUO 31FR,SUP-2862987,CDM,C1889,HCPCS,0278,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
TAP SURG SILVERTON OD4.5MM,SUP-2211141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
STEM RAD L33X17MM DIA9MM NK OFFSET 2MM TI ALIGN,SUP-2340151,CDM,C1776,CPT,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
KWIRE 3.2X450MM,SUP-2473005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
HC Thyroid Metastases Imaging; Whole Body,PX-3417801800,CDM,78018,CPT,0341,RC,,,,outpatient,,,2192.00,1424.80,,,,,,,,,,,,,
GRAFT BNE EVANS WDG LG 19X12 MM STRL TITAN 3-D,SUP-2742084,CDM,C1713,HCPCS,0278,RC,,,,both,,,5396.88,3507.97,,,,,,,,,,,,,
FORCEPS BPLR BAYNT 7IN IRR NONSTICK COHEN,SUP-2858213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
CAP SCR FOR EXT FIX SYS,SUP-2263011,CDM,C1713,HCPCS,0278,RC,,,,both,,,607.78,395.06,,,,,,,,,,,,,
BOOT CAST SM W5XL11 1 4IN OPN TOE AND HEEL MOLD ROCK,SUP-2276728,CDM,L4386,HCPCS,0274,RC,,,,both,,,16.17,10.51,,,,,,,,,,,,,
KIT CAGE SPINAL APREVO 4-LEVEL,SUP-2912825,CDM,C1889,HCPCS,0278,RC,,,,both,,,138160.00,89804.00,,,,,,,,,,,,,
KIT HAD CATH AD 15.5FR L28CM BASIC PRECRV STK TIP DBL LUMN,SUP-2116544,CDM,C1750,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
PROBE LASER DIRECTIONAL 25G,SUP-2863700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.76,231.24,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-3612061100,CDM,20611,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
COMPONENT FEM SZ 3 CO CHROM L KNEE REV STEMLESS POST STBL,SUP-2346124,CDM,C1776,CPT,0278,RC,,,,both,,,23513.11,15283.52,,,,,,,,,,,,,
PLATE BNE 2 T-SHAPE1.0MM 4-HOLE,SUP-2247342,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
MESH WND DERM REP FET BOV DERM PRIMATRIX FEN 20X25,SUP-2243691,CDM,Q4110,HCPCS,0636,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
GRAFT DURA W1XL3IN BOV ABSRB POR DURAGN,SUP-2244080,CDM,C1713,HCPCS,0278,RC,,,,both,,,724.40,470.86,,,,,,,,,,,,,
PLATE BNE DELT SM 117 MM LT DSTL DORS RADIAL 8 HOLE BUTTRESS,SUP-2458845,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.21,1402.19,,,,,,,,,,,,,
BLADE SHV DIA2.5MM FULL RAD CUT GRY HUB FOR SM JT,SUP-2366887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,249.66,162.28,,,,,,,,,,,,,
PLATE BNE LCK XL LT CALCANEAL MESH STRL ALPS LTX,SUP-2860967,CDM,C1713,HCPCS,0278,RC,,,,both,,,4075.09,2648.81,,,,,,,,,,,,,
PLATE BONE W8XL144MM THK3.3MM 18 H STRL BILAT PELV S STL,SUP-2186246,CDM,C1713,HCPCS,0278,RC,,,,both,,,2057.05,1337.08,,,,,,,,,,,,,
PLATE BNE L142MM 6 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185670,CDM,C1713,HCPCS,0278,RC,,,,both,,,4176.48,2714.71,,,,,,,,,,,,,
HC Cv Cath Plac W/Port Tun >5,PX-3613656100,CDM,36561,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 4 CM LG AMNIO MEMBRN RESRB STRL,SUP-2913456,CDM,Q4173,HCPCS,0636,RC,,,,both,,,8807.70,5725.00,,,,,,,,,,,,,
GUIDEWIRE VASC L 45 CM DIA 0.021 IN STRL,SUP-2744704,CDM,C1729,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 55 CM OD 7 FR ID 0.078 IN TIP,SUP-2158733,CDM,C1887,HCPCS,0272,RC,,,,both,,,563.79,366.46,,,,,,,,,,,,,
BLADE SHV ARTHSCP INCIS 4 MM STR STRL DISP,SUP-2341602,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.17,286.76,,,,,,,,,,,,,
KIT TKR TRABECULAR MTL FEM TIB PAT AND VIT E SURF PERSONA,SUP-2212239,CDM,C1776,CPT,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
SPACER SPNL NO PROF 7 DEG 14X13X6 MM INTEGR NS SHORELINE ACS,SUP-2245650,CDM,C1821,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
SCREW BNE L19MM DIA3.5MM HIP FULL THRD HEX HD COMPR,SUP-2342407,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.32,273.21,,,,,,,,,,,,,
PLATE BNE 2.7X44 MM 7 HOLE MULTIPLE FRAG SS NS,SUP-2568762,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.15,377.10,,,,,,,,,,,,,
PACEMAKER CARD REOCOR S SINGLE CHMBR EXT TEMP NS,SUP-2138197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
KNIFE SURG ROYCE 7.5 INX8 MM EAR BAYNT DN CUT MICROFRANCE,SUP-2498047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.85,302.15,,,,,,,,,,,,,
CATHETER INFUS 5FR 30CM INFUS LEN 90CM LEN - 5FR 30CM INFUS,SUP-2117008,CDM,C1757,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
PLATE BNE L THK0.8MM 3X4 H L BILAT CRANIOMAXILLOFACIAL G TI,SUP-2181706,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.35,752.93,,,,,,,,,,,,,
SCREW BNE ST 2X12 MM CRTX COARSE PITCH TI NS LF,SUP-2189672,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.37,161.44,,,,,,,,,,,,,
RETRACTOR SURG COLUMELLA W WT GRUBER,SUP-2244333,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.67,264.99,,,,,,,,,,,,,
MESH SURG L20XW15CM MACRO POLYFORM POR POLYPR SYN SGL USE N,SUP-2139415,CDM,C1781,HCPCS,0278,RC,,,,both,,,3671.04,2386.18,,,,,,,,,,,,,
COUNTERSINK DRL DIA6MM SLD FOR ANK FRAC SYS ORTHOLOC 3DI,SUP-2398335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
WAND ARTHSCP 90DEG IFS AMBIENT SUP TURBOVAC,SUP-2342015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.025 IN L 7 CM FLPY TIP L 2.5,SUP-2167594,CDM,C1769,HCPCS,0272,RC,,,,both,,,55.17,35.86,,,,,,,,,,,,,
LEAD CARD PACE PERM ATR LD PACE BPLR PASS FIX IS 1 CONN 46CM,SUP-2356655,CDM,C1898,HCPCS,0275,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
NEEDLE BX FLX TIP 18 GAX60 CM TRNSJUG LIV SYS STRL TLAB LTX,SUP-2876886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
INSERT SURG 18MM INTERSPINOUS FUS TI UNILINK,SUP-2205259,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
BAR EXT FIX L 750 MM DIA10.5 MM COMP STRL DISP JET-X,SUP-2933463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,920.84,598.55,,,,,,,,,,,,,
STEM FEM SZ 11 L145MM CEM POLISHED INTRIGUE,SUP-2406816,CDM,C1776,CPT,0278,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L POST STBL NP BAL SYS,SUP-2314595,CDM,C1776,CPT,0278,RC,,,,both,,,6958.24,4522.86,,,,,,,,,,,,,
COIL VASC I-ED COIL L 10 CM DIA 0.012 IN SECONDARY 2-3 MM,SUP-2865319,CDM,C1889,HCPCS,0278,RC,,,,both,,,5432.20,3530.93,,,,,,,,,,,,,
FLUVOXAMINE MALEATE 100 MG PO TABS,RX-10084,CDM,6370000000,HCPCS,0637,RC,60505-0166-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STAPLE BONE FIX W20XL20X20MM 2X2MM WIRE FIX BARB IMPL OSSTPL,SUP-2191866,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
PLATE BNE TBLR UNIV 2.7 MM 6 HOLE 1/4 2 COMPR LCK FOR SCR,SUP-2474079,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.70,571.80,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00990-7922-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
IMPLANT BRST 425CC P5.2CM DIA12CM SFT COHESIVE SIL GEL STYL,SUP-2113229,CDM,C1789,HCPCS,0278,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
PLATE BONE L55MM 8 H BILAT MAND ORAL MAXILLOFACIAL TI STR LO,SUP-2191326,CDM,C1713,HCPCS,0278,RC,,,,both,,,1536.40,998.66,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX19 CM PRE CRV PALINDROMIC,SUP-2283950,CDM,C1881,HCPCS,0278,RC,,,,both,,,1037.20,674.18,,,,,,,,,,,,,
PLATE BNE 20 H ST BILAT S STL NAR CRV LOK COMPR FOR 35MM SCR,SUP-2178052,CDM,C1713,HCPCS,0278,RC,,,,both,,,3331.41,2165.42,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 4.01-5.0 MCI STRL ADVANTAGE 2029ELS2] ISOAID LLC],SUP-2247270,CDM,C2642,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
NAIL IM L235MM DIA12MM NK 130DEG GRN PROX FEM TI,SUP-2192102,CDM,C1713,HCPCS,0278,RC,,,,both,,,3901.23,2535.80,,,,,,,,,,,,,
PLATE BONE METACARPAL MINI 2.7X60X8X2.5 MM METATARSAL PHALAN,SUP-2836996,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.85,987.90,,,,,,,,,,,,,
CATHETER PICC ARROWG+ARD BLUE ADVANCE TAPERFREE 6FR 55CM 3-LUM,SUP-2887071,CDM,C1751,HCPCS,0278,RC,,,,both,,,724.30,470.79,,,,,,,,,,,,,
CATHETER SET GASTROSTMY 12 FRX35 CM 12 SP WILLS-OGLESBY,SUP-2168069,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.57,324.07,,,,,,,,,,,,,
ELECTRODE ES 14GA L25CM TALON SEMI FLX RF FOR TISS ABLAT,SUP-2118721,CDM,C1819,HCPCS,0278,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
COIL NEUROVASCULAR PRESIDIO 18 CERECYTE L 50 CM LOOP DIA20,SUP-2249259,CDM,C1889,HCPCS,0278,RC,,,,both,,,9518.13,6186.78,,,,,,,,,,,,,
GRAFT BNE FRZN STRUCTURAL L PROX FIB IMPL ALLGRFT,SUP-2307383,CDM,C1713,HCPCS,0278,RC,,,,both,,,5221.95,3394.27,,,,,,,,,,,,,
HC MRI Lower Ext Jnt W/O Cont,PX-6107372100,CDM,73721,CPT,0610,RC,,,,both,,,3764.00,2446.60,,,,,,,,,,,,,
STEM HUM L110MM DIA10.5MM 135DEG CO CHROM MOLYBDENUM,SUP-2204813,CDM,C1776,CPT,0278,RC,,,,both,,,9928.68,6453.64,,,,,,,,,,,,,
TUBE EXT FIX L300MM OD20MM BLU C FOR UNILAT MONOTB TRIAX SYS,SUP-2372610,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.18,364.12,,,,,,,,,,,,,
PLATE BNE L171MM SHT WRST SPANNING ACU LOC,SUP-2416950,CDM,C1713,HCPCS,0278,RC,,,,both,,,6744.72,4384.07,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 46 MM ANTR CERV,SUP-2414259,CDM,C1713,HCPCS,0278,RC,,,,both,,,4882.76,3173.79,,,,,,,,,,,,,
PIN 3.0X355MM,SUP-2500376,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
PLATE BONE L203MM 95DEG 10 SLOT STD SUPCNDYL,SUP-2412161,CDM,C1713,HCPCS,0278,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
CATHETER THRMDLTN VLMTRC 75FR LMNX7 110CML CNTNS CRDC OUTPT,SUP-2696591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.14,529.84,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 3MM X 800MM BEAD TIP FOR TIBIOTALOCALCANEAL FUSION DYNANAIL,SUP-2878463,CDM,C1769,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
SCREW BNE PARTIALLY THRD 5X110 MM PANTA PAN10101710NS,SUP-2434157,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.55,1388.11,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6 MM EPTFE STR TW,SUP-2525470,CDM,C1768,CPT,0278,RC,,,,both,,,2677.51,1740.38,,,,,,,,,,,,,
TRIAL PAT OD29MM ULTEM NXGN,SUP-2201312,CDM,C1776,CPT,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
CATHETER PERIPH ATHRCTMY CLIRPATH TURBO + EXCIMER LSR,SUP-2353078,CDM,C1724,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
GRAFT HUM TISS W12XL12CM THK1.04-2.28MM THCK REGEN TISS,SUP-2113000,CDM,Q4116,HCPCS,0636,RC,,,,both,,,16528.96,10743.82,,,,,,,,,,,,,
HC Bleeding Time Test,PX-3058500200,CDM,85002,CPT,0305,RC,,,,both,,,294.00,191.10,,,,,,,,,,,,,
ROD SPNL ANTR RT SMOOTH 5.0MM DIA 600MM LEN,SUP-2290521,CDM,C1713,HCPCS,0278,RC,,,,both,,,2411.52,1567.49,,,,,,,,,,,,,
CATHETER CV FULL TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0043,SUP-2759848,CDM,C1751,HCPCS,0278,RC,,,,both,,,444.84,289.15,,,,,,,,,,,,,
GUIDEWIRE VASC L175CM DIA0035IN PTFE STR SHP TIP FLPY,SUP-2281743,CDM,C1769,HCPCS,0272,RC,,,,both,,,193.64,125.87,,,,,,,,,,,,,
SCREW BNE L100MM DIA3MM THRD L30MM CORT SELF DRL,SUP-2316454,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
PLATE BNE MEDL CLMN SM 2.7/3.5 MM MIDFOOT 6 HOLE COMPR TI,SUP-2398189,CDM,C1713,HCPCS,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
PLATE BONE SM W10XL50MM THK1.2MM 3X3 H RT DSTL S STL T SHP,SUP-2343782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1056.89,686.98,,,,,,,,,,,,,
COIL VASC TORNADO EMBOLUS L 12.5 CM DIA10-4 MM CATH DIA,SUP-2168581,CDM,C1889,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BELOW LIMB PREPARATORY,SUP-2388205,CDM,L5530,HCPCS,0274,RC,,,,both,,,4784.51,3109.93,,,,,,,,,,,,,
ALLOGRAFT DERMAL THCK 4X4 CMX0.8-1.7 MM DEHYDR ALLOPATCH HD,SUP-2489516,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4123.61,2680.35,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 25 MM CABLE L 1 M PRASS PR 2 CHANNEL,SUP-2902120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.93,297.00,,,,,,,,,,,,,
OXF CEM FEM/CEM TIB/STD AS/BLD,SUP-2212437,CDM,C1776,CPT,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY LG 20 IN PERF WRP ARND FOAM,SUP-2194894,CDM,L1830,CPT,0274,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
KIT CATH DRNGE 155FR DIA 15CML SLCNE HYDRO GLIDE CTD STLT 1,SUP-2676360,CDM,C1729,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER VASC GUID N 5 PERIPH W/ HYDRPHLC COAT AD RADPQ,SUP-2116878,CDM,C1887,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
KIT IM NAIL SM L150MM DIA10MM R HINDFOOT FUS VALOR,SUP-2397553,CDM,C1713,HCPCS,0278,RC,,,,both,,,5909.48,3841.16,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ ACTIVE CTRL DBL UPR FABRICATED,SUP-2435759,CDM,L3740,HCPCS,0274,RC,,,,both,,,2768.51,1799.53,,,,,,,,,,,,,
BASKET STONE 1.8 FR POLYMER SHTH WIRE ULTRA-CATCH NT,SUP-2457150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
STRAP CLAV M HVY DUTY BCKL CLSR,SUP-2194646,CDM,L3650,HCPCS,0272,RC,,,,both,,,18.12,11.78,,,,,,,,,,,,,
LINER ACET HW +3 28 40 MM HIP ARCM XL POLYETH RINGLOK,SUP-2409549,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
TEMPLATE SZ THK27MM 26 H MAND PLT TI STR LOK FOR 27MM SCR,SUP-2262980,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.08,129.40,,,,,,,,,,,,,
POST STR OUTRIG 11MM,SUP-2188507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
SPACER SPNL W26XH10MM PEEK-OPTIMA 1 LEV ANTR INTERVERTEBRAL,SUP-2385988,CDM,C1889,HCPCS,0278,RC,,,,both,,,10701.12,6955.73,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK0.8-1.7MM MESHED SKIN TISS PERF,SUP-2307575,CDM,C1781,HCPCS,0278,RC,,,,both,,,10132.15,6585.90,,,,,,,,,,,,,
PROSTHESIS PENILE 18X12 CM PMP PRECONNECT INFLATABLE AMS 700,SUP-2140300,CDM,C1813,HCPCS,0278,RC,,,,both,,,18353.30,11929.64,,,,,,,,,,,,,
PLATE BNE SET FOR LG FRAG PERI-LOC,SUP-2351389,CDM,C1713,HCPCS,0278,RC,,,,both,,,60523.50,39340.27,,,,,,,,,,,,,
PROBE NERVE STIM DIA2.3 MM MONOPOLAR BALL TIP STRL DISP,SUP-2901988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,380.07,247.05,,,,,,,,,,,,,
CONNECTOR SPNL TI ROD STR SLT FOR 6.35MM ROD MNRCH,SUP-2254509,CDM,C1713,HCPCS,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
SET CATH HEMODIALYSI ESCHLN CHRONIC BASIC 15FR DIA 32CM STRG,SUP-2610558,CDM,C1750,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 5-8 MM EPTFE STP STD WALL N,SUP-2127041,CDM,C1768,CPT,0278,RC,,,,both,,,1297.92,843.65,,,,,,,,,,,,,
ROD SPNL L480MM DIA5.5MM POST THORLUM CO CHROM SMOOTH STR,SUP-2256567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
TIP SUCT L3.13IN DIA0.1IN 23KHZ FLUE CUSA EXCEL MACROTIP,SUP-2243956,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SEMITENDINOSUS/GRACILIS TEND FRZN COMB,SUP-2321843,CDM,C1762,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SCREW BNE L20MM DIA6.5MM CTRL FOR REV SHLDR SYS COMPHSVE,SUP-2404735,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
COMPONENT TIB DIA12MM CANN FUS NAIL NONLOCKING WICH,SUP-2377549,CDM,C1776,CPT,0278,RC,,,,both,,,8153.01,5299.46,,,,,,,,,,,,,
IMPLANT HUM TISS L 35 X W 25 MM THK 5 MM ACHILLES TEND RC,SUP-2932882,CDM,C1762,CPT,0278,RC,,,,both,,,8928.12,5803.28,,,,,,,,,,,,,
INSERTER SURG AID FOR GUIDEWIRE,SUP-2433930,CDM,C1776,CPT,0278,RC,,,,both,,,110.90,72.08,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 45 CM DIA 5-8 MM EPTFE TRMPT GRAD WALL,SUP-2681849,CDM,C1768,CPT,0278,RC,,,,both,,,3166.50,2058.22,,,,,,,,,,,,,
MATRIX SURGICAL WOUND 0.015OZ CONNEXT,SUP-2758895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 5.25X5.25 IN FNGR W/ BLB RADLUC,SUP-2276774,CDM,L3933,HCPCS,0272,RC,,,,both,,,5.21,3.39,,,,,,,,,,,,,
CATHETERIZATION TRAY 4 FR DL NIT GUIDEWIRE POWERPICC PROVENA,SUP-2127010,CDM,C1751,HCPCS,0278,RC,,,,both,,,461.20,299.78,,,,,,,,,,,,,
ALLOGRAFT DERMAL HUM TISS THCK 20X12 CMX2.3-3.3 MM ALLDERM,SUP-2475878,CDM,Q4116,HCPCS,0636,RC,,,,both,,,26002.34,16901.52,,,,,,,,,,,,,
PLATE BNE 15 MM FEM OPENING WDG OSTEOTMY SS,SUP-2431989,CDM,C1713,HCPCS,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
VARIABLE TI SCREW LOCK SCREW 3.5MM X 10MM LGTH,SUP-2586567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.36,763.98,,,,,,,,,,,,,
SCREW BONE L65MM DIA6.5MM THRD L20MM CANN EXTREMFIX,SUP-2319559,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
STEM FEM SZ 7 L155MM OD11MM 5MM OFFSET HA DST HIP STR,SUP-2379085,CDM,C1776,CPT,0278,RC,,,,both,,,15844.44,10298.89,,,,,,,,,,,,,
GRAFT VASC L70CM ID6MM REM RNGD L60CM THN WALLED CBAS HEP,SUP-2395813,CDM,C1768,CPT,0278,RC,,,,both,,,7978.74,5186.18,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE MOD CUP TRAB MEL,SUP-2212692,CDM,C1776,CPT,0278,RC,,,,both,,,1142.08,742.35,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L90CM STD REG W INTEGR PERI CATH OPN,SUP-2628592,CDM,C1729,HCPCS,0272,RC,,,,both,,,14974.38,9733.35,,,,,,,,,,,,,
PLATE RIM RAD HD LNG,SUP-2361552,CDM,C1713,HCPCS,0278,RC,,,,both,,,3275.33,2128.96,,,,,,,,,,,,,
KIT CEM MIXING/DELIVERY 10CC HALF DOSE,SUP-2367023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1722.79,1119.81,,,,,,,,,,,,,
TIP ASPIR L4.5IN OD1.92MM ID1.5MM SFT TISS STR FOR SONOPET,SUP-2367531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1700.94,1105.61,,,,,,,,,,,,,
PLATE BNE L 46 MM TI RT DSTL VOLAR RADIAL NAR NS VARIAX,SUP-2900750,CDM,C1713,HCPCS,0278,RC,,,,both,,,6331.40,4115.41,,,,,,,,,,,,,
PLATE BNE L 10 H R CLAV LOK,SUP-2107748,CDM,C1713,HCPCS,0278,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
CLIP APPL INT 5 MMX35 CM ENDOSCP AUTO HEMOLOCK TI,SUP-2384725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
HC Ablate Bone Tumor(S) Perq,PX-3612098300,CDM,20983,CPT,0361,RC,,,,outpatient,,,10314.00,6704.10,,,,,,,,,,,,,
BUR SURG L72MM DIA3MM TOOL STL LNG FLUT RND,SUP-2284262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,250.35,162.73,,,,,,,,,,,,,
PLATE BNE THK1.3MM 5 H MTCRPL TI STR COMPR FOR 2/2.3MM SCR,SUP-2267913,CDM,C1713,HCPCS,0278,RC,,,,both,,,821.42,533.92,,,,,,,,,,,,,
WIRE FIX DIA13MM ANK FT SMOOTH OLV,SUP-2321632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
SPHERE GLEN INFERIOR 2.5+ MM 24X45 MM,SUP-2845825,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
NAIL IM L28CM DIA7MM L MED LAT FEM LOK CANN RG FOR SUPCNDYL,SUP-2318915,CDM,C1713,HCPCS,0278,RC,,,,both,,,7279.78,4731.86,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 300-500 UM 2 ML PVA PREFIL SYR,SUP-2148448,CDM,C1889,HCPCS,0278,RC,,,,both,,,750.96,488.12,,,,,,,,,,,,,
PLATE BNE L40MM 2X4 H BILAT S STL T SHP LO PROF RIG NEUT,SUP-2186360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1931.38,1255.40,,,,,,,,,,,,,
HEAD HUM OD56MM THK21MM YEL CO CHROM STD MORSE TAPR AFFINITI,SUP-2396770,CDM,C1776,HCPCS,0278,RC,,,,both,,,7075.68,4599.19,,,,,,,,,,,,,
SHAFT TIB TRAD ALLGRFT 200 MM FRZN,SUP-2294184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3150.05,2047.53,,,,,,,,,,,,,
RIVAROXABAN 15 MG PO TABS,RX-111544,CDM,6370000000,HCPCS,0637,RC,50458-0578-10,NDC,,both,1,UN,89.80,58.37,,,,,,,,,,,,,
CATHETER CTRL VEN L20CM OD12FR 3 LUMN N TUNNELED FULL KT,SUP-2120611,CDM,C1751,HCPCS,0278,RC,,,,both,,,545.73,354.72,,,,,,,,,,,,,
PLATE BONE THK0.8MM 4 H HND DBL ROW TRILOK FOR 1.5MM SCR,SUP-2267906,CDM,C1713,HCPCS,0278,RC,,,,both,,,1762.73,1145.77,,,,,,,,,,,,,
BIT DRL DIA3.8MM TIM CANN DISP,SUP-2412627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
TACROLIMUS 1 MG PO CAPS,RX-12933,CDM,J7507,HCPCS,0636,RC,00904-7097-61,NDC,,both,1,UN,6.20,4.03,,,,,,,,,,,,,
PLATE BONE X LNG L18MM THK0.6MM 6 H TI DBL Y SHP FOR 1.5MM,SUP-2402885,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
PLATE BNE L435MM 3 H ST BILAT S STL SPR LO PROF RIG,SUP-2177157,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.27,828.28,,,,,,,,,,,,,
ELEVATOR SURG L11IN TIP W19MM S STL SATIN FINISH COBB,SUP-2160985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.27,211.43,,,,,,,,,,,,,
ROD IM L180MM DIA3.6MM FIBULAR,SUP-2106892,CDM,C1713,HCPCS,0278,RC,,,,both,,,5146.46,3345.20,,,,,,,,,,,,,
PLATE BNE THK 1 MM ADV 8 MM SCREW DIA2 MM MINI RT,SUP-2883140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1896.65,1232.82,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE SILHOUETTE CATH 10 CM 5 FR NIT PD,SUP-2633290,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.61,95.30,,,,,,,,,,,,,
PLATE BNE RNG ATTCH LG 3.5 MM RT PROX GTR TROCH STRL VALCP,SUP-2789578,CDM,C1713,HCPCS,0278,RC,,,,both,,,4796.57,3117.77,,,,,,,,,,,,,
IMPLANT HUM TISS L 8 X W 4 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881935,CDM,C1762,CPT,0278,RC,,,,both,,,14115.87,9175.32,,,,,,,,,,,,,
GRAFT BNE BLOCK FULL ACHILLES TEND,SUP-2335254,CDM,C1713,HCPCS,0278,RC,,,,both,,,9278.70,6031.15,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 6 MM STR STD WALL HELIX,SUP-2525445,CDM,C1768,CPT,0278,RC,,,,both,,,1129.18,733.97,,,,,,,,,,,,,
CLAMP SURG ROD TO ROD 5.5-6.5 MM REVERE,SUP-2584886,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 3FR 55CM 1 LUMAN R S1173108,SUP-2632783,CDM,C1751,HCPCS,0278,RC,,,,both,,,771.94,501.76,,,,,,,,,,,,,
BUR SURG 10 FLUT MED 5 MM RND M ATTCH FOR CORE/TPS TOOL STL,SUP-2363426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,274.53,178.44,,,,,,,,,,,,,
PLATE L FUSION VA LCP 2.4/2.7MM SHRT RT TI STRL,SUP-2546990,CDM,C1713,HCPCS,0278,RC,,,,both,,,3427.47,2227.86,,,,,,,,,,,,,
PROBE TEMP SM,SUP-2308193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1342.13,872.38,,,,,,,,,,,,,
SCREW OD13MM W 4MM STP,SUP-2365065,CDM,C1713,HCPCS,0278,RC,,,,both,,,275.91,179.34,,,,,,,,,,,,,
KIT THR POR STEM TRABECULAR MTL CUP L VIT E LNR AND L 98000100580] ZIMMER BIOMET INC],SUP-2212077,CDM,C1776,CPT,0278,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
KIT BILI STENT PRE ASSEMB INSRTN 1725MM PUSH CATH LEN 2090MM,SUP-2313251,CDM,C1894,HCPCS,0272,RC,,,,both,,,205.14,133.34,,,,,,,,,,,,,
BLADE RETRACTOR 5 IN HIP STD T BAR HNDL SELF RET,SUP-2242481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1128.80,733.72,,,,,,,,,,,,,
STEM TIB L150MM DIA12MM KNEE EXTN STABILIZING PRI FLUT,SUP-2253322,CDM,C1713,HCPCS,0278,RC,,,,both,,,3783.70,2459.40,,,,,,,,,,,,,
INSERT TIB THK 19 MM SZ 0 POLYETHYL LT ANK FIX XT REV STRL,SUP-2933230,CDM,C1776,CPT,0278,RC,,,,both,,,9519.54,6187.70,,,,,,,,,,,,,
SET DCOMPR DRNGE CATH 10FR L350CM ACCSRY CHAN 3.7MM 0.035IN,SUP-2169320,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 19-24 MM PA COMPETENT VLV STRL,SUP-2884023,CDM,C1768,CPT,0278,RC,,,,both,,,47881.86,31123.21,,,,,,,,,,,,,
DRILL TWST L 9 MM DIA1.1 MM STP 7 MM HALL FOR 1.5 SYS NS,SUP-2935115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
PLATE BNE MESHED 1 MM MXLFCL 12 HOLE LF,SUP-2469443,CDM,C1713,HCPCS,0278,RC,,,,both,,,5111.32,3322.36,,,,,,,,,,,,,
CROWN PRI S STL D-LL-5,SUP-2322201,CDM,D6783,CPT,0278,RC,,,,both,,,27.32,17.76,,,,,,,,,,,,,
PIN DRL TRIANG END 3.1X76.2 MM FIX TRCR PT RND END,SUP-2760757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
HC Assay of Phosphorus Inorganic,PX-3018410000,CDM,84100,CPT,0301,RC,,,,both,,,83.00,53.95,,,,,,,,,,,,,
SCREW INTFR L25MM DIA9MM RND HD STAR DRV FOR ACL RECON,SUP-2212841,CDM,C1713,HCPCS,0278,RC,,,,both,,,1350.45,877.79,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 5CM H2O 30CM H2O VALVE SYSTEM SPRUNG RES,SUP-2825936,CDM,C1889,HCPCS,0278,RC,,,,both,,,8188.84,5322.75,,,,,,,,,,,,,
DRESSING 4INX10.0YD DOME PASTE OR UNNA BOOT GELOCAST,SUP-2324582,CDM,L4387,HCPCS,0274,RC,,,,both,,,31.75,20.64,,,,,,,,,,,,,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-40840058,CDM,2580000003,HCPCS,0258,RC,00338-0125-03,NDC,,both,250,ML,25.50,16.57,,,,,,,,,,,,,
SCREW BNE SD 2X4 MM CRTX MAND TI SLV NS PLUSDRIVE,SUP-2189343,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.66,183.73,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN FLX FREJKA TYP W/CVR,SUP-2435595,CDM,L1600,HCPCS,0274,RC,,,,both,,,364.81,237.13,,,,,,,,,,,,,
SCREW BNE L35MM DIA5MM CORT TI LOK FULL THRD SHFT FOR T2 IM,SUP-2369901,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
RING EXT FIX FULL 120 MM CIR,SUP-2400625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
"Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral)",PX-3008718600,CDM,87186,CPT,0300,RC,,,,both,,,102.00,66.30,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 30-50X10 MM 25X10 MM FRZN PATELLAR TEND,SUP-2866904,CDM,C1762,CPT,0278,RC,,,,both,,,7218.86,4692.26,,,,,,,,,,,,,
GRAFT DURA W5XL7IN ULTRAPURE REGEN CLLGN MTRX ABSRB DURAGN,SUP-2244009,CDM,C1763,HCPCS,0278,RC,,,,both,,,6950.45,4517.79,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM SIL TI SELF DRL FULL THRD,SUP-2181627,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BONE L73MM 5 H OBLQ T SHP PERI-LOC SM FRAG SYS,SUP-2348452,CDM,C1713,HCPCS,0278,RC,,,,both,,,2068.10,1344.26,,,,,,,,,,,,,
COTTON OSTEOTOMY WEDGE TI/PEEK 16MMX4.5MM STERILE,SUP-2547172,CDM,C1713,HCPCS,0278,RC,,,,both,,,5583.36,3629.18,,,,,,,,,,,,,
BIOPSY TRAY COMPHSVE 11 GAX152 MM BNE MAR SYS NDL ONCONTROL,SUP-2766677,CDM,C1830,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
TROCAR SURG SM FOR 3 MM BLOCK,SUP-2458593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,532.54,346.15,,,,,,,,,,,,,
CAGE SPNL L W10XH10XL30MM 5DEG ANT CERV INTBDY FUS PEEK,SUP-2310886,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
PACK PRIMING ECMO,SUP-2867340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
KIT CARD PACE ARW CATH L 110 CM DIA 5 FR INTRO 6 FR ELECTRD,SUP-2904194,CDM,C1730,HCPCS,0272,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
KIT CATH TWO LUMN CTRL VEN ACCS SUP W/ ARROWG+ARD BLU ACCS,SUP-2383303,CDM,C1894,HCPCS,0272,RC,,,,both,,,188.09,122.26,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit,PX-3613690100,CDM,36901,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
DRIVER SURG SQ TIP DIA2MM PEG TORQ LIMITING FOR GEMINUS,SUP-2340184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 IN 3 CM 5 FRX24 CM 6 FR POLARIS,SUP-2537711,CDM,C2617,HCPCS,0278,RC,,,,both,,,592.08,384.85,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 60 CM DIA 0.025 IN NIT PERIPH MARKED,SUP-2763344,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.71,28.41,,,,,,,,,,,,,
SCREW INTRF L23MM DIA8MM KNEE PLLA CANN BIOABSRB THRD WDG,SUP-2362044,CDM,C1713,HCPCS,0278,RC,,,,both,,,611.36,397.38,,,,,,,,,,,,,
KIT THROMCTMY JETI L 120 CM DIA 6 FR PERIPH HYDRODYNAMIC,SUP-2753186,CDM,C1757,HCPCS,0272,RC,,,,both,,,11743.60,7633.34,,,,,,,,,,,,,
DRILL SURG ANGLED INDEPENDENCE,SUP-2598869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 4",PX-7619920400,CDM,99204,CPT,0761,RC,,,,outpatient,,,344.00,223.60,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA22/13 MM DEL,SUP-2934472,CDM,C1713,HCPCS,0278,RC,,,,both,,,21714.26,14114.27,,,,,,,,,,,,,
SCREWDRIVER BLADE 2/2.3 MM CENTRE DRV SS 508102007,SUP-2525662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.76,255.94,,,,,,,,,,,,,
GRAFT BONE FEMORAL HD W/ TROCH FZ IRR,SUP-2875985,CDM,C1762,CPT,0278,RC,,,,both,,,3973.36,2582.68,,,,,,,,,,,,,
ROD EXT FIX 11X350MM C FBR,SUP-2188664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,955.03,620.77,,,,,,,,,,,,,
ENALAPRIL MALEATE 2.5 MG PO TABS,RX-9925,CDM,6370000000,HCPCS,0637,RC,16714-0442-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT CORONARY CYPHER L 23 MM DIA2.75 MM DEL SYS L 137 CM,SUP-2158715,CDM,C1874,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
SYSTEM INT FIX PEEK PELV APPL ANCHR PP SUT F,SUP-2308302,CDM,C1713,HCPCS,0278,RC,,,,both,,,1523.31,990.15,,,,,,,,,,,,,
INSERT TIB THICKNESS 11MM SM CNDYL KNEE PRI STBL NEUT UNIV,SUP-2377405,CDM,C1776,CPT,0278,RC,,,,both,,,2403.98,1562.59,,,,,,,,,,,,,
CONT MESH PTERIONAL PED L06MM,SUP-2681437,CDM,C1713,HCPCS,0278,RC,,,,both,,,9430.55,6129.86,,,,,,,,,,,,,
PIN FIX OD5MM DISP SCHNZ,SUP-2399235,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
LEAD DEFIB PROTEGO SD L 65 CM TIP DISTANCE 16 CM PTIR,SUP-2138428,CDM,C1896,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
SCREW BNE ASMBLY 165 MM SHLDR ADJ REVERSED AEQUALIS,SUP-2715376,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
PLATE BNE T RT 2X4 HOLE OBLQ COMPR NS LTX 3102244,SUP-2855817,CDM,C1713,HCPCS,0278,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
SPACER FEM +0MM OFFSET 12/14 TAPR HIP MOD CATHCART UPLR,SUP-2251027,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PIN FIX L635MM OD4MM CORT N CANN SELF TAP DRL N LOK SNAP,SUP-2409680,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
STENT URO KT DBL PGTL FLX TIP .038IN PTFE STIFF SUT,SUP-2139117,CDM,C2617,HCPCS,0278,RC,,,,both,,,454.39,295.35,,,,,,,,,,,,,
PI AGBA PICC KIT: 3-L 6 FRX40 CM W/VPS,SUP-2822089,CDM,C1751,HCPCS,0278,RC,,,,both,,,1063.36,691.18,,,,,,,,,,,,,
BOLT EXT FIX CANN RNG MT FOR SCHNZ SCREW MR SAFE NS,SUP-2179135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.09,429.06,,,,,,,,,,,,,
COLLAR CERV M DENS AD CNTOUR CNTCT CLSR FOAM W/ STOCK SERP,SUP-2210884,CDM,L0120,HCPCS,0274,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
HC So Cadmium,PX-3018230066,CDM,82300,CPT,0301,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
STEM VNGD CR HOUSING 75 LEFT,SUP-2506443,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ELECTRODE ELECSURG CUT LOOP 3 FRX115 CM MONOPOLAR RITECUT,SUP-2313511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1222.50,794.62,,,,,,,,,,,,,
BOLT EXT FIX HALF PIN FIX STRL TRUELOK EVO LTX,SUP-2875631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,288.69,187.65,,,,,,,,,,,,,
TUBE TRACH PED L93MM OD6MM ID4MM SIL CUF STR NK FLNG W OBT,SUP-2352028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.39,538.45,,,,,,,,,,,,,
JOINT TOE 1ST MTP 8 MM HA COAT ENCOMPASS LTX,SUP-2857525,CDM,C1776,CPT,0278,RC,,,,both,,,4179.34,2716.57,,,,,,,,,,,,,
NUCLEUS PROFILE PLUS W/ SLIM 20 ELECTRODE (CI624),SUP-2858186,CDM,L8614,HCPCS,0278,RC,,,,both,,,75666.15,49183.00,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.038 IN STR TIP TORQUE,SUP-2169671,CDM,C1769,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
NAIL IM L75CM OD13MM RT KNEE FUS FAN,SUP-2349054,CDM,C1713,HCPCS,0278,RC,,,,both,,,9241.02,6006.66,,,,,,,,,,,,,
DRESSING HEMOSTATIC ABSORBABLE 4X3 IN SL FABRIC STRL,SUP-2266129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
SCREW BNE L75MM DIA27MM MTPHSEAL S STL ST STARDRV RECESS,SUP-2177779,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.62,190.20,,,,,,,,,,,,,
HOOK SPNL L S STL PEDCL NEUT BILAT OPN THRT TOP LD WIDE,SUP-2288835,CDM,C1713,HCPCS,0278,RC,,,,both,,,2379.81,1546.88,,,,,,,,,,,,,
GRAFT BNE VIABLE 5 CC BIO4,SUP-2319183,CDM,C1713,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
INSERT TIB SZ 6 THK23MM SEMICONSTRAINED FIX GMK,SUP-2267551,CDM,C1776,CPT,0278,RC,,,,both,,,6860.90,4459.58,,,,,,,,,,,,,
BRACE ORTH LACE CLOSURE SM 5.5X6.25 IN WRST LT SPECTR,SUP-2319267,CDM,L3906,HCPCS,0274,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP DIA55FR CATHETER  L200CM WIRE L30MM T,SUP-2436453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.19,208.12,,,,,,,,,,,,,
BASEPLATE TIB L63MM KNEE CO CHROME MOD ORTH SALV SYS,SUP-2435905,CDM,C1776,CPT,0278,RC,,,,both,,,9339.93,6070.95,,,,,,,,,,,,,
GRAFT TISS FRZN FEM CORT STRUT 200MML THIRDS 3MM,SUP-2307539,CDM,C1713,HCPCS,0278,RC,,,,both,,,2298.48,1494.01,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1275108FD3,SUP-2632806,CDM,C1751,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 30X50X0.4 MM CRAN,SUP-2352051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1635.94,1063.36,,,,,,,,,,,,,
SPACER SPNL W11XH11XL44MM 4DEG PEEK OPTMA ANT CERV INTBDY,SUP-2286270,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
GUIDEWIRE VASC L 100 CM DIA 0.038 IN TAPR L 9.5 CM FLPY TIP,SUP-2638699,CDM,C1769,HCPCS,0272,RC,,,,both,,,66.57,43.27,,,,,,,,,,,,,
FEM OPENG WEDG OSTEOTOME PLT 12.5MM,SUP-2811662,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
SCREW BNE L70MM DIA65MM THRD L15MM LO PROF HD COMPR,SUP-2315947,CDM,C1713,HCPCS,0278,RC,,,,both,,,1116.27,725.58,,,,,,,,,,,,,
PLATE BNE L19MM THK0.6MM LNG 4 H SIL TI STR FOR 1.5MM SCR,SUP-2402872,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
PLATE BONE L31MM 100DEG 3X4 H LT CRANIOMAXILLOFACIAL TI L,SUP-2191287,CDM,C1713,HCPCS,0278,RC,,,,both,,,936.35,608.63,,,,,,,,,,,,,
WEDGE TIB SZ 2.5 THK10MM KNEE STP CEM MOD + PFC,SUP-2253294,CDM,C1776,CPT,0278,RC,,,,both,,,3759.21,2443.49,,,,,,,,,,,,,
SCREW SPNL ST 4.2X10 MM FIX,SUP-2414364,CDM,C1713,HCPCS,0278,RC,,,,both,,,883.13,574.03,,,,,,,,,,,,,
HEAD HUM H22MM DIA40MM STD SHLDR FOR COMPHSVE FRAC SYS,SUP-2404610,CDM,C1776,CPT,0278,RC,,,,both,,,2643.88,1718.52,,,,,,,,,,,,,
KIT AUTOTRASFUSION DIA4.8MM QUIK DC AND PVC DRN BLD CONSERV,SUP-2361131,CDM,C1729,HCPCS,0272,RC,,,,both,,,524.69,341.05,,,,,,,,,,,,,
SPLINT ORTH L4IN STD PLAS FNGR MLLT W/O PD STAX,SUP-2205660,CDM,L3913,HCPCS,0272,RC,,,,both,,,5.28,3.43,,,,,,,,,,,,,
HIP BIP PRSFT SYST 98000100601,SUP-2212080,CDM,C1776,CPT,0278,RC,,,,both,,,5499.02,3574.36,,,,,,,,,,,,,
ZONISAMIDE 100 MG PO CAPS,RX-27780,CDM,6370000000,HCPCS,0637,RC,50268-0816-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
WEDGE TIB SM/M 7/6DEG L MED KNEE PEEK ABSRB FOR HTO OPN SYS,SUP-2121065,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
BUR SURG SPRL 2.3X16.4 MM 8 CM TAPR FOOTED SM BOR MIDAS REX,SUP-2631920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.43,181.63,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IN-LINE W/ SIPHONGUARD CATH CERTAS +,SUP-2666574,CDM,C1889,HCPCS,0278,RC,,,,both,,,13375.90,8694.33,,,,,,,,,,,,,
SYSTEM GASTRIC BANDING STANDARD ADJUSTABLE RAPIDPORT EZ LAP-BAND AP,SUP-2119256,CDM,C1889,HCPCS,0278,RC,,,,both,,,14412.60,9368.19,,,,,,,,,,,,,
PROSTHESIS CEM FEM W/ COCR HD AND XLPE LNR,SUP-2347944,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
MESH BONE SIZE 8 TTNM STNDRD LATEX FREE LEFT SBCCPTL CRNL,SUP-2677395,CDM,C1713,HCPCS,0278,RC,,,,both,,,1060.85,689.55,,,,,,,,,,,,,
BEARING TIB 1MAXIM VI ARCM CON BRNG 12X63MM,SUP-2841752,CDM,C1776,CPT,0278,RC,,,,both,,,4207.60,2734.94,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.032IN TIP L7CM PTFE COAT S STL,SUP-2355271,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
HOOK SPNL ANGLED MED LAM PROTEX,SUP-2592385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 9 FR ANTIMICROBIAL,SUP-2763369,CDM,C1892,HCPCS,0272,RC,,,,both,,,447.14,290.64,,,,,,,,,,,,,
"HC Culture, Chlamydia, Any Source",PX-3008711000,CDM,87110,CPT,0300,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 14X11X6 MM UNICORTICAL CANC LIFEGRAFT,SUP-2309677,CDM,C1713,HCPCS,0278,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
ROD SPNL L48CM DIA4MM RT ANTR S STL PRECRV SMOOTH MOSS,SUP-2254426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1.5X2 CMX0.76-1.25 MM DECELL DERM ORACELL,SUP-2740796,CDM,C1762,CPT,0278,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
COLLAR CERV TRACH OPN ADJ AD 3.25IN 13-16IN M PHIL,SUP-2195170,CDM,L0172,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
ROD TI MIS PREBENT 5.5X65,SUP-2840517,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SCREW BONE L85MM DIA6.5MM PROX CANC FEM ANK S STL PARTIALLY,SUP-2350277,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.60,285.09,,,,,,,,,,,,,
HEAD HUM H16.5MM DIA44MM STD SHLDR CO CHROM REV NECKLESS,SUP-2193858,CDM,C1776,CPT,0278,RC,,,,both,,,8527.17,5542.66,,,,,,,,,,,,,
GRAFT DURA 1X1 IN CLLGN MTRX DURAGN CLASSIC,SUP-2243067,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.46,593.75,,,,,,,,,,,,,
HC NM Quant Lung Perfusion,PX-3417859700,CDM,78597,CPT,0341,RC,,,,both,,,2923.00,1899.95,,,,,,,,,,,,,
STENT TRACHBRONCH L60MM DIA6MM DEL SYS L117CM DIA8FR,SUP-2128281,CDM,C1874,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
ALLOGRAFT BNE TIB 210X3 MM FD STRUT 1/2 SPLIT 31026021,SUP-2717902,CDM,C1762,CPT,0278,RC,,,,both,,,4498.65,2924.12,,,,,,,,,,,,,
SCREW ST 1.5X6MM UN3,SUP-2363854,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.18,151.57,,,,,,,,,,,,,
ADJUSTER SPNL 14MM LUM TAPR FUS DEV L CAGE IMPL,SUP-2291614,CDM,C1713,HCPCS,0278,RC,,,,both,,,991.20,644.28,,,,,,,,,,,,,
PLATE CRAN 60X20X40 MM PT SPEC IMPL PEEK,SUP-2860114,CDM,C1713,HCPCS,0278,RC,,,,both,,,24487.92,15917.15,,,,,,,,,,,,,
HC So1 Antithyroglobulin Antibody,PX-3028680067,CDM,86800,CPT,0302,RC,,,,both,,,163.00,105.95,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 80 CM DIA 0.035 IN TAPR L 22 CM FLPY,SUP-2638726,CDM,C1769,HCPCS,0272,RC,,,,both,,,96.27,62.58,,,,,,,,,,,,,
HC X-Ray Exam Entire Spine 1 Vw,PX-3207208100,CDM,72081,CPT,0320,RC,,,,both,,,969.00,629.85,,,,,,,,,,,,,
GUIDEWIRE URO STR MOVABLE COR .035IN PTFE CTD 150CM,SUP-2312643,CDM,C1769,HCPCS,0272,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
INSERT TIB SZ 1-2 THK25MMXLPE POST STBL HI FLX KNEE OXINIUM,SUP-2346939,CDM,C1776,CPT,0278,RC,,,,both,,,5908.70,3840.65,,,,,,,,,,,,,
CONNECTOR SPNL 10MM LAT OFFSET CLS END RECON SYS VERTEX,SUP-2289130,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 30 CM DIA 4-7 MM EPTFE CARBON STP N,SUP-2128784,CDM,L8670,HCPCS,0278,RC,,,,both,,,5625.62,3656.65,,,,,,,,,,,,,
BIT DRL 4.3 MM CALIB NAT NAIL,SUP-2862256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
ORTHOPEDIC KIT 8X240 MM HUM NAIL HMRX,SUP-2431227,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
PLATE EXT FIX OPN ROCK SALVATION,SUP-2401125,CDM,C1713,HCPCS,0278,RC,,,,both,,,6236.04,4053.43,,,,,,,,,,,,,
HC Obstetrical Care,PX-4505940900,CDM,59409,CPT,0450,RC,,,,both,,,3074.00,1998.10,,,,,,,,,,,,,
GRAFT BNE STRP 50X10X7 MM COMPRESSIBLE BNE MTRX,SUP-2644322,CDM,C1713,HCPCS,0278,RC,,,,both,,,4621.77,3004.15,,,,,,,,,,,,,
CATHETER CCOMBO VINCLUDES SVO2 AND EDV VIP W/ AMC THROMSHLD,SUP-2214323,CDM,C1751,HCPCS,0278,RC,,,,both,,,793.64,515.87,,,,,,,,,,,,,
PLATE BNE 2X2 H CRANIOMAXILLOFACIAL TI 3D BX LO PROF FOR,SUP-2366201,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.12,373.18,,,,,,,,,,,,,
PATCH CV W10XL15CM THK0.8MM FOR CARD RECON EPTFE GOR TX,SUP-2395310,CDM,C1768,CPT,0278,RC,,,,both,,,4449.38,2892.10,,,,,,,,,,,,,
CUP ACET OD46MM ID40MM DUROM,SUP-2204668,CDM,C1776,CPT,0278,RC,,,,both,,,12811.20,8327.28,,,,,,,,,,,,,
PROSTHESIS OSS MEGERIAN SRP 0.6X4.25 MM PISTON NIT PTFE,SUP-2467226,CDM,L8613,CPT,0278,RC,,,,both,,,1687.88,1097.12,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0258,RC,00990-7983-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
PLATE BNE MESHED 0.6 MM LT MXLFCL NEURO SMRT KASSAM,SUP-2489849,CDM,C1713,HCPCS,0278,RC,,,,both,,,6373.60,4142.84,,,,,,,,,,,,,
CAGE SPNL 3D 10 DEG 40X18X10 MM LAT WAVEFORM L,SUP-2711319,CDM,C1889,HCPCS,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
PACK VITRCTMY ANT DISP INFIN,SUP-2109881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.61,380.65,,,,,,,,,,,,,
CLAMP REPROC COMBO MR SAFE MED,SUP-2466315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.64,231.82,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 29GM W53XH48CM THK11CM SPNL CRD,SUP-2356758,CDM,C1820,HCPCS,0278,RC,,,,both,,,54522.96,35439.92,,,,,,,,,,,,,
KIT INTRO MAK-NV L 20 CM DIA 6FR 0.018IN CHIBA NDL 15CM SS,SUP-2477486,CDM,C1894,HCPCS,0272,RC,,,,both,,,205.67,133.69,,,,,,,,,,,,,
CATHETER GUID CXI L 150 CM DIA 2.6 FR 0.018 IN SS STR TIP,SUP-2170701,CDM,C1887,HCPCS,0272,RC,,,,both,,,1541.74,1002.13,,,,,,,,,,,,,
GRAFT HUM TISS W6XL3CM 12SQCM UMB CRD AMNIO MEM,SUP-2116291,CDM,Q4148,HCPCS,0636,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
FORCEPS ENDO MIC GRSP AMHED,SUP-2304857,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
IMPLANT SET TOT HIP,SUP-2347960,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
COMPONENT FEM L32MM DIA15.6MM TAPR POST HEMICAP,SUP-2123645,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
KNIFE SURG MALTZ CART 50 DEG 6.75 INX10 MM MICROFRANCE,SUP-2464267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,752.06,488.84,,,,,,,,,,,,,
PLATE BONE MESHED 109X78 MM CRANIAL PREFORMED FRONTAL RIGID,SUP-2837721,CDM,C1713,HCPCS,0278,RC,,,,both,,,14781.86,9608.21,,,,,,,,,,,,,
VALVE MITRL CARP EDW DURAFLEX DIA 31 MM SEW RNG DIA 40 MM,SUP-2214283,CDM,C1889,HCPCS,0278,RC,,,,both,,,12638.50,8215.02,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 6 FRX10 CM 51 IN KT SPIN-LOCK ACCEL,SUP-2659259,CDM,C1729,HCPCS,0272,RC,,,,both,,,131.50,85.47,,,,,,,,,,,,,
CATHETER DRAINAGE 12 FRX30 CM REG FLEXIMA,SUP-2147862,CDM,C1729,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE L103MM 8 H TI FIBULAR COMP LOK COMPR FOR,SUP-2413683,CDM,C1713,HCPCS,0278,RC,,,,both,,,804.09,522.66,,,,,,,,,,,,,
CAGE SPNL L H6MM 7DEG CERV THORLUM C FBR INTBDY FUS REINF,SUP-2256333,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER DRNGE SUMP LOOP PERCFLX MAT N COAT W/ TEMPTIP,SUP-2147745,CDM,C1729,HCPCS,0272,RC,,,,both,,,323.45,210.24,,,,,,,,,,,,,
BURR SURG 4MM DIA HD XLN MIC 8MML HD CARBIDE SM BNE OVL FLUT,SUP-2605579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
PLATE BONE M W9XL78MM THK2.5MM 8 H TI STR LO PROF FOR,SUP-2225499,CDM,C1713,HCPCS,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
HC RBC Irradiated Each Unit,PX-3900903800,CDM,P9038,CPT,0390,RC,,,,both,,,1444.00,938.60,,,,,,,,,,,,,
TIP OSTEOTOM DIA4MM HELIX DISP FOR ULTRASONIC REV SYS UDRV,SUP-2136774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.50,501.47,,,,,,,,,,,,,
CATHETER GUID CONCIERGE L 100 CM 5 FR 0.07 IN AL1 2 SIDE H,SUP-2665548,CDM,C1887,HCPCS,0272,RC,,,,both,,,179.61,116.75,,,,,,,,,,,,,
SPACER SPNL 10X22X50 MM,SUP-2310600,CDM,C1821,HCPCS,0278,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
PLATE BNE L 43 MM SCREW DIA2 MM 8 SHFT H SS COMPACT STR VA NS,SUP-2908859,CDM,C1713,HCPCS,0278,RC,,,,both,,,3944.88,2564.17,,,,,,,,,,,,,
HC Cart-T Therapy Prepj Bld Drv T Lmphcyt F/Trans,PX-8723822600,CDM,38226,CPT,0872,RC,,,,outpatient,,,1184.00,769.60,,,,,,,,,,,,,
NEEDLE 60DEG SLDE STR,SUP-2366706,CDM,C1713,HCPCS,0278,RC,,,,both,,,880.61,572.40,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 60 MM DIA 8 MM CATH TOT L 100,SUP-2148381,CDM,C1876,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
CATHETER THERMODILUTION 7.5 FRX110 CM AMC THROMSHLD SWN GZ,SUP-2214319,CDM,C1751,HCPCS,0278,RC,,,,both,,,623.20,405.08,,,,,,,,,,,,,
TI WASHER 12.7MM OD {} 6.5 ID,SUP-2818893,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.97,344.48,,,,,,,,,,,,,
CURVED JAW 23CM LENGTH BOX 5,SUP-2693696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GRAFT BONE 21CM FRZN 1/2 SPL STRUT TIB SHFT,SUP-2113906,CDM,C1776,CPT,0278,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
PLATE BNE NAR 4.5X70 MM 4 HOLE SS LC-DCP,SUP-2569256,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.60,141.44,,,,,,,,,,,,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,0636,RC,23155-0687-31,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER KIT DL 5 FR PLCMNT POWERPICC,SUP-2126775,CDM,C1751,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
BLADE SURG 48MM ACET REV SYS EZOUT,SUP-2365134,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE L118MM 6 H NONSTERILE R LAT PROX TIB S STL LOK,SUP-2185712,CDM,C1713,HCPCS,0278,RC,,,,both,,,4177.96,2715.67,,,,,,,,,,,,,
SET GJ CATHETER L7CM DIA22X102FR DBL LUMN 2 SIDEPRT NDL ADPT,SUP-2168098,CDM,C1713,HCPCS,0278,RC,,,,both,,,1110.62,721.90,,,,,,,,,,,,,
STENT URET TRIA L 20 CM DIA 6 FR POLYUR PERCUSHIELD SFT,SUP-2457256,CDM,C2617,HCPCS,0278,RC,,,,both,,,695.79,452.26,,,,,,,,,,,,,
INSTRUMENT OP RM DRILLS 1.7X110MM DRIL,SUP-2321598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
PLATE BNE STRUT 1.3X43 MM CRANIOMAXILLOFACIAL 18 HOLE TI NS,SUP-2190670,CDM,C1713,HCPCS,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
PLATE BONE W22XL51MM THK1.6MM 12 H LT DSTL RAD VOLAR TI NAR,SUP-2267963,CDM,C1713,HCPCS,0278,RC,,,,both,,,3315.31,2154.95,,,,,,,,,,,,,
IMPLANT FACE L 40 X W 28 MM 7.5 MM LG RT ORBIT FLR WDG,SUP-2883583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1886.42,1226.17,,,,,,,,,,,,,
HC Explore Wound Extremity,PX-4502010300,CDM,20103,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
GRAFT BNE MORSL 2-6 MM 30 CC SCAFFOLD ATTRAX,SUP-2736504,CDM,C1713,HCPCS,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
PLATE FT CARBONLONG FOR RNG FIX SYS 160MM,SUP-2365270,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
GADOBUTROL 1 MMOL/ML IV SOLN,RX-104340,CDM,A9585,HCPCS,0636,RC,65219-0281-08,NDC,,both,10,ML,14.20,9.23,,,,,,,,,,,,,
EXTRACTOR STONE HELCL 4.5 FRX65 CM TIPLSS NIT NCIRCLE,SUP-2835777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.92,282.70,,,,,,,,,,,,,
SPLINT ANK M SHOE SZ 9-10.5 IN LG POLYPRO PLAS LT FT,SUP-2930190,CDM,L1930,HCPCS,0274,RC,,,,both,,,182.15,118.40,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA20 MM RNG L 20 CM EPTFE STR STD,SUP-2396034,CDM,C1768,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
NUT DISTR TTNM MXLFCL LOK FRGD EXTRNL DISTR DVCE RED II 51,SUP-2679225,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 160 MM FRZN GAM PRESHAPED ACHILLES TEND,SUP-2866902,CDM,C1762,CPT,0278,RC,,,,both,,,5086.02,3305.91,,,,,,,,,,,,,
HC Antibody Rubella,PX-3028676200,CDM,86762,CPT,0302,RC,,,,outpatient,,,137.00,89.05,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO L 50 CM DIA 7 FR PERIPH ART VEIN,SUP-2714064,CDM,C1887,HCPCS,0272,RC,,,,both,,,8195.40,5327.01,,,,,,,,,,,,,
POST EXT FIX M 5 HOLE,SUP-2197285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.51,247.98,,,,,,,,,,,,,
PLATE BNE CRV 4.5X439 MM RT CNDYL 22 HOLE VA LCK COMPR SS,SUP-2177872,CDM,C1713,HCPCS,0278,RC,,,,both,,,8967.27,5828.73,,,,,,,,,,,,,
PLATE BNE L189MM THK3MM 12 H BILAT S STL STR LIMIT CNTCT,SUP-2185346,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.12,1381.33,,,,,,,,,,,,,
VALVE SHUNT HI PRESSURE CSF FLO CTRL DELT,SUP-2284511,CDM,C1713,HCPCS,0278,RC,,,,both,,,2083.30,1354.14,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 75 CM DIA12 FR GUIDEWIRE 0.038 IN,SUP-2355526,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
SPACER SPNL 8X23X10MM INTBDY POST LUM PEEK 0 DEG CYL VISTA P,SUP-2414312,CDM,C1713,HCPCS,0278,RC,,,,both,,,8121.61,5279.05,,,,,,,,,,,,,
RASP SURG 16MM CONE DISP FOR MTP FUS PLATING SYS OMNI,SUP-2223753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT L190CM VASC BAREWIRE DSTL ACC FLTR DEL,SUP-2101961,CDM,C1769,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
SCAFFOLD CELLULAR INJ 20CC SYR FOR STBL BONE DEFECTS,SUP-2399076,CDM,C1713,HCPCS,0278,RC,,,,both,,,3271.88,2126.72,,,,,,,,,,,,,
TUNNELER SURG FLUID SHTH 16 GAX8 IN REMOVABLE WNG STRL ON Q,SUP-2424457,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE BNE L161MM 8 H NONSTERILE R MED DST TIB S STL LOK,SUP-2184172,CDM,C1713,HCPCS,0278,RC,,,,both,,,3773.93,2453.05,,,,,,,,,,,,,
PLATE BONE W100XL100MM THK0.6MM TI DYN MESH FOR COMP CRAN,SUP-2243967,CDM,C1713,HCPCS,0278,RC,,,,both,,,1499.13,974.43,,,,,,,,,,,,,
BOLT ORTH FUSION 6.5X50 MM MIDFOOT TI NS,SUP-2799613,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.06,1054.34,,,,,,,,,,,,,
SCREW INTRF L35MM DIA11MM KNEE PLLA HA BIOABSRB FOR ACL PCL,SUP-2341582,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.46,602.20,,,,,,,,,,,,,
MATRIX DERM ACELLULAR DERMAMTRX THCK 1.8 4 MMX6X16 CM,SUP-2307010,CDM,C1762,CPT,0278,RC,,,,both,,,16401.95,10661.27,,,,,,,,,,,,,
BIT DRL L 300 MM DIA13 MM STRL DISP PICCOLO COMP,SUP-2930823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.51,273.33,,,,,,,,,,,,,
PLATE BNE L37MM +90DEG 2X3 H ST DST DORS RAD S STL L SHP,SUP-2177488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2108.95,1370.82,,,,,,,,,,,,,
DRILL SURG STP 3.2X165 MM CANN,SUP-2749973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 20X8 CM HYDRATED BIOLOGIC TISSUE MA,SUP-2838612,CDM,C1763,HCPCS,0278,RC,,,,both,,,14849.69,9652.30,,,,,,,,,,,,,
REGULATOR SUCT CONT INTMIT PED,SUP-2113856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
CLAMP CLP SCR FOR ORTHOFIX PREFIX FIX,SUP-2316287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.75,441.84,,,,,,,,,,,,,
HC Autologous Blood Process,PX-3008689000,CDM,86890,CPT,0300,RC,,,,both,,,518.00,336.70,,,,,,,,,,,,,
STEM HUM CEM STD UNIV 8X115 MM REV W/ ALIGN HOLE TI PLASMA,SUP-2431670,CDM,C1776,CPT,0278,RC,,,,both,,,10358.86,6733.26,,,,,,,,,,,,,
STENT BILI ZILVER L 4 CM DIA 6 MM INTRO L 208 CM DIA 7 FR,SUP-2169572,CDM,C1876,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE 20MM SYS MINI L SHAPE 3X3 HOLE MED CP TTNM,SUP-2694756,CDM,C1713,HCPCS,0278,RC,,,,both,,,462.58,300.68,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX60 CM 5 CM BASIC KT PRO-LINE,SUP-2268423,CDM,C1751,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
INSERTER SLNG TRNSVAG DISP,SUP-2140288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2073.19,1347.57,,,,,,,,,,,,,
STEM FEM SZ 17 L190MM 131DEG HIP CO CHROM POR STD CLLR STR,SUP-2345219,CDM,C1776,CPT,0278,RC,,,,both,,,16930.88,11005.07,,,,,,,,,,,,,
PLATE BNE L180MM 7 H NONSTERILE R LAT PROX TIB TI LOK COMPR,SUP-2190713,CDM,C1713,HCPCS,0278,RC,,,,both,,,4303.78,2797.46,,,,,,,,,,,,,
PLATE BNE L76MM 4 H R PROX TIB S STL LO BEND LOK COMPR NEUT,SUP-2184301,CDM,C1713,HCPCS,0278,RC,,,,both,,,3790.23,2463.65,,,,,,,,,,,,,
COLLAR CERV SFT 3X22IN UNIV,SUP-2276583,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.59,4.28,,,,,,,,,,,,,
HC So Hepatitis Be Antigen,PX-3068735066,CDM,87350,CPT,0306,RC,,,,both,,,106.00,68.90,,,,,,,,,,,,,
PLATE BNE L 331 MM SCREW DIA 3.5/4.5 MM 14 H LT TROCHANTERIC 72586114,SUP-2933041,CDM,C1713,HCPCS,0278,RC,,,,both,,,21552.96,14009.42,,,,,,,,,,,,,
BASEPLATE 26 MM TM RVS 15M,SUP-2501801,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STRUT FX MAXIFRAME STANDOFF 80MM,SUP-2737905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.22,233.49,,,,,,,,,,,,,
PLATE BONE L108MM 4 H RT MEDL DSTL TIB LCK FOR 3.5MM SCR,SUP-2348249,CDM,C1713,HCPCS,0278,RC,,,,both,,,16493.01,10720.46,,,,,,,,,,,,,
LEAD DEFIB L59CM ENDOCARD SGL COIL ACT NO CHRG RELIANCE S,SUP-2148546,CDM,C1896,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
PLATE BNE LCK 2.4X45 MM RT DSTL RADIAL 7X3 HOLE COMPR CLMN,SUP-2190182,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.23,1775.30,,,,,,,,,,,,,
PERI-LOC 4.5MM S-T LOCK SCREW 36MM,SUP-2819183,CDM,C1713,HCPCS,0278,RC,,,,both,,,1221.37,793.89,,,,,,,,,,,,,
CATHETER PICC KT SAFT MST SGL LUMN 6FR RVS TAPR DIA 15.5GA,SUP-2118955,CDM,C1751,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
DEFIBRILLATOR CARD 36ML DF4 IS4 IS1 SENSE PACE CONN RF,SUP-2356319,CDM,C1882,HCPCS,0275,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
HEAD FEM DIA44MM OFFSET +15MM 12 14 TAPR HIP ASPHERE M SPEC,SUP-2251154,CDM,C1776,CPT,0278,RC,,,,both,,,8370.61,5440.90,,,,,,,,,,,,,
WAND ARTHSCP 90DEG ABLAT HK COOLCUT,SUP-2123443,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ANCHOR SUT L135MM DIA35MM FOR LISFRANC INTERNALBRACE LIG,SUP-2123215,CDM,C1776,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HANDLE PRB CANN DETACH FOR GRP MOD MOD PEDIGUARD,SUP-2354605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
SCREW TOE JT 10 DEG MED SLD ANGLED STRL PHALINX,SUP-2900632,CDM,C1713,HCPCS,0278,RC,,,,both,,,4744.54,3083.95,,,,,,,,,,,,,
SURGICAL INSTRUMENT KIT 4 MM MINIMALLY INVASIVE PONTO CANN,SUP-2430321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1647.87,1071.12,,,,,,,,,,,,,
PLATE BONE L74MM 6 H POST LAT S STL 1/3 TBLR LCK COMPR FOR,SUP-2349795,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.88,1377.92,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED NARROW LCP PLATE 14 HOLE STERILE,SUP-2546927,CDM,C1713,HCPCS,0278,RC,,,,both,,,3116.83,2025.94,,,,,,,,,,,,,
BOLT FUSION MIDFOOT 6.5X125MM TI STRL,SUP-2546679,CDM,C1713,HCPCS,0278,RC,,,,both,,,1833.67,1191.89,,,,,,,,,,,,,
CEMENT BNE HI VISC 40 GM PALACOS R PRO,SUP-2738874,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX12 TTNM CNTRD F2.7MM LOK SCREW S,SUP-2720930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1144.91,744.19,,,,,,,,,,,,,
SCREW BONE CANNULATED 6.5X70 MM FULLY THREADED CANNULATED LO,SUP-2837563,CDM,C1713,HCPCS,0278,RC,,,,both,,,1690.42,1098.77,,,,,,,,,,,,,
CATHETER CTRL VEN 6FR L60CM 2 LUMN BASIC NONTUNNELED,SUP-2267059,CDM,C1751,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
CANNULA SURG 25GA 41GA AT TIP 0.10MM DBL END SUBRETINAL INJ,SUP-2129187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.55,248.66,,,,,,,,,,,,,
TRAY HAD FULL SHT TERM 3 LUMN 15.5FRX20CM T-3,SUP-2266986,CDM,C1751,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
ASSEMBLY CRKSCR LAT L,SUP-2293413,CDM,C1713,HCPCS,0278,RC,,,,both,,,7438.66,4835.13,,,,,,,,,,,,,
PLATE BNE 12 H STRNL TI STR LO PROF NEUT LOK COMPR FOR 3MM,SUP-2192430,CDM,C1713,HCPCS,0278,RC,,,,both,,,5123.54,3330.30,,,,,,,,,,,,,
NEEDLE PERC L7CM DIA18GA ART VEN RADPQ CATHETER THN WALL,SUP-2169616,CDM,C1894,HCPCS,0272,RC,,,,both,,,21.20,13.78,,,,,,,,,,,,,
KIT LD L75CM 8 ELECTRD PERC COMP CONTAIN LD ANCHR GWIRE NDL,SUP-2284648,CDM,2780000010,LOCAL,0278,RC,,,,both,,,7529.72,4894.32,,,,,,,,,,,,,
LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),RX-430042,CDM,J2003,HCPCS,0636,RC,55150-0165-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE SET 3 MM CANN 1/2 THRD EXT TAB,SUP-2861019,CDM,C1713,HCPCS,0278,RC,,,,both,,,22354.79,14530.61,,,,,,,,,,,,,
STRUT TRANSPORT 402X43X24,SUP-2481481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
KIT ENDOSCP DRL DRL GUID OBT DISP FOR 1.8MM Q-FIX,SUP-2341379,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM CORT TI ST FULL THRD W/ FLUT TIP,SUP-2189222,CDM,C1713,HCPCS,0278,RC,,,,both,,,228.59,148.58,,,,,,,,,,,,,
BUR SURGICAL DIAMETER 9MM FOR SKULL OPENING NEUROSURGERY HUD,SUP-2805594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.94,339.91,,,,,,,,,,,,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,340b,HCPCS,0637,RC,00121-4950-15,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER KIT 3 LUMEN 6 FR W/ PASV PWR INJ XCELA,SUP-2117188,CDM,C1751,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
SPACER SPNL 11X14X8MM 7 DEG CERV LORD CALIX,SUP-2402241,CDM,C1821,HCPCS,0278,RC,,,,both,,,4421.12,2873.73,,,,,,,,,,,,,
NAIL IM L260MM DIA7.5MM 120DEG ST BLU L/R HUM TI CANN LOK,SUP-2192492,CDM,C1713,HCPCS,0278,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
SET ENDOBRONCH BLK PED 7FR L65CM ETT 7MM BAL SPHR W/ SYR,SUP-2169658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
NAIL IM L300MM OD15MM PUR TI FEM NONLOCKING CANN FLX E,SUP-2192724,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.73,516.57,,,,,,,,,,,,,
GRAFT HUM TISS XL W60XL210MM FRZ DRY FASC LATA,SUP-2307097,CDM,C1762,CPT,0278,RC,,,,both,,,3438.68,2235.14,,,,,,,,,,,,,
DRILL SURG PEG TROCHANTERIC HI PERF SIG,SUP-2453117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
SCREW BONE L115MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190371,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.12,58.58,,,,,,,,,,,,,
PROBE FLX TIP TRNSLUMN A PACE 2.4X135CM SWAN GANZ,SUP-2214434,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.20,235.43,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X295 MM 18 HOLE SS DCP,SUP-2569182,CDM,C1713,HCPCS,0278,RC,,,,both,,,564.73,367.07,,,,,,,,,,,,,
CLAMP EXT FIX L25MM RED TB TO TB FOR MONOTB TRIAX SYS,SUP-2372626,CDM,C1713,HCPCS,0278,RC,,,,both,,,3149.73,2047.32,,,,,,,,,,,,,
PLATE BNE MIC THK06MM 8 H R CRANIOMAXILLOFACIAL TI,SUP-2262724,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.37,377.24,,,,,,,,,,,,,
BURR SURG 1MM DIA HD SHRT 26MML HD CTTNG MICROPOWER MCR100 S,SUP-2605534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,68.36,44.43,,,,,,,,,,,,,
INSTRUMENT SET 2.7 MM IFP IMPL DRVR ASMBLY,SUP-2400027,CDM,C1776,CPT,0278,RC,,,,both,,,4543.58,2953.33,,,,,,,,,,,,,
HC Autolog Prp Not Diab Ulcer,PX-3610046000,CDM,G0460,CPT,0361,RC,,,,both,,,4802.00,3121.30,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE MED THN 20X11 CMX0.7-1.4 MM KT FLEXHD,SUP-2307615,CDM,Q4128,HCPCS,0636,RC,,,,both,,,37296.92,24243.00,,,,,,,,,,,,,
BIT DRL SLD LNG 2X115 MM,SUP-2321710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.65,250.02,,,,,,,,,,,,,
INTRODUCER SHTH 0.021 IN 6 FRX23 CM 21 GAX4 CM PRELUDEEASE,SUP-2464429,CDM,C1894,HCPCS,0272,RC,,,,both,,,126.60,82.29,,,,,,,,,,,,,
VALVE SUCTION CHANGE-OVER W/ CLMP HOLDER,SUP-2464457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,845.32,549.46,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X14 MM 6 LOBE,SUP-2602073,CDM,C1889,HCPCS,0278,RC,,,,both,,,8233.08,5351.50,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X20 MM FD STRUCTURAL ILIUM ORAGRAFT,SUP-2740880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.32,749.66,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.038 IN TAPR L 9.5 CM FLPY TIP,SUP-2167915,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.16,55.35,,,,,,,,,,,,,
BIT DRILL L7IN OD2MM TRK,SUP-2249399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
FIBER LASER SLIMLINE SIS 365,SUP-2525910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1409.20,915.98,,,,,,,,,,,,,
BUR SURG RND XLN 1.5 MM 77 MM ENT FLUT CARBIDE,SUP-2628881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.91,370.44,,,,,,,,,,,,,
ALLOGRAFT BNE 2 CC OSTEOCONDUCTIVE MTRX +,SUP-2716041,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 10.5X92 MM TEND FLEXIGRAFT GRAFTLINK TS,SUP-2845893,CDM,C1762,CPT,0278,RC,,,,both,,,7815.46,5080.05,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC TRCR PT 1.35 MM,SUP-2121782,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
DRILL TWST L 54 MM DIA1.4 MM STP 1.7 MM DENT SHFT NS DISP,SUP-2883323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.31,242.65,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 5MM R MED L LAT KNEE HEMI STP SCR ON,SUP-2346182,CDM,C1776,CPT,0278,RC,,,,both,,,5068.75,3294.69,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE TIB CUST FRAC RIGID,SUP-2435650,CDM,L2116,HCPCS,0274,RC,,,,both,,,2182.11,1418.37,,,,,,,,,,,,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-144490,CDM,J3374,HCPCS,0636,RC,67457-0824-99,NDC,,both,1,UN,138.70,90.15,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6-8 MM EPTFE TAPR TW N RING,SUP-2396731,CDM,C1768,CPT,0278,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
SCREW BNE PED L12MM DIA3.5MM L R CORT PROX FEM TIB S STL,SUP-2318532,CDM,C1713,HCPCS,0278,RC,,,,both,,,774.39,503.35,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL GUID 8FR L81CM DIL 8FR L85CM 0.032IN,SUP-2357242,CDM,C1893,HCPCS,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
PROSTHESIS OSS 4X51 MM CENTERED HD FULL RICHARDS PORP HA,SUP-2312572,CDM,L8613,CPT,0278,RC,,,,both,,,1069.42,695.12,,,,,,,,,,,,,
MATRIX BIO SZ 114 SQCM FISH SKIN DERMAL MIC STRL GRAFTGUIDE,SUP-2909276,CDM,Q4158,HCPCS,0636,RC,,,,both,,,15429.96,10029.47,,,,,,,,,,,,,
KIT ANCHR DISP FOR KNOTLESS SUTURETAK SHAVERDRILL,SUP-2121611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
IMMOBILIZER ORTH OPN PAT MED 19 IN 16-18 IN CANVS BLU,SUP-2194399,CDM,L1830,CPT,0274,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
SYSTEM EMB LIQ 1GM N BCA TANT PWD 10CC ETHIODIZED OIL VI,SUP-2257886,CDM,C1889,HCPCS,0278,RC,,,,both,,,13464.32,8751.81,,,,,,,,,,,,,
ELECTRODE NERVE STIM MED INTOP LD ACCSRY GRDIAN,SUP-2854976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
BIT DRL 4.5 MM PROX QC STRL,SUP-2875384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1034.00,672.10,,,,,,,,,,,,,
GRAFT HUM TISS L 8 X W 4 CM 2XL AMNIO MEMBRN RESRB STRL,SUP-2913438,CDM,Q4173,HCPCS,0636,RC,,,,both,,,11250.62,7312.90,,,,,,,,,,,,,
SHEATH INTRO ARW GLIDETHRU L 19.5 CM DIA 5 FR DIL 5 FR,SUP-2384049,CDM,C1894,HCPCS,0272,RC,,,,both,,,619.30,402.54,,,,,,,,,,,,,
GRAFT HUMAN TSSUE MTRX 48SQCM THIN SM 4CMW X 12CML 023 051,SUP-2675763,CDM,Q4116,HCPCS,0636,RC,,,,both,,,4841.88,3147.22,,,,,,,,,,,,,
ELECTRODE ELECTROTHERAPY NIT MPLR 25GA L100MM VENOM,SUP-2366970,CDM,C1713,HCPCS,0278,RC,,,,both,,,5903.20,3837.08,,,,,,,,,,,,,
HC Dress or Debride Burn Medium,PX-4501602500,CDM,16025,CPT,0450,RC,,,,both,,,632.00,410.80,,,,,,,,,,,,,
RELOAD STPLR 45 MM WHT SUREFORM DAVINCI XI,SUP-2422167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
DRILL SURG 1 TRIGGER MOD HALL TITAN,SUP-2607716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,25897.15,16833.15,,,,,,,,,,,,,
PLATE BNE W12XL270MM THK25MM LNG 12 H NONSTERILE BILAT PROX,SUP-2190994,CDM,C1713,HCPCS,0278,RC,,,,both,,,5580.97,3627.63,,,,,,,,,,,,,
INSERT TIB SZ 1 1+ H6MM ANK POLYETH INFIN,SUP-2397281,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
SPHERE ORBIT DIA20 MM SMTH POROUS ANTR SURF SUTURE TUNN,SUP-2909476,CDM,L8610,HCPCS,0278,RC,,,,both,,,2227.42,1447.82,,,,,,,,,,,,,
ELECTRODE NDL CANN L15CM ARRY 3CM OPN AND PERC RF M001262220,SUP-2149341,CDM,C1713,HCPCS,0278,RC,,,,both,,,5918.90,3847.28,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2 MM TI MAND ST AXS NS UNIV 2.0 MP,SUP-2909574,CDM,C1713,HCPCS,0278,RC,,,,both,,,299.74,194.83,,,,,,,,,,,,,
OXYCODONE HCL ER 10 MG PO T12A,RX-123648,CDM,6370000000,HCPCS,0637,RC,59011-0410-20,NDC,,both,1,UN,26.20,17.03,,,,,,,,,,,,,
PLATE BNE W10XL21MM THK13MM 6 H GRID LOK TI FOR 2 23MM SCR,SUP-2267950,CDM,C1713,HCPCS,0278,RC,,,,both,,,3083.04,2003.98,,,,,,,,,,,,,
CATHETER HD KT 12 FRX20 CM DL INTRO INJ NDL TISS DIL SUTURE,SUP-2762985,CDM,C1752,HCPCS,0278,RC,,,,both,,,253.08,164.50,,,,,,,,,,,,,
PUMP INFUS 2X10IN CATH 4ML/HOUR 550ML,SUP-2361468,CDM,C1751,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CLAMP EXT FIX M OD20MM BLU FOR MONOTUBE RNG HYBRID TRIAX SYS,SUP-2372627,CDM,C1713,HCPCS,0278,RC,,,,both,,,5011.75,3257.64,,,,,,,,,,,,,
PROSTHESIS PENILE PLUG INFL TRUE-LOCK,SUP-2165392,CDM,C1813,HCPCS,0278,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
GUIDEWIRE VASC COPE L 60 CM DIA 0.018 IN TAPR L 3.25 CM FLPY,SUP-2168436,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.58,61.48,,,,,,,,,,,,,
GRAFT BNE SPACER 8 DEG LG 12 MM FOR ALIF STRL LF DISP,SUP-2632278,CDM,C1713,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
PLATE BNE CNDYL MINI 1.5 MM LT 6 HOLE,SUP-2346879,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.53,275.94,,,,,,,,,,,,,
PROVEN SYMMETRICAL REV FEM SZ 1,SUP-2359204,CDM,C1776,CPT,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5 FRX32 CM LT DL FULL SET TITAN HD,SUP-2627363,CDM,C1750,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
SCREW TENODESIS BICEP BICEPTOR BIOSURE PK 9MM X 15MM,SUP-2341823,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
HC Assay of Gammaglobulin Iga Igd Igg Igm Each,PX-3018278400,CDM,82784,CPT,0301,RC,,,,both,,,204.00,132.60,,,,,,,,,,,,,
SHEATH INTRO PRELUDE ROADSTER L 65 CM DIA 6 FR COAT L 35 CM,SUP-2900369,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SET EXT FIX L35MM DIA5MM X SH UNILAT HALF PIN TIN JETX,SUP-2342924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
GRAFT BONE 15GM 15ML PARTICULATE SYNTH OSTEOCONDUCTIVE CLLGN,SUP-2288537,CDM,C1713,HCPCS,0278,RC,,,,both,,,2267.90,1474.13,,,,,,,,,,,,,
PLATE BONE REG THK0.6MM 2X2 H MIDFACE SLV TI RT L SHP FOR,SUP-2135911,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
COMPONENT TIB SZ 3 THK9.5MM RT MEDL LT LAT ANTR POST KNEE,SUP-2251258,CDM,C1776,CPT,0278,RC,,,,both,,,4970.62,3230.90,,,,,,,,,,,,,
ANCHOR SPNL 13 MM COALITION MIS,SUP-2733248,CDM,C1889,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM SZ 4 SQCM AMNION-CHORION-AMNION,SUP-2909214,CDM,Q4137,HCPCS,0636,RC,,,,both,,,3250.06,2112.54,,,,,,,,,,,,,
GRAFT HUM TISS W10-20MMXL19.5-20CM ACHILLES TEND FRZN,SUP-2307275,CDM,C1762,CPT,0278,RC,,,,both,,,5943.80,3863.47,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 4H 81MM RIGHT-STER,SUP-2549538,CDM,C1713,HCPCS,0278,RC,,,,both,,,4584.93,2980.20,,,,,,,,,,,,,
GRAFT BNE CORTICAL 22X1 CM,SUP-2165532,CDM,C1713,HCPCS,0278,RC,,,,both,,,10453.06,6794.49,,,,,,,,,,,,,
APPLIER CLP MED LG 5 MMX45 CM MANUAL LOAD HEM-O-LOK ENDO5,SUP-2656813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 1 or 2 Muscles,PX-4202056000,CDM,20560,CPT,0940,RC,,,,both,,,42.00,27.30,,,,,,,,,,,,,
DEVICE FIX SFT TISS 2.9 MM W/O NDL W/ ZIPLOOP TOGGLELOC,SUP-2663990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1920.17,1248.11,,,,,,,,,,,,,
EXTRACTOR SURG HK FOR HINDFOOT TTC/TC NAIL SYS NS DISP,SUP-2909097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
STENT BILI M L13MM BLLN L17MM DIA6MM CATH L135CM 12ATM,SUP-2159119,CDM,C1876,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
ADAPTER PACEMKR CABLE TCH PRF IS1 FOR PK 67 S OR PK 67 L,SUP-2137933,CDM,C1883,HCPCS,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
ROD SPNL 4 MM VIPER,SUP-2256283,CDM,C1713,HCPCS,0278,RC,,,,both,,,2472.75,1607.29,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 3 MM EPTFE STR STD WALL N RING,SUP-2396413,CDM,C1768,CPT,0278,RC,,,,both,,,1855.74,1206.23,,,,,,,,,,,,,
MATRIX BIO L 10 X W 18 CM SZ 180 SQCM FISH SKIN SIL DERMAL SINGLE,SUP-2909459,CDM,Q4158,HCPCS,0636,RC,,,,both,,,28930.17,18804.61,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 180 CM DIA 0.038 IN TAPR L 15 CM FLPY,SUP-2167861,CDM,C1769,HCPCS,0272,RC,,,,both,,,67.07,43.60,,,,,,,,,,,,,
BALANCED SALT IO SOLN,RX-37578,CDM,2500000003,HCPCS,0250,RC,00065-0795-15,NDC,,both,15,ML,72.80,47.32,,,,,,,,,,,,,
ETOPOSIDE PHOSPHATE 100 MG IV SOLR,RX-17451,CDM,J9181,HCPCS,0636,RC,61269-0410-20,NDC,,both,1,UN,490.70,318.95,,,,,,,,,,,,,
STEM FEM SZ 13MM L140MM STD BODY EXT NK VERSYS,SUP-2210336,CDM,C1776,CPT,0278,RC,,,,both,,,26752.80,17389.32,,,,,,,,,,,,,
PROBE BRST BX DIA12GA VERTICAL ENCOR,SUP-2715833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,517.79,336.56,,,,,,,,,,,,,
PLATE BONE LOCKING 4.5X408 MM 22 HOLE COMPRESSION,SUP-2837371,CDM,C1713,HCPCS,0278,RC,,,,both,,,12046.14,7829.99,,,,,,,,,,,,,
STEM FEM L150MM DIA12.5MM IM TI POR STR LNG BODY MOD NEUT,SUP-2405800,CDM,C1776,CPT,0278,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,CQ,both,,,195.00,126.75,,,,,,,,,,,,,
LIGATOR ENDOSCP L122CM DIA9.5-13MM 4 BND SAEED 6 SHOT,SUP-2169398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
SCREW BNE SET 3.5 MM CANN FT EXT TAB,SUP-2861020,CDM,C1713,HCPCS,0278,RC,,,,both,,,15795.83,10267.29,,,,,,,,,,,,,
SCREW SPNL 5.5X30 MM,SUP-2402798,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
CUTTER PYRAMESH LOT NUMBER RS06M004,SUP-2280089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,820.33,533.21,,,,,,,,,,,,,
KIT ORTH INSTR GUIDEWIRE L 254 CM DIA1.6 X 0.8MM DEPTH GA,SUP-2882151,CDM,C1769,HCPCS,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
HC Treat Radius Fx,PX-4502550000,CDM,25500,CPT,0450,RC,,,,both,,,692.00,449.80,,,,,,,,,,,,,
IMPLANT OP RM TISS 12 X 6MM CALCANEO CUBOID JT WDG,SUP-2321657,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
STEM FEM NO3 NP,SUP-2253261,CDM,C1776,CPT,0278,RC,,,,both,,,5538.96,3600.32,,,,,,,,,,,,,
COAGULATOR ELECSURG MONOPOLAR 5 MMX33 CM J HK FLAT TIP,SUP-2478460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1338.21,869.84,,,,,,,,,,,,,
IMPL HAMMERTOE MED 10 DEG,SUP-2704889,CDM,C1713,HCPCS,0278,RC,,,,both,,,4181.44,2717.94,,,,,,,,,,,,,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,0636,RC,00049-0520-22,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
HC Rmvl Transvns Pm Eltrd Dual Lead Sys,PX-4803323500,CDM,33235,CPT,0480,RC,,,,inpatient,,,5391.00,3504.15,,,,,,,,,,,,,
BUMPER TIB 3 DEG HINGE REV STRL TRIATHLON,SUP-2889781,CDM,C1776,CPT,0278,RC,,,,both,,,2959.45,1923.64,,,,,,,,,,,,,
HEAD RADIAL 6+ MM 10X22 MM 7.5 MM ELBW STRL,SUP-2789815,CDM,C1776,CPT,0278,RC,,,,both,,,8788.04,5712.23,,,,,,,,,,,,,
SCREW BNE L50MM DIA3.5MM SHT THRD HD MINI-MONSTER,SUP-2320524,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
CURETTE SURG XLN 2-0 9.5 IN BNE BKWRD STR RUGGLES-REDMOND,SUP-2537767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.06,276.29,,,,,,,,,,,,,
PLATE BNE 5 HOLE 90 DEG 1.2 MM,SUP-2491853,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.81,598.53,,,,,,,,,,,,,
HC So Angiotensin Conv Enzyme,PX-3018216466,CDM,82164,CPT,0301,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
RIVAROXABAN 10 MG PO TABS,RX-110026,CDM,6370000000,HCPCS,0637,RC,50458-0580-10,NDC,,both,1,UN,89.80,58.37,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,2500000003,HCPCS,0250,RC,00338-0048-04,NDC,,both,500,ML,21.30,13.84,,,,,,,,,,,,,
NEEDLE SUT STR FOR DEL MENISCI REP SYS FAST-FIX 360,SUP-2341832,CDM,C1713,HCPCS,0278,RC,,,,both,,,1534.96,997.72,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER L 115 CM 8 FR 4 MM D-F CRV,SUP-2248504,CDM,C1732,HCPCS,0278,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 12X1X0.3 MM CONTOURED FOR SCR TI NS,SUP-2459375,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.84,437.35,,,,,,,,,,,,,
SYSTEM FIX OPTIFIX ABSORB 30 FASTENERS W/ART TECH,SUP-2731836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
RING EXT FIX ID140MM TI C FBR HYBRID 3/4 FOR DST TIB FRME,SUP-2188609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1292.02,839.81,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST DBL SLD STIRRUP W/O JT,SUP-2435635,CDM,L2030,HCPCS,0272,RC,,,,both,,,3066.65,1993.32,,,,,,,,,,,,,
KIT INTRO MST L 2CM DIA2FR GUIDEWIRE L 20CM DIA 0.010IN 24GA,SUP-2905025,CDM,C1892,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
PLATE BONE W15XL200MM THK2MM 10 H BILAT S STL COVERLEAF RIG,SUP-2186011,CDM,C1713,HCPCS,0278,RC,,,,both,,,4582.20,2978.43,,,,,,,,,,,,,
IMMOBILIZER SLNG LOOP CLOSURE UNIV UNISX SHLDR PROCARE,SUP-2196933,CDM,L3660,HCPCS,0274,RC,,,,both,,,21.26,13.82,,,,,,,,,,,,,
STENT URET 6FR L22CM HYDR+ DBL PGTL THRD TAPR TIP RADPQ,SUP-2139649,CDM,C2617,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
MESH SURG W10XH11XL10MM OD10-14MM TI OVOID THORLUM INTBDY,SUP-2292059,CDM,C1713,HCPCS,0278,RC,,,,both,,,6452.61,4194.20,,,,,,,,,,,,,
RING DIA140MM ALUM,SUP-2701755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4535.73,2948.22,,,,,,,,,,,,,
WRAP KNEE INSRT ICE W/2 DURA SFT,SUP-2197214,CDM,L1820,HCPCS,0272,RC,,,,both,,,98.63,64.11,,,,,,,,,,,,,
GUIDEWIRE VASC MCNAM 90 DEG L 180 CM DIA 0.018 IN TAPR L 3,SUP-2168643,CDM,C1769,HCPCS,0272,RC,,,,both,,,267.34,173.77,,,,,,,,,,,,,
CATHETER REPERFUSION L132CM INNR LUMN DIA0.068IN UNIQUE,SUP-2323551,CDM,C1725,HCPCS,0272,RC,,,,both,,,7441.80,4837.17,,,,,,,,,,,,,
TROCAR ENDO BLADELESS 2/3MM 65MM NON-OPTI W/ SMOOTH SLV,SUP-2855493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,521.05,338.68,,,,,,,,,,,,,
HC Prealbumin,PX-3018413400,CDM,84134,CPT,0301,RC,,,,both,,,379.00,246.35,,,,,,,,,,,,,
PROSTHESIS OSS MIC 3X3 MM 1 MM MONOLITHIC OFF CENTERED TI,SUP-2638138,CDM,L8613,CPT,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PIN EXT FIX HALF SELF-THREADED 6X180 MM TAPR NS TRUELOK,SUP-2875027,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.11,210.02,,,,,,,,,,,,,
MONSELS FERRIC SUBSULFATE EX SOLN,RX-121273,CDM,6370000000,HCPCS,0637,RC,10481-0112-08,NDC,,both,8,ML,52.50,34.12,,,,,,,,,,,,,
RING EXT FIX FULL 180 MM CIR SIDEKCK,SUP-2850714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2948.46,1916.50,,,,,,,,,,,,,
GRAFT BONE SUB 15CC CA PHOS VOID FIL PUTTY FOR CRS NORIAN,SUP-2193978,CDM,C1713,HCPCS,0278,RC,,,,both,,,14940.12,9711.08,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM SZ 2 BLU WHT PEEK OPTMA COBRAID TWINFIX,SUP-2341841,CDM,C1713,HCPCS,0278,RC,,,,both,,,845.70,549.70,,,,,,,,,,,,,
PACK PROC 120ML BX ASPIR CONC NDL FLTR BMAC SMARTPREP 2,SUP-2384780,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
PLATE BNE GRIFFIN MOD LINDORF 11 MM CHIN FOR 2.0 MM CP TI,SUP-2496758,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.46,420.20,,,,,,,,,,,,,
PLATE EXT FIX NEUT STP OFF NS DISP SMRT TSF,SUP-2933350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2340.84,1521.55,,,,,,,,,,,,,
SLEEVE COMPR 9 10IN UNIV AMBI CRPL GEL HYPOALRG REUSE,SUP-2340101,CDM,L3912,HCPCS,0274,RC,,,,both,,,53.16,34.55,,,,,,,,,,,,,
PLATE BONE L103MM 7 H RT MEDL DSTL HUM LCK FOR 2.7/3.5MM SCR,SUP-2348597,CDM,C1713,HCPCS,0278,RC,,,,both,,,11239.00,7305.35,,,,,,,,,,,,,
PLATE BNE Y LNG 1.5X0.6 MM NEURO LP TI STRL LEVEL 1,SUP-2496663,CDM,C1713,HCPCS,0278,RC,,,,both,,,661.63,430.06,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 24 MM DIA 5 MM SS RX BALLOON,SUP-2144508,CDM,C1876,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SCREW BONE L30MM DIA4MM TIB FEM BLU LCK FOR IM LIMB,SUP-2312231,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
FORCEPS STONE RETRV 2.4FR L120CM PTFE RETRACTING GRSP,SUP-2139263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.86,350.26,,,,,,,,,,,,,
MESH SYN ABD N ABSRB OVL POLYPR W EXP,SUP-2125819,CDM,C1781,HCPCS,0278,RC,,,,both,,,3386.80,2201.42,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X394 MM 22 HOLE SS LC-DCP,SUP-2569273,CDM,C1713,HCPCS,0278,RC,,,,both,,,632.08,410.85,,,,,,,,,,,,,
PLATE BONE L W13.5XL358MM THK4.2MM 20 H BILAT TI STR RIG,SUP-2190836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1912.26,1242.97,,,,,,,,,,,,,
MATRIX BIO L 6 X W 14 CM SZ 84 SQCM FISH SKIN SIL DERMAL FEN SINGLE,SUP-2909458,CDM,Q4158,HCPCS,0636,RC,,,,both,,,14872.30,9666.99,,,,,,,,,,,,,
MESH COMPOSIX LP ELP 8.2IN X 10.2IN W/ INTRO,SUP-2125818,CDM,C1781,HCPCS,0278,RC,,,,both,,,3606.60,2344.29,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.506,SUP-2860188,CDM,C1713,HCPCS,0278,RC,,,,both,,,25855.07,16805.80,,,,,,,,,,,,,
SYSTEM IMPLANT WITH 5.5MM CROSSFT KNOTLESS CUFFLINK,SUP-2824388,CDM,C1713,HCPCS,0278,RC,,,,both,,,9034.72,5872.57,,,,,,,,,,,,,
SCREW BNE L40MM DIA5.5MM CORT PROX TIB SLD FULL THRD,SUP-2412189,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.79,336.56,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X79 MM RT LAT DSTL 3 HOLE NS VA-LCP,SUP-2758191,CDM,C1713,HCPCS,0278,RC,,,,both,,,2455.73,1596.22,,,,,,,,,,,,,
ATROPINE SULFATE 0.4 MG/ML IV SOLN,RX-153338,CDM,J0462,HCPCS,0636,RC,00517-1004-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE CNDYL 1.5MM 2H HD 6H SHFT STRL VAL,SUP-2546074,CDM,C1713,HCPCS,0278,RC,,,,both,,,1656.57,1076.77,,,,,,,,,,,,,
CATHETER NEPHSTMY 18FR 4 WNG MCOT DISP,SUP-2129074,CDM,C2627,HCPCS,0272,RC,,,,both,,,76.74,49.88,,,,,,,,,,,,,
CATHETER EP LG CURL 4 MM TIP SAFIRE TX,SUP-2357027,CDM,C1733,HCPCS,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
KIT VERTPLSTY BX NDL 13GA CRV W BFC TRCR TAMP CDS GUN AND,SUP-2281726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
SET PERICARDCENT CATH L 40 CM DIA 8.3 FR GUIDEWIRE L 70 CM,SUP-2760056,CDM,C1729,HCPCS,0272,RC,,,,both,,,586.55,381.26,,,,,,,,,,,,,
PLATE BNE PREBENT 1.7X3X0.9 MM LT 11 HOLE FOR SCREW TI NS,SUP-2366351,CDM,C1713,HCPCS,0278,RC,,,,both,,,1071.21,696.29,,,,,,,,,,,,,
SHEATH GUID AD L45CM OD7FR ID2.5MM 0.018/0.038IN MP POLYUR,SUP-2169817,CDM,C1894,HCPCS,0272,RC,,,,both,,,151.07,98.20,,,,,,,,,,,,,
CAGE SPNL SM 12 MM PEEK,SUP-2136812,CDM,C1889,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
DEFIBRILLATOR CRD 69X51X12 MM 31 CC 71 GM SYS DF4 ENTRANT DR,SUP-2876020,CDM,C1721,HCPCS,0275,RC,,,,both,,,53725.40,34921.51,,,,,,,,,,,,,
HC Bil Niv Arterial With Stress Tc,PX-9219392400,CDM,93924,CPT,0921,RC,,,,both,,,1868.00,1214.20,,,,,,,,,,,,,
STRAP TRAC L6FT UP ARM W PD TRAC TWR,SUP-2166901,CDM,L3660,HCPCS,0272,RC,,,,both,,,415.23,269.90,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 360 DEG L 11 CM DIA2.9 MM SPD 7500 RPM,SUP-2902025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,756.11,491.47,,,,,,,,,,,,,
CATHETER CV OXMTR 16 CM 3L SCVO2 MONITORING KT STRL,SUP-2466466,CDM,C1751,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
GUIDEWIRE ORTH 2X330 MM FT SINGLE END SPADE PT DRL TIP,SUP-2186890,CDM,C1769,HCPCS,0272,RC,,,,both,,,144.35,93.83,,,,,,,,,,,,,
PLATE BONE STR 12 H M FRAG SYS FPS FOR 3.5/4 MM SCR,SUP-2319608,CDM,C1713,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
PLEGISOL PF SOLN,RX-30272,CDM,2500000003,HCPCS,0250,RC,00338-0341-04,NDC,,both,1000,ML,304.80,198.12,,,,,,,,,,,,,
SCREW BNE CRTX 3.5X32 MM LP ST HD HEXDRIVE TI NS,SUP-2758236,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.92,65.60,,,,,,,,,,,,,
PLATE BNE L 125 MM SCREW DIA2.4 MM 20 SHFT H TI ADPT MINI,SUP-2908062,CDM,C1713,HCPCS,0278,RC,,,,both,,,4604.24,2992.76,,,,,,,,,,,,,
SCREW BNE LCK 3.5X48 MM PERIARTICULAR N CANN SS NS,SUP-2410817,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.48,201.81,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4409753000,CDM,97530,CPT,0440,RC,,,KX|CQ,both,,,191.00,124.15,,,,,,,,,,,,,
GRAFT BNE FIBER 1 CC DBM CORTICAL PUREBONE,SUP-2424606,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.75,438.59,,,,,,,,,,,,,
VALVE AORT CARBOMEDICS DIA18.5 MM TAD 18.5 MM OH 7.3 MM SZ,SUP-2265216,CDM,C1889,HCPCS,0278,RC,,,,both,,,15904.10,10337.66,,,,,,,,,,,,,
PIN HALF THRD 6X200 MM 80 MM EXT FIX SS HA,SUP-2343025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
GRAFT HUM TISS W10XL150MM THK3 12MM FEM CORT STRUT FRZN,SUP-2307353,CDM,C1713,HCPCS,0278,RC,,,,both,,,2683.88,1744.52,,,,,,,,,,,,,
BRACE GAUNTLET WR LT 1 SZ FITS MOST REG ELAS SUPP FABRIFOAM,SUP-2334826,CDM,L3809,HCPCS,0272,RC,,,,both,,,34.26,22.27,,,,,,,,,,,,,
STEM HUM SZ 14 L153MM STD SHLDR PORCOAT FOR ARTHROPLASTY,SUP-2250054,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 80.5 X 61.5 X 2 MM LG POLYETHYL OCCPTL,SUP-2935439,CDM,C1713,HCPCS,0278,RC,,,,both,,,4374.02,2843.11,,,,,,,,,,,,,
GRAFT DERMAL N FEN 4X4 CMX1-2 MM DERMAL MTRX PARADERM,SUP-2742063,CDM,C1763,HCPCS,0278,RC,,,,both,,,4930.59,3204.88,,,,,,,,,,,,,
BLOCKER SPNL PEDCL LG FOR 8.2 MM SCREW,SUP-2864174,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
NAIL IM L320MM DIA13MM TIB TI CANN LCK RG GLD META-NAIL,SUP-2347528,CDM,C1713,HCPCS,0278,RC,,,,both,,,11558.81,7513.23,,,,,,,,,,,,,
NEEDLE BX 25GA ADJ EXTN 0-8CM SHTH 5.2FR ACC CHN 2.8MM STYL,SUP-2171106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL FIX COR 3 CM 0.038 INX145 CM STD,SUP-2835667,CDM,C1769,HCPCS,0272,RC,,,,both,,,52.97,34.43,,,,,,,,,,,,,
"HC Neuromuscular Re-Education, Ot",PX-4309711200,CDM,97112,CPT,0430,RC,,,,both,,,159.00,103.35,,,,,,,,,,,,,
RESERVOIR L60CM OD2.5MM 20MM D5.65MM EXTERNAL VENTRICULAR DR,SUP-2826646,CDM,C1889,HCPCS,0278,RC,,,,both,,,1475.93,959.35,,,,,,,,,,,,,
TRAY THOR VENT PROC 13FR L13CM TRU-CLOSE,SUP-2391585,CDM,C1729,HCPCS,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
BIT DRILL LG 3 MM POWEREASE,SUP-2660005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.40,811.46,,,,,,,,,,,,,
TAP SURG 4-5X30 MM ACUTRK,SUP-2107227,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.42,172.52,,,,,,,,,,,,,
COMPONENT HIP PRIMARY 1,SUP-2212582,CDM,C1776,CPT,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
MESH SURG W6.4XL6.4CM CIR VENTRAL PTCH FOR TISS SEPARATING,SUP-2219820,CDM,C1781,HCPCS,0278,RC,,,,both,,,1586.99,1031.54,,,,,,,,,,,,,
PROSTHESIS OSS L 14 MM SHFT DIA1.14 MM HD DIA 3.25 MM TI HA,SUP-2902119,CDM,L8613,CPT,0278,RC,,,,both,,,1681.78,1093.16,,,,,,,,,,,,,
SHEPARD GRMMT VENT TUBE 102MM ID BLUE FLRPLSTC 30 PACK,SUP-2669497,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.48,13.96,,,,,,,,,,,,,
KIT MAG 24 SOFTWEAR PD,SUP-2165020,CDM,L8690,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 30 MM DIA10 MM CATH L 116 CM,SUP-2140222,CDM,C1874,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
CATHETER MAP 8.5 FR 50 MMX128 CM FIRMAP,SUP-2473916,CDM,C1730,HCPCS,0272,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
MESH SURG L 40 X W 20 CM D 1.5 MM PORCINE DERMAL CLLGN ABD,SUP-2901739,CDM,C9364,HCPCS,0278,RC,,,,both,,,58572.65,38072.22,,,,,,,,,,,,,
MANIPULATOR UTER 3 CM FOR HARM SCALPEL/LASER SS NS KOH CUP,SUP-2756069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1836.02,1193.41,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM 2-0 CRV 37 MM STR 89 MM SS M-24,SUP-2101193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,39.03,25.37,,,,,,,,,,,,,
BAND ORTHODONTIC M SZ 30 LO MAND S STL SEAMLESS CHAIRSIDE,SUP-2176639,CDM,D6783,CPT,0278,RC,,,,both,,,21.48,13.96,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 260 CM DIA 0.035 IN TIP L 5 CM,SUP-2385592,CDM,C1769,HCPCS,0272,RC,,,,both,,,176.78,114.91,,,,,,,,,,,,,
ENDCAP ORTH 0MM EXTN G TI CANN T40 STARDRV RECESS FOR,SUP-2179788,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.68,420.34,,,,,,,,,,,,,
BRACE KNEE POSTOP 1 SZ FITS MOST SH UNIV UNISX FASTEN ON HNG,SUP-2150852,CDM,L1832,HCPCS,0274,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FEN 20X9 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871493,CDM,C1762,CPT,0278,RC,,,,both,,,40568.80,26369.72,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 8 MM EPTFE FLX STD WALL SM BEAD,SUP-2761449,CDM,C1768,CPT,0278,RC,,,,both,,,2069.01,1344.86,,,,,,,,,,,,,
SCREW BNE L60MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190393,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.20,40.43,,,,,,,,,,,,,
PLATE BONE SM RT GLD 3D ORBIT FLR FOR 1.2MM SCR,SUP-2363676,CDM,C1713,HCPCS,0278,RC,,,,both,,,3998.76,2599.19,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC 0.035N DIA RGLR 260CML 3CML HDRPHLC CTD BL,SUP-2483272,CDM,C1769,HCPCS,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
AMBI SHORT PL 5SL 120MM 140,SUP-2818070,CDM,C1713,HCPCS,0278,RC,,,,both,,,3852.94,2504.41,,,,,,,,,,,,,
CATH REPROC EP JSN 2-5-2 MM 6FR 120CM SUPREME,SUP-2877821,CDM,C1730,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PATCH CV CARDIOCEL L 8 X W 5 CM THK 0.5 MM BOV PERICARD,SUP-2433944,CDM,C1768,CPT,0278,RC,,,,both,,,6214.06,4039.14,,,,,,,,,,,,,
SCREW BONE 5X20MM PERIPH SYS FT STRL TRABECULAR MTL,SUP-2202926,CDM,C1713,HCPCS,0278,RC,,,,both,,,416.99,271.04,,,,,,,,,,,,,
COMPONENT FEM L8CM RT DSTL KNEE FINN STYL SEG IMP,SUP-2406045,CDM,C1776,CPT,0278,RC,,,,both,,,16494.42,10721.37,,,,,,,,,,,,,
CANNULA SURG INTUTER MANIP W/ TWO ACORNS COHEN,SUP-2332826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1019.65,662.77,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RESPON L 120 CM DIA 6 FR SPC 5 MM,SUP-2526065,CDM,C1730,HCPCS,0272,RC,,,,both,,,169.78,110.36,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE GT L 180CM 0.016IN 90/60 DEG,SUP-2385631,CDM,C1769,HCPCS,0272,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
PLATE BONE SM W10XL97MM THK3.4MM 8 H UNIV DSTL HUM RAD ULN,SUP-2343770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.47,884.96,,,,,,,,,,,,,
CATHETER HD STR 8 FRX12 CM SHT TERM DL BASIC SET SIL HEMCATH,SUP-2627300,CDM,C1752,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
BIT DRILL OD2.6MM FLUTED NONCANNULATED PRESSFT,SUP-2824999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1146.38,745.15,,,,,,,,,,,,,
RESTRICTOR CEM M DIA24MM UNIV,SUP-2378790,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
TUBE VENT ARMSTR R 1.14 MM 1 MM 2.7 MM FLROPLAS STRL 520503,SUP-2535146,CDM,L8699,HCPCS,0278,RC,,,,both,,,39.72,25.82,,,,,,,,,,,,,
MESH HERN RND 15 CM COMP PARIETENE DS,SUP-2430043,CDM,C1781,HCPCS,0278,RC,,,,both,,,3002.34,1951.52,,,,,,,,,,,,,
SCREW VAL SCREOPTILINK SLF TAP SD 5.0X95MM ST,SUP-2752105,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.23,473.35,,,,,,,,,,,,,
NEEDLE LOCALIZATION HAWKINS II 20GA 12.5CM 29.4CM WIRE,SUP-2875915,CDM,A4648,CPT,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
CRYOABLATION KIT PROST RENAL ICESPHERE,SUP-2225661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11702.00,7606.30,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC CLLGN MEMBRN PLATFORM CM,SUP-2691587,CDM,C1713,HCPCS,0278,RC,,,,both,,,3118.02,2026.71,,,,,,,,,,,,,
PLATE BONE L25MM BLDE L15MM THK0.9MM 3X3 H RT MAX TI L SHP,SUP-2191199,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
SPACER SPNL 37X12X6 MM MIDLN VBR,SUP-2320300,CDM,C1889,HCPCS,0278,RC,,,,both,,,25151.40,16348.41,,,,,,,,,,,,,
SYSTEM IMPL INCL NDL 1.3MM WHT WHT/BLUE WHT/BLACK,SUP-2122782,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO L 135 CM 6/6FR 0.014-0.038IN DYN,SUP-2323574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6986.50,4541.22,,,,,,,,,,,,,
SCREW BNE MAND 2.3X17 MM SELF RET TI CENTRE-DRIVE,SUP-2463194,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.22,132.09,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC EXCHANGE 14.5 5397420,SUP-2632957,CDM,C1750,HCPCS,0278,RC,,,,both,,,1341.88,872.22,,,,,,,,,,,,,
SET URET STENT L 20 CM DIA 7 FR CATH 6 FR PTFE GUIDEWIRE,SUP-2461939,CDM,C2617,HCPCS,0278,RC,,,,both,,,397.46,258.35,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.408,SUP-2859972,CDM,C1713,HCPCS,0278,RC,,,,both,,,33304.10,21647.66,,,,,,,,,,,,,
IMMOBILIZER SHLDR M STRP 39IN,SUP-2324218,CDM,L3650,HCPCS,0272,RC,,,,both,,,19.12,12.43,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2931789,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.93,88.35,,,,,,,,,,,,,
PAD ORTHOT ANTR CUST ASIS,SUP-2435588,CDM,L1250,HCPCS,0274,RC,,,,both,,,223.91,145.54,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 16 CM OD 6 FR ID 0.087 IN TIP DIA,SUP-2384841,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19MM CUT EDGE 80MM CUT DEPTH 1.2MM CUT TH,SUP-2605468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,67.26,43.72,,,,,,,,,,,,,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,6370000000,HCPCS,0637,RC,61314-0396-01,NDC,,both,2,ML,53.80,34.97,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX20 CM KT SAFETY VANTEX,SUP-2277021,CDM,C1751,HCPCS,0278,RC,,,,both,,,192.17,124.91,,,,,,,,,,,,,
PLATE BNE RADIAL 2.4X63 MM RT VOLAR CLMN DSTL 6X5 HOLE LCK,SUP-2177243,CDM,C1713,HCPCS,0278,RC,,,,both,,,2739.40,1780.61,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET XMI RX RHEOLYTIC STRL,SUP-2277421,CDM,C1757,HCPCS,0272,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD TC SER TI6 FOR 2.0/2.5,SUP-2609665,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.34,16.47,,,,,,,,,,,,,
GUIDEWIRE ORTH L900MM OD2MM S STL SMOOTH BALL TIP FOR,SUP-2343578,CDM,C1769,HCPCS,0272,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
STRUT EXT FIX L 195- 310 MM LNG UNIV HEX,SUP-2898453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4578.12,2975.78,,,,,,,,,,,,,
CATHETER DIAG L150CM OD0.042X0.034IN TIP OD1.9FR 15MM SPC,SUP-2353146,CDM,C1887,HCPCS,0272,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
SCREW IM NAIL L 75 MM DIA 4.5 MM TI LP STRL TRIGEN,SUP-2933739,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.26,498.72,,,,,,,,,,,,,
SCREW BNE L35MM DIA6.5MM CTRL FOR REV SHLDR SYS COMPHSVE,SUP-2404738,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DEFIBRILLATOR CRD 40 J 2 CHMBR UNIFY DR,SUP-2356312,CDM,C1882,HCPCS,0275,RC,,,,both,,,53851.00,35003.15,,,,,,,,,,,,,
SLING GYN OUTPT PROSPECTIVE PAYMENT IN FAST,SUP-2140294,CDM,C1771,HCPCS,0278,RC,,,,both,,,4698.23,3053.85,,,,,,,,,,,,,
CATHETER EP CRD 10 MM 5 FRX120 CM QPLR RESPON,SUP-2356784,CDM,C1730,HCPCS,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
SCREW SPINAL EMERGENCY 3 MM 20/PK TITANIUM NONSTERILE MATRIX,SUP-2842243,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.67,168.14,,,,,,,,,,,,,
PLATE BNE L THK0.8MM 2X3 H L BILAT CRANIOMAXILLOFACIAL G TI,SUP-2181704,CDM,C1713,HCPCS,0278,RC,,,,both,,,1131.97,735.78,,,,,,,,,,,,,
TUBE VENT 1.14 MM 12 MM 9.8 MM T TUBE SIL STRL 510101,SUP-2535097,CDM,L8699,HCPCS,0278,RC,,,,both,,,55.11,35.82,,,,,,,,,,,,,
PLATE BNE BAR L8MM THK1MM 4 H L CRANIOMAXILLOFACIAL TI MINI,SUP-2366320,CDM,C1713,HCPCS,0278,RC,,,,both,,,638.99,415.34,,,,,,,,,,,,,
KNIFE SURG ASTN 3 MM SCKL LF,SUP-2469858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.41,204.37,,,,,,,,,,,,,
BLADE SHAVER STR 4 MM DOUBLE SERRATED DISP,SUP-2720013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
ATORVASTATIN CALCIUM 20 MG PO TABS,RX-19178,CDM,6370000000,HCPCS,0637,RC,00904-6291-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
LINER ACET OD50MM ID28MM +4MM ENDRN HIP CONSTRN LCK RNG PRI,SUP-2250690,CDM,C1776,CPT,0278,RC,,,,both,,,8291.48,5389.46,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA2.7 MM MANDIBULAR UNIV AXS ST EMER NS,SUP-2909471,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.61,236.35,,,,,,,,,,,,,
STENT BILI ABS L 40 MM UNCONSTRAINED DIA10 MM CATH L 80 CM,SUP-2101743,CDM,C1876,HCPCS,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
PLATE BONE 8 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413752,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.54,779.70,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 5 CC FD IRRADIATED CANC,SUP-2867154,CDM,C1762,CPT,0278,RC,,,,both,,,563.79,366.46,,,,,,,,,,,,,
NAIL IM L235MM DIA11MM 130DEG SHT GRN R PROX FEM TI,SUP-2180538,CDM,C1713,HCPCS,0278,RC,,,,both,,,4957.93,3222.65,,,,,,,,,,,,,
POST FIX PLATE COMPR 25 MM SYS IMPL INSTRUMENT AXIS,SUP-2610265,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
CATHETER CV KT 8 FRX16 CM DL PRESSURE INJ J ARROWG+ARD BLU,SUP-2763338,CDM,C1751,HCPCS,0278,RC,,,,both,,,258.11,167.77,,,,,,,,,,,,,
CATHETER VENTRICULAR HI CLS PRESSURE 91 CM SHUNT ACCU-FLO,SUP-2243781,CDM,C1729,HCPCS,0272,RC,,,,both,,,281.03,182.67,,,,,,,,,,,,,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,J1163,HCPCS,0636,RC,00409-4350-03,NDC,,both,1,UN,65.70,42.70,,,,,,,,,,,,,
PLATE FIXATION BURR HOLE LG 26MM,SUP-2719503,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.69,366.40,,,,,,,,,,,,,
HC So Thyroid Stim Immunoglobulin,PX-3018444566,CDM,84445,CPT,0301,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
ALLOGRAFT BNE WHL ILIUM,SUP-2321821,CDM,C1713,HCPCS,0278,RC,,,,both,,,10286.64,6686.32,,,,,,,,,,,,,
PLATE BNE FRAG 2.7X60 MM NS,SUP-2518448,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
POST EXT FIX STR,SUP-2750002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
CATHETER URET 5FR L70CM LT WHSTL TIP FOR DRNGE RG PYELOGRAM,SUP-2168873,CDM,C1758,HCPCS,0278,RC,,,,both,,,52.60,34.19,,,,,,,,,,,,,
SHELL ACET DIA46MM LNR SZ B 2 H MPACT,SUP-2267360,CDM,C1776,CPT,0278,RC,,,,both,,,6558.96,4263.32,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM SM CP TI RT MANDIBULAR HEMI,SUP-2883702,CDM,C1713,HCPCS,0278,RC,,,,both,,,13884.14,9024.69,,,,,,,,,,,,,
KIT HIP IMPL CAPPED H1 STD COCR HD VE LNR H1VEZIMMERBIOMET,SUP-2894109,CDM,C1776,CPT,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
VENT CANN 10FR CONN DIA025IN L VENT PVC VENT CONN R ANG,SUP-2277637,CDM,C1729,HCPCS,0272,RC,,,,both,,,64.31,41.80,,,,,,,,,,,,,
SET URET STENT L 22 CM DIA 4.8 FR CATH 6 FR PTFE GUIDEWIRE,SUP-2139090,CDM,C2617,HCPCS,0278,RC,,,,both,,,406.82,264.43,,,,,,,,,,,,,
SCREW TEMP FIX SH THOR CONTRA ANG FOR RIBFIX BLU SYS,SUP-2413090,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
WIRE FIX L4IN OD0045IN K FOR LESSER METATARSAL HD IMPL,SUP-2400126,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
PROBE PEDCL PEDIGUARD 3.2MM,SUP-2353384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4392.86,2855.36,,,,,,,,,,,,,
PACEMAKER CARD EVIA HF-T BIV 3 CHMBR CLS TECHNOLOGY STRL,SUP-2138423,CDM,C2621,HCPCS,0275,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
PLATE BNE W8XL100MM THK2MM 0DEG 12 H BILAT S STL STR RIG,SUP-2186183,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.53,662.69,,,,,,,,,,,,,
STEM FEM CEM LO OFFSET FORGED CO CHROM C SER SZ 3 ACUMATCH,SUP-2221725,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
SPLINT KNEE L24IN FOR 32IN THGH UNIV FOAM 3 PC DSGN TRIMMED,SUP-2196755,CDM,L1830,CPT,0274,RC,,,,both,,,46.69,30.35,,,,,,,,,,,,,
GRAFT VSCLR L50CM D26MM BRNCH D10MM THRCC CLLGN BFRCTD WOVEN,SUP-2463393,CDM,C1768,CPT,0278,RC,,,,both,,,4459.93,2898.95,,,,,,,,,,,,,
PLATE BNE L 143 MM SCREW DIA 3.5 MM 12 SHFT H TI 1/3 TUBLR,SUP-2908126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2502.42,1626.57,,,,,,,,,,,,,
SLEEVE SURG ENTRY 7.5 MM,SUP-2460639,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 12 H TI O JUNCTION LP NS,SUP-2894535,CDM,C1713,HCPCS,0278,RC,,,,both,,,3353.52,2179.79,,,,,,,,,,,,,
BLADE SCRDRVR FOR 1.2/1.7MM MIDFACE UPPERFACE,SUP-2364402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,804.25,522.76,,,,,,,,,,,,,
BIT DRL TWST LNG 1.75 MM,SUP-2389423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,151.72,98.62,,,,,,,,,,,,,
CATHETER ETER DIAG OD7FR 2 10 2 SPC STABLEMAPR SM,SUP-2281831,CDM,C1731,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE DBL T MINI REG 2X0.5 MM LP W/ BAR TI LEVEL 1 LF,SUP-2471249,CDM,C1713,HCPCS,0278,RC,,,,both,,,557.38,362.30,,,,,,,,,,,,,
BLOOD PUMP KIT CANN 31 FRX28 CM 18 FRX51 CM OXGNTR LIFESPARC,SUP-2570701,CDM,C1889,HCPCS,0278,RC,,,,both,,,75360.00,48984.00,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM BIOCRYL RAPIDE ABSRB MILAGRO ADV,SUP-2249511,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
DEVICE THROMCTMY ARROW-TREROTOLA PTD L 120 CM DIA 7 FR,SUP-2384059,CDM,C1724,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
STRIP RETIN SCLER BCKL 1.25X4 MM STYL 42 SIL,SUP-2213476,CDM,C1784,HCPCS,0278,RC,,,,both,,,54.64,35.52,,,,,,,,,,,,,
HMDIAL SET 24CM 14.5FR PU HMFL BSC PRECURVE,SUP-2633005,CDM,C1750,HCPCS,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
CAP HEALING DIA30MM W/ PLUG BAHA,SUP-2164967,CDM,L8690,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,0636,RC,63323-0642-50,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
SYSTEM PACE ANALYZER 2 CHMBR 4 CHANNEL RCRD BLT IN PRNT PT,SUP-2137946,CDM,C1713,HCPCS,0278,RC,,,,both,,,50711.00,32962.15,,,,,,,,,,,,,
CATHETER IV NEOMAGIC L 40 CM DIA1.9 FR SIL PICC 1 LUMEN STRL,SUP-2874157,CDM,C1751,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
TRIAL KNEE SYS FEM AND TIB TRLING KT CONTENTS CRUCIAL RET,SUP-2363756,CDM,C1776,CPT,0278,RC,,,,both,,,404.12,262.68,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP STR TIP 0.035 INX30 MM DSTL VISIGLIDE,SUP-2465029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11423.38,7425.20,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430078,CDM,Q5135,HCPCS,0636,RC,65219-0594-20,NDC,,both,20,ML,5777.30,3755.24,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDIC CUT AWAY UNIV 16 IN 14-29 IN KNEE,SUP-2428783,CDM,L1830,CPT,0272,RC,,,,both,,,28.04,18.23,,,,,,,,,,,,,
HEAD HUM H18MM DIA56MM DUOFIX HA RESURF GLOB CAP,SUP-2250672,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
LINER ACET OD46-48MM ID28MM +4MM 20DEG XLPE REFLCT,SUP-2344757,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE STD CORT FULL THRD N CANN ST N LOK SNAP OFF HD,SUP-2242899,CDM,C1713,HCPCS,0278,RC,,,,both,,,1138.34,739.92,,,,,,,,,,,,,
SCREW CANC 5.0MMX55.0MM POLARUS,SUP-2107659,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
GRAFT BNE SUB 15ML TRICALCIUM PHSPTE GRAN CONT RESRB,SUP-2255616,CDM,C1713,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
SCORER ARTC CART CARTIFORM 20MM,SUP-2120739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
TRANSDUCER KIT PROC,SUP-2302909,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.58,23.78,,,,,,,,,,,,,
ROPIVACAINE HCL 10 MG/ML IJ SOLN,RX-18194,CDM,J2795,HCPCS,0636,RC,63323-0288-29,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO BASIC 18GA 10CM WNG F118100TX,SUP-2632724,CDM,C1751,HCPCS,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
CLAMP EXT FIX ANG POST 11MM 30DEG 5 H PIN FOR HOFFMANN III,SUP-2372223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
WASHER EXT FIX TABBED FOR 03.313.885 OR 03.311.050 MAXFRAME,SUP-2758005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.50,199.87,,,,,,,,,,,,,
HC NM Hepatobiliary Imaging W Pharm,PX-3417822700,CDM,78227,CPT,0341,RC,,,,both,,,4423.00,2874.95,,,,,,,,,,,,,
POST EXT FIX DIA11MM 30DEG ANG FOR HOFFMANN III MOD SYS,SUP-2372222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.86,244.31,,,,,,,,,,,,,
BAR SPNL S STL INTEGR CRMP ATLS,SUP-2289630,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
FLOSEAL NT 5ML,SUP-2822244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.44,238.19,,,,,,,,,,,,,
LENS IOL HYDROPHOBIC ACRYL POST CHMBR ASPHERIC UV CCW0T7,SUP-2881009,CDM,V2788,HCPCS,0276,RC,,,,both,,,415.00,269.75,,,,,,,,,,,,,
SHEATH UROLOGICAL AMPLTZ L 16 CM DIL L 30 CM DIA18 FR RENAL,SUP-2835771,CDM,C1894,HCPCS,0272,RC,,,,both,,,122.99,79.94,,,,,,,,,,,,,
PROSTHESIS PENILE KT,SUP-2140116,CDM,C1769,HCPCS,0272,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
PLATE BNE MIC THK06MM 100DEG 6 H LNG L CRANIOMAXILLOFACIAL,SUP-2262721,CDM,C1713,HCPCS,0278,RC,,,,both,,,597.60,388.44,,,,,,,,,,,,,
GUIDEWIRE ORTH 3X980 MM W/ OLV FOR FEM NAILING SYS SS NS LTX,SUP-2874963,CDM,C1769,HCPCS,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
NAIL IM L 210 MM DIA 5.5 MM TI ULN UNIV LP ATRAUM BLNT TIP,SUP-2900405,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CEMENT BONE SCULP,SUP-2408551,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
SCREW INTRF L25MM DIA8MM STD CORT NONLOCKING SMARTSCR ACL,SUP-2166539,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.75,279.99,,,,,,,,,,,,,
HC ED Rmvl Foreign Body Pharynx,PX-4504280900,CDM,42809,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
CAGE SPNL H88MM DIA12MM ANT THORLUM TI RND MESH INTBDY FUS,SUP-2193220,CDM,C1889,HCPCS,0278,RC,,,,both,,,13106.36,8519.13,,,,,,,,,,,,,
PLATE BNE STR 1.3X24X0.75 MM 6 HOLE LCK SS NS,SUP-2177981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.66,770.68,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X143 MM 8 HOLE SS LCP,SUP-2569361,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.09,386.16,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 23 CM DIA 4 FR 80 CM 0.035 IN SS,SUP-2740719,CDM,C1894,HCPCS,0272,RC,,,,both,,,80.13,52.08,,,,,,,,,,,,,
VALVE SHUNT SYSTEM WITH NO DIFFERENTIAL PRESSURE UNIT WITH D,SUP-2821803,CDM,C1889,HCPCS,0278,RC,,,,both,,,11035.56,7173.11,,,,,,,,,,,,,
PATCH HERN XL W7.7XL9.7IN UNCOATED MFIL PROPYLENE OVL ABSRB,SUP-2125900,CDM,C1781,HCPCS,0278,RC,,,,both,,,4179.03,2716.37,,,,,,,,,,,,,
GRAFT BNE SM TRICORT BLK FOR OSTEOTMY ALLOPURE,SUP-2400549,CDM,C1762,CPT,0278,RC,,,,both,,,5469.88,3555.42,,,,,,,,,,,,,
CAP PROTCT FOR FIX PIN W/ 4.5 MM,SUP-2188623,CDM,C1713,HCPCS,0278,RC,,,,both,,,4571.68,2971.59,,,,,,,,,,,,,
CONNECTOR NRV L10MM DIA3MM PORCINE EXTRACELLULAR MTRX,SUP-2124865,CDM,C1763,HCPCS,0278,RC,,,,both,,,4477.64,2910.47,,,,,,,,,,,,,
PLATE BNE L 25 MM SCREW DIA1.6 MM TI LT OFFSET GRID 2 COMPR,SUP-2912902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE GT L 180CM 0.018IN 90 DEG ANGLED,SUP-2385630,CDM,C1769,HCPCS,0272,RC,,,,both,,,619.08,402.40,,,,,,,,,,,,,
ANCHOR SUT W/ ORTHOCORD W/ NDL 6.5MM HEALIX BRAID,SUP-2249426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
MATRIX BIO SZ 95 SQCM FISH SKIN DERMAL MIC INTACT STRL,SUP-2909247,CDM,Q4158,HCPCS,0636,RC,,,,both,,,10930.34,7104.72,,,,,,,,,,,,,
PLATE BONE 130DEG 4 H SUPCNDYL S STL COMPR FRELOK,SUP-2197723,CDM,C1713,HCPCS,0278,RC,,,,both,,,1313.43,853.73,,,,,,,,,,,,,
SHOE ORTHOT ADDITION SPEC EXTN INSTEP LTHR,SUP-2435741,CDM,L3570,HCPCS,0274,RC,,,,both,,,241.31,156.85,,,,,,,,,,,,,
CATHETER DRNGE 30FR 2 EYE PROPORTIONATE HD DISP FOR,SUP-2129056,CDM,C2627,HCPCS,0272,RC,,,,both,,,23.17,15.06,,,,,,,,,,,,,
SWIFTSTITCH HIP SUT PASS,SUP-2417055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
BASEPLATE TIB HINGED BEAR XS 21 MM KNEE S-ROM NOILES,SUP-2455912,CDM,C1713,HCPCS,0278,RC,,,,both,,,8479.26,5511.52,,,,,,,,,,,,,
PLATE BNE 5 DEG SM LT METATARSOPHALANGEAL FUSION NS ORTHOLOC,SUP-2900669,CDM,C1713,HCPCS,0278,RC,,,,both,,,8594.18,5586.22,,,,,,,,,,,,,
SET BILI DRNGE 14FR L35CM GWIRE 0.038IN 5 H PGTL POLYETH,SUP-2141065,CDM,C1729,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SHEATH INTRO NEURON MAX L 90 CM 6 FR 0.088 IN STR TIP XCUT,SUP-2323606,CDM,C1887,HCPCS,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
ANCHOR SUT 65MM DIA W NDL PEEK INTRALINE,SUP-2417097,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.42,498.82,,,,,,,,,,,,,
WIRE FIX 1.6 MM SS NS KIRSCHNER,SUP-2432332,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.73,285.82,,,,,,,,,,,,,
PLATE BNE L 91 MM SCREW DIA 3.5 MM 6 H SS RL PROX TIB STRL,SUP-2931146,CDM,C1713,HCPCS,0278,RC,,,,both,,,6799.67,4419.79,,,,,,,,,,,,,
SCREW BNE L34MM DIA3.8MM CORT FULL THRD S STL MULT DIR N,SUP-2414114,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.44,234.29,,,,,,,,,,,,,
HC Parathyrd Planar W/WO Subtrj,PX-3417807100,CDM,78071,CPT,0341,RC,,,,both,,,8208.00,5335.20,,,,,,,,,,,,,
BEAM FIX 4.5X140 MM,SUP-2422262,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
RING EXT FIX FULL D 140 MM RX STRL TRUELOK EVO LTX,SUP-2875599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9369.32,6090.06,,,,,,,,,,,,,
HC X-Ray Knee 1-2 Views,PX-3207356000,CDM,73560,CPT,0320,RC,,,,both,,,424.00,275.60,,,,,,,,,,,,,
BLOCK FEM SZ 9 THK10MM UNIV DST KNEE CO CHROM TOT STBL FULL,SUP-2378530,CDM,C1776,CPT,0278,RC,,,,both,,,3696.41,2402.67,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 15 CM DIA 5 FR SS PLAT,SUP-2635415,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.74,49.88,,,,,,,,,,,,,
GRAFT HUM TISS R MED FEM HEMICONDYLE FRSH REFRIGERATED,SUP-2264628,CDM,C1762,CPT,0278,RC,,,,both,,,36168.09,23509.26,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.529,SUP-2860046,CDM,C1713,HCPCS,0278,RC,,,,both,,,41388.34,26902.42,,,,,,,,,,,,,
PLATE BNE CRV 4.5X230 MM RT CNDYL 10 HOLE VA LCK NS VA-LCP,SUP-2758213,CDM,C1713,HCPCS,0278,RC,,,,both,,,5803.85,3772.50,,,,,,,,,,,,,
SCREW BNE L32MM DIA3MM CANC ST CANN NONLOCKING LAG,SUP-2319426,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
BLADE SURG FOR ADENOTOMES WT540602,SUP-2649905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1582.81,1028.83,,,,,,,,,,,,,
HC Splint - Short Arm,PX-7612912500,CDM,29125,CPT,0761,RC,,,,both,,,700.00,455.00,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA16 FR GUIDEWIRE 0.038 IN,SUP-2168488,CDM,C1894,HCPCS,0272,RC,,,,both,,,176.22,114.54,,,,,,,,,,,,,
NAIL IM TIB STD 8X345 MM,SUP-2552326,CDM,C1713,HCPCS,0278,RC,,,,both,,,3680.27,2392.18,,,,,,,,,,,,,
CUP ACET DIA 41 MM SS TI SPRY HA HIP 2 MOBILITY CMTLS PF 3,SUP-2913774,CDM,C1776,CPT,0278,RC,,,,both,,,29030.68,18869.94,,,,,,,,,,,,,
HC Assay of Prostate Specific Antigen Total|NOT REASONABLE AND NECESSARY,PX-3018415300,CDM,84153,CPT,0301,RC,,,GZ,both,,,242.00,157.30,,,,,,,,,,,,,
BRACE KNEE L FOR 205 23IN NEOPRENE OPN POPLITEAL WRP ARND,SUP-2196840,CDM,L1810,HCPCS,0272,RC,,,,both,,,64.87,42.17,,,,,,,,,,,,,
SHELL ACET OD56MM ID53MM TI R HIP MH CEM RECON COMP RESTR,SUP-2370295,CDM,C1776,CPT,0278,RC,,,,both,,,7340.06,4771.04,,,,,,,,,,,,,
ANCHOR SUTURE 2.9MM DIAMETER NO 2 ABSORBABLE POLYESTER ULTRA,SUP-2824089,CDM,C1713,HCPCS,0278,RC,,,,both,,,843.03,547.97,,,,,,,,,,,,,
CATHETER THORACENTESIS RT ANGLED 32 FR,SUP-2431310,CDM,C1729,HCPCS,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7040,HCPCS,0258,RC,00264-7800-10,NDC,,both,250,ML,14.90,9.68,,,,,,,,,,,,,
CATHETER CTRL VEN 7FR POLYUR MULTILUMEN INDWL RADPQ W/ BLU,SUP-2120637,CDM,C1751,HCPCS,0278,RC,,,,both,,,102.36,66.53,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 12.9 MM 33 CC 70 GM ATR EPIC DR V235SYS] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356541,CDM,C1721,HCPCS,0275,RC,,,,both,,,74575.00,48473.75,,,,,,,,,,,,,
ALIGNER SURG PELV LEV,SUP-2378896,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.40,344.11,,,,,,,,,,,,,
BASKET STONE ERCP FLOWER BSKT 20MM,SUP-2313155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
GRAFT BNE DWL FRZ DRY UNICORTICAL L 16 40MM OD 17MM,SUP-2307090,CDM,C1713,HCPCS,0278,RC,,,,both,,,2012.74,1308.28,,,,,,,,,,,,,
NEEDLE ENDOSCP STR JAW 5X250 MM W/O SUTURE FOR FACE CLOSURE,SUP-2797597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1188.21,772.34,,,,,,,,,,,,,
SCREW INTRF 7X30 MM 1 MM GUIDEWIRE STRL CANNFLX SILK LTX,SUP-2876928,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
BIT DRL L35MM DIA3.2MM ACET SCR FLEX REFLCT,SUP-2345717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
K WIRE FIX L15.2CM DIA2MM S STL SMOOTH DBL SHRP TIP,SUP-2414096,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.64,53.72,,,,,,,,,,,,,
PIN FIXATION DISPOSABLE SM FRAGMENT PLATING SYSTEM L26MM,SUP-2462661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
KIT EXTN L60CM DP BRAIN STIM ACTIVA,SUP-2284463,CDM,C1883,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
CATHETER CARD ABLATION RF ENH II L 90 CM DIA 7 FR TIP L 65,SUP-2281900,CDM,C1733,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
COLLAR CERV SFT DENS W/ CHIN SUPP ADJ AD CNTOUR HK AND LOOP,SUP-2324378,CDM,L0120,HCPCS,0272,RC,,,,both,,,16.64,10.82,,,,,,,,,,,,,
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG PO TABS,RX-21290,CDM,6370000000,HCPCS,0637,RC,00904-6704-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHUNT CAR 8FR L31CM REG TEMP W/O RESVR T PRT,SUP-2264219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
POST EXT FIX SHT WIRE MR CONDITIONAL FOR DISTR OSTEOGENESIS,SUP-2179141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.98,384.79,,,,,,,,,,,,,
GRAFT DERMAL MESH 3X3 CM FEN + WND MTRX MIRODERM,SUP-2431550,CDM,Q4175,HCPCS,0636,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
DRILL TWST DIA2MM DSTL RAD COLE,SUP-2342947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2235.62,1453.15,,,,,,,,,,,,,
SHEARS ENDOSCP L23CM DIA5.5MM SCALP CRV DISP HARM,SUP-2218884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1049.89,682.43,,,,,,,,,,,,,
FILTER VASC GIANTURCO-ROEHM BIRD'S NEST DIA 40 MM CATH L 40,SUP-2168156,CDM,C1880,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
TUBE NASOPHARYNGEAL W/ BLLN CATH,SUP-2106339,CDM,C1726,HCPCS,0272,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
CLAMP EXT FIX SYMTRC 5 MM HEX CLMP NUT TI STRL X FIX,SUP-2423208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1455.61,946.15,,,,,,,,,,,,,
PLATE BONE 8 H STR THOR FIX RIBFIX BLU,SUP-2413096,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.88,2024.67,,,,,,,,,,,,,
ANTEROLATERAL PILON FUSION PLATE 12H LT,SUP-2814968,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
PLATE BONE L155MM 6 H RT DSTL LAT FEM S STL LCK FOR 4.5MM,SUP-2348215,CDM,C1713,HCPCS,0278,RC,,,,both,,,12944.65,8414.02,,,,,,,,,,,,,
HANDPIECE ENDO L33CM 10MM VES SEAL STR SCIS DISP PK,SUP-2312644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
COMPONENT HIP CAPPED BPLR SH1] STELKAST CO],SUP-2359390,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
NAIL IM L255MM DIA10MM UNIV TIB TI CANN LCK BENT UNREAMED,SUP-2192791,CDM,C1713,HCPCS,0278,RC,,,,both,,,4193.31,2725.65,,,,,,,,,,,,,
PLATE BNE ORBIT MED RT TEF,SUP-2468399,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.57,81.62,,,,,,,,,,,,,
BIT DRL TWST 1.9X115 MM 9 MM W/ STP NOTCH LEVEL 1 DISP,SUP-2470020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.38,332.40,,,,,,,,,,,,,
ASPIRIN 1 MG/ML PO SUSP (FOR DESENSITIZATION),RX-4081557,CDM,6370000000,HCPCS,0637,RC,09999-9909-92,NDC,,both,10,ML,2.70,1.75,,,,,,,,,,,,,
DISTRACTOR SURG NO4 L60MM S STL DTT,SUP-2280176,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
SET INSTR FOR 8MM SM JT OATS,SUP-2123217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
PLATE BNE L184MM BLDE W11.7XL30MM 90DEG 10 H ST BILAT S STL,SUP-2185446,CDM,C1713,HCPCS,0278,RC,,,,both,,,4408.03,2865.22,,,,,,,,,,,,,
BLADE SCRWDRVR 74MML ULTRA LOW PRFLE F/NRO PLTNG SSTM,SUP-2500774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,692.06,449.84,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 180 CM 0.038 IN TAPR L 22 CM ANGLED,SUP-2170351,CDM,C1769,HCPCS,0272,RC,,,,both,,,580.99,377.64,,,,,,,,,,,,,
LEAD PACE EMBLEM Q-TRAK W 83.1 X H 69.1 MM D 12.7 MM SIL,SUP-2421444,CDM,C1896,HCPCS,0275,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
GRAFT BNE PTTY SM 4 CC BIOACTIVE FIBERGRAFT BG GPS,SUP-2736518,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
CITALOPRAM HYDROBROMIDE 10 MG PO TABS,RX-30264,CDM,6370000000,HCPCS,0637,RC,00904-6084-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE L127MM 10 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349639,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.23,787.95,,,,,,,,,,,,,
TUBE SALIVARY BYPASS RADIOPAQUE MONTGOMERY 191X36X10MM,SUP-2713902,CDM,C1889,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE NS CS1LCN] ISORAY MEDICAL],SUP-2247303,CDM,C2643,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG PO PACK,RX-70284,CDM,6370000000,HCPCS,0637,RC,60258-0006-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE CRAN 200X140X40 MM PT SPEC IMPL PEEK,SUP-2860159,CDM,C1713,HCPCS,0278,RC,,,,both,,,48059.27,31238.53,,,,,,,,,,,,,
STEM FEM L150MM DIA115MM NEUT KNEE CO CHROME POR BOW MOD,SUP-2252639,CDM,C1776,CPT,0278,RC,,,,both,,,10508.48,6830.51,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 5 MM RNG L 30 CM EPTFE STR TW,SUP-2396109,CDM,C1768,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
SHEATH INTRO L 23 CM DIA 9 FR PEELWY STRL,SUP-2148845,CDM,C1894,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
SCREW BNE MINI FOR BASE PLT TI 20MMX7MM MAXDRIVE,SUP-2262844,CDM,C1713,HCPCS,0278,RC,,,,both,,,811.22,527.29,,,,,,,,,,,,,
RING EXT FIX DIA180MM ANK FT FULL TL HEX,SUP-2316202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4227.70,2748.00,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.6MM CORT CRANIOMAXILLOFACIAL TI SELF,SUP-2189296,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.38,154.30,,,,,,,,,,,,,
IMPLANT OTOLRYNGOLOGY 04MM DIAM 45MM LEN LOOP STAP PIST,SUP-2313684,CDM,L8613,CPT,0278,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THK0.1-.2MM AMNIO MEM 2 LAYR,SUP-2370451,CDM,Q4150,HCPCS,0636,RC,,,,both,,,8314.72,5404.57,,,,,,,,,,,,,
BOOT WALKING DISTRACTOR BLOCK ALUM,SUP-2391502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
GRAFT BNE 50X10X2 MM 2 CC DBM BI-OSTETIC FOAM,SUP-2225965,CDM,C1713,HCPCS,0278,RC,,,,both,,,7193.74,4675.93,,,,,,,,,,,,,
PLATE BNE STR 2.7X113 MM 14 HOLE RECON LCK SS STRL,SUP-2472691,CDM,C1713,HCPCS,0278,RC,,,,both,,,1707.66,1109.98,,,,,,,,,,,,,
NEEDLE BRST BX L12CM OD9GA 20MM ATEC,SUP-2239991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.91,514.74,,,,,,,,,,,,,
STEM FEM REV 0+ MM LNG 11 MM LT HIP POLISHED BOW EMPERION,SUP-2434535,CDM,C1776,CPT,0278,RC,,,,both,,,13483.16,8764.05,,,,,,,,,,,,,
GRAFT VASC L80CM ID6MM EPTFE STD WALLED STRTCH TECHNOLOGY,SUP-2395780,CDM,C1768,CPT,0278,RC,,,,both,,,6741.58,4382.03,,,,,,,,,,,,,
STAPLE CART W4MM L60MM 0DEG GRN RELD ENDO UNIV THCK TISS 4,SUP-2257587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.31,275.80,,,,,,,,,,,,,
SCREW EXT FIX LCK ANAT DNP,SUP-2477708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
COIL NEUROVASCULAR L 50 CM DIA16 MM PLATINUM/TUNGSTEN SFT,SUP-2895555,CDM,C1889,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
GRAFT HUM TISS SZ 8 X 8 CM AMNIO MEMBRN RESRB AIR DRY SPEC,SUP-2913448,CDM,Q4173,HCPCS,0636,RC,,,,both,,,16067.38,10443.80,,,,,,,,,,,,,
PLATE BNE HUM 154 MM RT DSTL DORSOLATERAL 7 HOLE LOQTEQ,SUP-2691244,CDM,C1713,HCPCS,0278,RC,,,,both,,,3981.52,2587.99,,,,,,,,,,,,,
BIT DRL 9.5X229 MM SENTNL,SUP-2765832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,688.13,447.28,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1.7X6 MM CRANIOMAXILLOFACIAL EMERGENC,SUP-2837663,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
SNARE ENDOSCP POLYP SM 2.4 MM 195 CM 13 MM 2.8 MM CAPTIVATOR,SUP-2494995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,61.45,39.94,,,,,,,,,,,,,
STEM TIB SMOOTH TOP 12 MM R/L TOT ANK COAT INBONE II,SUP-2483477,CDM,C1776,CPT,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
INBONE  TALAR DOME SIZE 6 RIGHT LEFT,SUP-2483877,CDM,C1776,CPT,0278,RC,,,,both,,,8503.12,5527.03,,,,,,,,,,,,,
CANNULA ART 10 MM,SUP-2106274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
CROWN DENT 4 S STL PRI ANTR UP LT LAT PREFABRICATED,SUP-2100359,CDM,D6783,CPT,0278,RC,,,,both,,,21.10,13.71,,,,,,,,,,,,,
HC Clip Placement Node Biops,PX-3613899900,CDM,38999,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SURGICAL INSTR SET- 8 MM,SUP-2400367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
BLADE ULTRSNC ASPIR WORKING L 140 MM L 1.8 X W 1.3 MM MINI,SUP-2889547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1798.09,1168.76,,,,,,,,,,,,,
SET TRNSF INSEM INTRAMURAL ECHOSIGHT JANSEN-ANDERSON,SUP-2171311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
CANNULATED 8.0MM TWIST DRILL,SUP-2823744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BRACE THORACOLUMBOSACRAL M 15DEG LORDOSIS HK RECV MAT BK,SUP-2195550,CDM,L0650,HCPCS,0272,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
PURAPLY AM 8X16 128SQ CM,SUP-2314120,CDM,Q4196,HCPCS,0636,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT BSC 5FR 0.026N 55CM 2 LUMAN 7957505,SUP-2632688,CDM,C1751,HCPCS,0278,RC,,,,both,,,487.89,317.13,,,,,,,,,,,,,
KIT PROS MALL SPECTR,SUP-2139043,CDM,C2622,HCPCS,0278,RC,,,,both,,,15709.42,10211.12,,,,,,,,,,,,,
SCREW BNE L55MM DIA4.5MM THRD L26MM HD DIA8MM MALL S STL,SUP-2184555,CDM,C1713,HCPCS,0278,RC,,,,both,,,129.12,83.93,,,,,,,,,,,,,
PLEDGET CV 3X7X1.5MM TEF FIRM ENV PRE-PUNCHED,SUP-2174633,CDM,C1768,CPT,0278,RC,,,,both,,,86.70,56.35,,,,,,,,,,,,,
PACK IMPL SM DIA3.8MM INCLUDE PROX DSTL SCR TAPR LCK PIN,SUP-2123608,CDM,C1713,HCPCS,0278,RC,,,,both,,,5617.46,3651.35,,,,,,,,,,,,,
PLATE BONE DIA30MM THK1.5MM NONSTERILE CRANIOMAXILLOFACIAL,SUP-2191126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2528.33,1643.41,,,,,,,,,,,,,
GRAFT HUM TISS L 3 X W 3 CM SZ 9 SQCM AMNION-CHORION-AMNION,SUP-2909309,CDM,Q4137,HCPCS,0636,RC,,,,both,,,4503.51,2927.28,,,,,,,,,,,,,
KIT PRB 17GA L100MM MULTI-3 COOLED RF W/ 4MM ACT TIP,SUP-2236769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SPACER SPNL LG 12 DEG 42X30X20 MM SOVEREIGN,SUP-2630956,CDM,C1889,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
NEEDLE ASPIR 19GA HISTOLOGY FLX VIZISHOT 2,SUP-2313405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
ALLOGRAFT BNE CROSS SECT 12 MM CALCANEUS MATRIGRAFT,SUP-2740772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1912.48,1243.11,,,,,,,,,,,,,
MESH CRAN L 85 X W 53 MM THK 0.8 MM SCREW DIA1.5 MM SM TI,SUP-2936898,CDM,C1713,HCPCS,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
ANCHOR SUTURE 25 DEG LT TIGHT CRV QUICKPASS LASSO,SUP-2121951,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA2 MM TI MAND ST AXS NS UNIV,SUP-2909553,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.97,213.18,,,,,,,,,,,,,
PLATE BNE L230MM 10 H L DST LAT FEM S STL LOK FOR 4.5MM SCR,SUP-2348211,CDM,C1713,HCPCS,0278,RC,,,,both,,,13934.54,9057.45,,,,,,,,,,,,,
DILATOR UTER HEG 1-26 MM 7.5 IN SET SINGLE END IN CANVS RL,SUP-2472815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2093.22,1360.59,,,,,,,,,,,,,
OXCARBAZEPINE 300 MG PO TABS,RX-21061,CDM,6370000000,HCPCS,0637,RC,00904-7263-61,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
COMPONENT PATELLAR FEM KNEE CUST,SUP-2136069,CDM,C1776,CPT,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 0-20CM H2O TI 2 CONN ADJ VLV BUR H,SUP-2108728,CDM,C1889,HCPCS,0278,RC,,,,both,,,10082.73,6553.77,,,,,,,,,,,,,
PLATE BONE 6 H T SHP FOR SM BONES ORTHOLOC 3DI,SUP-2398058,CDM,C1713,HCPCS,0278,RC,,,,both,,,1862.02,1210.31,,,,,,,,,,,,,
CURETTE SURG 000 9 IN CERV AX CUT BKWRD ANGLED DN STRL ULTRA,SUP-2473466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.30,385.64,,,,,,,,,,,,,
SHELL ACET TOT HIP PRI PRESSFIT POR UNIV TI 44MM ID 44MM OD,SUP-2204667,CDM,C1776,CPT,0278,RC,,,,both,,,12811.20,8327.28,,,,,,,,,,,,,
LINER ACET TRIL SZ II 36 MM,SUP-2203897,CDM,C1776,CPT,0278,RC,,,,both,,,3893.25,2530.61,,,,,,,,,,,,,
ADAPTER TIB TY NEUT OFFSET KNEE INTLOK VANGUARD COMPLT SYS,SUP-2405428,CDM,C1776,CPT,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
SET SURG THYROPLASTY INSTR NONSTERILE 13 PC W/ CUST STRL TY,SUP-2138768,CDM,L8509,HCPCS,0274,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
GRAFT BNE SUB 12ML W2XL10MM B TRICALCIUM PHSPTE CLLGN HA,SUP-2289161,CDM,C1713,HCPCS,0278,RC,,,,both,,,4876.42,3169.67,,,,,,,,,,,,,
CATHETER ANGIO ACCU-VU L 70 CM DIA 5 FR 0.035 IN 20 CM PIG,SUP-2117060,CDM,C1887,HCPCS,0272,RC,,,,both,,,300.18,195.12,,,,,,,,,,,,,
RING EXT FIX ID165MM TI C FBR HYBRID 3/4 FOR DST TIB FRME,SUP-2188611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1357.11,882.12,,,,,,,,,,,,,
PLATE BONE L W12XL71MM THK1MM 4 H BILAT TI SEMI TBLR LO PROF,SUP-2190702,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.13,158.03,,,,,,,,,,,,,
POST EXT FIX L DIA8MM S STL STR HOFFMANN II,SUP-2372203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
IMPLANT SHLDR 40MM VERSA-DIAL GLEN STD,SUP-2418154,CDM,C1776,CPT,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
JOINT SHOULDER HUMERAL PROSTHESIS EQUINOXE MID SEGMENT 25MM,SUP-2855530,CDM,C1776,CPT,0278,RC,,,,both,,,19389.50,12603.17,,,,,,,,,,,,,
SET URET STENT SOFFLX L 28 CM DIA10 FR INSRTR L 40 CM DIA10,SUP-2171262,CDM,C2617,HCPCS,0278,RC,,,,both,,,437.09,284.11,,,,,,,,,,,,,
TUBING HUMIDIFICATION HI FLO 0.88 IN,SUP-2305967,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
PROSTHESIS PENILE INCL BLNT TIP STAY HK DEAVER M WILSON,SUP-2165464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
NEXGEN FEMORAL AUGMENT SCREW,SUP-2503254,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CROWN DENT NODUR-6 1ST PRI M UP R S STL,SUP-2322208,CDM,D6783,CPT,0278,RC,,,,both,,,33.60,21.84,,,,,,,,,,,,,
PLATE BNE L131MM 9 H ST R DST LAT FIBULAR VAR ANG LOK FOR,SUP-2349841,CDM,C1713,HCPCS,0278,RC,,,,both,,,6487.55,4216.91,,,,,,,,,,,,,
PLATE BONE L71MM THK3.8MM 4 H BILAT S STL NAR DYN COMPR FOR,SUP-2185203,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.39,129.60,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 15 PED W/ SHUNT ASST AND BUR H RESVR,SUP-2108748,CDM,C1729,HCPCS,0272,RC,,,,both,,,7918.42,5146.97,,,,,,,,,,,,,
SCREW BONE L14MM OD1.3MM CO CHROM CORT ST NONLOCKING FULL,SUP-2411756,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.90,126.03,,,,,,,,,,,,,
MODEL ANAT MANDIBULAR/MAXILLARY RECON CASE BNDL VSP,SUP-2884205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21775.90,14154.33,,,,,,,,,,,,,
BLADE SHAVER XOMED STRAIGHTSHOT SYSTEM XPS ENDOSCOPIC 2.9MM 11CM PEDI,SUP-2902788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
PLEDGET SURG W3/16XL0.25IN THK1.65MM PTFE OVL FELT FOR THE,SUP-2127904,CDM,C1781,HCPCS,0278,RC,,,,both,,,23.71,15.41,,,,,,,,,,,,,
BIT DRL TWST 1.5X9 MM ANGLED SCREWDRIVER STRL ANGULUS 2,SUP-2457824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
DISTRACTION INTRNL ST SIZER 51 567 09 71SZE 1 9 MM 2 HOLE T,SUP-2679215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,475.30,308.94,,,,,,,,,,,,,
BIT DRL L44.5MM DIA0.7MM STP 3MM STRYKR J LATCH FOR 1MM SCR,SUP-2187623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.27,377.18,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM NO2 TWINFIX PK FT W/ 3 WHT COBRAID BLU,SUP-2341785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN,RX-14868,CDM,J2002,HCPCS,0636,RC,00264-9594-10,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL L 3.5 IN DIA22 GA SGL SHT LIDO NACL,SUP-2936602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,52.72,34.27,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 16X8 CMX1.8-4 MM HYDRATED,SUP-2307502,CDM,Q4128,HCPCS,0636,RC,,,,both,,,12516.95,8136.02,,,,,,,,,,,,,
PLATE BNE L316MM 13 H NONSTERILE R DST FEM S STL LOK COMPR,SUP-2184903,CDM,C1713,HCPCS,0278,RC,,,,both,,,4661.90,3030.23,,,,,,,,,,,,,
SCREW BNE L60MM OD5MM 6.5MM TI HND FT ST CANN NONLOCKING,SUP-2107233,CDM,C1713,HCPCS,0278,RC,,,,both,,,3510.52,2281.84,,,,,,,,,,,,,
ELECTRODE ES 36CM LAP STR SPAT COAT DISPOSABLE CLEANCOAT,SUP-2283544,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.37,75.64,,,,,,,,,,,,,
LIDOCAINE HCL 4 % MT SOLN,RX-43717,CDM,6370000000,HCPCS,0637,RC,76329-6300-05,NDC,,both,4,ML,173.70,112.90,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 80 MG/4ML IV SOLN,RX-167520,CDM,Q5135,HCPCS,0636,RC,65219-0590-04,NDC,,both,4,ML,1155.50,751.07,,,,,,,,,,,,,
SCREWDRIVER SURG MINI QUIKDRIVE REUSE,SUP-2435307,CDM,C1713,HCPCS,0278,RC,,,,both,,,14887.05,9676.58,,,,,,,,,,,,,
CATHETER ENDO S-30 TIP SINUS GUID RELIEVA FLX,SUP-2106346,CDM,C1729,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
FIBER SURG LASER DIA1000 UM STD RFID BLU BUFF FOR HOLM,SUP-2937401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
STENT ESOPH HANAROSTENT L 150 MM DIA22 MM DEL SYS L 700 MM,SUP-2417323,CDM,C1874,HCPCS,0278,RC,,,,both,,,6860.90,4459.58,,,,,,,,,,,,,
SCREW BNE 2.7X10 MM THORECON,SUP-2720003,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.13,63.78,,,,,,,,,,,,,
COMPONENT PAT DIA37MM KNEE SEMICONSTRAINED REGENEREX,SUP-2405418,CDM,C1776,CPT,0278,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
REAMER SURG FOR FEM NK COMPLETE OPENING SYS NS,SUP-2417586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4624.91,3006.19,,,,,,,,,,,,,
ALLOGRAFT BNE SHT 25X20X7 MM CANC CONFORM Q-PACK,SUP-2737084,CDM,C1713,HCPCS,0278,RC,,,,both,,,4123.61,2680.35,,,,,,,,,,,,,
STAPLE BONE FIXATION 20X20MM WIRE 2.3X1.6MM NONSTERILE SNIPER,SUP-2878265,CDM,C1713,HCPCS,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
MESH CRAN THK 0.6 MM SCREW DIA1.5 MM TI GRD II OCCPTL PREFRM,SUP-2935070,CDM,C1713,HCPCS,0278,RC,,,,both,,,15238.42,9904.97,,,,,,,,,,,,,
PLATE EXT FIX 180MM FT ALUM,SUP-2242954,CDM,C1713,HCPCS,0278,RC,,,,both,,,5638.31,3664.90,,,,,,,,,,,,,
FIBER LASER 200 MH HOLM DISP,SUP-2430215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.13,936.73,,,,,,,,,,,,,
ALLOGRAFT BNE FD MEDL TO LAT WHL FEM CONDYLE,SUP-2866851,CDM,C1762,CPT,0278,RC,,,,both,,,6473.11,4207.52,,,,,,,,,,,,,
GUIDE DRL BUSHING 25 DEG 8 MM,SUP-2167405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
TRAY CATH MIDLN POWERMIDLINE MAXBARR 3FR 20CM 1 LUMAN RVRSE,SUP-2613516,CDM,C1751,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SYSTEM DEL IMPL L 25 X W 23 MM FOR RC REP STRL BIOBRACE RC,SUP-2930545,CDM,C1763,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SPACER SPNL ANTEROLATERAL XL 17 MM RADLUC SUSTAIN,SUP-2585261,CDM,C1889,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
INTRODUCER IV CATH NEOMAGIC CATH 1.9/2 FR SIL TIP PUSH BTTN,SUP-2874177,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.71,87.56,,,,,,,,,,,,,
DEVICE GLAUCOMA DRNGE 1/4IN CLR CORNEA W/ SCLER,SUP-2247189,CDM,V2785,HCPCS,0810,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
GRAFT BIO TISS W13XL15CM HERN FOR IMPLANTATION TO REINF SFT,SUP-2170303,CDM,C1781,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
PROSTHESIS OSS CLASSIC STAP 4X1 MM 0.4 MM TI,SUP-2638170,CDM,L8613,CPT,0278,RC,,,,both,,,708.10,460.26,,,,,,,,,,,,,
SCREW BNE HEX HD 6.5X40 MM CANC SS NS,SUP-2184600,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MR L 135 CM BALLOON L 9 MM DIA 4 MM,SUP-2139714,CDM,C1725,HCPCS,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
STOCKING ORTHOT SUPP GRP CUST PREFABRICATED OFF THE SHLF,SUP-2435567,CDM,L0982,HCPCS,0272,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMOS DR-T SZ 6.7 CM TI EPOXY RESIN SIL 2,SUP-2138062,CDM,C1721,HCPCS,0275,RC,,,,both,,,43702.52,28406.64,,,,,,,,,,,,,
CATHETER INFUSION MISTIQUE L 135 CM DIA 5 FR SEG L 5 CM,SUP-2701991,CDM,C1751,HCPCS,0278,RC,,,,both,,,167.68,108.99,,,,,,,,,,,,,
PLATE RAD HD RIM 2.4MM 3H LT TI LCP,SUP-2549709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1983.16,1289.05,,,,,,,,,,,,,
HC Biopsy of Salivary Gland,PX-3614240000,CDM,42400,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SHELL ACET REV 56 MM HIP HEMI ANAT,SUP-2363244,CDM,C1776,CPT,0278,RC,,,,both,,,12735.84,8278.30,,,,,,,,,,,,,
ELECTRODE SUCT HIP CHSL TIP VAPR ARCTIC,SUP-2176894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1843.18,1198.07,,,,,,,,,,,,,
SET HEMOFILTER W THE AN 69 DLYZR MEM FOR CRRT M150,SUP-2129951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,843.34,548.17,,,,,,,,,,,,,
GRAFT BONE CHIP IRRADIATED FRZ DRY CANC CORT 15CC,SUP-2113892,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 92MML HLX7 STNLSS STEEL CNTRD ST,SUP-2588599,CDM,C1713,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND XL 11-14 MM 122 CM 6 SHOT MBL6XLI,SUP-2737557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
GRAFT VASC VLV 31 MM AORT ROTATABLE STENT MSTR SER,SUP-2355156,CDM,C1768,CPT,0278,RC,,,,both,,,20045.76,13029.74,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM BRNZ CORT TI ST NONCANNULATED,SUP-2181608,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.71,207.16,,,,,,,,,,,,,
PLATE BNE L142MM 8 H ST R ANTEROMEDIAL DST TIB S STL VAR ANG,SUP-2177675,CDM,C1713,HCPCS,0278,RC,,,,both,,,5707.99,3710.19,,,,,,,,,,,,,
NAIL IM L345MM DIA10MM NONSTERILE GRN TIB TI CANN LCK,SUP-2192802,CDM,C1713,HCPCS,0278,RC,,,,both,,,3833.44,2491.74,,,,,,,,,,,,,
INJECTOR PELLET 3 MM 1.25 CC OSTEOSET,SUP-2468000,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.37,934.94,,,,,,,,,,,,,
BLADE SAW OSCLLTNG CLSSC 19MMW X90MML 1.19MM THK INNVTVE TOO,SUP-2605823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,82.11,53.37,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE LG ECON BUCK,SUP-2336329,CDM,L4398,HCPCS,0272,RC,,,,both,,,27.60,17.94,,,,,,,,,,,,,
ELECTRODE ES 12DEG LOOP HF RESECT MPLR DISPOSABLE,SUP-2313571,CDM,C1713,HCPCS,0278,RC,,,,both,,,556.69,361.85,,,,,,,,,,,,,
IMPLANT ANKLE JOINT 3 TIBIAL IMPLANTABLE,SUP-2490913,CDM,C1776,CPT,0278,RC,,,,both,,,9831.34,6390.37,,,,,,,,,,,,,
SCREW BONE STD CANC FULL THRD CANN N LCK NSTERILE 4MM DIA,SUP-2348388,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.96,173.52,,,,,,,,,,,,,
PLATE BONE L153MM 18 H STRL S STL COMPR FOR 2.7MM SCR EVOS,SUP-2349626,CDM,C1713,HCPCS,0278,RC,,,,both,,,2616.34,1700.62,,,,,,,,,,,,,
DESONIDE 0.05 % EX CREA,RX-2291,CDM,6370000000,HCPCS,0637,RC,62332-0632-15,NDC,,both,15,GR,92.60,60.19,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 8 MM RNG L 20 CM EPTFE STR TW,SUP-2396165,CDM,C1768,CPT,0278,RC,,,,both,,,2992.42,1945.07,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT IR 5FR 55CM 2 LUMAN RVS 3275355F,SUP-2632671,CDM,C1751,HCPCS,0278,RC,,,,both,,,351.93,228.75,,,,,,,,,,,,,
MESH SYNTH INGUINAL N ABSRB TITANIZED POLYPR LT 30CM LEN,SUP-2402532,CDM,C1781,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
SYSTEM IV INFUSION 5 FRX45 CM 10 CM 1 CC,SUP-2471137,CDM,C1751,HCPCS,0278,RC,,,,both,,,273.65,177.87,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM LIN SPNL CRD DISP PHASE III,SUP-2141901,CDM,C1778,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
GRAFT VASC GELSFT + L 25 CM DIA20 MM POLYESTER GEL,SUP-2384948,CDM,C1768,CPT,0278,RC,,,,both,,,1079.50,701.67,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA12MM BLNT STBL SL DISP ENDOPATH,SUP-2219091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
PLATE LCK FOR STRNL APPRX WOLVEK,SUP-2383724,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.90,114.33,,,,,,,,,,,,,
COIL EMB L15CM OD5MM 360DEG SFT DETACH TARGET,SUP-2368026,CDM,C1889,HCPCS,0278,RC,,,,both,,,7269.10,4724.91,,,,,,,,,,,,,
SUPPORT TENNIS ELBW GEL AIR FRARM CIRC 8-14IN REG,SUP-2324441,CDM,L3702,HCPCS,0272,RC,,,,both,,,31.97,20.78,,,,,,,,,,,,,
SCREW BNE COMPR 6.5X90 MM 15 MM HDLSS BITE,SUP-2644930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1612.39,1048.05,,,,,,,,,,,,,
CATHETER ART SET 035X60 CM 5.8 FRX24 CM NYL BUNEGIN-ALBIN,SUP-2760074,CDM,C1769,HCPCS,0272,RC,,,,both,,,261.44,169.94,,,,,,,,,,,,,
GRAFT TENDON FASCIA LATA > 150CM FRESH FROZEN,SUP-2866788,CDM,C1762,CPT,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
GRAFT BNE PERONEOUS LONGUS SM,SUP-2307292,CDM,C1713,HCPCS,0278,RC,,,,both,,,4150.83,2698.04,,,,,,,,,,,,,
BOOT WALKING X SM,SUP-2194769,CDM,L4396,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2.5 MM RECON PT SPEC,SUP-2860097,CDM,C1713,HCPCS,0278,RC,,,,both,,,27404.66,17813.03,,,,,,,,,,,,,
PLATE BNE COMPR SM 2.7X76 MM 9 HOLE DYN NS DCP LTX,SUP-2861902,CDM,C1713,HCPCS,0278,RC,,,,both,,,446.32,290.11,,,,,,,,,,,,,
CATHETER EP 7FR L99CM 1-4-1MM SPC 20 POLE MAP DUO DECAPOLAR,SUP-2357021,CDM,C1731,HCPCS,0278,RC,,,,both,,,5466.74,3553.38,,,,,,,,,,,,,
PIN FIX L4MM DIA21MM CRANIOMAXILLOFACIAL SELF RET,SUP-2263016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.94,748.76,,,,,,,,,,,,,
CATHETER ABLATN MED CURL 7 FR QPLR LIVEWIRE TC,SUP-2356991,CDM,C1733,HCPCS,0272,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
CAGE SPNL L10XW10XH9MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317724,CDM,C1889,HCPCS,0278,RC,,,,both,,,4311.22,2802.29,,,,,,,,,,,,,
SCREW VA LCK ST 2X30MM SS W/T6 STARDRV RECESS VAL,SUP-2546090,CDM,C1713,HCPCS,0278,RC,,,,both,,,484.35,314.83,,,,,,,,,,,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,0636,RC,00641-6175-10,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT TOT HIP 1 PRIMARY,SUP-2378853,CDM,C1776,CPT,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
STEM RADIAL SM ELBW SIG NOTCH,SUP-2478595,CDM,C1776,CPT,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
CATHETER PTCA 8FR L100CM BLLN DIA10-46MM SHTH 12FR GWIRE,SUP-2296785,CDM,C1725,HCPCS,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
CATHETER HD SHT TERM 11.5 FRX20 CM J HEMO-CATH,SUP-2627425,CDM,C1752,HCPCS,0278,RC,,,,both,,,384.65,250.02,,,,,,,,,,,,,
INSERT TIB SZ 2 THK9.5MM RT MEDL LT LAT KNEE FIX BEAR,SUP-2251271,CDM,C1776,CPT,0278,RC,,,,both,,,2530.84,1645.05,,,,,,,,,,,,,
SCREW CRTX FT SELF TAP HEX HD 4.5MM DIA 42MML,SUP-2342660,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.63,30.31,,,,,,,,,,,,,
CATHETER HAD AD L40CM INSRT L23CM DIA14.5FR POLYUR PRE CRV,SUP-2174241,CDM,C1881,HCPCS,0278,RC,,,,both,,,2173.60,1412.84,,,,,,,,,,,,,
CATHETER INTRAAORTIC 8FR BAL 30CC POLYUR NYL CARDIOTHANE II,SUP-2383459,CDM,C1713,HCPCS,0278,RC,,,,both,,,4254.70,2765.55,,,,,,,,,,,,,
HC Assay of Folic Acid Serum,PX-3018274600,CDM,82746,CPT,0301,RC,,,,both,,,210.00,136.50,,,,,,,,,,,,,
HC Telethx Isodose Plan Cplx,PX-3337730700,CDM,77307,CPT,0333,RC,,,,outpatient,,,3311.00,2152.15,,,,,,,,,,,,,
HC Hemoglobin Methemoglobin Quantitative,PX-3018305000,CDM,83050,CPT,0301,RC,,,,inpatient,,,89.00,57.85,,,,,,,,,,,,,
SCREW BONE L8MM DIA2.5MM CORT WR TI TRILOK APTUS HEXADRIVE 7,SUP-2268222,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
IMPLANT SPNL L50MM OD4MM POR TI PLSM SPRAYED SACROILIAC JT,SUP-2337737,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PACEMAKER CARD ALTURA 60 TI 2 CHMBR 1 LD BATTERY PWR EXT,SUP-2149110,CDM,C1786,HCPCS,0275,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND 8.6-11.3 MM 4 SHOT SAEED,SUP-2737558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
HC IV Push Diff Drug,PX-2609637500,CDM,96375,CPT,0260,RC,,,,both,,,91.00,59.15,,,,,,,,,,,,,
BLADE CUT DIA2.5IN S STL FOR 940 CAST REM SYS,SUP-2365263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
ALLOGRAFT FRZ DRY FASC LATA IRRADIATED 60-120MM N WT BEAR,SUP-2115976,CDM,C1762,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
NITINOL GUIDEWIRE 2MM DIAMETER X 38.5CM,SUP-2574103,CDM,C1769,HCPCS,0272,RC,,,,both,,,17.21,11.19,,,,,,,,,,,,,
DRESSING BIO L 7 X W 5 CM SZ 200 UM PORCINE SM INTEST,SUP-2905523,CDM,Q4103,HCPCS,0636,RC,,,,both,,,1353.15,879.55,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL PLUSXL,SUP-2195534,CDM,L1830,CPT,0272,RC,,,,both,,,115.55,75.11,,,,,,,,,,,,,
PLATE BONE W5XL23MM THK0.9MM 4 H MINI S STL STR,SUP-2343833,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.47,322.71,,,,,,,,,,,,,
CUTTER SURG OD31MM TUNGSTEN CARB HI LINE XS III,SUP-2108792,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.23,349.85,,,,,,,,,,,,,
PLATE BNE RECTANGULAR MIC 1X0.6 MM CRANIOMAXILLOFACIAL 3X2,SUP-2463780,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.04,455.68,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESH 12X12 CMX2.31-3.30 MM TISS ALLDERM,SUP-2113050,CDM,Q4116,HCPCS,0636,RC,,,,both,,,16880.64,10972.42,,,,,,,,,,,,,
LEAD PACE AD 8.6FR L72CM ATR VENT SIL POLYUR INSUL 3PLR,SUP-2282251,CDM,C1777,HCPCS,0275,RC,,,,both,,,9744.24,6333.76,,,,,,,,,,,,,
GUIDEWIRE ORTH SUPER STIFF 3X200 MM SHLDR MARKER AEQUALIS,SUP-2715409,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SET INTUB CATH 14FR L70CM GWIRE L110CM 0.038IN RG W/ PTFE,SUP-2168590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD FRAC,SUP-2365970,CDM,C1776,CPT,0278,RC,,,,both,,,8807.70,5725.00,,,,,,,,,,,,,
BRAIN STIMULATOR KIT IMPL PULSE GENRTR P8 VERCISE GENUS,SUP-2845262,CDM,C1820,HCPCS,0278,RC,,,,both,,,27946.00,18164.90,,,,,,,,,,,,,
PLATE BNE 2 H POST RIM BROAD NS PRO,SUP-2902270,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.47,1429.01,,,,,,,,,,,,,
SCREW BONE L80MM D35MM STNLSS STEEL CRTCL PRRTCLR SELF TPPNG,SUP-2460904,CDM,C1713,HCPCS,0278,RC,,,,both,,,93.16,60.55,,,,,,,,,,,,,
NAIL IM L 225 MM DIA10.5 MM ARTH OSTEOSYN NITINAIL,SUP-2898595,CDM,C1713,HCPCS,0278,RC,,,,both,,,32813.00,21328.45,,,,,,,,,,,,,
FILTER VASC ACCUNET SZ 6.5 MM CATH 8 FR SHTH 6 FR GUIDEWIRE,SUP-2104679,CDM,C1876,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
TRABECULAR METAL REVISION SHELL 56MM,SUP-2503824,CDM,C1776,CPT,0278,RC,,,,both,,,7510.88,4882.07,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0250,RC,00264-7520-10,NDC,,both,125,ML,9.60,6.24,,,,,,,,,,,,,
PIN TRANSFIXING L275MM DIA5MM THRD L6MM S STL EXTRAFIX,SUP-2205303,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.87,351.57,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 6-4 MM EPTFE SHRT TAPR,SUP-2126767,CDM,C1768,CPT,0278,RC,,,,both,,,2214.39,1439.35,,,,,,,,,,,,,
GRIP CBL L195MM STD TROCHANTERIC HIP 8 CBL ACCORD,SUP-2345208,CDM,C1776,CPT,0278,RC,,,,both,,,7762.08,5045.35,,,,,,,,,,,,,
BUR SURG DIA5MM LNG S STL RND CUT FLUT ELITE TPS,SUP-2363476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.93,203.40,,,,,,,,,,,,,
BASEPLATE TIB SZ 3 KNEE CO CHROM MOLYBDENUM TI ALLY ROT,SUP-2251421,CDM,C1776,CPT,0278,RC,,,,both,,,11278.88,7331.27,,,,,,,,,,,,,
SYSTEM TOT KNEE,SUP-2212227,CDM,C1776,CPT,0278,RC,,,,both,,,14484.82,9415.13,,,,,,,,,,,,,
HC Thoracic Myelogram S&I,PX-3207225500,CDM,72255,CPT,0320,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
ALLOGRAFT BNE SM 100-125 MM FRZN IRRADIATED CORTICAL SHFT,SUP-2866975,CDM,C1762,CPT,0278,RC,,,,both,,,2076.17,1349.51,,,,,,,,,,,,,
DISSECTOR GLIDEPATH SYS FOR OPN CHST LUMITIP,SUP-2124451,CDM,C1713,HCPCS,0278,RC,,,,both,,,4185.62,2720.65,,,,,,,,,,,,,
POROUS STEM W/STD HD,SUP-2212342,CDM,C1776,CPT,0278,RC,,,,both,,,6772.98,4402.44,,,,,,,,,,,,,
GRAFT DERMAL MESH 7X10 CM FEN + WND MTRX MIRODERM,SUP-2431542,CDM,Q4175,HCPCS,0636,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
CEMENT BNE HI VISC 80 GM GENTAMICIN PALACOS R+G PRO,SUP-2738877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR 16 CHAN NONRECHARGEABLE EONC,SUP-2356749,CDM,C1778,HCPCS,0278,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L13CM NDL 18GA GWIRE 0.035IN SYR VLV,SUP-2281845,CDM,C1892,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
MONITOR CARD 1.4CC INSERTABLE SLIM PROF REMOT MONING RDY,SUP-2356338,CDM,C1764,HCPCS,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
ALLOGRAFT BNE IRRADIATED HUM HD,SUP-2867158,CDM,C1762,CPT,0278,RC,,,,both,,,3490.11,2268.57,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING XTALL ADLT 4.5 IN TRNS ATLS PROCARE,SUP-2195753,CDM,L0180,HCPCS,0272,RC,,,,both,,,74.51,48.43,,,,,,,,,,,,,
GRAFT BONE SUB 10ML HUM CORT BONE DEMIN FBR STAGRFT,SUP-2136832,CDM,C1713,HCPCS,0278,RC,,,,both,,,7357.81,4782.58,,,,,,,,,,,,,
LEAD KIT STIM TST INTERSTIM,SUP-2640134,CDM,C1897,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
STENT ENTERPRISE VASC 2 TIP 4.0X16MM,SUP-2470070,CDM,C1874,HCPCS,0278,RC,,,,both,,,28918.83,18797.24,,,,,,,,,,,,,
GRAFT DERM FLD HYDRATED THCK KT BILAT BRST ACELLULAR DERM,SUP-2307582,CDM,Q4128,HCPCS,0636,RC,,,,both,,,7597.23,4938.20,,,,,,,,,,,,,
GUIDEWIRE VASC N L 190 CM DIA 0.035 IN LLT TAPR CRV STRL,SUP-2170313,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
PORT INFUS ODSEC66FR PLAS NONPOWERED SGL LUMN NONFILLED SUT,SUP-2127729,CDM,C1788,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
BUR SURG DIA3MM S STL DMND NEURO CVD DISP,SUP-2365187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,572.74,372.28,,,,,,,,,,,,,
DRILL SURG 10 MM SHORELINE ACS,SUP-2709726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
EPIFIX DISK 14MM,SUP-2305746,CDM,Q4186,HCPCS,0636,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
ALLOGRAFT BNE 4-10 MM 60 CC FD DEMINERALIZED CORTICAL CANC,SUP-2866846,CDM,C1762,CPT,0278,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
PLATE EXT FIX SHT 200 MM FT RNG TI NS,SUP-2800130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3143.45,2043.24,,,,,,,,,,,,,
SCREW BNE L 40 MM DIA2 MM TI CORTICAL ST T6 DRV NS VLP,SUP-2932390,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.16,115.80,,,,,,,,,,,,,
HC Tcat Impl Wrls P-Art Prs Snr L-T Hemodyn,PX-4803328900,CDM,33289,CPT,0480,RC,,,,both,,,89941.00,58461.65,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED OXFORD,SUP-2137378,CDM,C1776,CPT,0278,RC,,,,both,,,12811.20,8327.28,,,,,,,,,,,,,
BLADE SURG 46 MM CALCAR RASP STYL EXACT,SUP-2443891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
COIL EMB L60CM LOOP OD16MM OD0.020IN STD NIT COMPLX FRME,SUP-2323381,CDM,C1889,HCPCS,0278,RC,,,,both,,,7510.88,4882.07,,,,,,,,,,,,,
STEM HUM M L116MM OD12.6X10.5MM MOD FOR REMEDY SHLDR SYS,SUP-2319844,CDM,C1776,CPT,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
BIT DRL L330MM DIA15MM CANN L QUIK CPL FOR RECON FEM NAIL,SUP-2178900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.16,752.80,,,,,,,,,,,,,
PLATE BONE L112MM W11.7XL30MM 90DEG 6 H CANN LCK COMPR ANG,SUP-2185438,CDM,C1713,HCPCS,0278,RC,,,,both,,,2555.96,1661.37,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE LARGE 0.6 MM PRECONTOURED TITANIUM,SUP-2842248,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.31,2593.70,,,,,,,,,,,,,
HC So Vitamin Nos,PX-3018459166,CDM,84591,CPT,0301,RC,,,,both,,,116.00,75.40,,,,,,,,,,,,,
METHENAMINE HIPPURATE 1 G PO TABS,RX-10549,CDM,6370000000,HCPCS,0637,RC,65862-0782-01,NDC,,both,1,UN,3.60,2.34,,,,,,,,,,,,,
STEM FEM L140MM DIA14MM 135DEG STD OFFSET DST HIP BILAT,SUP-2252552,CDM,C1776,CPT,0278,RC,,,,both,,,8947.74,5816.03,,,,,,,,,,,,,
STEM FEM DSTL MOD W/ SLOT POR RL HARDENED OD15MM L 300MM,SUP-2404203,CDM,C1776,CPT,0278,RC,,,,both,,,10063.70,6541.40,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 8X20 CMX0.75-1.5 MM SFT DERMACELL,SUP-2427792,CDM,Q4122,HCPCS,0636,RC,,,,both,,,39935.96,25958.37,,,,,,,,,,,,,
SCREW SPNL MULTAXL XS 3X18 MM OCCIPITOCERVICAL UPPER THOR,SUP-2631942,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
SCREW BONE 6.4MMX90MM CAPT RECON SCR TI TRIGEN,SUP-2347067,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0250,RC,00338-0017-31,NDC,,both,250,ML,108.40,70.46,,,,,,,,,,,,,
PLATE BONE W18XL24MM THK1.4MM STRL TRAP FOR 2.4MM SCR EVOS,SUP-2349690,CDM,C1713,HCPCS,0278,RC,,,,both,,,5269.23,3425.00,,,,,,,,,,,,,
MATRIX BIO L 6 X W 4 CM FISH SKIN DERMAL INTACT STRL OMEGA3 10/BX,SUP-2909454,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3843.36,2498.18,,,,,,,,,,,,,
PLATE BONE THK0.6MM 6 H ORBIT RIM SLV FOR 2MM SCR LORENZ,SUP-2402930,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SCREW KIT MED PEDIATRIC 5 MM STRL GALAXY,SUP-2646381,CDM,C1713,HCPCS,0278,RC,,,,both,,,10055.10,6535.81,,,,,,,,,,,,,
CLIP NRV STIM DYN INLINE ACT M5,SUP-2310418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
GRAFT HUM TISS 11+CM FIB SEG STRUCTURAL FRZN,SUP-2165541,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
ALLOGRAFT BNE WHL FEM FRZN RT HD,SUP-2717939,CDM,C1762,CPT,0278,RC,,,,both,,,40678.70,26441.15,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 740 HF-T TI EPOXY RESIN SIL 3 CHMBR,SUP-2138412,CDM,C1722,HCPCS,0275,RC,,,,both,,,61230.00,39799.50,,,,,,,,,,,,,
CATHETER ATHRCTMY 8FR L110CM TIP L2.5MM 0.018IN OVR THE WIRE,SUP-2353081,CDM,C1714,HCPCS,0272,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR 0.062X14 IN NIT DISP,SUP-2608183,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.09,46.86,,,,,,,,,,,,,
TRIAL PLATE 1.3 MM ROTATIONAL CORRECTION,SUP-2525719,CDM,C1713,HCPCS,0278,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
PLATE BNE L90MM 6 H NONSTERILE L POSTEROLATERAL DST TIB S,SUP-2177704,CDM,C1713,HCPCS,0278,RC,,,,both,,,2906.13,1888.98,,,,,,,,,,,,,
ANCHOR SUT PEEK W/ FORC FBR GRYPHON,SUP-2249465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.64,971.52,,,,,,,,,,,,,
DEVICE SUT CAPT L25CM DIA12MM OPN ACCS W/O SLNG FOR,SUP-2139398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2186.92,1421.50,,,,,,,,,,,,,
CAGE SPNL W10XH9XL27MM 5-10DEG LUM PEEK INTBDY SELF EXP POR,SUP-2353372,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
BLADE RTRCTR SHRT TEETH 15MMW X 25MML SPNL SELF RTNNG BLACK,SUP-2668375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,773.95,503.07,,,,,,,,,,,,,
WIRE EXT FIX HALF 1.8X400 MM SMOOTH,SUP-2749888,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
HC Transesophageal Echo,PX-4809331300,CDM,93313,CPT,0480,RC,,,,outpatient,,,3039.00,1975.35,,,,,,,,,,,,,
RASP DISTAL SMART TOE,SUP-2495619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.89,384.73,,,,,,,,,,,,,
PLATE BNE 3.5X76 MM CLAV RT 6 HOLE SHFT TI LOQTEQ,SUP-2431898,CDM,C1713,HCPCS,0278,RC,,,,both,,,4678.60,3041.09,,,,,,,,,,,,,
GUIDEWIRE ORTH L300MM DIA2.8MM S STL TRCR TIP FOR MIDFOOT,SUP-2185083,CDM,C1769,HCPCS,0272,RC,,,,both,,,99.91,64.94,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 0.018 INX260 CM 3 CM X SUPP RDRUN,SUP-2738312,CDM,C1729,HCPCS,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
SPLINT ARM M L13IN FOR 5 17IN ARM POLY FAB MP MACH WSH,SUP-2274801,CDM,L3809,HCPCS,0272,RC,,,,both,,,29.99,19.49,,,,,,,,,,,,,
SCREW BNE FIX 4.3X55 MM QWIX,SUP-2242837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.01,707.21,,,,,,,,,,,,,
IMPLANT OSS L5.5MM DIA1.14MM HA CAP FULL CANN CONSERVATIVE,SUP-2313680,CDM,L8613,CPT,0278,RC,,,,both,,,915.18,594.87,,,,,,,,,,,,,
ANCHOR SUT SZ 2 DIA5MM ABSRB ETHBND MINI FASTIN RC,SUP-2249446,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
IMPLANT SYNDESMOTIC SCREW L 47 MM DIA 4.2 MM NOTCH 14 MM,SUP-2899006,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GRAFT HUM TISS HAMSTRING 50R503] ZIMMER BIOMET INC],SUP-2208435,CDM,C1762,CPT,0278,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
SCREW BNE FT 4.5X72 MM CANN W/ LG HEX SOCKET SD ST TI NS,SUP-2190452,CDM,C1713,HCPCS,0278,RC,,,,both,,,557.38,362.30,,,,,,,,,,,,,
CAGE SPNL LORDTC 7 DEG LG 36X24X16 MM ENDOSKELETON TAS,SUP-2431464,CDM,C1889,HCPCS,0278,RC,,,,both,,,23236.00,15103.40,,,,,,,,,,,,,
BIT DRL DIA4.0MM LNG HUM AO DISP SURESHOT,SUP-2340921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1324.92,861.20,,,,,,,,,,,,,
GRAFT MTRX DEMIN DEMIN BONE PUTTY ALLGRFT ALLOGENIX 10CC,SUP-2402967,CDM,C1713,HCPCS,0278,RC,,,,both,,,4085.14,2655.34,,,,,,,,,,,,,
"HC So Enterovirus,Amplified Probe",PX-3068749866,CDM,87498,CPT,0306,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
ADAPTER ORTHOPEDIC TORQUE LIMITING PEAK FX,SUP-2472725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3607.86,2345.11,,,,,,,,,,,,,
PLATE BONE L 2X2 H BX FOR 1.5MM CRAN FIX UNIV NEURO III SYS,SUP-2363626,CDM,C1713,HCPCS,0278,RC,,,,both,,,966.71,628.36,,,,,,,,,,,,,
PLATE BONE W17.5XL178MM THK5.2MM 10 H TI BROAD LIMIT CNTCT,SUP-2190848,CDM,C1713,HCPCS,0278,RC,,,,both,,,999.84,649.90,,,,,,,,,,,,,
PLATE BONE LT CALCNL FX TUBEROSITY BTTRS SINUS TARSI APPRCH,SUP-2321445,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
SCREW BONE L85MM DIA6.5MM THRD L20MM CANN GUID ASNS 2,SUP-2362438,CDM,C1713,HCPCS,0278,RC,,,,both,,,588.75,382.69,,,,,,,,,,,,,
SPHERE EMB 900-1200UM 20ML SYR PUR TRISACRYL GEL RND PREFIL,SUP-2303392,CDM,C1889,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
ADAPTER TUBING DUAL VALVE Y CHECK VALUE OPTISTAR ELITE,SUP-2427451,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
PLATE BNE SM L97MM THK1MM 6 H BILAT S STL 1/3 TBLR NEUT DYN,SUP-2185847,CDM,C1713,HCPCS,0278,RC,,,,both,,,3701.31,2405.85,,,,,,,,,,,,,
SCREW BONE CANNULATED 6.5X105 MM ANKLE PROXIMAL FEMORAL PART,SUP-2837562,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.79,898.81,,,,,,,,,,,,,
HC Rem Int Ureteral Stent,PX-3615038400,CDM,50384,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
STENT BILI ST-2 SOEH TANNENBAUM L 5 CM DIA10 FR ENDOSCP,SUP-2738114,CDM,C2625,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 100 CM DIA 9 FR BALLOON L 20 MM DIA 3,SUP-2140991,CDM,C1725,HCPCS,0272,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CALF CUST SLD STIRRUP,SUP-2435630,CDM,L1980,HCPCS,0272,RC,,,,both,,,1143.12,743.03,,,,,,,,,,,,,
SET IMPL GRPHC CA FOR 4.5MM PROX FEM LCK COMPR PLT,SUP-2183066,CDM,C1713,HCPCS,0278,RC,,,,both,,,74523.50,48440.27,,,,,,,,,,,,,
COIL VASC HILAL MICROCOIL EMBOLUS L 1 CM CATH 0.018 IN,SUP-2638567,CDM,C1889,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
BRACE KNEE SM FOR 15-18IN LT PAT PREFABRICATED AIRTECH FRME,SUP-2151021,CDM,L3660,HCPCS,0274,RC,,,,both,,,931.29,605.34,,,,,,,,,,,,,
PLATE EXT FIX DIA160MM ANK FT FOR TRUELOK FRME ASSEMB,SUP-2316191,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1725.46,1121.55,,,,,,,,,,,,,
STEM FEM L200MM OD10MM TIB KNEE CEM SPLINED BOW CVD IMP,SUP-2405527,CDM,C1776,CPT,0278,RC,,,,both,,,4556.14,2961.49,,,,,,,,,,,,,
BLADE SURG 50MM ACET REV SYS EZOUT,SUP-2365135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 12H TI STRL,SUP-2546933,CDM,C1713,HCPCS,0278,RC,,,,both,,,2511.50,1632.47,,,,,,,,,,,,,
BIT DRL KNOTLESS 4.75 MM LINK ANCHR STRL VENTIX DISP,SUP-2608607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.12,288.03,,,,,,,,,,,,,
LOCK SFS 27/40 NL CADDY LIDS,SUP-2724038,CDM,C1725,HCPCS,0272,RC,,,,both,,,1144.91,744.19,,,,,,,,,,,,,
CATHETER EP DIAG MAP L CRV QPLR 2-5-2MM SPC 5MM TIP BI DIR,SUP-2357032,CDM,C1733,HCPCS,0272,RC,,,,both,,,2647.02,1720.56,,,,,,,,,,,,,
CATHETER IV NEOMAGIC L 8 CM DIA1.9 FR SIL PICC 1 LUMEN EPIV,SUP-2874832,CDM,C1751,HCPCS,0278,RC,,,,both,,,91.53,59.49,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM LG CP TI RT MANDIBULAR HEMI,SUP-2883706,CDM,C1713,HCPCS,0278,RC,,,,both,,,14994.88,9746.67,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.5MM TI ALUM NIOBIUM ALLY FULL THRD,SUP-2180222,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.39,478.65,,,,,,,,,,,,,
CATHETER GUID HEARTRAIL III L 100 CM DIA 6 FR 700 PSI IL4,SUP-2384861,CDM,C1887,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
KAWAMOTO MIDFACE DIST CVD30MM4X4 MESH,SUP-2679181,CDM,C1713,HCPCS,0278,RC,,,,both,,,18810.36,12226.73,,,,,,,,,,,,,
HC So Nuclear Antigen Antibody,PX-3028623566,CDM,86235,CPT,0302,RC,,,,both,,,71.00,46.15,,,,,,,,,,,,,
CAGE SPNL 10X27X10MM LUM PARA PEEK VISTA P,SUP-2414321,CDM,C1889,HCPCS,0278,RC,,,,both,,,9923.97,6450.58,,,,,,,,,,,,,
BIT DRILL 2.0MM SYNTHES 323.002,SUP-2855403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.66,264.33,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE MED 5.4 CC CORTICOCANCELLOUS VIABLE 002,SUP-2936804,CDM,C1762,CPT,0278,RC,,,,both,,,6837.00,4444.05,,,,,,,,,,,,,
CAGE HUM STEMLESS 1 EQUINOXE,SUP-2606121,CDM,C1889,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
PLATE BNE L17MM 3 H S STL STR FOR 2MM SCR MINI FRAG SYS,SUP-2411311,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.75,110.34,,,,,,,,,,,,,
STEM HUM L83MM DIA15MM MINI UNIV CO CHROM POR PRI PRESSFIT,SUP-2404568,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SCREW BNE STYLOID 2X28 MM ST HI ANGLE T5 DRV,SUP-2466651,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.59,101.78,,,,,,,,,,,,,
IMPLANT SYNTH 13 X 38 MM THK 6 MM POLYETHYL CRANIOFACIAL,SUP-2883239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1820.95,1183.62,,,,,,,,,,,,,
IMMOBILIZER ORTH M TIETEX SHLDR,SUP-2195526,CDM,L3650,HCPCS,0272,RC,,,,both,,,11.43,7.43,,,,,,,,,,,,,
CLAMP SURG VASOVASOSTOMY SET SILBER,SUP-2160639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,896.69,582.85,,,,,,,,,,,,,
CHOLANGIOGRAM KIT 450 CM AUTOTOME RX 44 SPHINTOM JAGWIRE,SUP-2525312,CDM,C1769,HCPCS,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
DRESSING BIO 500 MG TYP I/III BOV CLLGN MTRX FIBRILLAR SHLF,SUP-2905505,CDM,C1763,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
KIT TKR THK4MM KNEE POLY BUSHING REPL MOST OPTIONS,SUP-2208390,CDM,C1776,CPT,0278,RC,,,,both,,,14525.64,9441.67,,,,,,,,,,,,,
PLATE SPNL W26XL43MM ANT THORLUM GRN TI LOK LO PROF FOR 55MM,SUP-2193111,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
GRAFT DURA W2XL2IN ULTRAPURE DURAGN+ 5PK/EA,SUP-2244011,CDM,C1713,HCPCS,0278,RC,,,,both,,,5792.42,3765.07,,,,,,,,,,,,,
KIT FIX ACL FEM ABSRB SL INTLOK TRCR FOR 2.7MM BNE TEND BNE,SUP-2249324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.44,706.19,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC OSTEOSURGE 300C,SUP-2644325,CDM,C1713,HCPCS,0278,RC,,,,both,,,3560.76,2314.49,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD,SUP-2248516,CDM,C1732,HCPCS,0278,RC,,,,both,,,6669.36,4335.08,,,,,,,,,,,,,
POST FIX DIA75MM TAPR CAPITATE,SUP-2123591,CDM,C1776,CPT,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
IMPLANT PENILE 18 CM CYL 21 MM INFL HYDROPHILLIC TI,SUP-2300755,CDM,C1813,HCPCS,0278,RC,,,,both,,,21552.96,14009.42,,,,,,,,,,,,,
CLAMP ROD CLP FOR ORTHOFIX PREFIX FIX,SUP-2316286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.33,589.11,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 50 CM DIA 7 MM EPTFE STR STD WALL REINF,SUP-2479793,CDM,C1768,CPT,0278,RC,,,,both,,,3298.51,2144.03,,,,,,,,,,,,,
SCREW BONE LG EZ,SUP-2720254,CDM,C1713,HCPCS,0278,RC,,,,both,,,1542.09,1002.36,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X8X8 MM FUSIONFLEX,SUP-2759441,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.67,898.74,,,,,,,,,,,,,
COMPONENT FEM L4CM KNEE TI DPHSEAL SEG OSS,SUP-2405833,CDM,C1776,CPT,0278,RC,,,,both,,,15288.66,9937.63,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ULTRATRACK HYBRID L 150 CM DIA 0.035 IN,SUP-2539336,CDM,C1769,HCPCS,0272,RC,,,,both,,,124.63,81.01,,,,,,,,,,,,,
Z ON EXTENDED BACKORDER VALVE CHST DRN 30ML W/ 30ML COLL PNEUMOSTAT,SUP-2227348,CDM,C1729,HCPCS,0272,RC,,,,both,,,108.93,70.80,,,,,,,,,,,,,
GRAFT BNE SUB 2.5ML HA SYN TISS CLLGN MTRX STRP RESRB,SUP-2255625,CDM,C9362,HCPCS,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
SCREW BONE L130MM OD7MM THRD L33MM PUR HINDFOOT ANK CANN LNG,SUP-2320958,CDM,C1713,HCPCS,0278,RC,,,,both,,,2787.06,1811.59,,,,,,,,,,,,,
EXTRACTOR STONE 12FR L38CM NIT COR HYDRPHLC TIPLSS PERC,SUP-2171357,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.71,453.51,,,,,,,,,,,,,
COIL FIL COMPLX SFT .020IN W DIA 15MM SEC DIA 45CM PENUMBRA,SUP-2323419,CDM,C1889,HCPCS,0278,RC,,,,both,,,8233.08,5351.50,,,,,,,,,,,,,
CLAMP ROD TO ROD SPNL 5.5MM TO 5.5MM 18MM WID,SUP-2230104,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
TIP ASPIR CLAW MIC 1.6X2 MM 18 CM APEX SONOPET IQ,SUP-2791057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3557.46,2312.35,,,,,,,,,,,,,
CATHETER THROMCTMY 4MAX L 139 CM PROX/DSTL OD 6,SUP-2323544,CDM,C1725,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
CLIP ANEUR CO CHROM ALLOY SLGHT BENT STD TYP 1/1MM OPN W,SUP-2306030,CDM,C1889,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
WASHER EXT FIX OD14MM ID7MM THK2MM SPC FOR ILIZ TAY SPAT,SUP-2342313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1291.17,839.26,,,,,,,,,,,,,
MESH SURG W6XL10IN OVL W/ ECHO PS POS SYS FOR LAP VENTRAL,SUP-2125916,CDM,C1781,HCPCS,0278,RC,,,,both,,,3881.04,2522.68,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY 2 DR TI 2 CHMBR STD 2 LD BPLR,SUP-2149080,CDM,C1721,HCPCS,0275,RC,,,,both,,,53223.00,34594.95,,,,,,,,,,,,,
CATHETER GUID WALRUS L 95 CM DIA 8 FR BALLOON DIA11.1 MM,SUP-2719537,CDM,C1887,HCPCS,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
HC X-Ray Exam Chest 2 Views,PX-3247104600,CDM,71046,CPT,0324,RC,,,,both,,,718.00,466.70,,,,,,,,,,,,,
BASKET SPEC RETRV EXTRACTION 0.035 IN 2X4 CM 8 FR DL MEM II,SUP-2737549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
TRAB METAL TIB CONE SZ 48-15MM FULL XSMALL,SUP-2502270,CDM,C1776,CPT,0278,RC,,,,both,,,10198.72,6629.17,,,,,,,,,,,,,
EPIFIX 2X4CM 8SQ CM,SUP-2305751,CDM,Q4186,HCPCS,0636,RC,,,,both,,,4571.84,2971.70,,,,,,,,,,,,,
PROSTHESIS OSS 141402ENT,SUP-2648903,CDM,L8613,CPT,0278,RC,,,,both,,,440.07,286.05,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED MOD PRIMARY APEX,SUP-2400116,CDM,C1776,CPT,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
PROVOX VEGA VOICE PROS IS AN INDWL LO RESISTANCE VOICE PROS,SUP-2124400,CDM,L8509,HCPCS,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
ELECTRODE CORTICAL 4 X 4 KT STRL DISP EVO,SUP-2934685,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
TISSEEL VHSD 2 ML KT,SUP-2130318,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
HC Leukaphoresis,PX-7613651100,CDM,36511,CPT,0761,RC,,,,outpatient,,,4768.00,3099.20,,,,,,,,,,,,,
FENTANYL 0.05 MG/ML SOLN (MIXTURES ONLY),RX-430015,CDM,J3010,HCPCS,0636,RC,00409-9094-22,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL L270MM DIA4MM CALIB L95MM 3 FLUT QUIK CPL,SUP-2188199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.87,500.42,,,,,,,,,,,,,
BIT DRILL AO T2 35X130MM,SUP-2701869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,529.88,344.42,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 13 HOLES,SUP-2549476,CDM,C1713,HCPCS,0278,RC,,,,both,,,3025.04,1966.28,,,,,,,,,,,,,
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG PO TABS,RX-141307,CDM,6370000000,HCPCS,0637,RC,61958-2501-03,NDC,,both,1,UN,632.50,411.12,,,,,,,,,,,,,
METFORMIN HCL ER 750 MG PO TB24,RX-35771,CDM,6370000000,HCPCS,0637,RC,70010-0492-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DRILL TWST 1.5X27X16MM,SUP-2364182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.62,437.20,,,,,,,,,,,,,
GUIDEWIRE VASC TEFCOR L 145 CM DIA 0.038 IN TAPR L 15 CM CRV,SUP-2167807,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.07,35.15,,,,,,,,,,,,,
VALVE AORT ON-X TISS ANNULUS 21 MM ORIFICE 19.4 MM CONFORM-X,SUP-2175255,CDM,C1889,HCPCS,0278,RC,,,,both,,,15696.86,10202.96,,,,,,,,,,,,,
BLOCK I/B II CCK AUG 59X15MM DIST,SUP-2205970,CDM,C1776,CPT,0278,RC,,,,both,,,7051.18,4583.27,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 THK10MM KNEE FULL STP HNG REV LEGION,SUP-2346600,CDM,C1776,CPT,0278,RC,,,,both,,,5695.96,3702.37,,,,,,,,,,,,,
COMPONENT PAT STANDARD+ POLYETH NP CEM 3 PEG RND REV,SUP-2251248,CDM,C1776,CPT,0278,RC,,,,both,,,2122.64,1379.72,,,,,,,,,,,,,
CATHETER VENTRICULAR W/ FEMALE LUER LCK CONN TRANSPARENT,SUP-2666384,CDM,C1729,HCPCS,0272,RC,,,,both,,,979.81,636.88,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 6 MM EPTFE STR STD WALL,SUP-2681080,CDM,C1768,CPT,0278,RC,,,,both,,,356.30,231.59,,,,,,,,,,,,,
HC US OB 1st Tr Fetal Tran Ea Add,PX-4027681400,CDM,76814,CPT,0402,RC,,,,both,,,519.00,337.35,,,,,,,,,,,,,
UB IMA RETRACTOR BLADE,SUP-2674216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.00,752.70,,,,,,,,,,,,,
NAIL IM L300MM DIA10MM THK1.5MM 1.5M CURVATURE RAD UNIV,SUP-2186413,CDM,C1713,HCPCS,0278,RC,,,,both,,,3741.00,2431.65,,,,,,,,,,,,,
ROD TOP LD 20-25 OFFSET SPC 5.5MM,SUP-2205149,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA SOLENT PROXI L 90 CM DIA 6,SUP-2142038,CDM,C1757,HCPCS,0272,RC,,,,both,,,13140.90,8541.58,,,,,,,,,,,,,
SCREW BNE COMPR 3.5 MM SS KREULOCK,SUP-2845740,CDM,C1713,HCPCS,0278,RC,,,,both,,,8399.50,5459.67,,,,,,,,,,,,,
CONE TIB SM H20MM CNTR 3DMETAL,SUP-2267615,CDM,C1776,CPT,0278,RC,,,,both,,,12385.73,8050.72,,,,,,,,,,,,,
DEVICE NEUROSURGICAL SET VERIF PROGAV CHECKMATE,SUP-2108719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1720.47,1118.31,,,,,,,,,,,,,
BLADE SHV L11CM DIA2.9MM STR NONROTATABLE SHFT IRRIG TBNG,SUP-2284127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,749.08,486.90,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ SUP COR L 300 CM DIA 0.035 IN,SUP-2103530,CDM,C1769,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX XSMALL 7X10 CM PLASTIC MATRISTEM,SUP-2106510,CDM,Q4166,HCPCS,0636,RC,,,,both,,,6508.28,4230.38,,,,,,,,,,,,,
HC Inj Aa&/Strd Nerves Nrvtg Si Joint W/Img,PX-3616445100,CDM,64451,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW BONE L10MM DIA4MM STD CANC S STL FULL THRD HEX HD,SUP-2344113,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.27,134.73,,,,,,,,,,,,,
SET LD EXTRACTION EVOLUTION SHORTIE L 13.6 CM OD 17 FR ID 11,SUP-2170681,CDM,C1773,HCPCS,0272,RC,,,,both,,,2734.03,1777.12,,,,,,,,,,,,,
HC Treatment Devices Simple,PX-3337733200,CDM,77332,CPT,0333,RC,,,,both,,,1161.00,754.65,,,,,,,,,,,,,
RING ACET TI PLSM SPRY HIP GRP 1 CONSTRN LCK COMPHSVE SYS,SUP-2222480,CDM,C1713,HCPCS,0278,RC,,,,both,,,2501.32,1625.86,,,,,,,,,,,,,
GRAFT BNE GEL 1 CC DBM GRFT,SUP-2306988,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
WIRE FIX SMOOTH 400 MM KIRSCHNER,SUP-2162649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
SCREW BNE FIX 87341008] ZIMMER BIOMET INC],SUP-2137137,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER PTCA L143CM BLLN L8MM DIA3.25MM 18ATM COR,SUP-2105045,CDM,C1725,HCPCS,0272,RC,,,,both,,,2033.12,1321.53,,,,,,,,,,,,,
APPLICATOR ELECSURG 35 MM RIGID PLASMA COAG FILTER NDL AR,SUP-2762596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.60,375.44,,,,,,,,,,,,,
HC Biopsy Endomyocardial,PX-4819350500,CDM,93505,CPT,0481,RC,,,,both,,,902.00,586.30,,,,,,,,,,,,,
GRAFT DURA L 1 X W 3 IN THK 0.3 MM TYP I CLLGN BOV ACHILLES,SUP-2889753,CDM,C1763,HCPCS,0278,RC,,,,both,,,1373.72,892.92,,,,,,,,,,,,,
CLOSURE TOP2102-2,SUP-2415298,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
CLIP ANEURYSM L5MM 2.3MM OPENING PHYNOX VASCULAR CURVED AVM,SUP-2825391,CDM,C1889,HCPCS,0278,RC,,,,both,,,745.62,484.65,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10CM 6MM 120CM 6FR RADIOPAQUE,SUP-2396647,CDM,C1874,HCPCS,0278,RC,,,,both,,,11818.96,7682.32,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT FRZN ASEP HEMI PATELLAR TEND,SUP-2867218,CDM,C1762,CPT,0278,RC,,,,both,,,9292.05,6039.83,,,,,,,,,,,,,
PLATE BNE SHT BRL 130 DEG 4.5X126 MM 25 MM 6 HOLE LCK STRL,SUP-2186825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1882.68,1223.74,,,,,,,,,,,,,
BLADE SAW T HNDL 10 MM AO CONN FOR MANUAL BNE HARV,SUP-2415426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PROTECTOR NRV L20MM DIA7MM PORCINE EXTRACELLULAR MTRX WRP,SUP-2124860,CDM,C1763,HCPCS,0278,RC,,,,both,,,7887.68,5126.99,,,,,,,,,,,,,
FILTER KT ART 2 CANN AND 2 M 11IN OVERALL LEN EMBOL-X GLDE,SUP-2214495,CDM,C1884,HCPCS,0278,RC,,,,both,,,1507.42,979.82,,,,,,,,,,,,,
HC So Antidepressant Tricyclic 1/2,PX-3018033566,CDM,G0480,CPT,0301,RC,,,,outpatient,,,380.00,247.00,,,,,,,,,,,,,
CARDIOPLEGIC PF SOLN,RX-30275,CDM,2500000003,HCPCS,0250,RC,00409-7969-05,NDC,,both,1000,ML,488.80,317.72,,,,,,,,,,,,,
ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP,RX-353,CDM,340b,HCPCS,0637,RC,09999-9902-57,NDC,,both,5,ML,0.40,0.26,,,,,,,,,,,,,
STIMULATOR BONE GROWTH SPINALOGIC,SUP-2196349,CDM,2780000010,LOCAL,0278,RC,,,,both,,,9435.70,6133.20,,,,,,,,,,,,,
SPLINT ANK FT 3-6 SM ORTHOSIS AD UNISX WMN SHOE R STRP CLSR,SUP-2326061,CDM,L4350,HCPCS,0274,RC,,,,both,,,123.59,80.33,,,,,,,,,,,,,
CUP ACET DIA48MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH,SUP-2250729,CDM,C1776,CPT,0278,RC,,,,both,,,6864.04,4461.63,,,,,,,,,,,,,
PIN BNE FIX LAT TEMP,SUP-2884722,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BIT DRL DIA1MM STRYKR J LATCH FOR MOD HND SYS,SUP-2187627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,273.78,177.96,,,,,,,,,,,,,
CATHETER DRNGE 14FR BILI LUERLOCK ADPT,SUP-2134679,CDM,C1876,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 23 CM DIA 8 FR GUIDEWIRE 0.038 IN,SUP-2355577,CDM,C1894,HCPCS,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
CABLE SPNL FLAT BAR ATLS 2PK,SUP-2289638,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
PLATE BNE W5XL27MM THK1MM 5 H BILAT TI STR RIG NEUT DYN,SUP-2191042,CDM,C1713,HCPCS,0278,RC,,,,both,,,733.10,476.51,,,,,,,,,,,,,
PLATE BNE STR NEURO 16 HOLE LP TI PUR STRL LEVEL 1,SUP-2491533,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.99,444.59,,,,,,,,,,,,,
SPHERE GLEN TI ECCENTER DSGN SHLDR EPOCA,SUP-2193867,CDM,C1776,CPT,0278,RC,,,,both,,,1868.36,1214.43,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY POLARIS X 270 DEG L 106 CM DIA 6,SUP-2652866,CDM,C1732,HCPCS,0272,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
TRAY PICC ARROW TAPERFREE MAX BARRIER MIDLINE 4FR 20CM 1-LUM,SUP-2887105,CDM,C1751,HCPCS,0278,RC,,,,both,,,425.16,276.35,,,,,,,,,,,,,
IMPLANT OSS L7.9MM HD DIA3X4MM SHFT DIA0.8MM 1.17MM HA HD,SUP-2312820,CDM,L8613,CPT,0278,RC,,,,both,,,1167.08,758.60,,,,,,,,,,,,,
FIBER LASER OD200UM HOLM SIDE FIRING DISP SLM LN VERSAPULSE,SUP-2141788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3800.97,2470.63,,,,,,,,,,,,,
SPLINT ORTH M WRST FA HND R FRAC FIRM SUPP ALUMINUM POLY,SUP-2276769,CDM,L3809,HCPCS,0274,RC,,,,both,,,14.48,9.41,,,,,,,,,,,,,
PIN EXT FIX HALF 5X35 MM 160 MM SD SHANK,SUP-2749884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
SCREW BONE 100X130MM LAG PEAK FX,SUP-2137044,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 6 MM EPTFE FLX TW RING HEMO,SUP-2128209,CDM,C1768,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Uni Niv Arterial Low Ext Duplex,PX-9219392600,CDM,93926,CPT,0921,RC,,,,both,,,1471.00,956.15,,,,,,,,,,,,,
POST AUG BLK SZ 1 5MM,SUP-2220859,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.025IN STD NIT HYDRPHLC STR TIP,SUP-2139329,CDM,C1769,HCPCS,0272,RC,,,,both,,,126.67,82.34,,,,,,,,,,,,,
HC So Hiv-2 Rna,PX-3068753867,CDM,87538,CPT,0306,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
BIT DRL L 280 MM DIA 4.5 MM COUNTERBORE MANUAL NS DISP,SUP-2902466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,848.30,551.39,,,,,,,,,,,,,
KIT INFLATION DEV PRIORITY PK INFLATED 20 ATM VLV ID 0.096,SUP-2103551,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
COMPONENT PAT RECESS ADV 28 MM MTL BK,SUP-2400119,CDM,C1776,CPT,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
SCREW BONE L95MM DIA5MM CANN CONCL HD,SUP-2184932,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
AGENT HEMSTAT W4XL4IN OXIDIZED REGENERATED CELOS ABSRB SFT,SUP-2218197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.93,233.30,,,,,,,,,,,,,
STEM HUM L200MM DIA8MM 135DEG LNG STD SHLDR TI ARTHROPLASTY,SUP-2250042,CDM,C1776,CPT,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IFORIA DX TI EPOXY RESIN SIL HYBRID MR,SUP-2138445,CDM,C1722,HCPCS,0275,RC,,,,both,,,54008.00,35105.20,,,,,,,,,,,,,
RT IB TIGHTROPE W FLIPCUTTER III DRILL,SUP-2811642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
HC Repair Liphc Repair Lip Full Thickness Vermilion Only,PX-4504065000,CDM,40650,CPT,0450,RC,,,,both,,,1526.00,991.90,,,,,,,,,,,,,
SCREW SPACER CROSS DRV TI,SUP-2496969,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.93,181.30,,,,,,,,,,,,,
VALVE VENT L32MM DIA18MM THK7.5MM LO PRSS CNTOUR REG FOR,SUP-2284509,CDM,C1889,HCPCS,0278,RC,,,,both,,,2083.30,1354.14,,,,,,,,,,,,,
SCREW ACET SPACER TIB,SUP-2449296,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
INTRODUCER HEMSTAS 20FR L30CM 0.035IN VLV SIDEPRT 2 TAPR DIL,SUP-2355621,CDM,C1894,HCPCS,0272,RC,,,,both,,,162.50,105.62,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO L 135 CM 6/6FR 0.014-0.038IN SEP 6,SUP-2323573,CDM,C1757,HCPCS,0272,RC,,,,both,,,5620.60,3653.39,,,,,,,,,,,,,
DEFIBRILLATOR PECTORAL 2 CHMBR BPLR RENEWAL,SUP-2236368,CDM,C1882,HCPCS,0275,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
BLADE SAGITTAL SAW 19.5MM X 50.0MM 5400-003-254S1,SUP-2844702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.17,213.96,,,,,,,,,,,,,
K WIRE FIX L200MM DIA2.5MM THRD L15MM TRCR PNT FOR TOMOFIX,SUP-2186905,CDM,C1713,HCPCS,0278,RC,,,,both,,,523.91,340.54,,,,,,,,,,,,,
CROSSLINK SPNL FIX PLATE 4.5X22 MM SS SHILLA,SUP-2630563,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
BIT DRL DIA4MM LNG S STL PILOT QUIK CONN FOR TRIGEN AG IM,SUP-2347046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.55,1061.16,,,,,,,,,,,,,
HC GI Endoscopic US S&I,PX-4027697500,CDM,76975,CPT,0402,RC,,,,both,,,269.00,174.85,,,,,,,,,,,,,
CAGE SPNL W9.5XH10XL22MM TI LORDTC LUM TIRBOLOX-L LUM,SUP-2152429,CDM,C1889,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
TRAY TIB SZ 2.5F/1.5T CEM OPTETRAK LOGIC,SUP-2220928,CDM,C1776,CPT,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
BUR SURG OD3MM SHANK L13CM LILAC COARSE DMND MTCH HD MIS,SUP-2365192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.16,382.95,,,,,,,,,,,,,
PLATE BNE L 100 DEG STD 1.7X12X0.55 MM RT 6 HOLE ADV BAR,SUP-2366249,CDM,C1713,HCPCS,0278,RC,,,,both,,,677.64,440.47,,,,,,,,,,,,,
GRAFT BNE L40MM OD2MM CORT FRZ DRY PIN IMPL ALLOFIX,SUP-2307226,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.37,522.19,,,,,,,,,,,,,
BOOT EQL BLK XL EA,SUP-2319312,CDM,L4360,HCPCS,0272,RC,,,,both,,,72.97,47.43,,,,,,,,,,,,,
CAPITATED KNEE UNI GENS ON-LAYCAPITATED PRICING,SUP-2347980,CDM,C1776,CPT,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 50 MM DIA 9 MM CATH TOT L 116 CM,SUP-2141195,CDM,C1874,HCPCS,0278,RC,,,,both,,,6446.42,4190.17,,,,,,,,,,,,,
SHEATH UROLOGY OD21FR ORNG CYSTOURETHROSCOPE USA ELITE SYS,SUP-2313053,CDM,C1894,HCPCS,0272,RC,,,,both,,,2331.51,1515.48,,,,,,,,,,,,,
PROSTHESIS OSS EAR 0.6X4 MM,SUP-2312491,CDM,L8613,CPT,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
CUTTER SUT SER 1 STR FIBERTAPE,SUP-2121026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
GRAFT BONE SUB 5CC VOID FIL OSTEOCRETE,SUP-2138671,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
PLATE BNE LCK 2.7 MM 5 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2459176,CDM,C1713,HCPCS,0278,RC,,,,both,,,827.96,538.17,,,,,,,,,,,,,
PLATE BNE L42MM 2X4 H R TI OBLQ L SHP LO PROF RIG NEUT LOK,SUP-2191460,CDM,C1713,HCPCS,0278,RC,,,,both,,,1172.13,761.88,,,,,,,,,,,,,
STENT PERIPH ABRE L 100 MM DIA10 MM CATH WORKING L 90 CM,SUP-2665373,CDM,C1876,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
SCREW INTFR L28MM DIA10MM KNEE PLLA CANN ABSRB THRD WDG,SUP-2366624,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SCREW BNE COMPR 3-4.3 MM MULTI-USE CHARLOTTE,SUP-2397725,CDM,C1713,HCPCS,0278,RC,,,,both,,,105774.04,68753.13,,,,,,,,,,,,,
SCREW INTFR L20MM OD8MM TTNM ACL CNNLTD BLUNT THRDD NNBSRBBL,SUP-2589300,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.31,203.65,,,,,,,,,,,,,
HEAD FEM UPLR 40 MM HIP FOR ADPT,SUP-2207898,CDM,C1776,CPT,0278,RC,,,,both,,,1127.57,732.92,,,,,,,,,,,,,
CAP L HIP VIT E LNR CERCAP PRICING,SUP-2212078,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
EVOS 3.5 MM 1/3 TUBULAR PL 7H 82MM,SUP-2820015,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.02,346.46,,,,,,,,,,,,,
MESH SURG L9MM OD16MM MET RND MP PYRAMESH,SUP-2292070,CDM,C1713,HCPCS,0278,RC,,,,both,,,3176.30,2064.59,,,,,,,,,,,,,
STEM FEM L225MM DIA11MM KNEE STR CEM OSS,SUP-2405840,CDM,C1776,CPT,0278,RC,,,,both,,,4761.81,3095.18,,,,,,,,,,,,,
PIN BNE FIX L 60 MM DIA 3.5 MM LG TARGETER PROV COMPR STRL,SUP-2931376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.03,666.92,,,,,,,,,,,,,
LINER ACET OD52MM ID28MM 0DEG +4MM HIP MARTHN LAT NEUT PINN,SUP-2250527,CDM,C1776,CPT,0278,RC,,,,both,,,5124.48,3330.91,,,,,,,,,,,,,
CATHETER ABLATN LG CRV 8 MM 2-5-2 MM 7 FRX110 CM SAFIRE TX,SUP-2357038,CDM,C1733,HCPCS,0272,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
PLATE BNE L217MM 12 H NONSTERILE L PROX TIB S STL,SUP-2185705,CDM,C1713,HCPCS,0278,RC,,,,both,,,3819.46,2482.65,,,,,,,,,,,,,
IMPLANT OTO L8MM SHFT DIA0.8MM HA PLASTIPORE GBERG,SUP-2312579,CDM,L8613,CPT,0278,RC,,,,both,,,1078.59,701.08,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309711000,CDM,97110,CPT,0430,RC,,,GP|CQ|XU,both,,,195.00,126.75,,,,,,,,,,,,,
HC I&D Pilonidal Cyst Simple,PX-4501008000,CDM,10080,CPT,0450,RC,,,,both,,,1458.00,947.70,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD KT LNG TERM ACC TWO LUMN 15FRX50CM,SUP-2120630,CDM,C1750,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
SPACER NSL FRONTAL SINUS 14MM CATH W/ PRECIS FRM MICPOR,SUP-2106332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PLATE BNE TBLR 100 DEG 2 HOLE STRL LTX,SUP-2861627,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.67,176.59,,,,,,,,,,,,,
COMPONENT ARTC 2.5X3MM OFFSET PATELLOFEMORAL HEMICAP,SUP-2123660,CDM,C1776,CPT,0278,RC,,,,both,,,14942.32,9712.51,,,,,,,,,,,,,
DISSECTOR ELECTROCAUTERY L 220 CM NDL L 1.5 MM CHANNEL,SUP-2881885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
"HC Est Pt, E/M Level 5",PX-5109921500,CDM,99215,CPT,0510,RC,,,,outpatient,,,369.00,239.85,,,,,,,,,,,,,
STEM TIB L150MM DIA14MM KNEE EXTN STABILIZING PRI FLUT,SUP-2253323,CDM,C1713,HCPCS,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 25 CM DIA 6 FR DIL PROTRUDING,SUP-2385641,CDM,C1894,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
MEXILETINE HCL 200 MG PO CAPS,RX-10596,CDM,6370000000,HCPCS,0637,RC,62559-0821-01,NDC,,both,1,UN,3.50,2.27,,,,,,,,,,,,,
KINECTIV MODULAR NECK G1,SUP-2504379,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
ELECTRODE ES 90DEG SUCT INTEGR HNDPC DISP COOLPULSE 90 VAPR,SUP-2249483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
KIT SUTURE ANCHR L 15 MM DIA 4.5 MM PEEK KNOTLESS TENSIONING,SUP-2899054,CDM,C1713,HCPCS,0278,RC,,,,both,,,1424.78,926.11,,,,,,,,,,,,,
CATHETER DRAINAGE TY 7 FRX15 CM PLEURAL SELD PGTL FURMAN,SUP-2759778,CDM,C1729,HCPCS,0272,RC,,,,both,,,536.12,348.48,,,,,,,,,,,,,
HC Immunofixj Electrophoresis Other Fluids,PX-3028633500,CDM,86335,CPT,0302,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
PIN FIX EXCHANGE 500 MM SI-LUTION,SUP-2872547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PROSTHESIS LARYN 10MM LO AIRFLO RESISTANCE EZ MAINT FOR,SUP-2124339,CDM,L8509,HCPCS,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
PLATE BONE L85MM 4 H S STL LCK COMPR FOR 4.5MM SCR PERI-LOC,SUP-2348940,CDM,C1713,HCPCS,0278,RC,,,,both,,,3152.40,2049.06,,,,,,,,,,,,,
STEM FEM L125MM OD12MM TI HA POR PROX KNEE STR PRESSFIT,SUP-2376525,CDM,C1776,CPT,0278,RC,,,,both,,,10953.58,7119.83,,,,,,,,,,,,,
SCREW BONE L11MM DIA2MM LCK CROSSDRIVE TI THREADLOCK TS,SUP-2262834,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.28,234.18,,,,,,,,,,,,,
ACET RECONSTRUCTION ROOF RING 64MM OD X60MM ID,SUP-2504603,CDM,C1776,CPT,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
STAPLER INT L L28MM DIA5MM GI BLU TI BARIATRIC CIR CUT 2,SUP-2283257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1459.75,948.84,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM BAL L20MM OD5MM DIL RX MRAIL,SUP-2140567,CDM,C1725,HCPCS,0272,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
CATHETER THOR 28FR STR SFT PLEUR-EVAC,SUP-2384355,CDM,C1729,HCPCS,0272,RC,,,,both,,,21.26,13.82,,,,,,,,,,,,,
MESH HERN DIA5.12IN OMEGA 3 FATTY ACID POLYPR RND BLT ON,SUP-2265960,CDM,C1781,HCPCS,0278,RC,,,,both,,,1228.96,798.82,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 5 CC FD ASEP CANC,SUP-2867153,CDM,C1762,CPT,0278,RC,,,,both,,,402.71,261.76,,,,,,,,,,,,,
CUP ACET OD43MM ID22MM MTL ON POLYETH NEUT PRI CEM W/ SPCR,SUP-2203593,CDM,C1776,CPT,0278,RC,,,,both,,,2255.78,1466.26,,,,,,,,,,,,,
STENT PERIPH L25MM DIA7MM CATH L120CM 0.018IN FEM IL ART,SUP-2396630,CDM,C1874,HCPCS,0278,RC,,,,both,,,9011.80,5857.67,,,,,,,,,,,,,
SLEEVE LD ANCHR,SUP-2282028,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L15CM ADMIN ACUTE BASIC KT 8 FR AD,SUP-2267028,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BASEPLATE TIB UNIV SZ 0F/1T CO CHROM MOLYBDENUM CEM PRI REV,SUP-2221010,CDM,C1776,CPT,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
BIT DRL MED 3 MM POWEREASE,SUP-2628248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.40,811.46,,,,,,,,,,,,,
ALLOGRAFT BNE FRSH W/ MENIS OSTEOCHNDRL RT TIB PLATEAU,SUP-2740828,CDM,C1762,CPT,0278,RC,,,,both,,,40519.09,26337.41,,,,,,,,,,,,,
PLATE BONE 10 H STR FOR 2MM SCR CRANIOMAXILLOFACIAL FX,SUP-2319363,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
BLADE LARYN L22.5CM DIA4MM NONROTATABLE STR TIP CURED AT,SUP-2284154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1548.24,1006.36,,,,,,,,,,,,,
PLATE BNE MESHED 106X31X1 MM SM GRID PLLA-PGA STRL RESORB XG,SUP-2476058,CDM,C1713,HCPCS,0278,RC,,,,both,,,5497.26,3573.22,,,,,,,,,,,,,
ENDCAP ORTHOPEDIC OFFSET +6MM SUBTALAR FUSION DYNANAIL MINI HYBRID MEDSHAPE,SUP-2878729,CDM,C1889,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
STENT CORONARY TAXUS LIBERTE L 8 MM DIA2.5 MM DEL SYS L 144,SUP-2140620,CDM,C1874,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
PLATE BNE L211MM 6 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186042,CDM,C1713,HCPCS,0278,RC,,,,both,,,4254.92,2765.70,,,,,,,,,,,,,
CATHETER CV INFUSE 7 FR 1 LUMEN,SUP-2214538,CDM,C1751,HCPCS,0278,RC,,,,both,,,45.40,29.51,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY DR TI 2 CHMBR IS1 COMPATIBLE CONN,SUP-2139584,CDM,C1785,HCPCS,0275,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
STENT URET 7FR L90CM SIL PTFE J SGL URIN DIV,SUP-2313760,CDM,C2617,HCPCS,0278,RC,,,,both,,,1144.37,743.84,,,,,,,,,,,,,
HC Tprnl Plmt Biodegrdabl Matrl,PX-3615587400,CDM,55874,CPT,0361,RC,,,,both,,,5169.00,3359.85,,,,,,,,,,,,,
CALCIUM CITRATE-VITAMIN D 315-6.25 MG-MCG PO TABS,RX-160015,CDM,6370000000,HCPCS,0637,RC,77333-0113-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT BILI LIFESTENT L 40 MM DIA 9 MM CATH L 80 CM DIA 6 FR,SUP-2128201,CDM,C1876,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
TUBE LARYNCTMY BLOM SINGER VOICE PROS PT CHANGEABLE LO PRSS,SUP-2242313,CDM,L8509,HCPCS,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2.4X16 MM MANDIBULAR 20/PK TITANIUM N,SUP-2842293,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.35,209.53,,,,,,,,,,,,,
SYSTEM CLOSURE VASC KNOT TYNG SNR XCLOSER,SUP-2241112,CDM,C1760,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE L235MM 10 H NONSTERILE L PERIARTC PROX HUM S STL,SUP-2184284,CDM,C1713,HCPCS,0278,RC,,,,both,,,5458.14,3547.79,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN 3MM PTFE J TIP EXCHG FIX,SUP-2302717,CDM,C1769,HCPCS,0272,RC,,,,both,,,23.55,15.31,,,,,,,,,,,,,
PLATE BNE L61MM THK1.3MM 100DEG 5 H TI TBLR FOR 3.5MM SCR,SUP-2412035,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
IRRIGATOR SUCTION STRL DISP CLR,SUP-2914829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
BUR SURG DIA5MM TI RND CUT NONFLUTED,SUP-2363803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,588.75,382.69,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 10 CM DIA 5 MM 0.018 IN HELCL,SUP-2385387,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PACEMAKER CARD EVIA SR SINGLE CHMBR W/ CLS AUTO RESPON STRL,SUP-2138258,CDM,C1786,HCPCS,0275,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
STENT ESOPH HANAROSTENT L 60MM 18MM L 1800MM 0.035/0.038IN,SUP-2865626,CDM,C1874,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
VALVE MITRL DIA31MM STD TI MECH FLEX SEW CUF STIFFENING RNG,SUP-2352679,CDM,C1889,HCPCS,0278,RC,,,,both,,,14990.36,9743.73,,,,,,,,,,,,,
CATHETER ITH L86CM ASCENDA SPNL SEG,SUP-2284626,CDM,C1755,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
TAMOXIFEN CITRATE 10 MG PO TABS,RX-7711,CDM,6370000000,HCPCS,0637,RC,59651-0299-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT HUM TISS W6MMXL25CM WHL CLLGN TEND STR KNOB END PASS,SUP-2400582,CDM,C1776,CPT,0278,RC,,,,both,,,3554.48,2310.41,,,,,,,,,,,,,
SCREW BNE 002360904035] ZIMMER BIOMET INC],SUP-2198528,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.39,189.40,,,,,,,,,,,,,
PLATE BNE L285MM 12 H R PROX PERIPROSTHETIC FEM TI NCB,SUP-2411490,CDM,C1713,HCPCS,0278,RC,,,,both,,,4098.39,2663.95,,,,,,,,,,,,,
SUTURE NOVOSTITCH PRO SZ 0 FOR MENIS REP DISP CTXA004,SUP-2419747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1829.84,1189.40,,,,,,,,,,,,,
IMPLANT TOE JT WEIL TYP FOR HAMRTOE FIX SYS SWNSN,SUP-2397762,CDM,C1776,CPT,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
HC Inj Proc Shoulder Arthro|BILATERAL PROCEDURE,PX-3612335000,CDM,23350,CPT,0361,RC,,,50,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
BIT DRL L115MM DIA1.9MM STP 35MM STRYKR END DISP FOR,SUP-2366428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.44,340.24,,,,,,,,,,,,,
CATHETER NEPHROSTOMY SET 035 6 FRX15 CM 19 GA SKATER,SUP-2753330,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
KIT DUAL OSIA 2 SOUND PROCESSOR,SUP-2858182,CDM,L8690,HCPCS,0278,RC,,,,both,,,21681.70,14093.10,,,,,,,,,,,,,
VALVE AORT DIA23MM ASCEND CONDUIT CARBO-SEAL VALSALVA,SUP-2352744,CDM,C1889,HCPCS,0278,RC,,,,both,,,19728.62,12823.60,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 80 CM DIA 6 MM EPTFE STR TW STRL,SUP-2227655,CDM,C1768,CPT,0278,RC,,,,both,,,2291.23,1489.30,,,,,,,,,,,,,
CANNULATED CHISEL FOR ADULT ANGLED BLADE PLATES 320MM,SUP-2548621,CDM,C1713,HCPCS,0278,RC,,,,both,,,2663.94,1731.56,,,,,,,,,,,,,
PLATE BONE TIBIAL RIGHT PROXIMAL LATERAL 10 HOLE LOCKING,SUP-2836984,CDM,C1713,HCPCS,0278,RC,,,,both,,,8513.01,5533.46,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 20 CM DIA 8 MM EPTFE STR TW USFT,SUP-2266005,CDM,C1768,CPT,0278,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
PLATE BONE L77MM 5 H LT LAT DSTL HUM LCK FOR 2.7/3.5MM SCR,SUP-2348655,CDM,C1713,HCPCS,0278,RC,,,,both,,,10355.72,6731.22,,,,,,,,,,,,,
KIT IR SMRT CT PICC 3 FR SGL LUMN RVS TAPR .018X130 CM S STL,SUP-2118437,CDM,C1751,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
HC R&L Heart Cath WO Graft,PX-4819345300,CDM,93453,CPT,0481,RC,,,,inpatient,,,9718.00,6316.70,,,,,,,,,,,,,
DOCUSATE SODIUM 50 MG/5ML PO LIQD,RX-36962,CDM,6370000000,HCPCS,0637,RC,63739-0976-01,NDC,,both,5,ML,2.90,1.88,,,,,,,,,,,,,
MEMBRANE AMNIO AMNIOFIX ALLGRFT 4.0X4.0CM,SUP-2305730,CDM,V2790,HCPCS,0274,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
BASEPLATE TIB N MOD SHT 63 MM KNEE POROUS OSS,SUP-2449771,CDM,C1776,CPT,0278,RC,,,,both,,,9163.31,5956.15,,,,,,,,,,,,,
IMPLANT SYS DX KL SLEEVE BC 4.75 MM CC FT,SUP-2815108,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
CAGE SPNL W9XH11XL27MM 0DEG C FBR REINF POLYMER POST LUM,SUP-2255223,CDM,C1889,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.427,SUP-2859991,CDM,C1713,HCPCS,0278,RC,,,,both,,,36930.80,24005.02,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD HD LNR COCR POLYETH,SUP-2267787,CDM,C1776,CPT,0278,RC,,,,both,,,13542.82,8802.83,,,,,,,,,,,,,
CANNULA SURG LNG 8 MM SCREW 00249004180,SUP-2463892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2018.14,1311.79,,,,,,,,,,,,,
PLATE SPNL 5 LEVEL WIDE 108 MM ANTR CERV ARCHON,SUP-2563466,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
GUIDEWIRE WITH OLIVE,SUP-2714104,CDM,C1769,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PLATE BNE 12 H WIDE LADDER STERNALOCK BLU PRI CLSR SYS,SUP-2403027,CDM,C1713,HCPCS,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24,RX-29274,CDM,6370000000,HCPCS,0637,RC,60687-0217-11,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
SET BILI STENT ZMMN L 5 CM DIA11.5 FR PUSH L 170 CM,SUP-2169030,CDM,C2625,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
CLINIMIX/DEXTROSE (4.25/5) 4.25 % IV SOLN,RX-25749,CDM,2500000003,HCPCS,0250,RC,00338-1133-03,NDC,,both,1000,ML,224.30,145.79,,,,,,,,,,,,,
CLAMP SURG ISOLATOR SYNERGY,SUP-2720063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
NEXEL TOT ELBW,SUP-2212313,CDM,C1776,CPT,0278,RC,,,,both,,,30144.00,19593.60,,,,,,,,,,,,,
"HC Tolerance Test, Addit.",PX-3018295200,CDM,82952,CPT,0301,RC,,,,outpatient,,,72.00,46.80,,,,,,,,,,,,,
SCREW BNE L50MM DIA6.5MM THRD L16MM STD CANC S STL,SUP-2373832,CDM,C1713,HCPCS,0278,RC,,,,both,,,146.01,94.91,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN COMP ONLY DBL LUMN POLYUR,SUP-2126508,CDM,C1752,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
POST FIXATOR EXTERNAL 2HOLE RINGFIX MALE,SUP-2696089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.60,268.19,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X242 MM 20 HOLE SS DCP,SUP-2569159,CDM,C1713,HCPCS,0278,RC,,,,both,,,462.84,300.85,,,,,,,,,,,,,
SPLINT WRST FA W ABDUCTED THMB L XSM,SUP-2276636,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 90 CM 4FR SLT 5CM 0.035 IN BALL,SUP-2117044,CDM,C1725,HCPCS,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
HC Sel Cath Plcmt Seg Pa,PX-3613601500,CDM,36015,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
COLLAR EXTRIC 1 PC RIG INF PERFIT,SUP-2389135,CDM,L0190,HCPCS,0274,RC,,,,both,,,18.81,12.23,,,,,,,,,,,,,
COMPONENT FEM KNEE CRUC RET LT UNISX PRI PRESSFIT POR SZ 1,SUP-2215666,CDM,C1776,CPT,0278,RC,,,,both,,,11137.58,7239.43,,,,,,,,,,,,,
SPACER FEM DIA25MM UNIV DST HIP CEM OMFIT,SUP-2368408,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PACK BOWL CELL SAVR BASIC HI SPD,SUP-2236450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.71,207.16,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK PRIZM 2 VR DEL ENERGY 31 J TI,SUP-2148620,CDM,C1722,HCPCS,0275,RC,,,,both,,,62784.30,40809.79,,,,,,,,,,,,,
INTRODUCER CATH 9FR 50CM BRAID WORLEY SAFSHTH,SUP-2282359,CDM,C1892,HCPCS,0272,RC,,,,both,,,664.90,432.18,,,,,,,,,,,,,
GRAFT BNE SYR 2.5 CC DBM ACCELL CONNEXUS,SUP-2641753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.41,782.22,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST ADJACENT W/AIR CHMBR,SUP-2435615,CDM,L1847,HCPCS,0272,RC,,,,both,,,1628.40,1058.46,,,,,,,,,,,,,
BUR SURG DIAMOND BULL 70 DEG 3 MMX13.5 CM STRL DISP,SUP-2638397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
HC Strapping Ankle/Foot,PX-4502954000,CDM,29540,CPT,0450,RC,,,,both,,,497.00,323.05,,,,,,,,,,,,,
BASEPLATE TIB L SZ 1 AP53MM ML77MM UNIV KNEE HA POR CEM,SUP-2377188,CDM,C1776,CPT,0278,RC,,,,both,,,4309.21,2800.99,,,,,,,,,,,,,
BUR ENDOSCP SHAVER 12 DEG L 11 CM DIA 3.2 MM SPD 12000 RPM,SUP-2902096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,829.81,539.38,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 6 FR SPC 2-5-2 MM D,SUP-2248677,CDM,C1732,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
FORCEPS BX L50CM OD5.4FR ENDOMYOCARD CVD LO PROF OVL SHP CUP,SUP-2355656,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA12 MM POLYESTER GEL,SUP-2385015,CDM,C1768,CPT,0278,RC,,,,both,,,1404.71,913.06,,,,,,,,,,,,,
PLATE BNE OLECRANON SM 79 MM 10 HOLE STRL A.L.P.S,SUP-2472849,CDM,C1713,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 5 MM STR STD WALL HELIX,SUP-2669692,CDM,C1768,CPT,0278,RC,,,,both,,,2034.31,1322.30,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.4X4.75 MM RICHARD SPRING BK FLROPLAS,SUP-2637901,CDM,L8613,CPT,0278,RC,,,,both,,,529.69,344.30,,,,,,,,,,,,,
NAIL ORTH 1.5IN LNG HD GMRS,SUP-2364863,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS 35X53 MMX62 CM FLEX-NECK CLASSIC,SUP-2302485,CDM,C1750,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
BURR SURG 2.1MM DIA HD LNG MIC 4.9MML HD SM BNE DIAMOND CROS,SUP-2605574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,119.38,77.60,,,,,,,,,,,,,
HC Treat Toe Fx,PX-4502851000,CDM,28510,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EDORA PROMRI 8 HF-T W 52 X H 53 MM D 6.5,SUP-2739240,CDM,C2621,HCPCS,0275,RC,,,,both,,,25826.50,16787.22,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 60 DEG L 11 CM DIA 4 MM 5000 RPM ENT,SUP-2901910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,745.06,484.29,,,,,,,,,,,,,
PLATE SPNL L75MM TI ANT CERV LOK LO PROF ATLNTS VISN,SUP-2293175,CDM,C1713,HCPCS,0278,RC,,,,both,,,3263.06,2120.99,,,,,,,,,,,,,
SCREW BNE L75MM DIA6.5MM THRD L32MM CANC BIODUR ALLY ST,SUP-2410054,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.22,437.59,,,,,,,,,,,,,
BOLT SPNL 6X17.5 MM ALIF FIX MODULUS,SUP-2736299,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT OPHTH DIA16MM AMNIO MEM OCU PROKERA,SUP-2135266,CDM,V2790,HCPCS,0278,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
IMPLANT PENILE 13CM CYIINDER 12MM INFL DURA II,SUP-2140239,CDM,C1813,HCPCS,0278,RC,,,,both,,,12387.30,8051.74,,,,,,,,,,,,,
MESH HERNIAXL W18XL12IN OMEGA 3 FATTY ACID COAT POLYPR,SUP-2265992,CDM,C1781,HCPCS,0278,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
POST EXT FIX ANK FT 4 H FOR TRUELOK FRME ASSEMB HEXAPOD SYS,SUP-2316132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
PLATE BNE L 154 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 11 72467311,SUP-2933155,CDM,C1713,HCPCS,0278,RC,,,,both,,,3358.23,2182.85,,,,,,,,,,,,,
BIT DRILL L3.3MM OD2.8MM KNOTLESS SUTURE ANCHOR POPLOK,SUP-2828522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,949.60,617.24,,,,,,,,,,,,,
SCREW BNE L18MM DIA4MM PERIARTC S STL ST LOK FULL THRD FOR,SUP-2184949,CDM,C1713,HCPCS,0278,RC,,,,both,,,415.86,270.31,,,,,,,,,,,,,
PLATE BNE L175MM 4 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186039,CDM,C1713,HCPCS,0278,RC,,,,both,,,3793.15,2465.55,,,,,,,,,,,,,
SET BLDE SCALP HK TRIANG FOR PLNTR FASCTMY DISP,SUP-2370273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1393.53,905.79,,,,,,,,,,,,,
SCREW BONE L85MM DIA6.5MM THRD L32MM STD CANC S STL LAG HEX,SUP-2344198,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.24,312.81,,,,,,,,,,,,,
COMPONENT GLEN INLAY UNIV MED SHLDR,SUP-2422329,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BNE L 1 MM LT 9 HOLE SS NS,SUP-2183610,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.45,512.49,,,,,,,,,,,,,
NAIL COMPR L200MM DIA10MM ANK TI CANN,SUP-2316330,CDM,C1713,HCPCS,0278,RC,,,,both,,,8330.61,5414.90,,,,,,,,,,,,,
NEXGEN TRAB METAL TIB AGMT BLK 30MM RLAT/LMED SZ3,SUP-2502194,CDM,C1776,CPT,0278,RC,,,,both,,,5501.28,3575.83,,,,,,,,,,,,,
SCREW BONE LOK 5MM DIA 20MML TTNM ALLOY CRTCL FLLY THRDD PAN,SUP-2586613,CDM,C1713,HCPCS,0278,RC,,,,both,,,1144.62,744.00,,,,,,,,,,,,,
PISTON OTOLARYN L4MM OD0.8MM S STL FLROPLAS STAP WIRE LOOP,SUP-2312533,CDM,L8613,CPT,0278,RC,,,,both,,,334.98,217.74,,,,,,,,,,,,,
HC Blood Occult Peroxidase Actv Qual Feces 1-3 Spec,PX-3018227200,CDM,82272,CPT,0301,RC,,,,both,,,87.00,56.55,,,,,,,,,,,,,
ASPIRATION NEEDLE 8GX23CM CLOSED TIP,SUP-2818024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
GRAFT BNE 10 CC KIR FILL SYNTH,SUP-2430788,CDM,C1713,HCPCS,0278,RC,,,,both,,,5944.02,3863.61,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|DOCUMENTATION ON FILE,PX-4309711000,CDM,97110,CPT,0430,RC,,,GP|CQ|KX,both,,,195.00,126.75,,,,,,,,,,,,,
BIT DRL L135MM DIA25MM AO FIT FOR TOT FT SYS,SUP-2244016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.81,377.53,,,,,,,,,,,,,
GRAFT BNE MEDL VERSAGRAFT,SUP-2257912,CDM,C1776,CPT,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
SCREW BNE HD 5X35 MM FOR FRAC REP FIX OSTEOTMY JT FUSION,SUP-2175041,CDM,C1713,HCPCS,0278,RC,,,,both,,,1624.95,1056.22,,,,,,,,,,,,,
ENDOSCOPE RIGID STRL,SUP-2225633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE 2 % VA CREA,RX-9624,CDM,6370000000,HCPCS,0637,RC,00168-0277-40,NDC,,both,40,GR,469.30,305.04,,,,,,,,,,,,,
GUIDEPIN ARTHSCP DIA0.054IN FOR POST TIB TEND DYSFUNCTION,SUP-2121851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SCREW BNE CONN CANN FOR EXPERT TIB NAIL NS,SUP-2799381,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.17,928.31,,,,,,,,,,,,,
ENDCAP SPNL 0 DEG 60X22X18 MM TI X-CORE 2,SUP-2560393,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PIN HALF FIXATION M6 L200MM THREAD L40MM STAINLESS STEEL,SUP-2586488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,622.19,404.42,,,,,,,,,,,,,
BIT DRL L32MM 2IN1 CANN AO DISP FOR HALLU-LOCK MTP ARTH SYS,SUP-2243021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.40,483.21,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X20 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851928,CDM,C1713,HCPCS,0278,RC,,,,both,,,711.15,462.25,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 DR-T W 59 X H 66 MM D 13 MM 40,SUP-2138130,CDM,C1882,HCPCS,0275,RC,,,,both,,,33912.00,22042.80,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX70 CM RADIALLY SUPP POLYESTER INTEGARD,SUP-2227567,CDM,C1768,CPT,0278,RC,,,,both,,,3069.51,1995.18,,,,,,,,,,,,,
FIBER LASER FLEXIVA PULSE 910,SUP-2718713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2303.69,1497.40,,,,,,,,,,,,,
PROBE BRST BX 11GA STEREOTACTIC BLADED DISP MAMTOM,SUP-2195658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,855.34,555.97,,,,,,,,,,,,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-104408,CDM,J0278,HCPCS,0636,RC,23155-0290-41,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE 5X8 H BILAT LT MAND ORAL MAXILLOFACIAL TI ANG LO,SUP-2191437,CDM,C1713,HCPCS,0278,RC,,,,both,,,5609.30,3646.04,,,,,,,,,,,,,
ENDCAP ORTH EXTN 0MM HINDFOOT AQUA TI CANN T25 STARDRV,SUP-2189266,CDM,C1713,HCPCS,0278,RC,,,,both,,,607.87,395.12,,,,,,,,,,,,,
SCREW SET PERI-LOC VLP,SUP-2351453,CDM,C1713,HCPCS,0278,RC,,,,both,,,66727.10,43372.61,,,,,,,,,,,,,
STENT CORONARY MULTLNK TRI L 23 MM DIA 3.5 MM GUIDE CATH,SUP-2101465,CDM,C1876,HCPCS,0278,RC,,,,both,,,6138.70,3990.15,,,,,,,,,,,,,
SEALER LAP L44CM MARYLAND JAW OPN NANO COAT MULTIFUNCTIONAL,SUP-2283565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1622.19,1054.42,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN (ADD-VANTAGE),RX-40860021,CDM,J7060,HCPCS,0250,RC,00409-7100-67,NDC,,both,100,ML,37.40,24.31,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 27GM VAGUS NRV POLYUR 2 PIN LI C,SUP-2175904,CDM,C1767,HCPCS,0278,RC,,,,both,,,52805.38,34323.50,,,,,,,,,,,,,
PLATE BNE W10XL214MM THK3.6MM 18 H BILAT S STL CRV RIG CLLR,SUP-2186260,CDM,C1713,HCPCS,0278,RC,,,,both,,,3076.85,1999.95,,,,,,,,,,,,,
ABUTMENT COCHLEAR 9MM BA300 BAHA,SUP-2823401,CDM,L8690,HCPCS,0278,RC,,,,both,,,6060.20,3939.13,,,,,,,,,,,,,
LAT TIB HEAD BUTT PLT STERILIZER 9HL 181 MM LT,SUP-2818115,CDM,C1713,HCPCS,0278,RC,,,,both,,,5802.25,3771.46,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 28 CM DIA 6 FR POLYUR AQ BRAIDED,SUP-2171438,CDM,C2617,HCPCS,0278,RC,,,,both,,,502.71,326.76,,,,,,,,,,,,,
SYSTEM STENT GRFT OVATION IX L 80 MM DIA20 MM DEL CATH 14 FR,SUP-2217718,CDM,C1874,HCPCS,0278,RC,,,,both,,,33280.86,21632.56,,,,,,,,,,,,,
ANCHOR SUTXL CVD W/ 1 SZ 2 ULTRABRAID BLU COBRAID SUT SUTFIX,SUP-2341938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.23,813.30,,,,,,,,,,,,,
PLUG VASC UNCONSTRAINED L13.5MM DIA8MM GWIRE 0.038IN W/,SUP-2355707,CDM,C1889,HCPCS,0278,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
GUIDEWIRE VASC L155CM DIA0035IN EXTN SYS WHLY,SUP-2281741,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
IMPLANT HUM TISS L 15 X W 7.5 CM AMNIO MEMBRN LYOPRESERVED,SUP-2905504,CDM,Q4133,HCPCS,0636,RC,,,,both,,,27318.00,17756.70,,,,,,,,,,,,,
BURR SURG OD4.7MM 127MM LEN M CUT DR FLUT ST EIUS SYS,SUP-2367441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.94,365.91,,,,,,,,,,,,,
INTRODUCER,SUP-2821961,CDM,C1894,HCPCS,0272,RC,,,,both,,,10.96,7.12,,,,,,,,,,,,,
HC CT Guide Visc Tissue Ablation,PX-3507701300,CDM,77013,CPT,0350,RC,,,,outpatient,,,2630.00,1709.50,,,,,,,,,,,,,
PLATE BONE L191MM 11 H LT PROX HUM LCK COMPR FOR 3.5MM SCR,SUP-2340928,CDM,C1776,CPT,0278,RC,,,,both,,,14345.72,9324.72,,,,,,,,,,,,,
HC NM Liver/Spleen W/Vasc,PX-3417821600,CDM,78216,CPT,0341,RC,,,,both,,,442.00,287.30,,,,,,,,,,,,,
KIT SPNL ROD PT SPEC PROC CDH UNID,SUP-2926400,CDM,C1713,HCPCS,0278,RC,,,,both,,,5632.38,3661.05,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR SMALL 0.4 MM LEFT SUBCONDYLAR PRECO,SUP-2837769,CDM,C1713,HCPCS,0278,RC,,,,both,,,5939.00,3860.35,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.535,SUP-2860216,CDM,C1713,HCPCS,0278,RC,,,,both,,,41146.56,26745.26,,,,,,,,,,,,,
WEDGE FEM SZ 7-8 THK5MM SHT UNIV POST KNEE CO CHROM PRI,SUP-2346039,CDM,C1776,CPT,0278,RC,,,,both,,,3574.89,2323.68,,,,,,,,,,,,,
SCREW BNE L 60 MM DIA 4.5 MM ST LCK STRL EVOS,SUP-2931198,CDM,C1713,HCPCS,0278,RC,,,,both,,,851.41,553.42,,,,,,,,,,,,,
HC MRI-Brain W Contrast,PX-6117055200,CDM,70552,CPT,0611,RC,,,,both,,,4146.00,2694.90,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CURRENT DR W 5 X H 7.6 CM 30 J 38 CC TI,SUP-2356699,CDM,C1721,HCPCS,0275,RC,,,,both,,,45530.00,29594.50,,,,,,,,,,,,,
BRACE THMB XSM AD FOR 725 LESS THAN 8IN L9IN R WRST BLK,SUP-2196550,CDM,L3931,HCPCS,0272,RC,,,,both,,,279.18,181.47,,,,,,,,,,,,,
VALVE AORT MITROFLOW H 11 MM OD 18.6 MM ID 15.4 MM SEW RNG W,SUP-2265194,CDM,C1889,HCPCS,0278,RC,,,,both,,,16817.84,10931.60,,,,,,,,,,,,,
DEVICE SIZING GRAFT FIX 0 1.3 MM KT TENODESIS SUTURETAPE W/ NDL,SUP-2423012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
KIT CATHETER PAINBUSTER 100ML X 1ML PER HR STD ON Q,SUP-2236821,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
SCREW BONE 2.7MM DIA 70MML STNLSS STEEL CRTCL SELF TPPNG,SUP-2588511,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.47,47.11,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.035IN TIP L3CM NIT COR,SUP-2171362,CDM,C1769,HCPCS,0272,RC,,,,both,,,119.73,77.82,,,,,,,,,,,,,
BASEPLATE TIB SZ 2+ THK10MM STD UNIV KNEE CO CHROM NP CRUC,SUP-2252435,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE L MINI REG 1 MM RT W/O SPACE BTWN HOLE TI,SUP-2458089,CDM,C1713,HCPCS,0278,RC,,,,both,,,597.60,388.44,,,,,,,,,,,,,
BRACE ORTHOPEDIC ANK FT PLAS,SUP-2388162,CDM,L1930,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
GEMFIBROZIL 600 MG PO TABS,RX-3378,CDM,6370000000,HCPCS,0637,RC,60687-0224-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NEUROMONITORING KIT,SUP-2124288,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 124 MM DIA26 MM SHTH 20 FR RVD 21-22,SUP-2170126,CDM,C1768,CPT,0278,RC,,,,both,,,32910.34,21391.72,,,,,,,,,,,,,
INSERTER SURGICAL 30X10X10MM 4 LEG INLINE PRELOADED DYNACLIP,SUP-2878201,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD OVERALL L40CM L24CM DIA14.5FR,SUP-2174238,CDM,C1750,HCPCS,0278,RC,,,,both,,,1306.08,848.95,,,,,,,,,,,,,
PACEMAKER CARD AZURE S SR MRI SURESCAN W 50.8 X H 42.6 MM D,SUP-2281732,CDM,C1786,HCPCS,0275,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
WRAP SURG W1.31XL1.34M CARD FOR PT 165-172CM THERMOWRP,SUP-2300140,CDM,C1713,HCPCS,0278,RC,,,,both,,,515.21,334.89,,,,,,,,,,,,,
CATHETER DRNGE 12FR 40CM BILI TOT ABSCESSION,SUP-2118569,CDM,C1729,HCPCS,0272,RC,,,,both,,,237.70,154.50,,,,,,,,,,,,,
PLATE BNE W12XL55MM THK1MM 3 H BILAT S STL SEMI TBLR LO,SUP-2184864,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.16,128.15,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK TOT CONTACT,SUP-2388207,CDM,L5637,HCPCS,0272,RC,,,,both,,,894.59,581.48,,,,,,,,,,,,,
CATHETER DLYS PALINDROME,SUP-2283921,CDM,C1750,HCPCS,0278,RC,,,,both,,,1014.66,659.53,,,,,,,,,,,,,
ELECTRODE UROLOGY VPR GRV RL BAR 24-28FR STRL DISP F/CIRCON,SUP-2313183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.31,318.05,,,,,,,,,,,,,
WIRE SURG L175MM DIA0.6MM S STL CERCLAGE PRECUT SMOOTH W/,SUP-2186849,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.73,22.57,,,,,,,,,,,,,
HC MRI-Spine Lumbar WO & W Cont,PX-6127215800,CDM,72158,CPT,0612,RC,,,,both,,,3486.00,2265.90,,,,,,,,,,,,,
SYSTEM SLNG POLYPRO TRNSVAG MIDURETHRAL MESH ASMBLY,SUP-2930142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5301.48,3445.96,,,,,,,,,,,,,
SPLINT ORTHOPEDIC ANTIMICROBIAL WHFO LG RT HND,SUP-2325146,CDM,L3809,HCPCS,0274,RC,,,,both,,,142.65,92.72,,,,,,,,,,,,,
SCREW SYS DUALTHRD HDLSS COMPR TI THRD 65 MM CANN 20 MM,SUP-2392787,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.03,386.77,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH BASIC 3FR 0.024IN 60CM 1 LUMAN RV,SUP-2613377,CDM,C1751,HCPCS,0278,RC,,,,both,,,161.77,105.15,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 80 MM DIA 30/32 MM,SUP-2168756,CDM,C1874,HCPCS,0278,RC,,,,both,,,6468.40,4204.46,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE STEM PREMIER,SUP-2212691,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST COUNT REINF PLAS,SUP-2435729,CDM,L3430,HCPCS,0274,RC,,,,both,,,453.70,294.90,,,,,,,,,,,,,
CATHETER DRNGE 14FR L45CM NDL 18GA 0.038IN PERC TRCR STYL,SUP-2168509,CDM,C1729,HCPCS,0272,RC,,,,both,,,242.16,157.40,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA0.053IN THRD W/ TRCR TIP LSR LN FOR,SUP-2122460,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 0.70 CC FD MINERALIZED ORAGRAFT,SUP-2741057,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.64,120.67,,,,,,,,,,,,,
HC Inc Thromb Hemorrhoid Ext,PX-4504608300,CDM,46083,CPT,0450,RC,,,,inpatient,,,383.00,248.95,,,,,,,,,,,,,
STENT GRFT ENDO 7MMX10CMX75CM,SUP-2396481,CDM,C1876,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
SYSTEM ELECTRODE DELIV EMBLEM S-ICD 2,SUP-2140137,CDM,C1725,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER DRNGE 28FR 4 WNG DISP FOR NEPHSTMY MALECOTS,SUP-2129077,CDM,C2627,HCPCS,0272,RC,,,,both,,,37.02,24.06,,,,,,,,,,,,,
HC So Assay of Metanephrines,PX-3018383566,CDM,83835,CPT,0301,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
NUCELXL 2.5 CC OR ML BIOACTIVE AMNIO SUSP,SUP-2314104,CDM,C1713,HCPCS,0278,RC,,,,both,,,10895.80,7082.27,,,,,,,,,,,,,
RETRACTOR SPNL L7CM DIA26MM D275IN S STL TB MED LAT DIL BLNT,SUP-2293060,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.68,721.29,,,,,,,,,,,,,
STRAP CLAV M HVY DUTY BCKL CLSR,SUP-2194646,CDM,L3650,HCPCS,0274,RC,,,,both,,,18.12,11.78,,,,,,,,,,,,,
CATHETER GUID FL3.5 0.070 INX6 FRX100 CM VASC ACCS MACH 1,SUP-2143760,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
INSERT TIB KNEE BUMPER MOD ROT HNG NEUT MONOGRAM,SUP-2376370,CDM,C1776,CPT,0278,RC,,,,both,,,1476.59,959.78,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CORTICOCANCELLOUS ALLGRFT,SUP-2932761,CDM,C1762,CPT,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 75 X W 13.5 MM MYRIAD HNDPC L 13 NN-2005,SUP-2930268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18005.55,11703.61,,,,,,,,,,,,,
MESH HERN XL W1.4XL2IN SYN POLY-4-HYDROXYBUTYRATE PLUG AND,SUP-2125876,CDM,C1781,HCPCS,0278,RC,,,,both,,,1444.43,938.88,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 BLLN L20MM BNE FILL DEV SYR IBT KYPHON,SUP-2293628,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
DRAIN SURG 16FR STEM 12IN XBAR 5IN GRAV T TB DEAVER,SUP-2127147,CDM,C1729,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
GUIDEWIRE VASC ADX L 150 CM DIA 0.035 IN TIP L 15 CM PTFE,SUP-2752483,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.65,28.37,,,,,,,,,,,,,
HC X-Ray Femur 1 View,PX-3207355100,CDM,73551,CPT,0320,RC,,,,inpatient,,,267.00,173.55,,,,,,,,,,,,,
HC Catheterize for Urine Spec,PX-4500961200,CDM,P9612,CPT,0300,RC,,,,inpatient,,,76.00,49.40,,,,,,,,,,,,,
PLATE BNE L1665MM THK25MM 14 H ACET S STL FLX ANNEALED,SUP-2362710,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.63,1981.61,,,,,,,,,,,,,
PLATE BNE HUM 3.5X302 MM RT DSTL 14 HOLE LCK LP RIGID STRL,SUP-2177172,CDM,C1713,HCPCS,0278,RC,,,,both,,,5798.54,3769.05,,,,,,,,,,,,,
INSERT TIB SZ C KNEE POLYETH SEG,SUP-2200504,CDM,C1776,CPT,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SCREW BONE 1.5X8MM CORT HEXADRIVE 4,SUP-2268037,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.67,218.19,,,,,,,,,,,,,
PLATE BNE STR 3 H TARSALIS,SUP-2243237,CDM,C1713,HCPCS,0278,RC,,,,both,,,5351.94,3478.76,,,,,,,,,,,,,
COMPONENT SHLDR CAPPED HUM GLEN REVERSED STEM HD ASCEND FLX,SUP-2424092,CDM,C1776,CPT,0278,RC,,,,both,,,27632.00,17960.80,,,,,,,,,,,,,
SYSTEM BNE BX MINI 13 GAX6 CM MADISON,SUP-2466658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
HANDPIECE 9GAX12MMX12CM BX BRST MAMMO ATEC MINIMALLY,SUP-2239990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BONE OD20MM 6 HOLE TITANIUM CONTOURED NONCOMPRESSION W,SUP-2826366,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.25,165.26,,,,,,,,,,,,,
LEAD PACE SETROX S L 45 CM DIA2.23 MM SIL INSUL FRACTAL COAT,SUP-2138046,CDM,C1898,HCPCS,0275,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
MATRIX BIO L 6 X W 14 CM SZ 84 SQCM FISH SKIN SIL DERMAL FEN,SUP-2909237,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9784.24,6359.76,,,,,,,,,,,,,
CATHETER LD DEL ATTAIN L 45 CM OD 9 FR ID 7.2 FR POLYETHER,SUP-2282152,CDM,C1887,HCPCS,0272,RC,,,,both,,,537.29,349.24,,,,,,,,,,,,,
BALLOON ANORECT MNOMTR AD KI ANO STIM FOR ANORECT COMPLIANCE,SUP-2336754,CDM,C1726,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
BUR SURG HD L18.3MM DIA3MM CARB MTL CUT LEGEND,SUP-2284690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.05,377.03,,,,,,,,,,,,,
ANCHOR SUT SZ 2 ABSRB BIOKNOTLESS,SUP-2249363,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
GRAFT BONE SUB 5GM CA PHOS CLASS BONESOURCE,SUP-2365152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE BNE FEM 3.5X142 MM RT DSTL PROX 4 HOLE NS VA-LCP,SUP-2757670,CDM,C1713,HCPCS,0278,RC,,,,both,,,3686.61,2396.30,,,,,,,,,,,,,
HC So1 Lipid Panel|NOT REASONABLE AND NECESSARY,PX-3018006167,CDM,80061,CPT,0301,RC,,,GZ,both,,,55.00,35.75,,,,,,,,,,,,,
GRAFT BNE STRP 5 CC BIOACTIVE GLS,SUP-2860950,CDM,C1713,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE MESHED 4X8CM,SUP-2905509,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
BEARING HUM DIA44MM +5MM OFFSET TI FOR RVS SHLDR SYS,SUP-2404730,CDM,C1776,CPT,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
KNIFE SURG FREER SEPT 7 IN ANGLED MICROFRANCE,SUP-2497729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.89,248.88,,,,,,,,,,,,,
SCREW BNE THMB NS REUSE,SUP-2489723,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
HEAD HUMERAL 46MM,SUP-2863709,CDM,C1776,CPT,0278,RC,,,,both,,,3350.38,2177.75,,,,,,,,,,,,,
HC So Gc/Ms Quantitative,PX-3018378966,CDM,83789,CPT,0301,RC,,,,both,,,116.00,75.40,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 70 CM DIA 4 FR SHFT DIA1.05 MM,SUP-2385515,CDM,C1887,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
HC Natriuretic Peptide|NOT REASONABLE AND NECESSARY,PX-3018388000,CDM,83880,CPT,0301,RC,,,GZ,both,,,179.00,116.35,,,,,,,,,,,,,
CANNULA ART LNG 21 FR UNCOATED HLS,SUP-2663472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,945.23,614.40,,,,,,,,,,,,,
VALVE TRICSP EVOQUE SZ 44 MM NIT SELF EXPANDABLE THERMAFIX,SUP-2930358,CDM,C1889,HCPCS,0278,RC,,,,both,,,135020.00,87763.00,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 80 MM DIA 7 MM DEL SYS L 120 CM,SUP-2158586,CDM,C1876,HCPCS,0278,RC,,,,both,,,4624.84,3006.15,,,,,,,,,,,,,
PIN BLUNT HALF 200X30MM,SUP-2695684,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.11,516.17,,,,,,,,,,,,,
COMPONENT TIB M THK11MM DST KNEE POLY KINEMATIC ROT HNG GMRS,SUP-2376400,CDM,C1776,CPT,0278,RC,,,,both,,,3642.71,2367.76,,,,,,,,,,,,,
BLADE RETRACTOR HARRINGTON UNIV 2/3X2.25 IN ABD RNG,SUP-2458924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1251.73,813.62,,,,,,,,,,,,,
SLING GYN SUPRPUB 5 DEL DEV 5 MESH ASMBLY LYNX,SUP-2141795,CDM,C1771,HCPCS,0278,RC,,,,both,,,2292.04,1489.83,,,,,,,,,,,,,
HC So Factor Inhibitor Test,PX-3058533566,CDM,85335,CPT,0305,RC,,,,inpatient,,,385.00,250.25,,,,,,,,,,,,,
GRAFT HUMAN TISSUE VIALIZE 4 X 4CM PLACENTAL MEMBRANE,SUP-2863009,CDM,C1762,CPT,0278,RC,,,,both,,,4223.30,2745.14,,,,,,,,,,,,,
SAW CAST ENGEL 5-5/8 INX73 MM SATIN FINISH SS REUSE,SUP-2468748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,664.30,431.79,,,,,,,,,,,,,
RAIL EXT FIX TRANSITION 5.5X495 MM CONTOURED 4D TI MESA,SUP-2517549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6987.38,4541.80,,,,,,,,,,,,,
CAGE SPNL L50XH12MM 6DEG PEEK LORD CLYDESDALE,SUP-2285049,CDM,C1889,HCPCS,0278,RC,,,,both,,,11514.38,7484.35,,,,,,,,,,,,,
TRACKER NONINVASIVE CRANIALMASK,SUP-2364151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,308.79,200.71,,,,,,,,,,,,,
STEM FEM L125MM OD17MM STD CO CHROM STR CLLRD DST CAP,SUP-2406296,CDM,C1776,CPT,0278,RC,,,,both,,,13721.80,8919.17,,,,,,,,,,,,,
NEEDLE LOC 19GA 1CM MRK ZONE SPINPERC,SUP-2392620,CDM,C1713,HCPCS,0278,RC,,,,both,,,2358.77,1533.20,,,,,,,,,,,,,
BIT DRL QC 2.5X135 MM 45 MM CALIB NS,SUP-2422951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.91,230.69,,,,,,,,,,,,,
SHEATH KIT NANONEEDLE 180 MM HI FLO OPERATIVE,SUP-2849274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK0.7-1.4MM THN ACELLULAR,SUP-2307574,CDM,Q4128,HCPCS,0636,RC,,,,both,,,26250.56,17062.86,,,,,,,,,,,,,
GENERATOR PLSE PT PRGMR EON,SUP-2355980,CDM,C1787,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ COMMND ES L 300 CM DIA 0.014 IN TIP L,SUP-2105881,CDM,C1769,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
TM STEM POR BPLR SY,SUP-2212128,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
ISOSORBIDE DINITRATE 5 MG PO TABS,RX-4068,CDM,6370000000,HCPCS,0637,RC,00143-1769-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Sinogram,PX-3207608000,CDM,76080,CPT,0320,RC,,,,outpatient,,,600.00,390.00,,,,,,,,,,,,,
HC Arterial Line Insertion,PX-7613662001,CDM,36620,CPT,0370,RC,,,,outpatient,,,789.00,512.85,,,,,,,,,,,,,
SCREW BONE L40MM DIA4MM CORT DSTL LCK FULL THRD FOR 7MM,SUP-2318931,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.20,553.93,,,,,,,,,,,,,
PLATE BONE SQUARE SHEET 50X50X0.8 MM DEMO STERILE SYNPOR,SUP-2837792,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
LINER ACET ANTEVERTED 4+ MM 20 DEG 28X46 MM HIP XLPE R3,SUP-2434669,CDM,C1776,CPT,0278,RC,,,,both,,,4477.64,2910.47,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM W/ ORTHOCORD SUT HEALIX BR,SUP-2249424,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.84,828.65,,,,,,,,,,,,,
LEAD PACEMKR SOLIA S PROMRI L 45 CM DF1 CONN MR CONDITIONAL,SUP-2138279,CDM,C1898,HCPCS,0275,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
SHEATH INTRO FLX BLKN L 40 CM OD 7 FR ID 2.5 MM GUIDEWIRE,SUP-2168569,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.87,92.22,,,,,,,,,,,,,
SHEATH INTRO CEREBASE DA L 70 CM OD 8 FR ID 0.090 IN PTFE SS,SUP-2655900,CDM,C1894,HCPCS,0272,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
PACK SAW BLDE 56MM D367MM CUT EDGE 10MM THK12MM FOR PWR,SUP-2365138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
COMPONENT GLENOSPHERE XTEND 42MM PLUS 6MM,SUP-2427755,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PROBE RF ABLAT 90-S CRUISE SERFAS ENERGY,SUP-2361322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.01,401.71,,,,,,,,,,,,,
SET STENT URTRL 5FR DIA 24CML PRCFLX DBLE PGTL LOW PRFLE LG,SUP-2724754,CDM,C2617,HCPCS,0278,RC,,,,both,,,519.07,337.40,,,,,,,,,,,,,
ENDPLATE SPNL 20MM 4DEG 22X40MM UP FORTIFY I,SUP-2230000,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT BIO TISS W8XL12CM SLD FET BOV ACELLULAR DERM MTRX,SUP-2243687,CDM,C1781,HCPCS,0278,RC,,,,both,,,9043.20,5878.08,,,,,,,,,,,,,
SINGLE CDP PM KT ST. ELIZABETH HOSP,SUP-2214644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46.25,30.06,,,,,,,,,,,,,
SYSTEM CLSR NDL STR SUT GUID SUT PASS CARTER-THOMASON II,SUP-2171687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE SPNL OCCIPITOCERVICAL UP THOR ADJ INFIN,SUP-2421093,CDM,C1713,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
ANCHOR SUT 2 DIA4.5MM BLU PEEK NONABSORBABLE ULTBRAID DBL,SUP-2341845,CDM,C1713,HCPCS,0278,RC,,,,both,,,974.34,633.32,,,,,,,,,,,,,
DIS HUM POSTLAT LT 25HOLE 250MM,SUP-2477945,CDM,C1713,HCPCS,0278,RC,,,,both,,,5422.78,3524.81,,,,,,,,,,,,,
CATHETER HD 15 FRX27 CM 21 GA ARROW-CLARK NEXTSTEP,SUP-2627054,CDM,C1750,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
KIT TRNSDUC PRSS MON 10 CA,SUP-2214649,CDM,C1751,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7040,HCPCS,0258,RC,00264-7800-10,NDC,,both,500,ML,29.80,19.37,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CUT WIRE SZ 20 MM SHRT,SUP-2889730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
TRAY PICC POWERPICC PROVENA L 55 CM DIA 4 FR CATH 18 GA,SUP-2632844,CDM,C1751,HCPCS,0278,RC,,,,both,,,461.20,299.78,,,,,,,,,,,,,
JIG SURG LT TIB KNEE PREF ROT PT SPEC DISP PERSONA,SUP-2205591,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT VASC ADVANTA SST L 80 CM DIA 8 MM EPTFE STR TW REINF 3,SUP-2265944,CDM,C1768,CPT,0278,RC,,,,both,,,4236.46,2753.70,,,,,,,,,,,,,
STIMULATOR NRV SPNL IMP PULSE PRECIS SPECTR AND CHARGING KT,SUP-2141892,CDM,C1820,HCPCS,0278,RC,,,,both,,,54322.00,35309.30,,,,,,,,,,,,,
PLATE BNE W4.3XL61.7MM THK1.1MM 12 H TI STR LOK LO PROF FOR,SUP-2411739,CDM,C1713,HCPCS,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
GRAFT VASC HYBRID L 50 CM DIA 6 MM REINF SECT L 5 CM DIA 6,SUP-2395254,CDM,C1768,CPT,0278,RC,,,,both,,,7884.54,5124.95,,,,,,,,,,,,,
ASSEMBLY SHUNT OPN END STD 120 CM BURR HOLE WALL SLT STRATA,SUP-2664459,CDM,C1889,HCPCS,0278,RC,,,,both,,,17088.70,11107.65,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 65 CM 5 FR 0.035 IN C1 BRAIDED,SUP-2116822,CDM,C1887,HCPCS,0272,RC,,,,both,,,108.64,70.62,,,,,,,,,,,,,
PROBE BX BRST L105MM DIA10GA SYS ULT FINESSE,SUP-2126874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
SCREWDRIVER SURG N CANN STD 25 MM HEX ATLNTS REUSE,SUP-2279318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.08,202.85,,,,,,,,,,,,,
COMPONENT TIB SZ 6 R REV GMK,SUP-2267557,CDM,C1776,CPT,0278,RC,,,,both,,,9785.81,6360.78,,,,,,,,,,,,,
ENDCAP SPNL DIA20MM 0DEG SM H1.5MM TEETH THORLUM GRY TI,SUP-2390810,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CATHETER GUID 70DEG TIP F-70 NSL SINUS RELIEVA FLX,SUP-2106347,CDM,C1887,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
CABLE ELECTRD ENH BLU MAIN 14 TO 14 PIN STARBURSTXLL,SUP-2117216,CDM,C1819,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ANCHOR SUT NO 0 2.5MM W/ 1 USP DBL ARMED MORPHIX,SUP-2277450,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE FIBULAR LT LAT ANK 11 HOLE STRL,SUP-2518407,CDM,C1713,HCPCS,0278,RC,,,,both,,,6258.02,4067.71,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD 8FR L15CM ADMIN BASIC KT DBL,SUP-2174128,CDM,C1750,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GRAFT BNE 10CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264812,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.22,315.39,,,,,,,,,,,,,
PROSTHESIS PENILE INFLATABLE 13 MMX18 CM AMS AMBICOR,SUP-2140275,CDM,C1813,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM 6FR 4MM B CRV QPLR UNIDIR,SUP-2248665,CDM,C1733,HCPCS,0272,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
COMPONENT TIB AUG 55X59X20 MM LL/RM KNEE OSS RS RD122164,SUP-2450003,CDM,C1776,CPT,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
COLLAR SPNL UNIV TI W/ GRV SM STAT USS,SUP-2193400,CDM,2780000010,LOCAL,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
STENT ENDOPROS L5CM DIA8MM CATH 8FR L75CM BAL DIA8MM,SUP-2396563,CDM,C1874,HCPCS,0278,RC,,,,both,,,9200.20,5980.13,,,,,,,,,,,,,
MYCOPHENOLATE MOFETIL 250 MG PO CAPS,RX-15113,CDM,J7517,HCPCS,0636,RC,60687-0885-01,NDC,,both,1,UN,3.00,1.95,,,,,,,,,,,,,
PLATE BONE L256MM BLDE W11.7XL30MM 90DEG 14 H STRL BILAT S,SUP-2185454,CDM,C1713,HCPCS,0278,RC,,,,both,,,4745.14,3084.34,,,,,,,,,,,,,
PLATE BNE KEYLESS 95 DEG 255 MM HIP 14 HOLE COMPR TUBE,SUP-2485113,CDM,C1713,HCPCS,0278,RC,,,,both,,,1811.15,1177.25,,,,,,,,,,,,,
BEARING HUM DIA4441MM H+0MM STD ARCOMXL FOR COMPHSVE REV,SUP-2409556,CDM,C1776,CPT,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL 250X20 MM FD STRUT,SUP-2717908,CDM,C1762,CPT,0278,RC,,,,both,,,5882.85,3823.85,,,,,,,,,,,,,
DEXAMETHASONE 0.2 MG/ML IJ SOLN (PED-NEO),RX-4090129,CDM,J1100,HCPCS,0636,RC,09999-9906-51,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
STENT PERIPH L59MM DIA9X13MM CATH L135CM INTRO SHTH 8FR,SUP-2395685,CDM,C1874,HCPCS,0278,RC,,,,both,,,9862.74,6410.78,,,,,,,,,,,,,
SCREW BNE ANTIROTATION 95 MM FOR FEM NK SYS TI NS,SUP-2181061,CDM,C1713,HCPCS,0278,RC,,,,both,,,817.40,531.31,,,,,,,,,,,,,
OSTEOTOME SURG SZ 17 CRV LAT NS,SUP-2930312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SPACER KNEE 3-10 8 MM DSTL SYS REV GUIDE ATTUNE,SUP-2454498,CDM,C1776,CPT,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
COMPONENT FEM 2XSM R DST KNEE CO CHROME ALLY POST STBL PRI C,SUP-2436158,CDM,C1776,CPT,0278,RC,,,,both,,,23761.01,15444.66,,,,,,,,,,,,,
GRAFT HUM TISS L 25-30 X W 15 MM THK T1 10 MM T2 7 MM IL,SUP-2913322,CDM,C1713,HCPCS,0278,RC,,,,both,,,4895.26,3181.92,,,,,,,,,,,,,
PLATE BNE L 441 MM SCREW DIA 3.5/4.5 MM 22 H SS LT DSTL FEM 72585122,SUP-2933084,CDM,C1713,HCPCS,0278,RC,,,,both,,,22986.37,14941.14,,,,,,,,,,,,,
ROD SPNL 72205510] ZIMMER SPINE],SUP-2415700,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
NERVE BLOCK SET 19 GAX60 CM 17 GAX9 CM CATH STIMUCATH,SUP-2383923,CDM,C1755,HCPCS,0278,RC,,,,both,,,186.39,121.15,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 18 FRX2.5 CM 5 CC N ENFIT SIL MIC-KEY,SUP-2764777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,535.24,347.91,,,,,,,,,,,,,
VALVE MITRL PASCAL REDUC LEAFLET STRESS INCREASE OPN ORIFICE,SUP-2884185,CDM,C1889,HCPCS,0278,RC,,,,both,,,96084.00,62454.60,,,,,,,,,,,,,
PRISMASATE BGK 4/0/1.2 DIALYSIS SOLUTION,RX-40850037,CDM,2500000003,HCPCS,0250,RC,09999-9907-68,NDC,,both,5000,ML,103.50,67.27,,,,,,,,,,,,,
ANTENNA ABLAT L20CM STD PERC W/ THERMOSPHERE TECHNOLOGY,SUP-2283238,CDM,C1886,HCPCS,0278,RC,,,,both,,,10010.32,6506.71,,,,,,,,,,,,,
ACTIVATOR MRI HANDHELD RAD WAVE COMM,SUP-2356409,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT BNE SUB 10CC SACROILIAC PTTY DEMIN MTRX JR FOR RIALTO,SUP-2294017,CDM,C9359,HCPCS,0278,RC,,,,both,,,4468.22,2904.34,,,,,,,,,,,,,
SHEATH INTRO CARDIAGUIDE L 63 CM DIA 8.5 FR ML1 TYP FIX CRV,SUP-2574352,CDM,C1893,HCPCS,0272,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
CONNECTOR SPNL L10MM LAT OFFSET OPN VERTEX MAX,SUP-2286781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1320.53,858.34,,,,,,,,,,,,,
CROWN DENT LL5 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176704,CDM,D6783,CPT,0278,RC,,,,both,,,26.53,17.24,,,,,,,,,,,,,
KIT CATHETER ARTERIAL 20GA 4.45CM RADIAL,SUP-2865692,CDM,C1751,HCPCS,0278,RC,,,,both,,,158.88,103.27,,,,,,,,,,,,,
PLATE BONE BAR L4MM THK1MM 6 H MAXILLOFACIAL TI CVD LO PROF,SUP-2191192,CDM,C1713,HCPCS,0278,RC,,,,both,,,1266.05,822.93,,,,,,,,,,,,,
PLATE BNE L 1.5X0.8 MM 4 MM MIDFACE 3X3 HOLE W/ TAB TI NS,SUP-2518111,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.39,597.60,,,,,,,,,,,,,
HC Removal Permanent Pacemaker Pulse Generator Only,PX-4813323300,CDM,33233,CPT,0481,RC,,,,both,,,5689.00,3697.85,,,,,,,,,,,,,
KIT INTRO L 5 CM DIA 4.5 FR GUIDEWIRE L 40 CM DIA 0.018 IN,SUP-2226021,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CATHETER DRAINAGE 14 FRX35 CM KT REG FLEXIMA VAN SONN SUMP,SUP-2147869,CDM,C1729,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE BNE W10XL100MM THK1.5MM 90DEG 8X4 H BILAT S STL T SHP,SUP-2185880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1675.32,1088.96,,,,,,,,,,,,,
NAIL IM L 130 MM DIA 4 MM TI RT FIBULAR STRL PHANTOM,SUP-2908995,CDM,C1713,HCPCS,0278,RC,,,,both,,,9239.45,6005.64,,,,,,,,,,,,,
CATHETER BLLN DIL URET,SUP-2835668,CDM,C1758,HCPCS,0278,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED H1B FOREVER,SUP-2212570,CDM,C1776,CPT,0278,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
PLATE BNE L250MM HIP TI 7 CBL FOR ACCORD SYS,SUP-2345380,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SPACER 14X12.5X8.22 MM PARL VERTIGRAFT,SUP-2264959,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
UNIVERSAL HUM NAIL 8X160MM,SUP-2587503,CDM,C1713,HCPCS,0278,RC,,,,both,,,4196.89,2727.98,,,,,,,,,,,,,
V-D-RIGHT LK PL STD HD RIGHT SMPL,SUP-2818690,CDM,C1713,HCPCS,0278,RC,,,,both,,,694.44,451.39,,,,,,,,,,,,,
CONNECTOR OFFSET 5MM FOR GMK REV SYS,SUP-2267452,CDM,C1776,CPT,0278,RC,,,,both,,,8917.60,5796.44,,,,,,,,,,,,,
LEAD NERVE STIM LNG 1.4 MMX60 CM 4 CHANNEL KT LAMITRODE S-4,SUP-2356738,CDM,C1778,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
GRAFT SKIN WXL65CM HUM AMNION CHORION MEM MULTILAYER DEHYDR,SUP-2305756,CDM,Q4186,HCPCS,0636,RC,,,,both,,,19549.64,12707.27,,,,,,,,,,,,,
KIT 5FR 3 LUMN PWR PICC HF HI FLOW W 70CM NITENOL GWIRE,SUP-2125553,CDM,C1751,HCPCS,0278,RC,,,,both,,,462.33,300.51,,,,,,,,,,,,,
GUIDE NERVE REP MTRX 5 MMX3 CM STRL NEURAGEN 3D LF,SUP-2877632,CDM,C9352,HCPCS,0278,RC,,,,both,,,8631.86,5610.71,,,,,,,,,,,,,
BASKET SPEC RETRV ACCORDIAN,SUP-2225715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BONE 4 H S STL ANK HK PLT,SUP-2389477,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
SHUNT CSF L10CM PROSA,SUP-2825718,CDM,C1889,HCPCS,0278,RC,,,,both,,,12055.97,7836.38,,,,,,,,,,,,,
COLLAR CERV FLAT REG 3 IN 1 PC IMMOB REHAB ORNG PROCARE,SUP-2196864,CDM,L0190,HCPCS,0272,RC,,,,both,,,25.47,16.56,,,,,,,,,,,,,
PLATE BNE L91MM 2 H ST R PERIARTC PROX HUM TI LOK LO PROF,SUP-2180957,CDM,C1713,HCPCS,0278,RC,,,,both,,,5600.22,3640.14,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ANGIOSCULPT L 155 CM 40 MM 2 MM,SUP-2353206,CDM,C1725,HCPCS,0272,RC,,,,both,,,3367.65,2188.97,,,,,,,,,,,,,
OSTEOTOME SURG BLADE 15 MM FLX FLAT SAW SS,SUP-2364278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
ROD SPNL TAPR OCCIPITOCERVICAL UPPER THOR FOR 5.5/6 MM SCREW,SUP-2631959,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
GUIDE PIN ORTHOPEDIC KNEE,SUP-2123460,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
STEM HUM 13 5X70 MM SHLDR,SUP-2123329,CDM,C1776,CPT,0278,RC,,,,both,,,7032.03,4570.82,,,,,,,,,,,,,
SCREW BNE LAG 12.7X50 MM 1 STP THRD SS STRL DH-DC,SUP-2186524,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.77,755.15,,,,,,,,,,,,,
NAIL IM L180MM DIA17-11MM PROX FEM COMP FOR THE STBL UNSTBL,SUP-2152594,CDM,C1713,HCPCS,0278,RC,,,,both,,,3717.13,2416.13,,,,,,,,,,,,,
MESH SURG DIA8CM POLY MFIL POLYLACTIC ACID KNIT PARTIALLY,SUP-2752164,CDM,C1781,HCPCS,0278,RC,,,,both,,,599.77,389.85,,,,,,,,,,,,,
FORCEPS ELECSURG L190MM BPLR STR BAYNT TRANSCONTINENTAL,SUP-2232205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE L164MM BRL L1IN 90DEG SUPCNDYL BILAT S STL SHT 8,SUP-2342447,CDM,C1713,HCPCS,0278,RC,,,,both,,,4995.11,3246.82,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 50 MM DIA10 MM CATH TOT L 116 CM,SUP-2148350,CDM,C1874,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
GUIDEWIRE ORTH L12IN OD1.5MM BLNT TIP CALIB MRK SCR DISP,SUP-2341338,CDM,C1769,HCPCS,0272,RC,,,,both,,,139.23,90.50,,,,,,,,,,,,,
COMPONENT TIB PS 5 UNIV 10 MM NP PRIMARY CEM STEM MONOBLOCK,SUP-2378473,CDM,C1776,CPT,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
PLATE BNE CRV SHT 2-2.5X2 MM FRAC NC LCK FOR SCR TI LEVEL 1,SUP-2467710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1408.04,915.23,,,,,,,,,,,,,
PATCH CV 1X7 CM FOR PERICARD SHELHIGH,SUP-2424961,CDM,C1768,CPT,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA 8 MM EPTFE STR TW N RING STRL,SUP-2396709,CDM,C1768,CPT,0278,RC,,,,both,,,794.42,516.37,,,,,,,,,,,,,
PLATE EXT FIX LNG 140 MM FT RNG CARBON FIBER NS,SUP-2799529,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2138.53,1390.04,,,,,,,,,,,,,
HC So Beta-2-Microglobulin,PX-3018223266,CDM,82232,CPT,0301,RC,,,,inpatient,,,426.00,276.90,,,,,,,,,,,,,
HC Transcath Closure of Asd,PX-4819358000,CDM,93580,CPT,0481,RC,,,,both,,,57405.00,37313.25,,,,,,,,,,,,,
ACETIC ACID 5 % SOLN,RX-14702,CDM,6370000000,HCPCS,0637,RC,51552-0055-03,NDC,,both,250,ML,194.10,126.16,,,,,,,,,,,,,
BIT DRL L200MM DIA3.3MM 3/16 SQ CONN CANN FOR MEDL CLMN,SUP-2321608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
IMPLANT OSS L5.9MM HD 4.25MM THK2.3MM 1.12MM INCUS STAP HA,SUP-2312818,CDM,L8613,CPT,0278,RC,,,,both,,,1368.38,889.45,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.038IN TIP L3IN NIT COR POLYUR JKT,SUP-2385123,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
PLATE BNE XS RL FIBULAR NS PENDING,SUP-2896972,CDM,C1713,HCPCS,0278,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM THN MTRX ANAT BARR FOR ORTH APPL,SUP-2120771,CDM,C1762,CPT,0278,RC,,,,both,,,2237.25,1454.21,,,,,,,,,,,,,
KIT ACL ANT CRUCE LIG CANN RUL PEN DRL PIN GWIRE RETRCT,SUP-2249535,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2885.66,1875.68,,,,,,,,,,,,,
SHEATH INTRO PRELUDE SNAP L 13 CM DIA 10 FR L 50/80 CM,SUP-2739252,CDM,C1892,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
ROD EXT FIX L250MM S STL THRD TELSCP ORIG CIR FOR TAY SPAT,SUP-2342305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.50,237.57,,,,,,,,,,,,,
PLATE BNE L66MM 6X4 H R VOLAR DST RAD S STL VAR ANG LOK,SUP-2184118,CDM,C1713,HCPCS,0278,RC,,,,both,,,2279.07,1481.40,,,,,,,,,,,,,
MESH SURG L3.5XW3.5IN POLYPR ABD NONABSORBABLE CIR IMP,SUP-2265973,CDM,C1781,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
KIT CANN W 8MM REDUC STPLR INTEGR DA VINCI SYS GUID INSTR,SUP-2246681,CDM,C1713,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
MESH HERN SQ 16X16 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855257,CDM,C1781,HCPCS,0278,RC,,,,both,,,66599.40,43289.61,,,,,,,,,,,,,
MESH HERNIAXL W8XL12IN OBLONG OVL ABD O3FA COAT POLYPR STR,SUP-2265989,CDM,C1781,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COBALT XT VR MRI SURESCAN W 51 X H 66 MM,SUP-2582927,CDM,C1722,HCPCS,0275,RC,,,,both,,,37648.60,24471.59,,,,,,,,,,,,,
CATHETER DRAINAGE 80CM CEREBROSPINAL FLUID NDL LUERLOCK CONN,SUP-2284545,CDM,C1713,HCPCS,0278,RC,,,,both,,,575.84,374.30,,,,,,,,,,,,,
JIG SURG MIS 3.5 MM RT PROX LAT,SUP-2517802,CDM,C1713,HCPCS,0278,RC,,,,both,,,25221.61,16394.05,,,,,,,,,,,,,
PLATE BONE L226MM 12 H LT MEDL DSTL TIB TIM LCK COMPR FOR,SUP-2137062,CDM,C1713,HCPCS,0278,RC,,,,both,,,5879.78,3821.86,,,,,,,,,,,,,
SCREW SPNL EMGCY 3.1X13 MM LCK MAXDRIVE,SUP-2470622,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.27,317.38,,,,,,,,,,,,,
BINDER MAMM SURG 3XL X SFT CUP,SUP-2113433,CDM,L8000,HCPCS,0274,RC,,,,both,,,132.82,86.33,,,,,,,,,,,,,
SCREW BNE CANN 7.3X60 MM 32 MM PART THRD TI STRL TRAUM FIX,SUP-2861362,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.04,592.83,,,,,,,,,,,,,
COMPONENT CRPL 3 STD WRST POLYETH FRDM,SUP-2610399,CDM,C1776,CPT,0278,RC,,,,both,,,4070.82,2646.03,,,,,,,,,,,,,
STEM FEM L160MM DIA16MM STD UNIV KNEE STR CEM PRI LEGION,SUP-2346811,CDM,C1776,CPT,0278,RC,,,,both,,,4056.88,2636.97,,,,,,,,,,,,,
HC Mech-Mv-Vc-Tv-Rr-Neg If,PX-4609479900,CDM,94799,CPT,0460,RC,,,,outpatient,,,491.00,319.15,,,,,,,,,,,,,
STENT LARYNGEAL MONTGOMERY L 11 X W 10 X H 37 MM SM SIL FIRM,SUP-2138741,CDM,C1875,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BNE L313MM 12 H ST PROX FEM S STL HK LO PROF LOK,SUP-2186063,CDM,C1713,HCPCS,0278,RC,,,,both,,,5493.65,3570.87,,,,,,,,,,,,,
BUTTON SUTURE FEM ADJ LOOP 2 LCK MECHANISM LP INFIN DISP,SUP-2846780,CDM,C1713,HCPCS,0278,RC,,,,both,,,3064.64,1992.02,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 75 CM OD 9 FR ID 3 MM HAUSDORF,SUP-2167960,CDM,C1894,HCPCS,0272,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
BUR SURG L10CM DIA2MM BALL DMND SM BOR MIDAS REX LEGEND,SUP-2277608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.94,213.16,,,,,,,,,,,,,
GRAFT EVAR L14CM AORT DIA23MM IL DIA12MM INFRARENAL TRUNK,SUP-2396039,CDM,C1768,CPT,0278,RC,,,,both,,,32342.00,21022.30,,,,,,,,,,,,,
PLATE BNE 5 X 7 H CRANIOMAXILLOFACIAL REG DISTRCTN NS,SUP-2883235,CDM,C1713,HCPCS,0278,RC,,,,both,,,5484.61,3565.00,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 20 CM DIA 6 MM CATH DIA 0.035 IN,SUP-2169462,CDM,C1889,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM CORT TI SELF DRL NONLOCKING FULL,SUP-2403075,CDM,C1713,HCPCS,0278,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
OCCLUDER SEPT 6FR WAIST L3MM DIA6MM ATR DISC DIA14X18MM,SUP-2355674,CDM,C1817,HCPCS,0278,RC,,,,both,,,20623.52,13405.29,,,,,,,,,,,,,
BOOT WALKING CAM,SUP-2390668,CDM,L4387,HCPCS,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
BIT DRL CANN 2.7 MM PERC,SUP-2862252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1047.88,681.12,,,,,,,,,,,,,
GRAFT HUM TISS W6XL12CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2112995,CDM,Q4116,HCPCS,0636,RC,,,,both,,,7818.60,5082.09,,,,,,,,,,,,,
PLATE BNE LP 1.5X0.6 MM NEURO 4X2 HOLE LADDER SQ SEG TI NS,SUP-2468727,CDM,C1713,HCPCS,0278,RC,,,,both,,,829.18,538.97,,,,,,,,,,,,,
DEFIBRILLATOR IMPL RIVACOR 7 HF-T PROMRI W 60 X H 67 MM D 10,SUP-2739235,CDM,C1898,HCPCS,0275,RC,,,,both,,,69529.02,45193.86,,,,,,,,,,,,,
SCREW BNE L36MM L19MM OD4.5MM MONSTER LNG THRD,SUP-2320609,CDM,C1713,HCPCS,0278,RC,,,,both,,,758.31,492.90,,,,,,,,,,,,,
SYSTEM CAST NO BOOT SZ 3 TCC-EZ DISP,SUP-2244454,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.41,328.52,,,,,,,,,,,,,
PLATE BNE W12XL196MM THK3.7MM LNG 8 H ST PROX HUM S STL LOK,SUP-2186020,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.60,3163.94,,,,,,,,,,,,,
NAIL IM M L260MM DIA11MM 5DEG HUM TI PROX BEND NK AG RG LOK,SUP-2408495,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
ANCHOR SUTURE 2.6 WITH TWO NO 1 4M HIFI 1 WHITE BLACK AND 1,SUP-2824684,CDM,C1713,HCPCS,0278,RC,,,,both,,,1744.52,1133.94,,,,,,,,,,,,,
CATHETER HAD 11.5FR L15CM STR POLYUR 3 LUMN FULL KT TR FL,SUP-2267013,CDM,C1751,HCPCS,0278,RC,,,,both,,,270.67,175.94,,,,,,,,,,,,,
WIRE FIX L229MM DIA2.5MM S STL PARTIALLY THRD DBL SHRP TIP,SUP-2409763,CDM,C1713,HCPCS,0278,RC,,,,both,,,41.39,26.90,,,,,,,,,,,,,
ROD SPNL POST R CRV SMOOTH TI ALLOYV 5.5MM DIA 45MM LEN,SUP-2415854,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
COIL EMB L30CM DIA13MM 0.018IN 360DEG STD STRTCH RESIST,SUP-2365687,CDM,C1889,HCPCS,0278,RC,,,,both,,,6490.57,4218.87,,,,,,,,,,,,,
PROBE LITHO 2.4FR L668MM RIG LNG FOR PNEUMAT SWISS,SUP-2140352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
SHEATH INTRO CLOSUREFAST L 7 CM DIA 6 FR SS POLYMER AD STRL,SUP-2393090,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.05,36.43,,,,,,,,,,,,,
DRILL SURG 1.5MM LNG MINI QUIK CONN VLP MINI-MOD,SUP-2351109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,721.85,469.20,,,,,,,,,,,,,
NAIL IM L150MM DIA13MM R HINDFOOT TI CANN LOK LAT BEND FLUT,SUP-2176983,CDM,C1713,HCPCS,0278,RC,,,,both,,,5611.31,3647.35,,,,,,,,,,,,,
HANDLE SURG INSTR DSTL IO-FLEX,SUP-2115827,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
WASHER ORTH LG 13 MM FOR 4.5-6.3MM SCR STRL,SUP-2461937,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.05,126.13,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.7MM DST VOLAR RAD MULTDIR FULL THRD SQ,SUP-2411813,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
STAPLE BONE FIX W9XL12MM LEG L10MM SPD TI FOR IMPL SELECTION,SUP-2135442,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PIN INT FIX GRFT PASS,SUP-2212873,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ANCHOR SUT ROT CUF EZ BRAID POLY W/ CP 2 NDL INSRTR ETHBND,SUP-2249356,CDM,C1713,HCPCS,0278,RC,,,,both,,,999.15,649.45,,,,,,,,,,,,,
ANCHOR SUTURE 5MM WITH 3 NO 2 SUTURES HI-FI DISPOSABLE DRIVE,SUP-2824809,CDM,C1713,HCPCS,0278,RC,,,,both,,,774.61,503.50,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 39 MM DIA26 MM SHTH 18 FR RVD,SUP-2170106,CDM,C1874,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
CLAMP REPROC EXT FIX PIN 5 HOLE,SUP-2516724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.10,371.21,,,,,,,,,,,,,
CANNULATED CHISEL FOR TODDLER OSTEOTOMY PLATES,SUP-2548626,CDM,C1713,HCPCS,0278,RC,,,,both,,,3026.52,1967.24,,,,,,,,,,,,,
PLATE NEURO SM 1.5MM,SUP-2277736,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
STENT CORONARY EXPRESS 2 L 16 MM DIA2.25 MM GUIDE CATH 5 FR,SUP-2144260,CDM,C1876,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE PHLANG BASE 1.5MM 2H HD 6H SHFT STRL VAL,SUP-2546073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
BAG DRNGE 1000ML DISP FOR ASPIRA SYS,SUP-2301570,CDM,C1729,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
CONTROLLER PT IPGS EON EON C EON MINI PROTEGE PROTEGE MRI,SUP-2355982,CDM,C1787,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PACK ARTHSCP HIP 3 GWIRE 2 NDL DISP,SUP-2341626,CDM,C1769,HCPCS,0272,RC,,,,both,,,930.79,605.01,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION|DISCARDED DRUG NOT ADMINISTE,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00264-7510-10,NDC,JW,both,250,ML,17.00,11.05,,,,,,,,,,,,,
PLATE BNE L 125 MM 14 H SCREW DIA2.7 MM BROAD LCK MINI FRAG,SUP-2902344,CDM,C1713,HCPCS,0278,RC,,,,both,,,4928.54,3203.55,,,,,,,,,,,,,
PROSTHESIS OSS VENT TUBE 1.27 MM W/ TAB PAPARELLA FLROPLAS,SUP-2312785,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.36,32.08,,,,,,,,,,,,,
HC Lumbar Myelogram S&I,PX-3207226500,CDM,72265,CPT,0320,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
HC Evacuation--Subungual Hematoma,PX-4501174000,CDM,11740,CPT,0450,RC,,,,both,,,396.00,257.40,,,,,,,,,,,,,
STRAP SPLNT NYL WHT 1INX14IN ROLYAN D RNG,SUP-2324779,CDM,L3908,HCPCS,0274,RC,,,,both,,,5.56,3.61,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 38 X 63 X 6 MM POLYETHYL BLOCK STRL DISP,SUP-2935525,CDM,C1713,HCPCS,0278,RC,,,,both,,,2804.02,1822.61,,,,,,,,,,,,,
MESH CRAN W50XL50MM THK0.8MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194073,CDM,C1781,HCPCS,0278,RC,,,,both,,,4846.59,3150.28,,,,,,,,,,,,,
CATHETER EP SINGLE 2-5-2MM 7FRX90CM MARINR,SUP-2281836,CDM,C1731,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
RETRACTOR W17MM H11MM L5CM TUBE D.4IN OD12MM SELF RET MEDL,SUP-2393989,CDM,C1894,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
ALLOGRAFT TISS 8 MM CORNERSTONE,SUP-2113943,CDM,C1713,HCPCS,0278,RC,,,,both,,,2662.34,1730.52,,,,,,,,,,,,,
TUBE VENT BUTTERFLY 1.27 MM 7.6X5.3 MM EAR TYMPANUM T SHP,SUP-2312834,CDM,L8699,HCPCS,0278,RC,,,,both,,,80.13,52.08,,,,,,,,,,,,,
SPACER 7770832 ELEV STD 32X8MM,SUP-2289144,CDM,C1889,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ALTRUA 40 TI SINGLE CHMBR BATTERY PWR,SUP-2149105,CDM,C1722,HCPCS,0275,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
GRAFT HUM TISS W3XL4CM MTRX CRD AMNION,SUP-2753990,CDM,C1765,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0258,RC,00264-7510-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
HC So Pregnenolone,PX-3018414066,CDM,84140,CPT,0301,RC,,,,inpatient,,,55.00,35.75,,,,,,,,,,,,,
GRAFT AORT VLV 33MM WVN DBL VEL HEMSHLD COAT,SUP-2356744,CDM,C1889,HCPCS,0278,RC,,,,both,,,25025.80,16266.77,,,,,,,,,,,,,
KIT LD DEL ACCSRY IS1 CTRL HEMOSTAS VLV INTRO TORQUE 3 W,SUP-2149006,CDM,C1887,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
LEAD DEFIB ENDOTK RELIANCE GS L 64 CM ENDOCARD STEROID ELUT,SUP-2139495,CDM,C1895,HCPCS,0275,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
PLATE BNE W14XL115MM THK3.8MM 90DEG 6 H L TIB S STL L SHP,SUP-2185781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1777.68,1155.49,,,,,,,,,,,,,
PLATE BONE SM 3X3 H T SHP,SUP-2198578,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
BEARING TIB L63/67MM THK14MM KNEE SUP STBL POST STBL CNDYL 183824] ZIMMER BIOMET ORTHOPEDICS],SUP-2407708,CDM,C1776,CPT,0278,RC,,,,both,,,7350.74,4777.98,,,,,,,,,,,,,
HEAD HUM H18.75MM DIA50MM CO CHROM ALLY BPLR STD OFFSET REV,SUP-2193861,CDM,C1776,CPT,0278,RC,,,,both,,,8962.82,5825.83,,,,,,,,,,,,,
IMMOBILIZER SHLDR E M RIB MEAS 44-48IN SZ XL,SUP-2196923,CDM,L3650,HCPCS,0272,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
NAIL FIX L 100 MM DIA 4 MM CANN TRIM HEX TAPR END DIR BARB,SUP-2904325,CDM,C1713,HCPCS,0278,RC,,,,both,,,7683.58,4994.33,,,,,,,,,,,,,
ALLOGRAFT BNE 0 DEG 10X16X6 MM COALITION AGX,SUP-2599260,CDM,C1762,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
BLADE SURG FROSTED 20 MM 8 MM TIP,SUP-2227206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1416.77,920.90,,,,,,,,,,,,,
SPACER HIP LG PMMA INNR SS GENTAMICIN TEMP RADIOPAQUE STRL,SUP-2905387,CDM,C1776,CPT,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
BOLT EXT FIX 16 MM MP,SUP-2464551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
PEG BNE FIX L18MM DIA2.5MM STD VOLAR NONLOCKING FULL THRD,SUP-2414178,CDM,C1713,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
BIT REPROC DRL CANN QUICK CPL 2.7MMX17.5CM,SUP-2653194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,592.39,385.05,,,,,,,,,,,,,
VALVE HYDROCEPHALUS WITH PEDIATRIC PRECHAMBER PROGRAM 2.0,SUP-2826122,CDM,C1889,HCPCS,0278,RC,,,,both,,,7764.75,5047.09,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN (MINI-BAG),RX-40850048,CDM,2580000003,HCPCS,0258,RC,00338-0551-18,NDC,,both,100,ML,62.10,40.36,,,,,,,,,,,,,
WIRE FIX DIA1.8MM LNG PROV,SUP-2351116,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.43,364.28,,,,,,,,,,,,,
SYSTEM VENTRICULAR DRAINAGE ANTIREFLX VLV W/ HERM VENT CATH,SUP-2883403,CDM,C1729,HCPCS,0272,RC,,,,both,,,619.90,402.93,,,,,,,,,,,,,
HC So1 Ptt / Thromboplastin Subs,PX-3058573267,CDM,85732,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
PLATE BNE L 73 MM SCREW DIA2 MM 5 HD 10 SHFT H SS T SHP VA ST,SUP-2909158,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.03,2024.12,,,,,,,,,,,,,
STENT COLON HANAROSTENT LOWAX L 90 MM DIA25 MM DEL SYS L RED,SUP-2418532,CDM,C1876,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
GUIDEWIRE URLGCL BNTSN 0.035N DIA 150CML 9CML TIP PTFE CTD S,SUP-2488661,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.06,55.29,,,,,,,,,,,,,
LEVEL CMF TMPLTE 50 799 28 XX ALMNM QT001 EA,SUP-2680247,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
DRILL SURG LAG SCR INTERTAN TRIGEN,SUP-2347575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3426.53,2227.24,,,,,,,,,,,,,
STENT BILI AD L140MM DIA7MM CATH L125CM SHTH 6FR 0.035IN,SUP-2170735,CDM,C1876,HCPCS,0278,RC,,,,both,,,3314.80,2154.62,,,,,,,,,,,,,
STENT PIPELINE FLEX EMBOL DEVICE W/ SHIELD TECH 4MMX 30MM,SUP-2854170,CDM,C2625,HCPCS,0278,RC,,,,both,,,46982.25,30538.46,,,,,,,,,,,,,
SPLINT WRST FA UNIV L 8 IN,SUP-2276643,CDM,L3809,HCPCS,0274,RC,,,,both,,,14.22,9.24,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM S STL CORT ST NONCANNULATED,SUP-2348770,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.20,99.58,,,,,,,,,,,,,
PLATE BNE 5 H CROSSCHECK UTIL ORTHOLOC 3DI,SUP-2398219,CDM,C1713,HCPCS,0278,RC,,,,both,,,5215.54,3390.10,,,,,,,,,,,,,
HC Cv Cath Plac WO Port <5yr(Tun),PX-3613655700,CDM,36557,CPT,0361,RC,,,,both,,,16763.00,10895.95,,,,,,,,,,,,,
MESH CRAN W50XL50MM THK0.5MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194071,CDM,C1781,HCPCS,0278,RC,,,,both,,,4642.18,3017.42,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|ADJ,PX-4409753000,CDM,97530,CPT,0440,RC,,,KX|CQ|ADJ,both,,,191.00,124.15,,,,,,,,,,,,,
BETHANECHOL CHLORIDE 10 MG PO TABS,RX-1043,CDM,6370000000,HCPCS,0637,RC,00832-0511-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SPACER SPNL SM W26XH40MM THORLUM PEEK CNTR INTBDY FUS ADD,SUP-2291510,CDM,C1889,HCPCS,0278,RC,,,,both,,,6430.72,4179.97,,,,,,,,,,,,,
CATHETER TRAY 6 FR 3L MAXIMAL BARR POWERHOHN,SUP-2126753,CDM,C1751,HCPCS,0278,RC,,,,both,,,851.51,553.48,,,,,,,,,,,,,
VINBLASTINE SULFATE 1 MG/ML IV SOLN,RX-8594,CDM,J9360,HCPCS,0636,RC,63323-0278-10,NDC,,both,10,ML,154.90,100.68,,,,,,,,,,,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,0636,RC,63323-0642-20,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCREW PIN GENDER SPEC FLX ZCKHIGLYPINGSF] ZIMMER BIOMET INC],SUP-2212707,CDM,C1776,CPT,0278,RC,,,,both,,,14015.77,9110.25,,,,,,,,,,,,,
KNOTLESS MINI TR IMPLANT AR8908DS,SUP-2843917,CDM,C1713,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
GUIDEWIRE VASC 0.9,SUP-2174975,CDM,C1769,HCPCS,0272,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
MATRIX BIO L 7 X W 10 CM SZ 126 SQCM FISH SKIN DERMAL MESHED,SUP-2909199,CDM,Q4158,HCPCS,0636,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS 6 L 135 CM DIA 3.1 FR,SUP-2516545,CDM,C1753,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ECLIPSE TRUNION 47MM SLOTTED TPS CAP,SUP-2815496,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
SPLINT KNEE L16IN FOR 29IN THGH UNIV FOAM LAM 3IN E CNTCT,SUP-2197153,CDM,L1810,HCPCS,0272,RC,,,,both,,,32.37,21.04,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 60 CM DIA 0.018 IN SS MANDREL TIP,SUP-2763450,CDM,C1769,HCPCS,0272,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 2.8X220 MM NS,SUP-2789097,CDM,C1769,HCPCS,0272,RC,,,,both,,,1374.82,893.63,,,,,,,,,,,,,
CEMENT BONE ROTARY MIX 3 CC REINFORCED STERILE CRANIOS,SUP-2838514,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/NONTORSION ELASTIC PREFABRICATED,SUP-2435787,CDM,L3930,HCPCS,0274,RC,,,,both,,,235.31,152.95,,,,,,,,,,,,,
SYSTEM EXTR BG 3400ML RNG DIA14CM CONTAINED W/ GELPOINT MINI,SUP-2119765,CDM,C1713,HCPCS,0278,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
CATHETER URET SET 038 5 FRX70 CM LT PGTL,SUP-2835660,CDM,C1758,HCPCS,0278,RC,,,,both,,,145.07,94.30,,,,,,,,,,,,,
SCREW BNE 4.2X50 MM,SUP-2198076,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.66,294.23,,,,,,,,,,,,,
SYSTEM REPAIR MENISCAL NOVOSTITCH PRO,SUP-2665298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2094.41,1361.37,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM LT WRST LTHR,SUP-2194370,CDM,L3809,HCPCS,0272,RC,,,,both,,,25.94,16.86,,,,,,,,,,,,,
STAPLER INT STR UNIV 45 MM REINF LINEAR GRN STRL ENDO GIA,SUP-2395287,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.43,334.38,,,,,,,,,,,,,
HC MRI Breast W&WO Cont Incl Cad Bilateral,PX-6107704900,CDM,C8908,CPT,0610,RC,,,,both,,,5627.00,3657.55,,,,,,,,,,,,,
KIT CVC AD 9FR L10CM POLYUR DBL LUMN NONTUNNELED AMLESS,SUP-2120578,CDM,C1751,HCPCS,0278,RC,,,,both,,,254.97,165.73,,,,,,,,,,,,,
PLATE BNE L 35.2 X W 18.29 MM THK 1 MM TI LT SUBCONDYLAR NS,SUP-2936431,CDM,C1713,HCPCS,0278,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
BOLT EXT FIX SPEEDWIRE,SUP-2898509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
CATHETER GUID SUPP 018 2.2-3.4 FRX150 CM QUIK CROSS SEL,SUP-2353127,CDM,C1887,HCPCS,0272,RC,,,,both,,,501.62,326.05,,,,,,,,,,,,,
COIL EMB L50CM DIA14MM HELI LSR ABLATED DARKER RADPQ MRK,SUP-2367741,CDM,C1889,HCPCS,0278,RC,,,,both,,,5467.21,3553.69,,,,,,,,,,,,,
GRAFT SURG PROC HUM DERM CLLGN RECTANG 1MM 4CMX12CM ALLOMAX,SUP-2126255,CDM,C1781,HCPCS,0278,RC,,,,both,,,3364.20,2186.73,,,,,,,,,,,,,
ROD MEAS ALIGN OPN WDG OSTEOTMY SYS SET,SUP-2121037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
INTRODUCER SHTH WORLEY RT SIDE 9FR,SUP-2329879,CDM,C1894,HCPCS,0272,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
ANCHOR FIX INLINE 6X14 MM MERID,SUP-2711020,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BNE W11XL154MM THK4.2MM 10 H MTPHSEAL S STL LOK COMPR,SUP-2185263,CDM,C1713,HCPCS,0278,RC,,,,both,,,2557.40,1662.31,,,,,,,,,,,,,
PLATE BNE L313MM 12 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186062,CDM,C1713,HCPCS,0278,RC,,,,both,,,4993.42,3245.72,,,,,,,,,,,,,
CAP NAIL FEM RETRGRD 5MM,SUP-2467184,CDM,C1776,CPT,0278,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
MESH SURG W4.3XL4.3CM CIR VENTRAL PTCH FOR TISS SEPARATING,SUP-2219821,CDM,C1781,HCPCS,0278,RC,,,,both,,,1326.90,862.48,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0018IN HYDRPHLC STD ANG FIX COR,SUP-2302956,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.54,94.60,,,,,,,,,,,,,
SCREW ACET DOME PLUG PK HIP IMP TRABECULAR MTL TI ALLOY,SUP-2203896,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
BLADE SHV L11CM 360DEG ENDO AIRWY ANG ROTATE RAD IRR TBNG,SUP-2284135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.26,511.07,,,,,,,,,,,,,
CPS SHRT CENTERING SLEEVE 27MM,SUP-2506439,CDM,C1776,CPT,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
PLATE BNE HUM 203 MM LT DSTL POSTEROLATERAL 15 HOLE LCK NS,SUP-2518323,CDM,C1713,HCPCS,0278,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
BHANSALI ALTO TOTAL DYNAMIC,SUP-2680308,CDM,L8613,CPT,0278,RC,,,,both,,,1343.29,873.14,,,,,,,,,,,,,
SPACER SPNL XL W16XH6MM D14MM 7DEG ANT CERV PEEK LORD SELF,SUP-2231287,CDM,C1821,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
SCREW BONE VARIAX 2.3MM 9MM LK TI T6 DRIVE,SUP-2695766,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.23,261.45,,,,,,,,,,,,,
KIT SUT SZ 2 L38IN FIBERWIRE W/ TAPR NDL STR NIT LOOP MIC,SUP-2122141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ALLOSYNC COTTON WEDGE 16MMX5.5MM,SUP-2811230,CDM,C1713,HCPCS,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
CEMENT BNE PMMA LO VISC RADIOPAQUE STRL V-FAST,SUP-2917103,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
SCREW BNE COMPR IDEAL COMPR 65MMX80MM ICOS,SUP-2242757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1567.52,1018.89,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ACUSON ACUNAV L 110 CM DIA 8 FR,SUP-2481874,CDM,C1753,HCPCS,0278,RC,,,,both,,,2348.41,1526.47,,,,,,,,,,,,,
CONTOURED MESH 10 XL LEFT FRNTTMPRPRTL APPRCH 0.6MM,SUP-2492074,CDM,C1713,HCPCS,0278,RC,,,,both,,,17154.54,11150.45,,,,,,,,,,,,,
PFC*MOD PL TB WDG STP-10MM SZ5,SUP-2515663,CDM,C1776,CPT,0278,RC,,,,both,,,3759.21,2443.49,,,,,,,,,,,,,
NEXGEN LCCK FEMORAL SIZE E-LT,SUP-2503327,CDM,C1776,CPT,0278,RC,,,,both,,,15448.80,10041.72,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM OD0.018IN TIP L2CM NIT COR TUNGSTEN,SUP-2172967,CDM,C1769,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
LINER ACET 0 DEG 32MM ID 60MM OD HI RIM W/PEG RNWT BRSTN,SUP-2403317,CDM,C1776,CPT,0278,RC,,,,both,,,1871.44,1216.44,,,,,,,,,,,,,
PANEL KIT 25.39X25.59X45.67 IN MOD W/ TIERX4 WM-NP1/WM-WP1,SUP-2484812,CDM,C1713,HCPCS,0278,RC,,,,both,,,2416.23,1570.55,,,,,,,,,,,,,
CATHETER CV PRESSURE MONITORING TY 018 3 FRX8 CM J TIP,SUP-2760124,CDM,C1751,HCPCS,0278,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 5X25 MM ARROW STAINLESS STEEL NON,SUP-2836752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1793.98,1166.09,,,,,,,,,,,,,
HC Ep & Ablate Ventric Tachy,PX-4819365400,CDM,93654,CPT,0481,RC,,,,both,,,39347.00,25575.55,,,,,,,,,,,,,
AZELASTINE HCL 0.1 % NA SOLN,RX-19179,CDM,6370000000,HCPCS,0637,RC,65162-0676-84,NDC,,both,30,ML,115.10,74.81,,,,,,,,,,,,,
PLATE BNE 3 H 7 PEG STD R VOLAR S STL BEAR,SUP-2389753,CDM,C1713,HCPCS,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
PLASMA-LYTE A IV SOLN,RX-6331,CDM,2580000003,HCPCS,0250,RC,00338-0221-03,NDC,,both,500,ML,80.50,52.32,,,,,,,,,,,,,
HC Breath Hydrogen/Met Test,PX-9209106500,CDM,91065,CPT,0920,RC,,,,both,,,362.00,235.30,,,,,,,,,,,,,
BIT DRL DIA4MM CALIB GRAD DEPTH MRK FOR ENCORE SYS,SUP-2197203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
SNARE ENDOSCP POLYP 2.8 MMX230 CM HEX ASMBLY SNAREMASTER +,SUP-2463704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.87,378.22,,,,,,,,,,,,,
HC a Line Insertion,PX-7613662000,CDM,36620,CPT,0761,RC,,,,both,,,789.00,512.85,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ANGIOSCULPT L 137 CM 20 MM 4 MM,SUP-2353194,CDM,C1725,HCPCS,0272,RC,,,,both,,,3022.25,1964.46,,,,,,,,,,,,,
SCREW BNE L32MM DIA4MM TIB BLU TI ST CANN LOK FULL THRD T25,SUP-2179893,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.74,325.48,,,,,,,,,,,,,
PLATE BNE L265MM THK3MM 14 H BILAT S STL STR LOK COMPR RECON,SUP-2185351,CDM,C1713,HCPCS,0278,RC,,,,both,,,2026.09,1316.96,,,,,,,,,,,,,
HC So Immunofluor per Spec Ea Add Ab,PX-3128835066,CDM,88350,CPT,0312,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
DRIVER SURG T7 CANN STK FIT HEXALOBE NS DISP,SUP-2912797,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR|DISCARDED DRUG NOT ADMINISTE,RX-6085,CDM,J2540,HCPCS,0636,RC,00049-0530-22,NDC,JW,both,1,UN,152.50,99.12,,,,,,,,,,,,,
CATHETER INFUSION 5 FRX90 CM 5 CM OCCL WIRE FOUNTAIN,SUP-2302779,CDM,C1751,HCPCS,0278,RC,,,,both,,,262.82,170.83,,,,,,,,,,,,,
CLIP SPNL SPR STIM FOR REVERE STBL SYS TRANSCONTINENTAL,SUP-2417901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BEAM BNE FIX L120MM DIA7MM FOR SALVATION SYS,SUP-2400786,CDM,C1713,HCPCS,0278,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD CEM STEM,SUP-2267788,CDM,C1776,CPT,0278,RC,,,,both,,,13545.96,8804.87,,,,,,,,,,,,,
SCREW BONE L11MM DIA2MM SNAP OFF SELF COMPRESSIVE TWST OFF,SUP-2224032,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY REFLEXION SPRL L 99 CM 7FR 6.3 MM,SUP-2678547,CDM,C1730,HCPCS,0272,RC,,,,both,,,1427.22,927.69,,,,,,,,,,,,,
IMPLANT COCHLEAR PK STRL MI1250 SYNCHRONY 2 FLEX26,SUP-2905158,CDM,L8614,HCPCS,0278,RC,,,,both,,,53851.00,35003.15,,,,,,,,,,,,,
SCREW INTFR L30MM DIA8MM BIOCRYL RAPIDE ABSRB MILAGRO ADV,SUP-2249514,CDM,C1713,HCPCS,0278,RC,,,,both,,,1595.12,1036.83,,,,,,,,,,,,,
HC Cntrl Orophary Hmrhg W Srg Int,PX-4504296200,CDM,42962,CPT,0450,RC,,,,both,,,3206.00,2083.90,,,,,,,,,,,,,
PLATE BNE L66MM 5 H RECON FOR 35MM SCR UNIV LOK SYS,SUP-2199386,CDM,C1713,HCPCS,0278,RC,,,,both,,,1210.91,787.09,,,,,,,,,,,,,
PLATE BNE FOR ORTHOPEDIC BRIDGE,SUP-2423029,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COIL NEUROVASCULAR ORBIT GALAXY G2 L 5 CM DIA 3.5 MM PRIMARY,SUP-2457746,CDM,C1889,HCPCS,0278,RC,,,,both,,,6542.13,4252.38,,,,,,,,,,,,,
CLAMP EXT FIX ANK JET-X FRDM,SUP-2342879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8284.58,5384.98,,,,,,,,,,,,,
COMPONENT FEM SZ 10 PRI ECH,SUP-2345288,CDM,C1776,CPT,0278,RC,,,,both,,,14287.00,9286.55,,,,,,,,,,,,,
MESH SURG 10 X 18.5 CM SUTURE SZ 5-0 OVINE POLYPRO,SUP-2914806,CDM,C1781,HCPCS,0278,RC,,,,both,,,9781.10,6357.71,,,,,,,,,,,,,
STEM TOE SM CO CHROM METATRSL IMP,SUP-2404753,CDM,C1776,CPT,0278,RC,,,,both,,,4797.92,3118.65,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 60 CM DIA 3 FR SIL MINI COMPR 2 STRL,SUP-2168564,CDM,C2628,HCPCS,0272,RC,,,,both,,,640.37,416.24,,,,,,,,,,,,,
STEM FEM STD OFFSET EF MAG NK W/ TRUNNION ARCOS,SUP-2443218,CDM,C1776,CPT,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
NAIL IM TROCH ENTRY 130 DEG 11 MMX40 CM LT FEM TI STRL,SUP-2412491,CDM,C1713,HCPCS,0278,RC,,,,both,,,6889.16,4477.95,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ABDUCTN ROT BAR W/SHOE,SUP-2435711,CDM,L3140,HCPCS,0272,RC,,,,both,,,252.05,163.83,,,,,,,,,,,,,
VALVE PULM HOMOGRAFT SZ 21 MM X 7.9 CM CONDUIT STRL,SUP-2175242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36251.30,23563.34,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRIMARY CAT EXCEPTION K3ZIMMER] ZIMMER BIOMET INC],SUP-2212591,CDM,C1776,CPT,0278,RC,,,,both,,,14522.50,9439.62,,,,,,,,,,,,,
HARVESTER TEND DIA 8 MM STRL DISP QUADPRO COR,SUP-2930461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
EVOS 2.7/3.5MM OLECRANON PL 8H L 114MM,SUP-2819866,CDM,C1713,HCPCS,0278,RC,,,,both,,,9076.48,5899.71,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 9X9 CM SHT AMNION/CHORION AMNIOFIX,SUP-2872718,CDM,C1762,CPT,0278,RC,,,,both,,,19675.24,12788.91,,,,,,,,,,,,,
HEAD FEM OFFSET 32 MM HIP CERM,SUP-2322454,CDM,C1776,CPT,0278,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
CABLE CATH ABLATN 5 FT EKG CONN STRL LF,SUP-2867398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
SCREW BNE L34MM DIA4MM CORT S STL ST NONCANNULATED LOK FULL,SUP-2185070,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.30,278.39,,,,,,,,,,,,,
BRACE WALKING N PNEUMATIC PRE FABRIC,SUP-2388198,CDM,L4386,HCPCS,0272,RC,,,,both,,,440.07,286.05,,,,,,,,,,,,,
SHEATH NEPHROSTOMY L 13 CM DIA22/24 FR,SUP-2937333,CDM,C1894,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER CV 3L 12.5 FRX90 CM LT KT,SUP-2626378,CDM,C1751,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PLATE BONE L46MM 6 H STRL S STL LCK COMPR FOR 2.7MM SCR EVOS,SUP-2349616,CDM,C1713,HCPCS,0278,RC,,,,both,,,2004.14,1302.69,,,,,,,,,,,,,
GRAFT BNE 1-2 MM 8 CC ACTIFUSE,SUP-2129859,CDM,C9362,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PUMP ENTERAL FEED 1-500ML/HR 1ML INCREMENT W/POLE CLAMP ST,SUP-2719878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
IMPLANT ORBIT SM W32XH13XL35MM THK1.2MM LT 3D FLR W/,SUP-2365169,CDM,C1713,HCPCS,0278,RC,,,,both,,,7488.90,4867.78,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RIVAL L 80 CM BALLOON L 4 CM DIA 6 MM,SUP-2128468,CDM,C1725,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM LT LAT VA LCK COMPR TI STRL VALCP,SUP-2789608,CDM,C1713,HCPCS,0278,RC,,,,both,,,3985.66,2590.68,,,,,,,,,,,,,
HC So Amino Acids Quantitation Each,PX-3018213166,CDM,82131,CPT,0301,RC,,,,both,,,156.00,101.40,,,,,,,,,,,,,
SET CLLR STOUT SORBATEX PD BIOENGINEERED CMFRT ADJ BTTN,SUP-2247595,CDM,L0120,HCPCS,0274,RC,,,,both,,,174.84,113.65,,,,,,,,,,,,,
PLATE BNE 2X5 H TI CRV MTRX NS DISP TRAUMAONE,SUP-2936012,CDM,C1713,HCPCS,0278,RC,,,,both,,,2766.34,1798.12,,,,,,,,,,,,,
VALVE SHUNT FLO CTRL SM PERF LEVEL 2 W/ BIOGLDE DELT,SUP-2631428,CDM,C1889,HCPCS,0278,RC,,,,both,,,4188.73,2722.67,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5 CC FIBER KORE,SUP-2736955,CDM,C1713,HCPCS,0278,RC,,,,both,,,1872.23,1216.95,,,,,,,,,,,,,
CATHETER IV 18 GAX10 CM FULL TY W/O GUARDIVA POWERGLIDE ST,SUP-2424483,CDM,C1751,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
PLATE BNE L61MM THK3.3MM 5 H BILAT S STL RIG STR DYN COMPR,SUP-2186329,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.46,305.15,,,,,,,,,,,,,
HC Repos Prev Impltbl Subq Dfb,PX-4803327300,CDM,33273,CPT,0480,RC,,,,both,,,12107.00,7869.55,,,,,,,,,,,,,
SCREW ARTHROERESIS SUBTALAR CONIC SFT THRD TI 11MM DIA 17MML,SUP-2399407,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
GRAFT VASC L40CM ID6MM THN WALLED CBAS HEP SURF PROPATEN,SUP-2395809,CDM,C1768,CPT,0278,RC,,,,both,,,3874.76,2518.59,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.8MM CORT CRANIOMAXILLOFACIAL NONLOCKING,SUP-2403077,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR TIP 035X2600 HYDRPHLC ZBR,SUP-2791284,CDM,C1769,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
HYDROCHLOROTHIAZIDE 25 MG PO TABS,RX-3720,CDM,6370000000,HCPCS,0637,RC,00172-2083-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HYPROMELLOSE 0.5 % OP SOLN,RX-91015,CDM,6370000000,HCPCS,0637,RC,00065-0408-72,NDC,,both,15,ML,125.90,81.83,,,,,,,,,,,,,
ANCHOR SUT L14.5MM DIA3MM W/ TWO SUTS BIO-SUTTAK,SUP-2121591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
GRAFT HUM TISS 2X4CM DEHYDR AMNIO MEMBRN FLOWERPATCH,SUP-2225381,CDM,Q4178,HCPCS,0636,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BONE M THK1MM 4 H MIDFACE SLV TI STR COMPR FOR 2MM SCR,SUP-2402955,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
INSERT TIB THK 12 MM IPOLY XE KNEE CR NO TRL SINGLE FACETED,SUP-2904522,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
BLADE OSTEOTOM W20MM LNG S STL HIP REV MNL THN CVD DISP,SUP-2402665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM 130DEG LNG TROCHANTERIC FEM HIP TI,SUP-2253395,CDM,C1713,HCPCS,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
SCREW BNE CORTICAL 2X6 MM 4 MM ST SS NS,SUP-2466086,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.62,127.15,,,,,,,,,,,,,
CANNULA IRRIGATION SUCTION 3.5 MM 240 MM,SUP-2537817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1887.33,1226.76,,,,,,,,,,,,,
CATHETER CV SET AD 12 FRX16 CM 3L N TUNNELED BASIC KT UNCUF,SUP-2763393,CDM,C1751,HCPCS,0278,RC,,,,both,,,256.22,166.54,,,,,,,,,,,,,
GRAFT BNE STRP 100X20X5 MM DEMINERALIZED CORTICAL BNE INFLUX,SUP-2423706,CDM,C1713,HCPCS,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
KIT INFUS PMP 100ML 5IN SOAK CATH NONNARCOTIC ELASTOMERIC,SUP-2236779,CDM,C2626,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX W 59 MM 30 J TI EPOXY RESIN SIL 3,SUP-2138111,CDM,C1882,HCPCS,0275,RC,,,,both,,,66677.90,43340.63,,,,,,,,,,,,,
SET THROMCTMY ASPIREX S L 85 CM DIA 8 FR GUIDEWIRE L 220 CM,SUP-2877647,CDM,C1757,HCPCS,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
BOOT TRAC L L20IN FOR 18IN CALF CONVOLUTED FOAM LNR STAY,SUP-2196870,CDM,L4631,HCPCS,0272,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
TRUFILL PUSH COIL COMPLEX 3MM,SUP-2464704,CDM,C1889,HCPCS,0278,RC,,,,both,,,3067.97,1994.18,,,,,,,,,,,,,
STEM HUM L190MM OD7MM UNIV TI REV CEM RVS TOT IMP BIOMOD,SUP-2403972,CDM,C1776,CPT,0278,RC,,,,both,,,12365.32,8037.46,,,,,,,,,,,,,
SHAVER BLADE SIGNATURE SERIES 4.2 MM HPS FRR PREBENT CONVEX,SUP-2824497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.03,339.32,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2.5MM FOR 5MM SCR,SUP-2187846,CDM,C1769,HCPCS,0272,RC,,,,both,,,732.56,476.16,,,,,,,,,,,,,
PIN FIX L40MM DIA2.7MM PROV VAR ANG LCK PERI-LOC VLP,SUP-2343969,CDM,C1713,HCPCS,0278,RC,,,,both,,,1385.84,900.80,,,,,,,,,,,,,
PACEMAKER CARD PHILOS II DR-T L 51 X W 44 X H 6 MM 12 CC 27,SUP-2137977,CDM,C1785,HCPCS,0275,RC,,,,both,,,16331.14,10615.24,,,,,,,,,,,,,
K WIRE FIX L4IN DIA0.062IN SMOOTH DBL TRCR PT,SUP-2304019,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.33,10.61,,,,,,,,,,,,,
TUBE VENT DIA127MM 137MM IIF TAPR BLU ULTRASIL SIL THN,SUP-2313876,CDM,L8699,HCPCS,0278,RC,,,,both,,,76.33,49.61,,,,,,,,,,,,,
BIT DRL 2.7 MM SLD W/ QUIK CONN,SUP-2848907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
GUIDEPIN ORTH 1.1X635 MM STRL DISP,SUP-2520357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BIOPSY KIT BNE MAR 11 GAX10 CM TREK,SUP-2754748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BNE W11XL298MM THK42MM 18 H MTPHSEAL S STL LOK COMPR,SUP-2185269,CDM,C1713,HCPCS,0278,RC,,,,both,,,3702.91,2406.89,,,,,,,,,,,,,
CATHETER IABP 8FR 50CC FBROPT CONN W INSRT KT TWO STATLOK,SUP-2582811,CDM,C1889,HCPCS,0278,RC,,,,both,,,3188.36,2072.43,,,,,,,,,,,,,
CANNULA SURG LNG 95 DEG 4.3 MM SCR NCB,SUP-2458046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
PLATE BNE L194MM 8 H L DST EXTRAARTICULAR HUM S STL LOK,SUP-2184049,CDM,C1713,HCPCS,0278,RC,,,,both,,,3958.91,2573.29,,,,,,,,,,,,,
SET URET STENT SOFFLX L 16 CM CATH 4.7 FR POS DIA 4.7 FR,SUP-2168898,CDM,C2617,HCPCS,0278,RC,,,,both,,,383.14,249.04,,,,,,,,,,,,,
ASSEMBLY INSTRUMENT SHUNT REG W/ BIOGLDE STRATA,SUP-2631758,CDM,C1729,HCPCS,0272,RC,,,,both,,,13084.44,8504.89,,,,,,,,,,,,,
ILLUMINATOR SURG EXAM LUMITEX VERSALIGHT,SUP-2713083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CABLE ADPT APM,SUP-2141581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
DISTRACTOR EXT FIX L100MM ANK FT TELSCP LIN FOR TRUELOK,SUP-2316064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1486.48,966.21,,,,,,,,,,,,,
DISSECTOR ULTRASONIC L26CM CRDLSS W/ TORQ WRNCH SONICISION,SUP-2283579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SCREW SPNL SD 4X11 MM VAR VENTURE,SUP-2293263,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ALLOGRAFT CELLULAR ALLOFUSE SELECT  CM 10CC,SUP-2653973,CDM,C1713,HCPCS,0278,RC,,,,both,,,16663.98,10831.59,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM PLCNTA MEM CRYOPRESERVED AMNION MTRX,SUP-2319164,CDM,Q4133,HCPCS,0636,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
COVER BURR H L 31.3 X W 24 MM SCREW DIA1.5 MM LG TI OBLNG,SUP-2936764,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
TRIAL SPNL H9MM ANT LAT LUM INTBDY FUS SPCR,SUP-2188389,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.13,477.18,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 76 MM LEG L 62 MM IPSILATERAL DIA24,SUP-2750369,CDM,C1768,CPT,0278,RC,,,,both,,,12132.96,7886.42,,,,,,,,,,,,,
FLEET ENEMA RE ENEM,RX-156779,CDM,6370000000,HCPCS,0637,RC,00132-0201-40,NDC,,both,133,ML,4.80,3.12,,,,,,,,,,,,,
ROD EXT FIX L200MM DIA8MM C CONN HOFF III,SUP-2372456,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
HEAD FEM PRI MTL ON MTL CO CHROM 28MM DIA +3 NK LEN,SUP-2404247,CDM,C1776,CPT,0278,RC,,,,both,,,3538.78,2300.21,,,,,,,,,,,,,
CANNULA ART LNG 19 FR UNCOATED HLS,SUP-2663471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.95,618.12,,,,,,,,,,,,,
PLATE BNE W10.2XL52MM THK2.7MM 4 H BILAT S STL STR LO PROF,SUP-2186191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.62,738.80,,,,,,,,,,,,,
PLATE EXTN FOR SHEFFIELD STERILISATION TY SYS,SUP-2316257,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.25,408.36,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE W/ SIPHONGUARD MIC II,SUP-2666807,CDM,C1889,HCPCS,0278,RC,,,,both,,,18930.46,12304.80,,,,,,,,,,,,,
RELOAD STPL SZ 2.3MM L60MM 0DEG UNIV WHT TI NONARTICULATING,SUP-2283061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,984.04,639.63,,,,,,,,,,,,,
BLADE SHAVER RESECT 4.5X120 MM FULL RAD BLU UNIDRIVE,SUP-2585906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,255.13,165.83,,,,,,,,,,,,,
SHELL ACET OD54MM STD UNIV GRP 2 CERAMIC MTL POLYETH POR,SUP-2304460,CDM,C1776,CPT,0278,RC,,,,both,,,7449.65,4842.27,,,,,,,,,,,,,
BRACE ORTH LUMBAR W/O RIGID STAY LSO,SUP-2388148,CDM,L0628,HCPCS,0274,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
BUR SURG DIAMOND SUPER LNG 60 K 3 MM HI SPD UNIDRIVE DISP,SUP-2599302,CDM,2720000010,LOCAL,0272,RC,,,,both,,,472.19,306.92,,,,,,,,,,,,,
STEM FEM L127MM DIA14MM DST HIP TI ALLY PLSM SPRAYED HA STR,SUP-2375620,CDM,C1776,CPT,0278,RC,,,,both,,,7720.63,5018.41,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 5 CC DBM ALLOSYNC,SUP-2431987,CDM,C1889,HCPCS,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
PLATE BNE CONN 90 DEG 3 HOLE OFFSET NS,SUP-2800048,CDM,C1713,HCPCS,0278,RC,,,,both,,,325.59,211.63,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 6 PLATE CUSTOMIZED FACE ID,SUP-2883693,CDM,C1713,HCPCS,0278,RC,,,,both,,,41921.76,27249.14,,,,,,,,,,,,,
LEAD DEFIB PERM VENT LD PACE BPLR PASS FIX IS 1 CONN 52CM,SUP-2356656,CDM,C1898,HCPCS,0275,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SHEATH KIT NANONEEDLE 125 MM,SUP-2849269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA2 MM TI MAND SD AXS NS UNIV 2.0 MP,SUP-2909526,CDM,C1713,HCPCS,0278,RC,,,,both,,,425.82,276.78,,,,,,,,,,,,,
BONE GROWTH STIM OSTEOGEN M,SUP-2136058,CDM,E0749,HCPCS,0278,RC,,,,both,,,16704.80,10858.12,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM SHT PRSS STR TIP PRIMEWIRE PRESTIGE,SUP-2327224,CDM,C1769,HCPCS,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
IMPLANT HUM TISS RT PAT OSTEOCHNDRL,SUP-2884879,CDM,C1762,CPT,0278,RC,,,,both,,,38653.40,25124.71,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM 1.5 MM CLLR BUTTON SIL STRL 510132,SUP-2535100,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.39,19.10,,,,,,,,,,,,,
GUIDEWIRE VASC AMPLTZ SST L 260 CM DIA 0.035 IN TIP L 5 CM,SUP-2763467,CDM,C1769,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5X240 MM 24 HOLE TITANIUM NON STERILE,SUP-2837695,CDM,C1713,HCPCS,0278,RC,,,,both,,,6603.42,4292.22,,,,,,,,,,,,,
FENTANYL CITRATE 1000 MCG/100ML IV SOLN,RX-156998,CDM,J7999,HCPCS,0636,RC,71266-5050-01,NDC,,both,100,ML,164.50,106.92,,,,,,,,,,,,,
BUR SURG DIA1.5 MM HUB I TWST DRL STRL REUSE HI-LINE,SUP-2928934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.25,306.31,,,,,,,,,,,,,
NEEDLE FIST 16GA L1IN ANTISTICK FIX WNG CLMP DISP BKEYE,SUP-2305492,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
LINER EXT FIX STD EZ FRAME,SUP-2500212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
PLATE BONE L96.5MM 5 H LT DSTL FIB TI ANAT FOR 2.7/3/3.5/4MM,SUP-2225370,CDM,C1713,HCPCS,0278,RC,,,,both,,,4416.10,2870.46,,,,,,,,,,,,,
THYROID 60 MG PO TABS,RX-7947,CDM,6370000000,HCPCS,0637,RC,62559-0742-01,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
DEVICE DEL BNE GRFT 10 CM W/CANN OSTEOPRECISION,SUP-2123475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT BONE L15CM FIBULAR SHFT FRZ DRY IMP,SUP-2113901,CDM,C1713,HCPCS,0278,RC,,,,both,,,2232.54,1451.15,,,,,,,,,,,,,
ACETAMINOPHEN 160 MG/5ML PO SUSP,RX-8943,CDM,340b,HCPCS,0637,RC,68094-0231-59,NDC,,both,10.15,ML,15.80,10.27,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 35 CM DIA 6 FR HYDRPHLC,SUP-2383979,CDM,C1894,HCPCS,0272,RC,,,,both,,,225.99,146.89,,,,,,,,,,,,,
SLING GYN FEM RETROPUBIC MIDURETHRAL MESH NDL TENS FRE VAG,SUP-2257135,CDM,C1771,HCPCS,0278,RC,,,,both,,,5546.06,3604.94,,,,,,,,,,,,,
GRAFT HUM TISS 7MM CERV F6183 4 007,SUP-2364351,CDM,C1713,HCPCS,0278,RC,,,,both,,,5255.04,3415.78,,,,,,,,,,,,,
FORCEPS SURG L215X115MM L12FT 15MM TIP BPLR INSUL CRD TIP (EACH = 10),SUP-2243380,CDM,C1713,HCPCS,0278,RC,,,,both,,,2086.62,1356.30,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 6X1 CM ROUNDED BOV PERICARD PHOTOFIX LTX,SUP-2859715,CDM,C1768,CPT,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SHAVER SURG HD W1.8XH1.3MM MIC HK W/ TIP SHT EXTN SIL SL,SUP-2305946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1185.66,770.68,,,,,,,,,,,,,
MESH SURG W200XL200MM THK1.5MMXCM ABD WALL BIOLOGIC PORCINE,SUP-2194312,CDM,C1763,HCPCS,0278,RC,,,,both,,,37122.02,24129.31,,,,,,,,,,,,,
COMPONENT FEM SZ 6 NP RT KNEE PRI CRUC RET CEM STEMLESS,SUP-2349035,CDM,C1776,CPT,0278,RC,,,,both,,,8728.57,5673.57,,,,,,,,,,,,,
CATHETER DRNGE L170CM OD3FR 0.018IN GRN ENDOSCP PUSH DISP,SUP-2169520,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
PLATE BONE L15MM THK0.8MM 3X2 H LCK COMPR GRID TRAP TI MALL,SUP-2267908,CDM,C1713,HCPCS,0278,RC,,,,both,,,1979.27,1286.53,,,,,,,,,,,,,
CAGE SPNL H16-25MM OD12MM 6DEG SM TI ANT THORLUM INTBDY FUS,SUP-2390790,CDM,C1889,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC IR 6FR 55CM 3 LUMAN RVS TAPR PWR IN,SUP-2613398,CDM,C1751,HCPCS,0278,RC,,,,both,,,512.76,333.29,,,,,,,,,,,,,
CLIP 9MM T BAR STANDARD PERMANENT JAWS KONKAV,SUP-2821765,CDM,C1889,HCPCS,0278,RC,,,,both,,,5952.40,3869.06,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 45 CM DIA 4-7 MM EPTFE TAPR STD,SUP-2396214,CDM,C1768,CPT,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
HC So Kit Gene Analysis D816 Variant,PX-3108127366,CDM,81273,CPT,0310,RC,,,,both,,,418.00,271.70,,,,,,,,,,,,,
COIL NEUROVASCULAR L 12 MM DIA 4 MM COMPLX SUPERSOFT XCEL,SUP-2895476,CDM,C1889,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
RELOAD STPL H41X2MM DIA45MM GRN THCK TISS NAT ARTC B FORM,SUP-2218987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.13,239.28,,,,,,,,,,,,,
PLATE BONE NAR DSTL VOLAR RAD CROSSLOCK RT STRL,SUP-2137032,CDM,C1713,HCPCS,0278,RC,,,,both,,,6267.88,4074.12,,,,,,,,,,,,,
HEAD FEM DIA32MM NK L+8MM LNG HIP ALUMINA CERAMIC FORTE,SUP-2344711,CDM,C1776,CPT,0278,RC,,,,both,,,4735.12,3077.83,,,,,,,,,,,,,
SHUNT VENTRICULAR L1.5CM DIAMETER 2.5MM CATHETER L18X120CM 1,SUP-2825944,CDM,C1889,HCPCS,0278,RC,,,,both,,,2727.75,1773.04,,,,,,,,,,,,,
GRAFT BNE DWL 14X13 MM FD CORTICAL CANC,SUP-2294047,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 30 CM FEM VEIN BLD TYP A B AB O,SUP-2884030,CDM,C1768,CPT,0278,RC,,,,both,,,24551.66,15958.58,,,,,,,,,,,,,
CATHETERIZATION KIT 0.018 IN 4 FRX2 IN CV ARROWG+ARD,SUP-2383309,CDM,C1751,HCPCS,0278,RC,,,,both,,,247.43,160.83,,,,,,,,,,,,,
GRAFT VASC L15CM BOR 32MM MAX SKRT L32MM DIA42MM PROX CLLR,SUP-2384988,CDM,C1768,CPT,0278,RC,,,,both,,,9900.42,6435.27,,,,,,,,,,,,,
GUIDEWIRE ORTH L1000MM DIA3.2MM S STL FULL THRD TIP FOR,SUP-2347060,CDM,C1769,HCPCS,0272,RC,,,,both,,,679.21,441.49,,,,,,,,,,,,,
PLATE BONE MESHED 150X150X0.6 MM CRANIAL RECONSTRUCTION RIGI,SUP-2837713,CDM,C1713,HCPCS,0278,RC,,,,both,,,11867.32,7713.76,,,,,,,,,,,,,
ROD SPNL 11X500 MM,SUP-2205344,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.20,524.03,,,,,,,,,,,,,
BIT DRL DIA 3.2/1.8 MM LNG CANN FOR HALF PIN NS DISP,SUP-2933050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1825.60,1186.64,,,,,,,,,,,,,
KIT CATH NPHRSTMY LNGMN 7FR DIA 150CML PRCTNS LOW PRFLE HIGH,SUP-2722034,CDM,C1729,HCPCS,0272,RC,,,,both,,,2002.66,1301.73,,,,,,,,,,,,,
PIN FIX L200MM OD4.8MM S STL BLNT TIP RND BVL PT SMOOTH,SUP-2342644,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
MESH HERN LG 15.7X10.2 CM W/ POCKET STRP,SUP-2858045,CDM,C1781,HCPCS,0278,RC,,,,both,,,879.17,571.46,,,,,,,,,,,,,
SCREW BNE L26MM DIA2.7MM DST RAD LOK FULL THRD SQ DRV HD LO,SUP-2411799,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
IMPLANT SZ 2 LESSER METATARSAL HD SYS,SUP-2400122,CDM,C1776,CPT,0278,RC,,,,both,,,10930.34,7104.72,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP FOR CANN,SUP-2585858,CDM,C1769,HCPCS,0272,RC,,,,both,,,263.60,171.34,,,,,,,,,,,,,
PLATE BNE 5 H R DST FIB ANK S STL LOK FOR FRAC MGMT SYS,SUP-2123023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
COIL EMB L1CM DIA0.02IN LOOP DIA2MM COMPLX EXTRA SFT FILL,SUP-2323438,CDM,C1889,HCPCS,0278,RC,,,,both,,,4954.92,3220.70,,,,,,,,,,,,,
HC ED Clsd Tx IP Disloc WO Anesth,PX-4502677000,CDM,26770,CPT,0450,RC,,,,inpatient,,,383.00,248.95,,,,,,,,,,,,,
BOOT CAST L W525XL125IN M SHOE SZ 12 155 CANVS THCK ROCK,SUP-2276729,CDM,L4387,HCPCS,0274,RC,,,,both,,,18.40,11.96,,,,,,,,,,,,,
COMPONENT HUM 8X8MM 40MM ARTC SURF OFFSET HEMICAP,SUP-2123569,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
CATHETER CV OXMTR 16 CM 3L SCVO2 MONITORING OLIGON,SUP-2480230,CDM,C1751,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
IMPLANT PIP SZ 30 SIL ELASTMR PK,SUP-2365881,CDM,C1776,CPT,0278,RC,,,,both,,,3138.12,2039.78,,,,,,,,,,,,,
PLATE BNE L61MM THK3MM 4 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185330,CDM,C1713,HCPCS,0278,RC,,,,both,,,1372.21,891.94,,,,,,,,,,,,,
PROCEDURE KIT CLOSUREFAST,SUP-2393088,CDM,C1888,HCPCS,0272,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
HC Pelvis Arteriogram,PX-3237573600,CDM,75736,CPT,0323,RC,,,,both,,,6773.00,4402.45,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 6 CM FLX TIP L 2,SUP-2167659,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.68,23.84,,,,,,,,,,,,,
ENDOBRONCHIAL KIT BX FORCEP GUIDE SLDE FOR 2MM CHANNEL STRL,SUP-2479442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.60,273.39,,,,,,,,,,,,,
PLATE BNE L215MM 12 H NONSTERILE R OLECRANON S STL LOK,SUP-2185432,CDM,C1713,HCPCS,0278,RC,,,,both,,,3340.27,2171.18,,,,,,,,,,,,,
VEST PT SURG ASST CERV HALO,SUP-2265013,CDM,L0810,HCPCS,0272,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|ADJ,PX-4309753000,CDM,97530,CPT,0430,RC,,,KX|CQ|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
CATHETER BLLN DIL 3 FRX150 CM 4 MMX4 CM 4 CM PASSPRT,SUP-2139183,CDM,C1726,HCPCS,0272,RC,,,,both,,,815.71,530.21,,,,,,,,,,,,,
GUIDE WIRE AND DRL L230 DIAM 20 SGL TRCR OPT FOR 65 SCR,SUP-2392814,CDM,C1769,HCPCS,0272,RC,,,,both,,,80.07,52.05,,,,,,,,,,,,,
DEVICE SUT M CONN OPUS SMARTSTITCH,SUP-2342087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
WAND PULSE LAVAGE 40 DEG 40 DEG NOZ CARBOJET DISP,SUP-2262259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
MEMANTINE HCL 5 MG PO TABS,RX-37170,CDM,6370000000,HCPCS,0637,RC,00904-6505-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHEATH INTRO MAX L 8.5 CM DIA 5 FR GUIDEWIRE 0.021 IN,SUP-2355462,CDM,C1894,HCPCS,0272,RC,,,,both,,,40.04,26.03,,,,,,,,,,,,,
INBONE  POLY SZ 6 13MM SULCUS,SUP-2483515,CDM,C1776,CPT,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
PLATE BONE L103MM 11 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349737,CDM,C1713,HCPCS,0278,RC,,,,both,,,4462.10,2900.36,,,,,,,,,,,,,
PLATE BONE 4X20X4 H BILAT TI DBL ANG RIG NONCOMPRESSION,SUP-2191422,CDM,C1713,HCPCS,0278,RC,,,,both,,,11256.90,7316.98,,,,,,,,,,,,,
HYDROCORTISONE VALERATE 0.2 % EX OINT,RX-10219,CDM,6370000000,HCPCS,0637,RC,51672-1292-01,NDC,,both,15,GR,354.30,230.29,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.7MM CORT CRANIOMAXILLOFACIAL MIDFACE TI 5PK,SUP-2366101,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.34,147.77,,,,,,,,,,,,,
PLATE BNE FEM 100 DEG 5 MM 14 MM PROX 4 HOLE SS STRL JPS,SUP-2645598,CDM,C1713,HCPCS,0278,RC,,,,both,,,10977.44,7135.34,,,,,,,,,,,,,
GRAFT BNE SUB 2ML DBM PTTY W/ GRAN BONUS SYN RESRB STAGRFT,SUP-2402608,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
PLATE CRAN 120X20X40 MM PT SPEC IMPL PEEK,SUP-2860117,CDM,C1713,HCPCS,0278,RC,,,,both,,,23461.45,15249.94,,,,,,,,,,,,,
CROWN DENT UR3 PED REFIL UP RT CTRL STRP FRM THN,SUP-2322243,CDM,D6783,CPT,0278,RC,,,,both,,,40.38,26.25,,,,,,,,,,,,,
AMIKACIN SULFATE 1 GM/4ML IJ SOLN (MIXTURES ONLY),RX-430075,CDM,J0278,HCPCS,0636,RC,23155-0290-41,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
LEAD DEFIB LT HRT POLYUR SIL STEROID UPLR S CRV QUICKSITE,SUP-2356618,CDM,C1900,HCPCS,0275,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X220 MM FOR CANN SCREW NS 03333014,SUP-2789095,CDM,C1769,HCPCS,0272,RC,,,,both,,,429.43,279.13,,,,,,,,,,,,,
SET URET STENT SOFFLX L 22 CM DIA10 FR INSRTR L 40 CM DIA10,SUP-2171246,CDM,C2617,HCPCS,0278,RC,,,,both,,,400.66,260.43,,,,,,,,,,,,,
PLATE OPHTH L4 3 8IN LID RETRCT S STL JAEGER,SUP-2161099,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.79,43.41,,,,,,,,,,,,,
HC Facial Bones Min 3 Views,PX-3207015000,CDM,70150,CPT,0320,RC,,,,inpatient,,,552.00,358.80,,,,,,,,,,,,,
PLATE BNE L393MM 21 H ST PERIPROSTHETIC R DST FEM TI NCB,SUP-2411451,CDM,C1713,HCPCS,0278,RC,,,,both,,,5009.15,3255.95,,,,,,,,,,,,,
PLATE BNE H MIC 140 DEG 1.5 MM CRANIOMAXILLOFACIAL 12 NS,SUP-2493025,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.51,345.48,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 30 CM DIA 5 FR GUIDEWIRE L 80,SUP-2633286,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.44,76.99,,,,,,,,,,,,,
TWIST DRILL 22MM DIA X 34MM 27MM STOP DNTL LATCH SNGLE USE,SUP-2681260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.29,268.64,,,,,,,,,,,,,
ALLOGRAFT BNE CROSS SECT 10 MM CALCANEUS MATRIGRAFT,SUP-2741036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1847.20,1200.68,,,,,,,,,,,,,
BIT DRL L 155/60 MM DIA2.5 MM CALIB AO QC STRL DISP V,SUP-2907658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,893.49,580.77,,,,,,,,,,,,,
PIN FIX L65MM SPD FOR JOURNEY II BCS KNEE SYS,SUP-2350287,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
PLUG BNE DIA10MM SM DIAM CEM,SUP-2408548,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.55,219.41,,,,,,,,,,,,,
STENT BILI OMLNK L 38 MM DIA 7 MM CATH L 135 CM GUIDEWIRE,SUP-2101584,CDM,C1876,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
COLLAR CERV SFT 375X15IN SM,SUP-2276590,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.12,3.98,,,,,,,,,,,,,
CATHETER NEPHROSTOMY PIG TIP 12 FRX25 CM SFT FLEXIMA,SUP-2147846,CDM,C1729,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
CATHETER PERI DLYS 15FR L42CM SIL 2 CUF HIGHLY KINK RESIST,SUP-2283888,CDM,C1750,HCPCS,0278,RC,,,,both,,,141.49,91.97,,,,,,,,,,,,,
GRAFT BONE SUB W1.5XL1.5CM DEMIN MTRX FLX GRFTON,SUP-2281662,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
PLATE BNE THK 0.5 MM SCREW DIA1.7 MM 3 X 21 H PLL STRUT,SUP-2883358,CDM,C1713,HCPCS,0278,RC,,,,both,,,16060.85,10439.55,,,,,,,,,,,,,
PASSER SUT 45DEG RT W/ SM PUNC FOOTPRINT SGL PORTAL PVT,SUP-2366737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 20CML 5625200,SUP-2632915,CDM,C1752,HCPCS,0278,RC,,,,both,,,838.47,545.01,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS INCUS AVG 2.7X1.5X1.6X3.5 MM DBL NOTCH,SUP-2637893,CDM,L8613,CPT,0278,RC,,,,both,,,1348.10,876.26,,,,,,,,,,,,,
TIP ASPIR L UNIV MIC CLAW DISP 25KHZ FOR ORTH SURG SONOPET,SUP-2363704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
CATHETER BLLN DIL L23CM OD9FR 2ML IU,SUP-2169837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,201.62,131.05,,,,,,,,,,,,,
SCREW BNE L5MM DIA1.5MM MIC CORT CRANIOMAXILLOFACIAL TI LEV 25678051] KLS MARTIN LP],SUP-2262820,CDM,C1713,HCPCS,0278,RC,,,,both,,,120.89,78.58,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 11.5MMW X7MML 0.4MM THK 0.6MM THK CUT INT,SUP-2605372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.77,223.45,,,,,,,,,,,,,
SYSTEM THERMOABLATION 28GA THRMCPL 20GA L180MM CANN,SUP-2293678,CDM,C1894,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
TILENE STRP 6CMX40CM LT 3PK,SUP-2402556,CDM,C1781,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
CATHETER ETER HAD 135FR 20CM CE PASS MAHRK ELITE,SUP-2613221,CDM,C1752,HCPCS,0278,RC,,,,both,,,417.81,271.58,,,,,,,,,,,,,
PLATE BNE THK06MM CHIN INSRT GRIFFIN MOD LINDORF CP TI SYS,SUP-2262500,CDM,C1713,HCPCS,0278,RC,,,,both,,,614.84,399.65,,,,,,,,,,,,,
DRIVER SURG DIA1.7MM SQ REUSE,SUP-2136621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
STENT BILI L80MM 120CM CATH LEN 9MM DIAM AD SMRT,SUP-2155438,CDM,C1876,HCPCS,0278,RC,,,,both,,,4770.26,3100.67,,,,,,,,,,,,,
CLIP ANEUR BLDE L5X49MM FEN DIA35MM OPN 49MM CLS FORC,SUP-2108333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1273.05,827.48,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 7 FRX4 CM ORNG HUB SHT GRFT PRELUDE,SUP-2303315,CDM,C1894,HCPCS,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
GUIDEWIRE VASC 0.18X300 CM CROSSING VICTORY,SUP-2140076,CDM,C1769,HCPCS,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
BUR SURG SHANNON STYL 3 MM BNE STRL BABY GORILLA,SUP-2751458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
LEVEL NEURO ST MESH 3D ULTRNE NEURO SCRW125 MM DIA T10 MM C,SUP-2677439,CDM,C1713,HCPCS,0278,RC,,,,both,,,9426.75,6127.39,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 2.8 MM RIGHT 7X23 HOLE RECONSTRUCTIO,SUP-2837768,CDM,C1713,HCPCS,0278,RC,,,,both,,,9587.68,6231.99,,,,,,,,,,,,,
SCREW BNE ST 2.7X30 MM CORTICAL LCK T8 SS NS,SUP-2177458,CDM,C1713,HCPCS,0278,RC,,,,both,,,2156.61,1401.80,,,,,,,,,,,,,
PIN DRL STR SUT BTTN FIX ON CORT BNE RETROBTTN,SUP-2121408,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
GRAFT DERM HYDRATED ULT THCK ACELLULAR DERM IMPL ALLGRFT 472510] MUSCULOSKELETAL TRANSPLANT FOUNDATION],SUP-2307496,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4276.68,2779.84,,,,,,,,,,,,,
PLATE BNE L324MM 13 H L DST FEM TI LOK COMPR NCB,SUP-2205039,CDM,C1713,HCPCS,0278,RC,,,,both,,,4139.78,2690.86,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 4 MM EPTFE STR TW N RING STRL,SUP-2396684,CDM,C1768,CPT,0278,RC,,,,both,,,2596.78,1687.91,,,,,,,,,,,,,
ROD IM FLUT 8 MM N-K II,SUP-2449178,CDM,C1713,HCPCS,0278,RC,,,,both,,,1031.49,670.47,,,,,,,,,,,,,
SCREW BNE 1.5X8 MM HEXADRIVE 4 TI SPEEDTIP,SUP-2423807,CDM,C1713,HCPCS,0278,RC,,,,both,,,429.24,279.01,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 135 CM 4.5X8 MM QUANTUM MAV,SUP-2144389,CDM,C1725,HCPCS,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
PLATE BNE ANGLED 2 MM LT 7X23 HOLE RECON MAXILLA PT SPEC,SUP-2860075,CDM,C1713,HCPCS,0278,RC,,,,both,,,23755.98,15441.39,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE|UNUSUAL NON-OVERLAPPING SERVICE,PX-4409712900,CDM,97129,CPT,0440,RC,,,GN|XU,both,,,186.00,120.90,,,,,,,,,,,,,
CITALOPRAM HYDROBROMIDE 20 MG PO TABS,RX-21062,CDM,6370000000,HCPCS,0637,RC,00904-6085-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L20MM IBT OSTEO INTRO KYPHON,SUP-2281102,CDM,C1894,HCPCS,0272,RC,,,,both,,,11062.22,7190.44,,,,,,,,,,,,,
RESERVOIR VENTRICULAR RT ANGLE STD 5 CM 0.1 CC CSF IMPREG BA,SUP-2631387,CDM,C1729,HCPCS,0272,RC,,,,both,,,1016.70,660.85,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM TRIATHLON TRIATHLONKNEE] STRYKER CORP],SUP-2366017,CDM,C1776,CPT,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
MATRIX BIO L 10 X W 4 IN BOV CLLGN CHONDROITIN-6-SULFATE,SUP-2909211,CDM,Q4108,HCPCS,0636,RC,,,,both,,,22995.04,14946.78,,,,,,,,,,,,,
CATHETER INFUSION SPEEDLYSER L 25 CM DIA 5 FR SLT PAT L 20,SUP-2118523,CDM,C1757,HCPCS,0272,RC,,,,both,,,509.37,331.09,,,,,,,,,,,,,
TUBE VENT 0.76 MM 3.81 MM 1.6 MM TINY TRIUNE SIL 510251,SUP-2473441,CDM,L8699,HCPCS,0278,RC,,,,both,,,51.84,33.70,,,,,,,,,,,,,
GRAFT BNE SYR 0.5 CC DBM ACCELL CONNEXUS,SUP-2641751,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.95,396.47,,,,,,,,,,,,,
MATRIX DURA MATER CLLGN 4X5IN SUTURABLE,SUP-2244026,CDM,C1763,HCPCS,0278,RC,,,,both,,,1001.88,651.22,,,,,,,,,,,,,
PREM ST/RGX CP/E1 LN/STD HD,SUP-2212400,CDM,C1776,CPT,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
NAIL IM L260MM DIA8MM R PROX HUM TI CANN LOK BEND T2,SUP-2369271,CDM,C1713,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
COIL EMB L20CM DIA8MM 0.018IN PERIPH HYDRGEL DETACH 18 SYS,SUP-2385419,CDM,C1889,HCPCS,0278,RC,,,,both,,,3216.36,2090.63,,,,,,,,,,,,,
PLATE BNE L 62 MM BAR 9 MM 5 H SHRT TI CRANIOMAXILLOFACIAL T,SUP-2883486,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.82,311.23,,,,,,,,,,,,,
BRACE ORTHOPEDIC PADDED UNIV ANK STIRRUP,SUP-2306212,CDM,L4350,HCPCS,0274,RC,,,,both,,,75.05,48.78,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT PELVIS HEMI STRUCTURAL L,SUP-2307413,CDM,C1713,HCPCS,0278,RC,,,,both,,,26063.13,16941.03,,,,,,,,,,,,,
CAP END OFFSET 15 MM PHOENIX,SUP-2517875,CDM,C1889,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
PPICC PROVENA SOLO SP 4F DL MAX TL,SUP-2613559,CDM,C1751,HCPCS,0278,RC,,,,both,,,765.56,497.61,,,,,,,,,,,,,
CATHETER ANGIOPLSTY IMPACT L 120 CM SHFT 7 FR BALLOON L 4 CM,SUP-2124917,CDM,C1725,HCPCS,0272,RC,,,,both,,,958.74,623.18,,,,,,,,,,,,,
KIT BNE FIX 43MM SBT 14X3.5MM LPS SCR 2.5MM PIN TIP DRL,SUP-2123091,CDM,C1713,HCPCS,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
PLATE BNE L241MM 8 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186058,CDM,C1713,HCPCS,0278,RC,,,,both,,,4599.75,2989.84,,,,,,,,,,,,,
PLATE BONE L98MM 6 H STRL RT POST DSTL TIB S STL FOR 3.5MM,SUP-2349734,CDM,C1713,HCPCS,0278,RC,,,,both,,,5147.40,3345.81,,,,,,,,,,,,,
HC Mammo Dgx Bilateral Incl Cad if Perf,PX-4017706600,CDM,77066,CPT,0401,RC,,,,outpatient,,,710.00,461.50,,,,,,,,,,,,,
STEM HUM SZ 6C L86MM 137.5DEG ANG SH STD SHLDR PTC PRESSFIT,SUP-2388553,CDM,C1776,CPT,0278,RC,,,,both,,,11539.50,7500.67,,,,,,,,,,,,,
GRAFT VSCLR L3XW1N THCKNSS 76MM TPRD END KNTTD DBLE VLR ST I,SUP-2473388,CDM,C1768,CPT,0278,RC,,,,both,,,445.60,289.64,,,,,,,,,,,,,
PROBE COAG 60DEG BLK MPLR MIC ABLAT SUCT,SUP-2341613,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
GRAFT BONE SUB 1CC DEMIN BONE MTRX ALLOSYNC PURE,SUP-2120752,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SYSTEM RETROPUBIC TENS FREE SUPP UTER PELV GYNECARE TVT,SUP-2717349,CDM,C1771,HCPCS,0278,RC,,,,both,,,5906.15,3839.00,,,,,,,,,,,,,
PLATE BONE L159MM 20 H BILAT MAND ORAL MAXILLOFACIAL TI LO,SUP-2191462,CDM,C1713,HCPCS,0278,RC,,,,both,,,4402.28,2861.48,,,,,,,,,,,,,
BIOPSY KIT BNE LESION 11 GAX6 CM 13 GAX10.8 CM TREK,SUP-2754745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
STEM FEM L205MM DIA14X9MM NK L36MM LNG STD NEUT HIP 11 13,SUP-2253038,CDM,C1776,CPT,0278,RC,,,,both,,,11707.18,7609.67,,,,,,,,,,,,,
RESERVOIR SHUNT L 14 MM DSTL CATH L 600 MM TI CTRL,SUP-2929195,CDM,C1889,HCPCS,0278,RC,,,,both,,,1936.44,1258.69,,,,,,,,,,,,,
PROCESSOR SOUND COCHLEAR IMPL UNILAT KT FOR OSI300 IMPL OSIA2I,SUP-2882740,CDM,L8614,HCPCS,0278,RC,,,,both,,,22789.74,14813.33,,,,,,,,,,,,,
CUP ACET DIA48MM RT HIP POR PRI PRESSFIT ASR,SUP-2254021,CDM,C1776,CPT,0278,RC,,,,both,,,15247.84,9911.10,,,,,,,,,,,,,
SHUNT CV SUNDT L 30 CM DSTL TBNG OD 3 MM ID 2 MM PROX TBNG,SUP-2308224,CDM,C1889,HCPCS,0278,RC,,,,both,,,2093.53,1360.79,,,,,,,,,,,,,
FIBER LSR .6MM DISP KTP/YAG,SUP-2225625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
BOLT WIRE OFFSET ADAPT SHRT,SUP-2702991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,864.76,562.09,,,,,,,,,,,,,
RELOAD STPLR MULTFI 30-25 MM LD UNIT TI STRL ENDO TA DISP,SUP-2787747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.83,371.69,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN TAPR L 4.5 CM FLPY TIP,SUP-2167777,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.39,26.90,,,,,,,,,,,,,
CATHETER CV DL 5 FRX20 CM MAX BARR DRP KT BIOFLO,SUP-2118840,CDM,C1751,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
BIT DRL CANN 2X145 MM QC FOR 2.5-3 MM SCREW PUR YEL NS,SUP-2422318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1273.58,827.83,,,,,,,,,,,,,
SCREW BNE L30MM DIA6.5MM CANC HIP S STL GRIPTION FULL THRD,SUP-2250204,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI PWR TRIALYSI SLIM CATH ACTE 1 5865150G,SUP-2632938,CDM,C1752,HCPCS,0278,RC,,,,both,,,1044.65,679.02,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 95 X W 13.5 MM MYRIAD HNDPC L 13 NN-3006,SUP-2930301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22236.19,14453.52,,,,,,,,,,,,,
BASEPLATE GLEN L AUGMENTED W/ TAPR ADPT COMPHSVE RVS SHLDR,SUP-2402734,CDM,C1776,CPT,0278,RC,,,,both,,,9294.40,6041.36,,,,,,,,,,,,,
SCREW BONE L125MM DIA7MM S STL SELF DRL ST CANN FULL THRD LO,SUP-2340800,CDM,C1713,HCPCS,0278,RC,,,,both,,,1614.27,1049.28,,,,,,,,,,,,,
CATHETER URET OPN END,SUP-2836005,CDM,C1758,HCPCS,0278,RC,,,,both,,,60.92,39.60,,,,,,,,,,,,,
BUR SURG FLUT BALL 1 MMX7 CM SM BOR MIDAS REX LEGEND,SUP-2422253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.92,227.45,,,,,,,,,,,,,
GRAFT BNE IL CREST FD,SUP-2684141,CDM,C1762,CPT,0278,RC,,,,both,,,6936.26,4508.57,,,,,,,,,,,,,
CATHETER REPERFUSION PROX 4.7FR ID0.043IN DST OD1.27MM,SUP-2323350,CDM,C1725,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
CUFF URETH L4.5CM PENILE INHIBZN OCCL SPHIN FOR URIN CTRL,SUP-2138950,CDM,C1815,HCPCS,0278,RC,,,,both,,,23003.64,14952.37,,,,,,,,,,,,,
WIRE ORTH L102MM OD1.4MM S STL SMOOTH SGL SHRP TIP TRCR PLN,SUP-2384028,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.71,41.41,,,,,,,,,,,,,
PLATE BNE COMPR SM 2.7X44 MM 5 HOLE DYN NS DCP LTX,SUP-2861898,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.48,201.81,,,,,,,,,,,,,
SCREW BONE L65MM DIA2.4MM CORT ST T7 SELF RET FOR MINI,SUP-2349287,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.21,182.14,,,,,,,,,,,,,
ANCHOR SUT PEEK KNOTLESS RADLUC OPUS SPEEDLOCK,SUP-2342086,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.01,1073.16,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,GP|KX|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCOPIC TRUETOME 39 30MM 10/BX,SUP-2677338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.19,348.52,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 5 FRX15 CM DL J TIP STRL,SUP-2759913,CDM,C1751,HCPCS,0278,RC,,,,both,,,452.00,293.80,,,,,,,,,,,,,
SEALANT TISS FIBRIN 2 CC DUPLOSPRAY TISSEEL 921052] BAXALTA US INC],SUP-2129878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
CATHETER URET PIG 0.038 IN 8 FRX70 CM C FLX LF,SUP-2470446,CDM,C1758,HCPCS,0278,RC,,,,both,,,212.08,137.85,,,,,,,,,,,,,
FIBER LASER CONCL TIP 0.6 MM FOR USE W/ KTP/YAG,SUP-2225626,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
PIN FIX DIA32MM THRD FOR CEPHALOMEDULLARY SM NAT NAIL SYS,SUP-2198687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
LACTULOSE 20 GM/30ML PO SOLN,RX-103297,CDM,6370000000,HCPCS,0637,RC,00116-4005-30,NDC,,both,30,ML,7.50,4.87,,,,,,,,,,,,,
PACK VENT ASST L SHLDR BG PT PERS SUPP,SUP-2282574,CDM,Q0498,HCPCS,0274,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
KIT NEUROSTIMULATOR LD DIA127MM ELECTRD SPC 15MM QPLR STR,SUP-2278245,CDM,C1778,HCPCS,0278,RC,,,,both,,,10723.10,6970.01,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY POLYCENTRIC,SUP-2435665,CDM,L2387,HCPCS,0272,RC,,,,both,,,540.46,351.30,,,,,,,,,,,,,
"HC So Hepatitis, a Igm Anitbody",PX-3028670966,CDM,86709,CPT,0302,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L125CM OD0035IN INTRO OD14FR STR TIP,SUP-2169710,CDM,C1769,HCPCS,0272,RC,,,,both,,,89.87,58.42,,,,,,,,,,,,,
PROX MEDIAL TIB 11 HOLE LEFT,SUP-2497741,CDM,C1713,HCPCS,0278,RC,,,,both,,,1239.67,805.79,,,,,,,,,,,,,
MESH HERNIAXL W8XL10IN INTRAABDOMINAL POLYPR OBLONG OVL,SUP-2265988,CDM,C1781,HCPCS,0278,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR INFIN 6 DBS,SUP-2431903,CDM,C1767,HCPCS,0278,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
CAGE SPNL W21XH20 25XL22MM 5DEG MIDTHORACIC INTBDY FUS TI,SUP-2182810,CDM,C1889,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
STENT URET 0.035 IN 7 FRX28 CM 6 FR MOVABLE FIRM PERC+,SUP-2470090,CDM,C1758,HCPCS,0278,RC,,,,both,,,365.21,237.39,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA 3.5 MM CORTICAL LO PROF STRL ORTHOLOC,SUP-2900508,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
CATHETER EP X LG CRV 7 FR BRAIDED COOL PATH,SUP-2357458,CDM,C2630,CPT,0272,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
PLATE BNE MIDSHAFT 180 MM FOREARM ULN 14 HOLE STRL,SUP-2518374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
BEARING TIB 2XSM THK14MM UNIV KNEE CO CHROM HNG FLAT ANT,SUP-2252665,CDM,C1776,CPT,0278,RC,,,,both,,,8160.08,5304.05,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L63CM DIL 8FR L67CM 0.032IN TRANSSEPTAL,SUP-2357159,CDM,C1893,HCPCS,0272,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
PLATE BNE L 10 H L CLAV LOK,SUP-2107747,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
INSERT TIB SZ 1 1+ H10MM ANK POLYETH INFIN,SUP-2397283,CDM,C1776,CPT,0278,RC,,,,both,,,6619.12,4302.43,,,,,,,,,,,,,
KGTI KENETIC GREAT TOE IMPL SYS INSTR TY DISP,SUP-2242676,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
GRAFT BONE SUB 30CC 0.5-3MM DEMIN CANC CORT CRUSH FRZ DRY,SUP-2294040,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
STENT URET UROGUIDE L 22 CM DIA 8.5 FR SIL NYL TETH HYDRPHLC,SUP-2480952,CDM,C2617,HCPCS,0278,RC,,,,both,,,352.53,229.14,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X4 CM BLOCKADE AMNIO PROTCT BARR,SUP-2538796,CDM,C1762,CPT,0278,RC,,,,both,,,13404.66,8713.03,,,,,,,,,,,,,
PROSTHESIS LARYN L6MM LO AIRFLO RESISTANCE EZ MAINT FOR,SUP-2124337,CDM,L8509,HCPCS,0272,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
SCREW BNE L10MM DIA3.5MM HD DIA6MM STD CORT TI ST SM HEX,SUP-2189845,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.35,38.58,,,,,,,,,,,,,
ROD EXT FIX L550MM DIA11MM UNIV C FBR RADLUC CONN,SUP-2188672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,755.48,491.06,,,,,,,,,,,,,
SPRAY PULSE 2 CK VLV,SUP-2117035,CDM,C1751,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
SPACER SPNL H9XL23-27MM 8DEG NAR ANTR LUM FEM RNG APPRCH,SUP-2306883,CDM,C1713,HCPCS,0278,RC,,,,both,,,11740.15,7631.10,,,,,,,,,,,,,
NAIL IM L320MM DIA11X11.5MM TIB FOR COMP NAILING SYS,SUP-2152504,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.31,3776.05,,,,,,,,,,,,,
LEAD PACE AD 8.6FR L62CM ATR VENT SIL POLYUR DF4 CONN INSUL,SUP-2282250,CDM,C1777,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
SPACER FEM IBII CCK AUG 74X2.5X5 POST,SUP-2199944,CDM,C1776,CPT,0278,RC,,,,both,,,5935.86,3858.31,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 1.75X1.75CM,SUP-2261683,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
HC Vertebroplasty Addl Inject,PX-3612251200,CDM,22512,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
PLATE BNE L183MM 11 H ST R DST LAT FIBULAR S STL VAR ANG,SUP-2177734,CDM,C1713,HCPCS,0278,RC,,,,both,,,3198.75,2079.19,,,,,,,,,,,,,
SHEATH INTRO PINNACLE PRECIS ACCS SYS L 10 CM 5 FR NIT STIFF,SUP-2538028,CDM,C1894,HCPCS,0272,RC,,,,both,,,194.21,126.24,,,,,,,,,,,,,
ASSEMBLY SCR HLD ENT BIPHASE,SUP-2135871,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309714000,CDM,97140,CPT,0430,RC,,,KX|CQ,both,,,194.00,126.10,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM 0.035 IN TIP L 3 MM PTFE HEPARIN J,SUP-2118918,CDM,C1769,HCPCS,0272,RC,,,,both,,,23.08,15.00,,,,,,,,,,,,,
INSERT TIB SZ 1 THK7MM UCONG BAL SYS,SUP-2314848,CDM,C1776,CPT,0278,RC,,,,both,,,3001.84,1951.20,,,,,,,,,,,,,
ENDO FUSE  FUSION ROD 7 X 60MM,SUP-2474082,CDM,C1713,HCPCS,0278,RC,,,,both,,,6518.64,4237.12,,,,,,,,,,,,,
BLADE SURG CRV SHFT LNG 2.9 MM 60 MM OSCILLATE TBNG RAD,SUP-2570715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
BIT DRL L 135 MM DIA2.7 MM AO QC NS REUSE V,SUP-2905567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.20,376.48,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 8 FRX45 CM POWERPORT ISP,SUP-2126313,CDM,C1788,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2X6 MM TITANIUM MATRIXMANDIBLE,SUP-2837725,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.09,165.16,,,,,,,,,,,,,
ALLOGRAFT BNE LG 4.1-5X0.7-0.9 CMX 1.8-2.2 MM FD NAR PROF,SUP-2499661,CDM,C1889,HCPCS,0278,RC,,,,both,,,2261.11,1469.72,,,,,,,,,,,,,
BUSHING ULN LG POLYETHYL LT ELBW TOT ARTHPLSTY STRL LATITUDE,SUP-2902294,CDM,C1776,CPT,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
NAIL IM L440MM DIA11MM 135DEG LNG LT FEM TI ALLOY CANN LCK,SUP-2371021,CDM,C1713,HCPCS,0278,RC,,,,both,,,5013.64,3258.87,,,,,,,,,,,,,
SYSTEM DEL VENTRAX L 95 CM SHTH 8.5 FR L 101 CM MS SUPP,SUP-2930562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BNE L26.6MM THK1.7MM CLP 15MM SLOT L15MM Z B,SUP-2175178,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
TUBE VENT ARMSTR R 1.14 MM 1 MM 2.7 MM FLROPLAS BLU 525502,SUP-2535157,CDM,L8699,HCPCS,0278,RC,,,,both,,,39.60,25.74,,,,,,,,,,,,,
SCREW BONE L7MM DIA1.3MM CORT CRANIOMAXILLOFACIAL TI ST FULL,SUP-2189054,CDM,C1713,HCPCS,0278,RC,,,,both,,,1326.65,862.32,,,,,,,,,,,,,
BLADE RTRCTR MED 45MMW X 130MML TTNM SPNL PRNGX5 LIGHT BLUE,SUP-2460989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1164.85,757.15,,,,,,,,,,,,,
HC US Transvaginal Obsetrical,PX-4027681700,CDM,76817,CPT,0402,RC,,,,inpatient,,,1263.00,820.95,,,,,,,,,,,,,
SLING LIFT PCH W13XL19IN SWTH W5XL54IN UNIV PERF FOAM ADJ,SUP-2194775,CDM,L3650,HCPCS,0274,RC,,,,both,,,21.70,14.10,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 68 CM DIA 0.035 IN SS PERIPH SFT,SUP-2383363,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.53,20.49,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 14 28MM 10CC B TRICALCIUM PHSPTE SYN,SUP-2194010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1860.32,1209.21,,,,,,,,,,,,,
PLATE BNE TBLR 3.5X185 MM 14 HOLE 1/3 2 COMPR LCK FOR SCR TI,SUP-2467640,CDM,C1713,HCPCS,0278,RC,,,,both,,,1138.44,739.99,,,,,,,,,,,,,
CLAMP EXT FIX SQ T-MAX,SUP-2849123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.67,235.09,,,,,,,,,,,,,
KIT PLNTR PLATE REP PEEK SINGLE TUNN NDL PASS INSRTR,SUP-2893400,CDM,C1713,HCPCS,0278,RC,,,,both,,,2424.08,1575.65,,,,,,,,,,,,,
STEM FEM L120MM MOD CEM POREX ENDO MOD,SUP-2265094,CDM,C1776,CPT,0278,RC,,,,both,,,15282.38,9933.55,,,,,,,,,,,,,
RING PESSARY SZ 4 275IN SIL W SUPP,SUP-2273826,CDM,A4562,HCPCS,0274,RC,,,,both,,,102.27,66.48,,,,,,,,,,,,,
KYPHOPLASTY KIT BLLN 10 GAX15 MM FRAC IVAS ELITE DISP,SUP-2422838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
BLADE BNE M THK5MM PARTICULATE MILL,SUP-2367526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1019.90,662.93,,,,,,,,,,,,,
STEM HUM L135MM DIA14MM UNIV DST SHLDR TI PRI REV CEM FOR,SUP-2372856,CDM,C1776,CPT,0278,RC,,,,both,,,9865.88,6412.82,,,,,,,,,,,,,
DRESSING WND ANTIMICROBIAL 12X12 IN JUMPSTART,SUP-2845383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
HC Vasc Embolize Occlude Organ,PX-3613724300,CDM,37243,CPT,0361,RC,,,,both,,,11772.00,7651.80,,,,,,,,,,,,,
HC I&D Ischio Perirectal Abs,PX-4504604000,CDM,46040,CPT,0450,RC,,,,both,,,1217.00,791.05,,,,,,,,,,,,,
HC Inject Sinus Tract Diagnostic,PX-3612050100,CDM,20501,CPT,0361,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
GRAFT BONE L50XW5XH5MM 1.25ML CANC DEMIN STRP STRL,SUP-2125419,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.63,318.91,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2.5 MM MAND 36 HOLE ANGLED-ANGLED STRL,SUP-2539584,CDM,C1713,HCPCS,0278,RC,,,,both,,,9010.17,5856.61,,,,,,,,,,,,,
ANCHOR SUT L19.5MM DIA7MM PEEK FORKED EYELET TENODESIS FOR,SUP-2121431,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
HC Anterior Nose Bleed Comp|BILATERAL PROCEDURE,PX-4503090300,CDM,30903,CPT,0450,RC,,,50,both,,,214.00,139.10,,,,,,,,,,,,,
STEM FEM SZ 1 LT N CLLRD POR NAT HIP,SUP-2210732,CDM,C1776,CPT,0278,RC,,,,both,,,14225.77,9246.75,,,,,,,,,,,,,
HEMOCONCENTRATOR PERF ACCSRY CONN HEMOCOR HPH MINI,SUP-2484378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.81,216.33,,,,,,,,,,,,,
PLATE BNE L128MM 8 H ST L PROX BILAT TIB S STL NEUT LOK,SUP-2177835,CDM,C1713,HCPCS,0278,RC,,,,both,,,4266.76,2773.39,,,,,,,,,,,,,
CATHETER HD TENCK 46 CM UNIV 1 PREPERITONEAL CUF KT ARGY,SUP-2626783,CDM,C1750,HCPCS,0278,RC,,,,both,,,219.17,142.46,,,,,,,,,,,,,
PLATE BNE T 3.5X64 MM DSTL TIB 3 HOLE SS NS LCP,SUP-2184168,CDM,C1713,HCPCS,0278,RC,,,,both,,,2008.31,1305.40,,,,,,,,,,,,,
PLATE BNE CRV SHT 1.5 MM FRAC LCK MOD TI,SUP-2489763,CDM,C1713,HCPCS,0278,RC,,,,both,,,1873.48,1217.76,,,,,,,,,,,,,
FOOT PLATE EXT FIX L 220 MM MONK RING,SUP-2899029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5345.07,3474.30,,,,,,,,,,,,,
HEAD HUM BPLR 22.2 MM OD RVS MORSE TAPR CO CHROM BI ANGULAR,SUP-2404514,CDM,C1776,CPT,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
SYSTEM INTRO SAFSHTH ULTRA DIA12 FR HEMOSTATIC TEARWY VLV,SUP-2159471,CDM,C1892,HCPCS,0272,RC,,,,both,,,626.30,407.09,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY MED AD 3.25 IN 13-16 IN PHILADELPHIA,SUP-2319294,CDM,L0172,HCPCS,0272,RC,,,,both,,,22.48,14.61,,,,,,,,,,,,,
BEAM FUS 7X90MM PROX FT SALVATION,SUP-2400744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
GRAFT HUM TISS W4XL16CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2113019,CDM,Q4116,HCPCS,0636,RC,,,,both,,,6559.46,4263.65,,,,,,,,,,,,,
SYSTEM INTRO 7FR L13CM NDL 18GA GWIRE L45CM DIA0.038IN STD,SUP-2302494,CDM,C1894,HCPCS,0272,RC,,,,both,,,85.72,55.72,,,,,,,,,,,,,
VALVE MITRL ON-X TISS ANNULUS 27-29 MM ORIFICE 23.4 MM SZ,SUP-2175263,CDM,C1889,HCPCS,0278,RC,,,,both,,,15696.86,10202.96,,,,,,,,,,,,,
KIT TEND COMPR BRDG FIBERTAPE,SUP-2122140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 12 MM DIA 3 MM SS RX BALLOON,SUP-2144487,CDM,C1876,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CATHETER HD DL 11.5 FRX15 CM FULL KT STR DUOFLO,SUP-2267017,CDM,C1750,HCPCS,0278,RC,,,,both,,,271.92,176.75,,,,,,,,,,,,,
CROWN S STL 1ST PERM M LR7 900347,SUP-2238829,CDM,D6783,CPT,0278,RC,,,,both,,,139.26,90.52,,,,,,,,,,,,,
CONNECTOR SPNL L40MM-55MM M CROSS POST ADJ TI CLMP,SUP-2415666,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.13,744.33,,,,,,,,,,,,,
HC So Dna Antibody Single Strand,PX-3028622666,CDM,86226,CPT,0302,RC,,,,both,,,48.00,31.20,,,,,,,,,,,,,
PLATE BNE T 119 MM RT DSTL DORS RADIAL 10 HOLE LCK SS,SUP-2410738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.35,1816.33,,,,,,,,,,,,,
SHUNT SURG SM ASSY 22017BLL,SUP-2628146,CDM,C1729,HCPCS,0272,RC,,,,both,,,3130.74,2034.98,,,,,,,,,,,,,
HC So Insitu Hybridization,PX-3128836466,CDM,88364,CPT,0312,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
PLATE BNE H0.5MM 18 H UP FACE BLU TI STR MAL LEIBINGER UNIV,SUP-2366231,CDM,C1713,HCPCS,0278,RC,,,,both,,,1568.68,1019.64,,,,,,,,,,,,,
MATRIX BIO L 25 X W 10 CM FET BOV DERM DERMAL SLD STRL,SUP-2909300,CDM,Q4110,HCPCS,0636,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PLATE BNE L 95 MM SCREW DIA2.4 MM 5 HD 10 SHFT H TI Y SHP,SUP-2908020,CDM,C1713,HCPCS,0278,RC,,,,both,,,3064.58,1991.98,,,,,,,,,,,,,
COMPONENT FEM SZ 3 RT POST STBL PRI STEMLESS NP UNISX PROFIX,SUP-2347021,CDM,C1776,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL AD 7FRX60CM,SUP-2357196,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
ARTEMETHER-LUMEFANTRINE 20-120 MG PO TABS,RX-96854,CDM,6370000000,HCPCS,0637,RC,00078-0568-45,NDC,,both,1,UN,25.30,16.44,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 5 MM DEL SHTH 1.8ML,SUP-2937070,CDM,C1713,HCPCS,0278,RC,,,,both,,,5030.28,3269.68,,,,,,,,,,,,,
STEM HUM 6 150 DEG 6X101 MM SHLDR RASP TI,SUP-2427330,CDM,C1776,CPT,0278,RC,,,,both,,,9253.58,6014.83,,,,,,,,,,,,,
SCREW COMPR 4.5X28MM HEADLESS TI SHRT THRD STRL,SUP-2547064,CDM,C1713,HCPCS,0278,RC,,,,both,,,917.10,596.11,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 5MM SMOOTH DISPOSABLE WITHOUT,SUP-2804749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.74,322.23,,,,,,,,,,,,,
KIT DRNGE STRT PERI INSRT TY W CATHETER DSG KT ASPIRA,SUP-2126465,CDM,C1729,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BNE L184MM 11 H NONSTERILE R DST RAD VOLAR DPHSEAL,SUP-2184059,CDM,C1713,HCPCS,0278,RC,,,,both,,,4623.43,3005.23,,,,,,,,,,,,,
SET PNEUMOTHOR CATHETER 63FR L20CM NDL 18GA PGTL TRUNER,SUP-2167918,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
HC Sinuses Min 3 Views,PX-3207022000,CDM,70220,CPT,0320,RC,,,,outpatient,,,664.00,431.60,,,,,,,,,,,,,
KIT INTRO VSI DE-CLOT SHTH L 4 CM DIA 7 FR GUIDEWIRE L 40 CM,SUP-2120538,CDM,C1757,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CROWN DENT 4UR UPPER RT LAT PRIMARY REFILL SS UNITEK,SUP-2322222,CDM,D6783,CPT,0278,RC,,,,both,,,12.40,8.06,,,,,,,,,,,,,
STIMULATOR NERVE PENTA SYS PROCLAIM ELITE XR 5,SUP-2862943,CDM,C1767,HCPCS,0278,RC,,,,both,,,48670.00,31635.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DYN XT L 65 CM DIA 6 FR SPC 5 MM,SUP-2142738,CDM,C1730,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BIT DRL L125MM DIA1.8MM QUIK CPL NONRADIOLUCENT W/O STP,SUP-2187303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.68,372.89,,,,,,,,,,,,,
CLIP EMG DYN STIM SZ L NEUROVISION,SUP-2309803,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
PLATE BNE L 95 X W 11.2 MM THK 3.5 MM 5 H SS LT PROX RADIAL,SUP-2933168,CDM,C1713,HCPCS,0278,RC,,,,both,,,2735.25,1777.91,,,,,,,,,,,,,
BAG TISS CLSR DIA10CM TRNSPAR SIL SILO SPR LD PROX OPN SFT,SUP-2134675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1560.58,1014.38,,,,,,,,,,,,,
SET SCR DBL HEX TI,SUP-2415553,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.92,260.60,,,,,,,,,,,,,
BIT DRILL ARTHSCP 7MM OD ACL/PCL CNNLTD F/LGMNT RCNSTRCTN LA,SUP-2589234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.14,1040.09,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 15 CM FLPY TIP L,SUP-2167731,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.68,42.04,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX55 CM FULL TY INJ POWERPICC,SUP-2126370,CDM,C1751,HCPCS,0278,RC,,,,both,,,448.24,291.36,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL M W90XL90MM THK0.3MM MALL UPGRADED,SUP-2419459,CDM,C1713,HCPCS,0278,RC,,,,both,,,5188.82,3372.73,,,,,,,,,,,,,
IMPLANT FACE 38 X 50 MM THK 0.85 MM POLYETHYL CRANIOFACIAL,SUP-2883226,CDM,C1713,HCPCS,0278,RC,,,,both,,,1374.19,893.22,,,,,,,,,,,,,
BIT DRL FOR SHT 5MM HALF PIN JET-X,SUP-2342943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2235.62,1453.15,,,,,,,,,,,,,
TRIAL KNEE TIB WDG FOR HTO,SUP-2121040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
HEAD FEM OD46MM ID28MM UNIV CO CHROM COMPHSVE SZ ARRY FOR,SUP-2379240,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
L-BUTT PLT STERILIZER 4 HL 86 MM LENGTH RIGHT,SUP-2818498,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.92,1639.25,,,,,,,,,,,,,
CATHETER URET OPN END 038 5 FRX85 CM MOD FLEXI-TIP,SUP-2835781,CDM,C1758,HCPCS,0278,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
HEAD FEM V40 TAPR LFIT ION IMP CO CHROM 26MM + 16MM TRIDENT,SUP-2364461,CDM,C1776,CPT,0278,RC,,,,both,,,1809.27,1176.03,,,,,,,,,,,,,
PLATE BNE HK SM 3.5/4.5X211 MM RT FEM PROX 5 HOLE NS VA-LCP,SUP-2750910,CDM,C1713,HCPCS,0278,RC,,,,both,,,7083.15,4604.05,,,,,,,,,,,,,
GRAFT BIO TISS MARIGEN EXPANSE 7X8CM MESHED,SUP-2909357,CDM,Q4158,HCPCS,0636,RC,,,,both,,,8352.40,5429.06,,,,,,,,,,,,,
CALIBRATED DRILL 4.4MM,SUP-2487831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1183.72,769.42,,,,,,,,,,,,,
SYSTEM URIN CTRL W2XL4CM W/O INHIBZN OCCL CUF BELT M AMS,SUP-2138919,CDM,C1815,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR PT FOR URIN CTRL INTERSTIM ICON,SUP-2284411,CDM,C1787,HCPCS,0278,RC,,,,both,,,3549.77,2307.35,,,,,,,,,,,,,
CATHETER CV KT 0.018 IN PEDIATRIC 4 FRX13 CM DL INTRO NDL,SUP-2763322,CDM,C1751,HCPCS,0278,RC,,,,both,,,131.25,85.31,,,,,,,,,,,,,
GRAFT VASC IMPRA L 20 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761251,CDM,C1768,CPT,0278,RC,,,,both,,,861.08,559.70,,,,,,,,,,,,,
HC Central Ven Cath 5+ Yrs|UNUSUAL NON-OVERLAPPING SERVICE,PX-4503655600,CDM,36556,CPT,0450,RC,,,XU,outpatient,,,9955.00,6470.75,,,,,,,,,,,,,
MIS LOCK CALC PLT SM EXD 2H LT,SUP-2586880,CDM,C1713,HCPCS,0278,RC,,,,both,,,2624.35,1705.83,,,,,,,,,,,,,
SYSTEM PRT CLOSURE 10/12 MM 15 MM XL CARTER-THOMASON II,SUP-2756023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.29,430.49,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 40 MM DIA18 MM SHTH 11 FR CATH L,SUP-2147038,CDM,C1876,HCPCS,0278,RC,,,,both,,,3464.93,2252.20,,,,,,,,,,,,,
ANCHOR SUT DIA2.9MM 2 DBL ARM NONABSORBABLE ULTRABRAID,SUP-2341742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
KIT IMPL L450MM DIA4MM TIM IM AND ENDCAP THE NANCY NAIL,SUP-2253253,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
RING EXT FIX DIA220 MM 1/2 CIR,SUP-2898403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM DIA 6 FR SPC 2-5-2 MM E,SUP-2248676,CDM,C1730,HCPCS,0272,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
GRAFT VASC STR 7 MMX50 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761304,CDM,C1768,CPT,0278,RC,,,,both,,,1910.78,1242.01,,,,,,,,,,,,,
STEM FEM L50MM DIA14MM KNEE CEM REV ATTUNE,SUP-2251474,CDM,C1776,CPT,0278,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
GRAFT BNE FEM HD STRUT FD,SUP-2684087,CDM,C1762,CPT,0278,RC,,,,both,,,9624.10,6255.66,,,,,,,,,,,,,
WALKER M SHT LEG NONSKID,SUP-2276711,CDM,L4387,HCPCS,0272,RC,,,,both,,,83.68,54.39,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK MOLD DSTL CUSH,SUP-2388209,CDM,L5668,HCPCS,0274,RC,,,,both,,,267.03,173.57,,,,,,,,,,,,,
SEGMENTAL DISTAL FEMUR SIZE C-RT,SUP-2502381,CDM,C1776,CPT,0278,RC,,,,both,,,21406.95,13914.52,,,,,,,,,,,,,
NUT SPNL,SUP-2585559,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
HC Tcp02/Abi 1-2 Levels,PX-9209392200,CDM,93922,CPT,0921,RC,,,,both,,,810.00,526.50,,,,,,,,,,,,,
BIT DRL DIA1.6 MM FOR STD TECH LOWER EXTREMITY ANAT PLATING,SUP-2905655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.51,359.13,,,,,,,,,,,,,
BLOCK LARYN NETTERVILLE PHONOFORM LT SIL,SUP-2243733,CDM,C1878,HCPCS,0278,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR PRSS FT STEM,SUP-2365426,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GRAFT BNE WDG 9 MM TISS TRICORT,SUP-2391738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 23 MMX5 CM ZMED II,SUP-2309687,CDM,C1725,HCPCS,0272,RC,,,,both,,,2089.76,1358.34,,,,,,,,,,,,,
IMPL BREAST GEL BOOST SMTH MOD + PROF 290CC,SUP-2738067,CDM,C1789,HCPCS,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
SPACER 7770823 ELEV STD 23X8MM,SUP-2289142,CDM,C1821,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
IMPLANT BRST SIL SHELL COHESIVE SMOOTH RND MOD PROF 600CC,SUP-2300429,CDM,C1789,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SHEATH TRANSSEPTAL 45 DEG L 63 CM DIA 8.5 FR GUIDEWIRE L 180,SUP-2913151,CDM,C1893,HCPCS,0272,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
GRAFT MTRX DERM PTCH SFT TISS REP 5CMX4CM,SUP-2335293,CDM,Q4128,HCPCS,0636,RC,,,,both,,,7686.72,4996.37,,,,,,,,,,,,,
HC Drug Screen Quantitative Tobramycin,PX-3018020000,CDM,80200,CPT,0301,RC,,,,outpatient,,,322.00,209.30,,,,,,,,,,,,,
PLATE BNE L86MM 4 H R DST LAT FIBULAR S STL LOK COMPR FOR,SUP-2177413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.5X150 MM AOS,SUP-2766032,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
IMPLANT SYNTH TISS L 122 X W 122 MM THK 0.5 MM 1.7 MM PLLA,SUP-2883135,CDM,C1713,HCPCS,0278,RC,,,,both,,,13360.64,8684.42,,,,,,,,,,,,,
CATHETER ETER URET OD8FR OPN END,SUP-2141718,CDM,C1758,HCPCS,0278,RC,,,,both,,,118.66,77.13,,,,,,,,,,,,,
WIRE SURG 400X2 MM REDUCTION MR SAFE,SUP-2187485,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.21,427.84,,,,,,,,,,,,,
TROCAR SURG OD5.5 MM SCR LCK VERSANAIL,SUP-2412770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
ANCHOR SUT L12.5MM DIA2.9MM SHT PEEK KNOTLESS REVISABLE,SUP-2121762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
CATHETER SOLEX 7 HEPARIN USA,SUP-2570572,CDM,C1751,HCPCS,0278,RC,,,,both,,,3316.34,2155.62,,,,,,,,,,,,,
WIRE FIX L350MM DIA1.8MM S STL SGL END SMOOTH SHRP TIP SPRD,SUP-2186869,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.54,141.40,,,,,,,,,,,,,
BLADE SAW SAG 6.5MMW X30MML 0.4MM THK 0.6MM THK CUT ANTR CRU,SUP-2605390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,79.35,51.58,,,,,,,,,,,,,
ALLOGRAFT HUM TISS INJ 2 CC AMNIO FLUID PRO3-FA,SUP-2434348,CDM,C1762,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
LIFT HEEL SM W2IN BRN FAB WDG 3 LAYR ORTHOT FT W/O CLSR,SUP-2325935,CDM,L3334,HCPCS,0274,RC,,,,both,,,18.34,11.92,,,,,,,,,,,,,
KIT IMPL HIP HYB HIP-CEM,SUP-2212103,CDM,C1776,CPT,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
EVOS 2.7/3.5 OLCRNN PL W/TNS 4H L 82MM,SUP-2819863,CDM,C1713,HCPCS,0278,RC,,,,both,,,8436.87,5483.97,,,,,,,,,,,,,
BRONCHOSCOPE FLX L 600 MM OD 5 MM ID 2.2 MM SAMP SET STRL,SUP-2882950,CDM,C1601,HCPCS,0272,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
HC Retro Urethrocystography S&I,PX-3207445000,CDM,74450,CPT,0320,RC,,,,both,,,911.00,592.15,,,,,,,,,,,,,
MESH HERN 30X30CM MACROPOROUS PARIETENE,SUP-2172437,CDM,C1781,HCPCS,0278,RC,,,,both,,,325.84,211.80,,,,,,,,,,,,,
CUBE EXTERNAL FIXATION 4 HOLE STAINLESS STEEL,SUP-2586503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,795.64,517.17,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,KX|CO,both,,,195.00,126.75,,,,,,,,,,,,,
HC Reposition of Venous Lead Cs,PX-3613322600,CDM,33226,CPT,0361,RC,,,,both,,,5379.00,3496.35,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM DIA 0.035 IN SS STR FIX COR STRL,SUP-2760015,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.36,28.18,,,,,,,,,,,,,
SCREW BONE L65MM OD2.7MM THRD L15MM S STL CORT ST PERIARTC,SUP-2349971,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.54,239.55,,,,,,,,,,,,,
LENS INTOCU BI-CONVEX ASYMMETRICAL 0.0 - 4.0 IN 1.0 DIOPT A,SUP-2129500,CDM,V2632,HCPCS,0276,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
TRAY TIB KNEE CR KT STRL ITOTAL,SUP-2904600,CDM,C1776,CPT,0278,RC,,,,both,,,7339.75,4770.84,,,,,,,,,,,,,
LNT IMPLANT SYSTEM 2.9 BC PUSHLOCK,SUP-2812050,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE THK 1 MM BAR 10 MM SCREW DIA2 MM 6 H MINI CRV,SUP-2883179,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.63,600.36,,,,,,,,,,,,,
GRAFT STENT 16 FR AAA,SUP-2395965,CDM,C1768,CPT,0278,RC,,,,both,,,11275.74,7329.23,,,,,,,,,,,,,
SCREW BNE LCK 3.5X38 MM CRTX NS PERI-LOC,SUP-2348576,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.19,50.82,,,,,,,,,,,,,
PROSTHESIS OSS SHEA HA/FP 3X5.4 MM 1.14 MM HA FLROPLAS,SUP-2637896,CDM,L8613,CPT,0278,RC,,,,both,,,1269.13,824.93,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 7 FRX15 CM 3L STRL,SUP-2759920,CDM,C1751,HCPCS,0278,RC,,,,both,,,557.35,362.28,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ LOOP LOK W STAY FIRM SUPP,SUP-2276658,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.45,10.69,,,,,,,,,,,,,
NECK FEM L38MM 8DEG GRN MOD HIP REJUVENATE,SUP-2365870,CDM,C1776,CPT,0278,RC,,,,both,,,2642.31,1717.50,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 5 MM 4.4 FRX20 MM TRUTOME 8309,SUP-2484706,CDM,C1713,HCPCS,0278,RC,,,,both,,,917.16,596.15,,,,,,,,,,,,,
CLAMP EXT FIX MULTIPIN STRL GALAXY FIX GEM LTX,SUP-2875642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5547.28,3605.73,,,,,,,,,,,,,
HC Cyclic Citrullinated Peptide Antibody,PX-3028620000,CDM,86200,CPT,0302,RC,,,,both,,,70.00,45.50,,,,,,,,,,,,,
BIT DRL OD37MM COUNTSINK,SUP-2417209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
SCREW BNE EMGCY 2X10 MM STARDRV RECESS TI NS,SUP-2188968,CDM,C1713,HCPCS,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
PROBE LSR 25GA PICK RFID ILLUMINATED MEMBRN PUREPOINT,SUP-2109948,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.78,309.91,,,,,,,,,,,,,
NEEDLE SPNL BVL 11 GAX6 IN FOR PEDCL ACCS SERENGETI,SUP-2855001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.81,424.33,,,,,,,,,,,,,
BUR SURG DIA 1MM GRU STERILE,SUP-2650030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18.68,12.14,,,,,,,,,,,,,
SCREW BONE L11MM DIA1.5MM TI TRILOK HEXADRIVE 4 APTUS,SUP-2268081,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.98,285.99,,,,,,,,,,,,,
LGN EXT FLUTE PRESSFIT STEM 20MMX160MM,SUP-2822667,CDM,C1776,CPT,0278,RC,,,,both,,,4100.84,2665.55,,,,,,,,,,,,,
FIXATOR EXT PEDIATRIC,SUP-2874976,CDM,C1713,HCPCS,0278,RC,,,,both,,,6000.54,3900.35,,,,,,,,,,,,,
PLATE TI LOCKING 1.3MM 3H HEAD 5H SHAFT STERILE,SUP-2546880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1538.85,1000.25,,,,,,,,,,,,,
PROBE LTHTRPSY DSPSBLE 19FR PNMTC F/UTRSCPY AUTLTH IEHL,SUP-2722575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
PLATE BNE THK 0.4 MM SCREW DIA1.5 MM LG RT MIDFACE ANAT SHP,SUP-2934897,CDM,C1713,HCPCS,0278,RC,,,,both,,,4854.44,3155.39,,,,,,,,,,,,,
PLATE BNE HK 4.5/5X169 MM PROX FEM 4 HOLE LP LCK COMPR SS,SUP-2186054,CDM,C1713,HCPCS,0278,RC,,,,both,,,4367.39,2838.80,,,,,,,,,,,,,
SHEATH INTRO PRELUDE PRESTIGE L 13 CM DIA10.5 FR 12 CC SYR,SUP-2458288,CDM,C1892,HCPCS,0272,RC,,,,both,,,45.72,29.72,,,,,,,,,,,,,
PLATE BONE CRANIAL MESH 40.2X25.2X0.3MM TITANIUM NEURO PLATI,SUP-2826280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1394.47,906.41,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK CATH AXS VECTA 46 CM VECTA 74,SUP-2878081,CDM,C1757,HCPCS,0272,RC,,,,both,,,13302.92,8646.90,,,,,,,,,,,,,
HC So1 Rickettsia Ab,PX-3028675767,CDM,86757,CPT,0302,RC,,,,both,,,443.00,287.95,,,,,,,,,,,,,
WIRE FIX THRD 2.5 MM OLV DISP,SUP-2417726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
GRAFT BNE 10 CC FILL KT STRL OSTEOCRETE,SUP-2418808,CDM,C1713,HCPCS,0278,RC,,,,both,,,9291.26,6039.32,,,,,,,,,,,,,
PLATE BNE 3.5X54 MM 4 HOLE SS LC-DCP,SUP-2569226,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.69,136.95,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN PTFE,SUP-2147061,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.91,29.84,,,,,,,,,,,,,
BENZOCAINE-MENTHOL 15-2.6 MG MT LOZG,RX-110389,CDM,6370000000,HCPCS,0637,RC,63824-0730-16,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALISKIREN FUMARATE 150 MG PO TABS,RX-78653,CDM,6370000000,HCPCS,0637,RC,49884-0424-11,NDC,,both,1,UN,25.00,16.25,,,,,,,,,,,,,
SET PICC 3L 6FR X 55CM BP,SUP-2887072,CDM,C1751,HCPCS,0278,RC,,,,both,,,1104.24,717.76,,,,,,,,,,,,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,J7131,HCPCS,0258,RC,00338-0054-03,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE 4.25X14MM CERV VAR SPIDER,SUP-2402174,CDM,C1713,HCPCS,0278,RC,,,,both,,,5286.03,3435.92,,,,,,,,,,,,,
POST EXT FIX 6 H FOR SIDEKCK EZ FRME FIX SYS,SUP-2418809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SCREW BONE L65MM DIA3.5MM PROX CORT TIB TYP II ANODIZED TI,SUP-2411705,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.42,125.72,,,,,,,,,,,,,
TRAY GRFT PREP SYS STRL,SUP-2256632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5397.66,3508.48,,,,,,,,,,,,,
RING RINGFIX SYS ALUM 180MM,SUP-2696082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4007.27,2604.73,,,,,,,,,,,,,
SHEATH NEPHSTMY L22CM DIA10MM RENAL ACCS BVL END GWIRE NOTCH,SUP-2126725,CDM,C1894,HCPCS,0272,RC,,,,both,,,150.22,97.64,,,,,,,,,,,,,
SCREW CORT 3.5MM DIAX40MM LNG,SUP-2205634,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
GUIDEWIRE STRAIGHT .035IN NITINOL FLEXIBLE SOLO,SUP-2655878,CDM,C1769,HCPCS,0272,RC,,,,both,,,249.03,161.87,,,,,,,,,,,,,
STEM HUM L74MM DIA3B 132.5DEG STD SHLDR PTC AEQUALIS ASCEND,SUP-2388733,CDM,C1776,CPT,0278,RC,,,,both,,,11016.69,7160.85,,,,,,,,,,,,,
NEEDLE SET CHESBROUGH 19 GAX2.75 IN 5 CM,SUP-2242570,CDM,C1819,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
PIN FIX 10 DSTL RADIOULNAR JT LCK,SUP-2435795,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BALLOON L11.5 MM RX STRL,SUP-2141486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
GRAFT BIO TISS W10XL25CM MESHED FET BOV ACELLULAR DERM MTRX,SUP-2243700,CDM,Q4110,HCPCS,0636,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
BLADE SAW W9XL31MM THK0.38MM OSC AND SAG MIC 2 CUT,SUP-2367515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,153.45,99.74,,,,,,,,,,,,,
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,LOCAL,31653,CPT,0360,RC,,,,outpatient,,,23138.48,13883.09,,,,,,,,,,,,,
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE|PO,CASE-64616,LOCAL,64616,CPT,0360,RC,,,50|PO,outpatient,,,6312.15,3787.29,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,LOCAL,29888,CPT,0360,RC,,,RT,outpatient,,,45851.97,27511.18,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open|RIGHT SIDE|PO,CASE-24358,LOCAL,24358,CPT,,,,,RT|PO,outpatient,,,16398.15,9838.89,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level|RIGHT SIDE",CASE-64495,LOCAL,64495,CPT,0360,RC,,,RT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FIFTH DIGIT|SEPARATE STRUCTURE",CASE-26440,LOCAL,26440,CPT,,,,,F9|XS,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,LOCAL,46260,CPT,,,,,,outpatient,,,16283.80,9770.28,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|LEFT FOOT, FIFTH DIGIT",CASE-28810,LOCAL,28810,CPT,,,,,T4,outpatient,,,19833.02,11899.81,,,,,,,,,,,,,
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE|PO,CASE-25447,LOCAL,25447,CPT,,,,,RT|PO,outpatient,,,18976.62,11385.97,,,,,,,,,,,,,
Arthrp Kne Condyle&Platu Medial&Lat Compartments|LEFT SIDE,CASE-27447,LOCAL,27447,CPT,0360,RC,,,LT,outpatient,,,57336.70,34402.02,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PO,CASE-20610,LOCAL,20610,CPT,0510,RC,,,50|PO,outpatient,,,4578.38,2747.03,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,LOCAL,38525,CPT,0360,RC,,,RT,outpatient,,,41466.28,24879.77,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,LOCAL,38525,CPT,,,,,RT|XU,outpatient,,,47697.25,28618.35,,,,,,,,,,,,,
Optx Greater Humeral Tuberosity Fx W/Int Fixj|RIGHT SIDE,CASE-23630,LOCAL,23630,CPT,,,,,RT,outpatient,,,57059.65,34235.79,,,,,,,,,,,,,
HC Inj Proc Elbow Arthrography,PX-3612422000,CDM,24220,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BONE 8 H MIC UN2 STR W/O BAR,SUP-2365225,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.02,428.36,,,,,,,,,,,,,
INSERT SHLDR C DIA39MM THK+6MM 7.5DEG REVERSED AEQUALIS,SUP-2416996,CDM,C1776,CPT,0278,RC,,,,both,,,4661.33,3029.86,,,,,,,,,,,,,
MESH WND DERM REP FET BOV DERM IONIC SLV PRIMATRIX AG FEN,SUP-2243709,CDM,Q4110,HCPCS,0636,RC,,,,both,,,27624.15,17955.70,,,,,,,,,,,,,
WIRE FIX L150MM OD1.1MM NICKEL CHROM SMOOTH DBL END TRCR,SUP-2321644,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,0636,RC,50242-0120-47,NDC,,both,1,UN,24477.00,15910.05,,,,,,,,,,,,,
GRAFT HUM TISS L 20X40MM PERICARD FRZ DRY READIGRFT,SUP-2264834,CDM,C1713,HCPCS,0278,RC,,,,both,,,539.04,350.38,,,,,,,,,,,,,
HINGE EXT FIX IN LN SALVATION,SUP-2401123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2075.54,1349.10,,,,,,,,,,,,,
SCREW BNE L36MM OD43MM TI LO EXT ST SELF DRL CANN FIX STBL,SUP-2242829,CDM,C1713,HCPCS,0278,RC,,,,both,,,1462.61,950.70,,,,,,,,,,,,,
Arthroscopy Knee Lateral Release|LEFT SIDE|PO,CASE-29873,LOCAL,29873,CPT,,,,,LT|PO,outpatient,,,30808.27,18484.96,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.5 Cm/<,CASE-11400,LOCAL,11400,CPT,0360,RC,,,,outpatient,,,11550.72,6930.43,,,,,,,,,,,,,
Tenotomy Open Extensor Foot/Toe Each Tendon,CASE-28234,LOCAL,28234,CPT,0360,RC,,,,outpatient,,,11454.52,6872.71,,,,,,,,,,,,,
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt|RIGHT SIDE|PO,CASE-27602,LOCAL,27602,CPT,0360,RC,,,RT|PO,outpatient,,,20832.28,12499.37,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit W Pta,CASE-36902,LOCAL,36902,CPT,0361,RC,,,,outpatient,,,26806.57,16083.94,,,,,,,,,,,,,
Adjnt Tis Trnsfr/Reargmt Any Area 30.1-60 Sq Cm,CASE-14301,LOCAL,14301,CPT,0360,RC,,,,outpatient,,,78411.37,47046.82,,,,,,,,,,,,,
Sgmdsc Flx Dired Sbmcsl Njx Any Sbst,CASE-45335,LOCAL,45335,CPT,0360,RC,,,,outpatient,,,11148.15,6688.89,,,,,,,,,,,,,
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE,CASE-24073,LOCAL,24073,CPT,,,,,LT,outpatient,,,35681.82,21409.09,,,,,,,,,,,,,
Ligj & Div Short Saph Vein Saphenopop Junct Spx|LEFT SIDE,CASE-37780,LOCAL,37780,CPT,0360,RC,,,LT,outpatient,,,39737.47,23842.48,,,,,,,,,,,,,
Grafting of Autologous Fat by Lipo 25 Cc or Less|PO,CASE-15773,LOCAL,15773,CPT,0360,RC,,,PO,outpatient,,,39270.40,23562.24,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,LOCAL,29824,CPT,0360,RC,,,RT,outpatient,,,42758.73,25655.24,,,,,,,,,,,,,
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE|PO,CASE-27650,LOCAL,27650,CPT,,,,,LT|PO,outpatient,,,35116.67,21070.00,,,,,,,,,,,,,
"Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn|LEFT HAND, FOURTH DIGIT|PO",CASE-26145,LOCAL,26145,CPT,0360,RC,,,F3|PO,outpatient,,,14915.00,8949.00,,,,,,,,,,,,,
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,LOCAL,46261,CPT,0360,RC,,,,outpatient,,,22140.22,13284.13,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,LOCAL,58662,CPT,,,,,,outpatient,,,37464.60,22478.76,,,,,,,,,,,,,
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,LOCAL,43238,CPT,,,,,,outpatient,,,22030.83,13218.50,,,,,,,,,,,,,
MESH HERN M W8.5XL13.7CM L INGUINAL WHT POLYPR MFIL,SUP-2125771,CDM,C1781,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
SCREW BNE X DRV 2.7X21 MM TI THREADLOCK TS LEVEL 1,SUP-2462009,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.83,194.24,,,,,,,,,,,,,
DEFIBRILLATOR CARD RESYNCHRONIZATION THER DEFIB CRT-D 3,SUP-2138032,CDM,C1721,HCPCS,0275,RC,,,,both,,,57257.90,37217.63,,,,,,,,,,,,,
CATHETER INTRAAORTIC BAL 8FR 30CC ULT,SUP-2383460,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
SCREW BNE X DRV 2X7 MM CRANIOMAXILLOFACIAL DRILL-FREE LEVEL1,SUP-2461567,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.44,114.69,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 18.5-21 IN CTR 14-15 IN CALF 14-16 IN DROPLK,SUP-2916919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.24,279.66,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 8 23-27X11 MM FRZN NAR LORDTC ANTR FRA,SUP-2736759,CDM,C1713,HCPCS,0278,RC,,,,both,,,11740.15,7631.10,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE|PO,CASE-25608,LOCAL,25608,CPT,0360,RC,,,RT|PO,outpatient,,,28201.32,16920.79,,,,,,,,,,,,,
HC Ccu R&B,PX-2100000000,CDM,2100000000,LOCAL,,,,,,outpatient,,,5765.50,3459.30,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE|PO,CASE-29826,LOCAL,29826,CPT,0360,RC,,,LT|PO,outpatient,,,55425.58,33255.35,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,LOCAL,28750,CPT,0360,RC,,,T5,outpatient,,,62578.70,37547.22,,,,,,,,,,,,,
Osteotomy Radius Distal Third|RIGHT SIDE|PO,CASE-25350,LOCAL,25350,CPT,0360,RC,,,RT|PO,outpatient,,,54421.65,32652.99,,,,,,,,,,,,,
Bladder Instillation Anticarcinogenic Agent|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51720,LOCAL,51720,CPT,,,,,XU,outpatient,,,22622.17,13573.30,,,,,,,,,,,,,
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,LOCAL,26480,CPT,0360,RC,,,,outpatient,,,15327.97,9196.78,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|PO,CASE-28308,LOCAL,28308,CPT,0360,RC,,,RT|PO,outpatient,,,27135.67,16281.40,,,,,,,,,,,,,
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,LOCAL,20552,CPT,0510,RC,,,,outpatient,,,3561.57,2136.94,,,,,,,,,,,,,
Repair Brow Ptosis|BILATERAL PROCEDURE|PO,CASE-67900,LOCAL,67900,CPT,0360,RC,,,50|PO,outpatient,,,61605.28,36963.17,,,,,,,,,,,,,
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|RIGHT SIDE|PO,CASE-28238,LOCAL,28238,CPT,0360,RC,,,RT|PO,outpatient,,,34347.48,20608.49,,,,,,,,,,,,,
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,LOCAL,51102,CPT,0360,RC,,,,outpatient,,,16492.77,9895.66,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|RIGHT SIDE|SEPARATE STRUCTURE,CASE-52332,LOCAL,52332,CPT,0360,RC,,,RT|XS,outpatient,,,24675.85,14805.51,,,,,,,,,,,,,
Axillary Lymphadenectomy Complete,CASE-38745,LOCAL,38745,CPT,0360,RC,,,,outpatient,,,48449.03,29069.42,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE|PO,CASE-64454,LOCAL,64454,CPT,,,,,LT|PO,outpatient,,,4722.57,2833.54,,,,,,,,,,,,,
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,LOCAL,52354,CPT,,,,,LT,outpatient,,,22753.05,13651.83,,,,,,,,,,,,,
HC Trluml Balo Angiop 1st Vein|RIGHT SIDE,CASE-37248,LOCAL,37248,CPT,0361,RC,,,RT,outpatient,,,27259.98,16355.99,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE|PO,CASE-29888,LOCAL,29888,CPT,0360,RC,,,LT|PO,outpatient,,,56524.38,33914.63,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26160,LOCAL,26160,CPT,,,,,F9|PO,outpatient,,,10505.60,6303.36,,,,,,,,,,,,,
PLATE BONE LOK 117MML HLX7 PRTSL 64 CNTRD NCB ST PRXML HMRL,SUP-2729943,CDM,C1713,HCPCS,0278,RC,,,,both,,,4719.36,3067.58,,,,,,,,,,,,,
PLATE BNE L TIM L CALCNL LNG LOK ALPS,SUP-2413698,CDM,C1713,HCPCS,0278,RC,,,,both,,,3400.62,2210.40,,,,,,,,,,,,,
SPLINT DORS NT M 10 14 WOM 11 15 SZ L XL,SUP-2196391,CDM,L4398,HCPCS,0274,RC,,,,both,,,97.53,63.39,,,,,,,,,,,,,
KT CTRL VEN CATH L20CM OD7FR SFTY 3 LUM,SUP-2927790,CDM,C1751,HCPCS,0278,RC,,,,both,,,209.97,136.48,,,,,,,,,,,,,
GRAFT BONE 2.5 CC GROWTH PROTEIN FACTOR MEDIUM,SUP-2424570,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,LOCAL,45380,CPT,0360,RC,,,XU|PT,outpatient,,,12009.52,7205.71,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,LOCAL,43236,CPT,0360,RC,,,XU,outpatient,,,22116.95,13270.17,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE|PO,CASE-29882,LOCAL,29882,CPT,,,,,LT|PO,outpatient,,,53517.53,32110.52,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27695,LOCAL,27695,CPT,,,,,LT|XU,outpatient,,,45301.70,27181.02,,,,,,,,,,,,,
Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT SIDE|PO,CASE-26111,LOCAL,26111,CPT,,,,,RT|PO,outpatient,,,8639.88,5183.93,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,LOCAL,38525,CPT,,,,,LT|XU,outpatient,,,33468.58,20081.15,,,,,,,,,,,,,
Excision Malignant Lesion S/N/H/F/G 0.6-1.0 Cm,CASE-11621,LOCAL,11621,CPT,0360,RC,,,,outpatient,,,17682.82,10609.69,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE|PO,CASE-64633,LOCAL,64633,CPT,,,,,LT|PO,outpatient,,,12270.58,7362.35,,,,,,,,,,,,,
Revis Shoulder Arthrplsty Humeral&Glenoid Compnt,CASE-23474,LOCAL,23474,CPT,0360,RC,,,,outpatient,,,104345.23,62607.14,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening,CASE-25390,LOCAL,25390,CPT,,,,,,outpatient,,,37299.03,22379.42,,,,,,,,,,,,,
Arthrt Elbow Capsular Excision Capsular Rls Spx,CASE-24006,LOCAL,24006,CPT,,,,,,outpatient,,,29263.73,17558.24,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,LOCAL,28289,CPT,0360,RC,,,T5,outpatient,,,34378.30,20626.98,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent,CASE-52332,LOCAL,52332,CPT,,,,,,outpatient,,,37858.80,22715.28,,,,,,,,,,,,,
Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins|RIGHT SIDE|PO,CASE-25320,LOCAL,25320,CPT,0360,RC,,,RT|PO,outpatient,,,18142.28,10885.37,,,,,,,,,,,,,
Mastectomy Simple Complete|LEFT SIDE,CASE-19303,LOCAL,19303,CPT,0360,RC,,,LT,outpatient,,,44917.28,26950.37,,,,,,,,,,,,,
Cystourethroscopy With Biopsy|SEPARATE STRUCTURE,CASE-52204,LOCAL,52204,CPT,0360,RC,,,XS,outpatient,,,26984.53,16190.72,,,,,,,,,,,,,
MESH BONE SM 0.6MM THK TTNM LATEX FREE TMPRL MXLFCL,SUP-2488358,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.85,2633.05,,,,,,,,,,,,,
ALLOGRAFT BNE SPNG 25X20X7 MM BLOCK DBM CANC H-GENIN,SUP-2225962,CDM,C1889,HCPCS,0278,RC,,,,both,,,7278.52,4731.04,,,,,,,,,,,,,
CONNECTOR SPNL THORLUM TI PARA SM STAT FOR 5 6MM ROD USS II,SUP-2193434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BONE L61MM 5 H S STL SELF COMPR FOR 3.5MM SCR ECT,SUP-2198564,CDM,C1713,HCPCS,0278,RC,,,,both,,,245.27,159.43,,,,,,,,,,,,,
TEMPLATE SURG ROD FLX PREF 2,SUP-2577917,CDM,C1821,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SCREW BONE SCHANZ 2.5 MM 4X22 MM SYMPHYSIS SELFDRILLING TITA,SUP-2842153,CDM,C1713,HCPCS,0278,RC,,,,both,,,1426.50,927.22,,,,,,,,,,,,,
WASHER ORTH DIA3.5/4.5MM FOR PROX TIB PLT,SUP-2185708,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.35,102.93,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE PRE THN SM 20X17.5 CMX0.7-1.4 MM FLEXHD,SUP-2430130,CDM,Q4128,HCPCS,0636,RC,,,,both,,,33346.80,21675.42,,,,,,,,,,,,,
GRAFT HUM TISS 5X5 CM GRAFIX COR,SUP-2319178,CDM,Q4132,HCPCS,0636,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
GRAFT BNE SUB SM 5CC DBM BIOCOMPOSITE OSTEOSET CANC CHIP,SUP-2399073,CDM,C9359,HCPCS,0278,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
SMALL KNOT PUSHER,SUP-2811802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
CATHETER VENTRICULAR NON-PRESSURE TBNG BLU STRP,SUP-2666734,CDM,C1729,HCPCS,0272,RC,,,,both,,,52.19,33.92,,,,,,,,,,,,,
BIT DRL DIA16MM FOR SM BNE PLATING SYS ORTHOLOC 3DI,SUP-2398069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
SCREW BNE CANC UNIV 4X32 MM LCK ST FT SM FRAG TI,SUP-2458615,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.66,51.13,,,,,,,,,,,,,
SLEEVE POS DIA11MM UNIV SHLDR CO CHROM CEM PRI FOR HUM FRAC,SUP-2404533,CDM,C1776,CPT,0278,RC,,,,both,,,659.24,428.51,,,,,,,,,,,,,
BIT DRILL CALIBRATED 4.2 EX-LONG,SUP-2718101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.43,466.98,,,,,,,,,,,,,
Open Treatment Talus Fracture|RIGHT SIDE,CASE-28445,LOCAL,28445,CPT,0360,RC,,,RT,outpatient,,,35280.80,21168.48,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE|PO,CASE-64633,LOCAL,64633,CPT,0360,RC,,,50|PO,outpatient,,,12270.58,7362.35,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|LEFT SIDE|PO,CASE-G0260,LOCAL,G0260,CPT,,,,,LT|PO,outpatient,,,4478.50,2687.10,,,,,,,,,,,,,
Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,CASE-55866,LOCAL,55866,CPT,0360,RC,,,,outpatient,,,112313.43,67388.06,,,,,,,,,,,,,
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl,CASE-37232,LOCAL,37232,CPT,,,,,,outpatient,,,124503.83,74702.30,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,LOCAL,28308,CPT,0360,RC,,,LT,outpatient,,,27750.93,16650.56,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FOURTH DIGIT|SEPARATE STRUCTURE",CASE-26440,LOCAL,26440,CPT,,,,,F8|XS,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
Rpr Nonunion Scaphoid Carpal Bne W/WO Rdl Stylec|RIGHT SIDE|PO,CASE-25440,LOCAL,25440,CPT,0360,RC,,,RT|PO,outpatient,,,24858.07,14914.84,,,,,,,,,,,,,
Rcnstj Angular Dfrm Toe Soft Tiss Px Only,CASE-28313,LOCAL,28313,CPT,,,,,,outpatient,,,21723.10,13033.86,,,,,,,,,,,,,
Unlisted Procedure Femur/Knee|RIGHT SIDE,CASE-27599,LOCAL,27599,CPT,0360,RC,,,RT,outpatient,,,11188.77,6713.26,,,,,,,,,,,,,
SCREW EXT FIX L200MM DIA5MM THRD L80MM CORT TI SELF DRL,SUP-2193169,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.76,341.74,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 22X0.5X1 MM SLGHT CONTOURED STRL,SUP-2479093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.66,796.03,,,,,,,,,,,,,
PLATE BNE L53MM 3X7 H S STL T LOK COMPR FOR 2MM SCR MOD,SUP-2186320,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.77,755.15,,,,,,,,,,,,,
IMPLANT FACE L 52 X W 40 MM THK 2.3 MM ORBIT FLR MINIPLATE,SUP-2883518,CDM,C1713,HCPCS,0278,RC,,,,both,,,2975.84,1934.30,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL III W 5.94 X H 7.77 CM D,SUP-2149223,CDM,C1722,HCPCS,0275,RC,,,,both,,,73790.00,47963.50,,,,,,,,,,,,,
RX MESH106 X 30 X 06MM SM GRID,SUP-2669267,CDM,C1713,HCPCS,0278,RC,,,,both,,,4245.25,2759.41,,,,,,,,,,,,,
DRESSING WND BIO FISH SKIN FENSTRTED 3CM X 3.5CM RSFH ONLY,SUP-2859689,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2103.49,1367.27,,,,,,,,,,,,,
BIT DRL 3.2X128 MM,SUP-2862472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,104.66,68.03,,,,,,,,,,,,,
GRAFT NRV REP L2.5CM ID5MM PERIPH NRV TYP I CLLGN,SUP-2378809,CDM,C9355,HCPCS,0278,RC,,,,both,,,3381.78,2198.16,,,,,,,,,,,,,
SCREW BNE SD 4X80 MM 20 MM THRD HA SCHNZ SS NS,SUP-2186976,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.41,293.42,,,,,,,,,,,,,
CURETTE SURG 4 6.75 IN 10.8X7.6 MM STR NS RUGGLES-REDMOND,SUP-2473280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.89,325.58,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO|SEPARATE STRUCTURE,CASE-62323,LOCAL,62323,CPT,0360,RC,,,PO|XS,outpatient,,,5330.43,3198.26,,,,,,,,,,,,,
Arthroscopy Knee Removal Loose/Foreign Body,CASE-29874,LOCAL,29874,CPT,0360,RC,,,,outpatient,,,18525.75,11115.45,,,,,,,,,,,,,
Cystourethroscopy W/Dil Bladder General Anesth,CASE-52260,LOCAL,52260,CPT,0360,RC,,,,outpatient,,,18956.38,11373.83,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE|PO,CASE-29880,LOCAL,29880,CPT,,,,,LT|PO,outpatient,,,21272.87,12763.72,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, SECOND DIGIT|PO",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F1|PO,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
Laparoscopy Surg Ablation Renal Cysts|RIGHT SIDE,CASE-50541,LOCAL,50541,CPT,,,,,RT,outpatient,,,102769.62,61661.77,,,,,,,,,,,,,
Repair Non/Malunion Humerus W/Iliac/Oth Agrft|LEFT SIDE,CASE-24435,LOCAL,24435,CPT,0360,RC,,,LT,outpatient,,,52858.08,31714.85,,,,,,,,,,,,,
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,LOCAL,49593,CPT,,,,,,outpatient,,,41189.45,24713.67,,,,,,,,,,,,,
HC Debride Subq First 20 Sq Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-11042,LOCAL,11042,CPT,0361,RC,,,XU,outpatient,,,16967.82,10180.69,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28291,LOCAL,28291,CPT,,,,,T5|PO,outpatient,,,22995.98,13797.59,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,LOCAL,49650,CPT,0360,RC,,,LT,outpatient,,,43070.95,25842.57,,,,,,,,,,,,,
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE|SEPARATE STRUCTURE,CASE-27339,LOCAL,27339,CPT,0360,RC,,,LT|XS,outpatient,,,30349.03,18209.42,,,,,,,,,,,,,
PSEUDOEPHEDRINE HCL ER 120 MG PO TB12,RX-6716,CDM,6370000000,HCPCS,0637,RC,45802-0107-52,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BLADE SURG STP AKIN,SUP-2897519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
KIT EEG ELECTRD L 26.5 MM 8 CONTACT STRL DISP EVO,SUP-2936437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3030.10,1969.56,,,,,,,,,,,,,
BRACE KNEE POSTOP UNIV UNISX FASTEN ON HNG ROM STRP CLSR AD,SUP-2196449,CDM,L1832,HCPCS,0274,RC,,,,both,,,401.45,260.94,,,,,,,,,,,,,
PLATE BNE L292MM 18 H ST R ANTLAT DST TIB S STL VAR ANG LOK,SUP-2177695,CDM,C1713,HCPCS,0278,RC,,,,both,,,7845.54,5099.60,,,,,,,,,,,,,
STIMULATOR NERVE PT CHARGER NS ETERNA LTX,SUP-2858396,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
STRUT TELESCOPIC MED 138 201MM BL,SUP-2695647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5255.10,3415.81,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED HA S2 TORNIER,SUP-2388886,CDM,C1776,CPT,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|PO,CASE-64493,LOCAL,64493,CPT,,,,,PO,outpatient,,,4354.35,2612.61,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FIFTH DIGIT|PO",CASE-26123,LOCAL,26123,CPT,,,,,F4|PO,outpatient,,,13579.88,8147.93,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,LOCAL,28122,CPT,0360,RC,,,RT|XU,outpatient,,,17062.68,10237.61,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Capsulorrhaphy|PO,CASE-29806,LOCAL,29806,CPT,0360,RC,,,PO,outpatient,,,43306.68,25984.01,,,,,,,,,,,,,
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,LOCAL,43282,CPT,0360,RC,,,,outpatient,,,125917.75,75550.65,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj 1st Metar|SEPARATE STRUCTURE|LEFT SIDE,CASE-28306,LOCAL,28306,CPT,0360,RC,,,XS|LT,outpatient,,,119772.13,71863.28,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE|PO,CASE-64483,LOCAL,64483,CPT,0360,RC,,,LT|PO,outpatient,,,3914.52,2348.71,,,,,,,,,,,,,
Tendon Sheath Incision|PO,CASE-26055,LOCAL,26055,CPT,0360,RC,,,PO,outpatient,,,8480.43,5088.26,,,,,,,,,,,,,
Syndactylization Toes|BILATERAL PROCEDURE|PO,CASE-28280,LOCAL,28280,CPT,0360,RC,,,50|PO,outpatient,,,21355.03,12813.02,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|PO",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F7|PO,outpatient,,,8252.15,4951.29,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,LOCAL,64718,CPT,0360,RC,,,,outpatient,,,13338.30,8002.98,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|SEPARATE STRUCTURE,CASE-23430,LOCAL,23430,CPT,,,,,XS,outpatient,,,75254.82,45152.89,,,,,,,,,,,,,
BONE VOID FILLERS MORSELIZED ALLOGRAFTS CANC MILLED CANC,SUP-2307071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2096.89,1362.98,,,,,,,,,,,,,
BIT DRL QC LG LNG 5 MM FOR CANN SCREW NS,SUP-2789109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1609.94,1046.46,,,,,,,,,,,,,
COMPONENT PAT DIA35MM THK8MM TRI PEG POLYETH ONLAY RM SYS,SUP-2304739,CDM,C1776,CPT,0278,RC,,,,both,,,2249.18,1461.97,,,,,,,,,,,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,0636,RC,63323-0402-03,NDC,,both,1,UN,295.90,192.33,,,,,,,,,,,,,
CARTRIDGE BNE MILL STRL PREP + LTX DISP,SUP-2859295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2410.45,1566.79,,,,,,,,,,,,,
PROBE ARTHSCP 90DEG 3.0MM WAND ABLAT BPLR RF SAPHYRE VULCAN,SUP-2341029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
CATH DAIG S2STR 5FR 100CM,SUP-2301645,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.93,49.35,,,,,,,,,,,,,
PASSER SUT FOR HIP ARTHRO CRESC XL ACCU-PASS DIR,SUP-2342824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
KIT INTRODUCER TRACH BLUE RHINO,SUP-2640126,CDM,C1769,HCPCS,0272,RC,,,,both,,,2001.75,1301.14,,,,,,,,,,,,,
GRAFT BNE 5 ML SUBSTITUTE VIABLE OSSIGRAFT,SUP-2901522,CDM,C1713,HCPCS,0278,RC,,,,both,,,8204.82,5333.13,,,,,,,,,,,,,
LOOP ELECSURG DIA0.3MM BLDR PROST YEL ORNG BPLR W/ 24FR,SUP-2261167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1298.14,843.79,,,,,,,,,,,,,
SCREW BONE L38MM DIA4MM PARTIALLY THRD HD M CANN FLOWERCUBE,SUP-2225336,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.68,491.84,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 1.01-2.0 MCI NS ADVANTAGE,SUP-2247262,CDM,C2643,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BONE SM W10XL73MM THK3.4MM 6 H UNIV DSTL HUM RAD ULN,SUP-2343768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1215.27,789.93,,,,,,,,,,,,,
Open Treatment Medial Malleolus Fracture|RIGHT SIDE,CASE-27766,LOCAL,27766,CPT,,,,,RT,outpatient,,,84455.38,50673.23,,,,,,,,,,,,,
Egd Transoral Control Bleeding Any Method,CASE-43255,LOCAL,43255,CPT,0360,RC,,,,outpatient,,,12111.30,7266.78,,,,,,,,,,,,,
Carpectomy All Bones Proximal Row,CASE-25215,LOCAL,25215,CPT,,,,,,outpatient,,,21219.00,12731.40,,,,,,,,,,,,,
Repair Complex Trunk 1.1-2.5 Cm,CASE-13100,LOCAL,13100,CPT,,,,,,outpatient,,,35089.77,21053.86,,,,,,,,,,,,,
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|RIGHT SIDE,CASE-24073,LOCAL,24073,CPT,0360,RC,,,RT,outpatient,,,17604.05,10562.43,,,,,,,,,,,,,
HC Tib per Territory Ather,CASE-37229,LOCAL,37229,CPT,0361,RC,,,,outpatient,,,45268.12,27160.87,,,,,,,,,,,,,
Fth/Gft Fr W/Dir Clsr F/C/C/M/N/Ax/G/H/F 20 Cm/<|PO,CASE-15240,LOCAL,15240,CPT,0360,RC,,,PO,outpatient,,,20241.10,12144.66,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,LOCAL,58661,CPT,,,,,RT,outpatient,,,33821.88,20293.13,,,,,,,,,,,,,
Osteotomy Radius Distal Third,CASE-25350,LOCAL,25350,CPT,,,,,,outpatient,,,37307.13,22384.28,,,,,,,,,,,,,
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE,CASE-54840,LOCAL,54840,CPT,,,,,LT,outpatient,,,18442.88,11065.73,,,,,,,,,,,,,
Cystostomy Cystotomy W/Drainage|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51040,LOCAL,51040,CPT,,,,,XU,outpatient,,,27232.07,16339.24,,,,,,,,,,,,,
Biopsy Vaginal Mucosa Simple,CASE-57100,LOCAL,57100,CPT,0360,RC,,,,outpatient,,,17844.23,10706.54,,,,,,,,,,,,,
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein,CASE-37249,LOCAL,37249,CPT,0360,RC,,,,outpatient,,,137700.13,82620.08,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28232,LOCAL,28232,CPT,0360,RC,,,T9|PO,outpatient,,,12145.77,7287.46,,,,,,,,,,,,,
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,LOCAL,52601,CPT,0360,RC,,,,outpatient,,,26789.72,16073.83,,,,,,,,,,,,,
Ostectomy Complete 5th Metatarsal Head|LEFT SIDE,CASE-28113,LOCAL,28113,CPT,,,,,LT,outpatient,,,26726.37,16035.82,,,,,,,,,,,,,
Revascularization Iliac Artery Angiop 1st Vsl|RIGHT SIDE,CASE-37220,LOCAL,37220,CPT,,,,,RT,outpatient,,,86014.20,51608.52,,,,,,,,,,,,,
Carpectomy All Bones Proximal Row|RIGHT SIDE|PO,CASE-25215,LOCAL,25215,CPT,,,,,RT|PO,outpatient,,,16481.05,9888.63,,,,,,,,,,,,,
Rectal Tumor Excision Transanal Endoscopic,CASE-0184T,LOCAL,0184T,CPT,0360,RC,,,,outpatient,,,62500.27,37500.16,,,,,,,,,,,,,
Egd Transoral Control Bleeding Any Method,CASE-43255,LOCAL,43255,CPT,,,,,,outpatient,,,12111.30,7266.78,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 5 MM STR STD WALL HELIX,SUP-2496134,CDM,C1768,CPT,0278,RC,,,,both,,,2791.99,1814.79,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 80 CM DIA 8 MM EPTFE STR TW USFT,SUP-2266008,CDM,C1768,CPT,0278,RC,,,,both,,,1961.97,1275.28,,,,,,,,,,,,,
PLATE BONE 3 H STD LT VOLAR TI D-RAD,SUP-2343910,CDM,C1713,HCPCS,0278,RC,,,,both,,,3198.09,2078.76,,,,,,,,,,,,,
BAG BLD TRNSFUS CONSOLIDATED VENTRICULAR ASST DEV BLK,SUP-2356005,CDM,Q0508,HCPCS,0274,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
CATHETER DIL BAL L12MM DIA3.5MM FOR INTRASINAL IRR RELIEVA,SUP-2106337,CDM,C1726,HCPCS,0272,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
STAPLE BNE FIX W18XL18MM LEG L18MM SPD TI W/O STP,SUP-2194267,CDM,C1713,HCPCS,0278,RC,,,,both,,,3186.16,2071.00,,,,,,,,,,,,,
BLADE OSTEO L12MM THN CRV END,SUP-2408597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
BRACE THMB LT FUNC POS ABDUCTED THMB W/ STAY STRP ON AD 8IN,SUP-2324312,CDM,L3931,HCPCS,0272,RC,,,,both,,,69.52,45.19,,,,,,,,,,,,,
CATHETER ETER DRNGE NEPHSTMY MCOT 16FRX35CM,SUP-2141725,CDM,C1729,HCPCS,0272,RC,,,,both,,,196.47,127.71,,,,,,,,,,,,,
HC Rep Cpx Face H Ft 1.1-2.5cm,PX-4501313100,CDM,13131,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
FIBER LASER HOLM 550 M FOR USE W/ H-30 RED SMARTSYNC DISP,SUP-2835950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1317.01,856.06,,,,,,,,,,,,,
Revise/Remove Neurostim/Receiver,CASE-64595,LOCAL,64595,CPT,,,,,,outpatient,,,14001.53,8400.92,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE|PO,CASE-64721,LOCAL,64721,CPT,0360,RC,,,50|PO,outpatient,,,15300.75,9180.45,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE|PO,CASE-64635,LOCAL,64635,CPT,,,,,50|PO,outpatient,,,12211.98,7327.19,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|PO",CASE-64491,LOCAL,64491,CPT,0360,RC,,,PO,outpatient,,,5111.60,3066.96,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT|PO",CASE-26160,LOCAL,26160,CPT,,,,,F1|PO,outpatient,,,11434.45,6860.67,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,LOCAL,64635,CPT,,,,,50,outpatient,,,12456.70,7474.02,,,,,,,,,,,,,
Rpr 1st Fem Hernia Any Age Incarcerated,CASE-49553,LOCAL,49553,CPT,,,,,,outpatient,,,33815.97,20289.58,,,,,,,,,,,,,
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|RIGHT SIDE,CASE-27446,LOCAL,27446,CPT,,,,,RT,outpatient,,,74572.42,44743.45,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid W/Excessive Skin,CASE-15823,LOCAL,15823,CPT,0360,RC,,,,outpatient,,,62659.03,37595.42,,,,,,,,,,,,,
Transection/Avulsion Oth Spinal Nrv Xdrl|PO,CASE-64772,LOCAL,64772,CPT,0360,RC,,,PO,outpatient,,,21425.95,12855.57,,,,,,,,,,,,,
Removal Implant Deep|RIGHT SIDE,CASE-20680,LOCAL,20680,CPT,,,,,RT,outpatient,,,34646.93,20788.16,,,,,,,,,,,,,
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,LOCAL,31654,CPT,0360,RC,,,,outpatient,,,23524.62,14114.77,,,,,,,,,,,,,
Arthrt Elbow Capsular Excision Capsular Rls Spx|LEFT SIDE|PO,CASE-24006,LOCAL,24006,CPT,,,,,LT|PO,outpatient,,,29722.00,17833.20,,,,,,,,,,,,,
Mediastinoscopy With Lymph Node Biopsy/Ies,CASE-39402,LOCAL,39402,CPT,0360,RC,,,,outpatient,,,32619.55,19571.73,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26540,LOCAL,26540,CPT,0360,RC,,,F6|PO,outpatient,,,16141.85,9685.11,,,,,,,,,,,,,
COMPLETION REV FEM SHIM LG/LG+,SUP-2513632,CDM,C1776,CPT,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
PLEDGET CV DEBAKEY L 10.2 X W 5.1 CM THK 0.28 MM POLYESTER,SUP-2761353,CDM,C1768,CPT,0278,RC,,,,both,,,262.63,170.71,,,,,,,,,,,,,
STEM FEM CEM HIP PRSS FT UPLR,SUP-2351416,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
DRILL SURG 1.6 MM STRL MICRORAPTOR LTX,SUP-2879935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
STEM TIB EXTN L30MM DIA15MM STR NXGN,SUP-2402750,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CLAMP EXT FIX LOK SCR FOR PENNING MINIFIXATOR,SUP-2316460,CDM,C1713,HCPCS,0278,RC,,,,both,,,56.65,36.82,,,,,,,,,,,,,
SCREW BNE ST 2.4X5 MM CRTX EMGCY W/ STARDRV RECESS TI NS,SUP-2189405,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.34,156.87,,,,,,,,,,,,,
ROD SPNL L300MM DIA3.5MM POST CERVICOTHORACIC TI SMOOTH,SUP-2289082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.99,776.09,,,,,,,,,,,,,
MESH HERN CIR 11 CM W/ ECHO 2 POS SYS POLYPR VENTRALIGHT ST,SUP-2126499,CDM,C1781,HCPCS,0278,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
HOOK 3714113 COTTLE DBL 3MM,SUP-2705133,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.31,212.75,,,,,,,,,,,,,
SCREW BONE M L25MM DIA8MM 60DEG BLU FOR INTOSS,SUP-2223907,CDM,C1713,HCPCS,0278,RC,,,,both,,,5002.02,3251.31,,,,,,,,,,,,,
TRAY PROC SZ 3 6DEG TAPR FEM HIP LNG STEM CUST,SUP-2205956,CDM,C1776,CPT,0278,RC,,,,both,,,10301.71,6696.11,,,,,,,,,,,,,
SET CATH HEMODIALYSI BIOFLXTESIO CHRONIC STNDRD 6.5FR DIA 29,SUP-2610623,CDM,C1750,HCPCS,0278,RC,,,,both,,,185.89,120.83,,,,,,,,,,,,,
BIT DRL 2.8 MM QC SS STRL,SUP-2875234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,614.81,399.63,,,,,,,,,,,,,
Vulvectomy Simple Partial,CASE-56620,LOCAL,56620,CPT,0360,RC,,,,outpatient,,,19672.25,11803.35,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,LOCAL,29807,CPT,0360,RC,,,LT,outpatient,,,44688.50,26813.10,,,,,,,,,,,,,
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE|SEPARATE STRUCTURE,CASE-27405,LOCAL,27405,CPT,,,,,LT|XS,outpatient,,,63869.23,38321.54,,,,,,,,,,,,,
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|LEFT SIDE|PO,CASE-24341,LOCAL,24341,CPT,,,,,LT|PO,outpatient,,,46105.48,27663.29,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,LOCAL,38525,CPT,,,,,LT,outpatient,,,43729.70,26237.82,,,,,,,,,,,,,
Litholapaxy Smpl/Sm <2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52317,LOCAL,52317,CPT,,,,,XU,outpatient,,,26374.88,15824.93,,,,,,,,,,,,,
Arthrodesis Great Toe Interphalangeal Joint,CASE-28755,LOCAL,28755,CPT,,,,,,outpatient,,,16439.88,9863.93,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,LOCAL,23515,CPT,,,,,LT,outpatient,,,37933.70,22760.22,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,LOCAL,64718,CPT,,,,,,outpatient,,,13338.30,8002.98,,,,,,,,,,,,,
Bx Anorectal Wall Anal Approach,CASE-45100,LOCAL,45100,CPT,,,,,,outpatient,,,36343.98,21806.39,,,,,,,,,,,,,
HC I & D Simple,CASE-10060,LOCAL,10060,CPT,0450,RC,,,,outpatient,,,684.67,410.80,,,,,,,,,,,,,
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,LOCAL,50590,CPT,0360,RC,,,LT,outpatient,,,21921.35,13152.81,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE|PO,CASE-27427,LOCAL,27427,CPT,0360,RC,,,LT|PO,outpatient,,,47575.93,28545.56,,,,,,,,,,,,,
Partial Excision Bone Tibia|LEFT SIDE,CASE-27640,LOCAL,27640,CPT,,,,,LT,outpatient,,,29585.72,17751.43,,,,,,,,,,,,,
Repair Fibula Nonunion/Malunion W/Int Fixation,CASE-27726,LOCAL,27726,CPT,,,,,,outpatient,,,40869.75,24521.85,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64415,LOCAL,64415,CPT,0360,RC,,,XU|LT,outpatient,,,47199.98,28319.99,,,,,,,,,,,,,
Mastectomy Simple Complete|RIGHT SIDE,CASE-19303,LOCAL,19303,CPT,0360,RC,,,RT,outpatient,,,51426.98,30856.19,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 100 MM DIA28 MM LIMB 40 MM 20 MM,SUP-2217684,CDM,C1768,CPT,0278,RC,,,,both,,,37052.00,24083.80,,,,,,,,,,,,,
PLASMABLADE ES L5.5-15CM SPAT TIP W3MM INTEGR SUCT TELSCP BEND,SUP-2281813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
CAGE SPNL MESH 17X13X10 MM 6 LOBE,SUP-2602078,CDM,C1889,HCPCS,0278,RC,,,,both,,,7787.20,5061.68,,,,,,,,,,,,,
ANCHOR SUT W/ ETHBND SZ 2-0 L18IN GRN POLY BRAID V5 DBL,SUP-2249347,CDM,C1713,HCPCS,0278,RC,,,,both,,,2267.08,1473.60,,,,,,,,,,,,,
SHEATH GUID TRANSSEPTAL DIL TORFLEX 8 FR,SUP-2131521,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
COMPONENT FEM SZ 7 KNEE HNG AXLE LEGION,SUP-2346404,CDM,C1776,CPT,0278,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
VARIAX CLAV - TRIAL- ANT LAT / 7 H,SUP-2377995,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.19,264.02,,,,,,,,,,,,,
PACK PROC HALF SHT W3XL5IN SOD HYALURONATE,SUP-2154016,CDM,C1765,HCPCS,0278,RC,,,,both,,,2950.94,1918.11,,,,,,,,,,,,,
GRAFT CV 1525X1525MM PLEDG PTFE SFT ST,SUP-2384072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1043.01,677.96,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CERM ON CERM STEJH5] STRYKER CORP],SUP-2365939,CDM,C1776,CPT,0278,RC,,,,both,,,16029.70,10419.30,,,,,,,,,,,,,
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx,CASE-29884,LOCAL,29884,CPT,0360,RC,,,,outpatient,,,26503.10,15901.86,,,,,,,,,,,,,
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26536,LOCAL,26536,CPT,,,,,F1|PO,outpatient,,,22471.93,13483.16,,,,,,,,,,,,,
Exc Tumor Soft Tissue Abdl Wall Subfascial <5cm,CASE-22900,LOCAL,22900,CPT,,,,,,outpatient,,,28101.77,16861.06,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28232,LOCAL,28232,CPT,,,,,T8|PO,outpatient,,,12145.77,7287.46,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,LOCAL,64494,CPT,,,,,LT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THUMB|SEPARATE STRUCTURE|PO",CASE-26055,LOCAL,26055,CPT,,,,,FA|XS|PO,outpatient,,,10914.55,6548.73,,,,,,,,,,,,,
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT SIDE|PO,CASE-26160,LOCAL,26160,CPT,,,,,LT|PO,outpatient,,,8596.35,5157.81,,,,,,,,,,,,,
Ostectomy Complete 5th Metatarsal Head|LEFT SIDE,CASE-28113,LOCAL,28113,CPT,0360,RC,,,LT,outpatient,,,26726.37,16035.82,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE|PO",CASE-64491,LOCAL,64491,CPT,0360,RC,,,50|PO,outpatient,,,4722.57,2833.54,,,,,,,,,,,,,
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, GREAT TOE|PO",CASE-28160,LOCAL,28160,CPT,0360,RC,,,T5|PO,outpatient,,,15739.18,9443.51,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,LOCAL,64718,CPT,0360,RC,,,RT,outpatient,,,13016.33,7809.80,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Simple,CASE-11770,LOCAL,11770,CPT,0360,RC,,,,outpatient,,,17263.13,10357.88,,,,,,,,,,,,,
Repair Non/Malunion Humerus W/Iliac/Oth Agrft,CASE-24435,LOCAL,24435,CPT,0360,RC,,,,outpatient,,,52858.08,31714.85,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE|PO,CASE-64454,LOCAL,64454,CPT,0360,RC,,,LT|PO,outpatient,,,4722.57,2833.54,,,,,,,,,,,,,
NAIL IM L400MM DIA10MM 130DEG STD R FEM KNEE ROSE TI CANN,SUP-2347364,CDM,C1713,HCPCS,0278,RC,,,,both,,,13066.48,8493.21,,,,,,,,,,,,,
HC So Rh Phenotype Complete,PX-3008690666,CDM,86906,CPT,0300,RC,,,,both,,,334.00,217.10,,,,,,,,,,,,,
KIT INFUS PMP 100ML 2M/HR SOAK CATH L2.5IN N NARC ON-Q,SUP-2236824,CDM,C9804,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
GRAFT BNE BLOCK 11X14X11 MM CORTICAL,SUP-2293858,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
MICRO PLATE 6 X 4 HOLES RCTNGLR SGMNTS 6MM 15MM SSTM CP TT,SUP-2707409,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.93,662.95,,,,,,,,,,,,,
HC Level V Surg Pathology Gross&Microscopic Exam,PX-3128830700,CDM,88307,CPT,0312,RC,,,,both,,,657.00,427.05,,,,,,,,,,,,,
BUR SURG L3.8MM OD3MM LESS AGG NEURO DRL NONFLUTED ELITE,SUP-2367601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1190.47,773.81,,,,,,,,,,,,,
SYSTEM IMPL FOREFOOT PEEK W/ 3X8MM TENODESIS SCR OBLONG,SUP-2121329,CDM,C1776,CPT,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
CATHETER ATHRCTMY CROSSER L 106 CM PERIPH S6 CTO,SUP-2126796,CDM,C1714,HCPCS,0272,RC,,,,both,,,9545.60,6204.64,,,,,,,,,,,,,
TI MATRIXMANDIBLE 8 HOLE STRUT,SUP-2827976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.67,1375.84,,,,,,,,,,,,,
GUIDEWIRE VASC PRESHAPED 0.035 INX275 CM X SM CRV SAFARI 2,SUP-2140935,CDM,C1769,HCPCS,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
PLATE BNE TBLR 73 MM 6-HOLE 1/3,SUP-2518438,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn|RIGHT SIDE|PO,CASE-26480,LOCAL,26480,CPT,0360,RC,,,RT|PO,outpatient,,,15327.97,9196.78,,,,,,,,,,,,,
Gastrocnemius Recession|LEFT SIDE,CASE-27687,LOCAL,27687,CPT,,,,,LT,outpatient,,,49796.85,29878.11,,,,,,,,,,,,,
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE|PO,CASE-64624,LOCAL,64624,CPT,,,,,50|PO,outpatient,,,12974.53,7784.72,,,,,,,,,,,,,
Repair Primary Open/Prq Ruptured Achilles Tendon|RIGHT SIDE|PO,CASE-27650,LOCAL,27650,CPT,,,,,RT|PO,outpatient,,,23531.40,14118.84,,,,,,,,,,,,,
Open Treatment Metatarsal Fracture Each|LEFT SIDE|PO,CASE-28485,LOCAL,28485,CPT,,,,,LT|PO,outpatient,,,37055.32,22233.19,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT FOOT, GREAT TOE",CASE-28297,LOCAL,28297,CPT,,,,,TA,outpatient,,,47460.68,28476.41,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE|PO,CASE-64633,LOCAL,64633,CPT,0360,RC,,,LT|PO,outpatient,,,12270.58,7362.35,,,,,,,,,,,,,
Rpr Aa Hernia Recr < 3 Cm Ncrc8/Strangulated,CASE-49614,LOCAL,49614,CPT,0360,RC,,,,outpatient,,,24573.08,14743.85,,,,,,,,,,,,,
Cystourethroscopy,CASE-52000,LOCAL,52000,CPT,,,,,,outpatient,,,15886.95,9532.17,,,,,,,,,,,,,
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE,CASE-27792,LOCAL,27792,CPT,,,,,LT,outpatient,,,37419.52,22451.71,,,,,,,,,,,,,
PLATE BONE L22MM 110DEG MINI LT L LHR,SUP-2364916,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.60,251.29,,,,,,,,,,,,,
STEM FEM SZ 8 L205MM OD14MM TI HA DST CALCAR HIP NEUT CEM,SUP-2374300,CDM,C1776,CPT,0278,RC,,,,both,,,16191.10,10524.21,,,,,,,,,,,,,
GRAFT HUMAN TSSUE 3CMW X 4CML AMNTC MEM DHDRTD FBLGC SCFFLD,SUP-2727661,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4775.63,3104.16,,,,,,,,,,,,,
SCREW BONE 2X8MM CORT TI BLU HEXADRIVE 6 TRILOK,SUP-2268141,CDM,C1713,HCPCS,0278,RC,,,,both,,,1544.88,1004.17,,,,,,,,,,,,,
IMPL BREAST GEL BOOST SMTH HI PROF 230CC,SUP-2738046,CDM,C1789,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT MINI #7 FORWARD ANGLE 8.5MM 201835,SUP-2844636,CDM,C1889,HCPCS,0278,RC,,,,both,,,867.36,563.78,,,,,,,,,,,,,
SET LD INTRO EVOLUTION RL L 40.6 CM OD 17 FR ID 9 FR CTRL,SUP-2169469,CDM,C1773,HCPCS,0272,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
CATHETER CV KT 7 FRX20 CM 3L PRESSURE INJ N TUNNELED UNCUF,SUP-2763385,CDM,C1751,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
HC Biliary Endo W/Stone Removal,PX-3614755400,CDM,47554,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
REAMER CONIC 1 STP FOR GAM 3 NAILING SYS,SUP-2361609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2577.31,1675.25,,,,,,,,,,,,,
PLATE SPNL CERV ANTR STD 1 LEV 24MM LEN UNIV LANX,SUP-2136798,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE L113MM THK3MM 6 H BILAT S STL STR LOK COMPR RECON,SUP-2185335,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.75,901.39,,,,,,,,,,,,,
DEFIBRILLATOR IMPL DYNAGEN EL W 5.37 X H 7.68 CM D 0.99 CM,SUP-2149176,CDM,C1721,HCPCS,0275,RC,,,,both,,,35233.94,22902.06,,,,,,,,,,,,,
SHEATH INTRO SOLOPATH WORKING L 35 CM EXPANDABLE L 30CM 22FR,SUP-2385691,CDM,C1894,HCPCS,0272,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT SIDE,CASE-28289,LOCAL,28289,CPT,,,,,RT,outpatient,,,17062.68,10237.61,,,,,,,,,,,,,
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,LOCAL,45330,CPT,0360,RC,,,,outpatient,,,8601.45,5160.87,,,,,,,,,,,,,
"Exc Tum/Vas Mal Sft Tis Hand/Fngr Subfasc<1.5cm|LEFT HAND, THUMB|PO",CASE-26116,LOCAL,26116,CPT,,,,,FA|PO,outpatient,,,9764.70,5858.82,,,,,,,,,,,,,
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45390,LOCAL,45390,CPT,0360,RC,,,XU,outpatient,,,17031.87,10219.12,,,,,,,,,,,,,
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|RIGHT SIDE,CASE-24073,LOCAL,24073,CPT,,,,,RT,outpatient,,,17604.05,10562.43,,,,,,,,,,,,,
Laps Supracrv Hysterec >250 G Rmvl Tube/Ovary,CASE-58544,LOCAL,58544,CPT,,,,,,outpatient,,,84701.17,50820.70,,,,,,,,,,,,,
Mastectomy Simple Complete|LEFT SIDE,CASE-19303,LOCAL,19303,CPT,,,,,LT,outpatient,,,44917.28,26950.37,,,,,,,,,,,,,
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, THIRD DIGIT|PO",CASE-26080,LOCAL,26080,CPT,,,,,F7|PO,outpatient,,,16814.63,10088.78,,,,,,,,,,,,,
Dstrj Lesion Anus Extensive,CASE-46924,LOCAL,46924,CPT,0360,RC,,,,outpatient,,,28670.73,17202.44,,,,,,,,,,,,,
Laparoscopy Proctopexy Prolapse,CASE-45400,LOCAL,45400,CPT,,,,,,outpatient,,,58571.82,35143.09,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE|PO,CASE-64484,LOCAL,64484,CPT,0360,RC,,,RT|PO,outpatient,,,3914.52,2348.71,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64718,LOCAL,64718,CPT,,,,,RT|XS|PO,outpatient,,,18340.05,11004.03,,,,,,,,,,,,,
Excision Vaginal Cyst/Tumor,CASE-57135,LOCAL,57135,CPT,0360,RC,,,,outpatient,,,20948.63,12569.18,,,,,,,,,,,,,
DRESSING NSL L 4 CM POLYMER X FIRM BIORESORBABLE STRL DISP,SUP-2900104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.03,374.42,,,,,,,,,,,,,
HC MRI-Pelvis WO Contrast,PX-6147219500,CDM,72195,CPT,0614,RC,,,,both,,,4626.00,3006.90,,,,,,,,,,,,,
CLOBAZAM 10 MG PO TABS,RX-111412,CDM,6370000000,HCPCS,0637,RC,60687-0423-11,NDC,,both,1,UN,11.70,7.60,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR KT SPECTR WAVEWRITER,SUP-2141898,CDM,C1820,HCPCS,0278,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
HC So Microdissection Manual,PX-3128838166,CDM,88381,CPT,0312,RC,,,,both,,,201.00,130.65,,,,,,,,,,,,,
BENZTROPINE MESYLATE 1 MG PO TABS,RX-999,CDM,6370000000,HCPCS,0637,RC,69315-0137-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER DLYS AD ADMIN SET STYL CONN TB,SUP-2125395,CDM,C1750,HCPCS,0278,RC,,,,both,,,48.17,31.31,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED RESURF H6MEDACTA] MEDACTA USA],SUP-2267791,CDM,C1776,CPT,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
ANCHOR SUTURE WHITE/GREEN CO BRAID USP NO2 SUTURE QUICKWHIP,SUP-2824865,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.87,118.87,,,,,,,,,,,,,
GRAFT BNE SUB 20CC W1XH1XL1CM CANC CUBE ALLGRFT FRZ DRY,SUP-2264688,CDM,C1713,HCPCS,0278,RC,,,,both,,,977.92,635.65,,,,,,,,,,,,,
STENT EVAR L29MM DIA8-16MM CATH L135CM 0.035IN PROX DST IL,SUP-2395708,CDM,C1874,HCPCS,0278,RC,,,,both,,,9862.74,6410.78,,,,,,,,,,,,,
KIT CATH L66CM OD7FR PROX ITH REV CLS TIP SIL ANCHR CONN,SUP-2284616,CDM,C1755,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PERI-LOC 2.5MM T7 CRTX SCREW 30MM S-T,SUP-2820432,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.13,191.83,,,,,,,,,,,,,
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,LOCAL,52281,CPT,0360,RC,,,,outpatient,,,18464.57,11078.74,,,,,,,,,,,,,
Cystourethroscopy,CASE-52000,LOCAL,52000,CPT,0360,RC,,,,outpatient,,,15886.95,9532.17,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FIFTH DIGIT|PO",CASE-28232,LOCAL,28232,CPT,0360,RC,,,T4|PO,outpatient,,,21238.90,12743.34,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE|PO,CASE-29807,LOCAL,29807,CPT,0360,RC,,,RT|PO,outpatient,,,35311.12,21186.67,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,LOCAL,29881,CPT,0360,RC,,,LT,outpatient,,,23483.85,14090.31,,,,,,,,,,,,,
HC Rm Private,PX-1100000000,CDM,1100000000,LOCAL,,,,,,outpatient,,,2724.58,1634.75,,,,,,,,,,,,,
Suture Quadriceps/Hamstring Rupture Primary|RIGHT SIDE|PO,CASE-27385,LOCAL,27385,CPT,0360,RC,,,RT|PO,outpatient,,,45972.65,27583.59,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,LOCAL,60500,CPT,,,,,LT,outpatient,,,55607.13,33364.28,,,,,,,,,,,,,
Open Treatment Tarsometatarsal Joint Dislocation|RIGHT SIDE|PO,CASE-28615,LOCAL,28615,CPT,,,,,RT|PO,outpatient,,,25249.70,15149.82,,,,,,,,,,,,,
Open Tx Fracture Phalanx/Phalanges Not Great Toe,CASE-28525,LOCAL,28525,CPT,,,,,,outpatient,,,15785.70,9471.42,,,,,,,,,,,,,
Dstrj Lesion Anus Extensive,CASE-46924,LOCAL,46924,CPT,,,,,,outpatient,,,28670.73,17202.44,,,,,,,,,,,,,
Sigmoidoscopy Flx Placement of Endoscopic Stent,CASE-45347,LOCAL,45347,CPT,0360,RC,,,,outpatient,,,29423.87,17654.32,,,,,,,,,,,,,
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|BILATERAL PROCEDURE,CASE-52354,LOCAL,52354,CPT,0360,RC,,,50,outpatient,,,20486.18,12291.71,,,,,,,,,,,,,
Claviculectomy Partial|LEFT SIDE,CASE-23120,LOCAL,23120,CPT,0360,RC,,,LT,outpatient,,,38909.32,23345.59,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,LOCAL,23430,CPT,,,,,RT|XU,outpatient,,,75667.90,45400.74,,,,,,,,,,,,,
WIRE EMBOLIC PROTCT L190CM OD0.014IN BAREWIRE DSGN PRELD,SUP-2101962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
VALVE TRACH SPEAK CLR,SUP-2322025,CDM,L8501,HCPCS,0274,RC,,,,both,,,198.61,129.10,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK MOLD DSTL CUSH,SUP-2388209,CDM,L5668,HCPCS,0272,RC,,,,both,,,267.03,173.57,,,,,,,,,,,,,
HC Creatinine Urine/Other,PX-3018257000,CDM,82570,CPT,0301,RC,,,,both,,,134.00,87.10,,,,,,,,,,,,,
HC MRI-Spine Thoracic WO Contrast,PX-6127214600,CDM,72146,CPT,0612,RC,,,,both,,,5225.00,3396.25,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT DIA5MM NICKEL TI TEMP EMBOSHIELD,SUP-2240288,CDM,C1880,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
PROGRAMMER PT EXT HANDHELD FOR RESTORE NEUROSTIMULATOR,SUP-2278229,CDM,C1787,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE LG TI MANDIBULAR 3D PRNT NS DISP ACCUPLATE,SUP-2935024,CDM,C1713,HCPCS,0278,RC,,,,both,,,35720.64,23218.42,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SEMITENDINOSUS TEND 4X230 MM FRZN,SUP-2264598,CDM,C1713,HCPCS,0278,RC,,,,both,,,4304.00,2797.60,,,,,,,,,,,,,
BURR SURG 4MM DIA HD LNG MIC 70MML 10MML HD CARBIDE SM BNE B,SUP-2605567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,73.98,48.09,,,,,,,,,,,,,
SUCCINYLCHOLINE CHLORIDE 200 MG/10ML IV SOSY,RX-133707,CDM,J0330,HCPCS,0250,RC,70004-0908-12,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE MESHED 246X11X1 MM CONTOURED SM GRID STRL,SUP-2477934,CDM,C1713,HCPCS,0278,RC,,,,both,,,5671.19,3686.27,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ W/POS LCK JT PREFABRICATED,SUP-2435760,CDM,L3761,HCPCS,0272,RC,,,,both,,,1288.59,837.58,,,,,,,,,,,,,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,2500000003,HCPCS,0250,RC,61314-0016-01,NDC,,both,15,ML,158.00,102.70,,,,,,,,,,,,,
STEM ULN HD 4.5 MED PART MOD REPL 1ST CHOICE,SUP-2610433,CDM,C1776,CPT,0278,RC,,,,both,,,12502.32,8126.51,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LCK W/INTEGR RELEASE MECHANISM,SUP-2435668,CDM,L2415,HCPCS,0272,RC,,,,both,,,343.96,223.57,,,,,,,,,,,,,
TRAY HEMO DYLS OR HD 15.5FR 19CM IMPL LEN CHRONIC 2 SPL TIP,SUP-2354974,CDM,C1752,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
Thrmbc Opn Arven Fstl W/O Revj Dial Grf,CASE-36831,LOCAL,36831,CPT,,,,,,outpatient,,,73056.27,43833.76,,,,,,,,,,,,,
HC Excis Nail Matrix Perm Rmvl|PO,CASE-11750,LOCAL,11750,CPT,0450,RC,,,PO,outpatient,,,21723.10,13033.86,,,,,,,,,,,,,
Arthrs Aid Tibial Fracture Proximal Unicondylar|RIGHT SIDE,CASE-29855,LOCAL,29855,CPT,0360,RC,,,RT,outpatient,,,44662.20,26797.32,,,,,,,,,,,,,
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,LOCAL,57250,CPT,,,,,,outpatient,,,51931.27,31158.76,,,,,,,,,,,,,
Open Treatment Fracture Distal Tibia & Fibula,CASE-27828,LOCAL,27828,CPT,,,,,,outpatient,,,44947.28,26968.37,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|PO",CASE-26055,LOCAL,26055,CPT,,,,,F7|PO,outpatient,,,8252.15,4951.29,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,LOCAL,62323,CPT,0360,RC,,,,outpatient,,,3968.35,2381.01,,,,,,,,,,,,,
Rhytidectomy Smas Flap|PO,CASE-15829,LOCAL,15829,CPT,,,,,PO,outpatient,,,61605.28,36963.17,,,,,,,,,,,,,
Lateral Retinacular Release Open,CASE-27425,LOCAL,27425,CPT,,,,,,outpatient,,,21598.42,12959.05,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|PO,CASE-64718,LOCAL,64718,CPT,0360,RC,,,LT|PO,outpatient,,,15212.78,9127.67,,,,,,,,,,,,,
Arthrt Glenohmrl Jt W/Jt Expl W/WO Rmvl Loose/FB,CASE-23107,LOCAL,23107,CPT,0360,RC,,,,outpatient,,,48915.32,29349.19,,,,,,,,,,,,,
Removal Non-Biodegradable Drug Delivery Implant,CASE-11982,LOCAL,11982,CPT,,,,,,outpatient,,,31968.40,19181.04,,,,,,,,,,,,,
CATHETER CV KT 7 FRX16 CM 3L PRESSURE INJ SPRING WIRE GUIDE,SUP-2763337,CDM,C1751,HCPCS,0278,RC,,,,both,,,273.81,177.98,,,,,,,,,,,,,
FIB NAIL LFT 2AP 1OBLQ 2.5MMX145MM,SUP-2829229,CDM,C1713,HCPCS,0278,RC,,,,both,,,8374.38,5443.35,,,,,,,,,,,,,
WASHER ORTH LCK 3.5 MM BNE THRD LIP SOCKET SS NS SURFIX DISP,SUP-2851965,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.38,315.50,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 90 CM DIA 5 FR HYDRPHLC,SUP-2383401,CDM,C1894,HCPCS,0272,RC,,,,both,,,416.05,270.43,,,,,,,,,,,,,
SODIUM ZIRCONIUM CYCLOSILICATE 5 G PO PACK,RX-143095,CDM,6370000000,HCPCS,0637,RC,00310-1105-39,NDC,,both,1,UN,129.30,84.04,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 80 CC CORTICAL CANC,SUP-2264691,CDM,C1713,HCPCS,0278,RC,,,,both,,,2395.04,1556.78,,,,,,,,,,,,,
GUIDEWIRE VASC LAUREATE L 150 CM DIA 0.038 IN NIT STR,SUP-2462167,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.79,60.96,,,,,,,,,,,,,
HEAD HUM DIA50MM THK21MM SHLDR CO CHROM PRI STD OFFSET NK,SUP-2372842,CDM,C1776,CPT,0278,RC,,,,both,,,2904.69,1888.05,,,,,,,,,,,,,
CATHETER INFUSION SINGLE LUMEN 5FRX100CM 30CM CRAGG-MCNAMARA,SUP-2172524,CDM,C1751,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX150 CM FIX COR INQWIRE DISP,SUP-2301900,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.73,18.67,,,,,,,,,,,,,
TAPE 24IN FIXATION NEEDLE WITH PASSING ENDOBUTTON,SUP-2880373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,LOCAL,64721,CPT,0360,RC,,,RT,outpatient,,,13016.33,7809.80,,,,,,,,,,,,,
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE,CASE-27822,LOCAL,27822,CPT,,,,,LT,outpatient,,,33550.63,20130.38,,,,,,,,,,,,,
Manipulation Knee Joint Under General Anesthesia,CASE-27570,LOCAL,27570,CPT,0360,RC,,,,outpatient,,,12454.65,7472.79,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT|PO",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F7|PO,outpatient,,,10188.97,6113.38,,,,,,,,,,,,,
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, THIRD DIGIT",CASE-28645,LOCAL,28645,CPT,,,,,T7,outpatient,,,34797.97,20878.78,,,,,,,,,,,,,
Arthroscopy Knee Lateral Release|LEFT SIDE|PO,CASE-29873,LOCAL,29873,CPT,0360,RC,,,LT|PO,outpatient,,,30808.27,18484.96,,,,,,,,,,,,,
Laparoscopy Enterolysis Separate Procedure,CASE-44180,LOCAL,44180,CPT,0360,RC,,,,outpatient,,,24708.15,14824.89,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G > 4.0cm,CASE-11426,LOCAL,11426,CPT,,,,,,outpatient,,,16326.80,9796.08,,,,,,,,,,,,,
Rhinp Prim Complete Xtrnl Parts|PO,CASE-30410,LOCAL,30410,CPT,,,,,PO,outpatient,,,36725.65,22035.39,,,,,,,,,,,,,
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, SECOND DIGIT|PO",CASE-28645,LOCAL,28645,CPT,,,,,T6|PO,outpatient,,,29334.38,17600.63,,,,,,,,,,,,,
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,LOCAL,46607,CPT,0360,RC,,,,outpatient,,,17539.27,10523.56,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,LOCAL,11403,CPT,0360,RC,,,,outpatient,,,15943.30,9565.98,,,,,,,,,,,,,
Adjt Tis Trnsfr/Reargmt Defec Ea Addl 30 Sqcm,CASE-14302,LOCAL,14302,CPT,0360,RC,,,,outpatient,,,78411.37,47046.82,,,,,,,,,,,,,
Arthrodesis Subtalar|RIGHT SIDE,CASE-28725,LOCAL,28725,CPT,,,,,RT,outpatient,,,71276.72,42766.03,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|LEFT SIDE|PO,CASE-G0260,LOCAL,G0260,CPT,0360,RC,,,LT|PO,outpatient,,,4478.50,2687.10,,,,,,,,,,,,,
KIT CTRL CATH 5.5FRX20CM PRSS INJ DBL LUMN ANTIMIC AND,SUP-2120620,CDM,C1751,HCPCS,0278,RC,,,,both,,,763.96,496.57,,,,,,,,,,,,,
CATHETER NASOBILIARY 7.5FR L250CM STL TEF W/ GWIRE DISP,SUP-2148627,CDM,C1883,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
RING EXT FIX SZ 5 8 DIA150MM FT C FBR COMP ILIZ,SUP-2342284,CDM,C1713,HCPCS,0278,RC,,,,both,,,8162.74,5305.78,,,,,,,,,,,,,
STEM FEM SZ 12 L190MM STD OFFSET MONOLITHIC SLVLSS REV,SUP-2345516,CDM,C1776,CPT,0278,RC,,,,both,,,16516.40,10735.66,,,,,,,,,,,,,
POST EXT FIX 3 H FOR RNG FIX SYS TRUELOK,SUP-2316131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.37,322.64,,,,,,,,,,,,,
APPLICATOR BRACHYTHERAPY BLLN W4XL6CM 60-65CC ELLIPSOIDAL,SUP-2239829,CDM,C1887,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
OXALIPLATIN 100 MG/20ML IV SOLN,RX-98540,CDM,J9263,HCPCS,0636,RC,00781-9317-80,NDC,,both,20,ML,57.60,37.44,,,,,,,,,,,,,
GRAFT PASTE SYNTHETIC CALCIUM PHOSPHATE 5G BONESOURCE BVF,SUP-2431338,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
SCREW BONE L40MM OD8MM STD S STL CORT ST SELF DRL CANN,SUP-2343404,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.08,997.80,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y DBL PLATE XDRV 12 PK,SUP-2935181,CDM,C1713,HCPCS,0278,RC,,,,both,,,27905.18,18138.37,,,,,,,,,,,,,
PLATE BNE CONTOURED 1.5X26X0.3 MM BURR HOLE CVR LP TI,SUP-2457016,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.65,535.37,,,,,,,,,,,,,
SPACER SPNL TI IMPL H18 TO 23MM 7DEG SM XPAND,SUP-2229123,CDM,C1821,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
RING ANNULPLSTY CARPENTIER MCCARTHY ADAMS IMR ETLOGIX 24 MM,SUP-2214124,CDM,C1889,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
WASHER ORTH DIA19 MM STAINLESS STELL FOR 6.5-8 MM SCREW NS,SUP-2902235,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.12,221.08,,,,,,,,,,,,,
DRILL SURG CANN 6.1 MM STRT MICRONAIL,SUP-2521557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
KIT GASTROSTMY 16FR L80CM L260CM UTHANE 2 LUMN POS ANCHR,SUP-2168204,CDM,C1894,HCPCS,0272,RC,,,,both,,,788.20,512.33,,,,,,,,,,,,,
BLADE RETRACTOR YOUNG 1.75X1.5 IN 8.25 IN PROST BIFUR,SUP-2470959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.53,310.39,,,,,,,,,,,,,
LEVEL CMF TMPLTE L SHP 25 310 70 XX 25 311 70 XX ALMNM QT001,SUP-2667280,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.62,123.25,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 7 FRX20 CM 3L RIFAMPIN SPECTRUM,SUP-2759875,CDM,C1751,HCPCS,0278,RC,,,,both,,,475.84,309.30,,,,,,,,,,,,,
Synovectomy Tendon Sheath Foot Extensor|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28088,LOCAL,28088,CPT,,,,,LT|XU,outpatient,,,22918.45,13751.07,,,,,,,,,,,,,
Repair Dislocating Peroneal Tendon W/Fib Osteot|LEFT SIDE|PO,CASE-27676,LOCAL,27676,CPT,,,,,LT|PO,outpatient,,,32962.88,19777.73,,,,,,,,,,,,,
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE|PO,CASE-28322,LOCAL,28322,CPT,0360,RC,,,LT|PO,outpatient,,,48283.90,28970.34,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE,CASE-29806,LOCAL,29806,CPT,0360,RC,,,LT,outpatient,,,52750.32,31650.19,,,,,,,,,,,,,
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE,CASE-27654,LOCAL,27654,CPT,0360,RC,,,LT,outpatient,,,49796.85,29878.11,,,,,,,,,,,,,
Exc Tumor Soft Tissue Abdominal Wall Subq <3cm,CASE-22902,LOCAL,22902,CPT,0360,RC,,,,outpatient,,,45200.57,27120.34,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|SEPARATE STRUCTURE|RIGHT SIDE|PO",CASE-64708,LOCAL,64708,CPT,0360,RC,,,XS|RT|PO,outpatient,,,20179.65,12107.79,,,,,,,,,,,,,
Laps Myomectomy Exc 1-4 Myomas 250 Gm/<,CASE-58545,LOCAL,58545,CPT,,,,,,outpatient,,,64178.98,38507.39,,,,,,,,,,,,,
Open Implantation Nea Sacral Nerve,CASE-64581,LOCAL,64581,CPT,0360,RC,,,,outpatient,,,84803.77,50882.26,,,,,,,,,,,,,
Ligation/Biopsy Temporal Artery|RIGHT SIDE,CASE-37609,LOCAL,37609,CPT,0360,RC,,,RT,outpatient,,,21730.68,13038.41,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,LOCAL,58661,CPT,0360,RC,,,LT,outpatient,,,28426.55,17055.93,,,,,,,,,,,,,
HC Debride Subq First 20 Sq Cm,CASE-11042,LOCAL,11042,CPT,0361,RC,,,,outpatient,,,1350.92,810.55,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,LOCAL,64633,CPT,0360,RC,,,RT,outpatient,,,12105.48,7263.29,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US|RIGHT SIDE|PO,CASE-20605,LOCAL,20605,CPT,0510,RC,,,RT|PO,outpatient,,,15271.40,9162.84,,,,,,,,,,,,,
Arthro/shoul surg; w/spacer,CASE-C9781,LOCAL,C9781,CPT,,,,,,outpatient,,,78078.60,46847.16,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, FIFTH DIGIT|PO",CASE-28308,LOCAL,28308,CPT,,,,,T4|PO,outpatient,,,66002.80,39601.68,,,,,,,,,,,,,
SCREW BONE 1.5MMX5MM ST CRUC TI CRAN PLATING SYS TIMESH,SUP-2277532,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
PLATE BNE L 79 MM SCREW DIA2.4/2.7 MM 7 HD 5 SHFT H LT DSTL,SUP-2913578,CDM,C1713,HCPCS,0278,RC,,,,both,,,6943.48,4513.26,,,,,,,,,,,,,
GRAFT STENT FLARED 0.035 IN 7X40 MM 9 FRX80 CM VASC FLAIR,SUP-2469671,CDM,C1874,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 6X10 CM,SUP-2383089,CDM,C1781,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 90 CC FD ASEP CORTICAL CANC,SUP-2867114,CDM,C1762,CPT,0278,RC,,,,both,,,2953.17,1919.56,,,,,,,,,,,,,
PIN FIX L70MM DIA16MM S STL TENS BND LO PROF EYELET DSGN,SUP-2106636,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
GUIDEWIRE SURG 0.032X14 IN INTRF SCR NIT,SUP-2765771,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.19,59.27,,,,,,,,,,,,,
STAPLE BNE ORTHOPEDIC 10 MM STRENGTH,SUP-2392829,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.76,44.04,,,,,,,,,,,,,
TISSUE CLOSURE KIT 4.5 MM PNCH PROX,SUP-2102275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
NEEDLE ASPIR 21GA L700MM US GUID TREAT DST END FOR EFFICIENT,SUP-2436511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.80,466.57,,,,,,,,,,,,,
NUT EXT FIX CIR NYL,SUP-2400605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
GRAFT HUM TISS W5XL180MM FIB SHFT FRZN,SUP-2307382,CDM,C1713,HCPCS,0278,RC,,,,both,,,2787.28,1811.73,,,,,,,,,,,,,
CANNULA SURG L12MM OD10MM ELP BLLN ATRAUM SURF DISK,SUP-2171752,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.04,243.13,,,,,,,,,,,,,
Unlisted Procedure Femur/Knee,CASE-27599,LOCAL,27599,CPT,,,,,,outpatient,,,21539.80,12923.88,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,LOCAL,52356,CPT,0360,RC,,,LT,outpatient,,,30801.07,18480.64,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FOURTH DIGIT|PO",CASE-26440,LOCAL,26440,CPT,,,,,F8|PO,outpatient,,,16093.22,9655.93,,,,,,,,,,,,,
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43277,LOCAL,43277,CPT,0360,RC,,,XU,outpatient,,,31284.85,18770.91,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|RIGHT SIDE,CASE-28309,LOCAL,28309,CPT,0360,RC,,,RT,outpatient,,,40956.73,24574.04,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO,CASE-29881,LOCAL,29881,CPT,,,,,LT|PO,outpatient,,,21036.48,12621.89,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,LOCAL,64636,CPT,0360,RC,,,RT,outpatient,,,12778.57,7667.14,,,,,,,,,,,,,
HC Peripheral Block - Femoral Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,LOCAL,64448,CPT,0360,RC,,,LT|XU,outpatient,,,56667.32,34000.39,,,,,,,,,,,,,
Excision Malignant Lesion S/N/H/F/G 2.1-3.0 Cm,CASE-11623,LOCAL,11623,CPT,,,,,,outpatient,,,24072.42,14443.45,,,,,,,,,,,,,
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, THUMB|PO",CASE-26445,LOCAL,26445,CPT,0360,RC,,,FA|PO,outpatient,,,10433.33,6260.00,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,LOCAL,60220,CPT,,,,,LT,outpatient,,,45409.38,27245.63,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE|PO,CASE-29807,LOCAL,29807,CPT,,,,,RT|PO,outpatient,,,35311.12,21186.67,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,LOCAL,52005,CPT,0360,RC,,,50|XU,outpatient,,,28847.67,17308.60,,,,,,,,,,,,,
Open Tx Trimalleolar Ankle Fx W/Fixj Pst Lip|LEFT SIDE|PO,CASE-27823,LOCAL,27823,CPT,,,,,LT|PO,outpatient,,,35805.08,21483.05,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,LOCAL,52332,CPT,0360,RC,,,LT,outpatient,,,20099.48,12059.69,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26123,LOCAL,26123,CPT,,,,,F8|PO,outpatient,,,10730.72,6438.43,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE|PO,CASE-29881,LOCAL,29881,CPT,0360,RC,,,LT|XS|PO,outpatient,,,44266.80,26560.08,,,,,,,,,,,,,
HC Iliac Territory Plasty Stent|LEFT SIDE,CASE-37221,LOCAL,37221,CPT,0361,RC,,,LT,outpatient,,,54064.12,32438.47,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE,CASE-27691,LOCAL,27691,CPT,0360,RC,,,LT,outpatient,,,23360.38,14016.23,,,,,,,,,,,,,
Inguinofem Lmphadec Supfc W/Cloquets Node Spx|RIGHT SIDE,CASE-38760,LOCAL,38760,CPT,,,,,RT,outpatient,,,33296.82,19978.09,,,,,,,,,,,,,
HARVESTER BONE AVITUS 6MM,SUP-2720053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
MODEL ANAT MAXILLA 3D CT BASE SEL CLR VITAL STRUCT CLRVW,SUP-2883414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8697.11,5653.12,,,,,,,,,,,,,
SET DRNGE UTHANE COOK COPE TYP LOK LOOP RNG MCLEAN,SUP-2168258,CDM,C1729,HCPCS,0272,RC,,,,both,,,503.19,327.07,,,,,,,,,,,,,
PLATE BNE 2 MM 20 HOLE PT SPEC MATRIXMANDIBLE,SUP-2860072,CDM,C1713,HCPCS,0278,RC,,,,both,,,16247.62,10560.95,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.511,SUP-2860028,CDM,C1713,HCPCS,0278,RC,,,,both,,,34884.46,22674.90,,,,,,,,,,,,,
GRAFT SYNTHECEL DURA MATER 3X3 IN (7.5 CM X 7.5 CM),SUP-2719497,CDM,C1763,HCPCS,0278,RC,,,,both,,,2931.98,1905.79,,,,,,,,,,,,,
Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,CASE-49592,LOCAL,49592,CPT,0360,RC,,,,outpatient,,,35690.37,21414.22,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,LOCAL,52287,CPT,,,,,XS,outpatient,,,36225.73,21735.44,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT|PO",CASE-26727,LOCAL,26727,CPT,0360,RC,,,F9|PO,outpatient,,,15865.68,9519.41,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,LOCAL,29823,CPT,,,,,RT,outpatient,,,43116.40,25869.84,,,,,,,,,,,,,
Laparoscopic Appendectomy,CASE-44970,LOCAL,44970,CPT,,,,,,outpatient,,,25927.50,15556.50,,,,,,,,,,,,,
Ostc Prtl Exostc/Condylc Metar Head|LEFT SIDE|PO,CASE-28288,LOCAL,28288,CPT,,,,,LT|PO,outpatient,,,27333.98,16400.39,,,,,,,,,,,,,
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw,CASE-37722,LOCAL,37722,CPT,0360,RC,,,,outpatient,,,29073.12,17443.87,,,,,,,,,,,,,
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26536,LOCAL,26536,CPT,0360,RC,,,F2|PO,outpatient,,,28192.65,16915.59,,,,,,,,,,,,,
Exc Tumor Soft Tissue Abdl Wall Subfascial <5cm,CASE-22900,LOCAL,22900,CPT,0360,RC,,,,outpatient,,,28101.77,16861.06,,,,,,,,,,,,,
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26125,LOCAL,26125,CPT,,,,,F3|PO,outpatient,,,15834.95,9500.97,,,,,,,,,,,,,
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO,CASE-14040,LOCAL,14040,CPT,0360,RC,,,PO,outpatient,,,15739.18,9443.51,,,,,,,,,,,,,
Bronchoscopy W/Removal Foreign Body,CASE-31635,LOCAL,31635,CPT,,,,,,outpatient,,,32974.88,19784.93,,,,,,,,,,,,,
Excision Tumor Soft Tis Foot/Toe Subq 1.5 Cm/>|RIGHT SIDE|PO,CASE-28039,LOCAL,28039,CPT,,,,,RT|PO,outpatient,,,13647.15,8188.29,,,,,,,,,,,,,
PACEMAKER CARD D6MM PERM 3 CHMBR STD UNIPOLAR/BIPOLAR W/,SUP-2357348,CDM,C2621,HCPCS,0275,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
SUTURE GORTX SZ 6-0 L30IN NONABSORBABLE L13MM TTC-13 3/8 CIR 7M06B,SUP-2395576,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
PIN XTRAFIX LG BLUNT 5 X 160 X 55MM,SUP-2721588,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
IMPLANT MALAR SUP PET 50X19X3MM RT DSGN RZ MEDPOR,SUP-2365283,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
"HC Debrid,Bone,1st 20sqcm or Less|SEPARATE STRUCTURE",PX-3611104400,CDM,11044,CPT,0361,RC,,,XS,both,,,4946.00,3214.90,,,,,,,,,,,,,
PAD FT SANDAL,SUP-2473252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.03,344.52,,,,,,,,,,,,,
TUBE GASTROSTMY ENTRL FEED 22 FR 15 CC ENFIT CONN COMPAT,SUP-2309465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,108.36,70.43,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 40X20X5MM DEMIN CANC FIL MTRX CNFRM FLX,SUP-2307021,CDM,C1713,HCPCS,0278,RC,,,,both,,,4750.51,3087.83,,,,,,,,,,,,,
Rmvl/Revj Sling Stress Incontinence,CASE-57287,LOCAL,57287,CPT,0360,RC,,,,outpatient,,,22306.70,13384.02,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE|PO",CASE-64708,LOCAL,64708,CPT,0360,RC,,,RT|PO,outpatient,,,18052.53,10831.52,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,LOCAL,28270,CPT,,,,,XS|T1|PO,outpatient,,,48283.90,28970.34,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE|PO,CASE-29824,LOCAL,29824,CPT,0360,RC,,,RT|PO,outpatient,,,52209.17,31325.50,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-28090,LOCAL,28090,CPT,0360,RC,,,XU|LT|PO,outpatient,,,21840.08,13104.05,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,LOCAL,29823,CPT,0360,RC,,,RT,outpatient,,,43116.40,25869.84,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|PO,CASE-12032,LOCAL,12032,CPT,0450,RC,,,PO,outpatient,,,11027.47,6616.48,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-29881,LOCAL,29881,CPT,0360,RC,,,XS|RT|PO,outpatient,,,49079.02,29447.41,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2|LEFT SIDE|PO,CASE-29822,LOCAL,29822,CPT,0360,RC,,,LT|PO,outpatient,,,40714.32,24428.59,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|LEFT FOOT, GREAT TOE|PO",CASE-28291,LOCAL,28291,CPT,0360,RC,,,TA|PO,outpatient,,,25713.85,15428.31,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,LOCAL,58662,CPT,,,,,RT,outpatient,,,67691.60,40614.96,,,,,,,,,,,,,
Fasciectomy Plantar Fascia Radical Spx|LEFT SIDE|PO,CASE-28062,LOCAL,28062,CPT,,,,,LT|PO,outpatient,,,20871.58,12522.95,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT|PO",CASE-26860,LOCAL,26860,CPT,0360,RC,,,F9|PO,outpatient,,,52028.68,31217.21,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,LOCAL,52332,CPT,,,,,LT,outpatient,,,20099.48,12059.69,,,,,,,,,,,,,
Revj Opn Arven Fstl W/O Thrmbc Dial Grf,CASE-36832,LOCAL,36832,CPT,,,,,,outpatient,,,37125.75,22275.45,,,,,,,,,,,,,
"HC ED Avulsion Nail Plate Single|LEFT HAND, THIRD DIGIT|PO",CASE-11730,LOCAL,11730,CPT,0450,RC,,,F2|PO,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,LOCAL,64635,CPT,0360,RC,,,RT,outpatient,,,12778.57,7667.14,,,,,,,,,,,,,
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|RIGHT SIDE,CASE-27446,LOCAL,27446,CPT,0360,RC,,,RT,outpatient,,,74572.42,44743.45,,,,,,,,,,,,,
Open Tx Radial&Ulnar Shaft Fx W/Fixj Radius&Ulna|RIGHT SIDE|PO,CASE-25575,LOCAL,25575,CPT,0360,RC,,,RT|PO,outpatient,,,46185.27,27711.16,,,,,,,,,,,,,
MATRIX BIO L 10 X W 7 CM FISH SKIN DERMAL FEN INTACT STRL 10/BX,SUP-2909356,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
SPACER SPNL W12XH8XL14MM ANTR THORLUM INTBDY FUS PEEK OPTMA,SUP-2205474,CDM,C1821,HCPCS,0278,RC,,,,both,,,5548.85,3606.75,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 22X60 MM PRESERVON TRICORT MATRIGRAFT,SUP-2741052,CDM,C1713,HCPCS,0278,RC,,,,both,,,7138.19,4639.82,,,,,,,,,,,,,
EVOS VOL PLATE 10H LEFT STD TI 141MM NS,SUP-2819155,CDM,C1713,HCPCS,0278,RC,,,,both,,,9213.55,5988.81,,,,,,,,,,,,,
PLATE BNE L36MM THK1MM 2X6 H CNDYL HND 316L S STL VAR ANG,SUP-2178010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1520.33,988.21,,,,,,,,,,,,,
GRAFT HUM TISS SZ A 2.5X2CM THK50-100UM OPHTH AMNIO MEM STK,SUP-2135258,CDM,V2790,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
COIL NEUROVASCULAR VFC L 3 CM DIA1-3 MM MICROCATHETER 0.0165,SUP-2305350,CDM,C1889,HCPCS,0278,RC,,,,both,,,5137.83,3339.59,,,,,,,,,,,,,
CAP END 0MM CANN LOK FOR CENTRONAIL ANK COMPR NAILING SYS,SUP-2316327,CDM,C1713,HCPCS,0278,RC,,,,both,,,688.10,447.26,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,J7060,HCPCS,0258,RC,00264-7510-10,NDC,,both,250,ML,17.00,11.05,,,,,,,,,,,,,
CATHETER HD STR 13 FRX30 CM SHT TERM BASIC SET DUO-SPLIT,SUP-2627180,CDM,C1752,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE W/ INS8301 SYS INS4500 CATH SET,SUP-2883677,CDM,C1729,HCPCS,0272,RC,,,,both,,,905.98,588.89,,,,,,,,,,,,,
PLATE BNE THK 2 MM SCREW DIA2/2.3 MM SM GRD IV TI MANDIBULAR,SUP-2935840,CDM,C1713,HCPCS,0278,RC,,,,both,,,5749.34,3737.07,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR L4MM PRELD IN SMRT INSRTR AND BRSH,SUP-2124396,CDM,L8509,HCPCS,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
STAPLE INT BIOABSRB FOR PROX 75 ILA 75 MULTFI GIA 80,SUP-2395619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
NAIL IM UNIV 11.5 MMX32 CM,SUP-2208238,CDM,C1713,HCPCS,0278,RC,,,,both,,,6129.28,3984.03,,,,,,,,,,,,,
BIT DRL L80MM DIA1MM JCBS,SUP-2389483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BONE L342MM 16 H RT DSTL LAT FEM S STL LCK FOR 4.5MM,SUP-2348219,CDM,C1713,HCPCS,0278,RC,,,,both,,,14863.50,9661.27,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,LOCAL,52332,CPT,0360,RC,,,50,outpatient,,,21502.90,12901.74,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE|PO,CASE-27691,LOCAL,27691,CPT,0360,RC,,,RT|PO,outpatient,,,35678.48,21407.09,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT|PO",CASE-26160,LOCAL,26160,CPT,,,,,F7|PO,outpatient,,,10188.97,6113.38,,,,,,,,,,,,,
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26536,LOCAL,26536,CPT,0360,RC,,,F4|PO,outpatient,,,41540.47,24924.28,,,,,,,,,,,,,
Lateral Retinacular Release Open|RIGHT SIDE|PO,CASE-27425,LOCAL,27425,CPT,0360,RC,,,RT|PO,outpatient,,,21598.42,12959.05,,,,,,,,,,,,,
Rpr Primary Torn Ligm&/Capsule Knee Collateral|RIGHT SIDE|PO,CASE-27405,LOCAL,27405,CPT,,,,,RT|PO,outpatient,,,32162.75,19297.65,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,LOCAL,52332,CPT,0360,RC,,,RT,outpatient,,,18153.38,10892.03,,,,,,,,,,,,,
Optx Prox Humeral Fx W/Int Fixj Rpr Tuberosity|LEFT SIDE,CASE-23615,LOCAL,23615,CPT,0360,RC,,,LT,outpatient,,,51849.98,31109.99,,,,,,,,,,,,,
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE|PO,CASE-27822,LOCAL,27822,CPT,0360,RC,,,LT|PO,outpatient,,,41260.75,24756.45,,,,,,,,,,,,,
Prostate Needle Biopsy Any Approach|SEPARATE STRUCTURE,CASE-55700,LOCAL,55700,CPT,,,,,XS,outpatient,,,36225.73,21735.44,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,LOCAL,45385,CPT,,,,,PT,outpatient,,,11059.10,6635.46,,,,,,,,,,,,,
Partial Excision Bone Fibula|LEFT SIDE,CASE-27641,LOCAL,27641,CPT,0360,RC,,,LT,outpatient,,,38842.92,23305.75,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26418,LOCAL,26418,CPT,0360,RC,,,F8|PO,outpatient,,,13355.42,8013.25,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE",CASE-28299,LOCAL,28299,CPT,0360,RC,,,T5,outpatient,,,40956.73,24574.04,,,,,,,,,,,,,
COMPONENT FEM SZ 3CM CO CHROM LT DSTL KNEE RESURF FINN,SUP-2406043,CDM,C1776,CPT,0278,RC,,,,both,,,16604.32,10792.81,,,,,,,,,,,,,
PLATE BNE L106MM 9 H BILAT TI RIG LO PROF RIG LOK COMPR,SUP-2191096,CDM,C1713,HCPCS,0278,RC,,,,both,,,1857.97,1207.68,,,,,,,,,,,,,
DILATOR ENDO CATH 7FR BAL L5.5CM DIA8MM COLON QNT TTC,SUP-2169385,CDM,C1726,HCPCS,0272,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
ROD SPNL L500MM DIA6.35MM S STL HEX LINKED,SUP-2293084,CDM,C1713,HCPCS,0278,RC,,,,both,,,1181.74,768.13,,,,,,,,,,,,,
COMPONENT FEM PS G RT KNEE PC NXGN,SUP-2201497,CDM,C1776,CPT,0278,RC,,,,both,,,14195.94,9227.36,,,,,,,,,,,,,
LINER POLYXLPE 10DEG 50/52/54X36MM,SUP-2202581,CDM,C1776,CPT,0278,RC,,,,both,,,5388.24,3502.36,,,,,,,,,,,,,
KIT ACCESS PORT 014CC RAPIDPORT EZ,SUP-2119255,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BUR SURG MATCHSTICK LNG 2.3 MM FLUT FOR QD14-S/QD14-G1/QD14,SUP-2848154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.94,237.86,,,,,,,,,,,,,
COVER BUR H L14MM W/ SHUNT,SUP-2365244,CDM,C1713,HCPCS,0278,RC,,,,both,,,831.25,540.31,,,,,,,,,,,,,
PLATE BONE 0DEG 16 H CRANIOMAXILLOFACIAL NONCOMPRESSION STR,SUP-2363621,CDM,C1713,HCPCS,0278,RC,,,,both,,,993.46,645.75,,,,,,,,,,,,,
HMRS ROT HINGE FEMORAL BUSHING,SUP-2512642,CDM,C1776,CPT,0278,RC,,,,both,,,1161.49,754.97,,,,,,,,,,,,,
GUIDEWIRE UROLOGY ANGLED 0.035 INX145 CM NIMB RDRUN PC,SUP-2835758,CDM,C1769,HCPCS,0272,RC,,,,both,,,133.92,87.05,,,,,,,,,,,,,
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,LOCAL,45378,CPT,0360,RC,,,74,outpatient,,,9811.63,5886.98,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT",CASE-28270,LOCAL,28270,CPT,0360,RC,,,XS|T7,outpatient,,,40956.73,24574.04,,,,,,,,,,,,,
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE,CASE-28322,LOCAL,28322,CPT,,,,,LT,outpatient,,,41782.87,25069.72,,,,,,,,,,,,,
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|PO,CASE-26080,LOCAL,26080,CPT,,,,,PO,outpatient,,,18820.85,11292.51,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, THIRD DIGIT|PO",CASE-28232,LOCAL,28232,CPT,,,,,T7|PO,outpatient,,,12145.77,7287.46,,,,,,,,,,,,,
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE,CASE-28200,LOCAL,28200,CPT,0360,RC,,,LT,outpatient,,,16535.67,9921.40,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,LOCAL,28122,CPT,,,,,RT|XU,outpatient,,,17062.68,10237.61,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,LOCAL,43236,CPT,,,,,XU,outpatient,,,22116.95,13270.17,,,,,,,,,,,,,
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,LOCAL,52317,CPT,,,,,,outpatient,,,27597.97,16558.78,,,,,,,,,,,,,
Cystoscopy prostatic imp 1-3,CASE-C9739,LOCAL,C9739,CPT,0360,RC,,,,outpatient,,,27125.80,16275.48,,,,,,,,,,,,,
Parathyroid Autotransplantation Add-On,CASE-60512,LOCAL,60512,CPT,,,,,,outpatient,,,49981.40,29988.84,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|PO",CASE-26055,LOCAL,26055,CPT,,,,,F2|PO,outpatient,,,10240.85,6144.51,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT HAND, THUMB",CASE-28750,LOCAL,28750,CPT,,,,,F5,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT SIDE,CASE-28292,LOCAL,28292,CPT,,,,,RT,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
Partial Excision Bone Talus/Calcaneus|LEFT SIDE|PO,CASE-28120,LOCAL,28120,CPT,,,,,LT|PO,outpatient,,,35935.35,21561.21,,,,,,,,,,,,,
Open Tx Tibial Fracture Proximal Unicondylar|LEFT SIDE,CASE-27535,LOCAL,27535,CPT,,,,,LT,outpatient,,,63869.23,38321.54,,,,,,,,,,,,,
Trurl Dstrj Prstate Tiss Rf Thermoth,CASE-53852,LOCAL,53852,CPT,0360,RC,,,,outpatient,,,40566.52,24339.91,,,,,,,,,,,,,
CLOMIPRAMINE HCL 25 MG PO CAPS,RX-9635,CDM,6370000000,HCPCS,0637,RC,51672-4011-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE ORTH L400MM DIA3.2MM FOR TFN,SUP-2188232,CDM,C1769,HCPCS,0272,RC,,,,both,,,283.86,184.51,,,,,,,,,,,,,
BUR SURG M L8MM DIA3MM RND FLUT CARB ELITE TPS,SUP-2367418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,271.36,176.38,,,,,,,,,,,,,
INSERT TIB SZ 5 THK19MM UNIV KNEEX3 BEAR TECHNOLOGY CNDYL,SUP-2373223,CDM,C1776,CPT,0278,RC,,,,both,,,6183.29,4019.14,,,,,,,,,,,,,
CLIP ANEURYSM L2MM 1.5MM OPENING PHYNOX CURVED AVM KOPITNIK,SUP-2821652,CDM,C1889,HCPCS,0278,RC,,,,both,,,745.62,484.65,,,,,,,,,,,,,
STENT BILI PRECIS L 40 MM DIA 5 MM CATH L 135 CM DIA 7 FR,SUP-2158938,CDM,C1876,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
PIN BNE FIX DIA 0.125 IN HDD THRD NS VANGUARD XP 2/PK,SUP-2887772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
KEEL LARYNGEAL MONTGOMERY SZ 12 MM SIL UMBRELLA SHP N ADH,SUP-2139779,CDM,C1889,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
NOZZLE SPRY FOR 2 RNG HNDPC L22 STRL DISP ELAN 4,SUP-2929259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.10,238.61,,,,,,,,,,,,,
PASSER SUT 0DEG NDL W/ PLGA IMPLANTS MENIS REP SYS TRUESPAN,SUP-2256749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SHEATH INTRO OPTISEAL L 25 CM OD 8 FR ID 0.112 IN DIL L 13,SUP-2281852,CDM,C1892,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr,CASE-27524,LOCAL,27524,CPT,0360,RC,,,,outpatient,,,31537.33,18922.40,,,,,,,,,,,,,
Arthrp Kne Condyle&Platu Medial&Lat Compartments|RIGHT SIDE,CASE-27447,LOCAL,27447,CPT,,,,,RT,outpatient,,,56419.12,33851.47,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE|PO,CASE-29880,LOCAL,29880,CPT,0360,RC,,,RT|PO,outpatient,,,21597.33,12958.40,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-27695,LOCAL,27695,CPT,,,,,XS|LT|PO,outpatient,,,35935.35,21561.21,,,,,,,,,,,,,
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|RIGHT SIDE,CASE-38570,LOCAL,38570,CPT,0360,RC,,,RT,outpatient,,,95238.53,57143.12,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT FOOT, SECOND DIGIT",CASE-28270,LOCAL,28270,CPT,,,,,XU|T1,outpatient,,,27750.93,16650.56,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|PO,CASE-G0260,LOCAL,G0260,CPT,0360,RC,,,PO,outpatient,,,4478.50,2687.10,,,,,,,,,,,,,
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,LOCAL,26437,CPT,0360,RC,,,,outpatient,,,15589.47,9353.68,,,,,,,,,,,,,
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, SECOND DIGIT|PO",CASE-26111,LOCAL,26111,CPT,0360,RC,,,F1|PO,outpatient,,,12366.98,7420.19,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,LOCAL,29807,CPT,,,,,LT,outpatient,,,44688.50,26813.10,,,,,,,,,,,,,
Rpr Component Inflatable Penile Prosthesis,CASE-54408,LOCAL,54408,CPT,0360,RC,,,,outpatient,,,67309.77,40385.86,,,,,,,,,,,,,
BIT DRILL L70MM DIA15MM JACOBS CHUCK REUSABLE,SUP-2480006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
NAIL INTRMDLLRY CNNLTD 30MM DIA 100 POLY L LCTC ACID HELI RS,SUP-2639523,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BONE INSERT 0.8 MM HALF HEIGHT MATRIXMIDFACE,SUP-2838506,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.67,380.04,,,,,,,,,,,,,
STAPLER INT 30 MM TA PREM REUSE,SUP-2787756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3190.90,2074.08,,,,,,,,,,,,,
EXTENSION STEM TIB STABILIZING PRI Y 14MM DIA 145MM,SUP-2199616,CDM,C1776,CPT,0278,RC,,,,both,,,4923.52,3200.29,,,,,,,,,,,,,
PLATE BNE LINDORF 2X6 MM CHIN MOD GRIFFIN TI,SUP-2457438,CDM,C1713,HCPCS,0278,RC,,,,both,,,614.84,399.65,,,,,,,,,,,,,
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,LOCAL,47563,CPT,0360,RC,,,,outpatient,,,27648.45,16589.07,,,,,,,,,,,,,
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE|PO,CASE-28300,LOCAL,28300,CPT,0360,RC,,,LT|PO,outpatient,,,37900.83,22740.50,,,,,,,,,,,,,
Synovectomy Tendon Sheath Foot Extensor|RIGHT SIDE|PO,CASE-28088,LOCAL,28088,CPT,0360,RC,,,RT|PO,outpatient,,,35678.48,21407.09,,,,,,,,,,,,,
Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt|LEFT SIDE|PO,CASE-25020,LOCAL,25020,CPT,0360,RC,,,LT|PO,outpatient,,,12738.37,7643.02,,,,,,,,,,,,,
Excision Malignant Lesion S/N/H/F/G 1.1-2.0 Cm,CASE-11622,LOCAL,11622,CPT,0360,RC,,,,outpatient,,,35089.77,21053.86,,,,,,,,,,,,,
Laps Supracervical Hysterectomy >250,CASE-58543,LOCAL,58543,CPT,,,,,,outpatient,,,67907.53,40744.52,,,,,,,,,,,,,
Removal Implant Deep|BILATERAL PROCEDURE,CASE-20680,LOCAL,20680,CPT,0360,RC,,,50,outpatient,,,15889.57,9533.74,,,,,,,,,,,,,
Excision Single External Papilla or Tag Anus,CASE-46220,LOCAL,46220,CPT,,,,,,outpatient,,,22882.95,13729.77,,,,,,,,,,,,,
Prostate Needle Biopsy Any Approach|SEPARATE STRUCTURE,CASE-55700,LOCAL,55700,CPT,0360,RC,,,XS,outpatient,,,36225.73,21735.44,,,,,,,,,,,,,
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY ANOTHER PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,LOCAL,93005,CPT,0730,RC,,,77|XU,outpatient,,,207031.48,124218.89,,,,,,,,,,,,,
Arthroplasty Ankle W/Implant|RIGHT SIDE,CASE-27702,LOCAL,27702,CPT,0360,RC,,,RT,outpatient,,,84455.38,50673.23,,,,,,,,,,,,,
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE|PO,CASE-27829,LOCAL,27829,CPT,0360,RC,,,LT|PO,outpatient,,,33391.62,20034.97,,,,,,,,,,,,,
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy,CASE-27675,LOCAL,27675,CPT,0360,RC,,,,outpatient,,,38224.85,22934.91,,,,,,,,,,,,,
Rcnstj Angular Dfrm Toe Soft Tiss Px Only|BILATERAL PROCEDURE|SEPARATE STRUCTURE|PO,CASE-28313,LOCAL,28313,CPT,0360,RC,,,50|XS|PO,outpatient,,,15759.98,9455.99,,,,,,,,,,,,,
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|LEFT SIDE|PO,CASE-29884,LOCAL,29884,CPT,,,,,LT|PO,outpatient,,,26503.10,15901.86,,,,,,,,,,,,,
Plmt Interstitial Dev Radiat Tx Prostate 1/Mult,CASE-55876,LOCAL,55876,CPT,0360,RC,,,,outpatient,,,13437.03,8062.22,,,,,,,,,,,,,
COMPONENT TALAR SZ 0 UHMWPE LT ANK STRL SALTO TALARIS,SUP-2931180,CDM,C1776,CPT,0278,RC,,,,both,,,23503.21,15277.09,,,,,,,,,,,,,
STEM HUM L200MM DIA7MM 135DEG CO CHROM MOLYBDENUM STD LNG,SUP-2204844,CDM,C1776,CPT,0278,RC,,,,both,,,10062.13,6540.38,,,,,,,,,,,,,
NEEDLE BX DIAMOND TIP 11 GA ACCS STRL DISP,SUP-2849292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3843.36,2498.18,,,,,,,,,,,,,
HC Surfactant Admin Thru Tube,PX-4109461000,CDM,94610,CPT,0410,RC,,,,both,,,443.00,287.95,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y PLT 12 PK STRL DISP,SUP-2935185,CDM,C1713,HCPCS,0278,RC,,,,both,,,23929.94,15554.46,,,,,,,,,,,,,
HC So Aquaporin-4 Antibody Cell-Based Imfluor Assay Ea,PX-3028605266,CDM,86052,CPT,0302,RC,,,,outpatient,,,858.00,557.70,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM 4.5 FRX3 IN W/ 20018M55 TAUT INTRO,SUP-2384044,CDM,C1894,HCPCS,0272,RC,,,,both,,,64.65,42.02,,,,,,,,,,,,,
PLATE BONE SM L53MM 3 H T SHP OBLQ ECT,SUP-2198579,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.80,248.82,,,,,,,,,,,,,
ANCHOR SUT 65MM LD W TWO STRANDS OF NO 2 STD BRAID POLY,SUP-2362554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
SPACER FEM M/L THK10MM R LAT DST DURAC,SUP-2377224,CDM,C1776,CPT,0278,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
BUR SURG L14CM DIA2MM BALL FLUT L BOR MIDAS REX LEGEND,SUP-2277718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.89,235.88,,,,,,,,,,,,,
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,LOCAL,47563,CPT,,,,,,outpatient,,,27648.45,16589.07,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T4|PO,outpatient,,,21355.03,12813.02,,,,,,,,,,,,,
Suture Infrapatellar Tendon Primary|RIGHT SIDE|PO,CASE-27380,LOCAL,27380,CPT,0360,RC,,,RT|PO,outpatient,,,40396.35,24237.81,,,,,,,,,,,,,
Revise/Remove Neurostim/Receiver,CASE-64595,LOCAL,64595,CPT,0360,RC,,,,outpatient,,,14001.53,8400.92,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-28309,LOCAL,28309,CPT,0360,RC,,,XS|RT|PO,outpatient,,,27783.90,16670.34,,,,,,,,,,,,,
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|RIGHT SIDE,CASE-37232,LOCAL,37232,CPT,0360,RC,,,RT,outpatient,,,72153.18,43291.91,,,,,,,,,,,,,
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,LOCAL,49321,CPT,,,,,,outpatient,,,29224.60,17534.76,,,,,,,,,,,,,
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,LOCAL,45171,CPT,,,,,,outpatient,,,19474.53,11684.72,,,,,,,,,,,,,
PLATE BONE L342MM 15 H RT PROX FEM LCK FOR 4.5MM SCR,SUP-2351131,CDM,C1713,HCPCS,0278,RC,,,,both,,,14680.76,9542.49,,,,,,,,,,,,,
LEVEL 1 THOR STERILEPLATE RIB LCK Z SHP2.3 MM SCREW12 H,SUP-2262531,CDM,C1713,HCPCS,0278,RC,,,,both,,,2778.59,1806.08,,,,,,,,,,,,,
PLATE BNE L45MM 10DEG L 6 H TI 1ST MT BILAT 2 COMPR SLOT,SUP-2399648,CDM,C1713,HCPCS,0278,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
PLATE SPNL DECADE 10 MM,SUP-2311213,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
JOINT TOE INSTRUMENT KT MED K WIRE MARKED DRL BIT OSSIOFIBER,SUP-2641890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.4 MM DISP,SUP-2223990,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
CATHETER PERI L90CM OD2.5MM STR W/ CATH W/OUT RESVR N,SUP-2108711,CDM,C1729,HCPCS,0272,RC,,,,both,,,442.02,287.31,,,,,,,,,,,,,
PLATE BNE W17.5XL265MM THK5.2MM 14 H ST BILAT S STL BROAD,SUP-2185306,CDM,C1713,HCPCS,0278,RC,,,,both,,,2344.26,1523.77,,,,,,,,,,,,,
CATHETER THROMCTMY FOGARTY L 80 CM DIA 6 FR BALLOON DIA CLR,SUP-2214112,CDM,C1757,HCPCS,0272,RC,,,,both,,,308.13,200.28,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT|PO",CASE-28124,LOCAL,28124,CPT,,,,,T2|PO,outpatient,,,56989.27,34193.56,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,LOCAL,45380,CPT,,,,,XU,outpatient,,,14574.40,8744.64,,,,,,,,,,,,,
Rhinoplasty Secondary Intermediate Revision,CASE-30435,LOCAL,30435,CPT,0360,RC,,,,outpatient,,,28608.23,17164.94,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,LOCAL,G0121,CPT,,,,,,outpatient,,,9867.32,5920.39,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,LOCAL,58662,CPT,0360,RC,,,50,outpatient,,,64158.35,38495.01,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, THIRD DIGIT",CASE-28308,LOCAL,28308,CPT,0360,RC,,,T2,outpatient,,,19207.23,11524.34,,,,,,,,,,,,,
HC Iliac Territory Plasty Stent|BILATERAL PROCEDURE,CASE-37221,LOCAL,37221,CPT,0361,RC,,,50,outpatient,,,74895.25,44937.15,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, SECOND DIGIT|PO",CASE-26418,LOCAL,26418,CPT,0360,RC,,,F1|PO,outpatient,,,15514.98,9308.99,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,LOCAL,28122,CPT,,,,,LT|XU,outpatient,,,19476.55,11685.93,,,,,,,,,,,,,
Open Treatment Tarsometatarsal Joint Dislocation,CASE-28615,LOCAL,28615,CPT,0360,RC,,,,outpatient,,,37055.32,22233.19,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|BILATERAL PROCEDURE,CASE-49507,LOCAL,49507,CPT,0360,RC,,,50,outpatient,,,30435.68,18261.41,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE,CASE-15823,LOCAL,15823,CPT,,,,,50,outpatient,,,36231.00,21738.60,,,,,,,,,,,,,
RING EXT FIX 5/8 IN 150 MM ALUM MAXFRAME,SUP-2422831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3378.80,2196.22,,,,,,,,,,,,,
CATHETER ART DL 0.018 IN 5 FRX90 CM MONITORING,SUP-2798486,CDM,C1727,CPT,0278,RC,,,,both,,,92.79,60.31,,,,,,,,,,,,,
COMPONENT GLEN SOCK REG CONSTRN CEM KEELED TRABECULAR MTL,SUP-2199071,CDM,C1776,CPT,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
CEMENT DENT 12ML RADPQ PERM GLS IONOMER LUTING KETAC,SUP-2238638,CDM,C1713,HCPCS,0278,RC,,,,both,,,142.84,92.85,,,,,,,,,,,,,
HC Surgery Ohs Addtl 15min,PX-3600000018,CDM,3600000018,LOCAL,0360,RC,,,,inpatient,,,5570.00,3620.50,,,,,,,,,,,,,
BIT DRL L300MM DIA13MM CANN,SUP-2188080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1822.24,1184.46,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-7 MM SHRT TAPR REINF,SUP-2681781,CDM,C1768,CPT,0278,RC,,,,both,,,950.70,617.95,,,,,,,,,,,,,
GENTAMICIN IN SALINE 2-0.9 MG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-15912,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,JW,both,50,ML,54.10,35.16,,,,,,,,,,,,,
HC Ivus Each Additional Vessel|RIGHT CORONARY ARTERY,PX-4819297900,CDM,92979,CPT,0481,RC,,,RC,both,,,758.00,492.70,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT 5FR 0.026N 55CM 2 LUMAN RVS 7927508,SUP-2632686,CDM,C1751,HCPCS,0278,RC,,,,both,,,455.65,296.17,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 5 CC ADIPOSE MTRX RENUVA,SUP-2479658,CDM,C1762,CPT,0278,RC,,,,both,,,5168.25,3359.36,,,,,,,,,,,,,
HANDPIECE LASER LAP-S FIBERLASE,SUP-2713722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, GREAT TOE",CASE-28270,LOCAL,28270,CPT,0360,RC,,,TA,outpatient,,,19625.32,11775.19,,,,,,,,,,,,,
Arthrs Aid Tibial Fracture Proximal Unicondylar|RIGHT SIDE,CASE-29855,LOCAL,29855,CPT,,,,,RT,outpatient,,,44662.20,26797.32,,,,,,,,,,,,,
Revision of Reconstructed Breast|RIGHT SIDE,CASE-19380,LOCAL,19380,CPT,0360,RC,,,RT,outpatient,,,78216.28,46929.77,,,,,,,,,,,,,
"Correction Hammertoe|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,LOCAL,28285,CPT,,,,,XU|T6|PO,outpatient,,,47230.27,28338.16,,,,,,,,,,,,,
Arthroplasty Glenohumeral Joint Total Shoulder|LEFT SIDE,CASE-23472,LOCAL,23472,CPT,0360,RC,,,LT,outpatient,,,78080.70,46848.42,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Mtcarphlngl Joint Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26520,LOCAL,26520,CPT,0360,RC,,,F8|PO,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
HC Debride/Musc/Fasc First 20 Sq Cm|SEPARATE STRUCTURE,CASE-11043,LOCAL,11043,CPT,0361,RC,,,XS,outpatient,,,71722.93,43033.76,,,,,,,,,,,,,
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>,CASE-25071,LOCAL,25071,CPT,,,,,,outpatient,,,17666.23,10599.74,,,,,,,,,,,,,
Excision Lesion Meniscus/Capsule Knee,CASE-27347,LOCAL,27347,CPT,0360,RC,,,,outpatient,,,18525.10,11115.06,,,,,,,,,,,,,
Amputation Metatarsal W/Toe Single,CASE-28810,LOCAL,28810,CPT,,,,,,outpatient,,,52018.77,31211.26,,,,,,,,,,,,,
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE|PO,CASE-28238,LOCAL,28238,CPT,,,,,LT|PO,outpatient,,,28424.68,17054.81,,,,,,,,,,,,,
CATHETER INFUS L150/5CM MIC STR PROWLER SEL +,SUP-2248999,CDM,C1887,HCPCS,0272,RC,,,,both,,,3918.94,2547.31,,,,,,,,,,,,,
PLATE BONE 3D PRNT SM MIDFACE MAND TI TRUMATCH,SUP-2860370,CDM,C1713,HCPCS,0278,RC,,,,both,,,30655.51,19926.08,,,,,,,,,,,,,
WEDGE ANK W18MM D18MM THK6.5MM EVANS TECH TI PORUS 3D OPN,SUP-2122988,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
ROD REPROC EXT FIX ATTCH FOR MED MULT PIN CLMP NS,SUP-2188526,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
COMPONENT GLEN 19X20MM 1MM OFFSET MATCHING OVO HD DIA58X55MM,SUP-2123638,CDM,C1776,CPT,0278,RC,,,,both,,,5108.78,3320.71,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 3 CM 0.035 INX150 CM FLX EZ GLIDER,SUP-2312659,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.43,67.23,,,,,,,,,,,,,
GRAFT BNE STRP FRZ DRY DEMINERALISED BNE MTRX L 5CMXW 25CM,SUP-2306999,CDM,C1713,HCPCS,0278,RC,,,,both,,,2453.13,1594.53,,,,,,,,,,,,,
HC CT L-Spine W/ Contrast,PX-3527213200,CDM,72132,CPT,0352,RC,,,,inpatient,,,1973.00,1282.45,,,,,,,,,,,,,
CLIP INT SNAP OFF 2X15 MM TI,SUP-2175089,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
MINI PLATE T SHAPE EXTENDED,SUP-2694758,CDM,C1713,HCPCS,0278,RC,,,,both,,,617.73,401.52,,,,,,,,,,,,,
STAPLER INTERNAL 12X4 MM TITANIUM MULTIFIRE ENDO HERNIA,SUP-2752260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1705.93,1108.85,,,,,,,,,,,,,
DECITABINE 50 MG/10ML IV (WET SOLR VIAL),RX-43076364,CDM,J0894,HCPCS,0636,RC,72205-0036-01,NDC,,both,1,UN,570.30,370.69,,,,,,,,,,,,,
SCREW BNE L 18 MM DIA2.3 MM TI MAND ST AXS NS UNIV,SUP-2909537,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.82,209.83,,,,,,,,,,,,,
Excision/Curettage Bone Cyst/Tumor Tibia/Fibula,CASE-27635,LOCAL,27635,CPT,,,,,,outpatient,,,36064.92,21638.95,,,,,,,,,,,,,
HC Debride/Musc/Fasc First 20 Sq Cm|SEPARATE STRUCTURE|PO,CASE-11043,LOCAL,11043,CPT,0361,RC,,,XS|PO,outpatient,,,15739.18,9443.51,,,,,,,,,,,,,
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|BILATERAL PROCEDURE,CASE-37766,LOCAL,37766,CPT,,,,,50,outpatient,,,23217.13,13930.28,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE|PO,CASE-29880,LOCAL,29880,CPT,,,,,50|PO,outpatient,,,21233.00,12739.80,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Simple,CASE-11770,LOCAL,11770,CPT,,,,,,outpatient,,,17263.13,10357.88,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,LOCAL,28270,CPT,,,,,XS|T6|PO,outpatient,,,27783.90,16670.34,,,,,,,,,,,,,
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,LOCAL,43235,CPT,0360,RC,,,74,outpatient,,,7667.07,4600.24,,,,,,,,,,,,,
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,LOCAL,49320,CPT,0360,RC,,,,outpatient,,,40052.20,24031.32,,,,,,,,,,,,,
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, GREAT TOE|PO",CASE-28160,LOCAL,28160,CPT,,,,,TA|PO,outpatient,,,22178.83,13307.30,,,,,,,,,,,,,
Mastectomy Gynecomastia|BILATERAL PROCEDURE,CASE-19300,LOCAL,19300,CPT,0360,RC,,,50,outpatient,,,17751.60,10650.96,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,LOCAL,38900,CPT,,,,,LT,outpatient,,,35681.82,21409.09,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F8,outpatient,,,13294.77,7976.86,,,,,,,,,,,,,
LINER ACET OD60MM ID32MM ENDRN CONSTRN DURALOC,SUP-2250716,CDM,C1776,CPT,0278,RC,,,,both,,,7499.58,4874.73,,,,,,,,,,,,,
PIN AXLE STABILIZING 1 PC EL SOLAR L,SUP-2372319,CDM,C1713,HCPCS,0278,RC,,,,both,,,1575.02,1023.76,,,,,,,,,,,,,
INSERT TIB ARTC CRUC RET POST LIP 10MM THCK 65MM MEDL LAT,SUP-2406312,CDM,C1776,CPT,0278,RC,,,,both,,,7570.54,4920.85,,,,,,,,,,,,,
THREADLOCK TRNSPRT DSTRCTR 60MM T 6L 4V SNGLE USE,SUP-2499166,CDM,C1713,HCPCS,0278,RC,,,,both,,,17385.14,11300.34,,,,,,,,,,,,,
CATHETER THOR 32FR L20IN PVC R ANG RADPQ SENTNL LN SENTNL,SUP-2154973,CDM,C1729,HCPCS,0272,RC,,,,both,,,64.62,42.00,,,,,,,,,,,,,
SYSTEM BLLN OCCL L150CM L30MM ODSEC4MM L4 MM TIP 01IN,SUP-2172473,CDM,C2628,HCPCS,0272,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
STEM FEM L250MM OD9MM RT HIP POR NONCOATED TYP 1 TAPR PRI,SUP-2406663,CDM,C1776,CPT,0278,RC,,,,both,,,18664.16,12131.70,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.5MM CANC PEDCL PEEK ST CANN,SUP-2287312,CDM,C1713,HCPCS,0278,RC,,,,both,,,5273.94,3428.06,,,,,,,,,,,,,
PICK ENDOSCP CHONDRAL 30 DEG 7 CM NANO ARTHSCP STRL BONESYNC,SUP-2859819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SYSTEM TRACTIONXL ADJ OPN BK HALO RNG COMPLT C GRAPHITE TI,SUP-2328134,CDM,L0810,HCPCS,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE|PO,CASE-29823,LOCAL,29823,CPT,,,,,RT|PO,outpatient,,,37391.27,22434.76,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,LOCAL,26055,CPT,0360,RC,,,FA,outpatient,,,13287.83,7972.70,,,,,,,,,,,,,
HC Thromb Mech Vein,CASE-37187,LOCAL,37187,CPT,0361,RC,,,,outpatient,,,62788.38,37673.03,,,,,,,,,,,,,
Parathyroid Autotransplantation Add-On,CASE-60512,LOCAL,60512,CPT,0360,RC,,,,outpatient,,,49981.40,29988.84,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,LOCAL,G0121,CPT,,,,,74,outpatient,,,7219.43,4331.66,,,,,,,,,,,,,
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28160,LOCAL,28160,CPT,0360,RC,,,T9|PO,outpatient,,,21238.90,12743.34,,,,,,,,,,,,,
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,LOCAL,51102,CPT,,,,,,outpatient,,,16492.77,9895.66,,,,,,,,,,,,,
Open Treatment Metatarsal Fracture Each|RIGHT SIDE|PO,CASE-28485,LOCAL,28485,CPT,0360,RC,,,RT|PO,outpatient,,,45080.53,27048.32,,,,,,,,,,,,,
Rhytidectomy Neck W/Platysmal Tightening|PO,CASE-15825,LOCAL,15825,CPT,0360,RC,,,PO,outpatient,,,60933.83,36560.30,,,,,,,,,,,,,
Partial Excision Bone Fibula|RIGHT SIDE,CASE-27641,LOCAL,27641,CPT,0360,RC,,,RT,outpatient,,,36459.58,21875.75,,,,,,,,,,,,,
Unlisted Procedure Male Genital System,CASE-55899,LOCAL,55899,CPT,0360,RC,,,,outpatient,,,22192.30,13315.38,,,,,,,,,,,,,
Rhinoplasty Secondary Intermediate Revision|PO,CASE-30435,LOCAL,30435,CPT,0360,RC,,,PO,outpatient,,,28608.23,17164.94,,,,,,,,,,,,,
HC Adrenal Arteriogram Unilateral,PX-3237573100,CDM,75731,CPT,0323,RC,,,,both,,,3142.00,2042.30,,,,,,,,,,,,,
FIBER LASER OMNIGUIDE,SUP-2225612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2110.08,1371.55,,,,,,,,,,,,,
BUR SURG BALL 1.5 MM 10 CM FLUT FOR MA-10 BEAR SL,SUP-2848267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,578.83,376.24,,,,,,,,,,,,,
CATHETER ARTHERECTOMY OTW 0.9X80 CM TURBO ELITE,SUP-2353045,CDM,C1885,CPT,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
PLATE BNE L96MM THK1.5MM 3X7 H L S STL OBLQ T SHP LOK COMPR,SUP-2186029,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.73,733.02,,,,,,,,,,,,,
HEAD FEM 15+ MM 32 MM HIP,SUP-2439597,CDM,C1776,CPT,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
FIBER LASER SIDE FIRE HPS,SUP-2225584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CATH REPROC EP 5FRX120CM JSN 6-ELECTRD 5-5-5-175-175MM,SUP-2653048,CDM,C1730,HCPCS,0272,RC,,,,both,,,177.57,115.42,,,,,,,,,,,,,
SURGICAL PREPARATION PACK SCAPHOLUNATE INT CRPL SLIC SCREW,SUP-2106423,CDM,C1713,HCPCS,0278,RC,,,,both,,,2596.78,1687.91,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CLARIA MRI CRT-D SURESCAN W 51 X H 71 MM,SUP-2282409,CDM,C1882,HCPCS,0275,RC,,,,both,,,58486.21,38016.04,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 24CML IN 5496240,SUP-2632897,CDM,C1752,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SHEATH INTRO FLX L 40 CM OD 6 FR GUIDEWIRE 0.035 IN AQ SM,SUP-2168573,CDM,C1894,HCPCS,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
FOOTPLATE BNE LNG L210MM ALUMINUM MAXFRAME,SUP-2176972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4685.57,3045.62,,,,,,,,,,,,,
CAP PROTCT FOR 8MM C FBR ROD M EXT FIX,SUP-2188737,CDM,C1713,HCPCS,0278,RC,,,,both,,,20.69,13.45,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT FOOT, GREAT TOE",CASE-28297,LOCAL,28297,CPT,0360,RC,,,TA,outpatient,,,47460.68,28476.41,,,,,,,,,,,,,
Partial Excision Bone Fibula|LEFT SIDE|PO,CASE-27641,LOCAL,27641,CPT,,,,,LT|PO,outpatient,,,32962.88,19777.73,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit,CASE-36901,LOCAL,36901,CPT,0361,RC,,,,outpatient,,,19846.00,11907.60,,,,,,,,,,,,,
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,LOCAL,58542,CPT,0360,RC,,,,outpatient,,,65620.70,39372.42,,,,,,,,,,,,,
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26080,LOCAL,26080,CPT,0360,RC,,,F1|PO,outpatient,,,12053.35,7232.01,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-28124,LOCAL,28124,CPT,0360,RC,,,XS|T5|PO,outpatient,,,21771.18,13062.71,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT HAND, FIFTH DIGIT|PO",CASE-26356,LOCAL,26356,CPT,,,,,F9|PO,outpatient,,,18158.58,10895.15,,,,,,,,,,,,,
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|LEFT SIDE,CASE-27130,LOCAL,27130,CPT,0360,RC,,,LT,outpatient,,,54770.73,32862.44,,,,,,,,,,,,,
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE|PO,CASE-29891,LOCAL,29891,CPT,,,,,RT|PO,outpatient,,,61983.88,37190.33,,,,,,,,,,,,,
Excision/Curettage Cyst/Tumor Phalanx Finger,CASE-26210,LOCAL,26210,CPT,0360,RC,,,,outpatient,,,10788.45,6473.07,,,,,,,,,,,,,
Excision Lesion Meniscus/Capsule Knee|LEFT SIDE|PO,CASE-27347,LOCAL,27347,CPT,,,,,LT|PO,outpatient,,,18525.10,11115.06,,,,,,,,,,,,,
HC Extremity Venogram|RIGHT SIDE,CASE-36005,LOCAL,36005,CPT,0361,RC,,,RT,outpatient,,,41604.63,24962.78,,,,,,,,,,,,,
Carpectomy 1 Bone|LEFT SIDE|PO,CASE-25210,LOCAL,25210,CPT,,,,,LT|PO,outpatient,,,15735.82,9441.49,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|RIGHT SIDE|SEPARATE STRUCTURE,CASE-52332,LOCAL,52332,CPT,,,,,RT|XS,outpatient,,,24675.85,14805.51,,,,,,,,,,,,,
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea,CASE-28465,LOCAL,28465,CPT,,,,,,outpatient,,,39583.60,23750.16,,,,,,,,,,,,,
Open Treatment Bimalleolar Ankle Fracture|RIGHT SIDE,CASE-27814,LOCAL,27814,CPT,0360,RC,,,RT,outpatient,,,36212.23,21727.34,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|RIGHT SIDE|PO,CASE-11422,LOCAL,11422,CPT,,,,,RT|PO,outpatient,,,10974.90,6584.94,,,,,,,,,,,,,
PROSTHESIS OTO L9MM OD3.25MM HA AND TI MID EAR OSS W/ SH,SUP-2284002,CDM,L8613,CPT,0278,RC,,,,both,,,1573.61,1022.85,,,,,,,,,,,,,
BASEPLATE TIB REVERSED 30 MM 26 MM KNEE TRABECULAR MTL,SUP-2436975,CDM,C1776,CPT,0278,RC,,,,both,,,7787.04,5061.58,,,,,,,,,,,,,
SCREW BNE L10MM DIA3.5MM CALCNL EL TI LOK HEXALOBE,SUP-2106642,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
PLATE BONE THK1.8MM 8 H STRNL TI STR LCK,SUP-2262581,CDM,C1713,HCPCS,0278,RC,,,,both,,,1618.20,1051.83,,,,,,,,,,,,,
STENT PERIPH ZILVER PTX L 140 MM DIA 6 MM CATH L 125 CM SHTH,SUP-2170401,CDM,C1874,HCPCS,0278,RC,,,,both,,,7523.41,4890.22,,,,,,,,,,,,,
BLADE REPROC SHV 4.5MM INCIS + ELITE SLATE,SUP-2652931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,54.82,35.63,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UPCHARGE VIVACIT-E,SUP-2212685,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GUIDEWIRE VASC L 100 CM DIA 0.035 IN CRV RAD 5 MM SS REUT,SUP-2167579,CDM,C1769,HCPCS,0272,RC,,,,both,,,205.98,133.89,,,,,,,,,,,,,
PLATE BNE L121MM THK1.3MM 100DEG 12 H TI TBLR FOR 3.5MM SCR,SUP-2412031,CDM,C1713,HCPCS,0278,RC,,,,both,,,299.56,194.71,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM TAPR L7CM TIP L25CM DIA0018IN S STL,SUP-2167587,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.49,32.17,,,,,,,,,,,,,
Bone Graft Any Donor Area Minor/Small|RIGHT SIDE,CASE-20900,LOCAL,20900,CPT,0360,RC,,,RT,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,LOCAL,52351,CPT,0360,RC,,,RT|XU,outpatient,,,21972.27,13183.36,,,,,,,,,,,,,
Open Treatment Fracture Distal Tibia Only|RIGHT SIDE|PO,CASE-27827,LOCAL,27827,CPT,0360,RC,,,RT|PO,outpatient,,,24184.28,14510.57,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT FOOT, GREAT TOE|PO",CASE-28292,LOCAL,28292,CPT,0360,RC,,,T5|PO,outpatient,,,40810.60,24486.36,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT FOOT, THIRD DIGIT",CASE-28270,LOCAL,28270,CPT,0360,RC,,,XU|T2,outpatient,,,27750.93,16650.56,,,,,,,,,,,,,
Revj Total Knee Arthrp W/WO Algrft 1 Component|LEFT SIDE,CASE-27486,LOCAL,27486,CPT,,,,,LT,outpatient,,,35968.07,21580.84,,,,,,,,,,,,,
Open Treatment of Ulnar Shaft Fracture|RIGHT SIDE,CASE-25545,LOCAL,25545,CPT,,,,,RT,outpatient,,,33527.12,20116.27,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-28309,LOCAL,28309,CPT,,,,,XS|RT|PO,outpatient,,,27783.90,16670.34,,,,,,,,,,,,,
Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea,CASE-25290,LOCAL,25290,CPT,,,,,,outpatient,,,12902.80,7741.68,,,,,,,,,,,,,
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,LOCAL,52235,CPT,,,,,,outpatient,,,18822.92,11293.75,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE,CASE-23515,LOCAL,23515,CPT,,,,,RT,outpatient,,,38268.27,22960.96,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm|PO,CASE-11404,LOCAL,11404,CPT,0360,RC,,,PO,outpatient,,,11027.47,6616.48,,,,,,,,,,,,,
HC App Skin Sub T/a/L Tot <100 1st 25|PBB CHARGE,CASE-15271,LOCAL,15271,CPT,0361,RC,,,PBB,outpatient,,,8324.10,4994.46,,,,,,,,,,,,,
SYSTEM THR HI DEMAND DOCTOR P 2C,SUP-2212120,CDM,C1776,CPT,0278,RC,,,,both,,,18315.62,11905.15,,,,,,,,,,,,,
PLATE SPNL L32MM 6 H TI ANT CERV 2 LEV PRECONTOURED BILAT,SUP-2415772,CDM,C1713,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
TUBE GAST JEJU 14FR L22CM STOMA L1.7CM LO PROF BTTN FEED,SUP-2119818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,0636,RC,63323-0341-25,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 15 CM FLX TIP L 6,SUP-2167759,CDM,C1769,HCPCS,0272,RC,,,,both,,,48.20,31.33,,,,,,,,,,,,,
STEM FEM SZ 2 STD HIP CEMENTLESS QUADRA R,SUP-2267203,CDM,C1776,CPT,0278,RC,,,,both,,,19808.69,12875.65,,,,,,,,,,,,,
SCREW BNE L 28 MM DIA 3 MM TI CANN HD NS LEOS,SUP-2932613,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.67,465.19,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRAFIX PRIME 1.5X2CM CYROPRESERVED,SUP-2319161,CDM,Q4133,HCPCS,0636,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.5MM PEEK HA PEDCL MULTIAXIAL,SUP-2289209,CDM,C1713,HCPCS,0278,RC,,,,both,,,3855.45,2506.04,,,,,,,,,,,,,
BIT DRL L228MM DIA2.7MM LNG QUIK CONN DISP FOR PERI-LOC L,SUP-2343997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,965.52,627.59,,,,,,,,,,,,,
MICROCATHETER INFUSION PROGREAT L 150 CM DIA2.4 FR COAT L 90,SUP-2385610,CDM,C1887,HCPCS,0272,RC,,,,both,,,1097.43,713.33,,,,,,,,,,,,,
CHOLECALCIFEROL 125 MCG (5000 UT) PO CAPS,RX-15636,CDM,6370000000,HCPCS,0637,RC,50268-0868-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE SUB 90CC SZ 05 5MM CORT CANC GRAN FRZN MORSELIZED,SUP-2307406,CDM,C1713,HCPCS,0278,RC,,,,both,,,3423.73,2225.42,,,,,,,,,,,,,
SCREW BNE ST 2.7X85 MM CRTX T8 STARDRV RECESS SS NS,SUP-2757636,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.62,101.80,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,LOCAL,58661,CPT,0360,RC,,,50,outpatient,,,27943.17,16765.90,,,,,,,,,,,,,
Bone Surgery Using Computer,CASE-0055T,LOCAL,0055T,CPT,,,,,,outpatient,,,61203.52,36722.11,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy Limited Spx,CASE-29875,LOCAL,29875,CPT,0360,RC,,,,outpatient,,,18368.57,11021.14,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|PO,CASE-28090,LOCAL,28090,CPT,,,,,PO,outpatient,,,39959.50,23975.70,,,,,,,,,,,,,
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE|PO,CASE-64421,LOCAL,64421,CPT,,,,,RT|PO,outpatient,,,5424.57,3254.74,,,,,,,,,,,,,
Open Treatment Fracture Distal Tibia Only|LEFT SIDE|PO,CASE-27827,LOCAL,27827,CPT,,,,,LT|PO,outpatient,,,28985.27,17391.16,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE,CASE-28306,LOCAL,28306,CPT,0360,RC,,,RT,outpatient,,,47822.53,28693.52,,,,,,,,,,,,,
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE|PO,CASE-27570,LOCAL,27570,CPT,,,,,LT|PO,outpatient,,,14424.15,8654.49,,,,,,,,,,,,,
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|RIGHT SIDE,CASE-38570,LOCAL,38570,CPT,,,,,RT,outpatient,,,95238.53,57143.12,,,,,,,,,,,,,
Excision Multiple External Papillae/Tags Anus,CASE-46230,LOCAL,46230,CPT,0360,RC,,,,outpatient,,,18879.13,11327.48,,,,,,,,,,,,,
ESTRADIOL 0.01 % VA CREA,RX-173615,CDM,6370000000,HCPCS,0637,RC,00093-3541-43,NDC,,both,42.5,GR,489.60,318.24,,,,,,,,,,,,,
PIN SCHNZ 6.0MM AO CONN,SUP-2321647,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI HEM CATH STRL ACTE 11.5FR DIA 15CM STR BX/1,SUP-2610537,CDM,C1752,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 260 CM DIA 0.038 IN TAPR L 22 CM,SUP-2170352,CDM,C1769,HCPCS,0272,RC,,,,both,,,584.29,379.79,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC SYR DBM ACCELL EVO3C,SUP-2641764,CDM,C1713,HCPCS,0278,RC,,,,both,,,3560.76,2314.49,,,,,,,,,,,,,
SCREW INTRF BIOSURE REGENESORB 6MMX25MM RT,SUP-2341911,CDM,C1713,HCPCS,0278,RC,,,,both,,,1072.06,696.84,,,,,,,,,,,,,
RASP SURG FEATHERTOUCH NSL HANDHELD SGL END STR TAPR FLAT,SUP-2284175,CDM,C1713,HCPCS,0278,RC,,,,both,,,899.30,584.54,,,,,,,,,,,,,
DEVICE BLLN DIL UROMX ULT HI PRSS HYDR+ COAT 30 FR X 8 MM,SUP-2139194,CDM,C1726,HCPCS,0272,RC,,,,both,,,777.28,505.23,,,,,,,,,,,,,
WASHER ORTH FOR IMPCT FOR SEG SYS TRABECULAR MTL,SUP-2437280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
DRILL SURG STEM 15 MM TIB FLUT NXGN,SUP-2438091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.33,376.56,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH WORLEY 120 DEG L 62 CM DIA 7 FR,SUP-2356427,CDM,C1894,HCPCS,0272,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT SIDE|PO,CASE-28297,LOCAL,28297,CPT,,,,,LT|PO,outpatient,,,47280.18,28368.11,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,LOCAL,29828,CPT,,,,,LT,outpatient,,,48402.82,29041.69,,,,,,,,,,,,,
Anesthesia Combined Upper&Lower GI Endoscopic Px,CASE-00813,LOCAL,00813,CPT,,,,,,outpatient,,,15300.02,9180.01,,,,,,,,,,,,,
Revj Total Knee Arthrp W/WO Algrft 1 Component,CASE-27486,LOCAL,27486,CPT,,,,,,outpatient,,,35968.07,21580.84,,,,,,,,,,,,,
Fasciotomy Foot&/Toe|BILATERAL PROCEDURE|PO,CASE-28008,LOCAL,28008,CPT,,,,,50|PO,outpatient,,,13586.57,8151.94,,,,,,,,,,,,,
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,LOCAL,31622,CPT,,,,,,outpatient,,,14368.78,8621.27,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr,CASE-27524,LOCAL,27524,CPT,,,,,,outpatient,,,31537.33,18922.40,,,,,,,,,,,,,
"HC Excis Nail Matrix Perm Rmvl|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-11750,LOCAL,11750,CPT,0450,RC,,,XS|TA|PO,outpatient,,,25037.65,15022.59,,,,,,,,,,,,,
Gastrocnemius Recession|RIGHT SIDE|PO,CASE-27687,LOCAL,27687,CPT,0360,RC,,,RT|PO,outpatient,,,35852.18,21511.31,,,,,,,,,,,,,
GRAFT DURA W4XL5IN WHT ABSRB MTRX CLLGN POR PLIABLE,SUP-2244085,CDM,C1763,HCPCS,0278,RC,,,,both,,,2687.87,1747.12,,,,,,,,,,,,,
SUTURE NONABSORBABLE MONOFILAMENT 5-0 CV-6 PT-9 24 IN GORTX 6K06B,SUP-2395523,CDM,C1713,HCPCS,0278,RC,,,,both,,,3118.02,2026.71,,,,,,,,,,,,,
HC Potassium 24hr Urine,PX-3018413300,CDM,84133,CPT,0301,RC,,,,inpatient,,,119.00,77.35,,,,,,,,,,,,,
FOUNDATION ULT CONG INSRT SZ 1 9 MM **SPECIAL ORD ONLY,SUP-2216512,CDM,C1776,CPT,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
SCREW INTRF L25MM OD7MM TI CANN NONABSORBABLE,SUP-2341508,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
PLATE BONE L289MM 14 HOLE NNSTRLE CRVD FMRL SHAFT TTNM NCB,SUP-2480791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1966.39,1278.15,,,,,,,,,,,,,
PROBE LITHO 9FR L60CM EHL,SUP-2313971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,792.54,515.15,,,,,,,,,,,,,
PLATE BNE L 2X20 MM LT 2 HOLE OBLQ SS,SUP-2569113,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.25,85.31,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7585,SUP-2525339,CDM,C1769,HCPCS,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
JOINT SHOULDER S1 EXACTECH TOTAL PLATFORM EQUINOX,SUP-2849998,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
KIT DBS EXT TUNN STRL DISP SENSIGHT,SUP-2883079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
PLATE BNE L 250.62 X W 48.01 MM THK 2.59 MM LG TI DBL ANGLE,SUP-2936845,CDM,C1713,HCPCS,0278,RC,,,,both,,,8405.78,5463.76,,,,,,,,,,,,,
GRAFT VASC PTCH 5X10 CMX1 MM SFT TISS GORTX,SUP-2395294,CDM,C1781,HCPCS,0278,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
CATHETER DRNGE INCIS SET GEN PURP J TIP W/ STIFF CANN TRCR,SUP-2391575,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
SCREW SPNL TEMP FIX LNG,SUP-2598343,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
HC So Bartonella Pcr,PX-3068747166,CDM,87471,CPT,0306,RC,,,,both,,,247.00,160.55,,,,,,,,,,,,,
PLATE BONE 6 H TI 3RD TBLR LCK,SUP-2419535,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
COIL EMB L7CM PRI DIA0.020IN NIT J SFT FILL STRTCH RESIST,SUP-2323424,CDM,C1889,HCPCS,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 5 FRX100 MM POLARCATH,SUP-2141984,CDM,C1725,HCPCS,0272,RC,,,,both,,,3278.16,2130.80,,,,,,,,,,,,,
ALLOGRAFT HUM TISS THN 8X4 CM REGENERATIVE GRAFTJACKET NOW,SUP-2759588,CDM,Q4107,HCPCS,0636,RC,,,,both,,,7158.76,4653.19,,,,,,,,,,,,,
STEM HUM L75MM OD6.5MM UNIV TI SHLDR IM PROX BODY MOD REV,SUP-2403672,CDM,C1776,CPT,0278,RC,,,,both,,,8434.04,5482.13,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON LG 8 IN RT WRST PLUSH FOAM LNR NYL,SUP-2276662,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.64,10.82,,,,,,,,,,,,,
SCREW BNE 2.3X11 MM STRNL TALON,SUP-2262554,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.35,81.48,,,,,,,,,,,,,
COIL EMB L15CM OD5MM HELI LOOP REG DEL SYS 2 TIP MRK,SUP-2305172,CDM,C1889,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
ALLOGRAFT BNE 100 MM PRESERVON FIBULAR SHFT MATRIGRAFT,SUP-2740897,CDM,C1762,CPT,0278,RC,,,,both,,,1995.53,1297.09,,,,,,,,,,,,,
FILM OPHTH ABSORBABLE 50X25 MM GEL STRL GELFLM,SUP-2424888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1021.57,664.02,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|DOCUMENTATION ON FILE|UNUSUAL NON-OVERLAPPING SERVICE",PX-4209711000,CDM,97110,CPT,0420,RC,,,KX|XU,both,,,195.00,126.75,,,,,,,,,,,,,
STEM FEM OD19MM 12/14 131DEG PRSS FIT TAPR STD OFFSET,SUP-2222218,CDM,C1776,CPT,0278,RC,,,,both,,,14318.40,9306.96,,,,,,,,,,,,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152148,CDM,6370000000,HCPCS,0637,RC,45802-0953-01,NDC,,both,100,GR,55.40,36.01,,,,,,,,,,,,,
PLATE BNE SM T SHP REDUC FOR TEMP FIX,SUP-2315956,CDM,C1713,HCPCS,0278,RC,,,,both,,,2108.51,1370.53,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 55 MM PROX/DSTL 18 MM SHTH,SUP-2171049,CDM,C1874,HCPCS,0278,RC,,,,both,,,6471.54,4206.50,,,,,,,,,,,,,
BUR SURG RND MED 4 MM 68 MM FLUT FOR DRL SYS SS,SUP-2628953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,202.97,131.93,,,,,,,,,,,,,
SCREW BONE L80MM D45MM THRD L24MM STNDRD CRTCL TTNM PRXML SE,SUP-2459544,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.89,363.28,,,,,,,,,,,,,
TILENE PLG ST SM 5CM DI PT 3PK,SUP-2402565,CDM,C1781,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CANN SCREW WASHER 13.0MM OD X 6.7MM ID,SUP-2639527,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
HC Eeg Extended More Than 1 Hour,PX-7409581300,CDM,95813,CPT,0740,RC,,,,outpatient,,,3429.00,2228.85,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO L 132 CM PROX/DSTL DIA 6/5,SUP-2323572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
WASHER BNE NAIL NAT NAIL,SUP-2499673,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.71,148.01,,,,,,,,,,,,,
CATHETER ATHRCTMY ROTLNK L 135 CM DIA 0.058 IN BUR SZ 2.5,SUP-2142285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4034.27,2622.28,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.038IN TIP L3CM STR FLX TIP DISP,SUP-2313744,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.69,97.95,,,,,,,,,,,,,
KIT BONE GRFT 3CC CANN L120MM NDL 11GA FT ANK FOR,SUP-2208437,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
FIXATION KIT OFFSET 15X20X20 MM 4 MM SPPEDSHIFT,SUP-2135438,CDM,C1713,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 28 MM CERV PROVIDENCE,SUP-2229844,CDM,C1713,HCPCS,0278,RC,,,,both,,,9752.84,6339.35,,,,,,,,,,,,,
SPLINT ORTH AD L24IN FOR 29IN THGH UNIV KNEE FOAM,SUP-2196749,CDM,L1830,CPT,0274,RC,,,,both,,,47.19,30.67,,,,,,,,,,,,,
FIBER LASER HOLM 150 M FOR USE W/ SMA-905 RED SMARTSYNC,SUP-2835952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.87,798.12,,,,,,,,,,,,,
METHOCARBAMOL 500 MG PO TABS,RX-4971,CDM,6370000000,HCPCS,0637,RC,00904-7057-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MESH CRAN W100XL100MM TI RECTANG MALL CNTOUR FOR 1.3MM SCR,SUP-2190621,CDM,C1713,HCPCS,0278,RC,,,,both,,,7178.04,4665.73,,,,,,,,,,,,,
INTRODUCER SHTH 5 FRX30 CM 7 CM W/ NIT WIRE REG MICRO-STICK,SUP-2267055,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
COIL NEUROVASCULAR AXIUM PRIM L 15 CM SECONDARY DIA 4 MM,SUP-2458373,CDM,C1889,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
CATHETER VENTILATOR L 70 CM DIA 4 MM PTFE LASER JET DL THOR,SUP-2662068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,542.59,352.68,,,,,,,,,,,,,
CATHETER CV DL AD 9 FRX90 CM TUNNELED BASIC KT INJ HICKMAN,SUP-2126551,CDM,C1751,HCPCS,0278,RC,,,,both,,,501.36,325.88,,,,,,,,,,,,,
FRAME EXT FIX 200 MM SALVATION SEFA0200,SUP-2851072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22783.84,14809.50,,,,,,,,,,,,,
GRAFT DERMAL 7X4 CM PORCINE DERMAL CLLGN REINF MTRX STRL,SUP-2852966,CDM,C1763,HCPCS,0278,RC,,,,both,,,8511.19,5532.27,,,,,,,,,,,,,
PIN FIXATION L40MM DIAMETER 4.5MM PLLA SELF REINFORCED SMART,SUP-2855304,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.98,346.44,,,,,,,,,,,,,
BUNDLE CASE ORTHOGNATHIC POSTOP VSP POSTOPORTHOG,SUP-2862821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7657.02,4977.06,,,,,,,,,,,,,
STEM FEM L180MM OD22.5MM S-5 TI HX COAT HIP CEMENTLESS 03,SUP-2397012,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
BIT DRL CANN 90-120 MM QR NS ACUTRK 6/7 LF DISP,SUP-2518492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
HC Sgpt (Alt),PX-3018446000,CDM,84460,CPT,0301,RC,,,,both,,,152.00,98.80,,,,,,,,,,,,,
GRAFT BNE W7XH11X13XL23MM 8DEG LORDOSIS TRAP RAMP VERTIGRFT,SUP-2264974,CDM,C1713,HCPCS,0278,RC,,,,both,,,7046.95,4580.52,,,,,,,,,,,,,
TAP BONE SPNL CERV PEDCL SCR W/ SL 3.0MM DIA,SUP-2108504,CDM,C1713,HCPCS,0278,RC,,,,both,,,3190.24,2073.66,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTEROLATERAL DISTAL HUMERUS 9H RIGHT,SUP-2549682,CDM,C1713,HCPCS,0278,RC,,,,both,,,3899.72,2534.82,,,,,,,,,,,,,
INTRODUCER NDL DIAMOND TIP 10 GA SIDE ACCS KT STRL SYNFLATE,SUP-2758542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.34,284.92,,,,,,,,,,,,,
PLATE BONE SM L26MM 2 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348989,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.85,728.55,,,,,,,,,,,,,
HC Drug Screen Quantitative Digoxin Total,PX-3018016200,CDM,80162,CPT,0301,RC,,,,both,,,287.00,186.55,,,,,,,,,,,,,
ANCHOR SUTURE PRE LD 2 2.9 MM W/ FORC FIBER QUATTRO GL2,SUP-2608893,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.78,786.36,,,,,,,,,,,,,
LAPIDUS DOME WASHER ORTHOLOC 2 LAPIFUSE,SUP-2830188,CDM,C1713,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
SHELL ACET SLD BK COCR ALLOY 50MM VITALOCK,SUP-2364625,CDM,C1776,CPT,0278,RC,,,,both,,,3065.43,1992.53,,,,,,,,,,,,,
PLATE BNE L90MM 4 H R POSTEROLATERAL DST FIBULAR S STL LOK,SUP-2177383,CDM,C1713,HCPCS,0278,RC,,,,both,,,1706.40,1109.16,,,,,,,,,,,,,
PIN BONE FIX L40MM CROSS CANN L15 AXL,SUP-2137195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
SCREW BONE LOCKING 2.4X10 MM MANDIBULAR SELFTAPPING 20/PK TI,SUP-2842337,CDM,C1713,HCPCS,0278,RC,,,,both,,,585.55,380.61,,,,,,,,,,,,,
SCREW BNE NLCK 4X14 MM,SUP-2315904,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
KIT DBS DEPTH STOP CRAN TUNN STRL DISP SENSIGHT,SUP-2883058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
BUR SURG L7.6MM DIA6MM LNG FLUT DR CUT TPS,SUP-2363386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,222.00,144.30,,,,,,,,,,,,,
COMPONENT FEM C- KNEE FEMALE NXGN LPS-FLEX GENDER SOL 00572401351] ZIMMER BIOMET INC],SUP-2200264,CDM,C1776,CPT,0278,RC,,,,both,,,18309.34,11901.07,,,,,,,,,,,,,
SURFACE ARTC TIB 3-4 FEM C-H THK10MM 6DEG RT KNEE YEL UHMWPE,SUP-2201406,CDM,C1776,CPT,0278,RC,,,,both,,,3367.65,2188.97,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION SMALL 2 MM DOUBLE ANGLE TITANIUM M,SUP-2837756,CDM,C1713,HCPCS,0278,RC,,,,both,,,8416.14,5470.49,,,,,,,,,,,,,
CATHETER GUID ENVOY DA XB L 95 CM DIA 6 FR ID 0.071 IN NYL,SUP-2257101,CDM,C1887,HCPCS,0272,RC,,,,both,,,2957.00,1922.05,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 8 MM EPTFE FLX TW SM BEAD RING,SUP-2126884,CDM,C1768,CPT,0278,RC,,,,both,,,3195.39,2077.00,,,,,,,,,,,,,
IMPLANT BIO PROXICOR PERICARDIAL CLOSURE 7X15CM,SUP-2172035,CDM,C1768,CPT,0278,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 1.8MM WITH TWO 1.3MM WHITE/BLUE AND W,SUP-2824773,CDM,C1713,HCPCS,0278,RC,,,,both,,,1588.84,1032.75,,,,,,,,,,,,,
SPACER KNEE L 74X54X80X48X18MM HI REL INTERSPACE,SUP-2223696,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
VALVE PERICARD AORT HRT BIOPROSTHESIS PERIMT MAGNA SZ 21MM 300021MM] EDWARDS LIFESCIENCES CORP],SUP-2214091,CDM,C1713,HCPCS,0278,RC,,,,both,,,16799.00,10919.35,,,,,,,,,,,,,
LINDEMANN BURR LG 80MM TOTAL LNGTH 35MM WRKNG LNGTH WNTCH,SUP-2677545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.33,223.16,,,,,,,,,,,,,
HC So Hexagonal Phospholipid,PX-3058559866,CDM,85598,CPT,0305,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
ORTHO ANCHRGE C TUBE PLATE STRGHT 2 HOLE 6MM BRDGE T06MM CP,SUP-2676763,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.30,219.24,,,,,,,,,,,,,
CATHETER EP DIAG MAP M CRV QPLR 2-5-2MM SPC 4MM TIP BI DIR,SUP-2356980,CDM,C1733,HCPCS,0272,RC,,,,both,,,2172.88,1412.37,,,,,,,,,,,,,
RESERVOIR VENTRICULAR 6MM STD PLAS STRL HOLTER RICKHAM,SUP-2666415,CDM,C1889,HCPCS,0278,RC,,,,both,,,1216.66,790.83,,,,,,,,,,,,,
STENT BILI WSTNT L 80 MM DIA10 MM CATH L 194 CM DIA 7.5 FR,SUP-2141481,CDM,C1876,HCPCS,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 5 FR POLYPRO TBNG,SUP-2699690,CDM,C1894,HCPCS,0272,RC,,,,both,,,68.92,44.80,,,,,,,,,,,,,
RING EXT FIX FULL 160 MM TI NS,SUP-2800051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2955.49,1921.07,,,,,,,,,,,,,
PLATE BNE STR 4 HOLE LATTICE LCK,SUP-2107935,CDM,C1713,HCPCS,0278,RC,,,,both,,,5325.44,3461.54,,,,,,,,,,,,,
STEM FEM OD12MM CALCAR CEM ENCORE,SUP-2216962,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
KIT HAD ADMIN CATH 13.5FR 50CM LEN BASIC DBL LUMN SIL STR,SUP-2127695,CDM,C1750,HCPCS,0278,RC,,,,both,,,870.41,565.77,,,,,,,,,,,,,
COIL EMB L30CM DIA0.02IN LOOP DIA4MM COMPLX STD FRME RUBY,SUP-2323658,CDM,C1889,HCPCS,0278,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR STD WALL HELIX,SUP-2525441,CDM,C1768,CPT,0278,RC,,,,both,,,1657.48,1077.36,,,,,,,,,,,,,
BLADE REPROC M4 TRICUT ROTATABLE,SUP-2526001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,198.26,128.87,,,,,,,,,,,,,
RING EXT FIX HALF 150 MM ALUM NS MAXFRAME,SUP-2757973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3334.96,2167.72,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 52 X 27 X 4 MM MED POLYETHYL LT MALAR,SUP-2934191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1767.82,1149.08,,,,,,,,,,,,,
GUIDEWIRE 1.5MM 9INX30CM STERILE ORTHOPAEDIC BLUNT,SUP-2880376,CDM,C1769,HCPCS,0272,RC,,,,both,,,158.26,102.87,,,,,,,,,,,,,
TUBE VNTLTN ARMSTRNG R 114MM ID LUMEN 254MM ID 381MM OD F,SUP-2669494,CDM,L8699,HCPCS,0278,RC,,,,both,,,41.64,27.07,,,,,,,,,,,,,
LEAD DEFIB LINOXSMART S L 65 CM SIL INSUL IRIDIUM OXIDE TIP,SUP-2138267,CDM,C1777,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
FORCEPS ENDOSCP L240CM ODSEC5.5FR RED 3 PRNG GRSP DISP,SUP-2171354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
GRAFT BNE 4X4 CM XPLUS HYDROMEMBRANE PALINGEN,SUP-2164365,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
BOLT IM L52MM DIA3.9MM BLU TI ALUM NIOBIUM TRCR TIP ST LCK,SUP-2192207,CDM,C1713,HCPCS,0278,RC,,,,both,,,573.68,372.89,,,,,,,,,,,,,
CAGE SPNL W23XH10-12XL27MM POST THORLUM TI INTBDY FUS OVL,SUP-2254465,CDM,C1889,HCPCS,0278,RC,,,,both,,,11143.86,7243.51,,,,,,,,,,,,,
GRAFT BONE CHIP FRZN CRUSH CANC 1.7MM-10MM RANG 90CC,SUP-2307401,CDM,C1713,HCPCS,0278,RC,,,,both,,,5311.15,3452.25,,,,,,,,,,,,,
PLATE CRAN 200X80X40 MM PT SPEC IMPL PEEK,SUP-2860144,CDM,C1713,HCPCS,0278,RC,,,,both,,,36524.17,23740.71,,,,,,,,,,,,,
ELECTRODE DEFIB EMBLEM MRI L 45 CM SHFT DIA 7 FR DSTL TIP,SUP-2148624,CDM,C1896,HCPCS,0275,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
SET ENDOSCP FIX ACL FOR BNE TEND RECON DISP VERSITOMIC,SUP-2366524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,975.85,634.30,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM LT BTTRS MOD NS DISP,SUP-2934877,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.78,565.36,,,,,,,,,,,,,
GRAFT BNE SUB L 50X20X7MM DEMIN CANC N IRRADIATED DBMFORM,SUP-2354400,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
CATHETER EP CRD 1 CM SPC 5 FRX100 CM NBIH,SUP-2871492,CDM,C1730,HCPCS,0272,RC,,,,both,,,127.45,82.84,,,,,,,,,,,,,
DRIVER SURG T10 HEXALOBE CALIB AO QC NS REUSE PHANTOM,SUP-2909077,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
INSERT TIB SZ 2 THK12.5MM UNIV KNEE POLYETH CRUC RET POST,SUP-2253784,CDM,C1776,CPT,0278,RC,,,,both,,,3214.10,2089.16,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM STR STD WALL REINF,SUP-2525434,CDM,C1768,CPT,0278,RC,,,,both,,,959.90,623.93,,,,,,,,,,,,,
MOD FEMORAL PROX LOCKING SCREW,SUP-2506000,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
APPLICATOR TY BRACHYTHERAPY SAVI 10-1,SUP-2164404,CDM,C1728,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
DEVICE FIX 15MM LOOP DYNEEMA PURITY BRAID CONT FOR ACL PCL,SUP-2366632,CDM,C1713,HCPCS,0278,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
PLATE QUIKFLAP BURRHOLE  SD AXS,SUP-2718054,CDM,C1713,HCPCS,0278,RC,,,,both,,,7479.48,4861.66,,,,,,,,,,,,,
HC Peripheral Block - Digital,PX-3606445500,CDM,64455,CPT,0360,RC,,,,both,,,920.00,598.00,,,,,,,,,,,,,
HC So1 Drvvt,PX-3058561367,CDM,85613,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
PLATE BNE ANT LAT R TIBIAXYS,SUP-2243000,CDM,C1713,HCPCS,0278,RC,,,,both,,,4928.26,3203.37,,,,,,,,,,,,,
REAMER SURG 18MM CNVX MOD FT,SUP-2400256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
BIT DRL ADJ,SUP-2792032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.74,577.03,,,,,,,,,,,,,
MESH SURG W6XL10IN OVL SEPRA TECHNOLOGY VENTRALIGHT,SUP-2125907,CDM,C1781,HCPCS,0278,RC,,,,both,,,2807.16,1824.65,,,,,,,,,,,,,
KIT INTRO ARW THMS L 4 IN DIA 8.5 FR 0.035 IN SIDEPRT,SUP-2120576,CDM,C1894,HCPCS,0272,RC,,,,both,,,96.90,62.98,,,,,,,,,,,,,
RING EXT FIX FULL 200 MM CARBON FIBER NS,SUP-2799524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3809.45,2476.14,,,,,,,,,,,,,
BLADE RETRACTOR SCOVILLE UNIV SM RNG,SUP-2480652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.05,567.48,,,,,,,,,,,,,
HC Iadna Herpes Somplx Virus Amplified Probe Tq,PX-3068752900,CDM,87529,CPT,0306,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
GRAFT BNE GRAN 1-2 MM 7.5 CC SUBSTITUTE MIS REFILL ACTIFUSE,SUP-2417667,CDM,C1713,HCPCS,0278,RC,,,,both,,,4913.57,3193.82,,,,,,,,,,,,,
CANNULA SCTN JRCHO 12.5NL TFLN SELF RTNNG MAL TIP W/RBBR ACR,SUP-2497863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,613.18,398.57,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEM CUP POROUS,SUP-2212087,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SCREW BNE EMGCY MIC 1.8X5 MM MAND MIC SELF RET TI,SUP-2470209,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.20,108.03,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 10X10X4MM DEMIN CANC FILL MTRX CNFRM,SUP-2894186,CDM,C1713,HCPCS,0278,RC,,,,both,,,798.19,518.82,,,,,,,,,,,,,
PACEMAKER CARD PHILOS II SR TI POLYUR SIL SINGLE CHMBR STRL,SUP-2137973,CDM,C1786,HCPCS,0275,RC,,,,both,,,11313.42,7353.72,,,,,,,,,,,,,
SEPARATOR THROMCTMY 4 200 CM FOR CAT RX ASPIR CATH INDIGO,SUP-2323714,CDM,C1757,HCPCS,0272,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
DRILL SURG CRTX STD 4.2 MM PROX AO QR NS LTX,SUP-2856022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PROSTATE SEEDING SET 18 GAX20 CM RIGID ETW STRL LTX,SUP-2876583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,38.31,24.90,,,,,,,,,,,,,
SCREW BNE L18MM DIA4MM DST CANC TIB TI NONCANNULATED,SUP-2413451,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
COMPONENT PAT L SZ 3 STD KNEE POLYETH NP RND PEG CEM REV,SUP-2251250,CDM,C1776,CPT,0278,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC CER GRAN TYPE-I BOV CLLGN RPM,SUP-2930789,CDM,C1763,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,340b,HCPCS,0637,RC,81033-0512-15,NDC,,both,15,ML,5.00,3.25,,,,,,,,,,,,,
CATHETER IVUS PIONEER + L 120 CM SHTH 6 FR GUIDEWIRE 0.014,SUP-2327245,CDM,C1887,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
INSERT TIB ULT CONG L 22MM SZ A NAT KNEE,SUP-2209475,CDM,C1776,CPT,0278,RC,,,,both,,,5903.20,3837.08,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MED 5 CC OSTEOCONDUCTIVE MTRX + NUCEL,SUP-2716038,CDM,C1762,CPT,0278,RC,,,,both,,,6609.70,4296.30,,,,,,,,,,,,,
KIT EXT FIX L ANK FRME,SUP-2179120,CDM,C1776,CPT,0278,RC,,,,both,,,10337.57,6719.42,,,,,,,,,,,,,
FASTAK ECONOMY PACK 100 2.8MM,SUP-2841400,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
BLADE SAW OSTEOTMY 12.5X12X0.38 MM MAND OFFSET STRL LTX,SUP-2862476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.47,212.86,,,,,,,,,,,,,
PLATE BNE L100MM 5 H T SHP FOR 45MM SCR L FRAG SYS,SUP-2411392,CDM,C1713,HCPCS,0278,RC,,,,both,,,620.97,403.63,,,,,,,,,,,,,
NAIL EBA ONE LONG 130DEG LEFT 36MM,SUP-2717572,CDM,C1713,HCPCS,0278,RC,,,,both,,,5143.32,3343.16,,,,,,,,,,,,,
PEG KIT FEED 20 FR TUBE CONCL PUL N ENFIT CORFLO,SUP-2764900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.36,218.63,,,,,,,,,,,,,
PIN EXT FIX FT 7X135 MM BEAM SALVATION,SUP-2850841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
PLATE BNE 2 MM 20 HOLE PT SPEC TI MATRIXMANDIBLE,SUP-2860073,CDM,C1713,HCPCS,0278,RC,,,,both,,,10719.65,6967.77,,,,,,,,,,,,,
NEEDLE RHOTON STRAIGHT 12 SEMI SHARP TITANIUM,SUP-2459728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.66,302.68,,,,,,,,,,,,,
MATRIX BIO SZ 300 SQCM FISH SKIN DERMAL MESHED 21 INTACT,SUP-2909230,CDM,Q4158,HCPCS,0636,RC,,,,both,,,30049.80,19532.37,,,,,,,,,,,,,
BIT DRILL 4.5MM DIA DISPO HOWMEDICA TOT KNEE SYS - 4.5MM,SUP-2377559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
AUGMENT FEM SZ 2.5 THK8MM STD POST TI CEM PFC SIG,SUP-2253619,CDM,C1776,CPT,0278,RC,,,,both,,,2334.90,1517.68,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X269 MM 15 HOLE SS LCP,SUP-2569368,CDM,C1713,HCPCS,0278,RC,,,,both,,,811.69,527.60,,,,,,,,,,,,,
DISTRACTION INTRNL ST SIZER 02 424 25 71 02 424 30 7125 30 M,SUP-2707284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
PLATE SPNL INFERIOR END LG STR,SUP-2194232,CDM,C1713,HCPCS,0278,RC,,,,both,,,15838.16,10294.80,,,,,,,,,,,,,
GRAFT BONE LT TALUS WHL TRAD FRZN,SUP-2294187,CDM,C1713,HCPCS,0278,RC,,,,both,,,8264.48,5371.91,,,,,,,,,,,,,
BUSHING ORTH L BEAR KT,SUP-2372317,CDM,C1776,CPT,0278,RC,,,,both,,,2875.61,1869.15,,,,,,,,,,,,,
SCREW BNE CANN LNG THRD 4X40 MM TI NS,SUP-2190032,CDM,C1713,HCPCS,0278,RC,,,,both,,,512.95,333.42,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLED 8 CM HYDROCEPHALUS THER BA,SUP-2665095,CDM,C1729,HCPCS,0272,RC,,,,both,,,385.75,250.74,,,,,,,,,,,,,
PLATE BNE W13.5XL142MM THK4.2MM 8 H BILAT S STL NAR LIMIT,SUP-2185239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1326.27,862.08,,,,,,,,,,,,,
PLATE BNE THK1MM 16 H MINI CRANIOMAXILLOFACIAL TI STR REG,SUP-2366316,CDM,C1713,HCPCS,0278,RC,,,,both,,,1483.71,964.41,,,,,,,,,,,,,
POROUS TIB BASE W SCREWHOLE MED+,SUP-2397059,CDM,C1776,CPT,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
RING ACET HIP TI POLY CONSTRN X RET RNGLOC II,SUP-2403875,CDM,C1776,CPT,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED LT MEDL FEM CONDYLE,SUP-2867081,CDM,C1762,CPT,0278,RC,,,,both,,,11356.28,7381.58,,,,,,,,,,,,,
HC So1 Infectious Agent Antigen,PX-3068789967,CDM,87899,CPT,0306,RC,,,,both,,,49.00,31.85,,,,,,,,,,,,,
KIT CATH HEMODIALYSI PWR TRIALYSI SLIM CATH ACTE 12FR DIA 15,SUP-2613258,CDM,C1752,HCPCS,0278,RC,,,,both,,,840.74,546.48,,,,,,,,,,,,,
EVOS 3.5MM SUP MS CLAV PL 10H RIGHT 108MM,SUP-2819913,CDM,C1713,HCPCS,0278,RC,,,,both,,,4797.14,3118.14,,,,,,,,,,,,,
SPONGE BNE GRFT CANC 10X7X4 MM OSTEOINDUCTIVE SCAFFOLD 2 PK,SUP-2431594,CDM,C1889,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5CM 7MM 75CM 8FR HEPARIN,SUP-2396604,CDM,C1876,HCPCS,0278,RC,,,,both,,,9391.74,6104.63,,,,,,,,,,,,,
TOPIRAMATE 25 MG PO TABS,RX-18920,CDM,6370000000,HCPCS,0637,RC,68084-0342-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BELT RIB ELAS FOAM FEM UNIV 6IN,SUP-2194538,CDM,L0220,HCPCS,0272,RC,,,,both,,,30.21,19.64,,,,,,,,,,,,,
MESH CRAN L 80.26 X W 60.96 MM THK 0.6 MM SCREW DIA1.5 MM TI,SUP-2936698,CDM,C1713,HCPCS,0278,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
GRAFT BNE 2.5CC VIABLE BNE MTRX COMPRESSIBLE MOLD RDY TO,SUP-2370452,CDM,C1763,HCPCS,0278,RC,,,,both,,,3037.95,1974.67,,,,,,,,,,,,,
CATHETER HD PRE CRV 13.5 FRX20 CM KT HI FLO NIAG,SUP-2125587,CDM,C1752,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
NEXGEN FULL BLOCK TIBIAL AUGMENT 10MM SIZE 6,SUP-2503153,CDM,C1776,CPT,0278,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CORTICOCANCELLOUS ALLGRFT,SUP-2932826,CDM,C1762,CPT,0278,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3 CM 035X260 STIFF COR HYDRPHLC CANALIZER,SUP-2120023,CDM,C1769,HCPCS,0272,RC,,,,both,,,160.77,104.50,,,,,,,,,,,,,
CANNULA ENDOSCP SUCTION 4 MMX12 CM SIMMEN INSUL ANGULAR,SUP-2774730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.83,465.29,,,,,,,,,,,,,
GRAFT BNE PTTY LG 11 CC FIBERGRAFT BG,SUP-2330554,CDM,C1713,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
PLATE 4.5MM LCP CONDYLAR 10 HOLES 242MM RIGHT STERILE,SUP-2547438,CDM,C1713,HCPCS,0278,RC,,,,both,,,4586.47,2981.21,,,,,,,,,,,,,
CATHETER CARD ABLATION QDOT MIC L 115 CM 8 FR 3.5 MM J SHP,SUP-2880102,CDM,C1732,HCPCS,0272,RC,,,,both,,,15813.04,10278.48,,,,,,,,,,,,,
SCREW BNE L44MM DIA5MM HD DIA8MM CORT GRN TI ALLY ST,SUP-2192323,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.74,428.18,,,,,,,,,,,,,
TUBE ENDOTRACHEAL LNG 7 MM ELECTROMYOGRAPHIC ELECTRD NVM5,SUP-2559662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CLIP SURG INT USE TI HEMSTAT MICROCLP,SUP-2382611,CDM,C1760,HCPCS,0278,RC,,,,both,,,36.64,23.82,,,,,,,,,,,,,
BIT DRL CANN 6 MM KNEE FOR ACL/PCL STRL DISP,SUP-2849068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,851.63,553.56,,,,,,,,,,,,,
DORAVIRINE 100 MG PO TABS,RX-143516,CDM,6370000000,HCPCS,0637,RC,00006-3069-01,NDC,,both,1,UN,276.00,179.40,,,,,,,,,,,,,
BASKET DISP FLOWER ROT 8W 20MM W/ BULL TIP ROT 2.8MMX1950MM,SUP-2313153,CDM,C1713,HCPCS,0278,RC,,,,both,,,825.07,536.30,,,,,,,,,,,,,
STALIF TT IMPL H11 MM 8 DEG LORDTC MIDLN 5.5X 25 MM 4 SCR,SUP-2320302,CDM,C1889,HCPCS,0278,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
IMMOBILIZER KNEE RIGID LT W/O KNEE JT CUST FABRICATED,SUP-2417693,CDM,L1834,HCPCS,0272,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
SCREW BNE L35MM DIA5MM THRD LOK FOR HIP FRAC SYS CHIMAERA,SUP-2316359,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.89,371.73,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 10 L 300 CM DIA 0.010 IN DSTL SEG L,SUP-2367859,CDM,C1769,HCPCS,0272,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
STEM EXT FLUT 16X160MM W/ SLOT,SUP-2222923,CDM,C1776,CPT,0278,RC,,,,both,,,3589.02,2332.86,,,,,,,,,,,,,
COMPONENT PATELLAR 25 MM KNEE ARCM POLYETH,SUP-2449779,CDM,C1776,CPT,0278,RC,,,,both,,,1904.72,1238.07,,,,,,,,,,,,,
GRAFT BONE 30GM 30CC PARTICULATE SYNTH OSTEOCONDUCTIVE CLLGN,SUP-2288538,CDM,C1713,HCPCS,0278,RC,,,,both,,,3037.20,1974.18,,,,,,,,,,,,,
KIT SHIM FIX MAXCESS IV SYS,SUP-2310432,CDM,C1713,HCPCS,0278,RC,,,,both,,,4033.02,2621.46,,,,,,,,,,,,,
HC Vertebroplasty Addl Inject,PX-3612251500,CDM,22515,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
FIBER LASER 1000U 100W ETFE SIL FLEXSHIELD HI PWR POLISHED,SUP-2141813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2160.19,1404.12,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X105 MM RT LAT DSTL 5 HOLE STRL VALCP,SUP-2789393,CDM,C1713,HCPCS,0278,RC,,,,both,,,2942.31,1912.50,,,,,,,,,,,,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,0636,RC,10019-0926-02,NDC,,both,1,UN,309.80,201.37,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT N ABSRB 3MM DIA ETHBND FASTIN,SUP-2256672,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.24,627.41,,,,,,,,,,,,,
WRENCH SURG SPNR,SUP-2355993,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0250,RC,00990-7984-20,NDC,,both,25,ML,29.20,18.98,,,,,,,,,,,,,
IMPLANT HUM TISS ANGIOGRAFT,SUP-2931356,CDM,C1762,CPT,0278,RC,,,,both,,,31888.80,20727.72,,,,,,,,,,,,,
MONOPOLAR STIMULATING PRB STRL SGL USE ONLY,SUP-2354657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HEAD RMR DIA14.5MM S STL CONIC TIP SHRP CUT EDGE ATTACH W/,SUP-2188155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2479.28,1611.53,,,,,,,,,,,,,
CEMENT BNE 80 GM SYS GENTA CEMEX,SUP-2222168,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Immunoassay Tumor Antigen Quantitative Ca 125|NOT REASONABLE AND NECESSARY,PX-3028630400,CDM,86304,CPT,0302,RC,,,GZ,both,,,506.00,328.90,,,,,,,,,,,,,
HEAD HUM H15MM OD40MM TI SHLDR TOT RVS MOD BIOMOD,SUP-2404604,CDM,C1776,CPT,0278,RC,,,,both,,,4879.56,3171.71,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 25 MCG PO TABS,RX-4420,CDM,6370000000,HCPCS,0637,RC,00904-6949-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT OSS L5.8MM FLNG DIA3.5MM 1.17MM HA HD HAPEX SHFT,SUP-2312813,CDM,L8613,CPT,0278,RC,,,,both,,,1230.28,799.68,,,,,,,,,,,,,
BLADE SHAVER 3.5 MMX7 CM TORPEDO,SUP-2424064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
BIT DRL 3.8X35 MM QUICKSET,SUP-2454001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.27,287.48,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM SGL TRCR FOR POLYAX COMPR,SUP-2397720,CDM,C1713,HCPCS,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X216 MM LT PROX 7 HOLE NS VA-LCP,SUP-2757659,CDM,C1713,HCPCS,0278,RC,,,,both,,,6579.96,4276.97,,,,,,,,,,,,,
CANNULA ART AD 7 FR BIOLINE COATED HLS,SUP-2663451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,41448.00,26941.20,,,,,,,,,,,,,
SUPPORT ORTHOT HIP BILATERAL CUST COMBINATION,SUP-2435602,CDM,L1690,HCPCS,0272,RC,,,,both,,,5474.75,3558.59,,,,,,,,,,,,,
HC Cystogram Routine Min 3 Views,PX-3207443000,CDM,74430,CPT,0320,RC,,,,both,,,900.00,585.00,,,,,,,,,,,,,
ANCHOR SUT ORTHOCORD SZ 2 L36IN COMP BRAID CP-2 ARMED NDL,SUP-2249447,CDM,C1713,HCPCS,0278,RC,,,,both,,,3067.78,1994.06,,,,,,,,,,,,,
IMPLANT BONE ANCHORED BAHA AD UNILAT W/SLEEPER,SUP-2165010,CDM,L8614,HCPCS,0278,RC,,,,both,,,20535.60,13348.14,,,,,,,,,,,,,
HEAD HUM 48X18 MM SHAPER GLOB CAP QC,SUP-2453844,CDM,C1776,CPT,0278,RC,,,,both,,,3111.74,2022.63,,,,,,,,,,,,,
STEM HUM L205MM DIA10MMXLONG UNIV SHLDR CO CHROM CEM REV,SUP-2193878,CDM,C1776,CPT,0278,RC,,,,both,,,12074.56,7848.46,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ZIPWIRE 0.025IN 150CM 3CM TAPER,SUP-2862316,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.56,109.56,,,,,,,,,,,,,
SPLINT ORTHOPEDIC DLX MED 8-9.5 9.5-11 RT ANK FT CLOSED HEEL,SUP-2195191,CDM,L1930,HCPCS,0272,RC,,,,both,,,103.68,67.39,,,,,,,,,,,,,
CLARITHROMYCIN 250 MG/5ML PO SUSR,RX-12886,CDM,340b,HCPCS,0637,RC,00781-6023-52,NDC,,both,50,ML,423.90,275.53,,,,,,,,,,,,,
CLAMP EXT FIX BAR TO RNG FOR JETXSYSTEM,SUP-2342864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3670.19,2385.62,,,,,,,,,,,,,
PLATE BNE W17.5XL196MM THK5.2MM 11 H BILAT S STL BROAD,SUP-2185295,CDM,C1713,HCPCS,0278,RC,,,,both,,,1736.11,1128.47,,,,,,,,,,,,,
BRACE LS M FOR 35 41IN HIP COT POLYAMIDE LYCRA AVG SUPP 2,SUP-2325578,CDM,L0625,HCPCS,0272,RC,,,,both,,,207.81,135.08,,,,,,,,,,,,,
WASHER ORTH SM DIA7MM FLAT RND S STL FOR 2.7-3.5-4MM SCR,SUP-2411297,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.25,43.06,,,,,,,,,,,,,
LEAD DEFIB LINOXSMART S L 60 CM SIL INSUL IRIDIUM OXIDE TIP,SUP-2138278,CDM,C1777,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
GRAFT BNE 30ML CANC MIC MORSL B-TCP VITOSS,SUP-2368166,CDM,C1713,HCPCS,0278,RC,,,,both,,,4524.74,2941.08,,,,,,,,,,,,,
STEM FEM PRSS FIT COCR HA COAT SZ 5/15MM MERID PA,SUP-2375312,CDM,C1776,CPT,0278,RC,,,,both,,,9037.99,5874.69,,,,,,,,,,,,,
CATHETER ETER HAD EXCHG STR KT 16FRX50CM GLIDEPATH,SUP-2126481,CDM,C1881,HCPCS,0278,RC,,,,both,,,1341.88,872.22,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0X38MM H,SUP-2320927,CDM,C1713,HCPCS,0278,RC,,,,both,,,846.23,550.05,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X28X2 MM 4 HOLE FRAC NC LCK FOR SCR TI,SUP-2465584,CDM,C1713,HCPCS,0278,RC,,,,both,,,1346.53,875.24,,,,,,,,,,,,,
KIT CATH 12FR L16CM MULTILUMEN CTRL VEN L BOR BLU FLEXTIP,SUP-2383307,CDM,C1751,HCPCS,0278,RC,,,,both,,,341.00,221.65,,,,,,,,,,,,,
CATHETER ASPIR 6FRX125CM SUPP STRL NAVIEN,SUP-2281410,CDM,C1887,HCPCS,0272,RC,,,,both,,,6421.30,4173.84,,,,,,,,,,,,,
CATHETER LUM PERI EXT DRNGE LUER LCK CONN SUT TAB TOUHY NDL,SUP-2244312,CDM,C1729,HCPCS,0272,RC,,,,both,,,1993.30,1295.64,,,,,,,,,,,,,
CUP ACET CEM 22 MM HIP HW W/ PLATE,SUP-2447855,CDM,C1776,CPT,0278,RC,,,,both,,,1624.95,1056.22,,,,,,,,,,,,,
COMPONENT PAT SGL PEG RND PRI STD CEM N POR POLYETHLYENE,SUP-2390325,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PIN FIX L9IN DIA28MM ST S STL 2 SIDE SGL DMND 1 END PNT,SUP-2150484,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.41,8.72,,,,,,,,,,,,,
PLATE BONE L38MM 3 H BILAT 1/3 TBLR NONCOMPRESSION RIG FOR,SUP-2348954,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.92,342.50,,,,,,,,,,,,,
ANCHOR SUT L THRD FOR ANK FUS PLATING SYS BB-TAK,SUP-2123201,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
FIBER LASER CONVERGENCE OPTICIS MVDF MULT,SUP-2748375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4556.30,2961.59,,,,,,,,,,,,,
BRACE KNEE FOR 26IN FOAM TELSCP FULL TECHNOLOGY QUIK LOK,SUP-2196499,CDM,L1832,HCPCS,0272,RC,,,,both,,,346.37,225.14,,,,,,,,,,,,,
STAPLE INT THK2.5X1.6MM W25XL22-22MM ANK FT NIT SUP E,SUP-2378849,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
TUBE VENT SHEP 1.02 MM 1.32 MM EAR FOR MYRINGOTOMY FLROPLAS,SUP-2312778,CDM,L8699,HCPCS,0278,RC,,,,both,,,19.59,12.73,,,,,,,,,,,,,
CARB CON ROD 8MMX200MM,SUP-2469226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
EVOS 2.7/3.5MM EA-D HUM PL 16H L 195MM,SUP-2819909,CDM,C1713,HCPCS,0278,RC,,,,both,,,9594.27,6236.28,,,,,,,,,,,,,
NAIL IM L440MM DIA2.5MM PROX TIB ROSE RED TI E STBL,SUP-2192728,CDM,C1713,HCPCS,0278,RC,,,,both,,,889.44,578.14,,,,,,,,,,,,,
GRAFT BNE SUB 6ML VOID FILL RESRB PTTY MASTERGRFT,SUP-2288542,CDM,C9359,HCPCS,0278,RC,,,,both,,,2150.90,1398.08,,,,,,,,,,,,,
CUBE EXT FIX 3 HOLE RANCHO,SUP-2749948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
PLATE BNE L86MM 4 H L TIB BILAT TI L BTTRS LO PROF RIG,SUP-2190897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1555.34,1010.97,,,,,,,,,,,,,
SLEEVE DECOMPRESSION DIA 40 FR SHRT GASTRECTOMY 3D CALIB SYS,SUP-2883550,CDM,C1889,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
CATHETER CARD ABLATION CHILLI II L 120 CM DIA 7 FR SPC 2.5,SUP-2139755,CDM,C1730,HCPCS,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
INTRODUCER INFUSION PMP 23 FR KT SHTH INSRTN DIL IMPELLA RP,SUP-2431909,CDM,C1894,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BNE STR 3.5X36.2 MM 3 HOLE RECON FOR SM FRAG SYS TI NS,SUP-2463023,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.40,479.31,,,,,,,,,,,,,
NEUROSTIMULATOR INTERSTIM X RECHRGE FREE TORQ WRNCH PROD,SUP-2738996,CDM,C1767,HCPCS,0278,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
SACUBITRIL-VALSARTAN 24-26 MG PO TABS,RX-130694,CDM,6370000000,HCPCS,0637,RC,43598-0643-60,NDC,,both,1,UN,23.90,15.53,,,,,,,,,,,,,
DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN,RX-125409,CDM,J1100,HCPCS,0636,RC,67457-0418-00,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
HC So1 T Cell Total,PX-3028635967,CDM,86359,CPT,0302,RC,,,,both,,,81.00,52.65,,,,,,,,,,,,,
HC So1 Encephalitis California,PX-3028665167,CDM,86651,CPT,0302,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
STENT COR 9MM 2.25MM CO CHROM PROBIO SCP HYDRPHLC,SUP-2138133,CDM,C1876,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
CATHETER GUID SHEATHLESS EAUCATH L 100 CM 7.5 FR JL3.5 ST,SUP-2722071,CDM,C1769,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
BUR SURG DIAMOND 1.5 MMX16 CM MTCH HD BRN STRL LTX,SUP-2859541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
LINER ACET SZ 26 DIA38MM 10DEG RINGLOC ARCOMXL,SUP-2409519,CDM,C1776,CPT,0278,RC,,,,both,,,3857.49,2507.37,,,,,,,,,,,,,
BLADE SHAVER 2.1MM STRAIGHT,SUP-2659959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
BIT REPROC DRL CANN TAP AO CPL 2.1MM,SUP-2653150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.24,266.01,,,,,,,,,,,,,
PLATE L 2.4MM 2H,SUP-2843930,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
HC So Chromium Serum,PX-3018249566,CDM,82495,CPT,0301,RC,,,,inpatient,,,60.00,39.00,,,,,,,,,,,,,
BETAXOLOL HCL 0.5 % OP SOLN,RX-9268,CDM,6370000000,HCPCS,0637,RC,61314-0245-01,NDC,,both,5,ML,229.50,149.17,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.5MM CO CHROM LOK SQ DRV MULTDIR PEGGED,SUP-2411663,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
PROSTHESIS OSS MIC 3X1.5 MM 1 MM MONOLITHIC CENTERED TI PORP,SUP-2638166,CDM,L8613,CPT,0278,RC,,,,both,,,1056.70,686.85,,,,,,,,,,,,,
SCREW BNE L8MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI ST 401158] DEPUY SYNTHES USA],SUP-2189368,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.99,151.44,,,,,,,,,,,,,
LEVOFLOXACIN 5 MG/ML SYRINGE (PED) <50 ML,RX-4090160,CDM,J1956,HCPCS,0636,RC,00143-9317-24,NDC,,both,50,ML,11.00,7.15,,,,,,,,,,,,,
REAMER SURG HIP GRTR DOME 52MM REFLCT,SUP-2345722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,586.68,381.34,,,,,,,,,,,,,
PLATE BONE CONDYLAR MINI SHORT TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878197,CDM,C1713,HCPCS,0278,RC,,,,both,,,4254.70,2765.55,,,,,,,,,,,,,
GENERATOR NEUROSTIM SPNL CRD PLSE STIM SYS PRECISION PLUS,SUP-2138775,CDM,C1820,HCPCS,0278,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
SPHERE EMB LC BEAD PARTIC SZ 70-150UM 2ML SULPHONATE BLK YEL,SUP-2135324,CDM,C1889,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X0.3 MM TRANSANTRAL FOR SCREW TI STRL,SUP-2498482,CDM,C1713,HCPCS,0278,RC,,,,both,,,2131.75,1385.64,,,,,,,,,,,,,
BOLT EXT FIX SLT WIRE MR CONDITIONAL FOR DISTR OSTEOGENESIS,SUP-2187901,CDM,C1713,HCPCS,0278,RC,,,,both,,,145.04,94.28,,,,,,,,,,,,,
PLATE BNE L2505MM THK25MM 16 H PELV S STL STR,SUP-2362704,CDM,C1713,HCPCS,0278,RC,,,,both,,,2894.77,1881.60,,,,,,,,,,,,,
NAVIGATION KIT 17/18 GA NDL APPL,SUP-2135315,CDM,C1715,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
ONDANSETRON HCL 4 MG/2ML IJ SOLN,RX-103562,CDM,J2405,HCPCS,0636,RC,00409-4755-18,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
LINER ACET OD64MM ID28MM +4MM OFFSET 10DEG HIP MARATHON,SUP-2250364,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
STENT URET 0.038 IN 5 FRX28 CM 6 FR DBL PGTL PERCFLX POLARIS,SUP-2482049,CDM,C2617,HCPCS,0278,RC,,,,both,,,485.41,315.52,,,,,,,,,,,,,
BASKET STONE STR 3 FR 12 MMX70 CM 4 WIR W/O TIP NIT STRL,SUP-2767533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1189.12,772.93,,,,,,,,,,,,,
PLATE BNE W10XL97MM THK1.5MM 90DEG 8X3 H BILAT S STL T SHP,SUP-2185879,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.25,1092.81,,,,,,,,,,,,,
HC So Delta Aminolevulinic Acid,PX-3018213566,CDM,82135,CPT,0301,RC,,,,outpatient,,,520.00,338.00,,,,,,,,,,,,,
BIT DRL QC 2.5X170 MM 80 MM CALIB STRL,SUP-2563751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.68,300.74,,,,,,,,,,,,,
HC Gonadotropin Follicle Stimulating Hormone,PX-3018300100,CDM,83001,CPT,0301,RC,,,,both,,,643.00,417.95,,,,,,,,,,,,,
GRAFT HUM TISS CART VIABLE CARTIMAX,SUP-2307231,CDM,C1762,CPT,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK ORTHOGNATHIC PLN IPS,SUP-2433937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
WIRE FIX TRCR PT 0.28 MMX4 IN NS KIRSCHNER,SUP-2361628,CDM,C1713,HCPCS,0278,RC,,,,both,,,5.90,3.83,,,,,,,,,,,,,
PLATE BNE L422MM 20 H ST R CNDYL S STL LOK COMPR CRV FOR,SUP-2177093,CDM,C1713,HCPCS,0278,RC,,,,both,,,5111.79,3322.66,,,,,,,,,,,,,
DEVICE DCOMPR SM EXP POST FUS COR AILERON,SUP-2264536,CDM,2780000010,LOCAL,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
DEVICE LENS FRAGMENTATION MILOOP,SUP-2420828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BNE L MINI 2X19 MM LT 4 HOLE OBLQ ANGLED TI,SUP-2481111,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.33,190.01,,,,,,,,,,,,,
PLATE STRNL 6 H TI STR NS MATRIXSTERNUM,SUP-2904233,CDM,C1713,HCPCS,0278,RC,,,,both,,,1860.48,1209.31,,,,,,,,,,,,,
PLATE BONE L200MM 16 H STRL RT LAT PROX TIB S STL FOR 3.5MM,SUP-2349728,CDM,C1713,HCPCS,0278,RC,,,,both,,,12061.37,7839.89,,,,,,,,,,,,,
SPACER SPNL SPIKLS 0 DEG 14X12X17 MM THORLUM TI FORTIFY I-R,SUP-2594900,CDM,C1821,HCPCS,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA14MM FOR IO FIX SYS,SUP-2400060,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
PROBE ABLATOR-S VULCAN 90 DEG HP,SUP-2850057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.07,383.55,,,,,,,,,,,,,
CONNECTOR SPNL ROD DIA 3.5 MM POST CERV PARALLEL DBL NS,SUP-2887235,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.90,109.13,,,,,,,,,,,,,
COMPONENT TIB REV C RT KNEE PERSONA,SUP-2508651,CDM,C1776,CPT,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
CONNECTOR SPNL L16MM ANTR PEDCL THORLUM TI CROSS FOR 5.5MM,SUP-2255188,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
KIT BONE BX 11GA L10CM HARP TIP CANN L14CM DIA2.4MM TRCR TIP,SUP-2263903,CDM,C1894,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CLAMP EXT FIX AD PELV PROCALLUS T FOR LIMB RECON SYS,SUP-2316282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.57,918.82,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK 2 ORTHOCORD SZ 2 L36IN VLT BLU,SUP-2249413,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
NAIL IM L160MM DIA11MM NONSTERILE AQUA L/R DST FEM TI LOK,SUP-2191738,CDM,C1713,HCPCS,0278,RC,,,,both,,,5147.62,3345.95,,,,,,,,,,,,,
TROCAR SURG TARGETING LNG 5 MM FOR M/DN IM NAIL,SUP-2478334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
PLATE BNE L349MM 18 H R LAT DST FEM S STL LOK COMPR FOR,SUP-2410721,CDM,C1713,HCPCS,0278,RC,,,,both,,,4740.05,3081.03,,,,,,,,,,,,,
REAMER SURG 18MM MT JT CONE GEN 2,SUP-2398338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS ILLIOTIBIAL BAND FZ ASP,SUP-2875983,CDM,C1762,CPT,0278,RC,,,,both,,,5387.30,3501.74,,,,,,,,,,,,,
PACEMAKER CARD PERM 2 CHMBR NOT MRI COMPATIBLE STD 2360L] ST JUDE MEDICAL INC],SUP-2356704,CDM,C1785,HCPCS,0275,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PLATE BONE L W13.5XL34MM THK4.2MM 2 H BILAT TI STR RIG LIMIT,SUP-2190803,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.63,353.36,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CC FRZN CRYOPRESERVED BNE MTRX VIVIGEN,SUP-2740836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1423.33,925.16,,,,,,,,,,,,,
MESH HERN W3.2XL3.2IN UMB EPIGASTRIC OMEGA 3 FATTY ACID,SUP-2227401,CDM,C1781,HCPCS,0278,RC,,,,both,,,1799.22,1169.49,,,,,,,,,,,,,
PLATE BNE L118MM 6 H L LAT DST FIBULAR S STL VAR ANG LOK,SUP-2177723,CDM,C1713,HCPCS,0278,RC,,,,both,,,2539.51,1650.68,,,,,,,,,,,,,
MESH HERN RECTANGULAR 1 45X30 CM MONOFILAMENT VERSATEX,SUP-2752220,CDM,C1781,HCPCS,0278,RC,,,,both,,,1278.77,831.20,,,,,,,,,,,,,
BIT DRL 2.7 MM FOR TOT WRST FUSION DISP,SUP-2852076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,922.12,599.38,,,,,,,,,,,,,
SCREW BNE L 3.5 MM DIA1.8 MM CRANIOMAXILOFACIAL HI TORQUE,SUP-2935623,CDM,C1713,HCPCS,0278,RC,,,,both,,,3011.26,1957.32,,,,,,,,,,,,,
RING ACET LCK 270 HIP RINGLOK,SUP-2441443,CDM,C1776,CPT,0278,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
IMPLANT NSL L 25 X W 11 MM THK 0.60 MM POLYETHYL THN,SUP-2883470,CDM,C1889,HCPCS,0278,RC,,,,both,,,1250.57,812.87,,,,,,,,,,,,,
PLATE CRAN L 52 X W 40 MM THK 0.6 MM SCREW DIA1.5 MM SM TI,SUP-2936415,CDM,C1713,HCPCS,0278,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 BLLN L15MM BNE FILL DEV SYR IBT,SUP-2293625,CDM,C1894,HCPCS,0272,RC,,,,both,,,8031.08,5220.20,,,,,,,,,,,,,
SYSTEM EMB EMBOSHIELD NAV6 DIA 7.2 MM WIRE L 190 CM SHTH 5,SUP-2105920,CDM,C1884,HCPCS,0278,RC,,,,both,,,5096.22,3312.54,,,,,,,,,,,,,
SYSTEM DEL 8 GAX10 CM,SUP-2194168,CDM,C1713,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
IMPLANT NSL L23MM MOMETASONE FUROATE PROPEL ? ORDER MULTIPLES OF 5 EACH,SUP-2246419,CDM,C2625,HCPCS,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
HC Voice Prosthesis Eval,PX-4449259700,CDM,92597,CPT,0444,RC,,,,inpatient,,,478.00,310.70,,,,,,,,,,,,,
KIT LD ANCHR STRL,SUP-2905260,CDM,L8699,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE STR 126 MM RIBLOC U +,SUP-2846285,CDM,C1713,HCPCS,0278,RC,,,,both,,,3165.12,2057.33,,,,,,,,,,,,,
PLEDGET CV SAUVAGE L 10.2 X W 5.1 CM THK 0.61 MM POLYESTER,SUP-2761352,CDM,C1768,CPT,0278,RC,,,,both,,,255.60,166.14,,,,,,,,,,,,,
HC I&D Perianal Absc Superficial,PX-4504605000,CDM,46050,CPT,0450,RC,,,,both,,,2029.00,1318.85,,,,,,,,,,,,,
CATHETER THROMCTMY EXTRACTION 0.014 IN 5.5 FRX138 CM PRONTO,SUP-2605995,CDM,C1757,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
KNIFE ENDOSCP PEDIATRIC STR FOR OPT URETHROTM STRL LF,SUP-2430221,CDM,C1713,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
BONE GRFT M 12MM 12 DEG S BLK PRO OSTEON 500,SUP-2415015,CDM,C1713,HCPCS,0278,RC,,,,both,,,2977.03,1935.07,,,,,,,,,,,,,
GRAFT DURA W1XH3IN ULTRAPURE CLLGN ADH BARR MTRX DURAGN +,SUP-2244005,CDM,C1781,HCPCS,0278,RC,,,,both,,,1548.43,1006.48,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 8 MM RNG L 30 CM EPTFE STR TW,SUP-2396133,CDM,C1768,CPT,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
CROWN DENT SZ LL5 LO LT 1ST PERM M S STL THCK OCCLUSAL SURF,SUP-2238806,CDM,D6783,CPT,0278,RC,,,,both,,,26.78,17.41,,,,,,,,,,,,,
SCREW BNE FT LG 4.5X48 MM HEX HD SS NS,SUP-2184490,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.48,439.06,,,,,,,,,,,,,
BRUSH CYTO 3FR L115CM DISP,SUP-2313965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,736.42,478.67,,,,,,,,,,,,,
PLATE BNE L 88 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 8 H,SUP-2936316,CDM,C1713,HCPCS,0278,RC,,,,both,,,1738.93,1130.30,,,,,,,,,,,,,
SET VASC ACCS PED 4FR L10CM NIT PLAT ECHOGENIC TIP 0018IN,SUP-2170548,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.20,52.78,,,,,,,,,,,,,
SEALENT TISS FIBRIN 10 ML VALUPAK KT TISSEEL,SUP-2129969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1659.80,1078.87,,,,,,,,,,,,,
BIT DRILL 3.8MM DIA 127MML STAINLESS STEEL CALIBRATED,SUP-2588762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.86,223.51,,,,,,,,,,,,,
PATCH VASC W6XL75MM CAR POLY STR STD WALL NONTAPERED,SUP-2227499,CDM,C1768,CPT,0278,RC,,,,both,,,314.06,204.14,,,,,,,,,,,,,
KIT PANCREAS STNT 5FR L7CM PLAS STR NO LD BARB TRAILING,SUP-2141477,CDM,C2625,HCPCS,0278,RC,,,,both,,,547.05,355.58,,,,,,,,,,,,,
LCKNG PL STR2X816 H GRID T15MM CP TI,SUP-2694191,CDM,C1713,HCPCS,0278,RC,,,,both,,,2830.68,1839.94,,,,,,,,,,,,,
BIT DRL L100MM DIA2.5MM PROX TIB TI CALIB NONRADIOLUCENT,SUP-2412634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
HC NM Bowel Imaging,PX-3417829000,CDM,78290,CPT,0341,RC,,,,both,,,3272.00,2126.80,,,,,,,,,,,,,
SCREW BNE ST 1.85X18 MM CRUCFRM HD EMGCY TI LT BLU NS,SUP-2181652,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.14,214.59,,,,,,,,,,,,,
PROSTHESIS PENILE RESERVOIR CONCEAL INFLATE,SUP-2140247,CDM,C1813,HCPCS,0278,RC,,,,both,,,7458.76,4848.19,,,,,,,,,,,,,
FORCEPS SURG 33X3CM CUT W/ CRD 9 PIN PLASMACISION 920005PK] OLYMPUS SURGICAL TECH - GYRUS],SUP-2313943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2275.24,1478.91,,,,,,,,,,,,,
BOLT EXT FIX M CIR HOFFMANN LRF,SUP-2363119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,330.64,214.92,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 120 CM DIA 0.038 IN PTFE PERIPH,SUP-2169790,CDM,C1769,HCPCS,0272,RC,,,,both,,,176.63,114.81,,,,,,,,,,,,,
DRIVER ST PK KT HEX 35MM CORETRAK,SUP-2399887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
HC Removal FB Skin|PO,PX-3611012000,CDM,10120,CPT,0361,RC,,,PO,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE SET DIA-META DSTL RAD VOLAR LCP,SUP-2177064,CDM,C1713,HCPCS,0278,RC,,,,both,,,41824.17,27185.71,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 4X36 MM HDLSS NS MINI-MONSTER,SUP-2742596,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.21,492.19,,,,,,,,,,,,,
ROD EXT FIX L280MM DIA8MM C FBR CONN REUSE,SUP-2188746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,444.00,288.60,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN BNE MTRX PTTY OSTEOINDUCTIVE INJ,SUP-2306996,CDM,C9359,HCPCS,0278,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
IMPLANT TIB POST STBL UNIV PRI PEG CEM SZ 8 E/F 10MM THCK,SUP-2200761,CDM,C1776,CPT,0278,RC,,,,both,,,14474.77,9408.60,,,,,,,,,,,,,
PLUG H APCL FOR LEGEND ACET SHELL,SUP-2314464,CDM,C1776,CPT,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
PLATE BNE X 0.4 MM 4 HOLE TI SLV NS MATRIXMIDFACE,SUP-2181675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.39,724.35,,,,,,,,,,,,,
BIT DRL QC 4.8X180 MM FOR DYN AX FIX TIN COAT NS LTX,SUP-2874957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.75,238.39,,,,,,,,,,,,,
ALLOGRAFT PLACENTAL MATRIX 4CM X 4CM AMNIOBAND,SUP-2877947,CDM,C1762,CPT,0278,RC,,,,both,,,7696.89,5002.98,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED INCRD MOTN ADD ON 1,SUP-2212531,CDM,C1776,CPT,0278,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
PLATE SPNL L17MM ANT LUM TI LO PROF AEGIS,SUP-2255173,CDM,C1713,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
CONNECTOR SPNL ROD LNG 300 MM CLOSED AX MARINER OUTRIG,SUP-2709820,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
CAP END 5MM EXTN SLD TI FOR HUM NAIL,SUP-2192530,CDM,C1713,HCPCS,0278,RC,,,,both,,,716.71,465.86,,,,,,,,,,,,,
PLATE BNE L 131 MM SCREW DIA 4.5 MM 7 H SS NAR COMPR NLCK,SUP-2932849,CDM,C1713,HCPCS,0278,RC,,,,both,,,1734.47,1127.41,,,,,,,,,,,,,
SET INT FIX 5 MM MIS CHMFR SCREW REDUCTION WIRE,SUP-2909099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.47,331.16,,,,,,,,,,,,,
COIL EMB L10CM DIA0.02IN LOOP DIA4MM CRV EXTRA SFT FILL,SUP-2323452,CDM,C1889,HCPCS,0278,RC,,,,both,,,7526.58,4892.28,,,,,,,,,,,,,
BLADE SAW W13XL90MM THK119MM S STL OSC STABLECUT,SUP-2253183,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.63,204.51,,,,,,,,,,,,,
HC Xray Exam of Peritoneum,PX-3207419000,CDM,74190,CPT,0320,RC,,,,both,,,908.00,590.20,,,,,,,,,,,,,
IMPLANT BEDROCK GRANITE IFUSE 10.5MM X 80MM,SUP-2858679,CDM,C1737,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
INSERT ACET OD46MM ID28MM 6MM OFFSET 20DEG X FRE HIP ECC,SUP-2379060,CDM,C1776,CPT,0278,RC,,,,both,,,3232.94,2101.41,,,,,,,,,,,,,
PLATE BNE FEM 196 MM LT DSTL 7 HOLE TI STRL LCP,SUP-2549450,CDM,C1713,HCPCS,0278,RC,,,,both,,,5273.13,3427.53,,,,,,,,,,,,,
TROCAR SURG TWIN FOR 2.7 MM PIN,SUP-2537826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.29,371.34,,,,,,,,,,,,,
BRACE WLK L SHOE MAN 10 13 WOMAN 11 15 EXTRA PNEUMAT SEMI,SUP-2196363,CDM,L4361,HCPCS,0272,RC,,,,both,,,224.82,146.13,,,,,,,,,,,,,
IMPLANT CRAN M PEEK PRIORITY CUSTOMIZED,SUP-2365149,CDM,C1713,HCPCS,0278,RC,,,,both,,,46446.28,30190.08,,,,,,,,,,,,,
SCREW BNE L55MM OD6MM CORT ST NONCANNULATED NONLOCKING FULL,SUP-2377557,CDM,C1713,HCPCS,0278,RC,,,,both,,,617.95,401.67,,,,,,,,,,,,,
PORT VLV TI STD POLYUR 8FR MEDI-PRT,SUP-2308251,CDM,C1788,HCPCS,0278,RC,,,,both,,,1025.24,666.41,,,,,,,,,,,,,
CLAMP SURG ROD TO ROD 6.5-6.5 MM SINGLE REVERE,SUP-2584884,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
HANDPIECE LASER LAP-R FIBERLASE,SUP-2713721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6179.52,4016.69,,,,,,,,,,,,,
COMPONENT FEMORALXL RT KNEE POST STABILIZING REV PRI,SUP-2364859,CDM,C1776,CPT,0278,RC,,,,both,,,13590.42,8833.77,,,,,,,,,,,,,
IMPLANT SPNL H45 73MM 6DEG LUM W L ENDPLATE RATCH MECHANISM,SUP-2193205,CDM,C1889,HCPCS,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
PROBE CRYOABLATION L 17 IN OD 8 MM BALL TIP STRL DISP,SUP-2889660,CDM,C9808,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH HTORQ L 100 CM DIA 6 FR,SUP-2937135,CDM,C1757,HCPCS,0272,RC,,,,both,,,30301.00,19695.65,,,,,,,,,,,,,
BLADE OSTEOTOM L10MM FLAT FLEX W/ BLDE AND DETACH HNDL,SUP-2364281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
COMPONENT FEM 1 LT KNEE POROUS MILLER-GALANTE II,SUP-2199486,CDM,C1776,CPT,0278,RC,,,,both,,,22118.16,14376.80,,,,,,,,,,,,,
SCREW BNE LCK 4.5X15 MM,SUP-2391494,CDM,C1713,HCPCS,0278,RC,,,,both,,,1096.49,712.72,,,,,,,,,,,,,
WASHER ORTH OVL 18X2 MM CANN SS NS,SUP-2178294,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.20,158.73,,,,,,,,,,,,,
ELECTRODE CORTICAL 2 X 4 T TAIL KT STRL DISP EVO,SUP-2935047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
CUP ACET 32X62 MM FEM HIP LONGEVITY,SUP-2202577,CDM,C1776,CPT,0278,RC,,,,both,,,2024.83,1316.14,,,,,,,,,,,,,
ROD THRD 120MM FOR RINGFIX SYS,SUP-2378779,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,J0281,HCPCS,0250,RC,00409-4346-73,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
HC Remote Afterld Brachy 2-12 Cha,PX-3337777100,CDM,77771,CPT,0333,RC,,,,both,,,5306.00,3448.90,,,,,,,,,,,,,
FEE PROC ARTIX THROMCTMY SYS,SUP-2905442,CDM,C1757,HCPCS,0272,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
STEM HUM L130MM DIA12MM UNIV DSTL SHLDR TI PRI REV CEM FOR,SUP-2363646,CDM,C1776,CPT,0278,RC,,,,both,,,9857.09,6407.11,,,,,,,,,,,,,
KIT BNE GRFT SUB 3CC SIDE DEL CANN L60MM NDL 15GA COMPLT FT,SUP-2208438,CDM,C1713,HCPCS,0278,RC,,,,both,,,9608.40,6245.46,,,,,,,,,,,,,
KIT INTRO L 14 CM DIA14 FR GUIDEWIRE L 50 CM DIA 0.038 IN,SUP-2125279,CDM,C1892,HCPCS,0272,RC,,,,both,,,108.30,70.39,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA 7 MM AX COMPLIANCE,SUP-2481628,CDM,C1768,CPT,0278,RC,,,,both,,,6373.89,4143.03,,,,,,,,,,,,,
CATHETER MNOMTR 5-3.5FR TIP L5MM SH 0.018IN LEHMAN SPHIN OF,SUP-2169517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
SCREW CORTICAL 3.5X30MM,SUP-2198417,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.58,23.13,,,,,,,,,,,,,
SIMETHICONE 40 MG/0.6ML PO SUSP,RX-7228,CDM,340b,HCPCS,0637,RC,70000-0051-01,NDC,,both,30,ML,30.60,19.89,,,,,,,,,,,,,
HC So Hsv Culture,PX-3008725266,CDM,87252,CPT,0300,RC,,,,both,,,236.00,153.40,,,,,,,,,,,,,
CATHETER THORACENTESIS 2 EYELET 8 FR PVC TAPR TIP DRAINAGE,SUP-2227441,CDM,C1729,HCPCS,0272,RC,,,,both,,,30.21,19.64,,,,,,,,,,,,,
GRAFT ALLGRFT SH CANC 20MMX50MM,SUP-2415402,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
BIT DRL 4.5X300 MM FITBONE TAA,SUP-2645728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,519.98,337.99,,,,,,,,,,,,,
PROX ULNAR PLT PROV RT,SUP-2724312,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.27,1083.08,,,,,,,,,,,,,
ROD EXT FIX L300MM LNG THRD MR CONDITIONAL FOR DISTR,SUP-2187912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,239.77,155.85,,,,,,,,,,,,,
STAPLE INT FIX W12XH10MM FT ANK NIT SUP E LO PROF NOTCH,SUP-2365478,CDM,C1713,HCPCS,0278,RC,,,,both,,,2728.91,1773.79,,,,,,,,,,,,,
SET SCREW SPNL CARBON FIBER PEDCL LCK ELEMENT FOR TRNSCONN,SUP-2883025,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC 0035N OD 260CML BLRY ANGLD TIP STIFF SHAF,SUP-2676534,CDM,C1729,HCPCS,0272,RC,,,,both,,,402.99,261.94,,,,,,,,,,,,,
TUBING ASPIR FOR REPERFUSION CATH PMP CANSTR LID STRL MAX,SUP-2323635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
HC Endoven Ther Chem Adhes Sbsq,PX-3613648300,CDM,36483,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PIN FIX L80MM DIA4MM BNE,SUP-2368437,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
CATHETER ANGIO LANGSTON 145 DEG L 110 CM WORKING L 102 CM OD,SUP-2383140,CDM,C1887,HCPCS,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
ANCHOR SUTURE ABSORBABLE 2 BRAIDED LUPINE LOOP COMP,SUP-2249328,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
MESH SPNL COLOSSEUM CVD 14MMX16MMX28MM,SUP-2417951,CDM,C1889,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA PHSPTE ROTARY MIX PTTY VOID FILL INJ,SUP-2194292,CDM,C1713,HCPCS,0278,RC,,,,both,,,10111.43,6572.43,,,,,,,,,,,,,
HC Reposition Ivc Filter,PX-3613719200,CDM,37192,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
COMPONENT PAT RND PRI STD CEM POR WITHOUTXRAY WIRE 26MM DIA,SUP-2200597,CDM,C1776,CPT,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
GUIDE SURG CUT SPEC PT FOR CAPPED C1SMITHNEPHEW] SMITH AND NEPHEW],SUP-2341216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SCREW INTFR L30MM DIA6-8MM TIB TCP/PLA BIOABSRB,SUP-2249564,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
PLATE BNE LCK 165 MM RT DSTL LAT HUM PERIARTICULAR 11 HOLE,SUP-2459468,CDM,C1713,HCPCS,0278,RC,,,,both,,,3063.45,1991.24,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.014IN TIP L8CM SCITANIUM,SUP-2145957,CDM,C1769,HCPCS,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
HEAD RMR DIA17.5MM MDLLRY PILOT NOSE,SUP-2188101,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.09,505.11,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US|UNUSUAL NON-OVERLAPPING SERVICE|PO,PX-5102060500,CDM,20605,CPT,0510,RC,,,XU|PO,both,,,908.00,590.20,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DIA 7 FR DUODECAPOLAR 20 POLE,SUP-2725655,CDM,C1731,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HC Ins/Repl of Ppm /Atrial Only,PX-3613320600,CDM,33206,CPT,0361,RC,,,,both,,,8901.00,5785.65,,,,,,,,,,,,,
STEM FEM OD18MM 12/14 CLLRLSS STD OFFSET TAPR HIP ZIRCONIA,SUP-2222364,CDM,C1776,CPT,0278,RC,,,,both,,,14506.80,9429.42,,,,,,,,,,,,,
PLATE BNE 2.4X32X1.7 MM 4 HOLE SS LCP,SUP-2569295,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
BRACE THMB SPICA RT REG SPICA MOD SUPP FOAM WRP AD SM,SUP-2324380,CDM,L3931,HCPCS,0272,RC,,,,both,,,28.89,18.78,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L60CM 8 CHN PADDLE TRIPOLE EXCLAIM,SUP-2356736,CDM,C1778,HCPCS,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
SHEATH RENAL DIL AMPLATZ TYP 24FRX17CM,SUP-2141697,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.74,87.58,,,,,,,,,,,,,
SNARE VASC CURRY FOLDED L 150 CM SHFT L 100 CM DIA 6.3 FR,SUP-2167936,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
GUIDEWIRE VASC SHORTY L 180 CM DIA 0.018 IN TAPR L 6 CM FLPY,SUP-2168621,CDM,C1769,HCPCS,0272,RC,,,,both,,,228.34,148.42,,,,,,,,,,,,,
PIN SPNL CASPR 11 MM ALTA,SUP-2692984,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRSS FT FLX POROUS GENDER SOL N-K,SUP-2212610,CDM,C1776,CPT,0278,RC,,,,both,,,15431.22,10030.29,,,,,,,,,,,,,
GUIDEWIRE ENDO L150CM DIA0.025IN TIP L3CM NIT COR HYDRPHLC,SUP-2171363,CDM,C1769,HCPCS,0272,RC,,,,both,,,122.08,79.35,,,,,,,,,,,,,
ANCHOR SUT 23MM 12MM 1 STRND SELF PUNCHING ICONIX,SUP-2362562,CDM,C1713,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRIMARY CEM X3 TRIATHLON,SUP-2365632,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
DIST LAT HUM LCK PLATE 7H,SUP-2464842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2545.97,1654.88,,,,,,,,,,,,,
BIT DRL 2.9X140 MM KT DRL STP 3MM ALLEN WRNCH DYN AX FIX,SUP-2644590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.67,261.09,,,,,,,,,,,,,
SEALER LAPAROSCOPIC L 20 CM DIA 3 MM,SUP-2904182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2302.66,1496.73,,,,,,,,,,,,,
CATHETER DLYS 13.5FR 13CM KT CVD EXTN MAHRK ELITE,SUP-2174258,CDM,C1752,HCPCS,0278,RC,,,,both,,,288.10,187.26,,,,,,,,,,,,,
STEM HUM L6MM SHT PRESERVE EQUINOXE,SUP-2435975,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
BAG LEFT CARRY CONSLDTD F/HEARTMATE II,SUP-2356023,CDM,Q0508,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
LOSARTAN POTASSIUM 25 MG PO TABS,RX-14823,CDM,6370000000,HCPCS,0637,RC,00904-7047-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE SUB 10CC 4-7MM CONT DBM PTTY CANC CHIP CUST,SUP-2399141,CDM,C9359,HCPCS,0278,RC,,,,both,,,5341.77,3472.15,,,,,,,,,,,,,
ANCHOR SUT L20MM DIA2.8MM FOR ROT CUF REP Q-FIX,SUP-2341380,CDM,C1776,CPT,0278,RC,,,,both,,,1235.40,803.01,,,,,,,,,,,,,
SCREW BNE L 135 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931510,CDM,C1713,HCPCS,0278,RC,,,,both,,,192.14,124.89,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY PRO L 135 CM 5FR SLT 50CM FLX Y,SUP-2117020,CDM,C1757,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN PC THE FIRM LT L 260 CM DIA 0.035 IN,SUP-2638706,CDM,C1769,HCPCS,0272,RC,,,,both,,,114.04,74.13,,,,,,,,,,,,,
ALIGNER DRL TIB HI OSTEOTMY N-K,SUP-2449290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1172.79,762.31,,,,,,,,,,,,,
STEM FEM SZ 15 L170X150MM ML34MM 135DEG TI PLSM SPRAYED HIP,SUP-2400570,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SCREW C806T CCD CL IMP 6MM PLG TI C806T,SUP-2280606,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
ELECTRODE EMG DISP 8 CNTCT STRP,SUP-2308207,CDM,C1713,HCPCS,0278,RC,,,,both,,,2073.91,1348.04,,,,,,,,,,,,,
GUIDE WIRE THRDED 1.1 MMX150 MM STR,SUP-2817430,CDM,C1769,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
DEWAN SUPRAPUBIC URODYNAMICS CATHETER SET,SUP-2822052,CDM,C2627,HCPCS,0272,RC,,,,both,,,246.49,160.22,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 20 CM DIA 6 MM EPTFE CARBON STR N,SUP-2128777,CDM,C1768,CPT,0278,RC,,,,both,,,1799.22,1169.49,,,,,,,,,,,,,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151524,CDM,2500000003,HCPCS,0250,RC,00517-9305-25,NDC,,both,1,ML,162.10,105.36,,,,,,,,,,,,,
SIMETHICONE 125 MG PO CHEW,RX-7226,CDM,6370000000,HCPCS,0637,RC,00536-1223-08,NDC,,both,1,UN,0.80,0.52,,,,,,,,,,,,,
GUIDEWIRE ENDO L260CM DIA0.035IN HYDRPHLC ANG TIP FOR BILI,SUP-2170081,CDM,C1769,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
DRILL SURG FAR CRTX FOR FIB,SUP-2857743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO STR PLT 12 PK STRL,SUP-2935487,CDM,C1713,HCPCS,0278,RC,,,,both,,,7871.98,5116.79,,,,,,,,,,,,,
WAND ABLAT SHFT DIA2.5MM 60DEG DOME COBLATION,SUP-2341980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.59,437.18,,,,,,,,,,,,,
PROBE ENDOSCP 5 MMX45 CM SUCTION IRRIGATION SURGFLX,SUP-2313817,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SIZE 1 COLLAR LAT ASSEMBLYRAD STEM IMPLANT 6MM,SUP-2492492,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
DRILL SURGICAL 1.5MM SOLID SPIDER,SUP-2586707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.63,412.51,,,,,,,,,,,,,
PLATE BONE L90MM THK0.6MM 20 H CRANIOMAXILLOFACIAL TI STR LO,SUP-2191136,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.24,662.51,,,,,,,,,,,,,
HC Arthrogram Shoulder S&I,PX-3227304000,CDM,73040,CPT,0322,RC,,,,both,,,1191.00,774.15,,,,,,,,,,,,,
HC Rhythm Strip,PX-7309304100,CDM,93041,CPT,0730,RC,,,,both,,,106.00,68.90,,,,,,,,,,,,,
SCREW BNE SNAP OFF 2.7X16 MM NS HALLI-FIX DISP,SUP-2242900,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.57,740.72,,,,,,,,,,,,,
HC X-Ray Spine 1 View,PX-3207202000,CDM,72020,CPT,0320,RC,,,,outpatient,,,233.00,151.45,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2.8MM BITE 6.5-8MM COMPR SCR,SUP-2315942,CDM,C1769,HCPCS,0272,RC,,,,both,,,499.10,324.41,,,,,,,,,,,,,
INQUIRY STEER 5F DEC 1110 5 2303 M,SUP-2698826,CDM,C1730,HCPCS,0272,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
PLATE BNE MEDL SM 3.5/4 MM CLMN NS FPS LTX,SUP-2856866,CDM,C1713,HCPCS,0278,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
PLATE BONE ULTRA LOW PRFLE HLX2X3 03MM THK TTNM BOX STYLE C,SUP-2676587,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.61,656.90,,,,,,,,,,,,,
BOLT EXT FIX DIA2MM WIRE PREASSEMBLED FOR SALVATION EXT FIX,SUP-2401135,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
CUP ACET M28MM DIA50MM HIP ZTT 2 S-ROM,SUP-2253171,CDM,C1776,CPT,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
KNIFE SURG ROYCE 3-3/8 INX8 MM EAR ANGLED DN CUT MICROFRANCE,SUP-2473762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.81,259.23,,,,,,,,,,,,,
STENT PIPELINE FLEX EMBOL DEVICE W/ SHIELD TECH 2.5MMX10MM,SUP-2854137,CDM,C2625,HCPCS,0278,RC,,,,both,,,43925.46,28551.55,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THCK 20X6 CMX0.8-1.7 MM FOLDING FLEXHD,SUP-2307554,CDM,Q4128,HCPCS,0636,RC,,,,both,,,10192.44,6625.09,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 025 5 FRX15 CM 3L STD,SUP-2759988,CDM,C1751,HCPCS,0278,RC,,,,both,,,383.83,249.49,,,,,,,,,,,,,
STAPLE BNE FIX W18XL15MM NIT COMPR W/ INSTR LO PROF FOR,SUP-2122351,CDM,C1776,CPT,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 3 MM EPTFE STR TW N RING STRL,SUP-2396678,CDM,C1768,CPT,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
ENDCAP ORTH L10MM DIA3.5MM STRL TI NAIL SPRL BLDE EXTN HUM,SUP-2192479,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.44,493.64,,,,,,,,,,,,,
CATHETER CTRL VEN 4.8FR L20CM SGL LUMN VES DIL GWIRE 18GA,SUP-2124938,CDM,C1751,HCPCS,0278,RC,,,,both,,,45.91,29.84,,,,,,,,,,,,,
LINER ACET SZ 25 OD38MM ID22MM 0DEG THK5.8MM HIP UHMWPE TPLR,SUP-2404283,CDM,C1776,CPT,0278,RC,,,,both,,,5242.23,3407.45,,,,,,,,,,,,,
DISPOSABLE KIT FOR 3.5MM PUSHLOCK,SUP-2812460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
INTRODUCER PACE LD PEELWY L 14 CM DIA12 FR STRL,SUP-2140192,CDM,C1892,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SLEEVE FEM +0MM OFFSET MOD 12/14 TAPR REDAPT,SUP-2350889,CDM,C1776,CPT,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
BUR SURG L9CM HD L16.4MM DIA3MM TAPR FOOTED L BOR MIDAS REX,SUP-2284684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.70,218.20,,,,,,,,,,,,,
SCREW BNE L40MM OD4.5MM FULL THRD IMPL MONSTER,SUP-2320614,CDM,C1713,HCPCS,0278,RC,,,,both,,,780.29,507.19,,,,,,,,,,,,,
SHAFT SCRDRVR AO CONN TORQ LIMITING T6 DRV FOR 1.9 2.7MM,SUP-2291796,CDM,C1713,HCPCS,0278,RC,,,,both,,,16356.26,10631.57,,,,,,,,,,,,,
HOOK BNE L1IN,SUP-2252707,CDM,C1713,HCPCS,0278,RC,,,,both,,,1689.32,1098.06,,,,,,,,,,,,,
GRAFT EVAR L166MM DIA23X13MM PROX DST AAA C DST DSGN,SUP-2295199,CDM,C1768,CPT,0278,RC,,,,both,,,31321.50,20358.97,,,,,,,,,,,,,
FIBER LASER 295 FT KRA-CPAOCHXL HDMI,SUP-2798102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2485.75,1615.74,,,,,,,,,,,,,
PROXIMAL LAT TIB PLATE LEFT 8 HOLE,SUP-2829401,CDM,C1713,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
SPACER CORPECTOMY W14XH21XD12MM SM SAG PROF 3.5/3.5DEG NIKO,SUP-2231166,CDM,C1821,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
TRAY VITRECTOMY DIA23 GA10000 CPM STR ENDOILLUMINATOR BVL,SUP-2914996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2609.43,1696.13,,,,,,,,,,,,,
PLATE BONE THK0.6MM 3X8 H BILAT HND T SHP COMPR GRID FOR,SUP-2267898,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
PLATE BONE SM L44MM THK1MM CENTRE SPACE 2.5MM 6 H MAND TI,SUP-2191206,CDM,C1713,HCPCS,0278,RC,,,,both,,,1659.49,1078.67,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 65 CM DIA 4 FR DIA1.05 MM C1,SUP-2385505,CDM,C1887,HCPCS,0272,RC,,,,both,,,59.13,38.43,,,,,,,,,,,,,
SYSTEM DEL CATH L107CM OD6.7MM SHTH 16FR AORT FOR TRANSCATH,SUP-2282431,CDM,C1894,HCPCS,0272,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 8 FR CANN L 11 CM POLYUR PLAS SS STD,SUP-2424893,CDM,C1894,HCPCS,0272,RC,,,,both,,,31.46,20.45,,,,,,,,,,,,,
HC Burn Dress/Debrid 5% or Less,PX-3611602000,CDM,16020,CPT,0361,RC,,,,inpatient,,,421.00,273.65,,,,,,,,,,,,,
SCREW BNE L16MM DIA2.7MM CORT DST FIBULAR TI ST,SUP-2413247,CDM,C1713,HCPCS,0278,RC,,,,both,,,126.48,82.21,,,,,,,,,,,,,
FOLLOWER URO 26FR L36CM PLAS STR TIP THRD DISP PHIL,SUP-2384627,CDM,C1726,HCPCS,0272,RC,,,,both,,,79.25,51.51,,,,,,,,,,,,,
SCREW SPNL L14MM OD4MM 0DEG FIX SELF DRL CANN TI SNOWCAP,SUP-2207843,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
BEARING HUM DIA36-44MM +3MM OFFSET ARCOMXL RETENTIVE FOR,SUP-2409555,CDM,C1776,CPT,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
CARTRIDGE SAW W1.33MM THK1.05MM D18.3MM S STL PRECIS OSC,SUP-2367670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1239.92,805.95,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 5/32X9 IN 4 PT STYL SMOOTH PLN STRL,SUP-2150494,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.03,12.37,,,,,,,,,,,,,
TUBE EXT FIX EXT 15 MM MONOTUBE,SUP-2459669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6256.76,4066.89,,,,,,,,,,,,,
GRAFT VASC STD WALL 6 MMX40 CM STR RNG REINF ADVANTA VXT,SUP-2469303,CDM,C1768,CPT,0278,RC,,,,both,,,1738.84,1130.25,,,,,,,,,,,,,
SCREW BNE L36MM OD3.5MM TI FT ANK CANN SHT THRD HD COMPR,SUP-2400883,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
DESOXIMETASONE 0.25 % EX CREA,RX-2296,CDM,6370000000,HCPCS,0637,RC,68180-0950-01,NDC,,both,15,GR,45.10,29.31,,,,,,,,,,,,,
CATH REPROC SOFTTIP BM VIKING JSN 4POLE 6FR 5MM 110CM,SUP-2526063,CDM,C1730,HCPCS,0272,RC,,,,both,,,113.89,74.03,,,,,,,,,,,,,
KIT ORTH W/ 120MM 11GA CANN 5ML SYR FT ANK END DEL DISP FOR,SUP-2402779,CDM,C1713,HCPCS,0278,RC,,,,both,,,12249.14,7961.94,,,,,,,,,,,,,
PLUG RMR DIA14MM SPNL LUM TAPR FUS L CAGE,SUP-2291607,CDM,C1713,HCPCS,0278,RC,,,,both,,,895.81,582.28,,,,,,,,,,,,,
HC Plmt Nephroureteral Catheter,PX-3615043300,CDM,50433,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 12 CM DIA11 FR GUIDEWIRE 0.038 IN,SUP-2355540,CDM,C1894,HCPCS,0272,RC,,,,both,,,48.67,31.64,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH RENU L 116 MM PROX/DSTL L 52/64,SUP-2170459,CDM,C1874,HCPCS,0278,RC,,,,both,,,20453.96,13295.07,,,,,,,,,,,,,
DEVICE BNE MAR EXTR AUTOLGS CELL 45S CELLXTRACT,SUP-2138516,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
DRESSING HEMSTAT W3INXL2YD 1 PLY Z FLD QUIKCLOT CONTROL+,SUP-2416086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.46,300.60,,,,,,,,,,,,,
WRENCH EXT FIX 10MM FLX FOR SIDEKCK EZ FRME FREE CIR FIX,SUP-2401155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
SYSTEM MCRCTHTR INTRVNTNL 3/2.4FR OD P/D 155CML 0.021N ID PT,SUP-2652839,CDM,C1887,HCPCS,0272,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED NARROW LCP PLATE 16 HOLE STERILE,SUP-2546928,CDM,C1713,HCPCS,0278,RC,,,,both,,,2894.83,1881.64,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 6 HOLE COMPR STRL ALPS LTX,SUP-2861815,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.42,542.37,,,,,,,,,,,,,
LINER ACET CUPS HOOD 28MM STD,SUP-2359075,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
COMPONENT FEM SZ 6 R POST STBL PRI STEMLESS NP UNISX PROFIX,SUP-2347025,CDM,C1776,CPT,0278,RC,,,,both,,,10526.07,6841.95,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00990-7922-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP JAGWIRE L 450 CM DSTL TIP DIA 0.025 IN,SUP-2141539,CDM,C1769,HCPCS,0272,RC,,,,both,,,361.57,235.02,,,,,,,,,,,,,
K WIRE FIX L152MM DIA1.6MM S STL 2 TRCR PNT,SUP-2412978,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.61,23.15,,,,,,,,,,,,,
PLATE BNE L90MM 4 H CRANIOMAXILLOFACIAL TI X SHP LO PROF,SUP-2191184,CDM,C1713,HCPCS,0278,RC,,,,both,,,768.67,499.64,,,,,,,,,,,,,
HC ED Lyr Clos Nk Hnd Ft 12.6-20,PX-4501204500,CDM,12045,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
BUR SURG DIA 3 MM HUB II NEURO CUT STRL REUSE HI-LINE,SUP-2928982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.46,330.50,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM CRANIOMAXILOFACIAL 3 LNG DOG BNE,SUP-2935313,CDM,C1713,HCPCS,0278,RC,,,,both,,,2015.88,1310.32,,,,,,,,,,,,,
NAIL IM L235MM DIA10MM NK 130DEG UNIV GRN PROX FEM TI,SUP-2191931,CDM,C1713,HCPCS,0278,RC,,,,both,,,3756.16,2441.50,,,,,,,,,,,,,
GRAFT STENT 13 MMX10 CM 120 CM ENDOPROSTHESIS,SUP-2396584,CDM,C1874,HCPCS,0278,RC,,,,both,,,10927.20,7102.68,,,,,,,,,,,,,
CHERRY PO SYRP,RX-1562,CDM,340b,HCPCS,0637,RC,00395-2662-16,NDC,,both,473,ML,126.20,82.03,,,,,,,,,,,,,
HC Drug Screen Quantitative Phenobarbital,PX-3018018400,CDM,80184,CPT,0301,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
PLATE BNE THK 2.6 MM 24 H TI STR NS DISP TRAUMAONE,SUP-2936182,CDM,C1713,HCPCS,0278,RC,,,,both,,,7994.44,5196.39,,,,,,,,,,,,,
SYSTEM IMPL DRL PIN CANN SUT PASSPRT CANN GRAFTLINK,SUP-2419010,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK0.5-.9MM ACELLULAR DERM MTRX,SUP-2421360,CDM,Q4126,HCPCS,0636,RC,,,,both,,,6160.68,4004.44,,,,,,,,,,,,,
SCREW BNE STD 2.7X14 MM STRL HALLU SNAP-OFF,SUP-2608916,CDM,C1713,HCPCS,0278,RC,,,,both,,,762.64,495.72,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H XLN TI NEURO DBL Y SHP PLATE 1PK,SUP-2937264,CDM,C1713,HCPCS,0278,RC,,,,both,,,1824.34,1185.82,,,,,,,,,,,,,
STEM FEM CEM 16/12X130 MM KNEE MOD W/ M TAPR FOR 6 MM NOSE,SUP-2423132,CDM,C1776,CPT,0278,RC,,,,both,,,4907.82,3190.08,,,,,,,,,,,,,
HC MRI-Upper Ext WO Cont,PX-6107321800,CDM,73218,CPT,0610,RC,,,,both,,,4976.00,3234.40,,,,,,,,,,,,,
ANCHOR SUT L14.7MM OD5.5MM 3 NO 2 FIBERWIRE BIOCRKSCR FT,SUP-2121552,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ALLOGRAFT BNE WHL RIB 4 CM FRZN,SUP-2717948,CDM,C1762,CPT,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX6 T SHAPED LEFT DORSAL DISTAL,SUP-2721275,CDM,C1713,HCPCS,0278,RC,,,,both,,,3066.02,1992.91,,,,,,,,,,,,,
STAPLE INT BIOABSRB LIN CUT SEAMGRD PROX 75,SUP-2395366,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
MASK CPAP M/L FULL FACE HDGEAR FORMA,SUP-2224716,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
PLATE BNE LT CORONOID ASSEMBLED PROTEAN,SUP-2340324,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM DIA10 FR TIP 3 MM GUIDEWIRE 0.038,SUP-2168222,CDM,C1894,HCPCS,0272,RC,,,,both,,,127.92,83.15,,,,,,,,,,,,,
SET INTRO EXACTA L 10 CM DIA 8.5 FR CANN L 7 CM DIA16 GA,SUP-2662689,CDM,C1894,HCPCS,0272,RC,,,,both,,,87.20,56.68,,,,,,,,,,,,,
PLATE BNE L145MM 5 H NONSTERILE L PERIARTC PROX HUM S STL,SUP-2177822,CDM,C1713,HCPCS,0278,RC,,,,both,,,4928.32,3203.41,,,,,,,,,,,,,
BLADE SAW L 60 X W 16 MM D 12 MM THK MATERIAL 0.5 MM CUT 0.5,SUP-2929166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.49,262.92,,,,,,,,,,,,,
SET BILI STENT COTTON-HUIBREGTSE L 9 CM DIA 7 FR PUSH L 170,SUP-2169187,CDM,C2625,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
PLATE BONE L201MM 10 H RT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348230,CDM,C1713,HCPCS,0278,RC,,,,both,,,15168.08,9859.25,,,,,,,,,,,,,
HC So Hla II Low Resolution One Antigen Equivalent Ea,PX-3108137766,CDM,81377,CPT,0310,RC,,,,inpatient,,,233.00,151.45,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL 21GA L71CM FOR L HRT ACCS,SUP-2167852,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
GRAFT BONE SUB 20ML VOID FIL GRAN PLEXUR +,SUP-2293936,CDM,C1713,HCPCS,0278,RC,,,,both,,,4640.92,3016.60,,,,,,,,,,,,,
HC Ins/Repl of Dual Cham Ppm Lead,PX-3613320800,CDM,33208,CPT,0361,RC,,,,both,,,23085.00,15005.25,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L19CM ODSEC14.5MM MTL CHRONIC,SUP-2118958,CDM,C1751,HCPCS,0278,RC,,,,both,,,1175.96,764.37,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X157 MM RT LAT DSTL 9 HOLE STRL VALCP,SUP-2789394,CDM,C1713,HCPCS,0278,RC,,,,both,,,3425.61,2226.65,,,,,,,,,,,,,
BLADE ARTHSCP SHV HIP CVD FULL RAD EXTREMELY SHRP TIP,SUP-2365415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.37,530.64,,,,,,,,,,,,,
NAIL IM FEM 14MM DIA 28CML TI VERSANAIL DEPUY ORTHOPEDICS,SUP-2412460,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
BLADE IM L110MM DIA12.5MM ST LT BLU CANC TI SPRL NTHREADED,SUP-2191889,CDM,C1713,HCPCS,0278,RC,,,,both,,,2644.32,1718.81,,,,,,,,,,,,,
STAPLER INT ARTC RELDABLE W/ 3X8 AND 1X5 DP PURCH TACK RELD,SUP-2283330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3045.08,1979.30,,,,,,,,,,,,,
BOLT EXT FIX WIRE PRE ASSEMBLED SALVATION,SUP-2851100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
INTRODUCER SHTH L12CM L50CM OD10FR HEMSTAS VLV SIDEPRT DIL,SUP-2355607,CDM,C1894,HCPCS,0272,RC,,,,both,,,2.67,1.74,,,,,,,,,,,,,
HC So Hla I Typing Complete Hr,PX-3108137966,CDM,81379,CPT,0310,RC,,,,inpatient,,,413.00,268.45,,,,,,,,,,,,,
SCREW BNE EMGCY 1.2X7 MM TI CENTRE-DRIVE LEVEL 1,SUP-2461682,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.68,147.99,,,,,,,,,,,,,
SET URET STENT L 22 CM DIA 6.0 FR GUIDEWIRE L 145 CM DIA,SUP-2171280,CDM,C2617,HCPCS,0278,RC,,,,both,,,483.72,314.42,,,,,,,,,,,,,
CATHETER CV TY 018 4 FRX8 CM DL J TIP POLYETH,SUP-2760009,CDM,C1751,HCPCS,0278,RC,,,,both,,,267.75,174.04,,,,,,,,,,,,,
STENT NSL L16MM DIA4MM 370UG MINI MOMETASONE FUROATE LO,SUP-2246418,CDM,C2625,HCPCS,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
STENT LACR MONO CRWFRD P,SUP-2224384,CDM,C1783,HCPCS,0278,RC,,,,both,,,240.74,156.48,,,,,,,,,,,,,
OVITEX PRS PERMANENT RECTANGLE 20X20.5 CM,SUP-2914637,CDM,C1781,HCPCS,0278,RC,,,,both,,,23179.48,15066.66,,,,,,,,,,,,,
PLATE EXT FIX 5 H ANK FT FOR TRUELOK FRME ASSEMB HEXAPOD,SUP-2316200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,808.90,525.78,,,,,,,,,,,,,
MODEL ANAT MAXILLOMANDIBULAR 3D CT BASE SEL CLR VITAL STRUCT,SUP-2883464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19320.07,12558.05,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE,PX-4409712900,CDM,97129,CPT,0440,RC,,,GN|XU|KX,both,,,186.00,120.90,,,,,,,,,,,,,
PLATE BNE L 48 MM 3 H LT VOLAR DSTL RADIAL WIDE NS VARIAX,SUP-2900628,CDM,C1713,HCPCS,0278,RC,,,,both,,,6498.01,4223.71,,,,,,,,,,,,,
SEALANT TISS FIBRIN 2 CC DUPLOSPRAY TISSEEL 921029] BAXALTA US INC],SUP-2129876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.21,420.04,,,,,,,,,,,,,
PLATE BNE H MINI MAXLOCK,SUP-2400409,CDM,C1713,HCPCS,0278,RC,,,,both,,,3070.92,1996.10,,,,,,,,,,,,,
COMPONENT FEM SZ 6 R CEM HNG GMK,SUP-2267634,CDM,C1776,CPT,0278,RC,,,,both,,,25320.96,16458.62,,,,,,,,,,,,,
PLATE BNE L60MM 15 H CALCNL FOR 35MM SCR,SUP-2199385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.66,820.73,,,,,,,,,,,,,
SCREW INTRF 10MM 35MM 1MM CANN KNEE ABSRB POLY-L LACTIC ACID,SUP-2366629,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.79,413.91,,,,,,,,,,,,,
K WIRE FIX L280MM DIA2MM W/ TRCR TIP FOR NCB PLATING SYS,SUP-2412825,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.25,43.06,,,,,,,,,,,,,
PLATE BNE SM W11XL155MM THK3.3MM 0DEG 12 H BILAT TI STR RIG,SUP-2190788,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.74,478.88,,,,,,,,,,,,,
BRACE ORTHOPEDIC MED RT WRST LTHR,SUP-2194367,CDM,L3931,HCPCS,0274,RC,,,,both,,,25.94,16.86,,,,,,,,,,,,,
BRACE WRST M FOR 17.1-19.1CM L PROTCT PD ADJ BAR D RNG CLSR,SUP-2326112,CDM,L3931,HCPCS,0272,RC,,,,both,,,50.77,33.00,,,,,,,,,,,,,
KIT FIX ANK STRL,SUP-2316326,CDM,C1713,HCPCS,0278,RC,,,,both,,,12101.56,7866.01,,,,,,,,,,,,,
COLLAR CERV PHILLY LG 4.25 IN 16-19 IN REHAB FOAM PROCARE,SUP-2196880,CDM,L0120,HCPCS,0272,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
SPACER SPNL W9XH26MM EXP 8-13MM TI CONVX SELF EXP CONCORDE,SUP-2257837,CDM,C1889,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
SCREW CORT 1.5MM SS HEX HD 18MM,SUP-2198410,CDM,C1713,HCPCS,0278,RC,,,,both,,,192.80,125.32,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 10MM R MED L LAT KNEE HEMI STP LEGION,SUP-2346580,CDM,C1776,CPT,0278,RC,,,,both,,,4226.44,2747.19,,,,,,,,,,,,,
PLATE EXT FIX 2 H CIR FIX SIDEKCK FREE,SUP-2400668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZ DRY DEMIN CANC 0.1MM-4MM RANG 30CC,SUP-2294025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1343.92,873.55,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2 MM BALL TIP STRL -RSFH,SUP-2881204,CDM,C1769,HCPCS,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
PIN EXT FIX L 150 MM DIA 4.5 MM THRD L 10 MM SHANK 6 MM HA,SUP-2932763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,900.33,585.21,,,,,,,,,,,,,
WIRE EXT FIX L 400 MM DIA2 MM SPD,SUP-2898547,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
PLATE BONE L165MM 8 H RT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348229,CDM,C1713,HCPCS,0278,RC,,,,both,,,15015.79,9760.26,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HYBRID SHELL TRAB MEL,SUP-2212727,CDM,C1776,CPT,0278,RC,,,,both,,,13517.17,8786.16,,,,,,,,,,,,,
CATHETER REPROC 8FRX110CM DIAG ACUNAV,SUP-2255864,CDM,C1759,HCPCS,0272,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
PLATE BONE W14.1XL39.3MM THK1.1MM 14 H TI T Y LCK LO PROF,SUP-2411742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1610.82,1047.03,,,,,,,,,,,,,
ALLOGRAFT BNE DBM 2 CC VESUVIUS 4104K1520DC,SUP-2717992,CDM,C1713,HCPCS,0278,RC,,,,both,,,3343.19,2173.07,,,,,,,,,,,,,
POST EXT FIX FREE FOR JET-X EXT FIX,SUP-2342958,CDM,C1776,CPT,0278,RC,,,,both,,,4614.39,2999.35,,,,,,,,,,,,,
MESH HERN 20X15 CM,SUP-2283400,CDM,C1781,HCPCS,0278,RC,,,,both,,,2271.48,1476.46,,,,,,,,,,,,,
PIN FIX L10MM DIA15MM PLLA SELF REINF FRAC SMRTPIN,SUP-2166471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.71,292.31,,,,,,,,,,,,,
SYSTEM EXT FIX HINGED RAIL STD 420 MM HOFFMANN PVC-FREE STRL,SUP-2486639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5077.38,3300.30,,,,,,,,,,,,,
PLATE VARIAX COMP BROAD CURVED 14HL,SUP-2705337,CDM,C1713,HCPCS,0278,RC,,,,both,,,3176.11,2064.47,,,,,,,,,,,,,
PLATE BNE L 55 X W 55 MM THK 1.4 MM SCREW DIA2.2 MM,SUP-2909627,CDM,C1713,HCPCS,0278,RC,,,,both,,,5277.12,3430.13,,,,,,,,,,,,,
IMPLANT BIO TISS L CLLGN SCFLD ARTHSCP REGENETEN,SUP-2334694,CDM,C1768,CPT,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
BLADE REPROC SHV ULTRACUT DUAL PURP LG HUB 4.2MM,SUP-2652969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,68.04,44.23,,,,,,,,,,,,,
CARBON FIBER BAR 6MM X 300MM,SUP-2720795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
BIT DRL L5IN DIA11/64IN S STL TWST,SUP-2412259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
MICROCATHETER INFUSION PURSUE 150CM DIA 2.9/2FR TRUEFORM,SUP-2457144,CDM,C1887,HCPCS,0272,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
BAR THRD 160MM FOR SHEFFIELD STRL TY SYS,SUP-2316267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,115.02,74.76,,,,,,,,,,,,,
PLATE BNE L305MM 10 H HIP S STL 10 BND CBL RDY,SUP-2410270,CDM,C1713,HCPCS,0278,RC,,,,both,,,3104.83,2018.14,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO MEMBRN PROVENDA,SUP-2762324,CDM,C1762,CPT,0278,RC,,,,both,,,4838.11,3144.77,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.4MM HDLSS COMPR SM CANN FLOWERCUBE,SUP-2225508,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.65,700.47,,,,,,,,,,,,,
SET URET STENT UTHANE L 26 CM DIA 6-9.5 FR PROX SEG L 13 CM,SUP-2835749,CDM,C2617,HCPCS,0278,RC,,,,both,,,431.09,280.21,,,,,,,,,,,,,
GUIDEPIN SURG L70MM DIA1MM FUS RECON SYS,SUP-2414158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
STEM FEM DIA13MM +10MM SHT TI HIP REV POLISHED EMPERION,SUP-2344350,CDM,C1776,CPT,0278,RC,,,,both,,,14662.23,9530.45,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4.8MM CANC ANTR CERV TI LCK VAR ANG,SUP-2254604,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
ALLOGRAFT BNE 20X45X5 MM DBM STRP INCITE,SUP-2517583,CDM,C1713,HCPCS,0278,RC,,,,both,,,8116.90,5275.98,,,,,,,,,,,,,
RING TRAC M 19-22IN CERV CLOSE BK W/ 2.5IN SKULL AND POS PIN,SUP-2328119,CDM,L0810,HCPCS,0274,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
HC Humerus Min 2 View,PX-3207306000,CDM,73060,CPT,0320,RC,,,,both,,,386.00,250.90,,,,,,,,,,,,,
MATRIX BIO L 2 X W 2 CM SZ 7 SQCM FISH SKIN DERMAL PREMESHED BX/10,SUP-2909359,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
BIT DRILL KLS NOTCH 18X70MM,SUP-2262755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.33,274.51,,,,,,,,,,,,,
GUIDEWIRE SURG PED DIA1.6MM CO CHROM THRD TRCR TIP,SUP-2318875,CDM,C1769,HCPCS,0272,RC,,,,both,,,155.62,101.15,,,,,,,,,,,,,
GRAFT BIO TISS 14MM DISC DERM REP MESHED SCAFFOLD PRIMATRIX,SUP-2243697,CDM,Q4110,HCPCS,0636,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PLATE BONE W10MM ASMBLY SPINOUS PROC SYS ASPN,SUP-2209056,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 22GA 8CM WNG 1 LUMAN F322088T,SUP-2632776,CDM,C1751,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
RESERVOIR VENTRICULAR 14 MM ACCU-FLO,SUP-2666408,CDM,C1889,HCPCS,0278,RC,,,,both,,,1301.78,846.16,,,,,,,,,,,,,
CAGE SPNL L W14XH9XL16MM 4DEG CERV THORLUM C FBR POLYMER,SUP-2256206,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
COIL EMB L3CM OD3MM .020IN NIT NEUROVASC COMPLX SFT FILL,SUP-2323388,CDM,C1889,HCPCS,0278,RC,,,,both,,,7360.16,4784.10,,,,,,,,,,,,,
ELECTRODE ELECSURG BUTTON 7 FR HI FREQ BUGBEE FLX UROLOGY,SUP-2468552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.00,434.20,,,,,,,,,,,,,
GRAFT ENDOVASC L40MM DIAM 8MM TRNSJUG INTRAHEPATIC VIATORR,SUP-2395920,CDM,C1874,HCPCS,0278,RC,,,,both,,,14202.22,9231.44,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC CLLGN MOZAIK,SUP-2431102,CDM,C9359,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER HD RAULERSON 11.5 FRX15 CM IJ DL BASIC SET DUOFLO,SUP-2627386,CDM,C1752,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
SPLINT ORTH AD W21XL80CM PVC DURABLE SGL CHMBR LNG ARM FOR,SUP-2309123,CDM,L3908,HCPCS,0274,RC,,,,both,,,149.43,97.13,,,,,,,,,,,,,
DEVICE FIX MTO N ABSRB STRL ENDOBUTTON,SUP-2849141,CDM,C1713,HCPCS,0278,RC,,,,both,,,2791.46,1814.45,,,,,,,,,,,,,
CATHETER PERI DLYS DBL CUF AD LT STR RADPQ STRP 15FR 43CM,SUP-2174275,CDM,C1752,HCPCS,0278,RC,,,,both,,,403.33,262.16,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP LT WHL TIB SHFT,SUP-2867032,CDM,C1762,CPT,0278,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
BLOCK SIL RECTANG DUROMETER SFT 12.0 CMX7.0 CMX1.5 CM,SUP-2242095,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
ALLOGRAFT BNE DIVERTED TUBE 3/4 FILL PREFIL FOR E,SUP-2538801,CDM,C1889,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
PROCESSOR SND BAHA 3 BP100,SUP-2165006,CDM,L8691,HCPCS,0274,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ COMMND 18 ST L 210 CM DIA 0.018 IN,SUP-2892923,CDM,C1769,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
KIT DRNGE PD W4XL4IN 500ML CATH VAC BTL W/ DRNGE LN DSG GZ,SUP-2133745,CDM,C1729,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CEMENT BONE ROTARY MIX 10 CC REINFORCED STERILE CRANIOS,SUP-2838516,CDM,C1713,HCPCS,0278,RC,,,,both,,,12121.97,7879.28,,,,,,,,,,,,,
SPLINT CLAVICLE MED,SUP-2849722,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.26,22.92,,,,,,,,,,,,,
SCREW BNE MXLFCL TI NS,SUP-2189221,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.25,199.71,,,,,,,,,,,,,
GRAFT BONE SUB 16MM CROSS SECT FEM FRZ DRY TRAD,SUP-2294085,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
AUGMENT ACET SM 8MM DIA48/50MM GRP 1 TI CEM REV PART HMSPHR,SUP-2222497,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 60 MM FRZN,SUP-2294142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
EXTERNAL FIXATION SET LOWER EXTREMITY WRNCH XCALIBER STRL,SUP-2646337,CDM,C1713,HCPCS,0278,RC,,,,both,,,9104.49,5917.92,,,,,,,,,,,,,
ACL FIBERTAG TIGHTROPE IMPLANT SYSTEM  AR1288QT80,SUP-2843664,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
IMPLANT TIB L30MM DIA10MM CANN DRVR FIX DEV APERFIX II,SUP-2402623,CDM,C1776,CPT,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
SCREW BNE L60MM DIA3.5MM CORT TIB CONIC S STL ST,SUP-2184291,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.87,246.27,,,,,,,,,,,,,
CLAMP SPNL L100MM OD5.5MM S STL THORLUM REVERE,SUP-2230986,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
BAR THRD 160MM,SUP-2316268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,123.59,80.33,,,,,,,,,,,,,
SCREW BONE LOCKING 3MM DIA SURFIX STERILE ALPHA,SUP-2586518,CDM,C1713,HCPCS,0278,RC,,,,both,,,460.48,299.31,,,,,,,,,,,,,
STRAP CLAV SM PD W3XL4IN STD FOAM PD STOCKINET MTL TOOTH,SUP-2276602,CDM,L3650,HCPCS,0272,RC,,,,both,,,16.30,10.59,,,,,,,,,,,,,
HC ER Level 5,PX-4509928500,CDM,99285,CPT,0450,RC,,,,inpatient,,,3911.00,2542.15,,,,,,,,,,,,,
TROCAR Z THRD 1ST ENTRY HNDL DISP 11MM X100MM KII FIOS,SUP-2119722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 110 MM DIA25 MM LIMB L 40 MM,SUP-2217673,CDM,C1874,HCPCS,0278,RC,,,,both,,,43956.86,28571.96,,,,,,,,,,,,,
BIT DRL L190MM DIA10MM CANN W/O STP QUIK CPL REUSE,SUP-2188295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1607.27,1044.73,,,,,,,,,,,,,
VLP 4.0MM P-T OST SCREW 28MM STER,SUP-2820006,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.50,281.12,,,,,,,,,,,,,
HC So1 Factor VIII,PX-3058524067,CDM,85240,CPT,0305,RC,,,,inpatient,,,637.00,414.05,,,,,,,,,,,,,
CAGE SPNL H5.5MM AP D12MM 6DEG TAPR LORDOSIS ANTR CERV PEEK,SUP-2163178,CDM,C1889,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
GRAFT BNE STRP 10X10X3 MM DBM ALLOSYNC,SUP-2845375,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
LINEZOLID 100 MG/5ML PO SUSR,RX-28225,CDM,340b,HCPCS,0637,RC,00054-0319-50,NDC,,both,30,ML,604.70,393.05,,,,,,,,,,,,,
COMPONENT PAT DIA41MM THK10MM STD TI POLY TRABECULAR MTL,SUP-2200605,CDM,C1776,CPT,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
CATHETER HD STR AD 12.5 FRX20 CM 3L SHT TERM MAHRK ELITE,SUP-2283973,CDM,C1752,HCPCS,0278,RC,,,,both,,,462.55,300.66,,,,,,,,,,,,,
CAGE SPNL SPIKLS 3.5 DEG 14X16 MM 12 MM UPPER LOWER ENDPLATE,SUP-2420875,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT HUM TISS PROX R TIB W BTB FRZN,SUP-2307301,CDM,C1713,HCPCS,0278,RC,,,,both,,,17581.11,11427.72,,,,,,,,,,,,,
PLATE BNE TBLR 159 MM 12 HOLE 1/3 LCK SS STRL,SUP-2499651,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.53,356.54,,,,,,,,,,,,,
NAIL IM L440MM DIA3MM PROX TIB G TI ALLY,SUP-2192729,CDM,C1713,HCPCS,0278,RC,,,,both,,,868.74,564.68,,,,,,,,,,,,,
BALLOON KYPHOPLASTY 10GA 10MM VERTEBRAL IVAS ELITE,SUP-2876066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3535.14,2297.84,,,,,,,,,,,,,
HC Debride/Musc/Fasc First 20 Sq Cm,PX-3611104300,CDM,11043,CPT,0361,RC,,,,both,,,625.00,406.25,,,,,,,,,,,,,
HC Rfa 1 or More Liver Tumors,PX-3614738200,CDM,47382,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW BNE L 160 MM DIA 8 MM TI ST SD CANN FULL THRD RVS CUT,SUP-2901010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.32,843.26,,,,,,,,,,,,,
GRAFT HUM TISS 7X14X11MM CANC SPCR BLK BNE MECH GIC58,SUP-2293807,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
MATRIX BIO MED SZ 147 SQCM FISH SKIN LT DORSUM RT PALMAR 10/BX,SUP-2909427,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12827.21,8337.69,,,,,,,,,,,,,
SCREW INT FIX LCK FX ADPT TY EQUINOXE,SUP-2223412,CDM,C1713,HCPCS,0278,RC,,,,both,,,1720.72,1118.47,,,,,,,,,,,,,
SWITCH PERF L13IN EQL LEG TBL MT MOD ARISS,SUP-2282550,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.97,85.78,,,,,,,,,,,,,
BLADE SHAVER ARTHSCP AGRSSVE PLU 5MM DIA LNG HIP STRGHT FORM,SUP-2605873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,191.07,124.20,,,,,,,,,,,,,
BLADE SAW 12MM THK.38MM SAG OSC VERTICAL RAMUS OSTEOTMY STRL,SUP-2319795,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
DRESSING BIO W2XL2CM CLLGN SH 0.1% POLYHEXMETHYLENEBIGUANIDE,SUP-2314087,CDM,Q4196,HCPCS,0636,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BLADE SURG CRV XL 4.2 MM FULL RAD + FMS,SUP-2637149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
CARVEDILOL 12.5 MG PO TABS,RX-15749,CDM,6370000000,HCPCS,0637,RC,68382-0094-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 7 MM CERV CORTICAL CANC ELEMAX,SUP-2731767,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
PLATE BNE CLAV CS1 2.7 MM RT LAT VA LCK COMPR SS NS VA-LCP,SUP-2757604,CDM,C1713,HCPCS,0278,RC,,,,both,,,3347.24,2175.71,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
GRAFT HUM TISS W27-32XH21XL21-26MM ANTR LUM INTBDY FUS SPCR,SUP-2306954,CDM,C1713,HCPCS,0278,RC,,,,both,,,16051.99,10433.79,,,,,,,,,,,,,
BUMETANIDE 1 MG PO TABS,RX-9310,CDM,6370000000,HCPCS,0637,RC,00904-7016-06,NDC,,both,1,UN,4.90,3.18,,,,,,,,,,,,,
BUR SURG DIAMOND LNG 3.2 MM COARSE MATCHSTICK QD14-S/QD14-G1,SUP-2848155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.01,247.66,,,,,,,,,,,,,
CENTRALIZER STEM DIA10MM DST FEM HIP POS PMMA ECHO,SUP-2406617,CDM,C1776,CPT,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
KIT CATH 12FR L16CM POLYUR CTRL VEN ANTIMIC 3 LUMN,SUP-2120608,CDM,C1751,HCPCS,0278,RC,,,,both,,,476.65,309.82,,,,,,,,,,,,,
BUR SURG DIA3MM NEURON CUT ELITE,SUP-2367599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
HEAD FEM DIA32MM +0MM OFFSET 11 13 TAPR ALUMINA PRI MOD SYS,SUP-2253046,CDM,C1776,CPT,0278,RC,,,,both,,,5037.82,3274.58,,,,,,,,,,,,,
CHIARI MLFRMTN PLATE MDFD CRSCNT SHAPE 06MM THICK CP TTNM,SUP-2707375,CDM,C1713,HCPCS,0278,RC,,,,both,,,3433.87,2232.02,,,,,,,,,,,,,
WASHER LKNG STTSCH RFNA 5 DEG RT ST,SUP-2718097,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.73,1867.92,,,,,,,,,,,,,
PLATE BNE L163MM THK3.4MM 12 H BILAT S STL STR LOK COMPR,SUP-2185146,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.33,704.16,,,,,,,,,,,,,
TUBE ENDOTRACHEL AD SZ 6 OD9.7MM ID6MM HI VOL LO PRSS,SUP-2383580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
JOINT FNGR 40 MED 11.6X21.8X9.9 MM 11.8 MM PYROCARBON NUGRIP,SUP-2852867,CDM,C1776,CPT,0278,RC,,,,both,,,11986.95,7791.52,,,,,,,,,,,,,
BIT DRL L50MM OD1.2MM STP D6.0MM,SUP-2364176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.96,313.92,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 150 CM BALLOON L 40 MM DIA 4,SUP-2148537,CDM,C1725,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN FLX FREJKA CVR ONLY,SUP-2435596,CDM,L1610,HCPCS,0274,RC,,,,both,,,154.96,100.72,,,,,,,,,,,,,
ASSEMBLY KYPHOPLASTY BI PEDICULAR 20 MM ADDL LEVEL STRL DISP,SUP-2846422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
DISTRACTOR EXT FIX 25 MM 1-1.2 MM 9 HOLE MID DRIVEN RATCH,SUP-2467477,CDM,C1713,HCPCS,0278,RC,,,,both,,,18129.67,11784.29,,,,,,,,,,,,,
GUIDE CORONARY SINUS WORLEY ADV CSG SHTH L 50 CM OD 0.157 IN,SUP-2303505,CDM,C1892,HCPCS,0272,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
SHELL ACET OD54MM TI HA HIP CLUS H IMPL SECUR FIT XTRA,SUP-2370242,CDM,C1776,CPT,0278,RC,,,,both,,,5359.98,3483.99,,,,,,,,,,,,,
DEVICE FN NDL BX 22GA ENDOBRONCH US,SUP-2418159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.14,746.29,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 110 CM 6FR LG OCTAPOLAR,SUP-2498967,CDM,C1730,HCPCS,0272,RC,,,,both,,,374.63,243.51,,,,,,,,,,,,,
HINGE COUPLING,SUP-2484255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1153.01,749.46,,,,,,,,,,,,,
CUP ACET DIA62MM DP PROF SOL,SUP-2250746,CDM,C1776,CPT,0278,RC,,,,both,,,10895.80,7082.27,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH TRIO L 23 CM DIA10 FR CATH 4/5 FR,SUP-2357122,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.05,24.08,,,,,,,,,,,,,
GRAFT HUM TISS ACHILLES TEND 160 MM W/ STRUT FRZN ASEP,SUP-2264580,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,0636,RC,00641-1410-35,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE SPNL L45-47MM POST THORLUM TI LO PROF FOR 5.5MM ROD,SUP-2289530,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
TRAY INTRO PERC UNIV STRL,SUP-2876581,CDM,C1894,HCPCS,0272,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
NUT SPNL PEDCL 12.7 MM SCREW LCK SILHOUETTE HEX,SUP-2414395,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ANCHOR SUT BIOCRYL RAPIDE ABSRB 2 PERMACORD SZ 2 L36IN BLU,SUP-2256704,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
SYSTEM PACEMKR SENSIA SR TI STRL,SUP-2282483,CDM,C1786,HCPCS,0275,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
ANCHOR SUTURE SLIDING 6.5 MM SHLDR DBL LD GRN QUATTRO X,SUP-2745506,CDM,C1776,CPT,0278,RC,,,,both,,,1346.75,875.39,,,,,,,,,,,,,
PROBE SURG NERVE PEDCL STR ACCS NDL,SUP-2730579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1886.45,1226.19,,,,,,,,,,,,,
ALLOGRAFT BNE COTTON WDG 20X14X6.5 MM OSTEOTMY SYMALIGN,SUP-2740776,CDM,C1713,HCPCS,0278,RC,,,,both,,,5204.33,3382.81,,,,,,,,,,,,,
STEM HUM L125MM OD9.5MM UNIV CO CHROM SHLDR PRI CEM IMP,SUP-2404714,CDM,C1776,CPT,0278,RC,,,,both,,,11275.74,7329.23,,,,,,,,,,,,,
PLATE BNE L46MM 3X8 H TI Y SHP FOR 1.5MM SCR MOD HND SYS,SUP-2191165,CDM,C1713,HCPCS,0278,RC,,,,both,,,1232.83,801.34,,,,,,,,,,,,,
NUT EXT FIX DIA6MM THK6MM 10MM HEX HD ITALIAN,SUP-2342991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4873.28,3167.63,,,,,,,,,,,,,
PLATE BNE L56MM THK2MM 9 H NAR R DST RAD VOLAR ANAT TI FOR,SUP-2372941,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
BLADE SHAVER RESECT 4.5X130 MM OVL DISP,SUP-2661222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,493.01,320.46,,,,,,,,,,,,,
POST EXT FIX 2 HOLE W/O THRD ATTCH,SUP-2749941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
SCREW PEDCL CANC FIX ANG N CANN TI 5.5MM ROD 8.5MM DIA 70MM,SUP-2280058,CDM,C1713,HCPCS,0278,RC,,,,both,,,3554.17,2310.21,,,,,,,,,,,,,
CATHETER ABLAT 7.5FR L110CM TIP L4MM 2.5MM SPC QPLR STD CRV,SUP-2141330,CDM,C2630,CPT,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PATCH VASC VASCU-GUARD L 9 X W 2 CM BOV PERICARD FOR CARTOID,SUP-2130384,CDM,C1768,CPT,0278,RC,,,,both,,,1090.43,708.78,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CLARIA MRI W 51 X H 74 MM D 13 MM,SUP-2282412,CDM,C1882,HCPCS,0275,RC,,,,both,,,52076.90,33849.98,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA2.5 MM TI CANN HDLSS NS LEOS,SUP-2932585,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.07,583.75,,,,,,,,,,,,,
PLATE FRACTURE 4H CRVD W/BAR 2MM,SUP-2740125,CDM,C1713,HCPCS,0278,RC,,,,both,,,1850.90,1203.08,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 40 MM DIA12 MM SHTH 9 FR CATH L,SUP-2147050,CDM,C1876,HCPCS,0278,RC,,,,both,,,3713.74,2413.93,,,,,,,,,,,,,
STENT COR 32MM 2.25MM S STL SELF EXP BAL PACLITAXEL,SUP-2139911,CDM,C1874,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X4 CMX0.80-1.4 MM N MESHED STRL MEMODERM,SUP-2366754,CDM,Q4126,HCPCS,0636,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
GRAFT BNE RND 7X0.6 CM DBM ACCELL TBM,SUP-2641758,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CASPIAN OCCIPITAL FIXATION ANCHOR 7 MM,SUP-2867345,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
SCREW BONE L100MM DIA9.5MM THRD L12.7MM S STL INTERMED LAG,SUP-2343609,CDM,C1713,HCPCS,0278,RC,,,,both,,,691.40,449.41,,,,,,,,,,,,,
IMPLANT HUM TISS DIA22 MM LG PULM VLV REDUC THROMBOSIS,SUP-2933269,CDM,C1762,CPT,0278,RC,,,,both,,,43374.01,28193.11,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 260 MM DIA17 MM DEL SHTH,SUP-2934602,CDM,C1713,HCPCS,0278,RC,,,,both,,,19996.43,12997.68,,,,,,,,,,,,,
STENT PERIPH OMLNK ELITE L 29 MM DIA 9 MM CATH L 80 CM SHTH,SUP-2105239,CDM,C1876,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
BURR SRGCL 5.3MM DIA HEAD CRBDE TRPHNE CTTNG RED F/SPNE NEUR,SUP-2586374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.91,353.54,,,,,,,,,,,,,
NAIL INTRMDLLRY L180MM D10MM ANKLE TTNM CORE LOCK TCHNLGY DU,SUP-2460343,CDM,C1713,HCPCS,0278,RC,,,,both,,,8107.92,5270.15,,,,,,,,,,,,,
HC Radiologic Small Intestine Follow-Through Study,PX-3207424800,CDM,74248,CPT,0320,RC,,,,both,,,1063.00,690.95,,,,,,,,,,,,,
ROD CONN 0 DEG LG 4.5-5.5/6 MM,SUP-2517437,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GUIDEWIRE ORTH BALL NOSE 2X800 MM STRL,SUP-2766031,CDM,C1769,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
GRAFT BONE SUB 10ML TRICALCIUM PHOS GRAN CONT RESRB CONDUIT,SUP-2256852,CDM,C1763,HCPCS,0278,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
ENDRING SPNL W17XL22MM STD GRN TI W LOK SCR FOR VERT BODY,SUP-2193255,CDM,C1889,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT CLLR BTTN FLNG 1.27 MM ID SIL STRL,SUP-2284034,CDM,L8699,HCPCS,0278,RC,,,,both,,,45.15,29.35,,,,,,,,,,,,,
SPHINCTEROTOME ENDO OD6.5FR 0.035IN TAPR MFIL CUT WIRE DISP,SUP-2171035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
COLLAR CERV RIGID SHT PD4 CH 11-16.5X2 IN HK,SUP-2246402,CDM,L0172,HCPCS,0272,RC,,,,both,,,64.56,41.96,,,,,,,,,,,,,
AMOXICILLIN 250 MG PO CAPS,RX-450,CDM,6370000000,HCPCS,0637,RC,00781-2020-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT BILI L60MM DIA8MM CATH 8.5FR L194CM GWIRE 0.035IN MTL,SUP-2149806,CDM,C1874,HCPCS,0278,RC,,,,both,,,7824.75,5086.09,,,,,,,,,,,,,
SCREW SPNL CANN 3.5X44 MM FT CORRIDOR,SUP-2593570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BIT DRL L30MM DIA2MM FOR VARIAX CLAVICULAR LOK PLT SYS,SUP-2378009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 55 MM OD 20 X 20 MM,SUP-2217558,CDM,C1768,CPT,0278,RC,,,,both,,,7363.30,4786.14,,,,,,,,,,,,,
GRAFT BNE SUB 10CC 25X50X8MM STRP BIMODAL VITOSS,SUP-2361880,CDM,C9362,HCPCS,0278,RC,,,,both,,,9437.71,6134.51,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BOOT CAST W/ CUF XL BLK,SUP-2277491,CDM,L4386,HCPCS,0272,RC,,,,both,,,267.06,173.59,,,,,,,,,,,,,
STAPLER ENDOSCP SKIN STRP CLSR W/ UNIV BOV PERICARD DEHYDR,SUP-2130377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.61,380.65,,,,,,,,,,,,,
PLATE BNE 2 T-SHAPE1.0MM 2-HOLE,SUP-2247340,CDM,C1713,HCPCS,0278,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
CATHETER GUID AXS OFFSET L 150 CM DSTL OD 0.036 IN ID 0.021,SUP-2884373,CDM,C1887,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SET PERICARDCENT CATH 8.3FR NDL 18GA CATH L40CM NDL L15CM,SUP-2168548,CDM,C1729,HCPCS,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
PIN EXT FIX L80X20MM FOR RX-FX MINI RAIL FIX,SUP-2396846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 10 FRX20 CM 10 GA 5 LUMEN,SUP-2759737,CDM,C1751,HCPCS,0278,RC,,,,both,,,628.06,408.24,,,,,,,,,,,,,
PLATE BONE W38XL45MM THK0.6MM NONSTERILE GLD CRAN TI RECTANG,SUP-2190620,CDM,C1713,HCPCS,0278,RC,,,,both,,,4598.84,2989.25,,,,,,,,,,,,,
BUR SURG MTCH HD 2.2X3.8 MM 10 CM FLUT SM BOR MIDAS REX 8,SUP-2664520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
GRAFT STRAVIX PL AMNIOTIC MEMBRANE 3CM X 6CM,SUP-2855456,CDM,Q4133,HCPCS,0636,RC,,,,both,,,9993.05,6495.48,,,,,,,,,,,,,
SEALANT TISS 10 CC FOR HUM FIBRIN VISTASEAL,SUP-2427765,CDM,C1713,HCPCS,0278,RC,,,,both,,,1562.65,1015.72,,,,,,,,,,,,,
JOINT GREAT TOE PHLANG 40 MOV,SUP-2609670,CDM,L8642,HCPCS,0278,RC,,,,both,,,7768.64,5049.62,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA13 MM EPTFE STR STD WALL LG,SUP-2761248,CDM,C1768,CPT,0278,RC,,,,both,,,751.53,488.49,,,,,,,,,,,,,
SCREW SCHANZ BLUNTED POINT 4.5MM 125MM/HA COATING-STERILE,SUP-2547735,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.80,346.32,,,,,,,,,,,,,
SCREW BONE L95MM DIA5MM PARTIALLY THRD FOR ARTH NAIL SYS,SUP-2244343,CDM,C1713,HCPCS,0278,RC,,,,both,,,1770.52,1150.84,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X20X30X0.25 MM RAPID RESORBABLE,SUP-2838571,CDM,C1713,HCPCS,0278,RC,,,,both,,,1250.66,812.93,,,,,,,,,,,,,
POINTER NAVIGATION DISPOSABLE TOUCH N GO AXIEM,SUP-2280216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1519.10,987.41,,,,,,,,,,,,,
SCREW BNE L85MM DIA6MM HD DIA27MM CANC TI ALLY PARTIALLY,SUP-2207995,CDM,C1713,HCPCS,0278,RC,,,,both,,,641.69,417.10,,,,,,,,,,,,,
CUP ACET POLYETH CEMENTEDCOMPONENTS I.D. INSIDE DIAM O.D.,SUP-2221684,CDM,C1776,CPT,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
CATHETER EP 6FR L110CM 1MM TIP 2-5-2MM SPC M CRV DECAPOLAR,SUP-2357621,CDM,C1730,HCPCS,0272,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
HC Stress Echo WO Contrast,PX-4839335001,CDM,93350,CPT,0483,RC,,,,both,,,1944.00,1263.60,,,,,,,,,,,,,
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP,RX-24731,CDM,6370000000,HCPCS,0637,RC,00574-7040-12,NDC,,both,1,UN,120.50,78.32,,,,,,,,,,,,,
PLATE SPINE FIX 56MM 4 LEV AMBASSADOR,SUP-2163989,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SIL TMPTUBE PAPARELLA XTAB 102 ID 5,SUP-2680277,CDM,L8699,HCPCS,0278,RC,,,,both,,,23.36,15.18,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD FEM TIB PERSONA,SUP-2212216,CDM,C1776,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
ROD SPNL L 100 MM DIA 6 MM RAD 450 BLACKARMOR CARBON PEEK,SUP-2917065,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM CATH DSTL L 1200 MM VENTRICULAR L 180 FX633T,SUP-2931050,CDM,C1729,HCPCS,0272,RC,,,,both,,,12824.23,8335.75,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUP CS L 60 CM DIA 6 FR SPC 2-8-2,SUP-2700001,CDM,C1730,HCPCS,0272,RC,,,,both,,,143.84,93.50,,,,,,,,,,,,,
PACEMAKER CARD ESSENTIO MRI W 4.45 X H 4.81 CM THK 0.75 CM,SUP-2149244,CDM,C1786,HCPCS,0275,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
BLADE RMR L35MM PAT PILOT H,SUP-2201485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
NAIL IM L360MM OD11MM 135DEG 2MM RAD LNG FEM TI IMPLANTS,SUP-2370051,CDM,C1713,HCPCS,0278,RC,,,,both,,,6097.25,3963.21,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 4 MM EPTFE STR STD WALL N RING,SUP-2396415,CDM,C1768,CPT,0278,RC,,,,both,,,2125.78,1381.76,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL 2,SUP-2435549,CDM,L0491,HCPCS,0272,RC,,,,both,,,2174.29,1413.29,,,,,,,,,,,,,
DEVICE EXT FIX ULTEM POLYMER PK STRL FOR DSTL RAD FX,SUP-2199199,CDM,C1713,HCPCS,0278,RC,,,,both,,,3882.99,2523.94,,,,,,,,,,,,,
SET LD INTRO FLOWGUARD L 20 CM DIA 9 FR 12 ML ART VLV,SUP-2281864,CDM,C1894,HCPCS,0272,RC,,,,both,,,105.35,68.48,,,,,,,,,,,,,
CANNULA LAP ROTATABLE INSUFFLATION STOPCOCK W/O VLV ENDOTIP,SUP-2767868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1789.17,1162.96,,,,,,,,,,,,,
TI MATRIXMIDFACE  1.7MM  450398201,SUP-2844137,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.82,281.98,,,,,,,,,,,,,
BLADE RTRCTR CHRNLEY LNG 1NW X 6 34NL X 3IND FINTL INCSN J,SUP-2700974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.60,251.29,,,,,,,,,,,,,
TRACKER NAVIGATION ENT INSTR FUS,SUP-2284343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.43,322.68,,,,,,,,,,,,,
PLATE BONE W13.5XL278MM THK4.2MM 15 H BILAT S STL NAR LCK,SUP-2185254,CDM,C1713,HCPCS,0278,RC,,,,both,,,2273.36,1477.68,,,,,,,,,,,,,
WIRE TENSIONER FOR SIDEKCK FRDM CIR FIX,SUP-2400681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
SYSTEM W/ INTEMESH INTEXEN INVANCE,SUP-2138946,CDM,C1771,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT VASC STR 12 MMX15 CM AORT ARCH 1 LAYR SFT HEMSHLD GLD,SUP-2473142,CDM,C1768,CPT,0278,RC,,,,both,,,1286.40,836.16,,,,,,,,,,,,,
GRAFT VASC STD WALL 5 MMX50 CM STR RNG REINF ADVANTA VXT,SUP-2473849,CDM,C1768,CPT,0278,RC,,,,both,,,1297.35,843.28,,,,,,,,,,,,,
ALLOGRAFT BNE 43 MM FRZN FEM HD W/ NK MATRIGRAFT,SUP-2741046,CDM,C1762,CPT,0278,RC,,,,both,,,4061.15,2639.75,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 4 H TI STR CONCV LP NS,SUP-2894446,CDM,C1713,HCPCS,0278,RC,,,,both,,,2015.88,1310.32,,,,,,,,,,,,,
PLATE BONE LNG DOGBONE NAR OMNI,SUP-2224008,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 25 MM PA COMPETENT VLV STRL,SUP-2884041,CDM,C1768,CPT,0278,RC,,,,both,,,60441.86,39287.21,,,,,,,,,,,,,
PIN FIX L100MM SPNL PERC DISP O ARM,SUP-2280201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
ANCHOR SUT DIA1.5MM SGL LD JUGGERKNOT,SUP-2212949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1160.54,754.35,,,,,,,,,,,,,
HC L-Spine 2-3 Views,PX-3207210000,CDM,72100,CPT,0320,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SET CATHETER L65CM OD4FR GWIRE OD0035IN STR TIP SHTH L55CN,SUP-2171152,CDM,C1894,HCPCS,0272,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
ELECTRODE VPR 24FR YEL RESECTSCP,SUP-2261178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.98,495.29,,,,,,,,,,,,,
SCREW BONE L5MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2188962,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.72,115.52,,,,,,,,,,,,,
BLADE SHAVER CRV 40 DEG 4.8 MM SERRATED HEMOSTATIC CONCV,SUP-2648915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.02,390.01,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10 CM DIA 8 MM NIT EPTFE LNR,SUP-2396483,CDM,C1874,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
GRAFT HUM TISS W0.5XL3CM NOM THK1.4MM HUM DERM REGEN TISS,SUP-2399058,CDM,Q4107,HCPCS,0636,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
GRAFT BNE STRP 100 MM 10 CC,SUP-2430787,CDM,C1713,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
TAPESTRY RC BIOINTEGRATIVE 30X30 MM ANTR LF,SUP-2867249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
LENS INTRAOCULAR 9.5 DIOPT CYL PWR 2.25 DIOPT L 13 MM DIA,SUP-2885275,CDM,V2632,HCPCS,0276,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
PLATE BNE L 378 MM SCREW DIA 4.5 MM 19 H SS RT DSTL FEM 72574219,SUP-2933045,CDM,C1713,HCPCS,0278,RC,,,,both,,,13194.28,8576.28,,,,,,,,,,,,,
PLATE BONE L20MM THK0.9MM 8MM OFFSET 0DEG 4 H BILAT CHIN,SUP-2191216,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.27,665.78,,,,,,,,,,,,,
HC Iaad Ia Severe Aqt Respir Synd Coronavirus,PX-3068742600,CDM,87426,CPT,0306,RC,,,,inpatient,,,71.00,46.15,,,,,,,,,,,,,
TAP SURG OD4MM CANN QUIK CONN FOR PERI-LOC SM FRAG PLATING,SUP-2344009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2582.84,1678.85,,,,,,,,,,,,,
CATHETER GUID EASYTRAK L 54 CM OD 2.7 MM ID 2.21 MM CORONARY,SUP-2148981,CDM,C1887,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
POST FIX 12MM BOLT 3 H ASSEMB TRUELOK RNG,SUP-2316109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM 6 H SCREW DIA1.5 MM LNG TI MIDFACE DBL,SUP-2883781,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
PLATE BNE THK1MM 20 H ORAL MAXILLOFACIAL MAND TI STR BILAT,SUP-2262952,CDM,C1713,HCPCS,0278,RC,,,,both,,,924.98,601.24,,,,,,,,,,,,,
TAP SURG DIA2.7MM QUIK REL SCR FOR CONG EL PLATING SYS,SUP-2107791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 4 MM RNG L 50 CM EPTFE STR TW,SUP-2396144,CDM,C1768,CPT,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
RASP SURG DBL SIDE SAW STRYKR IO FRDM CARTILAGINATOR,SUP-2865105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
SHEETING SILAS W6XL8IN THK0.040IN SIL REINF,SUP-2134690,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CANNULA SUCTION DIAMETER 2MM SHARP TIP 45DEG MINOP,SUP-2825705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,987.00,641.55,,,,,,,,,,,,,
HC Perc D-E Cor Stent Ather Br,PX-4810960300,CDM,C9603,CPT,0481,RC,,,,both,,,9805.00,6373.25,,,,,,,,,,,,,
PLATE LOCKING WEB 1.3MM 14 HOLES STERILE,SUP-2546069,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.77,921.55,,,,,,,,,,,,,
SCREW BNE 2.6X26 MM SELF COMPRESSIVE DYNAFIT,SUP-2610295,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
ROD IM IM BLOCK ASSY PERSONA,SUP-2449668,CDM,C1713,HCPCS,0278,RC,,,,both,,,5327.01,3462.56,,,,,,,,,,,,,
LCCK 7D SZ4 5MM 31X31 CPL,SUP-2502156,CDM,C1776,CPT,0278,RC,,,,both,,,12095.28,7861.93,,,,,,,,,,,,,
ENDCAP RG NAIL,SUP-2316248,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
MARKER BRST BX 11GA FOR PRB 11 MAMMOMARK,SUP-2195638,CDM,A4648,CPT,0278,RC,,,,both,,,333.15,216.55,,,,,,,,,,,,,
RESERVOIR SHUNT BURR HOLE 1.5 CM 0.68 CC PUDENZ CONV,SUP-2851450,CDM,C1889,HCPCS,0278,RC,,,,both,,,1343.83,873.49,,,,,,,,,,,,,
SET INFUS PRT L75CM OD66FR ID13MM STD POLYUR CATHETER TI DEV,SUP-2118802,CDM,C1788,HCPCS,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
BAR EXT FIX CRV 11X500 MM CARBON XTRAFIX,SUP-2534565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1956.06,1271.44,,,,,,,,,,,,,
MICROCATHETER ETER VASC PROXIMAL DISTAL 3X24FR L130CM LUMN,SUP-2141063,CDM,C1887,HCPCS,0272,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
CLIP SPNL CONN XLNK,SUP-2286716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1655.25,1075.91,,,,,,,,,,,,,
SCREW BNE 22MM DIA 6MM EMGCY ABSRB LEIBINGER DELT SYS 10PK,SUP-2364997,CDM,C1713,HCPCS,0278,RC,,,,both,,,1869.43,1215.13,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC FD DEMINERALIZED CORTICAL FLEXIGRAFT,SUP-2740949,CDM,C1713,HCPCS,0278,RC,,,,both,,,2746.40,1785.16,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 3.5X85/110 MM STERILE TC100 DISPOSA,SUP-2837034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,801.05,520.68,,,,,,,,,,,,,
SET HEMO DYLS OR HD ADMIN ST150 HI PERM HEMDLYZR EXCORP CIRC,SUP-2885237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5254.76,3415.59,,,,,,,,,,,,,
IMPLANT MESH DYNAMIC  1.7  200X200X8,SUP-2761706,CDM,C1713,HCPCS,0278,RC,,,,both,,,24907.33,16189.76,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 3 PACK,SUP-2855637,CDM,C2642,HCPCS,0278,RC,,,,both,,,24073.34,15647.67,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA 4 MM EPTFE STR STD WALL N RING,SUP-2761360,CDM,C1768,CPT,0278,RC,,,,both,,,2601.49,1690.97,,,,,,,,,,,,,
RING EXT FIX HALF 180 MM,SUP-2197284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
SHEARS ENDOSCP L36CM DIA5MM ULTRASONIC CRV TIP HARM,SUP-2219112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8183.63,5319.36,,,,,,,,,,,,,
KNIFE BALLENGER SWIVEL BAYONET 4MM BLADE 20CM 8IN,SUP-2677477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.90,428.93,,,,,,,,,,,,,
SHEATH UROLOGICAL 1 STP TROCAR L 20 CM L 17 CM CATH 14 FR,SUP-2835964,CDM,C1894,HCPCS,0272,RC,,,,both,,,390.93,254.10,,,,,,,,,,,,,
LASER CATH EXTRM II OTW 2.3MM,SUP-2353067,CDM,C1725,HCPCS,0272,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
CATHETER URETH 24 FR 5 CM BLLN W/ INFLATION DRUG OPTILUME,SUP-2863023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11806.40,7674.16,,,,,,,,,,,,,
PLATE BNE L 121 X W 9 MM THK 1 MM DIA12 MM CLLR H 0.5 MM,SUP-2908035,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.91,234.59,,,,,,,,,,,,,
SHEATH INTRO ACCEL L 20 CM DIA 6 FR TRUEGLIDE ACCS 3 PC,SUP-2659239,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.72,85.62,,,,,,,,,,,,,
HC Replace Picc Same Access,PX-3613658400,CDM,36584,CPT,0361,RC,,,,both,,,4973.00,3232.45,,,,,,,,,,,,,
INTRODUCER TUBE SET 8.5/9/10 MM MULTI PERC TY W/O PHAR,SUP-2759713,CDM,C1769,HCPCS,0272,RC,,,,both,,,1163.56,756.31,,,,,,,,,,,,,
PIN ABSRB 1.5X40.0MM STRL F/BIOMET - 1.5X40.0MM,SUP-2136733,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 3 CM 0.018 INX150 CM ZIPWIRE,SUP-2862341,CDM,C1769,HCPCS,0272,RC,,,,both,,,166.04,107.93,,,,,,,,,,,,,
PROSTHESIS OSS OVL TOP UNIV 4X3X6 MM 1.15X0.8 MM HA TORP,SUP-2637865,CDM,L8613,CPT,0278,RC,,,,both,,,1582.34,1028.52,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM TWINFIX ULT PK W/ SUT WHT BLU,SUP-2341844,CDM,C1713,HCPCS,0278,RC,,,,both,,,846.17,550.01,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 45 CM 5FR SLT 10CM 0.035IN BALL,SUP-2117038,CDM,C1887,HCPCS,0272,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
CATHETER CV KT 0.032 IN 16 GAX20 CM SINGLE LUMEN EXTN LN,SUP-2763360,CDM,C1751,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
SCREW BNE L35MM DIA5MM GLEN TI NONLOCKING LO PROF BIOMOD,SUP-2404635,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
IMPLANT ORBIT FLR L 36X37X17MM THK1.2MM LT ORAL,SUP-2365171,CDM,C1713,HCPCS,0278,RC,,,,both,,,7112.10,4622.86,,,,,,,,,,,,,
BIT DRL L110MM DIA2MM REUSE,SUP-2167108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
BIT DRL AO CONN 1.8 MM BLU,SUP-2421747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.99,313.94,,,,,,,,,,,,,
SCREW DISTRACTOR L14MM MAXCESS-C,SUP-2311382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM LG CP TI MANDIBULAR FULL,SUP-2883714,CDM,C1713,HCPCS,0278,RC,,,,both,,,17771.71,11551.61,,,,,,,,,,,,,
PLATE BONE L86MM THK2MM 4 H LT LAT TIB L SHP ANG RT BTTRS,SUP-2343790,CDM,C1713,HCPCS,0278,RC,,,,both,,,2783.86,1809.51,,,,,,,,,,,,,
WIRE EXT FIX OLV,SUP-2197289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
STRUT EXT FIX MED CE MARKED QUIK ADJ NS TRUELOK + LTX,SUP-2875010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3191.34,2074.37,,,,,,,,,,,,,
SUPPORT WRST XSM L7IN FOR 55IN L HND SUEDE FLANNEL PERF LACE,SUP-2197030,CDM,L3931,HCPCS,0272,RC,,,,both,,,22.61,14.70,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX 7X10 CM PLASTIC MATRISTEM,SUP-2106492,CDM,Q4166,HCPCS,0636,RC,,,,both,,,4403.85,2862.50,,,,,,,,,,,,,
ARM EXT FIX ACTIVATION 53 MM RIGID,SUP-2463580,CDM,C1713,HCPCS,0278,RC,,,,both,,,2841.32,1846.86,,,,,,,,,,,,,
GRAFT HUM TISS SM W10XL17CM THK07 14MM THN ACELLULAR,SUP-2307603,CDM,Q4128,HCPCS,0636,RC,,,,both,,,18089.04,11757.88,,,,,,,,,,,,,
ANKLE ARTHRODESIS NUT,SUP-2701069,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.79,456.16,,,,,,,,,,,,,
RESTRICTOR CEM DIA10MM SILAS FEM CNL UNIV SWNSN,SUP-2304515,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
INTRODUCER HEMSTAS MAX 7FRX23CM SHTH W/ 0.025 IN GWIRE AND,SUP-2355566,CDM,C1894,HCPCS,0272,RC,,,,both,,,48.67,31.64,,,,,,,,,,,,,
NAIL IM L 22 CM DIA 3.5 MM SS FOREARM,SUP-2885030,CDM,C1713,HCPCS,0278,RC,,,,both,,,4288.55,2787.56,,,,,,,,,,,,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,2500000003,HCPCS,0250,RC,00264-7578-10,NDC,,both,125,ML,71.90,46.73,,,,,,,,,,,,,
ANKLE FUSION PLATE LATERAL TTC 4H,SUP-2815313,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
BAND ANNULPLSTY DURAN ANCORE L 63 X 33.8 MM ORIFICE L 27.8 X,SUP-2282715,CDM,C1889,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
DEVICE ERECTILE RESTR FOR PENILE PROSTHESIS,SUP-2138945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1547.39,1005.80,,,,,,,,,,,,,
VLP 2.5MM TALUS PLT MDL L LT 11X20MM ST,SUP-2820181,CDM,C1713,HCPCS,0278,RC,,,,both,,,5832.71,3791.26,,,,,,,,,,,,,
HC So Tsh 3rd Generation,PX-3018444366,CDM,84443,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
BRACE ORTH AD SM FOR 8 9IN HND SHT R THMB SPICA BLK,SUP-2196531,CDM,L3923,HCPCS,0274,RC,,,,both,,,123.75,80.44,,,,,,,,,,,,,
DRILL HND OD2.4MM PILOT M FRAG SYS DISP FOR 3.5 / 4MM SCR,SUP-2319604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SHEATH INTRO FLX L 80 CM OD 12 FR GUIDEWIRE 0.038 IN LG,SUP-2170677,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.86,95.46,,,,,,,,,,,,,
IMPLANT MAXILLOFACIAL W61XL78MM THK18MM SM LT TEMPORAL FOSSA,SUP-2365350,CDM,C1889,HCPCS,0278,RC,,,,both,,,5193.56,3375.81,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 30MM POLYESTER BOV CLLGN STR,SUP-2265932,CDM,C1768,CPT,0278,RC,,,,both,,,1912.13,1242.88,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1294108D1,SUP-2632809,CDM,C1751,HCPCS,0278,RC,,,,both,,,853.30,554.64,,,,,,,,,,,,,
SCREW BNE 1.5X7 MM 4 MM X DRV DRILL-FREE TI LEVEL 1 19700791,SUP-2462795,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.61,185.00,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED RESURF H6SN] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351364,CDM,C1776,CPT,0278,RC,,,,both,,,25905.00,16838.25,,,,,,,,,,,,,
TRAY HUM THK+6MM 35MM OFFSET SHLDR HI REVERSED AEQUALIS,SUP-2399873,CDM,C1776,CPT,0278,RC,,,,both,,,5666.13,3682.98,,,,,,,,,,,,,
CATHETER GUID L 184 CM OD 14 FR FEM CANN STRL,SUP-2214525,CDM,C1887,HCPCS,0272,RC,,,,both,,,64.31,41.80,,,,,,,,,,,,,
PROBE ELECSURG DYNABLATOR RF DISP,SUP-2745536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
KNIFE SURG FUKUSHIMA GIANNOTTA MIC 90 DEG 7.25 INX4.1 MM,SUP-2485319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.03,331.52,,,,,,,,,,,,,
SPLINT WRST SM R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG,SUP-2326135,CDM,L3908,HCPCS,0274,RC,,,,both,,,72.06,46.84,,,,,,,,,,,,,
INTRODUCER DIAG SWARTZ L 63 CM DIA 8.5 FR DIL L 67 CM DIA,SUP-2877987,CDM,C1893,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SCREW BNE L4MM OD1.7MM PNK TI CORT ST NONCANNULATED FT CRSS,SUP-2366100,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.70,142.15,,,,,,,,,,,,,
HELMET SURG PROTCT HRD PREFABRICATED,SUP-2265008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
VLP 2.7MM PERC CALC PLT LG RIGHT 62MM STER,SUP-2819965,CDM,C1713,HCPCS,0278,RC,,,,both,,,7096.71,4612.86,,,,,,,,,,,,,
SCREW BNE PEDCL 6X50 MM MOSS MIAMI,SUP-2256220,CDM,C1713,HCPCS,0278,RC,,,,both,,,3405.33,2213.46,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 13-15.5 IN CTR 12-13 IN CALF 10-12 IN XS,SUP-2915235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.69,204.55,,,,,,,,,,,,,
ALUM CON ROD 8MMX450MM,SUP-2473149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
ANCHOR SUT NEEDLE CRV FOR DEL MENISCI REP SYS FAST-FIX 360,SUP-2341833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1534.96,997.72,,,,,,,,,,,,,
PLATE BNE MESH 1.1 MM 84 HOLE LCK TI BABY GORILLA,SUP-2750991,CDM,C1713,HCPCS,0278,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
SPLINT WR FRARM RIGHTXL INSTABILITY INJ W/ STAY FIRM SUPP,SUP-2195253,CDM,L3931,HCPCS,0274,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
FORCEPS LAPSCP L310MM OD10MM DISECT RT ANG DBL ACT W/ RATCH,SUP-2332845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3262.46,2120.60,,,,,,,,,,,,,
DEVICE STONE RMVL 115MM DIA BLLN 55FR OD TIP 30MM CUT WIRE,SUP-2675768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
INSTRUMENT ABLATN ACCS 2 VERTEBRA,SUP-2874138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6845.20,4449.38,,,,,,,,,,,,,
BIT DRILL 5MM CANNULATED DISPOSABLE FOR DYNANAIL MINI AND HYBRID,SUP-2878234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
HC Icd Interrogate,PX-4809328900,CDM,93289,CPT,0480,RC,,,,both,,,132.00,85.80,,,,,,,,,,,,,
CATHETER DRAINAGE EXPEL L 25 CM DIA14 FR FLEXITHANE HYDRPHLC,SUP-2652767,CDM,C1729,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
IMPLANT PELV RECON PORCINE CLLGN GRFT HERN 1 LAYR ADV TISS,SUP-2168799,CDM,C1763,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GRAFT BNE 451559,SUP-2684152,CDM,C1713,HCPCS,0278,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
BASKET STONE RETRV 1.9FR L120CM NIT PARACHUTE 4 WIR DISP,SUP-2139282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,842.59,547.68,,,,,,,,,,,,,
WIRE BNE FIX L 229 MM DIA1.6 MM NS LEOS KIRSCHNER,SUP-2933119,CDM,C1713,HCPCS,0278,RC,,,,both,,,137.09,89.11,,,,,,,,,,,,,
PROBE LITHO 1.9 FRX375 CM BILI ELEC HYDRLC AUTOLITH TCH DISP,SUP-2141488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM CRYOPRESERVED PLCNTA TISS UMB AMNION,SUP-2319184,CDM,Q4133,HCPCS,0636,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
MESH CRAN L 50.8 X W 50.8 MM THK 0.8 MM SCREW DIA1.5 MM SM,SUP-2935998,CDM,C1713,HCPCS,0278,RC,,,,both,,,4449.38,2892.10,,,,,,,,,,,,,
SHEATH NEPHSTMY L17CM DIA10MM RENAL ACCS BVL END GWIRE NOTCH,SUP-2126726,CDM,C1894,HCPCS,0272,RC,,,,both,,,124.75,81.09,,,,,,,,,,,,,
CIRCUIT VEN DRNGE W/ BUB TRAP EC BYPS PROC ANGIOVAC,SUP-2118780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
CONE FEM SM H30MM R DPHSEAL TRABECULAR MTL,SUP-2200209,CDM,C1776,CPT,0278,RC,,,,both,,,9558.16,6212.80,,,,,,,,,,,,,
BOLT ORTHOPEDIC LCK 4.9 MM TI NS,SUP-2192369,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
FIXATOR ENER KT LENGTHENER 202MML,SUP-2495579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9176.65,5964.82,,,,,,,,,,,,,
SCREW BNE L16MM OD27MM TI CORT DST FIBULAR ST LOK FULL THRD,SUP-2417469,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.43,322.68,,,,,,,,,,,,,
PLATE BNE W14XL118MM THK3.8MM 5 H R LAT TIB HD BTTRS S STL,SUP-2185776,CDM,C1713,HCPCS,0278,RC,,,,both,,,2206.45,1434.19,,,,,,,,,,,,,
RECON PLATE 13X154MM 3.5MM,SUP-2818475,CDM,C1713,HCPCS,0278,RC,,,,both,,,5025.57,3266.62,,,,,,,,,,,,,
RELOAD STPLR RADIAL 30 MM SALUTE LOAD ENDO GIA TRI-STAPLE,SUP-2126286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1087.44,706.84,,,,,,,,,,,,,
SEVELAMER CARBONATE 2.4 G PO PACK,RX-98616,CDM,J0602,HCPCS,0637,RC,65862-0931-90,NDC,,both,1,UN,8.60,5.59,,,,,,,,,,,,,
TRAY PROVEN REV MOD TIB 2T3F,SUP-2359294,CDM,C1776,CPT,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK1MM ACELLULAR DERM MTRX,SUP-2335286,CDM,C1762,CPT,0278,RC,,,,both,,,9840.76,6396.49,,,,,,,,,,,,,
GUIDEWIRE FLX STK 1.2MMX18IN,SUP-2366743,CDM,C1769,HCPCS,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
BIT DRL L44.5MM DIA0.76MM STP 12MM MINI QUIK CPL FOR,SUP-2187637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.54,285.70,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED ADV REVERSED,SUP-2267728,CDM,C1776,CPT,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
PLATE BNE L123MM 8 H ST R SUP CLAV S STL LOK COMPR FOR,SUP-2177368,CDM,C1713,HCPCS,0278,RC,,,,both,,,3088.69,2007.65,,,,,,,,,,,,,
CATHETER URODYN DL 7 FRX30 CM VLY,SUP-2835711,CDM,C1726,HCPCS,0272,RC,,,,both,,,60.79,39.51,,,,,,,,,,,,,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-135456,CDM,J2312,HCPCS,0636,RC,76329-3369-01,NDC,,both,0.4,ML,54.10,35.16,,,,,,,,,,,,,
SET INSTR IMPL SCR DIA7.3MM FULL THRD CANN,SUP-2183059,CDM,C1713,HCPCS,0278,RC,,,,both,,,72293.35,46990.68,,,,,,,,,,,,,
GRAFT BNE XL,SUP-2424566,CDM,C1713,HCPCS,0278,RC,,,,both,,,9809.36,6376.08,,,,,,,,,,,,,
COMPONENT PATELLAR E 12 MM ARTC KNEE,SUP-2200796,CDM,C1776,CPT,0278,RC,,,,both,,,9011.80,5857.67,,,,,,,,,,,,,
PLATE BNE L25MM DOGBNE SLNT W/ COMPR GORILLA,SUP-2321547,CDM,C1713,HCPCS,0278,RC,,,,both,,,4385.01,2850.26,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA2.3 MM TI MAND ST LCK AXS NS UNIV,SUP-2909528,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.98,341.24,,,,,,,,,,,,,
PAD ORTHOT LAT TROCHANTERIC CUST,SUP-2435592,CDM,L1290,HCPCS,0274,RC,,,,both,,,219.99,142.99,,,,,,,,,,,,,
KNIFE ENDOSCP JR 3.5X4.5 MM 2300 MM 2.8 MM STRL SB KNIFE,SUP-2464540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SPACER SPNL 32X11X7 MM NANOMETALENE STRL VENTURA,SUP-2244933,CDM,C1821,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
CUSTOM KT DLYS KT-1540,SUP-2263925,CDM,C1752,HCPCS,0278,RC,,,,both,,,11.62,7.55,,,,,,,,,,,,,
PLATE BNE T 2.7X32 MM 3 HOLE SS,SUP-2569102,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.34,105.52,,,,,,,,,,,,,
SCREW BONE 65MM DIA 100MML CNCLLS HXGNL HEAD 16MML PRTLLY T,SUP-2722502,CDM,C1713,HCPCS,0278,RC,,,,both,,,77.62,50.45,,,,,,,,,,,,,
ANCHOR SUT DIA2.3MM CRV COBRAID SZ 2 ULTRABRAID BLK SUT,SUP-2341873,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
ANCHOR SUT OD4.5MM BIOCOMP W/ 2X STRND NDL INSITE FT,SUP-2388891,CDM,C1713,HCPCS,0278,RC,,,,both,,,2172.88,1412.37,,,,,,,,,,,,,
PLATE BNE NEURO MED 2 HOLE LP WIDE TI STRL LEVEL 1,SUP-2475864,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.95,226.82,,,,,,,,,,,,,
PLATE OLECRANON 3.5MM 4H RT 112MM SS LCP STRL,SUP-2547482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3304.79,2148.11,,,,,,,,,,,,,
STEM HUM H120MM DIA8MM 135DEG TI PRI CEM AND PRSS FIT UNIV,SUP-2224494,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRAFT BNE SUB W12XH22XL38MM BOV CANC WDG RECT CANCELLO-PURE,SUP-2397870,CDM,C1713,HCPCS,0278,RC,,,,both,,,5532.68,3596.24,,,,,,,,,,,,,
LABETALOL HCL 20 MG/4ML IV SOSY,RX-141251,CDM,J1920,HCPCS,0636,RC,70004-0700-28,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
MATRIX BIO DIA 50 MM FISH SKIN SIL DERMAL STD CIR INTACT FEN,SUP-2909216,CDM,Q4158,HCPCS,0636,RC,,,,both,,,46346.40,30125.16,,,,,,,,,,,,,
ALLOGRAFT BONE CORTICOCANCELLOUS MINERALIZED 0.5MM -,SUP-2418451,CDM,C1889,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
REAMER SURG OD7MM HUM SHLDR STRL ACORN MILAGRO,SUP-2256777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
ROD IM SPEC KNEE LNG LNG,SUP-2254015,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
DEVICE ORTH L8.5MM OD3.5MM KNEE ACL PCL RETRODRILL,SUP-2120841,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
STEM HUM SZ 3 NUCLS ANAT STRL PERFORM,SUP-2894285,CDM,C1776,CPT,0278,RC,,,,both,,,17140.88,11141.57,,,,,,,,,,,,,
WIRE SPINAL FIXATION KIRSCHNER 0.45IN DIA 500MML BLUNT TIP,SUP-2232217,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BRACE ORTH LACE CLOSURE SM 5.5X6.25 IN WRST RT SPECTR,SUP-2319268,CDM,L3931,HCPCS,0272,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
SPLINT ANK STRRP AIR AND FOAM S,SUP-2276706,CDM,L4350,HCPCS,0272,RC,,,,both,,,38.18,24.82,,,,,,,,,,,,,
RETRIEVER ENDOSCP L160CM SHTH DIA2.5MM NET 4X5.5CM PLAT,SUP-2391611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.40,203.06,,,,,,,,,,,,,
CROWN DENT 5 UP RT SEC PRI M S STL GLD PREFABRICATED REPL,SUP-2238933,CDM,D6783,CPT,0278,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
PASSER SUTURE HUMPBACK 16 MM FLUSHPORT SCORPION,SUP-2849257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
VALVE MITRL DIA29MM MECH EXP CUF,SUP-2356719,CDM,C1889,HCPCS,0278,RC,,,,both,,,13822.28,8984.48,,,,,,,,,,,,,
TI CLASSIC 4 HOLE 135 DEG,SUP-2818990,CDM,C1713,HCPCS,0278,RC,,,,both,,,4507.78,2930.06,,,,,,,,,,,,,
HC Irradiation Service Charge,PX-3008694500,CDM,86945,CPT,0300,RC,,,,both,,,364.00,236.60,,,,,,,,,,,,,
SYSTEM ACCS DISECT BLLN OVL BLNT TIP LP 2 PK KII,SUP-2424365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BIT DRL L195MM DIA6MM STRL JCBS CHK NONRADIOPAQUE W/O STP,SUP-2187323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.46,313.60,,,,,,,,,,,,,
CURETTE SURG FUSION 2 8 IN 8.1X5.1 MM STR STD CUP HLLW HNDL,SUP-2482195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.96,173.52,,,,,,,,,,,,,
XD DFS SCR15X11MM TNTNG11MM THD5MM H,SUP-2669680,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.57,222.67,,,,,,,,,,,,,
JOINT TOE ANGLED 0 DEG 16 MM PIP IM 1 PC NIT SMRT TOE II,SUP-2431339,CDM,C1776,CPT,0278,RC,,,,both,,,2624.41,1705.87,,,,,,,,,,,,,
CATH DRAINAGE SET ALL-PURPOSE 6FR X 20CM,SUP-2844710,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED XL KT STRL MEDPOR LTX,SUP-2862741,CDM,C1713,HCPCS,0278,RC,,,,both,,,65097.04,42313.08,,,,,,,,,,,,,
COMPONENT FEM SZ 0 LT CO CHROM NP REV CONSTRN N-K II,SUP-2209859,CDM,C1776,CPT,0278,RC,,,,both,,,16943.44,11013.24,,,,,,,,,,,,,
CATHETER REPROC EP 4 FR 15-25 MM DUO,SUP-2471500,CDM,C1731,HCPCS,0278,RC,,,,both,,,3070.45,1995.79,,,,,,,,,,,,,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,0636,RC,00517-5602-25,NDC,,both,0.5,ML,66.80,43.42,,,,,,,,,,,,,
PLATE BNE L1 2X110X0.5 MM CRANIOMAXILLOFACIAL 7 HOLE TI NS,SUP-2465043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1090.84,709.05,,,,,,,,,,,,,
PROSTHESIS OSS NAR LG 0.4X1X5 MM CLASSIC STAP TI,SUP-2648920,CDM,L8613,CPT,0278,RC,,,,both,,,727.16,472.65,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.527,SUP-2860044,CDM,C1713,HCPCS,0278,RC,,,,both,,,40577.28,26375.23,,,,,,,,,,,,,
SPACER TIB CONCV 10 MM UNI M/G,SUP-2437228,CDM,C1776,CPT,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
KIT CATH 1.9FR X 40CM 1-LUMEN PICC 30GA MOD INTRO 1958-1640,SUP-2874835,CDM,C1751,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
HC So Hla II Typing 1 Locus Lr,PX-3108137666,CDM,81376,CPT,0310,RC,,,,outpatient,,,143.00,92.95,,,,,,,,,,,,,
COAGULATOR ELECSURG MONOPOLAR 5 MMX33 CM OPN END DSTL TIP,SUP-2490488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1242.06,807.34,,,,,,,,,,,,,
WIRE FIX OLV 2.4 MM THRD STRL STRATUM RS LTX DISP,SUP-2862182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.89,214.43,,,,,,,,,,,,,
TUBE TRACH 8X120 MM CUST SHILEY,SUP-2264411,CDM,A7521,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SCREW EXT FIX L200MM DIA5MM THRD L80MM S STL HA SELF DRL MR,SUP-2186989,CDM,C1713,HCPCS,0278,RC,,,,both,,,861.33,559.86,,,,,,,,,,,,,
STENT ENDOPROS L10CM DIA7MM CATH 8FR L120CM BLLN DIA7MM,SUP-2396558,CDM,C1874,HCPCS,0278,RC,,,,both,,,11209.80,7286.37,,,,,,,,,,,,,
PLATE BNE L 81 X W 8.5 MM THK 2.4 MM SCREW DIA2.7 MM 3 H SS 72468703,SUP-2932782,CDM,C1713,HCPCS,0278,RC,,,,both,,,2550.31,1657.70,,,,,,,,,,,,,
CATHETER ETER EP 4FR L110CM ELECTRD SPC 2 5 2MM BND ELECTRD 1MM L,SUP-2357650,CDM,C1730,HCPCS,0272,RC,,,,both,,,1654.00,1075.10,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.6MM TI SELF DRL CRUC FOR CRAN PLATING,SUP-2280076,CDM,C1713,HCPCS,0278,RC,,,,both,,,184.73,120.07,,,,,,,,,,,,,
POLARUS 3 SCREW CADDY 4.3 MM 48 64 MM,SUP-2639809,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 7-4 MM EPTFE TAPR STD WALL N,SUP-2761335,CDM,C1768,CPT,0278,RC,,,,both,,,2318.51,1507.03,,,,,,,,,,,,,
HC So Acetylcholn Rcptr Blckg Antb,PX-3028604266,CDM,86042,CPT,0302,RC,,,,both,,,256.00,166.40,,,,,,,,,,,,,
PLATE BONE W10XL58MM THK3.3MM HK D15MM 6 H LT CLAV S STL LCK,SUP-2185831,CDM,C1713,HCPCS,0278,RC,,,,both,,,2294.71,1491.56,,,,,,,,,,,,,
PLATE BNE CONN 2 HOLE +,SUP-2484660,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
HEAD REAMER 11.5 MM FOR RIA 2 STRL,SUP-2563903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2478.59,1611.08,,,,,,,,,,,,,
PIN FIX L200MM DIA5MM S STL MRI CONDITIONAL FOR TRAC STNMN,SUP-2186923,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.03,135.22,,,,,,,,,,,,,
CARTRIDGE RADIOTHERAPY 1X5 MM PLCMNT FUSIONCOIL MARKER STRL,SUP-2164571,CDM,A4648,CPT,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
DRILL SURG ANGLED,SUP-2660234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.23,333.60,,,,,,,,,,,,,
PASTE INTRACORDAL INJ 7ML,SUP-2300152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
SCREW SET MULTAXL 6.5X45 MM FOR 4.75 MM ROD FEN CD HORZ,SUP-2629320,CDM,C1713,HCPCS,0278,RC,,,,both,,,4027.05,2617.58,,,,,,,,,,,,,
VINCENT TOTAL 11MM 0.4MM X 11MM L HA/TI/FLUOROPLASTIC,SUP-2488899,CDM,L8613,CPT,0278,RC,,,,both,,,1346.21,875.04,,,,,,,,,,,,,
"HC N.Gonorrhea, Dna, Amp Probe",PX-3068759100,CDM,87591,CPT,0306,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
COMPONENT PAT SM DIA29MM THK7.5MM RESURF BI CRUCE STBL CEM,SUP-2350587,CDM,C1776,CPT,0278,RC,,,,both,,,2840.92,1846.60,,,,,,,,,,,,,
NEXGEN RH KNEE TM 10MM FULL BLK TIB AGMT SZ 2,SUP-2502547,CDM,C1776,CPT,0278,RC,,,,both,,,10456.20,6796.53,,,,,,,,,,,,,
KIT HMRL EL ORTHOPAEDIC CONDYLAR ALIGNMENT HEXALOBULAR,SUP-2879150,CDM,C1776,CPT,0278,RC,,,,both,,,6345.94,4124.86,,,,,,,,,,,,,
BIT DRL L40MM DIA2MM CANN POLYAX LOK SCR FOR DST VOLAR RAD,SUP-2421213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.63,222.06,,,,,,,,,,,,,
BIPOLAR ASSY COCR 26MM ID 56MM OD,SUP-2509100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER NEPHSTMY 8FR L25CM FLEXIMA TEMPTIP HYDRPHLC TIP,SUP-2147906,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
OLECR PLATE RT 21H 194MM,SUP-2588823,CDM,C1713,HCPCS,0278,RC,,,,both,,,3455.26,2245.92,,,,,,,,,,,,,
"HC So Ag Detect Nos, Eia Multi Step",PX-3068744966,CDM,87449,CPT,0306,RC,,,,both,,,146.00,94.90,,,,,,,,,,,,,
DRILL TWST L115MM DIA1.9MM WRK L35MM CLR STRP,SUP-2365240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.39,622.30,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR DIA 700-900 UM 2 ML PVA,SUP-2140325,CDM,C1889,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN S STL COR SLX STEER SFT,SUP-2157309,CDM,C1769,HCPCS,0272,RC,,,,both,,,194.05,126.13,,,,,,,,,,,,,
KIT VASC CLOSURE VASOSEAL CLLGN MEDIATED EXTRAVASCULAR BLU,SUP-2227423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
KIT INSTR DIA1.5MM STR SFT KT DISP FOR JUGGERKNOT SYS,SUP-2212954,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.02,614.91,,,,,,,,,,,,,
SCREW BNE L 135 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2931584,CDM,C1713,HCPCS,0278,RC,,,,both,,,212.08,137.85,,,,,,,,,,,,,
IMPLANT BIO TISS W4XL7CM BOV PERICARD CLLGN MTRX MESH SGL,SUP-2130298,CDM,C9354,HCPCS,0278,RC,,,,both,,,2225.13,1446.33,,,,,,,,,,,,,
PIN GUID SQ 3.2X89.5,SUP-2263117,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
INTRODUCER IV CATH NEOMAGIC L 40 CM CATH 1.9 FR SIL PICC 1,SUP-2874154,CDM,C1751,HCPCS,0278,RC,,,,both,,,212.89,138.38,,,,,,,,,,,,,
SCREW BONE L70MM OD4.5MM STD CORT ST NONLOCKING FULL THRD LO,SUP-2343761,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.95,36.37,,,,,,,,,,,,,
COMPONENT FEM PRIMARY X SM RT KNEE POROUS ASCNT,SUP-2407166,CDM,C1776,CPT,0278,RC,,,,both,,,10550.40,6857.76,,,,,,,,,,,,,
STENT COLON 0.035 IN 22-27X120 MM 10 FRX135 CM NIT WALLFLEX,SUP-2458673,CDM,C2617,HCPCS,0278,RC,,,,both,,,7968.44,5179.49,,,,,,,,,,,,,
BAG SHWR PROTECT DISP,SUP-2356015,CDM,Q0501,HCPCS,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
CATHETER CV SET 032 8 FRX15 CM DL J TIP POLYURETHANE,SUP-2759960,CDM,C1751,HCPCS,0278,RC,,,,both,,,229.09,148.91,,,,,,,,,,,,,
EXTRACTOR SURG L675IN 24MM TIB PIN DRVR RUSH,SUP-2409753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1314.40,854.36,,,,,,,,,,,,,
INTRO SHEATH CATH LOCK 7FRX12CM,SUP-2698824,CDM,C1894,HCPCS,0272,RC,,,,both,,,43.08,28.00,,,,,,,,,,,,,
SCREW SPNL DBL LD 4X36 MM THRD,SUP-2414777,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
HC Reticulocyte,PX-3058504500,CDM,85045,CPT,0305,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
PLATE ANAT REPLICATOR 15MM FOR PRI REV TOT SHLDR,SUP-2223284,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BNE L ANAT TENS SIDE PLNTR PYTHON LAPIPLASTY,SUP-2389089,CDM,C1713,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
TUBING IRRIGATION 0.104X0.192 IN 14.6 FR 50 FT SILAS SIL NS,SUP-2466365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,561.28,364.83,,,,,,,,,,,,,
EXTENSION STEM L100MM OD12MM STABILIZING FEM PRI REV,SUP-2215638,CDM,C1776,CPT,0278,RC,,,,both,,,2651.32,1723.36,,,,,,,,,,,,,
SYSTEM REPAIR ANCHOR  ACL IMPLANT,SUP-2754752,CDM,C1713,HCPCS,0278,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
BLADE SAW SAG 90X18 MMX1.37 IN,SUP-2364333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,193.46,125.75,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 15.5-18.5 IN CALF 12 IN SM SZ 2 TI RT,SUP-2915084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1753.53,1139.79,,,,,,,,,,,,,
MESH HERN BIOMATERIAL 15X10 CMX2 MM 2 SURF EPTFE DUALMESH,SUP-2395328,CDM,C1781,HCPCS,0278,RC,,,,both,,,3224.78,2096.11,,,,,,,,,,,,,
CURVED PLATE,SUP-2820656,CDM,C1713,HCPCS,0278,RC,,,,both,,,1324.92,861.20,,,,,,,,,,,,,
SLEEVE IM NAIL DIA 8-13 MM PROTCT RIGID LNG STRL DISP,SUP-2905678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,972.99,632.44,,,,,,,,,,,,,
BIT DRL CALIB XLN 4.2 MM STRL,SUP-2789937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.39,541.70,,,,,,,,,,,,,
SYSTEM EXT DRNGE AND MON INTLNK W LCATH DUET,SUP-2278393,CDM,C1729,HCPCS,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
SPLINT THMB M L5IN SH LT 1 STRP THERMOPLASTIC INSRT,SUP-2324195,CDM,L3931,HCPCS,0274,RC,,,,both,,,42.26,27.47,,,,,,,,,,,,,
ROSUVASTATIN CALCIUM 20 MG PO TABS,RX-35135,CDM,6370000000,HCPCS,0637,RC,60687-0256-01,NDC,,both,1,UN,6.30,4.09,,,,,,,,,,,,,
MESH HERN W6XL6IN POLYPR VENTRAL BIOABSRB FLX MFIL SQ,SUP-2219765,CDM,C1781,HCPCS,0278,RC,,,,both,,,1854.33,1205.31,,,,,,,,,,,,,
TI RAISED HEAD EMERG SCREW  1.7MM  431576405,SUP-2844082,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.01,392.61,,,,,,,,,,,,,
CATHETER REPROC EP 4 FR 15-25 MM LASSO,SUP-2471903,CDM,C1730,HCPCS,0272,RC,,,,both,,,3070.45,1995.79,,,,,,,,,,,,,
BIT DRL L50MM DIA1.35MM TWST FOR 1.7MM SCR,SUP-2366404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.43,284.33,,,,,,,,,,,,,
BIT DRILL SHANK SHORT 3.5 MM WITH QUICK CONNECT PERILOC,SUP-2837022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1446.76,940.39,,,,,,,,,,,,,
PLATE BNE 8 H CORT WRST TI SHT BEND SM FRAG SYS FOR,SUP-2191036,CDM,C1713,HCPCS,0278,RC,,,,both,,,2110.08,1371.55,,,,,,,,,,,,,
THEOPHYLLINE ER 400 MG PO TB24,RX-36973,CDM,6370000000,HCPCS,0637,RC,29033-0001-01,NDC,,both,1,UN,5.50,3.57,,,,,,,,,,,,,
REPAIR KIT 3.5 MM KNOTLESS SYS W/ INSRTR ACU-SINCH,SUP-2857596,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.88,2024.67,,,,,,,,,,,,,
PLATE BONE ADAPTION 0.5 MM 7 HOLE TITANIUM NON STERILE LOW P,SUP-2838362,CDM,C1713,HCPCS,0278,RC,,,,both,,,1013.59,658.83,,,,,,,,,,,,,
COIL EMB L11CM LOOP DIA5MM 0.035IN HYDRGEL TECHNOLOGY,SUP-2421309,CDM,C1889,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
MESH CRAN W40XL62MM THK1MM TIIUM POLYETH MTRX POR BARR,SUP-2365173,CDM,C1713,HCPCS,0278,RC,,,,both,,,3668.84,2384.75,,,,,,,,,,,,,
PLATE BONE LOK SHFT 210MML HLX10 PRTSL 64 CRVD NON CNTCT BRD,SUP-2471402,CDM,C1713,HCPCS,0278,RC,,,,both,,,1862.90,1210.88,,,,,,,,,,,,,
POWERPORT IMPL CLEARVUE ISP 8FR,SUP-2748439,CDM,C1788,HCPCS,0278,RC,,,,both,,,812.13,527.88,,,,,,,,,,,,,
PLATE BONE THK0.6MM 6 H ORBIT RIM TI CVD FOR 1.5MM SCR,SUP-2402886,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
SCREW BNE L34MM DIA2.7MM STD CORT S STL HEX SOCK,SUP-2183351,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.98,35.09,,,,,,,,,,,,,
TIP VITRCTMY CUT HI SPD DISP 25GA,SUP-2129350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
MODULE ACCESS PRONE TRANSPSOAS LATERAL INTERBODY FUSION,SUP-2933964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
PLATE BNE L58MM 5 H BILAT S STL STR RECON NONLOCKING,SUP-2197670,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.37,565.09,,,,,,,,,,,,,
PLATE BNE M W20XL30MM NONSTERILE BILAT S STL X SHP LO PROF,SUP-2186322,CDM,C1713,HCPCS,0278,RC,,,,both,,,2332.42,1516.07,,,,,,,,,,,,,
BASEPLATE GLEN REVERSED SM SHLDR EQUINOXE,SUP-2451445,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
FOOTPLATE EXT FIX L 155 MM LNG GRN NS DISP SPAT FRME TSF,SUP-2933233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5406.61,3514.30,,,,,,,,,,,,,
BIT DRL L300MM DIA4.3MM QUIK CPL PERC CALIB W/O STP REUSE,SUP-2187852,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.02,334.76,,,,,,,,,,,,,
INTRODUCER KT 10.7FR,SUP-2327387,CDM,C1894,HCPCS,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
KIT PROC 600MH 4FR L24CM BRT TIP LSR FBR VARI-LASE,SUP-2120512,CDM,C1894,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT VASC L50CM DIA8MM RNG L40CM EPTFE THN WALLED CBAS HEP,SUP-2395823,CDM,C1768,CPT,0278,RC,,,,both,,,5670.84,3686.05,,,,,,,,,,,,,
STAPLE INTERNAL W22XL16MM VITALLIUM WIRE,SUP-2704414,CDM,C1713,HCPCS,0278,RC,,,,both,,,575.25,373.91,,,,,,,,,,,,,
BRACE ANK LACE UP FIGURE 8 X L,SUP-2276709,CDM,L4350,HCPCS,0272,RC,,,,both,,,23.55,15.31,,,,,,,,,,,,,
SCREW SPNL L25MM DIA5MM FACET SYS AX LIF,SUP-2389069,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PLATE BONE L30MM MAXILLOFACIAL DBL T NONCOMPRESSION FOR MINI,SUP-2364907,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.24,373.26,,,,,,,,,,,,,
IMPLANT HUM TISS ALLGRFT SUPRAMALLEOLAR OSTEOTOM MODIFIABLE,SUP-2899157,CDM,C1713,HCPCS,0278,RC,,,,both,,,6433.08,4181.50,,,,,,,,,,,,,
PATCH TISS 5X10 CM FOR CLLGN REP,SUP-2431728,CDM,C1763,HCPCS,0278,RC,,,,both,,,7714.98,5014.74,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT PORE 500 UM 2 CC CALCIUM PHOSPHATE HA,SUP-2883829,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
BOOT WALKING PREFORTED FT GTT,SUP-2265019,CDM,L4387,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 L 3 CM DIA2.5 MM MICROCATHETER,SUP-2365659,CDM,C1889,HCPCS,0278,RC,,,,both,,,4619.25,3002.51,,,,,,,,,,,,,
KIT INTMED MST CATHETER SGL LUMN S STL GWIRE AND LIDO W PASV,SUP-2118830,CDM,C1751,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
MESH HERN W10XL14IN POLYPR MID WT MFIL RECTANG OVL FLAT SH,SUP-2265906,CDM,C1781,HCPCS,0278,RC,,,,both,,,281.82,183.18,,,,,,,,,,,,,
STENT TRACHBRONCH L 80 MM DIA20 MM CATH L 95 CM DIA16 FR,SUP-2148910,CDM,C1883,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BONE GRAFT KIT COR DECOMPRESSION 15 CC INDUCTIVE PRO-STIM,SUP-2759595,CDM,C1713,HCPCS,0278,RC,,,,both,,,12638.50,8215.02,,,,,,,,,,,,,
DRESSING WND 3 LAYR 5X5 CM MTRX CYTAL,SUP-2106528,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2995.87,1947.32,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE",PX-4209711000,CDM,97110,CPT,0420,RC,,,GO|CO|XU,both,,,195.00,126.75,,,,,,,,,,,,,
BOOT CHARCOT TCC EZ EXTRA L,SUP-2194343,CDM,L4387,HCPCS,0274,RC,,,,both,,,312.27,202.98,,,,,,,,,,,,,
SAW HND JOS 7.25 IN STR BAYNT,SUP-2487362,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.68,233.14,,,,,,,,,,,,,
DISC INTERVERTEBRAL 6DEG SPNL SUP ENDPLATE PRODISC-L,SUP-2163213,CDM,C1713,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
ELECTRODE RF ABLATIONXL 25CM 7CM STARBURST,SUP-2117214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
NEEDLE PROC AD 18GA L798CM 50DEG S STL TRANSSEPTAL POINTER,SUP-2357227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
SEALER LIGASURE MARYLAND THORACIC 5MM L 30CM,SUP-2898396,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2154.20,1400.23,,,,,,,,,,,,,
CLIP ANEUR BLDE L15MM MAX OPN 9.2MM 70GM STD TEMP PHYNOX,SUP-2108390,CDM,C1889,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 1MM 8MM RANG 40CC READIGRFT,SUP-2264730,CDM,C1713,HCPCS,0278,RC,,,,both,,,1492.00,969.80,,,,,,,,,,,,,
SCREW BONE L5MM DIA2MM CRANIOMAXILLOFACIAL LACTOSORB PUSH,SUP-2137234,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.61,176.55,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X65 MM 8 HOLE 1/4 SS,SUP-2536111,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
LOOP OSS HOUSE TYP 0.13X4.25 MM WIRE TANTALUM,SUP-2637831,CDM,L8613,CPT,0278,RC,,,,both,,,250.54,162.85,,,,,,,,,,,,,
COMPONENT FEM SEG C RT DSTL KNEE,SUP-2437243,CDM,C1776,CPT,0278,RC,,,,both,,,21406.95,13914.52,,,,,,,,,,,,,
CLAMP EXT FIX 4 POS MULTIPIN,SUP-2188524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1873.64,1217.87,,,,,,,,,,,,,
GRAFT DERMAL MESH 16X8 CM SM CRV RECON TISS MTRX STRATTICE,SUP-2422960,CDM,C1781,HCPCS,0278,RC,,,,both,,,7344.46,4773.90,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP 15MM,SUP-2249444,CDM,C1713,HCPCS,0278,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
SLIDER SPINE DEV TI GIC54,SUP-2293363,CDM,2780000010,LOCAL,0278,RC,,,,both,,,358.09,232.76,,,,,,,,,,,,,
COLLAR FEM L30MM KNEE TRABECULAR MTL SEG FOR 9-16MM STEM,SUP-2200564,CDM,C1776,CPT,0278,RC,,,,both,,,6231.33,4050.36,,,,,,,,,,,,,
PLATING,SUP-2900677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
SCREW INTRF POLYPR INTRAFIX ADV SM 30MM,SUP-2256835,CDM,C1713,HCPCS,0278,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
HC Drain Ovary Abscess Perq,PX-3615882200,CDM,58822,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN,RX-2335,CDM,6370000000,HCPCS,0637,RC,24208-0720-02,NDC,,both,5,ML,242.60,157.69,,,,,,,,,,,,,
BRACE KNEE MCL LCL EC HNG NEOPRENE W POPLITEAL PAT UNIV,SUP-2196414,CDM,L1810,HCPCS,0274,RC,,,,both,,,119.48,77.66,,,,,,,,,,,,,
HC Pt Manual Therapy Ea 15|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209714000,CDM,97140,CPT,0420,RC,,,KX|CQ,both,,,194.00,126.10,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN UNIGLIDE L 80 CM DIA 0.038 IN TAPR L 20,SUP-2171135,CDM,C1769,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
SCREW CPL LNG FOR DH DC SYS,SUP-2187945,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.91,196.24,,,,,,,,,,,,,
MESO BIOMATRIX 4CM W X5CML X 03MM THICK,SUP-2675732,CDM,C1763,HCPCS,0278,RC,,,,both,,,1972.92,1282.40,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 25CM 6MM 120CM 6FR RADIOPAQUE,SUP-2396650,CDM,C1874,HCPCS,0278,RC,,,,both,,,22717.90,14766.63,,,,,,,,,,,,,
SCREW BNE PART THRD 4X40 MM CANC TI,SUP-2374495,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
PLATE BNE 150DEG 5 H PROX FEM LOK FOR 3.5MM SCR PEDILOC,SUP-2318560,CDM,C1713,HCPCS,0278,RC,,,,both,,,7319.34,4757.57,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2188960,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.41,115.32,,,,,,,,,,,,,
NAIL IM FEM ANTERGRADE RG LCK CANN TI 12MM 320MM,SUP-2408508,CDM,C1713,HCPCS,0278,RC,,,,both,,,5680.26,3692.17,,,,,,,,,,,,,
SCREW BNE PERIARTICULAR 3.5X120 MM ST FN THRD HD HEX NS LTX,SUP-2861325,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.05,126.13,,,,,,,,,,,,,
SET COLON DCOMPR CATH 8.5FR L350CM GWIRE 0.035IN MIN ACC,SUP-2169144,CDM,C1729,HCPCS,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
SPLINT WRST R INSTABILITY INJ LOOP LOK W STAY FIRM SUPP,SUP-2276663,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.36,10.63,,,,,,,,,,,,,
CONNECTOR OFFSET 3MM FOR GMK REV SYS,SUP-2267451,CDM,C1776,CPT,0278,RC,,,,both,,,7788.77,5062.70,,,,,,,,,,,,,
CATHETER PICC L55CM OD6FR 3 LUMN N COAT N CT COMPATIBLE PWR,SUP-2118838,CDM,C1751,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
DISTRACTION INTRNL ST SIZER 51 429 30 7130 MM 54 HOLE T 6L 4,SUP-2494431,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
GRAFT BNE INJ 3 CC AUG,SUP-2759545,CDM,C1734,HCPCS,0278,RC,,,,both,,,8449.74,5492.33,,,,,,,,,,,,,
DRAIN SURG W7MMXL20CM SIL FULL PERF HUBLESS FLAT RADPQ STRP,SUP-2127515,CDM,C1729,HCPCS,0272,RC,,,,both,,,14.13,9.18,,,,,,,,,,,,,
PLATE BNE COMPR SM 2.7X100 MM 12 HOLE DYN NS DCP LTX,SUP-2861904,CDM,C1713,HCPCS,0278,RC,,,,both,,,523.94,340.56,,,,,,,,,,,,,
SUPPORT BK LO FRIC PUL,SUP-2276691,CDM,L0641,HCPCS,0272,RC,,,,both,,,74.23,48.25,,,,,,,,,,,,,
SHUNT SURG MED ULTRA,SUP-2628142,CDM,C1729,HCPCS,0272,RC,,,,both,,,1406.56,914.26,,,,,,,,,,,,,
STEM EXTN L65MM DIA13MM KNEE CEMENTLESS FLUT GMK,SUP-2267623,CDM,C1776,CPT,0278,RC,,,,both,,,6554.75,4260.59,,,,,,,,,,,,,
PLATE BONE W8XL112MM THK3.3MM 14 H STRL BILAT PELV S STL,SUP-2186242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1557.13,1012.13,,,,,,,,,,,,,
PLATE BNE L145MM 8 H ST L MED PROX TIB S STL LOK COMPR LO,SUP-2185641,CDM,C1713,HCPCS,0278,RC,,,,both,,,4260.82,2769.53,,,,,,,,,,,,,
TUNNELER INFUS 16GA L12IN SHTH DISP ON-Q,SUP-2236855,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
FOUNDATION FOUNDATION PS INSRT SZ 2 9 MM,SUP-2216363,CDM,C1776,CPT,0278,RC,,,,both,,,3268.74,2124.68,,,,,,,,,,,,,
CATHETER HAD AD 14.5FR L50CM INSRT L33CM POLYUR CARBOTHANE,SUP-2283943,CDM,C1881,HCPCS,0278,RC,,,,both,,,768.67,499.64,,,,,,,,,,,,,
RX TEMPLATE125 X 125LARGE GRID MALLEABLE T0.6MM,SUP-2488345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,191.45,124.44,,,,,,,,,,,,,
CATHETER VALVULOPLASTY ZMED L 100 CM DIA 6 FR 3 CM 11 MM,SUP-2659421,CDM,C1725,HCPCS,0272,RC,,,,both,,,2219.60,1442.74,,,,,,,,,,,,,
GRAFT BONE SUB W1XH10XL0.8CM DEMIN MTRX GRFTON,SUP-2281665,CDM,C9362,HCPCS,0278,RC,,,,both,,,3506.60,2279.29,,,,,,,,,,,,,
PIN 12 APEX SELF DRILL SS 2X45MM,SUP-2695709,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.60,225.94,,,,,,,,,,,,,
RING EXT FIX ID130MM 5/8 COMP C ILIZ,SUP-2342283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8162.74,5305.78,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L63CM DIL L67CM CRV TYP SL4 SUP STIFF,SUP-2357259,CDM,C1894,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SCREW BNE L36MM CORT S STL ST NONCANNULATED NONLOCKING FULL,SUP-2186582,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.04,166.43,,,,,,,,,,,,,
SCREW EXT 4X100 MM HA SPADE PT MR CONDITIONAL SS,SUP-2186950,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.80,346.32,,,,,,,,,,,,,
STEM HUM LNG 130 DEG 12X210 MM SHLDR HA AEQUALIS,SUP-2715552,CDM,C1776,CPT,0278,RC,,,,both,,,15426.82,10027.43,,,,,,,,,,,,,
OXYGENATOR FX15 W/O RESERVOIR,SUP-2849774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-103565,CDM,J0665,HCPCS,0636,RC,63323-0466-01,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
TEMPLATE PLT 24MM 2 CLMN VOLAR DST RAD VAR ANG LCP,SUP-2417332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,268.60,174.59,,,,,,,,,,,,,
NALTREXONE HCL 50 MG PO TABS,RX-10685,CDM,6370000000,HCPCS,0637,RC,00904-7036-04,NDC,,both,1,UN,8.10,5.26,,,,,,,,,,,,,
CATHETER THRMDIL 7.5FRX110CM SIX LUMN REFOX VOL OXMTR W/ AMC,SUP-2214321,CDM,C1751,HCPCS,0278,RC,,,,both,,,624.36,405.83,,,,,,,,,,,,,
REAMER EXTRACTION SZ 4 MM SCREW DIA 3.4-4 MM STRL DISP,SUP-2913585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2748.07,1786.25,,,,,,,,,,,,,
CUBE EXT FIX 2 H S STL RANCHO FOR ILIZ TAY SPAT FRME EXT,SUP-2342333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.46,797.85,,,,,,,,,,,,,
STENT CAR ENROUTE L 40 MM DIA 9-7 MM WORKING L 57 CM,SUP-2884055,CDM,C1876,HCPCS,0278,RC,,,,both,,,8412.06,5467.84,,,,,,,,,,,,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,J7131,HCPCS,0250,RC,00338-0054-03,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
PAD ORTHOT ABD CUST,SUP-2435590,CDM,L1270,HCPCS,0272,RC,,,,both,,,234.65,152.52,,,,,,,,,,,,,
HC Rh With Coron With Graft Nolv,PX-4819345700,CDM,93457,CPT,0481,RC,,,,inpatient,,,17800.00,11570.00,,,,,,,,,,,,,
GUIDEWIRE VASC REGATTA + L 195 CM DIA 0.014 IN DSTL TIP L 3,SUP-2154112,CDM,C1769,HCPCS,0272,RC,,,,both,,,225.30,146.44,,,,,,,,,,,,,
PLATE BNE LCK 3.5X105 MM 8 HOLE CNTOUR 2 COMPR SS STRL,SUP-2495934,CDM,C1713,HCPCS,0278,RC,,,,both,,,972.87,632.37,,,,,,,,,,,,,
PLATE BNE SM LT MEDL CLMN FUSION STRATUM,SUP-2497933,CDM,C1713,HCPCS,0278,RC,,,,both,,,6539.55,4250.71,,,,,,,,,,,,,
CER OPTION 12/14 TPR SLEEVE +7,SUP-2510213,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
HC Trim Nondystrophic Nails,PX-3611171900,CDM,11719,CPT,0361,RC,,,,outpatient,,,195.00,126.75,,,,,,,,,,,,,
AGENT VISCOELASTIC 8.5ML CLR POLYDIMETHYLSILOXANE RETIN,SUP-2109825,CDM,C1814,HCPCS,0278,RC,,,,both,,,1488.93,967.80,,,,,,,,,,,,,
DRESSING WND 3 LAYR 10X15 CM MTRX CYTAL,SUP-2106530,CDM,Q4166,HCPCS,0636,RC,,,,both,,,11564.62,7517.00,,,,,,,,,,,,,
CIPROFLOXACIN HCL 500 MG PO TABS,RX-25119,CDM,6370000000,HCPCS,0637,RC,60687-0860-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BASEPLATE GLEN OD25MM 15DEG HALF WDG AUG REVERSED AEQUALIS,SUP-2388802,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
MICROCATHETER VASC PROXIMAL/DST 3/2.8FR L150CM LUMN,SUP-2147591,CDM,C1887,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
SCREW SPNL L15MM DIA4.5MM CANC ANT CERV TI ALLY SELF DRL,SUP-2291140,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER EP DIAG MAP HISSER CRV QPLR 5MM SPC 1MM TIP UNI IBI81483] ST JUDE MEDICAL INC],SUP-2357638,CDM,C1730,HCPCS,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
SYSTEM BX L114MM DIA1.9MM COR PROPRIETARY BLDE DSGN FOR,SUP-2281537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1579.42,1026.62,,,,,,,,,,,,,
PACKING NSL W2.4XL4CM THK0.3CMXEROGEL 8 PER BX,SUP-2217804,CDM,C1713,HCPCS,0278,RC,,,,both,,,510.25,331.66,,,,,,,,,,,,,
CATHETER HD STR 16 FRX24 CM LT SET W/ 2 STYL SPLIT CATH III,SUP-2627106,CDM,C1750,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BONE SM L25MM 3 H S STL STR ECT,SUP-2198581,CDM,C1713,HCPCS,0278,RC,,,,both,,,215.47,140.06,,,,,,,,,,,,,
GRAFT BONE 16X20MM DWL HUM TISS CANC CORT FRZN TISS MDII,SUP-2293890,CDM,C1713,HCPCS,0278,RC,,,,both,,,11278.88,7331.27,,,,,,,,,,,,,
KIT INFUS PMP 270ML 4ML/HR 2ML/SITE SOAK CATH L5IN N NARC,SUP-2236835,CDM,C9804,HCPCS,0272,RC,,,,both,,,558.48,363.01,,,,,,,,,,,,,
LCCK 0D SZ4 5MM 46X34 CPL,SUP-2502174,CDM,C1776,CPT,0278,RC,,,,both,,,12095.28,7861.93,,,,,,,,,,,,,
NEEDLE VENTRICULAR DERRICO 12 GAX3.75 IN 1 HOLE LUER LCK HUB,SUP-2666381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.38,673.00,,,,,,,,,,,,,
KIT AORT VLV SAPIEN 3 ULTRA RESILIA DIA29 MM BOV PERICARD,SUP-2882185,CDM,C1889,HCPCS,0278,RC,,,,both,,,106760.00,69394.00,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS 5 L 135 CM DIA 3 FR,SUP-2884934,CDM,C1887,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC Nasotracheal Catheter Aspiration,PX-7613172000,CDM,31720,CPT,0761,RC,,,,inpatient,,,99.00,64.35,,,,,,,,,,,,,
PLATE BNE 3X8 H ST S STL T SHP LOK COMPR W SHT THRD DRL GUID,SUP-2177476,CDM,C1713,HCPCS,0278,RC,,,,both,,,1448.89,941.78,,,,,,,,,,,,,
GUIDEWIRE ORTH SHT 115 MM 47 IN MARKER NIT CORAL,SUP-2707642,CDM,C1769,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
REAMER SURG 27MM CALIB TENFUSE,SUP-2401437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
PLUG ANCHR OD10MM STD COMPR,SUP-2406886,CDM,C1713,HCPCS,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
BIT DRL COUNTSINK 7 MM,SUP-2315924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
PACEMAKER CARD 23GM 12.81CC W52XH52MM THK6MM SGL CHMBR IS-1,SUP-2356452,CDM,C1786,HCPCS,0275,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 8 MM RNG L 30 CM EPTFE,SUP-2396302,CDM,C1768,CPT,0278,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
GUIDEWIRE UROLOGY L145CM OD0.038IN TIP L3CM S STL PTFE STR,SUP-2171181,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
SPLINT THMB M L5IN SH RT 1 STRP THERMOPLASTIC INSRT,SUP-2324196,CDM,L3931,HCPCS,0274,RC,,,,both,,,42.23,27.45,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.014 IN ENDOVASC ANEUR REP TEDV,SUP-2217587,CDM,C1769,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE L 163 X W 115 MM THK 0.6 MM SCREW DIA1.5 MM TI CMF,SUP-2883885,CDM,C1713,HCPCS,0278,RC,,,,both,,,6254.88,4065.67,,,,,,,,,,,,,
HC Rem/Repl Int Uret Stent,PX-3615038200,CDM,50382,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 -1 Visit (Bulk Charge for 45 Visits),PX-9900000116,CDM,9900000116,LOCAL,0990,RC,,,,both,,,225.00,146.25,,,,,,,,,,,,,
PLATE SPNL LUM LOK AVS ANCHOR L,SUP-2363037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
HC So Bartonella Henselae,PX-3028661166,CDM,86611,CPT,0302,RC,,,,both,,,62.00,40.30,,,,,,,,,,,,,
KIT KYPHOPLASTY L 15 MM DIA13 GA VERT AUG INFLATABLE SYS,SUP-2930269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4777.51,3105.38,,,,,,,,,,,,,
CROWN FORM DENT STRP U1 PRIMARY ANTR UPPER LT LAT PLAS,SUP-2322245,CDM,D6783,CPT,0278,RC,,,,both,,,31.90,20.73,,,,,,,,,,,,,
TUBE FEED 14FR BLLN 7-10ML L45CM JEJU SIL INFL INT SECUR,SUP-2124594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.26,277.07,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE LG SHT ANK ROCKER BTM INLINE,SUP-2336133,CDM,L4361,HCPCS,0274,RC,,,,both,,,99.85,64.90,,,,,,,,,,,,,
BUR SURG DIA 5 MM HUB II CONE STRL REUSE HI-LINE,SUP-2929248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.87,297.62,,,,,,,,,,,,,
PLATE BNE L 246 MM SCREW DIA 3.5/4.5 MM 10 H UTIL STRL EVOS,SUP-2933713,CDM,C1713,HCPCS,0278,RC,,,,both,,,16708.73,10860.67,,,,,,,,,,,,,
TIP SACROCOLPOPEXY LARGE,SUP-2719538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE H1MM 90DEG REG MINI 6 H T CRANIOMAXILLOFACIAL FOR,SUP-2366325,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.78,327.46,,,,,,,,,,,,,
OCCLUDER CV AMPLATZER TALISMAN ATR DISC DIA R/L 25/18 MM,SUP-2716345,CDM,C1817,HCPCS,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.4MM CORT MAND TI ST NONCANNULATED,SUP-2189414,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
PLATE BONE 7 H LT FIBULAR ANAT FOR ANK FX GORILLA,SUP-2321561,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
WASHER ORTH FOR 2 MM CANN SCREW NS DISP,SUP-2908291,CDM,C1713,HCPCS,0278,RC,,,,both,,,129.96,84.47,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 3.01-4.0 MCI STRL ADVANTAGE 2029DLS1] ISOAID LLC],SUP-2247266,CDM,C2640,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR (MIXTURES ONLY),RX-430072,CDM,J2919,HCPCS,0636,RC,00009-0047-26,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
KIT ENDOSCP HIP DRL DRL GUID OBT DISP FOR 1.8MM Q-FIX,SUP-2342829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.01,354.26,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.049 INX150 MM TI MAG KIRSCHNER,SUP-2476935,CDM,C1713,HCPCS,0278,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
GUIDE PIN SL SHT 30 MM FOR AG FEM NAT NAIL SYS,SUP-2198663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1097.05,713.08,,,,,,,,,,,,,
SCREW LCKNG MATRIXRIB TI SLF DRL 2.7X11MM,SUP-2752103,CDM,C1713,HCPCS,0278,RC,,,,both,,,843.09,548.01,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC DBM CORTICAL FIBER XCITE -RSFH,SUP-2881406,CDM,C1713,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
HC Sternum Min 2 Views,PX-3207112000,CDM,71120,CPT,0320,RC,,,,both,,,668.00,434.20,,,,,,,,,,,,,
PLATE VARIAX COMP 7HL 91MM,SUP-2695726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1819.94,1182.96,,,,,,,,,,,,,
PLATE QUIKFLAP 3X2 SD AXS,SUP-2718051,CDM,C1713,HCPCS,0278,RC,,,,both,,,6550.04,4257.53,,,,,,,,,,,,,
GRAFT HUM TISS W18XL30MM THK18MM FRZ DRY ALLGRFT BLK CANC,SUP-2307116,CDM,C1713,HCPCS,0278,RC,,,,both,,,3052.49,1984.12,,,,,,,,,,,,,
HOOK SUT STR FOR ORIG SPECTRM,SUP-2166878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.33,555.31,,,,,,,,,,,,,
DRIVER PIN CIR FIX SQ END FRDM SIDEKCK,SUP-2400682,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
FIXATOR BNE PLT ORTH AO FIT TEMP,SUP-2378029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
GRAFT HUM TISS L 35-48 X W 10 MM TIB BLOCK L 23 X W 10 MM,SUP-2913225,CDM,C1762,CPT,0278,RC,,,,both,,,13304.18,8647.72,,,,,,,,,,,,,
PLATE BNE SM TI L CALCNL LOK,SUP-2106920,CDM,C1713,HCPCS,0278,RC,,,,both,,,7162.34,4655.52,,,,,,,,,,,,,
BUR DENT NO 369/025 FOOTBALL COARSE FRIC GRP MAXIMA DMND,SUP-2238963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,137.94,89.66,,,,,,,,,,,,,
LEAD PACE L86CM 7.5CM ELECTRD SPACE L VENT QPLR TINES 3D,SUP-2148718,CDM,C1900,HCPCS,0275,RC,,,,both,,,4816.76,3130.89,,,,,,,,,,,,,
BUR SURG OD7MM DMND ST CRNRSTN MAESTRO,SUP-2363370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,PX-3606444600,CDM,64446,CPT,0360,RC,,,RT|XU,both,,,2895.00,1881.75,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM 2-5-2MM SPC 8MM TIP 1MM BND QPLR,SUP-2357037,CDM,C1733,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
WEDGE HEEL 3/4 2.5X9/16 HAPAD,SUP-2325445,CDM,L3350,HCPCS,0272,RC,,,,both,,,12.91,8.39,,,,,,,,,,,,,
BUR SURG TAPR 2.4 MMX16 CM MIDAS REX LEGEND,SUP-2627869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.68,216.24,,,,,,,,,,,,,
PLATE BONE LNG RT LAT CLAVICULAR,SUP-2399401,CDM,C1713,HCPCS,0278,RC,,,,both,,,5799.58,3769.73,,,,,,,,,,,,,
PLATE BNE 2.7X84 MM 10 HOLE SS DCP,SUP-2569132,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.58,215.53,,,,,,,,,,,,,
TRANEXAMIC ACID 2000 MG IN 250 ML NS (PREMIX) IVPB,RX-4082739,CDM,2500000003,HCPCS,0250,RC,09999-9919-28,NDC,,both,250,ML,1395.90,907.33,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 23 CM DIA 6 FR 0.018 IN NIT 7CM 21 GA,SUP-2677276,CDM,C1894,HCPCS,0272,RC,,,,both,,,168.18,109.32,,,,,,,,,,,,,
ANCHOR SUT HIP LEN INSRTR KNOTLESS BIORAPTOR,SUP-2341829,CDM,C1713,HCPCS,0278,RC,,,,both,,,1305.61,848.65,,,,,,,,,,,,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT,RX-856,CDM,6370000000,HCPCS,0637,RC,24208-0555-55,NDC,,both,3.5,GR,103.20,67.08,,,,,,,,,,,,,
TROCAR ENDOSCP SHFT L100MM DIA8MM TEAL BLDELSS W/ STBL,SUP-2218796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
CATHETER PI PICC KIT 3-L 6 FR X 55 CM TIPTRACKER,SUP-2655668,CDM,C1751,HCPCS,0278,RC,,,,both,,,733.72,476.92,,,,,,,,,,,,,
INSTRUMENT TRAY SONICPIN SONICFUSION,SUP-2486460,CDM,C1713,HCPCS,0278,RC,,,,both,,,2396.70,1557.85,,,,,,,,,,,,,
SCREW BNE L 36 MM DIA 4.5 MM TI ST SD CANN SHRT THRD COMPR,SUP-2912868,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
STENT LACR DUCT M COLLARETTE W3MM SIL S STL TIP,SUP-2224379,CDM,C1783,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
OBTURATOR SHTH L 15 CM DIA 4 FR LL STRL,SUP-2355468,CDM,C1894,HCPCS,0272,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
HC Debrid Wound Tis 20 Cm/<|PBB CHARGE,PX-7619759700,CDM,97597,CPT,0761,RC,,,PBB,both,,,583.00,378.95,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 111 MM DIA22 MM SHTH 18 FR RVD,SUP-2170609,CDM,C1889,HCPCS,0278,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA11 MM DEL SHTH,SUP-2934482,CDM,C1713,HCPCS,0278,RC,,,,both,,,13100.08,8515.05,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 4 HOLES 75MM,SUP-2549504,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.83,657.04,,,,,,,,,,,,,
RESERVOIR SHUNT BURR HOLE 6.4X0.8 MM XR DETECTABLE SIDE,SUP-2851487,CDM,C1889,HCPCS,0278,RC,,,,both,,,619.74,402.83,,,,,,,,,,,,,
POTASSIUM CHLORIDE ER 10 MEQ PO CPCR,RX-13644,CDM,6370000000,HCPCS,0637,RC,50268-0671-11,NDC,,both,1,UN,4.40,2.86,,,,,,,,,,,,,
MESH BIO ALLOMAX 3INX6INMESH BIO ALLO,SUP-2849864,CDM,C1762,CPT,0278,RC,,,,both,,,8155.84,5301.30,,,,,,,,,,,,,
BASEPLATE TIB SZ 5 THK11MM R POLYETH CRUCE RET CEM PRI STEM,SUP-2345922,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BONE THK0.9MM OFFSET 0MM 10 H LT MAX ORAL,SUP-2191114,CDM,C1713,HCPCS,0278,RC,,,,both,,,1571.57,1021.52,,,,,,,,,,,,,
STERILE DRILL BOLD DIA3 2IN1 L32MM AO NON CANULATED,SUP-2586517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.40,483.21,,,,,,,,,,,,,
PLATE BNE THK 0.3 MM SCREW DIA1.5 MM MED TI ORBIT FLR PREFRM,SUP-2883810,CDM,C1713,HCPCS,0278,RC,,,,both,,,2210.56,1436.86,,,,,,,,,,,,,
PLATE BNE L146MM BLDE W4.8XL25MM 95DEG 8 H NONSTERILE HIP S,SUP-2186771,CDM,C1713,HCPCS,0278,RC,,,,both,,,2732.02,1775.81,,,,,,,,,,,,,
STEM HUM UNIV STD L122MM DIA13MM SHLDR CO CHROM PRI CEM,SUP-2404595,CDM,C1776,CPT,0278,RC,,,,both,,,12738.98,8280.34,,,,,,,,,,,,,
VALVE HEMOSTAS MBA DIA 9 FR POLYCARB SIL Y LG BOR STRL,SUP-2303050,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.26,44.37,,,,,,,,,,,,,
PACEMAKER CARD STRATOS LT VENTRICULAR 2 CHMBR STRL,SUP-2138183,CDM,C2621,HCPCS,0275,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
COLLAR CERV PHILLY SM 4.25 IN 10-13 IN REHAB FOAM PROCARE,SUP-2196878,CDM,L0180,HCPCS,0272,RC,,,,both,,,35.67,23.19,,,,,,,,,,,,,
COMPONENT ULN XSM L4.5IN L EL TIV PLSM INTERCHANGEABLE CEM,SUP-2205945,CDM,C1776,CPT,0278,RC,,,,both,,,14823.16,9635.05,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 8 MM THK 0.49 MM POLYESTER,SUP-2462139,CDM,C1768,CPT,0278,RC,,,,both,,,1785.12,1160.33,,,,,,,,,,,,,
ROD ORTH THRD 75 MM PILLAR,SUP-2749917,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1544.88,1004.17,,,,,,,,,,,,,
SPACER FEM SM THK5MM L MED DST DURAC,SUP-2377192,CDM,C1776,CPT,0278,RC,,,,both,,,2362.54,1535.65,,,,,,,,,,,,,
PORT LAP DIA5MM CANN OBT SFT FLX SILS,SUP-2283386,CDM,C1713,HCPCS,0278,RC,,,,both,,,1059.72,688.82,,,,,,,,,,,,,
HC Irrigation of Vad - Only,PX-7619652300,CDM,96523,CPT,0761,RC,,,,both,,,265.00,172.25,,,,,,,,,,,,,
GRAFT BNE L TRICORT BLK FOR OSTEOTMY ALLOPURE,SUP-2400551,CDM,C1762,CPT,0278,RC,,,,both,,,6369.77,4140.35,,,,,,,,,,,,,
SPACER SPNL W18XH8XL55MM PEEK ANTR CERV INTBDY FUS,SUP-2311622,CDM,C1821,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ITREVIA VR-T W 55 X H 65 MM D 11 MM 33 CC,SUP-2138374,CDM,C1722,HCPCS,0275,RC,,,,both,,,33707.90,21910.13,,,,,,,,,,,,,
HC Indwelling Catheter,PX-4505170200,CDM,51702,CPT,0450,RC,,,,inpatient,,,204.00,132.60,,,,,,,,,,,,,
GUIDEWIRE SURG 3X980 MM W/O OLV,SUP-2315997,CDM,C1769,HCPCS,0272,RC,,,,both,,,320.03,208.02,,,,,,,,,,,,,
TWINFIX TI 5.0 (2) USP #2,SUP-2341587,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.77,359.95,,,,,,,,,,,,,
CAGE SPNL MED 24 DEG 16 MM DIVERGENCE-L,SUP-2422248,CDM,C1889,HCPCS,0278,RC,,,,both,,,16365.68,10637.69,,,,,,,,,,,,,
CATHETER ADM050300130L ADM US 05L300 UL1300,SUP-2715866,CDM,C1725,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GUIDE SURG DRL UNIV FOR EXTREMITIES STRL DISP,SUP-2882999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SCREW BNE L45MM DIA5.5MM FT ANK HDLSS COMPR SYS ACUTRK 2,SUP-2106630,CDM,C1713,HCPCS,0278,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
HC Remote Afterload Brachy >12,PX-3337777200,CDM,77772,CPT,0333,RC,,,,both,,,5584.00,3629.60,,,,,,,,,,,,,
BRACE ORTHOPEDIC ADJ SAG RIGID PANEL PREFABRICATED LO,SUP-2124234,CDM,L1810,HCPCS,0274,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
GUIDEPIN ORTH L330MM DIA3.2MM TRCR TIP DISP,SUP-2312267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
PLATE BNE LP 1 MM NEURO 4X2 HOLE LADDER SQ SEG FOR SCR TI NS,SUP-2470479,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.09,199.61,,,,,,,,,,,,,
HC So Prothrombin Time,PX-3058561066,CDM,85610,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
GRAFT BNE SUB 15ML 25GM SYN TISS PSTE CA PHSPTE HA RESRB,SUP-2374937,CDM,C1713,HCPCS,0278,RC,,,,both,,,6886.02,4475.91,,,,,,,,,,,,,
CONTROLLER NEUROSTIMULATOR HND HELD PRGMR WIRELESS PTM FOR,SUP-2284642,CDM,C1787,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
BLADE MONOPOLAR SERRATED 0-40 DEG 4 MM MALL STRL DISP,SUP-2638416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.87,356.77,,,,,,,,,,,,,
BUR SURG M L25MM DIA0.8MM DMND HD NONFLUTED TPS,SUP-2367475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.27,236.78,,,,,,,,,,,,,
PROBE GUID HUM DRL SURESHOT,SUP-2340920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1681.28,1092.83,,,,,,,,,,,,,
ANCHOR SUT DIA5MM BIOZIP PLLA TWO STRND FORC FBR SEP CHN,SUP-2366665,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
GRAFT ENDOPROS L3.3CM DIA26MM ID22-23MM AORT EXT EXCLUDER,SUP-2395891,CDM,C1768,CPT,0278,RC,,,,both,,,9432.56,6131.16,,,,,,,,,,,,,
SET URET STENT UNIVERSA L 26 CM DIA 6 FR HYDRPHLC SFT,SUP-2171330,CDM,C2617,HCPCS,0278,RC,,,,both,,,523.12,340.03,,,,,,,,,,,,,
PLATE FIX ORTHO LCP 4.5MM 2HL 44MM,SUP-2185227,CDM,C1713,HCPCS,0278,RC,,,,both,,,871.70,566.60,,,,,,,,,,,,,
CATHETER ETER CTRL VEN OD7FR 3 LUMN COMP,SUP-2120646,CDM,C1751,HCPCS,0278,RC,,,,both,,,107.39,69.80,,,,,,,,,,,,,
STENT CAR L20MM DIA6MM CATH L135CM SHTH DIA6FR GWIRE,SUP-2173464,CDM,C1876,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
CATHETER PICC ARROW TAPERFREE 6FR 55CM 3-LUMEN,SUP-2887056,CDM,C1751,HCPCS,0278,RC,,,,both,,,780.82,507.53,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ACHILLES TEND BNE BLOCK,SUP-2264668,CDM,C1762,CPT,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
BOLT EXT FIX 20 MM MP,SUP-2471481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
TITANIUM MESH PANEL ROUND CNTRD 45MM DIA 6MM 15MM SSTM CP,SUP-2676588,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.97,1551.53,,,,,,,,,,,,,
KETAMINE HCL-SODIUM CHLORIDE 50-0.9 MG/5ML-% IJ SOSY,RX-151965,CDM,2500000003,HCPCS,0250,RC,70004-0430-09,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.37XH8.08CM D0.99CM IS-1 DF-1 CONN,SUP-2149206,CDM,C1882,HCPCS,0275,RC,,,,both,,,52883.88,34374.52,,,,,,,,,,,,,
NAIL IM L340MM OD11MM LIME TI LT INTERTROCHANTERIC FEM AG,SUP-2205959,CDM,C1713,HCPCS,0278,RC,,,,both,,,12755.97,8291.38,,,,,,,,,,,,,
GRAFT STR STD WALL N RING POLY KNIT RADIALLY 8MM DIA 70CM,SUP-2227575,CDM,C1768,CPT,0278,RC,,,,both,,,2882.68,1873.74,,,,,,,,,,,,,
COMPONENT HUM 80MM SHLDR PROX REV MOD MOSAIC,SUP-2403499,CDM,C1776,CPT,0278,RC,,,,both,,,15878.98,10321.34,,,,,,,,,,,,,
DRILL SURG DIA2MM SH AO QUIK CPL VLP MINI-MOD,SUP-2344067,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.39,405.85,,,,,,,,,,,,,
K WIRE FIX DIA1.6MM S STL FOR DST VOLAR PLATING SYS,SUP-2414095,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.15,37.80,,,,,,,,,,,,,
SCREW BNE CEPHALIC 10.5X80 MM EBA 1,SUP-2719839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1626.52,1057.24,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED K2 HYBRID POROUS CAPZIMMERK2] ZIMMER BIOMET INC],SUP-2212501,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
BIT DRL L L280MM DIA15MM TI CANN OPN MDLLRY CNL FLX QUIK,SUP-2178840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1459.41,948.62,,,,,,,,,,,,,
WASHER ORTH COMPR 6.5 MM HD SCR RIVAL,SUP-2645125,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
BIT DRL L14MM DIA2.2MM G FLAT CHK FOR ANT CERV PLT SYS,SUP-2255671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
FIXATION KIT SFT TISS STD STRL TENOTAC,SUP-2749804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
PLATE BNE TALUS 2 MET LNG 1.5 MM LT CNTRL CLMN,SUP-2751049,CDM,C1713,HCPCS,0278,RC,,,,both,,,5517.77,3586.55,,,,,,,,,,,,,
BOLT EXT FIX SLT WIRE DISP RINGFIX,SUP-2378775,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.21,108.69,,,,,,,,,,,,,
PLATE BNE W13.5XL106MM THK4.2MM 6 H BILAT S STL NAR LIMIT,SUP-2185235,CDM,C1713,HCPCS,0278,RC,,,,both,,,1082.95,703.92,,,,,,,,,,,,,
BUR SURG DIA06MM BLU WHT DMND NONFLUTED RND SKEETER,SUP-2278155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.94,446.51,,,,,,,,,,,,,
SUPPORT ORTHOT CUST SOLE WDG BTWN,SUP-2435723,CDM,L3370,HCPCS,0272,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
SHEATH INTRO FLX L 13 CM OD 9 FR ID 3.2 MM GUIDEWIRE 0.038,SUP-2168276,CDM,C1894,HCPCS,0272,RC,,,,both,,,153.83,99.99,,,,,,,,,,,,,
SCREW BNE CORTICAL 4.5X62 MM SS,SUP-2198224,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
TAP SURG 3.5MM STD THRD MTL TIP SYM,SUP-2433921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
DRILL 4.5MM FOR 5.5MM ANCHR SL,SUP-2419009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
HC I&D Abcess Complic Multiple,PX-7611006100,CDM,10061,CPT,0761,RC,,,,both,,,1233.00,801.45,,,,,,,,,,,,,
HC Ecmo/Eclx Initiation Veno-Venous,PX-3603394600,CDM,33946,CPT,0360,RC,,,,both,,,37949.00,24666.85,,,,,,,,,,,,,
PLATE BNE L 76 MM 7 H RT VOLAR DSTL RADIAL WIDE NS VARIAX,SUP-2902168,CDM,C1713,HCPCS,0278,RC,,,,both,,,5198.40,3378.96,,,,,,,,,,,,,
NEEDLE INTRO 10GA L9IN BVL TIP MTCH GRND W/O SYR N RADPQ ACM,SUP-2366867,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
MESH BIO W10XL16CM BOV PERICARD NONCROSSLINKED CLLGN MTRX,SUP-2130832,CDM,C9354,HCPCS,0278,RC,,,,both,,,12046.80,7830.42,,,,,,,,,,,,,
GABAPENTIN 300 MG PO CAPS,RX-18308,CDM,6370000000,HCPCS,0637,RC,16714-0662-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GENII CONST ART ISRT SZ7-8 9MM,SUP-2827846,CDM,C1776,CPT,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
SCREW BNE L32MM DIA4.5MM S STL CORT HIP ST NONCANNULATED,SUP-2343706,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.63,111.56,,,,,,,,,,,,,
PLATE BNE L31MM 4 H S STL 1 4TH TBLR W/ CLLR FOR 2.7MM SCR,SUP-2186032,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.67,303.99,,,,,,,,,,,,,
PLATE BNE 6 H ULN SHORTNG,SUP-2107842,CDM,C1713,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
MESH SURG L 20 X W 15 CM POLYPRO POLYLACTIC ACD GRP,SUP-2901749,CDM,C1781,HCPCS,0278,RC,,,,both,,,2447.69,1591.00,,,,,,,,,,,,,
WEDGE TIB SZ 5-6 5MM L MED R LAT KNEE HEMI STP SCR ON,SUP-2346179,CDM,C1776,CPT,0278,RC,,,,both,,,4147.16,2695.65,,,,,,,,,,,,,
GRAFT BNE SUB 10ML DEMIN BNE MTRX PSTE FRZ DRY DBX,SUP-2306992,CDM,C1713,HCPCS,0278,RC,,,,both,,,3821.85,2484.20,,,,,,,,,,,,,
IMPLANT SYNTH L 50 X W 25 MM THK 6 MM POLYETHYL CRANIOFACIAL,SUP-2883603,CDM,C1713,HCPCS,0278,RC,,,,both,,,2948.33,1916.41,,,,,,,,,,,,,
VALVE SHUNT L23.7MM 20CM H2O PRSS TI 2 CONN GRAVITATIONAL,SUP-2108716,CDM,C1889,HCPCS,0278,RC,,,,both,,,4341.65,2822.07,,,,,,,,,,,,,
HC Remove Impacted Cerumen,PX-4506921000,CDM,69210,CPT,0450,RC,,,,both,,,195.00,126.75,,,,,,,,,,,,,
CATHETER INFUS 2.1-1.3FR L167CM ID0.0165IN MIC STR 2 MRK,SUP-2305459,CDM,C1887,HCPCS,0272,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
GRAFT HUM TISS SM 30X60MM <4400MM FASC LATA FRZ DRY,SUP-2264781,CDM,C1762,CPT,0278,RC,,,,both,,,2400.18,1560.12,,,,,,,,,,,,,
SHELL ACET DIA58MM GRP G BIOFOAM TI MTL FOAM HIP PRESSFIT,SUP-2304549,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
SYSTEM LAP W/ GELSEAL CAP ALEXIS WND PROTECTOR/RETRACTOR,SUP-2119637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
NUT SPNL ANT TI FIX VANTAGE,SUP-2292684,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
ROD SPNL CRV 5.5X70 MM TSRH CHROMALOY +,SUP-2627764,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SCREW BNE SET 4 MM CANN 1/3 THRD EXT TAB,SUP-2861013,CDM,C1713,HCPCS,0278,RC,,,,both,,,20181.41,13117.92,,,,,,,,,,,,,
FIBER LASER KIT NEURO OMNIGUIDE,SUP-2225630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
SPACER SPINE PARA PEEK 23MM 31MMH 12MMW 8DEG ABBT SPINE,SUP-2416031,CDM,C1713,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
JIG SURG LT TIB KNEE AREF ROT PT SPEC DISP PERSONA,SUP-2205588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
IMPLANT FNGR JT 20 SIL PYROCARBON TRANSFORMING EXTREMITIES,SUP-2123858,CDM,C1776,CPT,0278,RC,,,,both,,,5667.70,3684.00,,,,,,,,,,,,,
HC So Lyme Disease Ab by Westrn Blot,PX-3028661766,CDM,86617,CPT,0302,RC,,,,both,,,75.00,48.75,,,,,,,,,,,,,
NAIL IM ZCKL II SUBTROCHANTERIC 17MMX400MM ROD LT,SUP-2364774,CDM,C1713,HCPCS,0278,RC,,,,both,,,4717.22,3066.19,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.6 MM PARALLEL MIS,SUP-2897200,CDM,C1769,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 9.5 CM FLPY TIP L,SUP-2168541,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.32,34.66,,,,,,,,,,,,,
PLATE BNE L37MM THK3.3MM 3 H BILAT S STL RIG STR DYN COMPR,SUP-2186327,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.52,330.54,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 4",PX-7619920400,CDM,99204,CPT,0761,RC,,,,inpatient,,,344.00,223.60,,,,,,,,,,,,,
PLATE BNE L CORONOID H FOR K WIRE OFFSET LOK SCR,SUP-2107074,CDM,C1713,HCPCS,0278,RC,,,,both,,,4593.82,2985.98,,,,,,,,,,,,,
SET HAD CATH 40CMX15.5FR LNG TERM STR W/ SIDE H HI DENS,SUP-2267099,CDM,C1881,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE THK2MM 26 H TI L LOK ANG MINI FOR 23MM SCR,SUP-2262973,CDM,C1713,HCPCS,0278,RC,,,,both,,,5034.93,3272.70,,,,,,,,,,,,,
HANDPIECE BREAST BIOPSY 9GA 14CML 3.7MML W/MR PETITE,SUP-2239992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2 MM RECON MAXILLA PT SPEC,SUP-2860087,CDM,C1713,HCPCS,0278,RC,,,,both,,,28448.71,18491.66,,,,,,,,,,,,,
HC So1 Infectious Agent Ab Quant,PX-3028631767,CDM,86317,CPT,0302,RC,,,,outpatient,,,44.00,28.60,,,,,,,,,,,,,
INSTRUMENT SET 3 MM SPHR FEM GMK,SUP-2267695,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 018 IN 5 FRX55 CM 135 CM POWERPICC,SUP-2126371,CDM,C1751,HCPCS,0278,RC,,,,both,,,318.24,206.86,,,,,,,,,,,,,
STAPLE CARTRIDGE STR 13X10 MM TI,SUP-2166804,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE L156MM THK37MM 12 H R J S STL LO PROF RIG RECON,SUP-2177161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2558.85,1663.25,,,,,,,,,,,,,
SCREW BNE GHST LONGITUDE II,SUP-2630464,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.62,224.00,,,,,,,,,,,,,
LEAD DEFIB LUMAX 300 2 COIL,SUP-2138118,CDM,C1721,HCPCS,0275,RC,,,,both,,,63921.01,41548.66,,,,,,,,,,,,,
KIT REVISION GRAFT BONE DOWEL 13 MM,SUP-2836345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HEAD FEM MOD 4- MM SHT 42 MM HIP BIRMINGHAM HIPTM RESURF,SUP-2435178,CDM,C1776,CPT,0278,RC,,,,both,,,10437.36,6784.28,,,,,,,,,,,,,
BLADE SURG ULTRA AGGRESSIVE XL 4.2 MM + STRL FMS VUE DISP,SUP-2624800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
KIT INTRO 9FR L13CM DIA0.118IN SPLITTABLE HEMSTAT ROBUST,SUP-2302497,CDM,C1892,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
COMPONENT STEPTECH APG 44+5MM RIGHT,SUP-2512728,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW SPNL L16MM DIA4.5MM CANC ANTR CERV TI ST LCK VAR ANG,SUP-2254603,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT GRAFT 2.5MM X 5MM SLIM-LINE,SUP-2849023,CDM,C1889,HCPCS,0278,RC,,,,both,,,1376.14,894.49,,,,,,,,,,,,,
HC Blood Administration,PX-3913643000,CDM,36430,CPT,0391,RC,,,,both,,,1574.00,1023.10,,,,,,,,,,,,,
SYSTEM FLD MGMT PRSS MON AND RESECT SYMPHION REUSE,SUP-2865688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
KIT PEG BEND 90 DEG DIA20 FR POLYUR CATH DOBBHOFF TIP SAFETY,SUP-2927549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.61,252.60,,,,,,,,,,,,,
OSTEOTOME SURG L93MM DIA12MM FLX ERGO HNDL CANN TREPH GRY,SUP-2375017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1136.05,738.43,,,,,,,,,,,,,
LOOP DISTR SLDBLE F/RTNTN PLATE 51 582 51/RGD EXTRNL DISTR D,SUP-2491472,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.03,357.52,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT MAXBARR 5FR 0.026IN 55CM 2 7927508D,SUP-2632687,CDM,C1751,HCPCS,0278,RC,,,,both,,,501.77,326.15,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CA PHSPTE HYALURONIC ACID CEM VOID FILL,SUP-2378763,CDM,C1713,HCPCS,0278,RC,,,,both,,,15645.36,10169.48,,,,,,,,,,,,,
PLATE BNE L210MM 15 H ST L ANTLAT DST TIB S STL LO PROF,SUP-2185965,CDM,C1713,HCPCS,0278,RC,,,,both,,,4660.45,3029.29,,,,,,,,,,,,,
SCREW BNE SET 3.5 MM CANN PART THRD EXT TAB,SUP-2861012,CDM,C1713,HCPCS,0278,RC,,,,both,,,20103.79,13067.46,,,,,,,,,,,,,
PLATE BNE 5X12 H ST BILAT MIDFOOT S STL LO PROF VAR ANG LOK,SUP-2178381,CDM,C1713,HCPCS,0278,RC,,,,both,,,5659.22,3678.49,,,,,,,,,,,,,
TRAY TIB L59MM KNEE TI ALLOY PRI CRUC RET POST STBL,SUP-2405402,CDM,C1776,CPT,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
ALLOGRAFT BNE SM 40-65 MM FD IRRADIATED CORTICAL SEG,SUP-2866970,CDM,C1762,CPT,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 135 CM BALLOON L 80 MM DIA 5 MM SHTH 6,SUP-2892911,CDM,C2623,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SCREW BNE L65MM DIA4.5MM THRD L30MM HD DIA8MM MALL S STL,SUP-2184557,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.87,45.42,,,,,,,,,,,,,
PLATE BNE 1 H TI ALPHA LOCKED REV MAXLOCK EXTRM LPS,SUP-2400379,CDM,C1713,HCPCS,0278,RC,,,,both,,,3064.64,1992.02,,,,,,,,,,,,,
ENDO FUSE  FUSION ROD 3 X 50MM,SUP-2464055,CDM,C1713,HCPCS,0278,RC,,,,both,,,4016.06,2610.44,,,,,,,,,,,,,
EXPANDER BRST 650CC W14.6XH12.6CM P7.6CM M HT CNTOUR PROF,SUP-2300698,CDM,C1789,HCPCS,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
HC Ot Group Therapy|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309715000,CDM,97150,CPT,0430,RC,,,GO|CO,outpatient,,,135.00,87.75,,,,,,,,,,,,,
SCREW BNE HDLSS SHT THRD 3.5X14 MM CANN MINI-MONSTER,SUP-2320899,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.02,550.56,,,,,,,,,,,,,
CATHETER THOR 36FR L23CM DIA12MM POLYVI CHL TAPR CONN TIP,SUP-2227434,CDM,C1729,HCPCS,0272,RC,,,,both,,,21.29,13.84,,,,,,,,,,,,,
TRUESPAN MENIS REP SYS PLGA 12 DEG ORTHOCORD VIO BRAID COMP,SUP-2256750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2254.52,1465.44,,,,,,,,,,,,,
BUR SURG L7CM HD L61MM DIA64MM REV TAPR L BOR MIDAS REX,SUP-2277725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.45,244.69,,,,,,,,,,,,,
DILATOR VES 5FR L20CM 0038FT,SUP-2301453,CDM,C1769,HCPCS,0272,RC,,,,both,,,16.33,10.61,,,,,,,,,,,,,
SYSTEM CATH INFSN 4FR DIA 135CML PEBAX OCCLDNG WIRE ACCSSPLS,SUP-2677052,CDM,C1751,HCPCS,0278,RC,,,,both,,,151.19,98.27,,,,,,,,,,,,,
PAD ORTHOT CERV THOR LUMBAR SACR CUST KYPHOSIS FLOATING,SUP-2435572,CDM,L1025,HCPCS,0272,RC,,,,both,,,440.17,286.11,,,,,,,,,,,,,
SCREW BNE L70MM L32MM OD75MM STD BIODUR CANC ST SELF DRL,SUP-2197560,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.46,470.25,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA10 MM EPTFE STR TW N RING STRL,SUP-2396717,CDM,C1768,CPT,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
PIN PERC 100MM,SUP-2756513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
HC Transcath Therapy Emboliz S&,PX-3207589400,CDM,75894,CPT,0320,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
SEALANT HEMOSTATIC FAST PREP 10.75X5.75X13.25 IN 10 CC,SUP-2424553,CDM,C1713,HCPCS,0278,RC,,,,both,,,1495.68,972.19,,,,,,,,,,,,,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT,RX-91352,CDM,6370000000,HCPCS,0637,RC,10135-0701-04,NDC,,both,113,GR,14.80,9.62,,,,,,,,,,,,,
SYSTEM MIC ACCS GLIDEACCESS 5 FR L 40 CM PLAT NIT ECHOGENIC,SUP-2385210,CDM,C1894,HCPCS,0272,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
CATHETER ANGIO L65CM L25CM OD5FR .038IN S STL POLYUR,SUP-2141093,CDM,C1725,HCPCS,0272,RC,,,,both,,,177.88,115.62,,,,,,,,,,,,,
BUR REPROC SURG 4.5MM BUR REPROC HELICUT SLATE,SUP-2652927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,72.38,47.05,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.448,SUP-2860012,CDM,C1713,HCPCS,0278,RC,,,,both,,,52461.86,34100.21,,,,,,,,,,,,,
INSERT TIB SZ 9 THK34MM ANTR POST KNEE UNI GEN,SUP-2344215,CDM,C1776,CPT,0278,RC,,,,both,,,3826.88,2487.47,,,,,,,,,,,,,
STENT GRFT VASC AFX L 55 MM DIA PROX/DSTL 16 MM COCR,SUP-2217703,CDM,C1768,CPT,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
HC Trluml Balo Angiop Addl Art,PX-3613724700,CDM,37247,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
PACK MTRX PORCINE L10 CMXW7 CM FEN STRL MATRISTEM,SUP-2106513,CDM,Q4166,HCPCS,0636,RC,,,,both,,,5505.05,3578.28,,,,,,,,,,,,,
CATHETER GUID AD 6FR L90CM DIA0.07IN MP1 TIP PTFE RADPQ W/O,SUP-2147673,CDM,C1887,HCPCS,0272,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
GRAFT BNE SUB 7.5GM PTTY SYN SIGNAFUSE,SUP-2138529,CDM,C9359,HCPCS,0278,RC,,,,both,,,2896.65,1882.82,,,,,,,,,,,,,
HC So Vdrl / Rpr,PX-3028659266,CDM,86592,CPT,0302,RC,,,,both,,,72.00,46.80,,,,,,,,,,,,,
BLADE RETRACTOR SPLANCHNIC 6X2 IN ABD RADLUC NS GHOSTRACT,SUP-2464374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1528.80,993.72,,,,,,,,,,,,,
SHEATH INTRO SILHOUETTE PEELWY L 30 CM DIA10 FR GUIDEWIRE,SUP-2168316,CDM,C1892,HCPCS,0272,RC,,,,both,,,154.65,100.52,,,,,,,,,,,,,
ANCHOR SUT DIA1.3MM W/ 3-0 ETHBND V-4 NDL DRL BIT MIC,SUP-2249369,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
GRAFT HUM TISS L LAT DST FEM OSTEOCHNDRL REFRIGERATED,SUP-2307438,CDM,C1713,HCPCS,0278,RC,,,,both,,,37554.40,24410.36,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN TAPR L 4.5 CM FLX TIP L,SUP-2167753,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.84,20.70,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED 4200] ARTHROSURFACE],SUP-2123521,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
SCREW BONE L14MM DIA4MM CORT MID/FOREFOOT S STL OSTEOPENIA,SUP-2349882,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
NAIL IM HUM 8 MMX16 CM NS LTX DISP,SUP-2861166,CDM,C1713,HCPCS,0278,RC,,,,both,,,4133.31,2686.65,,,,,,,,,,,,,
SYSTEM CAPPING SCALP COOLING LARGE,SUP-2866233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.16,2041.10,,,,,,,,,,,,,
PIN EXT FIX CYL SET CONN ELEMENT STRL TRUELOK EVO LTX,SUP-2875603,CDM,C1713,HCPCS,0278,RC,,,,both,,,18487.19,12016.67,,,,,,,,,,,,,
DEVICE BNE FILL SZ 3 1ML 10GA DIR RADPQ FOR INTVENT THER DEL,SUP-2280928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
CABLE LT DISP FOR MAXCESS SYS,SUP-2310429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT BONE SUB 1CC VIABLE BONE MTRX BIOFUSE,SUP-2224014,CDM,C1762,CPT,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
SIZER PARTIAL ALTO DORNHOFFER,SUP-2232511,CDM,L8613,CPT,0278,RC,,,,both,,,1302.97,846.93,,,,,,,,,,,,,
HANDPIECE HYDROSURGERY DIA14MM 15DEG TBNG SET VERSAJET,SUP-2340770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE L 130 MM SCREW DIA2.7/3.5 MM 9 H SS LT DSTL MEDL,SUP-2931267,CDM,C1713,HCPCS,0278,RC,,,,both,,,7691.43,4999.43,,,,,,,,,,,,,
IMPLANT TOT KNEE FLX TIB PAT GENDER,SUP-2212268,CDM,C1776,CPT,0278,RC,,,,both,,,15112.82,9823.33,,,,,,,,,,,,,
CONNECTOR SPNL STD POST TRNSVRS CONN FIX ASMBLY FOR 3MM ROD,SUP-2254417,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
STAPLER INT DIA5MM SHT FIX DEV W/ 20 TACK ABSORBATACK,SUP-2283223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1105.19,718.37,,,,,,,,,,,,,
HC Venography Svc,PX-3207582700,CDM,75827,CPT,0320,RC,,,,both,,,3006.00,1953.90,,,,,,,,,,,,,
SCREW BNE L20MM DIA3.5MM CORT DST RAD VOLAR TI NONLOCKING,SUP-2340298,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
HC Peripheral Block - Ilioinguinal/Iliohypogastric,PX-3606442500,CDM,64425,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
DRILL SURG CRTX 3.2 MM PROX QR NS LTX,SUP-2855985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
CATHETER PERFSN CRESCENT INSRTN L 8.9 CM DIA13 FR CONN 1/4,SUP-2745304,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
WASHER ORTHOPAEDIC 13 MM STAINLESS STEEL,SUP-2836677,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.49,168.67,,,,,,,,,,,,,
PLATE BNE L230MM 10 H R DST EXTRAARTICULAR HUM S STL LOK,SUP-2184044,CDM,C1713,HCPCS,0278,RC,,,,both,,,4189.80,2723.37,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 30 CM DIA 7 MM CLLGN BOV CAR ART,SUP-2880935,CDM,C1768,CPT,0278,RC,,,,both,,,7721.26,5018.82,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 8 MM RNG L 70 CM EPTFE STR TW,SUP-2396171,CDM,C1768,CPT,0278,RC,,,,both,,,4637.78,3014.56,,,,,,,,,,,,,
HC Elec Alys Implt Cplx Cn Npgt Prgrmg,PX-9209597700,CDM,95977,CPT,0920,RC,,,,outpatient,,,298.00,193.70,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM CORT S STL ST OSTEOPENIA FOR VAR,SUP-2348561,CDM,C1713,HCPCS,0278,RC,,,,both,,,192.36,125.03,,,,,,,,,,,,,
GRAFT BNE SUB 60CC 4 10MM PARTIC CANC FRZ DRY,SUP-2264680,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.34,1347.02,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5 MM DIA10 MM CATH L 120 CM,SUP-2639011,CDM,C1768,CPT,0278,RC,,,,both,,,9391.74,6104.63,,,,,,,,,,,,,
URETEROSCOPE FLX 100 DEG FLD VW SHFT L 670 MM WORKING,SUP-2909499,CDM,C1747,HCPCS,0272,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
ROD SPNL SCOLIOSIS 5.5X400/80 MM PREBENT TI NS MTRX,SUP-2589417,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT BNE SUB 5ML DEMIN BNE MTRX PSTE SYR FRZ DRY DBX,SUP-2306991,CDM,C1713,HCPCS,0278,RC,,,,both,,,2484.84,1615.15,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 25X20 CMX1.8-4 MM FLEXHD,SUP-2307488,CDM,Q4128,HCPCS,0636,RC,,,,both,,,44521.84,28939.20,,,,,,,,,,,,,
PPICC PROVENA SOLO SP 4F DL IR W/NIT70,SUP-2613543,CDM,C1751,HCPCS,0278,RC,,,,both,,,529.78,344.36,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 5 MM STR REINF SLDE GDS,SUP-2681172,CDM,C1768,CPT,0278,RC,,,,both,,,1290.29,838.69,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 10ML SIGNIFY CRUNCH BIOACTIVE,SUP-2232305,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
BODY HUM OFFSET 5 MM POLY TY ADPT STD FOR RVS SHLDR SYS,SUP-2884027,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW BNE L16MM OD35MM TI REARFT LOK HEX TOT FT SYS,SUP-2243252,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.94,463.41,,,,,,,,,,,,,
CORTEX HEX SCREW S-T 2.7X32 MM STRL,SUP-2818130,CDM,C1713,HCPCS,0278,RC,,,,both,,,212.30,137.99,,,,,,,,,,,,,
WIRE BNE FIX L 255 MM DIA 2 MM TROCAR TIP EVOS KIRSCHNER,SUP-2931394,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.79,498.41,,,,,,,,,,,,,
STAPLE INT L13XW13MM S STL COMPR INTERAXIS NONSTERILE IMPL,SUP-2243122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.57,1939.32,,,,,,,,,,,,,
MESH SURG 25X20 CM BIOMATERIAL PREPERITONEAL ENFORM,SUP-2435400,CDM,C1781,HCPCS,0278,RC,,,,both,,,20890.42,13578.77,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-40840053,CDM,J3490,HCPCS,0250,RC,00338-0043-04,NDC,,both,250,ML,12.80,8.32,,,,,,,,,,,,,
CATHETER CTRL VEN SGL LUMN N TUNNELED BASIC SET POLYUR N,SUP-2120633,CDM,C1751,HCPCS,0278,RC,,,,both,,,42.67,27.74,,,,,,,,,,,,,
ROD ORTH FIX ALIGN N SPIK IMPL GEN II,SUP-2346872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.10,277.61,,,,,,,,,,,,,
LIFT HEEL SM W2IN BRN FAB WDG 3 LAYR ORTHOT FT W/O CLSR,SUP-2325935,CDM,L3334,HCPCS,0272,RC,,,,both,,,18.34,11.92,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE MICRO ZRCH 2 URATA END DRV RT,SUP-2680325,CDM,C1713,HCPCS,0278,RC,,,,both,,,20140.59,13091.38,,,,,,,,,,,,,
SCREW BNE L60MM DIA4.5MM THRD L28MM HD DIA8MM MALL S STL,SUP-2184556,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.51,86.78,,,,,,,,,,,,,
STENT CORONARY MULTLNK TRI L 18 MM DIA 3 MM GUIDE CATH 0.064,SUP-2101459,CDM,C1876,HCPCS,0278,RC,,,,both,,,4926.66,3202.33,,,,,,,,,,,,,
TUBE TYMPLSTY PED L1.5MM DIA0.76MM TI VENT MORETZ TAB GRMMT,SUP-2284041,CDM,L8699,HCPCS,0278,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
SEALANT TISS GLUE 4ML PLEUR AIR LEAK PROGEL,SUP-2126993,CDM,C1713,HCPCS,0278,RC,,,,both,,,3957.91,2572.64,,,,,,,,,,,,,
SCREW BNE L20MM DIA45MM SHT THRD L7MM ST S STL SELF DRL CANN,SUP-2178576,CDM,C1713,HCPCS,0278,RC,,,,both,,,984.83,640.14,,,,,,,,,,,,,
BAG TISS CLSR DIA3CM TRNSPAR SIL SILO SPR LD PROX OPN SFT,SUP-2134677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
CLAMP SPNL UNIV THORLUM TI SM STAT FOR OPN TRNSVRS BAR 6MM,SUP-2193455,CDM,C1713,HCPCS,0278,RC,,,,both,,,1705.02,1108.26,,,,,,,,,,,,,
SHUNT CSF PEDIATRIC 0-20CM H2O ADJUSTABLE 25CM H2O GRAVITATI,SUP-2821855,CDM,C1889,HCPCS,0278,RC,,,,both,,,9161.52,5954.99,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY DR HE TI 2 CHMBR A IS1 BPLR V,SUP-2149288,CDM,C1721,HCPCS,0275,RC,,,,both,,,67510.00,43881.50,,,,,,,,,,,,,
BLADE SURG W40XL545MM THK038MM S STL SAW SAG HVY DUTY,SUP-2361911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 8 MM EPTFE STR TW N RING HEMO,SUP-2761285,CDM,C1768,CPT,0278,RC,,,,both,,,1706.94,1109.51,,,,,,,,,,,,,
CATHETER HAD ADMIN COMP ONLY DBL LUMN POLYUR STR HYDR TIP,SUP-2266972,CDM,C1752,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
IMPLANT SYNTH L 127 X W 76 MM THK 1.5 MM POLYETHYL,SUP-2883392,CDM,C1713,HCPCS,0278,RC,,,,both,,,3199.97,2079.98,,,,,,,,,,,,,
PROSTHESIS OSS CLASSIC STAP 4.5X1 MM 0.6 MM TI,SUP-2638174,CDM,L8613,CPT,0278,RC,,,,both,,,706.72,459.37,,,,,,,,,,,,,
MESH HERN W11XL6CM TRNSPAR MACROPOROUS MFIL POLYPR INGUINAL,SUP-2752153,CDM,C1781,HCPCS,0278,RC,,,,both,,,109.81,71.38,,,,,,,,,,,,,
CATHETER LITHO 4X40 MM FOR VASCULATURE CALCIFIED,SUP-2337679,CDM,C1725,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
RITONAVIR 100 MG PO PACK,RX-142246,CDM,6370000000,HCPCS,0637,RC,00074-3399-30,NDC,,both,1,UN,38.60,25.09,,,,,,,,,,,,,
VERSACROSS RF WIRE 12.5FR 180CM/67CM PIGTAIL D0,SUP-2857954,CDM,C1769,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 35 X 32 X 4 MM SM POLYETHYL CHIN 3 PC SQ,SUP-2935184,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
BRACE ORTH 30 150DEG SHLDR UNIV MOTN CTRL CHST STRP WAIST,SUP-2196399,CDM,L3650,HCPCS,0272,RC,,,,both,,,716.83,465.94,,,,,,,,,,,,,
SCREW BONE L115MM DIA3.5MM CORT ST,SUP-2183608,CDM,C1713,HCPCS,0278,RC,,,,both,,,145.54,94.60,,,,,,,,,,,,,
GRAFT BONE L10XW2.5CM DEMIN BONE MTRX MAGNIFUSE II,SUP-2279579,CDM,C1713,HCPCS,0278,RC,,,,both,,,15646.62,10170.30,,,,,,,,,,,,,
NEEDLE INSUFFLATION PNEUMOPERI 18 CM VERES SPRING LD BLNT LL,SUP-2767139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,884.19,574.72,,,,,,,,,,,,,
BIT DRL OD3.2MM RADLUC,SUP-2362675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.61,252.60,,,,,,,,,,,,,
BIT DRL DIA2MM CANN FOR HDLSS SCR SYS DART-FIRE,SUP-2399825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
GRAFT VASC VENAFLO L 25 CM DIA 4-7 MM EPTFE CARBON STP STR,SUP-2127059,CDM,C1768,CPT,0278,RC,,,,both,,,1977.29,1285.24,,,,,,,,,,,,,
OBTURATOR STD ORNG 21FR,SUP-2313052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2233.36,1451.68,,,,,,,,,,,,,
TWIST DRILL 22MM X 50MM W/NOTCH SINGLE USE,SUP-2676751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.17,321.21,,,,,,,,,,,,,
HC So Cea|NOT REASONABLE AND NECESSARY,PX-3018237866,CDM,82378,CPT,0301,RC,,,GZ,outpatient,,,67.00,43.55,,,,,,,,,,,,,
SPACER SPNL W18XH10XL55MM PEEK OPTMA COROENT XLF,SUP-2311626,CDM,C1821,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
BOLT 7.0X40 SHT POST TIX0207088,SUP-2293711,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SHUNT CAR 9 FRX15 CM INLYING BLU YEL PRUITT F3,SUP-2761874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
BUR SURG SYMTRC 7 MM 7.5 CM FOR DISECT TOOL MIDAS REX LEGEND,SUP-2630554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,479.32,311.56,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 5 MM STR HELIX SLDE GDS,SUP-2525460,CDM,C1768,CPT,0278,RC,,,,both,,,1687.88,1097.12,,,,,,,,,,,,,
FILLER BNE VOID 5ML INJ OSTEOVATIONEX,SUP-2319787,CDM,C1713,HCPCS,0278,RC,,,,both,,,5440.05,3536.03,,,,,,,,,,,,,
CATHETER PTCA DIA10MM BLLN DIA2.75MM HYDRCOAT 2 SWAGED MRK,SUP-2103590,CDM,C1725,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BONE 192MML HLX24 STNLSS STEEL STRGHT RCNSTRCTN F2.7M,SUP-2724376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1914.65,1244.52,,,,,,,,,,,,,
ELSA SPCR 20X50MM 11-20MM 15-30 DEG,SUP-2228778,CDM,C1821,HCPCS,0278,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM W/ SZ 3-0 BIOCRYLRAPIDE ORTHOCORD SUT,SUP-2256657,CDM,C1713,HCPCS,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
"HC So Total Protein, Urine",PX-3018415666,CDM,84156,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
PROSTHESIS PENILE L15CM MINOCYCLINE RIFAMPIN INHIBIZONE,SUP-2140260,CDM,C1813,HCPCS,0278,RC,,,,both,,,11068.50,7194.52,,,,,,,,,,,,,
INSERT TIB X FRE 10 DEG 22 MM SER II OMFIT,SUP-2451565,CDM,C1776,CPT,0278,RC,,,,both,,,1201.33,780.86,,,,,,,,,,,,,
KIT SCR LEG L80MM DIA11MM COMPR L75MM DIA7MM INTEGR INTLOK,SUP-2347846,CDM,C1713,HCPCS,0278,RC,,,,both,,,4720.99,3068.64,,,,,,,,,,,,,
BIT DRL L360MM OD42MM SM ST GRN AO QUIK CPL GAMMA3,SUP-2361620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.81,292.38,,,,,,,,,,,,,
DEVICE STRNL CLSR MULTIIMPLANT STRNLOCK 360,SUP-2403038,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
BIT DRILL LNG 4.3MM,SUP-2483730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1262.66,820.73,,,,,,,,,,,,,
Z DUP USE 2355961 ADAPTER PACE L60CM LD SGL 8 EXTN,SUP-2356743,CDM,C1883,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
HC Spine Thoracolumbar 2 Views,PX-3207208000,CDM,72080,CPT,0320,RC,,,,inpatient,,,286.00,185.90,,,,,,,,,,,,,
TROCAR ENDOPATH XCEL BLADELESS 5MM 75MM W/ STABILITY SLV,SUP-2855497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
NEEDLE 4FR MPIS TRNSTLSS PED ECHOGENIC,SUP-2170549,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.98,56.54,,,,,,,,,,,,,
PLATE BNE L342MM 16 H NONSTERILE L DST FEM LOK FOR 4.5MM,SUP-2348458,CDM,C1713,HCPCS,0278,RC,,,,both,,,11497.90,7473.63,,,,,,,,,,,,,
PLATE BNE CLAV CS3 2.7 MM RT VA LCK COMPR SS STRL VA-LCP,SUP-2750822,CDM,C1713,HCPCS,0278,RC,,,,both,,,3458.27,2247.88,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 45 CM DIA 4-7 MM EPTFE GRAD WALL TAPR 3,SUP-2265953,CDM,C1768,CPT,0278,RC,,,,both,,,4075.06,2648.79,,,,,,,,,,,,,
IMPLANT TISS FIX L 120 MM ADJ LOOP OPN W/O BTTN STRL,SUP-2908727,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
CATHETER MULTPURP DRN J TIP 8FRX25CM STIFF CANN W/ TRCR,SUP-2141067,CDM,C1729,HCPCS,0272,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
BASKET STONE REMV L90CM DIA14MM TIP L5CM DIA3FR S STL FLAT,SUP-2126138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,736.17,478.51,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 60X25MM,SUP-2484144,CDM,C1713,HCPCS,0278,RC,,,,both,,,9313.24,6053.61,,,,,,,,,,,,,
IMPLANT ORBIT RT LAT BICOMPARTMENTAL KNEE W/O PAT RESURF,SUP-2165965,CDM,C1776,CPT,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
RING EXT FIX HALF 80 MM NS TRUELOK LTX,SUP-2875062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
PLATE CRAN 120X120X40 MM PT SPEC IMPL PEEK,SUP-2860151,CDM,C1713,HCPCS,0278,RC,,,,both,,,39955.24,25970.91,,,,,,,,,,,,,
PLATE-CUTTING FORCEPS FOR 1.5MM-2.7MM PLATES,SUP-2548842,CDM,C1713,HCPCS,0278,RC,,,,both,,,4854.31,3155.30,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 28 HOLE SS NS LCP,SUP-2799225,CDM,C1713,HCPCS,0278,RC,,,,both,,,3568.23,2319.35,,,,,,,,,,,,,
INCOBOTULINUMTOXINA 100 UNITS IM SOLR,RX-106138,CDM,J0588,HCPCS,0636,RC,00259-1610-01,NDC,,both,1,UN,1507.50,979.87,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM 20 MM POLYESTER BOV CLLGN STR,SUP-2265894,CDM,C1768,CPT,0278,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
CLAMP 11MM PROV FIX WIRE 6MM,SUP-2351107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.47,322.71,,,,,,,,,,,,,
SCREW INTRF L16MM DIA11MM SUBTALAR FOR ARTHROEREISIS PROSTOP,SUP-2121858,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
BIT DRL FLX 3.2 MM OCCIPITOCERVICAL NS VERTEX SEL,SUP-2630771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1456.46,946.70,,,,,,,,,,,,,
CATHETER KIT 2 LUMEN 5 FR W/ PASV BIOFLO,SUP-2117194,CDM,C1751,HCPCS,0278,RC,,,,both,,,770.49,500.82,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT L 125 CM DIA 7 FR TIP 8,SUP-2248933,CDM,C1732,HCPCS,0278,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
BALLOON STONE REM DIA8.5/12/15MM CATH 7-5FR L200CM GWIRE,SUP-2169613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
ANCHOR SUTURE NONABSORBABLE 35 MM TWIN LOOP SFT EYELET,SUP-2608455,CDM,C1713,HCPCS,0278,RC,,,,both,,,1066.75,693.39,,,,,,,,,,,,,
PROBE TRACHBRONCH AR PLSM FLX DISP FOR APC 300 SYS DIA1.5MM,SUP-2217934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
SCREW BNE L24MM OD3MM TI LO EXT ST SELF DRL CANN FIX STBL,SUP-2242807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1027.69,668.00,,,,,,,,,,,,,
HC So Assay of Psa Complexed,PX-3018415266,CDM,84152,CPT,0301,RC,,,,both,,,98.00,63.70,,,,,,,,,,,,,
PIN FIX 4X150 MM FOR TRACTION SS NS STEINMANN,SUP-2905607,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.49,91.97,,,,,,,,,,,,,
POST EXT FIX 2 H FOR SIDEKCK FREE CIR FIX M,SUP-2400669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
GUIDEWIRE ARTHSCP L12IN DIA1MM NIT BLNT TIP SMOOTH FLEX W/,SUP-2340697,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
TUBE VENT ID1.52MM SIL NOTCH TAB TWST IN INSRT PAPARELLA,SUP-2284016,CDM,L8699,HCPCS,0278,RC,,,,both,,,73.60,47.84,,,,,,,,,,,,,
SHEATH INTRO FLEXCATH CNTOUR L 65.5 CM DIA12 FR TIP SZ 20 MM,SUP-2882552,CDM,C1766,CPT,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BNE OVL SM 1.5X0.2 MM SCRN MESH JANNETTA TI NS,SUP-2481163,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.54,587.95,,,,,,,,,,,,,
PASSER SUT L220MM 45DEG NIT LT CRV EXT REINF SHFT FOR HIP,SUP-2121815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
KIT BONE MAR ASPIR L4IN 1 H NDL CELLECT,SUP-2255618,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
COMPONENT TIB CR 3XS UNIV PEDIATRIC 8 MM STEM NP MONOBLOCK,SUP-2376413,CDM,C1776,CPT,0278,RC,,,,both,,,3973.36,2582.68,,,,,,,,,,,,,
BAR EXT FIX L 350 MM DIA11 MM UNILAT NS DISP MAV,SUP-2931323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
PLATE BONE L199MM 10 H TI TIM LT FIBULAR LCK COMPR ANAT FOR,SUP-2413691,CDM,C1713,HCPCS,0278,RC,,,,both,,,3318.98,2157.34,,,,,,,,,,,,,
PLATE BNE CLAV CS3 2.7 MM RT LAT VA LCK COMPR SS NS VA-LCP,SUP-2750790,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.26,2143.87,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX12 TTNM RCNSTRCTN F/3.5MM SCREW U,SUP-2494324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1624.89,1056.18,,,,,,,,,,,,,
PLATE BONE L80MM STRL LT POST ANK FUS FOR 3.5MM SCR PERI-LOC,SUP-2349832,CDM,C1713,HCPCS,0278,RC,,,,both,,,6700.76,4355.49,,,,,,,,,,,,,
LINER ACET GRP 2 NEUT HIP BLU NOVATION CRWN CUP,SUP-2222028,CDM,C1776,CPT,0278,RC,,,,both,,,5581.35,3627.88,,,,,,,,,,,,,
CATHETER EP 3 MM 2 MM TIP 4 FRX120 CM,SUP-2356900,CDM,C1730,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BASEPLATE TIB N MOD LNG 63X10 MM KNEE POROUS OSS,SUP-2449774,CDM,C1776,CPT,0278,RC,,,,both,,,9687.53,6296.89,,,,,,,,,,,,,
BRA SURG SUPP MED 34-36 IN ZIPPER,SUP-2213722,CDM,L8000,HCPCS,0272,RC,,,,both,,,120.54,78.35,,,,,,,,,,,,,
SPLINT WRST THMB L L8IN R BLK FOAM D RNG CLSR ADJ REUSE,SUP-2336030,CDM,L3809,HCPCS,0274,RC,,,,both,,,42.20,27.43,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA2 MM MANDIBULAR SD NS UNIV AXS,SUP-2909481,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.89,283.33,,,,,,,,,,,,,
GRAFT HUM TISS L150-250MM DIA4.5MM FRZN PRESUTURED TEND,SUP-2257911,CDM,C1713,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
LIFT HEEL SOLE NEOPRNE,SUP-2388189,CDM,L3310,HCPCS,0274,RC,,,,both,,,209.63,136.26,,,,,,,,,,,,,
WASHER ORTHOPEDIC SPIKED ANKLE SCREW GRIDLOCK,SUP-2878529,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
CEMENT BNE 40 GM RADIOPAQUE FORTRESS +,SUP-2595683,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SCREW BNE CANN 2X6 MM TS-SERIES TI TI6,SUP-2609937,CDM,C1713,HCPCS,0278,RC,,,,both,,,575.12,373.83,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY KNEE CTRL FULL KNEECAP,SUP-2435698,CDM,L2795,HCPCS,0272,RC,,,,both,,,232.17,150.91,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STEM ADD ON TRAB MEL,SUP-2212525,CDM,C1776,CPT,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.054X4 IN SS NS KIRSCHNER,SUP-2791250,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.35,5.43,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT SEG TIB,SUP-2321916,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SAW SURG STRGHT SAG PERM LEVER FLFSMLL BNE MICROPOWER HALL,SUP-2605593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8930.29,5804.69,,,,,,,,,,,,,
COMPONENT HIP CAPPED BPLR H31] STRYKER CORP],SUP-2365530,CDM,C1776,CPT,0278,RC,,,,both,,,7906.08,5138.95,,,,,,,,,,,,,
TUBE JEJUSTMY 12FR L27IN PUL RADPQ 2 PRT FEED ADPT,SUP-2127676,CDM,C1769,HCPCS,0272,RC,,,,both,,,137.38,89.30,,,,,,,,,,,,,
RING FIX DIA7MM SMER MAT FLEX INCREASED SPACE MALYUGIN 2.0,SUP-2304868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1032.46,671.10,,,,,,,,,,,,,
CATHETER DRNGE L80CM OD1.5MM ID0.7MM LUM CLS TIP W/ 14GA,SUP-2244097,CDM,C1729,HCPCS,0272,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 5CMD SPNL MSCLE MULTI TTHD BLACK FNSH U,SUP-2667617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.04,380.28,,,,,,,,,,,,,
SHAVER SURG MIC TUBESET HK MIS NEXUS BONESCALPEL,SUP-2745902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2385.21,1550.39,,,,,,,,,,,,,
CLAMP EXT FIX 6MM COMP BAR CLMP MRI SAFE STD W/ TIN HALF PIN,SUP-2342869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3350.38,2177.75,,,,,,,,,,,,,
HC So Helicobacter Phyloric Culture (First Cpt),PX-3008708168,CDM,87081,CPT,0300,RC,,,,both,,,22.00,14.30,,,,,,,,,,,,,
TONGUE SUSPENSION KIT BNE ANCHR KNOTLESS ENCORE,SUP-2339950,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
BLADE SAW 12X5X0.38 MM INT ORAL OSCILLATING SAW THN STRL LTX,SUP-2862527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.57,209.67,,,,,,,,,,,,,
RESERVOIR CEREBROSPINAL SM LUM PERI TWO MTL CONN SPETZLER,SUP-2244301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,865.07,562.30,,,,,,,,,,,,,
PLATE BONE L202MM 10 H BILAT S STL COBRA HD LO PROF RIG NEUT,SUP-2185801,CDM,C1713,HCPCS,0278,RC,,,,both,,,2087.10,1356.61,,,,,,,,,,,,,
PREM ST/G7 CP/E1 AA DM LN/STD,SUP-2212431,CDM,C1776,CPT,0278,RC,,,,both,,,16745.62,10884.65,,,,,,,,,,,,,
RELOAD STPL L45MM OPN H4.1MM CLS H2MM THCK TISS GRN 4 ROW,SUP-2220065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.38,239.45,,,,,,,,,,,,,
SHUNT SURG 90 CM W/ VENTRICULOPERITONEAL CATH,SUP-2628568,CDM,C1729,HCPCS,0272,RC,,,,both,,,3784.64,2460.02,,,,,,,,,,,,,
BIT DRL CANN SHT 12 MM STRL,SUP-2789599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2310.47,1501.81,,,,,,,,,,,,,
SYSTEM LIF ILLUMINATION STERILE,SUP-2716321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
MATRIX BIO SZ 250 SQCM ACELLULAR FISH SKIN DERMAL STRL 10/BX,SUP-2909435,CDM,Q4158,HCPCS,0636,RC,,,,both,,,19625.00,12756.25,,,,,,,,,,,,,
HOLDER SCR SUPLMNT W/ OUTRIG,SUP-2645903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1889.15,1227.95,,,,,,,,,,,,,
COLLAR CERV 2 PC SM AD 10-20X2 IN ADJ EMS MIAMI J PLAS FOAM,SUP-2247597,CDM,L0190,HCPCS,0272,RC,,,,both,,,174.84,113.65,,,,,,,,,,,,,
HC Drug Assay Carbamazepine Total,PX-3018015600,CDM,80156,CPT,0301,RC,,,,both,,,510.00,331.50,,,,,,,,,,,,,
CATHETER CV FULL TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0020,SUP-2759954,CDM,C1751,HCPCS,0278,RC,,,,both,,,448.67,291.64,,,,,,,,,,,,,
DEVICE TORQ GWIRE DIA0010 0020IN COMPATIBLE YEL H2O TORQ,SUP-2303479,CDM,C1769,HCPCS,0272,RC,,,,both,,,12.56,8.16,,,,,,,,,,,,,
CATHETER PTCA L130CM BLLN L40MM DIA4MM PACLITAXEL OVR THE,SUP-2280373,CDM,C2623,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
HC Burn Initial Treatment of Burn(S) 1st Degree,PX-3611600000,CDM,16000,CPT,0361,RC,,,,both,,,618.00,401.70,,,,,,,,,,,,,
CATHETER HAD AD 12FR L16CM ADMIN FULL KT 3 LUMN POLYUR CRV,SUP-2283984,CDM,C1751,HCPCS,0278,RC,,,,both,,,293.84,191.00,,,,,,,,,,,,,
SPACER SPNL H12XL26MM PEEK POST THORLUM INTBDY FUS SET TYP,SUP-2285128,CDM,C1821,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN SINGLE AXIS MANUAL LCK,SUP-2388216,CDM,L5810,HCPCS,0272,RC,,,,both,,,1312.87,853.37,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM DIA10 FR GUIDEWIRE 0.038 IN,SUP-2168246,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.47,63.36,,,,,,,,,,,,,
PLATE BONE L LCK CRV RT 7 H TI PROX TIB PLATING SYS ALPS,SUP-2413722,CDM,C1713,HCPCS,0278,RC,,,,both,,,4043.54,2628.30,,,,,,,,,,,,,
MOLD FEM STEM L145MM DIA13MM HD DIA57MM HIP SIL CLLRLSS,SUP-2408621,CDM,C1776,CPT,0278,RC,,,,both,,,4848.16,3151.30,,,,,,,,,,,,,
TUBE ENDOBRONCH 5 FR 65 CM LEN ARNDT,SUP-2168833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.46,572.30,,,,,,,,,,,,,
PIN EXT FIX SZ 150 X 45 X 5 MM HALF,SUP-2932900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1709.51,1111.18,,,,,,,,,,,,,
GRAFT NERVE REP L 4 X W 2 CM AMNIO MEMBRN MULTLYRED MTRX,SUP-2914047,CDM,C1762,CPT,0278,RC,,,,both,,,7049.30,4582.04,,,,,,,,,,,,,
FILLER BNE VOID 2.5 CC CORTICAL BNE SODIUM HYALURONATE,SUP-2927224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
CATHETER VENTRICULAR 8 CM 14 CM STYL RT ANGLE BACTISEAL,SUP-2666830,CDM,C1729,HCPCS,0272,RC,,,,both,,,1656.07,1076.45,,,,,,,,,,,,,
CANNULA ENDOSCP 3.5 MMX10 CM W/ LUER LCK CONN GRN YEL,SUP-2767459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1467.51,953.88,,,,,,,,,,,,,
"HC So Urine,Microalbumin,Quantitativ",PX-3078204366,CDM,82043,CPT,0307,RC,,,,both,,,196.00,127.40,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INOGEN W 5.37 X H 8.18 CM D 0.99 CM 32.5,SUP-2149208,CDM,C1882,HCPCS,0275,RC,,,,both,,,53389.42,34703.12,,,,,,,,,,,,,
PIN FIX L40MM DIA2.7MM DRL GUID PROV FOR PLATING SYS,SUP-2343966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1717.83,1116.59,,,,,,,,,,,,,
CATHETER CV 3L 6 FR STYL NURSE FULL TY POWERPICC SHERLOCK,SUP-2125642,CDM,C1751,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
DISTRACTION INTRNL ST SIZER 51 525 06 71 51 525 09 71 51 525,SUP-2499483,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.96,215.12,,,,,,,,,,,,,
DRILL SURGICAL,SUP-2633880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.14,282.84,,,,,,,,,,,,,
PLATE BONE 11 H FIBULAR ANAT ANK FX GORILLA,SUP-2321563,CDM,C1713,HCPCS,0278,RC,,,,both,,,5044.41,3278.87,,,,,,,,,,,,,
PLATE BNE W101XL84MM THK35MM 6 H BILAT TI STR RIG LOK COMPR,SUP-2191082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1474.07,958.15,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 60 MM DIA12 MM SHTH 9 FR CATH L 75,SUP-2147030,CDM,C1876,HCPCS,0278,RC,,,,both,,,3199.50,2079.67,,,,,,,,,,,,,
HC So Hhv-6 Dna Quant,PX-3068753366,CDM,87533,CPT,0306,RC,,,,inpatient,,,268.00,174.20,,,,,,,,,,,,,
MESH CRAN L 120 X W 120 MM THK 0.3 MM SCREW DIA1.5/1.7 MM LG,SUP-2883680,CDM,C1713,HCPCS,0278,RC,,,,both,,,7508.59,4880.58,,,,,,,,,,,,,
PLATE BNE L78MM 6 H L MED DST PERIARTC RAD VOLAR S STL LOK,SUP-2198466,CDM,C1713,HCPCS,0278,RC,,,,both,,,2483.87,1614.52,,,,,,,,,,,,,
STEM FEM L120MM DIA11MM HIP ZMLY STD OFFSET CEM CLLRD,SUP-2203443,CDM,C1776,CPT,0278,RC,,,,both,,,8839.57,5745.72,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 130 CM DIA 0.018 IN NIT MANDREL,SUP-2383179,CDM,C1769,HCPCS,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
SPLINT WRST SM L7IN AD R FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276655,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.36,6.08,,,,,,,,,,,,,
TIAGABINE HCL 4 MG PO TABS,RX-21827,CDM,6370000000,HCPCS,0637,RC,62756-0224-83,NDC,,both,1,UN,28.60,18.59,,,,,,,,,,,,,
TAP SURG 5.5MM CANN,SUP-2223984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 1.6X17 MM LP FOR SHUNT OR DRAINAGE,SUP-2431414,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.98,506.99,,,,,,,,,,,,,
DEVICE INFL FLD 20CC BILI FOR DEFLATION PRSS MON OF GI QNT,SUP-2169415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
PLATE BNE DBL Y MED 1.5X18X0.8 MM MIDFACE 6 HOLE W/ TAB NS,SUP-2491633,CDM,C1713,HCPCS,0278,RC,,,,both,,,884.91,575.19,,,,,,,,,,,,,
CATHETER INTVASC OCCL CODA L 100 CM DIA 9 FR BALLOON DIA 32,SUP-2167963,CDM,C2628,HCPCS,0272,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
BIT DRILL COMPRESSION SCREW CANN 18MM,SUP-2813096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CANNULA SUCT L165CM M STD TIP MAL,SUP-2280210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,943.88,613.52,,,,,,,,,,,,,
COMPONENT GLEN PE SM BIOMET - SM,SUP-2408631,CDM,C1776,CPT,0278,RC,,,,both,,,6455.84,4196.30,,,,,,,,,,,,,
WAND ABLAT SHFT DIA33MM 20DEG CUT W 55MM CANN COBLATION,SUP-2341985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
DRILL TWST OD5/16IN MRI,SUP-2505165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLATE BNE 3X8 H NONSTERILE S STL T SHP LOK COMPR W/ SHT,SUP-2184182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.85,847.50,,,,,,,,,,,,,
CATHETER DRAINAGE VENTRICULAR TRNSLUC SS EDM,SUP-2665143,CDM,C1729,HCPCS,0272,RC,,,,both,,,585.23,380.40,,,,,,,,,,,,,
SHEATH INTRO ARW GLIDETHRU L 10 CM DIA 4.5 FR DIL 4.5 FR,SUP-2887202,CDM,C1894,HCPCS,0272,RC,,,,both,,,47.41,30.82,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM OD 3 FR ID 1 MM GUIDEWIRE 0.021 IN,SUP-2169799,CDM,C1894,HCPCS,0272,RC,,,,both,,,122.52,79.64,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND VIEWFLEX X ICE L 90 CM DIA 9 FR,SUP-2880927,CDM,C1759,HCPCS,0272,RC,,,,both,,,3612.88,2348.37,,,,,,,,,,,,,
VALVE AORT EPIC + SUP SZ 21 MM TISS ANNULUS DIA21 MM STENT,SUP-2893994,CDM,C1889,HCPCS,0278,RC,,,,both,,,15706.28,10209.08,,,,,,,,,,,,,
PLATE BNE L53MM THK1.2MM 3X8 H TI T SHP FOR 2MM SCR,SUP-2191244,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.18,759.97,,,,,,,,,,,,,
MEMANTINE HCL 10 MG PO TABS,RX-36966,CDM,6370000000,HCPCS,0637,RC,00904-6506-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMPONENT ULN L84MM 2.5MM OFFSET BOND COAT LT ELBW BEAR,SUP-2215465,CDM,C1776,CPT,0278,RC,,,,both,,,13169.16,8559.95,,,,,,,,,,,,,
BIT DRL 1.5 MM WIRE PASS,SUP-2462176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
PLATE BNE OLECRANON LNG 162 MM RT 19 HOLE EVOLVE EPS,SUP-2535926,CDM,C1713,HCPCS,0278,RC,,,,both,,,3965.82,2577.78,,,,,,,,,,,,,
CATHETER DIAG 5MAX DDC TOT L 119 CM L 115 CM DIA 6/5 FR,SUP-2323553,CDM,C1725,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
METHADONE HCL 10 MG/ML PO CONC,RX-15996,CDM,340b,HCPCS,0637,RC,09999-9910-19,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
MINOCYCLINE HCL 100 MG PO CAPS,RX-5110,CDM,6370000000,HCPCS,0637,RC,65862-0211-50,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
T-PLT OBLQ 53MM STER HEAD 3HL SHAFT 3HL,SUP-2818495,CDM,C1713,HCPCS,0278,RC,,,,both,,,1717.83,1116.59,,,,,,,,,,,,,
NUSHIELD 2X4CM 8SQ CM,SUP-2314108,CDM,Q4160,HCPCS,0636,RC,,,,both,,,2565.38,1667.50,,,,,,,,,,,,,
GRAFT HUM TISS W4XL12CM THK04 08MM ACELLULAR DERM MTRX,SUP-2307446,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2486.10,1615.96,,,,,,,,,,,,,
CATHETER EP JSN 5 MM 4 FRX110 CM QPLR WOVEN,SUP-2424742,CDM,C1730,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
PLATE BNE L93MM 4 H R MED PROX TIB S STL LOK COMPR LO PROF,SUP-2185631,CDM,C1713,HCPCS,0278,RC,,,,both,,,4155.76,2701.24,,,,,,,,,,,,,
PASSER SUT 90DEG CRV TIP W/ WIRE LOOP FOR ARTHSCP BANKART,SUP-2121806,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CATHETER EMB NOVASIL SYNTEL L 60 CM DIA2 FR BALLOON DIA 4 MM,SUP-2264193,CDM,C1757,HCPCS,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
CABLE CATH L 9 FT LG SPLIT HNDL CARTO 3 STRL,SUP-2737871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3629.84,2359.40,,,,,,,,,,,,,
PLATE BNE STR 17X0.35 MM NEURO 2 HOLE W/ TAB TI STRL LEVEL 1,SUP-2498873,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.16,229.55,,,,,,,,,,,,,
PLATE BONE TARSALIS 2.7 1.6MM 6 H T-SHAPE LT FIX ANG LCK,SUP-2321013,CDM,C1713,HCPCS,0278,RC,,,,both,,,3055.22,1985.89,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED H4 HA UPLR BPLR,SUP-2419700,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
ROD ORTH THRD 150 MM PILLAR,SUP-2749919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THK45UM AMNIO MEMBRN DEHYDR OMNI DIR,SUP-2340453,CDM,C1762,CPT,0278,RC,,,,both,,,13530.26,8794.67,,,,,,,,,,,,,
DRILL SURG SHT 5.5X185 MM COUNTERBORE STRL T2,SUP-2466861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,865.57,562.62,,,,,,,,,,,,,
ABLATOR ARTHROSCOPIC APOLLORF H50,SUP-2744795,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CLAV SUP PLT RT 12H 125MM NS,SUP-2724399,CDM,C1713,HCPCS,0278,RC,,,,both,,,4731.98,3075.79,,,,,,,,,,,,,
TUBING HD ACCURA DISP,SUP-2129896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.47,229.11,,,,,,,,,,,,,
WASHER ORTH FIX BICONCAVE TI NONSTERILE SZ 40MM,SUP-2366374,CDM,C1713,HCPCS,0278,RC,,,,both,,,120.95,78.62,,,,,,,,,,,,,
PLATE BNE H0.6MM 24 H STD MID FACE G TI STR LEIBINGER UNIV,SUP-2366290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.82,987.88,,,,,,,,,,,,,
CONNECTOR SPNL OD4-4.5MM ROD PARA QUARTEX,SUP-2229083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HC So Cytopath C/V Auto Fluid Redo,PX-3118817566,CDM,88175,CPT,0311,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
SET URET STENT MARD L 24 CM DIA 6 FR PERCFLX HYDROPLUS SFT,SUP-2139582,CDM,C2617,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
GRAFT FIB SHFT FRZ DRY ALLGRFT 50 75MM,SUP-2335589,CDM,C1713,HCPCS,0278,RC,,,,both,,,1801.58,1171.03,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC EXCHANGE 16 5327420,SUP-2632950,CDM,C1750,HCPCS,0278,RC,,,,both,,,7088.55,4607.56,,,,,,,,,,,,,
NEEDLE BRST LOC BLNT 20 GAX10 CM SADOWSKY STYL STRL ACCURA,SUP-2876191,CDM,C1819,HCPCS,0278,RC,,,,both,,,142.87,92.87,,,,,,,,,,,,,
CATHETER PERIT1AL DLYS L42CM OD15FR STR 1 SUBQ CUF LIN,SUP-2283890,CDM,C1750,HCPCS,0278,RC,,,,both,,,167.74,109.03,,,,,,,,,,,,,
CATHETER DRNGE 10FR L25CM TIGHT LOOP TIP GLYCE MULTPURP TRCR,SUP-2118773,CDM,C1729,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
MOLD FEM HIP STEM L125MM OD9MM HD OD43MM SIL W/ S STL REINF,SUP-2408619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4848.16,3151.30,,,,,,,,,,,,,
PLATE BNE 8 H NONSTERILE S STL LOK COMPR ATTCH FOR 35 45MM,SUP-2177782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1604.29,1042.79,,,,,,,,,,,,,
SCREW BNE C 5X75 MM PART THRD PANTA,SUP-2539634,CDM,C1713,HCPCS,0278,RC,,,,both,,,1760.88,1144.57,,,,,,,,,,,,,
BUR SURG DIAMOND 2.5 MM 14 CM BALL LG BOR MIDAS REX 8 LEGEND,SUP-2664553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.67,294.89,,,,,,,,,,,,,
RING EXT FIX HALF 100 MM CARBON FIBER RINGFIX,SUP-2365273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
INSERT TIB REV KNEE EMPOWR VVC+ E+ SZ 3 19MM,SUP-2890768,CDM,C1776,CPT,0278,RC,,,,both,,,9336.79,6068.91,,,,,,,,,,,,,
COIL VASC HILAL MICROCOIL EMBOLUS L 1 CM DIA 3 MM CATH DIA,SUP-2168032,CDM,C1889,HCPCS,0278,RC,,,,both,,,120.58,78.38,,,,,,,,,,,,,
SCREW CRTX FT SELF TAP HEX HD 4.5MM DIA 46MML,SUP-2342662,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.18,58.62,,,,,,,,,,,,,
TUBE SALIVARY BYPASS RADIOPAQUE MONTGOMERY 191X38X12MM,SUP-2713903,CDM,C1889,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
COLLAR CERV L H3XL18IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335995,CDM,L0120,HCPCS,0274,RC,,,,both,,,17.68,11.49,,,,,,,,,,,,,
PANTOPRAZOLE SODIUM 40 MG PO PACK,RX-89791,CDM,6370000000,HCPCS,0637,RC,62756-0071-64,NDC,,both,1,UN,63.80,41.47,,,,,,,,,,,,,
LINER ACET SZ B ID22MM FLAT UHMWPE HIGHCROSS MPACT,SUP-2267391,CDM,C1776,CPT,0278,RC,,,,both,,,6034.23,3922.25,,,,,,,,,,,,,
ANCHOR SUT PILOT H SGL LD 5 FORC FBR INTELLIBRAID,SUP-2366694,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
RING EXT FIX DIA200MM TI HALF MR CONDITIONAL FOR DISTR,SUP-2176968,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1721.19,1118.77,,,,,,,,,,,,,
MESH SURG 15CM OMEGA 3 FATTY ACID POLYPR SEE THRU CLARITY,SUP-2265961,CDM,C1781,HCPCS,0278,RC,,,,both,,,1702.79,1106.81,,,,,,,,,,,,,
TUBE VENT DIA1.14MM SIL FOR MYR PAPARELLA 2000 TYP 1,SUP-2312786,CDM,L8699,HCPCS,0278,RC,,,,both,,,50.71,32.96,,,,,,,,,,,,,
TRAY BX W/ 102MM BX NDL INC. ANCIL ITEMS,SUP-2383232,CDM,C1713,HCPCS,0278,RC,,,,both,,,501.36,325.88,,,,,,,,,,,,,
PROBE THERMOMETER L 65 CM OD 10 FR TECOTHANE URETHANE SHFT,SUP-2890331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL LCK,SUP-2435683,CDM,L2610,HCPCS,0274,RC,,,,both,,,667.25,433.71,,,,,,,,,,,,,
HC 6-Minute Walk Test/Pulm Stress Test,PX-4609461800,CDM,94618,CPT,0460,RC,,,,inpatient,,,387.00,251.55,,,,,,,,,,,,,
BAND M 31 PRIMARY UPPER,SUP-2100492,CDM,D6783,CPT,0278,RC,,,,both,,,15.42,10.02,,,,,,,,,,,,,
STENT URET SOFFLX L 8 CM DIA 4.7 FR POLYUR SMALLER SIZED,SUP-2826628,CDM,C2617,HCPCS,0278,RC,,,,both,,,298.61,194.10,,,,,,,,,,,,,
PLATE BNE STR 2X35 MM 6 HOLE,SUP-2569073,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.88,103.27,,,,,,,,,,,,,
STENT URET L 26 CM DIA 8.5 FR PTFE GUIDEWIRE L 100 CM DIA,SUP-2312686,CDM,C2617,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT BNE W15XH5XL125MM ANT CERV INTBDY FUS SPCR PARA PROF,SUP-2306971,CDM,C1713,HCPCS,0278,RC,,,,both,,,4414.31,2869.30,,,,,,,,,,,,,
CATHETER INTERMED CEREGLIDE 71 L 132 CM PROX/DSTL OD,SUP-2893571,CDM,C1887,HCPCS,0272,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
MATRIX BIO L 4 X W 4 CM SZ 29 SQCM FISH SKIN DERMAL BX/5,SUP-2909374,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4719.42,3067.62,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.032 IN TAPR L 6 CM FLX TIP L,SUP-2167596,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.67,22.54,,,,,,,,,,,,,
PLATE BONE L86MM 4 H STRL LT LAT DSTL FIBULAR TI LCK COMPR,SUP-2177004,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.15,1499.65,,,,,,,,,,,,,
PUTTY FIBER CORTICAL 5CC BB76050,SUP-2847027,CDM,C1713,HCPCS,0278,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
BRACE ORTH 2X UPR SLD STIR AFO,SUP-2388168,CDM,L1990,HCPCS,0274,RC,,,,both,,,1099.75,714.84,,,,,,,,,,,,,
GUIDE WIRE BLUNT 1.1MM X 31CM,SUP-2574076,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.25,37.86,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .018 L 135 CM COAT L 31 CM OUTER,SUP-2327231,CDM,C1753,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
SOUND PROC HEARING DEV LT KT USER NS REUSE SAMBA2 BB,SUP-2905155,CDM,L8691,HCPCS,0278,RC,,,,both,,,16026.56,10417.26,,,,,,,,,,,,,
COMPONENT FEM SZ 65 POST L KNEE REV INTLOK CEM STBL STEM,SUP-2407548,CDM,C1776,CPT,0278,RC,,,,both,,,15197.60,9878.44,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 6-8 MM EPTFE TAPR STD WALL N,SUP-2396456,CDM,C1768,CPT,0278,RC,,,,both,,,1635.94,1063.36,,,,,,,,,,,,,
NEEDLE BX 22GA EXTN 0-8CM SHTH 5.2FR US RECESS BALL TIP,SUP-2171105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1205.76,783.74,,,,,,,,,,,,,
SCREW BONE L14MM DIA2MM PARTIALLY THRD HD SM CANN FLOWERCUBE,SUP-2225319,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.33,453.26,,,,,,,,,,,,,
GUIDEWIRE FIX 3MMX100CM IM SMOOTH TIP ZMS,SUP-2410277,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.60,107.64,,,,,,,,,,,,,
SPACER DSTL AUG 10 MM REV VANGUARD,SUP-2446635,CDM,C1776,CPT,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
DRILL TWST L 58 MM DIA1.9 MM WORKING L 9 MM SCREW DIA 6/7 MM,SUP-2883609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1129.87,734.42,,,,,,,,,,,,,
RELOAD STPLR LINEAR 30 MM REG VERY THCK B FRM PROX,SUP-2220063,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
CURETTE SURG BRUNS 0 22.9 CM 5.6X5 MM BNE STR OVL CUP SS NS,SUP-2482213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSPLIT XK CHRONIC STD 16FR D 5685190,SUP-2632959,CDM,C1750,HCPCS,0278,RC,,,,both,,,1496.84,972.95,,,,,,,,,,,,,
PROCESSOR BONE MAR W/ ACC AND 2 RET LN BG,SUP-2255622,CDM,C1713,HCPCS,0278,RC,,,,both,,,1527.61,992.95,,,,,,,,,,,,,
BUR DENT 8 FLUT 6 1.8 MM RND UNCOATED HNDPC RT ANGLE CARBIDE,SUP-2322154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
CRYOABLATION KIT PROST ICEPEARL 2.1 CX 10890] FORTEC MEDICAL INC],SUP-2225693,CDM,C2618,HCPCS,0272,RC,,,,both,,,12073.30,7847.64,,,,,,,,,,,,,
BUR SURG M L64MM DIA2MM NEURO RND CUT FLUT CARB INDIGO,SUP-2284183,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.94,365.91,,,,,,,,,,,,,
SPACER SPNL 6X14X11 MM STRUT VERTE-STACK CORNERSTONE PSR,SUP-2286342,CDM,C1889,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
BLOCK RETAINING SPINAL PEDICLE SCREW,SUP-2867348,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW BNE L 85 MM DIA 6.5 MM SS CANN LCK NS EVOS,SUP-2931450,CDM,C1713,HCPCS,0278,RC,,,,both,,,1490.40,968.76,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 5 CM SEG FRZN FIB,SUP-2321863,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
FIDUCIAL MARKER KIT SFT TISS SEED GLD,SUP-2267150,CDM,A4648,CPT,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
PORT IMPL INFUSION 16X26 MM PWR INJ POLYURETHANE CATH XCELA,SUP-2118803,CDM,C1788,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 17 MM 6 HOLE LP CONTOURED TI NS,SUP-2479308,CDM,C1713,HCPCS,0278,RC,,,,both,,,855.56,556.11,,,,,,,,,,,,,
GRAFT BIO TISS W6XL10CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2112975,CDM,Q4130,HCPCS,0636,RC,,,,both,,,6179.52,4016.69,,,,,,,,,,,,,
RAIL EXT FIX TRANSITION 5.5X495 MM 4D COBALT CHROM,SUP-2517552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
BETAMETHASONE DIPROPIONATE 0.05 % EX CREA,RX-1027,CDM,6370000000,HCPCS,0637,RC,16714-0996-01,NDC,,both,15,GR,163.50,106.27,,,,,,,,,,,,,
HC Chemo It Inj Incl Spinal Punct,PX-3319645000,CDM,96450,CPT,0331,RC,,,,both,,,7197.00,4678.05,,,,,,,,,,,,,
PLATE BNE L139MM 6 H TI TIM R DST FIBULAR LOK COMPR ANAT,SUP-2413694,CDM,C1713,HCPCS,0278,RC,,,,both,,,2484.84,1615.15,,,,,,,,,,,,,
SHEATH SPLIT 11F,SUP-2424640,CDM,C1894,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ADMINISTRATION SET PMP PCA IV,SUP-2424817,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.141X9 IN RND END SS NS STEINMANN,SUP-2791268,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.46,20.45,,,,,,,,,,,,,
BLADE SAW L 79 MM L 17 MM D 4 MM THK MATERIAL 0.4 MM CUT 0.6,SUP-2929480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,982.57,638.67,,,,,,,,,,,,,
GUIDE PIN 3.2MM,SUP-2496814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
SLEEVE WIRE DIA2MM THRD DRL GUID,SUP-2187772,CDM,C1769,HCPCS,0272,RC,,,,both,,,924.98,601.24,,,,,,,,,,,,,
INTRODUCER SHTH 0.032 IN LAMP 90 8 FRX81 CM 8 FRX85 CM CRV,SUP-2357229,CDM,C1893,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
DEVICE EMB PIPELINE 2.50X10MM,SUP-2465674,CDM,C1889,HCPCS,0278,RC,,,,both,,,41831.08,27190.20,,,,,,,,,,,,,
HC So1 Column Chromotography Quant,PX-3018254267,CDM,82542,CPT,0301,RC,,,,both,,,322.00,209.30,,,,,,,,,,,,,
TRAY TIBIAL SLEEVE SIZE 3 BALANCED KNEE REVISION SYSTEM,SUP-2603527,CDM,C1776,CPT,0278,RC,,,,both,,,8543.94,5553.56,,,,,,,,,,,,,
NAIL LOCKING PROXIMAL 150MML LEFT STERILE POLARUS 3,SUP-2639494,CDM,C1713,HCPCS,0278,RC,,,,both,,,7127.80,4633.07,,,,,,,,,,,,,
HC Trach Tube Change,PX-3600000034,CDM,3600000034,LOCAL,0360,RC,,,,both,,,1451.00,943.15,,,,,,,,,,,,,
ALLOGRAFT DERMAL SHP THN SM 17X10 CMX0.7-1.4 MM FLEXHD,SUP-2458339,CDM,Q4128,HCPCS,0636,RC,,,,both,,,9044.52,5878.94,,,,,,,,,,,,,
HC E/M Crit Care Each Addit 30min,PX-4509929200,CDM,99292,CPT,0450,RC,,,,outpatient,,,362.00,235.30,,,,,,,,,,,,,
CANNULA CEM DEL FEN OPN DISP VIPER,SUP-2255637,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER 2 CHMBR 27 J BPLR VVED REMOT MON,SUP-2236352,CDM,C1721,HCPCS,0275,RC,,,,both,,,70964.00,46126.60,,,,,,,,,,,,,
PLATE BNE L48MM 8 H TI DYN LOK COMPR FOR 2MM SCR MOD HND,SUP-2191481,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.62,883.10,,,,,,,,,,,,,
CARTRIDGE BONE CEM MX UNIV VAC PLUNG W/ BRK OFF NOZ W/OUT,SUP-2397004,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CONSTRUCT PRE-SUTURED QUADLINK 9-11MM 60-75MM,SUP-2656688,CDM,C1762,CPT,0278,RC,,,,both,,,8143.59,5293.33,,,,,,,,,,,,,
PLATE BNE L 46 MM SCREW DIA2 MM 8 H LCK NAR NS VARIAX,SUP-2900570,CDM,C1713,HCPCS,0278,RC,,,,both,,,3167.95,2059.17,,,,,,,,,,,,,
STAPLER INT L16CM STD UNIV RELD DISP TRI-STAPLE ENDO GIA,SUP-2283270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.11,257.47,,,,,,,,,,,,,
SYSTEM EXT FIX FOR PIP JT FLX CNTRCT AGEE DGT WIDGET,SUP-2237246,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
PLATE BONE L220MM BLDE W11.7XL40MM 90DEG 12 H NONSTERILE,SUP-2190873,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.52,2693.94,,,,,,,,,,,,,
SCREW BNE LCK 2.7 X70 MM T10 DRV FT STRL VARIAX 2,SUP-2457673,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.04,541.48,,,,,,,,,,,,,
ALLOGRAFT BNE PARTICULATE 250-1000 MH 1 CC CANC ORAGRAFT,SUP-2740948,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.50,187.52,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH II DIA 8.5 FR GUIDEWIRE 0.038 IN,SUP-2909643,CDM,C1894,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
SCREW BONE L22MM DIA1.5MM CO CHROM CORT ST NONLOCKING FULL,SUP-2411774,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.60,149.89,,,,,,,,,,,,,
SCREW BNE 4X14 MM,SUP-2199216,CDM,C1713,HCPCS,0278,RC,,,,both,,,60.29,39.19,,,,,,,,,,,,,
PLATE BONE SM L60MM LT CALCNL LCK FOR 3.5MM SCR PERI-LOC,SUP-2348514,CDM,C1713,HCPCS,0278,RC,,,,both,,,5056.03,3286.42,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 135 CM DIA 3 FR SLT PAT L 20,SUP-2118506,CDM,C1757,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
TRAY CATHETER NEO 19FR L30CM SGL LUMN,SUP-2173950,CDM,C1751,HCPCS,0278,RC,,,,both,,,139.45,90.64,,,,,,,,,,,,,
BRA SURG LG 40-42IN WHT LYCRA FR HK AND LOOP CLSR WIDE ADJ,SUP-2336338,CDM,L8000,HCPCS,0272,RC,,,,both,,,107.61,69.95,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM SUTURE TAPE SZ 1.8 MM PEEK W/ 2,SUP-2905878,CDM,C1713,HCPCS,0278,RC,,,,both,,,1642.22,1067.44,,,,,,,,,,,,,
GUIDEWIRE VASC DIA.035IN L260CM TAPR COR NIT STIFF 3CM TIP,SUP-2141159,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.70,107.70,,,,,,,,,,,,,
GUIDEWIRE URO L145CM DIA0.035IN TIP L7CM S STL PTFE BENT,SUP-2139353,CDM,C1769,HCPCS,0272,RC,,,,both,,,88.14,57.29,,,,,,,,,,,,,
TAP SURG 4MM,SUP-2320976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,588.75,382.69,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 4FR 20CM 2 LUMAN S4254108DG,SUP-2632867,CDM,C1751,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
BLADE SAW W049XL295IN THK005IN CUT THK0057IN REPL SAG W,SUP-2150372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
HC NM Bone Multiple,PX-3417830500,CDM,78305,CPT,0341,RC,,,,both,,,2265.00,1472.25,,,,,,,,,,,,,
KIT INSERTION INTRA-AORTIC CATH 8FR 40ML 0.25IN GUIDEWIRE 6IN INTRO,SUP-2876891,CDM,C1769,HCPCS,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA24 MM L 10/10/10CM 8/8/8MM,SUP-2894594,CDM,C1768,CPT,0278,RC,,,,both,,,13674.70,8888.55,,,,,,,,,,,,,
DEVICE PESSARY RNG W/ SUPP FLD 3IN,SUP-2171843,CDM,A4562,HCPCS,0274,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
ELECTRODE ELECSURG FLUT VAPORTRODE,SUP-2313977,CDM,C1713,HCPCS,0278,RC,,,,both,,,3231.06,2100.19,,,,,,,,,,,,,
CANNULA SURG GUIDE PIN LNG 3 MM,SUP-2474006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1645.58,1069.63,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 LOCK SCREW 125MM S-T,SUP-2820251,CDM,C1713,HCPCS,0278,RC,,,,both,,,1541.17,1001.76,,,,,,,,,,,,,
BIT DRL L44.5MM DIA0.7MM STP 6MM L6MM STRL MAXILLOFACIAL S,SUP-2187642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,636.51,413.73,,,,,,,,,,,,,
ALLOGRAFT CELLULAR ALLOFUSE SELECT  CM 5CC,SUP-2653972,CDM,C1713,HCPCS,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
GRAFT BNE SUB 30CC SZ 1-5MM MILLED CANC CHIP FRZ DRY,SUP-2307070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
TRAY PROC SZ 0 130MM 6DEG STD OFFSET ZMLY HIP FEM STEM TAPR,SUP-2205949,CDM,C1776,CPT,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
SCALPEL BONE 20MM BLUNT BLADE AND TUBESET NEXUS,SUP-2113035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1638.04,1064.73,,,,,,,,,,,,,
PLATE BNE L W10.1XL56MM THK3.5MM 4 H BILAT S STL STR RIG,SUP-2186207,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.97,769.58,,,,,,,,,,,,,
GAUGE DEPTH 4MM CANN COUNTSINK,SUP-2319583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2879.38,1871.60,,,,,,,,,,,,,
INTRODUCER KIT STIFFEN 5 FR SFT TIP SS VSI MIC,SUP-2120528,CDM,C1894,HCPCS,0272,RC,,,,both,,,96.37,62.64,,,,,,,,,,,,,
GRAFT BNE CHIP FRZN CANC CORT 17MM 10MM RANG 30CC,SUP-2307404,CDM,C1713,HCPCS,0278,RC,,,,both,,,1609.66,1046.28,,,,,,,,,,,,,
KIT INTRO ACCS 5FR L15CM GWIRE 0018IN NDL 21GA L7CM,SUP-2303438,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
CABLE SURG L750MM DIA1MM STRNL S STL SMOOTH W/OUT NDL CUT,SUP-2186851,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.03,182.67,,,,,,,,,,,,,
LINER ACET 15 DEG STD POLYETH 28MM SZ G ACUMATCH,SUP-2221894,CDM,C1776,CPT,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
PACK VTRCTMY 25GA PSTRR STAND WIDE FIELD ILLMNTR F/VSN ENHNC,SUP-2497590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1650.38,1072.75,,,,,,,,,,,,,
SIZER SURG GEL 2.5 CM PROJCT 10.3 CM 150 CC BRST SMOOTH RND,SUP-2300903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
HC Arterial Puncture Withdrawal Blood Dx,PX-3003660000,CDM,36600,CPT,0300,RC,,,,both,,,39.00,25.35,,,,,,,,,,,,,
ALLOGRAFT BNE SM 5 CC DBM FIBER OSTEOSTRAND PLUS,SUP-2731814,CDM,C1713,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
PLATE BNE COMPR 2.7/3.5X20X25 MM PROX BILATERAL FT ANK LP SS,SUP-2397470,CDM,C1713,HCPCS,0278,RC,,,,both,,,3450.86,2243.06,,,,,,,,,,,,,
SCREW INTFR L20MM DIA8MM OPN ARCHITECTURE DSGN BIOSURE,SUP-2341916,CDM,C1713,HCPCS,0278,RC,,,,both,,,1160.54,754.35,,,,,,,,,,,,,
BIT DRL DIA2.4MM,SUP-2280970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1387.10,901.61,,,,,,,,,,,,,
FILLER DEMIN CANC 5CC,SUP-2138526,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.80,1253.07,,,,,,,,,,,,,
PPICC PROV SOLO PED 4F DL DELTA,SUP-2613527,CDM,C1751,HCPCS,0278,RC,,,,both,,,1015.79,660.26,,,,,,,,,,,,,
PACEMAKER CARD TRIL DR + 2 CHMBR NOT MRI COMPATIBLE STD,SUP-2320134,CDM,C1785,HCPCS,0275,RC,,,,both,,,15370.30,9990.69,,,,,,,,,,,,,
SCREW BNE LCK 2.7X22 MM CORTICAL NS,SUP-2423257,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.42,227.77,,,,,,,,,,,,,
GRAFT SFT TISS W9XL20CM NAT BARR OPTIMIZE SURG PERF,SUP-2305728,CDM,V2790,HCPCS,0274,RC,,,,both,,,29644.74,19269.08,,,,,,,,,,,,,
SCREW BNE LCK 4.5X36 MM SILVERBACK PLATE,SUP-2434354,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.27,521.48,,,,,,,,,,,,,
HC Repair Nail Bed,PX-4501176000,CDM,11760,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
ELEVATOR SURG L11XW5IN SPNL BLDE COBB,SUP-2244791,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.90,198.83,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 10GM VOID FILLER CALCIGEN,SUP-2470153,CDM,C1713,HCPCS,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
CATHETER ABLATN F-F 1-7-4 MM 8MM 7 FRX115 CM EZ STEER,SUP-2248499,CDM,C1733,HCPCS,0272,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
PLATE AC NRW 11 HOLE 45MM,SUP-2720916,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
TROCAR SURG DIA28MM FOR MULT WIRE GUID,SUP-2187474,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.40,225.16,,,,,,,,,,,,,
DEVICE VES SEAL FR DAVINCI ENERGY SYS SYNCHROSEAL DISP,SUP-2558676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2274.93,1478.70,,,,,,,,,,,,,
SLING MID URETH SYS ACELLULAR HALO NEEDLEX2 GUID TUBE HNDL,SUP-2129054,CDM,C1771,HCPCS,0278,RC,,,,both,,,2841.23,1846.80,,,,,,,,,,,,,
PLATE BNE LO BEND NEUT 3.5X128 MM RT PROX TIB 8 HOLE LCK TI,SUP-2180958,CDM,C1713,HCPCS,0278,RC,,,,both,,,4654.48,3025.41,,,,,,,,,,,,,
COMPONENT ACET TRIFLANGED 23 MM HIP CUST,SUP-2418773,CDM,C1776,CPT,0278,RC,,,,both,,,40082.10,26053.36,,,,,,,,,,,,,
TACROLIMUS 0.5 MG PO CAPS,RX-24914,CDM,J7507,HCPCS,0636,RC,00904-6623-61,NDC,,both,1,UN,4.80,3.12,,,,,,,,,,,,,
CLAMP EXT FIX TI ALLY ROD TO ROD,SUP-2188498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1786.44,1161.19,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA 3.5 MM TI NLCK T15 DRV NS LEOS,SUP-2931488,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.76,255.94,,,,,,,,,,,,,
COIL NEUROVASCULAR HYPERSOFT L 1 CM LOOP DIA1.5 MM,SUP-2305389,CDM,C1889,HCPCS,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
CATHETER VENTRICULAR SHUNT STANDARD STRAIGHT RIGHT ANGLE 1.2,SUP-2825901,CDM,C1729,HCPCS,0272,RC,,,,both,,,872.86,567.36,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 12X6 CM HYDRATED BIOLOGIC TISSUE MA,SUP-2838608,CDM,C1763,HCPCS,0278,RC,,,,both,,,6681.92,4343.25,,,,,,,,,,,,,
PROSTHESIS PENILE L18CM DIA12MM INFL PS APPRCH W/ INHIBZN 2,SUP-2138973,CDM,C1813,HCPCS,0278,RC,,,,both,,,26620.92,17303.60,,,,,,,,,,,,,
TRAY CATH CNTRL VENOU LUMENX3 12.5FR DIA SIL 1.6/0.7/0.7ML P,SUP-2613070,CDM,C1751,HCPCS,0278,RC,,,,both,,,1409.36,916.08,,,,,,,,,,,,,
PUSHER KNOT CLOSED END 5X400 MM,SUP-2850582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.12,237.98,,,,,,,,,,,,,
DEVICE ORTH TARGET FREEHAND DSTL WHT VERSANAIL,SUP-2412774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
TUBE VENT ARMSTR 8 MM 1.14 MM 2.79 MM BVL PLN END FLROPLAS,SUP-2535142,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
SCREW BNE L75MM DIA5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412136,CDM,C1713,HCPCS,0278,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
SUPPORT ORTHOT RIB CUST GUSSET ELASTIC,SUP-2435591,CDM,L1280,HCPCS,0274,RC,,,,both,,,247.37,160.79,,,,,,,,,,,,,
CATHETER THERMODILUTION 4 LUMEN 5 FRX75 CM STD CO SWN GZ,SUP-2214027,CDM,C1725,HCPCS,0272,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
HC Continuous Inhale Tx Addl Hour,PX-4109464500,CDM,94645,CPT,0410,RC,,,,outpatient,,,16.00,10.40,,,,,,,,,,,,,
PLATE BNE L168MM 8 H ST R MED DST TIB S STL LOK COMPR FOR,SUP-2185587,CDM,C1713,HCPCS,0278,RC,,,,both,,,5037.44,3274.34,,,,,,,,,,,,,
COMPONENT FEM TROCH NEUT PROX KNEE REPL ANTIROTATION TAB TI,SUP-2252621,CDM,C1776,CPT,0278,RC,,,,both,,,13025.03,8466.27,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM OFFSET RNG L 20 CM EPTFE,SUP-2396154,CDM,C1768,CPT,0278,RC,,,,both,,,3199.66,2079.78,,,,,,,,,,,,,
PLATE EXT FIX 3 H THRD CONN MRI CONDITIONAL FOR DISTR,SUP-2255811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,270.86,176.06,,,,,,,,,,,,,
CATHETER EMB ARW L 80 CM DIA 5 FR 2 LUMEN STRL,SUP-2383506,CDM,C1757,HCPCS,0272,RC,,,,both,,,243.98,158.59,,,,,,,,,,,,,
ANG BLDE PL 130 9H 80/152,SUP-2819399,CDM,C1713,HCPCS,0278,RC,,,,both,,,5649.96,3672.47,,,,,,,,,,,,,
CALCIUM CARBONATE ANTACID 1250 MG/5ML PO SUSP,RX-138274,CDM,340b,HCPCS,0637,RC,00121-4766-05,NDC,,both,5,ML,11.60,7.54,,,,,,,,,,,,,
CARBON FIBER BAR 6MM X 150MM,SUP-2730030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
RETRACTOR EXTENDED WEAR PANNICULUS REG,SUP-2880687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
BLOCK TIB AUG FULL FLAT 2 SM 10 MM LT KNEE PRIMARY PRSS FT,SUP-2377112,CDM,C1776,CPT,0278,RC,,,,both,,,4136.95,2689.02,,,,,,,,,,,,,
DEVICE GUIDEWIRE EXCHANGE TRAPPER STR STRL,SUP-2140451,CDM,C1769,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
COMPONENT TIB UNI SM 9 MM LL/RM KNEE ONLAY GEN,SUP-2344216,CDM,C1776,CPT,0278,RC,,,,both,,,5337.22,3469.19,,,,,,,,,,,,,
STENT URET 47FR L26CM DBL PIGTAILS LUBRICIOUS COAT TAPR TIP,SUP-2126633,CDM,C2617,HCPCS,0278,RC,,,,both,,,578.11,375.77,,,,,,,,,,,,,
PLATE BNE L227MM THK3MM 12 H BILAT S STL STR LOK COMPR RECON,SUP-2185347,CDM,C1713,HCPCS,0278,RC,,,,both,,,1854.39,1205.35,,,,,,,,,,,,,
HC Biopsy of Liver; Perc Needle,PX-3614700100,CDM,47001,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
ANCHOR SUT CROSSFT BC 55MMX17MM W TWO NUMBER 2 HI FI SUTS,SUP-2167093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1495.33,971.96,,,,,,,,,,,,,
STAPLER INT POWDERED 45 MM LNG END CUT ECHELON CIR,SUP-2257515,CDM,C1713,HCPCS,0278,RC,,,,both,,,845.51,549.58,,,,,,,,,,,,,
MARKER BRST BX 17 GAX 10 CM 3 MM NDL COIL ULTRACLIP II,SUP-2127913,CDM,A4648,CPT,0278,RC,,,,both,,,194.93,126.70,,,,,,,,,,,,,
PLATE BNE L209MM 13 H ST R DST LAT FIBULAR S STL VAR ANG,SUP-2177738,CDM,C1713,HCPCS,0278,RC,,,,both,,,3442.63,2237.71,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 55CM 6 FR 0.018/0.038 IN AQ MULTPURP,SUP-2169821,CDM,C1894,HCPCS,0272,RC,,,,both,,,162.84,105.85,,,,,,,,,,,,,
MESH HERN W6XL6IN POLYPR MFIL SQ NONABSORBABLE,SUP-2125749,CDM,C1781,HCPCS,0278,RC,,,,both,,,456.87,296.97,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 0.032 INX150 CM TORQUABLE ZBR DISP,SUP-2139360,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.79,107.76,,,,,,,,,,,,,
COMPONENT FEM PS 3 UNISX LT KNEE PRIMARY CEM STEMLESS BASIC,SUP-2378090,CDM,C1776,CPT,0278,RC,,,,both,,,6215.32,4039.96,,,,,,,,,,,,,
GUIDEWIRE VASC CLOSUREFAST L 45 CM DIA 0.018 IN PTFE SINGLE,SUP-2883978,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.69,29.70,,,,,,,,,,,,,
PLATE BNE L34MM 3 H BILAT S STL STR RECON NONLOCKING,SUP-2197668,CDM,C1713,HCPCS,0278,RC,,,,both,,,817.62,531.45,,,,,,,,,,,,,
DRESSING GEL F/REAGENT COMBO BIODYNAMIC HEMATOGEL THERAPY AURIX,SUP-2878091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GUIDE SURG PLN NYL LP DISTRCTN CUSTOMIZABLE UNILAT VSP,SUP-2883941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15959.05,10373.38,,,,,,,,,,,,,
LINER ACET SZ 54-58 DIA28MM 5/15DEG MCS GXL,SUP-2221663,CDM,C1776,CPT,0278,RC,,,,both,,,7410.40,4816.76,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC DBM DBMP10] UNIVERSAL MEDICAL PRODUCTS],SUP-2391507,CDM,C9359,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
TIP LD PULLING FOR ENDOTK RELIANCE 4-SITE NS,SUP-2481178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
BLADE SHAVER 3.5 MMX13 CM ULTRACUT,SUP-2765752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.29,319.99,,,,,,,,,,,,,
CATHETER HD CPU 14CM 13CM PLAS STERIL PK CHNG NEW MAT,SUP-2117116,CDM,C1881,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
AUGMENT FEM SZ 3 R KNEE TRITANIUM CONE TRIATHLON,SUP-2373593,CDM,C1776,CPT,0278,RC,,,,both,,,10847.98,7051.19,,,,,,,,,,,,,
SCREW BNE PEGGED 2.5X10 MM THRD MULTIDIRECTIONAL STRL LTX,SUP-2861105,CDM,C1713,HCPCS,0278,RC,,,,both,,,582.16,378.40,,,,,,,,,,,,,
HC Cv Cath Plac W/Pump Tun,PX-3613656300,CDM,36563,CPT,0361,RC,,,,both,,,16763.00,10895.95,,,,,,,,,,,,,
CANNULA BONE GRAFT,SUP-2814449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + S,SUP-2195531,CDM,L1830,CPT,0274,RC,,,,both,,,46.66,30.33,,,,,,,,,,,,,
PLATE BNE SHFT L204MM BLDE L70MM THK4.8MM 95DEG 12 H,SUP-2185464,CDM,C1713,HCPCS,0278,RC,,,,both,,,3227.83,2098.09,,,,,,,,,,,,,
HOOK SPNL W6.5MM THRT BILAT PEDCL S STL NEUT CLOSE NAR FOR,SUP-2255716,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.88,1514.42,,,,,,,,,,,,,
BUR SURG FLUT 60 DEG 4.2 MM BRL SUCTION IRRIGATING,SUP-2638217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,669.51,435.18,,,,,,,,,,,,,
CATHETER ETER EP 4FR 2 2 2MM ELECTRD SPC QPLR SUPREME,SUP-2356960,CDM,C1730,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PLATE BONE 3 H STD RT VOLAR WR 7 PEG FIX ANG,SUP-2389783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
PLATE BNE 8 H CRANIOMAXILLOFACIAL TI Y SHP FOR 2MM SCR,SUP-2191311,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.25,680.06,,,,,,,,,,,,,
TETRAHYDROZOLINE HCL 0.05 % OP SOLN,RX-7800,CDM,6370000000,HCPCS,0637,RC,12547-0493-80,NDC,,both,15,ML,18.90,12.28,,,,,,,,,,,,,
ROD SPNL STR 5.5X90 MM CD HORZ,SUP-2279595,CDM,C1713,HCPCS,0278,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY NYL FIX SPEC DECAPOLAR DX STRL,SUP-2727180,CDM,C1730,HCPCS,0272,RC,,,,both,,,1237.16,804.15,,,,,,,,,,,,,
HANDPIECE VITRECTOMY 23 GA 225 TD ESA VITESSE,SUP-2537896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
BIT DRL L110MM WRK L20MM DIA1.9MM CLR DEPTH MRK FOR,SUP-2364194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1373.40,892.71,,,,,,,,,,,,,
NAIL IM L320MM DIA8.5MM TIB KNEE GRY TI CANN LOK RG BENT,SUP-2347076,CDM,C1713,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
NAIL EBA ONE LONG 130 DEG RIGHT,SUP-2714105,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SPLINT ORTH SUPP MED YTH WRST FOREARM RT ALUM FOAM,SUP-2194488,CDM,L3808,HCPCS,0272,RC,,,,both,,,12.15,7.90,,,,,,,,,,,,,
KIT LD L60CM 1X8 COMP TRL SCRN FOR SACR NRV STIM VECTRIS,SUP-2284653,CDM,C1897,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
SYSTEM NAIL FIBULA 2 3.0MMX190MM,SUP-2882446,CDM,C1713,HCPCS,0278,RC,,,,both,,,11052.80,7184.32,,,,,,,,,,,,,
PROBE LASER WDG DSGN DESTRUCTIVE RFID PARAMETER MEM ENABLED,SUP-2247222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP GRACILIS TEND,SUP-2867230,CDM,C1762,CPT,0278,RC,,,,both,,,3862.99,2510.94,,,,,,,,,,,,,
PIN HALF EXT FIX UNILAT 6MM DIA 25MM THRD LEN TI ALLY HEX,SUP-2342849,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.90,1249.23,,,,,,,,,,,,,
HC So Glucose,PX-3018294766,CDM,82947,CPT,0301,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
TAP SURG L180MM DIA4MM HEX CPL FOR 6MM 2 COR SCR,SUP-2179457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER ART STD 0.025 IN 7.5 FRX110 CM 5 LUMEN WDG/SL,SUP-2798496,CDM,C1727,CPT,0278,RC,,,,both,,,155.78,101.26,,,,,,,,,,,,,
KIT REV ADPT SUPP SEAL GRFT EXP VASC CLMP AND SYR HERO,SUP-2302615,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
BIT DRL CANN 40-65 MM QR NS ACUTRK 6/7 LF DISP,SUP-2518490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
COLLAR EXTRIC AD 35IN FOR 11 23IN FR 1 PC FLAT LOK TAB CLS,SUP-2194415,CDM,L0120,HCPCS,0272,RC,,,,both,,,16.52,10.74,,,,,,,,,,,,,
GUIDE CATH VENTRICULAR STRL,SUP-2852699,CDM,C1729,HCPCS,0272,RC,,,,both,,,184.38,119.85,,,,,,,,,,,,,
SHELL ACET SZ 24 OD64MM 3 H UNIV TI ALLY POR PLSM SPR,SUP-2404804,CDM,C1776,CPT,0278,RC,,,,both,,,4761.81,3095.18,,,,,,,,,,,,,
SCREW INTFR L30MM DIA7-9MM TIB TCP/PLA BIOABSRB,SUP-2249560,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
BIT DRL L205MM DIA2.7MM STD QUIK CONN W/O STP N RADLUC,SUP-2410868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.95,248.92,,,,,,,,,,,,,
SCREW BNE MAXILLOMANDIBULAR 2X14 MM 10 MM SS MAXDRIVE LEVEL1,SUP-2495286,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.00,203.45,,,,,,,,,,,,,
GRAFT SOFT TISSUE TIB 8X30 MM WITH DRIVER APERFIX II,SUP-2664012,CDM,C1713,HCPCS,0278,RC,,,,both,,,1645.86,1069.81,,,,,,,,,,,,,
NEEDLE BX MED CANULATED STRL CORB LF,SUP-2472088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1272.99,827.44,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X2 CM AMNIO MEMBRN MTRX NEOX,SUP-2135261,CDM,Q4148,HCPCS,0636,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CATHETER IV 6 FRX60 CM 2 LUMEN POWERLINE,SUP-2217981,CDM,C1751,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BONE 6 H STR FOR SM BONES ORTHOLOC 3DI,SUP-2398061,CDM,C1713,HCPCS,0278,RC,,,,both,,,2069.26,1345.02,,,,,,,,,,,,,
CUP ACET OD49MM ID32MM HIP LONGEVITY PRI CEM NEUT SPCR ZCA,SUP-2203741,CDM,C1776,CPT,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
COMPONENT PATELLAR 3 PEG 26X7.5 MM CEM NP RND REV PRSS FT,SUP-2251220,CDM,C1776,CPT,0278,RC,,,,both,,,3357.29,2182.24,,,,,,,,,,,,,
DEVICE FIX GRFT LG 16.5X3.9 MM 60 MM 12 MM BUTTON ULT GFS,SUP-2762074,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
PLATE BONE THK0.6MM 2MM OFFSET 3X5 H BILAT MAX,SUP-2191171,CDM,C1713,HCPCS,0278,RC,,,,both,,,1215.49,790.07,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL 85FRX85FR 81CMX85CM W 032IN GWIRE,SUP-2357269,CDM,C1893,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
MASK LARYN CHLD 30 50KG SZ 3 20ML CLASS,SUP-2384073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.4MM TI ST FULL THRD MATRIXMANDIBLE,SUP-2181728,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.07,238.60,,,,,,,,,,,,,
GRAFT HUM TISS L W13XL22CM THK0.7-1.4MM THN ACELLULAR,SUP-2307606,CDM,Q4128,HCPCS,0636,RC,,,,both,,,14190.29,9223.69,,,,,,,,,,,,,
CANNULA ENDOSCP FLX 6 MMX8.5 CM W/ THRD SIL LEAFLET VLV BLK,SUP-2767566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1010.51,656.83,,,,,,,,,,,,,
PLATE BONE L45MM 6 H TI GAP FOR CRAN CLSR SYS,SUP-2243976,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.22,343.99,,,,,,,,,,,,,
PLATE EXT FIX L 75 MM 6 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.91,412.69,,,,,,,,,,,,,
HC So Primidone,PX-3018018866,CDM,80188,CPT,0301,RC,,,,both,,,155.00,100.75,,,,,,,,,,,,,
CATHETER HEM DYLS OR HD CRV 12 FRX20 CM TRPL LUMEN,SUP-2283986,CDM,C1752,HCPCS,0278,RC,,,,both,,,304.86,198.16,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X25X6 MM DEMINERALIZED CANC FLEXIGRAFT,SUP-2740835,CDM,C1713,HCPCS,0278,RC,,,,both,,,4299.23,2794.50,,,,,,,,,,,,,
PLATE BNE 150DEG FEM TRL DHS,SUP-2187958,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.90,581.03,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 6 MM MIDFACIAL 20/PK TITANIUM BRONZE,SUP-2842252,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.84,207.25,,,,,,,,,,,,,
SCREW INTRF L30MM DIA5MM B TRICALCIUM PHOS BIOCOMP MILAGRO,SUP-2249501,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
ENDCAP ORTHOPEDIC 0.5 CM HUM NAIL,SUP-2412249,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SCREW BNE ST 2.7X10 MM 2.4 MM LCK HD W/ T8 STARDRV RECESS SS,SUP-2569615,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.99,61.74,,,,,,,,,,,,,
SIZER SURG NACL BRST CNTOUR PROF HI STRL,SUP-2748623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
KIT VAG BALLOON ALATUS HDR BRACHYTHERAPY DEL 2 ATTACH,SUP-2752567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP,RX-9009,CDM,340b,HCPCS,0637,RC,17856-6764-01,NDC,,both,15,ML,5.70,3.70,,,,,,,,,,,,,
STEM EXTN FEM OR TIB FOR PROVEN OD10MM L 80MM,SUP-2359180,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SPACER PROX CNTRLZR HIP 13MM SL VERSYS,SUP-2203479,CDM,C1776,CPT,0278,RC,,,,both,,,224.51,145.93,,,,,,,,,,,,,
STEM FEM SZ 18 L140MM DIA14MM 12/14 TAPR CEM SYNERGY,SUP-2344529,CDM,C1776,CPT,0278,RC,,,,both,,,7967.75,5179.04,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7 MM UNIV LCK ULS,SUP-2861472,CDM,C1713,HCPCS,0278,RC,,,,both,,,14282.23,9283.45,,,,,,,,,,,,,
HC Speech/Language Therapy,PX-4409250700,CDM,92507,CPT,0440,RC,,,,both,,,443.00,287.95,,,,,,,,,,,,,
DEVICE TISS FIX BNE BLOCK ADJ STRL,SUP-2896385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
STEM FEM M L54MM NK L25MM LNG CEMEX GENT HI REL IMPREG,SUP-2223685,CDM,C1776,CPT,0278,RC,,,,both,,,11183.11,7269.02,,,,,,,,,,,,,
PLATE PA LK NAVICULAR CUNEIFORM RT LNG,SUP-2695657,CDM,C1713,HCPCS,0278,RC,,,,both,,,5451.04,3543.18,,,,,,,,,,,,,
HC So Chromosome Karyotype Study,PX-3118828066,CDM,88280,CPT,0311,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
PLATE BNE L265MM THK3.3MM 22 H BILAT S STL RIG STR DYN,SUP-2186340,CDM,C1713,HCPCS,0278,RC,,,,both,,,1893.51,1230.78,,,,,,,,,,,,,
COMPONENT GLEN OD46MM 40MM SURF MTL SHLDR TRABECULAR SIDUS,SUP-2199086,CDM,C1776,CPT,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L10MM DIA16MM NDL DIA016IN ADD,SUP-2293658,CDM,C1713,HCPCS,0278,RC,,,,both,,,7404.12,4812.68,,,,,,,,,,,,,
GUIDEWIRE ORTH L381MM OD1.6MM SMOOTH SHRP TIP FLEX CANNFLX,SUP-2341565,CDM,C1769,HCPCS,0272,RC,,,,both,,,167.46,108.85,,,,,,,,,,,,,
HC X-Ray Exam Uni Hip W/Pelvis 4/> Views,PX-3207350300,CDM,73503,CPT,0320,RC,,,,inpatient,,,128.00,83.20,,,,,,,,,,,,,
PLATE SPNL M L23MM DIA8MM ANTI GIC59 STR VBR PEEK,SUP-2211899,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
PC TOUMA VENT TUBE WTAB 1.14MM ID 50D,SUP-2682417,CDM,L8699,HCPCS,0278,RC,,,,both,,,60.35,39.23,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA0.034IN W/ TRCR TIP LSR MRK DISP FOR MIC,SUP-2122473,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
NERVE STIMULATOR KIT IMPLANTABLE PULSE GENERATOR VERCISE GEV,SUP-2836323,CDM,C1820,HCPCS,0278,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
PIN OCCL L12IN OD14MM L TI SERR HD APPL STRL FOR HEMORRHAGE,SUP-2381978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1310.95,852.12,,,,,,,,,,,,,
PLATE EXT FIX DIA180MM ANK FT FOR TRUELOK FRME ASSEMB,SUP-2316195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.81,1220.58,,,,,,,,,,,,,
KIT REVISION GRAFT BONE DOWEL 16 MM,SUP-2836347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SUCTION BLADE DBL SRRTD EDGE ANGLD 40DGRS RECT WNDW4MMX12CM5,SUP-2574172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.07,366.65,,,,,,,,,,,,,
MESH HERN W10XL15CM THK0.5MM SYNTH ABD ABSRB COAT POLYPR,SUP-2265976,CDM,C1781,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
CATHETER ABLAT L115 7FR 2-5-2MM SPC TR DEFL A TYP 4 POLE 10,SUP-2248785,CDM,C1730,HCPCS,0272,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
SCORPION NEEDLE KNEE,SUP-2811651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SCREW SPNL L35MM OD6.5MM TI PEDCL ST LO PROF POLYAX CANN IMP,SUP-2353328,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
KNIFE ARTHSCP L254MM HIP BAN,SUP-2121997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
MESH CRAN THK03MM TI ORBIT FLR FOR 15MM SCR MIC SYS,SUP-2262595,CDM,C1713,HCPCS,0278,RC,,,,both,,,1722.92,1119.90,,,,,,,,,,,,,
SCREW BNE LOK HINDFOOT S STL L35MM OD4.5MM SURFIX ADVANSYS,SUP-2243410,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.45,750.39,,,,,,,,,,,,,
STEM HUM SZ 10 L125MM TI EPOCA PRESSFIT,SUP-2193871,CDM,C1776,CPT,0278,RC,,,,both,,,11323.31,7360.15,,,,,,,,,,,,,
BIT DRL STP GLIDING H HERB WHPPL,SUP-2410166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,755.52,491.09,,,,,,,,,,,,,
KIT HAD ADMIN TY CHRONIC SIDE H INTRO NDL J STR GWIRE SHTH,SUP-2283954,CDM,C1750,HCPCS,0278,RC,,,,both,,,691.46,449.45,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0258,RC,00990-7983-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
TROCAR ENTRY PORTAL AFFIXUS HIP FX NAIL SYS,SUP-2412785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
FUROSEMIDE 20 MG PO TABS,RX-3294,CDM,6370000000,HCPCS,0637,RC,00904-7177-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT HUM TISS BNE TEND BNE HEMI W/ QUADRICEPS W>13MM FRZN,SUP-2307267,CDM,C1713,HCPCS,0278,RC,,,,both,,,7311.08,4752.20,,,,,,,,,,,,,
PLATE BNE L211MM 12 H ST L PROX ULN EXTRA ARTC S STL LO,SUP-2177211,CDM,C1713,HCPCS,0278,RC,,,,both,,,4098.52,2664.04,,,,,,,,,,,,,
STAPLER INT VASC 45 MM TI,SUP-2395622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
STEM FEM SZ 2 HIP CEM LUSTER,SUP-2251952,CDM,C1776,CPT,0278,RC,,,,both,,,11724.76,7621.09,,,,,,,,,,,,,
POST SURG ANKLEXPOST INTOSS FIX GRN L25MM OD6.6MM 60DEG,SUP-2223898,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
HEAD FEM DIA32MM +5MM OFFSET 12/14 TAPR HIP CERAMIC BIOLOX,SUP-2251101,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 25X55 MM FD PERIO FASC LATA ORAGRAFT,SUP-2740898,CDM,C1762,CPT,0278,RC,,,,both,,,463.78,301.46,,,,,,,,,,,,,
BIT DRL DIA4.3MM LNG DST GRAD FOR AFFIXUS HIP FRAC NAIL,SUP-2412612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1003.54,652.30,,,,,,,,,,,,,
SCREW BONE L60MM DIA6.5MM THRD L20MM CANN GUID ASNS 2,SUP-2362433,CDM,C1713,HCPCS,0278,RC,,,,both,,,862.09,560.36,,,,,,,,,,,,,
GRAFT SKIN GRAFIX PL PRIME 3X3CM LYPOPRESERVED,SUP-2319173,CDM,Q4133,HCPCS,0636,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
SYSTEM MIC ACCS GLIDEACCESS DIA 4 FR L 40 CM SS WIRE,SUP-2385207,CDM,C1894,HCPCS,0272,RC,,,,both,,,79.29,51.54,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 12 HOLE,SUP-2518365,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
BUR SURG STD LNG 100 K 2 MM HI SPD HNDPC STRL UNIDRIVE DISP,SUP-2599315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.36,427.28,,,,,,,,,,,,,
INSERT TIB SZ 4 THK10MM STD R KNEE POLYETH CRUCE RET PRI,SUP-2304718,CDM,C1776,CPT,0278,RC,,,,both,,,4520.82,2938.53,,,,,,,,,,,,,
BUR SURG RND MED 0.5 MM 64 MM ENT FLUT CARBIDE,SUP-2628878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.27,368.73,,,,,,,,,,,,,
SCREW BNE CORT HND TI L19MM OD1.5MM APTUS HEXADRIVE 4,SUP-2268059,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.85,166.30,,,,,,,,,,,,,
SYSTEM PNS 2 LD NS DISP SPRNT EXTENSA XT,SUP-2910591,CDM,C1778,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
STENT URET L 24 CM DIA 7 FR PTFE GUIDEWIRE L 100 CM DIA BLK,SUP-2312684,CDM,C2617,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BIT DRL DIA2.7MM PERC QUIK CONN,SUP-2410870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
BLADE SRGCL LMLLR STRGHT BVLD SHARP GRNDLSS SMOOTH UNDRSRFCE,SUP-2573959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
HC Fna Bx W/Fluor Gdn Ea Addl,PX-3611000800,CDM,10008,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
IMPLANT HUM TISS L 12 X W 2 CM PLCNTA MTRX MEMBRN DEHYDR,SUP-2905527,CDM,Q4184,HCPCS,0636,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
SCREW BONE L20MM OD5MM ANK CANN LAG TAPR INTOSS FIX IOFIX +,SUP-2223853,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
LAT DIST FIB PLATE LONG 15 HOLE RT,SUP-2829318,CDM,C1713,HCPCS,0278,RC,,,,both,,,5542.10,3602.36,,,,,,,,,,,,,
NAIL IM L440MM DIA2.5MM PROX TIB PNK TI ALLY FOR E STBL MOD,SUP-2192727,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.87,534.87,,,,,,,,,,,,,
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,0636,RC,00270-1315-35,NDC,,both,100,ML,25.20,16.38,,,,,,,,,,,,,
PROBE LASER 20GA PRECIS FBR CNTR PLAS HND PC STR DISP RFID,SUP-2109917,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.12,304.93,,,,,,,,,,,,,
HC Brachytherapy Isodose Plan Simple,PX-3337731600,CDM,77316,CPT,0333,RC,,,,inpatient,,,953.00,619.45,,,,,,,,,,,,,
PORT INFUS PLAS SGL LUMN W/ 9.6FR SIL CATH AIRGUARD VLV,SUP-2126328,CDM,C1788,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
HC So1 Jak2 Gene Analysis,PX-3108127067,CDM,81270,CPT,0310,RC,,,,both,,,201.00,130.65,,,,,,,,,,,,,
ANCHOR SUT OD3.5MM 2 1 MAXBRAID ABSRB LACTOSCREW,SUP-2212847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1244.95,809.22,,,,,,,,,,,,,
"HC Whole/Red Bld,Leuko Red,Cmv",PX-3900905100,CDM,P9051,CPT,0390,RC,,,,both,,,1072.00,696.80,,,,,,,,,,,,,
DRILL SURG STP 4X200 MM CANN,SUP-2749974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
ZIDOVUDINE 100 MG PO CAPS,RX-11692,CDM,6370000000,HCPCS,0637,RC,65862-0107-01,NDC,,both,1,UN,6.90,4.48,,,,,,,,,,,,,
BIT DRL 3 MM LEVERAGE,SUP-2311373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
WASHER SPNL DIA5.5MM TI FIX STPL MOSS MIAMI,SUP-2254453,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT HUM TISS W4XL16CM THK08 17MM THCK PLIABLE BRST KT,SUP-2307583,CDM,Q4128,HCPCS,0636,RC,,,,both,,,10253.67,6664.89,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RETRO CHRONIC STD 16FR DIA 40CM 35CML I,SUP-2613318,CDM,C1750,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
HC So Cyclic Amp,PX-3078203066,CDM,82030,CPT,0307,RC,,,,both,,,437.00,284.05,,,,,,,,,,,,,
PLATE BONE W15XL168MM THK2MM 8 H BILAT TI THN BLDE RIG,SUP-2190986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1674.59,1088.48,,,,,,,,,,,,,
SYSTEM CARD ICD SYS 2 CHMBR W/ RIATA ST OPTIM SYS FOR V-255,SUP-2356557,CDM,C1721,HCPCS,0275,RC,,,,both,,,71906.00,46738.90,,,,,,,,,,,,,
SCREW BNE SD 6.5X75 MM CANN HEX SOCKET TI NS,SUP-2190079,CDM,C1713,HCPCS,0278,RC,,,,both,,,680.63,442.41,,,,,,,,,,,,,
TUBE SZ 5.5 11 MM OVL,SUP-2349211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 20 CM DIA12 MM SIDE BRANCH L 10 CM DIA,SUP-2384998,CDM,C1768,CPT,0278,RC,,,,both,,,5086.80,3306.42,,,,,,,,,,,,,
COIL EMB L15CM LOOP DIA4MM PERIPH SELF EXP HYDRGEL POLYMER,SUP-2385397,CDM,C1889,HCPCS,0278,RC,,,,both,,,3995.96,2597.37,,,,,,,,,,,,,
S-ROM*SCREWTROCHANTER52MM,SUP-2515617,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-157666,CDM,J1650,HCPCS,0636,RC,63323-0589-21,NDC,,both,1,ML,80.30,52.19,,,,,,,,,,,,,
GUIDEPIN SURG DIA2MM MINIMALLY INVASIVE SACROILIAC JT SURG,SUP-2337769,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
STEM HUM 12-130 MM SHLDR TI ANAT SHLDR,SUP-2440606,CDM,C1776,CPT,0278,RC,,,,both,,,8901.90,5786.23,,,,,,,,,,,,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,2500000003,HCPCS,0250,RC,00409-3294-51,NDC,,both,50,ML,64.40,41.86,,,,,,,,,,,,,
SCREW BNE L14MM OD2.7MM TI LOK FOR TOT FT SYS,SUP-2243271,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.73,439.87,,,,,,,,,,,,,
HC Treat Thigh Fx,PX-4502750800,CDM,27508,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
ALLOGRAFT BNE HUM HD FRZN TISS,SUP-2165581,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PACEMAKER CARD ESSENTIO DR W 4.45 X H 5.88 CM THK 0.75 CM,SUP-2149246,CDM,C1785,HCPCS,0275,RC,,,,both,,,25336.66,16468.83,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.2MM SELF DRL LO PROF HD HT AXS 5PK,SUP-2363852,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.62,225.30,,,,,,,,,,,,,
PLATE BNE W15XL152MM THK2MM 7 H BILAT S STL COVERLEAF RIG,SUP-2186009,CDM,C1713,HCPCS,0278,RC,,,,both,,,1611.79,1047.66,,,,,,,,,,,,,
CATHETER GUID WINGMAN 14 L 65 CM OD 0.035 IN TIP DIA 0.022,SUP-2227762,CDM,C1887,HCPCS,0272,RC,,,,both,,,2028.44,1318.49,,,,,,,,,,,,,
SCREW BNE L44MM DIA3.5MM EL TI LOK MULTDIR FOR ALPS FRAC,SUP-2413775,CDM,C1713,HCPCS,0278,RC,,,,both,,,641.82,417.18,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE TIB CUST FRAC RIGID,SUP-2435650,CDM,L2116,HCPCS,0272,RC,,,,both,,,2182.11,1418.37,,,,,,,,,,,,,
"HC Plmt Nephrostomy Catheter,Perc",PX-3615043200,CDM,50432,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
INSTRUMENT KIT 5.5 MM ANCHR SUTURE DRL GUIDE GRAVITY DISP,SUP-2401441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BIT DRILL CANN 4.5 MM ACROMIOCLAVICULAR JT MTO,SUP-2849153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
VALVE VENT LO REG W O RESVR N PROGRAMMABLE 54FR 3CM,SUP-2284395,CDM,C1713,HCPCS,0278,RC,,,,both,,,1926.77,1252.40,,,,,,,,,,,,,
PLATE BNE H1MM 16 H MAND BLU TI MINI STR LOK LEIBINGER,SUP-2366345,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.52,325.34,,,,,,,,,,,,,
SEMI-TUBULAR PL 12X199MM,SUP-2818488,CDM,C1713,HCPCS,0278,RC,,,,both,,,977.70,635.50,,,,,,,,,,,,,
SET URET STENT L 24 CM DIA 7 FR GUIDEWIRE L 145 CM DIA 0.038,SUP-2171274,CDM,C2617,HCPCS,0278,RC,,,,both,,,422.80,274.82,,,,,,,,,,,,,
KIT MINI ACCS STIFF DIL W 5FR 10CM COAX INTRO SHTH 40CM,SUP-2303436,CDM,C1893,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
CIPROFLOXACIN (CIPRO) IV (PEDS),RX-4085029,CDM,J0744,HCPCS,0636,RC,00409-2300-24,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL DIA2.7 MM SCREW DIA 3.5 MM LNG CANN BUNION SYS NS,SUP-2899038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.87,555.67,,,,,,,,,,,,,
CATHETER ENDO BILI BAL 5FR 4MM OD 4CM 180CM WRK LEN INFL W/,SUP-2148886,CDM,C1887,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
IMPLANT FACE L 130 X W 130 MM THK 3 MM POLYETHYL EMBEDDED TI,SUP-2883612,CDM,C1713,HCPCS,0278,RC,,,,both,,,28043.72,18228.42,,,,,,,,,,,,,
GOUGE 8IN CRV 1 1 4IN SMITH PETERSEN,SUP-2244788,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.88,162.42,,,,,,,,,,,,,
PLUG BNE DIA8MM SM DIAM CEM,SUP-2408547,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
BIT DRL OD9.5MM SACROILIAC CANN SI-LOK,SUP-2232172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
TUBE GASTROSTMY 40FR L107CM CLS ROUNDED TIP SM SIDE H,SUP-2138634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
PLATE BNE MESH PANEL SM 2X30X23X1 MM SPECIALITY GRID TI NS,SUP-2486415,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.09,616.26,,,,,,,,,,,,,
HC Assay of Testosterone Total|NOT REASONABLE AND NECESSARY,PX-3018440300,CDM,84403,CPT,0301,RC,,,GZ,both,,,359.00,233.35,,,,,,,,,,,,,
HC So Tissue Level IV,PX-3128830566,CDM,88305,CPT,0312,RC,,,,both,,,968.00,629.20,,,,,,,,,,,,,
SYSTEM DRL GUID ACL PCL COMPONENTS GRAD DRL TIP PASS PIN,SUP-2341114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.97,237.88,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 40 CM DIA 0.018 IN NIT MANDREL SS TIP,SUP-2383178,CDM,C1769,HCPCS,0272,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
KIT CATH HEMODIALYSI AHDC SAFETY 12FR DIA 16CM 3 CDC12123P1A,SUP-2632983,CDM,C1751,HCPCS,0278,RC,,,,both,,,402.55,261.66,,,,,,,,,,,,,
TITANIUM 3D MESH 200MM X 200MM 6MM 15MM SSTM CP TTNM,SUP-2676603,CDM,C1713,HCPCS,0278,RC,,,,both,,,19720.99,12818.64,,,,,,,,,,,,,
STRUT EXT FIX ANGULAR,SUP-2197287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
PLATE BNE L85MM 7 H BILAT S STL 1/3 TBLR FOR 3.5MM SCR,SUP-2411342,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.88,131.87,,,,,,,,,,,,,
CATHETER KT ABSC DRNGE CUST MTN STATES MSHA,SUP-2302881,CDM,C1729,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
PEEK SWIVELOCK BICEPS TENO AR1662PSL710,SUP-2843734,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB W/ 10110A SYS INS5010 HERM,SUP-2883636,CDM,C1729,HCPCS,0272,RC,,,,both,,,1024.11,665.67,,,,,,,,,,,,,
PLATE BONE L171MM 6 H LT SHFT FOR BUTTRESSING MULTIFRAGMENT,SUP-2152509,CDM,C1713,HCPCS,0278,RC,,,,both,,,4155.19,2700.87,,,,,,,,,,,,,
HC So2 Amino Acids 6 or < Ea Spec,PX-3018213968,CDM,82139,CPT,0301,RC,,,,both,,,410.00,266.50,,,,,,,,,,,,,
PLATE BNE L185MM 12 H NONSTERILE R PROX TIB TI LOK COMPR LO,SUP-2190886,CDM,C1713,HCPCS,0278,RC,,,,both,,,4370.35,2840.73,,,,,,,,,,,,,
ELECTRODE ENDOSCP OD2428FR 0.35 WIRE 12DEG 30DEG MPLR W/,SUP-2797226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.42,504.02,,,,,,,,,,,,,
IMPL SHOULDER BEARING 36MM +3,SUP-2418103,CDM,C1776,CPT,0278,RC,,,,both,,,5903.20,3837.08,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.4MM TI ST NONCANNULATED LOK FULL THRD,SUP-2181150,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.13,298.43,,,,,,,,,,,,,
SCREW BNE L13MM DIA2.4MM S STL CANN COMPR HAMRTOE FIX SYS,SUP-2397841,CDM,C1713,HCPCS,0278,RC,,,,both,,,2524.56,1640.96,,,,,,,,,,,,,
PLATE CRAN L 53 X W 48 MM THK 0.3 MM SCREW DIA1.5 MM LG TI,SUP-2936461,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
PLATE BNE FEM 305 MM LT DSTL LAT CNDYL 16 HOLE BUTTRESS SS,SUP-2460588,CDM,C1713,HCPCS,0278,RC,,,,both,,,2442.48,1587.61,,,,,,,,,,,,,
ALLOGRAFT BNE ACETABULUM,SUP-2321752,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
PATCH DURA L 3.1 X W 2.4 IN SURF AREA 7.4 SQ IN BOV PERICARD,SUP-2884046,CDM,C1763,HCPCS,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
GUIDEWIRE ORTH FLUT TIP 2.8X450 MM STRL,SUP-2789103,CDM,C1769,HCPCS,0272,RC,,,,both,,,644.96,419.22,,,,,,,,,,,,,
HC Exclusion L Atr Appendage Thoracoscopic Any Meth,PX-3603362900,CDM,33269,CPT,0360,RC,,,,both,,,7823.00,5084.95,,,,,,,,,,,,,
PIN EXT FIX THRD L30MM DIA5MM SHANK L110MM DIA5MM S STL,SUP-2342918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
PLATE BNE W10XL166MM THK3.6MM 14 H BILAT S STL CRV RIG CLLR,SUP-2186257,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.85,1735.40,,,,,,,,,,,,,
STEM HUM SZ 0 PRSS FIT + PROMOS,SUP-2351212,CDM,C1776,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
BLOCK FEM AUG HINGED XS UNIV 10 MM DSTL PRIMARY PRSS FT,SUP-2376357,CDM,C1776,CPT,0278,RC,,,,both,,,1823.71,1185.41,,,,,,,,,,,,,
PLATE BNE L100MM 20 H MAX BILAT TI STR NONCOMPRESSION LO,SUP-2191228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1872.70,1217.25,,,,,,,,,,,,,
BAR EXTERNAL FIXATION L150MM DIA11MM XTRAFIX SYSTEM,SUP-2467698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.53,356.54,,,,,,,,,,,,,
FIBER LASER 365 MH N TAPR POLISHED TIP HOLM ACCUMAX,SUP-2537762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.97,633.08,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE MATERIAL 5 CC PREFILL STRL ACCUFILL LF,SUP-2866848,CDM,C1713,HCPCS,0278,RC,,,,both,,,11114.66,7224.53,,,,,,,,,,,,,
CANNULA VEN LNG 23 FR BIOLINE COATED HLS,SUP-2663462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1575.37,1023.99,,,,,,,,,,,,,
CATHETER DIL 5.8FR L180CM BLLN L4CM DIA8MM GWIRE 0.035IN,SUP-2149601,CDM,C1726,HCPCS,0272,RC,,,,both,,,774.32,503.31,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 5.5MM WITH NEEDLE SOFT TISSUE NONBIOA,SUP-2824897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
CATHETER CV KT 9 FRX11.5 CM DSTL DL FOR 7.5-8 FR MAC,SUP-2763355,CDM,C1751,HCPCS,0278,RC,,,,both,,,568.97,369.83,,,,,,,,,,,,,
DRILL SURGICAL BONE  MOORE,SUP-2793438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1528.40,993.46,,,,,,,,,,,,,
COMPLETION REV FEM DISTL BLOCK,SUP-2513639,CDM,C1776,CPT,0278,RC,,,,both,,,6911.14,4492.24,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0.035IN TIP L4CM NIT HYDRPHLC,SUP-2170149,CDM,C1769,HCPCS,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
TR PN W/CV PT 150X50X5 HP,SUP-2818275,CDM,C1713,HCPCS,0278,RC,,,,both,,,1599.05,1039.38,,,,,,,,,,,,,
COMPONENT 1X1.5MM OFFSET KNEE RESURF ARTC UNICAP,SUP-2123714,CDM,C1776,CPT,0278,RC,,,,both,,,2053.56,1334.81,,,,,,,,,,,,,
PROCESSOR HEARING AID W65XH30MM COCHLEAR SANDY BRN CP950,SUP-2165028,CDM,L8614,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
JONES BOLT NAIL 4.5MMX47MM STERILE,SUP-2815802,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
PROBE VITRECTOMY 23 GA STR ENDOILLUMINATOR PK EDGEPLUS,SUP-2109956,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.37,1377.59,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM HI FLX M HXLPE,SUP-2212706,CDM,C1776,CPT,0278,RC,,,,both,,,11991.69,7794.60,,,,,,,,,,,,,
PLATE BONE 4 H STR OMNI,SUP-2223995,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
APPLIER LIG CLP 5MM CONTAIN 16 TI CLP DISP ENDO CLP,SUP-2283167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1593.55,1035.81,,,,,,,,,,,,,
LEAD PACE SWEET PICOTIP RX L 70 CM SIL ENDOCARD RT,SUP-2148637,CDM,C1898,HCPCS,0275,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
COMPONENT FEM 1 KNEE RESTORIS,SUP-2265732,CDM,C1776,CPT,0278,RC,,,,both,,,6676.43,4339.68,,,,,,,,,,,,,
EXTERNAL FIXATION KIT B FLD STRL HOFFMANN 3,SUP-2431372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,20924.96,13601.22,,,,,,,,,,,,,
BLADE SURGICAL CURVED CAPFIX,SUP-2880378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 88 MM CORTICAL CRANIOMAXILLOFACIAL E,SUP-2838217,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.98,158.59,,,,,,,,,,,,,
T-PLT STERILIZER 8 HL 148 MM LENGTH,SUP-2818458,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.99,2031.24,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 4-10 MM 10 CC CANC PROX DSTL END LNG,SUP-2913283,CDM,C1713,HCPCS,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
BRACE WRST SUPP LG 7.5-8.5 IN RT STABILIZING,SUP-2196519,CDM,L3931,HCPCS,0274,RC,,,,both,,,26.72,17.37,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 8.5 FRX50 CM BILI SET 32 HOLE UTHANE,SUP-2168185,CDM,C1729,HCPCS,0272,RC,,,,both,,,166.89,108.48,,,,,,,,,,,,,
SHUNT CAR 9 FRX31 CM OUTLYING 2 BLLN OCCL TPORT PRUITT F3,SUP-2589471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4298.66,2794.13,,,,,,,,,,,,,
CATHETER INTVASC LITHO E8 WORKING L 150 CM L 80 MM DIA 4 MM,SUP-2895276,CDM,C1725,HCPCS,0272,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
MESH SURG W4XL6IN OMEGA 3 FATTY ACIDS NAT BIORESORBABLE,SUP-2265964,CDM,C1781,HCPCS,0278,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
PIN BNE FIX DIA17MM SUP E NIT SYS MEMOFIX,SUP-2244268,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.91,565.44,,,,,,,,,,,,,
COVER BUR H DIA17MM 6 H BILAT TI CNTOUR RIG NONCOMPRESSION,SUP-2190696,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.29,622.24,,,,,,,,,,,,,
MARKER IDENTIFIER BX SITE MRI,SUP-2382011,CDM,A4648,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
MESH CRNL SIZE 1 06MM THK TTNM CNTRD STNDRD LATEX FREE BFRN,SUP-2707377,CDM,C1713,HCPCS,0278,RC,,,,both,,,8430.84,5480.05,,,,,,,,,,,,,
PROGRAMMER DBS PT NS REUSE PERCEPT,SUP-2883011,CDM,C1787,HCPCS,0278,RC,,,,both,,,5115.44,3325.04,,,,,,,,,,,,,
CATHETER EP D CRV 2-5-2 MM 6 FRX120 CM FIX,SUP-2356814,CDM,C1730,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SPACER SPNL H15MM ASMBLY PRIMALOK SP,SUP-2319814,CDM,C1713,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
GYN ESG PLASMABAND MED 12 30 DEG,SUP-2722603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1615.47,1050.06,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM 2-5-2MM SPC RF L CRV THRMCPL QPLR,SUP-2357655,CDM,C2630,CPT,0272,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
DYNANITE COMP PLATE SEGMENTED 20/20,SUP-2814532,CDM,C1713,HCPCS,0278,RC,,,,both,,,10346.30,6725.09,,,,,,,,,,,,,
PLATE BNE SM W11XL241MM THK34MM 18 H BILAT TI RIG NEUT LOK,SUP-2190797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2243.62,1458.35,,,,,,,,,,,,,
SYSTEM TISS COLLCTN SM SFT PD SEG REV SYS MOD AUG REGENEREX,SUP-2402757,CDM,C1776,CPT,0278,RC,,,,both,,,11454.72,7445.57,,,,,,,,,,,,,
STENT PERIPH L 18 MM DIA2.5 MM POST DIL DIA 3 MM SHTH 5 FR,SUP-2892902,CDM,C1874,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 2X1 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651372,CDM,Q4154,HCPCS,0636,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SHEATH INTRO L 45 CM DIA 6 FR GUIDEWIRE 0.038 IN MULTPURP,SUP-2876096,CDM,C1894,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 5000RPM 40DEG ROT STR SHOT CRV SHFT,SUP-2284147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.65,496.37,,,,,,,,,,,,,
BUR SURG RND XLN 1 MM 77 MM ENT FLUT CARBIDE,SUP-2628880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.97,382.18,,,,,,,,,,,,,
ROD SPNL L95MM DIA6.35MM R ANT TI SMOOTH PRECRV MNRCH,SUP-2254475,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.40,802.36,,,,,,,,,,,,,
SCREW INTFR L25MM DIA8MM TI RND HD CANN FOR ACL RECON,SUP-2212929,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE L 36 MM DIA 3.5 MM FT LAG STRL ORTHOLOC 3DI,SUP-2900557,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT GWIRE L300CM DIA0.014IN BSKT DIA6MM,SUP-2158108,CDM,C1769,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
CATHETER ABLAT D-F CRV BIDIR TACTICATH CNTCT FORC SENS,SUP-2418133,CDM,C2630,CPT,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
CAP SGL SITE LPSCPC SEAL,SUP-2219933,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
HC CT Pelvis W/WO Contrast,PX-3527219400,CDM,72194,CPT,0352,RC,,,,outpatient,,,2630.00,1709.50,,,,,,,,,,,,,
GRAFT HUMAN TISSUE BIOLOGICAL TISSUE MATRIX THICK 35X20 CM NON CROSSLINKED SCAFFOLD NATURALLY OCCURRING PORCINE STERILE GENTRIX DISPOSABLE,SUP-2106504,CDM,Q4166,HCPCS,0636,RC,,,,both,,,59510.85,38682.05,,,,,,,,,,,,,
TOTAL TM ANK,SUP-2212315,CDM,C1776,CPT,0278,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
STEM HUM DIA11MM 132.5DEG STD SHLDR PROX BODY AEQUALIS FLX,SUP-2418013,CDM,C1776,CPT,0278,RC,,,,both,,,13489.44,8768.14,,,,,,,,,,,,,
INSERT TIB KNEE ARTC SURF FLAT CRUC RET A B PUR LT RT 11MM,SUP-2199500,CDM,C1776,CPT,0278,RC,,,,both,,,6011.22,3907.29,,,,,,,,,,,,,
PLATE BNE T 1.5X1 MM 6 MM LT 2X3 HOLE C-TUBE HK BRIDGE TI NS,SUP-2468186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.47,888.86,,,,,,,,,,,,,
PLATE BNE 7 H R LAPIDUS TI LO PROF MAL FOR 35MM SCR CONTOURS,SUP-2316435,CDM,C1713,HCPCS,0278,RC,,,,both,,,4372.01,2841.81,,,,,,,,,,,,,
PLATE BNE 6 H TI STR FOR 2MM SCR MOD HND SYS,SUP-2191190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.94,867.71,,,,,,,,,,,,,
DEVICE PROSTHETIC TYP BK SOCKET MOLD,SUP-2388180,CDM,L2350,HCPCS,0272,RC,,,,both,,,2452.91,1594.39,,,,,,,,,,,,,
KIT BONE CEM PRECIS W/ MX AND DEL SYS W/OUT NDL PCD,SUP-2367029,CDM,C1713,HCPCS,0278,RC,,,,both,,,1325.36,861.48,,,,,,,,,,,,,
SCREW BNE L24MM DIA2MM CORT TI ST FOR MOD HND SYS PRO-PAK,SUP-2189608,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.69,63.50,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X3 CM CRYOPRESERVED UMB CRD NEOX CRD 1K,SUP-2648686,CDM,Q4148,HCPCS,0636,RC,,,,both,,,3180.82,2067.53,,,,,,,,,,,,,
GRAFT VASC GORTX L 60 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2396424,CDM,C1768,CPT,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
SCREW BNE L14MM DIA4MM CORT S STL ST NONCANNULATED LOK FULL,SUP-2185052,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.85,243.65,,,,,,,,,,,,,
"HC Phlebotomy,Tx",PX-9409919500,CDM,99195,CPT,0940,RC,,,,inpatient,,,330.00,214.50,,,,,,,,,,,,,
HEAD HUM OD22.2MM -2MM SHLDR BPLR INNR IMP FOR SHLDR,SUP-2404517,CDM,C1776,CPT,0278,RC,,,,both,,,4091.42,2659.42,,,,,,,,,,,,,
HEAD SPNL POLYAX MARINER,SUP-2431111,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COLLAR CERV SFT DENS W/ CHIN SUPP ADJ AD CNTOUR HK AND LOOP,SUP-2324378,CDM,L0120,HCPCS,0274,RC,,,,both,,,16.64,10.82,,,,,,,,,,,,,
KIT BONE MAR ASPIR SYR 60CC PREP TY,SUP-2120787,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
BLADE SAW THK0.38MM CUT D10MM CUT EDGE 9MM OSC THN PRECIS,SUP-2367235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,104.31,67.80,,,,,,,,,,,,,
HC Abdominal Aortogram,PX-3237562500,CDM,75625,CPT,0323,RC,,,,both,,,2979.00,1936.35,,,,,,,,,,,,,
KIT CATH 7FR L8IN POLYUR CTRL VEN 3 LUMN ANTIMIC SURF BLU,SUP-2383390,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.75,220.84,,,,,,,,,,,,,
HC So Column Chromotography Quant,PX-3018254266,CDM,82542,CPT,0301,RC,,,,both,,,202.00,131.30,,,,,,,,,,,,,
MESH C-QUR EDGE OBLONG OVL 6 INX9 IN,SUP-2265967,CDM,C1781,HCPCS,0278,RC,,,,both,,,2502.58,1626.68,,,,,,,,,,,,,
SCREW INTFR L20MM DIA7MM VENT BIOCOMPOSITE,SUP-2121791,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PLATE BNE L132MM 12 H ST POST DST TIB S STL T LOK COMPR FOR,SUP-2177439,CDM,C1713,HCPCS,0278,RC,,,,both,,,4709.25,3061.01,,,,,,,,,,,,,
SUTURE NONABSORBABLE MONOFILAMENT 7-0 BV1756 4X24 IN PRONOVA M3735,SUP-2219569,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.62,242.20,,,,,,,,,,,,,
DISSECTOR DIERKS 2 LNG 18.5CM7 1/4IN,SUP-2495024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,561.81,365.18,,,,,,,,,,,,,
SWAN GANZ VIPOXIMETRY,SUP-2696338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,644.55,418.96,,,,,,,,,,,,,
BAND COMPR CHST LIFEBAND AUTOPULSE DISP,SUP-2416147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.50,280.47,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 8 H SCREW DIA2 MM MED TI MIDFACE STR CMPRSS,SUP-2883775,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
HC Open/Perq Place Stent Ea Add A,PX-3603723700,CDM,37237,CPT,0360,RC,,,,outpatient,,,15457.00,10047.05,,,,,,,,,,,,,
STEM FEM SZ 4 L141MM 135DEG TI HIP CEMENTLESS BILAT STR,SUP-2304831,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
HC Respirator Motion Mgmt Simul,PX-3337729300,CDM,77293,CPT,0333,RC,,,,outpatient,,,4423.00,2874.95,,,,,,,,,,,,,
DICLOFENAC SODIUM 25 MG PO TBEC,RX-15339,CDM,6370000000,HCPCS,0637,RC,16571-0203-10,NDC,,both,1,UN,4.80,3.12,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 24MM POLYESTER BOV CLLGN STR,SUP-2265929,CDM,C1768,CPT,0278,RC,,,,both,,,2348.72,1526.67,,,,,,,,,,,,,
SHEARS ENDOSCP L9CM CRV HARM FOCS +,SUP-2219103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1371.14,891.24,,,,,,,,,,,,,
BUSHING TIB POLY LO FRIC INTFACE OSS,SUP-2405827,CDM,C1776,CPT,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
RULER SURG FEM XR S2,SUP-2473062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
TROCAR SURG DBL SL 5X120 MM ASMBLY,SUP-2517248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.83,427.59,,,,,,,,,,,,,
CUP ACET OD43MM ID22MM LONGEVITY HXLPE NEUT SPCR ALL POLY,SUP-2203732,CDM,C1776,CPT,0278,RC,,,,both,,,3837.08,2494.10,,,,,,,,,,,,,
CATHETER EP H 1-7-1 MM 7 FRX110 CM INQUIRY,SUP-2357627,CDM,C1731,HCPCS,0278,RC,,,,both,,,3070.92,1996.10,,,,,,,,,,,,,
GUIDEWIRE VASC L200CM COIL L10CM DIA0012IN GREATER THAN,SUP-2172468,CDM,C1769,HCPCS,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
RING ANNULPLSTY TRICSP 26MM EDW MC3 4900T26] EDWARDS LIFESCIENCES CORP],SUP-2214221,CDM,C1713,HCPCS,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
BUR SURG DIA6MM CARB RND,SUP-2364021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,864.82,562.13,,,,,,,,,,,,,
PLATE BONE W12XL167MM THK1MM 10 H BILAT TI SEMI TBLR LO PROF,SUP-2190708,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.40,229.06,,,,,,,,,,,,,
PREM ST/CER HD,SUP-2137302,CDM,C1776,CPT,0278,RC,,,,both,,,9052.62,5884.20,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EPIC II HF THK 13 MM 36 CC 74 GM TI,SUP-2356586,CDM,C1882,HCPCS,0275,RC,,,,both,,,65940.00,42861.00,,,,,,,,,,,,,
SCREW BONE L5MM DIA1.4MM EMER LO PROF HD HT AXS 5PK,SUP-2363853,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.17,210.06,,,,,,,,,,,,,
GRAFT BNE FRZN STRUT CORT IMPL ALLGRFT L200XW15MM MATRIGRFT,SUP-2264746,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.18,871.12,,,,,,,,,,,,,
BLADE RETRACTOR ABH 8X1 IN RENAL ALUM,SUP-2480945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1443.65,938.37,,,,,,,,,,,,,
PLATE BNE 3.5X261 MM 20 HOLE SS LCP,SUP-2569331,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.63,383.91,,,,,,,,,,,,,
COLLAR CERV AD TALL CUSH FLX TAB OCCIPITAL SUPP STRP,SUP-2123893,CDM,L0180,HCPCS,0272,RC,,,,both,,,59.63,38.76,,,,,,,,,,,,,
SPLINT WR AND FRARM TITEX W/ LOOP LCK LT M,SUP-2195255,CDM,L3809,HCPCS,0274,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
STENT URET 7FR L26CM POLYMER BLEND PH FREE COAT GRADUAL,SUP-2129073,CDM,C2617,HCPCS,0278,RC,,,,both,,,611.73,397.62,,,,,,,,,,,,,
PLATE BONE L87MM THK3.8MM 11 H BILAT S STL NAR DYN COMPR FOR,SUP-2185212,CDM,C1713,HCPCS,0278,RC,,,,both,,,696.61,452.80,,,,,,,,,,,,,
EXTENSION TIB STEM L 20 MM TI KNEE CR CEM STRL ITOTAL,SUP-2904369,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
DRILL SURG TWST 1.8 MM ALL-SUTURE ANCHR STRL Q-FIX MINI LTX,SUP-2880231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.98,375.04,,,,,,,,,,,,,
COMPONENT FEM ML 64 MM AP 60 MM SZ D TINBN LT KNEE PS STRL,SUP-2914453,CDM,C1776,CPT,0278,RC,,,,both,,,5196.70,3377.85,,,,,,,,,,,,,
MESH SURG W4XL6IN STD FOR INGUINAL HERN REP PROLITE ULT,SUP-2227396,CDM,C1781,HCPCS,0278,RC,,,,both,,,141.43,91.93,,,,,,,,,,,,,
AUGMENT FEM L55MM THK10MM RT MEDL LT LAT POST KNEE CONSTRN,SUP-2405656,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBM FRZ DRY I/C CHMBR,SUP-2264798,CDM,C1762,CPT,0278,RC,,,,both,,,2803.55,1822.31,,,,,,,,,,,,,
BIT DRL DIA4.3MM SH 2IN1 AO FOR HALLU-LOCK MTP ARTH SYS,SUP-2242909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
MINI PLATE Z SHAPE 6 HOLE RGHT 10 MM BAR 3MM WIDTH CP TTNM,SUP-2669687,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.80,547.17,,,,,,,,,,,,,
PLATE SPNL W6.5XL17MM UNIV 2 H TI ANTR LUM LCK CVR SET SCR,SUP-2291665,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GUIDEWIRE 3.2MM GUIDE WIRE 475MM STERILE,SUP-2547184,CDM,C1769,HCPCS,0272,RC,,,,both,,,455.24,295.91,,,,,,,,,,,,,
JOINT TOE INTRAOSSEOUS 2.4 MM D8 CANNULINK,SUP-2400026,CDM,C1713,HCPCS,0278,RC,,,,both,,,4543.58,2953.33,,,,,,,,,,,,,
VALVE HEMOSTAS HONOR DIA 7.2 FR POLYCARB SIL MTL ROTATING,SUP-2303048,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.93,49.35,,,,,,,,,,,,,
MESH BIO PORCINE MTRX TENDON/LIGAMENT REP 9CM LEN 6CM W,SUP-2244087,CDM,C1763,HCPCS,0278,RC,,,,both,,,9994.62,6496.50,,,,,,,,,,,,,
BARRIER ADH W3XL5IN SM INCIS SEPRAFILM,SUP-2227090,CDM,C1765,HCPCS,0278,RC,,,,both,,,913.49,593.77,,,,,,,,,,,,,
PLATE BNE LCK 3.5X224 MM RT PROX LAT TIB 16 HOLE STRL,SUP-2462536,CDM,C1713,HCPCS,0278,RC,,,,both,,,4201.89,2731.23,,,,,,,,,,,,,
PLATE BNE W6.3XL48MM THK1.6MM 5 H R DST RAD VOLAR S STL STR,SUP-2186101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1605.76,1043.74,,,,,,,,,,,,,
PLATE BNE 2X27X1 MM 5 HOLE SS DCP,SUP-2569120,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.14,176.24,,,,,,,,,,,,,
PLATE BNE L71MM 4 H SEMI TBLR FOR 4.5MM SCR,SUP-2411384,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.89,113.03,,,,,,,,,,,,,
SEAT CLOSE MULTAXL VAR ANG LCK,SUP-2415639,CDM,C1713,HCPCS,0278,RC,,,,both,,,1735.54,1128.10,,,,,,,,,,,,,
HYDROCERIN EX CREA,RX-20102,CDM,6370000000,HCPCS,0637,RC,00904-7751-27,NDC,,both,454,GR,18.40,11.96,,,,,,,,,,,,,
RETRACTOR LAT VEO,SUP-2164090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
STEM FEM L152MM OD11MM FINN L14CM HIP SEGMENTED COMP,SUP-2406101,CDM,C1776,CPT,0278,RC,,,,both,,,12917.65,8396.47,,,,,,,,,,,,,
SYSTEM FIX KNOTLESS TENSIONABLE BICEPS IMPL STRL FIBERTAK,SUP-2859829,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
TRAY HEMODLYS INSRT L15CM SHT TERM STR DLYS CATH,SUP-2125593,CDM,C1752,HCPCS,0278,RC,,,,both,,,639.68,415.79,,,,,,,,,,,,,
COMPONENT FEM CRUC RET ASYM RT SZ 1 LOGIC,SUP-2220840,CDM,C1776,CPT,0278,RC,,,,both,,,17169.52,11160.19,,,,,,,,,,,,,
TRIAL INSRT CS 6 10 MM TIB KNEE SLD TRIATHLON,SUP-2422367,CDM,C1776,CPT,0278,RC,,,,both,,,557.35,362.28,,,,,,,,,,,,,
UNIT THER COMB CRYO W PD MULT USE W TB PWR OPERATED W BD,SUP-2196470,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.62,259.10,,,,,,,,,,,,,
PROSTHESIS OSS NOTCHED 4.0MM DIA 0.8MM SHAFT 7.0MML,SUP-2902787,CDM,L8613,CPT,0278,RC,,,,both,,,1519.26,987.52,,,,,,,,,,,,,
WASHER ORTH OD8MM ID4MM THK1MM S STL FOR 4MM CANN SCR SYS,SUP-2343600,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.12,178.18,,,,,,,,,,,,,
COIL EMB L3CM OD25MM 360DEG HELI USFT STRTCH RESIST BIG,SUP-2365768,CDM,C1889,HCPCS,0278,RC,,,,both,,,6800.61,4420.40,,,,,,,,,,,,,
SPINAL SET LCK 30 MM CAP/ROD COMB NEWPORT MIS,SUP-2245597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
COMPONENT ARTC SURF 12 MM KNEE NXGN LEG,SUP-2402783,CDM,C1776,CPT,0278,RC,,,,both,,,6382.99,4148.94,,,,,,,,,,,,,
BIT DRL L70MM DIA19MM BLK S STL TWST J NOTCH W O STP REUSE,SUP-2262756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.78,280.01,,,,,,,,,,,,,
TIP US SONOTRODE STD STR FOR SONICWELD RX II,SUP-2486770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.24,474.66,,,,,,,,,,,,,
BURR SURG 6.5MM DIA HD CARBIDE SM BNE RND FLUTEX10 MICROPOWE,SUP-2605578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,124.56,80.96,,,,,,,,,,,,,
GRAFT BNE STRP 20X15X5 MM COMPRESSIBLE BNE MTRX,SUP-2644318,CDM,C1713,HCPCS,0278,RC,,,,both,,,2742.16,1782.40,,,,,,,,,,,,,
GUIDEWIRE VASC ARISTOTLE ZOOM WIRE 14 L 200CM 0.014IN SUPP,SUP-2656741,CDM,C1769,HCPCS,0272,RC,,,,both,,,1742.70,1132.75,,,,,,,,,,,,,
FORCEPS BX STD 5.5FR L50CM SHFT 1.85MM INT JUG APPRCH DISP,SUP-2157334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
CONNECTOR TI DOM CL 45 CL 55,SUP-2279853,CDM,C1713,HCPCS,0278,RC,,,,both,,,2775.76,1804.24,,,,,,,,,,,,,
SCREW BNE CANN LNG THRD 4X38 MM,SUP-2194004,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.19,375.17,,,,,,,,,,,,,
KNIFE SRGCL YASRGL BCKWRD CTTNG ARCHND LATEX FREE,SUP-2673044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.71,253.96,,,,,,,,,,,,,
STAPLER HERN H48MM DIA12MM ENDO MULTFI,SUP-2752143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.25,267.96,,,,,,,,,,,,,
PLATE BNE TIB LT ANTEROLATERAL 27 HOLE NS LTX,SUP-2857006,CDM,C1713,HCPCS,0278,RC,,,,both,,,9055.76,5886.24,,,,,,,,,,,,,
ROD DISTRACTOR MAXILLOFCL ACTIVATION FLX NS,SUP-2883546,CDM,C1713,HCPCS,0278,RC,,,,both,,,2385.71,1550.71,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA SULF HI STRENGTH INJ RESRB MIIG X3,SUP-2399046,CDM,C1713,HCPCS,0278,RC,,,,both,,,5451.42,3543.42,,,,,,,,,,,,,
MONITOR CARD BIOMONITOR 2 AF PROMRI SIL HOME MONITORING MR,SUP-2138426,CDM,C1764,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
KNIFE SURG L160MM SHTH,SUP-2284813,CDM,C1713,HCPCS,0278,RC,,,,both,,,1192.92,775.40,,,,,,,,,,,,,
STRATTICE RCNSTRCTVE TSSUE MTRX PRFRTD 15 35 FIRM,SUP-2680183,CDM,Q4116,HCPCS,0636,RC,,,,both,,,51976.42,33784.67,,,,,,,,,,,,,
STEM FEM CMNTLS STD 14 HIP MONOBLOC REV STD OFFSET RECLAIM,SUP-2874188,CDM,C1776,CPT,0278,RC,,,,both,,,27152.21,17648.94,,,,,,,,,,,,,
PACK ORTH INSTR DEPTHING FOR 5 MM CHMFR SCREW K WIRE 1.8 MM,SUP-2902694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2902.30,1886.49,,,,,,,,,,,,,
LEAD KIT 28 CM SACR MRI MR CONDITIONAL INTERSTIM SURESCAN,SUP-2641994,CDM,C1778,HCPCS,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
MICROFREE SAGITTAL SAW,SUP-2605745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19795.00,12866.75,,,,,,,,,,,,,
FIBER LASER OTO-M OMNIGUIDE,SUP-2225613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CATHETER HD STR 16 FRX42 CM STD KT AIRGUARD HEMOSPLIT XK,SUP-2127837,CDM,C1750,HCPCS,0278,RC,,,,both,,,1486.95,966.52,,,,,,,,,,,,,
HC So Histoplasma Capsulatum,PX-3068738566,CDM,87385,CPT,0306,RC,,,,inpatient,,,315.00,204.75,,,,,,,,,,,,,
PLATE BONE L120MM 8 H STRL LT ANTEROLATERAL DSTL TIB S STL,SUP-2349731,CDM,C1713,HCPCS,0278,RC,,,,both,,,12624.84,8206.15,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS TEND 20-26X3 CM FD IRRADIATED,SUP-2307129,CDM,C1762,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
ROD SPNL POST CRV PREBENT SMOOTH TI ALLY OD5.5MM L90MM,SUP-2415873,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.75,612.79,,,,,,,,,,,,,
STOP DRL FOR 6/10MM STP CANN DRL BIT,SUP-2188236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,895.40,582.01,,,,,,,,,,,,,
SCREW SPNL FIX ANGLE 4.5X13 MM ANTR CERV TI TETH,SUP-2379308,CDM,C1713,HCPCS,0278,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
BLADE SURG AGGRESSIVE XL 4.2 MM + STRL FMS VUE DISP,SUP-2637154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
WIRE FIX L102MM DIA1.1MM S STL SMOOTH DBL BAYNT TIP K,SUP-2207938,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT TISSUE HALO PERICARDIUM,SUP-2844927,CDM,V2785,HCPCS,0810,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
PLATE BNE RADIAL SHT MED LT VOLAR DSTL,SUP-2646869,CDM,C1713,HCPCS,0278,RC,,,,both,,,2126.78,1382.41,,,,,,,,,,,,,
SCREW BNE L130MM DIA35MM CORT S STL ST NONCANNULATED FULL,SUP-2178092,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.78,177.96,,,,,,,,,,,,,
CATHETER BLLN DIL WIRE GUID 8-9-10 MMX180 CM ELATION 5,SUP-2468604,CDM,C1726,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PLATE CHIN DBL Y ARNETT 6MM,SUP-2262921,CDM,C1713,HCPCS,0278,RC,,,,both,,,851.07,553.20,,,,,,,,,,,,,
DRILL SURG MOD 16 MM RELIANT ACPS,SUP-2601919,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
STEM RAD L30X15MM DIA8MM NK OFFSET 0MM TI ALIGN,SUP-2340145,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
PROSTHESIS PENILE INFLATABLE 0 DEG 18 CM INFPUB TITAN TCH LF,SUP-2848009,CDM,C1813,HCPCS,0278,RC,,,,both,,,38811.97,25227.78,,,,,,,,,,,,,
COMPONENT PAT SZ 32MM POLYETH PATONSET PROFIX,SUP-2347041,CDM,C1776,CPT,0278,RC,,,,both,,,2102.23,1366.45,,,,,,,,,,,,,
GRAFT BNE SUB 0.5CC DEMIN MTRX PTTY FRZ DRY JR DBX,SUP-2306993,CDM,C9359,HCPCS,0278,RC,,,,both,,,307.09,199.61,,,,,,,,,,,,,
CROWN DENT 4 UPPER LT,SUP-2100307,CDM,D6783,CPT,0278,RC,,,,both,,,18.37,11.94,,,,,,,,,,,,,
ROD BENDR FOR 5.5 ROD,SUP-2232126,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
HC ED Layer Clos Face 7.6-12.5,PX-4501205400,CDM,12054,CPT,0450,RC,,,,both,,,1674.00,1088.10,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE ZRCH 2 3DX WLLMS U PLATE RGHT,SUP-2669828,CDM,C1713,HCPCS,0278,RC,,,,both,,,17933.89,11657.03,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM 125DEG LNG LT HIP TIM CANN LCK FOR,SUP-2211478,CDM,C1713,HCPCS,0278,RC,,,,both,,,3906.16,2539.00,,,,,,,,,,,,,
BAR EXT FIX L400MM DIA11MM FOR XTRAFIX SYS,SUP-2199714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,755.52,491.09,,,,,,,,,,,,,
BLADE REPROC SAW OSCIL LG BONE 19.5X95X1.27MM,SUP-2652957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,92.88,60.37,,,,,,,,,,,,,
BASE GLEN L COMPHSVE MOD HYBRID,SUP-2404687,CDM,C1776,CPT,0278,RC,,,,both,,,5617.46,3651.35,,,,,,,,,,,,,
SUPPORT MAMM SURG 48-50 IN 2XL BRA,SUP-2336341,CDM,L8000,HCPCS,0272,RC,,,,both,,,123.50,80.27,,,,,,,,,,,,,
BOOT ORTHOSIS FOR 11-13IN ANK FOAM STATIC FOR POS AND PRSS,SUP-2194764,CDM,L4387,HCPCS,0272,RC,,,,both,,,138.54,90.05,,,,,,,,,,,,,
DONEPEZIL HCL 5 MG PO TABS,RX-18786,CDM,6370000000,HCPCS,0637,RC,60687-0292-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HYDRALAZINE 1 MG/ML INJ SOLN (NEO),RX-4090132,CDM,J0360,HCPCS,0636,RC,09999-9906-56,NDC,,both,10,ML,144.30,93.79,,,,,,,,,,,,,
GRAFT HUM TISS W4XL12CM THK0.75-1.50MM DERM DECELLULARIZED,SUP-2264717,CDM,Q4122,HCPCS,0636,RC,,,,both,,,4253.32,2764.66,,,,,,,,,,,,,
VALVE SHUNT LUMBAR AD 14 GA MIN VENTRICULAR ENLARGEMENT BLU,SUP-2852675,CDM,C1889,HCPCS,0278,RC,,,,both,,,4206.12,2733.98,,,,,,,,,,,,,
HC Autolog Prp Diab Wound Ulcer,PX-3610046500,CDM,G0465,CPT,0361,RC,,,,inpatient,,,4802.00,3121.30,,,,,,,,,,,,,
SPACER SPNL 8MM GLD INDIR DCOMPR STRL SUPERION,SUP-2392698,CDM,C1821,HCPCS,0278,RC,,,,both,,,26062.00,16940.30,,,,,,,,,,,,,
CONNECTOR SPNL L30MM OD5.5MM CLOSE OFFSET CREO AMP,SUP-2228675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
DRIVER SURG H10 SELF RET STRL DISP MOTOBAND CP,SUP-2893267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
TRIAL SURG FOR ELONG L PLT FLOWERCUBE,SUP-2225459,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
GUIDEWIRE VASC 0.014 INX300 CM 35 CM EXCHANGE LEN SYNCHRO-14,SUP-2367845,CDM,C1769,HCPCS,0272,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
CATHETER GUID MINNIE L 150 CM DIA 5 FR SHFT OD/ID PROX,SUP-2383153,CDM,C1887,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
COIL NEUROVASCULAR TRUFILL L 10 MM DIA 5 MM MICROCATHETER,SUP-2474361,CDM,C1889,HCPCS,0278,RC,,,,both,,,1843.24,1198.11,,,,,,,,,,,,,
HYOSCYAMINE SULFATE 0.125 MG SL SUBL,RX-17023,CDM,6370000000,HCPCS,0637,RC,62559-0424-01,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
CATHETER URETH 36 FR 5 CM BLLN W/ INFLATION DRUG OPTILUME,SUP-2863027,CDM,C1889,HCPCS,0278,RC,,,,both,,,10754.50,6990.42,,,,,,,,,,,,,
FRACTURE KIT BASE SHT 10 ML W/ PWR CRV STABILIT MX,SUP-2463110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8010.45,5206.79,,,,,,,,,,,,,
ARTIFICIAL TEARS 83-15 % OP OINT,RX-122202,CDM,6370000000,HCPCS,0637,RC,00023-0312-04,NDC,,both,3.5,GR,44.00,28.60,,,,,,,,,,,,,
FORCEP SURG TAPR 3608T LOWER ANTR SS X-TRAC,SUP-2238496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.47,459.21,,,,,,,,,,,,,
SET SCR SPNL L32MM DIA0.25MM IL TI LOK BRK OFF HEX CLS CDH,SUP-2287228,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.95,257.37,,,,,,,,,,,,,
PROBE DISCECTOMY 17GA L6IN PERC LUM STR DISP DEKOMPRESSOR,SUP-2366993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7483.47,4864.26,,,,,,,,,,,,,
SCREW BNE L10MM DIA1.5MM CO CHROM NONLOCKING FOR ALPS HND,SUP-2411778,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
HC Imhchem/Imcytchm Ea Addl Single Antb Stain Px,PX-3128834100,CDM,88341,CPT,0312,RC,,,,both,,,371.00,241.15,,,,,,,,,,,,,
DRAINAGE SET STD INTEGR 1 PC M LL CONN TUBE ADJ CLP EXAFLOW,SUP-2666668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.41,208.27,,,,,,,,,,,,,
WAND ARTHROSCOPICXL TIP 1.4MM 15DEG BPLR TOPAZ,SUP-2341213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
ELECTRODE ENDO COAG BALL END STRL YEL OD24FR 5MM,SUP-2261176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
ASPIRATION TRAY 102 MM ONCONTROL,SUP-2766680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,481.46,312.95,,,,,,,,,,,,,
NUT FOR 4.5MM CORTEX SCW,SUP-2820891,CDM,C1713,HCPCS,0278,RC,,,,both,,,236.19,153.52,,,,,,,,,,,,,
SYSTEM GASTRIC BANDING L ADJUSTABLE ACCESS PORT II OMNIFORM ADULT FOR WEIGHT LOSS LAPBAND AP,SUP-2119235,CDM,C1889,HCPCS,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT PAT BTB HEMI W/ SHP BONE BLK W/OUT,SUP-2307537,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
DRAINAGE KIT PEDIATRIC 85 CM W/ ICP CUP CATH 5-10 CM EXAFLOW,SUP-2666663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,454.33,295.31,,,,,,,,,,,,,
COMPONENT TIB HINGED NEUT MED 65 MM KNEE ROTATIONAL PROS,SUP-2423135,CDM,C1776,CPT,0278,RC,,,,both,,,8587.90,5582.13,,,,,,,,,,,,,
PREP SCORER 12X19MM,SUP-2841267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
SPACER HUM DIA36MM +9MM OFFSET SHLDR REV SEMICONSTRAINED,SUP-2254086,CDM,C1776,CPT,0278,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
POST EXT FIX ANK FT 5 H FOR TRUELOK FRME ASSEMB HEXAPOD SYS,SUP-2316133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.62,339.70,,,,,,,,,,,,,
TRAY PICC AD 4FR TRIM LEN INTMED DBL LUMN SIL NRS NPOWER,SUP-2125580,CDM,C1751,HCPCS,0278,RC,,,,both,,,187.77,122.05,,,,,,,,,,,,,
END CAP ORTH DIA1 MM TI FOR FIBULAR NAIL NS PHANTOM,SUP-2908990,CDM,C1889,HCPCS,0278,RC,,,,both,,,846.23,550.05,,,,,,,,,,,,,
MESH WND DERM REP FET BOV DERM IONIC SIL PRIMATRIX AG FEN,SUP-2420902,CDM,Q4110,HCPCS,0636,RC,,,,both,,,16249.50,10562.17,,,,,,,,,,,,,
REMDESIVIR 100 MG IV SOLR,RX-150300,CDM,J0248,HCPCS,0636,RC,61958-2901-02,NDC,,both,1,UN,2600.00,1690.00,,,,,,,,,,,,,
HC So Activated Protein C (Apc),PX-3058530766,CDM,85307,CPT,0305,RC,,,,both,,,100.00,65.00,,,,,,,,,,,,,
SCREW SPNL 4.5X35 MM FOR 4.75 MM ROD ATS CD HORZ SOLERA,SUP-2629451,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X53X19X1.8 MM THOR 18 HOLE LADDER LEVEL 1,SUP-2869268,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.29,1387.94,,,,,,,,,,,,,
SCREW BNE SELF DRILLING 3X12 MM CANN FIX QWIX,SUP-2434150,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.03,616.22,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0035IN S STL BENT STR STLFLEX TI,SUP-2436270,CDM,C1769,HCPCS,0272,RC,,,,both,,,81.11,52.72,,,,,,,,,,,,,
FOOTPLATE EXT FIX D 180 MM RX STRL TRUELOK EVO LTX,SUP-2875618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15233.52,9901.79,,,,,,,,,,,,,
HC So Igh Gene Rearrange Amp Meth,PX-3108126167,CDM,81261,CPT,0310,RC,,,,both,,,445.00,289.25,,,,,,,,,,,,,
WASHER ORTH LCK 2.7 MM BNE THRD LIP SOCKET SS NS SURFIX DISP,SUP-2852096,CDM,C1713,HCPCS,0278,RC,,,,both,,,519.73,337.82,,,,,,,,,,,,,
HC Surgery Level 5 Addtl 15min,PX-3600000015,CDM,3600000015,LOCAL,0360,RC,,,,both,,,4347.00,2825.55,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM ADV 10 MM SCREW DIA2 MM 4 H MINI CHIN,SUP-2883156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1434.82,932.63,,,,,,,,,,,,,
HC Removal FB Skin,PX-3611012000,CDM,10120,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PROBE ENDSCPC BPLR 10FR DIA 350CML SNGLE PLUG HEMSTAS CXL CN,SUP-2675372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.90,534.88,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 20 MM DIA14 MM SHTH 10 FR CATH L,SUP-2147032,CDM,C1876,HCPCS,0278,RC,,,,both,,,3199.50,2079.67,,,,,,,,,,,,,
STEM FEM L267MM OD11MM BOW FLUT TI ALLY HA DST HIP REV MOD,SUP-2375777,CDM,C1776,CPT,0278,RC,,,,both,,,7916.57,5145.77,,,,,,,,,,,,,
TUBE SET 1.9 MMX30 CM LNG LAP TIP NEXUS SONASTAR,SUP-2748597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3165.12,2057.33,,,,,,,,,,,,,
SYRINGE GEL INJECTABLE BARRIGEL 3ML,SUP-2875934,CDM,C1889,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
SLEEVE TIB L9CM ELLIP TI POR PROX KNEE REDUC SZ OSS MARTI,SUP-2406488,CDM,C1776,CPT,0278,RC,,,,both,,,14139.89,9190.93,,,,,,,,,,,,,
COIL NEUROVASCULAR DELTAFILL 18 L 12 CM DIA 3 MM PRIMARY DIA,SUP-2518790,CDM,C1889,HCPCS,0278,RC,,,,both,,,8906.67,5789.34,,,,,,,,,,,,,
HYALURONIDASE BOVINE 150 UNIT/ML IJ SOLN,RX-91037,CDM,J3470,HCPCS,0636,RC,00548-9090-10,NDC,,both,0.02,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE LOK 81MML HLX6 STNLSS STEEL 1/3 TBLR W/CLLR NON S,SUP-2474678,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
SPLINT WR AD SM UPTO W3.5IN RT MCP DLX KAY-SPLNT III,SUP-2324558,CDM,L3906,HCPCS,0272,RC,,,,both,,,75.96,49.37,,,,,,,,,,,,,
PLATE BNE W33XL121MM 8 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185111,CDM,C1713,HCPCS,0278,RC,,,,both,,,3400.97,2210.63,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 22 CM LOOP DIA 9 MM PRIMARY,SUP-2249275,CDM,C1889,HCPCS,0278,RC,,,,both,,,4127.06,2682.59,,,,,,,,,,,,,
STENT URET ASCERTA L 20 CM DIA 7 FR SYNTH POLYMER FIRM STRL,SUP-2461151,CDM,C2617,HCPCS,0278,RC,,,,both,,,265.33,172.46,,,,,,,,,,,,,
CATHETER HD STR 12 FRX20 CM SHT TERM SLIM KT NIAG,SUP-2126490,CDM,C1752,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
SCREW BNE L80 MM OD5.5 MM FULL THRD MONSTER IMPL,SUP-2320700,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
CEMENT BNE 20GM PMMA TWIN PK VERTAPLEX HV,SUP-2368276,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.79,881.91,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MESHED 8X6 CMX0.3 MM PERITONEUM MTRX MESO,SUP-2482885,CDM,C1763,HCPCS,0278,RC,,,,both,,,3158.34,2052.92,,,,,,,,,,,,,
DILATOR URETH RENAL RADPQ CATH AMPLATZ,SUP-2171201,CDM,C1726,HCPCS,0272,RC,,,,both,,,1156.78,751.91,,,,,,,,,,,,,
PORT INFUS OD8FR ID16MM SHTH DIA8FR TI POLYUR SGL LUMN PASV,SUP-2118950,CDM,C1788,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
BODY EXT FIX L72MM STD PENNIG MINIFIXATOR,SUP-2316456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2013.49,1308.77,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0250,RC,00264-1800-32,NDC,,both,100,ML,23.00,14.95,,,,,,,,,,,,,
METHOCARBAMOL 750 MG PO TABS,RX-4972,CDM,6370000000,HCPCS,0637,RC,60687-0568-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE VOLAR MED 24X62 MM LT LCK STRL DVR,SUP-2477141,CDM,C1713,HCPCS,0278,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
PLATE BNE L 39 MM LT DORS MEDL DSTL RADIAL SHRT NS VARIAX 2,SUP-2902242,CDM,C1713,HCPCS,0278,RC,,,,both,,,3143.80,2043.47,,,,,,,,,,,,,
TRAY NERVE BLOCK CANN DIA25 GA SPNL P25BKN NRFIT STRL DISP,SUP-2936530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,55.99,36.39,,,,,,,,,,,,,
BRACE WRST R INSTABILITY INJ LOOP LOK W/ STAY COCK UP E,SUP-2197948,CDM,L3931,HCPCS,0274,RC,,,,both,,,25.37,16.49,,,,,,,,,,,,,
FLANGE ACET PAR 5 SHT L W/ SCR,SUP-2403445,CDM,C1776,CPT,0278,RC,,,,both,,,2223.12,1445.03,,,,,,,,,,,,,
BAR EXT FIX LNG CALIB TOMAHAWK MINI FIX SIDEKCK,SUP-2400616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
CATHETER EMB ARW L 40 CM DIA 5 FR SPRING GUIDEWIRE 0.035 IN,SUP-2383505,CDM,C1757,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
COMPONENT TOE DIA15MM 2.5X3.5MM OFFSET MT CE ARTC TOE2,SUP-2123615,CDM,C1776,CPT,0278,RC,,,,both,,,11630.56,7559.86,,,,,,,,,,,,,
ZIPRASIDONE HCL 20 MG PO CAPS,RX-29778,CDM,6370000000,HCPCS,0637,RC,60505-2528-06,NDC,,both,1,UN,6.00,3.90,,,,,,,,,,,,,
COMPONENT FEM DSTL 5 CM RT KNEE POROUS MAK RS OSS,SUP-2449855,CDM,C1776,CPT,0278,RC,,,,both,,,16970.13,11030.58,,,,,,,,,,,,,
STENT PERIPH INNOVA L 200 MM DIA 5 MM CATH L 160 CM WORKING,SUP-2146846,CDM,C1876,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
COMPONENT PATELLAR G 12 MM ARTC KNEE,SUP-2200802,CDM,C1776,CPT,0278,RC,,,,both,,,9168.80,5959.72,,,,,,,,,,,,,
PLATE BNE FEM 90 DEG 240 MM ARCHED MR SAFE NS,SUP-2863409,CDM,C1713,HCPCS,0278,RC,,,,both,,,3100.53,2015.34,,,,,,,,,,,,,
WASHER SPNL THORLUM PEDCL TI XIA,SUP-2379331,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
HC So Hemoglobin Chromatography,PX-3018302166,CDM,83021,CPT,0301,RC,,,,outpatient,,,267.00,173.55,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 3 MM EPTFE TW PED SHUNT STRL,SUP-2396676,CDM,C1768,CPT,0278,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
ANCHOR SUT L17.9MM DIA5MM TI W/ 2 FIBERWIRE BIO CRKSCR,SUP-2121495,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
SCREW CRANIO MAXILLOFACIAL CRSS DRV DRL FREE TI ALLY,SUP-2262633,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.49,122.52,,,,,,,,,,,,,
BLADE SAW 25.4X63.5X0.38 MM RECIP THN STRL PRECIS LTX,SUP-2862502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.48,251.86,,,,,,,,,,,,,
PLATE BNE L57MM 6 H NONSTERILE DST DORS RAD S STL CLMN LOK,SUP-2177513,CDM,C1713,HCPCS,0278,RC,,,,both,,,1982.85,1288.85,,,,,,,,,,,,,
COMPONENT ARTC 15X1.5X2.5 MM,SUP-2123535,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM COR CTO RE ENTRY SYS STINGRAY,SUP-2140968,CDM,C1769,HCPCS,0272,RC,,,,both,,,1165.73,757.72,,,,,,,,,,,,,
SPACER SPNL 10MM CORT CANC CERV PARA GRFT,SUP-2364354,CDM,C1762,CPT,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
JOINT SACROILIAC 10.75X45 MM IFUSE,SUP-2663550,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BONE L88MM 4 HOLE STERILE PROXIMAL HUMERAL NCB,SUP-2470473,CDM,C1713,HCPCS,0278,RC,,,,both,,,3870.71,2515.96,,,,,,,,,,,,,
KIT ANAS 14GM 1 TO 4MM ACTUATOR TOOL NDL PROX DEV AORT PNCH,SUP-2282927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1819.10,1182.41,,,,,,,,,,,,,
INTRODUCER LD L13CM OD6FR SPLITTABLE DIL W/ J TIP GWIRE SYR,SUP-2356433,CDM,C1892,HCPCS,0272,RC,,,,both,,,110.37,71.74,,,,,,,,,,,,,
PLATE BNE STR MINI 2-2.5X1 MM 12 HOLE LCK LADDER TI LEVEL 1,SUP-2468380,CDM,C1713,HCPCS,0278,RC,,,,both,,,1548.55,1006.56,,,,,,,,,,,,,
CATHETER HD RETROGRADE 23 CM CHRONIC REPL HUB ARW NEXTSTEP,SUP-2627066,CDM,C1750,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L60CM LAMITRODE TRIPOL 16C,SUP-2356734,CDM,C1778,HCPCS,0278,RC,,,,both,,,21556.10,14011.46,,,,,,,,,,,,,
POST EXT FIX 3 H FEM FOR SIDEKCK FREE CIR FIX,SUP-2400685,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 150 MM DIA 7 MM CATH L 130 CM DIA 6,SUP-2128196,CDM,C1876,HCPCS,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
KIT BNE CEM KNEE W/ L APPL MIX AND DEL SYS,SUP-2120718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
GUIDEWIRE FUS 5CM AQUA COAT TIP 0.035 INCHX205 CM,SUP-2170086,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 90 CC CANC,SUP-2743352,CDM,C1713,HCPCS,0278,RC,,,,both,,,5077.38,3300.30,,,,,,,,,,,,,
MAGNET IMPL TI CONIC FOR ATTRACT 1 STG SURG BAHA BIM400,SUP-2164992,CDM,L8614,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
BLADE SCRWDRVR F/RED II CMPLTE RIGID EXTRNL DISTR SSTM,SUP-2496051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.84,501.70,,,,,,,,,,,,,
MESH HERN RECTANGULAR 10X10 CM PREPERITONEAL ENFORM,SUP-2539549,CDM,C1781,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
SET URET STENT SOFFLX L 70 CM DIA 7.2FR GUIDEWIRE L 145CM RT,SUP-2835688,CDM,C2617,HCPCS,0278,RC,,,,both,,,280.72,182.47,,,,,,,,,,,,,
PLATE BURR H L 44.55 MM DIA 38 MM SCREW DIA1.5 MM TI NS DISP,SUP-2936681,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
PLATE BNE L W135XL332MM THK42MM 18 H BILAT TI NAR RIG NEUT,SUP-2190835,CDM,C1713,HCPCS,0278,RC,,,,both,,,2965.86,1927.81,,,,,,,,,,,,,
PORT ACCESS GASTRIC LAPAROSCOPIC LAP-BAND AP,SUP-2119225,CDM,C1788,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
TUBE TRACH PED L44MM OD73MM ID5MM SIL CUF V NK FLNG W OBT,SUP-2352451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.03,399.77,,,,,,,,,,,,,
VALVE AORT EVOLUT PRO + DIA23 MM ANNULUS 17/18-20 MM PORCINE,SUP-2418291,CDM,C1889,HCPCS,0278,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X233 MM 13 HOLE SS LCP,SUP-2569366,CDM,C1713,HCPCS,0278,RC,,,,both,,,751.25,488.31,,,,,,,,,,,,,
BUR SURG TAPR SIDE CUT XCUT,SUP-2628916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,575.12,373.83,,,,,,,,,,,,,
INSERT TIB 12MM SZ 1 CONG POST STABILIZING POLYETH PROVEN,SUP-2359101,CDM,C1776,CPT,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
PLATE EXT FIX L155MM SH ALUM FT RNG FOR ILIZ TAY SPAT FRME,SUP-2340789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8969.88,5830.42,,,,,,,,,,,,,
CATHETER ABLAT 7FR TIP L4MM 2.5MM SPC QPLR ASYM 4 CRV STD,SUP-2141276,CDM,C1733,HCPCS,0272,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
IMPLANT HUM TISS RT HEMI PA NO LEAFLET REDUC THROMBOSIS,SUP-2932957,CDM,C1762,CPT,0278,RC,,,,both,,,20495.47,13322.06,,,,,,,,,,,,,
STENT URET STR 0.038 IN 3 CM 7 FRX22-30 CM 6 FR CNTOUR VL,SUP-2464452,CDM,C2617,HCPCS,0278,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
GRAFT HUM TISS L200 500MM DIA10MM FEM SHFT FRZN,SUP-2307350,CDM,C1713,HCPCS,0278,RC,,,,both,,,6396.75,4157.89,,,,,,,,,,,,,
PLATE TUBULAR 3.5MM 1/3 6HL,SUP-2720115,CDM,C1713,HCPCS,0278,RC,,,,both,,,985.58,640.63,,,,,,,,,,,,,
PIN EXT FIX HALF 5X200 MM 20 MM BLNT ST THRD HA NS APEX,SUP-2472832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,779.98,506.99,,,,,,,,,,,,,
INSERT ACET OD40MM ID22MM 20DEG UHMWPE HIP COMP SER I OMFIT,SUP-2369975,CDM,C1776,CPT,0278,RC,,,,both,,,2535.86,1648.31,,,,,,,,,,,,,
BIT DRL QC 2X110 MM STRL,SUP-2563746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.95,282.07,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.032 IN CRV RAD 2.5 MM HVY DBL,SUP-2760034,CDM,C1769,HCPCS,0272,RC,,,,both,,,83.93,54.55,,,,,,,,,,,,,
STENT GRFT VASC AFX COCR STRATA LT IL EXT AAA STRL,SUP-2217711,CDM,C1768,CPT,0278,RC,,,,both,,,10613.20,6898.58,,,,,,,,,,,,,
PLATE BNE L45MM THK3MM 3 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185328,CDM,C1713,HCPCS,0278,RC,,,,both,,,1319.05,857.38,,,,,,,,,,,,,
ANCHOR SUT PEEK DBL STRND W/ ORTHOCORD GRYPHON,SUP-2249322,CDM,C1713,HCPCS,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
HEAD BPLR OD53MM ID28MM FEM HIP SELF CNTR,SUP-2249843,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
NEXGEN LCCK ART SURF EF 5-6/GREEN 10MM,SUP-2503357,CDM,C1776,CPT,0278,RC,,,,both,,,5375.68,3494.19,,,,,,,,,,,,,
PLATE BNE T 116 MM 6 HOLE SS,SUP-2569108,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.40,236.86,,,,,,,,,,,,,
SCREW BNE L85MM DIA6MM ST AQUA CORT TI ST CANN LOK FULL,SUP-2191851,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.38,591.75,,,,,,,,,,,,,
PLATE BNE L13MM THK0.3MM 4 H CRANIOMAXILLOFACIAL TI SQ FOR,SUP-2402998,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
BARICITINIB 2 MG PO TABS,RX-142620,CDM,6370000000,HCPCS,0637,RC,00002-4182-30,NDC,,both,1,UN,415.20,269.88,,,,,,,,,,,,,
PLATE BONE L14MM S STL 5 H PHILOS PROX HUM PLT STRL F/3.5MM,SUP-2186014,CDM,C1713,HCPCS,0278,RC,,,,both,,,4360.39,2834.25,,,,,,,,,,,,,
PLUG BNE DIA14MM SM DIAM CEM,SUP-2408550,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
GUIDEWIRE SURG L230MM DIA2MM BLK S STL FULL THRD SHRP TIP,SUP-2186887,CDM,C1769,HCPCS,0272,RC,,,,both,,,98.82,64.23,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 1.5 MM LEFT 7X23 HOLE RECONSTRUCTION,SUP-2842351,CDM,C1713,HCPCS,0278,RC,,,,both,,,6772.04,4401.83,,,,,,,,,,,,,
COUPLING REPROC EXT FIX ROD TO ROD STR4940-1-010,SUP-2516727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.11,215.22,,,,,,,,,,,,,
HEAD FEM OD28MM NK -3MM CO CHROM MTL ON POLY PRI,SUP-2406707,CDM,C1776,CPT,0278,RC,,,,both,,,10770.20,7000.63,,,,,,,,,,,,,
CATHETER ATHRCTMY SILVERHAWK L 110 CM TIP L 6 CM SHTH 8 FR,SUP-2424887,CDM,C1714,HCPCS,0272,RC,,,,both,,,3409.66,2216.28,,,,,,,,,,,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-123633,CDM,J0665,HCPCS,0636,RC,55150-0172-30,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER URETERAL 7FR L78CM TAMPONADE BLLN INFLATED,SUP-2119472,CDM,C1758,HCPCS,0278,RC,,,,both,,,625.80,406.77,,,,,,,,,,,,,
ANCHOR SUT SM 1.7MM NO5 POLY SFT SGL LD W/ 1 NO2 BLU COBRAID,SUP-2341894,CDM,C1713,HCPCS,0278,RC,,,,both,,,976.41,634.67,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND CUST ADJ FIT W/NONTORSION JT,SUP-2435763,CDM,L3764,HCPCS,0274,RC,,,,both,,,2017.89,1311.63,,,,,,,,,,,,,
LEAD ELECTRODE CLIP ALLIGATOR,SUP-2719740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,178.04,115.73,,,,,,,,,,,,,
PLATE BONE RT STP METATARSOPHALANGEAL JT VAR LCK COMPR,SUP-2390554,CDM,C1713,HCPCS,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
BRACE KNEE POSTOP COOL PROCARE TROM ADV,SUP-2195713,CDM,L1810,HCPCS,0272,RC,,,,both,,,226.68,147.34,,,,,,,,,,,,,
TROSPIUM CHLORIDE 20 MG PO TABS,RX-38977,CDM,6370000000,HCPCS,0637,RC,23155-0530-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
FOOT RING SHRT 140MM,SUP-2701803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5950.93,3868.10,,,,,,,,,,,,,
SPIRONOLACTONE 100 MG PO TABS,RX-11425,CDM,6370000000,HCPCS,0637,RC,60687-0487-11,NDC,,both,1,UN,3.30,2.14,,,,,,,,,,,,,
ISONIAZID 300 MG PO TABS,RX-4027,CDM,6370000000,HCPCS,0637,RC,81665-0108-30,NDC,,both,1,UN,17.60,11.44,,,,,,,,,,,,,
DARUNAVIR 800 MG PO TABS,RX-157646,CDM,6370000000,HCPCS,0637,RC,68180-0346-06,NDC,,both,1,UN,14.90,9.68,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD CUP HD LNR ST POROUS TRAB MTL,SUP-2212317,CDM,C1776,CPT,0278,RC,,,,both,,,15440.29,10036.19,,,,,,,,,,,,,
GRAFT FISH-SKIN 7X10CM SURGICLOSE,SUP-2858155,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9256.72,6016.87,,,,,,,,,,,,,
KIT ARTHSCP INSTR DRL DIA1.8 MM MED CRV FLX FLUT SPEAR CANN,SUP-2882277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5.5X40 MM ESSENCE KT,SUP-2631911,CDM,C1713,HCPCS,0278,RC,,,,both,,,8102.77,5266.80,,,,,,,,,,,,,
BIOSURGE V WITH 12MM ALLOSYNC BUTTON,SUP-2811309,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
ANCHOR SUT OD6.5MM PLLA ABSRB TWO SZ 2 ULTRABRAID NDL STR,SUP-2341675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTEXSM 2CC BIOACTIVE GLS PUTTY FIBERGRFT,SUP-2417166,CDM,C1713,HCPCS,0278,RC,,,,both,,,2710.61,1761.90,,,,,,,,,,,,,
PROSTHESIS OSSCLR FRSBEE PRTL 117MM DIA DST END 3MM DIA HEA,SUP-2669520,CDM,L8613,CPT,0278,RC,,,,both,,,1086.31,706.10,,,,,,,,,,,,,
PIN ORTH SMOOTH SGL SHRP TIP S STL ST 2.0MM DIA 229MM,SUP-2212973,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
HC Ep Comp Eval W Svt Ablation,PX-4819365300,CDM,93653,CPT,0481,RC,,,,both,,,39150.00,25447.50,,,,,,,,,,,,,
CATHETER HAD AD 14.5FR L28CM PRECRV POLYUR DBL LUMN STP TIP,SUP-2266978,CDM,C1881,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SET DIL RENAL AMPLTZ MOD 6-30FRX30CM SHTH LEN 20CM,SUP-2171221,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.80,483.47,,,,,,,,,,,,,
HANDLE SET SCR TIB DSTL INSTR,SUP-2137064,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
HC So Drug Assay Clozapine,PX-3018015966,CDM,80159,CPT,0301,RC,,,,outpatient,,,63.00,40.95,,,,,,,,,,,,,
PLATE BNE L 27.8 X W 4.5 MM THK 1.6 MM SCREW DIA2 MM GAP 12,SUP-2936477,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
CAGE SPNL W11XH11XL21MM 5DEG POST THORLUM C FBR REINF,SUP-2256325,CDM,C1889,HCPCS,0278,RC,,,,both,,,7802.90,5071.88,,,,,,,,,,,,,
RESECTOR PHLEBECTOMY DEV DIA 5.5 MM DISP PHASTIPP,SUP-2908886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
LEAD PACE AD 8.6FR L55CM ATR VENT SIL POLYUR DF4 CONN INSUL,SUP-2282249,CDM,C1777,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
COMPONENT FEM SZ 6 R KNEE CO CHROM NP CRUCE RET PRI,SUP-2345818,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
HC Pelvis Ap Only,PX-3207217000,CDM,72170,CPT,0320,RC,,,,both,,,420.00,273.00,,,,,,,,,,,,,
CATHETER DRNGE 12FR L40CM 0.038IN 32 SIDEPORTS BILI RIG,SUP-2168458,CDM,C1729,HCPCS,0272,RC,,,,both,,,218.98,142.34,,,,,,,,,,,,,
HC Platelet Conc. Each Unit,PX-3900901900,CDM,P9019,CPT,0390,RC,,,,both,,,374.00,243.10,,,,,,,,,,,,,
COMPONENT TIB UNI LM/RL 9MM M EIUS,SUP-2364889,CDM,C1776,CPT,0278,RC,,,,both,,,3856.55,2506.76,,,,,,,,,,,,,
STAPLE BONE FIX W20XL20MM S STL FOREFOOT NTHRD COMPR,SUP-2397620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
PLATE BNE W12XL268MM THK3.7MM LNG 12 H NONSTERILE PROX HUM,SUP-2186023,CDM,C1713,HCPCS,0278,RC,,,,both,,,5073.33,3297.66,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN CRV RAD 5 MM SS HEPARIN,SUP-2168252,CDM,C1769,HCPCS,0272,RC,,,,both,,,164.13,106.68,,,,,,,,,,,,,
LEAD PACE L65CMXOD5.6FR 21CM SPACE SIL POLYUR TRNSVEN TRUE,SUP-2356670,CDM,C1900,HCPCS,0275,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
SCREW BNE 4X20MM F ANK N LOK PART THRD MAXLOCK EXTRM,SUP-2400213,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
PLATE BNE 3D PRNT SM MIDFACE MAND FOR ORBIT THN TI TRUMATCH,SUP-2860376,CDM,C1713,HCPCS,0278,RC,,,,both,,,23355.95,15181.37,,,,,,,,,,,,,
KIT INT FIX W4.75XL19.1MM 2ND W/ SWIVELOCK FOR ACL/PCL REP,SUP-2121407,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
DEVICE GUIDEWIRE EXCHANGE TRAPPER DIA2 FR BALLOON L 10 MM,SUP-2146907,CDM,C1725,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SCREW BNE CANN 8X90 MM 25 MM,SUP-2364321,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.71,220.16,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK DR FUREY,SUP-2110976,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.09,369.91,,,,,,,,,,,,,
ANKLE FUSION PLATE ANTERIOR TT LT 6H,SUP-2815306,CDM,C1713,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X2 CM AMNIO WND MTRX BIOSKIN,SUP-2759485,CDM,C1762,CPT,0278,RC,,,,both,,,3100.40,2015.26,,,,,,,,,,,,,
GRAFT BNE REABSORABLE 40X30 MM MEMBRN CLLGN EXT BIOMEND,SUP-2335234,CDM,C1713,HCPCS,0278,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
ELECTRODE ELECSURG RF 100 MM SELF GRND NITRODE,SUP-2366982,CDM,C1713,HCPCS,0278,RC,,,,both,,,8252.17,5363.91,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE 4 MM ANK GALAXY FIX GEM LTX,SUP-2875649,CDM,C1713,HCPCS,0278,RC,,,,both,,,26548.70,17256.65,,,,,,,,,,,,,
HC So Arsenic,PX-3018217566,CDM,82175,CPT,0301,RC,,,,inpatient,,,125.00,81.25,,,,,,,,,,,,,
WIRE FIX DIA1.3MM ANK FT THRD OLV,SUP-2321635,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
SPACER ORTH FEM SEG 1 20 MM LAT KNEE TILASTAN ENDO-MODEL-M,SUP-2421834,CDM,C1776,CPT,0278,RC,,,,both,,,2555.96,1661.37,,,,,,,,,,,,,
PLATE BNE STRUT 2X45X1.3 MM 12 HOLE RECTANGULAR VA LCK SS NS,SUP-2178039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1829.77,1189.35,,,,,,,,,,,,,
STRUT EXT FIX 2XSH STD NS DISP SMRT TSF,SUP-2932803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4604.21,2992.74,,,,,,,,,,,,,
CLAMP EXT FIX DBL MULTIPIN STRL GALAXY FIX GEM LTX,SUP-2875644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4868.13,3164.28,,,,,,,,,,,,,
LEAD PACEMKR OPTISENSE OPTIM 40CM,SUP-2356692,CDM,C1898,HCPCS,0275,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
BAND SURG ADJ DISECT INJ PRT APPL REALIZE,SUP-2257754,CDM,2780000010,LOCAL,0278,RC,,,,both,,,9043.20,5878.08,,,,,,,,,,,,,
PLATE BNE STR 4 H IMPL MAXLOCK EXTRM ORTHOLINK,SUP-2400403,CDM,C1713,HCPCS,0278,RC,,,,both,,,3149.42,2047.12,,,,,,,,,,,,,
ALBUTEROL SULFATE (5 MG/ML) 0.5% IN NEBU,RX-251,CDM,J7611,HCPCS,0636,RC,00487-9901-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
WIRE FIX SH L150MM FOR BRISTOW LATARJET INSTABILITY SHLDR,SUP-2256873,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
SCREW BONE SCHANZ 2.5 MM 4X60 MM BLUNT TIP TITANIUM NONSTERI,SUP-2842148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
BIT DRILL/MINI QC/50MM 1.0MM,SUP-2842394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,805.76,523.74,,,,,,,,,,,,,
SET HAD CATH AD 14FR L15CM POLYUR ADMIN BASIC DBL LUMN STR,SUP-2266964,CDM,C1752,HCPCS,0278,RC,,,,both,,,237.38,154.30,,,,,,,,,,,,,
ANCHOR SFT TISS L10MM DIA11MM KNEE COPOLYMER SGL SELF REINF,SUP-2166728,CDM,C1776,CPT,0278,RC,,,,both,,,391.56,254.51,,,,,,,,,,,,,
PLATE ORTH DELT STRIKE NS T2 ALPHA,SUP-2900558,CDM,C1713,HCPCS,0278,RC,,,,both,,,1818.44,1181.99,,,,,,,,,,,,,
PLATE BONE L56MM STD 4 H LT DSTL VOLAR RAD S STL LO PROF,SUP-2341162,CDM,C1713,HCPCS,0278,RC,,,,both,,,2730.80,1775.02,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 115 CM DIA 6 FR POLYUR,SUP-2462422,CDM,C1730,HCPCS,0272,RC,,,,both,,,383.61,249.35,,,,,,,,,,,,,
GRAFT BNE FEM HD 4.5 CM W/O CART 130456024,SUP-2165599,CDM,C1776,CPT,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
GENERATOR NERVE STIM PULSE IMPL DBS INFIN,SUP-2637203,CDM,C1767,HCPCS,0278,RC,,,,both,,,34372.67,22342.24,,,,,,,,,,,,,
BLADE SURG OSCILLATING 15 DEG 4 MMX37 CM TRICUT DISP,SUP-2691284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1816.18,1180.52,,,,,,,,,,,,,
KIT SPNL 4 DEG L 26 X W 20 MM SM BLACKARMOR CARBON PEEK,SUP-2917102,CDM,C1889,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PACEMAKER CARD PULSAR MAX SR TI SINGLE CHMBR IS1 COMPATIBLE,SUP-2148593,CDM,C1786,HCPCS,0275,RC,,,,both,,,13866.24,9013.06,,,,,,,,,,,,,
SCREW BONE L50MM OD4MM ANK CANN LAG TAPR INTOSS FIX IOFIX +,SUP-2223803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
DEVICE DCOMPR SM H12-17MM DIA12MM 0DEG THORLUM TI SIMP EZ,SUP-2390788,CDM,C1713,HCPCS,0278,RC,,,,both,,,23393.00,15205.45,,,,,,,,,,,,,
NAIL IM L700MM OD13MM RT FEM KNEE AG FOR FUS TRIGEN,SUP-2349053,CDM,C1713,HCPCS,0278,RC,,,,both,,,10165.12,6607.33,,,,,,,,,,,,,
SPACER SPNL W18XH8MM D15MM 7DEG ANT CERV INTBDY FUS INTEGR,SUP-2231402,CDM,C1821,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SPLINT ANKLE FOOT ORTHOSIS MALE 8-10 RT LG,SUP-2326060,CDM,L4350,HCPCS,0274,RC,,,,both,,,98.56,64.06,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 4 CM LG AMNIO MEMBRN RESRB AIR DRY,SUP-2913441,CDM,Q4173,HCPCS,0636,RC,,,,both,,,8810.84,5727.05,,,,,,,,,,,,,
MICRO ACC SET 4F PLAT TIP,SUP-2116524,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,0636,RC,18657-0117-04,NDC,,both,0.02,ML,54.10,35.16,,,,,,,,,,,,,
STAPLER INT L L21MM DIA5MM GI AQUA TI BARIATRIC CIR CUT 2,SUP-2283254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4598.53,2989.04,,,,,,,,,,,,,
PLATE BNE L 80 X W 8 MM THK 3.2 MM SCREW DIA2.7 MM 10 H SS 72440110,SUP-2932759,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.93,1623.00,,,,,,,,,,,,,
BIT DRILL SURG 3.5 MM ALPS DISP,SUP-2607156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.47,357.81,,,,,,,,,,,,,
SET VASC ACCS PERFRMR L 13 CM OD 6 FR ID 2 MM GUIDEWIRE L 40,SUP-2168554,CDM,C1894,HCPCS,0272,RC,,,,both,,,104.25,67.76,,,,,,,,,,,,,
PI PICC 3-L: 6FRX55CM WITH 80CM HYDRO NI,SUP-2822096,CDM,C1751,HCPCS,0278,RC,,,,both,,,472.26,306.97,,,,,,,,,,,,,
BUR SURG OD7.9MM 9.1MMXLONG CUT DR FLUT,SUP-2363409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.60,255.84,,,,,,,,,,,,,
OCCLUDER SEPT WAIST L3MM DIA5MM SHTH 6FR 45DEG CRV NIT,SUP-2355673,CDM,C1817,HCPCS,0278,RC,,,,both,,,21628.07,14058.25,,,,,,,,,,,,,
STEM WR JT ULN PRI N COAT CO CHROM PRSS FIT BILAT 14.5 MM,SUP-2244021,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY DIA8MM BAL DIA3.5MM HYDRCOAT RAP EXCHG 2,SUP-2101496,CDM,C1725,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SONICPIN RX 21 X 9MM 2/CTG,SUP-2669329,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.94,174.81,,,,,,,,,,,,,
PLATE BNE CLAV SUP,SUP-2846075,CDM,C1713,HCPCS,0278,RC,,,,both,,,6088.46,3957.50,,,,,,,,,,,,,
TRAY CATH MIDLN POWERMIDLINE 3FR 20CM 1 LUMAN RVRSE TAPR PWR P4153108,SUP-2613515,CDM,C1751,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 45 CM DIA 6 FR HYDRPHLC,SUP-2383404,CDM,C1894,HCPCS,0272,RC,,,,both,,,528.15,343.30,,,,,,,,,,,,,
IMPLANT TIB L30MM DIA9MM CANN DRVR FIX DEV APERFIX II,SUP-2402622,CDM,C1776,CPT,0278,RC,,,,both,,,1645.86,1069.81,,,,,,,,,,,,,
CLIP BRAIDED 360 CATHETER RESOLUTION ULTRA – UOM 1 EACH,SUP-2754413,CDM,C1889,HCPCS,0278,RC,,,,both,,,837.66,544.48,,,,,,,,,,,,,
BRACE ORTH CUST FABRICATED RIGID W/O INTFACE LNR TLSO,SUP-2388143,CDM,L0450,HCPCS,0274,RC,,,,both,,,4930.40,3204.76,,,,,,,,,,,,,
PLATE BNE THK 0.3 MM SCREW DIA1.5 MM XS RETRO NS DISP,SUP-2936975,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
RING 5 8 200MM FOR TRUELOK FIX SYS,SUP-2316186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2224.47,1445.91,,,,,,,,,,,,,
GRASPER ARTHSCP OD34MM STR SHFT BLNT TIP NONRATCHETING HNDL,SUP-2120910,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
VALVE CSF STD 15 CM STR CATH RADIOPAQUE LEN DOTS F8 WHT DP,SUP-2852666,CDM,C1889,HCPCS,0278,RC,,,,both,,,3560.04,2314.03,,,,,,,,,,,,,
BLADE SAW THK1.27 MM 8 MM D70 MM CUT EDGE STERILE LATEX FREE DISPOSABLE,SUP-2880143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE MANTA DIA18 FR CLLGN FEM ART FOR VASC,SUP-2667223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
IMPLANT SYNTH 78 X 61 MM THK 18 MM SM POLYETHYL RT TEMPORAL,SUP-2883436,CDM,C1713,HCPCS,0278,RC,,,,both,,,4745.04,3084.28,,,,,,,,,,,,,
SPLINT ORTHOT M L LIMB REST HND FNGR WRST WIRE FOAM FRME,SUP-2194508,CDM,L3807,HCPCS,0272,RC,,,,both,,,111.53,72.49,,,,,,,,,,,,,
SET PANCREATIC STENT GEENEN L 9 CM DIA 7 FR NO INT FLAP,SUP-2169207,CDM,C2625,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
SEALER TISS L45CM DIA5MM ARTC ADV BPLR STR TIP LAP APPRCH,SUP-2219737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8587.90,5582.13,,,,,,,,,,,,,
SHELL ACET A SER,SUP-2221813,CDM,C1776,CPT,0278,RC,,,,both,,,12.56,8.16,,,,,,,,,,,,,
GRAFT BONE SUB 5ML PASTE DEMIN BONE OPTECURE,SUP-2223574,CDM,C1713,HCPCS,0278,RC,,,,both,,,3187.10,2071.61,,,,,,,,,,,,,
FRACTURE ADAPTER SZ 6-9 TALL,SUP-2815878,CDM,C1776,CPT,0278,RC,,,,both,,,7112.10,4622.86,,,,,,,,,,,,,
PLATE BNE FUSION LG CLOSED ALPS,SUP-2413841,CDM,C1713,HCPCS,0278,RC,,,,both,,,2015.13,1309.83,,,,,,,,,,,,,
IMPLANT HAMMERTUBE 3.50MM 0 DEG CANN,SUP-2419715,CDM,C1713,HCPCS,0278,RC,,,,both,,,3867.70,2514.00,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 8 MM EPTFE FLX STD WALL RING,SUP-2126873,CDM,C1768,CPT,0278,RC,,,,both,,,701.29,455.84,,,,,,,,,,,,,
GALILEOTROCHNAIL RIGHT 10MMX39CMX125 DEGREE,SUP-2828776,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
PLATE BONE 4 H AUX 1 CBL TRITIUM SCP,SUP-2335607,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
INTRODUCER PACE LD L 14 CM DIA14 FR DI-LOCK DIL L 19 CM,SUP-2357071,CDM,C1892,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 130 CM DIA 0.014 IN SS SIL STR LNG,SUP-2148329,CDM,C1769,HCPCS,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
HC Inject Sacroiliac Joint|BILATERAL PROCEDURE|PO,PX-3612709600,CDM,27096,CPT,0361,RC,,,50|PO,both,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER GUID VIPERCATH XC 30 DEG L 200 CM DIA 5 FR,SUP-2417482,CDM,C1887,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ATTACHMENT SH O STR,SUP-2367373,CDM,C1713,HCPCS,0278,RC,,,,both,,,2455.51,1596.08,,,,,,,,,,,,,
CATHETER MAP 4 MM 8 FRX120 CM 48 MM 64 ELECTRD CONSTELLATION,SUP-2424696,CDM,C1732,HCPCS,0272,RC,,,,both,,,14626.12,9506.98,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X215 MM 12 HOLE SS LCP,SUP-2569365,CDM,C1713,HCPCS,0278,RC,,,,both,,,720.16,468.10,,,,,,,,,,,,,
DEVICE OCCL CLP L35MM PRELD FOR THORACOSCOPIC PROC GILLINOV,SUP-2124471,CDM,C1889,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING 8MM DIA 50CM LEN GORTX,SUP-2396016,CDM,C1768,CPT,0278,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
SCREW SPNL CANN 4X32 MM CORRIDOR,SUP-2423406,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ENDCAP ORTH L16MM DIA6.5MM STD TI FOR T2 IM NAIL,SUP-2368731,CDM,C1776,CPT,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 82 MM DIA24 MM SHTH 18 FR RVD,SUP-2170612,CDM,C1768,CPT,0278,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
PIN FIX L230MM DIA2MM TRCR PNT PLN STNMN,SUP-2371628,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ASSEMBLY SURG SAW BLADE SZ 15 MM IM STRL DISP,SUP-2887650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1964.07,1276.65,,,,,,,,,,,,,
GRAFT BONE 1ML DEMIN BONE MTRX PASTE INTERGRO,SUP-2414008,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
MICROCATHETER VASC EXCELSIOR XT-27 FLX L 150 CM DSTL L 18 CM,SUP-2365845,CDM,C1725,HCPCS,0272,RC,,,,both,,,3163.24,2056.11,,,,,,,,,,,,,
CATHETER PA L 80 CM DIA 5.3 FR BALLOON DIA10 MM GUIDEWIRE,SUP-2168609,CDM,C2628,HCPCS,0272,RC,,,,both,,,215.53,140.09,,,,,,,,,,,,,
SHEARS LAPSCP L35CM DIA5MM PSTL GRP OPEN/UNUSED ONLY KNF DN,SUP-2257665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1053.09,684.51,,,,,,,,,,,,,
FRACTURE PLATE 8 HOLES 55MM 23MM SYSTEM TI 6AL 4V,SUP-2679142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1074.54,698.45,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.25MM S STL TRCR PNT,SUP-2186859,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.55,15.96,,,,,,,,,,,,,
SCREW BNE SM EZ-OUT,SUP-2475360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.27,1083.08,,,,,,,,,,,,,
BLADE SCRWDRVR 2MM2.3MM DIA STNLSS STEEL CNTRE DRIVE,SUP-2694256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.38,221.25,,,,,,,,,,,,,
AB DISTRACTOR BODY END ACT  4315054,SUP-2844067,CDM,C1713,HCPCS,0278,RC,,,,both,,,17779.62,11556.75,,,,,,,,,,,,,
PATCH VASC HEMGRD L 150 X W 25 MM THK 0.65 MM POLYESTER BOV,SUP-2266050,CDM,C1768,CPT,0278,RC,,,,both,,,451.69,293.60,,,,,,,,,,,,,
K WIRE FIX L80MM DIA0.9MM S STL AUTOFIX,SUP-2372156,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CANNULA ENDOSCP 6.5 MM HIP MTL,SUP-2845561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1092.15,709.90,,,,,,,,,,,,,
EPINEPHRINE 1 MG/10 ML IJ SOLN (MIXTURES ONLY),RX-430063,CDM,J0169,HCPCS,0636,RC,00409-4921-34,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SYSTEM LD DEL ACUITY BREAK-AWAY CORONARY VEN GUIDE CATH,SUP-2149158,CDM,C1769,HCPCS,0272,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
STAPLER INT LN 60 MM ENDO GIA II PSD6002UN] BAXALTA US INC],SUP-2129892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
PURAPLY AM 2X2CM 4SQ CM,SUP-2314115,CDM,Q4196,HCPCS,0636,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SACCHAROMYCES BOULARDII 250 MG PO CAPS,RX-37343,CDM,6370000000,HCPCS,0637,RC,77333-0800-25,NDC,,both,1,UN,3.40,2.21,,,,,,,,,,,,,
SCREW BNE L20MM DIA3.5MM CORT FT ANK TI NONLOCKING FULL,SUP-2398303,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BONE DOUBLE BEND 1.5X4 MM CHIN 6 HOLE ADVANCEMENT TITA,SUP-2838382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1290.23,838.65,,,,,,,,,,,,,
DRILL ARTHSCP TOP HAT CORACOID,SUP-2256888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
MICROCATHETER GUID SNIPER L 130 CM DIA PROX/DSTL,SUP-2431937,CDM,C2628,HCPCS,0272,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
PUNCH BX SCHUMACHER 2 6 MM,SUP-2273872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,450.87,293.07,,,,,,,,,,,,,
PLATE BNE 14 H SS RT PELV ACET SUPRAPECTINEAL FLX ANAT STRL,SUP-2902660,CDM,C1713,HCPCS,0278,RC,,,,both,,,10605.04,6893.28,,,,,,,,,,,,,
EELECTRODE COAG 0.35 24/26 FR POINTED,SUP-2585817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1298.14,843.79,,,,,,,,,,,,,
PLATE BNE PROF THK 0.6 MM 5 X 3 H SCREW DIA1 MM RT CMF L SHP,SUP-2883729,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW PA TRUNK STRL,SUP-2884013,CDM,C1768,CPT,0278,RC,,,,both,,,25901.86,16836.21,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL SPENCO,SUP-2435701,CDM,L3001,HCPCS,0274,RC,,,,both,,,374.48,243.41,,,,,,,,,,,,,
VITAMINS A & D EX OINT,RX-8723,CDM,6370000000,HCPCS,0637,RC,71399-0122-04,NDC,,both,113,GR,17.80,11.57,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE DIA15-35 UM GLS HEPATIC ART STRL,SUP-2135330,CDM,C2616,HCPCS,0278,RC,,,,both,,,63836.20,41493.53,,,,,,,,,,,,,
KIT PRSS MON ICP MICROSENSOR BASIC FOR SUBDURAL,SUP-2243820,CDM,C1713,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
COMPONENT TIB SZ 4 RT MEDL LT LAT MOB BEAR CEM PRESERVATION,SUP-2251290,CDM,C1776,CPT,0278,RC,,,,both,,,4873.28,3167.63,,,,,,,,,,,,,
COMPONENT TALAR FLAT CUT 3 LT ANK DBL COAT HINTERMANN SER H3,SUP-2751687,CDM,C1776,CPT,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
BASEPLATE TIB SZ 6 REV STRL TRIATHLON,SUP-2889780,CDM,C1776,CPT,0278,RC,,,,both,,,14086.98,9156.54,,,,,,,,,,,,,
WAND ABLAT DIA2.9MM ANG TIP TURB REDUC W/ SUCT COBLATION,SUP-2342044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1044.74,679.08,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN FRIC SINGLE AXIS ULT,SUP-2388217,CDM,L5811,HCPCS,0272,RC,,,,both,,,1916.97,1246.03,,,,,,,,,,,,,
SCREW BNE LCK 2.5X13 MM CRANIOMAXILLOFACIAL TI MAXDRIVE,SUP-2468299,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.01,302.91,,,,,,,,,,,,,
KIT BONE GRAFT HARVESTING 20 MM STRL,SUP-2563899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10129.89,6584.43,,,,,,,,,,,,,
SPLINT WRST ADJ 10 IN UNIV 7.5 IN LT COOL SFT QUIK FIT,SUP-2197068,CDM,L3908,HCPCS,0272,RC,,,,both,,,24.90,16.18,,,,,,,,,,,,,
DRESSING PURAPLY ANTIMICROB WND MATRIX 3.02X3.02CM,SUP-2719558,CDM,Q4196,HCPCS,0636,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GLUCOSE 4 G PO CHEW,RX-16050,CDM,6370000000,HCPCS,0637,RC,09999-9916-34,NDC,,both,1,UN,0.60,0.39,,,,,,,,,,,,,
CATHETER NEPHROSTOMY LCK PIG 0.035 IN 6 FRX25 CM SKATER,SUP-2269626,CDM,C1729,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.038IN TAPR 3CM HYDRPHLC NIT ANG,SUP-2148169,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.63,56.31,,,,,,,,,,,,,
PREM ST/LG HD,SUP-2212356,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
KIT IMPL DIA1.1MM CMC S STL REP MINI TIGHTROPE,SUP-2122813,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 15X9 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871497,CDM,C1762,CPT,0278,RC,,,,both,,,32781.60,21308.04,,,,,,,,,,,,,
REAMER SURG 10 20 METATARSAL GREAT TOE SYS SURF MOV,SUP-2244270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.09,505.76,,,,,,,,,,,,,
CLIP MULTI-STAGE  STRL SINGLE-USE,SUP-2114096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 4 FR 7 CM 21 GA NIT MANDREL SS TIP,SUP-2606002,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.36,36.63,,,,,,,,,,,,,
HC Feeding Tube Plcmt W Fluoro,PX-3614375200,CDM,43752,CPT,0361,RC,,,,outpatient,,,1485.00,965.25,,,,,,,,,,,,,
PLATE BONE LOK CMPRSSN HLX9 TIMAX CRTCL WIDE PRE CNTRD ANTMC,SUP-2588754,CDM,C1713,HCPCS,0278,RC,,,,both,,,3889.68,2528.29,,,,,,,,,,,,,
SCREW BONE CORTICAL 1X2 MM SELFTAPPING PLUSDRIVE RECESS TITA,SUP-2838136,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.08,231.45,,,,,,,,,,,,,
ELECTRODE THERMOABLATION L 1393 MM TIP L 10 MM DIA19 GA,SUP-2881884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
BLOCK CUT TIB MYKNEE R MED SZ 4 ST,SUP-2267765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,6370000000,HCPCS,0637,RC,21922-0062-04,NDC,,both,15,GR,13.50,8.77,,,,,,,,,,,,,
STEM HUM L90MM DIA9MM SHLDR TI PLSM SPRY AEQUALIS FLX,SUP-2417742,CDM,C1776,CPT,0278,RC,,,,both,,,12140.81,7891.53,,,,,,,,,,,,,
KIT SCR L25MM DIA9MM W/ BICEPTOR BIOSURE,SUP-2341828,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
SYSTEM FIX ORTHO BOLT WIRE EXT SHRT LRF 15 20MM,SUP-2701752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,330.64,214.92,,,,,,,,,,,,,
CATHETER HD 3L 11.5 FRX20 CM STR TRIFLO,SUP-2433955,CDM,C1752,HCPCS,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.4MM TI ST LOK FULL THRD MATRIXMANDIBLE,SUP-2181751,CDM,C1713,HCPCS,0278,RC,,,,both,,,586.87,381.47,,,,,,,,,,,,,
COMPONENT TIB 6 TOT ANK TRABECULAR MTL,SUP-2490848,CDM,C1776,CPT,0278,RC,,,,both,,,9831.34,6390.37,,,,,,,,,,,,,
SCISSORS 4.5IN CVD SUP CUT STEVENS,SUP-2162150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.96,505.02,,,,,,,,,,,,,
FIXER XR FOR RAPID REDI-CHEM HSI SOLUTION AUTO,SUP-2238458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
COMPONENT FMRL MED LEFT RTTNG PLTFRMFLXN GSB LATEX FREE ST,SUP-2720777,CDM,C1776,CPT,0278,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
SLIDER NDL DEG 25 R,SUP-2366701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
KCL-LACTATED RINGERS-D5W 20 MEQ/L IV SOLN,RX-16014,CDM,2500000003,HCPCS,0250,RC,00990-7111-09,NDC,,both,1000,ML,63.30,41.14,,,,,,,,,,,,,
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-128570,CDM,J0695,HCPCS,0636,RC,67919-0030-01,NDC,,both,1,UN,1002.60,651.69,,,,,,,,,,,,,
FIXATOR 5/8 RNG 200MM FRDM CIR,SUP-2400666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2741.22,1781.79,,,,,,,,,,,,,
PLATE BONE MIC THK0.4MM 8 H BILAT CRANIOMAXILLOFACIAL SLV TI,SUP-2181663,CDM,C1713,HCPCS,0278,RC,,,,both,,,1255.06,815.79,,,,,,,,,,,,,
PROSTHESIS PENILE DSTL TIP 12 MMX4 CM DURA II,SUP-2140240,CDM,C1813,HCPCS,0278,RC,,,,both,,,1241.09,806.71,,,,,,,,,,,,,
SCREW BONE L55MM DIA6.5MM CORT TI ALLOY ST FT VERSANAIL,SUP-2411529,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.77,389.85,,,,,,,,,,,,,
SPLITTER T BLNT NOSE CEM FOR GRY SYS STRL,SUP-2375022,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.13,843.13,,,,,,,,,,,,,
PLATE SPNL L 10 MM TI ANTR CERV LEVEL 1 NS SONOMA,SUP-2887249,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.63,38.76,,,,,,,,,,,,,
ENDCAP SPINAL 5MM PHOENIX,SUP-2497351,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
CATHETER ETER PICC AD 5FR L55CM 2 LUMN NRS PWR INJ N COAT CT,SUP-2126708,CDM,C1751,HCPCS,0278,RC,,,,both,,,623.98,405.59,,,,,,,,,,,,,
SCREW 2 THRD. 8.0X70 TI ST,SUP-2392806,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
KIT NEUROSTIMULATOR CHRG SENZA,SUP-2308584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
WAND ABLAT 70DEG 3 WIRE ACT ELECTRD FOR ADENOTONSILLECTOMY,SUP-2342042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLATE BONE W14XL181MM THK3.8MM 90DEG 10 H RT TIB L BTTRS LT,SUP-2185772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1952.83,1269.34,,,,,,,,,,,,,
PLATE BNE W102XL130MM THK27MM 10 H BILAT S STL STR LO PROF,SUP-2420784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1478.50,961.02,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 30 CC CANC DBM POWER BIO,SUP-2718029,CDM,C1713,HCPCS,0278,RC,,,,both,,,8388.67,5452.64,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM OD 7.5 MM ID 2.5 MM GUIDEWIRE,SUP-2169707,CDM,C1894,HCPCS,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-4504376200,CDM,43762,CPT,0450,RC,,,,inpatient,,,935.00,607.75,,,,,,,,,,,,,
PROBE SURG 6.9FR L18CM ES GAST INT REF INFUSED 6 IMPED 2 PH,SUP-2336766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
HC US Pelvis Complete,PX-4027685600,CDM,76856,CPT,0402,RC,,,,both,,,1227.00,797.55,,,,,,,,,,,,,
PSN TIB HALF BLOCK SZ EF LL 5MM,SUP-2508711,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
GUIDEWIRE VASC BACK-UP MEIER L 300 CM DIA 0.035 IN TIP L 10,SUP-2147055,CDM,C1769,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
CATHETER UROLOGICAL MTL TIP SM 4.5-6 FR RAMROD,SUP-2312762,CDM,C1726,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE W14XL24MM 2X3 H CRANIOMAXILLOFACIAL BILAT BLU TI,SUP-2181567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
CAP END F/RFNA 0MM STERILE,SUP-2719549,CDM,C1889,HCPCS,0278,RC,,,,both,,,590.54,383.85,,,,,,,,,,,,,
CORTEX HEX SCREW S-T 3.5X85 MM STRL,SUP-2818137,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.55,181.06,,,,,,,,,,,,,
CATHETER DIL BAL L24MM DIA7MM SINUS RELIEVA SOLO PRO,SUP-2106328,CDM,C1729,HCPCS,0272,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
DRESSING WND SURG MTRX THCK 10X15 CM MATRISTEM,SUP-2106498,CDM,Q4166,HCPCS,0636,RC,,,,both,,,14836.50,9643.72,,,,,,,,,,,,,
HC Cholesterol Serum/Whole Blood Total,PX-3018246500,CDM,82465,CPT,0301,RC,,,,both,,,78.00,50.70,,,,,,,,,,,,,
HC Inf 1st Hour Hyd,PX-2609636000,CDM,96360,CPT,0260,RC,,,,both,,,370.00,240.50,,,,,,,,,,,,,
RESERVOIR VENT DRNGE 6MM BUR H CATHETER CONN STR SHAL,SUP-2278367,CDM,C1889,HCPCS,0278,RC,,,,both,,,390.11,253.57,,,,,,,,,,,,,
ROD SPNL POST SMOOTH TI ALLOY OD4.75MM L60MM SYNERGY,SUP-2415688,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.94,416.61,,,,,,,,,,,,,
CONTAINER SPEC PRESERV NS DISP MYRIAD,SUP-2930214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4775.69,3104.20,,,,,,,,,,,,,
FORCEPS BONE CUT L10.5IN CVD STILLE LISTON,SUP-2249534,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SCREW BNE ST STD 2X15 MM CORTICAL COMPR TI,SUP-2189448,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.79,103.86,,,,,,,,,,,,,
CATHETER VENTRICULAR SYSTEM VENTRICULAR RESERVOIR RIGHT ANGL,SUP-2826649,CDM,C1729,HCPCS,0272,RC,,,,both,,,1685.77,1095.75,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC FRZN CRYOPRESERVED BNE MTRX VIVIGEN,SUP-2741017,CDM,C1713,HCPCS,0278,RC,,,,both,,,5822.69,3784.75,,,,,,,,,,,,,
CATHETER EP 8FR L105CM LOOP DIA15MM 3-3-3MM SPC D CRV CIR,SUP-2357571,CDM,C1732,HCPCS,0278,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
DRESSING BIO L 8 X W 16 CM PORCINE CLLGN PHMB CROSS LINKED,SUP-2909415,CDM,C1763,HCPCS,0278,RC,,,,both,,,24115.20,15674.88,,,,,,,,,,,,,
SCREW BONE L20MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189339,CDM,C1713,HCPCS,0278,RC,,,,both,,,221.37,143.89,,,,,,,,,,,,,
CATHETER CV TRPL LUMEN 5 FRX55 CM BASIC KT TCS POWERPICC HF,SUP-2759203,CDM,C1751,HCPCS,0278,RC,,,,both,,,1250.98,813.14,,,,,,,,,,,,,
SPACER SPNL H13MM 8DEG M ANTR LUM INTBDY FUS LORDTC INTEGR,SUP-2231341,CDM,C1821,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
BIT DRL 4.4 MM TIB STRL DISP,SUP-2606667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,582.03,378.32,,,,,,,,,,,,,
NEEDLE ENDOSCP 30678ND MANHES MONOPOLAR FOR 30678ND REPL,SUP-2767361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.37,305.74,,,,,,,,,,,,,
BONE CEMENT SURG 40 GM PMMA STD VISC RADIOPAQUE STRL G1 40,SUP-2898467,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
ANCHOR SUT MORPHIX USP NO 2 SUTS 3.5X8 MM,SUP-2277448,CDM,C1713,HCPCS,0278,RC,,,,both,,,1767.82,1149.08,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SPC 10 MM F CRV FIX ORTHOGONAL,SUP-2248947,CDM,C1730,HCPCS,0272,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
TUBE EXT FIX L400MM OD25MM RED C FOR UNILAT MONOTB TRIAX SYS,SUP-2372619,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.89,393.18,,,,,,,,,,,,,
RELOAD STPL SZ 2 PUR RAD MEDIUM/THICK TRI-STPL,SUP-2283369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1705.99,1108.89,,,,,,,,,,,,,
AMBI CHSP 8SL 180MM 150D,SUP-2818068,CDM,C1713,HCPCS,0278,RC,,,,both,,,4964.65,3227.02,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX450 CM VISIGLIDE G2403545AA,SUP-2473407,CDM,C1769,HCPCS,0272,RC,,,,both,,,10595.62,6887.15,,,,,,,,,,,,,
EVOS 2.7/3.5MM EA-D HUM PL 25H L 294MM,SUP-2820165,CDM,C1713,HCPCS,0278,RC,,,,both,,,11299.92,7344.95,,,,,,,,,,,,,
SYSTEM PROLAPSE REP APOGEE W/ INTEPRO,SUP-2140311,CDM,C1781,HCPCS,0278,RC,,,,both,,,3564.69,2317.05,,,,,,,,,,,,,
SET INTRO NEFF SHTH L 18 CM OD 6 FR ID 4 FR 15 CM 21 GA,SUP-2168589,CDM,C1894,HCPCS,0272,RC,,,,both,,,224.07,145.65,,,,,,,,,,,,,
CANNULA SURG PERC 1.6 MM UNIV LCK SYS,SUP-2480117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.69,417.10,,,,,,,,,,,,,
PLATE BONE ANGLED 2 MM LEFT 7X23 HOLE RECONSTRUCTION PRECONT,SUP-2837754,CDM,C1713,HCPCS,0278,RC,,,,both,,,7270.98,4726.14,,,,,,,,,,,,,
PROSTHESIS OSS EAR INCUS-STAPE WEHRS,SUP-2342764,CDM,L8613,CPT,0278,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
ROD ORTH THRD 300 MM,SUP-2749914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
MESH CRAN CHIARI MIDLN NS DISP,SUP-2936971,CDM,C1713,HCPCS,0278,RC,,,,both,,,5397.66,3508.48,,,,,,,,,,,,,
PIN FIX L9IN DIA48MM ST S STL 3 SIDE SGL TRCR 1 END PNT,SUP-2150504,CDM,C1713,HCPCS,0278,RC,,,,both,,,26.34,17.12,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 4X2 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651375,CDM,Q4154,HCPCS,0636,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX8 IN KT ARROWG+ARD BLU,SUP-2383337,CDM,C1751,HCPCS,0278,RC,,,,both,,,212.77,138.30,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LCK W/INTEGR RELEASE MECHANISM,SUP-2435668,CDM,L2415,HCPCS,0274,RC,,,,both,,,343.96,223.57,,,,,,,,,,,,,
INFLUENZA VIRUS VACC SPLIT PF 0.5 ML IM SUSY,RX-129230,CDM,90656,HCPCS,0636,RC,58160-0912-41,NDC,,both,.5,ML,97.40,63.31,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 8 MM EPTFE STR TW REINF 2,SUP-2681200,CDM,C1768,CPT,0278,RC,,,,both,,,1449.86,942.41,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 12.5 MM 4 CHANNEL PRASS PR SM HUB,SUP-2901947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.13,396.58,,,,,,,,,,,,,
HEAD HUM STD 44 MM OLYMPIA,SUP-2538188,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
EXPANDER TISS SELF TIGHT CONT EXT DERMACLOSE,SUP-2396767,CDM,C1789,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
MESH HERN FLAT SHT 8X10 IN RECT OVL KNITTED PROLITE ULTRA,SUP-2227248,CDM,C1781,HCPCS,0278,RC,,,,both,,,259.14,168.44,,,,,,,,,,,,,
GUIDEWIRE VASC TAPR 035-018X145 LOC EXTN STRL TAD,SUP-2264465,CDM,C1769,HCPCS,0272,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
STAPLER INT BRTRC REINF LN FOR PROX TCT 75 TLC 55 BIODESIGN,SUP-2863654,CDM,C1763,HCPCS,0278,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
PUMP INFUSION ELASTOMERIC 100 CC 2 ML/HR 2 FIX FLO STRL ON-Q,SUP-2424458,CDM,C9804,HCPCS,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
BRACE ORTH MOLD ANK FT,SUP-2388164,CDM,L1945,HCPCS,0274,RC,,,,both,,,2917.09,1896.11,,,,,,,,,,,,,
SET SCR SPNL L32MM OD6.35MM S IL STL BRK OFF,SUP-2287059,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.36,205.63,,,,,,,,,,,,,
PLATE BNE 8 H L TI H SHP OBLQ ANG STRUT EXT FOR 1.5MM SCR,SUP-2191148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.30,802.29,,,,,,,,,,,,,
KETOROLAC TROMETHAMINE 10 MG PO TABS,RX-10371,CDM,6370000000,HCPCS,0637,RC,00093-0314-01,NDC,,both,1,UN,4.90,3.18,,,,,,,,,,,,,
STENT GI AXIOS SADL L 10 MM LUMEN DIA20 MM CATH L 138 CM,SUP-2141523,CDM,C1874,HCPCS,0278,RC,,,,both,,,16154.83,10500.64,,,,,,,,,,,,,
BLOCK CANC TRAD ALLGRFT 30 MM LX13 MM WX13 MM H FRZ DRY,SUP-2294053,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE 5 GBQ YTTRIUM-90 GLS DOSE VI,SUP-2135306,CDM,C1889,HCPCS,0278,RC,,,,both,,,54322.00,35309.30,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 9.12MMW X25.22MML 0.64MM/0.64MM THK CUT B,SUP-2605486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,77.50,50.37,,,,,,,,,,,,,
PROSTHESIS MXLFCL ADD RECON VSP,SUP-2862822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5185.52,3370.59,,,,,,,,,,,,,
CATHETER DRNGE 8.5FR L25CM UTHANE DAWSON MUELLER 5 SIDEPRT,SUP-2168489,CDM,C1729,HCPCS,0272,RC,,,,both,,,200.46,130.30,,,,,,,,,,,,,
SCREW INTFR L20MM DIA8MM TAPR 7.5-8.3MM KNEE CANN RND THRD,SUP-2341574,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
SYSTEM FIX SHFT L36CM DIA5MM FAST L67MM POLY LACTIDE ABSRB,SUP-2125760,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
ANCHOR SUT FOR ARTHSCP INSTABILITY REP LUPINE BR ORTHOCORD,SUP-2256590,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.82,1659.33,,,,,,,,,,,,,
STOP DRL DIA45 65MM TI CANN STP BIT FOR LAT ENTRY FEM,SUP-2178866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.52,504.09,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM COARSE BALL FOR MIA16-G1/MIA16,SUP-2848317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,463.90,301.53,,,,,,,,,,,,,
STEM FEM L127MM DIA13MM KNEE TI POR BODY STR CEM GMRS,SUP-2376422,CDM,C1776,CPT,0278,RC,,,,both,,,9248.09,6011.26,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LIVIAN HE TI CRT BATTERY PWR HI ENERGY,SUP-2149236,CDM,C1882,HCPCS,0275,RC,,,,both,,,58090.00,37758.50,,,,,,,,,,,,,
RING SPNL L TI ALLOY CLS HALF FOR RIB SUPP VEPTR,SUP-2193302,CDM,C1713,HCPCS,0278,RC,,,,both,,,3290.72,2138.97,,,,,,,,,,,,,
FIBER LASER RFID 200 MH REUSE,SUP-2474911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3842.23,2497.45,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE SALERA 2CM X 3CM DEHYDRATED,SUP-2907553,CDM,C1762,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SHUNT SURG CORONARY 3X12 MM VES BLB TIP RADIOPAQUE TAB SIL,SUP-2159485,CDM,C1889,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
ELECTRODE BPLR CUT 21FR,SUP-2332802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1236.85,803.95,,,,,,,,,,,,,
REDAPT 300MM SLV REV STEM SZ 19 STD OFFSET,SUP-2419251,CDM,C1776,CPT,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
PLATE BNE W8XL112MM THK3.3MM 14 H NONSTERILE BILAT PELV S,SUP-2186241,CDM,C1713,HCPCS,0278,RC,,,,both,,,2128.20,1383.33,,,,,,,,,,,,,
HC Inj Proc Wrist,PX-3612524600,CDM,25246,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 7CMD STNLSS STEEL SPNL MSCLE NRRW BLACK,SUP-2494782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.79,269.61,,,,,,,,,,,,,
CANNULA KYPHOPLASTY BVL W/ INTRO ULT AFFIRM,SUP-2232190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
SOUND PROCESSOR MAGNET STRENGTH 4,SUP-2858180,CDM,L8690,HCPCS,0278,RC,,,,both,,,412.38,268.05,,,,,,,,,,,,,
KIT PICC MAX BARRIER PRLOADED 5FR X 55CM 2L,SUP-2864580,CDM,C1751,HCPCS,0278,RC,,,,both,,,732.66,476.23,,,,,,,,,,,,,
HC Endo Level 1 Base 15 Min,PX-3600007501,CDM,3600007501,LOCAL,0360,RC,,,,both,,,3939.00,2560.35,,,,,,,,,,,,,
STENT DUODENAL 0.035 IN 22 MMX230 CM 27 MMX6 CM NIT WALLFLEX,SUP-2485759,CDM,C1874,HCPCS,0278,RC,,,,both,,,7968.44,5179.49,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 10/40CM WATER WITH SPRUNG RESERVOIR NON,SUP-2825676,CDM,C1889,HCPCS,0278,RC,,,,both,,,7222.35,4694.53,,,,,,,,,,,,,
DEVICE INFLATION BALLOON L 5 CM DIA24/18 FR PACLITAXEL COAT,SUP-2881839,CDM,C1889,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
BIT DRL DIA2MM CANN,SUP-2122275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
COMPONENT FEM L5CM RT DSTL HIP TOT RESURF FIN IMP,SUP-2406047,CDM,C1776,CPT,0278,RC,,,,both,,,17876.02,11619.41,,,,,,,,,,,,,
CORTICAL BONE SCR 5.0MM X 20MM,SUP-2588707,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.65,347.52,,,,,,,,,,,,,
CATHETER DIAG EP STEER 5MM ELECTRD SPC QPLR LONGEST CRV,SUP-2141295,CDM,C1725,HCPCS,0272,RC,,,,both,,,1439.38,935.60,,,,,,,,,,,,,
COMPONENT HIP CAPPED H2 INSITU BIOLOGIC COCR,SUP-2308993,CDM,C1776,CPT,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,J7131,HCPCS,0258,RC,63323-0093-30,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
"HC So2 Immunoassay,Analyte,Nos",PX-3018352068,CDM,83520,CPT,0301,RC,,,,both,,,496.00,322.40,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 5-8 MM EPTFE LNG TAPR STD,SUP-2669627,CDM,C1768,CPT,0278,RC,,,,both,,,528.18,343.32,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 209X13X3 MM FD STRUT,SUP-2717898,CDM,C1762,CPT,0278,RC,,,,both,,,3315.06,2154.79,,,,,,,,,,,,,
MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR,RX-25005,CDM,J7528,HCPCS,0636,RC,66689-0307-08,NDC,,both,1.25,ML,16.00,10.40,,,,,,,,,,,,,
CATHETER VENT L23CM OD2.5MM ID1.3MM S STL ANTIBIO IMPREG,SUP-2284709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1364.74,887.08,,,,,,,,,,,,,
PILLAR EXT FIX L 120 MM THRD MONK RING,SUP-2899190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1467.95,954.17,,,,,,,,,,,,,
DEVICE FIX GRFT MINI 12X3.9 MM 15 MM BUTTON GFS,SUP-2762035,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
PLATE BNE Y SM NS LTX,SUP-2861123,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.80,491.92,,,,,,,,,,,,,
MESH SURG DIA4IN POLYPR PLUG MK PTCH W POSIFLEX MEM,SUP-2126067,CDM,C1781,HCPCS,0278,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
EXTENSION STEM 12X135 MM KNEE REV PERSONA,SUP-2435463,CDM,C1776,CPT,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
SPACER SPNL L W30XH20XL24MM 8DEG ANG PEEK PERIMETER,SUP-2285369,CDM,C1713,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
MARKER TISS 17X10CM RBBN5/CS,SUP-2127911,CDM,A4648,CPT,0278,RC,,,,both,,,204.04,132.63,,,,,,,,,,,,,
HC Perq Replacement Gtube Req Revj Gstrst Trc,PX-3614376300,CDM,43763,CPT,0361,RC,,,,both,,,935.00,607.75,,,,,,,,,,,,,
WASHER ORTH CANN 4.6X10 MM FOR BNE SCR,SUP-2657750,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
PLATE BONE L174MM 13 H RT MEDL DSTL HUM LCK FOR 2.7/3.5MM,SUP-2348600,CDM,C1713,HCPCS,0278,RC,,,,both,,,13340.60,8671.39,,,,,,,,,,,,,
KIT EXT FIX DSTL RAD FOR MINI BAR JET-X,SUP-2342909,CDM,C1713,HCPCS,0278,RC,,,,both,,,15426.98,10027.54,,,,,,,,,,,,,
CANNULA VEN SHT 25 FR UNCOATED HLS,SUP-2663487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1255.31,815.95,,,,,,,,,,,,,
DRILL 6.5MM CANNULATED,SUP-2811645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
INTRODUCER SHTH L81CM L85CM OD8.5FR 3MM TIP .032IN SL0,SUP-2357265,CDM,C1894,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
PLATE BNE W10XL67MM THK1.5MM 3X5 H BILAT S STL T SHP R ANG,SUP-2185870,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.53,624.34,,,,,,,,,,,,,
PLATE BONE LOW PROFILE 100X0.4 MM CONTOURABLE MESH MALLEABLE,SUP-2838373,CDM,C1713,HCPCS,0278,RC,,,,both,,,6418.79,4172.21,,,,,,,,,,,,,
PLATE BNE SM W11XL98MM THK3.4MM 7 H BILAT TI RIG NEUT LOK,SUP-2420739,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.54,622.40,,,,,,,,,,,,,
BUR SURG SUCTION 35 MMX30 CM INTEGR IRRIGATION STR SHFT,SUP-2775985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3096.42,2012.67,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,2500000003,HCPCS,0250,RC,00338-0048-02,NDC,,both,500,ML,80.80,52.52,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA10MM STRUCTURAL BLLN FOR LAP,SUP-2283314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,487.14,316.64,,,,,,,,,,,,,
GRAFT VASC IMPRA L 60 CM DIA 7-4 MM EPTFE SHRT TAPR STD WALL,SUP-2761311,CDM,C1768,CPT,0278,RC,,,,both,,,2184.62,1420.00,,,,,,,,,,,,,
INSERT ACET SZ P4 ID32MM 15DEG HIP UHMWPE CO CHROM,SUP-2376175,CDM,C1776,CPT,0278,RC,,,,both,,,2024.67,1316.04,,,,,,,,,,,,,
LEAD DEFIB 5.6FR L65CM PERM TRNSVEN BPLR ACT FIX STEROID,SUP-2356668,CDM,C1777,HCPCS,0275,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
CEMENT BNE ARTHRPLSTY ORTHOPEDIC N MEDICATED GENTAMICIN,SUP-2156016,CDM,C1713,HCPCS,0278,RC,,,,both,,,554.65,360.52,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO MEMBRN 4X8 CM DRY ALLOWRAP DRY,SUP-2717793,CDM,Q4150,HCPCS,0636,RC,,,,both,,,15599.52,10139.69,,,,,,,,,,,,,
INTRODUCER CATH CANN L 10 CM MINI WIRE L 43 CM DIA 0.021 IN,SUP-2909813,CDM,C1894,HCPCS,0272,RC,,,,both,,,181.34,117.87,,,,,,,,,,,,,
HC Admin Influenza Vaccine,PX-7710000800,CDM,G0008,HCPCS,0771,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
CATHETER EP D-D 8 MM 7 FRX115 CM 4 CELSIUS DS,SUP-2248495,CDM,C1733,HCPCS,0272,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
BASEPLATE KNEE MG II PC PEG TIB E/GREEN,SUP-2199603,CDM,C1776,CPT,0278,RC,,,,both,,,11354.24,7380.26,,,,,,,,,,,,,
HC Bx Breast 1st Lesion US Img,PX-3611908300,CDM,19083,CPT,0361,RC,,,,inpatient,,,7265.00,4722.25,,,,,,,,,,,,,
HC So Immunoglobulin,PX-3018278466,CDM,82784,CPT,0301,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
STAPLER INT STR 4.8X45 MM RT BIOABSORBABLE GRN SEAMGRD,SUP-2468455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
GRAFT SPNL W12XL36MM CORT FRZ DRY CAPSTONE,SUP-2293994,CDM,C1713,HCPCS,0278,RC,,,,both,,,17298.26,11243.87,,,,,,,,,,,,,
MATRIX BIO L 8 X W 6 CM FISH SKIN DERMAL INTACT STRL OMEGA3 10/BX,SUP-2909453,CDM,Q4158,HCPCS,0636,RC,,,,both,,,7184.32,4669.81,,,,,,,,,,,,,
PLATE BNE L288MM 21 H R ANTLAT DST TIB TI LOK COMPR FOR 35MM,SUP-2190976,CDM,C1713,HCPCS,0278,RC,,,,both,,,4949.02,3216.86,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7040,HCPCS,0258,RC,00264-7800-10,NDC,,both,500,ML,29.80,19.37,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 90 CM 5 FR 0.035 IN RACKET SFT,SUP-2116615,CDM,C1887,HCPCS,0272,RC,,,,both,,,99.35,64.58,,,,,,,,,,,,,
HC Wheelchair Training per 15 Min,PX-4209754200,CDM,97542,CPT,0420,RC,,,,both,,,154.00,100.10,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE AMNIOBAND 3CM X 8CM,SUP-2907551,CDM,Q4151,HCPCS,0636,RC,,,,both,,,7634.47,4962.41,,,,,,,,,,,,,
GRAFT BNE SUB 15CC PARTIC 4-9.5MM CANC FRZ DRY CHIP,SUP-2113907,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.12,581.18,,,,,,,,,,,,,
SET INTRO L 30 CM DIA 9 FR GUIDEWIRE 0.038 IN PTFE TEARWY,SUP-2226014,CDM,C1892,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
PLATE BNE GAP 25 MM NEURO LORENZ,SUP-2402911,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
COIL NEUROVASCULAR V-TRAK HYDROFRAME 10 L 12 CM LOOP DIA 4,SUP-2430110,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BUR SHAVER HI VISIBILITY SHTH LG 4X180 MM FLAT TOP,SUP-2848631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
DIREXION/SINGLE/021/J/1RO/105,SUP-2652824,CDM,C1887,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
VALVE VENT DRNGE PRECIS FIX INLINE W/ STR CONN INTRO PRIMING,SUP-2243816,CDM,C1729,HCPCS,0272,RC,,,,both,,,3035.12,1972.83,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE,PX-4209711600,CDM,97116,CPT,0420,RC,,,GP|CQ|XU|KX,both,,,164.00,106.60,,,,,,,,,,,,,
BIT DRL TWST 5.75 INX146 MM CASPR ULTRA LF,SUP-2469658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.85,328.80,,,,,,,,,,,,,
POST ANG HOFFMANN II SS EXT FIXATION 30D,SUP-2701726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.20,325.13,,,,,,,,,,,,,
HC Myelogram Cervical,PX-3616230200,CDM,62302,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT DERMAL MESH THCK 16X8 CMX0.8-1.7 MM PLIABLE KT FLEXHD,SUP-2307596,CDM,C1781,HCPCS,0278,RC,,,,both,,,20264.30,13171.79,,,,,,,,,,,,,
Z DISCONTINUED USE 2284564 SET VENT DRNGE HYDROPHOBIC VENT BLU STRP TBNG CRD LOK GRAD,SUP-2284542,CDM,C1729,HCPCS,0272,RC,,,,both,,,594.21,386.24,,,,,,,,,,,,,
HC So Tacrolimus,PX-3018019766,CDM,80197,CPT,0301,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
PLATE BONE L56MM 4 H RT ANG T SHP PERI-LOC SM FRAG SYS,SUP-2348448,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.40,752.31,,,,,,,,,,,,,
BIT DRL L82MM OD1MM 20MM STP TWST DENT N RADLUC DISP,SUP-2267816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
RELOAD STPLR L 100 MM CLOSED STPL H 2.2 MM THCK 4 ROW LINEAR,SUP-2912267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.41,294.07,,,,,,,,,,,,,
STENT BILI WALLFLEX L 40 MM DIA 8 MM CATH L 194 CM DIA 8 FR,SUP-2148505,CDM,C1876,HCPCS,0278,RC,,,,both,,,5427.84,3528.10,,,,,,,,,,,,,
STENT PANCREATIC ZMMN L 120 MM DIA 7 FR CHANNEL 3.2 MM,SUP-2480092,CDM,C1877,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SUPPORT ORTHOT CUST OUTFLARE WDG,SUP-2435725,CDM,L3390,HCPCS,0274,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
FLAT WASHER 5.0MM STERILE,SUP-2489432,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.52,108.89,,,,,,,,,,,,,
DOCUSATE SODIUM 50 MG PO CAPS,RX-2568,CDM,6370000000,HCPCS,0637,RC,67618-0111-28,NDC,,both,1,UN,2.30,1.49,,,,,,,,,,,,,
PROSTHESIS OSS L 7 MM SHFT DIA 0.8 MM HD DIA 4 MM TI HA TOT,SUP-2901996,CDM,L8613,CPT,0278,RC,,,,both,,,1366.53,888.24,,,,,,,,,,,,,
PROSTHESIS OSS 1 CENTERED DUO ALTO TOT,SUP-2479517,CDM,L8613,CPT,0278,RC,,,,both,,,1279.05,831.38,,,,,,,,,,,,,
ANCHOR SUT NO 2 PRELD NDL L12CM OD17GA SECUR ADJ GI ENTUIT,SUP-2170291,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
RING EXT FIX COMP FT 140MM INT DIAM 160MM LEN,SUP-2342278,CDM,C1713,HCPCS,0278,RC,,,,both,,,8695.76,5652.24,,,,,,,,,,,,,
CATHETER ABLATION L 35 MM DIA12 FR CARD PULSED FLD STRL DISP,SUP-2930291,CDM,C1732,HCPCS,0272,RC,,,,both,,,26533.00,17246.45,,,,,,,,,,,,,
CARBON FT PLT LNG 180MM FOR RNG FIX SYS,SUP-2365271,CDM,C1713,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
PATIENT PRGRMMR KIT INCLDS RMTE CNTRL RMTE CNTRL HLSTR PTNT,SUP-2679260,CDM,C1787,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SPLINT ANK STRRP AIR AND FOAM S,SUP-2276706,CDM,L4350,HCPCS,0274,RC,,,,both,,,38.18,24.82,,,,,,,,,,,,,
COIL EMB L4CM OD3MM .020IN NIT NEUROVASC COMPLX SFT FILL,SUP-2323389,CDM,C1889,HCPCS,0278,RC,,,,both,,,7391.56,4804.51,,,,,,,,,,,,,
BUR SURG L 95 MM DIA2.35 MM HD DIA 7 MM BRL NS REUSE,SUP-2929114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.60,229.84,,,,,,,,,,,,,
IMPL CAPPED KNEE LPS FXTICMFMTBPRLNOPATPLG,SUP-2212335,CDM,C1776,CPT,0278,RC,,,,both,,,14359.69,9333.80,,,,,,,,,,,,,
PLATE BONE L119MM 5 H RT PROX HUM LCK FOR 4.5MM SCR PERI-LOC,SUP-2348275,CDM,C1713,HCPCS,0278,RC,,,,both,,,14970.11,9730.57,,,,,,,,,,,,,
CAGE SPNL CORPECTOMY 0 DEG 28X36X82-106 MM EXT HSNG CAPRI,SUP-2519629,CDM,C1889,HCPCS,0278,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
HC So1 Immunoassay Quant,PX-3018351967,CDM,83519,CPT,0301,RC,,,,inpatient,,,264.00,171.60,,,,,,,,,,,,,
HC So Cea,PX-3018237866,CDM,82378,CPT,0301,RC,,,,inpatient,,,67.00,43.55,,,,,,,,,,,,,
PLATE BNE L184MM 11 H ST L DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177224,CDM,C1713,HCPCS,0278,RC,,,,both,,,5086.67,3306.34,,,,,,,,,,,,,
LEVETIRACETAM 500 MG PO TABS,RX-26817,CDM,6370000000,HCPCS,0637,RC,51079-0821-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SYSTEM DEL ENDOSCP US W/ 22GA FNF PRELD NDL BEAC,SUP-2173692,CDM,A4648,CPT,0278,RC,,,,both,,,2059.84,1338.90,,,,,,,,,,,,,
GRAFT VASC GORTX L 60 CM DIA 6 MM RNG L 30 CM EPTFE STR TW,SUP-2396116,CDM,C1768,CPT,0278,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
PLATE BONE LOK LNG HLX6 1MM THK CP TTNM LATEX FREE,SUP-2668742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.09,730.66,,,,,,,,,,,,,
FLECAINIDE ACETATE 100 MG PO TABS,RX-10041,CDM,6370000000,HCPCS,0637,RC,00054-0011-20,NDC,,both,1,UN,4.30,2.79,,,,,,,,,,,,,
RING ANNULPLSTY DIA26MM MI VLV TI CLASS KID SHP,SUP-2214148,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.5MM SIL TI SELF DRL FULL THRD 0450310320] DEPUY SYNTHES USA],SUP-2181589,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.67,168.14,,,,,,,,,,,,,
PLATE BNE L80MM 4 H L LAT DST PERIARTC FIBULAR S STL LOK,SUP-2410715,CDM,C1713,HCPCS,0278,RC,,,,both,,,1935.37,1257.99,,,,,,,,,,,,,
DABIGATRAN ETEXILATE MESYLATE 75 MG PO CAPS,RX-103560,CDM,6370000000,HCPCS,0637,RC,00597-0355-56,NDC,,both,1,UN,14.90,9.68,,,,,,,,,,,,,
HC Mech Rem Fibrin via Sep Acces,PX-3613659500,CDM,36595,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
GUIDEWIRE SM PASS R ANG,SUP-2286521,CDM,C1769,HCPCS,0272,RC,,,,both,,,184.10,119.66,,,,,,,,,,,,,
BIT DRL L13MM DIA2.8MM TAP FOR POLARUS 2 HUM ROD SYS,SUP-2107700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
KIT INTRO INTRACLUDE L 3.7 IN DIA19 FR GUIDEWIRE L 100 CM,SUP-2890128,CDM,C1894,HCPCS,0272,RC,,,,both,,,1876.84,1219.95,,,,,,,,,,,,,
SCREW BNE FT 4X70 MM CANC STRL PERI-LOC,SUP-2348410,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.27,227.68,,,,,,,,,,,,,
SCREW 65 L115 FT CANN,SUP-2243585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.72,867.57,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 6 MM EPTFE FLX STD WALL RING,SUP-2128208,CDM,C1768,CPT,0278,RC,,,,both,,,2201.14,1430.74,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR HI RL CUF,SUP-2435679,CDM,L2550,HCPCS,0272,RC,,,,both,,,963.29,626.14,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 137 MCG PO TABS,RX-10405,CDM,6370000000,HCPCS,0637,RC,42292-0041-01,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
MIDAZOLAM 5 MG/ML SOLN (MIXTURES ONLY),RX-430000,CDM,J2250,HCPCS,0636,RC,00409-2308-01,NDC,,both,0.4,ML,54.10,35.16,,,,,,,,,,,,,
TROCAR SURG STRUCTURAL OVL DISECT BLLN SPCMKR +,SUP-2283394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1379.25,896.51,,,,,,,,,,,,,
SCREW BNE L58MM DIA4MM CORT S STL ST NONCANNULATED LOK FULL,SUP-2185081,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
SHELL HUM DIA52MM SHLDR CO CHROM BPLR ABS,SUP-2404522,CDM,C1776,CPT,0278,RC,,,,both,,,5350.56,3477.86,,,,,,,,,,,,,
CATHETER BLLN 038 10 FRX100 CM 10-50 MM 3-60 CC BLU Q50,SUP-2458769,CDM,C2628,HCPCS,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
PLATE BNE L230MM 10 H NONSTERILE R CNDYL S STL CRV LOK,SUP-2177852,CDM,C1713,HCPCS,0278,RC,,,,both,,,5741.62,3732.05,,,,,,,,,,,,,
BIT DRL CANN LG 5X215 MM QC STRL,SUP-2563804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1462.99,950.94,,,,,,,,,,,,,
GUIDEWIRE VASC L 110 CM DIA 0.018 IN TIP CRV RAD 10 MM SS,SUP-2169668,CDM,C1769,HCPCS,0272,RC,,,,both,,,192.64,125.22,,,,,,,,,,,,,
HANDPIECE ASPIR 0.4 MM 23 GAX113 MM POL ROUGHENED SURF TI,SUP-2462252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.03,356.87,,,,,,,,,,,,,
ENDCAP ORTH ST BLU TI FOR SLD TIB IM NAIL,SUP-2192163,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.24,364.16,,,,,,,,,,,,,
CATHETER ETER EP 5FR L120CM 5MM SPC 1MM BND QPLR TORQ CTRL,SUP-2355229,CDM,C1730,HCPCS,0272,RC,,,,both,,,401.70,261.10,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 12X1 MM CONTOURED PDLLA STRL,SUP-2460733,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.53,586.64,,,,,,,,,,,,,
HEAD FEM DIA36MM OFFSET 3MM 11 13 TAPR HIP ASPHERE M SPEC,SUP-2251080,CDM,C1776,CPT,0278,RC,,,,both,,,5179.12,3366.43,,,,,,,,,,,,,
CATHETER DRAINAGE 8.5 FRX40 CM BILI STD LCK LOOP UTHANE,SUP-2168120,CDM,C1729,HCPCS,0272,RC,,,,both,,,305.33,198.46,,,,,,,,,,,,,
CURETTE SURG SIMS 6 10.25 IN UTER SHRP 1 PC CONSTRUCTION,SUP-2484829,CDM,C1713,HCPCS,0278,RC,,,,both,,,102.55,66.66,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE PUROS 12X12MM 9MM THK WEDGE FD,SUP-2863659,CDM,C1713,HCPCS,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
DRILL SURG SM DIA4-5.5MM STP,SUP-2417457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1531.28,995.33,,,,,,,,,,,,,
IMPLANT OPHTH 15MM MERIDIONAL,SUP-2213507,CDM,L8610,HCPCS,0278,RC,,,,both,,,69.71,45.31,,,,,,,,,,,,,
COMPONENT FEM SZ 5 R REV POST STBL GMK,SUP-2267612,CDM,C1776,CPT,0278,RC,,,,both,,,22765.00,14797.25,,,,,,,,,,,,,
SYSTEM INTRO SHTH 9FR L25CM BLK HUB W O SIDEPRT SPLITTABLE,SUP-2303232,CDM,C1892,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
SHOE ORTHOT CUST DENNIS BRN SPLNT,SUP-2435749,CDM,L3640,HCPCS,0274,RC,,,,both,,,122.49,79.62,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.510,SUP-2860192,CDM,C1713,HCPCS,0278,RC,,,,both,,,28622.36,18604.53,,,,,,,,,,,,,
BRACE THMB UNIV LT SPICA,SUP-2319328,CDM,L3906,HCPCS,0272,RC,,,,both,,,25.28,16.43,,,,,,,,,,,,,
PLATE BONE W16XL253MM THK5MM 13 H LT CNDYL FEM S STL BTTRS,SUP-2185795,CDM,C1713,HCPCS,0278,RC,,,,both,,,2775.51,1804.08,,,,,,,,,,,,,
BEARING TIB 9 XL KNEE OXFORD,SUP-2136411,CDM,C1776,CPT,0278,RC,,,,both,,,3510.52,2281.84,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|ADJ|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|ADJ|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
IMPLANT FNGR JT SM PIP FUSION,SUP-2897385,CDM,C1713,HCPCS,0278,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
OSTEOTOME 4MM 8.1IN LEN LT CVD W/ GRD ANDRSN NEIVERT,SUP-2129697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
SCREW BONE 32MM 6.5MM CANC LCK EQUINOXE,SUP-2223450,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
MIS CALC PLT LG RT STE,SUP-2587005,CDM,C1713,HCPCS,0278,RC,,,,both,,,2233.83,1451.99,,,,,,,,,,,,,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147265,CDM,6370000000,HCPCS,0637,RC,42571-0382-71,NDC,,both,0.25,UN,10.20,6.63,,,,,,,,,,,,,
PLATE BONE L94MM 8 H STRL S STL 1/3 TBLR FOR 3.5MM SCR EVOS,SUP-2349635,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.75,378.14,,,,,,,,,,,,,
SET SCR 130DEG TI FOR TROCHANTERIC FIX NAIL,SUP-2180358,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.56,309.76,,,,,,,,,,,,,
HC ER Level 3,PX-4509928300,CDM,99283,CPT,0450,RC,,,,outpatient,,,1556.00,1011.40,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 23.5-26.5 IN CTR 17-19 IN CALF 18-20 IN,SUP-2914921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,905.89,588.83,,,,,,,,,,,,,
DISTRACTOR ANGULAR 100MM FOR TRUELOK FIX SYS,SUP-2316082,CDM,C1713,HCPCS,0278,RC,,,,both,,,3246.01,2109.91,,,,,,,,,,,,,
BIT REPROC DRL CANN LG 5X300MM,SUP-2526041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.00,225.55,,,,,,,,,,,,,
EVOS 3.5/4.5PP TROC RING PL L 3H X 132MM,SUP-2931282,CDM,C1713,HCPCS,0278,RC,,,,both,,,20698.10,13453.76,,,,,,,,,,,,,
CATHETER SET 0.018 IN 5 FRX60 CM CV DL STD TURBO-FLO,SUP-2168838,CDM,C1751,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
CAP END NAIL OLECRANON OSTEOTMY,SUP-2177095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1812.66,1178.23,,,,,,,,,,,,,
PIN REINFORCEMENT LARGE 16MM,SUP-2890769,CDM,C1713,HCPCS,0278,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
RING EXT FIX HALF 120 MM CARBON FIBER RINGFIX,SUP-2365275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
COMPONENT FEM SZ 6 R REV POST STBL GMK,SUP-2267613,CDM,C1776,CPT,0278,RC,,,,both,,,19866.78,12913.41,,,,,,,,,,,,,
GRAFT VASC GELSFT L 60 CM DIA10 MM POLYESTER GEL ABD PERIPH,SUP-2384967,CDM,C1768,CPT,0278,RC,,,,both,,,1383.11,899.02,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA10 MM EPTFE STR TW N RING,SUP-2396358,CDM,C1768,CPT,0278,RC,,,,both,,,2320.46,1508.30,,,,,,,,,,,,,
CRYOABLATION KIT PROST RENAL ICEROD +,SUP-2225660,CDM,C2618,HCPCS,0272,RC,,,,both,,,11702.00,7606.30,,,,,,,,,,,,,
GRAFT HUM TISS L69MM DIA9.5MM FRZN FLEXIGRFT GRFTLINK,SUP-2264635,CDM,C1762,CPT,0278,RC,,,,both,,,7033.91,4572.04,,,,,,,,,,,,,
PLATE BNE SM L42MM 0DEG 6 H NONSTERILE R 1ST MTP FUS S STL,SUP-2184815,CDM,C1713,HCPCS,0278,RC,,,,both,,,3213.92,2089.05,,,,,,,,,,,,,
HIGH DMD SYS W/TBL(LG HD,SUP-2212093,CDM,C1776,CPT,0278,RC,,,,both,,,15175.62,9864.15,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5 FRX24 CM LT DL BASIC SET TITAN HD,SUP-2627351,CDM,C1750,HCPCS,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
MESH HERN W10XL15CM FLAT MACRO X3 STD DISPOSABLE PARIETENE,SUP-2174737,CDM,C1781,HCPCS,0278,RC,,,,both,,,227.74,148.03,,,,,,,,,,,,,
PLATE ILLIOSACRAL POST STD LEN RT 30MM,SUP-2290618,CDM,C1713,HCPCS,0278,RC,,,,both,,,9398.02,6108.71,,,,,,,,,,,,,
PATCH VASC HEMGRD L 150 X W 50 MM THK 0.65 MM POLYESTER BOV,SUP-2535428,CDM,C1768,CPT,0278,RC,,,,both,,,1109.83,721.39,,,,,,,,,,,,,
IMMOBILIZER ORTH XSM SHLDR,SUP-2196914,CDM,L3660,HCPCS,0274,RC,,,,both,,,12.59,8.18,,,,,,,,,,,,,
FERROUS GLUCONATE 324 (38 FE) MG PO TABS,RX-3066,CDM,6370000000,HCPCS,0637,RC,00574-0508-01,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
PEDIATRIC LAG SCREW - 25MM,SUP-2818377,CDM,C1713,HCPCS,0278,RC,,,,both,,,4477.33,2910.26,,,,,,,,,,,,,
BUR SURG BALL 4 MM FLUT,SUP-2848214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,531.35,345.38,,,,,,,,,,,,,
HC Myelography 2+ Regions S&I,PX-3207227000,CDM,72270,CPT,0320,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
BLADE SCREWDRIVER 15MM/2MM/23MM DIA TORX,SUP-2694403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.60,251.29,,,,,,,,,,,,,
GUIDE TARGETING STD LT 2 VDR ACU LOC,SUP-2107132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3912.44,2543.09,,,,,,,,,,,,,
COIL EMB L2CM DIA0.02IN LOOP DIA2MM COMPLX EXTRA SFT FILL,SUP-2323425,CDM,C1889,HCPCS,0278,RC,,,,both,,,5548.38,3606.45,,,,,,,,,,,,,
BUR SURG L 12 CM DIA 5 MM SHRT BALL DISECT TOOL STRL DISP,SUP-2929985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.28,284.23,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN TIP L3CM NIT COR HYDRPHLC,SUP-2421308,CDM,C1769,HCPCS,0272,RC,,,,both,,,146.39,95.15,,,,,,,,,,,,,
SCREW BONE L20MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190345,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.25,34.61,,,,,,,,,,,,,
KIT KYPHOPLASTY 10CC L9IN W/ STR SH EXTN TUBE MX AND DEL,SUP-2367030,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
BLADE SHV L11CM DIA29MM SNUS 360DEG ROT STR SHFT TRICUT,SUP-2277856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
BRACE KNEE AD L23 17IN UNIV COOL FOAM UNISX TRANSITION,SUP-2195291,CDM,L1810,HCPCS,0274,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
INSERT TIB SZ 1 THK10MM LT ANK FIX BEAR VANTAGE,SUP-2223499,CDM,C1776,CPT,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
PLATE BONE CRANIAL 4 HOLE STRAIGHT 21.4X3.4MM TITANIUM NEURO,SUP-2827188,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.80,58.37,,,,,,,,,,,,,
REAMER SURG SZ 40/44MM CTRL LO PROF GLOB APG+,SUP-2252721,CDM,C1776,CPT,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HC Tcat Rmvl Perm 1chmbr Ldls Pacemaker R Atrial,PX-4810824000,CDM,0824T,CPT,0481,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
SCREW BNE L32MM DIA4MM THRD L14MM CANC TI SELF DRL ST,SUP-2189939,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.62,38.10,,,,,,,,,,,,,
SYSTEM IV PRT ACC NDL 16GA APHERESIS POWERFLOW,SUP-2126744,CDM,C1788,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-160837,CDM,90734,HCPCS,0636,RC,58160-0827-03,NDC,,both,.5,ML,750.40,487.76,,,,,,,,,,,,,
CLAMP SURG T CONN LT PROTEX CT,SUP-2584528,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Revasc Intravasc Lithotripsy,PX-4810976400,CDM,C9764,CPT,0481,RC,,,,inpatient,,,57405.00,37313.25,,,,,,,,,,,,,
CANNULA SURG TALL ENTRY,SUP-2463629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2080.25,1352.16,,,,,,,,,,,,,
PLATE BNE L292MM 16 H R ANTEROMEDIAL DST TIB S STL VAR ANG,SUP-2177664,CDM,C1713,HCPCS,0278,RC,,,,both,,,7233.37,4701.69,,,,,,,,,,,,,
RING EXT FIX DIA180 MM LNG FT BLU NS DISP SMRT TSF,SUP-2932835,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5650.12,3672.58,,,,,,,,,,,,,
TUBE FEED 18FR L30CM TRANSGASTRIC JEJU UNIV CONN,SUP-2124611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.62,479.45,,,,,,,,,,,,,
BIT DRL L115MM DIA1.5MM RED S STL TWST J NOTCH W/O STP,SUP-2262760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.33,274.51,,,,,,,,,,,,,
PLATE BNE RECON 3.5X238 MM 20 HOLE SS,SUP-2569093,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.09,398.51,,,,,,,,,,,,,
DEFIBRILLATOR IMPL RIVACOR 7 VR-T PROMRI W 60 X H 61.5 MM D,SUP-2739236,CDM,C1898,HCPCS,0275,RC,,,,both,,,55590.56,36133.86,,,,,,,,,,,,,
SPHERE GLEN DIA41MM +6MM OFFSET CO CHROM SHLDR REV SYS,SUP-2404724,CDM,C1776,CPT,0278,RC,,,,both,,,4703.72,3057.42,,,,,,,,,,,,,
PLATE BNE L74MM 9 H L LAT POST HUM TIM LO PROF RIG ALPS,SUP-2411721,CDM,C1713,HCPCS,0278,RC,,,,both,,,4227.70,2748.00,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA 6 MM EPTFE CENTERFLEX RING HEMO,SUP-2761406,CDM,C1768,CPT,0278,RC,,,,both,,,3480.82,2262.53,,,,,,,,,,,,,
HC Drug Tst Prsmv Instrmnt Chem Analyzers PR Date,PX-3018030700,CDM,80307,CPT,0301,RC,,,,both,,,400.00,260.00,,,,,,,,,,,,,
DEVICE BRST BX NDL L9CM DIA12GA 20MM ATEC,SUP-2239995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.91,514.74,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST STD NEW LTHR,SUP-2435732,CDM,L3455,HCPCS,0272,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
TOTAL KNEE REPLACEMENT KIT END-DELIVERY 11 GAX120 MM 3 CC,SUP-2866889,CDM,C1713,HCPCS,0278,RC,,,,both,,,8138.88,5290.27,,,,,,,,,,,,,
HC So1 Prothrombin Time,PX-3058561067,CDM,85610,CPT,0305,RC,,,,both,,,7.00,4.55,,,,,,,,,,,,,
BUR SURG L 70 MM DIA2.35 MM HD DIA 6 MM DIAMOND NS REUSE,SUP-2928866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.33,210.81,,,,,,,,,,,,,
CLAMP SURG DBL SHT OCPTL PROTEX CT,SUP-2584537,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
PLATE BNE 15MM INTERAXIS COMPR FOR 2.7MM SCR CHARLOTTE CLAW,SUP-2397350,CDM,C1713,HCPCS,0278,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
ORTHOLINK 2-HOLE 4MM WEDGE,SUP-2830214,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT HUM TISS H 18 MM TRICORT IL CREST WDG PARALLEL FD STRL,SUP-2913421,CDM,C1762,CPT,0278,RC,,,,both,,,5626.88,3657.47,,,,,,,,,,,,,
PAD TRACH STOMA 1 35X30 MM INNOVATIVE CUSH SIL.FLEX,SUP-2352874,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE BNE 5 H RT CRANIOMAXILLOFACIAL L SHP W/O BAR NS,SUP-2883241,CDM,C1713,HCPCS,0278,RC,,,,both,,,669.20,434.98,,,,,,,,,,,,,
SPLINT ANK FT L R POST LEAF LTWT SEMI RIG ROLYAN,SUP-2324822,CDM,L4397,HCPCS,0274,RC,,,,both,,,98.56,64.06,,,,,,,,,,,,,
PLATE BNE L92MM 7 H BILAT FIBULAR TIM LOK COMPR FOR,SUP-2413682,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.82,510.78,,,,,,,,,,,,,
PUNCH OPHTH DIA8.25MM NONVACUUM DISP FOR DONOR CORNEAL BRRN,SUP-2261435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,190.91,124.09,,,,,,,,,,,,,
BINDER ABD XL W15IN 62 74IN CIRC UNISX 5 PNL E CNTCT CLSR,SUP-2197130,CDM,L3650,HCPCS,0272,RC,,,,both,,,70.18,45.62,,,,,,,,,,,,,
COVER BUR H DIA14MM STD CRAN TI FAN BLDE TIMESH,SUP-2277539,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.02,411.46,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.4 MM TAPR,SUP-2535943,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
SCREW BONE L20MM DIA3.5MM CORT S STL ST SELF DRL CANN,SUP-2183897,CDM,C1713,HCPCS,0278,RC,,,,both,,,754.29,490.29,,,,,,,,,,,,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,0636,RC,67457-0857-30,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
IMPLANT CRANIALXL CUST DEFORMITY PEEK,SUP-2365130,CDM,C1713,HCPCS,0278,RC,,,,both,,,61739.03,40130.37,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450395305,SUP-2844118,CDM,C1713,HCPCS,0278,RC,,,,both,,,2634.99,1712.74,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-40840056,CDM,J3490,HCPCS,0250,RC,00338-0085-04,NDC,,both,250,ML,12.80,8.32,,,,,,,,,,,,,
PLATE BNE L19MM 8 H L TI EXT H SHP NONCOMPRESSION FOR 1.3MM,SUP-2190691,CDM,C1713,HCPCS,0278,RC,,,,both,,,1241.68,807.09,,,,,,,,,,,,,
TRUMATCH SHLDR APG GUIDE,SUP-2823513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SPLINT KNEE L12IN UNIV PERF FOAM HK AND LOOP CLSR QUICK-FIT,SUP-2197151,CDM,L1851,HCPCS,0272,RC,,,,both,,,31.34,20.37,,,,,,,,,,,,,
BLOCK ORTH AIMING LT PROX LAT HUM LCK FOR PLATE TI AXSOS 3,SUP-2472735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2321.09,1508.71,,,,,,,,,,,,,
BUR SURG DIAMOND 4.5 MM 9 CM MTCH HD TELSCP MIDAS REX LEGEND,SUP-2632226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.51,243.43,,,,,,,,,,,,,
DRIVER SURG TORQUE STRL DISP STERNALOCK XP,SUP-2894509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 20MM X 20MM X 4MM,SUP-2547190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1316.01,855.41,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO MEMBRN 2X2 CM DRY ALLOWRAP DRY,SUP-2717790,CDM,Q4150,HCPCS,0636,RC,,,,both,,,3852.59,2504.18,,,,,,,,,,,,,
KIT CATH PARENCHYMA W/ TRNSDUC TIP CATH THRMSTER CAMINO BOLT,SUP-2242792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2807.07,1824.60,,,,,,,,,,,,,
SHELL ACET SZ B DIA44MM RIM 8 H HIP TI W ARC DEPOSIT SURF,SUP-2372526,CDM,C1776,CPT,0278,RC,,,,both,,,5324.18,3460.72,,,,,,,,,,,,,
HC So Lead,PX-3018365566,CDM,83655,CPT,0301,RC,,,,both,,,102.00,66.30,,,,,,,,,,,,,
GRAFT HUMAN TISSUE BIOLOGICAL TISSUE MATRIX THICK 30X30 CM NON CROSSLINKED SCAFFOLD NATURALLY OCCURRING PORCINE STERILE GENTRIX DISPOSABLE,SUP-2106505,CDM,Q4166,HCPCS,0636,RC,,,,both,,,76513.95,49734.07,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.035IN TIP 2.5CM RAD 3MM HEPARIN,SUP-2167603,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.14,23.49,,,,,,,,,,,,,
ENOXAPARIN SODIUM 300 MG/3ML IJ SOLN,RX-106118,CDM,J1650,HCPCS,0636,RC,00548-5608-00,NDC,,both,3,ML,184.10,119.66,,,,,,,,,,,,,
PLATE BNE W10.2XL195MM THK2.7MM 15 H BILAT S STL STR LO,SUP-2186202,CDM,C1713,HCPCS,0278,RC,,,,both,,,1851.44,1203.44,,,,,,,,,,,,,
PLATE BNE L92MM 4 H ST R DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177715,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.73,1643.02,,,,,,,,,,,,,
VALVE CSF REG PERF LEVEL 2 W/ BIOGLDE DELT,SUP-2631431,CDM,C1889,HCPCS,0278,RC,,,,both,,,4271.03,2776.17,,,,,,,,,,,,,
CABLE SPNL STRL LIGAPASS 2.0,SUP-2926032,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE RECON 2.7 MM MAND 17 HOLE LT ANGLED TI LEVEL 1,SUP-2461971,CDM,C1713,HCPCS,0278,RC,,,,both,,,4063.07,2641.00,,,,,,,,,,,,,
CATHETER INTVENT 2X2.5FR L156CM ID0.021IN TIP DIA0.021IN,SUP-2305466,CDM,C1887,HCPCS,0272,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
SHEEHY CLLR BTTN VENT TUBE 127MM ID FLRPLSTC 50 PACK,SUP-2680287,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.51,14.63,,,,,,,,,,,,,
COMPONENT HUM FLNG 4X100 MM LT SHLDR BOND COAT MOSAIC STRL,SUP-2215487,CDM,C1776,CPT,0278,RC,,,,both,,,10902.08,7086.35,,,,,,,,,,,,,
INTRODUCER SHTH 12FR L28CM ID4.1MM HYDRPHLC DRYSEAL,SUP-2395740,CDM,C1894,HCPCS,0272,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
GRAFT VASC L45CM ID6MM EPTFE STD WALLED FIX RNGD STR IMPL,SUP-2395807,CDM,C1768,CPT,0278,RC,,,,both,,,3921.86,2549.21,,,,,,,,,,,,,
DEVICE CRPL TUNN RELEASE SEC GENERATION ULTRAGUIDECTR,SUP-2928366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
CATHETER INTVASC OCCL L 65 CM DIA 7 FR BALLOON DIA11.5 MM,SUP-2142113,CDM,C1725,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE TIB 202 MM LAT 9 HOLE BUTTRESS HD TI NS LC-DCP,SUP-2569063,CDM,C1713,HCPCS,0278,RC,,,,both,,,2614.87,1699.67,,,,,,,,,,,,,
NEEDLE ASPIR INJ 18 GAX45 CM NS ENDOLAP LTX REUSE,SUP-2868579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.54,465.10,,,,,,,,,,,,,
CATHETER PUSH 8.5FR L170CM 0.035IN MINI ACCSRY CHAN L3.2MM,SUP-2169109,CDM,C1729,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
SEALANT FIBRIN VHSD FRZN 2 ML SYR TISSEEL,SUP-2130313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.88,256.02,,,,,,,,,,,,,
VALVE CSF PERF LEVEL 1 SM EXTRACTED DELT,SUP-2628541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4967.54,3228.90,,,,,,,,,,,,,
CATHETER SPNL FOR USE W/ INTRO NDL SPINECATH,SUP-2341606,CDM,C1754,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BIT DRL L465MM DIA13MM ST CANN FLX L QUIK CPL FOR NAIL,SUP-2178843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2195.80,1427.27,,,,,,,,,,,,,
LK RECON PLATE 6HL 94MM,SUP-2695559,CDM,C1713,HCPCS,0278,RC,,,,both,,,2192.98,1425.44,,,,,,,,,,,,,
SCREW ACET PLR PROV LCK LNR,SUP-2438404,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA PHSPTE INJ DRILLABLE VOID FILL NORIAN,SUP-2182828,CDM,C9359,HCPCS,0278,RC,,,,both,,,7263.70,4721.40,,,,,,,,,,,,,
SCREW BONE 3.5MM DIA 18MML CRTCL F/TTL WRIST FSN SSTM NON ST,SUP-2586700,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.30,219.89,,,,,,,,,,,,,
TAP SURG L16MM CANN DIL BIO-COMPRESSION,SUP-2121894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
FELT SURG W1XL1IN THK1.65MM SQ PTFE STRL,SUP-2126674,CDM,C1781,HCPCS,0278,RC,,,,both,,,186.96,121.52,,,,,,,,,,,,,
CATHETER NEPHSTMY 22FR L30CM POLYUR PERC W/ RADPQ STRP MCOT,SUP-2171231,CDM,C1729,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Hand Routine Min 3 Views,PX-3207313000,CDM,73130,CPT,0320,RC,,,,both,,,623.00,404.95,,,,,,,,,,,,,
BIT DRL TWST 3.2 MMX5 IN SLD NS,SUP-2435476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.13,221.73,,,,,,,,,,,,,
BIT DRL OD10.5MM SACROILIAC CANN SI-LOK,SUP-2232173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
STRUT C D 60 80MM SALVATION,SUP-2401127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3221.64,2094.07,,,,,,,,,,,,,
BIT TWST DRL L66MM DIA1.2MM STP 10MM ADD ON QUIK CPL SHFT,SUP-2267823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,291.39,189.40,,,,,,,,,,,,,
PLATE BONE L67MM THK3.4MM 4 H BILAT S STL LCK COMPR NEUT RIG,SUP-2348980,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.53,1708.54,,,,,,,,,,,,,
CATHETER GUID MRESS CRV 5 FRX110 CM LG LUMEN LAUNCHER,SUP-2429725,CDM,C1887,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
HC Cell Count Misc Body Fluids W/Differential Count,PX-3008905100,CDM,89051,CPT,0300,RC,,,,both,,,340.00,221.00,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2.8 MM 32 HOLE ANGLED-ANGLED LCK NS,SUP-2483887,CDM,C1713,HCPCS,0278,RC,,,,both,,,8377.90,5445.63,,,,,,,,,,,,,
MESH HERN CIR 6 IN W/ ECHO 2 POS SYS PHASIX ST,SUP-2421795,CDM,C1781,HCPCS,0278,RC,,,,both,,,11555.20,7510.88,,,,,,,,,,,,,
PLATE BONE 10 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413754,CDM,C1713,HCPCS,0278,RC,,,,both,,,1349.51,877.18,,,,,,,,,,,,,
SPACER M 54X5MM LT CEM,SUP-2209026,CDM,C1776,CPT,0278,RC,,,,both,,,11366.17,7388.01,,,,,,,,,,,,,
CAGE SPNL 15 DEG L 43 X W 30 X H 16 MM 2 H 3D PRNT NO PROF,SUP-2884670,CDM,C1889,HCPCS,0278,RC,,,,both,,,18997.00,12348.05,,,,,,,,,,,,,
DRILL SURG LATCH 2.7 MM USED FOR DENS BNE,SUP-2608734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1244.95,809.22,,,,,,,,,,,,,
SCREW BONE L60MM DIA4.5MM CORT LCK FULL THRD RECON FOR,SUP-2318958,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.10,558.41,,,,,,,,,,,,,
PLATE POSTLAT DSTL HUM 3.5MM 14H RT 208MM LCP STRL,SUP-2547576,CDM,C1713,HCPCS,0278,RC,,,,both,,,3433.53,2231.79,,,,,,,,,,,,,
CEMENT BONE 70GM FULL DOSE CA PHOS W/ GENTMYCN HI VISC N,SUP-2221984,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
FOMEPIZOLE 1.5 GM/1.5ML IV SOLN,RX-91363,CDM,J1451,HCPCS,0636,RC,70710-1478-01,NDC,,both,1.5,ML,2666.20,1733.03,,,,,,,,,,,,,
SCREW SPNL L45MM DIA4.75MM SUPLMNT CANC TI MULTAXL ST TOP,SUP-2137265,CDM,C1713,HCPCS,0278,RC,,,,both,,,3067.91,1994.14,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL 85FRX60CM TM,SUP-2357191,CDM,C1893,HCPCS,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
PLATE BNE 0 LT MCS,SUP-2315900,CDM,C1713,HCPCS,0278,RC,,,,both,,,5058.54,3288.05,,,,,,,,,,,,,
FIBER LASER 600 MH 1.8 MM,SUP-2427799,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.02 MM INNR FLANGE DIA2.40 MM FLROPLAS,SUP-2902027,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.04,27.33,,,,,,,,,,,,,
PLATE BNE W10XL85MM THK15MM 3X6 H L TI T SHP OBLQ RIG NEUT,SUP-2190998,CDM,C1713,HCPCS,0278,RC,,,,both,,,1223.94,795.56,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT MAGNA MT 29MM 28MM 34MM 19MM BOV,SUP-2214110,CDM,C1889,HCPCS,0278,RC,,,,both,,,17113.00,11123.45,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 22 CM DIA 6 FR POLYUR AQ BRAIDED,SUP-2171436,CDM,C2617,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EMBLEM MRI W 83.1 X H 69.1 MM D 12.7 MM,SUP-2149157,CDM,C1722,HCPCS,0275,RC,,,,both,,,61148.36,39746.43,,,,,,,,,,,,,
CUP ACET DIA58MM RT HIP POR PRI PRESSFIT ASR,SUP-2254023,CDM,C1776,CPT,0278,RC,,,,both,,,16017.14,10411.14,,,,,,,,,,,,,
CUP SUCT ACET STR HNDL DISP TRIL IT,SUP-2204133,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CATHETER PICC 5FR L55CM 2 LUMN MAX BARR W/ SHERLOCK 3CG TPS,SUP-2125512,CDM,C1751,HCPCS,0278,RC,,,,both,,,662.82,430.83,,,,,,,,,,,,,
COMPONENT FEM KNEE KT STRL IUNI,SUP-2904912,CDM,C1776,CPT,0278,RC,,,,both,,,5612.75,3648.29,,,,,,,,,,,,,
SCREW BONE L90MM DIA4MM PROX HUM S STL ST NONCANNULATED LCK,SUP-2371545,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.04,260.03,,,,,,,,,,,,,
GUIDEWIRE SUBTALAR TRUARCH 16 X 2286 MM,SUP-2586665,CDM,C1769,HCPCS,0272,RC,,,,both,,,163.91,106.54,,,,,,,,,,,,,
NAIL IM TRIM 4X50 MM 1 IMPL SYS BIO INTEGRATIVE OSSIOFIBER,SUP-2641888,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC SYR DBM ACCELL EVO3,SUP-2641759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
BAR EXTN STD NS OSCAR 3 LTX,SUP-2875719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
PLATE BNE STR 45 MM TCP,SUP-2535871,CDM,C1713,HCPCS,0278,RC,,,,both,,,3523.08,2290.00,,,,,,,,,,,,,
HC Cbc (Hemogram),PX-3058502700,CDM,85027,CPT,0305,RC,,,,both,,,116.00,75.40,,,,,,,,,,,,,
PLATE BNE RND 1.5X70 MM CRANIOFACIAL MESH MALL CONTOURABLE,SUP-2191124,CDM,C1713,HCPCS,0278,RC,,,,both,,,5447.90,3541.13,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY REFLEXION SPRL L 99CM 7FR 20 POLE,SUP-2700013,CDM,C1731,HCPCS,0278,RC,,,,both,,,905.14,588.34,,,,,,,,,,,,,
SUPPORT ORTHOT MTCRPL HND OFF-THE-SHELF PREFABRICATED,SUP-2435779,CDM,L3918,HCPCS,0272,RC,,,,both,,,272.08,176.85,,,,,,,,,,,,,
CENTRALIZER MS 30 DIST CAP SZ 10 STEM 12MM DIA,SUP-2204698,CDM,C1776,CPT,0278,RC,,,,both,,,311.49,202.47,,,,,,,,,,,,,
CATHETER ETER ABLAT M 7FR L115CM SPC 2 5 2MM SWP QPLR BI DIR STEER,SUP-2357031,CDM,C1733,HCPCS,0272,RC,,,,both,,,2647.02,1720.56,,,,,,,,,,,,,
CLOVERLEAF PLT STERILIZER 104 MM 4 HL,SUP-2818114,CDM,C1713,HCPCS,0278,RC,,,,both,,,2430.55,1579.86,,,,,,,,,,,,,
ALIGNRITE WRIST BLK SHRT RGHT MED,SUP-2462313,CDM,L3906,HCPCS,0272,RC,,,,both,,,54.13,35.18,,,,,,,,,,,,,
GRAFT VASC STD WALL 4 MMX10 CM STR REINF DEL SYS ADVANTA VXT,SUP-2472522,CDM,C1768,CPT,0278,RC,,,,both,,,356.30,231.59,,,,,,,,,,,,,
CANNULA SUCTION IRRIGATION 10MM 330MM COLOR CODED,SUP-2489332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1751.40,1138.41,,,,,,,,,,,,,
ELECTRODE ES URLGY 24 28FR DIA LNG 12DG CTTNG RLLR HF RSCTN,SUP-2722601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.69,361.85,,,,,,,,,,,,,
SCREW IM L 50 MM DIA 5 MM LAG STRL TRIGEN MAX,SUP-2931466,CDM,C1713,HCPCS,0278,RC,,,,both,,,1488.36,967.43,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 130 CM DIA 0.014 IN SS SIL J LNG,SUP-2148330,CDM,C1769,HCPCS,0272,RC,,,,both,,,329.54,214.20,,,,,,,,,,,,,
KIT OCN004 OSTEOCOOL BNE ACCS 10G 095,SUP-2281272,CDM,C1894,HCPCS,0272,RC,,,,both,,,1424.30,925.79,,,,,,,,,,,,,
GUIDEWIRE ORTH L1000MM DIA2.4MM SMOOTH BLNT TIP S STL,SUP-2413016,CDM,C1769,HCPCS,0272,RC,,,,both,,,289.79,188.36,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X300 MM FOR CANN SCREW NS 0333301504,SUP-2789106,CDM,C1769,HCPCS,0272,RC,,,,both,,,461.27,299.83,,,,,,,,,,,,,
BOLT FIX HALF PIN UNIV,SUP-2197244,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
HC Transesophageal Echo W/Ctrst,PX-4809331201,CDM,C8925,HCPCS,0480,RC,,,,both,,,3039.00,1975.35,,,,,,,,,,,,,
GUIDEWIRE VASC AD L195CM DIA0.014IN TIP 3CM FLPY J TIP,SUP-2158057,CDM,C1769,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
SCREW SPNL MONOAX 6.5X35 MM PEDCL,SUP-2175442,CDM,C1713,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
PATCH CV W1XL9CM THK0.5MM SQ TIP,SUP-2395321,CDM,C1768,CPT,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
SCREW 6X75MM STEM HMRL MODULAR INTRAMEDULLARY SHOULDER,SUP-2880536,CDM,C1713,HCPCS,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
DISP DRILL HIP PL SHORT HB 2.9MM,SUP-2812597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
STEM FEM STR 12/14 SM LNG 165 MM REV TAPR COCR SPECTRN EF,SUP-2434573,CDM,C1776,CPT,0278,RC,,,,both,,,12277.40,7980.31,,,,,,,,,,,,,
PLATE BNE COMPR STD 146 MM ST FOR HELIX BLADE SS NS,SUP-2186777,CDM,C1713,HCPCS,0278,RC,,,,both,,,1035.98,673.39,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.14 MM INNR FLANGE DIA2.6 MM FLROPLAS,SUP-2901998,CDM,L8699,HCPCS,0278,RC,,,,both,,,63.43,41.23,,,,,,,,,,,,,
BAND STRUT ACUTE QC STRL DISP,SUP-2933784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,186.77,121.40,,,,,,,,,,,,,
GRAFT BNE W10 16XL30 40MM IL CREST WDG FRZN,SUP-2307417,CDM,C1713,HCPCS,0278,RC,,,,both,,,3278.16,2130.80,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 100X0.6 MM RIGID TI SLV NS,SUP-2859915,CDM,C1713,HCPCS,0278,RC,,,,both,,,6249.23,4062.00,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 145 CM DIA 0.038 IN TAPR L 15 CM FLPY,SUP-2167848,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.26,60.62,,,,,,,,,,,,,
PLATE BONE WEB LCK FOR 1.5MM SCR ALPS HND FX SYS,SUP-2411743,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
LEVEL NEURO ST MESH 3D ULTRNE NEURO SCRW75 MM DIA T06 MM CP,SUP-2676604,CDM,C1713,HCPCS,0278,RC,,,,both,,,3348.81,2176.73,,,,,,,,,,,,,
GRAFT DURA W1XL1IN CLLGN SUTURELESS HIGHLY CNFRM RESTR,SUP-2165123,CDM,C1763,HCPCS,0278,RC,,,,both,,,703.77,457.45,,,,,,,,,,,,,
PL LCKNG RCN ANG ANG36H T28MM,SUP-2694247,CDM,C1713,HCPCS,0278,RC,,,,both,,,9665.89,6282.83,,,,,,,,,,,,,
SCREW BONE L30MM INTERTROCHANTERIC TI COMPR TRIGEN INTERTAN,SUP-2347568,CDM,C1713,HCPCS,0278,RC,,,,both,,,2183.84,1419.50,,,,,,,,,,,,,
KIT CEM MIXING/DELIVERY W/ 10CC HALF DOSE,SUP-2367020,CDM,C1713,HCPCS,0278,RC,,,,both,,,1888.05,1227.23,,,,,,,,,,,,,
PLATE BNE 8 H STR STERNALOCK BLU PRI CLSR SYS,SUP-2403016,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
SLEEVE KNEE RIGID SUPP ADJ JT,SUP-2388160,CDM,L1832,HCPCS,0274,RC,,,,both,,,2659.58,1728.73,,,,,,,,,,,,,
NAIL IM L19.5CM DIA14MM 130DEG RT FEM HIP GRN TI CANN LCK,SUP-2347890,CDM,C1713,HCPCS,0278,RC,,,,both,,,2886.60,1876.29,,,,,,,,,,,,,
PLATE BNE FEM 401 MM LT PROX 21 HOLE BRIDGE N CONTACT POLYAX,SUP-2472295,CDM,C1713,HCPCS,0278,RC,,,,both,,,5009.15,3255.95,,,,,,,,,,,,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,6370000000,HCPCS,0637,RC,42571-0147-26,NDC,,both,10,ML,225.00,146.25,,,,,,,,,,,,,
BUR DENT 3X70 MM CARBIDE STRL PM2 80K,SUP-2134828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
BEARING TIB L59MM THK10MM UHMWPE KNEE PRI NEUT HI POST POST,SUP-2405892,CDM,C1776,CPT,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
GRAFT BONE RADLUC DEMIN CORT STRL 50MMX25MMXL OSTEOWRAP,SUP-2125430,CDM,C1713,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
CANNULA SUCTION COAG 5 MMX20 CM INSUL,SUP-2772869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2329.88,1514.42,,,,,,,,,,,,,
LEAD DEFIB BPLR 58 CM ACTIVE FIX DURATA,SUP-2357374,CDM,C1895,HCPCS,0275,RC,,,,both,,,13797.95,8968.67,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 7/64X9 IN 4 PT STYL SMOOTH PLN STRL,SUP-2150498,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.59,8.18,,,,,,,,,,,,,
HC Abd Paracentesis W Guide,PX-3614908300,CDM,49083,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
HC Pericardiocentesis Including Imag Guid When Performed,PX-3613301600,CDM,33016,CPT,0361,RC,,,,inpatient,,,3477.00,2260.05,,,,,,,,,,,,,
ENALAPRIL MALEATE 5 MG PO TABS,RX-9927,CDM,6370000000,HCPCS,0637,RC,16714-0443-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHUNT SURG 1X20.25 MM,SUP-2266071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ASSEMBLY BLDE DISP SMARTRELEASE ONYX,SUP-2419627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.34,544.27,,,,,,,,,,,,,
ARM EXT FIX ACTIVATION 20 MM EMGCY EXTN RIGID REMOT DETACH,SUP-2499781,CDM,C1713,HCPCS,0278,RC,,,,both,,,2732.18,1775.92,,,,,,,,,,,,,
IMMOBILIZER KNEE CLOSE PATTELLA FOAM VELC LOOP STRP LT OR RT,SUP-2330405,CDM,L1830,CPT,0272,RC,,,,both,,,80.64,52.42,,,,,,,,,,,,,
SET CIRC BRTH NEO L150CM 2 LIMB EXPIRATORY VLV PRESSEMBLED,SUP-2237225,CDM,C1713,HCPCS,0278,RC,,,,both,,,196.22,127.54,,,,,,,,,,,,,
PLATE BNE STR WRST FUSION BEND SS NS LCP,SUP-2183196,CDM,C1713,HCPCS,0278,RC,,,,both,,,4935.08,3207.80,,,,,,,,,,,,,
SROM*STMXXL36+21+4L 16X11X300L,SUP-2540378,CDM,C1776,CPT,0278,RC,,,,both,,,19359.98,12583.99,,,,,,,,,,,,,
FOUNDATION ALL POLY PAT W/ CTRL PEG 29 MM ** SPEC ORD ONLY,SUP-2215523,CDM,C1776,CPT,0278,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
PLATE BNE DSTL C1 STD RT VOLAR RAD TI,SUP-2646874,CDM,C1713,HCPCS,0278,RC,,,,both,,,1432.28,930.98,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 6 MM EPTFE STR STD WALL,SUP-2396186,CDM,C1768,CPT,0278,RC,,,,both,,,1739.56,1130.71,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 3.5X3 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651376,CDM,Q4154,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
LIFT HEEL MED 2.5 IN WDG 3 LAYR ORTHOT FT FABRIC BRN ADJLFT,SUP-2325936,CDM,L3332,HCPCS,0272,RC,,,,both,,,18.37,11.94,,,,,,,,,,,,,
GENERATOR NEUROSTIM SPNL CRD PLSE STIM SYS PRECISION SPECTRA,SUP-2138776,CDM,C1820,HCPCS,0278,RC,,,,both,,,62580.55,40677.36,,,,,,,,,,,,,
GRAFT HUM TISS W16XH6XL22MM PRESHAPED FRZ DRY FOR FLATFOOT,SUP-2307233,CDM,C1713,HCPCS,0278,RC,,,,both,,,2922.56,1899.66,,,,,,,,,,,,,
KIT IRRIG ALL CHN W 30ML SYR,SUP-2313030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
DILATOR SURG 8-24FR L37CM FASCIAL POLYETH RADPQ,SUP-2171194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.21,750.89,,,,,,,,,,,,,
NEEDLE BX ASPIR 1.6 MMX47 CM ANGLED,SUP-2771791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
PLATE BNE TBLR 3.5X159 MM 12 HOLE 1/3 2 COMPR LCK FOR SCR TI,SUP-2490037,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
COMPONENT FEM SZ 2 TIV POR LT KNEE PRI PRESSFIT CRUC RET,SUP-2199488,CDM,C1776,CPT,0278,RC,,,,both,,,21532.55,13996.16,,,,,,,,,,,,,
TRAY TIB SZ 2 A/P25MM M/L44MM R LAT L MED KNEE TI NP PRI,SUP-2342840,CDM,C1776,CPT,0278,RC,,,,both,,,5928.32,3853.41,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 130 CM DIA 0.014 IN SS SIL STR SHRT,SUP-2148327,CDM,C1769,HCPCS,0272,RC,,,,both,,,322.95,209.92,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2.5 MM RECON PT SPEC TI,SUP-2860102,CDM,C1713,HCPCS,0278,RC,,,,both,,,23307.59,15149.93,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP LT PROX TIB W/ PATELLAR,SUP-2867048,CDM,C1762,CPT,0278,RC,,,,both,,,15839.73,10295.82,,,,,,,,,,,,,
NAIL INTRMDLLRY L42CM D93MM RGHT GRTR TRCHNTR FMRL GREEN TTN,SUP-2487065,CDM,C1713,HCPCS,0278,RC,,,,both,,,5112.64,3323.22,,,,,,,,,,,,,
CANNULA SURG CEPHALOMEDULLARY LAG SCREW,SUP-2488398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
CATHETER ATHRCTMY ROTLNK L 135 CM DIA 0.058 IN BUR SZ 1.25,SUP-2142284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
CATHETER GUID BRANCHOR L 90 CM DIA 9 FR SHFT OD 3 MM COAT L,SUP-2879945,CDM,C2628,HCPCS,0272,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 90CM 7FR COAT L 15CM XCUT,SUP-2385652,CDM,C1894,HCPCS,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
STENT CORONARY CYPHER L 23 MM DIA2.5 MM DEL SYS L 145 CM,SUP-2158698,CDM,C1874,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
SCREW BNE L38MM DIA4.5MM ST CORT NONLOCKING L FRAG SET,SUP-2348858,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.23,111.95,,,,,,,,,,,,,
SODIUM THIOSULFATE 250 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-156090,CDM,J0209,HCPCS,0636,RC,60267-0705-50,NDC,JW,both,1,ML,54.10,35.16,,,,,,,,,,,,,
BONE GRFT SUB L 12.5CC BIOACTIVE GLS MTRX,SUP-2419733,CDM,C9359,HCPCS,0278,RC,,,,both,,,11869.20,7714.98,,,,,,,,,,,,,
PLATE BNE SM W10XL56MM THK1.2MM 90DEG 4X4 H TI T SHP R ANG,SUP-2190928,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.60,324.09,,,,,,,,,,,,,
ROD SPNL L200MM DIA3MM POST BILAT TI SMOOTH SYNERGY SUMMIT,SUP-2254416,CDM,C1713,HCPCS,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
TUBE TRACHEOSTOMY REGULAR ADULT 0.6MM SILVER FENESTRATED UNC,SUP-2793415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.87,122.77,,,,,,,,,,,,,
TRAY HAD CATH 12FR L13CM 2 LUMN ACUTE STR EXTN MAHRK ELITE,SUP-2172336,CDM,C1752,HCPCS,0278,RC,,,,both,,,238.73,155.17,,,,,,,,,,,,,
CATHETER ETER CARD 7FR 2 5 2MM ELECTRD SPC 115CM ABLAT L CRV QPLR,SUP-2357035,CDM,C1733,HCPCS,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
CLIP INT 12MM BLK SGL ABSRB LIG LAPRO,SUP-2172327,CDM,C1889,HCPCS,0278,RC,,,,both,,,276.48,179.71,,,,,,,,,,,,,
SYSTEM TRAC L ADJ OPN BK HALO RNG COMPLT C GRAPHITE TI SKULL,SUP-2328131,CDM,L0810,HCPCS,0272,RC,,,,both,,,7837.44,5094.34,,,,,,,,,,,,,
BOLT TISS ATTACH SH TI STRL MOST OPTIONS,SUP-2208299,CDM,C1713,HCPCS,0278,RC,,,,both,,,765.85,497.80,,,,,,,,,,,,,
HOOK MRK L FOR M8 SPNL SYS CDH,SUP-2293464,CDM,A4648,CPT,0278,RC,,,,both,,,427.17,277.66,,,,,,,,,,,,,
COLLAR CERV REG AD XTW EXT WR LF,SUP-2335999,CDM,L0120,HCPCS,0272,RC,,,,both,,,51.43,33.43,,,,,,,,,,,,,
PLATE M L PAT PROTCT TRIATHLON,SUP-2364730,CDM,C1776,CPT,0278,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
STIMULATOR NRV PERIPH W/ SENSE ELECTRD CBL HNS12 STIMUPLEX,SUP-2125190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2916.21,1895.54,,,,,,,,,,,,,
GRAFT HUM TISS ARTC CART NAT DENOVO,SUP-2200262,CDM,C1762,CPT,0278,RC,,,,both,,,14638.68,9515.14,,,,,,,,,,,,,
SYSTEM NEG PRSS INCIS MGMT PEEL AND PLC DISP PREVENA,SUP-2261592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1429.96,929.47,,,,,,,,,,,,,
HC NM Lung Scan Perfusion Only,PX-3417858000,CDM,78580,CPT,0341,RC,,,,both,,,2067.00,1343.55,,,,,,,,,,,,,
KIT HEMO DYLS OR HD 11FR INSRTN L15CM POLYUR BODYSOFT CATH,SUP-2126494,CDM,C1752,HCPCS,0278,RC,,,,both,,,358.71,233.16,,,,,,,,,,,,,
HC Med Nutr Ther Group Init/Fu 30 Min,PX-9429780400,CDM,97804,CPT,0940,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
PACK IMPL L DIA4.7MM INCLUDE PROX DSTL SCR TAPR LCK PIN,SUP-2123606,CDM,C1776,CPT,0278,RC,,,,both,,,3953.26,2569.62,,,,,,,,,,,,,
PROBE ENDOSCP T TYP 2.3 MMX1.9 MR HYBRIDKNIFE I-JET,SUP-2734135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1755.26,1140.92,,,,,,,,,,,,,
MG II KNEE 8MM PAT 35MM DIA,SUP-2199563,CDM,C1776,CPT,0278,RC,,,,both,,,5204.86,3383.16,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE MED FD ASEP FEM,SUP-2867021,CDM,C1762,CPT,0278,RC,,,,both,,,2389.38,1553.10,,,,,,,,,,,,,
DRESSING BIO 2000 MG TYP I/III BOV CLLGN MTRX FIBRILLAR SHLF,SUP-2905521,CDM,C1763,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
KIT EEG ELECTRD L 26.5 MM 8 CONTACT RF PRB STRL DISP EVO,SUP-2936689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3161.98,2055.29,,,,,,,,,,,,,
DEVICE FILTRATION GLAUCOMA MINI SHUNT EX-PRESS,SUP-2110073,CDM,C1783,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
IMPLANT SYNTH 38 X 63 MM THK 6 MM POLYETHYL CRANIOFACIAL,SUP-2883170,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.43,2439.08,,,,,,,,,,,,,
HC Extracranial Uni/Ltd Study,PX-9219388200,CDM,93882,CPT,0921,RC,,,,both,,,596.00,387.40,,,,,,,,,,,,,
IMPLANT BIO TISS W7XL17CM THK1MM RECT ACELLULAR CLLGN MTRX,SUP-2243670,CDM,C9360,HCPCS,0278,RC,,,,both,,,7846.86,5100.46,,,,,,,,,,,,,
PLATE BONE AD PED L135MM 8 H LT FIBULAR TI ANAT PRECONTOURED,SUP-2319686,CDM,C1713,HCPCS,0278,RC,,,,both,,,6603.42,4292.22,,,,,,,,,,,,,
SERENGETI MINIMALLY INVASIVE RETRCT QTY 2,SUP-2258073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
BOLT FIX L150MM DIA6.5MM NONSTERILE MIDFOOT FUS S STL,SUP-2184105,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.42,988.92,,,,,,,,,,,,,
SHELL ACET OD65MM UNIV CO CHROM HIP REV PRESSFIT MULTIH,SUP-2199985,CDM,C1776,CPT,0278,RC,,,,both,,,4785.36,3110.48,,,,,,,,,,,,,
HC Treatment of Miscarriage,PX-4505981200,CDM,59812,CPT,0450,RC,,,,both,,,3074.00,1998.10,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE L 11 CM DIA 6 FR GUIDEWIRE 0.035 IN,SUP-2474314,CDM,C1894,HCPCS,0272,RC,,,,both,,,108.80,70.72,,,,,,,,,,,,,
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,RX-10162,CDM,J1631,HCPCS,0636,RC,63323-0471-05,NDC,,both,0.25,ML,74.10,48.16,,,,,,,,,,,,,
TEMOZOLOMIDE 20 MG PO CAPS,RX-25893,CDM,J8700,HCPCS,0637,RC,65162-0802-14,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
SPLINT ARM SM L7IN L ALUMINUM FOAM PD MAL COLLES,SUP-2276768,CDM,L3809,HCPCS,0274,RC,,,,both,,,17.80,11.57,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM SZ 2-0 CRV 37 MM STR 89 MM SS WNG,SUP-2101192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,59.91,38.94,,,,,,,,,,,,,
SCREW SPNL ST 2.3X18 MM TI CENTREDRIVE,SUP-2459813,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.22,132.09,,,,,,,,,,,,,
DISTRACTOR 30MM TLSCPNG LFT 20MM SCRWS MAX DRIVE BRSTN BODY,SUP-2669776,CDM,C1713,HCPCS,0278,RC,,,,both,,,15042.20,9777.43,,,,,,,,,,,,,
GRAFT BONE L14XW11XH7MM 7DEG CERV SPCR INTBDY LORDTC STRL,SUP-2415683,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UNI K10] STRYKER CORP],SUP-2365622,CDM,C1776,CPT,0278,RC,,,,both,,,8244.01,5358.61,,,,,,,,,,,,,
SCREW SPNL L10MM OD4MM CERV VAR ANG THRD,SUP-2353289,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
IMPLANT SCLER 2.5X9 MM STYL 279 GROOVED TIRE SIL,SUP-2213509,CDM,C1784,HCPCS,0278,RC,,,,both,,,40.19,26.12,,,,,,,,,,,,,
CATHETER PICC DIA 4 FR MAX POLY DUAL LUM PICC,SUP-2913462,CDM,C1751,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PROSTHESIS PENILE DSTL TIP 12 MMX3 CM DURA II,SUP-2140243,CDM,C1813,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BONE L45MM OD6.5MM STD NONSTERILE TI CANC CORT ST SELF,SUP-2374387,CDM,C1713,HCPCS,0278,RC,,,,both,,,771.50,501.47,,,,,,,,,,,,,
UNIT DISTRACTOR 4CM COMPR STD FOR EL FIX,SUP-2315961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
IMPLANT STAP L45MM STD PIST DIA06MM STD WELL DIA09MM CLASS,SUP-2313855,CDM,L8613,CPT,0278,RC,,,,both,,,647.15,420.65,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.7MM S STL LOK HEX MTP CHARLOTTE CLAW,SUP-2397524,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
HC So2 Collagen Cross-Link N-Telopep,PX-3018252368,CDM,82523,CPT,0301,RC,,,,outpatient,,,254.00,165.10,,,,,,,,,,,,,
CENTRALIZER STEM DIA14MM DST FEM HIP NP CEM PFC SIG,SUP-2253267,CDM,C1776,CPT,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
PLATE END RETRACTOR,SUP-2587575,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.74,504.88,,,,,,,,,,,,,
WIRE FIX DISPNS TELLURIDE K FOR MIS SPNL FIX SYS,SUP-2211172,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
HEAD HUM .44-16IN ARW CO CHROM CNTR,SUP-2224501,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
CATHETER VASC GUID CLS CRV 3.75 COR W/O HYDRPHLC COAT AD,SUP-2139824,CDM,C1887,HCPCS,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
KIT INT FIX MED COLLATERAL LIG FOR KNEE LIG AUG REP,SUP-2121947,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 1.76X6 MM CORTICAL EMERGENCY CRICIFO,SUP-2838193,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.66,216.88,,,,,,,,,,,,,
PLATE BNE HUM LNG 3.5X266 MM LT DSTL X ARTC 12 HOLE SS NS,SUP-2184052,CDM,C1713,HCPCS,0278,RC,,,,both,,,4787.68,3111.99,,,,,,,,,,,,,
SCREW BNE HUM SHLDR INTERCALARY STEM ASSEMB MRS,SUP-2376487,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.95,702.62,,,,,,,,,,,,,
PLATE BONE SHFT L428MM BLDE L60MM THK4.8MM 95DEG 26 H BILAT,SUP-2185471,CDM,C1713,HCPCS,0278,RC,,,,both,,,3939.26,2560.52,,,,,,,,,,,,,
PROSTHESIS OSS L 5 MM SHFT DIA1.14 MM HD DIA2 X 4.4 MM TI HA,SUP-2901929,CDM,L8613,CPT,0278,RC,,,,both,,,1726.69,1122.35,,,,,,,,,,,,,
PLATE BONE L115MM 7 H STRL RT POSTEROLATERAL DSTL FIBULAR S,SUP-2349769,CDM,C1713,HCPCS,0278,RC,,,,both,,,7249.00,4711.85,,,,,,,,,,,,,
GUIDEWIRE VASC LAUREATE L 80 CM DIA 0.018 IN NIT COR,SUP-2459599,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
TUBE ET AD DIA6MM 6ML MAX INFL VOL PHYCON UNIVENT,SUP-2115123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,578.92,376.30,,,,,,,,,,,,,
PLATE BNE L47MM 2 H 140DEG S STL HIP COMPR LO PROF STD BRL,SUP-2364136,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.10,1513.91,,,,,,,,,,,,,
HEAD ULN MOD 17.5 MM ELBW,SUP-2610430,CDM,C1776,CPT,0278,RC,,,,both,,,5045.07,3279.30,,,,,,,,,,,,,
SCREW BNE CRTX 1.5X10 MM,SUP-2569460,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.81,21.33,,,,,,,,,,,,,
BUNDLE CASE MICROTIA CUST VSP,SUP-2862839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18463.20,12001.08,,,,,,,,,,,,,
SOLUTION IV 250ML 0.9% SODIUM CHLORIDE INJ USP,SUP-2900294,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.91,4.49,,,,,,,,,,,,,
SLEEVE FEM M HIP MECTACER BIOLOX OPT SYS,SUP-2267358,CDM,C1776,CPT,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
SCREW BONE L125MM DIA10.5MM TROCHANTERIC NAIL LAG ATN,SUP-2413939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 7 CM DIA 6 MM STD SFT HELCL,SUP-2604642,CDM,C1889,HCPCS,0278,RC,,,,both,,,333.34,216.67,,,,,,,,,,,,,
CATHETER DRAINAGE INTRO MINI 11 FRX10.5 CM RET BIO-MEDICUS,SUP-2745325,CDM,C1729,HCPCS,0272,RC,,,,both,,,1212.35,788.03,,,,,,,,,,,,,
SPLINT WRST AND THMB BLK FOAM XS 8 IN R,SUP-2336034,CDM,L3809,HCPCS,0272,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
SCREW BNE L 24 MM DIA2.5 MM TI CANN HD NS LEOS,SUP-2932584,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.65,441.77,,,,,,,,,,,,,
CATHETER CHRONIC TOT OCCL 180DEG 0.066INX150CM 20X2.75X1MM,SUP-2280835,CDM,C1887,HCPCS,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
AUGMENT TIB SZ 6 THK5MM R MED L LAT KNEE CO CHROM REV,SUP-2373556,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 12.5CML 5496120,SUP-2632894,CDM,C1752,HCPCS,0278,RC,,,,both,,,624.55,405.96,,,,,,,,,,,,,
STENT URTRL 48FR DIA 22 30CML FLXMA STRGHT TIP W/0035N 150,SUP-2724948,CDM,C2617,HCPCS,0278,RC,,,,both,,,469.65,305.27,,,,,,,,,,,,,
HC So Protein Electrophoresis Serum,PX-3018416566,CDM,84165,CPT,0301,RC,,,,both,,,369.00,239.85,,,,,,,,,,,,,
COMPONENT TIB TY DSTL PLATE NS OPTILOCK LTX,SUP-2861373,CDM,C1776,CPT,0278,RC,,,,both,,,12302.90,7996.88,,,,,,,,,,,,,
SCREW BNE SELF RET MIC 1X4 MM MAX SINUS TI CENTRE-DRIVE LF,SUP-2460895,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.46,138.75,,,,,,,,,,,,,
ENDCAP SCR SPNL TITLE 2,SUP-2211411,CDM,2780000010,LOCAL,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
DISC NEUROSURGICAL N PROGRAMMABLE SM W/O RESERVOIR PROGAV,SUP-2846928,CDM,C1889,HCPCS,0278,RC,,,,both,,,1271.42,826.42,,,,,,,,,,,,,
PLATE STRNL 8 H TI PI NS MATRIXSTERNUM,SUP-2904258,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.32,1306.06,,,,,,,,,,,,,
BIT DRL CANN 1.6X100 MM QC,SUP-2221710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
DEVICE PESSARY 3 IN INCONT RNG,SUP-2171747,CDM,A4562,HCPCS,0274,RC,,,,both,,,181.90,118.23,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0250,RC,00338-0049-11,NDC,,both,250,ML,123.30,80.14,,,,,,,,,,,,,
PLATE BNE L62MM LNG 2X2 H NONSTERILE R BILAT 1ST MTP FUS S,SUP-2184838,CDM,C1713,HCPCS,0278,RC,,,,both,,,3007.02,1954.56,,,,,,,,,,,,,
ROD SPNL L95MM PEEK POST THORACOLUMBOSACRAL PERC APPRCH CDH,SUP-2279684,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
GRAFT VASC L80CM ID8MM EPTFE HEP THN WALLED NONRINGED STR,SUP-2395821,CDM,C1768,CPT,0278,RC,,,,both,,,7451.22,4843.29,,,,,,,,,,,,,
SET DIL L 45 CM DIA16 FR/18 FR GUIDEWIRE 0.035 IN HYDRPHLC,SUP-2170999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,941.97,612.28,,,,,,,,,,,,,
PLATE BNE L145MM 8 H R PROX MED PERIARTC TIB S STL,SUP-2410553,CDM,C1713,HCPCS,0278,RC,,,,both,,,2380.37,1547.24,,,,,,,,,,,,,
CATHETER CV 3L 5 FRX135 CM NIT GUIDEWIRE POWERPICC PROVENA,SUP-2127011,CDM,C1751,HCPCS,0278,RC,,,,both,,,525.32,341.46,,,,,,,,,,,,,
CANNULA SURG PERC FOR 3MM SCREW,SUP-2459884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1024.61,666.00,,,,,,,,,,,,,
TI NARROW 6 HOLE PLATE 78MM,SUP-2703168,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
GRAFT HD FEM BONE W/O CART FRZN ALLGRFT,SUP-2165539,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00264-7510-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
PIN EXT FIX L120MM DIA5MM THRD L35MM CORT S STL ST SELF DRL,SUP-2372356,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BONE GRFT SUB GRFT PSTE 10ML,SUP-2293918,CDM,C1713,HCPCS,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
ALLOGRAFT BNE INJ MINI 4 CC IGNITE PWR MIX,SUP-2759447,CDM,C1713,HCPCS,0278,RC,,,,both,,,4705.20,3058.38,,,,,,,,,,,,,
DRESSING NSL L3.15IN 100% SYNTH PROPRIETARY POLYMER,SUP-2363655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 9 7/8 IN RETROGRADE NS,SUP-2436427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.21,223.74,,,,,,,,,,,,,
AUGMENT TIB SZ 5 THK10MM R MED L LAT KNEE CO CHROM REV,SUP-2373570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1840.32,1196.21,,,,,,,,,,,,,
HC Drain External Ear Lesion,PX-4506900500,CDM,69005,CPT,0450,RC,,,,both,,,1649.00,1071.85,,,,,,,,,,,,,
WIRE FIX L200MM OD2MM K,SUP-2417736,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
EXTENSION SET 0.5 CC M LUER LCK ACTIVATED VLV HANDISTRIP LF,SUP-2484890,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.39,10.00,,,,,,,,,,,,,
HC OP Traction Intermittent,PX-4209701200,CDM,97012,CPT,0420,RC,,,,inpatient,,,292.00,189.80,,,,,,,,,,,,,
RING EXT FIX DIA240 MM SS 5/8 NS DISP ILIZ,SUP-2933416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4256.87,2766.97,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 500 HF-T 59X 66MM 12MM 30J LANDLINE,SUP-2138409,CDM,C1882,HCPCS,0275,RC,,,,both,,,79285.00,51535.25,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED ADV REV,SUP-2197232,CDM,C1776,CPT,0278,RC,,,,both,,,21823.00,14184.95,,,,,,,,,,,,,
PLATE BNE L 120 MM TI EXTRATHORACIC PREBENT NS RIBFIX TITAN,SUP-2905464,CDM,C1713,HCPCS,0278,RC,,,,both,,,15624.64,10156.02,,,,,,,,,,,,,
KIT NEUROSURGICAL DEV MILD TISS SCULPTER TROCAR HNDL PORTAL,SUP-2927636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
PLATE BNE FIBULAR 3.5X103 MM LT LAT DSTL 7 HOLE EVOS,SUP-2349743,CDM,C1713,HCPCS,0278,RC,,,,both,,,4614.39,2999.35,,,,,,,,,,,,,
GRAFT BONE 8ML CORT CANC DEMIN CONT G2 PRECIS,SUP-2307036,CDM,C1713,HCPCS,0278,RC,,,,both,,,3849.64,2502.27,,,,,,,,,,,,,
PLATE BNE L125MM THK3MM 8 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185338,CDM,C1713,HCPCS,0278,RC,,,,both,,,1742.92,1132.90,,,,,,,,,,,,,
HC Neuromusc Junct Testing Ea Nrv,PX-9229593700,CDM,95937,CPT,0922,RC,,,,both,,,457.00,297.05,,,,,,,,,,,,,
HC Remove Intrvas Foreign Body,PX-3613719700,CDM,37197,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
PIN TEMP FIX L 14 MM DIA 3. 5MM LG TARGETER PROV STRL DISP,SUP-2931142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
TAP SURG L4.9IN QUIK CONN FOR 4.5MM SCR,SUP-2410965,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING 6MM DIA 90CM LEN GORTX,SUP-2396012,CDM,C1768,CPT,0278,RC,,,,both,,,4901.54,3186.00,,,,,,,,,,,,,
ROD ORTH THRD 200 MM PILLAR,SUP-2749920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 4 H TI BX LP NS STERNALOCK EZ,SUP-2894461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
IMPLANT BIO L 3 X W 7 CM FISH SKIN DERMAL SLD INTACT FLAT,SUP-2909282,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
PANC STRAIGHT STENT KIT 5FX4CM,SUP-2676503,CDM,C2617,HCPCS,0278,RC,,,,both,,,547.05,355.58,,,,,,,,,,,,,
SHELL ACET SZ D DIA50MM MH OSSEOTI 2 MOBILITY G7,SUP-2403476,CDM,C1776,CPT,0278,RC,,,,both,,,7950.48,5167.81,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 20 CM DIA 6 MM EPTFE STR STD WALL,SUP-2227640,CDM,C1768,CPT,0278,RC,,,,both,,,593.68,385.89,,,,,,,,,,,,,
SCREW BNE L42MM DIA3.5MM CORT S STL ST FULL THRD T15 DRV,SUP-2178224,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.33,71.06,,,,,,,,,,,,,
"HC Gonadotropin, Chorionic (Hcg) Qualitative",PX-3018470300,CDM,84703,CPT,0301,RC,,,,both,,,455.00,295.75,,,,,,,,,,,,,
PACEMAKER CARD ATTESTA S DR MRI SURESCAN W 42.9 X H 44.7 X D,SUP-2665247,CDM,C1785,HCPCS,0275,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
GRAFT BIO TISS W3.9XL5.9IN RECT XENMATRIX,SUP-2125845,CDM,C1781,HCPCS,0278,RC,,,,both,,,10465.62,6802.65,,,,,,,,,,,,,
HEAD FEM 28MM DIA 12/14 TAPR + 7 NK LEN PRI MTL ON POLY CO,SUP-2203691,CDM,C1776,CPT,0278,RC,,,,both,,,2769.48,1800.16,,,,,,,,,,,,,
TITANIUM CABLE CRIMP-STERILE,SUP-2549743,CDM,C1713,HCPCS,0278,RC,,,,both,,,99.13,64.43,,,,,,,,,,,,,
GUIDE SURG PLN TI LP DISTRCTN CUSTOMIZABLE UNILAT VSP,SUP-2883942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17554.96,11410.72,,,,,,,,,,,,,
MODEL ANAT PLN CASE BNDL MANDIBULAR MAX VSP,SUP-2883956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,27819.46,18082.65,,,,,,,,,,,,,
PLATE BONE L146MM 6 H NONSTERILE RT MEDL DSTL TIB LCK FOR,SUP-2348486,CDM,C1713,HCPCS,0278,RC,,,,both,,,12868.51,8364.53,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 120 MM DIA13/10 MM DEL,SUP-2934294,CDM,C1713,HCPCS,0278,RC,,,,both,,,16932.95,11006.42,,,,,,,,,,,,,
WRENCH L SOCKET,SUP-2491354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW BNE L100MM DIA4.9MM 3.5MM HEX HD NONSTERILE GRN CORT,SUP-2192367,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.09,365.36,,,,,,,,,,,,,
RESERVOIR DRAINAGE 12 MM 0.6 CC BUR HOLE SIDE INLET,SUP-2277898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,853.14,554.54,,,,,,,,,,,,,
INTRODUCER SHTH SL1 0.032 IN 8.5 FRX63 CM BRAIDED SWARTZ SL,SUP-2457832,CDM,C1893,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
INSERT TIB SZ 9 THICKNESS 21MM UHMWPE KNEE PRI NEUT UNIV,SUP-2365107,CDM,C1776,CPT,0278,RC,,,,both,,,2043.51,1328.28,,,,,,,,,,,,,
TRACKER NAVIGATION ENT ELECTROMAGNETIC STRL DISP,SUP-2902102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,532.98,346.44,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 5FR SS HYDRPHLC CORONARY,SUP-2385664,CDM,C1894,HCPCS,0272,RC,,,,both,,,35.48,23.06,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 3 CM 0.035 INX150 CM EZ GLIDER,SUP-2312667,CDM,C1769,HCPCS,0272,RC,,,,both,,,110.21,71.64,,,,,,,,,,,,,
COIL EMB L10CM LOOP DIA5MM 0.035IN PLAT HYDRGEL POLYMER,SUP-2385373,CDM,C1889,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
DRESSING WND SURG MTRX 8X16 CM THCK MATRISTEM,SUP-2106497,CDM,Q4166,HCPCS,0636,RC,,,,both,,,10881.98,7073.29,,,,,,,,,,,,,
DISTAL POSTERIOR LATERAL HUMERUS TRIAL 4 HOLELEFT,SUP-2704935,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.31,381.75,,,,,,,,,,,,,
REAMER SURG L87MM DIA17MM QUIK CPL FOR 2.0/2.3 TRILOK ARTH,SUP-2267855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
BIT DRL L110MM DIA3.5MM STRL 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.67,300.09,,,,,,,,,,,,,
BLADE ELECSURG 5.5 MM COMPATIBLE W/ ERBE GENRTR,SUP-2848550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
SUPPORT ANK UNIV LG PLAS,SUP-2330385,CDM,L4350,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLEDGET CV L 6 X W 6 MM THK 1.65 MM PTFE FELT SQ FOR SEPTAL,SUP-2761355,CDM,C1768,CPT,0278,RC,,,,both,,,37.99,24.69,,,,,,,,,,,,,
BRACE THORACOLUMBOSACRAL SM LTX W ADD STRP VELC CLSR E ANT,SUP-2195549,CDM,L0650,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 4 FR L 4 CM NIT PD,SUP-2635417,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.61,95.30,,,,,,,,,,,,,
LENS INTOCU +5.0 DIOPT L13MM DIA5.5MM D3.39MM 0.5DEG HAPTIC,SUP-2110858,CDM,V2630,CPT,0276,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
FELT SURG W2XL2IN THK1.65MM PTFE FOR THE REP OF SEPT DEFCT,SUP-2127906,CDM,C1768,CPT,0278,RC,,,,both,,,246.74,160.38,,,,,,,,,,,,,
HC Biopsy-Pleura Needle,PX-3613240000,CDM,32400,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
NAIL IM L440MM DIA3MM OLECRANON GLD S STL ELAS FLEX,SUP-2186444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.91,667.49,,,,,,,,,,,,,
KIT INTRO ARW THMS DIA 8.5 FR GUIDEWIRE 0.025 IN POLYUR PERC,SUP-2383286,CDM,C1894,HCPCS,0272,RC,,,,both,,,82.61,53.70,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RESPON L 120 CM DIA 5 FR SPC 10,SUP-2526064,CDM,C1730,HCPCS,0272,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
HC NM Bone Limited,PX-3417830000,CDM,78300,CPT,0341,RC,,,,inpatient,,,1898.00,1233.70,,,,,,,,,,,,,
HC Dress or Debride Burn Small,PX-4501602000,CDM,16020,CPT,0450,RC,,,,inpatient,,,421.00,273.65,,,,,,,,,,,,,
SET ACC NDL OD21GA GWIRE OD0.038IN NEFF TRCR TIP NIT RADPQ,SUP-2170307,CDM,C1894,HCPCS,0272,RC,,,,both,,,301.47,195.96,,,,,,,,,,,,,
NAIL OSSIOFIBER CANNULATED TRIMMABLE FIXATION IMPLANT 4.0 X 100MM,SUP-2904886,CDM,C1713,HCPCS,0278,RC,,,,both,,,5485.58,3565.63,,,,,,,,,,,,,
BLOCK CANC TRAD ALLGRFT 30 MM LX20 MM WX20 MM H FRZ DRY,SUP-2294054,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
CLIP ASSURANCE 13MM,SUP-2862313,CDM,C1889,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BUSPIRONE HCL 10 MG PO TABS,RX-9323,CDM,6370000000,HCPCS,0637,RC,00904-7121-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.8 MM TI MANDIBULAR FULL CUSTOMIZED,SUP-2883222,CDM,C1713,HCPCS,0278,RC,,,,both,,,32467.60,21103.94,,,,,,,,,,,,,
SPLINT WRST XSM AD L8IN FOR 5 65IN R NYL LN FOAM PUL ON,SUP-2276666,CDM,L3908,HCPCS,0272,RC,,,,both,,,18.21,11.84,,,,,,,,,,,,,
PLATE BNE MESHED 52X31X1 MM SM GRID PLLA-PGA STRL RESORB XG,SUP-2487491,CDM,C1713,HCPCS,0278,RC,,,,both,,,2537.43,1649.33,,,,,,,,,,,,,
REAMER MDI RMR TAPR FOR SZ 3 AND 4,SUP-2400145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX1.2 CM BLLN BUTTON SIL MINI 1,SUP-2754572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.81,331.38,,,,,,,,,,,,,
IMMOBILIZER ORTH OPN PAT MED 19 IN 16-18 IN CANVS BLU,SUP-2194399,CDM,L1830,CPT,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
SCREW BNE 3X16 MM SNAP-OFF,SUP-2608926,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.41,812.12,,,,,,,,,,,,,
COMPONENT ULN XSM L4.5IN R EL TIV PLSM INTERCHANGEABLE CEM,SUP-2205946,CDM,C1776,CPT,0278,RC,,,,both,,,14871.04,9666.18,,,,,,,,,,,,,
FIBER GYN BP-LE OMNIGUIDE,SUP-2225631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
KIT GASTJEJUSTMY 16FR L45CM BAL 7-10ML SIL TRANSGASTRIC JEJU,SUP-2236564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.69,476.90,,,,,,,,,,,,,
FENTANYL CITRATE (PF) 250 MCG/5ML IJ SOLN,RX-133094,CDM,J3010,HCPCS,0636,RC,00409-9094-18,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER GUID FUBUKI L 90 CM OD 7 FR ID 2.05 MM STR TIP,SUP-2539649,CDM,C1887,HCPCS,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
CAP HIP POR W/ EPOCH STEM TM CUPXLPE LG HD,SUP-2212324,CDM,C1776,CPT,0278,RC,,,,both,,,17524.37,11390.84,,,,,,,,,,,,,
CATHETER ABLAT 8FR L CRV INTELLATIP MIFI XP,SUP-2148491,CDM,C1733,HCPCS,0272,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
HC Direct Referral Observation Surcharge,PX-7620037900,CDM,G0379,CPT,0762,RC,,,,both,,,460.00,299.00,,,,,,,,,,,,,
SET BILI STENT COT-LNG L 18 CM DIA10 FR PUSH L 170 CM GUIDE,SUP-2169130,CDM,C2625,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
TRAY INTRODUCER BLUE RHINO G2 MULTI PDT,SUP-2718706,CDM,C1769,HCPCS,0272,RC,,,,both,,,1791.37,1164.39,,,,,,,,,,,,,
BLADE IM L42MM ST G TI SPRL FOR HUM NAIL,SUP-2192461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1645.52,1069.59,,,,,,,,,,,,,
PLATE BNE L18MM THK0.4MM 5 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181560,CDM,C1713,HCPCS,0278,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
TIP SUCT L32CM OD5MM BALL TIP REPOSABLE STRYKEPROBE,SUP-2361200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.23,273.80,,,,,,,,,,,,,
IMPLANT FNGR JT SZ 2 FLEXSPAN FLX SWNSN,SUP-2397894,CDM,C1776,CPT,0278,RC,,,,both,,,2800.88,1820.57,,,,,,,,,,,,,
SCREW BNE L30MM DIA2.7MM STD CORT S STL NONCANNULATED FULL,SUP-2183349,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.93,87.70,,,,,,,,,,,,,
GRAFT BIO TISS W25XL40CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113042,CDM,Q4130,HCPCS,0636,RC,,,,both,,,86525.84,56241.80,,,,,,,,,,,,,
COMPONENT FEM UNI XS KNEE COCR GEN,SUP-2349775,CDM,C1776,CPT,0278,RC,,,,both,,,9011.02,5857.16,,,,,,,,,,,,,
PLATE VOLAR DISTL RADL SMARTLOCK,SUP-2702960,CDM,C1713,HCPCS,0278,RC,,,,both,,,3112.05,2022.83,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 160 MMX0.1 CM FRZN,SUP-2717862,CDM,C1762,CPT,0278,RC,,,,both,,,4814.59,3129.48,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC BSC 5FR 55CM 1 LUMAN RVS TA 9175118,SUP-2632696,CDM,C1751,HCPCS,0278,RC,,,,both,,,434.32,282.31,,,,,,,,,,,,,
PLATE BNE 100 DEG L 40.51 MM THK 0.6 MM SCREW DIA1.5 MM 5 X,SUP-2935916,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
VALVE HYDROCEPHALUS PED W/ BUR H RESVR PROGAV 2.0,SUP-2108750,CDM,C1729,HCPCS,0272,RC,,,,both,,,8903.16,5787.05,,,,,,,,,,,,,
TUBE ORTH OD8MM IM FLR EXCHG NONSTERILE M/DN,SUP-2410448,CDM,C1713,HCPCS,0278,RC,,,,both,,,294.97,191.73,,,,,,,,,,,,,
PIN FIX L9IN DIA32MM ST S STL 3 SIDE DBL TRCR BOTH END PNT,SUP-2150516,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.69,16.70,,,,,,,,,,,,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,6370000000,HCPCS,0637,RC,00054-0742-87,NDC,,both,6.7,GR,162.00,105.30,,,,,,,,,,,,,
PATCH VASC HEMAPATCH L 140 X W 20 MM THK 0.65 MM POLYESTER,SUP-2914839,CDM,C1768,CPT,0278,RC,,,,both,,,538.10,349.76,,,,,,,,,,,,,
STENT CORONARY VELOC L 28 MM DIA2.5 MM SS HEPARIN OTW STRL,SUP-2156005,CDM,C1874,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
KIT THORCENT 8FR L5IN POLYUR W/ 18/22/25GA NDL 3 W STPCOCK,SUP-2383254,CDM,C1729,HCPCS,0272,RC,,,,both,,,109.27,71.03,,,,,,,,,,,,,
PIN FIX L150MM DIA4.5MM S STL SGL END SHRP TIP CTRL THRD,SUP-2186929,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.13,195.73,,,,,,,,,,,,,
BOOT WALKING CAM,SUP-2390668,CDM,L4387,HCPCS,0274,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
FEMORAL VG POR POR TIB/E1/STD,SUP-2137310,CDM,C1713,HCPCS,0278,RC,,,,both,,,16682.82,10843.83,,,,,,,,,,,,,
GRAFT BNE SUB 2.5CC B TRICALCIUM PHSPTE VERSATILE ULT POR,SUP-2370372,CDM,C1713,HCPCS,0278,RC,,,,both,,,2977.19,1935.17,,,,,,,,,,,,,
PATCH CV HEMGRD L 75 X W 8 MM THK 0.65 MM POLYESTER BOV UTHN,SUP-2535437,CDM,C1768,CPT,0278,RC,,,,both,,,3229.71,2099.31,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 40 CM DIA24 MM SIDE BRANCH L 15 MM DIA,SUP-2385033,CDM,C1768,CPT,0278,RC,,,,both,,,2464.33,1601.81,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 1MM 8MM RANG 160CC READIGRFT,SUP-2264734,CDM,C1713,HCPCS,0278,RC,,,,both,,,5584.11,3629.67,,,,,,,,,,,,,
EXTRACTOR SURG FOR FEM NK SCR TI TROCHANTERIC FIX NAIL SYS,SUP-2188254,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.31,1810.45,,,,,,,,,,,,,
MONITOR DOPP PERC SMARTNEEDLE,SUP-2120518,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.39,48.35,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA 9 FR HYDRPHLC,SUP-2383419,CDM,C1894,HCPCS,0272,RC,,,,both,,,263.13,171.03,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST SWEDISH TYP,SUP-2435617,CDM,L1850,HCPCS,0274,RC,,,,both,,,806.57,524.27,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X60 MM 7 HOLE TI,SUP-2536116,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.23,261.45,,,,,,,,,,,,,
LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),RX-430042,CDM,J2003,HCPCS,0636,RC,63323-0486-57,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
ITRACONAZOLE 100 MG PO CAPS,RX-10364,CDM,6370000000,HCPCS,0637,RC,10147-1700-03,NDC,,both,1,UN,33.40,21.71,,,,,,,,,,,,,
SCREW ACET 6.5X30 MM CANC HIP LOGICAL 111129130],SUP-2322443,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.44,153.04,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 65 CM DIA 5 FR DIA1.12 MM SIM2,SUP-2385535,CDM,C1887,HCPCS,0272,RC,,,,both,,,164.85,107.15,,,,,,,,,,,,,
RING EXT FIX UNIV LAM THOR TI FRONTAL HALF HK USS,SUP-2193624,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETERIZATION KIT 17.75 IN 7 FRX16 CM ARROWG+ARD +,SUP-2383331,CDM,C1751,HCPCS,0278,RC,,,,both,,,206.08,133.95,,,,,,,,,,,,,
PLATE BNE THK1.7MM STD 2X2 H MIDFACE G 3D,SUP-2366291,CDM,C1713,HCPCS,0278,RC,,,,both,,,726.34,472.12,,,,,,,,,,,,,
CLAMP EXT FIX M 4 POS PIN,SUP-2188512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1244.66,809.03,,,,,,,,,,,,,
PLATE BNE STR MINI REG 2X0.6 MM 6 HOLE LP FOR SCR TI STRL,SUP-2458636,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.31,186.75,,,,,,,,,,,,,
LINER WLK BOOT VENTURE TALL SM,SUP-2151034,CDM,L4386,HCPCS,0274,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
GAUGE OPHTH 20GA BACKFLUSH INSTR DISP,SUP-2213457,CDM,C1713,HCPCS,0278,RC,,,,both,,,358.59,233.08,,,,,,,,,,,,,
COUPLER EXT FIX LOK 3X3 MM,SUP-2464145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1782.58,1158.68,,,,,,,,,,,,,
RING EXT FIX DIA160 MM 1/6 CLOSURE NS DISP MONK RING,SUP-2881131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1718.37,1116.94,,,,,,,,,,,,,
COMPONENT FEM L75MM L KNEE POR ANAT PRI MAXM,SUP-2251196,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
ENDCAP ORTH EXTN 0MM FEM G TI CANN T40 STARDRV RECESS FOR,SUP-2180032,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.66,366.38,,,,,,,,,,,,,
NEEDLE SUT KNEE LO PROF SCORPION,SUP-2120939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
TI STERNAL LCKNG DOUBLE T-PL,SUP-2823436,CDM,C1713,HCPCS,0278,RC,,,,both,,,3526.85,2292.45,,,,,,,,,,,,,
WRE FX 6IN .028IN KRSH ORTH SS,SUP-2361608,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.18,15.72,,,,,,,,,,,,,
BRACE KNEE AD UNIV FOAM POSTOP 1 SZ FIT MOST AVG LEN FASTEN,SUP-2195290,CDM,L1810,HCPCS,0274,RC,,,,both,,,310.23,201.65,,,,,,,,,,,,,
BAR SPNL STR TIP 5.5X200 MM HEX TEXT COCR,SUP-2707929,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PROSTHESIS VOICE RAPID EXCHANGE 16 FRX6 MM BLOM-SINGER,SUP-2238266,CDM,L8507,HCPCS,0274,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
HC Reposition of Ppm/Icd Lead (1),PX-3613321500,CDM,33215,CPT,0361,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
K WIRE FIX L228MM DIA1.4MM FOR TOT ANK SYS INBONE II,SUP-2397997,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
PLATE BNE THK1MM 4X2 H BLU MAND TI 3D SQ FOR LEIBINGER,SUP-2366347,CDM,C1713,HCPCS,0278,RC,,,,both,,,1113.98,724.09,,,,,,,,,,,,,
HC So Assay of Estrone,PX-3018267966,CDM,82679,CPT,0301,RC,,,,inpatient,,,139.00,90.35,,,,,,,,,,,,,
MATERIAL REINF STPL LN BIOABSRB FOR ENDOPATH ETS45 SEAMGRD,SUP-2395282,CDM,C1781,HCPCS,0278,RC,,,,both,,,514.43,334.38,,,,,,,,,,,,,
PLATE BNE L92MM 6 H BILAT S STL STR NONCOMPRESSION RECON RIG,SUP-2410177,CDM,C1713,HCPCS,0278,RC,,,,both,,,1014.25,659.26,,,,,,,,,,,,,
STRIPPER TENDON QUADPRO HARVESTER 10MM,SUP-2660682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE L73MM THK3.3MM 6 H BILAT S STL RIG STR DYN COMPR,SUP-2186330,CDM,C1713,HCPCS,0278,RC,,,,both,,,937.79,609.56,,,,,,,,,,,,,
LACTATED RINGERS IV BOLUS,RX-40840057,CDM,J7120,HCPCS,0250,RC,00338-0117-04,NDC,,both,250,ML,10.70,6.95,,,,,,,,,,,,,
COIL EMB L15CM DIA10MM 0.018IN PERIPH HYDRGEL DETACH 18 SYS,SUP-2385421,CDM,C1889,HCPCS,0278,RC,,,,both,,,3048.85,1981.75,,,,,,,,,,,,,
STEM ULN SZ 4 L75MM L CEM CONSTRN NEXEL,SUP-2203815,CDM,C1776,CPT,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
BLADE SURG 50 MM CALCAR RASP STYL EXACT,SUP-2443892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1144.53,743.94,,,,,,,,,,,,,
PLATE BNE L41MM +20DEG 3X3 H NONSTERILE DST DORS RAD S STL,SUP-2177506,CDM,C1713,HCPCS,0278,RC,,,,both,,,1917.22,1246.19,,,,,,,,,,,,,
COIL EMB L8CM OD0.020IN LOOP OD4MM NIT STRTCH RESIST FILL,SUP-2323394,CDM,C1889,HCPCS,0278,RC,,,,both,,,7021.04,4563.68,,,,,,,,,,,,,
MOLD CEMENT SPACER SHLDR CUST MOD EXT,SUP-2898665,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 500 MG IJ SOLR,RX-9490,CDM,J0696,HCPCS,0636,RC,00409-7338-20,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L135CM BAL L40MM DIA7MM 0.035IN PERIPH,SUP-2101678,CDM,C1725,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BIT DRL CALIB 2 MM W/ SL STRL STRATUM RS LTX DISP,SUP-2861973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.91,277.49,,,,,,,,,,,,,
COMPONENT SEG DSTL TOT FEM 8CM LT SEGAL FINN,SUP-2406046,CDM,C1776,CPT,0278,RC,,,,both,,,16494.42,10721.37,,,,,,,,,,,,,
GUIDEWIRE VASC L 175 MM DIA 0.018 IN SS STR STEER,SUP-2158112,CDM,C1769,HCPCS,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
BIT DRL OVR T6 2X122 MM 2 MM FOR SCR VARIAX,SUP-2613647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
CONNECTOR SHUNT STR LUMPERITON FOR HYDROCEPHALUS SPETZLER,SUP-2852698,CDM,C1889,HCPCS,0278,RC,,,,both,,,298.36,193.93,,,,,,,,,,,,,
CATHETER CTRL VEN 5FR 16CM LEN SGL LUMN N TUNNELED BASIC KT,SUP-2120594,CDM,C1751,HCPCS,0278,RC,,,,both,,,89.49,58.17,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA1.7 MM CRANIOMAXILLOFACIAL ST LCK NS AXS 5PK,SUP-2884114,CDM,C1713,HCPCS,0278,RC,,,,both,,,1658.55,1078.06,,,,,,,,,,,,,
HC Plmt Access Bil Tree Sm Bwl,PX-3614754100,CDM,47541,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC Rsf Lab Bmh - Case / Block,PX-9900000123,CDM,9900000123,LOCAL,0990,RC,,,,both,,,12.00,7.80,,,,,,,,,,,,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,J7131,HCPCS,0258,RC,63323-0088-61,NDC,,both,100,ML,67.90,44.13,,,,,,,,,,,,,
PLATE BNE 17 H MIDFOOT S STL BILAT VAR ANG LOK COMPR FOR,SUP-2184814,CDM,C1713,HCPCS,0278,RC,,,,both,,,5144.61,3344.00,,,,,,,,,,,,,
INDWELLING VOICE PROS L FLNG T,SUP-2242343,CDM,L8509,HCPCS,0274,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
"HC So1 Enzyme Activity,Cells/Tissue",PX-3018265767,CDM,82657,CPT,0301,RC,,,,both,,,53.00,34.45,,,,,,,,,,,,,
CAP HEALING H30MM DIA30MM W/ PLUG BAHA,SUP-2165000,CDM,L8614,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
LINER ACET OD47MM ID28MMXLPE HIP BPLR SHELL TNDM,SUP-2344654,CDM,C1776,CPT,0278,RC,,,,both,,,3692.64,2400.22,,,,,,,,,,,,,
SCREW BNE DIA 4.5 MM SS LCK H INSRT STRL EVOS,SUP-2932215,CDM,C1713,HCPCS,0278,RC,,,,both,,,638.99,415.34,,,,,,,,,,,,,
CATHETER HD STR 9 FRX12 CM CATH INTRO NDL DUOFLO,SUP-2627100,CDM,C1752,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
LEVEL NEURO ST MESH SPCLTY PTTSBRGH SMCRCLE NEURO SCRW61 X 4,SUP-2677464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.01,1157.66,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-3612060400,CDM,20604,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 4 FRX130 CM 4X200 MM PACIFIC+,SUP-2281330,CDM,C1725,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP MARKED SPRING TIP 210 CM SAFEGUIDE DISP,SUP-2423867,CDM,C1769,HCPCS,0272,RC,,,,both,,,23.55,15.31,,,,,,,,,,,,,
POTASSIUM PHOSPHATE 3 MMOL/ML IV SOLN (MIXTURES ONLY),RX-430008,CDM,2500000003,HCPCS,0250,RC,65219-0056-29,NDC,,both,50,ML,682.60,443.69,,,,,,,,,,,,,
INBONE  TIBIAL TRAY RIGHT SIZE 6 RIGHT,SUP-2462502,CDM,C1776,CPT,0278,RC,,,,both,,,3771.14,2451.24,,,,,,,,,,,,,
PLATE BNE W175XL206MM THK52MM 8 H ST L CNDYL FEM S STL LOK,SUP-2185021,CDM,C1713,HCPCS,0278,RC,,,,both,,,4595.33,2986.96,,,,,,,,,,,,,
PLATE BNE STR MIC 1X0.6 MM 24 HOLE ADPT TI NS LEVEL 1,SUP-2472552,CDM,C1713,HCPCS,0278,RC,,,,both,,,887.77,577.05,,,,,,,,,,,,,
GRAFT BNE FIBULAR STRUT 110MM LX65MM,SUP-2307388,CDM,C1713,HCPCS,0278,RC,,,,both,,,3193.07,2075.50,,,,,,,,,,,,,
FORCEP ENDOSCP RUBBER TIP 4.8X1900 MM 2 MM GRASPING CHANNEL,SUP-2865648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.00,387.40,,,,,,,,,,,,,
GRAFT DERMAL FEN 5X5 CM CLLGN TISS MTRX,SUP-2243693,CDM,Q4110,HCPCS,0636,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
BIT DRILL SURG 4.5 MM SLD STRL ALPS DISP,SUP-2607150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,561.24,364.81,,,,,,,,,,,,,
LITHOTRIPTER SURG FIBER SUREFLEX REUSE RLLF550] LASER VENTURES],SUP-2263898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,0636,RC,71288-0107-20,NDC,,both,1,UN,192.10,124.86,,,,,,,,,,,,,
STIMULATOR NERVE SURESCAN MRI CLOSED LOOP TECHNOLOGY RECHRG,SUP-2889722,CDM,C1826,HCPCS,0278,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
PLATE BNE STR 1.5X0.4 MM MIDFACE 4 HOLE W/ TAB FOR SCREW NS,SUP-2494849,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.93,296.35,,,,,,,,,,,,,
STEM FEM L150MM DIA13MM HIP TI HI OFFSET PRESSFIT NEUT PRI,SUP-2344348,CDM,C1776,CPT,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
DILATOR UTER 185MM SGL END HEG,SUP-2245454,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.95,87.07,,,,,,,,,,,,,
PLATE BNE WDG 10 MM BOW ARW EVANS GORILLA,SUP-2751041,CDM,C1713,HCPCS,0278,RC,,,,both,,,3917.15,2546.15,,,,,,,,,,,,,
MICRO PLATE 3 X 2 HOLES RCTNGLR SGMNTS 10MM 15MM SSTM CP T,SUP-2681101,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.72,386.57,,,,,,,,,,,,,
BANDAGE COMPR SM MAMM COMFORTABLE HIGHLY ABSRB POST SURG,SUP-2276344,CDM,L8000,HCPCS,0274,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
SYSTEM BNE CEMENT SYR 5 ML SEMIMANUAL MX CLOSED SPATULA,SUP-2917178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
CATHETER CV FULL TY 018 4 FRX15 CM DL J TIP STR NDL SPECTRUM,SUP-2759856,CDM,C1751,HCPCS,0278,RC,,,,both,,,577.38,375.30,,,,,,,,,,,,,
HC Gerd Test W/Electrode (Bravo),PX-3604323500,CDM,3604323500,LOCAL,0750,RC,,,,both,,,2447.00,1590.55,,,,,,,,,,,,,
KIT INTRO L14CM DIA11FR GWIRE L50CM DIA0.038IN NDL 18GA,SUP-2357067,CDM,C1892,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
TRIAL BONE PLT 10 H 1/3 TBLR W/ CLLR FOR 3.5MM SCR TC-100 SM,SUP-2343725,CDM,C1713,HCPCS,0278,RC,,,,both,,,831.50,540.47,,,,,,,,,,,,,
COMPONENT HIP FOR PK 4500,SUP-2212672,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
DRILL SURG TIB POROUS ATTUNE RP,SUP-2454828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.156X9 IN SHANK END SS NS STEINMANN,SUP-2791377,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.33,35.96,,,,,,,,,,,,,
REDUCTION TWR,SUP-2232138,CDM,2780000010,LOCAL,0278,RC,,,,both,,,7027.32,4567.76,,,,,,,,,,,,,
COVER BUR H DIA13MM 5 H TI BENT W/O TAB NONCOMPRESSION LO,SUP-2402999,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
GRAFT HUM TISS 4X7CM PROC PERICARD TUTOPLAST,SUP-2300763,CDM,C1762,CPT,0278,RC,,,,both,,,7140.36,4641.23,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 20 MM DIA12 MM DEL SYS L 80 CM,SUP-2158636,CDM,C1876,HCPCS,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED SM PRIORITY + PEEK NS LTX,SUP-2862815,CDM,C1713,HCPCS,0278,RC,,,,both,,,44685.65,29045.67,,,,,,,,,,,,,
HANDPIECE IRRIG STD W/ A ROT SPR 270DEG ARTC HYDRODEBRIDER,SUP-2284172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,977.64,635.47,,,,,,,,,,,,,
VALVE MITRL CARP EDW DURAFLEX DIA 35 MM SEW RNG DIA 44 MM,SUP-2214285,CDM,C1713,HCPCS,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
QUICKSET KIT 16CC,SUP-2811321,CDM,C1713,HCPCS,0278,RC,,,,both,,,8456.81,5496.93,,,,,,,,,,,,,
IMMOBILIZER SHLDR E M RIB MEAS 44-48IN SZ XL,SUP-2196923,CDM,L3650,HCPCS,0274,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
KIT ART LN 20GA L12CM FEP RADPQ 0.025X13.75IN SPR GWIRE,SUP-2383269,CDM,C1751,HCPCS,0278,RC,,,,both,,,97.65,63.47,,,,,,,,,,,,,
TAP SURG DIA6.5MM QUIK CONN FOR PLATING SYS PERI-LOC,SUP-2344003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2558.47,1663.01,,,,,,,,,,,,,
DEVICE INTVASC OCCL TRUEPATH CTO L 165 CM GUIDEWIRE 0.018 IN,SUP-2145955,CDM,C1769,HCPCS,0272,RC,,,,both,,,8820.26,5733.17,,,,,,,,,,,,,
BEARING TIB PS 11X71/75 MM ASCNT,SUP-2449791,CDM,C1776,CPT,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
PLATE BNE L 1.6 MM RT LCK NS LTX,SUP-2856935,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
DEFIBRILLATOR CRD 63X51X12 MM 30 CC 69 GM SYS DF4 ENTRANT VR,SUP-2876022,CDM,C1722,HCPCS,0275,RC,,,,both,,,49360.80,32084.52,,,,,,,,,,,,,
PURAPLY 6X9CM 54SQ CM,SUP-2314123,CDM,Q4195,HCPCS,0636,RC,,,,both,,,16108.20,10470.33,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND XL 6 SHOT SAEED,SUP-2737556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
PLATE BNE STR 28 MM 5 HOLE W/ COMPR GORILLA,SUP-2321441,CDM,C1713,HCPCS,0278,RC,,,,both,,,3505.81,2278.78,,,,,,,,,,,,,
SYSTEM ENDO FIX ARTHROTUNNELER + TUNNELPRO LAT IMPL,SUP-2388892,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
VALVE MITRL OPN PVT DIA25 MM TISS ANNULUS 25.5 MM ORIFICE,SUP-2124484,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
DRAINAGE KIT CATH 180 DEG 25 CM FOR CYST PUNC TAPR EXAFLOW,SUP-2666677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1378.68,896.14,,,,,,,,,,,,,
SCREW LK ADV IMN SYS 5X525MM,SUP-2701136,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.74,780.48,,,,,,,,,,,,,
RING EXT FIX DIA140 MM 5/8 MONK RING,SUP-2898982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3713.05,2413.48,,,,,,,,,,,,,
BIT DRL L135MM DIA3MM DISP,SUP-2418852,CDM,2720000010,LOCAL,0272,RC,,,,both,,,608.85,395.75,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 145 CM TIP L 6 CM DIA 0.035 IN SS,SUP-2148176,CDM,C1769,HCPCS,0272,RC,,,,both,,,541.49,351.97,,,,,,,,,,,,,
DEVICE FIX ARTICULATING RELD W/ 5 DP PURCH RELIATACK,SUP-2752197,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.23,176.30,,,,,,,,,,,,,
GUIDEWIRE ORTH L 220 MM DIA2.8 MM SCREW DIA 6.5/7.5 MM,SUP-2908344,CDM,C1769,HCPCS,0272,RC,,,,both,,,449.40,292.11,,,,,,,,,,,,,
CATHETER DRAINAGE 26X49 MMX35 CM VENTRICULAR LUERLOCK CONN,SUP-2284403,CDM,C1729,HCPCS,0272,RC,,,,both,,,407.32,264.76,,,,,,,,,,,,,
INTRODUCER SHTH 8.5FR L63CM 8.5FR DIL GWIRE L145CM,SUP-2357172,CDM,C1893,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
HC Sputum Obtaining Spec Aerosol Induced Tx Spx,PX-4108922000,CDM,89220,CPT,0300,RC,,,,outpatient,,,39.00,25.35,,,,,,,,,,,,,
ROD SPNL L50MM DIA5.5MM THORACOLUMBOSACRAL TI PREBENT CDH,SUP-2290741,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 1/8X9 IN 4 PT STYL SMOOTH PLN STRL,SUP-2150488,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.45,10.04,,,,,,,,,,,,,
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-143623,CDM,J0694,HCPCS,0636,RC,00264-3125-11,NDC,,both,1,UN,192.90,125.38,,,,,,,,,,,,,
COLLAR CERV PED H1.5/1.75/2IN FOR 8-18IN NK HDPE FOAM 1 PC,SUP-2196873,CDM,L0150,HCPCS,0274,RC,,,,both,,,16.20,10.53,,,,,,,,,,,,,
STIMULATOR BNE DST TIB FIB TARSAL METATARSAL CASTED APPL,SUP-2316038,CDM,E0749,HCPCS,0278,RC,,,,both,,,7842.15,5097.40,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 10 CM OD 5 FR ID 0.074 IN SPRING,SUP-2385324,CDM,C1893,HCPCS,0272,RC,,,,both,,,144.75,94.09,,,,,,,,,,,,,
PLATE NSL W40XL50MM THK0.15MM POLYDIOXANONE FLX ABSRB DISP,SUP-2301043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1669.44,1085.14,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT CORT STRUT FEM FRZ DRY,SUP-2264711,CDM,C1713,HCPCS,0278,RC,,,,both,,,2436.70,1583.85,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 14 HOLES 265MM,SUP-2549514,CDM,C1713,HCPCS,0278,RC,,,,both,,,1704.93,1108.20,,,,,,,,,,,,,
CLIP LIG CVD UP JAW FILSHIE 10 PER BX,SUP-2716342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC Aspir/Inj Thyroid Cyst,PX-3616030000,CDM,60300,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SET INTUB LACR PRB SIL TBNG CRWFRD,SUP-2247574,CDM,C1783,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
LENS INTOCU BI CONVX TORIC NO HAPTIC ANG SGL PC POST CHMBR,SUP-2111273,CDM,V2787,HCPCS,0276,RC,,,,both,,,395.00,256.75,,,,,,,,,,,,,
PLATE BNE HUM 3.5X127 MM LT PERIARTICULAR PROX 4 HOLE LCK LP,SUP-2255803,CDM,C1713,HCPCS,0278,RC,,,,both,,,5286.44,3436.19,,,,,,,,,,,,,
PLATE BNE T 50 MM 3X9 HOLE COMPR,SUP-2435431,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.53,356.54,,,,,,,,,,,,,
BRACE ORTHOPEDIC SIMP 22-34 IN UNIV KNEE,SUP-2269750,CDM,2740000010,LOCAL,0274,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
STENT BILI PRECIS L 20 MM DIA 8 MM CATH L 135 CM DIA 8 FR,SUP-2158958,CDM,C1876,HCPCS,0278,RC,,,,both,,,7046.16,4580.00,,,,,,,,,,,,,
POST EXT FIX 1 H SPEEDWIRE M,SUP-2898444,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SIZER INSTR 7 20MM 7 PC DISPOSABLE PROCHONDRIX,SUP-2363973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.02,811.21,,,,,,,,,,,,,
FORCEPS BX 3.3FR L115CM CUP 0.85CUMM OVL TO OBTAIN TISS,SUP-2171270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1144.53,743.94,,,,,,,,,,,,,
BUTTON SUT LNG CORT ADJ RIGIDLOOP,SUP-2256784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1683.04,1093.98,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X84 MM 10 HOLE TI,SUP-2536119,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
BIT DRL CANN 5.5X150 MM,SUP-2606630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,794.42,516.37,,,,,,,,,,,,,
TAP SURG L 43 MM DIA2.2 MM SCREW DIA 6 MM SHRT SD HEX NS,SUP-2909559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.63,812.26,,,,,,,,,,,,,
KIT FIBERLOCK SUSPENSION IMPLANT,SUP-2740179,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
CATHETER PERITONEAL LAVAGE SET 038X40 CM 9 FRX20 CM 90,SUP-2760072,CDM,C1892,HCPCS,0272,RC,,,,both,,,290.36,188.73,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 3.5X118 MM 10 HOLE FOR SCREW STERI,SUP-2836655,CDM,C1713,HCPCS,0278,RC,,,,both,,,3502.67,2276.74,,,,,,,,,,,,,
MATRIX HUM TISS L 8 X W 10 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909205,CDM,Q4122,HCPCS,0636,RC,,,,both,,,19356.81,12581.93,,,,,,,,,,,,,
HC Thromb Mech 1st Vssl,PX-3613718400,CDM,37184,CPT,0361,RC,,,,outpatient,,,10740.00,6981.00,,,,,,,,,,,,,
HC Plmt Nephroureteral Catheter,PX-3615043300,CDM,50433,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL LCK,SUP-2435683,CDM,L2610,HCPCS,0272,RC,,,,both,,,667.25,433.71,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH BSC 5FR 0.034IN 60CM 2 LU 9255115,SUP-2632697,CDM,C1751,HCPCS,0278,RC,,,,both,,,433.63,281.86,,,,,,,,,,,,,
RETRACTOR SPINE L4CM OD22MM L D157IN STR MED LAT STR TBLR,SUP-2292996,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.64,898.72,,,,,,,,,,,,,
CATHETER KIT DL PEDIATRIC 4 FRX13 CM 20 GA ANTIMICROBIAL,SUP-2429390,CDM,C1751,HCPCS,0278,RC,,,,both,,,399.41,259.62,,,,,,,,,,,,,
HC Peripheral Block - Peribulbar or Retrobulbar,PX-3606750000,CDM,67500,CPT,0360,RC,,,,both,,,920.00,598.00,,,,,,,,,,,,,
ELECTRODE RESECTOSCOPE UPLR 24 FRX5 MM CYL TYP,SUP-2360972,CDM,C1713,HCPCS,0278,RC,,,,both,,,641.09,416.71,,,,,,,,,,,,,
STAPLE BNE RELIABLE 3 20X20X25 MM COMPR STRL EXPRESS XL,SUP-2223983,CDM,C1713,HCPCS,0278,RC,,,,both,,,4314.36,2804.33,,,,,,,,,,,,,
MOUNT TBL 2 MICROTOUCH,SUP-2364166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.84,173.45,,,,,,,,,,,,,
DESMOPRESSIN ACETATE 0.1 MG PO TABS,RX-16052,CDM,6370000000,HCPCS,0637,RC,23155-0489-01,NDC,,both,1,UN,4.80,3.12,,,,,,,,,,,,,
PLATE BNE H06MM BAR L4MM 6 H CHIN TI ADV LEIBINGER UNIV 2,SUP-2366336,CDM,C1713,HCPCS,0278,RC,,,,both,,,761.14,494.74,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM COMP TRAB MEL PERSONA FEMZIMCOMPNTS] ZIMMER BIOMET INC],SUP-2212568,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
ENDCAP ORTH DIA25MM 0MM EXTN ST STARDRV T25 RECESS FOR HUM,SUP-2179611,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.19,344.62,,,,,,,,,,,,,
TUBE VENT 1.14 MM 4 MM 1.8 MM RAZRBAC TI BLU STRL,SUP-2477044,CDM,L8699,HCPCS,0278,RC,,,,both,,,77.09,50.11,,,,,,,,,,,,,
VALVE CSF FLO BUTTON CONTOURED REG MED PRESSURE STRATA,SUP-2640142,CDM,C1889,HCPCS,0278,RC,,,,both,,,2083.30,1354.14,,,,,,,,,,,,,
CANNULA ENDOSCP EVAC 180 MM LL 1 STP COCK,SUP-2768386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.80,384.67,,,,,,,,,,,,,
DEVICE FIX 5 MM KNOT PUSH SUTURE CUT STRL TWINFIX QUICK-T,SUP-2341073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
HC So Estriol,PX-3018267766,CDM,82677,CPT,0301,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
SHUNT CV SM CAR ART NL8505400,SUP-2633897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.24,483.11,,,,,,,,,,,,,
PILLAR EXT FIX L 400 MM THRD MONK RING,SUP-2899175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1856.53,1206.74,,,,,,,,,,,,,
CONNECTOR PENILE PROS QC PENPRO,SUP-2138931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
PIN SELF DRILLING TIP 3.0X25X60MM,SUP-2480996,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
DRIVER SURG OD15MM M HEX FOR EVOLUTION C CERV IMPL REM SYS,SUP-2293604,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.42,103.62,,,,,,,,,,,,,
ELECTRODE PLSM WANDS INTEGR SUCT PRT NACL DEL DURABLE ACT,SUP-2342032,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PIN DRL L12MM KNEE GUID RG RMR DISP FLIPCUTTER II,SUP-2120811,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HC So Phenotype Infect Agent Drug,PX-3068790066,CDM,87900,CPT,0306,RC,,,,outpatient,,,442.00,287.30,,,,,,,,,,,,,
PLATE BONE L34MM THK1.4MM SHFT W6MM 5 H STRL STR TINE FOR,SUP-2349682,CDM,C1713,HCPCS,0278,RC,,,,both,,,4446.87,2890.47,,,,,,,,,,,,,
TRANSFER SET 6 LD NONVENTED PREASSEMBLED BARCODED PINNACLE,SUP-2774378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1536.25,998.56,,,,,,,,,,,,,
PEN ISOLATOR ELECTRD L7MM BPLR TRANSPOLAR UNIDIR LESION MAX1] ATRICURE INC],SUP-2124459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
BLADE 110DEG CVD DIEGO,SUP-2312776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.29,243.29,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM CARBON FIBER RINGFIX,SUP-2365279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3328.40,2163.46,,,,,,,,,,,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,0250,RC,00338-0117-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
GRAFT BONE SUB 3ML DEMIN BONE MTRX PUTTY GRFTON,SUP-2281669,CDM,C9359,HCPCS,0278,RC,,,,both,,,1868.93,1214.80,,,,,,,,,,,,,
MATRIX BIO SZ 250-540 SQCM FISH SKIN DERMAL MESHED 21 SINGLE,SUP-2909426,CDM,Q4158,HCPCS,0636,RC,,,,both,,,27082.50,17603.62,,,,,,,,,,,,,
NEEDLE BX L 257 MM DIA2.1 MM PRE CALIB DISP,SUP-2909952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1957.48,1272.36,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB II NEURO CUT STRL DISP HI-LINE XS GE555SU,SUP-2928830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.42,223.22,,,,,,,,,,,,,
UNIT DRNAGE PLEUR CAV SGL COLL SUCT CTRL REGULATED STR CONN,SUP-2266004,CDM,C1729,HCPCS,0272,RC,,,,both,,,154.14,100.19,,,,,,,,,,,,,
PACEMAKER CARD AZURE XT DR MRI SURESCAN W 50.8 X H 46.6 MM D,SUP-2282505,CDM,C1785,HCPCS,0275,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
DEVICE MENIS REP STR NDL ALL-SUTURE CROSSFIX II,SUP-2402629,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PROBE E ENDOSCP SPAT TIP 5MMX45CM DISPOSABLE ST 0250070554,SUP-2361228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.58,436.53,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 5 GM/50ML IV SOLN,RX-104396,CDM,J1459,HCPCS,0636,RC,44206-0436-05,NDC,,both,50,ML,2830.00,1839.50,,,,,,,,,,,,,
GRAFT BIO TISS 18MM DISC DERM REP MESHED SCAFFOLD PRIMATRIX,SUP-2243698,CDM,Q4110,HCPCS,0636,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
DEVICE TISS REMOVAL MANUAL MYOSURE,SUP-2472977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
PROBE ELECTRD SINGLE 25 CM IRREVERSIBLE NANOKNIFE,SUP-2752604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
PLATE BONE 6 H CRANIO FACE MAND FULL SEC RECON 6 + 15 + TI,SUP-2363754,CDM,C1713,HCPCS,0278,RC,,,,both,,,4242.77,2757.80,,,,,,,,,,,,,
CATHETER SUPP QUICK-CROSS L 150 CM 5 FR 0.063/0.05IN 0.035IN,SUP-2823684,CDM,C1887,HCPCS,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
KIT GASTROSTMY TB 24FR BLLN 5ML STOMA L3CM SIL SECURLOK INT,SUP-2236551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,302.01,196.31,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST CORSET FRONT,SUP-2435563,CDM,L0970,HCPCS,0274,RC,,,,both,,,302.54,196.65,,,,,,,,,,,,,
PLATE BNE RECON 3.5X190 MM 16 HOLE SS,SUP-2569091,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.56,326.66,,,,,,,,,,,,,
INSTRUMENT COR BX 18GA L9CM PEN 11MM PNK ACTUATOR DISP MPTY,SUP-2127808,CDM,C1713,HCPCS,0278,RC,,,,both,,,71.91,46.74,,,,,,,,,,,,,
ELECTRODE ELECSURG MONOPOLAR 5X400 MM FLAT J HK HI FREQ DISP,SUP-2797662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.80,486.72,,,,,,,,,,,,,
HC Cltx Med Ankle Fx W/Mnpj,PX-4502776200,CDM,27762,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
RING EXT FIX DIA160 MM FT SPEEDWIRE ANAT,SUP-2898537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS TENCK PEDIATRIC 37.5 CM LT SIL ARGY,SUP-2754733,CDM,C1752,HCPCS,0278,RC,,,,both,,,434.42,282.37,,,,,,,,,,,,,
CAGE SPNL 4 DEG 18X40 MM 16 MM UPPER ENDPLATE FOOTPRINT TI,SUP-2422376,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
REPAIR KIT SYNDESMOSIS TI NS FIBULINK,SUP-2790021,CDM,C1713,HCPCS,0278,RC,,,,both,,,3678.38,2390.95,,,,,,,,,,,,,
VALVE ENDOSCP WSH CASE - SUCTION,SUP-2457314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.29,693.74,,,,,,,,,,,,,
KNIFE SURG BALLENGER SWVL 8 IN 3 MM STR,SUP-2474030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.70,320.25,,,,,,,,,,,,,
COLLAR CERV LG MED 4.5X24 IN POLY CVR FOAM,SUP-2194442,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.93,7.10,,,,,,,,,,,,,
MESH TISS L 250 MM DIA 5 MM TYP 1 CLLGN MTRX PLLA,SUP-2895935,CDM,C1781,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SET INTRO S-MAK L 10 CM DIA 5 FR L 40 CM NIT COR PLAT TIP,SUP-2475724,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
PLATE BNE W12XL151MM THK1MM 9 H BILAT S STL SEMI TBLR LO,SUP-2184870,CDM,C1713,HCPCS,0278,RC,,,,both,,,283.26,184.12,,,,,,,,,,,,,
LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),RX-430042,CDM,J2003,HCPCS,0636,RC,00409-4277-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PIN BONE FIX L40MM OD4MM LACTOSORB L15 BIOABSRB ACL,SUP-2212875,CDM,C1713,HCPCS,0278,RC,,,,both,,,1607.68,1044.99,,,,,,,,,,,,,
HC Sinuses Min 3 Views,PX-3207022000,CDM,70220,CPT,0320,RC,,,,inpatient,,,664.00,431.60,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-142364,CDM,Q5106,HCPCS,0636,RC,00069-1308-10,NDC,,both,1,ML,325.40,211.51,,,,,,,,,,,,,
BIT DRL DIA2.9MM CANN DISP FOR PEDILOC LOK PROX FEM SYS,SUP-2318866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
DISSECTOR ENDOSCP CRV JAW 26 CM CRDLSS FOR US SONICISION,SUP-2422350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
LITHIUM CARBONATE ER 450 MG PO TBCR,RX-10455,CDM,6370000000,HCPCS,0637,RC,68084-0655-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NEEDLE ENDOSCP 22GA FNF PRELD US DEL SYS BEAC,SUP-2173694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1358.99,883.34,,,,,,,,,,,,,
INTRODUCER SHTH FLPY TIP 0.021 IN 6 FRX11 CM 21 GAX4 CM,SUP-2430074,CDM,C1893,HCPCS,0272,RC,,,,both,,,184.63,120.01,,,,,,,,,,,,,
SODIUM CHLORIDE (HYPERTONIC) 2 % OP SOLN,RX-11404,CDM,6370000000,HCPCS,0637,RC,24208-0276-15,NDC,,both,15,ML,71.80,46.67,,,,,,,,,,,,,
PLATE BONE LOK 3.5MM DIA HLX12 RIGHT LTRL PRXML TBL,SUP-2588158,CDM,C1713,HCPCS,0278,RC,,,,both,,,3994.90,2596.68,,,,,,,,,,,,,
TUBE ENDOTRACH WIRE REINF 7MM ID,SUP-2525905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,62.49,40.62,,,,,,,,,,,,,
SCREW BNE L70MM DIA5.5MM LNG PERIARTC CORT S STL ST CANN,SUP-2410842,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.83,343.09,,,,,,,,,,,,,
GUIDEWIRE INTRMDLRY BALL TP SS 2.4MMX70CM,SUP-2460195,CDM,C1769,HCPCS,0272,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
SCREW BNE CRTX 3.5X40 MM LP ST HD T15 STARDRV RECESS TI NS,SUP-2758268,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.08,78.70,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS MAXXEUS SEMIT FZ,SUP-2875993,CDM,C1762,CPT,0278,RC,,,,both,,,5533.47,3596.76,,,,,,,,,,,,,
PLATE BNE TALONAVICULAR SM LT STRATUM,SUP-2474525,CDM,C1713,HCPCS,0278,RC,,,,both,,,5220.00,3393.00,,,,,,,,,,,,,
SHELL ACET OD62MM R HIP MTL POR CEMENTLESS HMSPHR ANAT,SUP-2363245,CDM,C1776,CPT,0278,RC,,,,both,,,8829.68,5739.29,,,,,,,,,,,,,
PLATE BONE STR MIDFACE 2X34 H MALL LO PROF 2 STRP NONSTERILE,SUP-2363723,CDM,C1713,HCPCS,0278,RC,,,,both,,,2753.59,1789.83,,,,,,,,,,,,,
PLATE BNE CROSS SHP SCR STYL HD FOR 6MM BRIDGE ORTHOANCHOR,SUP-2471447,CDM,C1713,HCPCS,0278,RC,,,,both,,,1306.71,849.36,,,,,,,,,,,,,
HC Pacu Recovery - First 15 Min,PX-7100000000,CDM,7100000000,LOCAL,0710,RC,,,,both,,,1362.00,885.30,,,,,,,,,,,,,
HC Driving Program Reassessment,PX-9900000144,CDM,,,0990,RC,,,,both,,,155.00,100.75,,,,,,,,,,,,,
BIT DRL DIA4.5/3.2MM STP TAPR FOR SALVATION SYS,SUP-2400807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1237.16,804.15,,,,,,,,,,,,,
GRAFT BIO TISS MESH 8X6 CM MIROMATRIX MIROMESH,SUP-2305882,CDM,C1781,HCPCS,0278,RC,,,,both,,,4355.81,2831.28,,,,,,,,,,,,,
PLATE BNE NC FUSION SM 2.7 MM NS FPS LTX,SUP-2856865,CDM,C1713,HCPCS,0278,RC,,,,both,,,4298.66,2794.13,,,,,,,,,,,,,
PIN DRVR L35IN BNE QUIK REL SMOOTH,SUP-2197199,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.24,189.31,,,,,,,,,,,,,
SHUNT PERI 7FR 90CM HI REG W/O RESVR CSF ASSEMB FLO CTRL,SUP-2284551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2447.66,1590.98,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR THK7MM 18GM 10ML VAGUS NRV 2 PIN,SUP-2265162,CDM,C1767,HCPCS,0278,RC,,,,both,,,99229.53,64499.19,,,,,,,,,,,,,
POST EXT FIX PIN MT MULTIPARALLEL 4 HI NS MAXFRAME,SUP-2758001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.70,367.05,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM SZ 2 CART ARAGONITE,SUP-2913173,CDM,C1763,HCPCS,0278,RC,,,,both,,,23864.00,15511.60,,,,,,,,,,,,,
SD BLADE15MM DRIVER XD58MM1SIDE BEVD,SUP-2676841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SHEPARD GROMMET VENT TUBE 102MM ID FLUOROPLASTIC 60 PACK,SUP-2681458,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.52,15.94,,,,,,,,,,,,,
STEM FEM CLLRD PRSS FIT LO OFFSET FORGED CO CHROM SZ 0,SUP-2221735,CDM,C1776,CPT,0278,RC,,,,both,,,15448.80,10041.72,,,,,,,,,,,,,
RING SALVATION 200MM,SUP-2487987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4188.76,2722.69,,,,,,,,,,,,,
TUBE SUCTION T FUKUSHIMA 5 FRX3.25 IN 6.5 IN TEARDROP,SUP-2475665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.75,242.29,,,,,,,,,,,,,
WEDGE ACF ILIUM CREST TRADITION ALLGRFT 13 - 15 MM FRZ DRY,SUP-2294065,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
FORCEPS OPHTH 23GA CRV DISP GRIESHABER REVOLUTION DSP,SUP-2109706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.20,354.38,,,,,,,,,,,,,
GUIDEWIRE ORTH L19IN DIA1.6MM NIT BLNT TIP SNIPER,SUP-2354677,CDM,C1769,HCPCS,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
HC Biopsy Thyroid Perc Needle|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3616010000,CDM,60100,CPT,0361,RC,,,73,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE L94MM 6 H L SUP ANT CLAV S STL LOK COMPR,SUP-2184140,CDM,C1713,HCPCS,0278,RC,,,,both,,,2668.37,1734.44,,,,,,,,,,,,,
SHELL ACET DIA50MM TI ALLY POR HA CALCICOAT CERAMIC MH PRI,SUP-2210228,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE SET 3 MM CANN 1/3 THRD EXT TAB,SUP-2861011,CDM,C1713,HCPCS,0278,RC,,,,both,,,13971.74,9081.63,,,,,,,,,,,,,
WIRE FIX 3+ MM 2X220 MM PRO KIRSCHNER,SUP-2536051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
HC So Insulin Antibodies,PX-3028633766,CDM,86337,CPT,0302,RC,,,,both,,,815.00,529.75,,,,,,,,,,,,,
PROBE ELECTROTHERAPY DENERVATION SIMPLICITY,SUP-2357697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SCREW BONE L45MM DIA6.4MM STD CORT LCK RECON FOR FEM NAIL,SUP-2342526,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.02,168.36,,,,,,,,,,,,,
DISTRACTION INTRNL DIST LFRT 3MNO MTTHWS TSSR 1.5 1.8 MM SC,SUP-2694296,CDM,C1713,HCPCS,0278,RC,,,,both,,,17269.03,11224.87,,,,,,,,,,,,,
BIT DRL L58MM DIA1.6MM FOR 20MM 2/2.3MM BNE SCR LEIBINGER,SUP-2366422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.60,281.84,,,,,,,,,,,,,
ELECTRODE CUT RITECUT R ANG 3FR 65CM,SUP-2313512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1493.23,970.60,,,,,,,,,,,,,
BLADE SURG EXTRACTOR HNDL,SUP-2653711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2720.97,1768.63,,,,,,,,,,,,,
HC So Enterovirus,PX-3028665866,CDM,86658,CPT,0302,RC,,,,inpatient,,,158.00,102.70,,,,,,,,,,,,,
BONE MACH BLK 12X20MM GIC58 BICORT,SUP-2293980,CDM,C1713,HCPCS,0278,RC,,,,both,,,6361.64,4135.07,,,,,,,,,,,,,
SPLINT ANK FT L L POST LEAF LTWT SEMI RIG ROLYAN,SUP-2326012,CDM,L4396,HCPCS,0274,RC,,,,both,,,98.56,64.06,,,,,,,,,,,,,
ALLOGRAFT BNE MOLD 10 CC VIABLE BNE MTRX VIBONE,SUP-2731791,CDM,C1762,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME RT KNEE PCL L/TH S/CF CUST,SUP-2915011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.03,841.77,,,,,,,,,,,,,
COIL DETACH NXT HELIX STD 10 7 MMX10 CM,SUP-2173054,CDM,C1889,HCPCS,0278,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
SCREW BNE L8MM DIA1.5MM CO CHROM CORT ST NONLOCKING FULL,SUP-2411776,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.27,202.98,,,,,,,,,,,,,
ABLATOR ENDOSCOPIC ELECTROCAUTERY 90 DEG RF ASPIRATING STERILE DISPOSABLE APOLLORF I90,SUP-2895201,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
DISTRACTOR SURG L 35 MM INTRAORAL MANDIBULAR FRME NS,SUP-2883457,CDM,C1713,HCPCS,0278,RC,,,,both,,,15299.40,9944.61,,,,,,,,,,,,,
BUR SHV L13CM DIA3.6MM 12000RPM LNG CVD HI SPD CANN FOR,SUP-2277866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1081.01,702.66,,,,,,,,,,,,,
PROBE VITRCTMY 23GA UNIV STR SGL END,SUP-2109902,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
PACEMAKER IMP CRT-P QUADRA ALLURE MP RF CRT-P MRI MERLINPKG,SUP-2356476,CDM,C2621,HCPCS,0275,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH RENU L 127 MM PROX/DSTL L 80/47,SUP-2750814,CDM,C1874,HCPCS,0278,RC,,,,both,,,21000.32,13650.21,,,,,,,,,,,,,
BUR SURG MATCHSTICK LNG 3 MM FLUT FOR QD14-S/QD14-G1/QD14,SUP-2848156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.20,269.88,,,,,,,,,,,,,
HC So2 Porphobilinogenurine Quant,PX-3018411068,CDM,84110,CPT,0301,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
MESH HERN W10XL12CM THK1.1MM 6MM GRID POLYPR OVINE,SUP-2383093,CDM,C1781,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
PLATE BNE L28MM THK1MM 6 H NONSTERILE HND S STL STR LOK VAR,SUP-2178005,CDM,C1713,HCPCS,0278,RC,,,,both,,,1333.68,866.89,,,,,,,,,,,,,
PLATE BONE L164MM 8 H LT OLECRANON TI FOR 2.7/3.5MM SCR,SUP-2419185,CDM,C1713,HCPCS,0278,RC,,,,both,,,3029.47,1969.16,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CANC CORT DEMIN CHIP OPTECURE,SUP-2223579,CDM,C1713,HCPCS,0278,RC,,,,both,,,3702.06,2406.34,,,,,,,,,,,,,
CATHETER GUID ZIPLINE ID 0.070 IN HYDRPHLC 1 LUMEN VAR,SUP-2929968,CDM,C1887,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
STENT GRFT VASC AFX L 100 MM UNCOVERED L 20 MM DIA 34 MM,SUP-2217607,CDM,C1768,CPT,0278,RC,,,,both,,,16532.10,10745.86,,,,,,,,,,,,,
PLATE SPNL W10XL30.5MM 4 H LAT FULL PROF FOR MOD FIX SYS,SUP-2137112,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
PLATE BNE MED RT POST FIB NS UNITE,SUP-2896533,CDM,C1713,HCPCS,0278,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
ROD SPNL L300MM DIA5.5MM R ANT TI ALLY SMOOTH MOSS MIAMI,SUP-2254456,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-3417859800,CDM,78598,CPT,0341,RC,,,,inpatient,,,4641.00,3016.65,,,,,,,,,,,,,
HC Insertion Uterine Tandem&/Vaginal Ovoids,PX-3425715500,CDM,57155,CPT,0342,RC,,,,outpatient,,,2249.00,1461.85,,,,,,,,,,,,,
DISSECTOR SURG SPATULA LG 8 2 MM RHOTON RUGGLES-REDMOND,SUP-2484766,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
SHEARS ENDOSCP HARM 36CM ULTRASONIC CRV TIP UPGRD,SUP-2615608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7364.90,4787.18,,,,,,,,,,,,,
PIN FIX 2 MM STRL INION OTPS LTX DISP,SUP-2857902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
SCREW BNE 65MM X 30MM SURFIT S STL HINDFOOT IMPLANTS,SUP-2243416,CDM,C1713,HCPCS,0278,RC,,,,both,,,1244.41,808.87,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD BLU,SUP-2248512,CDM,C1732,HCPCS,0278,RC,,,,both,,,6220.34,4043.22,,,,,,,,,,,,,
CANNULA ART LNG 17 FR BIOLINE COATED HLS,SUP-2663453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.73,694.02,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 5-6 EF 14 MM KNEE GRN NXGN LPS,SUP-2208735,CDM,C1776,CPT,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
MESH GYN POLYPR ULT LTWT SMARTMESH TECHNOLOGY FOR POST PELV,SUP-2165312,CDM,C1781,HCPCS,0278,RC,,,,both,,,4819.90,3132.93,,,,,,,,,,,,,
HC So Ethosuximide (Zarontin),PX-3018016866,CDM,80168,CPT,0301,RC,,,,both,,,470.00,305.50,,,,,,,,,,,,,
INSERT TIB BEAR SZ 4 THK16MM KNEE X3 CNDYL STABILIZING,SUP-2373218,CDM,C1776,CPT,0278,RC,,,,both,,,6057.06,3937.09,,,,,,,,,,,,,
IMPLANT SACROILIAC JT L 170 MM DIA 8.7 MM TI 3D PRNT POROUS,SUP-2905397,CDM,C1889,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
MESH MXLFCL 126.2X11 MM 1 MM FOIL PLLA-PGA STRL RESORB XG,SUP-2487956,CDM,C1713,HCPCS,0278,RC,,,,both,,,1741.26,1131.82,,,,,,,,,,,,,
STYLUS NSL BREATHING RHINAER,SUP-2739151,CDM,C1889,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
HC Wound Vac >50 Sq Cm Dme,PX-7619760600,CDM,97606,CPT,0761,RC,,,,both,,,461.00,299.65,,,,,,,,,,,,,
WHEEL SURG DIA254MM GRIT 150MM MTL CUT CEBOTOME,SUP-2166350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.53,348.74,,,,,,,,,,,,,
VALVE VENTRICULAR 5/35CM WATER WITHOUT RESERVOIR NON PROGRAM,SUP-2825652,CDM,C1889,HCPCS,0278,RC,,,,both,,,5900.03,3835.02,,,,,,,,,,,,,
FEM FULL AGMT BLK 59X25,SUP-2205982,CDM,C1776,CPT,0278,RC,,,,both,,,24391.52,15854.49,,,,,,,,,,,,,
PROBE ABLATN SING 15 MM OPTABLATE,SUP-2877226,CDM,C1886,HCPCS,0278,RC,,,,both,,,11853.50,7704.77,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM POLY L LACTIC ACID KNEE CANN,SUP-2249498,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
STENT PANCREATIC ELECTROCAUTERY 24X15X10 MM 10.8 FRX138 CM,SUP-2459413,CDM,C1874,HCPCS,0278,RC,,,,both,,,12289.96,7988.47,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 350CM 0.035IN NIT POLYUR 45 ANGLED,SUP-2535550,CDM,C1769,HCPCS,0272,RC,,,,both,,,245.86,159.81,,,,,,,,,,,,,
CATHETER EP 7FR L115CM 2-5-2MM SPC M CURL QPLR BIDIR STEER,SUP-2357028,CDM,C1733,HCPCS,0272,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
KIT SUTURE ANCHR L 15 MM DIA 4.5 MM TI PRELD 1.5 MM PASS,SUP-2899082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.27,780.18,,,,,,,,,,,,,
PLATE BNE 16 H SCR H DIA1.2MM L N COMPR CRV,SUP-2267876,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.77,512.70,,,,,,,,,,,,,
DILATOR UROLOGICAL SET 6-24 FRX20 CM FASCIAL POLYETH,SUP-2835684,CDM,C2627,HCPCS,0272,RC,,,,both,,,507.08,329.60,,,,,,,,,,,,,
RILPIVIRINE HCL 25 MG PO TABS,RX-108761,CDM,6370000000,HCPCS,0637,RC,59676-0278-01,NDC,,both,1,UN,222.60,144.69,,,,,,,,,,,,,
PLATE CRAN L 31 MM DIA25 MM THK 0.5 MM SCREW DIA1.5 MM TI,SUP-2937029,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
CATHETER GUID BNCHMRK 071 L 115 CM OD 6 FR 0.071 IN MP,SUP-2716391,CDM,C1887,HCPCS,0272,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2.5 MM RECON PT SPEC,SUP-2860100,CDM,C1713,HCPCS,0278,RC,,,,both,,,28600.38,18590.25,,,,,,,,,,,,,
CATHETER PTCA BLLN L10MM DIA2.25MM COR OVR THE WIRE SCORED,SUP-2142793,CDM,C1725,HCPCS,0272,RC,,,,both,,,2697.26,1753.22,,,,,,,,,,,,,
BUR SURG X COARSE DIAMOND 4 MM 10 CM BALL SM BOR MIDAS REX 8,SUP-2664492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
DEFIBRILLATOR IMPL AMPLIA MRI SURESCAN W 51 X H 71 MM D 13,SUP-2282413,CDM,C1882,HCPCS,0275,RC,,,,both,,,58137.35,37789.28,,,,,,,,,,,,,
PLATE BONE SM STRL UTIL FOR 2.7MM SCR VLP,SUP-2349945,CDM,C1713,HCPCS,0278,RC,,,,both,,,5680.42,3692.27,,,,,,,,,,,,,
BUR SURGICALXL DIA4MM DMND RND,SUP-2361442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.98,588.24,,,,,,,,,,,,,
DRILL HAND HUDSON BRACE STANDARD JARIT STERILE,SUP-2705660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,964.48,626.91,,,,,,,,,,,,,
PLATE FOOT LK T PLT OBLQ LT,SUP-2701924,CDM,C1713,HCPCS,0278,RC,,,,both,,,2388.91,1552.79,,,,,,,,,,,,,
PROBE NSL STR 90 DEG W/ LT HND MIRROR SMK EVAC,SUP-2713683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.47,842.06,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC BLNT TIP 9 IN STRL CANNFLX LTX,SUP-2879294,CDM,C1769,HCPCS,0272,RC,,,,both,,,187.93,122.15,,,,,,,,,,,,,
WIRE BNE FIX L 23 MM SHRT FT COMPR NS A.L.P.S.,SUP-2211521,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
TUBE EXT FIX L300MM OD25MM RED C FOR UNILAT MONOTB TRIAX SYS,SUP-2372616,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.86,355.46,,,,,,,,,,,,,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-3058546100,CDM,85461,CPT,0305,RC,,,,both,,,254.00,165.10,,,,,,,,,,,,,
TUBE T SURG DRAIN 8F SIL STRL,SUP-2752235,CDM,C1729,HCPCS,0272,RC,,,,both,,,1215.37,789.99,,,,,,,,,,,,,
PLATE BONE L154MM 12 HOLE RIGHT LTRL PRXML PRRTCLR TBL STNLS,SUP-2457771,CDM,C1713,HCPCS,0278,RC,,,,both,,,2401.10,1560.71,,,,,,,,,,,,,
PLATE BONE L61MM 5 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349735,CDM,C1713,HCPCS,0278,RC,,,,both,,,3594.04,2336.13,,,,,,,,,,,,,
SET AUTOTRNS PROC 125ML BOWL PASXTRA,SUP-2352719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
ROTH NET RETRIEVER 360,SUP-2720127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
GRAFT VASC STD WALL 5 MMX70 CM STR RNG REINF ADVANTA VXT,SUP-2466490,CDM,C1768,CPT,0278,RC,,,,both,,,1705.52,1108.59,,,,,,,,,,,,,
GRAFT BNE SPNG 25X20X7 MM DBM CANC,SUP-2641784,CDM,C1713,HCPCS,0278,RC,,,,both,,,4364.29,2836.79,,,,,,,,,,,,,
IMPLANT HUM TISS L 7 X W 7 CM PLCNTA MEMBRN MTRX FLX FOR WND,SUP-2905483,CDM,Q4151,HCPCS,0636,RC,,,,both,,,22620.06,14703.04,,,,,,,,,,,,,
KIT TENODESIS WITH 5MM TENOLOK ANCHOR AND ONE NO2 HI FI SUTU,SUP-2825210,CDM,C1713,HCPCS,0278,RC,,,,both,,,3817.93,2481.65,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 14CM 4CM 20.5MM 900MM 8CM L VALVE SYSTEM,SUP-2826689,CDM,C1889,HCPCS,0278,RC,,,,both,,,6154.71,4000.56,,,,,,,,,,,,,
VALVE PULM HOMOGRAFT SZ 28 MM CONDUIT STRL,SUP-2175246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22922.00,14899.30,,,,,,,,,,,,,
KIT INTRO MAK-NV L 20 CM DIA 6 FR DIL 4 FR GUIDEWIRE L 60 CM,SUP-2303019,CDM,C1894,HCPCS,0272,RC,,,,both,,,192.73,125.27,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0250,RC,00338-0023-02,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
IMMOBILIZER KNEE SIZED CANVS 16 IN L,SUP-2336062,CDM,L1830,CPT,0274,RC,,,,both,,,35.76,23.24,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK PRIZM VR HE DEL ENERGY 31 J TI,SUP-2148619,CDM,C1722,HCPCS,0275,RC,,,,both,,,72534.00,47147.10,,,,,,,,,,,,,
PASSER SUTURE STRL DISP LATITUDE EV,SUP-2902539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.25,331.66,,,,,,,,,,,,,
SCREW CORTEX ST 2.4X7MM W/3.5MM HD,SUP-2547196,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.66,111.58,,,,,,,,,,,,,
KIT ENDOSCP 2MM TIGERTAPE LOOP 3MM CANN DRL SUTLASS SD WIRE,SUP-2121672,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
HC X-Ray Tibia/Fibula 2 Views,PX-3207359000,CDM,73590,CPT,0320,RC,,,,both,,,613.00,398.45,,,,,,,,,,,,,
HC Thromb Mech Vein,PX-3613718700,CDM,37187,CPT,0361,RC,,,,inpatient,,,7160.00,4654.00,,,,,,,,,,,,,
KIT EXT FIX DYNAMIZATION STRL DISP SMRT TSF,SUP-2933448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2340.84,1521.55,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 16 FRX30 CM 2 CM 3-5 CC MIC-KEY,SUP-2764813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1113.29,723.64,,,,,,,,,,,,,
CANNULA ENDOSCP TROCAR 2.5 MMX3.5 CM,SUP-2767309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1372.31,892.00,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 110 MM DIA25 MM LIMB 30 MM 16 MM,SUP-2217629,CDM,C1874,HCPCS,0278,RC,,,,both,,,36361.20,23634.78,,,,,,,,,,,,,
KIT SHTH DESTINO L 87 CM L 67 CM DIA10 FR CRV BEND 50 MM,SUP-2616179,CDM,C1766,CPT,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 3 HOLES 56MM,SUP-2549503,CDM,C1713,HCPCS,0278,RC,,,,both,,,964.95,627.22,,,,,,,,,,,,,
MODULE EMG W/ NVM5 HARN 2 NEEDLE/NEUROVISION 2 SLD GEL,SUP-2311747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
NECK FEM SHT CO CHROM HIP NEUT MOD PROFEMUR,SUP-2304837,CDM,C1776,CPT,0278,RC,,,,both,,,8368.10,5439.26,,,,,,,,,,,,,
GRAFT VASC PERIPH BYPS STR THN WALL N RING SM BEAD 7MM,SUP-2126883,CDM,C1768,CPT,0278,RC,,,,both,,,3775.94,2454.36,,,,,,,,,,,,,
PLATE BNE ARNETT MINI XL 1X1 MM 4 HOLE STR RIGID SIDE TI NS,SUP-2472701,CDM,C1713,HCPCS,0278,RC,,,,both,,,1113.57,723.82,,,,,,,,,,,,,
CLAMP REPROC PIN 4 HOLE,SUP-2484024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.72,246.82,,,,,,,,,,,,,
SET BLADE RTRCTR SHRT TEETH SPNL RGGLS RDMND FLEXI SPINE,SUP-2672161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9609.84,6246.40,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL CTRL ABD,SUP-2435555,CDM,L0636,HCPCS,0272,RC,,,,both,,,3838.43,2494.98,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA0.062IN W/ TRCR TIP DISP FOR ANK,SUP-2122969,CDM,C1713,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
DRILL TWST L 58 MM DIA1.9 MM WORKING L 26 MM DENT SHFT FOR,SUP-2883483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.97,213.18,,,,,,,,,,,,,
VALVE AORT EPIC MAX SZ 25 MM TISS ANNULUS DIA25 MM STENT,SUP-2893587,CDM,C1889,HCPCS,0278,RC,,,,both,,,15703.14,10207.04,,,,,,,,,,,,,
SYSTEM TKR L MED LUNI KNEE UNI UNI KT,SUP-2165954,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
STEM FEM L150MM DIA11MM RESECT LEV 34MM HD NK HIP CO CHROM,SUP-2405033,CDM,C1776,CPT,0278,RC,,,,both,,,14067.20,9143.68,,,,,,,,,,,,,
TRAY BX L152MM OD11GA S STL NDL PWR BNE ACCS ARW ONCONTROL,SUP-2383231,CDM,C1830,HCPCS,0278,RC,,,,both,,,461.05,299.68,,,,,,,,,,,,,
CUSHION HEEL W/ BLU DOT S,SUP-2151867,CDM,L3334,HCPCS,0274,RC,,,,both,,,48.36,31.43,,,,,,,,,,,,,
ROD SPNL L60MM TOP LD FOR DYN STBL SYS DYNESYS,SUP-2414280,CDM,C1713,HCPCS,0278,RC,,,,both,,,9702.60,6306.69,,,,,,,,,,,,,
IMPLANT GYN Y MESH 27X5 CM UTER PELV SACROCOLPOPEXY ARTISYN,SUP-2717350,CDM,C1781,HCPCS,0278,RC,,,,both,,,2363.70,1536.40,,,,,,,,,,,,,
GUIDEWIRE INTRMDLLRY NAIL 4MM SHAFT 60CML SMTHBLNT TIPS,SUP-2723337,CDM,C1769,HCPCS,0272,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-141224,CDM,J0583,HCPCS,0636,RC,71288-0427-10,NDC,,both,1,UN,402.50,261.62,,,,,,,,,,,,,
DRIVER SURG 120MM SLD H10,SUP-2167420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
HC So Ggtp,PX-3018297766,CDM,82977,CPT,0301,RC,,,,outpatient,,,40.00,26.00,,,,,,,,,,,,,
MESH SURG L 20 X W 15 CM GLYCOLIDE LACTIDE COPOLYMER,SUP-2931124,CDM,C1781,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
REAMER SURG SZ 2MM CROSSCHECK,SUP-2399367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
SCREW SPNL 5.5X40MM PEDCL TURRET TI,SUP-2211270,CDM,C1713,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
PROCEDURE KIT HAMRTOE 3.5 MM SAW CUT STRL NEXTRA,SUP-2137576,CDM,C1713,HCPCS,0278,RC,,,,both,,,3460.53,2249.34,,,,,,,,,,,,,
DRILL SURG 1/8 SHLDR PATELLAR S-ROM,SUP-2455984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
PLATE BNE L69.3MM 10 H ST BILAT VAR LOK NONCOMPRESSION,SUP-2349959,CDM,C1713,HCPCS,0278,RC,,,,both,,,6913.97,4494.08,,,,,,,,,,,,,
BIT DRL CANN 1.6X95 MM QC,SUP-2432236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
GENII CONST ART ISRT SZ3-4 9MM,SUP-2822791,CDM,C1776,CPT,0278,RC,,,,both,,,2442.92,1587.90,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX L 31 CM LOOP DIA12 MM,SUP-2305215,CDM,C1889,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
HC So Fungus ID Mold,PX-3008710766,CDM,87107,CPT,0300,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 95 CM OD 9 FR GUIDEWIRE 0.038 IN,SUP-2170372,CDM,C1894,HCPCS,0272,RC,,,,both,,,122.59,79.68,,,,,,,,,,,,,
CATHETER MAP 2 MM 8 FRX120 CM 31 MM 64 ELECTRD CONSTELLATION,SUP-2424694,CDM,C1732,HCPCS,0272,RC,,,,both,,,11486.12,7465.98,,,,,,,,,,,,,
HC So Jak2 Gene Trget Seq Analysis,PX-3108127966,CDM,81279,CPT,0310,RC,,,,both,,,441.00,286.65,,,,,,,,,,,,,
PLATE BNE THK1.3MM 6 H HND T SHP LOK TRILOK FOR 2MM SCR,SUP-2267936,CDM,C1713,HCPCS,0278,RC,,,,both,,,2744.36,1783.83,,,,,,,,,,,,,
SCREW SPNL L14MM OD45MM GRY TI CORT CERV VAR ANG,SUP-2286775,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.05,632.48,,,,,,,,,,,,,
HOOK SPNL 5.5MM LAM ROD DIAM NEUT BILAT OPN 9MM THRT 5MM,SUP-2415305,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SYSTEM IMPL W/ SZ 0 BLU FIBERWIRE SUT NDL LNG RETRV RUL CPR,SUP-2122323,CDM,C1776,CPT,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
KIT DRN CANN 70MM W/ OBT SHRP TRCR,SUP-2361365,CDM,C1729,HCPCS,0272,RC,,,,both,,,2983.72,1939.42,,,,,,,,,,,,,
HC Burn Dress/Debrid 5% or Less,PX-3611602000,CDM,16020,CPT,0361,RC,,,,outpatient,,,421.00,273.65,,,,,,,,,,,,,
GUIDEWIRE ORTH L 16 IN DIA2.8 MM LG TROCAR TIP STRL DISP,SUP-2934252,CDM,C1769,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 124 MM DIA 32 MM SHTH 20 FR RVD,SUP-2170128,CDM,C1874,HCPCS,0278,RC,,,,both,,,32910.34,21391.72,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTEROMEDIAL PROX TIBIA 10H 183 MM STER,SUP-2546841,CDM,C1713,HCPCS,0278,RC,,,,both,,,3954.48,2570.41,,,,,,,,,,,,,
SCREW BNE SHFT PLATE STRL NCB,SUP-2862099,CDM,C1713,HCPCS,0278,RC,,,,both,,,4269.14,2774.94,,,,,,,,,,,,,
IMPLANT PIST L4.5MM DIA0.6MM WELL DIA1MM S STL CUP FEN MATTE,SUP-2284058,CDM,L8613,CPT,0278,RC,,,,both,,,433.45,281.74,,,,,,,,,,,,,
STEM FEM FLNG LT PROX KNEE W/ LIG WSH OSS,SUP-2449905,CDM,C1776,CPT,0278,RC,,,,both,,,15613.65,10148.87,,,,,,,,,,,,,
HC Cardiac Nonmonitored Exer Sess,PX-9439379700,CDM,93797,CPT,0943,RC,,,,inpatient,,,309.00,200.85,,,,,,,,,,,,,
ENDCAP SPNL DIA20MM 5DEG SM H1.5MM TEETH THORLUM GRY TI,SUP-2390811,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BUR SURG L90MM DIA5MM DMND NONFLUTED RND LEGEND MIDAS REX,SUP-2284660,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
DEVICE SUT L7IN 0 GRN POLY SURGDAC COAT BRAID 3 STIT SGL USE,SUP-2787656,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.51,370.83,,,,,,,,,,,,,
MESH HERN XL L5XW3.8CM INGUINAL POLYPR SYN PRESHAPED LT WT,SUP-2125792,CDM,C1781,HCPCS,0278,RC,,,,both,,,565.51,367.58,,,,,,,,,,,,,
BEAM FIX 5.5X100 MM,SUP-2421803,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
SCREW SPNL L26MM DIA4MM CANC TI PARTIALLY THRD MULTIAXIAL,SUP-2286887,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
LASER SURG W/ 3 YR WARR SELECTA DUET,SUP-2713806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219800.00,142870.00,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN LNG TIP 1.5MM HYDRPHLC J,SUP-2385575,CDM,C1769,HCPCS,0272,RC,,,,both,,,140.83,91.54,,,,,,,,,,,,,
GRAFT BNE SUB 15CC PARTIC 4-9.5MM CANC FRZ DRY CHIP CHIPS15CC] US TISSUE AND CELL],SUP-2391733,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.71,819.46,,,,,,,,,,,,,
STEM FEM LG 13.5 MM LT HIP W/ BODY POROUS APR II,SUP-2449425,CDM,C1776,CPT,0278,RC,,,,both,,,10470.33,6805.71,,,,,,,,,,,,,
CATHETER BLLN DIL 15 FRX10 CM URET URETEROSCOPY EZDILATE,SUP-2457665,CDM,C1726,HCPCS,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
SHIM RETRACTOR SZ 51.5 MM SS SPIKE BLNT LCK NS DISP,SUP-2891844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CROWN DENT STRP U3 PEDIATRIC UPPER CUSPID,SUP-2337144,CDM,D6783,CPT,0278,RC,,,,both,,,37.02,24.06,,,,,,,,,,,,,
STEM ULN HD 5.5 SM PART MOD REPL 1ST CHOICE,SUP-2610437,CDM,C1776,CPT,0278,RC,,,,both,,,11663.94,7581.56,,,,,,,,,,,,,
KIT SPLNT CSTNG TCC EZ 4INW FIBERGLAS 1 PC WOVEN OP TCC24005,SUP-2194348,CDM,L4386,HCPCS,0272,RC,,,,both,,,371.96,241.77,,,,,,,,,,,,,
HC N Block Paravert Thoracic 1st|BILATERAL PROCEDURE|PO,PX-3606449000,CDM,64490,CPT,0360,RC,,,50|PO,both,,,4864.00,3161.60,,,,,,,,,,,,,
CLIP HEMOSTAS L 235 CM X W 22 MM SHTH DIA2.6 MM CHANNEL,SUP-2909405,CDM,C1889,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
CAPTURED END CAP WITH POST 1MM,SUP-2828826,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
FIBER LASER DIA550UM FLEXSHIELD COAT HOLM HI PWR POLISHED,SUP-2139421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1258.83,818.24,,,,,,,,,,,,,
SET ORTH GRPHC CA W/ PLT FOR 3.5MM DSTL MEDL TIB W/OUT TAB,SUP-2177072,CDM,C1776,CPT,0278,RC,,,,both,,,67061.61,43590.05,,,,,,,,,,,,,
CAGE SPNL L14XW14XH17MM 4 LOBE MESH NGAGE,SUP-2317738,CDM,C1889,HCPCS,0278,RC,,,,both,,,8258.20,5367.83,,,,,,,,,,,,,
COMPONENT FEM L200MM CSTI POR KNEE TOT SEG IMP MOST OPTIONS,SUP-2208269,CDM,C1776,CPT,0278,RC,,,,both,,,14299.56,9294.71,,,,,,,,,,,,,
CAGE ACET OD60MM L HIP TI PPS MOD REV PRESSFIT MAX-TI,SUP-2405124,CDM,C1776,CPT,0278,RC,,,,both,,,13326.16,8662.00,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST RIGID W/O JT,SUP-2435611,CDM,L1836,HCPCS,0272,RC,,,,both,,,377.71,245.51,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK TRICORT 800128,SUP-2743367,CDM,C1713,HCPCS,0278,RC,,,,both,,,9206.48,5984.21,,,,,,,,,,,,,
TUBE TRACH STD 10 MM CLR MONTGOMERY SAFE-T-TUBE,SUP-2138747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
ANCHOR SUT L12.5MM DIA2.9MM SH HIP BIOCOMP PEEK EYELET,SUP-2121756,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
CATHETER BI-CAVAL 2 LUMN 23FR ELITE,SUP-2124558,CDM,C1729,HCPCS,0272,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
BUR SURG DIAMOND 3 MM,SUP-2521573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SHEATH INTRO 5FR L12CM GWIRE 0.038IN ACT W/ SMOOTH TAPERS,SUP-2355637,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
CATHETER IV MIDLN 3 FR,SUP-2133383,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min,PX-4309711000,CDM,97110,CPT,0430,RC,,,,both,,,195.00,126.75,,,,,,,,,,,,,
SCREW BONE FULL THRD CANN SELF REINF PLLA 3.5MMX40MM,SUP-2166533,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
TUBE TRACH BLUE RHINO G2-MULTI TRAY W/ SHILEY FLEX 8.5,SUP-2714086,CDM,C1769,HCPCS,0272,RC,,,,both,,,2001.75,1301.14,,,,,,,,,,,,,
WASHER ORTH FLAT F/3 MM CANN SCREW NS,SUP-2464113,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.52,108.89,,,,,,,,,,,,,
VARENICLINE TARTRATE 0.5 MG PO TABS,RX-76444,CDM,6370000000,HCPCS,0637,RC,49884-0155-76,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
SCREW BNE EMGCY 1.8X5 MM SELF RET DRILL-FREE TI MAXDRIVE,SUP-2460366,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.23,128.85,,,,,,,,,,,,,
PROSTHESIS 1.65MM DIAM 2.1MM LEN INCUS DBL NOTCH HA WEHRS,SUP-2312567,CDM,L8613,CPT,0278,RC,,,,both,,,1145.47,744.56,,,,,,,,,,,,,
BLADE SAW PEDCL STRL DISP VADER,SUP-2917209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PLATE BONE L25MM BLDE L15MM THK0.9MM 3X3 H LT MAX TI L SHP,SUP-2191200,CDM,C1713,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
BRACE EXT FIX DRL ASMBLY 3-6 MM APEX,SUP-2479410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1094.29,711.29,,,,,,,,,,,,,
STENT GRFT VASC AFX2 VELA L 95 MM DIA PROX/DSTL 25 MM,SUP-2217597,CDM,C1874,HCPCS,0278,RC,,,,both,,,14224.20,9245.73,,,,,,,,,,,,,
BASEPLATE GLEN DIA25MM STD REVERSED AEQUALIS PERFORM,SUP-2388798,CDM,C1776,CPT,0278,RC,,,,both,,,5237.52,3404.39,,,,,,,,,,,,,
STENT VASC 6X140 MM 125 CM DRUG ELUT ZILVER PTX,SUP-2417689,CDM,C1876,HCPCS,0278,RC,,,,both,,,5918.90,3847.28,,,,,,,,,,,,,
BLADE RETRACTOR KELLY 2INW X 1.5IND F / UNIVERSAL RING,SUP-2467436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.84,565.40,,,,,,,,,,,,,
CATHETERIZATION KIT ART 021 22 GAX5 CM 25 GA 3 CC SAFGLDE LF,SUP-2865595,CDM,C1751,HCPCS,0278,RC,,,,both,,,135.65,88.17,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.6MM THRD L20MM TI PARTIALLY THRDED FOR,SUP-2179086,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.63,94.01,,,,,,,,,,,,,
PLATE BONE 8 H DBL Y FOR 1.7MM SCR,SUP-2365074,CDM,C1713,HCPCS,0278,RC,,,,both,,,1822.68,1184.74,,,,,,,,,,,,,
RING W COMPR DISTR UNIT ATTCH FOR LIMB RECON SYS DYNA,SUP-2316075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,793.04,515.48,,,,,,,,,,,,,
PLATE BNE H0.5MM 6X2 H UP FACE BLU TI 3D MAL LEIBINGER UNIV,SUP-2366233,CDM,C1713,HCPCS,0278,RC,,,,both,,,1290.95,839.12,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM SZ 2-0 NDL L 89 MM SS TEMP ORN,SUP-2101188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,86.10,55.96,,,,,,,,,,,,,
SCREW BNE DIA3MM PLNTR GRAV,SUP-2399115,CDM,C1713,HCPCS,0278,RC,,,,both,,,3212.22,2087.94,,,,,,,,,,,,,
SHUNT STERILE COR 375FR L16CM DIA125MM NONPROGRAM REG TAPR PK/5,SUP-2582814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.67,1034.59,,,,,,,,,,,,,
SCREW BONE L75MM DIA5MM PARTIALLY THRD FOR ARTH NAIL SYS,SUP-2417303,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.65,1347.22,,,,,,,,,,,,,
SCREW ENDPLATE MED STRL XRL,SUP-2602232,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HEPARIN NA (PORK) LOCK FLSH PF 100 UNIT/ML IV SOLN,RX-162828,CDM,J1642,HCPCS,0636,RC,64253-0333-35,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP,RX-28836,CDM,6370000000,HCPCS,0637,RC,57237-0314-03,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
SET TARGETING 11GA 3.1MM L115MM SH UNIV MR,SUP-2195614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BONE THK2MM 0DEG 20 H MAND ORAL MAXILLOFACIAL TI,SUP-2191272,CDM,C1713,HCPCS,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR,RX-6085,CDM,J2540,HCPCS,0636,RC,00049-0530-22,NDC,,both,1,UN,152.50,99.12,,,,,,,,,,,,,
IMMOBILIZER KNEE RIGID LT W/O KNEE JT CUST FABRICATED,SUP-2417693,CDM,L1834,HCPCS,0274,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
KWIRE FIX XSM SM L102MM DIA09MM FOR HAMRTOE FIX SYS,SUP-2397787,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
PLATE BNE THK1.4MM HND ARTH TRILOK 4 FUS CORNER FOR,SUP-2267955,CDM,C1713,HCPCS,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
TIP SACROCERVICOPEXY SM HOYTE DISP,SUP-2755961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.93,343.15,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.531,SUP-2860212,CDM,C1713,HCPCS,0278,RC,,,,both,,,37581.40,24427.91,,,,,,,,,,,,,
COVER BUR H DIA14MM STD UNIV CRANIOMAXILLOFACIAL TI LO PROF,SUP-2366281,CDM,C1713,HCPCS,0278,RC,,,,both,,,790.81,514.03,,,,,,,,,,,,,
CONNECTOR SPNL S STL THORLUM LO PROF PARA W FOR 5.5/5.5MM,SUP-2230978,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
WASHER ORTH DIA13.5MM SPIK PEEK FOR 3.5/4MM SCR,SUP-2184672,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
PLATE BNE CRV 1.5X50X1 MM MIDFACE ORBIT 12 HOLE TI LEVEL 1,SUP-2422378,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.30,554.64,,,,,,,,,,,,,
RETRACTOR SCR 13GA NDL L30CM DIA5MM LAPSCP KT REDDICK SAYE,SUP-2264297,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
NEEDLE SUTURE L9.5IN BLUNT LIGATURE FOR RIGHT HAND DESCHAMPS,SUP-2802483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.26,230.92,,,,,,,,,,,,,
PLATE BONE L181MM THK4MM 9 H LT LAT TIB HD BTTRS FOR,SUP-2343794,CDM,C1713,HCPCS,0278,RC,,,,both,,,6396.18,4157.52,,,,,,,,,,,,,
MATRIX BIO MED SZ 147 SQCM FISH SKIN LT DORSUM RT PALMAR,SUP-2909195,CDM,Q4158,HCPCS,0636,RC,,,,both,,,14252.46,9264.10,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X4 CM TEND REINF MTRX PURAFORCE,SUP-2716036,CDM,C1765,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
HC So Lacosamide Level,PX-3018023566,CDM,80235,CPT,0301,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM SPR COIL L17CM TIP DIA0014IN S STL COR,SUP-2140861,CDM,C1769,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
TIP ASPIR SUP LNG ULTRASONIC SONOPET,SUP-2419434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2945.89,1914.83,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5 MM 20 HOLE TITANIUM MATRIXMANDIBLE,SUP-2837749,CDM,C1713,HCPCS,0278,RC,,,,both,,,4198.18,2728.82,,,,,,,,,,,,,
RING EXT FIX DIA230MM TAY 2/3 SPAT FRME ILIZ,SUP-2342979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6061.14,3939.74,,,,,,,,,,,,,
TIP ASPIR SERRATED LG 2X2.51 MM 12 CM SONOPET IQ,SUP-2791058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3151.93,2048.75,,,,,,,,,,,,,
PLATE BONE L106MM THK3.4MM 7 H BILAT NONLOCKING COMPR FOR,SUP-2348950,CDM,C1713,HCPCS,0278,RC,,,,both,,,1489.40,968.11,,,,,,,,,,,,,
HEAD HUM 58X27 MM SHLDR COCR BIO MOD,SUP-2449916,CDM,C1776,CPT,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
SET PROC W/ 250ML BOWL 30UM FLTR RESVR BRAT 2,SUP-2352646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
FIBER LASER HOLM 10608] FORTEC MEDICAL INC],SUP-2225648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
HC So Heparin Assoc Platelet Antibo,PX-3028602266,CDM,86022,CPT,0302,RC,,,,inpatient,,,170.00,110.50,,,,,,,,,,,,,
SHUNT SURG ASCITES DBL VLV,SUP-2153662,CDM,C1729,HCPCS,0272,RC,,,,both,,,3450.86,2243.06,,,,,,,,,,,,,
PICC KIT: 4 FRX19-5/8IN 50 CM,SUP-2383962,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.67,286.44,,,,,,,,,,,,,
STAPLE BNE 26 DEG 10 MM FOR LOWER EXTREMITY NS SOLUSTAPLE,SUP-2608914,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.95,388.02,,,,,,,,,,,,,
UCL INTERNAL BRACE IMPLANT SYSTEM,SUP-2814081,CDM,C1713,HCPCS,0278,RC,,,,both,,,3702.06,2406.34,,,,,,,,,,,,,
BOLT BNE FIX L165MM DIA65MM PROX L10MM DST L24MM MIDFOOT,SUP-2400772,CDM,C1713,HCPCS,0278,RC,,,,both,,,5184.14,3369.69,,,,,,,,,,,,,
PIN EXT FIX L300MM DIA4MM TRANSFIXING FOR SIDEKCK STLTH,SUP-2400691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
IMPLANT OPHTH 125MM RETIN STRP SCLER BCKL STYL 42 SIL,SUP-2129437,CDM,C1784,HCPCS,0278,RC,,,,both,,,144.13,93.68,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS ASEP,SUP-2418650,CDM,C1762,CPT,0278,RC,,,,both,,,4204.46,2732.90,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 5FR 55CM 3 LUMAN R S9385108,SUP-2632878,CDM,C1751,HCPCS,0278,RC,,,,both,,,695.64,452.17,,,,,,,,,,,,,
AZATHIOPRINE 50 MG PO TABS,RX-9183,CDM,J7500,HCPCS,0636,RC,68084-0229-11,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
SPACER FEM SM MOD HIP STEM PMMA GENTMYCN BASE,SUP-2319838,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 10 WITH SHUNT ASSISTANT PROGAV 2.0,SUP-2821861,CDM,C1889,HCPCS,0278,RC,,,,both,,,9344.33,6073.81,,,,,,,,,,,,,
INSERT SHOE ANK JT,SUP-2388172,CDM,L2180,HCPCS,0272,RC,,,,both,,,295.98,192.39,,,,,,,,,,,,,
CUBE EXT FIX 5 H RANCHO FEMALE,SUP-2898462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
SET DCOMPR 14FR DRNGE CATH 6FR GUID CATH GWIRE L480CM,SUP-2169298,CDM,C1729,HCPCS,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
GRAFT HUM TISS L20MM FIBULAR SEG FRZ DRY ALLGRFT MATRIGRFT,SUP-2264767,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.70,941.00,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 30X30X0.8 MM POROUS POLYETHYLENE ST,SUP-2837796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.05,1248.68,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 65 CM 5 FR 0.038 IN SOS OMNI2 SFT,SUP-2882719,CDM,C1725,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
IMPLANT SYSTEM BIO-TRANSFIX,SUP-2811664,CDM,C1713,HCPCS,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 9.6 FR DETACHED SIL CATH TI,SUP-2118760,CDM,C1788,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
BIT DRL L 255 MM DIA 4.5 MM LNG COUNTERBORE NS DISP,SUP-2902200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.10,494.06,,,,,,,,,,,,,
POSITIONER 2 HRT STARFISH,SUP-2282585,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY CUST STR,SUP-2435664,CDM,L2385,HCPCS,0274,RC,,,,both,,,416.02,270.41,,,,,,,,,,,,,
BASKET SPEC RETRV HRD WIRE MEM,SUP-2759295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,756.74,491.88,,,,,,,,,,,,,
COMPONENT TIB UNI 3 12 MM RT LAT MEDL KNEE M/G,SUP-2205997,CDM,C1776,CPT,0278,RC,,,,both,,,4477.64,2910.47,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|ADJ,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|CO|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE BNE STR NAR 4.5X183 MM 11 HOLE 2 COMPR FOR SCR SS NS,SUP-2463098,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
BLADE ENDOSCP LP SHRP SCRP TIP ASMBLY BLK SMARTRELEASE ONYX,SUP-2760599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
MATRIX BONE 2ML GRFT SUB DEMIN PASTE INTERGRO +,SUP-2414013,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
Additional Level Access Instruments,SUP-2757213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SAFEWIRE 2 = 1.10X559MM,SUP-2867356,CDM,C1769,HCPCS,0272,RC,,,,both,,,969.48,630.16,,,,,,,,,,,,,
PERI-LOC 5.7MM CANN LCK SCREW 80MM,SUP-2819542,CDM,C1713,HCPCS,0278,RC,,,,both,,,2092.46,1360.10,,,,,,,,,,,,,
HC Sinuses Less Than 3 Views,PX-3207021000,CDM,70210,CPT,0320,RC,,,,both,,,433.00,281.45,,,,,,,,,,,,,
SUTURE ULTRABRAID SZ 2-0 L24IN NONABSORBABLE WHT,SUP-2349217,CDM,C1713,HCPCS,0278,RC,,,,both,,,5375.84,3494.30,,,,,,,,,,,,,
PLATE BNE GAP SM 4 HOLE NS UNIV NEURO III LTX,SUP-2862820,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.74,1036.58,,,,,,,,,,,,,
BLADE SHV OD4MM 40DEG CRV SNUS ADEN SERR CNVX WIND DIEGO,SUP-2313827,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.72,217.57,,,,,,,,,,,,,
CAP ORTH LCK 4 MM SM STAT T25 STARDRV COCR DAYTONA,SUP-2709418,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CATHETER MIDLINE PI 1-L 4FR X 20CM,SUP-2855516,CDM,C1751,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
BIT DRL L 360 MM DIA 3.5 MM LCK STRL DISP,SUP-2902137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1103.11,717.02,,,,,,,,,,,,,
BIT DRILL SURG DIA2.5 MM LNG AO QC ATTACH STRL DISP EVOS,SUP-2931401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1062.95,690.92,,,,,,,,,,,,,
CROWN DENT 5 UP RT 1ST PERM M S STL GLD PREFABRICATED REPL,SUP-2238805,CDM,D6783,CPT,0278,RC,,,,both,,,26.91,17.49,,,,,,,,,,,,,
STAPLER INT 12MM 60MM CART SHT NEW KNF BLDE W/ EVERY FIRING,SUP-2283269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,385.87,250.82,,,,,,,,,,,,,
PROSTHESIS VOICE OD16FR SIL DUCKBILL BLOM SINGER,SUP-2242309,CDM,L8509,HCPCS,0272,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
DEFIBRILLATOR CARD ATLS II HF,SUP-2357759,CDM,C1882,HCPCS,0275,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
GRAFT BONE PRO DENS 7CC,SUP-2399147,CDM,C1713,HCPCS,0278,RC,,,,both,,,6762.46,4395.60,,,,,,,,,,,,,
TROCAR SURG DIA8MM FOR 8X11MM PROTCT SL,SUP-2188183,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.71,253.96,,,,,,,,,,,,,
PLATE BONE W7XL23MM THK1MM 3 H BILAT TI 1/4 TBLR RIG,SUP-2191001,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.52,168.69,,,,,,,,,,,,,
STENT URET TAIL + L 34 CM DIA PROX/DSTL 6/3 FR PERCFLX,SUP-2141647,CDM,C1874,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SCRAPER OPHTH 23GA DMND DUSTED MEM TANO DDMS,SUP-2382593,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.53,204.44,,,,,,,,,,,,,
SCREW BNE LCK 4X10 MM CANC STRL ALPS LTX,SUP-2861778,CDM,C1713,HCPCS,0278,RC,,,,both,,,1009.07,655.90,,,,,,,,,,,,,
MESH HERN REP DIA8CM P4HB MFIL RESRB RND W/ HYDRGEL BARR,SUP-2125879,CDM,C1781,HCPCS,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
GUIDEWIRE VASC L400CM DIA0.035IN NIT INTMED STR TIP FLX,SUP-2173022,CDM,C1769,HCPCS,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
EXTRACTOR SURG FEM STEM RAM,SUP-2885049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,601.56,391.01,,,,,,,,,,,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-102315,CDM,J2003,HCPCS,0636,RC,83090-0006-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLUENCY + L 40 MM DIA 8 MM CATH L 117 CM,SUP-2128240,CDM,C1874,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
CABLE ORTH L610MM DIA1.8M GREATER TROCHANTERIC S STL SMOOTH,SUP-2410271,CDM,C1713,HCPCS,0278,RC,,,,both,,,786.57,511.27,,,,,,,,,,,,,
STEM FEM L255MM OD12MM SZ 8 TI HA L HIP REV CEM BOW REDUC,SUP-2379112,CDM,C1776,CPT,0278,RC,,,,both,,,17408.16,11315.30,,,,,,,,,,,,,
SHEATH INTRO OPTISEAL L 25 CM OD 9 FR ID 0.125 IN DIL L 13,SUP-2281853,CDM,C1892,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2.5 MM MAND 34 HOLE LCK 507603409,SUP-2539582,CDM,C1713,HCPCS,0278,RC,,,,both,,,6867.40,4463.81,,,,,,,,,,,,,
NEEDLE BX MED PLUNG CANULATED STRL CORB LF,SUP-2479377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.64,396.92,,,,,,,,,,,,,
HC Plmt Ureteral Stent Prq,PX-3615069500,CDM,50695,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
BLADE SAW CUT D20MM THK9MM SAG COR CASPR,SUP-2363667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.45,363.64,,,,,,,,,,,,,
HEAD UPLR DIA38MM 6DEG FEM HIP CO CHROM,SUP-2204170,CDM,C1776,CPT,0278,RC,,,,both,,,1489.93,968.45,,,,,,,,,,,,,
TUBE TRACH BLUE RHINO G2-MULTI TRAY W/SHILEY FLEX 7.5,SUP-2715854,CDM,C1769,HCPCS,0272,RC,,,,both,,,1362.07,885.35,,,,,,,,,,,,,
MESH SURG 20X15CM RECT PARIETEX PROGRIP,SUP-2174795,CDM,C1781,HCPCS,0278,RC,,,,both,,,923.47,600.26,,,,,,,,,,,,,
INSERT TIB SM THK26MM UNIV PLATEAU CEM PRI STEM CRUCE RET,SUP-2253231,CDM,C1713,HCPCS,0278,RC,,,,both,,,8479.26,5511.52,,,,,,,,,,,,,
CATHETERIZATION KIT DL 5 FR MAX BARR BIOFLO,SUP-2118856,CDM,C1751,HCPCS,0278,RC,,,,both,,,684.83,445.14,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR,RX-31177,CDM,340b,HCPCS,0637,RC,16714-0294-02,NDC,,both,5,ML,4.50,2.92,,,,,,,,,,,,,
MESH HERN W10XL12IN RECT FULL RESRB FOR SFT TISS RECON,SUP-2125872,CDM,C1781,HCPCS,0278,RC,,,,both,,,29924.20,19450.73,,,,,,,,,,,,,
PLATE BONE 135DEG 10 H HIP FRELOK,SUP-2197726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
GUIDEWIRE VASC STR 15 CM 0.038 INX145 CM FIX COR SS BENT,SUP-2167685,CDM,C1769,HCPCS,0272,RC,,,,both,,,44.05,28.63,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI 400XL ACTE 14FR DIA 20CM STRGHT TAPR T,SUP-2610526,CDM,C1752,HCPCS,0278,RC,,,,both,,,335.29,217.94,,,,,,,,,,,,,
DEVICE FIX BIOABSORBABLE 3 MM SFT TISS FOREHEAD ULTRATINE,SUP-2760662,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.81,561.48,,,,,,,,,,,,,
HC So Hemoglobin|NOT REASONABLE AND NECESSARY,PX-3058501866,CDM,85018,CPT,0305,RC,,,GZ,both,,,34.00,22.10,,,,,,,,,,,,,
CLAMP EXT FIX 4 H PIN JET-X,SUP-2342952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3807.25,2474.71,,,,,,,,,,,,,
ASCENSION RADFX PROX RAD FIX SYS 02 STD STEM,SUP-2244258,CDM,C1776,CPT,0278,RC,,,,both,,,10699.36,6954.58,,,,,,,,,,,,,
TUBE ET OD11.8MM ID8MM EVAC ORAL MURPHY EYE TAPERGUARD CUF,SUP-2172243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,75.71,49.21,,,,,,,,,,,,,
BURR MED 51MM RND 6 FLUTED CARB 3MM,SUP-2586354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,26.12,16.98,,,,,,,,,,,,,
BASEPLATE TIB 42X66 MM KNEE PRE COAT,SUP-2205578,CDM,C1776,CPT,0278,RC,,,,both,,,5881.19,3822.77,,,,,,,,,,,,,
GRAFT DURA 12X16 CM SUTURABLE BIO TISS BOV PERICARD DURAGN,SUP-2466261,CDM,C1763,HCPCS,0278,RC,,,,both,,,5202.20,3381.43,,,,,,,,,,,,,
KNIFE SURG SEXTON 7 IN EAR REVERSIBLE SWVL HNDL,SUP-2493157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
SCREW BNE CANN 7X110 MM 16 MM CAPTURE HIGH-TORQUE,SUP-2609029,CDM,C1713,HCPCS,0278,RC,,,,both,,,1409.29,916.04,,,,,,,,,,,,,
GRAFT HUM TISS M COVERING WND INVIVO NUCEL,SUP-2314101,CDM,C1713,HCPCS,0278,RC,,,,both,,,4733.68,3076.89,,,,,,,,,,,,,
FIBERTAK SHAVERDRILL 2.6MM,SUP-2812925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,0258,RC,00338-0117-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
CATHETER PICC 3FR L50CM AND 3.5FR L7CM GWIRE 0.018IN S STL,SUP-2168435,CDM,C1751,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
ANCHOR SUT DIA3.5MM 2 BLK WHT KNOTLESS FORC FBR COBRAIDED,SUP-2388894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
LOCK DIST TIB MED RT 12H STE,SUP-2501034,CDM,C1713,HCPCS,0278,RC,,,,both,,,4404.23,2862.75,,,,,,,,,,,,,
WASHER ORTH DIA7MM FOR CANN SCR,SUP-2184680,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.08,44.25,,,,,,,,,,,,,
SCREW INTRF L25MM DIA6MM PEEK OPTMA CANN N ABSRB ACL PCL,SUP-2341816,CDM,C1713,HCPCS,0278,RC,,,,both,,,830.84,540.05,,,,,,,,,,,,,
GRAFT BNE 40CC W/ BIOACTIVE GLS MOLD MTRX PLATFORM,SUP-2719785,CDM,C1713,HCPCS,0278,RC,,,,both,,,39187.20,25471.68,,,,,,,,,,,,,
LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN,RX-112651,CDM,J1953,HCPCS,0636,RC,67457-0255-10,NDC,,both,100,ML,80.50,52.32,,,,,,,,,,,,,
SPHINCTEROTOME BILI OR PANCREAS SEAL CAP PRECUT DISP STR,SUP-2313218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,319.15,207.45,,,,,,,,,,,,,
KIT REP S STL SYNDESMOSIS TIGHTROPE +,SUP-2122822,CDM,C1713,HCPCS,0278,RC,,,,both,,,2223.12,1445.03,,,,,,,,,,,,,
MESH BIO PORCINE MTRX HERN 4 LAYR ADV TISS ABD 3CM LEN 2CM,SUP-2168862,CDM,C1763,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
RAIL EXT FIX RT WALKER,SUP-2898530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
SCREW BNE HIP S STL LO PROF CBL ACCORD,SUP-2345211,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.03,242.47,,,,,,,,,,,,,
STAPLE BNE FIX 20X7MM BRDG 3 20MM LEG Y SHP IMPL,SUP-2194189,CDM,C1713,HCPCS,0278,RC,,,,both,,,5091.67,3309.59,,,,,,,,,,,,,
OVERTUBE ENDOSCP FOR OVERSTITCH SYS OVRTB,SUP-2119260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,727.44,472.84,,,,,,,,,,,,,
SUPPORT WRST PUL LACE CLOSURE UNIV RT PROCARE QUICK-FIT,SUP-2195779,CDM,L3931,HCPCS,0272,RC,,,,both,,,35.11,22.82,,,,,,,,,,,,,
ROD EXT FIX XSM L45MM DIA3MM C FBR COMP STR NONRADIOPAQUE,SUP-2188689,CDM,C1713,HCPCS,0278,RC,,,,both,,,118.41,76.97,,,,,,,,,,,,,
SCREW SPNL L35MM OD5MM TI CORT PEDCL NONCANNULATED TOP LD,SUP-2288104,CDM,C1713,HCPCS,0278,RC,,,,both,,,4377.47,2845.36,,,,,,,,,,,,,
STEM FEM L150MM OD12.5MM BOW TI POR IM REV NEUT MOD LNG,SUP-2405742,CDM,C1776,CPT,0278,RC,,,,both,,,5298.75,3444.19,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 5 FRX12 CM 6 FR POLARIS ULTRA,SUP-2522248,CDM,C2617,HCPCS,0278,RC,,,,both,,,470.59,305.88,,,,,,,,,,,,,
SEALANT TISS 10 ML FIBRIN VISTASEAL,SUP-2423173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1571.92,1021.75,,,,,,,,,,,,,
ANCHOR SUT GLOK XL,SUP-2589313,CDM,C1713,HCPCS,0278,RC,,,,both,,,666.72,433.37,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.5 MM THOR 10 HOLE LCK BODY NS LEVEL 1,SUP-2869267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1828.05,1188.23,,,,,,,,,,,,,
DEFIBRILLATOR CRD 40 J 2 CHMBR SJ4 CONN UNIFY DR,SUP-2356313,CDM,C1882,HCPCS,0275,RC,,,,both,,,47145.03,30644.27,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 60 CM DIA 6 MM SUPP L 60 CM EPTFE,SUP-2227648,CDM,C1768,CPT,0278,RC,,,,both,,,2228.93,1448.80,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 50 CM DIA 8 MM EPTFE STR STD WALL REINF,SUP-2474614,CDM,C1768,CPT,0278,RC,,,,both,,,3298.51,2144.03,,,,,,,,,,,,,
CATHETER ART L16CM DIA18GA 0.025IN FEM SFTY SET W/ SHRP,SUP-2383350,CDM,C1894,HCPCS,0272,RC,,,,both,,,168.62,109.60,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305761,CDM,V2790,HCPCS,0278,RC,,,,both,,,7824.88,5086.17,,,,,,,,,,,,,
HC So Immunoglobulin Light Chains Free Each,PX-3018352166,CDM,83521,CPT,0301,RC,,,,both,,,59.00,38.35,,,,,,,,,,,,,
PROBE SPNL L PEDCL STR NRV STIM DISP,SUP-2310402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX0.8 CM BLLN BUTTON SIL MINI 1,SUP-2754571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.94,442.61,,,,,,,,,,,,,
PLATE BONE H2.8MM 11 H MAND TI STR SEC RECON LEIBINGER,SUP-2363748,CDM,C1713,HCPCS,0278,RC,,,,both,,,2575.80,1674.27,,,,,,,,,,,,,
PROBE SPNL 90DEG BALL TIP LNG MTRX,SUP-2292921,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 12 CM PRIMARY DIA,SUP-2323356,CDM,C1889,HCPCS,0278,RC,,,,both,,,6559.46,4263.65,,,,,,,,,,,,,
KIT BLLN DIL CATH 5.8FR L75CM BLLN 18FR L6CM GWIRE 0.038IN,SUP-2139203,CDM,C1726,HCPCS,0272,RC,,,,both,,,859.07,558.40,,,,,,,,,,,,,
SPHINCTEROTOME 44 20MM TRUETOME,SUP-2141622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.30,325.84,,,,,,,,,,,,,
PLATE BONE STRL T SHP VAR LCK FOR 2.7MM SCR VLP FT PERC,SUP-2349924,CDM,C1713,HCPCS,0278,RC,,,,both,,,3578.82,2326.23,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.7MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2188948,CDM,C1713,HCPCS,0278,RC,,,,both,,,240.21,156.14,,,,,,,,,,,,,
PLATE BNE THK 2 MM SCREW DIA2/2.3 MM LG GRD IV TI MANDIBULAR,SUP-2935785,CDM,C1713,HCPCS,0278,RC,,,,both,,,4713.14,3063.54,,,,,,,,,,,,,
SHUTTLE SUT 45DEG LT W/ CHIA IDEAL,SUP-2256802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
BLADE SURG SERR DIM 4MM ANG 60DEG,SUP-2363533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.20,294.58,,,,,,,,,,,,,
PLATE SPNL L66MM LEV 3 ANTR BILAT CERV TI LCK LO PROF,SUP-2254595,CDM,C1713,HCPCS,0278,RC,,,,both,,,3984.66,2590.03,,,,,,,,,,,,,
CAPTOPRIL 25 MG PO TABS,RX-9402,CDM,6370000000,HCPCS,0637,RC,27241-0161-01,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
SCREW BNE L13MM DIA2.5MM CO CHROM MULTDIR LOK THRD PEGGED,SUP-2421379,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.63,341.01,,,,,,,,,,,,,
PLATE BNE W7.5XL61MM THK1.6MM 5X5 H R DST VOLAR RAD TI RIG,SUP-2191022,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.83,1737.34,,,,,,,,,,,,,
HEAD HUM DIA40MM THK12MM SHLDR CO CHROM PRI STD OFFSET NK,SUP-2372831,CDM,C1776,CPT,0278,RC,,,,both,,,5609.61,3646.25,,,,,,,,,,,,,
PLATE BNE 2/2.4X49X1.7 MM 6 HOLE SS LC-DCP,SUP-2569205,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.14,188.59,,,,,,,,,,,,,
RESVR PROS TI 75ML LCK OUT VLV,SUP-2165355,CDM,C1813,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X286 MM 16 HOLE TI NS LC-DCP,SUP-2568783,CDM,C1713,HCPCS,0278,RC,,,,both,,,3078.64,2001.12,,,,,,,,,,,,,
SCREW BNE L58MM DIA6MM CANC FOR TIB FIX WASHERLOC,SUP-2212923,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
CATHETER THROMCTMY SOLITAIRE X L 40 MM DIA 4 MM PUSH SPC 10,SUP-2434107,CDM,C1757,HCPCS,0272,RC,,,,both,,,21125.92,13731.85,,,,,,,,,,,,,
POST TAPR L32MM DIA12MM FOR OVO ONLY HEMICAP,SUP-2123536,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BASEPLATE TIB MOD LT REV STEM CEM NP SZ 3 FOUNDATION,SUP-2215784,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
NAIL IM SUPCNDYL 10 MMX15 CM NS AIM LTX DISP,SUP-2861167,CDM,C1713,HCPCS,0278,RC,,,,both,,,4560.22,2964.14,,,,,,,,,,,,,
COMPONENT ACET TRIFLANGED LT HIP,SUP-2137602,CDM,C1776,CPT,0278,RC,,,,both,,,5469.88,3555.42,,,,,,,,,,,,,
COMPONENT FEM SZ 7 STD LT KNEE CO CHROM CEM CRUC RET COR SET,SUP-2206280,CDM,C1776,CPT,0278,RC,,,,both,,,21543.32,14003.16,,,,,,,,,,,,,
STOP DRL 2 MM PENNIG DYN WRST FIX,SUP-2644603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,92.69,60.25,,,,,,,,,,,,,
SCREW BNE L85MM DIA6.5MM THRD L32MM HD DIA8MM CANC S STL ST,SUP-2184612,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.98,74.09,,,,,,,,,,,,,
LORAZEPAM 2 MG/ML PO CONC,RX-4571,CDM,340b,HCPCS,0637,RC,09999-9905-54,NDC,,both,0.25,ML,2.70,1.75,,,,,,,,,,,,,
CATHETER HD STR 14.5 FRX24 CM 19 CM STD LT KT STYL GLIDEPATH - ORDER UOM CA,SUP-2126473,CDM,C1750,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
PHENYLEPHRINE-MINERAL OIL-PET 0.25-14-74.9 % RE OINT,RX-124243,CDM,6370000000,HCPCS,0637,RC,45802-0188-16,NDC,,both,57,GR,11.80,7.67,,,,,,,,,,,,,
GRAFT HUM TISS W3XL7CM THK0.2-0.4MM ULTRATHIN FLEXHD,SUP-2307506,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1603.25,1042.11,,,,,,,,,,,,,
"HC Albumin Other Source, Quan Ea",PX-3078204200,CDM,82042,CPT,0307,RC,,,,both,,,154.00,100.10,,,,,,,,,,,,,
COMPONENT FEM STBL 13 RT KNEE,SUP-2365176,CDM,C1776,CPT,0278,RC,,,,both,,,6136.56,3988.76,,,,,,,,,,,,,
ANCHOR SUT SZ 2-0 ULTRABRAID BLU COBRAID SUT PRELD,SUP-2341136,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
INTRODUCER GWIRE FIX COR DSGN W/ J TIP STD STR GUIDERIGHT,SUP-2355265,CDM,C1769,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
TREPHINE BONE BX ORTH DISECT SZ 11 MM SHRP STR,SUP-2136787,CDM,C1776,CPT,0278,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
PLATE BNE UNIV 5TH METATARSAL HK,SUP-2123143,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC MED CANNULATED F/SMALL JOINT,SUP-2586646,CDM,C1769,HCPCS,0272,RC,,,,both,,,6800.83,4420.54,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTMA L 47 CM DIA14 MM SZ 0.018 IN PLAT,SUP-2753934,CDM,C1889,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
PROCHLORPERAZINE MALEATE 5 MG PO TABS,RX-6583,CDM,Q0164,HCPCS,0637,RC,00904-7381-06,NDC,,both,1,UN,5.80,3.77,,,,,,,,,,,,,
PLATE BNE L161MM THK38MM 8 H R MED DST TIB S STL NEUT,SUP-2185218,CDM,C1713,HCPCS,0278,RC,,,,both,,,3645.16,2369.35,,,,,,,,,,,,,
HC MR Safety Implant Elec Prepj,PX-6107601800,CDM,76018,CPT,0610,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM PEEK OPTMA LINK SELF PUNCHING KNOTLESS,SUP-2416349,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.43,1010.38,,,,,,,,,,,,,
NAIL IM L30CM DIA1.5MM S STL TAPR TIP ELAS PEDIFLEX,SUP-2318623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1804.43,1172.88,,,,,,,,,,,,,
SCREW SPNL L45MM DIA7MM PEDCL TI POLYAX MNRCH,SUP-2254497,CDM,C1713,HCPCS,0278,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
PLATE BONE 14 H ANTR BOW LAT PROX FOR 3.5 SCR,SUP-2349062,CDM,C1713,HCPCS,0278,RC,,,,both,,,1035.48,673.06,,,,,,,,,,,,,
PLATE BNE L16MM BLU 8 FOR GUID GROWTH SYS,SUP-2316392,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.71,564.01,,,,,,,,,,,,,
BIT DRL SLD 2.5X110 MM FOR UNIV 2 WRST IMPL SYS STRL,SUP-2610344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.50,446.87,,,,,,,,,,,,,
CLAMP PAT-DUCTUS STR AG GLOVER,SUP-2383758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.83,307.99,,,,,,,,,,,,,
STEM FEM SZ 3 L115MM NK L34MM 40MM OFFSET 132DEG HIP FORGED,SUP-2375350,CDM,C1776,CPT,0278,RC,,,,both,,,5775.72,3754.22,,,,,,,,,,,,,
MICRO PLATE STRAIGHT 4 HOLE LNG CP TITANIUM,SUP-2677540,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.03,169.67,,,,,,,,,,,,,
GRAFT BIO TISS W6XL8CM THK08 17MM ACELLULAR DERM MTRX THCK,SUP-2307474,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4332.98,2816.44,,,,,,,,,,,,,
DRILL SURG TIB ATTUNE,SUP-2454814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
RING EXT FIX 2/3 150 MM CARBON DFS DYNAFIX,SUP-2466706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE STR WTAB 1.5 MM SCRW4 HOLE T0.6 MM,SUP-2707486,CDM,C1713,HCPCS,0278,RC,,,,both,,,472.88,307.37,,,,,,,,,,,,,
GRAFT VASC STD WALL 4-7 MMX45 CM STR SHT TAPR ADVANTA VXT,SUP-2471230,CDM,C1768,CPT,0278,RC,,,,both,,,2009.57,1306.22,,,,,,,,,,,,,
PLATE BNE HK 2 HOLE,SUP-2518428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3855.92,2506.35,,,,,,,,,,,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,0636,RC,63323-0286-63,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED KNEECAP] ZIMMER BIOMET INC],SUP-2212604,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
PLATE BNE LCK UNIV 131 MM TROCHANTERIC STBL COMPR SS NS DHHS,SUP-2863370,CDM,C1713,HCPCS,0278,RC,,,,both,,,2549.96,1657.47,,,,,,,,,,,,,
KIT INTRO ONESTIC DIA 6 FR PERC MIC ACCS STRL,SUP-2876563,CDM,C1894,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
BIT DRL DIA2.4 MM PIN DIA 3 MM STP NS DISP MAV MINI,SUP-2933866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1131.97,735.78,,,,,,,,,,,,,
DRILL SURG 2 MM OSTEOPOWER,SUP-2856483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 30 CM PRIMARY DIA,SUP-2323366,CDM,C1889,HCPCS,0278,RC,,,,both,,,7077.56,4600.41,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. L 20 MM DIA10 MM CATH L 120 CM NIT,SUP-2158890,CDM,C1876,HCPCS,0278,RC,,,,both,,,3231.06,2100.19,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 4X50 MM CORTICAL HUMERAL TITANIUM NON,SUP-2837140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
KIT CATHETER 6FR POLYUR PORTAL SGL LUMN PORT A CATHETER,SUP-2351857,CDM,C1788,HCPCS,0278,RC,,,,both,,,1310.23,851.65,,,,,,,,,,,,,
SCREW IM NAIL L 120 MM DIA10.5 MM HIP LAG STRL GAMMA4,SUP-2900568,CDM,C1713,HCPCS,0278,RC,,,,both,,,2124.87,1381.17,,,,,,,,,,,,,
BRACE ORTH JEWETT,SUP-2138672,CDM,L0472,HCPCS,0274,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
MONITOR CARD IMPL 12CC 448X72X4MM REVEAL LINQ,SUP-2281137,CDM,C1764,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
CROWN DENT UR4 1ST PRI M INDIV SPACE MAINTAINER,SUP-2176668,CDM,D6783,CPT,0278,RC,,,,both,,,24.18,15.72,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 65CM 8FR COAT L 35CM XCUT,SUP-2385458,CDM,C1894,HCPCS,0272,RC,,,,both,,,386.09,250.96,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 6 FR 13MM/7FR 0.035IN,SUP-2214022,CDM,C1757,HCPCS,0272,RC,,,,both,,,381.26,247.82,,,,,,,,,,,,,
CUP HUM DIA36MM +6MM OFFSET SHLDR POLYETH REV LAT DELT CTA,SUP-2252976,CDM,C1776,CPT,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
PLATE SPNL L13MM THK1.75-2.3MM BILAT ANT CERV 1 LEV,SUP-2255543,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
I/B II KNEE TIBIAL WEDGESIZE 59 20 DEG 22MM,SUP-2502057,CDM,C1776,CPT,0278,RC,,,,both,,,7096.40,4612.66,,,,,,,,,,,,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,2500000003,HCPCS,0250,RC,00409-8183-01,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
ARTHROTOME SURG 13 MM ANK AQ/AC,SUP-2897730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
BIT DRL 10 GA STR HND COMPATIBLE OSSEOFLEX,SUP-2464598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE 4.5MM TI LCP T 6 HOLES 115MM,SUP-2549653,CDM,C1713,HCPCS,0278,RC,,,,both,,,2051.27,1333.33,,,,,,,,,,,,,
KIT INTRO ARW THMS L 4 IN DIA 8.5 FR 0.035 IN INTEGR VLV,SUP-2383283,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.90,59.08,,,,,,,,,,,,,
JOINT EXT FIX BALL NS DISP,SUP-2885054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1552.42,1009.07,,,,,,,,,,,,,
CLIP MED SUTURE LESS 40 MM SYS 1 HND STRL ATRICLIP FLX V,SUP-2424443,CDM,C1889,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP IGUANA REG 20 MM 450 CM BILI,SUP-2125960,CDM,C1769,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
BASEPLATE GLEN UNIV TI SHLDR PRESSFIT PROMOS +,SUP-2351199,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X17.5 MM WRST TI STRL FRDM,SUP-2851945,CDM,C1713,HCPCS,0278,RC,,,,both,,,947.21,615.69,,,,,,,,,,,,,
CANNULA DEL 15GA DRL L60MM KNEE END DEL FOR ARTHRO ACCUPORT,SUP-2402765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
TUBE VENT 1.14 MM 1.17 MM 2.54 MM PHOSPHORYLCHOLINE COAT SIL,SUP-2535105,CDM,L8699,HCPCS,0278,RC,,,,both,,,63.68,41.39,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 3 MM 10 CM BALL MIDAS REX 8 LEGEND,SUP-2664481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.36,253.73,,,,,,,,,,,,,
BIT DRL L125MM DIA2MM S STL QUIK CPL FOR LOK COMPR PLT,SUP-2187216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.76,252.04,,,,,,,,,,,,,
DISTRACTION INTRNL PLATE MICRO TRACK TRACK PLUS ALVLR STBLZR,SUP-2694328,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.03,603.87,,,,,,,,,,,,,
HC Dysphagia/Swallowing Study,PX-3207423000,CDM,74230,CPT,0320,RC,,,,both,,,857.00,557.05,,,,,,,,,,,,,
CATHETER HAD L32CM DIA15.5FR BASIC LNG TERM POLYUR STR,SUP-2267097,CDM,C1881,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
STENT CORONARY XIENCE PRIM LL L 28 MM DIA2.5 MM SYS L 143 CM,SUP-2104686,CDM,C1874,HCPCS,0278,RC,,,,both,,,4537.30,2949.24,,,,,,,,,,,,,
PLUG VASC AMPLATZER UNCONSTRAINED L 7 MM DIA10 MM DEL SYS L,SUP-2116330,CDM,C1889,HCPCS,0278,RC,,,,both,,,2285.92,1485.85,,,,,,,,,,,,,
BOOT CAST L W525XL125IN M SHOE SZ 12 155 CANVS THCK ROCK,SUP-2276729,CDM,L4387,HCPCS,0272,RC,,,,both,,,18.40,11.96,,,,,,,,,,,,,
BRACE ANK H85IN SM AD BILAT STRP CLSR OPN HEEL TOE RIG W,SUP-2195185,CDM,L4350,HCPCS,0274,RC,,,,both,,,71.72,46.62,,,,,,,,,,,,,
KIT ARTHSCP DEL APPL TIP,SUP-2402579,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,0636,RC,00409-1176-30,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE 2/PK L 10 MM DIA2.2 MM PLA GLYCOLIDE,SUP-2884154,CDM,C1713,HCPCS,0278,RC,,,,both,,,980.87,637.57,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CMNTLS TRIATHLON,SUP-2365949,CDM,C1776,CPT,0278,RC,,,,both,,,17188.36,11172.43,,,,,,,,,,,,,
SPLINT FNGR OVL 8 11,SUP-2100002,CDM,L3933,HCPCS,0274,RC,,,,both,,,28.51,18.53,,,,,,,,,,,,,
CATHETER DRAINAGE FIX LUER 4 FRX12 CM 4 SH 1 STP,SUP-2303158,CDM,C1729,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
HC Iaadiadoo Influenza,PX-3068780400,CDM,87804,CPT,0306,RC,,,,inpatient,,,225.00,146.25,,,,,,,,,,,,,
BIT DRL QC 2X140 MM 60 MM CALIB NS,SUP-2563747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.69,285.80,,,,,,,,,,,,,
BIT DRL L125MM DIA1.5MM 2 FLUT FOR J LATCH CPL,SUP-2179221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,740.73,481.47,,,,,,,,,,,,,
OSTEOTOME ACET 40MM,SUP-2364385,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1975.69,1284.20,,,,,,,,,,,,,
SPLINT ORTH COTATION HUM ARM,SUP-2388194,CDM,L3980,HCPCS,0274,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC FIBER PLIAFX PRIM,SUP-2740838,CDM,C1713,HCPCS,0278,RC,,,,both,,,2123.46,1380.25,,,,,,,,,,,,,
MESH CRAN L 12 X W 9 IN THK 0.6 MM SCREW DIA1.5 MM TI,SUP-2936844,CDM,C1713,HCPCS,0278,RC,,,,both,,,9250.44,6012.79,,,,,,,,,,,,,
MATRIX HUM TISS L 8 X W 8 CM DECELL PLCNTA MEMBRN,SUP-2909261,CDM,Q4201,HCPCS,0636,RC,,,,both,,,24287.90,15787.13,,,,,,,,,,,,,
CATH 5F 4POLE 5 5 5 SPAE F CURVE,SUP-2471478,CDM,C1730,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
GRAFT HUM TISS THN 4X4 CM AMNIO TISS MEMBRN ACTISHIELD CF,SUP-2422261,CDM,C1762,CPT,0278,RC,,,,both,,,6292.56,4090.16,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK08 17MM DERM HUM ACELLULAR,SUP-2307046,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5036.40,3273.66,,,,,,,,,,,,,
STAPLER INT CRV TIP 30 MM 2 MM GRY STRL SIGNIA TRI-STAPLE,SUP-2787704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.23,540.95,,,,,,,,,,,,,
JOINT KNEE GLIDING SURFACE VEGA PS ALL POLY T0/0+ 14MM,SUP-2841690,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BIT DRL DIA2.5MM CALIB DISP FOR 3.5MM LOK PROX FEM SCR,SUP-2318879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 10 CC DEMINERALIZED CORTICAL FIBER HSA,SUP-2881923,CDM,C1713,HCPCS,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
FIBER LSR 365UM HOLM,SUP-2225590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BNE ORBIT FLR LG 0.4 MM LT SMRT GRV 3D TI NS LEVEL 1,SUP-2462546,CDM,C1713,HCPCS,0278,RC,,,,both,,,3597.09,2338.11,,,,,,,,,,,,,
PLATE BNE RECON 2.7X40 MM 5 HOLE SS,SUP-2569077,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.04,230.13,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X33 MM 4 HOLE 1/4 SS,SUP-2536103,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
PLATE BNE NONBIOABSORBABLE NS,SUP-2635378,CDM,C1713,HCPCS,0278,RC,,,,both,,,3600.32,2340.21,,,,,,,,,,,,,
KIT INSTRUMENT SPINAL SPINEJACK 5.8MM PREPARATION,SUP-2876927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4358.73,2833.17,,,,,,,,,,,,,
"HC New Pt, E/M Level 3",PX-5109920300,CDM,99203,CPT,0510,RC,,,,outpatient,,,321.00,208.65,,,,,,,,,,,,,
BONE GRAFTING KIT CELLULAR BNE MTRX,SUP-2741916,CDM,C1713,HCPCS,0278,RC,,,,both,,,4869.17,3164.96,,,,,,,,,,,,,
ADAPTER STEM 2MM OFFSET FEM FOR KNEE SYS REV ATTUNE,SUP-2251479,CDM,C1776,CPT,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
PLATE BNE L104MM 4 H BILAT TI LOK COMPR RIG BTTRS THN BLDE,SUP-2190982,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.14,819.09,,,,,,,,,,,,,
PLATE BONE CRANIAL LONG 6 HOLE GAP 48.8X16.2X0.4MM TITANIUM,SUP-2826278,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.94,408.81,,,,,,,,,,,,,
INSERT ACET SZ P2 OD46-48MM ID28MM THK5MM 10DEG X FRE CO,SUP-2376204,CDM,C1776,CPT,0278,RC,,,,both,,,1166.98,758.54,,,,,,,,,,,,,
COMPONENT TIB G KNEE PERSONA,SUP-2207896,CDM,C1776,CPT,0278,RC,,,,both,,,5887.53,3826.89,,,,,,,,,,,,,
SYRINGE (DISPOSABLE) 3 ML MISC,RX-11479,CDM,2500000003,HCPCS,0250,RC,08290-3096-57,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
ROD EXT FIX L 400 MM THRD P45-310-0400,SUP-2900178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.58,252.58,,,,,,,,,,,,,
COMPONENT TOT HIP PRIMARY CERM ALTRX,SUP-2249586,CDM,C1776,CPT,0278,RC,,,,both,,,16799.00,10919.35,,,,,,,,,,,,,
PLATE LCK 2.4/2.7MM 2H STRL,SUP-2547593,CDM,C1713,HCPCS,0278,RC,,,,both,,,1269.82,825.38,,,,,,,,,,,,,
WAVE CALCANEAL FRACTURE PLATE GUIDE PIN MODEL 1.6X130MM,SUP-2830336,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
MICRO PLATE STRAIGHT 2 HOLE LNG RIGID BLUE TI 6AL 4V,SUP-2680997,CDM,C1713,HCPCS,0278,RC,,,,both,,,186.77,121.40,,,,,,,,,,,,,
CATHETER URET 3FR L70CM 0.018IN PVC OPN END FOR DRNGE RG,SUP-2171250,CDM,C1758,HCPCS,0278,RC,,,,both,,,42.86,27.86,,,,,,,,,,,,,
HC Hcg Quantitative,PX-3018470200,CDM,84702,CPT,0301,RC,,,,both,,,393.00,255.45,,,,,,,,,,,,,
CATHETER NEPHSTMY L30CM OD16FR ODSEC6FR 2 FLX STYL CONN TB,SUP-2139310,CDM,C1729,HCPCS,0272,RC,,,,both,,,208.03,135.22,,,,,,,,,,,,,
SPACER SPNL 22-34MM COR DIA12MM FOR MINI SELF EXP VBR SYS,SUP-2310548,CDM,C1821,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
PLATE CRAN L 48 X W 45 MM THK 0.3 MM SCREW DIA1.5 MM MED TI,SUP-2936500,CDM,C1713,HCPCS,0278,RC,,,,both,,,2414.66,1569.53,,,,,,,,,,,,,
TROCAR SURG L75MM OD5MM BLDELSS XCEL,SUP-2218268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.35,412.98,,,,,,,,,,,,,
ANCHOR SUT OD2.8MM TI PRELD TWO SZ 2-0 DURABRAID NDL TWINFIX,SUP-2341047,CDM,C1713,HCPCS,0278,RC,,,,both,,,1022.07,664.35,,,,,,,,,,,,,
BUTTON NSL SEPT DIA3CM SIL FOR OUTPT PROC,SUP-2277734,CDM,C1889,HCPCS,0278,RC,,,,both,,,687.82,447.08,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X270 MM 15 HOLE SS LCP,SUP-2569376,CDM,C1713,HCPCS,0278,RC,,,,both,,,958.49,623.02,,,,,,,,,,,,,
SCREW BNE PED L12MM DIA3.5MM L R CORT PROX FEM TIB S STL ST,SUP-2318504,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.49,134.87,,,,,,,,,,,,,
COMPONENT PATELLAR 3 PEG XS KNEE ONSET UKNEE,SUP-2391488,CDM,C1776,CPT,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
GRAFT BNE SUB 20CC W25XH8XL100MM FOAM STRP COMPR RESIST FLX,SUP-2361881,CDM,C1713,HCPCS,0278,RC,,,,both,,,15729.52,10224.19,,,,,,,,,,,,,
KIT PICC 5FR L50CM POLYUR DBL LUMN PRSS INJ BLU FLEXTIP T,SUP-2383371,CDM,C1751,HCPCS,0278,RC,,,,both,,,413.66,268.88,,,,,,,,,,,,,
SCREW SPNL L35MM OD8MM TI CANC ANT THORLUM PEDCL ST FIX ANG,SUP-2292733,CDM,C1713,HCPCS,0278,RC,,,,both,,,5856.10,3806.46,,,,,,,,,,,,,
PLATE BNE BAR 14 MM 6 H SHRT CRANIOMAXILLOFACIAL SAG SPLIT,SUP-2883182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.98,885.29,,,,,,,,,,,,,
GUIDEWIRE ORTH L350MM DIA3.2MM ACC DISP,SUP-2152525,CDM,C1769,HCPCS,0272,RC,,,,both,,,95.46,62.05,,,,,,,,,,,,,
DEVICE PAIN CTRL 100ML 2ML/HR W/ 2.5IN FIX HUB CONDUCTION,SUP-2196473,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN PTFE J FIX CRV,SUP-2147062,CDM,C1769,HCPCS,0272,RC,,,,both,,,56.96,37.02,,,,,,,,,,,,,
MATRIX BIO L 7 X W 5 CM FISH SKIN DERMAL INTACT OMEGA3,SUP-2909268,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
CATHETER PICCS SGL LUMN W/ CLMP IR KT W/ WIRE 130CM 4FR,SUP-2118953,CDM,C1751,HCPCS,0278,RC,,,,both,,,192.45,125.09,,,,,,,,,,,,,
LIOU CLEFT TRNSPRT DSTRCTR RGHT 15MM 06MM PLTS T 6L 4V,SUP-2669829,CDM,C1713,HCPCS,0278,RC,,,,both,,,10839.50,7045.67,,,,,,,,,,,,,
PIN ABSRB ST 2.0X30.0MM,SUP-2412906,CDM,C1776,CPT,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
SEGMENTAL PROXIMAL TIBIA SIZE 3,SUP-2502380,CDM,C1776,CPT,0278,RC,,,,both,,,22918.86,14897.26,,,,,,,,,,,,,
PLATE BONE W24XL51MM 12 HOLE RIGHT DST VOLAR RDL WRIST STNDR,SUP-2481672,CDM,C1713,HCPCS,0278,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
SCREW BONE L17MM OD2.0MM CRANIO MAXILLOFACIAL HD TI MINI,SUP-2262656,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.68,71.29,,,,,,,,,,,,,
ALLOGRAFT BNE MATCHSTICK LG FD IRRADIATED CORTICAL CANC,SUP-2867197,CDM,C1762,CPT,0278,RC,,,,both,,,481.27,312.83,,,,,,,,,,,,,
ANCHOR SUTURE 1 2.8 MM W/ 2 ULTRABRAID TI TWINFIX,SUP-2848914,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.38,498.80,,,,,,,,,,,,,
SCREW HI LO F/HEADBOARD ASMBLY ADVANTA,SUP-2239291,CDM,C1713,HCPCS,0278,RC,,,,both,,,1.44,0.94,,,,,,,,,,,,,
GRAFT BNE SUB W25XH4XL240MM THK4MM 24ML B TRICALCIUM PHSPTE,SUP-2368174,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
HC Hepatitis B Surf Antibody Hbsab,PX-3028670600,CDM,86706,CPT,0302,RC,,,,both,,,551.00,358.15,,,,,,,,,,,,,
SUPPORT HD SECT FOR SPNL SURG JACK,SUP-2257072,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
SCREW EXT FIX L12MM FOR DISTRCTN,SUP-2359061,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
SCREW BONE 4X40MM ANKLE CANNULATED ARSENAL,SUP-2878141,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
GRAFT 10MM TEND ACHILLES ALLGRFT W/ BONE PRE SHP MACHINED,SUP-2165609,CDM,C1713,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
ALTIUS CROSS CONN 20MM,SUP-2414612,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
IMPLANT BIO L 6 X W 4 CM OMEGA 3 21 PRE-MESHED FISH STRL,SUP-2909171,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4885.84,3175.80,,,,,,,,,,,,,
"HC Debridement, Skin, Sub-Q Tissue,Each Add 20 Sq Cm|PBB CHARGE",PX-4501104500,CDM,11045,CPT,0450,RC,,,PBB,both,,,207.00,134.55,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L20MM SYR 11GA 1ST FRAC RADPQ,SUP-2293654,CDM,C1894,HCPCS,0272,RC,,,,both,,,9900.42,6435.27,,,,,,,,,,,,,
PLATE BNE L109MM 4 H ST L MED DST TIB S STL LO BEND LOK,SUP-2177444,CDM,C1713,HCPCS,0278,RC,,,,both,,,4065.48,2642.56,,,,,,,,,,,,,
PROTECTOR NERVE L 6 X W 3 CM PORCINE SODIUM HYALURONATE,SUP-2890394,CDM,C1763,HCPCS,0278,RC,,,,both,,,11731.04,7625.18,,,,,,,,,,,,,
PORT IMPL INFUSION STR 26X70 MM SS,SUP-2232157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
PLATE CONDYLAR VA LCP TITANIUM CRVD  18HL RT 370MM,SUP-2653991,CDM,C1713,HCPCS,0278,RC,,,,both,,,6863.38,4461.20,,,,,,,,,,,,,
PLATE BONE 1.5MM 8 H STR UNIV NEURO III,SUP-2363642,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.16,369.95,,,,,,,,,,,,,
K WIRE FIXATION L400MM STAINLESS STEEL OLIVE,SUP-2586484,CDM,C1713,HCPCS,0278,RC,,,,both,,,821.52,533.99,,,,,,,,,,,,,
GUIDEWIRE VASC L 30 CM DIA 0.015 IN CRV RAD 2 MM SS SAFE-T-J,SUP-2760092,CDM,C1769,HCPCS,0272,RC,,,,both,,,92.50,60.12,,,,,,,,,,,,,
HC Clsd Tx IP Disloc WO Anes,PX-4502866000,CDM,28660,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
ANCHOR SFT TISS L 10 MM DIA 5 MM CITREGEN BIOMIMETIC RESRB,SUP-2902209,CDM,C1713,HCPCS,0278,RC,,,,both,,,2565.38,1667.50,,,,,,,,,,,,,
DEVICE TORQUE GLIDEWIRE DIA 0.010-0.038 IN ACCOMODATE WIRE,SUP-2385710,CDM,C1769,HCPCS,0272,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
KIT STPL FIX BRDG L9MM LEG L12/10MM WIRE 1.3X1.5MM IDEAL,SUP-2194250,CDM,C1713,HCPCS,0278,RC,,,,both,,,2641.31,1716.85,,,,,,,,,,,,,
SPLINT FLX HND ADL NVY TERRY,SUP-2165484,CDM,L3807,HCPCS,0274,RC,,,,both,,,153.77,99.95,,,,,,,,,,,,,
RESTRICTOR FEM CNL SZ 4 DIA15.75MM POLYETH NONRESORBABLE,SUP-2253089,CDM,C1776,CPT,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 7CMD SPNL MSCLE MULTI TTHD BLACK FNSH U,SUP-2672371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.36,380.48,,,,,,,,,,,,,
GRAFT BNE SYR 10 CC DBM ACCELL CONNEXUS,SUP-2641755,CDM,C1713,HCPCS,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
DRILL FOR 2.4MM PL HIP HARD BONE,SUP-2812340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SPACER SPNL W10XH9-13XL31MM 15DEG THORLUM INTBDY FUS LORD,SUP-2228791,CDM,C1821,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
GRAFT HUM TISS W6XL12CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2125861,CDM,C1781,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
BLADE SCRWDRIVER T7AOSR,SUP-2462583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PLATE BNE 6 H 98DEG SUPCNDYL HIP S STL LOK BILAT RIG SHT BRL,SUP-2370899,CDM,C1713,HCPCS,0278,RC,,,,both,,,3367.34,2188.77,,,,,,,,,,,,,
OCCLUDER CV AMPLATZER PI MUSCULAR VSD WAIST L 10 MM DIA24 MM,SUP-2737597,CDM,C1817,HCPCS,0278,RC,,,,both,,,20535.60,13348.14,,,,,,,,,,,,,
TRAY CATH PICC LUMENX2 6FR DIA 55CML POLYURETHANE 0.62ML PRI,SUP-2613437,CDM,C1751,HCPCS,0278,RC,,,,both,,,706.81,459.43,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,GO|KX|CO,both,,,195.00,126.75,,,,,,,,,,,,,
SET SCR SPNL L5-7MM PEDFUSE,SUP-2353729,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
CATHETER MAP 2 MM 8 FRX120 CM 31 MM 64 ELECTRD CONSTELLATION,SUP-2424694,CDM,C1732,HCPCS,0278,RC,,,,both,,,11486.12,7465.98,,,,,,,,,,,,,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG PO CP12,RX-27644,CDM,6370000000,HCPCS,0637,RC,16714-0964-01,NDC,,both,1,UN,22.30,14.49,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA5MM THRD L30MM TI NITRIDE HALF FOR,SUP-2400700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
GRAFT EVAR L18CM AORT OD28.5MM ID24-26MM IL OD12MM,SUP-2395988,CDM,C1768,CPT,0278,RC,,,,both,,,24426.06,15876.94,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED RT LAT FEM HEMICONDYLE,SUP-2740863,CDM,C1713,HCPCS,0278,RC,,,,both,,,35358.76,22983.19,,,,,,,,,,,,,
PROBE LITHO L570MM DIA1MM PNEUMAT SWISS LITHOCLAST,SUP-2139041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.85,486.10,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-9.5 MM 5 CC FD CANC STRL 31021405 ALLOSOURCE,SUP-2431936,CDM,C1889,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 25.4MMW X 90MML 1.37MM/1.37MM THK CUT BRZ,SUP-2586310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,94.70,61.55,,,,,,,,,,,,,
HC So Histochemical Staining,PX-3128831466,CDM,88314,CPT,0312,RC,,,,both,,,197.00,128.05,,,,,,,,,,,,,
COMPONENT HIP H5 PREMIER HYBIRD,SUP-2351361,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
STAPLE BONE FIX L15MM SHP MEM,SUP-2137594,CDM,C1713,HCPCS,0278,RC,,,,both,,,1125.50,731.57,,,,,,,,,,,,,
BIOCOMP SWVLK BICEPS TENO 8X23 KIT,SUP-2811897,CDM,C1713,HCPCS,0278,RC,,,,both,,,2257.66,1467.48,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L81CM 0.038IN TRANSSEPTAL SR0 CRV,SUP-2357245,CDM,C1893,HCPCS,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
ROD SPNL PREBENT 5.5X600 MM TI NS MONARCH,SUP-2583128,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
HC Ins/Rep Subq Defibrillator,PX-3603327000,CDM,33270,CPT,0360,RC,,,,outpatient,,,30094.00,19561.10,,,,,,,,,,,,,
HC So Culture Virus,PX-3068725566,CDM,87255,CPT,0306,RC,,,,both,,,84.00,54.60,,,,,,,,,,,,,
CATHETER REPROC EP 5FR 5MM 4 POLE CRD2,SUP-2270125,CDM,C1730,HCPCS,0272,RC,,,,both,,,102.33,66.51,,,,,,,,,,,,,
PLATE BNE L 107 X W 12 MM THK 2.4 MM SCREW DIA2.7 MM 16 H SS 72469716,SUP-2933423,CDM,C1713,HCPCS,0278,RC,,,,both,,,2579.51,1676.68,,,,,,,,,,,,,
CANNULA SUCTION MONOPOLAR 3 MMX30 CM COAG W/ TRMPT VLV,SUP-2767732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1745.40,1134.51,,,,,,,,,,,,,
ALLOGRAFT BNE HEMI MAND FD,SUP-2321822,CDM,C1713,HCPCS,0278,RC,,,,both,,,5196.70,3377.85,,,,,,,,,,,,,
ENDCAP ORTH 10+ MM FOR FIB,SUP-2857590,CDM,C1889,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
LENS IOL TORIC MX60ETE125 20.0D,SUP-2423521,CDM,V2632,HCPCS,0276,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY VIK L 65 CM DIA 6 FR SPC 2 MM,SUP-2142636,CDM,C1730,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CATHETER THROMCTMY PRODIGY TWST L 154 CM SHTH 5 FR STRL,SUP-2864592,CDM,C1757,HCPCS,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
ALLOGRAFT FRZN MENISCI RT MEDL,SUP-2175248,CDM,C1762,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
PASSER SUT WHT POLYPR CART COBRAID SMARTSTITCH MAGNUMWIRE,SUP-2342098,CDM,C1713,HCPCS,0278,RC,,,,both,,,980.75,637.49,,,,,,,,,,,,,
MELATONIN 5 MG PO TABS,RX-17427,CDM,6370000000,HCPCS,0637,RC,16571-0873-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
K WIRE FIX L15IN DIA1.5MM,SUP-2167176,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.19,56.02,,,,,,,,,,,,,
CATHETER CTRL VEN PED 7FR 1/0.5ML RED WHT L65CM 2 LUMN,SUP-2127701,CDM,C1751,HCPCS,0278,RC,,,,both,,,1118.94,727.31,,,,,,,,,,,,,
PLATE BNE W12XL135MM THK1MM 8 H BILAT S STL SEMI TBLR LO,SUP-2184869,CDM,C1713,HCPCS,0278,RC,,,,both,,,270.73,175.97,,,,,,,,,,,,,
COMPRESSOR SURG SPNL 14-59 MM SILVERTON,SUP-2211160,CDM,2780000010,LOCAL,0278,RC,,,,both,,,3916.84,2545.95,,,,,,,,,,,,,
WIRE FIX .062MM K,SUP-2123452,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP L20MM TIP L5MM DIA49FR GWIRE L260CM,SUP-2149847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.07,847.00,,,,,,,,,,,,,
BIT DRL 3.8 MM,SUP-2402764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
CATHETER HD SHT TERM 14 FRX15 CM MAX BARR TY 400XL STR TAPR,SUP-2550544,CDM,C1752,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
STENT NEPHURET COPE L 22 CM DIA 8.5 FR GUIDEWIRE 0.038 IN,SUP-2170578,CDM,C2625,HCPCS,0278,RC,,,,both,,,284.17,184.71,,,,,,,,,,,,,
STENT URTRL 6FR DIA 30CML SLCNE TCFLX OPEN END WPSH CATH UR,SUP-2724147,CDM,C2617,HCPCS,0278,RC,,,,both,,,378.31,245.90,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 8 CM FLPY TIP L 2,SUP-2167574,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.61,19.25,,,,,,,,,,,,,
GRAFT DURA W2XL2IN ULTRAPURE POR SUTURABLE DURAGN,SUP-2244024,CDM,C1713,HCPCS,0278,RC,,,,both,,,1684.92,1095.20,,,,,,,,,,,,,
BISMUTH SUBSALICYLATE 262 MG/15ML PO SUSP,RX-1090,CDM,340b,HCPCS,0637,RC,01490-0039-16,NDC,,both,30,ML,2.70,1.75,,,,,,,,,,,,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,Q4081,HCPCS,0636,RC,55513-0144-01,NDC,,both,1,ML,489.20,317.98,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6 MM STR STD WALL REINF,SUP-2525438,CDM,C1768,CPT,0278,RC,,,,both,,,922.94,599.91,,,,,,,,,,,,,
PLATE BNE RADIAL C1 STD LT VOLAR DSTL SCR ANGLE MOD TI,SUP-2646865,CDM,C1713,HCPCS,0278,RC,,,,both,,,1895.05,1231.78,,,,,,,,,,,,,
PLATE BONE L146MM 12 H POST LAT S STL 1/3 TBLR LCK COMPR FOR,SUP-2349799,CDM,C1713,HCPCS,0278,RC,,,,both,,,3076.26,1999.57,,,,,,,,,,,,,
PLATE BONE THK1.5MM 5X2 H CVD 3D,SUP-2365234,CDM,C1713,HCPCS,0278,RC,,,,both,,,2267.90,1474.13,,,,,,,,,,,,,
PISTON SMRT 6X55 MALLOUS,SUP-2313851,CDM,L8613,CPT,0278,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
SPACER TIB SMALL/SMALL + 17.5 MM LCS,SUP-2453975,CDM,C1776,CPT,0278,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
VENETOCLAX 50 MG PO TABS,RX-133766,CDM,J8999,HCPCS,0636,RC,00074-0566-11,NDC,,both,1,UN,293.00,190.45,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 6 HOLES 113MM,SUP-2549506,CDM,C1713,HCPCS,0278,RC,,,,both,,,1525.85,991.80,,,,,,,,,,,,,
ENDOPROBE MOD STD STR 23 GA,SUP-2247215,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.56,343.56,,,,,,,,,,,,,
GUIDEWIRE ORTH L9IN DIA2MM S STL SGL TRCR THRD FOR MAYO LOK,SUP-2107902,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
SLEEVE FEM DIA13MM HIP MALLORY-HEAD PMMA CNTR CEM BIPLANAR,SUP-2406640,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW SPNL POLYAX 04.5X25 MM ASMBLY REDUCTION,SUP-2175708,CDM,C1713,HCPCS,0278,RC,,,,both,,,6534.34,4247.32,,,,,,,,,,,,,
PLATE BONE L105MM 8 HOLE RCNSTRCTN 35MM SCREW UNVRSL LOK SST,SUP-2460268,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.67,975.44,,,,,,,,,,,,,
PLATE BONE 5X20 HOLE RIGHT RECONSTRUCTION WITH CONDYLAR HEAD,SUP-2838423,CDM,C1713,HCPCS,0278,RC,,,,both,,,18634.64,12112.52,,,,,,,,,,,,,
PLATE BNE TIB 238 MM LAT 11 HOLE BUTTRESS HD TI NS LC-DCP,SUP-2569061,CDM,C1713,HCPCS,0278,RC,,,,both,,,2780.88,1807.57,,,,,,,,,,,,,
RING EXT FIX MED 160 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29376.65,19094.82,,,,,,,,,,,,,
CIDOFOVIR 75 MG/ML IV SOLN,RX-17378,CDM,J0740,HCPCS,0636,RC,23155-0216-31,NDC,,both,5,ML,2183.00,1418.95,,,,,,,,,,,,,
ENDCAP SPINAL 12MM X 5MM OFFSET,SUP-2587319,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.70,295.55,,,,,,,,,,,,,
PLATE BNE INTRAPELVIC RT 5 HOLE,SUP-2518357,CDM,C1713,HCPCS,0278,RC,,,,both,,,4556.14,2961.49,,,,,,,,,,,,,
STENT PERIPH PALMAZ GEN L 19 MM BALLOON L 17 MM DIA10 MM,SUP-2159189,CDM,C1877,HCPCS,0278,RC,,,,both,,,3749.16,2436.95,,,,,,,,,,,,,
NERVE STIMULATOR CARD 51X68 MM 61 G 2 CHMBR PERCEPT PC,SUP-2516490,CDM,C1767,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 10 CM OD 5FR ID 0.074IN FLPY TIP,SUP-2384810,CDM,C1894,HCPCS,0272,RC,,,,both,,,232.74,151.28,,,,,,,,,,,,,
STEM HUM PRSS FIT EQUINOXE,SUP-2223290,CDM,C1776,CPT,0278,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
BLADE RETRACTOR 7 IN SELF RET MALL BOOKWALTER,SUP-2382588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2439.97,1585.98,,,,,,,,,,,,,
COIL NEUROVASCULAR HELIPAQ 18 CERECYTE L 8 CM DIA 3 MM,SUP-2460440,CDM,C1889,HCPCS,0278,RC,,,,both,,,5086.61,3306.30,,,,,,,,,,,,,
CLIP ANEURYSM L5MM 45DEG STANDARD T BAR FENESTRATED PERMANEN,SUP-2825663,CDM,C1889,HCPCS,0278,RC,,,,both,,,4291.34,2789.37,,,,,,,,,,,,,
PLATE BONE M STRL UTIL FOR 2.7MM SCR VLP,SUP-2349946,CDM,C1713,HCPCS,0278,RC,,,,both,,,6228.66,4048.63,,,,,,,,,,,,,
INTRODUCER SET INTROFLEX 85F,SUP-2272865,CDM,C1894,HCPCS,0272,RC,,,,both,,,130.94,85.11,,,,,,,,,,,,,
BLADE SAW OSCLLTNG CLSSC 19MMW X90MML 0.89MM THK INNVTVE TOO,SUP-2605817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,73.19,47.57,,,,,,,,,,,,,
PROSTHESIS OSS EAR 3X7 MM CENTER,SUP-2304877,CDM,L8613,CPT,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
GRAFT STRGHT ULTRA THIN WALL NON RNGD PLSTR 6MM DIA 70CM LNG,SUP-2470252,CDM,C1768,CPT,0278,RC,,,,both,,,2113.94,1374.06,,,,,,,,,,,,,
MESH HERN W4XL6IN POLYPR MID WT MFIL RECTANG OVL FLAT SHT,SUP-2227327,CDM,C1781,HCPCS,0278,RC,,,,both,,,119.82,77.88,,,,,,,,,,,,,
STAPLER INT 60 UNIV PUR W/ TRI-STAPLE TECHNOLOGY ULT FOR,SUP-2395286,CDM,C1781,HCPCS,0278,RC,,,,both,,,517.06,336.09,,,,,,,,,,,,,
SUPPORT ANK L PUL ON WHT PROCARE,SUP-2196786,CDM,L1906,HCPCS,0274,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE LG XL 28 IN BLK LTX,SUP-2421706,CDM,L1833,HCPCS,0274,RC,,,,both,,,228.18,148.32,,,,,,,,,,,,,
SCREW COMPRESSION DART FIRE EDGE,SUP-2765151,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
ARCOS 15X250MM CYL DIST,SUP-2506084,CDM,C1776,CPT,0278,RC,,,,both,,,7812.32,5078.01,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.0 MMX14 IN NIT,SUP-2664004,CDM,C1769,HCPCS,0272,RC,,,,both,,,203.97,132.58,,,,,,,,,,,,,
KIT ELECTRD 17GA TIP 3CM RAD FREQ ABLAT COOL-TIP,SUP-2172360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6604.99,4293.24,,,,,,,,,,,,,
GRAFT CHIP CANC OSTEOCEL 10CC,SUP-2310450,CDM,C1713,HCPCS,0278,RC,,,,both,,,10519.00,6837.35,,,,,,,,,,,,,
DRILL ENDO OD10MM STD LEN CANN BIT RMR HD FEM TUNN ARTHSCP,SUP-2342263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,946.24,615.06,,,,,,,,,,,,,
BIT DRL CANN 13.5 MM ENTRY,SUP-2476955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE DBLE Y SHAPE LNG CP TTNM ST,SUP-2677803,CDM,C1713,HCPCS,0278,RC,,,,both,,,695.13,451.83,,,,,,,,,,,,,
RAIL EXT FIX SM 100 MM,SUP-2461387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3158.84,2053.25,,,,,,,,,,,,,
SHOULDER IMMOB VELPEAU ELAS XLG,SUP-2194409,CDM,L3650,HCPCS,0272,RC,,,,both,,,19.66,12.78,,,,,,,,,,,,,
STIMULATOR SPNL CRD W 47 X H 57 MM D 6 MM SPC 2.8 MM 29 GM,SUP-2913244,CDM,C1820,HCPCS,0278,RC,,,,both,,,62172.00,40411.80,,,,,,,,,,,,,
CAGE SPNL L16XW16XH50MM SPNL 4 LOBE IMP NGAGE,SUP-2317743,CDM,C1889,HCPCS,0278,RC,,,,both,,,16337.42,10619.32,,,,,,,,,,,,,
CONNECTOR ROD CLS OPN AX TI IMPL OD55X45MM CDH LEG,SUP-2279783,CDM,C1713,HCPCS,0278,RC,,,,both,,,3583.18,2329.07,,,,,,,,,,,,,
K WIRE FIX L5.5IN DIA0.045IN SMOOTH DBL TRCR,SUP-2304014,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.66,12.78,,,,,,,,,,,,,
CATHETER IV SINGLE LEMEN 4 FR DOT KT MBP PC POWERMIDLINE,SUP-2626734,CDM,C1751,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
KIT LD INTRO OPTISEAL L 25 CM OD 8 FR ID 0.112 IN GUIDEWIRE,SUP-2763416,CDM,C1894,HCPCS,0272,RC,,,,both,,,170.19,110.62,,,,,,,,,,,,,
GUIDEWIRE VASC L18CM L15CM OD8FR ID64FR 0018IN 0038IN S,SUP-2167887,CDM,C1769,HCPCS,0272,RC,,,,both,,,268.34,174.42,,,,,,,,,,,,,
SLING GYN MESH ASSEMB HALO NDL GUID TB HNDL TRANSOBTURATOR,SUP-2139450,CDM,C1771,HCPCS,0278,RC,,,,both,,,5251.96,3413.77,,,,,,,,,,,,,
PLATE 4 H 2.3 TRAUM MOD TI 1.5MM LNG,SUP-2262997,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.02,521.31,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL,SUP-2435543,CDM,L0468,HCPCS,0274,RC,,,,both,,,1346.15,875.00,,,,,,,,,,,,,
GRAFT BONE 5CC HCT/P REGULATED VIABLE CELLULAR,SUP-2718753,CDM,C1713,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
GRAFT BONE SUB 5CC VIABLE BONE MTRX BIOFUSE,SUP-2224016,CDM,C1762,CPT,0278,RC,,,,both,,,8515.68,5535.19,,,,,,,,,,,,,
PLATE EXT FIX L160MM FT DBL H FOR SIDEKCK FRDM CIR FIX,SUP-2400651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
PIN BONE FIX L15MM DIA3MM EXT THRD,SUP-2254087,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 39 MM DIA 32 MM SHTH 20 FR RVD,SUP-2170109,CDM,C1874,HCPCS,0278,RC,,,,both,,,5664.56,3681.96,,,,,,,,,,,,,
SET HAD CATHETER 155FR L20CM 3 LUMN STR EXTN BASIC SHT TERM,SUP-2266990,CDM,C1752,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
HALF RING 160 MM INT DIAM,SUP-2818049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8162.74,5305.78,,,,,,,,,,,,,
HC Vasc Embolize Occlude Artery,PX-3613724200,CDM,37242,CPT,0361,RC,,,,both,,,20612.00,13397.80,,,,,,,,,,,,,
PLATE BONE L147MM 11 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349759,CDM,C1713,HCPCS,0278,RC,,,,both,,,5619.50,3652.67,,,,,,,,,,,,,
CLAMP SURG 00361IN AD 3 H WIRE SLDE STD TISS REUSE,SUP-2316250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.27,632.63,,,,,,,,,,,,,
PLATE BNE CLAV CS3 2.7 MM LT VA LCK COMPR SS NS VA-LCP,SUP-2757610,CDM,C1713,HCPCS,0278,RC,,,,both,,,3143.14,2043.04,,,,,,,,,,,,,
BLADE SCRDRVR DIA2.3MM NONCANNULATED CRSS PIN,SUP-2375073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
KIT PERICARDCENT W/ 6FR PGTL CATH DIL ANES NDL LUERLOCK SYR,SUP-2303220,CDM,C1769,HCPCS,0272,RC,,,,both,,,310.08,201.55,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA 34 MM POLYESTER GEL STR 3,SUP-2894634,CDM,C1889,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-103580,CDM,J0137,HCPCS,0636,RC,24201-0110-01,NDC,,both,65,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER URET FLX TIP 0.038 IN 7 FRX70 CM OPN END SET C FLX,SUP-2467894,CDM,C1758,HCPCS,0278,RC,,,,both,,,123.59,80.33,,,,,,,,,,,,,
ASSEMBLY DIL MORPHEUS DIA 4 FR SPLITTABLE SHTH STRL,SUP-2734843,CDM,C1894,HCPCS,0272,RC,,,,both,,,6.59,4.28,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 13 CM SPD 15000 RPM ENT SET PWR,SUP-2902116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.24,441.51,,,,,,,,,,,,,
PLATE BONE L113MM 14 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348299,CDM,C1713,HCPCS,0278,RC,,,,both,,,6502.78,4226.81,,,,,,,,,,,,,
DEVICE LAA EXCLUSION CLP L 50 MM NIT SPRING POLYESTER CVR,SUP-2905441,CDM,C1889,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
KNIFE SURG BLDE L190MM DBL CUT FOR AMPUTATION LISTON,SUP-2108448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.53,314.94,,,,,,,,,,,,,
CATHETER EP 6FR L110CM 1MM TIP 2-5-2MM SPC L CRV DECAPOLAR,SUP-2357622,CDM,C1730,HCPCS,0272,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
MESH DERM IMPL SFT TISS MTRX PORCINE 2X16CM INTEXEN LP,SUP-2140307,CDM,C1763,HCPCS,0278,RC,,,,both,,,1595.91,1037.34,,,,,,,,,,,,,
HC Unlisted Procedure Small Intestine,PX-3614479901,CDM,44799,CPT,0361,RC,,,,both,,,2846.00,1849.90,,,,,,,,,,,,,
HC So Diphtheria Antibody,PX-3028664866,CDM,86648,CPT,0302,RC,,,,outpatient,,,202.00,131.30,,,,,,,,,,,,,
CATHETER KIT PICC LN NEONATAL,SUP-2431429,CDM,C1751,HCPCS,0278,RC,,,,both,,,158.57,103.07,,,,,,,,,,,,,
ROD SPNL L480MM DIA5.5MM RT ANTR TI ALLOY SMOOTH MOSS MIAMI,SUP-2254454,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 150 CM DIA 0.035 IN RAD DIA1.5 MM,SUP-2153999,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.22,46.29,,,,,,,,,,,,,
INSTRUMENT BACKFLUSH 25GA W/ BRSH NDL ACT ASPIR DISP,SUP-2213461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
MESH HERN W10XL15.2CM POLY 4 HYDROXYBUTYRATE SYN RECTANG,SUP-2125869,CDM,C1781,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
HC Chemo Infuse Addl Hour Chemo,PX-3359641500,CDM,96415,CPT,0335,RC,,,,both,,,377.00,245.05,,,,,,,,,,,,,
OXYGENATOR PERF CARDOTMY RESERVOIR CORTIVA COAT AFFIN PIXIE,SUP-2477430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ROD REPROC EXT FIX CARBN FIBR 8.0X320MM,SUP-2480136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.41,102.32,,,,,,,,,,,,,
VALVE AORT BIOPROSTHESES 27 MM MODEL 3000TFX PERIMT MAGNA,SUP-2214109,CDM,C1713,HCPCS,0278,RC,,,,both,,,21336.30,13868.59,,,,,,,,,,,,,
BLADE SAW SAG 19MMW X41MML 0.4MM/0.69MM THK CUT ANTR CRUC LI,SUP-2605388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,194.96,126.72,,,,,,,,,,,,,
WASHER ORTH S STL FOR 4MM SCR ASNS III,SUP-2371649,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
HC Splint App/Short Leg|BILATERAL PROCEDURE,PX-4502951500,CDM,29515,CPT,0450,RC,,,50,outpatient,,,497.00,323.05,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 HF 5FR 55CM 3 LUMAN 1395108Q,SUP-2632640,CDM,C1751,HCPCS,0278,RC,,,,both,,,942.66,612.73,,,,,,,,,,,,,
PIN ALIGN 2.5X150 MM STRL AEQUALIS REVERSED II DISP,SUP-2715608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - Monthly,PX-9900000038,CDM,9900000038,LOCAL,0990,RC,,,,both,,,30.00,19.50,,,,,,,,,,,,,
GRAFT HUM TISS L100MM FRZN SHFT TIB STRUCTURAL ALLGRFT,SUP-2307366,CDM,C1713,HCPCS,0278,RC,,,,both,,,3317.69,2156.50,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|CQ|XU|KX,both,,,144.00,93.60,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 13FRX30CM SHTH W/ L LUMN AND,SUP-2355436,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
SET ACCS L 38.5 CM DIA 9 FR NDL L 50.5 CM DIA16 GA TRNSJUG,SUP-2168168,CDM,C1894,HCPCS,0272,RC,,,,both,,,1789.96,1163.47,,,,,,,,,,,,,
SPACER SPNL 15 DEG 30X24X11 MM ALIF INDEPENDENCE MIS,SUP-2594749,CDM,C1821,HCPCS,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
SCREW BNE LCK 2.7 MM TOT WR STARDRV FUSION BLK STRL SURFIX,SUP-2610310,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.96,297.02,,,,,,,,,,,,,
EXPEL NEPH 10.3/25,SUP-2652775,CDM,C1729,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
ROD SPNL S STL STR L125MM L125MM OD5.5MM REVERE,SUP-2185222,CDM,C1713,HCPCS,0278,RC,,,,both,,,4639.70,3015.80,,,,,,,,,,,,,
EXTENSION STEM L150MM DIA12MM KNEE FLUT BAL REV SYS,SUP-2315652,CDM,C1776,CPT,0278,RC,,,,both,,,2687.84,1747.10,,,,,,,,,,,,,
GRAFT HUMAN TSSUE CLLGN SPCR MNSCS FRZN IRRDTD WO TBL PLTEA,SUP-2727097,CDM,C1762,CPT,0278,RC,,,,both,,,4842.63,3147.71,,,,,,,,,,,,,
KIT INTRO L10CM OD4FR 1 1/4IN GWIRE OD0.025IN NDL OD20GA,SUP-2384830,CDM,C1894,HCPCS,0272,RC,,,,both,,,280.09,182.06,,,,,,,,,,,,,
PLATE BNE LCK 324 MM LT PROX FEM 15 HOLE BRIDGE N CONTACT,SUP-2470912,CDM,C1713,HCPCS,0278,RC,,,,both,,,4346.76,2825.39,,,,,,,,,,,,,
WIRE FIX 1.45-1.75+ MM 40-150 MM PERCUFIX KIRSCHNER,SUP-2483740,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
TUBE VNTLTN MRTZ 076MM ID LUMEN 086MM OD FLNGE 1MM DIA INN,SUP-2680276,CDM,L8699,HCPCS,0278,RC,,,,both,,,66.54,43.25,,,,,,,,,,,,,
CATHETER CV JACC 5.5 FRX35 CM DL PRESSURE INJ ADV LF,SUP-2763381,CDM,C1751,HCPCS,0278,RC,,,,both,,,814.30,529.29,,,,,,,,,,,,,
NEEDLE BIOPSY BRAIN 19CM,SUP-2842435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
HEAD PLT PHLANG THK075MM R HND 316L S STL LOK FOR 13MM SCR,SUP-2177986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1483.34,964.17,,,,,,,,,,,,,
PLATE BNE CRV MIC 1.5X0.6 MM 3X2 HOLE SQ SEG W/ CROSS BAR TI,SUP-2459657,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.37,624.24,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 9.5MMW X30MML 0.64MM THK 0.84 THK CUT ANT,SUP-2605516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,201.65,131.07,,,,,,,,,,,,,
KNIFE 3724293 STAPEDECTOMY 45 DEG,SUP-2667370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,644.96,419.22,,,,,,,,,,,,,
METHOTREXATE SODIUM (PF) 1 GM/40ML IJ SOLN,RX-117356,CDM,J9260,HCPCS,0636,RC,61703-0408-25,NDC,,both,40,ML,54.10,35.16,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 65 MM 20/25 MM FLARED,SUP-2217560,CDM,C1874,HCPCS,0278,RC,,,,both,,,8933.30,5806.64,,,,,,,,,,,,,
POINTER NAVIGATION PRB FOR STEREOTACTIC SURG SYS AXIEM DISP,SUP-2284346,CDM,C1713,HCPCS,0278,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
GUIDEWIRE SURG 0.062X14 IN HYPRFLX,SUP-2765744,CDM,C1769,HCPCS,0272,RC,,,,both,,,112.63,73.21,,,,,,,,,,,,,
BURR CARBIDE BALL FLUTED 7.0MM 14 FLUTES,SUP-2801009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.16,450.55,,,,,,,,,,,,,
SPACER KNEE M GENT IMPREG CEMEX PMMA CLASS PREFRM ARTC PART,SUP-2223693,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL 1-4 MM 1-9.5 MM 100 CC FRZN ASEP CANC,SUP-2717969,CDM,C1713,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.503,SUP-2860185,CDM,C1713,HCPCS,0278,RC,,,,both,,,27470.60,17855.89,,,,,,,,,,,,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,0636,RC,00143-9877-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
BIOCOM SWIVELOCK BICEPS TENO 7X23,SUP-2812251,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
STEM HUM L173MM DIA9MM SHLDR TI SHLDR FX SYS UNIVERSE,SUP-2123245,CDM,C1776,CPT,0278,RC,,,,both,,,8556.50,5561.72,,,,,,,,,,,,,
HEAD BPLR HXL SZ 40 ENCORE MOD,SUP-2216822,CDM,C1776,CPT,0278,RC,,,,both,,,3102.32,2016.51,,,,,,,,,,,,,
WASHER ORTH LAPIDUS SYS FOR 3.5 MM SCREW IO FRDM,SUP-2864919,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
PLATE BNE STR SM LT,SUP-2398594,CDM,C1713,HCPCS,0278,RC,,,,both,,,5940.88,3861.57,,,,,,,,,,,,,
GUIDEWIRE VASC APPRCH HYDR ST L 190 CM DIA 0.014 IN TAPR L,SUP-2171007,CDM,C1769,HCPCS,0272,RC,,,,both,,,429.71,279.31,,,,,,,,,,,,,
GRAFT BNE XS 1.25 CC DBM STRND +,SUP-2641766,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L10CM OD4X5MM CAR STR INT FULL SPR,SUP-2308222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1718.46,1117.00,,,,,,,,,,,,,
IMPLANT BIO L 60 X W 40 MM CLLGN SPNG REINF STRL BIOBRACE,SUP-2930524,CDM,C1763,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
ANCHOR SUTURE 5MM WITH 2 NO 2 SUTURES HI-FI DISPOSABLE DRIVE,SUP-2828533,CDM,C1713,HCPCS,0278,RC,,,,both,,,720.85,468.55,,,,,,,,,,,,,
IMPLANT ANK FUSION DISP BX,SUP-2933444,CDM,C1776,CPT,0278,RC,,,,both,,,378.84,246.25,,,,,,,,,,,,,
CABLE SPNL L470MM DIA1MM THOR LUM S STL SGL LD CRMP,SUP-2186853,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CARTRIDGE 37X14X8 BI CONVX LORODTIC EXP IMPL 9 WAFERS,SUP-2354684,CDM,C1713,HCPCS,0278,RC,,,,both,,,22356.80,14531.92,,,,,,,,,,,,,
LENS IOL BCNVX 16.5+ DIOPT 6X12.5 MM ACRYL ENVISTA,SUP-2129618,CDM,V2632,HCPCS,0276,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
HC Remove Vad Different Session,PX-3603399200,CDM,33992,CPT,0360,RC,,,,outpatient,,,5261.00,3419.65,,,,,,,,,,,,,
JOINT TOE SM MINI 12 MTL HD,SUP-2392826,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
LINER IMP ACET SHELL 32/52 SURPS,SUP-2359355,CDM,C1776,CPT,0278,RC,,,,both,,,5617.46,3651.35,,,,,,,,,,,,,
MTOSCR INTF NON-CANN 9X20 STER,SUP-2341295,CDM,C1713,HCPCS,0278,RC,,,,both,,,325.74,211.73,,,,,,,,,,,,,
MESH SURG 18X23CM W/ POS SYS ECHO 2 VENTRALIGHT ST,SUP-2125929,CDM,C1781,HCPCS,0278,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
ANKLE FUSION PLATE LATERAL TTC 5H STRL,SUP-2815100,CDM,C1713,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
GRAFT 15CMX15CM SURGIMEND PRS,SUP-2243673,CDM,C9360,HCPCS,0278,RC,,,,both,,,14836.50,9643.72,,,,,,,,,,,,,
BIT DRL 1.6X90 MM CONTOURS VPS,SUP-2646712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,199.86,129.91,,,,,,,,,,,,,
PLATE BNE FIBULAR 3.5X169 MM LT LAT DSTL 13 HOLE EVOS,SUP-2349746,CDM,C1713,HCPCS,0278,RC,,,,both,,,5726.10,3721.96,,,,,,,,,,,,,
CATHETER DIAG 2.9X2.7FR L135CM DSTL L6CM ID0.027IN 0.018IN,SUP-2368151,CDM,C1887,HCPCS,0272,RC,,,,both,,,2833.85,1842.00,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 120 MM DIA 8 MM DEL SHTH,SUP-2934286,CDM,C1713,HCPCS,0278,RC,,,,both,,,11822.10,7684.36,,,,,,,,,,,,,
HC Ccu R&B,PX-2100000000,CDM,2100000000,LOCAL,0210,RC,,,,inpatient,,,5322.00,3459.30,,,,,,,,,,,,,
HC Core Needle Bx Lung/Mediastinum Perq W/Img|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3613240800,CDM,32408,CPT,0361,RC,,,73,both,,,3707.00,2409.55,,,,,,,,,,,,,
CONNECTOR CATH TWO PART AD FOR PERITONEAL DLYS FLX NK,SUP-2302452,CDM,C2628,HCPCS,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
KIT CATH MIC VENT BOLT INTCRAN PRSS MON CAMINO,SUP-2308098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2577.44,1675.34,,,,,,,,,,,,,
BASEPLATE TIB SZ 3 AP48MM ML68MM THK5.5MM L KNEE TI ALLY NP,SUP-2346726,CDM,C1776,CPT,0278,RC,,,,both,,,8025.84,5216.80,,,,,,,,,,,,,
GUIDEWIRE ORTH L9IN DIA0.062IN SGL TRCR THRD S STL ACUTRK +,SUP-2107901,CDM,C1769,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
EASYFUSE INSTRUMENT PACK MID / HINDFOOT,SUP-2830243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH SWARTZ SR L 60 CM DIA 8 FR GUIDEWIRE,SUP-2357154,CDM,C1893,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SET IMPL L FRAG LCP W/ 4.5MM BROAD NAR T PLT,SUP-2183081,CDM,C1713,HCPCS,0278,RC,,,,both,,,65377.94,42495.66,,,,,,,,,,,,,
PLATE BONE L107MM 8 H LT POSTEROLATERAL DSTL HUM FOR,SUP-2349771,CDM,C1713,HCPCS,0278,RC,,,,both,,,7888.62,5127.60,,,,,,,,,,,,,
HC Endo Level 2 Base 15 Min,PX-3600007502,CDM,3600007502,LOCAL,0360,RC,,,,both,,,4270.00,2775.50,,,,,,,,,,,,,
STAPLE BNE FIX DIA1 MM STD OBLQ NS VARISATION,SUP-2885080,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
HC Remove Retrievable Filter,PX-3613719300,CDM,37193,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
DRILL SURG DIA2.52 MM MINI STRL REUSE ACUTRK 3,SUP-2912760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1623.38,1055.20,,,,,,,,,,,,,
PROSTHESIS VOICE 22.5FR 12.5MM RADPQ VLV SEAT ENLD ESOPH,SUP-2124411,CDM,L8509,HCPCS,0274,RC,,,,both,,,1060.22,689.14,,,,,,,,,,,,,
GRAFT BNE LG 10 CC DBM STRND +,SUP-2641769,CDM,C1713,HCPCS,0278,RC,,,,both,,,13282.20,8633.43,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM LT VA LCK COMPR SS NS VA-LCP,SUP-2750792,CDM,C1713,HCPCS,0278,RC,,,,both,,,3089.26,2008.02,,,,,,,,,,,,,
PLUG VASC SM 5 MM AZUR,SUP-2853095,CDM,C1889,HCPCS,0278,RC,,,,both,,,6124.57,3980.97,,,,,,,,,,,,,
POST EXT FIX 5 HOLE WIRE NS,SUP-2548518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.43,483.88,,,,,,,,,,,,,
GENERATOR PULSE IMPLANTABLE SENZA HFX IQ IPG,SUP-2930186,CDM,C1822,CPT,0278,RC,,,,both,,,58090.00,37758.50,,,,,,,,,,,,,
STENT PERIPH ELUVIA L 120 MM DIA 6 MM CATH L 130 CM DIA 6 FR,SUP-2140848,CDM,C1874,HCPCS,0278,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
SCREW BNE 2X16 MM VARIAX,SUP-2363428,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.82,170.83,,,,,,,,,,,,,
NUT ORTH FOR 4.5MM CORT SCR,SUP-2184677,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.42,52.92,,,,,,,,,,,,,
IMPLANT WRST OD15MM ID7MM CRPL STD HD IMPLABLE MAESTRO,SUP-2407289,CDM,C1776,CPT,0278,RC,,,,both,,,2898.22,1883.84,,,,,,,,,,,,,
STIMULATOR NRV SPNL IMP PULSE PRECIS IPG AND CHARGING KT,SUP-2138773,CDM,C1767,HCPCS,0278,RC,,,,both,,,61261.40,39819.91,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 8CMD SPNL MSCLE NRRW BLACK FNSH ULTRA,SUP-2672367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.67,270.19,,,,,,,,,,,,,
HC So Hiv2 Probe,PX-3068753868,CDM,87538,CPT,0306,RC,,,,outpatient,,,118.00,76.70,,,,,,,,,,,,,
PATCH EXT REF REFSTAR RMT QWIKPATCH NS,SUP-2248953,CDM,C1713,HCPCS,0278,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
COMPONENT PATELLAR 3 PEG STD KNEE MOD RND RP PRIMARY CEM,SUP-2252414,CDM,C1776,CPT,0278,RC,,,,both,,,5188.54,3372.55,,,,,,,,,,,,,
CRANIAL ACCESS KIT MANUAL CRAN ROTARY HNDPC DISP HITHSP06,SUP-2666708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,908.34,590.42,,,,,,,,,,,,,
SYSTEM PEDCL ACCS INSUL DMND TIP JAMSH I-PASS II,SUP-2310403,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
GRAFT DURA 4X5 CM SUTURABLE BCNVX BOV PERICARD DURAGN,SUP-2457670,CDM,C1763,HCPCS,0278,RC,,,,both,,,1222.40,794.56,,,,,,,,,,,,,
ALLOGRAFT HUM TISS DERMAL REGENRATION MTRX 12X6 CM AXIS,SUP-2763315,CDM,C1762,CPT,0278,RC,,,,both,,,8471.72,5506.62,,,,,,,,,,,,,
STABILIZER SURG APEX SUCTION XPOSE AXIUS,SUP-2142008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ANCHOR SUT W/ ETHBND SZ 4-0 DRL P-3 PRECIS PT NDL WHT,SUP-2256609,CDM,C1713,HCPCS,0278,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
PLATE BNE OPN WDG PROX METATARSAL OSTEOTMY FIX 5MM,SUP-2243305,CDM,C1713,HCPCS,0278,RC,,,,both,,,6005.25,3903.41,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA 32 MM BRANCH SZ 10 MM,SUP-2227365,CDM,C1768,CPT,0278,RC,,,,both,,,4132.59,2686.18,,,,,,,,,,,,,
SPIRONOLACTONE 25 MG/5ML PO SUSP,RX-139604,CDM,6370000000,HCPCS,0637,RC,46287-0020-04,NDC,,both,5,ML,82.50,53.62,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X57 MM 7 HOLE 1/4 TI,SUP-2536110,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.20,282.88,,,,,,,,,,,,,
HC So RBC Pretx Incubatj W/Chemicl,PX-3008697066,CDM,86970,CPT,0300,RC,,,,both,,,183.00,118.95,,,,,,,,,,,,,
SCREW BNE L18MM DIA4MM ST BLU CORT TI ST NONCANNULATED LOK,SUP-2192240,CDM,C1713,HCPCS,0278,RC,,,,both,,,735.48,478.06,,,,,,,,,,,,,
SIZER MAMM IMPL NACL STRL 275CC,SUP-2300471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING PEDIATRIC CH TODDLER 2 IN PROCARE,SUP-2195749,CDM,L0180,HCPCS,0272,RC,,,,both,,,81.01,52.66,,,,,,,,,,,,,
PUMP BLD CENTRIMAG,SUP-2355998,CDM,C1713,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
BAYONET BPLR FRCP N STK IRRIG TIP 05MM LENGTH: 8IN 203CM,SUP-2160425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.59,275.33,,,,,,,,,,,,,
UPCHARGE HIP MODULAR DUAL MOBILITY LINER STRYKER,SUP-2501356,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GRAFT HUMAN TISSUE PELVIC FLOOR MATRIX 10X7 CM MATRISTEM,SUP-2106486,CDM,C1763,HCPCS,0278,RC,,,,both,,,6923.70,4500.40,,,,,,,,,,,,,
FEEDING TUBE KIT LP 12 FRX1.2 CM BLLN BUTTON SIL MINI 1,SUP-2754569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,704.62,458.00,,,,,,,,,,,,,
PIN COMPR NEXFIX 2X10 MM NS,SUP-2400518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 10X25X8 MM UNICORTICAL IL ORAGRAFT,SUP-2740924,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
GRAFT BNE STRP 2.5X5 CMX3 MM DBM TI NS DBX,SUP-2653619,CDM,C1713,HCPCS,0278,RC,,,,both,,,2021.03,1313.67,,,,,,,,,,,,,
BLADE SURG W10MM CASPR,SUP-2363308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.86,355.46,,,,,,,,,,,,,
COMPONENT HUM DIA25MM 3.5X3.5MM OFFSET ARTC HEMICAP,SUP-2123540,CDM,C1776,CPT,0278,RC,,,,both,,,12695.02,8251.76,,,,,,,,,,,,,
LEVEL NEURO SCREWDRIVER BLADE ULTRAONE80 MM QTY001 EA,SUP-2677980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,692.06,449.84,,,,,,,,,,,,,
GRAFT CORNEAL W1.5XL2CM THK50-100UM BIO TRANSPLANTATION,SUP-2135257,CDM,V2790,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
SCREW SPNL L15MM DIA4.5MM ST CANC ANT CERV TI FIX ANG,SUP-2293268,CDM,C1713,HCPCS,0278,RC,,,,both,,,1140.92,741.60,,,,,,,,,,,,,
CANNULA ARTHSCP HIP SHLDR MOD HNDL OBTURATOR HYDRODAM REUSE,SUP-2745447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2055.76,1336.24,,,,,,,,,,,,,
SCREW BONE L26MM DIA3MM CANC ST CANN NONLOCKING LAG,SUP-2319423,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
NEEDLE PROC 86 DEG 18 GAX71 CM TRANSSEPTAL ANGLED HEARTSPAN,SUP-2550595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SET LD EXTRACTION EVOLUTION SHORTIE RL L 13.6 CM OD 19 FR ID,SUP-2169473,CDM,C1773,HCPCS,0272,RC,,,,both,,,4395.97,2857.38,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6MM STR TW REINF SLDE GDS,SUP-2491940,CDM,C1768,CPT,0278,RC,,,,both,,,1745.56,1134.61,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM PEDCL REDUCTION MULTAXL,SUP-2926392,CDM,C1713,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
PLATE BNE W101XL308MM THK35MM 22 H BILAT TI STR RIG LOK,SUP-2191098,CDM,C1713,HCPCS,0278,RC,,,,both,,,2979.17,1936.46,,,,,,,,,,,,,
BASEPLATE KNEE MG II PC PEG TIB A/PURPLE,SUP-2199595,CDM,C1713,HCPCS,0278,RC,,,,both,,,11354.24,7380.26,,,,,,,,,,,,,
CATHETER GUID AD 7FR L55CM ID0.078IN RENAL DBL CRV W/ SLIX,SUP-2156084,CDM,C1887,HCPCS,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
KIT BNE FIX 35MM CRKSCR FULL THRD SUT ANCHR NO0 48IN BLU,SUP-2122810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
GUIDEWIRE VASC L70CM DIA0035IN J W ADV FLX,SUP-2269533,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0250,RC,00990-7983-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
ROD SPNL L65MM DIA6.35MM RT ANTR TI STR SMOOTH MNRCH,SUP-2254519,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
SLEEVE DRL 3.7 MM,SUP-2473948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.42,329.82,,,,,,,,,,,,,
STEM FEM HIP CEM PRIMARY,SUP-2249583,CDM,C1776,CPT,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
PLATE BNE L85MM 4 H ANG L T SHP BTTRS FOR 45MM SCR L,SUP-2411388,CDM,C1713,HCPCS,0278,RC,,,,both,,,755.52,491.09,,,,,,,,,,,,,
PIN EXT FIX THRD L45MM DIA5MM SHANK L110MM DIA5MM S STL,SUP-2342932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3 CM 0.014 INX180 CM 20 CM SS PROWATER,SUP-2123767,CDM,C1769,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
GRAFT TEND SEMI TENDOSIS ALLGRFT FRZ DRY 20 259CM L 3 10MM,SUP-2307125,CDM,C1762,CPT,0278,RC,,,,both,,,5420.68,3523.44,,,,,,,,,,,,,
BUR SURG DIAMOND SUPER LNG 60 K 2 MM HI SPD UNIDRIVE DISP,SUP-2599301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.17,371.26,,,,,,,,,,,,,
BLADE SURG 4MM DETACH STR W/ HNDL CAPSULECUT,SUP-2121993,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
DISTRACTOR SURG L 20 MM INTRAORAL MANDIBULAR FRME NS,SUP-2883442,CDM,C1713,HCPCS,0278,RC,,,,both,,,14539.77,9450.85,,,,,,,,,,,,,
DOXEPIN HCL 50 MG PO CAPS,RX-2612,CDM,6370000000,HCPCS,0637,RC,00904-7054-61,NDC,,both,1,UN,5.10,3.31,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM L8MM THRD TI NONDRILLING THRDED,SUP-2262643,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.04,205.43,,,,,,,,,,,,,
GRAFT BNE SUB L40MM OD7MM PLUG FRZ DRY,SUP-2306983,CDM,C1713,HCPCS,0278,RC,,,,both,,,2896.24,1882.56,,,,,,,,,,,,,
TAP BNE S STL HOAR TAP CANN W/ CLLR FOR 6 MM SCR CDH LEG,SUP-2290332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1470.56,955.86,,,,,,,,,,,,,
PLATE BNE THK1MM LNG 6 H TI CRV LOK MINI FOR 27MM SCR,SUP-2262966,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.52,823.89,,,,,,,,,,,,,
PLATE BNE FUSION 2 HOLE SINGLE LISFRANC STRATUM RS,SUP-2861193,CDM,C1713,HCPCS,0278,RC,,,,both,,,3881.04,2522.68,,,,,,,,,,,,,
BIT DRL OD2.0MM MRK,SUP-2137065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.46,241.45,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 6 FRX150 CM 2X120 MM COYOTE,SUP-2140810,CDM,C1725,HCPCS,0272,RC,,,,both,,,600.05,390.03,,,,,,,,,,,,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,2500000003,HCPCS,0250,RC,63323-0424-05,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT DURA L 5 X W 4 IN TYP I CLLGN BOV ACHILLES TEND RESRB,SUP-2889755,CDM,C1763,HCPCS,0278,RC,,,,both,,,3602.58,2341.68,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.018 IN SS PTFE SAFE-T-J STR FIX,SUP-2760058,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.50,55.57,,,,,,,,,,,,,
HC Biopsy of Salivary Gland,PX-3614240000,CDM,42400,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
VITAMIN C 250 MG PO TABS,RX-8679,CDM,6370000000,HCPCS,0637,RC,50268-0860-11,NDC,,both,1,UN,1.90,1.23,,,,,,,,,,,,,
PLATE BNE L 170 X W 11.4 MM THK 3.4 MM SCREW DIA 3.5 MM 13 H,SUP-2936308,CDM,C1713,HCPCS,0278,RC,,,,both,,,5879.34,3821.57,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.93 MM 2.8 MM REUT BOB HOLE MYRINGOTOMY,SUP-2478009,CDM,L8699,HCPCS,0278,RC,,,,both,,,43.99,28.59,,,,,,,,,,,,,
CATHETER HAD ADMIN BASIC KT DBL LUMN SIL CRV SPL TIP CUF N,SUP-2267087,CDM,C1881,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
CONNECTOR NRV L15MM DIA5MM PORCINE EXTRACELLULAR MTRX,SUP-2124868,CDM,C1763,HCPCS,0278,RC,,,,both,,,6889.16,4477.95,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM 0.035IN L7CM 2CM STR TIP HVY DTY FIX,SUP-2638692,CDM,C1769,HCPCS,0272,RC,,,,both,,,111.12,72.23,,,,,,,,,,,,,
PLATE BNE W175XL404MM THK52MM 22 H BILAT S STL BROAD LOK,SUP-2185324,CDM,C1713,HCPCS,0278,RC,,,,both,,,3813.91,2479.04,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN HEPARIN J FIX CRV,SUP-2147060,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.70,22.55,,,,,,,,,,,,,
IMMOBILIZER ORTH ADJ UNIV SHLDR CANVS NAVY NS,SUP-2336314,CDM,L3670,HCPCS,0272,RC,,,,both,,,25.72,16.72,,,,,,,,,,,,,
BOOT ORTHOT LOWER EXTREMITY CUST MOLD INNR BOOT,SUP-2435657,CDM,L4386,HCPCS,0272,RC,,,,both,,,1598.23,1038.85,,,,,,,,,,,,,
SCREW BONE L80MM DIA5MM HDLSS PA DYNANAIL,SUP-2277470,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
PLATE BNE L234MM THK37MM 18 H BILAT S STL STR LO PROF RIG,SUP-2177149,CDM,C1713,HCPCS,0278,RC,,,,both,,,2899.26,1884.52,,,,,,,,,,,,,
CATHETER ANGIO RAVI MG2 038 5 FRX150 CM SS GLIDECATH XP,SUP-2852409,CDM,C1887,HCPCS,0272,RC,,,,both,,,167.17,108.66,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ANGIOSCULPT EVO 139CM 5FR 15MM 2.5 MM,SUP-2353215,CDM,C1725,HCPCS,0272,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
COUPLING EXT FIX HINGED RAIL FOR ADV LRS SYS NS LTX,SUP-2875012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2028.72,1318.67,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT CANC OR CORT DWL BONE 14MM,SUP-2307026,CDM,C1713,HCPCS,0278,RC,,,,both,,,1409.86,916.41,,,,,,,,,,,,,
BIT DRILL CANNULATED 4.5MM,SUP-2719559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1430.21,929.64,,,,,,,,,,,,,
BASEPLATE TIB L71MM SHT UHMWPE NONMODULAR OSS,SUP-2405769,CDM,C1776,CPT,0278,RC,,,,both,,,8322.57,5409.67,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC SCREW 2 MMX12 IN BLNT TIP STRL CANNFLX,SUP-2879297,CDM,C1769,HCPCS,0272,RC,,,,both,,,158.26,102.87,,,,,,,,,,,,,
KIT IMPL L450MM DIA2.5MM TIM IM AND ENDCAP THE NANCY NAIL,SUP-2253250,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
STEM FEM REV PRSS FIT L BOW TI POR PLSM COAT RESTR 203MML,SUP-2375450,CDM,C1776,CPT,0278,RC,,,,both,,,17487.29,11366.74,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX10 TTNM CNTRD F/2.7MM SCREW UNVRS,SUP-2491568,CDM,C1713,HCPCS,0278,RC,,,,both,,,941.81,612.18,,,,,,,,,,,,,
SPLINT IM SM W4MM TI ALLOY MATRIXRIB,SUP-2181512,CDM,C1713,HCPCS,0278,RC,,,,both,,,2220.77,1443.50,,,,,,,,,,,,,
CATHETER PICC 4FR L20CM SGL LUMN MAX BARR CT TY MIDLN,SUP-2267041,CDM,C1751,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
ROD SPNL L30MM PRECRV TI ALLOY,SUP-2415625,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X230 MM NS EXTRIMIFIX LTX,SUP-2856033,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
INSTRUMENT KIT 18X22X24X8 MM STRL DYNAFORCE,SUP-2427206,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BONE COMPRESSION 2 MM MANDIBULAR 8 HOLE INTERMEDIATE L,SUP-2838409,CDM,C1713,HCPCS,0278,RC,,,,both,,,1965.01,1277.26,,,,,,,,,,,,,
SCREW BNE 3.5X45 MM SS NS,SUP-2183715,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.65,45.27,,,,,,,,,,,,,
ANKLE FUSION PLATE ANTERIOR TT RIGHT 6H STRL,SUP-2815300,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
INTRODUCER SHTH L14CM DIA6FR GWIRE L50CM DIA0.38IN NDL,SUP-2357059,CDM,C1892,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
GRAFT HUM TISS FRZN 3 STRND GRFTLINK,SUP-2264636,CDM,C1713,HCPCS,0278,RC,,,,both,,,7642.45,4967.59,,,,,,,,,,,,,
SET PICC 3L 6FR X 55CM W TEGADERM,SUP-2887057,CDM,C1751,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
NAIL IM L34CM OD10MM 130DEG S STL HIP R LOK CANN,SUP-2343923,CDM,C1713,HCPCS,0278,RC,,,,both,,,5830.98,3790.14,,,,,,,,,,,,,
PLATE BNE W21XL25MM 10 H RAD HD EL SYS BTTRS FOR 2MM SCR,SUP-2267954,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.35,1136.43,,,,,,,,,,,,,
CATHETER ABLATN B CRV 4 MM 7 FR SFT TIP THRMCPL NAVISTAR,SUP-2248470,CDM,C1732,HCPCS,0278,RC,,,,both,,,5802.72,3771.77,,,,,,,,,,,,,
PLATE BNE MESHED 11X126X1 MM 2 HOLE SM GRID STR PDLLA STRL,SUP-2464434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1844.56,1198.96,,,,,,,,,,,,,
SCREW BNE CORTICAL 2X12 MM ST HEX HD MINI SS NS,SUP-2469222,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.47,47.11,,,,,,,,,,,,,
EIUS UNI TIB MED 10MM RM/LL,SUP-2364891,CDM,C1776,CPT,0278,RC,,,,both,,,3857.49,2507.37,,,,,,,,,,,,,
BIT DRL L33MM LNG G FOR 32MM HDLSS COMPR SCR DARCO,SUP-2400360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
TRAY 3.5MM PLATE LCP HOOK PL RETROFIT KIT FOR OLECRANON,SUP-2549794,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.97,30.53,,,,,,,,,,,,,
IMPLANT FINGER JOINT SIZE 1 PROXIMAL INTERPHALANGEAL COBALT CHROME TITANIUM POLYETHYLENE SEMI CONSTRAINED SR PIP,SUP-2879157,CDM,C1776,CPT,0278,RC,,,,both,,,6396.18,4157.52,,,,,,,,,,,,,
STEM FEM PRSS FT NEUT 10X130 MM COLLRED REDUC STD X-SERIES,SUP-2409351,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
CATHETER ATHRCTMY COR 1.7MM DIA 135CM LEN RAP EXCHG VITESSE,SUP-2353047,CDM,C1885,CPT,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
SHEATH INTRO SOLOPATH WORKING L 25 CM EXPANDABLE L 20CM 16FR,SUP-2385695,CDM,C1894,HCPCS,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
PLATE BONE 2 H UNIV COMPR,SUP-2243483,CDM,C1713,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
HC 3rd Order Sel Abd/Lower Ext|BILATERAL PROCEDURE,PX-3613624700,CDM,36247,CPT,0361,RC,,,50,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BNE VA RT VOLAR DSTL RADIAL 5X3 HOLE SS NS VA-LCP,SUP-2177270,CDM,C1713,HCPCS,0278,RC,,,,both,,,3099.18,2014.47,,,,,,,,,,,,,
NAIL IM 2 L345MM OD12MM TI DST RAD MINIMALLY INVASIVE FIX,SUP-2398593,CDM,C1713,HCPCS,0278,RC,,,,both,,,6983.36,4539.18,,,,,,,,,,,,,
ANCHOR SUT DIA5MM TI W/ PRELD ULTRABRAID SUT TWINFIX,SUP-2341740,CDM,C1713,HCPCS,0278,RC,,,,both,,,875.34,568.97,,,,,,,,,,,,,
NAFCILLIN SODIUM 2 G IJ SOLR,RX-5335,CDM,J2290,HCPCS,0636,RC,55150-0123-16,NDC,,both,1,UN,71.90,46.73,,,,,,,,,,,,,
STAPLER INT 75MM CUT LN L73MM STPL LN L77MM LNAR B-FORM,SUP-2220029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.01,302.91,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 30 MG PWD MICROMATRIX,SUP-2106468,CDM,Q4118,HCPCS,0636,RC,,,,both,,,360.10,234.06,,,,,,,,,,,,,
PASSER SUT NIT WIRE FOR ACL CONSTR PROC RETROPASS,SUP-2120921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
SCREW BNE L25MM DIA4.75MM CORT FIX ANG NONCANNULATED LOK,SUP-2407389,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H XLN TI NEURO STR PLT SD HI 12PK,SUP-2937265,CDM,C1713,HCPCS,0278,RC,,,,both,,,15759.66,10243.78,,,,,,,,,,,,,
HC Prog Eval Dual Lead Pacemaker,PX-4809328000,CDM,93280,CPT,0480,RC,,,,both,,,132.00,85.80,,,,,,,,,,,,,
SCREW BONE CNNLTD 2MM DIA 12MML TTNM COUNTSINK DEPTH GAUGE F,SUP-2586653,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.10,600.01,,,,,,,,,,,,,
HC So Anti Striated Antibody,PX-3028625566,CDM,86255,CPT,0302,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
GRAFT HUM TISS 3X2 CM DBM AMNION,SUP-2431988,CDM,C1762,CPT,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
HC So Calr Gene Analysis,PX-3108121966,CDM,81219,CPT,0310,RC,,,,outpatient,,,395.00,256.75,,,,,,,,,,,,,
PLATE BNE SZ 2.6 MM MIDFACE PMI NS DISP ACCUPLATE,SUP-2936197,CDM,C1713,HCPCS,0278,RC,,,,both,,,39805.78,25873.76,,,,,,,,,,,,,
SCREW BONE CORT LCK ACU-LOC 3.5X54 MM TI,SUP-2107545,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
STRM MCF PLATE LG RT,SUP-2492549,CDM,C1713,HCPCS,0278,RC,,,,both,,,6869.44,4465.14,,,,,,,,,,,,,
HC Noncontact R-T Fluor Wnd Img Ea Addl Antmc Site,PX-3200599000,CDM,0599T,CPT,0320,RC,,,,both,,,1010.00,656.50,,,,,,,,,,,,,
BURR SURG 1.5MM DIA HD LNG MIC 5.1MML HD CARBIDE SM BNE STRG,SUP-2605563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,68.39,44.45,,,,,,,,,,,,,
INSERT TIB L65MM THK10MM MEDL LAT KNEE ARTC POST STBL HI,SUP-2405945,CDM,C1776,CPT,0278,RC,,,,both,,,6477.82,4210.58,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA20 GA NDL DIA18 GA CE18TKSTN CONT SFT,SUP-2936784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,83.37,54.19,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA 34 MM POLYESTER GEL,SUP-2385025,CDM,L8670,HCPCS,0278,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
CONNECTOR SHUNT 1.10X1.95X10.4 MM STR SS STRL,SUP-2666465,CDM,C1889,HCPCS,0278,RC,,,,both,,,274.66,178.53,,,,,,,,,,,,,
UNIVERS II HUMERAL INSTRUMENTATION SET,SUP-2817736,CDM,C1713,HCPCS,0278,RC,,,,both,,,160140.00,104091.00,,,,,,,,,,,,,
"HC Culture, Aerobic",PX-3008707000,CDM,87070,CPT,0300,RC,,,,both,,,207.00,134.55,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE MED 5.4 CC CORTICOCANCELLOUS VIABLE,SUP-2933296,CDM,C1762,CPT,0278,RC,,,,both,,,26546.31,17255.10,,,,,,,,,,,,,
GRAFT BONE SUB 10MM CROSS SECT FEM FRZ DRY TRAD,SUP-2294079,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
BLADE RETRACTOR MAGRINA DEAVER SM 1X3.5 IN SYS BOOKWALTER,SUP-2483538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1137.28,739.23,,,,,,,,,,,,,
PLATE BNE L292MM 16 H NONSTERILE R MED DST TIB S STL VAR ANG,SUP-2177652,CDM,C1713,HCPCS,0278,RC,,,,both,,,6565.68,4267.69,,,,,,,,,,,,,
PIN TEMP FIX 268530000] JNJ HEALTHCARE],SUP-2256845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
ENVELOPE CV DEV M W6.5XL6.9CM PORCINE DERIVED EXTRACELLULAR,SUP-2172040,CDM,C1889,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
BIT DRL L150MM DIA7.4MM GLEN SCR W/O STP NONRADIOPAQUE,SUP-2194186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.85,332.05,,,,,,,,,,,,,
RETRIEVER THROMCTMY MERCI L5 L 180 CM DIA2.5 MM DIA 0.014 IN,SUP-2367767,CDM,C1713,HCPCS,0278,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE SL L 90 CM OD 5 FR GUIDEWIRE,SUP-2169825,CDM,C1894,HCPCS,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
HC Asp Injection Major Joint,PX-4502061000,CDM,20610,CPT,0450,RC,,,,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
OSTEOTOME SURG OD20MM BLDE THN FLX,SUP-2408596,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BIT DRL CALIB W/ SPIK FOR SURTAC II JCBS CHK,SUP-2341330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.07,252.25,,,,,,,,,,,,,
SYSTEM FASCIAL CLSR UNIQUE SHLDED WNG SAFE UNIF CONSISTENT,SUP-2384365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
STAPLE SPNL ANTR THORACO LUM PRNG TI COLORADO 2,SUP-2290577,CDM,C1713,HCPCS,0278,RC,,,,both,,,1692.46,1100.10,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 8 MM STR TW HELIX,SUP-2484051,CDM,C1768,CPT,0278,RC,,,,both,,,2600.42,1690.27,,,,,,,,,,,,,
DEVICE THROMCTMY MINDFRAME CAPTURE LP L 20 MM DIA 3 X 15 MM,SUP-2278033,CDM,C1887,HCPCS,0272,RC,,,,both,,,23942.50,15562.62,,,,,,,,,,,,,
CATHETER PERF 154CM 2.8FRX.026IN PROX WRK POS CONT ASPIR,SUP-2323621,CDM,C1757,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE REG RT ANGLE W/O SIPHONGUARD HAKIM,SUP-2666512,CDM,C1889,HCPCS,0278,RC,,,,both,,,14668.20,9534.33,,,,,,,,,,,,,
HARD BONE INTRODUCER COMPATIBLE WITH KBDKBC 1110,SUP-2702553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CLAMP CATH MTL DISP,SUP-2126566,CDM,C1751,HCPCS,0278,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
SPHERE GLEN OD36MM GLENOSPHRS ARW,SUP-2224542,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
HYDROCORTISONE 2.5 % EX LOTN,RX-3729,CDM,6370000000,HCPCS,0637,RC,45802-0937-16,NDC,,both,59,ML,134.90,87.68,,,,,,,,,,,,,
POST EXT FIX NS DISP ILIZ,SUP-2933359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,929.47,604.16,,,,,,,,,,,,,
STEM GLOBAL UNITE REV SZ 8,SUP-2512721,CDM,C1776,CPT,0278,RC,,,,both,,,7975.60,5184.14,,,,,,,,,,,,,
MESH HERN XL W22.1XL27.1CM POLYPR OVL UNCOATED MFIL,SUP-2125901,CDM,C1781,HCPCS,0278,RC,,,,both,,,4925.09,3201.31,,,,,,,,,,,,,
PLATE BNE L93MM 4X6 H S STL L DST VOLAR RAD FOR 3MM SCR,SUP-2372084,CDM,C1713,HCPCS,0278,RC,,,,both,,,2174.45,1413.39,,,,,,,,,,,,,
SEED BRACHYTHERAPY 17/18 GA CART ANCHR,SUP-2135317,CDM,C2639,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
GRAFT BNE W16XH5XL22MM FRZ DRY COT WDG FOR FLATFOOT,SUP-2307235,CDM,C1713,HCPCS,0278,RC,,,,both,,,2388.76,1552.69,,,,,,,,,,,,,
POWERPICC PROVENA SOLO FT 5 FR 2 LUMAN CATH MAXBARR TY WTH S,SUP-2613531,CDM,C1751,HCPCS,0278,RC,,,,both,,,772.13,501.88,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY E STRP 40IN CIRC 28IN,SUP-2194900,CDM,L1830,CPT,0272,RC,,,,both,,,115.65,75.17,,,,,,,,,,,,,
RESORB XG ST PLATE ORBTL FLR40 X 40 MM T0.6 MM PLLA PGA QT00,SUP-2498078,CDM,C1713,HCPCS,0278,RC,,,,both,,,2908.21,1890.34,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 14H LT 223MM-STER,SUP-2549587,CDM,C1713,HCPCS,0278,RC,,,,both,,,4809.91,3126.44,,,,,,,,,,,,,
DILATOR SURG 24FR EN BLT IN PEEL AWAY SHTH FOR 20FR MIC KEY,SUP-2236744,CDM,C1894,HCPCS,0272,RC,,,,both,,,315.66,205.18,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L22IN FOAM WRP ARND UNIV CLS PAT,SUP-2195242,CDM,L1830,CPT,0274,RC,,,,both,,,23.99,15.59,,,,,,,,,,,,,
IMPLANT OTO 4MM W/ 6MM ABUTMENT TI FOR BAHA FAST SURG BAHA 3,SUP-2164960,CDM,L8690,HCPCS,0278,RC,,,,both,,,8748.04,5686.23,,,,,,,,,,,,,
NEEDLE BX FRNSN DISP 20GAX9CM,SUP-2269635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
PLATE BNE L63MM 3 H 130DEG S STL HIP COMPR LO PROF SHT BRL,SUP-2364144,CDM,C1713,HCPCS,0278,RC,,,,both,,,1841.61,1197.05,,,,,,,,,,,,,
SPLINT WRST SM L11IN L FA BLU CANVS HK AND LOOP PREMIERPRO,SUP-2336038,CDM,L3809,HCPCS,0272,RC,,,,both,,,18.65,12.12,,,,,,,,,,,,,
WASHER ORTH OD4MM G CNTOUR MAXTORQUE,SUP-2399469,CDM,C1776,CPT,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
HC So Ptt,PX-3058573066,CDM,85730,CPT,0305,RC,,,,both,,,47.00,30.55,,,,,,,,,,,,,
SHEATH URET ACC 12FR 35CML W/ DIL,SUP-2119490,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PLATE BNE W9XL45MM THK1MM 4 H TI 1 3 TBLR W CLLR LOK COMPR,SUP-2190948,CDM,C1713,HCPCS,0278,RC,,,,both,,,513.55,333.81,,,,,,,,,,,,,
KIT CATH HEMODIALYSI NIAG ACUTE 13.5FR DIA 15CML INS 5593150,SUP-2632907,CDM,C1752,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SCREW DISTRCTN 12MM TI STRL ULTRA LF,SUP-2489624,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.25,80.76,,,,,,,,,,,,,
ENDCAP SPNL LORDTC 15 DEG 14X22X19 MM MONOLITH,SUP-2567566,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT HUM TISS 10.5X71 MM QUADRICEPS TEND QUADLINK,SUP-2845956,CDM,C1762,CPT,0278,RC,,,,both,,,7347.60,4775.94,,,,,,,,,,,,,
COIL VASC AZUR L 26 CM DIA10 MM MICROCATHETER 0.035 IN LOOP,SUP-2385431,CDM,C1889,HCPCS,0278,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
SUPPORT EXT FIX OBLQ CONN RINGFIX,SUP-2472830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
BLADE SAW KNEE 18.5MM CUT EDGE 90MM CUT DEPTH 1.26MM CUT THI,SUP-2605517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,240.05,156.03,,,,,,,,,,,,,
ANCHOR SPNL FIX 15 MM COALITION MIS,SUP-2663503,CDM,C1889,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ENDCAP SPNL L10XW10MM 0DEG TI 4 LOBE SURG MESH LORDTC DMND,SUP-2317745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
HC So Lipoprotein A,PX-3018369566,CDM,83695,CPT,0301,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
SCREW BNE L25MM DIA6.28MM S STL CANC CANN LOK FULL THRD,SUP-2370998,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.23,201.65,,,,,,,,,,,,,
COMPONENT TIB AUG UNIV 47X51X10 MM KNEE OSS RS RD122160,SUP-2449999,CDM,C1776,CPT,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
SHEATH LD INTRO WORLEY ADV L 66 CM DIA 5.5 FR PEBAX HS,SUP-2497056,CDM,C1893,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COIL NEUROVASCULAR L 10 CM DIA 5 MM PLATINUM/TUNGSTEN,SUP-2895582,CDM,C1889,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
PLATE BNE L238MM 10X5 H S STL L DST LAT PERIARTC FEM LOK FOR,SUP-2372092,CDM,C1713,HCPCS,0278,RC,,,,both,,,4389.41,2853.12,,,,,,,,,,,,,
PLATE BNE L MIC XLN EXT 1.5 MM 12 MM LT BAR TI NS LEVEL 1,SUP-2458674,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.17,321.21,,,,,,,,,,,,,
LEAD DEFIB ENDOTK SQ ARRY XP L 70 CM SIL SUBQ SUTURE FIX DF1,SUP-2148542,CDM,C1895,HCPCS,0275,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
PLATE BNE L260MM 11 H NONSTERILE R PROX LAT TIB S STL LOK,SUP-2184883,CDM,C1713,HCPCS,0278,RC,,,,both,,,4072.89,2647.38,,,,,,,,,,,,,
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129223,CDM,2500000003,HCPCS,0250,RC,00781-3040-95,NDC,,both,0.4,ML,54.10,35.16,,,,,,,,,,,,,
SCREW SPNL L10MM DIA2MM CORT TI ST NONLOCKING FULL THRD,SUP-2189439,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST ADJ FIT STRP W/O JT FABRICATED,SUP-2435775,CDM,L3913,HCPCS,0274,RC,,,,both,,,697.80,453.57,,,,,,,,,,,,,
SCREW BNE L8MM DIA2MM CORT TI ST NONCANNULATED FULL THRD 0450360801] DEPUY SYNTHES USA],SUP-2181744,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
PLATE BONE L69MM 6 H STRL LT POSTEROLATERAL DSTL FIBULAR S,SUP-2349720,CDM,C1713,HCPCS,0278,RC,,,,both,,,3654.96,2375.72,,,,,,,,,,,,,
COMPONENT GLEN FIX L BILAT SHLDR POLYETH KEELED CONSTRN CEM,SUP-2399847,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT NERVE REP 4X2 CM SFT TISS MEMBRN AVIVE,SUP-2424161,CDM,C1762,CPT,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
SHEATH INTRO FARADRIVE TOT L 91 CM DIA13 FR L 74 CM STEER,SUP-2885431,CDM,C1766,CPT,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
HC Treat Big Toe Fx,PX-4502849000,CDM,28490,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
ENDOPROSTHESIS TRACHBRONCH VIABAHN L 5 CM DIA11 MM CATH L 75,SUP-2396466,CDM,C1874,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTIMAX L 1 CM DIA1 MM COMPLX SUPER SFT,SUP-2743542,CDM,C1889,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
COMPONENT TIB M 70MM KNEE SPCR ANTIBIO TREAT REMEDY,SUP-2319842,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SPACER SPNL W12XH18XL50MM 10DEG PEEK OPTMA COROENTXLCT,SUP-2310619,CDM,C1821,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PLATE BNE 3.5X49 MM 4 HOLE SS DCP,SUP-2569136,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.97,135.83,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 5.5MMW X25.5MML 0.6MM/0.8MM THK CUT BRAZO,SUP-2605487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,82.36,53.53,,,,,,,,,,,,,
CONNECTOR SPNL L13MM POST LAT OFFSET OPN MULTIAXIAL VERTEX,SUP-2286782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1320.53,858.34,,,,,,,,,,,,,
CATHETER PTCA L120CM L10CM ODSEC3MM .035IN PERIPH OVR THE,SUP-2128652,CDM,C1725,HCPCS,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
MESH HERNIAXL W10XH14IN INT ABD OMEGA 3 FATTY ACID POLYPR,SUP-2265991,CDM,C1781,HCPCS,0278,RC,,,,both,,,4741.40,3081.91,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 50 MCG PO TABS,RX-4421,CDM,6370000000,HCPCS,0637,RC,51079-0440-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET ORTH GRPHC CA W/ K WIRE FOR MOD MINI FRAG INSTR AND,SUP-2177067,CDM,C1713,HCPCS,0278,RC,,,,both,,,128032.09,83220.86,,,,,,,,,,,,,
IMPLANT TOE JT DIA11MM ZIRCONIUM ORTHOSPHERE,SUP-2399051,CDM,C1776,CPT,0278,RC,,,,both,,,7787.20,5061.68,,,,,,,,,,,,,
COIL EMB L20CM DIA5MM 3D V01 FRAMING,SUP-2280958,CDM,C1889,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
BLADE SURG SHT 60 MM,SUP-2363413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
BRACE THMB IP TO WR CREASE UP TO 3 3/4INXSM COLLUM CMC REG,SUP-2324972,CDM,L3931,HCPCS,0272,RC,,,,both,,,70.08,45.55,,,,,,,,,,,,,
PLATE BONEXL THK2MM 5X22X5 H MAND TI DBL ANG LCKING FOR 2MM,SUP-2191276,CDM,C1713,HCPCS,0278,RC,,,,both,,,9416.23,6120.55,,,,,,,,,,,,,
LINER APR NEUTRAL STANDARD POLY 22X41MM,SUP-2508858,CDM,C1776,CPT,0278,RC,,,,both,,,2898.22,1883.84,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 22X45 MM PRESERVON TRICORT MATRIGRAFT,SUP-2741055,CDM,C1713,HCPCS,0278,RC,,,,both,,,4843.95,3148.57,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY 16 IN,SUP-2336079,CDM,L1830,CPT,0272,RC,,,,both,,,40.29,26.19,,,,,,,,,,,,,
GRAFT BONE 5ML DEMIN MTRX PASTE OSTEOFIL RT,SUP-2278379,CDM,C1713,HCPCS,0278,RC,,,,both,,,2210.56,1436.86,,,,,,,,,,,,,
PLATE BNE STR 2.4 MM 6 HOLE TI GLD NS LTX,SUP-2856964,CDM,C1713,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
ARM IMMOB W ABDUCTION PLLW MED,SUP-2196389,CDM,L3670,HCPCS,0272,RC,,,,both,,,83.43,54.23,,,,,,,,,,,,,
PLATE BNE SET FOR SM FRAG PERI-LOC,SUP-2351407,CDM,C1713,HCPCS,0278,RC,,,,both,,,63600.70,41340.45,,,,,,,,,,,,,
SET LD INTRO FLOWGUARD L 20 CM DIA 7 FR 12 ML ART VLV,SUP-2281862,CDM,C1894,HCPCS,0272,RC,,,,both,,,105.35,68.48,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 85 CM DIA 8 MM RNG L 45 CM,SUP-2495572,CDM,C1768,CPT,0278,RC,,,,both,,,3162.92,2055.90,,,,,,,,,,,,,
DEVICE EMBOLIC PROTCT SPIDERFX WIRE L 190 CM DIA 0.014 IN,SUP-2173562,CDM,C1884,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SUPPORT ORTHOT FNGR W/NONTORSION JT FABRICATED SFT INTFACE,SUP-2435790,CDM,L3935,HCPCS,0272,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
PORT INFUS 8FR TI PWR INJ ATTACH CHRONOFLEX CATH SIL FIL SUT,SUP-2127820,CDM,C1788,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
GRAFT VASC STP 4-7 MMX50 CM STD WALL CARBOFLO CENTERFLEX,SUP-2761414,CDM,C1768,CPT,0278,RC,,,,both,,,2522.36,1639.53,,,,,,,,,,,,,
PUMP ONLY KT SEL A FLOW 270ML X1 THRU 7ML PER HR ON Q,SUP-2236853,CDM,C9804,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
CANNULA VEN 24FR 60CM W/ 21FR INTRO CARDPULM PROTEKSOLO,SUP-2152642,CDM,C1889,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE L 156 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 13 H 72466013N,SUP-2933194,CDM,C1713,HCPCS,0278,RC,,,,both,,,5694.39,3701.35,,,,,,,,,,,,,
STRAP SPLNT NYL WHT 2INX14IN ROLYAN D RNG,SUP-2324780,CDM,L3908,HCPCS,0272,RC,,,,both,,,9.11,5.92,,,,,,,,,,,,,
FLUCYTOSINE 500 MG PO CAPS,RX-10052,CDM,6370000000,HCPCS,0637,RC,43386-0770-01,NDC,,both,1,UN,90.00,58.50,,,,,,,,,,,,,
COMPONENT ARTC SURF CR 3-4 CH 14 MM TIB KNEE YEL NXGN,SUP-2201356,CDM,C1776,CPT,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
PROPHECY PATIENT SPEC GUIDES FOR INVISION WITH FOOTPRINT,SUP-2830301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3852.78,2504.31,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM WDG SHP CANN ROUNDED THRD CRUCE,SUP-2366626,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.79,447.06,,,,,,,,,,,,,
HC So Hepatitis B Surface Ag - Ref,PX-3068734067,CDM,87340,CPT,0306,RC,,,,both,,,21.00,13.65,,,,,,,,,,,,,
BUR SURG L 13 MM DIA 3 MM NEURO CUT STRL DISP ELAN 4 MIS,SUP-2929030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.12,304.93,,,,,,,,,,,,,
HC So2 Column Chromotography Quant,PX-3018254268,CDM,82542,CPT,0301,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
PROPOFOL BOLUS 10 MG/ML SOLN (WRAPPER),RX-430074,CDM,J2704,HCPCS,0636,RC,00409-4699-33,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE VASC WORKER 150CM 0.035IN 6.5CM 7.5CM AMPLTZ J CRV,SUP-2876080,CDM,C1769,HCPCS,0272,RC,,,,both,,,252.46,164.10,,,,,,,,,,,,,
COIL NEUROVASCULAR MICRUSPHERE 10 L 25 CM DIA 9 MM PRIMARY,SUP-2457861,CDM,C1889,HCPCS,0278,RC,,,,both,,,5388.18,3502.32,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X229 MM RT LAT DSTL 15 HOLE SS,SUP-2184167,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.27,1261.18,,,,,,,,,,,,,
STEM XL POROUS 16.5X170MM BOWED,SUP-2504978,CDM,C1776,CPT,0278,RC,,,,both,,,8214.24,5339.26,,,,,,,,,,,,,
ORTHOPAEDIC KIT ATLS,SUP-2761973,CDM,C1713,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
CATHETER NEPHROSTOMY CANN 12 FRX19.5 CM COPE LOOP,SUP-2835682,CDM,C1729,HCPCS,0272,RC,,,,both,,,265.80,172.77,,,,,,,,,,,,,
CANNULA ENDOSCP 11GA L120MM END DEL ACCUPORT,SUP-2414253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 70 CM EPTFE STR TW,SUP-2396161,CDM,C1768,CPT,0278,RC,,,,both,,,4135.38,2688.00,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PROTEGO TD W 5 X L 65 CM D 1.3 CM DIA2.6,SUP-2138099,CDM,C1895,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET DISTAFLEX L 145 CM DIA 4/3 FR,SUP-2664299,CDM,C1757,HCPCS,0272,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY DIA 5 FR SPC 5 MM BND 1,SUP-2102297,CDM,C1730,HCPCS,0272,RC,,,,both,,,476.97,310.03,,,,,,,,,,,,,
SHEATH URO L30CM DIA30FR NEPHSTMY TRACT CONT FLO OPQ AMPLTZ,SUP-2168948,CDM,C1894,HCPCS,0272,RC,,,,both,,,112.54,73.15,,,,,,,,,,,,,
CAGE SPNL W17XH7IN D14IN 7DEG LORDTC CERV HI STRENGTH FOR,SUP-2101161,CDM,C1889,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCREW BNE SLD 6.5X10 MM PEDCL THRESHOLD,SUP-2435244,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
COMPONENT PAT SM DUR KNEE KINEMATIC,SUP-2376390,CDM,C1776,CPT,0278,RC,,,,both,,,1979.61,1286.75,,,,,,,,,,,,,
COLLAR CERV ADJ XL 20X3 IN COTTON MED DENS PREMIERPRO,SUP-2335997,CDM,L0120,HCPCS,0274,RC,,,,both,,,22.55,14.66,,,,,,,,,,,,,
GUIDEWIRE INTRMDLLRY NAIL 32MM SHAFT 60CML SMTH/BLNT TIPS,SUP-2726657,CDM,C1769,HCPCS,0272,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
GRAFT BNE BIPHASIC 18 CC 2 STRP OSTEOMATRIX +,SUP-2499102,CDM,C1713,HCPCS,0278,RC,,,,both,,,6005.85,3903.80,,,,,,,,,,,,,
HOLDER HK OFFSET,SUP-2232087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2216.84,1440.95,,,,,,,,,,,,,
BUNDLE CASE DISTRCTN CRAN MXLFCL 3 FULL SKULL RECON VSP,SUP-2862827,CDM,2720000010,LOCAL,0272,RC,,,,both,,,24538.38,15949.95,,,,,,,,,,,,,
BRACE THMB W ADJUSTABLE STRP UNIV,SUP-2276642,CDM,L3931,HCPCS,0274,RC,,,,both,,,12.21,7.94,,,,,,,,,,,,,
TUBE VENT ID1.32MM BLU SIL T MOD FOR MYR RICHARDS 6PK,SUP-2313723,CDM,L8699,HCPCS,0278,RC,,,,both,,,78.09,50.76,,,,,,,,,,,,,
RADIAL STYLOID LK PL 5H R,SUP-2726464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
K WIRE FIX DIA1.6MM THRD TIP,SUP-2413866,CDM,C1713,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
TAP SURG DIA3.5MM QUIK CONN FOR DSTL RAD ULN JT PROS,SUP-2119936,CDM,C1776,CPT,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
EVOS TI 3.5MMX11MM LCK SCREW T15 S-T,SUP-2821484,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.12,437.53,,,,,,,,,,,,,
HC So Antithyroglobulin Antibody|ADJ,PX-3028680066,CDM,86800,CPT,0302,RC,,,ADJ,both,,,69.00,44.85,,,,,,,,,,,,,
PLATE BNE L24MM THK075MM 6 H NONSTERILE HND TI STR LOK FOR,SUP-2180985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1286.58,836.28,,,,,,,,,,,,,
BIT DRL TWST 1.5X19 MM ANGULUS 2,SUP-2463344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.09,361.46,,,,,,,,,,,,,
CATHETER ANGIOPLSTY AGNT L 144 MM BALLOON L 12 MM DIA2.25 MM,SUP-2892819,CDM,C2623,HCPCS,0278,RC,,,,both,,,19389.50,12603.17,,,,,,,,,,,,,
CAP ORTH FEM LCK TAPR COMPR,SUP-2406937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CAP END STANDARD PANTA STERILE,SUP-2586600,CDM,C1889,HCPCS,0278,RC,,,,both,,,1145.28,744.43,,,,,,,,,,,,,
SYSTEM REPAIR MENISCAL AIR+ CURVED UP,SUP-2749430,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 400 MG/20ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-167521,CDM,Q5135,HCPCS,0636,RC,65219-0594-20,NDC,JW,both,20,ML,5777.30,3755.24,,,,,,,,,,,,,
PATCH BIO W6XL8CM DECELLULARIZED BOV PERICARD RECTANG,SUP-2175266,CDM,C1763,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.431,SUP-2859995,CDM,C1713,HCPCS,0278,RC,,,,both,,,42012.57,27308.17,,,,,,,,,,,,,
SHOE ORTHOT CALIP PLATE EXISTING TRANSFER,SUP-2435745,CDM,L3600,HCPCS,0272,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
PLATE BNE L81MM 7 H S STL 1/3 TBLR LOK COMPR W/ CLLR FOR,SUP-2185932,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.77,300.15,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-7 MM SHRT TAPR DBL SLDE,SUP-2669697,CDM,C1768,CPT,0278,RC,,,,both,,,1766.82,1148.43,,,,,,,,,,,,,
TAPE FIBER CARCLAGE W/ TIGER LINK (ORDER MUTLIPLES OF 5 EACH),SUP-2749337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
BLADE SAW W165MM D20MM CUT THK6MM FOR L BNE GRFT HARV HALL,SUP-2166096,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.22,233.49,,,,,,,,,,,,,
GRAFT HUMAN TISSUE AMNIOBAND MEMBRANE 5CMX6CM,SUP-2858220,CDM,Q4151,HCPCS,0636,RC,,,,both,,,14463.28,9401.13,,,,,,,,,,,,,
CATHETER GUID WINGMAN 14 L 135 CM OD 0.035 IN TIP DIA 0.022,SUP-2227763,CDM,C1887,HCPCS,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SEED BRACHYTHERAPY IODINE-125 NS ADVANTAGE,SUP-2247255,CDM,C2638,HCPCS,0278,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
STEM HUM 11MM MINI SHLDR CO CHROM COMPHSVE REV PRI CEM,SUP-2404564,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SUPPORT KNEE THGH CIRC 12 15IN XSM SLIP ON NEOPRENE OPN PAT,SUP-2150846,CDM,L1810,HCPCS,0272,RC,,,,both,,,69.71,45.31,,,,,,,,,,,,,
PLATE BONE THK0.5MM 2 H STR FOR 1.7MM SCR DELT,SUP-2365073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.06,820.34,,,,,,,,,,,,,
PLATE BNE L 59 MM 4 H LT DSTL VOLAR RADIAL STD EXT STRL,SUP-2902195,CDM,C1713,HCPCS,0278,RC,,,,both,,,5415.02,3519.76,,,,,,,,,,,,,
GRAFT BNE SUB 1CC DEMIN BNE MTRX OSTEOCONDUCTIVE STRATOFUSE,SUP-2164153,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
KIT CATH EPIDRL NDL L3.5IN OD17GA FLEXTIP + CATH,SUP-2384036,CDM,C1755,HCPCS,0278,RC,,,,both,,,124.09,80.66,,,,,,,,,,,,,
SPACER SPNL 7 DEG 14X12 MM 12 MM UPPER ENDPLATE FORTIFY I,SUP-2584699,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BRACE STRNL PD KT TLSO BLK SM,SUP-2123926,CDM,L0462,HCPCS,0274,RC,,,,both,,,281.60,183.04,,,,,,,,,,,,,
JIG SURG TARGETING ACCS 57104] CONVENTUS ORTHOPAEDICS],SUP-2167391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
GRAFT HERN 20X30CM DERM PORCINE TISS RECON PERF STRATTICE,SUP-2113040,CDM,Q4130,HCPCS,0636,RC,,,,both,,,59405.66,38613.68,,,,,,,,,,,,,
PLATE BONE 189MML HLX16 STNLSS STEEL STRGHT RCNSTRCTN F/3.5M,SUP-2475827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.59,935.08,,,,,,,,,,,,,
PLATE BNE L 48 MM SCREW DIA2.7 MM 6 H LCK RECON STRL EVOS,SUP-2931393,CDM,C1713,HCPCS,0278,RC,,,,both,,,2211.56,1437.51,,,,,,,,,,,,,
PLATE BNE L182MM THK37MM 14 H R J S STL LO PROF RIG RECON,SUP-2177163,CDM,C1713,HCPCS,0278,RC,,,,both,,,2697.98,1753.69,,,,,,,,,,,,,
PUSHER ROD,SUP-2232113,CDM,C1713,HCPCS,0278,RC,,,,both,,,3783.70,2459.40,,,,,,,,,,,,,
GRAFT VASC VECTRA L 50 CM DIA 6 MM POLYUR STR STD WALL N,SUP-2761534,CDM,C1768,CPT,0278,RC,,,,both,,,3502.04,2276.33,,,,,,,,,,,,,
PLATE SPNL RT STD POST S STL COLORADO 2 SACR AND SACROILIAC,SUP-2290566,CDM,C1713,HCPCS,0278,RC,,,,both,,,9134.26,5937.27,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF 115CM 8FR DD,SUP-2248620,CDM,C1732,HCPCS,0272,RC,,,,both,,,9492.22,6169.94,,,,,,,,,,,,,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135014,CDM,Q9968,HCPCS,0636,RC,00517-0374-05,NDC,,both,10,ML,1347.80,876.07,,,,,,,,,,,,,
SCREW BONE L40MM DIA9.5MM THRD L12.7MM S STL INTERMED LAG,SUP-2343606,CDM,C1713,HCPCS,0278,RC,,,,both,,,4142.29,2692.49,,,,,,,,,,,,,
INSERT ANK THK 11 MM SZ 1 UHMWPE RT FIX MOD REV STRL SALTO,SUP-2931148,CDM,C1776,CPT,0278,RC,,,,both,,,5626.88,3657.47,,,,,,,,,,,,,
OBTURATOR SURG LSR CUT TRANSOBT GYNECARE TVT,SUP-2218517,CDM,C1771,HCPCS,0278,RC,,,,both,,,6620.44,4303.29,,,,,,,,,,,,,
TECHNETIUM TC 99M SESTAMIBI - MIRALUMA,RX-4080060,CDM,A9500,HCPCS,0343,RC,,,,both,1,UN,97.00,63.05,,,,,,,,,,,,,
KIT CATH REP 2.7FR SGL LUMN W/ TISS INGROWTH CUF BASIC TY,SUP-2127717,CDM,C1894,HCPCS,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PLATE BNE L193MM 8 H R DST FEM LOK FOR 4.5MM SCR PERI-LOC,SUP-2348460,CDM,C1713,HCPCS,0278,RC,,,,both,,,10568.93,6869.80,,,,,,,,,,,,,
PLATE BNE BAR 14 MM 6 H LNG CRANIOMAXILLOFACIAL SAG SPLIT,SUP-2883177,CDM,C1713,HCPCS,0278,RC,,,,both,,,1408.67,915.64,,,,,,,,,,,,,
BUR DMND PEAR AUTOCLV,SUP-2227830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
PACEMAKER CARD EDORA DR-T W 44 X H 48 MM D 6.5 MM 11 CC 23,SUP-2138476,CDM,C1785,HCPCS,0275,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
STAPLER INT 20X15X15 MM NIT MEMOFIX,SUP-2609680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5736.84,3728.95,,,,,,,,,,,,,
GRAFT BNE W10 30XL50 130MM THK1 20MM RIB FRZ DRY SEG,SUP-2307186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1585.92,1030.85,,,,,,,,,,,,,
CATHETER EP LG 2-5-2 MM 5 FRX110 CM INQUIRY,SUP-2102278,CDM,C1730,HCPCS,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
COMPONENT FEM SZ 9 R KNEE CO CHROM CEM POST STBL MOD LO,SUP-2378547,CDM,C1776,CPT,0278,RC,,,,both,,,12497.20,8123.18,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 5 FR L 4 CM SS PED,SUP-2170540,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.98,56.54,,,,,,,,,,,,,
GRAFT VASC STR 8 MMX70 CM RADIALLY SUPP POLYESTER INTEGARD,SUP-2227576,CDM,C1768,CPT,0278,RC,,,,both,,,2976.09,1934.46,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG BVL 1.14 MM ID FLROPLAS ARMSTR,SUP-2312595,CDM,L8613,CPT,0278,RC,,,,both,,,30.40,19.76,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 110 X 97.5 X 5.25 MM POLYETHYL CRAN WFL,SUP-2936211,CDM,C1713,HCPCS,0278,RC,,,,both,,,15552.42,10109.07,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 300 CM DIA 0.018 IN SS SIL STR SHRT,SUP-2148323,CDM,C1769,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
PLATE BNE HUM 4.5/6.5X107 MM RT PROX LAT 4 HOLE BUTTRESS,SUP-2464138,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.18,1466.52,,,,,,,,,,,,,
FORCEP SURG RATCH 8 IN 5X15 MM LAUFE LCK FNGR RNG HNDL CRV,SUP-2245498,CDM,C1713,HCPCS,0278,RC,,,,both,,,192.04,124.83,,,,,,,,,,,,,
BALLOON ULTRASONIC FOR BF-UC160F E,SUP-2313245,CDM,C1725,HCPCS,0272,RC,,,,both,,,90.62,58.90,,,,,,,,,,,,,
NEEDLE KIT 45 MM SET MANUAL DISP,SUP-2759199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT BNE SUB 16X10MM DBM MTRX PLUG GRFTON,SUP-2278335,CDM,C1713,HCPCS,0278,RC,,,,both,,,2064.61,1342.00,,,,,,,,,,,,,
TRAY PICC 5FR L55CM 2 LUMN CATH FULL NRS POWERPICC SV,SUP-2125539,CDM,C1751,HCPCS,0278,RC,,,,both,,,448.24,291.36,,,,,,,,,,,,,
PI PICC 1-LUMEN: 4FRX50CM WITH 80CM SS S,SUP-2826701,CDM,C1751,HCPCS,0278,RC,,,,both,,,330.33,214.71,,,,,,,,,,,,,
CATHETER DIL 11.5FR L200CM TAPR TIP 7FR L3CM 0.035IN TO DIL,SUP-2169250,CDM,C1729,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
DONGLE USB UPGRD CROSSFLOW,SUP-2908612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER THERMODILUTION LUMENX7 8FRX110CM COMB SWN GZ,SUP-2214322,CDM,C1751,HCPCS,0278,RC,,,,both,,,815.14,529.84,,,,,,,,,,,,,
SCREW SET XCR TRAUM,SUP-2366045,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 18 MM CABLE L 2 M 2 CHANNEL PRASS PR,SUP-2901967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,529.00,343.85,,,,,,,,,,,,,
PLATE BNE W11XL138MM THK33MM 10 H BILAT MTPHSEAL TI LOK,SUP-2190764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.93,1827.75,,,,,,,,,,,,,
GUIDEWIRE ORTH 11/32X222 MM FOR TI FIX NAIL LCK SET,SUP-2188219,CDM,C1769,HCPCS,0272,RC,,,,both,,,1525.85,991.80,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD CUP HD LNR ST TRAB MTL XLPE,SUP-2212323,CDM,C1776,CPT,0278,RC,,,,both,,,17210.37,11186.74,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE MRI W 4.45 X H 5.02 CM THK 0.75 CM,SUP-2149251,CDM,C1785,HCPCS,0275,RC,,,,both,,,9036.92,5874.00,,,,,,,,,,,,,
TUBE ET OD11.2/13MM ID7.5MM INFL VOL 40ML SIL FLEX WIRE,SUP-2383582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
STAPLE EXT 8X8X8 MM DYNACLIP,SUP-2537987,CDM,C1713,HCPCS,0278,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
ENVELOP TISS LG 8X6.9 CM SFT SUPPLE CORMATRIX CANGAROO EMC,SUP-2653869,CDM,C1889,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
INTRODUCER TUBE CATH 14 FRX70 CM STIFFENING STYL INTUB FROVA,SUP-2759925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,323.07,210.00,,,,,,,,,,,,,
PLATE BNE LG DSTL MEDL TIB SUPRAMALLEOLAR OSTEOTOM NS,SUP-2898977,CDM,C1713,HCPCS,0278,RC,,,,both,,,5163.73,3356.42,,,,,,,,,,,,,
GRAFT BNE SUB SM 20CC DBM BIOCOMPOSITE OSTEOSET CANC CHIP,SUP-2399075,CDM,C9359,HCPCS,0278,RC,,,,both,,,6774.80,4403.62,,,,,,,,,,,,,
HC MRI-Chest WO Contrast,PX-6107155000,CDM,71550,CPT,0610,RC,,,,inpatient,,,4190.00,2723.50,,,,,,,,,,,,,
LIFT HEEL MED 2.5 IN WDG 3 LAYR ORTHOT FT FABRIC BRN ADJLFT,SUP-2325936,CDM,L3332,HCPCS,0274,RC,,,,both,,,18.37,11.94,,,,,,,,,,,,,
SCREW BNE FT 4.5X8 MM DARCO,SUP-2400983,CDM,C1713,HCPCS,0278,RC,,,,both,,,782.49,508.62,,,,,,,,,,,,,
CANNULA ENDOSCP TERMANIAN ENDOTIP 6 MMX8.5 CM W/ THRD,SUP-2776349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1906.17,1239.01,,,,,,,,,,,,,
EVOS LARGE TGTR 2.5MM DRILL W/AO QC,SUP-2931251,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
ELECTRODE ELECSURG PED 11.5FR HK FOR RESECTSCP,SUP-2332848,CDM,C1713,HCPCS,0278,RC,,,,both,,,437.72,284.52,,,,,,,,,,,,,
DEVICE FIX W/ 15MM TI HELI TACK PSTL GRP DISP STAT TACK,SUP-2283318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.48,303.21,,,,,,,,,,,,,
BLADE RTRCTR BKWLTR KELLY MDFD STNDRD 2INW X 2 12ND,SUP-2706031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
GRAFT BNE SUB 3CC CA PHSPTE HA PTTY INJ HYDROSET,SUP-2371661,CDM,C1713,HCPCS,0278,RC,,,,both,,,3331.85,2165.70,,,,,,,,,,,,,
SPACER SPNL W22XH10XL60MM 8DEG 4.2CC STD LAT LUM PEEK OPTMA,SUP-2137134,CDM,C1821,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
GLYCERIN EX LIQD,RX-28813,CDM,340b,HCPCS,0637,RC,37205-0011-30,NDC,,both,177,ML,28.70,18.65,,,,,,,,,,,,,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV,RX-135994,CDM,2500000003,HCPCS,0250,RC,44567-0641-01,NDC,,both,250,ML,281.80,183.17,,,,,,,,,,,,,
SUPPORT ORTHOT PIP FNGR DSTL INTERPHALANGEAL SPRING W/JT,SUP-2435784,CDM,L3925,HCPCS,0272,RC,,,,both,,,169.25,110.01,,,,,,,,,,,,,
CEFIDEROCOL SULFATE TOSYLATE 1 G IV SOLR,RX-149129,CDM,J0699,HCPCS,0636,RC,59630-0266-10,NDC,,both,1,UN,1338.90,870.28,,,,,,,,,,,,,
MESH SURG 20X25CM W/ POS SYS ECHO 2 VENTRALIGHT ST,SUP-2125930,CDM,C1781,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 30 CM DIA 8 MM EPTFE CARBON FLX,SUP-2761439,CDM,C1768,CPT,0278,RC,,,,both,,,2233.33,1451.66,,,,,,,,,,,,,
BIT DRL PILOT TIP LNG 5 MM IM PROX W/ STP SS NS M/DN,SUP-2467232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,807.26,524.72,,,,,,,,,,,,,
MESH HERN LG 4.1X6.3 IN ANAT O3FA FIL COAT C-QUR CENTRIFX,SUP-2227254,CDM,C1781,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
SPACER SPNL SM W8.5XH7MM D20MM 5DEG LORDOSIS POST RAMP,SUP-2279965,CDM,C1889,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
STEM ULN 55MM R STR PRSS FIT TI SOLAR,SUP-2372332,CDM,C1713,HCPCS,0278,RC,,,,both,,,14086.98,9156.54,,,,,,,,,,,,,
CUP ACET FLNG C HIP CUST,SUP-2419096,CDM,C1776,CPT,0278,RC,,,,both,,,42704.00,27757.60,,,,,,,,,,,,,
SCREW SPNL L30MM DIA6.25MM CANC ANTR PEDCL TI MNRCH,SUP-2254476,CDM,C1713,HCPCS,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
CATHETER UROLOGICAL L 75 CM DIA 5.3 FR SIL BALLOON UPJ OCCL,SUP-2822051,CDM,C2628,HCPCS,0272,RC,,,,both,,,430.27,279.68,,,,,,,,,,,,,
HC Peripheral Nerve Neurolysis,PX-3600007519,CDM,3600007519,LOCAL,0360,RC,,,,outpatient,,,9630.00,6259.50,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 5 MM DEL SHTH 2ML,SUP-2936807,CDM,C1713,HCPCS,0278,RC,,,,both,,,6897.17,4483.16,,,,,,,,,,,,,
GRAFT BNE SUB W25XH8XL100MM 20ML SIL SOD CA PHOS OXIDE FOAM,SUP-2368188,CDM,C1713,HCPCS,0278,RC,,,,both,,,8160.08,5304.05,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1295108FD2,SUP-2632815,CDM,C1751,HCPCS,0278,RC,,,,both,,,1003.80,652.47,,,,,,,,,,,,,
HC Carcinoembryonic Antigen Cea,PX-3018237800,CDM,82378,CPT,0301,RC,,,,both,,,334.00,217.10,,,,,,,,,,,,,
HUMERAL TRAY +3 STD SHLDR TI COMPHSVE,SUP-2431693,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
UB BLADE MALLEABLE 6IN X 12IN,SUP-2672839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1414.00,919.10,,,,,,,,,,,,,
SCREW BNE L25MM DIA4.5MM TIB KNEE GRY TI FULL THRD HEX DRV,SUP-2347227,CDM,C1713,HCPCS,0278,RC,,,,both,,,1422.39,924.55,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 6 MM L 70CM STR STD WALL,SUP-2396271,CDM,C1768,CPT,0278,RC,,,,both,,,4600.10,2990.06,,,,,,,,,,,,,
DRILL SURG L 185 MM DIA 3.5 MM FREE HND STRL DISP T2 ALPHA,SUP-2902355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1103.11,717.02,,,,,,,,,,,,,
PLATE BNE L159MM 6 H ST R CNDYL S STL CRV LOK COMPR VAR ANG,SUP-2177846,CDM,C1713,HCPCS,0278,RC,,,,both,,,5918.21,3846.84,,,,,,,,,,,,,
HC So Platelet Aggr(Invitro) Ea Agnt,PX-3058557666,CDM,85576,CPT,0305,RC,,,,outpatient,,,111.00,72.15,,,,,,,,,,,,,
PROBE SURG WORST 9 MMX5.9 IN PGTL CRV BLNT RND KNURLED HNDL,SUP-2465763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,616.38,400.65,,,,,,,,,,,,,
HC Asp Injection Major Joint|RIGHT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-4502061000,CDM,20610,CPT,0450,RC,,,RT|73,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
CATHETER KIT 7 FRX55 CM 30 FRX12 CM NEPHROSTOMY LP NEPHROMAX,SUP-2141676,CDM,C1726,HCPCS,0272,RC,,,,both,,,1046.03,679.92,,,,,,,,,,,,,
PIN FIX SERR FOR SCORP FEM BLK,SUP-2378533,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450395301,SUP-2844117,CDM,C1713,HCPCS,0278,RC,,,,both,,,13174.94,8563.71,,,,,,,,,,,,,
PLATE BONE 3 H STRL BILAT 1/4 TBLR COMPR FOR 2.7MM SCR VLP,SUP-2349935,CDM,C1713,HCPCS,0278,RC,,,,both,,,4294.58,2791.48,,,,,,,,,,,,,
INSERT TIB SZ 1 THICKNESS 9MM KNEE SL IMP MOST OPTIONS,SUP-2208280,CDM,C1776,CPT,0278,RC,,,,both,,,6415.02,4169.76,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 90 CM DIA 5 FR SLT PAT L 5 CM,SUP-2118499,CDM,C1757,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
BIT DRL L260MM DIA11MM CANN FOR IM LIMB LENGTHENING SYS,SUP-2312223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
POROUS FINN STEM 152MMX17.5MM,SUP-2510737,CDM,C1776,CPT,0278,RC,,,,both,,,4448.12,2891.28,,,,,,,,,,,,,
DEFIBRILLATOR IMPL UNIFY QUADRA W 41 X H 75 MM THK 14 MM 45,SUP-2357559,CDM,C1900,HCPCS,0275,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
HC Dysphagia Therapy,PX-4409252600,CDM,92526,CPT,0440,RC,,,,both,,,347.00,225.55,,,,,,,,,,,,,
PROSTHESIS OSS L 2 MM DIA1.1 MM HD DIA 3.25 MM TI HA PART DP,SUP-2902095,CDM,L8613,CPT,0278,RC,,,,both,,,1585.57,1030.62,,,,,,,,,,,,,
PEG BNE FIX L24MM DIA2.5MM DST VOLAR RAD PARTIALLY THRD FOR,SUP-2414246,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
PLATE BNE STR MIC MED 1.5 MM CRANIOMAXILLOFACIAL 4 HOLE TI,SUP-2465718,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.69,166.20,,,,,,,,,,,,,
PLATE BNE L48MM 3X8 H TI Y SHP FOR 2MM SCR,SUP-2191309,CDM,C1713,HCPCS,0278,RC,,,,both,,,1592.45,1035.09,,,,,,,,,,,,,
PLATE BNE L141MM 12 H S STL 1/3 TBLR LOK COMPR W/ CLLR FOR,SUP-2185941,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.66,328.03,,,,,,,,,,,,,
GRAFT ADIPOSE MATRIX 1.5CC LENEVA,SUP-2857969,CDM,C1762,CPT,0278,RC,,,,both,,,3692.64,2400.22,,,,,,,,,,,,,
BIT DRL 3.8X45 MM QUICKSET,SUP-2454002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,779.98,506.99,,,,,,,,,,,,,
GRAFT HUM TISS L 80 MM FIB SHFT LYOPH,SUP-2913231,CDM,C1762,CPT,0278,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
DRESSING NSL 8CM NASOPORE FD,SUP-2367695,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.02,469.96,,,,,,,,,,,,,
STENT CORONARY XIENCE SKYPOINT L 48 MM DIA 3 MM SYS L 145 CM,SUP-2928550,CDM,C1874,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
BURR SURG 64X5.0MM RND CUT NEURO L NONFLUTED CARB ST,SUP-2284255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,614.06,399.14,,,,,,,,,,,,,
DRILL SRGCL TWIST MRRSN STYLE 22MM DIA 105MML CLNDRCL F/LVL,SUP-2681045,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.83,414.59,,,,,,,,,,,,,
ANCHOR SUTURE 1-0 SHT 1.4X1 MM SINGLE LD WHT JUGGERKNOT,SUP-2745512,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 40 CM DIA10 MM EXTERNALLY SUPP,SUP-2475869,CDM,C1768,CPT,0278,RC,,,,both,,,5830.79,3790.01,,,,,,,,,,,,,
ANCHOR NEUROSTIMULATOR 2CM SPNL CRD PERC LD LOK SYS FOR,SUP-2141929,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC MRI - Tmj Unilat or Bilat,PX-6107033600,CDM,70336,CPT,0610,RC,,,,outpatient,,,4365.00,2837.25,,,,,,,,,,,,,
IMIPRAMINE HCL 10 MG PO TABS,RX-3860,CDM,6370000000,HCPCS,0637,RC,64380-0169-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT DURA W2XL2IN REABSORBABLE MTRX SUB FOR SFT TISS REP,SUP-2244081,CDM,C1763,HCPCS,0278,RC,,,,both,,,953.18,619.57,,,,,,,,,,,,,
LANSOPRAZOLE 15 MG PO TBDD,RX-34594,CDM,6370000000,HCPCS,0637,RC,16714-0185-01,NDC,,both,1,UN,40.20,26.13,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 20 CM DIA 6 MM POLYESTER BOV CLLGN STR,SUP-2227526,CDM,C1768,CPT,0278,RC,,,,both,,,1401.29,910.84,,,,,,,,,,,,,
SPLINT ORTH HND M 80DEG PLAS R MTCRPL JT W O STRP BRN,SUP-2112605,CDM,L3807,HCPCS,0272,RC,,,,both,,,167.71,109.01,,,,,,,,,,,,,
HC So Hiv Genotype for Retrov Resist,PX-3068790166,CDM,87901,CPT,0306,RC,,,,inpatient,,,1147.00,745.55,,,,,,,,,,,,,
SHEATH INTRO FLX L 80 CM OD 10 FR GUIDEWIRE 0.038 IN SM,SUP-2168816,CDM,C1894,HCPCS,0272,RC,,,,both,,,243.66,158.38,,,,,,,,,,,,,
FIBERTAPE STERNAL CLOSURE WITH CUTTING NDL,SUP-2814066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SMALL PLATE 3X37MM 3.5MM,SUP-2820874,CDM,C1713,HCPCS,0278,RC,,,,both,,,1041.66,677.08,,,,,,,,,,,,,
CATHETER INT AORT BAL ULT 8 40CC,SUP-2383462,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
BURR SURG 4MM DIA HD XLN MIC 95MML SM BNE RND DIAMOND MICROP,SUP-2605581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 20 HOLE CRV,SUP-2424069,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.97,1096.53,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X197 MM 11 HOLE SS LCP,SUP-2569364,CDM,C1713,HCPCS,0278,RC,,,,both,,,689.07,447.90,,,,,,,,,,,,,
RIGEL CERV PRNT 12MMX12MMX7MMX6 CGE TI 3D,SUP-2664102,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-137305,CDM,J3370,HCPCS,0636,RC,71506-0048-59,NDC,,both,500,ML,146.70,95.35,,,,,,,,,,,,,
DEVICE NEUROSTIMULATOR 13.9CC W1.9XH2.2IN 29.1GM RECHRG,SUP-2284637,CDM,C1820,HCPCS,0278,RC,,,,both,,,58356.90,37931.98,,,,,,,,,,,,,
SPLINT A SPA BALL SP S LF,SUP-2163829,CDM,L3807,HCPCS,0274,RC,,,,both,,,108.33,70.41,,,,,,,,,,,,,
CATHETER INFUS 5FR 10CM INFUS LEN 90CM LEN - 5FR 10CM INFUS,SUP-2117006,CDM,C1751,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
KIT DISP MINI W/ AC 1 SEP TUBE TWO 30ML SYR 1 10ML SYR 1,SUP-2402585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
VALVE CSF ULTRAVS NL8501129,SUP-2666750,CDM,C1889,HCPCS,0278,RC,,,,both,,,3037.48,1974.36,,,,,,,,,,,,,
PLATE BNE L37MM 3X3 H ST DST DORS RAD S STL T SHP LOK COMPR,SUP-2177504,CDM,C1713,HCPCS,0278,RC,,,,both,,,2179.60,1416.74,,,,,,,,,,,,,
CAGE SPNL T2 XVBR CENTERPIECE TI COCR NIT 4 DEG L22 MM,SUP-2292819,CDM,C1889,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 75 CM OD 5 FR ID 1.7 MM 0.035IN,SUP-2168789,CDM,C1894,HCPCS,0272,RC,,,,both,,,213.21,138.59,,,,,,,,,,,,,
BLADE SHAVER RESECT 5.5X130 MM CRV CONCV SMOOTH DISP,SUP-2661227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.05,287.98,,,,,,,,,,,,,
GRAFT VASC INTERGARD BODY/BRANCH L 85/55 CM RNG L 45/20 CM,SUP-2227603,CDM,C1768,CPT,0278,RC,,,,both,,,5221.19,3393.77,,,,,,,,,,,,,
METOPROLOL SUCCINATE ER 50 MG PO TB24,RX-30070,CDM,6370000000,HCPCS,0637,RC,00904-6323-61,NDC,,both,1,UN,4.80,3.12,,,,,,,,,,,,,
CATHETER HD DL 14.5 FRX23 CM CHRONIC DLYS STRL VAXCEL +,SUP-2141136,CDM,C1750,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE LADDER 9X0.6 MM NEURO 2X2 HOLE TI STRL LEVEL 1,SUP-2487842,CDM,C1713,HCPCS,0278,RC,,,,both,,,856.78,556.91,,,,,,,,,,,,,
PLATE BONE L20MM 90DEG 2X3 H RT CRANIOMAXILLOFACIAL TI L SHP,SUP-2191285,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
CALCIUM CARBONATE ANTACID 500 MG PO CHEW,RX-9385,CDM,6370000000,HCPCS,0637,RC,66553-0004-01,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
SCREW BONE L26MM DIA3MM HDLSS COMPR M CANN FLOWERCUBE,SUP-2225511,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.89,733.13,,,,,,,,,,,,,
BIT DRL 7 MM NS GOTFRIED PCCP,SUP-2644756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.35,455.23,,,,,,,,,,,,,
CUP ACET 28X52 MM W/ SULMESH,SUP-2442449,CDM,C1776,CPT,0278,RC,,,,both,,,3150.99,2048.14,,,,,,,,,,,,,
PATCH VASC HEMAPATCH L 75 X W 75 MM THK 0.65 MM POLYESTER,SUP-2227516,CDM,C1781,HCPCS,0278,RC,,,,both,,,538.10,349.76,,,,,,,,,,,,,
NAIL IM L320MM DIA15MM AQUA FEM TI CANN LOK RG AG BEND FLUT,SUP-2180147,CDM,C1713,HCPCS,0278,RC,,,,both,,,4636.62,3013.80,,,,,,,,,,,,,
ETOPOSIDE 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430002,CDM,J9181,HCPCS,0636,RC,00143-9376-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
SIDEPLATE STD BARL 150 DEG 3H STRL LCP DHHS,SUP-2547682,CDM,C1713,HCPCS,0278,RC,,,,both,,,1641.28,1066.83,,,,,,,,,,,,,
FIBER LASER 550UM DUST THULIUM,SUP-2885424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
PLATE BNE T 1.5X49 MM 4X9 HOLE FOR MINI FRAG SYS SS NS,SUP-2463312,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
HC Paracentesis WO Img Gd,PX-4504908200,CDM,49082,CPT,0450,RC,,,,inpatient,,,2844.00,1848.60,,,,,,,,,,,,,
CANNULA SUCTION COHEN ACORN 260X3.2X55 MM UTER SPRING MT NS,SUP-2465989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,940.12,611.08,,,,,,,,,,,,,
CATHETER SPEC RETRV BKSTP 3 FR GEL STONE ANTIRETROPULSION,SUP-2149867,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PLATE HEAD LCKNG PHALANGEAL 1.3MM LEFT-STERILE,SUP-2546066,CDM,C1713,HCPCS,0278,RC,,,,both,,,1523.69,990.40,,,,,,,,,,,,,
BRACE ORTH WAIST CIRC 53 IN BELT L 18 IN HIP HINGE ROM HT,SUP-2914920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,842.68,547.74,,,,,,,,,,,,,
MOST FEMORAL SEGMENT 55MM,SUP-2509221,CDM,C1776,CPT,0278,RC,,,,both,,,7276.95,4730.02,,,,,,,,,,,,,
DRILL TWST L 115 MM DIA1.5 MM STP 37 MM SCREW DIA2 MM J-NT,SUP-2883860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
HC Hepatitis Antibody Haab Igm Antibody,PX-3028670900,CDM,86709,CPT,0302,RC,,,,both,,,574.00,373.10,,,,,,,,,,,,,
SET PRE-DILUTE PRISMA M60,SUP-2384759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,553.90,360.03,,,,,,,,,,,,,
MOD ARTHRO NL 1CM ELIP CNCTR,SUP-2510746,CDM,C1776,CPT,0278,RC,,,,both,,,7630.20,4959.63,,,,,,,,,,,,,
HC Ot Group Therapy,PX-4309715000,CDM,97150,CPT,0430,RC,,,,outpatient,,,135.00,87.75,,,,,,,,,,,,,
NEEDLES 2-0 SUTURETAPE MENIS REP MINIMUM ORDER 10 EACH,SUP-2417039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
GRAFT BONE 15ML CANC SUB FOAM FLO B-TCP VITOSS,SUP-2370371,CDM,C1713,HCPCS,0278,RC,,,,both,,,8195.40,5327.01,,,,,,,,,,,,,
IMPL BREAST GEL BOOST SMTH HI PROF 370CC,SUP-2738050,CDM,C1789,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
DRILL SURG FOR 1.7MM SUTFIX CVD SHLDR FLEX SUT ANCHR,SUP-2341936,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.01,354.26,,,,,,,,,,,,,
TRAY PICC 3FR SGL LUMN CATHETER FULL PROC SFTY FLSH,SUP-2125615,CDM,C1751,HCPCS,0278,RC,,,,both,,,324.68,211.04,,,,,,,,,,,,,
KIT NEUROSTIMULATOR ANCHRING SYS W BI-WING ANCHR INJEX,SUP-2631820,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,0636,RC,64281-0100-06,NDC,,both,1,UN,523.30,340.14,,,,,,,,,,,,,
BUTTON FIX FOR ACL RECON W/ TI AND UHMWPE TIGHTROPE,SUP-2121388,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PUMP 270ML X 5ML/HR ANTIMIC,SUP-2420885,CDM,C2626,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
GUIDE WIRE F/USE W/BOUGIES745808/9/10 745711/12/,SUP-2574269,CDM,C1769,HCPCS,0272,RC,,,,both,,,112.66,73.23,,,,,,,,,,,,,
PRESSURE MONITORING KIT INTCRAN CATH O2 MONITORING CAMINO,SUP-2851508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2422.26,1574.47,,,,,,,,,,,,,
CATHETER ATHRCTMY TURBOHAWK L 133 CM SHTH 6 FR RVD 2-4 MM,SUP-2281688,CDM,C1714,HCPCS,0272,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
CAGE SPNL MESH 28X22X70 MM 6 LOBE,SUP-2602088,CDM,C1889,HCPCS,0278,RC,,,,both,,,19292.16,12539.90,,,,,,,,,,,,,
SCREW BONE L38MM OD3.5MM COARSE THRD CRUCFRM WDRUFF HD,SUP-2362299,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.16,13.75,,,,,,,,,,,,,
PLATE DISTR 90MML 15MM THK CP TTNM RTNTN F/RGD EXTRNL DISTR,SUP-2694382,CDM,C1713,HCPCS,0278,RC,,,,both,,,3066.18,1993.02,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 70 MM DIA25 MM LIMB L 30 MM DIA16,SUP-2217634,CDM,C1768,CPT,0278,RC,,,,both,,,35152.30,22848.99,,,,,,,,,,,,,
SHEATH INTRO L 90 CM DIA 6 FR GUIDEWIRE 0.035 IN SIL,SUP-2913543,CDM,C1894,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
IMPLANT PROX INTERPHALANGEAL SZ 4 SIL NONCOATED CEMENTLESS,SUP-2250681,CDM,L8630,HCPCS,0278,RC,,,,both,,,2441.04,1586.68,,,,,,,,,,,,,
BLADE SAW 31.8X.64X61.0MM HVY DUTY SAG,SUP-2367218,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
FIBER LASER 550UM HOLM,SUP-2225720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
LINER ACET B 0 DEG 28 MM HIP X3 POLYETH TRIDENT,SUP-2364434,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CONNECTOR ROD PARL 3.5/5.5 MM SINGLE SIERRA,SUP-2245455,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
GRAFT BNE 10ML CA PHSPTE DRILLABLE SYN CALLOS,SUP-2106909,CDM,C1713,HCPCS,0278,RC,,,,both,,,9294.40,6041.36,,,,,,,,,,,,,
GRAFT BNE SUB 1CC CELLULAR MTRX OSTEOCEL +,SUP-2310448,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
HC Intro Need/Intracath Translum,PX-3613616000,CDM,36160,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
COMPONENT FEM KNEE SZ 2 RT HINGE REV STRL TRIATHLON,SUP-2889762,CDM,C1776,CPT,0278,RC,,,,both,,,25951.32,16868.36,,,,,,,,,,,,,
TISURE 7 CMX10 CM 3PK,SUP-2402538,CDM,C1781,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
BODY HUM 36MM METAPHYSIS CEM AEQUALIS REVERSED II,SUP-2388649,CDM,C1776,CPT,0278,RC,,,,both,,,6361.33,4134.86,,,,,,,,,,,,,
PLATE BNE L233MM 14 H BILAT S STL STR NONCOMPRESSION RECON,SUP-2410185,CDM,C1713,HCPCS,0278,RC,,,,both,,,1479.98,961.99,,,,,,,,,,,,,
CATHETER ATHRCTMY OCELOT L 110 CM DIA 6 FR GUIDEWIRE 0.014,SUP-2124793,CDM,C1753,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 5X2.5 CM DBM FIBERFUSE,SUP-2736952,CDM,C1713,HCPCS,0278,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
CATHETER DRAINAGE INTRO 19 FRX55 CM RET FLEX XL BIO-MEDICUS,SUP-2745348,CDM,C1729,HCPCS,0272,RC,,,,both,,,1632.02,1060.81,,,,,,,,,,,,,
COMPONENT FEM SZ 3 RT POST STBL CEM GMK,SUP-2267593,CDM,C1776,CPT,0278,RC,,,,both,,,8439.85,5485.90,,,,,,,,,,,,,
HC Fluoro Guidance Spine,PX-3207700300,CDM,77003,CPT,0320,RC,,,,outpatient,,,987.00,641.55,,,,,,,,,,,,,
STAPLER INT DIA12MM 65DEG BLK 6 ROW 10 TI STPL PRELD DISPL,SUP-2752259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,475.77,309.25,,,,,,,,,,,,,
HC Iliac Atherectomy,PX-3610238000,CDM,0238T,CPT,0361,RC,,,,both,,,10136.00,6588.40,,,,,,,,,,,,,
BRACE ORTHOPEDIC CUST SACR LUMBAR LSO CYBERTECH,SUP-2123928,CDM,L0638,HCPCS,0274,RC,,,,both,,,4750.82,3088.03,,,,,,,,,,,,,
BIT DRL MIC LNG ACUTRK 2,SUP-2218774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1406.28,914.08,,,,,,,,,,,,,
PLATE BNE L L210MM THK4MM TROCH GRP VIT LO PROF W 2MM CBL,SUP-2377576,CDM,C1713,HCPCS,0278,RC,,,,both,,,5674.61,3688.50,,,,,,,,,,,,,
CANNULA OPHTH LAMBERT 33 GAX1-5/32 IN SUBRETINAL BLNT TIP,SUP-2457158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.30,206.89,,,,,,,,,,,,,
SET INTRO L 45 CM DIA 5 FR NIT WIRE PLAT TIP MIC SHRT B BVL,SUP-2117206,CDM,C1769,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
RELOAD STPL 60MM CRV TIP ARTC FOR MEDIUM/VASCULAR TISS,SUP-2283361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2111.27,1372.33,,,,,,,,,,,,,
SCREW BONE 2X5 MM LOCKING SELFDRILLING PLUSDRIVE RECESS TITA,SUP-2838327,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.10,354.31,,,,,,,,,,,,,
BIT DRL RETROGRADE 5.5 MM CANN W/ SUTURE RETRV ACUFEX TRUNAV,SUP-2849161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1153.95,750.07,,,,,,,,,,,,,
APPLICATOR ELECSURG 100 MM RIGID PLASMA COAG FILTER SPATULA,SUP-2762597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.28,399.93,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TRUE L 110 CM BALLOON L 4.5 CM DIA20,SUP-2127689,CDM,C1725,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BONE 135DEG 14 H SUPCNDYL S STL COMPR FRELOK,SUP-2197731,CDM,C1713,HCPCS,0278,RC,,,,both,,,2266.99,1473.54,,,,,,,,,,,,,
DUODENOSCOPE FLX RETRO SIDE VIEWING 13.7X11.3X1240 MM ASCOPE,SUP-2659123,CDM,C1748,HCPCS,0278,RC,,,,both,,,43944.30,28563.79,,,,,,,,,,,,,
PLATE RINGFIX SYS 13 HL ALUM,SUP-2696087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,802.58,521.68,,,,,,,,,,,,,
BLADE RTRCTR SM 24MMW X 60MML TTNM SPNL TTHX3 THIN LMBRTRK R,SUP-2703605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.40,577.46,,,,,,,,,,,,,
PLATE BONE 2.7MM 10 H LCK COMPR FRAG SYS PEDILOC,SUP-2318666,CDM,C1713,HCPCS,0278,RC,,,,both,,,2373.06,1542.49,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR CUST FIG OF EIGHT DESIGN ABDUCTN,SUP-2435750,CDM,L3650,HCPCS,0272,RC,,,,both,,,185.67,120.69,,,,,,,,,,,,,
HC Endoscopy Nasal Diagnostic,PX-4503123100,CDM,31231,CPT,0450,RC,,,,both,,,779.00,506.35,,,,,,,,,,,,,
SEGMENTAL BWD FLUTED STEM 15X250MM,SUP-2502482,CDM,C1776,CPT,0278,RC,,,,both,,,9919.26,6447.52,,,,,,,,,,,,,
HC Med Nut Therapy Ind Fu 15 Min,PX-9429780300,CDM,97803,CPT,0942,RC,,,,both,,,42.00,27.30,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT L 125 CM DIA 7 FR TIP 8,SUP-2248933,CDM,C1732,HCPCS,0272,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 51X63X12 MM 30 CC GALLANT VR,SUP-2707580,CDM,C1722,HCPCS,0275,RC,,,,both,,,40091.52,26059.49,,,,,,,,,,,,,
KIT INSTR TENFUSE PIP,SUP-2399029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
STIMULATOR NERVE PT PRGMR 35 CM SPNL 8 CONTACT,SUP-2138824,CDM,C1787,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
HOLE PIN CLAMP 1 POST STRAIGHT DIA 456MM,SUP-2704574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2323.29,1510.14,,,,,,,,,,,,,
PROSTHESIS LARYN L8MM DIA20FR PRELD W/ SMRT INSRTR TRNSPAR,SUP-2124374,CDM,L8509,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4409753000,CDM,97530,CPT,0440,RC,,,GO|KX|CO,both,,,191.00,124.15,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 25 CM OD 6FR ID 0.087IN 0.021IN,SUP-2384836,CDM,C1894,HCPCS,0272,RC,,,,both,,,280.09,182.06,,,,,,,,,,,,,
PLATE BONE REG THK0.6MM 2X2 H MIDFACE SLV TI LT L SHP FOR,SUP-2135912,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
DEVICE PESSARY OD2 1/2IN GELLHORN FLEX IMP,SUP-2171735,CDM,A4562,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L KNEE TRITANIUM PERI APATITE POST STBL 5516F101] STRYKER ORTHOPEDICS HOWM],SUP-2373044,CDM,C1776,CPT,0278,RC,,,,both,,,13331.18,8665.27,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 50 CM DIA 6 MM EPTFE CARBON STR STD,SUP-2127047,CDM,C1768,CPT,0278,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0045,SUP-2759873,CDM,C1751,HCPCS,0278,RC,,,,both,,,520.83,338.54,,,,,,,,,,,,,
SYSTEM NERVESTIMULATOR W48XH65CM THK11CM 32CUCM SPNL CLMN,SUP-2357674,CDM,C1767,HCPCS,0278,RC,,,,both,,,60999.24,39649.51,,,,,,,,,,,,,
BLADE SCREWDRIVER 2MM/2.3MM DIA STAINLESS STEEL MAXDRIVE,SUP-2494082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,644.33,418.81,,,,,,,,,,,,,
MAND ANGLE PLATE TSLCKNG LT X LNG 3 X 3 23MM SSTM T 6L 4V,SUP-2707237,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.97,986.03,,,,,,,,,,,,,
CATHETER GUID JARIT L 18 IN WORKING L 340 MM DIA 4 FR TIP W,SUP-2488570,CDM,C1769,HCPCS,0272,RC,,,,both,,,44.62,29.00,,,,,,,,,,,,,
INTRODUCER SHTH WORLEY-JUMBO 9 FRX50 CM DIL SAFSHTH CSG,SUP-2282364,CDM,C1892,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
GRAFT BNE SUB 30CC SZ 17 10MM CANC CHIP TISS FRZN CRUSH,SUP-2307396,CDM,C1713,HCPCS,0278,RC,,,,both,,,1525.35,991.48,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM 18MM POLYESTER BOV CLLGN STR,SUP-2265915,CDM,C1768,CPT,0278,RC,,,,both,,,1054.66,685.53,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH DUO L 75 CM DIA14 FR GUIDEWIRE 0.038,SUP-2357123,CDM,C1894,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
HEAD HUM 40-14 MM SHLDR ANAT SHLDR,SUP-2440625,CDM,C1776,CPT,0278,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
SCREW BNE L55MM DIA7MM SHT THRD,SUP-2390530,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 154 MM DIA 36 MM SHTH 22 FR RVD,SUP-2750383,CDM,C1768,CPT,0278,RC,,,,both,,,56641.52,36816.99,,,,,,,,,,,,,
BIT REPROC DRL CANN 4MM W/AO CPL 2.7MM,SUP-2653174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.33,304.41,,,,,,,,,,,,,
PLATE BNE 1/3 TBLR 5 HOLE W/ CLLRD NS LTX,SUP-2861945,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.46,138.75,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-2364,CDM,J7060,HCPCS,0258,RC,00264-7510-20,NDC,JW,both,250,ML,31.90,20.73,,,,,,,,,,,,,
NEEDLE PERC L2.5CM DIA20GA VASC ACCS,SUP-2169708,CDM,C1725,HCPCS,0272,RC,,,,both,,,10.61,6.90,,,,,,,,,,,,,
COIL EMB L22CM OD5MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305174,CDM,C1889,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
HC So Genomic Seq Dna&Rna Analys Neo 5-50 Gene,PX-3108145066,CDM,81450,CPT,0310,RC,,,,both,,,4002.00,2601.30,,,,,,,,,,,,,
K PHOS MONO-SOD PHOS DI & MONO 155-852-130 MG PO TABS,RX-10365,CDM,6370000000,HCPCS,0637,RC,69367-0250-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE 100 DEG L 2.28 CM THK 0.6 MM SCREW DIA1.5 MM 4X4 H,SUP-2936658,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
GUIDEWIRE ORTH L220MM DIA1.6MM S STL SMOOTH DRL TIP FOR,SUP-2410860,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.17,99.56,,,,,,,,,,,,,
NEEDLE BRST LOC L5CM OD20GA REPOSIT H STYL,SUP-2174908,CDM,C1819,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
LASER SURG 532 NM 1 197.25IT AUTO SL130,SUP-2713781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8917.60,5796.44,,,,,,,,,,,,,
SUPPORT WR SM LNG LEN RT FRARM WVN COT RUB FAB BGE FIRM W/,SUP-2324893,CDM,L3931,HCPCS,0272,RC,,,,both,,,41.01,26.66,,,,,,,,,,,,,
GLYCOPYRROLATE 0.4 MG/2ML IJ SOLN,RX-120967,CDM,J1596,HCPCS,0636,RC,00517-4602-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER PERI STR OPN END RADPQ 120CM LNG,SUP-2108712,CDM,C1729,HCPCS,0272,RC,,,,both,,,490.75,318.99,,,,,,,,,,,,,
FIXATOR KIT SHT PVC FREE STRL PROCALLUS,SUP-2645897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7204.29,4682.79,,,,,,,,,,,,,
MESH CRAN THK 0.65 MM SCREW DIA1.5 MM SZ 203 X 205 MM TI,SUP-2935893,CDM,C1713,HCPCS,0278,RC,,,,both,,,20469.66,13305.28,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 X 30 X 30 X 30 X 30 CM DIA26 X 10,SUP-2461923,CDM,C1768,CPT,0278,RC,,,,both,,,5679.48,3691.66,,,,,,,,,,,,,
PLATE POST SPINE BODY ASPN 8MM,SUP-2415557,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
BLOCK TIB AUG 3 5 MM RT LAT LT MEDL NXGN,SUP-2437111,CDM,C1713,HCPCS,0278,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
HOOK SPNL TRNSVRS PEDCL CONN FOR 3MM ROD SUMMIT FIX SYS,SUP-2254418,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.02,700.06,,,,,,,,,,,,,
SYSTEM PLT PREP AUTOLGS CASCADE,SUP-2307546,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
WASHER ORTHOPEDIC SMOOTH GRIDLOCK,SUP-2878257,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CATHETER INTRAAORTIC BAL L174MM OD8FR BAL OD14.7MM 25ML N,SUP-2265880,CDM,C1725,HCPCS,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
HEAD FEM OD32MM +0MM OFFSET HIP 12/14 TAPR RESTORIS Z,SUP-2370462,CDM,C1776,CPT,0278,RC,,,,both,,,1005.11,653.32,,,,,,,,,,,,,
CATHETER CV OXMTR 20 CM 3L SCVO2 MONITORING,SUP-2537554,CDM,C1751,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR PRSS FT CHIPBIOBIPPRS] ZIMMER BIOMET INC],SUP-2137371,CDM,C1776,CPT,0278,RC,,,,both,,,11325.98,7361.89,,,,,,,,,,,,,
PLATE BNE L230MM 10 H ST R DST HUM EXTRA ARTC S STL LOK,SUP-2177170,CDM,C1713,HCPCS,0278,RC,,,,both,,,4610.12,2996.58,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM DIA3MM SGL PIN SIL INSUL VNS,SUP-2175909,CDM,C1778,HCPCS,0278,RC,,,,both,,,9809.36,6376.08,,,,,,,,,,,,,
DIPHTH-ACELL PERTUSSIS-TETANUS 25-58-10 LF-MCG/0.5 IM SUSP,RX-19451,CDM,90700,HCPCS,0636,RC,58160-0810-43,NDC,,both,.5,ML,133.20,86.58,,,,,,,,,,,,,
SUTURE NONABSORBABLE WHT CART FOR SMARTSTITCH PERFECT PASS OM8178,SUP-2342099,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 8.01-9.0 MCI NS ADVANTAGE,SUP-2247283,CDM,C2643,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SCREW SPNL CANN 9.5X70 MM MULTAXL COCR CD HORZ SOLERA 5.5/6,SUP-2629689,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
LP PLATE L SHAPE RGHT RGLR 110 BLMQST 0.6MM T 6L 4V,SUP-2500165,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.65,343.62,,,,,,,,,,,,,
IMPLANT STAP L4MM STD PIST DIA0.6MM L WELL DIA1MM CLASS TI,SUP-2312797,CDM,2780000010,LOCAL,0278,RC,,,,both,,,556.13,361.48,,,,,,,,,,,,,
MESH BONE SIZE 1 06MM THK TTNM CNTRD STNDRD LATEX FREE ST B,SUP-2676601,CDM,C1713,HCPCS,0278,RC,,,,both,,,8732.43,5676.08,,,,,,,,,,,,,
HC Surgery Hybrid Addl 15min,PX-3600000017,CDM,3600000017,LOCAL,0360,RC,,,,both,,,5305.00,3448.25,,,,,,,,,,,,,
NEEDLE BX 22GA L15CM CHIBA ASPIR FN ADJ STP CLR CODE STYL,SUP-2381917,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CATHETER GUID SIM2 AD 0.078 INX7 FRX100 CM PTFE NYL SS ENVOY,SUP-2154492,CDM,C1887,HCPCS,0272,RC,,,,both,,,1781.32,1157.86,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 30 MM DIA 6 MM DEL SYS L 120 CM,SUP-2155437,CDM,C1876,HCPCS,0278,RC,,,,both,,,3821.38,2483.90,,,,,,,,,,,,,
IMPLANT FACE 76 X 50MM THK 0.25 MM POLYETHYL MIC THN SHT FOR,SUP-2883161,CDM,C1713,HCPCS,0278,RC,,,,both,,,1919.98,1247.99,,,,,,,,,,,,,
BLADE SAW 90MML X 19MMW 1.37MM THK OSCILLATING M CLASS,SUP-2586417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,202.28,131.48,,,,,,,,,,,,,
GRAFT HUMAN TSSUE MTRX 2SQCM THIN SM 1CMW X 2CML 023 051MM,SUP-2675764,CDM,Q4116,HCPCS,0636,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
CLAMP CRAN TEXT 22 MM FLAPFIX FOR EXT FIX TI STRL LF,SUP-2431410,CDM,C1713,HCPCS,0278,RC,,,,both,,,1320.68,858.44,,,,,,,,,,,,,
COMPONENT FEM SMALLL LT KNEE ZNG LIBRA,SUP-2442356,CDM,C1776,CPT,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 30 CC FD CRUSH CANC READIGRAFT,SUP-2741032,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.76,885.14,,,,,,,,,,,,,
ANCHOR SUT 30MM LOOP VERSITOMIC G LOK,SUP-2366527,CDM,C1713,HCPCS,0278,RC,,,,both,,,1694.19,1101.22,,,,,,,,,,,,,
BLADE RTRCTR CHRNLEY LNG 1NW X 6 3/4NL X 5IND F/INTL INCSN J,SUP-2480580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.79,307.96,,,,,,,,,,,,,
DEVICE URO BLEED CTRL 24FR L54CM 500ML BLLN POSTPARTUM W/,SUP-2169481,CDM,C2628,HCPCS,0272,RC,,,,both,,,1334.56,867.46,,,,,,,,,,,,,
SCREW BNE CORTICAL 5X38 MM FT HEX DRV SOCKET TIM AFFIXUS,SUP-2489960,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.65,347.52,,,,,,,,,,,,,
BLADE ENDO 4MM PURP,SUP-2399180,CDM,C1713,HCPCS,0278,RC,,,,both,,,2122.64,1379.72,,,,,,,,,,,,,
BRACE KNEE L FOR 21 24IN THGH UNIV NEOPRENE PUL ON ACL PLC,SUP-2151024,CDM,L1810,HCPCS,0272,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
GRAFT HUM TISS FIB SHFT BNE 200MM LEN 8 15MM W FRZN,SUP-2264756,CDM,C1713,HCPCS,0278,RC,,,,both,,,2897.75,1883.54,,,,,,,,,,,,,
GRAFT BNE FRZN L SCAPULA IMPL ALLGRFT,SUP-2307322,CDM,C1713,HCPCS,0278,RC,,,,both,,,11081.34,7202.87,,,,,,,,,,,,,
BIT DRILL W  STOP 2.2MM,SUP-2706715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1329.79,864.36,,,,,,,,,,,,,
PLATE BNE T 2.7/3.5X20 MM BILATERAL FT ANK 3 HOLE POLYAX LP,SUP-2397463,CDM,C1713,HCPCS,0278,RC,,,,both,,,2760.06,1794.04,,,,,,,,,,,,,
TRAY TIB SZ 3 COCR ALLOY TI PLASMA SPRY ANK CEM USE STRL,SUP-2932843,CDM,C1776,CPT,0278,RC,,,,both,,,21925.05,14251.28,,,,,,,,,,,,,
HANDPIECE SHAVER DRL DEPTH 0 DEG 4 MM POWERPICK,SUP-2845794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
PEG KIT DOBBHOFF 90 DEG BEND 16 FR SAFETY SINGLE PASS PUL,SUP-2852146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
PAINPUMP2 250 CC PMP W/ LUER LCK TBNG,SUP-2363508,CDM,C2626,HCPCS,0278,RC,,,,both,,,825.41,536.52,,,,,,,,,,,,,
RESERVOIR EXT DRNGE 01ML DIA12MM BA IMPREG CONV INTEGR R ANG,SUP-2278364,CDM,C1889,HCPCS,0278,RC,,,,both,,,1006.68,654.34,,,,,,,,,,,,,
STAPLE BNE FIX INTERAXIS L 9 MM LEG L 9 X 9 X W 1.5 MM THK,SUP-2893424,CDM,C1713,HCPCS,0278,RC,,,,both,,,2471.18,1606.27,,,,,,,,,,,,,
SYSTEM EMB ONYX 18 1.5 ML EVOH DMSO VI SYR N ADH LIQ STRL,SUP-2172495,CDM,C1889,HCPCS,0278,RC,,,,both,,,9878.44,6420.99,,,,,,,,,,,,,
STEM HIP FEM COMP SIZE2 PREMISE,SUP-2364446,CDM,C1776,CPT,0278,RC,,,,both,,,4335.37,2817.99,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X2 CM AMNIO WND MTRX BIOSKIN,SUP-2759486,CDM,C1762,CPT,0278,RC,,,,both,,,5028.74,3268.68,,,,,,,,,,,,,
BROACH GREAT TOE L CANN INSTR KT LPT,SUP-2397196,CDM,C1776,CPT,0278,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
FIBER LSR HOLM 200UM,SUP-2225705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 15.5 CM DIA15 FR DIL 20 CM GUIDEWIRE,SUP-2168165,CDM,C1892,HCPCS,0272,RC,,,,both,,,109.96,71.47,,,,,,,,,,,,,
SCREW BONE L30MM DIA5MM TI ST FULL THRD PERIPH FOR GLEN,SUP-2388794,CDM,C1713,HCPCS,0278,RC,,,,both,,,519.67,337.79,,,,,,,,,,,,,
CATHETER THROMCTMY AXS VECTA 71 L 115 CM ID 1.8 MM,SUP-2551060,CDM,C1757,HCPCS,0272,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
HC Rp Loclzj Tum Plnr 1 Area Single Day Imaging,PX-3417880000,CDM,78800,CPT,0341,RC,,,,inpatient,,,1691.00,1099.15,,,,,,,,,,,,,
BLADE SHV DIA4.5MM STR YEL LATCH FULL RAD BONECUTTER RESECT,SUP-2341525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.28,160.73,,,,,,,,,,,,,
PLATE BNE L 185 MM SCREW DIA 3.5 MM 16 H SS HUM FEM TIB,SUP-2931259,CDM,C1713,HCPCS,0278,RC,,,,both,,,2909.37,1891.09,,,,,,,,,,,,,
HC So Proinsulin Level,PX-3018420666,CDM,84206,CPT,0301,RC,,,,both,,,123.00,79.95,,,,,,,,,,,,,
PLATE BNE L 124 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 7 H 72465507N,SUP-2932804,CDM,C1713,HCPCS,0278,RC,,,,both,,,5343.97,3473.58,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO SQ PLATE XDRV 12 PK,SUP-2935258,CDM,C1713,HCPCS,0278,RC,,,,both,,,20695.74,13452.23,,,,,,,,,,,,,
STEM TIB L150MM DIA12MM TI KNEE PRI GEN II LEGION,SUP-2346007,CDM,C1776,CPT,0278,RC,,,,both,,,3351.95,2178.77,,,,,,,,,,,,,
SNARE VASC DOTTER SHFT L 95 CM DIA 8 FR BSKT L 7 CM DIA 3 CM,SUP-2167937,CDM,C1713,HCPCS,0278,RC,,,,both,,,955.91,621.34,,,,,,,,,,,,,
SYSTEM SINUPLASTY BLLN L16MM DIA6MM MAX TIP M-110 SGL HND,SUP-2106363,CDM,C1726,HCPCS,0272,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X388 MM LT PROX 12 HOLE STRL VALCP,SUP-2789624,CDM,C1713,HCPCS,0278,RC,,,,both,,,10174.79,6613.61,,,,,,,,,,,,,
PLATE BNE L88MM 3 H BILAT TI LOK COMPR RIG BTTRS THN BLDE,SUP-2190981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1178.29,765.89,,,,,,,,,,,,,
ELECTRODE NERVE MONITORING SZ 2-3 MM STRL DISP APS,SUP-2901931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.98,477.09,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 60 X W 13.5 MM MYRIAD HNDPC L 13 NN-3004,SUP-2930300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22369.83,14540.39,,,,,,,,,,,,,
PLATE GLEN STD SHLDR CEM REV EQUINOXE,SUP-2223380,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
DRILL KIT 2 MM SPD,SUP-2564465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,835.49,543.07,,,,,,,,,,,,,
GRFT CHIPS CANC 4-9.5MM 60CC PUROS,SUP-2693923,CDM,C1713,HCPCS,0278,RC,,,,both,,,5300.32,3445.21,,,,,,,,,,,,,
BIOXPRESS GRAFT DELIVERY 10CM BLUNT TIP,SUP-2811224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CATHETER EP MAP 5FR L65CM 2-5-2MM SPC COR SNUS FIX CRV,SUP-2281824,CDM,C1730,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT VASC 2XL 10.8X8.9CM BIOSCAFFOLD ENV CANGAROO ECM,SUP-2417653,CDM,C1768,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
KIT CEMENT BONE COMBO W/MIXER 20GM KYPHON HV-R,SUP-2540321,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.84,195.55,,,,,,,,,,,,,
ANCHOR SUT PNCRYL 2-0 ABSRB STR NDL POLY BRAID FOR RAPIDLOC,SUP-2249490,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
STAPLE BNE FIX L9MM S STL INTERAXIS QUIK CHARLOTTE,SUP-2397591,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,2500000003,HCPCS,0250,RC,00409-0024-01,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BONE L38MM DIA4.5MM HIP TI LCK FULL THRD CAPT FOR IM,SUP-2347553,CDM,C1713,HCPCS,0278,RC,,,,both,,,511.76,332.64,,,,,,,,,,,,,
PLATE BNE STR 1.3X48X0.75 MM 12 HOLE LCK SS NS,SUP-2177982,CDM,C1713,HCPCS,0278,RC,,,,both,,,1301.69,846.10,,,,,,,,,,,,,
BRACKET EXT FIX L LG SALVATION SEF11112,SUP-2493328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
PLATE OLECRANON 2.7/3.5MM 2H LT 73MM TI VA LCP STRL,SUP-2546629,CDM,C1713,HCPCS,0278,RC,,,,both,,,3457.74,2247.53,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA17 MM DEL SHTH 51ML,SUP-2937087,CDM,C1713,HCPCS,0278,RC,,,,both,,,15282.38,9933.55,,,,,,,,,,,,,
PLATE BONE W15XL136MM THK2MM 6 H BILAT TI THN BLDE RIG,SUP-2190984,CDM,C1713,HCPCS,0278,RC,,,,both,,,1464.24,951.76,,,,,,,,,,,,,
PLATE BNE 90 DEG 1X4 MM,SUP-2517345,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.00,258.70,,,,,,,,,,,,,
BUR SURG 5 MMX21 CM W/ LG BOR FLUT BALL MIDAS REX LEGEND,SUP-2628135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.64,325.42,,,,,,,,,,,,,
BONE GRAFT KIT DOWEL 18 MM REVISION,SUP-2836348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SHOE ORTHOT ADDITION CONVERT INSTEP VELCRO CLOSURE,SUP-2435742,CDM,L3580,HCPCS,0274,RC,,,,both,,,183.63,119.36,,,,,,,,,,,,,
DRILL TWST L 87 MM DIA1.1 MM STP 3 MM HALL FOR 1.5 SYS NS,SUP-2934790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
GUIDEWIRE VASC L205CM TAPR L33CM OD0016IN STD S STL PLAT TIP,SUP-2257077,CDM,C1769,HCPCS,0272,RC,,,,both,,,1888.21,1227.34,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD DF,SUP-2248496,CDM,C1733,HCPCS,0272,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
PLATE BNE L30MM 4 H FOREFOOT MULTIFUNCTIONAL FLAT SLIM DSGN,SUP-2243219,CDM,C1713,HCPCS,0278,RC,,,,both,,,3976.78,2584.91,,,,,,,,,,,,,
COMPONENT CRPL LG STD WRST POLYETH,SUP-2610307,CDM,C1776,CPT,0278,RC,,,,both,,,8989.95,5843.47,,,,,,,,,,,,,
GRAFT BNE SUB 25CC 2 4MM GRAN GROWTH FACT ALLGRFT OSTEOAMP,SUP-2138501,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM F CRV UNIDIR,SUP-2248942,CDM,C1732,HCPCS,0278,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
HC So Testosterone Free,PX-3018440266,CDM,84402,CPT,0301,RC,,,,both,,,98.00,63.70,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CANC CORT DEMIN CHIP OPTECURE,SUP-2223580,CDM,C1713,HCPCS,0278,RC,,,,both,,,6207.78,4035.06,,,,,,,,,,,,,
PASSER SUTURE 3MM LIGATURE GUIDE BLUNT STRAIGHT REUSABLE,SUP-2824102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.33,257.61,,,,,,,,,,,,,
INSERT TIB PS 3 UNIV NEUT 12 MM KNEE BEAR TECHNOLOGY COCR,SUP-2378643,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PATCH AMNION 2 LAYR PROTCT 4 X 6CM STERISHIELD II,SUP-2138665,CDM,C1762,CPT,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
HC So Topiramate,PX-3018020166,CDM,80201,CPT,0301,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
CONNECTOR SPNL ROD DIA 3.5/5.5 MM POST CERV PARALLEL DBL NS,SUP-2887232,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.57,56.92,,,,,,,,,,,,,
GUIDE SURG PLN NYL LP DISTRCTN CUSTOMIZABLE VSP,SUP-2883939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5593.13,3635.53,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX23 CM SET W/ SIDE H STYL SYMETREX,SUP-2627449,CDM,C1750,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
WRIST CARPAL BALL IMPLANT SM PLUS,SUP-2706713,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SCREW ACET L 40 MM DIA 5 MM SS CORTICAL HIP STRL NOVAE VCI,SUP-2913814,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
MESH HERN W30XL30CM POLYGLACTIN 910 WVN FLAT VCRL,SUP-2257602,CDM,C1781,HCPCS,0278,RC,,,,both,,,3278.10,2130.76,,,,,,,,,,,,,
ALLOGRAFT BNE MENIS LAT LT FRZN FOR GLEN REPL HEMI PLATEAU,SUP-2494197,CDM,C1889,HCPCS,0278,RC,,,,both,,,18103.83,11767.49,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WOVENFLEXIE DIA 6 FR SPC 2-10 MM,SUP-2142740,CDM,C1730,HCPCS,0272,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
SET SPL CATH 14FRX32CM W/ TEARLAWAY SHTH INTRO VES DIL TUNN,SUP-2266946,CDM,C1750,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
CATHETERIZATION KIT 7 FRX8 IN CV 3 LUMEN BLU FLEXTIP,SUP-2383298,CDM,C1751,HCPCS,0278,RC,,,,both,,,102.02,66.31,,,,,,,,,,,,,
PLATE BNE L W10.1XL98MM THK3.5MM 7 H BILAT S STL STR RIG,SUP-2186212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1404.49,912.92,,,,,,,,,,,,,
KIT STPL BNE FIX BRDG L20MM SPEEDTITAN BME,SUP-2194279,CDM,C1713,HCPCS,0278,RC,,,,both,,,3978.13,2585.78,,,,,,,,,,,,,
SCREW BONE L4MM OD1.7MM TI CORT CRANIOMAXILLOFACIAL,SUP-2363332,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.58,74.48,,,,,,,,,,,,,
PLATE BNE L 110 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 10 H 72440910N,SUP-2933234,CDM,C1713,HCPCS,0278,RC,,,,both,,,1794.67,1166.54,,,,,,,,,,,,,
NAIL IM FEM 8X300 MM RT GREATER TROCHANTERIC STRL T2 ALPHA,SUP-2457008,CDM,C1713,HCPCS,0278,RC,,,,both,,,10070.42,6545.77,,,,,,,,,,,,,
PLATE BNE 2.7X100 MM 11 HOLE SS LC-DCP,SUP-2569220,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.13,225.63,,,,,,,,,,,,,
ADAPTER ROD LNG 88MM,SUP-2704698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,491.72,319.62,,,,,,,,,,,,,
PIN FIX TEMP FOR ANK PLATE,SUP-2766043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE R DORS DST RAD S STL FOR 2.4/2.7MM SCR AND 1.8MM,SUP-2186097,CDM,C1713,HCPCS,0278,RC,,,,both,,,2742.22,1782.44,,,,,,,,,,,,,
LENS INTOCU +10.5 DIOPT L13MM DIA5.5MM D3.39MM 0.5DEG,SUP-2110782,CDM,V2630,CPT,0276,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
CONNECTOR SPINE TRNSVRS ROD OMEGA 21 FIX TI,SUP-2414725,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
BUR SURG BRL 4 MM + STRL FMS VUE DISP,SUP-2624803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,234.87,152.67,,,,,,,,,,,,,
BIT DRL CANN 10 MM KNEE SINGLE FLUT MTO,SUP-2849085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2238.82,1455.23,,,,,,,,,,,,,
CONTROLLER DETACH FOR WEB ANEUR EMB SYS,SUP-2418995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
STAPLE BNE FIX W16XL22MM M TBL RICHARDS,SUP-2342746,CDM,C1713,HCPCS,0278,RC,,,,both,,,2259.98,1468.99,,,,,,,,,,,,,
COMPONENT FEM CR 1 55X53 MM LT CEM ANAT DP PAT GRV POROUS,SUP-2390343,CDM,C1776,CPT,0278,RC,,,,both,,,12048.18,7831.32,,,,,,,,,,,,,
MICROCATHETER GUID CANTATA L 135 CM OD 2.9 FR ID 0.027 IN,SUP-2638530,CDM,C1887,HCPCS,0272,RC,,,,both,,,953.93,620.05,,,,,,,,,,,,,
PROBE DOPP MIC 20MHZ L231MM TIP 0.8MM BAYONETED DISP,SUP-2305982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
SLEEVE TIB H40MM AP27MM ML45MM MTPHSEAL TI PORCOAT POR REV,SUP-2250949,CDM,C1776,CPT,0278,RC,,,,both,,,6886.65,4476.32,,,,,,,,,,,,,
BLUE FLPL ARMSTRONG R 114MM ID 60,SUP-2695108,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.56,25.06,,,,,,,,,,,,,
STEM HUM L130MM DIA12MM UNIV TI ALLY W/ PALMA COAT REV,SUP-2193872,CDM,C1776,CPT,0278,RC,,,,both,,,12234.38,7952.35,,,,,,,,,,,,,
CRADLE SPNL RAD 220MM SUP CRAN GLD TI ALLOY RT ANG FOR RIB,SUP-2193284,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 75 CM DIA11 FR GUIDEWIRE 0.038 IN,SUP-2355525,CDM,C1894,HCPCS,0272,RC,,,,both,,,85.57,55.62,,,,,,,,,,,,,
FORCEPS SURG THERM WIELDING ENTCEPS,SUP-2358752,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
FIBER LASER 550 MH HOLM,SUP-2225591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ITREVIA VR-T W 54 X H 65 MM D 11 MM 31 CC,SUP-2138375,CDM,C1722,HCPCS,0275,RC,,,,both,,,33707.90,21910.13,,,,,,,,,,,,,
CATHETER ATHRCTMY 1.8MM L130CM DIA0.014IN NONDEFLECTING,SUP-2327238,CDM,C1724,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
CATHETER IVL L 150 CM DIA1.5 MM SHTH 5 FR GUIDEWIRE 0.014 IN,SUP-2910584,CDM,C1725,HCPCS,0272,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
BRACE ORTH ABDUCTN CTRL HIP ORTHOSIS CTRL,SUP-2388158,CDM,L1680,HCPCS,0272,RC,,,,both,,,3006.05,1953.93,,,,,,,,,,,,,
BIT DRL 3 FLUT 2.7X125 MM QC SS STRL LCP,SUP-2187592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.40,317.46,,,,,,,,,,,,,
HC So Histoplasma Capsulatum,PX-3068738566,CDM,87385,CPT,0306,RC,,,,outpatient,,,315.00,204.75,,,,,,,,,,,,,
HEAD HUM H27MM DIA44MM SHLDR CO CHROM TOT REV BIO MOD,SUP-2404616,CDM,C1776,CPT,0278,RC,,,,both,,,3405.33,2213.46,,,,,,,,,,,,,
SCREW BNE L70MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413588,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.20,273.78,,,,,,,,,,,,,
PLATE BNE L119MM 7 H BROAD CNTOUR 2 COMPR FOR 4.5MM SCR L,SUP-2411406,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.83,343.09,,,,,,,,,,,,,
MESH SURG 1.25 IN LIGHT-WEIGHT SELF FORMING PROLITE ULTRA,SUP-2265956,CDM,C1781,HCPCS,0278,RC,,,,both,,,386.35,251.13,,,,,,,,,,,,,
PLATE LCK HIND/MIDFOOT 2.4/2.7MM 8H 45MM,SUP-2547595,CDM,C1713,HCPCS,0278,RC,,,,both,,,2446.41,1590.17,,,,,,,,,,,,,
BIT DRILL 2.6MM FOR PRESSFT SUTURE ANCHOR,SUP-2825000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.86,788.36,,,,,,,,,,,,,
SPLINT SPNL SM CHILD W5XL60CM BCKL STRP CNTCT CLSR PD MCLEOD,SUP-2197368,CDM,L3650,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
RING TRNSJUG INTRAHEPATIC LIV ACCS AND BX SET,SUP-2169805,CDM,C1894,HCPCS,0272,RC,,,,both,,,1679.87,1091.92,,,,,,,,,,,,,
"HC So Calcium,Serum",PX-3018231066,CDM,82310,CPT,0301,RC,,,,both,,,78.00,50.70,,,,,,,,,,,,,
PURAPLY AM 2X4CM 8SQ CM,SUP-2314117,CDM,Q4196,HCPCS,0636,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,6370000000,HCPCS,0637,RC,62559-0138-07,NDC,,both,60,ML,96.40,62.66,,,,,,,,,,,,,
CATHETER INTRO 10.06FR UNIV OUTER SLITTABLE WIDE CRV CPS,SUP-2356382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL PLUSXL,SUP-2195534,CDM,L1830,CPT,0274,RC,,,,both,,,115.55,75.11,,,,,,,,,,,,,
SYSTEM DEL 7FR PANCREAS NAVIFLEX RX,SUP-2149499,CDM,C2625,HCPCS,0278,RC,,,,both,,,258.64,168.12,,,,,,,,,,,,,
GRAFT OPHTH THK300-400UM W0.75XL1CM COVERING GLAUCOMA DRNGE,SUP-2135260,CDM,V2790,HCPCS,0274,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
ANCHOR SUT 29MM NO2 PRE DEPLOYED SUT ONLY PRE THRD W POLY,SUP-2166459,CDM,C1713,HCPCS,0278,RC,,,,both,,,666.50,433.22,,,,,,,,,,,,,
TRAY PICC 5FR L55CM POLYUR NRS SGL LUMN FULL PWR INJ N COAT,SUP-2125636,CDM,C1751,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SCREW FIX L32MM DIA4.3MM TI SELF DRL ST QWIX,SUP-2242825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
BRACE ANK AD H95IN UNIV BILAT SEMI RIG SHELL PROTCT,SUP-2196371,CDM,L4350,HCPCS,0272,RC,,,,both,,,53.25,34.61,,,,,,,,,,,,,
DYNACORD STR BLUE W MO 7 NDLS 12 PK,SUP-2256652,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.30,355.74,,,,,,,,,,,,,
MESH SURG W10XL15CM THK1MM OVL BIOMATERIAL MYCROMESH,SUP-2395361,CDM,C1781,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
FEATHERVAC DISPOSABLE STAPES SEAT,SUP-2680416,CDM,L8613,CPT,0278,RC,,,,both,,,120.11,78.07,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA3MM SCHNZ TYP DISP,SUP-2150265,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
FUTURA FLX DGT IMPL ULTRASIL SIL ANAT KEYHOLE HNG RND STEM,SUP-2399889,CDM,C1776,CPT,0278,RC,,,,both,,,3008.12,1955.28,,,,,,,,,,,,,
HC Blood Split Unit,PX-3900901100,CDM,P9011,HCPCS,0390,RC,,,,both,,,730.00,474.50,,,,,,,,,,,,,
LINER ACET ELEV JJ 36X56 MM HIP POLYETH VIVACIT-E XLPE TRIL,SUP-2204092,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SCREW INTRF L35MM DIA12MM CANN 1.5MM BIOABSRB PLLA RND THRD,SUP-2341003,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.40,437.06,,,,,,,,,,,,,
STEM HUM L86MM 6A 127.5DEG ANG STD PTC AEQUALIS ASCEND FLX,SUP-2421317,CDM,C1776,CPT,0278,RC,,,,both,,,12632.22,8210.94,,,,,,,,,,,,,
LENS IOL SN60WF 12.0D,SUP-2111294,CDM,V2632,HCPCS,0276,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BIT DRILL DIA2MM PERCUTANEOUS QUICK CONNECT,SUP-2478318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.02,423.81,,,,,,,,,,,,,
STENT NEPHURET L 22 CM DIA 8 FR PERCFLX THRD,SUP-2141082,CDM,C2617,HCPCS,0278,RC,,,,both,,,376.08,244.45,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SLIP ON LG 8.5 IN WRST COMFORTFORM,SUP-2197053,CDM,L3906,HCPCS,0274,RC,,,,both,,,42.77,27.80,,,,,,,,,,,,,
STENT VASC SELF EXPANDABLE 7X120 MM 6 FRX75 CM EPIC,SUP-2138746,CDM,C1876,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
CUP HUM DIA36MM SHLDR NEUT SUT UNIVERS REVERS,SUP-2123345,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT VASC VECTRA L 40 CM DIA 5 MM POLYUR STR STD WALL N,SUP-2126220,CDM,C1768,CPT,0278,RC,,,,both,,,3072.05,1996.83,,,,,,,,,,,,,
RING EXT FIX DIA230 MM HALF NS DISP SMRT TSF,SUP-2933073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4775.75,3104.24,,,,,,,,,,,,,
IMPLANT BIO TISS W5XL10CM PORCINE DERM MTRX RECON THINNER BCP051020] TORNIER INC],SUP-2388575,CDM,C1763,HCPCS,0278,RC,,,,both,,,9896.65,6432.82,,,,,,,,,,,,,
HC Treatment Devices Complex,PX-3337733400,CDM,77334,CPT,0333,RC,,,,inpatient,,,2276.00,1479.40,,,,,,,,,,,,,
DRIVER SURG SH EXCEL,SUP-2255609,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S9274108PD,SUP-2632876,CDM,C1751,HCPCS,0278,RC,,,,both,,,702.76,456.79,,,,,,,,,,,,,
CATHETER DIL L 75 CM DIA 5 FR BALLOON L 4 CM DIA 6 MM UT,SUP-2139597,CDM,C1725,HCPCS,0272,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
BIT DRL L200MM DIA32MM QUIK CPL W O STP NONRADIOLUCENT,SUP-2315985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,450.59,292.88,,,,,,,,,,,,,
SCREW BNE L9MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189436,CDM,C1713,HCPCS,0278,RC,,,,both,,,140.58,91.38,,,,,,,,,,,,,
CATHETER GASTJEJUSTMY 22/10.2 FRX7/80 CM 2 SP CAR ALZ COON,SUP-2169721,CDM,C1729,HCPCS,0272,RC,,,,both,,,310.80,202.02,,,,,,,,,,,,,
FIBER LASER FOR PVP GREENLIGHT LASERSCOPE,SUP-2835043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
"HC So Cholinesterase, RBC",PX-3018248266,CDM,82482,CPT,0301,RC,,,,both,,,274.00,178.10,,,,,,,,,,,,,
PROBE NERVE STIM DIA1 MM BALL TIP INCREMENTING STRL DISP,SUP-2902011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.60,442.39,,,,,,,,,,,,,
TUBE MYR 114MM DIAM GRN GRMMT TAB FLROPLAS SHEP,SUP-2313656,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.60,17.29,,,,,,,,,,,,,
GUN BNE CEMENT ANGLED TIP L 12 IN 15 ML HI PRESSURE INJ SYS,SUP-2917159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307553,CDM,Q4128,HCPCS,0636,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
SHELL ACET OD60MM LNR DML DBL MOBILITY MPACT,SUP-2267382,CDM,C1776,CPT,0278,RC,,,,both,,,8732.34,5676.02,,,,,,,,,,,,,
SCREW CRTX FT SELF TAP HEX HD 4.5MM DIA 50MML,SUP-2342665,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.87,37.62,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL LNG LT RECON CROSSCHECK NX,SUP-2486196,CDM,C1713,HCPCS,0278,RC,,,,both,,,5677.12,3690.13,,,,,,,,,,,,,
TEMPORAL BONE PLATE LG 25MM X 45MM 6MM 15MM SSTM CP TTNM,SUP-2677465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1060.85,689.55,,,,,,,,,,,,,
COIL EMB L2CM DIA2MM 00115IN INTCRAN MICROFILAMENT DETACH,SUP-2173090,CDM,C1889,HCPCS,0278,RC,,,,both,,,5680.26,3692.17,,,,,,,,,,,,,
STAPLER INT L60MM DIA12MM STD TISS TI LNAR CUT LN 6 ROW,SUP-2218984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1304.32,847.81,,,,,,,,,,,,,
PLATE 4.5MM TI LCP T 4 HOLES 83MM,SUP-2549652,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.30,1163.04,,,,,,,,,,,,,
SCREW BNE L10MM OD2.4MM GRN TI PEEK OPTMA NONLOKING FULL,SUP-2400436,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
PROSTHESIS DRUMSTAPES 140059,SUP-2312529,CDM,L8613,CPT,0278,RC,,,,both,,,674.85,438.65,,,,,,,,,,,,,
GRAFT HUM TISS,SUP-2213682,CDM,V2785,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
SAW SURG JOS 7.5 INX38 MM NSL ANGL R BAYNT MICROFRANCE,SUP-2470560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.63,446.96,,,,,,,,,,,,,
CATHETER EP MED CRV 2-5-2 MM 1 MM 7 FRX110 CM,SUP-2867386,CDM,C1730,HCPCS,0272,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAG CTRL OFF THE SHLF,SUP-2435542,CDM,L0467,HCPCS,0272,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
BLADE SHV L18CM DIA4.5MM LNG ANG RESECT CRV INCIS + ELITE,SUP-2341723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),RX-40850049,CDM,2580000003,HCPCS,0250,RC,00338-0553-18,NDC,,both,100,ML,62.10,40.36,,,,,,,,,,,,,
KIT IMPL NEUROSTIMULATOR THK 10.7 MM BATTERY 200 MAH REMOT,SUP-2899871,CDM,C1767,HCPCS,0278,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
PLATE BNE L25MM 4 H T POLYAX COMPR CLAW II,SUP-2397467,CDM,C1713,HCPCS,0278,RC,,,,both,,,3033.24,1971.61,,,,,,,,,,,,,
VALVE MITRL MECH EXPAND MSTR SER,SUP-2356720,CDM,C1889,HCPCS,0278,RC,,,,both,,,17659.36,11478.58,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 150 CM 0.038 IN TAPR L 15 CM STR,SUP-2170343,CDM,C1769,HCPCS,0272,RC,,,,both,,,531.19,345.27,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI 400XL ACUTE 14FR DIA 20CM CRV EXTN TAP,SUP-2610501,CDM,C1752,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
REAMER CNL IM HVY DUTY TRINKLE,SUP-2362646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2748.63,1786.61,,,,,,,,,,,,,
CATHETER ATHRCTMY OCELOT PIXL L 150 CM DIA 5 FR GUIDEWIRE,SUP-2124795,CDM,C1753,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
PATCH PERICARD W5XL10CM THK0.2-0.4MM BOV PERICARD FLEX SFT,SUP-2357533,CDM,C1768,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT BONE SUB 15CC FRZ DRY DEMIN CANC CHIP,SUP-2294030,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
GRAFT BNE SUB 2.5CC SIL SOD CA PHOS OXIDE VERSATILE RESRB,SUP-2368182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC Renal Art 1st Order Bil,PX-4813625200,CDM,36252,CPT,0481,RC,,,,outpatient,,,10063.00,6540.95,,,,,,,,,,,,,
PLATE BNE 6 H MIC TI NONSTERILE 1.5MM SCR 0.6MM,SUP-2262674,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.79,209.16,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GA 9CM REPOSITIONAL DISP KOPAN,SUP-2169673,CDM,C1819,HCPCS,0278,RC,,,,both,,,127.77,83.05,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 200X200X0.6 MM RIGID SLV NS,SUP-2859899,CDM,C1713,HCPCS,0278,RC,,,,both,,,25505.59,16578.63,,,,,,,,,,,,,
KIT CATH L35CM OD3.3MM ID1.9MM VENT STYL CONN SUT CLLR TRCR,SUP-2244108,CDM,C1729,HCPCS,0272,RC,,,,both,,,387.07,251.60,,,,,,,,,,,,,
NEEDLE BX 19GA SHTH 5.2FR ENDO US DISP FOR SFT TISS Q COR,SUP-2169552,CDM,C1713,HCPCS,0278,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
PIN PERC 150MM PACKED IN BLISTER,SUP-2739164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THCK 20X8 CMX0.8-1.7 MM BRST KT FLEXHD,SUP-2307581,CDM,Q4128,HCPCS,0636,RC,,,,both,,,23980.97,15587.63,,,,,,,,,,,,,
PLATE BONE SM TITANIUM GRIDLOCK VLC PLATING SYSTEM FOR 2.4/3/4MM SCREW,SUP-2878140,CDM,C1713,HCPCS,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 5 PLATE CUSTOMIZED FACE ID,SUP-2883692,CDM,C1713,HCPCS,0278,RC,,,,both,,,40016.85,26010.95,,,,,,,,,,,,,
STENT URET CNTOUR VL L 22-30 CM DIA 6 FR CATH 6 FR GLIDEWIRE,SUP-2141662,CDM,C2617,HCPCS,0278,RC,,,,both,,,504.66,328.03,,,,,,,,,,,,,
KIT NRV BLK 270ML FOR SURG PROC W/ L INCISIONS SOAK MOD,SUP-2236748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
DILATOR ENDOSCP L90CM CATH 14FR BLLN L10CM DIA30MM 0.038IN,SUP-2149642,CDM,C1726,HCPCS,0272,RC,,,,both,,,1989.03,1292.87,,,,,,,,,,,,,
PATCH CV GELSEAL L 120 X W 40 CM THK 0.53 MM POLYESTER GEL,SUP-2385077,CDM,C1768,CPT,0278,RC,,,,both,,,486.79,316.41,,,,,,,,,,,,,
SYRINGE ASPIR 20ML BONE MAR PROCURE,SUP-2194027,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
ADAPTER HUM L6MM SHLDR RSP,SUP-2217361,CDM,C1776,CPT,0278,RC,,,,both,,,2381.85,1548.20,,,,,,,,,,,,,
SPACER SPNL 22X9X15MM LO PROF PEEK CERV CONVX TALL FOR IN,SUP-2353386,CDM,C1889,HCPCS,0278,RC,,,,both,,,22961.25,14924.81,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM WHL MEM AMNIO SHT NO ANG AMINOFIX,SUP-2305726,CDM,V2790,HCPCS,0274,RC,,,,both,,,4980.04,3237.03,,,,,,,,,,,,,
BIT DRILL SURG DIA 4.2 MM CALIB NS DISP,SUP-2930400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
CLARIVEIN CLARIVEIN IC INFUS CATHETER 65CM,SUP-2301895,CDM,C1887,HCPCS,0272,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
PLATE BONE W16XL253MM THK5MM 13 H RT CNDYL FEM S STL BTTRS,SUP-2185798,CDM,C1713,HCPCS,0278,RC,,,,both,,,2813.69,1828.90,,,,,,,,,,,,,
CABLE SPNL TI INTEGR CRMP DBL MFIL WIRE ATLS 12PK,SUP-2289633,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BRACE THMB SPICA RT REG SPICA MOD SUPP FOAM WRP AD SM,SUP-2324380,CDM,L3931,HCPCS,0274,RC,,,,both,,,28.89,18.78,,,,,,,,,,,,,
FORCEPS BPLR L33CM DIA5MM SERR JAW DISP FOR PK SUPERPULSE,SUP-2313738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
KYPHOPLASTY KIT TROCAR 13 GA OSTEO INTRO BVL KYPHON V,SUP-2665005,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
DRILL TWST 90 DEG L 29.2 MM DIA1.5 MM STP 16 MM DENT SHFT NS,SUP-2883209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
GUIDEWIRE URO L145CM DIA0.035IN TIP 5CM ULT STIFF FLEX S STL,SUP-2417169,CDM,C1769,HCPCS,0272,RC,,,,both,,,113.29,73.64,,,,,,,,,,,,,
GRAFT BNE H10MM UNICORTICAL CANC SPCR PARA FRZ DRY MATRIGRFT,SUP-2264699,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
SCREW SPNL L50MM DIA5.5MM CANC PEDCL TI MULTIAXIAL SEXTANT,SUP-2288494,CDM,C1713,HCPCS,0278,RC,,,,both,,,5049.43,3282.13,,,,,,,,,,,,,
BAND ANNULPLSTY COSGROVE-EDWARDS SZ 36 MM L 78.7 MM OD 43.6,SUP-2214201,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
HC Layer Clos Face 5.1-7.5 Cm,PX-4501205300,CDM,12053,CPT,0450,RC,,,,both,,,1445.00,939.25,,,,,,,,,,,,,
PERI SCR  45MM X 38MM,SUP-2720898,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.84,88.30,,,,,,,,,,,,,
IMMOBILIZER SHLDR SM ENV L13IN D7IN POLY COT CLIN SLNG W/,SUP-2196915,CDM,L3650,HCPCS,0274,RC,,,,both,,,12.59,8.18,,,,,,,,,,,,,
PUTTY 1CC DBM INCL CANC BONE CHIP MTRX VIVEX,SUP-2393071,CDM,C1713,HCPCS,0278,RC,,,,both,,,987.53,641.89,,,,,,,,,,,,,
SHEATH KIT NANONEEDLE 180 MM HIP ACCS,SUP-2849275,CDM,C1769,HCPCS,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
PLATE BNE CHIN 1.7X12 MM 6 HOLE PRE-BENT ADV GLD NS LTX,SUP-2862770,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
SCREW SPNL L25MM OD4.5MM PEDCL VAR ANG CANN SHANK SPHERX PPS,SUP-2311472,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SHUNT CV 4X5 MM,SUP-2633895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2203.93,1432.55,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0250,RC,00264-7520-00,NDC,,both,125,ML,6.40,4.16,,,,,,,,,,,,,
MORCELLATOR ENDO L335MM OD4.75MM ROT SGL USE OUTER AND INNR,SUP-2332805,CDM,C1782,HCPCS,0272,RC,,,,both,,,1340.06,871.04,,,,,,,,,,,,,
STENT GRFT VASC ALTO L 80 MM DIA PROX 20 MM DEL SYS ID/OD,SUP-2691408,CDM,C1768,CPT,0278,RC,,,,both,,,32615.18,21199.87,,,,,,,,,,,,,
COIL EMB L12CM PRI DIA0.020IN 2ND DIA4MM NIT COMPLX SFT,SUP-2323395,CDM,C1889,HCPCS,0278,RC,,,,both,,,7137.22,4639.19,,,,,,,,,,,,,
CATHETER ABLATN INTRACARDION 9 FR VIEWFLEX XTRA,SUP-2356615,CDM,C1757,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
GRAFT EVAR ID8-10MM LN L7CM UNLN L2CM SHTH 10FR BLLN,SUP-2395935,CDM,C1874,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
GRAFT BNE L100MM FIBULAR SHFT FRZN MATRIGRFT,SUP-2264754,CDM,C1713,HCPCS,0278,RC,,,,both,,,2035.35,1322.98,,,,,,,,,,,,,
KIT TIB MOD ROT HNG HDP ASSEMB,SUP-2376373,CDM,C1776,CPT,0278,RC,,,,both,,,3881.51,2522.98,,,,,,,,,,,,,
TAP SURG L5.5MM FT ANK CANN FOR JONE FIX SYS SCR CHARLOTTE,SUP-2398099,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BNE LCK 5.5X372 MM LT PROX LAT TIB 22 HOLE SS STRL,SUP-2473560,CDM,C1713,HCPCS,0278,RC,,,,both,,,6251.08,4063.20,,,,,,,,,,,,,
KNIFE 3722149 MYRINGOTOMY 90120 DEG,SUP-2667294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.40,437.71,,,,,,,,,,,,,
BRACE ORTH CORSET FRONT,SUP-2388154,CDM,L0972,HCPCS,0272,RC,,,,both,,,297.99,193.69,,,,,,,,,,,,,
HC So Lipid Cascade|NOT REASONABLE AND NECESSARY,PX-3018006168,CDM,80061,CPT,0301,RC,,,GZ,both,,,66.00,42.90,,,,,,,,,,,,,
END CAP ORTH IM NAIL STD STRL T2,SUP-2900634,CDM,C1889,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PIN FIX L14MM DIA2.7MM PROV FOR LCK DRL GUID,SUP-2344007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1717.83,1116.59,,,,,,,,,,,,,
COMPONENT TOE SZ 3 4 METATARSAL DCOMPR IMPL BRCH,SUP-2398626,CDM,C1776,CPT,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
WASHER ORTH FIX TI SZ 13.0MM,SUP-2412666,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE 4.5MM TI LCP PROXIMAL TIBIA 14 HOLES 262MM LEFT,SUP-2549650,CDM,C1713,HCPCS,0278,RC,,,,both,,,3504.59,2277.98,,,,,,,,,,,,,
RASP SURG JT PREP STRL DISP OMNI,SUP-2898484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
BRACE KNEE M FOR 18 21IN THGH NEOPRENE PAT STBL SFT,SUP-2150848,CDM,L1810,HCPCS,0274,RC,,,,both,,,75.39,49.00,,,,,,,,,,,,,
BIT DRL 3 FLUT 4.2X145 MM QC NDL PT,SUP-2432345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.39,333.70,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0250,RC,00990-7984-20,NDC,,both,250,ML,291.20,189.28,,,,,,,,,,,,,
STRIP FNGR ALUM W/ FOAM 1INX18IN XL,SUP-2194457,CDM,L3933,HCPCS,0274,RC,,,,both,,,3.86,2.51,,,,,,,,,,,,,
PROBE XL NRV STIM DISPOSABLE NEURO TRA VEO,SUP-2164082,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ANCHOR SUT L14.5MM DIA3MM BIOCOMP SUTTAK,SUP-2121592,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SPACER EXT FIX 5 MM SIDEKCK EZ FRAME EF3005PK,SUP-2493824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
SLEEVE ORTH SUSP ANK PELV CTRL,SUP-2388213,CDM,L5695,HCPCS,0274,RC,,,,both,,,500.23,325.15,,,,,,,,,,,,,
TOUMA VENT TUBE W TAB 1.14MM ID SILICONE 5 PACK,SUP-2669496,CDM,L8699,HCPCS,0278,RC,,,,both,,,43.99,28.59,,,,,,,,,,,,,
ALLOGRAFT BNE 7 DEG 18X10.5X5 MM COALITION,SUP-2418002,CDM,C1734,HCPCS,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 90 CM OD 5 FR ID 0.074 IN DIL L,SUP-2170360,CDM,C1894,HCPCS,0272,RC,,,,both,,,385.47,250.56,,,,,,,,,,,,,
EXTRACTOR STONE HELCL 3.2 FRX115 CM 3 WIR NIT NCIRCLE,SUP-2835766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.72,446.37,,,,,,,,,,,,,
PLATE BNE T 3.5/4 MM RT 10 HOLE OBLQ NS FPS LTX,SUP-2856878,CDM,C1713,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
HC Ecmo/Ecls Insj of Prph Cannula 6 Yrs&Older Perq,PX-3603395200,CDM,33952,CPT,0360,RC,,,,both,,,37949.00,24666.85,,,,,,,,,,,,,
KIT LASER L45CM 0.035IN NDL 21GA GRP GLD TIP FRS FBR,SUP-2118072,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.75,599.14,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA17 MM DEL SHTH,SUP-2934161,CDM,C1713,HCPCS,0278,RC,,,,both,,,19135.51,12438.08,,,,,,,,,,,,,
POST EXT FIX CIR FEMALE 4 HOLE,SUP-2400692,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.41,277.17,,,,,,,,,,,,,
GRAFT HUM TISS L230MM DIA 7.5MM ANT TIBIALIS TEND FLEXIGRFT,SUP-2264723,CDM,C1762,CPT,0278,RC,,,,both,,,5505.71,3578.71,,,,,,,,,,,,,
SHUNT SURG 90 CM PERF LEVEL 1.0 CHMBR DELT,SUP-2628291,CDM,C1729,HCPCS,0272,RC,,,,both,,,6499.02,4224.36,,,,,,,,,,,,,
WIRE FIX 1.6X150 MM KIRSCHNER HALLU,SUP-2242883,CDM,C1713,HCPCS,0278,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
SET IMPL FOR PROX TIB 4.5MM LCK COMPR PLT,SUP-2183064,CDM,C1713,HCPCS,0278,RC,,,,both,,,57597.08,37438.10,,,,,,,,,,,,,
NAIL IM L240MM OD10MM TI DST TIB CEPHALOMEDULLARY PROX LAT,SUP-2368851,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GRAFT HUM TISS L 8 X W 4 CM AMNION-CHORION-AMNION LAYR,SUP-2909253,CDM,Q4140,HCPCS,0636,RC,,,,both,,,21225.43,13796.53,,,,,,,,,,,,,
LINER HUM DIA38MM +0MM OFFSET STD POLY FOR REV SHLDR SYS,SUP-2223395,CDM,C1776,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
BIT DRL L L266MM DIA16MM FEM FLX CANN QUIK CPL,SUP-2187060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2369.85,1540.40,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 1.4-2.8MM 10CC B TRICALCIUM PHSPTE SYN,SUP-2194011,CDM,C1713,HCPCS,0278,RC,,,,both,,,2769.48,1800.16,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 5MM TIP 2-5-2MM SPC SM CURL QPLR,SUP-2421254,CDM,C1733,HCPCS,0272,RC,,,,both,,,2230.97,1450.13,,,,,,,,,,,,,
ROD SPNL POST R CRV SMOOTH TI ALLY PREBENT 5.5MM DIA 70MM,SUP-2415860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
PLATE BNE L 100 DEG 1.7X5 MM LT 6 HOLE BAR TI GLD NS,SUP-2366306,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.01,418.61,,,,,,,,,,,,,
DRILL SURG MED SPD W/O HOSE FLFORTHPDC ORLORALMXLLFCL OTOLAR,SUP-2605427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6192.55,4025.16,,,,,,,,,,,,,
TWIST DRILL ANGULUS 15 X 9MM,SUP-2679094,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.09,361.46,,,,,,,,,,,,,
EXPANDER TISS BRST LO HT SILTEX CPX4T,SUP-2748632,CDM,C1889,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
TIP HNDPC BARRACUDA SONOPET IQ,SUP-2423053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2895.14,1881.84,,,,,,,,,,,,,
CANNULA ARTHRO 3.2 MM DRNG OBTURATOR FLOW VALVE,SUP-2747512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,870.69,565.95,,,,,,,,,,,,,
ALLOGRAFT PROCHONDRIX CR 11.0 X 1.0MM,SUP-2751542,CDM,C1762,CPT,0278,RC,,,,both,,,11916.30,7745.59,,,,,,,,,,,,,
BIT DRL DIA4MM ANTIROTATION NOTCH FOR PROPHECY INBONE TOT,SUP-2397089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
TRAY PICC 6FR L55CM POLYUR NRS DBL LUMN FULL PWR INJ N COAT,SUP-2126709,CDM,C1751,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
BIT DRL LATITUDE EV DISP,SUP-2715606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
DRAIN SURG W7XL20CM SIL FULL PERF FLAT W/O TRCR,SUP-2198723,CDM,C1729,HCPCS,0272,RC,,,,both,,,64.09,41.66,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 8MM L 50 CM STR STD WALL,SUP-2396275,CDM,C1768,CPT,0278,RC,,,,both,,,4028.62,2618.60,,,,,,,,,,,,,
SCREW CANC 4.5MM DIA 20MM ST FULL TI F/BIOMET - 4.5MM DIAM,SUP-2408778,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
ALLOGRAFT BNE INJ 8 CC IGNITE PWR MIX,SUP-2759448,CDM,C1713,HCPCS,0278,RC,,,,both,,,6096.69,3962.85,,,,,,,,,,,,,
WIRE FIX KIRSCHNER 72090120] SMITH AND NEPHEW ENDOSCOPY],SUP-2341577,CDM,C1713,HCPCS,0278,RC,,,,both,,,685.21,445.39,,,,,,,,,,,,,
STRIP ILIUM BICORTICAL TRAD ALLGRFT 22X45 MM FRZ DRY,SUP-2294075,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.517,SUP-2860034,CDM,C1713,HCPCS,0278,RC,,,,both,,,40331.10,26215.21,,,,,,,,,,,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,0636,RC,55111-0678-10,NDC,,both,0.5,ML,135.20,87.88,,,,,,,,,,,,,
ANCHOR SUTURE PRE LD 2 1.4 MM SURELOCK UHMWIPE,SUP-2608902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.40,802.36,,,,,,,,,,,,,
CUBE EXT FIX 5 H S STL RANCHO FOR ILIZ TAY SPAT FRME EXT,SUP-2342336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1614.27,1049.28,,,,,,,,,,,,,
BIT DRL DIA3MM CLAV CANN DOG BNE,SUP-2121659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
HEMI GREAT TOE IMPL M,SUP-2319775,CDM,C1776,CPT,0278,RC,,,,both,,,5626.88,3657.47,,,,,,,,,,,,,
BIT DRL L465MM DIA12MM CANN FLX L QUIK CPL FOR TIB NAIL,SUP-2178845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1684.33,1094.81,,,,,,,,,,,,,
FIXATOR EXT LNG MOD S STL W DISTR FOR WRST PENNIG II,SUP-2316047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5100.68,3315.44,,,,,,,,,,,,,
LISFRANC HEX DRIVER 2.5MM,SUP-2473956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
DRILL TWIST D3.2MM RDLCNT TRGTNG DVCE TBL NAIL SSTM PHNX,SUP-2488930,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
STABILIT FRACTURE KIT SHRT,SUP-2700643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
RING 5 8 140MM FOR TRUELOK FIX SYS,SUP-2316183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1801.64,1171.07,,,,,,,,,,,,,
SNARE ENDO L230CM SHTH DIA3MM NDL 25GA L5MM OLY STYL CRD OVL,SUP-2391600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
ROD SPNL L40MM OD4.75MM CO CHROM MOLYBDENUM POST,SUP-2284729,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
PLATE BNE DBL Y NEURO LP Q STYL FOR SCR TI LEVEL 1 LF,SUP-2471493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1270.26,825.67,,,,,,,,,,,,,
NAFCILLIN SODIUM 10 G IV SOLR,RX-141211,CDM,J2290,HCPCS,0250,RC,55150-0124-99,NDC,,both,1,UN,641.20,416.78,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 5 CC CELLENTRA ADV,SUP-2866898,CDM,C1713,HCPCS,0278,RC,,,,both,,,6634.19,4312.22,,,,,,,,,,,,,
SCREW BNE L35MM DIA5MM CANC HUM S STL FOR PROX PLT SYS,SUP-2107652,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
CATHETER HD STR EXTN 11.5 FRX20 CM SHT TERM DL HEMCATH,SUP-2627308,CDM,C1752,HCPCS,0278,RC,,,,both,,,12.56,8.16,,,,,,,,,,,,,
ALLOGRAFT BNE CERV 5.75X7.22 MM LORDTC VERTIGRAFT VG2,SUP-2264652,CDM,C1889,HCPCS,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 45CM 6FR COAT 35CM XCUT,SUP-2385455,CDM,C1894,HCPCS,0272,RC,,,,both,,,347.82,226.08,,,,,,,,,,,,,
GRAFT BNE SPACER 7.54X9 MM MATRISPINE,SUP-2264621,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
DEVICE SECUREMENT PEDIATRIC UNIV FOAM ANCHR PD,SUP-2127661,CDM,C1751,HCPCS,0278,RC,,,,both,,,11.90,7.73,,,,,,,,,,,,,
PSN TIB HALF BLOCK SZ GH RL 5MM,SUP-2508726,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
BLADE SHV AD L13CM DIA4.5MM TNSLCTMY ADENOIDECTOMY 45DEG,SUP-2284162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,627.00,407.55,,,,,,,,,,,,,
PLATE BONE L85MM 6 H LT POSTEROLATERAL DSTL HUM FOR,SUP-2349770,CDM,C1713,HCPCS,0278,RC,,,,both,,,7172.86,4662.36,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.1MM DRL TIP W/O STP NONRADIOPAQUE,SUP-2343041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1754.38,1140.35,,,,,,,,,,,,,
ROD EXT FIX L500MM DIA11MM UNIV C FBR RADLUC CONN 39489R] DEPUY SYNTHES USA],SUP-2188671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
PLATE STRNL CLOSURE 70 DEG 8 H TI L NS STERNALOCK BLU,SUP-2894528,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
CATHETER NINJA FX JAPAN 2.25X10,SUP-2157897,CDM,C1725,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
BIT DRL L 400 MM DIA2.5 MM CALIB L 120 MM QC NS DISP,SUP-2905664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1738.05,1129.73,,,,,,,,,,,,,
CATHETER NEPHROSTOMY X-FORCE N30 L 15 CM BALLOON L 8 CM DULA,SUP-2655877,CDM,C1726,HCPCS,0272,RC,,,,both,,,1384.58,899.98,,,,,,,,,,,,,
CATHETER GUID 0.066 INX6 FRX100 CM CORONARY,SUP-2103094,CDM,C1887,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
HC Inj Proc Hip,PX-3612709300,CDM,27093,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PORT TI IMP LO PROF PRE ATTACH OPN END SIL 6.6FR SGL LUMN,SUP-2127723,CDM,C1788,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
DRILL SURG FOR 1.7MMXL SUTFIX CVD FLEX SUT ANCHR,SUP-2341939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1759.53,1143.69,,,,,,,,,,,,,
PLATE BNE 3.5X196 MM 15 HOLE SS LCP,SUP-2569328,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.65,334.52,,,,,,,,,,,,,
CATHETER EP 14.51 7 FRX110 1525 MM INQUIRY,SUP-2468757,CDM,C1731,HCPCS,0278,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
GUIDE CATHETER 17IN VAN BUREN,SUP-2305660,CDM,C1887,HCPCS,0272,RC,,,,both,,,54.04,35.13,,,,,,,,,,,,,
HC Strapping Knee,PX-4502953000,CDM,29530,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 23.5-26.5 IN CTR 17-19 IN CALF 18-20 IN XL,SUP-2915239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.01,239.21,,,,,,,,,,,,,
PRX HUM HI PLT RT 11H 197MM,SUP-2472710,CDM,C1713,HCPCS,0278,RC,,,,both,,,6079.04,3951.38,,,,,,,,,,,,,
PATCH BIOLOGIC SURG 10CM WX16CM L .55MM THICKNESSXENOSURE,SUP-2264164,CDM,C1781,HCPCS,0278,RC,,,,both,,,2760.06,1794.04,,,,,,,,,,,,,
LINER ACET OD46MM ID28MM STD UHMWPE HIP PRI CEM NEUT HOOD,SUP-2207577,CDM,C1776,CPT,0278,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
GRAFT BNE SUB 5ML HA FAST SET PTTY FILL BNE VOID CA PHSPTE,SUP-2194288,CDM,C9359,HCPCS,0278,RC,,,,both,,,4660.07,3029.05,,,,,,,,,,,,,
SEALER TISS L45CM SHFT DIA5MM 360DEG ROT CVD JAW TAPR TIP,SUP-2219741,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1758.46,1143.00,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 37 CM DIA 4 MM SPD 1200 RPM TRACH STR,SUP-2901937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1592.61,1035.20,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 0.5 CC LECITHIN CARR DBM NS REGENEROSS +,SUP-2862035,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.87,250.17,,,,,,,,,,,,,
SCREW SPNL TI L15 MM OD4 MM REV PARA COR STALIF C,SUP-2163206,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL TR TI CRT BIV BATTERY PWR,SUP-2140444,CDM,C1882,HCPCS,0275,RC,,,,both,,,77482.64,50363.72,,,,,,,,,,,,,
ALLOGRAFT BNE LORDTC 6 DEG 30X16 MM FD FEE CORTICAL CRESCENT,SUP-2743434,CDM,C1713,HCPCS,0278,RC,,,,both,,,17295.12,11241.83,,,,,,,,,,,,,
BRA SURG 3XL WHT POST SURG MAMM COMPR DSG W/ REM STRP FR HK,SUP-2276930,CDM,L8000,HCPCS,0274,RC,,,,both,,,50.08,32.55,,,,,,,,,,,,,
STAPLER INT DIA5MM 25 ABSRB STRP FIX DISP FOR HERN MESH,SUP-2219935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1622.12,1054.38,,,,,,,,,,,,,
SCREW BONE L20MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189676,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.65,147.97,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 5-8 MM EPTFE SHRT TAPR,SUP-2763160,CDM,C1768,CPT,0278,RC,,,,both,,,1678.39,1090.95,,,,,,,,,,,,,
BRACE ORTH EXTN ORTHOSIS WRST CTRL,SUP-2388193,CDM,L3908,HCPCS,0272,RC,,,,both,,,162.43,105.58,,,,,,,,,,,,,
RELOAD STPL 45MM THN VASC TISS WHT W/ GRIPPING SURF,SUP-2283263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.93,445.85,,,,,,,,,,,,,
GRAFT VASC W/ RADPQ MRK THORACOABDOMINAL 14MM BOR SIZEX25CM,SUP-2384990,CDM,C1768,CPT,0278,RC,,,,both,,,10487.60,6816.94,,,,,,,,,,,,,
LEAD PACE FINELINE II STEROX L 58 CM DIA 5 FR SIL STEROID,SUP-2140111,CDM,C1900,HCPCS,0275,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
WASHER CUP L FRAG PLATING SYS ALPS 3PK,SUP-2412017,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.64,261.72,,,,,,,,,,,,,
DEVICE COMBINATION TISS FIX BIOCOMP 3 SWIVELOCK FIBERTAK,SUP-2882411,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
HC Surgery Level 4 Base,PX-3600000004,CDM,3600000004,LOCAL,0360,RC,,,,both,,,6734.00,4377.10,,,,,,,,,,,,,
PACEMAKER CARD AVEIR DR L 32.2 MM DIA 6.5 MM 1 ML 2.1 GM TI,SUP-2895732,CDM,C1786,HCPCS,0275,RC,,,,both,,,39721.00,25818.65,,,,,,,,,,,,,
FIXATOR 5/8 RNG 120MM FRDM CIR,SUP-2400631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG PO TB24,RX-27660,CDM,6370000000,HCPCS,0637,RC,00904-7082-06,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX24 CM LT DL VASCPAK KT DURAMAX LF,SUP-2493675,CDM,C1750,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BLADE RETRACTOR BALFOUR 4IN SPREAD 1INW X 1INL FENESTRATED,SUP-2489592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.91,315.19,,,,,,,,,,,,,
VALVE AORT STENT 21 MM GRAFTMASTER,SUP-2356697,CDM,C1889,HCPCS,0278,RC,,,,both,,,25025.80,16266.77,,,,,,,,,,,,,
PLATE BONE THK0.5MM 6 H ORBIT GRN TI CVD HX FOR 1.5MM SCR,SUP-2135901,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
MODEL SURG PLN CR IDENTITY IMPRNT IVIEW,SUP-2904500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ANCHOR SUT 20 MM DIA SGL ARMED TI N ABSRB BRAID RIGIDLOOP,SUP-2431833,CDM,C1713,HCPCS,0278,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
PROTECTOR TEND W4XL5IN SHT BOV CLLGN GLYCOSAMINOGLYCAN POR,SUP-2244460,CDM,C1776,CPT,0278,RC,,,,both,,,8827.92,5738.15,,,,,,,,,,,,,
PLATE BNE L35MM THK1.3MM 2X4 H L HND TI L SHP LOK TRILOK,SUP-2267942,CDM,C1713,HCPCS,0278,RC,,,,both,,,1738.30,1129.89,,,,,,,,,,,,,
CATHETER HD SET 12 FRX25 CM ACUTE DL TURBO-FLO HD,SUP-2759834,CDM,C1752,HCPCS,0278,RC,,,,both,,,422.77,274.80,,,,,,,,,,,,,
GUIDEPIN SURG LESSER 0.71 IN ENCOMPASS,SUP-2319780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
HC Convert Nephrostomy Catheter,PX-3615043400,CDM,50434,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
SUPPORT ANK XL FOR 14 15IN UNIV NYL STBL NONSTRETCH LACE UP,SUP-2196816,CDM,L4350,HCPCS,0274,RC,,,,both,,,33.03,21.47,,,,,,,,,,,,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,6370000000,HCPCS,0637,RC,70954-0518-10,NDC,,both,50,ML,119.70,77.80,,,,,,,,,,,,,
SCREW BONE STD -5 MM DIA 50 MM LEN CANC THRD N CANN N LCK N,SUP-2417719,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
PLATE BNE W200XL200MM THK1MM CRANIOMAXILLOFACIAL TI,SUP-2262591,CDM,C1713,HCPCS,0278,RC,,,,both,,,19720.99,12818.64,,,,,,,,,,,,,
CATHETER VENTRICULAR EXT LG 1.9 MMX35 CM BA STRIPE TEM,SUP-2851444,CDM,C1729,HCPCS,0272,RC,,,,both,,,476.68,309.84,,,,,,,,,,,,,
PLATE BNE L 88 MM SCREW DIA2.4 MM HD 2 SHFT 10 H SS CNDYL NS,SUP-2905642,CDM,C1713,HCPCS,0278,RC,,,,both,,,2589.81,1683.38,,,,,,,,,,,,,
CROWN DENT NOELL-5 M NICKEL CHROM,SUP-2322205,CDM,D6783,CPT,0278,RC,,,,both,,,33.22,21.59,,,,,,,,,,,,,
MICROCATHETER INFUSION PROGREAT ALPHA L 110 CM DIA2.7 FR,SUP-2385150,CDM,C1887,HCPCS,0272,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
STENT PERIPH L100MM DIA10MM CATH L110CM NIT EPTFE IL,SUP-2396464,CDM,C1874,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
BIT DRL L195MM DIA4.5MM QUIK CPL FOR L EXT FIX,SUP-2187288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.21,228.94,,,,,,,,,,,,,
POST EXT FIX 3 HOLE W/O THRD ATTCH,SUP-2749942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
SYSTEM IMPL INCL PEEK SWIVELOCK ANCHR W/ FIBERTAPE NDL DRL,SUP-2122834,CDM,C1713,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96896,CDM,J9100,HCPCS,0636,RC,61703-0305-58,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
MESH BIO W8XL8CM BOV PERICARD NONCROSSLINKED CLLGN MTRX,SUP-2130302,CDM,C9354,HCPCS,0278,RC,,,,both,,,14513.11,9433.52,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 7-4 MM EPTFE TAPR FLX TW RING,SUP-2761494,CDM,C1768,CPT,0278,RC,,,,both,,,3572.10,2321.86,,,,,,,,,,,,,
SPHERE EMB GEL-BEAD DIA 300-500 UM GEL BIORESORBABLE SPHR,SUP-2120485,CDM,C1889,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
CATHETER INTVASC OCCL FOGARTY L 80 CM DIA 8 FR BALLOON DIA,SUP-2214271,CDM,C2628,HCPCS,0272,RC,,,,both,,,698.59,454.08,,,,,,,,,,,,,
CROMOLYN SODIUM 5.2 MG/ACT NA AERS,RX-24325,CDM,6370000000,HCPCS,0637,RC,57782-0397-26,NDC,,both,26,ML,31.50,20.47,,,,,,,,,,,,,
CATHETERIZATION KIT ART 018 20 GAX4.45 CM 18/25 GA 3 CC LF,SUP-2865589,CDM,C1751,HCPCS,0278,RC,,,,both,,,142.87,92.87,,,,,,,,,,,,,
GAUGE MEAS + 0 MM C TAPR NK EXTN,SUP-2368458,CDM,C1776,CPT,0278,RC,,,,both,,,3433.28,2231.63,,,,,,,,,,,,,
Z DISCONTINUED CATHETER IABP 7FR 34CC SHTH LAIN FBROPT DATASCP SYS,SUP-2227312,CDM,C1725,HCPCS,0272,RC,,,,both,,,2976.06,1934.44,,,,,,,,,,,,,
DEVICE THROMCTMY TIGERTRIEVER 13 L 20.5 MM DIA 0.5-2.5 MM,SUP-2864551,CDM,C1757,HCPCS,0272,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
SET BNE BX NDL 13X16GA L15X22.1CM MURPHY COAX OSTEO SITE,SUP-2170378,CDM,C1713,HCPCS,0278,RC,,,,both,,,370.43,240.78,,,,,,,,,,,,,
HC Gram Stain,PX-3008720500,CDM,87205,CPT,0300,RC,,,,both,,,159.00,103.35,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC IR 4FR 55CM 1 LUMAN RVS TAP 3174335,SUP-2632654,CDM,C1751,HCPCS,0278,RC,,,,both,,,359.00,233.35,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV 20-24 IN XS PRNG BCKL PROCARE,SUP-2196976,CDM,L3650,HCPCS,0272,RC,,,,both,,,14.57,9.47,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 20 CM LOOP DIA 8 MM PRIMARY,SUP-2249274,CDM,C1889,HCPCS,0278,RC,,,,both,,,4096.60,2662.79,,,,,,,,,,,,,
SUPPORT KNEE GEL FORC L PRO-TEC,SUP-2324031,CDM,L1810,HCPCS,0272,RC,,,,both,,,75.71,49.21,,,,,,,,,,,,,
STENT TRACHBRONCH L35MM DIA22MM CATH L75CM SHTH 11FR,SUP-2140091,CDM,C1876,HCPCS,0278,RC,,,,both,,,3188.89,2072.78,,,,,,,,,,,,,
HEAD FEM DIA40MM 3MM OFFSET 11 13 TAPR HIP CO CHROME MTL ON,SUP-2251127,CDM,C1776,CPT,0278,RC,,,,both,,,7850.63,5102.91,,,,,,,,,,,,,
PLATE BNE L 65 MM SCREW DIA2 MM 12 SHFT H SS ADPT VA SLV,SUP-2907842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2893.13,1880.53,,,,,,,,,,,,,
SPACER SPNL 16X13X6MM 7 DEG CERV LORDOTICTITANIUM IRIX-C,SUP-2401535,CDM,C1889,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 180 CM DIA 0.035 IN TAPR L 15,SUP-2170674,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.01,94.26,,,,,,,,,,,,,
PLATE BNE L194MM THK3.7MM 10 H NONSTERILE L DST MED TIB S,SUP-2185533,CDM,C1713,HCPCS,0278,RC,,,,both,,,3859.31,2508.55,,,,,,,,,,,,,
PLATE BONE HLX6 3MM THK TTNM STRGHT WBAR THRDLCK TS LATEX F,SUP-2669762,CDM,C1713,HCPCS,0278,RC,,,,both,,,2880.45,1872.29,,,,,,,,,,,,,
PROSTHESIS OSS EAR 3X4.75X1.17 MM PART PLAS POR PORP SHEEHY,SUP-2312526,CDM,L8613,CPT,0278,RC,,,,both,,,762.55,495.66,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM OD 4 FR ID 1.3 MM GUIDEWIRE,SUP-2168305,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.35,35.33,,,,,,,,,,,,,
NEEDLE SURGICAL L6.5IN CURVED DELICATE HOUSE,SUP-2806063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.47,297.36,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.533,SUP-2860214,CDM,C1713,HCPCS,0278,RC,,,,both,,,36823.09,23935.01,,,,,,,,,,,,,
KIT PROCEDURE BRONCHOSCOPY GALAXY (MUST BE PURCHASED IN INCREMENTS OF 4 EA),SUP-2881765,CDM,C1601,HCPCS,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SCREW INTRF 6X40MM BIOSTEON PLLA CROSS PIN,SUP-2362052,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.62,484.65,,,,,,,,,,,,,
SCREW BNE DIA 3.5 MM COMPR HDLSS STRL SPEEDMTP,SUP-2908894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1855.74,1206.23,,,,,,,,,,,,,
HOOK SPNL M PEDCL S STL NEUT BILAT FOR 5.5MM ROD CDH LEG,SUP-2288175,CDM,C1713,HCPCS,0278,RC,,,,both,,,1861.39,1209.90,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PLU MAXBARR 4FR 55CM 1 LU 1174108D4,SUP-2632628,CDM,C1751,HCPCS,0278,RC,,,,both,,,823.15,535.05,,,,,,,,,,,,,
HC Debride Subq First 20 Sq Cm,PX-3611104200,CDM,11042,CPT,0361,RC,,,,outpatient,,,1247.00,810.55,,,,,,,,,,,,,
PIN EXT FIX L15MM DIA3MM S STL HALF UNILAT JET-X,SUP-2342883,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.68,504.84,,,,,,,,,,,,,
STEM HUM L L150MM LT CO CHROM PRI CEM FOR TOT ELBW PROS,SUP-2388535,CDM,C1776,CPT,0278,RC,,,,both,,,29535.31,19197.95,,,,,,,,,,,,,
SCREW BNE LCK UNIV 2.7X34 MM TI STRL,SUP-2458163,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.54,222.00,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI HEM CATH ACTE 8FR DIA 18CM STRGHT RND,SUP-2610595,CDM,C1750,HCPCS,0278,RC,,,,both,,,732.88,476.37,,,,,,,,,,,,,
MESH HERN REP W15XL20CM RECT SKIRTED MFIL COMP POLY ABSRB,SUP-2173621,CDM,C1781,HCPCS,0278,RC,,,,both,,,4492.05,2919.83,,,,,,,,,,,,,
KIT RAILWAY ACCESS 7FR VBT SHEATHLESS,SUP-2424883,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
STEM FEM STD NK 0/1 HIP ACTIS,SUP-2452985,CDM,C1776,CPT,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA 8 FR HYDRPHLC,SUP-2383415,CDM,C1894,HCPCS,0272,RC,,,,both,,,481.68,313.09,,,,,,,,,,,,,
PISTON L4MM DIA0.6MM S STL STAP FOR STAPEDECTOMY MCGEE,SUP-2312540,CDM,L8613,CPT,0278,RC,,,,both,,,244.48,158.91,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 3FR 20CM 1 LUMAN S4153108DG,SUP-2632860,CDM,C1751,HCPCS,0278,RC,,,,both,,,516.18,335.52,,,,,,,,,,,,,
TROCAR SURG T SHP VITAL JAMSH,SUP-2693357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW BNE ST 2.7X80 MM CRTX T8 STARDRV RECESS SS NS,SUP-2757635,CDM,C1713,HCPCS,0278,RC,,,,both,,,143.69,93.40,,,,,,,,,,,,,
GRAFT BONE SUB 15CC TRICORT ILIUM BLK FRZ DRY,SUP-2115983,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.78,1381.76,,,,,,,,,,,,,
CURVED RECON 3.5MM 12X142MM,SUP-2818804,CDM,C1713,HCPCS,0278,RC,,,,both,,,4187.98,2722.19,,,,,,,,,,,,,
RETRACTOR EXTENDED WEAR PANNICULUS XL,SUP-2880688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
GRAFT VASC STR 16 MMX15 CM AORT ARCH 1 LAYR SFT HEMSHLD GLD,SUP-2463790,CDM,C1768,CPT,0278,RC,,,,both,,,1324.83,861.14,,,,,,,,,,,,,
SYSTEM LD DEL ACUITY BREAK-AWAY CORONARY VEN PACE LD SPRL,SUP-2149159,CDM,C1894,HCPCS,0272,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
LINER ACET ANTEVERTED 4+ MM 20 DEG 40X58 MM HIP XLPE R3,SUP-2434696,CDM,C1776,CPT,0278,RC,,,,both,,,6116.72,3975.87,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 6 MM STR STD WALL REINF,SUP-2494266,CDM,C1768,CPT,0278,RC,,,,both,,,673.88,438.02,,,,,,,,,,,,,
CATHETER VENT DRNGE L14CM OD2.7MM ID1.4MM SIL BA STYL INTRO,SUP-2257149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
STYLET LD POS L46CM DEFL LOC +,SUP-2356065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TEMPLATE SURG M W6.5XL19MM 10DEG IM CHT FIX SYS ANG SZ NIT,SUP-2194204,CDM,C1776,CPT,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 50-59 CM SAPH VEIN BLD TYP A B AB,SUP-2884053,CDM,C1768,CPT,0278,RC,,,,both,,,30297.86,19693.61,,,,,,,,,,,,,
PLATE BNE L241MM 8 H PROX FEM S STL HK LOK COMPR FOR 4.5MM,SUP-2186059,CDM,C1713,HCPCS,0278,RC,,,,both,,,5061.49,3289.97,,,,,,,,,,,,,
IMMOBILIZER KNEE XL L19IN FOR 20 22IN BLU CANVS T BAR STAY,SUP-2336066,CDM,L1830,CPT,0272,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
HC Ot Orthotic Fit/Train Subsq per 15 Min,PX-4309776300,CDM,97763,CPT,0430,RC,,,,both,,,160.00,104.00,,,,,,,,,,,,,
WIRE DRL KT 1-6.5 MM EXCHANGE TUBE STRL,SUP-2905284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER HAD 11.5FR L20CM STR POLYUR DBL LUMN FULL KT,SUP-2267018,CDM,C1752,HCPCS,0278,RC,,,,both,,,271.92,176.75,,,,,,,,,,,,,
ANCHOR SUT 0889 MM DIA SGL ARMED S STL LTX FREE,SUP-2168713,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
KIT ACCS TRANSRADIAL SPR WIRE RADIALSOURCE RED 4FRX10CM,SUP-2157412,CDM,C1713,HCPCS,0278,RC,,,,both,,,101.27,65.83,,,,,,,,,,,,,
PASSER SUTURE LOOP W/ BRAIDED NIT GRAPPLER DISP P419600030,SUP-2749800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
PLATE BNE MINI TI MANDIBULAR PMI ORTHOGNATHIC 3D PRNT NS,SUP-2934920,CDM,C1713,HCPCS,0278,RC,,,,both,,,18434.94,11982.71,,,,,,,,,,,,,
SHEATH DEL AMPLATZER TALISMAN TIP 45 DEG L 80 CM DIA 8 FR OD,SUP-2716356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
ROD SPNL CRV 3.5X200 MM PRE BENT INFIN,SUP-2421098,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED S5 RESURF,SUP-2419705,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
STEM FEM SEG 15 CM DPHSEAL KNEE POROUS OSS,SUP-2449781,CDM,C1776,CPT,0278,RC,,,,both,,,14854.87,9655.67,,,,,,,,,,,,,
COLLAR CERV M AD W3.5XL23.5IN M DENS CNTOUR CNTCT CLSR FOAM,SUP-2197375,CDM,L0120,HCPCS,0274,RC,,,,both,,,17.46,11.35,,,,,,,,,,,,,
TREPHINE 14MM ID X 8IN,SUP-2515458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
PLATE BONE L THK1.5MM 5X22X5 H MAND TI LCKING DBL ANG FOR,SUP-2191269,CDM,C1713,HCPCS,0278,RC,,,,both,,,8974.43,5833.38,,,,,,,,,,,,,
TAMP BNE INFLATABLE 2 10 MM KYPHON EXPRESS II,SUP-2664463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3746.65,2435.32,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 0.5 CC FD CORTICAL PWD ORAGRAFT,SUP-2741028,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.90,101.33,,,,,,,,,,,,,
FIBER LASER DBL W/ WALL PLATE,SUP-2798098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1854.14,1205.19,,,,,,,,,,,,,
PROBE RF STR 21 GAX50 MM DURABLE SS REUSE,SUP-2753307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3173.82,2062.98,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 58 MM DIA 32 MM SHTH 20 FR RVD,SUP-2170441,CDM,C1874,HCPCS,0278,RC,,,,both,,,5925.18,3851.37,,,,,,,,,,,,,
PLATE RAD DIST VOLAR VA LOQTEQ 2.5 BROAD 4HL,SUP-2717531,CDM,C1713,HCPCS,0278,RC,,,,both,,,4232.22,2750.94,,,,,,,,,,,,,
BUSPIRONE HCL 5 MG PO TABS,RX-9324,CDM,6370000000,HCPCS,0637,RC,00904-7122-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE L98MM 7 H LT PROX POSTEROMEDIAL VAR ANG LCK FOR,SUP-2349801,CDM,C1713,HCPCS,0278,RC,,,,both,,,9533.35,6196.68,,,,,,,,,,,,,
STEM RADIAL SM 6.5 ULN WRST MOD COCR 1ST CHOICE,SUP-2852823,CDM,C1776,CPT,0278,RC,,,,both,,,11398.20,7408.83,,,,,,,,,,,,,
WIRE FIX COMPR 1.6X150 MM 25 MM THRD NS,SUP-2863401,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.63,94.01,,,,,,,,,,,,,
SCREW BONE L8MM DIA24MM CORTICAL HEADED NON LOCKING MSP,SUP-2465084,CDM,C1713,HCPCS,0278,RC,,,,both,,,286.31,186.10,,,,,,,,,,,,,
ANCHOR SONIC KIT FORCE FIBER 2.5X10MM 2,SUP-2479334,CDM,C1713,HCPCS,0278,RC,,,,both,,,1016.36,660.63,,,,,,,,,,,,,
HEAD FEM OD36MM HIP BACKFILLED BFH TECHNOLOGY DYNASTY,SUP-2304508,CDM,C1776,CPT,0278,RC,,,,both,,,11562.27,7515.48,,,,,,,,,,,,,
COMPONENT TIB TY PROX PLATE NS OPTILOCK LTX,SUP-2861371,CDM,C1776,CPT,0278,RC,,,,both,,,7315.76,4755.24,,,,,,,,,,,,,
ELECTRODE ES 035MM WIRE LOOP HF RESECT FOR 3MM 12DEG TELSCP,SUP-2313596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.89,218.98,,,,,,,,,,,,,
MESH SPNL H7XL10MM TI RND,SUP-2254462,CDM,C1713,HCPCS,0278,RC,,,,both,,,4207.60,2734.94,,,,,,,,,,,,,
SPLINT WRST XL AD L8IN FOR 85 95IN R NYL LN FOAM PUL ON,SUP-2276665,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.42,10.67,,,,,,,,,,,,,
CATHETER INFUS L150CM OD2.4 1.7FR ID.017IN MIC HYDRPHLC STR,SUP-2305464,CDM,C1887,HCPCS,0272,RC,,,,both,,,2529.27,1644.03,,,,,,,,,,,,,
PLATE BNE STRIKE HIP RASPING GRIPTION TF PINNACLE,SUP-2453617,CDM,C1713,HCPCS,0278,RC,,,,both,,,1843.18,1198.07,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.078X9 IN RND END SS NS STEINMANN,SUP-2791820,CDM,C1713,HCPCS,0278,RC,,,,both,,,9.99,6.49,,,,,,,,,,,,,
INSERT SHOE PART FT,SUP-2388200,CDM,L5000,HCPCS,0272,RC,,,,both,,,1465.03,952.27,,,,,,,,,,,,,
SLIDER NDL 30DEG STAIGHT,SUP-2366705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,767.79,499.06,,,,,,,,,,,,,
CLIP SUT TI W/ MT DEV,SUP-2332803,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.28,208.83,,,,,,,,,,,,,
ANCHOR SUT L17MM DIA55MM BIOCOMPOSITE FULL THRD W 3 SZ 2 0,SUP-2167095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1559.95,1013.97,,,,,,,,,,,,,
STEM FEM STD OFFSET 5-9 MAG NK W/ TRUNNION TAPRLOK,SUP-2442567,CDM,C1776,CPT,0278,RC,,,,both,,,1031.49,670.47,,,,,,,,,,,,,
TRAY CATH PICC RADPICC BSC 5FR 0.042N 60CM 1 LUMAN R 3165335,SUP-2632647,CDM,C1751,HCPCS,0278,RC,,,,both,,,184.32,119.81,,,,,,,,,,,,,
WASHER BOLT FIXATION FLT SLOTTED 4MM,SUP-2497045,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.75,76.54,,,,,,,,,,,,,
ANCHOR SUTURE WHITE/BLUE BLUE WHITE/BLACK HI FI RIBBON FOR R,SUP-2825230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1574.02,1023.11,,,,,,,,,,,,,
STEM FEM PRSS FIT COCR MLRY HD SZ 5/7 135MML,SUP-2403344,CDM,C1776,CPT,0278,RC,,,,both,,,8050.96,5233.12,,,,,,,,,,,,,
SCREW BNE L55MM DIA6MM ST AQUA CORT TI ST CANN LOK FULL,SUP-2191839,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
ORTHOPAEDIC INSTRUMENT KIT 18X14X14 MM STPL DYNAFORCE HIMAXC,SUP-2866432,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
STEM FEM L130MM OD11MM STD BODY NK OFFSET CO CHROM HIP PRI,SUP-2211295,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC So Antb Severe Aqt Respir Synd Sars-Cov-D Covid-19,PX-3028676966,CDM,86769,CPT,0302,RC,,,,outpatient,,,74.00,48.10,,,,,,,,,,,,,
GRAFT VASC HEMGRD BODY/BRANCH L 85/55 CM RNG L 45/30 CM DSTL,SUP-2474157,CDM,C1768,CPT,0278,RC,,,,both,,,5221.19,3393.77,,,,,,,,,,,,,
SYSTEM ENDO SOFT TISSUE RELEASE CLEARGUARD LE,SUP-2715890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
MESH GORE SYNECOR 40CM X 50CM RECTANGLE,SUP-2763183,CDM,C1781,HCPCS,0278,RC,,,,both,,,48516.14,31535.49,,,,,,,,,,,,,
CATHETER HD SWAN NK 62 CM CURL CATH MISSOURI 2 CUF RT ARGY,SUP-2626973,CDM,C1750,HCPCS,0278,RC,,,,both,,,584.42,379.87,,,,,,,,,,,,,
HC So Prostatic Acid Phosphatase,PX-3018406666,CDM,84066,CPT,0301,RC,,,,both,,,179.00,116.35,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN TIP L 3 MM PTFE AMPLTZ,SUP-2117308,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.53,29.59,,,,,,,,,,,,,
POUCH GENRTR FOR PACEMKR BARD PARSONNET,SUP-2137978,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BIT DRL DIA2.7MM PERIPH SCR REUSE FOR COMPHSVE REV SHLDR,SUP-2408540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.19,272.47,,,,,,,,,,,,,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-149995,CDM,6370000000,HCPCS,0637,RC,69315-0312-28,NDC,,both,28,GR,315.00,204.75,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILESTO 7 HF-T W 56 X H 65 MM D 11 MM 40 J,SUP-2138297,CDM,C1882,HCPCS,0275,RC,,,,both,,,47885.00,31125.25,,,,,,,,,,,,,
ADAPTER LD L 40 CM SIL INSUL UPLR LV1 RECEPTACLE IS1 CONN,SUP-2616254,CDM,C1883,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
CANNULA ARTHSCP 2.9 MM OPERATIVE SHT WINDOW NS LTX,SUP-2877933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.04,469.33,,,,,,,,,,,,,
WIRE SURG OD1MM S STL VIT SMOOTH SUT,SUP-2377567,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.89,222.88,,,,,,,,,,,,,
STENT BILI EVOLUTION L 6 CM FLANGE DIA11 MM BODY DIA10 MM,SUP-2169451,CDM,C1876,HCPCS,0278,RC,,,,both,,,6160.68,4004.44,,,,,,,,,,,,,
STEM EXTN L220MM OD10MM FEM KNEE BOW PRSS FIT SYMMETRIC,SUP-2349116,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
SNARE VASC INDY SHTH L 100 CM DIA 8 FR BSKT DIA 40 MM,SUP-2170848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.17,908.16,,,,,,,,,,,,,
SCREW BNE L 120 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2931996,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.11,133.97,,,,,,,,,,,,,
PUNCH SURG KNOTLESS 4.75-5.5 MM BROACHING CROSSFT DISP,SUP-2423296,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.67,457.39,,,,,,,,,,,,,
NAIL IM L350MM OD15MM SUBTROCHANTERIC ROD RT ZCKL II,SUP-2364777,CDM,C1713,HCPCS,0278,RC,,,,both,,,4704.98,3058.24,,,,,,,,,,,,,
GRAFT HUM TISS W4XL16CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307558,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5508.35,3580.43,,,,,,,,,,,,,
GRAFT BNE FN 1-4 MM 30 CC FRZN CANC,SUP-2766765,CDM,C1713,HCPCS,0278,RC,,,,both,,,2111.02,1372.16,,,,,,,,,,,,,
CONNECTOR SPNL 4.5/6.35MM L10MM ROD IL CLS LAT CDH,SUP-2286987,CDM,C1713,HCPCS,0278,RC,,,,both,,,2343.07,1523.00,,,,,,,,,,,,,
PLATE VA-LCKNG CALCANEAL W/TABS 2.7MM LARGE 70MM RGHT-STER,SUP-2546129,CDM,C1713,HCPCS,0278,RC,,,,both,,,3550.27,2307.68,,,,,,,,,,,,,
OSTEOTOME SURG L8 1 4IN BLDE W1 4IN STR S STL SATIN FINISH,SUP-2161283,CDM,C1713,HCPCS,0278,RC,,,,both,,,309.16,200.95,,,,,,,,,,,,,
PLATE BNE L63MM THK1.5MM 3X4 H BILAT S STL T SHP OBLQ ANG,SUP-2185884,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.93,500.45,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 68 CM DIA 0.018 IN SS PERIPH J/STRAIGHT,SUP-2383972,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.91,22.04,,,,,,,,,,,,,
MESH SURG W15XL20CM OVL FOR TISS SEPARATING AND HERN FIX,SUP-2219761,CDM,C1781,HCPCS,0278,RC,,,,both,,,3009.88,1956.42,,,,,,,,,,,,,
LIDOCAINE HCL 1% INJ (MIXTURES ONLY),RX-430017,CDM,J2003,HCPCS,0636,RC,63323-0492-26,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
HEAD HUM H24MM OD58MM ID54MM SHLDR CO CHROM MOD NECKLESS,SUP-2404507,CDM,C1776,CPT,0278,RC,,,,both,,,5705.38,3708.50,,,,,,,,,,,,,
WASHER ORTH FOR 2.0 SCR VLP,SUP-2350903,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.67,201.94,,,,,,,,,,,,,
PLATE BONE W8XL96MM THK3.3MM 12 H STRL BILAT PELV S STL,SUP-2186240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1472.44,957.09,,,,,,,,,,,,,
SCREW BONE L9MM DIA2MM CRANIOMAXILLOFACIAL TI FOR MINI SYS,SUP-2262648,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.77,71.35,,,,,,,,,,,,,
BLADE 4.5MMX20CM 1 STR AND 1 25DEG ANG SET,SUP-2284308,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PUSHER KNOT SUT CUT DISP,SUP-2163482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.97,382.18,,,,,,,,,,,,,
INTRODUCER KYPHOPLASTY SZ 3 8GA 42MM OSTEO KYPHON ADV,SUP-2281649,CDM,C1894,HCPCS,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
ANCHOR SUT 2 ORTHOCORD L36IN VLT BLU COMP BRAID SUT CP-2,SUP-2249448,CDM,C1713,HCPCS,0278,RC,,,,both,,,2719.24,1767.51,,,,,,,,,,,,,
SET INT FIX DIA18.5 MM TI NEURO XDRV 1 PK STRL DISP LORENZ,SUP-2935670,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
DEVICE FIX SUT BAR DBL FOR MENIS REP SYS FAST-FIX,SUP-2341340,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.34,255.02,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 11 HOLES 208MM,SUP-2549511,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.17,1265.01,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MM 12 CM SYMMETRI PROX MIDAS REX 8 CLRVW,SUP-2632186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
PERI-LOC 2.7MM S-T LOCK SCREW 16MM,SUP-2819077,CDM,C1713,HCPCS,0278,RC,,,,both,,,941.15,611.75,,,,,,,,,,,,,
ROD IM OD5/16IN FEM W/T-HANDLE,SUP-2365122,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
TI NARROW 8 HOLE PLATE 104MM,SUP-2695589,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.47,234.31,,,,,,,,,,,,,
GORE 9MMX7.5CM 8FR 120CMCATH.,SUP-2396625,CDM,C1874,HCPCS,0278,RC,,,,both,,,10748.22,6986.34,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 2000 MG IJ SOLR,RX-10579,CDM,J2919,HCPCS,0636,RC,00009-0850-01,NDC,,both,1,UN,626.00,406.90,,,,,,,,,,,,,
REMOTE SCS SYS W 6.7 X H 13.8 CM D 0.7 CM 144 GM SMRT,SUP-2905296,CDM,C1787,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE L112MM HK D18MM 7 H R CLAV S STL LOK COMPR FOR,SUP-2185861,CDM,C1713,HCPCS,0278,RC,,,,both,,,3528.26,2293.37,,,,,,,,,,,,,
PLATE BNE RADIAL 2.4X59.5 MM LT DSTL 8X4 HOLE VOLAR CLMN TI,SUP-2190181,CDM,C1713,HCPCS,0278,RC,,,,both,,,2816.80,1830.92,,,,,,,,,,,,,
PLATE BNE ULN 110 MM LT DORS PROX 8 HOLE BUTTRESS SS STRL,SUP-2471813,CDM,C1713,HCPCS,0278,RC,,,,both,,,2359.68,1533.79,,,,,,,,,,,,,
WIRE ORTH OD2MM L450MM FIX S STL DBL END SMOOTH DBL SHRP,SUP-2316255,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.31,152.30,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 40 CM BALLOON L 2 CM DIA2 MM,SUP-2140993,CDM,C1725,HCPCS,0272,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
GUIDE SURG RT TIB RESECT TRIATHLON,SUP-2364720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1237.16,804.15,,,,,,,,,,,,,
MATRIX BIO L 8 X W 6 CM FISH SKIN DERMAL INTACT STRL OMEGA3,SUP-2909258,CDM,Q4158,HCPCS,0636,RC,,,,both,,,8449.74,5492.33,,,,,,,,,,,,,
PLATE BONE L61MM 8 H STRL S STL LCK COMPR FOR 2.7MM SCR EVOS,SUP-2349617,CDM,C1713,HCPCS,0278,RC,,,,both,,,2278.26,1480.87,,,,,,,,,,,,,
BASEPLATE BONE ELBW TI ASMBLY FOR STBL SYS IJS,SUP-2340387,CDM,C1713,HCPCS,0278,RC,,,,both,,,15345.18,9974.37,,,,,,,,,,,,,
ALLOGRAFT DERMAL MED 4X12 CMX1.6/0.4 MM RDY TO USE ALLDERM,SUP-2492476,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX15 CM 13 GA 3L CUTLM701JABRMHCRD,SUP-2759885,CDM,C1751,HCPCS,0278,RC,,,,both,,,245.71,159.71,,,,,,,,,,,,,
SCREW SPNL L45MM DIA7MM TI POLYAX EXT TAB FOR MINIMALLY,SUP-2255045,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
"HC So2 Spectrophotometry, Analyte Nes",PX-3018431168,CDM,84311,CPT,0301,RC,,,,outpatient,,,191.00,124.15,,,,,,,,,,,,,
CATHETER ETER IRRIG 6FR L80CM FOR VASC CLOT MGMT,SUP-2119769,CDM,C1757,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
KIT PRB 17GA L50MM ACT TIP 4MM COOLED RF COOLIEF,SUP-2237175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
DEVICE FIX L37CM PEEK SMOOTH CANN 30 ABSRB FAST FOR LAP,SUP-2125767,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CATHETER PICC 4FR GWIRE L70CM POLYUR NIT GWIRE,SUP-2125533,CDM,C1751,HCPCS,0278,RC,,,,both,,,264.23,171.75,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 7 28X26X14 MM CC-ALIF CANC ALLOQUENT,SUP-2736943,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PLATE COND CRVD VA TI 4.5 X336MM LT 16HL,SUP-2720089,CDM,C1713,HCPCS,0278,RC,,,,both,,,6444.60,4188.99,,,,,,,,,,,,,
NAIL IM L215MM DIA10.7MM STROKE 50MM 10DEG FEM RG FOR LIMB,SUP-2418824,CDM,C1713,HCPCS,0278,RC,,,,both,,,72734.96,47277.72,,,,,,,,,,,,,
LORAZEPAM 4 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-10468,CDM,J2060,HCPCS,0636,RC,00641-6049-25,NDC,JW,both,0.75,ML,54.10,35.16,,,,,,,,,,,,,
STAPLER REINF SEAMGRD ECHELON 45,SUP-2395314,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
INSERT TIB SZ 3 THK20MM STD L KNEE POLYETH CRUCE RET PRI,SUP-2304713,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
KIT TUNNELED CTRL VEN CATH SGL LUMN 9.8 FRX85 CM L,SUP-2332924,CDM,C1751,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
IMPLANT HUM TISS W20MMXL5CM FASC LATA FRZ DRY,SUP-2307109,CDM,C1762,CPT,0278,RC,,,,both,,,1012.27,657.98,,,,,,,,,,,,,
VALVE CSF IN LN REG 25 CM LUMPERITON LO PRESSURE SPETZLER,SUP-2852599,CDM,C1889,HCPCS,0278,RC,,,,both,,,2740.72,1781.47,,,,,,,,,,,,,
EPHEDRINE SULFATE (PRESSORS) 25 MG/5ML IV SOSY,RX-143102,CDM,2500000003,HCPCS,0250,RC,69374-0901-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN FRIC,SUP-2388218,CDM,L5812,HCPCS,0274,RC,,,,both,,,1485.85,965.80,,,,,,,,,,,,,
CANNULA ORTH L 250 MM DIA 8 GA ACCESS/DELIVERY DRILLABLE,SUP-2893110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SHEATH CV KT PERM VLV NO RADPQ BND 0.038IN NO HYDRPHLC COAT 406195] ST JUDE MED CARDIOVASCULAR DIV],SUP-2355443,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
SCREW BNE CORTICAL STD 6 MM SHFT 6-5X200 MM 50 MM ST NS,SUP-2644426,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.60,225.94,,,,,,,,,,,,,
BLADE CARTILAGE CHISEL MENEZES MST,SUP-2494245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.86,350.26,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X30 MM CANN FOR 4.5 MM ROD SHILLA,SUP-2630591,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S1294108PD,SUP-2632814,CDM,C1751,HCPCS,0278,RC,,,,both,,,878.42,570.97,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X86X23X1.8 MM THOR 34 HOLE LADDER LEVEL 1,SUP-2869247,CDM,C1713,HCPCS,0278,RC,,,,both,,,3180.73,2067.47,,,,,,,,,,,,,
CATHETER ETER DIL FILIFORMS WVN STR TIP 5FR 3175CM REUSE,SUP-2126119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.40,322.01,,,,,,,,,,,,,
PROSTHESIS TESTICULAR XS 22X3 CM SIL ELASTMR NACL TOROSA,SUP-2165301,CDM,C1713,HCPCS,0278,RC,,,,both,,,7542.28,4902.48,,,,,,,,,,,,,
CLAMP CIRC XS 1.1 CM GMCO REUSE,SUP-2393505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1304.86,848.16,,,,,,,,,,,,,
STEM WR 6X15MM CAPITATE IMP MAESTRO,SUP-2136461,CDM,C1776,CPT,0278,RC,,,,both,,,2604.32,1692.81,,,,,,,,,,,,,
SCREW CORT BONE SELF TAP 4.5X32MM,SUP-2342655,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.60,17.94,,,,,,,,,,,,,
BAR SPNL STD 6.35 MM IL TI EXPEDIUM,SUP-2693674,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
ALLOGRAFT BNE WDG FD IRRADIATED IL CREST,SUP-2867053,CDM,C1762,CPT,0278,RC,,,,both,,,2496.77,1622.90,,,,,,,,,,,,,
GRAFT BONE MATRIC V92-FC 2.5CC,SUP-2740173,CDM,C1713,HCPCS,0278,RC,,,,both,,,5785.45,3760.54,,,,,,,,,,,,,
SLING ORTH FNGR 3 IN DYN REINF EYELET SUP-R-SOFT LF,SUP-2477659,CDM,L3933,HCPCS,0272,RC,,,,both,,,2.70,1.75,,,,,,,,,,,,,
CURETTE SURG HOUSE-SHEEHY 6-5/8 INX2.5 MM KNIFE MALL SHFT SM,SUP-2500197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,217.10,141.11,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 4.5-6.5 MM EPTFE TAPR TW N RING,SUP-2396727,CDM,C1768,CPT,0278,RC,,,,both,,,2128.92,1383.80,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305759,CDM,V2790,HCPCS,0278,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
HC So Npm1 Gene Analysis,PX-3108131066,CDM,81310,CPT,0310,RC,,,,both,,,318.00,206.70,,,,,,,,,,,,,
IMPLANT BIO L 6 X W 8.2 CM PORCINE TEND DERIVED,SUP-2909164,CDM,A2008,HCPCS,0636,RC,,,,both,,,8616.16,5600.50,,,,,,,,,,,,,
K WIRE FIX DIA0.90MM NTHRD,SUP-2378864,CDM,C1713,HCPCS,0278,RC,,,,both,,,101.99,66.29,,,,,,,,,,,,,
SCREW BNE FT 3.5X44 MM CORTICAL SLD TI NS,SUP-2413377,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.84,131.85,,,,,,,,,,,,,
SCREW BNE DPHSEAL KNEE TI LOK,SUP-2405832,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
SPACER FEM L THK5MM R MED DST DURAC,SUP-2377205,CDM,C1776,CPT,0278,RC,,,,both,,,2345.42,1524.52,,,,,,,,,,,,,
BIT DRL DIA3.2MM CALIB DISP FOR 4.5MM LCK PROX FEM SCR,SUP-2318883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,829.96,539.47,,,,,,,,,,,,,
PROBE PEDCL L165MM CANN W/ MOD JAMSH NDL NO1 MOD MOD,SUP-2354606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE 3 X 8 H MIDFACE NAR DISTRCTN,SUP-2883149,CDM,C1713,HCPCS,0278,RC,,,,both,,,4569.45,2970.14,,,,,,,,,,,,,
ROD SPNL L360MM DIA5.5MM CERV TI THRD VERTEX SEL,SUP-2289125,CDM,C1713,HCPCS,0278,RC,,,,both,,,1675.66,1089.18,,,,,,,,,,,,,
BOLT FIX 3 H M,SUP-2197277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 300 DR-T 55 X 66MM 12MM 30J BPLR,SUP-2138110,CDM,C1721,HCPCS,0275,RC,,,,both,,,60730.74,39474.98,,,,,,,,,,,,,
PLATE BNE TBLR 37 MM 3-HOLE 1/3,SUP-2518432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 63 CM DIA 8 FR DIL L 67 CM,SUP-2357250,CDM,C1893,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-143503,CDM,6370000000,HCPCS,0637,RC,00378-0873-99,NDC,,both,1,UN,278.60,181.09,,,,,,,,,,,,,
IBUPROFEN 200 MG PO TABS,RX-3841,CDM,6370000000,HCPCS,0637,RC,00904-6747-80,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
SCREW SPNL 4.5X55 MM HA TSRH 3DX OSTEOGRIP,SUP-2631153,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
HC Labor and Delivery Epidural,PX-3700000025,CDM,3700000025,LOCAL,0370,RC,,,,both,,,641.00,416.65,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ANTR TIBIALIS TEND FRZN NO-RAD,SUP-2321830,CDM,C1762,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 8 HOLE STR STRL LTX,SUP-2861618,CDM,C1713,HCPCS,0278,RC,,,,both,,,795.61,517.15,,,,,,,,,,,,,
CATHETER DIAGNOSTIC LASSOSTAR NAV OD20 MM CIRCULAR MAPPING CATHETER STERILE,SUP-2880094,CDM,C1730,HCPCS,0272,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
BUR SURG OD4.0MM CUT DR N FLUT FOR ELITE SABER SHANK,SUP-2363999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.28,225.73,,,,,,,,,,,,,
STENT PERIPH FORMULA 414 L 12 MM DIA 4 MM CATH L 80 CM SHTH,SUP-2639028,CDM,C1876,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,6370000000,HCPCS,0637,RC,24208-0315-10,NDC,,both,10,ML,48.40,31.46,,,,,,,,,,,,,
DRESSING WND TALYMED L 5 X W 5 CM POLY-N-ACETYL GLUCOSAMINE,SUP-2266131,CDM,Q4127,HCPCS,0636,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
ARM EXT FIX ANAT JIG DNP,SUP-2499130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
GRAFT VASC IMPRA L 45 CM DIA 6-4 MM EPTFE SHRT TAPR STD WALL,SUP-2761289,CDM,C1768,CPT,0278,RC,,,,both,,,1743.45,1133.24,,,,,,,,,,,,,
HC Inj Proc Lymphangiogram,PX-3613879000,CDM,38790,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
COLLAR CERV SM H425IN POLY FOAM PLAS SUPP TWO PC CA PROCARE,SUP-2196883,CDM,L0172,HCPCS,0274,RC,,,,both,,,42.42,27.57,,,,,,,,,,,,,
COMPONENT TIB SZ 1 8MM LT MEDL RT LAT POLYETH UNI OPTETRAK,SUP-2223235,CDM,C1776,CPT,0278,RC,,,,both,,,4471.36,2906.38,,,,,,,,,,,,,
PROSTHESIS OTO L425MM SHFT OD06MM TI MID EAR STAP FLROPLAS P,SUP-2436525,CDM,L8613,CPT,0278,RC,,,,both,,,557.76,362.54,,,,,,,,,,,,,
POST EX FX MAXFRAME MULTIPAR PIN MNT 2HIGH,SUP-2737903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
GUIDEWIRE VASC L200CM COIL L10CM DIA0.01IN HYDRPHLC,SUP-2172467,CDM,C1769,HCPCS,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
HC So Glucagon,PX-3018294366,CDM,82943,CPT,0301,RC,,,,both,,,767.00,498.55,,,,,,,,,,,,,
SET INFUS ORTHOFUSOR,SUP-2352681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
GRAFT OPHTH THK300-400UM W0.75XL1CM COVERING GLAUCOMA DRNGE,SUP-2135260,CDM,V2790,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
WASHER ORTH FOREFOOT MIDFOOT 2.2/2.7 MM SCR TI TOT FT SYS 2,SUP-2609139,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.17,345.91,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA2.3 MM CRANIOFACIAL CROSS PIN HD EMER 5PK,SUP-2884168,CDM,C1713,HCPCS,0278,RC,,,,both,,,1815.39,1180.00,,,,,,,,,,,,,
LINER EXT FIX LG SIDEKCK EZ FRAME,SUP-2484239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
STENT ENDOPROS L15CM DIA6MM CATH 7FR L75CM 0.035IN VES,SUP-2396601,CDM,C1874,HCPCS,0278,RC,,,,both,,,11906.88,7739.47,,,,,,,,,,,,,
COMPONENT FEM POROUS 4 KNEE MILLER-GALANTE II,SUP-2199615,CDM,C1776,CPT,0278,RC,,,,both,,,22130.72,14384.97,,,,,,,,,,,,,
CONTROLLER NEUROSTIMULATOR ACC REVW THER,SUP-2284583,CDM,C1787,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE MESHED SM 1.5X0.6 MM MIDFACE 6X2 HOLE TI NS,SUP-2472843,CDM,C1713,HCPCS,0278,RC,,,,both,,,1022.82,664.83,,,,,,,,,,,,,
GUIDEWIRE VASC CRV 7 CM 0.035 INX180 CM 3 CMX3 MM AMPLATZ,SUP-2167955,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.46,32.15,,,,,,,,,,,,,
CATHETER DRNGE 18GA L40CM 0.038IN HYDRPHLC 32 SIDEPRT,SUP-2168515,CDM,C1729,HCPCS,0272,RC,,,,both,,,277.51,180.38,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 30 CM DIA 8 MM CLLGN BOV CAR ART,SUP-2120660,CDM,C1768,CPT,0278,RC,,,,both,,,12054.46,7835.40,,,,,,,,,,,,,
BOOT HEEL FLOAT SYS W/ STRP 1 SZ ROCK,SUP-2319142,CDM,L4386,HCPCS,0274,RC,,,,both,,,303.01,196.96,,,,,,,,,,,,,
PLATE BNE L 102 MM SCREW DIA2.7/3.5 MM 5 H LT MEDL DSTL HUM,SUP-2931317,CDM,C1713,HCPCS,0278,RC,,,,both,,,4964.34,3226.82,,,,,,,,,,,,,
PLATE BNE L122MM 4 H NONSTERILE R DST HUM EXTRA ARTC S STL,SUP-2184041,CDM,C1713,HCPCS,0278,RC,,,,both,,,3260.39,2119.25,,,,,,,,,,,,,
FEEDING TUBE KIT LP 20 FRX2 CM BLLN BUTTON SIL CLR MINI 1,SUP-2754579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.22,429.14,,,,,,,,,,,,,
HC Echo Cong Anom Complete,PX-4839330300,CDM,93303,CPT,0483,RC,,,,both,,,1853.00,1204.45,,,,,,,,,,,,,
STANDOFF EXT FIX 100 MM NS MAXFRAME,SUP-2758004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.93,267.10,,,,,,,,,,,,,
COIL EMB L60CM DIA28MM NIT STD COMPLX FRME STRTCH RESIST,SUP-2323386,CDM,C1889,HCPCS,0278,RC,,,,both,,,8377.52,5445.39,,,,,,,,,,,,,
PACEMAKER SR SYS ACCENT,SUP-2356449,CDM,C1786,HCPCS,0275,RC,,,,both,,,13470.60,8755.89,,,,,,,,,,,,,
PROSTHESIS OSS CLASSIC STAP 5X0.9 MM 0.6 MM TI,SUP-2638176,CDM,L8613,CPT,0278,RC,,,,both,,,822.99,534.94,,,,,,,,,,,,,
PLATE BNE FUSION RT ANTR ANK 9 HOLE CONSTRUCT,SUP-2609570,CDM,C1713,HCPCS,0278,RC,,,,both,,,6585.55,4280.61,,,,,,,,,,,,,
CATHETER DRAINAGE 0.038 IN 8.5 FRX25 CM MP NLCK 6 SP UTHANE,SUP-2168159,CDM,C1729,HCPCS,0272,RC,,,,both,,,198.98,129.34,,,,,,,,,,,,,
KYPHOPLASTY KIT BVL 13 GA OSTEO INTRO KYPHON V VPT13B,SUP-2632238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SHEATH GUID 0.018 IN 5 FRX10 CM THN WALLED HYDRPHLC HALO 1,SUP-2719762,CDM,C1887,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE BNE L46MM THK3.4MM 3 H BILAT S STL STR LOK COMPR FOR,SUP-2185126,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.12,475.23,,,,,,,,,,,,,
MICROCATHETER GUID 2.8-3.1FR L150CM ID0.027IN SEG DST L6CM,SUP-2280963,CDM,C1887,HCPCS,0272,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
MANOMETER PRSS INTDISC DGT,SUP-2342059,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BIT DRL L50MM DIA1.6MM 7MM STP FOR 2/2.3MM SCR LEIBINGER,SUP-2366417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.72,263.72,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 80 CM 5 FR SOS OMNI1 NONBRAIDED,SUP-2118257,CDM,C1887,HCPCS,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
TI LCP VOLR CLMN DSTL RADIUS PL 6H HEAD/5H SHAFT/RT-STERILE,SUP-2546656,CDM,C1713,HCPCS,0278,RC,,,,both,,,3162.48,2055.61,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE SM MED 28 IN BLK LTX,SUP-2421714,CDM,L1833,HCPCS,0272,RC,,,,both,,,233.74,151.93,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 50 CM DIA 8 MM EPTFE STR TW USFT,SUP-2266006,CDM,C1768,CPT,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
ELECTRODE ARTHSCP RAD FREQ SUCT HK 2.5MM ARTHCARE,SUP-2342027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
AB DISTRACTOR BODY END ACT 4315003,SUP-2844057,CDM,C1713,HCPCS,0278,RC,,,,both,,,16854.26,10955.27,,,,,,,,,,,,,
HEAD RAD DIA24MM R EL CO CHROM ANAT,SUP-2107858,CDM,C1776,CPT,0278,RC,,,,both,,,9259.86,6018.91,,,,,,,,,,,,,
ALLOGRAFT BNE 8.5X240 MM ANTR TIBIALIS,SUP-2866874,CDM,C1762,CPT,0278,RC,,,,both,,,4435.72,2883.22,,,,,,,,,,,,,
STENT GRFT VASC BIFURCATE 3 AORT LIMB EXT,SUP-2777591,CDM,C1768,CPT,0278,RC,,,,both,,,48713.96,31664.07,,,,,,,,,,,,,
MESH HERN W30XL30CM POLY HYDRPHLC SQ KNIT HNYCMB 3D FLAT,SUP-2174806,CDM,C1781,HCPCS,0278,RC,,,,both,,,590.82,384.03,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH 90 DEG L 60 CM DIA 8 FR DIL L 67 CM,SUP-2357129,CDM,C1893,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
PROCESSOR SND RT SET FOR PRO PWR WHT SLV PONTO,SUP-2319885,CDM,L8691,HCPCS,0274,RC,,,,both,,,13486.30,8766.09,,,,,,,,,,,,,
CANNULA BIO MEDICUS 14FR,SUP-2721116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.05,577.23,,,,,,,,,,,,,
PLATE BNE HK SHT 2.7X9 MM LT CLAV VA LCK COMPR NS VA-LCP,SUP-2750823,CDM,C1713,HCPCS,0278,RC,,,,both,,,3456.64,2246.82,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 10X12 MM TRICORT IL CREST,SUP-2867122,CDM,C1762,CPT,0278,RC,,,,both,,,2282.00,1483.30,,,,,,,,,,,,,
PROSTHESIS OSS L 5 MM SHFT DIA1.14 MM HD DIA 4 MM HA FLX H/A,SUP-2902100,CDM,L8613,CPT,0278,RC,,,,both,,,1587.90,1032.13,,,,,,,,,,,,,
TRAY PICC CATHETER 6FR 2 LUMN W MICROINTRODUCER MAXIMAL BARR,SUP-2126752,CDM,C1751,HCPCS,0278,RC,,,,both,,,758.62,493.10,,,,,,,,,,,,,
STEM RAD DIA8MM 4MM OFFSET STD EL CO CHROM ANAT,SUP-2107873,CDM,C1776,CPT,0278,RC,,,,both,,,5692.82,3700.33,,,,,,,,,,,,,
PLATE BNE TIB 172 MM RT DSTL MEDL 10X4 HOLE SS NS AXSOS,SUP-2459192,CDM,C1713,HCPCS,0278,RC,,,,both,,,5409.28,3516.03,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2X14 MM LOCKING TITANIUM MATRIXMANDI,SUP-2837733,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.65,309.17,,,,,,,,,,,,,
ANCHOR SUTURE ALLOSYNC PUSHLOCK,SUP-2930455,CDM,C1713,HCPCS,0278,RC,,,,both,,,2802.45,1821.59,,,,,,,,,,,,,
ROD TEND W4XL24.5MM STD SIL HUNTER,SUP-2401386,CDM,C1713,HCPCS,0278,RC,,,,both,,,3554.48,2310.41,,,,,,,,,,,,,
LOW PROFILE SCREW CADDY 4.5/6.7MM,SUP-2817599,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC So Rickettsia Ab,PX-3028675766,CDM,86757,CPT,0302,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
HC So Anti-Hbs,PX-3028670666,CDM,86706,CPT,0302,RC,,,,both,,,21.00,13.65,,,,,,,,,,,,,
PLATE BNE L 220.6 X W 8.3 MM THK 2.6 MM SCREW DIA2/2.3 MM SM,SUP-2937004,CDM,C1713,HCPCS,0278,RC,,,,both,,,7696.14,5002.49,,,,,,,,,,,,,
PLATE BNE L97MM 8 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT DYN,SUP-2185933,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.87,318.42,,,,,,,,,,,,,
DRILL TWST OD2.9MM FLUT STP FOR SUT ANCHR INLINE SYS,SUP-2341831,CDM,C1713,HCPCS,0278,RC,,,,both,,,1368.26,889.37,,,,,,,,,,,,,
HC Cervical Myelogram S&I,PX-3207224000,CDM,72240,CPT,0320,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 30 CM DIA26 MM THK 0.38 MM POLYESTER,SUP-2476591,CDM,C1768,CPT,0278,RC,,,,both,,,1715.66,1115.18,,,,,,,,,,,,,
SCREW BNE L20MM DIA3MM LOK PLATING SYS MOTOBAND CP,SUP-2175140,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
FORCEP ENDOSCP RAT TOOTH 7.3X1621 MM 2.8 MM GRASPING CHANNEL,SUP-2865649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.20,333.58,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.7MM UNIV CORT CRANIOMAXILLOFACIAL SIL S 5PK,SUP-2366105,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.65,126.52,,,,,,,,,,,,,
BRACE HND SHT THMB LG LT SPICA,SUP-2196530,CDM,L3984,HCPCS,0274,RC,,,,both,,,105.50,68.57,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 2X160 MM KT,SUP-2236759,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
BAG DRNGE C650ML H SZ 5-38 MAMM TISS EXP CNTOUR PROF NACL,SUP-2300522,CDM,C1789,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GRAFT BNE 80 MM FD FIB SHFT,SUP-2424326,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
UREA 20 % EX CREA,RX-19776,CDM,6370000000,HCPCS,0637,RC,00536-1109-45,NDC,,both,85,GR,32.60,21.19,,,,,,,,,,,,,
SET NG TB 8FR L70CM 3 SIDEPRT STD STR PTFE S STL GWIRE,SUP-2168215,CDM,C1769,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
GRAFT BONE VOID FIL CYL MTRX REGENERATIVE TISS 7MMX25MM,SUP-2293938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PROXIMAL HUMERAL PLATE SYSTEM CASE,SUP-2811369,CDM,C1713,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
PLATE NECK RADIAL HEAD LCP 3 HOLE 2.4MM SYNTHES 241.691,SUP-2849748,CDM,C1713,HCPCS,0278,RC,,,,both,,,60.51,39.33,,,,,,,,,,,,,
PIN TRACTION SKULL AD 1 PROC TI POLYMER BLK STRL DORO LUC,SUP-2887038,CDM,C1713,HCPCS,0278,RC,,,,both,,,1720.72,1118.47,,,,,,,,,,,,,
GENTAMICIN SULFATE 2 MG/ML SYRINGE (PED-NEO) <50 ML,RX-4090289,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
INSERT TIB IMPCT ASMBLY N-K II,SUP-2449213,CDM,C1776,CPT,0278,RC,,,,both,,,1511.91,982.74,,,,,,,,,,,,,
SYSTEM SHUNT W/ BA STRIPE PERITONEAL CATH 120CM W/ DRAINAGE,SUP-2666831,CDM,C1729,HCPCS,0272,RC,,,,both,,,1953.43,1269.73,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 23 CM DIA 6 FR 80 CM 0.038 IN POLYPRO,SUP-2493361,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.18,63.17,,,,,,,,,,,,,
STEM FEM L135MM DIA14MM TIV TI HIP 12/14 NK TAPR PRI NEUT,SUP-2203497,CDM,C1776,CPT,0278,RC,,,,both,,,17646.80,11470.42,,,,,,,,,,,,,
STENT VASC 4X24 MM INTCRAN W/O TIP SYS NEUROFORM ATLS,SUP-2431333,CDM,C1877,HCPCS,0278,RC,,,,both,,,23864.00,15511.60,,,,,,,,,,,,,
BUR SURG BALL LNG 3.5 MM 7.5 CM FLUT MIDAS REX LEGEND,SUP-2630538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.63,242.86,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 40 MM DIA22 MM LIMB 40 MM 16 MM,SUP-2846414,CDM,C1768,HCPCS,0278,RC,,,,both,,,30577.32,19875.26,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM ADV 6 MM SCREW DIA2 MM 4 H MINI CHIN,SUP-2883181,CDM,C1713,HCPCS,0278,RC,,,,both,,,1283.82,834.48,,,,,,,,,,,,,
ROD EXT FIX L207MM DIA11MM 45DEG UNIV C FBR SEMI CIR CRV,SUP-2188642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1559.01,1013.36,,,,,,,,,,,,,
INTRODUCER SHTH AD L12CM DIA6FR 0.032IN CV PERM VLV NO RADPQ,SUP-2355390,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
"HC So Electron Microscopy, Diag",PX-3128834866,CDM,88348,CPT,0312,RC,,,,both,,,2028.00,1318.20,,,,,,,,,,,,,
PLATE BNE RECON 3.5X106 MM 9 HOLE SS,SUP-2569084,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.03,254.82,,,,,,,,,,,,,
BAR FIX SGL SUT STR INTRO FOR MENIS REP SYS FAST-FIX,SUP-2341341,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.53,263.59,,,,,,,,,,,,,
PLATE BONE M THK1MM 4 H MIDFACE SLV TI STR FOR 2MM SCR,SUP-2402957,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
PLATE BNE ULN SM 33 MM RT DSTL MEDL VOLAR 2 HOLE BUTTRESS,SUP-2477437,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.03,1526.22,,,,,,,,,,,,,
BIT DRL L220MM DIA4.6MM 3/16 SQ CANN,SUP-2321611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,818.60,532.09,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANG TIP TORQUABLE HYDRPHLC RADPQ NIT DISP,SUP-2139362,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.03,123.52,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA LOW BEND 10H 154MM LT STER,SUP-2546871,CDM,C1713,HCPCS,0278,RC,,,,both,,,4744.79,3084.11,,,,,,,,,,,,,
AUGMENT TIB SZ 4 THK10MM R MED L LAT KNEE CO CHROM TOT STBL,SUP-2373568,CDM,C1776,CPT,0278,RC,,,,both,,,1840.32,1196.21,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,GO|CO,both,,,195.00,126.75,,,,,,,,,,,,,
STRUT EXT FIX MED TRNSPRT NS DISP ILIZ,SUP-2933528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6087.27,3956.73,,,,,,,,,,,,,
BLADE TNGE DINGMAN 3 LG 136X32X75 MM,SUP-2476735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,583.35,379.18,,,,,,,,,,,,,
HC Plmt Biliary Drainage Cath Internal-External,PX-3614753400,CDM,47534,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
POR ST/RGX CP/XL LN/STD HD,SUP-2212375,CDM,C1776,CPT,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE 10.5 GBQ YTTRIUM-90 GLS DOSE VI,SUP-2135280,CDM,C2616,HCPCS,0278,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX14 RCNSTRCTN F3.5MM LOK SCREW ST,SUP-2722264,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
THERA-DERM EX LOTN,RX-7831,CDM,6370000000,HCPCS,0637,RC,00299-0241-32,NDC,,both,237,ML,29.90,19.43,,,,,,,,,,,,,
CATHETER VENT SM BA IMPREG R ANG CLP S STL STYL,SUP-2284502,CDM,C1729,HCPCS,0272,RC,,,,both,,,342.35,222.53,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 PLU MAXBARR 4FR 55C 1194108D4,SUP-2632632,CDM,C1751,HCPCS,0278,RC,,,,both,,,956.32,621.61,,,,,,,,,,,,,
DIREXION/TRANSEND/021/BERN/1RO/155,SUP-2652845,CDM,C1887,HCPCS,0272,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
TAP BNE PEDCL SCR QUIK CONN 55MM DIA,SUP-2290729,CDM,C1713,HCPCS,0278,RC,,,,both,,,2035.00,1322.75,,,,,,,,,,,,,
BIT DRL DIA2.7MM CANN QUIK CONN FOR 4MM SCR,SUP-2107200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
SHELL ACET OD50MM GRP C BIOFOAM TI POR HIP PRESSFIT DYNASTY,SUP-2304551,CDM,C1776,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
QUARTEX PARA CONNECTOR4.0MM ROD TO4.0MM ROD,SUP-2229082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE L68MM 7X4 H R VOLAR DST RAD S STL VAR ANG LOK,SUP-2184124,CDM,C1713,HCPCS,0278,RC,,,,both,,,2282.50,1483.62,,,,,,,,,,,,,
STENT BILI L20MM 8FR 135CM CATH LEN 10MM DIAM AD PRECIS,SUP-2158892,CDM,C1876,HCPCS,0278,RC,,,,both,,,6085.32,3955.46,,,,,,,,,,,,,
SLING SHLDR UNIV SWTH W5XL54IN PCH W13XL19IN LTWT PERF FOAM,SUP-2195038,CDM,L3660,HCPCS,0272,RC,,,,both,,,27.41,17.82,,,,,,,,,,,,,
SET HAD CATHETER AD 14FR L15CM BASIC DBL LUMN DIL SCALP,SUP-2266996,CDM,C1752,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
SCREW BNE L50MM DIA4X5MM CORT CANN HDLSS TAPR PROF ACUTRK,SUP-2107223,CDM,C1713,HCPCS,0278,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
PLATE DIST ANT TIB RT 6HL 127MM,SUP-2695698,CDM,C1713,HCPCS,0278,RC,,,,both,,,6866.55,4463.26,,,,,,,,,,,,,
CATHETER INFUSION L 130 CM DIA 5 FR GUIDEWIRE 0.035 IN SEG L,SUP-2168150,CDM,C1751,HCPCS,0278,RC,,,,both,,,282.69,183.75,,,,,,,,,,,,,
ROD EXT FIX DIA11MM L220MM SEMI CIR CRV HOFFMANN 3,SUP-2372224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1450.68,942.94,,,,,,,,,,,,,
COMPONENT FEM L10CM KNEE TI DPHSEAL CPLR OSS,SUP-2405813,CDM,C1776,CPT,0278,RC,,,,both,,,15288.66,9937.63,,,,,,,,,,,,,
COMPONENT TIB TY W/ 2 TIB AND 2 FEM LO PROF REV KNEE SYS,SUP-2359218,CDM,C1776,CPT,0278,RC,,,,both,,,9498.50,6174.02,,,,,,,,,,,,,
COIL NEUROVASCULAR CEREPAK UNIF L 17 CM DIA 5 MM PRIMARY DIA,SUP-2865181,CDM,C1889,HCPCS,0278,RC,,,,both,,,7080.83,4602.54,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SLIP ON SM AD 7.5 IN WRST COMFORTFORM,SUP-2197051,CDM,L3931,HCPCS,0272,RC,,,,both,,,42.77,27.80,,,,,,,,,,,,,
MICONAZOLE NITRATE 200 MG VA SUPP,RX-10604,CDM,6370000000,HCPCS,0637,RC,00472-1738-03,NDC,,both,1,UN,71.70,46.60,,,,,,,,,,,,,
SCREW BNE CANN 2.5X14 MM LAG SS,SUP-2392863,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.37,245.94,,,,,,,,,,,,,
COIL EMB L25MM DIA3.75MM NEUROVASC BRAID DSGN FLXIBLE,SUP-2296731,CDM,C1889,HCPCS,0278,RC,,,,both,,,46982.25,30538.46,,,,,,,,,,,,,
HC Postural Drainage Sub,PX-4109466800,CDM,94668,CPT,0410,RC,,,,outpatient,,,109.00,70.85,,,,,,,,,,,,,
KIT PERC NEUROPHYSIOLOGICAL MON INTOP SCR TST W/ PEDCL PRB,SUP-2311740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3987.80,2592.07,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.0X12MM H,SUP-2320867,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
JOINT FNGR MP 50 WW DSTL PYROCARBON,SUP-2610416,CDM,L8630,HCPCS,0278,RC,,,,both,,,4608.55,2995.56,,,,,,,,,,,,,
LEVEL CMF ST PLATE MINI TLTS CVD 20 25 MM SCRW6 HOLE 29 MM,SUP-2669725,CDM,C1713,HCPCS,0278,RC,,,,both,,,1348.44,876.49,,,,,,,,,,,,,
PLATE BNE L31MM 4 H TI RIG DYN LOK COMPR FOR 2.4MM SCR MOD,SUP-2191476,CDM,C1713,HCPCS,0278,RC,,,,both,,,1636.85,1063.95,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US|RIGHT SIDE|PO,PX-5102060500,CDM,20605,CPT,0510,RC,,,RT|PO,both,,,908.00,590.20,,,,,,,,,,,,,
MESH BONE LG 06MM THK TTNM LATEX FREE TMPRL MXLFCL,SUP-2707376,CDM,C1713,HCPCS,0278,RC,,,,both,,,4341.18,2821.77,,,,,,,,,,,,,
HC Continuing Medical Physics,PX-3337733600,CDM,77336,CPT,0333,RC,,,,both,,,605.00,393.25,,,,,,,,,,,,,
COMP SHRT ST/POLY GLD/VRSDL/INS,SUP-2212449,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
GUIDE WIRE O 0.7MM 41CM 5/PKG,SUP-2574077,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.78,42.11,,,,,,,,,,,,,
INSERT TIB L71MM THK12MM UNIV KNEE PRI ANT STBL NEUT ASCNT,SUP-2407214,CDM,C1776,CPT,0278,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
SCREW BNE L48MM DIA3.5MM S STL CANN FULL THRD HD HEX SOCK,SUP-2183654,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.34,296.62,,,,,,,,,,,,,
DRIVER SURG SM CRUCFRM UNIV SM SCR EXTR SYSTEMXTRACT ALL,SUP-2337695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
BRACE KNEE UNIV L22 27IN 10DEG FLX TELSCP PDDLE POSTOP FOAM,SUP-2195288,CDM,L1810,HCPCS,0272,RC,,,,both,,,220.59,143.38,,,,,,,,,,,,,
VALVE MITRL STENT 23 MM BIOCOR,SUP-2357531,CDM,C1889,HCPCS,0278,RC,,,,both,,,22294.00,14491.10,,,,,,,,,,,,,
ARM EXT FIX VERTICLE ADJ 24 MM TUBE LEFORT 1 BUTTRESS,SUP-2458659,CDM,C1713,HCPCS,0278,RC,,,,both,,,6228.63,4048.61,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID THN 7X7 CM AMNIO PLCNTA PRO3-P,SUP-2742040,CDM,C1762,CPT,0278,RC,,,,both,,,11225.50,7296.57,,,,,,,,,,,,,
BLADE SHAVER CRV 40 DEG 4.8 MM SERRATED HEMOSTATIC CONVX,SUP-2638102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.09,381.61,,,,,,,,,,,,,
COLLAR CERV TALL AD 2 PC ATLS,SUP-2319263,CDM,L0172,HCPCS,0274,RC,,,,both,,,104.62,68.00,,,,,,,,,,,,,
SCREW BNE L10MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI ST 400790] DEPUY SYNTHES USA],SUP-2189259,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.59,101.78,,,,,,,,,,,,,
CATHETER EP 6FR L110CM 2-4-2MM SPC POLYUR FIX SM CRV 24 PLAT,SUP-2142306,CDM,C1731,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER DLYS L62CM PERI 2 FELT CUF RADPQ STRP ARGY CURL,SUP-2283899,CDM,C1750,HCPCS,0278,RC,,,,both,,,262.98,170.94,,,,,,,,,,,,,
PROTECTOR TISS 1X2 IN 1 CC FLAT DRY SHT TRNSLUC VERSAWRAP,SUP-2740207,CDM,C1889,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.7MM HND TI NONLOCKING CRUCFRM,SUP-2107498,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
BLADE SAW WIDE MICROAIRE STRYKR STRL INBONE,SUP-2463497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.516,SUP-2860198,CDM,C1713,HCPCS,0278,RC,,,,both,,,30218.10,19641.76,,,,,,,,,,,,,
FORCEP ALGTR 3 1/2IN DISP,SUP-2340439,CDM,C1776,CPT,0278,RC,,,,both,,,55.77,36.25,,,,,,,,,,,,,
PLATE BNE L161MM 8 H ST R MED DST TIB S STL LOK COMPR LO,SUP-2177447,CDM,C1713,HCPCS,0278,RC,,,,both,,,4149.82,2697.38,,,,,,,,,,,,,
PROBE ABLATN NERVE BLOCK 180 DEG 8 MM BALL TIP CRYOSPHERE,SUP-2124444,CDM,C2618,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
ALLOGRAFT BNE TIB 210X3 MM FD STRUT 1/2 SPLIT 31026022,SUP-2717903,CDM,C1762,CPT,0278,RC,,,,both,,,5802.59,3771.68,,,,,,,,,,,,,
GRAFT BNE DEMIN BNE MTRX BIO DBM BOAT,SUP-2364715,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
NAIL ELASTIC 1.5MM SS 300MM,SUP-2547599,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.02,479.06,,,,,,,,,,,,,
HC So Drug Assay Clozapine,PX-3018015966,CDM,80159,CPT,0301,RC,,,,inpatient,,,63.00,40.95,,,,,,,,,,,,,
NAIL IM L380MM DIA14MM NK 130DEG GRN L FEM TI TROCHANTERIC,SUP-2192114,CDM,C1713,HCPCS,0278,RC,,,,both,,,5466.99,3553.54,,,,,,,,,,,,,
BUR SURG L14CM DIA7MM BALL EXTRA COARSE DMND L BOR MIDAS,SUP-2277721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.86,257.31,,,,,,,,,,,,,
PLATE BNE L133MM 7 H L PROX HUM LO ALPS,SUP-2411634,CDM,C1713,HCPCS,0278,RC,,,,both,,,6939.40,4510.61,,,,,,,,,,,,,
CATHETER HEMODIALYSI NIAG ACUTE 13.5FR DIA 24CML INSER 400ML,SUP-2613254,CDM,C1752,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
GRAFT SFT TISS FLOWABLE 1 CC 167 MG TISS MTRX INTERFYL,SUP-2651380,CDM,Q4171,HCPCS,0636,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PUNCH ENDOSCP TIP 9 DEG DIA 3.4 MM SQ UPSHAFT NS REUSE,SUP-2908582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4895.26,3181.92,,,,,,,,,,,,,
STENT BILI DIA7FR ASMBLY L50CM DIA8.5FR LAPSCP ENDOBILI SET,SUP-2168855,CDM,C2625,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
INSERT TIB SZ 6-7 THK11MM LT KNEE HNG GUID MOTN LEGION,SUP-2346690,CDM,C1776,CPT,0278,RC,,,,both,,,7165.48,4657.56,,,,,,,,,,,,,
PLATE 1ST MTCRPL 1.5MM LAT RT STRL VAL,SUP-2546083,CDM,C1713,HCPCS,0278,RC,,,,both,,,2023.20,1315.08,,,,,,,,,,,,,
OBTURATOR ENDOSCP CONCL NS ECTRA II LTX,SUP-2877786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.31,276.45,,,,,,,,,,,,,
HC Gas Dilution or Washout,PX-4609472700,CDM,94727,CPT,0460,RC,,,,outpatient,,,411.00,267.15,,,,,,,,,,,,,
BIT DRL L110MM DIA2.1MM FOR L10-36MM DIA3MM TWST CANN SM,SUP-2389433,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
KIT BIOPSY BONE 10GAX5IN STRL,SUP-2366855,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
HC Percutaneous Trach Insert,PX-3613160000,CDM,31600,CPT,0361,RC,,,,both,,,9617.00,6251.05,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GAX57 MM DUALOK,SUP-2108890,CDM,C1819,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
PLATE BNE TIB MEDL 2 HOLE NS LTX,SUP-2857070,CDM,C1713,HCPCS,0278,RC,,,,both,,,8066.66,5243.33,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 4 FRX10 CM 21 GAX7 CM NDL NIT S-MAK,SUP-2472762,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.18,63.17,,,,,,,,,,,,,
HC MRI-Abdomen W Contrast,PX-6107418200,CDM,74182,CPT,0610,RC,,,,both,,,5019.00,3262.35,,,,,,,,,,,,,
VALVE MITRL BIOCOR STENTED TISS PERICARD SHLD FLEXFIT HLDR,SUP-2355766,CDM,C1889,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
HC Red Cell Depletion,PX-3623821200,CDM,38212,CPT,0362,RC,,,,both,,,1287.00,836.55,,,,,,,,,,,,,
CONNECTOR SPNL TI MULTIAXIAL FOR 3.2-5.5MM ROD VERTEX MAX,SUP-2286714,CDM,C1713,HCPCS,0278,RC,,,,both,,,1889.97,1228.48,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5 MM SS NS,SUP-2183529,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL LSO,SUP-2388146,CDM,L0626,HCPCS,0274,RC,,,,both,,,200.71,130.46,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ESOPHASTAR L 125 CM DIA 8 FR BLU,SUP-2248921,CDM,C1732,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SHEATH INTRO INPUT L 11 CM DIA 6 FR OBTURATOR ACTIVE LCK HUB,SUP-2294581,CDM,C1894,HCPCS,0272,RC,,,,both,,,17.27,11.23,,,,,,,,,,,,,
BUR SURG HUB III CRANIOTOME CUT STRL REUSE HI-LINE,SUP-2928858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.92,354.20,,,,,,,,,,,,,
GRAFT BNE SUB 3CC CA PHSPTE HYALURONIC ACID CEM VOID FILL,SUP-2365202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
RING EXT FIX HALF 130 MM TI NS,SUP-2799569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1228.40,798.46,,,,,,,,,,,,,
KNIFE SHAVER 15 MMX9.5 CM BLADE FOR MORCELLATOR ROTOCUT MTP,SUP-2261063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
PLATE BONE L288MM 12 H LT PROX FEM LCK FOR 4.5MM SCR,SUP-2351171,CDM,C1713,HCPCS,0278,RC,,,,both,,,13614.73,8849.57,,,,,,,,,,,,,
BUR SURG DIA 7 MM HUB II BRL STRL REUSE HI-LINE,SUP-2928974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.86,257.96,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 5 MM DEL SHTH,SUP-2934465,CDM,C1713,HCPCS,0278,RC,,,,both,,,6583.29,4279.14,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 7X7CM,SUP-2883368,CDM,Q4158,HCPCS,0636,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
SCREW BNE LAG 60 MM HIP SUPLMNT TI STRL CHIMAERA HFS,SUP-2646677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1449.49,942.17,,,,,,,,,,,,,
PLATE COMPRSS BROAD CRVD 16 HL 199MM,SUP-2705334,CDM,C1713,HCPCS,0278,RC,,,,both,,,4393.80,2855.97,,,,,,,,,,,,,
ALLOGRAFT BNE LORDTC 7 DEG 12X14.5X9.2X7.75 MM FD VERTIGRAFT,SUP-2264912,CDM,C1713,HCPCS,0278,RC,,,,both,,,2919.89,1897.93,,,,,,,,,,,,,
HC So Beta 2 Glycoprotein 1 Ab,PX-3028614666,CDM,86146,CPT,0302,RC,,,,both,,,172.00,111.80,,,,,,,,,,,,,
EXPANDER TISS 300CC P5.9CM W11XH10CM NACL STYL 133MX,SUP-2113152,CDM,C1789,HCPCS,0278,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
PLATE BNE L132MM 8 H NONSTERILE POST DST TIB S STL T LOK,SUP-2177436,CDM,C1713,HCPCS,0278,RC,,,,both,,,4012.23,2607.95,,,,,,,,,,,,,
GRAFT ALLGRFT DERM ACELLULAR HYDRATED THCK HUM TISS 5CM,SUP-2307473,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5553.78,3609.96,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X25 MM 3 HOLE 1/4 SS,SUP-2536101,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
LASER SURG HAAG-STRAIT LASERLINK,SUP-2713642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17414.44,11319.39,,,,,,,,,,,,,
PLATE BNE COMPR 2.7X184 MM 20 HOLE LCK TI STRL LCP,SUP-2789990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.50,1072.17,,,,,,,,,,,,,
HC N Block Paravert Lumbar 1st|BILATERAL PROCEDURE|PO,PX-3606449300,CDM,64493,CPT,0360,RC,,,50|PO,both,,,4864.00,3161.60,,,,,,,,,,,,,
NEPHROSTOMY SET CATH 14 FR RE-ENTRY,SUP-2141726,CDM,C1729,HCPCS,0272,RC,,,,both,,,231.73,150.62,,,,,,,,,,,,,
BUR SURG DIA95MM CONIC W QUIK CPL,SUP-2188267,CDM,C1713,HCPCS,0278,RC,,,,both,,,947.18,615.67,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 16 HOLES 303MM,SUP-2549516,CDM,C1713,HCPCS,0278,RC,,,,both,,,1823.30,1185.14,,,,,,,,,,,,,
PROBE SURG GUIDEWIRE 2.4 MM ACUTRK 2,SUP-2525725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
PLATE BNE L98MM 6 H NONSTERILE R LAT PROX TIB LOK FOR 35MM,SUP-2348473,CDM,C1713,HCPCS,0278,RC,,,,both,,,11436.98,7434.04,,,,,,,,,,,,,
GUIDEWIRE ORTH L 150 MM DIA 0.9 MM DBL TROCAR NS ACUTRK 3,SUP-2912794,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
PEG BONE SBCHNDRL DST VOLAR RDS THRD 2.5X34 MM TTNM,SUP-2588902,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.03,148.87,,,,,,,,,,,,,
DUALKNIFEJ LOWER LENGTH 1 UNITBX,SUP-2677729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
LASER SURG WVLNGTH 190-534 NM 960-1064 NM 925-1070 NM 7 MM,SUP-2713601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
HC So Bilirubin Total,PX-3018224766,CDM,82247,CPT,0301,RC,,,,outpatient,,,38.00,24.70,,,,,,,,,,,,,
COMPOUND RESTORATIVE 14ML OXIDE-EUGENOL INTERMED POLYMER IRM,SUP-2238598,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.05,44.88,,,,,,,,,,,,,
GRAFT HERN REP 25X30CM POLYPR PERM POLYMER 6 LAYR OVITEX 1S,SUP-2383098,CDM,C1781,HCPCS,0278,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
PLATE BNE L142MM THK3.7MM 6 H NONSTERILE R DST MED TIB S,SUP-2185527,CDM,C1713,HCPCS,0278,RC,,,,both,,,3783.89,2459.53,,,,,,,,,,,,,
VEST HOLSTER POCKET SM CTRL,SUP-2356012,CDM,Q0499,HCPCS,0272,RC,,,,both,,,1339.52,870.69,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH ATTCH TO SHOE LONGITUDINAL,SUP-2435709,CDM,L3090,HCPCS,0272,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
GORE PRECL VES GRD SZ 5 CMX6 CM,SUP-2395508,CDM,C1768,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PATCH CV GORTX NOM L 15 X W 5 CM THK 0.6 MM EPTFE CNFRM,SUP-2395302,CDM,C1768,CPT,0278,RC,,,,both,,,2282.78,1483.81,,,,,,,,,,,,,
SCREW BONE 2MM DIA 12MML STNLSS STEEL MXDRVE 8MM THRDD FMLT,SUP-2681179,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.40,203.06,,,,,,,,,,,,,
SCREW BNE L 55 MM DIA 5.5 MM CANN HDLSS NS,SUP-2896544,CDM,C1713,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
BLADE SAW KEEN RECIP CEM REPROC FOR STRYKR SYS 7/6/5/4/2000,SUP-2408663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.75,574.44,,,,,,,,,,,,,
HALF RING-SBF 90MM,SUP-2818147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4523.01,2939.96,,,,,,,,,,,,,
BLOCK CUT W10XL69MM TIB CONSTRN CNDYL KNEE INSALL-BURSTEIN,SUP-2205968,CDM,C1776,CPT,0278,RC,,,,both,,,5875.57,3819.12,,,,,,,,,,,,,
DEVICE ABLATN ENDOMET US NOVASURE V5,SUP-2765146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
TUBE FEED NG RADPQ POLYUR AD W OUT CO2 CONN DBL LUMN,SUP-2172146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,59.09,38.41,,,,,,,,,,,,,
SCREW BONE L8MM OD4.5MM STD TI CORT ST LCK FULL THRD L HEX,SUP-2413627,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.43,253.78,,,,,,,,,,,,,
ENDCAP SPNL 14 MM INFIX,SUP-2683620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SCREW CONN REPL FOR VALOCKING PPFX GREATER TROCH RNG STRL,SUP-2789948,CDM,C1713,HCPCS,0278,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
SCREW BNE L18MM DIA3.5MM DST FIBULAR NONLOCKING FULL THRD,SUP-2400175,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
PIN GUIDE L 300 MM DIA1.9 MM DRL TIP STRL DISP,SUP-2933130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,255.19,165.87,,,,,,,,,,,,,
SCREW SPNL L14MM OD4MM CEPHALAD CAUD BIASED ANG POST,SUP-2317654,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.23,261.45,,,,,,,,,,,,,
NAIL IM L 400 MM DIA13 MM TYP II,SUP-2902167,CDM,C1713,HCPCS,0278,RC,,,,both,,,10466.25,6803.06,,,,,,,,,,,,,
BAG DRNGE REPL 700ML HERM II,SUP-2244306,CDM,C1729,HCPCS,0272,RC,,,,both,,,489.56,318.21,,,,,,,,,,,,,
PLATE BNE FIBULAR 12 HOLE COMP STRL LTX,SUP-2861668,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.20,971.23,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 73 MM DIA 36 MM SHTH 20 FR RVD,SUP-2170457,CDM,C1768,CPT,0278,RC,,,,both,,,5925.18,3851.37,,,,,,,,,,,,,
OMEGA PLUS LAG SCREW 85MM NS,SUP-2706059,CDM,C1713,HCPCS,0278,RC,,,,both,,,1156.31,751.60,,,,,,,,,,,,,
GRAFT BNE DRILLABLE 10 CC VOID FILL STRL LTX,SUP-2865884,CDM,C1713,HCPCS,0278,RC,,,,both,,,10275.37,6678.99,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L30CM OD9FR CK VLV BLLN W/O RESVR,SUP-2214694,CDM,C1889,HCPCS,0278,RC,,,,both,,,524.63,341.01,,,,,,,,,,,,,
PORT ACCESS GASTRIC LAP-BAND AP,SUP-2119224,CDM,C1788,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE BNE L 222 MM SCREW DIA 4.5 MM 13 H RT PROX HUM STRL,SUP-2933323,CDM,C1713,HCPCS,0278,RC,,,,both,,,10802.39,7021.55,,,,,,,,,,,,,
GASTROSCOPE FLX FOV 120 DEG L 1.1 M OD 3.5 MM ID 2 MM UPPER,SUP-2895197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
ALLOGRAFT BNE GEL 5 CC FD PREFILLED OPTIUM,SUP-2264602,CDM,C1889,HCPCS,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
BATTERY SET 14 V LVAD LITHIUM HEARTMATE,SUP-2356043,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
GRAFT VASC 6 MMX70 CM 50 CM RNG GORTX,SUP-2396007,CDM,C1768,CPT,0278,RC,,,,both,,,3259.32,2118.56,,,,,,,,,,,,,
BODY EXT FIX XLN PENNIG MINIFIXATOR,SUP-2316457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2183.43,1419.23,,,,,,,,,,,,,
NAIL IM L28CM OD10MM GRY TI TIB DSTL LCK CANN TRIGEN,SUP-2347127,CDM,C1713,HCPCS,0278,RC,,,,both,,,3887.16,2526.65,,,,,,,,,,,,,
REDAPT SLVD MONO STEM 240MM SZ 19 SO,SUP-2511021,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
COVER SPNL LCK WIDE ARCHON,SUP-2751694,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE BONE 5 H 2.4MM SCR STRNL TI STRNLOCK,SUP-2136980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
SET 16CM NAR BASE CYL PMP INFPUB OTR TI,SUP-2165359,CDM,C1813,HCPCS,0278,RC,,,,both,,,22623.70,14705.40,,,,,,,,,,,,,
HC Treat Tibia Fx,PX-4502775000,CDM,27750,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BONE L63MM 3 H STRL LT POST DSTL TIB S STL PART ARTC,SUP-2349717,CDM,C1713,HCPCS,0278,RC,,,,both,,,4401.18,2860.77,,,,,,,,,,,,,
LMA PROSEAL AIRWY PK - SZ 5,SUP-2383635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,911.86,592.71,,,,,,,,,,,,,
HC Anterior Nose Bleed Comp|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,PX-4503090300,CDM,30903,CPT,0450,RC,,,50|XU,both,,,214.00,139.10,,,,,,,,,,,,,
WASHER ORTH 7 MM F/4 MM SCREW NS,SUP-2458557,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.74,75.23,,,,,,,,,,,,,
HC So1 Hemoglobin Electrophoresis,PX-3018302067,CDM,83020,CPT,0301,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
PLATE BONE L162MM 14 H STRL S STL LCK COMPR FOR 3.5MM SCR,SUP-2349633,CDM,C1713,HCPCS,0278,RC,,,,both,,,4416.41,2870.67,,,,,,,,,,,,,
PIN FIX IMPL OD198MM,SUP-2290644,CDM,C1713,HCPCS,0278,RC,,,,both,,,399.47,259.66,,,,,,,,,,,,,
WIRE FIX L4IN OD.9MM XSM SM PHALINX K,SUP-2396964,CDM,C1713,HCPCS,0278,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
CATHETER SUPRAPUBIC SET 8 FRX30 CM PERC MCOT UNIVERSA,SUP-2836205,CDM,C2627,HCPCS,0272,RC,,,,both,,,142.59,92.68,,,,,,,,,,,,,
AZITHROMYCIN 600 MG PO TABS,RX-17387,CDM,6370000000,HCPCS,0637,RC,50111-0789-10,NDC,,both,1,UN,20.80,13.52,,,,,,,,,,,,,
PUMP INFUSION PAIN I-FLOW,SUP-2236746,CDM,E0783,HCPCS,0278,RC,,,,both,,,92.63,60.21,,,,,,,,,,,,,
PLATE BNE L 60 MM BAR 9 MM 3 H SHRT TI CRANIOMAXILLOFACIAL,SUP-2883481,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.58,453.43,,,,,,,,,,,,,
GRAFT HUM TISS DIA24MM AMNIO MEMBRN DISK AMNIOEXCEL,SUP-2194319,CDM,Q4137,HCPCS,0636,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.7MM BOB TI BLU STRL 500001,SUP-2535060,CDM,L8699,HCPCS,0278,RC,,,,both,,,98.60,64.09,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 5/30CM WATER WITHOUT RESERVOIR NON PROGR,SUP-2825655,CDM,C1889,HCPCS,0278,RC,,,,both,,,6113.52,3973.79,,,,,,,,,,,,,
HYDROXYZINE HCL 25 MG PO TABS,RX-3774,CDM,6370000000,HCPCS,0637,RC,23155-0501-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT PERIPH INSRT W/ SCALP NDL SYR GWIRE DIL,SUP-2214619,CDM,C1769,HCPCS,0272,RC,,,,both,,,225.42,146.52,,,,,,,,,,,,,
CATHETER ANGIO SLIP-CATH L 150 CM DIA 3 FR GUIDEWIRE 0.025,SUP-2168705,CDM,C1751,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BUR SURG CUT RND N FLUT 20MM ZYPHR,SUP-2367561,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.03,357.52,,,,,,,,,,,,,
SCREW BONE L36MM DIA4MM TI NONLOCKING T15 DBL LD FOR,SUP-2319753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
DEVICE GLAUCOMA DRAINAGE NDL DIA23 GA AREA250 SQMM SIL TUBE,SUP-2928456,CDM,C1783,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE CRAN L 48 X W 38 MM THK 0.85 MM TI SKULL BASE CRV,SUP-2883682,CDM,C1713,HCPCS,0278,RC,,,,both,,,4785.11,3110.32,,,,,,,,,,,,,
GUIDEWIRE FIX COR PTFE COAT 15MM J TI .035INX145CMP,SUP-2308258,CDM,C1769,HCPCS,0272,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
GAUGE DEPTH CALCANEAL PLATE MIS NS VARIAX,SUP-2902301,CDM,C1713,HCPCS,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 90 MM DIA28 MM LIMB 30 MM 20 MM,SUP-2217658,CDM,C1768,CPT,0278,RC,,,,both,,,34398.70,22359.15,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,KX|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
PLATE BONE SM L39MM 3 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.31,748.35,,,,,,,,,,,,,
PLATE BONE L113MM 7 H LT PROX LAT TIB TI FOR 3.5MM SCR,SUP-2418114,CDM,C1713,HCPCS,0278,RC,,,,both,,,4385.95,2850.87,,,,,,,,,,,,,
BLADE SURG HMSPHR LNG 46 MM HIP FULL EXPLANT,SUP-2206128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 236 MM BLADE L 50 MM 14 H SS CNDYL,SUP-2908364,CDM,C1713,HCPCS,0278,RC,,,,both,,,5535.57,3598.12,,,,,,,,,,,,,
BOOT WLK LO XS NOAIR EA,SUP-2319305,CDM,L4386,HCPCS,0272,RC,,,,both,,,72.97,47.43,,,,,,,,,,,,,
BIT DRL OD2MM PIN MIC HELCL NAIL BIOTRAK,SUP-2107107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
HC So Cyclosporine,PX-3018015866,CDM,80158,CPT,0301,RC,,,,both,,,326.00,211.90,,,,,,,,,,,,,
CLAMP EXT FIX L 11 TO 5-6 MM SWVL UNILAT NS DISP MAV,SUP-2931344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4794.78,3116.61,,,,,,,,,,,,,
ENDCAP ORTH EXTN 0MM AQUA TI ALLY STARDRV T25 RECESS MOST,SUP-2180013,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.23,503.90,,,,,,,,,,,,,
GLIDEWIRE ENDO L260CM OD0.035IN ANG BILI DEV,SUP-2141515,CDM,C1769,HCPCS,0272,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
CANNULA LAP 3.9 MMX25 CM FOR 30117J VERES NDL TROCAR,SUP-2767479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.48,325.31,,,,,,,,,,,,,
HC Fluro Esophagram,PX-3207422000,CDM,74220,CPT,0320,RC,,,,both,,,937.00,609.05,,,,,,,,,,,,,
HEAD FEM 2XL DIA28MM CO CHROM AMISTEM,SUP-2267302,CDM,C1776,CPT,0278,RC,,,,both,,,1600.93,1040.60,,,,,,,,,,,,,
STAPLE POD CLOVER 4 LEG 8 MMX10 MMX12.5 MM,SUP-2137802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
GREAT TOE BIOACTION PHLANG SM NEUT CO,SUP-2303799,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PIN GUIDE L 2.5 IN DIA 0.101 IN METATRSL K WIRE REAMER NS,SUP-2913228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
EXTRACTOR SURG UNIV FEM STEM SLAP HAMR,SUP-2252702,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.54,413.75,,,,,,,,,,,,,
CATHETER THERMOABLATION TORONTO RF TRANSSEPTAL SEPTOSTOMY,SUP-2131522,CDM,C1733,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT HUM TISS 10MM ACHILLES TEND PRESHAPED FRZN,SUP-2335544,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SCREW BNE COMPR LNG THRD 6.5X50 MM LT CANN HDLSS TI NS,SUP-2423243,CDM,C1713,HCPCS,0278,RC,,,,both,,,2008.34,1305.42,,,,,,,,,,,,,
STEM FEM SZ 1 L100MM NK L31MM 34MM OFFSET 132DEG HIP FORGED,SUP-2375348,CDM,C1776,CPT,0278,RC,,,,both,,,6428.21,4178.34,,,,,,,,,,,,,
IMPLANT BIOLOGICAL TISSUE W5XL5CM RS SURGICAL MATRIX MATRISTEM,SUP-2106515,CDM,Q4166,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.035IN TIP 2.5CM RAD 3MM PTFE,SUP-2167602,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.13,21.53,,,,,,,,,,,,,
KNIFE SURG VIRCHOW 11.25 IN 158X19 MM BRAIN DBL EDGED STR,SUP-2485829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.27,394.08,,,,,,,,,,,,,
PROSTHESIS OSS SCHEER PISTON SHT 0.6X3.33 MM SLIM SS,SUP-2637779,CDM,L8613,CPT,0278,RC,,,,both,,,314.53,204.44,,,,,,,,,,,,,
MESH HERN W3.5XL3.5IN SQ ABD O3FA COAT POLYPR STR KNIT,SUP-2265993,CDM,C1781,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW BONE L10MM DIA1.3MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA 6 MM EXTERNALLY SUPP,SUP-2266010,CDM,C1768,CPT,0278,RC,,,,both,,,7473.20,4857.58,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 8MM 120CM 8FR HEPARIN,SUP-2396619,CDM,C1874,HCPCS,0278,RC,,,,both,,,10748.22,6986.34,,,,,,,,,,,,,
TUBE VENTILATION 1.14MM ID 1.58MM FLUOROPLSTC SHANK EAR,SUP-2902751,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.21,45.64,,,,,,,,,,,,,
CATHETER CTRL VEN L23CM OD14.5FR CARBOTHANE CHRONIC MTL TUNN,SUP-2308264,CDM,C1751,HCPCS,0278,RC,,,,both,,,1388.29,902.39,,,,,,,,,,,,,
HC Allo Manual Plasma Re,PX-3623821400,CDM,38214,CPT,0362,RC,,,,outpatient,,,3672.00,2386.80,,,,,,,,,,,,,
SCREW SPNL L SET FOR CONN SYS,SUP-2317813,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW BNE L 44 MM DIA 5.5 MM SHRT TI CANN HD NS LEOS,SUP-2931500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1073.50,697.77,,,,,,,,,,,,,
PLATE BNE LG TI PMI LEFORT ORTHOGNATHIC 3D PRNT NS DISP,SUP-2934724,CDM,C1713,HCPCS,0278,RC,,,,both,,,26994.58,17546.48,,,,,,,,,,,,,
GUIDEWIRE ORTH L70CM OD2.4MM CO CHROM S STL SMOOTH BLNT TIP,SUP-2410449,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.20,99.58,,,,,,,,,,,,,
BRACE KNEE M FOR 18 21IN THGH NEOPRENE PAT STBL SFT,SUP-2150848,CDM,L1810,HCPCS,0272,RC,,,,both,,,75.39,49.00,,,,,,,,,,,,,
SYSTEM URO W/ IMPL DEL DEV FOR TREAT OF URIN OUTFLO,SUP-2308351,CDM,C1889,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST THMS W/WDG,SUP-2435734,CDM,L3465,HCPCS,0272,RC,,,,both,,,165.73,107.72,,,,,,,,,,,,,
SCREW SPNL MONOAX 4.5X25 MM PEDCL,SUP-2175428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
BLADE RTRCTR 40MMW X 30MML TTNM LEFT SCRL PRNGX2 LIGHT BLUE,SUP-2668042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.53,441.69,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN VBX L 79 MM 8/11 MM 135 CM 7 FR,SUP-2892800,CDM,C1874,HCPCS,0278,RC,,,,both,,,11049.66,7182.28,,,,,,,,,,,,,
GRAFT BNE SUB 1CC PTTY DBM FIBERS AND GLYC FRZ DRY OPTIUM,SUP-2264861,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.48,210.26,,,,,,,,,,,,,
STENT GRFT VASC ANEURX L 165 MM DIA PROX/DSTL 26/15 MM,SUP-2281771,CDM,C1874,HCPCS,0278,RC,,,,both,,,23707.00,15409.55,,,,,,,,,,,,,
TUBE HARV L8MM BNE DWL DISPOSABLE,SUP-2212801,CDM,C1713,HCPCS,0278,RC,,,,both,,,1689.32,1098.06,,,,,,,,,,,,,
SCREW BNE LCK 3.5X42 MM MULT DIR FOR T15,SUP-2411597,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.37,416.24,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 CM DIA22 X 11 MM THK 0.49 MM,SUP-2458544,CDM,C1768,CPT,0278,RC,,,,both,,,2492.44,1620.09,,,,,,,,,,,,,
SCREW SPNL L45MM OD7.5MM TI CANC PEDCL ST VAR ANG CANN,SUP-2211438,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.91,16.84,,,,,,,,,,,,,
SET URET STENT C FLX L 8-20 CM DIA 3.7 FR GUIDEWIRE 0.038 IN,SUP-2168935,CDM,C2617,HCPCS,0278,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
ALLOGRAFT BNE CERV 7.75X9.22 MM LORDTC VERTIGRAFT VG2,SUP-2264654,CDM,C1889,HCPCS,0278,RC,,,,both,,,3444.58,2238.98,,,,,,,,,,,,,
COIL DETACH 4MM DIA 10CM COIL OUTER DIA 0125IN VOL 792MM,SUP-2173104,CDM,C1889,HCPCS,0278,RC,,,,both,,,5947.16,3865.65,,,,,,,,,,,,,
BLADE RTRCTR BLFR STNDRD 2 5/8NW X 12NL X 1 1/2ND ABDMNL CNT,SUP-2459927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,418.66,272.13,,,,,,,,,,,,,
KNIFE ROSEN 20MM DIAMETER,SUP-2681599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.92,252.15,,,,,,,,,,,,,
KIT PICC PI 2-L 5FR X 55CM TIPTRACKER,SUP-2855518,CDM,C1751,HCPCS,0278,RC,,,,both,,,631.93,410.75,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 8X12 MM TRICORT IL CREST,SUP-2867120,CDM,C1762,CPT,0278,RC,,,,both,,,2174.61,1413.50,,,,,,,,,,,,,
ALLOGRAFT PERICARD RESRB MEMBRN NAT BARR 2.0CMX3.0CM MAXXEUS,SUP-2418450,CDM,C1762,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ALLOGRAFT BNE WHL ULNA FRZN LT,SUP-2717950,CDM,C1762,CPT,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM AMNION PLCNTA MEMBRN SINGLE LAYR,SUP-2913195,CDM,C1762,CPT,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
STEM FEM PRSS FT 14X150 MM KNEE TRIATHLON,SUP-2373844,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE NAR 4.5X55 MM 3 HOLE SS DCP,SUP-2569161,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.61,129.10,,,,,,,,,,,,,
IMMOBILIZER SHLDR L STRP 43IN,SUP-2324219,CDM,L3650,HCPCS,0274,RC,,,,both,,,19.75,12.84,,,,,,,,,,,,,
DRILL SURG CANN 15 MM GLEN W/ STP GLOB UNITE,SUP-2454287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
KIT INTRO SHTH DIA9FR PERC HI FLO BONDED ATRAUM VLV,SUP-2272867,CDM,C1894,HCPCS,0272,RC,,,,both,,,129.81,84.38,,,,,,,,,,,,,
SHEET SPLNT THK0.13IN STD W18XL24IN BILAT WR AND HND WHT SLD,SUP-2324794,CDM,L3730,HCPCS,0274,RC,,,,both,,,116.05,75.43,,,,,,,,,,,,,
SCALPEL SURG SAFETY GRD LCK SZ 12 STAINLES STL LCK RTRCTBLE,SUP-2605890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5.62,3.65,,,,,,,,,,,,,
CLIP INT LIG MED LG TI VESOCCLUDE,SUP-2757595,CDM,C1889,HCPCS,0278,RC,,,,both,,,10.68,6.94,,,,,,,,,,,,,
CATHETERIZATION SET ART 20 GAX4.45 CM 22 GA VEN 1 LUMEN LF,SUP-2865590,CDM,C1751,HCPCS,0278,RC,,,,both,,,16.83,10.94,,,,,,,,,,,,,
WIRE FIX L 6 IN DIA24 GA SS PRESTRETCH NS DISP OMNIMAX,SUP-2935363,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
GRAFT SFT TISS STRP FASC LATA IMPL ALLGRFT L150XW3MM,SUP-2264782,CDM,C1762,CPT,0278,RC,,,,both,,,634.44,412.39,,,,,,,,,,,,,
BRACE ORTHOPEDIC INT FT AUG REP SYS,SUP-2121624,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
PROBE SUCT N CNTCT COAG TARGETED THER CLR VIS BEAMER L320CM,SUP-2166255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.82,502.33,,,,,,,,,,,,,
BLADE CRVD MEDIAL HIP 12MM 16CM STER DISP,SUP-2800993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
ANCHOR SUTURE SFT LNG 1.45 MM CRV SET JUGGERKNOT DISP,SUP-2608812,CDM,C1713,HCPCS,0278,RC,,,,both,,,1033.94,672.06,,,,,,,,,,,,,
GUARD SEAM STPL LN REINF ENDOPATH FOR THORACOSCOPIC AND ENDO,SUP-2396262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
COMPONENT FEM SZ 4 RT KNEE CO CHROM NP PRI CEM STEMLESS,SUP-2304635,CDM,C1776,CPT,0278,RC,,,,both,,,9817.21,6381.19,,,,,,,,,,,,,
GUIDEWIRE TGS XPRESS FOR LOPROFILE ENT NAVIGATION SYS STRL,SUP-2659958,CDM,C1769,HCPCS,0272,RC,,,,both,,,786.63,511.31,,,,,,,,,,,,,
LENS IOL BCNVX 24.5+ DIOPT 6X13 MM MONO FOC TECNIS,SUP-2102416,CDM,V2632,HCPCS,0276,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
BIT OVERDRILL DIA 5.5 MM AO QC LG TARGETER SYS STRL DISP,SUP-2933095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1543.94,1003.56,,,,,,,,,,,,,
"HC So Molecular Pathology, Unlisted",PX-3108147966,CDM,81479,CPT,0310,RC,,,,outpatient,,,3280.00,2132.00,,,,,,,,,,,,,
STEM HUM 7.9X125MM MOD II +,SUP-2408648,CDM,C1776,CPT,0278,RC,,,,both,,,10497.02,6823.06,,,,,,,,,,,,,
GUIDEWIRE VASC MORPHEUS L 130 CM DIA 0.018 IN SS PERIPH,SUP-2117373,CDM,C1769,HCPCS,0272,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
PROSTHESIS OSS BCKT HNDL 0.4X3.50 MM 1 MM RICHARD FLROPLAS,SUP-2637904,CDM,L8613,CPT,0278,RC,,,,both,,,396.24,257.56,,,,,,,,,,,,,
PLATE BNE L181MM 10 H NONSTERILE L PROX TIB S STL,SUP-2185703,CDM,C1713,HCPCS,0278,RC,,,,both,,,3772.49,2452.12,,,,,,,,,,,,,
TRAY PICC MAXIMAL BARR 4FR 2 LUMN CATHETER W BIOPATCH PROTCT,SUP-2125697,CDM,C1751,HCPCS,0278,RC,,,,both,,,1066.53,693.24,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED BROAD LCP TM 24 HOLES 443MM STERILE,SUP-2549501,CDM,C1713,HCPCS,0278,RC,,,,both,,,5135.47,3338.06,,,,,,,,,,,,,
STENT 7X22 ULT W 035 ZIPWIRE GWIRE POLARIS,SUP-2141672,CDM,C2617,HCPCS,0278,RC,,,,both,,,574.84,373.65,,,,,,,,,,,,,
MICROCATHETER DIAG FASTRACKER 325 TRANSEND L 105 CM DIA 3 FR,SUP-2148475,CDM,C1887,HCPCS,0272,RC,,,,both,,,1843.24,1198.11,,,,,,,,,,,,,
PLATE BNE W17.5XL152MM THK5.2MM 8 H BILAT S STL BROAD LOK,SUP-2185290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1456.30,946.59,,,,,,,,,,,,,
VALVE DRAINAGE PUDENZ 16 MM BURR HOLE HI PRESSURE,SUP-2244294,CDM,C1729,HCPCS,0272,RC,,,,both,,,1357.80,882.57,,,,,,,,,,,,,
HOUSING DISTRACTOR 8DEG 10MM ALLGRFT INSRT STR,SUP-2292240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1973.46,1282.75,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH XP L 100 CM DIA 5 FR DIA1.22 MM STR,SUP-2385626,CDM,C1887,HCPCS,0272,RC,,,,both,,,86.76,56.39,,,,,,,,,,,,,
GUIDEWIRE ARTHSCP DIA1.35MM FOR PAT FRAC SYS,SUP-2121927,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
PLATE BNE H0.5MM 24 H MID FACE BLU TI STR COND MAL,SUP-2366240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1705.99,1108.89,,,,,,,,,,,,,
PLATE BNE L 196 X W 11.4 MM THK 3.5 MM SCREW DIA 3.5 MM 15 H 72464615N,SUP-2932845,CDM,C1713,HCPCS,0278,RC,,,,both,,,3979.48,2586.66,,,,,,,,,,,,,
SPLINT SWEDISH AFO WOMAN RT WHT,SUP-2324308,CDM,L4350,HCPCS,0274,RC,,,,both,,,69.87,45.42,,,,,,,,,,,,,
PLATE ANCHR ORTHODONTIC 17 MM 1 MM W/ FLAT 5 MM AREA CP TI,SUP-2490538,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.23,367.40,,,,,,,,,,,,,
STRIPS ILIUM TRICORT TRAD ALLGRFT 22X60 MM FRZ DRY,SUP-2294074,CDM,C1713,HCPCS,0278,RC,,,,both,,,6568.88,4269.77,,,,,,,,,,,,,
PLATE BNE L 60 MM SCREW DIA2.4/2.7 MM 6 HD 3 SHFT H LT DSTL,SUP-2913507,CDM,C1713,HCPCS,0278,RC,,,,both,,,6686.32,4346.11,,,,,,,,,,,,,
BROACH SURG F 60 MM PROX HI OFFSET PPS COAT ARCOS,SUP-2441644,CDM,C1776,CPT,0278,RC,,,,both,,,14330.96,9315.12,,,,,,,,,,,,,
PATCH CV HEMSHLD L 6 X W 0.3 IN THK 0.76 MM POLYESTER BOV,SUP-2694186,CDM,C1768,CPT,0278,RC,,,,both,,,409.14,265.94,,,,,,,,,,,,,
GRAFT BNE SUB 2CC CA PHSPTE VIT E ACETT HEMSTAT COHESIVE,SUP-2431805,CDM,C9359,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ADV ENFORCER 35 L 80 CM L 4 CM DIA 10 MM,SUP-2635410,CDM,C1725,HCPCS,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
PLATE SPNL W33MM CVR PILLAR SA,SUP-2317121,CDM,C1821,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SET INSTR IMPL S STL W/ 2.4MM DSTL RAD PLT LCP,SUP-2183074,CDM,C1713,HCPCS,0278,RC,,,,both,,,112258.14,72967.79,,,,,,,,,,,,,
KIT PROC LATARJET,SUP-2256896,CDM,C1713,HCPCS,0278,RC,,,,both,,,3161.98,2055.29,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO FLUID LG 1 CC RESTORIGIN RT,SUP-2321884,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 10 CM DIA 6 MM EPTFE CARBON FLX,SUP-2761426,CDM,C1768,CPT,0278,RC,,,,both,,,1174.45,763.39,,,,,,,,,,,,,
PROCESSOR HEARING AID BLONDE SND BAHA 5,SUP-2165001,CDM,L8691,HCPCS,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO LUMBAR 4 MOD SACR SCRAP PRE,SUP-2265011,CDM,L0464,HCPCS,0272,RC,,,,both,,,5736.78,3728.91,,,,,,,,,,,,,
SPECULUM OPHTH DEVGAN LIEBERMAN 86 MM TEMPORAL APPRCH TI NS,SUP-2473741,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1575.65,1024.17,,,,,,,,,,,,,
CONNECTOR ROD TI OD55 635 MM SDLD,SUP-2279799,CDM,C1713,HCPCS,0278,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
STENT PERIPH ELUVIA L 120 MM DIA 7 MM CATH L 130 CM DIA 6 FR,SUP-2146904,CDM,C1876,HCPCS,0278,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
IMPLANT GYN W4XL7CM FASC LATA TUTOPLAST PROC ALLGRFT TISS,SUP-2300759,CDM,C1762,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PLATE BONE L103MM 6 H BILAT COMPR STR BROAD FOR 4.5MM SCR,SUP-2343795,CDM,C1713,HCPCS,0278,RC,,,,both,,,1839.66,1195.78,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM CORT S STL ST T8 STARDRV RECESS,SUP-2183472,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.59,67.33,,,,,,,,,,,,,
HC So Drg Scrn Class List A,PX-3018030766,CDM,80307,CPT,0301,RC,,,,inpatient,,,79.00,51.35,,,,,,,,,,,,,
ELECTRODE ELECSURG CUT LOOP 30 DEG 28 FR 0.35 IN MONOPOLAR,SUP-2457480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,391.21,254.29,,,,,,,,,,,,,
HC So Chlamydia Antibody,PX-3028663166,CDM,86631,CPT,0302,RC,,,,inpatient,,,236.00,153.40,,,,,,,,,,,,,
GUIDEWIRE UROLOGY STR 0.038 INX150 CM STANDARD-BODY HIWIRE,SUP-2835972,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.97,67.58,,,,,,,,,,,,,
KIT IMPL FNGR CUST,SUP-2397185,CDM,L8630,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 1.20 CC FD CORTICAL PWD ORAGRAFT,SUP-2741035,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.20,150.93,,,,,,,,,,,,,
BUR SURG L48MM DIA07MM 150 200 GRIT DMND RND FOR OTO,SUP-2166380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.07,205.45,,,,,,,,,,,,,
SCREW BONE L3.5MM DIA1.6MM TI SELF DRL CRUC FOR CRAN PLATING,SUP-2280075,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.37,114.64,,,,,,,,,,,,,
ROD SPNL THORLUM CRV PREBENT TI OD5.5MM L50MM SILVERTON,SUP-2415726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.96,760.47,,,,,,,,,,,,,
CROWN DENT 7 LO LT 1ST PRI M S STL GLD PREFABRICATED REPL,SUP-2322216,CDM,D6783,CPT,0278,RC,,,,both,,,31.27,20.33,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM OD 5 FR ID 1.7 MM GUIDEWIRE L 40,SUP-2168551,CDM,C1894,HCPCS,0272,RC,,,,both,,,104.09,67.66,,,,,,,,,,,,,
ALLOGRAFT BNE SPNG 15 CC DBM FIBER VESUVIUS,SUP-2717979,CDM,C1713,HCPCS,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
PLATE BNE L356MM 15 H R DST FEM S STL LOK COMPR FOR 45MM SCR,SUP-2177824,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.47,3265.91,,,,,,,,,,,,,
SCREW LK F/IM NAIL 5X60MM XL25 ST,SUP-2718118,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.08,427.75,,,,,,,,,,,,,
COLLAR CERV PHILLY SM 4.25 IN 10-13 IN REHAB FOAM PROCARE,SUP-2196878,CDM,L0180,HCPCS,0274,RC,,,,both,,,35.67,23.19,,,,,,,,,,,,,
RECON PLATE 13X205MM 4.5MM,SUP-2818434,CDM,C1713,HCPCS,0278,RC,,,,both,,,5710.88,3712.07,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 42 MM DIA10 MM CATH TOT L 100,SUP-2148386,CDM,C1876,HCPCS,0278,RC,,,,both,,,3244.00,2108.60,,,,,,,,,,,,,
KIT INTRO L 15 CM DIA 4 FR GUIDEWIRE L 60 CM NDL L 12 CM,SUP-2226026,CDM,C1894,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
GRAFT BIO TISS W10XL15CM THK1MM PORCINE DERM CLLGN HERN ABD,SUP-2174696,CDM,C9364,HCPCS,0278,RC,,,,both,,,10317.60,6706.44,,,,,,,,,,,,,
STAPLE BNE FIX W9XL10MM NIT W/ INSTR DYNANITE,SUP-2122338,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L6MM INDWL 2 VLV BLOM-SINGER,SUP-2242331,CDM,L8509,HCPCS,0274,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
NAIL IM L180MM DIA9MM 130DEG SHT TROCHANTERIC FEM HIP CANN,SUP-2253388,CDM,C1713,HCPCS,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
IMPLANT STAP L3.75MM DIA0.6MM NIT MID EAR STAP INCUS WIRE,SUP-2313865,CDM,2780000010,LOCAL,0278,RC,,,,both,,,840.48,546.31,,,,,,,,,,,,,
COMPONENT TOT ANK NEUT 1 9 MM POLYETH VIT E APEX 3D,SUP-2742164,CDM,C1776,CPT,0278,RC,,,,both,,,6633.25,4311.61,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DECATHLON DF CHRONIC STD 16FR DIA 24CM,SUP-2613308,CDM,C1750,HCPCS,0278,RC,,,,both,,,1134.17,737.21,,,,,,,,,,,,,
SNARE SURG NDL EYE 13 MMX54 CM 12X12 FR WORKSTATION,SUP-2638742,CDM,C1773,HCPCS,0272,RC,,,,both,,,3537.87,2299.62,,,,,,,,,,,,,
SLEEVE KNEE NEOPRENE OPN PAT BLK SM 1 8IN,SUP-2319239,CDM,L1810,HCPCS,0272,RC,,,,both,,,19.15,12.45,,,,,,,,,,,,,
SCREW BNE L100MM DIA7.3MM THRD L32MM S STL ST SELF DRL CANN,SUP-2184003,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.09,399.81,,,,,,,,,,,,,
PLATE BONE L NONSTERILE CRAN TI ARC CNTOUR MESH MALL FOR,SUP-2190627,CDM,C1713,HCPCS,0278,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
PLATE BNE W175XL134MM THK52MM 7 H BILAT TI RIG NEUT LOK,SUP-2190843,CDM,C1713,HCPCS,0278,RC,,,,both,,,1311.26,852.32,,,,,,,,,,,,,
GRAFT VASC W12XL12CM THK0.1MM EPTFE PERICARD MEM PRECL,SUP-2395370,CDM,C1768,CPT,0278,RC,,,,both,,,2546.54,1655.25,,,,,,,,,,,,,
GRAFT BNE CRUSH 60 CC TISS CANC,SUP-2165615,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 2 300CM 0.014IN SEG 35CM SFT FLAT,SUP-2367904,CDM,C1769,HCPCS,0272,RC,,,,both,,,2267.71,1474.01,,,,,,,,,,,,,
IMPLANT DERM W50XL160MM CLLGN RECTANG SHT ALLOMAX,SUP-2125855,CDM,C1781,HCPCS,0278,RC,,,,both,,,6342.80,4122.82,,,,,,,,,,,,,
PLATE BONE RT VOLAR DSTL RAD S STL FOR 2.4/2.7MM 1.8MM BTTRS,SUP-2186098,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.93,1520.95,,,,,,,,,,,,,
PLATE BNE MTP STD RT MFT002SR] ORTHO HELIX SURGICAL DESIGN],SUP-2315903,CDM,C1713,HCPCS,0278,RC,,,,both,,,4122.82,2679.83,,,,,,,,,,,,,
SCREW BNE THRD 4X100 MM SPADE PT SCHNZ SS NS,SUP-2186948,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
COIL VASC AZUR CX L 9 CM DIA 6 MM MICROCATHETER 0.035 IN,SUP-2385439,CDM,C1889,HCPCS,0278,RC,,,,both,,,1910.69,1241.95,,,,,,,,,,,,,
DRILL SURGICAL DIA55MM CANNULATED NFORCE,SUP-2588966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1222.72,794.77,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT L 125 CM DIA 8 FR SHTH,SUP-2248931,CDM,C1732,HCPCS,0278,RC,,,,both,,,6575.16,4273.85,,,,,,,,,,,,,
TRIAL ANKLE JOINT 7MM SUBTALAR COMPONENT TWISTED,SUP-2878144,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
GRAFT BONE SUB 25X50X4MM 5ML STRP BIOLOGIC SPINE SURG,SUP-2232306,CDM,C9362,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 45 CM DIA 8 MM RNG L 5 CM EPTFE,SUP-2396272,CDM,C1768,CPT,0278,RC,,,,both,,,2270.22,1475.64,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 175 CM DIA2-4 MM,SUP-2120066,CDM,C1773,HCPCS,0272,RC,,,,both,,,848.74,551.68,,,,,,,,,,,,,
PLATE BNE ADAPTIVE WIDE LNG 2.5 MM RT 15 HOLE,SUP-2433960,CDM,C1713,HCPCS,0278,RC,,,,both,,,5085.54,3305.60,,,,,,,,,,,,,
PLATE QUIKFLAP BURR 20MM SD AXS,SUP-2718053,CDM,C1713,HCPCS,0278,RC,,,,both,,,10154.76,6600.59,,,,,,,,,,,,,
SHELL ACET PRESSFIT PRI 40 MM OD UNIV NO H CERAMIC COAT TI,SUP-2210213,CDM,C1776,CPT,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
SCREW SPNL TAPR 5X14 MM OCCIPITOCERVICAL UPPER THOR,SUP-2632011,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
PACK ARTHSCP ACL PCL PIN WIRE PAC C FOR FAST-FIX 360 MENIS,SUP-2341004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
SCREW SPNL L40MM DIA6.5MM CANC THORACOLUMBOSACRAL PEDCL S,SUP-2288422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
DEVICE PESSARY SZ 3 SIL FIT RNG MILEX,SUP-2171769,CDM,A4562,HCPCS,0272,RC,,,,both,,,228.75,148.69,,,,,,,,,,,,,
SPLINT KNEE L16IN FOR 29IN THGH UNIV FOAM LAM 3IN E CNTCT,SUP-2197153,CDM,L1810,HCPCS,0274,RC,,,,both,,,32.37,21.04,,,,,,,,,,,,,
CATHETER KIT 4001] COLLINGWOOD],SUP-2165194,CDM,C1894,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.14 MM 1.6 MM 2.3 MM W/ WIRE 525121W,SUP-2471319,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.53,17.24,,,,,,,,,,,,,
PLATE BNE L 177 MM SCREW DIA2.4 MM 20 SHFT H SS ADPT COMB VA,SUP-2908445,CDM,C1713,HCPCS,0278,RC,,,,both,,,4272.91,2777.39,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0250,RC,00264-1510-32,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
BIT DRILL SURG DIA2.5 MM SHRT AO QC STRL DISP EVOS LG,SUP-2931237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.21,648.84,,,,,,,,,,,,,
SHELL ACET OD44MM ID21MM UNIV PPS HIP RECON QUAD SPRNG IMP,SUP-2403681,CDM,C1776,CPT,0278,RC,,,,both,,,5513.84,3584.00,,,,,,,,,,,,,
COIL EMB SUPER SFT 010 1 MMX1 CM DETACHABLE COMPLX OPTMA,SUP-2753875,CDM,C1889,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
PATELLA SUTPLT II STAR POLE FRACTURE M STRL,SUP-2811472,CDM,C1713,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
IMPLANT INSITE FT TI ANCHR 4.5MM W/ NDL,SUP-2388906,CDM,C1713,HCPCS,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
PLATE BNE L79MM 2 H ST POST MED PROX TIB S STL LOK COMPR,SUP-2177793,CDM,C1713,HCPCS,0278,RC,,,,both,,,3381.72,2198.12,,,,,,,,,,,,,
VALVE VENT L36MM DIA13MM THK6MM REG PERF LEV 1 DELT,SUP-2284516,CDM,C1889,HCPCS,0278,RC,,,,both,,,3473.56,2257.81,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM DIL L 13 CM OD 4 FR ID 1.3 MM,SUP-2168342,CDM,C1894,HCPCS,0272,RC,,,,both,,,60.98,39.64,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 100 CM DIA 9 FR BALLOON L 30 MM DIA15,SUP-2140990,CDM,C1725,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
PLATE BNE W9XL141MM THK1MM 12 H TI 1/3 TBLR W/ CLLR LOK,SUP-2190959,CDM,C1713,HCPCS,0278,RC,,,,both,,,556.47,361.71,,,,,,,,,,,,,
PLATE BONE W14.9XL216MM THK1.2MM 13 H DSTL TIB S STL,SUP-2185742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.71,955.31,,,,,,,,,,,,,
GRAFT HUM TISS PERONEUS LONGUS TEND >22CM FRZN (FOLDED DIAM,SUP-2307283,CDM,C1713,HCPCS,0278,RC,,,,both,,,4150.83,2698.04,,,,,,,,,,,,,
GRAFT VASC W/ RADPQ MRK SIDE BRANCH LEN THOR ARCH 14MM BOR,SUP-2385005,CDM,C1768,CPT,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
PLATE BNE SHRT STD TI RT ANTR TT FUSION NS,SUP-2896806,CDM,C1713,HCPCS,0278,RC,,,,both,,,6276.86,4079.96,,,,,,,,,,,,,
HC CT Heart No Contrast Quant Eval Coronry Calcium|NOT REASONABLE AND NECESSARY,PX-3507557100,CDM,75571,CPT,0350,RC,,,GZ,both,,,362.00,362.00,,,,,,,,,,,,,
PLATE BONE W14.9XL152MM THK1.2MM 9 H DSTL TIB S STL,SUP-2185738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1125.50,731.57,,,,,,,,,,,,,
KIT CRICOTHYROIDOTOMY AD TB ID6MM EMGCY AIRWY ACCS VERES NDL,SUP-2351754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.59,404.03,,,,,,,,,,,,,
BIT DRL QC 4.3X245 MM FEM PERIPROSTHETIC NCB,SUP-2466361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
KETOROLAC TROMETHAMINE 0.5 % OP SOLN,RX-19733,CDM,6370000000,HCPCS,0637,RC,60505-1003-01,NDC,,both,5,ML,144.30,93.79,,,,,,,,,,,,,
PLATE MED SLDE BEAV,SUP-2321505,CDM,C1713,HCPCS,0278,RC,,,,both,,,5923.61,3850.35,,,,,,,,,,,,,
SCREW SPNL EXT 60 MM TSRH 3DX,SUP-2631104,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.65,361.17,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 22 HOLE SS NS LCP,SUP-2799224,CDM,C1713,HCPCS,0278,RC,,,,both,,,3062.07,1990.35,,,,,,,,,,,,,
GUIDEWIRE URLGCL 0038N DIA 150CML 3CML TIP STRGHT TIP STIFF,SUP-2722858,CDM,C1769,HCPCS,0272,RC,,,,both,,,110.21,71.64,,,,,,,,,,,,,
TIP ASPIR SPETZLER MIC SUPER LNG UNIV 1.8X2 MMX7.9 SONOPET,SUP-2791032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2729.95,1774.47,,,,,,,,,,,,,
HC So T-3 Uptake,PX-3018447966,CDM,84479,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
CAGE CERV B TI ALLOY DISP DTRAX,SUP-2330582,CDM,C1889,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP LG 8 IN LT WRST COCK UP ELASTIC,SUP-2108133,CDM,L3809,HCPCS,0272,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
COIL EMB L18CM OD6MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305176,CDM,C1889,HCPCS,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
CONNECTOR SPNL 635-7MM DOMINO CDH,SUP-2631754,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
PLATE BONE 17 H PRI RECON W/ TEMPLT,SUP-2365247,CDM,C1713,HCPCS,0278,RC,,,,both,,,8831.19,5740.27,,,,,,,,,,,,,
MOLD FEM SPCR M AP44MM ML67MM PMMA URETHANE GENT KASM,SUP-2315775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 16 HOLE STRAIGHT 63MM TITANIU,SUP-2826363,CDM,C1713,HCPCS,0278,RC,,,,both,,,183.03,118.97,,,,,,,,,,,,,
PUMP PERFSN CENTRIFUGE CONN 1/4 IN FLO RATE 1.5 L/MIN,SUP-2894490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,31400.00,20410.00,,,,,,,,,,,,,
PLATE BNE T LT TARSALIS MID FT 5 HOLE LCK,SUP-2609121,CDM,C1713,HCPCS,0278,RC,,,,both,,,5254.63,3415.51,,,,,,,,,,,,,
PLATE BNE L112MM 6 H R DST LAT FIBULAR S STL LOK COMPR,SUP-2184159,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.99,1104.34,,,,,,,,,,,,,
CONNECTOR ROD TI LAT CLS L10MM OD6.35X6.35MM,SUP-2287164,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
PLATE BONE NARROW 4.5X39 MM 2 HOLE FOR SCREW STERILE TC100,SUP-2836674,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.39,665.20,,,,,,,,,,,,,
SCREW BNE EMGCY 3.1X9 MM NLCK TI MAXDRIVE LEVEL 1 258880991,SUP-2458049,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.13,238.63,,,,,,,,,,,,,
KNIFE SURG DACRYOCYSTORHINOSTOMY 5-7/8 INX4.3 MM MICROFRANCE,SUP-2461060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.23,336.85,,,,,,,,,,,,,
LASER FBR ANG DEL DEV GREENLIGHT HPS,SUP-2138863,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CANNULA SURG CEPHALOMEDULLARY ENTRY ASIA,SUP-2490613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
SCREW BONE 16MM THRD 6.5X35MM CANC S STL,SUP-2198292,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.47,43.21,,,,,,,,,,,,,
CUP ACET OD46MM ID22MM ALL POLYETH CEM REFLCT,SUP-2345387,CDM,C1776,CPT,0278,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
KIT INFSN 4FR CATH 90CML LNGTH 10CM CHECK RELF VLV HEMSTAS V,SUP-2676953,CDM,C1751,HCPCS,0278,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
PLATE BNE W9XL69MM THK1MM 6 H TI 1/3 TBLR W/ CLLR LOK COMPR,SUP-2420738,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.23,325.15,,,,,,,,,,,,,
GRAFT BONE 0.5-3MM 90ML CORT CANC CRUSH CHIP FRZN,SUP-2294137,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
ALLOGRAFT DERMAL 15X140X1.5 MM ACELLULAR DERMAL ARTHROFLEX,SUP-2740766,CDM,Q4125,HCPCS,0636,RC,,,,both,,,5044.41,3278.87,,,,,,,,,,,,,
BIT DRILL 0.76X75 MM 14 MM J LATCH,SUP-2841945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.21,275.74,,,,,,,,,,,,,
CUBE EXT FIX 1 H RANCHO FEMALE,SUP-2898437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
LITHOTRIPTER SURG MECH GUIDEWIRE TYP STRL DISP,SUP-2912507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1352.05,878.83,,,,,,,,,,,,,
STEM MOD FEM REV NEUT PRESSFIT POR TAPR HIP SZ 1 200MM LEN,SUP-2217420,CDM,C1776,CPT,0278,RC,,,,both,,,13706.10,8908.96,,,,,,,,,,,,,
HANDPIECE (package is the only valid order uom) ABLAT DISP FOR ENDOMET SYS,SUP-2305833,CDM,C1886,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
BEAM FIX L110MM DIA8.5MM ARTH,SUP-2223962,CDM,C1776,CPT,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
NEEDLE ENDOSCP BPLR 5 MMX36 CM HNDL 3 RNG,SUP-2767413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3152.40,2049.06,,,,,,,,,,,,,
SCREW SPNL L35MM DIA6.5MM STD CANC TI MULTIAXIAL ST TOP LEV,SUP-2415875,CDM,C1713,HCPCS,0278,RC,,,,both,,,3314.33,2154.31,,,,,,,,,,,,,
DRILL TWST 1.4X18X8MM,SUP-2364181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,620.75,403.49,,,,,,,,,,,,,
CURETTE BONE STR SZ 0,SUP-2292912,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
HC Fetal Eval 2-3 Trim Sgl Gest,PX-4027680500,CDM,76805,CPT,0402,RC,,,,both,,,1288.00,837.20,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE SYGNACEL 5CC T90105,SUP-2929798,CDM,C1713,HCPCS,0278,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
BRACE KNEE AD LG UNISX R MED HNG FASTEN ON OPN,SUP-2196476,CDM,L1852,HCPCS,0274,RC,,,,both,,,1212.07,787.85,,,,,,,,,,,,,
BIT DRL L300MM OD5.5MM W/O STP NONRADIOLUCENT AO QUIK CPL,SUP-2368454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.23,405.75,,,,,,,,,,,,,
BIT DRL STRL VERSANAIL,SUP-2606671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 3X20 MM LOCKING FOR STERNAL PLATE TI,SUP-2838336,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.22,412.89,,,,,,,,,,,,,
MASK LARYN AIRWY SZ 2 DEV ONLY INTEGR DRN TUBE REUSE LMA,SUP-2383624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,856.59,556.78,,,,,,,,,,,,,
GRAFT BONE PROX FIB TRAD FRZN,SUP-2294141,CDM,C1713,HCPCS,0278,RC,,,,both,,,5325.44,3461.54,,,,,,,,,,,,,
SHROUD CEMENT CONSTRN 28 MM LNR TRABECULAR MTL,SUP-2438927,CDM,C1776,CPT,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
SPACER SPNL 2.5X7-7.5 MM FOR SCR TI MALIBU,SUP-2707656,CDM,C1889,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GRAFT SURG 1MM PROC HUM DERM CLLGN RECTANG 8CMX12CM ALLOMAX,SUP-2126260,CDM,C1781,HCPCS,0278,RC,,,,both,,,6728.71,4373.66,,,,,,,,,,,,,
PLATE SPNL 4 LEV VIS WIND QUIK LCK BUSHING ANTR CERV,SUP-2207840,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER THORACIC X-LARGE 20FR L26CM EXTENDED LENGTH STRAIGH,SUP-2825233,CDM,C1729,HCPCS,0272,RC,,,,both,,,83.74,54.43,,,,,,,,,,,,,
STENT GRFT VASC CP STENT L 3.4 CM 14 FR 3.5CM 18MM 2.5CM 9MM,SUP-2125284,CDM,C1874,HCPCS,0278,RC,,,,both,,,21038.00,13674.70,,,,,,,,,,,,,
LEGION ELIP RESURF PAT W/JRNY PEG 32,SUP-2822784,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COMPONENT FEM XL L KNEE REV CEM CRUCE RET STEM NONBEADED,SUP-2377072,CDM,C1776,CPT,0278,RC,,,,both,,,5116.44,3325.69,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 5 MM STR STD WALL REINF,SUP-2525437,CDM,C1768,CPT,0278,RC,,,,both,,,1343.73,873.42,,,,,,,,,,,,,
HC Facial Bones Less Than 3 Views,PX-3207014000,CDM,70140,CPT,0320,RC,,,,outpatient,,,446.00,289.90,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 6 H TI STR LP NS STERNALOCK,SUP-2894506,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
ENDCAP ORTHOPEDIC 0 MM COLECT PROT HMRX,SUP-2431228,CDM,C1889,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GUIDEPIN ORTHOPAEDIC 3.2X300 MM THREADED STAINLESS STEEL STE,SUP-2836890,CDM,C1713,HCPCS,0278,RC,,,,both,,,201.02,130.66,,,,,,,,,,,,,
KIT SURG INTERPHALANGEAL STRL,SUP-2319762,CDM,C1776,CPT,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
HC So Total Protein,PX-3018415566,CDM,84155,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
SCREW BNE L6MM DIA1MM STD CORT S STL ST NONCANNULATED,SUP-2183135,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.32,128.91,,,,,,,,,,,,,
PLATE BNE TI ORTHOGNATHIC 8 PLATE CUSTOMIZED FACE ID,SUP-2883700,CDM,C1713,HCPCS,0278,RC,,,,both,,,36293.12,23590.53,,,,,,,,,,,,,
PLATE STR 1.5MM 6H VAL,SUP-2546070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1473.26,957.62,,,,,,,,,,,,,
COMPONENT PATELLAR D 12 MM ARTC KNEE,SUP-2200794,CDM,C1776,CPT,0278,RC,,,,both,,,4140.09,2691.06,,,,,,,,,,,,,
BUR SURG L25.4MM DIA1MM DMND RND NONFLUTED ELITE TPS,SUP-2363320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.11,245.12,,,,,,,,,,,,,
DEVICE TISS FIX INT BRAC FLIP CUT III DRL FIBERSNARE SUTURE,SUP-2910087,CDM,C1713,HCPCS,0278,RC,,,,both,,,4653.92,3025.05,,,,,,,,,,,,,
RIVAROXABAN 20 MG PO TABS,RX-111545,CDM,6370000000,HCPCS,0637,RC,50458-0579-10,NDC,,both,1,UN,89.80,58.37,,,,,,,,,,,,,
BLINATUMOMAB 35 MCG IV SOLR,RX-128517,CDM,J9039,HCPCS,0636,RC,55513-0160-01,NDC,,both,1,UN,16003.50,10402.27,,,,,,,,,,,,,
HC So1 Fluorescent Antibody Screen,PX-3028625567,CDM,86255,CPT,0302,RC,,,,inpatient,,,588.00,382.20,,,,,,,,,,,,,
ROD REPROC EXT FIX HYBRID CARBN 11X125MM,SUP-2495467,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.58,155.08,,,,,,,,,,,,,
BURR ARTHSCP 5.5MM DIA ROUND FLTDX6 UNHDD BROWN HUB F/DSTL C,SUP-2589373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,179.17,116.46,,,,,,,,,,,,,
DRILL SURG CANN 10.3 MM FOR HIP SCR,SUP-2766130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.018 IN TIP L 5 CM NIT MANDREL,SUP-2828288,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.43,45.13,,,,,,,,,,,,,
LIFT HEEL LG ADJLFT,SUP-2394116,CDM,L3334,HCPCS,0274,RC,,,,both,,,40.66,26.43,,,,,,,,,,,,,
WIRE FIX SHRP 1.5X350 MM NS PHANTOM XL KIRSCHNER DISP,SUP-2750843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SHEATH KIT NANONEEDLE 125 MM HI FLO OPERATIVE CRWN TIP FEN,SUP-2849271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
SCREW CORT FT ST HEX HD 4.5MM DIA 40MML,SUP-2342659,CDM,C1713,HCPCS,0278,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
MODEL ANAT FULL SKULL PED UPTO 5YR 3D CT BASE OSTEOVIEW,SUP-2883400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4763.69,3096.40,,,,,,,,,,,,,
COLLAR CERV 3IN 12 24IN L TRACH OPN W  CHIN SUPP ADJUSTABLE,SUP-2431856,CDM,L0174,HCPCS,0272,RC,,,,both,,,182.91,118.89,,,,,,,,,,,,,
HC So Assay of Nucleotidase,PX-3018391566,CDM,83915,CPT,0301,RC,,,,inpatient,,,397.00,258.05,,,,,,,,,,,,,
LINER CUP 28X48-50MM SZ MP5 3.15MM THCK 0 DEG ACET MTL ON,SUP-2217295,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 55 CM DIA 6 MM EPTFE STR STD WALL,SUP-2669693,CDM,C1768,CPT,0278,RC,,,,both,,,1690.29,1098.69,,,,,,,,,,,,,
GRAFT HUM TISS SM W10XL17CM THK15 22MM THCK PERF FLEXHD,SUP-2307602,CDM,Q4126,HCPCS,0636,RC,,,,both,,,9044.52,5878.94,,,,,,,,,,,,,
GRAFT HUM TISS W2XL12CM WHL MEM AMNIO SHT NO ANG AMINOFIX,SUP-2305723,CDM,C1762,CPT,0278,RC,,,,both,,,3965.19,2577.37,,,,,,,,,,,,,
STIMULATOR NERVE VAGEL ASPIRE GEN,SUP-2265164,CDM,C1767,HCPCS,0278,RC,,,,both,,,92944.91,60414.19,,,,,,,,,,,,,
MESH CRAN L 55 X W 55 MM THK 1 MM SCREW DIA1.7 MM PLLA PDLA,SUP-2883463,CDM,C1713,HCPCS,0278,RC,,,,both,,,5976.11,3884.47,,,,,,,,,,,,,
WIRE FLTR DEL SUP .014INX315CM BAREWIRE,SUP-2105942,CDM,C1876,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X266 MM 22 HOLE SS DCP,SUP-2569160,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.29,315.44,,,,,,,,,,,,,
PLATE BNE W9XL121MM THK1MM 10 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190957,CDM,C1713,HCPCS,0278,RC,,,,both,,,559.42,363.62,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 115 CM DIA 5 FR SPC 2,SUP-2356876,CDM,C1730,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW BNE SELF COMPRESSIVE 3.2X16 MM DYNAFIT,SUP-2610267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
OBTURATOR ENDOSCP CINCHLOCK FLX,SUP-2663982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1815.67,1180.19,,,,,,,,,,,,,
PLATE BNE CONN 4 HOLE FOR DISTRCTN OSTEOGENESIS RNG SYS,SUP-2179150,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.55,189.51,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM 1.5 MM 2.75 MM CLLR BUTTON SIL STRL,SUP-2473435,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.55,19.21,,,,,,,,,,,,,
BIT DRL SLD 1.5 MM FOR SPIDER LIMIT WRST FUSION,SUP-2852811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.17,512.31,,,,,,,,,,,,,
CATHETER PTCA 4FR L170CM 0.014IN BLLN L20MM DIA2.5MM PERIPH,SUP-2170809,CDM,C1725,HCPCS,0272,RC,,,,both,,,938.26,609.87,,,,,,,,,,,,,
HC 2 Cv Cath Plac W/Ports,PX-3613656600,CDM,36566,CPT,0361,RC,,,,both,,,16763.00,10895.95,,,,,,,,,,,,,
CATHETER GUID RAPIDO WORKING L 47 CM DIA 8 FR SS PTFE PEBAX,SUP-2148900,CDM,C1887,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
COMPONENT FEM SZ B KNEE ZMLY PC UNI HI FLX ZUK,SUP-2342157,CDM,C1776,CPT,0278,RC,,,,both,,,9511.06,6182.19,,,,,,,,,,,,,
NAIL IM FEM 9X300 MM RETROGRADE TI STRL DISP,SUP-2457616,CDM,C1713,HCPCS,0278,RC,,,,both,,,5818.42,3781.97,,,,,,,,,,,,,
HC Chemo Push Each Addt Drug,PX-3319641100,CDM,96411,CPT,0331,RC,,,,outpatient,,,432.00,280.80,,,,,,,,,,,,,
DRILL COUNTSINK MINI MAXLOCK EXTRM MTP POCKETLOCK,SUP-2400511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
GUIDE STAPLE WIRE/DRILL 2.6MM,SUP-2652942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
HC Plmt Biliary Drainage Cath External,PX-3614753300,CDM,47533,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW BONE L100MM OD6.4MM BLU TI CORT ST SELF DRL,SUP-2347063,CDM,C1713,HCPCS,0278,RC,,,,both,,,843.53,548.29,,,,,,,,,,,,,
KIT DISP RETACTOR SYS SERENGETINO 484-4507-1 MINIMALLY,SUP-2258075,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
INDOMETHACIN 50 MG PO CAPS,RX-3898,CDM,6370000000,HCPCS,0637,RC,31722-0543-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DRILL SURG STP 10 MM PATELLAR KNEE I/B II,SUP-2437038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
"HC Concentratn ,Any, Infect Agent",PX-3008701500,CDM,87015,CPT,0300,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
GRAFT BNE PWD 1 CC DBM MAROMATCH,SUP-2120699,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CONNECTOR SPNL U 6.35-6.35X200 MM LT REVERE,SUP-2584895,CDM,C1713,HCPCS,0278,RC,,,,both,,,8333.56,5416.81,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 8 CM DIA 3.5 MM SPD 5000 RPM INTNSL,SUP-2900126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.49,279.82,,,,,,,,,,,,,
SCREW BNE L 110 MM DIA 6.5 MM TI ST SD CANN FULL THRD RVS,SUP-2900988,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.66,625.08,,,,,,,,,,,,,
PLATE BNE STR LNG CRANIOFACIAL NEURO 2 HOLE LP NS LEVEL 1,SUP-2482448,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.38,124.40,,,,,,,,,,,,,
IMPLANT TOE JT HEMI CANN VILEX MINI,SUP-2392822,CDM,C1776,CPT,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
PACEMAKER CARD INGENIO W 4.45 X H 4.70 CM THK 0.75 CM 24.5,SUP-2149241,CDM,C1785,HCPCS,0275,RC,,,,both,,,11077.92,7200.65,,,,,,,,,,,,,
PROSTHESIS OTO L4.5MM SHFT OD0.6MM L LOOP 0.8MM MID EAR STAP,SUP-2284054,CDM,L8613,CPT,0278,RC,,,,both,,,254.09,165.16,,,,,,,,,,,,,
DISTRACTION INTRNL PLATE CNSLDTN RAMUS TRNSPRT DVCE 15 MM S,SUP-2679192,CDM,C1713,HCPCS,0278,RC,,,,both,,,1837.69,1194.50,,,,,,,,,,,,,
ANCHOR ENDOSCP L 38 CM DIA2.4 MM NDL W 12 MM STIT D 4 MM NIT,SUP-2881865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY II DR TI 2 CHMBR IS1 COMPATIBLE,SUP-2139586,CDM,C1785,HCPCS,0275,RC,,,,both,,,14597.86,9488.61,,,,,,,,,,,,,
CORD CONN BAN STYL ADPT L HK NDL STRL REUSE F/ EVERST FCPS,SUP-2312666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
DEVICE SPNL INTBDY POST PLT OCTAVE 8MM,SUP-2264523,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SPACER SPNL W30XH9MM D24MM LAT THORLUM INTBDY FUS RADLUC,SUP-2194098,CDM,C1821,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
MARKER PRB SET 4 PALPATOR XIA,SUP-2734609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
KIT SUC IRR DRAINAGE STRL DISP CLR,SUP-2914837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
MESH HERN ELLIPSE 15X10 CM W/ ECHO 2 POS SYS VENTRALIGHT ST,SUP-2126502,CDM,C1781,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SCREW BONE 3.0MM X 80MM DUAL TRAK CLAVICLE S,SUP-2639496,CDM,C1713,HCPCS,0278,RC,,,,both,,,4113.40,2673.71,,,,,,,,,,,,,
INSTRUMENT KIT 2.5X7 MM NANO SWIVELOCK DISP,SUP-2421833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
BRACE ORTHOPEDIC IMMOB KNEE CUST,SUP-2265015,CDM,L1810,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE L90MM THK1MM 7 H S STL NONLOCKING 1/3 TBLR FOR,SUP-2372053,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CATHETER HD 15 FRX19 CM 39 CM HEPARIN PALINDROME PRECIS,SUP-2172341,CDM,C1750,HCPCS,0278,RC,,,,both,,,704.62,458.00,,,,,,,,,,,,,
HC N Block Lumbar/Thoracic,PX-3606452000,CDM,64520,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
BLADE OSTEOTOM L25MM FOR OPN WDG OSTEOTMY SYS SET,SUP-2121033,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
ANCHOR SUT 50MM LOOP VERSITOMIC G LOK,SUP-2366637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1232.04,800.83,,,,,,,,,,,,,
GUIDEWIRE ORTH L750MM DIA3MM DRV BLNT BALL TIP GAM,SUP-2371036,CDM,C1769,HCPCS,0272,RC,,,,both,,,487.96,317.17,,,,,,,,,,,,,
SCREW SPNL 2 OUTER DIAMETER 9.5-8X95 MM HD SHANK CREO 5.5,SUP-2732543,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
STEM FEM 60MM SH WDG HIP INTERSPACE,SUP-2223680,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X50 MM DSTL FEM ST FT HEX TI NCB,SUP-2474543,CDM,C1713,HCPCS,0278,RC,,,,both,,,289.79,188.36,,,,,,,,,,,,,
BIT DRL L70MM OD4MM TWST W/O STP NONRADIOLUCENT SLD SCP,SUP-2413874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE STR MINI 6 HOLE COMPR NS LTX,SUP-2855822,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
WEDGE FEM SZ 3 THK5MM STD UNIV DST KNEE CO CHROM PRI,SUP-2346020,CDM,C1776,CPT,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
ANCHOR SUTURE 3.3MM POPLOK KNOTLESS WITH ONE STRAND OF NUMBE,SUP-2825150,CDM,C1713,HCPCS,0278,RC,,,,both,,,1690.89,1099.08,,,,,,,,,,,,,
MEMBRANE CLLGN DURA REP DURAMATRIX SUTURABLE 2IN X 2IN,SUP-2165130,CDM,C1763,HCPCS,0278,RC,,,,both,,,1638.08,1064.75,,,,,,,,,,,,,
HANDPIECE 5 MMX20 CM THUNDERBEAT ENDO FR ACTUATED GRP,SUP-2313547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
BIT DRL L DIA2MM PROX P1 ADD ON DISP FOR IM SMRT TOE II SYS,SUP-2367680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.57,205.12,,,,,,,,,,,,,
GRAFT HUM TISS L16SQCM DEHYDR AMNION CHORION MEM MESH,SUP-2305754,CDM,Q4186,HCPCS,0636,RC,,,,both,,,10299.20,6694.48,,,,,,,,,,,,,
HC Adult Cpap Titration Study,PX-9209581100,CDM,95811,CPT,0920,RC,,,,inpatient,,,5739.00,3730.35,,,,,,,,,,,,,
BIT DRL CANN 7.5 MM ACL VERSITOMIC,SUP-2608194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,987.22,641.69,,,,,,,,,,,,,
EXPANDER TISS 19X6.5 CM 17 CM 320-480 CC TEXT SOFTSPAN,SUP-2467554,CDM,C1889,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
CHUCK DRILL 4MM,SUP-2705307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
PLATE BONE LOK 51MML HLX5 STNLSS STEEL NON ST RIGHT STLD RDL,SUP-2721443,CDM,C1713,HCPCS,0278,RC,,,,both,,,2289.81,1488.38,,,,,,,,,,,,,
NOREPINEPHRINE-SODIUM CHLORIDE 4-0.9 MG/250ML-% IV SOLN,RX-135216,CDM,2500000003,HCPCS,0250,RC,81298-9659-01,NDC,,both,250,ML,155.30,100.94,,,,,,,,,,,,,
CATHETER THROMCTMY FREECLIMB 54 L 148 CM REPERFUSION TENZING,SUP-2898950,CDM,C1757,HCPCS,0272,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
WIRE TEMP FIX 48 MM DIAM S STL DBL END SMOOTH DBL SHRP TIP,SUP-2342728,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.12,178.18,,,,,,,,,,,,,
SPACER SPNL 30X8 MM CRESCENT,SUP-2631448,CDM,C1889,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA ZELANTEDVT L 105 CM DIA 8,SUP-2142041,CDM,C1757,HCPCS,0272,RC,,,,both,,,19734.90,12827.68,,,,,,,,,,,,,
ALLOGRAFT BNE PARTICULATE 250-1000 MUM 2 CC CORTICAL PUROS,SUP-2335278,CDM,C1889,HCPCS,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
LEAD NERVE STIM 4 MM SPC 90 CM 3 MM PADDLE OCTRODE,SUP-2356730,CDM,C1778,HCPCS,0278,RC,,,,both,,,7223.13,4695.03,,,,,,,,,,,,,
HC Amputation of Finger/Thumb With Flaps,PX-4502695200,CDM,26952,CPT,0450,RC,,,,both,,,3319.00,2157.35,,,,,,,,,,,,,
PLATE BONE L70MM 4 H STRL RT LAT PROX TIB S STL FOR 3.5MM,SUP-2349725,CDM,C1713,HCPCS,0278,RC,,,,both,,,10934.42,7107.37,,,,,,,,,,,,,
COMPONENT TIB L240MM THK11MM PROX 1 PC NONMODULAR OSS,SUP-2405863,CDM,C1776,CPT,0278,RC,,,,both,,,18821.16,12233.75,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE FEM CUST FRAC SEMI RIGID,SUP-2435651,CDM,L2134,HCPCS,0272,RC,,,,both,,,3262.59,2120.68,,,,,,,,,,,,,
HA CONT ACT RECON RG 46MM LT,SUP-2822562,CDM,C1776,CPT,0278,RC,,,,both,,,6393.04,4155.48,,,,,,,,,,,,,
BUR SURG EGG 2.5 MM FOR RESURF TOOL F1,SUP-2423978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.43,211.53,,,,,,,,,,,,,
SCREW BONE L2MM DIA1MM CORT CRANIOMAXILLOFACIAL TI SELF DRL,SUP-2189045,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.63,238.31,,,,,,,,,,,,,
BIT DRL CONCL 4.5X300 MM FITBONE,SUP-2645849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,850.56,552.86,,,,,,,,,,,,,
ALLOGRAFT BNE STRP LG FD ASEP IL CREST,SUP-2867020,CDM,C1762,CPT,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
GRAFT VASC ALBOGRAFT L 30 CM DIA20 MM POLYESTER STR KNITTED,SUP-2264281,CDM,C1768,CPT,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 1.3CM X 2.5CM,SUP-2874115,CDM,A2007,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Ep Study WO Attempt/Induc Arrh,PX-4819361900,CDM,93619,CPT,0481,RC,,,,both,,,6664.00,4331.60,,,,,,,,,,,,,
ROD SPNL L70MM DIA5.5MM SAG THOR LUM TI CDH,SUP-2289156,CDM,C1713,HCPCS,0278,RC,,,,both,,,3098.24,2013.86,,,,,,,,,,,,,
GRAFT BNE SUB W20XH7XL50MM POSTEROLATERAL STRP,SUP-2138514,CDM,C1713,HCPCS,0278,RC,,,,both,,,9080.28,5902.18,,,,,,,,,,,,,
TUBE VENT ID127MM BLU POLYETH MORETZ,SUP-2313858,CDM,L8699,HCPCS,0278,RC,,,,both,,,33.13,21.53,,,,,,,,,,,,,
COIL NEUROVASCULAR TARGET 360 DEG L 4 CM DIA2 MM STD,SUP-2368017,CDM,C1889,HCPCS,0278,RC,,,,both,,,6271.99,4076.79,,,,,,,,,,,,,
JOURNEY II BCSXLPE ART ISRT SZ 5-6 RT 1,SUP-2340967,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
KIT INTRO ARW THMS DIA 8.5 FR GUIDEWIRE 0.035 IN POLYUR PERC,SUP-2383287,CDM,C1894,HCPCS,0272,RC,,,,both,,,95.36,61.98,,,,,,,,,,,,,
DEVICE TISS SEAL L45CM BPLR CRV TIP ENSEAL TRIO,SUP-2257601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SPACER SPNL STRL TRANSFORAMINAL LUM SHIM HOOP DISP MAS,SUP-2310434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
POST EXT FIX 2 H S STL M SUPP FOR ILIZ TAY SPAT FRME SYS,SUP-2342286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,874.14,568.19,,,,,,,,,,,,,
SCREW BONE L5MM OD1.8MM MAG TI CRANIOMAXILLOFACIAL ST,SUP-2403082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
TROCAR EXT FIX GRN,SUP-2534567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL LNR,SUP-2435547,CDM,L0488,HCPCS,0272,RC,,,,both,,,2842.01,1847.31,,,,,,,,,,,,,
RETRIEVER SNR CATH L 152 CM DIA 3 FR VASC MULTIUSE STRL,SUP-2368064,CDM,C1773,HCPCS,0272,RC,,,,both,,,11209.80,7286.37,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT PORE 500 UM 5 CC CALCIUM PHOSPHATE HA,SUP-2883749,CDM,C1713,HCPCS,0278,RC,,,,both,,,2882.52,1873.64,,,,,,,,,,,,,
TUBE MYR 1.02MM DIAM WHT RED BLK REUT BOB FLROPLAS ST,SUP-2284045,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.20,27.43,,,,,,,,,,,,,
BAG EXT DRNGE ANTIREFLX VLV NDL FREE SAMP SITE HYDROPHOBIC,SUP-2244107,CDM,C1729,HCPCS,0272,RC,,,,both,,,666.59,433.28,,,,,,,,,,,,,
CAP ADDON KNEE CUST GUID PSI,SUP-2212281,CDM,C1776,CPT,0278,RC,,,,both,,,17022.79,11064.81,,,,,,,,,,,,,
HC Iaad Ia Severe Aqt Respir Synd Coronavirus,PX-3068742600,CDM,87426,CPT,0306,RC,,,,outpatient,,,71.00,46.15,,,,,,,,,,,,,
SCREW BONE L6MM THRD DIA2.7MM HD DIA4.5MM COR DIA2MM PITCH,SUP-2349291,CDM,C1713,HCPCS,0278,RC,,,,both,,,215.50,140.07,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN HYDRPHLC STD STR FIX COR,SUP-2302964,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 1.8MM WITH TWO SIZE 2 BLUE AND WHITE/,SUP-2828693,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
STIMULATOR NERVE 2 PRT ACCSRY ADPT,SUP-2423993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER GUID 5FR L100CM ID0.056IN NYL POLYUR S STL BRAID,SUP-2248993,CDM,C1887,HCPCS,0272,RC,,,,both,,,1480.13,962.08,,,,,,,,,,,,,
TUBE VENT W9.8XL12MM DIA1.14MM SIL RICHARD T,SUP-2312833,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.56,45.86,,,,,,,,,,,,,
PLATE BNE S 3 5 DEG 55 MM RT HALLU-LOCK,SUP-2609238,CDM,C1713,HCPCS,0278,RC,,,,both,,,5009.02,3255.86,,,,,,,,,,,,,
COLLAR CERV ADJ BAR FLX THERMOPLASTIC,SUP-2388137,CDM,L0190,HCPCS,0272,RC,,,,both,,,1222.12,794.38,,,,,,,,,,,,,
BIT DRL QC 2X140 MM 60 MM CALIB STRL,SUP-2563748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.78,313.81,,,,,,,,,,,,,
GUIDEWIRE SMOOTH 2.0X150MM,SUP-2720114,CDM,C1769,HCPCS,0272,RC,,,,both,,,129.68,84.29,,,,,,,,,,,,,
PLATE CRAN 140X80X40 MM PT SPEC IMPL PEEK,SUP-2860141,CDM,C1713,HCPCS,0278,RC,,,,both,,,36009.83,23406.39,,,,,,,,,,,,,
PLATE BONE COMPRESSION SMALL 208 MM PELVIC 16 HOLE CONTOURED,SUP-2837527,CDM,C1713,HCPCS,0278,RC,,,,both,,,4583.93,2979.55,,,,,,,,,,,,,
BUTTON GAST 12FR STOMA L1.2CM APPLE SHP BAL DURABLE EXT,SUP-2119862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 500 MG MATRISTEM MICROMATRIX,SUP-2106478,CDM,Q4118,HCPCS,0636,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
CARBAMAZEPINE ER 100 MG PO TB12,RX-27634,CDM,6370000000,HCPCS,0637,RC,16571-0680-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PACEMAKER CARD EDORA HF-T SENTUS TI HSNG EPOXY RESIN HEADER,SUP-2138475,CDM,C2621,HCPCS,0275,RC,,,,both,,,30772.00,20001.80,,,,,,,,,,,,,
SYSTEM ES CUP DIA4CM PNEUMO OCCL BLLN DISP FOR CLIN POS,SUP-2171721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
PLATE BONE 13 HOLE 2X65 MM STATIC ZYDAPTION TITANIUM,SUP-2838390,CDM,C1713,HCPCS,0278,RC,,,,both,,,1316.60,855.79,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 12 MM BLB DIA1.25 MM SIL RUBBER,SUP-2130324,CDM,C1760,HCPCS,0278,RC,,,,both,,,229.66,149.28,,,,,,,,,,,,,
BUR SURG 2 MM ROT,SUP-2140973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
SCREW INTRF L20MM DIA11MM KNEE PLLA RND HD CANN ABSRB,SUP-2166524,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
GRAFT ALLGRFT AMNIO MEMBRN 1.5CMX2CM AMBIODRY,SUP-2247195,CDM,V2790,HCPCS,0274,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PORT ENDO W/ INFL BLB 50MM OMNIPRT,SUP-2383992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
KIT INTRO OD5FR MIC VSI NIT MANDREL S STL SFT TIP L60CM,SUP-2383167,CDM,C1894,HCPCS,0272,RC,,,,both,,,133.45,86.74,,,,,,,,,,,,,
RING EXT FIX DIA155 MM FULL RED NS DISP SMRT TSF,SUP-2932915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4820.03,3133.02,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA4MM THRD L40MM HALF FOR SIDEKCK FREE,SUP-2400696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.2MM NONLOCKING COMPR FOR PLATING SYS,SUP-2321257,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.53,390.34,,,,,,,,,,,,,
LINER ACET OD56MM ID32MM +4MM OFFSET HIP GVF POLYETH TI NEUT,SUP-2250251,CDM,C1776,CPT,0278,RC,,,,both,,,10561.70,6865.10,,,,,,,,,,,,,
CATHETER VENTRICULAR 12X21 MMX23 CM STYL RT ANGLE BA IMPREG,SUP-2277970,CDM,C1729,HCPCS,0272,RC,,,,both,,,346.53,225.24,,,,,,,,,,,,,
PLATE BNE LCK UNIV 2.7X187 MM 16 HOLE CONTOURED 2 COMPR,SUP-2458326,CDM,C1713,HCPCS,0278,RC,,,,both,,,1231.60,800.54,,,,,,,,,,,,,
PLATE BNE DBL Y 1.5X0.6 MM MIDFACE 6 HOLE W/ TAB TI STRL,SUP-2489704,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.26,546.17,,,,,,,,,,,,,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,2500000003,HCPCS,0250,RC,70100-0424-01,NDC,,both,1,UN,556.80,361.92,,,,,,,,,,,,,
DISC BNE SCREW DIA 4.5 MM NIT DYN REFLX,SUP-2897520,CDM,C1713,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM 15 CM BALL FOR MA-15 BEAR SL,SUP-2848284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.68,356.64,,,,,,,,,,,,,
CATHETER CV DL 5 FRX45 CM SHERLOCK STYL GROSH NXT,SUP-2126722,CDM,C1751,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|ADJ|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4409753000,CDM,97530,CPT,0440,RC,,,ADJ|CQ,both,,,191.00,124.15,,,,,,,,,,,,,
PLATE BNE MESHED 123X123X0.8 MM SM GRID PDLLA STRL RESORB X,SUP-2480844,CDM,C1713,HCPCS,0278,RC,,,,both,,,8861.24,5759.81,,,,,,,,,,,,,
GRAFT BONE L15XW12XH8MM 5DEG UNIV PEEK TI COMP SPCR ANTR,SUP-2317061,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
ENDPLATE SPNL FUSION WNG ANGLE 60 DEG L 12 MM HA COAT MIS,SUP-2912001,CDM,C1713,HCPCS,0278,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
PIN HALF THRD 5X180 MM,SUP-2197301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
IMPL EXPANDER SMOOTH W/FILL SYSTEM 200CC,SUP-2423832,CDM,C1789,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW INTFR L25MM DIA8MM CANN W/ DISP SHTH,SUP-2121170,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV,SUP-2435690,CDM,L2650,HCPCS,0272,RC,,,,both,,,391.78,254.66,,,,,,,,,,,,,
GRAFT BNE SPNG 14X14X14 MM BLOCK CANC DBM,SUP-2354411,CDM,C1713,HCPCS,0278,RC,,,,both,,,6210.92,4037.10,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENESTRATED ADULT 10.6MM UNCUFFED ADAPTER,SUP-2793423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.76,264.39,,,,,,,,,,,,,
DEFIBRILLATOR CRD 69X51X12 MM 31 CC 71 GM SYS DF4 GALLANT DR,SUP-2876021,CDM,C1721,HCPCS,0275,RC,,,,both,,,55245.16,35909.35,,,,,,,,,,,,,
SHEATH TRANSSEPTAL 90 DEG L 63 CM DIA 8.5 FR SS BRAIDED NYL,SUP-2913238,CDM,C1893,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SPLINT ORTH 3 1 2 4 1 4 M L L WRST THMB LTWT SFT INNR LINING,SUP-2194733,CDM,L3931,HCPCS,0274,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
SYSTEM DEFIB VR-T LUMAX 300,SUP-2138116,CDM,C1722,HCPCS,0275,RC,,,,both,,,56303.34,36597.17,,,,,,,,,,,,,
PLATE BONE SM LT EPIPHYSIS OBLQ,SUP-2198586,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
DRILL F. 6+7MM SCR DENT SHFT,SUP-2366420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,478.44,310.99,,,,,,,,,,,,,
SYSTEM CARD DEFIB ATLS II VR,SUP-2356519,CDM,C1722,HCPCS,0275,RC,,,,both,,,68766.00,44697.90,,,,,,,,,,,,,
HC Hemoglobin F Fetal Qualitative,PX-3018303300,CDM,83033,CPT,0301,RC,,,,both,,,269.00,174.85,,,,,,,,,,,,,
SCREW BNE L 70 MM DIA 7.3 MM THRD L 20 MM TI CANN NS,SUP-2912941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
PLATE BNE W8XL48MM THK3.3MM 6 H NONSTERILE BILAT PELV S STL,SUP-2186231,CDM,C1713,HCPCS,0278,RC,,,,both,,,1515.49,985.07,,,,,,,,,,,,,
CLAMP SURG DIA20MM TI CRAN CRANIOFIX 2,SUP-2108415,CDM,C1713,HCPCS,0278,RC,,,,both,,,583.88,379.52,,,,,,,,,,,,,
SYSTEM SFT TISS FIX PEEK ACHILLES JUMPSTART SPEEDBRIDGE,SUP-2122835,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
HC Njx Aa&/Strd Ntrcost Nrv 1,PX-3616442000,CDM,64420,CPT,0361,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
POST FIX 4 H M,SUP-2197282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
COMPONENT PART SHLDR,SUP-2212641,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
BUNDLE GRFT ENDURANT II NIT POLYESTER 3 PC HELI-FX,SUP-2873747,CDM,C1768,CPT,0278,RC,,,,both,,,75360.00,48984.00,,,,,,,,,,,,,
DEVICE PESSARY RNG W/ SUPP FLD 3IN,SUP-2171843,CDM,A4562,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SPACER HUM +8MM MONOBLOCK W RET SCR RSP,SUP-2217386,CDM,C1776,CPT,0278,RC,,,,both,,,4252.69,2764.25,,,,,,,,,,,,,
HYDROXYZINE HCL 10 MG PO TABS,RX-3772,CDM,6370000000,HCPCS,0637,RC,60687-0664-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE 3.5X90 MM PERI ARTC,SUP-2402643,CDM,C1713,HCPCS,0278,RC,,,,both,,,104.50,67.92,,,,,,,,,,,,,
INTRODUCER DIAG SAFECROSS TRANSSEPTAL SM CRV RF PUNC STEER,SUP-2866239,CDM,C1893,HCPCS,0272,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
CATHETER EP A 5-5-5-175-175 MM 5 FRX120 CM,SUP-2356899,CDM,C1730,HCPCS,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
NAIL IM L420MM DIA12MM 130DEG NONSTERILE GRN HIP TI CANN,SUP-2192643,CDM,C1713,HCPCS,0278,RC,,,,both,,,4217.65,2741.47,,,,,,,,,,,,,
GUIDEWIRE ORTH L 450 MM DIA 3.2 MM SMTH W/O THRD STRL ASNS,SUP-2902286,CDM,C1769,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE L53MM 0DEG 7 H NONSTERILE R 1ST MTP FUS TI VAR ANG,SUP-2181237,CDM,C1713,HCPCS,0278,RC,,,,both,,,4460.09,2899.06,,,,,,,,,,,,,
SCREW BNE 2X15 MM 10 MM HEX X DRV DRILL-FREE TI LEVEL 1,SUP-2460275,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.63,235.06,,,,,,,,,,,,,
CABLE SURG L750MM DIA1MM S STL SMOOTH W/ CRMP,SUP-2187028,CDM,C1776,CPT,0278,RC,,,,both,,,1334.94,867.71,,,,,,,,,,,,,
ALLOGRAFT BNE CRUNCH 15 CC FD DBM GRFT,SUP-2787766,CDM,C1713,HCPCS,0278,RC,,,,both,,,5066.70,3293.35,,,,,,,,,,,,,
HC Pacer Upgrade,PX-4813321400,CDM,33214,CPT,0481,RC,,,,both,,,36553.00,23759.45,,,,,,,,,,,,,
PENTAMIDINE ISETHIONATE 300 MG IN SOLR,RX-28235,CDM,J2545,HCPCS,0636,RC,13925-0522-01,NDC,,both,1,UN,830.90,540.08,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 2 CM DIA 2MM 0.018IN PLAT HYDRGEL,SUP-2384875,CDM,C1889,HCPCS,0278,RC,,,,both,,,2661.15,1729.75,,,,,,,,,,,,,
ALLOGRAFT DRML LG THICK CNTR PRFRTD READY USE ALLDRM,SUP-2466700,CDM,Q4116,HCPCS,0636,RC,,,,both,,,17769.26,11550.02,,,,,,,,,,,,,
DEVICE COAG GUIDED EPI-SENSE ST W/ 30MM CANNULA,SUP-2858422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,42390.00,27553.50,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL METATRSL CUST LIFT ELEVATION PER INCH,SUP-2435716,CDM,L3300,HCPCS,0272,RC,,,,both,,,147.64,95.97,,,,,,,,,,,,,
CONNECTOR SPNL TI POST THOR LUM ADJ LAT CONN CLS SIDELOAD,SUP-2289155,CDM,C1713,HCPCS,0278,RC,,,,both,,,3583.18,2329.07,,,,,,,,,,,,,
COMPONENT FEM SZ 4 R REV POST STBL GMK,SUP-2267610,CDM,C1776,CPT,0278,RC,,,,both,,,8116.90,5275.98,,,,,,,,,,,,,
SPLINT WR L AD W3.5-4IN BGE LT FAB GEL CRPL TUNN REG INSRT,SUP-2324880,CDM,L3809,HCPCS,0272,RC,,,,both,,,48.54,31.55,,,,,,,,,,,,,
GRAFT BNE SUB 90CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264828,CDM,C1713,HCPCS,0278,RC,,,,both,,,3089.10,2007.91,,,,,,,,,,,,,
BLADE SAW OSC STRL 25.4MM CUT EDGE 85MM CUT DEPTH 1.35MM CUT,SUP-2408659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
PROSTHESIS PENILE L14CM W/ GIRTH EXP PS INHIBZN INFL,SUP-2138995,CDM,C1813,HCPCS,0278,RC,,,,both,,,30026.25,19517.06,,,,,,,,,,,,,
OXYCODONE-ACETAMINOPHEN 10-325 MG PO TABS,RX-31864,CDM,6370000000,HCPCS,0637,RC,00406-0523-62,NDC,,both,1,UN,11.90,7.73,,,,,,,,,,,,,
SCREW BONE SM L40MM DIA3MM CANN HDLSS COMPR QFX,SUP-2343147,CDM,C1713,HCPCS,0278,RC,,,,both,,,1985.86,1290.81,,,,,,,,,,,,,
HC Cysto Bladder W/Ureteral Catheterization,PX-4505200500,CDM,52005,CPT,0450,RC,,,,both,,,2099.00,1364.35,,,,,,,,,,,,,
PLATE BNE L 177 MM SCREW DIA2.7 MM 20 SHFT H TI ADPT COMB,SUP-2907581,CDM,C1713,HCPCS,0278,RC,,,,both,,,4487.22,2916.69,,,,,,,,,,,,,
PLATE BONE 9 H RT BOARDER SCAPULA,SUP-2107834,CDM,C1713,HCPCS,0278,RC,,,,both,,,5419.64,3522.77,,,,,,,,,,,,,
PROTECTOR ENDOSCP TIP FLX XL 10.7-17.9 MM DSTL STRL DISP,SUP-2865658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9.23,6.00,,,,,,,,,,,,,
ALLOGRAFT BNE RNG 20 CM FD TISS FEM,SUP-2165580,CDM,C1889,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
KIT CEM 12ML 33GM GLS IONOMER CEM LUTING RADPQ,SUP-2238633,CDM,C1713,HCPCS,0278,RC,,,,both,,,617.92,401.65,,,,,,,,,,,,,
SHELL ACET TOT HIP PRI PRESSFIT COCR ALLOY CLUS H UNIV 48MM,SUP-2364616,CDM,C1776,CPT,0278,RC,,,,both,,,3756.07,2441.45,,,,,,,,,,,,,
SCREW BNE CANN MED THRD 7X46 MM HDLSS NS MONSTER,SUP-2742679,CDM,C1713,HCPCS,0278,RC,,,,both,,,2155.14,1400.84,,,,,,,,,,,,,
HC So Hhv-6 Dna Quant,PX-3068753366,CDM,87533,CPT,0306,RC,,,,outpatient,,,268.00,174.20,,,,,,,,,,,,,
SCREW SPNL L50MM DIA6MM CORT PEDCL TI ST FIX ANG CANN FOR,SUP-2254921,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GRAFT BNE FIBER 1 CC OSTEOAMP SEL,SUP-2424597,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 3 MM 9 CM MTCH HD MIDAS REX LEGEND,SUP-2631879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,380.35,247.23,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|KX|CQ|XU,both,,,144.00,93.60,,,,,,,,,,,,,
HC Lumbar Myelogram S&I,PX-3207226500,CDM,72265,CPT,0320,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
COLLAR SPNL TI SM STAT FOR VAR AXIS SCR USS,SUP-2193308,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT HUM TISS L100MM FRZN SHFT HUM STRUCTURAL ALLGRFT,SUP-2307375,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.61,1775.55,,,,,,,,,,,,,
CATHETER BAL DBL LUMN,SUP-2169611,CDM,C1726,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COLLAR CERV AD H25XL19IN FIRM DENS CNTOUR HK AND LOOP CLSR,SUP-2276595,CDM,L0120,HCPCS,0272,RC,,,,both,,,8.04,5.23,,,,,,,,,,,,,
KIT CARD POS 0035IN W NDL SYR CPS,SUP-2357315,CDM,C1769,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
ENVELOPE DEFIB BIOENVELOPE 2XL FIVE PK STRL,SUP-2138486,CDM,C1713,HCPCS,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
COUPLING REPROC EXT FIX ROD TO ROD STR4941-1-010,SUP-2516728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.02,211.26,,,,,,,,,,,,,
GRAFT DURA L 2 X W 2 IN TYP I CLLGN BOV ACHILLES TEND RESRB,SUP-2889749,CDM,C1763,HCPCS,0278,RC,,,,both,,,1478.03,960.72,,,,,,,,,,,,,
ORTHOPEDIC KIT GLENOSPHERE 38 MM EXT LCK CAP,SUP-2451417,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
LINER ACET ECC POLYETH 26MMX46MM 10DEG,SUP-2379025,CDM,C1776,CPT,0278,RC,,,,both,,,4753.96,3090.07,,,,,,,,,,,,,
CATHETER THROMCTMY CLOTTRIEVER L 115 CM DIA11 FR COR ELEMENT,SUP-2740186,CDM,C1757,HCPCS,0272,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
TI MACHINE SCREW,SUP-2827975,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.43,262.88,,,,,,,,,,,,,
GRAFT HUM TISS WHL PAT LIGMNT W/ QUAD EXTENSOR MECHANISM,SUP-2264795,CDM,C1762,CPT,0278,RC,,,,both,,,14839.80,9645.87,,,,,,,,,,,,,
MEROPENEM-VABORBACTAM 2 (1-1) G IV SOLR,RX-139607,CDM,J2186,HCPCS,0636,RC,70842-0120-06,NDC,,both,1,UN,1279.40,831.61,,,,,,,,,,,,,
GUIDE WIRE BALL TIP 2.7/3.75MM X800MM,SUP-2750033,CDM,C1769,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC Indwelling Catheter,PX-4505170200,CDM,51702,CPT,0450,RC,,,,outpatient,,,204.00,132.60,,,,,,,,,,,,,
DEVICE EMBOLIC PROTCT FLTR L4MM GWIRE L320/190CM DIA0.014IN,SUP-2173561,CDM,C1884,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
HARD BONE ACCESS NEEDLE WITH DRILL 11 G 6.5 CM,SUP-2462215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BNE W17.5XL196MM THK5.2MM 11 H TI BROAD LIMIT CNTCT,SUP-2190850,CDM,C1713,HCPCS,0278,RC,,,,both,,,1101.64,716.07,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM TIP 4MM 2-5-2MM SPC 4 ELECTRD D,SUP-2248806,CDM,C1733,HCPCS,0272,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL 110-240X20 MM FRZN STRUT,SUP-2717910,CDM,C1762,CPT,0278,RC,,,,both,,,4699.26,3054.52,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00338-0017-31,NDC,,both,250,ML,108.40,70.46,,,,,,,,,,,,,
NEPHROSTOMY SET 0.038 IN 12 FRX35 CM LCK ALL PURP SKATER,SUP-2269627,CDM,C1729,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
KIT MICROINTRODUCER COAX STD NIT TUNGSTEN 0.018IN GWIRE,SUP-2118826,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
PIN GUIDE 2.4X230 MM,SUP-2391523,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.13,243.18,,,,,,,,,,,,,
CATHETER PTCA BLLN DIL COR SNUS LV LD PLCMNT ATTAIN PERIPH,SUP-2282150,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MESH SURG H16MM DIA12MM SPNL TI SGL LEV RND,SUP-2254375,CDM,C1781,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE MESH SCREEN 1.3X20X30X0.2 MM TITANIUM,SUP-2838349,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.73,481.47,,,,,,,,,,,,,
BLADE SAW SAG 5.5MMW X25.5MML 0.6MM/0.6MM THK CUT SM BNE HAL,SUP-2605395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,137.53,89.39,,,,,,,,,,,,,
TUBE VENT JAHN 1X9.5 MM BIOCOMPATIBLE DENS LT HA,SUP-2637886,CDM,L8699,HCPCS,0278,RC,,,,both,,,571.92,371.75,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0258,RC,00409-7101-67,NDC,,both,100,ML,37.40,24.31,,,,,,,,,,,,,
BRONCHOSCOPE EXALT MODEL B REGULAR,SUP-2855172,CDM,C1601,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
COMPONENT FEM CEM C MACR LT KNEE,SUP-2201885,CDM,C1776,CPT,0278,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
MARKER FIDUCIAL VISICOIL 20CM,SUP-2844757,CDM,A4648,CPT,0278,RC,,,,both,,,536.59,348.78,,,,,,,,,,,,,
BIT DRL CANN SHT 2.5 MM,SUP-2693944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
ANASTROZOLE 1 MG PO TABS,RX-16205,CDM,6370000000,HCPCS,0637,RC,16729-0035-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PIN FIX DIA28MM LNG QUIK REL FOR CONG EL PLATING SYS STNMN,SUP-2107730,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PIN FIX BUTTRESS 10X24 MM SFC COMBINATION,SUP-2389690,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PLATE BONE WITHOUT ANGLE THICK 2 MM MANDIBLE PATIENT SPECIFI,SUP-2838606,CDM,C1713,HCPCS,0278,RC,,,,both,,,16463.02,10700.96,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.018 IN SS SAFE-T-J STR FIX COR,SUP-2760105,CDM,C1769,HCPCS,0272,RC,,,,both,,,65.85,42.80,,,,,,,,,,,,,
PLATE BNE DBL T MINI 2X1 MM CRANIOMAXILLOFACIAL 8 HOLE TI NS,SUP-2493421,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
CATHETER HD AG 15 FRX19 CM CHRONIC ARROW-CLARK VECTORFLOW,SUP-2627049,CDM,C1750,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
IMMUNE GLOBULIN (PRIVIGEN) 10%,RX-4081762,CDM,J1459,HCPCS,0636,RC,44206-0438-20,NDC,,both,200,ML,11319.80,7357.87,,,,,,,,,,,,,
TOE IMPL INSRTN KT GREAT SIZE: 0 TO 4 CONTENTS: TI IMPL,SUP-2397201,CDM,C1776,CPT,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
K WIRE FIX L110MM DIA2.8MM FOR PHLANG PROS ANATOEMIC,SUP-2123380,CDM,C1776,CPT,0278,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
HEAD FEM DIA32MM NK L+0MM ALUMINA CERAMIC 12/14 TAPR,SUP-2344800,CDM,C1776,CPT,0278,RC,,,,both,,,4980.04,3237.03,,,,,,,,,,,,,
HC So Sickling of RBC,PX-3058566066,CDM,85660,CPT,0305,RC,,,,both,,,55.00,35.75,,,,,,,,,,,,,
GRAFT PERICARD PROC TUTOPLAST 2X7CM,SUP-2300762,CDM,C1762,CPT,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
PLATE BNE THK0.6MM 1 H BILAT HND COMPR 2 HK APTUS,SUP-2267902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1395.10,906.81,,,,,,,,,,,,,
GRAFT HUMAN TISSUE BIOLOGICAL TISSUE MATRIX THICK 40X30 CM NON CROSSLINKED SCAFFOLD NATURALLY OCCURRING PORCINE STERILE GENTRIX DISPOSABLE,SUP-2106506,CDM,Q4166,HCPCS,0636,RC,,,,both,,,102018.60,66312.09,,,,,,,,,,,,,
BIT DRL TWST 1.5X13 MM ANGULUS 2,SUP-2465286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.59,487.88,,,,,,,,,,,,,
CATHETER PTCA L150CM BLLN L100MM DIA2MM GWIRE 0.018IN SHTH,SUP-2145374,CDM,C1725,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE L386MM 18 H ST R CNDYL S STL LOK COMPR CRV FOR,SUP-2177092,CDM,C1713,HCPCS,0278,RC,,,,both,,,5398.92,3509.30,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP CANC 800107,SUP-2743332,CDM,C1713,HCPCS,0278,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
SIZER SURG GEL BRST RND ULTRA HI RESTERILIZABLE MEMORYSHAPE,SUP-2748639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
BUTTON SEPT SILIC1 1 PC STYL,SUP-2313941,CDM,C1889,HCPCS,0278,RC,,,,both,,,250.54,162.85,,,,,,,,,,,,,
HEAD HUM STD OFFSET 40X15 MM SHLDR PRIMARY NECKLESS COCR,SUP-2249977,CDM,C1776,CPT,0278,RC,,,,both,,,4909.70,3191.30,,,,,,,,,,,,,
BLADE RTRCTR RVL 60MMW X 70MML TTNM LMBR 15DG ANGLD TTHD ULT,SUP-2477388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,557.66,362.48,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA10 FR HYDRPHLC,SUP-2120623,CDM,C1894,HCPCS,0272,RC,,,,both,,,481.68,313.09,,,,,,,,,,,,,
GRAFT VASC GELSFT ERS L 100 CM SUPP L 85 CM DIA 8 MM,SUP-2384973,CDM,C1768,CPT,0278,RC,,,,both,,,2424.83,1576.14,,,,,,,,,,,,,
EXTENSION STEM XSM L80MM KNEE CO CHROM CEM MOD MONOGRAM,SUP-2376293,CDM,C1776,CPT,0278,RC,,,,both,,,1972.27,1281.98,,,,,,,,,,,,,
CANNULA INJ LL 3.5 MM FOR POS PRESSURE ASST VENT SYS LF,SUP-2772363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.17,240.61,,,,,,,,,,,,,
PLATE BNE 2X2 H PHLANG RECTANG GRID TI FOR 1.5MM SCR H,SUP-2267907,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.47,1008.46,,,,,,,,,,,,,
HC Biopsy Soft Tissue Neck/T,PX-3612155000,CDM,21550,CPT,0361,RC,,,,outpatient,,,5012.00,3257.80,,,,,,,,,,,,,
HC So Ceruloplasmin,PX-3018239066,CDM,82390,CPT,0301,RC,,,,both,,,114.00,74.10,,,,,,,,,,,,,
BLADE SAW L 65 X W 7.5 MM D 4 MM THK MATERIAL 0.3 MM CUT 0.4,SUP-2929048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.27,389.53,,,,,,,,,,,,,
REAMER SURG DIA 4.2 MM CANN AO QC STRL DISP FLEX-THREAD,SUP-2900375,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
MOST FEMORAL SEGMENT 42.5MM,SUP-2509220,CDM,C1776,CPT,0278,RC,,,,both,,,7276.95,4730.02,,,,,,,,,,,,,
IMPLANT IM L 130 MM DIA 9.5 MM BODY DIA 8 MM SS THRD ST,SUP-2905261,CDM,C1713,HCPCS,0278,RC,,,,both,,,9922.40,6449.56,,,,,,,,,,,,,
GRAFT HUM TISS W14 18XL25MM FRZ DRY ALLGRFT FIB SHFT BNE,SUP-2307189,CDM,C1713,HCPCS,0278,RC,,,,both,,,1707.91,1110.14,,,,,,,,,,,,,
PROSTHESIS PENILE INFLATABLE 11 MMX16 CM AMS AMBICOR,SUP-2140273,CDM,C1813,HCPCS,0278,RC,,,,both,,,13737.50,8929.37,,,,,,,,,,,,,
LEAD DEFIB PERM TRNSVEN LD PACE BPLR PASS FIX IS 1 CONN 53CM,SUP-2137969,CDM,C1898,HCPCS,0275,RC,,,,both,,,1986.80,1291.42,,,,,,,,,,,,,
SET HAD CATHETER 125FR L32CM W INJ CAP SCALP SHTH NDL GWIRE,SUP-2267083,CDM,C1750,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
MESH CRAN KASSAM LG 0.3 MM SCRN PANEL NEURO SCREW CP TI,SUP-2494905,CDM,C1713,HCPCS,0278,RC,,,,both,,,829.18,538.97,,,,,,,,,,,,,
STENT PERIPH ZILVER 635 L 40 MM DIA10 MM DEL SYS L 125 CM,SUP-2171396,CDM,C1876,HCPCS,0278,RC,,,,both,,,1972.83,1282.34,,,,,,,,,,,,,
TI MATRIXMANDIBLE 3X3H,SUP-2823271,CDM,C1713,HCPCS,0278,RC,,,,both,,,1885.88,1225.82,,,,,,,,,,,,,
CATHETER ETER NEPHSTMY 14FR L35CM INCL C FLX RE ENTRY MCOT C,SUP-2436250,CDM,C1729,HCPCS,0272,RC,,,,both,,,231.73,150.62,,,,,,,,,,,,,
SET URET STENT SOFFLX L 14 CM DIA 6 FR POS L 46 CM DIA 7 FR,SUP-2168899,CDM,C2617,HCPCS,0278,RC,,,,both,,,468.24,304.36,,,,,,,,,,,,,
MARKER RAD 0.9X3MM SFT TISS GLD PRELOAD,SUP-2418127,CDM,A4648,CPT,0278,RC,,,,both,,,171.66,111.58,,,,,,,,,,,,,
WAND ABLAT 50DEG DIA3MM RAD FREQ SUCT,SUP-2341996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 100 MM FRZN,SUP-2294144,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W4XL12CM THK1.04 2.28MM THICK RGNRTVE TSSU,SUP-2480659,CDM,Q4116,HCPCS,0636,RC,,,,both,,,4920.38,3198.25,,,,,,,,,,,,,
PESSARY UTER DSH 3 65 MM SFT PLIABLE W/O SUPP SIL WHT LF,SUP-2794444,CDM,A4562,HCPCS,0274,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
STEM FEM SZ 7 L250MM OD12.4MM NK L30MM R HIP CEM LNG BODY,SUP-2374732,CDM,C1776,CPT,0278,RC,,,,both,,,12356.53,8031.74,,,,,,,,,,,,,
MATRIX HUM TISS L 8 X W 12 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909333,CDM,Q4122,HCPCS,0636,RC,,,,both,,,23228.18,15098.32,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 9 HOLES,SUP-2549472,CDM,C1713,HCPCS,0278,RC,,,,both,,,2246.61,1460.30,,,,,,,,,,,,,
PIN DISTRACTOR 14 MM TI NS,SUP-2591705,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
TUBE ABLATN SHT 1.1 MM SET W/ PRECIS TIP SONASTAR,SUP-2539638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 90 CM DIA 5 FR SLT PAT 5 CM,SUP-2118474,CDM,C1751,HCPCS,0278,RC,,,,both,,,356.70,231.85,,,,,,,,,,,,,
KIT INFUS PRT DIA7FR SIL PLAS 2 LUMN L SEPT PEEL APART,SUP-2127757,CDM,C1788,HCPCS,0278,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA PLU 4FR 20CM 2 LUMAN RVS S4254108BP,SUP-2632866,CDM,C1751,HCPCS,0278,RC,,,,both,,,609.38,396.10,,,,,,,,,,,,,
COLLAR CERV 4 MONTH-10YR CH FOR TORTICOLLIS TREAT TOT,SUP-2324278,CDM,L0180,HCPCS,0274,RC,,,,both,,,131.06,85.19,,,,,,,,,,,,,
SET ORTH SM/L 0-1DEG PRO-TOE VO,SUP-2397813,CDM,C1776,CPT,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
STEM HUMERAL L SHOULDER MODULAR PMMA GENTAMICIN BASE,SUP-2718070,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BUR SURG TOT L 82 MM CUT L 30 MM DIA 3 MM SHANNON-STYLE STR AO,SUP-2881148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,728.64,473.62,,,,,,,,,,,,,
TUBING SUCT L520MM ASSEMB DISP FOR RMR IRRIG ASPIR DRV SHFT,SUP-2187573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2992.11,1944.87,,,,,,,,,,,,,
PROBE NSL 20 DEG W/ SMK EVAC,SUP-2713685,CDM,2720000010,LOCAL,0272,RC,,,,both,,,749.99,487.49,,,,,,,,,,,,,
SHEATH INTRO PINNACLE PRECIS ACCS SYS L 10 CM DIA 4 FR NIT,SUP-2385474,CDM,C1894,HCPCS,0272,RC,,,,both,,,194.24,126.26,,,,,,,,,,,,,
SET CATH 5FR 200CM GWIRE .018IN 1MM MRK WIRE GUID BILI,SUP-2169240,CDM,C1713,HCPCS,0278,RC,,,,both,,,748.73,486.67,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN (MINI-BAG),RX-40850048,CDM,2580000003,HCPCS,0250,RC,00338-0551-11,NDC,,both,50,ML,56.60,36.79,,,,,,,,,,,,,
GRAFT BNE MED 5 CC DBM STRND +,SUP-2641768,CDM,C1713,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
DEVICE FIX OVL HD RAP DEL SYS STRL DISP SURTAC III,SUP-2341627,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.27,593.63,,,,,,,,,,,,,
SHAFT RMR L470MM DIA5MM FLX,SUP-2188123,CDM,C1776,CPT,0278,RC,,,,both,,,7075.74,4599.23,,,,,,,,,,,,,
GUIDE SURG PLN NYL LP CUSTOMIZABLE JAW IN A DAY RECON VSP,SUP-2883954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,31321.50,20358.97,,,,,,,,,,,,,
RETRACTOR LAP 2XL SHTH L36CM INCIS RANG 17-25CM WND PROTCT,SUP-2119634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
MATRIX BIO L 9.4 X W 7.9 IN SZ 480 SQCM PORCINE TEND DERIVED,SUP-2909328,CDM,A2008,HCPCS,0636,RC,,,,both,,,24617.60,16001.44,,,,,,,,,,,,,
CUBE EXT FIX 1 HOLE SS,SUP-2162665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
HC Thrombolytic Art Therapy,PX-3613721100,CDM,37211,CPT,0361,RC,,,,both,,,16763.00,10895.95,,,,,,,,,,,,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-15981,CDM,J1250,HCPCS,0636,RC,00409-2346-32,NDC,,both,250,ML,126.50,82.22,,,,,,,,,,,,,
GRAFT BIOLOGICAL MESH TISSUE TEMPLATE 4IN X 5IN SHEET 2-LAYER REGENERATIVE COLLAGEN DERMAL MATRIX SILICONE DOMESTIC,SUP-2243491,CDM,Q4105,HCPCS,0636,RC,,,,both,,,20935.32,13607.96,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CELLULAR DBM VIVIGEN,SUP-2264615,CDM,C1713,HCPCS,0278,RC,,,,both,,,13683.34,8894.17,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 10 CM DIA 6 MM EPTFE STR STD WALL,SUP-2227639,CDM,C1768,CPT,0278,RC,,,,both,,,371.56,241.51,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0258,RC,00264-1510-32,NDC,,both,100,ML,21.30,13.84,,,,,,,,,,,,,
HC Intro Long Gastro Tube - 15202,PX-3614450000,CDM,44500,CPT,0361,RC,,,,both,,,2461.00,1599.65,,,,,,,,,,,,,
KIT NOVASURE V5 THERMOABLATION DEVICE,SUP-2718088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4141.66,2692.08,,,,,,,,,,,,,
CLAMP REPROC PIN ROD HII MRI 4TO5X8MM,SUP-2700533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.91,306.74,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 0.018 IN 130 CM 6X300 MM LUTONIX,SUP-2431946,CDM,C1725,HCPCS,0272,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
ALLOGRAFT PLACENTAL MATRIX 4CM X 6CM AMNIOBAND,SUP-2877946,CDM,C1762,CPT,0278,RC,,,,both,,,8049.20,5231.98,,,,,,,,,,,,,
TUBE VENT INTERFLNG DISTANCE 117MM FLNG OD450X272MM LUMN,SUP-2232493,CDM,L8699,HCPCS,0278,RC,,,,both,,,68.70,44.65,,,,,,,,,,,,,
PLATE PROX LATERAL TIB 3.5 RT 9H,SUP-2854931,CDM,C1713,HCPCS,0278,RC,,,,both,,,7186.77,4671.40,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP BONE-PATELLAR TENDON-BONE,SUP-2867144,CDM,C1762,CPT,0278,RC,,,,both,,,9187.64,5971.97,,,,,,,,,,,,,
HC Inj/Asp Maj Jnt or Bursa|BILATERAL PROCEDURE|PO,PX-7612061000,CDM,20610,CPT,0761,RC,,,50|PO,both,,,1092.00,709.80,,,,,,,,,,,,,
CATHETER DRAINAGE OTW 40 CM 6 MMX2 CM GLDEX,SUP-2140997,CDM,C1725,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SIROLIMUS 1 MG/ML PO SOLN,RX-26336,CDM,J7520,HCPCS,0637,RC,60505-6197-02,NDC,,both,2,ML,157.90,102.63,,,,,,,,,,,,,
CANNULA ORTH L 110 MM DIA11 GA ACCESS/DELIVERY OPN TIP,SUP-2893108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
KIT CHOLGM PROC L13CM OD10FR SAFE SHTH W/ SIDE PRT AND,SUP-2148972,CDM,C1894,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
NAIL-EX FEM RECON 14X300MM RT PRFMIS FOSSA STRL,SUP-2546539,CDM,C1713,HCPCS,0278,RC,,,,both,,,6138.51,3990.03,,,,,,,,,,,,,
SLEEVE CONN ID5.5MM SLV TI STRL ADJ TRNSVRS SET SCR ST360,SUP-2205136,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM DIA24 MM POLYESTER BOV CLLGN,SUP-2499321,CDM,C1768,CPT,0278,RC,,,,both,,,2009.44,1306.14,,,,,,,,,,,,,
GRAFT HUM TISS 3.5X3.5CM ALLGRFT MEMBRN AMNIO AMNIOEXC,SUP-2194320,CDM,Q4137,HCPCS,0636,RC,,,,both,,,3000.27,1950.18,,,,,,,,,,,,,
CENTRALIZER STEM 15 MM POST HIP SPECTRN EF COBRA,SUP-2434606,CDM,C1776,CPT,0278,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
HC Inj Anes/Steroid L/S Facet Sg|BILATERAL PROCEDURE,PX-3616449300,CDM,64493,CPT,0361,RC,,,50,both,,,4864.00,3161.60,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min,PX-4409753000,CDM,97530,CPT,0440,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
IMPLANT ANK SZ 1 TOT FIX BEAR VANTAGE,SUP-2223473,CDM,C1776,CPT,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
BIT DRL TWST 4X260 MM 3 FLUT QC SLD REPL SS NS,SUP-2607937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.06,233.39,,,,,,,,,,,,,
PROBE NERVE STIMULATOR BIPOLAR FLEXIBLE TIP INSULATED STERILE SINGLE-USE,SUP-2887763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.81,352.18,,,,,,,,,,,,,
CAP HEALING 20MM W/ PLUG BAHA,SUP-2164966,CDM,L8614,HCPCS,0278,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
INSERTER SURG STR IN SCP HANDLE.,SUP-2140251,CDM,C2631,HCPCS,0278,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
EXTENSION NEUROSTIMULATOR L30CM SGL 8 3383] ST JUDE MEDICAL INC],SUP-2356742,CDM,C1883,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
BIT DRL CANN 90-120 MM 85-100 MM FT SCREW YEL ACUTRK 6/7,SUP-2107242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2964.16,1926.70,,,,,,,,,,,,,
MESH BIO POST TRANSOBTURATOR PORCINE CLLGN MTRX TENS SUT,SUP-2140309,CDM,C1771,HCPCS,0278,RC,,,,both,,,5951.09,3868.21,,,,,,,,,,,,,
OCCLUDER CV HELEX L 75 CM DIA15 MM NIT EPTFE HYDRPHLC DBL,SUP-2395827,CDM,C1817,HCPCS,0278,RC,,,,both,,,19530.80,12695.02,,,,,,,,,,,,,
CLAMP REPROC ADJUSTABLE WIRE/PIN CLAMP REPROC HYBRID FIXATOR,SUP-2464999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,479.82,311.88,,,,,,,,,,,,,
CATHETER HD MAXIMAL BARR TY 035 12 FRX15 CM DL TURBO-FLO HD,SUP-2759842,CDM,C1752,HCPCS,0278,RC,,,,both,,,522.31,339.50,,,,,,,,,,,,,
CATHETER URET 10FR L54CM 2 TORQUEABLE,SUP-2139305,CDM,C1758,HCPCS,0278,RC,,,,both,,,234.12,152.18,,,,,,,,,,,,,
ROD SPNL L72-220MM DIA3.5-6.35MM POST OCCIPITOCERVICAL TI,SUP-2176891,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SPLINT EL M,SUP-2276616,CDM,L3702,HCPCS,0272,RC,,,,both,,,29.01,18.86,,,,,,,,,,,,,
PLATE BONE 6 H TI STR FOR CRAN CLSR SYS,SUP-2243971,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.99,130.64,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG 1.14 MM ID SIL STRL BLU,SUP-2381503,CDM,L8699,HCPCS,0278,RC,,,,both,,,145.07,94.30,,,,,,,,,,,,,
PLATE BONE L THK0.3MM MULT H ORBIT FLR TI MESH PREFRM FOR,SUP-2135900,CDM,C1713,HCPCS,0278,RC,,,,both,,,2285.92,1485.85,,,,,,,,,,,,,
PIN FIX L4MM DIA21MM RESORB X SONICPINS RX,SUP-2263018,CDM,C1713,HCPCS,0278,RC,,,,both,,,5082.88,3303.87,,,,,,,,,,,,,
GRAFT BNE L80MM FIBULAR SHFT SEG FRZ DRY MATRIGRFT,SUP-2264770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.98,1153.74,,,,,,,,,,,,,
CARTRIDGE SAW BLADE OSCILLATING TIP 19.5X1.28X105MM PRECISION FALCON,SUP-2367673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
RING TRAC M 19-22IN CERV CLOSE BK W/ 2.5IN SKULL AND POS PIN,SUP-2328119,CDM,L0810,HCPCS,0272,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
METHOHEXITAL SODIUM 0.5 G IJ SOLR,RX-70545,CDM,2500000003,HCPCS,0250,RC,42023-0105-01,NDC,,both,1,UN,641.30,416.84,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST ADJACENT W/AIR CHMBR,SUP-2435615,CDM,L1847,HCPCS,0274,RC,,,,both,,,1628.40,1058.46,,,,,,,,,,,,,
SYSTEM IMPL S STL KNOTLESS FOR SYNDESMOSIS REP TIGHTROPE,SUP-2122825,CDM,C1713,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
WIRE FIX L285MM DIA2MM TI TRCR PNT SMOOTH DBL SHRP TIP K,SUP-2193150,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTMA L 17 CM DIA 5 MM SZ 0.010 IN STD,SUP-2753290,CDM,C1778,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM DEHYDR AMNIO MEMBRN ALLGRFT FLOWERPATCH,SUP-2225382,CDM,2780000010,LOCAL,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 74 CM DIA 8.5 FR CRV ANGLE 36 MM,SUP-2492434,CDM,C1893,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BNE L151MM 9 H ST R LAT DST FIBULAR S STL LOK COMPR,SUP-2177422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2077.86,1350.61,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE HA PTTY INJ HYDROSET,SUP-2371662,CDM,C1713,HCPCS,0278,RC,,,,both,,,6219.56,4042.71,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 4X16 CMX1-2 MM PROLAYER,SUP-2717798,CDM,C1763,HCPCS,0278,RC,,,,both,,,18086.40,11756.16,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 360 DEG L 20 CM DIA10 MM,SUP-2362409,CDM,C1889,HCPCS,0278,RC,,,,both,,,6013.73,3908.92,,,,,,,,,,,,,
GRAFT DERM L7CMXW4CM PORCINE IMPL IMPLABLE INTEXEN LP,SUP-2140304,CDM,C1781,HCPCS,0278,RC,,,,both,,,1774.89,1153.68,,,,,,,,,,,,,
SUCRALFATE 1 G PO TABS,RX-11442,CDM,6370000000,HCPCS,0637,RC,00093-2210-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 CM OD 4-10 MM FEM ART CRYOPRESERVED,SUP-2931247,CDM,C1762,CPT,0278,RC,,,,both,,,22949.10,14916.91,,,,,,,,,,,,,
ANCHOR SUT L19.5MM DIA8MM PEEK FORKED EYELET TENODESIS,SUP-2121438,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
TISSUE GRFT 13CMX22CM 8 LAYR TISS W/ PERFORATIONS SURGISIS,SUP-2169661,CDM,C1781,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
GUIDEWIRE ORTH LNG SALVATION,SUP-2850526,CDM,C1769,HCPCS,0272,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
ENDCAP SPNL 5,SUP-2361819,CDM,C1889,HCPCS,0278,RC,,,,both,,,438.50,285.02,,,,,,,,,,,,,
HC MRI-Spine Lumbar W Contrast,PX-6127214900,CDM,72149,CPT,0612,RC,,,,both,,,4146.00,2694.90,,,,,,,,,,,,,
GRAFT BNE SUB 15CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264815,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.44,455.94,,,,,,,,,,,,,
SCREW PED GIC52 4.5-6.35MM CLS LAT CON 30MM SS 7021230,SUP-2286989,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
SPIRONOLACTONE 50 MG PO TABS,RX-11426,CDM,6370000000,HCPCS,0637,RC,60687-0476-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MESH SURG W15XL20CM PTFE OVL KNIT FLM PARTIALLY ABSRB,SUP-2395759,CDM,C1781,HCPCS,0278,RC,,,,both,,,4688.02,3047.21,,,,,,,,,,,,,
SLEEVE TIB STD UNIV POLYETH MOD CEM STEM ROT HNG REV,SUP-2376372,CDM,C1776,CPT,0278,RC,,,,both,,,1234.96,802.72,,,,,,,,,,,,,
BLADE REPROC TURBINATE INFERIOR M4 ROTAT W/O TUBE 2MM,SUP-2653211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.62,245.45,,,,,,,,,,,,,
PLATE BNE LCK 3.5X104 MM RT DSTL MEDL HUM 5 HOLE FIX ANGLE,SUP-2500304,CDM,C1713,HCPCS,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
KIT ENDSCPC INSTRMNT 112 118MM DIA 18MM OD CAP 165CML WRKN,SUP-2675481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,658.05,427.73,,,,,,,,,,,,,
STAPLER SKIN S STL RELD STPL DISP,SUP-2283075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.52,219.39,,,,,,,,,,,,,
BIT DRL DIA4.4MM DARCO HD FOR 6.5MM SCR,SUP-2398639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INOGEN MINI TI SINGLE CHMBR DF4 CONN 1 LD,SUP-2140375,CDM,C1722,HCPCS,0275,RC,,,,both,,,52752.00,34288.80,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - Monthly (Other Ind),PX-9900000039,CDM,9900000039,LOCAL,0990,RC,,,,both,,,15.00,9.75,,,,,,,,,,,,,
FLUOROURACIL 1 GM/20ML IV SOLN,RX-82204,CDM,J9190,HCPCS,0636,RC,63323-0117-20,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT FEM CR 1 55X53 MM LT KNEE CEM ANAT DP PAT GRV TI,SUP-2390327,CDM,C1776,CPT,0278,RC,,,,both,,,15150.50,9847.82,,,,,,,,,,,,,
PACK PHACO RND ABS 30DEG 9MM,SUP-2109876,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.09,938.66,,,,,,,,,,,,,
SLEEVE IM NAIL NAIL DIA 8-11 MM LNG RIGID TIB FIX STRL,SUP-2905668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.11,470.02,,,,,,,,,,,,,
RING EXT FIX FULL 200 MM TAB,SUP-2749874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4700.58,3055.38,,,,,,,,,,,,,
FUROSEMIDE 8 MG/ML PO SOLN,RX-3293,CDM,340b,HCPCS,0637,RC,68094-0867-59,NDC,,both,1.25,ML,2.70,1.75,,,,,,,,,,,,,
NEEDLE ENDOSCP 21 MMX10 CM VERES LL SPRING LD BLNT INNR CANN,SUP-2766955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.78,441.86,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM NOM THK1.1MM STD HUM DERM REGEN TISS,SUP-2399134,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6716.46,4365.70,,,,,,,,,,,,,
SPACER SPNL W11XH10XL28MM PEEK OPTMA LUM OBLQ LO PROF RADLUC,SUP-2211919,CDM,C1821,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
NEEDLE SUTURE PASS PTS ANIKA,SUP-2761961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
HEAD FEM DIA28MM +10MM OFFSET 10/12 TAPR CO CHROM SKIRTED,SUP-2253273,CDM,C1776,CPT,0278,RC,,,,both,,,2093.75,1360.94,,,,,,,,,,,,,
CATHETER URET L65CM DIA5FR BERN IMAGER II,SUP-2139303,CDM,C1758,HCPCS,0278,RC,,,,both,,,61.17,39.76,,,,,,,,,,,,,
BOOT ANK AD L8 13IN FOR 16IN CALF UNIV DK BLU FLEECE LN,SUP-2165483,CDM,L4631,HCPCS,0272,RC,,,,both,,,145.38,94.50,,,,,,,,,,,,,
HC Sleep Study Unattended|NOT REASONABLE AND NECESSARY,PX-9209580000,CDM,95800,CPT,0920,RC,,,GZ,both,,,898.00,583.70,,,,,,,,,,,,,
ELECTRODE ELECSURG CYL 12-30 DEG HF RESECT W/ SPIKE STRL,SUP-2430223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.91,263.84,,,,,,,,,,,,,
ANTLAT DIST TIB PLATE XXL 31-HOLE LT,SUP-2829294,CDM,C1713,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
SYSTEM IMPL DELTOID LIGMNT RECON,SUP-2122811,CDM,C1776,CPT,0278,RC,,,,both,,,6138.70,3990.15,,,,,,,,,,,,,
KNIFE ENDOSCP 0.7 MMX195 CM 2 MM FLAT ERCP LF DISP,SUP-2497990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1117.37,726.29,,,,,,,,,,,,,
SHUNT SURG REG SNAP ASMBLY STRATA II,SUP-2628615,CDM,C1729,HCPCS,0272,RC,,,,both,,,14397.18,9358.17,,,,,,,,,,,,,
PLATE LOQTEQ PROXIMAL HUMERUS 3.5 4H,SUP-2858202,CDM,C1713,HCPCS,0278,RC,,,,both,,,7605.77,4943.75,,,,,,,,,,,,,
"HC So Aldosterone, Serum",PX-3018208866,CDM,82088,CPT,0301,RC,,,,both,,,341.00,221.65,,,,,,,,,,,,,
SET NEPHROSTOMY STENT L 7 CM DIA 4.7 FR CATH L 15 CM DIA 8.2,SUP-2835700,CDM,C1729,HCPCS,0272,RC,,,,both,,,219.89,142.93,,,,,,,,,,,,,
GRAFT BONE 1ML DEMIN BONE MTRX SYR POLOXAMER RVS PHASE M,SUP-2247312,CDM,C9359,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
MESH HERN DIA4.5IN CIR W/ ECHO PS POS SYS VENTRALIGHT ST,SUP-2125913,CDM,C1781,HCPCS,0278,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
PLATE BNE STR 1.3 MM HND 10 HOLE STRL,SUP-2518390,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
GUIDE WIRE 32MM X 38,SUP-2724396,CDM,C1769,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
HC CT Brain W/O Contrast,PX-3517045000,CDM,70450,CPT,0351,RC,,,,both,,,2762.00,1795.30,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX15 CM 3L RIFAMPIN SPECTRUM,SUP-2759759,CDM,C1751,HCPCS,0278,RC,,,,both,,,133.67,86.89,,,,,,,,,,,,,
SCREW BONE L26MM DIA2.7MM FT TI LCK T8 DBL LD EXTREMILOCK,SUP-2319729,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ROD SPNL L360MM DIA5.5MM POST CERVICOTHORACIC TI THRD RECON,SUP-2286758,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.02,1036.11,,,,,,,,,,,,,
KIT CATH NPHRSTMY PRCTNS W/STNT 0.038N 150CML GDWRE STPCCK S,SUP-2468752,CDM,C1769,HCPCS,0272,RC,,,,both,,,477.25,310.21,,,,,,,,,,,,,
ELECTRODE ES VPR FOR USA ELITE SYS,SUP-2314003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,695.67,452.19,,,,,,,,,,,,,
DEVICE ANTISIPH 2.2X1.2 MM FLAT BTM ASD PUDENZ STR CONN,SUP-2852571,CDM,C1889,HCPCS,0278,RC,,,,both,,,1467.07,953.60,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM ID2MM 180 TO 250OHM SIL VAGUS NRV,SUP-2175911,CDM,C1778,HCPCS,0278,RC,,,,both,,,21439.92,13935.95,,,,,,,,,,,,,
GRAFT VASC GELSFT + L 45 CM DIA22 MM LEG DIA11 MM POLYESTER,SUP-2384942,CDM,C1768,CPT,0278,RC,,,,both,,,2128.20,1383.33,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED SM 8 IN LT WRST FOREARM THMB,SUP-2276634,CDM,L3809,HCPCS,0274,RC,,,,both,,,21.92,14.25,,,,,,,,,,,,,
PACEMAKER CARD CYLOS VR W 39 X H 57 MM D 6 MM 2.8 V 11 CC 27,SUP-2138040,CDM,C1786,HCPCS,0275,RC,,,,both,,,12459.52,8098.69,,,,,,,,,,,,,
MESH HERN W15XL30CM VENTRAL SYN POLY CLLGN POLYLACTIC ACID,SUP-2174796,CDM,C1781,HCPCS,0278,RC,,,,both,,,1286.24,836.06,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 15X10 CM RND POLYESTER PARIETEX,SUP-2752181,CDM,C1781,HCPCS,0278,RC,,,,both,,,2354.56,1530.46,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|DOCUMENTATION ON FILE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|CO|KX,both,,,144.00,93.60,,,,,,,,,,,,,
BIT DRL QC 2.8X170 MM 80 MM CALIB STRL,SUP-2563759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.93,297.00,,,,,,,,,,,,,
CAGE SPNL ANGLED 0 DEG 12X39-65 MM TI SM VBR,SUP-2431557,CDM,C1889,HCPCS,0278,RC,,,,both,,,26533.00,17246.45,,,,,,,,,,,,,
SAW GUIDE FOR CHILD/ADOLESCENT OSTEOTOMY PLATES,SUP-2548628,CDM,C1713,HCPCS,0278,RC,,,,both,,,2077.86,1350.61,,,,,,,,,,,,,
COVER BUR H DIA20MM SHUNT LO PROF W/ TAB FOR 1.5MM SCR CRAN,SUP-2363639,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.66,625.08,,,,,,,,,,,,,
STEM FEM L150MM DIA9MM HIP CO CHROM INTLOK PRI CEM TAPR,SUP-2403346,CDM,C1776,CPT,0278,RC,,,,both,,,6323.96,4110.57,,,,,,,,,,,,,
ROD SPNL THRD LNG 350 MM MR SAFE NS,SUP-2863417,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.77,155.85,,,,,,,,,,,,,
RING EXT FIX 5/8 210 MM ALUM MAXFRAME,SUP-2432234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3378.80,2196.22,,,,,,,,,,,,,
PLATE BNE RECON 2.7 MM MAND 21 HOLE LT ANGLED TI LEVEL 1,SUP-2478642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3243.43,2108.23,,,,,,,,,,,,,
BLADE SAW OSC DISP STABLECUT,SUP-2408657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1401.23,910.80,,,,,,,,,,,,,
SCREW CONN MTPHSEAL HUM ADPT STEM UNION FOR REVERSED II FX,SUP-2399857,CDM,C1713,HCPCS,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 135 CM BALLOON L 20 MM DIA 4,SUP-2141985,CDM,C1725,HCPCS,0272,RC,,,,both,,,2387.91,1552.14,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 13 MM 33 CC 71 GM EPIC II VR V158RST] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356512,CDM,C1722,HCPCS,0275,RC,,,,both,,,55578.00,36125.70,,,,,,,,,,,,,
LEAD PACE EASYTRAK L 65 CM SIL POLYUR ENDOCARD LT,SUP-2148677,CDM,C1900,HCPCS,0275,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC MRI Lower Ext Jnt W/ Cont,PX-6107372200,CDM,73722,CPT,0610,RC,,,,outpatient,,,5019.00,3262.35,,,,,,,,,,,,,
GRAFT BNE SUB 5ML SIL SOD CA PHOS OXIDE FOAM PK RECT CONT,SUP-2368183,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
INSERT TIB SZ 2 THK12MM POST STBL FIX GMK,SUP-2267477,CDM,C1776,CPT,0278,RC,,,,both,,,3415.66,2220.18,,,,,,,,,,,,,
GUIDEWIRE VASC REGALIA XS 1.0 L 300 CM DIA 0.014 IN,SUP-2123851,CDM,C1769,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 100 CM DIA 4 FR DIA1.05 MM ANGLED,SUP-2385513,CDM,C1887,HCPCS,0272,RC,,,,both,,,88.71,57.66,,,,,,,,,,,,,
PASSER SUT 45DEG LT ARTHSCP SLINGSHOT,SUP-2365418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.38,740.60,,,,,,,,,,,,,
STENT BILI M L18MM BLLN L20MM DIA5MM CATH L80CM GWIRE,SUP-2159158,CDM,C1876,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
SYRINGE ANGIO 8ML CONTROLED PALM PLUNG FIX M CONN RNG GRP,SUP-2302472,CDM,C1713,HCPCS,0278,RC,,,,both,,,14.38,9.35,,,,,,,,,,,,,
GUIDEWIRE ORTH L 150 MM DIA1.4 MM SCREW DIA 3.5/4 MM TROCAR,SUP-2908060,CDM,C1769,HCPCS,0272,RC,,,,both,,,312.56,203.16,,,,,,,,,,,,,
PLATE BONE THK2MM 14 H CP TI LCK STRNL MANUBRIUM,SUP-2262565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
SEALER TISS L35CM DIA5MM ARTC ADV BPLR STR TIP LAP APPRCH,SUP-2219735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4187.44,2721.84,,,,,,,,,,,,,
PLATE BNE STR 1 MM 3 HOLE C-TUBE FOR 12MM BRIDGE ORTHOANCHOR,SUP-2457414,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.34,373.32,,,,,,,,,,,,,
NUT SPNL LAT PLT LOK XLP,SUP-2311326,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC DBM BEAST +,SUP-2742046,CDM,C1713,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
MESH HERN W10XL14IN POLYPR MFIL RECTANG,SUP-2125745,CDM,C1781,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
COIL NEUROVASCULAR HYDROSOFT L 2 CM LOOP DIA1.5 MM,SUP-2305281,CDM,C1889,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
CONTROL REMOT FREELINK,SUP-2141943,CDM,C1787,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PIN EXT FIX THRD NONSTERILE DISPOSABLE L70MM L11MM OD32MM,SUP-2263013,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.45,430.59,,,,,,,,,,,,,
SLEEVE TIB L9CM TI POR PROX KNEE REDUC SZ OSS MARTI VIERZON,SUP-2406489,CDM,C1776,CPT,0278,RC,,,,both,,,17945.10,11664.31,,,,,,,,,,,,,
STEM FEM L200MM OD15MM 3DEG TI POR PLSM SPR HIP REV,SUP-2405029,CDM,C1776,CPT,0278,RC,,,,both,,,19279.60,12531.74,,,,,,,,,,,,,
HC Ther Infusion Addl Hr,PX-2609637000,CDM,96370,CPT,0260,RC,,,,both,,,87.00,56.55,,,,,,,,,,,,,
ADAPTER FEM 5DEG STEM FOR PFC SIG REV,SUP-2253592,CDM,C1776,CPT,0278,RC,,,,both,,,1953.08,1269.50,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CC FIBER PLIAFX PRIM,SUP-2741021,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.85,337.25,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY DEMIN CANC 1.7MM-10MM RANG 5CC,SUP-2294029,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
NEEDLE INSUFFLATION VERES 2.1X150 MM 1.6 MM DSTL TIP,SUP-2850590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.93,228.75,,,,,,,,,,,,,
COMPONENT TIB PS 7 UNIV 15 MM NP PRIMARY CEM STEM MONOBLOCK,SUP-2378478,CDM,C1776,CPT,0278,RC,,,,both,,,3085.99,2005.89,,,,,,,,,,,,,
DEXTROSE 20 % IV SOLN,RX-2359,CDM,2580000003,HCPCS,0258,RC,00990-7935-19,NDC,,both,500,ML,123.30,80.14,,,,,,,,,,,,,
PLATE BNE L 170 X W 11.4 MM THK 3.4 MM SCREW DIA 3.5 MM 13 H 72463313,SUP-2932750,CDM,C1713,HCPCS,0278,RC,,,,both,,,5651.53,3673.49,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 180 CM DIA 0.018 IN NIT HYDRPHLC,SUP-2141152,CDM,C1769,HCPCS,0272,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
POST EXT FIX 4 H M,SUP-2898539,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
GRAFT HUM TISS L 2.75 X W 1.5 CM PLCNTA MEMBRN ALLGRFT 3D,SUP-2909395,CDM,Q4194,HCPCS,0636,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
PLUG MESH SM ANCHR 3CM RIM 5CM SYN POLYPR POLIGLECAPRONE 25,SUP-2220114,CDM,C1781,HCPCS,0278,RC,,,,both,,,624.99,406.24,,,,,,,,,,,,,
NITROFURANTOIN MACROCRYSTAL 50 MG PO CAPS,RX-5595,CDM,6370000000,HCPCS,0637,RC,00904-7026-61,NDC,,both,1,UN,9.20,5.98,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ STEELCORE L 300 CM DIA 0.018 IN TIP L,SUP-2103534,CDM,C1769,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
GUIDEWIRE VASC STR 0.038 INX145 CM X STIFF TAPR SS AMPLATZ,SUP-2167903,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.51,35.43,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM SM 24X18MM TI STRL,SUP-2549725,CDM,C1713,HCPCS,0278,RC,,,,both,,,2290.98,1489.14,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE QUADRILATERAL GALAXY FIX GEM,SUP-2875651,CDM,C1713,HCPCS,0278,RC,,,,both,,,21605.02,14043.26,,,,,,,,,,,,,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,6370000000,HCPCS,0637,RC,00436-0672-16,NDC,,both,473,ML,51.10,33.21,,,,,,,,,,,,,
PIN FXTN L65MM D4MM CABLE L508MM HIP STNLSS STEEL CBLRDY,SUP-2491489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.72,514.62,,,,,,,,,,,,,
TAP SURG DIA2 MM CRANIOMAXILLOFACIAL NS DISP LORENZ,SUP-2937000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
HC So H Pylori Breath Test,PX-3018301366,CDM,83013,CPT,0301,RC,,,,both,,,638.00,414.70,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH TRL 8 CONTACT,SUP-2917077,CDM,C1816,LOCAL,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W20MM LEG L20X20MM WIRE DIA2X3MM S STL,SUP-2194228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
NAIL IM 10.7X245 MM KNEE PRECICE,SUP-2309822,CDM,C1713,HCPCS,0278,RC,,,,both,,,50937.08,33109.10,,,,,,,,,,,,,
SCOUT 5CM DEL NDL AND REFLECTOR PSA,SUP-2164408,CDM,C1819,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 0.038 INX260 CM STD EXCHANGE LAUREATE,SUP-2463109,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
SCREW BONE L35MM DIA4MM CORT DSTL LCK FULL THRD FOR 7MM,SUP-2318930,CDM,C1713,HCPCS,0278,RC,,,,both,,,610.67,396.94,,,,,,,,,,,,,
CLIP ANEURYSM L5MM BLADE L13MM 90DEG STANDARD PERMANENT ANGL,SUP-2821637,CDM,C1889,HCPCS,0278,RC,,,,both,,,6437.03,4184.07,,,,,,,,,,,,,
VALVE 10 WITH MCLANAHAN RESERVOIR MININAV,SUP-2825729,CDM,C1889,HCPCS,0278,RC,,,,both,,,2055.04,1335.78,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 8 MM STR TW STRL,SUP-2396318,CDM,C1768,CPT,0278,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
GRAFT DERM L6.3XW3.1IN ACELLULAR HUM DERM NONCROSSLINKED ST,SUP-2125865,CDM,C1781,HCPCS,0278,RC,,,,both,,,20817.26,13531.22,,,,,,,,,,,,,
DISTRACTION PIN LRGE 3.2X62MM7MM CTTNG SHAFT PK2T 6L 4V SN,SUP-2681380,CDM,C1713,HCPCS,0278,RC,,,,both,,,510.53,331.84,,,,,,,,,,,,,
BIT DRL L 195 MM DIA 6 MM 3 FLUT FOR QC FOR RADLUC DRV NS,SUP-2907751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.28,365.48,,,,,,,,,,,,,
STEM FEM L235MM DIA20MM BOW CONIC TI ALLY HA DST HIP REV,SUP-2375861,CDM,C1776,CPT,0278,RC,,,,both,,,8266.99,5373.54,,,,,,,,,,,,,
GUIDEWIRE ORTH L 220 MM DIA1.6 MM SCREW DIA 4.5/5 MM THRD,SUP-2907902,CDM,C1769,HCPCS,0272,RC,,,,both,,,489.27,318.03,,,,,,,,,,,,,
GRAFT HUM TISS W220XH18 4XL300MM MESHED SKIN TISS ASEP DMND,SUP-2307518,CDM,Q4128,HCPCS,0636,RC,,,,both,,,48698.57,31654.07,,,,,,,,,,,,,
PLATE BNE CNDYL 1.5X37 MM RT 7 HOLE FOR MINI FRAG SYS SS NS,SUP-2470482,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.18,484.37,,,,,,,,,,,,,
PLATE BNE L199MM 8 H NONSTERILE R PERIARTC PROX HUM S STL,SUP-2177810,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.81,3418.88,,,,,,,,,,,,,
CATHETER CV 5 FRX45 CM SHERLOCK STYL BARR KT GROSH,SUP-2126721,CDM,C1751,HCPCS,0278,RC,,,,both,,,785.31,510.45,,,,,,,,,,,,,
PLATE BNE L NEUT 2.7X72 MM RT DSTL TIB 4 HOLE VA LCK COMPR,SUP-2177698,CDM,C1713,HCPCS,0278,RC,,,,both,,,2791.77,1814.65,,,,,,,,,,,,,
CATHETER ANGIO PERFORMA 100 CM 4 FR 0.042 IN ULT1 1 SIDE H,SUP-2301467,CDM,C1713,HCPCS,0278,RC,,,,both,,,74.29,48.29,,,,,,,,,,,,,
IMPLANT HUM TISS L 8 X W 2 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881924,CDM,C1762,CPT,0278,RC,,,,both,,,8463.87,5501.52,,,,,,,,,,,,,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-3417859800,CDM,78598,CPT,0341,RC,,,,outpatient,,,4641.00,3016.65,,,,,,,,,,,,,
HANDPIECE ELECSURG L20CM 9MM JAW OPN EXT FR ACTUATED GRP,SUP-2313550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1460.73,949.47,,,,,,,,,,,,,
BRACE LS M 15DEG BK HK RECV MAT SFT BRTH LNR RIG TAPR PLAS,SUP-2195545,CDM,L0625,HCPCS,0274,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
PLATE BONE W38XL42MM 4X4MM H SPC CRAN TI MESH FOR 1MM SCR,SUP-2190567,CDM,C1713,HCPCS,0278,RC,,,,both,,,4622.39,3004.55,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR PULSE GENRTR DDDR UPLR IS 1 TEMP W/,SUP-2278428,CDM,C1785,HCPCS,0275,RC,,,,both,,,11391.92,7404.75,,,,,,,,,,,,,
SCREW INTFR L25MM DIA7MM KT LOT BICEPTOR,SUP-2341826,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
ROD EXT FIX 90 MM FOR SM BNE SHFT FIX CARBON FIBER,SUP-2525825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
CONDYLAR PLATE RIGHT 13X253MM,SUP-2820887,CDM,C1713,HCPCS,0278,RC,,,,both,,,7934.31,5157.30,,,,,,,,,,,,,
BAR EXT FIX CALIB TOMAHAWK MINI FIX SIDEKCK,SUP-2400615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
VALVE FACEPLT BODY AND DIAPH ATSV II,SUP-2242325,CDM,L8501,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
GRAFT BNE SCAFFOLD 20X20X4 MM MOLD DBM FUSIONFLEX,SUP-2859709,CDM,C1713,HCPCS,0278,RC,,,,both,,,4427.09,2877.61,,,,,,,,,,,,,
LEVEL CMF MESH STNDRD CNTRD 15 MM SCREW 148 X 82 MM T06 MM,SUP-2676647,CDM,C1713,HCPCS,0278,RC,,,,both,,,14167.52,9208.89,,,,,,,,,,,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-102314,CDM,J2003,HCPCS,0636,RC,70756-0641-85,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE EXT FIX L 85 MM 7 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,654.44,425.39,,,,,,,,,,,,,
CAGE SPNL 0 DEG 25X12 MM,SUP-2362925,CDM,C1889,HCPCS,0278,RC,,,,both,,,12285.88,7985.82,,,,,,,,,,,,,
TRAY GASTSTMY L17CM L12CM OD14FR SIL RADPQ STRL DISP PERC,SUP-2168068,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GRAFT BNE 10CC W/ BIOACTIVE GLS MOLD MTRX PLATFORM,SUP-2719783,CDM,C1713,HCPCS,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
BIT DRL DIA3.2MM CANN EIGHT-PLATE,SUP-2316399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.33,376.56,,,,,,,,,,,,,
GRAFT VASC FLIXENE 6MMX40CM,SUP-2470173,CDM,C1768,CPT,0278,RC,,,,both,,,3598.38,2338.95,,,,,,,,,,,,,
LAMIVUDINE 150 MG PO TABS,RX-15880,CDM,6370000000,HCPCS,0637,RC,33342-0001-09,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
KIT OTOLOGICAL INSTR INCLUDE CANN GUID DRL WNING DRL SFT,SUP-2319921,CDM,C1713,HCPCS,0278,RC,,,,both,,,1588.06,1032.24,,,,,,,,,,,,,
CATHETER CV DL 10 FR CUT DN PROC TY LNRD,SUP-2626324,CDM,C1751,HCPCS,0278,RC,,,,both,,,504.13,327.68,,,,,,,,,,,,,
SCREW BNE ST 2X8 MM LCK T8 TI NS,SUP-2189382,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
HC So Elution Procedure,PX-3028686066,CDM,86860,CPT,0302,RC,,,,outpatient,,,282.00,183.30,,,,,,,,,,,,,
FIBER LASER 600UM DISP FLAT TIP HOLM 10X SINGLEFLEX,SUP-2213048,CDM,C1713,HCPCS,0278,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
RELOAD STPL L100MM REG TISS BLU TI FOR PROX LIN CUT DST SER,SUP-2283274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM THK200UM AMNIO MEMBRN DEHYDR CHORION,SUP-2340447,CDM,C1762,CPT,0278,RC,,,,both,,,6732.16,4375.90,,,,,,,,,,,,,
GRAFT BIO TISS W7XL10CM HIATAL HERN STD FOR IMPLANTATION TO,SUP-2170839,CDM,C1763,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 2 5755240,SUP-2632921,CDM,C1752,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
GUIDEWIRE VASC 3 CM 014X190 CORONARY HI TORQ BAL HVYWT,SUP-2101875,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.6 MMX6 IN FOR HDLSS SCR SYS NS LTX,SUP-2862166,CDM,C1769,HCPCS,0272,RC,,,,both,,,135.84,88.30,,,,,,,,,,,,,
PLATE BNE L 233 MM SCREW DIA 4.5 MM 11 H SS LT DSTL FEM 72574111N,SUP-2932746,CDM,C1713,HCPCS,0278,RC,,,,both,,,11501.82,7476.18,,,,,,,,,,,,,
NEEDLE BX MENG LIV 16 GA 5 MMX36 CM LL,SUP-2767446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.86,495.21,,,,,,,,,,,,,
GRAFT BNE SUB L SZ 28 56MM 10CC B TRICALCIUM PHSPTE SYN,SUP-2194017,CDM,C1713,HCPCS,0278,RC,,,,both,,,2077.11,1350.12,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00264-1510-32,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
GUIDEWIRE VASC L175CM DIA0035IN PTFE MOD S STL COIL PLAT,SUP-2281745,CDM,C1769,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
REMOVER SCR FOR ORTH FIX SYS,SUP-2319565,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
GRAFT BONE 2.5ML DEMIN BONE MTRX PUTTY ACCELL CONNEXUS,SUP-2242681,CDM,C9359,HCPCS,0278,RC,,,,both,,,1218.57,792.07,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 28MM POLYESTER BOV CLLGN STR,SUP-2265931,CDM,C1768,CPT,0278,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
STEM FEM SZ 11 HIP TI PLSM SPR EXT OVATION,SUP-2314423,CDM,C1776,CPT,0278,RC,,,,both,,,9696.32,6302.61,,,,,,,,,,,,,
SET APPLICATOR LOCALIZER-S 20 10 CM HOLOGIC,SUP-2874144,CDM,A4648,CPT,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
APPLIER CLP ENDOSCP MED LG 10 MMX18 IN LIG HORZ MTL LIG SYS,SUP-2656781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
BUR SURG CANN 6 MM FLX SHFT,SUP-2598325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL FIX COR 3 MM 0.038 INX80 CM SAFE-T-J,SUP-2835663,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.97,76.03,,,,,,,,,,,,,
SCREW BNE CORTICAL 4X42 MM PROX HUM CANN SD HEX DRV NS NCB,SUP-2459937,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
ELECTRODE ELECSURG 24 FR CUT LOOP RT ANGLED,SUP-2313975,CDM,C1713,HCPCS,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
ORTHOLOC SPS 105MM POSTERIOR4 HOLE PLATE-LEFT,SUP-2827742,CDM,C1713,HCPCS,0278,RC,,,,both,,,8839.10,5745.41,,,,,,,,,,,,,
GRAFT BNE L ANK TALUS FRSH REFRIGERATED,SUP-2264605,CDM,C1713,HCPCS,0278,RC,,,,both,,,20671.84,13436.70,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE 70 MM PRECIS REG CATH W/ SIPHONGUARD,SUP-2666507,CDM,C1889,HCPCS,0278,RC,,,,both,,,3866.91,2513.49,,,,,,,,,,,,,
HC Fluoro for Central Line Place,PX-3207700100,CDM,77001,CPT,0320,RC,,,,both,,,1072.00,696.80,,,,,,,,,,,,,
STENT ESOPH EVOLUTION L 10 CM BODY DIA20 MM FLANGE DIA25 MM,SUP-2170565,CDM,C1874,HCPCS,0278,RC,,,,both,,,5460.46,3549.30,,,,,,,,,,,,,
DRILL SURG DIA2.8MM TWST CAPTURE,SUP-2244278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,770.81,501.03,,,,,,,,,,,,,
STEM FEM PRSS FT 6 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267800,CDM,C1776,CPT,0278,RC,,,,both,,,21509.00,13980.85,,,,,,,,,,,,,
MICRUSFRAME C 14 STRTCH RESIST COIL CONTENTS 1 DETACH COIL,SUP-2249230,CDM,C1889,HCPCS,0278,RC,,,,both,,,4090.23,2658.65,,,,,,,,,,,,,
GRAFT L SEG RECON TISS FRZN PELV ILIUM WHL L,SUP-2307411,CDM,C1713,HCPCS,0278,RC,,,,both,,,21021.64,13664.07,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.093X9 IN THRD SS NS STEINMANN,SUP-2791383,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.56,45.86,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 23.5-32 IN CTR 17-23 IN CALF 18-24 IN RT MED LT LAT,SUP-2916947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1183.81,769.48,,,,,,,,,,,,,
ALLOGRAFT GRAFTON DBF 6CC W/DELIVERY TUBE,SUP-2738997,CDM,C1713,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
HC Nras/Kras Gene Analys,PX-3000111066,CDM,0111U,CPT,0300,RC,,,,inpatient,,,797.00,518.05,,,,,,,,,,,,,
HC Insert Vent Assist Device; Artery Access Only,PX-3603399000,CDM,33990,CPT,0360,RC,,,,both,,,7747.00,5035.55,,,,,,,,,,,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,2500000003,HCPCS,0250,RC,81665-0200-01,NDC,,both,25,ML,59.60,38.74,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE LDDR WTAB 1.5 MM SCRW6 X 2 HOLES 2,SUP-2667274,CDM,C1713,HCPCS,0278,RC,,,,both,,,1100.26,715.17,,,,,,,,,,,,,
SPACER GRFT BNE ANTR 16MM SM 13 DEG LORDTC PUROS S2,SUP-2693853,CDM,C1713,HCPCS,0278,RC,,,,both,,,13354.42,8680.37,,,,,,,,,,,,,
PUMP INFUS 100ML 2ML/HR W/ STD CATH PAINPMP,SUP-2361460,CDM,E0783,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
COLLAR CERV SM H425IN POLY FOAM PLAS SUPP TWO PC CA PROCARE,SUP-2196883,CDM,L0172,HCPCS,0272,RC,,,,both,,,42.42,27.57,,,,,,,,,,,,,
MESH SURG L 5 X W 5 CM D 1 MM PORCINE DERMAL CLLGN ABD HERN,SUP-2901798,CDM,C9364,HCPCS,0278,RC,,,,both,,,1719.59,1117.73,,,,,,,,,,,,,
SENSOR PULSE OXMTR CABLE L 90 CM FNGR SPO2 CLP AD NS LF,SUP-2929795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,198.86,129.26,,,,,,,,,,,,,
NAIL IM PROX LNG 7X220 MM RT HUM AFFIXUS NAT NAIL,SUP-2606956,CDM,C1713,HCPCS,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
KIT STBL POS SHLDR SPIDER 2 EXCEPTIONAL LIMB CTRL,SUP-2341137,CDM,L3650,HCPCS,0274,RC,,,,both,,,519.70,337.80,,,,,,,,,,,,,
SHEAR SURG RIB 12 IN RT CORYLLOS-BETHUNE,SUP-2484900,CDM,C1713,HCPCS,0278,RC,,,,both,,,1423.61,925.35,,,,,,,,,,,,,
GRAFT BNE SUB 10CC 15% HYDROXYAPATITE/85% B-TCP GRAN POR,SUP-2288532,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.23,910.80,,,,,,,,,,,,,
MESH SURG 8 X 15 CM SUTURE SZ 6-0 OVINE PGA REINF TISS MTRX,SUP-2914799,CDM,C1781,HCPCS,0278,RC,,,,both,,,6327.10,4112.61,,,,,,,,,,,,,
SHEET THERMOPLASTIC W18XL24IN THK0.09IN STD CHAR SLD SPLNT,SUP-2323989,CDM,L4350,HCPCS,0274,RC,,,,both,,,156.97,102.03,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y DBL PLATE 12 PK STRL,SUP-2935455,CDM,C1713,HCPCS,0278,RC,,,,both,,,24950.44,16217.79,,,,,,,,,,,,,
PLATE BNE L73MM 6 H BILAT S STL CNTOUR 2 COMPR FOR 35MM SCR,SUP-2411340,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
TOCILIZUMAB 200 MG/10ML IV SOLN,RX-104371,CDM,J3262,HCPCS,0636,RC,50242-0136-01,NDC,,both,10,ML,3917.40,2546.31,,,,,,,,,,,,,
DISSECTOR SRGCL RHTN SPTLA SIZE 6 SM 7 1/2NL TTNM JARIT,SUP-2495071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.74,343.03,,,,,,,,,,,,,
STRUT FX MAXIFRAME POLYAX STRUT LONG,SUP-2737907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3849.36,2502.08,,,,,,,,,,,,,
HC So Cytomegalovirus Pcr,PX-3068749666,CDM,87496,CPT,0306,RC,,,,inpatient,,,254.00,165.10,,,,,,,,,,,,,
PLATE L FUSION VA LCP 2.4/2.7MM STD LT TI STRL,SUP-2546993,CDM,C1713,HCPCS,0278,RC,,,,both,,,3516.61,2285.80,,,,,,,,,,,,,
GUIDEPIN ORTH DIA2.5MM PROX LOK DISP FOR ATN TROCHANTERIC,SUP-2413925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
CATHETER HD SET 15 FRX50 CM RETROGRADE HUB CANNON II +,SUP-2762986,CDM,C1750,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GUIDEWIRE THREADED 3.2 X 450MM,SUP-2855646,CDM,C1769,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PIN FIX L22.9MM OD2.8MM 316L S STL 5 TRCR PNT PLN SMOOTH,SUP-2409659,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.53,16.59,,,,,,,,,,,,,
NEEDLE LOC L7.5CM OD20GA BRST REPOSITIONABLE PATENTED SIDE,SUP-2269616,CDM,C1819,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
BIT DRL TWST 1.9X115 MM 11 MM W/ STP NOTCH LEVEL 1 DISP,SUP-2473660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
ANCHOR SUTURE SLIDING 2-0 SHT 2.9 MM 1.5 MM BLK JUGGERKNOT,SUP-2745525,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
INSTRUMENT EXT FIX REARFOOT 3 ARTH FOR SIDEKCK FIX,SUP-2400591,CDM,C1894,HCPCS,0272,RC,,,,both,,,16541.52,10751.99,,,,,,,,,,,,,
PROBE ELECSURG FLX 1.3 MMX2.2 MR ERBEJET 2 DISP,SUP-2734129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
GUIDEWIRE VASC L125CM DIA0032IN FOR QUATTRO,SUP-2416133,CDM,C1769,HCPCS,0272,RC,,,,both,,,60.66,39.43,,,,,,,,,,,,,
STAPLE 6MM STEPOFF MEMOSTEP,SUP-2696120,CDM,C1776,CPT,0278,RC,,,,both,,,5327.95,3463.17,,,,,,,,,,,,,
WASHER ORTH 3.5 MM ANK SYNDESMOSIS REP KT ACU-SINCH,SUP-2857602,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
PLATE BONE SM 6 H GAP LO PROF FOR 1.5MM SCR CRAN FIX SYS,SUP-2363637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1071.12,696.23,,,,,,,,,,,,,
TUBE ET OD9.5MM ID7MM STD PVC NONREINFORCED EMG NIM,SUP-2284335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1140.54,741.35,,,,,,,,,,,,,
GRAFT BNE 2.5 CC OSTEOCURRENT,SUP-2644332,CDM,C1713,HCPCS,0278,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 40 CM DIA 6 MM EPTFE CARBON,SUP-2761415,CDM,C1768,CPT,0278,RC,,,,both,,,2939.20,1910.48,,,,,,,,,,,,,
SPLINT THMB AD SM FOR 4.75-6.25IN RT WR REG TRIOXON LINING,SUP-2324737,CDM,L3931,HCPCS,0272,RC,,,,both,,,59.72,38.82,,,,,,,,,,,,,
COMPONENT GLEN PEGGED SM SHLDR AEQUALIS,SUP-2715556,CDM,C1776,CPT,0278,RC,,,,both,,,6041.36,3926.88,,,,,,,,,,,,,
GRAFT BIO W25XL13CM THK2MM NONDENATURED BOV CLLGN RECTANG,SUP-2243683,CDM,C9360,HCPCS,0278,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
PLATE BONE L80MM THK3.4MM 5 H BILAT NONLOCKING COMPR FOR,SUP-2348948,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.56,888.91,,,,,,,,,,,,,
SLEEVE KNEE PROSTHETIC,SUP-2323332,CDM,L5685,LOCAL,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
PLATE BONE L64MM THK0.5-1.6MM 7 H LCK COMPR RT SH MALL TI,SUP-2267981,CDM,C1713,HCPCS,0278,RC,,,,both,,,2841.70,1847.10,,,,,,,,,,,,,
SLEEVE REDUC PUSH PUL FOR 3.5MM LCP PLT,SUP-2187792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1216.53,790.74,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.545,SUP-2860062,CDM,C1713,HCPCS,0278,RC,,,,both,,,52738.81,34280.23,,,,,,,,,,,,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,0636,RC,63323-0604-00,NDC,,both,1,ML,66.10,42.96,,,,,,,,,,,,,
STRUT EXT FIX L 110-135 MM XSH POLYAXL UTIL,SUP-2898483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
IMPLANT TOE 30 283X127X8X76X14X31X10X64X34X44X44MM,SUP-2244195,CDM,C1776,CPT,0278,RC,,,,both,,,4353.20,2829.58,,,,,,,,,,,,,
ROD REPROC EXT FIX HYBRID CARBN 11X400MM,SUP-2489330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,238.58,155.08,,,,,,,,,,,,,
HC Venography Canal Inferior,PX-3207582500,CDM,75825,CPT,0320,RC,,,,outpatient,,,3006.00,1953.90,,,,,,,,,,,,,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,6370000000,HCPCS,0637,RC,41100-0811-23,NDC,,both,15,ML,27.50,17.87,,,,,,,,,,,,,
PLATE BNE L 107 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 5 H 72467705,SUP-2932769,CDM,C1713,HCPCS,0278,RC,,,,both,,,3202.49,2081.62,,,,,,,,,,,,,
COMPRESSION BLK 100 MM RIG,SUP-2197286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC THRD,SUP-2316516,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.12,58.58,,,,,,,,,,,,,
SYSTEM IMPL 4.75MM SWIVELOCK C ANCHR W/ SCORPION NDL 1 PRELD,SUP-2121719,CDM,C1713,HCPCS,0278,RC,,,,both,,,5997.40,3898.31,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CANNULA PERF 25FR L30IN MULTISTAGE FEM VEN W/ INSRT KT,SUP-2282887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1291.67,839.59,,,,,,,,,,,,,
CATHETER GUID HELI-FX ENDOANCHOR L 90 CM DIA18 FR NK,SUP-2280990,CDM,C1713,HCPCS,0278,RC,,,,both,,,7215.72,4690.22,,,,,,,,,,,,,
SCREW EXT FIX L 80 MM THRD L 20 MM DIA 4/3 MM SS ST NS SCHNZ,SUP-2908208,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.62,173.30,,,,,,,,,,,,,
CATHETER BLLN DIL FIX WIRE 6-7-8 MMX7.5 FRX180 CM ELATION,SUP-2473228,CDM,C1726,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
LEAD PACEMKR VENT UPLR STEROID ELUT CAPSUR SP,SUP-2281902,CDM,C1898,HCPCS,0275,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST THMS EXT TO BALL,SUP-2435735,CDM,L3470,HCPCS,0274,RC,,,,both,,,176.41,114.67,,,,,,,,,,,,,
GUIDEWIRE SOLO PLUS 0.035IN STRAIGHT TIP,SUP-2655881,CDM,C1769,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
GUIDEWIRE INTRMDLLRY NAIL 32MM SHAFT 60CML 5MM TIP BLLT TIP,SUP-2723228,CDM,C1769,HCPCS,0272,RC,,,,both,,,683.08,444.00,,,,,,,,,,,,,
SET INTRO MICROEZ L 35 CM CATH 5 FR NDL L 5 CM SS GUIDEWIRE,SUP-2125497,CDM,C1751,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
PLATE BONE CMPRSSN 87MM ID 1219MM OD TUBE 214MML HLX12 38,SUP-2726709,CDM,C1713,HCPCS,0278,RC,,,,both,,,2192.79,1425.31,,,,,,,,,,,,,
TWIST DRILL 15MM DIA X 20MM 5MM STOP DNTL LATCH SNGLE USE,SUP-2669770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.99,304.19,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT FILTERWIRE EZ L 300 CM RVD 3.5 - 5.5,SUP-2143664,CDM,C1769,HCPCS,0272,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
BLOM-SINGER INDWL LO PRSS VOICE PROS REPL KT SER 8MM,SUP-2246404,CDM,L8509,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
HC Observation per Hour,PX-7620037800,CDM,G0378,CPT,0762,RC,,,,both,,,78.00,50.70,,,,,,,,,,,,,
PLATE BNE WDG 0 MM BOW ARW BASE GORILLA,SUP-2751028,CDM,C1713,HCPCS,0278,RC,,,,both,,,3289.15,2137.95,,,,,,,,,,,,,
SCREW BONE SUBTROCHANTERIC SET ZCKL II,SUP-2364779,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.96,479.02,,,,,,,,,,,,,
STRAP CLAV SM PD W3XL4IN STD FOAM PD STOCKINET MTL TOOTH,SUP-2276602,CDM,L3650,HCPCS,0274,RC,,,,both,,,16.30,10.59,,,,,,,,,,,,,
INSERT TIB SZ 2 THK16MM UNIV POST STBL CONG NEUT ANAT MOD,SUP-2252461,CDM,C1776,CPT,0278,RC,,,,both,,,4502.76,2926.79,,,,,,,,,,,,,
BASKET STONE RETRV 3FR L120MM POLYIMIDE PTFE NIT 4 WIR 0,SUP-2138885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.02,394.56,,,,,,,,,,,,,
GRAFT CELLR BNE MATRX INFLUX SPARC 5CC,SUP-2615609,CDM,C1713,HCPCS,0278,RC,,,,both,,,10864.40,7061.86,,,,,,,,,,,,,
ANCHOR SFT TISS L17MM OD4MM DISP GUN ECLIPSE,SUP-2277473,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
LENS INTOCU +6.0 DIOPT L13MM DIA6MM 10DEG HAPTIC ANG A,SUP-2110603,CDM,V2632,HCPCS,0276,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
SPEEDBRG IMPLANTED SYS WITH PEEK SWVLK,SUP-2812572,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PEG SAFETY ENFIT 20FR ENTRSTAR,SUP-2719889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
STENT PERIPH HERCLNK ELITE L 12 MM DIA 6 MM CATH L 135 CM,SUP-2104664,CDM,C1876,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
GUN BONE CEM REVOLUTION,SUP-2361483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2272.42,1477.07,,,,,,,,,,,,,
INSERT TIB SZ 6-7 THK11MM RT KNEE HNG GUID MOTN LEGION,SUP-2346691,CDM,C1776,CPT,0278,RC,,,,both,,,6663.08,4331.00,,,,,,,,,,,,,
BUR SURG DIA5MM CARB RND,SUP-2364020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,735.36,477.98,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.7MM MAG MAND NONLOCKINGXDRIVE FOR,SUP-2136765,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
PLATE BNE L37MM 2X2 H SHT R FOREFOOT/MIDFOOT S STL VAR ANG,SUP-2184834,CDM,C1713,HCPCS,0278,RC,,,,both,,,2857.37,1857.29,,,,,,,,,,,,,
COMPONENT TALAR SZ 1 DOME TOT ANK SYS INFIN,SUP-2397268,CDM,C1776,CPT,0278,RC,,,,both,,,14836.50,9643.72,,,,,,,,,,,,,
ULTRA HGH HP SYSLG HD XLPE LN,SUP-2212068,CDM,C1776,CPT,0278,RC,,,,both,,,15227.87,9898.12,,,,,,,,,,,,,
GRAFT HUM TISS W10XL36MM REV COR FRZ DRY LIG RECON,SUP-2307072,CDM,C1713,HCPCS,0278,RC,,,,both,,,3230.75,2099.99,,,,,,,,,,,,,
SYSTEM IMPL 7MM DBL LD W/ SH FLIPCUTTER II TIGHTROPE RT,SUP-2120927,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
DIANEAL PD-2/1.5% DEXTROSE 346 MOSM/L IP SOLN,RX-15434,CDM,A4722,HCPCS,0258,RC,00941-0411-11,NDC,,both,1000,ML,63.30,41.14,,,,,,,,,,,,,
BRACE GAUNTLET WR LT 1 SZ FITS MOST REG ELAS SUPP FABRIFOAM,SUP-2334826,CDM,L3809,HCPCS,0274,RC,,,,both,,,34.26,22.27,,,,,,,,,,,,,
GRAFT VASC IMPRA L 45 CM DIA 5-8 MM EPTFE STP STD WALL N,SUP-2127037,CDM,C1768,CPT,0278,RC,,,,both,,,1150.53,747.84,,,,,,,,,,,,,
PLATE BNE HUM 3.5X199 MM LT PERIARTICULAR PROX 8 HOLE LCK LP,SUP-2177813,CDM,C1713,HCPCS,0278,RC,,,,both,,,5785.20,3760.38,,,,,,,,,,,,,
SCREW BONE L14MM DIA4MM CORT TI ST NONCANNULATED LCK FULL,SUP-2181106,CDM,C1713,HCPCS,0278,RC,,,,both,,,472.60,307.19,,,,,,,,,,,,,
BUR SURG DIA12MM 6 H TI CVR H W/O TAB CNTOUR LO PROF,SUP-2191186,CDM,C1781,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
GRAFT BNE SUB W9.5-10XL8-13MM THK30-53MM PAT TEND HEMI SHP,SUP-2307266,CDM,C1713,HCPCS,0278,RC,,,,both,,,8171.94,5311.76,,,,,,,,,,,,,
GUIDEWIRE VASC L 45 CM DIA 0.032 IN STR TIP STRL,SUP-2214526,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.43,16.53,,,,,,,,,,,,,
CATHETER DRAINAGE RESOLV L 25 CM DIA10 FR GUIDEWIRE 0.038 IN,SUP-2303333,CDM,C1729,HCPCS,0272,RC,,,,both,,,189.81,123.38,,,,,,,,,,,,,
STOCKING ORTHOT SUPP GRP CUST PREFABRICATED OFF THE SHLF,SUP-2435567,CDM,L0982,HCPCS,0274,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
NEXGEN LPS ART SURF EF 3-4/STR YEL 20MM,SUP-2201952,CDM,C1776,CPT,0278,RC,,,,both,,,4041.18,2626.77,,,,,,,,,,,,,
CATHETER EP DAO 5 MM 6 FRX120 CM SUPREME,SUP-2458303,CDM,C1730,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH THCK 7X5 CM ACELLULAR HYDRATED DERM,SUP-2321763,CDM,C1713,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
JOINT PHALANX 0 DEG 2 MM DIGIFUSE,SUP-2609620,CDM,C1713,HCPCS,0278,RC,,,,both,,,5736.84,3728.95,,,,,,,,,,,,,
SPACER SPNL 13-16 MM TI ACCULIF,SUP-2381479,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
PLATE BNE THK15MM SHT TI FIX CRV LOK,SUP-2262964,CDM,C1713,HCPCS,0278,RC,,,,both,,,1847.14,1200.64,,,,,,,,,,,,,
IMPLANT BRST W11.5XH10.8CM 295ML P4.9CM SIL GEL MOD +,SUP-2300200,CDM,C1789,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
SCREW BNE DIA3.5MM SURFIX LOK REPL FOR TOT WRST FUS SYS,SUP-2243056,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.77,321.60,,,,,,,,,,,,,
SCREW SPNL L30MM OD5.5MM TI CANC PEDCL ST TSRH-3D,SUP-2289888,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X3 CM CRYOPRESERVED UMB CRD NEOX CRD 1K,SUP-2648687,CDM,Q4148,HCPCS,0636,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
WASHER ORTH DIA7MM DOMED FOR CANN SCR SYS MAXTORQUE,SUP-2399472,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
ROD SPNL OD5.5MM L500MM TI R POST SMOOTH STR HEX CDH LEG,SUP-2290758,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PACK BX ASPIR BONE MAR CONC PROC NDL,SUP-2384782,CDM,C1713,HCPCS,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,0636,RC,68516-5216-02,NDC,,both,50,ML,267.70,174.00,,,,,,,,,,,,,
SPACER SPNL W26XH10XL50MM 0DEG NONSTANDARD PEEK OPTMA LAT,SUP-2402802,CDM,C1889,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
NAIL IM L38CM DIA12MM 130DEG LT FEM HIP GRN TI CANN LCK AG,SUP-2347903,CDM,C1713,HCPCS,0278,RC,,,,both,,,5764.10,3746.66,,,,,,,,,,,,,
TR-28 HIP PROTRUSIO RNG 58MM,SUP-2203819,CDM,C1776,CPT,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
COMPACTOR SURG SZ 7/9 UNIV FOR NOTCH/PATELLA GRV PREP SCORP,SUP-2378559,CDM,C1776,CPT,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
ADAPTER CBL NEO W6XH4XL25MM Y LUERLOCK,SUP-2281983,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.91,233.94,,,,,,,,,,,,,
ENDCAP ORTH LCK 4.5 MM WRST FOR FRDM 4.5 MM SCR STRL,SUP-2851947,CDM,C1889,HCPCS,0278,RC,,,,both,,,533.74,346.93,,,,,,,,,,,,,
"HC Total Protein, Other Source",PX-3018415700,CDM,84157,CPT,0301,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
HC Injection for Ductogram,PX-3611903000,CDM,19030,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
NAIL IM L380MM OD11MM 125DEG LNG TIM RT HIP AG CANN LCK,SUP-2211476,CDM,C1713,HCPCS,0278,RC,,,,both,,,4515.32,2934.96,,,,,,,,,,,,,
PLATE BNE W33XL95MM 6 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185109,CDM,C1713,HCPCS,0278,RC,,,,both,,,2925.91,1901.84,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SLXACUTE 14FR DIA 24CM STRGHT TAPR TIP,SUP-2610565,CDM,C1752,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
TITANIUM SCRN MESH PANEL 80MM X 80MM1MM10MM SSTM CP TTNM,SUP-2677463,CDM,C1713,HCPCS,0278,RC,,,,both,,,3079.96,2001.97,,,,,,,,,,,,,
DILTIAZEM HCL ER 90 MG PO CP12,RX-14101,CDM,6370000000,HCPCS,0637,RC,51079-0925-01,NDC,,both,1,UN,17.60,11.44,,,,,,,,,,,,,
PLATE BNE ULNA UNILAT CROSSLOCK DVR,SUP-2411824,CDM,C1713,HCPCS,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
PLATE BNE MESHED 11.2X248.7X1 MM SM GRID OFFSET PDLLA STRL,SUP-2486480,CDM,C1713,HCPCS,0278,RC,,,,both,,,5907.47,3839.86,,,,,,,,,,,,,
COMPONENT GLEN FIX 44 HAP CONVX MTL BK BASE ARW,SUP-2224545,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
WALKER L SHT LEG NONSKID,SUP-2276710,CDM,L4387,HCPCS,0274,RC,,,,both,,,83.56,54.31,,,,,,,,,,,,,
PLATE BNE 4 H R DST FIB ANK S STL LOK FOR FRAC MGMT SYS,SUP-2123022,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
COMPONENT FEM INTERCALARY 55 MM KNEE SEG LPS,SUP-2452897,CDM,C1776,CPT,0278,RC,,,,both,,,3526.22,2292.04,,,,,,,,,,,,,
SPACER SPNL H8XL50MM 6DEG VERT BODY CLYDESDALE,SUP-2285061,CDM,C1821,HCPCS,0278,RC,,,,both,,,11514.38,7484.35,,,,,,,,,,,,,
PLATE BNE DSTL C2 STD RT VOLAR RAD TI,SUP-2646875,CDM,C1713,HCPCS,0278,RC,,,,both,,,1532.23,995.95,,,,,,,,,,,,,
SET CATH HEMODIALYSI 400XL ACUTE BSC 14FR DIA 24CM CRVD EXTN,SUP-2610502,CDM,C1752,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.4 MM TI CRANIOMAXILLOFACIAL EMER ST,SUP-2884140,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.67,151.24,,,,,,,,,,,,,
PROBE OPHTH LASER FIX FBR MOV SHFT ST DIR 20GA,SUP-2382598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
PLATE BNE L 242 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 22 H 72440622N,SUP-2932785,CDM,C1713,HCPCS,0278,RC,,,,both,,,4078.55,2651.06,,,,,,,,,,,,,
CATHETER HEMODIALYSI DUO SPLIT ACTE 13FR DIA 12CM STRGHT 2LU,SUP-2610504,CDM,C1752,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
STENT PERIPH ZILVER PTX L 120 MM DIA 6 MM CATH L 125 CM SHTH,SUP-2170400,CDM,C1874,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
EMR KIT 18 MMX165 CM FOR ENDOSCP MUCOSAL RESECT UPPER GI,SUP-2313210,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.05,427.73,,,,,,,,,,,,,
BIT DRL RETROGRADE 6 MM CANN W/ SUTURE RETRV ACUFEX TRUNAV,SUP-2848647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1236.38,803.65,,,,,,,,,,,,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,0250,RC,00338-0125-03,NDC,,both,500,ML,51.00,33.15,,,,,,,,,,,,,
PLATELET CONCENTRATION KIT ARTERIOCYTE SEP MAGELLAN PRP,SUP-2120696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
RELOAD STPL L60MM H1-2.6MM MESENTERY THN TISS WHT 6 ROW,SUP-2219090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,639.93,415.95,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX15 CM 20 GA SAFETY ACCEL,SUP-2659269,CDM,C1729,HCPCS,0272,RC,,,,both,,,71.59,46.53,,,,,,,,,,,,,
PLATE BNE W17.5XL250MM THK5.2MM 14 H BILAT S STL BROAD,SUP-2185303,CDM,C1713,HCPCS,0278,RC,,,,both,,,2049.20,1331.98,,,,,,,,,,,,,
ROD SPNL S STL OD45 MM X L200 MM SAG,SUP-2279841,CDM,C1713,HCPCS,0278,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
SCREW BNE L30MM DIA4MM PERIARTC S STL ST LOK FULL THRD FOR,SUP-2184953,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
ALLOGRAFT TEND SEMI TENDOSIS 5MMXGREATER THAN 200MM,SUP-2335257,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
BUR SURG DIA4MM RND PRECIS RIM GLDE TECHNOLOGY RAP SMOOTH,SUP-2363785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.65,284.47,,,,,,,,,,,,,
CANNULA THERMOCAN 7FT CASE OF 50,SUP-2307711,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
BIT DRL L 155/60 MM DIA2.8 MM CALIB AO QC NS REUSE V,SUP-2908109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,801.17,520.76,,,,,,,,,,,,,
HC Cardioversion Electric Internal,PX-4809296100,CDM,92961,CPT,0480,RC,,,,both,,,1966.00,1277.90,,,,,,,,,,,,,
PACK AUTOLOG AUTOTRANSUFION,SUP-2280541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
COMPONENT PAT STD + 3PEG RND REV ROT CEM NP LCS,SUP-2252420,CDM,C1776,CPT,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
PATCH VASC CAR 8 MM W 75 MM LEN STD WALL N TAPR N RING KNIT,SUP-2395790,CDM,C1768,CPT,0278,RC,,,,both,,,2866.82,1863.43,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 82 MM DIA 30 MM SHTH 20 FR RVD,SUP-2170627,CDM,C1874,HCPCS,0278,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM HD 2.7MM S STL CORT PERIARTC ST,SUP-2410681,CDM,C1713,HCPCS,0278,RC,,,,both,,,107.64,69.97,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO V3 L 140 CM DIA 6 FR SECT L 20 CM,SUP-2120491,CDM,C1757,HCPCS,0272,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
COMPONENT FEM SZ 3 RT KNEE OXINIUM CEM ASMBLY HNG LEGION,SUP-2346251,CDM,C1776,CPT,0278,RC,,,,both,,,28674.48,18638.41,,,,,,,,,,,,,
VERAPAMIL HCL ER 180 MG PO TBCR,RX-14626,CDM,6370000000,HCPCS,0637,RC,68462-0293-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER EP 6FR L115CM 2.5-2.5-2.5 2.5-247.5MM SPC TIP 1MM,SUP-2248459,CDM,C1730,HCPCS,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
GRAFT BNE SUB 20CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264814,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.37,504.64,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL CTRL ABD,SUP-2435555,CDM,L0636,HCPCS,0274,RC,,,,both,,,3838.43,2494.98,,,,,,,,,,,,,
BEAM FIX 7.5X155 MM CHARCOAT FIX SYS AXIS,SUP-2610030,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
BIT DRL L58MM DIA1.9MM CRANIOMAXILLOFACIAL FOR 20MM,SUP-2366430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.11,334.17,,,,,,,,,,,,,
PLATE BONE L15MM MAXILLOFACIAL DBL T NONCOMPRESSION FOR MINI,SUP-2364905,CDM,C1713,HCPCS,0278,RC,,,,both,,,437.72,284.52,,,,,,,,,,,,,
LEAD NERVE STIM KT 3 MM ELECTRD 4 MM SPC 60 CM QUATTRODE,SUP-2615498,CDM,C1778,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
DOXYCYCLINE HYCLATE 100 MG PO CAPS,RX-2623,CDM,6370000000,HCPCS,0637,RC,50268-0278-15,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 1 DBL Y SHP XLN PLATE,SUP-2936611,CDM,C1713,HCPCS,0278,RC,,,,both,,,30304.14,19697.69,,,,,,,,,,,,,
REAMER CRANTOM DISPOSABLE HI LN XS,SUP-2108780,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
ELECTRODE ENDOSCP PLASMA NDL 12-30 DEG 24 FR LNG ESG TCRIS,SUP-2485562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1627.12,1057.63,,,,,,,,,,,,,
ROPIVACAINE HCL 2 MG/ML IJ SOLN,RX-18192,CDM,J2795,HCPCS,0636,RC,25021-0671-67,NDC,,both,200,ML,178.30,115.89,,,,,,,,,,,,,
HC Tx Spinal Pnxr Drainage CSF W/Fluor/CT,PX-3616232900,CDM,62329,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
UB BLADE KELLY 2 1/2IN X 3IN,SUP-2676580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.89,653.18,,,,,,,,,,,,,
NAIL IM L190MM DIA7.5MM 120DEG STRL BLU L/R HUM TI CANN LCK,SUP-2192483,CDM,C1713,HCPCS,0278,RC,,,,both,,,5665.75,3682.74,,,,,,,,,,,,,
SCREW BNE 7.5X30 MM VOYAGER SOLERA MAS,SUP-2432047,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SAW SURG 105X20X1.27MM WIDE OSC TIP W/ CART FOR BNE CUT,SUP-2367672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
GRAFT TISS DEHYDR TUTOPLAST PERICARD PTCH ST 1.5X1.5CM,SUP-2247188,CDM,C1762,CPT,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
BIT DRL OD2.5MM CANN INTOSS FIX SYS,SUP-2315899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
CATHETER DRNGE 12FR L25CM BILI ARRY MULTPURP W/ STD PGTL,SUP-2308250,CDM,C1729,HCPCS,0272,RC,,,,both,,,235.44,153.04,,,,,,,,,,,,,
BEARING TIB XSM THK12MM UNIV KNEE CO CHROM HNG FLAT ANT,SUP-2252669,CDM,C1776,CPT,0278,RC,,,,both,,,8160.08,5304.05,,,,,,,,,,,,,
PLATE BNE L73MM 2 H L PROX OLECRANON S STL VAR ANG LOK,SUP-2177182,CDM,C1713,HCPCS,0278,RC,,,,both,,,2880.92,1872.60,,,,,,,,,,,,,
PLATE BNE CRV 4.5X159 MM LT CNDYL 6 HOLE VA LCK NS VA-LCP,SUP-2758210,CDM,C1713,HCPCS,0278,RC,,,,both,,,5437.22,3534.19,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM REGENESORB OPN ARCHITECTURE DESIGN,SUP-2882958,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 3.25X3.25 IN FNGR W/ BLB RADLUC,SUP-2276772,CDM,L3933,HCPCS,0274,RC,,,,both,,,3.89,2.53,,,,,,,,,,,,,
PLATE BNE L73MM 4 H NONSTERILE L PROX TIB S STL,SUP-2185697,CDM,C1713,HCPCS,0278,RC,,,,both,,,3647.27,2370.73,,,,,,,,,,,,,
NOREPINEPHRINE 8 MG/250 ML INFUSION NS,RX-4083027,CDM,2500000003,HCPCS,0250,RC,09999-9920-24,NDC,,both,250,ML,127.70,83.00,,,,,,,,,,,,,
COMPONENT FEM KNEE SEMI CONSTRN CEM MTL POLYMER,SUP-2684575,CDM,C1776,CPT,0278,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
PIN EXT FIX L300MM OD4MM TI NITRIDE WIRE H TIP TRANSFIXING,SUP-2400695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
INSTRUMENT KIT LAPIDUS STRATUM,SUP-2423336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1048.76,681.69,,,,,,,,,,,,,
BIT DRL L11MM TIB FOR GEN II SYS,SUP-2346859,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.99,355.54,,,,,,,,,,,,,
GRAFT HUM TISS L THK2 279MM RDY TO USE CNTOUR ALLDERM,SUP-2416980,CDM,Q4116,HCPCS,0636,RC,,,,both,,,19169.70,12460.30,,,,,,,,,,,,,
BLADE SHAVER QUADCUT M4 3X130MM,SUP-2656689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1168.36,759.43,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB FLX CEM SURF GENDER SOL,SUP-2212246,CDM,C1776,CPT,0278,RC,,,,both,,,11732.77,7626.30,,,,,,,,,,,,,
CARTRIDGE HAD EXPR ACUTE DISPOSABLE,SUP-2312275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.44,370.79,,,,,,,,,,,,,
KIT INTRO ARW SHTH L 10 CM DIA 9 FR DIL L 17.75 IN DIA 0.035,SUP-2120577,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.77,104.50,,,,,,,,,,,,,
BRACE WRIST SM 14.6 16.5CM LEFT PRTCTVE PDDNG ADJSTBLE BAR D,SUP-2480988,CDM,L3931,HCPCS,0274,RC,,,,both,,,36.64,23.82,,,,,,,,,,,,,
PLATE BONE DOUBLE ANGLE MEDIUM 1.5 MM PRECONTOURED RECONSTRU,SUP-2842354,CDM,C1713,HCPCS,0278,RC,,,,both,,,8271.07,5376.20,,,,,,,,,,,,,
SPACER SPNL H33-53MM 12MM COR VERT BODY REPL LORD,SUP-2229956,CDM,C1821,HCPCS,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
DEVICE WND CLSR V-LOC 3-0 CV-23 90,SUP-2174853,CDM,C1760,HCPCS,0278,RC,,,,both,,,70.78,46.01,,,,,,,,,,,,,
HC Pt Re-Eval Est Plan Care,PX-4249716400,CDM,97164,CPT,0424,RC,,,,inpatient,,,153.00,99.45,,,,,,,,,,,,,
AUGMENT TIB SZ 1 110DEG L MED R LAT WDG BAL REV SYS,SUP-2315680,CDM,C1776,CPT,0278,RC,,,,both,,,2926.48,1902.21,,,,,,,,,,,,,
CANNULA ENDOSCP TERNAMIAN ENDOTIP 13 MMX15 CM VLV STOPCOCK,SUP-2768737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2838.59,1845.08,,,,,,,,,,,,,
HC Resuscitation,PX-4809295000,CDM,92950,CPT,0480,RC,,,,outpatient,,,424.00,275.60,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 80 CM DIA 7-4 MM EPTFE CARBON,SUP-2761514,CDM,C1768,CPT,0278,RC,,,,both,,,4808.38,3125.45,,,,,,,,,,,,,
SCREW BNE MULT DIR 2.4X18 MM STRL STRATUM RS,SUP-2862012,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.67,409.94,,,,,,,,,,,,,
GUIDE GLEN REVERSED BLUEPRINT,SUP-2388828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
RETRACTOR SURG W18XL240MM S STL SHT NAR TIP HOHMN,SUP-2410972,CDM,C1713,HCPCS,0278,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
BRACE CERV HRD CUST,SUP-2388135,CDM,L0174,HCPCS,0272,RC,,,,both,,,1074.63,698.51,,,,,,,,,,,,,
BOWL BONE CEM MX OPTITWIST,SUP-2196560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
MARKER CLP ULTRACOR FOR 14GA S STL,SUP-2126904,CDM,A4648,CPT,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA16MM NONCOLORED S STL W SPADE PNT,SUP-2186900,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.16,46.90,,,,,,,,,,,,,
BASKET RETRV L2700MM DIA16MM MIN WRK CHN 2.8MM ROT 6 WIR TO,SUP-2313142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.74,411.28,,,,,,,,,,,,,
WASHER ORTH 4.5MM DIA2.2MM S STL RND FIX,SUP-2184678,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.14,40.39,,,,,,,,,,,,,
FORCEP ENDOSCP BX AD 4 MMX180 CM 2 MM GI SPEC RETRV STD FEN,SUP-2865645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1679.43,1091.63,,,,,,,,,,,,,
SCREW CRAN L 4 MM DIA1.7 MM 10PK PLLA PGA PDLA RESRB STRL DEL,SUP-2883348,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
PLATE BONE THK1MM 2X4 H LT HND L SHP LCK TRILOK FOR 2MM SCR,SUP-2267926,CDM,C1713,HCPCS,0278,RC,,,,both,,,1110.30,721.69,,,,,,,,,,,,,
CATHETER HD PRE CRV 14 FRX20 CM DL 400 XL FULL TY,SUP-2266967,CDM,C1750,HCPCS,0278,RC,,,,both,,,287.62,186.95,,,,,,,,,,,,,
CATHETER GUID RAPIDO CUT-AWAY WORKING L 47 CM OD 2.7 MM ID,SUP-2149001,CDM,C1887,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SOCKS COMPR UPPER EXTREMITY FRAC BRAC,SUP-2388195,CDM,L3995,HCPCS,0274,RC,,,,both,,,86.10,55.96,,,,,,,,,,,,,
PLATE BONE 1 MM 20 HOLE ADAPTION TITANIUM MATRIXMANDIBLE,SUP-2837747,CDM,C1713,HCPCS,0278,RC,,,,both,,,2696.95,1753.02,,,,,,,,,,,,,
LEAD NERVE STIM 50 CM PADDLE KT ARTISAN,SUP-2138834,CDM,C1778,HCPCS,0278,RC,,,,both,,,12961.92,8425.25,,,,,,,,,,,,,
ALLOGRAFT BNE FEM HD 4.8 CM FRZN W/O CART,SUP-2717885,CDM,C1762,CPT,0278,RC,,,,both,,,6931.02,4505.16,,,,,,,,,,,,,
TUBING SUCTION 15 FRX3 MM 32 CM SIL,SUP-2394845,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 5 MM RNG L 30 CM EPTFE,SUP-2396284,CDM,C1768,CPT,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
COUPLER SURG PWR SM NEW EXT SVC 1YR,SUP-2760773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
NUT REDUC SPNL VERT BODY EXT TSRH 3D,SUP-2289810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1043.01,677.96,,,,,,,,,,,,,
GRAFT VASC PROPATEN L 10 CM DIA 3 MM EPTFE CBAS HEPARIN TW,SUP-2655621,CDM,C1768,CPT,0278,RC,,,,both,,,2895.08,1881.80,,,,,,,,,,,,,
CLAMP FIX S STL ANGULAR FOR HALF PIN,SUP-2242957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1302.19,846.42,,,,,,,,,,,,,
CARPEL ORTH TRAPEZIUM 20 MM AVANTA CMC,SUP-2469007,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
BLADE SHAVER BPLR 4 MM CONVX FOR DIEGO ELITE TURB,SUP-2648962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.91,361.34,,,,,,,,,,,,,
COMPONENT FEM SM L DST KNEE MOD REPL SYS GMRS,SUP-2376510,CDM,C1776,CPT,0278,RC,,,,both,,,17297.95,11243.67,,,,,,,,,,,,,
PLATE ANCHORAGE 2 MTP CP RT,SUP-2695662,CDM,C1713,HCPCS,0278,RC,,,,both,,,9571.66,6221.58,,,,,,,,,,,,,
ANCHOR SUT GRN SGL SUT CP 2 NDL PANALOK QUICKANCHR,SUP-2184245,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
DISTRACTION INTRNL SCREW MXDRVEHEX ZRCH DRILL FREE 2.0 MM H,SUP-2678356,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
GUIDEWIRE LD PERC,SUP-2615459,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
ALLOGRAFT BNE 15 CC FIBERCEL,SUP-2787759,CDM,C1713,HCPCS,0278,RC,,,,both,,,12235.45,7953.04,,,,,,,,,,,,,
MIDFACE KIT CUSTOMIZED RECON PEEK NS FACE ID LTX,SUP-2862809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,47506.98,30879.54,,,,,,,,,,,,,
STEM HUM LNG 8 MM SHLDR AFFINITI PC,SUP-2715293,CDM,C1776,CPT,0278,RC,,,,both,,,17668.78,11484.71,,,,,,,,,,,,,
ROD IM L20CM DIA14MM TOT FEM TI FOR ORTH SALV SYS,SUP-2405849,CDM,C1713,HCPCS,0278,RC,,,,both,,,7672.59,4987.18,,,,,,,,,,,,,
GUIDEWIRE SURG L240MM DIA2MM S STL TRCR TIP FOR HUM NAIL,SUP-2178839,CDM,C1769,HCPCS,0272,RC,,,,both,,,99.07,64.40,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT VOID FILL CA PHSPTE ST 3CC OSTEOVATION,SUP-2319786,CDM,C1713,HCPCS,0278,RC,,,,both,,,3576.46,2324.70,,,,,,,,,,,,,
PLATE BNE VA 2.7X211 MM ARTC PROX 12 HOLE SS NS VA-LCP,SUP-2184187,CDM,C1713,HCPCS,0278,RC,,,,both,,,4015.49,2610.07,,,,,,,,,,,,,
WASHER ORTH 4 MM FOR PROV TISS CRV TRABECULAR MTL,SUP-2437276,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
HEAD FEM BALL 12/14 LNG 32 MM ANTR POST,SUP-2440890,CDM,C1776,CPT,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 3-4 CD 14 MM KNEE YEL NXGN LPS,SUP-2201940,CDM,C1776,CPT,0278,RC,,,,both,,,2455.48,1596.06,,,,,,,,,,,,,
PLATE BNE W24XL43MM 12 H L DST RAD TI LOK COMPR LO PROF NAR,SUP-2411821,CDM,C1713,HCPCS,0278,RC,,,,both,,,3397.48,2208.36,,,,,,,,,,,,,
CANNULA ENDOSCP L 100 MM IN/OUTFLOW DRN SHRP TROCAR,SUP-2908669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
GRAFT VASC ADVANTA AFT L 30 CM DIA 6 MM EPTFE STR STD WALL,SUP-2493251,CDM,C1768,CPT,0278,RC,,,,both,,,992.87,645.37,,,,,,,,,,,,,
"HC So Hiv-1, Quantification",PX-3068753666,CDM,87536,CPT,0306,RC,,,,both,,,621.00,403.65,,,,,,,,,,,,,
HC So1 Beta 2 Glycoprotein 1 Ab,PX-3028614667,CDM,86146,CPT,0302,RC,,,,both,,,30.00,19.50,,,,,,,,,,,,,
STEM ULN L3CM DIA6MM DSTL RAD EXT,SUP-2119918,CDM,C1776,CPT,0278,RC,,,,both,,,7432.38,4831.05,,,,,,,,,,,,,
CEMENT BONE CONFLOW G,SUP-2736176,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.76,418.44,,,,,,,,,,,,,
BIT DRL DIA4.9MM SH CALIB FOR NAT NAIL SYS,SUP-2205652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,391.87,254.72,,,,,,,,,,,,,
BIT DRL L66MM DIA2.35MM STP 10MM TWST QUIK NONRADIOLUCENT,SUP-2267851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
KIT SUT SZ 0 L7MM DIA2.2MM W/ SUT ANCHR FIBERWIRE NDL V TAK,SUP-2122459,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
SCISSORS 5MM 32CML LAPSCP CVD MPLR STD NU TIP REUSE HNDL,SUP-2171742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
EYELET ORTH LP VUEPOINT II,SUP-2563645,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
DEVICE FIX TWIN TAIL TECH TIGHTROPE,SUP-2121666,CDM,C1776,CPT,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PIN FIX TIBIAL SZR TEMPLATE 2PK,SUP-2890804,CDM,C1776,CPT,0278,RC,,,,both,,,582.47,378.61,,,,,,,,,,,,,
PIN MXLFCL 1.6X4 MM PDLLA STRL SONICPIN RX,SUP-2466544,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.79,166.91,,,,,,,,,,,,,
HC Stool Culture Add Pathogens,PX-3008704600,CDM,87046,CPT,0300,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA2 L 112 MM DIA 34 MM SHTH 18 FR,SUP-2912008,CDM,C1768,CPT,0278,RC,,,,both,,,41218.78,26792.21,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CANN 5 MM 4.4 FRX20 MM TRUETOME 44,SUP-2141621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.06,450.49,,,,,,,,,,,,,
CATHETER GUID ATTAIN L 45 CM OD 3.3 MM ID 7.2 FR HYDRPHLC,SUP-2282166,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT HEMO DYLS OR HD CATH AD 15.5FR L20CM BASIC PRECRV STK,SUP-2116541,CDM,C1750,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
GRAFT BNE WDG 8 DEG 8 MM LAPIDUS,SUP-2321726,CDM,C1713,HCPCS,0278,RC,,,,both,,,5418.95,3522.32,,,,,,,,,,,,,
HC So Targeted Genomic Seq Analys,PX-3108145566,CDM,81455,CPT,0310,RC,,,,outpatient,,,3287.00,2136.55,,,,,,,,,,,,,
INTRODUCER PACE LD SOLO-TRAK KR DIA 7 FR PERC 10 LUMEN STRL,SUP-2282092,CDM,C1894,HCPCS,0272,RC,,,,both,,,193.80,125.97,,,,,,,,,,,,,
PLATE BNE L60MM THK1.2MM BILAT CALCNL S STL LOK COMPR FOR,SUP-2185984,CDM,C1713,HCPCS,0278,RC,,,,both,,,2866.69,1863.35,,,,,,,,,,,,,
RELOAD STPL L60MM DIA4.8MM UNIV ROTIC ENDO GIA,SUP-2283063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1063.49,691.27,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ W/POS LCK JT PREFABRICATED,SUP-2435760,CDM,L3761,HCPCS,0274,RC,,,,both,,,1288.59,837.58,,,,,,,,,,,,,
KIT REP HAD BLNT TRCR TUNN X L,SUP-2116793,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP DST 3.9FR L20MM TIP L5MM GWIRE,SUP-2149819,CDM,C1769,HCPCS,0272,RC,,,,both,,,978.83,636.24,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC DEMINERALIZED CORT CANC BNE,SUP-2905180,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.65,760.27,,,,,,,,,,,,,
KIT INSTR APREVO,SUP-2912093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SCREW BNE L16MM DIA3MM SHT THRD L4MM CANC TI CANN ST SELF,SUP-2181306,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.36,571.58,,,,,,,,,,,,,
PLATE BNE L W13.5XL88MM THK4.2MM 5 H BILAT TI STR RIG LIMIT,SUP-2190809,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.96,360.07,,,,,,,,,,,,,
WASHER ORTH DIA6.0MM,SUP-2343054,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.97,8.43,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 16 CHAN RECHRG ECON MINI,SUP-2356760,CDM,C1820,HCPCS,0278,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
BIT DRILL SURG DIA2 MM AO STYL NS DISP,SUP-2930412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.98,375.04,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 9 FR CANN L 11 CM GUIDEWIRE 0.038 IN,SUP-2157380,CDM,C1894,HCPCS,0272,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
MESH BONE SIZE 11 0.6MM THK TTNM CNTRD STNDRD LATEX FREE RIG,SUP-2500946,CDM,C1713,HCPCS,0278,RC,,,,both,,,16574.52,10773.44,,,,,,,,,,,,,
COMPONENT HIP CEM BPLR HA LD/FX,SUP-2212769,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CANC MORSELIZED W/ VIABLE CELL FRZN,SUP-2307245,CDM,C1713,HCPCS,0278,RC,,,,both,,,14396.90,9357.98,,,,,,,,,,,,,
STEM FEM HI OFFSET 1 120 MM HIP NK SEG ENDUR,SUP-2454651,CDM,C1776,CPT,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
PLATE BONE CURVED 3.5X70 MM 6 HOLE RECONSTRUCTION FOR SCREW,SUP-2836668,CDM,C1713,HCPCS,0278,RC,,,,both,,,3167.63,2058.96,,,,,,,,,,,,,
NEEDLE HOLDER 3744016 HALSEY SMOOTH,SUP-2473758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.61,287.70,,,,,,,,,,,,,
ZINC OXIDE 13 % EX CREA,RX-92811,CDM,6370000000,HCPCS,0637,RC,74300-0003-00,NDC,,both,57,GR,17.50,11.37,,,,,,,,,,,,,
PLATE BNE W9XL73MM THK1MM 6 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190950,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.97,336.68,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM LO AIRFLO RESISTANCE PROVOX2,SUP-2124340,CDM,L8509,HCPCS,0274,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
SCREW BNE L20MM DIA2MM CORT HND EL FT TI TRILOK APTUS,SUP-2268162,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.23,252.35,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0258,RC,00264-1800-32,NDC,,both,250,ML,57.40,37.31,,,,,,,,,,,,,
SCREW BNE MYOMA 5X320 MM LAP FOR MANIPULATION,SUP-2470303,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.18,288.72,,,,,,,,,,,,,
GUIDEWIRE THRD CALIB 32X300,SUP-2695784,CDM,C1769,HCPCS,0272,RC,,,,both,,,268.16,174.30,,,,,,,,,,,,,
SLEEVE CNTR L38.1MM OD12.7MM ID9MM FOR IM HIP SCR,SUP-2351365,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.73,465.22,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM REDUCTION UNIAXIAL STRL CD 2PK,SUP-2928052,CDM,C1713,HCPCS,0278,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
GUIDEWIRE ENDO L480CM OD0.035IN LOOP TIP 2X4MM NIT SPRL MRK,SUP-2170836,CDM,C1769,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
PLATE BNE L77MM 3 H R PROX PERIARTC ULNA LOK,SUP-2198451,CDM,C1713,HCPCS,0278,RC,,,,both,,,2214.80,1439.62,,,,,,,,,,,,,
OXYBUTYNIN CHLORIDE ER 5 MG PO TB24,RX-24470,CDM,6370000000,HCPCS,0637,RC,00904-6570-06,NDC,,both,1,UN,12.60,8.19,,,,,,,,,,,,,
BUR SURG 64X60MM NEURO RND CUT FLUT CARB ST MICROFRANCE,SUP-2284184,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.45,342.19,,,,,,,,,,,,,
GUIDEWIRE SURG 0.062X18.5 IN NIT HYPRFLX,SUP-2765928,CDM,C1769,HCPCS,0272,RC,,,,both,,,121.68,79.09,,,,,,,,,,,,,
PEG FIX LCK 2X28 MM OPTILOCK,SUP-2473128,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
STEM FEM VERSYS 7.5 INCH BEADED FC REV 13.5X190MM STRAIGHT,SUP-2504240,CDM,C1776,CPT,0278,RC,,,,both,,,13966.72,9078.37,,,,,,,,,,,,,
CONNECTOR SPNL M SZ 6 L32-37MM STD POST LUM THOR TI SCR,SUP-2254361,CDM,C1713,HCPCS,0278,RC,,,,both,,,4242.14,2757.39,,,,,,,,,,,,,
STEM FEM VERSYS ADVOCATE CEMENTED STEM 14X135 STANDARD,SUP-2504398,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
BLADE RETRACTOR INSTRUMENT,SUP-2242480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.87,722.72,,,,,,,,,,,,,
SPLINT WR COLLES ALUM W/ FOAM LT M,SUP-2195268,CDM,L3906,HCPCS,0272,RC,,,,both,,,28.54,18.55,,,,,,,,,,,,,
CATHETER THOR 24FR L15.75IN PVC SHRP TRCR TIP RADPQ SENTNL,SUP-2154957,CDM,C1729,HCPCS,0272,RC,,,,both,,,37.62,24.45,,,,,,,,,,,,,
SAW SURG JOS 190 BAYNT SHP STR,SUP-2649607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
BASKET SPEC RETRV FB 35 CM W/O HNDL FOR 10386B,SUP-2771788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1062.42,690.57,,,,,,,,,,,,,
SCREW CRTX FT ST HEX HD 4.5MM DIA 38MML,SUP-2342658,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.67,201.94,,,,,,,,,,,,,
KIT TKR HYBRID CEM FEM TRABECULAR MTL TIB PROLONG SURF AND,SUP-2402812,CDM,C1776,CPT,0278,RC,,,,both,,,13542.82,8802.83,,,,,,,,,,,,,
ROD EXT FIX L860MM DIA8MM SPAN L540MM 180DEG C FBR CVD,SUP-2188724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1559.95,1013.97,,,,,,,,,,,,,
PLATE BNE W135XL332MM THK42MM 18 H BILAT S STL NAR LOK,SUP-2185257,CDM,C1713,HCPCS,0278,RC,,,,both,,,2696.51,1752.73,,,,,,,,,,,,,
GUIDEROD ORTH L600MM DIA3MM SMOOTH BALL TIP,SUP-2347567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.52,274.64,,,,,,,,,,,,,
NEEDLE ENDO KNEE STRL SCORPION,SUP-2121201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SCREW BNE L30MM DIA6MM CORT ST NONCANNULATED NONLOCKING,SUP-2377552,CDM,C1713,HCPCS,0278,RC,,,,both,,,865.86,562.81,,,,,,,,,,,,,
SLING ARM M FOR 11-13IN UNIV PREM QUAL BRTH EXTRA PD FAB,SUP-2196420,CDM,L3660,HCPCS,0274,RC,,,,both,,,164.38,106.85,,,,,,,,,,,,,
STEM FEM 19.5 MM HIP MOCK ZMR,SUP-2439593,CDM,C1776,CPT,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
IMMOBILIZER KNEE CLOSE PATTELLA FOAM VELC LOOP STRP LT OR RT,SUP-2330405,CDM,L1830,CPT,0274,RC,,,,both,,,80.64,52.42,,,,,,,,,,,,,
MESH HERN W8XL12IN RECT SEPRAMESH IP COMP,SUP-2125925,CDM,C1781,HCPCS,0278,RC,,,,both,,,3223.84,2095.50,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X182X2 MM RT MAND 26 HOLE ANGLED STRL,SUP-2478108,CDM,C1713,HCPCS,0278,RC,,,,both,,,6238.11,4054.77,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX50 CM STD WALL EPTFE CARBOFLO CENTERFLEX,SUP-2761402,CDM,C1768,CPT,0278,RC,,,,both,,,2351.99,1528.79,,,,,,,,,,,,,
CRANIAL ACCESS KIT W/ DRUG 2 DRL BIT RAZOR,SUP-2852690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.88,1106.22,,,,,,,,,,,,,
SHEATH LENS CLN SYS 4MM 30DEG FOR STRYKR 502-477-031,SUP-2277883,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.30,104.19,,,,,,,,,,,,,
PLATE BNE Y SM 3.5 MM FOR RECON SYS NS LTX,SUP-2861122,CDM,C1713,HCPCS,0278,RC,,,,both,,,717.99,466.69,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA16 FR DIL L 20 CM GUIDEWIRE,SUP-2168022,CDM,C1892,HCPCS,0272,RC,,,,both,,,155.40,101.01,,,,,,,,,,,,,
BUR ENDOSCP RND MED 4.2X120 MM GRY ORNG STRL UNIDRIVE DISP,SUP-2585885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,136.46,88.70,,,,,,,,,,,,,
PLATE TI VA-LOCKING CALCANEALMED 2.7MM 64MM LEFT STRL,SUP-2547002,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.75,2367.79,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 4H /85MM/60MM STRL,SUP-2547506,CDM,C1713,HCPCS,0278,RC,,,,both,,,2563.31,1666.15,,,,,,,,,,,,,
HC Pt Neuro Facilitation Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209711200,CDM,97112,CPT,0420,RC,,,GO|CO|XU,both,,,159.00,103.35,,,,,,,,,,,,,
GRAFT TEND SEMI TENDOSIS ALLGRFT FRZ DRY 26CM L,SUP-2307098,CDM,C1762,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PLU MAXBARR 4FR 55CM 1 LU 1174108D2,SUP-2632626,CDM,C1751,HCPCS,0278,RC,,,,both,,,974.97,633.73,,,,,,,,,,,,,
LINER TRL RNWT BRSTN MAX-TI SIZE: 64X32,SUP-2403318,CDM,C1776,CPT,0278,RC,,,,both,,,1871.44,1216.44,,,,,,,,,,,,,
PLATE BNE RT FLX STRL F3 LTX,SUP-2861101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1746.47,1135.21,,,,,,,,,,,,,
HC Puncture Shunt/Reservoir,PX-3616107000,CDM,61070,CPT,0361,RC,,,,both,,,1818.00,1181.70,,,,,,,,,,,,,
HC Treat Wrist Bone Fx,PX-4502563500,CDM,25635,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
ROD RMR L650MM DIA2.5MM W/ EXTN BALL TIP,SUP-2188109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE SPNL FIX 4.5X28 MM SS CROSSLINK,SUP-2630565,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
SET ORTH INSTR SHLDR PERC COR DECOMPRESSION SYS STRL DISP,SUP-2884256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5510.70,3581.95,,,,,,,,,,,,,
SCREW BONE L105MM DIA6.5MM CANC TI FULL THRD PLATING SYS,SUP-2413553,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
HC Intubation/Endotracheal/Emerg,PX-4503150000,CDM,31500,CPT,0450,RC,,,,inpatient,,,403.00,261.95,,,,,,,,,,,,,
SET ORTH GWIRE DRL BIT FOR CARPOMETACARPAL LIGMNT RECON,SUP-2121450,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
HC So Osmolality Serum,PX-3018393066,CDM,83930,CPT,0301,RC,,,,outpatient,,,26.00,16.90,,,,,,,,,,,,,
SCREW INTRF KNEE CANN N ABSRB TI 7MM 20MM,SUP-2249496,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
SHEATH ENDOSCP 10-12 FRX54 CM ACCS VARI-PASS,SUP-2497201,CDM,C1894,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM ID2MM 180-250OHM LT VAGUS NRV,SUP-2175910,CDM,C1778,HCPCS,0278,RC,,,,both,,,26878.40,17470.96,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 22-25 CM ART CUF SET TROCAR TESIO,SUP-2627150,CDM,C1750,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
LNT IMP SYSTEM 4.75 PEEK KL SWIVELOCK,SUP-2812244,CDM,C1713,HCPCS,0278,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
ANKLE FUSION PLATE ANTERIOR TT RIGHT 5H,SUP-2815299,CDM,C1713,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
SCREW BNE ST 1.2X5 MM EMGCY THRD W/ FLUT TIP TI NS,SUP-2189154,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
SYSTEM STENT INTRO CATH PUSH 8.5FR GUID 5FR L195CM 0.035IN,SUP-2170075,CDM,C1894,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
GRAFT VASC GELSFT L 20 MM DIA12 MM POLYESTER GEL ABD PERIPH,SUP-2384940,CDM,C1768,CPT,0278,RC,,,,both,,,1688.88,1097.77,,,,,,,,,,,,,
SHELL HMSPHR SHELL 44 MM,SUP-2217267,CDM,C1776,CPT,0278,RC,,,,both,,,15511.60,10082.54,,,,,,,,,,,,,
SCREW BNE FEM FOR REV KNEE SYS VANGUARD,SUP-2407545,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.22,136.64,,,,,,,,,,,,,
PROBE CRYOABLATION L10CM ALUM SMOOTH MAL CRYOICE,SUP-2124442,CDM,C2618,HCPCS,0272,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
TAP SURG DIA17MM SELF DRL HEX FOR 3 4MM,SUP-2365069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1147.07,745.60,,,,,,,,,,,,,
PLATE BNE L355MM 14 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186050,CDM,C1713,HCPCS,0278,RC,,,,both,,,5468.47,3554.51,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY 2 EL VR W 6.3 X H 7.1 CM D 1.1,SUP-2149287,CDM,C1722,HCPCS,0275,RC,,,,both,,,40035.00,26022.75,,,,,,,,,,,,,
KIT THROMCTMY 5MAX L 132 CM PROX/DSTL OD 6/5.75 FR ID,SUP-2323548,CDM,C1887,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 19 HOLE/436MM RIGHT-STERILE,SUP-2546863,CDM,C1713,HCPCS,0278,RC,,,,both,,,5730.44,3724.79,,,,,,,,,,,,,
PUMP PENILE PROS STANDALONE ELONGATED NK HI PROF DEFLATION,SUP-2930715,CDM,C1813,HCPCS,0278,RC,,,,both,,,30104.91,19568.19,,,,,,,,,,,,,
MESH HERN FLAT SHT 6X6 IN SQ RND FLX KNITTED PROLITE ULTRA,SUP-2227247,CDM,C1781,HCPCS,0278,RC,,,,both,,,112.79,73.31,,,,,,,,,,,,,
PLATE BNE LG FT LAT CLMN STRL A.L.P.S,SUP-2486267,CDM,C1713,HCPCS,0278,RC,,,,both,,,2378.77,1546.20,,,,,,,,,,,,,
BLADE RTRCTR RVL SHRT TOOTH 50MML VLT F/ANTRR CRVCL FSN RMVL,SUP-2468708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.14,307.54,,,,,,,,,,,,,
CATHETER HD LNG TERM ACCS CANNON II +,SUP-2383987,CDM,C1881,HCPCS,0278,RC,,,,both,,,1096.39,712.65,,,,,,,,,,,,,
COIL VASC TORNADO EMBOLUS L 14 CM DIA 6 MM CATH DIA 0.035 IN,SUP-2168828,CDM,C1889,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
KIT PRESSURE MONITOR VENTRICULAR CATH TUNN TROCAR ANCHR CLP,SUP-2883380,CDM,C1729,HCPCS,0272,RC,,,,both,,,2312.04,1502.83,,,,,,,,,,,,,
HC Prothrombin Time,PX-3058561000,CDM,85610,CPT,0305,RC,,,,both,,,106.00,68.90,,,,,,,,,,,,,
GRAFT SYNTH TISS 25 CC CALCIUM SULF CALCIGEN S,SUP-2462784,CDM,C1713,HCPCS,0278,RC,,,,both,,,3334.68,2167.54,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-102363,CDM,2500000003,HCPCS,0250,RC,00264-7638-00,NDC,,both,1000,ML,57.50,37.37,,,,,,,,,,,,,
KETOROLAC-ROPIV-KETAMINE 15-100-30 MG/50ML IJ SOSY,RX-146777,CDM,2500000003,HCPCS,0250,RC,69374-0519-50,NDC,,both,50,ML,287.50,186.87,,,,,,,,,,,,,
PIN EXT FIX HALF LNG 5X180 MM 35 MM THRD TIN SIDEKCK FRDM,SUP-2460889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
SYSTEM SPEC RETRV EXTRACTION 12 MM 16 MMX4 CM 6500 CC ALEXIS,SUP-2119764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
HOOK PED GIC52 5.5 RHT THOR HK TI88905532,SUP-2291328,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BIT DRILL CANN LG 14 MM FLX QC NS,SUP-2422900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2364.58,1536.98,,,,,,,,,,,,,
HYDROMORPHONE HCL 1 MG/ML IV SOLN,RX-156956,CDM,2500000003,HCPCS,0250,RC,71266-9115-01,NDC,,both,30,ML,123.20,80.08,,,,,,,,,,,,,
PLATE BNE VOLAR RT 12 HOLE ANAT X EXT STRL DVR,SUP-2476728,CDM,C1713,HCPCS,0278,RC,,,,both,,,4110.26,2671.67,,,,,,,,,,,,,
BUR SURG RND STD 3.5 MM 57 MM TOOL STL POWERFORMA,SUP-2629014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,237.82,154.58,,,,,,,,,,,,,
CATHETER GUID ENVOY L 95 CM OD 6 FR ID 0.071 IN DSTL L 8 CM,SUP-2249008,CDM,C1887,HCPCS,0272,RC,,,,both,,,2538.69,1650.15,,,,,,,,,,,,,
HC Insert Wrls Car Stim Lv Pacg Complete Sys,PX-4810515000,CDM,0515T,CPT,0481,RC,,,,both,,,72867.00,47363.55,,,,,,,,,,,,,
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-107208,CDM,J0897,HCPCS,0636,RC,55513-0730-01,NDC,,both,1.7,ML,10176.80,6614.92,,,,,,,,,,,,,
DANAZOL 100 MG PO CAPS,RX-9714,CDM,6370000000,HCPCS,0637,RC,00555-0634-02,NDC,,both,1,UN,17.20,11.18,,,,,,,,,,,,,
BLADE IM L90MM DIA11MM TI HELI FOR TROCHANTERIC NAIL FIX,SUP-2191899,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.13,1122.63,,,,,,,,,,,,,
BIT DRIL SURG DIA35MM FOR DIA5MM SCR FOR LT LIF XIA 45 CT,SUP-2381178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BNE L64MM THK2MM L CALCNL S STL LOK COMPR FOR,SUP-2185986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1765.62,1147.65,,,,,,,,,,,,,
SET PICC INSERTION 4.5FR,SUP-2624225,CDM,C1892,HCPCS,0272,RC,,,,both,,,118.69,77.15,,,,,,,,,,,,,
GRAFT BONE L 150MM LT ANK WHL TRAD FRZN,SUP-2294189,CDM,C1713,HCPCS,0278,RC,,,,both,,,18651.60,12123.54,,,,,,,,,,,,,
ALLOGRAFT BNE 15 CC PRIMAGEN ADV,SUP-2693647,CDM,C1713,HCPCS,0278,RC,,,,both,,,10782.76,7008.79,,,,,,,,,,,,,
MONTELUKAST SODIUM 5 MG PO CHEW,RX-22510,CDM,6370000000,HCPCS,0637,RC,42291-0623-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ANCHOR SUT OD6.5MM INTRALINE PEEK,SUP-2421259,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.91,370.44,,,,,,,,,,,,,
ROD EXT FIX L125MM DIA11MM C FBR MR CONDITIONAL FOR LNG,SUP-2188650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
FILTER VASC GRNFLD L 28 MM DIA12 FR TI INTRO ENTRY KT PERM,SUP-2142720,CDM,C1880,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
SCREW INTFR 8MM 20MM KNEE CANN TAPR TIP N ABSRB TI GUARDSMAN,SUP-2167013,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.29,269.29,,,,,,,,,,,,,
STEM FEM INTLOK C 11X300 MM LT HIP BIMTRC,SUP-2449884,CDM,C1776,CPT,0278,RC,,,,both,,,15260.40,9919.26,,,,,,,,,,,,,
CATHETER HD STR 15.5 FRX24 CM SHT TERM 3L T-3 CT,SUP-2627215,CDM,C1752,HCPCS,0278,RC,,,,both,,,112.16,72.90,,,,,,,,,,,,,
PLATE EXT FIX LNG 100 MM FT RNG CARBON FIBER NS,SUP-2800196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2055.66,1336.18,,,,,,,,,,,,,
SCREW BONE L100MM DIA7MM THRD L16MM S STL SELF DRL ST CANN,SUP-2343698,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.28,1092.83,,,,,,,,,,,,,
SCREW DISTRCTN ST 14 MM DISP,SUP-2106567,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
GRAFT BNE PARTICULATE 250-1000 M UM 0.5 CC CANC PUROS,SUP-2860956,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
MESH HERN TIMESH 8X6 IN,SUP-2402533,CDM,C1781,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
WIRE BNE FIX L 255 MM DIA2 MM DRL TIP STRL KIRSCHNER,SUP-2933808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.66,1612.43,,,,,,,,,,,,,
COUNTERSINK DRL M3X SYS,SUP-2422266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SPACER SPNL W11XH6XL11MM 4DEG PEEK ANT CERV INTBDY FUS LORD,SUP-2286323,CDM,C1889,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
BIT DRL TWST 3.8MMX310 COIL 50 QUIK CPL DISP,SUP-2101267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.19,434.32,,,,,,,,,,,,,
GRAFT HUM TISS W20XL15MM THK10MM FRZ DRY ALLGRFT BLK CANC,SUP-2307118,CDM,C1713,HCPCS,0278,RC,,,,both,,,2453.16,1594.55,,,,,,,,,,,,,
INSERT TIB SZ 1 THK7MM E VITALIZE POST STBL HI FLX,SUP-2314968,CDM,C1776,CPT,0278,RC,,,,both,,,4232.72,2751.27,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA6MM THRD L30MM S STL SELF DRL MR,SUP-2186991,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.60,320.19,,,,,,,,,,,,,
CATHETER URO L20CM OD1FR NDL OD28GA SPL INTRO PREEMIECATH,SUP-2394007,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
KIT ENDO INSTR CATH MEDL FIRM TIP EXT WRK CHAN LOCATABLE,SUP-2281539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
PEG FIX VOLAR 22X51 MM RT DORS RADIAL NAR LCK W/ SMOOTH STRL,SUP-2861573,CDM,C1713,HCPCS,0278,RC,,,,both,,,6267.88,4074.12,,,,,,,,,,,,,
NAIL IM MOD SM LCK CLLR BOLT,SUP-2449909,CDM,C1713,HCPCS,0278,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
TRAY VERT AUG SYS BAL L10MM W/ 13GA NDL IVAS,SUP-2361540,CDM,C1726,HCPCS,0272,RC,,,,both,,,4777.51,3105.38,,,,,,,,,,,,,
PLATE BNE 11 H ST L CUBOID TI MAL LO PROF FOR 24 27MM SCR,SUP-2180785,CDM,C1713,HCPCS,0278,RC,,,,both,,,2760.15,1794.10,,,,,,,,,,,,,
PLATE BNE GRIFFIN MOD LINDORF 7 MM CHIN FOR 2.0 MM SYS CP TI,SUP-2458596,CDM,C1713,HCPCS,0278,RC,,,,both,,,614.84,399.65,,,,,,,,,,,,,
HOOK LENS SINSKEY II 90 DEG 4-5/8 IN BLNT FLAT HNDL ANGLED,SUP-2871892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.91,225.49,,,,,,,,,,,,,
HC Radiation Treatment Delivery Level 3,PX-3337741200,CDM,77412,CPT,0333,RC,,,,both,,,3090.00,2008.50,,,,,,,,,,,,,
SUPPORT NEW EDGE CLAVICLEXL,SUP-2324200,CDM,L3670,HCPCS,0274,RC,,,,both,,,115.96,75.37,,,,,,,,,,,,,
MESH SURG 15CM OMEGA 3 FATTY ACID FIL POLYPR SEE THRU,SUP-2265980,CDM,C1781,HCPCS,0278,RC,,,,both,,,1547.99,1006.19,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 14 28MM 20CC B TRICALCIUM PHSPTE SYN,SUP-2194013,CDM,C1713,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR PT ITREL III,SUP-2284581,CDM,C1787,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SET CENTESIS 1 STP CATH L 10 CM DIA 4 FR INTRO NDL 20 GA NO,SUP-2484924,CDM,C1729,HCPCS,0272,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
DRAINAGE SET STD INTEGR 1 PC M LL CONN CLP EXAFLOW,SUP-2666669,CDM,C1729,HCPCS,0272,RC,,,,both,,,571.20,371.28,,,,,,,,,,,,,
CEMENT BNE 2 VISC FULL DOSE LOWER POROSITY SIMPLEX P,SUP-2365914,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
KIT INTRO MAK L 10 CM DIA 4 FR 40 CM 0.018 IN PLAT ECHO COAX,SUP-2303000,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
GRAFT EVAR L11.5CM DIA20MM IL LIMB EXCLUDER,SUP-2395956,CDM,C1768,CPT,0278,RC,,,,both,,,12497.20,8123.18,,,,,,,,,,,,,
COVER BUR H DIA17MM 6 H TI FOR 1.5MM SCR,SUP-2191189,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
KIT CBL AD PUSHBUTTON HD FOR LO LIMB PAIN NEUROSTIM AXIUM,SUP-2357681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1419.56,922.71,,,,,,,,,,,,,
HC Drain Cerebro Spinal Flui,PX-4506227200,CDM,62272,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
SCREW SPNL L10MM DIA3.5MM CANC TI ST MULTIAXIAL TOP LD,SUP-2286840,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
PLATE BNE L184MM 9 H R MED DST TIB TIM LOK COMPR FOR 3.5MM,SUP-2413703,CDM,C1713,HCPCS,0278,RC,,,,both,,,4422.50,2874.62,,,,,,,,,,,,,
SD BLADE 2.0MM PHLLPS WSLVE 2.0MMBSNRORCT USR DRVR,SUP-2682214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,892.51,580.13,,,,,,,,,,,,,
PLATE BONE L149MM THK4MM 7 H LT LAT TIB HD BTTRS FOR,SUP-2343793,CDM,C1713,HCPCS,0278,RC,,,,both,,,6000.23,3900.15,,,,,,,,,,,,,
ALLOGRAFT DISC DBM AND CORT CANC BONE CHIP FRZN OPTEFORM,SUP-2223554,CDM,C1762,CPT,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
RESECTOR PHLEBECTOMY DEV DIA 4.5 MM DISP PHASTIPP,SUP-2908876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
PIN EXT FIX L300MM DIA5/6MM THRD L40MM TRANSFIXING APEX,SUP-2372504,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
COIL DETACH 3MM DIA 12CM 4MM THER DIA NXT HELIX STD 10,SUP-2173001,CDM,C1889,HCPCS,0278,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
STENT LARYNGEAL MONTGOMERY L 15 X W 16 X H 47 MM LG SIL FIRM,SUP-2138743,CDM,C1875,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BIT DRL DIA2MM STD QUIK CONN FOR PERIARTC LOK PLT SYS,SUP-2410867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,620.97,403.63,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 16.5MMW X20MML 0.4MM THK X11MM THK CUT AN,SUP-2605459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.43,229.08,,,,,,,,,,,,,
SEMI-TUB PLT STERILIZER 71 MM LENGTH 4 HL,SUP-2818125,CDM,C1713,HCPCS,0278,RC,,,,both,,,487.33,316.76,,,,,,,,,,,,,
HC Rm Private Oncology,PX-1170000000,CDM,1170000000,LOCAL,0117,RC,,,,inpatient,,,3713.00,2413.45,,,,,,,,,,,,,
SCREW BNE LCK 2.7X28 MM CORTICAL NS,SUP-2423259,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.42,227.77,,,,,,,,,,,,,
ORTHOPEDIC KIT CENTERING SLEEVE 1.4 MM DISP,SUP-2664008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.85,251.45,,,,,,,,,,,,,
BUR SURG DIAMOND 6 MM 10 CM BALL SM BOR MIDAS REX 8 LEGEND,SUP-2664503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
PLATE CRAN 80X80X40 MM PT SPEC IMPL PEEK,SUP-2860138,CDM,C1713,HCPCS,0278,RC,,,,both,,,30967.62,20128.95,,,,,,,,,,,,,
CLAMP SURG 4-6X11 MM OPN PIN TO ROD TRANSFX,SUP-2362752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
SHUNT KIT OPN END LUMPERITON 2 VLV STRATA NSC,SUP-2629180,CDM,C1729,HCPCS,0272,RC,,,,both,,,13716.18,8915.52,,,,,,,,,,,,,
ANCHOR SUT DIA2.9MM SUT SZ 2 MAXBRAID BLU POLY DBL LD SGL,SUP-2212964,CDM,C1713,HCPCS,0278,RC,,,,both,,,1181.64,768.07,,,,,,,,,,,,,
BAXTER BEVELED BOBBIN VT 1.27MM FLPL,SUP-2500853,CDM,L8699,HCPCS,0278,RC,,,,both,,,33.28,21.63,,,,,,,,,,,,,
PIN EXTRACTOR,SUP-2136768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
BIT DRL CANN QUIK COUPLE COUNTSINK FOR 4.5/5.5 MM SCREW NS,SUP-2197517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1034.94,672.71,,,,,,,,,,,,,
IMIPRAMINE PAMOATE 75 MG PO CAPS,RX-10254,CDM,6370000000,HCPCS,0637,RC,00054-0273-13,NDC,,both,1,UN,53.10,34.51,,,,,,,,,,,,,
CAGE SPNL INTBDY 7 DEG 16X14X12 MM NS SHORELINE ACS,SUP-2245752,CDM,C1889,HCPCS,0278,RC,,,,both,,,2151.21,1398.29,,,,,,,,,,,,,
SHUNT SURG L 8.9 MM VENTRICULAR CATH L 250 MM PRESSURE 15 CM FV677T,SUP-2928851,CDM,C1889,HCPCS,0278,RC,,,,both,,,2992.04,1944.83,,,,,,,,,,,,,
PLATE BONE W8XL52MM 6 H TI DYN COMPR FOR 2.7MM SCR,SUP-2191070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1294.87,841.67,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 6H 107MM LEFT-STER,SUP-2549544,CDM,C1713,HCPCS,0278,RC,,,,both,,,4641.20,3016.78,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 HF IR 5FR 55CM 3 LUMAN RVRSE,SUP-2613400,CDM,C1751,HCPCS,0278,RC,,,,both,,,666.84,433.45,,,,,,,,,,,,,
ANCHOR SUTURE WITH TWO NO 2 HI FI SUTURES WITH NEEDLES 5.0MM,SUP-2828568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1110.46,721.80,,,,,,,,,,,,,
MARKER FIDUCIAL VISICOIL 12CM,SUP-2844926,CDM,A4648,CPT,0278,RC,,,,both,,,497.44,323.34,,,,,,,,,,,,,
MATRIX BIO L 10 X W 8 IN BOV CLLGN CHONDROITIN-6-SULFATE,SUP-2909331,CDM,Q4108,HCPCS,0636,RC,,,,both,,,38956.00,25321.40,,,,,,,,,,,,,
GRAFT BNE SUB 5ML CANC FRZN MORSELIZED VIABLE CELL TRINITY,SUP-2307244,CDM,C1713,HCPCS,0278,RC,,,,both,,,7985.02,5190.26,,,,,,,,,,,,,
GRAFT SYN 25ML CA SULF SCFLD HI STRENGTH INJ MIIG HV,SUP-2399043,CDM,C1713,HCPCS,0278,RC,,,,both,,,10252.10,6663.86,,,,,,,,,,,,,
CATHETER DRAINAGE 0.035 IN 14 FRX30 CM LCK RESOLV +,SUP-2303342,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.25,136.66,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC DBM BEAST +,SUP-2742047,CDM,C1713,HCPCS,0278,RC,,,,both,,,7080.70,4602.45,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X157 MM RT LAT DSTL 9 HOLE NS VA-LCP,SUP-2758201,CDM,C1713,HCPCS,0278,RC,,,,both,,,3120.28,2028.18,,,,,,,,,,,,,
RING EXT FIX DIA155 MM LNG FT 2/3 BLU NS DISP SMRT TSF,SUP-2933202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4167.03,2708.57,,,,,,,,,,,,,
SPLINT ORTHOPEDIC THMB ABDUCTED UNIV LTHR,SUP-2336237,CDM,L3931,HCPCS,0274,RC,,,,both,,,14.60,9.49,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT CHIPBIOPRES] ZIMMER BIOMET INC],SUP-2137375,CDM,C1776,CPT,0278,RC,,,,both,,,17719.02,11517.36,,,,,,,,,,,,,
CANNULA INJ F/POS PRESSURE ASST VENT 8588 A/B/BV,SUP-2776890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.59,356.58,,,,,,,,,,,,,
IMPLANT FACE L 43 X W 18 MM THK 3.2 MM RT INFERIOR ORBIT RIM,SUP-2883471,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.92,941.15,,,,,,,,,,,,,
DILATOR UROLOGICAL 0.038 IN 14 FR URETH PROC SHTH SET PTFE,SUP-2141687,CDM,C1726,HCPCS,0272,RC,,,,both,,,611.73,397.62,,,,,,,,,,,,,
GRAFT DERM HYDRATED THCK ACELLULAR DERM IMPL ALLGRFT L4XW1CM,SUP-2307450,CDM,Q4128,HCPCS,0636,RC,,,,both,,,492.51,320.13,,,,,,,,,,,,,
GRAFT VASC L40CM DIA6MM PTFE CBAS HEP SURF STD WALLED,SUP-2395778,CDM,C1768,CPT,0278,RC,,,,both,,,3322.12,2159.38,,,,,,,,,,,,,
COMPONENT FEM L TROCHANTERIC CALCAR HIP MALLORY-HEAD CO,SUP-2403679,CDM,C1776,CPT,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 80 MM DIA10 MM DEL SYS L 80 CM,SUP-2158631,CDM,C1876,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
GRAFT HUM TISS W14XH5XL12MM ANT CERV INTBDY FUS LORD SPCR,SUP-2306955,CDM,C1713,HCPCS,0278,RC,,,,both,,,3378.33,2195.91,,,,,,,,,,,,,
TUBE EXT FIX SEMI CIR CRV 85% RADLUC HOFFMANN XPRESS,SUP-2465634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
WASHER 2.5X17MM RND SFT TISS FIX SPIK POST HT LO PROF TI ST,SUP-2166926,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.49,398.12,,,,,,,,,,,,,
CATHETER EP F CRV 5-5-5MM SPC 6FRX110CM TORQR,SUP-2281819,CDM,C1730,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PLATE BONE INSERT 0.50.7 MM HALF HEIGHT MATRIXMIDFACE,SUP-2838505,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.66,387.18,,,,,,,,,,,,,
PLATE BONE 8 H MEDL TIB,SUP-2319682,CDM,C1713,HCPCS,0278,RC,,,,both,,,8066.66,5243.33,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4409753000,CDM,97530,CPT,0440,RC,,,GO|CO,both,,,191.00,124.15,,,,,,,,,,,,,
GUIDEWIRE 1.5MMX12IN FOR CANNFLX SCR,SUP-2341355,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.33,99.66,,,,,,,,,,,,,
LINER ACET SZ MP5 ID28MM HIP CONSTRN FMP,SUP-2217141,CDM,C1776,CPT,0278,RC,,,,both,,,4588.33,2982.41,,,,,,,,,,,,,
CONNECTOR VENT DRNGE OD1.8MM ID1.2MM S STL 3 W T SHP,SUP-2243838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,695.89,452.33,,,,,,,,,,,,,
HC So Allergen Spec Ige Recombinant/Purified Compnt Ea,PX-3028600866,CDM,86008,CPT,0302,RC,,,,both,,,61.00,39.65,,,,,,,,,,,,,
HINGE EXT FIX STD S STL FEM FOR ILIZ TAY SPAT FRME EXT FIX,SUP-2342292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.91,514.74,,,,,,,,,,,,,
RING EXT FIX HALF 200 MM CIR SIDEKCK,SUP-2458427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1673.62,1087.85,,,,,,,,,,,,,
PLATE BONE COMPRESSION BROAD 198 MM PELVIC 11 HOLE CONTOURED,SUP-2837530,CDM,C1713,HCPCS,0278,RC,,,,both,,,3039.71,1975.81,,,,,,,,,,,,,
BIT DRL DIA2.7MM CALIB,SUP-2412632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,291.49,189.47,,,,,,,,,,,,,
CATHETER HD SET 14 FRX15 CM DL INDWL CRV N COAT BLU FLEXTIP,SUP-2762994,CDM,C1752,HCPCS,0278,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
GUIDEWIRE VASC VSI TRU-TORQUE L 180 CM DIA 0.035 IN PTFE MOD,SUP-2763463,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
CATHETER IABP 7.5FR 40CC SHTH LAIN DATASCP SYS COMPATIBLE,SUP-2227318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3188.36,2072.43,,,,,,,,,,,,,
DVR VOLAR RIM L ST,SUP-2474808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2728.66,1773.63,,,,,,,,,,,,,
CABLE CATH 150 CM 24 PIN STRL LF,SUP-2867399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
PLATE BNE L 93 X W 10 MM THK 2 MM SCREW DIA2.7/3.5 MM 5 H SS 72465405N,SUP-2933247,CDM,C1713,HCPCS,0278,RC,,,,both,,,4157.83,2702.59,,,,,,,,,,,,,
GUIDEWIRE BENT TYP STR 0038INX150CM ZIPWIRE,SUP-2139342,CDM,C1769,HCPCS,0272,RC,,,,both,,,143.22,93.09,,,,,,,,,,,,,
GUIDEPIN BNE FIX DIA 6 MM CANC REDUCTION THRD NS VARIAX,SUP-2902189,CDM,C1713,HCPCS,0278,RC,,,,both,,,1627.78,1058.06,,,,,,,,,,,,,
HC Bladder Scan|UNUSUAL NON-OVERLAPPING SERVICE,PX-4505179800,CDM,51798,CPT,0450,RC,,,XU,outpatient,,,191.00,124.15,,,,,,,,,,,,,
BOLT ORTHOPEDIC GUIDE,SUP-2196673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM TRIATHLON K15] STRYKER CORP],SUP-2365626,CDM,C1776,CPT,0278,RC,,,,both,,,15438.44,10034.99,,,,,,,,,,,,,
SUPPORT WR L LNG LEN RT FRARM WVN COT RUB FAB BGE FIRM W/,SUP-2324897,CDM,L3809,HCPCS,0272,RC,,,,both,,,41.01,26.66,,,,,,,,,,,,,
HC Assay of Triglycerides,PX-3018447800,CDM,84478,CPT,0301,RC,,,,both,,,146.00,94.90,,,,,,,,,,,,,
PROBE OPHTH LASER STR STRL 25GA,SUP-2129219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.83,240.39,,,,,,,,,,,,,
CAGE SPNL STAND ALONE C 3D PRNT TECHNOLOGY SCR INTEGR DESIGN,SUP-2935294,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
COMPONENT FEM L25MM TI ALLY M FEM TAPR ANTI ROT TAB SLOT,SUP-2252610,CDM,C1776,CPT,0278,RC,,,,both,,,4335.08,2817.80,,,,,,,,,,,,,
DEVICE PESSARY L 55 MM SZ 1 SIL SUPP WHT NS LF GEHRUNG,SUP-2895812,CDM,A4562,HCPCS,0274,RC,,,,both,,,108.27,70.38,,,,,,,,,,,,,
PROBE LITHO 3FR FOR PNEUMAT SWISS LITHOCLAST,SUP-2141769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
TI LCP PROX LATERAL TIBIA PL 13 HOLES/300MM/LEFT-STERILE,SUP-2549446,CDM,C1713,HCPCS,0278,RC,,,,both,,,4980.10,3237.06,,,,,,,,,,,,,
CATHETER EP MAP SUPREME 4FR QPLR 2-2-2MM ELECTRD SPC JSN,SUP-2356958,CDM,C1730,HCPCS,0272,RC,,,,both,,,584.67,380.04,,,,,,,,,,,,,
LINER ACET SZ QU OD68MM ID28MM STD DURASUL UNCEMENTED HOOD,SUP-2205267,CDM,C1776,CPT,0278,RC,,,,both,,,6719.60,4367.74,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 900-1200 UM 2 ML PVA PREFIL,SUP-2148452,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.55,516.46,,,,,,,,,,,,,
PLATE BNE SS NS LCP,SUP-2178460,CDM,C1713,HCPCS,0278,RC,,,,both,,,1543.69,1003.40,,,,,,,,,,,,,
SCREW INTRF L30MM DIA10MM PEEK FOR INTRAFIX ADV TIB FAST SYS,SUP-2256833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
ENDCAP ORTH L0MM DIA2.5MM STRL HUM TI NAIL EXTN HEX RECESS,SUP-2192529,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.59,552.23,,,,,,,,,,,,,
SET INTRO INSUL CANN SFT TISS BX FOR RF 3000 GENRTR,SUP-2139748,CDM,C1894,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
WASHER ORTH BRNZ BTTN FOR DSTL ELBW PLATING SYS,SUP-2340389,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.45,86.74,,,,,,,,,,,,,
COLLAR CERV EXTRIC COMB PK PERFIT ACE,SUP-2115130,CDM,L0120,HCPCS,0274,RC,,,,both,,,45.81,29.78,,,,,,,,,,,,,
VALVE PRESSURE FIX 120 CM PV RR UNTZ D CATH,SUP-2666781,CDM,C1889,HCPCS,0278,RC,,,,both,,,3422.66,2224.73,,,,,,,,,,,,,
TIRE SIL 12.5MM CONCV GROOVE2.5MM,SUP-2213513,CDM,L8610,HCPCS,0278,RC,,,,both,,,55.26,35.92,,,,,,,,,,,,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,J7644,HCPCS,0636,RC,00378-7970-52,NDC,,both,2.5,ML,2.70,1.75,,,,,,,,,,,,,
CATHETER EP DAMATO CRV 5 MM SPC 6 FR INQUIRY,SUP-2357415,CDM,C1730,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
ALLOGRAFT NERVE 4-5X50 MM PROC STRL AVANCE LTX,SUP-2753341,CDM,C1762,CPT,0278,RC,,,,both,,,22695.92,14752.35,,,,,,,,,,,,,
PLATE BONE L62MM 5 H 1/3 TBLR BILAT NONCOMPRESSION RIG FOR,SUP-2348956,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.25,399.91,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX20 CM SHT TERM DL TAPR TIP DUOFLO,SUP-2627389,CDM,C1752,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.27MM GRN SIL VENT CLLR BTTN SHEEHY,SUP-2284029,CDM,L8699,HCPCS,0278,RC,,,,both,,,61.04,39.68,,,,,,,,,,,,,
PROSTHESIS TEMP LT CNDYL RIG LEIBINGER,SUP-2363871,CDM,C1713,HCPCS,0278,RC,,,,both,,,3157.71,2052.51,,,,,,,,,,,,,
MESH HERN OVL 12X6 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855272,CDM,C1781,HCPCS,0278,RC,,,,both,,,25057.20,16287.18,,,,,,,,,,,,,
SET PNEUMOTHOR CATH 9FR L29CM NDL 18GA L20CM 20 SIDEPRT,SUP-2167923,CDM,C1729,HCPCS,0272,RC,,,,both,,,780.92,507.60,,,,,,,,,,,,,
TIP SONOPET IQ LARGE 12CM,SUP-2755027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.53,1785.89,,,,,,,,,,,,,
BUR SURG RND 2 MM EXT CARBIDE STRL LTX,SUP-2859492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,702.67,456.74,,,,,,,,,,,,,
NAIL IM 8.5 MMX38 CM FAN,SUP-2347219,CDM,C1713,HCPCS,0278,RC,,,,both,,,4132.24,2685.96,,,,,,,,,,,,,
PLATE BONE 3 H RT PROX TIB TIM L CRV LCK ALPS,SUP-2413720,CDM,C1713,HCPCS,0278,RC,,,,both,,,3963.47,2576.26,,,,,,,,,,,,,
TUBE MYR DIA1MM S STL REUT BOB,SUP-2313690,CDM,L8699,HCPCS,0278,RC,,,,both,,,110.18,71.62,,,,,,,,,,,,,
GRAFT DECELLULARIZED DERM 1.25-2.00MM 16X20CM RM TEMP,SUP-2264624,CDM,Q4122,HCPCS,0636,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
BLADE SHV L22CM OD32MM LARYN CONCAVE WIND SUPERFICIAL DIEGO,SUP-2313832,CDM,C1713,HCPCS,0278,RC,,,,both,,,915.75,595.24,,,,,,,,,,,,,
STENT CORONARY RESOLUTE ONYX L 8 MM DIA2.25 MM CATH L 140 CM,SUP-2517067,CDM,C1874,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BNE MESHED 1 MM MXLFCL 8 HOLE LF,SUP-2461932,CDM,C1713,HCPCS,0278,RC,,,,both,,,3886.66,2526.33,,,,,,,,,,,,,
BLADE OSTEOTOM SM W50MM S STL FULL HMSPHR EXPLANT,SUP-2210646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
HC So Chlamydia Antibody,PX-3028663166,CDM,86631,CPT,0302,RC,,,,outpatient,,,236.00,153.40,,,,,,,,,,,,,
PLATE BNE L390MM 24 H BROAD COMPR RIG FOR 45MM SCR L FRAG,SUP-2411435,CDM,C1713,HCPCS,0278,RC,,,,both,,,1366.15,888.00,,,,,,,,,,,,,
HC Cath Urethral Simple,PX-7615170200,CDM,51702,CPT,0761,RC,,,,both,,,204.00,132.60,,,,,,,,,,,,,
PLATE BONE L35MM 6 H MAND ORAL MAXILLOFACIAL TI STR TENS BND,SUP-2191345,CDM,C1713,HCPCS,0278,RC,,,,both,,,1725.43,1121.53,,,,,,,,,,,,,
FIBER LASER KIT TMR DISPLAY,SUP-2225629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 115 CM DIA 7 MM SPC,SUP-2489510,CDM,C1731,HCPCS,0278,RC,,,,both,,,963.10,626.01,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN TIP L3IN NIT COR POLYUR,SUP-2385571,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
CLIP SCALP UNIV NEURO SYS SGL MTL STR EDGE AD 1.5MM/1.7MM,SUP-2363680,CDM,C1889,HCPCS,0278,RC,,,,both,,,324.68,211.04,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE SM FD IRRADIATED TIB,SUP-2867175,CDM,C1762,CPT,0278,RC,,,,both,,,2094.07,1361.15,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 60 MM DIA 8 MM DEL SYS L 150 CM,SUP-2866180,CDM,C1876,HCPCS,0278,RC,,,,both,,,3730.07,2424.55,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CUT WIRE 20MM TIP L5MM 4.4FR 0.035IN,SUP-2149568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.75,437.94,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY AFOCUS L 110 CM DIA 5 FR,SUP-2357652,CDM,C1730,HCPCS,0272,RC,,,,both,,,3400.62,2210.40,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X198 MM 11 HOLE SS LCP,SUP-2569372,CDM,C1713,HCPCS,0278,RC,,,,both,,,780.60,507.39,,,,,,,,,,,,,
HC Lactate Dehydrogenase Isoenzymes Sep&Quan,PX-3018362500,CDM,83625,CPT,0301,RC,,,,both,,,385.00,250.25,,,,,,,,,,,,,
TAP SURG OD9MM SACROILIAC CANN SI-LOK,SUP-2232166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
STENT PERIPH EXPRESS LD L 37 MM DIA 8 MM CATH L 75 CM DIA 6,SUP-2144315,CDM,C1876,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
BIT DRL L300MM DIA3.2MM PERC QUIK CPL CALIB W/O STP REUSE,SUP-2187851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,553.52,359.79,,,,,,,,,,,,,
TITANIUM SCRN MESH PANEL 100MM X 100MM 2MM 1MM SSTM CP TTN,SUP-2681105,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.34,1981.42,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 260 CM DIA 0.018 IN TAPR L 15 CM,SUP-2170335,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.65,109.62,,,,,,,,,,,,,
PRESSURE MONITORING KIT TRANSDUCER 72 IN POLE MT RESERVOIR,SUP-2473695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
GRAFT BNE SUB CANC CORT DEMIN 1/2 FILL TB STR AFT G2,SUP-2307038,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
KIT CATH LOCATABLE GUID OLY,SUP-2381759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3476.77,2259.90,,,,,,,,,,,,,
ADAPTER FEM SL +5MM OFFSET MTPHSEAL TI PORCOAT FOR PRESSFIT,SUP-2252608,CDM,C1776,CPT,0278,RC,,,,both,,,1544.41,1003.87,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 14X14X14 MM SPNG FD CANC,SUP-2717781,CDM,C1713,HCPCS,0278,RC,,,,both,,,2282.21,1483.44,,,,,,,,,,,,,
PLATE BONE SM W11XL195MM THK3.3MM 0DEG 15 H BILAT TI STR RIG,SUP-2190793,CDM,C1713,HCPCS,0278,RC,,,,both,,,1237.51,804.38,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CLARIA MRI QUAD CRT-D SURESCAN W 51 X H,SUP-2282411,CDM,C1882,HCPCS,0275,RC,,,,both,,,52080.04,33852.03,,,,,,,,,,,,,
SUTURE N ABSRB 2-0 W/CRV TAPR NDL BLK BLU MAXBRAID CM0222N,SUP-2435478,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.54,142.05,,,,,,,,,,,,,
CATHETER EP CS,SUP-2256927,CDM,C1730,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
SET IM NAIL L 50 MM DIA 3 MM K WIRE CANN DRL BIT DEPTH GA,SUP-2904307,CDM,C1713,HCPCS,0278,RC,,,,both,,,4976.90,3234.98,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 25.4MMW X90MML 0.8MM THK 0.9MM THK CUT ME,SUP-2605470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,94.70,61.55,,,,,,,,,,,,,
REAMER SURG HLLW COMPLT FOR 4.5MM SCR,SUP-2187148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1170.65,760.92,,,,,,,,,,,,,
PLATE BNE BAR 1.8 MM 4 H SHRT RT MIDFACE L SHP MALL MINI NS,SUP-2883151,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.25,943.96,,,,,,,,,,,,,
GRAFT BNE SUB W6-20X9-21XL25-35MM THK16-18MM IL CREST,SUP-2307147,CDM,C1776,CPT,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
CANNULA ARTHSCP DIA5MM W/ OBT FOR IATROGENIC DAMAGE,SUP-2366734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
KIT FIX FNGR JT PROX INTERPHALANGEAL UNIV RADLUC PLAS,SUP-2342291,CDM,C1713,HCPCS,0278,RC,,,,both,,,14482.78,9413.81,,,,,,,,,,,,,
CONNECTOR SPNL S STL THORLUM LO PROF PARA FOR 5.5/5.5MM ROD,SUP-2230977,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
CAP AIRWY MANIFOLD ACCSRY BALLARD LIBERATOR,SUP-2774316,CDM,C1887,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
TUBE FEED NSL 8 FR SIL WHT BRIDLE PRO LF,SUP-2754580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,604.92,393.20,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.3MM CORT NONTOGGLING FOR VOLAR DST RAD,SUP-2107556,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
SCREW BNE L32MM DIA4.5MM PERIARTC CORT S STL ST,SUP-2410621,CDM,C1713,HCPCS,0278,RC,,,,both,,,101.45,65.94,,,,,,,,,,,,,
CARBON FIBER ROD,SUP-2823202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.15,462.90,,,,,,,,,,,,,
SHELL ACET DIA60MM LNR SZ DMI BRN VERSAFITCUP DM,SUP-2267333,CDM,C1776,CPT,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
STAPLER CUT L 100 MM CLOSED STPL H 1.5/2.2 MM 4 ROW LINEAR,SUP-2912269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.74,224.08,,,,,,,,,,,,,
KIT INTRO ENDOAVF CV CATH SHTH STRL,SUP-2859464,CDM,C1894,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PLATE BONE 18 H STRNL LCK LADDER FOR 1.5MM SCR,SUP-2262570,CDM,C1713,HCPCS,0278,RC,,,,both,,,2097.52,1363.39,,,,,,,,,,,,,
LINER FEM OD46MM ID32MM BPLR CENTRAX,SUP-2364425,CDM,C1776,CPT,0278,RC,,,,both,,,1892.67,1230.24,,,,,,,,,,,,,
BETAMETHASONE DIPROPIONATE 0.05 % EX OINT,RX-1029,CDM,6370000000,HCPCS,0637,RC,72578-0093-01,NDC,,both,15,GR,221.00,143.65,,,,,,,,,,,,,
CATHETER CTRL VEN 9.5FR NONPOWER INJ 2 LUMN W/ TISS,SUP-2127897,CDM,C1751,HCPCS,0278,RC,,,,both,,,2411.77,1567.65,,,,,,,,,,,,,
SYSTEM IMPL DST BICEPS REP DEL W/ BICEPS BTTN 7X10MM PEEK,SUP-2121661,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SHEATH INTRO AXS INFIN LS L 70 CM OD 8 FR ID 0.088 IN SS LNR,SUP-2367810,CDM,C1894,HCPCS,0272,RC,,,,both,,,1429.96,929.47,,,,,,,,,,,,,
PROSTHESIS OTO L12MM OD0.4MM MALL CAUSSE LOOP FLROPLAS,SUP-2284064,CDM,L8613,CPT,0278,RC,,,,both,,,339.50,220.67,,,,,,,,,,,,,
SET SCR SPNL N BRK OFF TI STRL 6.35MM DIA,SUP-2415640,CDM,C1713,HCPCS,0278,RC,,,,both,,,1247.58,810.93,,,,,,,,,,,,,
BIT DRL L52MM DIA1MM STP 20MM TWST DENT NONRADIOLUCENT DISP,SUP-2267818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.34,245.92,,,,,,,,,,,,,
NEEDLE SURG 21GAX4 MM 0.8 MM MID BVL DISP,SUP-2430213,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.15,114.50,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS AK HIP ALIGNABLE SYS,SUP-2388220,CDM,L5920,HCPCS,0274,RC,,,,both,,,1394.63,906.51,,,,,,,,,,,,,
SCREW CORT NON-LOCKING MULTI-DIRECTIONAL 3.8 MMX20.0 MM S3,SUP-2414098,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.67,218.84,,,,,,,,,,,,,
FIBER LASER 600 MICRON SINGLE USE WITH FLAT TIP,SUP-2883717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER GUID LUMAX L 80 CM DIA 8 FR GUIDEWIRE 0.038 IN,SUP-2638618,CDM,C1887,HCPCS,0272,RC,,,,both,,,1058.97,688.33,,,,,,,,,,,,,
DEVICE FIXATION LADDER PLATE NARROW 14 HOLES,SUP-2719530,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED 2 MOBILITY RESURF H6ZIMMER] ZIMMER BIOMET INC],SUP-2212581,CDM,C1776,CPT,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
SYSTEM SET MINI RAIL,SUP-2457473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10600.64,6890.42,,,,,,,,,,,,,
CATHETER KIT OPN TIP 84 CM LUMBAR IMPREG TUOHY NDL HUBER,SUP-2664453,CDM,C1729,HCPCS,0272,RC,,,,both,,,1491.44,969.44,,,,,,,,,,,,,
METRONIDAZOLE (FLAGYL) IVPB (PEDS),RX-4085042,CDM,J1836,HCPCS,0636,RC,99999-9913-19,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 PLU MAXBARR 4FR 55C 1194108D2,SUP-2632630,CDM,C1751,HCPCS,0278,RC,,,,both,,,949.54,617.20,,,,,,,,,,,,,
SCREW BNE L14MM DIA1.5MM TI ST LOK T4 RECESS STARDRV,SUP-2181269,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.01,214.51,,,,,,,,,,,,,
AMK UNIV STEM 10X50MM,SUP-2251243,CDM,C1776,CPT,0278,RC,,,,both,,,2254.52,1465.44,,,,,,,,,,,,,
PLATE BNE L44MM 5 H S STL COMPR FOR 27MM SCR MINI FRAG SYS,SUP-2199359,CDM,C1713,HCPCS,0278,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
BIT DRL OD5MM TRIFLAT LO PROF,SUP-2290256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.14,270.49,,,,,,,,,,,,,
PLATE BONE W8XL160MM THK3.3MM 20 H STRL BILAT PELV S STL,SUP-2186248,CDM,C1713,HCPCS,0278,RC,,,,both,,,2193.64,1425.87,,,,,,,,,,,,,
GRISEOFULVIN ULTRAMICROSIZE 250 MG PO TABS,RX-3536,CDM,6370000000,HCPCS,0637,RC,23155-0864-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
COLLAR CERV ATLS REG PD5 PEDIATRIC 3-6 YR OCPTL SUPP STRP,SUP-2420905,CDM,L0172,HCPCS,0274,RC,,,,both,,,149.09,96.91,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 4.5 MM TWST SCR IN WHT BLU GRN,SUP-2762183,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
SPLINT WRST XL L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276628,CDM,L3809,HCPCS,0274,RC,,,,both,,,21.48,13.96,,,,,,,,,,,,,
CANNULA SUCTION COAG 3 MMX30 CM INSUL,SUP-2776947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.54,740.70,,,,,,,,,,,,,
SPECULUM VAG L12IN BLDE L3 15 16XW1IN MIR AND SATIN FINISH,SUP-2160546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.13,494.08,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZ DRY DEMIN CANC 0.1MM-4MM RANG 60CC,SUP-2294026,CDM,C1713,HCPCS,0278,RC,,,,both,,,3008.12,1955.28,,,,,,,,,,,,,
PLATE SPNL L24MM 2 LEV STR BILAT LCK ANTR CERV TI VUELOCK,SUP-2415768,CDM,C1713,HCPCS,0278,RC,,,,both,,,4669.18,3034.97,,,,,,,,,,,,,
CAGE SPNL W33XH11MM 12DEG ANTR LUM PEEK COMMERCIALLY PURE,SUP-2163225,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
BIT DRL DIA38MM STP 20MM QUIK CPL,SUP-2179052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BIT DRL DIA24MM OCCIPITOCERVICAL UP THOR NAVIGATED INFIN,SUP-2293677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
SCREW BONE 2MM DIA 16MML TTNM ALLOY CROSS DRIVE 12MM THRDD S,SUP-2677471,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.04,205.43,,,,,,,,,,,,,
MIDLINE APPRCH 42MMX17MMX8DEG,SUP-2320310,CDM,C1889,HCPCS,0278,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
TIP CATHETER 110DEG MAX SNUS GUID FOR BLLN SINUPLASTY SYS,SUP-2106366,CDM,C1887,HCPCS,0272,RC,,,,both,,,546.39,355.15,,,,,,,,,,,,,
PIN EXT FIX L9IN DIA5/64IN S STL DMND PNT W/ SMOOTH SHFT,SUP-2342707,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
BONE MACH BLK 7X15MM GIC58 TRICORT ILIUM,SUP-2293821,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
BLADE ARTHSCP 4MM CVD W/O HNDL CAPSULECUT,SUP-2121996,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 5 MM 4.4 FRX20 MM TRUTOME 8316,SUP-2467574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1245.17,809.36,,,,,,,,,,,,,
RETRIEVER VASC 035 8 FRX55 CM 4 LOOP SNR INDY OTW,SUP-2750812,CDM,C1773,HCPCS,0272,RC,,,,both,,,1397.17,908.16,,,,,,,,,,,,,
PROPRANOLOL HCL 20 MG PO TABS,RX-6657,CDM,6370000000,HCPCS,0637,RC,00603-5483-21,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUSHING FEM UNIV KNEE PLOY MOD CEM STEM ROT HNG REV,SUP-2376368,CDM,C1776,CPT,0278,RC,,,,both,,,719.22,467.49,,,,,,,,,,,,,
CATHETER INTVASC LITHO BALLOON L 40 MM DIA 4 MM PERIPH DIL,SUP-2417261,CDM,C1725,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
BIT DRL HIP ANTIROTATION SCR FOR AFFIXUS SYS,SUP-2412615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR FIX CEM,SUP-2212515,CDM,C1776,CPT,0278,RC,,,,both,,,5983.27,3889.13,,,,,,,,,,,,,
PLATE CRANIOFACIAL MAND RECON COMPR 2.7MM 12 H 150MM VIT,SUP-2364677,CDM,C1713,HCPCS,0278,RC,,,,both,,,2926.48,1902.21,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10CM DIA 8.5FR ANTIMICROBIAL,SUP-2763367,CDM,C1892,HCPCS,0272,RC,,,,both,,,413.85,269.00,,,,,,,,,,,,,
PANTOPRAZOLE SODIUM 40 MG PO TBEC,RX-26225,CDM,6370000000,HCPCS,0637,RC,60687-0736-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STEM FEM CEM -5 MM 8/14 205 MM LT HIP BOW REV REDUC NK,SUP-2376570,CDM,C1776,CPT,0278,RC,,,,both,,,16882.52,10973.64,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WEBST CS L 115 CM DIA 7 FR SPC,SUP-2535607,CDM,C1730,HCPCS,0272,RC,,,,both,,,792.91,515.39,,,,,,,,,,,,,
MESH CRAN W120XL120MM PROF H0.6MM MIC MID FACE,SUP-2363672,CDM,C1713,HCPCS,0278,RC,,,,both,,,7994.94,5196.71,,,,,,,,,,,,,
CRVD INSERT KIT 2.0MM S-TAK 1.7,SUP-2812339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CAGE SPNL MESH 17X13X9 MM 6 LOBE,SUP-2602077,CDM,C1889,HCPCS,0278,RC,,,,both,,,7617.64,4951.47,,,,,,,,,,,,,
ALLOGRAFT HUM TISS RT WHL BONE-PATELLAR TENDON-BONE,SUP-2867063,CDM,C1762,CPT,0278,RC,,,,both,,,10309.25,6701.01,,,,,,,,,,,,,
BEARING TIB L63/67MM THK14MM KNEE SUP STBL POST STBL CNDYL 183864] ZIMMER BIOMET ORTHOPEDICS],SUP-2407724,CDM,C1776,CPT,0278,RC,,,,both,,,6571.24,4271.31,,,,,,,,,,,,,
BLADE RTRCTR SM 24MMW X 70MML TTNM SPNL TTHX3 THIN LMBRTRK R,SUP-2479895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.55,504.76,,,,,,,,,,,,,
PLATE FIXATION STERNAL LADDER 10 HOLES,SUP-2849061,CDM,C1713,HCPCS,0278,RC,,,,both,,,2011.74,1307.63,,,,,,,,,,,,,
CATHETER ETER PERI DLYS COILED W DBL CUF SET 63CM,SUP-2269530,CDM,C1750,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
LINER ACET OD48MM ID28MM 0DEG NEUT HIP MARATHON PINN,SUP-2250339,CDM,C1776,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PLATE BONE SPNL ASPN M 8 MM,SUP-2136958,CDM,C1713,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PROBE SURG L175MM BALL TIP,SUP-2280152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.32,396.71,,,,,,,,,,,,,
CANNULA OPHTH 25GA TRANSCONJUNCTIVAL CHOW SIL OIL INJ 6 PER,SUP-2129205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
DISTRACTION INTRNL PLATE TLCK TRANS 1 HOLE 27 32 MM SCREW,SUP-2679288,CDM,C1713,HCPCS,0278,RC,,,,both,,,3008.53,1955.54,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM DIA12 MM BRANCH SZ 8 MM,SUP-2694338,CDM,C1768,CPT,0278,RC,,,,both,,,4260.79,2769.51,,,,,,,,,,,,,
CANNULA ASPIR L15CM OD3MM 1 PC REUSE ACCEL III,SUP-2152202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
IMPLANT NSL DORSUM SM 53X5 MM DESIGN A STRL MEDPOR LF,SUP-2366462,CDM,C1889,HCPCS,0278,RC,,,,both,,,1191.66,774.58,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM CATH DSTL L 1200/200 MM VENTRICULAR L,SUP-2928860,CDM,C1889,HCPCS,0278,RC,,,,both,,,12824.23,8335.75,,,,,,,,,,,,,
CATHETER INFUSION 0.035 IN 5 FRX35 CM 10 CM 20 SH MEWISSEN,SUP-2141163,CDM,C1725,HCPCS,0272,RC,,,,both,,,237.16,154.15,,,,,,,,,,,,,
SCREW BNE LCK STD 4.5X25 MM,SUP-2875148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1061.95,690.27,,,,,,,,,,,,,
MATRIX WND W7XL10CM TRI LAYR OASIS ULT,SUP-2341245,CDM,Q4124,HCPCS,0636,RC,,,,both,,,2559.23,1663.50,,,,,,,,,,,,,
GUIDEWIRE .035INDIA STERILE 13INL BLUNT F/SHOULDER,SUP-2574087,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.25,37.86,,,,,,,,,,,,,
RASP SURG SINGLE SIDE SAW STRYKR IO FRDM CARTILAGINATOR,SUP-2865104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2232.54,1451.15,,,,,,,,,,,,,
HC So Clot Inhibit Protein S Total,PX-3058530566,CDM,85305,CPT,0305,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
PLATE BNE L232MM 14 H ST L ANTEROMEDIAL DST TIB S STL VAR,SUP-2177689,CDM,C1713,HCPCS,0278,RC,,,,both,,,7297.27,4743.23,,,,,,,,,,,,,
SCREW BONE L76MM DIA4.5MM S STL CORT FEM ST NONLCK FULL THRD,SUP-2348873,CDM,C1713,HCPCS,0278,RC,,,,both,,,319.81,207.88,,,,,,,,,,,,,
SPLINT ORTH M LT ANTI SPASMOTIC NEUROLOGIC CONTRACTURES REG,SUP-2324561,CDM,L3906,HCPCS,0274,RC,,,,both,,,77.93,50.65,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 120 CM DIA 6-10 MM,SUP-2120068,CDM,C1773,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GRAFT TISS REGEN MATRIX 4X4CM GRAFTJACKET,SUP-2262293,CDM,Q4107,HCPCS,0636,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
HC Iron Binding Capacity|NOT REASONABLE AND NECESSARY,PX-3018355000,CDM,83550,CPT,0301,RC,,,GZ,both,,,128.00,83.20,,,,,,,,,,,,,
URETERAL URETERAL DILATOR,SUP-2822050,CDM,C2627,HCPCS,0272,RC,,,,both,,,844.13,548.68,,,,,,,,,,,,,
FOOTRING EXT FIX LNG 210 MM ALUM HOFFMANN,SUP-2472797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5174.72,3363.57,,,,,,,,,,,,,
SYSTEM SHLDR RVS TOT S1 BIOMET,SUP-2137606,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
STENT BILI L11MM CATH 6FR L80CM BLLN L15MM DIA7MM 0.018IN,SUP-2159000,CDM,C1876,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER GUID AR1 7 FRX100 CM SH CONCIERGE,SUP-2302491,CDM,C1887,HCPCS,0272,RC,,,,both,,,179.61,116.75,,,,,,,,,,,,,
LOCKNUT ORTH CORTICAL 4.5 MM STRL LTX,SUP-2861519,CDM,C1713,HCPCS,0278,RC,,,,both,,,523.94,340.56,,,,,,,,,,,,,
CATHETER GUID AR1.2 0.078 INX7 FR VASC BRAIDING ECOPAC BLU,SUP-2158418,CDM,C1887,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM 0.035 IN CRV RAD 3MM HVY DBL FLX STRL,SUP-2760022,CDM,C1769,HCPCS,0272,RC,,,,both,,,97.69,63.50,,,,,,,,,,,,,
TRAY CATH 4GA OR 18GA L8CM 0.018/21T DBL LUMN POLYP,SUP-2169663,CDM,C1751,HCPCS,0278,RC,,,,both,,,374.85,243.65,,,,,,,,,,,,,
MESH HERN W18XL23CM VENTRAL OVL COMPOSIX E/X,SUP-2125807,CDM,C1781,HCPCS,0278,RC,,,,both,,,2779.84,1806.90,,,,,,,,,,,,,
SPINAL IMPLANT KIT SHLDR KNEE STRL ASSISTARM,SUP-2765731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST W/NONTORSION JT FABRICATED,SUP-2435781,CDM,L3921,HCPCS,0272,RC,,,,both,,,827.64,537.97,,,,,,,,,,,,,
HC So Vip(Vasoact.Intest.Polypept.),PX-3018458666,CDM,84586,CPT,0301,RC,,,,outpatient,,,2406.00,1563.90,,,,,,,,,,,,,
MESH CRAN L 40 X W 40 MM THK 0.6 MM SCREW DIA1.5/1.7 MM SM,SUP-2883495,CDM,C1713,HCPCS,0278,RC,,,,both,,,4114.28,2674.28,,,,,,,,,,,,,
IMPLANT HUMAN TSSUE W4XL7CM THICK SKIN RGNRTVE MTRX FRZE DRI,SUP-2458846,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2835.42,1843.02,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 260 CM DIA 0.035 IN NIT HYDRPHLC,SUP-2141144,CDM,C1769,HCPCS,0272,RC,,,,both,,,187.62,121.95,,,,,,,,,,,,,
SHUNT CAR 9FR L31CM CLR REG 2 LUMN TEMP CONDUIT T PRT W/O,SUP-2264203,CDM,C1757,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
RXG PLATE STR 4 HLE 40MM 24MM BRG RDCD HOLE SPCNG T1.0MM,SUP-2488145,CDM,C1713,HCPCS,0278,RC,,,,both,,,2658.98,1728.34,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 45 CM DIA 5-8 MM EPTFE TAPR REINF 3,SUP-2681857,CDM,C1768,CPT,0278,RC,,,,both,,,3111.39,2022.40,,,,,,,,,,,,,
STENT URET IMAJIN L 22 MM DIA 6 FR SIL HYDRPHLC DBL LOOP,SUP-2844965,CDM,C2617,HCPCS,0278,RC,,,,both,,,439.29,285.54,,,,,,,,,,,,,
SCREW BNE LCK 2.3X7 MM THOR DRL FREE LEVEL 1 RIBLOC SYS TI,SUP-2262538,CDM,C1713,HCPCS,0278,RC,,,,both,,,470.22,305.64,,,,,,,,,,,,,
SPLINT WR AND FRARM TITEX W/ LOOP LCK LT M,SUP-2195255,CDM,L3809,HCPCS,0272,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
DRILL SURG L495MM OD105MM LAG SCR STP W O STP NONRADIOLUCENT,SUP-2361614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5234.76,3402.59,,,,,,,,,,,,,
HC Inject Trigger Point 1/2 Muscle,PX-3612055200,CDM,20552,CPT,0361,RC,,,,both,,,613.00,398.45,,,,,,,,,,,,,
PLATE STRNL LG 8 H TI X SHP NS MATRIXSTERNUM,SUP-2904220,CDM,C1713,HCPCS,0278,RC,,,,both,,,2129.52,1384.19,,,,,,,,,,,,,
NUT ORTH COMPR OLECRANON IMP STRL OD6MM,SUP-2106884,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GRAFT VASC 13 CM EXCLUDER AAA,SUP-2395633,CDM,C1768,CPT,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
SET ART LN CATH 3FR L5CM RAD ART SGL LUMN W/ SCALP NDL OINT,SUP-2167832,CDM,C1751,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
TIP IRRIG FEM CNL BRSH W SUCT 9IN PULSAVAC,SUP-2199679,CDM,C1713,HCPCS,0278,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
ROD RMR L950MM DIA3MM W/ STR BALL TIP,SUP-2188116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.02,334.76,,,,,,,,,,,,,
GUIDEWIRE ORTH 3/32X13 IN,SUP-2664007,CDM,C1769,HCPCS,0272,RC,,,,both,,,519.36,337.58,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM GRAVITATIONAL L 12 MM CATH DSTL L FX578T,SUP-2928865,CDM,C1889,HCPCS,0278,RC,,,,both,,,16003.92,10402.55,,,,,,,,,,,,,
GRAFT EVAR L30MM DIA8MM CATH 9FR L80CM 0.035IN EXP PTFE C,SUP-2128219,CDM,C1874,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
SCREW BONE L48MM DIA4MM SM DK BLU TI ST SELF DRL CANN,SUP-2399816,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
PLATE BNE W16XL156MM BLDE L60MM THK4.8MM 95DEG 9 H,SUP-2185517,CDM,C1713,HCPCS,0278,RC,,,,both,,,2964.38,1926.85,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X16 MM 6 LOBE,SUP-2602075,CDM,C1889,HCPCS,0278,RC,,,,both,,,9479.66,6161.78,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 60 CC PRESERVON CANC READIGRAFT,SUP-2740982,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.73,1396.02,,,,,,,,,,,,,
IMMOBILIZER ORTH 3 PANEL UNIV KNEE COTTON CANVS FOAM,SUP-2276704,CDM,L1830,CPT,0272,RC,,,,both,,,32.88,21.37,,,,,,,,,,,,,
CATHETER REPROC EP SUPER LG 2-5 INQUIRY,SUP-2473347,CDM,C1731,HCPCS,0278,RC,,,,both,,,1226.20,797.03,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 1.4X18 MM THRD KIRSCHNER 108319418,SUP-2740220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SYSTEM CARD ICD SYS 2 CHMBR W/ RIATA ST OPTIM SYS FOR V-265,SUP-2356567,CDM,C1721,HCPCS,0275,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
SLEEVE DRL LCK 2.5 MM TCP,SUP-2521528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PIN HOLDING HDLSS 3.2X75 MM TROCAR ZUK,SUP-2853446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
LEAD DEFIB SIL BPLR,SUP-2357723,CDM,C1895,HCPCS,0275,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
COIL DETACH 3MM DIA 10CM 3.1MM THER DIA NXT HELIX SFT 10,SUP-2172999,CDM,C1889,HCPCS,0278,RC,,,,both,,,2615.62,1700.15,,,,,,,,,,,,,
SHEATH INTRO BAN PEEL L 15 CM DIA16 FR STRL,SUP-2141072,CDM,C1892,HCPCS,0272,RC,,,,both,,,131.41,85.42,,,,,,,,,,,,,
HEPATITIS A VACCINE 1440 EL U/ML IM (WRAPPER),RX-430086,CDM,J3376,HCPCS,0636,RC,58160-0826-52,NDC,,both,1,ML,387.70,252.00,,,,,,,,,,,,,
FIBER LASER 272 MICRON 3/PKG STERILE INCLUDES 1,SUP-2574063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.95,566.77,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 33 CM DIA20 FR BODY DIA 7.5 MM,SUP-2395732,CDM,C1894,HCPCS,0272,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
STENT CORONARY EXPRESS 2 L 24 MM DIA2.5 MM GUIDE CATH 6 FR,SUP-2144274,CDM,C1876,HCPCS,0278,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
PLATE BNE 25 MM MOD Y SHP RIGID SAG CRV 6 TRI SHP HOLE BLU,SUP-2478291,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.22,408.99,,,,,,,,,,,,,
HEAD FEM L28MM +4 NK MTL ON POLY,SUP-2364466,CDM,C1776,CPT,0278,RC,,,,both,,,1081.51,702.98,,,,,,,,,,,,,
BASEPLATE TIB SZ 4 THK9-19MM LT TI ALLOY POR RESURF STEM,SUP-2215745,CDM,C1776,CPT,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
BASEPLATE TIB 26 DEG D+ RL/LM KNEE WDG MILLER-GALANTE II,SUP-2199627,CDM,C1776,CPT,0278,RC,,,,both,,,15659.81,10178.88,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10 CM DIA11 MM NIT EPTFE LNR,SUP-2396468,CDM,C1874,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
HC So1 Hla Class II Typing Ea,PX-3108138267,CDM,81382,CPT,0310,RC,,,,inpatient,,,144.00,93.60,,,,,,,,,,,,,
KIT SUTURE ANCHR L 12 MM DIA 4.2 MM LCK PRELD PASS TAPE ON,SUP-2899050,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.08,813.85,,,,,,,,,,,,,
PLATE BNE SM W11XL51MM THK3.3MM 0DEG 4 H BILAT TI STR RIG,SUP-2190774,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.68,317.64,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 6 MM RNG L 20 CM EPTFE STR STD,SUP-2396092,CDM,C1768,CPT,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 35 CM DIA 0.025 IN SS PERIPH SPRING STR,SUP-2838739,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.04,22.13,,,,,,,,,,,,,
PACK VITRCTMY 20GA ANT PNEUMAT CUT W/ IRRIG DP,SUP-2129357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.60,217.49,,,,,,,,,,,,,
SHEATH INTRO 9FR L10CM DIL PROTRUDING L2.5CM 0.038IN GWIRE,SUP-2385201,CDM,C1894,HCPCS,0272,RC,,,,both,,,189.34,123.07,,,,,,,,,,,,,
HC So Targ Geonomic Seq Analy,PX-3108144566,CDM,81445,CPT,0310,RC,,,,both,,,2715.00,1764.75,,,,,,,,,,,,,
PLATE STRNL CLOSURE 100 DEG 8 H TI X NS STERNALOCK BLU,SUP-2894475,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
"HC So Ra Titer, Quantitative",PX-3028643166,CDM,86431,CPT,0302,RC,,,,both,,,21.00,13.65,,,,,,,,,,,,,
STEM FEM SEG 7 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449808,CDM,C1776,CPT,0278,RC,,,,both,,,11079.33,7201.56,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 200 MG MATRISTEM MICROMATRIX,SUP-2106475,CDM,Q4118,HCPCS,0636,RC,,,,both,,,1927.02,1252.56,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ TAB W/ V SHP TAB 1.14 MM ID,SUP-2277594,CDM,L8699,HCPCS,0278,RC,,,,both,,,54.32,35.31,,,,,,,,,,,,,
DHHS HELIX BLADE 130MM-STERILE,SUP-2547637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
DEVICE SUT CAPT W ALIGN INDIC NDL DRVR BTTN SUT FOR OPN RAD,SUP-2139406,CDM,C2631,HCPCS,0278,RC,,,,both,,,778.63,506.11,,,,,,,,,,,,,
GRAFT HUMAN TSSUE SGMNT SM 8MML BRCHMTTRSL FRZE DRIED IRRDTD,SUP-2727663,CDM,C1713,HCPCS,0278,RC,,,,both,,,3733.15,2426.55,,,,,,,,,,,,,
CATHETER CV SET 018 PEDIATRIC 3 FRX5 CM 1 LUMEN J TIP,SUP-2760148,CDM,C1751,HCPCS,0278,RC,,,,both,,,144.91,94.19,,,,,,,,,,,,,
CATHETER DRNGE 8FR L25CM FLEXIMA GLDEX ALL PURP LOOP RADPQ,SUP-2147781,CDM,C1729,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PIN POS DIA5MM S STL LOK CRMP SEAT FOR 4.5MM LCP PLATING,SUP-2178464,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.33,487.71,,,,,,,,,,,,,
DIANEAL PD-2/4.25% DEXTROSE 485 MOSM/L IP SOLN,RX-15436,CDM,2580000003,HCPCS,0250,RC,00941-0415-07,NDC,,both,1000,ML,57.50,37.37,,,,,,,,,,,,,
"HC Urinalysis, Auto, W/O Scope",PX-3078100300,CDM,81003,CPT,0307,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
GUIDEWIRE VASCULAR L95CM DIA0.014IN ENROUTE,SUP-2431163,CDM,C1769,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
CUP ACET DIA66MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH,SUP-2250732,CDM,C1776,CPT,0278,RC,,,,both,,,6864.04,4461.63,,,,,,,,,,,,,
BRACE ORTHOPEDIC MED RT WRST LTHR,SUP-2194367,CDM,L3931,HCPCS,0272,RC,,,,both,,,25.94,16.86,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM 7 FR 1-3-1 MM TIP 3 MM,SUP-2702613,CDM,C1730,HCPCS,0272,RC,,,,both,,,1414.07,919.15,,,,,,,,,,,,,
BRACE KNEE FOR 26IN FOAM TELSCP FULL TECHNOLOGY QUIK LOK,SUP-2196499,CDM,L1832,HCPCS,0274,RC,,,,both,,,346.37,225.14,,,,,,,,,,,,,
BUR SURG FLUT BRL 15 DEG 14.2 MMX13.5 CM STRL DISP,SUP-2638400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
PLATE BONE L15MM THK1.5MM 2X2 H MINI BLU TI,SUP-2319369,CDM,C1713,HCPCS,0278,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
PLATE BNE 3.5X183 MM 14 HOLE SS LCP,SUP-2569327,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.10,324.41,,,,,,,,,,,,,
RING EXT FIX HALF 110 MM TI NS,SUP-2800189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1075.95,699.37,,,,,,,,,,,,,
KIT CEMENT AND MIXING SYSTEM COMBO,SUP-2823660,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CANNULATED SCREW 8.0X75MM,SUP-2900832,CDM,C1713,HCPCS,0278,RC,,,,both,,,997.95,648.67,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 14 ATM 5 FRX139 CM 2.5X12 MM EMPIRA RX,SUP-2158511,CDM,C1725,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
INTRODUCER SHTH 5 FRX4 CM SHT GRY HUB FOR DECLOT PRELUDE,SUP-2303308,CDM,C1893,HCPCS,0272,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
HC 2-D Tte Lmt W/Contrast,PX-4839330801,CDM,C8924,HCPCS,0483,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 8 FR HYDRPHLC,SUP-2754008,CDM,C1892,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
HEMOCONCENTRATOR PERF MEDIVATORS HEMOCOR HPH 1400,SUP-2489325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,226.39,147.15,,,,,,,,,,,,,
SHELL ACET MH 40 MM HIP GRP 0 CUP ALTEON,SUP-2432482,CDM,C1776,CPT,0278,RC,,,,both,,,5659.85,3678.90,,,,,,,,,,,,,
PLATE BONE SM 44MML HLX1 STNLSS STEEL DELTA BTTRSS ST RIGHT,SUP-2720785,CDM,C1713,HCPCS,0278,RC,,,,both,,,2309.22,1500.99,,,,,,,,,,,,,
PLATE BNE L 57 MM SCREW DIA2.4 MM 8 SHFT H SS COMPACT STR VA ST,SUP-2910648,CDM,C1713,HCPCS,0278,RC,,,,both,,,4604.28,2992.78,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.025IN TIP L3CM NIT HYDRPHLC,SUP-2139343,CDM,C1769,HCPCS,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
PLATE BNE L47MM 6 H S STL 1/4 TBLR CLLRD FOR 2.7MM SCR,SUP-2411324,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.74,168.18,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-3612060600,CDM,20606,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SPACER 56300810 12W 30MM X 8MM 10 DG TI,SUP-2429520,CDM,C1821,HCPCS,0278,RC,,,,both,,,15660.75,10179.49,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 6 HOLE 2 COMPR LCK FOR SCR TI STRL,SUP-2459238,CDM,C1713,HCPCS,0278,RC,,,,both,,,1335.10,867.81,,,,,,,,,,,,,
WASHER ORTH 0 DEG 86-130 MM,SUP-2609262,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.73,341.07,,,,,,,,,,,,,
ALLOGRAFT BNE CHIPS 1-8 MM 15 CC CANC DEMINERALIZED BNE BIO,SUP-2637037,CDM,C1713,HCPCS,0278,RC,,,,both,,,5051.07,3283.20,,,,,,,,,,,,,
MESH HERN OVL 12X10 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855274,CDM,C1781,HCPCS,0278,RC,,,,both,,,40804.30,26522.79,,,,,,,,,,,,,
PLATE TI ANTEGRA TWO LEVEL LUMBAR/99MM-04.102.299,SUP-2866728,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
NKII ULTRA ALL-POLY TIBIA LT SZ 0 11MM,SUP-2509862,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GRAFT HUM TISS TIB CORT STRUT BNE FRZ DRY ALLGRFT 100MM LEN,SUP-2264713,CDM,C1713,HCPCS,0278,RC,,,,both,,,2274.24,1478.26,,,,,,,,,,,,,
GRAFT VASC MAXIFLO L 50 CM DIA 7 MM EPTFE SEAL PTFE TW STRL,SUP-2392564,CDM,C1768,CPT,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
CATHETER ETER EP L115CM OD7FR 2 5 2MM SPC TIP L4MM 2 CRV DIAG MAP L,SUP-2356992,CDM,C1733,HCPCS,0272,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
HC So Infliximab Level,PX-3018023066,CDM,80230,CPT,0301,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
HC Pt Orthotic Fit/Train Subsq per 15 Min,PX-4209776300,CDM,97763,CPT,0420,RC,,,,outpatient,,,160.00,104.00,,,,,,,,,,,,,
CATHETER INFUS 7FR L8IN SGL LUMN FOR USE W/ PERC SHTH INTRO,SUP-2383495,CDM,C1751,HCPCS,0278,RC,,,,both,,,27.26,17.72,,,,,,,,,,,,,
DEVICE TISS FIX FIBERTAG TIGHTROPE II,SUP-2903959,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLUG IM OD10MM FEM CNL BNE CEM RESTRIC EXETER X CHANGE,SUP-2368342,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.09,76.11,,,,,,,,,,,,,
BLADE RTRCTR BLFR 3 1/8NW X 2 7/8ND ABDMNL CNTR,SUP-2497563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
ALLOGRAFT DERMAL SM THCK PERF CNTOUR TISS MTRX ALLDERM,SUP-2113061,CDM,Q4116,HCPCS,0636,RC,,,,both,,,8594.18,5586.22,,,,,,,,,,,,,
CLAMP EXT FIX L MULTIPIN 4 POS,SUP-2188492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2037.92,1324.65,,,,,,,,,,,,,
SUPPORT EXT FIX U 200 MM TRAUM STRL TRUELOK LTX,SUP-2875380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3852.65,2504.22,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 18 CM DIA2.9 MM SPD 500-1500 RPM ENT,SUP-2902046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1439.38,935.60,,,,,,,,,,,,,
SCREW BNE L16MM DIA5MM PERIPROSTHETIC LOK,SUP-2381386,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
CATHETER CV 3L 5 FR MAX BARR TY POWERPICC SOLO 2,SUP-2125645,CDM,C1751,HCPCS,0278,RC,,,,both,,,861.36,559.88,,,,,,,,,,,,,
BIT DRL 2.4 MM CERV FOR 3.5 MM SCREW S4,SUP-2108734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.31,492.90,,,,,,,,,,,,,
HC So1 Alpha Fetoprotein,PX-3018210567,CDM,82105,CPT,0301,RC,,,,inpatient,,,107.00,69.55,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR IMPL HEX IQ PORT PLUG,SUP-2900853,CDM,C1822,CPT,0278,RC,,,,both,,,75360.00,48984.00,,,,,,,,,,,,,
STABILIZER SURG FOR BEAT HRT SURG URCHIN EVO,SUP-2282944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BLADE SHV 2MM TYP A BPLR STR DISPOSABLE,SUP-2312958,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.68,355.99,,,,,,,,,,,,,
BOLT IM L18MM DIA3.9MM ST BLU CORT TI ST FULL THRD LOK HEX,SUP-2192170,CDM,C1713,HCPCS,0278,RC,,,,both,,,812.66,528.23,,,,,,,,,,,,,
CILOSTAZOL 100 MG PO TABS,RX-24474,CDM,6370000000,HCPCS,0637,RC,50268-0177-11,NDC,,both,1,UN,4.80,3.12,,,,,,,,,,,,,
SCREW BNE L44MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190357,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.32,34.66,,,,,,,,,,,,,
SCREW BNE L4MM DIA2MM CRANIOMAXILLOFACIAL TI EMGCY FOR,SUP-2189252,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.10,158.01,,,,,,,,,,,,,
HOLDER INSTRUMENT LG 7.5 MM MT TYP B SIL,SUP-2484760,CDM,C1713,HCPCS,0278,RC,,,,both,,,60.82,39.53,,,,,,,,,,,,,
DEVICE TORQ WIRE GUID HYDROSTEER,SUP-2357057,CDM,C1894,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
GRAFT BNE W18XH8XL18MM EVANS FOR TIPEEK FT OSTEOTMY WDG SYS,SUP-2183040,CDM,C1713,HCPCS,0278,RC,,,,both,,,5986.82,3891.43,,,,,,,,,,,,,
NEEDLE PUNCTURE W/LUER-LOCK,SUP-2761700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.50,344.82,,,,,,,,,,,,,
HC So Iron,PX-3018354066,CDM,83540,CPT,0301,RC,,,,both,,,521.00,338.65,,,,,,,,,,,,,
SCREW BONE L36MM DIA3.5MM STD FT ANK TI LCK,SUP-2321027,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
HC Conversion Ext Bil Drng Cath to Intrnl/Extrnl,PX-3614753500,CDM,47535,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 14X30-35 MM PRESERVON X LNG REV FLEXIGRAFT,SUP-2740908,CDM,C1713,HCPCS,0278,RC,,,,both,,,3711.26,2412.32,,,,,,,,,,,,,
GRAFT VASC GELSFT ERS L 75 CM SUPP L 60 CM DIA 6 MM,SUP-2384969,CDM,C1768,CPT,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
HC So Antigen Typing,PX-3008690566,CDM,86905,CPT,0300,RC,,,,both,,,160.00,104.00,,,,,,,,,,,,,
GRAFT BNE SUB 40CC 125 1000U DEMIN CORT PARTICULATE FRZ DRY,SUP-2264722,CDM,C1713,HCPCS,0278,RC,,,,both,,,1878.13,1220.78,,,,,,,,,,,,,
DEFIBRILLATOR SGL CHMBR CARDIOVERTER ADV 7.30CM HT 4.00CM,SUP-2356262,CDM,C1722,HCPCS,0275,RC,,,,both,,,46315.00,30104.75,,,,,,,,,,,,,
CATHETER PICC AD 6FR L55CM 3 LUMN NRS PWR INJ N COAT CT,SUP-2125646,CDM,C1751,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR 25 MM BOV PERICARD COCR REDUC,SUP-2214072,CDM,C1889,HCPCS,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
EXPANDER BRST TISS 455CC W11XH11CM P7.6CM SIL SMOOTH ULT HI,SUP-2301017,CDM,C1789,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
PLANER SURG LAT,SUP-2418046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
GRASPER ENDOSCP ALLIGATOR 15 DEG 3.4 MM HK JAW WISHBONE,SUP-2849251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT INTERMED 5FR 0.026IN 45CM 2 LUMAN R,SUP-2613423,CDM,C1751,HCPCS,0278,RC,,,,both,,,390.93,254.10,,,,,,,,,,,,,
STYLET PACE 86 CM LT HRT LD DEL SYS CPS DUO,SUP-2357580,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SHELL ACET UNIV DIA46MM NO H HA PRI PRESSFIT SECUR FIT PSL,SUP-2370224,CDM,C1776,CPT,0278,RC,,,,both,,,4630.87,3010.07,,,,,,,,,,,,,
DRILL TWST DIA1.8 MM STP 6 MM SCREW DIA 5-6 MM CHK NS DISP,SUP-2883220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
PLATE 3.5MM TI LCP EXTRA-ARTICLR DSTL HUM 10H/RT 230MM-STER,SUP-2546621,CDM,C1713,HCPCS,0278,RC,,,,both,,,5027.45,3267.84,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT 5FR 0.026N 55CM 2 LUMAN RVS 9927508,SUP-2632713,CDM,C1751,HCPCS,0278,RC,,,,both,,,584.89,380.18,,,,,,,,,,,,,
INSERT TIB SZ 1 THICKNESS 8MM KNEE POST STBL INSRT IMP SCORP,SUP-2365109,CDM,C1776,CPT,0278,RC,,,,both,,,2000.21,1300.14,,,,,,,,,,,,,
SCREW 4.X32MM CANN COMPR HDLSS 2 THRD TI,SUP-2392778,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.43,305.13,,,,,,,,,,,,,
KIT TUNNELED CTRL VEN CATH DBL LUMN 10.1 FRX74 CM L,SUP-2332925,CDM,C1751,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE BNE L269MM THK38MM 14 H R MED DST TIB S STL NEUT,SUP-2185224,CDM,C1713,HCPCS,0278,RC,,,,both,,,5175.44,3364.04,,,,,,,,,,,,,
STYLER SPNL SINGLE STP,SUP-2114058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
BIT DRL K WIRE 1.6X200 MM 2 MM FOR SCR VARIAX,SUP-2613646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
PLATE BONE MESHED 151X125 MM LEFT CRANIAL PREFORMED FRONTOTE,SUP-2837719,CDM,C1713,HCPCS,0278,RC,,,,both,,,22851.04,14853.18,,,,,,,,,,,,,
CAPSULE ENDO CAM L26.2MM DIA11.4MM BIOCOMPATIBLE PLAS SB3-EX,SUP-2227941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1664.83,1082.14,,,,,,,,,,,,,
CATHETER PICC 4FR SIL SGL LUMN W/ EXCALIBUR INTRO FLSH THRU,SUP-2125572,CDM,C1751,HCPCS,0278,RC,,,,both,,,161.40,104.91,,,,,,,,,,,,,
TIP IRR DIA0.3MM SM BOR THRD FOR USE W/ INFIN SER 20000 LEG,SUP-2109660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
CAP END 0MM CANN LCK FOR CENTRONAIL ANK COMPR NAILING SYS,SUP-2316507,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.60,438.49,,,,,,,,,,,,,
EXTRACTOR PRO RX S 9 12MM ABV,SUP-2141495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.96,304.82,,,,,,,,,,,,,
TROCAR SURG TOT ANK SYS INFIN,SUP-2397260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
BRACE ANK AIR STRRP SM HT 85 IN,SUP-2336085,CDM,L1930,HCPCS,0272,RC,,,,both,,,28.79,18.71,,,,,,,,,,,,,
HC Intmd Wnd Repair S/Tr/Ext,PX-4501203700,CDM,12037,CPT,0450,RC,,,,both,,,2009.00,1305.85,,,,,,,,,,,,,
ROD SPNL L70MM DIA5.5MM POST BILAT PEEK S STL PRECRV SMOOTH,SUP-2256305,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.31,1449.05,,,,,,,,,,,,,
SET THROMCTMY ANGIOJET XVG L 140 CM DIA 5 FR SHTH 5 FR,SUP-2142033,CDM,C1757,HCPCS,0272,RC,,,,both,,,5118.20,3326.83,,,,,,,,,,,,,
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation,PX-3612251300,CDM,22513,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
PLATE BNE 4X5 H R CRANIOMAXILLOFACIAL TI L SHP FOR 1MM SCR,SUP-2190607,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.29,651.49,,,,,,,,,,,,,
STEM FEM SZ 3 L190MM HIP 12/14 TAPR ENDUR,SUP-2251941,CDM,C1776,CPT,0278,RC,,,,both,,,11994.80,7796.62,,,,,,,,,,,,,
GRAFT BONE SUB 1-4MM 60ML ALLGRFT CHIP CANC DEMIN COPIOS,SUP-2205388,CDM,C1734,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
BRONCHOSCOPE FLX L 600 MM OD 4.2 MM ID 2.2 MM STRL DISP,SUP-2882948,CDM,C1601,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PROCESSOR SOUND PONTO 3 SUPER POWER RIGHT CHROMA BEIGE,SUP-2430359,CDM,L8690,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
EXTENSION EXT FIX 20 MM RIGID FOR ACTIVATION ARM TI,SUP-2461285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2087.66,1356.98,,,,,,,,,,,,,
PLATE BNE L 172 MM 6 H SCREW DIA 4.5 MM LT PROX FEM LG FRAG,SUP-2931368,CDM,C1713,HCPCS,0278,RC,,,,both,,,9679.84,6291.90,,,,,,,,,,,,,
KIT ART CATH INTEGR 1 3 4IN LF,SUP-2384037,CDM,C1894,HCPCS,0272,RC,,,,both,,,105.50,68.57,,,,,,,,,,,,,
TUBE VENT MYR PAPARELLA TYP MAT BLU SIL W/ TAB ID1.27MM,SUP-2341375,CDM,L8699,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE RECON 3.5X112 MM 8 HOLE SS LCP,SUP-2569392,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.30,278.39,,,,,,,,,,,,,
STENT PERIPH TACK L 6 MM OD 4 FR ID 0.014 IN L 120 CM DIA 6,SUP-2716198,CDM,C1876,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
ADAPTER HUM 1 FOR REVERSIBLE SHLDR SYS TI HUMELOCK II,SUP-2741780,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE Z MINI REG RT NO SPACE BTWN HOLE TI LEVEL 1 LF,SUP-2468855,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.00,352.95,,,,,,,,,,,,,
GUIDEWIRE ORTH ANGLED PROP FOR 3.5/5 MM PLATE,SUP-2644636,CDM,C1769,HCPCS,0272,RC,,,,both,,,1214.55,789.46,,,,,,,,,,,,,
PLATE BNE L240MM ALUMINUM BRDG FOR 5 8 RNG MAXFRAME,SUP-2176973,CDM,C1713,HCPCS,0278,RC,,,,both,,,4903.14,3187.04,,,,,,,,,,,,,
SET SCR SPNL L55MM DIA6.4MM PEDCL HA TI ALLOY FOR DYN STBL,SUP-2414277,CDM,C1713,HCPCS,0278,RC,,,,both,,,10596.24,6887.56,,,,,,,,,,,,,
COLLAR CERV TALL AD 2 PC ATLS,SUP-2319263,CDM,L0172,HCPCS,0272,RC,,,,both,,,104.62,68.00,,,,,,,,,,,,,
ANTICOAGULANT SODIUM CITRATE 46.7 % VI CONC,RX-16646,CDM,2500000003,HCPCS,0250,RC,23731-6030-03,NDC,,both,30,ML,434.70,282.55,,,,,,,,,,,,,
PLATE BONE LOK SHAFT 289MML PRTSL 64 CRVD NON CNTCT BRDGE PO,SUP-2721986,CDM,C1713,HCPCS,0278,RC,,,,both,,,2038.86,1325.26,,,,,,,,,,,,,
PUMP ANALGESIC FLO RATE 8 ML/HR 400 ML ELASTOMERIC FIX SOAK,SUP-2892658,CDM,C9804,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
KNIFE SURG MIKAEEL 10 23 CM SCKL STRONG TTL,SUP-2459906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.34,412.32,,,,,,,,,,,,,
CATHETER CV FULL TY 032 10 FRX25 CM 10 GA 5 LUMEN SPECTRUM,SUP-2759734,CDM,C1751,HCPCS,0278,RC,,,,both,,,617.58,401.43,,,,,,,,,,,,,
HC Splint App Short Arm Stat,PX-4302912500,CDM,29125,CPT,0430,RC,,,,both,,,404.00,262.60,,,,,,,,,,,,,
GRAFT DERM L10CM W5CM THK.8-1.7MM THCK DERMAMATRIX ACELLULAR,SUP-2306914,CDM,C1762,CPT,0278,RC,,,,both,,,4484.92,2915.20,,,,,,,,,,,,,
COIL NEUROVASCULAR PRESIDIO 18 CERECYTE L 50 CM LOOP DIA15,SUP-2457160,CDM,C1889,HCPCS,0278,RC,,,,both,,,11333.33,7366.66,,,,,,,,,,,,,
CATHETER CTRL VEN 7FR L6IN POLYUR 2 LUMN W/ BLU FLEXTIP AND,SUP-2120645,CDM,C1751,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO MEMBRN 2X4 CM DRY ALLOWRAP DRY,SUP-2717791,CDM,Q4150,HCPCS,0636,RC,,,,both,,,6181.88,4018.22,,,,,,,,,,,,,
CATHETER EMB 3FR L80CM BLLN DIA5MM 4.5FR INTRO 0.018IN ART,SUP-2214019,CDM,C1757,HCPCS,0272,RC,,,,both,,,359.40,233.61,,,,,,,,,,,,,
BIT DRILL 1.8 MM WITH STRYKER JLATCH FOR BASIC TROCAR SYSTEM,SUP-2838103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,639.62,415.75,,,,,,,,,,,,,
SHEATH FEM ACCS WRK L35CM EXP L30CM OD23FR ID19FR INSRT,SUP-2385217,CDM,C1894,HCPCS,0272,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
PLATE BONE BAR L11.9MM THK0.6MM SH 2X2 H RT,SUP-2191304,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.85,532.90,,,,,,,,,,,,,
PLATE BONE L18MM 6 H CRANIOFACIAL VIT STR COND FOR 1.3MM SCR,SUP-2364697,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-131187,CDM,Q5101,HCPCS,0636,RC,61314-0318-01,NDC,,both,0.5,ML,809.40,526.11,,,,,,,,,,,,,
PROSTHESIS VOICE 16 FRX20 CM DUCKBILL SIL,SUP-2242272,CDM,L8509,HCPCS,0274,RC,,,,both,,,277.58,180.43,,,,,,,,,,,,,
MESH HERN W25.9XL36CM VENTRAL HERN POLYPR EPTFE RECTANG,SUP-2125812,CDM,C1781,HCPCS,0278,RC,,,,both,,,4798.86,3119.26,,,,,,,,,,,,,
SCREW WDG FEM L15MM DSTL KNEE PRI PRESSFIT LEGION,SUP-2346335,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CAGE SPNL EXPANDABLE 0 DEG 27X10-15X11 MM PLIF EZSPAND,SUP-2572219,CDM,C1889,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
COIL EMB HELCL 12 MMX80.4 CM DETACHABLE SUPER SFT AXIUM PRIM,SUP-2429577,CDM,C1889,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BNE L33MM THK1MM 2X6 H NONSTERILE HND TI ROT CORR LOK,SUP-2255846,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.73,1426.57,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CROSPERIO L 150 CM L40MM 3.5MM INFLATION,SUP-2384785,CDM,C1725,HCPCS,0272,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
SYSTEM VENTRICULAR DRAINAGE W/ HERM VENT CATH SET ACCUDRAIN,SUP-2883383,CDM,C1729,HCPCS,0272,RC,,,,both,,,1025.40,666.51,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT L 23 CM DIA 9 FR BALLOON DIA18,SUP-2264223,CDM,C2628,HCPCS,0272,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
PIN FEM 2 LT RESURF KT GRDIAN,SUP-2304395,CDM,C1713,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
PLATE BNE L63MM 3X4 H L T SHP OBLQ FOR 3.5MM SCR UNIV LOK,SUP-2411380,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.61,666.00,,,,,,,,,,,,,
CAGE SPNL 5.5X14MM TAPR CERV STALIF C,SUP-2163186,CDM,C1889,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH 10 CM 5FR 7CM SS PLAT ECHOGENIC,SUP-2170489,CDM,C1894,HCPCS,0272,RC,,,,both,,,73.73,47.92,,,,,,,,,,,,,
STEM FEM SEG 1.5 CM DPHSEAL KNEE OSS 161078,SUP-2441794,CDM,C1776,CPT,0278,RC,,,,both,,,15288.66,9937.63,,,,,,,,,,,,,
BLADE SAW 10X31MM ANG CONSIGNED BUR BLDE RASP MIC OSC DISP,SUP-2361966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 30 CC CANC PUROS,SUP-2687382,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
SUPPORT INSTR PEDICULAR STPL COLORADO 2,SUP-2290548,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
CAGE SPNL LORDTC 7 DEG 16X13X7 MM CERV TI PEEK IRIX-C,SUP-2366041,CDM,C1889,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SCREW SPNL 12 MM,SUP-2242800,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SHEATH URET PROXIS L 45 CM OD 14 FR ID 12 FR ACCS SHRT DIL,SUP-2655867,CDM,C1894,HCPCS,0272,RC,,,,both,,,846.14,549.99,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM TRAD 4 FRX7 IN OPN DISP,SUP-2330479,CDM,C1726,HCPCS,0272,RC,,,,both,,,72.47,47.11,,,,,,,,,,,,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,6370000000,HCPCS,0637,RC,51672-2075-01,NDC,,both,14.2,GR,14.40,9.36,,,,,,,,,,,,,
DISTRACTOR EXT FIX 20 MM 1-1.2 MM 9 HOLE MID DRIVEN RATCH,SUP-2465567,CDM,C1713,HCPCS,0278,RC,,,,both,,,15966.27,10378.08,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP SEMITENDINOSUS W/ GRACILIS,SUP-2867231,CDM,C1762,CPT,0278,RC,,,,both,,,6848.97,4451.83,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM HI FLX M HXLPE TI,SUP-2212712,CDM,C1776,CPT,0278,RC,,,,both,,,26158.59,17003.08,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE FEM CUST FRAC SEMI RIGID,SUP-2435651,CDM,L2134,HCPCS,0274,RC,,,,both,,,3262.59,2120.68,,,,,,,,,,,,,
PLATE BNE LCK 158 MM LT DSTL LAT FIBULAR 10 HOLE SS STRL,SUP-2457652,CDM,C1713,HCPCS,0278,RC,,,,both,,,2380.37,1547.24,,,,,,,,,,,,,
DEVICE TISS REM FOR HYSTEROSCOPIC IU PROC MYOSURE XL,SUP-2239854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SYSTEM TRANSSEPTAL ACCESS ACQCROSS QX AG 71CM,SUP-2854451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
TRIAL KNEE POST FEM ROT PLATFRM REV ATTUNE,SUP-2436168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
REGULATOR SUCTION CONT INTERMITTENT DISS M VACUTRON,SUP-2305890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SPACER SPNL W12XH8XL14MM FORTITUDE DUO,SUP-2414776,CDM,C1821,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
KIT VLV SZR SZ 19/21/23/25/27/29 MM AORT COMMON L/R N,SUP-2895323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9363.48,6086.26,,,,,,,,,,,,,
PLATE BNE THK075MM 3X5 H HND 316L S STL T SHP LOK FOR 13MM,SUP-2177983,CDM,C1713,HCPCS,0278,RC,,,,both,,,1301.69,846.10,,,,,,,,,,,,,
EXTRACTOR STONE 2.2FR L115CM BSKT DIA8MM NIT FOR URET STONE,SUP-2171431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1128.20,733.33,,,,,,,,,,,,,
BURR SURG DIAMOND 5 MM,SUP-2661405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
INTRODUCER SHTH 6FR L12CM 0.038IN L50CM W/ LUERLOK HEMSTAS,SUP-2355454,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
PLATE BNE STD 14 MM,SUP-2243117,CDM,C1713,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
BOLT FEM HIP MOD LCK FOUNDATION,SUP-2217196,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BEAM FIX L70MM DIA6.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223944,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
HC Blood Culture Multiplex Pcr 2,PX-3008715400,CDM,87154,CPT,0300,RC,,,,both,,,524.00,340.60,,,,,,,,,,,,,
BIT DRILL DIA3.2MM BLU CALIB DISP FOR FEM NAIL PEDINAIL,SUP-2318889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1040.91,676.59,,,,,,,,,,,,,
CATHETER EP ABLAT THER 2 8 7FR QPLR 1304-7-25-S-TE8TC2,SUP-2357456,CDM,C1733,HCPCS,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115 CM 8FR STRL,SUP-2257364,CDM,C1733,HCPCS,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
STEM FEM SEG 17 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449813,CDM,C1776,CPT,0278,RC,,,,both,,,11945.50,7764.57,,,,,,,,,,,,,
STEM HUM SLT 14X125 MM SHLDR OLYMPIA,SUP-2535972,CDM,C1776,CPT,0278,RC,,,,both,,,11197.24,7278.21,,,,,,,,,,,,,
BLADE SAW KNEE 19.5MM CUT EDGE 90MM CUT DEPTH 1.2MM CUT THCK,SUP-2586313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,111.85,72.70,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM SUT SZ 2 COBRAID PEEK OPTMA BLK BLU,SUP-2341850,CDM,C1713,HCPCS,0278,RC,,,,both,,,1007.94,655.16,,,,,,,,,,,,,
GRAFT HUM TISS SM 9MM W8.5MM D20MM 5DEG LORDOSIS POST RAMP,SUP-2294225,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
CONNECTOR SPNL CLOSE 2 FOR 6.35MM ROD ISOLA,SUP-2255601,CDM,C1713,HCPCS,0278,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
CAGE SPNL 0 DEG 25X11X8 MM POST LUMBAR INTBDY PEEK CEZANNE,SUP-2578160,CDM,C1889,HCPCS,0278,RC,,,,both,,,6229.76,4049.34,,,,,,,,,,,,,
CATHETER ASPIR 6FR L55IN 100% S STL BRAID KINK RESIST,SUP-2302443,CDM,C1757,HCPCS,0272,RC,,,,both,,,950.85,618.05,,,,,,,,,,,,,
BLADE SHAVER SUPERFICIAL 18 DEG 2.9X270 MM LARYNGEAL DBL,SUP-2648908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1061.60,690.04,,,,,,,,,,,,,
KIT ORTH EXT PROC PMT INSTR FLUT GWIRE TISS PROTCT DRL BIT,SUP-2400578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3486.34,2266.12,,,,,,,,,,,,,
MESH HERN W5XL15CM THK1MM INGUINAL BIOMATERIAL FOR SFT TISS,SUP-2395363,CDM,C1781,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
DEFIBRILLATOR CRD 40 J 4X7.3X1.4 CM 36 CC 77 CC UNIFY,SUP-2356314,CDM,C1882,HCPCS,0275,RC,,,,both,,,89490.00,58168.50,,,,,,,,,,,,,
BRACE KNEE AD LG UNISX R MED HNG FASTEN ON OPN,SUP-2196476,CDM,L1852,HCPCS,0272,RC,,,,both,,,1212.07,787.85,,,,,,,,,,,,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,0636,RC,00548-5900-00,NDC,,both,1,UN,148.20,96.33,,,,,,,,,,,,,
GRAFT HUM TISS L 3.2 X W 3.2 CM PLCNTA MEMBRN ALLGRFT,SUP-2909401,CDM,Q4160,HCPCS,0636,RC,,,,both,,,2291.57,1489.52,,,,,,,,,,,,,
CATHETER US 8FR L90CM HI RESOL 4 W STEERING PRECIS DOPP,SUP-2248452,CDM,C1759,HCPCS,0272,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
CATHETER DRNGE 12FR L45CM 0.038IN 6 SIDEPRT PERC HYDRPHLC,SUP-2168508,CDM,C1729,HCPCS,0272,RC,,,,both,,,242.16,157.40,,,,,,,,,,,,,
GUIDEWIRE VASC STRT L 150 CM DIA 0.038 IN TAPR 0 CM SS PTFE,SUP-2148262,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.89,14.88,,,,,,,,,,,,,
SUPPORT ORTHOT HND CUST STRP W/O JT FABRICATED SFT INTFACE,SUP-2435780,CDM,L3919,HCPCS,0274,RC,,,,both,,,697.80,453.57,,,,,,,,,,,,,
KIT CVC AD 7FR L20CM POLYUR BLU FLEXTIP ANTIMIC MULTILUMEN,SUP-2383391,CDM,C1751,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SHEATH URO 12/14FR L36CM SGL TAPR FLX DIL TIP NAVIGATOR HD,SUP-2139225,CDM,C1894,HCPCS,0272,RC,,,,both,,,420.23,273.15,,,,,,,,,,,,,
PLATE BONE L86MM 7 H LT POSTEROLATERAL DSTL FIBULAR VAR ANG,SUP-2349821,CDM,C1713,HCPCS,0278,RC,,,,both,,,5299.69,3444.80,,,,,,,,,,,,,
CANNULA ENDOSCP L 55 MM DIA 4.5 MM STRL DISP PARALLELPORTAL,SUP-2908738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC SYR DBM ACCELL EVO3C,SUP-2641765,CDM,C1713,HCPCS,0278,RC,,,,both,,,6612.84,4298.35,,,,,,,,,,,,,
PROSTHESIS OSS 0.5X4.50 MM PISTON NIT/FLROPLAS SMRT 360,SUP-2651576,CDM,L8613,CPT,0278,RC,,,,both,,,996.79,647.91,,,,,,,,,,,,,
HC Removal Permanent Pacemaker Pulse Generator Only|DOCUMENTATION ON FILE,PX-4813323300,CDM,33233,CPT,0481,RC,,,KX,both,,,5689.00,3697.85,,,,,,,,,,,,,
PLATE BONE L100MM THK2MM 5 H SPN FOR 4.5MM SCR TC-100 L FRAG,SUP-2343814,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.78,1892.66,,,,,,,,,,,,,
PEG BNE HOLDING TOT KNEE SYS MG II,SUP-2437017,CDM,C1713,HCPCS,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 18GA 10CM WNGD 1 LU F218108PT,SUP-2632753,CDM,C1751,HCPCS,0278,RC,,,,both,,,397.02,258.06,,,,,,,,,,,,,
SCREW INTFR L35MM DIA9MM KNEE PLLA CANN ABSRB RND HD,SUP-2249523,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PATCH BIO TISS W4XL4CM BOV PERICARD,SUP-2130363,CDM,C1768,CPT,0278,RC,,,,both,,,835.87,543.32,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 FT 5FR 55CM 2 LUMAN 3295108F,SUP-2632675,CDM,C1751,HCPCS,0278,RC,,,,both,,,526.04,341.93,,,,,,,,,,,,,
DRILL SURG CANN SM 5 MM HUDSON,SUP-2766114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
GROMMET VENT TB ID1.27MM FLNG ID2.75MM TI MICROPOLISHED,SUP-2284042,CDM,L8699,HCPCS,0278,RC,,,,both,,,65.06,42.29,,,,,,,,,,,,,
MASK FULL FACE W/ PREM HDGEAR SM COMFORTGEL,SUP-2326785,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
HC So1 Serotonin,PX-3018426067,CDM,84260,CPT,0301,RC,,,,outpatient,,,436.00,283.40,,,,,,,,,,,,,
CHIARI MLFRMTN PLATE CRSCNT SHAPE LG 06MM THICK CP TTNM,SUP-2676600,CDM,C1713,HCPCS,0278,RC,,,,both,,,4955.39,3221.00,,,,,,,,,,,,,
ROD SPNL 28 MM TRANSITION,SUP-2230032,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
CATHETER RF ENDOVENOUS ABLAT CLOSUREFAST 60CM,SUP-2120510,CDM,C1760,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
SCREW SPNL L45MM DIA7.5MM MULT AX REV ANG THRD LOK,SUP-2288006,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ELECTRODE EMG 25 MM 0.30 MM LFRIC CONCENTRIC SS TECA DISP 25/BX,SUP-2308208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
HC Hepatic Vein W/Hemo Eval,PX-3207588900,CDM,75889,CPT,0320,RC,,,,both,,,5817.00,3781.05,,,,,,,,,,,,,
HC Gliadin Antibody Each Immunoglobulin Class,PX-3028625800,CDM,86258,CPT,0302,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
COMPONENT TIB CR ALL POLY 9MM SZ 1,SUP-2222623,CDM,C1776,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
GUIDE WIRE .090X4,SUP-2814017,CDM,C1769,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,340b,HCPCS,0637,RC,78112-0011-03,NDC,,both,177,ML,20.00,13.00,,,,,,,,,,,,,
CONNECTOR PACE LD SELECTSECURE MRI SURESCAN L 3.66 M,SUP-2937136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1007.94,655.16,,,,,,,,,,,,,
CATHETER DRNGE L40CM OD8FR TOT ABSCESSION BILI,SUP-2118567,CDM,C1729,HCPCS,0272,RC,,,,both,,,237.70,154.50,,,,,,,,,,,,,
PIN EXT FIX L9IN DIA3/32IN S STL DMND PNT W/ SMOOTH SHFT,SUP-2342709,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.05,261.33,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND 9.5-13 MMX142 CM BND 6 SHOT SAEED,SUP-2737553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
CANNULA 25GA MAINTAINER CHAMBER,SUP-2854487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,35.48,23.06,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 5 MM RNG L 70 CM EPTFE,SUP-2396287,CDM,C1768,CPT,0278,RC,,,,both,,,3783.70,2459.40,,,,,,,,,,,,,
GRAFT VASC W5XL6CM EPTFE PTCH DURA SUB NONBIOLOGICAL PRECL,SUP-2395355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
PLATE BNE L208MM 14 H L DST POSTEROLATERAL HUM S STL LOK,SUP-2185917,CDM,C1713,HCPCS,0278,RC,,,,both,,,3121.25,2028.81,,,,,,,,,,,,,
CATHETER PICC 3FR POLYUR NCOATED MICROINTRODUCER TRIM LEN,SUP-2127455,CDM,C1751,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
MESH HERN RECT OVL 4X1 IN FLAT SHT KNITTED POLYPR PROLITE,SUP-2227231,CDM,C1781,HCPCS,0278,RC,,,,both,,,67.51,43.88,,,,,,,,,,,,,
GUIDEWIRE VASC 014X300 SPECTR WAVEWRITER,SUP-2240283,CDM,C1769,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
CATHETER OCCL 5FR L90CM BLLN L80MM IMAG GUID BRDG,SUP-2353169,CDM,C2628,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
LEAD DEFIB PROTEGO SD L 60 CM TIP DISTANCE 16 CM PTIR,SUP-2138427,CDM,C1895,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX270 CM VISIGLIDE (BX OF 10 EA),SUP-2479295,CDM,C1769,HCPCS,0272,RC,,,,both,,,5529.57,3594.22,,,,,,,,,,,,,
HC MRI-Upper Ext Jnt W & WO Cont,PX-6107322300,CDM,73223,CPT,0610,RC,,,,both,,,4220.00,2743.00,,,,,,,,,,,,,
CATHETER BAL OCCL L65CM OD7FR OD34FR,SUP-2139719,CDM,C2628,HCPCS,0272,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
OSTEOTOME SURG 6MM PROX SL,SUP-2400080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
ST APG SYNV RASP SM +5 LINV,SUP-2514072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.46,470.25,,,,,,,,,,,,,
TRIAL INSRT L20MM SZ 2 TIB REV PROVEN,SUP-2359243,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PROBE CYL TIP DEB TI SONIC 1,SUP-2305953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
FRACTURE KIT 10 ML BNE CEMENT SATURATE MIXING STABILIT ER,SUP-2457092,CDM,C1713,HCPCS,0278,RC,,,,both,,,2232.54,1451.15,,,,,,,,,,,,,
BIT DRL DIA2MM QUIK REL SURGIBIT,SUP-2107099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
SCREW SYS PARTIALLY THRD LAG 316 L VM S THRD 2.5MM CANN,SUP-2392883,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CATHETER THORACIC X-LARGE 24FR L26IN EXTENDED LENGTH STRAIGH,SUP-2825082,CDM,C1729,HCPCS,0272,RC,,,,both,,,83.74,54.43,,,,,,,,,,,,,
HC Pt Eval Low Complex,PX-4249716100,CDM,97161,CPT,0424,RC,,,,both,,,174.00,113.10,,,,,,,,,,,,,
TROCAR SURG L232MM DIA32MM FOR TI TROCHANTERIC NAIL FIX SYS,SUP-2188220,CDM,C1769,HCPCS,0272,RC,,,,both,,,1001.94,651.26,,,,,,,,,,,,,
PLATE X VA LCK 2.4/2.7MM LG TI STRL,SUP-2546957,CDM,C1713,HCPCS,0278,RC,,,,both,,,3785.71,2460.71,,,,,,,,,,,,,
GRAFT BONE CORT STRUT ALLGRFT FRZN,SUP-2165593,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
RING ACET SZ F CONSTRAINING SNAP FOR CLUS AND MH SHELL,SUP-2222081,CDM,C1776,CPT,0278,RC,,,,both,,,2336.47,1518.71,,,,,,,,,,,,,
VALVE AORT SZ 21 H16MM CUF DIA26MM TISS ANNULUS DIA21MM SUP,SUP-2355875,CDM,C1889,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
IMPLANT PENILE L 16 CM INFPUB PRECONNECT INFLATABLE,SUP-2930708,CDM,C1813,HCPCS,0278,RC,,,,both,,,44202.88,28731.87,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN 150 DEG L 63 CM DIA 8.5 FR NDL L 71,SUP-2701795,CDM,C1893,HCPCS,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
SCREW BONE L100MM OD5MM FLLY THRDD CNNLTD TTNM NNSTRLE,SUP-2488455,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.06,348.44,,,,,,,,,,,,,
PIN DIL 28MM NAIL TENFUSE,SUP-2401424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PLATE BONE W14.9XL248MM THK1.2MM 15 H DSTL TIB S STL,SUP-2185744,CDM,C1713,HCPCS,0278,RC,,,,both,,,1650.01,1072.51,,,,,,,,,,,,,
ESCITALOPRAM OXALATE 10 MG PO TABS,RX-33512,CDM,6370000000,HCPCS,0637,RC,00904-6426-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BONE L95MM D45MM CRTCL SELF TPPNG FLLY THRDD L HEX RCS,SUP-2464162,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
HOOK SPNL M PEDCL TI RAMPED THOR NAR BLDE FOR 5.5MM ROD CDH,SUP-2287867,CDM,C1713,HCPCS,0278,RC,,,,both,,,2377.77,1545.55,,,,,,,,,,,,,
INSERT TIB CR 67X14 MM KNEE PRIMARY BEAR MAXM VI,SUP-2404015,CDM,C1776,CPT,0278,RC,,,,both,,,2424.08,1575.65,,,,,,,,,,,,,
CONNECTOR NEUROSTIMULATOR L35CM M1 PRECIS,SUP-2138844,CDM,C1883,HCPCS,0278,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
CATHETER PACE ARW L 110 CM DIA 5 FR BALLOON DIA 7 MM INTRO 6,SUP-2383249,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BNE L 148.08 MM THK 1 MM 20 H TI STR NS DISP TRAUMAONE,SUP-2936645,CDM,C1713,HCPCS,0278,RC,,,,both,,,2524.56,1640.96,,,,,,,,,,,,,
PLATE BNE L54MM BLDE W9.2XL30MM 90DEG 4 H BILAT S STL LOK,SUP-2185359,CDM,C1713,HCPCS,0278,RC,,,,both,,,3175.17,2063.86,,,,,,,,,,,,,
TUBE VENT DIA1.14MM INTERFLANGE DISTANCE 3.5MM ACTIVENT SIL,SUP-2284019,CDM,L8699,HCPCS,0278,RC,,,,both,,,71.87,46.72,,,,,,,,,,,,,
CYSTOSCOPE RIGID 0 DEGREE 2.7X113 MM,SUP-2862635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
CATHETER PTCA L150CM 0.018IN BLLN L12CM DIA3MM 15ATM PERIPH,SUP-2156646,CDM,C1725,HCPCS,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
COLLAR CERV PHILLY LG 4.25 IN 16-19 IN REHAB FOAM PROCARE,SUP-2196880,CDM,L0120,HCPCS,0274,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
GUIDEWIRE VASC NITINOL HYDROPHIL STR 3 CM 0.035 INX150 CM STD NIT ZIPWIRE,SUP-2139333,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.56,109.56,,,,,,,,,,,,,
RETRACTOR SURG BLNT 25 MMX4 CM SPNL MEDL LAT DIL HLLW SS,SUP-2293011,CDM,C1713,HCPCS,0278,RC,,,,both,,,4108.53,2670.54,,,,,,,,,,,,,
BUR MED RND 31MM,SUP-2398604,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 14X8 CM RECT BOV PERICARD PHOTOFIX LTX,SUP-2859717,CDM,C1768,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
IMPLANT BRST GEL 4.6 CM PROJCT 8.6 CM 185 CC ULTRA HI SILTEX,SUP-2300602,CDM,C1789,HCPCS,0278,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
KIT BNE FIX STPL BRIDGE L 20 X 20 MM MAX NIT ANK FT ULTRA LP,SUP-2896921,CDM,C1713,HCPCS,0278,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-106535,CDM,2500000003,HCPCS,0250,RC,63323-0462-17,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
ENDPLATE SPNL DISK L20MM 20MM FOOTPRINT 8DEG VERT BODY REPL,SUP-2229981,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BALLOON PRSS REG 71-80CM H20 M FOR AMS 800 URIN CTRL SYS,SUP-2138915,CDM,C1815,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
GRAFT HUM TISS POST TIBIALIS TEND SM DIAM ALL FLD DIAM 75MM,SUP-2307282,CDM,C1762,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
CATHETER LAPSCP L13IN DISP CHOLGM FOR PRT INSRTN,SUP-2330476,CDM,C1713,HCPCS,0278,RC,,,,both,,,856.34,556.62,,,,,,,,,,,,,
PATCH BIO L 10 X W 1.5 CM BOV PERICARD XENOSURE,SUP-2884043,CDM,C1768,CPT,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
WIRE GUID PRSS PRIMEWIRE SHT J TIP .014INX185CM PRESTIGE,SUP-2327225,CDM,C1769,HCPCS,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
KNIFE SURG LO BRECK 10.75 IN CART STR EDGE GUARDS CRV,SUP-2459935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC BONE STABILIZATION SYSTEM 17 X 260MM,SUP-2881211,CDM,C1713,HCPCS,0278,RC,,,,both,,,15941.78,10362.16,,,,,,,,,,,,,
POR FEM/CEM MON TIB/PAT,SUP-2137306,CDM,C1713,HCPCS,0278,RC,,,,both,,,13542.82,8802.83,,,,,,,,,,,,,
SET INTRO SHTH L 68.6 CM OD 16 FR GUIDEWIRE 0.038 IN FEM CRV,SUP-2169595,CDM,C1894,HCPCS,0272,RC,,,,both,,,1890.25,1228.66,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 20H LT 301MM-STER,SUP-2549599,CDM,C1713,HCPCS,0278,RC,,,,both,,,5504.01,3577.61,,,,,,,,,,,,,
PLATE BNE THK 0.5 MM SCREW DIA1.7 MM 2 X 21 H PLL,SUP-2883202,CDM,C1713,HCPCS,0278,RC,,,,both,,,12848.88,8351.77,,,,,,,,,,,,,
PLATE BONE L234MM 16 HOLE RIGHT LTRL PRXML PRRTCLR HMRL LOK,SUP-2470267,CDM,C1713,HCPCS,0278,RC,,,,both,,,4636.56,3013.76,,,,,,,,,,,,,
ROD IM POLARUS,SUP-2107701,CDM,C1713,HCPCS,0278,RC,,,,both,,,3318.98,2157.34,,,,,,,,,,,,,
ALLOGRAFT BNE RNG FD ULNA,SUP-2321918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
DEVICE FIX BIOABSORBABLE 2.5 MM RIBBON ENDOTINE,SUP-2760658,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.25,280.31,,,,,,,,,,,,,
NANOBITER 15 DEGREE UP TIP AR10902D,SUP-2843580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-125412,CDM,J0169,HCPCS,0636,RC,49502-0501-02,NDC,,both,2,UN,3499.60,2274.74,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE SALERA 2CM X 2CM DEHYDRATED,SUP-2907552,CDM,C1762,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC So Hepatitis C Virus Antibody,PX-3028680366,CDM,86803,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
VIEN HARVEST KIT VASCUCLEAR ENDOSCP SM RETRACTOR,SUP-2265220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1831.66,1190.58,,,,,,,,,,,,,
PLATE BONE L120MM THK2MM 6 H SPN FOR 4.5MM SCR TC-100 L FRAG,SUP-2343815,CDM,C1713,HCPCS,0278,RC,,,,both,,,2528.01,1643.21,,,,,,,,,,,,,
IMPLANT SPNL H31 46MM 0DEG LUM W L ENDPLATE RATCH MECHANISM,SUP-2193200,CDM,C1889,HCPCS,0278,RC,,,,both,,,20724.00,13470.60,,,,,,,,,,,,,
RESERVOIR WRM 3L RAP INFUS RI-2 BELMONT,SUP-2134635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.87,326.22,,,,,,,,,,,,,
CATHETER BRACHYTHERAPY MULT LUMEN 4.5 CM BLNT CONTURAFLEX,SUP-2239954,CDM,C1725,HCPCS,0272,RC,,,,both,,,8375.95,5444.37,,,,,,,,,,,,,
SCREW BNE 1.5X4 MM CRANIOMAXILLOFACIAL F3 MAXDRIVE 258580491,SUP-2463374,CDM,C1713,HCPCS,0278,RC,,,,both,,,187.02,121.56,,,,,,,,,,,,,
SYSTEM FIX MED 4.5X2.2X7.5 MM FEMALE SFT TISS TENOTAC,SUP-2749807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
PLATE BNE L149MM 8 H R DST ANTLAT TIB S STL LOK FOR 35 4MM,SUP-2362745,CDM,C1713,HCPCS,0278,RC,,,,both,,,6134.62,3987.50,,,,,,,,,,,,,
GENTAMICIN IN SALINE 0.8-0.9 MG/ML-% IV SOLN,RX-15906,CDM,J1580,HCPCS,0636,RC,00338-0503-48,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L8MM DIA1.2MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189160,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
SCREW BNE ST 5 MM LCK TI NS,SUP-2190373,CDM,C1713,HCPCS,0278,RC,,,,both,,,49.55,32.21,,,,,,,,,,,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,0636,RC,67457-0426-00,NDC,,both,0.2,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L71MM THK13MM 12 H NONSTERILE HND TI STR LOK VAR,SUP-2181037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1809.61,1176.25,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2 MM RECON MAXILLA PT SPEC,SUP-2860081,CDM,C1713,HCPCS,0278,RC,,,,both,,,26314.46,17104.40,,,,,,,,,,,,,
PLATE BONE W14.9XL232MM THK1.2MM 14 H DSTL TIB S STL,SUP-2185743,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.66,1008.58,,,,,,,,,,,,,
BRACE ORTHPDC D RING SM ADLT 21.6 CM 14.6 16.5 CM RIGHT WRIS,SUP-2457443,CDM,L3931,HCPCS,0274,RC,,,,both,,,40.95,26.62,,,,,,,,,,,,,
MESH HERN CIR 10X15CM W/ ECHO 2 POS SYS PHASIX ST,SUP-2716209,CDM,C1781,HCPCS,0278,RC,,,,both,,,8603.60,5592.34,,,,,,,,,,,,,
INSERT ACET SZ E OD50 52MM ID26MM 0DEG UHMWPE CONSTRN REFLCT,SUP-2344624,CDM,C1776,CPT,0278,RC,,,,both,,,7510.88,4882.07,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 70MM H2O MED LO RANG HAKIM,SUP-2666794,CDM,C1889,HCPCS,0278,RC,,,,both,,,4370.19,2840.62,,,,,,,,,,,,,
PIN BNE FIX LNG SHOULDERED CADENCE,SUP-2933705,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.51,235.63,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 45 CM DIA 4-7 MM EPTFE CARBON STP N,SUP-2128790,CDM,L8670,HCPCS,0278,RC,,,,both,,,5984.59,3889.98,,,,,,,,,,,,,
PIN FIX 1.6X6 MM FLAT HD US ACTIVATION POLY-D-L-LACTIC ACID,SUP-2474788,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.63,174.61,,,,,,,,,,,,,
KIT NEUROSTIM L8IN 1X8 LO PROF CLS BOOT PLUG FOR INTERSTIM,SUP-2284436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE TISS MEND 4CMX4CM PTCH,SUP-2364668,CDM,Q4109,HCPCS,0636,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
PLATE BONE L218MM 11 H BILAT S STL COBRA HD LO PROF RIG NEUT,SUP-2185802,CDM,C1713,HCPCS,0278,RC,,,,both,,,2199.10,1429.41,,,,,,,,,,,,,
BIT DRL DIA3.5MM QUIK CPL REUSE TARGETER,SUP-2343982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.57,673.12,,,,,,,,,,,,,
SCREW SPNL L40MM OD4MM TI MULTAXL NONCANNULATED FOR 5.5MM,SUP-2415137,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
"HC So Chlamydia, Ab, Igm",PX-3028663266,CDM,86632,CPT,0302,RC,,,,inpatient,,,225.00,146.25,,,,,,,,,,,,,
BIT DRL DIA3.2MM MID FOR PHALINX SYS,SUP-2397839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
MESH SURG W0.2XL2.7CM SPCR POLYETH SGL USE OPTIMESH,SUP-2354629,CDM,C1781,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
AMNION DELIVERY DEVICE,SUP-2811352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
BOLT IM L18MM DIA3.9MM NONSTERILE BLU CORT TI ST FULL THRD,SUP-2192169,CDM,C1713,HCPCS,0278,RC,,,,both,,,573.68,372.89,,,,,,,,,,,,,
PLATE BNE W12.9XL43.7MM 8 H Y HI STRENGTH FOR FLX FRAG FIX,SUP-2411673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1902.84,1236.85,,,,,,,,,,,,,
BLADE SURG KNF L11MM PARA GRFT,SUP-2121679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
HC Intrvasc US Noncoronary Addl,PX-3613725300,CDM,37253,CPT,0361,RC,,,,outpatient,,,1485.00,965.25,,,,,,,,,,,,,
HC Sacroplasty,PX-3610200000,CDM,0200T,CPT,0361,RC,,,,both,,,7342.00,4772.30,,,,,,,,,,,,,
NAIL IM L400MM OD13MM 125DEG LNG TIM RT HIP AG CANN LCK,SUP-2402793,CDM,C1776,CPT,0278,RC,,,,both,,,4954.92,3220.70,,,,,,,,,,,,,
CABLE ASSY CERCLAGE SST 18MM X 914MM,SUP-2721369,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.66,820.73,,,,,,,,,,,,,
IMPLANT NSL 17 X 13 X 3 MM OVL PERF 2PC MAGNETICALLY COUPLED,SUP-2887847,CDM,C1889,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
BIT DRL L221MM DIA4.3MM QUIK CPL REUSE,SUP-2187278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.70,422.30,,,,,,,,,,,,,
MESH SURG L 15 X W 10 CM GLYCOLIDE LACTIDE COPOLYMER,SUP-2931122,CDM,C1781,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
FIXATOR EXT GUID DORS PIN PREDRILLED TRNSVRS CAP APPL CUT,SUP-2237248,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
GRAFT BONE SUB L 10ML CORT RESRB MOLD MINERALIZED PLEXUR M,SUP-2293949,CDM,C1713,HCPCS,0278,RC,,,,both,,,7979.53,5186.69,,,,,,,,,,,,,
BLADE IM L46MM ST G TI SPRL FOR HUM NAIL,SUP-2192465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1645.52,1069.59,,,,,,,,,,,,,
AMNION THIN 7X7,SUP-2811236,CDM,C1762,CPT,0278,RC,,,,both,,,11598.38,7538.95,,,,,,,,,,,,,
INSERT TIB SZ 2 THK10MM POST STBL FIX GMK,SUP-2267474,CDM,C1776,CPT,0278,RC,,,,both,,,2974.93,1933.70,,,,,,,,,,,,,
LINER ACET NEUT B 5+ MM 28 MM PROV G7,SUP-2441106,CDM,C1776,CPT,0278,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
PASSER SUT SELF CAPTURE ROT CUF REP REUSE COBRA,SUP-2362568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT BNE SUB 05CC DEMIN BNE MTRX PRIM HD,SUP-2307260,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
CATHETER EMB TUFTEX L 60 CM DIA2 FR BALLOON DIA 4.5 MM 0.05,SUP-2264174,CDM,C1757,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
PLATE BNE L12MM THK0.4MM 2 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181555,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
GRAFT BNE SUB 5CC 1 4MM DEMIN CANC SPNG CHIP FLEXIGRFT,SUP-2264611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1592.45,1035.09,,,,,,,,,,,,,
SET BLD COLLCTN SPECTR 2 NDL LRS ISBT COBE,SUP-2162577,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BONE MESH SCREEN 1.3X15X25X0.2 MM TITANIUM,SUP-2838348,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
RETRIEVER SUT 15DEG SELF RATCHETING MECHANISM PENETRATOR,SUP-2121651,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
RING EXT FIX CIR 5/8 120 MM SIDEKCK,SUP-2483229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
CEMENT BONE RADPQ HALF DOSE VERTAPLEX,SUP-2361427,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
STENT CORONARY ION MR L 8 MM DIA 4 MM CATH L 144 CM DIA,SUP-2144867,CDM,C1874,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
MATRIX BIO L 2.5 X W 2.5 CM BOV CLLGN CHONDROITIN-6-SULFATE,SUP-2909266,CDM,Q4105,HCPCS,0636,RC,,,,both,,,2698.05,1753.73,,,,,,,,,,,,,
COIL VASC I-ED COIL L 15 CM DIA 0.012 IN SECONDARY 5 MM,SUP-2865309,CDM,C1889,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
SPACER SPNL 3 MM OFFSET,SUP-2569441,CDM,C1821,HCPCS,0278,RC,,,,both,,,77.72,50.52,,,,,,,,,,,,,
HC External Ecg Rec>7d<15d Scanning Alys W/Report,PX-7309324700,CDM,93247,CPT,0731,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
SYSTEM SHTH 9FR L40CM OD0.157IN ID0.13IN TIP ID0.122IN STD CSGWORBC19M] MEDTRONIC CARDIAC RTHYM MGT],SUP-2282358,CDM,C1892,HCPCS,0272,RC,,,,both,,,664.90,432.18,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC FLUT TIP 2.8X220 MM,SUP-2423242,CDM,C1769,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
PLATE BONE THK0.9MM OFFSET 0MM 10 H RT MAX ORAL,SUP-2191113,CDM,C1713,HCPCS,0278,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
OSTEOTOME SURG L9 1 2IN BLDE W1 4IN CRV HIBBS,SUP-2161306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.84,233.25,,,,,,,,,,,,,
STIMULATOR NRV 386CC 583GM W502XH668CM THK135CM BRAIN DP,SUP-2357361,CDM,C1767,HCPCS,0278,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
MESH HERN RECT 8X4 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855250,CDM,C1781,HCPCS,0278,RC,,,,both,,,8901.90,5786.23,,,,,,,,,,,,,
BIT DRL L 245 MM DIA 8 MM FOR DH-DC 3 REAMER NS REUSE,SUP-2908158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1723.04,1119.98,,,,,,,,,,,,,
GUIDEWIRE ORTH L 220 MM DIA1.6 MM SCREW DIA 4.5/5.5 MM,SUP-2908198,CDM,C1769,HCPCS,0272,RC,,,,both,,,338.99,220.34,,,,,,,,,,,,,
PLATE 2 CLMN DSTL VLR RAD 2.4MM 7H HD 2H SHFT RT STRL TI,SUP-2546705,CDM,C1713,HCPCS,0278,RC,,,,both,,,2537.37,1649.29,,,,,,,,,,,,,
EXPEL APD 8.3/20,SUP-2652752,CDM,C1729,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
LEAD DEFIB LINOX SD L 65 CM DIA2.6 MM TIP DISTANCE 16 CM SIL,SUP-2138041,CDM,C1895,HCPCS,0275,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 3 HOLE STR STRL LTX,SUP-2861615,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.78,428.86,,,,,,,,,,,,,
IMPLANT BIO TISS W4XL4CM THK0.7MM DERM SCAFFOLD FEN,SUP-2243710,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2339.93,1520.95,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED + SM COMPLX + PEEK NS LTX,SUP-2862810,CDM,C1713,HCPCS,0278,RC,,,,both,,,38021.38,24713.90,,,,,,,,,,,,,
CLAMP REPROC COMBO MR SAFE 8 11MM,SUP-2477612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.82,421.73,,,,,,,,,,,,,
PROSTHESIS OSS EAR 3.2 MM TORP W/ CRDL,SUP-2312770,CDM,L8613,CPT,0278,RC,,,,both,,,975.25,633.91,,,,,,,,,,,,,
SCREW BONE L5MM DIA2MM CORT TI ST LCK PLUSDRIVE RECESS,SUP-2189393,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.78,327.46,,,,,,,,,,,,,
HC So Ldh,PX-3018361566,CDM,83615,CPT,0301,RC,,,,both,,,25.00,16.25,,,,,,,,,,,,,
SHOE ORTHOT ADDITION SPEC EXTN INSTEP LTHR,SUP-2435741,CDM,L3570,HCPCS,0272,RC,,,,both,,,241.31,156.85,,,,,,,,,,,,,
DRILL SURG BUSHING 10.7 MM IMPLEX,SUP-2437389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA 3.5 MM TI ST LCK T15 DRV NS EVOS,SUP-2931551,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.93,263.20,,,,,,,,,,,,,
INSERT TIB CR 2.5 10 MM KNEE HI FLX EXP POLYETH VIT E,SUP-2390440,CDM,C1776,CPT,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
COMPONENT EXT FIX FOOTING FOR THREADLOCK TRNSPRT,SUP-2459456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2765.34,1797.47,,,,,,,,,,,,,
WEDGE 10MM SUBTUBULAR DISTRACTION ALLOGRAFT ARTHRODESIS,SUP-2741757,CDM,C1762,CPT,0278,RC,,,,both,,,7017.90,4561.63,,,,,,,,,,,,,
MATRIX BIO L 7 X W 20 CM FISH SKIN DERMAL STD INTACT STRL,SUP-2909218,CDM,Q4158,HCPCS,0636,RC,,,,both,,,11209.80,7286.37,,,,,,,,,,,,,
INTRODUCER SHTH 0.018/0.038 IN 5 FRX55 CM TOUHY BORST FLX,SUP-2169827,CDM,C1894,HCPCS,0272,RC,,,,both,,,180.24,117.16,,,,,,,,,,,,,
PLATE BNE L129MM 7 H NONSTERILE R POSTEROLATERAL DST FIBULAR,SUP-2177391,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.89,1158.23,,,,,,,,,,,,,
MOLD CEM SPCR NK L+6MM HIP SIL S STL ADPT FOR MAKING TEMP,SUP-2408607,CDM,C1776,CPT,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
PLATE BNE W16XL10MM THK0.4MM 4 H CRANIOMAXILLOFACIAL BILAT,SUP-2181566,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.64,478.82,,,,,,,,,,,,,
AUGMENT FEM CO CHROM R DST KNEE SL RESURF OSS,SUP-2405804,CDM,C1776,CPT,0278,RC,,,,both,,,2359.71,1533.81,,,,,,,,,,,,,
COMPONENT FEM BOSS 7.5 MM RT FEM KNEE MOD VANGUARD 360,SUP-2444765,CDM,C1776,CPT,0278,RC,,,,both,,,2048.85,1331.75,,,,,,,,,,,,,
GRAFT HUM TISS LR THAN 11CM FEM SHFT STRUCTURAL FRZ DRY,SUP-2165573,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SCREW BONE 4.5X14MM SPNL VAR ANG ST,SUP-2353302,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
PLATE BNE T SM 2.7X32 MM 2/3 HOLE SS,SUP-2536129,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.75,178.59,,,,,,,,,,,,,
WAND ELECSURG OD0.8MM 45DEG TENDONS FASC EPF MICRODEBRIDER,SUP-2342116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1196.34,777.62,,,,,,,,,,,,,
BLOCK CUT CORNEAL N SLT TEF 18 IN HT KAUFMAN,SUP-2129393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.10,391.36,,,,,,,,,,,,,
PLATE BNE W16XL92MM BLDE L80MM THK4.8MM 95DEG 5 H,SUP-2185489,CDM,C1713,HCPCS,0278,RC,,,,both,,,2683.19,1744.07,,,,,,,,,,,,,
BRACE ORTH ORTHOSIS LUMBAR,SUP-2388145,CDM,L0625,HCPCS,0272,RC,,,,both,,,141.83,92.19,,,,,,,,,,,,,
PLATE BNE W17.5XL247MM THK5.2MM 13 H S STL BROAD CRV LOK,SUP-2185301,CDM,C1713,HCPCS,0278,RC,,,,both,,,2029.04,1318.88,,,,,,,,,,,,,
HC Fna Bx W/CT Gdn 1st Les,PX-3611000900,CDM,10009,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BONE L99MM 2 H LT PROX FEM LCK FOR 4.5MM SCR PERI-LOC,SUP-2351167,CDM,C1713,HCPCS,0278,RC,,,,both,,,11254.23,7315.25,,,,,,,,,,,,,
CHISEL 9 3 4IN CRV 1 2IN HIBBS,SUP-2244781,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.35,115.28,,,,,,,,,,,,,
SPLINT FNGR SZ 2 OPN TIP FOR FNGRTIP NAILBED INJ STAX,SUP-2195098,CDM,L3933,HCPCS,0272,RC,,,,both,,,7.03,4.57,,,,,,,,,,,,,
SUPPORT KNEE OPN PAT SM KNEE NEOPRNE,SUP-2195466,CDM,L1810,HCPCS,0272,RC,,,,both,,,12.25,7.96,,,,,,,,,,,,,
HC Venography Extremity Bilateral,PX-3207582200,CDM,75822,CPT,0320,RC,,,,inpatient,,,1284.00,834.60,,,,,,,,,,,,,
SPACER CERV 7MM HYDRATED LORD,SUP-2415953,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER DEL CARR L 152 CM SM HYDRPHLC 1 LUMEN COMP VAR PK 1,SUP-2912477,CDM,C1887,HCPCS,0272,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
SCREW BNE L30MM DIA65MM UNIV CTRL SHLDR NONLOCKING FOR,SUP-2123297,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.555,SUP-2860236,CDM,C1713,HCPCS,0278,RC,,,,both,,,23802.14,15471.39,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6 MM EPTFE TRMPT TAPR TW,SUP-2227381,CDM,C1768,CPT,0278,RC,,,,both,,,4807.25,3124.71,,,,,,,,,,,,,
BLADE RETRCT W23MM D40MM M LEN SELF RET LNG TEETH BALL SNAP,SUP-2244383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.59,262.98,,,,,,,,,,,,,
CLIP ANEUR 2X3MM S STL GRFT ENCIRCLE DISP SUNDT SLIM-LINE,SUP-2243078,CDM,C1713,HCPCS,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
COIL EMB DETACHABLE 0.010 IN 2 MMX2 CM FILL PLAT DELTAPAQ 10,SUP-2249030,CDM,C1889,HCPCS,0278,RC,,,,both,,,3259.01,2118.36,,,,,,,,,,,,,
ALLOGRAFT BNE FD EO RT HEMI MAND,SUP-2867073,CDM,C1762,CPT,0278,RC,,,,both,,,6604.36,4292.83,,,,,,,,,,,,,
KIT INTRO MAK-NV NDL L 15 CM DIA21 GA NONVASCULAR CHIBA STYL,SUP-2653964,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.62,19.90,,,,,,,,,,,,,
GUIDEWIRE VASC SENS L 145 CM DIA 0.018 IN TIP 3 MM SS SIL,SUP-2227414,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.03,84.52,,,,,,,,,,,,,
BIT DRL 2 .7X215MM STRL DISP,SUP-2152617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,448.39,291.45,,,,,,,,,,,,,
IMPLANT SHLDR SPCR INTERSPACE STD FOR TWO STG REV,SUP-2223700,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
ARROW FIXATION L13MM 1.1MM NONSUTURE MENISCAL CONTOUR PRELOA,SUP-2824129,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.01,341.91,,,,,,,,,,,,,
PSN REV 3MM OFFSET STEM EXT 12X135MM,SUP-2508801,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
"HC New Pt, E/M Level 4",PX-5109920400,CDM,99204,CPT,0510,RC,,,,inpatient,,,344.00,223.60,,,,,,,,,,,,,
GUIDE RESECT TIB MOD CAPTURE RT TRIATHLON,SUP-2364722,CDM,C1776,CPT,0278,RC,,,,both,,,2706.37,1759.14,,,,,,,,,,,,,
EXTENSION STEM 2MM OFFSET CPLR,SUP-2221223,CDM,C1776,CPT,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
IMPLANT HAMRTOE LG PEEK CANN FIX SYS STRL,SUP-2893058,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
PROBE DOPP L265MM TIP L2MM 8MHZ ENDO NSL BAYONATED HNDL DISP,SUP-2419092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1746.63,1135.31,,,,,,,,,,,,,
NAIL IM L360MM DIA13MM FEM TI CANN LOK AG RG T2,SUP-2368970,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
NI CB STERILE,SUP-2720575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
HC Paracentesis WO Img Gd,PX-4504908200,CDM,49082,CPT,0450,RC,,,,outpatient,,,2844.00,1848.60,,,,,,,,,,,,,
DEVICE FIX OD7-8MM SH FEM ANCHR SFT TISS FOR BELOW 35MM TUNN,SUP-2212831,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
PROSTHESIS TOT OSS OFFSET HD PLASTIPORE 4MM DIA .8MM SHFT,SUP-2312531,CDM,L8613,CPT,0278,RC,,,,both,,,655.07,425.80,,,,,,,,,,,,,
PLATE BONE L390MM 24 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185283,CDM,C1713,HCPCS,0278,RC,,,,both,,,1819.38,1182.60,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 10H 235MM LT STRL,SUP-2546850,CDM,C1713,HCPCS,0278,RC,,,,both,,,6548.88,4256.77,,,,,,,,,,,,,
SCREW CORTCL 27X12MM SELF TAP,SUP-2695478,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.70,274.10,,,,,,,,,,,,,
CANNULA ENDOSCP W/O VLV 11 MMX13 CM W/ 2 FLNG ADJ CONE,SUP-2767245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.58,707.58,,,,,,,,,,,,,
BLADE SAW OSCILLATING MIC 25.5X15X0.51 MM CRESC CUT EDGE,SUP-2862469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.20,227.63,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 50 CM DIA 6 MM EPTFE CARBON STR N,SUP-2127058,CDM,C1768,CPT,0278,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
ALLOGRAFT BNE MACHINED 7 DEG 14X11X5 MM PUROS S2,SUP-2415682,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE L249MM 12 H NONSTERILE CRV FEM SHFT TI NCB,SUP-2411493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1873.26,1217.62,,,,,,,,,,,,,
PLATE TI VA-LOCKING CALCANEAL 2.7MM SMALL 58MM RGHT STRL,SUP-2546999,CDM,C1713,HCPCS,0278,RC,,,,both,,,3614.17,2349.21,,,,,,,,,,,,,
SYSTEM FIX SHFT L36CM DIA5MM FAST L6.7MM POLY LACTIDE ABSRB,SUP-2125761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SCREW INTRF KNEE CANN N ABSRB TI 9MM 20MM,SUP-2256755,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
NAIL INTRMDLLRY 130 DGREE LNG 9X380 MM RIGHT HNDFT HIP FSN A,SUP-2495553,CDM,C1713,HCPCS,0278,RC,,,,both,,,6992.78,4545.31,,,,,,,,,,,,,
PLUG SCREW HOLE G7,SUP-2440058,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SHEATH INTRO 4FR L12CM GWIRE 0.035IN ACT W/ SMOOTH TAPERS,SUP-2355635,CDM,C1894,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 65X10X15-25 MM FD TRICORT IL CREST,SUP-2866879,CDM,C1762,CPT,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
BIT DRL CANN 4.7X215 MM POLYPR CLR EPIC,SUP-2420821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HEAD HUM H10MM FOR TOT SHLDR ARTHROPLASTY SYS GLOB ADVNTG,SUP-2250011,CDM,C1776,CPT,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
REFILL SYR B1 PK DYRACT FLO,SUP-2238601,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.39,87.35,,,,,,,,,,,,,
PERFUSION PACK CUST OPN HRT,SUP-2352732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
INFUSION PUMP KIT PAINBUSTER 6.5 CM 270 CC ON-Q SILVERSOAKER,SUP-2236827,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
HC Biopsy Soft Tissue Thigh/Knee Area Superficial,PX-3612732300,CDM,27323,CPT,0361,RC,,,,both,,,5104.00,3317.60,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 6 FRX22-30 CM CNTOURVL 18015519,SUP-2484376,CDM,C2617,HCPCS,0278,RC,,,,both,,,524.07,340.65,,,,,,,,,,,,,
SUPPORT ORTHOT BK PREPARATORY NO CVR SACH FT PREFABRICATED,SUP-2694035,CDM,L5535,HCPCS,0272,RC,,,,both,,,5487.28,3566.73,,,,,,,,,,,,,
PLATE BNE L90MM 5 H NONSTERILE DST TIB S STL T LOK COMPR,SUP-2177434,CDM,C1713,HCPCS,0278,RC,,,,both,,,2085.27,1355.43,,,,,,,,,,,,,
RESERVOIR 65MM,SUP-2140263,CDM,C1813,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX12 CM DL J TIP POLYURETHANE,SUP-2759958,CDM,C1751,HCPCS,0278,RC,,,,both,,,233.84,152.00,,,,,,,,,,,,,
JOINT FNGR MP 50 WW PROX PYROCARBON,SUP-2610417,CDM,L8630,HCPCS,0278,RC,,,,both,,,7200.08,4680.05,,,,,,,,,,,,,
PLATE BNE L131MM 6 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177796,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.04,2038.43,,,,,,,,,,,,,
PLATE BNE X 8 HOLE STERNALOCK,SUP-2423213,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
INTRODUCER LD PLCMNT 85FR 81CM N PEEL AWAY N COR SNUS ACCS,SUP-2357220,CDM,C1893,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
BLADE SHV L11CM DIA2MM 3000RPM LNG STR SNUS M4 ROT INFERIOR,SUP-2284123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,927.93,603.15,,,,,,,,,,,,,
HC So1 Immunoglobulin,PX-3018278467,CDM,82784,CPT,0301,RC,,,,both,,,456.00,296.40,,,,,,,,,,,,,
TAP SURG DIA55MM QUIK CONN SCR,SUP-2179452,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER HD RVS TUNNELED 53 CM 33 CM KT PALINDROME PRECIS RT,SUP-2626976,CDM,C1750,HCPCS,0278,RC,,,,both,,,954.97,620.73,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST ADJ W/JT FABRICATED,SUP-2435766,CDM,L3806,HCPCS,0272,RC,,,,both,,,1170.37,760.74,,,,,,,,,,,,,
TIP CRYOSURGERY L 8.5 MM DIA 3 MM GEN 2 STRL DISP IOVERA,SUP-2882197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1505.94,978.86,,,,,,,,,,,,,
SCREW FEAT PART THRD LCK DIAM 3.7MM LEN 35MM ALTA,SUP-2363500,CDM,C1713,HCPCS,0278,RC,,,,both,,,319.18,207.47,,,,,,,,,,,,,
PLATE BNE FIBULAR SHT LT DSTL,SUP-2315877,CDM,C1713,HCPCS,0278,RC,,,,both,,,3859.06,2508.39,,,,,,,,,,,,,
GUIDEWIRE VASC IMAG L190CM DIA0.014IN STR TIP OCCL HYDRPHLC,SUP-2148712,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SHEATH INTRO STR 5FRX15 CM SMOOTH TAPR SS PTFE GRN COMPASS,SUP-2846722,CDM,C1894,HCPCS,0272,RC,,,,both,,,184.29,119.79,,,,,,,,,,,,,
BRACE ORTH ORTHOSIS LUMBAR,SUP-2388145,CDM,L0625,HCPCS,0274,RC,,,,both,,,141.83,92.19,,,,,,,,,,,,,
SCREW BNE 4 MM 71823212] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2348745,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.64,40.72,,,,,,,,,,,,,
CLAMP EXT FIX M 6 POS MULTIPIN,SUP-2188529,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2039.40,1325.61,,,,,,,,,,,,,
GRAFT BNE FIBULAR STRUT 100MM,SUP-2293968,CDM,C1713,HCPCS,0278,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
CATHETER GUID JCR3.5 0.066 INX8 FRX100 CM CORONARY VKG,SUP-2103236,CDM,C1887,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 12 DEG L 11 CM DIA 4 MM SPD 7500 RPM,SUP-2902114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,752.60,489.19,,,,,,,,,,,,,
BIT DRL DIA5MM CANN FOR 6.5MM L SCR SYS,SUP-2344064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3182.86,2068.86,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EPIC HF TI POLYUR SIL IS1/DF1 CONN BPLR,SUP-2356576,CDM,C1882,HCPCS,0275,RC,,,,both,,,61898.82,40234.23,,,,,,,,,,,,,
HC Assay of Phosphorus Inorganic Urine,PX-3018410500,CDM,84105,CPT,0301,RC,,,,outpatient,,,193.00,125.45,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR ATLS + DR,SUP-2357755,CDM,C1721,HCPCS,0275,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L145CM BAL L12MM DIA1.5MM GWIRE 0.014IN,SUP-2418141,CDM,C1725,HCPCS,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
STENT TRACH POLYFLEX L 40 MM DIA14 MM DEL SYS DIA 9 MM,SUP-2436473,CDM,C1874,HCPCS,0278,RC,,,,both,,,6001.11,3900.72,,,,,,,,,,,,,
GRAFT BONE PUTTY IRRADIATED DEMINERLIZED BONE MTRX 10CC,SUP-2307529,CDM,C9359,HCPCS,0278,RC,,,,both,,,3497.96,2273.67,,,,,,,,,,,,,
GUIDEPIN ORTH L230MM OD3.2MM S STL THRD,SUP-2340798,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.45,235.59,,,,,,,,,,,,,
DILATOR SURG DISP FOR ERECTILE REST 4 PK,SUP-2138905,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
CYSTOURETHROSCOPE FLX OD 16.5 FR WORKING CHANNEL 7.2 FR,SUP-2882440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
MESH SURG DIA6.6CM POLY PGLA CLLGN FLM RIG ABSRB EXP SEMI,SUP-2283994,CDM,C1781,HCPCS,0278,RC,,,,both,,,1960.68,1274.44,,,,,,,,,,,,,
HEAD FEM 8+ MM 12/14 XLN 36 MM HIP TAPR ALUMINA CERM,SUP-2434737,CDM,C1776,CPT,0278,RC,,,,both,,,4483.92,2914.55,,,,,,,,,,,,,
GRAFT ENDOVASC L3.3CM DIA23MM AORT EXT ENDOPROS EXCLUDER,SUP-2395938,CDM,C1768,CPT,0278,RC,,,,both,,,7903.38,5137.20,,,,,,,,,,,,,
SCREW BNE SYMM PROF 3.5X10 MM LCK TI NS SURFIX,SUP-2609173,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.93,734.45,,,,,,,,,,,,,
SAPHENOUS VEIN 39CM,SUP-2931207,CDM,C1762,CPT,0278,RC,,,,both,,,23255.06,15115.79,,,,,,,,,,,,,
STEM HUM L55MM DIA14MM MIC SHLDR CO CHROM POR CEM PRESSFIT,SUP-2404550,CDM,C1776,CPT,0278,RC,,,,both,,,10484.46,6814.90,,,,,,,,,,,,,
CEMENT DENT REFIL W/ TIP FUJI AUTOMX,SUP-2226109,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.15,291.95,,,,,,,,,,,,,
CANNULA RF L 150 MM DIA18 GA TIP L 5 MM LNG HYBRID ACTIVE,SUP-2917886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ABACAVIR SULFATE 20 MG/ML PO SOLN,RX-24439,CDM,340b,HCPCS,0637,RC,64980-0405-24,NDC,,both,10,ML,23.60,15.34,,,,,,,,,,,,,
RING EXT FIX DIA140 MM 5/6 TAB NS DISP MONK RING,SUP-2881098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3272.67,2127.24,,,,,,,,,,,,,
CATHETER EP MED CRV 5 MM SPACING 6 FR INQUIRY,SUP-2102279,CDM,C1730,HCPCS,0272,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
SCREW BNE THRD 6.5X25 MM 16 MM SS,SUP-2198290,CDM,C1713,HCPCS,0278,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
PLATE BNE L117MM 6 H L PROX TIB S STL SM BEND VAR ANG LOK,SUP-2177913,CDM,C1713,HCPCS,0278,RC,,,,both,,,5146.27,3345.08,,,,,,,,,,,,,
PLATE BNE L 195 X W 11.4 MM THK 3.4 MM SCREW DIA2.7/3.5 MM 72464015,SUP-2932805,CDM,C1713,HCPCS,0278,RC,,,,both,,,7970.11,5180.57,,,,,,,,,,,,,
VALVE 10 WITH SPRUNG RESERVOIR MININAV,SUP-2821808,CDM,C1889,HCPCS,0278,RC,,,,both,,,1718.68,1117.14,,,,,,,,,,,,,
BLADE LARYNSCP FBR OPT CLD LT SZ 4 MACINTOSH,SUP-2261366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,537.57,349.42,,,,,,,,,,,,,
BOOT WLK VENTURE 61 TALL M,SUP-2150951,CDM,L4386,HCPCS,0272,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
STENT BILI COT-LNG L 17 CM DIA11.5 FR GUIDEWIRE 0.035 IN PUR,SUP-2169361,CDM,C2617,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
PLATE BONE 4 H CRANIOMAXILLOFACIAL TI STR FOR 1.3MM SCR,SUP-2190644,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.21,113.89,,,,,,,,,,,,,
THIOTEPA 15 MG IJ SOLR,RX-7901,CDM,J9342,HCPCS,0636,RC,72205-0045-01,NDC,,both,1,UN,2016.00,1310.40,,,,,,,,,,,,,
GUIDEPIN ORTH 3.5 MM SPADE TIP TAPR KNEE RECON INFIN DISP,SUP-2846783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.23,711.90,,,,,,,,,,,,,
COIL NEUROVASCULAR CEREPAK HELIFORM XL L 45 CM DIA14 MM SLV,SUP-2865255,CDM,C1889,HCPCS,0278,RC,,,,both,,,7433.35,4831.68,,,,,,,,,,,,,
PLATE BNE L319MM 12 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186048,CDM,C1713,HCPCS,0278,RC,,,,both,,,5064.44,3291.89,,,,,,,,,,,,,
STEM RADIAL BPLR 7.5 MM ELBW ASMBLY SHFT KATALYST,SUP-2610315,CDM,C1776,CPT,0278,RC,,,,both,,,9237.00,6004.05,,,,,,,,,,,,,
TUBE DYNAMIZATION DISTRACTION,SUP-2494737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9310.73,6051.97,,,,,,,,,,,,,
ROD SPNL 5X210 MM,SUP-2564523,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.81,46.03,,,,,,,,,,,,,
SYSTEM BX 25GA FN NDL SIX DST CUT EDG SHARKCORE,SUP-2174357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1623.38,1055.20,,,,,,,,,,,,,
SCREW BONE L130MM DIA6.5MM THRD L22MM STD CORT TI ST SELF,SUP-2343367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1955.40,1271.01,,,,,,,,,,,,,
PACEMAKER CARD EVIA HF-T RESYNCHRONIZATION BIV LANDLINE HM,SUP-2138362,CDM,C2621,HCPCS,0275,RC,,,,both,,,25245.60,16409.64,,,,,,,,,,,,,
SODIUM CHLORIDE 3% IV BOLUS,RX-4082505,CDM,J7131,HCPCS,0250,RC,00338-0054-03,NDC,,both,100,ML,11.10,7.21,,,,,,,,,,,,,
FORCEPS ES AD PED L9IN DIA15MM 2 IRRIG BPLR NONCORDED,SUP-2364932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1191.44,774.44,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 3 X 21 H PLL STRUT,SUP-2883361,CDM,C1713,HCPCS,0278,RC,,,,both,,,19273.01,12527.46,,,,,,,,,,,,,
BRACE WRST LEN 6 1 4IN CIRC UP TO 5 3 4IN XSM L REG D RNG W,SUP-2326020,CDM,L3908,HCPCS,0272,RC,,,,both,,,79.54,51.70,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILESTO 7 VR-T W 52 X H 65 MM D 11 MM 40 J,SUP-2138301,CDM,C1722,HCPCS,0275,RC,,,,both,,,33707.90,21910.13,,,,,,,,,,,,,
GRAFT VASC IMPRA L 35 CM DIA19 MM EPTFE STR STD WALL LG,SUP-2761269,CDM,C1768,CPT,0278,RC,,,,both,,,2288.09,1487.26,,,,,,,,,,,,,
PIN EXT FIX L 200 MM DIA 6 MM THRD L 35 MM HA EXT STRL DISP,SUP-2932995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,817.72,531.52,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 12MM THREADED DISPOSABLE WITH,SUP-2809465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.76,430.79,,,,,,,,,,,,,
ATTACHMENT POS 2S FNGR DISP STABLESOFT,SUP-2385708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
PLATE BONE 8 H Y SHP FOR 2MM SCR VLP MINI-MOD SM BONE SYS,SUP-2351080,CDM,C1713,HCPCS,0278,RC,,,,both,,,4949.43,3217.13,,,,,,,,,,,,,
POR ST/RGX CP/LGXL/LG HD,SUP-2212377,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
BRACE ORTH LNR 3 SHELL TLSO,SUP-2388140,CDM,L0462,HCPCS,0272,RC,,,,both,,,3215.55,2090.11,,,,,,,,,,,,,
ZINC SULFATE 220 (50 ZN) MG PO CAPS,RX-8880,CDM,6370000000,HCPCS,0637,RC,20555-0040-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER INTVENT 0.014 IN 135 CM TURNPIKE LP,SUP-2605999,CDM,C1887,HCPCS,0272,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
ELECTRODE SUCTION BLNT 5 MMX33 CM W/ VLV,SUP-2850585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.68,619.24,,,,,,,,,,,,,
MESH HERN W6XL8IN VENTRAL POLYPR EPTFE REP ELP LO PROF MFIL,SUP-2125806,CDM,C1781,HCPCS,0278,RC,,,,both,,,2097.52,1363.39,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1385108D2,SUP-2632821,CDM,C1751,HCPCS,0278,RC,,,,both,,,878.26,570.87,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 BLLN L10MM BNE FILL DEV SYR IBT KYPHON,SUP-2293623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8031.08,5220.20,,,,,,,,,,,,,
IMPLANT METATRSL SZ 3.5 METATRSL SLOT SHORTNG NS,SUP-2898941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
GRAFT HUM TISS ANTR TIBIALIS TEND,SUP-2294000,CDM,C1762,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
UPCHARGE BLUEPRINT GUIDE GLEN,SUP-2388597,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
TRAY CATHETER SILICONE URINE METER 12 FR 10ML,SUP-2526981,CDM,C1776,CPT,0278,RC,,,,both,,,55.74,36.23,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.6 MM MED TI CRANIOMAXILLOFACIAL DBL,SUP-2937052,CDM,C1713,HCPCS,0278,RC,,,,both,,,9316.38,6055.65,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK KNOTLESS FOR SFT TISS FIX MULTIFIX,SUP-2342077,CDM,C1713,HCPCS,0278,RC,,,,both,,,3751.48,2438.46,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 7 FRX25 IN 13 GA 3L SPECTRUM,SUP-2759722,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
PLATE BONE 176MML HLX22 STNLSS STEEL STRGHT RCNSTRCTN F/2.7M,SUP-2488178,CDM,C1713,HCPCS,0278,RC,,,,both,,,1707.66,1109.98,,,,,,,,,,,,,
GRIP CBL M TROCH VIT W/ 2/2MM CBL DALL-M,SUP-2377569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2721.75,1769.14,,,,,,,,,,,,,
BIT DRL TWST 3.2MMX310 COIL 50 QUIK CPL DISP,SUP-2101266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.22,233.49,,,,,,,,,,,,,
NEEDLE SUTURE L7.75IN SLIGHTLY CURVED REVERDIN,SUP-2802447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,677.30,440.24,,,,,,,,,,,,,
CATHETER REPERFUSION L200CM WRK L155CM DIA0.022IN PROX CONT,SUP-2323631,CDM,C1757,HCPCS,0272,RC,,,,both,,,6876.60,4469.79,,,,,,,,,,,,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,6370000000,HCPCS,0637,RC,81033-0032-01,NDC,,both,1,GR,6.30,4.09,,,,,,,,,,,,,
SUCROSE 24 % (PRESERVATIVE FREE) ORAL SOLN,RX-40850012,CDM,6370000000,HCPCS,0637,RC,89805-0603-40,NDC,,both,15,ML,3.60,2.34,,,,,,,,,,,,,
KIT BNE VOID FILL IMPACT DEL CALLOS,SUP-2106913,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
PROSTHESIS PENILE 18CM N PRECONN SNAP FIT RT LGX,SUP-2139018,CDM,C1813,HCPCS,0278,RC,,,,both,,,24466.88,15903.47,,,,,,,,,,,,,
SET FLAP REP OSTEOCHNDRL SGL SHOT W/ SHTH DRL DART INSRT,SUP-2121789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
DEVICE VBR SZ 16A H17MM DIA16MM THORLUM TI CO CHROM NIT,SUP-2292779,CDM,C1889,HCPCS,0278,RC,,,,both,,,21477.60,13960.44,,,,,,,,,,,,,
GRAFT VASC CARBOFLO 6 MMX50 CM EPTFE FLX THN WALL SM BEAD,SUP-2126880,CDM,C1768,CPT,0278,RC,,,,both,,,3307.36,2149.78,,,,,,,,,,,,,
HC Chemo Infuse New Drug 1st Hour,PX-3359641700,CDM,96417,CPT,0335,RC,,,,both,,,377.00,245.05,,,,,,,,,,,,,
"HC Estrogens, Fractionated, Assay of Estrone",PX-3018267967,CDM,82679,CPT,0301,RC,,,,both,,,43.00,27.95,,,,,,,,,,,,,
NAIL L 11MMX320MM LNG GAM,SUP-2370305,CDM,C1713,HCPCS,0278,RC,,,,both,,,4265.69,2772.70,,,,,,,,,,,,,
MESH BIO PORCINE MTRX BRST TISS RECON 16CM LEN 4CM W,SUP-2113068,CDM,Q4130,HCPCS,0636,RC,,,,both,,,4989.46,3243.15,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING 6MM DIA 70CM LEN GORTX,SUP-2396009,CDM,C1768,CPT,0278,RC,,,,both,,,3805.68,2473.69,,,,,,,,,,,,,
SLEEVE CBL M DIA1.6MM S STL DALL-M,SUP-2371519,CDM,C1713,HCPCS,0278,RC,,,,both,,,790.02,513.51,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN HYDRPHLC STIFF SHFT,SUP-2141154,CDM,C1769,HCPCS,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
SCREW BNE MAXILLOFACIAL CORT CENTRE-DRIVE 2.3 250850901] KLS MARTIN LP],SUP-2262626,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
ONDANSETRON 4 MG PO TBDP,RX-27697,CDM,Q0162,HCPCS,0637,RC,68462-0157-13,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT HUM TISS W3XL3CM THN MTRX ANAT BARR FOR ORTH APPL,SUP-2120773,CDM,C1762,CPT,0278,RC,,,,both,,,3709.13,2410.93,,,,,,,,,,,,,
GRAFT HUM TISS W1XL2CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307551,CDM,Q4128,HCPCS,0636,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
CATHETER CV DL 7 FRX150 MM 16 GAX70 MM W/ EXTN TY CAREFLOW,SUP-2516614,CDM,C1751,HCPCS,0278,RC,,,,both,,,71.84,46.70,,,,,,,,,,,,,
GRAFT ALLGRFT AMNIO MEMBRN 1.5CMX2CM AMBIODRY,SUP-2247195,CDM,V2790,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
ROD SPNL TOP LD 5.5X24 MM,SUP-2414400,CDM,C1713,HCPCS,0278,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
RETRACTOR BLDE TOP OBLQ SPRD SPNL CATLYST SURG MED LAT SELF,SUP-2285278,CDM,C1713,HCPCS,0278,RC,,,,both,,,799.26,519.52,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 65 CM 5 FR 0.038 IN RIM NONBRAIDED,SUP-2116923,CDM,C1725,HCPCS,0272,RC,,,,both,,,151.98,98.79,,,,,,,,,,,,,
DONALDSON VT PC SI 114MM,SUP-2669490,CDM,L8699,HCPCS,0278,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
TELMISARTAN 80 MG PO TABS,RX-24336,CDM,6370000000,HCPCS,0637,RC,68382-0473-30,NDC,,both,1,UN,6.80,4.42,,,,,,,,,,,,,
TAP SURG DIA6MM CANN SELF DRL SCR 2 LD VIPER 2,SUP-2256881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE L82MM 7 H BILAT S STL STR RECON NONLOCKING,SUP-2197672,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.67,686.19,,,,,,,,,,,,,
NAIL IM L460MM DIA10MM NONSTERILE AQUA L/R DSTL FEM TI LCK,SUP-2191730,CDM,C1713,HCPCS,0278,RC,,,,both,,,5390.50,3503.82,,,,,,,,,,,,,
RING EXT FIX FULL 120 MM CIR SIDEKCK,SUP-2487292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
COMPONENT HIP FOR PK 5400,SUP-2212668,CDM,C1776,CPT,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE,PX-4409712900,CDM,97129,CPT,0440,RC,,,GN,both,,,186.00,120.90,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.552,SUP-2860069,CDM,C1713,HCPCS,0278,RC,,,,both,,,66788.43,43412.48,,,,,,,,,,,,,
SHELL ACET BPLR 22X45 MM HIP RINGLOK,SUP-2449897,CDM,C1776,CPT,0278,RC,,,,both,,,3574.89,2323.68,,,,,,,,,,,,,
BOOT CAST SM FOR WMN 55 8 SQ TOE DSGN UNIV FOREFOOT CLSR,SUP-2176232,CDM,L4386,HCPCS,0272,RC,,,,both,,,27.38,17.80,,,,,,,,,,,,,
HEAD FEM TYP 1 3- MM 36 MM HIP CERM,SUP-2449631,CDM,C1776,CPT,0278,RC,,,,both,,,6090.03,3958.52,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE STRGHT 2 HOLE SHRT CP TTNM,SUP-2676764,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.38,124.40,,,,,,,,,,,,,
GRAFT HUM TISS DIA10 MM AMNION PLCNTA MEMBRN 2 LAYR PROTCT,SUP-2913307,CDM,C1762,CPT,0278,RC,,,,both,,,2405.24,1563.41,,,,,,,,,,,,,
ANCHOR SUT PRELD SMOOTH ENLD LO PROF STITCHPAK ST DISPOSABLE,SUP-2166458,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.48,409.81,,,,,,,,,,,,,
LINER ACET CUP NEUT PRI CEM MTL ON POLY ULT HI MOL WT,SUP-2203661,CDM,C1776,CPT,0278,RC,,,,both,,,5044.10,3278.66,,,,,,,,,,,,,
SHEATH INTRO PINNACLE TIF TIP L 10 CM DIA 6 FR 0.038 IN,SUP-2384799,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
HC Replacement Tracheostomy Tube,PX-4503150200,CDM,31502,CPT,0450,RC,,,,both,,,694.00,451.10,,,,,,,,,,,,,
FIBER LASER AURA ACCUSTAT 125UM 5W SINGLE-MODE,SUP-2885320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
LEVEL CMF ST PLATE ORTHG GNPLSTY FAB DBL Y SHP WTAB 2.0 2.5,SUP-2669082,CDM,C1713,HCPCS,0278,RC,,,,both,,,654.88,425.67,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 7 MM EPTFE STR TW,SUP-2492849,CDM,C1768,CPT,0278,RC,,,,both,,,776.11,504.47,,,,,,,,,,,,,
CATHETER HD DL 14.5FRX28CM 45CM ADMIN CHRONIC PALINDROME,SUP-2283946,CDM,C1750,HCPCS,0278,RC,,,,both,,,1069.08,694.90,,,,,,,,,,,,,
COMPONENT RADIAL IM 4 DSTL WRST MICRONAIL,SUP-2538185,CDM,C1776,CPT,0278,RC,,,,both,,,6983.36,4539.18,,,,,,,,,,,,,
DRILL COUNTSINK 2.5MM MINI HCS MASTORQUE K,SUP-2400009,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
NAIL IM L34.5CM OD11MM TIB CANN LCK DELT RUSS TAY,SUP-2342521,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.75,625.14,,,,,,,,,,,,,
BIT DRL L58MM OD1.6MM 20MM STP DENT SHFT END NONRADIOLUCENT,SUP-2364187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.43,296.03,,,,,,,,,,,,,
EXTENSION STEM L175MM DIA11MM NK L130MM FLUT NXGN,SUP-2208712,CDM,C1776,CPT,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
HC US Extrem Complete Nonvasc,PX-4027688100,CDM,76881,CPT,0402,RC,,,,both,,,405.00,263.25,,,,,,,,,,,,,
PLATE BONE L145MM THK3.3MM 12 H BILAT S STL RIG STR DYN,SUP-2186335,CDM,C1713,HCPCS,0278,RC,,,,both,,,1211.00,787.15,,,,,,,,,,,,,
CATHETER DRAINAGE LCK PIG 8 FRX40 CM BILI SFT POLYURETHANE,SUP-2303560,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
BRA SURG 2XL WHT POST SURG MAMM COMPR DSG W/ REM STRP FR HK,SUP-2276929,CDM,L8000,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
STEM FEM 135 NK 15X225 MM REV ANGLED,SUP-2204638,CDM,C1776,CPT,0278,RC,,,,both,,,24391.52,15854.49,,,,,,,,,,,,,
EXTRACTOR SURG EASYOUT 4 MM QR ACUTRK,SUP-2857694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1331.36,865.38,,,,,,,,,,,,,
GRAFT EVAR 14FR L82MM DIA16X16MM HI DENS MULTIFILAMENT POLY,SUP-2295253,CDM,C1768,CPT,0278,RC,,,,both,,,15204.63,9883.01,,,,,,,,,,,,,
CATHETER GUID Q4 6 FRX110 CM VASC RUNWAY DISP,SUP-2423584,CDM,C1887,HCPCS,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
PLATE BONE LOK NON CMPRSSN HLX20 25MM THK TTNM STRGHT LVLX1,SUP-2694213,CDM,C1713,HCPCS,0278,RC,,,,both,,,4282.61,2783.70,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ADVISOR HD SENSOR ENABLED L 105,SUP-2102267,CDM,C1730,HCPCS,0272,RC,,,,both,,,7083.84,4604.50,,,,,,,,,,,,,
CEMENT FLX FEM/CEM TIB/STD SURF/NO PT/TP PL,SUP-2212161,CDM,C1776,CPT,0278,RC,,,,both,,,13439.67,8735.79,,,,,,,,,,,,,
IMPLANT BIO TISS W6XL6CM PORCINE DERM MTRX RECON THINNER,SUP-2388576,CDM,C1713,HCPCS,0278,RC,,,,both,,,8605.17,5593.36,,,,,,,,,,,,,
MESH SURG L THK0.4MM SLV TI MASTOID MALL CNTOUR LO PROF,SUP-2181586,CDM,C1781,HCPCS,0278,RC,,,,both,,,3097.30,2013.24,,,,,,,,,,,,,
CATHETER DRNGE 8FR L15CM UNIV NIT LCK PGTL NAVARRE,SUP-2128422,CDM,C1729,HCPCS,0272,RC,,,,both,,,247.18,160.67,,,,,,,,,,,,,
KNIFE URETHROTOME CLD SERR BLDE FOR USA ELITE SYSTEM/USA,SUP-2313990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,620.97,403.63,,,,,,,,,,,,,
CATHETER NEPHROSTOMY INTRODUCTORY SET 8 FRX30 CM UNIVERSA,SUP-2836201,CDM,C1729,HCPCS,0272,RC,,,,both,,,1303.41,847.22,,,,,,,,,,,,,
STABILIZER SHLDR SM UNIV HARN ARM BND FOR FOOTBALL PLAYER,SUP-2150933,CDM,L3660,HCPCS,0274,RC,,,,both,,,325.93,211.85,,,,,,,,,,,,,
SCREW SPNL L80MM DIA10MM CANC ANTR IL S STL CLOSE FOR 6.35MM,SUP-2255703,CDM,C1713,HCPCS,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-104433,CDM,J1956,HCPCS,0636,RC,25021-0132-81,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE CANN 6.5X90 MM COMPR FT TI STRL 04355790S,SUP-2787799,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
PIN FIX L9IN DIA2MM ST S STL 3 SIDE SGL TRCR 1 END PNT STYL,SUP-2150454,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.69,8.90,,,,,,,,,,,,,
PIN FIX FEM KNEE REF TS3 ROSA REUSE,SUP-2656955,CDM,C1713,HCPCS,0278,RC,,,,both,,,3460.28,2249.18,,,,,,,,,,,,,
DRILL TWST L61MM DIA2.6MM STP 10MM AO QUIK CPL SHFT END,SUP-2267865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CATHETER GUID NAVICROSS L 65 CM DIA 1.39 MM L 40 CM ANGLED,SUP-2385618,CDM,C1887,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE BNE L206MM 14 H ST R PROX BILAT TIB S STL NEUT LOK,SUP-2177840,CDM,C1713,HCPCS,0278,RC,,,,both,,,4567.19,2968.67,,,,,,,,,,,,,
NAIL IM L340MM OD11MM TIB PICCOLO,SUP-2152616,CDM,C1713,HCPCS,0278,RC,,,,both,,,4696.81,3052.93,,,,,,,,,,,,,
PLATE BNE T 1.5X50 MM 4X9 HOLE SS,SUP-2569096,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.77,218.90,,,,,,,,,,,,,
GUIDEWIRE ORTH L DIA2.8MM,SUP-2417459,CDM,C1769,HCPCS,0272,RC,,,,both,,,243.04,157.98,,,,,,,,,,,,,
MESH HERN W3XL6IN SFT POLYPR OPN WV PROL SURGPRO,SUP-2219918,CDM,C1781,HCPCS,0278,RC,,,,both,,,790.02,513.51,,,,,,,,,,,,,
IMPLANT OPERATING ROOM MINI-MONSTER 4.0 X 30MM H,SUP-2430559,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.36,427.28,,,,,,,,,,,,,
PLATE BNE H0.6MM BAR L5MM 100DEG 5 H R MID FACE G TI L,SUP-2366298,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.79,298.86,,,,,,,,,,,,,
PLATE BNE L 14.86 X W 9.35 MM THK 0.6 MM SCREW DIA1.5 MM 6 H,SUP-2936944,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.74,491.88,,,,,,,,,,,,,
CANNULA SUBTLE L40CM WITH GUIDE KIT,SUP-2424450,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BNE W175XL372MM THK52MM 20 H BILAT S STL BROAD CRV,SUP-2185322,CDM,C1713,HCPCS,0278,RC,,,,both,,,3477.93,2260.65,,,,,,,,,,,,,
PROSTHESIS PENILE 65ML INFL PMP INHIBIZONE IMP AMS 700,SUP-2140255,CDM,C1813,HCPCS,0278,RC,,,,both,,,3121.16,2028.75,,,,,,,,,,,,,
HEMOSTAT SURG LG TEND PASS,SUP-2474134,CDM,C1713,HCPCS,0278,RC,,,,both,,,1149.24,747.01,,,,,,,,,,,,,
BOLT ORTHOPEDIC FUSION 6.5X75 MM MIDFOOT SS NS,SUP-2184090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1468.11,954.27,,,,,,,,,,,,,
MESH HERN SZ 5.12IN OMEGA 3 FATTY ACID COAT POLYPR RND,SUP-2265979,CDM,C1781,HCPCS,0278,RC,,,,both,,,1117.24,726.21,,,,,,,,,,,,,
KIT COOL M HYDRGEL COAT 3 LAYERED CONSTR NONINVASIVE DISP,SUP-2127458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3876.33,2519.61,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 10X15+ MM PRESERVON MATRIGRAFT,SUP-2740819,CDM,C1713,HCPCS,0278,RC,,,,both,,,1712.59,1113.18,,,,,,,,,,,,,
HC So Blood Type Antigen Donor Ea,PX-3008690266,CDM,86902,CPT,0300,RC,,,,both,,,172.00,111.80,,,,,,,,,,,,,
PLATE BNE MID FUS BRDG XSM L ST,SUP-2401274,CDM,C1713,HCPCS,0278,RC,,,,both,,,8861.08,5759.70,,,,,,,,,,,,,
DEFIBRILLATOR CARD 76GM 35CC W40XH74MM THK14MM DF1 IS1 CONN,SUP-2356285,CDM,C1721,HCPCS,0275,RC,,,,both,,,33385.67,21700.69,,,,,,,,,,,,,
WASHER BNE ANK MED MALL SLED,SUP-2389601,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
HC Group Exercise Pt|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209715000,CDM,97150,CPT,0420,RC,,,GO|CO,outpatient,,,135.00,87.75,,,,,,,,,,,,,
STEM FEM SZ 1 135DEG STD HIP CEMENTLESS RESTORIS METAFIX,SUP-2265769,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X159X2.5 MM MAND 20 HOLE RECON TI STRL,SUP-2485016,CDM,C1713,HCPCS,0278,RC,,,,both,,,4869.01,3164.86,,,,,,,,,,,,,
DISTRACTION EXTRNL DIST CRNIO MNDBLE FXTR W/WDGE 18 MM STEP,SUP-2488604,CDM,C1713,HCPCS,0278,RC,,,,both,,,17306.86,11249.46,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK0.9-1.99MM ACELLULAR DERM MTRX,SUP-2402507,CDM,Q4126,HCPCS,0636,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
PLATE BONE L57MM 4 H BILAT 1/3 TBLR LCK COMPR RIG FOR 3.5MM,SUP-2343753,CDM,C1713,HCPCS,0278,RC,,,,both,,,267.18,173.67,,,,,,,,,,,,,
KIT NRV STIM BLUETOOTH INTERSTIM,SUP-2281689,CDM,C1897,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BONE L50MM DIA4.8MM CANC FOR VERSANAIL UNIV HUM,SUP-2412558,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.55,274.01,,,,,,,,,,,,,
GUIDE DRL DIA2.3MM S STL REM SPCR DISP,SUP-2164968,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.05,427.08,,,,,,,,,,,,,
WASHER SPNL 1MM FIX BNE POLYAX TI MNRCH,SUP-2254525,CDM,C1713,HCPCS,0278,RC,,,,both,,,306.68,199.34,,,,,,,,,,,,,
CHANDELIER INFUS 25GA AWH,SUP-2129241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.41,217.37,,,,,,,,,,,,,
HC Gas Dilution or Washout,PX-4609472700,CDM,94727,CPT,0460,RC,,,,inpatient,,,411.00,267.15,,,,,,,,,,,,,
CONDYLAR PL 95 9H 40/156,SUP-2818819,CDM,C1713,HCPCS,0278,RC,,,,both,,,5208.32,3385.41,,,,,,,,,,,,,
SHELL ACET SZ 25 OD60MM HIP LIMIT H LOK RNG RANAWAT,SUP-2403853,CDM,C1776,CPT,0278,RC,,,,both,,,4535.73,2948.22,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM 0.035IN TIP 1.5 MM J STD FIX,SUP-2479513,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.03,20.82,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL SM RT TCP,SUP-2485258,CDM,C1713,HCPCS,0278,RC,,,,both,,,4248.42,2761.47,,,,,,,,,,,,,
SCREW BNE L70MM DIA6MM DST FEM TI ST CANN LOK FULL THRD,SUP-2191844,CDM,C1713,HCPCS,0278,RC,,,,both,,,650.95,423.12,,,,,,,,,,,,,
GUIDEWIRE VASC 300 CM STINGRAY,SUP-2466233,CDM,C1769,HCPCS,0272,RC,,,,both,,,1541.74,1002.13,,,,,,,,,,,,,
TITANIUM MESH PANEL ROUND CNTRD 73MM DIA 6MM 15MM SSTM CP,SUP-2677366,CDM,C1713,HCPCS,0278,RC,,,,both,,,3495.26,2271.92,,,,,,,,,,,,,
HC Assay of Urea Nitrogen Urine,PX-3018454000,CDM,84540,CPT,0301,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
CATHETER GUID L57CM OD7.1FR 90DEG PEBA POLYAMIDE 12 CRV FOR,SUP-2282183,CDM,C1887,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
MATRIX BIO L 7 X W 3 CM FISH SKIN DERMAL INTACT OMEGA3 10/BX,SUP-2909380,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
STEM RADIAL 9X2 MM ARH PART BLAST DEMO,SUP-2798394,CDM,C1776,CPT,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
OCCLUDER CV 45 DEG 18 MM 8 FR AMPLATZER PFO,SUP-2357476,CDM,C1817,HCPCS,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CUP TRAB MEL,SUP-2212524,CDM,C1776,CPT,0278,RC,,,,both,,,18111.52,11772.49,,,,,,,,,,,,,
OPIUM 10 MG/ML (1%) PO TINC,RX-99771,CDM,6370000000,HCPCS,0637,RC,62559-0153-04,NDC,,both,0.6,ML,10.30,6.69,,,,,,,,,,,,,
KIT DIAG CATH ER-REBOA POLYMER CONVENIENCE W/ ACCS NDL INTRO,SUP-2417427,CDM,C1894,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
NEEDLE NERVE STIM TROCAR PEDCL ACCS NAV PK NIM,SUP-2792159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2552.25,1658.96,,,,,,,,,,,,,
CONNECTOR SHUNT DIAMETER 1.9MM TITANIUM F SHAPED FOR HYDROCE,SUP-2825888,CDM,C1889,HCPCS,0278,RC,,,,both,,,1105.06,718.29,,,,,,,,,,,,,
CATHETER DRAINAGE 10.2 FRX25 CM MP COOKCOPE TYP UTHANE,SUP-2168200,CDM,C1729,HCPCS,0272,RC,,,,both,,,231.29,150.34,,,,,,,,,,,,,
TRIAL PLATE CRV 0.8 MM ML,SUP-2525715,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
HC Insertion Swan-Ganz Catheter,PX-4819350300,CDM,93503,CPT,0481,RC,,,,outpatient,,,6214.00,4039.10,,,,,,,,,,,,,
COMPONENT HUM SM L8IN UNIV DSTL ELBW TIV PLSM,SUP-2205914,CDM,C1776,CPT,0278,RC,,,,both,,,11511.24,7482.31,,,,,,,,,,,,,
GRAFT BNE INJ 1.5 CC AUG,SUP-2759481,CDM,C1734,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SCREW BNE PERIARTICULAR 6.5X115 MM CANC FT HD HEX NS LTX,SUP-2861327,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
GRAFT BNE SUB 1CC REHYDRATED PTTY OSTEOAMP,SUP-2138510,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
MESH HERN W30XL30CM SQ PARTIALLY ABSRB LTWT ULTRAPRO,SUP-2220104,CDM,C1781,HCPCS,0278,RC,,,,both,,,1075.54,699.10,,,,,,,,,,,,,
POST EXTERNAL FIXATION 11MM 30DEG ANGLED XTRAFIX SYSTEM,SUP-2479018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
GRAFT BNE CHIP FRZ DRY CANC CORT 1MM 8MM RANG 10CC READIGRFT,SUP-2264692,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.03,237.92,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 60 CM DIA2 FR BALLOON DIA,SUP-2213998,CDM,C1757,HCPCS,0272,RC,,,,both,,,75.58,49.13,,,,,,,,,,,,,
LEAD PACE L65IN ATR VENT,SUP-2356689,CDM,C1898,HCPCS,0275,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
EXTENDER EXT FIX HALO FOR RED II ALUM TI PUR,SUP-2459173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2883.87,1874.52,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,6370000000,HCPCS,0637,RC,24208-0631-10,NDC,,both,10,ML,377.60,245.44,,,,,,,,,,,,,
BUR SURG OD2MM SM CYL LEADER PNT,SUP-2398606,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
SHEATH INTRO BAN PEEL L 15 CM DIA11 FR STRL,SUP-2141069,CDM,C1892,HCPCS,0272,RC,,,,both,,,144.13,93.68,,,,,,,,,,,,,
HC Temporary External Pacing,PX-4809295300,CDM,92953,CPT,0480,RC,,,,inpatient,,,1976.00,1284.40,,,,,,,,,,,,,
PROSTHESIS OSS 1.17X3.9 MM PART STRUT HA,SUP-2461568,CDM,L8613,CPT,0278,RC,,,,both,,,1109.68,721.29,,,,,,,,,,,,,
ENDCAP ORTH DIA1 MM THRD T8 STRL FLEX-THREAD,SUP-2900420,CDM,C1889,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
BLADE LARYNSCP SZ 3 FBR OPT CLD LT CARR INCORPORATED,SUP-2261367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.12,340.03,,,,,,,,,,,,,
BIT DRL S STL W/ STP CANN DISP,SUP-2208225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
IMMOBOLIZER SHLDR SUPP UNIV COT UNISX VELPEAU M,SUP-2211099,CDM,L3660,HCPCS,0274,RC,,,,both,,,7.91,5.14,,,,,,,,,,,,,
DEMINERALIZED CORT OSTEOCONDUCTIVE FRZ DRY 5CC FIBEROS,SUP-2314098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8MM STR HELIX SLDE GDS,SUP-2489377,CDM,C1768,CPT,0278,RC,,,,both,,,2529.84,1644.40,,,,,,,,,,,,,
SHOULDER INSTRUMENTS-DRILLS,SUP-2212311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
DEVICE BNE ACCS SZ 3 8GA L18MM DIA42MM INTRO FOR VERTPLSTY,SUP-2280279,CDM,C1894,HCPCS,0272,RC,,,,both,,,1160.54,754.35,,,,,,,,,,,,,
PSYLLIUM 51.7 % PO PACK,RX-137582,CDM,6370000000,HCPCS,0637,RC,37000-0024-04,NDC,,both,1,UN,4.00,2.60,,,,,,,,,,,,,
PLATE BNE 5-10DEG 6 H R REV LOK COMPR MAL MTP TI FOR,SUP-2400370,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
COLLAR EXTRIC AD REG 2 PC TRACH OPN VELC CLSR W/ CHIN SUPP,SUP-2194469,CDM,L0180,HCPCS,0274,RC,,,,both,,,61.83,40.19,,,,,,,,,,,,,
LOCKNUT POS HDRST 0.375 IN NEUROSURGICAL,SUP-2336996,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2 MM RECON PT SPEC TI,SUP-2860082,CDM,C1713,HCPCS,0278,RC,,,,both,,,20509.54,13331.20,,,,,,,,,,,,,
ANCHOR SUT OD5.5MM PEEK ORTHOCORD NDL HEALIX,SUP-2249414,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
POST SURG ANK INTOSS FIX L14MM OD4.6MM 60DEG IOFIX,SUP-2223850,CDM,C1713,HCPCS,0278,RC,,,,both,,,3698.92,2404.30,,,,,,,,,,,,,
CATHETER NEPHROSTOMY PIG 038 IN 8.3 FRX25 CM REPL KT JINRO,SUP-2520662,CDM,C1729,HCPCS,0272,RC,,,,both,,,58.44,37.99,,,,,,,,,,,,,
GUIDEWIRE VASC PULSE SPRY L 109 CM DIA 0.035 IN FLPY TIP L 2,SUP-2118468,CDM,C1757,HCPCS,0272,RC,,,,both,,,241.15,156.75,,,,,,,,,,,,,
CATHETER DIL BAL L16MM DIA6MM SINUS RELIEVA SOLO PRO,SUP-2106320,CDM,C1729,HCPCS,0272,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
PLATE BONE LOK 93MML HLX8 STNLSS STEEL 14 TBLR ST,SUP-2724113,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.18,441.47,,,,,,,,,,,,,
SCREW BNE SM L40MM DIA3.5MM HD DIA6MM CORT TI NONCANNULATED,SUP-2189877,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.72,42.72,,,,,,,,,,,,,
HC Ultrasound Procedure Unlisted,PX-4027699900,CDM,76999,CPT,0402,RC,,,,inpatient,,,276.00,179.40,,,,,,,,,,,,,
CANNULA PERFSN DIA 31 FR VEN ECLS 2 LUMEN STRL DISP PROTEK,SUP-2929864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,39956.50,25971.72,,,,,,,,,,,,,
NEEDLE ASPIR DIA25GA SHTH DIA1.52MM WRK CHAN 2.4MM STD HNDL,SUP-2141501,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
HC US Breast Ltd,PX-4027664200,CDM,76642,CPT,0402,RC,,,,both,,,1221.00,793.65,,,,,,,,,,,,,
SPACER AUG SZ 10 STD TAPR CEM PRI,SUP-2251031,CDM,C1776,CPT,0278,RC,,,,both,,,616.07,400.45,,,,,,,,,,,,,
PLATE BNE L72MM 12 H TI STR NONCOMPRESSION RIG FOR 2.4MM,SUP-2191470,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.84,871.55,,,,,,,,,,,,,
IMPLANT OPHTH SCLER TISS,SUP-2303760,CDM,C1762,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
DISSECTOR ENDOSCP RND BLLN SHRP TIP SPCMKR +,SUP-2283395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2013.05,1308.48,,,,,,,,,,,,,
LINER ACET OD68MM ID36MM 0DEG MARATHON HIP REV NEUT PINN,SUP-2250463,CDM,C1776,CPT,0278,RC,,,,both,,,4666.67,3033.34,,,,,,,,,,,,,
CONE FEM SZ D H60MM PROX HIP TI PPS STD OFFSET MOD REV,SUP-2404451,CDM,C1776,CPT,0278,RC,,,,both,,,15159.92,9853.95,,,,,,,,,,,,,
COLLAR CERV L13-16IN H3.25IN M TRACH OPN W/ CHIN SUPP ADJ,SUP-2197923,CDM,L0120,HCPCS,0274,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
OPES 90 ASPIRATING ABLATOR,SUP-2815984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CATHETER CV SECALON-T L 160 MM DIA14 GA OD 2 MM 206 ML/MIN,SUP-2490878,CDM,C1751,HCPCS,0278,RC,,,,both,,,16.80,10.92,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM TWO ULTRABRAID FOR ROT CUF SFT TISS FIX,SUP-2341877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1235.40,803.01,,,,,,,,,,,,,
GUIDEWIRE ORTH L161MM DIA17/3.2MM FOR TI TROCHANTERIC NAIL,SUP-2188225,CDM,C1769,HCPCS,0272,RC,,,,both,,,1237.29,804.24,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 30 MM DIA 9 MM DEL SYS L 120 CM,SUP-2155366,CDM,C1876,HCPCS,0278,RC,,,,both,,,4183.89,2719.53,,,,,,,,,,,,,
ROD IM L1150MM DIA25MM TI RM BALL TIP,SUP-2188105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.33,249.16,,,,,,,,,,,,,
CATH REPROC EP INQUIRY STRBL DECAPLR 2-5-2MM LG CRV 6FR 110CM,SUP-2526274,CDM,C1730,HCPCS,0272,RC,,,,both,,,958.05,622.73,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 6 FR SPC 2-5-2 MM D,SUP-2248677,CDM,C1732,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
NEEDLE ENDOSCP FNA 19 GA NIT,SUP-2427167,CDM,C1713,HCPCS,0278,RC,,,,both,,,1372.18,891.92,,,,,,,,,,,,,
KYPHOPLASTY TRAY 15/3 OSTEO INTRO CDS KYPHOPAK XPANDER II,SUP-2632078,CDM,C1713,HCPCS,0278,RC,,,,both,,,12898.49,8384.02,,,,,,,,,,,,,
HC Neg Pressure Wnd <= 50 Sq Cm Disposable,PX-7619760700,CDM,97607,CPT,0761,RC,,,,inpatient,,,813.00,528.45,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,2580000003,HCPCS,0258,RC,00264-7520-10,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
HC G Tube Removal,PX-3600000033,CDM,3600000033,LOCAL,0360,RC,,,,both,,,322.00,209.30,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 35 CM DIA 4-7 MM EPTFE CARBON STP N,SUP-2128786,CDM,L8670,HCPCS,0278,RC,,,,both,,,5481.18,3562.77,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL CTRL LAT,SUP-2435554,CDM,L0635,HCPCS,0274,RC,,,,both,,,2828.95,1838.82,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 45 CM DIA12 FR BODY DIA 4.7 MM,SUP-2395727,CDM,C1894,HCPCS,0272,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
PLATE BNE SUP 3.5X94 MM RT ANTR CLAV 5 HOLE W/ LAT EXTN SS,SUP-2184133,CDM,C1713,HCPCS,0278,RC,,,,both,,,2638.79,1715.21,,,,,,,,,,,,,
GUIDEWIRE VASC L 220 CM DIA 0.035 IN TAPR L 6 CM FLPY TIP L,SUP-2638693,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.42,112.07,,,,,,,,,,,,,
PLATE BNE L254MM THK4MM 9 H 10 GRV STD S STL BILAT COMPR,SUP-2371522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
GUIDEWIRE SURG L300MM DIA2.8MM S STL CALIB FOR 6.5/7.3MM,SUP-2186894,CDM,C1769,HCPCS,0272,RC,,,,both,,,352.12,228.88,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC DBM BONUS TRIAD,SUP-2607050,CDM,C1889,HCPCS,0278,RC,,,,both,,,6711.75,4362.64,,,,,,,,,,,,,
CAGE SPNL MESH 28X22X15 MM 6 LOBE,SUP-2602087,CDM,C1889,HCPCS,0278,RC,,,,both,,,10487.60,6816.94,,,,,,,,,,,,,
COLLAR CERV ADJ LP THERMOPLASTIC OSSUR MIAMI J,SUP-2388136,CDM,L0180,HCPCS,0274,RC,,,,both,,,939.80,610.87,,,,,,,,,,,,,
NAIL INTRAMEDULLARY SUBTALAR MEDIAL COLUMN 8MM X 80MM NITINOL DYNANAIL MINI,SUP-2878181,CDM,C1713,HCPCS,0278,RC,,,,both,,,17788.10,11562.26,,,,,,,,,,,,,
BIT DRL L10CM DIA11MM S STL STR SHANK,SUP-2410509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,96.59,62.78,,,,,,,,,,,,,
SCREW BNE SET STD 6.5 MM 32 MM CANN THRD,SUP-2861008,CDM,C1713,HCPCS,0278,RC,,,,both,,,27012.04,17557.83,,,,,,,,,,,,,
KIT INTRO ONESTIC L 11 CM DIA 5 FR GUIDEWIRE L 40 CM DIA,SUP-2876547,CDM,C1894,HCPCS,0272,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
BUR SURG L 240 MM DIA 5 MM R DIAMOND FOR SLIM ATTACH STRL,SUP-2937165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
IMPL HIP TRIFLANGE SZ24 LT,SUP-2422277,CDM,C1776,CPT,0278,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
INTRODUCER VASC 7FR 12CM LEN AD,SUP-2355251,CDM,C1894,HCPCS,0272,RC,,,,both,,,36.90,23.98,,,,,,,,,,,,,
COMPONENT ULN L3.5IN REG R EL TIV PLSM INTERCHANGEABLE CEM,SUP-2205939,CDM,C1776,CPT,0278,RC,,,,both,,,18758.36,12192.93,,,,,,,,,,,,,
SCREW BNE L8MM THRD 17MM HD 24MM TI LNG THRD CANN HDLESS,SUP-2389486,CDM,C1713,HCPCS,0278,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH PERM 4 CONTACT,SUP-2917095,CDM,C1816,LOCAL,0278,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
SHUNT SURG VENTRICULAR CATH L 180 MM PRESSURE DIFF 5 CM H2O,SUP-2931100,CDM,C1729,HCPCS,0272,RC,,,,both,,,16930.91,11005.09,,,,,,,,,,,,,
GRAFT HUM TISS W9XL20CM AMNIO MEM FEN EPIXL,SUP-2305735,CDM,Q4186,HCPCS,0636,RC,,,,both,,,37100.67,24115.44,,,,,,,,,,,,,
IMPLANT OPHTH RND 7.5X80 MM SPNG SIL,SUP-2263416,CDM,L8610,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SPACER SPNL 11X11X11 MM CERV CORNERSTONE PSR,SUP-2279533,CDM,C1821,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT TIB WHL L W BTB,SUP-2307302,CDM,C1713,HCPCS,0278,RC,,,,both,,,30481.68,19813.09,,,,,,,,,,,,,
GRAFT HUM TISS W/O SCLER RIM,SUP-2388444,CDM,V2785,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
GRAFT VASC TW 8 MMX80 CM AORT STR REINF SLDE GDS ADVANTA VXT,SUP-2468148,CDM,C1768,CPT,0278,RC,,,,both,,,2399.09,1559.41,,,,,,,,,,,,,
NATRELLE INSPIRA SCF 200CC BREAST IMPLANT,SUP-2669558,CDM,C1769,HCPCS,0278,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
CONNECTOR SUT PASS INTEGR GRSP DISP SMARTSTITCH,SUP-2342089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,980.75,637.49,,,,,,,,,,,,,
VALVE HYDROCEPHALUS W/ DSTL CATH PROGAV 2.0,SUP-2108743,CDM,C1729,HCPCS,0272,RC,,,,both,,,8274.50,5378.42,,,,,,,,,,,,,
MESH SURG L55MM W55MM OD5MM DELT LP,SUP-2364976,CDM,C1781,HCPCS,0278,RC,,,,both,,,8248.78,5361.71,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM DIA0.014IN TIP L35CM HYDRPHLC STR LT,SUP-2142048,CDM,C1769,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
PIN PRECSION TM 9X495 MM,SUP-2854224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,826.70,537.35,,,,,,,,,,,,,
COLLAR CERV CNTOUR LNG NAR 24X2 IN 17-22 IN MED FOAM PROCARE,SUP-2196863,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.71,6.96,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX L 15 CM LOOP DIA 6 MM,SUP-2305207,CDM,C1889,HCPCS,0278,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY CUST OFFSET HVY DTY,SUP-2435667,CDM,L2395,HCPCS,0272,RC,,,,both,,,414.17,269.21,,,,,,,,,,,,,
PIN EXT FIX L65MM OD5MM TI CIR HALF HEX FIX RANCHO,SUP-2342566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1081.26,702.82,,,,,,,,,,,,,
STEM FEM 41MM SZ 1 HIP TARA POR HD,SUP-2255794,CDM,C1776,CPT,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
PACEMAKER CRD UPLR/BPLR SINGLE CHMBR IS-1 CONN SOLUS II SR,SUP-2356696,CDM,C1786,HCPCS,0275,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
MESH HERN L33.7XW26.1CM THICKNESS 15MM POLYPR EPTFE VENTRAL,SUP-2125811,CDM,C1781,HCPCS,0278,RC,,,,both,,,4560.54,2964.35,,,,,,,,,,,,,
CATHETER ERCP L200CM L100CM OD5.5FR .025IN TFE SH TAPR TIP,SUP-2169061,CDM,C1726,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
DEVICE REATTACHMENT W23XL121MM LNG GREATER TROCHANTERIC,SUP-2410264,CDM,C1713,HCPCS,0278,RC,,,,both,,,7182.53,4668.64,,,,,,,,,,,,,
HC Renal Arteriogram|LEFT SIDE,PX-3233625100,CDM,36251,CPT,0323,RC,,,LT,both,,,10063.00,6540.95,,,,,,,,,,,,,
SCREW BNE L20MM DIA7MM COMPR CANC FULL THRD CANN ST SELF,SUP-2409839,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.31,450.65,,,,,,,,,,,,,
HOOK SPNL 45DEG LT LUM TI S FOR 5MM ROD ALA,SUP-2193332,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BATTERY MOD HEARTMATE II,SUP-2356035,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
TWIST DRILL 3.6MM,SUP-2818386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.18,483.07,,,,,,,,,,,,,
PROBE ELECSURG 2.3 MMX1.9 MR HYBRIDAPC,SUP-2734128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1686.18,1096.02,,,,,,,,,,,,,
HC FB Removal From Ear,PX-4506920000,CDM,69200,CPT,0450,RC,,,,both,,,396.00,257.40,,,,,,,,,,,,,
CLIP SURG IRRIG SYS RIO,SUP-2368438,CDM,C1760,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
CAGE SPNL 14X12X6 MM AVS AS,SUP-2362858,CDM,C1889,HCPCS,0278,RC,,,,both,,,5733.39,3726.70,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1385108D1,SUP-2632820,CDM,C1751,HCPCS,0278,RC,,,,both,,,853.14,554.54,,,,,,,,,,,,,
GRAFT STENT LIMB AAA ENDOPROSTHESIS,SUP-2395937,CDM,C1768,HCPCS,0278,RC,,,,both,,,8509.40,5531.11,,,,,,,,,,,,,
HC Repositioning Vad Cath,PX-3613659700,CDM,36597,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA15 MM DEL SHTH 40ML,SUP-2937083,CDM,C1713,HCPCS,0278,RC,,,,both,,,14789.40,9613.11,,,,,,,,,,,,,
CAGE SPNL L10XW10XH7MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317722,CDM,C1889,HCPCS,0278,RC,,,,both,,,3859.06,2508.39,,,,,,,,,,,,,
COLLAR CERV XL H4XL20IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335998,CDM,L0120,HCPCS,0272,RC,,,,both,,,13.53,8.79,,,,,,,,,,,,,
CATHETER DRNGE 10.2FR L25CM NDL 18GA 0.038IN 6 SIDEPRT MP,SUP-2168461,CDM,C1729,HCPCS,0272,RC,,,,both,,,214.65,139.52,,,,,,,,,,,,,
SCREW BONE L10MM DIA2MM STD TI LCK FULL THRD ANG FOR HND,SUP-2319612,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM OD16FR TRACHEOESOPHAGEAL INDWL CLASS,SUP-2242366,CDM,L8509,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
INSERT TIB H6MM MED POLYETH FOR KNEE ARTHROPLASTY,SUP-2165989,CDM,C1776,CPT,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
STENT DUODENAL HANAROSTENT LOWAX L 12 CM DIA22 MM DEL SYS L,SUP-2675384,CDM,C1874,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
PLATE SPNL FACE 18 MM 2 HOLE NO-PROFILE INTBDY MERID,SUP-2711060,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STEM FEM L160MM DIA20MM PRESSFIT BILAT PRI STD OFFSET STR,SUP-2210351,CDM,C1776,CPT,0278,RC,,,,both,,,18411.39,11967.40,,,,,,,,,,,,,
GRAFT ENDOVASC L13CM AORT DIA31MM IL DIA14.5MM TRUNK,SUP-2395993,CDM,C1768,CPT,0278,RC,,,,both,,,27883.20,18124.08,,,,,,,,,,,,,
MODIFIED CLLR BTTN VENT TUBE 127MM ID PC SLCNE 30 PACK,SUP-2680284,CDM,L8699,HCPCS,0278,RC,,,,both,,,34.79,22.61,,,,,,,,,,,,,
BOOT CAST W/ CUF SM BLK,SUP-2277488,CDM,L4386,HCPCS,0272,RC,,,,both,,,238.45,154.99,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 105 MM DIA24 MM SHTH 16 FR RVD,SUP-2170225,CDM,C1874,HCPCS,0278,RC,,,,both,,,50130.10,32584.56,,,,,,,,,,,,,
SEED BRACHYTHERAPY FOR CALIB IOD I 125,SUP-2423884,CDM,C2638,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BNE L12MM 4 H BILAT S STL H SHP LO PROF RIG NEUT,SUP-2186161,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.85,358.05,,,,,,,,,,,,,
HC Perq Dev Breast Add US Image,PX-3611928600,CDM,19286,CPT,0361,RC,,,,both,,,1593.00,1035.45,,,,,,,,,,,,,
CATHETER THORACENTESIS RT ANGLE 3 FRX21 IN PVC DRN SFT,SUP-2384349,CDM,C1729,HCPCS,0272,RC,,,,both,,,65.47,42.56,,,,,,,,,,,,,
MARKER SITE SECURMARK FOR 12GA BX DEV ATEC,SUP-2240041,CDM,A4648,CPT,0278,RC,,,,both,,,218.86,142.26,,,,,,,,,,,,,
PLATE BONE L84MM 4 H BILAT TI T SHP LIMIT CNTCT DYN LCK,SUP-2190890,CDM,C1713,HCPCS,0278,RC,,,,both,,,934.28,607.28,,,,,,,,,,,,,
SCREW BNE L50MM DIA3.5MM CORT S STL ST LOK FULL THRD,SUP-2184234,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
ANCHOR LATERAL PEEK MANTICORE KNOTLESS 4.8MM WITH SUTURE LAS,SUP-2842562,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PLATE BNE STR 1.3X45 MM COND LUHR PANFIX,SUP-2364700,CDM,C1713,HCPCS,0278,RC,,,,both,,,661.28,429.83,,,,,,,,,,,,,
PLATE BONE MINI M RIG BLU SAG 6 H CLVRLF STYL TI ALLOY,SUP-2262505,CDM,C1713,HCPCS,0278,RC,,,,both,,,557.73,362.52,,,,,,,,,,,,,
GUIDEWIRE ORTH 0.045X5 IN MALIBU,SUP-2709732,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BONE L36MM THK0.9MM 4 H S STL H SHP NONCOMPRESSION FOR,SUP-2343831,CDM,C1713,HCPCS,0278,RC,,,,both,,,1236.59,803.78,,,,,,,,,,,,,
STEM HUM L90MM DIA13MM DSTL SHLDR PTC AEQUALIS FLX REVIVE,SUP-2419076,CDM,C1776,CPT,0278,RC,,,,both,,,10926.73,7102.37,,,,,,,,,,,,,
PLATE BNE CANC 3.5 MM RT,SUP-2349952,CDM,C1713,HCPCS,0278,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
NEONATAL AND PEDIATRIC PERCUTANEOUS PIGTAIL NEPHROSTOMY CATH,SUP-2822049,CDM,C1729,HCPCS,0272,RC,,,,both,,,512.92,333.40,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.038 IN TAPR L 9.5 CM FLPY TIP,SUP-2167904,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.67,40.09,,,,,,,,,,,,,
CABLE SPNL DIA1.1MM ST TI DBL LOOP W/ TWO CRMP SONGER,SUP-2255761,CDM,C1713,HCPCS,0278,RC,,,,both,,,1264.04,821.63,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 73 MM DIA20 MM SHTH 16 FR SS,SUP-2170649,CDM,C1874,HCPCS,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
PLATE BONE XLONG HLX4 06MM THK CP TTNM STRGHT LVLX1 F/15MM,SUP-2707485,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.01,188.51,,,,,,,,,,,,,
BIT DRILL 1.5X75 MM STRYKER J LATCH NON STERILE PROPAK,SUP-2837898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.67,380.04,,,,,,,,,,,,,
MICRUSPHERE XL 6MMX12CM,SUP-2464405,CDM,C1889,HCPCS,0278,RC,,,,both,,,6231.33,4050.36,,,,,,,,,,,,,
MATRIX 1.4MM BIT DRILL W/12MM,SUP-2823233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1324.61,861.00,,,,,,,,,,,,,
HC Cisternal or Lat Cervical Punc,PX-3616105500,CDM,61055,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
BURR ARTHSCP AGGRSSVE 5.5MM DIA 120MML BONE BRRL DARK GRAY P,SUP-2574098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,136.46,88.70,,,,,,,,,,,,,
PLATE BNE L 176 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 16 HL NS LK,SUP-2937313,CDM,C1713,HCPCS,0278,RC,,,,both,,,3221.95,2094.27,,,,,,,,,,,,,
GREAT TOE METATRSL MED 15 DEG NP BIOPRO,SUP-2137798,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ILLUMINATOR SURG MULTIFUNCTIONAL TBNG VERSALIGHT,SUP-2175744,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
AXLE TIB FOR SM DST FEM GMRS,SUP-2376515,CDM,C1776,CPT,0278,RC,,,,both,,,2465.69,1602.70,,,,,,,,,,,,,
BLOCK CUT FEM MYKNEE SZ 4 R ST,SUP-2417454,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SPLINT ORTHOT M L LIMB REST HND FNGR WRST WIRE FOAM FRME,SUP-2194508,CDM,L3807,HCPCS,0274,RC,,,,both,,,111.53,72.49,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-102355,CDM,2500000003,HCPCS,0250,RC,00264-7634-00,NDC,,both,1000,ML,57.50,37.37,,,,,,,,,,,,,
MESH CRAN L 121 X W 125 MM SCREW DIA2 MM TI PANEL NS DISP,SUP-2936559,CDM,C1713,HCPCS,0278,RC,,,,both,,,4097.70,2663.50,,,,,,,,,,,,,
SCREW BNE LCK 6.5X26 MM ANK FUSION CONSTRUCT,SUP-2609803,CDM,C1713,HCPCS,0278,RC,,,,both,,,1097.96,713.67,,,,,,,,,,,,,
CATHETER HD STR 12.5 FRX24 CM LT DL STP BASIC SET HEMCATH,SUP-2627219,CDM,C1750,HCPCS,0278,RC,,,,both,,,112.16,72.90,,,,,,,,,,,,,
ADAPTER TIB TY 0MM OFFSET MOD BAL REV SYS,SUP-2315556,CDM,C1776,CPT,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
HEAD RMR DIA9.5MM PILOT NOSE FOR CLINICALLY PROVEN IM HIP,SUP-2343581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,801.33,520.86,,,,,,,,,,,,,
KNIFE SURG HARRISON 45 DEG 159X1.8 MM ANGLED,SUP-2467933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.02,266.51,,,,,,,,,,,,,
COMPONENT ARTC 2X3MM OFFSET PATELLOFEMORAL HEMICAP,SUP-2123657,CDM,C1776,CPT,0278,RC,,,,both,,,17411.30,11317.34,,,,,,,,,,,,,
GUIDE DRILL 4.5MM 90 DEG CANN LC-ANGLED BLADE PLATE,SUP-2548631,CDM,C1713,HCPCS,0278,RC,,,,both,,,3289.12,2137.93,,,,,,,,,,,,,
INSERT VNGD 360 OTI TIB SLV SM FULL,SUP-2506506,CDM,C1776,CPT,0278,RC,,,,both,,,5765.04,3747.28,,,,,,,,,,,,,
PLATE BONE L84MM 4 H T SHP FOR 4.5MM CORTEX/MALLEOLAR/SHAFT,SUP-2343816,CDM,C1713,HCPCS,0278,RC,,,,both,,,2129.01,1383.86,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext <2.5 Cm,PX-4501203100,CDM,12031,CPT,0450,RC,,,,both,,,810.00,526.50,,,,,,,,,,,,,
KIT EVLT-2 PROC L45CM VENACURE,SUP-2117299,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
VALVE HYDROCEPHALUS PROGAV 2.0,SUP-2825851,CDM,C1889,HCPCS,0278,RC,,,,both,,,8274.50,5378.42,,,,,,,,,,,,,
DILATOR ENDOSCP THRD 6.5 MM SUTURE ANCHR STRL TWINFIX AB LTX,SUP-2879125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
DEVICE REVASCULARIZATION STNT L20MM CATHETER DIA0021IN VES,SUP-2281560,CDM,C1757,HCPCS,0272,RC,,,,both,,,19216.80,12490.92,,,,,,,,,,,,,
CATHETER THERMOABLATION CLOSUREPLUS DIA 8 FR GUIDEWIRE 0.025,SUP-2393082,CDM,C1760,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
BLADE ENDOSCP CRV W/ HNDL STRL CAP-FIX LTX,SUP-2879951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
NAIL IM L 275 MM DIA11.5 MM ARTH OSTEOSYN NITINAIL,SUP-2898429,CDM,C1713,HCPCS,0278,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
SYSTEM INFUSION BENEPHIT CV L 30 CM SHTH 8 FR BIFURCATE CATH,SUP-2117155,CDM,C1751,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
SCREW BNE CORTICAL 6X20-70 MM 2.5-3 MM SD THRD SHFT,SUP-2874953,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.66,221.43,,,,,,,,,,,,,
SYSTEM DRAINAGE CATH SHUNT FOR EDS III,SUP-2308156,CDM,C1729,HCPCS,0272,RC,,,,both,,,121.24,78.81,,,,,,,,,,,,,
NECK FEM L42MM 8DEG YEL MOD HIP REJUVENATE,SUP-2365871,CDM,C1776,CPT,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN L 180 CM DIA 0.018 IN TAPR L 7 CM FLPY,SUP-2168240,CDM,C1769,HCPCS,0272,RC,,,,both,,,272.05,176.83,,,,,,,,,,,,,
HC So1 Cardiolipin Antibody,PX-3028614767,CDM,86147,CPT,0302,RC,,,,both,,,58.00,37.70,,,,,,,,,,,,,
ANCHOR SUT 5.5MM HEALICOIL W/ ULTRATAPE BLU ULTRABRAID NO2,SUP-2341903,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
CATHETER INTVASC OCCL STINGRAY LP 180 DEG L 135 CM DIA 3.2,SUP-2146905,CDM,C1725,HCPCS,0272,RC,,,,both,,,7203.16,4682.05,,,,,,,,,,,,,
WASHER ORTH SPIK 8 MM BOLT OSS,SUP-2441746,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.36,265.43,,,,,,,,,,,,,
SCREW BNE LCK 3.2X18 MM VW REDUC,SUP-2645273,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.39,507.90,,,,,,,,,,,,,
LENS SFTY WRP ARND LO PROF,SUP-2366927,CDM,V2632,HCPCS,0276,RC,,,,both,,,41.32,26.86,,,,,,,,,,,,,
SYRINGE TB 27 GAX1/2 IN 1 CC SAFETY,SUP-2693958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14795.68,9617.19,,,,,,,,,,,,,
CUFF ORTHOT HIP BILATERAL THGH CUST W/SPRD BAR,SUP-2435600,CDM,L1652,HCPCS,0272,RC,,,,both,,,1009.23,656.00,,,,,,,,,,,,,
ESCITALOPRAM OXALATE 5 MG/5ML PO SOLN,RX-34897,CDM,6370000000,HCPCS,0637,RC,16571-0769-24,NDC,,both,5,ML,9.50,6.17,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH II WORLEY DIA 9 FR RT SIDE ACCS,SUP-2483625,CDM,C1893,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
SCREW BNE L7MM OD2.0MM EMGCY TI CENTRE DRV,SUP-2262624,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
ALLOGRAFT FASC RESRB MEMBRN NAT BARR 2.0CMX3.0CM MAXXEUS,SUP-2165616,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SPACER SPNL W22XH7-10XL50MM LAT LUM INTBDY FUS SELF EXP,SUP-2232010,CDM,C1821,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
JOINT SUBTALAR 6 SINUS TARSI ANK,SUP-2236092,CDM,C1713,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
CATH BLLN STENT GRAFT 10 50MMX65CM,SUP-2700281,CDM,C2628,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
PYRAZINAMIDE 500 MG PO TABS,RX-6738,CDM,6370000000,HCPCS,0637,RC,70954-0484-10,NDC,,both,1,UN,20.50,13.32,,,,,,,,,,,,,
SYSTEM PROX SEAL DEL DEV AND LOADER HEARTSTRING II,SUP-2266053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1527.99,993.19,,,,,,,,,,,,,
PLATE BONE L118MM THK2.8MM 10 H BILAT S STL NONCOMPRESSION,SUP-2348978,CDM,C1713,HCPCS,0278,RC,,,,both,,,3929.08,2553.90,,,,,,,,,,,,,
MESH CRAN DIA100MM THK0.4MM BLU TI MALL PLT CNTOUR LO PROF,SUP-2190697,CDM,C1713,HCPCS,0278,RC,,,,both,,,6249.23,4062.00,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 2 X 4 H SCREW DIA2 MM TI MIDFACE,SUP-2883876,CDM,C1713,HCPCS,0278,RC,,,,both,,,1048.76,681.69,,,,,,,,,,,,,
TRAY KYPHOPLASTY BLLN 4ML L20MM DIA19.2MM NDL 10GA SYR 20ML,SUP-2367081,CDM,C1894,HCPCS,0272,RC,,,,both,,,8087.07,5256.60,,,,,,,,,,,,,
CABLE SPNL DBL LOOP 1.1 MM W/ 2 CRMP SS STRL LENTUR,SUP-2685267,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 4X4 CM PLCNTA BASE MEMBRN AMNIOEFFECT,SUP-2871499,CDM,C1762,CPT,0278,RC,,,,both,,,7162.34,4655.52,,,,,,,,,,,,,
MODULE NEUROSURGICAL MAXCESS III,SUP-2311771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2394.25,1556.26,,,,,,,,,,,,,
SCREW LCK 1.50X8MM APTUS HD4,SUP-2268076,CDM,C1713,HCPCS,0278,RC,,,,both,,,381.51,247.98,,,,,,,,,,,,,
HC Assay of Testosterone Total|UNUSUAL NON-OVERLAPPING SERVICE,PX-3018440300,CDM,84403,CPT,0301,RC,,,XU,both,,,359.00,233.35,,,,,,,,,,,,,
GRAFT HERN PORCINE CLLGN PERMACOL 1.5MM THICKNESS 5CMX10CM,SUP-2388447,CDM,C9364,HCPCS,0278,RC,,,,both,,,8704.08,5657.65,,,,,,,,,,,,,
HC Peripheral Block - Tap Bilateral Infusion,PX-3606448900,CDM,64489,CPT,0360,RC,,,,both,,,1238.00,804.70,,,,,,,,,,,,,
BUR SURG STR 2.9X13 MM,SUP-2432007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SCREW BNE L6MM DIA1.85MM TI SELF DRL FOR MMF SYS MATRIXWAVE,SUP-2181784,CDM,C1713,HCPCS,0278,RC,,,,both,,,470.37,305.74,,,,,,,,,,,,,
SPACER SPNL 8 MM,SUP-2708788,CDM,C1821,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 14 CM DIA 4 MM CATH DIA 0.018 IN,SUP-2169678,CDM,C1889,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
BLADE SAW W5.5XL28.5MM THK0.4MM CUT THK0.6MM FN TOOTH STR,SUP-2166582,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.09,54.66,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 3FR 20CM 1 LUMAN S4153108BD,SUP-2632858,CDM,C1751,HCPCS,0278,RC,,,,both,,,529.75,344.34,,,,,,,,,,,,,
CLIP ANEUR NO14 L25MM OPN 14MM 35DEG 1.67N STD TI BAYNT SERR,SUP-2306069,CDM,C1889,HCPCS,0278,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.530,SUP-2860047,CDM,C1713,HCPCS,0278,RC,,,,both,,,43775.37,28453.99,,,,,,,,,,,,,
DRILL TWST L 58 MM DIA1.5 MM STP 20 MM DENT SHFT NS DISP,SUP-2883284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.47,259.01,,,,,,,,,,,,,
GRAFT BNE SUB MACRO 15CC B TRICALCIUM PHSPTE SYN TISS BNE,SUP-2368161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2003.32,1302.16,,,,,,,,,,,,,
GRAFT BIO TISS W8XL8CM SLD FET BOV ACELLULAR DERM MTRX,SUP-2243688,CDM,Q4110,HCPCS,0636,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
PATCH VASC W15XL10CM THK0.5MM BIO TISS BOV MTRX PERICARD,SUP-2214210,CDM,C1768,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CATHETER INTVASC OCCL FOGARTY L 80 CM DIA 8 FR BALLON DIA,SUP-2214270,CDM,C2628,HCPCS,0272,RC,,,,both,,,229.85,149.40,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 70 MM DIA22 MM LIMB L 30 MM DIA20,SUP-2217621,CDM,C1874,HCPCS,0278,RC,,,,both,,,36361.20,23634.78,,,,,,,,,,,,,
STAPLER INT L37CM STPL 21MM CIR ENDOSCP CRV INTLUMN B FRM,SUP-2218993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.35,502.03,,,,,,,,,,,,,
SCREW BONE 12.7MM THRD 55MM LAG S STL RED STRL FRELOK,SUP-2197690,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.99,555.74,,,,,,,,,,,,,
KIT CARTER-THOMASON II PRT CLSR SYS INCL 1-SUT PASS,SUP-2171685,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.10,340.66,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 4H 82MM LEFT STERILE,SUP-2549631,CDM,C1713,HCPCS,0278,RC,,,,both,,,4950.49,3217.82,,,,,,,,,,,,,
BRACE KNEE 17 27IN R L UNIV FIT UPTO 305IN THGH T SCP,SUP-2150870,CDM,L1810,HCPCS,0272,RC,,,,both,,,290.23,188.65,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK0.75-1.5MM DECELLULARIZED DERM,SUP-2264623,CDM,Q4122,HCPCS,0636,RC,,,,both,,,27989.18,18192.97,,,,,,,,,,,,,
BOUGIE SURG 40FR TIP L13MM BLU SIL TAPR MLNY TIP ULT FLX,SUP-2277361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.78,565.36,,,,,,,,,,,,,
PROSTHESIS PENILE L18CM DIA12.5MM INFL TWO PC W/ PREFIL,SUP-2138936,CDM,C1813,HCPCS,0278,RC,,,,both,,,61909.50,40241.17,,,,,,,,,,,,,
ANCHOR SUT OD3.4MM BIOCRYL RAPIDE DBL ARMED NONABSORBABLE,SUP-2256665,CDM,C1713,HCPCS,0278,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
CERAMIC ON CERAMIC W/ POR FEM,SUP-2348005,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
WASHER ORTH DIA3.5MM CORT DST FIBULAR EL LO PROF FOR FRAC,SUP-2411678,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
GRAFT BNE SUB 3ML CA PHSPTE ROTARY MIX PTTY VOID FILL INJ,SUP-2194286,CDM,C1713,HCPCS,0278,RC,,,,both,,,3134.03,2037.12,,,,,,,,,,,,,
TUBE GASTROSTMY 36FR L107CM CLS ROUNDED TIP SM SIDE H,SUP-2138632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
GUIDEPIN ORTH EXT CUT DISP FOR 2 PLATFRM SHLDR ARTHROPLASTY,SUP-2224556,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.47,259.01,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 5ML DEMIN PUTTY BONE CONT,SUP-2277640,CDM,C9359,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE L17MM THK0.6MM 4MM OFFSET 5 H BILAT CHIN ORAL,SUP-2191217,CDM,C1713,HCPCS,0278,RC,,,,both,,,1149.55,747.21,,,,,,,,,,,,,
HC Inj Anes/Steroid L/S Facet Sg|BILATERAL PROCEDURE|PO,PX-3616449300,CDM,64493,CPT,0361,RC,,,50|PO,both,,,4864.00,3161.60,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 7 H TI T LP NS STERNALOCK EZ,SUP-2894464,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 39 MM DIA24 MM SHTH 18 FR SS,SUP-2171054,CDM,C1874,HCPCS,0278,RC,,,,both,,,6258.02,4067.71,,,,,,,,,,,,,
HC Rp Loclzj Tum Spect 1 Area Single Day Imaging,PX-3417880300,CDM,78803,CPT,0341,RC,,,,both,,,5028.00,3268.20,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 7FR L300CM WRK CHN 2.8MM G PRB STD,SUP-2149698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.22,327.74,,,,,,,,,,,,,
COMPONENT FEM SZ 3 KNEE HNG AXLE LEGION,SUP-2346400,CDM,C1776,CPT,0278,RC,,,,both,,,1343.92,873.55,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 8 MM STR STD WALL HELIX,SUP-2493106,CDM,C1768,CPT,0278,RC,,,,both,,,440.35,286.23,,,,,,,,,,,,,
CLAMP RING HOFFMAN II HYBRID,SUP-2678698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.02,215.81,,,,,,,,,,,,,
SCREW INTRF CANN 10X25 MM RND HD CRKSCR TIP TI STRL SOFTSILK,SUP-2849125,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
CATHETER DIL L40MM DIA10MM HI PRSS NONCOMPLIANT INTEGR STYL,SUP-2106330,CDM,C1726,HCPCS,0272,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
NEEDLE SPNL TIG 3.7X20-45 MM PEDCL ACCS LT,SUP-2538789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1841.99,1197.29,,,,,,,,,,,,,
COMPONENT GLEN PEGGED 7 4 MM SHLDR KEELED FIX UHMWPE STRL,SUP-2372875,CDM,C1776,CPT,0278,RC,,,,both,,,7576.51,4924.73,,,,,,,,,,,,,
GRAFT VASC DYNAFLO L 50 CM DIA 8 MM EPTFE CARBON PERIPH STR,SUP-2126821,CDM,C1768,CPT,0278,RC,,,,both,,,4552.91,2959.39,,,,,,,,,,,,,
ROD SPINE BENT TI 6.35 X 80MM,SUP-2293090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.13,651.38,,,,,,,,,,,,,
WIRE FIX L6IN OD11MM S STL PARTIALLY THRD DBL SHRP TIP FOR,SUP-2137267,CDM,C1769,HCPCS,0272,RC,,,,both,,,776.37,504.64,,,,,,,,,,,,,
INBONE  FUSION ROD 7.0 MM 7.0 MM X 45 MM LG,SUP-2459231,CDM,C1713,HCPCS,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
PROSTHESIS OSS VENT TUBE 1.02X0.040X1 MM ROCK EAR FLROPLAS,SUP-2312783,CDM,L8699,HCPCS,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
HC MRI-Myocardium WO Contrast,PX-6107555700,CDM,75557,CPT,0610,RC,,,,outpatient,,,4146.00,2694.90,,,,,,,,,,,,,
LINER ACET SZ F OD54-56MM ID28MM 20DEG XLPE CONSTRN PRI LOK,SUP-2348109,CDM,C1776,CPT,0278,RC,,,,both,,,2673.71,1737.91,,,,,,,,,,,,,
PLATE BNE LCK 236 MM RT DSTL LAT FIBULAR 16 HOLE SS STRL,SUP-2463621,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.35,1816.33,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED BIOMET5500] ZIMMER BIOMET INC],SUP-2137328,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PLATE BNE L 369 MM SCREW DIA 3.5/4.5 MM 18 H RT DSTL FEM,SUP-2931416,CDM,C1713,HCPCS,0278,RC,,,,both,,,20844.89,13549.18,,,,,,,,,,,,,
PIN GUIDE L 360 MM DIA 3.2 MM DRL TIP TRIGEN MAX,SUP-2932781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
STEM FEM XSM L40MM STD CO CHROMIUM KNEE EXTN CEM BILAT,SUP-2376289,CDM,C1776,CPT,0278,RC,,,,both,,,2400.22,1560.14,,,,,,,,,,,,,
GRAFT VASC 8 MMX25/15X70 CMX0.49 MM 30 CM RVS LOCKNIT HEMGRD,SUP-2471991,CDM,C1768,CPT,0278,RC,,,,both,,,3069.51,1995.18,,,,,,,,,,,,,
NAIL IM L30CM DIA8.5MM TIB KNEE GRY TI CANN LOK RG BEND,SUP-2347075,CDM,C1713,HCPCS,0278,RC,,,,both,,,3738.80,2430.22,,,,,,,,,,,,,
HC Flow Volume Loop,PX-4609437500,CDM,94375,CPT,0460,RC,,,,both,,,936.00,608.40,,,,,,,,,,,,,
PLATE BONE CRANIAL 4 HOLE STRAIGHT 24.4X3.4MM TITANIUM NEURO,SUP-2827190,CDM,C1713,HCPCS,0278,RC,,,,both,,,99.85,64.90,,,,,,,,,,,,,
FORCEPS OPHTH 25GA + BLNT DST END MIC TEXT BROAD GRSP SURF,SUP-2109691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.24,377.16,,,,,,,,,,,,,
ELECTRODE VPR M LOOP FOR 12DEG TELESCOPES PLASMABUTTON,SUP-2313580,CDM,C1713,HCPCS,0278,RC,,,,both,,,1596.88,1037.97,,,,,,,,,,,,,
GRAFT DERMAL 10X10 CMX1 MM PORCINE DERMAL CLLGN PERMACOL,SUP-2174695,CDM,C9364,HCPCS,0278,RC,,,,both,,,6878.42,4470.97,,,,,,,,,,,,,
PACEMAKER CARD ALTURA20 TI 2 CHMBR 2 LD BATTERY PWR STRL,SUP-2149111,CDM,C1785,HCPCS,0275,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
HC Quan MRI Alys Brain With Diagnostic MRI,PX-6110866000,CDM,0866T,CPT,0611,RC,,,,both,,,1344.00,873.60,,,,,,,,,,,,,
SYSTEM THROMCTMY POUNCE L 14 CM DIA12 FR GUIDEWIRE 0.035 IN,SUP-2914010,CDM,C1894,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BLADE RTRCTR SCVLLE MRDNG SM MED 1INW X 3IND SRRTD TIP ULTRA,SUP-2487609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.70,240.30,,,,,,,,,,,,,
HC Gbl Wheelchair Training per 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-9829754200,CDM,97542,CPT,0982,RC,,,GP|CQ,both,,,247.00,160.55,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 7MM 120CM 7FR RADIOPAQUE,SUP-2719625,CDM,C1768,HCPCS,0278,RC,,,,both,,,11093.62,7210.85,,,,,,,,,,,,,
GRAFT SYNTH TISS 20X30X0.3 MM DENT RESRB CLLGN MEMBRN RCM6,SUP-2106459,CDM,C1763,HCPCS,0278,RC,,,,both,,,376.77,244.90,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L22IN FOR UP TO 27IN THGH UNIV FOAM NYL,SUP-2197966,CDM,L1830,CPT,0274,RC,,,,both,,,179.61,116.75,,,,,,,,,,,,,
GRAFT BNE SPHR 23 MM PRO OSTEON 200,SUP-2861988,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.43,309.03,,,,,,,,,,,,,
ETHAMBUTOL HCL 400 MG PO TABS,RX-9983,CDM,6370000000,HCPCS,0637,RC,68084-0280-11,NDC,,both,1,UN,4.90,3.18,,,,,,,,,,,,,
PLATE BNE L67MM BLDE W9.2XL30MM 90DEG 5 H BILAT S STL LOK,SUP-2185363,CDM,C1713,HCPCS,0278,RC,,,,both,,,3356.25,2181.56,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 45 CM 7 FR CRV BEND 9 MM STD UNIDIR,SUP-2604661,CDM,C1887,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW SFTAP HEX 3.5X100MM,SUP-2818585,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.63,199.96,,,,,,,,,,,,,
BLADE SAW D 31 MM CUT EDGE 9 MM CUT THK 0.5 MM MATERIAL THK,SUP-2898831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.06,102.09,,,,,,,,,,,,,
ANCHOR SUT 4.75X22MM PEEK DBL LD SWIVELOCK W/ TIGERTAIL,SUP-2121705,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
BUCK CEMENT REST SIZE 35MM,SUP-2822555,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
HEAD RMR DIA17MM S STL CONIC TIP SHRP CUT EDGE ATTACH W/,SUP-2188161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2453.88,1595.02,,,,,,,,,,,,,
CATHETER DIAG STEER L CRV 5MM ELECTRD SPC QPLR POLES 6FR,SUP-2142287,CDM,C1730,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 3 CC CORTICOCANCELLOUS CELLULAR BNE,SUP-2933286,CDM,C1762,CPT,0278,RC,,,,both,,,5623.36,3655.18,,,,,,,,,,,,,
OSS SM TAPERED OSSEOTI AUGMENT,SUP-2506338,CDM,C1776,CPT,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
SPLINT WRST HK LOOP CLOSURE MED 6 IN RT ELASTIC COTTON,SUP-2336321,CDM,L3809,HCPCS,0272,RC,,,,both,,,11.15,7.25,,,,,,,,,,,,,
BIT DRL 3X220 MM TORNIER,SUP-2388668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
PLATE BONE W10XL94MM THK2.8MM 8 H S STL STR NONCOMPRESSION,SUP-2343765,CDM,C1713,HCPCS,0278,RC,,,,both,,,3761.56,2445.01,,,,,,,,,,,,,
CATHETER EP 6FR L110CM 5-5-5MM SPC STABILENE QPLR FIX,SUP-2141260,CDM,C1730,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
IMMOBOLIZER SHLDR SUPP UNIV COT UNISX VELPEAU M,SUP-2211099,CDM,L3660,HCPCS,0272,RC,,,,both,,,7.91,5.14,,,,,,,,,,,,,
HC Cervical Myelogram S&I,PX-3207224000,CDM,72240,CPT,0320,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
STEM FEM 15X150 MM KNEE SS NS LF,SUP-2471858,CDM,C1776,CPT,0278,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
COMPONENT TOT KNEE HYBRID FIX BEAR RP POROUS,SUP-2249595,CDM,C1776,CPT,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
SPLINT ORTH SPICA THMB,SUP-2388192,CDM,L3807,HCPCS,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
STEM FEM SEG 3 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449806,CDM,C1776,CPT,0278,RC,,,,both,,,10557.94,6862.66,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE TORSION CTRL STRL,SUP-2388181,CDM,L2380,HCPCS,0272,RC,,,,both,,,303.73,197.42,,,,,,,,,,,,,
CATHETER INFUSION STR 150 CM 50 CM 2 MARKER BND PROWLER 10,SUP-2469714,CDM,C1887,HCPCS,0272,RC,,,,both,,,3847.69,2501.00,,,,,,,,,,,,,
WRENCH SURG HEX ROD,SUP-2232099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
SPACER SPNL H18XL20MM TI INTBDY FUS VLIFT,SUP-2380363,CDM,C1713,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
PLATE BNE L68MM 3X5 H T SHP FOR 3.5MM SCR,SUP-2411363,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
MESH HERN RECT 6.3X3 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855248,CDM,C1781,HCPCS,0278,RC,,,,both,,,7247.12,4710.63,,,,,,,,,,,,,
COLLAR PREMIER PRO CERV UNIV ADJ CLS CELL FOAM LNR L TRACH,SUP-2336010,CDM,L0140,HCPCS,0272,RC,,,,both,,,14.10,9.16,,,,,,,,,,,,,
CATHETER LA 6F 100CM RACAO,SUP-2429772,CDM,C1887,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
MESH GYN W4XL24CM POLYPR UNIDIR Y CNTOUR FOR TRANSABDOMINAL,SUP-2165308,CDM,C1781,HCPCS,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
PERI SCR 40MMX10MM,SUP-2720896,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.24,100.91,,,,,,,,,,,,,
STENT URETH FIRLIT-KLUGE L 31 CM DIA 8 FR SIL BALL/TUBING,SUP-2826947,CDM,C2617,HCPCS,0278,RC,,,,both,,,105.76,68.74,,,,,,,,,,,,,
KNOT PUSHER,SUP-2811803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
OCCLUDER CV L12MM BLB DIA2.75MM SIL RUB COR VES RADPQ DISP,SUP-2130330,CDM,C1760,HCPCS,0278,RC,,,,both,,,266.02,172.91,,,,,,,,,,,,,
GASTROSTOMY SET PUL METHOD 24 FRX150 CM 0.035 260 CM PEG24,SUP-2738239,CDM,C1769,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST ADJ W/O JT FABRICATED,SUP-2435767,CDM,L3808,HCPCS,0272,RC,,,,both,,,917.82,596.58,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL RECIP CABLE,SUP-2435687,CDM,L2628,HCPCS,0272,RC,,,,both,,,4435.12,2882.83,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL SIL GEL,SUP-2435703,CDM,L3003,HCPCS,0272,RC,,,,both,,,493.26,320.62,,,,,,,,,,,,,
PLATE BNE SM NONSTERILE CRANIOFACIAL ORBIT TI ANAT FLR FOR,SUP-2190650,CDM,C1713,HCPCS,0278,RC,,,,both,,,4334.46,2817.40,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF ADULT 6X200 MM 20 MM ANKLE FOOT H,SUP-2836740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3517.90,2286.63,,,,,,,,,,,,,
COLLAR CERV SFT 4X22IN UNIV,SUP-2276584,CDM,L0120,HCPCS,0272,RC,,,,both,,,7.79,5.06,,,,,,,,,,,,,
SCREW BONE L5MM PAN FIX LUHR,SUP-2364706,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.22,76.19,,,,,,,,,,,,,
STEM FEM SZ 4 L149MM DIA14MM STD CO CHROM MOD STANMORE,SUP-2405087,CDM,C1776,CPT,0278,RC,,,,both,,,6637.96,4314.67,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL VIT 2.0MM DIA 6MML,SUP-2364636,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.08,79.35,,,,,,,,,,,,,
PLATE HLS STR 1.5 4HL 215044,SUP-2247336,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
HC Leg Bones Lengthening Study,PX-3207707300,CDM,77073,CPT,0320,RC,,,,inpatient,,,802.00,521.30,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK PRIZM VR DEL ENERGY 27 J TI SINGLE,SUP-2148616,CDM,C1722,HCPCS,0275,RC,,,,both,,,66254.00,43065.10,,,,,,,,,,,,,
STENT URET INLAY OPTMA L 30 CM DIA 6 FR POLYMER BLEND,SUP-2126659,CDM,C2617,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BNE L316MM 13 H L DST FEM TI LOK COMPR LO PROF RIG,SUP-2190745,CDM,C1713,HCPCS,0278,RC,,,,both,,,4151.71,2698.61,,,,,,,,,,,,,
OATS KIT FOR 16MM ALLOGRAFT PLUGS,SUP-2816374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2190.15,1423.60,,,,,,,,,,,,,
LINER ACET OD54MM ID22MM POLYETH CONSTRN R3,SUP-2345189,CDM,C1776,CPT,0278,RC,,,,both,,,7391.56,4804.51,,,,,,,,,,,,,
PLATE BONE SM 4X4 H T SHP,SUP-2198580,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
TWIST DRILL 0.7MM DIA X 18MM 5MM STOP DNTL LATCH SNGLE USE,SUP-2488431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.74,253.98,,,,,,,,,,,,,
SUTURE FIBERTAPE SZ 2-0 L36IN NONABSORBABLE BLU 2MM EA END AR7237,SUP-2122112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
DEVICE FIX 7MM DIR ENDOBUTTON,SUP-2341085,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PIN BOLT APEX 3 6MM,SUP-2499937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
KIT LD STYL SFT FEATURING ISOFLEX OPTIM PACE,SUP-2357110,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE BONE L64MM 8 H STRL S STL LCK RECON FOR 2.7MM SCR EVOS,SUP-2349614,CDM,C1713,HCPCS,0278,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
INTRODUCER SHTH 5 FRX55 CM W/ TUOHY-BORST SIDEARM FLX ANSEL,SUP-2423711,CDM,C1894,HCPCS,0272,RC,,,,both,,,166.83,108.44,,,,,,,,,,,,,
GUIDEPIN ORTH L431MM DIA2.4MM TRCR TIP PASS LSR MRK,SUP-2341539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
BASEPLATE TIB MOD 75 MM KNEE OSS AVL,SUP-2441784,CDM,C1776,CPT,0278,RC,,,,both,,,9339.93,6070.95,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 150 CM 0.035 IN TAPR L 15 CM STR,SUP-2170340,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.23,69.05,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LG CUP HD LNR ST POROUS CERM EPOCH,SUP-2212320,CDM,C1776,CPT,0278,RC,,,,both,,,18152.37,11799.04,,,,,,,,,,,,,
PLATE BNE L239MM 14 H NONSTERILE L MED DST TIB S STL LOK,SUP-2184177,CDM,C1713,HCPCS,0278,RC,,,,both,,,3904.15,2537.70,,,,,,,,,,,,,
LEAD PACE L90CM STEROID GORE ENDOCARD 2 COIL BPLR PASS FIX,SUP-2148562,CDM,C1895,HCPCS,0275,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
PLATE BNE ORTHOGNATHIC 1 NS FACE ID,SUP-2883352,CDM,C1713,HCPCS,0278,RC,,,,both,,,22922.72,14899.77,,,,,,,,,,,,,
FLUCONAZOLE (DIFLUCAN) 2 MG/ML (PED-NEO) >/= 50 MLS,RX-4090490,CDM,2500000003,HCPCS,0250,RC,25021-0184-67,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 5FR 0.021IN PLAS,SUP-2385463,CDM,C1894,HCPCS,0272,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
GRAFT HUM TISS W3MMXL20-25.9CM SEMITENDINOSUS TEND FRZN FOR,SUP-2307286,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
HC Transferase Aspartate Amino Ast Sgot,PX-3018445000,CDM,84450,CPT,0301,RC,,,,both,,,122.00,79.30,,,,,,,,,,,,,
STEM FEM L250MM OD19MM LT HIP REV CO CHROM 3DEG BIPLANAR,SUP-2405149,CDM,C1713,HCPCS,0278,RC,,,,both,,,14820.80,9633.52,,,,,,,,,,,,,
PLATE BNE FEM 130 MM LT DSTL LAT 4 HOLE SS NS AXSOS,SUP-2461830,CDM,C1713,HCPCS,0278,RC,,,,both,,,5844.48,3798.91,,,,,,,,,,,,,
EXTENSION NEUROSTIMULATOR L40CM OD38MM ID15MM SPC 43MM,SUP-2629128,CDM,C1883,HCPCS,0278,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
SCREW BNE EMGCY 1.2X7 MM MAND X DRV TI,SUP-2470631,CDM,C1713,HCPCS,0278,RC,,,,both,,,220.27,143.18,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 5X175 MM 23/15 MM HIP 9 HOLE LCP,SUP-2799112,CDM,C1713,HCPCS,0278,RC,,,,both,,,2967.36,1928.78,,,,,,,,,,,,,
CAP END LOK LO EXT PANTA TI ST XL,SUP-2243618,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.28,744.43,,,,,,,,,,,,,
CUP ACET FLNG E LT HIP,SUP-2419769,CDM,C1776,CPT,0278,RC,,,,both,,,31400.00,20410.00,,,,,,,,,,,,,
CANNULA OPHTH ANIS VECTIS 16 GA LOOP,SUP-2471397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.00,258.70,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 8 MM STR TW SLDE GDS,SUP-2227380,CDM,C1768,CPT,0278,RC,,,,both,,,3119.12,2027.43,,,,,,,,,,,,,
BLADE IM L75MM DIA12.5MM NSTERILE CANC TI SPRL NTHREADED,SUP-2192128,CDM,C1713,HCPCS,0278,RC,,,,both,,,2259.64,1468.77,,,,,,,,,,,,,
GRAFT SFT TISS 100 MG PARTICULATE IN VI TISS MTRX INTERFYL,SUP-2651385,CDM,Q4171,HCPCS,0636,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
APPLIER CLP XL 10 MMX34 CM MANUAL LOAD HEM-O-LOK ENDO10,SUP-2656816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
SET SCR SPNL POST THORACOLUMBOSACRAL TI MULTIAXIAL REDUC,SUP-2287854,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.62,343.60,,,,,,,,,,,,,
ELECTRODE LOOP L W CBL FOR 30DEG TELSCP 0112041] MEDACTA USA],SUP-2267192,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,0636,RC,39822-0412-06,NDC,,both,1,UN,431.30,280.34,,,,,,,,,,,,,
BRACE WALKING LP XL 14-17 IN AD M FOAM MAXTRAX AIR,SUP-2427325,CDM,L4360,HCPCS,0274,RC,,,,both,,,97.50,63.37,,,,,,,,,,,,,
PLATE BONE L70MM THK3.1MM 6 H BILAT S STL LCK COMPR RECON,SUP-2348688,CDM,C1713,HCPCS,0278,RC,,,,both,,,4690.53,3048.84,,,,,,,,,,,,,
HOLDER NDLE 13 1/4NL 7MMW TIP TNGSTN CRBDE STRGHT F/SZE 40 N,SUP-2473723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.08,1805.75,,,,,,,,,,,,,
VALVE CSF MINI,SUP-2666620,CDM,C1889,HCPCS,0278,RC,,,,both,,,9341.47,6071.96,,,,,,,,,,,,,
PLATE BNE OFFSET GRID 2 MM RT LCK NS LTX,SUP-2856943,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
COMPONENT PATELLAR XS KNEE,SUP-2361582,CDM,C1776,CPT,0278,RC,,,,both,,,1461.04,949.68,,,,,,,,,,,,,
GRAFT BNE STRP 30 MM FIRM DBM,SUP-2134704,CDM,C1713,HCPCS,0278,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
BANDAGE SUPP ANK AK SILESIAN,SUP-2388215,CDM,L5698,HCPCS,0274,RC,,,,both,,,276.13,179.48,,,,,,,,,,,,,
ANCHOR SUTURE 5.0 MM KNOTLESS HEALICOIL,SUP-2653383,CDM,C1713,HCPCS,0278,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
SET CLMP INSRT L33MM HYDRA/TRACTION JAW DISP FGRTY,SUP-2214535,CDM,C1894,HCPCS,0272,RC,,,,both,,,93.60,60.84,,,,,,,,,,,,,
GRAFT BNE 8X4MM CALCANEOCUBOID JT WDG,SUP-2321655,CDM,C1776,CPT,0278,RC,,,,both,,,6341.23,4121.80,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE 10 MM PRECIS CYL PRE-CHAMBER VERY LO,SUP-2666443,CDM,C1889,HCPCS,0278,RC,,,,both,,,3035.12,1972.83,,,,,,,,,,,,,
BRACE ORTHOSIS SPNL S M EXOS FRM II 637,SUP-2196548,CDM,L0641,HCPCS,0274,RC,,,,both,,,488.40,317.46,,,,,,,,,,,,,
PLATE EXT FIX DIA160MM ANK FT DBL ROW TL HEX,SUP-2417463,CDM,C1713,HCPCS,0278,RC,,,,both,,,6764.31,4396.80,,,,,,,,,,,,,
KIT THR TRABECULAR MTL STEM CUP XLPE LNR,SUP-2212129,CDM,C1776,CPT,0278,RC,,,,both,,,16745.62,10884.65,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH TRL 4 CONTACT 1 CHAN,SUP-2925122,CDM,C1897,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
DURACON ALL POLY TIB L1 13MM,SUP-2364903,CDM,C1776,CPT,0278,RC,,,,both,,,3782.88,2458.87,,,,,,,,,,,,,
MESH HERN 20X15 CMX1 MM HYDRATED PORCINE CLLGN PERMACOL,SUP-2174697,CDM,C1781,HCPCS,0278,RC,,,,both,,,20635.20,13412.88,,,,,,,,,,,,,
"HC Culture,Fungus Other",PX-3008710200,CDM,87102,CPT,0300,RC,,,,both,,,247.00,160.55,,,,,,,,,,,,,
GRAFT BNE SUB 125ML PSTE MIX INQU +,SUP-2247319,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
INFUSION PUMP KIT 10 IN 270 CC W/ 2 SILVERSOAKER ON-Q,SUP-2236846,CDM,C2626,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
CANNULA INJ 8.5 CM F/POS PRESSURE VENT LARYNGOSCOPE 8590KC,SUP-2774910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.65,369.62,,,,,,,,,,,,,
TAP FOR 2.3MM MAND SCR,SUP-2364419,CDM,C1713,HCPCS,0278,RC,,,,both,,,881.68,573.09,,,,,,,,,,,,,
NAIL INTRMDLLRY L40CM D14MM FMRL RTRGRDE CNNLTD LOK M/DN,SUP-2467342,CDM,C1713,HCPCS,0278,RC,,,,both,,,4512.37,2933.04,,,,,,,,,,,,,
PLATE BONE L108MM 6 H STD BILAT COMPR CNTOUR + BROAD FOR,SUP-2349000,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.13,1259.13,,,,,,,,,,,,,
RIB PLATE 14MMX46MM,SUP-2841907,CDM,C1713,HCPCS,0278,RC,,,,both,,,3683.22,2394.09,,,,,,,,,,,,,
HC Path Consltj Surg Cytologic Exam Each Addl Site,PX-3118833400,CDM,88334,CPT,0311,RC,,,,both,,,227.00,147.55,,,,,,,,,,,,,
"HC So Morph Analysis,Tumor,Ea Ab",PX-3128836066,CDM,88360,CPT,0312,RC,,,,both,,,431.00,280.15,,,,,,,,,,,,,
GUIDEWIRE INSRT FOR SYS,SUP-2289239,CDM,C1769,HCPCS,0272,RC,,,,both,,,2233.89,1452.03,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 110 CM 5FR 5MM MED QPLR,SUP-2499986,CDM,C1730,HCPCS,0272,RC,,,,both,,,503.66,327.38,,,,,,,,,,,,,
PLATE BONE M W11XL162MM THK3.7MM 12 H TI STR REV FOR,SUP-2225498,CDM,C1713,HCPCS,0278,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
RECON PLATE 4X46MM 3.5MM,SUP-2818473,CDM,C1713,HCPCS,0278,RC,,,,both,,,2942.24,1912.46,,,,,,,,,,,,,
GRAFT BNE MIN W10MM WHL PAT W SMER BLK FRZN FLEXIGRFT,SUP-2264796,CDM,C1713,HCPCS,0278,RC,,,,both,,,11006.39,7154.15,,,,,,,,,,,,,
PLATE BNE W135XL368MM THK42MM 20 H BILAT S STL NAR LOK,SUP-2185259,CDM,C1713,HCPCS,0278,RC,,,,both,,,3429.07,2228.90,,,,,,,,,,,,,
PLATE BNE MESH PANEL 1X32X32X0.2 MM SCRN TI NS LEVEL 1,SUP-2468182,CDM,C1713,HCPCS,0278,RC,,,,both,,,735.51,478.08,,,,,,,,,,,,,
SCREW BNE 30 DEG L 8 MM DIA2.7 MM TI LCK VA T15 DRV NS LEOS,SUP-2931451,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.28,292.68,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY POLARIS X 270 DEG L 106 CM DIA 6,SUP-2652866,CDM,C1732,HCPCS,0278,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
SPACER TIB LIMB SALV LO BODY POLY ELEOS 12MM,SUP-2314040,CDM,C1776,CPT,0278,RC,,,,both,,,8851.66,5753.58,,,,,,,,,,,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,J7626,HCPCS,0636,RC,00093-6816-19,NDC,,both,2,ML,39.90,25.93,,,,,,,,,,,,,
CATHETER EP CSL 2-8-2 MM 6 FRX65 CM RESPON,SUP-2356827,CDM,C1730,HCPCS,0272,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
PLATE J RECON LO PROF 3.5MM 12H RT,SUP-2547583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1841.08,1196.70,,,,,,,,,,,,,
CANNULA ARTHSCP L165MM W/ OBT FOR TRNSPRT HIP ACCS SYS SCP,SUP-2366745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1316.16,855.50,,,,,,,,,,,,,
CATHETER GUID L100CM COR S STL PTFE IR 2 FLX SHFT L LUMN HI,SUP-2384868,CDM,C1887,HCPCS,0272,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
CROWN DENT 5 SEC PERM M LO LT S STL UNITEK,SUP-2238851,CDM,D6783,CPT,0278,RC,,,,both,,,122.27,79.48,,,,,,,,,,,,,
SYSTEM SPNL TETHERING DISPOSABLE TRANSLACE,SUP-2417657,CDM,C1713,HCPCS,0278,RC,,,,both,,,1802.36,1171.53,,,,,,,,,,,,,
CATHETER DRAINAGE SET 5 FRX8 CM FURMAN CPPD500WOODIMH,SUP-2759774,CDM,C1729,HCPCS,0272,RC,,,,both,,,402.86,261.86,,,,,,,,,,,,,
FOLIC ACID 400 MCG PO TABS,RX-3234,CDM,6370000000,HCPCS,0637,RC,50268-0346-15,NDC,,both,1,UN,1.70,1.10,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W2XL4CM THK023 051MM GRFTBLE RGNRTVE TSS,SUP-2707154,CDM,Q4116,HCPCS,0636,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION MEDIUM 2 MM DOUBLE ANGLE TITANIUM,SUP-2837757,CDM,C1713,HCPCS,0278,RC,,,,both,,,8895.31,5781.95,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4.5MM CANC ANTR CERV TI SELF DRL VAR ANG,SUP-2254606,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
PIN EXT FIX L28CM DIA2.4MM SPADE TIP 3MM EYELET GRFT PASS,SUP-2341287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
COMPONENT FEM KNEE CRUC RET CR FLX LT UNISX PRI PRESSFIT,SUP-2200894,CDM,C1776,CPT,0278,RC,,,,both,,,15082.99,9803.94,,,,,,,,,,,,,
CATHETER INTVASC L38CM OD9.3FR 3 LUMN 3 HEAT EXCHG BLLN FOR,SUP-2416142,CDM,C1751,HCPCS,0278,RC,,,,both,,,2727.03,1772.57,,,,,,,,,,,,,
DILATOR TRANSSEPTAL L 67 CM GUIDEWIRE L 230 CM HDPE HYPOTUBE,SUP-2913159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
AXLE FEM STD KNEE OSS,SUP-2405831,CDM,C1776,CPT,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
RELOAD STPL L100MM OPN H3.8MM CLS H1.5MM WIRE DIA0.2MM BLU,SUP-2220023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.25,225.71,,,,,,,,,,,,,
TOOL VLV BYPS FOR SLITTABLE OUTER GUID CATH CPS DIR SL II,SUP-2356362,CDM,C1893,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
STENT URET 360 DEG L 10 CM DIA 4.5 FR PIGTL OPN END KID CURL,SUP-2478856,CDM,C2617,HCPCS,0278,RC,,,,both,,,190.47,123.81,,,,,,,,,,,,,
COMPONENT FEMORALXSM RT KNEE PRI CEM STEMLESS POST,SUP-2406873,CDM,C1776,CPT,0278,RC,,,,both,,,14566.46,9468.20,,,,,,,,,,,,,
SPACER SPNL 10X22X60MM 10DEG TI MODULUS XLW,SUP-2421144,CDM,C1821,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
PLATE BNE L33MM THK12MM 0DEG 5 H BILAT S STL STR RIG LIMIT,SUP-2186168,CDM,C1713,HCPCS,0278,RC,,,,both,,,1025.62,666.65,,,,,,,,,,,,,
BOLT EXP L41MM SH CO CHROM MOLYBDENUM ALLOY FOR RECON PROS,SUP-2265099,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM TIP 8MM 1-6-2MM SPC 4 ELECTRD BLK,SUP-2248803,CDM,C1733,HCPCS,0272,RC,,,,both,,,3460.28,2249.18,,,,,,,,,,,,,
FIBER LASER HOLM SUREFLEX 10807] FORTEC MEDICAL INC],SUP-2225687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE IM LT FEM KNEE REV LCS COMPLETE,SUP-2453531,CDM,C1713,HCPCS,0278,RC,,,,both,,,2389.54,1553.20,,,,,,,,,,,,,
HC So Islet Cell Antibody,PX-3028634166,CDM,86341,CPT,0302,RC,,,,inpatient,,,698.00,453.70,,,,,,,,,,,,,
MESH CRAN L 100 X W 120 MM SCREW DIA2 MM TI PANEL NS DISP,SUP-2936730,CDM,C1713,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV SUSP,RX-169094,CDM,Q2050,HCPCS,0636,RC,43598-0541-25,NDC,,both,25,ML,1150.00,747.50,,,,,,,,,,,,,
TRIAL HIP OD54MM ID36MM 0DEG CROSSLINKED POLYETH LNR DISP R3,SUP-2345756,CDM,C1776,CPT,0278,RC,,,,both,,,519.70,337.80,,,,,,,,,,,,,
PLATE BNE THK1MM MINI 4 H CRANIOMAXILLOFACIAL BLU STR UNIV,SUP-2366340,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.78,182.51,,,,,,,,,,,,,
SPLINT RST PAN MIT SP S LF,SUP-2163830,CDM,L3807,HCPCS,0272,RC,,,,both,,,81.29,52.84,,,,,,,,,,,,,
CARTRIDGE BNE CEMENT PARALLAX,SUP-2308556,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
BENDER PLT RAD HD EVOLVE,SUP-2397210,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
PROBE SPNL DCOMPR DISCECTOMY 15GA L6IN LUM STR LORD KT,SUP-2367000,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT TEMPORARY #6 SLIGHT CURVE 6MM 201860,SUP-2844637,CDM,C1889,HCPCS,0278,RC,,,,both,,,867.46,563.85,,,,,,,,,,,,,
SCREW BNE COMPR 7.5X55 MM 15 MM HDLSS BITE,SUP-2644947,CDM,C1713,HCPCS,0278,RC,,,,both,,,2232.54,1451.15,,,,,,,,,,,,,
COIL EMB MIC EXT EMBOLUS L14CM COILED DIA12MM CATH 0.035IN,SUP-2169685,CDM,C1889,HCPCS,0278,RC,,,,both,,,395.61,257.15,,,,,,,,,,,,,
PLATE BNE SCREW DIA 3/3.5/4 MM MED TI ALLOY TALONAVICULAR,SUP-2907925,CDM,C1713,HCPCS,0278,RC,,,,both,,,6486.36,4216.13,,,,,,,,,,,,,
SCREW SPNL L40MM DIA5.5MM REDUC MULTIAXIAL FOR 5.5/6MM 2,SUP-2278812,CDM,C1713,HCPCS,0278,RC,,,,both,,,6879.74,4471.83,,,,,,,,,,,,,
HEAD FEM FD 40 MM TIMS CRFT,SUP-2423183,CDM,C1776,CPT,0278,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
ADAPTER LD L 16 CM 4.75 MM TO IS1 BPLR CONN,SUP-2148783,CDM,C1883,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COIL EMB 3 DIM 8 MMX25 CM GDC 18,SUP-2365730,CDM,C1889,HCPCS,0278,RC,,,,both,,,7897.73,5133.52,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER SGL CHMBR 40J BPLR ADV VVEV,SUP-2138076,CDM,C1722,HCPCS,0275,RC,,,,both,,,42633.70,27711.90,,,,,,,,,,,,,
GUIDEPIN SURG TIB PC CR-FLEX FIX NXGN,SUP-2201241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TIP RASP DIA8MM FN FOR SUCT TBNG FEATHERTOUCH,SUP-2284176,CDM,C1713,HCPCS,0278,RC,,,,both,,,899.30,584.54,,,,,,,,,,,,,
SCREW ACET EXTRACT REMOVAL 8 MM,SUP-2453035,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
UPCHARGE KNEE PRIMARY ATTUNE AOX INSERT DEPUY SYNTHES,SUP-2501359,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-40840054,CDM,2580000003,HCPCS,0258,RC,00338-0089-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
TUBE SUCTION FRAZIER 7 FRX4 IN 7.5 IN ANGLED SS STRL,SUP-2498054,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.16,42.35,,,,,,,,,,,,,
INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN,RX-10289,CDM,J1815,HCPCS,0637,RC,00002-8215-01,NDC,,both,10,ML,35.70,23.20,,,,,,,,,,,,,
PLATE BNE L125MM 7 H NONSTERILE L DST RAD VOLAR DPHSEAL,SUP-2184061,CDM,C1713,HCPCS,0278,RC,,,,both,,,4256.40,2766.66,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.035IN FLPY TIP L3CM TAPR L7CM CRV,SUP-2167999,CDM,C1769,HCPCS,0272,RC,,,,both,,,68.55,44.56,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST ADJ W/O JT FABRICATED,SUP-2435767,CDM,L3808,HCPCS,0274,RC,,,,both,,,917.82,596.58,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX8 CM 18 GA DL J TIP SPECTRUM,SUP-2759746,CDM,C1751,HCPCS,0278,RC,,,,both,,,424.31,275.80,,,,,,,,,,,,,
DRESSING NEG PRESSURE INCISION MGMT SYS 90 CM KIT PREVENA +,SUP-2433936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1204.35,782.83,,,,,,,,,,,,,
LINER ACET OD50MM ID32MM 20DEG ENDRN HIP CEM ENDUR,SUP-2250675,CDM,C1776,CPT,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 90 CM BALLOON L 250 MM DIA2 MM SHTH 4,SUP-2909705,CDM,C1725,HCPCS,0272,RC,,,,both,,,793.76,515.94,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 11 CM DIA 5 FR IV CATH L 2.5 CM,SUP-2740585,CDM,C1892,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
COIL EMB L1CM DIA1MM HELI DETACH TARGET NANO,SUP-2367948,CDM,C1889,HCPCS,0278,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
SCREW BONE L6MM DIA3.5MM STRL CORT S STL ST FOR SM PLATING,SUP-2349331,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.02,100.76,,,,,,,,,,,,,
FILTER VASC L103CM DIA9FR INTRO 28MM VENA CAVA AC DEL KT FOR,SUP-2127811,CDM,C1880,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 10 CM DIA 8 MM EPTFE STR STD WALL REINF,SUP-2500396,CDM,C1768,CPT,0278,RC,,,,both,,,852.54,554.15,,,,,,,,,,,,,
GRAFT BIO TISS W7XL10CM 1 LAYR PORCINE MTRX SFT TISS REINF,SUP-2168773,CDM,C1763,HCPCS,0278,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
SUTURE ANCHOR CROSSFT KNOTLESS 4.0MM WITH WHITE BLACK HI-FI,SUP-2824386,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.67,1375.84,,,,,,,,,,,,,
FIXATION SCREW WASHER,SUP-2829166,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
HC Image Cath Fluid Trns/Vgnl,PX-3614940700,CDM,49407,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER EP LG 2-5-2 6 FRX110 STEER INQUIRY,SUP-2488439,CDM,C1730,HCPCS,0272,RC,,,,both,,,1425.56,926.61,,,,,,,,,,,,,
PLATE BONE W10XL70MM THK2.8MM 6 H S STL STR NONCOMPRESSION,SUP-2343763,CDM,C1713,HCPCS,0278,RC,,,,both,,,3441.75,2237.14,,,,,,,,,,,,,
BIT DRL L260.4MM DIA3.5MM S STL GRAD ADD ON CONN FOR BAR,SUP-2342881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1839.66,1195.78,,,,,,,,,,,,,
PLATE BNE SPLNT PT SPEC ORTHOGNATHIC FINAL,SUP-2194244,CDM,C1713,HCPCS,0278,RC,,,,both,,,3182.70,2068.75,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR PHILOS II DR,SUP-2138035,CDM,C1785,HCPCS,0275,RC,,,,both,,,15866.42,10313.17,,,,,,,,,,,,,
QUETIAPINE FUMARATE 100 MG PO TABS,RX-21824,CDM,6370000000,HCPCS,0637,RC,00904-6640-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE CRV NAR 4.5 MM 16 HOLE SS NS LCP,SUP-2178061,CDM,C1713,HCPCS,0278,RC,,,,both,,,2918.50,1897.02,,,,,,,,,,,,,
SCREW BONE L75MM OD4.5MM CORT SLD FULL THRD STRL,SUP-2413175,CDM,C1713,HCPCS,0278,RC,,,,both,,,181.05,117.68,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 22X55 MM PRESERVON TRICORT MATRIGRAFT,SUP-2740788,CDM,C1713,HCPCS,0278,RC,,,,both,,,6589.13,4282.93,,,,,,,,,,,,,
VALVE TRACH WHT SPEAK VENT PASSY MUIR,SUP-2322021,CDM,L8501,HCPCS,0272,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
PERFORATOR SURG L11MM DIA7MM CRAN AUTO CAMMED LUG RELEASING,SUP-2106557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
DEVICE FIX TIB SM ADJ STRL ULTRABUTTON LTX,SUP-2880219,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
PLATE SPNL 1 LEVEL 26 MM ANTR CERV NEO-SL,SUP-2430718,CDM,C1713,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
CLAMP CRAN DIA13MM TI FLAP TUBE,SUP-2192428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1462.30,950.49,,,,,,,,,,,,,
SCREW BONE L7MM DIA1MM CORT CRANIOMAXILLOFACIAL TI ST FULL,SUP-2189038,CDM,C1713,HCPCS,0278,RC,,,,both,,,1420.85,923.55,,,,,,,,,,,,,
SCREW BONE L5MM DIA1.5MM GRN TI CRANIOMAXILLOFACIAL SELF DRL,SUP-2403085,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.85,166.95,,,,,,,,,,,,,
INSERT TIB SZ 6 THK10MM RT KNEE CRUC SUB UHMWPE PRI FIX,SUP-2304586,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CROWN DENT LR1 1ST PRI M INDIV SPACE MAINTAINER,SUP-2176679,CDM,D6783,CPT,0278,RC,,,,both,,,22.61,14.70,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED REVERSED SHOULDERCAP79000] STRYKER CORP],SUP-2365913,CDM,C1776,CPT,0278,RC,,,,both,,,24806.00,16123.90,,,,,,,,,,,,,
FORCEPS NAVIGATION SYS DIA1.8MM OVL CUP ALWAYS ON TIP,SUP-2392611,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC LOOP LCK 5.5-6.5 IN SM 7.5 IN LT PROCARE,SUP-2197046,CDM,L3931,HCPCS,0272,RC,,,,both,,,20.44,13.29,,,,,,,,,,,,,
CABLE ORTH DIA2MM HIP S STL W/ CLMP ACCORD,SUP-2345205,CDM,C1776,CPT,0278,RC,,,,both,,,1129.14,733.94,,,,,,,,,,,,,
SCREW BNE FT 20 5 MM PANTA,SUP-2421866,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.33,767.21,,,,,,,,,,,,,
ORAL SWEETENER (MIXTURES ONLY),RX-430033,CDM,2580000003,HCPCS,0258,RC,00395-2661-16,NDC,,both,473,ML,66.00,42.90,,,,,,,,,,,,,
PLATE BNE L 265 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 22 H 72463122,SUP-2933433,CDM,C1713,HCPCS,0278,RC,,,,both,,,8092.72,5260.27,,,,,,,,,,,,,
KIT BONE CEM DEL 11GM W/ BOWL CANN INJ DMND STYL AND GRN TIP,SUP-2342068,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
PLATE BNE L44MM THK13MM 2X6 H NONSTERILE CNDYL HND TI LOK,SUP-2181040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1935.75,1258.24,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 0.035 IN 17 ATM 5 FRX80 CM 6X120 MM,SUP-2865997,CDM,C1725,HCPCS,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE|DOCUMENTATION ON FILE,PX-4309712900,CDM,97129,CPT,0430,RC,,,GN|KX,outpatient,,,186.00,120.90,,,,,,,,,,,,,
SCREW BONE L9MM OD1.5MM LCK TI T4 S-T VLP MINI MOD,SUP-2341191,CDM,C1713,HCPCS,0278,RC,,,,both,,,575.66,374.18,,,,,,,,,,,,,
STEM FEM L300MM OD17MM TI 60% POR PLSM SPR DST CALCAR MOD,SUP-2403918,CDM,C1776,CPT,0278,RC,,,,both,,,8716.64,5665.82,,,,,,,,,,,,,
INFLATION DVCBSXT30 ATMBR20 MLMP952FL50MTL INSRT TLTRQUE DV,SUP-2701655,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.62,84.90,,,,,,,,,,,,,
STRM PEANUT PLATE 1 HOLE,SUP-2478558,CDM,C1713,HCPCS,0278,RC,,,,both,,,2891.37,1879.39,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT + DIA27 MM SEW RNG DIA 36 MM,SUP-2214292,CDM,C1889,HCPCS,0278,RC,,,,both,,,15197.60,9878.44,,,,,,,,,,,,,
CAP NAIL H0MM TIB NAT NAIL,SUP-2413038,CDM,C1713,HCPCS,0278,RC,,,,both,,,620.97,403.63,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN L15CM STR TIP PTFE S STL,SUP-2142705,CDM,C1769,HCPCS,0272,RC,,,,both,,,48.36,31.43,,,,,,,,,,,,,
BIT OVERDRILL L 229 MM DIA 7 MM LG AO NS DISP LEOS,SUP-2932999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1312.83,853.34,,,,,,,,,,,,,
MESH SURG W7XL9IN UNCOATED MFIL POLYPR ABSRB HYDRGEL LO,SUP-2125909,CDM,C1781,HCPCS,0278,RC,,,,both,,,2907.64,1889.97,,,,,,,,,,,,,
CLIP ANEUR PERM 8.3 MM SLIGHTLY CRV YASRG,SUP-2108664,CDM,C1889,HCPCS,0278,RC,,,,both,,,958.20,622.83,,,,,,,,,,,,,
PAD BED SENSOR ALARM 30 DAY,SUP-2529125,CDM,C1776,CPT,0278,RC,,,,both,,,41.39,26.90,,,,,,,,,,,,,
STIMULATOR IMPL FUS,SUP-2414469,CDM,E0749,HCPCS,0278,RC,,,,both,,,17725.30,11521.44,,,,,,,,,,,,,
ADAPTER HUM HD STD TAPR FOR COMPHSVE REV SHLDR SYS,SUP-2404757,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W16XL20CM THK1.04 2.28MM HICK RGNRTVE TSSU,SUP-2485846,CDM,Q4116,HCPCS,0636,RC,,,,both,,,34675.02,22538.76,,,,,,,,,,,,,
LNT IMPLANT SYSTEM 4.75 PEEK SWIVELOCK,SUP-2816638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
CATH REPROC EP STRBL QUADRPLR LG CRV 6FR 5MM 110CM,SUP-2526277,CDM,C1730,HCPCS,0272,RC,,,,both,,,662.16,430.40,,,,,,,,,,,,,
SHEATH ARTHSCP 2.8 MM DIA STPCOCK,SUP-2361366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1019.87,662.92,,,,,,,,,,,,,
GRAFT BNE GEL 1 CC DBM MAROFUSE,SUP-2120697,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE BONE ORBITAL LARGE RIGHT PREFORMED TITANIUM GOLD STERI,SUP-2837775,CDM,C1713,HCPCS,0278,RC,,,,both,,,6354.42,4130.37,,,,,,,,,,,,,
BLADE SHV 4.5MM DIA ENDO ANG CVD DBL SERR ULT SER DISP CUT,SUP-2341583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.35,222.53,,,,,,,,,,,,,
TUBING IRRGTN 0.104N ID 0.192N OD 14.6FR 10FTL SLSTC SLCNE N,SUP-2492551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.85,221.55,,,,,,,,,,,,,
PLATE DISPLAY PORTFOLIO,SUP-2550456,CDM,C1713,HCPCS,0278,RC,,,,both,,,181.40,117.91,,,,,,,,,,,,,
CATHETER EP LG CRV 2-5-2 MM 6 FRX110 CM QPLR STJ81104] ST JUDE MEDICAL INC],SUP-2357724,CDM,C1730,HCPCS,0272,RC,,,,both,,,509.90,331.43,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 L 6 CM DIA 4 MM 3D HELCL STRL,SUP-2365673,CDM,C1889,HCPCS,0278,RC,,,,both,,,4929.17,3203.96,,,,,,,,,,,,,
SPACER SPNL 24X14X18 MM PEEK,SUP-2211891,CDM,C1821,HCPCS,0278,RC,,,,both,,,17816.36,11580.63,,,,,,,,,,,,,
K WIRE FIX L180MM DIA1.6MM W/ TRCR PT,SUP-2418381,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.63,17.96,,,,,,,,,,,,,
"HC So Antibody Virus, Nos",PX-3028679066,CDM,86790,CPT,0302,RC,,,,both,,,87.00,56.55,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 15MM L MED R LAT KNEE HEMI STP LEGION,SUP-2346584,CDM,C1776,CPT,0278,RC,,,,both,,,3399.05,2209.38,,,,,,,,,,,,,
GRAFT BONE L50-100MM SHFT FRZN,SUP-2335280,CDM,C1762,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
PATCH DURAL SUB 5X5CM ONLAY LYCOPLANT,SUP-2714085,CDM,C1763,HCPCS,0278,RC,,,,both,,,865.54,562.60,,,,,,,,,,,,,
BLADE SHV DIA4MM 75DEG CRV SERR DISECT CONCAVE WIND FOR,SUP-2313833,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.76,260.49,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 4X4 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651377,CDM,Q4154,HCPCS,0636,RC,,,,both,,,6287.85,4087.10,,,,,,,,,,,,,
CATHETER URET 3FR L70CM POLYVINYLCHLORIDE CLOSE END RT,SUP-2168867,CDM,C1758,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
HC Asp Injection Major Joint|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,PX-4502061000,CDM,20610,CPT,0450,RC,,,50|XU,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
HEAD HUM H18MM OD42MM OFFSET 1.5MM LO CO CHROM SFT TISS,SUP-2388756,CDM,C1776,CPT,0278,RC,,,,both,,,9295.97,6042.38,,,,,,,,,,,,,
STABILIZER PELV TPOD ORNG TRAUM ORTHOT DEV TPODOR,SUP-2150009,CDM,L0469,HCPCS,0272,RC,,,,both,,,423.87,275.52,,,,,,,,,,,,,
PUSHER KNOT SUT CUT DISP FOR 2-0 FIBERWIRE,SUP-2121863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
COMPONENT FEM L65MM L KNEE POR ANAT PRI MAXM,SUP-2405270,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM OD0035IN 3MM TIP CRV RAD S STL PTFE J,SUP-2167581,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.09,24.76,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 5 CC PRESERVON CANC READIGRAFT,SUP-2740975,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.71,274.76,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 2 CM AMNIO MEMBRN RESRB STRL PALINGEN,SUP-2913452,CDM,Q4173,HCPCS,0636,RC,,,,both,,,6427.58,4177.93,,,,,,,,,,,,,
SNARE SURG HEX 3 MMX230 CM ISNARE,SUP-2736642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
DILATOR URO L35CM OD24FR ID8FR AMPLTZ TYP TEF RENAL TAPR,SUP-2139745,CDM,C1894,HCPCS,0272,RC,,,,both,,,66.41,43.17,,,,,,,,,,,,,
SET ORTH INSTR DISP IDUO,SUP-2904896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CROWN DENT SZ UL3 UP LT 1ST PERM M S STL THCK OCCLUSAL SURF,SUP-2238936,CDM,D6783,CPT,0278,RC,,,,both,,,111.56,72.51,,,,,,,,,,,,,
STENT URETH UROLUME L 2 CM DIA 42 FR ELGILOY SELF EXPANDABLE,SUP-2140269,CDM,C1876,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
CATHETER URODYN BLLN 7.4 FRX30 CM W/ OVL PRT COUDE TIP,SUP-2835744,CDM,C1726,HCPCS,0272,RC,,,,both,,,149.97,97.48,,,,,,,,,,,,,
HC Creatinine Clearance,PX-3018257500,CDM,82575,CPT,0301,RC,,,,inpatient,,,265.00,172.25,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.093X9 IN RND END SS NS STEINMANN,SUP-2791839,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.18,7.92,,,,,,,,,,,,,
CATHETER CRICOTHYROTOMY SET 4 MMX4.2 CM 6 MMX7.5 CM MELK,SUP-2760018,CDM,C1769,HCPCS,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
TUBE NG AD DIA20FR BLLN L8X1.5IN SPEC FOR ES VARICES BLAKMR,SUP-2127130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1726.09,1121.96,,,,,,,,,,,,,
PROBE ARTHSCP FOR SLIC SCR SYS NS BIOTRAK LF REUSE,SUP-2535223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
LOCKING FRAC PLATE CRVD LNG NON CMPRSSN 20MM THICK T 6L 4V,SUP-2679057,CDM,C1713,HCPCS,0278,RC,,,,both,,,2578.94,1676.31,,,,,,,,,,,,,
PLUG HERN XL W1.6XL2IN INGUINAL POLYPR REP PRESHAPED ONLAY,SUP-2125757,CDM,C1781,HCPCS,0278,RC,,,,both,,,721.57,469.02,,,,,,,,,,,,,
HOOK MNPLTNG CLLR 7MM 4.9NL STNLSS STEEL RCTS MSCLE PLSHD FN,SUP-2501229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
HC Clsd Tx Navicular Fx Manip,PX-4502562400,CDM,25624,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
HC Add Lt Vent Pacing Lead to Pcm,PX-3613322400,CDM,33224,CPT,0361,RC,,,,inpatient,,,35488.00,23067.20,,,,,,,,,,,,,
HC Trluml Balo Angiop 1st Art,PX-3613724600,CDM,37246,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
BATTALION LAT INTDISC SHIM STRL,SUP-2114089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
CROSSLINK MECH GIC55 TRNSVRS LINK W/ 60MM BAR 806LT55L60T,SUP-2289278,CDM,C1713,HCPCS,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
PLATE BNE STR 2.7X81 MM 10 HOLE RECON LCK SS STRL,SUP-2469656,CDM,C1713,HCPCS,0278,RC,,,,both,,,1435.98,933.39,,,,,,,,,,,,,
HC Implant Spinal Cord Stim,PX-3600007518,CDM,3600007518,LOCAL,0360,RC,,,,outpatient,,,6232.00,4050.80,,,,,,,,,,,,,
BOOT WALKING HI TOP SM FT ANK LIFESTRIDE,SUP-2108144,CDM,L4386,HCPCS,0274,RC,,,,both,,,109.59,71.23,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 90 CM DIA 6 FR HYDRPHLC,SUP-2383406,CDM,C1894,HCPCS,0272,RC,,,,both,,,163.03,105.97,,,,,,,,,,,,,
PLATE BNE L 100.33 X W 5.08 MM THK 0.6 MM SCREW DIA2 MM 16 H,SUP-2936893,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
WIRE FIX KIRSCHNER KWIRE] TORNIER INC],SUP-2388810,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
PIN FIX L3IN W HNDL STNMN PFC,SUP-2253359,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE DSTL RAD 2 CLMN 2.4MM 7H HD 3H SHFT RT SS VA LCP STRL,SUP-2546051,CDM,C1713,HCPCS,0278,RC,,,,both,,,4148.94,2696.81,,,,,,,,,,,,,
PLATE BNE X ARTC 2.4 MM RT DSTL RADIAL VOLAR 5X5 HOLE VA NS,SUP-2549104,CDM,C1713,HCPCS,0278,RC,,,,both,,,2562.52,1665.64,,,,,,,,,,,,,
SPLINT FT MED NT PLNTR FASCIITI,SUP-2195478,CDM,L4398,HCPCS,0274,RC,,,,both,,,77.18,50.17,,,,,,,,,,,,,
HC Soft Tissue Lat Neck,PX-3207036000,CDM,70360,CPT,0320,RC,,,,both,,,734.00,477.10,,,,,,,,,,,,,
SHUNT CSF CONNECTOR 1.9MM VALVE 4MM CATHETER 1.2MM 2.5MM VAL,SUP-2821793,CDM,C1889,HCPCS,0278,RC,,,,both,,,6315.83,4105.29,,,,,,,,,,,,,
MODULUS XLW 8X22X60MM 10 DEG INDIV ST PKG,SUP-2421140,CDM,C1889,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.546,SUP-2860063,CDM,C1713,HCPCS,0278,RC,,,,both,,,55690.73,36198.97,,,,,,,,,,,,,
HC Inf Agent Det Nucleic Acid Clostridium Amp Probe,PX-3068749300,CDM,87493,CPT,0306,RC,,,,both,,,171.00,111.15,,,,,,,,,,,,,
IMPLANT HUM TISS W5XL8CM THK1MM PROC DERM CLLGN RECTANG,SUP-2126257,CDM,C1781,HCPCS,0278,RC,,,,both,,,2803.71,1822.41,,,,,,,,,,,,,
NEEDLE INSUF 12CM LEN 2MM DIAM ENDOSCP ABD PNEUMOPERI,SUP-2261123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.33,474.71,,,,,,,,,,,,,
TUBE VENT ID1.14MM INNR FLNG OD2.4MM INTERFLNG DISTANCE,SUP-2277574,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.87,46.07,,,,,,,,,,,,,
RX PLATE DOUBLE Y SHAPE 6 HOLE 10MM PROFILE,SUP-2681420,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.99,406.89,,,,,,,,,,,,,
HC Portogram W/O Hemo S&I,PX-3207588700,CDM,75887,CPT,0320,RC,,,,both,,,7130.00,4634.50,,,,,,,,,,,,,
COMPONENT TIB AUG SL LG,SUP-2445634,CDM,C1776,CPT,0278,RC,,,,both,,,1596.69,1037.85,,,,,,,,,,,,,
PLATE BNE Z MIC MED 100 1.5X0.6 MM LT CRANIOMAXILLOFACIAL,SUP-2467507,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.00,352.95,,,,,,,,,,,,,
PLATE BNE STR 63X0.6 MM NEURO 16 HOLE TI STRL LEVEL 1,SUP-2486933,CDM,C1713,HCPCS,0278,RC,,,,both,,,909.85,591.40,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK CATH AXS VECTA 74 L 132 CM,SUP-2884579,CDM,C1757,HCPCS,0272,RC,,,,both,,,9577.00,6225.05,,,,,,,,,,,,,
PLATE BNE L91MM 2 H ST R PERIARTC PROX HUM S STL LOK LO PROF,SUP-2177802,CDM,C1713,HCPCS,0278,RC,,,,both,,,5132.55,3336.16,,,,,,,,,,,,,
BRACE WRISTXSM FOR 14.6CM LT PROTCT PD ADJ BAR D RNG CLSR,SUP-2324887,CDM,L3931,HCPCS,0272,RC,,,,both,,,41.07,26.70,,,,,,,,,,,,,
INTRAAORTIC PUMP KIT 7.5 FR 30/40 CC INSRTN SHTH MEGA,SUP-2534220,CDM,C1894,HCPCS,0272,RC,,,,both,,,388.83,252.74,,,,,,,,,,,,,
PLATE BNE 4 H XS ORBIT FLR NS DISP,SUP-2934900,CDM,C1713,HCPCS,0278,RC,,,,both,,,8813.98,5729.09,,,,,,,,,,,,,
COMPONENT FEM L25MM OD12MM CSTI POR KNEE STEM SEGMENTED HEX,SUP-2208270,CDM,C1776,CPT,0278,RC,,,,both,,,11530.08,7494.55,,,,,,,,,,,,,
BIT DRL 1.2X87 MM 6 MM STP TPS END NS UNIV NEURO III LTX,SUP-2862796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.26,427.22,,,,,,,,,,,,,
FIXATOR EXT FIX D40MM STD CORETRAK STERIPACK,SUP-2401435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5482.44,3563.59,,,,,,,,,,,,,
COMPONENT GLEN KEELED 40 MM SHLDR W/ 46 MM ARTC SURF,SUP-2436693,CDM,C1776,CPT,0278,RC,,,,both,,,4899.72,3184.82,,,,,,,,,,,,,
NUT LCK SPNL F ZM 8MM 8MM,SUP-2205109,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BNE L100MM STD 7 H L OLECRANON EL TI LO PROF FOR,SUP-2107003,CDM,C1713,HCPCS,0278,RC,,,,both,,,4295.52,2792.09,,,,,,,,,,,,,
STENT URET UROGUIDE L 30 CM DIA 8.5 FR SIL NYL TETH HYDRPHLC,SUP-2476987,CDM,C2617,HCPCS,0278,RC,,,,both,,,429.90,279.43,,,,,,,,,,,,,
MOLD SURG 10-1/2 IN FOR ACRYL SPLNT X-FIX 51-671-27-07,SUP-2478537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.95,252.82,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX15 CM DL J TIP POLYETH CUDLM401JLSC,SUP-2760054,CDM,C1751,HCPCS,0278,RC,,,,both,,,234.46,152.40,,,,,,,,,,,,,
BIT DRL ADJ STRL ZEVO,SUP-2628870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1109.68,721.29,,,,,,,,,,,,,
HUMERAL SUTURE PLATE 5 HOLE STRL,SUP-2816581,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
PLATE B1 STP 2 MM SCREW DIA 3/3.5/4 MM TI ALLOY LT FT,SUP-2907618,CDM,C1713,HCPCS,0278,RC,,,,both,,,7523.53,4890.29,,,,,,,,,,,,,
TISSUE T00246 ILIUMTRICORTSTRIP22MMX50MM,SUP-2281640,CDM,C1762,CPT,0278,RC,,,,both,,,6886.02,4475.91,,,,,,,,,,,,,
INSERT HUM 32 MM SHLDR SOCKET RSP,SUP-2217310,CDM,C1776,CPT,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
WAND ARTHSCP 7.5IN MINI COBLATOR FOR LARYN SURG DISP,SUP-2342036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
DEVICE PROSTHETIC FT KNEELING EXT,SUP-2388222,CDM,L5970,HCPCS,0272,RC,,,,both,,,577.04,375.08,,,,,,,,,,,,,
SYSTEM VLV SHUNT ADJ DIFF PRSS 0-20CM H2O W/ GRAVITATIONAL,SUP-2108723,CDM,C1713,HCPCS,0278,RC,,,,both,,,10393.40,6755.71,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY LG AD 3.25 IN 16-19 IN PHILADELPHIA,SUP-2319293,CDM,L0172,HCPCS,0272,RC,,,,both,,,39.60,25.74,,,,,,,,,,,,,
GRAFT HUM TISS 10X14MM THK2MM ACELLULAR DERM MTRX BIOWASHER,SUP-2120780,CDM,Q4125,HCPCS,0636,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
HC Place Percu-Abd/Plv-No Prost,PX-3334941100,CDM,49411,CPT,0333,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
MODULE TST NEUROVISION TST PLCMNT SCR DISPOSABLEXLIF,SUP-2311744,CDM,C1713,HCPCS,0278,RC,,,,both,,,6452.76,4194.29,,,,,,,,,,,,,
HOLDER NDL L55IN JAW L9MM S STL TUNGSTEN CARB G SATIN FINISH,SUP-2161165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,746.19,485.02,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 55 CM OD 6 FR ID 0.07 IN TIP L,SUP-2158730,CDM,C1887,HCPCS,0272,RC,,,,both,,,444.31,288.80,,,,,,,,,,,,,
SET INTRO OUTER CATH 4FR L10CM NDL 21GA L7CM 0.018IN PLAT,SUP-2170545,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.98,56.54,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL STD L W120XL120MM THK0.6MM,SUP-2419460,CDM,C1713,HCPCS,0278,RC,,,,both,,,8443.08,5488.00,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CERM ON POLYETH STEJH6] STRYKER CORP],SUP-2365940,CDM,C1776,CPT,0278,RC,,,,both,,,15367.16,9988.65,,,,,,,,,,,,,
CUP ACET OD48MM ID42MM HIP CO CHROM HA POR PRI CEMENTLESS,SUP-2350844,CDM,C1776,CPT,0278,RC,,,,both,,,15562.63,10115.71,,,,,,,,,,,,,
PLATE BNE L 186 X W 12.7 MM THK 3.5 MM SCREW DIA2.7/3.5 MM 72464314N,SUP-2933523,CDM,C1713,HCPCS,0278,RC,,,,both,,,7925.52,5151.59,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 40 CM DIA10 MM AX COMPLIANCE,SUP-2682140,CDM,C1768,CPT,0278,RC,,,,both,,,4498.02,2923.71,,,,,,,,,,,,,
HYDROTENOTOMY SET PERC HNDPC STRL TENJET LTX DISP,SUP-2875923,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CEMENT DENT RADPQ KETAC,SUP-2100140,CDM,C1713,HCPCS,0278,RC,,,,both,,,484.78,315.11,,,,,,,,,,,,,
BRACE ORTH CORSET FRONT,SUP-2388154,CDM,L0972,HCPCS,0274,RC,,,,both,,,297.99,193.69,,,,,,,,,,,,,
DRILL SURG PROF MIC STRL ACUTRK 2 LTX DISP,SUP-2857806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + XL MEDPOR PTERIONAL +,SUP-2862747,CDM,C1713,HCPCS,0278,RC,,,,both,,,68297.32,44393.26,,,,,,,,,,,,,
BUSHING FEM KNEE POLY REDUC SZ ORTH SALV SYS,SUP-2406496,CDM,C1776,CPT,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
STEM FEM L150MM OD11MM BOW CLLRD TI IM OSS,SUP-2405837,CDM,C1776,CPT,0278,RC,,,,both,,,5171.58,3361.53,,,,,,,,,,,,,
TAP SURG SZ 4.75 MM PEEK STRL ALPHAVENT,SUP-2882662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
MESH HERN W15.9XL21CM VENTRAL POLYPR EPTFE OVL,SUP-2125816,CDM,C1781,HCPCS,0278,RC,,,,both,,,2181.36,1417.88,,,,,,,,,,,,,
TUBE MYR 1.14MM DIAM VENT PAPARELLA,SUP-2313843,CDM,L8699,HCPCS,0278,RC,,,,both,,,51.62,33.55,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 100 CM DIA 8 MM RNG L 70 CM EPTFE,SUP-2396306,CDM,C1768,CPT,0278,RC,,,,both,,,5721.08,3718.70,,,,,,,,,,,,,
SCREW BONE L50MM OD4MM LACTOSORB COPOLYMER SHLDR CANN FULL,SUP-2137296,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.44,706.19,,,,,,,,,,,,,
DULOXETINE HCL 30 MG PO CPEP,RX-39276,CDM,6370000000,HCPCS,0637,RC,68180-0295-09,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE SIDE L 25 X W 25 MM THK 0.5 MM SCREW DIA1.7 MM PLL,SUP-2883325,CDM,C1713,HCPCS,0278,RC,,,,both,,,2820.91,1833.59,,,,,,,,,,,,,
ATAZANAVIR SULFATE 150 MG PO CAPS,RX-36149,CDM,6370000000,HCPCS,0637,RC,42385-0920-60,NDC,,both,1,UN,13.40,8.71,,,,,,,,,,,,,
CATHETER INFUSION 0.018 IN 2.4 FRX150 CM PROGREAT GLIDEWIRE,SUP-2423783,CDM,C1887,HCPCS,0272,RC,,,,both,,,1858.88,1208.27,,,,,,,,,,,,,
COMPONENT FEM KNEE POST STABILIZING LT UNISX REV CEM STEM,SUP-2199876,CDM,C1776,CPT,0278,RC,,,,both,,,30731.81,19975.68,,,,,,,,,,,,,
INSERT TIB CR 67X10 MM KNEE PRIMARY BEAR MAXM VI,SUP-2404013,CDM,C1776,CPT,0278,RC,,,,both,,,2332.39,1516.05,,,,,,,,,,,,,
HANDPIECE ELECSURG AQUABEAM - ORDER MULTIPLES OF 5,SUP-2745940,CDM,C2596,HCPCS,0272,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
PLATE SPNL L21MM ANT LUM TI LO PROF AEGIS,SUP-2255174,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 10-19 CM FEM VEIN BLD TYP A B AB O,SUP-2884032,CDM,C1768,CPT,0278,RC,,,,both,,,19339.26,12570.52,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE CUTAWAY CNTOUR 22INCH COOL BLU,SUP-2336081,CDM,L1830,CPT,0272,RC,,,,both,,,81.73,53.12,,,,,,,,,,,,,
HC Smr Prim Src Wet Mount Nfct Agt|UNUSUAL NON-OVERLAPPING SERVICE,PX-3008721001,CDM,87210,CPT,0300,RC,,,XU,outpatient,,,208.00,135.20,,,,,,,,,,,,,
KIT PICC CATH AD 5FR L55CM GWIRE L13 1/8IN 0.018IN POLYUR,SUP-2383477,CDM,C1751,HCPCS,0278,RC,,,,both,,,175.97,114.38,,,,,,,,,,,,,
HC Rem Neph Tube,PX-3615038900,CDM,50389,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
METRONIDAZOLE 0.75 % VA GEL,RX-10592,CDM,6370000000,HCPCS,0637,RC,71656-0067-70,NDC,,both,70,GR,67.50,43.87,,,,,,,,,,,,,
PLATE BNE L 129 X W 11 MM THK 3.3 MM SCREW DIA 3.5 MM,SUP-2908399,CDM,C1713,HCPCS,0278,RC,,,,both,,,1204.35,782.83,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 7 MM OSTEOCHNDRL,SUP-2866829,CDM,C1762,CPT,0278,RC,,,,both,,,9217.47,5991.36,,,,,,,,,,,,,
ELECTRODE DEFIB Q-TRAK L 45 CM DIA 7 FR COIL DIA 9FR 59.5 CC,SUP-2148623,CDM,C1896,HCPCS,0275,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
STEM HUM REVERSED LNG 11X180 MM SHLDR FRAC AEQUALIS REVERSED,SUP-2715635,CDM,C1776,CPT,0278,RC,,,,both,,,17224.47,11195.91,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 145 CM DIA 0.038 IN PTFE PERIPH,SUP-2167789,CDM,C1769,HCPCS,0272,RC,,,,both,,,104.31,67.80,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.141X9 IN SS NS STEINMANN,SUP-2791822,CDM,C1713,HCPCS,0278,RC,,,,both,,,33.35,21.68,,,,,,,,,,,,,
ULTRATHANE SUPRAPUBIC CATHETER SET,SUP-2822057,CDM,C2627,HCPCS,0272,RC,,,,both,,,234.72,152.57,,,,,,,,,,,,,
SCREW BNE L18MM OD35MM DST VPS III,SUP-2316491,CDM,C1713,HCPCS,0278,RC,,,,both,,,270.35,175.73,,,,,,,,,,,,,
FORCEPS BPLR FOR GRD I AND II INT HEMORRHOID HET,SUP-2172227,CDM,C1713,HCPCS,0278,RC,,,,both,,,2144.62,1394.00,,,,,,,,,,,,,
HEAD FEM PRI MTL ON POLY VIT 28MM DIA +12 NK LEN ABG II V40,SUP-2364468,CDM,C1776,CPT,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
Z INACTIVE UNKNOWN PART NUMBER KIT BNE CEM SZ 3 MIX MULT TAP ADPT XPEDE KYPHON,SUP-2293485,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
PATCH SURGICALXENOSURE W0.45XH1MMXL6CM PERICARD BOV,SUP-2264294,CDM,C1768,CPT,0278,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
CATHETER EP A 5 MM 4 FRX100 CM 4 ELECTRD FIX,SUP-2248842,CDM,C1730,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX60 CM DL OTW SS SPECTRUM TURBO-JECT,SUP-2759826,CDM,C1751,HCPCS,0278,RC,,,,both,,,430.40,279.76,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 360 DEG L 11 CM DIA 4 MM SPD 7500 RPM,SUP-2901963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.58,486.58,,,,,,,,,,,,,
TUNNELER SURG L 700 MM XL RIGID NO RNG MARKING STRL DISP,SUP-2928844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,497.09,323.11,,,,,,,,,,,,,
SCREW BNE CANC 4.5X15 MM TOT WR UNIV 2,SUP-2610339,CDM,C1713,HCPCS,0278,RC,,,,both,,,655.22,425.89,,,,,,,,,,,,,
PROSTHESIS OSS MASS PISTON 0.6X4.50 MM EYE EAR FLROPLAS PLAT,SUP-2638118,CDM,L8613,CPT,0278,RC,,,,both,,,441.20,286.78,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT 50 MM FRZN WHL PATELLAR TEND QUAD,SUP-2866906,CDM,C1762,CPT,0278,RC,,,,both,,,7382.93,4798.90,,,,,,,,,,,,,
DSG WND MICRONIZED PARTIC 20 MG MATRISTEM MICROMATRIX,SUP-2106466,CDM,Q4118,HCPCS,0636,RC,,,,both,,,144.53,93.94,,,,,,,,,,,,,
VARIABLE ANGLE LOCK SCRWWSHR ST TTNM D2.7 L22MM,SUP-2586566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.34,676.22,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0250,RC,00990-7922-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
STAPLER INT 45MM OPN 4X3.5MM B SHP CLSR 1.5MM BLU TI LIN 7,SUP-2283414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1255.69,816.20,,,,,,,,,,,,,
KIT PRESSURE MONITOR HNDL TUOHY BORST ADPT W/ SKULL BOLT SPC,SUP-2883589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2393.90,1556.03,,,,,,,,,,,,,
SLING ORTHOT CERV THOR LUMBAR SACR CUST AX,SUP-2435570,CDM,L1010,HCPCS,0272,RC,,,,both,,,236.88,153.97,,,,,,,,,,,,,
HC Inj/Asp Maj Jnt or Bursa|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,PX-7612061000,CDM,20610,CPT,0761,RC,,,50|XU,both,,,1092.00,709.80,,,,,,,,,,,,,
CATHETER KIT MICROCATHETER 180 CM 10 CM TIP 135 CM RENEGADE,SUP-2141042,CDM,C1887,HCPCS,0272,RC,,,,both,,,2060.34,1339.22,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND MED 60 K 3 MM HI SPD UNIDRIVE DISP,SUP-2599312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.04,405.63,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM AMNIO MEMBRN AMNIOEXCEL,SUP-2243186,CDM,Q4137,HCPCS,0636,RC,,,,both,,,6107.30,3969.74,,,,,,,,,,,,,
SHEATH GLD OPER VERSASCOPE,SUP-2257610,CDM,C1894,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
BLADE SHAVER CRV 4.5 MMX11.5 CM 45 DEG PRE BENT STRL ROUTER,SUP-2607704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,859.83,558.89,,,,,,,,,,,,,
CATHETER ETER NEPHSTMY 8FR L25CM COMB STNT PERCFLX,SUP-2141727,CDM,C1729,HCPCS,0272,RC,,,,both,,,280.75,182.49,,,,,,,,,,,,,
SET URET STENT C FLX L 8 CM DIA 5 FR GUIDEWIRE 0.038 IN SM,SUP-2171208,CDM,C2617,HCPCS,0278,RC,,,,both,,,300.03,195.02,,,,,,,,,,,,,
SYRINGE GRFT DEL 7 CC ADV DISP,SUP-2731718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER HYDRPHLC COAT XP GLDECATH SIM 1 TIP 5FRX65CM,SUP-2385159,CDM,C1887,HCPCS,0272,RC,,,,both,,,159.20,103.48,,,,,,,,,,,,,
CATHETER BLLN DIL 6FR L180CM L6CM DIA15MM ES HI PERF,SUP-2149862,CDM,C1726,HCPCS,0272,RC,,,,both,,,291.08,189.20,,,,,,,,,,,,,
ZIEGLER KNIFE NEEDLE 7MM,SUP-2482096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
DEVICE THROMBOLYTIC ARROW-TREROTOLA PTD L 65 CM DIA 5 FR,SUP-2383482,CDM,C1894,HCPCS,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
PLATE BNE L111MM 8 H NONSTERILE R PROX TIB S STL LO PROF,SUP-2185813,CDM,C1713,HCPCS,0278,RC,,,,both,,,3619.79,2352.86,,,,,,,,,,,,,
ES TROCH NAIL RIGHT 11MMX45CMX130 DEGREE,SUP-2810991,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
DEFIBRILLATOR CRD LUMAX 340 HF-T,SUP-2138072,CDM,C1882,HCPCS,0275,RC,,,,both,,,58687.17,38146.66,,,,,,,,,,,,,
SCREW BONE L9MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189667,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.16,141.15,,,,,,,,,,,,,
GUIDEWIRE VASC BLNT 610 MM NIT,SUP-2630451,CDM,C1769,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
CATHETER INFUSION STR 2.4-3 FRX130 CM 20 CM RENEGADE STC-18,SUP-2141033,CDM,C1887,HCPCS,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
"HC Est Pt, E/M Level 1",PX-5109921100,CDM,99211,CPT,0510,RC,,,,outpatient,,,174.00,113.10,,,,,,,,,,,,,
HC Remove Icd Lead Single or Dual,PX-4813324400,CDM,33244,CPT,0481,RC,,,,both,,,11199.00,7279.35,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 20X10X4 MM FUSIONFLEX,SUP-2759530,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
CATHETER VENTRICULAR PORTNOY FLNG 18 CM FULL BA W/ STYL,SUP-2851451,CDM,C1729,HCPCS,0272,RC,,,,both,,,1129.43,734.13,,,,,,,,,,,,,
DEVICE SPEC RETRV MAXI ESOPH SWIRLNET,SUP-2490688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.02,287.31,,,,,,,,,,,,,
COLLAR CERV MULT POST BRAC VISTA,SUP-2388138,CDM,L0190,HCPCS,0272,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
SCREW BNE L 105 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931556,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.82,111.68,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS MULTAXL STRL CD HORZ MODULEX 2PK,SUP-2928043,CDM,C1713,HCPCS,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
SLING SHLDR M CHST CIRC 36IN TO 40IN UNIV BLU SUPP NEOPRNE,SUP-2324512,CDM,L3650,HCPCS,0274,RC,,,,both,,,88.67,57.64,,,,,,,,,,,,,
PACK SURG PROC KNEE USER GPS,SUP-2223588,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
MICROSPHERE EMB EMBOSPHERE DIA 50-100 UM 2 CC 20 CC SYR GRA,SUP-2700439,CDM,C1889,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM CORT TI SELF DRL ST NONCANNULATED,SUP-2189865,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.74,45.33,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 6 MM 5 CM STR TW STRL,SUP-2396308,CDM,C1768,CPT,0278,RC,,,,both,,,2659.58,1728.73,,,,,,,,,,,,,
GRAFT BONE STRP CORT 14MMX50MM INDUX,SUP-2415400,CDM,C1713,HCPCS,0278,RC,,,,both,,,5611.18,3647.27,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY L20CM OD18GA PROST STABILIZING,SUP-2134785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 60 CM DIA28 MM THK 0.38 MM POLYESTER,SUP-2476757,CDM,C1768,CPT,0278,RC,,,,both,,,1991.58,1294.53,,,,,,,,,,,,,
HC Ot Massage 15 Min,PX-4309712400,CDM,97124,CPT,0430,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
IMPLANT ORBIT COMPLT L IMPLABLE L93XW75MM MEDPOR,SUP-2366500,CDM,C1713,HCPCS,0278,RC,,,,both,,,14018.69,9112.15,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM OD.025IN 14FR INTRO FLX TIP FIX,SUP-2139323,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.86,23.96,,,,,,,,,,,,,
KIT CATH HEMODIALYSI SFT CELL CHRONIC STD 12.5FR DIA 27CM 12,SUP-2613293,CDM,C1750,HCPCS,0278,RC,,,,both,,,629.73,409.32,,,,,,,,,,,,,
SCREW BNE COUNTSINK 2X2.7 MM,SUP-2435342,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
KIT HAD 145FR CATHETER L55CM INSRT L50CM STR POLYUR CATHETER,SUP-2126477,CDM,C1750,HCPCS,0278,RC,,,,both,,,1374.85,893.65,,,,,,,,,,,,,
HC Perq Prcrd Drg 6yr+ W/O Congenital Car Anomaly,PX-3603301700,CDM,33017,CPT,0360,RC,,,,both,,,5261.00,3419.65,,,,,,,,,,,,,
CAGE SPNL 8X18X40MM PEEK LLIF ZEUS,SUP-2115633,CDM,C1889,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
WEDGE PAT TRAD ALLGRFT 13 - 15 MM FRZ DRY,SUP-2294119,CDM,C1713,HCPCS,0278,RC,,,,both,,,2895.08,1881.80,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 14 CM DIA20 MM CATH DIA 0.035 IN,SUP-2638554,CDM,C1889,HCPCS,0278,RC,,,,both,,,380.57,247.37,,,,,,,,,,,,,
TR3100-L/R OTIS KNEE FEMORAL/TIBIA CUT GIDE SET FOR STRYKR,SUP-2366016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
LEADWIRE EKG HOLTER 24 IN SEER 1000 AHA 3 LD 3 CHANNEL,SUP-2713577,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.78,599.16,,,,,,,,,,,,,
SNARE VASC 1 SNR L 100 CM DIA 4 FR TUNGSTEN NIT GLD PLT STRL,SUP-2677173,CDM,C1773,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GRAFT HUM TISS 1CC PLCNTA TISS MTRX ALLGRFT FLOWERFLO,SUP-2225378,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840056,CDM,J7042,HCPCS,0258,RC,00338-0085-03,NDC,JW,both,250,ML,19.20,12.48,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE 4X4CM,SUP-2307619,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2728.66,1773.63,,,,,,,,,,,,,
SP PLASMALOOP ANGLED,SUP-2725840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.83,1040.54,,,,,,,,,,,,,
TUBE VENT 1.14 MM TOUMA W/ TAB SIL,SUP-2466627,CDM,L8699,HCPCS,0278,RC,,,,both,,,44.78,29.11,,,,,,,,,,,,,
HANDPIECE ELECSURG SONICFUSION,SUP-2484828,CDM,C1713,HCPCS,0278,RC,,,,both,,,19342.40,12572.56,,,,,,,,,,,,,
WIRE SURG 0.062X6 IN TRCR PT NS KIRSCHNER LTX,SUP-2862422,CDM,C1713,HCPCS,0278,RC,,,,both,,,10.68,6.94,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 80 CM DIA14 FR DIL L 91 CM GUIDEWIRE,SUP-2168516,CDM,C1894,HCPCS,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
DISTAL RAD NAIL 6.5MM / 7.6MMX59MM TI,SUP-2340236,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
SPLINT WRST M L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276626,CDM,L3809,HCPCS,0272,RC,,,,both,,,21.38,13.90,,,,,,,,,,,,,
PLATE BNE L157MM THK3MM 10 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185342,CDM,C1713,HCPCS,0278,RC,,,,both,,,1959.89,1273.93,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 8 MM EPTFE STR TW REINF 2,SUP-2525451,CDM,C1768,CPT,0278,RC,,,,both,,,983.23,639.10,,,,,,,,,,,,,
STAPLER INT SZ 10 4.8MM TI MULTFI VERSATACK,SUP-2283146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.35,225.78,,,,,,,,,,,,,
STEM FEM 13 155 MM HIP POROUS SYNERGY,SUP-2344408,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
TRAY PACE ELECTRD L 110 CM DIA 5 FR TRNSVEN LIDO TEMP,SUP-2119989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1799.22,1169.49,,,,,,,,,,,,,
PROSOURCE NO CARB PO LIQD,RX-102212,CDM,6370000000,HCPCS,0637,RC,94688-0114-76,NDC,,both,30,ML,6.10,3.96,,,,,,,,,,,,,
SYSTEM ENDOSCP VES HARV W/ TOOL CANN SEAL SHT PRT BLNT TIP,SUP-2227791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4021.15,2613.75,,,,,,,,,,,,,
KIT DRNGE SUMP J TIP CATH TRCR STYL .038IN GUIDWIRE CANN,SUP-2147873,CDM,C1729,HCPCS,0272,RC,,,,both,,,471.47,306.46,,,,,,,,,,,,,
GRAFT NRV PROTCT L4CM ID5MM CLLGN ABSRB PERIPH NEURAWRAP,SUP-2244319,CDM,C9352,HCPCS,0278,RC,,,,both,,,5766.17,3748.01,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS PK MICRORAPTOR,SUP-2848661,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
COLLAR CERV PADDED SM SHT 2X10X20 IN COMFORT ADJ MIAMI J,SUP-2434341,CDM,L0174,HCPCS,0274,RC,,,,both,,,150.66,97.93,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SAVVY L 120 CM BALLOON L 40 MM DIA 3 MM,SUP-2156574,CDM,C1725,HCPCS,0272,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
PROSTHESIS PENILE 16CMX9.5MM 700 CXR,SUP-2140301,CDM,C1813,HCPCS,0278,RC,,,,both,,,8525.10,5541.31,,,,,,,,,,,,,
PLATE BONE W14XL101MM THK3.8MM 90DEG 5 H LT TIB S STL L SHP,SUP-2185780,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.77,1120.45,,,,,,,,,,,,,
CROWN DENT 6 S STL PRETRIMMED BELLED CRIMPED 6 LO LT PERM M,SUP-2100247,CDM,D6783,CPT,0278,RC,,,,both,,,35.48,23.06,,,,,,,,,,,,,
KIT HIP PREP W/ PLUG INSRT BRSH SPNG PRSSZR,SUP-2408589,CDM,C1713,HCPCS,0278,RC,,,,both,,,371.46,241.45,,,,,,,,,,,,,
HC Chemo Push Technique Arterial,PX-3619642000,CDM,96420,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5ML PO SUER,RX-9773,CDM,340b,HCPCS,0637,RC,09999-9907-56,NDC,,both,10,ML,3.20,2.08,,,,,,,,,,,,,
SAPHENOUS VEIN 46CM,SUP-2931384,CDM,C1762,CPT,0278,RC,,,,both,,,25771.11,16751.22,,,,,,,,,,,,,
LINER ACET DIA28MM 10DEG CONSTRN M SER S ROM,SUP-2253362,CDM,C1776,CPT,0278,RC,,,,both,,,6889.79,4478.36,,,,,,,,,,,,,
PROSTHESIS OSS EAR 1.17X5.6 MM PROP GOLDENBERG MALL,SUP-2312826,CDM,L8613,CPT,0278,RC,,,,both,,,1290.60,838.89,,,,,,,,,,,,,
CATHETER EP MED LG 2-8-2 5 FRX110 INQUIRY,SUP-2467795,CDM,C1730,HCPCS,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
BIT DRL 6.5X210 MM AEQUALIS,SUP-2715484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.09,445.96,,,,,,,,,,,,,
CATHETER ANGIO ACCU-VU L 70 CM DIA 5 FR GUIDEWIRE 0.035 IN,SUP-2117054,CDM,C1887,HCPCS,0272,RC,,,,both,,,98.91,64.29,,,,,,,,,,,,,
KIT IMPL DST BICEPS BTTN INSRT W/ NO2 FIBERLOOP SUT,SUP-2121662,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BONE TIBIAL 214X14X4 MM TIBIAL HEAD 11 HOLE BUTTRESS S,SUP-2836989,CDM,C1713,HCPCS,0278,RC,,,,both,,,8406.41,5464.17,,,,,,,,,,,,,
INTRODUCER VASC L14CM DIA16FR VLV PEELABLE TEARAWAY,SUP-2269550,CDM,C1892,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
PLATE BNE THK 2 MM SCREW DIA2/2.3 MM MED GRD IV TI,SUP-2935991,CDM,C1713,HCPCS,0278,RC,,,,both,,,6085.32,3955.46,,,,,,,,,,,,,
PLATE BONE 4 H STD RT DSTL VOLAR RAD D-RAD SMRT PK,SUP-2343909,CDM,C1713,HCPCS,0278,RC,,,,both,,,3563.59,2316.33,,,,,,,,,,,,,
CATHETER FIST WAVELINQ ENDOAVF L ART VEN 50/43 CM DIA 4 FR,SUP-2133516,CDM,C1887,HCPCS,0272,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
PLATE BNE Z LG 1.7 MM RT MIDFACE 4 HOLE GSP GLD NS LTX,SUP-2862764,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.84,488.05,,,,,,,,,,,,,
STEM HUM L 77 MM MED STD TI PLASMA SPRY LT ELBW SQ TOT,SUP-2902154,CDM,C1776,CPT,0278,RC,,,,both,,,25843.14,16798.04,,,,,,,,,,,,,
BIOPROSTHESIS VASC PROCOL L 40 CM DIA 6 MM BOV MESENTERIC,SUP-2175239,CDM,C1768,CPT,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
SCREW BNE COMPR 4.5X24 MM ANK FUSION CONSTRUCT,SUP-2609766,CDM,C1713,HCPCS,0278,RC,,,,both,,,933.68,606.89,,,,,,,,,,,,,
"HC So Mituberculosis,Dna,Amp.Probe",PX-3068755666,CDM,87556,CPT,0306,RC,,,,both,,,438.00,284.70,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESHED 8X16 CMX0.4-1.0 MM 1:1 PROLAYER EDM,SUP-2717795,CDM,C1763,HCPCS,0278,RC,,,,both,,,23894.68,15531.54,,,,,,,,,,,,,
SET GUID CATH GORE TIP L 49 CM DIA10 FR SHTH L 40 CM DIA10,SUP-2396408,CDM,C1894,HCPCS,0272,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
DISPOSABLES KIT FOR DX KNOTLESS FIBERTAK,SUP-2815355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 5|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-7619920500,CDM,99205,CPT,0761,RC,,,27,both,,,387.00,251.55,,,,,,,,,,,,,
DEFIBRILLATOR CARD 76GM 35CC W40XH74MM THK14MM PARYLENE,SUP-2356295,CDM,C1721,HCPCS,0275,RC,,,,both,,,37994.00,24696.10,,,,,,,,,,,,,
STRIP BIOACTIVE KINEX 20 CC 25X100X8 MM,SUP-2232309,CDM,C1713,HCPCS,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
CATHETER CV STD SET 035 7.5 FRX15 CM DL J TIP POLYETH,SUP-2760165,CDM,C1751,HCPCS,0278,RC,,,,both,,,261.44,169.94,,,,,,,,,,,,,
PROSTHESIS OSS SHEA 3X0.8X7 MM MALL SHFT HA TORP,SUP-2637878,CDM,L8613,CPT,0278,RC,,,,both,,,1399.84,909.90,,,,,,,,,,,,,
PLATE BNE 6 H CRANIOMAXILLOFACIAL TI H SHP FOR 1MM SCR,SUP-2190616,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.73,618.62,,,,,,,,,,,,,
COLLAR CERV M AD MIAMI J,SUP-2151872,CDM,L0172,HCPCS,0272,RC,,,,both,,,133.89,87.03,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB I DIAMOND STRL REUSE HI-LINE,SUP-2929280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.38,264.15,,,,,,,,,,,,,
BUR SURG DIA1MM S STL STAP RND CUT REUSE FOR VIPER OTO DRL,SUP-2313878,CDM,C1713,HCPCS,0278,RC,,,,both,,,358.05,232.73,,,,,,,,,,,,,
SCREW BNE LCK 5X110 MM CANN OPTILINK TECHNOLOGY STRL VALCP,SUP-2789509,CDM,C1713,HCPCS,0278,RC,,,,both,,,931.70,605.60,,,,,,,,,,,,,
OBTURATOR SURG CONCL TIP 3.8 MM 2.7 MM,SUP-2849701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.44,403.94,,,,,,,,,,,,,
COLLAR CERV L20XW4IN L CNTOUR COT STOCK M DENS STOUT AD FOR,SUP-2196871,CDM,L0120,HCPCS,0274,RC,,,,both,,,12.75,8.29,,,,,,,,,,,,,
PLATE BONE REG L95MM THK1MM 16 H MIDFACE SLV TI STR FOR 2MM,SUP-2402949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
SYSTEM KYPHOPLASTY INTRO OSTEO KYPHON XPANDER II,SUP-2281648,CDM,C1894,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
STEM HUM 7 SHLDR CAP COAT STRL UNIVERS REVERS LF,SUP-2123315,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW CLASSIC OD 26 MM ID 24.3 MM TI SIL,SUP-2214176,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
INSERTER SURG CRV FLX STRL FAST-FIX LTX,SUP-2880223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1711.14,1112.24,,,,,,,,,,,,,
PIN BNE FIX TEMP L80MM DIA4MM MAKO,SUP-2368491,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
SCREW DENT 4.3X11.5 MM CONCL CONN RP NOBELREPLACE,SUP-2430155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1000.88,650.57,,,,,,,,,,,,,
CATHETER EP DIAG MAP M CRV QPLR 2-5-2MM SPC 2MM TIP UNI DIR,SUP-2356857,CDM,C1730,HCPCS,0272,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
TUBE GASTROJEJU 14FR L22CM STOMA L1.5CM MICRO GJET,SUP-2713901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4016.06,2610.44,,,,,,,,,,,,,
PLATE BNE LCK NAR 4.5 MM 5 HOLE COMPR STRL ALPS LTX,SUP-2861819,CDM,C1713,HCPCS,0278,RC,,,,both,,,1280.74,832.48,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 1.5MM X 4IN STT,SUP-2640113,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
WASHER ORTH SM 2 MM FOR CABLE STRL,SUP-2563694,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.84,79.85,,,,,,,,,,,,,
TUBE DCOMPR 12FR CATH L35IN GAST PUSH JEJU FEED,SUP-2127677,CDM,C1769,HCPCS,0272,RC,,,,both,,,547.58,355.93,,,,,,,,,,,,,
BIT DRL L195MM DIA4.5MM ST TI QUIK CPL NONRADIOPAQUE W/O,SUP-2187289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,497.28,323.23,,,,,,,,,,,,,
COLLAR CERV UNIV AD AIR VENT MIAMI OCCIAN,SUP-2276575,CDM,L0180,HCPCS,0272,RC,,,,both,,,373.44,242.74,,,,,,,,,,,,,
CATHETER DIAG PERCFLX GUIDEWIRE L 30 CM DIA 0.014 IN SS,SUP-2147725,CDM,C1729,HCPCS,0272,RC,,,,both,,,323.45,210.24,,,,,,,,,,,,,
CHP TITAN 135 LNGTH 16 THD,SUP-2818366,CDM,C1713,HCPCS,0278,RC,,,,both,,,2567.61,1668.95,,,,,,,,,,,,,
PLATE BONE L163MM 12 H NONSTERILE LT PROX TIB S STL LO PROF,SUP-2185818,CDM,C1713,HCPCS,0278,RC,,,,both,,,3856.55,2506.76,,,,,,,,,,,,,
R-T HUMERAL NAIL 8X30CM,SUP-2818079,CDM,C1713,HCPCS,0278,RC,,,,both,,,19843.39,12898.20,,,,,,,,,,,,,
HC Hysterosalpingogram,PX-3207474000,CDM,74740,CPT,0320,RC,,,,inpatient,,,686.00,445.90,,,,,,,,,,,,,
CATHETER REPROC INQUIRY QUAD,SUP-2470791,CDM,C1730,HCPCS,0272,RC,,,,both,,,479.01,311.36,,,,,,,,,,,,,
SCREW BNE LCK 2.7X12 MM WRST COMPR FUSION SS NS SURFIX,SUP-2852054,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.19,642.97,,,,,,,,,,,,,
COVID-19MRNA BIVAL VACC PFIZER 30 MCG/0.3ML IM SUSP,RX-4082344,CDM,2500000003,HCPCS,0250,RC,09999-9916-86,NDC,,both,.3,ML,0.10,0.06,,,,,,,,,,,,,
COMPONENT FEM SZ 5 L KNEE TOT STBL TRIATHLON,SUP-2372989,CDM,C1776,CPT,0278,RC,,,,both,,,14927.56,9702.91,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 3.5 X 36MM HD CANN SHT THRD SCR,SUP-2320510,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED NARROW LCP PLATE 18 HOLE STERILE,SUP-2546929,CDM,C1713,HCPCS,0278,RC,,,,both,,,3497.18,2273.17,,,,,,,,,,,,,
SHEATH INTRO 5FR L10CM 21/19GA ECHOGENIC TAPR NDL W/ NIT,SUP-2385251,CDM,C1894,HCPCS,0272,RC,,,,both,,,190.22,123.64,,,,,,,,,,,,,
KIT INTRO PEELPRO L 14 CM DIA 5 FR PTFE TEARWY STD,SUP-2118929,CDM,C1892,HCPCS,0272,RC,,,,both,,,154.49,100.42,,,,,,,,,,,,,
IMPLANT THYROPLASTY VOCAL CRD 12 M STRL MONTGOMERY,SUP-2141839,CDM,L8509,HCPCS,0272,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
PLATE BONE L190MM 4 H TROCHANTERIC TI GRP SUPERCABLE,SUP-2262261,CDM,C1713,HCPCS,0278,RC,,,,both,,,6546.90,4255.48,,,,,,,,,,,,,
SHEATH INTRO L 14 CM DIA 9 FR GUIDEWIRE 0.038 IN PTFE X TW,SUP-2615900,CDM,C1894,HCPCS,0272,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
LINER ACET OD48MM ID28MM GG METASUL HIP ALPHA UNCEMENTED STD,SUP-2204545,CDM,C1776,CPT,0278,RC,,,,both,,,5286.19,3436.02,,,,,,,,,,,,,
PROSTHESIS OSS L3.75MM SHFT OD0.5MM PLAT STAP FLROPLAS PIST,SUP-2419763,CDM,L8613,CPT,0278,RC,,,,both,,,592.80,385.32,,,,,,,,,,,,,
PLATE BNE 2.7X108 MM 12 HOLE SS LCP,SUP-2569312,CDM,C1713,HCPCS,0278,RC,,,,both,,,426.57,277.27,,,,,,,,,,,,,
PLATE BNE X 2.3X1.5 MM THOR RIB 10 HOLE LCK SLD SEMI LEVEL 1,SUP-2869173,CDM,C1713,HCPCS,0278,RC,,,,both,,,3398.74,2209.18,,,,,,,,,,,,,
PREMASOL 10 % IV SOLN,RX-36160,CDM,2500000003,HCPCS,0250,RC,00338-1130-03,NDC,,both,500,ML,310.50,201.82,,,,,,,,,,,,,
BODY EXT FIX L62MM SHT 1 STD BAR PENNIG MINIFIXATOR,SUP-2316455,CDM,C1713,HCPCS,0278,RC,,,,both,,,1925.95,1251.87,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 5 MM EPTFE STR STD WALL,SUP-2396177,CDM,C1768,CPT,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC So Hepatic Function Panel,PX-3018007666,CDM,80076,CPT,0301,RC,,,,both,,,30.00,19.50,,,,,,,,,,,,,
PLATE BNE 2.7X59 MM 5 HOLE,SUP-2200825,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
PROSTHESIS OSS 0.5X6.50 MM EAR PISTON NIT FLROPLAS ECLIPSE,SUP-2232528,CDM,L8613,CPT,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PROBE SURG FUKUSHIMA-GIANNOTTA 7.25 IN STR RUGGLES-REDMOND,SUP-2465762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,310.26,201.67,,,,,,,,,,,,,
PIN DISTR L16MM SELF DRL CASPR,SUP-2108437,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PENTOXIFYLLINE ER 400 MG PO TBCR,RX-21300,CDM,6370000000,HCPCS,0637,RC,00904-5448-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER ANGIOPLSTY LP 0.018 IN 130 CM 6X100 MM LUTONIX 018,SUP-2126960,CDM,C2623,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.177X9 IN SHANK END SS NS STEINMANN,SUP-2791598,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.08,35.80,,,,,,,,,,,,,
CARTRIDGE BONE CEMENT MANIFOLD 8GA VERTEPORT X4,SUP-2876049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1192.54,775.15,,,,,,,,,,,,,
CAGE SPINALXL W26XH10XL60MM X W ANTR CERV INTBDY FUS PEEK,SUP-2310684,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96886,CDM,C9254,HCPCS,0636,RC,00131-1810-67,NDC,,both,5,ML,142.50,92.62,,,,,,,,,,,,,
HC So Mpl Gene Analysis Common Variants,PX-3108133866,CDM,81338,CPT,0310,RC,,,,both,,,441.00,286.65,,,,,,,,,,,,,
GRAFT BNE MPJ SEG 14 MM,SUP-2107947,CDM,C1713,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
CATHETER HD STR 13.5 FRX24 CM SHT TERM 3L MAX BARR TRIO-CT,SUP-2627088,CDM,C1752,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
KIT PT SAFETY MED POSTFREE HIP DISTRACTOR STRL DISP PVT,SUP-2907464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2562.24,1665.46,,,,,,,,,,,,,
ANCHOR SUTURE 4MM KNOTLESS BIOCOMPOSITE WITH ONE 2MM HI FI B,SUP-2824390,CDM,C1713,HCPCS,0278,RC,,,,both,,,2144.93,1394.20,,,,,,,,,,,,,
KIT CATH HEMODIALYSI SAFETY 12FR DIA 20CM 3 LUMAN INDWL BLU,SUP-2613322,CDM,C1751,HCPCS,0278,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
PHENAZOPYRIDINE HCL 200 MG PO TABS,RX-6194,CDM,6370000000,HCPCS,0637,RC,75826-0115-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SPACER SPNL 12MM MAG INDIR DCOMPR STRL SUPERION,SUP-2392700,CDM,C1821,HCPCS,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
SYSTEM ORTH REV MOD TIB TAPE 63 SHT OSS,SUP-2441797,CDM,C1776,CPT,0278,RC,,,,both,,,8831.25,5740.31,,,,,,,,,,,,,
KIT PERICARDCENT PROC HI FLO PGTL CATH CE MRK 6FR,SUP-2303219,CDM,C1729,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
DRILL SURG DOME 35 MM REV PINNACLE,SUP-2453991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1729.51,1124.18,,,,,,,,,,,,,
BIT DRL PROF FOR MIC COMPR FULL THRD SCR,SUP-2122479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM MAND 32 HOLE ANGLED-ANGLED NS,SUP-2486910,CDM,C1713,HCPCS,0278,RC,,,,both,,,6141.46,3991.95,,,,,,,,,,,,,
GRAFT DURA W3XL3IN CLLGN MEM SUTURABLE DURAMATRIX,SUP-2165131,CDM,C1763,HCPCS,0278,RC,,,,both,,,2430.80,1580.02,,,,,,,,,,,,,
SCREW BNE L14MM DOA2.7MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321176,CDM,C1713,HCPCS,0278,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
SCREW BONE L12MM OD2MM MINI CRANIOMAXILLOFACIAL VIT LUHR LP,SUP-2364682,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.17,9.86,,,,,,,,,,,,,
IMPLANT TOE JT PHLANG KGTI SZ 2,SUP-2242675,CDM,C1776,CPT,0278,RC,,,,both,,,6458.98,4198.34,,,,,,,,,,,,,
CANNULA TRACH ID8MM INNR FOR 9MM PERC TB PER FIT PORTEX,SUP-2352318,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.36,325.23,,,,,,,,,,,,,
CATHETER ENDOSCP 180 DEG SPIN ACCS INS5925,SUP-2797902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
GRAFT BNE SUB 20CC 2 4MM GRAN GROWTH FACT ALLGRFT OSTEOAMP,SUP-2138500,CDM,C1713,HCPCS,0278,RC,,,,both,,,8741.45,5681.94,,,,,,,,,,,,,
INSERT TIB SZ 5 THK9MM CRUCE RET BAL SYS,SUP-2314817,CDM,C1713,HCPCS,0278,RC,,,,both,,,3316.78,2155.91,,,,,,,,,,,,,
"HC Total Protein, Urine",PX-3018415600,CDM,84156,CPT,0301,RC,,,,both,,,213.00,138.45,,,,,,,,,,,,,
CATHETER URET 5FR L70CM POLYUR CONE FLX TIP KINK RESIST W/,SUP-2129014,CDM,C1758,HCPCS,0278,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
KIT FASTENER IMPL SEROSAFUSE,SUP-2660819,CDM,C1889,HCPCS,0278,RC,,,,both,,,21964.30,14276.79,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-15882,CDM,J7042,HCPCS,0250,RC,00264-7610-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
SHEATH INTRO TORFLEX 55 DEG L 63 CM DIA 8.5 FR GUIDEWIRE L,SUP-2131518,CDM,C1893,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
KIT ROBOTIC ORTHOPAEDIC X-SCAN PLAN DISP MAZORX,SUP-2266518,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SPHINCTEROTOME ENDO 5.5FR L200CM EXPOSED CUT WIRE VAR SOEH,SUP-2169149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X36 MM ST T15 FOR GRID LCK TI LOQTEQ,SUP-2539611,CDM,C1713,HCPCS,0278,RC,,,,both,,,758.62,493.10,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.038IN TIP L3CM STD PTFE ANG,SUP-2385262,CDM,C1769,HCPCS,0272,RC,,,,both,,,118.44,76.99,,,,,,,,,,,,,
ARTHROSCOPIC KIT 2 MM PIN STRL INION FREEDOMPIN LTX DISP,SUP-2857899,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.18,1096.02,,,,,,,,,,,,,
HC Mra Chest W Contrast,PX-6107155500,CDM,C8909,CPT,0610,RC,,,,both,,,4146.00,2694.90,,,,,,,,,,,,,
BLADE SHV L18CM DIA3.5MM 15DEG AIRWY NONROTATABLE ANG TIP,SUP-2284140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
STENT BILI L50MM 2.83MM DIAM AD ST-2 SOEH TANNENBAUM,SUP-2169328,CDM,C2617,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
ELECTRODE ELECSURG UROLOGY 12-30 DEG BPLR CURET 24-28FR,SUP-2474315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3405.61,2213.65,,,,,,,,,,,,,
HC MRI-Abdomen WO Contrast,PX-6107418100,CDM,74181,CPT,0610,RC,,,,both,,,3764.00,2446.60,,,,,,,,,,,,,
HEAD FEM 40 MM HIP BIOLOX DELT,SUP-2448640,CDM,C1776,CPT,0278,RC,,,,both,,,19386.36,12601.13,,,,,,,,,,,,,
BAR CONN FOR VERTEX RECON SYS XLNK,SUP-2286717,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
GRAFT BNE W14XH25X6XL24MM BICORT COT WDG FOR OSTEOTMY,SUP-2399104,CDM,C1734,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
GRAFT DURA XS 3X1 IN REGEN MTRX DURAGN,SUP-2624231,CDM,C1763,HCPCS,0278,RC,,,,both,,,2695.94,1752.36,,,,,,,,,,,,,
BAND ANNULPLSTY COSGROVE-EDWARDS SZ 26 MM L 57.9 MM OD 33.6,SUP-2214191,CDM,C1713,HCPCS,0278,RC,,,,both,,,8446.91,5490.49,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING 6MM DIA 80CM LEN 70CM GORTX,SUP-2396010,CDM,C1768,CPT,0278,RC,,,,both,,,4097.70,2663.50,,,,,,,,,,,,,
MODEL ANAT MAXILLOMANDIBULAR OSTEOVIEW,SUP-2883673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5121.28,3328.83,,,,,,,,,,,,,
BONE GRAFTING KIT BILATERAL CELLULAR BNE MTRX VIVIGEN MIS,SUP-2740950,CDM,C1713,HCPCS,0278,RC,,,,both,,,15608.44,10145.49,,,,,,,,,,,,,
PLATE BNE T 4.5X148 MM 8 HOLE TI NS LCP,SUP-2569056,CDM,C1713,HCPCS,0278,RC,,,,both,,,2560.10,1664.06,,,,,,,,,,,,,
ROD SPNL ANTR RT CVD SMOOTH S STL 5.0MM DIA 110MM LEN,SUP-2290505,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
CATHETER IRRIGATION 4 FRX65 CM CLINICATH,SUP-2352473,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SYSTEM TEND REP POLYETHYL SS HND WR FRARM SUTURE ANCHR FIBER,SUP-2881062,CDM,C1889,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SCREW BONE LOK 3.5MM DIA 44MML TTNM VRBLE ANGLE SRFX ST,SUP-2586582,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.84,764.30,,,,,,,,,,,,,
CLOTRIMAZOLE 1 % EX SOLN,RX-1768,CDM,6370000000,HCPCS,0637,RC,70954-0036-20,NDC,,both,30,ML,135.00,87.75,,,,,,,,,,,,,
PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG PO TABS,RX-155114,CDM,6370000000,HCPCS,0637,RC,00024-1596-01,NDC,,both,1,UN,9.30,6.04,,,,,,,,,,,,,
I/B II KNEE PSCK II TIB ART SURF SIZE 59 25MM,SUP-2502019,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
BRACE ORTHOPEDIC FIG 8 SHLDR,SUP-2417064,CDM,L3660,HCPCS,0274,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 55CM 6FR ID 2.2MM 0.035IN AQ MULTPURP,SUP-2171148,CDM,C1894,HCPCS,0272,RC,,,,both,,,177.57,115.42,,,,,,,,,,,,,
GRAFT VASC VLV 19 MM AORT ROTATABLE STENT MSTR SER,SUP-2356695,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
HEAD HUM SZ 4 HA COAT SHLDR RESURF COPELAND,SUP-2403988,CDM,C1776,CPT,0278,RC,,,,both,,,9272.42,6027.07,,,,,,,,,,,,,
SHUNT LUMBO PERI 3.6MM HOFF HOLTER,SUP-2243797,CDM,C1889,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
PROSTHESIS OSS BCKT HNDL 0.6X4.5 MM 1 MM TI,SUP-2638178,CDM,L8613,CPT,0278,RC,,,,both,,,713.53,463.79,,,,,,,,,,,,,
DIVALPROEX SODIUM 250 MG PO TBEC,RX-2552,CDM,6370000000,HCPCS,0637,RC,62756-0797-88,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NERVE STIMULATOR KIT PT PRGMR,SUP-2141945,CDM,C1787,HCPCS,0278,RC,,,,both,,,2743.73,1783.42,,,,,,,,,,,,,
ANCHOR SUT VERSALOK ORTHOCORD,SUP-2256593,CDM,C1713,HCPCS,0278,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
GRAFT HUM TISS L W4XL16CM THK0.53-1.02MM DERM TISS MTRX M,SUP-2112996,CDM,Q4116,HCPCS,0636,RC,,,,both,,,6951.96,4518.77,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER LNG 30X11X11 MM BIO AVS UNILIF,SUP-2637046,CDM,C1713,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
DEVICE CSF FLO CTRL SIPHONGUARD,SUP-2243808,CDM,C1729,HCPCS,0272,RC,,,,both,,,2394.50,1556.42,,,,,,,,,,,,,
WASHER ORTH DIA12.7MM S STL RND FOR FIX,SUP-2343055,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.82,294.98,,,,,,,,,,,,,
CONNECTOR SPNL TRNSVRS CROSS CONN,SUP-2415585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.17,707.31,,,,,,,,,,,,,
TUBE VENT PAPARELLA 1.27 PHOSPHORYLCHOLINE COAT SIL 510212C,SUP-2535116,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
INSERT TIB SZ 4 THK8MM ALL POLYETH STBL CEM PFC SIG,SUP-2253818,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
INTRODUCER SHTH 0.032 IN 5 FRX12 CM VEN PERC CATHER,SUP-2355247,CDM,C1894,HCPCS,0272,RC,,,,both,,,33.76,21.94,,,,,,,,,,,,,
HC So Receptor Assay Nonendocrine,PX-3018423866,CDM,84238,CPT,0301,RC,,,,both,,,213.00,138.45,,,,,,,,,,,,,
CLONIDINE HCL 0.3 MG PO TABS,RX-1757,CDM,6370000000,HCPCS,0637,RC,50268-0194-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6-8 MM EPTFE LNG TAPR TW,SUP-2485305,CDM,C1768,CPT,0278,RC,,,,both,,,3442.35,2237.53,,,,,,,,,,,,,
BAND MOLAR LOWER SZ30+ NARROW GEN PURP,SUP-2100462,CDM,D6783,CPT,0278,RC,,,,both,,,13.78,8.96,,,,,,,,,,,,,
RELOAD STPLR REINF 60 MM X THCK W/ TRISTAPLE TECHNOLOGY BLK,SUP-2174668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.88,1106.22,,,,,,,,,,,,,
PLATE BNE W11XL125MM THK33MM 9 H BILAT MTPHSEAL TI LOK COMPR,SUP-2190763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2766.06,1797.94,,,,,,,,,,,,,
PROBE DOPP 8.2MHZ FLO DTECT PNCL,SUP-2321978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
MESH SURG W15XL15CM WHT POLYPR MACROPOROUS NONABSORABLE,SUP-2752157,CDM,C1781,HCPCS,0278,RC,,,,both,,,264.20,171.73,,,,,,,,,,,,,
DRESSING WND MTRX 7X3 IN,SUP-2106518,CDM,Q4166,HCPCS,0636,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
HANDPIECE ULTRSNC SYS 5 DEG L 180 MM M/F TIP EXT CRV DRVR,SUP-2883740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2931.69,1905.60,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 1-10 MM 10 CC CANC,SUP-2165596,CDM,C1889,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE L112MM 6 H NONSTERILE R ANTEROMEDIAL DST TIB S,SUP-2177670,CDM,C1713,HCPCS,0278,RC,,,,both,,,5134.50,3337.42,,,,,,,,,,,,,
GUIDEWIRE ORTH L 600 MM DIA 3 MM BALL TIP STRL,SUP-2930408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
LEAD PLEXA S 60,SUP-2418500,CDM,C1777,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
INTRODUCER SHTH L40CM OD0157IN ID0130IN TIP DIA012IN STD CRV,SUP-2356333,CDM,C1892,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER HD MAXIMAL BARR TY 035 12 FRX20 CM DRY TURBO-FLO HD,SUP-2759847,CDM,C1752,HCPCS,0278,RC,,,,both,,,475.62,309.15,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 45 CM DIA 4-7 MM EPTFE CARBON,SUP-2761418,CDM,C1768,CPT,0278,RC,,,,both,,,3258.69,2118.15,,,,,,,,,,,,,
KIT PICC IMTERMEDIATE SAFT MST 4FR SGL LUMN W/45CM WIRE,SUP-2117119,CDM,C1751,HCPCS,0278,RC,,,,both,,,407.51,264.88,,,,,,,,,,,,,
HC Hdr Vaginal Cyl Insertion,PX-3335715600,CDM,57156,CPT,0333,RC,,,,outpatient,,,2400.00,1560.00,,,,,,,,,,,,,
RXG PLATE STR 8 HOLE T06MM,SUP-2681862,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.28,420.73,,,,,,,,,,,,,
KIT HUM COMP SZ 5 6 EL VIVACIT E ARTC NEXEL,SUP-2402661,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE 7 H L CNDYL TI FOR 2MM SCR MOD HND SYS,SUP-2191064,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.19,1479.52,,,,,,,,,,,,,
APPLIER CLIP 725INL SPRING,SUP-2672287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.77,231.90,,,,,,,,,,,,,
APPLIER CLIP 6.75IN ANEURYSM MINI FINGER TIP GRIP BAYONET RE,SUP-2826147,CDM,C1889,HCPCS,0278,RC,,,,both,,,4648.96,3021.82,,,,,,,,,,,,,
MESH HERN W18XL24CM THK2MM EPTFE PTCH RECT 2 SIDE FOR,SUP-2126080,CDM,C1781,HCPCS,0278,RC,,,,both,,,4882.70,3173.75,,,,,,,,,,,,,
PLATE BNE L MINI 2-2.5X1 MM LT FOR SCR 9 HOLE TLTS LCK TI,SUP-2458650,CDM,C1713,HCPCS,0278,RC,,,,both,,,1009.92,656.45,,,,,,,,,,,,,
PLATE BNE L167MM 10 H BROAD COMPR RIG FOR 4.5MM SCR L FRAG,SUP-2411417,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 5 FR L 7 CM SS PLAT,SUP-2170535,CDM,C1894,HCPCS,0272,RC,,,,both,,,77.50,50.37,,,,,,,,,,,,,
TUBE CHST SET 8 FRX18 CM 1 LUMEN 3 SIDEPRT THAL-QUICK,SUP-2760091,CDM,C1729,HCPCS,0272,RC,,,,both,,,439.07,285.40,,,,,,,,,,,,,
CUP FEM OD39XID22MM BPLR,SUP-2359148,CDM,C1776,CPT,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 8CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2674041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,407.89,265.13,,,,,,,,,,,,,
STAPLER SKIN AUTOSUT,SUP-2155526,CDM,C1889,HCPCS,0278,RC,,,,both,,,1280.59,832.38,,,,,,,,,,,,,
EXTERNAL FIXATION SET ARTICULATED ANK PVC FREE STRL XCALIBER,SUP-2646340,CDM,C1713,HCPCS,0278,RC,,,,both,,,11344.57,7373.97,,,,,,,,,,,,,
PLATE BNE L116MM 4 H ST R MED DST TIB S STL LOK COMPR FOR,SUP-2185579,CDM,C1713,HCPCS,0278,RC,,,,both,,,4939.09,3210.41,,,,,,,,,,,,,
"HC Peripheral Art Disease Rehab, Ea",PX-9409366800,CDM,93668,CPT,0940,RC,,,,outpatient,,,336.00,218.40,,,,,,,,,,,,,
LINER ACET 28X46-48 MM HIP ALUMINA CERM REFLECTION,SUP-2434786,CDM,C1776,CPT,0278,RC,,,,both,,,5532.68,3596.24,,,,,,,,,,,,,
CATHETER URTRL 48FR DIA 70CML PLSTC OPEN ENDED FLXBLE TIP W,SUP-2730109,CDM,C1758,HCPCS,0278,RC,,,,both,,,132.16,85.90,,,,,,,,,,,,,
FIBER LSR FLEXIVA PULSE 910,SUP-2717690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2289.03,1487.87,,,,,,,,,,,,,
MESH SURG W26XL34CM THK1MM EPTFE CORDUROY SURF CNFRM TEXT,SUP-2395336,CDM,C1781,HCPCS,0278,RC,,,,both,,,6314.54,4104.45,,,,,,,,,,,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-125413,CDM,J3490,HCPCS,0636,RC,00115-1694-49,NDC,,both,1,UN,862.50,560.62,,,,,,,,,,,,,
COLLAR CERV FIRM DENS W CHIN SUPP AD CNTOUR W COT CVR SERP,SUP-2276598,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.30,6.69,,,,,,,,,,,,,
PLATE BNE L93MM THK3MM 6 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185334,CDM,C1713,HCPCS,0278,RC,,,,both,,,1587.74,1032.03,,,,,,,,,,,,,
MESH SURG W6XL8IN ELLIPSE SEPRA TECHNOLOGY VENTRALIGHT,SUP-2125908,CDM,C1781,HCPCS,0278,RC,,,,both,,,2047.28,1330.73,,,,,,,,,,,,,
BUTTON NSL SEPT LG 7CM SIL STRL,SUP-2381502,CDM,C1889,HCPCS,0278,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L110CM STD LO PRSS 2PC VLV,SUP-2243849,CDM,C1889,HCPCS,0278,RC,,,,both,,,9115.48,5925.06,,,,,,,,,,,,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG PO TABS,RX-18289,CDM,6370000000,HCPCS,0637,RC,29300-0189-13,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SECUREMENT KIT FOR BLD PMP,SUP-2152644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP,SUP-2435537,CDM,L0450,HCPCS,0274,RC,,,,both,,,460.07,299.05,,,,,,,,,,,,,
JOINT FNGR 30 MP SIL,SUP-2852869,CDM,C1776,CPT,0278,RC,,,,both,,,4812.46,3128.10,,,,,,,,,,,,,
IMPLANT BIA300 3 MM W ABUTMENT 6 MM,SUP-2858175,CDM,L8690,HCPCS,0278,RC,,,,both,,,8315.94,5405.36,,,,,,,,,,,,,
PROBE ARTHSCP OD3MM BLK ABLAT MPLR RF INTEGR VULCAN DYONICS,SUP-2341028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
GRAFT HUM TISS L155MM DIA4 5MM LAT ANK TEND SUTURED FRZN,SUP-2264638,CDM,C1713,HCPCS,0278,RC,,,,both,,,4295.83,2792.29,,,,,,,,,,,,,
DRILL HND BUNNELL 5/32 IN CANN LIGHTWEIGHT GEAR JCBS CHK KEY,SUP-2872463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2340.15,1521.10,,,,,,,,,,,,,
WIRE TRCR 11M X 100MM SGL END,SUP-2392813,CDM,C1769,HCPCS,0272,RC,,,,both,,,80.07,52.05,,,,,,,,,,,,,
BLADE SHAVER SERRATED STD 75 DEG 2.9 MM N DSTL SUCTION STRL,SUP-2638419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.29,294.64,,,,,,,,,,,,,
FORCEP RETRV ALLIGATOR 5.2 FRX65 CM TOOTH SINGLE JAW,SUP-2835705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,969.04,629.88,,,,,,,,,,,,,
HC Image Cath Fluid Peri/Retro,PX-3614940600,CDM,49406,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
STIMULATOR COCHLEAR BILATERAL AD 1 STG BAHA,SUP-2165011,CDM,L8614,HCPCS,0278,RC,,,,both,,,27035.40,17573.01,,,,,,,,,,,,,
BOLT EXT FIX EYE NS,SUP-2863451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.59,211.63,,,,,,,,,,,,,
COMPONENT FEM KNEE POST STABILIZING UNISX REV CEM STEM LT RT,SUP-2199737,CDM,C1776,CPT,0278,RC,,,,both,,,17226.04,11196.93,,,,,,,,,,,,,
BIT DRL CANLT W/AO 2.0MM INTOSS FXTN SYS,SUP-2400074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.32,383.71,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN STIFF SHFT ANG HYDRPHLC,SUP-2302968,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
DRILL SURG 9 MM IM HI PERF PATHWY,SUP-2453508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,794.42,516.37,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 4 MM 94 MM RND CRV HI SPD SS VISAO,SUP-2628980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,765.06,497.29,,,,,,,,,,,,,
IMPLANT MP SZ 20 30DEG SIL ELASTMR PREFLEXED FLX HNG PROS,SUP-2244438,CDM,L8630,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
VALVE FACEPLT BODY AND DIAPH ATSV II,SUP-2242325,CDM,L8501,HCPCS,0274,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE SPNL 4 LEVEL 67 MM ANTR CERV ARCHON ACP,SUP-2563564,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
RETRACTOR PED OP OPN 3 1 2 89CM BALF,SUP-2162002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1179.35,766.58,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM BAL L15MM OD5MM DIL RX MRAIL,SUP-2140566,CDM,C1725,HCPCS,0272,RC,,,,both,,,1168.68,759.64,,,,,,,,,,,,,
BEARING TIB CR 63X14 MM KNEE INSRT LCK VANGUARD MONO-LOCK,SUP-2408141,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
LEAD PACE L100CM LT COR VEN POLYUR PLAT SIL IRIDIUM OXIDE,SUP-2141485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BENDAMUSTINE HCL (VIVIMUSTA) 100 MG/4ML IV SOLN,RX-4082825,CDM,J9056,HCPCS,0636,RC,24338-0270-01,NDC,,both,4,ML,9428.40,6128.46,,,,,,,,,,,,,
SNARE VASC MIC ELITE L 180 CM DIA 0.014 IN LOOP DIA 7 MM,SUP-2763474,CDM,C1773,HCPCS,0272,RC,,,,both,,,8738.62,5680.10,,,,,,,,,,,,,
TRIAL KNEE DIA38MM PAT CONVENTIONAL MEDIALIZED DOME DRL,SUP-2436174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
GRAFT BNE BLOCK SM 13X13 MM CANC,SUP-2766758,CDM,C1713,HCPCS,0278,RC,,,,both,,,2655.66,1726.18,,,,,,,,,,,,,
PROBE ENDOSCP BPLR 350 CM,SUP-2308205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.93,288.55,,,,,,,,,,,,,
PATCH CV W3XL6CM THK05MM PTFE STR STD WALL NONTAPERED,SUP-2395325,CDM,C1768,CPT,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
K WIRE FIX L100MM DIA0.9MM S STL,SUP-2389798,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
CATHETER EP L115CM OD7FR SPC 2-8-2MM BLU D CRV DECAPOLAR,SUP-2248704,CDM,C1732,HCPCS,0272,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
COIL EMB L 6 CM DIA1.5 MM PLAT TUNGSTEN NEUROVASCULAR LG VOL,SUP-2934022,CDM,C1889,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
SET INT FIX LEG L8MM DRL 1.5MM WIRE 1.2MM BACKSPAN 8MM,SUP-2418147,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.14,1736.89,,,,,,,,,,,,,
GRAFT TISSUE HALO PERICARDIUM,SUP-2844927,CDM,V2785,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
NEEDLE REPROC TRANSSEPTAL AD 18G 71CM 30DEG BVL BRK-1 XS CV S,SUP-2877988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
STEM FEM PRSS FT 16.25 40 MM OFFSET 34X133 MM HIP PROVIDENT,SUP-2390364,CDM,C1776,CPT,0278,RC,,,,both,,,24649.00,16021.85,,,,,,,,,,,,,
PLATE BONE 12 H TI STR LCK COMPR BILAT NEUT LO PROF FOR,SUP-2319665,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X289 MM 22 HOLE SS LCP,SUP-2569346,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.81,411.98,,,,,,,,,,,,,
CANNULA KYPHOPLASTY BVL TIP W/ INTRO PREMIER AFFIRM,SUP-2232189,CDM,C1894,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
CATHETER US INT CARD ECHOCARDIOGRAPHY VIEWFLEX +,SUP-2356603,CDM,C1759,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
MESH HERN W26XL34CM THK1MM EPTFE 2 SURF ANTIMIC PROTCT GORE,SUP-2395344,CDM,C1781,HCPCS,0278,RC,,,,both,,,6584.58,4279.98,,,,,,,,,,,,,
ROD SPNL POST RT PRECUT SMOOTH HRD TI ALLOY OD6MM L35MM,SUP-2414708,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.74,695.98,,,,,,,,,,,,,
MESH HERN OVL 6X4 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855270,CDM,C1781,HCPCS,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
COMPONENT CARPOMETACARPAL FIX SYS CABLEFIX XPRESS,SUP-2476449,CDM,C1713,HCPCS,0278,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
TUBE VENT 1.27 MM 3 MM BAXTER BVL BOB TAPR FLROPLAS,SUP-2535149,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.47,26.31,,,,,,,,,,,,,
HC Balo Angiop Ctr Dialysis Seg,PX-3613690700,CDM,36907,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
SYSTEM CLP DEL MITRACLIP NTR L 109.5 CM DIA16 FR BALLOON L,SUP-2102259,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
RETRACTOR SURG L8CM DIA26MM TB DISP FOR MICRODISCECTOMY,SUP-2293061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1109.68,721.29,,,,,,,,,,,,,
OPIUM 10 MG/ML (1%) PO TINC,RX-99771,CDM,6370000000,HCPCS,0637,RC,09999-9908-42,NDC,,both,0.6,ML,10.30,6.69,,,,,,,,,,,,,
PLATE BNE SM TI MANDIBULAR 3D PRNT NS DISP ACCUPLATE,SUP-2934959,CDM,C1713,HCPCS,0278,RC,,,,both,,,24391.52,15854.49,,,,,,,,,,,,,
BLADE RETRACTOR HOHMN 12 CMX29 MM OLIF,SUP-2627604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2436.36,1583.63,,,,,,,,,,,,,
BRACE WR ADULTXL LT INSTABILITY INJ,SUP-2198769,CDM,L3809,HCPCS,0272,RC,,,,both,,,69.39,45.10,,,,,,,,,,,,,
JOINT TOE 14 MM STR KT DYNANITE PIP,SUP-2432009,CDM,C1713,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
CATHETER EP JSN 2-5-2MM SPC 5FRX110CM TORQR,SUP-2281820,CDM,C1730,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.14 MM INNR FLANGE DIA 3.5 MM FLROPLAS,SUP-2901921,CDM,L8699,HCPCS,0278,RC,,,,both,,,86.13,55.98,,,,,,,,,,,,,
POST ORTHOPEDIC 4 HOLE W/ 12MM BOLT TRUELOK,SUP-2316112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
COMPONENT FEM TROCHANTERIC KNEE MOD OSSEO TI OSS,SUP-2441740,CDM,C1776,CPT,0278,RC,,,,both,,,14313.69,9303.90,,,,,,,,,,,,,
PLATE BNE L35MM 4 H MAXILLOFACIAL ORAL TI CRESC LIMIT CNTCT,SUP-2191401,CDM,C1713,HCPCS,0278,RC,,,,both,,,2582.65,1678.72,,,,,,,,,,,,,
CAGE GLENOID SHOULDER BETA EQUINOXE LG CEMENTED,SUP-2880193,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC THRD PEDICULAR FIX SYS THRESHOLD,SUP-2354644,CDM,C1769,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 20 PED W/ SHUNT ASST AND BUR H RESVR,SUP-2108749,CDM,C1729,HCPCS,0272,RC,,,,both,,,8990.95,5844.12,,,,,,,,,,,,,
STEM HUM OD4MM MIC CO CHROM SHLDR REV PRI CEM PRESSFIT,SUP-2404540,CDM,C1776,CPT,0278,RC,,,,both,,,14067.20,9143.68,,,,,,,,,,,,,
GRAFT HUM TISS XL W15XL24CM THK0.7-1.4MM THN ACELLULAR,SUP-2307608,CDM,Q4128,HCPCS,0636,RC,,,,both,,,18996.37,12347.64,,,,,,,,,,,,,
PLATE BNE L86MM 4 H ST R LAT DST FIBULAR S STL LOK COMPR,SUP-2177414,CDM,C1713,HCPCS,0278,RC,,,,both,,,1898.82,1234.23,,,,,,,,,,,,,
WASHER ORTH 3.5-4 MM FOR 2.7 MM INSTRUMENT NS LTX,SUP-2857168,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
PROBE SURG KARLIN 9.5 IN LUMBAR SQ HNDL M-DISC,SUP-2475655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1071.18,696.27,,,,,,,,,,,,,
SCREW BNE LCK FOR IM NAIL RACK,SUP-2789519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2115.07,1374.80,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE W/ INS8302 SYS INS4500 CATH SET,SUP-2883669,CDM,C1729,HCPCS,0272,RC,,,,both,,,905.95,588.87,,,,,,,,,,,,,
FORCEPS BX L230CM DIA32MM BLU ALGTR CUP NDL FEN DISPOSABLE,SUP-2313108,CDM,C1713,HCPCS,0278,RC,,,,both,,,52.94,34.41,,,,,,,,,,,,,
LIGATOR ENDOSCP TRIG CRD L122CM SCP DIA9.5-13MM ACC CHN,SUP-2169392,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
HC So Urinary Stone Analysis,PX-3018236566,CDM,82365,CPT,0301,RC,,,,both,,,181.00,117.65,,,,,,,,,,,,,
SPLINT WRST XL L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276628,CDM,L3809,HCPCS,0272,RC,,,,both,,,21.48,13.96,,,,,,,,,,,,,
AMLODIPINE BESYLATE 5 MG PO TABS,RX-9071,CDM,6370000000,HCPCS,0637,RC,00904-6370-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE 3MM MAXILLOFACIAL LT,SUP-2372897,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
CATHETER IV SINGLE LEMEN 4 FR DOT KT GIVA PC NG POWERMIDLINE,SUP-2626737,CDM,C1751,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
BALLOON DIL 12FR DIA4MM 0.035IN DISP FOR STRICTURE OF BILI,SUP-2170668,CDM,C1726,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
"HC RBC Antigen Typing,Genotyping 12 Blood Group System Genes",PX-3100282066,CDM,0282U,CPT,0310,RC,,,,both,,,830.00,539.50,,,,,,,,,,,,,
RELOAD STPL OPN H2.5MM CLOSE H1MM VASC THN TISS WHT 6 ROW,SUP-2220064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1235.50,803.07,,,,,,,,,,,,,
SHEATH ENDOSCP CYSTOURETHROSCOPE 21 FRX7 MM CONT FLO,SUP-2313978,CDM,C1894,HCPCS,0272,RC,,,,both,,,3570.31,2320.70,,,,,,,,,,,,,
PROBE ES L75MM OD17GA THERACOOL,SUP-2237208,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
CATHETER GUID ZIPLINE ID 0.088 IN HYDRPHLC VAR STIFFNESS,SUP-2929970,CDM,C1757,HCPCS,0272,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
CATHETER URET 10FR 2 LUMN,SUP-2313814,CDM,C1726,HCPCS,0272,RC,,,,both,,,144.13,93.68,,,,,,,,,,,,,
SIDEKICK  HALF PIN5X50 TIN 180MM LNG,SUP-2499229,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
PIN CLAMP 3 HOLE,SUP-2853454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1906.67,1239.34,,,,,,,,,,,,,
ANCHOR SUT DIA2.3MM BLU COBRAID CVD W/ NO2 ULTRABRAID SUT,SUP-2341133,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
COIL VASC AZUR CX L 16 CM DIA 5 MM MICROCATHETER 0.018 IN,SUP-2385234,CDM,C1889,HCPCS,0278,RC,,,,both,,,2827.57,1837.92,,,,,,,,,,,,,
PASSER SUT 90DEG STR NIT WIRE LOOP 2 FIBERSTICK MFIL SUT,SUP-2121958,CDM,C1769,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-4502365500,CDM,23655,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
SCREW SPNL L6.5MM DIA3MM 0DEG TI SURG MESH FOR THOR AND LUM,SUP-2256180,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
PLATE BNE L220MM 9 H L PROX TIB TI NONCOMPRESSION FOR 4.5MM,SUP-2190735,CDM,C1713,HCPCS,0278,RC,,,,both,,,4065.64,2642.67,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12X14X7 MM FD PARL ACF,SUP-2736817,CDM,C1713,HCPCS,0278,RC,,,,both,,,3378.33,2195.91,,,,,,,,,,,,,
REAMER SURG 10MM FLEX LO PROF,SUP-2121255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2126264,CDM,C1781,HCPCS,0278,RC,,,,both,,,19936.49,12958.72,,,,,,,,,,,,,
GRAFT HUM TISS W7XL10CM THK1MM PROC DERM CLLGN RECTANG,SUP-2126259,CDM,C1781,HCPCS,0278,RC,,,,both,,,4906.25,3189.06,,,,,,,,,,,,,
AMMONIA AROMATIC IN INHA,RX-439,CDM,6370000000,HCPCS,0637,RC,09999-9910-47,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 15 CC CRUSH CANC,SUP-2435351,CDM,C1889,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
COIL EMB L8CM DIA2MM SFT HELI DETACH GDC 18,SUP-2365701,CDM,C1889,HCPCS,0278,RC,,,,both,,,3057.42,1987.32,,,,,,,,,,,,,
PLATE L FUSION VA LCP 2.4/2.7MM SHRT LT TI STRL,SUP-2546991,CDM,C1713,HCPCS,0278,RC,,,,both,,,3334.99,2167.74,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN L 115CM 4-4-4,SUP-2248592,CDM,C1732,HCPCS,0272,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
HC Repair 2 Leads for Dual Chambr,PX-4813322000,CDM,33220,CPT,0481,RC,,,,both,,,12140.00,7891.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OPTA LP L 80 CM BALLOON L 40 MM DIA 6 MM,SUP-2156111,CDM,C1725,HCPCS,0272,RC,,,,both,,,509.25,331.01,,,,,,,,,,,,,
STENT URET L 22 CM DIA 6 FR PERCFLX 2 PIGTL FIRM DUROMETER,SUP-2138866,CDM,C2617,HCPCS,0278,RC,,,,both,,,268.69,174.65,,,,,,,,,,,,,
IMPLANT OSS L2.75MM DIA1.17MM SHT INCUS STAP HA FULL CANN,SUP-2313671,CDM,L8613,CPT,0278,RC,,,,both,,,1160.80,754.52,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.177X9 IN RND END SS NS STEINMANN,SUP-2791371,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.65,28.37,,,,,,,,,,,,,
CARTRIDGE GRFT PREP HEALOS CELLECT,SUP-2255624,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
GRAFT HUM TISS W20XL100MM CORT BONE FEM STRP FRZ DRY,SUP-2115984,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BONE L29MM 4 H BILAT MAXILLOFACIAL MAND ORAL TI STR,SUP-2191324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.41,847.22,,,,,,,,,,,,,
SPLINT ORTHOT CUST HALLUS VALGUS NT DYN,SUP-2435710,CDM,L3100,HCPCS,0274,RC,,,,both,,,122.49,79.62,,,,,,,,,,,,,
DONALDSON VENT TUBE 114MM ID BLUE FLUOROPLASTIC 10 PACK,SUP-2695104,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.58,14.68,,,,,,,,,,,,,
SPACER SPNL 7 DEG 14X13X8 MM INTBDY SHORELINE RT,SUP-2709647,CDM,C1821,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
SCREW BONE L52MM DIA4.9MM NONSTERILE CORT S STL,SUP-2186392,CDM,C1713,HCPCS,0278,RC,,,,both,,,535.43,348.03,,,,,,,,,,,,,
BIT REPROC DRL PILOT LNG AO FIT 4MM,SUP-2653028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.13,256.18,,,,,,,,,,,,,
STEM FEM CEM -5 MM 5 9X145 MM 25 MM HIP CRV REDUC NK TAPR,SUP-2376609,CDM,C1776,CPT,0278,RC,,,,both,,,14962.73,9725.77,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 120 CM DIA27-45 MM,SUP-2120071,CDM,C1773,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BNE STR LCK,SUP-2477810,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.43,538.48,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.5MM SELF DRL SELF CNTR AX STBL FOR CRAN 5PK,SUP-2363858,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.06,131.34,,,,,,,,,,,,,
HC Repl Duo/Jeju Tube Under Fluor|TECHNICAL COMPONENT,PX-4504945100,CDM,49451,CPT,0450,RC,,,TC,both,,,1056.00,686.40,,,,,,,,,,,,,
DEVICE COMBINATION TISS FIX BIOCOMP 4 SWIVELOCK FIBERTAK,SUP-2882316,CDM,C1713,HCPCS,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
INSERT TIB SZ 2 THK175MM CRUCE SUB STBL MOD PFC,SUP-2254012,CDM,C1776,CPT,0278,RC,,,,both,,,4261.61,2770.05,,,,,,,,,,,,,
CATHETER DRAINAGE MP 10 FR NAVARRE,SUP-2128424,CDM,C1729,HCPCS,0272,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
STEM HUM 5X100 MM LT SHLDR DISCOVERY,SUP-2136215,CDM,C1776,CPT,0278,RC,,,,both,,,9282.47,6033.61,,,,,,,,,,,,,
GRAFT HUM TISS DIA16 MM AMNION PLCNTA MEMBRN 2 LAYR PROTCT,SUP-2913281,CDM,C1762,CPT,0278,RC,,,,both,,,3482.26,2263.47,,,,,,,,,,,,,
HEAD HUM SZ 5 HA COAT SHLDR RESURF COPELAND,SUP-2403989,CDM,C1776,CPT,0278,RC,,,,both,,,13583.64,8829.37,,,,,,,,,,,,,
BIT DRL TWST 1.4X54 MM 12 MM 5 HOLE JCBS CHK END W/ STP,SUP-2366407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.07,256.15,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 8X8X8 MM FD SPNG CANC READIGRAFT BLX,SUP-2740981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1134.51,737.43,,,,,,,,,,,,,
ANCHOR SUTURE SUPER WITH 5MM HI-FI SUTURE REVO,SUP-2828534,CDM,C1713,HCPCS,0278,RC,,,,both,,,789.62,513.25,,,,,,,,,,,,,
PLATE BNE EXTRA-ARTICULAR 3.5X266 MM DSTL HUM 12 HOLE TI LCP,SUP-2432241,CDM,C1713,HCPCS,0278,RC,,,,both,,,5743.75,3733.44,,,,,,,,,,,,,
INTRODUCER SHTH 22FR L25CM 0.035IN HEMSTAS VLV SIDEPRT 2,SUP-2355622,CDM,C1894,HCPCS,0272,RC,,,,both,,,88.71,57.66,,,,,,,,,,,,,
SUTURE ANCHR 65 MM CROSSFT SUT ANCHR W TWO NUMBER 2 HI FI,SUP-2167101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1509.37,981.09,,,,,,,,,,,,,
PLATE BONE L152MM 12 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349640,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.43,882.98,,,,,,,,,,,,,
GRAFT HUM TISS H6MM CANC PLUG CORT RNG CERV SPCR FIBULAR WDG,SUP-2293797,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
HAMMERTOE IMPL SZ 2,SUP-2397609,CDM,C1776,CPT,0278,RC,,,,both,,,2031.58,1320.53,,,,,,,,,,,,,
PLATE BONE SM UNIV 6 H VAR DEG W LO N COMPR BARBELL,SUP-2363610,CDM,C1713,HCPCS,0278,RC,,,,both,,,940.78,611.51,,,,,,,,,,,,,
GRAFT SFT TISS CRV LG 10X22 CM RECON TISS MTRX STRATTICE,SUP-2460257,CDM,Q4130,HCPCS,0636,RC,,,,both,,,8098.06,5263.74,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR W 1.1 CM 2 CHANNEL ADAPTIVESTIM,SUP-2883485,CDM,C1767,HCPCS,0278,RC,,,,both,,,49612.00,32247.80,,,,,,,,,,,,,
CATHETER DIAG L 10 CM PLAS MEWISSEN INFUSION MPEN-18 STRL,SUP-2140126,CDM,C1725,HCPCS,0272,RC,,,,both,,,236.54,153.75,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL III W 5.94 X H 7.75 CM D,SUP-2149224,CDM,C1895,HCPCS,0275,RC,,,,both,,,82977.64,53935.47,,,,,,,,,,,,,
BIT DRL L150MM DIA2MM ST CANN QUIK CPL NONRADIOPAQUE W/O,SUP-2187218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1180.26,767.17,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM HELIX SLDE GDS,SUP-2525461,CDM,C1768,CPT,0278,RC,,,,both,,,1968.43,1279.48,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX5 TTNM 14 TBLR F2.7MM SCREW UNV,SUP-2721009,CDM,C1713,HCPCS,0278,RC,,,,both,,,796.93,518.00,,,,,,,,,,,,,
RING EXT FIX ID180MM ALUM FULL W/ 7 H MSTR TAB FOR ILIZ TAY,SUP-2342965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7629.73,4959.32,,,,,,,,,,,,,
SUPPORT WR L AD RT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324890,CDM,L3931,HCPCS,0274,RC,,,,both,,,47.51,30.88,,,,,,,,,,,,,
ELECTRODE ENDO MPLR BALL ELECTRD DISP 22FR,SUP-2361453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.45,273.29,,,,,,,,,,,,,
BIT DRILL FOR 2.8MM SCREW DISP,SUP-2864790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
HEAD HUM 44X16 MM SHLDR STEM FREE SIDUS,SUP-2440779,CDM,C1776,CPT,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
ELECTRODE ELECSURG PLUNG CLIP-ON DISP,SUP-2523883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
GRAFT BNE WDG THCK ASEP IL CREST,SUP-2742342,CDM,C1713,HCPCS,0278,RC,,,,both,,,4360.68,2834.44,,,,,,,,,,,,,
ANCHOR SUTURE DIA1.4 MM SUTURE 1.2 MM HA COAT 1 STRND XBRAID,SUP-2908699,CDM,C1713,HCPCS,0278,RC,,,,both,,,1770.96,1151.12,,,,,,,,,,,,,
MESH HERN W45XL10CM POLYPR PRESHAPED HERN ABD G STD MFIL,SUP-2126050,CDM,C1781,HCPCS,0278,RC,,,,both,,,209.44,136.14,,,,,,,,,,,,,
STRUT HEXAPOD SM,SUP-2491201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HC Aspiration of Bladder,PX-3615110100,CDM,51101,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
ANTICOAGULANT SODIUM CITRATE 4 GM/100ML VI SOLN,RX-91391,CDM,2500000003,HCPCS,0250,RC,00942-9504-10,NDC,,both,500,ML,57.50,37.37,,,,,,,,,,,,,
BIT DRL DIA1.8MM LNG AO QUIK CONN DISP,SUP-2344031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,694.44,451.39,,,,,,,,,,,,,
KIT INSTRUMENT SPINAL SPINEJACK 5MM EXPANSION,SUP-2876963,CDM,C1062,HCPCS,0278,RC,,,,both,,,4359.36,2833.58,,,,,,,,,,,,,
CATHETER DIL L 135 CM DIA 3.3 FR BALLOON L 2 CM DIA 4 MM,SUP-2139578,CDM,C1725,HCPCS,0272,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRICING PERSONA,SUP-2212485,CDM,C1776,CPT,0278,RC,,,,both,,,13659.00,8878.35,,,,,,,,,,,,,
LINER ACET 2 MOBILITY H 50 MM PROV G7,SUP-2441322,CDM,C1776,CPT,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
SCREW SPNL TRANS FACET INT FIXATION SYSTEM MARINER CAP SP,SUP-2708144,CDM,C1821,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
BLADE ARTHSCP SHV L180MM DIA4MM LNG ANG HIP CUT TOMCAT FRMLA,SUP-2362529,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1165.07,757.30,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM CRYOPRESERVED AMNIO MEM LO PROF FOR,SUP-2116286,CDM,Q4148,HCPCS,0636,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
PEG BONE FXTN L24MM D2.5MM FLLY THRDD ALPS HAND FRAC SSTM,SUP-2458480,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
MESH 45IN PTCH MK W POSIFLEX CIR W STRP AND PRESHAPED,SUP-2126068,CDM,C1781,HCPCS,0278,RC,,,,both,,,315.57,205.12,,,,,,,,,,,,,
KIT LD INTRO SAFSHTH L 13 CM DIA11 FR NDL 18 GA10 ML,SUP-2148863,CDM,C1894,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
BUTTON SUT L12MM DIA2.6MM TI FOR TENS SLDE TECH DST BICEPS,SUP-2121663,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
BRACE KNEE CUST W/ ADJ HNG FUSIONXT OA,SUP-2150833,CDM,L1810,HCPCS,0272,RC,,,,both,,,1709.73,1111.32,,,,,,,,,,,,,
INSERTER SURG FOR ABUTMENT BAHA,SUP-2164942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
BIT DRL QC 2.8X135 MM 45 MM CALIB STRL,SUP-2563757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.65,249.37,,,,,,,,,,,,,
MOLD FEM STEM L155MM DIA15MM HIP SIL W/ S STL REINF,SUP-2408612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2876.24,1869.56,,,,,,,,,,,,,
HC Ins Icd Gen Only Exist Mult Ld,PX-3613323100,CDM,33231,CPT,0361,RC,,,,outpatient,,,107193.00,69675.45,,,,,,,,,,,,,
ARCH EXT FIX 200-220 MM PLNTR,SUP-2898493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA20 GA NDL DIA18 GA CE18HKN ACCU BLOC,SUP-2936632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,73.44,47.74,,,,,,,,,,,,,
PLATE HOLDER FOR MINIMALLY INVASIVE PLATING,SUP-2548451,CDM,C1713,HCPCS,0278,RC,,,,both,,,3981.11,2587.72,,,,,,,,,,,,,
BLADE SHAVER 3.5 MM PLAT DYONICS INCISIOR +,SUP-2849164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.55,219.41,,,,,,,,,,,,,
PLATE BNE W23XL54MM THK2MM 13 H R DST RAD TI ADAPTIVE FOR,SUP-2267975,CDM,C1713,HCPCS,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
MATRIX BIO L 7 X W 8 CM SZ 101 SQCM FISH SKIN DERMAL,SUP-2909202,CDM,Q4158,HCPCS,0636,RC,,,,both,,,6521.15,4238.75,,,,,,,,,,,,,
SCREW SPNL N CANN 8.5X35 MM FOR PEEK ROD HA CD HORZ,SUP-2630797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
FIBER LSR UROLOGICALXPS GREENLIGHT,SUP-2225712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3337.82,2169.58,,,,,,,,,,,,,
SCREW BNE ST 2.7X16 MM CORTICAL PERI ARTC,SUP-2177058,CDM,C1713,HCPCS,0278,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
MIXER BNE CEM 120GM 3 MIX OPTVAC VAC SYS 60050120] ENCORE MEDICAL - DJO SURGICAL],SUP-2217405,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BNE L 265 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 22 HL NS,SUP-2937392,CDM,C1713,HCPCS,0278,RC,,,,both,,,8419.91,5472.94,,,,,,,,,,,,,
PERFORATOR SURG AD AND PED OD13MM ID9MM DISP DGR-II,SUP-2106555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
DEVICE COAG 3 CM GUID 6140 EPISENSE,SUP-2424448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
"HC Smear,Afb",PX-3008720600,CDM,87206,CPT,0300,RC,,,,both,,,228.00,148.20,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 100 CM DIA10 MM POLYESTER BOV CLLGN,SUP-2265898,CDM,C1768,CPT,0278,RC,,,,both,,,1500.07,975.05,,,,,,,,,,,,,
SHEATH INTRO PRELUDE PRO L 11 CM DIA 4 FR POLYPRO RED,SUP-2303250,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.38,17.15,,,,,,,,,,,,,
BUR SURG TAPR 1.1X6.4 MM 7 CM SM BOR MIDAS REX 8 LEGEND,SUP-2664805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,293.65,190.87,,,,,,,,,,,,,
HC X-Ray Exam Bil Hips W/Pelvis 3-4 Views,PX-3207352200,CDM,73522,CPT,0320,RC,,,,both,,,853.00,554.45,,,,,,,,,,,,,
TITANIUM END CAP FOR TITANIUM ELASTIC NAIL3.0-4.0MM-STERILE,SUP-2549738,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 60 CM DIA 7 MM EPTFE CARBON PERIPH STR,SUP-2126812,CDM,C1768,CPT,0278,RC,,,,both,,,3038.86,1975.26,,,,,,,,,,,,,
PLATE BNE L277MM 10 H ST PROX FEM S STL HK LO PROF LOK,SUP-2177029,CDM,C1713,HCPCS,0278,RC,,,,both,,,5319.00,3457.35,,,,,,,,,,,,,
SCREW BONE CNNLTD CMPRSSN 3MM DIA LNG 22MML TTNM ALLOY SELF,SUP-2586442,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.20,668.98,,,,,,,,,,,,,
PLATE BNE SCREW DIA1.5 MM SM TI OCCPTL BUTTERFLY SHP NS DISP,SUP-2935997,CDM,C1713,HCPCS,0278,RC,,,,both,,,3337.82,2169.58,,,,,,,,,,,,,
IMPLANT OPHTH EYE BNK,SUP-2309110,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
LEAD DEFIB OPTISURE L 58 CM DIA 8 FR POLYUR SIL ENDOCARD,SUP-2356414,CDM,C1777,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
COMPONENT FIX DIA13.6MM DF-P TOEMOTION,SUP-2123622,CDM,C1776,CPT,0278,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ATLNTS L 135 CM DIA 6 FR,SUP-2141200,CDM,C1725,HCPCS,0272,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
SYSTEM THR NP UPLR PART CAPITATED,SUP-2347956,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
DEVICE LD SZ EZ L65CM DIA0.38-0.58MM LOK CLR STYL LO PROF,SUP-2353133,CDM,C1773,HCPCS,0272,RC,,,,both,,,1983.44,1289.24,,,,,,,,,,,,,
HC So Blood Typing Patient Serum,PX-3008690466,CDM,86904,CPT,0300,RC,,,,outpatient,,,163.00,105.95,,,,,,,,,,,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-143505,CDM,J3373,HCPCS,0636,RC,70436-0021-82,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
BIT DRL DIA 4 MM MARKING 0 MM LNG PILOT AO CONN STRL TRIGEN,SUP-2933880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.21,636.49,,,,,,,,,,,,,
BLADE SAW 8MM CUT W 70MML 127MM THICKNESS ST UNI,SUP-2253193,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.35,217.98,,,,,,,,,,,,,
PLATE BNE UPPER RAMUS 2.3 MM RT FRAC SMRT FOR SCR TI LEVEL 1,SUP-2469602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1703.73,1107.42,,,,,,,,,,,,,
SCREW BONE L45MM DIA6.5MM 5.5MM ROD VAR ANG TI PEDCL CANN,SUP-2414591,CDM,C1713,HCPCS,0278,RC,,,,both,,,4282.96,2783.92,,,,,,,,,,,,,
SCREW BNE ST 1.5X12 MM LCK VA W/ T4 STARDRV TI NS,SUP-2181045,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.18,245.82,,,,,,,,,,,,,
BIT DRL L127MM DIA3.5MM W/OUT STP NONRADIOLUCENT W/ JACOB,SUP-2412257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
SCREW BNE CANN 4X50 MM,SUP-2221524,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
GRAFT VASC 4-7 MMX40 CM 25 CM DVAG,SUP-2395724,CDM,C1768,CPT,0278,RC,,,,both,,,3545.06,2304.29,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 7 MM STR STD WALL HELIX,SUP-2525444,CDM,C1768,CPT,0278,RC,,,,both,,,1928.49,1253.52,,,,,,,,,,,,,
BAR EXTERNAL FIXATION L300MM DIA11MM XTRAFIX SYSTEM,SUP-2476763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
BURRROUNDHLRETRACT8 ROUND HL RETRACT 8 FLUT,SUP-2121967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
PLATE COMPRSS VARIAX BRD CRV 16H,SUP-2705338,CDM,C1713,HCPCS,0278,RC,,,,both,,,4267.73,2774.02,,,,,,,,,,,,,
BASEPLATE TIB CEM 1 SM UNIV KNEE CRUCFRM BEAD HA POROUS,SUP-2377175,CDM,C1776,CPT,0278,RC,,,,both,,,6769.21,4399.99,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 88 MCG PO TABS,RX-10403,CDM,6370000000,HCPCS,0637,RC,60687-0486-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST TURNBUCKLE W/NONTORSION JT,SUP-2435777,CDM,L3916,HCPCS,0274,RC,,,,both,,,1369.64,890.27,,,,,,,,,,,,,
BOOT TRAC AD UNIV LEG FELT CONVOLUTED FOAM LNR FULL FT OPN,SUP-2194994,CDM,L4398,HCPCS,0274,RC,,,,both,,,59.25,38.51,,,,,,,,,,,,,
STENT BILI L80MM DIA10MM PARTIALLY CVR L70MM CATH L194CM,SUP-2149799,CDM,C1874,HCPCS,0278,RC,,,,both,,,5250.17,3412.61,,,,,,,,,,,,,
LENS INTOCU 6.0 TO 30.0 DIOPT 118.4 A CONSTANT 0DEG ANG,SUP-2110986,CDM,V2632,HCPCS,0276,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE LCK 234 MM RT DSTL MEDL HUM 15 HOLE GRN STRL,SUP-2470412,CDM,C1713,HCPCS,0278,RC,,,,both,,,3415.32,2219.96,,,,,,,,,,,,,
HANDLE CATH SNUS GUID LO PROF RELIEVA SIDEKCK,SUP-2106378,CDM,C1729,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CATHETER ANGIO L 110 CM DIA 5 FR PIG FLSH STRL,SUP-2116792,CDM,C1887,HCPCS,0272,RC,,,,both,,,101.42,65.92,,,,,,,,,,,,,
PLATE BONE L35MM THK0.8MM ORBIT FLR POLYETH TI REINF SYNPOR,SUP-2182842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2035.35,1322.98,,,,,,,,,,,,,
SCREW SPNL 4.5X12 MM MOUNTAINEER,SUP-2256378,CDM,C1713,HCPCS,0278,RC,,,,both,,,1229.31,799.05,,,,,,,,,,,,,
PLATE BNE L29MM THK075MM 14 H NONSTERILE HND TI WEB LOK FOR,SUP-2180994,CDM,C1713,HCPCS,0278,RC,,,,both,,,1485.03,965.27,,,,,,,,,,,,,
PLATE BNE 3.5X288 MM 22 HOLE SS LC-DCP,SUP-2569240,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.83,313.19,,,,,,,,,,,,,
GRAFT NRV L70MM DIA4 5MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2418486,CDM,C1762,CPT,0278,RC,,,,both,,,29443.78,19138.46,,,,,,,,,,,,,
GRAFT BNE SQ 5X5X0.5 CM DBM ACCELL TBM,SUP-2641757,CDM,C1713,HCPCS,0278,RC,,,,both,,,6074.33,3948.31,,,,,,,,,,,,,
HC Remv & Replc Pm Gen Dual,PX-4813322800,CDM,33228,CPT,0481,RC,,,,outpatient,,,36553.00,23759.45,,,,,,,,,,,,,
SPACER CEM M SHT L94MM DIA54MM PMMA HI REL GENT IMPREG TEMP,SUP-2223676,CDM,C1776,CPT,0278,RC,,,,both,,,13156.60,8551.79,,,,,,,,,,,,,
BOLT EXT FIX UNIV FOR 4-6MM HALF PIN RNG FIX SYS TRUELOK,SUP-2316126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.43,249.23,,,,,,,,,,,,,
COUNTERSINK SURG HDLSS 4 MM MINI-MONSTER,SUP-2320972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
SPLINT FNGR SM 4 PRNG PD,SUP-2194501,CDM,L3809,HCPCS,0274,RC,,,,both,,,3.20,2.08,,,,,,,,,,,,,
BIT DRL CANN 16 MM HLLW PERC NS TFN-ADVANCED,SUP-2799412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2800.97,1820.63,,,,,,,,,,,,,
HC Surgery Ohs Addtl 15min,PX-3600000018,CDM,3600000018,LOCAL,0360,RC,,,,outpatient,,,5570.00,3620.50,,,,,,,,,,,,,
GUIDEWIRE OD1.4 MM K,SUP-2320977,CDM,C1769,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
STOP ORTH HNG KNEE HYPEREXTENSION AX PLUG LEGION,SUP-2346319,CDM,C1776,CPT,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
TRIAL PLATE T 1.3 MM,SUP-2525717,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE SPNL 4 LEVEL WIDE 64 MM ANTR CERV ARCHON,SUP-2563427,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
GLIMEPIRIDE 2 MG PO TABS,RX-16356,CDM,6370000000,HCPCS,0637,RC,50268-0359-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC GELSFT L 30 CM DIA16 MM POLYESTER GEL ABD PERIPH,SUP-2384959,CDM,C1768,CPT,0278,RC,,,,both,,,1326.30,862.09,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 45 CM DIA18 MM LEG DIA 9 MM POLYESTER,SUP-2384996,CDM,C1768,CPT,0278,RC,,,,both,,,1603.60,1042.34,,,,,,,,,,,,,
SHUNT LP L80CM OD15MM CLS END W FIX TAB AND NDL RADPQ,SUP-2278369,CDM,C1755,HCPCS,0278,RC,,,,both,,,1491.44,969.44,,,,,,,,,,,,,
STEM FEM L127MM OD11MM STR FLUT TI ALLY HA DST HIP REV MOD,SUP-2375713,CDM,C1776,CPT,0278,RC,,,,both,,,6045.13,3929.33,,,,,,,,,,,,,
SCREW BNE CANN 2.8X20 MM PART THRD BIODRIVE,SUP-2606679,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.13,345.23,,,,,,,,,,,,,
GRAFT TIB STRUT ALLGRFT FRZN 20MMX200MM MATRIGRFT,SUP-2264789,CDM,C1713,HCPCS,0278,RC,,,,both,,,1278.07,830.75,,,,,,,,,,,,,
PIN FIX L229MM OD4MM S STL SMOOTH SGL SHRP TIP SGL TRCR,SUP-2304050,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.90,11.63,,,,,,,,,,,,,
CATHETER BLLN DIL 16-17-18 MM FIX EZDILATE BD400P1880A,SUP-2865616,CDM,C1726,HCPCS,0272,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
CARTRIDGE IOD LD MICK STRL K,SUP-2127062,CDM,C2639,HCPCS,0278,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
WASHER ORTH TIB,SUP-2449671,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
IMMOBILIZER SHOULDERXL W25XL57CM UNIV TITEX W/ BODY STRP,SUP-2197383,CDM,L3650,HCPCS,0272,RC,,,,both,,,10.64,6.92,,,,,,,,,,,,,
PIN FIX STERILE L150MM DIA3.2MM FLUT,SUP-2877819,CDM,C1776,CPT,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE SM THK1.6MM 4 H L L COMPR MED WALL SPANNING,SUP-2321486,CDM,C1713,HCPCS,0278,RC,,,,both,,,5703.81,3707.48,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 70 CM DIA 6 MM RNG L 20 CM THK 0.49 MM,SUP-2484216,CDM,C1768,CPT,0278,RC,,,,both,,,2882.68,1873.74,,,,,,,,,,,,,
MOST OPTIONS POLY REPLACEMENT KIT 4MM,SUP-2509225,CDM,C1776,CPT,0278,RC,,,,both,,,3433.59,2231.83,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.507,SUP-2860024,CDM,C1713,HCPCS,0278,RC,,,,both,,,36220.84,23543.55,,,,,,,,,,,,,
FOLLOWER URETH BOUG TIP 8 FRX13.5 IN WOVEN PHIL DIL CATH,SUP-2126120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.68,219.49,,,,,,,,,,,,,
NUT ORTH DIA6MM S STL HEX FOR SACR BAR FIX,SUP-2187003,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.54,213.55,,,,,,,,,,,,,
GRAFT BNE CHIP 1-4 MM 60 CC CANC PUREBONE,SUP-2424602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.66,1093.08,,,,,,,,,,,,,
DEVICE REATTACHMENT L50MM DIA1MM STD TROCHANTERIC TI W/ CO,SUP-2193591,CDM,C1713,HCPCS,0278,RC,,,,both,,,5279.03,3431.37,,,,,,,,,,,,,
BUR SURG MTCH HD LNG 1.8X2.4 MM 16 CM FLUT MIDAS REX 8,SUP-2664657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.26,248.47,,,,,,,,,,,,,
THORACENTESIS PRCNTSS SET 6F X 10 CM VLVD STEP SLIP,SUP-2677294,CDM,C1729,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
KIT BNE CEM 5CC CA PHSPTE MACROPOROUS INJ 2 CHAMBERED SYR W,SUP-2120761,CDM,C1713,HCPCS,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX19 CM STR STD KT SYMETREX,SUP-2269555,CDM,C1881,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
ANCHOR SUTURE PLNTR PLATE REP STRL DISP PARATROOPER,SUP-2899139,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
ANCHOR SUTURE L11MM DIAMETER 3.5MM WITH 1 NO2 HI-FI SUTURE P,SUP-2824900,CDM,C1713,HCPCS,0278,RC,,,,both,,,1642.82,1067.83,,,,,,,,,,,,,
DEVICE EMB L14MM OD3MM 55DEG SFT DST TIP BRAID 4 FLX,SUP-2296700,CDM,C1884,HCPCS,0278,RC,,,,both,,,43925.46,28551.55,,,,,,,,,,,,,
DEVICE BRST BX 9 GAX13 CM 12 MM FOR STEREOTACTIC HNDPC PRB,SUP-2427468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
CLAMP REPROC ADJ OPEN DYNAMIZATION MRI SAFE EXT,SUP-2482943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.68,352.09,,,,,,,,,,,,,
CATHETER HD MAXIMAL BARR TY 035 12 FRX25 CM DL TURBO-FLO HD,SUP-2759843,CDM,C1752,HCPCS,0278,RC,,,,both,,,509.81,331.38,,,,,,,,,,,,,
PIN EXT FIX HALF 3X20 MM 100 MM THRD TI NITRIDE STRL,SUP-2851107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
HC So Fungus Culture Skin,PX-3008710166,CDM,87101,CPT,0300,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
TRIAL-SET COPAL EXCHANGE G HIP S,SUP-2905383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
ROD EXT FIX L600MM DIA11MM MRI C CONN FOR HOFFMANN III EXT,SUP-2372235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.25,1105.81,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5 CC VIABLE BNE MTRX BIO4,SUP-2637050,CDM,C1713,HCPCS,0278,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
GUIDEWIRE UROLOGY DBL FLX 038 INX145 CM ULTRA STIFF AMPLATZ,SUP-2836143,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.95,61.07,,,,,,,,,,,,,
LINER MOBILITY CAPPED HIP LINER 50/43,SUP-2718085,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
LEAD DEFIB LINOXSMART TD L 65 CM DIA2.6 MM TIP DISTANCE 18,SUP-2138098,CDM,C1895,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
DRESSING BIO W3XL7CM PORCINE TRILAYER MTRX FEN OASIS ULT,SUP-2341248,CDM,Q4124,HCPCS,0636,RC,,,,both,,,959.43,623.63,,,,,,,,,,,,,
COMPONENT TIB INLAY 2 KNEE STRL RESTORIS,SUP-2265740,CDM,C1776,CPT,0278,RC,,,,both,,,4149.48,2697.16,,,,,,,,,,,,,
CATHETER CV 16 GAX160 MM 1.7 MM PTFE GRY STRL SECALON-T DISP,SUP-2662691,CDM,C1751,HCPCS,0278,RC,,,,both,,,16.80,10.92,,,,,,,,,,,,,
SCREW BNE L14MM DIA3MM HDLSS FOR FRAC REP AND FIX OSTEOTMY,SUP-2175071,CDM,C1713,HCPCS,0278,RC,,,,both,,,1342.35,872.53,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WOVEN L 125 CM DIA 6 FR DECAPOLAR,SUP-2535572,CDM,C1730,HCPCS,0272,RC,,,,both,,,305.68,198.69,,,,,,,,,,,,,
RESTRICTOR CEM ELBW W/ NOZ COONRAD/MORREY,SUP-2205931,CDM,C1776,CPT,0278,RC,,,,both,,,881.71,573.11,,,,,,,,,,,,,
STAPLER INT CIR X THCK 25 MM 4/4.5/5 MM TRI-STAPLE BLK EEA,SUP-2858012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3415.38,2220.00,,,,,,,,,,,,,
TUBE JEJUSTMY 12FR BLLN 2-3ML SIL SECURELOK R ANG CONN 2,SUP-2124593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.26,277.07,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCORP NRG,SUP-2365625,CDM,C1776,CPT,0278,RC,,,,both,,,11359.86,7383.91,,,,,,,,,,,,,
SPACER HUM GLEN 36X+9 MM SHLDR AEQUALIS RVS,SUP-2431491,CDM,C1776,CPT,0278,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
SYSTEM HIP CEM BPLR,SUP-2212083,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN HEPARIN J FLX,SUP-2147058,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.36,32.08,,,,,,,,,,,,,
CAGE SPNL L10XW10XH30MM 4 LOBE LORDTC END CAP IMP NGAGE,SUP-2317727,CDM,C1889,HCPCS,0278,RC,,,,both,,,11592.88,7535.37,,,,,,,,,,,,,
BLADE ENDO L220MM MPLR STEER NAV-X,SUP-2121999,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
MESH ACET TI FEM HIP X CHANGE,SUP-2368354,CDM,C1713,HCPCS,0278,RC,,,,both,,,567.52,368.89,,,,,,,,,,,,,
MESH CRAN L 41 X W 41 MM TI CLR NS DISP,SUP-2935337,CDM,C1713,HCPCS,0278,RC,,,,both,,,6207.78,4035.06,,,,,,,,,,,,,
SCREW BONE L22MM D27MM STNLSS STEEL CRTCL PRRTCLR SELF TPPNG,SUP-2498118,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.74,168.18,,,,,,,,,,,,,
SCREW LANCER SET MT20 001,SUP-2164311,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
KIT LD INTRO SAFSHTH ULTRA L 13 CM DIA 9 FR GUIDEWIRE L 50,SUP-2707589,CDM,C1892,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT BONE SUB W2.5XL5CM DEMIN BONE MTRX PLF GRFTON,SUP-2281664,CDM,C1713,HCPCS,0278,RC,,,,both,,,4109.48,2671.16,,,,,,,,,,,,,
HC RBC Deglycerolized,PX-3900903900,CDM,P9039,CPT,0390,RC,,,,both,,,2154.00,1400.10,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO LIGHTNING BOLT 12 L 100 CM DIA12,SUP-2930522,CDM,C1757,HCPCS,0272,RC,,,,both,,,30520.80,19838.52,,,,,,,,,,,,,
CONNECTOR SPNL XLNK ASMBLY FIX TRNSVRS CONN ANTR STD TI,SUP-2415715,CDM,C1713,HCPCS,0278,RC,,,,both,,,1448.04,941.23,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM BIOCOMP KNOTLESS DX CC STRL MIS,SUP-2882191,CDM,C1713,HCPCS,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
HC NM Gastric Emptying Study,PX-3417826400,CDM,78264,CPT,0341,RC,,,,both,,,2796.00,1817.40,,,,,,,,,,,,,
PLATE BONE L62MM 5 H POST LAT S STL 1/3 TBLR LCK COMPR FOR,SUP-2349794,CDM,C1713,HCPCS,0278,RC,,,,both,,,1876.21,1219.54,,,,,,,,,,,,,
HC Placement Central Venous Cath,PX-3613655600,CDM,36556,CPT,0361,RC,,,,both,,,9955.00,6470.75,,,,,,,,,,,,,
INSERT TIB SZ 2 THK12.5MM GVF POLYETH CRV FIX BEAR PFC,SUP-2253974,CDM,C1776,CPT,0278,RC,,,,both,,,3417.58,2221.43,,,,,,,,,,,,,
ALLOGRAFT BNE FIB FRZN DSTL,SUP-2321785,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
EXTRACTOR SURG BOLT TRIGEN DISP IM NAIL,SUP-2347055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1519.85,987.90,,,,,,,,,,,,,
WIRE FIX Y 1.28X559 MM ES2 COMPATIBLE LT FC12822B2,SUP-2734737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,969.48,630.16,,,,,,,,,,,,,
PLATE BNE L121MM 10 H BILAT S STL CNTOUR 2 COMPR FOR 3.5MM,SUP-2411350,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
GRAFT HUM TISS W20XL15MM THK8MM FRZ DRY ALLGRFT BLK CANC,SUP-2307117,CDM,C1713,HCPCS,0278,RC,,,,both,,,2400.09,1560.06,,,,,,,,,,,,,
PLATE BONE 4X4 H BILAT MAND ORAL MAXILLOFACIAL TI ANG LO,SUP-2191436,CDM,C1713,HCPCS,0278,RC,,,,both,,,5141.12,3341.73,,,,,,,,,,,,,
CAGE SPNL W9XH8XL23MM 0DEG C FBR REINF POLYMER POST LUM,SUP-2255218,CDM,C1889,HCPCS,0278,RC,,,,both,,,11705.92,7608.85,,,,,,,,,,,,,
JOINT FNGR BASIL THMB 2 TI SWNSN,SUP-2538166,CDM,C1776,CPT,0278,RC,,,,both,,,6995.92,4547.35,,,,,,,,,,,,,
GRAFT VASC TAPR 7-4 MMX70 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761336,CDM,C1768,CPT,0278,RC,,,,both,,,3511.24,2282.31,,,,,,,,,,,,,
HC Insertion of Chest Tube,PX-4503255100,CDM,32551,CPT,0450,RC,,,,outpatient,,,4942.00,3212.30,,,,,,,,,,,,,
NAIL IM HUM 8/7MMX24CM,SUP-2348161,CDM,C1713,HCPCS,0278,RC,,,,both,,,10294.80,6691.62,,,,,,,,,,,,,
COMPONENT TIB TY 3 73X47 MM,SUP-2390306,CDM,C1776,CPT,0278,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
PLATE BNE NAR L VOLAR DST RAD WRST LOK ACU-LOC,SUP-2107768,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
ADAPTER LD L 40 CM SIL INSUL UPLR 5 MM RECEPTACLE IS1 CONN,SUP-2616257,CDM,C1883,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
GUIDEWIRE SURG L14IN DIA1.1MM S STL W/ TRCR TIP,SUP-2256614,CDM,C1769,HCPCS,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
SCREW BNE L100MM DIA35MM CORT S STL ST NONCANNULATED FULL,SUP-2178086,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.85,55.80,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THN AMNIO BARR MEM CHORION FREE,SUP-2399186,CDM,C1762,CPT,0278,RC,,,,both,,,10085.68,6555.69,,,,,,,,,,,,,
GRAFT SYS DEL AGF SYR,SUP-2415892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.31,306.35,,,,,,,,,,,,,
BIT DRL TWST 40 MM 2.2X85 MM 35 MM FLUT W/ STP NOTCH LEVEL 1,SUP-2485268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.96,411.42,,,,,,,,,,,,,
MESH GYN M W10XL15CM FLAT FLR POLYPR FOR TRANSABDOMINAL,SUP-2165307,CDM,C1781,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE L131MM 6 H POSTEROMEDIAL PROX TIB S STL LOK COMPR,SUP-2177797,CDM,C1713,HCPCS,0278,RC,,,,both,,,3449.82,2242.38,,,,,,,,,,,,,
DRILL TWST L85MM DIA1.9MM WRK L20MM FOR 2/2.3MM SCR,SUP-2366431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.94,267.76,,,,,,,,,,,,,
PROCESSOR HEARING AID SFT BLK FULL PROGRAMMABLE BP100 BAHA 3,SUP-2164958,CDM,L8691,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.021 IN L 7 CM 2CM STR TIP FIX COR,SUP-2167647,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.73,47.92,,,,,,,,,,,,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,0636,RC,00143-9567-25,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
IMPLANT ANTIREFLX SZ 13 LAPSCP FUNDIC SPRNG MRI COMPATIBLE,SUP-2219559,CDM,C1889,HCPCS,0278,RC,,,,both,,,19405.20,12613.38,,,,,,,,,,,,,
COMPONENT FEM 2 CT-MRI ROTATING NS MYKNEE LBS,SUP-2575560,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC MRI Lower Ext W/O Cont,PX-6107371800,CDM,73718,CPT,0610,RC,,,,both,,,3764.00,2446.60,,,,,,,,,,,,,
ULNAR STEM EXT ULN STEMS,SUP-2398597,CDM,C1776,CPT,0278,RC,,,,both,,,1671.58,1086.53,,,,,,,,,,,,,
PLATE BONE LOW PROFILE MEDIUM 1.6X0.4 MM CONTOURABLE MESH MA,SUP-2838374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS,RX-39255,CDM,6370000000,HCPCS,0637,RC,42385-0953-30,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
CATHETER ANGIOPLSTY IMPACT L 75 CM SHFT 9 FR BALLOON L 4 CM,SUP-2124919,CDM,C1725,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
WASHER ORTH SCREW DIA 4.5 MM DBL STRL EVOS,SUP-2933764,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
SCREW BNE L 19 MM DIA2 MM XDRV NS DISP LORENZ,SUP-2935133,CDM,C1713,HCPCS,0278,RC,,,,both,,,96.71,62.86,,,,,,,,,,,,,
BLADE SHV L22CM OD2.9MM DST BEND 15DEG 60-500RPM DBL CRV,SUP-2284128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2029.70,1319.30,,,,,,,,,,,,,
BIT DRL L60MM DIA1MM STRL MAXILLOFACIAL S STL W/ J LATCH,SUP-2187628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.79,239.71,,,,,,,,,,,,,
STENT PERIPH EXPRESS SD MR L 19 MM DIA 5 MM CATH L 150 CM,SUP-2142391,CDM,C1876,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
HEAD RMR REPL WRST FUS HUB CAP,SUP-2107839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
SCREW BONE L11MM THRD DIA2.4MM HD DIA3.8MM COR DIA1.6MM,SUP-2349258,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.67,133.04,,,,,,,,,,,,,
GUIDEWIRE PC STR TIP 035INX145CM RDRUN THE FIRM LT,SUP-2168205,CDM,C1769,HCPCS,0272,RC,,,,both,,,82.90,53.88,,,,,,,,,,,,,
PLATE BNE W3.8XL100MM 20 H BILAT S STL STR LO PROF NEUT LOK,SUP-2186287,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.26,507.82,,,,,,,,,,,,,
GRAFT HUM TISS SM PERF M REGENERATIVE TISS MTRX CNTOUR,SUP-2113443,CDM,Q4116,HCPCS,0636,RC,,,,both,,,18742.66,12182.73,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET XMI L 135 CM DIA 4 FR INTRO 4 FR,SUP-2142032,CDM,C1757,HCPCS,0272,RC,,,,both,,,6185.80,4020.77,,,,,,,,,,,,,
NEEDLE SUT SHUTTLE FLEX STRL REUSE ELITE PASS,SUP-2341667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.32,264.11,,,,,,,,,,,,,
GRAFT VASC TW 7 MMX50 CM RNG SFT WRP TUNN ATTCH ADVANTA VXT,SUP-2464993,CDM,C1768,CPT,0278,RC,,,,both,,,1445.56,939.61,,,,,,,,,,,,,
MESH HERN XL W4XL5CM INGUINAL POLYPR SYN PRESHAPED LT WT,SUP-2125789,CDM,C1781,HCPCS,0278,RC,,,,both,,,573.05,372.48,,,,,,,,,,,,,
SCREW ACET LCK 28/32/36 MM PROV APCL,SUP-2440986,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
PLATE BNE CLAV 2.7 MM LT VA LCK COMPR TI NS VA-LCP,SUP-2758171,CDM,C1713,HCPCS,0278,RC,,,,both,,,4364.47,2836.91,,,,,,,,,,,,,
STEM FEM DIA12MM LT HIP SM STAT SH REPLICA,SUP-2251973,CDM,C1776,CPT,0278,RC,,,,both,,,16397.08,10658.10,,,,,,,,,,,,,
STEM FEM L317MM OD13MM BOW TRI SLOT PLSM SPRAYED HA DST HIP,SUP-2375912,CDM,C1776,CPT,0278,RC,,,,both,,,9793.03,6365.47,,,,,,,,,,,,,
LINER ACET SNAP IN NEUT STD 22X39 MM HIP PRIMARY DURASUL,SUP-2207438,CDM,C1776,CPT,0278,RC,,,,both,,,2347.15,1525.65,,,,,,,,,,,,,
MESH GYN L 30 X W 30 IN XL POLYPRO OR PPL FLAT CNTOUR PORE,SUP-2896108,CDM,C1781,HCPCS,0278,RC,,,,both,,,5155.88,3351.32,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2.8MM 300/150MM CALIB W/ FLUT FOR 6.5MM,SUP-2186907,CDM,C1769,HCPCS,0272,RC,,,,both,,,246.49,160.22,,,,,,,,,,,,,
WIRE FIX L150MM OD1.4MM NICKEL CHROM SMOOTH SGL END TRCR,SUP-2321619,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
KIT HEMO DYLS OR HD 14.5FR L23CM CATH LNG TERM STD STR,SUP-2126522,CDM,C1750,HCPCS,0278,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
GUIDE PILOT 5-10MM DISP,SUP-2171840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.28,160.73,,,,,,,,,,,,,
MICROSPHERE EMB EMBOSPHERE DIA100-300 UM 1 CC 20 CC SYR YEL,SUP-2303399,CDM,C1889,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
STENT URO KT PGTL FLEX TIP TETHERED POS RADPQ Y 8FR 28CM,SUP-2171033,CDM,C2617,HCPCS,0278,RC,,,,both,,,419.76,272.84,,,,,,,,,,,,,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2680,HCPCS,0636,RC,63323-0281-10,NDC,,both,10,ML,1104.50,717.92,,,,,,,,,,,,,
DRILL 4.75MM HEALICOIL KNOTLESS,SUP-2823681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1097.05,713.08,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 24X10X9/5.7 MM FD PLIF LUMINARY,SUP-2736798,CDM,C1713,HCPCS,0278,RC,,,,both,,,8535.43,5548.03,,,,,,,,,,,,,
RAMIPRIL 1.25 MG PO CAPS,RX-11258,CDM,6370000000,HCPCS,0637,RC,68382-0144-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CAPSULE ENDO CAM CALIB FRE REFLX W/ DEL SYS BRAVO,SUP-2227943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,992.24,644.96,,,,,,,,,,,,,
GRAFT BNE SUB 10CC SZ 0212 0850MM DEMIN CORT PWD FRZ DRY,SUP-2307257,CDM,C1713,HCPCS,0278,RC,,,,both,,,886.58,576.28,,,,,,,,,,,,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,0636,RC,63323-0651-02,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 40-49 CM SAPH VEIN BLD TYP A B AB,SUP-2884061,CDM,C1768,CPT,0278,RC,,,,both,,,29983.86,19489.51,,,,,,,,,,,,,
PLATE BONE HOLEX8 STAINLES STEEL RECESSED SPIDER WRIST,SUP-2604355,CDM,C1713,HCPCS,0278,RC,,,,both,,,5956.99,3872.04,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF SHORT 3X10 MM RADIAL DISTAL STAIN,SUP-2836762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.68,504.84,,,,,,,,,,,,,
SAW RECIP H4MM THK635MM BLDE,SUP-2363296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,244.32,158.81,,,,,,,,,,,,,
SET PICC L 15 CM DIA 5.5 FR SHTH L 7 CM DIA 5.5 FR,SUP-2887027,CDM,C1751,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
HC So Legionnaires Titer,PX-3028671366,CDM,86713,CPT,0302,RC,,,,outpatient,,,668.00,434.20,,,,,,,,,,,,,
METHOTREXATE SODIUM 2.5 MG PO TABS,RX-13594,CDM,J8610,HCPCS,0636,RC,00904-7141-10,NDC,,both,1,UN,13.50,8.77,,,,,,,,,,,,,
STRUT EXT FIX L 145-205 MM MED LINEAR,SUP-2898582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
GUIDEWIRE UROLOGY STR 0.035 INX150 CM COR STIFF-BODY BIWIRE,SUP-2836007,CDM,C1769,HCPCS,0272,RC,,,,both,,,185.04,120.28,,,,,,,,,,,,,
GRAFT HUM TISS W29XL100MM THK3-12MM FEM CORT FRZN,SUP-2307357,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.68,823.99,,,,,,,,,,,,,
BIT DRL L310MM DIA15MM CANN FLX FOR EXPERT LAT FEM NAILING,SUP-2178893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2005.68,1303.69,,,,,,,,,,,,,
NAIL IM L275MM DIA12.5MM STROKE 80MM 10DEG TROCHANTERIC FEM,SUP-2312261,CDM,C1713,HCPCS,0278,RC,,,,both,,,59628.60,38758.59,,,,,,,,,,,,,
ALLOGRAFT BNE OSTEOTMY WDG FD IRRADIATED,SUP-2867106,CDM,C1762,CPT,0278,RC,,,,both,,,5181.47,3367.96,,,,,,,,,,,,,
HC US Guidance for Amniocentsis,PX-4027694600,CDM,76946,CPT,0402,RC,,,,both,,,1605.00,1043.25,,,,,,,,,,,,,
RING SPNL STD 28X22 MM 6 LOBE,SUP-2602108,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 10X20X3-6 MM SPNG FD CANC,SUP-2717782,CDM,C1713,HCPCS,0278,RC,,,,both,,,2586.10,1680.96,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.5CM 20SEC 3 CHMBR CARD,SUP-2138071,CDM,C1882,HCPCS,0275,RC,,,,both,,,55753.84,36240.00,,,,,,,,,,,,,
BIT DRL TWST 1.5 MM,SUP-2389416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
SET TBNG INTEGR DISPOSABLE FOR ARTHRO PMP,SUP-2361368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.46,224.55,,,,,,,,,,,,,
NAIL IM L400MM DIA8MM FEM TIB TI SLD LOK AG UNREAMED ENDCAP,SUP-2192765,CDM,C1713,HCPCS,0278,RC,,,,both,,,5329.84,3464.40,,,,,,,,,,,,,
WEDGE TIB M SZ 2 THK10MM KNEE PRI PRESSFIT FULL FLAT BLK,SUP-2377114,CDM,C1776,CPT,0278,RC,,,,both,,,3244.12,2108.68,,,,,,,,,,,,,
HOLDER NDL L23CM 0.035IN QUIK ACCS,SUP-2353173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT DERMAL N FEN 4X4 CMX0.4-0.8 MM DERMAL MTRX PARADERM,SUP-2742061,CDM,C1763,HCPCS,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
PLATE SPNL L27MM ANT CERV TI ALLY CNVGNT ATLNTS,SUP-2291073,CDM,C1713,HCPCS,0278,RC,,,,both,,,2768.73,1799.67,,,,,,,,,,,,,
SYSTEM CATH INFSN 4FR DIA 45CML 10CML PEBAX OCCLDNG WIRE ACC,SUP-2676952,CDM,C1751,HCPCS,0278,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
MESH SURGICAL 5CM X 5CM RESTRATA,SUP-2874125,CDM,A2007,HCPCS,0636,RC,,,,both,,,9671.20,6286.28,,,,,,,,,,,,,
SPLINT WRST AND THMB UNIV,SUP-2336035,CDM,L3809,HCPCS,0272,RC,,,,both,,,37.55,24.41,,,,,,,,,,,,,
SHEATH PROSTHETIC BK,SUP-2388223,CDM,L8400,HCPCS,0274,RC,,,,both,,,45.66,29.68,,,,,,,,,,,,,
GUIDE SURG PLN NYL LP DISTRCTN CUSTOMIZABLE BILATERAL VSP,SUP-2883943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19986.10,12990.96,,,,,,,,,,,,,
CATHETER DRAINAGE 90 CM PERITONEAL PUDENZ HI PRESSURE RATE,SUP-2550574,CDM,C1729,HCPCS,0272,RC,,,,both,,,608.53,395.54,,,,,,,,,,,,,
INSERT HUM LAT 6+ MM 42 MM SHLDR AEQUALIS REVERSED FX,SUP-2715640,CDM,C1776,CPT,0278,RC,,,,both,,,5213.97,3389.08,,,,,,,,,,,,,
PROBE TIP ANGLE 0 DEGREES,SUP-2736163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PATCH DURA L 6.3 X W 3.9 IN SURF AREA24.6 SQ IN BOV PERICARD,SUP-2884057,CDM,C1763,HCPCS,0278,RC,,,,both,,,2791.46,1814.45,,,,,,,,,,,,,
PISTON OTO FUNC L4.25MM DIA0.6MM HASH MRK 0.5MM,SUP-2312545,CDM,L8613,CPT,0278,RC,,,,both,,,402.86,261.86,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L POST STBL POR BAL SYS,SUP-2314627,CDM,C1776,CPT,0278,RC,,,,both,,,7636.48,4963.71,,,,,,,,,,,,,
PIN HALF HYBRID SELF DRL 45X150MM,SUP-2705300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,669.76,435.34,,,,,,,,,,,,,
DEFIBRILLATOR CARD W537XH779CM D099CM SGL CHMBR VR IS 1 DF 1,SUP-2149168,CDM,C1722,HCPCS,0275,RC,,,,both,,,47360.62,30784.40,,,,,,,,,,,,,
BOLT EX FX MAXFRAME MULTIPAR PIN MNT,SUP-2737904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,512.95,333.42,,,,,,,,,,,,,
COMPONENT FEM L70MM LT KNEE POR ANAT PRI MAXM,SUP-2405272,CDM,C1776,CPT,0278,RC,,,,both,,,21176.16,13764.50,,,,,,,,,,,,,
SCREW BNE L42MM DIA4MM THRD L14MM STD CANC S STL ST CANN,SUP-2342504,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.72,8.92,,,,,,,,,,,,,
PLEDGET VASCULAR 3X6MM OVAL FIRM,SUP-2427112,CDM,C1768,CPT,0278,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
GRAFT HUM TISS L 250 MM DIA 5 MM GRACILIS TEND FRZN STRL,SUP-2913201,CDM,C1762,CPT,0278,RC,,,,both,,,5843.54,3798.30,,,,,,,,,,,,,
NEXGEN LEGACY 3 DEG FLUTED TIBIAL 7D FULL WDG SZ2,SUP-2503474,CDM,C1776,CPT,0278,RC,,,,both,,,2411.52,1567.49,,,,,,,,,,,,,
GRAFT VASC STD WALLED INTEGR RNG IMPL L40CM L40CM ID6MM,SUP-2395836,CDM,C1768,CPT,0278,RC,,,,both,,,3460.28,2249.18,,,,,,,,,,,,,
ALLOGRAFT BNE 4X8X13 MM BIOEXPAND,SUP-2636998,CDM,C1713,HCPCS,0278,RC,,,,both,,,2608.40,1695.46,,,,,,,,,,,,,
PLATE BNE SM W11XL50MM THK15MM 90DEG 4X3 H TI T SHP R ANG,SUP-2190927,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.07,621.45,,,,,,,,,,,,,
PLATE BONE L121MM 6 H S STL LCK COMPR FOR 4.5MM SCR PERI-LOC,SUP-2348941,CDM,C1713,HCPCS,0278,RC,,,,both,,,3792.02,2464.81,,,,,,,,,,,,,
PROPHECY PATIENT SPEC GUIDES FOR INFINITY WITH FOOTPRINT,SUP-2830300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR PULSE SENZA,SUP-2308595,CDM,C1822,CPT,0278,RC,,,,both,,,48042.00,31227.30,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 FT 5FR 55CM 2 LUMAN 1295108F,SUP-2632637,CDM,C1751,HCPCS,0278,RC,,,,both,,,665.59,432.63,,,,,,,,,,,,,
HC Nasopharyngoscopy Sep Px,PX-3619251100,CDM,92511,CPT,0361,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
SCREW BNE LOK 35MMX18MM CONTOURS LPS LAPIDUS PLATING SYS,SUP-2316495,CDM,C1713,HCPCS,0278,RC,,,,both,,,440.01,286.01,,,,,,,,,,,,,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,6370000000,HCPCS,0637,RC,00781-7133-58,NDC,,both,1,UN,83.60,54.34,,,,,,,,,,,,,
DISSECTOR SURG MIC 2 MM 7 IN RHOTON RUGGLES-REDMOND,SUP-2473178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,274.56,178.46,,,,,,,,,,,,,
GRAFT TISS ACELLULAR PORCINE CROSSLINKED FEN ACELLULAR,SUP-2126251,CDM,C1781,HCPCS,0278,RC,,,,both,,,6037.28,3924.23,,,,,,,,,,,,,
HOOK RETRCT STRL DISP SECUREHOLD,SUP-2930232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1301.03,845.67,,,,,,,,,,,,,
INSERT TIB SZ 5 THK14MM HNG GMK,SUP-2267633,CDM,C1776,CPT,0278,RC,,,,both,,,8113.76,5273.94,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST THOR CTRL BND,SUP-2435691,CDM,L2660,HCPCS,0272,RC,,,,both,,,507.27,329.73,,,,,,,,,,,,,
PLATE BONE L93MM THK3.4MM 6 H BILAT NONLOCKING COMPR FOR,SUP-2348949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.34,922.57,,,,,,,,,,,,,
PLATE BONE 5 H LT MIDFOOT NAVICULAR CUNEIFORM TI FOR,SUP-2225435,CDM,C1713,HCPCS,0278,RC,,,,both,,,6823.22,4435.09,,,,,,,,,,,,,
SPLINT FNGR 9CM L 3.5IN 4 PRNG PROTCT ALUMINIUM NONPADDED,SUP-2197320,CDM,L3933,HCPCS,0272,RC,,,,both,,,126.35,82.13,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX260 CM STIFF RND JAGWIRE,SUP-2141543,CDM,C1769,HCPCS,0272,RC,,,,both,,,402.99,261.94,,,,,,,,,,,,,
TUBING CONN L10FT VASC COMPR ASSEMB FLOTRN,SUP-2240678,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE 8H,SUP-2247339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
MESH SURG 20CM W/ POS SYS ECHO 2 VENTRALIGHT ST,SUP-2126546,CDM,C1781,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CUP HUM DIA36MM NEUT OFFSET SHLDR CAP UNIVERS REVERS,SUP-2123335,CDM,C1776,CPT,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
SCREW BNE THMB SHT REPL TRABECULAR MTL BIGLIANI/FLATOW,SUP-2436703,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
EXTENSION REM TOOL PROX HUM ACUTE PH FOR CONVENTUS CAGE SYS,SUP-2167378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
CAGE SPNL 6X30 MM REV ABO TI STRL STALIF MIDLN,SUP-2577757,CDM,C1889,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE CRV 4.5X405 MM RT CNDYL 20 HOLE VA LCK STRL VALCP,SUP-2789785,CDM,C1713,HCPCS,0278,RC,,,,both,,,8442.55,5487.66,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X306 MM 17 HOLE SS LCP,SUP-2569378,CDM,C1713,HCPCS,0278,RC,,,,both,,,1079.38,701.60,,,,,,,,,,,,,
WIRE FIX SMOOTH 1.4X100 MM KIRSCHNER VARIAX,SUP-2362640,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
HYOSCYAMINE SULFATE 0.125 MG/ML PO SOLN,RX-3782,CDM,340b,HCPCS,0637,RC,54838-0506-15,NDC,,both,0.125,ML,2.70,1.75,,,,,,,,,,,,,
PLATE BONE L132MM THK3.4MM 9 H BILAT NONLOCKING COMPR FOR,SUP-2348952,CDM,C1713,HCPCS,0278,RC,,,,both,,,1577.72,1025.52,,,,,,,,,,,,,
CATHETER DRNGE 10.2FR L50CM 0.038IN UNIV 6 SIDE PRT AMPLATZ,SUP-2168697,CDM,C1729,HCPCS,0272,RC,,,,both,,,198.23,128.85,,,,,,,,,,,,,
WEIGHT EYELID 1.2GM STD GLD SMOOTH SURF RND TAPR EDGE STRL,SUP-2247199,CDM,L8610,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM TI W/ ORTHOCORD HEALIX,SUP-2249430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
SCREW BNE ASMBLY 50 MM SHLDR ADJ REVERSED AEQUALIS,SUP-2715362,CDM,C1713,HCPCS,0278,RC,,,,both,,,2168.17,1409.31,,,,,,,,,,,,,
DEVICE PESSARY DIA1.75IN SIL FLEX GELLHORN SH STEM FOR 3RD,SUP-2171824,CDM,A4562,HCPCS,0274,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES ORTHOSIS SCOTTISH R,SUP-2435605,CDM,L1730,HCPCS,0274,RC,,,,both,,,3525.84,2291.80,,,,,,,,,,,,,
PIN BNE FIX L3IN KNEE SMOOTH,SUP-2252734,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
DEVICE CRAN FIX XL ST CRAN LOOP FIX SYS,SUP-2263029,CDM,C1713,HCPCS,0278,RC,,,,both,,,482.93,313.90,,,,,,,,,,,,,
TRIAL BONE PLT 4 H T SHP TC-100 L FRAG SYS,SUP-2343747,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.08,738.45,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH 135 DEG L 60 CM DIA 8 FR DIL DIA 8 FR,SUP-2357187,CDM,C1893,HCPCS,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 40 CM DIA 0.018 IN NIT MANDREL TUNGSTEN,SUP-2606006,CDM,C1769,HCPCS,0272,RC,,,,both,,,60.29,39.19,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 4FR 60CML PU RADPQ STYL SFTY EXC 3254107,SUP-2632659,CDM,C1751,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
SHUNT CV L13CM DIA12FR CAR BYPS STR 1 SIDE H EA END DISP,SUP-2127889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
SET URET STENT L 30 CM DIA 4.8 FR SENSOR GUIDEWIRE 0.035 IN,SUP-2458021,CDM,C2617,HCPCS,0278,RC,,,,both,,,473.86,308.01,,,,,,,,,,,,,
ANCHOR SUT 2.2 MM CANNULINK TRUVIEW,SUP-2315892,CDM,C1713,HCPCS,0278,RC,,,,both,,,5243.80,3408.47,,,,,,,,,,,,,
GRAFT DERM L12CMXW4CM CLLGN RECTANG IMPL ALLOMAX,SUP-2125853,CDM,C1781,HCPCS,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X142 MM 8 HOLE SS LC-DCP,SUP-2569267,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.85,251.45,,,,,,,,,,,,,
SCREW SPNL L40MM DIA6.25MM CANC ANT PEDCL TI MNRCH,SUP-2254477,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.23,1265.05,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CROSPERIO L 150 CM L 80MM DIA 4 MM OTW,SUP-2761745,CDM,C1725,HCPCS,0272,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
PLATE BNE STR 20X0.6 MM NEURO 4 HOLE TI NS LEVEL 1 ULTRAONE,SUP-2489532,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.49,292.17,,,,,,,,,,,,,
THEOPHYLLINE 80 MG/15ML PO ELIX,RX-7820,CDM,340b,HCPCS,0637,RC,00121-0820-16,NDC,,both,18.75,ML,7.20,4.68,,,,,,,,,,,,,
PAD ORTHOT LUMBAR RIB CUST,SUP-2435574,CDM,L1040,HCPCS,0272,RC,,,,both,,,251.01,163.16,,,,,,,,,,,,,
POST EXT FIX TALL WIRE PREASSEMBLED FOR SALVATION EXT FIX,SUP-2401119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
BIT DRL L248MM DIA33MM FOR QUIK CPL,SUP-2188457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE L SHP WTAB UNI 1.5 MM SCRW6 X 4 HO,SUP-2677638,CDM,C1713,HCPCS,0278,RC,,,,both,,,881.71,573.11,,,,,,,,,,,,,
ARM IMMOB W ABDUCTION PLLW MED,SUP-2196389,CDM,L3670,HCPCS,0274,RC,,,,both,,,83.43,54.23,,,,,,,,,,,,,
STAPLER INT 35 MM LT ATR APPENDAGE 7 PIN TIGERPAW PRO,SUP-2717308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X105 MM LT LAT DSTL 5 HOLE NS VA-LCP,SUP-2758196,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.06,1742.69,,,,,,,,,,,,,
PIN EXT FIX AXIS 2.5X55 MM ELBW IJS-E,SUP-2340386,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
DEFIBRILLATOR CARD 30J STD SGL CHMBR LD BPLR REMOT MON,SUP-2357752,CDM,C1721,HCPCS,0275,RC,,,,both,,,59189.00,38472.85,,,,,,,,,,,,,
STEM HUM L200MM DIA9MM LNG UNIV DSTL SHLDR TI PRI REV CEM,SUP-2372860,CDM,C1776,CPT,0278,RC,,,,both,,,11991.66,7794.58,,,,,,,,,,,,,
CABLE ORTH SWAGE 2 MM RCS COCR 745220,SUP-2450890,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BONE SHAFT 230MML HLX16 STRGHT NRRW F/PRPRSTHTC FRAC N,SUP-2469446,CDM,C1713,HCPCS,0278,RC,,,,both,,,1800.82,1170.53,,,,,,,,,,,,,
SCREW BNE L34MM DIA4MM PERIARTC S STL ST LOK FULL THRD FOR,SUP-2184954,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
ALLOGRAFT BNE 4X8X16 MM BIOEXPAND,SUP-2636999,CDM,C1713,HCPCS,0278,RC,,,,both,,,2782.29,1808.49,,,,,,,,,,,,,
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,0636,RC,00074-3642-03,NDC,,both,1,UN,656.90,426.98,,,,,,,,,,,,,
PIN BNE FIX STR DRL TIP CADENCE,SUP-2933321,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.28,241.98,,,,,,,,,,,,,
STEM HUM L100MM OD6.5MM UNIV TI SHLDR IM PROX BODY MOD REV,SUP-2403502,CDM,C1776,CPT,0278,RC,,,,both,,,6126.14,3981.99,,,,,,,,,,,,,
STENT COR 0.018 IN 3 MM 135 CM,SUP-2159051,CDM,C1876,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
BIT DRL L233MM DIA4.5MM CANN FOR LC ANG BLDE PLT,SUP-2187341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.40,722.41,,,,,,,,,,,,,
IMPLANT BIO W 7 X H 4 CM THK 2P PORCINE SM INTEST SUBMUCOSA CMCV-099-204,SUP-2884120,CDM,C1768,CPT,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min,PX-4209711600,CDM,97116,CPT,0420,RC,,,,both,,,164.00,106.60,,,,,,,,,,,,,
PLASMA-LYTE A IV SOLN,RX-6331,CDM,2580000003,HCPCS,0258,RC,00338-0221-04,NDC,,both,1000,ML,97.80,63.57,,,,,,,,,,,,,
KIT STEREOTACTIC BRAIN INT BX TRAJECTORY GUID FRAMELESS,SUP-2284362,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4152.08,2698.85,,,,,,,,,,,,,
SHEATH TRANSSEPTAL L 72 CM DIA 8.5 FR CRV L 22 MM DIL L 95 MED,SUP-2913481,CDM,C1766,HCPCS,0272,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
STENT URET OPN END 7 FRX24 CM KT TWO DUROMETER SOF-CURL,SUP-2313812,CDM,C2617,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SPINAL KIT FACET FUSION LG NORTHSTAR,SUP-2741242,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
DRILL HIP PL HARD BONE 2.9MM,SUP-2812123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
HC Drain Outer Ear Canal Lesion,PX-4506902000,CDM,69020,CPT,0450,RC,,,,both,,,730.00,474.50,,,,,,,,,,,,,
CLIP ANEUR BLDE MIC L1.0MM 10GM NO1 S STL GRFT SLIM-LINE,SUP-2243091,CDM,C1889,HCPCS,0278,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
SET SCR SPNL L L10MM DIA1.5MM LUM TI OPTMA,SUP-2212645,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
PEG FIX SUBCHONDRIAL TI,SUP-2257720,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
GUIDEWIRE VASC L 210 CM DIA 0.035 IN TIP L 1.5 MM PTFE J SHP,SUP-2763622,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.52,32.19,,,,,,,,,,,,,
WIRE BNE FIX L 152 MM DIA1.1 MM DBL END TROCAR TIP NS LEOS,SUP-2933896,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.31,80.80,,,,,,,,,,,,,
PLATE BNE K 1.5X0.2 MM ORBIT FLR FOR SCREW TI NS LEVEL 1,SUP-2457682,CDM,C1713,HCPCS,0278,RC,,,,both,,,1917.60,1246.44,,,,,,,,,,,,,
PLATE BNE L105MM 4 H TI L POST LAT EL LOK VARIAX,SUP-2376028,CDM,C1713,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 6 MM STR STD WALL REINF,SUP-2681081,CDM,C1768,CPT,0278,RC,,,,both,,,491.91,319.74,,,,,,,,,,,,,
SCREW BNE L20MM DIA3MM BLU TI ST SELF DRL CANN COMPR CONIC,SUP-2242805,CDM,C1713,HCPCS,0278,RC,,,,both,,,940.05,611.03,,,,,,,,,,,,,
SCREW BNE CRTX 3.5X38 MM LP ST HD T15 STARDRV RECESS TI NS,SUP-2758267,CDM,C1713,HCPCS,0278,RC,,,,both,,,102.62,66.70,,,,,,,,,,,,,
DOBUTAMINE HCL 12.5 MG/ML IV SOLN,RX-9892,CDM,J1250,HCPCS,0636,RC,00409-2344-88,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
POST EXT FIX CIR FEMALE 5 HOLE,SUP-2400699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.87,296.97,,,,,,,,,,,,,
SCREW BNE L45MM DIA3.5MM CALCNL TI NONLOCKING HEXALOBE,SUP-2106678,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
FOOTPLATE EXT FIX 5 HOLE EXTN NS TRUELOK LTX,SUP-2875090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.28,370.03,,,,,,,,,,,,,
NECK FEM +0MM 12/14 HI OFFSET LPB FORGED SEG HIP TI ACUMATCH,SUP-2222200,CDM,C1776,CPT,0278,RC,,,,both,,,5421.37,3523.89,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM 34 HOLE ANGLED-ANGLED LCK TI STRL,SUP-2539591,CDM,C1713,HCPCS,0278,RC,,,,both,,,9818.12,6381.78,,,,,,,,,,,,,
GRAFT HUM TISS THK19-21MM IL CREST WDG TRICORT STRUCTURAL,SUP-2307028,CDM,C1713,HCPCS,0278,RC,,,,both,,,3463.42,2251.22,,,,,,,,,,,,,
KEEL LARYNGEAL MONTGOMERY SZ 14 MM SIL UMBRELLA SHP N ADH,SUP-2139780,CDM,C1889,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
DEVICE FIX 5 MMX39 CM CANN ABSORBABLE FAST OBTIFIX,SUP-2125765,CDM,C1713,HCPCS,0278,RC,,,,both,,,6860.90,4459.58,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE TIB CUST FRAC SFT,SUP-2435648,CDM,L2112,HCPCS,0272,RC,,,,both,,,1428.32,928.41,,,,,,,,,,,,,
BLADE SCREWDRIVER 15MM DIA 40MML CROSS DRIVE,SUP-2681046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,613.30,398.64,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC DIA2.5 MM STRL,SUP-2264158,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
GRAFT AMNIOTIC MEMBRANE FLOWERAMNIOPATCH 10MM DISC SIZE,SUP-2866790,CDM,Q4178,HCPCS,0636,RC,,,,both,,,2943.75,1913.44,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 IN 6 FRX26 CM 6 FR PERCFLX + DISP,SUP-2139106,CDM,C2617,HCPCS,0278,RC,,,,both,,,441.14,286.74,,,,,,,,,,,,,
CUTTER BOLT THOR LUM SPNL FOR INNR TB,SUP-2289764,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.76,1008.64,,,,,,,,,,,,,
CATHETER PTCA 4FR L150CM BLLN L120MM DIA2MM 14ATM 0.014IN,SUP-2172592,CDM,C1725,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
OSS 5CM OSSEOTI PROX TIB SLV,SUP-2506333,CDM,C1776,CPT,0278,RC,,,,both,,,9311.67,6052.59,,,,,,,,,,,,,
NAIL IM L32CM DIA93MM UNIV TIB YEL TI ALLY NAT NAIL,SUP-2208206,CDM,C1713,HCPCS,0278,RC,,,,both,,,4864.24,3161.76,,,,,,,,,,,,,
SCREW BONE 4.5X12MM SPNL VAR ANG ST,SUP-2353301,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
CATHETER CV JACC 5.5 FRX30 CM DL PRESSURE INJ ADV LF,SUP-2763378,CDM,C1751,HCPCS,0278,RC,,,,both,,,814.30,529.29,,,,,,,,,,,,,
NEEDLE LOC L5CM DIA21GA BRST LESION MOD NONPALPABLE DISP QK,SUP-2167885,CDM,C1819,HCPCS,0278,RC,,,,both,,,93.51,60.78,,,,,,,,,,,,,
SET CATH HEMODIALYSI ACUTE 12FR DIA 20CM 2LM INDWL BLU FLEXT,SUP-2613328,CDM,C1752,HCPCS,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
SHOE POSTOP SM 7-9 LO PROF FOAM/NYLON MESH M LOOP LOK CLSR,SUP-2197104,CDM,L4387,HCPCS,0272,RC,,,,both,,,15.13,9.83,,,,,,,,,,,,,
GUIDEWIRE VASC ARISTOTLE ZOOM WIRE 14 L 300CM 0.014IN SUPP,SUP-2656743,CDM,C1769,HCPCS,0272,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
IMMOBILIZER KNEE 3 PNL 19 IN,SUP-2336076,CDM,L1830,CPT,0274,RC,,,,both,,,37.65,24.47,,,,,,,,,,,,,
CANNULA SURG A INSUL MARS 3V,SUP-2417904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
SPACER UROLOGICAL PEG HYDROGEL PERIRECTAL TEMPORARY RADIOTHERAPY SPACEOAR VUE,SUP-2902926,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GRAFT HUM TISS PERICARD 5X7 CM LT,SUP-2400554,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
BLADE SHV OD4MM 40DEG STD SERR CLS DS ELITE COMPATIBLE DIEGO,SUP-2313526,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.17,273.76,,,,,,,,,,,,,
T-PLT STERILIZER 6 HL 116 MM LENGTH,SUP-2818507,CDM,C1713,HCPCS,0278,RC,,,,both,,,2259.98,1468.99,,,,,,,,,,,,,
PLATE BNE L193MM 10 H S STL LOK COMPR FOR 4.5MM SCR,SUP-2348943,CDM,C1713,HCPCS,0278,RC,,,,both,,,5695.65,3702.17,,,,,,,,,,,,,
METACARPAL NAIL 4.6MM / 7.6MMX60MM TI,SUP-2340240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1813.35,1178.68,,,,,,,,,,,,,
PLATE SPNL L28MM ANT CERV TI ALLY LEV 2 XTEND,SUP-2230260,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
GRAFT BNE 8MM WDG ALLGRFT,SUP-2244473,CDM,C1713,HCPCS,0278,RC,,,,both,,,6614.06,4299.14,,,,,,,,,,,,,
PLATE BONE MINI L L37MM 110DEG RT,SUP-2364918,CDM,C1713,HCPCS,0278,RC,,,,both,,,270.83,176.04,,,,,,,,,,,,,
CAGE SPINAL ANTERIOR LUMBAR 22MM AERO-AL,SUP-2867351,CDM,C1889,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SPACER SPNL W20XH8XL60MM M TRANSCONTINENTAL,SUP-2231326,CDM,C1821,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
PLATE BNE 8 H L DST MED TIB LOK W/O TAB FOR 3.5MM SCR,SUP-2349081,CDM,C1713,HCPCS,0278,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
PACEMAKER CRD BI VENTRIC IS-1/IS4-LLLL QUADRA ALLURE MP RF,SUP-2356475,CDM,C2621,HCPCS,0275,RC,,,,both,,,24601.90,15991.23,,,,,,,,,,,,,
PIN FIX CLLRLSS 2.6 MM THRD ERGO,SUP-2451462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CANNULA ENDOSCP LT 10X41 MM STRL MONTGOMERY DISP,SUP-2139783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
WASHER ORTH DIA13MM STRL TRIGEN MAX,SUP-2933160,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN (ADD-VANTAGE),RX-40860021,CDM,J7060,HCPCS,0250,RC,00409-7100-02,NDC,,both,250,ML,48.90,31.78,,,,,,,,,,,,,
SET INSTR SM EXT FIX GRPHC CA W/ S STL SELF DRL SCHNZ SCR,SUP-2183086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,45414.17,29519.21,,,,,,,,,,,,,
HC Cta Heart W/WO Calcium|REDUCED SERVICES,PX-3507557400,CDM,75574,CPT,0480,RC,,,52,both,,,2388.00,1552.20,,,,,,,,,,,,,
HEAD RAD DIA18MM CO CHROM W/ LOK SCR ALIGN,SUP-2340136,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
COMPONENT TIB CEM FIN 1F/1T 2F/1T,SUP-2222592,CDM,C1776,CPT,0278,RC,,,,both,,,6367.92,4139.15,,,,,,,,,,,,,
STEM HUM CEM 2C STD 137.5 DEG 66 MM SHLDR AEQUALIS ASCEND,SUP-2715765,CDM,C1776,CPT,0278,RC,,,,both,,,11062.22,7190.44,,,,,,,,,,,,,
HC Culture Type Immunolog,PX-3008714700,CDM,87147,CPT,0300,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
CATHETER MAHRK ELITE ST 3 LUMN 12.5 FR X .016 CM,SUP-2283966,CDM,C1752,HCPCS,0278,RC,,,,both,,,342.86,222.86,,,,,,,,,,,,,
PLUG FEN HIP STEM NO 3,SUP-2377824,CDM,C1776,CPT,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX TI EPOXY RESIN SIL STRL,SUP-2138113,CDM,C1882,HCPCS,0275,RC,,,,both,,,78766.90,51198.48,,,,,,,,,,,,,
SIZER BRST 620CC W14XH13.2CM P6.9CM COHESIVE III SIL GEL HI,SUP-2300824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN 55 DEG L 79.4 CM DIA 8.5 FR BRAIDED,SUP-2880097,CDM,C1893,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SCREW AX MULT 3603536 35 X 36MM,SUP-2285460,CDM,C1713,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
CRYOABLATION PROC KT - VAR (4X CVA2400 4X CRYO-55-F 1X,SUP-2885357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12324.50,8010.92,,,,,,,,,,,,,
MATRIX HUM TISS L 6 X W 7 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909281,CDM,Q4122,HCPCS,0636,RC,,,,both,,,9198.63,5979.11,,,,,,,,,,,,,
TUBE MYR DIA132MM L132MM T GRMMT SIL ST RICHARDS,SUP-2313725,CDM,L8699,HCPCS,0278,RC,,,,both,,,66.54,43.25,,,,,,,,,,,,,
STENT URET 7 FRX28 CM W/O GUIDEWIRE LUB FLX,SUP-2313790,CDM,C2617,HCPCS,0278,RC,,,,both,,,275.28,178.93,,,,,,,,,,,,,
HEAD FEM OD36MM CO CHROM MTL ON MTL HIP CEM CONSERVE +,SUP-2304497,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-40840056,CDM,J3490,HCPCS,0258,RC,00338-0085-04,NDC,,both,250,ML,12.80,8.32,,,,,,,,,,,,,
GRAFT SURG REGEN PORCINE CLLGN XENMATRIX RECT 10CM X 28CM,SUP-2126241,CDM,C1781,HCPCS,0278,RC,,,,both,,,26844.80,17449.12,,,,,,,,,,,,,
SCREW BNE ST 2X4 MM MAND MXLFCL MONOCORTICAL TI BLU NS LF,SUP-2189547,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.33,190.01,,,,,,,,,,,,,
GRAFT HUM TISS W8XL20CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307555,CDM,Q4128,HCPCS,0636,RC,,,,both,,,13588.35,8832.43,,,,,,,,,,,,,
SCREW BNE EMGCY 2.3X14 MM ST MINI PLATING CROSS PIN HD TI 5PK,SUP-2366174,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.10,141.76,,,,,,,,,,,,,
WIRE ORTH L229MM DIA1.6MM S STL DBL DMND BAYNT TIP SMOOTH K,SUP-2412970,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.61,23.15,,,,,,,,,,,,,
PLATE BNE L MED NAR 0.6 MM RT LP WEB TI,SUP-2473225,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0035IN S STL PTFE HVY DUTY SAFE T J,SUP-2167580,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.79,21.96,,,,,,,,,,,,,
BLADE SURG TISSUE LIBERATOR UP BEND,SUP-2745478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
STEM FEM DIA15MM LT HIP L STAT LNG REPLICA,SUP-2251984,CDM,C1776,CPT,0278,RC,,,,both,,,21863.82,14211.48,,,,,,,,,,,,,
CATHETER NEPHROSTOMY HYDRPHLC TIP 10 FRX25 CM KT REG TEMPTIP,SUP-2147905,CDM,C1729,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SCREW BNE CANN 4X32 MM FT,SUP-2342796,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.83,265.74,,,,,,,,,,,,,
ARCOS 9.5X175MM BRCH BODY STD,SUP-2506134,CDM,C1776,CPT,0278,RC,,,,both,,,12107.84,7870.10,,,,,,,,,,,,,
PLATE BNE W13.5XL260MM THK4.2MM 14 H BILAT S STL NAR LOK,SUP-2185253,CDM,C1713,HCPCS,0278,RC,,,,both,,,1901.74,1236.13,,,,,,,,,,,,,
GRAFT BNE VIABLE 5CC TIM MTRX FIBERCEL,SUP-2422146,CDM,C1762,CPT,0278,RC,,,,both,,,9592.70,6235.25,,,,,,,,,,,,,
CAGE SPNL 22X9X8MM 15DEG LO PROF LORDTC EXP W/ TANT MRK,SUP-2354698,CDM,C1889,HCPCS,0278,RC,,,,both,,,17332.80,11266.32,,,,,,,,,,,,,
VALVE SHUNT REG EXTRACTED STRATA II,SUP-2628601,CDM,C1889,HCPCS,0278,RC,,,,both,,,13380.89,8697.58,,,,,,,,,,,,,
NECK FEM L30MM 8DEG YEL MOD HIP REJUVENATE,SUP-2378895,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BONE CAP FOR GAM NAIL,SUP-2370986,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.03,267.17,,,,,,,,,,,,,
STRAIGHT SCTN BLADE W/SRRTD EDGE RCTNGLR WNDW4MMX12CM5/PKG S,SUP-2574158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
GRAFT BNE SUB 5CC 2MM GRAN ALLOGENIC MORPHOGENETIC PROT W,SUP-2138491,CDM,C1713,HCPCS,0278,RC,,,,both,,,3250.69,2112.95,,,,,,,,,,,,,
BIT DRL DIA48MM HI SPD,SUP-2187155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,799.19,519.47,,,,,,,,,,,,,
SLITTER PACE SELECTRA CORONARY SINUS FOR TELSCP LD DEL SYS,SUP-2699211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE W13XL109MM THK2MM 6 H S STL CLVRLF BTTRS BILAT,SUP-2362732,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.65,1252.97,,,,,,,,,,,,,
CATHETER CHOLGM L50CM L52CM OD5FR 0.035IN GWIRE DISP FOR,SUP-2168432,CDM,C1894,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
HEAD FEM FRSH FRZN,SUP-2113953,CDM,C1713,HCPCS,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
IMPLANT TOE L13MM DIA2MM S STL CANN COMPR HAMRTOE FIX SYS,SUP-2397840,CDM,C1776,CPT,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
CATHETER DRIANAGE SUMP PERCFLX MAT N COAT 12FR 30CM,SUP-2147732,CDM,C1729,HCPCS,0272,RC,,,,both,,,294.31,191.30,,,,,,,,,,,,,
PLATE BONE THK0.5MM 10 H RESRB POLYMER CRANIOMAXILLOFACIAL,SUP-2365071,CDM,C1713,HCPCS,0278,RC,,,,both,,,1629.38,1059.10,,,,,,,,,,,,,
STEM FEM SZ 0 LT SH NK N CLLRD POR NATURAL-HIP,SUP-2210767,CDM,C1776,CPT,0278,RC,,,,both,,,13531.83,8795.69,,,,,,,,,,,,,
RASP SURG L10.5IN SATIN FINISH DBL END W/ FLAT TAPERING,SUP-2161317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.15,202.90,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X4.75 MM ARMSTR STYL PLASTI PORE,SUP-2637840,CDM,L8613,CPT,0278,RC,,,,both,,,509.28,331.03,,,,,,,,,,,,,
PLATE BNE STR MINI SM 2-2.5X1 MM 7 MM 4 HOLE LCK TLTS TI,SUP-2459206,CDM,C1713,HCPCS,0278,RC,,,,both,,,1668.56,1084.56,,,,,,,,,,,,,
GUIDEWIRE HYDR 0.014IN 8CM ANG 190CM,SUP-2303425,CDM,C1769,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
WASHER EXT FIX D SALVATION,SUP-2459036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
PLATE BNE W12XL90MM THK2.5MM 3 H BILAT PROX HUM TI RIG LOK,SUP-2190988,CDM,C1713,HCPCS,0278,RC,,,,both,,,4624.91,3006.19,,,,,,,,,,,,,
FIBER LASER BALL TIP 1000 MH FOR USE W/ KTP/YAG,SUP-2225627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1325.08,861.30,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZN 4CMX5CM M HMTRX,SUP-2125441,CDM,Q4134,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
LENS INTOCU PMMA +15 D L12.5 MM OD6 MM EQCNVX ANTR CHMBR,SUP-2129478,CDM,V2630,CPT,0276,RC,,,,both,,,160.71,104.46,,,,,,,,,,,,,
TUBING ANGIO L72IN OD0.142IN ID0.071IN 1200PSI POLYUR DST,SUP-2302661,CDM,C1713,HCPCS,0278,RC,,,,both,,,20.25,13.16,,,,,,,,,,,,,
STRUT EXT FIX XSH UNIV HINGED,SUP-2475657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PLATE BNE L 213 MM 15 H SS LT PROX HUM CRV STRL EVOS,SUP-2931174,CDM,C1713,HCPCS,0278,RC,,,,both,,,6331.50,4115.47,,,,,,,,,,,,,
INTRODUCER SHTH LAMP 90 CRV AD 8.5 FRX81 CM ACCS PEELWY,SUP-2357231,CDM,C1893,HCPCS,0272,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
COLCHICINE 0.6 MG PO TABS,RX-1821,CDM,6370000000,HCPCS,0637,RC,67877-0589-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE L65MM DIA5MM CORT TI SELF DRL LOK HEX RECESS,SUP-2190751,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.00,382.85,,,,,,,,,,,,,
PLATE BNE RNG ATTCH LG 3.5 MM RT PROX GTR TROCH NS VA-LCP,SUP-2757654,CDM,C1713,HCPCS,0278,RC,,,,both,,,4360.02,2834.01,,,,,,,,,,,,,
SCREW BNE L75MM DIA4.5MM LNG THRD L30MM TAN CANN SELF DRL,SUP-2181437,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.55,618.51,,,,,,,,,,,,,
INSERT TIBIALXS-SM THK8MM UNI UNI GEN,SUP-2344271,CDM,C1776,CPT,0278,RC,,,,both,,,2720.03,1768.02,,,,,,,,,,,,,
BOOT WLK N PNEUMAT,SUP-2319135,CDM,L4386,HCPCS,0274,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
BRACE ORTH CLOSURE XL AD BK SHLDR BLK QUIKDRAW PRO,SUP-2123913,CDM,L0628,HCPCS,0272,RC,,,,both,,,321.98,209.29,,,,,,,,,,,,,
HC Tmvi W/Prosthetic Valve Percutaneous Approach,PX-3600483000,CDM,0483T,CPT,0360,RC,,,,both,,,44930.00,29204.50,,,,,,,,,,,,,
COMPONENT TIB MOD PROX 130MM LGTH FINN - 130MM LEN,SUP-2406135,CDM,C1776,CPT,0278,RC,,,,both,,,16811.56,10927.51,,,,,,,,,,,,,
PLATE BNE STR MED 1.5X108X0.8 MM MIDFACE 24 HOLE W/ TAB NS,SUP-2483419,CDM,C1713,HCPCS,0278,RC,,,,both,,,1063.05,690.98,,,,,,,,,,,,,
HC Removal of FB,PX-4502052500,CDM,20525,CPT,0450,RC,,,,both,,,8301.00,5395.65,,,,,,,,,,,,,
IMPL CAPPED KNEE GSF FXCM FEMTIB SUR STDPAT,SUP-2212248,CDM,C1776,CPT,0278,RC,,,,both,,,16180.36,10517.23,,,,,,,,,,,,,
SET CATH PERITONEAL DIALYSI V SER BASIC 15FR DIA MC20VS43LS,SUP-2633014,CDM,C1752,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8 MM EPTFE STR TW REINF 2,SUP-2681202,CDM,C1768,CPT,0278,RC,,,,both,,,2189.21,1422.99,,,,,,,,,,,,,
CATHETER CV 3L 6 FRX135 CM TY IRRIGATION POWERPICC SOLO 2,SUP-2126405,CDM,C1751,HCPCS,0278,RC,,,,both,,,743.24,483.11,,,,,,,,,,,,,
BASEPLATE TIB 00 POR PRI LT STEM N-K LL,SUP-2209282,CDM,C1776,CPT,0278,RC,,,,both,,,7429.24,4829.01,,,,,,,,,,,,,
COMPONENT FEM 67.5MM R KNEE TINBN NP POST STBL OPN BX,SUP-2407485,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CLAMP EXT FIX DBL UNIV MULT PIN GEM FIX NS GALAXY LTX,SUP-2875227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4975.83,3234.29,,,,,,,,,,,,,
INTRODUCER CATHETER L32CM PERC SHLD,SUP-2133169,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.92,77.95,,,,,,,,,,,,,
KIT EEG ELECTRD L 80 MM 16 CONTACT STRL DISP EVO,SUP-2936489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3567.04,2318.58,,,,,,,,,,,,,
TUBE TRACH JACKSON 4 8 MMX2.75 IN REG LEN 3 PC SET DBL ACT,SUP-2867585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.83,223.49,,,,,,,,,,,,,
GUAIFENESIN-DM 100-10 MG/5ML PO SYRP,RX-15816,CDM,6370000000,HCPCS,0637,RC,00121-1276-10,NDC,,both,5,ML,10.00,6.50,,,,,,,,,,,,,
INTRODUCER LD 9 FRX50 CM SET CRD STD CS ACCS SAFSHTH WORLEY,SUP-2138101,CDM,C1893,HCPCS,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
ROD SPNL REVOLVE OD5.5 MMXL80 MM,SUP-2230517,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRIP CBL SM L75MM TROCHANTERIC HIP 3 CBL ACCORD,SUP-2345200,CDM,C1776,CPT,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
BASKET RETRV L1550MM DIA32MM MIN WRK CHN 2MM 4 WIRE TRAP,SUP-2313130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.11,754.72,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM DIA 8 MM POLYESTER BOV CLLGN,SUP-2476065,CDM,C1768,CPT,0278,RC,,,,both,,,1182.37,768.54,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT TI DURABRAID W/ TWO 38 5MM DIA TWINFIX,SUP-2341650,CDM,C1713,HCPCS,0278,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
GRAFT BNE SPNG 20X15X5 MM DBM CANC,SUP-2641782,CDM,C1713,HCPCS,0278,RC,,,,both,,,2742.16,1782.40,,,,,,,,,,,,,
CATHETER THROMCTMY 4.5 MM REVIVE PV,SUP-2530214,CDM,C1757,HCPCS,0272,RC,,,,both,,,6609.70,4296.30,,,,,,,,,,,,,
SCREW SPNL L45MM DIA5.5MM ANTR THORLUM FOR TRAVERSEXLP + SYS,SUP-2311617,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE L68MM 3 H BILAT TI T SHP LIMIT CNTCT DYN LOK,SUP-2190889,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.47,600.26,,,,,,,,,,,,,
PLATE BNE L43MM 2X2 H ST BILAT TARSOMETATARSAL TI T SHP LO,SUP-2181257,CDM,C1713,HCPCS,0278,RC,,,,both,,,3504.84,2278.15,,,,,,,,,,,,,
HC Inj Aa&/Strd Greater Occipital Nerve,PX-4506440500,CDM,64405,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BONE W9XL43MM AUG 11MM CO CHROM RIG FOR MAESTRO TOT WR,SUP-2407333,CDM,C1776,CPT,0278,RC,,,,both,,,19615.58,12750.13,,,,,,,,,,,,,
COLLAR CERV ADJ XL 20X3 IN COTTON MED DENS PREMIERPRO,SUP-2335997,CDM,L0120,HCPCS,0272,RC,,,,both,,,22.55,14.66,,,,,,,,,,,,,
ROD SPNL CLP 6.35 MM,SUP-2661696,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
ALLOGRAFT ACHILLES TEND W/ CALCANEUS FRZN LEN 19.5-38CM,SUP-2419467,CDM,C1762,CPT,0278,RC,,,,both,,,6226.24,4047.06,,,,,,,,,,,,,
STEM RAD L40MM OD9MM WRST IMPL MAESTRO,SUP-2407299,CDM,C1776,CPT,0278,RC,,,,both,,,4049.34,2632.07,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 90 CM DIA 4 FR SLT PAT L 50 CM,SUP-2117145,CDM,C1889,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
HC Renal Biopsy Percutaneous,PX-3615020000,CDM,50200,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW BNE L120MM DIA12MM HIP NAIL LAG FOR TRAUM GAM,SUP-2370995,CDM,C1713,HCPCS,0278,RC,,,,both,,,865.07,562.30,,,,,,,,,,,,,
EXTRACTOR STONE L38CM DIA10FR BSKT DIA2CM TIPLSS NIT WIRE S,SUP-2171367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,490.78,319.01,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 100 MM DIA 6 MM DEL SYS L 190 CM,SUP-2866171,CDM,C1876,HCPCS,0278,RC,,,,both,,,4168.88,2709.77,,,,,,,,,,,,,
CATHETER CV TY STRL LTX,SUP-2876536,CDM,C1751,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CAP END 7.5 DEG 14 MM 10 MM CAGE VUMESH,SUP-2707739,CDM,C1889,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
"HC Est Pt, E/M Level 1",PX-5109921100,CDM,99211,CPT,0510,RC,,,,inpatient,,,174.00,113.10,,,,,,,,,,,,,
CATHETER PERITONEAL DSTL OPN ACCU-FLO,SUP-2666407,CDM,C1729,HCPCS,0272,RC,,,,both,,,700.35,455.23,,,,,,,,,,,,,
BAR CRV FIBERGLASS 380MM,SUP-2484869,CDM,C1713,HCPCS,0278,RC,,,,both,,,1852.57,1204.17,,,,,,,,,,,,,
CANNULA ENDOSCP SUCTION 4.5 MMX12 CM SIMMEN INSUL ANGULAR,SUP-2774731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.83,465.29,,,,,,,,,,,,,
STENT PERIPH L25CM DIA8MM CATH 7FR L120CM BAL DIA8MM,SUP-2396638,CDM,C1874,HCPCS,0278,RC,,,,both,,,20080.30,13052.19,,,,,,,,,,,,,
GRAFT SURG PROC HUM DERM CLLGN RECTANG 1MM 16CMX20CM,SUP-2125867,CDM,C1781,HCPCS,0278,RC,,,,both,,,36832.20,23940.93,,,,,,,,,,,,,
MESH HERN PTCH 14 MMX8 CM NYL SUPRAMESH,SUP-2335982,CDM,C1781,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,J7060,HCPCS,0258,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
CUP ACET MLRY HD 26X62 MM 3 HOLE HIP SYS,SUP-2449900,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM 36 HOLE ANGLED-ANGLED LCK TI STRL,SUP-2539592,CDM,C1713,HCPCS,0278,RC,,,,both,,,10421.13,6773.73,,,,,,,,,,,,,
PROPOFOL 100 MG/10ML IV EMUL,RX-133089,CDM,J2704,HCPCS,0636,RC,63323-0269-16,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
VALVE HEMOSTAS DBL PLAY LUMEN DIA 9 FR POLYCARB SIL Y LG BOR,SUP-2303044,CDM,C1713,HCPCS,0278,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
HC Mra Lower Extremities W/Contr,PX-6107372500,CDM,C8912,CPT,0610,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
CATHETER GUID AD 6FR L100CM COR PERIPH GRN NYL PTFE JL 5,SUP-2158129,CDM,C1887,HCPCS,0272,RC,,,,both,,,112.10,72.86,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|ADJ|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4409753000,CDM,97530,CPT,0440,RC,,,GO|ADJ|CQ,both,,,191.00,124.15,,,,,,,,,,,,,
NEBIVOLOL HCL 10 MG PO TABS,RX-89286,CDM,6370000000,HCPCS,0637,RC,00904-7499-04,NDC,,both,1,UN,15.80,10.27,,,,,,,,,,,,,
KIT PERC DILATIONAL TRACH TUBE DIA 8 MM CONN 15 MM DIL ERGO,SUP-2887140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1183.81,769.48,,,,,,,,,,,,,
GRAFT BNE SUB 10ML HA CLLGN INJ FILL RESRB HEALOS FX,SUP-2255630,CDM,C1713,HCPCS,0278,RC,,,,both,,,5595.48,3637.06,,,,,,,,,,,,,
SPACER SPNL W10XH8-12XL22MM TRANSFORAMINAL LUM INTBDY FUS,SUP-2230679,CDM,C1821,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
PLATE BNE L51MM THK3.3MM 4 H BILAT S STL STR LIMIT CNTCT,SUP-2185127,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.97,531.03,,,,,,,,,,,,,
KNIFE SRGCL GLDMN 7INL 3MM GUIDE LEFT ANGLD LATEX FREE,SUP-2705498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.38,289.50,,,,,,,,,,,,,
DRILL SURG GRAD BRAD PT,SUP-2196675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CATHETER HD DL 15.5 FRX32 CM STACKED TIP CHRONIC DURAMAX,SUP-2117417,CDM,C1750,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE EXT FIX L50MM ANK FT FOR TRUELOK FRME ASSEMB HEXAPOD,SUP-2316157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.31,268.00,,,,,,,,,,,,,
HEAD RADIAL REPL EXPLORE,SUP-2416960,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
SCREWDRIVER BLADE 2 MM MAXILLOMANDIBULAR SL FIX SCR MAXDRIVE,SUP-2457855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1555.93,1011.35,,,,,,,,,,,,,
PROBE LASER 25GA STANDARD STRAIGHT STELLARIS PC,SUP-2494234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.82,213.08,,,,,,,,,,,,,
BLADE SAW 11.5X7 MM INT ORAL,SUP-2632407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.41,213.47,,,,,,,,,,,,,
GUIDEPIN SURG L16MM CRUC RET FLX,SUP-2201245,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT PT TRL INCLUDE EXT BELT AND BTTRY FOR SPNL CRD STIM,SUP-2141951,CDM,C1897,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE PROX 3.5X232 MM LT TIB 16 HOLE SS NS,SUP-2177844,CDM,C1713,HCPCS,0278,RC,,,,both,,,5315.71,3455.21,,,,,,,,,,,,,
BLADE SURG OPHTH 20 GAX1.2 MM 23 MM MVR DISP,SUP-2458241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,68.55,44.56,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT COMPRESSIBLE SPNG M GROWTH FACT,SUP-2138503,CDM,C1713,HCPCS,0278,RC,,,,both,,,8035.26,5222.92,,,,,,,,,,,,,
ADAPTER SL +4MM OFFSET UNIV HIP TI V40 TAPR ACCOLADE II,SUP-2376608,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
KIT VASC SNR AMPLTZ GOOSE NK 90 DEG L 120 MM LOOP DIA25 MM,SUP-2172948,CDM,C1773,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1274108D1,SUP-2632799,CDM,C1751,HCPCS,0278,RC,,,,both,,,790.50,513.82,,,,,,,,,,,,,
HC CT for Limited or Localized St,PX-3507638000,CDM,76380,CPT,0350,RC,,,,both,,,2769.00,1799.85,,,,,,,,,,,,,
PARTICLE EMB EMBOCUBE HYDRATED SZ 5 MM CATH 0.04 IN 100MG,SUP-2701310,CDM,C1889,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SHOE ORTHOT ADDITION TOE TAP HRS,SUP-2435740,CDM,L3560,HCPCS,0274,RC,,,,both,,,64.75,42.09,,,,,,,,,,,,,
BROMOCRIPTINE MESYLATE 5 MG PO CAPS,RX-9296,CDM,6370000000,HCPCS,0637,RC,00378-7096-93,NDC,,both,1,UN,33.60,21.84,,,,,,,,,,,,,
MONITOR CARD JOT DX L 9.4 X H 49 MM THK 3.1 MM 1.4 ML 3 GM,SUP-2754048,CDM,C1764,HCPCS,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
CATHETER ABLATN D-D 2-5-2 MM 2MM 7 FRX115 CM EZ STEER LF,SUP-2248510,CDM,C1732,HCPCS,0278,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
CATHETER HEMODIALYSI SLXACUTE 14FR DIA LG 15CM STRGHT TAPR T,SUP-2610567,CDM,C1752,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
PIN FIX ANCHR 4X55 MM DISP,SUP-2657180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1487.45,966.84,,,,,,,,,,,,,
BRACE WR AD UNIV LT AND RT ELAS SUPP STRP FOAM CUSH WRP ARND,SUP-2309133,CDM,L3931,HCPCS,0272,RC,,,,both,,,52.09,33.86,,,,,,,,,,,,,
DEVICE FIX MED MIS BUNION MAX SHIFT PROSTEP TBC,SUP-2435406,CDM,C1713,HCPCS,0278,RC,,,,both,,,4012.92,2608.40,,,,,,,,,,,,,
CATHETER REPROC DIAG EP MAPPING 5FRX10MMX120CM,SUP-2467425,CDM,C1730,HCPCS,0272,RC,,,,both,,,221.68,144.09,,,,,,,,,,,,,
RAMIPRIL 2.5 MG PO CAPS,RX-11260,CDM,6370000000,HCPCS,0637,RC,65862-0475-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT ACCSRY 1.5MM FOR INSTAFIX IMPL KT,SUP-2418145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
SET GASTSTMY M DIL 16X18FR SHTH 18X20FR DISP STRT INIT,SUP-2170216,CDM,C1769,HCPCS,0272,RC,,,,both,,,331.24,215.31,,,,,,,,,,,,,
CENTRALIZER STEM DIA13MM DST FEM HIP NP CEM PFC SIG,SUP-2253266,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
BEARING TOE SM POLYETH PHLANG IMPL,SUP-2404749,CDM,C1776,CPT,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
PEG BNE L 11 MM DIA1.8 MM SS WR LCK T7 DRV STRL EVOS,SUP-2931457,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.25,255.61,,,,,,,,,,,,,
SCREW BONE 2.7MM DIA 6MML CORTICAL HEX,SUP-2588490,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.96,37.67,,,,,,,,,,,,,
GUIDEWIRE SINGLE ENDED TROCAR TIP SMOOTH 1.1 X 100MM,SUP-2321615,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA4X3MM THRD L20MM CORT TI SELF DRL,SUP-2193158,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.19,327.07,,,,,,,,,,,,,
OCCLUDER OCL12US TALENT AAA 12MM,SUP-2281269,CDM,C1768,CPT,0278,RC,,,,both,,,7771.50,5051.47,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH SWARTZ SL L 85 CM DIA10 FR GUIDEWIRE,SUP-2357209,CDM,C1893,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE STR 2.3 MM 27 HOLE FRAC FOR SCR TI LEVEL 1,SUP-2468678,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.33,1010.31,,,,,,,,,,,,,
PERI-LOC 2.5MM T7 LOCK SCREW 30MM S-T,SUP-2820439,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.52,627.59,,,,,,,,,,,,,
MESH 3IN PTCH MK W POSIFLEX CIR W STRP AND PRESHAPED,SUP-2126066,CDM,C1781,HCPCS,0278,RC,,,,both,,,246.33,160.11,,,,,,,,,,,,,
GUIDEWIRE VASC SOLO + L 150 CM DIA 0.035 IN PTFE TRITON,SUP-2655880,CDM,C1769,HCPCS,0272,RC,,,,both,,,206.17,134.01,,,,,,,,,,,,,
PLATE BONE LOK 124MML HLX7 YELLW ST RIGHT PSTRLTRL DST HMRL,SUP-2481713,CDM,C1713,HCPCS,0278,RC,,,,both,,,2835.77,1843.25,,,,,,,,,,,,,
SPACER SPNL 10 DEG L 14 X W 11 X H 6 MM PEEK TI ANTR CERV,SUP-2925361,CDM,C1889,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
PLUG BONE INSRTR CALIB W/ DEPTH MRK RETRCT PCL PUSH CEM,SUP-2364406,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.77,704.45,,,,,,,,,,,,,
CATHETER HD 11.5 FRX15 CM FULL TY KINK RESISTANCE 5/BX,SUP-2267019,CDM,C1750,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 6-10 CM SEG FD FIB,SUP-2321798,CDM,C1713,HCPCS,0278,RC,,,,both,,,1654.78,1075.61,,,,,,,,,,,,,
KIT CUTTING S17 DISP BIO UNI,SUP-2741103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
HC So Ehrlichia Chaffeensis Igg /Igm,PX-3028666666,CDM,86666,CPT,0302,RC,,,,both,,,132.00,85.80,,,,,,,,,,,,,
HEAD FEM 12/14 TAPR PRI MTL ON POLY CO CHROM 22MM DIA +0 NK,SUP-2198944,CDM,C1776,CPT,0278,RC,,,,both,,,2265.51,1472.58,,,,,,,,,,,,,
CARTRIDGE SUT WHT MAG WIRE AND COBRAID SPEEDSTITCH,SUP-2342096,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 0.70 CC FD CORTICAL PWD ORAGRAFT,SUP-2741047,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.57,129.07,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 100MM H2O + OR MINUS 10MM H2O,SUP-2666798,CDM,C1889,HCPCS,0278,RC,,,,both,,,3386.08,2200.95,,,,,,,,,,,,,
ALLOGRAFT SI INTRA ART FUS 11MM,SUP-2880425,CDM,C1713,HCPCS,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
KIT SURG PROC STD COR KNOT DEV,SUP-2265303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CEMENT BONE 40GM FULL DOSE POLYMETHYLMETHACRYLATE W/O,SUP-2253082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1134.17,737.21,,,,,,,,,,,,,
PLATE BNE LOK COMPR FOR 3.5MM SCR SYS,SUP-2413709,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.16,612.40,,,,,,,,,,,,,
BIT DRL TWST SUT ANCHR 1.9MM DBL LD DISP SUTFIX ULT,SUP-2341897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,729.67,474.29,,,,,,,,,,,,,
PLATE CRAN L 23.62 X W 18.5 MM SCREW DIA1.5 MM TI,SUP-2935842,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
SCREW BNE HD 5X22.5 MM CORTICAL DYNANAIL,SUP-2277460,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
OBTURATOR ENDOSCP BLNT 10 MM SINGLE PRT DA VINCI REUSE,SUP-2246709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PROCESSOR COCHLEAR SUPER POWER BAHA 5,SUP-2823578,CDM,L8690,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
WAND ABLAT ELIM W/O SUCT 90DEG 4.5MM,SUP-2341960,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
PLATE BNE L155MM 9 H L PROX PERIARTC ULNA LOK,SUP-2198454,CDM,C1713,HCPCS,0278,RC,,,,both,,,2504.59,1627.98,,,,,,,,,,,,,
LARGE EXTERNAL FIXATOR TRAUMA KIT-STERILE,SUP-2546225,CDM,C1713,HCPCS,0278,RC,,,,both,,,10833.38,7041.70,,,,,,,,,,,,,
AUGMENT FEM 2XL THK12MM STD UNIV LT MEDL RT LAT DSTL KNEE,SUP-2407026,CDM,C1776,CPT,0278,RC,,,,both,,,2226.89,1447.48,,,,,,,,,,,,,
DEVICE FIXATION 35MM NONSUTURE FOR SOFT TISSUE CONTINUOUS LO,SUP-2824701,CDM,C1713,HCPCS,0278,RC,,,,both,,,702.54,456.65,,,,,,,,,,,,,
BLADE SAW SM BNE 90X12.5 MM RASP,SUP-2661990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,76.24,49.56,,,,,,,,,,,,,
CANNULA ENDOSCP W/ OBTURATOR FLOWPORT II,SUP-2663978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.94,812.46,,,,,,,,,,,,,
PLATE BNE L 78 MM SCREW DIA 3.5 MM 4 HD 6 SHFT H TI T SHP NS,SUP-2907621,CDM,C1713,HCPCS,0278,RC,,,,both,,,3709.13,2410.93,,,,,,,,,,,,,
KIT BNE SCR 3MM HDLSS W/ RMR,SUP-2175121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
CROWN DENT 3 S STL LO RT 1ST PRI M MINIMAL ADJ PRETRIMMED,SUP-2238877,CDM,D6783,CPT,0278,RC,,,,both,,,25.87,16.82,,,,,,,,,,,,,
LEAD DEFIB SPRNT QUATTRO SECUR S L 58 CM DIA 8.6 FR SIL,SUP-2282247,CDM,C1777,HCPCS,0275,RC,,,,both,,,9744.24,6333.76,,,,,,,,,,,,,
BUR SURG 7.5MMDIA 4.5MML LNG FLUT DR CUT HD TPS MIDAS REX,SUP-2363367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.36,227.73,,,,,,,,,,,,,
MODEL ANAT MAXILLA 3D CT BASE OSTEOVIEW,SUP-2883626,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4386.52,2851.24,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, SECOND DIGIT",CASE-28308,LOCAL,28308,CPT,,,,,T1,outpatient,,,19207.23,11524.34,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,LOCAL,26055,CPT,,,,,F7|XU,outpatient,,,14409.52,8645.71,,,,,,,,,,,,,
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,LOCAL,67900,CPT,,,,,50,outpatient,,,64260.53,38556.32,,,,,,,,,,,,,
Arthroplasty Ankle W/Implant|LEFT SIDE,CASE-27702,LOCAL,27702,CPT,0360,RC,,,LT,outpatient,,,85042.58,51025.55,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE|PO,CASE-28090,LOCAL,28090,CPT,,,,,LT|PO,outpatient,,,16375.20,9825.12,,,,,,,,,,,,,
Fasciectomy Plantar Fascia Partial Spx|BILATERAL PROCEDURE|PO,CASE-28060,LOCAL,28060,CPT,,,,,50|PO,outpatient,,,13107.12,7864.27,,,,,,,,,,,,,
Cystoscopy prostatic imp 1-3,CASE-C9739,LOCAL,C9739,CPT,,,,,,outpatient,,,27125.80,16275.48,,,,,,,,,,,,,
HC Peripheral Block - Femoral Continuous W/Img Gdn,CASE-64448,LOCAL,64448,CPT,0360,RC,,,,outpatient,,,63583.63,38150.18,,,,,,,,,,,,,
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf|LEFT SIDE,CASE-36825,LOCAL,36825,CPT,0360,RC,,,LT,outpatient,,,32989.25,19793.55,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,LOCAL,38900,CPT,,,,,RT,outpatient,,,41466.28,24879.77,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T8,outpatient,,,22334.18,13400.51,,,,,,,,,,,,,
CATHETER HAD L28CM OD14.5FR POLYUR STR SHTH INTRO DIL TUNN,SUP-2117422,CDM,C1750,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
GASTROSTOMY SET PUL METHOD 24 FRX150 CM 5.5 FR 260 CM PEG24,SUP-2738137,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
DISC COR SLDE INTERVERTEBRAL SZ B UNIV,SUP-2390785,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STD 12X2 CM REGENERATIVE GRAFTJACKET NOW,SUP-2759533,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6535.53,4248.09,,,,,,,,,,,,,
BLADE SAW 78.7X40.5X0.64 MM RECIP STRL PRECIS LTX,SUP-2862493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.71,228.61,,,,,,,,,,,,,
DRILL TWST L29MM DIA1.6MM WRK L18MM FOR 2/2.3MM SCR,SUP-2364185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,560.90,364.58,,,,,,,,,,,,,
FILLER BNE VOID 1 CC CORTICAL BNE SODIUM HYALURONATE KOLOSIS,SUP-2927223,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
CATHETER URET L70CM OD6FR POLYUR 2 SIDE EYE OLV TIP FLX,SUP-2129010,CDM,C1758,HCPCS,0278,RC,,,,both,,,21.26,13.82,,,,,,,,,,,,,
DEVICE CLSR ANGIO-SEAL VIP 6FR 0.035IN V TWST INTEGR PLATFRM,SUP-2385247,CDM,C1760,HCPCS,0278,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
PYRIDOSTIGMINE BROMIDE 60 MG PO TABS,RX-11239,CDM,6370000000,HCPCS,0637,RC,68084-0494-01,NDC,,both,1,UN,6.30,4.09,,,,,,,,,,,,,
STIMULATOR BONE ELEC LTWT FOR BONE GROWTH STIM PHYSIO-STIM,SUP-2316215,CDM,E0749,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
WEDGE ACF ILIUM CREST TRADITION ALLGRFT 24 - 26 MM FRZ DRY,SUP-2294068,CDM,C1713,HCPCS,0278,RC,,,,both,,,3604.72,2343.07,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE PRE THN MED 22X19 CMX0.7-1.4 MM FLEXHD,SUP-2430132,CDM,Q4128,HCPCS,0636,RC,,,,both,,,38308.00,24900.20,,,,,,,,,,,,,
PIN EXT FIX 240X5 MM APEX SD,SUP-2517219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,250.57,162.87,,,,,,,,,,,,,
BLADE OPHTHLMC SHARP SM CTTNG EDGE MULTI SIDED SCLRTME,SUP-2573865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,41.29,26.84,,,,,,,,,,,,,
RELOAD STPL OPN H42MM CLS H18MM WIRE DIA02MM REG THCK TISS,SUP-2693603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,255.91,166.34,,,,,,,,,,,,,
HEAD HUM RESURF HA COAT SZ 8 COPELAND,SUP-2403992,CDM,C1776,CPT,0278,RC,,,,both,,,15951.20,10368.28,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT|PO",CASE-26727,LOCAL,26727,CPT,,,,,F3|PO,outpatient,,,10491.15,6294.69,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,LOCAL,23430,CPT,0360,RC,,,LT,outpatient,,,30594.10,18356.46,,,,,,,,,,,,,
Open Treatment Ulnar Fracture Proximal End|RIGHT SIDE|PO,CASE-24685,LOCAL,24685,CPT,,,,,RT|PO,outpatient,,,30358.23,18214.94,,,,,,,,,,,,,
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt,CASE-28291,LOCAL,28291,CPT,0360,RC,,,,outpatient,,,26259.73,15755.84,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE|PO,CASE-64493,LOCAL,64493,CPT,,,,,RT|PO,outpatient,,,4626.15,2775.69,,,,,,,,,,,,,
"Prq Skeletal Fix Carpo/Metacarpal Fx Dislc Thumb|RIGHT HAND, THUMB|PO",CASE-26650,LOCAL,26650,CPT,0360,RC,,,F5|PO,outpatient,,,10640.50,6384.30,,,,,,,,,,,,,
Curtg/Caut Anal Fissure W/Dilat Sphnctr Spx 1st,CASE-46940,LOCAL,46940,CPT,,,,,,outpatient,,,11531.65,6918.99,,,,,,,,,,,,,
Tenolysis Extensor Foot Single Tendon|LEFT SIDE|PO,CASE-28225,LOCAL,28225,CPT,0360,RC,,,LT|PO,outpatient,,,21325.52,12795.31,,,,,,,,,,,,,
Destruction Vaginal Lesions Simple,CASE-57061,LOCAL,57061,CPT,0360,RC,,,,outpatient,,,19380.93,11628.56,,,,,,,,,,,,,
Open Tx Metatarsophalangeal Joint Dislocation,CASE-28645,LOCAL,28645,CPT,0360,RC,,,,outpatient,,,34797.97,20878.78,,,,,,,,,,,,,
HC Iliac Territory Plasty Stent,CASE-37221,LOCAL,37221,CPT,0361,RC,,,,outpatient,,,124503.83,74702.30,,,,,,,,,,,,,
PLATE BNE L36MM THK1MM 12 H NONSTERILE HND S STL RECTANG LOK,SUP-2178014,CDM,C1713,HCPCS,0278,RC,,,,both,,,1587.62,1031.95,,,,,,,,,,,,,
TUBE ENTRL FEED GAST-JEJU 14 FRX1.7X15 CM LP G-JET BUTTON,SUP-2754588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2807.69,1825.00,,,,,,,,,,,,,
ALLOSYNC DBM CORTICAL FIBERS 1.0CC,SUP-2811279,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
TUBING IRR DISP FOR ULTSONIC REV SYS ULT DRV 3,SUP-2408553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT HUM W/O ROT CUF PROX STRUCTURAL,SUP-2307342,CDM,C1762,CPT,0278,RC,,,,both,,,15938.64,10360.12,,,,,,,,,,,,,
GRAFT BNE 150X11 MM BLLST 021100000,SUP-2644295,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
HC Perq Trluml Revsc Tot/Stot Occls Ami 1maj C Art,PX-4819294100,CDM,92941,CPT,0481,RC,,,,inpatient,,,23915.00,15544.75,,,,,,,,,,,,,
SPLINT WRST THMB XL L8IN R BLK FOAM D RNG CLSR ADJ REUSE,SUP-2336033,CDM,L3809,HCPCS,0274,RC,,,,both,,,20.82,13.53,,,,,,,,,,,,,
TOTAL KNEE REPLACEMENT KIT SIDE-DELIVERY 11 GAX120 MM 3 CC,SUP-2866888,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
PLATE BNE W7.5XL43MM THK1.6MM 5X3 H L DST VOLAR RAD TI RIG,SUP-2191019,CDM,C1713,HCPCS,0278,RC,,,,both,,,2523.37,1640.19,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT|PO",CASE-26160,LOCAL,26160,CPT,,,,,F6|PO,outpatient,,,9121.97,5473.18,,,,,,,,,,,,,
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE|PO,CASE-23700,LOCAL,23700,CPT,0360,RC,,,LT|PO,outpatient,,,12195.95,7317.57,,,,,,,,,,,,,
Esophagogastroduodenoscopy US Scope W/Adj Strxrs|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43237,LOCAL,43237,CPT,0360,RC,,,74,outpatient,,,11511.00,6906.60,,,,,,,,,,,,,
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,LOCAL,64772,CPT,0360,RC,,,,outpatient,,,18678.83,11207.30,,,,,,,,,,,,,
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE|PO,CASE-27829,LOCAL,27829,CPT,0360,RC,,,RT|PO,outpatient,,,38444.12,23066.47,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,LOCAL,52352,CPT,,,,,RT,outpatient,,,19597.77,11758.66,,,,,,,,,,,,,
Fasciectomy Plantar Fascia Radical Spx|LEFT SIDE|PO,CASE-28062,LOCAL,28062,CPT,0360,RC,,,LT|PO,outpatient,,,20871.58,12522.95,,,,,,,,,,,,,
Laparoscopy Enterolysis Separate Procedure,CASE-44180,LOCAL,44180,CPT,,,,,,outpatient,,,24708.15,14824.89,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,LOCAL,64494,CPT,,,,,,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY SAME PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,LOCAL,93005,CPT,0730,RC,,,76|XU,outpatient,,,108550.85,65130.51,,,,,,,,,,,,,
Open Treatment Ulnar Fracture Proximal End|RIGHT SIDE|PO,CASE-24685,LOCAL,24685,CPT,0360,RC,,,RT|PO,outpatient,,,30358.23,18214.94,,,,,,,,,,,,,
HC Extremity Venogram|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,LOCAL,36005,CPT,0361,RC,,,LT|XU,outpatient,,,41705.80,25023.48,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,LOCAL,28825,CPT,,,,,T1,outpatient,,,12560.27,7536.16,,,,,,,,,,,,,
Arteriovenous Anastomosis Open Direct,CASE-36821,LOCAL,36821,CPT,,,,,,outpatient,,,34207.47,20524.48,,,,,,,,,,,,,
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|LEFT SIDE,CASE-24341,LOCAL,24341,CPT,0360,RC,,,LT,outpatient,,,25273.95,15164.37,,,,,,,,,,,,,
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,LOCAL,45381,CPT,0360,RC,,,,outpatient,,,22839.05,13703.43,,,,,,,,,,,,,
"Synovectomy Metatarsophalangeal Joint Each|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-28072,LOCAL,28072,CPT,,,,,XS|T5|PO,outpatient,,,23775.28,14265.17,,,,,,,,,,,,,
TRAY CATH 5FR 2 LUMN MAX BARR SHERLOCK 3CG TPS STYL PWR,SUP-2125513,CDM,C1751,HCPCS,0278,RC,,,,both,,,771.18,501.27,,,,,,,,,,,,,
WIRE BNE FIX DIA1.6 MM THRD NS LEOS KIRSCHNER,SUP-2933033,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.52,78.99,,,,,,,,,,,,,
ELECTRODE ES DIA3MM 50DEG KNEE SUCT W INTEGR HNDPC VAPR,SUP-2256739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
VORICONAZOLE 40 MG/ML PO SUSR,RX-38103,CDM,340b,HCPCS,0637,RC,00049-3160-44,NDC,,both,2.5,ML,92.10,59.86,,,,,,,,,,,,,
SLEEVE IRRIGATION FOR PM2 STRL LF DISP,SUP-2900576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1557.28,1012.23,,,,,,,,,,,,,
STAPLER INT AD L31MM DIA5MM STD GI GRN TI CIR CUT 2 ROW,SUP-2421064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2301.65,1496.07,,,,,,,,,,,,,
ELECTRODE ENDOSCP MPLR RLER DISP 24FR,SUP-2261200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.71,338.46,,,,,,,,,,,,,
PLATE BNE L317MM 15 H L DST PERIPROSTHETIC FEM TI NCB,SUP-2411492,CDM,C1713,HCPCS,0278,RC,,,,both,,,4346.76,2825.39,,,,,,,,,,,,,
KIT ELECTROPHYSIOLOGY NAVX PTCH ADVISOR HD GRID CATH,SUP-2899920,CDM,C1730,HCPCS,0272,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM DIA0.014INCH COIL L19CM STR TIP,SUP-2123808,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
DAUNORUBICIN HCL 20 MG/4ML IV SOLN,RX-142398,CDM,J9150,HCPCS,0636,RC,00143-9551-10,NDC,,both,4,ML,386.40,251.16,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FIFTH DIGIT|SEPARATE STRUCTURE",CASE-26440,LOCAL,26440,CPT,0360,RC,,,F9|XS,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
Excision Lesion Meniscus/Capsule Knee,CASE-27347,LOCAL,27347,CPT,,,,,,outpatient,,,18525.10,11115.06,,,,,,,,,,,,,
Cysto W/Removal of Tumors Small,CASE-52234,LOCAL,52234,CPT,,,,,,outpatient,,,23999.48,14399.69,,,,,,,,,,,,,
Litholapaxy Smpl/Sm <2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52317,LOCAL,52317,CPT,0360,RC,,,XU,outpatient,,,26374.88,15824.93,,,,,,,,,,,,,
Arthrp Kne Condyle&Platu Medial&Lat Compartments|LEFT SIDE,CASE-27447,LOCAL,27447,CPT,,,,,LT,outpatient,,,57336.70,34402.02,,,,,,,,,,,,,
HC Debrid Wound Tis 20 Cm/<,CASE-97597,LOCAL,97597,CPT,0761,RC,,,,outpatient,,,631.58,378.95,,,,,,,,,,,,,
Arven Anast Opn Upr Arm Basilic Vein Trpos|RIGHT SIDE,CASE-36819,LOCAL,36819,CPT,0360,RC,,,RT,outpatient,,,48540.40,29124.24,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FOURTH DIGIT|SEPARATE STRUCTURE",CASE-26440,LOCAL,26440,CPT,0360,RC,,,F8|XS,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,LOCAL,57425,CPT,0360,RC,,,,outpatient,,,93190.15,55914.09,,,,,,,,,,,,,
Hrhc 2/> Col/Grp W/Fstulectmy Incl Fssrectmy,CASE-46262,LOCAL,46262,CPT,0360,RC,,,,outpatient,,,19581.88,11749.13,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,LOCAL,43239,CPT,0360,RC,,,XS,outpatient,,,92380.78,55428.47,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IPERIA 7 HF-T W58.5XH65MM D11MM 40J 3.2MM,SUP-2138439,CDM,C1882,HCPCS,0275,RC,,,,both,,,54165.00,35207.25,,,,,,,,,,,,,
HC So Estradiol,PX-3018267066,CDM,82670,CPT,0301,RC,,,,both,,,43.00,27.95,,,,,,,,,,,,,
METOLAZONE 2.5 MG PO TABS,RX-10587,CDM,6370000000,HCPCS,0637,RC,00378-6172-01,NDC,,both,1,UN,8.20,5.33,,,,,,,,,,,,,
EPOCH POR ST/HA CUP/LGXLPE LINER/LG STD HD,SUP-2212321,CDM,C1776,CPT,0278,RC,,,,both,,,15754.29,10240.29,,,,,,,,,,,,,
SCREW BNE LCK 2.7X20 MM SS,SUP-2361758,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.93,236.55,,,,,,,,,,,,,
BASKET STONE RETRV L110CM DIA7MM SHTH 22FR POLYIMIDE 12 WIRE,SUP-2141782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,588.28,382.38,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CMNTLS,SUP-2365522,CDM,C1776,CPT,0278,RC,,,,both,,,14138.85,9190.25,,,,,,,,,,,,,
STENT URET 6FR L12CM SIL CLS TIP DBL J,SUP-2313752,CDM,C2617,HCPCS,0278,RC,,,,both,,,426.91,277.49,,,,,,,,,,,,,
HOOK RETRCT SUGITA STRL DISP BRAINPATH SHEPHARD'S,SUP-2930206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.26,205.57,,,,,,,,,,,,,
SCREW BNE L 40 MM DIA 3 MM TI CANN HDLSS NS LEOS,SUP-2932589,CDM,C1713,HCPCS,0278,RC,,,,both,,,801.64,521.07,,,,,,,,,,,,,
GRAFT BNE SUB 7GA 16ML CA PHSPTE SYR DISPNS GUN CANN,SUP-2348207,CDM,C1713,HCPCS,0278,RC,,,,both,,,12419.33,8072.56,,,,,,,,,,,,,
SENNA 8.6 MG PO TABS,RX-18138,CDM,6370000000,HCPCS,0637,RC,00904-7252-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 7 FR SPC 1-7-1 MM H,SUP-2141324,CDM,C1730,HCPCS,0272,RC,,,,both,,,3314.58,2154.48,,,,,,,,,,,,,
MESH SURG L MED HIP TI WALL X CHANGE,SUP-2368355,CDM,C1781,HCPCS,0278,RC,,,,both,,,567.52,368.89,,,,,,,,,,,,,
CLAMP REPROC EXT FIX D R ADJ 4MM,SUP-2679121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,780.79,507.51,,,,,,,,,,,,,
AUGMENT SL TIB LG CO CHROM FINN,SUP-2406084,CDM,C1776,CPT,0278,RC,,,,both,,,2270.22,1475.64,,,,,,,,,,,,,
STENT PERIPH L5CM DIA7MM CATH L110CM NIT PTFE FLEX SELF EXP,SUP-2396480,CDM,C1874,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
Arthrt Elbow Capsular Excision Capsular Rls Spx|RIGHT SIDE|PO,CASE-24006,LOCAL,24006,CPT,0360,RC,,,RT|PO,outpatient,,,16276.97,9766.18,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,LOCAL,64708,CPT,,,,,RT,outpatient,,,30270.30,18162.18,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE,CASE-29876,LOCAL,29876,CPT,0360,RC,,,LT,outpatient,,,22068.90,13241.34,,,,,,,,,,,,,
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw,CASE-37722,LOCAL,37722,CPT,,,,,,outpatient,,,29073.12,17443.87,,,,,,,,,,,,,
HC Debrid Wound Tis 20 Cm/<|ADJ,CASE-97597,LOCAL,97597,CPT,0761,RC,,,ADJ,outpatient,,,1678.08,1006.85,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,LOCAL,49650,CPT,,,,,LT,outpatient,,,43070.95,25842.57,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,LOCAL,28285,CPT,,,,,T6|PO,outpatient,,,29334.38,17600.63,,,,,,,,,,,,,
Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT SIDE,CASE-28292,LOCAL,28292,CPT,0360,RC,,,RT,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
Laps Insertion Tunneled Intraperitoneal Catheter,CASE-49324,LOCAL,49324,CPT,0360,RC,,,,outpatient,,,20854.85,12512.91,,,,,,,,,,,,,
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|LEFT FOOT, SECOND DIGIT|PO",CASE-28313,LOCAL,28313,CPT,,,,,T1|PO,outpatient,,,14876.03,8925.62,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE|PO,CASE-64635,LOCAL,64635,CPT,,,,,RT|PO,outpatient,,,11960.10,7176.06,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,LOCAL,64633,CPT,0360,RC,,,LT,outpatient,,,11775.07,7065.04,,,,,,,,,,,,,
Gastrocnemius Recession|RIGHT SIDE,CASE-27687,LOCAL,27687,CPT,,,,,RT,outpatient,,,38377.33,23026.40,,,,,,,,,,,,,
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT SIDE|PO,CASE-26540,LOCAL,26540,CPT,,,,,LT|PO,outpatient,,,15256.77,9154.06,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|LEFT HAND, FIFTH DIGIT|PO",CASE-26440,LOCAL,26440,CPT,,,,,F4|PO,outpatient,,,10585.43,6351.26,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,LT,outpatient,,,3988.83,2393.30,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.538,SUP-2860055,CDM,C1713,HCPCS,0278,RC,,,,both,,,50881.50,33072.97,,,,,,,,,,,,,
SUPPORT WR M AD LT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324891,CDM,L3931,HCPCS,0272,RC,,,,both,,,48.92,31.80,,,,,,,,,,,,,
SPACER SPNL 0 DEG SM L14 MMXW12 MMXH19 MM CORPECTOMY PARA,SUP-2417200,CDM,C1889,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
PLATE BNE L78MM BLDE W5.8XL38MM 130DEG 4 H ST BILAT PELV,SUP-2186598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1737.49,1129.37,,,,,,,,,,,,,
DOXEPIN HCL 10 MG PO CAPS,RX-2608,CDM,6370000000,HCPCS,0637,RC,51079-0436-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DRILL SURG 5.5X220 MM DSTL SS GAM 12145180] STRYKER ORTHOPEDICS HOWM],SUP-2368456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BIT DRL DIA145MM SHT RIG FOR SFT SUT ANCHR JUGGERKNOT,SUP-2136095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,239.05,155.38,,,,,,,,,,,,,
GRAFT HUM TISS 25MG AMNIO MEM UMB CRD MTRX PARTICULATE FOR,SUP-2420276,CDM,Q4155,HCPCS,0636,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CAGE SPNL 7X18X60 MM LAT COROENT XL+,SUP-2560069,CDM,C1889,HCPCS,0278,RC,,,,both,,,13257.08,8617.10,,,,,,,,,,,,,
INSTRUMENT TRAY 11 GA W/ INFLATABLE BNE TAMP KYPHON XPANDER,SUP-2293647,CDM,C1894,HCPCS,0272,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
SPLINT THMB AD FOR 4.5-9.5IN REG KUHL PERF NEOPRNE WRP ARND,SUP-2324315,CDM,L3931,HCPCS,0274,RC,,,,both,,,73.70,47.90,,,,,,,,,,,,,
IRINOTECAN HCL 40 MG/2ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-91055,CDM,J9206,HCPCS,0636,RC,70700-0169-22,NDC,JW,both,2,ML,54.10,35.16,,,,,,,,,,,,,
SPLINT ORTH W4IN LT HND BASE THMB SPICA ROLYAN,SUP-2324964,CDM,L3931,HCPCS,0274,RC,,,,both,,,91.91,59.74,,,,,,,,,,,,,
SPLINT THMB L FOR 8-9IN WRST L ADJ STAY SPICA 3 DIM MOLDING,SUP-2334802,CDM,L3908,HCPCS,0274,RC,,,,both,,,74.10,48.16,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE,CASE-27601,LOCAL,27601,CPT,,,,,LT,outpatient,,,26973.92,16184.35,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt,CASE-28309,LOCAL,28309,CPT,0360,RC,,,,outpatient,,,50809.40,30485.64,,,,,,,,,,,,,
Ercp Remove Foreign Body/Stent Biliary/Panc Duct|SEPARATE STRUCTURE,CASE-43275,LOCAL,43275,CPT,0360,RC,,,XS,outpatient,,,27493.70,16496.22,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28308,LOCAL,28308,CPT,,,,,RT|XS,outpatient,,,39850.62,23910.37,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|BILATERAL PROCEDURE,CASE-64494,LOCAL,64494,CPT,0360,RC,,,50,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Sling Operation Stress Incontinence,CASE-57288,LOCAL,57288,CPT,,,,,,outpatient,,,51931.27,31158.76,,,,,,,,,,,,,
Arthroplasty Interphalangeal Jt W/Prosthetic Ea,CASE-26536,LOCAL,26536,CPT,,,,,,outpatient,,,22471.93,13483.16,,,,,,,,,,,,,
Open Treatment Medial Malleolus Fracture|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27766,LOCAL,27766,CPT,0360,RC,,,LT|XU,outpatient,,,45301.70,27181.02,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB|PO",CASE-26160,LOCAL,26160,CPT,0360,RC,,,FA|PO,outpatient,,,8780.85,5268.51,,,,,,,,,,,,,
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE,CASE-29891,LOCAL,29891,CPT,,,,,RT,outpatient,,,29753.75,17852.25,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|RIGHT SIDE,CASE-28309,LOCAL,28309,CPT,,,,,RT,outpatient,,,40956.73,24574.04,,,,,,,,,,,,,
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26125,LOCAL,26125,CPT,,,,,F9|PO,outpatient,,,16206.85,9724.11,,,,,,,,,,,,,
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,LOCAL,26356,CPT,0360,RC,,,,outpatient,,,18158.58,10895.15,,,,,,,,,,,,,
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE,CASE-27685,LOCAL,27685,CPT,0360,RC,,,RT,outpatient,,,87970.43,52782.26,,,,,,,,,,,,,
Ercp Dx Collection Specimen Brushing/Washing,CASE-43260,LOCAL,43260,CPT,0360,RC,,,,outpatient,,,21575.25,12945.15,,,,,,,,,,,,,
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|RIGHT SIDE|PO,CASE-28465,LOCAL,28465,CPT,0360,RC,,,RT|PO,outpatient,,,45080.53,27048.32,,,,,,,,,,,,,
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE|PO,CASE-29898,LOCAL,29898,CPT,0360,RC,,,LT|PO,outpatient,,,35793.97,21476.38,,,,,,,,,,,,,
LEAD PACE FINELINE II STEROX EZ L 52 CM DIA 5.1 FR POLYUR,SUP-2148670,CDM,C1898,HCPCS,0275,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
COMPONENT PAT OD32MM THICKNESS 7MM STD UHMWPE NP PRI REV CEM,SUP-2199752,CDM,C1776,CPT,0278,RC,,,,both,,,4755.53,3091.09,,,,,,,,,,,,,
BIT DRL 3 MMX6 IN FOR HDLSS SCR SYS NS LTX,SUP-2862178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1086.69,706.35,,,,,,,,,,,,,
SCREW BNE L80 MM L17 MM OD5.5 MM SHT THRD MONSTER IMPL,SUP-2320702,CDM,C1713,HCPCS,0278,RC,,,,both,,,978.11,635.77,,,,,,,,,,,,,
HC Ot Ultrasound 15 Min,PX-4309703500,CDM,97035,CPT,0430,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
BRACE WLK L SHOE MAN 10 13 WOMAN 11 15 SHT PNEUMAT SEMI RIG,SUP-2196355,CDM,L4361,HCPCS,0274,RC,,,,both,,,122.96,79.92,,,,,,,,,,,,,
CATHETER EP 7 MM 7 FRX110 CM 1525 MM INQUIRY,SUP-2538004,CDM,C1730,HCPCS,0272,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
GRAFT BIO TISS W3.9XL7.9IN PORCINE DERM RIFAMPIN,SUP-2125836,CDM,C1781,HCPCS,0278,RC,,,,both,,,15847.58,10300.93,,,,,,,,,,,,,
PORT INFUS OD8FR 2 LUMN PLAS FILL N VLV NH BIOFLO,SUP-2118788,CDM,C1788,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
PLATE BONE FEMORAL 4.5X99 MM RIGHT PROXIMAL 2 HOLE LOCKING F,SUP-2837600,CDM,C1713,HCPCS,0278,RC,,,,both,,,10903.96,7087.57,,,,,,,,,,,,,
EXTENDER NDL L3IN S STL PLAS W/ LUERLOCK ADPT STR DISP,SUP-2340423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
CATHETER NEPHSTMY 14FR 4 WNG MCOT DISP G14488] COOK UROLOGY],SUP-2171222,CDM,C1729,HCPCS,0272,RC,,,,both,,,64.02,41.61,,,,,,,,,,,,,
SCREW BONE L110MM DIA5MM THRD L16MM 3.5MM HD HEX RECESS GLD,SUP-2192150,CDM,C1713,HCPCS,0278,RC,,,,both,,,885.67,575.69,,,,,,,,,,,,,
PLATE BNE FEM 90 DEG 180 MM ARCHED MR SAFE NS,SUP-2863457,CDM,C1713,HCPCS,0278,RC,,,,both,,,2859.28,1858.53,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0250,RC,00990-7984-20,NDC,,both,25,ML,29.20,18.98,,,,,,,,,,,,,
PLATE BNE SM W11XL89MM THK15MM 90DEG 4X7 H TI T SHP R ANG,SUP-2190938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1537.66,999.48,,,,,,,,,,,,,
CAP HIP POR TM/CER HDCAP,SUP-2212134,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst W/Indwelling Cath Intrlmnr Lmbr/Sac W/Img Gdn,PX-3606232700,CDM,62327,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
VALVE CSF CRAN 2PC HYDROCEPHALUS OSV II,SUP-2666689,CDM,C1889,HCPCS,0278,RC,,,,both,,,9293.24,6040.61,,,,,,,,,,,,,
PLATE BNE W6.3XL49MM THK1.6MM +90DEG 2X4 H DST RAD TI L SHP,SUP-2191026,CDM,C1713,HCPCS,0278,RC,,,,both,,,1886.95,1226.52,,,,,,,,,,,,,
HC CT C-Spine W/O Contrast,PX-3527212500,CDM,72125,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
HANDPIECE SEAL 44X5CM VES PSTL GRP LIGASURE ADV,SUP-2174894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
SHEATH RESECTSCP BLU 28FR STD USA ELITE,SUP-2313082,CDM,C1894,HCPCS,0272,RC,,,,both,,,3615.18,2349.87,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, SECOND DIGIT|PO",CASE-26860,LOCAL,26860,CPT,,,,,F6|PO,outpatient,,,18675.95,11205.57,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE|PO,CASE-29823,LOCAL,29823,CPT,0360,RC,,,RT|PO,outpatient,,,37391.27,22434.76,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|RIGHT SIDE,CASE-23430,LOCAL,23430,CPT,0360,RC,,,RT,outpatient,,,59392.75,35635.65,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-29881,LOCAL,29881,CPT,,,,,XS|RT|PO,outpatient,,,49079.02,29447.41,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,LOCAL,58661,CPT,0360,RC,,,,outpatient,,,27544.83,16526.90,,,,,,,,,,,,,
Partial Excision Bone Fibula,CASE-27641,LOCAL,27641,CPT,,,,,,outpatient,,,35935.35,21561.21,,,,,,,,,,,,,
Partial Excision Bone Fibula|RIGHT SIDE,CASE-27641,LOCAL,27641,CPT,,,,,RT,outpatient,,,36459.58,21875.75,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|PO,CASE-28090,LOCAL,28090,CPT,0360,RC,,,PO,outpatient,,,39959.50,23975.70,,,,,,,,,,,,,
Excision Mal Lesion Trunk/Arm/Leg 3.1-4.0 Cm,CASE-11604,LOCAL,11604,CPT,,,,,,outpatient,,,35367.78,21220.67,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,LOCAL,52352,CPT,0360,RC,,,50,outpatient,,,28467.83,17080.70,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT|PO",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T7|PO,outpatient,,,29334.38,17600.63,,,,,,,,,,,,,
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|LEFT SIDE|PO,CASE-28465,LOCAL,28465,CPT,0360,RC,,,LT|PO,outpatient,,,37055.32,22233.19,,,,,,,,,,,,,
HC Tib per Territory Ather|RIGHT SIDE,CASE-37229,LOCAL,37229,CPT,0361,RC,,,RT,outpatient,,,53548.50,32129.10,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE",CASE-28299,LOCAL,28299,CPT,0360,RC,,,TA,outpatient,,,40130.43,24078.26,,,,,,,,,,,,,
Arthroscopy Ankle Surgical Debridement Extensive|RIGHT SIDE|PO,CASE-29898,LOCAL,29898,CPT,0360,RC,,,RT|PO,outpatient,,,32164.05,19298.43,,,,,,,,,,,,,
HC Fem Pop Territory Plasty|LEFT SIDE,CASE-37224,LOCAL,37224,CPT,0361,RC,,,LT,outpatient,,,46607.03,27964.22,,,,,,,,,,,,,
PACEMAKER CARD VALITUDE W 4.45 X H 6.13 MM THK 0.75 MM 15.2,SUP-2149289,CDM,C2621,HCPCS,0275,RC,,,,both,,,17411.30,11317.34,,,,,,,,,,,,,
KIT SLNG BIOARC SP,SUP-2140292,CDM,C1771,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE X MED 1.5X0.8 MM MIDFACE 4 HOLE W/ TAB STRL,SUP-2461998,CDM,C1713,HCPCS,0278,RC,,,,both,,,815.77,530.25,,,,,,,,,,,,,
PLATE BNE MESHED 126X126X1 MM SM GRID PDLLA STRL RESORB X,SUP-2459732,CDM,C1713,HCPCS,0278,RC,,,,both,,,9648.31,6271.40,,,,,,,,,,,,,
SYSTEM RINGFIX 1 HL HALF PIN POST,SUP-2469032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SUTURE ENDOSCOPIC LONG CINCH,SUP-2878002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.05,372.48,,,,,,,,,,,,,
PLATE LK COMPRSS NAR 12 HL 223MM,SUP-2702813,CDM,C1713,HCPCS,0278,RC,,,,both,,,1048.45,681.49,,,,,,,,,,,,,
GUIDEWIRE VASC IMPELLA RP DIA 0.027 IN PTFE STR TIP STIFF,SUP-2106271,CDM,C1769,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
TUBE TRACH AD L80MM OD10MM ID7MM SIL CUF W TLK ATTCH MID,SUP-2352453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
BIT DRL L7MM DIA3.2MM CANN,SUP-2337746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
"Avulsion Nail Plate Partial/Comp Simple Ea Addl|LEFT HAND, FOURTH DIGIT|PO",CASE-11732,LOCAL,11732,CPT,0360,RC,,,F3|PO,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
Rcnstj Angular Dfrm Toe Soft Tiss Px Only,CASE-28313,LOCAL,28313,CPT,0360,RC,,,,outpatient,,,21723.10,13033.86,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,LOCAL,11403,CPT,,,,,,outpatient,,,15943.30,9565.98,,,,,,,,,,,,,
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, FIFTH DIGIT|PO",CASE-26531,LOCAL,26531,CPT,,,,,F4|PO,outpatient,,,26296.00,15777.60,,,,,,,,,,,,,
Manipulation Knee Joint Under General Anesthesia,CASE-27570,LOCAL,27570,CPT,,,,,,outpatient,,,12454.65,7472.79,,,,,,,,,,,,,
Exc Tumor Soft Tissue Leg/Ankle Subq <3cm|LEFT SIDE,CASE-27618,LOCAL,27618,CPT,0360,RC,,,LT,outpatient,,,27637.02,16582.21,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ITREVIA DR-T W 55 X H 65 MM D 11 MM 33 CC,SUP-2138364,CDM,C1721,HCPCS,0275,RC,,,,both,,,41605.00,27043.25,,,,,,,,,,,,,
BIT DRILL NON QUICK COUPLING 2.5X95 MM JACOBS CHUCK END GOLD,SUP-2837044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,992.93,645.40,,,,,,,,,,,,,
GRAFT BNE SUB 2.5CC DEMIN BNE MTRX PTTY,SUP-2306995,CDM,C9359,HCPCS,0278,RC,,,,both,,,1201.99,781.29,,,,,,,,,,,,,
BLADE SURGICAL MINI EDGE 64 CHISEL SM STERILE,SUP-2582892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,27.88,18.12,,,,,,,,,,,,,
PLATE BNE RADIAL HD 1 LNG PROX FIX ANGLE FIX MAX STRENGTH SS,SUP-2397917,CDM,C1713,HCPCS,0278,RC,,,,both,,,4113.40,2673.71,,,,,,,,,,,,,
CATHETER ATHRCTMY JETSTREAM SC L 145 CM TIP DIA1.85 MM INTRO,SUP-2148529,CDM,C1724,HCPCS,0278,RC,,,,both,,,20253.00,13164.45,,,,,,,,,,,,,
HC 3rd Order Sel Abd/Lower Ext,PX-3613624700,CDM,36247,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE POSTLAT DSTL HUM 3.5MM 3H RT 65MM LCP STRL,SUP-2547554,CDM,C1713,HCPCS,0278,RC,,,,both,,,2532.25,1645.96,,,,,,,,,,,,,
SCREW BNE L8MM OD2.7MM LOK FOR PLT TUFFNEK TECHNOLOGY,SUP-2321094,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.35,464.33,,,,,,,,,,,,,
K WIRE FIX L450MM DIA2.85MM FOR COMP PROX FEM LAG SCR,SUP-2152588,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
ALLODERM SELECT RESTORE X-LARGE PERFORATED - THICK 2.4 0.4MM,SUP-2822080,CDM,Q4116,HCPCS,0636,RC,,,,both,,,45508.02,29580.21,,,,,,,,,,,,,
Exc Tumor Soft Tissue Leg/Ankle Subq <3cm|LEFT SIDE,CASE-27618,LOCAL,27618,CPT,,,,,LT,outpatient,,,27637.02,16582.21,,,,,,,,,,,,,
Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT SIDE|PO,CASE-28297,LOCAL,28297,CPT,0360,RC,,,LT|PO,outpatient,,,47280.18,28368.11,,,,,,,,,,,,,
Wmhc Perc Implant Stim Lead Ea|PO,CASE-63650,LOCAL,63650,CPT,0360,RC,,,PO,outpatient,,,12088.58,7253.15,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,LOCAL,60220,CPT,,,,,,outpatient,,,41490.02,24894.01,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node|LEFT SIDE,CASE-38792,LOCAL,38792,CPT,0361,RC,,,LT,outpatient,,,54292.47,32575.48,,,,,,,,,,,,,
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|RIGHT SIDE|PO,CASE-24341,LOCAL,24341,CPT,,,,,RT|PO,outpatient,,,15782.53,9469.52,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|RIGHT SIDE|PO,CASE-28309,LOCAL,28309,CPT,0360,RC,,,RT|PO,outpatient,,,50809.40,30485.64,,,,,,,,,,,,,
Excision Prepatellar Bursa|LEFT SIDE|SEPARATE STRUCTURE,CASE-27340,LOCAL,27340,CPT,,,,,LT|XS,outpatient,,,30349.03,18209.42,,,,,,,,,,,,,
Revasc lithotrip tibi/perone,CASE-C9772,LOCAL,C9772,CPT,0360,RC,,,,outpatient,,,89370.43,53622.26,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-25111,LOCAL,25111,CPT,0360,RC,,,XS|LT|PO,outpatient,,,13095.20,7857.12,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE,CASE-29827,LOCAL,29827,CPT,0360,RC,,,RT,outpatient,,,50274.85,30164.91,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,LOCAL,52352,CPT,,,,,50,outpatient,,,28467.83,17080.70,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, SECOND DIGIT|PO",CASE-26357,LOCAL,26357,CPT,0360,RC,,,F1|PO,outpatient,,,21815.82,13089.49,,,,,,,,,,,,,
Tx Missed Abortion First Trimester Surgical,CASE-59820,LOCAL,59820,CPT,0360,RC,,,,outpatient,,,16636.97,9982.18,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple,CASE-43239,LOCAL,43239,CPT,,,,,,outpatient,,,11327.98,6796.79,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy Limited Spx|RIGHT SIDE|PO,CASE-29875,LOCAL,29875,CPT,0360,RC,,,RT|PO,outpatient,,,18368.57,11021.14,,,,,,,,,,,,,
Repair Fibula Nonunion/Malunion W/Int Fixation,CASE-27726,LOCAL,27726,CPT,0360,RC,,,,outpatient,,,40869.75,24521.85,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28285,LOCAL,28285,CPT,,,,,T9|PO,outpatient,,,18154.98,10892.99,,,,,,,,,,,,,
Ostectomy Complete 5th Metatarsal Head,CASE-28113,LOCAL,28113,CPT,,,,,,outpatient,,,21781.68,13069.01,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,LOCAL,28820,CPT,,,,,T1,outpatient,,,28436.42,17061.85,,,,,,,,,,,,,
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,LOCAL,57520,CPT,,,,,,outpatient,,,22066.28,13239.77,,,,,,,,,,,,,
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE,CASE-28730,LOCAL,28730,CPT,0360,RC,,,RT,outpatient,,,87131.53,52278.92,,,,,,,,,,,,,
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,LOCAL,43274,CPT,,,,,,outpatient,,,37200.60,22320.36,,,,,,,,,,,,,
Unlisted Procedure Pelvis/Hip Joint|RIGHT SIDE,CASE-27299,LOCAL,27299,CPT,0360,RC,,,RT,outpatient,,,79625.53,47775.32,,,,,,,,,,,,,
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|LEFT SIDE,CASE-37232,LOCAL,37232,CPT,0360,RC,,,LT,outpatient,,,49148.80,29489.28,,,,,,,,,,,,,
BAR EXT FIX L180MM DIA4MM S STL CONN FOR SM FIX,SUP-2188731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,124.91,81.19,,,,,,,,,,,,,
FIBER LASER FLAT TIP 400 MH ASMBLY HOLM MF400BH] GALLAGHER MEDICAL PRODUCTS LLC],SUP-2225999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
SCREW BONE LOCKING 2.9X20 MM SELFTAPPING 5/pk TITANIUM NONST,SUP-2842216,CDM,C1713,HCPCS,0278,RC,,,,both,,,768.67,499.64,,,,,,,,,,,,,
BIT DRL L 1.33 IN OD 12 MM ID 2.7 MM TROCAR TIP NS DISP,SUP-2905455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
CATHETER ATHRCTMY DIAMONDBACK 360 SHFT L 200 CM CRWN DIA1.5,SUP-2159509,CDM,C1724,HCPCS,0278,RC,,,,both,,,11288.30,7337.39,,,,,,,,,,,,,
BASKET STONE HELCL 3 FR 16 MMX120 CM 4 WIR W/ TIP NIT STRL,SUP-2769752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1225.51,796.58,,,,,,,,,,,,,
TUBE FEED 16FR 3 5ML STOMA L15CM JEJU L22CM SIL INT RETEN,SUP-2236569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.27,716.48,,,,,,,,,,,,,
SCREW EXT FIX L65MM DIA4X25MM S STL TRCR PNT MR CONDITIONAL,SUP-2186969,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.07,260.70,,,,,,,,,,,,,
BLADE ARTHSCP STR HIP BLNT TIP,SUP-2608320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1047.94,681.16,,,,,,,,,,,,,
MESH MONOFILAMENT 10CM X 25CM,SUP-2873696,CDM,C1781,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
KIT SURG PWR MINIMALLY INVASIVE INSTR STRL LF DISP FJ-2000,SUP-2881141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
PLATE BNE LAPIDUS LG RT STRATUM,SUP-2423338,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.97,3796.63,,,,,,,,,,,,,
GUIDEWIRE ORTH OFFSET BLOCK AIMING DEV NS,SUP-2799290,CDM,C1769,HCPCS,0272,RC,,,,both,,,1176.56,764.76,,,,,,,,,,,,,
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt,CASE-38570,LOCAL,38570,CPT,0360,RC,,,,outpatient,,,50863.18,30517.91,,,,,,,,,,,,,
Revj/Rmvl Prosthetic Vaginal Graft Vaginal App,CASE-57295,LOCAL,57295,CPT,,,,,,outpatient,,,32711.57,19626.94,,,,,,,,,,,,,
Open Treatment Fracture Distal Tibia Only|LEFT SIDE|PO,CASE-27827,LOCAL,27827,CPT,0360,RC,,,LT|PO,outpatient,,,28985.27,17391.16,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,LOCAL,64636,CPT,0360,RC,,,,outpatient,,,12456.70,7474.02,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,LOCAL,64490,CPT,0361,RC,,,,outpatient,,,5170.20,3102.12,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,LOCAL,52332,CPT,0360,RC,,,LT|XU,outpatient,,,21644.35,12986.61,,,,,,,,,,,,,
Bone Graft Any Donor Area Major/Large|SEPARATE STRUCTURE,CASE-20902,LOCAL,20902,CPT,0360,RC,,,XS,outpatient,,,119772.13,71863.28,,,,,,,,,,,,,
Exc Benign Tumor/Cyst Maxl Intra-Oral Osteot,CASE-21048,LOCAL,21048,CPT,0360,RC,,,,outpatient,,,28307.82,16984.69,,,,,,,,,,,,,
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|LEFT SIDE,CASE-38570,LOCAL,38570,CPT,0360,RC,,,LT,outpatient,,,68298.87,40979.32,,,,,,,,,,,,,
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT HAND, THIRD DIGIT|PO",CASE-26111,LOCAL,26111,CPT,,,,,F7|PO,outpatient,,,14343.30,8605.98,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,LOCAL,11421,CPT,,,,,,outpatient,,,24976.52,14985.91,,,,,,,,,,,,,
Adjt Tis Trnsfr/Reargmt Defec Ea Addl 30 Sqcm,CASE-14302,LOCAL,14302,CPT,,,,,,outpatient,,,78411.37,47046.82,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,LOCAL,64484,CPT,0360,RC,,,RT,outpatient,,,3990.02,2394.01,,,,,,,,,,,,,
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,LOCAL,43235,CPT,,,,,74,outpatient,,,7667.07,4600.24,,,,,,,,,,,,,
Ligj & Div Short Saph Vein Saphenopop Junct Spx,CASE-37780,LOCAL,37780,CPT,,,,,,outpatient,,,39737.47,23842.48,,,,,,,,,,,,,
BASEPLATE TIB INLAY KNEE,SUP-2440395,CDM,C1776,CPT,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
ADAPTER O2 DPLX INLET STEM AND TWO CK OUTLETS,SUP-2301210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,519.98,337.99,,,,,,,,,,,,,
GUIDEWIRE ENDO STR REG HYDRPHLC UROLOGY L3CM L260CM OD.025IN,SUP-2385538,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT DELIVERY SYSTEM SET 9 CC W/ GRFT DBF CANN ACCELERATE,SUP-2787602,CDM,C1713,HCPCS,0278,RC,,,,both,,,5628.95,3658.82,,,,,,,,,,,,,
PLATE BNE SZ 2 MM MIDFACE PMI NS DISP ACCUPLATE,SUP-2936114,CDM,C1713,HCPCS,0278,RC,,,,both,,,34273.10,22277.51,,,,,,,,,,,,,
"Avulsion Nail Plate Partial/Comp Simple Ea Addl|LEFT HAND, FOURTH DIGIT|PO",CASE-11732,LOCAL,11732,CPT,,,,,F3|PO,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT HAND, THIRD DIGIT|PO",CASE-26111,LOCAL,26111,CPT,0360,RC,,,F7|PO,outpatient,,,14343.30,8605.98,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open,CASE-24358,LOCAL,24358,CPT,,,,,,outpatient,,,17366.70,10420.02,,,,,,,,,,,,,
Fasciectomy Plantar Fascia Radical Spx|RIGHT SIDE,CASE-28062,LOCAL,28062,CPT,,,,,RT,outpatient,,,16549.10,9929.46,,,,,,,,,,,,,
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,LOCAL,52300,CPT,0360,RC,,,,outpatient,,,25329.37,15197.62,,,,,,,,,,,,,
Excision Local Lesion Epididymis|RIGHT SIDE,CASE-54830,LOCAL,54830,CPT,,,,,RT,outpatient,,,21664.60,12998.76,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE|PO,CASE-28090,LOCAL,28090,CPT,0360,RC,,,LT|PO,outpatient,,,16375.20,9825.12,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT FOOT, GREAT TOE|PO",CASE-28292,LOCAL,28292,CPT,,,,,T5|PO,outpatient,,,40810.60,24486.36,,,,,,,,,,,,,
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,LOCAL,45378,CPT,0360,RC,,,,outpatient,,,10139.13,6083.48,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FIFTH DIGIT|PO",CASE-26440,LOCAL,26440,CPT,,,,,F9|PO,outpatient,,,16093.22,9655.93,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening|LEFT SIDE|PO,CASE-25390,LOCAL,25390,CPT,0360,RC,,,LT|PO,outpatient,,,34095.55,20457.33,,,,,,,,,,,,,
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|PO,CASE-26160,LOCAL,26160,CPT,0360,RC,,,PO,outpatient,,,10855.00,6513.00,,,,,,,,,,,,,
Unlisted Procedure Arthroscopy,CASE-29999,LOCAL,29999,CPT,,,,,,outpatient,,,48468.53,29081.12,,,,,,,,,,,,,
PLATE BNE L 16 MM STRL ORTHOLOC 3DI,SUP-2900676,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
PLATE BNE NAR 4.5X103 MM 6 HOLE SS DCP,SUP-2569164,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.60,166.14,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 3 CM THK 0.2 MM HUM AMNIO MEMBRN,SUP-2909418,CDM,Q4282,HCPCS,0636,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE STEM EPOCH II,SUP-2212678,CDM,C1776,CPT,0278,RC,,,,both,,,2511.97,1632.78,,,,,,,,,,,,,
PATCH CV W2XL9CM THK0.4MM EPTFE CNFRM GORE TEX,SUP-2395305,CDM,C1768,CPT,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
PLATE BNE M 5DEG L MT GORILLA,SUP-2321452,CDM,C1713,HCPCS,0278,RC,,,,both,,,4388.15,2852.30,,,,,,,,,,,,,
CALCITRIOL 1 MCG/ML IV SOLN,RX-9348,CDM,J0636,HCPCS,0636,RC,72266-0251-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L142MM 6 H ST R OLECRANON TI LO PROF VAR ANG LOK,SUP-2180815,CDM,C1713,HCPCS,0278,RC,,,,both,,,3920.26,2548.17,,,,,,,,,,,,,
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132070,CDM,6370000000,HCPCS,0637,RC,45802-0578-84,NDC,,both,2,UN,180.00,117.00,,,,,,,,,,,,,
CATHETER EP DECAPOLAR 2-5-2 MM LG 7 FR STEER,SUP-2102302,CDM,C1730,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA2.2 MM PLLA PGA PDLA CRANIOMAXILLOFACIAL,SUP-2909557,CDM,C1713,HCPCS,0278,RC,,,,both,,,2018.08,1311.75,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 L 4 CM DIA2.5 MM MICROCATHETER,SUP-2365660,CDM,C1889,HCPCS,0278,RC,,,,both,,,4600.41,2990.27,,,,,,,,,,,,,
CATHETER URO L180CM DIA5FR BLLN L4CM DIA12FR 0.035IN BILI,SUP-2149781,CDM,C1726,HCPCS,0272,RC,,,,both,,,716.39,465.65,,,,,,,,,,,,,
GRAFT BONE SUB 3ML CA PHOS PUTTY FOR CRS NORIAN,SUP-2193975,CDM,C1713,HCPCS,0278,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
PACEMAKER CARD 24GM 14CC W59XH55MM THK6MM RESYNCH THER IS1,SUP-2356470,CDM,C2621,HCPCS,0275,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
BIT DRL OCPTL CERV THOR INFIN,SUP-2278949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SCREW PEDCL SPNL LCK VAR TI MOD 5.5MMDIA 35MML,SUP-2415523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2199.76,1429.84,,,,,,,,,,,,,
BUR SURG FLUT BRL 60 DEG 4.2 MMX13.5 CM STRL DISP,SUP-2648964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.37,441.59,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,LOCAL,52287,CPT,0360,RC,,,,outpatient,,,15300.45,9180.27,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<|PO,CASE-11420,LOCAL,11420,CPT,,,,,PO,outpatient,,,8985.38,5391.23,,,,,,,,,,,,,
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, THIRD DIGIT|PO",CASE-26111,LOCAL,26111,CPT,0360,RC,,,F2|PO,outpatient,,,15971.02,9582.61,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE|PO,CASE-23515,LOCAL,23515,CPT,0360,RC,,,RT|PO,outpatient,,,38878.82,23327.29,,,,,,,,,,,,,
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE|PO,CASE-28615,LOCAL,28615,CPT,,,,,LT|PO,outpatient,,,39583.60,23750.16,,,,,,,,,,,,,
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,LOCAL,26080,CPT,,,,,,outpatient,,,14915.00,8949.00,,,,,,,,,,,,,
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE|PO,CASE-27685,LOCAL,27685,CPT,,,,,LT|PO,outpatient,,,34429.60,20657.76,,,,,,,,,,,,,
HC Sleep Study Unattended|NOT REASONABLE AND NECESSARY,CASE-95800,LOCAL,95800,CPT,0920,RC,,,GZ,outpatient,,,972.83,583.70,,,,,,,,,,,,,
Conv Prev Hip Tot Hip Arthrp W/WO Agrft/Algrft|RIGHT SIDE,CASE-27132,LOCAL,27132,CPT,0360,RC,,,RT,outpatient,,,82195.42,49317.25,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,LOCAL,64484,CPT,,,,,RT,outpatient,,,3990.02,2394.01,,,,,,,,,,,,,
SHEATH LD INTRO WORLEY ADV L 45 CM DIA 9 FR PEBAX LAT VEIN,SUP-2481363,CDM,C1892,HCPCS,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
CENTRALIZER VERSYS ADVOCATE PROXIMAL 14MM STD,SUP-2504399,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
AM PICC SET: 2-L 5.5FRX55CM 130CM HYDR,SUP-2827502,CDM,C1751,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
ROD ALIGN L165MM CO CHROME FOR SUBTALAR IMPL SYS BIOARCH,SUP-2401367,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
TRAY PROVEN REV MOD TIB 3T2F,SUP-2359295,CDM,C1776,CPT,0278,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
DILATOR PK ADVNTG ESOPH BAL 15MMX8CM BAL 180CM CATH,SUP-2166054,CDM,C1726,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
SCREW BNE LCK 3.5X18 MM NS PERI-LOC,SUP-2348523,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
GRAFT VASC IMPRA L 30 CM DIA 6 MM EPTFE STR TW N RING HEMO,SUP-2761264,CDM,C1768,CPT,0278,RC,,,,both,,,1490.90,969.08,,,,,,,,,,,,,
WAND ABLAT DIA3.5MM PRB ENERGY SUCT 50-S SERFAS,SUP-2367326,CDM,2720000010,LOCAL,0272,RC,,,,both,,,539.86,350.91,,,,,,,,,,,,,
CATHETER THROMCTMY ZOOM 35 L 160 CM DIA 5 FR DSTL OD/ID 4,SUP-2739210,CDM,C1757,HCPCS,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
DEVICE PESSARY TNDM CUBE 7-5 2.25X1.75 IN PROCIDENTIA MILEX,SUP-2755566,CDM,A4562,HCPCS,0272,RC,,,,both,,,301.60,196.04,,,,,,,,,,,,,
PIN FIX HALF LG 15X55 MM 3 MM,SUP-2861364,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.65,113.52,,,,,,,,,,,,,
SPLINT WR ADULTXL LT THMB NEOPRNE TRIOXON LNR FIRM STRP ON,SUP-2326120,CDM,L3908,HCPCS,0272,RC,,,,both,,,138.00,89.70,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA2.2 MM PLLA PGA PDLA ST 2 THRD RESRB,SUP-2909493,CDM,C1713,HCPCS,0278,RC,,,,both,,,3302.31,2146.50,,,,,,,,,,,,,
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO|UNUSUAL NON-OVERLAPPING SERVICE,CASE-14040,LOCAL,14040,CPT,0360,RC,,,PO|XU,outpatient,,,26381.72,15829.03,,,,,,,,,,,,,
Laparoscopy Surg Cholecystectomy,CASE-47562,LOCAL,47562,CPT,0360,RC,,,,outpatient,,,25449.88,15269.93,,,,,,,,,,,,,
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE|PO,CASE-24685,LOCAL,24685,CPT,0360,RC,,,LT|PO,outpatient,,,36714.83,22028.90,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PO,CASE-20610,LOCAL,20610,CPT,0510,RC,,,LT|PO,outpatient,,,4470.70,2682.42,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,LOCAL,45385,CPT,,,,,PT|XU,outpatient,,,23559.47,14135.68,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-27695,LOCAL,27695,CPT,0360,RC,,,XS|LT|PO,outpatient,,,35935.35,21561.21,,,,,,,,,,,,,
Open Treatment Metatarsal Fracture Each|LEFT SIDE|PO,CASE-28485,LOCAL,28485,CPT,0360,RC,,,LT|PO,outpatient,,,37055.32,22233.19,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,LOCAL,64484,CPT,0360,RC,,,LT,outpatient,,,3990.02,2394.01,,,,,,,,,,,,,
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,LOCAL,26356,CPT,,,,,,outpatient,,,18158.58,10895.15,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE|PO",CASE-28750,LOCAL,28750,CPT,,,,,T5|PO,outpatient,,,42596.50,25557.90,,,,,,,,,,,,,
Cysto W/Destruction of Lesions,CASE-52214,LOCAL,52214,CPT,,,,,,outpatient,,,26107.60,15664.56,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-36901,LOCAL,36901,CPT,0361,RC,,,74,outpatient,,,13695.30,8217.18,,,,,,,,,,,,,
Split Agrft T/a/L Ea 100 Cm/Ea 1% Bdy Inft/Chld,CASE-15101,LOCAL,15101,CPT,0360,RC,,,,outpatient,,,28702.92,17221.75,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FOURTH DIGIT",CASE-28810,LOCAL,28810,CPT,0360,RC,,,T8,outpatient,,,24993.17,14995.90,,,,,,,,,,,,,
Arthroplasty Glenohumeral Joint Total Shoulder|RIGHT SIDE,CASE-23472,LOCAL,23472,CPT,0360,RC,,,RT,outpatient,,,77824.52,46694.71,,,,,,,,,,,,,
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,LOCAL,G0105,CPT,,,,,74,outpatient,,,7667.07,4600.24,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28124,LOCAL,28124,CPT,0360,RC,,,T4|PO,outpatient,,,15256.77,9154.06,,,,,,,,,,,,,
Gastrocnemius Recession|RIGHT SIDE,CASE-27687,LOCAL,27687,CPT,0360,RC,,,RT,outpatient,,,38377.33,23026.40,,,,,,,,,,,,,
Sgmdsc Flx Dired Sbmcsl Njx Any Sbst,CASE-45335,LOCAL,45335,CPT,,,,,,outpatient,,,11148.15,6688.89,,,,,,,,,,,,,
"Tenolysis Extensor Tendon Hand/Finger Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26445,LOCAL,26445,CPT,,,,,F8|PO,outpatient,,,13068.78,7841.27,,,,,,,,,,,,,
STEM VERSYS ENHANCED TAPER FEM 9X110MM,SUP-2203492,CDM,C1776,CPT,0278,RC,,,,both,,,12899.12,8384.43,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2 MM RECON PT SPEC,SUP-2860086,CDM,C1713,HCPCS,0278,RC,,,,both,,,26791.42,17414.42,,,,,,,,,,,,,
ENDOSCOPIC KIT RETRV SYS SL DIR DRV LCA,SUP-2119770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
TI MATRIXMANDIBLE 4 HOLE BOX,SUP-2823039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1079.22,701.49,,,,,,,,,,,,,
PLATE BNE INTERMED CLMN -90 DEG 2.4X49 MM DSTL RADIAL 2X4,SUP-2180923,CDM,C1713,HCPCS,0278,RC,,,,both,,,2356.19,1531.52,,,,,,,,,,,,,
ROD GRADUATED TELESCOPIC,SUP-2699972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.21,385.59,,,,,,,,,,,,,
DEFIBRILLATOR IMPL MOMENTUM X4 W 5.37 X H 8.08 CM D 0.99 CM,SUP-2420681,CDM,C1882,HCPCS,0275,RC,,,,both,,,52883.88,34374.52,,,,,,,,,,,,,
MESH BIO W6XL8CM BOV PERICARD NONCROSSLINKED CLLGN MTRX,SUP-2130299,CDM,C9354,HCPCS,0278,RC,,,,both,,,4612.16,2997.90,,,,,,,,,,,,,
PORT CT SIL FIL SUT H 8FR ATTACH TRINIFLEX CATH,SUP-2269554,CDM,C1788,HCPCS,0278,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
DOXEPIN HCL 25 MG PO CAPS,RX-2611,CDM,6370000000,HCPCS,0637,RC,00904-7053-61,NDC,,both,1,UN,3.70,2.40,,,,,,,,,,,,,
PLATE BNE L 154 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 14 HL,SUP-2936832,CDM,C1713,HCPCS,0278,RC,,,,both,,,2853.63,1854.86,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE|BILATERAL PROCEDURE,CASE-52005,LOCAL,52005,CPT,0360,RC,,,XU|50,outpatient,,,14294.82,8576.89,,,,,,,,,,,,,
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|SEPARATE STRUCTURE|PO,CASE-14040,LOCAL,14040,CPT,0360,RC,,,XS|PO,outpatient,,,16315.30,9789.18,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,LOCAL,43236,CPT,,,,,XS,outpatient,,,14351.03,8610.62,,,,,,,,,,,,,
Application Uniplane External Fixation System|PO,CASE-20690,LOCAL,20690,CPT,0360,RC,,,PO,outpatient,,,18537.08,11122.25,,,,,,,,,,,,,
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, THIRD DIGIT|PO",CASE-26531,LOCAL,26531,CPT,,,,,F7|PO,outpatient,,,24951.15,14970.69,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,LOCAL,45380,CPT,0360,RC,,,PT|XU,outpatient,,,15043.82,9026.29,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,LOCAL,29826,CPT,0360,RC,,,RT,outpatient,,,45202.47,27121.48,,,,,,,,,,,,,
"HC Aerosol, Hhn, Mdi, Ippb|ADJ",CASE-94640,LOCAL,94640,CPT,0410,RC,,,ADJ,outpatient,,,51743.57,31046.14,,,,,,,,,,,,,
Osteotomy Radius Distal Third|LEFT SIDE|PO,CASE-25350,LOCAL,25350,CPT,,,,,LT|PO,outpatient,,,37307.13,22384.28,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,LOCAL,49650,CPT,0360,RC,,,50,outpatient,,,50195.70,30117.42,,,,,,,,,,,,,
Implant Neurostim/Receiver,CASE-64590,LOCAL,64590,CPT,0360,RC,,,,outpatient,,,59446.15,35667.69,,,,,,,,,,,,,
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,LOCAL,43275,CPT,,,,,,outpatient,,,25796.43,15477.86,,,,,,,,,,,,,
PLATE BONE RT MAND RECON FOR 2.4MM SCR,SUP-2365237,CDM,C1713,HCPCS,0278,RC,,,,both,,,7837.50,5094.37,,,,,,,,,,,,,
BIT DRL TWST 1.8X70 MM 6 MM W/ STP RESORB-X DISP,SUP-2457083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.70,290.35,,,,,,,,,,,,,
PLATE BONE L71MM 6 H FIB TI STR LCK FOR 2.7/3/3.5/4MM SCR,SUP-2225374,CDM,C1713,HCPCS,0278,RC,,,,both,,,3325.89,2161.83,,,,,,,,,,,,,
CATHETER EP LG 2 MM 6 FRX110 STEER INQUIRY,SUP-2469550,CDM,C1730,HCPCS,0272,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND CUST ADJ FIT W/O JT FABRICATED,SUP-2435762,CDM,L3762,HCPCS,0274,RC,,,,both,,,1928.18,1253.32,,,,,,,,,,,,,
SHEATH INTRO COMPASS L 45 CM OD 4 FR ID 1.60 MM GUIDEWIRE,SUP-2838701,CDM,C1894,HCPCS,0272,RC,,,,both,,,265.55,172.61,,,,,,,,,,,,,
SCREW BNE L16MM DIA2.4MM CORT S STL ST NONCANNULATED,SUP-2183247,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.69,85.60,,,,,,,,,,,,,
ROD SPNL CONN 5.5/6X500 MM COCR NS,SUP-2592124,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
MATRIX BIO DIA 80 MM FISH SKIN SIL DERMAL SPRL PERF FEN MRK,SUP-2909231,CDM,Q4158,HCPCS,0636,RC,,,,both,,,72110.10,46871.56,,,,,,,,,,,,,
GRAFT TISS SPCR CERV CANC FRZ DRY ALLGRFT 6MM,SUP-2307221,CDM,C1713,HCPCS,0278,RC,,,,both,,,3004.89,1953.18,,,,,,,,,,,,,
APPLICATOR BRACHYTHERAPY CONTURA BLLN L44CM DIA 5CM 58ML,SUP-2239952,CDM,C1728,HCPCS,0272,RC,,,,both,,,8375.95,5444.37,,,,,,,,,,,,,
CEMENT BONE 10GM ACRYL W/ CNTRST AGNT AND TANT,SUP-2342070,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC DBM FLOWABLE FIBER AMBIENT STOR,SUP-2933249,CDM,C1762,CPT,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
ANCHOR SUT OD4.5MM BIOCRYL RAPIDE ORTHOCORD HEALIX ADV BR,SUP-2256656,CDM,C1713,HCPCS,0278,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
HC So1 Encephalitis Western Equine,PX-3028665467,CDM,86654,CPT,0302,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
ALLOGRAFT TISS AMNIO NUCEL SM W/ FIBEROS,SUP-2314100,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
Rpr Recrt Inguinal Hernia Any Age Reducible|LEFT SIDE,CASE-49520,LOCAL,49520,CPT,0360,RC,,,LT,outpatient,,,22019.75,13211.85,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2|RIGHT SIDE|PO,CASE-29822,LOCAL,29822,CPT,0360,RC,,,RT|PO,outpatient,,,26409.28,15845.57,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L >4.0 Cm|RIGHT SIDE,CASE-11406,LOCAL,11406,CPT,0360,RC,,,RT,outpatient,,,11523.42,6914.05,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-20605,LOCAL,20605,CPT,0510,RC,,,XU|PO,outpatient,,,11520.57,6912.34,,,,,,,,,,,,,
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|RIGHT SIDE,CASE-37225,LOCAL,37225,CPT,0360,RC,,,RT,outpatient,,,75093.20,45055.92,,,,,,,,,,,,,
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE,CASE-27650,LOCAL,27650,CPT,,,,,LT,outpatient,,,26973.92,16184.35,,,,,,,,,,,,,
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE|PO,CASE-28300,LOCAL,28300,CPT,0360,RC,,,RT|PO,outpatient,,,58835.72,35301.43,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,LOCAL,29828,CPT,0360,RC,,,LT,outpatient,,,48402.82,29041.69,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L >4.0 Cm,CASE-11406,LOCAL,11406,CPT,,,,,,outpatient,,,16509.78,9905.87,,,,,,,,,,,,,
COIL VASC EMBOLUS L 1 CM DIA2 MM GUIDEWIRE 0.035 IN STRTCH,SUP-2167992,CDM,C1889,HCPCS,0278,RC,,,,both,,,274.44,178.39,,,,,,,,,,,,,
CATHETER ATRSEPTSTMY Z-5 L 50 CM DIA 5 FR BALLOON L 1.35 CM,SUP-2125231,CDM,C1725,HCPCS,0272,RC,,,,both,,,994.85,646.65,,,,,,,,,,,,,
GRAFT BIO TISS W7.5XL13.8IN PORCINE DERM RIFAMPIN,SUP-2125841,CDM,C1781,HCPCS,0278,RC,,,,both,,,46158.00,30002.70,,,,,,,,,,,,,
PLATE BNE L 159 X W 10 MM THK 2 MM SCREW DIA2.7/3.5 MM 11 H 72465311N,SUP-2932854,CDM,C1713,HCPCS,0278,RC,,,,both,,,5350.56,3477.86,,,,,,,,,,,,,
KIT REP FULL THRD DISP FOR HALLUX VALGUS MINI TIGHTROPE,SUP-2122785,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
BIT DRL DIA4.5MM CANN FOR INTOSS FIX IOFIX,SUP-2223750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2X6 MM MANDIBULAR 20/PK TITANIUM NONS,SUP-2842274,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.89,163.73,,,,,,,,,,,,,
PLATE 8HL 2.7X93MM,SUP-2484713,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.09,309.46,,,,,,,,,,,,,
STAPLER ENDOSCP 45MM L34CM STD NAT ARTC LIN CUT ECHELON FLX,SUP-2218982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.44,740.64,,,,,,,,,,,,,
SCREW BNE COMPR 4.5X36 MM HIP CORTICAL TALON,SUP-2391512,CDM,C1713,HCPCS,0278,RC,,,,both,,,104.09,67.66,,,,,,,,,,,,,
KIT IM NAIL L150MM DIA8MM PROX HUM LCK,SUP-2412504,CDM,C1713,HCPCS,0278,RC,,,,both,,,3890.46,2528.80,,,,,,,,,,,,,
RAIL ORTH 2 TRANSITION 5.5X500 MM 100 MM MESA,SUP-2732244,CDM,C1713,HCPCS,0278,RC,,,,both,,,6929.51,4504.18,,,,,,,,,,,,,
HC Intra Art Admin Radpharm,PX-3407944500,CDM,79445,CPT,0340,RC,,,,outpatient,,,3319.00,2157.35,,,,,,,,,,,,,
SCREW BONE L22MM OD3.5MM CORT,SUP-2412507,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.64,79.07,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|LEFT SIDE,CASE-27524,LOCAL,27524,CPT,,,,,LT,outpatient,,,31537.33,18922.40,,,,,,,,,,,,,
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,LOCAL,31628,CPT,0360,RC,,,,outpatient,,,22274.95,13364.97,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE,CASE-28306,LOCAL,28306,CPT,,,,,RT,outpatient,,,47822.53,28693.52,,,,,,,,,,,,,
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|SEPARATE STRUCTURE,CASE-14040,LOCAL,14040,CPT,,,,,XS,outpatient,,,22334.18,13400.51,,,,,,,,,,,,,
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO,CASE-27654,LOCAL,27654,CPT,0360,RC,,,LT|PO,outpatient,,,36741.33,22044.80,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple,CASE-43239,LOCAL,43239,CPT,0360,RC,,,,outpatient,,,11327.98,6796.79,,,,,,,,,,,,,
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|LEFT SIDE,CASE-37766,LOCAL,37766,CPT,,,,,LT,outpatient,,,29073.12,17443.87,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy 2/>Compartments|RIGHT SIDE|PO,CASE-29876,LOCAL,29876,CPT,0360,RC,,,RT|PO,outpatient,,,25814.42,15488.65,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Extensive,CASE-11771,LOCAL,11771,CPT,0360,RC,,,,outpatient,,,19303.15,11581.89,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE|PO,CASE-28308,LOCAL,28308,CPT,0360,RC,,,LT|PO,outpatient,,,27333.98,16400.39,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE|PO,CASE-27691,LOCAL,27691,CPT,,,,,RT|PO,outpatient,,,35678.48,21407.09,,,,,,,,,,,,,
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,LOCAL,46922,CPT,0360,RC,,,,outpatient,,,22101.17,13260.70,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|RIGHT SIDE|PO,CASE-G0260,LOCAL,G0260,CPT,0360,RC,,,RT|PO,outpatient,,,4478.50,2687.10,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,LOCAL,28825,CPT,,,,,T6,outpatient,,,17785.52,10671.31,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE|PO,CASE-29825,LOCAL,29825,CPT,,,,,RT|PO,outpatient,,,33578.62,20147.17,,,,,,,,,,,,,
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,LOCAL,43249,CPT,,,,,,outpatient,,,14344.32,8606.59,,,,,,,,,,,,,
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36556,LOCAL,36556,CPT,0761,RC,,,XU,outpatient,,,20969.02,12581.41,,,,,,,,,,,,,
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE|PO,CASE-27685,LOCAL,27685,CPT,,,,,RT|PO,outpatient,,,33874.72,20324.83,,,,,,,,,,,,,
Arthroplasty Ankle W/Implant|LEFT SIDE,CASE-27702,LOCAL,27702,CPT,,,,,LT,outpatient,,,85042.58,51025.55,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 4 FR SHERLOCK STYL GROSH NXT,SUP-2126717,CDM,C1751,HCPCS,0278,RC,,,,both,,,659.34,428.57,,,,,,,,,,,,,
PLATE BNE 3 H LAT S STL FOR ANK FRAC MGMT,SUP-2123043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ICROSS L 135 CM DIA 3.6 FR FREQ,SUP-2146959,CDM,C1753,HCPCS,0278,RC,,,,both,,,3086.43,2006.18,,,,,,,,,,,,,
"HC So Cortisol,Free",PX-3018253066,CDM,82530,CPT,0301,RC,,,,both,,,355.00,230.75,,,,,,,,,,,,,
HC Peripheral Block - Femoral Continuous W/Img Gdn,PX-3606444800,CDM,64448,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
SCREW BNE EMGCY 2.4X6 MM T8 TI NS,SUP-2189470,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.97,123.48,,,,,,,,,,,,,
PLATE BNE L94MM 6 H ST L SUP CLAV TI LOK COMPR FOR 35MM SCR,SUP-2180888,CDM,C1713,HCPCS,0278,RC,,,,both,,,3201.17,2080.76,,,,,,,,,,,,,
HC Intubation Emergent,PX-7613150000,CDM,31500,CPT,0761,RC,,,,inpatient,,,403.00,261.95,,,,,,,,,,,,,
REAMER SURG OD4.8MM BNE CANN HIP RESURF,SUP-2342344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,441.64,287.07,,,,,,,,,,,,,
HC ED Clsd Tx Distal Fib Fx Manip,PX-4502778800,CDM,27788,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
GUIDEWIRE VASC MICROPUNCTURE L 60 CM DIA 0.018 IN TAPR L 10,SUP-2171100,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.33,32.06,,,,,,,,,,,,,
PILOCARPINE HCL 4 % OP SOLN,RX-6282,CDM,6370000000,HCPCS,0637,RC,61314-0206-15,NDC,,both,15,ML,380.50,247.32,,,,,,,,,,,,,
IMPLANT PATELLARXLPE CEMENTLESS KNEE PROLONG,SUP-2212169,CDM,C1776,CPT,0278,RC,,,,both,,,11972.82,7782.33,,,,,,,,,,,,,
HC So Factor VII,PX-3058523066,CDM,85230,CPT,0305,RC,,,,inpatient,,,280.00,182.00,,,,,,,,,,,,,
HC Plcmt Tunnel Pleural Drain Cat,PX-3613255000,CDM,32550,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
PUMP PAIN 120MLX2CC HR 6.5CM 500120025,SUP-2367018,CDM,C1713,HCPCS,0278,RC,,,,both,,,2746.12,1784.98,,,,,,,,,,,,,
BASEPLATE TIB 4 CEM LT PRI STEM STD N POR W/ SCR H PROFIX,SUP-2351222,CDM,C1776,CPT,0278,RC,,,,both,,,3414.75,2219.59,,,,,,,,,,,,,
INTRODUCER PACE LD DIA 8.5 FR HEMOSTAS,SUP-2357105,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
KIT BIO STABLE 5F DL 55CM CATHETER VLV PG,SUP-2118831,CDM,C1751,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
ALLODERM SELECT 12X12 MEDIUM 1.2-2.0,SUP-2827043,CDM,Q4116,HCPCS,0636,RC,,,,both,,,16833.54,10941.80,,,,,,,,,,,,,
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|BILATERAL PROCEDURE,CASE-52354,LOCAL,52354,CPT,,,,,50,outpatient,,,20486.18,12291.71,,,,,,,,,,,,,
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE,CASE-28615,LOCAL,28615,CPT,,,,,LT,outpatient,,,31089.57,18653.74,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE|PO,CASE-29823,LOCAL,29823,CPT,,,,,LT|PO,outpatient,,,34593.22,20755.93,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|PO",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F2|PO,outpatient,,,10240.85,6144.51,,,,,,,,,,,,,
Fth/Gft Free W/Direct Closure S/a/L 20 Cm/<,CASE-15220,LOCAL,15220,CPT,0360,RC,,,,outpatient,,,39572.23,23743.34,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE,CASE-29825,LOCAL,29825,CPT,0360,RC,,,RT,outpatient,,,48673.63,29204.18,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm|PO,CASE-11421,LOCAL,11421,CPT,,,,,PO,outpatient,,,10680.12,6408.07,,,,,,,,,,,,,
Laps Myomectomy Exc 1-4 Myomas 250 Gm/<,CASE-58545,LOCAL,58545,CPT,0360,RC,,,,outpatient,,,64178.98,38507.39,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FIFTH DIGIT|PO",CASE-26123,LOCAL,26123,CPT,0360,RC,,,F4|PO,outpatient,,,13579.88,8147.93,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE,CASE-27695,LOCAL,27695,CPT,0360,RC,,,RT,outpatient,,,36064.92,21638.95,,,,,,,,,,,,,
HC Remove Lung Catheter,CASE-32552,LOCAL,32552,CPT,0361,RC,,,,outpatient,,,11018.90,6611.34,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THIRD DIGIT|PO",CASE-26727,LOCAL,26727,CPT,0360,RC,,,F7|PO,outpatient,,,13035.73,7821.44,,,,,,,,,,,,,
TRAY ACCS ENDOSCP W TWO BLDELSS STBL SLV 5 12X100MM,SUP-2220457,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.61,188.90,,,,,,,,,,,,,
CATHETERIZATION KIT ART 025 18 GAX4.45 CM 18/25 GA 3 CC LF,SUP-2865587,CDM,C1751,HCPCS,0278,RC,,,,both,,,59.35,38.58,,,,,,,,,,,,,
CELECOXIB 100 MG PO CAPS,RX-24500,CDM,6370000000,HCPCS,0637,RC,50268-0168-15,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
ROD IM UNIV 7 DEG PFC,SUP-2456052,CDM,C1713,HCPCS,0278,RC,,,,both,,,1604.54,1042.95,,,,,,,,,,,,,
SHUNT CV L14MM DIA1.5MM IC SIL TAPR TIP RADPQ CLRVW,SUP-2282638,CDM,C1889,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PATCH DURA L 3.5 X W 0.8 IN SURF AREA2.8 SQ IN BOV PERICARD,SUP-2884063,CDM,C1763,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
STEM RAD L32MM OD10MM UNIV TI POR PLSM SPRY ANTR DSTL ELBW,SUP-2404381,CDM,C1776,CPT,0278,RC,,,,both,,,4782.22,3108.44,,,,,,,,,,,,,
GUIDE LT 5MM UNIV NONTRANSPARENT,SUP-2166954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.04,380.28,,,,,,,,,,,,,
BIT DRL L215MM DIA3.2MM CALIB L82MM 3 FLUT QUIK CPL,SUP-2188197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,656.07,426.45,,,,,,,,,,,,,
RECON PLATE 16X190MM 3.5MM,SUP-2818795,CDM,C1713,HCPCS,0278,RC,,,,both,,,4720.99,3068.64,,,,,,,,,,,,,
EPINEPHRINE (ANAPHYLAXIS) 30 MG/30ML IJ SOLN,RX-140394,CDM,J0169,HCPCS,0636,RC,76329-9060-00,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE W15XL120MM THK2MM 5 H BILAT S STL COVERLEAF RIG,SUP-2186007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.62,1028.70,,,,,,,,,,,,,
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,LOCAL,31622,CPT,0360,RC,,,,outpatient,,,14368.78,8621.27,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,LOCAL,29880,CPT,,,,,LT,outpatient,,,21791.13,13074.68,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids,CASE-60500,LOCAL,60500,CPT,0360,RC,,,,outpatient,,,44699.83,26819.90,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,LOCAL,11424,CPT,,,,,,outpatient,,,16266.03,9759.62,,,,,,,,,,,,,
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|RIGHT SIDE|PO,CASE-23700,LOCAL,23700,CPT,0360,RC,,,RT|PO,outpatient,,,19064.73,11438.84,,,,,,,,,,,,,
"Open Tx Fracture Phalanx/Phalanges Not Great Toe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28525,LOCAL,28525,CPT,0360,RC,,,T9|PO,outpatient,,,15785.70,9471.42,,,,,,,,,,,,,
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE|PO,CASE-25447,LOCAL,25447,CPT,0360,RC,,,LT|PO,outpatient,,,18647.28,11188.37,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52352,LOCAL,52352,CPT,0360,RC,,,LT|XU,outpatient,,,30801.07,18480.64,,,,,,,,,,,,,
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, SECOND DIGIT|PO",CASE-26080,LOCAL,26080,CPT,0360,RC,,,F6|PO,outpatient,,,16814.63,10088.78,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28750,LOCAL,28750,CPT,0360,RC,,,TA|PO,outpatient,,,38243.75,22946.25,,,,,,,,,,,,,
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,LOCAL,51990,CPT,0360,RC,,,,outpatient,,,110018.55,66011.13,,,,,,,,,,,,,
CAP ORTH WSHR FOR 27MM STD LOK SURFIX SCR HALLU LOCK MTP,SUP-2243051,CDM,C1713,HCPCS,0278,RC,,,,both,,,460.48,299.31,,,,,,,,,,,,,
COIL NEUROVASCULAR ORBIT GALAXY L 4 CM DIA 4 MM OD 0.012 IN,SUP-2427693,CDM,C1713,HCPCS,0278,RC,,,,both,,,6542.13,4252.38,,,,,,,,,,,,,
MESH HERN ELLIPSE 14X12 IN W/ ECHO2 POS SYS VENTRALIGHT ST,SUP-2855276,CDM,C1781,HCPCS,0278,RC,,,,both,,,6719.60,4367.74,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP ANGLED 0.025 INX30 MM KDVC631Q07303A,SUP-2468879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1745.24,1134.41,,,,,,,,,,,,,
INTRODUCER TUBE TY PERC FLX CIAGLIA BLU RHINO,SUP-2759813,CDM,C1769,HCPCS,0272,RC,,,,both,,,1276.22,829.54,,,,,,,,,,,,,
MESH CRAN L 85 X W 55 MM THK 0.3 MM SCREW DIA1.5 MM TI,SUP-2936475,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
CATHETER REPROC ULTRASOUND 8 FRX90 CM ACUSON ACUNAV,SUP-2469525,CDM,C1759,HCPCS,0272,RC,,,,both,,,2348.41,1526.47,,,,,,,,,,,,,
PLATE BONE W14XL214MM THK3.8MM 90DEG 12 H RT TIB L BTTRS LT,SUP-2185774,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.15,1466.50,,,,,,,,,,,,,
KIT BNE CEMENT SINGLE DBL VAC MIXING DEL SYS STRL DISP,SUP-2884017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.73,252.02,,,,,,,,,,,,,
MESH HERN SM W1XL1.4IN SYN POLY-4-HYDROXYBUTYRATE PLUG AND,SUP-2125873,CDM,C1781,HCPCS,0278,RC,,,,both,,,1349.35,877.08,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ULTRA ICE L 110 CM DIA 9 FR,SUP-2141334,CDM,C1759,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ROD SPNL L 90 MM DIA 6 MM TI ALLOY PREBENT NS PASS LP,SUP-2926375,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
TUBE HARV L9MM BNE DWL DISPOSABLE,SUP-2212802,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
PLATE BONE LOK 36MML HLX3 STNLSS STEEL 14 TBLR ST,SUP-2726489,CDM,C1713,HCPCS,0278,RC,,,,both,,,601.56,391.01,,,,,,,,,,,,,
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,LOCAL,26480,CPT,,,,,,outpatient,,,15327.97,9196.78,,,,,,,,,,,,,
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,LOCAL,45381,CPT,,,,,,outpatient,,,22839.05,13703.43,,,,,,,,,,,,,
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|RIGHT FOOT, SECOND DIGIT|PO",CASE-28092,LOCAL,28092,CPT,0360,RC,,,T6|PO,outpatient,,,12964.35,7778.61,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,LOCAL,50080,CPT,0360,RC,,,RT,outpatient,,,57388.50,34433.10,,,,,,,,,,,,,
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|RIGHT SIDE,CASE-37765,LOCAL,37765,CPT,,,,,RT,outpatient,,,41347.82,24808.69,,,,,,,,,,,,,
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE|PO,CASE-27650,LOCAL,27650,CPT,0360,RC,,,LT|PO,outpatient,,,35116.67,21070.00,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,LOCAL,64493,CPT,0360,RC,,,RT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|PO,CASE-64483,LOCAL,64483,CPT,0360,RC,,,PO,outpatient,,,3914.52,2348.71,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28296,LOCAL,28296,CPT,,,,,T5|PO,outpatient,,,26155.97,15693.58,,,,,,,,,,,,,
Amp Mtcrpl W/Finger/Thumb W/WO Inteross Transfer,CASE-26910,LOCAL,26910,CPT,,,,,,outpatient,,,10837.33,6502.40,,,,,,,,,,,,,
Dcmprn Fasct Leg Ant&/Lat Compartments Only,CASE-27600,LOCAL,27600,CPT,,,,,,outpatient,,,20812.13,12487.28,,,,,,,,,,,,,
Fth/Gft Fr W/Dir Clsr F/C/C/M/N/Ax/G/H/F 20 Cm/<|PO,CASE-15240,LOCAL,15240,CPT,,,,,PO,outpatient,,,20241.10,12144.66,,,,,,,,,,,,,
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26531,LOCAL,26531,CPT,0360,RC,,,F6|PO,outpatient,,,35112.83,21067.70,,,,,,,,,,,,,
Debridement Bone Each Additional 20 Sq Cm,CASE-11047,LOCAL,11047,CPT,,,,,,outpatient,,,19365.23,11619.14,,,,,,,,,,,,,
COVER BUR H DIA17MM 6 H TI NONCOMPRESSION LO PROF W/O TAB,SUP-2191321,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 2.5 CC DBM BIO,SUP-2637040,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
NEEDLE SUTURE L8.75IN SLIGHTLY CURVED REVERDIN,SUP-2802448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.35,493.58,,,,,,,,,,,,,
WALKER BOOT HI PRESSURE MED ANK AIR TRIO,SUP-2227874,CDM,L4386,HCPCS,0272,RC,,,,both,,,187.93,122.15,,,,,,,,,,,,,
GRAFT BNE 1 8MM 60ML CORTICAL CANELLOUS CHIP FRZ DRY,SUP-2264696,CDM,C1713,HCPCS,0278,RC,,,,both,,,1971.83,1281.69,,,,,,,,,,,,,
PLATE BNE LCK 159 MM RT DSTL LAT FEM 6 HOLE SS STRL,SUP-2467657,CDM,C1713,HCPCS,0278,RC,,,,both,,,4077.70,2650.50,,,,,,,,,,,,,
STRAP BITE BLOCK CLAV HVY DUTY,SUP-2148720,CDM,L3650,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE EXT FIX 90 DEG 180 MM FEM ARCH CARBON FIBER NS,SUP-2800127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2626.96,1707.52,,,,,,,,,,,,,
HC IV Inf Ea Add Hour,PX-2609636600,CDM,96366,CPT,0260,RC,,,,both,,,87.00,56.55,,,,,,,,,,,,,
SYSTEM INTRO ACUSTK II L 60 CM GUIDEWIRE 0.038 IN TIP 7.5 CM,SUP-2147741,CDM,C1894,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
Arven Anast Opn Upr Arm Basilic Vein Trpos|LEFT SIDE,CASE-36819,LOCAL,36819,CPT,0360,RC,,,LT,outpatient,,,50418.80,30251.28,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|RIGHT SIDE,CASE-28308,LOCAL,28308,CPT,0360,RC,,,XS|RT,outpatient,,,30270.30,18162.18,,,,,,,,,,,,,
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,LOCAL,43266,CPT,0360,RC,,,,outpatient,,,17099.42,10259.65,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|RIGHT SIDE|PO,CASE-23430,LOCAL,23430,CPT,0360,RC,,,RT|PO,outpatient,,,48936.28,29361.77,,,,,,,,,,,,,
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms|LEFT SIDE|PO,CASE-27696,LOCAL,27696,CPT,0360,RC,,,LT|PO,outpatient,,,56183.12,33709.87,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28232,LOCAL,28232,CPT,,,,,T6|PO,outpatient,,,23775.28,14265.17,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE|PO,CASE-29806,LOCAL,29806,CPT,,,,,LT|PO,outpatient,,,37838.58,22703.15,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-28308,LOCAL,28308,CPT,,,,,XS|LT|PO,outpatient,,,57075.62,34245.37,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,LOCAL,45385,CPT,,,,,,outpatient,,,11909.62,7145.77,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Complicated,CASE-11772,LOCAL,11772,CPT,0360,RC,,,,outpatient,,,31686.82,19012.09,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28285,LOCAL,28285,CPT,,,,,T3|PO,outpatient,,,25077.23,15046.34,,,,,,,,,,,,,
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE|PO,CASE-27654,LOCAL,27654,CPT,0360,RC,,,RT|PO,outpatient,,,34921.98,20953.19,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, SECOND DIGIT|PO",CASE-26727,LOCAL,26727,CPT,,,,,F1|PO,outpatient,,,10791.63,6474.98,,,,,,,,,,,,,
HC Icu R&B,PX-2000000000,CDM,2000000000,LOCAL,,,,,,outpatient,,,5346.25,3207.75,,,,,,,,,,,,,
Partial Excision Bone Talus/Calcaneus|LEFT SIDE,CASE-28120,LOCAL,28120,CPT,,,,,LT,outpatient,,,42614.05,25568.43,,,,,,,,,,,,,
Repair Primary Open/Prq Ruptured Achilles Tendon|RIGHT SIDE|PO,CASE-27650,LOCAL,27650,CPT,0360,RC,,,RT|PO,outpatient,,,23531.40,14118.84,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, THIRD DIGIT|PO",CASE-26123,LOCAL,26123,CPT,0360,RC,,,F7|PO,outpatient,,,13286.83,7972.10,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,LOCAL,23430,CPT,,,,,LT|XU,outpatient,,,75673.05,45403.83,,,,,,,,,,,,,
HC Cta Upper Extremity W & W/O Cont,PX-3527320600,CDM,73206,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
PLATE BNE L25MM 2 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT DYN,SUP-2185922,CDM,C1713,HCPCS,0278,RC,,,,both,,,387.76,252.04,,,,,,,,,,,,,
APPLIER CLP M-L DIA5MM ENDOSCP LIG SGL SITE DA VINCI,SUP-2246691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
NAIL IM L34CM DIA11.5MM LT LIME META-TAN,SUP-2340898,CDM,C1713,HCPCS,0278,RC,,,,both,,,11391.29,7404.34,,,,,,,,,,,,,
SCREW CANC 4X16,SUP-2741734,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
PLATE BNE T MINI LNG 2-2.5X3X7X1 MM LCK PEREZ TI LEVEL 1,SUP-2487788,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.19,1408.02,,,,,,,,,,,,,
BIT DRILL 42 X 300,SUP-2700664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
BLADE RTRCTR MAYO 2INW X 35NL ALMNM NON RDPQUE NON ST,SUP-2703357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1370.67,890.94,,,,,,,,,,,,,
MARKER FIDUCIAL 20G X 20CM X 0.40MM,SUP-2745233,CDM,A4648,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS MAXXEUS TIBIALIS POSTERIOR FZ,SUP-2875991,CDM,C1762,CPT,0278,RC,,,,both,,,5554.35,3610.33,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28820,LOCAL,28820,CPT,,,,,T5,outpatient,,,17197.70,10318.62,,,,,,,,,,,,,
Excision Mal Lesion Trunk/Arm/Leg 2.1-3.0 Cm,CASE-11603,LOCAL,11603,CPT,,,,,,outpatient,,,34347.35,20608.41,,,,,,,,,,,,,
Unlisted Procedure Pelvis/Hip Joint|RIGHT SIDE,CASE-27299,LOCAL,27299,CPT,,,,,RT,outpatient,,,79625.53,47775.32,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE|PO,CASE-64633,LOCAL,64633,CPT,,,,,RT|PO,outpatient,,,4471.57,2682.94,,,,,,,,,,,,,
Inguinofem Lmphadec Supfc W/Cloquets Node Spx,CASE-38760,LOCAL,38760,CPT,0360,RC,,,,outpatient,,,33296.82,19978.09,,,,,,,,,,,,,
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,LOCAL,46200,CPT,,,,,,outpatient,,,20061.38,12036.83,,,,,,,,,,,,,
Bladder Instillation Anticarcinogenic Agent|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51720,LOCAL,51720,CPT,0360,RC,,,XU,outpatient,,,22622.17,13573.30,,,,,,,,,,,,,
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|RIGHT SIDE,CASE-37765,LOCAL,37765,CPT,0360,RC,,,RT,outpatient,,,41347.82,24808.69,,,,,,,,,,,,,
Arthrs Knee Debridement/Shaving Artclr Crtlg|LEFT SIDE|PO,CASE-29877,LOCAL,29877,CPT,,,,,LT|PO,outpatient,,,21367.02,12820.21,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE|PO,CASE-29846,LOCAL,29846,CPT,0360,RC,,,RT|PO,outpatient,,,31695.40,19017.24,,,,,,,,,,,,,
Amputation Metatarsal W/Toe Single,CASE-28810,LOCAL,28810,CPT,0360,RC,,,,outpatient,,,52018.77,31211.26,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,50,outpatient,,,4416.53,2649.92,,,,,,,,,,,,,
Fasciotomy Foot&/Toe|LEFT SIDE|PO,CASE-28008,LOCAL,28008,CPT,,,,,LT|PO,outpatient,,,40088.18,24052.91,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-20610,LOCAL,20610,CPT,0510,RC,,,XS|LT|PO,outpatient,,,5643.08,3385.85,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE|PO,CASE-28306,LOCAL,28306,CPT,0360,RC,,,RT|PO,outpatient,,,24033.37,14420.02,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular,CASE-27427,LOCAL,27427,CPT,,,,,,outpatient,,,47575.93,28545.56,,,,,,,,,,,,,
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT SIDE|PO,CASE-26540,LOCAL,26540,CPT,0360,RC,,,LT|PO,outpatient,,,15256.77,9154.06,,,,,,,,,,,,,
Exc Tumor Soft Tissue Neck/Thorax Subfasc 5 Cm/>,CASE-21554,LOCAL,21554,CPT,,,,,,outpatient,,,15925.22,9555.13,,,,,,,,,,,,,
HC Clsd Tx Dist Phlnx Fx Manip,PX-4502675500,CDM,26755,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE FIBULAR RT LAT ANK 4 HOLE NS,SUP-2518398,CDM,C1713,HCPCS,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
PLATE BNE SHRT TALO NAVICULAR POLYAXL LCK T10 SM FRAG NS,SUP-2902440,CDM,C1713,HCPCS,0278,RC,,,,both,,,4745.48,3084.56,,,,,,,,,,,,,
GRAFT HUM TISS SAPH VEIN 5X6 MMX58 CM,SUP-2175204,CDM,C1768,CPT,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
IMPLANT BRST SIL SIENTRA TEXT RND LO PROJCT 310CC,SUP-2339854,CDM,C1789,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
FOOT RING SHRT DIA 210 MM ALUMINIUM,SUP-2695673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5325.44,3461.54,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 162 MM DIA 32/28 MM SHTH 20 FR,SUP-2751307,CDM,C1874,HCPCS,0278,RC,,,,both,,,56641.52,36816.99,,,,,,,,,,,,,
SPACER FEM 8 MM POST REV CONSTRN SCREW N-K II,SUP-2448991,CDM,C1776,CPT,0278,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
COVER ORTHOT CUST FOR UPR,SUP-2435583,CDM,L1120,HCPCS,0272,RC,,,,both,,,107.67,69.99,,,,,,,,,,,,,
Arthrodesis Iphal Jt W/WO Int Fixj Ea Iphal Jt,CASE-26861,LOCAL,26861,CPT,0360,RC,,,,outpatient,,,18675.95,11205.57,,,,,,,,,,,,,
HC I&D Hematoma Seroma Fluid,CASE-10140,LOCAL,10140,CPT,0450,RC,,,,outpatient,,,5358.17,3214.90,,,,,,,,,,,,,
Cystectomy Partial Simple,CASE-51550,LOCAL,51550,CPT,0360,RC,,,,outpatient,,,45487.02,27292.21,,,,,,,,,,,,,
"Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn|LEFT HAND, FOURTH DIGIT|PO",CASE-26145,LOCAL,26145,CPT,,,,,F3|PO,outpatient,,,14915.00,8949.00,,,,,,,,,,,,,
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|LEFT SIDE,CASE-27446,LOCAL,27446,CPT,,,,,LT,outpatient,,,66643.50,39986.10,,,,,,,,,,,,,
Rpr Tdn/Musc Xtnsr F/Arm&/Wrist Prim 1 Ea Tdn|LEFT SIDE|PO,CASE-25270,LOCAL,25270,CPT,,,,,LT|PO,outpatient,,,28009.37,16805.62,,,,,,,,,,,,,
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>|RIGHT SIDE,CASE-23071,LOCAL,23071,CPT,0360,RC,,,RT,outpatient,,,13689.87,8213.92,,,,,,,,,,,,,
Open Treatment of Ulnar Shaft Fracture|RIGHT SIDE|PO,CASE-25545,LOCAL,25545,CPT,,,,,RT|PO,outpatient,,,35323.03,21193.82,,,,,,,,,,,,,
Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt,CASE-25020,LOCAL,25020,CPT,,,,,,outpatient,,,12738.37,7643.02,,,,,,,,,,,,,
Suture Infrapatellar Tendon Primary|LEFT SIDE,CASE-27380,LOCAL,27380,CPT,,,,,LT,outpatient,,,34938.87,20963.32,,,,,,,,,,,,,
Transperineal Plmt Biodegradable Matrl 1/Mlt Njx,CASE-55874,LOCAL,55874,CPT,,,,,,outpatient,,,37395.83,22437.50,,,,,,,,,,,,,
CATHETER THROMCTMY QUICKCLEAR L 130 CM DIA10 FR NOM DIA,SUP-2823716,CDM,C1757,HCPCS,0272,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
INSERT TIB SM 60MM WDG KNEE SPCR ANTIBIO TREAT REMEDY,SUP-2419484,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW CLASSIC DIA28MM OD 33.2MM TRICSP,SUP-2214184,CDM,C1889,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PACK PROC 6FT IVTM DISPOSABLE STRT UP KT COOL LN,SUP-2416137,CDM,C1751,HCPCS,0278,RC,,,,both,,,8932.17,5805.91,,,,,,,,,,,,,
RING EXT FIX HALF 100 MM TI NS,SUP-2799568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1047.82,681.08,,,,,,,,,,,,,
COUPLER EXT FIX DIA5/8/11MM PIN DIA5MM ROD TO ROD DELT,SUP-2372218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2890.37,1878.74,,,,,,,,,,,,,
PLATE BNE L 175 MM SCREW DIA 4.5 MM 10 H NAR COMPR LCK NS,SUP-2932851,CDM,C1713,HCPCS,0278,RC,,,,both,,,2150.12,1397.58,,,,,,,,,,,,,
PLATE BNE W100XL100MM CRANIOMAXILLOFACIAL TI MESH SCRN FOR,SUP-2190572,CDM,C1713,HCPCS,0278,RC,,,,both,,,2094.38,1361.35,,,,,,,,,,,,,
SHEATH TRANSSEPTAL L 72 CM DIA 8.5 FR CRV L 17 MM DIL L 95,SUP-2913156,CDM,C1893,HCPCS,0272,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
SPHINCTEROTOME ENDO 3 LUMN MFIL CUT GWIRE PC CANN OF DUCTAL,SUP-2170667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
SCREW SCHANZ BLNT PT 5X250MM HA COAT STRL,SUP-2547734,CDM,C1713,HCPCS,0278,RC,,,,both,,,572.77,372.30,,,,,,,,,,,,,
SYSTEM DEL ACUITY PRO LD,SUP-2141881,CDM,C1887,HCPCS,0272,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
SYSTEM IMPLANT BICEPS DISTAL TWO INCISION,SUP-2750916,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
GRAFT HUMAN TSSUE PLBLE 16X8 CM RCNSTRCTVE TSSUE MTRX STRTTC,SUP-2484083,CDM,Q4130,HCPCS,0636,RC,,,,both,,,12305.66,7998.68,,,,,,,,,,,,,
Vaginectomy Partial Removal Vaginal Wall,CASE-57106,LOCAL,57106,CPT,,,,,,outpatient,,,19746.45,11847.87,,,,,,,,,,,,,
Excision Hidradenitis Axillary Smpl/Intrm Rpr,CASE-11450,LOCAL,11450,CPT,0360,RC,,,,outpatient,,,11221.82,6733.09,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node|SEPARATE PRACTITIONER,CASE-38792,LOCAL,38792,CPT,0361,RC,,,XP,outpatient,,,49448.83,29669.30,,,,,,,,,,,,,
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms|LEFT SIDE|PO,CASE-27696,LOCAL,27696,CPT,,,,,LT|PO,outpatient,,,56183.12,33709.87,,,,,,,,,,,,,
Partial Excision Bone Fibula|RIGHT SIDE|PO,CASE-27641,LOCAL,27641,CPT,,,,,RT|PO,outpatient,,,32164.05,19298.43,,,,,,,,,,,,,
Lengthening Tendon Extensor Hand/Finger Each,CASE-26476,LOCAL,26476,CPT,,,,,,outpatient,,,8193.55,4916.13,,,,,,,,,,,,,
Laps Surg Gastrostomy W/O Constj Gstr Tube Spx,CASE-43653,LOCAL,43653,CPT,0360,RC,,,,outpatient,,,36779.38,22067.63,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm,CASE-11401,LOCAL,11401,CPT,0360,RC,,,,outpatient,,,22448.28,13468.97,,,,,,,,,,,,,
HC Cv Cath Plac W/Port Tun >5,CASE-36561,LOCAL,36561,CPT,0361,RC,,,,outpatient,,,17491.08,10494.65,,,,,,,,,,,,,
Inguinofem Lmphadec Supfc W/Cloquets Node Spx,CASE-38760,LOCAL,38760,CPT,,,,,,outpatient,,,33296.82,19978.09,,,,,,,,,,,,,
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE,CASE-27792,LOCAL,27792,CPT,0360,RC,,,LT,outpatient,,,37419.52,22451.71,,,,,,,,,,,,,
TUBE SUCTION POOLE 23FR DIA 8 3/4INL CURVED ANGLED,SUP-2501227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78.85,51.25,,,,,,,,,,,,,
PUSHER KNOT 6TH FNGR W/ SUT PASS DISP,SUP-2121576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
GRAFT BNE PTTY FLX DBM GRFT,SUP-2280138,CDM,C9359,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
BIT DRL L145MM DIA3.2MM 3 FLUT QUIK CPL FOR EXPERT TIB,SUP-2178873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.72,322.87,,,,,,,,,,,,,
COMPONENT FEM CRUC RET N POR RT 74MM MEDL LAT 47MM ANT POST,SUP-2252374,CDM,C1776,CPT,0278,RC,,,,both,,,8468.58,5504.58,,,,,,,,,,,,,
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE,CASE-27829,LOCAL,27829,CPT,0360,RC,,,RT,outpatient,,,36581.78,21949.07,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE|PO,CASE-64721,LOCAL,64721,CPT,,,,,50|PO,outpatient,,,15300.75,9180.45,,,,,,,,,,,,,
Arthrt Elbow Capsular Excision Capsular Rls Spx,CASE-24006,LOCAL,24006,CPT,0360,RC,,,,outpatient,,,29263.73,17558.24,,,,,,,,,,,,,
HC Wound Vac <=50 Sq Cm Dme,CASE-97605,LOCAL,97605,CPT,0761,RC,,,,outpatient,,,297.92,178.75,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T7,outpatient,,,34797.97,20878.78,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,LOCAL,29827,CPT,0360,RC,,,LT,outpatient,,,50810.77,30486.46,,,,,,,,,,,,,
"Sesamoidectomy First Toe Spx|LEFT FOOT, GREAT TOE|PO",CASE-28315,LOCAL,28315,CPT,,,,,TA|PO,outpatient,,,22178.83,13307.30,,,,,,,,,,,,,
Excision Mal Lesion Trunk/Arm/Leg 2.1-3.0 Cm,CASE-11603,LOCAL,11603,CPT,0360,RC,,,,outpatient,,,34347.35,20608.41,,,,,,,,,,,,,
HC Debride Infected Skin,PX-4501100000,CDM,11000,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
LOPERAMIDE HCL 1 MG/7.5ML PO SOLN,RX-150665,CDM,340b,HCPCS,0637,RC,68094-0129-62,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
STEM HUM SZ 1 DIA8MM LNG CO CHROM CEM MONOBLOC EPIPHYSIS,SUP-2250978,CDM,C1776,CPT,0278,RC,,,,both,,,11963.40,7776.21,,,,,,,,,,,,,
NAIL IM L340MM DIA10.5MM TI ALLOY RG CORELOCK TECHNOLOGY,SUP-2405538,CDM,C1713,HCPCS,0278,RC,,,,both,,,8003.86,5202.51,,,,,,,,,,,,,
PLATE BNE 1ST MTP 5 DEG NAR 2.7 MM LT 5 HOLE,SUP-2857045,CDM,C1713,HCPCS,0278,RC,,,,both,,,8578.48,5576.01,,,,,,,,,,,,,
GUIDE STAPLE WIRE/DRILL 1.5MM,SUP-2652944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BIOPSY PROCEDURE KIT UNIV LNG BLDELSS PRB MARKER MAMTOM MUK302] DEVICOR MED PRODUCTS MAMMOTOME],SUP-2195661,CDM,C1713,HCPCS,0278,RC,,,,both,,,1847.89,1201.13,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.14 MM 1.6 MM 2.3 MM W/O TAB 525126,SUP-2535155,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.11,14.37,,,,,,,,,,,,,
WASHER ORTHOPEDIC WIRE FOR PLATE,SUP-2389786,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.5X400 MM KNEE NIT NS DISP,SUP-2762003,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,LOCAL,28285,CPT,,,,,T6,outpatient,,,40956.73,24574.04,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28232,LOCAL,28232,CPT,0360,RC,,,T6|PO,outpatient,,,23775.28,14265.17,,,,,,,,,,,,,
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64448,LOCAL,64448,CPT,0360,RC,,,XU|RT,outpatient,,,58183.75,34910.25,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE|PO,CASE-64633,LOCAL,64633,CPT,,,,,50|PO,outpatient,,,12270.58,7362.35,,,,,,,,,,,,,
HC Intro Cath in Svc or Ivc|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36010,LOCAL,36010,CPT,0361,RC,,,XU,outpatient,,,43722.95,26233.77,,,,,,,,,,,,,
Open Treatment Metatarsal Fracture Each|RIGHT SIDE|PO,CASE-28485,LOCAL,28485,CPT,,,,,RT|PO,outpatient,,,45080.53,27048.32,,,,,,,,,,,,,
Mastectomy Simple Complete,CASE-19303,LOCAL,19303,CPT,0360,RC,,,,outpatient,,,56000.47,33600.28,,,,,,,,,,,,,
Arthroplasty Glenohumeral Joint Total Shoulder,CASE-23472,LOCAL,23472,CPT,,,,,,outpatient,,,70589.23,42353.54,,,,,,,,,,,,,
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,LOCAL,58550,CPT,0360,RC,,,,outpatient,,,69732.95,41839.77,,,,,,,,,,,,,
Cptr-Asst Surgical Navigation Image-Less,CASE-20985,LOCAL,20985,CPT,,,,,,outpatient,,,78524.87,47114.92,,,,,,,,,,,,,
GRAFT VASC QUADFURCATED 20 MMX50 CM 10/10/8/8 MM HEMSHLD,SUP-2470100,CDM,C1768,CPT,0278,RC,,,,both,,,5383.78,3499.46,,,,,,,,,,,,,
UNIT PWR MOB W/ CRD,SUP-2356032,CDM,C1713,HCPCS,0278,RC,,,,both,,,27129.60,17634.24,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 5-8 MM EPTFE LNG TAPR TW,SUP-2695235,CDM,C1768,CPT,0278,RC,,,,both,,,3558.37,2312.94,,,,,,,,,,,,,
HC Debrid Wound Tis Addl 20 Cm<,PX-4309759800,CDM,97598,CPT,0430,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
PLATE BNE SM 8 H R MIDFOOT TI POLYAX U SHP LOK COMPR LO PROF,SUP-2398192,CDM,C1713,HCPCS,0278,RC,,,,both,,,5466.74,3553.38,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH BSC 4FR 0.034IN 60CM 1 LU 9154115,SUP-2632692,CDM,C1751,HCPCS,0278,RC,,,,both,,,349.92,227.45,,,,,,,,,,,,,
KIT INTRO SHTH 5 CM GUIDEWIRE L 30 CM DIA 4.5 FR NDL L 1.5,SUP-2734924,CDM,C1894,HCPCS,0272,RC,,,,both,,,11.93,7.75,,,,,,,,,,,,,
ENDCAP SPNL 17X22MM TI OVL MESH,SUP-2254468,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
SET SCR SPNL TI INNR FOR HD TO HD CONN 3.5MM ROD OCT SYS,SUP-2255335,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF L115CM 8FR F,SUP-2248618,CDM,C1732,HCPCS,0278,RC,,,,both,,,9410.58,6116.88,,,,,,,,,,,,,
KIT INSTR SHT W/ MTL SPEAR TRCR DRL DISP FOR 2.9MM PUSHLOCK,SUP-2121759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BIT DRL L90MM DIA1.8MM MINI FLUT PROX END DISP,SUP-2389424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
Carpectomy All Bones Proximal Row|LEFT SIDE|PO,CASE-25215,LOCAL,25215,CPT,,,,,LT|PO,outpatient,,,21219.00,12731.40,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,LOCAL,64446,CPT,0360,RC,,,RT|XU,outpatient,,,87970.43,52782.26,,,,,,,,,,,,,
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|RIGHT SIDE,CASE-26121,LOCAL,26121,CPT,,,,,RT,outpatient,,,14409.52,8645.71,,,,,,,,,,,,,
Split Agrft T/a/L 1st 100 Cm/&/1% Bdy Inft/Chld,CASE-15100,LOCAL,15100,CPT,,,,,,outpatient,,,23548.95,14129.37,,,,,,,,,,,,,
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,LOCAL,45378,CPT,,,,,,outpatient,,,10139.13,6083.48,,,,,,,,,,,,,
Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT SIDE,CASE-28297,LOCAL,28297,CPT,,,,,LT,outpatient,,,102832.62,61699.57,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|PREVENTIVE SERVICES,CASE-45385,LOCAL,45385,CPT,,,,,33,outpatient,,,10944.37,6566.62,,,,,,,,,,,,,
KIT PT PRGMR NEUROSTIMULATOR AVTIVIA DBS,SUP-2284468,CDM,C1787,HCPCS,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
BUR SURG DIA6MM RND PRECIS RIM GLDE TECHNOLOGY RAP SMOOTH,SUP-2363787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.65,284.47,,,,,,,,,,,,,
DEVICE FIX CL BTB 15 MM STRL ENDOBUTTON,SUP-2849159,CDM,C1713,HCPCS,0278,RC,,,,both,,,1015.38,660.00,,,,,,,,,,,,,
ALLOGRAFT BNE 10X45.1-50 MM BONE-PATELLAR TENDON-BONE,SUP-2866882,CDM,C1762,CPT,0278,RC,,,,both,,,7934.78,5157.61,,,,,,,,,,,,,
SCREW BNE FT 3.5X16 MM CORTICAL PER ARTC,SUP-2198461,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.61,159.00,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 34 MM ANTR CERV NEO-SL,SUP-2430703,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
PLATE BNE W8XL64MM THK3.3MM 8 H NONSTERILE BILAT PELV S STL,SUP-2186234,CDM,C1713,HCPCS,0278,RC,,,,both,,,1568.78,1019.71,,,,,,,,,,,,,
HC Decalcification Procedure,PX-3128831100,CDM,88311,CPT,0312,RC,,,,both,,,105.00,68.25,,,,,,,,,,,,,
VANCOMYCIN HCL 250 MG/5ML PO SOLR,RX-147516,CDM,340b,HCPCS,0250,RC,62559-0830-55,NDC,,both,150,ML,1535.70,998.20,,,,,,,,,,,,,
PLATE BNE 5 H FIBULAR NS UNITE,SUP-2896553,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
PLATE BONE L142MM THK3.1MM 12 H BILAT S STL LCK COMPR RECON,SUP-2348697,CDM,C1713,HCPCS,0278,RC,,,,both,,,5771.79,3751.66,,,,,,,,,,,,,
INTRODUCER SHTH 6FR L5CM DBL DSTL GWIRE L50CM 0.038IN,SUP-2355427,CDM,C1894,HCPCS,0272,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
CLAMP SRGCL CLEY 8 1/2NL 12MMW X 60MMD JAW F/PRTL OCCLSN LAT,SUP-2494973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,631.89,410.73,,,,,,,,,,,,,
CONNECTOR SPNL L36-56MM POST OCCIPITOCERVICOTHORACIC T STR,SUP-2230465,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PROBE NERVE STIM FLSH TIP 100 MM,SUP-2631505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.32,396.71,,,,,,,,,,,,,
KIT HEMODLYS L24CM BASIC DLYS CATH 16FR VLV BRKWY INTRO,SUP-2117389,CDM,C1750,HCPCS,0278,RC,,,,both,,,1191.98,774.79,,,,,,,,,,,,,
KIT THROMCTMY ACE68 L 132 CM OD 6 FR ID 0.068 IN HI FLO TBNG,SUP-2323550,CDM,C1757,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SCREW BNE L24MM DIA3.8MM 90DEG S STL CORT PROX HUM CANN LOK,SUP-2414109,CDM,C1713,HCPCS,0278,RC,,,,both,,,396.08,257.45,,,,,,,,,,,,,
PLATE ACET STR MATTA SS 10 118.5MM,SUP-2465158,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
DISTRACTOR EXT FIX ROZELLE 15 MM 1 - 1.2 MM 9 HOLE MESH,SUP-2471260,CDM,C1713,HCPCS,0278,RC,,,,both,,,16631.51,10810.48,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FOURTH DIGIT|PO",CASE-26951,LOCAL,26951,CPT,,,,,F3|PO,outpatient,,,15455.88,9273.53,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level|RIGHT SIDE",CASE-64495,LOCAL,64495,CPT,,,,,RT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
"Arthro, Loose Body + Chondro",CASE-G0289,LOCAL,G0289,CPT,,,,,,outpatient,,,27637.02,16582.21,,,,,,,,,,,,,
Patellectomy/Hemipatellectomy,CASE-27350,LOCAL,27350,CPT,0360,RC,,,,outpatient,,,21647.35,12988.41,,,,,,,,,,,,,
Partial Excision Bone Metacarpal,CASE-26230,LOCAL,26230,CPT,,,,,,outpatient,,,10847.07,6508.24,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-28124,LOCAL,28124,CPT,,,,,XS|T5|PO,outpatient,,,21771.18,13062.71,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, FOURTH DIGIT",CASE-28308,LOCAL,28308,CPT,,,,,T3,outpatient,,,19207.23,11524.34,,,,,,,,,,,,,
Mastectomy Simple Complete|BILATERAL PROCEDURE,CASE-19303,LOCAL,19303,CPT,,,,,50,outpatient,,,78411.37,47046.82,,,,,,,,,,,,,
"HC Unlisted Procedure, Nervous System",CASE-64999,LOCAL,64999,CPT,0360,RC,,,,outpatient,,,48970.88,29382.53,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,LOCAL,38525,CPT,0360,RC,,,LT|XU,outpatient,,,33468.58,20081.15,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE|PO,CASE-29876,LOCAL,29876,CPT,0360,RC,,,LT|PO,outpatient,,,18100.22,10860.13,,,,,,,,,,,,,
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,LOCAL,13160,CPT,0360,RC,,,,outpatient,,,29271.23,17562.74,,,,,,,,,,,,,
HC Removal Subcutaneous Cardiac Rhythm Monitor|UNUSUAL NON-OVERLAPPING SERVICE,CASE-33286,LOCAL,33286,CPT,0361,RC,,,XU,outpatient,,,25770.43,15462.26,,,,,,,,,,,,,
I&D Ischiorct/Intramural Absc W/WO Seton,CASE-46060,LOCAL,46060,CPT,,,,,,outpatient,,,16704.02,10022.41,,,,,,,,,,,,,
Laps Bi Tot Pel Lmphadec & Pri-Aortic Lymph Bx 1,CASE-38572,LOCAL,38572,CPT,,,,,,outpatient,,,66908.52,40145.11,,,,,,,,,,,,,
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE|PO,CASE-28615,LOCAL,28615,CPT,0360,RC,,,LT|PO,outpatient,,,39583.60,23750.16,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26160,LOCAL,26160,CPT,,,,,F8|PO,outpatient,,,6433.13,3859.88,,,,,,,,,,,,,
HC Vasc Embolize Occlude Organ|BILATERAL PROCEDURE,CASE-37243,LOCAL,37243,CPT,0361,RC,,,50,outpatient,,,49478.52,29687.11,,,,,,,,,,,,,
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|LEFT SIDE,CASE-24341,LOCAL,24341,CPT,,,,,LT,outpatient,,,25273.95,15164.37,,,,,,,,,,,,,
HC Pbb Carpal Tunnel Inj Pmc|LEFT SIDE|PO,CASE-20526,LOCAL,20526,CPT,0510,RC,,,LT|PO,outpatient,,,10580.57,6348.34,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE|PO,CASE-27427,LOCAL,27427,CPT,,,,,RT|PO,outpatient,,,41942.65,25165.59,,,,,,,,,,,,,
TUBE TRACH DIA7MM S STL CUF FIT REINF SPRL COR KINK RESIST,SUP-2384500,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
CATHETER URET 6-10FR L50CM 2 LUMN STD ACCS W/ AQ FLEXI-TIP,SUP-2171303,CDM,C1758,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PLATE BNE L132MM 12 H NONSTERILE POST DST TIB S STL T LOK,SUP-2177438,CDM,C1713,HCPCS,0278,RC,,,,both,,,4280.07,2782.05,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR 7 CM NIT SHFT PLAT TIP STIFF DIL,SUP-2615875,CDM,C1894,HCPCS,0272,RC,,,,both,,,139.42,90.62,,,,,,,,,,,,,
BIT DRL 2 MM W/ MINI-QUICK CONN ALPS FAST,SUP-2606625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,42.20,27.43,,,,,,,,,,,,,
CATHETER CARD ABLATION QDOT MIC L 115 CM 8 FR 3.5 MM J SHP,SUP-2880102,CDM,C1732,HCPCS,0278,RC,,,,both,,,15813.04,10278.48,,,,,,,,,,,,,
TERBUTALINE SULFATE 2.5 MG PO TABS,RX-11508,CDM,6370000000,HCPCS,0637,RC,62559-0721-01,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
PROSTHESIS PENILE L16CM 0DEG BIOFLX SIL INFPUB INFL SELF,SUP-2165448,CDM,C1813,HCPCS,0278,RC,,,,both,,,23298.80,15144.22,,,,,,,,,,,,,
JOINT GREAT TOE MED MTL HEMI,SUP-2519588,CDM,C1776,CPT,0278,RC,,,,both,,,4574.98,2973.74,,,,,,,,,,,,,
PLATE 15 H 230MM,SUP-2485234,CDM,C1713,HCPCS,0278,RC,,,,both,,,3373.93,2193.05,,,,,,,,,,,,,
KIT INSTR 13MM CRUC RET DISP PROCHONDRIX,SUP-2363972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6239.75,4055.84,,,,,,,,,,,,,
ABUTMENT FOR 3MM FLNG FIX 5.5MM BAHA BA210,SUP-2164963,CDM,L8614,HCPCS,0278,RC,,,,both,,,7429.24,4829.01,,,,,,,,,,,,,
CATHETER INTVASC 9.3FR L45CM POLYUR APPLAUSE HEAT EXCHG FLX,SUP-2416150,CDM,C1751,HCPCS,0278,RC,,,,both,,,3359.67,2183.79,,,,,,,,,,,,,
WIRE BNE FIX L 350 MM DIA2 MM DRL TIP STRL EVOS KIRSCHNER,SUP-2933537,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.38,298.60,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX14 TTNM CNTRD F3.5MM SCREW UNVRS,SUP-2720368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1604.16,1042.70,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|RIGHT SIDE|PO,CASE-G0260,LOCAL,G0260,CPT,,,,,RT|PO,outpatient,,,4478.50,2687.10,,,,,,,,,,,,,
HC Biopsy of Vulva/Perineum,CASE-56605,LOCAL,56605,CPT,0361,RC,,,,outpatient,,,19681.45,11808.87,,,,,,,,,,,,,
HC Debride Subq First 20 Sq Cm|SEPARATE STRUCTURE|PO,CASE-11042,LOCAL,11042,CPT,0361,RC,,,XS|PO,outpatient,,,21983.18,13189.91,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,LOCAL,28289,CPT,,,,,T5,outpatient,,,34378.30,20626.98,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,LOCAL,29823,CPT,,,,,LT,outpatient,,,42560.58,25536.35,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm,CASE-11422,LOCAL,11422,CPT,,,,,,outpatient,,,25293.23,15175.94,,,,,,,,,,,,,
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein,CASE-37249,LOCAL,37249,CPT,,,,,,outpatient,,,137700.13,82620.08,,,,,,,,,,,,,
Destruction Mal Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-17266,LOCAL,17266,CPT,,,,,,outpatient,,,15776.15,9465.69,,,,,,,,,,,,,
HC Insertion Uterine Tandem&/Vaginal Ovoids,CASE-57155,LOCAL,57155,CPT,0342,RC,,,,outpatient,,,16138.73,9683.24,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|PO,CASE-29881,LOCAL,29881,CPT,,,,,RT|PO,outpatient,,,21247.73,12748.64,,,,,,,,,,,,,
Application Uniplane External Fixation System|PO,CASE-20690,LOCAL,20690,CPT,,,,,PO,outpatient,,,18537.08,11122.25,,,,,,,,,,,,,
Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-34421,LOCAL,34421,CPT,,,,,74,outpatient,,,68578.52,41147.11,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE,PX-4309711000,CDM,97110,CPT,0430,RC,,,GP|CQ|XU|KX,both,,,195.00,126.75,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1 CC AMNION AMNIFLO CRYOPRESERVED,SUP-2138667,CDM,2780000010,LOCAL,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
PROCEDURE KIT PRB KNOT PUSH SUTURE CUT INTRO CROSSFIX II,SUP-2402628,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 25 MG UMB CRD CLARIX FLO,SUP-2648677,CDM,Q4155,HCPCS,0636,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
MEPIVACAINE HCL (PF) 1 % IJ SOLN,RX-106537,CDM,J0670,HCPCS,0636,RC,63323-0260-37,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE L60MM 1 H LT LCK CONQ FN,SUP-2341200,CDM,C1713,HCPCS,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
PROBE DOPPLER PENCIL,SUP-2321985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
TUBE ET LASERTUBUS 6MM STRL DISPOSAB,SUP-2265587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.00,238.55,,,,,,,,,,,,,
DEBRIDER SURG SHFT L 255 MM DIA 8 MM IM CNL SUCTION CURET,SUP-2910632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
IMPLANT RADIAL SIZE 2 LEFT WRIST FREEDOM,SUP-2586703,CDM,C1776,CPT,0278,RC,,,,both,,,23457.15,15247.15,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT MAXBARR 5FR 55CM 1 LUMAN RVS TAP,SUP-2613436,CDM,C1751,HCPCS,0278,RC,,,,both,,,712.15,462.90,,,,,,,,,,,,,
SET URET STENT UNIVERSA SFT 30CM 7FR WIREGUIDE MULTILENGTH,SUP-2835793,CDM,C2617,HCPCS,0278,RC,,,,both,,,292.08,189.85,,,,,,,,,,,,,
INTRODUCER SHTH L14CM OD10.5FR 0.038IN ENDHOLE DI-LOCK DIL,SUP-2357098,CDM,C1892,HCPCS,0272,RC,,,,both,,,20.10,13.06,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X160X2.8 MM 20 HOLE RECON LCK TI STRL,SUP-2460959,CDM,C1713,HCPCS,0278,RC,,,,both,,,5219.25,3392.51,,,,,,,,,,,,,
PROBE VITRCTMY 20GA CONSTELLATION ULTRAVIT 5000,SUP-2109909,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
PACEMAKER CARD ENTOVIS PROMRI SR-T SINGLE CHMBR MR,SUP-2138276,CDM,C1786,HCPCS,0275,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
COMPONENT TIB W33.5MMXL D45MM ANK CO CHROM TI CEMENTLESS SGL,SUP-2362589,CDM,C1776,CPT,0278,RC,,,,both,,,12486.84,8116.45,,,,,,,,,,,,,
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE|PO,CASE-27619,LOCAL,27619,CPT,,,,,LT|PO,outpatient,,,21689.50,13013.70,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|PO,CASE-64721,LOCAL,64721,CPT,0360,RC,,,RT|PO,outpatient,,,10407.58,6244.55,,,,,,,,,,,,,
Realignment Extensor Tendon Hand Each Tendon|RIGHT SIDE|PO,CASE-26437,LOCAL,26437,CPT,,,,,RT|PO,outpatient,,,15589.47,9353.68,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,LOCAL,58662,CPT,0360,RC,,,,outpatient,,,37464.60,22478.76,,,,,,,,,,,,,
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE|PO,CASE-24073,LOCAL,24073,CPT,,,,,LT|PO,outpatient,,,15900.18,9540.11,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,LOCAL,28270,CPT,0360,RC,,,T1|PO,outpatient,,,19110.18,11466.11,,,,,,,,,,,,,
Amp Mtcrpl W/Finger/Thumb W/WO Inteross Transfer,CASE-26910,LOCAL,26910,CPT,0360,RC,,,,outpatient,,,10837.33,6502.40,,,,,,,,,,,,,
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE|PO,CASE-28730,LOCAL,28730,CPT,0360,RC,,,RT|PO,outpatient,,,84914.28,50948.57,,,,,,,,,,,,,
SCREW SPNL L40MM DIA5.5MM S STL FIX ANG FOR 5.5MM ROD CDH,SUP-2288234,CDM,C1713,HCPCS,0278,RC,,,,both,,,2349.19,1526.97,,,,,,,,,,,,,
KIT INTRO L 10 CM NIT WIRE TUNGSTEN TIP MIC B BVL STD,SUP-2752723,CDM,C1894,HCPCS,0272,RC,,,,both,,,78.09,50.76,,,,,,,,,,,,,
CUSTOM KT PTCA INFL DEV K05 00053H (ORDER MUTLIPLES OF 5 EACH),SUP-2302818,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.68,138.89,,,,,,,,,,,,,
GRAFT BNE SUB GRFT 5CC VIA FRM MOLD,SUP-2393059,CDM,C1713,HCPCS,0278,RC,,,,both,,,6013.10,3908.51,,,,,,,,,,,,,
ALLOGRAFT HUM TISS INJ LG 1 CC STRL ALLOGEN AMINON,SUP-2393046,CDM,Q4139,HCPCS,0636,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SCREW BNE L95MM OD6.4MM BLU TI CORT ST SELF DRL,SUP-2347068,CDM,C1713,HCPCS,0278,RC,,,,both,,,704.62,458.00,,,,,,,,,,,,,
KNIFE 3722150 MYRINGOPLASTY 90115 DEG,SUP-2706207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.88,446.47,,,,,,,,,,,,,
CATHETER GUID ATTAIN SEL II 130 DEG L 65 CM OD 2.4 MM ID 5.7,SUP-2282174,CDM,C1887,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
DRILL SURG ANGLED STAND ALONE NO-P INTBDY CAGE DIVERGENCE,SUP-2630132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2488.70,1617.65,,,,,,,,,,,,,
ALLOGRAFT DERMAL MED 4X16 CMX1.6/0.4 MM RDY TO USE ALLDERM,SUP-2474753,CDM,Q4116,HCPCS,0636,RC,,,,both,,,7077.56,4600.41,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL 109X10 MM FRZN STRUT,SUP-2717909,CDM,C1762,CPT,0278,RC,,,,both,,,3831.62,2490.55,,,,,,,,,,,,,
CATHETER HD FULL SAFETY TY 035 12 FRX15 CM DL TURBO-FLO HD,SUP-2759836,CDM,C1752,HCPCS,0278,RC,,,,both,,,491.25,319.31,,,,,,,,,,,,,
COMPONENT FEM UNI LM/RL L EIUS,SUP-2364878,CDM,C1776,CPT,0278,RC,,,,both,,,8729.20,5673.98,,,,,,,,,,,,,
PLATE 3.5MM TI LCP OLECRANON 10 HOLES RIGHT 190MM,SUP-2549529,CDM,C1713,HCPCS,0278,RC,,,,both,,,3615.58,2350.13,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA1.8MM S STL BAYNT PNT W/ STPR FOR,SUP-2342296,CDM,C1769,HCPCS,0272,RC,,,,both,,,19736.78,12828.91,,,,,,,,,,,,,
BUR SURG DIA3MM RND FLUT CUT ELITE,SUP-2367545,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.45,265.49,,,,,,,,,,,,,
HANDLE RMR PIN PUL JCBS CHK FOR KNEE LIG RECON,SUP-2121289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
ENDOSCOPIC PACK INSTRUMENT 30 DEG 4X138 MM RIGID SCP,SUP-2243452,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3603.84,2342.50,,,,,,,,,,,,,
BIT DRL L100MM DIA2.7MM PROX TIB TI CALIB NONRADIOLUCENT,SUP-2412633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.72,284.52,,,,,,,,,,,,,
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE,CASE-23700,LOCAL,23700,CPT,0360,RC,,,LT,outpatient,,,17623.45,10574.07,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|LEFT FOOT, FIFTH DIGIT",CASE-28810,LOCAL,28810,CPT,0360,RC,,,T4,outpatient,,,19833.02,11899.81,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE|PO,CASE-24359,LOCAL,24359,CPT,0360,RC,,,LT|PO,outpatient,,,13245.50,7947.30,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT|PO",CASE-28270,LOCAL,28270,CPT,,,,,XS|T7|PO,outpatient,,,27783.90,16670.34,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE,CASE-27601,LOCAL,27601,CPT,,,,,RT,outpatient,,,33279.22,19967.53,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE|PO,CASE-29806,LOCAL,29806,CPT,,,,,RT|PO,outpatient,,,38273.60,22964.16,,,,,,,,,,,,,
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE|PO,CASE-28120,LOCAL,28120,CPT,0360,RC,,,RT|PO,outpatient,,,35852.18,21511.31,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,LOCAL,52352,CPT,,,,,LT,outpatient,,,16798.43,10079.06,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,LOCAL,49651,CPT,,,,,LT,outpatient,,,39248.22,23548.93,,,,,,,,,,,,,
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FIFTH DIGIT|PO",CASE-26125,LOCAL,26125,CPT,0360,RC,,,F4|PO,outpatient,,,16072.42,9643.45,,,,,,,,,,,,,
Osteotomy Radius Distal Third|RIGHT SIDE|PO,CASE-25350,LOCAL,25350,CPT,,,,,RT|PO,outpatient,,,54421.65,32652.99,,,,,,,,,,,,,
HC Debrid Wound Tis 20 Cm/<|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97597,LOCAL,97597,CPT,0761,RC,,,XU,outpatient,,,1316.25,789.75,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FOURTH DIGIT|PO",CASE-26440,LOCAL,26440,CPT,0360,RC,,,F8|PO,outpatient,,,16093.22,9655.93,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,LOCAL,50080,CPT,,,,,RT,outpatient,,,57388.50,34433.10,,,,,,,,,,,,,
Revision of Reconstructed Breast|RIGHT SIDE,CASE-19380,LOCAL,19380,CPT,,,,,RT,outpatient,,,78216.28,46929.77,,,,,,,,,,,,,
Mastectomy Partial W/Axillary Lymphadenectomy|RIGHT SIDE,CASE-19302,LOCAL,19302,CPT,0360,RC,,,RT,outpatient,,,47697.25,28618.35,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|PO,CASE-28122,LOCAL,28122,CPT,,,,,RT|PO,outpatient,,,18198.27,10918.96,,,,,,,,,,,,,
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|LEFT SIDE|PO,CASE-27675,LOCAL,27675,CPT,0360,RC,,,LT|PO,outpatient,,,68579.72,41147.83,,,,,,,,,,,,,
Arthrt Elbow W/Exploration Drainage/Removal FB|RIGHT SIDE|PO,CASE-24000,LOCAL,24000,CPT,,,,,RT|PO,outpatient,,,40834.40,24500.64,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,LOCAL,60220,CPT,0360,RC,,,,outpatient,,,41490.02,24894.01,,,,,,,,,,,,,
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|LEFT SIDE|PO,CASE-25260,LOCAL,25260,CPT,0360,RC,,,LT|PO,outpatient,,,23567.05,14140.23,,,,,,,,,,,,,
STEM HUM 79MM DST R STR PRSS FIT TI SOLAR,SUP-2372322,CDM,C1776,CPT,0278,RC,,,,both,,,19863.33,12911.16,,,,,,,,,,,,,
PASSER ACL RECON 2 PIN,SUP-2166843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,638.55,415.06,,,,,,,,,,,,,
SHEATH NRV STIM UNIV DYN DISP NEUROVISION,SUP-2310410,CDM,C1894,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
PLATE BNE L 44 MM SCREW DIA2.4 MM 6 SHFT H SS COMPACT STR VA,SUP-2908105,CDM,C1713,HCPCS,0278,RC,,,,both,,,2790.89,1814.08,,,,,,,,,,,,,
COLLAR CERV MOTN CTRL STOUT W/ REPL PD MIAMI J XTRA,SUP-2270252,CDM,L0174,HCPCS,0274,RC,,,,both,,,120.23,78.15,,,,,,,,,,,,,
GRAFT BNE SUB W10XH25XL20MM 18DEG B TRICALCIUM PHSPTE GRAN,SUP-2194023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2071.96,1346.77,,,,,,,,,,,,,
IMPLANT SUBTALAR 8MM TI NON-BIOABSORBABLE HORZ,SUP-2137777,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
Open Treatment Bimalleolar Ankle Fracture|RIGHT SIDE|PO,CASE-27814,LOCAL,27814,CPT,0360,RC,,,RT|PO,outpatient,,,28469.98,17081.99,,,,,,,,,,,,,
Lig/Banding Angioaccess Arteriovenous Fistula,CASE-37607,LOCAL,37607,CPT,,,,,,outpatient,,,35362.92,21217.75,,,,,,,,,,,,,
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,LOCAL,52300,CPT,,,,,,outpatient,,,25329.37,15197.62,,,,,,,,,,,,,
Arthrodesis Great Toe Interphalangeal Joint,CASE-28755,LOCAL,28755,CPT,0360,RC,,,,outpatient,,,16439.88,9863.93,,,,,,,,,,,,,
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE|PO,CASE-27570,LOCAL,27570,CPT,0360,RC,,,LT|PO,outpatient,,,14424.15,8654.49,,,,,,,,,,,,,
Unlisted Procedure Femur/Knee|RIGHT SIDE,CASE-27599,LOCAL,27599,CPT,,,,,RT,outpatient,,,11188.77,6713.26,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE,CASE-29807,LOCAL,29807,CPT,0360,RC,,,RT,outpatient,,,40724.82,24434.89,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy Limited Spx,CASE-29875,LOCAL,29875,CPT,,,,,,outpatient,,,18368.57,11021.14,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB|PO",CASE-26540,LOCAL,26540,CPT,,,,,FA|PO,outpatient,,,21626.93,12976.16,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,LOCAL,29824,CPT,0360,RC,,,LT,outpatient,,,46233.03,27739.82,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy Limited Spx|RIGHT SIDE|PO,CASE-29875,LOCAL,29875,CPT,,,,,RT|PO,outpatient,,,18368.57,11021.14,,,,,,,,,,,,,
Grafting of Autologous Fat by Lipo 50 Cc or Less,CASE-15771,LOCAL,15771,CPT,0360,RC,,,,outpatient,,,78216.28,46929.77,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE,CASE-29880,LOCAL,29880,CPT,,,,,50,outpatient,,,25491.58,15294.95,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,LOCAL,29826,CPT,0360,RC,,,LT,outpatient,,,46233.03,27739.82,,,,,,,,,,,,,
HC >= 12 Lead Ekg|ADJ,CASE-93005,LOCAL,93005,CPT,0730,RC,,,ADJ,outpatient,,,33083.00,19849.80,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE|PO,CASE-64483,LOCAL,64483,CPT,0360,RC,,,50|PO,outpatient,,,4090.33,2454.20,,,,,,,,,,,,,
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE,CASE-27680,LOCAL,27680,CPT,0360,RC,,,LT,outpatient,,,85907.05,51544.23,,,,,,,,,,,,,
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|LEFT FOOT, GREAT TOE|PO",CASE-28092,LOCAL,28092,CPT,,,,,TA|PO,outpatient,,,19025.68,11415.41,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE|PO,CASE-27524,LOCAL,27524,CPT,,,,,RT|PO,outpatient,,,21598.42,12959.05,,,,,,,,,,,,,
Colonoscopy Flx W/Endoscopic Mucosal Resection|COLORECTAL CANCER SCREEN,CASE-45390,LOCAL,45390,CPT,0360,RC,,,PT,outpatient,,,11346.18,6807.71,,,,,,,,,,,,,
HC Revasc Intravasc Lithotripsy|RIGHT SIDE,CASE-C9764,LOCAL,C9764,CPT,0481,RC,,,RT,outpatient,,,72783.52,43670.11,,,,,,,,,,,,,
PLATE BNE L945MM THK25MM 8 H ACET S STL FLX ANNEALED,SUP-2362707,CDM,C1713,HCPCS,0278,RC,,,,both,,,2762.89,1795.88,,,,,,,,,,,,,
GRAFT FRZ DRY ALLGRFT 50-99CM2,SUP-2165569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM THN MTRX ANAT BARR FOR ORTH APPL,SUP-2120775,CDM,C1762,CPT,0278,RC,,,,both,,,7123.88,4630.52,,,,,,,,,,,,,
TUBE FEED GASTRO ENTERIC BLLN 3 5ML 18FR 254CM MIC,SUP-2124602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.33,363.56,,,,,,,,,,,,,
DRILL SURG MOD 1.5-3 13 MM TIB NP SPEC 2,SUP-2456603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
GRAFT BONE SUB 10CC DEMIN HUM BONE W/ POLOXAMER RESRB PUTTY,SUP-2244481,CDM,C9359,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
SCREW BNE CRTX 2X4 MM RAPID RESRB W/PLATE STRL 80600410S,SUP-2859939,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.73,205.87,,,,,,,,,,,,,
PEN MRK 80DEG 20MM TOT HD ARTC 2 PSS ELECTRD LIN ISOLATOR,SUP-2124464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
Mastectomy Partial W/Axillary Lymphadenectomy,CASE-19302,LOCAL,19302,CPT,0360,RC,,,,outpatient,,,47697.25,28618.35,,,,,,,,,,,,,
Partial Excision Bone Tibia|RIGHT SIDE,CASE-27640,LOCAL,27640,CPT,,,,,RT,outpatient,,,32572.72,19543.63,,,,,,,,,,,,,
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE,CASE-27570,LOCAL,27570,CPT,0360,RC,,,LT,outpatient,,,13456.40,8073.84,,,,,,,,,,,,,
Gastrocnemius Recession|RIGHT SIDE|PO,CASE-27687,LOCAL,27687,CPT,,,,,RT|PO,outpatient,,,35852.18,21511.31,,,,,,,,,,,,,
Open Treatment Bimalleolar Ankle Fracture|RIGHT SIDE|PO,CASE-27814,LOCAL,27814,CPT,,,,,RT|PO,outpatient,,,28469.98,17081.99,,,,,,,,,,,,,
HC Intrvasc US Noncoronary 1st,CASE-37252,LOCAL,37252,CPT,0361,RC,,,,outpatient,,,55057.63,33034.58,,,,,,,,,,,,,
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE,CASE-27619,LOCAL,27619,CPT,0360,RC,,,LT,outpatient,,,33361.07,20016.64,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT",CASE-28285,LOCAL,28285,CPT,,,,,T8,outpatient,,,22334.18,13400.51,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE,CASE-29875,LOCAL,29875,CPT,0360,RC,,,LT,outpatient,,,27637.02,16582.21,,,,,,,,,,,,,
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE,CASE-24685,LOCAL,24685,CPT,0360,RC,,,LT,outpatient,,,28602.35,17161.41,,,,,,,,,,,,,
HC 3rd Order Sel Abd/Lower Ext|RIGHT SIDE,CASE-36247,LOCAL,36247,CPT,0361,RC,,,RT,outpatient,,,42956.78,25774.07,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,LOCAL,43239,CPT,,,,,74,outpatient,,,14828.12,8896.87,,,,,,,,,,,,,
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE|PO,CASE-28300,LOCAL,28300,CPT,,,,,RT|PO,outpatient,,,58835.72,35301.43,,,,,,,,,,,,,
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,LOCAL,50590,CPT,0360,RC,,,RT,outpatient,,,21962.30,13177.38,,,,,,,,,,,,,
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE|PO,CASE-27619,LOCAL,27619,CPT,0360,RC,,,LT|PO,outpatient,,,21689.50,13013.70,,,,,,,,,,,,,
Repair Brow Ptosis,CASE-67900,LOCAL,67900,CPT,,,,,,outpatient,,,36231.00,21738.60,,,,,,,,,,,,,
COMPONENT CTRL BODY EXT FIX SH FOR JET-X,SUP-2342857,CDM,C1776,CPT,0278,RC,,,,both,,,6538.11,4249.77,,,,,,,,,,,,,
PLATE BONE L34MM 4 H RIG EDC FOR 2.4MM SCR,SUP-2319391,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + M,SUP-2195532,CDM,L1830,CPT,0274,RC,,,,both,,,60.92,39.60,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED MED PRIORITY STRL MEDPOR,SUP-2862751,CDM,C1713,HCPCS,0278,RC,,,,both,,,53294.18,34641.22,,,,,,,,,,,,,
KIT INTRO AXCESS L 23 CM DIA 7 FR 0.035-0.038 IN W/O WIRE,SUP-2876447,CDM,C1894,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
SPLINT HND THM ADL NVY TERRY,SUP-2165485,CDM,L3807,HCPCS,0274,RC,,,,both,,,198.10,128.76,,,,,,,,,,,,,
BLADE SAW W13.5XL25.5MM THK0.4MM CUT THK0.6MM FN TOOTH,SUP-2166586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
TAP SURG 35MM SCR LOK QUIK CONN PERIARTC,SUP-2198526,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
CUP HUM DIA 33 MM OFFSET 2 MM RT STRL UNIVERS REVERS,SUP-2933960,CDM,C1776,CPT,0278,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 12 CM AORTIC/ILIAC 23/14.5 MM,SUP-2737604,CDM,C1768,CPT,0278,RC,,,,both,,,36279.56,23581.71,,,,,,,,,,,,,
RING CAPSULAR TENS DIA13MM STABILEYES,SUP-2247789,CDM,L8610,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|LEFT SIDE|PO,CASE-25111,LOCAL,25111,CPT,0360,RC,,,LT|PO,outpatient,,,11617.85,6970.71,,,,,,,,,,,,,
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26125,LOCAL,26125,CPT,0360,RC,,,F3|PO,outpatient,,,15834.95,9500.97,,,,,,,,,,,,,
Arteriovenous Anastomosis Open Direct|LEFT SIDE,CASE-36821,LOCAL,36821,CPT,,,,,LT,outpatient,,,30015.05,18009.03,,,,,,,,,,,,,
Dilation Esophagus Guide Wire,CASE-43453,LOCAL,43453,CPT,0360,RC,,,,outpatient,,,15221.77,9133.06,,,,,,,,,,,,,
Arthrs Aid Tibial Fracture Proximal Unicondylar,CASE-29855,LOCAL,29855,CPT,0360,RC,,,,outpatient,,,44662.20,26797.32,,,,,,,,,,,,,
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,LOCAL,32550,CPT,0361,RC,,,,outpatient,,,19988.12,11992.87,,,,,,,,,,,,,
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,LOCAL,64405,CPT,0450,RC,,,LT,outpatient,,,3502.95,2101.77,,,,,,,,,,,,,
Gastrocnemius Recession|LEFT SIDE|PO,CASE-27687,LOCAL,27687,CPT,,,,,LT|PO,outpatient,,,36063.18,21637.91,,,,,,,,,,,,,
Transurethral Resection Bladder Neck|SEPARATE STRUCTURE,CASE-52500,LOCAL,52500,CPT,0360,RC,,,XS,outpatient,,,27597.97,16558.78,,,,,,,,,,,,,
Mastectomy Simple Complete|BILATERAL PROCEDURE,CASE-19303,LOCAL,19303,CPT,0360,RC,,,50,outpatient,,,78411.37,47046.82,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,LOCAL,64418,CPT,0360,RC,,,LT,outpatient,,,3979.95,2387.97,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE|PO",CASE-28289,LOCAL,28289,CPT,,,,,TA|PO,outpatient,,,19110.18,11466.11,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64446,LOCAL,64446,CPT,0360,RC,,,XU|RT,outpatient,,,48979.75,29387.85,,,,,,,,,,,,,
Exc Tumor Soft Tiss Back/Flank Subfascial 5 Cm/>,CASE-21933,LOCAL,21933,CPT,0360,RC,,,,outpatient,,,22592.27,13555.36,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE|PO,CASE-29824,LOCAL,29824,CPT,,,,,LT|PO,outpatient,,,62784.27,37670.56,,,,,,,,,,,,,
Bronchoscopy W/Removal Foreign Body,CASE-31635,LOCAL,31635,CPT,0360,RC,,,,outpatient,,,32974.88,19784.93,,,,,,,,,,,,,
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE|PO,CASE-26615,LOCAL,26615,CPT,0360,RC,,,RT|PO,outpatient,,,19728.23,11836.94,,,,,,,,,,,,,
STENT PERIPH L40MM DIA7MM CATH L135CM NIT SELF EXP RADPQ,SUP-2104818,CDM,C1876,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
SCREW 7713510 ZEVO VAR SD 3.5MM X 10MM,SUP-2289033,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
GUIDEPIN ORTHOPAEDIC CALIBRATED 1.6X152 MM THREADED TIP WITH,SUP-2836611,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.30,142.54,,,,,,,,,,,,,
TRAY CATH 4FR SGL LUMN MAX BARR SHERLOCK 3CG TPS STYL,SUP-2125509,CDM,C1751,HCPCS,0278,RC,,,,both,,,764.40,496.86,,,,,,,,,,,,,
SCREW BONE L28MM DIA3.5MM S STL PARTIALLY THRD HEX SOCK AX,SUP-2183536,CDM,C1713,HCPCS,0278,RC,,,,both,,,64.02,41.61,,,,,,,,,,,,,
HC So Antidepressant Tricyclic 1/2,PX-3018033567,CDM,G0480,CPT,0301,RC,,,,inpatient,,,609.00,395.85,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN ALLGRFT AMBIO5,SUP-2247197,CDM,V2790,HCPCS,0274,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
COMPONENT KNEE PT SPEC INSTRUMENT MOLD,SUP-2212605,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
K-WIRE .062X4 2PT TR,SUP-2818089,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.47,106.91,,,,,,,,,,,,,
BUR SURG DIA9MM S STL ACORN PRECIS ELITE TPS,SUP-2363424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.73,226.67,,,,,,,,,,,,,
PROTECTOR NRV L40MM DIA10MM PORCINE EXTRACELLULAR MTRX WRP,SUP-2124862,CDM,C1763,HCPCS,0278,RC,,,,both,,,9821.92,6384.25,,,,,,,,,,,,,
PERIKABIVEN 2.4-7.5-3.5-0.5 % IV EMUL,RX-127990,CDM,2500000003,HCPCS,0250,RC,63323-0714-14,NDC,,both,1440,ML,1000.00,650.00,,,,,,,,,,,,,
CATHETER GUID MP HS 0.086 IN 8 FR W/ SH WISEGUIDE,SUP-2139638,CDM,C1887,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
GUIDEWIRE VASC 0.018 INX60 CM PLAT TIP INTRO KT SS MAKNV,SUP-2302991,CDM,C1769,HCPCS,0272,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
DRILL PACK 2.8 MM RCG 2 SL STRL T FIX DISP,SUP-2849076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
COLLAR BUTTON VT 127MM FLPL,SUP-2680288,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.29,14.49,,,,,,,,,,,,,
HC So Haptoglobin,PX-3018301066,CDM,83010,CPT,0301,RC,,,,outpatient,,,38.00,24.70,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT SHFT TIB STRUCTURAL 50MM LEN,SUP-2307364,CDM,C1713,HCPCS,0278,RC,,,,both,,,2275.46,1479.05,,,,,,,,,,,,,
CATHETER 4FR 70CM GWIRE RAD BASIC TY ST PWR PICC SOLO,SUP-2125531,CDM,C1751,HCPCS,0278,RC,,,,both,,,377.87,245.62,,,,,,,,,,,,,
CATHETER NEPHSTMY 7FR L65CM 35FR INFLATED LTX BLLN OCCL,SUP-2139187,CDM,C2628,HCPCS,0272,RC,,,,both,,,485.44,315.54,,,,,,,,,,,,,
PLATE BONE L81MM 3 H PROX HUM LCK FOR 3.5MM SCR,SUP-2349161,CDM,C1713,HCPCS,0278,RC,,,,both,,,7108.33,4620.41,,,,,,,,,,,,,
BRACE ANK AD H10IN STD BILAT STRP CLSR OPN HEEL AND TOE,SUP-2195182,CDM,L4397,HCPCS,0274,RC,,,,both,,,54.51,35.43,,,,,,,,,,,,,
PIN FIX L9IN OD3/32IN S STL THRD TYP A STNMN,SUP-2342676,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.36,231.63,,,,,,,,,,,,,
CATHETER GUID AXS CATLYST 7 L 125 CM PROX/DSTL OD,SUP-2715844,CDM,C1887,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
MESH SURG 25X20 CM BIOMATERIAL INTRAPERITONEAL ENFORM,SUP-2435397,CDM,C1781,HCPCS,0278,RC,,,,both,,,29035.58,18873.13,,,,,,,,,,,,,
PLATE BNE W12XL142MM THK3.7MM LNG 5 H NONSTERILE PROX HUM S,SUP-2186015,CDM,C1713,HCPCS,0278,RC,,,,both,,,4379.23,2846.50,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM DIA0.014IN FULL COAT STR TIP HI TORQ,SUP-2105270,CDM,C1876,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
TUBE VENT 1.14 MM 1 MM RUBE TAB MYRINGOTOMY SIL STRL 510183,SUP-2535111,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.11,27.37,,,,,,,,,,,,,
L PLATE RIGHT 2.0MM,SUP-2819059,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.14,265.29,,,,,,,,,,,,,
GUIDE SURG TRUMATCH STEPTECH,SUP-2421899,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE BNE 20 H ST BILAT S STL NAR CRV LOK COMPR FOR 45MM SCR,SUP-2178066,CDM,C1713,HCPCS,0278,RC,,,,both,,,4630.81,3010.03,,,,,,,,,,,,,
METATARSAL PHLANG STBL ROD 8MM,SUP-2319764,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL PREFABRICATED LSO,SUP-2388147,CDM,L0627,HCPCS,0274,RC,,,,both,,,1058.59,688.08,,,,,,,,,,,,,
IMPLANT TALAR SZ 2 R ANK VANTAGE,SUP-2420825,CDM,C1776,CPT,0278,RC,,,,both,,,13585.52,8830.59,,,,,,,,,,,,,
PLATE BNE W13.5XL134MM THK4.2MM 7 H BILAT S STL NAR LOK,SUP-2185238,CDM,C1713,HCPCS,0278,RC,,,,both,,,1218.01,791.71,,,,,,,,,,,,,
HC Path Consltj Surg Ea Addl Blk Frozen Section,PX-3128833200,CDM,88332,CPT,0312,RC,,,,both,,,182.00,118.30,,,,,,,,,,,,,
TRANEXAMIC ACID 2000 MG IN 200 ML NS (PREMIX) IVPB,RX-4082396,CDM,2500000003,HCPCS,0250,RC,09999-9917-09,NDC,,both,200,ML,1116.70,725.85,,,,,,,,,,,,,
SET NEUROSURGICAL 10MM BUMPER ST TRANSITION,SUP-2231440,CDM,C1776,CPT,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS,RX-10235,CDM,6370000000,HCPCS,0637,RC,00904-7046-61,NDC,,both,1,UN,6.30,4.09,,,,,,,,,,,,,
SIGMA HP UNI FEM FIN BLK SZ 2,SUP-2513378,CDM,C1776,CPT,0278,RC,,,,both,,,6283.14,4084.04,,,,,,,,,,,,,
INSERT TIB THK 8 MM OFFSET 3.25 MM SZ 2 XLPE VIT E POST ANK,SUP-2899021,CDM,C1776,CPT,0278,RC,,,,both,,,7653.75,4974.94,,,,,,,,,,,,,
BLADE SURG 9MM S STL ST DISPOSABLE GRFT PARASMILLIE,SUP-2167032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.56,262.96,,,,,,,,,,,,,
SLEEVE KNEE PROSTHETIC,SUP-2323332,CDM,L5685,LOCAL,0274,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
PLATE EXT FIX L 35 MM 2 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.02,321.11,,,,,,,,,,,,,
CONTOURED MESH GRDNR STYLE 1.0MM STNDRD STYLE T 6L 4V,SUP-2499852,CDM,C1713,HCPCS,0278,RC,,,,both,,,8953.18,5819.57,,,,,,,,,,,,,
ANKLE FUSION PLATE LATERAL TT 4H STRL,SUP-2815341,CDM,C1713,HCPCS,0278,RC,,,,both,,,6986.50,4541.22,,,,,,,,,,,,,
HC Aspir &/or Inject of Renal Cys,PX-3615039000,CDM,50390,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
ANCHOR SUT DIA5MM W/O ORTHOCORD NDL SPIRALOK,SUP-2256678,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE FEM CUST FRAC RIGID,SUP-2435652,CDM,L2136,HCPCS,0274,RC,,,,both,,,3570.43,2320.78,,,,,,,,,,,,,
DILATOR SET HEG UTER DBL END CANVS RL,SUP-2850403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.99,241.14,,,,,,,,,,,,,
PLATE BNE L 83 X W 51 MM THK 0.3 MM SCREW DIA1 MM CMF MESH,SUP-2883837,CDM,C1713,HCPCS,0278,RC,,,,both,,,3196.52,2077.74,,,,,,,,,,,,,
HC Thrmbc/Nfs Dialysis W Pta,PX-3613690500,CDM,36905,CPT,0361,RC,,,,both,,,11772.00,7651.80,,,,,,,,,,,,,
CLIP NSL TB RET AD 16FR YEL REPL AMT BRIDLE,SUP-2119781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
GUIDEWIRE VASC IQ L 185 CM DIA 0.014 IN SIL STR TIP STRL,SUP-2139930,CDM,C1769,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
PLATE BONE 4 H 3RD LCK TBLR,SUP-2122775,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
STEM FEM PRSS FT 3 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267797,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
PASSER SUT 30DEG STR QUICKPASS LASSO,SUP-2121955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC So Drug or Substance Nos 1-3,PX-3018037566,CDM,G0480,CPT,0301,RC,,,,both,,,88.00,57.20,,,,,,,,,,,,,
BASEPLATE TIB SZ 1 +4MM POR LT MOD THCK STEM PRESSFIT REV,SUP-2209091,CDM,C1776,CPT,0278,RC,,,,both,,,9545.60,6204.64,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct Ea Addl 15 Mins,PX-4309713000,CDM,97130,CPT,0430,RC,,,,outpatient,,,186.00,120.90,,,,,,,,,,,,,
COLLAR CERV FIRM DENS AD 3IN 19IN L,SUP-2276591,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.66,4.33,,,,,,,,,,,,,
IMPLANT HUM TISS L 2-2.4 X W 1-2 CM THK 1.8-2.2 MM 2XS,SUP-2894574,CDM,C1762,CPT,0278,RC,,,,both,,,1407.60,914.94,,,,,,,,,,,,,
PLATE BNE FEM 90 18 DEG 3.5 MM 18 MM DSTL 6 HOLE SS STRL JPS,SUP-2645612,CDM,C1713,HCPCS,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
CATHETER ABLATN LG 2-5-2 8 MM 7 FRX110 1304-7-25-L-TE8 THER,SUP-2538006,CDM,C1733,HCPCS,0272,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
STEM HUM METAPHYSIS 13 MM SHLDR ADJ REVERSED AEQUALIS,SUP-2715405,CDM,C1776,CPT,0278,RC,,,,both,,,11938.28,7759.88,,,,,,,,,,,,,
CANNULA SUCTION COAG 3 MMX17 CM ANGULAR,SUP-2776833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.75,344.99,,,,,,,,,,,,,
SPLINT WRST FOAM PADDING YTH FOREARM RT PERF DESIGN ALUM,SUP-2336021,CDM,L3908,HCPCS,0272,RC,,,,both,,,11.43,7.43,,,,,,,,,,,,,
SHEPARD GROMMET VT 102MM FLPL,SUP-2681456,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.43,15.88,,,,,,,,,,,,,
PLATE BNE H0.6MM BAR L12MM 100DEG 6 H R MID FACE G TI L,SUP-2366302,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.23,405.75,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT,RX-103568,CDM,6370000000,HCPCS,0637,RC,61314-0631-36,NDC,,both,3.5,GR,81.10,52.71,,,,,,,,,,,,,
GUIDEWIRE VASC L 110 CM DIA 0.038 IN CRV RAD 3 MM STR J DBL,SUP-2760010,CDM,C1769,HCPCS,0272,RC,,,,both,,,203.85,132.50,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC CHIP DBM PUROS,SUP-2335247,CDM,C9359,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
CANNULA KNEE ENTRY RECONSTRUCTION INSTRUMENT,SUP-2824435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.19,544.17,,,,,,,,,,,,,
HC Perq Trluml Coronary Mchnl Aspir Thrombectomy,PX-4819297300,CDM,92973,CPT,0481,RC,,,,inpatient,,,828.00,538.20,,,,,,,,,,,,,
PLATE BONE L40MM SH NONSTERILE RT ANTEROLATERAL CALCNL S STL,SUP-2178426,CDM,C1713,HCPCS,0278,RC,,,,both,,,2798.49,1819.02,,,,,,,,,,,,,
PLATE CRAN 180X40X40 MM PT SPEC IMPL PEEK,SUP-2860128,CDM,C1713,HCPCS,0278,RC,,,,both,,,28198.14,18328.79,,,,,,,,,,,,,
GENESIS II OXINIUM FEM W/ CEM TIB,SUP-2347973,CDM,C1776,CPT,0278,RC,,,,both,,,16171.00,10511.15,,,,,,,,,,,,,
CATHETER THRMDIL 7FR L110CM TORQ CTRL INFUS PRT HND OFF 5,SUP-2383926,CDM,C1751,HCPCS,0278,RC,,,,both,,,438.34,284.92,,,,,,,,,,,,,
SHEATH INTRO CEREBASE DA L 90 CM OD 8 FR ID 0.090 IN PTFE SS,SUP-2655902,CDM,C1894,HCPCS,0272,RC,,,,both,,,1870.40,1215.76,,,,,,,,,,,,,
FLUOROMETHOLONE 0.1 % OP SUSP,RX-3208,CDM,6370000000,HCPCS,0637,RC,60758-0880-05,NDC,,both,5,ML,348.50,226.52,,,,,,,,,,,,,
HC CT Orbit/Ear/Fossa W/WO Contrast,PX-3517048200,CDM,70482,CPT,0351,RC,,,,outpatient,,,2630.00,1709.50,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 14 200CM 0.014IN SEG 35CM ACCS STR,SUP-2367843,CDM,C1769,HCPCS,0272,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
PAROXETINE HCL 10 MG PO TABS,RX-16632,CDM,6370000000,HCPCS,0637,RC,00904-5676-61,NDC,,both,1,UN,3.60,2.34,,,,,,,,,,,,,
CUFF URETH L4CM INHIBZN OCCL SPHIN FOR AMS 800 SYS,SUP-2138949,CDM,C1815,HCPCS,0278,RC,,,,both,,,23003.64,14952.37,,,,,,,,,,,,,
SHEET BARR W38XL50MM THK1MM ORBIT,SUP-2366488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2131.18,1385.27,,,,,,,,,,,,,
SIZER KIT ACCSRY STRL INSTAFIX LTX DISP,SUP-2857586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
COMPONENT TIB 1 PC PROX 15MM DIA 95MML FINN,SUP-2406146,CDM,C1776,CPT,0278,RC,,,,both,,,20767.96,13499.17,,,,,,,,,,,,,
PLATE BONE CRANIAL 8 HOLE MATRIX 34X14MM TITANIUM NEURO PLAT,SUP-2825986,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
INSERTER INTOSS FIX FOR 3MM IMPL CROSSTIE,SUP-2175160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
REAMER SURG 5MM CANN ACORN,SUP-2277478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE BONE L256MM BLDE W11.7XL60MM 90DEG 14 H STRL BILAT TI,SUP-2190880,CDM,C1713,HCPCS,0278,RC,,,,both,,,4736.94,3079.01,,,,,,,,,,,,,
PLATE 3.5 MM TI LCP POSTEROMEDIAL PROX TIBIA 6 H/131 MM-STER,SUP-2546839,CDM,C1713,HCPCS,0278,RC,,,,both,,,3765.05,2447.28,,,,,,,,,,,,,
GUIDEWIRE SURG 0.045X14 IN NIT INTRF SCR BIOSCREW HYPRFLX,SUP-2765767,CDM,C1769,HCPCS,0272,RC,,,,both,,,123.87,80.52,,,,,,,,,,,,,
REAMER SURG 65MM IM FLX PRSS SENTNL,SUP-2198021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1769.77,1150.35,,,,,,,,,,,,,
SPLINT THMB AD M L BGE R MCP CMC JT PREFRM PERF FLX BASE LAM,SUP-2326183,CDM,L3908,HCPCS,0272,RC,,,,both,,,65.81,42.78,,,,,,,,,,,,,
WIRE FIX L234 OD2MM W/ DRL TIP ST K,SUP-2378028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,226.83,147.44,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 19 FRX30 CM PROC KT PWR INJ ARGY,SUP-2173948,CDM,C1751,HCPCS,0278,RC,,,,both,,,118.28,76.88,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX HUMERUS LONG 10H SHAFT 232MM STER,SUP-2549718,CDM,C1713,HCPCS,0278,RC,,,,both,,,5888.79,3827.71,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK2.3-3.3MM ULT THCK REGENERATIVE,SUP-2113417,CDM,Q4116,HCPCS,0636,RC,,,,both,,,14685.78,9545.76,,,,,,,,,,,,,
INTRODUCER TUBE SET 6.5/7/7.5/8 MM MULTI PERC TY W/ PHAR,SUP-2759710,CDM,C1769,HCPCS,0272,RC,,,,both,,,1791.37,1164.39,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 12 H TI WIDE Y LP NS,SUP-2894527,CDM,C1713,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
STENT URET OPN END 6 FRX22 CM KID CURL TAPR SIL MULTI-FLEX,SUP-2313764,CDM,C2617,HCPCS,0278,RC,,,,both,,,306.21,199.04,,,,,,,,,,,,,
SHEATH UROLOGICAL AMPLTZ L 16 CM DIL L 30 CM DIA24 FR RENAL,SUP-2835769,CDM,C1894,HCPCS,0272,RC,,,,both,,,106.98,69.54,,,,,,,,,,,,,
GRAFT HUM TISS L100MM FIBULAR SHFT FRZ DRY ALLGRFT MATRIGRFT,SUP-2264766,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.41,1259.32,,,,,,,,,,,,,
ENDCAP ORTH VN 2 HOLE IMPING STRL LTX,SUP-2861518,CDM,C1889,HCPCS,0278,RC,,,,both,,,717.99,466.69,,,,,,,,,,,,,
CATHETER TEMP PACE L 110 CM DIA 5 FR PROX 1 CM POLYUR SS,SUP-2127113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.34,501.37,,,,,,,,,,,,,
SCREW BNE L45MM OD65MM S STL HINDFOOT LOK ADVANSYS SURFIX,SUP-2243420,CDM,C1713,HCPCS,0278,RC,,,,both,,,1248.31,811.40,,,,,,,,,,,,,
SHUNT CAR KT W/O RESVR N PROGRAMMABLE 8FR 13CM,SUP-2264222,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
SET CBL SL SM DIA2MM S STL FOR RECON TRAUM SYS DALL-M,SUP-2371517,CDM,C1713,HCPCS,0278,RC,,,,both,,,790.02,513.51,,,,,,,,,,,,,
CATHETER GUID ARMADILLO 95CM 7FR 0.072IN L22CM 0.035-0.038IN,SUP-2759488,CDM,C1887,HCPCS,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CATHETER CV TY 025 5 FRX12 CM 3L POLYETH,SUP-2760002,CDM,C1751,HCPCS,0278,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.551,SUP-2860232,CDM,C1713,HCPCS,0278,RC,,,,both,,,55837.99,36294.69,,,,,,,,,,,,,
VALVE SHUNT PED ASST PRSS LEV 0 LAYING 10CM H2O UPR 20MM,SUP-2108718,CDM,C1729,HCPCS,0272,RC,,,,both,,,4341.65,2822.07,,,,,,,,,,,,,
GRAFT VSCLR 20CMW X 30CML 2MM THK EPTFE AORTA RCTNGLR NON AB,SUP-2676131,CDM,C1768,CPT,0278,RC,,,,both,,,8361.82,5435.18,,,,,,,,,,,,,
SET THORCENT CATH 10.2FR L29CM 20 SIDEPRT TRCR WIRE GUID TO,SUP-2171160,CDM,C1729,HCPCS,0272,RC,,,,both,,,1173.70,762.90,,,,,,,,,,,,,
COLLAR CERV ADJ UNIV AD 13-19 IN 2 PC RIGID REPL PD VISTA TX,SUP-2196893,CDM,L0120,HCPCS,0274,RC,,,,both,,,140.48,91.31,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 210 MMX0.3 CM FD,SUP-2717850,CDM,C1762,CPT,0278,RC,,,,both,,,7191.79,4674.66,,,,,,,,,,,,,
SCREW BNE LCK 3 MM VA TI KREULOCK,SUP-2845745,CDM,C1713,HCPCS,0278,RC,,,,both,,,10095.10,6561.81,,,,,,,,,,,,,
SPLINT CLAV XSM 20 24IN WHT HVY PD FELT FOAM CNTCT CLSR,SUP-2196987,CDM,L3650,HCPCS,0272,RC,,,,both,,,17.40,11.31,,,,,,,,,,,,,
AWL SURG SPNL FIX ANG REUSE ATLNTS,SUP-2279319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1553.61,1009.85,,,,,,,,,,,,,
MESH SURG W18XL24CM THK1MM EPTFE BIOMATERIAL ANTIMIC FOR,SUP-2395342,CDM,C1781,HCPCS,0278,RC,,,,both,,,3915.58,2545.13,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR REINF SLDE GDS,SUP-2681173,CDM,C1768,CPT,0278,RC,,,,both,,,1942.72,1262.77,,,,,,,,,,,,,
TUBE VENT L2.50MM ID1.27MM SIL MICROGEL DISP FOR MYR GRMMT,SUP-2284011,CDM,L8699,HCPCS,0278,RC,,,,both,,,101.39,65.90,,,,,,,,,,,,,
HC IV Dop Vel&/Press C/Flo Rsrv Meas Ea Addl Vsl,PX-4819357200,CDM,93572,CPT,0481,RC,,,,both,,,614.00,399.10,,,,,,,,,,,,,
BASEPLATE TIB L47MM SH MEDL LAT KNEE CO CHROM RESURF,SUP-2406477,CDM,C1776,CPT,0278,RC,,,,both,,,8322.57,5409.67,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST PATTEN BTM,SUP-2435662,CDM,L2370,HCPCS,0272,RC,,,,both,,,906.08,588.95,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED HUM REVERSED 2 INSRT LNR TRAB MEL,SUP-2212305,CDM,C1776,CPT,0278,RC,,,,both,,,15307.50,9949.87,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSTAR XK CHRONIC STD 16FR DI 5885230,SUP-2632971,CDM,C1750,HCPCS,0278,RC,,,,both,,,1470.46,955.80,,,,,,,,,,,,,
"HC Debrid,Bone,1st 20sqcm or Less",PX-3611104400,CDM,11044,CPT,0361,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX20 CM COAT W/ RNG SUPP FUSION BIOLINE,SUP-2468599,CDM,C1768,CPT,0278,RC,,,,both,,,1264.57,821.97,,,,,,,,,,,,,
BRACKET TRAC SUPP KNEE TBL BTTRS LEG HLDR LT BRKT FT,SUP-2197869,CDM,C1713,HCPCS,0278,RC,,,,both,,,8474.86,5508.66,,,,,,,,,,,,,
HC Radiologic Exam Small Int Single Contrast Study,PX-3207425000,CDM,74250,CPT,0320,RC,,,,outpatient,,,1702.00,1106.30,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 3",PX-7619920300,CDM,99203,CPT,0761,RC,,,,inpatient,,,321.00,208.65,,,,,,,,,,,,,
SET SCR BRKOFF M10 REDUC,SUP-2293093,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE 909707S VC1,SUP-2883647,CDM,C1729,HCPCS,0272,RC,,,,both,,,9794.51,6366.43,,,,,,,,,,,,,
GRAFT BONE SUB 2-5MM 30ML MORSELIZED CANC CORT SPIERING,SUP-2307426,CDM,C1713,HCPCS,0278,RC,,,,both,,,3207.35,2084.78,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.7MM DST VOLAR RAD MULTDIR FULL THRD SQ,SUP-2411812,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
RFID SINGLEUSE 200SRS LSR FIBR,SUP-2722584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1450.77,943.00,,,,,,,,,,,,,
PROSTHESIS OSS 8.1 MM 1.1 MM WEHRS DBL NOTCH INCUS OTOSIL HA,SUP-2460792,CDM,L8613,CPT,0278,RC,,,,both,,,1533.11,996.52,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 0.5 CC FD CANC PWD ORAGRAFT,SUP-2740969,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.68,147.99,,,,,,,,,,,,,
PLATE BNE MTP SM RT FUSION SLM LN,SUP-2397488,CDM,C1713,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
SCREW INTRF L20MM DIA9MM 8.6-9.4MM CANN 1.5MM KNEE POLY L,SUP-2341550,CDM,C1713,HCPCS,0278,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 5 CC FD ASEP CANC,SUP-2867141,CDM,C1762,CPT,0278,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
HC So Plasminogen Activator,PX-3058541566,CDM,85415,CPT,0305,RC,,,,inpatient,,,544.00,353.60,,,,,,,,,,,,,
BURR SURG MED SS DIAMOND TEMPOROMANDIBULAR JT NS DISP,SUP-2934559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
INTRODUCER ORTHOPEDIC ADD FRAC TOOL KYPHON XPANDER 10/3 IBT,SUP-2293644,CDM,C1894,HCPCS,0272,RC,,,,both,,,7171.76,4661.64,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID 2 CC AMNIO PLCNTA MEMBRN PRO3-F,SUP-2742033,CDM,C1762,CPT,0278,RC,,,,both,,,13384.25,8699.76,,,,,,,,,,,,,
BENAZEPRIL HCL 10 MG PO TABS,RX-9220,CDM,6370000000,HCPCS,0637,RC,50268-0110-15,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
MESH SURG SM ARC THK0.4MM SLV CRANIOFACIAL TI MALL CNTOUR,SUP-2181574,CDM,C1781,HCPCS,0278,RC,,,,both,,,2566.01,1667.91,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT FASC LATA HUM TISS 18CM LX100MM W,SUP-2307096,CDM,C1762,CPT,0278,RC,,,,both,,,3410.70,2216.95,,,,,,,,,,,,,
TUBE VENT MOD 1.27 MM 6 MM 7.6 MM T TUBE SIL STRL,SUP-2535098,CDM,L8699,HCPCS,0278,RC,,,,both,,,55.33,35.96,,,,,,,,,,,,,
COLLAR ASPN AD REG EA,SUP-2196889,CDM,L0172,HCPCS,0272,RC,,,,both,,,73.57,47.82,,,,,,,,,,,,,
GUIDE WIRE 1.3 MMX35.6 CM NIT,SUP-2608337,CDM,C1769,HCPCS,0272,RC,,,,both,,,661.60,430.04,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION|DISCARDED DRUG NOT ADMINISTE,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00264-7510-20,NDC,JW,both,250,ML,31.90,20.73,,,,,,,,,,,,,
PATCH VASC HEMAPATCH L 100 X W 25 MM THK 0.65 MM POLYESTER,SUP-2525490,CDM,C1768,CPT,0278,RC,,,,both,,,430.21,279.64,,,,,,,,,,,,,
SCREW BNE FT 6.5X55 MM CANN STRL,SUP-2458754,CDM,C1713,HCPCS,0278,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
GUIDEPIN ORTH SHLDR TEMP NS,SUP-2315866,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE MED SHT ANK ROCKER BTM INLINE,SUP-2336132,CDM,L4361,HCPCS,0274,RC,,,,both,,,79.35,51.58,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING BOLT INDIGO L 130 CM SHTH 7 FR,SUP-2880239,CDM,C1757,HCPCS,0272,RC,,,,both,,,25999.20,16899.48,,,,,,,,,,,,,
CATHETER INFUSION 35 DEG 1.9 FRX165 CM PROGREAT LAMBDA,SUP-2852402,CDM,C1887,HCPCS,0272,RC,,,,both,,,2446.06,1589.94,,,,,,,,,,,,,
PLATE BNE L213MM 12 H NONSTERILE L MED DST TIB S STL LOK,SUP-2177453,CDM,C1713,HCPCS,0278,RC,,,,both,,,3853.85,2505.00,,,,,,,,,,,,,
PLATE BNE RND 1.5X30 MM CRANIOFACIAL MESH MALL CONTOURABLE,SUP-2191123,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.32,1710.36,,,,,,,,,,,,,
BRACE ORTHPDC ADLT M 6 6.5N RIGHT THUMB NPRN WRAP HOOK LOOP,SUP-2472988,CDM,L3931,HCPCS,0274,RC,,,,both,,,53.57,34.82,,,,,,,,,,,,,
ROD IM L 140 MM DIA22/13 MM PHOTODYNAMIC BNE STBL PROC PK,SUP-2934112,CDM,C1713,HCPCS,0278,RC,,,,both,,,14626.12,9506.98,,,,,,,,,,,,,
ANCHOR SFT TISS BICEPS FIBERTAK,SUP-2419689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
PROSTHESIS PENILE 12CM SNAP FIT REAR TIP INHIBIZONE LGX,SUP-2138981,CDM,C1813,HCPCS,0278,RC,,,,both,,,25154.54,16350.45,,,,,,,,,,,,,
GUIDE BLOCK F/LCP(TM) PROXIMAL LATERAL TIBIA PLATES-RIGHT,SUP-2548287,CDM,C1713,HCPCS,0278,RC,,,,both,,,1352.68,879.24,,,,,,,,,,,,,
SCALPEL SURG TIP 25MM MPLR CANADY HYBRID PLSM,SUP-2391726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
WAND ARTHSCP L3MM 30DEG FOR H 2000-20 BEND TOOL ARTHWAND,SUP-2341963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
HOOK BNE L9IN DIA3 4IN S STL SATIN FINISH HVY MOD SHRP,SUP-2161260,CDM,C1713,HCPCS,0278,RC,,,,both,,,152.64,99.22,,,,,,,,,,,,,
SCREW BONE TI LCK THRD CANC TRIFLANGE ACET COMP L20MM,SUP-2137415,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
VALVE PUDENZ 12MM DIAM,SUP-2244291,CDM,C1729,HCPCS,0272,RC,,,,both,,,2140.54,1391.35,,,,,,,,,,,,,
DRILL SURG STEM TIB CEM NXGN,SUP-2438090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
GRAFT VASC GORTX L 90 CM DIA 6 MM RNG L 60 CM EPTFE STR TW,SUP-2396123,CDM,C1768,CPT,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
COIL EMB L30CM DIA 14MM HELIX FBR 0.021IN MICROCATHETER,SUP-2281265,CDM,C1889,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
SHEATH INTRO 14FR 15CML DRNGE CATH BAN PEEL,SUP-2141071,CDM,C1894,HCPCS,0272,RC,,,,both,,,142.46,92.60,,,,,,,,,,,,,
FAMOTIDINE (PF) 20 MG/2ML IV SOLN,RX-157659,CDM,J1308,HCPCS,0636,RC,63323-0739-12,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT HIP BPLR 5 HIP5ZI1800] ZIMMER BIOMET INC],SUP-2212583,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
HC Clsd Tx Bimall Fx W Manip,PX-4502781000,CDM,27810,CPT,0450,RC,,,,inpatient,,,1633.00,1061.45,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ATLNTS PV L 95 CM DIA 8 FR SHTH,SUP-2140560,CDM,C1753,HCPCS,0278,RC,,,,both,,,1735.57,1128.12,,,,,,,,,,,,,
SET URET STENT POLARIS ULTRA L 28 CM DIA 5 FR PERCFLX,SUP-2139168,CDM,C2617,HCPCS,0278,RC,,,,both,,,481.93,313.25,,,,,,,,,,,,,
MESH SURG XL OPTIMESH,SUP-2536960,CDM,C1713,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
HC So Serum Hgb Quantitative,PX-3018305166,CDM,83051,CPT,0301,RC,,,,inpatient,,,75.00,48.75,,,,,,,,,,,,,
PLATE BNE L 168 MM SCREW DIA 4.5 MM 10 H COMPR LCK NS EVOS,SUP-2932840,CDM,C1713,HCPCS,0278,RC,,,,both,,,3099.97,2014.98,,,,,,,,,,,,,
BLADE RETRCT 24X70MM CERV SLD TI LAT CASPER,SUP-2108276,CDM,C1713,HCPCS,0278,RC,,,,both,,,1514.30,984.29,,,,,,,,,,,,,
FILTER VASC OPTEASE L 90 CM NIT CLOSED CAGE LP LNG SIDE,SUP-2157004,CDM,C1725,HCPCS,0272,RC,,,,both,,,5063.63,3291.36,,,,,,,,,,,,,
SOUND PROC HEARING DEV TWO PT KT SONNET 2,SUP-2905156,CDM,L8619,HCPCS,0278,RC,,,,both,,,37513.58,24383.83,,,,,,,,,,,,,
HC Assay of Magnesium|NOT REASONABLE AND NECESSARY|REPEAT CLINICAL DIAGNOSTIC LABORATORY TEST,PX-3018373500,CDM,83735,CPT,0301,RC,,,GZ|91,both,,,122.00,79.30,,,,,,,,,,,,,
MESH HERN L9CM O3FA COAT POLYPR STR KNIT CONSTRUCTION SEE,SUP-2265978,CDM,C1781,HCPCS,0278,RC,,,,both,,,807.64,524.97,,,,,,,,,,,,,
RELOAD STPL L60MM THCK TISS GRN W/ GRIPPING SURF TECHNOLOGY,SUP-2283358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1410.43,916.78,,,,,,,,,,,,,
CATHETER CARD ABLATION RF MARINR L 80 CM DIA 5 FR TIP L 65,SUP-2749546,CDM,C1732,HCPCS,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
CATHETER CRICOTHYROTOMY SET 5X7.2 MMX9 CM EMGCY CUF MELK,SUP-2759806,CDM,C1769,HCPCS,0272,RC,,,,both,,,623.60,405.34,,,,,,,,,,,,,
STEM FEM SEG 7 CM RT KNEE REDUC RESECT TAPR COMPRESS,SUP-2441845,CDM,C1776,CPT,0278,RC,,,,both,,,17888.58,11627.58,,,,,,,,,,,,,
RING ACET MUELLER ROOF REINF RNG 36MM,SUP-2212042,CDM,C1776,CPT,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
FOOTRING EXT FIX SHT 120 MM HOFFMANN,SUP-2478527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6182.03,4018.32,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 4X25 MM V-SYSTEM 3 LUMEN,SUP-2313220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
CAGE SPNL 27X11X9 IN CONCORDE BULL,SUP-2255187,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK TRICORT 800123,SUP-2743388,CDM,C1713,HCPCS,0278,RC,,,,both,,,4138.52,2690.04,,,,,,,,,,,,,
GUIDEWIRE VASC STRUXURE L 60 CM DIA 0.032 IN NIT SS STAND,SUP-2613260,CDM,C1769,HCPCS,0272,RC,,,,both,,,121.99,79.29,,,,,,,,,,,,,
PLATE BNE L164MM 90DEG 8 H SUPCNDYL BILAT S STL TB STD BRL,SUP-2342590,CDM,C1713,HCPCS,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
ROD SPNL TI TMPLT DEFORMITY SILVERTON-D,SUP-2211158,CDM,C1713,HCPCS,0278,RC,,,,both,,,293.90,191.03,,,,,,,,,,,,,
PLATE BNE COMPR FIBULAR 5 HOLE,SUP-2490400,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.53,152.44,,,,,,,,,,,,,
SHUNT CAR 9 FRX30 CM BLLN W/ CHECK VLV SIL VASCUSHUNT II,SUP-2755079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1455.39,946.00,,,,,,,,,,,,,
GRAFT BNE 2.5X10 CM FLX DBM GRFT,SUP-2293899,CDM,C1713,HCPCS,0278,RC,,,,both,,,3055.22,1985.89,,,,,,,,,,,,,
ROD DISTRCTN 24 MM WAVE D,SUP-2628467,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.65,182.42,,,,,,,,,,,,,
PERI SCR 40MMX60MM,SUP-2726463,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.02,57.86,,,,,,,,,,,,,
PASSER SUTURE STR 16 MM FLUSHPORT MULTFI SCORPION,SUP-2849259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14114.30,9174.29,,,,,,,,,,,,,
NIACIN 500 MG PO TABS,RX-5542,CDM,6370000000,HCPCS,0637,RC,00904-2272-60,NDC,,both,1,UN,0.30,0.19,,,,,,,,,,,,,
ALLOSYNC DBM CHIPS 1-4MM 5.0CC,SUP-2811278,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
CAGE SPNL MESH 17X13X15 MM 6 LOBE,SUP-2602080,CDM,C1889,HCPCS,0278,RC,,,,both,,,9646.08,6269.95,,,,,,,,,,,,,
LEAD PACE 0.5 MM SPC 40 CM BLK,SUP-2637198,CDM,C1778,HCPCS,0278,RC,,,,both,,,10688.06,6947.24,,,,,,,,,,,,,
DRILL SURG PILOT 2.4 MM CANN QR NS LTX,SUP-2855941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
SCREW IM L 36 MM DIA 3.5 MM TI CORTICAL ST FLUT THRD HD ZERO,SUP-2900422,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PLATE BNE L223MM 14 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185651,CDM,C1713,HCPCS,0278,RC,,,,both,,,4408.81,2865.73,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X4 CMX1.26-1.75 MM DECELL DERM ORACELL,SUP-2740974,CDM,C1762,CPT,0278,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
NEXGEN PRECOAT STEMMED TIBIAL PLATE SZ 3,SUP-2503040,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC So Thrombin Clotting Level,PX-3058567066,CDM,85670,CPT,0305,RC,,,,inpatient,,,122.00,79.30,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 20 CM DIA 7 MM STD,SUP-2323363,CDM,C1889,HCPCS,0278,RC,,,,both,,,6788.68,4412.64,,,,,,,,,,,,,
SIZER BRST IMPL 1030 CC SIL GEL ULTRA HI PROF FOR SUHE-1030,SUP-2927330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
MESH CRAN L 122 X W 122 MM THK 0.75 MM SCREW DIA1.7 MM PLLA,SUP-2883511,CDM,C1713,HCPCS,0278,RC,,,,both,,,13260.22,8619.14,,,,,,,,,,,,,
PLATE BONE L97MM 12 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348298,CDM,C1713,HCPCS,0278,RC,,,,both,,,5924.08,3850.65,,,,,,,,,,,,,
STENT URET POLARIS L 24 CM DIA 5 FR PERCFLX HYDROPLUS 2,SUP-2139605,CDM,C2617,HCPCS,0278,RC,,,,both,,,476.34,309.62,,,,,,,,,,,,,
HC Repeat Control Nosebleed,PX-4503090600,CDM,30906,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
RING EXT FIX HALF 150 MM MR SAFE TI,SUP-2422193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1357.11,882.12,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM LOK FOR TUFFNEK TECHNOLOGY GORILLA,SUP-2321122,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
HC Eeg Awake and Asleep,PX-7409581900,CDM,95819,CPT,0740,RC,,,,outpatient,,,2577.00,1675.05,,,,,,,,,,,,,
CALCIUM ACETATE (PHOS BINDER) 667 MG PO CAPS,RX-131745,CDM,J0615,HCPCS,0250,RC,68084-0479-01,NDC,,both,1,UN,6.30,4.09,,,,,,,,,,,,,
NEXGEN KNEE LPS OPT FEM SZ D RT,SUP-2201886,CDM,C1776,CPT,0278,RC,,,,both,,,7090.12,4608.58,,,,,,,,,,,,,
STEM FEM PRSS FIT STD OFFSET FORGED TI ALLOY SZ 0 ACUMATCH,SUP-2221751,CDM,C1776,CPT,0278,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
TITANIUM 3D MESH 120MM X 120MM 10MM 15MM SSTM CP TTNM,SUP-2681440,CDM,C1713,HCPCS,0278,RC,,,,both,,,7459.57,4848.72,,,,,,,,,,,,,
BIT DRL DIA14MM SGL FLX FOR SFT SUT ANCHR JUGGERKNOT,SUP-2137231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.06,212.59,,,,,,,,,,,,,
ASSEMBLY ADPT GUIDEWIRE DIA1.5 MM AO,SUP-2934632,CDM,C1769,HCPCS,0272,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
INTRAAORTIC PUMP KIT 34 CC 40 CC INSRTN SENS,SUP-2534219,CDM,C1894,HCPCS,0272,RC,,,,both,,,414.35,269.33,,,,,,,,,,,,,
PLATE BONE L77MM 6 H FIB TI STR LCK W/ SYNDESMOTIC SLOT FOR,SUP-2225368,CDM,C1713,HCPCS,0278,RC,,,,both,,,3263.09,2121.01,,,,,,,,,,,,,
NAIL IM ANK ARTH N LCK CANN TI 10MM 180MM,SUP-2412889,CDM,C1713,HCPCS,0278,RC,,,,both,,,3931.28,2555.33,,,,,,,,,,,,,
SCREW BNE LCK 6.5X290 MM CONCL,SUP-2349806,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
KIT LD INTRO SAFSHTH L 13 CM DIA 8 FR GUIDEWIRE L 45 CM DIA,SUP-2329858,CDM,C1892,HCPCS,0272,RC,,,,both,,,174.62,113.50,,,,,,,,,,,,,
GRAFT VASC PERIPH BYPS STR THN WALL N RNGD EPTFE SM BEAD,SUP-2128210,CDM,C1768,CPT,0278,RC,,,,both,,,4004.13,2602.68,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 40 CM DIA 6 FR PERIPH BLKN STRL,SUP-2168414,CDM,C1894,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
TACROLIMUS ER 1 MG PO TB24,RX-151350,CDM,J7503,HCPCS,0636,RC,68992-3010-01,NDC,,both,1,UN,31.90,20.73,,,,,,,,,,,,,
STENT DUODENAL L90MM DIA22MM CATH L230CM 10FR 0.035IN NIT,SUP-2149758,CDM,C1876,HCPCS,0278,RC,,,,both,,,7968.44,5179.49,,,,,,,,,,,,,
SYSTEM VITRCTMY L4MM VLV ENTRY EDGEPLUS 27+,SUP-2109960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.99,322.39,,,,,,,,,,,,,
SCREW BONE L175MM DIA6.5MM STD CORT S STL ST SELF DRL CANN,SUP-2343258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.24,1134.41,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR 27 MM BOV PERICARD COCR REDUC,SUP-2214074,CDM,C1889,HCPCS,0278,RC,,,,both,,,20408.43,13265.48,,,,,,,,,,,,,
PIN BTTRS L16MM DIA1.8MM DST RAD TAN T8 STARDRV RECESS VAR,SUP-2181135,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.31,271.90,,,,,,,,,,,,,
MICROCATHETER DIAG NAVVUS II L 335 CM WORKING L 150 CM DSTL,SUP-2862936,CDM,C1887,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
HC So1 Tissue Level IV,PX-3128830567,CDM,88305,CPT,0312,RC,,,,both,,,103.00,66.95,,,,,,,,,,,,,
GRAFT HUM TISS L195MM FRZN ALLGRFT ACHILLES GRFT TEND W/,SUP-2307276,CDM,C1762,CPT,0278,RC,,,,both,,,7070.65,4595.92,,,,,,,,,,,,,
PLATE BNE 2.7X100 MM 12 HOLE SS DCP,SUP-2569133,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.94,234.61,,,,,,,,,,,,,
BLOCK FEM STD THCK UNIV DSTL PRI PRESSFIT TITANIUMXSM 4MM,SUP-2407178,CDM,C1776,CPT,0278,RC,,,,both,,,2860.54,1859.35,,,,,,,,,,,,,
ELTROMBOPAG OLAMINE 25 MG PO TABS,RX-94579,CDM,6370000000,HCPCS,0637,RC,00078-0685-15,NDC,,both,1,UN,1174.00,763.10,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 X W 2 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905528,CDM,Q4184,HCPCS,0636,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H LNG TI NEURO SQ XDRV 12 PK,SUP-2935338,CDM,C1713,HCPCS,0278,RC,,,,both,,,24027.28,15617.73,,,,,,,,,,,,,
PLATE BONE W5.4XL35MM THK1.5MM 6 H FOREFOOT TI STR FOR,SUP-2225447,CDM,C1713,HCPCS,0278,RC,,,,both,,,1906.61,1239.30,,,,,,,,,,,,,
PLATE BONE MINI CVD,SUP-2418783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1405.18,913.37,,,,,,,,,,,,,
DEVICE SUT W/ V-LOC SUT SZ 2-0 L8IN ABSRB LD UNIT SUT BARB,SUP-2174811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.05,257.43,,,,,,,,,,,,,
COLLAR CERV M DENS AD VELC CLSR FOAM W/ STOCK 3.5IN 23.5IN M,SUP-2198742,CDM,L0120,HCPCS,0272,RC,,,,both,,,16.58,10.78,,,,,,,,,,,,,
SCREW BNE LCK 6.5X24 MM ANK FUSION CONSTRUCT,SUP-2609802,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.22,714.49,,,,,,,,,,,,,
APPLIER INT CLP MULT FIRE SM MED 5 MMX31 CM CHALLENGER TIP,SUP-2852455,CDM,C1889,HCPCS,0278,RC,,,,both,,,6200.43,4030.28,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 1 DBL Y SHP XLN PLATE 1,SUP-2936729,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
DRILL SURG DIA3.7MM PERC,SUP-2410871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,765.88,497.82,,,,,,,,,,,,,
PLATE BNE W8XL60MM THK2MM 0DEG 7 H BILAT S STL STR RIG DYN,SUP-2186179,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.03,450.47,,,,,,,,,,,,,
IMPLANT HUM TISS L 3 X W 2 CM AMNIO MEMBRN FLX MULTLYR,SUP-2905526,CDM,C1762,CPT,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
DEFIBRILLATOR IMPL DYNAGEN X4 W 5.37 X H 8.08 CM D 0.99 CM,SUP-2149215,CDM,C1882,HCPCS,0275,RC,,,,both,,,47925.82,31151.78,,,,,,,,,,,,,
DRILL SURG OD39MM SALVATION,SUP-2401154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
TROCAR FOR 6.5MM AND 7.3MM CANNULATED SCREWS,SUP-2548323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1772.06,1151.84,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 120 CM DIA 4 FR 0.038 IN ANGLED,SUP-2385514,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.33,112.66,,,,,,,,,,,,,
HC Echocardiogram Ltd Doppler,PX-4839332100,CDM,93321,CPT,0483,RC,,,,both,,,1077.00,700.05,,,,,,,,,,,,,
COIL EMB 10 L12CM OD5MM COMPLX STRTCH RESIST FNSH V TRAK,SUP-2305170,CDM,C1889,HCPCS,0278,RC,,,,both,,,2882.52,1873.64,,,,,,,,,,,,,
FEMORAL KNEE CEM W/ MTL BASEPLT AND STD POLY INSRT USED IN,SUP-2351385,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
FEMORAL M UNI PHASE 4 CEM OXFORD,SUP-2136450,CDM,C1776,CPT,0278,RC,,,,both,,,12776.66,8304.83,,,,,,,,,,,,,
TRIAL NERVE STIM LD 60 CM KT OCTRODE,SUP-2615496,CDM,C1897,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HMRL TRAY +6 +5,SUP-2505930,CDM,C1776,CPT,0278,RC,,,,both,,,5146.46,3345.20,,,,,,,,,,,,,
GRAFT BIO TISS W8XL8CM MESHED FET BOV DERM DERM IONIC SLV,SUP-2243719,CDM,Q4110,HCPCS,0636,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
CABLE CATH EP 16 24 POL150 CML E FIXED STEERABLE,SUP-2676241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SET ACCS SHTH 4X7FR L18CM NDL 22GA L15CM 0.018IN PLAT TIP S,SUP-2168002,CDM,C1894,HCPCS,0272,RC,,,,both,,,195.90,127.33,,,,,,,,,,,,,
SYSTEM AUTOTRANSFUSION EMGCY CELL SALV,SUP-2280764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2207.55,1434.91,,,,,,,,,,,,,
CATHETER ETER ANGIO 27X2FR ID0019IN L150CM 0016IN HYDRPHLC STR,SUP-2422359,CDM,C1887,HCPCS,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
COLLAR CERV 4IN 24IN M XLN M DENS AD CNTOUR HK AND LOOP CLSR,SUP-2194441,CDM,L0120,HCPCS,0274,RC,,,,both,,,11.05,7.18,,,,,,,,,,,,,
PLATE BNE L 209 MM SCREW DIA 4.5 MM 11 H LT PROX LAT TIB NS,SUP-2932989,CDM,C1713,HCPCS,0278,RC,,,,both,,,10223.84,6645.50,,,,,,,,,,,,,
WAND ABLAT VULCAN TACS,SUP-2314077,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
INSERT TIB BUMPER 3 DEG,SUP-2452026,CDM,C1776,CPT,0278,RC,,,,both,,,2167.54,1408.90,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 80 CM SUPP L 60 CM DIA 6 MM EPTFE,SUP-2266066,CDM,C1768,CPT,0278,RC,,,,both,,,4377.16,2845.15,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 20MMW X 80MML SPNL MSCLE NRRW RGGLS RDM,SUP-2670370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1606.49,1044.22,,,,,,,,,,,,,
BLOCK VERSYS CEM/REV/CALCAR BUILD-UP 13/15X20MM,SUP-2504502,CDM,C1776,CPT,0278,RC,,,,both,,,1172.79,762.31,,,,,,,,,,,,,
DEVICE VASC CLOSURE VASOSEAL DIA 5-8 FR FEM ART CLLGN,SUP-2227421,CDM,C1760,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE STR 1.5MM 6H TI STRL VAL,SUP-2546888,CDM,C1713,HCPCS,0278,RC,,,,both,,,1384.11,899.67,,,,,,,,,,,,,
PLATE BNE L 113 MM SCREW DIA 4.5 MM 6 H SS NAR COMPR NLCK,SUP-2933360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1634.94,1062.71,,,,,,,,,,,,,
BLOCK CARVING CONTOURED SILICONE,SUP-2757603,CDM,C1889,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
PLATE BNE DEBURRER RIB NS LEVEL 1 LTX,SUP-2869275,CDM,C1713,HCPCS,0278,RC,,,,both,,,1313.78,853.96,,,,,,,,,,,,,
HC Drug Screen Quantitative Tacrolimus,PX-3018019700,CDM,80197,CPT,0301,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
SPLINT ELBOW/KNEE M L13.5IN FOR 10-12IN VLY MESH COT LINING,SUP-2324946,CDM,L3702,HCPCS,0272,RC,,,,both,,,78.44,50.99,,,,,,,,,,,,,
PLATE BONE CRANIAL 4 HOLE X-PLATE 11X11MM TITANIUM NEURO PLA,SUP-2826282,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.96,190.42,,,,,,,,,,,,,
METAL HEMI IMPLANT TRIAL SM METAL HEMI SYSTEM,SUP-2473637,CDM,C1776,CPT,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|ADJ|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|ADJ|CO,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE BNE L45MM 6X2 H R VOLAR DST RAD S STL VAR ANG LOK,SUP-2184116,CDM,C1713,HCPCS,0278,RC,,,,both,,,2103.05,1366.98,,,,,,,,,,,,,
ALLOGRAFT BNE 10X10X20 MM BIOEXPAND,SUP-2637003,CDM,C1713,HCPCS,0278,RC,,,,both,,,3999.54,2599.70,,,,,,,,,,,,,
CATHETER URET 5FR L70CM UNIV POLYUR TAPR TIP SGL LUMN W/,SUP-2168890,CDM,C1758,HCPCS,0278,RC,,,,both,,,113.01,73.46,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L135CM SHFT OD5.8FR BAL L4CM OD10MM OVR,SUP-2139692,CDM,C1725,HCPCS,0272,RC,,,,both,,,581.59,378.03,,,,,,,,,,,,,
PLATE BNE L79MM 2 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177792,CDM,C1713,HCPCS,0278,RC,,,,both,,,3073.90,1998.03,,,,,,,,,,,,,
PLATE BNE SM L263MM 22 H BILAT S STL LO PROF RIG LIMIT,SUP-2186219,CDM,C1713,HCPCS,0278,RC,,,,both,,,2708.34,1760.42,,,,,,,,,,,,,
SYSTEM IMPL MOD OPUS MAG,SUP-2342075,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 2 200CM 0.014IN SEG 35CM PRESHAPED,SUP-2367902,CDM,C1769,HCPCS,0272,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 4 MESH KT NS FACE ID,SUP-2909538,CDM,C1713,HCPCS,0278,RC,,,,both,,,41703.50,27107.27,,,,,,,,,,,,,
STAPLER INT 60 MM RELD TRISTAPLE TECHNOLOGY BLK STRL SEAMGRD,SUP-2489651,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40 CM DIA16 X 8 MM POLYESTER BOV,SUP-2227670,CDM,C1768,CPT,0278,RC,,,,both,,,2364.67,1537.04,,,,,,,,,,,,,
SPLINT FT MED NT PLNTR FASCIITI,SUP-2195478,CDM,L4398,HCPCS,0272,RC,,,,both,,,77.18,50.17,,,,,,,,,,,,,
BOOT CAST XSM BLK UNISX AD SQ OPN TOE FOREFOOT CLSR HIGHER,SUP-2176231,CDM,L4386,HCPCS,0272,RC,,,,both,,,40.54,26.35,,,,,,,,,,,,,
PLATE BNE T MINI 1.5 MM 9X4 HOLE,SUP-2346878,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.40,206.96,,,,,,,,,,,,,
NAIL IM L200MM DIA4.8MM FEM HIP S STL CANN NONLOCKING RUSH,SUP-2362427,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.18,436.27,,,,,,,,,,,,,
HC Sclerotx Fluid Collection,PX-3614918500,CDM,49185,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CRUNCH DBM GRFTON,SUP-2294018,CDM,C1713,HCPCS,0278,RC,,,,both,,,2498.66,1624.13,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 0.030 IN IN-LINE HAKIM NS5045,SUP-2666809,CDM,C1889,HCPCS,0278,RC,,,,both,,,16873.07,10967.50,,,,,,,,,,,,,
SCREW SPNL L13MM DIA4.6MM ANT CERV VLT TI SELF DRL LOK FOR,SUP-2255539,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
DRAIN SURG 19FR SIL RND HUBLESS W/ 0.25IN BEND TRCR BLAK,SUP-2256705,CDM,C1729,HCPCS,0272,RC,,,,both,,,410.62,266.90,,,,,,,,,,,,,
CLAMP EXT FIX L TI ALLY COMB CLP ON SELF HLD,SUP-2188494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.45,1124.79,,,,,,,,,,,,,
SPLINT FNGR M W075XL18IN ALUMINUM MAL,SUP-2276739,CDM,L3933,HCPCS,0274,RC,,,,both,,,3.01,1.96,,,,,,,,,,,,,
SCREW BNE HIP 6.5X80 MM RECON THRD XL40 TI STRL FRNADVANCED,SUP-2789378,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.82,486.08,,,,,,,,,,,,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-125367,CDM,J9181,HCPCS,0636,RC,00143-9376-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
BRACE ORTH SH UNIV KNEE FAST HNG ROM STRP CLSR FOAM AD UNISX,SUP-2196518,CDM,L1810,HCPCS,0274,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BNE W33XL225MM 16 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185119,CDM,C1713,HCPCS,0278,RC,,,,both,,,5472.93,3557.40,,,,,,,,,,,,,
SYRINGE (DISPOSABLE) 1 ML MISC,RX-11474,CDM,2500000003,HCPCS,0250,RC,08290-3096-28,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
IMPLANT TOE JT SZ 2 L15MM REG TI MED BILAT PERF H LPT,SUP-2397910,CDM,C1776,CPT,0278,RC,,,,both,,,2760.06,1794.04,,,,,,,,,,,,,
SHOE ORTHOT WOMAN CUST OXFORD INTEGR PART OF BRAC,SUP-2435714,CDM,L3224,HCPCS,0274,RC,,,,both,,,191.29,124.34,,,,,,,,,,,,,
GRAFT BNE 4-10 MM 60 CC CORTICAL CANC,SUP-2766766,CDM,C1713,HCPCS,0278,RC,,,,both,,,2724.26,1770.77,,,,,,,,,,,,,
EXTENSION STEM L80MM OD11MM REG TI KNEE PRI PRESSFIT FLUT,SUP-2376325,CDM,C1776,CPT,0278,RC,,,,both,,,2412.56,1568.16,,,,,,,,,,,,,
CANNULA SRGCL 48MML PIN TIP WCMPLTE RACK FTRNSBCCL SSTM,SUP-2680125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.39,252.45,,,,,,,,,,,,,
NAIL INTRMDLLRY 13MM DIA LNG 340MML TTNM ALLOY LEFT CPHLMDLL,SUP-2588420,CDM,C1713,HCPCS,0278,RC,,,,both,,,5828.12,3788.28,,,,,,,,,,,,,
PLATE BNE L100MM 34 H CRANIOMAXILLOFACIAL TI ADPT FOR 1MM,SUP-2190574,CDM,C1713,HCPCS,0278,RC,,,,both,,,2494.73,1621.57,,,,,,,,,,,,,
PATCH CV HEMACAROTID L 100 X W 25 MM THK 0.41 MM POLYESTER,SUP-2914823,CDM,C1768,CPT,0278,RC,,,,both,,,467.11,303.62,,,,,,,,,,,,,
SIZER MAMM 250CC DIA10.8CM P4CM NACL SMOOTH RND MOD + PROF,SUP-2300453,CDM,C1789,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE L 33 MM 4 HOLE SCREW DIA 2.7 MM STAINLESS STL RECO,SUP-2931381,CDM,C1713,HCPCS,0278,RC,,,,both,,,1246.52,810.24,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN 16X8 CMX0.7-1.4 MM FLEXHD,SUP-2307562,CDM,Q4128,HCPCS,0636,RC,,,,both,,,11937.50,7759.37,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 6 FRX22 CM 6 FR STIFF CNTOUR,SUP-2458338,CDM,C2617,HCPCS,0278,RC,,,,both,,,601.59,391.03,,,,,,,,,,,,,
SPLINT KNEE L16IN FOR 29IN THGH UNIV NYL FBR LAM ALUM FOAM,SUP-2196753,CDM,L1830,CPT,0272,RC,,,,both,,,43.08,28.00,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|CO|XU,both,,,144.00,93.60,,,,,,,,,,,,,
KIT DIL 8/12/16/20/24FR NDL 18GA GWIRE L180CM DIA0.035IN,SUP-2352728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.14 MM MICROGEL INTERMED BLU STRL DISP,SUP-2902012,CDM,L8699,HCPCS,0278,RC,,,,both,,,80.70,52.45,,,,,,,,,,,,,
SET ORTH INSTR SCREW SZ 1.5 MM 2 2 DIAMETER GUIDE WIRE,SUP-2912778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
ROD EXT FIX 4X150 MM FOR CONSOLIDATION 3DX CARBON FIBER,SUP-2525359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.13,209.38,,,,,,,,,,,,,
TROCAR ENDOSCP L110MM DIA5-11MM STD OPT SMOOTH RADLUC,SUP-2283177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.61,296.15,,,,,,,,,,,,,
GUIDEWIRE VASC L325CM STR TIP DIA0.014IN COR IMAG VIPEWIRE,SUP-2159523,CDM,C1769,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
WIRE SURG BLNT 0.64X160 MM 22 GA KNEE LIG,SUP-2361096,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.57,34.82,,,,,,,,,,,,,
PLANER BONE 8MM,SUP-2419452,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE STRGHT 4 HOLE RGLR CP TTNM ST,SUP-2676765,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.33,201.71,,,,,,,,,,,,,
SCREW BNE LCK 3.5X80 MM PERIARTICULAR CANN CONCL SS,SUP-2410847,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
MESH PELV Y SHP ARTISYN,SUP-2257355,CDM,C1781,HCPCS,0278,RC,,,,both,,,4305.32,2798.46,,,,,,,,,,,,,
HC Cta Pelvis W & W/O Cont,PX-3527219100,CDM,72191,CPT,0352,RC,,,,both,,,3184.00,2069.60,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 150 CM 4 FR 0.035 IN BERN BRAIDED,SUP-2116915,CDM,C1887,HCPCS,0272,RC,,,,both,,,312.87,203.37,,,,,,,,,,,,,
COIL EMB STRTCH RESIST 0.018 IN 9 MMX33 CM MICRUSFRAME C,SUP-2249242,CDM,C1889,HCPCS,0278,RC,,,,both,,,11108.69,7220.65,,,,,,,,,,,,,
CLAMP PIN XTRAFIX 1 BAR 45MM BL,SUP-2463618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3725.80,2421.77,,,,,,,,,,,,,
SCREW SPNL MULTAXL 9X100 MM BLLST,SUP-2423589,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
STENT URET INLAY L 16 CM DIA 4.7 FR POLYUR HYDRPHLC,SUP-2126619,CDM,C2617,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KENSINGTON GUIDE WIRE BONE BIOPSY KIT 11 G 10 CM,SUP-2477116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 70 CM SUPP L 70 CM DIA 7 MM EPTFE,SUP-2227658,CDM,C1768,CPT,0278,RC,,,,both,,,2688.97,1747.83,,,,,,,,,,,,,
SCREW ACET TI PPS HIP FLNG MOD IMP PAR-5,SUP-2403457,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X120 MM 9 HOLE SS LC-DCP,SUP-2569243,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.95,209.92,,,,,,,,,,,,,
STENT TRACHBRONCH 6X40MM STNT GRFT 117CM 8FR DEL SYS NIT,SUP-2128280,CDM,C1874,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDIC CUST KNEE,SUP-2422975,CDM,L2308,HCPCS,0274,RC,,,,both,,,4166.78,2708.41,,,,,,,,,,,,,
TUBE VENT PAPARELLA 1.27 MM 1 MM PHOSPHORYLCHOLINE COAT SIL,SUP-2535117,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.21,24.84,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDIC CUT AWAY UNIV 16 IN 14-29 IN KNEE,SUP-2428783,CDM,L1830,CPT,0274,RC,,,,both,,,28.04,18.23,,,,,,,,,,,,,
PLATE BNE X REG 1.5 MM MIDFACE TI,SUP-2754970,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
STENT PERIPH L80MM DIA6MM DEL SYS L125CM SHTH 6FR 0.035IN,SUP-2170398,CDM,C1874,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
SCREW BONE L85MM DIA3.5MM STRL S STL LCK ST FOR SM PLATING,SUP-2349507,CDM,C1713,HCPCS,0278,RC,,,,both,,,855.87,556.32,,,,,,,,,,,,,
HC Spcl Stn 2 I&R Excpt Microorg/Enzyme/Imcyt,PX-3128831300,CDM,88313,CPT,0312,RC,,,,both,,,249.00,161.85,,,,,,,,,,,,,
CONNECTOR SPNL OFFSET 35-47.5 MM UPPER THOR DOMINO INFIN,SUP-2285408,CDM,C1713,HCPCS,0278,RC,,,,both,,,2646.58,1720.28,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 50-100 CM FASC,SUP-2321780,CDM,C1762,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
REMOVER SPNL SCR COR NEO-SL KINETIC-SL,SUP-2264521,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
PLATE B1 THK1.8MM 4 H STRNL THOR CP TI STR LCK LEV 1 FOR,SUP-2262579,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
HC Ot Wheelchair Mngment Training|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309754200,CDM,97542,CPT,0430,RC,,,GP|CQ,outpatient,,,154.00,100.10,,,,,,,,,,,,,
BOLT EXT FIX HALF PIN FOR SIDEKCK FREE CIR FIX,SUP-2400704,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
SPLINT THMB AD L4IN UNIV R FOAM LAM INSTABILITY LOOP LOK E,SUP-2197017,CDM,L3809,HCPCS,0274,RC,,,,both,,,19.78,12.86,,,,,,,,,,,,,
ADAPTER SPNL ANGLED RT OCT MULTIPOINT SYM,SUP-2718799,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
ROD FOR GALAXY FIXATION SYSTEM 12MM 400MM,SUP-2633889,CDM,C1713,HCPCS,0278,RC,,,,both,,,858.54,558.05,,,,,,,,,,,,,
BRAIN STIM IMPL BRAINSENSE TECHNOLOGY RECHARGEABLE MRI,SUP-2883003,CDM,C1820,HCPCS,0278,RC,,,,both,,,97135.90,63138.33,,,,,,,,,,,,,
GRAFT BNE SUB W25MMXL25CM FASC LATA FRZN,SUP-2307102,CDM,C1762,CPT,0278,RC,,,,both,,,1711.71,1112.61,,,,,,,,,,,,,
BIT DRL DIA1.7MM PREDRLING H FOR DISTR PIN CASPR,SUP-2108441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1755.04,1140.78,,,,,,,,,,,,,
WEDGE RAD TRAD ALLGRFT 6 MM FRZ DRY,SUP-2294088,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
GRAFT DURAL 4IN X 5IN ULTRPRE CLLGN ONLAY STRLSS CLSRE ENHNC,SUP-2491974,CDM,C1763,HCPCS,0278,RC,,,,both,,,4534.38,2947.35,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 5 MM RND UPWR,SUP-2166788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,158.26,102.87,,,,,,,,,,,,,
SHELL ACET OD70MM ID28MM UNIV PPS HIP RECON QUAD SPRNG,SUP-2403694,CDM,C1776,CPT,0278,RC,,,,both,,,4860.72,3159.47,,,,,,,,,,,,,
MINERAL OIL PO OIL,RX-5086,CDM,340b,HCPCS,0637,RC,48433-0202-30,NDC,,both,15,ML,8.60,5.59,,,,,,,,,,,,,
COMPONENT HUM L6IN REG ELBW TIV PLSM INTERCHANGEABLE CEM,SUP-2205916,CDM,C1776,CPT,0278,RC,,,,both,,,11643.12,7568.03,,,,,,,,,,,,,
TUBE EXT FIX DYN 20MM RED MONOTUBE TRIAX,SUP-2372606,CDM,C1713,HCPCS,0278,RC,,,,both,,,6382.99,4148.94,,,,,,,,,,,,,
GRAFT HUM TISS PLAS NAT DUMMY DENOVO,SUP-2200263,CDM,C1762,CPT,0278,RC,,,,both,,,13659.00,8878.35,,,,,,,,,,,,,
LANSOPRAZOLE 30 MG PO TBDD,RX-147436,CDM,6370000000,HCPCS,0637,RC,16714-0186-02,NDC,,both,1,UN,40.20,26.13,,,,,,,,,,,,,
PROBE ABLAT 90DEG MPLR W/ SUCT ABLATOR-S,SUP-2341619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
CATHETER URET 5FR L120CM 0.038IN MOD OPN END,SUP-2168917,CDM,C1758,HCPCS,0278,RC,,,,both,,,32.66,21.23,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC BIOMAX,SUP-2731740,CDM,C1713,HCPCS,0278,RC,,,,both,,,982.82,638.83,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 5 CM DIA2 MM CATH DIA 0.018 IN LOOP,SUP-2638545,CDM,C1889,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
PLATE EXT FIX 4 H SIDEKCK FREE CIR FIX,SUP-2400693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CLAMP SURG STR FOR LIMB RECON SYS PROCALLUS,SUP-2316281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1372.37,892.04,,,,,,,,,,,,,
PLATE BONE SM W11XL259MM THK3.3MM 0DEG 20 H BILAT TI STR RIG,SUP-2190801,CDM,C1713,HCPCS,0278,RC,,,,both,,,1682.79,1093.81,,,,,,,,,,,,,
CATHETER HD SHT TERM 11.5 FRX15 CM DL STYL HEMCATH DSL15IJ,SUP-2627304,CDM,C1752,HCPCS,0278,RC,,,,both,,,14.82,9.63,,,,,,,,,,,,,
IMPLANT TOE SM L13MM PROX L7MM DIA2.8MM DST L5.5MM DIA4MM,SUP-2397780,CDM,C1776,CPT,0278,RC,,,,both,,,1548.02,1006.21,,,,,,,,,,,,,
BIT DRILL RADLUC 4 MM,SUP-2632387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.61,252.60,,,,,,,,,,,,,
CAGE SPNL W10XH10XL28MM 5DEG ANTR THORLUM C FBR REINF,SUP-2254814,CDM,C1889,HCPCS,0278,RC,,,,both,,,17034.50,11072.42,,,,,,,,,,,,,
SCREW BNE L26MM DIA2MM PUR TI ALLY THRD AND ROUNDED CONIC HD,SUP-2181034,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.79,320.31,,,,,,,,,,,,,
COMPONENT TIB SZ 1 IMPL TALARIS,SUP-2244136,CDM,C1776,CPT,0278,RC,,,,both,,,30172.26,19611.97,,,,,,,,,,,,,
KIT INTRO ONESTIC L 11 CM DIA 4 FR GUIDEWIRE L 40 CM DIA RED,SUP-2876556,CDM,C1894,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
SYSTEM ENDOSCP PLNTR FASCTMY DISPOSABLE EPF,SUP-2422354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2659.58,1728.73,,,,,,,,,,,,,
PLATE BNE L57MM THK34MM 4 H BILAT PUBIC S STL LO PROF RIG,SUP-2177137,CDM,C1713,HCPCS,0278,RC,,,,both,,,2261.40,1469.91,,,,,,,,,,,,,
PERFORATOR CRAN AD PED 14/11MM DGR O ROUNDED CUT EDGE DISP,SUP-2106556,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS MR SAFE W/ BIOGLDE,SUP-2664551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.84,339.85,,,,,,,,,,,,,
MARKER FIDUCIAL GOLD DELIVERY NEEDLES 1.2MM X 3MM (3EA) IZI,SUP-2848835,CDM,A4648,CPT,0278,RC,,,,both,,,189.62,123.25,,,,,,,,,,,,,
PLATE BNE L 73 MM SCREW DIA2 MM 3 HD 10 SHFT H TI T SHP MINI,SUP-2908017,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.00,2024.10,,,,,,,,,,,,,
SCREW BNE CRTX 2.4X85 MM ST T8 STARDRV RECESS TI NS,SUP-2758285,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.74,129.83,,,,,,,,,,,,,
GUIDEWIRE VASC L 30 CM DIA 0.025 IN SS PTFE STR FIX COR STRL,SUP-2167841,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
DILATOR NOTTINGHAM 1 STP HYDR+ COAT 12 FR TO 18 FR TAPR 70CM,SUP-2139732,CDM,C2627,HCPCS,0272,RC,,,,both,,,431.00,280.15,,,,,,,,,,,,,
GUIDEWIRE VASC 0035IN DIA 150CML 3MM J TIP DBL END W STR END,SUP-2302706,CDM,C1769,HCPCS,0272,RC,,,,both,,,23.86,15.51,,,,,,,,,,,,,
ENDCAP DIA9.5MM EXTN 0MM GRY TI 6% ALUM 7% NIOBIUM THRD T25,SUP-2180201,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.98,413.39,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 0.035 INX150 CM STIFF GLIDEWIRE,SUP-2385588,CDM,C1769,HCPCS,0272,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
KIT OLV WIRE M ADV W/ T15 SCRS DRVR PLATING DEPTH GA FOR,SUP-2225527,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM BIOCRYLRAPIDE NDL FOR ROT CUF REP HEALIX,SUP-2256659,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
PIN BIOABS SONICPIN 022X26MM,SUP-2700934,CDM,C1713,HCPCS,0278,RC,,,,both,,,2192.98,1425.44,,,,,,,,,,,,,
PLATE BNE L99MM HK D15MM 6 H L CLAVICULAR S STL LOK COMPR,SUP-2185856,CDM,C1713,HCPCS,0278,RC,,,,both,,,3384.70,2200.05,,,,,,,,,,,,,
OSCILLATOR BLADE COATED 19.5 X95 X1.27 MM 5PK,SUP-2605495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
FOOTPEDAL ATHRCTMY DYNAGLIDE REPL NS,SUP-2664401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6914.28,4494.28,,,,,,,,,,,,,
CONNECTOR SPNL M DORS PEDCL SCR ADJ FOR SURG TECH TSRH-3DX,SUP-2289710,CDM,C1713,HCPCS,0278,RC,,,,both,,,3081.91,2003.24,,,,,,,,,,,,,
GUIDEWIRE INTRO L 450 MM DIA2.8 MM THRD NS DISP,SUP-2905628,CDM,C1769,HCPCS,0272,RC,,,,both,,,925.01,601.26,,,,,,,,,,,,,
ALLOGRAFT BNE CHIPS 1-8 MM 5 CC CANC DEMINERALIZED BNE BIO,SUP-2637035,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.86,1188.11,,,,,,,,,,,,,
SCREW BONE L60MM DIA6.7MM THRD L18MM FT ANK TI CANN LO PROF,SUP-2123175,CDM,C1713,HCPCS,0278,RC,,,,both,,,698.65,454.12,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM STD CORT TI NCANNULATED FULL THRD N,SUP-2189308,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.85,73.35,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 1.7X3 MM CORTICAL EMERGENCY CRICIFOR,SUP-2838190,CDM,C1713,HCPCS,0278,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
VENLAFAXINE HCL 75 MG PO TABS,RX-12206,CDM,6370000000,HCPCS,0637,RC,68084-0856-01,NDC,,both,1,UN,4.30,2.79,,,,,,,,,,,,,
SET CHST TUBE 24 FR SMGA 17CM LEN 40CM SIDEPORTS 4/4 INCL,SUP-2170314,CDM,C1729,HCPCS,0272,RC,,,,both,,,476.78,309.91,,,,,,,,,,,,,
FILLER BONE VOID 3ML CA PHOS CEM STRL IMP HYDROSET,SUP-2364371,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
STEM FEM REV CEM STR LT NAT HIP SZ 2,SUP-2210702,CDM,C1776,CPT,0278,RC,,,,both,,,15307.50,9949.87,,,,,,,,,,,,,
CLIP ANEURYSM OPENING W1.7MM BLADE L3MM MICRO PHYNOX CURVED,SUP-2821650,CDM,C1889,HCPCS,0278,RC,,,,both,,,833.23,541.60,,,,,,,,,,,,,
PLATE BONE L47MM 3 H LT POST DSTL TIB LCK FOR 3.5MM SCR,SUP-2349802,CDM,C1713,HCPCS,0278,RC,,,,both,,,5878.39,3820.95,,,,,,,,,,,,,
ES RETROGRADE FEM NAIL CASE 12/13MM,SUP-2811382,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
HC Bx Breast 1st Les MR Image,PX-3611908500,CDM,19085,CPT,0361,RC,,,,both,,,6672.00,4336.80,,,,,,,,,,,,,
PIN FIX L300MM OD3MM S STL SMOOTH BLNT TIP IMPL,SUP-2199026,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PLATE BONE L130MM 11 HOLE BLTRL STNLSS STEEL STRGHT RCNSTRCT,SUP-2474985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1179.86,766.91,,,,,,,,,,,,,
FOOTPLATE EXT FIX LNG 120 MM ALUM MAXFRAME,SUP-2423877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4685.57,3045.62,,,,,,,,,,,,,
KNIFE SURG REINER CAST 7 IN CRV SATIN FINISH SS MTL REUSE,SUP-2476730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.66,276.68,,,,,,,,,,,,,
NEEDLE ASPIR WITH SYRINGE 22GA L700MM US GUID TREAT DST END FOR,SUP-2313404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.80,466.57,,,,,,,,,,,,,
ANCHOR SUTURE ANK FIBERWIRE,SUP-2122818,CDM,C1776,CPT,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PLATE BNE TI LT ANTR ANK FUSION STRL AXSOS 3,SUP-2902316,CDM,C1713,HCPCS,0278,RC,,,,both,,,9608.40,6245.46,,,,,,,,,,,,,
HC Peripheral Block - Peripheral Nerve or Branch,PX-3606445000,CDM,64450,CPT,0360,RC,,,,both,,,2232.00,1450.80,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM TI MANDIBULAR FULL CUSTOMIZED,SUP-2883266,CDM,C1713,HCPCS,0278,RC,,,,both,,,30253.90,19665.03,,,,,,,,,,,,,
PLATE BONE L93MM 3 H RT PROX HUM LCK FOR 4.5MM SCR PERI-LOC,SUP-2348274,CDM,C1713,HCPCS,0278,RC,,,,both,,,14421.86,9374.21,,,,,,,,,,,,,
SCREW ARTHROERESIS SUBTALAR 8MM DIA 14MML CONIC SFT THRD TI,SUP-2388615,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE SPRING 3.5 MM PELV 3 HOLE SS NS,SUP-2863439,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.31,706.10,,,,,,,,,,,,,
POST EXT FIX 2 H FEM FOR SIDEKCK FREE CIR FIX,SUP-2400670,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
NAIL IM L315MM OD10MM TIB PLATFRM CANN LCK VERSANAIL,SUP-2412337,CDM,C1713,HCPCS,0278,RC,,,,both,,,3143.14,2043.04,,,,,,,,,,,,,
PLATE BNE L112MM 6 H ST R ANTEROMEDIAL DST TIB S STL VAR,SUP-2177671,CDM,C1713,HCPCS,0278,RC,,,,both,,,5647.42,3670.82,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 5.5X50 MM HDLSS NS MONSTER,SUP-2742658,CDM,C1713,HCPCS,0278,RC,,,,both,,,1323.04,859.98,,,,,,,,,,,,,
MESH RESTRATA 12.5CM X 17.5CM,SUP-2874128,CDM,A2007,HCPCS,0636,RC,,,,both,,,30740.60,19981.39,,,,,,,,,,,,,
STEM EXTN L65MM DIA16MM KNEE CEM GMK,SUP-2267632,CDM,C1776,CPT,0278,RC,,,,both,,,5402.37,3511.54,,,,,,,,,,,,,
SHEATH INTRO FIX CRV LVI/75-5-62-07-HO STRL,SUP-2739220,CDM,C1893,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
PLATE BNE COMPR 60 DEG 2.3X35X2.3 MM MAND 6 HOLE TI LEVEL 1,SUP-2490319,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.45,788.09,,,,,,,,,,,,,
EXPANDER MAMM IMPL OVL TEXT 500ML,SUP-2113318,CDM,C1789,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
NAIL IM L340MM OD11MM 125DEG 2MM RAD TI R IMPLANTS SET SCR,SUP-2370044,CDM,C1713,HCPCS,0278,RC,,,,both,,,6918.05,4496.73,,,,,,,,,,,,,
BUR SURG DIAMOND LNG MED 4X69 MM RND FOR SM BNE STRL,SUP-2363285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,174.27,113.28,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 X W 4 CM AMNIO MEMBRN FLX MULTLYR,SUP-2905513,CDM,C1762,CPT,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
SPACER HUM W42XH5MM RVS BODY PROMOS,SUP-2351200,CDM,C1776,CPT,0278,RC,,,,both,,,5165.30,3357.44,,,,,,,,,,,,,
FIBER LASER 1000UM HOLM LT GUID,SUP-2313983,CDM,C1713,HCPCS,0278,RC,,,,both,,,2822.20,1834.43,,,,,,,,,,,,,
RING FOOT SHRT 180MM,SUP-2703091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5392.01,3504.81,,,,,,,,,,,,,
SCREW INTFR L30MM DIA9MM SHTH L L30MM TIB BIOCRYL RAPIDE FOR,SUP-2256829,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SHEATH INTRO L10CM DIA7FR TIF TIP PINN,SUP-2384800,CDM,C1894,HCPCS,0272,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
ICD COBALT XT DR MRI DF1 2 CHMBR,SUP-2582921,CDM,C1721,HCPCS,0275,RC,,,,both,,,46237.94,30054.66,,,,,,,,,,,,,
STEM RADIAL STD 8X10 MM ELBW,SUP-2107884,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
BOOT CAST XSM L17CM TOE W9CM BILAT BLK ETHYL VYN ACETT PRNT,SUP-2196780,CDM,L4387,HCPCS,0274,RC,,,,both,,,14.85,9.65,,,,,,,,,,,,,
SHEATH INTRO 6FR L90CM DIL L15CM HYDRPHLC COAT MULT PURP,SUP-2385202,CDM,C1894,HCPCS,0272,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
GRAFT HERN REP W26XL34CM THK2MM OVL SFT TISS PTCH GOR TX,SUP-2395293,CDM,C1768,CPT,0278,RC,,,,both,,,13608.76,8845.69,,,,,,,,,,,,,
NEEDLE PARACENTESIS YUEH 5 FRX15 CM 19 GA PGTL PERC ASPIR,SUP-2168539,CDM,C1729,HCPCS,0272,RC,,,,both,,,73.82,47.98,,,,,,,,,,,,,
SCREW BONE L10MM DIA1.85MM TI COARSE PITCH ST,SUP-2181790,CDM,C1713,HCPCS,0278,RC,,,,both,,,315.63,205.16,,,,,,,,,,,,,
GRAFT EVAR L140MM DIAM 23MM AORT AND 14.5MM IL ABD AORT IL,SUP-2395974,CDM,C1768,CPT,0278,RC,,,,both,,,26281.80,17083.17,,,,,,,,,,,,,
SCREW BNE SLD 3.5X14 MM GUID GROWTH PLATE SYS + TI,SUP-2646859,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
STAPLE BNE FIX L W14.2XL23MM CO CHROM LIG SPIK,SUP-2342743,CDM,C1713,HCPCS,0278,RC,,,,both,,,1760.47,1144.31,,,,,,,,,,,,,
PLATE BNE THK1.8MM 8 H STRNL TI X SHP LOK,SUP-2262576,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.55,908.41,,,,,,,,,,,,,
FIBER ENT-L,SUP-2225614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE W17.5XL188MM THK5.2MM 10 H BILAT S STL BROAD LOK,SUP-2185294,CDM,C1713,HCPCS,0278,RC,,,,both,,,1696.04,1102.43,,,,,,,,,,,,,
HC CT T-Spine W/ Contrast,PX-3527212900,CDM,72129,CPT,0352,RC,,,,inpatient,,,2630.00,1709.50,,,,,,,,,,,,,
PLATE BNE L112MM 8 H BILAT MTPHSEAL S STL LOK COMPR LO PROF,SUP-2185101,CDM,C1713,HCPCS,0278,RC,,,,both,,,2471.53,1606.49,,,,,,,,,,,,,
SPACER ORTH TALAR PT SPEC,SUP-2742002,CDM,C1776,CPT,0278,RC,,,,both,,,28024.50,18215.92,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 20X20 MM FRZN THRD SVC FEE MDII,SUP-2791141,CDM,C1713,HCPCS,0278,RC,,,,both,,,9772.81,6352.33,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE 20 GA CUST,SUP-2110949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1495.05,971.78,,,,,,,,,,,,,
SCISSOR SURG FOMON 5.25 IN DORS SUPER CUT ANGLED BLNT/BLNT,SUP-2872585,CDM,C1889,HCPCS,0278,RC,,,,both,,,235.41,153.02,,,,,,,,,,,,,
KIT ART LN CATH 20GA L12CM,SUP-2383352,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
CAGE SPNL INTBDY 3.5X17 MM STAND ALONE SCREW DIVERGENCE 2PK,SUP-2660610,CDM,C1889,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
LEAD PACE L60CM 8 CHAN FLX EXTN DIR INFIN,SUP-2357359,CDM,C1883,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT BSC 5FR 0.026N 45CM 2 LUMAN RVS TAP,SUP-2613450,CDM,C1751,HCPCS,0278,RC,,,,both,,,451.22,293.29,,,,,,,,,,,,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,J1955,HCPCS,0636,RC,54482-0147-01,NDC,,both,5,ML,223.60,145.34,,,,,,,,,,,,,
BIT DRILL SHANK LONG 3.5 MM WITH QUICK CONNECT PERILOC,SUP-2837023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1787.88,1162.12,,,,,,,,,,,,,
COMPONENT FEM SZ 5 LT OXINIUM ZIRCON POST STBL PRI STEMLESS,SUP-2347028,CDM,C1776,CPT,0278,RC,,,,both,,,10439.72,6785.82,,,,,,,,,,,,,
TAP SURG AO CONN 3.2 MM,SUP-2421717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE CRV MIC 1.5X0.5 MM NEURO GAP TI,SUP-2476123,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.30,554.64,,,,,,,,,,,,,
WASHER ORTH SCREW SYS IMPL INSTRUMENT AXIS,SUP-2610215,CDM,C1713,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
CATHETER DIAG SAFSHTH WORLEY LVI L 66 CM DIA 5.5 FR POLYMER,SUP-2329861,CDM,C1894,HCPCS,0272,RC,,,,both,,,1453.82,944.98,,,,,,,,,,,,,
SPLINT HND AD UNIV L W STAY WLK,SUP-2112604,CDM,L3807,HCPCS,0272,RC,,,,both,,,148.43,96.48,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM SCREW PIN M HXLPE,SUP-2212709,CDM,C1776,CPT,0278,RC,,,,both,,,12288.77,7987.70,,,,,,,,,,,,,
GRAFT HUM TISS W4XL3CM 12SQCM UMB CRD AMNIO MEM,SUP-2116290,CDM,Q4148,HCPCS,0636,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
SCREW BONE L3MM OD1.7MM TI CORT CRANIOMAXILLOFACIAL ST LO,SUP-2363420,CDM,C1713,HCPCS,0278,RC,,,,both,,,77.56,50.41,,,,,,,,,,,,,
CATHETER HD STR 15.5X20 CM LT DL STP BASIC SET HEMO-FLOW XF,SUP-2627236,CDM,C1750,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
INTRODUCER GUIDEWIRE FOR 0.010-0.018 IN STRL,SUP-2105890,CDM,C1769,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
PLATE BONE CRANIAL 8 HOLE MATRIX 28X12MM TITANIUM NEURO PLAT,SUP-2825987,CDM,C1713,HCPCS,0278,RC,,,,both,,,303.01,196.96,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X150X150X0.8 MM RAPID RESORBABLE,SUP-2838569,CDM,C1713,HCPCS,0278,RC,,,,both,,,18757.73,12192.52,,,,,,,,,,,,,
HC Ins/Rep Subq Defibrillator,PX-3603327000,CDM,33270,CPT,0360,RC,,,,inpatient,,,30094.00,19561.10,,,,,,,,,,,,,
GRAFT BONE 5GM 5ML PARTICULATE SYNTH OSTEOCONDUCTIVE CLLGN,SUP-2288535,CDM,C1713,HCPCS,0278,RC,,,,both,,,978.55,636.06,,,,,,,,,,,,,
CONNECTOR SPNL TI STR SLT W/ WSHR FOR 6.35MM ROD MNRCH,SUP-2254511,CDM,C1713,HCPCS,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
TRAY ENDO INSTR LOCATABLE GUID OLY,SUP-2381723,CDM,C1769,HCPCS,0272,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
PLATE BNE 2 HOLE STRATUM PNUT,SUP-2464099,CDM,C1713,HCPCS,0278,RC,,,,both,,,2969.00,1929.85,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IN-LINE UNITZ DSTL CATH CERTAS +,SUP-2666572,CDM,C1889,HCPCS,0278,RC,,,,both,,,12086.77,7856.40,,,,,,,,,,,,,
PLATE CLAV 2.7MM VA LCP CS1 RT,SUP-2720069,CDM,C1713,HCPCS,0278,RC,,,,both,,,3183.96,2069.57,,,,,,,,,,,,,
TRAY CATH 6FR 2 LUMN NRS PWR INJ REV TAPR DSGN MAXIMAL BARR,SUP-2125643,CDM,C1751,HCPCS,0278,RC,,,,both,,,814.83,529.64,,,,,,,,,,,,,
BURR HOLE COVER CNTRD 3MM 22MM DIA 15MM SSTM CP TTNM,SUP-2678290,CDM,C1713,HCPCS,0278,RC,,,,both,,,704.74,458.08,,,,,,,,,,,,,
CABLE BNE FIX DIA1.5MM POLYMER FLX TENSILE STRENGTH W/ TI,SUP-2262260,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
CABLE ABLATION CATH EXT FOR AFFERA SPHR 9 STRL,SUP-2911934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PROBE ULTRASONIC LITHO 3.5X370MM RIG URETRON,SUP-2332894,CDM,C1713,HCPCS,0278,RC,,,,both,,,2227.36,1447.78,,,,,,,,,,,,,
BUR SURG DIA4MM CARB RND,SUP-2367605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.88,446.47,,,,,,,,,,,,,
PLATE BNE L57MM THK3.4MM 4 H BILAT PUBIC S STL 2 DCP H LO,SUP-2184021,CDM,C1713,HCPCS,0278,RC,,,,both,,,2484.87,1615.17,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM EPIFIX,SUP-2305755,CDM,Q4186,HCPCS,0636,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
HEAD HUM 50X16 MM SHLDR TI AEQUALIS,SUP-2715525,CDM,C1776,CPT,0278,RC,,,,both,,,8994.53,5846.44,,,,,,,,,,,,,
STEM HUM STD 6 MM SHLDR NP AFFINITI,SUP-2715297,CDM,C1776,CPT,0278,RC,,,,both,,,11143.86,7243.51,,,,,,,,,,,,,
CONNECTOR XLNK 40-50MM SPNL POST ADJ ST360,SUP-2212637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BLOCK FEM M THK10MM DST KNEE MOD ROT HNG,SUP-2376359,CDM,C1776,CPT,0278,RC,,,,both,,,1688.54,1097.55,,,,,,,,,,,,,
SPLINT WR AD L GREATER THAN W4IN RT MCP DLX KAY-SPLNT III,SUP-2324562,CDM,L3906,HCPCS,0272,RC,,,,both,,,82.80,53.82,,,,,,,,,,,,,
HC So Lipoprotein Bld Hr Fraction,PX-3018370166,CDM,83701,CPT,0301,RC,,,,both,,,183.00,118.95,,,,,,,,,,,,,
BUR SURG L30MM DIA1.5MM FLUT 6MM RND FLUTD OSTEON,SUP-2166640,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.38,221.90,,,,,,,,,,,,,
SET URET STENT GREENE L 8-20 CM DIA 6 FR CATH L 70 CM DIA 6,SUP-2835727,CDM,C2617,HCPCS,0278,RC,,,,both,,,438.53,285.04,,,,,,,,,,,,,
SPACER SPNL W27XH12XL55MM 12DEG LORD OBLQ LAT LUM INTBDY,SUP-2284923,CDM,C1821,HCPCS,0278,RC,,,,both,,,17599.70,11439.80,,,,,,,,,,,,,
SHEATH INTRO VASC RENAL 6FR 45CML ACCEPTS .038IN DIA GWIRE,SUP-2141016,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SCREW BNE CANN SHRT THRD 4X24 MM 10 MM MIDFOOT HD COMPR SS,SUP-2609268,CDM,C1713,HCPCS,0278,RC,,,,both,,,1138.50,740.02,,,,,,,,,,,,,
STENT URET 0.038 IN 6 FRX22 CM 6 FR DBL PGTL 2 FLX PERCFLX +,SUP-2465260,CDM,C2617,HCPCS,0278,RC,,,,both,,,548.12,356.28,,,,,,,,,,,,,
TAP BONE L12MM DIA8MM BIO-TENODESIS,SUP-2121455,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
COMPONENT FEM CR 49X60 MM KNEE BEAD IMPL HA POROUS DURAC,SUP-2377119,CDM,C1776,CPT,0278,RC,,,,both,,,10510.84,6832.05,,,,,,,,,,,,,
BLADE RETRACTOR 80 MM CMF CRV FOR TROCAR TRANSBUCCAL LEVEL 1,SUP-2462262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1653.78,1074.96,,,,,,,,,,,,,
KIT CELL HARVESTING AUTOLGS FOR WND HEALING THERM BURN FULL,SUP-2927449,CDM,C1832,CPT,0272,RC,,,,both,,,21587.50,14031.87,,,,,,,,,,,,,
LEAD PACE L40CM DIA1.27MM 1.5MM ELECTRD SPACE BLK 8 CHAN DIR,SUP-2357357,CDM,C1778,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PARTIALLY THREADED SCREW 6.5 X 110MM,SUP-2586689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
KIT INSTR W/ IMPL PRELD TUNN BTTN SYS FOR PLNTR PLT REP,SUP-2175157,CDM,C1713,HCPCS,0278,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 6 MM EPTFE STR TW N RING,SUP-2396340,CDM,C1768,CPT,0278,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
HC Aspirate/Inj Ganglion Cys,PX-4502061200,CDM,20612,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SYSTEM VES HARV ENDOSCP VASOVIEW HEMOPRO,SUP-2227299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3443.01,2237.96,,,,,,,,,,,,,
SET GUIDEPIN DIA2.4MM DRL TIP DIA2.4MM GWIRE DIA2.8MM FOR,SUP-2123379,CDM,C1769,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE W10XL58MM THK3.3MM HK D15MM 6 H R CLAV S STL LOK,SUP-2185830,CDM,C1713,HCPCS,0278,RC,,,,both,,,2353.49,1529.77,,,,,,,,,,,,,
TAMSULOSIN HCL 0.4 MG PO CAPS,RX-101727,CDM,6370000000,HCPCS,0637,RC,00904-7383-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BLADE DERMTOM DISP FOR BAHA OSSCORA AND WS-75,SUP-2164929,CDM,2720000010,LOCAL,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
BIT DRL L225MM DIA3.2MM ST QUIK CPL NONRADIOPAQUE W/O STP,SUP-2187167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.87,390.57,,,,,,,,,,,,,
HA CONT ACT RECONS RG 46MM RT,SUP-2822563,CDM,C1776,CPT,0278,RC,,,,both,,,6393.04,4155.48,,,,,,,,,,,,,
HC Culture Blood,PX-3008704000,CDM,87040,CPT,0300,RC,,,,both,,,344.00,223.60,,,,,,,,,,,,,
CATHETER THROMCTMY L 180 CM DIA 0.014 IN HELCL STRL,SUP-2365834,CDM,C1757,HCPCS,0272,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 35 DEG 1 CM 014X180 25 CM GLIDEWIRE,SUP-2851655,CDM,C1769,HCPCS,0272,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
PIN FIX POLYETH BUMPER LCK OSS,SUP-2405860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
CONTROLLER VAC ASST VEN DRNGE,SUP-2266017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7963.04,5175.98,,,,,,,,,,,,,
CATHETER URETH MEAS AMS,SUP-2140261,CDM,C1813,HCPCS,0278,RC,,,,both,,,12167.50,7908.87,,,,,,,,,,,,,
STENT GRFT VASC ANCURE L 10 CM DIA22 MM POLYESTER TUBE,SUP-2139775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
PACEMAKER CARD D6MM PERM 2 CHMBR STD UNIPOLAR/BIPOLAR DDDR,SUP-2357337,CDM,C1785,HCPCS,0275,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
PLATE BNE STRL LF LAPIPLASTY,SUP-2893047,CDM,C1713,HCPCS,0278,RC,,,,both,,,14601.00,9490.65,,,,,,,,,,,,,
SCREW BONE L28MM OD6.3MM VIT CORT NONLOCKING BOSWORTH,SUP-2364658,CDM,C1713,HCPCS,0278,RC,,,,both,,,755.33,490.96,,,,,,,,,,,,,
DEFIBRILLATOR CRD 5.23X7.14X0.99 CM 2 IS1 DF1 PERCIVA DR,SUP-2149181,CDM,C1721,HCPCS,0275,RC,,,,both,,,40192.00,26124.80,,,,,,,,,,,,,
CATHETER CV KT 9 FRX10 CM DL ANTIMICROBIAL FOR 7.5-8 FR MAC,SUP-2763353,CDM,C1751,HCPCS,0278,RC,,,,both,,,570.85,371.05,,,,,,,,,,,,,
STENT URET FLX 0.035 IN 7 FRX22 CM 6 FR TAPR POLARIS ULTRA,SUP-2473618,CDM,C2617,HCPCS,0278,RC,,,,both,,,633.43,411.73,,,,,,,,,,,,,
NAIL IM FEM LT LCK CANN 12MMX36CM GROSSE AND KEMPF,SUP-2362420,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.25,782.11,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.7X16 MM MANDIBULAR SELFTAPPING 20/PK,SUP-2842307,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.92,226.80,,,,,,,,,,,,,
SYSTEM DEL DUCT OCCL II AMPLATZER TORQVUE SHTH OD8FR TIP ANG,SUP-2355720,CDM,C1713,HCPCS,0278,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
CROWN DENT SZ LL6 LO LT 1ST PERM M S STL THCK OCCLUSAL SURF,SUP-2238808,CDM,D6783,CPT,0278,RC,,,,both,,,24.46,15.90,,,,,,,,,,,,,
HC Ot Elec Stim Unattended,PX-4309701400,CDM,97014,CPT,0430,RC,,,,inpatient,,,206.00,133.90,,,,,,,,,,,,,
PLATE BNE SM W11XL46MM THK34MM 3 H BILAT TI RIG NEUT LOK,SUP-2190773,CDM,C1713,HCPCS,0278,RC,,,,both,,,805.10,523.31,,,,,,,,,,,,,
PLATE SPNL L5CM STD ANT THOR TI VANTAGE,SUP-2292707,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SPHERE GLEN DIA36MM +3MM OFFSET CO CHROM SHLDR REV SYS,SUP-2404720,CDM,C1776,CPT,0278,RC,,,,both,,,5491.86,3569.71,,,,,,,,,,,,,
KIT EVAC 400CC DIA1/8IN H PAT 12.5IN 3 SPR RND SHP PVC DRN,SUP-2127101,CDM,C1729,HCPCS,0272,RC,,,,both,,,24.24,15.76,,,,,,,,,,,,,
BUR SURG BALL 2 MM 19 CM FLUT FOR MA-19 BEAR SL,SUP-2848290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.71,377.46,,,,,,,,,,,,,
BUR SURG MED 2.4 MM,SUP-2166717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
PLATE BONE 8 H NONSTERILE STRNL TI STR LCK FOR 3MM SCR,SUP-2192446,CDM,C1713,HCPCS,0278,RC,,,,both,,,2937.16,1909.15,,,,,,,,,,,,,
SPLINT WRST FA W ABDUCTED THMB L XSM,SUP-2276636,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK04 08MM ACELLULAR DERM MTRX,SUP-2307444,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1689.70,1098.30,,,,,,,,,,,,,
SUPERMX COMPRESSION STAPLE 18WX15L,SUP-2814267,CDM,C1713,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00990-7922-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
SCREW BNE SELF DRL CANN COMPR TI L19MM L5MM OD3MM APTUS,SUP-2268332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1446.91,940.49,,,,,,,,,,,,,
STAPLE BNE FIX W8XL20MM CO CHROM SPIK LIG LO PROF W/ ATTCH,SUP-2120785,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
CATHETER CV DL 018 5 FRX135 CM FLX POWERPICC,SUP-2126385,CDM,C1751,HCPCS,0278,RC,,,,both,,,337.11,219.12,,,,,,,,,,,,,
CLADRIBINE 10 MG/10ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-133071,CDM,J9065,HCPCS,0636,RC,00143-9871-01,NDC,JW,both,10,ML,278.30,180.89,,,,,,,,,,,,,
FRAC ST/COMP RVS GLN/XLPE,SUP-2212472,CDM,C1776,CPT,0278,RC,,,,both,,,24064.96,15642.22,,,,,,,,,,,,,
LINER ACET PRSS FT HIP POROUS POLYETH MTL,SUP-2223614,CDM,C1776,CPT,0278,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
SET GASTROSTMY 14FR L30CM 6 SIDEPRT PERC LOK PGTL,SUP-2168334,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.62,326.70,,,,,,,,,,,,,
SCREW BNE PEGGED 2.5X14 MM DSTL RADIAL VOLAR FT LCK FT COCR,SUP-2476040,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.03,148.87,,,,,,,,,,,,,
PLATE BONE L RT GLD 3D ORBIT FLR FOR 1.2MM SCR,SUP-2363677,CDM,C1713,HCPCS,0278,RC,,,,both,,,4249.96,2762.47,,,,,,,,,,,,,
"HC So Helminth, Nos",PX-3028668266,CDM,86682,CPT,0302,RC,,,,both,,,268.00,174.20,,,,,,,,,,,,,
PLATE BNE THK0.8MM BAR L2MM 5 H CRANIOMAXILLOFACIAL GRY TI,SUP-2366261,CDM,C1713,HCPCS,0278,RC,,,,both,,,677.55,440.41,,,,,,,,,,,,,
HC So Tetanus Antibodies,PX-3028677466,CDM,86774,CPT,0302,RC,,,,outpatient,,,225.00,146.25,,,,,,,,,,,,,
PLATE BONE L87MM THK3.8MM 20 H BILAT S STL NAR DYN COMPR FOR,SUP-2185215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1387.75,902.04,,,,,,,,,,,,,
SCREW BNE L 74 MM DIA 5.5 MM SHRT TI CANN HD NS LEOS,SUP-2931442,CDM,C1713,HCPCS,0278,RC,,,,both,,,909.69,591.30,,,,,,,,,,,,,
SPACER SPNL 4 DEG 25X20X10 MM,SUP-2380370,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
PLATE BNE STR BROAD 5 HOLE COMPR VARIAX,SUP-2365254,CDM,C1713,HCPCS,0278,RC,,,,both,,,2010.92,1307.10,,,,,,,,,,,,,
STEM FEM SZ 7 L135MM NK L39MM 52MM OFFSET 132DEG HIP FORGED,SUP-2375354,CDM,C1776,CPT,0278,RC,,,,both,,,8653.21,5624.59,,,,,,,,,,,,,
SET SCR SPNL L50MM DIA6.4MM PEDCL HA TI ALLOY FOR DYN STBL,SUP-2414276,CDM,C1713,HCPCS,0278,RC,,,,both,,,10920.92,7098.60,,,,,,,,,,,,,
COMPONENT FEM L145MM DIA13MM LAT HIP CO CHROM POR CEM ANS,SUP-2406609,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
TEMAZEPAM 7.5 MG PO CAPS,RX-11500,CDM,6370000000,HCPCS,0637,RC,68084-0549-21,NDC,,both,1,UN,13.60,8.84,,,,,,,,,,,,,
COUPLER ANAS 1.5 MM MICROVASCULAR SINGLE POLYETH SS BLU GEM,SUP-2382617,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
HC Lipid Panel|NOT REASONABLE AND NECESSARY,PX-3018006100,CDM,80061,CPT,0301,RC,,,GZ,both,,,191.00,124.15,,,,,,,,,,,,,
TROCAR ENDOSCP L 150 MM DIA11 MM LNG OPT FIX CANN DOLPHIN,SUP-2896238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.80,308.62,,,,,,,,,,,,,
PLATE BNE ORBIT FLR LG 0.4 MM LT SMRT GRV 3D TI STRL LEVEL 1,SUP-2518089,CDM,C1713,HCPCS,0278,RC,,,,both,,,3878.65,2521.12,,,,,,,,,,,,,
BLADE SURG W18XL100MM,SUP-2660666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
BLADE SCALPEL ENDOTRIG DISP,SUP-2691421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
KIT CRICOTHYROTOMY ADULT 14GA SPLITTING NEEDLE L6.8CM AIRWAY,SUP-2824153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,418.53,272.04,,,,,,,,,,,,,
SAW WIRE 509 MM RESEGONE CAGE SYS CAPRI,SUP-2732241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.90,798.13,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT STEM HD EPOCH CERM,SUP-2212731,CDM,C1776,CPT,0278,RC,,,,both,,,15343.61,9973.35,,,,,,,,,,,,,
UNIT LITHO MECH ERCP LITHOCRUSH 22 MM,SUP-2312976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
PLATE BNE L232MM 12 H NONSTERILE R MED DST TIB S STL VAR,SUP-2177644,CDM,C1713,HCPCS,0278,RC,,,,both,,,5743.31,3733.15,,,,,,,,,,,,,
GRAFT HUM TISS BIOINTEGRATIVE 40X30 MM W/ INTRO LAT TAPESTRY,SUP-2867252,CDM,C1763,HCPCS,0278,RC,,,,both,,,4207.60,2734.94,,,,,,,,,,,,,
PATCH DURAL SUB 7.5X7.5CM ONLAY LYCOPLANT,SUP-2717536,CDM,C1763,HCPCS,0278,RC,,,,both,,,1731.05,1125.18,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 9X9X9 MM 0.7 CC DEMINERALIZED CONFORM,SUP-2737080,CDM,C1713,HCPCS,0278,RC,,,,both,,,1414.57,919.47,,,,,,,,,,,,,
WIRE EXT FIX 2 MM OLV SIDEKCK EZ FRAME,SUP-2850512,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
GUIDEWIRE VASC L 15 CM DIA 0.018 IN SS PTFE SAFE-T-J STR FIX,SUP-2760012,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.79,57.06,,,,,,,,,,,,,
CATHETER PICC 5FR L55CM 2 LUMN W/ PASV VLV TECHNOLOGY,SUP-2118889,CDM,C1751,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
GRAFT BIO TISS W6XL16CM DERM PORCINE ABD RECON FIRM,SUP-2112976,CDM,Q4130,HCPCS,0636,RC,,,,both,,,9228.46,5998.50,,,,,,,,,,,,,
DEVICE PESSARY CUBE 4 DRN,SUP-2119333,CDM,A4562,HCPCS,0274,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
KIT MIXING AND DELIVERY NUMATRIX,SUP-2828504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.34,249.82,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 18 ATM 4 FRX190 CM 2.5X30 MM SABERX,SUP-2866053,CDM,C1725,HCPCS,0272,RC,,,,both,,,987.56,641.91,,,,,,,,,,,,,
WIRE FIX SUBLAMINAR 1.2 MM ESS MALIBU,SUP-2707689,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SLEEVE COMPR 9 10IN UNIV AMBI CRPL GEL HYPOALRG REUSE,SUP-2340101,CDM,L3912,HCPCS,0272,RC,,,,both,,,53.16,34.55,,,,,,,,,,,,,
COIL EMB COMPLX 2 MMX6 CM ORBIT GALAXY XTRASOFT,SUP-2427736,CDM,C1713,HCPCS,0278,RC,,,,both,,,5700.26,3705.17,,,,,,,,,,,,,
SCREW BNE SET 7 MM 16 MM CANN THRD EXT TAB,SUP-2861023,CDM,C1713,HCPCS,0278,RC,,,,both,,,5705.13,3708.33,,,,,,,,,,,,,
STENT LACR DUCT GOLDBERG BICANALICULUS CERCLAGE,SUP-2224382,CDM,C1783,HCPCS,0278,RC,,,,both,,,167.46,108.85,,,,,,,,,,,,,
PLATE BONE L49MM 4 H S STL 1/3 TBLR ECT,SUP-2198531,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.66,84.93,,,,,,,,,,,,,
GUIDE PIN FIX 3.2X980MM SMOOTH DRL TIP FLEX W/ LEN MRK S STL,SUP-2197435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.22,437.59,,,,,,,,,,,,,
ADAPTER EXT L 20 CM FOR BSX NEVRO LD STRL DISP,SUP-2882921,CDM,C1883,HCPCS,0278,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
PLATE BNE L306MM BLDE W48XL25MM 95DEG 18 H NONSTERILE HIP S,SUP-2186764,CDM,C1713,HCPCS,0278,RC,,,,both,,,4191.27,2724.33,,,,,,,,,,,,,
BUR SURG 10 FLUT 9 MM RND CARBIDE UPWR,SUP-2166781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,240.52,156.34,,,,,,,,,,,,,
SCREW BONE L70MM DIA6.5MM THRD L40MM TI CANN,SUP-2205345,CDM,C1713,HCPCS,0278,RC,,,,both,,,1102.30,716.49,,,,,,,,,,,,,
COVER BURR HOLE CONTOURED 22X0.3 MM LP TI,SUP-2495649,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.25,680.06,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 7 FR SPC 3 MM D CRV,SUP-2248945,CDM,C1730,HCPCS,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 40X60 MM FRZN ASEP TRICORT IL CREST,SUP-2867193,CDM,C1762,CPT,0278,RC,,,,both,,,4402.91,2861.89,,,,,,,,,,,,,
PLATE BNE L89MM 3 H L PROX HUM LOK FOR 3.5MM SCR PERI-LOC,SUP-2348590,CDM,C1713,HCPCS,0278,RC,,,,both,,,12670.53,8235.84,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 210 CM DIA 0.035 IN TIP L 1.5 MM,SUP-2665428,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.65,20.57,,,,,,,,,,,,,
SCREW BNE L70MM OD7MM PUR HINDFOOT ANK CANN FULL THRD HD,SUP-2320749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
BAR EXT FIX L200MM DIA11MM FOR XTRAFIX SYS,SUP-2199710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 45 CM DIA 6 MM STR STD WALL STRL,SUP-2396279,CDM,C1768,CPT,0278,RC,,,,both,,,2932.76,1906.29,,,,,,,,,,,,,
TRIAL UNIV STD FEM HD BPLR UPLR UHT V-40,SUP-2361589,CDM,C1776,CPT,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
STEM FEM L160MM DIA12MM 12/14 TAPR HIP 5/8 POR STD NK AML,SUP-2252066,CDM,C1776,CPT,0278,RC,,,,both,,,8647.56,5620.91,,,,,,,,,,,,,
MARKER TISS VERAFORM,SUP-2662074,CDM,A4648,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
NAIL IM CANN 125 DEG 11X380 MM RT TROCHANTERIC FIX TI GRN,SUP-2191999,CDM,C1713,HCPCS,0278,RC,,,,both,,,3984.09,2589.66,,,,,,,,,,,,,
STEM HUM DSTL 13X130 MM SHLDR AEQUALIS FLX REVIVE PTC,SUP-2715468,CDM,C1776,CPT,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY L115CM 7FR 2-6-2MM D CRV,SUP-2912313,CDM,C1731,HCPCS,0278,RC,,,,both,,,3559.25,2313.51,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 20X14 - 18 MM FRZ DRY,SUP-2294101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1456.96,947.02,,,,,,,,,,,,,
BIT DRL DIA32MM FLX SHFT REUSE FOR OCCIPITAL CERV FUS SYS,SUP-2179054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 2X2 CM UMB CRD RESTORIGIN,SUP-2321891,CDM,Q4191,HCPCS,0636,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC Unlisted Therapeutic Proph/Dx IV/Ia Njx/Nfs,PX-2609637900,CDM,96379,CPT,0260,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM W/ SZ 3-0 BIOCRYLRAPIDE ORTHOCORD SUT,SUP-2256658,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.56,1743.01,,,,,,,,,,,,,
GRAFT BNE FIBER 15 CC OSTEOAMP SEL,SUP-2424598,CDM,C1713,HCPCS,0278,RC,,,,both,,,10555.39,6861.00,,,,,,,,,,,,,
GRAFT BNE FEN 15X50 MM DEMINERALIZED CORTICAL FENFLEX,SUP-2742005,CDM,C1713,HCPCS,0278,RC,,,,both,,,1338.43,869.98,,,,,,,,,,,,,
CATHETER CARD ABLATION ISOLATOR SYNERGY L 64 CM SS ABS RT,SUP-2124448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
CATHETER INFUSION OCCL 4 FRX135 CM 30 CM 1 CC 20 CC FOUNTAIN,SUP-2302565,CDM,C1751,HCPCS,0278,RC,,,,both,,,379.63,246.76,,,,,,,,,,,,,
STRAIGHT REDUCTION CLAMP BROAD,SUP-2473831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2030.95,1320.12,,,,,,,,,,,,,
PLATE BNE SM W11XL215MM THK34MM 16 H BILAT TI RIG NEUT LOK,SUP-2190796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1999.43,1299.63,,,,,,,,,,,,,
CARBON FIBER ROD 9.5MMX150MM,SUP-2828990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
PLATE BNE W10.3XL137.6MM THK3.7MM 10 H TI LOK COMPR LO PROF,SUP-2413710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 30X30X12 MM 10.8 CC PRO OSTEON 500R,SUP-2684315,CDM,C1713,HCPCS,0278,RC,,,,both,,,5881.22,3822.79,,,,,,,,,,,,,
KIT INSTR W/ 2.4MM GUIDEPIN SUT PASS WIRE NO2 FIBERWIRE(ORDER MULTIPLES OF 5 EA),SUP-2121448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
WIRE FIX L100MM DIA11MM K UNIVERSAL2,SUP-2243201,CDM,C1713,HCPCS,0278,RC,,,,both,,,88.67,57.64,,,,,,,,,,,,,
SCREW BNE L10MM DIA5MM S STL ST LOK FULL THRD T25 STARDRV,SUP-2184875,CDM,C1713,HCPCS,0278,RC,,,,both,,,578.67,376.14,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H LNG TI NEURO STR PLT 12 PK,SUP-2935696,CDM,C1713,HCPCS,0278,RC,,,,both,,,21072.54,13697.15,,,,,,,,,,,,,
BLADE SHV L11CM OD3.5MM S STL STR SHFT IRRIG TBNG REUSE FOR,SUP-2284132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,705.87,458.82,,,,,,,,,,,,,
RESORB X TWIST DRILL 21MM X 50MM 8MM STOP CLNDRCL 24MM SCR,SUP-2694404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.70,290.35,,,,,,,,,,,,,
HC Assay of Uric Acid Other Source,PX-3018456000,CDM,84560,CPT,0301,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
TICAGRELOR 60 MG PO TABS,RX-131283,CDM,6370000000,HCPCS,0637,RC,00186-0776-60,NDC,,both,1,UN,34.90,22.68,,,,,,,,,,,,,
SCREW BNE L4MM DIA2MM MAND CRANIOMAXILLOFACIAL GRN ST MINI 5PK,SUP-2366138,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.67,129.79,,,,,,,,,,,,,
NAIL IM FEM 15X270 MM RETROGRADE PHOENIX,SUP-2606411,CDM,C1713,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
SLEEVE DECOMPRESSION DIA 32 FR SHRT GASTRECTOMY 3D CALIB SYS,SUP-2883407,CDM,C1889,HCPCS,0278,RC,,,,both,,,3064.64,1992.02,,,,,,,,,,,,,
SHEATH INTRO CKFLO XL STRL,SUP-2142009,CDM,C1894,HCPCS,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
SHOE ORTHOT MEN CUST OXFORD INTEGR PART OF BRAC,SUP-2435715,CDM,L3225,HCPCS,0274,RC,,,,both,,,208.97,135.83,,,,,,,,,,,,,
PROSTHESIS STD SLD CO CHROM ALLOY CEM 1 PC HIP 38MM 127MM,SUP-2205792,CDM,C1776,CPT,0278,RC,,,,both,,,3163.55,2056.31,,,,,,,,,,,,,
GUIDEWIRE VASC PRELUDE L 50 CM DIA 0.035 IN TIP L 3 MM SS,SUP-2303468,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
PLATE CERV PEEK CONVEX OPEL-C 18MM 14MM X 12MM X 7MM 7 DEG,SUP-2847825,CDM,C1713,HCPCS,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
HC So RBC Pretx Incubatj W/Chemicl,PX-3008697266,CDM,86972,CPT,0300,RC,,,,both,,,494.00,321.10,,,,,,,,,,,,,
PACK VITRCTMY PRB 20GA 20CC SYR CASS DRN BG ENDOILLUMINATOR,SUP-2109871,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
PROBE LITHO ULTRASOUND 1.5X370 MM FOR LUS-2 REUSE,SUP-2458466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1074.07,698.15,,,,,,,,,,,,,
STEM HUM PRSS FT SHLDR TOT,SUP-2379211,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
HC So Heparin Assoc Platelet Antibo,PX-3028602266,CDM,86022,CPT,0302,RC,,,,outpatient,,,170.00,110.50,,,,,,,,,,,,,
INSERT TIB SZ 3 THK15MM KNEE GVF ROT PLATFRM PFC SIG TC3,SUP-2253756,CDM,C1776,CPT,0278,RC,,,,both,,,6600.28,4290.18,,,,,,,,,,,,,
CATHETER EP CRD 2-3-2-5-2(60)2-10-2 SUPREME,SUP-2537999,CDM,C1730,HCPCS,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 30 WITH SHUNT ASSISTANT PROGAV 2.0  FX41,SUP-2844508,CDM,C1889,HCPCS,0278,RC,,,,both,,,9010.01,5856.51,,,,,,,,,,,,,
STENT BILI L30MM 6FR 135CM CATH LEN 10MM DIAM AD,SUP-2158932,CDM,C2625,HCPCS,0278,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
COLLAR BK SZ UNIV VISTA,SUP-2196895,CDM,L0120,HCPCS,0272,RC,,,,both,,,61.51,39.98,,,,,,,,,,,,,
PHENYTOIN 50 MG PO CHEW,RX-11018,CDM,6370000000,HCPCS,0637,RC,00904-7199-07,NDC,,both,1,UN,5.90,3.83,,,,,,,,,,,,,
GUIDE CATH 47 CM FIX CRV SLITTABLE CPS DIR,SUP-2357578,CDM,C1887,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BIT DRL L110MM DIA2.5MM STD RMR ADD ON DISP,SUP-2379291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SPIKE CBL HIP S STL LO PROF ACCORD,SUP-2345210,CDM,C1776,CPT,0278,RC,,,,both,,,410.71,266.96,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT HUM DST STRUCTURAL L,SUP-2307325,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.38,3469.95,,,,,,,,,,,,,
CATHETER HAD L15CM OD15FR SIL POLYUR ACUTE 2 LUMN TIP CLP,SUP-2118062,CDM,C1752,HCPCS,0278,RC,,,,both,,,333.06,216.49,,,,,,,,,,,,,
SCREW BNE L 44 MM DIA 3 MM THRD L 11 MM TI CANN COMPR HDLSS,SUP-2905718,CDM,C1713,HCPCS,0278,RC,,,,both,,,1486.54,966.25,,,,,,,,,,,,,
BRACE ORTH CLOSURE XL AD BK SHLDR BLK QUIKDRAW PRO,SUP-2123913,CDM,L0628,HCPCS,0274,RC,,,,both,,,321.98,209.29,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM PHOSPHORYLCHOLINE COAT SIL 510132C,SUP-2535101,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.55,24.41,,,,,,,,,,,,,
VALVE AORT ORIFICE DIA18.6MM TISS ANNULUS DIA21MM 85DEG,SUP-2355090,CDM,C1889,HCPCS,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
GUIDEPIN SURG FEM TIB PT SPEC FIX BLK CUT CUST W/ DRL SET,SUP-2201242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
NAIL FIX OD4MMX46MMX7.6MM MINI TI MTCRPL WR ARTH IMPLATE,SUP-2340238,CDM,C1713,HCPCS,0278,RC,,,,both,,,1813.35,1178.68,,,,,,,,,,,,,
SAW SURG HOLE 5.4X48 3 MM 9 CM LG BOR MIDAS REX 8,SUP-2664884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.01,307.46,,,,,,,,,,,,,
HC So1 Amoebic Antibodies by Iha,PX-3028675367,CDM,86753,CPT,0302,RC,,,,outpatient,,,588.00,382.20,,,,,,,,,,,,,
IMMOBILIZER SHLDR SWTH UNIV DEV BLK P.A.D. III,SUP-2336074,CDM,L3650,HCPCS,0274,RC,,,,both,,,167.86,109.11,,,,,,,,,,,,,
KIT INFUS PMP PAINBUSTER W/ ON Q SILVERSOAK 65MLX0.5ML PER,SUP-2236782,CDM,E0783,HCPCS,0278,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON XL 7 IN LT WRST ELASTIC LTX,SUP-2276651,CDM,L3809,HCPCS,0274,RC,,,,both,,,10.77,7.00,,,,,,,,,,,,,
DRILL SUT ANCHR MICRORAPTOR HIP,SUP-2418767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
STEM HUM UNIV STD L122MM DIA8MM SHLDR CO CHROM PRI CEM,SUP-2404590,CDM,C1776,CPT,0278,RC,,,,both,,,12368.46,8039.50,,,,,,,,,,,,,
HC Drain/Inject Joint/Bursa,PX-4502060000,CDM,20600,CPT,0450,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
CLIP ANEURYSM BLADE L5MM MAX OPENING 2.3MM MICRO TYPE,SUP-2826322,CDM,C1889,HCPCS,0278,RC,,,,both,,,731.31,475.35,,,,,,,,,,,,,
COLLAR CERV MED DENS UNIV 24X4 IN CNTOUR PROCARE LF,SUP-2195755,CDM,L0180,HCPCS,0272,RC,,,,both,,,7.10,4.61,,,,,,,,,,,,,
CATHETER ART L46CM OD2.2MM ID1MM BA IMPREG HAKIM,SUP-2243803,CDM,C1729,HCPCS,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED 3 PART,SUP-2212514,CDM,C1776,CPT,0278,RC,,,,both,,,16494.42,10721.37,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM BIOCOMP KNOTLESS DX CC STRL DISP,SUP-2882173,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
HC Tcat Insj/Rpl Perm Ldls Pm,PX-3613327400,CDM,33274,CPT,0361,RC,,,,outpatient,,,56457.00,36697.05,,,,,,,,,,,,,
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-157660,CDM,J1650,HCPCS,0636,RC,63323-0559-93,NDC,,both,0.3,ML,54.10,35.16,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE MIC W/ RICKHAM RESERVOIR DSTL CATH,SUP-2666481,CDM,C1889,HCPCS,0278,RC,,,,both,,,14668.20,9534.33,,,,,,,,,,,,,
FIBERRING WITH SHUTTLE LOOP 35MM 12PACK,SUP-2814146,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
TEMPLATE SURG SM ANTR STPL REVERE,SUP-2232149,CDM,C1713,HCPCS,0278,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
SCREW BONE L16MM DIA2.5MM DSTL RAD TI TRILOK EXPR APTUS,SUP-2268239,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 4 MM EPTFE STR TW N RING,SUP-2396331,CDM,C1768,CPT,0278,RC,,,,both,,,3287.58,2136.93,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP T9,SUP-2435538,CDM,L0455,HCPCS,0272,RC,,,,both,,,981.88,638.22,,,,,,,,,,,,,
HC Pt Manual Therapy Ea 15,PX-4209714000,CDM,97140,CPT,0420,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
ANCHOR SUTURE SS IMPL JUGGERKNOTLESS,SUP-2608584,CDM,C1713,HCPCS,0278,RC,,,,both,,,1259.71,818.81,,,,,,,,,,,,,
OSS TIBIAL SLEEVE AUGMENT SM,SUP-2506412,CDM,C1776,CPT,0278,RC,,,,both,,,2274.93,1478.70,,,,,,,,,,,,,
CANNULA PERF 22FR 20DEG W/ DIL EC BYPS PROC ANGIOVAC,SUP-2118779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
GRAFT VASC L 50 CM DIA14 MM POLYESTER THOR ABD AORT STR TB,SUP-2482837,CDM,C1768,CPT,0278,RC,,,,both,,,1399.94,909.96,,,,,,,,,,,,,
COVER BUR H L20MM W/ TAB,SUP-2365243,CDM,C1713,HCPCS,0278,RC,,,,both,,,1290.79,839.01,,,,,,,,,,,,,
CATHETER BLLN 1.5MM X 15MM TAKERU RX GWIRE 0.014IN,SUP-2385537,CDM,C1725,HCPCS,0272,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
CATHETER HD STR 16 FRX24 CM LT SPLIT TIP SET SPLIT STRM,SUP-2267085,CDM,C1750,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BUR SURG RND 0.5 MM 64 MM W/ GRD FOR DRL SYS SS POWERFORMA,SUP-2628945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,168.12,109.28,,,,,,,,,,,,,
CATHETER SET DRAINAGE 6 FRX15 CM SINGLE LUMEN PIG MP UTHANE,SUP-2168624,CDM,C1729,HCPCS,0272,RC,,,,both,,,248.53,161.54,,,,,,,,,,,,,
GRAFT NSL REP N DERM BIODESIGN 4X7 CM,SUP-2170297,CDM,C1763,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
KNIFE SEPTUM FREER D SHAPED BLADE 16CM 6 14IN,SUP-2678372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.95,214.47,,,,,,,,,,,,,
PLATE BNE L L PROX HUM POLARUS,SUP-2107824,CDM,C1713,HCPCS,0278,RC,,,,both,,,6666.22,4333.04,,,,,,,,,,,,,
BEARING HUM +3MM 3X44-41MM RETENTIVE REV SHLDR COMPHSVE,SUP-2409558,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BONE L93MM 5 HOLE STERILE PROXIMAL HUMERAL NCB,SUP-2463527,CDM,C1713,HCPCS,0278,RC,,,,both,,,3932.79,2556.31,,,,,,,,,,,,,
RING EXT FIX RADLUC 2/3 D 175 MM CE MARKED,SUP-2875115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2715.06,1764.79,,,,,,,,,,,,,
CATHETER CTRL VEN L12CM OD5FR PED DBL LUMN N TUNNELED BASIC,SUP-2167978,CDM,C1751,HCPCS,0278,RC,,,,both,,,296.42,192.67,,,,,,,,,,,,,
BIT DRL L 229 MM DIA 3 MM LG AO NS DISP LEOS,SUP-2932790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,859.73,558.82,,,,,,,,,,,,,
RING EXT FIX DIA155 MM HALF RED NS DISP SMRT TSF,SUP-2933338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4338.57,2820.07,,,,,,,,,,,,,
SCREW BONE L70MM OD4.5MM STD CORT ST LCK,SUP-2343757,CDM,C1713,HCPCS,0278,RC,,,,both,,,302.95,196.92,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 12 CM DIA14 FR GUIDEWIRE 0.038 IN,SUP-2355543,CDM,C1893,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
CATHETER ABLATN MED CURL 4 MM 2-5-2 MM 7 FRX110 CM COOL PATH,SUP-2357492,CDM,C2630,CPT,0272,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
PLATE CRAN SM TI PT SPEC NS DISP ACCUSHAPE,SUP-2936590,CDM,C1713,HCPCS,0278,RC,,,,both,,,56648.74,36821.68,,,,,,,,,,,,,
MILL BNE ELECTR SGL PASS CUT ACT,SUP-2363674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
HC So Thyroglobulin,PX-3018443266,CDM,84432,CPT,0301,RC,,,,outpatient,,,63.00,40.95,,,,,,,,,,,,,
STEM FEM L MOD HIP REMEDY,SUP-2319837,CDM,C1776,CPT,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
STEM FEM CALCAR HIP PLANER W/ BODY AVENIR COMPLETE,SUP-2448592,CDM,C1776,CPT,0278,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 6 MM STR STD WALL STRL,SUP-2396266,CDM,C1768,CPT,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
SCREW DEGENERATIVE IMPL MOD SEQUOIA PREBENT ROD CP TI 45MM,SUP-2206008,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC Sed Rate,PX-3058565200,CDM,85652,CPT,0305,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
SUPPORT WR SM AD FOR 7-8IN RT CRPL TUNN REG FIRM SUPP,SUP-2324888,CDM,L3931,HCPCS,0272,RC,,,,both,,,47.32,30.76,,,,,,,,,,,,,
PLATE BONE LOK 65MML HLX8 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2721567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.58,920.78,,,,,,,,,,,,,
BIT DRL 4 MM W/ STP FOR FRDM WRST ARTHROPLAST,SUP-2852120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.80,602.42,,,,,,,,,,,,,
PACEMAKER CARD VITALITY 2 DR TI 2 CHMBR STRL,SUP-2149087,CDM,C1722,HCPCS,0275,RC,,,,both,,,92944.00,60413.60,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 17 10MM CORT CANC CHIP MORSELIZED FRZ,SUP-2307051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.26,898.47,,,,,,,,,,,,,
CLIP EXT FIX DYNAMIZATION FOR M COMB CLMP,SUP-2188523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX 3X100 MM BLU,SUP-2205299,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.00,258.70,,,,,,,,,,,,,
SCREW INTRF MOD LF,SUP-2608348,CDM,C1713,HCPCS,0278,RC,,,,both,,,5.50,3.57,,,,,,,,,,,,,
MODEL 8F MACH 1 AL2 90CM SH HOLES,SUP-2664329,CDM,C1887,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
MARKER SKIN PREP ULTRA FN TIP RESIST INK STRL MINI XL DISP,SUP-2718590,CDM,C1713,HCPCS,0278,RC,,,,both,,,3.01,1.96,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 7 MM RND TPS MIDAS REX UPWR,SUP-2363383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
GUIDEWIRE SURG RET SLT FOR RG INSRTN OF PROVOX INDWL VOICE,SUP-2124335,CDM,C1769,HCPCS,0272,RC,,,,both,,,405.75,263.74,,,,,,,,,,,,,
BIOPSY PROCEDURE KIT UNIV LNG BLDELSS PRB MARKER MAMTOM MUK304] DEVICOR MED PRODUCTS MAMMOTOME],SUP-2195663,CDM,C1713,HCPCS,0278,RC,,,,both,,,1986.68,1291.34,,,,,,,,,,,,,
SET INTRO V-STICK DIA 5 FR SS COAX NONECHOGENIC STD,SUP-2120081,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 1.1X150 MM NS,SUP-2789082,CDM,C1769,HCPCS,0272,RC,,,,both,,,827.83,538.09,,,,,,,,,,,,,
PLATE BONE 2 H TI STR FOR CRAN CLSR SYS,SUP-2243969,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.90,100.68,,,,,,,,,,,,,
LEAD PACE ATTAIN ABIL + MRI SURESCAN L 88 CM DIA 5.3 FR SIL,SUP-2281928,CDM,C1900,HCPCS,0275,RC,,,,both,,,4865.52,3162.59,,,,,,,,,,,,,
SHEATH URET SZ 2 14FR DIL 12FR L28CM FORTE ACCS,SUP-2119493,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
NOREPINEPHRINE-SODIUM CHLORIDE 16-0.9 MG/250ML-% IV SOLN (WEIGHT-BASED),RX-4082011,CDM,2500000003,HCPCS,0250,RC,44567-0642-01,NDC,,both,250,ML,454.30,295.29,,,,,,,,,,,,,
PLATE BNE L72MM 5 H S STL LOK COMPR FOR 3.5MM SCR LCP,SUP-2185130,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.83,512.74,,,,,,,,,,,,,
SEGMENTAL ART SURF SZ C 17MM,SUP-2502390,CDM,C1776,CPT,0278,RC,,,,both,,,5736.78,3728.91,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.534,SUP-2860215,CDM,C1713,HCPCS,0278,RC,,,,both,,,38979.33,25336.56,,,,,,,,,,,,,
CLAMP SURG 5.5MM ROD CONNECTOR ROD PARALLEL SPINAL XIA,SUP-2879269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW SPNL 6.5MMDIA 35MM LEN PEDCL POLYAX CANC 5.5MM ROD TOP,SUP-2414589,CDM,C1713,HCPCS,0278,RC,,,,both,,,4496.48,2922.71,,,,,,,,,,,,,
BUSHING FEM SM FOR DST FEM GMRS,SUP-2376514,CDM,C1776,CPT,0278,RC,,,,both,,,740.41,481.27,,,,,,,,,,,,,
TIP IRRIG ASPIR CRV 03MM IT 03MM ULTRAFLOW,SUP-2110006,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.71,615.36,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN W/ ROT CUF LT WHL HUM,SUP-2740791,CDM,C1762,CPT,0278,RC,,,,both,,,17811.49,11577.47,,,,,,,,,,,,,
ALLOGRAFT HUM TISS CRYOPRESERVED ACHILLES TEND,SUP-2867087,CDM,C1762,CPT,0278,RC,,,,both,,,4322.37,2809.54,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 2 CC LECITHIN CARR DBM NS REGENEROSS +,SUP-2862037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1335.72,868.22,,,,,,,,,,,,,
WIRE SURG 0.045X6 IN TRCR PT NS KIRSCHNER LTX,SUP-2862421,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.24,7.31,,,,,,,,,,,,,
COIL EMB INST PNEUMAT FOR SYS DETACHER AXIUM ID,SUP-2172953,CDM,C1889,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY DEMIN CANC CORT 4MM-10MM RANG 30CC,SUP-2294043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
TUBE VENT ID1.14MM 6IFD GRN SIL STRL T GOODE,SUP-2277940,CDM,L8699,HCPCS,0278,RC,,,,both,,,75.52,49.09,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 80 MM DIA18/22 MM DEL,SUP-2934158,CDM,C1713,HCPCS,0278,RC,,,,both,,,21289.07,13837.90,,,,,,,,,,,,,
BIT DRILL SURG 4 MM ALPS DISP,SUP-2607159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.73,384.62,,,,,,,,,,,,,
BIT DRL QC 4.3 MM SS,SUP-2646003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.79,214.36,,,,,,,,,,,,,
SHOE CAST WALKING XS PEDIATRIC,SUP-2306064,CDM,L4387,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
PROBE VITRCTMY ODSEC20GA ACCURUS 2500,SUP-2109872,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
CRYOABLATION KIT PROST HE-THAW ICEROD,SUP-2225659,CDM,C2618,HCPCS,0272,RC,,,,both,,,11480.63,7462.41,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM STR REINF SLDE GDS,SUP-2484260,CDM,C1768,CPT,0278,RC,,,,both,,,1557.31,1012.25,,,,,,,,,,,,,
HOOK ENDOSCP L4-9CM TIP FOR SEAL AND DISECT HARM,SUP-2219115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1672.74,1087.28,,,,,,,,,,,,,
PROBE LASER CRV 23 GA ENDO OCU W/ SMA906 CONN LUMEPROBE,SUP-2713784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4072.58,2647.18,,,,,,,,,,,,,
COLLAR EXTRIC PED 1.5IN FOR 8-18IN FR 1 PC FLAT LOK TAB CLS,SUP-2194417,CDM,L0120,HCPCS,0272,RC,,,,both,,,18.09,11.76,,,,,,,,,,,,,
FLECAINIDE ACETATE 50 MG PO TABS,RX-10043,CDM,6370000000,HCPCS,0637,RC,00054-0010-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CROWN DENT PED SZ UR3 RT UP CTRL PRI M TRNSPAR PLAS GLS,SUP-2100386,CDM,D6783,CPT,0278,RC,,,,both,,,27.91,18.14,,,,,,,,,,,,,
GRAFT HUM TISS 9X73 MM QUADRICEPS TEND FLEXIGRAFT QUADLINK,SUP-2845910,CDM,C1762,CPT,0278,RC,,,,both,,,7421.08,4823.70,,,,,,,,,,,,,
IMPLANT LOOP ADJ W/O BTTN STRL DISP PROCINCH,SUP-2905820,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
CLIP ANEUR PERM MINI 4 MM CRV YASRG,SUP-2108350,CDM,C1889,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
PIN FIX FOR TEMP HLD PROVIDENCE,SUP-2232178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 14X11X7 MM UNICORTICAL CANC MATRIGRAFT,SUP-2264702,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
TUBE ES DIA6MM 4 LUMN DBL BLLN ELONG SPEC MINNESOTA,SUP-2126033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1765.94,1147.86,,,,,,,,,,,,,
SYSTEM OCCL DEL AMPLATZER 45 DEG L 80 CM SHTH 8 FR NIT MESH,SUP-2116322,CDM,C1817,HCPCS,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
CAGE SPNL SHELL SHT 25 MM VERSION C NS FLAREHAWK 9 LTX,SUP-2877239,CDM,C1889,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
BEARING TIB SHT COMP ROT HNG KINEMATIC,SUP-2376472,CDM,C1776,CPT,0278,RC,,,,both,,,6960.44,4524.29,,,,,,,,,,,,,
TUBE FEED GASTROJEJU 14FR L22CM STOMA L1.0CM MICRO GJET,SUP-2665175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-15863,CDM,J3490,HCPCS,0250,RC,00338-0077-04,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
PLATE BNE X 2.3X2 MM THOR RIB 32 HOLE LCK SLD TI LEVEL 1 LTX,SUP-2869154,CDM,C1713,HCPCS,0278,RC,,,,both,,,5625.62,3656.65,,,,,,,,,,,,,
WASHER ORTH ANK FIX FOR 4 MM SCREW,SUP-2389354,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
RESERVOIR SHUNT ONOFF DEV W/O ANTI SIPHON DEV PROX OCCL,SUP-2851446,CDM,C1889,HCPCS,0278,RC,,,,both,,,3165.09,2057.31,,,,,,,,,,,,,
POLYSACCHARIDE IRON COMPLEX 150 MG PO CAPS,RX-11050,CDM,6370000000,HCPCS,0637,RC,51991-0203-11,NDC,,both,1,UN,1.10,0.71,,,,,,,,,,,,,
LEAD PACE FINELINE II STEROX L 52 CM DIA 7 FR SIL STEROID,SUP-2148662,CDM,C1898,HCPCS,0275,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY DIA 6 FR SPC 5 MM EXT,SUP-2357651,CDM,C1730,HCPCS,0272,RC,,,,both,,,1389.36,903.08,,,,,,,,,,,,,
STABILIZER TISS CANSTR TBNG EVOLUTION AS OCTPS,SUP-2283007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
PLATE CRAN L 40.2 X W 24.8 MM THK 0.3 MM SCREW DIA1.5 MM TI,SUP-2937002,CDM,C1713,HCPCS,0278,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
SCREW BNE L95MM DIA5MM S STL ST VAR ANG FULL THRD CANN LOK,SUP-2178740,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.49,589.22,,,,,,,,,,,,,
SHEATH PEELAWAY INTRODUCER 14 FR 5-PACK,SUP-2854425,CDM,C1894,HCPCS,0272,RC,,,,both,,,1285.52,835.59,,,,,,,,,,,,,
HC Doppler Color Flow Mapping,PX-4839332500,CDM,93325,CPT,0483,RC,,,,both,,,1015.00,659.75,,,,,,,,,,,,,
BLOCK CUT TIB,SUP-2392667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
JOINT EXT FIX MOD BALL ASMBLY NS DISP MONK RING,SUP-2881065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1545.67,1004.69,,,,,,,,,,,,,
HC So Antibody Screen,PX-3028685066,CDM,86850,CPT,0302,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
PLATE BONE L70MM THK1.2MM DISTANCE BTWN H 10.5MM CALCNL TI,SUP-2190979,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.13,1157.73,,,,,,,,,,,,,
SCREW BNE L18MM OD6.5MM VIT ST HEX DRV,SUP-2376067,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5.5X15 MM OCCIPITOCERVICAL UPPER THOR,SUP-2631978,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 24 X 13 X 6.5 MM POLYETHYL BUR H CVR DRN,SUP-2935531,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.524,SUP-2860205,CDM,C1713,HCPCS,0278,RC,,,,both,,,33422.79,21724.81,,,,,,,,,,,,,
ENDPLATE SPNL DISK 14X16MM FOOTPRINT 0DEG CO CHROM,SUP-2232285,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
COIL NEUROVASCULAR MICRUSPHERE 18 L 24.3 CM DIA14 MM PRIMARY,SUP-2461161,CDM,C1889,HCPCS,0278,RC,,,,both,,,5806.68,3774.34,,,,,,,,,,,,,
MICROCATHETER INFUSION MAESTRO 150CM 2.9/2.9FR SWAN TIP,SUP-2301446,CDM,C1887,HCPCS,0272,RC,,,,both,,,857.06,557.09,,,,,,,,,,,,,
HC Treat Wrist Bone Fx,PX-4502562200,CDM,25622,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
HC Repair Wounds 20.1cm to 30cm,PX-4501203600,CDM,12036,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
PLATE BNE W101XL196MM THK35MM 14 H BILAT TI STR RIG LOK,SUP-2191089,CDM,C1713,HCPCS,0278,RC,,,,both,,,2080.85,1352.55,,,,,,,,,,,,,
SCREW INTRF BIOSURE REGENESORB 11MMX35MM,SUP-2341931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1073.13,697.53,,,,,,,,,,,,,
HYSTEROSCOPE VID DIA 6.2 MM HTX60S DISP,SUP-2913697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.95,414.67,,,,,,,,,,,,,
GRAFT AAA BIFUR 22X16X120MM,SUP-2217563,CDM,C1874,HCPCS,0278,RC,,,,both,,,33896.30,22032.59,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THN 2CMX4CM,SUP-2306986,CDM,C1762,CPT,0278,RC,,,,both,,,589.88,383.42,,,,,,,,,,,,,
HC Debride Skin at Fx Site,PX-4501101000,CDM,11010,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
SHELL ACET SZ 50B 3 H LOGICAL G SER,SUP-2322426,CDM,C1776,CPT,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
CEMENT BONE ROTARY MIX 5 CC REINFORCED STERILE CRANIOS,SUP-2838515,CDM,C1713,HCPCS,0278,RC,,,,both,,,6167.59,4008.93,,,,,,,,,,,,,
SCREW SPNL L25MM DIA6MM TI FIX ANG SOVEREIGN,SUP-2279888,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
PORT LAP L12MM SFT FLX W 5 12MM CANN AND OBT FOR TRANSANAL,SUP-2283384,CDM,C1713,HCPCS,0278,RC,,,,both,,,1211.10,787.21,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRP 25X10X7 MM MTRX OI,SUP-2135424,CDM,C1762,CPT,0278,RC,,,,both,,,3381.78,2198.16,,,,,,,,,,,,,
WEDGE EVANS 3D PRNT TI L 19X8MM,SUP-2320324,CDM,C1713,HCPCS,0278,RC,,,,both,,,6868.75,4464.69,,,,,,,,,,,,,
PLATE BNE L125MM THK38MM 6 H R MED DST TIB S STL NEUT,SUP-2185216,CDM,C1713,HCPCS,0278,RC,,,,both,,,3236.71,2103.86,,,,,,,,,,,,,
PROBE HEAT HPU-20,SUP-2313015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3367.68,2188.99,,,,,,,,,,,,,
KIT VAG SUPP SYS REP ARISE,SUP-2141762,CDM,C1771,HCPCS,0278,RC,,,,both,,,5129.19,3333.97,,,,,,,,,,,,,
CATHETER ABLATN C 2-5-2 MM 4 MM 7 FRX115 CM BRAIDED CELSIUS,SUP-2248726,CDM,C1733,HCPCS,0272,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
PLATE BNE RHOMBOID 20X13X1 MM CNDYL FRAC 3D LCK TI NS,SUP-2457043,CDM,C1713,HCPCS,0278,RC,,,,both,,,821.68,534.09,,,,,,,,,,,,,
KIT LD L65CM 2X8 MRI COMPATIBLE SURESCAN SPEC,SUP-2284650,CDM,C1778,HCPCS,0278,RC,,,,both,,,19954.70,12970.55,,,,,,,,,,,,,
MINI PLATE 6 HOLE LNG RIGHT BAR TURNED 110 CP TITANIUM,SUP-2676430,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.06,323.09,,,,,,,,,,,,,
LEAD PACE L60CM ATR VENT SIL INSUL STEROID ELUT TEMP BPLR,SUP-2278401,CDM,C1898,HCPCS,0275,RC,,,,both,,,1462.46,950.60,,,,,,,,,,,,,
KIT MICROSNARE 2.3-3FR L175CM LOOP DIA4MM CATH L150CM G PLT,SUP-2173553,CDM,C1773,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SCREW BNE EMGCY 2.5X9 MM SELF RET TI CENTRE-DRIVE,SUP-2495884,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.61,134.30,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 16 H TI STR LP NS STERNALOCK,SUP-2894451,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SYSTEM ENDOSCP VES HARV CONIC DISECT TIP W/ SYRNGE CANN AND,SUP-2227759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
CUFF BLD PRESSURE CIRC 17-45 CM URETHANE NYL MRI,SUP-2893209,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BONE CEMENT SURG 40 GM PWDR 13.3 GM LIQ PMMA LO VISC STRL,SUP-2894045,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.98,133.24,,,,,,,,,,,,,
SET URET STENT SALLE L 12-18 CM DIA 4.0 FR GUIDEWIRE L 145,SUP-2171180,CDM,C2625,HCPCS,0278,RC,,,,both,,,488.58,317.58,,,,,,,,,,,,,
ACEBUTOLOL HCL 200 MG PO CAPS,RX-8939,CDM,6370000000,HCPCS,0637,RC,50268-0050-15,NDC,,both,1,UN,6.70,4.35,,,,,,,,,,,,,
PLATE BNE SHT BENT 2.5 MM WRST TRILOK,SUP-2423180,CDM,C1713,HCPCS,0278,RC,,,,both,,,7754.54,5040.45,,,,,,,,,,,,,
IMPLANT BLGCL TSSUE 15CMW X 24CML 06 17MM THK ACLLLR ALLGR,SUP-2675795,CDM,Q4128,HCPCS,0636,RC,,,,both,,,19312.98,12553.44,,,,,,,,,,,,,
ELECTRODE ELECSURG 3FR L110CM COAG BUGBY TIP FLEXXC,SUP-2261087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.73,222.12,,,,,,,,,,,,,
CATHETER PULM ART 5FR INFL 0.75CC L110CM BAL DIA8MM SGL WDG,SUP-2383931,CDM,C1887,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
STEM FEM L130MM OD10MM STD BODY NK OFFSET CO CHROM HIP PRI,SUP-2203076,CDM,C1776,CPT,0278,RC,,,,both,,,24554.80,15960.62,,,,,,,,,,,,,
STENT BILI SELF SELF EXP 8FR CATH 194CM CATH LEN 10MM DIA,SUP-2149335,CDM,C1874,HCPCS,0278,RC,,,,both,,,5141.62,3342.05,,,,,,,,,,,,,
COVER CRAN L 41 X W 39 MM THK 0.3 MM SCREW DIA1.5 MM SM TI,SUP-2935870,CDM,C1713,HCPCS,0278,RC,,,,both,,,2364.42,1536.87,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PROF MD TI POLYUR SIL SINGLE CHMBR IS1,SUP-2357744,CDM,C1722,HCPCS,0275,RC,,,,both,,,76616.00,49800.40,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV ECO 115CM 7FR4-4-4 D,SUP-2880938,CDM,C1732,HCPCS,0278,RC,,,,both,,,4279.82,2781.88,,,,,,,,,,,,,
DRUM BUR OD8MM MIC FLUT CORNERSTONE,SUP-2363372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.91,796.19,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X3.75 MM NIT FLROPLAS SMRT,SUP-2638193,CDM,L8613,CPT,0278,RC,,,,both,,,950.48,617.81,,,,,,,,,,,,,
MICROCATHETER GUID TELEPORT L 150 CM DIA PROX 2.6/2 FR,SUP-2755116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PROBE ENDOSCP L150CM OD1.5MM CONVENIENT BLT IN FLTR (ORDER MUTLIPLES OF 10 EACH),SUP-2217944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
JOINT TOE INTRAOSSEOUS NEUT 2.2 MM CANNULINK,SUP-2400045,CDM,C1776,CPT,0278,RC,,,,both,,,4195.04,2726.78,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 4FR 0.034IN 60CM 1 LUMAN 3154107,SUP-2632643,CDM,C1751,HCPCS,0278,RC,,,,both,,,314.94,204.71,,,,,,,,,,,,,
NEXGEN ROTATING HINGE STEM TIBIAL PLATE SIZE 5,SUP-2502527,CDM,C1776,CPT,0278,RC,,,,both,,,10781.19,7007.77,,,,,,,,,,,,,
BIT DRL DIA4.5MM CANN FOR DOCKING TECH,SUP-2120805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
COMPONENT FEM CEM SM UNISX RT KNEE REV CR STEM BEAD VIT,SUP-2377035,CDM,C1776,CPT,0278,RC,,,,both,,,13768.90,8949.78,,,,,,,,,,,,,
VALVE DRNGE W/ INTEGR PLAS CONN 14CM VENT CATH 120CM DSTL,SUP-2194063,CDM,C1729,HCPCS,0272,RC,,,,both,,,13061.77,8490.15,,,,,,,,,,,,,
RETRIEVER FLAT WIRE LOOP STONE 3FRX115CM,SUP-2171233,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.20,299.78,,,,,,,,,,,,,
PIN FIX ENDOBROW 2.1X4 MM STRL SONICWELD RX,SUP-2472570,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.50,229.12,,,,,,,,,,,,,
PLATE PL LAT SUPP 2.7/3.5MM 13H LT 205MM TI DHP STRL,SUP-2546781,CDM,C1713,HCPCS,0278,RC,,,,both,,,4443.29,2888.14,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL CUST ARCH ATTCH TO SHOE,SUP-2435708,CDM,L3080,HCPCS,0274,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
CATHETER HD CRV EXTN 11 FRX20 CM CATH NDL DUOFLO,SUP-2627070,CDM,C1752,HCPCS,0278,RC,,,,both,,,246.49,160.22,,,,,,,,,,,,,
PLATE BONE 7 H UNIV TI HK,SUP-2319688,CDM,C1713,HCPCS,0278,RC,,,,both,,,6110.44,3971.79,,,,,,,,,,,,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,0636,RC,00143-9280-01,NDC,,both,1,UN,2880.00,1872.00,,,,,,,,,,,,,
ERYTHROMYCIN 250 MG PO TBEC,RX-146851,CDM,6370000000,HCPCS,0637,RC,13668-0586-30,NDC,,both,1,UN,22.50,14.62,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM UNIAXIAL STRL CD HORZ 4PK,SUP-2928638,CDM,C1713,HCPCS,0278,RC,,,,both,,,9168.80,5959.72,,,,,,,,,,,,,
PLATE EXT FIX ID180MM DBL ROW OF H M/L REF MRK ERGO DSGN,SUP-2316196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2854.79,1855.61,,,,,,,,,,,,,
CUP ACET CEM 28X44 MM HW ALL POLY HIP SYS ARCOMXL,SUP-2450465,CDM,C1776,CPT,0278,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
DEVICE APPLIER CLIP F/AVM CLIPS 90MM X 3 1/2 IN,SUP-2734744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4198.34,2728.92,,,,,,,,,,,,,
HC Aspirate Pleura W/ Imaging,PX-3503255500,CDM,32555,CPT,0350,RC,,,,both,,,3598.00,2338.70,,,,,,,,,,,,,
ARTHROSCOPIC SET HIP,SUP-2123487,CDM,C1769,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
TUBE VENT 1.0MM REUT BOB,SUP-2312592,CDM,L8699,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
SET EMB TRUFILL 10 ML 1 GM 1 GM N-BCA TANTALUM ETHIODIZED,SUP-2913680,CDM,C1889,HCPCS,0278,RC,,,,both,,,14287.00,9286.55,,,,,,,,,,,,,
NAIL INT FIX L20MM DIA3.5MM 8MM OFFSET HD 96L/4D PLA,SUP-2166735,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.76,430.79,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 10 FRX20 CM 5 LUMEN STRL,SUP-2759924,CDM,C1751,HCPCS,0278,RC,,,,both,,,587.53,381.89,,,,,,,,,,,,,
HC Layer Clos Face 2.6-5.0 Cm,PX-4501205200,CDM,12052,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
RASP SURG RND SHANK 73X5.5 MM RECIP,SUP-2607480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP FEM HD,SUP-2867013,CDM,C1762,CPT,0278,RC,,,,both,,,3624.35,2355.83,,,,,,,,,,,,,
ROD EXT FIX L200MM S STL CIR THRD TELSCP ORIG ILIZ,SUP-2342304,CDM,C1713,HCPCS,0278,RC,,,,both,,,1599.05,1039.38,,,,,,,,,,,,,
ANCHOR SUTURE BIOCOMP SWIVELOCK FIBERTAPE LOOP STRL,SUP-2882187,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
GRAFT HUM TISS SZ >80CM SAPH VEIN CRYOPRESERVED ANGIOGRFT,SUP-2264714,CDM,C1762,CPT,0278,RC,,,,both,,,34569.92,22470.45,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 45 CM 5-8 MM EPTFE GRAD TAPR REINF SLDE,SUP-2525475,CDM,C1768,CPT,0278,RC,,,,both,,,2975.75,1934.24,,,,,,,,,,,,,
HC Abscess Catheter Injection,PX-3614942400,CDM,49424,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SPACER FEM AUG 5 MM TIB MAG VANGUARD 360,SUP-2444539,CDM,C1776,CPT,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
ELECTRODE RF SUCT HND CTRL DISPOSABLE VAPR COOLPULSE 90,SUP-2256748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1541.74,1002.13,,,,,,,,,,,,,
DEVICE PESSARY SZ 6 83MM RNG W KNOB AND SUPP GEHRUNG,SUP-2417157,CDM,A4562,HCPCS,0272,RC,,,,both,,,112.66,73.23,,,,,,,,,,,,,
STENT NEURO SURPS EVOLVE L 12 MM DIA 4 MM COCR PLAT FLO,SUP-2541448,CDM,C1876,HCPCS,0278,RC,,,,both,,,42898.68,27884.14,,,,,,,,,,,,,
KIT BNE MAR ASPIR L10.16CM 3 H BX CELLECT,SUP-2255619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM CORT DST TIB TI NONCANNULATED,SUP-2413361,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
COMPONENT HIP FOR PK 6100,SUP-2212669,CDM,C1776,CPT,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
SPLINT FNGR SM 4 PRNG PD,SUP-2194501,CDM,L3809,HCPCS,0272,RC,,,,both,,,3.20,2.08,,,,,,,,,,,,,
HC MRI-Angio Neck W Contrast,PX-6157054800,CDM,70548,CPT,0615,RC,,,,both,,,3633.00,2361.45,,,,,,,,,,,,,
DRESSING HEMSTAT W12XL12IN 3 PLY QUIKCLOT CONTROL+,SUP-2416087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,834.99,542.74,,,,,,,,,,,,,
MICROPOWER RECIPROCATING SAW,SUP-2605740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8908.21,5790.34,,,,,,,,,,,,,
DRESSING BIOLOGICAL L15XW6CM PORCINE EXTRACELLULAR MATRIX SHEET STERILE DISPOSABLE FOR SOFT TISSUE REINFORCEMENT MATRISTEM RS,SUP-2106516,CDM,Q4166,HCPCS,0636,RC,,,,both,,,4184.99,2720.24,,,,,,,,,,,,,
SCREW BNE 1X9 MM CRANIOMAXILLOFACIAL TI CENTRE-DRIVE LEVEL 1,SUP-2458080,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.00,144.30,,,,,,,,,,,,,
CANNULA HEMO DYLS ANGIOVAC 180 DEG NIT TIP SELF EXPND,SUP-2421876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 80 CM DIA 8 FR HYDRPHLC,SUP-2383416,CDM,C1894,HCPCS,0272,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
BUR SURG TORNADO MINI 2-80 MM RND + FMS,SUP-2637141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,237.38,154.30,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA 3.5 MM TI CANN HD NS LEOS,SUP-2932591,CDM,C1713,HCPCS,0278,RC,,,,both,,,764.46,496.90,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC N THRD 1.4X150 MM,SUP-2221706,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
KIT ORTHOPEDIC SHORT 56MM INTERMEDIATE LEFT DISTAL RADIUS VARIAX F/T8 INSTRUMENT STERILE,SUP-2696117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5211.46,3387.45,,,,,,,,,,,,,
GRAFT BIO TISS MESH 20X10 CM MIROMATRIX MIROMESH,SUP-2115026,CDM,C1781,HCPCS,0278,RC,,,,both,,,18149.20,11796.98,,,,,,,,,,,,,
BAR PECTUS L 9.5 IN TI PREBENT NS PECTUS BLU,SUP-2895711,CDM,C1713,HCPCS,0278,RC,,,,both,,,15637.20,10164.18,,,,,,,,,,,,,
TAPE SUTURE SZ 1.8 MM UHMWPE SMTH LP N ABSRB BLACK/WHITE,SUP-2906177,CDM,C1713,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 10ML PUTTY TRANZGRFT,SUP-2353941,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321194,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.88,344.42,,,,,,,,,,,,,
GRAFT WDG IMPACTED FRZ DRY 12X20 TANGENT,SUP-2293768,CDM,C1713,HCPCS,0278,RC,,,,both,,,8173.42,5312.72,,,,,,,,,,,,,
BLADE SHV XL L180MM DIA5.5MM 8 FLUT HIP BRL BUR FOR ARTHRO,SUP-2366594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,241.21,156.79,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM DIA 0.025 IN CRV RAD 2 MM SS SAFE-T-J,SUP-2760082,CDM,C1769,HCPCS,0272,RC,,,,both,,,112.88,73.37,,,,,,,,,,,,,
KIT PICC 5FR GWIRE L70CM NIT POWERPICC SOLO,SUP-2125551,CDM,C1751,HCPCS,0278,RC,,,,both,,,385.28,250.43,,,,,,,,,,,,,
COUNTERSINK SURG FOR 4.5/6.5MM SCR,SUP-2187361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.66,688.78,,,,,,,,,,,,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,0636,RC,71288-0803-21,NDC,,both,1,UN,160.80,104.52,,,,,,,,,,,,,
SPLINT WR AD L GREATER THAN W4IN LT MCP DLX KAY-SPLNT III,SUP-2324563,CDM,L3906,HCPCS,0272,RC,,,,both,,,87.95,57.17,,,,,,,,,,,,,
PLATE BONE L122MM 10 H POST LAT S STL 1/3 TBLR LCK COMPR FOR,SUP-2349798,CDM,C1713,HCPCS,0278,RC,,,,both,,,2820.41,1833.27,,,,,,,,,,,,,
COIL EMB L2CM LOOP DIA2MM 0.018IN PLAT HYDRGEL POLYMER HELI,SUP-2385379,CDM,C1889,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
GRAFT HUM TISS FEMORAL POPLITEAL ARTERY,SUP-2740181,CDM,C1768,CPT,0278,RC,,,,both,,,24319.30,15807.54,,,,,,,,,,,,,
STEM ULN SZ 2 STD EL UHEAD,SUP-2379272,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
IMMOBILIZER SHLDR XL L9X22.5IN R/L CANVS W/ WAIST STRP THMB,SUP-2336107,CDM,L3660,HCPCS,0274,RC,,,,both,,,14.60,9.49,,,,,,,,,,,,,
LIGATOR ENDOSCP L230CM CHN DIA2.8MM DETACH LOOP,SUP-2313204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,300.81,195.53,,,,,,,,,,,,,
EXTENSION STEM TIB STABILIZING REV SMOOTH STR Y 17.5MM DIA,SUP-2209373,CDM,C1776,CPT,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 7/25 MM 6 FRX195 CM PUL TYP,SUP-2481238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1633.59,1061.83,,,,,,,,,,,,,
STAPLE SPNL 4 MM SFS,SUP-2601819,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
RING ACET DIA62MM HIP DYN LOK CEMENTLESS RECON DURALOC,SUP-2250741,CDM,C1776,CPT,0278,RC,,,,both,,,786.26,511.07,,,,,,,,,,,,,
BIT DRL L95MM DIA1.5MM STRL TI JCBS CHK NONRADIOPAQUE W/O,SUP-2187195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.53,251.24,,,,,,,,,,,,,
HALF PIN EXT FIX L180MM DIA4MM ANK FT THRD ELEMENTS QUIK,SUP-2316102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.96,283.37,,,,,,,,,,,,,
BIT DRL L195MM DIA3MM FEM S STL W/ QUIK CPL DISP FOR NCB,SUP-2204936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
HEAD FEM SM DIA36MM CO CHROM AMISTEM,SUP-2267308,CDM,C1776,CPT,0278,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
BIT DRL DIA 5 MM CANN HALL JCBS LG SYS STRL DISP EVOS,SUP-2933342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1649.29,1072.04,,,,,,,,,,,,,
SCREW INTRF L28MM DIA6MM SHLDR PLA CANN ARTHSCP FOR ANCHR,SUP-2166534,CDM,C1713,HCPCS,0278,RC,,,,both,,,686.62,446.30,,,,,,,,,,,,,
PLATE BNE L262MM 16 H ST R ANTLAT DST TIB S STL VAR ANG LOK,SUP-2177691,CDM,C1713,HCPCS,0278,RC,,,,both,,,7700.91,5005.59,,,,,,,,,,,,,
CLAMP EXT FIX LCK LG 2D,SUP-2473751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1852.57,1204.17,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA BASIC 4FR 20CM 2 LUMAN RVS TAPR PWR,SUP-2613551,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.80,321.62,,,,,,,,,,,,,
GUIDEWIRE VASC JTP POLY 0.14IN 300CM 3CM,SUP-2143076,CDM,C1769,HCPCS,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
PORT VENT DRNGE 23CMX16MM STYL BTM INLET CONN BA IMPREG W,SUP-2278360,CDM,C1889,HCPCS,0278,RC,,,,both,,,931.67,605.59,,,,,,,,,,,,,
STEM FEM PRSS FT 2 LAT HIP,SUP-2216923,CDM,C1776,CPT,0278,RC,,,,both,,,12170.64,7910.92,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX 5X5 CM PLASTIC MATRISTEM,SUP-2106490,CDM,Q4166,HCPCS,0636,RC,,,,both,,,1738.49,1130.02,,,,,,,,,,,,,
CONFORMER EYE M AD W20XL23MM BILAT OCU METHYLMETHACRYLATE M,SUP-2391940,CDM,L8610,HCPCS,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
SPACER SPNL W10XH7XL23MM 0DEG PEEK OPTMA INTERVERTEBRAL LUM,SUP-2211907,CDM,C1821,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
ELECTRODE UROLOGY CUT LOOP 1 STEM STRL DISP 7MM 24FR,SUP-2261163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
WRENCH SURG COUNT TORQ FOR BAHA 4 CONN SYS,SUP-2165026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SLEEVE COMPR SUSP,SUP-2388182,CDM,L2397,HCPCS,0274,RC,,,,both,,,300.78,195.51,,,,,,,,,,,,,
SCREW BNE L70MM DIA6MM ST AQUA CORT TI ST CANN LOK FULL,SUP-2191845,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
PLATE BNE W13.5XL70MM THK4.2MM 4 H BILAT S STL NAR LIMIT,SUP-2185230,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.29,621.59,,,,,,,,,,,,,
HC So Creatinine Urine/Other,PX-3018257066,CDM,82570,CPT,0301,RC,,,,both,,,29.00,18.85,,,,,,,,,,,,,
STIMULATOR BONE SER 233284,SUP-2137325,CDM,E0749,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
POST ORTHOPEDIC 3 HOLE W/ 12MM BOLT TRUELOK,SUP-2316110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ACCESS KIT 19 GAX0.018 IN AXERA RX,SUP-2424406,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PUTTY IS INDICATED FOR USE AS A BNE VOID FILL FOR VOIDS OR,SUP-2125446,CDM,C9359,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
METOPROLOL SUCCINATE ER 100 MG PO TB24,RX-30071,CDM,6370000000,HCPCS,0637,RC,00904-6324-61,NDC,,both,1,UN,5.50,3.57,,,,,,,,,,,,,
ALLOGRAFT SPEEDSPIRAL CMC 13X13,SUP-2419421,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
FIBER LASER 33 FT KRA-CPAOCHXL HDMI,SUP-2798088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,830.40,539.76,,,,,,,,,,,,,
CAPSULE ENDOSCP INGESTIBLE CAM FOR SM BWL NS DISP PILLCAM SB,SUP-2905445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1870.81,1216.03,,,,,,,,,,,,,
PROBE ABLAT 90DEG MPLR ABLAT,SUP-2341620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
COIL EMB 10 L6CM OD3MM HELCL STRTCH RESIST FNSH HYDRGEL,SUP-2305152,CDM,C1889,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
KNIFE SURG TABB 15.5 CM MUCOUS SS,SUP-2474747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.31,242.00,,,,,,,,,,,,,
CRANIAL ACCESS KIT W/ DRUG 2 DRL BIT NO RAZOR,SUP-2852685,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
SCREW BNE COMPARTMENT ALLOFIT,SUP-2448650,CDM,C1713,HCPCS,0278,RC,,,,both,,,1511.91,982.74,,,,,,,,,,,,,
CATHETER CTRL VEN 9.6FR 1.8ML L90CM SIL SGL LUMN OD3.2MM,SUP-2127699,CDM,C1751,HCPCS,0278,RC,,,,both,,,948.31,616.40,,,,,,,,,,,,,
GRAFT VASC STR 4 MMX10 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761231,CDM,C1768,CPT,0278,RC,,,,both,,,450.31,292.70,,,,,,,,,,,,,
BLADE SURG SAW SAG FLR ST 325MM CUT EDGE 64MM CUT DEPTH,SUP-2363584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,86.66,56.33,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209711600,CDM,97116,CPT,0420,RC,,,GP|KX|CQ,both,,,164.00,106.60,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL AD 18GA L71CM 30DEG BVL BRK XS CRV S STL,SUP-2357590,CDM,C1893,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
SPLINT ORTHOPEDIC MED LT MTCRPL,SUP-2124892,CDM,L3808,HCPCS,0272,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
BLOCK CUT FOR FEM,SUP-2249579,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
GRAFT BNE SUB 90CC SZ 05 5MM CORT CANC GRAN FRZ DRY,SUP-2307058,CDM,C1713,HCPCS,0278,RC,,,,both,,,3135.01,2037.76,,,,,,,,,,,,,
GUIDE DRL DIA3-4MM DISP FOR PONTO SYS,SUP-2319871,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 60 CM DIA2 FR BALLOON DIA 4 MM,SUP-2214007,CDM,C1757,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
SCREW BNE LAG 2.3X32 MM CRANIOMAXILLOFACIAL TI STRL LEVEL 1,SUP-2458251,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.97,174.83,,,,,,,,,,,,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-157648,CDM,J0561,HCPCS,0636,RC,60793-0701-10,NDC,,both,2,ML,1088.70,707.65,,,,,,,,,,,,,
SCREW LCK CANC 2.7X14MM,SUP-2397247,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.65,279.92,,,,,,,,,,,,,
PLATE BNE 3 H SPRING NS PRO,SUP-2902462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.11,780.07,,,,,,,,,,,,,
FEEDING TUBE KIT LP 12 FRX1.5 CM BLLN BUTTON SIL MINI 1,SUP-2754570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.98,579.14,,,,,,,,,,,,,
BUR SURG DIA3.2MM CARB FLUT SIDE CUT FOR 6.1CM SIL ATTCH,SUP-2176828,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
VALVE SHUNT SYS ADJ DIFF PRSS 0-20CM H2O W/ GRAVITATIONAL,SUP-2108725,CDM,C1729,HCPCS,0272,RC,,,,both,,,10082.73,6553.77,,,,,,,,,,,,,
TUBE VENT ARMSTR BVLD PLN END 1.14MM IMMUNDIFF 7.6MML FLROPL,SUP-2637683,CDM,L8699,HCPCS,0278,RC,,,,both,,,430.34,279.72,,,,,,,,,,,,,
GRAFT BNE STRP 12.5X1X0.4 CM 20 CC PLATFORM CM,SUP-2691585,CDM,C1713,HCPCS,0278,RC,,,,both,,,12462.66,8100.73,,,,,,,,,,,,,
PLATE BONE MINI THK1MM 2X2 H CRANIOMAXILLOFACIAL ORAL,SUP-2181777,CDM,C1713,HCPCS,0278,RC,,,,both,,,1721.03,1118.67,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR CUST VEST TYP ABDUCTN RESTRAINER,SUP-2435755,CDM,L3675,HCPCS,0274,RC,,,,both,,,452.25,293.96,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX15 CM SHT TERM DL TAPR SIL HEMCATH,SUP-2627302,CDM,C1752,HCPCS,0278,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
BASKET STONE REM SZ 16MM L120CM DIA3FR PR 6W SUR-CATCH NT,SUP-2312752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
GRAFT BIO 8X12CM BOV PERICARD DURA SUTURABLE RESRB,SUP-2243936,CDM,C1763,HCPCS,0278,RC,,,,both,,,2604.22,1692.74,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 14-16 MM FD ILIUM TRICORT,SUP-2717914,CDM,C1713,HCPCS,0278,RC,,,,both,,,4593.95,2986.07,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X1 CMX1.26-1.75 MM DECELL DERM ORACELL,SUP-2740801,CDM,C1762,CPT,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
SHEATH LASER 14FR L50CM DIA4.88MM 15DEG 25-40 REPETITION RATE,SUP-2353104,CDM,C2629,CPT,0272,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
BUR SURG OD30MM DMND RND EXTRA COARSE TAPR N FLUT ST FOR,SUP-2364026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.77,237.10,,,,,,,,,,,,,
GRAFT HUM TISS W1XL2CM THK1.04-2.28MM THCK REGENERATIVE TISS,SUP-2113073,CDM,Q4116,HCPCS,0636,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM FIX ANG LOK FULL THRD MAXLOCK,SUP-2400223,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
BIT DRILL AO 2.6X220MM,SUP-2737603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2116.36,1375.63,,,,,,,,,,,,,
SCREW BNE DIA1.5 MM HI TORQUE XLOCK SHRT BLADE NS,SUP-2934126,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
BASKET RETRV W10XL1150MM MIN WRK CHN 1.2MM 3 WIR FOR GRSP,SUP-2313148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,703.99,457.59,,,,,,,,,,,,,
PLATE BONE 4 H VOLAR WR S STL HK,SUP-2389791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
MESH HERN M W11XL14CM INGUINAL OVL SELF EXP PTCH KUGEL,SUP-2125979,CDM,C1781,HCPCS,0278,RC,,,,both,,,373.19,242.57,,,,,,,,,,,,,
SCREW SPNL CORTICAL 5X40 MM FIX FEN X-TAB STRL VIPER PRIM,SUP-2590945,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
KIT CATH DRNGE PERI FEN DRP SUT DSG ALC PD LN DISP PERITX,SUP-2734747,CDM,C1729,HCPCS,0272,RC,,,,both,,,1859.67,1208.79,,,,,,,,,,,,,
RALOXIFENE HCL 60 MG PO TABS,RX-22143,CDM,6370000000,HCPCS,0637,RC,43598-0505-01,NDC,,both,1,UN,3.00,1.95,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE DR LAKHANI,SUP-2110954,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.23,512.35,,,,,,,,,,,,,
GRAFT BONE SUB 25X100X4MM 10ML STRP BIOLOGIC SPINE SURG,SUP-2232308,CDM,C1713,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-155577,CDM,J1670,HCPCS,0636,RC,13533-0634-02,NDC,,both,1,ML,1915.10,1244.81,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 50X20X7 MM FD ILIUM TRICORT,SUP-2717880,CDM,C1762,CPT,0278,RC,,,,both,,,12217.05,7941.08,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 45300015] STRYKER CORP],SUP-2362778,CDM,C1769,HCPCS,0272,RC,,,,both,,,101.42,65.92,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRUT CORT TRAD 120X20MM,SUP-2294116,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 10 CM DIA 5 FR 2.5CM 0.038 IN,SUP-2385185,CDM,C1894,HCPCS,0272,RC,,,,both,,,200.65,130.42,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 59 MM EXPANSION DIA10 MM SHTH 8 FR,SUP-2159284,CDM,C1877,HCPCS,0278,RC,,,,both,,,2150.90,1398.08,,,,,,,,,,,,,
SLEEVE SURG THRD,SUP-2484449,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.65,955.27,,,,,,,,,,,,,
GRAFT BONE SUB 5CC FIL BONE VOID SOLUM IV,SUP-2163077,CDM,C1763,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
GUIDEPIN ORTH INTERMETATARSAL/FRONTAL PLANE ANGLE 20/40 DEG,SUP-2907570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5368.27,3489.38,,,,,,,,,,,,,
PLATE BNE L 90 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 7 H 72441007,SUP-2932757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.78,718.76,,,,,,,,,,,,,
HC So Brca1&2 Seq & Full Dup/Del,PX-3108116266,CDM,81162,CPT,0310,RC,,,,both,,,2714.00,1764.10,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 120 MM DIA 9 MM DEL SHTH,SUP-2934469,CDM,C1713,HCPCS,0278,RC,,,,both,,,12302.52,7996.64,,,,,,,,,,,,,
CATHETER INFUSION DIA2.4-3 FR 1 LUMEN STRL,SUP-2365833,CDM,C1887,HCPCS,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
RETROGRADE FEMORAL NAIL 12MMX44CM,SUP-2811095,CDM,C1713,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
HC So1 Amoebic Antibodies by Iha,PX-3028675367,CDM,86753,CPT,0302,RC,,,,inpatient,,,588.00,382.20,,,,,,,,,,,,,
CATHETER URODYN FLD FIL SIL RECT BAL AD SHFT SZ 10 FR BAL SZ,SUP-2263382,CDM,C1726,HCPCS,0272,RC,,,,both,,,597.86,388.61,,,,,,,,,,,,,
GUIDE NAVIGATION SYS EXT WORKING CHANNEL ONLY,SUP-2381724,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
GRAFT BNE SUB 15ML HA CA PHSPTE INJ DISP HYDROSET,SUP-2374939,CDM,C1713,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
ANCHOR VERSALOOP 1.8MM DL SUTURE,SUP-2756500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
OCCLUDER OCL20US TALENT AAA 20MM,SUP-2296679,CDM,C1874,HCPCS,0278,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
MESH BONE 126MMW X 126MML 06MM THK RSRB XG SM GRID LATEX FR,SUP-2694977,CDM,C1713,HCPCS,0278,RC,,,,both,,,8506.79,5529.41,,,,,,,,,,,,,
PLATE SPNL L19MM 2 H UNIV ANT LUM TI TRIANG CVR SET SCR,SUP-2291666,CDM,C1713,HCPCS,0278,RC,,,,both,,,2061.69,1340.10,,,,,,,,,,,,,
CATHETER INFUSION 014 2.1/1.7 FRX150 CM STR MICRO ECHELON 10,SUP-2470027,CDM,C1887,HCPCS,0272,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
PIN BNE FIX SHRT STR CADENCE,SUP-2932811,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.05,227.53,,,,,,,,,,,,,
SUPPORT LUMBAR LP,SUP-2388156,CDM,L1220,HCPCS,0272,RC,,,,both,,,616.66,400.83,,,,,,,,,,,,,
ALLOGRAFT HUM TISS W/O STRUT CRYOPRESERVED ACHILLES TEND,SUP-2867092,CDM,C1762,CPT,0278,RC,,,,both,,,3591.53,2334.49,,,,,,,,,,,,,
CATHETER IV REINF TIP 18 GAX8 CM FULL TY POWERGLIDE PRO,SUP-2125668,CDM,C1751,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
CLIP ENDOSCP L220CM CAP D6MM DIA8.5-11MM NIT PT TEETH,SUP-2319933,CDM,C1889,HCPCS,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0 X 44MM HD CANN SHT THRD SCR,SUP-2320565,CDM,C1713,HCPCS,0278,RC,,,,both,,,868.21,564.34,,,,,,,,,,,,,
BIT DRL FLX 3.2 MM OCCIPITOCERVICAL INFIN,SUP-2660497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3467.75,2254.04,,,,,,,,,,,,,
LASER SURG CRV 23 GA ILL,SUP-2713794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.70,333.90,,,,,,,,,,,,,
BRACE ANK LACE UP X LG ELASTIC CUF CLOSURE SPRT ORTHOSIS NYL,SUP-2336333,CDM,L4350,HCPCS,0274,RC,,,,both,,,33.69,21.90,,,,,,,,,,,,,
ELECTRODE NDL L4IN INSUL LO PWR SET EDGE,SUP-2283487,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.30,10.59,,,,,,,,,,,,,
REGULATOR CARBON DIOX 90 DEG 50 LB SINGLE STG,SUP-2389347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.17,367.36,,,,,,,,,,,,,
SEED BRACHYTHERAPY PRELD CARTRIDGE NS MICK DISP,SUP-2247306,CDM,C2643,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
PUMP PAIN 400X5ML HR ON Q C BLOC ON DEMAND W REFIL,SUP-2236809,CDM,C9804,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GRAFT HUM TISS L MED FEM CONDYLE HEMI FRSH,SUP-2264743,CDM,C1713,HCPCS,0278,RC,,,,both,,,36168.09,23509.26,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.6MM CORT TI NEURO NONCANNULATED FULL,SUP-2189295,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.51,155.03,,,,,,,,,,,,,
CANNULA INFLTR 12GA L23CM HUNSTAD,SUP-2300769,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER GUID L 100 CM OD 7 FR ID 0.078 IN PTFE LNR AR 1 SH,SUP-2910572,CDM,C1887,HCPCS,0272,RC,,,,both,,,123.53,80.29,,,,,,,,,,,,,
BIT DRL CALIB LNG 1.8X110 MM QC,SUP-2653739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,835.11,542.82,,,,,,,,,,,,,
CATHETER DRNAGE 14FR L40CM POLYUR HYDRPHLC BILI W/ LCK PGTL,SUP-2419069,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
CAP END FLSH IMPING 10 MM HUM 1ST SCREW VERSANAIL,SUP-2472246,CDM,C1889,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BONE MEDIALMAX POCKETLOCK NEUT ALPHA,SUP-2400133,CDM,C1713,HCPCS,0278,RC,,,,both,,,6129.28,3984.03,,,,,,,,,,,,,
CATHETER DRAINAGE SET 5 FRX8 CM FURMAN CPPDJ500WOODIMH,SUP-2759775,CDM,C1729,HCPCS,0272,RC,,,,both,,,397.90,258.63,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO 2 SQ PLATE 12 PK,SUP-2936501,CDM,C1713,HCPCS,0278,RC,,,,both,,,46136.02,29988.41,,,,,,,,,,,,,
BUR SURG DIA2MM S STL DMND TAPR RND REUSE FOR ELITE SABER 582012320] STRYKER CORP],SUP-2364023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
PLATE BNE L19MM THK075MM 8 H NONSTERILE R HND TI STRUT OBLQ,SUP-2180992,CDM,C1713,HCPCS,0278,RC,,,,both,,,1204.16,782.70,,,,,,,,,,,,,
BUR SURG CYL LNG 5 MMX10 CM FLUT SM BOR MIDAS REX LEGEND,SUP-2627633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.08,210.65,,,,,,,,,,,,,
PLATE SPNL ADPT 5 HOLE TI BLU NS MATRIXNEURO,SUP-2181563,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR N MESHED NAT,SUP-2366751,CDM,Q4126,HCPCS,0636,RC,,,,both,,,3661.24,2379.81,,,,,,,,,,,,,
COUNTERSINK SURG DIA 6.5/7.5 MM LNG CANN HD STRL DISP,SUP-2905556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2435.29,1582.94,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 6-8 MM EPTFE TAPR TW N RING,SUP-2396730,CDM,C1768,CPT,0278,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
HOOK RETRCT DIA12.5MM E THRD DISP DURAHK,SUP-2384707,CDM,C1819,HCPCS,0278,RC,,,,both,,,102.36,66.53,,,,,,,,,,,,,
GRAFT HUM TISS L W80XL200MM FASC LATA FRZ DRY READIGRFT,SUP-2264778,CDM,C1762,CPT,0278,RC,,,,both,,,4319.01,2807.36,,,,,,,,,,,,,
BIT DRL DIA2.7MM FOR 2.5MM PEDIFLEX ELAS STBL IM NAIL SYS,SUP-2318870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,841.08,546.70,,,,,,,,,,,,,
ASSEMBLY GWIRE DIA0.054IN PARA FOR MIC ACUTRK 2,SUP-2107283,CDM,C1769,HCPCS,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
PLATE BNE STR MED 1 MM 4 HOLE W/ INTERMED SPACE STRL,SUP-2457062,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.03,357.52,,,,,,,,,,,,,
BIT DRL CANN 3.2X150 MM W/ WIRE STRL,SUP-2645998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,491.79,319.66,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 120 CM CYL W/ SUTURE TABS HAKIM,SUP-2666801,CDM,C1889,HCPCS,0278,RC,,,,both,,,11315.78,7355.26,,,,,,,,,,,,,
DIAMOND SHAVER TUBESET,SUP-2745900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1638.04,1064.73,,,,,,,,,,,,,
SEPARATOR 7,SUP-2655666,CDM,C1757,HCPCS,0272,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
TUBE TRACH 4.5X56 MM 35545C56] BRYAN MEDICAL INC],SUP-2151575,CDM,A7521,HCPCS,0278,RC,,,,both,,,533.64,346.87,,,,,,,,,,,,,
HC Dest Botox-1 Extrem 1-4 Muscl,PX-5106464200,CDM,64642,CPT,0510,RC,,,,inpatient,,,2154.00,1400.10,,,,,,,,,,,,,
TUBE ET DIA7MM REINF SUBDERM NDL KT EMG MON,SUP-2310415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRAFIX PRIME 3X4CM CYROPRESERVED,SUP-2319163,CDM,Q4133,HCPCS,0636,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
TIGHTROPE XP BUTTRESS PLATE IMPLANT SYS,SUP-2830108,CDM,C1713,HCPCS,0278,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
SEEKER BALLOON L 17 MM DIA 5 MM SPHND FOR ENT,SUP-2902051,CDM,C1726,HCPCS,0272,RC,,,,both,,,1309.69,851.30,,,,,,,,,,,,,
HC Nips Eps,PX-4819361800,CDM,93618,CPT,0481,RC,,,,both,,,3734.00,2427.10,,,,,,,,,,,,,
BEARING TIB SZ 3/4 HINGE STRL TRIATHLON,SUP-2889783,CDM,C1776,CPT,0278,RC,,,,both,,,15474.86,10058.66,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.5 MM PEEK KNOTLESS BRIDGELINE ADAPTIVE,SUP-2899265,CDM,C1713,HCPCS,0278,RC,,,,both,,,3618.07,2351.75,,,,,,,,,,,,,
TRAY MAXIMAL BARR PICC CATH SGL LUMN 6 FR 55 CM LEN N COAT N,SUP-2118890,CDM,C1751,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
BOLT HINGE LNG,SUP-2492712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,291.11,189.22,,,,,,,,,,,,,
PLATE BONE LT LAT TIBIOTALAR ANK FUS ALIGNX,SUP-2418038,CDM,C1713,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
SET VASC FILTER SHTH 10 FR JUG 6 MM PHYNOX VENA CAVA,SUP-2124925,CDM,C1880,HCPCS,0278,RC,,,,both,,,3447.25,2240.71,,,,,,,,,,,,,
LEAD PERC MRI AVISTA 8 CONTACT 56CM,SUP-2138798,CDM,C1778,HCPCS,0278,RC,,,,both,,,10519.00,6837.35,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 39 MM EXPANSION DIA10-12 MM SHTH 8,SUP-2159261,CDM,C1877,HCPCS,0278,RC,,,,both,,,3975.24,2583.91,,,,,,,,,,,,,
BRUSH RUST RNG REMOVER MED BATTERY OPERATED BUR HNDL DIAMOND,SUP-2478531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.93,224.20,,,,,,,,,,,,,
TRAY TIB SZ 1 SLOPED MOD BAL REV SYS,SUP-2315550,CDM,C1776,CPT,0278,RC,,,,both,,,6380.48,4147.31,,,,,,,,,,,,,
PROSTHESIS 16F 5MM SPEC LEN INDWL VOICE,SUP-2242346,CDM,L8509,HCPCS,0274,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.6X220 MM FOR CANN SCREW NS 03333013,SUP-2789099,CDM,C1769,HCPCS,0272,RC,,,,both,,,323.29,210.14,,,,,,,,,,,,,
HYOSCYAMINE SULFATE 0.125 MG/ML PO SOLN,RX-3782,CDM,340b,HCPCS,0637,RC,62135-0513-52,NDC,,both,0.125,ML,3.70,2.40,,,,,,,,,,,,,
COIL EMB L6CM DIA2.5MM EXTRA SFT HELIX DETACH AXIUM PRIM,SUP-2295035,CDM,C1889,HCPCS,0278,RC,,,,both,,,4524.74,2941.08,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 8 MM EPTFE STR TW N RING HEMO,SUP-2761243,CDM,C1768,CPT,0278,RC,,,,both,,,514.21,334.24,,,,,,,,,,,,,
INSERT TIB CLP FOR SYNATOMIC ULT VF COORDINATE PLT AMK,SUP-2250103,CDM,C1776,CPT,0278,RC,,,,both,,,757.37,492.29,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 10X12 CM,SUP-2383090,CDM,C1781,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
ASSEMBLY EXT FIX PIN CLMP FOR SIDEKCK STLTH REARFOOT FIX,SUP-2400594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 7 FRX20 IN 13 GA 3L SPECTRUM,SUP-2759721,CDM,C1751,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
DRESSING BIO W2XL2IN BOV CLLGN GLYCOSAMINOGLYCAN,SUP-2243931,CDM,Q4104,HCPCS,0636,RC,,,,both,,,11287.48,7336.86,,,,,,,,,,,,,
KIT REV CATH ITH DST SPNL SEG,SUP-2284618,CDM,C1755,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC CT Perc Asp Disc Para Vent Tis,PX-3616226700,CDM,62267,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW BNE L 18 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2931922,CDM,C1713,HCPCS,0278,RC,,,,both,,,136.40,88.66,,,,,,,,,,,,,
DRILL SURG 11 MM ACP,SUP-2561592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SLEEVE TIB 1 KNEE PLUG GRDIAN,SUP-2304398,CDM,C1776,CPT,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
STEM FEM L152MM OD17MM FINN L8.5CM HIP SEGMENTED COMP,SUP-2406098,CDM,C1776,CPT,0278,RC,,,,both,,,12914.82,8394.63,,,,,,,,,,,,,
ALLOGRAFT KIT NAT TISS DENOVO OAC,SUP-2866915,CDM,C1763,HCPCS,0278,RC,,,,both,,,14663.80,9531.47,,,,,,,,,,,,,
SCREW BONE L45MM DIA6.5MM THRD L24MM HD DIA8MM CANC S STL ST,SUP-2184598,CDM,C1713,HCPCS,0278,RC,,,,both,,,99.38,64.60,,,,,,,,,,,,,
BIT DRL OD3.5MM TTC LO EXT FOR 6.5MM SCR ADVANSYS,SUP-2243132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,719.31,467.55,,,,,,,,,,,,,
GRAFT BNE SPACER 4 DEG 16 MM FOR ALIF,SUP-2632276,CDM,C1713,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
CATHETER NEPHROSTOMY SET 7/22 FRX20 CM MCOT STENT,SUP-2835671,CDM,C1729,HCPCS,0272,RC,,,,both,,,262.69,170.75,,,,,,,,,,,,,
WEDGE EVANS 3D PRNT TI SM 17X6MM,SUP-2320322,CDM,C1713,HCPCS,0278,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
COMPONENT TIB SZ 2 THK19MM RT KNEE POLYETH NP CRUC RET PRI,SUP-2209428,CDM,C1776,CPT,0278,RC,,,,both,,,4143.23,2693.10,,,,,,,,,,,,,
COLLAR CERV PROGLIDE UNIV,SUP-2276573,CDM,L0172,HCPCS,0272,RC,,,,both,,,219.55,142.71,,,,,,,,,,,,,
HC Fluoro Exam Gtube Jtube,PX-3204946500,CDM,49465,CPT,0320,RC,,,,both,,,780.00,507.00,,,,,,,,,,,,,
SYSTEM DRAINAGE SFOR DRAINAGE,SUP-2666843,CDM,C1729,HCPCS,0272,RC,,,,both,,,589.54,383.20,,,,,,,,,,,,,
METHYLERGONOVINE MALEATE 0.2 MG PO TABS,RX-10572,CDM,6370000000,HCPCS,0637,RC,69238-1605-08,NDC,,both,1,UN,74.30,48.29,,,,,,,,,,,,,
GRAFT BNE SPACER 14X11.5X6 MM CERV CORTICAL LORDTC CESPACE,SUP-2108960,CDM,C1889,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
STIMULATOR NERVE CHARGER MOB EON,SUP-2355969,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
STAPLER INT CIR XLN MED THCK 25 MM 3/3.5/4 MM TRI-STAPLE EEA,SUP-2858015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4865.84,3162.80,,,,,,,,,,,,,
TRAY CATH 4FR SGL LUMN INTMED MIDLN PER-Q-CATH,SUP-2125574,CDM,C1751,HCPCS,0278,RC,,,,both,,,241.15,156.75,,,,,,,,,,,,,
HC Drug Assay Valproic Dipropylacetic Acid Total,PX-3018016400,CDM,80164,CPT,0301,RC,,,,both,,,520.00,338.00,,,,,,,,,,,,,
SCREW BNE L7MM DIA2MM CRANIOMAXILLOFACIAL TI SELF RET,SUP-2262833,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
PARACENTESIS TRAY PIG 8 FRX17 CM SLIP FIT CATH ONESTEP,SUP-2472400,CDM,C1729,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
CATHETER ANGIOPLSTY PFLX + L 80 CM BALLOON L 40 MM DIA 4 MM,SUP-2153810,CDM,C1725,HCPCS,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
NAIL IM L315MM DIA10MM NONSTERILE GRN TIB TI CANN LOK,SUP-2192798,CDM,C1713,HCPCS,0278,RC,,,,both,,,4071.61,2646.55,,,,,,,,,,,,,
CAGE SPNL LORDTC 14X12X48 MM CORPECTOMY,SUP-2435229,CDM,C1889,HCPCS,0278,RC,,,,both,,,10354.15,6730.20,,,,,,,,,,,,,
GLENOID AUGMENTED LARGE 15R,SUP-2751548,CDM,C1776,CPT,0278,RC,,,,both,,,9655.50,6276.07,,,,,,,,,,,,,
HC Chloride Urine,PX-3018243600,CDM,82436,CPT,0301,RC,,,,both,,,195.00,126.75,,,,,,,,,,,,,
SCREW CONN FEM TI NAIL STD INSRT AND LOK INSTR FOR HNDL,SUP-2188258,CDM,C1713,HCPCS,0278,RC,,,,both,,,2558.85,1663.25,,,,,,,,,,,,,
KIT BIOSURGE W/ 2.5CC ALLOSYNC PURE,SUP-2665302,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
SHEATH GUID 8FR L95CM HYDRPHLC COAT L60CM S STL COIL STR CRV,SUP-2384900,CDM,C1887,HCPCS,0272,RC,,,,both,,,424.37,275.84,,,,,,,,,,,,,
BONE GRAFT KIT COR DECOMPRESSION 15 CC INJ PRO-DENSE,SUP-2759602,CDM,C1713,HCPCS,0278,RC,,,,both,,,14090.15,9158.60,,,,,,,,,,,,,
PROSTHESIS PENILE PMP M ASMBLY TITAN TCH,SUP-2847985,CDM,C1813,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
GRAFT BONE L220-300MM OD6.5-8.5MM PERONEUS,SUP-2335255,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
INFUSION PUMP KIT PAINBUSTSTER 5 INX12.5 CM 270 CC ON-Q,SUP-2236833,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
GRAFT BONE SUB 5ML DEMIN MTRX SYR PUTTY TREL-XPRESS 300,SUP-2244480,CDM,C9359,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
BIT DRL L65MM DIA2.2MM 2IN1 AO DISP FOR HALLU-LOCK MTP ARTH,SUP-2243024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.70,482.10,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MMX13 CM MTCH HD LILAC STRL LTX,SUP-2859530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.05,368.58,,,,,,,,,,,,,
CATHETER CV 3L 6 FRX55 CM SAFETY INTRO NDL XCELA,SUP-2118819,CDM,C1751,HCPCS,0278,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
HC So Anaerobic Culture,PX-3008707566,CDM,87075,CPT,0300,RC,,,,both,,,50.00,32.50,,,,,,,,,,,,,
PLATE BNE 12 H NONSTERILE STRNL TI ANG LOK FOR 3MM SCR,SUP-2192443,CDM,C1713,HCPCS,0278,RC,,,,both,,,4120.31,2678.20,,,,,,,,,,,,,
ALLOGRAFT BNE 100-15 MM FRZN IRRADIATED HUM SHFT,SUP-2866869,CDM,C1762,CPT,0278,RC,,,,both,,,6001.80,3901.17,,,,,,,,,,,,,
PIN EXT FIX L 220 MM DIA 4 MM THRD L 55 MM HA HALF,SUP-2898497,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
SCREW BONE L55MM DIA6.5MM THRD L16MM STD CANC S STL LAG HEX,SUP-2344178,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.27,271.23,,,,,,,,,,,,,
SET INSTR IMPL SCR DIA4.5MM ORTH CANN,SUP-2183053,CDM,C1713,HCPCS,0278,RC,,,,both,,,43488.03,28267.22,,,,,,,,,,,,,
PLATE BNE L 241 MM SCREW DIA 3.5/4.5 MM 9 H LT TROCHANTERIC 72586109N,SUP-2933435,CDM,C1713,HCPCS,0278,RC,,,,both,,,21121.21,13728.79,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 22 MM 6 HOLE LP CONTOURED TI NS,SUP-2499636,CDM,C1713,HCPCS,0278,RC,,,,both,,,899.04,584.38,,,,,,,,,,,,,
PLATE BNE 110 DEG MED BAR MINI LT CRANIOMAXILLOFACIAL L SHP,SUP-2883157,CDM,C1713,HCPCS,0278,RC,,,,both,,,1502.58,976.68,,,,,,,,,,,,,
GRAFT HUM TISS W12XL12CM THK.9-1.99MM ACELLULAR DERM MTRX,SUP-2402515,CDM,Q4126,HCPCS,0636,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
SUTURE PASSER CAPFIX 70 DEG,SUP-2801015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.00,786.50,,,,,,,,,,,,,
HC So Vip(Vasoact.Intest.Polypept.),PX-3018458666,CDM,84586,CPT,0301,RC,,,,inpatient,,,2406.00,1563.90,,,,,,,,,,,,,
GUIDEWIRE SURG 320 MM TROCAR TIP SS IDENTITI,SUP-2544218,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
CATH GUIDE CPS LOCATOR MEDIUM EXTRA LONG 3D,SUP-2873675,CDM,C1887,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
GRAFT HUM TISS 40MG AMNIO MEM PARTICULATE DEHYDR AMNIOFIX,SUP-2305719,CDM,V2790,HCPCS,0274,RC,,,,both,,,2278.07,1480.75,,,,,,,,,,,,,
HC X-Ray Exam Uni Hip W/Pelvis 4/> Views,PX-3207350300,CDM,73503,CPT,0320,RC,,,,outpatient,,,128.00,83.20,,,,,,,,,,,,,
PLATE BNE L 203 MM SCREW DIA 3.5 MM 13 H SS PROX HUM STR,SUP-2932802,CDM,C1713,HCPCS,0278,RC,,,,both,,,8760.60,5694.39,,,,,,,,,,,,,
GRAFT BNE SUB 10CC VI DIA3MM CA SULF PELLET RESRB PRELD,SUP-2399038,CDM,C1713,HCPCS,0278,RC,,,,both,,,2165.69,1407.70,,,,,,,,,,,,,
GRAFT DERMAL FEN 2X2 CM CLLGN TISS MTRX,SUP-2243690,CDM,Q4110,HCPCS,0636,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE L 260 MM SCREW DIA 3.5 MM 20 SHFT H SS MTPHSEAL VA,SUP-2908069,CDM,C1713,HCPCS,0278,RC,,,,both,,,5075.75,3299.24,,,,,,,,,,,,,
LEAD PACE CAPSURFIX NOVUS MRI SURESCAN L 110 CM DIA 6 FR SIL,SUP-2281971,CDM,C1898,HCPCS,0275,RC,,,,both,,,1477.06,960.09,,,,,,,,,,,,,
SPACER SPNL OD22MM TI INTBDY FUS VLIFT,SUP-2362884,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ANCHOR SFT TISS L20MM OD6MM DISP GUN ECLIPSE,SUP-2277476,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 4.5 CM DIA23 MM SHTH 15 FR,SUP-2737994,CDM,C1768,CPT,0278,RC,,,,both,,,13162.88,8555.87,,,,,,,,,,,,,
SCREW BNE ST 2.7X20 MM MAND MINI PLATING CROSS PIN HD TI 5PK,SUP-2366183,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.40,147.81,,,,,,,,,,,,,
KIT ACP DOUBLE SYRINGE SERIES II WITH ALCOHOL PAD BAND AID FEMALE TO FEMALE LUER SIDE PINCH CLAMP STOP COCK TOURNIQUET ANGEL WING INFUSION SET CUP HYPODERMIC NEEDLE,SUP-2120723,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC So1 Factor XI,PX-3058527067,CDM,85270,CPT,0305,RC,,,,both,,,48.00,31.20,,,,,,,,,,,,,
CATHETER PTCA BLLN PERIPH OTW N COMPLIANT 10.0MM DIA 100MM,SUP-2117090,CDM,C1725,HCPCS,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
ADHESIVE SKIN CLOSURE 4X44 CM PREMIERPRO EXOFINFUSION DISP,SUP-2336222,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT HUM TISS CHORION FREE THN 4X2 CM AMNIO ACTISHIELD CF,SUP-2759477,CDM,C1762,CPT,0278,RC,,,,both,,,4355.18,2830.87,,,,,,,,,,,,,
IMPLANT SPNL L40MM DIA7MM SACROILIAC JT TI POR PLSM SPR,SUP-2421209,CDM,C1776,CPT,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
CLIP SURG L155CM CHN DIA2.8MM OPN W11IN RESOL 360 10/BX,SUP-2676488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
CATHETER GUID AXS CATLYST 7 L 132 CM PROX/DSTL OD,SUP-2715845,CDM,C1887,HCPCS,0272,RC,,,,both,,,6629.80,4309.37,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ATLS II HF THK 14 MM 30 J 41 CC 79 GM TI,SUP-2356591,CDM,C1882,HCPCS,0275,RC,,,,both,,,66725.00,43371.25,,,,,,,,,,,,,
STAPLE BNE COMPR 18 MM 15 MM CONT 2 LEG BME ELITE,SUP-2564467,CDM,C1713,HCPCS,0278,RC,,,,both,,,4052.55,2634.16,,,,,,,,,,,,,
TISSEEL VHSD 10 ML KT 1504516] BAXTER BIOSURGERY],SUP-2130320,CDM,C1713,HCPCS,0278,RC,,,,both,,,1363.48,886.26,,,,,,,,,,,,,
PLATE BONE L119MM 7 H STR SEMITUBULAR FOR 4.5MM,SUP-2343805,CDM,C1713,HCPCS,0278,RC,,,,both,,,639.62,415.75,,,,,,,,,,,,,
PLATE BONEXL L120MM HD W22MM 11 H RT DSTL VOLAR RAD TI NAR,SUP-2101272,CDM,C1713,HCPCS,0278,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
WIRE FIX L5IN DIA0035IN DBL END SPADE TIP,SUP-2166348,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.43,11.98,,,,,,,,,,,,,
BODY EXT FIX ARTICULATED FEMALE SELF ALIGNING SUPP PROCALLUS,SUP-2645902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4534.22,2947.24,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN L10CM DIA3MM J TIP PTFE,SUP-2142708,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.42,23.67,,,,,,,,,,,,,
BLADE SURG SAW GRFT HARV ST S STL ACL 20MM LEN 10MM W .4MM,SUP-2236517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC PRE-MIXED MOLD SYR DBM PUROS LF,SUP-2205389,CDM,C1734,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
STENT URET 0.038 IN 8 FRX26 CM 6 FR FLX FIRM PERCFLX +,SUP-2464911,CDM,C2617,HCPCS,0278,RC,,,,both,,,526.04,341.93,,,,,,,,,,,,,
PLATE BONE TUBULAR 61 MM 5 HOLE 1/3 WITH COLLAR STERILE TC10,SUP-2836663,CDM,C1713,HCPCS,0278,RC,,,,both,,,642.66,417.73,,,,,,,,,,,,,
PLATE BNE L71MM 4 H ST R DST LAT FIBULAR VAR ANG LOK FOR,SUP-2349838,CDM,C1713,HCPCS,0278,RC,,,,both,,,5512.90,3583.38,,,,,,,,,,,,,
SCREW BNE CHAMFERED 4.5X45 MM SLD COR TI ORTHOLOC 2,SUP-2539833,CDM,C1713,HCPCS,0278,RC,,,,both,,,3755.44,2441.04,,,,,,,,,,,,,
SCREW BONE L100MM D13MM 145DG CNCLLS HIP TTNM SELF TPPNG NNL,SUP-2482156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
HC Bil Niv Arterial Upp Ext Duplex,PX-9219393000,CDM,93930,CPT,0921,RC,,,,both,,,1661.00,1079.65,,,,,,,,,,,,,
MESH HERN 20X15 CM COMP PARIETEX,SUP-2174713,CDM,C1781,HCPCS,0278,RC,,,,both,,,2477.49,1610.37,,,,,,,,,,,,,
WAND ABLAT R ANG 90DEG W/O SUCT 3.5MM,SUP-2341957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
BODY HUM TI6AL4V RVS PROX ELECTIVE ZERO OFFSET LCK SCR FOR,SUP-2265034,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ALLOGRAFT TISS DEHYDR 2X3 CM AMNIO MEMBRN AMBIO2,SUP-2242545,CDM,V2790,HCPCS,0274,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-102357,CDM,2500000003,HCPCS,0250,RC,00264-7645-00,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
LEAD DEFIB EPSILA EV MRI SURESCAN L 63 CM SUBSTERNAL QPLR,SUP-2891572,CDM,C1896,HCPCS,0275,RC,,,,both,,,16924.60,11000.99,,,,,,,,,,,,,
STYLET NRV STIM KT 50CM W STEERING CAP,SUP-2138820,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
PLATE BONE LT DSTL RAD W,SUP-2136554,CDM,C1713,HCPCS,0278,RC,,,,both,,,619.21,402.49,,,,,,,,,,,,,
SPACER SPNL W10XH11XL11MM PEEK CERV INTBDY FUS TANT MRK,SUP-2278919,CDM,C1889,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
PLATE BNE L155MM 9 H ST R DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177217,CDM,C1713,HCPCS,0278,RC,,,,both,,,4793.62,3115.85,,,,,,,,,,,,,
SCREW BONE L46MM DIA5MM L HDLSS COMPR FULL THRD,SUP-2122563,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
GRAFT BNE SUB 5ML DBM HA PTTY W/ GRAN BONUS SYN RESRB,SUP-2402609,CDM,C1713,HCPCS,0278,RC,,,,both,,,3180.82,2067.53,,,,,,,,,,,,,
BIT DRL L400MM DIA25MM W O STP CALIB JCBS CHK,SUP-2188815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1527.33,992.76,,,,,,,,,,,,,
RELOAD STPL 35MM THN VASC TISS WHT,SUP-2283262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1624.86,1056.16,,,,,,,,,,,,,
ALLOGRAFT BNE 2 CC VIABLE BNE MTRX VIBONE,SUP-2731786,CDM,C1762,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
BUTTON SUTURE 10X5 MM TISSUE STERILE,SUP-2836436,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
GRAFT WND BURN 7X10 CM FEN EXTRACELLULAR MTRX MATRISTEM,SUP-2106463,CDM,Q4166,HCPCS,0636,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
KIT GUIDEWIRE DIA 0.096 IN CORONARY ROTATING HEMOSTATIC VLV,SUP-2101941,CDM,C1769,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0258,RC,00264-7520-00,NDC,,both,125,ML,6.40,4.16,,,,,,,,,,,,,
SCREW BNE DRILL-FREE MIC 1.5X4 MM STRL MAXDRIVE LEVEL1 NEURO,SUP-2540267,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.99,130.64,,,,,,,,,,,,,
CARTRIDGE BONE TUNN L22MM L CURVTEK,SUP-2137206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2097.52,1363.39,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.6MM THRD FOR PEDILOC LCK PROX FEM PLT,SUP-2318865,CDM,C1769,HCPCS,0272,RC,,,,both,,,732.25,475.96,,,,,,,,,,,,,
PLATE SPNL L35MM SPINOUS PROC LCK SP-FIX,SUP-2230593,CDM,C1713,HCPCS,0278,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST CABLE DRIVEN FABRICATED,SUP-2435770,CDM,L3901,HCPCS,0272,RC,,,,both,,,5470.16,3555.60,,,,,,,,,,,,,
CATHETER IV DL 5 FR DOT KT MBP BIOP PC POWERMIDLINE,SUP-2626739,CDM,C1751,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
STENT URET 2 FLX 038 7 FRX30 CM PGTL SENSOR POLARIS ULTRA,SUP-2754252,CDM,C2617,HCPCS,0278,RC,,,,both,,,617.36,401.28,,,,,,,,,,,,,
SEALER BPLR DIA6.0MM DISP AQUAMANTYS,SUP-2281802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ELECTRODE KIT RF 2.5X10 CM COOL TIP,SUP-2174637,CDM,C1733,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BIT DRL L170MM DIA3.2MM CANN QUIK CPL ADJ STP REUSE FOR,SUP-2187331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1039.25,675.51,,,,,,,,,,,,,
PLATE BONE FAN 44.6X1.5 MM REINFORCED POROUS POLYETHYLENE TI,SUP-2837805,CDM,C1713,HCPCS,0278,RC,,,,both,,,4804.83,3123.14,,,,,,,,,,,,,
EPINEPHRINE 1 MG/ML IJ SOLN (MIXTURES ONLY),RX-430031,CDM,J0169,HCPCS,0636,RC,42023-0159-25,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
PROXILOCK COCR BEAD STEM 10MM 01-230-10241,SUP-2198963,CDM,C1776,CPT,0278,RC,,,,both,,,15051.90,9783.73,,,,,,,,,,,,,
KIT INTRO INTDYN TEARWY L 14 CM DIA12 FR GUIDEWIRE 0.038 IN,SUP-2125218,CDM,C1892,HCPCS,0272,RC,,,,both,,,165.35,107.48,,,,,,,,,,,,,
TIP ASPIR L4.78IN DIA0.06IN SUCT EXT FLUE CRV DISP CUSA,SUP-2243959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2259.98,1468.99,,,,,,,,,,,,,
PLATE BNE L 46 X W 9 MM THK 1.1 MM SCREW DIA 3.5 MM 4 H SS,SUP-2932906,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.87,220.27,,,,,,,,,,,,,
BEAM FIX L85MM DIA5.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223940,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
PLATE BNE 2.7X90 MM 10 HOLE SS LCP,SUP-2569311,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.57,264.92,,,,,,,,,,,,,
LENS INTOCU +40.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111100,CDM,V2632,HCPCS,0276,RC,,,,both,,,395.51,257.08,,,,,,,,,,,,,
COLLAR CERV PD REG INF BK PANEL REPL,SUP-2124226,CDM,L0174,HCPCS,0272,RC,,,,both,,,56.14,36.49,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND C7 DRAGONFLY L 135 CM DIA2.7 FR,SUP-2356657,CDM,C1753,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
RIB PLATE 10MMX61MM,SUP-2841909,CDM,C1713,HCPCS,0278,RC,,,,both,,,3739.74,2430.83,,,,,,,,,,,,,
ANCHOR SUTURE DIA 5.5 MM SZ 2 PEEK 3 STRND FORC FIBER,SUP-2882666,CDM,C1713,HCPCS,0278,RC,,,,both,,,2530.84,1645.05,,,,,,,,,,,,,
SINCALIDE 5 MCG IJ SOLR,RX-11368,CDM,J2805,HCPCS,0636,RC,72266-0248-01,NDC,,both,1,UN,785.70,510.70,,,,,,,,,,,,,
ENDPLATE SPNL DISK H6MM 13X14MM FOOTPRINT 6DEG CO CHROM,SUP-2420862,CDM,C1713,HCPCS,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
NEEDLE INJ FLX 6 FRX50 CM,SUP-2767913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,889.47,578.16,,,,,,,,,,,,,
PLATE CRAN DIA18.5 MM THK 0.5 MM SCREW DIA1.5 MM TI SHUNT NS,SUP-2935839,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 3X8 CM UMB CRD RESTORIGIN,SUP-2321895,CDM,Q4191,HCPCS,0636,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
FOOTRING EXT FIX TY SHT,SUP-2461213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8607.37,5594.79,,,,,,,,,,,,,
VALVE AORT ON-X TISS ANNULUS 25 MM ORIFICE 23.4 MM STD,SUP-2484841,CDM,C1713,HCPCS,0278,RC,,,,both,,,15696.86,10202.96,,,,,,,,,,,,,
CUP ACET DIA52MM R HIP X3 MOB BEAR FOR RESTR ADM,SUP-2368461,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN IRRADIATED PRECUT ACHILLES TEND,SUP-2867185,CDM,C1762,CPT,0278,RC,,,,both,,,6577.52,4275.39,,,,,,,,,,,,,
BLADE OSTEO LNG 2015] UNIVERSAL MEDICAL INC],SUP-2391404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn,PX-3606444600,CDM,64446,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
PLATE BONE DIA100MM NONSTERILE CRAN TI RND CNTOUR MESH RIG,SUP-2190641,CDM,C1713,HCPCS,0278,RC,,,,both,,,7444.94,4839.21,,,,,,,,,,,,,
SEGMENT FEM OD23MM 5DEG SM TRAPEZOIDAL FLARE COMP SCR FORGED,SUP-2222175,CDM,C1776,CPT,0278,RC,,,,both,,,6004.94,3903.21,,,,,,,,,,,,,
GUIDEWIRE STRL DISP STD STR TIP NO TORQ VISE,SUP-2166103,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HANDPIECE ABLAT BPLR DISP FOR ATRICURE ABLAT UNIT L5.0CM,SUP-2124457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6670.71,4335.96,,,,,,,,,,,,,
CANNULA SPNL SCREW CARBON FIBER PEDCL FOR FEN PEDCL SCREW,SUP-2883066,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BONE 1 MM MEDIAL WALL RIGHT TITANIUM NON STERILE,SUP-2838345,CDM,C1713,HCPCS,0278,RC,,,,both,,,4923.52,3200.29,,,,,,,,,,,,,
WIRE BNE FIX L 152 MM DIA1.4 MM NS LEOS KIRSCHNER,SUP-2933468,CDM,C1713,HCPCS,0278,RC,,,,both,,,104.56,67.96,,,,,,,,,,,,,
MANAGER PERS PAIN THER COMM HANDSET PROGRAMMABLE PROXIMITY,SUP-2284697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
HC Spinal Puncture Lumbar Diagnos,PX-4506227000,CDM,62270,CPT,0450,RC,,,,outpatient,,,2232.00,1450.80,,,,,,,,,,,,,
PLATE BNE 8 HOLE 0.5 MM ADAPTATION 1.3 MM SCR MATRIXMIDFACE,SUP-2776727,CDM,C1713,HCPCS,0278,RC,,,,both,,,7634.72,4962.57,,,,,,,,,,,,,
SCREW BNE ST 4.5X18 MM CRTX,SUP-2364654,CDM,C1713,HCPCS,0278,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
CLIP INT USE L 50 X W 8.1 X H 11 OPENING 23.2 MM PEEK NIT,SUP-2890345,CDM,C1889,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 4 ML STR W/ BFD OSSEOFLEX SB OCP0014,SUP-2516664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5353.70,3479.90,,,,,,,,,,,,,
GRAFT HUM TISS W3XL3CM COMP AMNIO MEM MTRX SHT AMNIOFIX,SUP-2305707,CDM,V2790,HCPCS,0278,RC,,,,both,,,4600.10,2990.06,,,,,,,,,,,,,
NAIL IM 10X300 MM LT TIBIOTALOCALCANEAL PHANTOM P31300300LS,SUP-2743195,CDM,C1713,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
DRESSING WND THERAGENESIS MESHED BILYR MATRIX 8.2X9CM,SUP-2755311,CDM,A2008,HCPCS,0636,RC,,,,both,,,9231.60,6000.54,,,,,,,,,,,,,
PLATE BNE CNDYL 285 MM 13 HOLE BUTTRESS TI NS LC-DCP,SUP-2569065,CDM,C1713,HCPCS,0278,RC,,,,both,,,4866.94,3163.51,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X50X3-6 MM SPNG FD CANC,SUP-2717784,CDM,C1713,HCPCS,0278,RC,,,,both,,,4862.79,3160.81,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.109X9 IN RND END SS NS STEINMANN,SUP-2791602,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.86,10.96,,,,,,,,,,,,,
CONNECTOR SPNL L19MM OPN LAT RECON VERTEX,SUP-2279736,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
IMMUNE GLOBULIN (FLEBOGAMMA) 10%|DISCARDED DRUG NOT ADMINISTE,RX-4081761,CDM,J1459,HCPCS,0636,RC,44206-0438-20,NDC,JW,both,200,ML,11319.80,7357.87,,,,,,,,,,,,,
CATHETERIZATION KIT 4 FRX8 CM CV BLU FLEXTIP,SUP-2120587,CDM,C1751,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
BLADE SAW NAR FOR STRYKR SYS 6 PROPHECY INBONE,SUP-2397083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
TUBE VENT POPE 1.14 MM 1 MM 2.5X3.5 MM SIL STRL,SUP-2535109,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.64,27.72,,,,,,,,,,,,,
ASCORBIC ACID 500 MG PO TABS,RX-664,CDM,6370000000,HCPCS,0637,RC,68094-0113-59,NDC,,both,1,UN,1.80,1.17,,,,,,,,,,,,,
OXYGENATOR PERFSN 215 ML BIOLINE COAT AD DIFFUS MEMBRN SCREW,SUP-2908605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4632.54,3011.15,,,,,,,,,,,,,
HOOK RETRCT GREENBERG LK BRAINPATH SHEPHARD'S SELECT-LOCK,SUP-2930216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.18,309.52,,,,,,,,,,,,,
STEM FEM SEG 3 CM DPHSEAL KNEE POROUS OSS,SUP-2449780,CDM,C1776,CPT,0278,RC,,,,both,,,13995.77,9097.25,,,,,,,,,,,,,
BUTTON SUTURE DIA11 MM SLT CONCV RND STRL PROCINCH,SUP-2908580,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 6H 107MM RIGHT-STER,SUP-2549542,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.04,2254.88,,,,,,,,,,,,,
CATHETER ASPIR MILLIPEDE 070 HYDRPHLC 1 LUMEN VAR STIFFNESS,SUP-2929969,CDM,C1757,HCPCS,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
STENT ENDOPROS TOT CVR L200MM PROX DIA38MM DST DIA38MM CATH,SUP-2298542,CDM,C1768,CPT,0278,RC,,,,both,,,61214.30,39789.29,,,,,,,,,,,,,
RING EXT FIX DIA130 MM ACCSRY SINGLE ROW 2/3 NS DISP TSF,SUP-2933055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5345.76,3474.74,,,,,,,,,,,,,
ARM EXT FIX VERTICLE ADJ 20 MM TUBE LEFORT 1 BUTTRESS,SUP-2497331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6228.63,4048.61,,,,,,,,,,,,,
STAPLE SPNL SINGLE 17 MM CD HORZ,SUP-2630059,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 55CM 5 FR 0.035 IN PTFE AQ STR,SUP-2171143,CDM,C1894,HCPCS,0272,RC,,,,both,,,167.52,108.89,,,,,,,,,,,,,
SCREW BNE L8MM DIA27MM MTPHSEAL TAN ST LO PROF COMPR T8,SUP-2180925,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.19,85.27,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 19CM 2,SUP-2613284,CDM,C1750,HCPCS,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 4 FRX45 CM 21 GAX7 CM MINI STK II,SUP-2118825,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
RING EXT FIX ID160MM ANK FT HALF FOR TRUELOK FRME ASSEMB,SUP-2316178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1651.95,1073.77,,,,,,,,,,,,,
COLLAR CERV X TALL AD 2 PC ATLS,SUP-2319264,CDM,L0172,HCPCS,0272,RC,,,,both,,,56.11,36.47,,,,,,,,,,,,,
MESH COMPOSIX LP ELP 7.2 IN X 9.2 IN W/ INTRO,SUP-2125817,CDM,C1781,HCPCS,0278,RC,,,,both,,,2891.00,1879.15,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 15 CC FD IRRADIATED CANC,SUP-2867068,CDM,C1762,CPT,0278,RC,,,,both,,,912.80,593.32,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM NONLOCKING MOTOBAND CP,SUP-2175154,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
NAIL IM L380MM DIA8.2MM BLU L FEM TI CANN LOK BEND FOR,SUP-2180349,CDM,C1713,HCPCS,0278,RC,,,,both,,,4180.91,2717.59,,,,,,,,,,,,,
SCREW PACK,SUP-2267684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PATCH BIO TISS W12XL25CM BOV PERICARD,SUP-2130369,CDM,C1768,CPT,0278,RC,,,,both,,,3073.62,1997.85,,,,,,,,,,,,,
GRAFT BNE W22XL38MM THK8/10/12X3.5MM CANC FULL EVANS WDG,SUP-2399093,CDM,C1713,HCPCS,0278,RC,,,,both,,,5388.24,3502.36,,,,,,,,,,,,,
FLUOROMETHOLONE 0.25 % OP SUSP,RX-19722,CDM,6370000000,HCPCS,0637,RC,11980-0228-05,NDC,,both,5,ML,757.90,492.63,,,,,,,,,,,,,
STEM FEM HI OFFSET EF MAG NK W/ TRUNNION ARCOS,SUP-2443223,CDM,C1776,CPT,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
BLADE SAW SAGITTAL MICRO W/O HOSE HALL STERILE,SUP-2605429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6678.78,4341.21,,,,,,,,,,,,,
BIT DRL KT 3.2X200 MM CANN DYN AX FIX 1.8 MM HOLE,SUP-2644556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.68,339.74,,,,,,,,,,,,,
KIT SURGICAL PROCEDURE QUADRICEP TEND HARV GUIDE QUADTRAC,SUP-2880214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SCREW CONN FEM TI NAIL CANN FOR PERC INSRTN HNDL,SUP-2178846,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM SHT THRD HD MINI-MONSTER,SUP-2320504,CDM,C1713,HCPCS,0278,RC,,,,both,,,718.28,466.88,,,,,,,,,,,,,
SCREW BNE HDLSS 7.2X50 MM CALCANEUS HINDFOOT NAIL NS PHANTOM,SUP-2749660,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
FORCEPS LUM L5.5IN BITE 2MM MIC SGL TOOTH CUP WLLMS,SUP-2257133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
KIT NEUROSTIM LD SPNL BOOT ANCHR FOR INTERSTIM SPNL CRD,SUP-2284433,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW SKULL REF L 6 MM DIA1.5 MM BNE FIX NS DISP,SUP-2910346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BASKET STONE REMV L115CM OPN W10MM CHN SZ 1.2MM 3 NAIL DISP,SUP-2313150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
TROCAR LAP OD7X8MM BLDELSS CANN DIL RADIALLY EXP SL REDUC,SUP-2283299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.90,254.08,,,,,,,,,,,,,
CATHETER PERITONEAL L 39 CM PED TENCK CURL 1 CUF STRL ARGY,SUP-2905038,CDM,C1750,HCPCS,0278,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
GRAFT BNE 3D 30 CC CORTICAL FIBER,SUP-2125433,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
BURR DIAMOND BALL COURSE XLONG 5.5MM,SUP-2843323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.07,315.30,,,,,,,,,,,,,
HC Surgery Level 3 Base,PX-3600000003,CDM,3600000003,LOCAL,0360,RC,,,,both,,,5325.00,3461.25,,,,,,,,,,,,,
PLATE BNE STR MINI XLN 4 HOLE W/ BREAK-AWAY TAB TI,SUP-2469478,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.90,590.13,,,,,,,,,,,,,
PIN DRL DIA4MM ACL KNEE OPN EYELET TIGHTROPE AR1595T] ARTHREX INC],SUP-2121410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PROSTHESIS VOICE 12 MM LO PRESSURE KT,SUP-2246405,CDM,L8509,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
HALF RING W/CVD EXTR 150,SUP-2820645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11086.71,7206.36,,,,,,,,,,,,,
PLATE BONE SINUS TARSI CALCANEUS LEFT TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878285,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
CATHETER DIAG AD 6FR L55CM 0.07IN BLU S STL PTFE NYL,SUP-2158180,CDM,C1887,HCPCS,0272,RC,,,,both,,,257.17,167.16,,,,,,,,,,,,,
PLATE BNE L229MM 15 H ST R LAT DST FIBULAR S STL LOK COMPR,SUP-2177430,CDM,C1713,HCPCS,0278,RC,,,,both,,,2231.82,1450.68,,,,,,,,,,,,,
HEAD HUM H15MM OD44MM CO CHROM SHLDR EXT ARTC SURF OFFSET,SUP-2404688,CDM,C1776,CPT,0278,RC,,,,both,,,5347.42,3475.82,,,,,,,,,,,,,
ALLOGRAFT BNE STRP FD IRRADIATED IL CREST,SUP-2867216,CDM,C1762,CPT,0278,RC,,,,both,,,8671.58,5636.53,,,,,,,,,,,,,
PLATE BONE LOK 145MML HLX18 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2723637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1804.68,1173.04,,,,,,,,,,,,,
CATHETER BLLN DIL 0.035 IN 75 CM 8-10 MMX3 CM CRE,SUP-2141508,CDM,C1726,HCPCS,0272,RC,,,,both,,,953.99,620.09,,,,,,,,,,,,,
STEM FEM L250MM L35MM OD165MM SZ 9 R HIP REV CEM BOW IMPL,SUP-2374705,CDM,C1776,CPT,0278,RC,,,,both,,,13172.93,8562.40,,,,,,,,,,,,,
HC Comprehensive Metabolic Panel,PX-3018005300,CDM,80053,CPT,0301,RC,,,,both,,,380.00,247.00,,,,,,,,,,,,,
PIN FXTN L275MM D5MM THRD L6MM BLACK HALF SIZE EXTRNL FXTN X,SUP-2501112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.53,356.54,,,,,,,,,,,,,
GRAFT VASC L80CM L30CM ID6MM THN WALLED REM RNGD,SUP-2396118,CDM,C1768,CPT,0278,RC,,,,both,,,3193.38,2075.70,,,,,,,,,,,,,
PLATE OMEGA3 STABILIZING 135 DEG 4 HOLE,SUP-2704777,CDM,C1713,HCPCS,0278,RC,,,,both,,,3122.73,2029.77,,,,,,,,,,,,,
PROBE ARTHSCP L220MM 60DEG MEAS FOR SUP CAPSULAR RECON,SUP-2121825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HEAD HUM H15MM OD42MM CO CHROM MOLYBDENUM SHLDR STD PRI,SUP-2204829,CDM,C1776,CPT,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0035IN TAPR L6CM S STL PTFE FIX COR,SUP-2167684,CDM,C1769,HCPCS,0272,RC,,,,both,,,60.88,39.57,,,,,,,,,,,,,
PLATE BNE BRIM W 10.5 MM THK 2.5 MM H SPC 12 MM 12 H SCREW,SUP-2902375,CDM,C1713,HCPCS,0278,RC,,,,both,,,5740.55,3731.36,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 9.6 FRX75 CM STD PROF PLAS,SUP-2126166,CDM,C1788,HCPCS,0278,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED MED 8 IN LT WRST FOREARM THMB,SUP-2276633,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.58,14.68,,,,,,,,,,,,,
SET PROC HYDROTHERMABLATOR STRL SGL,SUP-2140173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
MESH CRAN L 75.18 X W 30.2 MM THK 0.3 MM SCREW DIA1.5 MM MED,SUP-2936686,CDM,C1713,HCPCS,0278,RC,,,,both,,,3432.02,2230.81,,,,,,,,,,,,,
EXTRACTOR STONE 15MMX200CM ABV INFL TO 8.5MM 12MM CLR CONN,SUP-2170078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
DRILL SURG FLX 8.5 MM CANN ANAT CRUCIATED GUIDE SYS CLANCY,SUP-2849155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3377.38,2195.30,,,,,,,,,,,,,
KIT SEEDNET INDIV ICE ROD NDL,SUP-2225990,CDM,C2618,HCPCS,0272,RC,,,,both,,,4702.15,3056.40,,,,,,,,,,,,,
CATHETER INFUSION CLEARWAY L 90 CM BALLOON L 50 MM DIA 5 MM,SUP-2227486,CDM,C1725,HCPCS,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
EXTRACTOR STONE 7FRX65CM CATH 4CMX6MM BAL TIP LEN 5CM HELCL,SUP-2171198,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.72,505.52,,,,,,,,,,,,,
KIT EXT REAR TIP PENILE PROS SNAPCONE,SUP-2138944,CDM,C1813,HCPCS,0278,RC,,,,both,,,1254.43,815.38,,,,,,,,,,,,,
HC So B Cell Total,PX-3028635566,CDM,86355,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
FORCEP GRASPING HK 3 MM 3 PRNG,SUP-2141711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BASEPLATE TIB SZ 1 LT KNEE NP REV CEM STEM MOD FOUNDATION,SUP-2215782,CDM,C1776,CPT,0278,RC,,,,both,,,6893.43,4480.73,,,,,,,,,,,,,
DEFIBRILLATOR CARD SGL CHMBR CARDIOVERTER STD BPLR REMOT MON,SUP-2236358,CDM,C1722,HCPCS,0275,RC,,,,both,,,83586.80,54331.42,,,,,,,,,,,,,
GRAFT HUM TISS W27-32XH11XL21-26MM POR CANC ANTR LUM INTBDY,SUP-2306951,CDM,C1713,HCPCS,0278,RC,,,,both,,,15292.08,9939.85,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.3MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189000,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.23,141.85,,,,,,,,,,,,,
HC So Hla I Typing 1 Antigen Lr,PX-3108137466,CDM,81374,CPT,0310,RC,,,,inpatient,,,153.00,99.45,,,,,,,,,,,,,
RHS RADIAMETERL HEAD DIAMETER 24MM,SUP-2830221,CDM,C1776,CPT,0278,RC,,,,both,,,4813.62,3128.85,,,,,,,,,,,,,
SAW SURGICAL OSCILLATING PNEUMATIC POWERPRO HALL,SUP-2586416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11503.39,7477.20,,,,,,,,,,,,,
MESH MIDFACIAL CUSTOMIZED PRIORITY RECON MEDPOR LTX,SUP-2862754,CDM,C1713,HCPCS,0278,RC,,,,both,,,57589.20,37432.98,,,,,,,,,,,,,
PAD ORTHOT THOR CUST,SUP-2435576,CDM,L1060,HCPCS,0272,RC,,,,both,,,306.62,199.30,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CA PHSPTE HA PTTY INJ HYDROSET,SUP-2366073,CDM,C1713,HCPCS,0278,RC,,,,both,,,14460.64,9399.42,,,,,,,,,,,,,
K WIRE FIX L6IN DIA0.062IN 1600662],SUP-2304025,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.20,10.53,,,,,,,,,,,,,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,6370000000,HCPCS,0637,RC,45802-0048-35,NDC,,both,15,GR,63.00,40.95,,,,,,,,,,,,,
BUR SURG OD6MM FLUT RND SFT TCH,SUP-2367565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.86,388.61,,,,,,,,,,,,,
PIN FIX HDLSS 1/8X4 IN,SUP-2361950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
CATHETER VENTRICULAR SM 12X21 MMX23 CM STD RT ANGLE OPUS PS,SUP-2284504,CDM,C1713,HCPCS,0278,RC,,,,both,,,446.19,290.02,,,,,,,,,,,,,
EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN,RX-140028,CDM,J0169,HCPCS,0636,RC,42023-0159-01,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE L148MM 10 H LT ANTEROLATERAL MEDL DSTL TIB LCK,SUP-2348479,CDM,C1713,HCPCS,0278,RC,,,,both,,,17147.85,11146.10,,,,,,,,,,,,,
TRAY PROC CHOLE,SUP-2219052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.90,420.48,,,,,,,,,,,,,
BRACE KNEE XL L17 27IN FOR 355IN THGH UNIV POSTOP TELSCP,SUP-2151049,CDM,L1832,HCPCS,0272,RC,,,,both,,,294.69,191.55,,,,,,,,,,,,,
AMOXICILLIN 250 MG/5ML PO SUSR,RX-454,CDM,340b,HCPCS,0637,RC,65862-0707-01,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
PERFORATOR SURG CRAN DISP 9MM DIA 14MM LEN DGR-II,SUP-2106558,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
INQUIRY 7F 1120 7 2 10 XXL,SUP-2698829,CDM,C1731,HCPCS,0278,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
CATHETER URTRL DLTN 58FR DIA 7MM OD BLLN 21FR DIA INFLTD 75,SUP-2724143,CDM,C1726,HCPCS,0272,RC,,,,both,,,864.54,561.95,,,,,,,,,,,,,
FIBER LASER 328 FT KRA-CPAOCHXL HDMI,SUP-2798106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2709.73,1761.32,,,,,,,,,,,,,
PLATE BONE THK1.6MM 16 H MAND TI STR FOR 2/2.3MM SCR,SUP-2136792,CDM,C1713,HCPCS,0278,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 18 FRX30 CM 1.2 CM STOMA LP AMT G-JET,SUP-2424373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1527.61,992.95,,,,,,,,,,,,,
MESH CRAN 135X90 MM 0.6 MM PLATE PROF PANEL OBLONG CP TI,SUP-2488057,CDM,C1713,HCPCS,0278,RC,,,,both,,,5510.57,3581.87,,,,,,,,,,,,,
TRIAL NK 25MM 127 DEG FEM C TAPR,SUP-2375985,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0035IN HI PERF HYDR JAGWIRE,SUP-2141528,CDM,C1769,HCPCS,0272,RC,,,,both,,,521.52,338.99,,,,,,,,,,,,,
INSERT TIB 12MM THCK SM ARTC UNI UHMWPE MOB BEAR RT MEDL LT,SUP-2136599,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BIT DRL DIA43MM LNG 2IN1 AO FOR HALLU LOCK MTP ARTH SYS,SUP-2242918,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.59,565.23,,,,,,,,,,,,,
GUIDE WIRE P4440-WG00,SUP-2752264,CDM,C1769,HCPCS,0272,RC,,,,both,,,1545.67,1004.69,,,,,,,,,,,,,
SCREW BNE CANN 3.5X32 MM HDLSS,SUP-2221505,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
PLATE BNE T MED 1.5X27X0.8 MM MIDFACE 8 HOLE W/ TAB TI NS,SUP-2469381,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.48,507.96,,,,,,,,,,,,,
PACK FIXATION LAPIPLASTY LESSER TMT,SUP-2652625,CDM,C1713,HCPCS,0278,RC,,,,both,,,5827.84,3788.10,,,,,,,,,,,,,
PLATE BNE STR 0.8 MM 6 HOLE,SUP-2262685,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.47,314.26,,,,,,,,,,,,,
SCREW BNE L12MM OD2.7MM THRD L6MM TI BRK OFF MONSTER BITE,SUP-2321001,CDM,C1713,HCPCS,0278,RC,,,,both,,,855.02,555.76,,,,,,,,,,,,,
GUIDEWIRE 11X120MM TRCR TIP PLN,SUP-2243904,CDM,C1769,HCPCS,0272,RC,,,,both,,,98.09,63.76,,,,,,,,,,,,,
ENDPLATE SPNL SM W19XL20MM 0DEG ANTR THORLUM TI SYNEX-II,SUP-2182821,CDM,C1713,HCPCS,0278,RC,,,,both,,,3329.03,2163.87,,,,,,,,,,,,,
SD BLADE XD 25 402 99 1.0MM SYSTEM,SUP-2667829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,613.30,398.64,,,,,,,,,,,,,
SCALPEL SRGCL SMLLIE 6 14NL MNSCS CRVD RIGHT ULTRA INSTR LA,SUP-2675393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,227.30,147.74,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.6MM FOR HALLU-LOCK MTP ARTH SYS K,SUP-2242885,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.93,87.70,,,,,,,,,,,,,
HC Before / After Bronchodilator,PX-4609406000,CDM,94060,CPT,0460,RC,,,,inpatient,,,569.00,369.85,,,,,,,,,,,,,
CATHETER DRNGE 30FR 3CM RETEN HD TWO EYE REINF TIP PEZZERS,SUP-2128986,CDM,C1729,HCPCS,0272,RC,,,,both,,,63.18,41.07,,,,,,,,,,,,,
STRUT SPNL CNTR IMPL ENCLAVE ANTR SPNL SYS,SUP-2205466,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR PRSS FT ADD ON,SUP-2212517,CDM,C1776,CPT,0278,RC,,,,both,,,3557.62,2312.45,,,,,,,,,,,,,
GRAFT EVAR L5X2CM ID8-10MM INTRO SHTH 10FR 0.035IN VIATORR,SUP-2395926,CDM,C1874,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
PLATE BNE FIBULAR 6 HOLE STR HK BABY GORILLA,SUP-2751151,CDM,C1713,HCPCS,0278,RC,,,,both,,,3100.75,2015.49,,,,,,,,,,,,,
PEG BONE FIX 15MM ACET REFECTION,SUP-2351123,CDM,C1776,CPT,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST W/ADJACENT JT ROT CNTRL MOLD,SUP-2435613,CDM,L1844,LOCAL,0272,RC,,,,both,,,4311.38,2802.40,,,,,,,,,,,,,
CUP ACET FULL PROF 36 MM TST,SUP-2448564,CDM,C1776,CPT,0278,RC,,,,both,,,98.91,64.29,,,,,,,,,,,,,
HC Dilate Nephrost Ureter Urethra,PX-3207448500,CDM,74485,CPT,0320,RC,,,,inpatient,,,1668.00,1084.20,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4409753000,CDM,97530,CPT,0440,RC,,,KX|CO,both,,,191.00,124.15,,,,,,,,,,,,,
TRIAL HD 1 SHLDR RVS COMPHSVE,SUP-2441591,CDM,C1776,CPT,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
DILATOR BAL DEV BILI QNT 10MMX3CMX180CM,SUP-2169435,CDM,C1726,HCPCS,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH BSC 4FR 0.034IN 60CM 1 LU 9154105,SUP-2632690,CDM,C1751,HCPCS,0278,RC,,,,both,,,330.01,214.51,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X40X2 MM FD SPNG CANC READIGRAFT BLX,SUP-2740883,CDM,C1713,HCPCS,0278,RC,,,,both,,,1439.09,935.41,,,,,,,,,,,,,
SIZER SURG GEL 6.7 CM PROJCT 14.5 CM 725 CC RND MEMORYGEL,SUP-2758680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GRAFT VASC L200MM DIA6MM UNIV PTFE STR STD WALL NONTAPERED,SUP-2395722,CDM,C1768,CPT,0278,RC,,,,both,,,2562.24,1665.46,,,,,,,,,,,,,
SET INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 9 FR GUIDEWIRE L,SUP-2383328,CDM,C1894,HCPCS,0272,RC,,,,both,,,190.76,123.99,,,,,,,,,,,,,
BRACE THORACOLUMBOSACRAL SM LTX W ADD STRP VELC CLSR E ANT,SUP-2195549,CDM,L0650,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TI MAXILLARY FOOTPLATE,SUP-2823036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1762.80,1145.82,,,,,,,,,,,,,
BOLT MODULUS ALIF 5.0X17.5MM FIX 2PK,SUP-2880400,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
TEMPLATE SKIN GRFT L 2 X W 2 IN OUTER SIL FLM INNR CROSS,SUP-2909177,CDM,Q4105,HCPCS,0636,RC,,,,both,,,8846.42,5750.17,,,,,,,,,,,,,
FIBER LASER L12FT DIA0.6MM SMARTCONNECTOR TECHNOLOGY FOR FLEX,SUP-2138858,CDM,C1713,HCPCS,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
WIRE FIX UNIV 17.5 MM FOR BOLT SS,SUP-2162663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
BOLT FUSION MIDFOOT 6.5X70MM TI STRL,SUP-2546668,CDM,C1713,HCPCS,0278,RC,,,,both,,,1768.54,1149.55,,,,,,,,,,,,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,0636,RC,80830-1673-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE 3.5X40 MM MOTIONLOC,SUP-2606815,CDM,C1713,HCPCS,0278,RC,,,,both,,,434.70,282.55,,,,,,,,,,,,,
DEVICE FIX INLINE STRL TOGGLELOC ZIPLOOP,SUP-2608599,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.13,221.73,,,,,,,,,,,,,
CATHETER BLLN DIL WIRE GUID 6 FR 12 MMX5.5 CM ECLIPSE TTC,SUP-2737307,CDM,C1726,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 10.2 FRX25 CM BILI SET 6 HOLE UTHANE,SUP-2168131,CDM,C1729,HCPCS,0272,RC,,,,both,,,277.42,180.32,,,,,,,,,,,,,
PLATE BNE THK 0.75 MM SCREW DIA1.7 MM 1 X 21 H PLL,SUP-2883154,CDM,C1713,HCPCS,0278,RC,,,,both,,,9636.50,6263.72,,,,,,,,,,,,,
COLLAR PREMIER PRO CERV RIG 3.25INCH SM LTX FREE,SUP-2336005,CDM,L0140,HCPCS,0274,RC,,,,both,,,36.99,24.04,,,,,,,,,,,,,
KIT BNE CEMENT PROX FEM PRESSURIZER BRKWY NOZ RESTRICTORS,SUP-2884211,CDM,C1776,CPT,0278,RC,,,,both,,,432.82,281.33,,,,,,,,,,,,,
HC Clsd Tx Tibial Fracture,PX-4502753200,CDM,27532,CPT,0450,RC,,,,both,,,3319.00,2157.35,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 8 MM FD ILIUM TRICORT,SUP-2717912,CDM,C1713,HCPCS,0278,RC,,,,both,,,2883.74,1874.43,,,,,,,,,,,,,
HALF PIN FIX BOLT 4 MM,SUP-2820651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1538.13,999.78,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN L15CM STR TIP PTFE HEP S,SUP-2148295,CDM,C1769,HCPCS,0272,RC,,,,both,,,46.16,30.00,,,,,,,,,,,,,
SCREW BNE L 42 MM DIA 7 MM TI CANN FT HD NS LEOS,SUP-2931542,CDM,C1713,HCPCS,0278,RC,,,,both,,,1179.23,766.50,,,,,,,,,,,,,
HC Ot Adl Training 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309753500,CDM,97535,CPT,0430,RC,,,GO|CO,both,,,131.00,85.15,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 180CM 0.035IN TIP 3 CM STIFF ANGLED,SUP-2385590,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.82,107.78,,,,,,,,,,,,,
GRAFT BNE GEL 5 CC DBM MAROFUSE,SUP-2120698,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY KNEE CTRL CNDYL PD,SUP-2435699,CDM,L2810,HCPCS,0272,RC,,,,both,,,231.23,150.30,,,,,,,,,,,,,
VALVE SHUNT MULTPURP LO PRSS W/ ANTISIPHON DEV,SUP-2244284,CDM,C1729,HCPCS,0272,RC,,,,both,,,4109.38,2671.10,,,,,,,,,,,,,
PLATE BNE STR 2.4X170 MM WRST SS STRL LCP,SUP-2422104,CDM,C1713,HCPCS,0278,RC,,,,both,,,11370.82,7391.03,,,,,,,,,,,,,
GUIDEPIN ORTH L14IN DIA3.2MM THRD DISP FOR VERSANAIL HUM 3PK,SUP-2411839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
DEVICE MNSCL RPR WTH PEEK ANCHR SIZE 2 UHMWPE STRE FLXBLE ND,SUP-2858618,CDM,C1713,HCPCS,0278,RC,,,,both,,,1458.15,947.80,,,,,,,,,,,,,
MATRIX BIO SZ 250 SQCM FISH SKIN DERMAL SLD INTACT STRL,SUP-2909210,CDM,Q4158,HCPCS,0636,RC,,,,both,,,25905.00,16838.25,,,,,,,,,,,,,
SCREW BNE L11MM OD2MM THRD L5.5MM TI BRK OFF MONSTER BITE,SUP-2320989,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.80,436.67,,,,,,,,,,,,,
KIT EXT FIX AUTO HEXAPOD ACCESSORIES MAXFRAME AUTOSTRUT,SUP-2908193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.018 IN SS MANDREL GLD COIL,SUP-2823950,CDM,C1769,HCPCS,0272,RC,,,,both,,,95.14,61.84,,,,,,,,,,,,,
SCREW BNE SYMM PROF 3.5X14 MM LCK TI NS SURFIX,SUP-2609175,CDM,C1713,HCPCS,0278,RC,,,,both,,,1113.60,723.84,,,,,,,,,,,,,
SPLINT ORTHOPEDIC PADDED FOAM PERF ALUM,SUP-2195267,CDM,L3931,HCPCS,0272,RC,,,,both,,,27.82,18.08,,,,,,,,,,,,,
COMPONENT TIB SM L80MM KNEE ROT PLATFRM GMRS,SUP-2376523,CDM,C1776,CPT,0278,RC,,,,both,,,7097.50,4613.37,,,,,,,,,,,,,
PROTECTOR NRV L20MM DIA3.5MM PORCINE EXTRACELLULAR MTRX WRP,SUP-2124856,CDM,C1763,HCPCS,0278,RC,,,,both,,,7714.98,5014.74,,,,,,,,,,,,,
AGENT HEMOSTATIC POLYSACCHARIDE 230 CM 2.8 MM 3 GM ENDOCLOT,SUP-2865641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HC Exclusion Laa Open Tm Strnt/Thrcm Any Method,PX-3603326800,CDM,33268,CPT,0360,RC,,,,both,,,7823.00,5084.95,,,,,,,,,,,,,
BIT DRILL OD95MM FLEXIBLE CLANCY,SUP-2847031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3368.22,2189.34,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED AB GLEN COMPHSVE REVERSED,SUP-2212454,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
TRAY PICC CATH 1.9FR 35CM 22GAX25MM INTRO COMPLT SGL LUMN,SUP-2391833,CDM,C1751,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
PLATE BONE L L55MM 7DEG 8 H LT 1ST METATARSOPHALANGEAL TIM,SUP-2137080,CDM,C1713,HCPCS,0278,RC,,,,both,,,3637.85,2364.60,,,,,,,,,,,,,
NUT ORTH W8MM DIA11MM TI FOR 45MM CORT SCR,SUP-2190559,CDM,C1713,HCPCS,0278,RC,,,,both,,,88.80,57.72,,,,,,,,,,,,,
HC Inj Thrombin for Aneurysm,PX-3613600200,CDM,36002,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
COMPONENT FEM M L KNEE REV CEM CRUCE RET STEM NONBEADED CO 66320315] STRYKER CORP],SUP-2364830,CDM,C1776,CPT,0278,RC,,,,both,,,5030.03,3269.52,,,,,,,,,,,,,
CATHETER DIAG 1.9FR L150CM DIA0.042X0.034IN SPC 15MM GWIRE,SUP-2353147,CDM,C1887,HCPCS,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
DEVICE PESSARY DSH 2 60 MM W/ SUPP,SUP-2273824,CDM,A4562,HCPCS,0272,RC,,,,both,,,94.45,61.39,,,,,,,,,,,,,
DRAIN SURG 8FR STEM 12IN XBAR 5IN GRAV W/ DEAVER T TB FOR,SUP-2127143,CDM,C1729,HCPCS,0272,RC,,,,both,,,35.45,23.04,,,,,,,,,,,,,
COMPONENT ARTC 6X6MM OFFSET L35MM FEM HD CO CHROM ALLOY,SUP-2123646,CDM,C1776,CPT,0278,RC,,,,both,,,19939.00,12960.35,,,,,,,,,,,,,
STENT CAR ACCULINK L 40 MM DIA 6-8 MM CATH L 132 CM SHTH 6,SUP-2104587,CDM,C1876,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
WIRE EXT FIX REDUCTION 1.5X400 MM MR SAFE,SUP-2422097,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
PLATE BONE W40XH0.3XL60MM CRANIOFACIAL VIT MESH MALL FOR,SUP-2364704,CDM,C1713,HCPCS,0278,RC,,,,both,,,2301.62,1496.05,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 50 X W 13.5 MM MYRIAD HNDPC L 13,SUP-2930202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17951.69,11668.60,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED VIVACIT-E POLYETH PERSONA,SUP-2212587,CDM,C1776,CPT,0278,RC,,,,both,,,15150.50,9847.82,,,,,,,,,,,,,
LASER SURG ZEISS LINK FOR 130SL,SUP-2713636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19282.74,12533.78,,,,,,,,,,,,,
TACH TUBE BLUE RHINO G2-MULTI SET WITH 8 FLEX,SUP-2718705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1675.82,1089.28,,,,,,,,,,,,,
STEM TIB 7 KNEE,SUP-2201508,CDM,C1713,HCPCS,0278,RC,,,,both,,,7586.68,4931.34,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP PATELLAR TEND W/ QUAD,SUP-2867093,CDM,C1762,CPT,0278,RC,,,,both,,,24242.84,15757.85,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US|SEPARATE STRUCTURE|LEFT SIDE|PO,PX-5102060500,CDM,20605,CPT,0510,RC,,,XS|LT|PO,both,,,908.00,590.20,,,,,,,,,,,,,
COBICISTAT 150 MG PO TABS,RX-128000,CDM,6370000000,HCPCS,0637,RC,61958-1401-01,NDC,,both,1,UN,47.30,30.74,,,,,,,,,,,,,
PLATE BNE 0DEG 12 H BILAT HND S STL STR LO PROF RIG,SUP-2184849,CDM,C1713,HCPCS,0278,RC,,,,both,,,1031.55,670.51,,,,,,,,,,,,,
INTRODUCER SET G2-MULTI PERC 7.5/8.5/9 MM W/ DIL BLU RHINO,SUP-2759707,CDM,C1769,HCPCS,0272,RC,,,,both,,,1804.24,1172.76,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 7.5 CC CANC,SUP-2867064,CDM,C1762,CPT,0278,RC,,,,both,,,668.19,434.32,,,,,,,,,,,,,
SPLINT WR AD M L6.25IN FOR 6.5-7.5IN LT REG W/ STAY ELAS,SUP-2309139,CDM,L3808,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GUIDEWIRE ORTH L500MM OD15MM BLNT THORLUM FOR MINIMALLY,SUP-2335564,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BRACE EL R ROM TELSCP 4 CUF X ACT,SUP-2196500,CDM,L3702,HCPCS,0272,RC,,,,both,,,294.38,191.35,,,,,,,,,,,,,
HC Glucose Tolerance Test,PX-3018295100,CDM,82951,CPT,0301,RC,,,,inpatient,,,445.00,289.25,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 30 CC FRZN IRRADIATED CANC,SUP-2867098,CDM,C1762,CPT,0278,RC,,,,both,,,1342.35,872.53,,,,,,,,,,,,,
SM FRAG PLT STERILIZER 3.5X49 MM 4 HL,SUP-2820734,CDM,C1713,HCPCS,0278,RC,,,,both,,,962.47,625.61,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CMNTLS CERM ON CERM,SUP-2365524,CDM,C1776,CPT,0278,RC,,,,both,,,20738.88,13480.27,,,,,,,,,,,,,
PLATE BONE LOK CMPRSSN 115MML HLX6 TIMAX CRTCL BROAD PRE CNT,SUP-2588753,CDM,C1713,HCPCS,0278,RC,,,,both,,,3842.83,2497.84,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.93 MM 2.8 MM REUT BOB W/ HOLE 520186,SUP-2472730,CDM,L8699,HCPCS,0278,RC,,,,both,,,35.29,22.94,,,,,,,,,,,,,
IMPLANT COSMETIC POLYETHYL ZB FLAT MED WIDTH STRL DISP,SUP-2936123,CDM,C1713,HCPCS,0278,RC,,,,both,,,7275.38,4729.00,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2 CHMBR,SUP-2140351,CDM,C1721,HCPCS,0275,RC,,,,both,,,90180.80,58617.52,,,,,,,,,,,,,
ENDCAP ORTH TI ALLY GRN FOR CANN NAIL,SUP-2192168,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.41,481.27,,,,,,,,,,,,,
SPLINT ARM M W18XL13IN FOR 6-17IN LIMB TRNSLUC FAB POLYSTYR,SUP-2328639,CDM,L3702,HCPCS,0272,RC,,,,both,,,34.95,22.72,,,,,,,,,,,,,
Gluc-6-Phosphate Dehydrogenase Quantitative,PX-3018295567,CDM,82955,CPT,0301,RC,,,,both,,,62.00,40.30,,,,,,,,,,,,,
PLATE BONE L61MM 2 H RT OLECRANON W/ TINES FOR 2.7/3.5MM SCR,SUP-2418064,CDM,C1713,HCPCS,0278,RC,,,,both,,,4944.87,3214.17,,,,,,,,,,,,,
PLATE BURR H L 36.2 MM DIA 30 MM SCREW DIA1.5 MM TI NS DISP,SUP-2936444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
KD TOMES PRELOADED WITH VISIGLIDE GUIDEWIRES,SUP-2675534,CDM,C1769,HCPCS,0272,RC,,,,both,,,1201.93,781.25,,,,,,,,,,,,,
CABLE CERV FIX S STL STRL CINCH SEAT WIRE,SUP-2257004,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
IMPLANT BIO TISS W10XL10CM REGEN PORCINE CLLGN SQ XENMATRIX,SUP-2125844,CDM,C1781,HCPCS,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
SCREW SPNL 4.5X50 MM TI TSRH 3DX OSTEOGRIP,SUP-2631146,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
HC So Chromosome Analysis Am Fl,PX-3118826966,CDM,88269,CPT,0311,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
GUIDEWIRE 09X120MM TRCR TIP PLN,SUP-2243909,CDM,C1769,HCPCS,0272,RC,,,,both,,,126.13,81.98,,,,,,,,,,,,,
GRAFT BIO TISS 4X8CM THK20 33MM PROLAYER,SUP-2362232,CDM,C1763,HCPCS,0278,RC,,,,both,,,9108.51,5920.53,,,,,,,,,,,,,
PLATE BNE L89MM 9 H ST ANT LAT CERV TI LOK COMPR VAR ANG FOR,SUP-2180883,CDM,C1713,HCPCS,0278,RC,,,,both,,,3369.91,2190.44,,,,,,,,,,,,,
VALVE ANGIO 10IN LEN Y VLV HEMSTAT HI PRSS TBNG W INSRT TOOL,SUP-2303054,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.67,52.44,,,,,,,,,,,,,
PLATE BONE L70MM HK D15MM 4 H LT CLAV S STL LCK COMPR FOR,SUP-2185843,CDM,C1713,HCPCS,0278,RC,,,,both,,,2730.07,1774.55,,,,,,,,,,,,,
HC Assay of L7383transferrin,PX-3018446600,CDM,84466,CPT,0301,RC,,,,both,,,350.00,227.50,,,,,,,,,,,,,
STAPLER INT USE DIA21 MM STPL H 3/3.5/4 MM MED/THICK CIR,SUP-2898377,CDM,C1713,HCPCS,0278,RC,,,,both,,,3073.84,1998.00,,,,,,,,,,,,,
ROD SPNL L55MM DIA5.5MM POST TI PREBENT SMOOTH CRV CDH,SUP-2290663,CDM,C1713,HCPCS,0278,RC,,,,both,,,1691.99,1099.79,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 5 FR 0.025IN PLAS,SUP-2691361,CDM,C1894,HCPCS,0272,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
PLATE BNE L UNIV 2.7X39 MM RT 3 HOLE 2 COMPR LCK OBLQ,SUP-2476507,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.12,598.73,,,,,,,,,,,,,
CATHETER CV KT 8 FRX20 CM DL PRESSURE INJ J ARROWG+ARD BLU,SUP-2763333,CDM,C1751,HCPCS,0278,RC,,,,both,,,324.05,210.63,,,,,,,,,,,,,
BIT DRILL SURG L 1/4 IN DIA 3.2 MM CANN,SUP-2896680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
SHUNT PERI REG W SNAP RESVR PROGRAMMABLE VENTCULSTMY CSF,SUP-2277983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14729.14,9573.94,,,,,,,,,,,,,
ADAPTER HEARING AID TV 3.0 2.4 G PONTO,SUP-2430287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 360DEG 5000RPM M4 ROT 12DEG LNG CRV,SUP-2284152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1220.83,793.54,,,,,,,,,,,,,
ORTHOMESH RESORBABLE STRAIGHT ROW 50MMX50MMX0.5MM-STERILE,SUP-2550441,CDM,C1781,HCPCS,0278,RC,,,,both,,,2859.28,1858.53,,,,,,,,,,,,,
CATHETER HAD L36CM INSRT L19CM PALINDROME,SUP-2283914,CDM,C1750,HCPCS,0278,RC,,,,both,,,1008.38,655.45,,,,,,,,,,,,,
CLIP LIGATOR LG TI REDUC LAT SLIPPAGE COMPATIBLE KONIG ORN,SUP-2895524,CDM,C1889,HCPCS,0278,RC,,,,both,,,2.79,1.81,,,,,,,,,,,,,
GRAFT BONE CERV SPCR FRZ DRY CANC H 8MM,SUP-2307223,CDM,C1713,HCPCS,0278,RC,,,,both,,,3068.16,1994.30,,,,,,,,,,,,,
SCREW BONE 3.5X9.4MM IMPL POLYAX,SUP-2317565,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
STENT URTRL 45FR DIA 22CML SLCNE TCFLX DBLE PGTL OPEN END C,SUP-2722572,CDM,C2617,HCPCS,0278,RC,,,,both,,,172.39,112.05,,,,,,,,,,,,,
ATENOLOL 50 MG PO TABS,RX-718,CDM,6370000000,HCPCS,0637,RC,51079-0684-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMPONENT FEM 3 CM RT KNEE RESURF OSS RS,SUP-2441724,CDM,C1776,CPT,0278,RC,,,,both,,,17365.77,11287.75,,,,,,,,,,,,,
SYSTEM BONE CEM DEL INJ CANN DMND STYL W/O CEM EZ FLO,SUP-2342020,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
PACEMAKER CARD OPTIMIZER SMRT SZ 47.5 X 65.4 X 11.5 MM 30.5,SUP-2639327,CDM,C2621,HCPCS,0275,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
BODY EXT FIX STD FEMALE FOR HIP COMP PVC FREE STRL PROCALLUS,SUP-2645896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4693.86,3051.01,,,,,,,,,,,,,
CATHETER PICC ARROWG+ARD BLUE ADVANCE TAPERFREE 5.5FR 55CM 2-LUMEN,SUP-2887068,CDM,C1751,HCPCS,0278,RC,,,,both,,,673.00,437.45,,,,,,,,,,,,,
IMPLANT FNGR JT L15MM SCR DIAM 4MM BARB L6.8MM DIAM 5.5MM,SUP-2223971,CDM,C1776,CPT,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
PLATE BONE W16XL221MM THK5MM 11 H LT CNDYL FEM S STL BTTRS,SUP-2185794,CDM,C1713,HCPCS,0278,RC,,,,both,,,2696.29,1752.59,,,,,,,,,,,,,
PLATE BNE L116MM 6 H S STL T LOK COMPR FOR 4.5/5MM SCR,SUP-2185756,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.28,1211.13,,,,,,,,,,,,,
BUR SURG 3MM SH TAPR ROUTER FOR DURAGUARD,SUP-2363356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
BIT DRL 3.2 MM DSTL,SUP-2644749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.94,607.71,,,,,,,,,,,,,
DRILL TWST L53MM OD13MM STP CHK END FOR 17X12MM SCR,SUP-2366403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,399.60,259.74,,,,,,,,,,,,,
BIT DRL DIA1.5MM ADD ON QUIK CONN DISP,SUP-2344027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,566.52,368.24,,,,,,,,,,,,,
STENT CORONARY JOSTENT GRAFTMASTER L 12 MM DIA 5 MM GUIDE,SUP-2106196,CDM,C1876,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
BUR SURGICAL PEDIATRIC SMALL L13MM TITANIUM WITH SUTURE FIXA,SUP-2825577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.38,255.70,,,,,,,,,,,,,
PLATE SPNL L28MM STD UNIV ANTR BILAT CERV TI LCK SLIM PROF,SUP-2256432,CDM,C1713,HCPCS,0278,RC,,,,both,,,4041.18,2626.77,,,,,,,,,,,,,
ELECTRODE ELECSURG LOOP MED 12 DEG BPLR QUICK-FIRE,SUP-2435504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,855.18,555.87,,,,,,,,,,,,,
PLATE BNE 3 H L PROX TIB TIM L CRV LOK ALPS,SUP-2413713,CDM,C1713,HCPCS,0278,RC,,,,both,,,5284.62,3435.00,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5CM 36J 2 CHMBR BPLR REMOT MON ENABLED,SUP-2357754,CDM,C1721,HCPCS,0275,RC,,,,both,,,56834.00,36942.10,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA 16 HOLES 237MM RIGHT,SUP-2549560,CDM,C1713,HCPCS,0278,RC,,,,both,,,3630.37,2359.74,,,,,,,,,,,,,
PLATE BNE RECON 3.5X130 MM PELV 10 HOLE LP WA SS NS,SUP-2863368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.41,940.82,,,,,,,,,,,,,
PLATE BNE TIB 4.5 MM LAT PROX SET PERI-LOC,SUP-2351390,CDM,C1713,HCPCS,0278,RC,,,,both,,,5683.40,3694.21,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS UNIAXIAL STRL CD HORZ 4PK,SUP-2928636,CDM,C1713,HCPCS,0278,RC,,,,both,,,10110.80,6572.02,,,,,,,,,,,,,
RESERVOIR CSF SM DRNGE FLD 1.1ML BA IMPREG L23CM VENT CATH,SUP-2284527,CDM,C1889,HCPCS,0278,RC,,,,both,,,894.62,581.50,,,,,,,,,,,,,
HC Sodium Serum Plasma or Whole Blood,PX-3018429500,CDM,84295,CPT,0301,RC,,,,both,,,134.00,87.10,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PHOTON DR TI POLYUR SIL 2 CHMBR IS1/DF1,SUP-2357751,CDM,C1721,HCPCS,0275,RC,,,,both,,,54086.50,35156.22,,,,,,,,,,,,,
BUR SURG L9CM DIA3MM MTCH HD FLUT L BOR MIDAS REX LEGEND,SUP-2284664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.64,219.47,,,,,,,,,,,,,
CATHETER DRAINAGE 14 FRX30 CM KT REG FLEXIMA VAN SONN SUMP,SUP-2147867,CDM,C1729,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE BONE L149MM 10 H NONSTERILE LT LAT PROX TIB LCK FOR,SUP-2348471,CDM,C1713,HCPCS,0278,RC,,,,both,,,11772.02,7651.81,,,,,,,,,,,,,
WAND ABLAT 45DEG 3 BLK DEPTH MRK REFLX ULT 45,SUP-2342038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
MATRIX BIO SZ 38 SQCM FISH SKIN DERMAL INTACT STRL OMEGA3,SUP-2909260,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
OSTEOTOME SURG THK 0.22 IN SPATULA,SUP-2936859,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
RAIL EXT FIX TRANSITION 5.5X495 MM CONTOURED 4D MESA,SUP-2517557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7395.45,4807.04,,,,,,,,,,,,,
BLADE TRIANG DISPOSABLE ST,SUP-2361844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,711.12,462.23,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115 CM 7FR 4MM C CRV SFT,SUP-2248471,CDM,C1732,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CLAMP EXT FIX 5 H PIN FOR HOFFMANN III MOD SYS,SUP-2372221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2147.45,1395.84,,,,,,,,,,,,,
HC Radiation Treatment Delivery Level 1,PX-3337740200,CDM,77402,CPT,0333,RC,,,,outpatient,,,614.00,399.10,,,,,,,,,,,,,
NAIL IM L330MM DIA8MM TIB DK BLU TI SLD LOK BEND,SUP-2192757,CDM,C1713,HCPCS,0278,RC,,,,both,,,5188.54,3372.55,,,,,,,,,,,,,
LAMOTRIGINE 25 MG PO TABS,RX-13981,CDM,6370000000,HCPCS,0637,RC,51672-4130-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE 9 H CORT WRST TI STR SM FRAG SYS FOR 2.7/3.5MM,SUP-2191037,CDM,C1713,HCPCS,0278,RC,,,,both,,,4268.14,2774.29,,,,,,,,,,,,,
SPACER TIB SM UNIV ANTIBIO REV PRESSFIT INTERSPACE,SUP-2223691,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 5",PX-7619920500,CDM,99205,CPT,0761,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE FIBERGRAFT 4CC,SUP-2741933,CDM,C1713,HCPCS,0278,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
PLATE BNE L221MM THK3MM 14 H BILAT S STL STR LIMIT CNTCT,SUP-2185350,CDM,C1713,HCPCS,0278,RC,,,,both,,,2324.86,1511.16,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT PRELD W 2 STRND BRAID POLY 5MM DIA 14MM,SUP-2366664,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.41,310.32,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM CORT TI ST NONCANNULATED LOK FULL,SUP-2189884,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.53,47.14,,,,,,,,,,,,,
RING EXT FIX FULL 200 MM TI NS,SUP-2863407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3446.84,2240.45,,,,,,,,,,,,,
PLATE BNE L63MM THK1.3MM SCR L8MM DIA2MM R MTCRPL TI COMPR,SUP-2267921,CDM,C1713,HCPCS,0278,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
PLATE BNE L 167 MM SCREW DIA 3.5 MM13 H RT PROX LAT TIB STRL,SUP-2931305,CDM,C1713,HCPCS,0278,RC,,,,both,,,7056.05,4586.43,,,,,,,,,,,,,
BIT DRL DIA2MM STP L12MM QUIK CPL REUSE,SUP-2179420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
LOW PROF LORDTC EXP IMPL 22X9X7X15 DEG 8 WAFERS W/ TI COAT,SUP-2354696,CDM,C1713,HCPCS,0278,RC,,,,both,,,17332.80,11266.32,,,,,,,,,,,,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,J7131,HCPCS,0250,RC,63323-0088-61,NDC,,both,100,ML,67.90,44.13,,,,,,,,,,,,,
HC Pt Contrast Baths 15min,PX-4209703400,CDM,97034,CPT,0420,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
PIN GUID 2.4MM 228MM SMOOTH SHRP TIP S STL,SUP-2166888,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.25,51.51,,,,,,,,,,,,,
RESERVOIR VENTRICULAR DRAINAGE WITH CATHETER 60CM CATHETER L,SUP-2826644,CDM,C1889,HCPCS,0278,RC,,,,both,,,929.03,603.87,,,,,,,,,,,,,
GRAFT HUM TISS W3XL3.5CM AMNIO MEMBRN TRNSLUC GRID PAT SGL,SUP-2113886,CDM,Q4154,HCPCS,0636,RC,,,,both,,,5191.36,3374.38,,,,,,,,,,,,,
HC ED Clsd Tx Rad Hd Sublux Child,PX-4502464000,CDM,24640,CPT,0450,RC,,,,both,,,243.00,157.95,,,,,,,,,,,,,
HC So Drug Assay Amiodarone,PX-3018015166,CDM,80151,CPT,0301,RC,,,,outpatient,,,189.00,122.85,,,,,,,,,,,,,
ELECTRODE ELECSURG RF 150 MM SELF GRND NITRODE,SUP-2366983,CDM,C1713,HCPCS,0278,RC,,,,both,,,9003.67,5852.39,,,,,,,,,,,,,
LEAD PACE BPLR 86 CM LT VENTRIC QUICKSITE,SUP-2356620,CDM,C1900,HCPCS,0275,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
HC Assay of Ferritin,PX-3018272800,CDM,82728,CPT,0301,RC,,,,both,,,255.00,165.75,,,,,,,,,,,,,
AMLODIPINE BESYLATE 10 MG PO TABS,RX-9069,CDM,6370000000,HCPCS,0637,RC,00904-6371-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE 5 CC CELLULAR BNE MTRX V92 FC+,SUP-2742071,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SCREW INTRF L23MM DIA9MM BIOCRYL CANN ABSRB TAPR,SUP-2256768,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN (MINI-BAG),RX-40850048,CDM,2580000003,HCPCS,0258,RC,00338-0551-11,NDC,,both,50,ML,56.60,36.79,,,,,,,,,,,,,
GRAFT DURA 5X4 IN REGEN MTRX DURAGN,SUP-2624230,CDM,C1763,HCPCS,0278,RC,,,,both,,,5148.41,3346.47,,,,,,,,,,,,,
PORT E DIA8MM FOR 8MM DA VINCI XI SYS SINGLE-SITE,SUP-2246786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT HUM TISS W14-18XL100MM FIB SHFT FRZ DRY,SUP-2307197,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.20,1430.78,,,,,,,,,,,,,
PLATE BNE TROCHANTERIC WIDE LT NCB,SUP-2459362,CDM,C1713,HCPCS,0278,RC,,,,both,,,3022.06,1964.34,,,,,,,,,,,,,
COMPONENT HUM SM L6IN EL INTERCHANGEABLE LNG FLNG ASSEMB,SUP-2205924,CDM,C1776,CPT,0278,RC,,,,both,,,16145.19,10494.37,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE BLOCK 15X30X8 MM FD CANC ORAGRAFT,SUP-2740847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.21,730.74,,,,,,,,,,,,,
HC Rsf Lab Bmh - Special Stain,PX-9900000124,CDM,9900000124,LOCAL,0990,RC,,,,both,,,94.00,61.10,,,,,,,,,,,,,
DEVICE RESECTING SZ 3.9 MM STRL DISP AVETA MAX,SUP-2914489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
FRAME EXT FIX L160MM CIR ASSEMB SIDEKCK,SUP-2400708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13586.78,8831.41,,,,,,,,,,,,,
APPLICATOR SURG 10 CM LOCALIZER 21,SUP-2137814,CDM,A4648,CPT,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
BUR SURG OD16.8MM 24.1MM M CUT RND N FLUT STRL PERF CHK,SUP-2363339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,294.19,191.22,,,,,,,,,,,,,
BIT DRL DIA 3.7 MM CORTICAL AO QC LG TARGETER SYS STRL DISP,SUP-2933208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2222.18,1444.42,,,,,,,,,,,,,
COMPONENT TIB SZ 3 CH AP43MM ML67MM H10MM UNIV KNEE YEL,SUP-2200664,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BNE RESRB INION,SUP-2365889,CDM,C1713,HCPCS,0278,RC,,,,both,,,3644.66,2369.03,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 20 A WITH SHUNT ASSISTANT PEDIATRIC PREC,SUP-2821859,CDM,C1889,HCPCS,0278,RC,,,,both,,,9412.21,6117.94,,,,,,,,,,,,,
GRAFT DERMAL RECT 40X20 CM REGENERATIVE CLLGN MTRX XENMATRIX,SUP-2126243,CDM,C1781,HCPCS,0278,RC,,,,both,,,74385.97,48350.88,,,,,,,,,,,,,
"HC So Cmv, Congenital,Qaul Pcr, Saliva",PX-3068749667,CDM,87496,CPT,0306,RC,,,,both,,,393.00,255.45,,,,,,,,,,,,,
ALLOGRAFT BNE EVANS WDG 18X18X8 MM,SUP-2864938,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
GRAFT BIO TISS W8XL8CM FEN FET BOV ACELLULAR DERM MTRX,SUP-2243696,CDM,Q4110,HCPCS,0636,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
SCREW BNE 30MM CTRL MOD,SUP-2123399,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
STABILIZER SURG L15 CM PIN,SUP-2280167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1040.31,676.20,,,,,,,,,,,,,
PLATE BNE L60MM THK1.3MM 2X8 H MTCRPL TI T SHP COMPR FOR,SUP-2267917,CDM,C1713,HCPCS,0278,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
CATHETER GUID CLS4 6 FRX110 CM RUNWAY,SUP-2140731,CDM,C1887,HCPCS,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
INTERFYL 1.0 ML FLOWABLE,SUP-2818017,CDM,Q4171,HCPCS,0636,RC,,,,both,,,5129.19,3333.97,,,,,,,,,,,,,
SCREW BNE L28 MM L11 MM OD45 MM SHT THRD MONSTER IMPL,SUP-2320598,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.64,448.92,,,,,,,,,,,,,
PIN FIX L14.9CM DIA4.8MM CORT S STL SELF TAP DRL,SUP-2409694,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.95,248.92,,,,,,,,,,,,,
KIT CHARGING CHRG BASE STN PWR SUPL CHRG BELT PRECIS SPECTR,SUP-2138831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SCREW BNE CANN MED THRD 5X75 MM HDLSS SHRP TIP BEAM JOUSTA,SUP-2742900,CDM,C1713,HCPCS,0278,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
STEM ULN HD 4.5 LG PART MOD REPL 1ST CHOICE,SUP-2610432,CDM,C1776,CPT,0278,RC,,,,both,,,13339.88,8670.92,,,,,,,,,,,,,
GRAFT BNE SUB 10CC TISS EXPONENT DBM,SUP-2138519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2677.98,1740.69,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 60 MM DIA 7 MM DEL SYS L 190 CM,SUP-2866202,CDM,C1725,HCPCS,0272,RC,,,,both,,,3730.07,2424.55,,,,,,,,,,,,,
HC Arterial Line Insertion,PX-3613662000,CDM,36620,CPT,0361,RC,,,,both,,,789.00,512.85,,,,,,,,,,,,,
PLATE MEDL CLMN LNG TI LT NAVICULOCUNEIFORM METATRSL NS,SUP-2896788,CDM,C1713,HCPCS,0278,RC,,,,both,,,5491.86,3569.71,,,,,,,,,,,,,
SHEATH INTRO OSCOR ADELANTE BREEZEWAY 70 DEG L 61 CM DIA 8,SUP-2753183,CDM,C1887,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,6370000000,HCPCS,0637,RC,51672-2069-02,NDC,,both,28.4,GR,14.90,9.68,,,,,,,,,,,,,
STEM HUM INTERCALARY 30 MM ANTI-ROTATION REV SEG W/ SCREW,SUP-2442436,CDM,C1776,CPT,0278,RC,,,,both,,,17097.30,11113.24,,,,,,,,,,,,,
SNARE VASC SYMPRO ELITE L 150 CM DIA 0.035 IN LOOP DIA10 MM,SUP-2763476,CDM,C1773,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STE LAT COL LENGTH PLT MED,SUP-2588799,CDM,C1713,HCPCS,0278,RC,,,,both,,,2015.13,1309.83,,,,,,,,,,,,,
COMPONENT HUM L200MM 4MM OFFSET BOND COAT LT SHLDR DISCVR,SUP-2215500,CDM,C1776,CPT,0278,RC,,,,both,,,12186.34,7921.12,,,,,,,,,,,,,
KIT BONE CEMING DEL W/ NDL 13GA CANN INJ DMND AND GRN TIP,SUP-2341406,CDM,C1713,HCPCS,0278,RC,,,,both,,,6468.40,4204.46,,,,,,,,,,,,,
WASHER ORTH DIA3MM S STL THRD FOR 3MM CANN SCR,SUP-2184667,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.42,218.67,,,,,,,,,,,,,
WALKER M SHT LEG NONSKID,SUP-2276711,CDM,L4387,HCPCS,0274,RC,,,,both,,,83.68,54.39,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 90 MM DIA12 MM SHTH 9 FR CATH L,SUP-2147052,CDM,C1876,HCPCS,0278,RC,,,,both,,,5430.41,3529.77,,,,,,,,,,,,,
CANNULA SUCTION 360 DEG 3 MMX30 CM 8 MM FLARED MERCED PAL,SUP-2760841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
CAGE SPNL L 73MM IM NIT SELF EXP 3 DIM FX MGMT,SUP-2167471,CDM,C1889,HCPCS,0278,RC,,,,both,,,15370.30,9990.69,,,,,,,,,,,,,
RASP SURG CROSSCUT BONE HANDHELD SGL END STR TAPR FLAT BLDE,SUP-2319802,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
ARCOS 17X150MM SPL TPR DIST,SUP-2505998,CDM,C1776,CPT,0278,RC,,,,both,,,7812.32,5078.01,,,,,,,,,,,,,
COVER BUR H DIA7MM PLT LO PROF W/ TAB UNIV NEURO III,SUP-2363629,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.52,512.54,,,,,,,,,,,,,
HC MRI Lower Ext W&W/O Cont,PX-6107372000,CDM,73720,CPT,0610,RC,,,,both,,,4220.00,2743.00,,,,,,,,,,,,,
KIT CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 15CM PCED 2LUM,SUP-2613268,CDM,C1752,HCPCS,0278,RC,,,,both,,,715.14,464.84,,,,,,,,,,,,,
INSERTER CVR TAPR H FOR REFLCT SYS,SUP-2349965,CDM,C1776,CPT,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
SCREW BNE L75MM DIA3.5MM PROX TIB S STL ST FULL THRD T15,SUP-2177901,CDM,C1713,HCPCS,0278,RC,,,,both,,,460.80,299.52,,,,,,,,,,,,,
OLMESARTAN MEDOXOMIL 5 MG PO TABS,RX-32761,CDM,6370000000,HCPCS,0637,RC,68462-0436-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BIRMINGHAM,SUP-2351333,CDM,C1776,CPT,0278,RC,,,,both,,,29139.20,18940.48,,,,,,,,,,,,,
GRAFT BONE SUB SM PROCELLULAR SPNL MTRX OSTEOCEL,SUP-2310455,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
MATRIX WOUND THERAGENESIS MESHED 4X3CM,SUP-2738094,CDM,A2008,HCPCS,0636,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
STRUT EXT FIX XSH L91-121MM FOR TAY SPAT FRME FAST FX,SUP-2343006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
SET PLUG FIST ENTEROCUTANEOUS CLLGN MULTPURP BIODESIGN,SUP-2169467,CDM,C1763,HCPCS,0278,RC,,,,both,,,12610.24,8196.66,,,,,,,,,,,,,
NAIL IM L150MM DIA8MM STRL HUM TI CANN LCK PROX BEND S2,SUP-2192539,CDM,C1713,HCPCS,0278,RC,,,,both,,,5277.84,3430.60,,,,,,,,,,,,,
SCREW BNE EMGCY 1.2X10 MM CRUCFRM HD W/ FLUT TIP TI,SUP-2189164,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.88,230.02,,,,,,,,,,,,,
SIMETHICONE 80 MG PO CHEW,RX-7227,CDM,6370000000,HCPCS,0637,RC,77333-0812-25,NDC,,both,1,UN,1.70,1.10,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN RT WHL ULNA,SUP-2740920,CDM,C1762,CPT,0278,RC,,,,both,,,10342.06,6722.34,,,,,,,,,,,,,
TUBE ENDOTRACHEL PED SZ 4.5 OD8.5MM ID4.5MM CUF HI VOL LO,SUP-2265227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.91,370.44,,,,,,,,,,,,,
BRACE ANKLEXL AD FOR 11.5-13IN UNIV VLY CNTOUR STL STAY,SUP-2197935,CDM,L4350,HCPCS,0274,RC,,,,both,,,30.21,19.64,,,,,,,,,,,,,
PORT INFUS PLAS SGL LUMN W 8FR CATHETER GROSH VLV OPN INTRO,SUP-2126341,CDM,C1788,HCPCS,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
HC Remote 30 Day Ecg Tech Supp,PX-7319322900,CDM,93229,CPT,0731,RC,,,,both,,,485.00,315.25,,,,,,,,,,,,,
NEEDLE INTRO COAX UNIV 17 GAX15 CM TEMNO,SUP-2482409,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.28,17.08,,,,,,,,,,,,,
LINER ACET CM ST/G7 CP/VE AA DM LN/MTL,SUP-2736177,CDM,C1776,CPT,0278,RC,,,,both,,,16171.00,10511.15,,,,,,,,,,,,,
KIT CTRL VEN CATH L13CM DIA12FR BLU DBL LUMN BEND FLEXTIP,SUP-2383356,CDM,C1750,HCPCS,0278,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
SEEKER BAL L7MM DIA6MM MAX SINUS FOR ENT ELECTROMAGNETIC,SUP-2284113,CDM,C1713,HCPCS,0278,RC,,,,both,,,1647.24,1070.71,,,,,,,,,,,,,
GRAFT HUM TISS 5CM OR SMER COSTAL CART STRUCTURAL NACL,SUP-2165590,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 035IN 6FRX80CM 8X40MM ADMIRAL XTREME,SUP-2280424,CDM,C1725,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER SPEC RETRV BELOW 15-18 MM EXTRACTOR PRO RX-S,SUP-2486268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.96,304.82,,,,,,,,,,,,,
POST SURG CANN CONN FOR 2.5 MM WIRE NS,SUP-2863400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.70,278.00,,,,,,,,,,,,,
KIT INSTRUMENT SPINAL SPINEJACK 4.2MM PREPARATION,SUP-2876925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4359.36,2833.58,,,,,,,,,,,,,
HC Screening Breast Tomo,PX-4037706300,CDM,77063,CPT,0403,RC,,,,inpatient,,,110.00,71.50,,,,,,,,,,,,,
CANNULA LAP W/O VLV 11 MM,SUP-2776234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1281.50,832.97,,,,,,,,,,,,,
VALVE 0 WITH PRECHAMBER MININAV,SUP-2825730,CDM,C1889,HCPCS,0278,RC,,,,both,,,2033.18,1321.57,,,,,,,,,,,,,
PLATE BNE L386MM 18 H NONSTERILE L CNDYL S STL LOK COMPR,SUP-2183119,CDM,C1713,HCPCS,0278,RC,,,,both,,,4909.04,3190.88,,,,,,,,,,,,,
BUR SURG L 95 MM DIA2.35 MM HD DIA 4.5 MM DIAMOND NS REUSE,SUP-2929039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.43,304.48,,,,,,,,,,,,,
HC Iadna Trichomonas Vaginalis Amplified Probe Tech,PX-3068766100,CDM,87661,CPT,0306,RC,,,,both,,,120.00,78.00,,,,,,,,,,,,,
INSERT SYS 12 10DEG DURATN P4 28MM,SUP-2376146,CDM,C1776,CPT,0278,RC,,,,both,,,1440.32,936.21,,,,,,,,,,,,,
PLATE BNE TI L CRANIOMAXILLOFACIAL 11 H ADV NONSTERILE LE,SUP-2366350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1052.87,684.37,,,,,,,,,,,,,
BIT DRL TWST 0.8 MM 4 MMX8 CM SM BOR MIDAS REX LEGEND,SUP-2631336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.62,262.35,,,,,,,,,,,,,
HC Cv Cath Plac W/Port Tun >5|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3613656100,CDM,36561,CPT,0361,RC,,,73,both,,,10303.00,6696.95,,,,,,,,,,,,,
PROSTHESIS OSS EAR 10.2 MM INCUS-STAPE WEHRS,SUP-2342766,CDM,L8613,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 29.5-32 IN CTR 21-23 IN CALF 22-24 IN BLK LT,SUP-2915250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,884.26,574.77,,,,,,,,,,,,,
GRAFT MTRX DERM PTCH SFT TISS REP 5X8CM,SUP-2335647,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5752.48,3739.11,,,,,,,,,,,,,
SCREW IM L 20 MM DIA 3.5 MM TI CORTICAL ST FLUT THRD HD ZERO,SUP-2900387,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SCREW BNE CANN 4X22 MM COMPR FT TI NS,SUP-2788078,CDM,C1713,HCPCS,0278,RC,,,,both,,,858.85,558.25,,,,,,,,,,,,,
KIT ART LN CATH 20GA L6IN NDL 21GA L2IN GWIRE L40CM,SUP-2120111,CDM,C1757,HCPCS,0272,RC,,,,both,,,67.98,44.19,,,,,,,,,,,,,
PLATE BNE 3.5X262 MM 20 HOLE SS LC-DCP,SUP-2569239,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.20,295.23,,,,,,,,,,,,,
PLATE BONE L91MM 6 H STRL LT LAT PROX TIB S STL FOR 3.5MM,SUP-2341155,CDM,C1713,HCPCS,0278,RC,,,,both,,,11086.71,7206.36,,,,,,,,,,,,,
PRESSURE INJECT AG BL THREE-LUM PI CVC KIT 3-L 7 FR X 20 CM,SUP-2660679,CDM,C1751,HCPCS,0278,RC,,,,both,,,423.74,275.43,,,,,,,,,,,,,
CLEARSIGHT FINGER CUFF MED,SUP-2696340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336040,CDM,L3809,HCPCS,0274,RC,,,,both,,,23.90,15.53,,,,,,,,,,,,,
TAP SURG SCR THRD W O HNDL DRL SHFT BNE SPNL 35MM L10 24MM,SUP-2286804,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.50,187.52,,,,,,,,,,,,,
BLADE RTRCTR ST MARKS 2 13NW X 7NL WLIP F  UNVRSL RING,SUP-2676583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1321.66,859.08,,,,,,,,,,,,,
COLLAR EXTRIC AD REG HI DENS POLYETH PD SET XTW,SUP-2194470,CDM,L0172,HCPCS,0274,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
SCREW BNE L60MM DIA7.3MM CORT S STL ST CANN LOK FULL THRD,SUP-2184935,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.22,506.49,,,,,,,,,,,,,
SCREW IM L 50 MM DIA 5 MM TI LCK HDLSS STRL TRIGEN MAX,SUP-2931446,CDM,C1713,HCPCS,0278,RC,,,,both,,,915.62,595.15,,,,,,,,,,,,,
DIVALPROEX SODIUM 500 MG PO TBEC,RX-2553,CDM,6370000000,HCPCS,0637,RC,00904-6861-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PIN FIX CASPER 14 MM,SUP-2391504,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
MODEL UPT-6 US PROC TY,SUP-2165758,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
HEAD HUM ECC 48X18 MM SHLDR AFFINITI,SUP-2715312,CDM,C1776,CPT,0278,RC,,,,both,,,7603.51,4942.28,,,,,,,,,,,,,
SCREW JONES FRACTR L 42 MM DIA 45 MM SLD NS,SUP-2896632,CDM,C1713,HCPCS,0278,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
STIMULATOR NERVE MIC,SUP-2240636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
INTRODUCER ORTH SHT 10 GA W/ BVL TIP STYL STABILIT,SUP-2491096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.80,423.67,,,,,,,,,,,,,
KIT OXGNTR NATILUS SMART,SUP-2711657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12183.20,7919.08,,,,,,,,,,,,,
BIT DRL L300MM DIA5MM CANN QUIK CPL ADJ STP REUSE,SUP-2187325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.70,665.40,,,,,,,,,,,,,
HC So Rubeola Igg / Igm,PX-3028676566,CDM,86765,CPT,0302,RC,,,,inpatient,,,121.00,78.65,,,,,,,,,,,,,
SHEATH LD INTRO OPTISEAL L 13 CM DIA12 FR SIDEPRT STEER STRL,SUP-2459376,CDM,C1766,CPT,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
CYGNUS ANTR CERV 14MM PLTE MTI LVL,SUP-2664161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
LOOP ENDOSCP ELECTROCAUTERY L 120 X W 85 MM UPLR SPARE NS,SUP-2884646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.42,652.87,,,,,,,,,,,,,
DRILL SURG LUG 0.25 IN W/ STP VANGUARD XP,SUP-2446450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
HC So Estrogens Total,PX-3018267266,CDM,82672,CPT,0301,RC,,,,outpatient,,,366.00,237.90,,,,,,,,,,,,,
VALPROIC ACID 250 MG PO CAPS,RX-8429,CDM,6370000000,HCPCS,0637,RC,00591-4012-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET PRO HYDR ABLAT,SUP-2141731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
GRAFT HUM TISS W2XL5CM THK04 07MM ACELLULAR HUM DERM,SUP-2307442,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1006.21,654.04,,,,,,,,,,,,,
ENDCAP ORTH L10MM DIA15MM ST FEM TI NAIL SPRL BLDE EXTN LOK,SUP-2192142,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.39,555.35,,,,,,,,,,,,,
GRAFT BNE MAR M CONC,SUP-2163081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
SYSTEM EMB EMBOLIC PROTCT TARGET VASC COIL DETACH INZONE 2,SUP-2367921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
HC Wrist Min 3 Views,PX-3207311000,CDM,73110,CPT,0320,RC,,,,both,,,562.00,365.30,,,,,,,,,,,,,
HC Asp Inj Intermediate Joint,PX-3612060500,CDM,20605,CPT,0361,RC,,,,outpatient,,,358.00,232.70,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE UNIV KNEE WARRIOR RECOVERY,SUP-2336061,CDM,L1810,HCPCS,0272,RC,,,,both,,,210.22,136.64,,,,,,,,,,,,,
HC Canalith Repositioning Proc,PX-4209599200,CDM,95992,CPT,0420,RC,,,,inpatient,,,333.00,216.45,,,,,,,,,,,,,
KIT IMPL DIA 9 MM ALL INSIDE STRL QUADLINK 2.0,SUP-2930401,CDM,C1713,HCPCS,0278,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
STENT CORONARY ABSORB GT1 L 8 MM DIA2.5 MM PLLA PDLLA,SUP-2105648,CDM,C1874,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SLING ORTHOT CUST TRAPEZIUS,SUP-2435577,CDM,L1070,HCPCS,0272,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
HEAD RAD DIA20MM CO CHROM W/ LCK SCR ALIGN,SUP-2340137,CDM,C1776,CPT,0278,RC,,,,both,,,5534.25,3597.26,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 1",PX-7619921100,CDM,99211,CPT,0761,RC,,,,both,,,174.00,113.10,,,,,,,,,,,,,
SET VASC ACCS PEELWY L 15.5 CM INTRO L 20 CM DIA18 FR,SUP-2168023,CDM,C1892,HCPCS,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
IMPLANT OTO L4.5MM HD DIA1.6MM INCUS HA DBL NOTCH WEHRS,SUP-2312815,CDM,L8613,CPT,0278,RC,,,,both,,,1165.98,757.89,,,,,,,,,,,,,
PLATE BNE L117MM 7 H ST R POSTEROLATERAL DST HUM S STL LOK,SUP-2417016,CDM,C1713,HCPCS,0278,RC,,,,both,,,3093.15,2010.55,,,,,,,,,,,,,
ORTHOLOC SPS 3.5MM BIT DRILL,SUP-2822291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
HC Pt Neuro Facilitation Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209711200,CDM,97112,CPT,0420,RC,,,GP|CQ,both,,,159.00,103.35,,,,,,,,,,,,,
MESH HERN W6XH4IN OMEGA 3 FATTY ACID POLYPR OBLONG OVL BLT,SUP-2227207,CDM,C1781,HCPCS,0278,RC,,,,both,,,1070.74,695.98,,,,,,,,,,,,,
FRAME EXT FIX DIA4.2MM FIX AO FIT HOFFMANN II,SUP-2377973,CDM,C1713,HCPCS,0278,RC,,,,both,,,1642.22,1067.44,,,,,,,,,,,,,
PLATE BONE L142MM BLDE W5.8XL38MM 150DEG 8 H STRL BILAT PELV,SUP-2186698,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST POS LCK,SUP-2435609,CDM,L1831,HCPCS,0274,RC,,,,both,,,833.23,541.60,,,,,,,,,,,,,
STEM RADIAL 8X28 MM TI NS,SUP-2190891,CDM,C1776,CPT,0278,RC,,,,both,,,7503.03,4876.97,,,,,,,,,,,,,
CATHETER DIL 5.8FR L75CM BLLN L4CM DIA4MM 0.038IN 20ATM HI,SUP-2139189,CDM,C1726,HCPCS,0272,RC,,,,both,,,758.18,492.82,,,,,,,,,,,,,
RELOAD STPL L45MM DIA4.8MM GRN UNIV ROTIC SULU ENDO GIA,SUP-2283060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.29,643.04,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 5X5X.5CM TOT BONE MTRX SQ ACCELL,SUP-2242683,CDM,C1713,HCPCS,0278,RC,,,,both,,,6150.88,3998.07,,,,,,,,,,,,,
GII CONST INSRT W/JRNY LOCK SZ 3-4 15MM,SUP-2822672,CDM,C1776,CPT,0278,RC,,,,both,,,7002.20,4551.43,,,,,,,,,,,,,
PLATE BONE LT DBL Y MOTOBAND CP,SUP-2174976,CDM,C1713,HCPCS,0278,RC,,,,both,,,7050.87,4583.07,,,,,,,,,,,,,
HC So Testosterone Bioavailable,PX-3018441066,CDM,84410,CPT,0301,RC,,,,both,,,83.00,53.95,,,,,,,,,,,,,
PATCH CV IMPRA L 60 X W 30 MM THK 0.4 MM EPTFE OVL SHP TW,SUP-2761261,CDM,C1768,CPT,0278,RC,,,,both,,,821.52,533.99,,,,,,,,,,,,,
KIT IMPL L450MM DIA3.5MM TIM IM AND ENDCAP THE NANCY NAIL,SUP-2253252,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
GRAFT GRAN L SYNTH RESRB PROOSTEON 500R 15CC VI,SUP-2413084,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
KIT INTRO 18FR ANCHR SET W/ 4 SAF-T-PEXY T FAST HEMSTAT FOR,SUP-2124618,CDM,C1894,HCPCS,0272,RC,,,,both,,,758.59,493.08,,,,,,,,,,,,,
KIT SHTH INTRO 9FR L10CM PERC INTEGR HEMSTAS VLV SIDEPRT,SUP-2383378,CDM,C1894,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
KNIFE SURG SKID ACET LIGMNT SS NS LF,SUP-2481985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.24,793.81,,,,,,,,,,,,,
STAPLE BNE COMPR 25 MM 20 MM CONT 2 LEG BME ELITE,SUP-2564469,CDM,C1713,HCPCS,0278,RC,,,,both,,,4518.74,2937.18,,,,,,,,,,,,,
BLADE SURG DISP KOBYGARD,SUP-2319776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
ADAPTER OTO ABUTMENT 4 MM BNE ANCHORED PONTO BHX SINGLE STG,SUP-2430258,CDM,L8690,HCPCS,0278,RC,,,,both,,,10688.56,6947.56,,,,,,,,,,,,,
BONE GRAFT KIT COR DECOMPRESSION 15 CC PRO-STIM,SUP-2759594,CDM,C1713,HCPCS,0278,RC,,,,both,,,18956.18,12321.52,,,,,,,,,,,,,
SPLINT WRST PADDED LG MTCRPL RT,SUP-2195719,CDM,L3809,HCPCS,0272,RC,,,,both,,,17.46,11.35,,,,,,,,,,,,,
STENT PERIPH L17MM DIA25MM INTLUMN SUPP UNCONSTRAINED VES,SUP-2305192,CDM,C1876,HCPCS,0278,RC,,,,both,,,22466.70,14603.35,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST LACER MOLD TO PT MODEL,SUP-2435659,CDM,L2330,HCPCS,0274,RC,,,,both,,,1039.47,675.66,,,,,,,,,,,,,
ENDCAP SPNL LOK FOR SCR REVERE,SUP-2229228,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 11 MM FRZN PRESHAPED PATELLAR FLEXIGRAFT,SUP-2741040,CDM,C1762,CPT,0278,RC,,,,both,,,9122.39,5929.55,,,,,,,,,,,,,
DRAIN WND POLY VYN CHL FIRM TRCR MID PERF L5IN OD9FR,SUP-2197888,CDM,C1729,HCPCS,0272,RC,,,,both,,,240.68,156.44,,,,,,,,,,,,,
TIP CEMENT 90X6 MM OSTEO WDG TI STRL OSCAR PRO LTX,SUP-2875657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4317.66,2806.48,,,,,,,,,,,,,
BIT DRL CANN 7 MM KNEE SINGLE FLUT MTO,SUP-2849080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2201.14,1430.74,,,,,,,,,,,,,
DOLUTEGRAVIR SODIUM 50 MG PO TABS,RX-123363,CDM,6370000000,HCPCS,0637,RC,49702-0228-13,NDC,,both,1,UN,348.80,226.72,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2125854,CDM,C1781,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
SET GUIDEWIRE EXCHANGE JEFFREY SHTH L 18 CM ID 6.3 FR OD 8,SUP-2168011,CDM,C1769,HCPCS,0272,RC,,,,both,,,253.34,164.67,,,,,,,,,,,,,
EXTRACTOR STONE 3 WIR 2.4 FRX115 CM 1.5 CM TIP NIT NCOMPASS,SUP-2737221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-ENTERIC 16 FRX57.9 CM 7-10 CC MIC,SUP-2764421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.33,363.56,,,,,,,,,,,,,
TALC 4 G PL POWD,RX-141989,CDM,2500000003,HCPCS,0250,RC,62327-0444-44,NDC,,both,1,UN,879.80,571.87,,,,,,,,,,,,,
SUPPORT WR L LNG LEN RT FRARM WVN COT RUB FAB BGE FIRM W/,SUP-2324897,CDM,L3809,HCPCS,0274,RC,,,,both,,,41.01,26.66,,,,,,,,,,,,,
HC Treat Radius Fx,PX-4502552000,CDM,25520,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
BUR SURG L57MM DIA2MM STD NEURO RND FN DMND CUT NONFLUTED,SUP-2278117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.18,317.97,,,,,,,,,,,,,
PIN HLD FOR 2.4/2.7MM VAR ANG LOK CALCNL PLATING SYS LCP,SUP-2179058,CDM,C1713,HCPCS,0278,RC,,,,both,,,936.76,608.89,,,,,,,,,,,,,
SCREW BNE L54MM DIA2.7MM CORT ANK FT S STL ST NONCANNULATED,SUP-2411039,CDM,C1713,HCPCS,0278,RC,,,,both,,,64.31,41.80,,,,,,,,,,,,,
WIRE GUID GLDEWIRE STR TIP .018INX150CM 3CM,SUP-2385249,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.94,110.46,,,,,,,,,,,,,
PLATE BONE L178MM 5X22X5 H BILAT MAND ORAL MAXILLOFACIAL TI,SUP-2191432,CDM,C1713,HCPCS,0278,RC,,,,both,,,10126.19,6582.02,,,,,,,,,,,,,
PLATE BNE RADIAL STD 22X54 MM LT VOLAR DSTL 6X3 HOLE VA,SUP-2546695,CDM,C1713,HCPCS,0278,RC,,,,both,,,4356.97,2832.03,,,,,,,,,,,,,
SET INSTR OSTEOCHNDRL FLAP REP MULTISHOT,SUP-2121826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
SHAFT FEM TRAD ALLGRFT 70 MM FRZN,SUP-2294167,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.88,1514.42,,,,,,,,,,,,,
LINER ACET COMP 28MM ID SZ A STD RIM LCK RNG UHMWPE ARCM,SUP-2404822,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
STEM HUM CEM LNG 9X157 MM SHLDR AEQUALIS,SUP-2715561,CDM,C1776,CPT,0278,RC,,,,both,,,14070.34,9145.72,,,,,,,,,,,,,
HANDLE COIL DETACH CEREPAK MECH RAPID RELIABLE STRL,SUP-2865225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,886.39,576.15,,,,,,,,,,,,,
ELECTRODE ELECSURG L25CM DIA14GA ENH SEMI FLEX RF FOR TISS,SUP-2118729,CDM,C1894,HCPCS,0272,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
INTRODUCER CATH L3.5IN DIA7.5FR FOR CHOLANGIOGRAPHY TAUT,SUP-2384692,CDM,C1894,HCPCS,0272,RC,,,,both,,,92.63,60.21,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PERICARD 12X2 CM M THN PROC TUTOPLAST,SUP-2847986,CDM,C1762,CPT,0278,RC,,,,both,,,6085.32,3955.46,,,,,,,,,,,,,
SLING URO M SYS INTRO VENTRAL ELEVATION ALEXIS VIRTUE,SUP-2165305,CDM,C1771,HCPCS,0278,RC,,,,both,,,20479.08,13311.40,,,,,,,,,,,,,
CATHETER EP BPLR JOSEPHSON FIX CRV POLYMER COAT DBL STRND,SUP-2142662,CDM,C1730,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL CABLE PLAS,SUP-2435686,CDM,L2627,HCPCS,0272,RC,,,,both,,,6050.84,3933.05,,,,,,,,,,,,,
MESH CRAN W7.5XL11CM THK.6MM SHFT L4MM TI PLATING GRID,SUP-2277534,CDM,C1781,HCPCS,0278,RC,,,,both,,,1645.36,1069.48,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 60 MM DIA10 MM DEL SYS L 80 CM,SUP-2155371,CDM,C1876,HCPCS,0278,RC,,,,both,,,3925.63,2551.66,,,,,,,,,,,,,
BLADE SURG STRT 58 MM FIX HNDL SHFT,SUP-2242468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PIN BNE FIX L 5.8 MM DIA 0.062 IN SMILLIE,SUP-2933027,CDM,C1713,HCPCS,0278,RC,,,,both,,,110.18,71.62,,,,,,,,,,,,,
ATTACHMENT ROD FOR M MULTIPIN CLMP,SUP-2188525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1077.43,700.33,,,,,,,,,,,,,
BRACE ORTH THGH CIRC 13-15.5 IN XS SZ 1 ALUM SUEDE RL KNEE,SUP-2914964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1251.82,813.68,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LG VIABLE AMNION MTRX ESSENCE,SUP-2538799,CDM,C1762,CPT,0278,RC,,,,both,,,14958.96,9723.32,,,,,,,,,,,,,
SYSTEM SURG HEMSTAT PWD 1 GM POLYSACCHARIDE HEMOSPHERES,SUP-2127018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
TRAY BIOPSY BONE T LOK,SUP-2854988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
BIT DRL L100MM DIA2.7MM,SUP-2247469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
PLATE BNE L 151 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 9 H 72467709N,SUP-2933042,CDM,C1713,HCPCS,0278,RC,,,,both,,,3309.56,2151.21,,,,,,,,,,,,,
PPICC PROVENA SOLO 4F DL TL,SUP-2613558,CDM,C1751,HCPCS,0278,RC,,,,both,,,656.83,426.94,,,,,,,,,,,,,
STENT PERIPH L200MM DIA6MM CATH L80CM VASC,SUP-2418940,CDM,C1876,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
KIT BNE CEMENT MIXING SYS FEM BRKWY NOZ MED SLD PROX,SUP-2884229,CDM,C1776,CPT,0278,RC,,,,both,,,560.24,364.16,,,,,,,,,,,,,
PLATE BONE L202MM 16 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349761,CDM,C1713,HCPCS,0278,RC,,,,both,,,6274.35,4078.33,,,,,,,,,,,,,
RING ANNULPLSTY 40MM MI W/ DEL SYS PHY CARPENTIER,SUP-2214173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
PLATE FOOT LK CRV 6 HL,SUP-2701923,CDM,C1713,HCPCS,0278,RC,,,,both,,,2866.19,1863.02,,,,,,,,,,,,,
GRAFT BIO TISS W7XL20CM 4 LAYR PORCINE MTRX SFT TISS REINF,SUP-2168771,CDM,C1781,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
INSTRUMENT ORTH L7IN DRSG IN TOME,SUP-2408289,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.75,365.14,,,,,,,,,,,,,
KIT ORTH 15X300MMX130 RT R2.0 LEGION,SUP-2370028,CDM,C1713,HCPCS,0278,RC,,,,both,,,6097.25,3963.21,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX36 CM PRECRV W/ SH TITAN HD,SUP-2269569,CDM,C1881,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
IMPLANT BIO TISS W18 25XL300MM THCK CLLGN DERM MTRX XENMTRX,SUP-2126245,CDM,C1781,HCPCS,0278,RC,,,,both,,,83692.62,54400.20,,,,,,,,,,,,,
BUR SURG L14CM HD L79MM DIA6MM CYL FLUT L BOR MIDAS REX,SUP-2284381,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.35,225.78,,,,,,,,,,,,,
PLATE BNE W11XL190MM THK4.2MM 12 H MTPHSEAL S STL LOK COMPR,SUP-2185265,CDM,C1713,HCPCS,0278,RC,,,,both,,,3353.61,2179.85,,,,,,,,,,,,,
COMPONENT KNEE CR PRIMARY E-POLY VANGUARD XP,SUP-2408817,CDM,C1776,CPT,0278,RC,,,,both,,,17552.60,11409.19,,,,,,,,,,,,,
DEVICE INT FIX SM 14 MM THOR DBL FT STRNL STRL TALON LEVEL 1,SUP-2869188,CDM,C1713,HCPCS,0278,RC,,,,both,,,4406.96,2864.52,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 4 CM THK 0.2 MM HUM AMNIO MEMBRN,SUP-2909396,CDM,Q4282,HCPCS,0636,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
COMPONENT FEM F AP55.5MM ML25MM UNI PC PRI CEM STEMLESS R,SUP-2342165,CDM,C1776,CPT,0278,RC,,,,both,,,6845.20,4449.38,,,,,,,,,,,,,
PROCESSOR SND BRN BAHA INTENSO,SUP-2164954,CDM,L8691,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER VENTRICULAR ANTIMICROBIAL BACTISEAL BA STRP NS0339,SUP-2666789,CDM,C1729,HCPCS,0272,RC,,,,both,,,1754.26,1140.27,,,,,,,,,,,,,
PLATE BNE THK0.8MM UNIV 7 H CRANIOMAXILLOFACIAL TI DBL Y,SUP-2366257,CDM,C1713,HCPCS,0278,RC,,,,both,,,936.91,608.99,,,,,,,,,,,,,
HINGE EXT FIX ANK STRL TRUELOK PHANTOM LTX,SUP-2875237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ W STAY COCK UP FIRM SUPP,SUP-2276618,CDM,L3809,HCPCS,0272,RC,,,,both,,,16.14,10.49,,,,,,,,,,,,,
CATHETER GUID CS-H AD 8 FRX49 CM ACUITY BREAK-AWAY,SUP-2148957,CDM,C1887,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CATHETER URET 4FRX70CM NYL RUTNR UNIV WDG,SUP-2171184,CDM,C1758,HCPCS,0278,RC,,,,both,,,60.23,39.15,,,,,,,,,,,,,
RITUXIMAB-ABBS 500 MG/50ML IV SOLN,RX-148010,CDM,Q5115,HCPCS,0636,RC,63459-0104-50,NDC,,both,50,ML,12176.00,7914.40,,,,,,,,,,,,,
STAPLER INT OD24MM 33MM LN 3.5MM STPL SHT GRN STD TISS CIR,SUP-2219807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
CANNULA SUC IRR 5X280 MM 2 TRMPT VLV LASER GUIDE SEAL SS,SUP-2467733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1126.38,732.15,,,,,,,,,,,,,
BIT DRL DIA4.3MM TIB CALIB FOR NAT NAIL 18 SYS,SUP-2410909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.69,417.10,,,,,,,,,,,,,
GUIDEWIRE VASC LAUREATE L 180 CM DIA 0.038 IN NIT ANGLED,SUP-2457657,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT WIRION L 144 CM RETRV L 145 CM OD 6 FR,SUP-2755161,CDM,C1884,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
COIL EMB TWO DIM 3 MMX6 CM OPN LOOP DSTL TARGET 360 SFT,SUP-2365796,CDM,C1889,HCPCS,0278,RC,,,,both,,,5951.09,3868.21,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 40 CM SAPH VEIN BLD TYP A B AB O,SUP-2264305,CDM,C1768,CPT,0278,RC,,,,both,,,27471.86,17856.71,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 14 FRX25 CM W/ STAYFIX RESOLV +,SUP-2303343,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.25,136.66,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FLSH MINI L 135 CM BALLOON L 8 MM DIA 3,SUP-2319852,CDM,C1713,HCPCS,0278,RC,,,,both,,,3921.86,2549.21,,,,,,,,,,,,,
ALLOGRAFT HUM TISS BIOFIX +,SUP-2225301,CDM,C1713,HCPCS,0278,RC,,,,both,,,6870.32,4465.71,,,,,,,,,,,,,
ANCHOR SUT DIA1.4MM SGL LD SFT JUGGERKNOT,SUP-2212948,CDM,C1713,HCPCS,0278,RC,,,,both,,,1076.14,699.49,,,,,,,,,,,,,
PACK HEAT AIR ACT SGL LACTOSORB,SUP-2403061,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,0636,RC,43598-0106-11,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE 2X22MM CANN LO PROF CAPTURE,SUP-2243884,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.66,438.53,,,,,,,,,,,,,
GENERATOR NERVE STIM PULSE IMPL INFIN,SUP-2637207,CDM,C1767,HCPCS,0278,RC,,,,both,,,57335.18,37267.87,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 TI LCK SCREW 78MM S-T,SUP-2819241,CDM,C1713,HCPCS,0278,RC,,,,both,,,1227.46,797.85,,,,,,,,,,,,,
IMPLANT NSL L 55 X W 4 MM THK 4 MM PET POLYETHYL DORSUM TAPR,SUP-2883448,CDM,C1889,HCPCS,0278,RC,,,,both,,,1036.29,673.59,,,,,,,,,,,,,
HC Pt Vasopneumatic Device Therapy,PX-4209701600,CDM,97016,CPT,0420,RC,,,,outpatient,,,206.00,133.90,,,,,,,,,,,,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,J0618,HCPCS,0636,RC,00409-1631-10,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L55CM OD13.5FR INSRTN L38CM SIL STR,SUP-2127696,CDM,C1750,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
HC Radiologic Exam Upr GI Trc Double Contrast Study,PX-3207424600,CDM,74246,CPT,0320,RC,,,,both,,,1412.00,917.80,,,,,,,,,,,,,
COMPONENT GLEN FIX METAGLENE GLOB UNITE PLATFRM SHLDR SYS,SUP-2251010,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
COLLAR CERV M H4.25IN POLYETH FOAM CA,SUP-2196884,CDM,L0120,HCPCS,0272,RC,,,,both,,,43.05,27.98,,,,,,,,,,,,,
CATHETER LD DEL ATTAIN LDS L 45 CM OD 9 FR ID 7.2 FR LT,SUP-2282151,CDM,C1893,HCPCS,0272,RC,,,,both,,,1645.80,1069.77,,,,,,,,,,,,,
GRAFT BNE H10MM IL CREST WDG PRESERVON MATRIGRFT,SUP-2264839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1746.81,1135.43,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4 FR 40 CM 0.018 IN 7CM PLAT TIP STD,SUP-2615865,CDM,C1894,HCPCS,0272,RC,,,,both,,,114.70,74.55,,,,,,,,,,,,,
EXTENSION POST 6+ MM TI HUMELOCK II,SUP-2741762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE W10XL49MM THK1.2MM 4X3 H S STL T OBLQ BILAT,SUP-2372069,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BNE L 49 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 6 H SS,SUP-2936378,CDM,C1713,HCPCS,0278,RC,,,,both,,,1434.79,932.61,,,,,,,,,,,,,
LIGATOR ENDOSCP XSM DIA8.6-9.5MM TRIG CRD L122CM MIN ACC,SUP-2169548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
BLADE SHAVER RESECT 3.5X130 MM OVL MICRO STICK S1 DISP,SUP-2661214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.56,263.61,,,,,,,,,,,,,
GRAFT BNE FRZN STRUT CORT IMPL ALLGRFT L45XW10MM MATRIGRFT,SUP-2264745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.79,813.66,,,,,,,,,,,,,
SPLINT WRST SM L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276627,CDM,L3809,HCPCS,0274,RC,,,,both,,,23.20,15.08,,,,,,,,,,,,,
KIT GUIDEWIRE INTRO TORQUE DEV COPILOT BLEEDBK CTRL,SUP-2103553,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
KIT BUSHING REG UNIV HUM DST PRSS FIT TI SOLAR,SUP-2372333,CDM,C1776,CPT,0278,RC,,,,both,,,3584.37,2329.84,,,,,,,,,,,,,
SUPPORT ORTHOT SACROILIAC PELV CUST FLX STRP FABRICATED,SUP-2435552,CDM,L0622,HCPCS,0274,RC,,,,both,,,756.71,491.86,,,,,,,,,,,,,
MESH HERN L20.3XW10.2CM POLYPR ABD ABSRB RECTANG SEPRAMESH,SUP-2125923,CDM,C1781,HCPCS,0278,RC,,,,both,,,1007.31,654.75,,,,,,,,,,,,,
SCREW BNE CORTICAL UNIV 3.5X55 MM FEM ST LCK TI ULS NCB,SUP-2466538,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.40,45.76,,,,,,,,,,,,,
KIT INTRO PEELPRO L 14 CM DIA 8 FR PTFE TEARWY STD,SUP-2118931,CDM,C1894,HCPCS,0272,RC,,,,both,,,154.49,100.42,,,,,,,,,,,,,
SCREW BNE L10MM DIA3.5MM CANC BIODUR ALLY ST SELF DRL CANN,SUP-2409797,CDM,C1713,HCPCS,0278,RC,,,,both,,,542.59,352.68,,,,,,,,,,,,,
PASSER SUT CAPSULECLOSE SCORPION,SUP-2121459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP FIXED 40MM,SUP-2749352,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
BLOCK TIB SZ 9 THK10MM UNIV CO CHROM KNEE HALF PRI CEM TOT,SUP-2378522,CDM,C1776,CPT,0278,RC,,,,both,,,2548.42,1656.47,,,,,,,,,,,,,
"HC Granulocytes, Phersis Unit",PX-3900905000,CDM,P9050,CPT,0390,RC,,,,both,,,5427.00,3527.55,,,,,,,,,,,,,
SCREW BNE SET STD 5.5 MM 16 MM CANN THRD,SUP-2860999,CDM,C1713,HCPCS,0278,RC,,,,both,,,19094.72,12411.57,,,,,,,,,,,,,
HC Venous Sel Blood Sampling,PX-3613650000,CDM,36500,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SPACER SPNL EXPANDABLE SM COR PROC POST FUSION AILERON-TRX,SUP-2430757,CDM,C1889,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
SHEATH DIL DXL 18.1X16FR ORNG POLYPR LD EXTR TELSCP DISP,SUP-2169009,CDM,C1893,HCPCS,0272,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
COMPONENT SHLDR CAPPED REVERSED TRAB MTL,SUP-2422940,CDM,C1776,CPT,0278,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
GRAFT BNE FEM,SUP-2264894,CDM,C1762,CPT,0278,RC,,,,both,,,9592.89,6235.38,,,,,,,,,,,,,
PIN FIX 4 MMX30.5 CM FEMALE SPEC,SUP-2457013,CDM,C1713,HCPCS,0278,RC,,,,both,,,2235.49,1453.07,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4.6MM ANT CERV BLU TI SELF DRL LOK FOR,SUP-2255538,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
CATHETER CV SET 018 PEDIATRIC 4 FRX5 CM DL CUDLM401JPED,SUP-2760046,CDM,C1751,HCPCS,0278,RC,,,,both,,,236.25,153.56,,,,,,,,,,,,,
PLATE EXT FIX L140MM FT DBL H FOR SIDEKCK FRDM CIR FIX,SUP-2400642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3121.16,2028.75,,,,,,,,,,,,,
MESH SYN W10XL15CM THK2MM EPTFE ABD OVL BIOMATERIAL,SUP-2395345,CDM,C1781,HCPCS,0278,RC,,,,both,,,2270.22,1475.64,,,,,,,,,,,,,
EXPANDER TISS BRST ULTRA HI PROF SILTEX,SUP-2748663,CDM,C1889,HCPCS,0278,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
GRIP CBL SM L255MM TROCHANTERIC HIP 3 CBL ACCORD,SUP-2345203,CDM,C1776,CPT,0278,RC,,,,both,,,8402.64,5461.72,,,,,,,,,,,,,
PROPOFOL 500 MG/50ML IV EMUL,RX-133091,CDM,J2704,HCPCS,0636,RC,00409-4699-33,NDC,,both,50,ML,62.10,40.36,,,,,,,,,,,,,
STEM FEM L220MM OD13MM TI HA 80% POR DST CALCAR HIP DPHSEAL,SUP-2408331,CDM,C1776,CPT,0278,RC,,,,both,,,7975.60,5184.14,,,,,,,,,,,,,
SCREW BNE L16MM TI HND WRST ANK FT FULL THRD COMPR HDLSS,SUP-2107210,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SPACER SPNL 10MM BLU INDIR DCOMPR STRL SUPERION,SUP-2392699,CDM,C1821,HCPCS,0278,RC,,,,both,,,28888.00,18777.20,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA 30 MM BRANCH SZ 10 MM,SUP-2474522,CDM,C1768,CPT,0278,RC,,,,both,,,4226.25,2747.06,,,,,,,,,,,,,
SYSTEM INTGAST BLLN ORBERA,SUP-2119252,CDM,C1889,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
PLATE BNE STR 1.5X1 MM 12 MM MXLFCL OPN LOOP BRIDGE TI NS,SUP-2478205,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.24,470.11,,,,,,,,,,,,,
CORD REUS MONO FOR VL ASP BOVI,SUP-2166508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.16,204.20,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X146 MM 11 HOLE SS LC-DCP,SUP-2569245,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.85,226.75,,,,,,,,,,,,,
SCREW BNE ZURICH 1.5X5 MM 3 MM DRILL-FREE HEX TI,SUP-2469542,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
LEAD NERVE STIM 3 MM ELECTRD 4 MM SPC 90 CM OCTRODE,SUP-2615508,CDM,C1897,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX3 T SHAPED LEFT DORSAL DISTAL,SUP-2721719,CDM,C1713,HCPCS,0278,RC,,,,both,,,2813.75,1828.94,,,,,,,,,,,,,
MESH SURG W15XL15CM SQ PARTIALLY ABSRB FLAT FOR SFT TISS,SUP-2220105,CDM,C1781,HCPCS,0278,RC,,,,both,,,526.01,341.91,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 5 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2499614,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.58,920.78,,,,,,,,,,,,,
CANNULA ARTHSCP L5.5MM OP OUTER,SUP-2341437,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.82,345.03,,,,,,,,,,,,,
BUSHING TIB FINN,SUP-2406066,CDM,C1776,CPT,0278,RC,,,,both,,,720.63,468.41,,,,,,,,,,,,,
PLATE BNE LCK 5.5X311 MM LT PROX LAT TIB 18 HOLE SS STRL,SUP-2458033,CDM,C1713,HCPCS,0278,RC,,,,both,,,5381.71,3498.11,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 1.5X12X0.5 MM LP CONTOURED TI NS,SUP-2460225,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
COMPONENT FEM 2XL R HIP TI ALLY INTLOK PRI ASCNT,SUP-2406943,CDM,C1776,CPT,0278,RC,,,,both,,,17364.20,11286.73,,,,,,,,,,,,,
ANCHOR SUT ZIP PEEK 6.5MM W/ NDL,SUP-2366668,CDM,C1713,HCPCS,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
RING EXT FIX SEG 240 MM ALUM HOFFMANN,SUP-2462724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3494.19,2271.22,,,,,,,,,,,,,
BUR SURG DIAMOND 7.5 MM 9 CM BALL LG BOR MIDAS REX LEGEND,SUP-2631872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
KIT HIP ARTHRO INCL 17GA SPNL NDL NIT GWIRE 30CC SYR RUL,SUP-2366733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
COLLAR CERV ADJ UNIV AD 13-19 IN 2 PC RIGID REPL PD VISTA TX,SUP-2196893,CDM,L0120,HCPCS,0272,RC,,,,both,,,140.48,91.31,,,,,,,,,,,,,
TEMPLATE SZ SALVATION,SUP-2401126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EP XT L 110CM 6FR SPC 4 OCTAPOLAR,SUP-2499090,CDM,C1730,HCPCS,0272,RC,,,,both,,,380.10,247.06,,,,,,,,,,,,,
VALVE SHUNT L16MM ODSEC1.9MM IDSEC1.1MM STD LO PRSS IMP,SUP-2244290,CDM,C1729,HCPCS,0272,RC,,,,both,,,959.08,623.40,,,,,,,,,,,,,
SET SCR ORTH KNEE LOK LEGION,SUP-2421233,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.58,215.53,,,,,,,,,,,,,
BUR SURG L10CM DIA3MM BALL FLUT SM BOR MIDAS REX LEGEND,SUP-2277609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,308.54,200.55,,,,,,,,,,,,,
SCREW BNE SIG NOTCH 26 MM NS,SUP-2463261,CDM,C1713,HCPCS,0278,RC,,,,both,,,535.06,347.79,,,,,,,,,,,,,
WIRE BNE FIX L 5 IN DIA 0.045 IN DMND PT BOTH END STRL,SUP-2933187,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
SPLINT ORTH SM SHOE SZ M 4 6 WOM 5 7 NT FT ANK PLNTR,SUP-2195477,CDM,L4396,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
INSERT ORTH DIA5MM TI FOR LISS SCR H,SUP-2190746,CDM,C1713,HCPCS,0278,RC,,,,both,,,267.87,174.12,,,,,,,,,,,,,
CATHETER HD KT 12 FRX25 CM DL STR SFT TIP PRE CRV HI VOL,SUP-2762991,CDM,C1752,HCPCS,0278,RC,,,,both,,,402.55,261.66,,,,,,,,,,,,,
LEVONORGESTREL 20.1 MCG/DAY IU IUD,RX-157956,CDM,J7297,HCPCS,0636,RC,00023-5858-01,NDC,,both,1,UN,5357.50,3482.37,,,,,,,,,,,,,
BIT DRL L180MM DIA25MM 3 FLUT QUIK CPL FOR NCB,SUP-2199207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 13 CM DIA20 FR DIL 20 CM GUIDEWIRE,SUP-2168153,CDM,C1894,HCPCS,0272,RC,,,,both,,,106.73,69.37,,,,,,,,,,,,,
COIL EMB L10CM OD0.020IN NIT J STRTCH RESIST FILL SFT STBL,SUP-2323421,CDM,C1889,HCPCS,0278,RC,,,,both,,,7281.66,4733.08,,,,,,,,,,,,,
ILLUMINATOR BLDE MINIMALLY INVASIVE SURG W/ INFORMATIONAL,SUP-2232231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
SLEEVE CBL L850MM DIA2MM COCR OSTEO-CLAGE,SUP-2106615,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
HC CT Abd W&W/O Cont,PX-3527417000,CDM,74170,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
CATHETER PTCA 4FR L120CM QUADFLEX BLLN L15CM DIA5MM SHTH,SUP-2156672,CDM,C1725,HCPCS,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
RASP SURG CTTL NSL HANDHELD SGL END STR TAPR FLAT BLDE CNVX,SUP-2367145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
SCREW CANC TI 4MMX1422MM TL9MM,SUP-2695552,CDM,C1713,HCPCS,0278,RC,,,,both,,,149.46,97.15,,,,,,,,,,,,,
PLATE BNE L 65 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 8 H SS 72440308,SUP-2932904,CDM,C1713,HCPCS,0278,RC,,,,both,,,1547.20,1005.68,,,,,,,,,,,,,
PLATE BNE L458MM 22 H ST L CNDYL S STL LOK COMPR CRV FOR,SUP-2177087,CDM,C1713,HCPCS,0278,RC,,,,both,,,5193.21,3375.59,,,,,,,,,,,,,
SCREW BONE L76MM OD3.5MM COARSE THRD CRUCFRM WDRUFF HD,SUP-2362307,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.81,16.78,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.018 IN CRV RAD 3 MM SS PTFE,SUP-2167681,CDM,C1769,HCPCS,0272,RC,,,,both,,,161.65,105.07,,,,,,,,,,,,,
BIT DRL DIA3.2MM SLD FOR JONE FRAC SYS CHARLOTTE CAROLINA,SUP-2398090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP PRESHAPED ACHILLES TEND,SUP-2867036,CDM,C1762,CPT,0278,RC,,,,both,,,7134.08,4637.15,,,,,,,,,,,,,
PACEMAKER CARD STD PERM 2 CHMBR DDDR BPLR IS-1 CONN NOT MRI,SUP-2138079,CDM,C1785,HCPCS,0275,RC,,,,both,,,16952.86,11019.36,,,,,,,,,,,,,
ALLOGRAFT BNE COR FRZN WHL PAT,SUP-2736962,CDM,C1762,CPT,0278,RC,,,,both,,,4530.96,2945.12,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00264-7510-10,NDC,,both,500,ML,34.00,22.10,,,,,,,,,,,,,
STEM FEM DIA15MM +0MM OFFSET LNG L HIP TI POLISHED REV BOW,SUP-2344353,CDM,C1776,CPT,0278,RC,,,,both,,,14403.18,9362.07,,,,,,,,,,,,,
SYSTEM ANCHR PELV PRESSIN,SUP-2141758,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
GRAFT BNE SUB 10ML CANC CORT DBM CHIP RM TEMP FRZ DRY,SUP-2223563,CDM,C1762,CPT,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
SPACER SPNL W14XH11XL24MM 0DEG PEEK ANT THORLUM INTBDY FUS,SUP-2286247,CDM,C1821,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
SCREW INTRF L30MM DIA10MM SHTH L L30MM TIB BIOCRYL RAPIDE,SUP-2256830,CDM,C1713,HCPCS,0278,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
TUBE MYRINGOTOMY 1.27 MM CLLR BUTTON FLROPLAS BLU,SUP-2430211,CDM,C1713,HCPCS,0278,RC,,,,both,,,1197.69,778.50,,,,,,,,,,,,,
IMPLANT HUM TISS L 11 X W 10 CM PLCNTA MEMBRN MULTILAYERED,SUP-2927338,CDM,Q4109,HCPCS,0636,RC,,,,both,,,301440.00,195936.00,,,,,,,,,,,,,
EXPANDER BRST TISS HSC TEXT RND MOD + PROJCT 650CC 148CM X,SUP-2422110,CDM,C1789,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BONE L94MM 4 H LT LAT PROX TIB S STL LCK FOR 4.5MM SCR,SUP-2348221,CDM,C1713,HCPCS,0278,RC,,,,both,,,12487.78,8117.06,,,,,,,,,,,,,
CANNULA SET 3.0MM NON-FENESTRATED,SUP-2812608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4223.30,2745.14,,,,,,,,,,,,,
CAP NAIL HUM 0 MM AG RETROGRADE STRL AFFIXUS NAT NAIL,SUP-2606872,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
SET SCR SPNL L35MM DIA5.2MM PEDCL HA TI ALLOY FOR DYN STBL,SUP-2414473,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SPLINT ARM M L85IN L ALUMINUM FOAM PD MAL COLLES,SUP-2276767,CDM,L3809,HCPCS,0272,RC,,,,both,,,14.10,9.16,,,,,,,,,,,,,
MATRIX BIO SZ 250 SQCM FISH SKIN DERMAL MESHED 21 INTACT,SUP-2909273,CDM,Q4158,HCPCS,0636,RC,,,,both,,,25041.50,16276.97,,,,,,,,,,,,,
OBTURATOR ENDOSCP L250MM DIA5MM FLX BLNT TIP DA VINCI,SUP-2246705,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
MESH SURG PROGRIP 6X6 CM POLY POLYLACTIC ACID MFIL KNIT RECTANG,SUP-2174794,CDM,C1781,HCPCS,0278,RC,,,,both,,,762.27,495.48,,,,,,,,,,,,,
CATHETER DLYS CHRONIC VAXCEL + 45552] NAVILYST MEDICAL],SUP-2308252,CDM,C1750,HCPCS,0278,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
RELOAD STPL CRV TIP 45 MM GRY SIGNIA ENDO GIA TRISTAPLE 20,SUP-2283356,CDM,C1713,HCPCS,0278,RC,,,,both,,,2095.13,1361.83,,,,,,,,,,,,,
SCREW BONE INTLOK CORT FULL THRD N CANN ST LCK NSTERILE 4.3,SUP-2204962,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.91,341.19,,,,,,,,,,,,,
SODIUM BICARBONATE 650 MG PO TABS,RX-7313,CDM,6370000000,HCPCS,0637,RC,00904-7261-61,NDC,,both,1,UN,1.40,0.91,,,,,,,,,,,,,
DRILL SURG L1524MM DIA36MM CAPTURE,SUP-2244279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.82,519.23,,,,,,,,,,,,,
CONNECTOR SPNL PARL WIDE 6.35-6.35 MM DBL SS REVERE,SUP-2594665,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SOCK PROSTHETIC IA BODY,SUP-2388155,CDM,L0984,HCPCS,0272,RC,,,,both,,,166.80,108.42,,,,,,,,,,,,,
LEUPROLIDE ACETATE 7.5 MG SC KIT,RX-32893,CDM,J9217,HCPCS,0636,RC,62935-0756-80,NDC,,both,1,UN,443.60,288.34,,,,,,,,,,,,,
COMP FEM AUG BTN STD+/LG+15DTL,SUP-2513646,CDM,C1776,CPT,0278,RC,,,,both,,,1306.24,849.06,,,,,,,,,,,,,
BEAM FIX 5.5X145 MM AXIS,SUP-2610010,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
PLATE BONE 3D PRNT MED MIDFACE MAND TI TRUMATCH,SUP-2860372,CDM,C1713,HCPCS,0278,RC,,,,both,,,41843.33,27198.16,,,,,,,,,,,,,
DRIVER SURG CANN FRAG LOC 1.5MM,SUP-2107138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
DRILL SURG PILOT DSTL TROCHANTERIC HI PERF SIG,SUP-2453138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1604.54,1042.95,,,,,,,,,,,,,
EVOS 2.7/3.5MM PL-D HUM PL 17H L 206MM,SUP-2819862,CDM,C1713,HCPCS,0278,RC,,,,both,,,9502.90,6176.88,,,,,,,,,,,,,
SEEKER BAL L17MM DIA7MM SPHENOID SINUS FOR ENT,SUP-2284118,CDM,C1713,HCPCS,0278,RC,,,,both,,,1309.69,851.30,,,,,,,,,,,,,
STENT ENDOVASC L79MM DIA6-8MM CATH L80CM INTRO SHTH 7FR,SUP-2395657,CDM,C1874,HCPCS,0278,RC,,,,both,,,9953.80,6469.97,,,,,,,,,,,,,
LEAD PACE COROX L 77 CM DIA1.6 MM POLYUR IRIDIUM OXIDE TIP,SUP-2138025,CDM,C1900,HCPCS,0275,RC,,,,both,,,5960.44,3874.29,,,,,,,,,,,,,
SPACER SHLDR SUBACROMIAL SM BIODEGRADABLE INSPACE,SUP-2736622,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
HC So1 Assay of Psa Total|NOT REASONABLE AND NECESSARY,PX-3018415367,CDM,84153,CPT,0301,RC,,,GZ,both,,,57.00,37.05,,,,,,,,,,,,,
SCREW BNE CANN 3.5X12 MM FA0120] ACUMED LLC],SUP-2107587,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BLLN L12MM DIA2MM TAKERU GWIRE 0.014IN RAP EXCHG,SUP-2418789,CDM,C1725,HCPCS,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 5 FR SS HYDRPHLC PERIPHERAL,SUP-2385292,CDM,C1894,HCPCS,0272,RC,,,,both,,,371.78,241.66,,,,,,,,,,,,,
PIN EXT FIX THRD 4X250 MM TRANSFIX APEX,SUP-2363241,CDM,C1713,HCPCS,0278,RC,,,,both,,,391.53,254.49,,,,,,,,,,,,,
SCREW BONE EMERGENCY 18 MM TITANIUM LIGHT BLUE NON STERILE M,SUP-2837724,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.80,189.02,,,,,,,,,,,,,
INSERT 3DKNEE SZ 2 9 MM LT CM,SUP-2216617,CDM,C1776,CPT,0278,RC,,,,both,,,3780.56,2457.36,,,,,,,,,,,,,
BIT DRL CALIB 3.3 MM HUM C LBL INSTRUMENT CASE STRL AFFIXUS,SUP-2606175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S9173108PD,SUP-2632873,CDM,C1751,HCPCS,0278,RC,,,,both,,,681.32,442.86,,,,,,,,,,,,,
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-157661,CDM,J1650,HCPCS,0636,RC,00075-0620-01,NDC,,both,0.4,ML,190.20,123.63,,,,,,,,,,,,,
ALLOGRAFT BNE IMPL 15X1 MM CRYOPRESERVED CART PROCHONDRIX CR,SUP-2361154,CDM,C1889,HCPCS,0278,RC,,,,both,,,20485.36,13315.48,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S9173108D,SUP-2632872,CDM,C1751,HCPCS,0278,RC,,,,both,,,618.52,402.04,,,,,,,,,,,,,
HC Inj Trigger Points 1-2 Musc,PX-4502055200,CDM,20552,CPT,0450,RC,,,,both,,,613.00,398.45,,,,,,,,,,,,,
PLATE BNE L 66 MM 14 H TI REAR FT RECON NS TOT FT SYS 2,SUP-2933698,CDM,C1713,HCPCS,0278,RC,,,,both,,,4412.80,2868.32,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 6 FR 0.021IN PLAS,SUP-2385464,CDM,C1894,HCPCS,0272,RC,,,,both,,,294.38,191.35,,,,,,,,,,,,,
GRAFT BNE VIABLE 1 CC TIM MTRX FIBERCEL,SUP-2422145,CDM,C1762,CPT,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
BLADE SAW SAG 16X7 MM 20 MM GRFT HARVESTING W/ STP SS HALL,SUP-2166196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
MAGNESIUM CHLORIDE 64 MG PO TBEC,RX-141212,CDM,6370000000,HCPCS,0637,RC,68585-0005-75,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
RAIL EXT FIX TRANSITION 5.5X495 MM 4D TI,SUP-2517544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6929.51,4504.18,,,,,,,,,,,,,
NAPHAZOLINE-PHENIRAMINE 0.025-0.3 % OP SOLN,RX-5384,CDM,6370000000,HCPCS,0637,RC,00065-0085-15,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
SET COMP CNTRLZR PAT LIMB SALV LO BODY UHMWPE INCL SM 12MM,SUP-2265085,CDM,C1776,CPT,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
COIL EMB L4CM DIA2.5MM EXTRA SFT 3D DETACH AXIUM PRIM,SUP-2295032,CDM,C1889,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
STENT ENDOPROS TOT CVR L150MM DIA42X38MM PROX DST CATH 25FR,SUP-2281713,CDM,C1768,CPT,0278,RC,,,,both,,,55719.30,36217.54,,,,,,,,,,,,,
HC So1 Hcv Ultraquant,PX-3068752267,CDM,87522,CPT,0306,RC,,,,both,,,565.00,367.25,,,,,,,,,,,,,
BIT DRL L 145/60 MM DIA2 MM SCREW DIA2.7 MM CALIB AO QC STRL,SUP-2907877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.60,574.34,,,,,,,,,,,,,
FIBER LASER 131 FT KRA-CPAOCHXL HDMI,SUP-2798081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1436.80,933.92,,,,,,,,,,,,,
HC So Dhea Sulfate,PX-3018262766,CDM,82627,CPT,0301,RC,,,,both,,,327.00,212.55,,,,,,,,,,,,,
STE NAVICULAR PLT RT SM,SUP-2588796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.78,944.31,,,,,,,,,,,,,
HC Inj for Cholangiogram New Acc,PX-3614753200,CDM,47532,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PENICILLIN V POTASSIUM 250 MG PO TABS,RX-6092,CDM,6370000000,HCPCS,0637,RC,65862-0175-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE W101XL182MM THK35MM 13 H BILAT TI STR RIG LOK,SUP-2191088,CDM,C1713,HCPCS,0278,RC,,,,both,,,2003.89,1302.53,,,,,,,,,,,,,
SCREW 5.0MM TI RECON W T25 STARDRIVE 80MM STERILE,SUP-2546400,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.76,396.34,,,,,,,,,,,,,
PLATE BNE SM W11XL103MM THK3.3MM 0DEG 7 H BILAT TI STR,SUP-2190780,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.31,390.20,,,,,,,,,,,,,
CATHETER REPROC EP INQUIRY DECAPOLAR 6FR,SUP-2465663,CDM,C1730,HCPCS,0272,RC,,,,both,,,694.19,451.22,,,,,,,,,,,,,
CANNULA SURG CEPHALOMEDULLARY DBL BRL,SUP-2487689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3849.64,2502.27,,,,,,,,,,,,,
PLATE BNE CALCANEAL LG LT SINUS TARSI FRAC TI BABY GORILLA,SUP-2751019,CDM,C1713,HCPCS,0278,RC,,,,both,,,3414.75,2219.59,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LIVIAN TI CRT 3 CHMBR DDDR BATTERY PWR,SUP-2149052,CDM,C1882,HCPCS,0275,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
SCREW BNE L15MM DIA65MM PORCOAT CANC KNEE REV THRD LO PROF,SUP-2253373,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.29,345.34,,,,,,,,,,,,,
DISTRACTOR EXT FIX 30 MM 1 - 1.2 MM 9 HOLE MESH END DRIVEN,SUP-2458111,CDM,C1713,HCPCS,0278,RC,,,,both,,,16631.51,10810.48,,,,,,,,,,,,,
PLATE BNE ANTI-GLADE MEDL 4 HOLE,SUP-2518427,CDM,C1713,HCPCS,0278,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
PLATE BONE L65MM 8 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348296,CDM,C1713,HCPCS,0278,RC,,,,both,,,5284.46,3434.90,,,,,,,,,,,,,
SHUNT CSF ADJUSTABLE GRAVITATIONAL UNIT 0-20CM H2O WITH PEDI,SUP-2825850,CDM,C1889,HCPCS,0278,RC,,,,both,,,9218.35,5991.93,,,,,,,,,,,,,
IMPLANT FACE L 48 X W 38 MM THK 1 MM POLYETHYL EMBEDDED TI,SUP-2883625,CDM,C1713,HCPCS,0278,RC,,,,both,,,5417.00,3521.05,,,,,,,,,,,,,
KIT VASC CLOSURE VASOSEAL CLLGN MEDIATED EXTRAVASCULAR ORN,SUP-2227428,CDM,C1760,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE W24XL45MM 8 H NONSTERILE BILAT MIDFOOT HINDFOOT TI,SUP-2191457,CDM,C1713,HCPCS,0278,RC,,,,both,,,2692.05,1749.83,,,,,,,,,,,,,
COMPONENT FEM CRUC RET N POR LT 68MM MEDL LAT 43MM ANT POST,SUP-2252373,CDM,C1776,CPT,0278,RC,,,,both,,,9492.22,6169.94,,,,,,,,,,,,,
SUTURE ANCHOR Y-KNOT RC WITH NEEDLES,SUP-2824746,CDM,C1713,HCPCS,0278,RC,,,,both,,,3230.12,2099.58,,,,,,,,,,,,,
CEFOXITIN SODIUM-DEXTROSE 1-4 GM-%(50ML) IV SOLR,RX-143618,CDM,J0694,HCPCS,0636,RC,00264-3123-11,NDC,,both,1,UN,108.50,70.52,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 125 CM OD 0.070 IN ID 0.058 IN FLX,SUP-2281409,CDM,C1887,HCPCS,0272,RC,,,,both,,,5133.90,3337.03,,,,,,,,,,,,,
PLATE BNE L262MM 14 H NONSTERILE R MED DST TIB S STL VAR ANG,SUP-2177648,CDM,C1713,HCPCS,0278,RC,,,,both,,,6405.95,4163.87,,,,,,,,,,,,,
GUIDEWIRE VASC L180MM DIA0.018MM TAPR L15CM FLPY TIP L3CM,SUP-2170334,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.87,75.97,,,,,,,,,,,,,
SCREW BNE L40MM DIA3.5MM CORT DST TIB TI NONCANNULATED,SUP-2413375,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
ALLOGRAFT BNE LG 126 MM FD IRRADIATED CORTICAL SHFT,SUP-2866974,CDM,C1762,CPT,0278,RC,,,,both,,,2117.93,1376.65,,,,,,,,,,,,,
CROWN DENT SZ 4 NOEUL-4 SEC PRI M UP L S STL,SUP-2322195,CDM,D6783,CPT,0278,RC,,,,both,,,28.45,18.49,,,,,,,,,,,,,
MESH HERN 3X6IN POLYPR SYN RECT NONABSORBABLE KNIT MFIL,SUP-2126053,CDM,C1781,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
HC C-Spine Min 4 Views,PX-3207205000,CDM,72050,CPT,0320,RC,,,,both,,,737.00,479.05,,,,,,,,,,,,,
HC Surgery Level 2 Base,PX-3600000002,CDM,3600000002,LOCAL,0360,RC,,,,both,,,4526.00,2941.90,,,,,,,,,,,,,
LEADWIRE KNDL DL DRCT CNCT DSPSBLE SHLD EKG 6 LEAD NHN KHDN,SUP-2917064,CDM,C1713,HCPCS,0278,RC,,,,both,,,42.08,27.35,,,,,,,,,,,,,
RESERVOIR SHUNT 14MM SMALL TITANIUM RADIOPAQUE GRADUATED VEN,SUP-2826651,CDM,C1889,HCPCS,0278,RC,,,,both,,,1573.17,1022.56,,,,,,,,,,,,,
RING EXT FIX FULL 200 MM CIR SIDEKCK,SUP-2850368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
WASHER ORTHOPEDIC DIA 19 MM SCREW DIA 6.5/8 MM,SUP-2900796,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.59,212.28,,,,,,,,,,,,,
KIT INT FIX 12 MM BUSHING SET SCR STRL TIP-LOC,SUP-2912744,CDM,C1713,HCPCS,0278,RC,,,,both,,,3918.72,2547.17,,,,,,,,,,,,,
FOOT RING LNG DIA 140 MM ALUMINIUM,SUP-2497655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4569.33,2970.06,,,,,,,,,,,,,
SET URET STENT L 20 CM DIA 7 FR TIP L 3 CM STIFF SHFT,SUP-2537669,CDM,C2617,HCPCS,0278,RC,,,,both,,,619.65,402.77,,,,,,,,,,,,,
STAPLER ENDO L45MM BLU STR ARTC NONABSORBABLE,SUP-2257563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1145.75,744.74,,,,,,,,,,,,,
DEVICE TISS FIX L 18 X W 2.5 MM TEND THK 1.5-4 MM W 3-7 MM,SUP-2900764,CDM,C1713,HCPCS,0278,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 20 CM RND SKIRTED PARIETEX,SUP-2752188,CDM,C1781,HCPCS,0278,RC,,,,both,,,4548.23,2956.35,,,,,,,,,,,,,
PLATE BNE L125MM 7 H ST L LAT DST FIBULAR S STL LOK COMPR,SUP-2177421,CDM,C1713,HCPCS,0278,RC,,,,both,,,1980.21,1287.14,,,,,,,,,,,,,
PLATE EXT FIX L40MM ANK FT FOR TRUELOK FRME ASSEMB HEXAPOD,SUP-2316156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.43,249.23,,,,,,,,,,,,,
KIT AUTOTRNS AUTOLGS PLT CONC DISP FOR HARV SMARTPREP 2 51404] TERUMO CARDIOVASCULAR],SUP-2384888,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
ALLOGRAFT BNE 4X8X20 MM BIOEXPAND,SUP-2637000,CDM,C1713,HCPCS,0278,RC,,,,both,,,2869.24,1865.01,,,,,,,,,,,,,
SCREW BNE L90MM DIA13MM STD CANC S STL LAG 1 STP RECESS FOR,SUP-2186581,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.36,78.88,,,,,,,,,,,,,
CONNECTOR SPNL TI AX MECH FOR 5.5MM ROD MOSS MIAMI,SUP-2254451,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC So Smear Afb,PX-3008720666,CDM,87206,CPT,0300,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
SCREW BONE L65MM OD7MM THRD L17MM PUR HINDFOOT ANK CANN SH,SUP-2320948,CDM,C1713,HCPCS,0278,RC,,,,both,,,2846.41,1850.17,,,,,,,,,,,,,
BUR SURG DIA 5 MM HUB XLI DIAMOND STRL DISP HI-LINE XS,SUP-2929057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,667.78,434.06,,,,,,,,,,,,,
TEMPLATE SURG 19X6 MM IM CHART FIX SYS STR SZ NIT HAMMERLOCK,SUP-2431398,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
HEAD HUM L15MM DIA40MM 3.5MM OFFSET PROX SHLDR COAT FOR,SUP-2388545,CDM,C1776,CPT,0278,RC,,,,both,,,5769.75,3750.34,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM TIP L5CM 0.25FR STR RND TIP TUNGSTEN,SUP-2420157,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.81,357.38,,,,,,,,,,,,,
RAIL L230MM AD SHT COMP FOR LIMB RECON SYS,SUP-2316077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3187.60,2071.94,,,,,,,,,,,,,
SET PRSS MON QUIK INT COMPARTMENTAL SYS,SUP-2366839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STENT GRFT VASC OVATION IX L 140 MM 185 MM 14/10 MM 10/12 FR,SUP-2217735,CDM,C1768,CPT,0278,RC,,,,both,,,13275.92,8629.35,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON SM 8 IN RT WRST PLUSH FOAM LNR NYL,SUP-2276664,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.86,10.96,,,,,,,,,,,,,
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,0636,RC,67457-0390-54,NDC,,both,5,ML,129.80,84.37,,,,,,,,,,,,,
GRAFT BNE 10ML CANC MIC MORSL B-TCP VITOSS,SUP-2368164,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
CLAMP SURG FOR DAF SUPLMNT SCREW HOLDER 10037,SUP-2874949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,953.93,620.05,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DBX MIX FRZ DRY FOR VOID FILL,SUP-2307002,CDM,C9359,HCPCS,0278,RC,,,,both,,,2620.64,1703.42,,,,,,,,,,,,,
WEGDE TS TANGENT TISS 160826 IMP WG 8X26 FF,SUP-2293758,CDM,C1713,HCPCS,0278,RC,,,,both,,,8173.42,5312.72,,,,,,,,,,,,,
MICROCATHETER INTRVNTNL 0.021N ID 130CML NTNL BERN ROX2 TRQB,SUP-2652829,CDM,C1887,HCPCS,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
IMPLANT TOE JT W10 14MMXH25MM THK5MM BNE COT WDG,SUP-2321661,CDM,C1713,HCPCS,0278,RC,,,,both,,,4519.09,2937.41,,,,,,,,,,,,,
BIT DRL OD6.4MM STP DISP FOR TRIGEN TAN FAN,SUP-2347045,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1891.44,1229.44,,,,,,,,,,,,,
MESH SURG 1.5X113X77MM THK0.6MM TI FLX STD CRAN PLATING SYS,SUP-2279903,CDM,C1781,HCPCS,0278,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
TUBE TRACH PED L42MM OD67MM ID45MM SIL CUF STR NK FLNG FLX,SUP-2352327,CDM,2720000010,LOCAL,0272,RC,,,,both,,,575.69,374.20,,,,,,,,,,,,,
BIT DRL QC 0.25 IN 25 MM U JT,SUP-2598584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SHEATH IVC FILTER REMOVAL LASER 16F CAVACLEAR,SUP-2850092,CDM,C1603,HCPCS,0272,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
INSERT TIB REG THK8.5MM POLYETH KNEE ARTC SURF NEUT UNIV PRI,SUP-2200353,CDM,C1776,CPT,0278,RC,,,,both,,,7451.22,4843.29,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 9 HOLE COMPR STRL ALPS LTX,SUP-2861818,CDM,C1713,HCPCS,0278,RC,,,,both,,,1009.07,655.90,,,,,,,,,,,,,
SCREW BNE CANN 7.3X80 MM PROX CONCL PART THRD SS NS LCP,SUP-2184788,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
CATHETER DRAINAGE RESOLV L 20 CM DIA 7.5 FR 0.038 IN J CRV,SUP-2460767,CDM,C1729,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
COUNTERSINK SURG CANN FOR 2.4MM SCR,SUP-2187346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1168.05,759.23,,,,,,,,,,,,,
INSERTER SURG,SUP-2437813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 27MMW X 30MML SPNL MSCLE WIDE RGGLS RDM,SUP-2458120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1708.51,1110.53,,,,,,,,,,,,,
PLATE BONE 8 HOLEXSHAPED STRNL CBL TRITIUM SCP,SUP-2335597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X119 MM 7 HOLE SS DCP,SUP-2569175,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.58,240.23,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL EMER CROSS PIN MID FACE VIT SLD,SUP-2364644,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.03,84.52,,,,,,,,,,,,,
RETRACTOR NRV ROOT WIDE 5 3 4IN ENDOSCP R ANG,SUP-2292919,CDM,C1713,HCPCS,0278,RC,,,,both,,,966.52,628.24,,,,,,,,,,,,,
DEVICE VENTRICULAR ASST INFLO CONDUIT SEAL HEARTMATE II,SUP-2356003,CDM,C1713,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
CONNECTOR SPNL 35.5MM-40MM SM CROSS CLMP ADJ TI,SUP-2415636,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.98,746.19,,,,,,,,,,,,,
HANDPIECE LASER 125 MM W/ SMK EVAC,SUP-2713687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5620.60,3653.39,,,,,,,,,,,,,
SCREW BNE 30 DEG L 45 MM DIA 3.5 MM TI LCK VA T15 DRV NS,SUP-2931494,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.90,317.78,,,,,,,,,,,,,
CATHETER GUID GUIDELINER V3 L 150 CM DIA 7 FR RX L 25 CM,SUP-2383145,CDM,C1887,HCPCS,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
SLING SHLDR UNIV SWTH W5XL54IN PCH W13XL19IN LTWT PERF FOAM,SUP-2195038,CDM,L3660,HCPCS,0274,RC,,,,both,,,27.41,17.82,,,,,,,,,,,,,
ELEVATOR SURG L11IN BLDE W32MM S STL COBB DAWSON YUHL,SUP-2160987,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.81,220.88,,,,,,,,,,,,,
SUPPORT WR SM AD LT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324889,CDM,L3931,HCPCS,0274,RC,,,,both,,,42.83,27.84,,,,,,,,,,,,,
KIT TKR 3 FEM PREP CRUCE RET DISPOSABLE TRIATHLON PRECIS,SUP-2373669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.10,421.26,,,,,,,,,,,,,
BRACE ORTHOPEDIC IMMOB KNEE CUST,SUP-2265015,CDM,L1810,HCPCS,0274,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GUIDE PLUNG 6MM DEL CLR COR,SUP-2256812,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
BIT DRL 2.3 MM 70720001] WRIGHT MEDICAL TECHNOLOGY INC],SUP-2398616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
PLATE BNE L220MM 9 H NONSTERILE R PROX LAT TIB S STL LOK,SUP-2184881,CDM,C1713,HCPCS,0278,RC,,,,both,,,3997.38,2598.30,,,,,,,,,,,,,
PLATE BNE L73MM 2 H ST L PROX OLECRANON S STL LO PROF VAR,SUP-2177183,CDM,C1713,HCPCS,0278,RC,,,,both,,,3168.48,2059.51,,,,,,,,,,,,,
BIT DRILL DIAM SIZE: 2.7MM,SUP-2243131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
ELECTRODE ELECSURG KNIFE 30 DEG UROLOGY BPLR STRL DISP,SUP-2494188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.40,437.06,,,,,,,,,,,,,
SCREW BNE PART THRD 5X55 MM PANTA,SUP-2609753,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.65,1347.22,,,,,,,,,,,,,
SCREWDRIVER SURG CANN ATTCH AO,SUP-2321712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,868.21,564.34,,,,,,,,,,,,,
BIT DRL L65MM DIA1.5MM ST MINI QUIK CPL NONRADIOPAQUE W/O,SUP-2187183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.08,236.65,,,,,,,,,,,,,
REAMER SURG L20MM DISP GLENOJET,SUP-2123642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
PLATE BNE W6.8XL90.2MM THK1.65MM 12 H TI STR LOK LO PROF,SUP-2411745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1793.57,1165.82,,,,,,,,,,,,,
SCREW BONE L5MM DIA2.7MM TI ST FULL THRD EMER MATRIXMANDIBLE,SUP-2181734,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.84,258.60,,,,,,,,,,,,,
COMPONENT FEM CEM 2XS UNISX LT KNEE REV CR STEM BEAD VIT,SUP-2377025,CDM,C1776,CPT,0278,RC,,,,both,,,14016.96,9111.02,,,,,,,,,,,,,
HC So Chromogenic Ish,PX-3128837766,CDM,88377,CPT,0312,RC,,,,both,,,456.00,296.40,,,,,,,,,,,,,
POR PRI BIPOLAR/STD HD,SUP-2408788,CDM,C1776,CPT,0278,RC,,,,both,,,6573.06,4272.49,,,,,,,,,,,,,
PLATE BNE L40MM 4 H NONSTERILE BILAT TARSOMETATARSAL S STL,SUP-2184841,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.65,1708.62,,,,,,,,,,,,,
SCREW BNE ST 1.3X14 MM CRTX W/ FLUT TIP TI MTRX GLD NS LF,SUP-2189190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1611.13,1047.23,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 12 MM IRRADIATED,SUP-2867104,CDM,C1762,CPT,0278,RC,,,,both,,,1932.98,1256.44,,,,,,,,,,,,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,J2003,HCPCS,0636,RC,55150-0251-10,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT NRV L70MM DIA3-4MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124853,CDM,C1763,HCPCS,0278,RC,,,,both,,,29443.78,19138.46,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 14 ATM 5 FRX139 CM 2X6 MM EMPIRA RX,SUP-2158489,CDM,C1725,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ADAPTER ORTH QC FOR 5 MM HALF PIN STRL,SUP-2749968,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
ANCHOR SUT 1.9 MM DIA NO 0 SUT ABSRB ANCHRLOC,SUP-2398002,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
SCREW SPNL POLYAX 6.5X60 MM CANN 35506560] ZIMMER SPINE],SUP-2415396,CDM,C1713,HCPCS,0278,RC,,,,both,,,5805.08,3773.30,,,,,,,,,,,,,
SPLINT WRST SM L6IN R CANVS LACE UP FIRM SUPP REM MAL PALMAR,SUP-2194831,CDM,L3908,HCPCS,0272,RC,,,,both,,,29.36,19.08,,,,,,,,,,,,,
CATHETER REPROC ETER EP 5FR 5MM 4 POLE JSN,SUP-2270124,CDM,C1730,HCPCS,0272,RC,,,,both,,,101.80,66.17,,,,,,,,,,,,,
BURR SURG 4MM PUR HIP HI VISIBILITY SHTH BRL ST DYONIC,SUP-2341870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
BIT DRL L195MM DIA6MM NONSTERILE JCBS CHK NONRADIOPAQUE W/O,SUP-2187322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.95,290.52,,,,,,,,,,,,,
GUIDE PIN LG 37.5X27.5 MM BIOPATELLA OATS,SUP-2845386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
SCREW BONE L10MM OD2.7MM TI CORT DSTL FIBULAR ST LCK FULL,SUP-2137066,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT 50CM 20MM SZ10MM POLYESTER BOV CLLGN,SUP-2227363,CDM,C1768,CPT,0278,RC,,,,both,,,4902.64,3186.72,,,,,,,,,,,,,
PLATE BONE LOK 210MML HLX14 STNLSS STEEL ST LEFT LTRL DST FB,SUP-2588183,CDM,C1713,HCPCS,0278,RC,,,,both,,,2452.53,1594.14,,,,,,,,,,,,,
BUR SURG DIA5MM DMND RND EXTRA COARSE EXPOSE MRK 5 STP,SUP-2367586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.49,266.82,,,,,,,,,,,,,
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-7613655600,CDM,36556,CPT,0761,RC,,,,both,,,9955.00,6470.75,,,,,,,,,,,,,
CROWN DENT 1 PEDIATRIC CTRL,SUP-2119367,CDM,D6783,CPT,0278,RC,,,,both,,,56.36,36.63,,,,,,,,,,,,,
HC Ot Group Therapy|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309715000,CDM,97150,CPT,0430,RC,,,GP|CQ,outpatient,,,135.00,87.75,,,,,,,,,,,,,
SCREW EXTR DIA2.5MM CONIC,SUP-2188322,CDM,C1713,HCPCS,0278,RC,,,,both,,,535.37,347.99,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND CUST ADJ FIT W/NONTORSION JT,SUP-2435763,CDM,L3764,HCPCS,0272,RC,,,,both,,,2017.89,1311.63,,,,,,,,,,,,,
IMPLANT SHTH ANT TALUS CVR,SUP-2399164,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE FIBERGRAFT 6CC,SUP-2741934,CDM,C1713,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
WEDGE SPNL 10X20MM TANGENT,SUP-2277837,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
GRAFT SYNTHECEL DURA REPR 2.5X2.5CM 1X1 IN S,SUP-2713885,CDM,C1763,HCPCS,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
ANCHOR SUT 1MM MINI W/ 2-0 NDL DRL JUGGERKNOT,SUP-2212960,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.23,945.90,,,,,,,,,,,,,
HC Sarscov-2 Ag/Flu Ab (Sophia),PX-3008742866,CDM,87428,CPT,0300,RC,,,,both,,,211.00,137.15,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 20CM A855200G,SUP-2632942,CDM,C1752,HCPCS,0278,RC,,,,both,,,823.47,535.26,,,,,,,,,,,,,
NEEDLE SUTURE L8.25IN SHARP LIGATURE FOR RIGHT HAND DESCHAMP,SUP-2802977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
PLATE BNE THK1.5MM 3X3 H CRANIOMAXILLOFACIAL ORAL SIL TI,SUP-2191610,CDM,C1713,HCPCS,0278,RC,,,,both,,,2510.12,1631.58,,,,,,,,,,,,,
GUIDEWIRE VASC L 300 CM 0.035IN L 7CM 3CM AMPLTZ STR X STIFF,SUP-2167976,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.31,58.70,,,,,,,,,,,,,
DUODENOSCOPE FLX 120/230 V 50-60 HZ 497X380X140 MM ABOX,SUP-2659122,CDM,C1748,HCPCS,0278,RC,,,,both,,,35701.80,23206.17,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.018 IN CRV RAD 2 MM STR J DBL,SUP-2760068,CDM,C1769,HCPCS,0272,RC,,,,both,,,119.01,77.36,,,,,,,,,,,,,
SCREW BNE L19MM FEM HIP CAPT COMPR,SUP-2347913,CDM,C1713,HCPCS,0278,RC,,,,both,,,515.40,335.01,,,,,,,,,,,,,
MICRO BONE PLATE TRNGLR 6MM 10MM SSTM CP TTNM,SUP-2707393,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.47,272.66,,,,,,,,,,,,,
IMPLANT BIO TISS W18XL28CM THK1.5MM CLLGN PERMACOL,SUP-2388450,CDM,C9364,HCPCS,0278,RC,,,,both,,,32170.30,20910.69,,,,,,,,,,,,,
PLATE BNE L MINI 2X23 MM OBLQ ANGLED SS,SUP-2460213,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.17,167.16,,,,,,,,,,,,,
ELECTRODE OPN VES SEAL SMOOTH DISP PK SUPERPULSE,SUP-2313927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1633.62,1061.85,,,,,,,,,,,,,
SCREW BNE EMGCY 1.4X9 MM ST NS AXS LTX,SUP-2862778,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.17,210.06,,,,,,,,,,,,,
CATHETER DIAG 6FRX65MMX100CM 5MM 2-5-2MM ELECTRD SPC EP,SUP-2141296,CDM,C1730,HCPCS,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
CUTTER KNOT ROTICULATING STR ARTHSCP,SUP-2122053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
GENERATOR PULSE IMP 16 CNTCT DP BRAIN STIM VERCISE GEVIA 16,SUP-2140418,CDM,C1820,HCPCS,0278,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
ANTENNA ABLAT L30CM PERC W/ THERMOSPHERE TECHNOLOGY EMPRINT,SUP-2283239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12790.16,8313.60,,,,,,,,,,,,,
STENT PERIPH PALMAZ L 30.3 MM DIA 3.5 MM SHTH 12-14 FR SS LG,SUP-2158988,CDM,C1877,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BONE L154MM THK3.4MM 10 H BILAT S STL LCK COMPR NEUT,SUP-2348986,CDM,C1713,HCPCS,0278,RC,,,,both,,,3472.21,2256.94,,,,,,,,,,,,,
DEVICE COMPR FEM PMP COMPLT FEMSTP II+,SUP-2356631,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
KIT WRIST MEDIUM FOR SPIDER 2,SUP-2753244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,227.52,147.89,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.27 MM INNR FLANGE DIA2.6 MM TI SHRT,SUP-2902094,CDM,L8699,HCPCS,0278,RC,,,,both,,,153.29,99.64,,,,,,,,,,,,,
BIT DRVR T10 STARDRV W/ AO END DISP,SUP-2242461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,497.12,323.13,,,,,,,,,,,,,
DEVICE FIX 40MM LOOP VERSITOMIC G-LOK,SUP-2366635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1232.04,800.83,,,,,,,,,,,,,
ROD REPROC CFBR XTRNFX MED XTRNFXTR 8X120MM,SUP-2478630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.41,102.32,,,,,,,,,,,,,
SCREW BNE EMGCY 3.2X16 MM MAND SELF RET X DRV THREADLOCK TS,SUP-2540220,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.90,229.38,,,,,,,,,,,,,
ELECTRODE ELECSURG 7 MM 18 GAX7 CM 9.9 CM MONOPOLAR RF DISP,SUP-2740360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
TROCAR SUPRPUB CAMPBELL,SUP-2160622,CDM,C1713,HCPCS,0278,RC,,,,both,,,1944.45,1263.89,,,,,,,,,,,,,
DOT PG PRO 18 GAUGE 8CM RT BP,SUP-2613505,CDM,C1751,HCPCS,0278,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|KX|CQ,both,,,191.00,124.15,,,,,,,,,,,,,
PLATE BONE L76MM 10 H STRL S STL LCK COMPR FOR 2.7MM SCR,SUP-2349618,CDM,C1713,HCPCS,0278,RC,,,,both,,,2406.18,1564.02,,,,,,,,,,,,,
SAW BLDE W10XL70MM THK1.19MM RECIP CEM FOR LINVATEC HALL,SUP-2408658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GRAFT BNE CRUSH 15 CC CANC,SUP-2312457,CDM,C1713,HCPCS,0278,RC,,,,both,,,1433.41,931.72,,,,,,,,,,,,,
PEG FEM AUG THK5MM KNEE VANGUARD,SUP-2407852,CDM,C1776,CPT,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
STENT COR 28MM OD2.25MM BARE MTL RX S STL MULT LINK,SUP-2103678,CDM,C1876,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
PLATE BNE THK0.5MM 7 H CRANIOMAXILLOFACIAL BLU TI DBL Y,SUP-2366236,CDM,C1713,HCPCS,0278,RC,,,,both,,,616.48,400.71,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 60 CM DIA2 FR DIA 4 MM FLAT PK PUR,SUP-2214580,CDM,C1757,HCPCS,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
GRAFT BNE FRZ DRY PROX FEM W O HD IMPL ALLGRFT MATRIGRFT,SUP-2264783,CDM,C1713,HCPCS,0278,RC,,,,both,,,11063.10,7191.01,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM THN REGENERATIVE TISS MTRX GRFTJACKET,SUP-2261537,CDM,Q4107,HCPCS,0636,RC,,,,both,,,4755.47,3091.06,,,,,,,,,,,,,
PLATE BONE DOUBLE ANGLE SMALL 1.5 MM PRECONTOURED RECONSTRUC,SUP-2842353,CDM,C1713,HCPCS,0278,RC,,,,both,,,7844.66,5099.03,,,,,,,,,,,,,
CATHETER REPROC EP CRD DIAG RESPON,SUP-2467200,CDM,C1730,HCPCS,0272,RC,,,,both,,,245.71,159.71,,,,,,,,,,,,,
SCREW INTRF L30MM DIA6-8MM TIB TAPR NONABSORBABLE FOR SFT,SUP-2256819,CDM,C1713,HCPCS,0278,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
COMPONENT TIB UNI RM/LL 10MM SM EIUS,SUP-2364887,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
STAPLE MEMOSTEP 4MM OFFSET,SUP-2479534,CDM,C1713,HCPCS,0278,RC,,,,both,,,5327.95,3463.17,,,,,,,,,,,,,
GRAFT 04 07MM 2CMX5CM THN DEHYDR ALLOPATCH HD,SUP-2307042,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1062.26,690.47,,,,,,,,,,,,,
PLUG VASC LG 10 MM AZUR,SUP-2853097,CDM,C1889,HCPCS,0278,RC,,,,both,,,7455.93,4846.35,,,,,,,,,,,,,
VENETOCLAX 10 MG PO TABS,RX-133765,CDM,J8999,HCPCS,0636,RC,00074-0561-11,NDC,,both,1,UN,58.60,38.09,,,,,,,,,,,,,
PLATE BNE RADIAL NAR BABY 2.5 MM RT DSTL VOLAR FT TRILOK,SUP-2267968,CDM,C1713,HCPCS,0278,RC,,,,both,,,2722.38,1769.55,,,,,,,,,,,,,
BASKET RETRV L1900MM DIA22MM MIN WRK CHN 28MM ROT 4 WIR BULL,SUP-2313157,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.95,461.47,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 8 MM STR STD WALL REINF,SUP-2525433,CDM,C1768,CPT,0278,RC,,,,both,,,751.18,488.27,,,,,,,,,,,,,
JACKET ORTHOT CUST BODY MOLD TO PT,SUP-2435593,CDM,L1300,HCPCS,0274,RC,,,,both,,,4879.40,3171.61,,,,,,,,,,,,,
FIBER LASER HOLMIUM L.UMENLS GI SLIMLINE,SUP-2885414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM COMP AMNIO MEM MTRX SHT AMNIOFIX,SUP-2305708,CDM,V2790,HCPCS,0278,RC,,,,both,,,7071.28,4596.33,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM GLD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2188924,CDM,C1713,HCPCS,0278,RC,,,,both,,,236.07,153.45,,,,,,,,,,,,,
OBTURATOR ENDOSCP SHT,SUP-2496811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1767.19,1148.67,,,,,,,,,,,,,
MESH HERN RECTANGULAR 8X16 CM PREPERITONEAL ENFORM,SUP-2495924,CDM,C1781,HCPCS,0278,RC,,,,both,,,5347.42,3475.82,,,,,,,,,,,,,
PLATE 3D PROFYLE REPLANT 4X12MM,SUP-2695488,CDM,C1713,HCPCS,0278,RC,,,,both,,,1156.31,751.60,,,,,,,,,,,,,
CATHETERIZATION KIT AD 7 FRX16 CM CV ARROWG+ARD,SUP-2383380,CDM,C1751,HCPCS,0278,RC,,,,both,,,254.18,165.22,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 45 CM DIA 5 FR HYDRPHLC,SUP-2383399,CDM,C1894,HCPCS,0272,RC,,,,both,,,313.50,203.77,,,,,,,,,,,,,
CATHETER PH 6FR ES SGL CHN 8 IMPED RNG DISP VERSAFLEX ZNIS,SUP-2173687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3567.04,2318.58,,,,,,,,,,,,,
MESH HERN W1.3XL1.55IN M POLYPR INGUINAL NONABSORBABLE,SUP-2125755,CDM,C1781,HCPCS,0278,RC,,,,both,,,397.84,258.60,,,,,,,,,,,,,
GRAFT VASC 6MMX50CM ACUSEAL,SUP-2395745,CDM,C1768,CPT,0278,RC,,,,both,,,4914.10,3194.16,,,,,,,,,,,,,
COMPONENT ARTC SURF RP 9 KNEE CR ATTUNE,SUP-2454952,CDM,C1776,CPT,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
COLLAR CERV PED H1.5/1.75/2IN FOR 8-18IN NK HDPE FOAM 1 PC,SUP-2196873,CDM,L0150,HCPCS,0272,RC,,,,both,,,16.20,10.53,,,,,,,,,,,,,
HEAD RAD H10MM DIA20MM ANT DST EL CO CHROM MOD CEM EXPLOR,SUP-2404359,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
GRAFT DELIVERY SYSTEM SET 12 CC W/ GRFT DBF CANN ACCELERATE,SUP-2787603,CDM,C1713,HCPCS,0278,RC,,,,both,,,6577.39,4275.30,,,,,,,,,,,,,
PROBE DRL GUID STD META-NAIL,SUP-2340922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1824.43,1185.88,,,,,,,,,,,,,
STENT TRACHBRONCH L80MM DIA6MM DEL SYS L117CM DIA8FR,SUP-2128282,CDM,C1874,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
COMPONENT TIB TY CR 2 5 MM KNEE FIX BEAR POLYETH AOX ATTUNE,SUP-2846300,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L KNEE OXINIUM POST STBL NP PRI STEMLESS,SUP-2346155,CDM,C1713,HCPCS,0278,RC,,,,both,,,10157.90,6602.63,,,,,,,,,,,,,
BRACE ANK AD H95IN UNIV BILAT SEMI RIG SHELL PROTCT,SUP-2196371,CDM,L4350,HCPCS,0274,RC,,,,both,,,53.25,34.61,,,,,,,,,,,,,
FORTILINK-L TETRAFUSE 26X55X13 12L,SUP-2335272,CDM,C1713,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
CONNECTOR SPNL ROD DIA 3.5/6.35 MM POST CERV PARALLEL DBL NS,SUP-2887229,CDM,C1713,HCPCS,0278,RC,,,,both,,,111.19,72.27,,,,,,,,,,,,,
K WIRE FIX L280MM DIA2MM S STL THRD TRCR TIP FOR LISS,SUP-2186895,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.98,74.09,,,,,,,,,,,,,
BIT DRL CANN 0.13X300 MM QC,SUP-2486745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1354.13,880.18,,,,,,,,,,,,,
PIN FIX 3.2 MM,SUP-2267559,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.97,81.23,,,,,,,,,,,,,
P GRSP 3.4 MM REG 1,SUP-2334699,CDM,C1763,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
AYR SALINE NASAL NA GEL,RX-15372,CDM,6370000000,HCPCS,0637,RC,00225-0525-47,NDC,,both,14.1,GR,54.10,35.16,,,,,,,,,,,,,
SCREW BNE 1.5X4 MM DRILL-FREE TI STRL ONEDRIVE 251530476,SUP-2478592,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.64,155.77,,,,,,,,,,,,,
BUR SURGICAL MR8 TWST DRILL 3MMX30MM0,SUP-2740421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
HC Tcp02/Abi 1-2 Levels,PX-9209392200,CDM,93922,CPT,0920,RC,,,,both,,,810.00,526.50,,,,,,,,,,,,,
OXYGENATOR PERFSN BARB CONN SZ 3/8 IN BLD FLO RATE 7 L/MIN,SUP-2895278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GRAFT BNE 115X11 MM DBM BLLST,SUP-2641773,CDM,C1713,HCPCS,0278,RC,,,,both,,,13753.20,8939.58,,,,,,,,,,,,,
TRIAL INSRT CD TIB ARTC KNEE,SUP-2201988,CDM,C1776,CPT,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 4 PLATE CUSTOMIZED FACE ID,SUP-2883691,CDM,C1713,HCPCS,0278,RC,,,,both,,,38109.18,24770.97,,,,,,,,,,,,,
PLATE TIBIAL SIZE 5 BASEPLATE TRABECULAR METAL,SUP-2493918,CDM,C1713,HCPCS,0278,RC,,,,both,,,9831.34,6390.37,,,,,,,,,,,,,
SCREW BNE NLCK 3.5X12 MM DBL STRT THRD SS JPS,SUP-2645448,CDM,C1713,HCPCS,0278,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
SPLINT CLAVICLEXSM INF W4XL52CM BCKL STRP CNTCT CLSR PD,SUP-2197367,CDM,L3650,HCPCS,0272,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
GRAFT BNE SUB 3CC TISS EXPONENT DBM,SUP-2138517,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC So Assay of Nucleotidase,PX-3018391566,CDM,83915,CPT,0301,RC,,,,outpatient,,,397.00,258.05,,,,,,,,,,,,,
SCREW BNE L8MM DIA24MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189583,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.15,181.45,,,,,,,,,,,,,
SYSTEM DIL BLLN L24MM DIA6MM MULT SNUS LO PROF SKR LIKE TIP,SUP-2106376,CDM,C1726,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
KIT SURG PROC 2 SPLNT PT SPEC INSTR PLN,SUP-2194242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9945.95,6464.87,,,,,,,,,,,,,
PROBE LASER CRV 23 GA ENDO OCU ILLUMINATING W/ SMA906 CONN,SUP-2713786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5137.04,3339.08,,,,,,,,,,,,,
REAMER SURG DIA 7.5 MM CANN SFT TISS FIX FOR TENODESIS SYS,SUP-2908584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
PROSTHESIS VOICE OD16FR SIL DUCKBILL BLOM SINGER,SUP-2242309,CDM,L8509,HCPCS,0274,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
HC So Babesia Mictroti Antibodies Igg & Igm,PX-3028675368,CDM,86753,CPT,0302,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 5 FR SPC 5 MM YEL,SUP-2248857,CDM,C1730,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
DRILL SURG STP STRT S-ROM,SUP-2455213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2226.26,1447.07,,,,,,,,,,,,,
GRAFT HUM TISS BOLSTER TRNS ABD WALL,SUP-2329846,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW BNE L 18 MM DIA2 MM TI CORTICAL LOWER EXTREMITY BLU NS,SUP-2905673,CDM,C1713,HCPCS,0278,RC,,,,both,,,240.71,156.46,,,,,,,,,,,,,
STAPLER INT USE DIA21 MM STPL H 3/3.5/4 MM XL MEDIUM/THICK,SUP-2896172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4569.33,2970.06,,,,,,,,,,,,,
PLATE BNE L169MM 8 H R OLECRANON S STL LO PROF VAR ANG LOK,SUP-2177190,CDM,C1713,HCPCS,0278,RC,,,,both,,,3398.89,2209.28,,,,,,,,,,,,,
SCREW BNE L42MM DIA4.5MM THRD L12MM S STL PARTIALLY THRDED,SUP-2184434,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.05,45.53,,,,,,,,,,,,,
MESH HERN W5XH5IN INT ABD OMEGA 3 FATTY ACID POLYPR SQ SEE,SUP-2265994,CDM,C1781,HCPCS,0278,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
FASCIAL IMPL GORTX EA,SUP-2395379,CDM,C1771,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SCREW BNE EMGCY 3.1X11 MM TI MAXDRIVE THREADLOCK TS LEVEL 1,SUP-2463702,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.71,321.56,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC HF 5FR 55CM 3 LUMAN RVRSE 1385108Q,SUP-2632639,CDM,C1751,HCPCS,0278,RC,,,,both,,,876.59,569.78,,,,,,,,,,,,,
IMMOBILIZER SHOULDERXL W25XL57CM UNIV TITEX W/ BODY STRP,SUP-2197383,CDM,L3650,HCPCS,0274,RC,,,,both,,,10.64,6.92,,,,,,,,,,,,,
HC MRI-Pelvis W Contrast,PX-6147219600,CDM,72196,CPT,0614,RC,,,,outpatient,,,4626.00,3006.90,,,,,,,,,,,,,
SCREW SPNL DIA14MM DISTRCTN SHADOW LN,SUP-2161614,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
GRAFT DURA W3XL3IN THK0.6MM CLLGN MEM DURAMATRIX-ONLAY +,SUP-2165126,CDM,C1763,HCPCS,0278,RC,,,,both,,,1964.54,1276.95,,,,,,,,,,,,,
VALVE SHUNT HYDROCEPHALUS 10CM H2O W/ SHUNT ASST PROGAV 2.0,SUP-2108740,CDM,C1729,HCPCS,0272,RC,,,,both,,,9010.01,5856.51,,,,,,,,,,,,,
PROBE STEREOTACTIC 8GA L12CM FOR MAMTOM REVOLVE,SUP-2195618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.27,346.63,,,,,,,,,,,,,
SYSTEM CONC WHL BLD INPUT 60ML PLT RICH POOR PLSM OUTPT,SUP-2402589,CDM,C1713,HCPCS,0278,RC,,,,both,,,3571.75,2321.64,,,,,,,,,,,,,
PLATE BONE L52MM 7X3 H TI RAD LT DSTL VOLAR LCK COMPR LO,SUP-2361544,CDM,C1713,HCPCS,0278,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
PROSTHESIS OSS 2.3X1.5 MM 2.25X3.5 MM 1.45 MM DSTL END TI,SUP-2232505,CDM,L8613,CPT,0278,RC,,,,both,,,1342.98,872.94,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.025IN L3CM STD SM VES NIT,SUP-2385563,CDM,C1769,HCPCS,0272,RC,,,,both,,,148.77,96.70,,,,,,,,,,,,,
HC Galactogram S&I,PX-3207705300,CDM,77053,CPT,0320,RC,,,,both,,,1175.00,763.75,,,,,,,,,,,,,
DRILL TWST DIA1.7MM SPNL DISTRCTN CUT SHADOW-LINE,SUP-2161619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,790.87,514.07,,,,,,,,,,,,,
SUPPORT ORTHOT MTCRPL HND ADJ FIT PREFABRICATED,SUP-2435778,CDM,L3917,HCPCS,0274,RC,,,,both,,,272.08,176.85,,,,,,,,,,,,,
RING EXT FIX DIA220 MM FT SPEEDWIRE,SUP-2898489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
SHELL ACET 3 HOLE 52 MM HIP LOGICAL G-SERIES,SUP-2322427,CDM,C1776,CPT,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
PLATE BNE L233MM THK38MM 12 H L MED DST TIB S STL NEUT,SUP-2185223,CDM,C1713,HCPCS,0278,RC,,,,both,,,4639.70,3015.80,,,,,,,,,,,,,
SCREW BNE ST 4X16 MM LCK SALVATION,SUP-2401330,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.74,491.88,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5 DEG 10 MM LORDTC PLIF BULL TIP STRL,SUP-2632318,CDM,C1713,HCPCS,0278,RC,,,,both,,,9383.95,6099.57,,,,,,,,,,,,,
TITANIUM FXTN SCREW KNRLD HEAD 45MM RD II DVCE,SUP-2681269,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.42,346.07,,,,,,,,,,,,,
FREELINK NOVI REMOTE CONTROL KIT,SUP-2700480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CRCLG STRAIGHT PASSER LRG DISPOSABLE,SUP-2814143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,0636,RC,63323-0614-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
BAND ORTHODONTIC M SZ 32 LO MAND S STL SEAMLESS CHAIRSIDE,SUP-2176641,CDM,D6783,CPT,0278,RC,,,,both,,,18.49,12.02,,,,,,,,,,,,,
PLATE BNE THK 1 MM BAR 16 MM SCREW DIA2 MM 6 H MINI CRV NS,SUP-2883142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1885.04,1225.28,,,,,,,,,,,,,
BUR SURG DIAMOND BALL 6 MMX7 CM SM BOR MIDAS REX LEGEND,SUP-2422342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.54,243.45,,,,,,,,,,,,,
GUIDEWIRE SPNL FOR IO-FLEX DSTL HNDL,SUP-2115837,CDM,C1769,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
CATHETER ATHRCTMY STLTH 360 L 145 CM DIA1.25 MM SHTH 6 FR,SUP-2159527,CDM,C1724,HCPCS,0278,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
CANNULA SURG JARCHO 12.5 IN UTER SELF-RETAINIG MALL TIP,SUP-2794553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1206.29,784.09,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR SMALL 1 MM CRANIOFACIAL ANATOMIC TI,SUP-2838342,CDM,C1713,HCPCS,0278,RC,,,,both,,,4705.92,3058.85,,,,,,,,,,,,,
HC Tmj Open/Closed Mouth Unilateral,PX-3207032800,CDM,70328,CPT,0320,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
SCISSORS 5IN CVD SUP CUT METZ,SUP-2162151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.26,221.82,,,,,,,,,,,,,
HC X-Ray Ankle Rout 3 Views,PX-3207361000,CDM,73610,CPT,0320,RC,,,,both,,,558.00,362.70,,,,,,,,,,,,,
SCREW BONE L16XOD2.3MM TI CORT CRANIO MAXIOFACIAL ST CROSS,SUP-2363449,CDM,C1713,HCPCS,0278,RC,,,,both,,,225.30,146.44,,,,,,,,,,,,,
HEAD FEM OD54MM CO CHROM MTL HIP CEM CONSERVE +,SUP-2304506,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
SCREW SET LAG GLOB ITST,SUP-2861293,CDM,C1713,HCPCS,0278,RC,,,,both,,,15155.46,9851.05,,,,,,,,,,,,,
BLADE RTRCTR RVL 45MMW X 50MML TTNM LMBR 15DG ANGLD TTHD ULT,SUP-2457455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.00,370.50,,,,,,,,,,,,,
COIL VASC AZUR L 34 CM DIA14 MM MICROCATHETER 0.035 IN LOOP,SUP-2385432,CDM,C1889,HCPCS,0278,RC,,,,both,,,4000.23,2600.15,,,,,,,,,,,,,
SCREW BNE L32MM DIA2.7MM ST CORT S STL ST NONCANNULATED LOK,SUP-2177117,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.20,409.63,,,,,,,,,,,,,
HC Declotting Central Vad,PX-4503659300,CDM,36593,CPT,0450,RC,,,,both,,,1120.00,728.00,,,,,,,,,,,,,
CATHETER EP DAO-1 2-5-2 5 FRX120 CM SUPREME,SUP-2537995,CDM,C1730,HCPCS,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
SCREW BNE OD45MM S STL HINDFOOT LOK REPL SURFIX,SUP-2243057,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.73,341.07,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X35 MM 6.35 MM PEDCL FOR ROD RED LEG,SUP-2288997,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
IMPLANT THYROPLASTY VOCAL CRD 8 M STRL MONTGOMERY,SUP-2141838,CDM,C1878,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
TUBE VENT ID76MM 1MM 030IN INNR FLNG TI MIC BOB,SUP-2313691,CDM,L8699,HCPCS,0278,RC,,,,both,,,87.45,56.84,,,,,,,,,,,,,
BLADE RETRACTOR CLOWARD SPREADER 55MML BLUNT,SUP-2500829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.89,248.88,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 54 MM DIA DSTL 12 MM SHTH 14 FR SS,SUP-2168729,CDM,C1768,CPT,0278,RC,,,,both,,,8992.96,5845.42,,,,,,,,,,,,,
SPLINT UP EXTRM MTL SPLNTS MTCRPL,SUP-2124890,CDM,L3913,HCPCS,0274,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
PLATE BNE PUBIC SYMPHYSIS PELV 4 HOLE,SUP-2518369,CDM,C1713,HCPCS,0278,RC,,,,both,,,3334.68,2167.54,,,,,,,,,,,,,
MESH SURG W10XL15CM POLY ANAT FOR L INGUINAL HERN PARIETEX,SUP-2174783,CDM,C1781,HCPCS,0278,RC,,,,both,,,370.30,240.69,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L200CM DIA0035IN BILI HYDRPHLC TIP EXTN HI,SUP-2149675,CDM,C1769,HCPCS,0272,RC,,,,both,,,279.62,181.75,,,,,,,,,,,,,
KIT TKR CEM FEM CEM TIB VIT E SURF NO PAT PERSONA,SUP-2212226,CDM,C1776,CPT,0278,RC,,,,both,,,13542.82,8802.83,,,,,,,,,,,,,
DEVICE LD LOK L65CM STYL,SUP-2353131,CDM,C1773,HCPCS,0272,RC,,,,both,,,1983.44,1289.24,,,,,,,,,,,,,
PLATE BNE L249MM 16 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185655,CDM,C1713,HCPCS,0278,RC,,,,both,,,4715.21,3064.89,,,,,,,,,,,,,
DEFIBRILLATOR IMPL TELIGEN W 6.17 X H 7.45 CM D 0.99 CM 31.5,SUP-2149195,CDM,C1721,HCPCS,0275,RC,,,,both,,,47728.00,31023.20,,,,,,,,,,,,,
MESH SURG BIOIMPLANT 9X10 CM ORTHADAPT,SUP-2323331,CDM,C1781,HCPCS,0278,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
CATHETER SUPP RUBICON 35 L 135 CM DIA 5 FR TIP 2.84 FR PROX,SUP-2146040,CDM,C1887,HCPCS,0272,RC,,,,both,,,477.91,310.64,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2.8 MM LT 26 HOLE ANGLED LCK TI NS,SUP-2459119,CDM,C1713,HCPCS,0278,RC,,,,both,,,7830.47,5089.81,,,,,,,,,,,,,
MARKER LOCKING SCREWS 2.3MM,SUP-2498041,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
PLATE BNE H06MM BAR L6MM 6 H CHIN TI ADV LEIBINGER UNIV 2,SUP-2366337,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.97,518.68,,,,,,,,,,,,,
STENT URIN DIV SUBQ CLOSE TIP 2 DIL 0.038IN STR GWIRE 8FR,SUP-2139622,CDM,C2617,HCPCS,0278,RC,,,,both,,,627.22,407.69,,,,,,,,,,,,,
CROWN DENT 3 S STL SEC PRI M UP LT ANTR CUSPID PREFABRICATED,SUP-2238920,CDM,D6783,CPT,0278,RC,,,,both,,,22.33,14.51,,,,,,,,,,,,,
CABLE CONN MULTI-RADIOFREQUENCY MOD 4 SITE V3 NS LF DISP,SUP-2859195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7460.64,4849.42,,,,,,,,,,,,,
GRAFT BNE SUB W11-20X14-27XL14-20MM THK24-26MM IL CREST,SUP-2307146,CDM,C1713,HCPCS,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
CAGE SPNL 12 MM INSRT INTERBRIDGE,SUP-2715280,CDM,C1889,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
CANNULA ENDOSCP TERNAMIAN 11 MMX15 CM ENDOTIP VLV STOPCOCK,SUP-2768544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2677.92,1740.65,,,,,,,,,,,,,
RING EXT FIX MOD 5/8 D 180 MM RX STRL TRUELOK EVO LTX,SUP-2875614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
HC Control Nosebleed Posterior,PX-4503090500,CDM,30905,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
HC Dest Botox-1 Extrem 1-4 Muscl,PX-5106464200,CDM,64642,CPT,0510,RC,,,,outpatient,,,2154.00,1400.10,,,,,,,,,,,,,
DEVICE VES SEAL L35CM OD5MM STD TIP TRIG SHFT HNDPC ENDOSCP,SUP-2257694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6051.44,3933.44,,,,,,,,,,,,,
ROD IM FEM NXGN,SUP-2437530,CDM,C1713,HCPCS,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
HANDPIECE BRST BX L13CMXW20MM OD12GA ID3.7MM TOT TISS,SUP-2240017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
BLADE SHV L11CM DIA3.5MM STR SNUS M4 ROT LNG SHFT IRRIG,SUP-2284133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,764.65,497.02,,,,,,,,,,,,,
REDAPT MODULAR SHELL 56MM,SUP-2511017,CDM,C1776,CPT,0278,RC,,,,both,,,6566.37,4268.14,,,,,,,,,,,,,
DRILL SURG MED SPD BURR CONTRA LINVATEC HOSE CONN BSPMICRO,SUP-2745751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5372.54,3492.15,,,,,,,,,,,,,
BLADE OSTEOTOM RAD 8MM,SUP-2136780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1985.74,1290.73,,,,,,,,,,,,,
PLATE BNE L 300 MM SCREW DIA 4.5 MM 18 H COMPR LCK STRL EVOS,SUP-2933439,CDM,C1713,HCPCS,0278,RC,,,,both,,,3514.45,2284.39,,,,,,,,,,,,,
SCREW BNE L16MM OD27MM ST LOK FULL THRD T8 DRV,SUP-2364744,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.15,462.90,,,,,,,,,,,,,
BLADE RETRACTOR HENLY 76MML LEFT RIGHT,SUP-2677345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.54,252.55,,,,,,,,,,,,,
COUNTERSINK BNE SM 6 MM REUSE,SUP-2422355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PIN EXT FIX CYL SET CONN ELEMENT K-WIRE STRL TRUELOK EVO LTX,SUP-2875606,CDM,C1713,HCPCS,0278,RC,,,,both,,,10895.80,7082.27,,,,,,,,,,,,,
MESH HERN W3XL8IN POLY-4-HYDROXYBUTYRATE SYN RECT WVN,SUP-2125877,CDM,C1781,HCPCS,0278,RC,,,,both,,,9350.92,6078.10,,,,,,,,,,,,,
GRAFT BNE SUB SM SZ 07 14MM 1ML B TRICALCIUM PHSPTE SYN,SUP-2194007,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.19,225.02,,,,,,,,,,,,,
INSTRUMENT KIT SHLDR HEX PIN GPS,SUP-2451486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
HC Adult Cpap Titration Study,PX-9209581100,CDM,95811,CPT,0920,RC,,,,outpatient,,,5739.00,3730.35,,,,,,,,,,,,,
BIT DRILL STP 4.5MM DIA HOWMEDICA TRAUM 5.0IN LGTH CHK END -,SUP-2363950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.99,241.14,,,,,,,,,,,,,
VALVE MITRL EPIC + SZ 31 MM TISS ANNULUS DIA 31 MM STENT,SUP-2893566,CDM,C1889,HCPCS,0278,RC,,,,both,,,15706.28,10209.08,,,,,,,,,,,,,
RETRACTOR HOSP CHLD 575IN DBL END,SUP-2244667,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
PLATE BNE W11XL136MM THK4.2MM 9 H MTPHSEAL S STL LOK COMPR,SUP-2185262,CDM,C1713,HCPCS,0278,RC,,,,both,,,2514.48,1634.41,,,,,,,,,,,,,
COMPONENT HUM XSM L4IN UNIV DST EL TIV PLSM INTERCHANGEABLE,SUP-2205919,CDM,C1776,CPT,0278,RC,,,,both,,,15009.36,9756.08,,,,,,,,,,,,,
ANCHOR SUTURE THRD PAT 4.75 MM PEEK CROSS FT KNOTLESS DT,SUP-2423295,CDM,C1713,HCPCS,0278,RC,,,,both,,,1280.12,832.08,,,,,,,,,,,,,
WASHER ORTH TIM FLAT FOR 3.5/4MM CANN SCR,SUP-2412157,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
ATENOLOL 25 MG PO TABS,RX-717,CDM,6370000000,HCPCS,0637,RC,51079-0759-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Perq Trluml Revsc of/-Cab Grf 1 Maj C Art&/Brnch,PX-4819293700,CDM,92937,CPT,0481,RC,,,,both,,,20807.00,13524.55,,,,,,,,,,,,,
GRAFT BNE 10 CC SUBSTITUTE ACTIFUSE,SUP-2129867,CDM,C1713,HCPCS,0278,RC,,,,both,,,3887.32,2526.76,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CATH 7FR 0.035IN ACC CHN 3.2MM DOME,SUP-2170082,CDM,C1769,HCPCS,0272,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
DRILL SURG W/ STP LCK SCREW NS LTX,SUP-2861398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
PLATE BNE W22XL145MM XLN STD 6X10 H ST L DST RAD VOLAR,SUP-2177309,CDM,C1713,HCPCS,0278,RC,,,,both,,,4847.28,3150.73,,,,,,,,,,,,,
K WIRE FIX L160MM DIA1.1MM FOR VAR DST - ORDER MULT OF 10 EA,SUP-2368331,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
TUBING ASPIR PRB TY DISP SET SONASTAR,SUP-2305937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HEAD FEM CONSTRN +6 MM 12/14 32 MM HIP MOD TYP 1 TAPR FRDM,SUP-2423251,CDM,C1776,CPT,0278,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
SCREW CORTEX RESORB 2X6MM F/ORTHOMESH STRL,SUP-2550440,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.71,253.96,,,,,,,,,,,,,
BIOSURGE KIT WITH 5.0CC ALLOSYNC PURE,SUP-2811311,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
INSERT HUM OD42MM THK+9MM A-12.5 SHLDR RETENTIVE REVERSED,SUP-2388719,CDM,C1776,CPT,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
SET PRT INFUS STD W/ Y-SITE 19 GAUGEX1 IN LIFEPRT,SUP-2118759,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
PLATE BNE W9XL61MM THK1MM 5 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190949,CDM,C1713,HCPCS,0278,RC,,,,both,,,506.14,328.99,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X287 MM 16 HOLE SS LCP,SUP-2569369,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.50,548.92,,,,,,,,,,,,,
WIRE FIXATION W1.25XL150MM THREADED DISPOSABLE KIRSCHNER 6PK,SUP-2472096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.27,271.23,,,,,,,,,,,,,
BLADE SAW THK 0.38 MM CUT EDGE 10 MM THK 0.51 MM TPI 32,SUP-2898854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.04,417.98,,,,,,,,,,,,,
KIT EEG ELECTRD L 33.5 MM 10 CONTACT STRL DISP EVO,SUP-2936623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3209.08,2085.90,,,,,,,,,,,,,
KIT DRNGE VENT EDM WIT 120ML GRAD CHMBR,SUP-2278380,CDM,C1729,HCPCS,0272,RC,,,,both,,,930.95,605.12,,,,,,,,,,,,,
PLATE BNE L45-55MM TROCHANTERIC HIP MALLORY-HEAD TI 2 PC,SUP-2405218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
INTRODUCER SHTH L30CM OD12FR FOR ABD AORT ANEURYSMS,SUP-2395871,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
CATHETER ETER EP ABLAT D CRV QPLR 1 7 4MM SPC 4MM TIP DEFL TEMP SENS,SUP-2248467,CDM,C1732,HCPCS,0272,RC,,,,both,,,5567.22,3618.69,,,,,,,,,,,,,
PLATE BNE SGL JT FUS COMPR FOR 3.5MM SCR ALPS,SUP-2413839,CDM,C1713,HCPCS,0278,RC,,,,both,,,2255.15,1465.85,,,,,,,,,,,,,
BOOT CAST XL VELC OPN TOE FOR TOT CNTCT SYS TCC-EZ,SUP-2244449,CDM,L4370,HCPCS,0274,RC,,,,both,,,370.33,240.71,,,,,,,,,,,,,
PLATE BNE L50MM 8 H TI LAT MED REARFOOT LOK COMPR RECON RPS,SUP-2399638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2738.08,1779.75,,,,,,,,,,,,,
CATHETER INFUS L134CM BAL L20MM DIA2MM 0.014IN THER LOC RAP,SUP-2266025,CDM,C1751,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 190 CM DIA 0.014 IN SS SIL STR SHRT,SUP-2142711,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CLIP ANEUR L8.6MM 7MM OPN 180GM CLS FORC STD PHYNOX CVD PERM,SUP-2108372,CDM,C1889,HCPCS,0278,RC,,,,both,,,1273.05,827.48,,,,,,,,,,,,,
MAGNET PATIENT REACTIV8,SUP-2877970,CDM,C1730,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
TUBE VENT 1.52 MM 1 MM 4.23/3.2 MM PAPARELLA W/ TAB SIL STRL,SUP-2479504,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.25,20.96,,,,,,,,,,,,,
NUT EXT FIX OD10MM FOR SIDEKCK FREE CIR FIX SALVATION,SUP-2400604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
DEXRAZOXANE HCL 500 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-145117,CDM,J1190,HCPCS,0636,RC,72266-0101-01,NDC,JW,both,1,UN,569.40,370.11,,,,,,,,,,,,,
PSEUDOEPHEDRINE HCL 30 MG PO TABS,RX-6714,CDM,6370000000,HCPCS,0637,RC,45802-0432-62,NDC,,both,1,UN,0.80,0.52,,,,,,,,,,,,,
SCREW BNE 2.4X18 MM CORTICAL MSP,SUP-2308950,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
KNIFE SURG L188MM BAYNT FOR THOR LUM SYS,SUP-2284811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.40,811.46,,,,,,,,,,,,,
TUBE TRACH L40MM OD5.3MM ID3.5MM FLX TEND +,SUP-2351996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.95,294.42,,,,,,,,,,,,,
CATHETER IV DL 5 FR DOT KT MBP GIVA PC POWERMIDLINE,SUP-2626741,CDM,C1751,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
HC Blood Gases Any Combination Ph Pco2 Po2 Co2 Hco3,PX-3018280300,CDM,82803,CPT,0301,RC,,,,both,,,301.00,195.65,,,,,,,,,,,,,
HC Chest Tube Insertion,PX-3613255100,CDM,32551,CPT,0361,RC,,,,outpatient,,,4942.00,3212.30,,,,,,,,,,,,,
CATHETER SURG L24 MM OD5 FR SINUS RELIEVA SOLO,SUP-2106313,CDM,C1729,HCPCS,0272,RC,,,,both,,,2562.24,1665.46,,,,,,,,,,,,,
INSTRUMENT KIT HIP STR KNOTLESS FIBERTAK DISP,SUP-2423108,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CALCIPOTRIENE 0.005 % EX CREA,RX-16034,CDM,6370000000,HCPCS,0637,RC,16714-0763-01,NDC,,both,60,GR,1194.00,776.10,,,,,,,,,,,,,
PROSTHESIS OSS 2-5.5 MM 1.5X2 MM 1.45 MM BOJRAB HA TI SIL,SUP-2490074,CDM,L8613,CPT,0278,RC,,,,both,,,1270.29,825.69,,,,,,,,,,,,,
BUR CORTICL OPENER DIA 3.5MM AO,SUP-2459267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.81,424.33,,,,,,,,,,,,,
STAPLER INT LN REINF DRY VERIT CLLGN MTRX PSD 6 FIRING,SUP-2130284,CDM,C9354,HCPCS,0278,RC,,,,both,,,734.19,477.22,,,,,,,,,,,,,
CATHETER ETER EP 7FR L110CM ELECTRD SPC 2 9 1MM BND ELECTRD 1MM H L,SUP-2357629,CDM,C1730,HCPCS,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HYDROMORPHONE HCL-NACL 20-0.9 MG/100ML-% IV SOLN,RX-139325,CDM,J1171,HCPCS,0636,RC,09999-5126-10,NDC,,both,100,ML,127.70,83.00,,,,,,,,,,,,,
MESH HERN FLAT SHT 6X3 IN RECT OVL FLX KNITTED PROLITE ULTRA,SUP-2227246,CDM,C1781,HCPCS,0278,RC,,,,both,,,98.72,64.17,,,,,,,,,,,,,
SHEATH INTRO L25CM L31.5CM ID9FR BLK LNG TEAR AWAY VLV W/,SUP-2329860,CDM,C1894,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PORT INFUS ODSEC6FR TI POLYUR SGL LUMN ATTACH OPN END,SUP-2127747,CDM,C1788,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
PLATE BNE RESECT 9 MM KNEE PERSONA,SUP-2447976,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
PNEUMOTHORAX KIT 8 FRX16 CM W/O HEIMLICH VLV LTX,SUP-2429389,CDM,C1729,HCPCS,0272,RC,,,,both,,,340.78,221.51,,,,,,,,,,,,,
CANNULA VEN SHT 21 FR BIOLINE COATED HLS,SUP-2663466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1584.10,1029.66,,,,,,,,,,,,,
BUR SURG DIAMOND 0.8 MM 5 CM BALL MIDAS REX 8 CLRVW LP,SUP-2664902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.23,405.75,,,,,,,,,,,,,
HC X-Ray Ankle 2 Views,PX-3207360000,CDM,73600,CPT,0320,RC,,,,both,,,458.00,297.70,,,,,,,,,,,,,
STEM FEM L150MM DIA12MM HIP TI POR IM BOW CEM ORTH SALV SYS,SUP-2405717,CDM,C1776,CPT,0278,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
IMPLANT HUM TISS L 3 X W 3 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881933,CDM,C1762,CPT,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
SHEATH TG0655517 6.5F 55CM 17MM,SUP-2298495,CDM,C1894,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7 MM EPTFE STR TW,SUP-2525469,CDM,C1768,CPT,0278,RC,,,,both,,,2116.33,1375.61,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM MED AMNIO MEMBRN RESRB STRL,SUP-2913451,CDM,Q4173,HCPCS,0636,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 60 X W 13.5 MM MYRIAD HNDPC L 13 NN-3008,SUP-2930305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22257.64,14467.47,,,,,,,,,,,,,
BIT DRL QC LG LNG 7.5 MM FOR CANN SCREW STRL,SUP-2789113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2129.17,1383.96,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE DIA 0.025 IN NIT HYDRPHLC ANGLED,SUP-2148190,CDM,C1769,HCPCS,0272,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
TUBE ET OD9.5MM ID7MM FOR EMG NIM TRIVANTAGE,SUP-2284333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.44,714.64,,,,,,,,,,,,,
CEMENT BNE DOUGH 20 CC 40 GM,SUP-2197444,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.50,140.72,,,,,,,,,,,,,
DRILL TWST L40MM DIA16MM 5MM STP CRANIOMAXILLOFACIAL S STL,SUP-2263017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.14,363.44,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZ DRY CANC 1MM 4MM RANG 40CC,SUP-2264678,CDM,C1713,HCPCS,0278,RC,,,,both,,,1571.98,1021.79,,,,,,,,,,,,,
BASKET STONE REMV L190CM DIA20MM BSKT W2.8MM 8 WIR,SUP-2313156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,870.03,565.52,,,,,,,,,,,,,
BIT DRL 5 MM DARCO,SUP-2398633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
SHEATH INTRO FLX BLKN L 40 CM OD 8 FR ID 2.9 MM GUIDEWIRE,SUP-2168570,CDM,C1894,HCPCS,0272,RC,,,,both,,,111.34,72.37,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH II L 23 CM DIA 8 FR GUIDEWIRE,SUP-2477457,CDM,C1892,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
PLATE BNE W15XL136MM THK2MM 6 H BILAT S STL COVERLEAF RIG,SUP-2186008,CDM,C1713,HCPCS,0278,RC,,,,both,,,1719.06,1117.39,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 120 MM DIA 8 MM DEL SYS L 150 CM,SUP-2866205,CDM,C1725,HCPCS,0272,RC,,,,both,,,5046.55,3280.26,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM M HXLPE,SUP-2212711,CDM,C1776,CPT,0278,RC,,,,both,,,11206.69,7284.35,,,,,,,,,,,,,
CROWN DENT B5 PEDIATRIC 1ST PRIMARY M UPPER RT,SUP-2119395,CDM,D6783,CPT,0278,RC,,,,both,,,62.64,40.72,,,,,,,,,,,,,
VTCBK 8/35 TEMP TIP,SUP-2141078,CDM,C1729,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SCREW BNE NLCK 4.5X14 MM DBL STRT THRD SS JPS,SUP-2645463,CDM,C1713,HCPCS,0278,RC,,,,both,,,245.55,159.61,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR PULSE SENZA II,SUP-2419569,CDM,C1822,CPT,0278,RC,,,,both,,,58404.00,37962.60,,,,,,,,,,,,,
OBTURATOR SHTH 9FRX33CM SNAP LCK,SUP-2355510,CDM,C1894,HCPCS,0272,RC,,,,both,,,18.06,11.74,,,,,,,,,,,,,
PLATE BNE L119MM THK3.8MM 7 H BILAT S STL NAR DYN COMPR FOR,SUP-2185207,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.85,885.20,,,,,,,,,,,,,
PLATE FRAC 2MM 6H TI STRL VAL,SUP-2546917,CDM,C1713,HCPCS,0278,RC,,,,both,,,2290.60,1488.89,,,,,,,,,,,,,
NAIL IM UNIV HUM VERSANAIL,SUP-2606563,CDM,C1713,HCPCS,0278,RC,,,,both,,,5325.44,3461.54,,,,,,,,,,,,,
SCREW BNE THRD 6.5X105 MM 32 MM,SUP-2198322,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,J2003,HCPCS,0636,RC,55150-0254-10,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE L225MM 5 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185271,CDM,C1713,HCPCS,0278,RC,,,,both,,,977.80,635.57,,,,,,,,,,,,,
GUIDEPIN ORTH FOR R SET TRUMATCH,SUP-2252966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC NM Lung Ventilation Imaging,PX-3417857900,CDM,78579,CPT,0341,RC,,,,both,,,3221.00,2093.65,,,,,,,,,,,,,
PLATE BONE 16 H PROX ANTR LAT BOW FOR 3.5MM SCR PERI-LOC,SUP-2349063,CDM,C1713,HCPCS,0278,RC,,,,both,,,1081.64,703.07,,,,,,,,,,,,,
FIBER LASER 365 MH N TAPR POLISHED TIP HOLM ACCUMAX 5/BX,SUP-2537763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.97,620.73,,,,,,,,,,,,,
BASKET EXTR STONE THE WEB 7 FR X 220 CM SHTH 2.5 CM X 5 CM,SUP-2169438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX12 TTNM RCNSTRCTN F/3.5MM LOK SCR,SUP-2480536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1624.89,1056.18,,,,,,,,,,,,,
HC Paracentesis W/O Imaging,PX-7614908200,CDM,49082,CPT,0761,RC,,,,both,,,2844.00,1848.60,,,,,,,,,,,,,
K WIRE FIX L6IN DIA1.1MM ST S STL 3 SIDE DBL TRCR BOTH END,SUP-2150607,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.06,8.49,,,,,,,,,,,,,
SCREW BNE L16MM OD2.7MM TI TARSALIS FULL THRD LOK TOT FT,SUP-2243272,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.02,436.16,,,,,,,,,,,,,
ROD SPNL POST SMOOTH 5.5MM DIA 150MM LEN,SUP-2289289,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
STYLET SURG 45 MM INVICTUS,SUP-2553925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
MESH HERN W12XL20CM SYN ABSRB POLY COMP ELP MFIL OVL,SUP-2174765,CDM,C1781,HCPCS,0278,RC,,,,both,,,3345.10,2174.31,,,,,,,,,,,,,
PLATE BNE RECON 3.5X82 MM 7 HOLE SS,SUP-2569082,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
CATHETER DRAINAGE 12 FRX60 CM MP COPE SIMP LCK LOOP UTHANE,SUP-2168286,CDM,C1729,HCPCS,0272,RC,,,,both,,,272.33,177.01,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA22/13 MM DEL,SUP-2934522,CDM,C1713,HCPCS,0278,RC,,,,both,,,19565.97,12717.88,,,,,,,,,,,,,
SCREW BNE L30MM DIA6.5MM HD L3.5MM CANC HIP X3 TRITANIUM,SUP-2372714,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ALLOGRAFT BNE DBM 5 CC VESUVIUS 4104K5005DP,SUP-2717994,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
"HC So Protein S, Free",PX-3058530666,CDM,85306,CPT,0305,RC,,,,both,,,147.00,95.55,,,,,,,,,,,,,
WIRE FIX RND TIP 1X80 MM W/ LANCET KIRSCHNER,SUP-2224017,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
BLADE RETRACTOR CLOWARD SPREADER 45MML BLUNT,SUP-2672937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,851.16,553.25,,,,,,,,,,,,,
STENT BILI COTTON-HUIBREGTSE L 10 CM DIA 8.5 FR GUIDEWIRE,SUP-2169305,CDM,C2617,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
SCREW BNE L115MM DIA10.5MM CANC TIM CANN LAG NONLOCKING,SUP-2413937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.44,1072.14,,,,,,,,,,,,,
PLATE LOCK WAO,SUP-2705046,CDM,C1713,HCPCS,0278,RC,,,,both,,,286.37,186.14,,,,,,,,,,,,,
GUIDE SURG WASHER HIP SEGMENTED TRABECULAR MTL,SUP-2437274,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
EXTENSION NERVE STIM OCTAPOLAR 20 CM 1X8 INLINE CONN LEGEND,SUP-2278214,CDM,C1883,HCPCS,0278,RC,,,,both,,,2257.66,1467.48,,,,,,,,,,,,,
SYSTEM IMPL S STL KNOTLESS SYNDESMOSIS TIGHTROPE XP,SUP-2122823,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
TIP SURG MECHANOMYOGRAPHY BALL SS NS,SUP-2693681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC So Lipid Panel,PX-3018006166,CDM,80061,CPT,0301,RC,,,,inpatient,,,43.00,27.95,,,,,,,,,,,,,
CATHETER ABLATN 8 MM SPC SPEC CELSIUS DS,SUP-2466831,CDM,C1733,HCPCS,0272,RC,,,,both,,,4031.76,2620.64,,,,,,,,,,,,,
JOINT TOE CANN SCR 3.5X16 MM COMPR SS HAMRTOE PROTOE XFLEX,SUP-2851265,CDM,C1776,CPT,0278,RC,,,,both,,,2524.56,1640.96,,,,,,,,,,,,,
STENT PERIPH L22MM DIA4.5MM CATH L220CM NO TIP INTCRAN,SUP-2249133,CDM,C1874,HCPCS,0278,RC,,,,both,,,21804.16,14172.70,,,,,,,,,,,,,
BLADE SAW RECIP 40MM CUT EDGE 9.5MM CUT DEPTH 0.4MM CUT,SUP-2136839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,82.74,53.78,,,,,,,,,,,,,
BIT DRL L270MM DIA38MM 3 FLUT QUIK CPL FOR MULTILOC HUM,SUP-2178940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.40,530.01,,,,,,,,,,,,,
PORT TI DEV W 6FR ATTCH CHRONOFLEX POLYUR OPN CATHETER AND,SUP-2126308,CDM,C1788,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
ALLOFUSE 1CC GEL,SUP-2415364,CDM,C1889,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
MESH PARIETEX COMP 37 CM X 28 CM,SUP-2752152,CDM,C1781,HCPCS,0278,RC,,,,both,,,8254.24,5365.26,,,,,,,,,,,,,
GRAFT BNE H14MMXL5.5CM CORT FRZ DRY WDG FOR HI TIB OSTEOTMY,SUP-2307172,CDM,C1713,HCPCS,0278,RC,,,,both,,,3314.90,2154.68,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4 FR SS WIRE TUNGSTEN TIP MIC B BVL,SUP-2752618,CDM,C1894,HCPCS,0272,RC,,,,both,,,112.07,72.85,,,,,,,,,,,,,
SET INTRO 16FR L70CM 0038IN FOR TRACHBRONCH STNT,SUP-2168376,CDM,C1894,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
DEVICE PESSARY DIA2.75IN SIL FLEX GELLHORN FOR 3RD DEG,SUP-2171827,CDM,A4562,HCPCS,0272,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
CATHETER DRAINAGE 6 FRX20 CM ALL PURP LOOP PIG PERCFLX,SUP-2147780,CDM,C1729,HCPCS,0272,RC,,,,both,,,258.92,168.30,,,,,,,,,,,,,
PLATE BONE L205MM 95DEG SUPCNDYL TUBE FRELOK,SUP-2197719,CDM,C1713,HCPCS,0278,RC,,,,both,,,1794.79,1166.61,,,,,,,,,,,,,
RIFAXIMIN 550 MG PO TABS,RX-102296,CDM,6370000000,HCPCS,0637,RC,65649-0303-03,NDC,,both,1,UN,259.80,168.87,,,,,,,,,,,,,
SET PICC 1L 4FR X 55CM W BP,SUP-2887043,CDM,C1751,HCPCS,0278,RC,,,,both,,,893.86,581.01,,,,,,,,,,,,,
STRAP ELBW TENNIS 8 IN BANDIT,SUP-2325152,CDM,L3702,HCPCS,0272,RC,,,,both,,,68.92,44.80,,,,,,,,,,,,,
AERO/VENT JR. KT W/ TWO TUBES HEPA FILTER,SUP-2927281,CDM,C1776,CPT,0278,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
SCREW 3.5MM TI CONICAL SLF-TPNG FULLY THREADED 80MM,SUP-2549324,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.45,265.49,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.526,SUP-2860207,CDM,C1713,HCPCS,0278,RC,,,,both,,,33231.56,21600.51,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-15861,CDM,J3490,HCPCS,0250,RC,00338-0085-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336042,CDM,L3809,HCPCS,0272,RC,,,,both,,,17.93,11.65,,,,,,,,,,,,,
PLATE SPNL POST 10 MM,SUP-2430747,CDM,C1713,HCPCS,0278,RC,,,,both,,,10365.14,6737.34,,,,,,,,,,,,,
IMPLANT FACE L 108 X W 75 MM RT INFERIOR 2/3 ORBIT,SUP-2883611,CDM,C1713,HCPCS,0278,RC,,,,both,,,12324.63,8011.01,,,,,,,,,,,,,
PLATE BNE L 56 MM 4 H SS LT DSTL VOLAR RADIAL WIDE LCK LP VA,SUP-2931331,CDM,C1713,HCPCS,0278,RC,,,,both,,,3397.17,2208.16,,,,,,,,,,,,,
COIL EMB L3CM DIA0.02IN LOOP DIA2MM COMPLX EXTRA SFT FILL,SUP-2323426,CDM,C1889,HCPCS,0278,RC,,,,both,,,5849.82,3802.38,,,,,,,,,,,,,
CATHETER DRNGE 30FR 4 WNG DISP FOR NEPHSTMY MALECOTS,SUP-2129078,CDM,C2627,HCPCS,0272,RC,,,,both,,,76.74,49.88,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN CRV RAD 3 MM SS PTFE,SUP-2167565,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.96,32.47,,,,,,,,,,,,,
SET INSTR ORTH SPHR IMPL,SUP-2399055,CDM,C1776,CPT,0278,RC,,,,both,,,30074.92,19548.70,,,,,,,,,,,,,
ROD EXT FIX L174MM DIA8MM UP L C FBR CRV SEMICIRCULAR MRI,SUP-2372442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
STEM FEM SZ 19 L190MM 131DEG HIP CO CHROM POR STD CLLR STR,SUP-2345221,CDM,C1776,CPT,0278,RC,,,,both,,,20881.00,13572.65,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA0.034IN W/ TRCR TIP THRD LSR MRK DISP FOR,SUP-2122475,CDM,C1769,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
PLATE BNE L 156 MM SCREW DIA 3.5 MM 12 SHFT H SS MTPHSEAL VA,SUP-2907691,CDM,C1713,HCPCS,0278,RC,,,,both,,,3076.10,1999.46,,,,,,,,,,,,,
HEAD HUM 44/17 CA REVERS UNIVERS,SUP-2123381,CDM,C1776,CPT,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
CATHETER HAD AD 13.5FR L28CM LUMN OD2MM ID2MM TIP L11CM SIL,SUP-2127707,CDM,C1752,HCPCS,0278,RC,,,,both,,,1045.15,679.35,,,,,,,,,,,,,
FORCEPS 25GA SERR +,SUP-2109697,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.51,307.78,,,,,,,,,,,,,
GRAFT HUMAN TISSUE BIOLOGICAL TISSUE MATRIX THICK 25X20 CM NON CROSSLINKED SCAFFOLD NATURALLY OCCURRING PORCINE STERILE GENTRIX DISPOSABLE,SUP-2106502,CDM,Q4166,HCPCS,0636,RC,,,,both,,,40553.10,26359.51,,,,,,,,,,,,,
CLAMP EXT FIX L PIN 6 POS MAG RESONANCE CONDITIONAL,SUP-2188504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1232.10,800.86,,,,,,,,,,,,,
SET INTRO FLX L 38.5 CM OD 9 FR GUIDEWIRE 0.035 IN CKFLO VLV,SUP-2168825,CDM,C1894,HCPCS,0272,RC,,,,both,,,284.30,184.79,,,,,,,,,,,,,
BUR SURG OD4.7MM 7.9MMXLONG CUT DR FLUT,SUP-2363405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.59,279.88,,,,,,,,,,,,,
SHUNT SURG SM UNIV W/ RA VENTILATOR 22097BM,SUP-2628153,CDM,C1729,HCPCS,0272,RC,,,,both,,,3757.95,2442.67,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.515,SUP-2860032,CDM,C1713,HCPCS,0278,RC,,,,both,,,38511.16,25032.25,,,,,,,,,,,,,
HC CT Chest Screening Low Dose Wout Cont,PX-3527127100,CDM,71271,CPT,0352,RC,,,,inpatient,,,529.00,343.85,,,,,,,,,,,,,
SCREW DENT 5.5X11.5 MM CONCL CONN WP NOBELPARALLEL,SUP-2430162,CDM,C1713,HCPCS,0278,RC,,,,both,,,1135.11,737.82,,,,,,,,,,,,,
NEEDLE EPIDURAL TUOHY 20GX4.5IN,SUP-2529755,CDM,C1776,CPT,0278,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS WITH TWO STRAND OF NUMBER 0 HI FI SUT,SUP-2828610,CDM,C1713,HCPCS,0278,RC,,,,both,,,1728.48,1123.51,,,,,,,,,,,,,
LINER ACET SZ E OD50-52MM ID32MM 0DEGXLPE CONSTRN PRI REFLCT,SUP-2348069,CDM,C1776,CPT,0278,RC,,,,both,,,3622.78,2354.81,,,,,,,,,,,,,
SCREW BNE L28MM OD3.5MM LOK TUFFNEK TECHNOLOGY FOR PLT,SUP-2321128,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.63,420.96,,,,,,,,,,,,,
PRAVASTATIN SODIUM 10 MG PO TABS,RX-11110,CDM,6370000000,HCPCS,0637,RC,00904-5891-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE 2 H RT CNDYL MANDIBULAR TEMP NS,SUP-2883604,CDM,C1713,HCPCS,0278,RC,,,,both,,,3157.71,2052.51,,,,,,,,,,,,,
KIT BNE CEM 180GM MIX UNIV W/ BWL CART TWR HI VAC ROTOR,SUP-2366877,CDM,C1713,HCPCS,0278,RC,,,,both,,,253.87,165.02,,,,,,,,,,,,,
SET SCR SPNL DIA5.5MM POST CERVICOTHORACOLUMBAR TI CLS,SUP-2311750,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SCREW BONE L26MM DIA3.5MM CORT T15 FULL THRD N CANN ST,SUP-2101288,CDM,C1713,HCPCS,0278,RC,,,,both,,,77.87,50.62,,,,,,,,,,,,,
SCREW BONE L14MM DIA3.5MM ST LCK CRTX,SUP-2348360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.63,718.66,,,,,,,,,,,,,
ANCHOR SUTURE 2 2.9 MM 1 ULTRABRAID II BLU OSTEORAPTOR,SUP-2849145,CDM,C1713,HCPCS,0278,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
ANCHOR SUTURE SFT 2.9 MM W/ TAPR NDL IMPL JUGGERKNOTLESS,SUP-2608585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.09,785.91,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPLR ENDOPROSTHESIS STRYKERHUNIE] STRYKER CORP],SUP-2365981,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BUR SURG DIA2.5 HUB II DIAMOND CUT DISK STRL REUSE HI-LINE,SUP-2928839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1280.21,832.14,,,,,,,,,,,,,
DEVICE RETRV DEPLOYMENT LITHOVUE EMPOWER,SUP-2436264,CDM,C2617,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
MESH HERN W10XL10CM OPN TISS SEPARATING PHYSIOMESH,SUP-2219744,CDM,C1781,HCPCS,0278,RC,,,,both,,,1317.76,856.54,,,,,,,,,,,,,
PLUG FIST ENTEROCUTANEOUS BIODESIGN,SUP-2419222,CDM,C1763,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
COIL NEUROVASCULAR HELIPAQ 10 CERECYTE L 8 CM DIA 3 MM,SUP-2460312,CDM,C1889,HCPCS,0278,RC,,,,both,,,4711.19,3062.27,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND NUVISION ICE DIA10 FR STRL,SUP-2880095,CDM,C1759,HCPCS,0272,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PLATE BNE L156MM 12 H L LAT DST PERIARTC FIBULAR S STL,SUP-2410569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1842.21,1197.44,,,,,,,,,,,,,
STENT NEURO NEVA VS L 22 MM DIA 4 MM CATH L 180 CM VESALIO,SUP-2895057,CDM,C1757,HCPCS,0272,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
GUIDE SURG SPCR BUR NTHRD,SUP-2292260,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.12,113.83,,,,,,,,,,,,,
SHEATH INTRO PINNACLE PRECIS ACCS SYS L 10 CM DIA 4 FR STIFF,SUP-2538026,CDM,C1894,HCPCS,0272,RC,,,,both,,,181.18,117.77,,,,,,,,,,,,,
ROD SPNL STR 5X400 MM COCR STRL RELINE,SUP-2559367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
WAND ABLAT DIA3.75MM 90DEG ANG INTEGR CBL TURBOVAC,SUP-2341998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
BIT DRL OD2.9MM INLINE REUSE ELITE PREM,SUP-2349208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.67,388.49,,,,,,,,,,,,,
STEM FEM SEG 13 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449811,CDM,C1776,CPT,0278,RC,,,,both,,,11595.08,7536.80,,,,,,,,,,,,,
CAGE SPNL L30MM DIA9MM CRESC INTBDY,SUP-2280121,CDM,C1889,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS MAXXEUS TIBIALIS ANTERIOR FZ,SUP-2875990,CDM,C1762,CPT,0278,RC,,,,both,,,4614.70,2999.55,,,,,,,,,,,,,
HC Insertion Picc W/Rs&I 5 Yr/>,PX-3613657300,CDM,36573,CPT,0361,RC,,,,both,,,5560.00,3614.00,,,,,,,,,,,,,
CLIP ANEUR 8MM STD PERM SIDE CRV EL GILOY SUGITA,SUP-2306040,CDM,C1889,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
PLATE BONE L243MM 10 H LT SHFT FOR BUTTRESSING MULTIFRAGMENT,SUP-2152510,CDM,C1713,HCPCS,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
SYSTEM OCCL DEL L60CM SHTH 6FR 180DEG CRV CBL DIL HEMSTAS,SUP-2355727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L 115 CM 7/15 FR D,SUP-2248625,CDM,C1732,HCPCS,0272,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
RETRACTOR SURG 1525X625X2IN WILLAUER DEAVER,SUP-2244676,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.18,373.22,,,,,,,,,,,,,
COLLAR EXTRIC AD ADJUSTABLE STFFNK SEL,SUP-2120410,CDM,L0172,HCPCS,0274,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
BRACE WRST L AD FOR 10 LESS THAN 11IN L1375IN R HND BLK,SUP-2196553,CDM,L3807,HCPCS,0274,RC,,,,both,,,276.01,179.41,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.018 IN TIP LOAD 4,SUP-2909324,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.58,40.03,,,,,,,,,,,,,
SYSTEM IMPL MPFL TIGHTROPE,SUP-2731856,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 16 MM CUBE,SUP-2547187,CDM,C1713,HCPCS,0278,RC,,,,both,,,1588.09,1032.26,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX HUMERUS LONG 8H SHAFT 196MM STER,SUP-2549717,CDM,C1713,HCPCS,0278,RC,,,,both,,,5672.72,3687.27,,,,,,,,,,,,,
STAPLER INT AD L55MM DIA5MM STD TISS TI LIN 2 ROW STR,SUP-2174486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1918.04,1246.73,,,,,,,,,,,,,
R-T DEL II FEM NAIL 8X32,SUP-2818077,CDM,C1713,HCPCS,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
SCREW LUHR MINI LP 2.0X10MM,SUP-2364681,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L15CM ADMIN ACUTE BASIC KT 8.5 FR,SUP-2267026,CDM,C1750,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT LTING DISP STRL LT CBL NONSTRL LT CBL ADPT ACMI,SUP-2354671,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SCREW BNE LNG THRD 4X23 MM,SUP-2315872,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
SPLINT SLD BGE 3/32IN TAILORSPLNT,SUP-2324804,CDM,L4350,HCPCS,0272,RC,,,,both,,,132.79,86.31,,,,,,,,,,,,,
KIT TLIF DISP TUF HOOP MAXCESS MAS,SUP-2310437,CDM,C1713,HCPCS,0278,RC,,,,both,,,8044.68,5229.04,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 30X20 CM RND POLYESTER PARIETEX,SUP-2752187,CDM,C1781,HCPCS,0278,RC,,,,both,,,7627.85,4958.10,,,,,,,,,,,,,
VALVE HYDROCEPHALUS WITH PEDIATRIC PRECHAMBER PROGAV 2.0,SUP-2826976,CDM,C1889,HCPCS,0278,RC,,,,both,,,8115.05,5274.78,,,,,,,,,,,,,
HC NM Pulmonary Perfusion & Vent,PX-3417858200,CDM,78582,CPT,0341,RC,,,,both,,,5075.00,3298.75,,,,,,,,,,,,,
WIRE BNE FIX DIA2.75 MM METATRSL SHORTNG PILOT H STRL,SUP-2898942,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
GUIDE NERVE REP MTRX 1.5 MMX2 CM STRL NEURAGEN 3D LF,SUP-2877623,CDM,C9352,HCPCS,0278,RC,,,,both,,,7681.32,4992.86,,,,,,,,,,,,,
PLATE SPNL POST 18 MM,SUP-2430749,CDM,C1713,HCPCS,0278,RC,,,,both,,,13596.20,8837.53,,,,,,,,,,,,,
SCREW BONE L36MM DIA5MM S STL CANC MIDFOOT HINDFOOT VOLAR,SUP-2348620,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.20,354.38,,,,,,,,,,,,,
INBONE EVERLAST SZ 3+ 20MM TOTAL ANKLE,SUP-2822312,CDM,C1776,CPT,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
HC So2enzyme Activitycells/Tissue,PX-3018265768,CDM,82657,CPT,0301,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
STENT BILI OTW 0.035 IN 6X30 MM 6 FRX135 CM LIFESTAR,SUP-2472542,CDM,C1876,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
NAIL RFNA 12MMX 320MM 5 DEG BEND/ ST,SUP-2718125,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.35,3367.88,,,,,,,,,,,,,
PLATE BNE L93MM 4 H NONSTERILE L MED PROX TIB S STL LOK,SUP-2185632,CDM,C1713,HCPCS,0278,RC,,,,both,,,3776.89,2454.98,,,,,,,,,,,,,
COMPONENT PATELLAR 3 PEG STD 26X7 MM KNEE DOMED ROUNDED X3,SUP-2390315,CDM,C1776,CPT,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
PLATE BNE CONTOURED 1.5X26X0.3 MM BURR HOLE CVR MOD TI,SUP-2479956,CDM,C1713,HCPCS,0278,RC,,,,both,,,655.44,426.04,,,,,,,,,,,,,
GRAFT DERMAL FEN 12X8 CM CLLGN TISS MTRX,SUP-2243695,CDM,Q4110,HCPCS,0636,RC,,,,both,,,10248.96,6661.82,,,,,,,,,,,,,
WEDGE TIB 12 DEG MED RT KNEE ANGLED DURAC,SUP-2364820,CDM,C1776,CPT,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
GRAFT BIO TISS W7XL10CM HIATAL HERN PRESHAPED BIODESIGN,SUP-2170065,CDM,C1763,HCPCS,0278,RC,,,,both,,,5209.26,3386.02,,,,,,,,,,,,,
PLATE FUSION VA LCK 2.4/2.7MM 2H TI STRL,SUP-2546996,CDM,C1713,HCPCS,0278,RC,,,,both,,,2981.81,1938.18,,,,,,,,,,,,,
SHUNT CAR ART 3X5MM L30CM SGL USE EXT INTEGRA SUNDT,SUP-2244281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4971.56,3231.51,,,,,,,,,,,,,
PLATE BNE L71MM 4 H L DST LAT FIBULAR VAR ANG LOK FOR 35MM,SUP-2349827,CDM,C1713,HCPCS,0278,RC,,,,both,,,5543.36,3603.18,,,,,,,,,,,,,
GREAT TOE METATRSL SZ 2 RT CO CHROM INTEGRA,SUP-2242673,CDM,C1776,CPT,0278,RC,,,,both,,,6760.42,4394.27,,,,,,,,,,,,,
CLAMP SURG CENTERING W/ 2 MM DRL NS LTX,SUP-2856602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
GUIDE SURG ACET CUST BONE MOD SET SIGN,SUP-2206141,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
HC So2 Complement C-3/C-4,PX-3028616068,CDM,86160,CPT,0302,RC,,,,both,,,41.00,26.65,,,,,,,,,,,,,
SCREW BONE L50MM DIA13MM THRD L22MM CANC S STL ST CANN LAG,SUP-2186522,CDM,C1713,HCPCS,0278,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
DISC NEUROSURGICAL LOW WITHOUT RESERVOIR NON PROGRAMMABLE PR,SUP-2826743,CDM,C1889,HCPCS,0278,RC,,,,both,,,1271.42,826.42,,,,,,,,,,,,,
SHEATH INTRO SOLOPATH WORKING L 35 CM EXPANDABLE L 30CM 21FR,SUP-2385699,CDM,C1894,HCPCS,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
SCREW BNE 3.5 MM TI KREULOCK,SUP-2845747,CDM,C1713,HCPCS,0278,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
COMP FEM AUG BTN SM/LG+ 5 POS,SUP-2513640,CDM,C1776,CPT,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED H6 RESURF CORMET,SUP-2365404,CDM,C1776,CPT,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
SYSTEM LD DEL PACE INTRO,SUP-2149190,CDM,C1898,HCPCS,0275,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
PICC KIT CHLOROGUARD 5.5 FR VPS PRECIS ARROWG+ARD BLU +,SUP-2763313,CDM,C1751,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
PATCH CV HEMGRD L 120 X W 6 MM POLYESTER BOV CLLGN CAR ART,SUP-2266051,CDM,C1768,CPT,0278,RC,,,,both,,,480.70,312.45,,,,,,,,,,,,,
PLATE BNE 10 H RT ANTEROLATERAL DSTL TIB NS,SUP-2896881,CDM,C1713,HCPCS,0278,RC,,,,both,,,5491.86,3569.71,,,,,,,,,,,,,
WASHER ORTH L DIA13MM S STL FLAT RND FOR 4.5-6.5MM SCR,SUP-2411299,CDM,C1713,HCPCS,0278,RC,,,,both,,,99.38,64.60,,,,,,,,,,,,,
HC Bladder Scan,PX-4025179800,CDM,51798,CPT,0402,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
PLATE BONE 7 H LT PROX TIB TIM STD CRV LCK ALPS,SUP-2413729,CDM,C1713,HCPCS,0278,RC,,,,both,,,3329.97,2164.48,,,,,,,,,,,,,
RESORB XG ST MESH SPCLTY SUN PTTRN PRTL SM GRD101 X 101 MM T,SUP-2679391,CDM,C1713,HCPCS,0278,RC,,,,both,,,19860.56,12909.36,,,,,,,,,,,,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,J7614,HCPCS,0636,RC,00093-4148-45,NDC,,both,3,ML,7.20,4.68,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 24X12 CMX1.8-4 MM FLEXHD,SUP-2307487,CDM,Q4128,HCPCS,0636,RC,,,,both,,,27286.82,17736.43,,,,,,,,,,,,,
COMPONENT TIB UNI UHMWPE LT RT 37MM ANTR POST 7.5MM REPPICI,SUP-2403268,CDM,C1776,CPT,0278,RC,,,,both,,,3761.72,2445.12,,,,,,,,,,,,,
SHEATH INTRO ACCEL L 20 CM DIA 6 FR L 60/145 CM DIA 21 GA SS,SUP-2659241,CDM,C1894,HCPCS,0272,RC,,,,both,,,253.71,164.91,,,,,,,,,,,,,
STABILIZER PECTUS BAR TI OFFSET NS PECTUS BLU,SUP-2895736,CDM,C1713,HCPCS,0278,RC,,,,both,,,10927.20,7102.68,,,,,,,,,,,,,
SET URET STENT L 28 CM DIA 7 FR CATH POS 6 FR PERCFLX +,SUP-2727311,CDM,C2617,HCPCS,0278,RC,,,,both,,,371.71,241.61,,,,,,,,,,,,,
PROCEDURE KIT PERFLUOROCARBON PERFLUORON,SUP-2109683,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1467.95,954.17,,,,,,,,,,,,,
COMPONENT PATELLAR 0 7 MM KNEE DURASUL N-K II,SUP-2209588,CDM,C1776,CPT,0278,RC,,,,both,,,3143.14,2043.04,,,,,,,,,,,,,
ROD SPNL POST RT TRNSVRS SMOOTH TI ALLOY OD4MM L40MM OMEGA,SUP-2414726,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
CLIP HEMSTAS W11MMXL230CM WRK CHAN 2.8MM W/ 360DEG ROT,SUP-2418561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
TUBE VENT FEUERSTEIN SPLIT 1.02X9 MM FLROPLAS,SUP-2637787,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.30,32.04,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN 120 DEG L 60 CM DIA 8.5 FR SHRT CRV,SUP-2516632,CDM,C1894,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE BNE PROX 3.5 MM MEDL SS STRL,SUP-2185354,CDM,C1713,HCPCS,0278,RC,,,,both,,,4684.88,3045.17,,,,,,,,,,,,,
COMPONENT PATELLAR KNEE POLYETH PERSONA,SUP-2207897,CDM,C1776,CPT,0278,RC,,,,both,,,2735.60,1778.14,,,,,,,,,,,,,
MESH HERN OVL 5X3 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855269,CDM,C1781,HCPCS,0278,RC,,,,both,,,5856.10,3806.46,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 55 CM OD 7 FR GUIDEWIRE 0.038 IN,SUP-2168675,CDM,C1894,HCPCS,0272,RC,,,,both,,,121.83,79.19,,,,,,,,,,,,,
GRAFT SFT TISS FLOWABLE 0.6 CC 100 MG TISS MTRX INTERFYL,SUP-2651384,CDM,Q4171,HCPCS,0636,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW BONE L14MM OD2.5MM CANN HD,SUP-2399804,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
PLATE BONE TUBULAR 98 MM 8 HOLE 1/3 STERILE PERILOC,SUP-2837394,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.76,421.69,,,,,,,,,,,,,
IMPLANT TOE STD 3X3MM 10DEG UNIQUE DSTL CROSS H CROSSTIE,SUP-2175161,CDM,C1713,HCPCS,0278,RC,,,,both,,,6203.07,4032.00,,,,,,,,,,,,,
PLUG VASC DIA 9 MM AMPLTZ DEL STRL,SUP-2167792,CDM,C1757,HCPCS,0272,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 200X200X0.6 MM PRECONTOURED TITANIU,SUP-2842246,CDM,C1713,HCPCS,0278,RC,,,,both,,,26545.56,17254.61,,,,,,,,,,,,,
SPACER SPNL 20X11X14MM INTBDY ANTR CERV TRABECULAR MTL VBR,SUP-2414288,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM CLAVICLE 6H RT-18MM HOOK DEPTH-STER,SUP-2549670,CDM,C1713,HCPCS,0278,RC,,,,both,,,3723.60,2420.34,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX6 T SHAPED RIGHT DORSAL DISTAL,SUP-2725612,CDM,C1713,HCPCS,0278,RC,,,,both,,,3066.02,1992.91,,,,,,,,,,,,,
SUPPORT ORTHOT HND CUST STRP W/O JT FABRICATED SFT INTFACE,SUP-2435780,CDM,L3919,HCPCS,0272,RC,,,,both,,,697.80,453.57,,,,,,,,,,,,,
RING EXT FIX FULL 160 MM CARBON FIBER NS,SUP-2800125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3174.51,2063.43,,,,,,,,,,,,,
BRACE WLK M M 5.5-10 FEM 6.5-11 SFT NYL FOAM LNR LO PROF,SUP-2197141,CDM,L4350,HCPCS,0272,RC,,,,both,,,84.62,55.00,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE",PX-4209711000,CDM,97110,CPT,0420,RC,,,KX|CQ|XU,both,,,195.00,126.75,,,,,,,,,,,,,
GUIDEWIRE ENDO L145CM OD0.035IN S STL PTFE COONS-BENTSON,SUP-2168892,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.45,60.74,,,,,,,,,,,,,
STAPLER INT AD L28MM DIA5MM STD GI BLU TI CIR CUT 2 ROW,SUP-2283244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1188.68,772.64,,,,,,,,,,,,,
OXYGENATOR PERF ART FILTER BAL AFFIN FUSION,SUP-2496214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
KIT LD REP ATR SINGLE CHMBR IS1 CONN STRL,SUP-2148912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KIT CRAN ACCS INCLUDE SYR 5CC NDL RAZ POVIDONE IOD SWAB LIDO,SUP-2244116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.53,632.79,,,,,,,,,,,,,
CATHETER HD 20 CM KT CHRONIC PRE CRV BASIC SHTH EVENMORE,SUP-2116552,CDM,C1750,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE L47MM 7X2 H L VOLAR DST RAD S STL VAR ANG LOK,SUP-2184122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2114.48,1374.41,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.412,SUP-2859976,CDM,C1713,HCPCS,0278,RC,,,,both,,,32134.76,20887.59,,,,,,,,,,,,,
GRAFT DERMACELL DERMAL 4X12CM X 1.25-2MM UNMESHED MATRIX,SUP-2878003,CDM,Q4122,HCPCS,0636,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR 35CM WIRE INTRAMUSCULAR NEUROSTIM,SUP-2281931,CDM,C1778,HCPCS,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
BLADE REPROC SHV 4.5MM FULL RAD BONECUTTER PLAT,SUP-2653220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,77.84,50.60,,,,,,,,,,,,,
KIT PRB 17GA L150MM ACT TIP 4MM COOLED RF COOLIEF,SUP-2236750,CDM,C1894,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
TUBE VENT 1.14 MM CLLR BUTTON SIL 510536,SUP-2478220,CDM,L8699,HCPCS,0278,RC,,,,both,,,1775.48,1154.06,,,,,,,,,,,,,
STEM TIB DIA16MM BILAT ANK PLSM BASE CEM PROPHECY INBONE,SUP-2397063,CDM,C1776,CPT,0278,RC,,,,both,,,1456.96,947.02,,,,,,,,,,,,,
SEALANT FIBRIN 10 CC FRZN PRE FILLED SYR TISSEEL,SUP-2130315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1967.18,1278.67,,,,,,,,,,,,,
PLATE POLYAXIAL LK CUBOID T8,SUP-2704973,CDM,C1713,HCPCS,0278,RC,,,,both,,,4611.40,2997.41,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM WHL MEM AMNIO SHT NO ANG AMINOFIX,SUP-2305726,CDM,V2790,HCPCS,0278,RC,,,,both,,,4980.04,3237.03,,,,,,,,,,,,,
SMARTBAND LIG KT,SUP-2313541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.21,258.84,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC HF BSC 5FR 55CM 3 LUMAN RV 3385118Q,SUP-2632680,CDM,C1751,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CLAMP ABLAT JAW L65MM L CRV 2 ELECTRD BPLR,SUP-2124466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
MESH SFT BARD PRESHAPED 2.4 IN X 5.4 IN,SUP-2125783,CDM,C1781,HCPCS,0278,RC,,,,both,,,197.51,128.38,,,,,,,,,,,,,
KIT CATH 14.5FR L36CM INSRT L19CM POLYUR DBL LUMN STD FLO,SUP-2283940,CDM,C1881,HCPCS,0278,RC,,,,both,,,805.76,523.74,,,,,,,,,,,,,
INSERT TIBIALXSM THK21MM UNIV KNEE HNG POST STBL BEAR PRI,SUP-2252653,CDM,C1776,CPT,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
CEMENT CAP LY 000240 FUJI I,SUP-2238618,CDM,C1713,HCPCS,0278,RC,,,,both,,,1006.78,654.41,,,,,,,,,,,,,
PLATE BNE RECON 3.5X94 MM 8 HOLE SS,SUP-2569083,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.21,245.84,,,,,,,,,,,,,
GRAFT HUM TISS XL 10X15 CM FRSH FRZN FASC LATA TEND,SUP-2777424,CDM,C1762,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
PLATE BNE FIBULAR 3.5X178 MM LT DSTL PL PERI ARTC 14 HOLE SS,SUP-2422116,CDM,C1713,HCPCS,0278,RC,,,,both,,,1966.39,1278.15,,,,,,,,,,,,,
REAMER SURG 4.5 MM FLX,SUP-2362047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
TUBE VENT MOD 1.27 MM CLLR BUTTON SIL,SUP-2480682,CDM,L8699,HCPCS,0278,RC,,,,both,,,27.26,17.72,,,,,,,,,,,,,
GUIDEWIRE VASC L 45 CM DIA 0.018 IN SS PERIPH AD X STIFF MIC,SUP-2117371,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.31,46.35,,,,,,,,,,,,,
PLATE CRAN 160X120X40 MM PT SPEC IMPL PEEK,SUP-2860153,CDM,C1713,HCPCS,0278,RC,,,,both,,,43632.50,28361.12,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA16MM FOR 37MM CANN LOK SCR,SUP-2188304,CDM,C1769,HCPCS,0272,RC,,,,both,,,685.05,445.28,,,,,,,,,,,,,
GUIDEWIRE ORTH L3IN OD0.035IN,SUP-2319793,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
VALVE SHUNT INLINE PROGRAMMABLE,SUP-2243811,CDM,C1729,HCPCS,0272,RC,,,,both,,,14668.20,9534.33,,,,,,,,,,,,,
PROSTHESIS PENILE L18CM CYL MALL 600M,SUP-2138932,CDM,C1813,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BUR DIAMOND RND 2.5MM,SUP-2736214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,897.63,583.46,,,,,,,,,,,,,
CONNECTOR SPNL SM SZ 1 L17-18MM STD POST LUM THOR TI SCR,SUP-2254356,CDM,C1713,HCPCS,0278,RC,,,,both,,,3680.08,2392.05,,,,,,,,,,,,,
HC So Mopath Procedure Level 5,PX-3108140466,CDM,81404,CPT,0310,RC,,,,both,,,659.00,428.35,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 5MM L MED R LAT KNEE HEMI STP SCR ON,SUP-2346177,CDM,C1776,CPT,0278,RC,,,,both,,,4257.84,2767.60,,,,,,,,,,,,,
PLATE BNE W21.6XL48.9MM SHT NAR ANAT FAST GUID TECHNOLOGY,SUP-2414022,CDM,C1713,HCPCS,0278,RC,,,,both,,,2709.82,1761.38,,,,,,,,,,,,,
TUBE TRACH PED L41MM OD6MM ID4MM SIL CUF STR NK FLNG FLX W,SUP-2352326,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.33,742.51,,,,,,,,,,,,,
ES TROCH NAIL LEFT 12.5X33CMX125 GOLD,SUP-2811011,CDM,C1713,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
SET URET STENT SOFFLX L 16 CM DIA 6 FR POS L 46 CM DIA 7 FR,SUP-2835689,CDM,C2617,HCPCS,0278,RC,,,,both,,,346.59,225.28,,,,,,,,,,,,,
CATHETER HD LT 15 FRX19 CM NEXTSTEP RETROGRADE,SUP-2383435,CDM,C1750,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CHRONOS(TM) BETA-TCP WEDGE 10 DEG/RECTANGULAR-STERILE,SUP-2550432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1846.98,1200.54,,,,,,,,,,,,,
GRAFT BNE SUB L30MM THK1MM STRP COMPRESSIBLE SPNG SM GROWTH,SUP-2138505,CDM,C1713,HCPCS,0278,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 100 CM 7 FR 0.078 IN NYL SIM2,SUP-2155869,CDM,C1887,HCPCS,0272,RC,,,,both,,,563.79,366.46,,,,,,,,,,,,,
ALLOGRAFT DERMAL 4X5 CMX2.5-3.5 MM DERMAL MTRX ARTHROFLEX,SUP-2741012,CDM,Q4125,HCPCS,0636,RC,,,,both,,,9133.63,5936.86,,,,,,,,,,,,,
SHUNT COR 12FR SHFT L1.1CM BLB 4MM STD FLO W/O RESVR,SUP-2214558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE BNE LCK 237 MM LT DSTL LAT TIB PERIARTICULAR 18 HOLE,SUP-2475092,CDM,C1713,HCPCS,0278,RC,,,,both,,,4615.86,3000.31,,,,,,,,,,,,,
BLADE SURG FASCIAL RELINE MAS,SUP-2557551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
COMPONENT TOT HIP MH GRIPTION,SUP-2257833,CDM,C1776,CPT,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
ANCHOR SUT DIA2.1MM W/ S STL INSRT FOR LABRAL REP,SUP-2212782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.15,836.65,,,,,,,,,,,,,
PLATE BONE CRANIAL 10 HOLE STRAIGHT 43.9X3.4MM TITANIUM NEUR,SUP-2821912,CDM,C1713,HCPCS,0278,RC,,,,both,,,143.18,93.07,,,,,,,,,,,,,
SCREW BNE CRTX 1.5X4 MM RAPID RESRB W/PLATE STRL 80560420S,SUP-2859930,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.39,205.65,,,,,,,,,,,,,
NAIL IM RETROGRADE 5 DEG 14X360 MM FEM BEND RFNADVANCED,SUP-2789418,CDM,C1713,HCPCS,0278,RC,,,,both,,,5628.20,3658.33,,,,,,,,,,,,,
HC Ep Study Avn Ablation,PX-4819365000,CDM,93650,CPT,0481,RC,,,,both,,,20849.00,13551.85,,,,,,,,,,,,,
NUT ORTH DIA6MM S STL RND FOR SACR BAR FIX,SUP-2187001,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
CROWN DENT D3 PEDIATRIC 1ST PRIMARY M UPPER LT SS,SUP-2240509,CDM,D6783,CPT,0278,RC,,,,both,,,23.24,15.11,,,,,,,,,,,,,
HC Dilation Stricture/Obst S&I,PX-3207436000,CDM,74360,CPT,0320,RC,,,,both,,,1253.00,814.45,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THK.4-.8MM ACELLULAR DERM MTRX MESH,SUP-2402503,CDM,Q4126,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
STENT TRACHBRONCH COOK-Z GIANTURCO-ROSCH L 5 CM DIA15 MM,SUP-2693656,CDM,C1877,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
IMPLANT OTO 4MM W/ 9MM ABUTMENT FOR BAHA FAST SURG,SUP-2164972,CDM,L8614,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
SPLINT HND AD L115IN L DK BLU HEADLINER BROAD CLTH REST,SUP-2165488,CDM,L3807,HCPCS,0274,RC,,,,both,,,211.04,137.18,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY 16 IN,SUP-2336079,CDM,L1830,CPT,0274,RC,,,,both,,,40.29,26.19,,,,,,,,,,,,,
LEAD PACE BPLR 40 CM ATRICLE VENTRIC ISOFLEX-S,SUP-2356086,CDM,C1898,HCPCS,0275,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
ABUTMENT OTO L12MM FOR BAHA TWO STG SURG,SUP-2164987,CDM,L8614,HCPCS,0278,RC,,,,both,,,6719.60,4367.74,,,,,,,,,,,,,
HC Syphilis Test Quantitative,PX-3028659300,CDM,86593,CPT,0302,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
BLADE SAW L 79 MM WORKING L 17 MM D 4 MM THK MATERIAL 0.4 MM,SUP-2928861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.05,389.38,,,,,,,,,,,,,
CATHETERIZATION KIT 13-1/8 IN 6 FRX50 CM 3L BLU FLEXTIP,SUP-2383372,CDM,C1751,HCPCS,0278,RC,,,,both,,,524.47,340.91,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X172 MM 13 HOLE SS LCP,SUP-2569339,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.37,335.64,,,,,,,,,,,,,
HC So Newborn Screen (Pku),PX-3018403066,CDM,84030,CPT,0301,RC,,,,both,,,564.00,366.60,,,,,,,,,,,,,
HC Iadna Orthopoxvirus Amp Probe Tech Ea,PX-3008759300,CDM,87593,CPT,0300,RC,,,,both,,,110.00,71.50,,,,,,,,,,,,,
GRAFT BONE SUB 2ML HUM CORT DEMIN FBR STAGRFT,SUP-2136830,CDM,C1763,HCPCS,0278,RC,,,,both,,,1228.05,798.23,,,,,,,,,,,,,
HC Surgery Level 3 Addtl 15min,PX-3600000013,CDM,3600000013,LOCAL,0360,RC,,,,both,,,2666.00,1732.90,,,,,,,,,,,,,
GUIDE SURG PRT CANN SINGLE SITE DISP,SUP-2246702,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
SCREW BNE CYL 4 MM SHFT 3X100 MM 20 MM XCALIBER,SUP-2645993,CDM,C1713,HCPCS,0278,RC,,,,both,,,437.72,284.52,,,,,,,,,,,,,
GRAFT EVAR L150MM DIA36X36MM PROX DST FREE FLO STR CLS WEB,SUP-2298537,CDM,C1768,CPT,0278,RC,,,,both,,,58074.30,37748.29,,,,,,,,,,,,,
SET BX NDL 13GA L10CM INFUS CANN W/ RATCH UNIDIR DRL ACT,SUP-2169482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
HC Drug Screen Quantitative Amikacin,PX-3018015000,CDM,80150,CPT,0301,RC,,,,both,,,467.00,303.55,,,,,,,,,,,,,
GRAFT SURG 1MM PROC HUM DERM CLLGN RECTANG 10CMX15CM ALLOMAX,SUP-2126263,CDM,C1781,HCPCS,0278,RC,,,,both,,,10406.59,6764.28,,,,,,,,,,,,,
STAPLER INST DISP PED 20CM X 5MM JUSTRIGHT,SUP-2427770,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SET ENDOSCP RETRV L 220 CM OD 16.9 MM ID 2.3 MM ENDOSCP DIA,SUP-2881873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
MUELLER FULL PROF ALL POLY CUP 32MM ID/46MM OD,SUP-2209463,CDM,C1776,CPT,0278,RC,,,,both,,,2265.82,1472.78,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 5 DEG 60X25X8 MM PRO OSTEON 500R,SUP-2684331,CDM,C1713,HCPCS,0278,RC,,,,both,,,2647.02,1720.56,,,,,,,,,,,,,
GUIDE WIRE THRDED 2.4 MMX203 MM STR,SUP-2815257,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
GRAFT BNE 1MM 4MM RANG 15CC CHIP CRUSH FRZN CANC ALLGRFT,SUP-2264732,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.54,545.05,,,,,,,,,,,,,
RASP SURG PWR RECIP 14.0X7MM L TEAR XCUT,SUP-2363297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.57,214.22,,,,,,,,,,,,,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOSY,RX-173412,CDM,J3376,HCPCS,0636,RC,65649-0551-07,NDC,,both,0.4,ML,651.40,423.41,,,,,,,,,,,,,
HC Treat Foot Disloc,PX-4502854000,CDM,28540,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM CLAVICLE 5H RT-15MM HOOK DEPTH-STER,SUP-2549664,CDM,C1713,HCPCS,0278,RC,,,,both,,,3620.01,2353.01,,,,,,,,,,,,,
GENTAMICIN SULFATE 0.1 % EX OINT,RX-3424,CDM,6370000000,HCPCS,0637,RC,00713-0682-15,NDC,,both,15,GR,177.80,115.57,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 70 MM DIA 7 MM DEL SHTH 3.7ML,SUP-2936812,CDM,C1713,HCPCS,0278,RC,,,,both,,,11496.58,7472.78,,,,,,,,,,,,,
GUIDEWIRE VASC CHIKAI BLK 18 L 200 CM DIA 0.018/0.014 IN,SUP-2518870,CDM,C1769,HCPCS,0272,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 3 MM EPTFE STR STD WALL N RING,SUP-2761227,CDM,C1768,CPT,0278,RC,,,,both,,,480.73,312.47,,,,,,,,,,,,,
GRAFT HUM TISS LT MEDL FEM KNEE OSTEOCHNDRL FRSH ASEP HEMI,SUP-2113920,CDM,C1713,HCPCS,0278,RC,,,,both,,,35953.00,23369.45,,,,,,,,,,,,,
SPLINT THMB AD M FOR 6.5-7.5IN RT WR REG TRIOXON LINING,SUP-2324738,CDM,L3931,HCPCS,0274,RC,,,,both,,,60.95,39.62,,,,,,,,,,,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-3614376200,CDM,43762,CPT,0361,RC,,,,both,,,935.00,607.75,,,,,,,,,,,,,
PLATE BNE H0.6MM 6 H CRANIOMAXILLOFACIAL G TI CRV W/ BAR,SUP-2366253,CDM,C1713,HCPCS,0278,RC,,,,both,,,755.33,490.96,,,,,,,,,,,,,
ARIPIPRAZOLE 5 MG PO TABS,RX-36438,CDM,6370000000,HCPCS,0637,RC,00904-7367-06,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
PLATE BNE SM W10XL67MM THK15MM 90DEG 3X5 H TI T SHP R ANG,SUP-2190932,CDM,C1713,HCPCS,0278,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
PROSTHESIS OSS GROTE SM 13X12X16 MM CNL WALL POROUS HA,SUP-2637868,CDM,L8613,CPT,0278,RC,,,,both,,,1429.80,929.37,,,,,,,,,,,,,
GRAFT BIO TISS W31XL31IN SQ XENMATRIX,SUP-2126239,CDM,C1781,HCPCS,0278,RC,,,,both,,,6081.24,3952.81,,,,,,,,,,,,,
SCREW BNE L38MM DIA35MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321207,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.89,354.83,,,,,,,,,,,,,
SEMI-TUB PLT STERILIZER 119 MM LENGTH 7 HL,SUP-2818492,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.79,380.11,,,,,,,,,,,,,
TRIAL NERVE STIM KT STIM BLDR ADV,SUP-2435500,CDM,C1778,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
COIL EMB L40CM DIA10MM 360DEG STD DETACH TARGET XL,SUP-2367728,CDM,C1889,HCPCS,0278,RC,,,,both,,,6685.53,4345.59,,,,,,,,,,,,,
PATCH CV HEMGRD L 75 X W 14 MM THK 0.65 MM POLYESTER BOV,SUP-2535421,CDM,C1768,CPT,0278,RC,,,,both,,,381.04,247.68,,,,,,,,,,,,,
COMPONENT ARTC SURF 5-6 17 MM KNEE NXGN LEG,SUP-2201195,CDM,C1776,CPT,0278,RC,,,,both,,,2476.99,1610.04,,,,,,,,,,,,,
CEMENT BNE 5 CC STRL FORTERA LTX,SUP-2855702,CDM,C1713,HCPCS,0278,RC,,,,both,,,9143.68,5943.39,,,,,,,,,,,,,
HC Dx Breast Tomo Uni,PX-4017706100,CDM,G0279,HCPCS,0401,RC,,,,outpatient,,,153.00,99.45,,,,,,,,,,,,,
CENTRALIZER KNEE L DIA16MM UHMWPE CEM ENDO-MODEL-M,SUP-2265086,CDM,C1776,CPT,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
HC Bladder Scan,PX-4505179800,CDM,51798,CPT,0450,RC,,,,inpatient,,,191.00,124.15,,,,,,,,,,,,,
BUR SURG L15CM DIA17MM MTCH HD FLUT SM BOR MIDAS REX,SUP-2284384,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.70,218.20,,,,,,,,,,,,,
BUR SURGICAL TRABECULAR METAL TOTAL ANKLE SYSTEM,SUP-2471018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,941.34,611.87,,,,,,,,,,,,,
MESH HERN ANAT 12X8 CM LT SELF GRIPPING BASE POLYPR PROGRIP,SUP-2752182,CDM,C1781,HCPCS,0278,RC,,,,both,,,1276.66,829.83,,,,,,,,,,,,,
HC Holter Monitor,PX-7319322500,CDM,93225,CPT,0731,RC,,,,both,,,903.00,586.95,,,,,,,,,,,,,
LEVEL CMF ST PLATE ORBTL FLOOR SMART LEFT 15 MM SCRW40 X 35,SUP-2676707,CDM,C1713,HCPCS,0278,RC,,,,both,,,4579.34,2976.57,,,,,,,,,,,,,
SCREW BNE 3 HD W/ DEPTH G SCRDRIVER COUNTSINK INSTR HNDL,SUP-2175122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
STEM FEM L8IN DIA15MM PLATFRM 15CM CALCAR HIP POR STR,SUP-2252183,CDM,C1776,CPT,0278,RC,,,,both,,,22323.52,14510.29,,,,,,,,,,,,,
HC So Ptt|NOT REASONABLE AND NECESSARY,PX-3058573066,CDM,85730,CPT,0305,RC,,,GZ,both,,,47.00,30.55,,,,,,,,,,,,,
SYSTEM KNEE LNG REINF FINN,SUP-2406069,CDM,C1776,CPT,0278,RC,,,,both,,,2752.52,1789.14,,,,,,,,,,,,,
PLATE BNE SQ MIC 1X0.6 MM CRANIOMAXILLOFACIAL 3X2 LADDER,SUP-2462804,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.89,487.43,,,,,,,,,,,,,
SPACER ORTH L30MM SALVATION,SUP-2401148,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
CATHETER CARD ABLATION SPHERE-9 L 115 CM DIA 8 FR ELECTRD,SUP-2911943,CDM,C1733,HCPCS,0272,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
COMPONENT CRPL SM STD BILAT WRST JT TI POR PRI PRSS FIT,SUP-2243197,CDM,C1776,CPT,0278,RC,,,,both,,,3141.98,2042.29,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CRYOPRESERVED RT MTCRPL PHLANG,SUP-2867044,CDM,C1762,CPT,0278,RC,,,,both,,,5074.08,3298.15,,,,,,,,,,,,,
TRIAL PLATE 0.8 MM OFFSET,SUP-2525713,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
KYPHOPLASTY KIT TROCAR 11 GA OSTEO INTRO BVL KYPHON V,SUP-2632234,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ULTRA HI DEMAND CERM ON CERM BIOMETHMONM] ZIMMER BIOMET INC],SUP-2137337,CDM,C1776,CPT,0278,RC,,,,both,,,23236.00,15103.40,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 120 CM DIA 3 FR BALLOON DIA,SUP-2214014,CDM,C1757,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
HC Drug Tst Prsmv Instrmnt Chem Analyzers PR Date|NOT REASONABLE AND NECESSARY,PX-3018030700,CDM,80307,CPT,0301,RC,,,GZ,both,,,400.00,260.00,,,,,,,,,,,,,
SHELL ACET OD50MM ID28MM HIP TI POR CLUS H DURALOC OPT,SUP-2252355,CDM,C1776,CPT,0278,RC,,,,both,,,5621.86,3654.21,,,,,,,,,,,,,
TRIAL BONE PLT 4 H CLVRLF TC-100 SM FRAG SYS,SUP-2343733,CDM,C1713,HCPCS,0278,RC,,,,both,,,2975.75,1934.24,,,,,,,,,,,,,
PLATE BNE L 102 MM 8 H SCREW DIA 3.5 MM TI ANTR MEDL CLAV,SUP-2905543,CDM,C1713,HCPCS,0278,RC,,,,both,,,5703.65,3707.37,,,,,,,,,,,,,
STEM FEM SZ 1 L115MM DIA11MM NK L31MM 34 OFFSET 132DEG ANG 62610003] STRYKER ORTHOPEDICS HOWM],SUP-2375304,CDM,C1776,CPT,0278,RC,,,,both,,,13455.53,8746.09,,,,,,,,,,,,,
COVER BUR H DIA20MM CRANIOMAXILLOFACIAL PLT LO PROF W/ TAB,SUP-2366207,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.45,481.94,,,,,,,,,,,,,
PLATE BNE TIB 3.5 MM LAT PROX SET PERI-LOC,SUP-2351408,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
SCREW BNE SD SHT THRD 7X80 MM CANN MAXTORQUE,SUP-2315912,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
CATHETER EP DIAG MAPPINGXLARGE CRV DECAPOLAR 2-8-2MM SPC,SUP-2356929,CDM,C1730,HCPCS,0272,RC,,,,both,,,1987.62,1291.95,,,,,,,,,,,,,
INTRODUCER PACE LD FLOWGUARD DIA 9 FR ART VLV PEELABLE STRL,SUP-2281860,CDM,C1894,HCPCS,0272,RC,,,,both,,,196.53,127.74,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 5 FR TIP 2 MM SPC 2,SUP-2248854,CDM,C1730,HCPCS,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
MESH HERN MED 14.2X8.6 CM W/ POCKET STRP,SUP-2858044,CDM,C1781,HCPCS,0278,RC,,,,both,,,586.11,380.97,,,,,,,,,,,,,
GRAFT EVAR L70MM DIA28X28MM C DST DSGN FOR ABD AORT ANEUR,SUP-2295272,CDM,C1768,CPT,0278,RC,,,,both,,,23785.50,15460.57,,,,,,,,,,,,,
KIT PROC L65CM 0.035IN NDL 19GA NEVER TCH FRS GLD TIP FBR,SUP-2116799,CDM,C1894,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
CATHETER KIT 1 LUMEN 4 FR W/ PASV BIOFLO,SUP-2117193,CDM,C1751,HCPCS,0278,RC,,,,both,,,634.59,412.48,,,,,,,,,,,,,
PLATE BNE L106MM 6 H L LAT DST PERIARTC FIBULAR S STL LOK,SUP-2410716,CDM,C1713,HCPCS,0278,RC,,,,both,,,2069.89,1345.43,,,,,,,,,,,,,
ANCHOR SUT 45MM DIA NO 2 ABSRB SFT TISS BRAID POLY TWO,SUP-2362543,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.99,469.94,,,,,,,,,,,,,
NAIL FIX L22MM OD2MM LACTOSORB COPOLYMER ABSRB SGL USE FOR,SUP-2212970,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J3490,HCPCS,0250,RC,00338-0043-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
PIN FIX KNEE PRI LOK AMK,SUP-2252438,CDM,C1776,CPT,0278,RC,,,,both,,,1051.27,683.33,,,,,,,,,,,,,
SCREW SPNL MULTAXL 8.5X60 MM CANC CD HORZ,SUP-2628372,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
CATHETER SUPP RUBICON 35 L 90 CM DIA 5 FR TIP 2.84 FR PROX,SUP-2140835,CDM,C1725,HCPCS,0272,RC,,,,both,,,477.91,310.64,,,,,,,,,,,,,
AGBA PI PICC KIT: 1L 4.5FR 40CM,SUP-2822086,CDM,C1751,HCPCS,0278,RC,,,,both,,,614.44,399.39,,,,,,,,,,,,,
HC So Tp53 Gene Full Gene Sequence,PX-3108135166,CDM,81351,CPT,0310,RC,,,,both,,,1471.00,956.15,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 156 MM BLADE L 50 MM 9 H SS CNDYL,SUP-2908528,CDM,C1713,HCPCS,0278,RC,,,,both,,,3395.34,2206.97,,,,,,,,,,,,,
LEFT LAT TTC FUS PLT,SUP-2315871,CDM,C1713,HCPCS,0278,RC,,,,both,,,9517.34,6186.27,,,,,,,,,,,,,
CEMENT BNE 51 GM GENTAMICIN PALACOS,SUP-2601061,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
IMPLANT WR SPCR CMC I,SUP-2361943,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
DRESSING WND 6 LAYR 5X5 CM MTRX CYTAL,SUP-2106531,CDM,Q4166,HCPCS,0636,RC,,,,both,,,3984.66,2590.03,,,,,,,,,,,,,
LEVEL CMF PLATE MDFCE STR WTAB 1.5 MM SCRW24 HOLE T0.4 MM C,SUP-2677539,CDM,C1713,HCPCS,0278,RC,,,,both,,,1115.33,724.96,,,,,,,,,,,,,
GAUGE DEPTH FIX SZR 14 CM RIB NS LEVEL 1 LTX,SUP-2869176,CDM,C1763,HCPCS,0278,RC,,,,both,,,1916.66,1245.83,,,,,,,,,,,,,
PLATE BONE L107MM 6 H DSTL ANTR TIB VAR ANG LCK FOR 3.5MM,SUP-2349814,CDM,C1713,HCPCS,0278,RC,,,,both,,,9244.00,6008.60,,,,,,,,,,,,,
LEAD PACE BPLR 6 FRX52 CM TENDRIL ST,SUP-2356688,CDM,C1898,HCPCS,0275,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
BLADE ARTHSCP L11CM DIA4MM 40DEG ANG PRECIS AGG SERR ESSX,SUP-2363528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,447.48,290.86,,,,,,,,,,,,,
HEAD FEM DIA40MM +5MM OFFSET 12/14 TAPR HIP CERAMIC TI SL,SUP-2251123,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
KIT REPL INDWL LO PRSS VOICE PROSTHESES SER 6MM BLOM SINGER,SUP-2246403,CDM,L8509,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
COIL VASC AZUR HYDROPACK L 20 CM SZ 18 MICROCATHETER 2.4/2.8,SUP-2896811,CDM,C1889,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
COMPONENT TOT SHLDR ONCOLOGY B-O3,SUP-2137348,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW SPNL L5MM DIA2.6MM LAM LEVERAGE LFS,SUP-2311374,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK XL INTUITRAK EXPRESS L 100 MM CVR,SUP-2217583,CDM,C1768,CPT,0278,RC,,,,both,,,13172.30,8561.99,,,,,,,,,,,,,
LISINOPRIL 20 MG PO TABS,RX-4526,CDM,6370000000,HCPCS,0637,RC,00904-6799-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT BRST 125CC DIA8.9CM P2.8CM SIL GEL SMOOTH RND MOD +,SUP-2300233,CDM,C1789,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
PLATE BONE LOK 144MML HLX11 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2588606,CDM,C1713,HCPCS,0278,RC,,,,both,,,1571.57,1021.52,,,,,,,,,,,,,
KIT TB RETEN SYS OD12FR NG CORGRIP,SUP-2236652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,260.21,169.14,,,,,,,,,,,,,
PROX ULNAR LOCKING PLT JIG LT,SUP-2723794,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.84,901.45,,,,,,,,,,,,,
BOLT IM L50MM DIA4.9MM 3.5MM TI ST LOK HEX RECESS GRN,SUP-2192395,CDM,C1713,HCPCS,0278,RC,,,,both,,,515.46,335.05,,,,,,,,,,,,,
PLATE BNE L78MM THK385MM 6 H BILAT S STL STR WIDE ANG LO,SUP-2177153,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.21,806.14,,,,,,,,,,,,,
SCREW CANN COUNTERSINC,SUP-2319442,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
KNIFE SURG PAPARELLA SCKL 6.5 INX5 MM STR MICROFRANCE,SUP-2494088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,429.05,278.88,,,,,,,,,,,,,
CATHETER PICC AD 6FR L55CM 3 LUMN NRS PWR INJ POLYUR N COAT,SUP-2125559,CDM,C1751,HCPCS,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
TRACKER NAVIGATION PT ELECTROMAGNETIC NONINVASIVE AXIEM,SUP-2284344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.53,390.34,,,,,,,,,,,,,
CATHETER DIAG L150CM DST L10CM MIC NEURO RENEGADE HI FLO,SUP-2367869,CDM,C1887,HCPCS,0272,RC,,,,both,,,2337.67,1519.49,,,,,,,,,,,,,
PLATE BNE 17 DEG THK 2.8 MM SCREW DIA2-2.3-2.7 MM 6 X 17 H,SUP-2883621,CDM,C1713,HCPCS,0278,RC,,,,both,,,4018.16,2611.80,,,,,,,,,,,,,
NOREPINEPHRINE-SODIUM CHLORIDE 16-0.9 MG/250ML-% IV SOLN,RX-137248,CDM,2500000003,HCPCS,0250,RC,44567-0642-01,NDC,,both,250,ML,454.30,295.29,,,,,,,,,,,,,
ROD 11MM 600MM C FBR,SUP-2188675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
SPLINT ORTHOPEDIC PADDED LG 9X4.5 IN LT PRE MOLD PROCARE,SUP-2196717,CDM,L3809,HCPCS,0274,RC,,,,both,,,13.69,8.90,,,,,,,,,,,,,
CATHETER HD STR 15.5 FRX24 CM LT DL STP TIP SIDE H TITAN HD,SUP-2627345,CDM,C1750,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
BIT DRL L150MM OD32MM N RADLUC CANN W O STP ORTHOFIX,SUP-2315979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.57,281.17,,,,,,,,,,,,,
HC Galactogram Multi S&I,PX-3207705400,CDM,77054,CPT,0320,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209711600,CDM,97116,CPT,0420,RC,,,GP|CQ|XU,both,,,164.00,106.60,,,,,,,,,,,,,
GRAFT DURA SUTURABLE 1X1 IN REGEN MTRX DURAGN + EACH=5 UNITS,SUP-2922527,CDM,C1763,HCPCS,0278,RC,,,,both,,,812.66,528.23,,,,,,,,,,,,,
MICROCATHETER VASC RENEGADE 18 L 150 CM PROX/DSTL,SUP-2367822,CDM,C1887,HCPCS,0272,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
COIL HELCL 10 COIL SZ SFT 2MM LOOP DIA 2CM V TRAK DEL,SUP-2305136,CDM,C1889,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
PREDNISONE 1 MG PO TABS,RX-6493,CDM,J7512,HCPCS,0637,RC,59651-0484-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 40X25 CM RECON TISS MTRX STRATTICE,SUP-2482660,CDM,Q4130,HCPCS,0636,RC,,,,both,,,99016.76,64360.89,,,,,,,,,,,,,
PATCH CV IMPRA L 150 X W 50 MM THK 0.6 MM EPTFE RECTANGULAR,SUP-2761294,CDM,C1768,CPT,0278,RC,,,,both,,,1728.22,1123.34,,,,,,,,,,,,,
HC NM Renal W/Vascular Flow,PX-3417870100,CDM,78701,CPT,0341,RC,,,,both,,,2410.00,1566.50,,,,,,,,,,,,,
PLATE BNE L154MM 9 H NONSTERILE R DST RAD VOLAR DPHSEAL,SUP-2184058,CDM,C1713,HCPCS,0278,RC,,,,both,,,4358.51,2833.03,,,,,,,,,,,,,
TUBE T SURG DRAIN 10F SIL STRL,SUP-2752236,CDM,C1729,HCPCS,0272,RC,,,,both,,,1263.63,821.36,,,,,,,,,,,,,
SCREW BONE 1.8X3MM STERILE EMERGENCY CROSS DRIVE SELF TAPPIN,SUP-2825714,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.30,54.14,,,,,,,,,,,,,
PLATE BNE 12 H TI STR FOR 2MM SCR MOD HND SYS,SUP-2191191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.63,714.76,,,,,,,,,,,,,
HC 2d Echo Without Contrast - Without Dop/Color Flow,PX-4839330701,CDM,93307,CPT,0483,RC,,,,both,,,1896.00,1232.40,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 0.25 CC FD SYR DBM GRFT,SUP-2787765,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
BASKET STONE RETRV L120CM DIA8MM SHTH 1.9FR NIT OPENSURE,SUP-2139284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.12,462.88,,,,,,,,,,,,,
PLATE BNE SM TI PMI LEFORT ORTHOGNATHIC 3D PRNT NS DISP,SUP-2934960,CDM,C1713,HCPCS,0278,RC,,,,both,,,20890.42,13578.77,,,,,,,,,,,,,
RESUSCITATION KIT DL 41 FR 20 CC 140 CC ESOPH COMBITUBE,SUP-2240633,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM ID DIA MM BRANCH SZ 10 MM,SUP-2763176,CDM,C1768,CPT,0278,RC,,,,both,,,4635.86,3013.31,,,,,,,,,,,,,
PLATE BONE 3D PRNT LG MIDFACE MAND TI TRUMATCH,SUP-2860369,CDM,C1713,HCPCS,0278,RC,,,,both,,,49048.37,31881.44,,,,,,,,,,,,,
SPLINT WRST M L7IN AD R FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276653,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.80,6.37,,,,,,,,,,,,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-104345,CDM,J1652,HCPCS,0636,RC,55150-0233-00,NDC,,both,0.8,ML,115.60,75.14,,,,,,,,,,,,,
PIN FIX L16MM STD CERV NEURO CONSTRUCT SECUR PLT,SUP-2255661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT BONE 76-98MM FIB SHFT FRZN BIOCLEANSE STRL,SUP-2335275,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
IMPLANT EAR 1.27 MM TUBE VENT PAPARELLA TYP 2INNR FLANGE SIL,SUP-2312832,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.88,26.57,,,,,,,,,,,,,
ELECTRODE ELECSURG LOOP STD 2.5 MM BPLR CUT PLASMAKINETIC,SUP-2747328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1520.95,988.62,,,,,,,,,,,,,
SCREW BNE CRANIO MAXILLOFACIAL ST TI 1.5X5MM 5PK,SUP-2366193,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.08,99.50,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0250,RC,00338-0017-31,NDC,,both,50,ML,21.70,14.10,,,,,,,,,,,,,
GUIDEWIRE ORTHO 1.1X150 MM TROCAR PT 1 END,SUP-2422317,CDM,C1769,HCPCS,0272,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
WASHER ORTH SM,SUP-2466763,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.22,80.74,,,,,,,,,,,,,
NAIL LOCKING BOLT FIBULAR NAIL,SUP-2811063,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE XR IMAGING 14X17 IN,SUP-2303642,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
BIT DRL L50MM FLEX FOR ACET SCR,SUP-2345718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.51,290.23,,,,,,,,,,,,,
SUPPORT ORTHOT CUST SOLE WDG BTWN,SUP-2435723,CDM,L3370,HCPCS,0274,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTMA L 8 CM DIA 3.5 MM SZ 0.010 IN PLAT,SUP-2753279,CDM,C1778,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
PLATE BONE L22MM 100DEG 2X3 H LT CRANIOMAXILLOFACIAL TEAL TI,SUP-2191157,CDM,C1713,HCPCS,0278,RC,,,,both,,,1028.66,668.63,,,,,,,,,,,,,
SPLINT WRST M L10IN FOR 6 7IN R FA VYN FLANNEL LN SLIP ON,SUP-2276623,CDM,L3908,HCPCS,0272,RC,,,,both,,,18.27,11.88,,,,,,,,,,,,,
CROWN DENT SZ 41 POLYCARB 1ST BICUSPID,SUP-2238429,CDM,D6783,CPT,0278,RC,,,,both,,,2.20,1.43,,,,,,,,,,,,,
SUPPORT KNEE OPN PAT SM KNEE NEOPRNE,SUP-2195466,CDM,L1810,HCPCS,0274,RC,,,,both,,,12.25,7.96,,,,,,,,,,,,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,0636,RC,63323-0306-02,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
MESH HERN W18XL24CM D15MM BIOMATERIAL ANTIMIC W H GORE,SUP-2395350,CDM,C1781,HCPCS,0278,RC,,,,both,,,4810.48,3126.81,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN (MINI-BAG),RX-40850048,CDM,2580000003,HCPCS,0250,RC,00338-0551-18,NDC,,both,100,ML,62.10,40.36,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL L 1.5 IN DIA18 GA SGL SHT CLR FEN,SUP-2936763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,50.40,32.76,,,,,,,,,,,,,
BOOT CAST 4IN TCC-EZ,SUP-2194354,CDM,L4386,HCPCS,0272,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
GUIDEWIRE VASC L 175 CM DIA16 FR MIC TAPR,SUP-2141066,CDM,C1769,HCPCS,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
COMPONENT TIB SZ 3 RT MEDL LT LAT FIX BEAR CEM PRESERVATION,SUP-2251283,CDM,C1776,CPT,0278,RC,,,,both,,,4873.28,3167.63,,,,,,,,,,,,,
MESH HERN SQ 1 50X50 CM MONOFILAMENT 3D TEXTILE VERSATEX,SUP-2752221,CDM,C1781,HCPCS,0278,RC,,,,both,,,3172.15,2061.90,,,,,,,,,,,,,
DEVICE VASC DISC BRTRC PT COMFORT COMPRESSAR,SUP-2337148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
MESH HERN RECT 16X10 IN FULL RESRB FOR SFT TISS RECON PHASIX,SUP-2855238,CDM,C1781,HCPCS,0278,RC,,,,both,,,42233.00,27451.45,,,,,,,,,,,,,
PIN FIX L38MM DIA13MM PROV,SUP-2343745,CDM,C1713,HCPCS,0278,RC,,,,both,,,752.31,489.00,,,,,,,,,,,,,
LASER SURG 532NM/577/659NM W/ SMA CONN VISION 1 LIO KEELER,SUP-2713800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30696.64,19952.82,,,,,,,,,,,,,
EXPANDER BRST TISS 225CC W10XH10CM P52CM SIL SMOOTH HI PROF,SUP-2301015,CDM,C1789,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
PLATE BNE L 47 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 4 H 72440704,SUP-2932890,CDM,C1713,HCPCS,0278,RC,,,,both,,,1201.65,781.07,,,,,,,,,,,,,
UNIT DRNGE AD CHILD 2500CC BG PLEUR CAV SGL CHMBR WET SUCT,SUP-2384314,CDM,C1729,HCPCS,0272,RC,,,,both,,,516.75,335.89,,,,,,,,,,,,,
SAW SURG IM LCK NUT,SUP-2448362,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY 2 DR W 5.9 X W 5.9 CM D 1.1 CM,SUP-2149286,CDM,C1722,HCPCS,0275,RC,,,,both,,,40506.00,26328.90,,,,,,,,,,,,,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-40840058,CDM,2580000003,HCPCS,0250,RC,00338-0125-03,NDC,,both,250,ML,25.50,16.57,,,,,,,,,,,,,
SPLINT DORS NT M 10 14 WOM 11 15 SZ L XL,SUP-2196391,CDM,L4398,HCPCS,0272,RC,,,,both,,,97.53,63.39,,,,,,,,,,,,,
PIN BNE FIX DIA5MM LOK LNR S-ROM,SUP-2253106,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.43,262.88,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 40 CM DIA 6 FR BALLOON DIA,SUP-2214018,CDM,C1757,HCPCS,0272,RC,,,,both,,,279.18,181.47,,,,,,,,,,,,,
HEAD FEM 0+ MM 10/12 36 MM TAPR OXIN,SUP-2434859,CDM,C1776,CPT,0278,RC,,,,both,,,6179.52,4016.69,,,,,,,,,,,,,
BLADE SCREWDRIVER 1.5X58 MM CENTRE DRV RATCHETED MAX-DRIVE,SUP-2457260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,757.62,492.45,,,,,,,,,,,,,
EVOS 4.5MM PROX HUM PL 11H L 196MM,SUP-2931182,CDM,C1713,HCPCS,0278,RC,,,,both,,,10431.08,6780.20,,,,,,,,,,,,,
PROCESSOR SND STL GRY PONTO 4,SUP-2430318,CDM,L8690,HCPCS,0278,RC,,,,both,,,12858.30,8357.89,,,,,,,,,,,,,
KIT CVC 7FR L8IN POLYUR BLU FLEXTIP 3 LUMN W SPRINGWIRE,SUP-2120607,CDM,C1751,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
HC Perc D-E Cor Revasc T Cabg S,PX-4810960400,CDM,C9604,CPT,0481,RC,,,,both,,,23915.00,15544.75,,,,,,,,,,,,,
SHEATH ENDOSCP 23FR INNR STD SH BEAK BLU,SUP-2313021,CDM,C2629,CPT,0272,RC,,,,both,,,6365.85,4137.80,,,,,,,,,,,,,
CLAMP REPROC ROD ROD HII MRI 8X8MM,SUP-2678696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.16,405.05,,,,,,,,,,,,,
SCREW BNE L75MM DIA5MM CANN LOK,SUP-2184919,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.87,399.02,,,,,,,,,,,,,
STAPLE BNE FIX 08X10X10MM NITINEX,SUP-2392910,CDM,C1713,HCPCS,0278,RC,,,,both,,,8352.40,5429.06,,,,,,,,,,,,,
ANCHOR SUTURE 4.5MM WITH WITH 3 HI FI NUMBER 2 SUTURES GENES,SUP-2824353,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING EPTFE 8MM DIA 40CM LEN,SUP-2126426,CDM,C1768,CPT,0278,RC,,,,both,,,1497.00,973.05,,,,,,,,,,,,,
HC So Assay Other Fluid Chorides,PX-3018243866,CDM,82438,CPT,0301,RC,,,,both,,,32.00,20.80,,,,,,,,,,,,,
GRAFT BNE SUB W20-24XL55MM ILIUM TRICORT STRP FRZ DRY FOR,SUP-2307166,CDM,C9362,HCPCS,0278,RC,,,,both,,,5972.28,3881.98,,,,,,,,,,,,,
PACEMAKER CARD AVEIR DR TI 2 CHMBR LEADLESS STRL,SUP-2905537,CDM,C1605,HCPCS,0275,RC,,,,both,,,78343.00,50922.95,,,,,,,,,,,,,
PUMP INFUS THK19.5MM DIA87.5MM 20ML TI PROGRAMMABLE,SUP-2284621,CDM,C1772,HCPCS,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 4 FR L 45 CM DIA 0.018 IN SS TUNGSTEN,SUP-2117210,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.31,46.35,,,,,,,,,,,,,
CONNECTOR SPNL THORLUM TI PARA SM STAT FOR 6MM ROD USS II,SUP-2193433,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
WASHER ORTH DOME 4.5 MM MONSTER,SUP-2742351,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.22,203.59,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST ROCKER BTM CONTACT,SUP-2435654,CDM,L2232,HCPCS,0274,RC,,,,both,,,275.03,178.77,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP LT LAT HALF MENIS,SUP-2866994,CDM,C1762,CPT,0278,RC,,,,both,,,16266.30,10573.09,,,,,,,,,,,,,
HC Sinogram,PX-3207608000,CDM,76080,CPT,0320,RC,,,,inpatient,,,600.00,390.00,,,,,,,,,,,,,
NAIL IM L320MM DIA10.5MM UNIV TIB TI ALLOY CANN LCK,SUP-2412955,CDM,C1713,HCPCS,0278,RC,,,,both,,,6468.40,4204.46,,,,,,,,,,,,,
PLATE SPNL ANCHR 50 MM OCPTL ASCNT POCT,SUP-2601973,CDM,C1713,HCPCS,0278,RC,,,,both,,,4038.04,2624.73,,,,,,,,,,,,,
HEAD HUM H15MM DIA40MM SHLDR CO CHROM TOT REV BIO MOD,SUP-2404611,CDM,C1776,CPT,0278,RC,,,,both,,,3067.78,1994.06,,,,,,,,,,,,,
VALVE MITRL CARP EDW TISS ANNULUS 25 MM SEW RNG DIA 34 MM,SUP-2214272,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 6 CM FLPY TIP L 2,SUP-2167663,CDM,C1769,HCPCS,0272,RC,,,,both,,,26.28,17.08,,,,,,,,,,,,,
CATHETER BLLN 95 CM GUIDE EMBOGUARD,SUP-2854947,CDM,C1725,HCPCS,0272,RC,,,,both,,,8042.51,5227.63,,,,,,,,,,,,,
BIT DRL CANN LG 17X310 MM FLX QC STRL,SUP-2178894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2144.90,1394.18,,,,,,,,,,,,,
COMPONENT HUM 50X46 MM SHLDR OVOMOTION,SUP-2423632,CDM,C1776,CPT,0278,RC,,,,both,,,18249.68,11862.29,,,,,,,,,,,,,
PLATE BNE L262MM 16 H NONSTERILE R ANTLAT DST TIB S STL VAR,SUP-2177690,CDM,C1713,HCPCS,0278,RC,,,,both,,,7001.29,4550.84,,,,,,,,,,,,,
HC Repair Wounds 20.1cm to 30.0cm,PX-4501205600,CDM,12056,CPT,0450,RC,,,,both,,,2133.00,1386.45,,,,,,,,,,,,,
TI LOW PROFILE NEURO X-PLATE,SUP-2823242,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|DOCUMENTATION ON FILE",PX-4209711000,CDM,97110,CPT,0420,RC,,,GO|CO|KX,both,,,195.00,126.75,,,,,,,,,,,,,
PLATE BNE 6 H ULNA SHORTNG LO PROF FOR OSTEOTMY SYS,SUP-2107841,CDM,C1713,HCPCS,0278,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
PLATE BNE L157MM 8 H ST POST MED PROX TIB S STL LOK COMPR,SUP-2177799,CDM,C1713,HCPCS,0278,RC,,,,both,,,3588.93,2332.80,,,,,,,,,,,,,
IBAL TKA FEM IMP PS CEMENTED SZ 4 LFT,SUP-2813065,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
KIT EXT FIX ANK CALCNL W/ T WRNCH DRL GUID FIX DISTR UNIT,SUP-2316325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15896.82,10332.93,,,,,,,,,,,,,
HC So Citric Acid 24hr Urine,PX-3018250766,CDM,82507,CPT,0301,RC,,,,both,,,139.00,90.35,,,,,,,,,,,,,
IMMUNE GLOBULIN (FLEBOGAMMA) 10%,RX-4081761,CDM,J1459,HCPCS,0636,RC,44206-0437-10,NDC,,both,100,ML,5659.90,3678.93,,,,,,,,,,,,,
BRACE KNEE LG W/ FAN STBL,SUP-2337058,CDM,L1810,HCPCS,0274,RC,,,,both,,,133.48,86.76,,,,,,,,,,,,,
TI LCP WRIST FUSION STANDARD BEND PLATE-STERILE,SUP-2546649,CDM,C1713,HCPCS,0278,RC,,,,both,,,5520.31,3588.20,,,,,,,,,,,,,
SYSTEM LD DEL ACUITY PRO,SUP-2149266,CDM,C1887,HCPCS,0272,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 5 MMX2.5 CM 7 FRX120 CM HEPARIN VIABAHN,SUP-2396533,CDM,C1874,HCPCS,0278,RC,,,,both,,,8446.60,5490.29,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X300 MM,SUP-2657782,CDM,C1769,HCPCS,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
CONNECTOR SPNL 1/4 STD POST S STL TRNSVRS CONN XLNK FIX FOR,SUP-2255597,CDM,C1713,HCPCS,0278,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
CATHETER THORACENTHESIS RT ANGLED 3.6 FR PLEUR-EVAC,SUP-2384350,CDM,C1729,HCPCS,0272,RC,,,,both,,,23.52,15.29,,,,,,,,,,,,,
GRAFT HUM TISS W1.5XL2CM THK35UN AMNIO MEMBRN DEHYDR SGL,SUP-2247193,CDM,V2790,HCPCS,0274,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
SYSTEM SHLDR ARTHRPLSTY GLEN PT SPEC MTCH PT,SUP-2197200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY DIA 36 MM TI ALLOY POLYESTER,SUP-2214266,CDM,C1889,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
STAPLE BONE 8 MM OFFSET NITINOL,SUP-2866282,CDM,C1713,HCPCS,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
HC Replace J Tube,PX-3614945100,CDM,49451,CPT,0361,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H LNG TI NEURO STR PLT XDRV 1,SUP-2935316,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
SLEEVE SURG HOLDING 3.5-4X123 MM,SUP-2472916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
KIT CATH AD L36CM DIA12FR ADMIN BASIC 2 LUMN STR STAGGERED,SUP-2283903,CDM,C1750,HCPCS,0278,RC,,,,both,,,518.73,337.17,,,,,,,,,,,,,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,J2760,HCPCS,0636,RC,00143-9564-01,NDC,,both,1,UN,2817.30,1831.24,,,,,,,,,,,,,
MESH CRAN L 122.58 X W 67.28 MM THK 0.6 MM SCREW DIA1.5 MM,SUP-2935809,CDM,C1713,HCPCS,0278,RC,,,,both,,,4446.24,2890.06,,,,,,,,,,,,,
COIL EMB L30CM OD10MM 0010IN 360DEG STD STRTCH RESIST,SUP-2365676,CDM,C1889,HCPCS,0278,RC,,,,both,,,5829.10,3788.91,,,,,,,,,,,,,
BUTTON SUT ADJUSTABLE FOR SFT TISS FIX ULTRABTTN,SUP-2341144,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.05,921.08,,,,,,,,,,,,,
MATRIX PLCNTA FLOWABLE CYROPRESERVED CRYOMTRX 1.0CC,SUP-2340460,CDM,C1762,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SERTRALINE HCL 50 MG PO TABS,RX-11351,CDM,6370000000,HCPCS,0637,RC,50268-0769-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER INTVASC OCCL ECLIPSE 2L L 160 CM 0.016IN L 15MM 6MM,SUP-2717626,CDM,C2628,HCPCS,0272,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
SET PICC 1L 4FR X 55CM W TEG CHG,SUP-2887042,CDM,C1751,HCPCS,0278,RC,,,,both,,,1595.12,1036.83,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.035IN STR FLOP BENSTON TYP,SUP-2140200,CDM,C1769,HCPCS,0272,RC,,,,both,,,133.89,87.03,,,,,,,,,,,,,
GUIDE SURG PT SPEC W/ PLN,SUP-2860269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6972.06,4531.84,,,,,,,,,,,,,
KIT SURG PWR OPN PROC SAG SAW STRL LF DISP FJ-2000,SUP-2881129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5560.94,3614.61,,,,,,,,,,,,,
HC Eeg Awake & Drowsy,PX-7409581600,CDM,95816,CPT,0740,RC,,,,both,,,1811.00,1177.15,,,,,,,,,,,,,
STEM FEM SZ 10.5 LT L BODY FULL TEXT APR,SUP-2210949,CDM,C1776,CPT,0278,RC,,,,both,,,10389.63,6753.26,,,,,,,,,,,,,
HC Procalcitonin (Pct),PX-3018414500,CDM,84145,CPT,0301,RC,,,,both,,,139.00,90.35,,,,,,,,,,,,,
SPACER SPNL 17X14 MM VALEO,SUP-2391432,CDM,C1821,HCPCS,0278,RC,,,,both,,,9671.20,6286.28,,,,,,,,,,,,,
TAFASITAMAB-CXIX 200 MG IV SOLR,RX-151542,CDM,J9349,HCPCS,0636,RC,50881-0013-03,NDC,,both,1,UN,4020.20,2613.13,,,,,,,,,,,,,
SCREW BNE L28MM OD4.5MM TI CANN SHT THRD HD COMPR DARCO,SUP-2401015,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
KIT NEUROSTIMULATOR LO PROF CYL WNG BOOT ANCHR FOR DP BRAIN,SUP-2284434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
GRAFT DERMAL MESH 2X2 CM FEN WND MTRX MIRODERM,SUP-2431546,CDM,Q4175,HCPCS,0636,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
ELECTRODE ELECSURG LOOP 30 DEG LG 24-28 FR HF RESECT RUNNER,SUP-2472658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
WASHER ORTH SPIDER HUM STRL AFFIXUS NAT NAIL,SUP-2606871,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
HC Catheterize for Urine Spec,PX-4500961200,CDM,P9612,CPT,0450,RC,,,,outpatient,,,76.00,49.40,,,,,,,,,,,,,
PLATE BNE CALCANEAL SM,SUP-2316474,CDM,C1713,HCPCS,0278,RC,,,,both,,,3734.40,2427.36,,,,,,,,,,,,,
DRILL SURG 75000 RPM I.D. TCH TECHNOLOGY KNURLED HSNG 8 SLOT,SUP-2898915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1342.35,872.53,,,,,,,,,,,,,
GRAFT HUM TISS R LAT FEM KNEE FRSH ASEP HEMI CNDYL,SUP-2113918,CDM,C1713,HCPCS,0278,RC,,,,both,,,35874.50,23318.42,,,,,,,,,,,,,
HANDPIECE BPLR LG CRD,SUP-2227494,CDM,C1713,HCPCS,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
GRAFT VASC GORTX L 110 CM DIA 5 MM RNG L 80 CM EPTFE STR TW,SUP-2396111,CDM,C1768,CPT,0278,RC,,,,both,,,4907.82,3190.08,,,,,,,,,,,,,
PERI LOC 2.7 SUP MED CLAV LK PLATE 6H RT,SUP-2821149,CDM,C1713,HCPCS,0278,RC,,,,both,,,6563.70,4266.40,,,,,,,,,,,,,
HC So Tiss Trnsgltmnase Ea Ig Clas,PX-3028636400,CDM,86364,CPT,0302,RC,,,,both,,,62.00,40.30,,,,,,,,,,,,,
PTERIONAL RT SMOOTH MEDPOR,SUP-2365256,CDM,C1889,HCPCS,0278,RC,,,,both,,,5570.36,3620.73,,,,,,,,,,,,,
GRAFT VASC IMPRA L 45 CM DIA 4-7 MM EPTFE STP STD WALL N,SUP-2127036,CDM,C1768,CPT,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
GRAFT EVAR L199MM DIA16X10MM CATH 16FR LIMB DST DSGN C DEL,SUP-2295242,CDM,C1768,CPT,0278,RC,,,,both,,,20394.30,13256.29,,,,,,,,,,,,,
RELOAD STPL 10 TACK STD PURCH ARTC RELIATACK,SUP-2283328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.80,274.82,,,,,,,,,,,,,
PROBE NERVE STIM DIA1 MM MONOPOLAR BALL TIP STRL DISP,SUP-2901933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,391.56,254.51,,,,,,,,,,,,,
BASEPLATE SHLDR SM AUGMENTED W/ TAPR ADPT FOR COMPHSVE REV,SUP-2205381,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF L115CM 8FR D,SUP-2248617,CDM,C1732,HCPCS,0278,RC,,,,both,,,8983.54,5839.30,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST N CORROSIVE FINISH,SUP-2435696,CDM,L2780,HCPCS,0274,RC,,,,both,,,179.17,116.46,,,,,,,,,,,,,
BLADE SAW KEEL RECIP CEM FOR LINVATEC HALL POWERPRO SYS,SUP-2136842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.6MM S STL THRD FOR 4.5MM CANN,SUP-2186898,CDM,C1769,HCPCS,0272,RC,,,,both,,,82.17,53.41,,,,,,,,,,,,,
TUBE VENT ID 0.76 MM IFD 1.5 MM TINY TYTAN TI PED STRL,SUP-2881787,CDM,L8699,HCPCS,0278,RC,,,,both,,,120.04,78.03,,,,,,,,,,,,,
GRAFT BNE SUB 5CC TRICALCIUM PHSPTE FOAM FLO INJ VITOSS,SUP-2368179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
FORCEPS SURG L200MM PELV RATCH FOR USE W SCR,SUP-2199236,CDM,C1713,HCPCS,0278,RC,,,,both,,,2111.30,1372.34,,,,,,,,,,,,,
SCREW BNE LP 5X82.5 MM TRIGEN,SUP-2347293,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.62,365.05,,,,,,,,,,,,,
FIBER LASER 200 MH FLX CUST GUID CONN HOLM ACCUTRAC DISP,SUP-2139426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1388.88,902.77,,,,,,,,,,,,,
CONNECTOR SHUNT DIAMETER 1.9MM TITANIUM STRAIGHT FOR HYDROCE,SUP-2825578,CDM,C1889,HCPCS,0278,RC,,,,both,,,243.10,158.01,,,,,,,,,,,,,
CATHETERIZATION KIT 26.75 IN 4 FRX30 CM BLU FLEXTIP,SUP-2120590,CDM,C1751,HCPCS,0278,RC,,,,both,,,95.46,62.05,,,,,,,,,,,,,
SLEEVE TIBIAL ML 40MM AP 28MM BALANCED KNEE REVISION SYSTEM,SUP-2603528,CDM,C1776,CPT,0278,RC,,,,both,,,6104.16,3967.70,,,,,,,,,,,,,
LOCK DIST TIB MED LT 15H STE,SUP-2588833,CDM,C1713,HCPCS,0278,RC,,,,both,,,3999.04,2599.38,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-10 MM 30 CC FD 30/70 MIX CORTICAL CANC,SUP-2792168,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.95,971.72,,,,,,,,,,,,,
STEM FEM TRI-SLOT 8 LNG 12X255 MM LT HIP BOW REV PRSS FT,SUP-2374196,CDM,C1776,CPT,0278,RC,,,,both,,,17751.05,11538.18,,,,,,,,,,,,,
HC So Buprenorphine,PX-3018034866,CDM,G0480,CPT,0301,RC,,,,both,,,169.00,109.85,,,,,,,,,,,,,
DRIVER SURG UNIV QUIK CONN T10 FOR VOLAR DST RAD PLATING,SUP-2340189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 40 X 35 CM DIA26 X 10 MM THK 0.38 MM,SUP-2227520,CDM,C1768,CPT,0278,RC,,,,both,,,4153.40,2699.71,,,,,,,,,,,,,
HC Initiate Prolonged Chemo Pump,PX-3359641600,CDM,96416,CPT,0335,RC,,,,both,,,1112.00,722.80,,,,,,,,,,,,,
PROBE US L330MM DIA33MM LITHO SWISS LITHOCLAST,SUP-2139433,CDM,C1713,HCPCS,0278,RC,,,,both,,,1725.62,1121.65,,,,,,,,,,,,,
GRAFT HUM TISS 100MG WHL MICRONIZED ALLGRFT AMNION CHORION,SUP-2305738,CDM,Q4186,HCPCS,0636,RC,,,,both,,,5747.77,3736.05,,,,,,,,,,,,,
CANNULA VEN LNG 21 FR UNCOATED HLS,SUP-2663480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.70,890.30,,,,,,,,,,,,,
CATHETER INFSN 5FR DIA 135CML 5CML PEBAX OCCLDNG WIRE FNTN L,SUP-2701664,CDM,C1751,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
"HC So2 Ag Detect Nos, Eia Multi Step",PX-3068744968,CDM,87449,CPT,0306,RC,,,,both,,,173.00,112.45,,,,,,,,,,,,,
KIT ELBW JT HUM PIN BUSHING COONRAD/MORREY,SUP-2205922,CDM,C1776,CPT,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
SCREW BNE L13MM OD27MM TI LOK TAPR THREADLOCK TS,SUP-2262839,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.73,294.92,,,,,,,,,,,,,
PIN FIX L229MM OD2MM S STL SGL TRCR PNT N THRD STNMN,SUP-2303793,CDM,C1713,HCPCS,0278,RC,,,,both,,,14.82,9.63,,,,,,,,,,,,,
PLATE BNE SPRING 3.5 MM PELV 2 HOLE SS NS,SUP-2863369,CDM,C1713,HCPCS,0278,RC,,,,both,,,990.10,643.56,,,,,,,,,,,,,
INSERT TIB SULCUS 1+ LG 14 MM LT RT TOT ANK REV INBONE II,SUP-2850402,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
PLATE BNE 2/2.4X73X2 MM 9 HOLE SS LC-DCP,SUP-2569209,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.31,216.65,,,,,,,,,,,,,
DEVICE COUNT TORQUE 1.2 NM LIMITING ATTCH NS LCP,SUP-2863390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4605.00,2993.25,,,,,,,,,,,,,
STABILIZER SHLDR SM UNIV HARN ARM BND FOR FOOTBALL PLAYER,SUP-2150933,CDM,L3660,HCPCS,0272,RC,,,,both,,,325.93,211.85,,,,,,,,,,,,,
GRAFT BNE BLOCK 15-18 MM TRICORT,SUP-2766768,CDM,C1713,HCPCS,0278,RC,,,,both,,,3039.99,1975.99,,,,,,,,,,,,,
REAMER SURG 9MM FEM FULL FLUT,SUP-2249542,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 6.25X6.25 IN FNGR W/ BLB RADLUC,SUP-2276775,CDM,L3933,HCPCS,0274,RC,,,,both,,,5.78,3.76,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA 7 FR HYDRPHLC,SUP-2383407,CDM,C1894,HCPCS,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
CYSTOSCOPE FLX UP 210 DEG DN 120 DEG L 15 2/5 IN DIA 5.4 MM,SUP-2882870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SCREW INTRF L14MM OD8MM SUBTALAR FOR ARTHROEREISIS PROSTOP +,SUP-2121854,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
TRAY TIB L63MM KNEE COMP INTLOK OFFSET FOR VANGUARD COMPLT,SUP-2405420,CDM,C1776,CPT,0278,RC,,,,both,,,5388.24,3502.36,,,,,,,,,,,,,
SNARE ENDOSCP POLYP BARB LOOP ASMBLY SHTH WIRE COLONSCP,SUP-2462427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
TRAY CTRL VEN CATH 5FR L15CM 0.035IN GWIRE TIP NDL BASEPLT G01915] COOK MEDICAL INC],SUP-2167824,CDM,C1751,HCPCS,0278,RC,,,,both,,,114.55,74.46,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 65 CM DIA 4 FR DIA1.05 MM ANGLED,SUP-2385512,CDM,C1887,HCPCS,0272,RC,,,,both,,,177.41,115.32,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2.8 MM MED CP TI RT MANDIBULAR,SUP-2883705,CDM,C1713,HCPCS,0278,RC,,,,both,,,16105.59,10468.63,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 5.5 CMX12 MM CORTICAL FD 2 PC STRL LF DISP,SUP-2495571,CDM,C1889,HCPCS,0278,RC,,,,both,,,3314.90,2154.68,,,,,,,,,,,,,
LEVEL CMF PLATE ORTHG TLTS BSSO L SHP W/TAB LFT 20 MM BRG 2.,SUP-2496300,CDM,C1713,HCPCS,0278,RC,,,,both,,,1198.00,778.70,,,,,,,,,,,,,
SHOULDER IMMOB VELPEAU ELAS XLG,SUP-2194409,CDM,L3650,HCPCS,0274,RC,,,,both,,,19.66,12.78,,,,,,,,,,,,,
CATHETER HAD L28CM OD14.5FR POLYUR 2 LUMN SPL TIP CUF 5704230] BARD INC],SUP-2126524,CDM,C1750,HCPCS,0278,RC,,,,both,,,1456.96,947.02,,,,,,,,,,,,,
STENT ESOPH EVOLUTION L 15 CM BODY DIA20 MM FLANGE DIA25 MM,SUP-2170567,CDM,C1874,HCPCS,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
PINN GRIP TF REV SHIM 5 DEG,SUP-2512731,CDM,C1776,CPT,0278,RC,,,,both,,,2219.35,1442.58,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 1.01-2.0 MCI STRL ADVANTAGE,SUP-2247261,CDM,C2642,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SNARE VASC ENSNARE L 175 CM DIA2-4 MM CATH L 150 CM DIA 3.2,SUP-2302532,CDM,C1773,HCPCS,0272,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
DEVICE RETRV L175CM OD2MM INTCRAN MICRO-MOVEMENT PRECIS,SUP-2280933,CDM,C1773,HCPCS,0272,RC,,,,both,,,10126.50,6582.22,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD PRSS FT N-K,SUP-2212611,CDM,C1776,CPT,0278,RC,,,,both,,,12013.64,7808.87,,,,,,,,,,,,,
SCREW SPNL OD5.5MM LCK CLOSE LAT COLORADO 2,SUP-2290609,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
PIN POS PROS OFFSET HD ALIGN BIO MOD,SUP-2403976,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
HC So Protoporphyrin RBC Quant,PX-3018420266,CDM,84202,CPT,0301,RC,,,,both,,,132.00,85.80,,,,,,,,,,,,,
HC Exclusion Left Atrial Appendage Open Any Method,PX-3603326700,CDM,33267,CPT,0360,RC,,,,both,,,7823.00,5084.95,,,,,,,,,,,,,
WIRE BNE FIX L 150 MM DIA2.5 MM SS TRCR PT NS KIRSCHNER,SUP-2900580,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE L 195 MM SHFT THK 3 MM HD 2 MM SCREW DIA2.7/3.5 MM,SUP-2931147,CDM,C1713,HCPCS,0278,RC,,,,both,,,6132.42,3986.07,,,,,,,,,,,,,
PORT GAST INJ SUTURELESS REPL W/ APPL REALIZE,SUP-2219871,CDM,C1788,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
DARBEPOETIN ALFA 40 MCG/0.4ML IJ SOSY,RX-131223,CDM,J0881,HCPCS,0636,RC,55513-0021-04,NDC,,both,0.4,ML,913.40,593.71,,,,,,,,,,,,,
ADVANCED LOCKING SCREW DIA 4X37.5MM,SUP-2900554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.74,780.48,,,,,,,,,,,,,
I/B II CCK TIB ART SURF SIZE 5925MM HEIGHT,SUP-2502089,CDM,C1776,CPT,0278,RC,,,,both,,,10110.80,6572.02,,,,,,,,,,,,,
PLATE BNE L60MM 7 H S STL COMPR FOR 27MM SCR MINI FRAG SYS,SUP-2199361,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
CAGE ACET OD64MM TI PPS LT HIP REV IMP MALLORY-HEAD,SUP-2405110,CDM,C1776,CPT,0278,RC,,,,both,,,11643.12,7568.03,,,,,,,,,,,,,
GRAFT BNE SUB 30CC SZ 0212 0850MM DEMIN CORT PWD FRZ DRY,SUP-2307259,CDM,C1713,HCPCS,0278,RC,,,,both,,,1872.82,1217.33,,,,,,,,,,,,,
BELLADONNA ALKALOIDS-OPIUM 16.2-30 MG RE SUPP,RX-9219,CDM,6370000000,HCPCS,0637,RC,00574-7045-12,NDC,,both,1,UN,99.10,64.41,,,,,,,,,,,,,
NEEDLE KYPHOPLASTY 13GA L5IN MTCH GRND BVL TIP INTRO N,SUP-2367334,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.84,85.05,,,,,,,,,,,,,
PLATE BNE OVL LG 1.5X0.2 MM SCRN MESH JANNETTA TI NS,SUP-2490318,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.62,700.45,,,,,,,,,,,,,
SPLINT FA WRST PED 6 IN L,SUP-2336053,CDM,L3908,HCPCS,0272,RC,,,,both,,,14.79,9.61,,,,,,,,,,,,,
PATCH HEMOSTAS SYVEK POLY-N GLUCOSAMINE EXT FOR 4-10 FEM,SUP-2266133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
SCREW BNE L55MM DIA6.5MM HD DIA8MM CANC S STL FULL THRD L,SUP-2184641,CDM,C1713,HCPCS,0278,RC,,,,both,,,105.10,68.31,,,,,,,,,,,,,
KIT REP PELV FLR ANTR APCL PINN,SUP-2141761,CDM,C1771,HCPCS,0278,RC,,,,both,,,5843.54,3798.30,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Continuous W/Img Gdn,PX-3606441600,CDM,64416,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
PIN IM SZ F L165MM DIA3.2MM S STL FOR ROD RUSH 8030107] ZIMMER BIOMET INC],SUP-2211449,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.43,165.38,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 5 CC FD CRUSH CANC READIGRAFT,SUP-2740843,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.28,267.33,,,,,,,,,,,,,
PLATE BONE TIBIAL 2.7X32 MM MEDIAL DISTAL 3 HOLE STRAIGHT LO,SUP-2836533,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX15 CM 1 STP,SUP-2303184,CDM,C1729,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
ANCHOR SUT L17.9MM DIA5MM W/ TWO SZ 2 FIBERWIRE AND NDL FOR,SUP-2121499,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE 18 H NONSTERILE BILAT S STL NAR CRV LOK COMPR FOR,SUP-2178049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2730.54,1774.85,,,,,,,,,,,,,
KIT INTRO AXCESS L 23 CM DIA 6 FR GUIDEWIRE 0.035-0.038 IN,SUP-2877842,CDM,C1894,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
SCREW BNE LAG 85 MM SS NS DH-DC,SUP-2186453,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.40,624.26,,,,,,,,,,,,,
IMPLANT OSS L6MM PIST DIA04MM LOOP DIA 06MM STAP FLROPLAS,SUP-2313665,CDM,L8613,CPT,0278,RC,,,,both,,,254.78,165.61,,,,,,,,,,,,,
KIT BNE CEMENT MIXING SYS FEM BRKWY NOZ MED PRESSURIZER STRL,SUP-2884225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.86,252.76,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.504,SUP-2860021,CDM,C1713,HCPCS,0278,RC,,,,both,,,34365.73,22337.72,,,,,,,,,,,,,
PLATE BONE L188MM 12 HOLE LEFT LTRL PRXML PRRTCLR HMRL 35MM,SUP-2478257,CDM,C1713,HCPCS,0278,RC,,,,both,,,2442.48,1587.61,,,,,,,,,,,,,
RETROBUTTON LONG 15MMX20MM LOOP,SUP-2811847,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SCREW CRTX ST TI STRL 4.5MM DIA 26MML,SUP-2343931,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.57,124.52,,,,,,,,,,,,,
INTRODUCER TUBE 14FR L65CM ID3MM RADPQ RAPI FIT ADPT,SUP-2168837,CDM,C1894,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
ALLOGRAFT BNE 8 CC ACTIFUSE ABX,SUP-2208430,CDM,C1889,HCPCS,0278,RC,,,,both,,,6327.10,4112.61,,,,,,,,,,,,,
NEXGEN ROTATING HINGE FEMORAL F-RT,SUP-2502540,CDM,C1776,CPT,0278,RC,,,,both,,,21746.07,14134.95,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 340 DR-T TI EPOXY RESIN SIL 2 CHMBR,SUP-2138119,CDM,C1721,HCPCS,0275,RC,,,,both,,,58244.39,37858.85,,,,,,,,,,,,,
EVOS 3.5MM LCK 1/3 TUBULAR PL 2H 22MM,SUP-2931423,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.64,465.17,,,,,,,,,,,,,
ANCHOR SUT 3.4 MM DIA SGL ARMED BIOCRYL RAPIDE ABSRB 2 SUT,SUP-2256654,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.88,1922.62,,,,,,,,,,,,,
TOOL VLV BYPS FOR SLITTABLE INNR GUID CATH CPS AIM SL,SUP-2356360,CDM,C1893,HCPCS,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
GRAFT HUM TISS 2CC CYMETRA REGEN TISS MTRX SYR ALLDERM,SUP-2113044,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1149.24,747.01,,,,,,,,,,,,,
SCREW BONE L16MM DIA3.5MM STD CORT S STL ST FULL THRD HEX HD,SUP-2343890,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.18,165.22,,,,,,,,,,,,,
CATHETER THROMCTMY INTHRILL L 65 CM DIA 8 FR RVD 4-10 FR,SUP-2862337,CDM,C1757,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
PATCH CV HEMSHLD L 3XW 0.3IN 0.76MM POLYESTER BOV NONTAPERED,SUP-2227367,CDM,C1768,CPT,0278,RC,,,,both,,,348.67,226.64,,,,,,,,,,,,,
ROD COMPR FOR ARTH NAIL SYS PANTA,SUP-2243643,CDM,C1713,HCPCS,0278,RC,,,,both,,,2123.33,1380.16,,,,,,,,,,,,,
ATORVASTATIN CALCIUM 40 MG PO TABS,RX-19177,CDM,6370000000,HCPCS,0637,RC,00904-6292-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 3 MED AD 130X22 MM GRNLN,SUP-2381520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,121.49,78.97,,,,,,,,,,,,,
MICROCATHETER GUID PG PRO L 165 CM PROX/DSTL OD 2.8 FR,SUP-2734754,CDM,C1887,HCPCS,0272,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
PLATE BNE Y UNIV 0.6 MM 6 HOLE W/ 13MM BAR TI,SUP-2457228,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
COMPONENT FEM TY PROX DSTL PERIARTICULAR PLATE NS OPTILOCK,SUP-2861372,CDM,C1776,CPT,0278,RC,,,,both,,,7917.32,5146.26,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA 7 MM DEL SHTH,SUP-2934162,CDM,C1713,HCPCS,0278,RC,,,,both,,,11925.72,7751.72,,,,,,,,,,,,,
PLATE SPNL BURR HOLE CVR CRAN GRDIAN,SUP-2637196,CDM,C1713,HCPCS,0278,RC,,,,both,,,2563.87,1666.52,,,,,,,,,,,,,
CUP ACET DIA52MM 10 H HIP TI GRIPTION MULT H II VIP TAPR,SUP-2250193,CDM,C1776,CPT,0278,RC,,,,both,,,4841.88,3147.22,,,,,,,,,,,,,
STRIP INT STPL CLLGN MTRX W/ VERIT REINF 6 FIRING COMPATIBLE,SUP-2130375,CDM,C1713,HCPCS,0278,RC,,,,both,,,541.40,351.91,,,,,,,,,,,,,
PLATE BNE THK16MM 7 H MAND TI STR FOR 2 23MM SCR TRAUMAONE,SUP-2136791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1730.14,1124.59,,,,,,,,,,,,,
BLADE RETRACTOR LNG TEETH 45X15 MM RED FLEXI-SPINE,SUP-2459643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,754.60,490.49,,,,,,,,,,,,,
BIT DRILL TWIST 2 MM FOR DISTAL RADIUS SYSTEM STERILE LATEXF,SUP-2836739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1955.40,1271.01,,,,,,,,,,,,,
HC Intubation/Endotracheal/Emerg,PX-4503150000,CDM,31500,CPT,0450,RC,,,,outpatient,,,403.00,261.95,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 10X10X10 MM FD SPNG CANC READIGRAFT BLX,SUP-2741070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1433.06,931.49,,,,,,,,,,,,,
SCREW INTFR L28MM DIA8MM KNEE PLLA WDG SHP ROUNDED THRD,SUP-2366520,CDM,C1713,HCPCS,0278,RC,,,,both,,,711.52,462.49,,,,,,,,,,,,,
GRAFT BIO TISS W10XL12CM FET BOV SLV MESHED ANTIMIC,SUP-2243714,CDM,Q4110,HCPCS,0636,RC,,,,both,,,15888.40,10327.46,,,,,,,,,,,,,
SHEATH INTRO J TIP 035 IN 45 DEG 63 CM 180 CM D0 VERSACROSS,SUP-2641950,CDM,C1893,HCPCS,0272,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H LNG TI NEURO STR PLT XDRV 12,SUP-2935190,CDM,C1713,HCPCS,0278,RC,,,,both,,,17125.56,11131.61,,,,,,,,,,,,,
PLATE PROX TIB 3.5MM 12H RT STRL,SUP-2547552,CDM,C1713,HCPCS,0278,RC,,,,both,,,4391.07,2854.20,,,,,,,,,,,,,
DRILL SURG CANN 18 MM ENTRY,SUP-2766137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CROWN FORM DENT STRP U1 PRIMARY ANTR UPPER RT LAT PLAS,SUP-2322249,CDM,D6783,CPT,0278,RC,,,,both,,,16.92,11.00,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT MANIFOLD CUST RICHMOND,SUP-2117307,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER ARTERIAL 20 GAX12 CM WITH NEEDLE LOCKING DISPOSAL C,SUP-2838741,CDM,C1751,HCPCS,0278,RC,,,,both,,,197.19,128.17,,,,,,,,,,,,,
PLATE BNE 2/2.7X300 MM 50 HOLE CUT-TO-LENGTH,SUP-2569076,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.39,261.55,,,,,,,,,,,,,
NAIL IM L240MM OD13MM TI FEM LOK AG CANN RG T2,SUP-2368964,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BNE THK2.3MM SHT CRV NONCOMPRESSION FRAC,SUP-2263002,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.90CM D1.30CM 40J 20SEC 5YR STD 2 CHMBR,SUP-2138074,CDM,C1721,HCPCS,0275,RC,,,,both,,,46891.16,30479.25,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0258,RC,00264-1800-32,NDC,,both,100,ML,23.00,14.95,,,,,,,,,,,,,
COIL NEUROVASCULAR HYDROFILL 10 L 6 CM LOOP DIA2 MM,SUP-2305308,CDM,C1889,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRAFT BNE L16MM DIA10MM CANC PLUG W CART FRZN FLEXIGRFT,SUP-2264630,CDM,C1713,HCPCS,0278,RC,,,,both,,,1265.58,822.63,,,,,,,,,,,,,
SPLINT WRST LOOP LCK CLOSURE SM 10 IN RT VELCRO PROCARE,SUP-2196996,CDM,L3809,HCPCS,0274,RC,,,,both,,,19.44,12.64,,,,,,,,,,,,,
PLATE BONE W14XL132MM THK3.8MM 90DEG 7 H RT TIB L BTTRS LT,SUP-2185769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1887.67,1226.99,,,,,,,,,,,,,
CLAMP EXT FIX RNG TENXOR,SUP-2372244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PLATE SPNL IMPL L20X16MM CENTERPIECE,SUP-2292780,CDM,C1889,HCPCS,0278,RC,,,,both,,,21477.60,13960.44,,,,,,,,,,,,,
BIT DRL DIA4MM DSTL RAD ULN CANN,SUP-2119910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
PIN EXTRNL FXTN L100MM D4MM THRD L20MM BLUE HALF XTRFX SSTM,SUP-2458511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0035IN S STL FLX TIP MOV COR,SUP-2313733,CDM,C1769,HCPCS,0272,RC,,,,both,,,74.39,48.35,,,,,,,,,,,,,
ANCHOR SUT DIA5MM ABSRB HNDL INSRT CRV FAST-FIX AB,SUP-2341594,CDM,C1713,HCPCS,0278,RC,,,,both,,,927.12,602.63,,,,,,,,,,,,,
PLATE BONE L97MM 8 H RT SUP MEDL CLAV LCK FOR 3.5MM SCR,SUP-2348753,CDM,C1713,HCPCS,0278,RC,,,,both,,,6441.87,4187.22,,,,,,,,,,,,,
ANCHOR SUT L28MM DIA4.5MM BIOCOMPOSITE SELF PUNCHING,SUP-2121507,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
BOLT EXT FIX UNIV WIRE NS TRUELOK LTX,SUP-2875030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,846.23,550.05,,,,,,,,,,,,,
DILATOR PENILE PROS 9-12MM DISP,SUP-2138906,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.79,545.21,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX40 CM TW N RING HD ACCS EPTFE CARBOFLO,SUP-2761281,CDM,C1768,CPT,0278,RC,,,,both,,,1807.35,1174.78,,,,,,,,,,,,,
PLATE BONE 4 H STR MOTOBAND CP,SUP-2174979,CDM,C1713,HCPCS,0278,RC,,,,both,,,5920.47,3848.31,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM DIA 0.025 IN TIP CRV RAD 2 MM HVY DBL,SUP-2759995,CDM,C1769,HCPCS,0272,RC,,,,both,,,136.78,88.91,,,,,,,,,,,,,
SLING ORTH ADJ STRP UNIV 5.4X5 IN 19X13 IN SHLDR DLX,SUP-2195027,CDM,L3660,HCPCS,0272,RC,,,,both,,,31.43,20.43,,,,,,,,,,,,,
SPACER TIB 8-16 MM VANGUARD XP,SUP-2446831,CDM,C1776,CPT,0278,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
GUIDEWIRE SURG 0.032X14 IN MATRYX SCR NIT,SUP-2765763,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.41,56.17,,,,,,,,,,,,,
COVER HOLE BURR MEDPORE 29MM X 7MM X 14MM (3/PK),SUP-2848972,CDM,C1713,HCPCS,0278,RC,,,,both,,,1811.78,1177.66,,,,,,,,,,,,,
PESSARY UTER DSH 3 65 MM SFT PLIABLE W/O SUPP SIL WHT LF,SUP-2794444,CDM,A4562,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 95 CM DIA 7 MM SPC,SUP-2496082,CDM,C1730,HCPCS,0272,RC,,,,both,,,963.10,626.01,,,,,,,,,,,,,
BRACE WALKING POSTOP XS PEDI PROCARE MAXTRAX,SUP-2195785,CDM,L4360,HCPCS,0274,RC,,,,both,,,84.00,54.60,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILIVIA DR-T 2 CHMBR DF4 CONN STRL,SUP-2138474,CDM,C1721,HCPCS,0275,RC,,,,both,,,68216.50,44340.72,,,,,,,,,,,,,
DILATOR SURG STRL DISP,SUP-2536958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
LEVEL NEURO SCREWDRIVER BLADE ULTRAONE58 MM QTY001 EA,SUP-2677979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,692.06,449.84,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 10X10X10 MM FUSIONFLEX,SUP-2759587,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
VALVE 0 WITH BURRHOLE RESERVOIR MININAV,SUP-2821809,CDM,C1889,HCPCS,0278,RC,,,,both,,,2018.20,1311.83,,,,,,,,,,,,,
HC So Cytogen Micro Array Copy No&Snp,PX-3108122966,CDM,81229,CPT,0310,RC,,,,both,,,1699.00,1104.35,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 50 MM DIA12 MM CATH TOT L 116 CM,SUP-2148351,CDM,C1874,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 95 CM DIA 7 FR TIP 2,SUP-2703684,CDM,C1730,HCPCS,0272,RC,,,,both,,,1005.18,653.37,,,,,,,,,,,,,
SLEEVE ILLUMINATION DIA13 GA FIBER PK STRL DISP MYRIAD-LX,SUP-2930200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PLATE BNE L 109 X W 8.5 MM THK 2.4 MM SCREW DIA2.7 MM 7 H SS 72468807,SUP-2932776,CDM,C1713,HCPCS,0278,RC,,,,both,,,2618.45,1701.99,,,,,,,,,,,,,
SYSTEM MENIS REP 12DEG BRAID ABSRB 2-0 PNCRYL SUT CRV NDL,SUP-2249488,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.62,577.60,,,,,,,,,,,,,
PLATE BNE PREBENT LG 2.6X2/2.3 MM TI MAG,SUP-2755237,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
ANCHOR BONE SP FBRTAK RC FBRTPE BLK/BLU,SUP-2757497,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
SCREW BNE L70MM DIA4.5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412116,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
HC Treatment Dehiscence Simple,PX-4501202000,CDM,12020,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
BLADE SHAVER SMOOTH BITE 3.5MM,SUP-2659168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,287.09,186.61,,,,,,,,,,,,,
TISSUE BIO MATRIDERM 10.5 X 14.8CM 2MM MED,SUP-2866497,CDM,A2027,HCPCS,0636,RC,,,,both,,,18162.20,11805.43,,,,,,,,,,,,,
BUR SURG DIA 3 MM DIAMOND COARSE 1 RNG STRL DISP ELAN 4 GP165SU,SUP-2928924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.27,292.03,,,,,,,,,,,,,
DEVICE INFLATION 22 ATM 12 ML ARIA GA STRL,SUP-2149336,CDM,C2625,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
COMPONENT PAT SM KNEE PRI REV PCA,SUP-2377626,CDM,C1776,CPT,0278,RC,,,,both,,,3740.37,2431.24,,,,,,,,,,,,,
PLATE BNE W6.3XL49MM THK1.6MM -90DEG 2X4 H DST RAD VOLAR S,SUP-2186111,CDM,C1713,HCPCS,0278,RC,,,,both,,,1715.29,1114.94,,,,,,,,,,,,,
WIRE FIX L150MM OD1.4MM NICKEL CHROM THRD SGL END TRCR TIP,SUP-2321627,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
STEM FEM HIP COXA VARA NK SEG AMT CORAIL,SUP-2456922,CDM,C1776,CPT,0278,RC,,,,both,,,2398.96,1559.32,,,,,,,,,,,,,
INJECTOR BONE CEMENT VERTEPORT X4 8GA MANIFOLD�,SUP-2863095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1543.31,1003.15,,,,,,,,,,,,,
GUIDEWIRE VASC PROTRACK L 175 CM DIA 0.025 IN COIL L 13 CM,SUP-2131511,CDM,C1769,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
MESH SURG W9XL13CM POLY 3 DIM RECTANG PARIETEX,SUP-2174799,CDM,C1781,HCPCS,0278,RC,,,,both,,,264.55,171.96,,,,,,,,,,,,,
TIP ABLATN 23 KHZ STD STRL CUSA CLARITY LTX,SUP-2863642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2649.63,1722.26,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 100 MCG PO TABS,RX-4423,CDM,6370000000,HCPCS,0637,RC,00904-6953-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
INSERT TIB THK 16 MM SZ 6 X3 REV STRL TRIATHLON,SUP-2889775,CDM,C1776,CPT,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
PLATE BNE LCK 46 MM RADIAL 5 HOLE STD CURVATURE HD TI NS,SUP-2518184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
GUIDEWIRE SURG SMOOTH 2.5X800 MM,SUP-2644703,CDM,C1769,HCPCS,0272,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
POST TOE JT L16MM DIA8MM HEMICAP TI ARTC COMP TAPR,SUP-2123593,CDM,C1776,CPT,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
BOOT CAST XSM BLK UNISX AD SQ OPN TOE FOREFOOT CLSR HIGHER,SUP-2176231,CDM,L4386,HCPCS,0274,RC,,,,both,,,40.54,26.35,,,,,,,,,,,,,
PLATE BNE W17.5XL134MM THK5.2MM 7 H BILAT S STL BROAD LOK,SUP-2185288,CDM,C1713,HCPCS,0278,RC,,,,both,,,1192.85,775.35,,,,,,,,,,,,,
GRAFT DURA W4XL5IN ULTRAPURE DURAGN +,SUP-2244008,CDM,C1763,HCPCS,0278,RC,,,,both,,,3927.42,2552.82,,,,,,,,,,,,,
BUR SURG L14CM DIA7.5MM BALL FLUT L BOR MIDAS REX LEGEND,SUP-2284379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
DRIVER SURG HEX 3.8 MM CANN,SUP-2423055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1824.34,1185.82,,,,,,,,,,,,,
BEARING TIB THK16MM KNEE UHMWPE ORTH SALV SYS,SUP-2405763,CDM,C1776,CPT,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 2.5CM X 2.5CM,SUP-2874116,CDM,A2007,HCPCS,0636,RC,,,,both,,,3070.92,1996.10,,,,,,,,,,,,,
ROD SPNL 3.5X200 MM OCCIPITOCERVICAL PLATE VERTEX SEL,SUP-2630737,CDM,C1713,HCPCS,0278,RC,,,,both,,,3881.04,2522.68,,,,,,,,,,,,,
EVOS 2.5MM SNAP IN DRL GUID,SUP-2344051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
"HC Est Pt, E/M Level 4",PX-5109921400,CDM,99214,CPT,0510,RC,,,,both,,,313.00,203.45,,,,,,,,,,,,,
GUIDEWIRE W/ THRD TIP FOR CERV SCR SMOOTH BLNT TIP L2.0MM,SUP-2204929,CDM,C1769,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
PLATE BNE FUSION UNIV POST 3 HOLE NS LTX,SUP-2857129,CDM,C1713,HCPCS,0278,RC,,,,both,,,8898.76,5784.19,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LG FD IRRADIATED FASC LATA 920428,SUP-2867046,CDM,C1762,CPT,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 3X2 CM PLCNTA BASE MEMBRN AMNIOEFFECT,SUP-2872719,CDM,C1762,CPT,0278,RC,,,,both,,,3177.68,2065.49,,,,,,,,,,,,,
COMPONENT TALAR FLAT CUT 1 RT ANK SALTO TALARIS,SUP-2421798,CDM,C1776,CPT,0278,RC,,,,both,,,23503.21,15277.09,,,,,,,,,,,,,
ROD PUSH GUIDEWIRE,SUP-2934549,CDM,C1769,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
ANCHOR KNOTLESS W/ INSRTR HNDL SPEEDSCREW,SUP-2342085,CDM,C1713,HCPCS,0278,RC,,,,both,,,1378.15,895.80,,,,,,,,,,,,,
MATRIX HUM TISS L 3 X W 2 CM DECELL PLCNTA MEMBRN,SUP-2909312,CDM,Q4201,HCPCS,0636,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
SPLINT ORTHOPEDIC COLLES LG WRST MONTREAL,SUP-2330387,CDM,L3808,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM OD 8 FR ID 2.6 MM DIL L 20 CM,SUP-2168227,CDM,C1894,HCPCS,0272,RC,,,,both,,,45.91,29.84,,,,,,,,,,,,,
PROSTHESIS PENILE 18 CM PMP ULTREX,SUP-2140262,CDM,C1813,HCPCS,0278,RC,,,,both,,,11068.50,7194.52,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM L7CM OD0035IN L25CM OD3MM S STL PTFE,SUP-2167708,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.59,24.43,,,,,,,,,,,,,
PROSTHESIS CNTR HD TOT OSS HA STRL 4MM DIA 7MM LEN TORP FLX,SUP-2277544,CDM,L8613,CPT,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
POST FIX L L31MM DIA10MM TAPR,SUP-2123531,CDM,C1776,CPT,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
BONE SCR,SUP-2281754,CDM,C1713,HCPCS,0278,RC,,,,both,,,3197.43,2078.33,,,,,,,,,,,,,
ADAPTER LL 165MM STR,SUP-2420216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
SPHERE EMB VI ACRYL GEL 500-700 MIC 2ML 5ML SYR N,SUP-2303495,CDM,C1889,HCPCS,0278,RC,,,,both,,,759.25,493.51,,,,,,,,,,,,,
BELT BK CRISSCROSS W/ SHLDR STRP CONTAINS VELC CLSR ELAS,SUP-2324538,CDM,L0642,HCPCS,0272,RC,,,,both,,,76.02,49.41,,,,,,,,,,,,,
CATHETER ETER ANGIO AD 7FR L80CM 0035IN XL CURL PLCMNT,SUP-2357043,CDM,C1730,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CATHETER QUATTRO 3 KT LUMN,SUP-2416143,CDM,C1751,HCPCS,0278,RC,,,,both,,,2909.02,1890.86,,,,,,,,,,,,,
WASHER ORTHOPAEDIC 6 MM STERILE,SUP-2836818,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.25,170.46,,,,,,,,,,,,,
PLATE BNE L75MM THK1.5MM 5X3 H BILAT S STL T SHP OBLQ ANG,SUP-2185888,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.29,464.29,,,,,,,,,,,,,
KIT CATH 20FR L10IN PVC CHST THORACOSTOMY THOR TRCR STR,SUP-2154961,CDM,C1729,HCPCS,0272,RC,,,,both,,,84.94,55.21,,,,,,,,,,,,,
ALLOGRAFT DERMAL THCK 6X12 CM RDY TO USE TISS MTRX ALLDERM,SUP-2113020,CDM,Q4116,HCPCS,0636,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
PLATE BNE W8XL68MM THK2MM 0DEG 8 H BILAT S STL STR RIG DYN,SUP-2186180,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.68,500.29,,,,,,,,,,,,,
PATCH CV FIBRIN SEAL 4.8X9.5 CM ABSORBABLE TACHOSIL,SUP-2130295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2437.71,1584.51,,,,,,,,,,,,,
PLATE BNE L76MM 4 H ST L PROX BILAT TIB S STL NEUT LOK,SUP-2177831,CDM,C1713,HCPCS,0278,RC,,,,both,,,4167.60,2708.94,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE DBL MECH ACT,SUP-2435632,CDM,L2005,HCPCS,0274,RC,,,,both,,,11601.23,7540.80,,,,,,,,,,,,,
EARPHONE HEARING MINI WIRELESS MICROPHONE USER MNL JACK CBL,SUP-2164999,CDM,L8616,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
COIL DET AXIUM 4X10 HELIX,SUP-2490177,CDM,C1889,HCPCS,0278,RC,,,,both,,,3422.60,2224.69,,,,,,,,,,,,,
SCREW BNE CORTICAL 5X22 MM STRL,SUP-2463013,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
TUBE BYPS 8 MM SALIVARY CLR MONTGOMERY,SUP-2139774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CATHETER DRAINAGE TY 10.2 FRX25 CM SELD PGTL FURMAN,SUP-2759779,CDM,C1729,HCPCS,0272,RC,,,,both,,,605.71,393.71,,,,,,,,,,,,,
CATHETER GUID DAC L 125 CM OD 3.9 FR ID 0.038 IN SS LNR PTFE,SUP-2367781,CDM,C1887,HCPCS,0272,RC,,,,both,,,3391.39,2204.40,,,,,,,,,,,,,
HC Trim Nondystrophic Nails,PX-4501171900,CDM,11719,CPT,0450,RC,,,,both,,,195.00,126.75,,,,,,,,,,,,,
RING EXT FIX FULL 140 MM CARBON FIBER NS,SUP-2800124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2859.28,1858.53,,,,,,,,,,,,,
CATHETER INFUSION 0.038 IN 5 FRX65 CM 15 CM 20 SH MEWISSEN,SUP-2141168,CDM,C1887,HCPCS,0272,RC,,,,both,,,236.44,153.69,,,,,,,,,,,,,
SEGMENT FEM OD23MM 5DEG M TRAPEZOIDAL FLARE COMP SCR FORGED,SUP-2222176,CDM,C1713,HCPCS,0278,RC,,,,both,,,6004.94,3903.21,,,,,,,,,,,,,
TRAY VERTPLSTY BNE ACCS AND PREP W INJ OSTEO FORCE,SUP-2168831,CDM,C1713,HCPCS,0278,RC,,,,both,,,793.73,515.92,,,,,,,,,,,,,
SET HEMO DYLS OR HD ADMIN ST60 HI PERM HEMDLYZR EXCORP CIRC,SUP-2885241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,727.35,472.78,,,,,,,,,,,,,
SCREW BNE CORT HND TI L20MM OD1.5MM APTUS HEXADRIVE 4,SUP-2268061,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.55,142.71,,,,,,,,,,,,,
CONNECTOR SPNL CROSS 24 MM FIX,SUP-2175299,CDM,C1713,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
HC Event Monitor-Analysis Up to 30 Day,PX-7319327100,CDM,93271,CPT,0731,RC,,,,both,,,299.00,194.35,,,,,,,,,,,,,
SCREW BONE L80MM DIA3MM CLAV FIX TI ALLOY 2 TRAK,SUP-2106894,CDM,C1713,HCPCS,0278,RC,,,,both,,,3742.88,2432.87,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WEBST CS L 115 CM 6 FR DECAPOLAR,SUP-2494254,CDM,C1730,HCPCS,0272,RC,,,,both,,,909.97,591.48,,,,,,,,,,,,,
IMPLANT SIZE 2 STANDARD CARPAL POLY,SUP-2586704,CDM,C1776,CPT,0278,RC,,,,both,,,3876.99,2520.04,,,,,,,,,,,,,
PLATE BONE 4 H MIDFOOT TI UTIL FOR 2.7/3/3.5/4MM SCR,SUP-2225434,CDM,C1713,HCPCS,0278,RC,,,,both,,,5649.17,3671.96,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR ATLS II + DR,SUP-2357756,CDM,C1721,HCPCS,0275,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
GRAFT HUM TISS TEND WHL QUADRICEP ALLGRFT,SUP-2307269,CDM,C1762,CPT,0278,RC,,,,both,,,15176.47,9864.71,,,,,,,,,,,,,
HC Hemodialysis,PX-8019093500,CDM,90935,CPT,0801,RC,,,,inpatient,,,924.00,600.60,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 50 MCG/ML PO SOLN,RX-145082,CDM,6370000000,HCPCS,0637,RC,71858-0115-05,NDC,,both,1,ML,22.70,14.75,,,,,,,,,,,,,
ELECTRODE MPLR NIT 50MM,SUP-2366965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8466.98,5503.54,,,,,,,,,,,,,
BIT DRL L145MM DIA4.2MM ST 3 FLUT NDL PNT QUIK CPL FOR FEM,SUP-2178879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.35,416.88,,,,,,,,,,,,,
LEAD PACE BPLR 7 FRX92 CM LT VENTRIC OPTIM IS-1 QUICKFLEX,SUP-2356060,CDM,C1900,HCPCS,0275,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
GRAFT BONE SUB 10CC HA INJ HYDROSET,SUP-2364372,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
GUIDEWIRE VASC STREAMER SS POLYMER HYDRPHLC J SHP X STIFF,SUP-2699322,CDM,C1769,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
CATHETER ANGIO CORODYN A L 50 CM DIA 5 FR BALLOON DIA 8 MM,SUP-2842669,CDM,C1725,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
HC Theraputc Proc Imprv Resp Func Oth Than G0237 1-1 Ea 15min,PX-4190023800,CDM,G0238,CPT,0419,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L60CM 16 ELECTRD PADDLE TRIPOLE,SUP-2356735,CDM,C1778,HCPCS,0278,RC,,,,both,,,15067.70,9794.00,,,,,,,,,,,,,
SPHERE GLEN DIA38MM SHLDR ECC FOR DELT XTEND REV SYS,SUP-2251011,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
GRAFT EVAR L10CM DIA12MM NIT EPTFE FEP BIFUR EXT LEG INT,SUP-2395717,CDM,C1768,CPT,0278,RC,,,,both,,,30957.26,20122.22,,,,,,,,,,,,,
STEM HUM DIA12MM SHLDR CO CHROM NP COMPHSVE,SUP-2403970,CDM,C1776,CPT,0278,RC,,,,both,,,9905.13,6438.33,,,,,,,,,,,,,
MESH CRAN SZ 120 X 175 X 80 MM THK 1 MM SCREW DIA1.5/1.7 MM,SUP-2883398,CDM,C1713,HCPCS,0278,RC,,,,both,,,41542.20,27002.43,,,,,,,,,,,,,
PLATE BNE L286MM 13 H NONSTERILE L DST FEM LOK FOR 4.5MM,SUP-2348457,CDM,C1713,HCPCS,0278,RC,,,,both,,,11284.69,7335.05,,,,,,,,,,,,,
EXPANDER BRST TISS 850CC W14XH14CM P8.9CM SIL SMOOTH ULT HI,SUP-2301023,CDM,C1789,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
CATHETER OCCL BAL URIN TRACT 26 FRX100 CM,SUP-2141680,CDM,C2628,HCPCS,0272,RC,,,,both,,,433.10,281.51,,,,,,,,,,,,,
VASOPRESSIN-SODIUM CHLORIDE 20-0.9 UT/100ML-% IV SOLN,RX-159164,CDM,J2601,HCPCS,0636,RC,00338-9640-12,NDC,,both,100,ML,431.30,280.34,,,,,,,,,,,,,
SCREW BONE L3.5MM OD1.5MM GRN TI CRANIOMAXILLOFACIAL SELF,SUP-2403083,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.54,142.05,,,,,,,,,,,,,
FORCEP SPEC RETRV GRASPING 3 FRX65 CM 14 MM,SUP-2835679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
SPACER 38X3MM M LT,SUP-2209009,CDM,C1776,CPT,0278,RC,,,,both,,,11366.17,7388.01,,,,,,,,,,,,,
PIN FIX L3.5IN DIA1/8IN S STL FLUT HDLSS SQ END,SUP-2150349,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.39,141.95,,,,,,,,,,,,,
SCREW BNE L16MM TIP DIA32MM BK END DIA35MM GWIRE 0035IN,SUP-2106857,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
INFINITY EVERLAST SZ 2+ 10MM TOTAL ANKLE,SUP-2822433,CDM,C1776,CPT,0278,RC,,,,both,,,7928.50,5153.52,,,,,,,,,,,,,
HC Perq Dev Soft Tiss Add Imag,PX-3611003600,CDM,10036,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT VASC L10CM ID6MM PTFE STD WALLED NONRINGED STRTCH,SUP-2395777,CDM,C1768,CPT,0278,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
GRAFT AMNIOTIC MEMBRANE FLOWERAMNIOPATCH 2CM X 2CM,SUP-2866793,CDM,Q4178,HCPCS,0636,RC,,,,both,,,7261.25,4719.81,,,,,,,,,,,,,
ALLOGRAFT BNE SHFT FD HUM,SUP-2321815,CDM,C1713,HCPCS,0278,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
MESH 1X4IN PROL SFT POLYPR SYN ABD NONABSORBABLE RECT SFT,SUP-2219921,CDM,C1781,HCPCS,0278,RC,,,,both,,,3485.49,2265.57,,,,,,,,,,,,,
LINER ACET OD54MM ID32MM +4MM OFFSET 10DEG HIP GVF POLYETH,SUP-2250263,CDM,C1776,CPT,0278,RC,,,,both,,,10203.74,6632.43,,,,,,,,,,,,,
TOCILIZUMAB 80 MG/4ML IV SOLN,RX-104370,CDM,J3262,HCPCS,0636,RC,50242-0135-01,NDC,,both,4,ML,1567.00,1018.55,,,,,,,,,,,,,
GRAFT BONE SUB 2.5CC DEMIN BONE MTRX PUTTY ALLOSYNC,SUP-2120754,CDM,C1776,CPT,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
BEARING TIB L71/75MM THK18MM KNEE ARCM CONSTRN DIR COMPR,SUP-2404160,CDM,C1776,CPT,0278,RC,,,,both,,,4295.52,2792.09,,,,,,,,,,,,,
PLATE BNE CNDYL 2.7X66 MM 7 HOLE LP RIGID LCK COMPR TI,SUP-2191449,CDM,C1713,HCPCS,0278,RC,,,,both,,,1894.36,1231.33,,,,,,,,,,,,,
TWISTER WIRE LUQ,SUP-2410238,CDM,C1713,HCPCS,0278,RC,,,,both,,,993.56,645.81,,,,,,,,,,,,,
KNIFE SURG TABB PICK 6.25 INX3 MM CRV LF,SUP-2489023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,333.06,216.49,,,,,,,,,,,,,
ACARBOSE 50 MG PO TABS,RX-15895,CDM,6370000000,HCPCS,0637,RC,64380-0759-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
VANTEX KT 3 LUMN 7 F 20 CM W/ HPRN,SUP-2214382,CDM,C1751,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PROSTHESIS OTO OD1.1MM HA INCUS STAP CONN SILVERSTEIN,SUP-2284051,CDM,L8613,CPT,0278,RC,,,,both,,,1253.99,815.09,,,,,,,,,,,,,
SCREW INTRF L20MM DIA9MM ANTR KNEE PLLA HA CANN FOR CRUC,SUP-2341105,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
PROBE LSR 20GA STR ENDO,SUP-2109736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.31,246.55,,,,,,,,,,,,,
PLATE BNE MESH PANEL 1X25X15X0.2 MM SCRN TI NS LEVEL 1,SUP-2464618,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.65,343.62,,,,,,,,,,,,,
BIT DRL L195MM DIA4MM ST 3 FLUT QUIK CPL NONRADIOPAQUE W/O,SUP-2187608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,617.23,401.20,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR DS L 115 CM 7 FR F CRV ORN,SUP-2248941,CDM,C1732,HCPCS,0272,RC,,,,both,,,7215.72,4690.22,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ LACE W STAY COCK UP FIRM SUPP,SUP-2197063,CDM,L3908,HCPCS,0272,RC,,,,both,,,27.41,17.82,,,,,,,,,,,,,
HC So Cmv Dna Quantitation by Pcr,PX-3068749766,CDM,87497,CPT,0306,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE IN NACL 900-0.9 MG/50ML-% IV SOLN,RX-138572,CDM,J0737,HCPCS,0636,RC,00338-9553-24,NDC,,both,50,ML,75.10,48.81,,,,,,,,,,,,,
PLATE BONE THK1.25MM 2X2 H CRANIOMAXILLOFACIAL ORAL SLV TI,SUP-2181766,CDM,C1713,HCPCS,0278,RC,,,,both,,,1336.38,868.65,,,,,,,,,,,,,
SCREW BNE COMPR 4 MM INSTRUMENT DISP,SUP-2641891,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
KIT HAD AD 16FR L23CM GWIRE L70CM 0.038 ADMIN CATH DBL LUMN,SUP-2127836,CDM,C1750,HCPCS,0278,RC,,,,both,,,1486.95,966.52,,,,,,,,,,,,,
BIT DRL OD45MM FIX VANTAGE,SUP-2292756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1185.41,770.52,,,,,,,,,,,,,
PLATE BNE L139MM 16 H L FIBULAR TIM LOK COMPR ANAT FOR,SUP-2413689,CDM,C1713,HCPCS,0278,RC,,,,both,,,3786.84,2461.45,,,,,,,,,,,,,
IMPLANT WR JT L60MM OD4.5MM FX MAESTRO,SUP-2407383,CDM,C1776,CPT,0278,RC,,,,both,,,4760.24,3094.16,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6 MM STR TW REINF,SUP-2763163,CDM,C1768,CPT,0278,RC,,,,both,,,1268.34,824.42,,,,,,,,,,,,,
SYSTEM TKR VERILAST OXI FEM TIB CEM PS HIFLEX,SUP-2348027,CDM,C1776,CPT,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
SPLINT SWEDISH AFO WOMAN RT WHT,SUP-2324308,CDM,L4350,HCPCS,0272,RC,,,,both,,,69.87,45.42,,,,,,,,,,,,,
GUIDEWIRE ENDO DIA1.5MM FOR TISS TAK II INSTR SET,SUP-2121578,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 4 MM STR STD WALL REINF,SUP-2486471,CDM,C1768,CPT,0278,RC,,,,both,,,1723.17,1120.06,,,,,,,,,,,,,
MARKER BRST BX L12CM 18GA NIT VISN SHP INTRO FREE HND TUMARK,SUP-2239916,CDM,A4648,CPT,0278,RC,,,,both,,,365.50,237.57,,,,,,,,,,,,,
GRAFT BONE SUB 1ML PUTTY CA PHOS SYNTH GRAN BIOABSRB ATTRAX,SUP-2310452,CDM,C1763,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BIT DRILL 2.5MM DIA WRIST LATEXFREEDOM,SUP-2605906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,801.64,521.07,,,,,,,,,,,,,
HEAD HUM DIA22MM NK L+0MM SHLDR CO CHROM ALLOY UHMWPE BPLR,SUP-2372522,CDM,C1776,CPT,0278,RC,,,,both,,,2262.68,1470.74,,,,,,,,,,,,,
DRILL SURG DIA4.3MM RADLUC FOR TARGET DEV,SUP-2371643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
KNIFE ELECSURG LOWER 4.5X1.3 MM 2.8X2300 MM HOOKKNIFE DISP,SUP-2499554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2968.09,1929.26,,,,,,,,,,,,,
EVOS VOL PLATE 10H RIGHT STD TI 141MM NS,SUP-2818924,CDM,C1713,HCPCS,0278,RC,,,,both,,,9259.23,6018.50,,,,,,,,,,,,,
VERAPAMIL HCL 80 MG PO TABS,RX-8530,CDM,6370000000,HCPCS,0637,RC,23155-0026-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
"HC Exchange Nephrostomy Cath, Perc",PX-3615043500,CDM,50435,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GRAFT HUM TISS W1 3-40MMXL13-20CM 30-80MM SPC PAT TEND HEMI,SUP-2307271,CDM,C1713,HCPCS,0278,RC,,,,both,,,15176.47,9864.71,,,,,,,,,,,,,
SCREW BNE 1.5X6 MM 3.5 MM HEX DRILL-FREE ENDOBROW 10281591,SUP-2466052,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.74,207.18,,,,,,,,,,,,,
GRAFT BNE CHIP 30 CC FRZN TISS,SUP-2109584,CDM,C1762,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BUTTON GASTROSTOMY 18FR DIA 24INL PUSH STEP,SUP-2676811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.26,353.77,,,,,,,,,,,,,
PLATE BNE HK LNG 2.7X9 MM LT CLAV VA LCK COMPR NS VA-LCP,SUP-2757614,CDM,C1713,HCPCS,0278,RC,,,,both,,,3482.76,2263.79,,,,,,,,,,,,,
WIRE ORTH SMOOTH DBL SHRP TIP S STL 2.0MM DIA 60MM K,SUP-2204886,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
BRACE KNEE HNG WRP 2X L,SUP-2276699,CDM,L1820,HCPCS,0272,RC,,,,both,,,55.08,35.80,,,,,,,,,,,,,
HC Receptor Assay Non-Endocrine Specify Receptor,PX-3018423800,CDM,84238,CPT,0301,RC,,,,both,,,213.00,138.45,,,,,,,,,,,,,
PIN STPL LOC DIA2 MM,SUP-2898105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
GRAFT BNE PROX FIB 18 CM TISS,SUP-2165533,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
BIT DRL L40MM DIA2.7MM DISP FOR PROX ULNA PLT DST EL SET,SUP-2340183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
IMPLANT SACROILIAC L30MM DIA7MM IFUSE,SUP-2337773,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
AXLE TIB SM ROT HNG KINEMATIC,SUP-2376474,CDM,C1776,CPT,0278,RC,,,,both,,,2530.68,1644.94,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 160-200 MMX0.3 CM FD,SUP-2717849,CDM,C1762,CPT,0278,RC,,,,both,,,6319.16,4107.45,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL APRON,SUP-2435545,CDM,L0470,HCPCS,0272,RC,,,,both,,,1862.77,1210.80,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|CO|XU|KX,both,,,144.00,93.60,,,,,,,,,,,,,
PARICALCITOL 1 MCG PO CAPS,RX-41497,CDM,6370000000,HCPCS,0637,RC,49483-0687-03,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 18.5-21 IN CTR 14-15 IN CALF 14-16 IN SPCR,SUP-2916973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.50,238.22,,,,,,,,,,,,,
COIL NEUROVASCULAR TRUFILL L 2 MM MICROCATHETER 0.021 IN,SUP-2699374,CDM,C1889,HCPCS,0278,RC,,,,both,,,1523.21,990.09,,,,,,,,,,,,,
PLATE BNE 24 DEG L 78 X W 8.5 MM THK 1.6 MM 5 H SS RT DSTL,SUP-2933082,CDM,C1713,HCPCS,0278,RC,,,,both,,,5110.35,3321.73,,,,,,,,,,,,,
LEAD PACE AJ ENDO RA IS-1 CONN UPLR SIL INSUL SELUTE,SUP-2148641,CDM,C1898,HCPCS,0275,RC,,,,both,,,2555.96,1661.37,,,,,,,,,,,,,
PLATE BNE L113MM 6 H R OLECRANON EL TI LOK VARIAX,SUP-2376048,CDM,C1713,HCPCS,0278,RC,,,,both,,,3030.10,1969.56,,,,,,,,,,,,,
PLATE SPNL 1 LEVEL 16 MM ANTR CERV TETH,SUP-2379300,CDM,C1713,HCPCS,0278,RC,,,,both,,,5305.34,3448.47,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT THERMOCOOL L 130 CM DIA,SUP-2248934,CDM,C1732,HCPCS,0278,RC,,,,both,,,7831.16,5090.25,,,,,,,,,,,,,
MELPHALAN HCL 50 MG IV SOLR,RX-10522,CDM,J9245,HCPCS,0636,RC,43598-0392-48,NDC,,both,1,UN,289.40,188.11,,,,,,,,,,,,,
NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS,RX-10724,CDM,6370000000,HCPCS,0637,RC,70756-0404-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT PENILE PROS W/ SUT TIE CONN CLLT 22GA AND 15GA NDL FOR,SUP-2138943,CDM,C1813,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
GUIDEWIRE ORTH L 50 MM DIA1.1 MM N THRD NS PENDING,SUP-2896855,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA2.7 MM MANDIBULAR ST EMER NS AXS,SUP-2909503,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.86,380.16,,,,,,,,,,,,,
IMPLANT MID PHALANX 55MM NEXTRA HAMRTOE CORR SYS,SUP-2137583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.78,786.36,,,,,,,,,,,,,
SCREW BONE CRANIO MAXILLOFACIAL HI TORQ CROSS DRV ST MIDFACE,SUP-2403040,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
ROD EXTR DIA7 8MM STD CONIC FOR UNIV NAIL DEV,SUP-2368583,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PIN FIX L150MM DIA6MM THRD L55MM S STL HA HALF CORT BULL,SUP-2343020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
"HC Compatibility Test, Immed.Spin",PX-3008692000,CDM,86920,CPT,0300,RC,,,,both,,,270.00,175.50,,,,,,,,,,,,,
BIT DRL QC 2 MM,SUP-2646723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,285.80,185.77,,,,,,,,,,,,,
PORT INFUS 14.3FR PERI TI ATTCH BASIC TY 2 SURECUF TISS,SUP-2127734,CDM,C1788,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GRAFT ENDOVASC L15CM OD5MM CATH L120CM STENT FEM IL AV ACC,SUP-2396544,CDM,C1874,HCPCS,0278,RC,,,,both,,,11916.30,7745.59,,,,,,,,,,,,,
PROBE ULTRASONIC ASPIR W HATCH WND DEB DISP FOR SONICONE OR,SUP-2305956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1309.85,851.40,,,,,,,,,,,,,
DRILL SURG 5MM LNG PIN FOR BIO-TRANSFIX II,SUP-2121628,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PLATE SHIFT CLAVICLE SHAFT 3.5 RT 7 HL L 88 R,SUP-2719491,CDM,C1713,HCPCS,0278,RC,,,,both,,,4301.39,2795.90,,,,,,,,,,,,,
ENDCAP ORTH L5MM DIA3.5MM NONSTERILE TI NAIL SPRL BLDE EXTN,SUP-2192476,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.63,383.26,,,,,,,,,,,,,
WIRE FIX THRD 2.8X200 MM 15 MM COMPR NS VA-LCP,SUP-2863399,CDM,C1713,HCPCS,0278,RC,,,,both,,,181.62,118.05,,,,,,,,,,,,,
DRILL RADLUC TARGET 37MM,SUP-2371640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.08,231.45,,,,,,,,,,,,,
WAND ARTHSCP 90DEG ABLAT COBLATION MEGAVAC AMBIENT,SUP-2342009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC X-Ray Scapula,PX-3207301000,CDM,73010,CPT,0320,RC,,,,both,,,569.00,369.85,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 9 CM LOOP DIA 6 MM PRIMARY,SUP-2249269,CDM,C1889,HCPCS,0278,RC,,,,both,,,3868.17,2514.31,,,,,,,,,,,,,
SCREW SPINAL DIA45X55MM TULIP OPEN RSS LOCK RELINE,SUP-2545991,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
CLAMP EXT FIX DBL PIN W/ BALL JT JET-X MINI,SUP-2342867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4964.65,3227.02,,,,,,,,,,,,,
KIT ACC ANCHR W DISPENSER TOOL CATHETER CONN 2 ATTCH CLLT,SUP-2280047,CDM,C1755,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
DUODENOSCOPE VID L 1240 MM OD 13.7 MM ID 4.2 MM BIOPLASTIC,SUP-2930278,CDM,C1748,HCPCS,0272,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 2 215CM 0.014IN SEG 35CM PRESHAPED,SUP-2716231,CDM,C1769,HCPCS,0272,RC,,,,both,,,1819.94,1182.96,,,,,,,,,,,,,
PLATE BNE L 75 MM SCREW DIA2 MM 2 HD 10 SHFT H SS TINE VA,SUP-2907851,CDM,C1713,HCPCS,0278,RC,,,,both,,,3334.93,2167.70,,,,,,,,,,,,,
ANCHOR SUT OD1MM NDL 2 0 MINI SFT JUGGERKNOT,SUP-2137229,CDM,C1713,HCPCS,0278,RC,,,,both,,,1427.79,928.06,,,,,,,,,,,,,
GRAFT BNE BNE BRIDGE RT MENIS LAT FRZN BIOCLEANSE,SUP-2335263,CDM,C1713,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
PLATE BNE SELLA RECON 20X20X0.3 MM W/ TAB PLLA-PGA STRL,SUP-2463081,CDM,C1713,HCPCS,0278,RC,,,,both,,,2376.38,1544.65,,,,,,,,,,,,,
BONE MARROW TRAY ECON 11 GAX4 IN 16 GAX2.688 IN ASPIR T-LOK,SUP-2876723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
PLATE BNE L140MM 5 H NONSTERILE R LAT PROX TIB TI LOK COMPR,SUP-2190711,CDM,C1713,HCPCS,0278,RC,,,,both,,,3933.76,2556.94,,,,,,,,,,,,,
CHLORTHALIDONE 25 MG PO TABS,RX-1661,CDM,6370000000,HCPCS,0637,RC,50268-0167-11,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
SYSTEM DRAINAGE EXT CSF SAMPLING SITE ACCUDRAIN,SUP-2244106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,674.91,438.69,,,,,,,,,,,,,
SCREW BNE L40MM DIA65MM CANC FLAT HD DOME MPACT,SUP-2267421,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.45,393.54,,,,,,,,,,,,,
IMPLANT STBL SYS AXIALIF 2L +,SUP-2389072,CDM,C1889,HCPCS,0278,RC,,,,both,,,46456.30,30196.59,,,,,,,,,,,,,
CATHETER CRICOTHYROTOMY SET UNIV 5 FRX9 CM EMGCY CUF MELK,SUP-2759814,CDM,C1769,HCPCS,0272,RC,,,,both,,,1599.83,1039.89,,,,,,,,,,,,,
IMPLANT SPINE 26X10X7MM 5 DEG PLIF CALIX PC STRL,SUP-2401479,CDM,C1889,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
HC Insertion Subq Cardiac Rhythm Monitor W/Prgrmg,PX-3613328500,CDM,33285,CPT,0361,RC,,,,both,,,2654.00,1725.10,,,,,,,,,,,,,
BLADE LARYNSCP L90MM SZ 2 PED MACINTOSH FBROPT MRI REUSE S,SUP-2309346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT THEON DIA25 MM SEW RNG DIA 34 MM,SUP-2214296,CDM,C1889,HCPCS,0278,RC,,,,both,,,19452.30,12643.99,,,,,,,,,,,,,
CATHETER THROMCTMY L 135 CM DIA 4.3 FR THROMBOLYTIC INFUSION,SUP-2117142,CDM,C1751,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
WASHER ORTH RT FEM NK LCK STRL CONQ FN,SUP-2933508,CDM,C1713,HCPCS,0278,RC,,,,both,,,5638.87,3665.27,,,,,,,,,,,,,
SCREW SPNL MULTAXL 7.5X60 MM 6.35 MM FOR ROD RED CD HORZ,SUP-2288753,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
GRAFT BNE SUB 5ML HCT P IN CORTICOCANCELLOUS CELLULAR BNE,SUP-2194156,CDM,C1713,HCPCS,0278,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 7.6-12cm,PX-4501203400,CDM,12034,CPT,0450,RC,,,,both,,,1445.00,939.25,,,,,,,,,,,,,
SCREW BNE L 6 MM DIA2.7 MM SS CORTICAL T8 RECESS FOR MINI,SUP-2905581,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.45,248.59,,,,,,,,,,,,,
PISTON OTOLARYN L4.5MM OD.6MM S STL FLROPLAS INCUS PIST WIRE,SUP-2312537,CDM,L8613,CPT,0278,RC,,,,both,,,328.16,213.30,,,,,,,,,,,,,
IMPLANT TOE L2.75MM 10DEG PIP JT TI SPRAYED PEEK CANN,SUP-2321072,CDM,C1776,CPT,0278,RC,,,,both,,,4165.21,2707.39,,,,,,,,,,,,,
PLATE BNE L 32.33 X W 5.72 MM THK 1.6 MM 4 H GRD III TI MOD,SUP-2936936,CDM,C1713,HCPCS,0278,RC,,,,both,,,1321.94,859.26,,,,,,,,,,,,,
NAIL FLEX PRECURVED 1.5X300MM,SUP-2463542,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
BALLOON SIL 9FR W/ CHECKVALVE T3103A,SUP-2214693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
HC Venography Sinus/Jugular Catheter,PX-3207586000,CDM,75860,CPT,0320,RC,,,,both,,,7130.00,4634.50,,,,,,,,,,,,,
"HC So Epstein-Barr Virus, Ea",PX-3028666366,CDM,86663,CPT,0302,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
PLATE BNE SM W11XL38MM THK3.3MM 0DEG 3 H BILAT TI STR RIG,SUP-2190772,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.28,309.58,,,,,,,,,,,,,
FIBER LASER SURGICAL 550 MH MASTERPULSE,SUP-2417215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
HANDLE HEAT THRM W AA BTTRY FOR PIST SMRT,SUP-2313821,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.03,216.47,,,,,,,,,,,,,
HEAD FEM 3.5+ MM 12/14 32 MM HIP TAPR CERM,SUP-2449605,CDM,C1776,CPT,0278,RC,,,,both,,,4140.09,2691.06,,,,,,,,,,,,,
NAIL IM NONSTERILE S STL END OLECRANON FOR OSTEOTMY,SUP-2183155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.90,955.43,,,,,,,,,,,,,
HC So Antidepressant Tricyclic 1/2,PX-3018033567,CDM,G0480,CPT,0301,RC,,,,outpatient,,,609.00,395.85,,,,,,,,,,,,,
PLUG VASC L10MM DIA4MM CATH L125CM 0.038IN NIT MULT LAYR,SUP-2355703,CDM,C1889,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 035X150 STIFF ZIPWIRE,SUP-2141745,CDM,C1769,HCPCS,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM RT LAT VA LCK COMPR SS STRL VA-LCP,SUP-2750789,CDM,C1713,HCPCS,0278,RC,,,,both,,,3623.18,2355.07,,,,,,,,,,,,,
RING EXT FIX DIA180 210MM L LNG ROCK SHOE HOFFMANN LRF,SUP-2363188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 20-22 MM FD ILIUM TRICORT,SUP-2717916,CDM,C1713,HCPCS,0278,RC,,,,both,,,5586.94,3631.51,,,,,,,,,,,,,
NAIL IM 4.5X450 MM SS STRL MJ-FLEX,SUP-2646280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.54,1051.40,,,,,,,,,,,,,
REAMER SURG OD47MM S STL ACET SPHR CUTTINGEDGE,SUP-2361871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1372.18,891.92,,,,,,,,,,,,,
SYSTEM PLATELET CONC GRAVITATIONAL SEP DBL GPS II,SUP-2424578,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SET GJ 16FR GAST 102FR JEJU 80CM MCOT DST END 100CM FULL,SUP-2167893,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.07,540.85,,,,,,,,,,,,,
BOLT FIX L90MM DIA65MM ST MIDFOOT FUS S STL,SUP-2177267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.66,1071.63,,,,,,,,,,,,,
PLATE BNE W12XL119MM THK1MM 7 H BILAT S STL SEMI TBLR LO,SUP-2184868,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
SACUBITRIL-VALSARTAN 97-103 MG PO TABS,RX-130696,CDM,6370000000,HCPCS,0637,RC,00078-0696-20,NDC,,both,1,UN,52.90,34.38,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 98 CM DIA1.5 MM HYDRPHLC DEPTH GRN,SUP-2264162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11300.86,7345.56,,,,,,,,,,,,,
BLADE RTRCTR BLFR 3 1/2ND ABDMNL WIRE LTRL JARIT NON ST,SUP-2483288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.47,225.21,,,,,,,,,,,,,
ROD SPNL L 300 MM DIA 5.5 MM TI STR,SUP-2930633,CDM,C1889,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PUSHER SURG ANT,SUP-2292673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.60,944.19,,,,,,,,,,,,,
GRAFT BNE WDG 12X11X10-12 MM TRICORT PUROS,SUP-2335231,CDM,C1713,HCPCS,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
MESH CRAN L 60 X W 60 MM THK 0.3 MM SCREW DIA1.5/1.7 MM SM,SUP-2883537,CDM,C1713,HCPCS,0278,RC,,,,both,,,4466.71,2903.36,,,,,,,,,,,,,
APPLICATOR WAND KIT CAV WAX +,SUP-2100443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1299.21,844.49,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 5 HOLES 94MM,SUP-2549505,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.17,928.31,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR LARGE 0.4 MM LEFT SUBCONDYLAR PRECO,SUP-2837771,CDM,C1713,HCPCS,0278,RC,,,,both,,,6143.41,3993.22,,,,,,,,,,,,,
ALLOGRAFT BNE FD IRRADIATED RT WHL FIBULAR,SUP-2867168,CDM,C1762,CPT,0278,RC,,,,both,,,4832.46,3141.10,,,,,,,,,,,,,
SPLINT WR AD L FOR 7.5-8.5IN STRP L4IN VENT ELAS,SUP-2324481,CDM,L3908,HCPCS,0272,RC,,,,both,,,44.15,28.70,,,,,,,,,,,,,
HC Oxygen Saturation Measurement,PX-4609476000,CDM,94760,CPT,0460,RC,,,,both,,,148.00,96.20,,,,,,,,,,,,,
SEALANT SURG 13 YR DURA AUTOSPRAY NUS-109 ADHERUS,SUP-2381863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2846.50,1850.22,,,,,,,,,,,,,
GUIDEWIRE VASC ROTAWIRE WIRECLIP L 325 CM DIA 0.014 IN FLPY,SUP-2140975,CDM,C1769,HCPCS,0272,RC,,,,both,,,584.98,380.24,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA12 X 6 MM EPTFE BIFURCATE,SUP-2396245,CDM,C1768,CPT,0278,RC,,,,both,,,3749.16,2436.95,,,,,,,,,,,,,
BRACE BK SUMMIT 456 1 SZ ADJ,SUP-2123906,CDM,L0456,HCPCS,0274,RC,,,,both,,,993.81,645.98,,,,,,,,,,,,,
GRAFT STENT THOR 42X42X100 MM 25 FR PROX FREEFLO STR VALIANT,SUP-2298548,CDM,C1768,CPT,0278,RC,,,,both,,,53364.30,34686.79,,,,,,,,,,,,,
COMPONENT FEM KNEE CUT COORDINATES TOT KNEE REPL PIGALILEO +,SUP-2450906,CDM,C1776,CPT,0278,RC,,,,both,,,91.19,59.27,,,,,,,,,,,,,
GRAFT HUM TISS 8 MM CERV RNG CORTICAL STRL LF DISP,SUP-2632288,CDM,C1713,HCPCS,0278,RC,,,,both,,,3903.74,2537.43,,,,,,,,,,,,,
GENERATOR PULSE IMPL V1 INTEGR RESP SENS STRL,SUP-2937408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69858.72,45408.17,,,,,,,,,,,,,
MESH HERN W55XL128CM DIA5CM POLYPR PTCH W EXT OVERLAY 3D,SUP-2218332,CDM,C1781,HCPCS,0278,RC,,,,both,,,847.86,551.11,,,,,,,,,,,,,
CLIP INT LIG SM WIDE TI NS VESOCCLUDE,SUP-2757590,CDM,C1889,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
HC Cta Abd & Pelvis W & W/O Cont,PX-3527417400,CDM,74174,CPT,0352,RC,,,,both,,,2760.00,1794.00,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP RT PROX TIB W/ PATELLAR,SUP-2867049,CDM,C1762,CPT,0278,RC,,,,both,,,15786.04,10260.93,,,,,,,,,,,,,
RING TRAC L 22-24IN CERV CLOSE BK W/ 2.5IN SKULL AND POS PIN,SUP-2328118,CDM,L0810,HCPCS,0274,RC,,,,both,,,5510.70,3581.95,,,,,,,,,,,,,
INTRODUCER TUBE SET PERC ADV CIAGLIA BLU RHINO G2,SUP-2759751,CDM,C1769,HCPCS,0272,RC,,,,both,,,1147.07,745.60,,,,,,,,,,,,,
PLATE BNE THK 1 MM ADV 10 MM SCREW DIA2 MM MINI LT,SUP-2883204,CDM,C1713,HCPCS,0278,RC,,,,both,,,1977.98,1285.69,,,,,,,,,,,,,
PLATE DISTL TIB ANTERIOR 3HOLE,SUP-2718080,CDM,C1713,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
KIT CATH URTRL BLLN DLTN 8MM X15CM NPHRO EZDLTE,SUP-2727216,CDM,C1758,HCPCS,0278,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRAFIX PRIME 2X3CM CYROPRESERVED,SUP-2319162,CDM,Q4133,HCPCS,0636,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
TREPHINE SURG OD9MM COR SL DISPOSABLE,SUP-2212798,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
GRAFT HUM TISS W8XL20CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2112989,CDM,Q4116,HCPCS,0636,RC,,,,both,,,18362.72,11935.77,,,,,,,,,,,,,
SCREW BNE L95MM DIA12.7MM SUBTROCHANTERIC HIP CANN,SUP-2347919,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.08,707.90,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SCOREFLEX NC 139 CM 10 CM 2.25 MM,SUP-2754697,CDM,C1725,HCPCS,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
PLATE DSTL RAD VLR RIM 2.4MM 7H HD 5H SHFT LT TI VA LCP STRL,SUP-2546769,CDM,C1713,HCPCS,0278,RC,,,,both,,,3222.30,2094.49,,,,,,,,,,,,,
PIN FIX L4MM DIA1.7MM AUTO PILOT,SUP-2363539,CDM,C1713,HCPCS,0278,RC,,,,both,,,108.14,70.29,,,,,,,,,,,,,
PLATE BONE 8 H STR FOR 2MM SCR VLP MINI-MOD SM BONE SYS,SUP-2351086,CDM,C1713,HCPCS,0278,RC,,,,both,,,3304.69,2148.05,,,,,,,,,,,,,
CAGE SPNL 16X23MM THRD INTBODY FUS INT FIX,SUP-2291441,CDM,C1889,HCPCS,0278,RC,,,,both,,,13685.00,8895.25,,,,,,,,,,,,,
SIZER MAMM DIA13.6-13.2CM P5.1-5.9CM 500-600CC SIL NACL,SUP-2300287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
HC So Factor Inhibitor Test,PX-3058533566,CDM,85335,CPT,0305,RC,,,,outpatient,,,385.00,250.25,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO V4 L 138 CM DIA 7 FR INTRO 6 FR,SUP-2120489,CDM,C1757,HCPCS,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 500 DR-T TI EPOXY RESIN SIL 2 CHMBR,SUP-2138127,CDM,C1721,HCPCS,0275,RC,,,,both,,,33284.00,21634.60,,,,,,,,,,,,,
ALLOGRAFT PUROS 250-1000MIC 1ML SCAFFOLD CANC CERVICAL,SUP-2863676,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.26,240.02,,,,,,,,,,,,,
PATCH VASC HEMAPATCH L 100 X W 100 MM THK 0.65 MM POLYESTER,SUP-2227506,CDM,C1781,HCPCS,0278,RC,,,,both,,,790.34,513.72,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 16H LT 322MM STER,SUP-2549627,CDM,C1713,HCPCS,0278,RC,,,,both,,,3659.95,2378.97,,,,,,,,,,,,,
SET ART PRSS MON RAD 2.5FR 2.5CM GWIRE INTRO NDL SYR,SUP-2167880,CDM,C1751,HCPCS,0278,RC,,,,both,,,281.12,182.73,,,,,,,,,,,,,
INSERT TIB AP40MM /ML58MM THICKNESS 9MM AB PUR UHMWPE KNEE,SUP-2199501,CDM,C1776,CPT,0278,RC,,,,both,,,5653.57,3674.82,,,,,,,,,,,,,
BLOCK GUID 6 H FOR 2.4MM VAR ANG 2 CLMN L DST RAD PLT LCP,SUP-2187380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1322.41,859.57,,,,,,,,,,,,,
PLATE BONE LG 20MMD TI LEGX2 SINGLE STERNAL TALON ST FOOT,SUP-2873680,CDM,C1713,HCPCS,0278,RC,,,,both,,,3464.96,2252.22,,,,,,,,,,,,,
SCREW BNE CORTICAL LG 2.7X24 MM FUSION HEX DRV SS STRL,SUP-2852007,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.45,328.54,,,,,,,,,,,,,
HC Oscill Chest Wall Mechani,PX-4109466900,CDM,94669,CPT,0410,RC,,,,both,,,496.00,322.40,,,,,,,,,,,,,
PLATE BNE L19MM 8 H R HND S STL EXT H SHP LO PROF RIG NEUT,SUP-2184850,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.50,744.57,,,,,,,,,,,,,
ANCHOR SUT PEEK SGL STRND OD35MM TWINLOOP,SUP-2366677,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.94,264.51,,,,,,,,,,,,,
GUIDEWIRE VASCULAR 0.018INX80CM STRAIGHT PLATINUM TIP NITINO,SUP-2823948,CDM,C1769,HCPCS,0272,RC,,,,both,,,129.21,83.99,,,,,,,,,,,,,
STENT BILI XPERT L 40 MM DIA 4 MM DEL SYS L 135 CM INTRO 4,SUP-2105963,CDM,C1876,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
STENT CAR PRECIS L 40 MM DIA 8 MM CATH L 135 CM SHTH 8 FR,SUP-2158965,CDM,C1876,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC MOLD DBM XEMPLIFI +,SUP-2423064,CDM,C9359,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PLATE BNE CRV 4.5X230 MM RT CNDYL 10 HOLE VA LCK STRL VALCP,SUP-2789389,CDM,C1713,HCPCS,0278,RC,,,,both,,,6384.06,4149.64,,,,,,,,,,,,,
CATHETER VENTRICULAR STRP STD 1.3X2.5 MMX18 CM GRAD PUDENZ,SUP-2852582,CDM,C1729,HCPCS,0272,RC,,,,both,,,442.05,287.33,,,,,,,,,,,,,
HC Rh Immune Globulin,PX-6360279000,CDM,J2790,CPT,0636,RC,,,,inpatient,,,543.00,352.95,,,,,,,,,,,,,
ALLOSYNC INJECTABLE FIBERS 2.5CC,SUP-2811314,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
CROWN POLYCARB SEC BICUSPID 53,SUP-2238347,CDM,D6783,CPT,0278,RC,,,,both,,,219.17,142.46,,,,,,,,,,,,,
MATRIX DERM 5X10CM ACELLULAR DERM MTRX N MESHED EXTRA THCK,SUP-2366757,CDM,Q4126,HCPCS,0636,RC,,,,both,,,9463.96,6151.57,,,,,,,,,,,,,
PACEMAKER CARD PHILOS II SR TI POLYUR SIL SINGLE CHMBR W/ LD,SUP-2138037,CDM,C1786,HCPCS,0275,RC,,,,both,,,13040.42,8476.27,,,,,,,,,,,,,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5ML PO SUSR,RX-2900,CDM,340b,HCPCS,0637,RC,75834-0294-01,NDC,,both,5,ML,66.00,42.90,,,,,,,,,,,,,
ELECTRODE ELECSURG VPR 27 FRX1.2 MM 2 STEM CUT LOOP BRN,SUP-2261203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
COLLAR CERV M W4XL21IN FIRM FOAM SERP STYL WSH,SUP-2276597,CDM,L0120,HCPCS,0274,RC,,,,both,,,7.38,4.80,,,,,,,,,,,,,
MESH SURG L W4.5XL10CM UNDERLAY 10CM CONN OD1.9CM ID1.3CM,SUP-2219789,CDM,C1781,HCPCS,0278,RC,,,,both,,,812.29,527.99,,,,,,,,,,,,,
COLLAR CERV PHILLY MED 4.25 IN 13-16 IN REHAB FOAM PROCARE,SUP-2196879,CDM,L0172,HCPCS,0274,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
HC Cytp Smrs Any Oth Src Scr&Interpj,PX-3118816000,CDM,88160,CPT,0311,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
BIT DRL MED 3.5 MM POWEREASE,SUP-2628251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.71,649.16,,,,,,,,,,,,,
COMPONENT FEM KNEE PS KT STRL ITOTAL,SUP-2904869,CDM,C1776,CPT,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR SMALL LEFT PREFORMED TITANIUM DARK,SUP-2837770,CDM,C1713,HCPCS,0278,RC,,,,both,,,6150.00,3997.50,,,,,,,,,,,,,
UNIPOLAR HIP-FITMORE POR ST/ ENDO HD,SUP-2417654,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SCREW BNE COMPR 4X36 MM FIBULAR ANK FT MTL OSSIOFIBULARER,SUP-2641867,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
TI NARROW 3 HOLE PLATE 39MM,SUP-2704598,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.98,158.59,,,,,,,,,,,,,
BUR SURG DIA 4 MM HUB XLI DIAMOND STRL DISP HI-LINE XS,SUP-2929233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.42,367.52,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 15CM A865150G,SUP-2632944,CDM,C1752,HCPCS,0278,RC,,,,both,,,869.00,564.85,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 15MM KNEE REV FULL STP LEGION,SUP-2346595,CDM,C1776,CPT,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
CATHETER INFUSION DIA 4 FR STRL,SUP-2117143,CDM,C1725,HCPCS,0272,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
URETEROSCOPE FLX DIGITAL 3.1X650 MM 1.2 MM AXIS DISP,SUP-2432367,CDM,C1747,HCPCS,0272,RC,,,,both,,,2471.18,1606.27,,,,,,,,,,,,,
CUP ACET DIA60MM 5 H STD PROF GRIPTION REV PINN,SUP-2250138,CDM,C1776,CPT,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR 6MM LESS STRAINED SPEAK VLV PROVOX,SUP-2124379,CDM,L8509,HCPCS,0272,RC,,,,both,,,940.08,611.05,,,,,,,,,,,,,
IMPLANT HUM TISS L 3 X W 3 CM THK 1 MM 9 SQ CM SUTURABLE,SUP-2898868,CDM,C1762,CPT,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
PLATE BNE L56MM 4X4 H T SHP FOR 3.5MM SCR,SUP-2411365,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.54,222.00,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM PTCH DECELLULARISED DERM,SUP-2264622,CDM,Q4122,HCPCS,0636,RC,,,,both,,,3344.10,2173.66,,,,,,,,,,,,,
PROSTHESIS OSS STAP 4 MM 0.4 MM GRACE BCKT HNDL NOTCH TI NIT,SUP-2462825,CDM,L8613,CPT,0278,RC,,,,both,,,852.70,554.25,,,,,,,,,,,,,
HC NM Liver Image With Flow,PX-3417820200,CDM,78202,CPT,0341,RC,,,,both,,,2641.00,1716.65,,,,,,,,,,,,,
SET DIL RENAL GRAD AMPLATZ,SUP-2139229,CDM,C1894,HCPCS,0272,RC,,,,both,,,780.48,507.31,,,,,,,,,,,,,
PLATE BNE L 57 MM SCREW DIA2.4 MM 8 SHFT H TI STR COMPACT,SUP-2907778,CDM,C1713,HCPCS,0278,RC,,,,both,,,4185.56,2720.61,,,,,,,,,,,,,
STEM FEM MED LNG 54 MM HIP HI RELEASE WEDGED TAPR INTERSPACE,SUP-2424088,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
BRACE ORTH 2X UPR ELBW CUF EO,SUP-2388190,CDM,L3720,HCPCS,0274,RC,,,,both,,,1683.35,1094.18,,,,,,,,,,,,,
NEEDLE BX BRST LOC KOPANS-STYLE STRL DISP 20GX10CM,SUP-2331833,CDM,C1819,HCPCS,0278,RC,,,,both,,,49.74,32.33,,,,,,,,,,,,,
GRAFT VASC SYNTH KNT DBL VELR 20MMX30CM,SUP-2496622,CDM,C1768,CPT,0278,RC,,,,both,,,1654.15,1075.20,,,,,,,,,,,,,
CATHETER GUID 16FR L62CM DEFLECTED TIP REACH 28MM NK,SUP-2119937,CDM,C1894,HCPCS,0272,RC,,,,both,,,5529.54,3594.20,,,,,,,,,,,,,
SHEATH DIL SM L23CM OD0.215IN ID0.168IN PEBAX TEF ROBUST,SUP-2353115,CDM,C1893,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
BOLT ATTCH TARGETING DEV FOR PEDINAIL PED FEM NAIL,SUP-2318963,CDM,C1776,CPT,0278,RC,,,,both,,,2649.22,1721.99,,,,,,,,,,,,,
IMPLANT ENDO FIX 6.5MM PEEK KNOTLESS,SUP-2341229,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
INTRODUCER CEMENT COMPLT FRAC SHT 10 GA STABILIT POWERCURVE,SUP-2421785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GRAFT BONE PARTICULATE SYNTH OSTEOCONDUCTIVE CLLGN 10GM 10CC,SUP-2288536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1818.63,1182.11,,,,,,,,,,,,,
ABUTMENT SNAP COUPLING 8.5MM,SUP-2858177,CDM,L8690,HCPCS,0278,RC,,,,both,,,5003.31,3252.15,,,,,,,,,,,,,
BLADE ARTHSCP 4.2MM DIA 30DEG 10.5CML SINUS BNDBLE TIP RHNTC,SUP-2586409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,271.01,176.16,,,,,,,,,,,,,
HC Isodose Plan-Simple,PX-3337730600,CDM,77306,CPT,0333,RC,,,,both,,,2451.00,1593.15,,,,,,,,,,,,,
CATHETER CENTESIS 4FR L7CM RADPQ KINK RESIST 2 L OVL SKIVED,SUP-2303563,CDM,C1729,HCPCS,0272,RC,,,,both,,,5.34,3.47,,,,,,,,,,,,,
DRILL SURG 5/32 IN JCBS STR CHK W/ KEY ATTCH BUSA BSPMAX II,SUP-2745859,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR UPLR PRSS FT STEM H5MEDACTA] MEDACTA USA],SUP-2267790,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SYSTEM VLV SHUNT GRAVITATIONAL UNIT L10CM TI ADJ,SUP-2108720,CDM,C1729,HCPCS,0272,RC,,,,both,,,8946.96,5815.52,,,,,,,,,,,,,
DEVICE BX L15CM OD18GA DISP EZ COR,SUP-2140105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.05,390.03,,,,,,,,,,,,,
CAGE SPNL THRD 21X12 MM RAY TFC UNITE,SUP-2381380,CDM,C1889,HCPCS,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
MESH HERN W15XL19CM THK2MM EPTFE PTCH OVL 2 SIDE FOR,SUP-2125770,CDM,C1781,HCPCS,0278,RC,,,,both,,,5010.18,3256.62,,,,,,,,,,,,,
STENT BILI AD L100MM DIA6MM CATH 6FR L80CM SHTH 0.035IN,SUP-2170730,CDM,C1876,HCPCS,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
BIT DRL TWST 1.6X75 MM SEGMENTED STP BOS ATTCH SONICWELD RX,SUP-2463875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.53,280.49,,,,,,,,,,,,,
GRAFT HUM TISS DIA16MM AMNIO TISS MEM DISK SHT AMNIOFIX,SUP-2305722,CDM,V2790,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
EXTRACTOR STONE 2.2FR L115CM BSKT DIA1CM NIT TIPLSS UNIDEX,SUP-2171315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1032.12,670.88,,,,,,,,,,,,,
EXPANDER TISS 1.5-4.3 CM 7.5X6 CM 35-89 CC TEXT SOFTSPAN,SUP-2458695,CDM,C1889,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
CUP ACET OD49MM ID32MM ALL POLYETH CEM REFLCT,SUP-2345431,CDM,C1776,CPT,0278,RC,,,,both,,,2004.26,1302.77,,,,,,,,,,,,,
SYRINGE INJ BONE CEM DEL,SUP-2194167,CDM,C1713,HCPCS,0278,RC,,,,both,,,603.73,392.42,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92CM 6FR 1MM D FIX AUTO-ID BLU,SUP-2248673,CDM,C1733,HCPCS,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
RECON PLATE 4X61MM 4.5MM,SUP-2820860,CDM,C1713,HCPCS,0278,RC,,,,both,,,2847.82,1851.08,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X16 MM FUSION HEX DRV YEL WRST SS NS,SUP-2852074,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.56,296.76,,,,,,,,,,,,,
SCREW SPNL 4.5X60 MM HA TSRH 3DX OSTEOGRIP,SUP-2631156,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
SYSTEM SURG ABLATION ISOLATOR SYNERGY RT CRV GLIDEPATH TAPE,SUP-2124422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
COMPONENT ARTC 58 MM 54 MM SHLDR HUM OFFSET HEMICAPOVO,SUP-2123587,CDM,C1776,CPT,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
HC Blood Count Red Blood Cell Automated,PX-3058504100,CDM,85041,CPT,0305,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
PLATE BONE 15 H ANAT FIBULAR ANK L SHP GORILLA,SUP-2321565,CDM,C1713,HCPCS,0278,RC,,,,both,,,5484.01,3564.61,,,,,,,,,,,,,
RESERVOIR PENILE PROS 700 AMS 65 ML,SUP-2138963,CDM,C1813,HCPCS,0278,RC,,,,both,,,6462.12,4200.38,,,,,,,,,,,,,
PLATE SPNL 43 MM ANTR LUMBAR 4 HOLE PYRAMID +4,SUP-2631828,CDM,C1713,HCPCS,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
SCREW BONE L10XOD2MM TI CORT CRANIOMAXILLOFACIAL CROSS PIN,SUP-2363434,CDM,C1713,HCPCS,0278,RC,,,,both,,,105.57,68.62,,,,,,,,,,,,,
PLATE BNE W16XL267MM BLDE L70MM THK48MM 95DEG 16 H ST BILAT,SUP-2185493,CDM,C1713,HCPCS,0278,RC,,,,both,,,5623.90,3655.53,,,,,,,,,,,,,
PLATE BNE TALAR 5 LNG 3 MM LT ANK PEGGED PROPHECY INVISION,SUP-2459965,CDM,C1713,HCPCS,0278,RC,,,,both,,,9570.72,6220.97,,,,,,,,,,,,,
GRAFT HUM TISS W14XL36MM REV CORES FRZ DRY LIG RECON,SUP-2307074,CDM,C1713,HCPCS,0278,RC,,,,both,,,3230.75,2099.99,,,,,,,,,,,,,
OSSEON 10 GAUGE VERTEBROPLASTY CONVENIENCE PACK,SUP-2702139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
SHEATH INTRO FLX L 45 CM OD 8 FR GUIDEWIRE 0.038 IN SM CKFLO,SUP-2168470,CDM,C1894,HCPCS,0272,RC,,,,both,,,173.61,112.85,,,,,,,,,,,,,
PACK ORTH INSTR OVR DRL COMPR SLV RECTANGULAR DRVR FOR 4 MM,SUP-2902446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1624.64,1056.02,,,,,,,,,,,,,
NAIL CPHLMDLLRY SM L38CM D10MM 130DG LNG TTNM LEFT CCD ANGLE,SUP-2468352,CDM,C1776,CPT,0278,RC,,,,both,,,6685.75,4345.74,,,,,,,,,,,,,
SIZER IMPL MAMM SMOOTH MOD PROF SIL GEL 275 ML RND,SUP-2300910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
GUIDEPIN SURG L80MM DIA0.09IN FOR ACL RECON,SUP-2212927,CDM,C1713,HCPCS,0278,RC,,,,both,,,752.60,489.19,,,,,,,,,,,,,
HC So Cardiolipin Antibody,PX-3028614766,CDM,86147,CPT,0302,RC,,,,both,,,434.00,282.10,,,,,,,,,,,,,
INTRODUCER SHTH SL2 SIDE H RADPQ TIP MRK HEMSTAS TECHNOLOGY,SUP-2357210,CDM,C1893,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
FIBER LASER ORTHOPEDIC 15 DEG HOLM INFRATOME,SUP-2225606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1471.88,956.72,,,,,,,,,,,,,
STENT CORONARY MULTLNK PENTA L 15 MM DIA 3.5 MM GUIDEWIRE,SUP-2101576,CDM,C1876,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
STAPLER INT AD L33MM DIA5MM STD GI YEL TI CIR CUT 2 ROW,SUP-2283246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2245.51,1459.58,,,,,,,,,,,,,
STEM FEM L220MM DIA15MM CALCAR HIP ZMLY CLLRD FOR VERSYS 78711561] ZIMMER BIOMET INC],SUP-2211407,CDM,C1776,CPT,0278,RC,,,,both,,,14068.61,9144.60,,,,,,,,,,,,,
ALLOSYNC CB DBM PUTTY 10CC,SUP-2816376,CDM,C1713,HCPCS,0278,RC,,,,both,,,3659.67,2378.79,,,,,,,,,,,,,
ALLOGRAFT BNE 5MM SPCR CERV CORT,SUP-2364361,CDM,C1889,HCPCS,0278,RC,,,,both,,,4504.33,2927.81,,,,,,,,,,,,,
CONNECTOR SPINE 5.5/6.35MM L30MM ANT IL S STL ASSEMB FIX,SUP-2286992,CDM,C1713,HCPCS,0278,RC,,,,both,,,2343.07,1523.00,,,,,,,,,,,,,
ATORVASTATIN CALCIUM 10 MG PO TABS,RX-19176,CDM,6370000000,HCPCS,0637,RC,00904-6290-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 24CM STRGHT 2,SUP-2613266,CDM,C1752,HCPCS,0278,RC,,,,both,,,814.05,529.13,,,,,,,,,,,,,
KYPHOPLASTY TRAY 10/2 OSTEO INTRO CDS SYS KYPHOPAK EXPRESS,SUP-2665110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8499.98,5524.99,,,,,,,,,,,,,
SCREW BNE L35MM THRD 3.5MM HD 4.5MM TI LNG THRD CANN HDLESS,SUP-2389530,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
KIT CATH ACCS PRT CONTAIN SYR EXTN TBNG CLMP NONCORING NDL,SUP-2284604,CDM,C1751,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 5X111 MM 23/15 MM HIP 5 HOLE LCP,SUP-2799111,CDM,C1713,HCPCS,0278,RC,,,,both,,,2625.48,1706.56,,,,,,,,,,,,,
PIN FIX L25MM DIA2.7MM PROV FOR LCK DRL GUID,SUP-2344008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1717.83,1116.59,,,,,,,,,,,,,
CHOLANGIOGRAPHY SET 4 FRX60 CM 14 GAX7.5 CM CATH NDL PETELIN,SUP-2863652,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
IMMOBILIZER KNEE WRP II W PAT UNIV,SUP-2196844,CDM,L1810,HCPCS,0272,RC,,,,both,,,40.47,26.31,,,,,,,,,,,,,
FENTANYL CITRATE (PF) 1000 MCG/20ML IJ SOLN,RX-133095,CDM,J3010,HCPCS,0636,RC,00409-9094-16,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE LT FIFTH METATRSL SPRL,SUP-2896522,CDM,C1713,HCPCS,0278,RC,,,,both,,,3921.86,2549.21,,,,,,,,,,,,,
CLAMP PERI ARTICULAR PIN,SUP-2678700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.25,238.71,,,,,,,,,,,,,
ALLODERM DERMAL X THICK 16CM X 20CM PERFORATED MATRIX,SUP-2866787,CDM,Q4116,HCPCS,0636,RC,,,,both,,,34222.86,22244.86,,,,,,,,,,,,,
ADAPTER FEM 5DEG KNEE PFC SIG,SUP-2253593,CDM,C1776,CPT,0278,RC,,,,both,,,4635.90,3013.33,,,,,,,,,,,,,
ELECTRODE ES VPR FRONTLOADING PK PLASMABUTTON,SUP-2313936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1704.64,1108.02,,,,,,,,,,,,,
MORPHINE SULFATE 10 MG/5ML PO SOLN,RX-5176,CDM,340b,HCPCS,0637,RC,00121-0904-94,NDC,,both,1.25,ML,2.70,1.75,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA1.5 MM TI SD PRELD NEURO MOD NS,SUP-2883431,CDM,C1713,HCPCS,0278,RC,,,,both,,,17342.25,11272.46,,,,,,,,,,,,,
PACK EYE CUST 23GA PPK571802] ALCON LABORATORIES INC],SUP-2110964,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.24,1193.56,,,,,,,,,,,,,
BRACE KNEE OFF THE SHLF STD MED R L UNLOADER 1 +,SUP-2319283,CDM,L1844,LOCAL,0274,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
CATHETER HD EXTN 14 FRX20 CM ACUTE STAGGERED FULL TY 400XL,SUP-2269513,CDM,C1752,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE L18MM THK0.4MM 7 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181564,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.10,558.41,,,,,,,,,,,,,
GUIDEWIRE ORTH L 300 MM DIA2.8 MM THRD FOR CANN SYS STRL,SUP-2908091,CDM,C1769,HCPCS,0272,RC,,,,both,,,814.23,529.25,,,,,,,,,,,,,
LINK TYPE: FEM SIZE: 52MM,SUP-2397006,CDM,C1776,CPT,0278,RC,,,,both,,,10770.20,7000.63,,,,,,,,,,,,,
IMPLANT FACE L 96 X W 61 MM THK 1.5 MM POLYETHYL EMBEDDED TI,SUP-2883594,CDM,C1713,HCPCS,0278,RC,,,,both,,,9400.00,6110.00,,,,,,,,,,,,,
COUNTERSINK SURG BNE FOR 65 75MM HD SCR DARCO,SUP-2399161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
COIL EMB L6CM DIA3MM EXTRA SFT 3D DETACH AXIUM PRIM,SUP-2295045,CDM,C1889,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
KIT INTRO L 14 CM DIA 6 FR GUIDEWIRE L 50 CM DIA 0.038 IN,SUP-2615890,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.34,67.17,,,,,,,,,,,,,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP SOLN,RX-7332,CDM,6370000000,HCPCS,0637,RC,00536-1254-94,NDC,,both,15,ML,19.80,12.87,,,,,,,,,,,,,
STEM HUM L200 MM OD6.5 MM LT LNG EQUINOXE,SUP-2223307,CDM,C1776,CPT,0278,RC,,,,both,,,13707.98,8910.19,,,,,,,,,,,,,
PLATE BNE SM W11XL56MM THK15MM 90DEG 4X4 H TI T SHP R ANG,SUP-2190929,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.45,626.24,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED SM 8 IN LT WRST FOREARM THMB,SUP-2276634,CDM,L3809,HCPCS,0272,RC,,,,both,,,21.92,14.25,,,,,,,,,,,,,
BASKET STONE RETRV L90CM DIA11MM SHTH DIA1MM 4 WIR HELI O,SUP-2139247,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.00,412.10,,,,,,,,,,,,,
SCREW BNE L11MM OD2.7MM LOK FOR PLT TUFFNEK TECHNOLOGY,SUP-2321097,CDM,C1713,HCPCS,0278,RC,,,,both,,,582.47,378.61,,,,,,,,,,,,,
BAR EXT FIX 11X350 MM CARBON,SUP-2749998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
BIT DRL DIA65MM CANN BITE COMPR SCR QUIK CONN,SUP-2315945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1329.16,863.95,,,,,,,,,,,,,
ANCHOR SUTURE 1.4 MM NANOTACK,SUP-2418173,CDM,C1713,HCPCS,0278,RC,,,,both,,,2081.19,1352.77,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS INCUS LNG 4.5X3.3X2.5 MM SINGLE NOTCH,SUP-2637874,CDM,L8613,CPT,0278,RC,,,,both,,,1220.11,793.07,,,,,,,,,,,,,
PLATE BNE SM W10.1XL82MM THK3.5MM 6 H BILAT S STL CRV RIG,SUP-2186261,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.11,1248.72,,,,,,,,,,,,,
PLATE BNE STR 3.5 MM 6 HOLE RECON FOR SM FRAG SYS TI NS,SUP-2466155,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.83,554.99,,,,,,,,,,,,,
NEEDLE ASPIR 11 GAX11 CM STRL MAR CELLUTION,SUP-2743330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
COMPONENT TOT SHLDR CTA,SUP-2249611,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
STAPLER INT 10X15X13 MM NIT MEMOFIX,SUP-2609671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3436.35,2233.63,,,,,,,,,,,,,
RING EXT FIX 180 MM TRAUM CLMP SIDE,SUP-2197264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BONE W12XL103MM 6 H SEMI TBLR ECT,SUP-2198538,CDM,C1713,HCPCS,0278,RC,,,,both,,,165.04,107.28,,,,,,,,,,,,,
ANCHOR SUT KNOTILUS 35MM,SUP-2366685,CDM,C1713,HCPCS,0278,RC,,,,both,,,1008.57,655.57,,,,,,,,,,,,,
CATHETER BLLN DIL 24 FRX15 CM NEPHROLITHOTOMY EZDILATE,SUP-2464490,CDM,C1758,HCPCS,0278,RC,,,,both,,,806.20,524.03,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.5MM LCK ST T7 PERI-LOC,SUP-2350049,CDM,C1713,HCPCS,0278,RC,,,,both,,,928.97,603.83,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS L 75 CM BALLOON L 4 CM DIA18 MM,SUP-2127936,CDM,C1725,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
GRAFT HUM TISS CHORION BASE THCK 8X4 CM AMNIO ACTISHIELD,SUP-2759476,CDM,C1762,CPT,0278,RC,,,,both,,,12023.06,7814.99,,,,,,,,,,,,,
POST FIX 12MM BOLT 2 H ASSEMB TRUELOK RNG,SUP-2316107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
LINER ACET LAT H 4+ MM 20 DEG 32X62-64 MM XLPE REFLECTION,SUP-2434803,CDM,C1776,CPT,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
S-T CORTEX SCREW 50MM 2.5MM,SUP-2844048,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.27,125.63,,,,,,,,,,,,,
PROBE HEMSTAT BICAP DST IRRIG ONLY 10FR,SUP-2313959,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
NEEDLE INSUFFLATION VERES 2.1X120 MM 1.6 MM DSTL TIP,SUP-2850635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.91,204.69,,,,,,,,,,,,,
CATHETER ABLATION SHFT L 110 CM DIA 7.5 FR TIP L 4 MM QD K2,SUP-2890569,CDM,C1769,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
NAIL IM L33CM OD10MM TIB CANN LCK DELT RUSS TAY,SUP-2342518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1735.16,1127.85,,,,,,,,,,,,,
GRAFT BONE MAR SM + CONC,SUP-2163084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
BRA SURG 3XL WHT POST SURG MAMM COMPR DSG W/ REM STRP FR HK,SUP-2276930,CDM,L8000,HCPCS,0272,RC,,,,both,,,50.08,32.55,,,,,,,,,,,,,
OBTURATOR SHTH FAST-CATH SWARTZ SR L 15 CM DIA 6 FR W/ HUB,SUP-2355497,CDM,C1893,HCPCS,0272,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
TUBE TRACH L40CM DIA8MM WHT SFT RUB LSR RESIST LSRTUBUS,SUP-2265588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,724.56,470.96,,,,,,,,,,,,,
SLEEVE IM NAIL DIA 8-13 MM LNG TIB RIGID PROTCT STRL DISP,SUP-2908074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,698.27,453.88,,,,,,,,,,,,,
CATHETER PERI L90CM STD OPN END W/ WALL SLT BA IMPREG,SUP-2284524,CDM,C1729,HCPCS,0272,RC,,,,both,,,402.49,261.62,,,,,,,,,,,,,
SHEATH INTRO TOURGUIDE L 55 CM DIA 6.5 FR DEFLECTION 180 DEG,SUP-2421117,CDM,C1887,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
TRUESPAN MENIS REP SYS PLGA 24 DEG ORTHOCORD VIO BRAID COMP,SUP-2256751,CDM,C1713,HCPCS,0278,RC,,,,both,,,2728.66,1773.63,,,,,,,,,,,,,
NAIL TIBIAL ADV. 10X 345MM STERILE,SUP-2761693,CDM,C1713,HCPCS,0278,RC,,,,both,,,4336.47,2818.71,,,,,,,,,,,,,
PLATE BNE W175XL318MM THK52MM 17 H ST BILAT S STL BROAD CRV,SUP-2185315,CDM,C1713,HCPCS,0278,RC,,,,both,,,2985.07,1940.30,,,,,,,,,,,,,
PLASMA-LYTE 148 IV SOLN,RX-6330,CDM,2500000003,HCPCS,0250,RC,00338-9593-01,NDC,,both,1000,ML,97.80,63.57,,,,,,,,,,,,,
INTRODUCER SHTH PERC KT W BONDED HEM AND CHLORAPREP,SUP-2272866,CDM,C1894,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE SM MED 28 IN BLK LTX,SUP-2421714,CDM,L1833,HCPCS,0274,RC,,,,both,,,233.74,151.93,,,,,,,,,,,,,
CATHETER HD TWO LUMEN PEDIATRIC 8 FRX4 3/8 IN KT ARW,SUP-2627028,CDM,C1752,HCPCS,0278,RC,,,,both,,,228.59,148.58,,,,,,,,,,,,,
HC Removal FB Skin,PX-4501012000,CDM,10120,CPT,0450,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER EP CRD 5/5/5 MM 6 FRX110 CM SOLOIST,SUP-2749538,CDM,C2630,CPT,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 90CC CORT CANC CHIP MORSELIZED BONE,SUP-2307053,CDM,C1713,HCPCS,0278,RC,,,,both,,,4292.69,2790.25,,,,,,,,,,,,,
ALLOGRAFT GEL DBM PUTTY 5CC,SUP-2307528,CDM,C9359,HCPCS,0278,RC,,,,both,,,2427.22,1577.69,,,,,,,,,,,,,
SCREW BNE 1.5X3.5 MM DRILL-FREE STRL LEVEL 1 NEURO ONEDRIVE,SUP-2495298,CDM,C1713,HCPCS,0278,RC,,,,both,,,223.35,145.18,,,,,,,,,,,,,
PLATE CRAN 180X180X40 MM PT SPEC IMPL PEEK,SUP-2860163,CDM,C1713,HCPCS,0278,RC,,,,both,,,53824.62,34986.00,,,,,,,,,,,,,
BUR SURG DIA1MM EXT FN DMND RIM GLDE TECHNOLOGY RAP SMOOTH,SUP-2363789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
IMPLANT PECTUS BAR L10IN S STL ROUNDED END BLNT EDGE FOR,SUP-2402854,CDM,C1713,HCPCS,0278,RC,,,,both,,,5623.74,3655.43,,,,,,,,,,,,,
PLATE BONE SM 138MML HLX10 STNLSS STEEL DELTA BTTRSS ST RIGH,SUP-2725823,CDM,C1713,HCPCS,0278,RC,,,,both,,,2852.56,1854.16,,,,,,,,,,,,,
PLATE BONE L59MM 3 H LT DSTL LAT FIBULAR VAR ANG LCK FOR,SUP-2349826,CDM,C1713,HCPCS,0278,RC,,,,both,,,5223.55,3395.31,,,,,,,,,,,,,
NAIL IM L 175 MM DIA13 MM ARTH OSTEOSYN NITINAIL,SUP-2898410,CDM,C1713,HCPCS,0278,RC,,,,both,,,31086.00,20205.90,,,,,,,,,,,,,
SCREW BNE SNAP OFF DRV FOR FRAC REP AND FIX OSTEOTMY JT FUS,SUP-2175120,CDM,C1713,HCPCS,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
DEROTATOR SURG 12MM 35DEG SPNL APCL DANEK,SUP-2292677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.60,944.19,,,,,,,,,,,,,
GRAFT BNE STRP LG 90X25X7 MM 1-2 MM 15.8 CC ACTIFUSE ABX,SUP-2130293,CDM,C1713,HCPCS,0278,RC,,,,both,,,10190.56,6623.86,,,,,,,,,,,,,
PLATE BNE L151MM 11 H BILAT MTPHSEAL S STL LOK COMPR LO,SUP-2185104,CDM,C1713,HCPCS,0278,RC,,,,both,,,2597.35,1688.28,,,,,,,,,,,,,
RETRACTOR SURG ORTH PROTECTOR SM SM 14 CM 2.5-8 CM FLX STRL,SUP-2864521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
MESH SURG M PTCH ONLAY W6XL12CM UNDERLAY 7.5CM HERN SYS,SUP-2220101,CDM,C1781,HCPCS,0278,RC,,,,both,,,984.30,639.79,,,,,,,,,,,,,
WIRE FIX L70MM DIA0.6MM S STL SMOOTH BOTH END TRCR PNT K,SUP-2186873,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.56,165.46,,,,,,,,,,,,,
GRAFT BNE SCAFFOLD 0.5 CC OSTEOINDUCTIVE DBM EXPONENT,SUP-2424595,CDM,C1889,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
POST EXT FIX L35 MM OD9.5 MM 60 DEG MAGENTAX-POST INTOSS,SUP-2223911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
WAND ABLAT 50DEG DIA3MM TRI 50 ICW,SUP-2342005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
K WIRE FIX L4IN DIA0.045IN DBL END TRCR SMOOTH,SUP-2384027,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.60,5.59,,,,,,,,,,,,,
HC Allo Manual Buffy Coa,PX-3623821500,CDM,38215,CPT,0362,RC,,,,both,,,1897.00,1233.05,,,,,,,,,,,,,
GRAFT TISS SPCR CERV CANC FRZ DRY ALLGRFT 10MM,SUP-2307225,CDM,C1713,HCPCS,0278,RC,,,,both,,,2895.08,1881.80,,,,,,,,,,,,,
BUTTON GASTROTOMY BLLN 12 FRX1 CM SAFETY PLUG MINIONE,SUP-2431941,CDM,C1889,HCPCS,0278,RC,,,,both,,,331.27,215.33,,,,,,,,,,,,,
INQUIRY AFOCUS II 1110 7 8 SM AF25,SUP-2699064,CDM,C1730,HCPCS,0272,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
EPICORD 2X3CM 6SQ CM,SUP-2305732,CDM,Q4187,HCPCS,0636,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
CATHETER THROMCTMY FOGARTY L 50 CM DIA 6 FR SPRL DIA,SUP-2214037,CDM,C1757,HCPCS,0272,RC,,,,both,,,1496.37,972.64,,,,,,,,,,,,,
LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY,RX-147640,CDM,6370000000,HCPCS,0637,RC,25021-0673-77,NDC,,both,11,ML,28.60,18.59,,,,,,,,,,,,,
PLATE BNE L 234 MM SCREW DIA 3.5 MM 18 SHFT H TI MTPHSEAL NS,SUP-2907836,CDM,C1713,HCPCS,0278,RC,,,,both,,,4614.17,2999.21,,,,,,,,,,,,,
MESH HERN W3.1XL5.3IN M POLYPR L INGUINAL NONABSORBABLE LT,SUP-2125793,CDM,C1781,HCPCS,0278,RC,,,,both,,,564.89,367.18,,,,,,,,,,,,,
STENT COR RX 2.75X23 MM 6 FRX145 CM COCR XIENCE ALPINE,SUP-2516975,CDM,C1874,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
HOOK RETRCT KRAYENBUEHL SM 2.7 MM 7.25 IN NERVE BLNT TIP NS,SUP-2473668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,205.70,133.70,,,,,,,,,,,,,
LORAZEPAM 4 MG/ML IJ SOLN,RX-10468,CDM,J2060,HCPCS,0636,RC,09999-9919-62,NDC,,both,0.75,ML,54.10,35.16,,,,,,,,,,,,,
HC So Adalimumab Level,PX-3018014566,CDM,80145,CPT,0301,RC,,,,outpatient,,,197.00,128.05,,,,,,,,,,,,,
TAMP SURG OD6MM FOR BNE GRFT,SUP-2285247,CDM,C1713,HCPCS,0278,RC,,,,both,,,799.26,519.52,,,,,,,,,,,,,
CATHETER ABLATN STD CRV 2.5 MM 8 MM 7 FR QPLR 8 MM BLZR II,SUP-2141269,CDM,C1733,HCPCS,0272,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
SHEARS ENDOSCP L23CM DIA5MM ULTRASONIC CRV TIP W/ ADV,SUP-2219105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1206.98,784.54,,,,,,,,,,,,,
OCCLUDER CV WATCHMAN TRUSEAL ERGO HUB 2 STRT THRD ACCS SYS,SUP-2892941,CDM,C1894,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BONE L12MM GRN EIGHT FOR GUID GROWTH SYS,SUP-2316386,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
DEVICE PROSTHETIC GRAPHITE LAMINATED CARBON,SUP-2388185,CDM,L2755,HCPCS,0274,RC,,,,both,,,336.45,218.69,,,,,,,,,,,,,
GUIDEWIRE VASC ROTAWIRE ROT L 325 CM DIA 0.009 IN SPRING TIP,SUP-2142055,CDM,C1769,HCPCS,0272,RC,,,,both,,,992.24,644.96,,,,,,,,,,,,,
PSN REV 6MM OFFSET STEM EXT 18X135MM,SUP-2508831,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
PLATE BNE L178MM 8 H NONSTERILE L MED PROX TIB S STL LOK,SUP-2185676,CDM,C1713,HCPCS,0278,RC,,,,both,,,4220.88,2743.57,,,,,,,,,,,,,
SHEATH INTRO CATAPULT L 60 CM DIA 5 FR GUIDEWIRE 0.035 IN,SUP-2913627,CDM,C1894,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM DIA PROX/DSTL 31/31 MM,SUP-2396388,CDM,C1768,CPT,0278,RC,,,,both,,,47778.24,31055.86,,,,,,,,,,,,,
GRAFT BNE CRUSH 30 CC CANC,SUP-2165605,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
NAIL IM OD2MM HUM SMOOTH SHRP TIP LCK GUID PIN GROSSE-KEMPF,SUP-2362524,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.86,393.81,,,,,,,,,,,,,
SHUNT SURG L 11.8 MM VENTRICULAR CATH L 180 MM PRESSURE 0 CM,SUP-2929123,CDM,C1889,HCPCS,0278,RC,,,,both,,,2761.88,1795.22,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED STD S1 ANAT,SUP-2419701,CDM,C1776,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
SCREW BNE CANC 6.5X95 MM,SUP-2205621,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.00,55.90,,,,,,,,,,,,,
CATHETER BILI 5FR L23CM BAL FOR CHOLANGIOGRAPHY SYNTEL,SUP-2119458,CDM,C1726,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER HD DL 14 FRX20 CM KT ANTIMICROBIAL ARROWG+ARD BLU,SUP-2435359,CDM,C1752,HCPCS,0278,RC,,,,both,,,433.95,282.07,,,,,,,,,,,,,
PLATE BNE L103MM 5 H ST L POSTEROLATERAL DST FIBULAR S STL,SUP-2420742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1989.06,1292.89,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE|PO,PX-3616449000,CDM,64490,CPT,0361,RC,,,50|PO,both,,,4864.00,3161.60,,,,,,,,,,,,,
PLATE BNE LCK LG RT CALCANEAL ALPS,SUP-2413701,CDM,C1713,HCPCS,0278,RC,,,,both,,,2646.80,1720.42,,,,,,,,,,,,,
PLUG ORTH HIP HNG AXLE LEGION,SUP-2346399,CDM,C1776,CPT,0278,RC,,,,both,,,511.19,332.27,,,,,,,,,,,,,
CHOPPER OPHTH NUCLS NAGAHARA LT,SUP-2472918,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.27,266.03,,,,,,,,,,,,,
HALOPERIDOL 0.5 MG PO TABS,RX-3578,CDM,6370000000,HCPCS,0637,RC,58657-0900-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT ESOPH WALLFLEX L 10 CM DIA18 FR DIA PROX/DSTL,SUP-2140108,CDM,C1876,HCPCS,0278,RC,,,,both,,,5863.17,3811.06,,,,,,,,,,,,,
IMPLANT COCHLEAR CNTOUR ADV ELECTRD NUCLS,SUP-2165046,CDM,L8614,HCPCS,0278,RC,,,,both,,,48670.00,31635.50,,,,,,,,,,,,,
STEM HUM OD8MM HYDROXYAPETITE SHLDR IMPL REUNION,SUP-2379010,CDM,C1776,CPT,0278,RC,,,,both,,,14157.63,9202.46,,,,,,,,,,,,,
CONNECTOR SPNL ROD LNG 100 MM CLOSED AX MARINER OUTRIG,SUP-2709810,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BNE L 34 MM SCREW DIA2.7 MM 4 SHFT H SS COMPACT STR VA NS,SUP-2911959,CDM,C1713,HCPCS,0278,RC,,,,both,,,3193.16,2075.55,,,,,,,,,,,,,
SCREW INTRF L20MM DIA8MM ANTR KNEE PLLA HA CANN FOR CRUC,SUP-2341101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.35,685.98,,,,,,,,,,,,,
CATHETER CV QUAD LUMEN 8.5 FRX16 CM ARROWG+ARD BLU,SUP-2383385,CDM,C1751,HCPCS,0278,RC,,,,both,,,330.33,214.71,,,,,,,,,,,,,
PLATE BNE WIDE MEDL LT 4 HOLE CLMN FUSION SS STRL SOLE MCF,SUP-2875511,CDM,C1713,HCPCS,0278,RC,,,,both,,,11863.08,7711.00,,,,,,,,,,,,,
KIT WARMING GALIL URETHRAL FPRPR4003,SUP-2885468,CDM,C2618,HCPCS,0272,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),RX-40850049,CDM,2580000003,HCPCS,0250,RC,00338-0553-11,NDC,,both,50,ML,61.70,40.10,,,,,,,,,,,,,
BOOT HEEL FLOAT SYS W/ STRP 1 SZ ROCK,SUP-2319142,CDM,L4386,HCPCS,0272,RC,,,,both,,,303.01,196.96,,,,,,,,,,,,,
PLATE BNE STR 1 MM 6 MM LT 4 HOLE C-TUBE HK BRIDGE TI NS,SUP-2518095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1261.12,819.73,,,,,,,,,,,,,
HEAD HUM H18MM DIA44MM PRI STD OFFSET GLOB AP,SUP-2249983,CDM,C1776,CPT,0278,RC,,,,both,,,5972.28,3881.98,,,,,,,,,,,,,
SCREW BNE L10MM DIA1.3MM STD CORT S STL ST NONCANNULATED,SUP-2183148,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.21,134.69,,,,,,,,,,,,,
PLATE BNE L54MM 2X8 H BILAT S STL T SHP LO PROF RIG NEUT,SUP-2186368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1738.96,1130.32,,,,,,,,,,,,,
COMPONENT HNG TIB LIMB SALV LO BODY W/O ROTATIONAL STP,SUP-2314042,CDM,C1776,CPT,0278,RC,,,,both,,,12038.76,7825.19,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC HF 5FR 55CM 3 LUMAN RVRSE 9385108Q,SUP-2632704,CDM,C1751,HCPCS,0278,RC,,,,both,,,695.64,452.17,,,,,,,,,,,,,
SCREW BNE CANN 7.5X45 MM COMPR FT TI NS,SUP-2787838,CDM,C1713,HCPCS,0278,RC,,,,both,,,1074.38,698.35,,,,,,,,,,,,,
FORCEP ENDOSCP ALLIGATOR CUP 2.4X1800 MM W/ SPIKE STRL DISP,SUP-2791292,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.43,16.53,,,,,,,,,,,,,
CATHETER EMB L 80 CM DIA 7 FR BALLOON DIA14 MM 1.75 CC 1 YEL,SUP-2589454,CDM,C1757,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
GRAFT BNE STRP 5X5 CMX3 MM DBM TI NS DBX 048.150,SUP-2653620,CDM,C1713,HCPCS,0278,RC,,,,both,,,3157.33,2052.26,,,,,,,,,,,,,
PATCH CV HEMGRD L 75 X W 10 MM THK 0.41 MM POLYESTER BOV,SUP-2535417,CDM,C1768,CPT,0278,RC,,,,both,,,454.01,295.11,,,,,,,,,,,,,
BASKET STONE RETRIVAL 22 MMX195 CM BILI BULL SHP TIP,SUP-2493853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.01,455.66,,,,,,,,,,,,,
HC Rehab R&B,PX-1280000000,CDM,1280000000,LOCAL,0128,RC,,,,inpatient,,,2441.00,1586.65,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 7 MM EPTFE STR STD WALL N RING,SUP-2396427,CDM,C1768,CPT,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
PACEMAKER CARD INSIGNIA I ULTRA W 4.45 X H 5.88 CM THK 0.75,SUP-2148598,CDM,C1786,HCPCS,0275,RC,,,,both,,,17128.70,11133.65,,,,,,,,,,,,,
SCREW HAND EMERG CRSS PIN 12X9MM,SUP-2695503,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.53,131.64,,,,,,,,,,,,,
BIT DRILL TWIST 2.1MM FOR SUTURE ANCHORS,SUP-2828539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1096.58,712.78,,,,,,,,,,,,,
SCREW BNE L80MM DIA7.3MM CORT S STL ST CANN LOK FULL THRD,SUP-2184940,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.67,584.14,,,,,,,,,,,,,
GRAFT DURA ABSRB STRL 3.93IN 2.75IN PORCINE SURGISIS,SUP-2169999,CDM,C1763,HCPCS,0278,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
WASHER ORTH FOR 4 MM CANN SCREW STRL,SUP-2788653,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.13,68.98,,,,,,,,,,,,,
BUR DENT 1 MM CARBIDE ORNG STRL OSSEO STAP,SUP-2134833,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HANDLE DRVR SLAP HAMMER END,SUP-2484709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1038.62,675.10,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN (MIXTURES ONLY),RX-430040,CDM,2500000003,HCPCS,0250,RC,00409-9045-17,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
BLADE RETRCT W2XL4CM BLK FINISH NAR MUSC 1 PR SPNL MED LAT,SUP-2382490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.92,456.25,,,,,,,,,,,,,
GRAFT BONE CORT STRUT ALLGRFT FRZ DRY,SUP-2165592,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
SCREW BNE L20MM DIA4.5MM PROX CORT TIB S STL ST LOK FULL,SUP-2184506,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.12,42.33,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 20 CC FD CRUSH CANC READIGRAFT,SUP-2741031,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.83,546.54,,,,,,,,,,,,,
ETHACRYNIC ACID 25 MG PO TABS,RX-9980,CDM,6370000000,HCPCS,0637,RC,68180-0159-01,NDC,,both,1,UN,8.80,5.72,,,,,,,,,,,,,
STENT BILI HERCLNK + L 12 MM DIA 6 MM CATH L 80 CM GUIDEWIRE,SUP-2101562,CDM,C1876,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
TIP URETH PROX 7FR DSTL 3.8FR L40CM TIP L6CM MALL FILFRM,SUP-2171188,CDM,C1726,HCPCS,0272,RC,,,,both,,,201.96,131.27,,,,,,,,,,,,,
CATHETER OCCL 12FR 50ML BLLN AORT S STL STYL DBL LUMN,SUP-2264227,CDM,C2628,HCPCS,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
"HC So Dihydroxyvitamin D, 1 25",PX-3018265266,CDM,82652,CPT,0301,RC,,,,both,,,229.00,148.85,,,,,,,,,,,,,
GLYCERIN 35 % MT LIQD,RX-118151,CDM,6370000000,HCPCS,0637,RC,98669-0002-01,NDC,,both,30,ML,20.30,13.19,,,,,,,,,,,,,
NAIL IM L320MM DIA11.5MM FEM TIB KNEE G TI CANN LOK AG RG,SUP-2347100,CDM,C1713,HCPCS,0278,RC,,,,both,,,4578.75,2976.19,,,,,,,,,,,,,
PORT INFUS 6FR POLYUR ATTACH CHRONOFLEX CATH TI SIL FIL SUT,SUP-2127782,CDM,C1788,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
ASSEMBLY SWIVEL CONNECTOR ION IF1000,SUP-2844581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN,RX-29302,CDM,J7510,HCPCS,0637,RC,42799-0815-01,NDC,,both,237,ML,179.20,116.48,,,,,,,,,,,,,
TUBE VENT 7 MM 0.9 MM 2.3 MM STR FLROPLAS STRL 520061,SUP-2535133,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.23,13.80,,,,,,,,,,,,,
DRILL HND MYOMA 5 MMX31 CM,SUP-2850205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,572.39,372.05,,,,,,,,,,,,,
CRYOABLATION KIT PROST ICEPEARL 2.1 CX 10891] FORTEC MEDICAL INC],SUP-2225694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12073.30,7847.64,,,,,,,,,,,,,
SLEEVE KNEE SM L13IN FOR 155 18IN NEOPRENE OPN PAT EXTRA LEN,SUP-2196828,CDM,L1820,HCPCS,0272,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
BLADE RTRCTR LNG TEETH 15MMW X 75MML SPNL BLACK FLEXI SPINE,SUP-2669144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,754.60,490.49,,,,,,,,,,,,,
ANCHOR SUTURE WITH THREE NO 2 HI FI SUTURES 5.0MM O.D.X18.0M,SUP-2824352,CDM,C1713,HCPCS,0278,RC,,,,both,,,1232.14,800.89,,,,,,,,,,,,,
PLATE BNE THK 1 MM ADV 5 MM SCREW DIA2 MM MINI RT,SUP-2883183,CDM,C1713,HCPCS,0278,RC,,,,both,,,1731.08,1125.20,,,,,,,,,,,,,
PATCH SFT TISS W15X20CM THK1MM EPTFE MICROPOROUS FOR,SUP-2395297,CDM,C1781,HCPCS,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
SCREW CRAN 5PK L 4 MM DIA1.5 MM NEURO SURG SD CROSS PIN HD NS,SUP-2883996,CDM,C1713,HCPCS,0278,RC,,,,both,,,161.49,104.97,,,,,,,,,,,,,
IMPLANT NSL L 37 X W 19 X H 18 MM REG POLYETHYL SHELL W/ SM,SUP-2883631,CDM,C1889,HCPCS,0278,RC,,,,both,,,1715.95,1115.37,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 20 HOLES,SUP-2549480,CDM,C1713,HCPCS,0278,RC,,,,both,,,3363.94,2186.56,,,,,,,,,,,,,
INSERT HUM DIA36/16MM RVS BODY MOD SYS PROMOS,SUP-2351189,CDM,C1776,CPT,0278,RC,,,,both,,,3069.35,1995.08,,,,,,,,,,,,,
RELOAD STPL 0.21MM L45MM 2MM 0.75MM CLSR UNIV GRY TI,SUP-2283057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,964.55,626.96,,,,,,,,,,,,,
STEM FEM L120MM HD NK L34MM HD OFFSET 37MM DIA10MM HIP TI,SUP-2390359,CDM,C1776,CPT,0278,RC,,,,both,,,5002.02,3251.31,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM L95MM OD0038IN L3CM 3MM RAD S STL PTFE,SUP-2167908,CDM,C1769,HCPCS,0272,RC,,,,both,,,66.47,43.21,,,,,,,,,,,,,
NEEDLE SPNL Y 400 MM ES2 LT,SUP-2532845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1841.99,1197.29,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.5MM CORT TI ANK LOK FULL THRD LO PROF,SUP-2398527,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
IMPLANT CRAN L PEEK PRIORITY CUSTOMIZED,SUP-2365150,CDM,C1713,HCPCS,0278,RC,,,,both,,,54847.70,35651.00,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 20 MG MICROMATRIX,SUP-2106465,CDM,Q4118,HCPCS,0636,RC,,,,both,,,305.84,198.80,,,,,,,,,,,,,
PLATE BNE 2.4X96X2 MM 12 HOLE SS LCP,SUP-2569303,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.38,298.60,,,,,,,,,,,,,
CONNECTOR SPNL W51-70MM DIA5.5MM TRNSVRS ADJ VITALITY,SUP-2402701,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER BLLN DIL SET 2 MMX100 CM ESOPH SAVARY-GILLIARD,SUP-2759281,CDM,C1769,HCPCS,0272,RC,,,,both,,,12864.58,8361.98,,,,,,,,,,,,,
ELECTRODE DEFIB AD 1 PC DEFIB CPR SYS CPR-D-PADZ,SUP-2416161,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.69,302.70,,,,,,,,,,,,,
K WIRE FIX L127MM DIA1.5MM DST VOLAR RAD STD TIP GEMINUS,SUP-2340262,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
GRAFT HUM TISS W35XL35MM THK1.5MM ACELLULAR DERM RM TEMP,SUP-2264600,CDM,Q4125,HCPCS,0636,RC,,,,both,,,5995.26,3896.92,,,,,,,,,,,,,
GRAFT BNE STRP 50X20X5 MM COMPRESSIBLE BNE MTRX,SUP-2644323,CDM,C1713,HCPCS,0278,RC,,,,both,,,5922.04,3849.33,,,,,,,,,,,,,
EXPANDER BRST TISS W14XH11.2CM P6-7.3CM 460-550CC SMOOTH,SUP-2339901,CDM,C1789,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
BRACE WR M L8IN LT FOAM LOOP LCK CLSR W/ THMB SPICA R-SOFT,SUP-2324348,CDM,L3931,HCPCS,0272,RC,,,,both,,,72.13,46.88,,,,,,,,,,,,,
SPHERE GLEN OD 42 MM ID 24.5 MM TI NIOBIUM NITRIDE LAT STRL,SUP-2888630,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SHUNT SURG 53 CM 5-9 CM RESERVOIR KT MED CLS UNI-SHUNT,SUP-2666559,CDM,C1889,HCPCS,0278,RC,,,,both,,,5297.81,3443.58,,,,,,,,,,,,,
MTOSCR INTRF NON-CANN 9X30 STER,SUP-2341297,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SCREW BNE L10MM DIA23MM LOK T6 VARIAX,SUP-2364896,CDM,C1713,HCPCS,0278,RC,,,,both,,,512.13,332.88,,,,,,,,,,,,,
MARKER BRST BX 12 CM NDL MAGSEED,SUP-2427297,CDM,A4648,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SCREW SPNL L35MM DIA5MM TI UNIAXIAL FOR 5.5MM ROD CDH LEG,SUP-2288039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
PLATE CRAN 100X40X20 MM PT SPEC IMPL PEEK,SUP-2860177,CDM,C1713,HCPCS,0278,RC,,,,both,,,24995.66,16247.18,,,,,,,,,,,,,
STEM FEM L155MM DIA105MM L HIP 12 14 TAPR POR SM STAT SHT,SUP-2251908,CDM,C1776,CPT,0278,RC,,,,both,,,14239.27,9255.53,,,,,,,,,,,,,
SHEATH INTRO L 45 CM DIA 9 FR STRL,SUP-2383418,CDM,C1894,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COLLAR CERV ADJ SM AD 10-20 IN 2 IN W/ PD MIAMI J,SUP-2196886,CDM,L0174,HCPCS,0272,RC,,,,both,,,143.56,93.31,,,,,,,,,,,,,
BLADE LARYNGOSCOPE 3 4 FLX TIP HEINE,SUP-2240612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
HC Molecular Pathology,PX-3108138166,CDM,81381,CPT,0310,RC,,,,both,,,437.00,284.05,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X2.8 MM 20 HOLE RECON LCK FOR SCR TI NS,SUP-2484089,CDM,C1713,HCPCS,0278,RC,,,,both,,,4443.63,2888.36,,,,,,,,,,,,,
PLATE BNE HK SM 3.5/4.5X211 MM RT FEM PROX 5 STRL VA-LCP,SUP-2750911,CDM,C1713,HCPCS,0278,RC,,,,both,,,7790.56,5063.86,,,,,,,,,,,,,
PLEDGET VASCULAR 45X6MM OVAL FIRM,SUP-2427114,CDM,C1768,CPT,0278,RC,,,,both,,,119.57,77.72,,,,,,,,,,,,,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,0636,RC,00046-0749-05,NDC,,both,1,UN,2167.10,1408.61,,,,,,,,,,,,,
ALLOGRAFT BNE TISS,SUP-2431592,CDM,C1889,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
PACEMAKER CARD CONFIENT RF HE TI W/O ATR LD STRL,SUP-2149140,CDM,C1721,HCPCS,0275,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
SPLINT WR AD M L1/8IN FOR 3.5-4.5IN BGE RT FRARM HND PRE FRM,SUP-2324807,CDM,L3906,HCPCS,0274,RC,,,,both,,,94.64,61.52,,,,,,,,,,,,,
PLATE BNE THK1.5MM L TARSOMETATARSAL LAPIDUS TI STP 1 COMPR,SUP-2378913,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
GRAFT BNE SUB 10ML POLYMER HYALURONIC ACID BASE PSTE MIX,SUP-2247322,CDM,C1713,HCPCS,0278,RC,,,,both,,,6458.98,4198.34,,,,,,,,,,,,,
CATHETER HD STR 14.5 FRX40 CM LT DL STP BASIC SET HEMO-FLOW,SUP-2627205,CDM,C1750,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
TM POR ST/TM CUP/LG VIT ELN/LG STD HD,SUP-2402810,CDM,C1776,CPT,0278,RC,,,,both,,,16745.62,10884.65,,,,,,,,,,,,,
SPACER SPNL ALIF TI STALIF,SUP-2163224,CDM,C1889,HCPCS,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
IMP SYS T-ROPE RIGHT W/8.0MM FLIPCUTR II,SUP-2812195,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
BIT DRL L16MM OD4MM TI W/O STP NONRADIOLUCENT FOR 4MM SCR,SUP-2415600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
HC So Dhea Level,PX-3018262666,CDM,82626,CPT,0301,RC,,,,outpatient,,,131.00,85.15,,,,,,,,,,,,,
CELLECT CATRIDGE EMP,SUP-2255623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1742.70,1132.75,,,,,,,,,,,,,
KIT SND PROC FOR OSI300 IMPL NS OSIA2I,SUP-2882744,CDM,L8691,HCPCS,0278,RC,,,,both,,,13647.38,8870.80,,,,,,,,,,,,,
RING EXT FIX DIA255 MM 2/3 NS DISP TAY SPAT FRME,SUP-2932944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7171.92,4661.75,,,,,,,,,,,,,
BIT DRL QC 4X245 MM FEM PERIPROSTHETIC NCB,SUP-2862215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,407.51,264.88,,,,,,,,,,,,,
BIT DRL CALIB 4.2X145 MM 3 FLUT QC NDL PT TFNA ADV,SUP-2178878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.02,342.56,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENEST CUFFLESS BLUSELECT,SUP-2915315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,94.26,61.27,,,,,,,,,,,,,
GUIDEWIRE 20X30CM RECTANG,SUP-2419664,CDM,C1769,HCPCS,0272,RC,,,,both,,,25066.62,16293.30,,,,,,,,,,,,,
NAIL IM L180MM DIA11MM TIB MAG PHOENIX,SUP-2412147,CDM,C1713,HCPCS,0278,RC,,,,both,,,8653.84,5625.00,,,,,,,,,,,,,
SCREW BNE L 65 MM DIA 4 MM SS CANC FULL THRD T15 STARDRV NS,SUP-2905748,CDM,C1713,HCPCS,0278,RC,,,,both,,,603.35,392.18,,,,,,,,,,,,,
BIT DRL BNE VERTECO R,SUP-2470883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.42,294.72,,,,,,,,,,,,,
GUIDEWIRE NEUROSTIMULATOR LD STRL,SUP-2356623,CDM,C1769,HCPCS,0272,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
NERVE STIMULATOR KIT REMOT CTRL PT PRGM PRECIS SPECTR,SUP-2141947,CDM,C1787,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GUIDEWIRE VASC OD.032IN L260CM L.3CM TIP J TIP VASC IMAG,SUP-2355312,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
SCREW SCHANZ BLNT PT 5.0X40MM,SUP-2739165,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.17,389.46,,,,,,,,,,,,,
BIT DRL 1.5X107 MM 20 MM END NS LTX,SUP-2862797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,915.15,594.85,,,,,,,,,,,,,
COVER BURR H BASE SUPPORT CLP STRL DISP SENSIGHT,SUP-2883057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1171,HCPCS,0636,RC,00409-1283-03,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 80 CM DIA 5 FR SPC 2-5-2 MM A,SUP-2248647,CDM,C1730,HCPCS,0272,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
CEMENT BNE 10 CC DEMINERALIZED BONE MATRIX STRL TRABEXUS LTX,SUP-2855700,CDM,C1713,HCPCS,0278,RC,,,,both,,,28115.56,18275.11,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM CARBON FIBER NS,SUP-2863410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1589.50,1033.17,,,,,,,,,,,,,
SCREW BNE L42MM OD4MM TI CANC CANN PARTIALLY THRD FOR EXT,SUP-2107617,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLATE BONE 9 H RT OLECRANON S STL LCK PERI-LOC,SUP-2350887,CDM,C1713,HCPCS,0278,RC,,,,both,,,1840.10,1196.06,,,,,,,,,,,,,
STIMULATOR NERVE 2 QUATTRODE LAMITRODE S-8 EPIDUCER PRODIGY,SUP-2862952,CDM,C1767,HCPCS,0278,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 5 MM EPTFE STR TW N RING STRL,SUP-2396689,CDM,C1768,CPT,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
CROSSLINK SPNL M L28-38MM TI FIX LO PROF CDH,SUP-2286945,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT TEMPORARY #7 SIDE ANGLE 10MM 201867,SUP-2844576,CDM,C1889,HCPCS,0278,RC,,,,both,,,867.27,563.73,,,,,,,,,,,,,
PROBE LARYNGEAL STR W/ SMK EVAC,SUP-2713695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1012.40,658.06,,,,,,,,,,,,,
PLATE BNE MED 20 MM RT GORILLA HEVANS,SUP-2321483,CDM,C1713,HCPCS,0278,RC,,,,both,,,4686.45,3046.19,,,,,,,,,,,,,
SCREW BNE LAG 125 MM 100 MM ASMBLY NS PEAK FX,SUP-2474818,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
SCREW BNE L14MM DIA4MM CORT S STL ST FOR VAR ANG LCP ANK,SUP-2183683,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.96,50.02,,,,,,,,,,,,,
HC Admin Hepatitis B Vaccine,PX-7710001000,CDM,G0010,HCPCS,0771,RC,,,,inpatient,,,116.00,75.40,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 30 CC FD IRRADIATED CANC,SUP-2867094,CDM,C1762,CPT,0278,RC,,,,both,,,1476.59,959.78,,,,,,,,,,,,,
ADAPTER LD 8 CHANNEL M 10 CM,SUP-2615487,CDM,C1883,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
GRAFT STRUT FEM CORT STRUCTURAL ALLGRFT FRZN 100MM,SUP-2307363,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.12,1322.18,,,,,,,,,,,,,
PIN FIX LCK MAK OSS,SUP-2440970,CDM,C1713,HCPCS,0278,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
PLATE BNE L55MM THK1.3MM 8 H MTCRPL TI STR COMPR FOR,SUP-2267915,CDM,C1713,HCPCS,0278,RC,,,,both,,,962.10,625.36,,,,,,,,,,,,,
GRAFT VASC L80CM ID4 7MM PTFE STD WALLED TAPR NONRINGED,SUP-2395786,CDM,C1768,CPT,0278,RC,,,,both,,,6873.46,4467.75,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 24 MM DIA 4.5 MM SS RX,SUP-2144507,CDM,C1876,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BLADE SAW 91.2X40.5X0.38 MM RECIP THN EXT STRL PRECIS LTX,SUP-2862503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.87,259.27,,,,,,,,,,,,,
MENTHOL-ZINC OXIDE 0.44-20.6 % EX OINT,RX-128035,CDM,6370000000,HCPCS,0637,RC,00799-0001-02,NDC,,both,71,GR,17.60,11.44,,,,,,,,,,,,,
HEAD HUM H24MM DIA46MM CO CHROM OFFSET PRI NECKLESS FOR TOT,SUP-2344306,CDM,C1776,CPT,0278,RC,,,,both,,,3147.85,2046.10,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK FORK STRP,SUP-2388211,CDM,L5684,HCPCS,0274,RC,,,,both,,,126.48,82.21,,,,,,,,,,,,,
NAIL INTRMDLLRY LOK CNNLTD UNVRSL 9MM DIA 285MML TTNM ALLOY,SUP-2587455,CDM,C1713,HCPCS,0278,RC,,,,both,,,3587.14,2331.64,,,,,,,,,,,,,
GRAFT BNE 12X12X12MM DEMIN CANC SPNG CUBE FLEXIGRFT,SUP-2264608,CDM,C1713,HCPCS,0278,RC,,,,both,,,1880.89,1222.58,,,,,,,,,,,,,
PLATE BNE W11XL246MM THK3.7MM 14 H NONSTERILE R MED DST TIB,SUP-2185598,CDM,C1713,HCPCS,0278,RC,,,,both,,,4142.51,2692.63,,,,,,,,,,,,,
DRILL TWST 3.5MM DIA 120MML,SUP-2413873,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
SCREW BNE LCK 2.7X7 MM MAXDRIVE LEVEL 1 258870791,SUP-2464242,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.73,294.92,,,,,,,,,,,,,
STENT TRACH POLYFLEX L 60 MM DIA14 MM DEL SYS DIA 9 MM,SUP-2675315,CDM,C1874,HCPCS,0278,RC,,,,both,,,6001.11,3900.72,,,,,,,,,,,,,
SCREW BNE LCK 3.5X12 MM DBL STRT THRD STRL JPS LTX,SUP-2875331,CDM,C1713,HCPCS,0278,RC,,,,both,,,1383.33,899.16,,,,,,,,,,,,,
CARTRIDGE PMP FOR ERBEJET 2 STRL DISP,SUP-2901809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
STEM FEM SZ 12 L300MM STD OFFSET MONOLITHIC SLVLSS REV,SUP-2345609,CDM,C1776,CPT,0278,RC,,,,both,,,19122.60,12429.69,,,,,,,,,,,,,
SPINAL SET LCK 35 MM CAP/ROD COMB 2 NEWPORT MIS,SUP-2245605,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BNE INFRAPECTINEAL SM RT QUADRILATERAL SURF NS,SUP-2461137,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
HC Arthrocent/Aspiration Maj Jnt|RIGHT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3612061000,CDM,20610,CPT,0361,RC,,,RT|73,both,,,1245.00,809.25,,,,,,,,,,,,,
SCREW INTFR BIOSURE REGENESORB 10MM X 35MM,SUP-2341930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1121.89,729.23,,,,,,,,,,,,,
CATHETER BAL 135CM L 5.3FR 6MM BAL DIA 40MM BAL LEN .035IN,SUP-2141049,CDM,C1725,HCPCS,0272,RC,,,,both,,,569.97,370.48,,,,,,,,,,,,,
SCREW L20MM TRAC MINI JT DISTRACTOR,SUP-2123104,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BNE 34 MM TI,SUP-2208316,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
LENS IOL 5 MM POST CHMBR,SUP-2110268,CDM,V2632,HCPCS,0276,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
SCREW BONE L5MM OD2MM SLV TI CRANIOMAXILLOFACIAL MIDFACE ST,SUP-2135918,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.27,95.73,,,,,,,,,,,,,
RING EXT FIX HALF 180 MM ALUM NS MAXFRAME,SUP-2757974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3464.27,2251.78,,,,,,,,,,,,,
HC So1 Creatinine Urine/Other,PX-3018257067,CDM,82570,CPT,0301,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
CANNULA ARTHSCP OBTURATOR SFT TISS STRL DISP INTEGRITY,SUP-2901938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
MESH SURG DIA10-15CM WHT POLY CLLGN FLM RECT MFIL BIOABSRB,SUP-2283399,CDM,C1781,HCPCS,0278,RC,,,,both,,,1218.48,792.01,,,,,,,,,,,,,
SCREW TRAC STNMN PIN HLDR THMB FOR REPL,SUP-2197326,CDM,C1713,HCPCS,0278,RC,,,,both,,,20.38,13.25,,,,,,,,,,,,,
GRAFT HUM TISS W26XH7MM D9-11MM TRANSFORAMINAL POST LUM,SUP-2306940,CDM,C1713,HCPCS,0278,RC,,,,both,,,13903.17,9037.06,,,,,,,,,,,,,
TAP SURG L125MM OD27MM SM FRAG AO FIT FOR 27MM SCR,SUP-2377948,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
INTRODUCER VASC 6FR 10CM LEN W/OUT CRV HEMSTAT VLV 45CM DIL,SUP-2385252,CDM,C1894,HCPCS,0272,RC,,,,both,,,215.09,139.81,,,,,,,,,,,,,
CATHETER CV PRESSURE MONITORING SET 015 2.5 FRX5 CM,SUP-2760060,CDM,C1751,HCPCS,0278,RC,,,,both,,,129.93,84.45,,,,,,,,,,,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,0636,RC,00409-1207-13,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
ANCHOR SUT OD2.9MM TI DBL ARMED PERM PRE LD PRE THRD 2 NO 2,SUP-2341743,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
CABLE EP CATH L 2.5 M 10 PIN MODEL 1910-S DIAG CONN GUID,SUP-2887273,CDM,C1732,HCPCS,0272,RC,,,,both,,,472.57,307.17,,,,,,,,,,,,,
BODY VERT H 20-24 MM DIA19 MM SM BLACKARMOR CARBON PEEK,SUP-2917145,CDM,C1889,HCPCS,0278,RC,,,,both,,,45216.00,29390.40,,,,,,,,,,,,,
INDWELLING VOICE PROS LEF,SUP-2242341,CDM,L8509,HCPCS,0274,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PIN FIX L30MM DIA2MM RESRB BIOTRAK,SUP-2106862,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
CATHETER BLLN DIL 26X48 MMX60 CM ANORECT BAROSTAT,SUP-2306877,CDM,C1726,HCPCS,0272,RC,,,,both,,,120.89,78.58,,,,,,,,,,,,,
CATHETER CTRL VEN L65CM OD9FR SIL DBL LUMN TUNNELED N COAT N,SUP-2126155,CDM,C1751,HCPCS,0278,RC,,,,both,,,356.39,231.65,,,,,,,,,,,,,
CONNECTOR SPNL L40-55MM M CROSS BUTTRES ADJ CLMP,SUP-2415665,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.13,744.33,,,,,,,,,,,,,
HYDROCORTISONE VALERATE 0.2 % EX CREA,RX-10218,CDM,6370000000,HCPCS,0637,RC,51672-1290-01,NDC,,both,15,GR,322.40,209.56,,,,,,,,,,,,,
BOOT M SZ GREATER THAN 10.5 WOM GREATER THAN 11.5 CALF CIRC,SUP-2197116,CDM,L4396,HCPCS,0274,RC,,,,both,,,108.08,70.25,,,,,,,,,,,,,
BIOMEPRO PO CPDR,RX-155409,CDM,6370000000,HCPCS,0637,RC,26608-0001-54,NDC,,both,1,UN,9.00,5.85,,,,,,,,,,,,,
HC Perq Trluml C Angioplasty 1 Maj C Art&/Branches,PX-4819292000,CDM,92920,CPT,0481,RC,,,,both,,,15307.00,9949.55,,,,,,,,,,,,,
GRAFT HUM TISS W12XL20CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307556,CDM,Q4128,HCPCS,0636,RC,,,,both,,,23967.62,15578.95,,,,,,,,,,,,,
SCREW BNE 1.5MM DIAM 4MM LEN STD TI CORT CRANIO 5PK,SUP-2366192,CDM,C1713,HCPCS,0278,RC,,,,both,,,143.91,93.54,,,,,,,,,,,,,
DILATOR ENDO L180CM BAL L3CM OD8MM GWIRE OD0.035IN,SUP-2169413,CDM,C1726,HCPCS,0272,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
STRM 1ST MPJ PLATE SM 7DEGREES RT,SUP-2471632,CDM,C1713,HCPCS,0278,RC,,,,both,,,5414.05,3519.13,,,,,,,,,,,,,
PLATE BNE NAR 4.5X52 MM 3 HOLE SS LC-DCP,SUP-2569255,CDM,C1713,HCPCS,0278,RC,,,,both,,,196.88,127.97,,,,,,,,,,,,,
KIT DIL PRB K WIRE DISP FOR EXTRM LUM INTBDY FUS,SUP-2310420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
BLADE RETRACTOR KEL 1X1.5 IN BOOKWALTER,SUP-2691294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
HC So RBC Pretreatment Serum,PX-3028697866,CDM,86978,CPT,0302,RC,,,,outpatient,,,351.00,228.15,,,,,,,,,,,,,
SLING GYN TRANSOBTURATOR APPRCH GYNECARE TVT ABBREVO,SUP-2220076,CDM,C1771,HCPCS,0278,RC,,,,both,,,6812.29,4427.99,,,,,,,,,,,,,
INTRODUCER IV CATH NEOMAGIC CATH L 40 CM DIA1.9/2 FR NDL 30,SUP-2874162,CDM,C1894,HCPCS,0272,RC,,,,both,,,227.96,148.17,,,,,,,,,,,,,
HC Replac Central Nt Cath WO Port,PX-3613658000,CDM,36580,CPT,0361,RC,,,,inpatient,,,1961.00,1274.65,,,,,,,,,,,,,
CATHETER DRNGE 10FR RNG BILI DUCT,SUP-2169777,CDM,C1729,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 10 CM DIA11 GA,SUP-2930220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46332.52,30116.14,,,,,,,,,,,,,
STRUT FIX 2XSHORT STD MAXFRAME,SUP-2176975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
PLATE BONE 3D PRNT MIDFACE MAND W/O PLN TI TRUMATCH,SUP-2860375,CDM,C1713,HCPCS,0278,RC,,,,both,,,33719.52,21917.69,,,,,,,,,,,,,
RING ANNULPLSTY SIMULUS L 30 X W 23.1 MM ORIFICE L 24 X W,SUP-2282790,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 4 FR DIA 9 MM TUBE PK RED,SUP-2214590,CDM,C1757,HCPCS,0272,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
EXTRACTOR STONE TIPLSS 2.2 FRX115 CM 2 CM MOD BSKT NCIRCLE,SUP-2835782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1063.52,691.29,,,,,,,,,,,,,
SET TBNG FOR AFFERA SPHR 9 HEXAFLOW IRRIGATION PMP STRL,SUP-2911942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
FLUOXETINE HCL 20 MG/5ML PO SOLN,RX-38488,CDM,340b,HCPCS,0637,RC,62135-0730-45,NDC,,both,2.5,ML,214.70,139.55,,,,,,,,,,,,,
NAIL IM L440MM DIA3MM 85DEG UNIV ST G L FEM TI CANN LOK CRV,SUP-2192730,CDM,C1713,HCPCS,0278,RC,,,,both,,,932.39,606.05,,,,,,,,,,,,,
TRAY TIB SZ 5 R HNG GMK,SUP-2267635,CDM,C1776,CPT,0278,RC,,,,both,,,13250.80,8613.02,,,,,,,,,,,,,
"HC So Calcium,Urine 24 Hr",PX-3018234066,CDM,82340,CPT,0301,RC,,,,both,,,29.00,18.85,,,,,,,,,,,,,
GUIDE SURG PLN TI LP CUSTOMIZABLE BNDL RECON VSP,SUP-2883953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,28189.35,18323.08,,,,,,,,,,,,,
HC Injection Onabotulinumtoxin a 1 Unit,PX-6360058500,CDM,J0585,HCPCS,0636,RC,,,,outpatient,,,16.00,10.40,,,,,,,,,,,,,
HC Rep Cpx Face H Ft Ea Add 5cm,PX-4501313300,CDM,13133,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
CATHETER AD COILED 1 CUF 62CM,SUP-2302488,CDM,C1750,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
HC Ins Cath Ren Art 2nd+ Unilat,PX-3613625300,CDM,36253,CPT,0361,RC,,,,inpatient,,,16763.00,10895.95,,,,,,,,,,,,,
CATHETER HD SHT TERM 9 FRX20 CM ADMIN BASIC SET STR DUOFLO,SUP-2267113,CDM,C1752,HCPCS,0278,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
STEM TIB L115MM DIA10MM KNEE EXTN STABILIZING PRI FLUT PFC,SUP-2253316,CDM,C1713,HCPCS,0278,RC,,,,both,,,3717.76,2416.54,,,,,,,,,,,,,
PLATE BNE L78MM THK3.4MM 6 H BILAT PUBIC S STL 2 DCP H LO,SUP-2184022,CDM,C1713,HCPCS,0278,RC,,,,both,,,2723.17,1770.06,,,,,,,,,,,,,
KIT NEG PRSS W10XL30CM INCL 2 DRESSINGS 1 PMP AND PMP CLP,SUP-2351614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PROBE MON NEURO DISP,SUP-2115733,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SCREW BNE ST 2X4 MM CRTX T8 STARDRV RECESS TI NS,SUP-2189423,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.75,586.79,,,,,,,,,,,,,
COUNTERSINK SRGCL CNNLTD QUICK CNNCT 35/4MM SCREW,SUP-2462551,CDM,C1713,HCPCS,0278,RC,,,,both,,,1034.94,672.71,,,,,,,,,,,,,
SCREW SPNL L40MM DIA7MM CORT COR DIA6MM CANC COR DIA5.3MM,SUP-2182453,CDM,C1713,HCPCS,0278,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
SET INTRO PERFRMR L 23 CM OD 6 FR ID 2 MM GUIDEWIRE L 80 CM,SUP-2168555,CDM,C1894,HCPCS,0272,RC,,,,both,,,109.74,71.33,,,,,,,,,,,,,
BLADE ULTRASONIC L25MM STD BNE BLNT DISP BNE SCALP,SUP-2305943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1255.50,816.07,,,,,,,,,,,,,
PLATE BNE FUSION STD NAR LT ANTR ANK ALIGNX,SUP-2610037,CDM,C1713,HCPCS,0278,RC,,,,both,,,9118.56,5927.06,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,PX-3606232100,CDM,62321,CPT,0360,RC,,,,inpatient,,,2230.00,1449.50,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.7MM FULL THRD STP FOR OLECRANON,SUP-2177107,CDM,C1713,HCPCS,0278,RC,,,,both,,,521.62,339.05,,,,,,,,,,,,,
COMPONENT TIB SZ 2 THK7MM RT MEDL LT LAT ANTR POST KNEE ALL,SUP-2251255,CDM,C1776,CPT,0278,RC,,,,both,,,4596.96,2988.02,,,,,,,,,,,,,
STENT CORONARY JOSTENT GRAFTMASTER L 26 MM DIA 5 MM,SUP-2105688,CDM,C1874,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BASEPLATE TIB M SZ 2 AP50MM ML74MM UNIV KNEE HA POR CEM,SUP-2377187,CDM,C1776,CPT,0278,RC,,,,both,,,3259.57,2118.72,,,,,,,,,,,,,
CAPTIVATOR EMR LG SCOPE,SUP-2679161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.79,626.46,,,,,,,,,,,,,
SCREW WRIST 30MM,SUP-2706178,CDM,C1776,CPT,0278,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
TAP SCREW STANDARD LOCKING 24 MM PERIARTICULAR,SUP-2460233,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
WAND ARTHSCP 90DEG SHFT DIA425MM ABLAT SUCT W INTEGR CBL,SUP-2342007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,0636,RC,00409-2987-03,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
TWIST DRL SURG L 8 CM DIA1.5 MM STP D 12 MM DISECT TOOL STRL,SUP-2930016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
COMPONENT TIB CR 00 9 MM LT KNEE PRIMARY STEM CEM NP UCONG,SUP-2209389,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
INTRODUCER SHTH 0.021 IN 6 FRX23 CM 21 GAX4 CM PRELUDE EASE,SUP-2798464,CDM,C1894,HCPCS,0272,RC,,,,both,,,230.79,150.01,,,,,,,,,,,,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX,RX-2511,CDM,6370000000,HCPCS,0637,RC,00121-0978-00,NDC,,both,2.5,ML,8.90,5.78,,,,,,,,,,,,,
GRAFT BNE W13XL34MM FOR DIA38MM GLEN GLENOJET,SUP-2123640,CDM,C1713,HCPCS,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
CATHETER GUID 7X5FR L62CM WRK L59CM ACUTE CRV PEBAX INNR,SUP-2356393,CDM,C1887,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE SINGLE UPR PREFABRICATED OFF THE SHLF,SUP-2435618,CDM,L1851,HCPCS,0272,RC,,,,both,,,2540.29,1651.19,,,,,,,,,,,,,
GUIDEWIRE ORTH SHRP 2.2X500 MM STRL AEQUALIS,SUP-2846066,CDM,C1769,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
IMPLANT PENILE CYL PROS FOR AMS MALL W/ TIP EXT 600M 16CM,SUP-2140257,CDM,C1813,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
HC Driving Program Assessment 2 Hrs,PX-9900000137,CDM,9900000137,LOCAL,0990,RC,,,,both,,,325.00,211.25,,,,,,,,,,,,,
COMPONENT HIP CAPPED CEM ENDO HD ST LD/FX,SUP-2212314,CDM,C1776,CPT,0278,RC,,,,both,,,9702.60,6306.69,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 30 CM DIA 5 MM CLLGN BOV CAR ART,SUP-2120661,CDM,C1768,CPT,0278,RC,,,,both,,,3639.26,2365.52,,,,,,,,,,,,,
PLATE BNE L57MM 6X5 H ST R DST RAD VOLAR RIM S STL LOK,SUP-2177522,CDM,C1713,HCPCS,0278,RC,,,,both,,,2953.20,1919.58,,,,,,,,,,,,,
HC Arthrocent/Aspiration Maj Jnt,PX-3612061000,CDM,20610,CPT,0361,RC,,,,both,,,1245.00,809.25,,,,,,,,,,,,,
KIT INTRO MINI ACCS NONVASCULAR 6FRX20CM 4FR W DIL 0038,SUP-2303022,CDM,C1894,HCPCS,0272,RC,,,,both,,,192.73,125.27,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/O JT PREFABRICATED SFT INTFACE,SUP-2435782,CDM,L3923,HCPCS,0272,RC,,,,both,,,248.88,161.77,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 48 X 25 MM POLYETHYL RT INFERIOR ORBIT,SUP-2935386,CDM,C1713,HCPCS,0278,RC,,,,both,,,2618.76,1702.19,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 7 FRX26 CM DBL PGTL PERCFLX,SUP-2464159,CDM,C2617,HCPCS,0278,RC,,,,both,,,344.43,223.88,,,,,,,,,,,,,
PLATE BNE LCK 3.5X104 MM LT PROX LAT TIB 6 HOLE STRL,SUP-2479491,CDM,C1713,HCPCS,0278,RC,,,,both,,,3829.29,2489.04,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY DEMIN CANC 1.7MM-10MM RANG 60CC,SUP-2294032,CDM,C1713,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
HEAD 22MM BPLR MOD NK NK+,SUP-2372634,CDM,C1776,CPT,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
DA VINCI TIBIAL NAIL CASE,SUP-2811246,CDM,C1713,HCPCS,0278,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
VALVE VOICE 4.5MM TRACH LT PROVOX ACTIVLV,SUP-2124317,CDM,L8509,HCPCS,0272,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.523,SUP-2860204,CDM,C1713,HCPCS,0278,RC,,,,both,,,32139.16,20890.45,,,,,,,,,,,,,
PIN EXT FIX 3MMDIA 16MM THRD L120MM COVE PT,SUP-2342851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.27,746.38,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.3MM STD CORT TI ST NONCANNULATED,SUP-2372652,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.50,123.17,,,,,,,,,,,,,
PLATE BURR H DIA20.1 MM THK 0.3 MM SCREW DIA1.5 MM SZ 20 MM,SUP-2935957,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
COIL NEUROVASCULAR TARGET L 2.5 CM DIA2 MM PLATINUM/TUNGSTEN,SUP-2866251,CDM,C1889,HCPCS,0278,RC,,,,both,,,7225.14,4696.34,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX25 CM 13 GA 3L CUTLM701JLSCABRMHCRD,SUP-2759886,CDM,C1751,HCPCS,0278,RC,,,,both,,,240.37,156.24,,,,,,,,,,,,,
CATHETER EP 5FR L60CM 2-8-2MM SPC TIP 1MM 10 ELECTRD PCS,SUP-2248847,CDM,C1730,HCPCS,0272,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
SLEEVE TROCAR L150MM DIAMETER 12MM SMOOTH DISPOSABLE WITH TA,SUP-2803691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.34,530.62,,,,,,,,,,,,,
CLAMP EXT FIX DIA8-8MM OPN ROD TO ROD FOR TRANSFX,SUP-2199163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1195.71,777.21,,,,,,,,,,,,,
PLATE BONE L20MM 7 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413744,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.26,546.17,,,,,,,,,,,,,
PLATE BNE LCK 2.7X118 MM 10 HOLE CNTOUR 2 COMPR SS STRL,SUP-2497102,CDM,C1713,HCPCS,0278,RC,,,,both,,,1014.25,659.26,,,,,,,,,,,,,
PLATE BNE W24.4XL175.3MM STD EXTRA EXT ANAT R GUID DVR,SUP-2414031,CDM,C1713,HCPCS,0278,RC,,,,both,,,5250.08,3412.55,,,,,,,,,,,,,
SPLINT ORTHOPEDIC BOUTONNIERE 10 FNGR BEAUTY STRENGTH,SUP-2325010,CDM,L3927,HCPCS,0274,RC,,,,both,,,253.27,164.63,,,,,,,,,,,,,
DRILL TWST L 48 MM WORKING L 4 MM DIA1.2 MM HEX SHFT NS DISP,SUP-2883376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,645.02,419.26,,,,,,,,,,,,,
GRAFT HUM TISS CORNEAL,SUP-2427794,CDM,V2785,HCPCS,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
MATRIX BIO L 1.6 X W 1.2 IN SZ 12 SQCM PORCINE TEND DERIVED,SUP-2909290,CDM,A2008,HCPCS,0636,RC,,,,both,,,4308.08,2800.25,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 2XL L 75 CM BALLOON L 40 MM DIA16 MM,SUP-2147269,CDM,C1725,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE SM W11XL163MM THK34MM 12 H BILAT TI RIG NEUT LOK,SUP-2190789,CDM,C1713,HCPCS,0278,RC,,,,both,,,1191.38,774.40,,,,,,,,,,,,,
NUT SPNL STACKABLE LCK SCR BENGAL,SUP-2583126,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
STENT PERIPH 8FR L10CM DIA8MM CATH L120CM 0.035IN FEM ART,SUP-2396490,CDM,C1874,HCPCS,0278,RC,,,,both,,,8415.20,5469.88,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE TIB CUST FRAC PLSTR MOLD,SUP-2435646,CDM,L2106,HCPCS,0272,RC,,,,both,,,2231.54,1450.50,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT 5FR 55CM 2 LUMAN RVS TA 1275108F,SUP-2632635,CDM,C1751,HCPCS,0278,RC,,,,both,,,608.66,395.63,,,,,,,,,,,,,
BASEPLATE TIB MOD STD R MED PRI STEM CEM REPICCI II,SUP-2408375,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SET CBL GRP SM DIA1.6MM VIT FOR HOWMEDICA OSTEONICS DALL-M,SUP-2377560,CDM,C1776,CPT,0278,RC,,,,both,,,2157.81,1402.58,,,,,,,,,,,,,
HC Brachytx Isodose Intermed,PX-3337731700,CDM,77317,CPT,0333,RC,,,,inpatient,,,1096.00,712.40,,,,,,,,,,,,,
LITHOTRIPTER SURG BSKT 30MM CHAN 4.2MM 1 BODY DISP,SUP-2312974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,980.15,637.10,,,,,,,,,,,,,
GRAFT HUM TISS 8MM ALLO-SPAN,SUP-2354360,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
STENT URET DBL PGTL FLX TIP SFT 035IN PTFE STIFF SUT POS,SUP-2139134,CDM,C2617,HCPCS,0278,RC,,,,both,,,415.08,269.80,,,,,,,,,,,,,
VALVE CSF CRAN IMPL HYDROCEPHALUS OSV II 9OS721,SUP-2666690,CDM,C1889,HCPCS,0278,RC,,,,both,,,9503.05,6176.98,,,,,,,,,,,,,
SCREW STRNL L 12 MM DIA2.7 MM TI ALLOY SD NS MATRIXSTERNUM,SUP-2904225,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.30,347.29,,,,,,,,,,,,,
DEFIBRILLATOR CARD W2.43XH2.93IN D0.39IN 2.54OZ SGL CHMBR,SUP-2149192,CDM,C1722,HCPCS,0275,RC,,,,both,,,36310.96,23602.12,,,,,,,,,,,,,
SYSTEM SACRALCOLPOPEXY PROLAPSE REP STRAIGHT-IN INTEPRO,SUP-2140285,CDM,C1771,HCPCS,0278,RC,,,,both,,,5538.96,3600.32,,,,,,,,,,,,,
ENDOSCOPIC KIT COLON W/ 2 OZ 2 END SEAL HYDR ORCA W/O SPNG,SUP-2473924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46.60,30.29,,,,,,,,,,,,,
SCREW BONE L65MM THRD DIA2.7MM HD DIA4.5MM COR DIA2MM PITCH,SUP-2349327,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.89,189.08,,,,,,,,,,,,,
GRAFT VASC GORTX L 90 CM DIA 6-8 MM EPTFE TAPR TW N RING,SUP-2396733,CDM,C1768,CPT,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 180 CM DIA 0.018 IN PTFE PERIPH STR,SUP-2301902,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
SYSTEM LOADING ENVEO R 34MM,SUP-2501426,CDM,C1889,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
BLADE SHV DIA4MM ENT MICRODEBRIDER AGG SERR,SUP-2366837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.18,212.02,,,,,,,,,,,,,
SPLINT SWEDISH AFO M RT WHT,SUP-2324310,CDM,L4350,HCPCS,0272,RC,,,,both,,,67.70,44.00,,,,,,,,,,,,,
MICROCATHETER ETER ANGIO 29FR L130CM 0021IN SWAN NK TIP NYL,SUP-2301442,CDM,C1887,HCPCS,0272,RC,,,,both,,,857.06,557.09,,,,,,,,,,,,,
CLAMP CRAN TEXT LG 18 MM FLAPFIX FOR EXT FIX TI NS LF,SUP-2431405,CDM,C1713,HCPCS,0278,RC,,,,both,,,1107.79,720.06,,,,,,,,,,,,,
TROCAR THOR 10IN 12FR PLEUR EVAC,SUP-2384359,CDM,C1729,HCPCS,0272,RC,,,,both,,,42.08,27.35,,,,,,,,,,,,,
ALLOGRAFT DERMAL 50X60X3 MM ACELLULAR DERMAL MTRX ARTHROFLEX,SUP-2740837,CDM,Q4125,HCPCS,0636,RC,,,,both,,,10408.63,6765.61,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 0212 0850MM DEMIN CORT PWD FRZ DRY,SUP-2307258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.52,785.54,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 16 CM DIA 4 FR GUIDEWIRE 0.021 IN,SUP-2385166,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-10 MM 15 CC CANC,SUP-2641777,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM BIOCOMP FLAG STRL SWIVELOCK,SUP-2910470,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.47,1092.96,,,,,,,,,,,,,
CATHETER ETER GUID 6FR 0071IN COR STD JUDKINS R 4 SIDE H MID,SUP-2281123,CDM,C1887,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE M PROFYLE STR 4 HL 2.3MM,SUP-2466867,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
COLLAR CERV LG BLK,SUP-2414450,CDM,L0120,HCPCS,0274,RC,,,,both,,,34.85,22.65,,,,,,,,,,,,,
IMPLANT BRST W14-13.7XH11.9CM P6.4-7.9CM 550-660CC NACL,SUP-2300539,CDM,C1789,HCPCS,0278,RC,,,,both,,,3563.90,2316.53,,,,,,,,,,,,,
PLATE BNE LG TI MANDIBULAR PMI ORTHOGNATHIC 3D PRNT NS DISP,SUP-2934994,CDM,C1713,HCPCS,0278,RC,,,,both,,,31999.74,20799.83,,,,,,,,,,,,,
SPHERE ORBIT DIA12MM PMMA FOR RET EYE SOCK CNTOUR,SUP-2236373,CDM,L8610,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
CATHETER INFUSION SINGLE LUMEN 7 FRX6 IN SLIC,SUP-2383499,CDM,C1751,HCPCS,0278,RC,,,,both,,,31.15,20.25,,,,,,,,,,,,,
BUR SURG DIA1.5 MM XSH TWST DRL STRL REUSE HI-LINE,SUP-2929406,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.22,314.74,,,,,,,,,,,,,
BLADE SAG W/ 30MM MRK,SUP-2361940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
SET UROLOGICAL SHTH PEELWY L 9 CM DIA 5 FR GUIDEWIRE L 65 CM,SUP-2168661,CDM,C1892,HCPCS,0272,RC,,,,both,,,202.22,131.44,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 1 CM SM AMNIO MEMBRN RESRB AIR DRY,SUP-2913453,CDM,Q4173,HCPCS,0636,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM 6FR 1MM D CRV FIX BLU,SUP-2248674,CDM,C1730,HCPCS,0272,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
HC Antihuman Globulin Indirect Each Antibody Titer,PX-3028688600,CDM,86886,CPT,0302,RC,,,,both,,,359.00,233.35,,,,,,,,,,,,,
PREGABALIN 25 MG PO CAPS,RX-42162,CDM,6370000000,HCPCS,0637,RC,60687-0473-11,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
PLATE SPNL XSM POST CERV UP THOR MULTIAXIAL VERTEX XLNK,SUP-2289098,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
TITANIUM CONDYLAR HEAD,SUP-2823268,CDM,C1889,HCPCS,0278,RC,,,,both,,,10372.36,6742.03,,,,,,,,,,,,,
SPLINT WRST M L7IN AD L FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276649,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.51,6.18,,,,,,,,,,,,,
OSSEOFLEX SB 10 GG4ML STRGHT SSTM W OSSFLX CD H CNVNNCE PA,SUP-2701995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7190.60,4673.89,,,,,,,,,,,,,
PROGRAMMER NERVE STIM FOR PERCEPT PC DBS,SUP-2516498,CDM,C1787,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SCREW BNE PART THRD LG 4.3X60 MM STRL PROPELLER HD LTX,SUP-2861175,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.80,491.92,,,,,,,,,,,,,
HC Car-T Therapy Autologous Cell Admin,PX-8723822800,CDM,38228,CPT,0874,RC,,,,both,,,926.00,601.90,,,,,,,,,,,,,
POST 12 PIN 2HL,SUP-2696088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,729.11,473.92,,,,,,,,,,,,,
KIT ART LN PERC W/ 100CM GWIRE NO11 SCALP 18GA INSRT NDL,SUP-2214618,CDM,C1769,HCPCS,0272,RC,,,,both,,,189.91,123.44,,,,,,,,,,,,,
HC So Microbe Susceptible Disk,PX-3008718466,CDM,87184,CPT,0300,RC,,,,both,,,100.00,65.00,,,,,,,,,,,,,
PLATE BNE 2/2.4X33X1.7 MM 4 HOLE SS LC-DCP,SUP-2569203,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.96,172.87,,,,,,,,,,,,,
SCREW BNE LCK 25 MM ASMBLY PRIMALOK FF,SUP-2319819,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
ARM RETRACTOR LEYLA FLX TENS,SUP-2473420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2408.38,1565.45,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDICS SM UNIV L R SHLDR SLNG,SUP-2195044,CDM,L3660,HCPCS,0274,RC,,,,both,,,25.62,16.65,,,,,,,,,,,,,
PLATE BNE L54MM 7 H BILAT S STL LOK COMPR LO PROF FOR 2MM,SUP-2186307,CDM,C1713,HCPCS,0278,RC,,,,both,,,2067.50,1343.87,,,,,,,,,,,,,
CATHETER ABLATN F-J CRV 1-7-4 MM 8 MM 7 FRX115 CM EZ STEER,SUP-2248517,CDM,C1732,HCPCS,0272,RC,,,,both,,,7762.08,5045.35,,,,,,,,,,,,,
"PANCRELIPASE (LIP-PROT-AMYL) 15000-47000-63,000 UNITS PO CPEP",RX-142325,CDM,6370000000,HCPCS,0637,RC,73562-0111-01,NDC,,both,1,UN,27.40,17.81,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM DIA 7 FR D CRV,SUP-2880105,CDM,C1732,HCPCS,0278,RC,,,,both,,,4282.96,2783.92,,,,,,,,,,,,,
SCREW BNE L28MM DIA5.5MM PERIPH LOK FOR MOD GLEN SYS,SUP-2123412,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
WIRE FIX L102MM OD1.6MM S STL TRCR PT SMOOTH SGL SHRP TIP K,SUP-2361625,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.24,7.31,,,,,,,,,,,,,
SHEATH RADIAL LONG 106F-071-100,SUP-2854131,CDM,C1887,HCPCS,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
SCREW BNE COMPR 3X32 MM MULT USE,SUP-2397494,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
SCREW BONE L12XOD2.7MM TI CORT ST EMER NONLOCKING HEX HD,SUP-2363469,CDM,C1713,HCPCS,0278,RC,,,,both,,,148.05,96.23,,,,,,,,,,,,,
GRAFT BONE SUB 15CC CANC CUBE FRZ DRY,SUP-2115981,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
KNIFE 3722008 SICKLE 3MM CVD BLADE,SUP-2705724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.96,254.12,,,,,,,,,,,,,
NAIL HELCL 50MM BIOTRAK,SUP-2106906,CDM,C1713,HCPCS,0278,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
PLATE BNE TBLR 100 DEG 12 HOLE STRL LTX,SUP-2861635,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.10,252.26,,,,,,,,,,,,,
SCREW BNE L16MM DIA2.7MM CORT DST RAD LOK FULL THRD SQ DRV,SUP-2411811,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
KIT SPNL CRD STIM TRL LD 1 INTELLIS,SUP-2882918,CDM,C1897,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN 1000 ML,RX-40861025,CDM,J7030,HCPCS,0258,RC,00338-9793-01,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
BIT DRL L 140/45 MM DIA2.8 MM CALIB AO QC STRL DISP V,SUP-2908348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
SCREW SPNL L30MM OD5.5MM TI CANC ANT THOR PEDCL ST,SUP-2292717,CDM,C1713,HCPCS,0278,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
PLATE BONE L53MM 5 H LCK COMPR FOR 2.7MM SCR PEDIFRAG,SUP-2318662,CDM,C1713,HCPCS,0278,RC,,,,both,,,2212.00,1437.80,,,,,,,,,,,,,
"HC Est Pt, E/M Level 3",PX-5109921300,CDM,99213,CPT,0510,RC,,,,both,,,257.00,167.05,,,,,,,,,,,,,
HC Car-T Therapy Hrvg Bld Drv T Lmphcyt PR Day,PX-8713822500,CDM,38225,CPT,0871,RC,,,,outpatient,,,2291.00,1489.15,,,,,,,,,,,,,
CATHETER ANGIO L48CM OD8FR GUID COR SINUS RAPIDO CUT AWAY,SUP-2148983,CDM,C1887,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT HUM TISS L220MM DIA3-6MM GRACILIS TEND FRZN,SUP-2335548,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
BLADE SCREWDRIVER TORX 17 UNIV 2 MM S/D STAR/T-DRIVE T7,SUP-2469495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.59,275.33,,,,,,,,,,,,,
BIT DRL TWST 1.5X15 MM ANGLED SCREWDRIVER STRL ANGULUS 2,SUP-2482155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
IMPLANT SUBTALAR BUNION CORRECTION SYS STRL LF NANOPLASTY 3D,SUP-2893049,CDM,C1713,HCPCS,0278,RC,,,,both,,,14123.72,9180.42,,,,,,,,,,,,,
TIP IRR DIA0.3MM 30DEG ASPIR BEND REUSE ULTRAFLOW,SUP-2110008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
STENT CORONARY RESOLUTE INTEGRITY L 22 MM DIA 3 MM CATH L,SUP-2573074,CDM,C1874,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
GRAFT BNE SPACER 12 MM ANTEROLATERAL FOR ALIF,SUP-2632282,CDM,C1713,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
CATHETER ATHRCTMY ROTLNK L 135 MM DIA 0.058 IN BUR DIA1.75,SUP-2147020,CDM,C1724,HCPCS,0278,RC,,,,both,,,3091.33,2009.36,,,,,,,,,,,,,
CATHETER IAB 0.025 IN 7 FRX26.8 IN 30 CC FLX WIRE REDIGUARD,SUP-2877610,CDM,C1894,HCPCS,0272,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
SYSTEM IMPL TENODESIS SCR EYELET,SUP-2122949,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
GRAFT BNE SUB 25CC SPNG DEMIN CORT FBR FLEXIGRFT,SUP-2264606,CDM,C1713,HCPCS,0278,RC,,,,both,,,1065.84,692.80,,,,,,,,,,,,,
COLLAR CERV L13-16IN H2.5IN UNIV TRACH OPN ADJ AD SIERRA,SUP-2123895,CDM,L0172,HCPCS,0272,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
SPLINT ORTH W4IN LT HND BASE THMB SPICA ROLYAN,SUP-2324964,CDM,L3931,HCPCS,0272,RC,,,,both,,,91.91,59.74,,,,,,,,,,,,,
PLATE SPNL L26MM 6 H STD ANT CERV TI LEV 2 FIX LOK MAXAN,SUP-2414939,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BNE HUM 227 MM LT PROX 14 HOLE LO NS A.L.P.S,SUP-2477254,CDM,C1713,HCPCS,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
PERSUADER ROD FOR SPNL FIX SYS SILVERTON,SUP-2211166,CDM,C1713,HCPCS,0278,RC,,,,both,,,3236.71,2103.86,,,,,,,,,,,,,
HC So1 Hla Class II Typing Ea,PX-3108138267,CDM,81382,CPT,0310,RC,,,,outpatient,,,144.00,93.60,,,,,,,,,,,,,
SCREW BNE L 85 MM DIA 6.7 MM SS FT HI TORQUE NS EVOS,SUP-2931196,CDM,C1713,HCPCS,0278,RC,,,,both,,,1063.83,691.49,,,,,,,,,,,,,
GRAFT BONE 10 CC,SUP-2424593,CDM,C1713,HCPCS,0278,RC,,,,both,,,7512.45,4883.09,,,,,,,,,,,,,
BIT DRL DIA3.2MM DISP FOR 4.5MM LCK PROX FEM SCR PEDILOC,SUP-2318885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,603.95,392.57,,,,,,,,,,,,,
PLATE BONE 5 H MAND TI CRESC SHP LIMIT CNTCT DYN COMPR FOR,SUP-2191402,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|ADJ|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|ADJ|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
BUR SURG DIAMOND BALL 1 MMX7 CM SM BOR MIDAS REX LEGEND,SUP-2422257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.57,248.02,,,,,,,,,,,,,
SCREW SPNL L20MM OD2MM NONLOCKING,SUP-2402828,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
STEM FEM SM 0-3 CM M LT NS LTX,SUP-2861253,CDM,C1776,CPT,0278,RC,,,,both,,,1280.74,832.48,,,,,,,,,,,,,
NAIL IM MTCRPL TI 7.6MM PROX DIAM 4.6MM DST DIAM 60MM LEN,SUP-2340239,CDM,C1713,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
SCREW BNE STATIC 4X30 MM PECA BUNION,SUP-2758562,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
PLATE BNE Y MIC 1.5X1 MM CRANIOMAXILLOFACIAL 5 HOLE TI NS,SUP-2466997,CDM,C1713,HCPCS,0278,RC,,,,both,,,666.53,433.24,,,,,,,,,,,,,
STEM FNGR JT SZ 60 MP SIL NONCOATED PRESSFIT CEMENTLESS,SUP-2250689,CDM,L8630,HCPCS,0278,RC,,,,both,,,3541.42,2301.92,,,,,,,,,,,,,
BIOCARTILAGE KIT,SUP-2841265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
GRAFT BNE 2 GM DBM FIBERSTACK,SUP-2861496,CDM,C1713,HCPCS,0278,RC,,,,both,,,5659.85,3678.90,,,,,,,,,,,,,
CATHETERIZATION KIT 16 GAX20 CM CV PRB NDL FAST,SUP-2383266,CDM,C1751,HCPCS,0278,RC,,,,both,,,83.52,54.29,,,,,,,,,,,,,
COLLAR CERV RIGID SHT PD4 CH 11-16.5X2 IN HK,SUP-2246402,CDM,L0172,HCPCS,0274,RC,,,,both,,,64.56,41.96,,,,,,,,,,,,,
PLATE BNE L 116 X W 17 MM THK 1.4 MM SCREW DIA2.2 MM,SUP-2909545,CDM,C1713,HCPCS,0278,RC,,,,both,,,15464.41,10051.87,,,,,,,,,,,,,
MOLD SPCR 12MM STEM W/ 54X21X64MM HD SHLDR CEM STAGEONE,SUP-2136796,CDM,C1776,CPT,0278,RC,,,,both,,,6016.24,3910.56,,,,,,,,,,,,,
SCREW BNE L40MM OD4MM CANN HD SHT THRD MINI-MONSTER,SUP-2320559,CDM,C1713,HCPCS,0278,RC,,,,both,,,554.21,360.24,,,,,,,,,,,,,
SCREW CRNIO MXLFCL 1.5MM DIA 11MML TTNM BMT MCRFXTN,SUP-2587862,CDM,C1713,HCPCS,0278,RC,,,,both,,,1914.11,1244.17,,,,,,,,,,,,,
ELECTRODE ES 14GA L25CM 90DEG SEMIFLEX ANG BEND TIP KATECHO,SUP-2118719,CDM,C1819,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
SCREW BNE L14.5MM DIA8MM CORT TI CANN NONLOCKING COMPR FOR,SUP-2368711,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PPICC PROV SOLO PED 3F SLEEVE MAXDELTA,SUP-2613524,CDM,C1751,HCPCS,0278,RC,,,,both,,,856.15,556.50,,,,,,,,,,,,,
ROD REPROC EXT FIX HYBRID 11X150 MM  CARBON FIBER,SUP-2188653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.62,493.10,,,,,,,,,,,,,
CATHETER BLLN DIL L75CM DIA5.3FR L20MM DIA4MM .035IN WIRE,SUP-2147605,CDM,C1725,HCPCS,0272,RC,,,,both,,,670.83,436.04,,,,,,,,,,,,,
CATHETER ANGIO 5FR L65CM PERIPH HYDRPHLC C2 SHP GLDECATH,SUP-2385162,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.52,112.79,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT ZHCPRESSFIT] ZIMMER BIOMET INC],SUP-2212729,CDM,C1776,CPT,0278,RC,,,,both,,,12674.61,8238.50,,,,,,,,,,,,,
SEAL BNE CEM SZ 1 4 FEM PRSSURING PRSS FIT DEF,SUP-2375320,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
INTRODUCER SHTH J TIP 0.038 IN 10.5 FRX25 CM HYDRPHLC COAT,SUP-2740679,CDM,C1892,HCPCS,0272,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
PROBE SURG GUIDEWIRE 1.6 MM ACUTRK 2,SUP-2525724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE L80MM 5 H ST R ANTLAT DST TIB S STL LO PROF NEUT,SUP-2185943,CDM,C1713,HCPCS,0278,RC,,,,both,,,4558.31,2962.90,,,,,,,,,,,,,
COMPONENT TIB BASE HNG W/ PIN,SUP-2304394,CDM,C1776,CPT,0278,RC,,,,both,,,5746.20,3735.03,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC DBM CRUNCH,SUP-2913355,CDM,C1713,HCPCS,0278,RC,,,,both,,,7714.98,5014.74,,,,,,,,,,,,,
PLATE ORTHO C TUBE X SH15MM BRG T15MM CP TITANIUM,SUP-2681868,CDM,C1713,HCPCS,0278,RC,,,,both,,,1808.11,1175.27,,,,,,,,,,,,,
SCREW BNE POLYAX 6.5X44 MM XIA,SUP-2319334,CDM,C1713,HCPCS,0278,RC,,,,both,,,2954.74,1920.58,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.522,SUP-2860203,CDM,C1713,HCPCS,0278,RC,,,,both,,,35383.40,22999.21,,,,,,,,,,,,,
INSTRUMENT KIT PLN PT SPEC LINEAR DISTRCTN,SUP-2860258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11930.74,7754.98,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.4MM FLX PIN W/ SUT EYE,SUP-2120934,CDM,C1769,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
GRAFT HUM TISS 5X5CM THK0.4-1MM MESHED REMODELABLE ACELLULAR,SUP-2225421,CDM,C1713,HCPCS,0278,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
KIT THROMCTMY INDIGO SYS LIGHTNING L 115 CM DIA,SUP-2550575,CDM,C1757,HCPCS,0272,RC,,,,both,,,21006.60,13654.29,,,,,,,,,,,,,
TAP SURG DIA7MM 2 LD SCR,SUP-2256861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
BIT DRL L85MM DIA2.7MM JCBS CHK FOR SM FRAG SYS,SUP-2187237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,214.59,139.48,,,,,,,,,,,,,
BIT DRILL 4.3X125MM SGL USE STRL,SUP-2152549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,175.40,114.01,,,,,,,,,,,,,
GUIDEWIRE FIX L6IN DIA0.045IN DBL TRCR,SUP-2319459,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
SET NDL 15GA L15MM STBL KT FOR IO VASC ACCS SYS EZ-IO,SUP-2383215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.19,314.72,,,,,,,,,,,,,
CANNULA SURG W/ STOPCOCK 70 MM 3.2 MM IRRIGATION OBTUTATOR,SUP-2794069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.32,383.06,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM DIA2MM VAGUS NRV BPLR HELCL ELEC,SUP-2175908,CDM,C1778,HCPCS,0278,RC,,,,both,,,13310.46,8651.80,,,,,,,,,,,,,
FILTER VASC CATH L48CM INTRO 7FR VENA CAVA NIT SNF/SL FEM,SUP-2127809,CDM,C1880,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
SCREW BNE LAG COMPR ROD,SUP-2644793,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.70,885.75,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.4 MM CRANIOMAXILLOFACIAL EMER ST 5PK,SUP-2884112,CDM,C1713,HCPCS,0278,RC,,,,both,,,1479.57,961.72,,,,,,,,,,,,,
SHELL ACET CLUS H ACUMATCH A SER 46,SUP-2221838,CDM,C1776,CPT,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 2 ML STR OSSEOFLEX OCP0201,SUP-2516668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
DARBEPOETIN ALFA 150 MCG/0.3ML IJ SOSY,RX-131231,CDM,J0881,HCPCS,0636,RC,55513-0027-04,NDC,,both,0.3,ML,3425.00,2226.25,,,,,,,,,,,,,
SCREW BNE SD 2X8 MM CRUCFRM AUTO DRV,SUP-2319380,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.87,75.32,,,,,,,,,,,,,
SYSTEM RETRV 15/15MM 12MM PRT INZII,SUP-2119646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER CV KT 8 FRX16 CM DL PRESSURE INJ ARROWG+ARD BLU +,SUP-2763375,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.86,286.56,,,,,,,,,,,,,
VERSACROSS STEERABLE SHEATH 8.5F 0.035IN ID LG CURL D0 DILATOR CRV,SUP-2857960,CDM,C1766,CPT,0272,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 5CC DEMINERALIZED BONE MATRIX GEL REVERSE PHASE MEDIUM STIMUBLAST,SUP-2120747,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 5FRX12CM SHTH W/ 0.038 IN GWIRE,SUP-2355476,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
SCREW BNE L115MM DIA3.5MM STD CORT S STL ST NONCANNULATED,SUP-2183565,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.42,52.92,,,,,,,,,,,,,
WEDGE FEM L10MM POST KNEE PRI PRESSFIT LEGION,SUP-2346392,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER GUID AXS CATLYST 7 L 115 CM PROX/DSTL OD,SUP-2715843,CDM,C1887,HCPCS,0272,RC,,,,both,,,6349.08,4126.90,,,,,,,,,,,,,
SHUNT VLV SINGLE PRESSURE 9X29 CM 19 CM H2O 2 CONN PAEDIGAV,SUP-2846923,CDM,C1889,HCPCS,0278,RC,,,,both,,,5525.43,3591.53,,,,,,,,,,,,,
CONNECTOR SHFT FLX CANN QUIK CPL FOR JCBS CHK,SUP-2188078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2012.74,1308.28,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2.4X10 MM MANDIBULAR 20/PK TITANIUM N,SUP-2842289,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.53,237.59,,,,,,,,,,,,,
COUNTERSINK IFS W/HANDLE,SUP-2400071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MUSTANG L 75 CM BALLOON L 40 MM DIA 4 MM,SUP-2145426,CDM,C1725,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
DILATOR URET 6-10FR L70CM HYDRGEL DIL 1 STP TAPR NOTTINGHAM,SUP-2139729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.56,246.06,,,,,,,,,,,,,
LEAD PACE L 52 CM SIL STEROID ENDOCARD RT VENTRICULAR PASS,SUP-2140102,CDM,C1898,HCPCS,0275,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BIT DRL 24902008] WRIGHT MEDICAL TECHNOLOGY INC],SUP-2397215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC Pt Adl Training 15min,PX-4409753500,CDM,97535,CPT,0440,RC,,,,both,,,174.00,113.10,,,,,,,,,,,,,
WIRE FIX 3X160 MM KIRSCHNER,SUP-2451413,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE METATRSL GALAXY FIX GEM LTX,SUP-2875650,CDM,C1713,HCPCS,0278,RC,,,,both,,,9553.17,6209.56,,,,,,,,,,,,,
RING ANNULPLSTY 28MM MEMO 3D,SUP-2352688,CDM,C1889,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
HC Ot Paraffin Bath,PX-4309701800,CDM,97018,CPT,0430,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
SHUNT VENTRICULOPERTIONEAL REG W/O RESVR N PROGRAMMABLE,SUP-2244307,CDM,C1889,HCPCS,0278,RC,,,,both,,,2597.41,1688.32,,,,,,,,,,,,,
SHAFT DRVR CANN T10 HEXALOBE,SUP-2122472,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE LADDER 43X0.6 MM NEURO 5X2 HOLE CRV STRL LEVEL 1,SUP-2486606,CDM,C1713,HCPCS,0278,RC,,,,both,,,1219.45,792.64,,,,,,,,,,,,,
BASKET STONE RETRV SUR CATCH 11MM 3X2 BSKT 24 FR X 120 CM,SUP-2312750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,608.34,395.42,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 10X11-16 MM PRESERVON TRICORT CANC,SUP-2740823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1941.40,1261.91,,,,,,,,,,,,,
HC NM 3 Phase Bone Scan,PX-3417831500,CDM,78315,CPT,0341,RC,,,,inpatient,,,3524.00,2290.60,,,,,,,,,,,,,
PLATE BONE L62MM 5 H LT POSTEROLATERAL DSTL FIBULAR VAR ANG,SUP-2349819,CDM,C1713,HCPCS,0278,RC,,,,both,,,4477.33,2910.26,,,,,,,,,,,,,
GRAFT 10ML PUTTY NOVABONE,SUP-2307534,CDM,C9359,HCPCS,0278,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-143502,CDM,6370000000,HCPCS,0637,RC,00378-0872-16,NDC,,both,1,UN,200.80,130.52,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 25 MG PO TABS,RX-4397,CDM,6370000000,HCPCS,0637,RC,50742-0184-25,NDC,,both,1,UN,9.00,5.85,,,,,,,,,,,,,
HC So Tiagubine,PX-3018019966,CDM,80199,CPT,0301,RC,,,,both,,,92.00,59.80,,,,,,,,,,,,,
BIT DRL CANN STD 2.5 MM 4.7 MM TAPR ACUTRK,SUP-2107356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
CUTTER OPHTH 19GA IOL PACKER CHANG,SUP-2304862,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
PROBE L12CM OD10GA MAMTOM REVOLVEST,SUP-2195619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
SHIELD PROTCT LO PROF SHT FOR T4 HLMT SYS,SUP-2366928,CDM,V2632,HCPCS,0276,RC,,,,both,,,34.51,22.43,,,,,,,,,,,,,
CATHETER EXT WRK CHAN 90 EDGE,SUP-2381748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
ANCHOR SUTURE SCR IN 1-0 6.5 MM TWST AP BLU,SUP-2761993,CDM,C1713,HCPCS,0278,RC,,,,both,,,1321.94,859.26,,,,,,,,,,,,,
WALKER PNEUMAT DLX L,SUP-2276721,CDM,L4361,HCPCS,0274,RC,,,,both,,,101.30,65.84,,,,,,,,,,,,,
TI STERNAL LOCKING DOUBLE-T,SUP-2823425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3234.83,2102.64,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 80 CM BALLOON L 80 MM DIA 5,SUP-2141861,CDM,C1725,HCPCS,0272,RC,,,,both,,,2320.46,1508.30,,,,,,,,,,,,,
LINER ACET OD64MM ID40MM +4MM OFFSET HIP GVF POLYETH TI,SUP-2250283,CDM,C1776,CPT,0278,RC,,,,both,,,11224.87,7296.17,,,,,,,,,,,,,
RING EXT FIX APCL SEW CENTERING,SUP-2356025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.47,1275.61,,,,,,,,,,,,,
PROBE ES L230CM CHN 28MM STR HEMSTAS REUSE HEATPRBS,SUP-2436501,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1342.10,872.36,,,,,,,,,,,,,
CATHETER DRNGE 10FR L30CM UNIV NIT LOK PGTL NAVARRE,SUP-2128418,CDM,C1729,HCPCS,0272,RC,,,,both,,,259.52,168.69,,,,,,,,,,,,,
WIRE FIXATION 32 GAX500 MM NEEDLE TITANIUM STERILE,SUP-2838463,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.98,302.89,,,,,,,,,,,,,
FORCEP SURG BPLR BI PLR VEO DISP,SUP-2800756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
ESOMEPRAZOLE MAGNESIUM 20 MG PO CPDR,RX-29745,CDM,6370000000,HCPCS,0637,RC,16714-0979-01,NDC,,both,1,UN,5.50,3.57,,,,,,,,,,,,,
SCREW BNE L 60 MM DIA 4 MM SHRT TI CANN HD NS LEOS,SUP-2931493,CDM,C1713,HCPCS,0278,RC,,,,both,,,814.42,529.37,,,,,,,,,,,,,
RING DIA155MM ALUM,SUP-2463278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4031.76,2620.64,,,,,,,,,,,,,
CATHETER GUID CELLO TOT L 100 CM EFFECTIVE L 92 CM OD 0.118,SUP-2277833,CDM,C1887,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
TWIST DRILL15X115MM W/NOTCH9MM STOP,SUP-2682163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.81,326.83,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 CM DIA18 X 9 MM THK 0.49 MM,SUP-2462938,CDM,L8670,HCPCS,0278,RC,,,,both,,,2492.44,1620.09,,,,,,,,,,,,,
PLATE BNE L100MM 5 H RIG SPN FOR 45MM SCR L FRAG SYS,SUP-2411395,CDM,C1713,HCPCS,0278,RC,,,,both,,,652.02,423.81,,,,,,,,,,,,,
SUPPORT KNEE THGH CIRC 12 15IN XSM SLIP ON NEOPRENE OPN PAT,SUP-2150846,CDM,L1810,HCPCS,0274,RC,,,,both,,,69.71,45.31,,,,,,,,,,,,,
PIN BONE FIXATION L30MM OD3.2MM NON LOCKING RESORBABLE SMOOT,SUP-2855300,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.34,335.62,,,,,,,,,,,,,
HC Telethx Isodose Plan Cplx,PX-3337730700,CDM,77307,CPT,0333,RC,,,,inpatient,,,3311.00,2152.15,,,,,,,,,,,,,
SCREW BNE L70MM DIA5MM CORT CONIC S STL ST CANN LOK,SUP-2184927,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
PROBE DOPP 20MHZ 280MML 2MM TIP MALEABLE DISP BIONET HNDL,SUP-2305970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
SYSTEM DRNGE W/ INTLNK NDLLSS INJ SITE DUET,SUP-2284564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.38,273.25,,,,,,,,,,,,,
RETRACTOR LAPSCP RNG DIA100MM W/ ALEXIS DEV GELPORT,SUP-2119623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1425.56,926.61,,,,,,,,,,,,,
GUIDEWIRE ARTHSCP L 3.2MM DISP FOR 4.5/8.5MM BEAMING SYS,SUP-2223913,CDM,C1769,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
STRIPS ILIUM TRICORT TRAD ALLGRFT 22X55 MM FRZ DRY,SUP-2294073,CDM,C1713,HCPCS,0278,RC,,,,both,,,5890.64,3828.92,,,,,,,,,,,,,
LPS PROX TIB REPLC COMP XSM,SUP-2513220,CDM,C1776,CPT,0278,RC,,,,both,,,21378.69,13896.15,,,,,,,,,,,,,
TRAY CHST TB 14FR L41CM 4 SIDEPRT SGL LUMN INTRO J TIP,SUP-2168192,CDM,C1729,HCPCS,0272,RC,,,,both,,,721.26,468.82,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 3.25X3.25 IN FNGR W/ BLB RADLUC,SUP-2276772,CDM,L3933,HCPCS,0272,RC,,,,both,,,3.89,2.53,,,,,,,,,,,,,
GRAFT HUM TISS 22X12X22MM WDG EVANS FOR ANAT RECON ALLOSYNC,SUP-2120760,CDM,C1713,HCPCS,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
IMPLANT OPHTH NORTH CAROLINA EYE BNK,SUP-2309109,CDM,V2785,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
CATHETER DRAINAGE RESOLV L 25 CM DIA 8.5 FR GUIDEWIRE 0.038,SUP-2303377,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.25,136.66,,,,,,,,,,,,,
ANCHOR ORTH HUM LG UNCEMENTED,SUP-2440776,CDM,C1776,CPT,0278,RC,,,,both,,,14327.82,9313.08,,,,,,,,,,,,,
GRAFT HUM TISS 200MM TISS FRZN SEMITENDINOSIS AND GRACILIS,SUP-2137248,CDM,C1762,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SYSTEM STIM BONE HEALING BTTRY OPERATED AC ADPT,SUP-2135919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6179.52,4016.69,,,,,,,,,,,,,
HEAD FEM 12/14 TAPR PRI MTL ON POLY S STL 22MM DIA -3.5 NK,SUP-2205782,CDM,C1776,CPT,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
CLIP ANEURYSM 3 5/3MM MINI PERMANENT FENESTRATED 90 YASARGIL,SUP-2825541,CDM,C1889,HCPCS,0278,RC,,,,both,,,1196.84,777.95,,,,,,,,,,,,,
PLATE BONE L58MM 3 H LT PROX MEDL TIB TI FOR 3.5MM SCR,SUP-2418113,CDM,C1713,HCPCS,0278,RC,,,,both,,,4320.64,2808.42,,,,,,,,,,,,,
HEAD HUM H15MM DIA40MM CO CHROM ALLOY BPLR STD OFFSET REV,SUP-2193856,CDM,C1776,CPT,0278,RC,,,,both,,,7392.25,4804.96,,,,,,,,,,,,,
LINER ACET OD36MM HIP RNG RECON COMP HK ROOF IMP GANZ,SUP-2212025,CDM,C1776,CPT,0278,RC,,,,both,,,5592.34,3635.02,,,,,,,,,,,,,
PLATE BNE STR FIVE HOLE STRATUM,SUP-2607253,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.16,1608.20,,,,,,,,,,,,,
BRACE ORTH ABDUCTN CTRL HIP ORTHOSIS CTRL,SUP-2388158,CDM,L1680,HCPCS,0274,RC,,,,both,,,3006.05,1953.93,,,,,,,,,,,,,
CATHETER GUID JUMBO 6 FRX80 CM CATLYST CONCIERGE,SUP-2798609,CDM,C1887,HCPCS,0272,RC,,,,both,,,1211.66,787.58,,,,,,,,,,,,,
COUNTERSINK SURG L 50 MM DIA1.3 MM SCREW DIA 3/4 MM NS DISP,SUP-2909578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,752.88,489.37,,,,,,,,,,,,,
BUNDLE CATH ACCESSORY FOR PRESEP CATH,SUP-2270771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,254.69,165.55,,,,,,,,,,,,,
PLATE BNE L197MM THK38MM 10 H L MED DST TIB S STL NEUT,SUP-2185221,CDM,C1713,HCPCS,0278,RC,,,,both,,,4154.28,2700.28,,,,,,,,,,,,,
INSTRUMENT SET LNG BASIC T2,SUP-2460755,CDM,C1713,HCPCS,0278,RC,,,,both,,,31413.82,20418.98,,,,,,,,,,,,,
SHEATH DIL BYRD 10 FR TELSCP POLYPR,SUP-2638735,CDM,C1893,HCPCS,0272,RC,,,,both,,,692.12,449.88,,,,,,,,,,,,,
PLATE BONE CONTOUR MESHED 200X200X0.4 MM CRANIAL RIGID TITAN,SUP-2837706,CDM,C1713,HCPCS,0278,RC,,,,both,,,28399.42,18459.62,,,,,,,,,,,,,
DISTRACTOR SURG COMPRESSOR,SUP-2279590,CDM,C1713,HCPCS,0278,RC,,,,both,,,5103.13,3317.03,,,,,,,,,,,,,
PLATE BNE W9XL33MM THK1MM 3 H TI 1 3 TBLR W CLLR LOK COMPR,SUP-2190946,CDM,C1713,HCPCS,0278,RC,,,,both,,,448.42,291.47,,,,,,,,,,,,,
PLATE BNE L208MM THK37MM 16 H BILAT S STL STR LO PROF RIG,SUP-2177148,CDM,C1713,HCPCS,0278,RC,,,,both,,,2817.87,1831.62,,,,,,,,,,,,,
PLATE BNE L130MM THK37MM 10 H R J S STL LO PROF RIG RECON,SUP-2177159,CDM,C1713,HCPCS,0278,RC,,,,both,,,2424.17,1575.71,,,,,,,,,,,,,
BIT DRILL DIA26MM STAINLESS STEEL FOR 4MM HALF PIN,SUP-2586489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,724.05,470.63,,,,,,,,,,,,,
FIBER LT VIS TRANSCUTANEOUS XPRESS PATHASSIST,SUP-2217801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2X12 MM MANDIBULAR 20/PK TITANIUM NON,SUP-2842278,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.21,165.24,,,,,,,,,,,,,
SET PUMP IMPELLA LD AIC,SUP-2106267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
STE 1ST MTP FUSION PLT LT SM,SUP-2588794,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.40,1248.91,,,,,,,,,,,,,
SCREW BONE LOCKING 4.5X105 MM CORTICAL TIBIAL FEMUR SELFTAPP,SUP-2837312,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.34,922.57,,,,,,,,,,,,,
PLATE BNE L255MM 95DEG SUPCNDYL TB FREE LOK,SUP-2197720,CDM,C1713,HCPCS,0278,RC,,,,both,,,2230.66,1449.93,,,,,,,,,,,,,
PLATE BONE 135DG 5 HOLE STNLSS STEEL FMRL BLTRL STNDRD TUBE,SUP-2500321,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.17,908.16,,,,,,,,,,,,,
JOINT TOE CANN PHLANG HEMI SYS BIOMOTION,SUP-2664033,CDM,C1776,CPT,0278,RC,,,,both,,,14016.96,9111.02,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0025IN TIP L3CM PTFE FLX STR FIX,SUP-2141738,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.60,25.74,,,,,,,,,,,,,
NEEDLE SURGICAL L6 3/8IN 20DEG PERFORATING MCGEE,SUP-2810175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,450.24,292.66,,,,,,,,,,,,,
HC Removal Iud,PX-4505830100,CDM,58301,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SHEATH ENDOSCP CATH 7FR L90CM DEFLECTION L9MM 2.3MM 180DEG,SUP-2298501,CDM,C1887,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT MAGNA DIA25 MM SEW RNG DIA 36 MM,SUP-2214302,CDM,C1713,HCPCS,0278,RC,,,,both,,,22881.18,14872.77,,,,,,,,,,,,,
IMPLANT NEUROSTIMULATOR ECOIN TIBIAL -  RSFH ONLY,SUP-2862632,CDM,C1767,HCPCS,0278,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
COMPONENT GLEN PEGGED SHLDR ANTI ROT,SUP-2388566,CDM,C1776,CPT,0278,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
CLAMP SURG L0.25IN SPINE BND MNRCH,SUP-2256195,CDM,C1713,HCPCS,0278,RC,,,,both,,,3338.07,2169.75,,,,,,,,,,,,,
DEVICE INT FIX ENDOBUTTON,SUP-2341633,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
COMPONENT PAT 8MM 30MM 1 DOME 3 PEG GEM,SUP-2262254,CDM,C1776,CPT,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
NAIL IM L140MM DIA7MM HUM TI CANN LOK RG BENT T2,SUP-2369206,CDM,C1713,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST ADJ POS RIGID SUPP PREFABRICATED,SUP-2435610,CDM,L1833,HCPCS,0272,RC,,,,both,,,1950.10,1267.56,,,,,,,,,,,,,
ALLOGRAFT BNE TIB DSTL,SUP-2321906,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X36 MM 4 HOLE TI,SUP-2474353,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
DEVICE INFL 60ML 12ATM CONVENIENT LOK REL HNDL HI PRSS FLX,SUP-2302540,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG PO TABS,RX-131997,CDM,6370000000,HCPCS,0637,RC,61958-1901-01,NDC,,both,1,UN,632.50,411.12,,,,,,,,,,,,,
GRAFT HUM TISS 17MM 200MM CORT STRUT FRZN,SUP-2115987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
PUMP INFUSION NACL FOR DIAMONDBACK 360 ORBIT ATHRCTMY SYS NS,SUP-2892841,CDM,C1724,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
SYSTEM TOT KNEE NAVIGATION INST RENTAL,SUP-2361518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1879.29,1221.54,,,,,,,,,,,,,
COMPONENT TIB LNG KNEE STEM REMEDY,SUP-2424083,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
CATHETER DLYS L40CM L23CM OD13.5FR 2 LUMN VITACUF ANTIMIC,SUP-2127708,CDM,C1881,HCPCS,0278,RC,,,,both,,,1045.15,679.35,,,,,,,,,,,,,
HC So Dna/Rna Sequencing,PX-3008715366,CDM,87153,CPT,0300,RC,,,,both,,,364.00,236.60,,,,,,,,,,,,,
CABLE CATHETER ELECTROPHYSIOLOGY 243CM 4-PIN CONNECTOR YELLOW,SUP-2281834,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
WIRE FIX L270MM DIA25MM LNG MIDFT HD THRD FOR ORTHOLOC 3DI,SUP-2398612,CDM,C1776,CPT,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
HC Automated Leukocyte Count,PX-3058504800,CDM,85048,CPT,0305,RC,,,,both,,,150.00,97.50,,,,,,,,,,,,,
PLATE BONE L172MM 10 H S STL NAR SELF COMPR,SUP-2198602,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.17,235.41,,,,,,,,,,,,,
NAIL IM L340MM OD11MM 135DEG BLU TI LT PROX HIP BEND NK,SUP-2371012,CDM,C1713,HCPCS,0278,RC,,,,both,,,4765.26,3097.42,,,,,,,,,,,,,
CATHETER THOR 32FR L16IN CLR PVC THERMOSENSITIVE SHRP TRCR,SUP-2154959,CDM,C1729,HCPCS,0272,RC,,,,both,,,147.23,95.70,,,,,,,,,,,,,
SET TRAUMA FIXATION 3.5MM DISTAL HUMERAL F/LCP PLATE,SUP-2177062,CDM,C1713,HCPCS,0278,RC,,,,both,,,190183.33,123619.16,,,,,,,,,,,,,
SAW SURG 0.060 IN CAPTURE WIDE SLOT LCS,SUP-2454060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3306.42,2149.17,,,,,,,,,,,,,
PROSTHESIS OSSCLR TOTAL 2MM2.5MM DIA HEAD 0.8MM2.3MM DST E,SUP-2681465,CDM,L8613,CPT,0278,RC,,,,both,,,1524.82,991.13,,,,,,,,,,,,,
PLATE BONE W35XL35MM THK0.5MM ORBIT FLR RAP RESRB FOR 1.5MM,SUP-2194079,CDM,C1713,HCPCS,0278,RC,,,,both,,,3105.77,2018.75,,,,,,,,,,,,,
IMPLANT BRST RND SIL GEL HI STRENGTH COHESIVE TEXT VOL 695CC,SUP-2339908,CDM,C1789,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
HC Assay of Sex Hormone Binding Globulin,PX-3018427000,CDM,84270,CPT,0301,RC,,,,inpatient,,,465.00,302.25,,,,,,,,,,,,,
HEAD RAD M PROS CO CHROM,SUP-2349031,CDM,C1776,CPT,0278,RC,,,,both,,,3194.89,2076.68,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-4 MM 30 CC FD CRUSH CANC,SUP-2743394,CDM,C1713,HCPCS,0278,RC,,,,both,,,2345.58,1524.63,,,,,,,,,,,,,
EASYFUSE STAPLE 15X20 NITINOL 2-LEG,SUP-2830230,CDM,C1713,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
BUR SURG DIAMOND 3 MM MTCH HD FOR MIS NEURO,SUP-2365186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,601.37,390.89,,,,,,,,,,,,,
IMPLANT OSS L2-5.6MM 2.5-3.5MM TI ADJ OFFSET PART AD ALTO,SUP-2232504,CDM,L8613,CPT,0278,RC,,,,both,,,1308.19,850.32,,,,,,,,,,,,,
CURETTE SURG COBB 3-0 11 IN 3.5X2 MM BNE STR SLD KNURLED,SUP-2473124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,666.47,433.21,,,,,,,,,,,,,
SPLINT ELBOW/KNEE M L13.5IN FOR 10-12IN VLY MESH COT LINING,SUP-2324946,CDM,L3702,HCPCS,0274,RC,,,,both,,,78.44,50.99,,,,,,,,,,,,,
RING EXT FIX L160MM HALF FOR SIDEKCK FREE CIR FIX,SUP-2400649,CDM,C1713,HCPCS,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
PLATE BNE CORONOID LG BUTTRESS EVOLVE TRIAD,SUP-2535909,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
ROD EXT FIX L200MM DIA5MM C CONN YEL HOFFMANN II MRI,SUP-2372488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
KIT REP SM PRELD 2-0 FIBERWIRE A SM KNOT PUSH DISP MENIS,SUP-2121189,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
SIGMA HP UNI POST LAT SHM 1-3,SUP-2513396,CDM,C1776,CPT,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
SCREW BONE L44MM OD4MM GRN FOREFOOT MIDFOOT HINDFOOT ANK,SUP-2320931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1000.09,650.06,,,,,,,,,,,,,
IMPLANT FACE L 42 X W 41 MM THK 0.6 MM SCREW DIA 0.5 MM,SUP-2883459,CDM,C1713,HCPCS,0278,RC,,,,both,,,3778.42,2455.97,,,,,,,,,,,,,
ROD EXT FIX L 550 MM DIA 11 MM CARBON FIBER NS DISP,SUP-2908933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.81,284.58,,,,,,,,,,,,,
NAIL IM 11MMX38CM RT FEM VERSANAIL,SUP-2412483,CDM,C1713,HCPCS,0278,RC,,,,both,,,5209.26,3386.02,,,,,,,,,,,,,
EXPANDER TISSUE MED HEIGHT TE SMOOTH 800CC,SUP-2718064,CDM,C1889,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
TRAY INTRO DIA 6 FR NDL 18/22/25 GA TUOHY BORST STRL,SUP-2877844,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0250,RC,00264-1800-32,NDC,,both,100,ML,23.00,14.95,,,,,,,,,,,,,
CARISOPRODOL 350 MG PO TABS,RX-1395,CDM,6370000000,HCPCS,0637,RC,50228-0109-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER THORACENTESIS SET PEDIATRIC 6.3 FRX19 CM 6 SIDEPRT,SUP-2760154,CDM,C1729,HCPCS,0272,RC,,,,both,,,676.29,439.59,,,,,,,,,,,,,
GALILEO TROCH NAIL TRAY 10MMX130 DEGREE,SUP-2816339,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN FRIC,SUP-2388218,CDM,L5812,HCPCS,0272,RC,,,,both,,,1485.85,965.80,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM 200M HUM AMNIO MEMBRN BIOFIX +,SUP-2417047,CDM,C1762,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
VLP MINIMOD 2.4 TALUS PLT MDL T RIGHT ST,SUP-2820413,CDM,C1713,HCPCS,0278,RC,,,,both,,,4096.60,2662.79,,,,,,,,,,,,,
PLATE BNE L112MM 4 H R ANTEROMEDIAL DST TIB S STL VAR ANG LO,SUP-2177656,CDM,C1713,HCPCS,0278,RC,,,,both,,,5516.26,3585.57,,,,,,,,,,,,,
SCREW SPNL POLYAX 8.5X110 MM FEN FLUT EXT TAB EVEREST,SUP-2533772,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC Repair Blood Vessel Direct Hand Finger,PX-4503520700,CDM,35207,CPT,0450,RC,,,,both,,,8262.00,5370.30,,,,,,,,,,,,,
SHEATH INTRO INPUT SSV L 13 CM DIA 7 FR DIL L 20 CM,SUP-2174531,CDM,C1894,HCPCS,0272,RC,,,,both,,,1286.77,836.40,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.025 IN TAPR L 7 CM FLX TIP L 2,SUP-2167650,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.27,23.58,,,,,,,,,,,,,
BIT DRL L300MM DIA10MM CANN TAPR L QUIK CPL FOR DH DC TFN,SUP-2178963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1400.47,910.31,,,,,,,,,,,,,
CATHETER ANGIOPLSTY GATEWY L 90 CM BALLOON L 15 MM DIA2 MM,SUP-2361855,CDM,C1725,HCPCS,0272,RC,,,,both,,,3466.56,2253.26,,,,,,,,,,,,,
BIT DRILL EXTRACTION SZ 7.5 MM SCREW DIA 6.6-7.5 MM STRL,SUP-2913513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2748.07,1786.25,,,,,,,,,,,,,
SCREW BNE PART THRD 2.7X34 MM TI MINICAN,SUP-2534675,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.57,413.77,,,,,,,,,,,,,
KIT INT FIX ACL INSTR DISP,SUP-2420184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.52,683.49,,,,,,,,,,,,,
LINER BPLR OD57-60MM ID28MM POLYETH CONVENE,SUP-2345767,CDM,C1776,CPT,0278,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
DRILL SURG HI SPD COOLFLEX,SUP-2607686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17503.62,11377.35,,,,,,,,,,,,,
IMPLANT TOE JT SZ 40 SIL FLX FUTURA,SUP-2244043,CDM,C1776,CPT,0278,RC,,,,both,,,4656.87,3026.97,,,,,,,,,,,,,
PLATE BNE L72MM SHT 1 H ST R MED DST HUM S STL VAR ANG FOR,SUP-2177589,CDM,C1713,HCPCS,0278,RC,,,,both,,,4258.28,2767.88,,,,,,,,,,,,,
PIN POSITIONING 5.0 MM VA STERILE,SUP-2546199,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.34,386.97,,,,,,,,,,,,,
INSERT HUM LAT 36X+6 MM SHLDR GLEN AEQUALIS REVERSED,SUP-2431490,CDM,C1776,CPT,0278,RC,,,,both,,,3573.32,2322.66,,,,,,,,,,,,,
PIN GUID L2.5IN DIA0.062IN FOR FT PLATING SYS EXTREMILOCK,SUP-2319606,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
DILATOR NEUROMONITORING W 22 MM LAT LUMBAR INSUL TRIANG,SUP-2884782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
BRACE KNEE AD UNIV FOAM POSTOP 1 SZ FIT MOST AVG LEN FASTEN,SUP-2195290,CDM,L1810,HCPCS,0272,RC,,,,both,,,310.23,201.65,,,,,,,,,,,,,
I/B II KNEE TIB TRAY 69 PLUS 60 A/P X 81MM M/L,SUP-2502005,CDM,C1776,CPT,0278,RC,,,,both,,,10148.48,6596.51,,,,,,,,,,,,,
PIN BNE FIX THRD L 50 MM DIA2.5 MM SHLDR SHRT SHANK NS APEX,SUP-2909058,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.72,55.72,,,,,,,,,,,,,
SCREW BONE L11MM OD2.5MM FOREFOOT CANN SH THRD HDLSS SHRP,SUP-2320873,CDM,C1713,HCPCS,0278,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
HC Ot Elec Stim Unattended,PX-4309701400,CDM,97014,CPT,0430,RC,,,,outpatient,,,206.00,133.90,,,,,,,,,,,,,
STENT CORONARY ION MR L 8 MM DIA2.5 MM CATH L 144 CM DIA,SUP-2144863,CDM,C1874,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PLATE BNE 2 HOLE STR SM BNE ORTHOLOC 3DI,SUP-2517176,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
HC Thoracentesis WO Imaging,PX-7613255400,CDM,32554,CPT,0761,RC,,,,both,,,1901.00,1235.65,,,,,,,,,,,,,
FOOTPLATE BNE L180MM DBL ROW ST TL HEX,SUP-2316310,CDM,C1713,HCPCS,0278,RC,,,,both,,,6764.31,4396.80,,,,,,,,,,,,,
SET INTRO SHTH 12FR L22CM OBT 7FR L26CM CATH 5FR L50CM,SUP-2171199,CDM,C1769,HCPCS,0272,RC,,,,both,,,185.39,120.50,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5X26X6 MM 4 HOLE RAPID RESORBABLE STER,SUP-2838545,CDM,C1713,HCPCS,0278,RC,,,,both,,,705.56,458.61,,,,,,,,,,,,,
DRILL SURGICAL 4.5MM PROXIMAL CANNULATED,SUP-2878971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SHELL ACET HIP,SUP-2205431,CDM,C1776,CPT,0278,RC,,,,both,,,3784.96,2460.22,,,,,,,,,,,,,
IMPLANT STAP 0.6MM DIAM 4MM LEN PIST LOOP FLROPLAS S STL,SUP-2312535,CDM,L8613,CPT,0278,RC,,,,both,,,257.73,167.52,,,,,,,,,,,,,
BLADE SURG PLANNER 28 MM 3-PEG,SUP-2444440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
KIT TESSYS ACCESS DISP JOIMAX,SUP-2848833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PLATE BNE L23MM 4 H ST S STL LOK COMPR W SHT THRD DRL GUID,SUP-2177470,CDM,C1713,HCPCS,0278,RC,,,,both,,,870.22,565.64,,,,,,,,,,,,,
BLADE BNE MILL MED STRL MILL + LTX DISP,SUP-2859294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.98,1153.74,,,,,,,,,,,,,
GRAFT HUM TISS 2X3CM THN AMNION,SUP-2120772,CDM,C1762,CPT,0278,RC,,,,both,,,2708.25,1760.36,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN S STL PTFE J TIP FIX COR,SUP-2120088,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
URETEROSCOPE FLX DIGITAL 3.6 FRX670 MM 8.6 FR STD WISCOPE,SUP-2653928,CDM,C1747,HCPCS,0272,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-ENTERIC 20 FRX57.9 CM 7-10 CC MIC,SUP-2764443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.95,354.87,,,,,,,,,,,,,
STAPLER INT LN 75 MM ENDO GIA II,SUP-2129895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,726.72,472.37,,,,,,,,,,,,,
KNIFE SURG SERR AGG FOR SONOPET ULTRASONIC ASPIR,SUP-2363705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.25,1428.86,,,,,,,,,,,,,
ANCHOR SUT L24.5MM DIA4.75MM SELF PUNCHING BIO-SWIVELOCK SP,SUP-2121700,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
ROD PUSH DIA5.5MM,SUP-2211165,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.38,154.30,,,,,,,,,,,,,
BIT DRL L195MM DIA3.5MM TI QUIK CPL FOR NCB SYS,SUP-2204938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 101-159 MMX0.1 CM FD,SUP-2717857,CDM,C1762,CPT,0278,RC,,,,both,,,3565.82,2317.78,,,,,,,,,,,,,
STAPLE BNE COMPR 2X20 MM STP,SUP-2135433,CDM,C1713,HCPCS,0278,RC,,,,both,,,4257.84,2767.60,,,,,,,,,,,,,
CLAMP SPNL UNIV THORLUM TI BODY TRNSCONN 2 COR SM STAT USS,SUP-2193593,CDM,C1713,HCPCS,0278,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN MICRO 4SQCM,SUP-2866741,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
CEMENT BONE 10CC CA PHOS HA INJ FAST SET ISOTHERMIC RADPQ,SUP-2365156,CDM,C1713,HCPCS,0278,RC,,,,both,,,12075.06,7848.79,,,,,,,,,,,,,
RESORB X TAP FRCTN STOP STYLE 100MM LGTH 24MM F0R 15MM DRV,SUP-2679317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.52,432.59,,,,,,,,,,,,,
CATHETER URET LSR 3.0FRX115CM,SUP-2171264,CDM,C1758,HCPCS,0278,RC,,,,both,,,48.07,31.25,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX15 CM SHT TERM DL SET SOFT-LINE,SUP-2627330,CDM,C1752,HCPCS,0278,RC,,,,both,,,196.25,127.56,,,,,,,,,,,,,
PLATE SPNL ANTR CERV C-TEK MAXAN 14521008,SUP-2689239,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.509,SUP-2860191,CDM,C1713,HCPCS,0278,RC,,,,both,,,27013.42,17558.72,,,,,,,,,,,,,
HC Orbits Min 4 Views,PX-3207020000,CDM,70200,CPT,0320,RC,,,,both,,,1219.00,792.35,,,,,,,,,,,,,
PLATE 4.5MM LCP CONDYLAR 18 HOLES 386MM RIGHT STERILE,SUP-2547446,CDM,C1713,HCPCS,0278,RC,,,,both,,,5132.93,3336.40,,,,,,,,,,,,,
SCREW EXT FIX L150MM DIA5MM THRD L150MM S STL SELF DRL MR,SUP-2186985,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.77,300.15,,,,,,,,,,,,,
NAIL IM L380MM DIA13MM LT GRN L LAT FEM TI CANN LOK CRV,SUP-2179774,CDM,C1713,HCPCS,0278,RC,,,,both,,,5032.82,3271.33,,,,,,,,,,,,,
PLATE BONE L60MM 3 H S STL NAR SELF COMPR,SUP-2198595,CDM,C1713,HCPCS,0278,RC,,,,both,,,252.14,163.89,,,,,,,,,,,,,
CANNULA VEN LNG 25 FR UNCOATED HLS,SUP-2663482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.67,890.29,,,,,,,,,,,,,
PLATE BNE T 4 HOLE FLAT,SUP-2315927,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.14,1736.89,,,,,,,,,,,,,
SCREW BNE CRTX 2X30 MM FOR STARDRV SS NS,SUP-2183199,CDM,C1713,HCPCS,0278,RC,,,,both,,,142.93,92.90,,,,,,,,,,,,,
CATHETER ABLATN LG CURL 2-5-2 4 MM 7 FRX115 CM LIVEWIRE TC,SUP-2460148,CDM,C1733,HCPCS,0272,RC,,,,both,,,2172.88,1412.37,,,,,,,,,,,,,
COIL NEUROVASCULAR TARGET XL L 50 CM DIA12 MM,SUP-2368039,CDM,C1889,HCPCS,0278,RC,,,,both,,,5829.41,3789.12,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 60 MG MATRISTEM MICROMATRIX,SUP-2106471,CDM,Q4118,HCPCS,0636,RC,,,,both,,,423.52,275.29,,,,,,,,,,,,,
PLATE BNE THK05MM 2X2 H UNIV CRANIOMAXILLOFACIAL TI 3D MAL,SUP-2366229,CDM,C1713,HCPCS,0278,RC,,,,both,,,564.60,366.99,,,,,,,,,,,,,
RING SPNL TI LOK FOR VAR AXIS SCR,SUP-2193305,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
HC Chemo Infusion 1st Hour Chemo,PX-3359641300,CDM,96413,CPT,0335,RC,,,,both,,,881.00,572.65,,,,,,,,,,,,,
KNIFE NDL CATH 10FR L165CM DIATHERMIC RNG 10FR ACCSRY CHAN,SUP-2169844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
DRILL SURG BUCKINGHAM HND MED 5.9INL FTPLT RND HNDL STRGHT S,SUP-2637580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.41,208.27,,,,,,,,,,,,,
DISC ARTIFICIAL M W27XL34.5MM INTERVERTEBRAL LUMSACR CO,SUP-2163215,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
COLLAR CERV UNIV AD AIR VENT MIAMI OCCIAN,SUP-2276575,CDM,L0180,HCPCS,0274,RC,,,,both,,,373.44,242.74,,,,,,,,,,,,,
GRAFT HUM TISS W10-17XL10-17MM THK13-15MM TRICORT IL FRZ,SUP-2307142,CDM,C1762,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
COMPONENT TALAR SZ 4 UNIV POST PROX ANK JT CO CHROM POR SEMI,SUP-2252062,CDM,C1776,CPT,0278,RC,,,,both,,,8638.14,5614.79,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X4.25 MM MCGEE SS,SUP-2637755,CDM,L8613,CPT,0278,RC,,,,both,,,272.33,177.01,,,,,,,,,,,,,
"HC X-Ray, Thoracic Spine/4 V",PX-3207207400,CDM,72074,CPT,0320,RC,,,,inpatient,,,795.00,516.75,,,,,,,,,,,,,
BUR SURG L14CM DIA5MM BALL DMND L BOR MIDAS REX LEGEND,SUP-2277720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.00,254.80,,,,,,,,,,,,,
NAIL SURG L38MM DIA15MM HD FOR TRIATHLON REV KNEE SYS,SUP-2364726,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
ELECTRODE ELECSURG MONOPOLAR 5X400 MM FLAT HI FREQ LNG HK,SUP-2797664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1069.70,695.30,,,,,,,,,,,,,
PROSTHESIS OSS L 8 MM SHFT DIA 0.6 MM POLYCEL SS MALL TOT,SUP-2902035,CDM,L8613,CPT,0278,RC,,,,both,,,976.67,634.84,,,,,,,,,,,,,
SHORT NAIL 11X135-TROCHANTERIC,SUP-2371035,CDM,C1713,HCPCS,0278,RC,,,,both,,,2237.25,1454.21,,,,,,,,,,,,,
CATHETER ETER DRNGE RNG 83FR L50CM BILI DUCT,SUP-2167744,CDM,C1729,HCPCS,0272,RC,,,,both,,,172.10,111.86,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 45 CM DIA 6 MM EPTFE TRMPT GRAD WALL,SUP-2475717,CDM,C1768,CPT,0278,RC,,,,both,,,3899.25,2534.51,,,,,,,,,,,,,
HC Sickling RBC Reduction,PX-3058566000,CDM,85660,CPT,0305,RC,,,,inpatient,,,228.00,148.20,,,,,,,,,,,,,
LOOP ELECSURG 21FR CUT BPLR,SUP-2261122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1216.47,790.71,,,,,,,,,,,,,
DEVICE BNE COLLCTN STRL DISP GRAFTNET XL,SUP-2930403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SCREW BONE IMPL KNOTLESS PEEK 6.5MM OPUS SPEEDSCR,SUP-2342100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1378.15,895.80,,,,,,,,,,,,,
SEALER BPLR DIA2.3MM DISP AQUAMANTYS,SUP-2281803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1411.56,917.51,,,,,,,,,,,,,
POWERPORT M.R.I. SGL LUMEN DEVICE W/ 9.6FR ATTACHABL,SUP-2844949,CDM,C1778,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
DVR LOCK STANDARD R ST,SUP-2587115,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.72,1526.67,,,,,,,,,,,,,
CARBON FT PLT LNG 140MM FOR RNG FIX SYS,SUP-2365269,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 8 H MAXILLOFCL CRV,SUP-2909569,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.62,636.75,,,,,,,,,,,,,
SET INT FIX DIA18.5 MM TI NEURO 1 PK STRL DISP LORENZ,SUP-2935547,CDM,C1713,HCPCS,0278,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
STEM FEM L127X203MM DIA11MM LNG DST KNEE TI W/O POR BODY,SUP-2376441,CDM,C1776,CPT,0278,RC,,,,both,,,9404.93,6113.20,,,,,,,,,,,,,
CLAMP SPINE OFFSET FOR TENOR,SUP-2289282,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
BOOT ORTHOSIS FOR 7-9IN ANK FOAM STATIC FOR POS AND PRSS,SUP-2194762,CDM,L4396,HCPCS,0274,RC,,,,both,,,149.37,97.09,,,,,,,,,,,,,
GRAFT VASC TW 6 MMX70 CM RNG SFT WRP TUNN ATTCH ADVANTA VXT,SUP-2472721,CDM,C1768,CPT,0278,RC,,,,both,,,1449.14,941.94,,,,,,,,,,,,,
PLATE BNE L 180 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 14,SUP-2936290,CDM,C1713,HCPCS,0278,RC,,,,both,,,6093.48,3960.76,,,,,,,,,,,,,
WEDGE ANK W18MM D18MM THK8MM EVANS TECH TI PORUS BIOSYNC,SUP-2122989,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PLATE BNE W12XL135MM THK1MM 8 H BILAT TI SEMI TBLR LO PROF,SUP-2190706,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.10,205.46,,,,,,,,,,,,,
SHEATH INTRO PRELUDE ACT L 11 CM DIA 4.5 FR GUIDEWIRE L 50,SUP-2459148,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.38,17.15,,,,,,,,,,,,,
PLATE BONE MEDIAL COLUMN LEFT SHORT TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878229,CDM,C1713,HCPCS,0278,RC,,,,both,,,7755.80,5041.27,,,,,,,,,,,,,
GRAFT SYN H7.5XL20MM WDG BIOFOAM,SUP-2397880,CDM,C1713,HCPCS,0278,RC,,,,both,,,5099.36,3314.58,,,,,,,,,,,,,
POST SURG 5.9X28 MM RT LAPIDUS INCORE,SUP-2435483,CDM,C1713,HCPCS,0278,RC,,,,both,,,7303.83,4747.49,,,,,,,,,,,,,
HC Bx Breast 1st Lesion Strtctc,PX-3611908100,CDM,19081,CPT,0361,RC,,,,both,,,6190.00,4023.50,,,,,,,,,,,,,
SYSTEM EN ACCS TB 12FR L43IN CORTRAK 2,SUP-2236634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,191.10,124.21,,,,,,,,,,,,,
SCREW BNE 5.5X80MM CORT PROX SLD FT TIM,SUP-2412197,CDM,C1713,HCPCS,0278,RC,,,,both,,,542.18,352.42,,,,,,,,,,,,,
ALLOGRAFT BNE LG PARTICULATE 1-4 MM 5 CC FD GRND ORAGRAFT,SUP-2740856,CDM,C1713,HCPCS,0278,RC,,,,both,,,601.56,391.01,,,,,,,,,,,,,
HC Assay of Thyroxine Total,PX-3018443600,CDM,84436,CPT,0301,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
ANCHOR FIX L 18 MM DIA 5.5 MM TI INLINE NS,SUP-2895467,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
INDIGOTINDISULFONATE SODIUM 8 MG/ML IV SOLN,RX-159797,CDM,J9220,HCPCS,0636,RC,81284-0315-05,NDC,,both,5,ML,2300.00,1495.00,,,,,,,,,,,,,
BIT DRL 4.2MM DSTL SH,SUP-2316018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.45,520.29,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1275108FD1,SUP-2632804,CDM,C1751,HCPCS,0278,RC,,,,both,,,714.04,464.13,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 7 MMX10 CM 8 FRX75 CM EPTFE VIABAHN,SUP-2396506,CDM,C1874,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
SCREW BONE L28MM DIA5.5MM THRD L16MM STD CORT S STL ST SELF,SUP-2343633,CDM,C1713,HCPCS,0278,RC,,,,both,,,324.05,210.63,,,,,,,,,,,,,
COIL VASC RUBY POD PLAT TUNGSTEN ALLOY INIT STRL,SUP-2487075,CDM,C1889,HCPCS,0278,RC,,,,both,,,31368.60,20389.59,,,,,,,,,,,,,
PLATE TI LOCKING 1.3MM PHALANGE BASE 2H HEAD 5H SHAFT STER,SUP-2546882,CDM,C1713,HCPCS,0278,RC,,,,both,,,1755.79,1141.26,,,,,,,,,,,,,
PACEMAKER CARD 10.4ML W50XH46MM THK6MM IS-1 CONN,SUP-2356460,CDM,C1785,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PIN BNE MEMOFIX STPL SYS 2 MM,SUP-2244269,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER NEPHROSTOMY PIG 16 FRX35 CM MCOT PERCFLX,SUP-2147758,CDM,C1729,HCPCS,0272,RC,,,,both,,,202.81,131.83,,,,,,,,,,,,,
REAMER SURG ACORN 11MM,SUP-2249539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
PLATE BNE NAR 4.5X295 MM 18 HOLE SS DCP,SUP-2569173,CDM,C1713,HCPCS,0278,RC,,,,both,,,468.02,304.21,,,,,,,,,,,,,
GRAFT HUMAN TSSUE 30CM FRZE DRIED LATEX FREE ST SNGLE USE,SUP-2727658,CDM,C1762,CPT,0278,RC,,,,both,,,1474.70,958.55,,,,,,,,,,,,,
PLATE BNE L184MM 13 H NONSTERILE R ANTLAT DST TIB S STL LO,SUP-2185958,CDM,C1713,HCPCS,0278,RC,,,,both,,,4180.91,2717.59,,,,,,,,,,,,,
PLATE BNE 1/3 TBLR 37 MM 3 HOLE NS LTX,SUP-2861939,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.65,113.52,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 9 INX2 MM STRL DISP,SUP-2479689,CDM,C1769,HCPCS,0272,RC,,,,both,,,82.24,53.46,,,,,,,,,,,,,
HC Sacroiliac Jnts Min 3 Views,PX-3207220200,CDM,72202,CPT,0320,RC,,,,outpatient,,,938.00,609.70,,,,,,,,,,,,,
HC Drug Screen Quantitative Lidocaine,PX-3018017600,CDM,80176,CPT,0301,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
DEVICE HYSTEROSCOPIC ROTARY STYL USE W/ 5C SYS TRUCLEAR,SUP-2172309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2014.40,1309.36,,,,,,,,,,,,,
PLATE BONE L246MM THK3.7MM 14 H LT DSTL MEDL TIB TI LCK,SUP-2190885,CDM,C1713,HCPCS,0278,RC,,,,both,,,4722.84,3069.85,,,,,,,,,,,,,
FORCEP ELECSURG SPETZLER MALIS 1.5 MM 23CM BPLR IRRIGATING,SUP-2859258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
PLATE CRAN 180X120X40 MM PT SPEC IMPL PEEK,SUP-2860154,CDM,C1713,HCPCS,0278,RC,,,,both,,,46802.01,30421.31,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX14 MM INDWL HRD VLV NS BLOM-SINGER,SUP-2242282,CDM,L8509,HCPCS,0274,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
ALLOGRAFT BNE FIB SHFT 15 CM,SUP-2423907,CDM,C1889,HCPCS,0278,RC,,,,both,,,3248.49,2111.52,,,,,,,,,,,,,
MESH HERN W20XL25CM BIOABSRB FLM TECHNOLOGY COMP SYMBOTEX,SUP-2173622,CDM,C1781,HCPCS,0278,RC,,,,both,,,7502.65,4876.72,,,,,,,,,,,,,
PROBE COAG BPLR 7 FRX350 MM SINGLE PRNG ROUNDED PUR BRIGHTON,SUP-2487039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PROSTHESIS PENILE 100ML PMP INHIBIZONE IMP ULTREX AMS 700,SUP-2140278,CDM,C1813,HCPCS,0278,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
INTRODUCER CATH L12CM OD5FR 0.038IN GWIRE VEN SHTH,SUP-2355259,CDM,C1894,HCPCS,0272,RC,,,,both,,,24.34,15.82,,,,,,,,,,,,,
MESH CRAN L 102.12 X W 39.22 MM THK 0.3 MM SCREW DIA1.5 MM,SUP-2936540,CDM,C1713,HCPCS,0278,RC,,,,both,,,4618.94,3002.31,,,,,,,,,,,,,
DEVICE STRNL CLSR MULTIIMPLANT STRNLOCK 360,SUP-2510512,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
SEALER LAP L37CM MARYLAND JAW OPN NANO COAT MULTIFUNCTIONAL,SUP-2283564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1494.83,971.64,,,,,,,,,,,,,
TI SCREW FOR CONDYLAR HEAD,SUP-2823269,CDM,C1889,HCPCS,0278,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
SPLINT ORTHOPEDIC COLLES SM WRST FOREARM LF,SUP-2330386,CDM,L3808,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
INTRODUCER EP 6 FR 45CM LEN HEMSTAT VLV AD,SUP-2357050,CDM,C1894,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
CANNULA BYPS ART 17FR VEN 24FR TANDEMHEART BLD PMP,SUP-2152649,CDM,C1889,HCPCS,0278,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
LGN STIKTITE POR STEM 18MMX160MM,SUP-2822931,CDM,C1776,CPT,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
INSERT HUM CONSTRN 6+ 39X42 MM COMBINATION UNIVERS REVERS,SUP-2845816,CDM,C1776,CPT,0278,RC,,,,both,,,3187.10,2071.61,,,,,,,,,,,,,
HEAD HUM ECC 3.5 MM 39X14 MM SHLDR ANAT HI OFFSET TI,SUP-2715729,CDM,C1776,CPT,0278,RC,,,,both,,,12373.17,8042.56,,,,,,,,,,,,,
SHUNT SURG INF 11.5FR L30CM REG DBL VLV 2 SWCH PMP CHMBR,SUP-2133689,CDM,C1889,HCPCS,0278,RC,,,,both,,,6513.21,4233.59,,,,,,,,,,,,,
NAIL IM PROX 7X160 MM RT HUM AFFIXUS NAT NAIL,SUP-2606944,CDM,C1713,HCPCS,0278,RC,,,,both,,,5969.14,3879.94,,,,,,,,,,,,,
CABLE EXT FIX L 1200 MM DIA1.8 MM SS NS DISP ILIZ,SUP-2933559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.65,479.47,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TIP L 1.5 MM SS PTFE,SUP-2733980,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.24,24.21,,,,,,,,,,,,,
CABLE SURG L610MM DIA1.8MM CO CHROM SL CTRL,SUP-2252407,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM DIA3MM THRD FOR TOMOFIX OSTEOTMY SYS,SUP-2177212,CDM,C1769,HCPCS,0272,RC,,,,both,,,515.02,334.76,,,,,,,,,,,,,
HC Intermediate Intracavitary Ap,PX-3337776200,CDM,77762,CPT,0333,RC,,,,both,,,8892.00,5779.80,,,,,,,,,,,,,
BUR SURG HI,SUP-2666758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1618.10,1051.76,,,,,,,,,,,,,
COLLAR CERV CAPITAL ENH,SUP-2336002,CDM,L0120,HCPCS,0272,RC,,,,both,,,84.62,55.00,,,,,,,,,,,,,
STEM FEM L7IN DIA15MM PLATFRM 1.5CM STD CALCAR HIP 12/14,SUP-2252159,CDM,C1776,CPT,0278,RC,,,,both,,,18248.42,11861.47,,,,,,,,,,,,,
CATHETER EP 5-3-8 MM 5 FRX115 CM WOVENFLEXIE,SUP-2424761,CDM,C1730,HCPCS,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
STEM EXTN TIB 11MM DIA 152MM LEN FINN - 11MM DIAM 152MM LEN,SUP-2406057,CDM,C1776,CPT,0278,RC,,,,both,,,4288.46,2787.50,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 5MM STR STD WALL SLDE GDS,SUP-2461988,CDM,C1768,CPT,0278,RC,,,,both,,,1885.76,1225.74,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.424,SUP-2859988,CDM,C1713,HCPCS,0278,RC,,,,both,,,38880.42,25272.27,,,,,,,,,,,,,
MESH SURG W8XL12CM THK1MM BIOMATERIAL OVL ANTIMIC GORE,SUP-2395339,CDM,C1781,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 X W 4 CM AMNIO MEMBRN FLX MULTLYR,SUP-2905508,CDM,C1762,CPT,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
PACEMAKER CARD 25GM 13.7CC W52XH58MM THK6MM RESYNCH THER,SUP-2356468,CDM,C2621,HCPCS,0275,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
SODIUM CHLORIDE 1 G PO TABS,RX-7328,CDM,6370000000,HCPCS,0637,RC,00223-1760-01,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
PLATE ADAPT 1.5MM 6H W/GUIDES STRL TI LCP,SUP-2546737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1330.51,864.83,,,,,,,,,,,,,
BIT DRL T HNDL KEY,SUP-2601139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SHEATH PROSTHETIC BK,SUP-2388223,CDM,L8400,HCPCS,0272,RC,,,,both,,,45.66,29.68,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 3X6 CM UMB CRD RESTORIGIN,SUP-2321894,CDM,Q4191,HCPCS,0636,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
DEVICE PESSARY DSH 2 60 MM W/ SUPP,SUP-2273824,CDM,A4562,HCPCS,0274,RC,,,,both,,,94.45,61.39,,,,,,,,,,,,,
PLATE BONE L113MM 8 H NONSTERILE RT LAT PROX TIB S STL FOR,SUP-2349726,CDM,C1713,HCPCS,0278,RC,,,,both,,,11193.32,7275.66,,,,,,,,,,,,,
CATHETER SUPRPUB 12FR L54CM LO PROF TRCR STYL DRNGE SET,SUP-2171298,CDM,C2627,HCPCS,0272,RC,,,,both,,,236.63,153.81,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X20 MM CANN FOR 4.5 MM ROD SHILLA,SUP-2630589,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
HEAD FEM MED 4+ MM 12/14 36 MM HIP TAPR CERM BIOLOX FORTE,SUP-2450926,CDM,C1776,CPT,0278,RC,,,,both,,,6455.84,4196.30,,,,,,,,,,,,,
PLATE BNE L139MM 9 H NONSTERILE R LAT DST PERIARTC HUM LOK,SUP-2198469,CDM,C1713,HCPCS,0278,RC,,,,both,,,2835.77,1843.25,,,,,,,,,,,,,
MESH HERN M DIA6.4CM VENTRAL POLYPR EPTFE CIR SELF EXP PTCH,SUP-2125720,CDM,C1781,HCPCS,0278,RC,,,,both,,,1798.28,1168.88,,,,,,,,,,,,,
GRAFT 25-49SQCM FASC FRZ DRY ALLGRFT,SUP-2165568,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CATHETER KT EXTN LEG REP FOR 3 LUMN NEOSTAR,SUP-2332928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PORT IMPL INFUSION ILLUMINATED 20 GA MIC FORCEP,SUP-2213471,CDM,C1788,HCPCS,0278,RC,,,,both,,,269.51,175.18,,,,,,,,,,,,,
PLATE BNE W10XL107MM THK15MM 3X8 H R TI T OBLQ LO PROF NEUT,SUP-2190923,CDM,C1713,HCPCS,0278,RC,,,,both,,,1342.32,872.51,,,,,,,,,,,,,
SCREW BNE COMPR FUS NAIL WICH,SUP-2377550,CDM,C1713,HCPCS,0278,RC,,,,both,,,5739.14,3730.44,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM BASIC NURSING KT PWR INJ POWERPICC,SUP-2125541,CDM,C1751,HCPCS,0278,RC,,,,both,,,409.36,266.08,,,,,,,,,,,,,
CATHETER PICC L130CM OD5FR 2 LUMN W/ CLMP IR KT W/ WIRE,SUP-2118952,CDM,C1751,HCPCS,0278,RC,,,,both,,,260.37,169.24,,,,,,,,,,,,,
PIN GUIDE L 8.5 MM SHLDR TRANSITION STRL DISP PERFORM,SUP-2912575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
LINER TIB CEM KNEE CR XLPE PREMIER STRYK6] STRYKER ORTHOPEDICS HOWM],SUP-2379183,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SYNDESMOTIC DRILL 3.5MM,SUP-2841620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
BLADE SURG TIP 09MM HK,SUP-2417747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.85,371.05,,,,,,,,,,,,,
HC ER Level 1,PX-4509928100,CDM,99281,CPT,0450,RC,,,,both,,,660.00,429.00,,,,,,,,,,,,,
PLATE SPNL ADJUSTABLE KEEL VUEPOINT II,SUP-2312172,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
STAPLE CART RELD ENDOSCP VASC THCK TISS 6 ROW CUT TI N ABSRB,SUP-2219723,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PROSTHESIS OSS 0.6X5.5 MM GRACE MALL PISTON TI,SUP-2461805,CDM,L8613,CPT,0278,RC,,,,both,,,1127.20,732.68,,,,,,,,,,,,,
DEVICE SPNL OFFSET 80 MM LAT,SUP-2175452,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CANNULA BONE GRAFTING L150MM PRECIS,SUP-2402791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
VALVE MITRL ON-X TISS ANNULUS 25 MM ORIFICE 23.4 MM SZ 25,SUP-2175262,CDM,C1889,HCPCS,0278,RC,,,,both,,,15696.86,10202.96,,,,,,,,,,,,,
PLATE BNE STR 1 MM 22 HOLE CONTOURED SM GRID PLLA-PGA STRL,SUP-2489846,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.26,622.22,,,,,,,,,,,,,
ALLOGRAFT BNE BOAT 50X25 MM 5 CC FD DBM CORTICAL FIBER,SUP-2717786,CDM,C1713,HCPCS,0278,RC,,,,both,,,4742.15,3082.40,,,,,,,,,,,,,
GRAFT BNE SUB HA CLLGN INJ FILL RESRB HEALOS FX,SUP-2255628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
SET SUT DISP FOR MEND II MENIS REP SYS,SUP-2341601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.79,332.66,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR EPIC II VR,SUP-2356513,CDM,C1722,HCPCS,0275,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 82 MM PROX/DSTL 36/12 MM,SUP-2171048,CDM,C1768,CPT,0278,RC,,,,both,,,7743.24,5033.11,,,,,,,,,,,,,
BANDAGE COMPR SM MAMM COMFORTABLE HIGHLY ABSRB POST SURG,SUP-2276344,CDM,L8000,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
MESH SURG L PTCH ONLAY W6XL12CM UNDERLAY 10CM HERN SYS,SUP-2220099,CDM,C1781,HCPCS,0278,RC,,,,both,,,1003.39,652.20,,,,,,,,,,,,,
ELECTRODE LARYNGEAL MAGSTIM SIZE 8/9,SUP-2844647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
BUR SURG SHFT L64MM DIA2.5MM LNG 80000RPM NEURO DMND CARB,SUP-2284217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT STENT PROX COMP 32X94 MM 20 FR AAA FEN ZENITH AAA,SUP-2423972,CDM,C1768,CPT,0278,RC,,,,both,,,32910.34,21391.72,,,,,,,,,,,,,
SHELL ACET TRIANG MILLER FRAME S-ROM,SUP-2455233,CDM,C1776,CPT,0278,RC,,,,both,,,5447.90,3541.13,,,,,,,,,,,,,
ACTIVATION ARM RIGID CRDNC 50MM DSTRCTR CLPBLE,SUP-2488786,CDM,C1713,HCPCS,0278,RC,,,,both,,,2248.74,1461.68,,,,,,,,,,,,,
DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML IV SOLN,RX-121454,CDM,2500000003,HCPCS,0250,RC,00143-9525-01,NDC,,both,100,ML,184.00,119.60,,,,,,,,,,,,,
Z DUPLICATE USE 2293484 KIT BONE CEMENT SIZE 2 MIXER MULTI TAP ADAPTER XPEDE KYPHON,SUP-2429496,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC So Cea,PX-3018237866,CDM,82378,CPT,0301,RC,,,,outpatient,,,67.00,43.55,,,,,,,,,,,,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,0636,RC,00338-1047-02,NDC,,both,250,ML,117.90,76.63,,,,,,,,,,,,,
BEARING TIB CR 12X63/67 MM,SUP-2409223,CDM,C1776,CPT,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
MICROCATHETER INTRVNTNL 0.021N ID 130CML NTNL STRGHT ROX 1 T,SUP-2652844,CDM,C1887,HCPCS,0272,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
RING EXT FIX HALF 170 MM CARBON FIBER RINGFIX,SUP-2365280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
SET ORTH INSTR DRL DIA2.9 MM DRL PIN DIA1.25 MM Q-FIX ULTRA,SUP-2882979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE BONE L96MM 12 H MAND TI STR LCK COMPR RECON FOR 2.4MM,SUP-2191425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3984.97,2590.23,,,,,,,,,,,,,
ALLOGRAFT BNE 40 MM PRESERVON FIBULAR SHFT MATRIGRAFT,SUP-2740995,CDM,C1762,CPT,0278,RC,,,,both,,,1601.84,1041.20,,,,,,,,,,,,,
CANN DRL BIT W/18MM DEPTH MARK 3.5MM,SUP-2816612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
TAP SURG DIA1.5MM FOR PLATING SYS TC-100,SUP-2343954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
HC Hospice Room,PX-1150000000,CDM,1150000000,LOCAL,0115,RC,,,,inpatient,,,2441.00,1586.65,,,,,,,,,,,,,
ANCHOR SUTURE UHMWPE POLYESTER POLYPRO OR PPL TI BTTN WASHER,SUP-2905453,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
ENDCAP ORTH DIA12MM EXTN 0MM GRN FEM TI FOR 9-12MM NAIL,SUP-2192361,CDM,C1713,HCPCS,0278,RC,,,,both,,,622.85,404.85,,,,,,,,,,,,,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,0636,RC,00024-5150-10,NDC,,both,1,UN,3265.70,2122.70,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 4MM 10MM RANG 30CC READIGRFT,SUP-2264737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1270.38,825.75,,,,,,,,,,,,,
PLATE BNE T 8 HOLE W/ PF HOLE FOR LG FRAG SET TC-100,SUP-2196669,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
SCREW BNE CRANIOMAXILLOFACIAL 2X17 MM MAXDRIVE THREADLOCK TS,SUP-2458986,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.70,243.55,,,,,,,,,,,,,
AUGMENT FEM STD THCK UNIV DST PRI PRESSFIT SZ 2 5MM,SUP-2223054,CDM,C1776,CPT,0278,RC,,,,both,,,3419.46,2222.65,,,,,,,,,,,,,
SCREW SPNL IL 7.5X80 MM ARM15T ARMDA,SUP-2561820,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 152 MM 90 MM 9 HOLE TI NS DCP,SUP-2569052,CDM,C1713,HCPCS,0278,RC,,,,both,,,1644.58,1068.98,,,,,,,,,,,,,
BIT DRL 3.2X65 MM STP NS,SUP-2591670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 3.5X114 MM 19/12 MM 7 HOLE LCP,SUP-2799199,CDM,C1713,HCPCS,0278,RC,,,,both,,,2618.07,1701.75,,,,,,,,,,,,,
HC Nasal Smear for Eosinophils,PX-3008919000,CDM,89190,CPT,0300,RC,,,,both,,,223.00,144.95,,,,,,,,,,,,,
SHEATH DIL TIGHTRAIL 11FR,SUP-2353155,CDM,C1894,HCPCS,0272,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
PLATE CRAN THK 0.75 MM SCREW DIA1.7 MM 2 H CRAN COUNTRSNK,SUP-2909570,CDM,C1713,HCPCS,0278,RC,,,,both,,,896.53,582.74,,,,,,,,,,,,,
CEMENT FEM/ CEM TIBIA/ PRLNGART SURF/ NO PAT,SUP-2212172,CDM,C1776,CPT,0278,RC,,,,both,,,10451.65,6793.57,,,,,,,,,,,,,
GRAFT BNE SUB XL W20XH7XL50MM COMPRESSIBLE SPNG STRP PROVIDE,SUP-2138509,CDM,C1713,HCPCS,0278,RC,,,,both,,,9594.33,6236.31,,,,,,,,,,,,,
CRANIAL ACCESS KIT SYR NDL SOLUTION DRP TOWEL RAZOR,SUP-2666709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.24,636.51,,,,,,,,,,,,,
NAIL SS ELASTIC 3.0MM 440MM,SUP-2547601,CDM,C1713,HCPCS,0278,RC,,,,both,,,895.40,582.01,,,,,,,,,,,,,
INSERT TIB SZ 4 THK17MM SEMICONSTRAINED FIX GMK,SUP-2267515,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GRAFT BNE CERV FIBULAR SPCR LORD FRZ DRY 11MM VERTIGRFT,SUP-2264884,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.00,1658.80,,,,,,,,,,,,,
PLATE BNE W13.5XL124MM THK4.2MM 7 H BILAT S STL NAR LIMIT,SUP-2185237,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.29,813.99,,,,,,,,,,,,,
TUBE TRACH OD12MM STD CLR SIL N ADH SMOOTH SURF 4200 SER,SUP-2138748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
STEM HUM L 210 MM SZ 15 XLN PLASMA SPRY POROUS TI SHLDR,SUP-2912557,CDM,C1776,CPT,0278,RC,,,,both,,,26847.00,17450.55,,,,,,,,,,,,,
PROBE BX BRST L105MM DIA14GA SYS FINESSE ULT,SUP-2126879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
COMPONENT TOT HIP PRIMARY CERM MTL MARATHON,SUP-2249585,CDM,C1776,CPT,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
GRAFT EVAR L140MM DIAM 23MM AORT AND 12MM IL ABD AORT IL,SUP-2395970,CDM,C1768,CPT,0278,RC,,,,both,,,25638.10,16664.76,,,,,,,,,,,,,
LINER ACET DIA32MM 15DEG STD GRP 2 HIP UHMWPE POLYETH,SUP-2304472,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
OBTURATOR SHTH 5FRX15CM LUERLOCK,SUP-2355469,CDM,C1894,HCPCS,0272,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
WAND ABLAT TI 80 DEG 4MM,SUP-2341997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
PLATE BNE LISFRANC SM LT OMNI,SUP-2610163,CDM,C1713,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
CLIP ANEUR STR 7 MM,SUP-2337204,CDM,C1889,HCPCS,0278,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
BLADE SURG BLACKLINE 40 MM BLNT TIP SS TI BLK LF,SUP-2763862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
SPINDLE INT FIX SM 12MM 800LB M FORC FEM POR INTFACE CPS,SUP-2406898,CDM,C1713,HCPCS,0278,RC,,,,both,,,9806.22,6374.04,,,,,,,,,,,,,
PLATE BONE DSTL RAD VOLAR S STL VAR ANG 2 CLMN FOR 2.4MM SCR,SUP-2177069,CDM,C1713,HCPCS,0278,RC,,,,both,,,60271.67,39176.59,,,,,,,,,,,,,
STEM FEM HI OFFSET 15-18 MM CLLR MAG NK W/ TRUNNION ARCOS,SUP-2441349,CDM,C1776,CPT,0278,RC,,,,both,,,974.97,633.73,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF 115CM 8FR BD NAVIGATION,SUP-2248525,CDM,C1732,HCPCS,0278,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
SPACER HIP 80MM LNG 70MM DIA L 1.7GM ANTIBIO ENDOPROSTESIS,SUP-2223695,CDM,C1776,CPT,0278,RC,,,,both,,,9388.60,6102.59,,,,,,,,,,,,,
FORCEP ELECSURG BAYNT 1.5 MM 24 CM PRECIS BPLR SILVERGLIDE,SUP-2859761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2888.20,1877.33,,,,,,,,,,,,,
PROBE OPHTH VITRECTOMY 25 GA 2 BIMANUAL ENDOPROBE,SUP-2225674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
INSERT TIB SULCUS 2+ LG 16 MM TOT ANK POLYETH INBONE II,SUP-2519592,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
FIXATOR 5/8 RNG 180MM FRDM CIR,SUP-2400657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
LACOSAMIDE 100 MG PO TABS,RX-96883,CDM,6370000000,HCPCS,0637,RC,60687-0687-57,NDC,,both,1,UN,13.90,9.03,,,,,,,,,,,,,
PIN STEINMANN 2.8 MM,SUP-2817723,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
IMMOBILIZER KIT ABDUCTN UNIV SHLDR NYL PROCARE 45-70DEG,SUP-2196974,CDM,L3660,HCPCS,0272,RC,,,,both,,,78.88,51.27,,,,,,,,,,,,,
BRACE ORTH ABDUCTN CTRL HIP ORTHOSIS FLX,SUP-2388157,CDM,L1620,HCPCS,0274,RC,,,,both,,,397.37,258.29,,,,,,,,,,,,,
HC Calcium Urine Quantitative Timed Specimen,PX-3018234000,CDM,82340,CPT,0301,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
BOLT SPNL L45MM OD8MM TI CANC ANT THORLUM PEDCL ST FIX ANG,SUP-2292735,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER PTCA L135CM DIA7FR BLLN L200MM DIA7MM 0.035IN,SUP-2172775,CDM,C1725,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
KIT ICP SKULL BOLT SPC WSHR OBT BIT DRL HEX WRNCH SCR,SUP-2243821,CDM,C1713,HCPCS,0278,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
KIT ELBW JT BUSHING PIN COMP REPL FOR SM ELBW COONRAD/MORREY,SUP-2205947,CDM,C1776,CPT,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLUENCY + L 60 MM DIA10 MM CATH L 80 CM,SUP-2128268,CDM,C1874,HCPCS,0278,RC,,,,both,,,23747.82,15436.08,,,,,,,,,,,,,
GRAFT TISS HUMAN THERASKIN 1.75 X 1.75 3 SQ CM,SUP-2716336,CDM,Q4121,HCPCS,0636,RC,,,,both,,,2641.68,1717.09,,,,,,,,,,,,,
GUIDEPIN SURG DIA1.1MM NIT FOR BIOINTERFERENCE SCR,SUP-2120909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
CODMAN DISPOSABLE FRCP 8 20 CM 05 MM VERSATRU,SUP-2243825,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
CLAMP ROD TO ROD,SUP-2749492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
PREM ST/MOM CP/LG E1 LN/CER HD,SUP-2212355,CDM,C1776,CPT,0278,RC,,,,both,,,15115.96,9825.37,,,,,,,,,,,,,
PIN FIX L9IN DIA4MM NONSTERILE S STL 2 SIDE DBL DMND BOTH,SUP-2150548,CDM,C1713,HCPCS,0278,RC,,,,both,,,129.78,84.36,,,,,,,,,,,,,
BEARING TIB L63/67MM THK10MM KNEE SUP STBL POST STBL SM,SUP-2407928,CDM,C1776,CPT,0278,RC,,,,both,,,5061.68,3290.09,,,,,,,,,,,,,
DILTIAZEM HCL 60 MG PO TABS,RX-2476,CDM,6370000000,HCPCS,0637,RC,60687-0728-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALIGNRITE WRIST BLK SHRT RGHT MED,SUP-2462313,CDM,L3906,HCPCS,0274,RC,,,,both,,,54.13,35.18,,,,,,,,,,,,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-157632,CDM,J0690,HCPCS,0636,RC,60505-6231-05,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
SHEATH INTRO L 25 CM DIA22 FR DIL L 41 CM GUIDEWIRE 0.035 IN,SUP-2168793,CDM,C1894,HCPCS,0272,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
TUBE MYR DIA114MM SIL VENT TAB DONALDSON,SUP-2313714,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.91,21.39,,,,,,,,,,,,,
BIT DRL DIA4.8MM SHT SHANK FOR HA HALF PIN,SUP-2342999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2293.49,1490.77,,,,,,,,,,,,,
VALVE SHUNT PROGRAMMABLE CEREB SPNL CONN SIPHONGUARD DEV,SUP-2194062,CDM,C1729,HCPCS,0272,RC,,,,both,,,16435.14,10682.84,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 145 CM TIP L 3 CM DIA 0.035 IN SS,SUP-2148174,CDM,C1769,HCPCS,0272,RC,,,,both,,,481.39,312.90,,,,,,,,,,,,,
KIT INSTR INTERNALBRACE LIG AUG REP CLLGN COAT FBR TAPE W/,SUP-2121456,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
HANDLE DETACH PENUMBRA COIL DH5] PENUMBRA INC],SUP-2323582,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
ENDCAP ORTH 0MM EXTN TI W/ T25 STARDRV FOR HUM NAIL-EX SPRL,SUP-2188943,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.31,255.00,,,,,,,,,,,,,
PLATE BNE L 111 MM 14 H SCREW DIA2.4 MM TI ALLOY MINI FRAG,SUP-2902398,CDM,C1713,HCPCS,0278,RC,,,,both,,,3180.91,2067.59,,,,,,,,,,,,,
PLATE BNE LAPIDUS STD 1.3 MM LT MEDL 4 HOLE W/ COMPR GORILLA,SUP-2321485,CDM,C1713,HCPCS,0278,RC,,,,both,,,4275.11,2778.82,,,,,,,,,,,,,
CAGE SPNL W17XH8XL22MM ANT CERV THORLUM TI OBLONG,SUP-2193227,CDM,C1889,HCPCS,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
FERRIC DERISOMALTOSE(ONE DOSE) 1000 MG/10ML IV SOLN,RX-151770,CDM,J1437,HCPCS,0636,RC,73594-9310-01,NDC,,both,5,ML,5387.00,3501.55,,,,,,,,,,,,,
SCREW INTFR L25MM DIA9MM CANN,SUP-2121185,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SPONGE IMPL 75X275X80MM SCLER BCKL OLK DSGN HALF OVL,SUP-2129439,CDM,L8610,HCPCS,0278,RC,,,,both,,,171.98,111.79,,,,,,,,,,,,,
SET SURG THYROPLASTY INSTR NONSTERILE 13 PC W/ CUST STRL TY,SUP-2138768,CDM,L8509,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 15 DEG L 22.5 CM DIA2.9 MM TIP 6 MM SPD,SUP-2902074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1635.31,1062.95,,,,,,,,,,,,,
PLATE BONE W24XL85MM 12 H LT DSTL RAD TI LCK COMPR LO PROF,SUP-2136266,CDM,C1713,HCPCS,0278,RC,,,,both,,,4295.52,2792.09,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7500,SUP-2491615,CDM,C1769,HCPCS,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA10 MM EPTFE STR STD WALL,SUP-2396203,CDM,C1768,CPT,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
PLATE BNE THK0.6MM 6X2 H STD UNIV CRANIOMAXILLOFACIAL TI 3D,SUP-2366292,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.33,853.01,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ 10IN LOOP LOK FIRM SUPP VYN,SUP-2276624,CDM,L3809,HCPCS,0274,RC,,,,both,,,17.40,11.31,,,,,,,,,,,,,
STEM FEM L140MM OD12MM STD BODY NK OFFSET CO CHROM HIP PRI,SUP-2203081,CDM,C1776,CPT,0278,RC,,,,both,,,14144.13,9193.68,,,,,,,,,,,,,
PLATE BNE HK 2.7X12 MM RT CLAV VA LCK COMPR STRL VALCP,SUP-2789377,CDM,C1713,HCPCS,0278,RC,,,,both,,,4609.39,2996.10,,,,,,,,,,,,,
PLATE BNE L203MM 13 H NONSTERILE R LAT DST FIBULAR S STL,SUP-2177426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1913.61,1243.85,,,,,,,,,,,,,
SYSTEM ENDOSCP US DEL W/ 25GA FNA NDL BEAC,SUP-2172391,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
ALLOGRAFT DERMAL 18X6 CM TISS MTRX ALLDERM,SUP-2113079,CDM,Q4116,HCPCS,0636,RC,,,,both,,,12478.36,8110.93,,,,,,,,,,,,,
CANNULA ENDOSCP L 110 MM DIA15 MM STD BLDELSS TROCAR SLV,SUP-2896260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.23,324.50,,,,,,,,,,,,,
REAMER SURG 3 COMPLT DHS,SUP-2417309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4149.82,2697.38,,,,,,,,,,,,,
GRAFT BONE 14X26MM BONE MECH IMPACTED WDG CORT FRZ DRY,SUP-2293770,CDM,C1713,HCPCS,0278,RC,,,,both,,,8173.42,5312.72,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE 3X2 HOLES CRVD SQRE SGMNTS 06MM 15MM,SUP-2676649,CDM,C1713,HCPCS,0278,RC,,,,both,,,820.76,533.49,,,,,,,,,,,,,
GRAFT VASC L 40 CM DIA16 X 8 MM POLYESTER BIFURCATE WOVEN,SUP-2265913,CDM,C1768,CPT,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
STENT ENDOPROS TOT CVR L100MM PROX DIA38MM DST DIA38MM CATH,SUP-2298540,CDM,C1768,CPT,0278,RC,,,,both,,,53364.30,34686.79,,,,,,,,,,,,,
BIT DRILL CANN STD 4.7MM,SUP-2490524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,558.89,363.28,,,,,,,,,,,,,
BRACE ORTH 2 MOD BK PRE CUST TLSO,SUP-2388139,CDM,L0460,HCPCS,0274,RC,,,,both,,,2585.10,1680.31,,,,,,,,,,,,,
GRAFT NERVE REP L 2 X W 2 CM AMNIO MEMBRN MULTLYRED MTRX,SUP-2914050,CDM,C1762,CPT,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
HC Cath/Intro Sal Cont Hyst,PX-3615834000,CDM,58340,CPT,0361,RC,,,,outpatient,,,445.00,289.25,,,,,,,,,,,,,
GRAFT DERM MTRX HUM TISS PLIABLE FLD SUPPLE ULT THCK,SUP-2307567,CDM,Q4128,HCPCS,0636,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
MARKER TAP L20MM DIA5MM CANN XIA 45,SUP-2381112,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
HC Assay of Lactate,PX-3018360500,CDM,83605,CPT,0301,RC,,,,both,,,231.00,150.15,,,,,,,,,,,,,
BIT DRL L150MM DIA3.2MM 3/16SQIN CONN ANK FT CANN,SUP-2321607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
GUIDEWIRE SPNL N THRD 500 MM NIT CORAL,SUP-2707968,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
IMMOBILIZER KNEE UNIV L19IN FOR 12-24IN THGH FOAM T BAR,SUP-2336080,CDM,L1830,CPT,0272,RC,,,,both,,,46.91,30.49,,,,,,,,,,,,,
NERVE STIM PERIPH 2 LD NS DISP SPRNT EXTENSA,SUP-2884033,CDM,C1778,HCPCS,0278,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
BIT DRL L 70 MM DIA1.5 MM STP 22 MM OC NS DISP,SUP-2936678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1117.84,726.60,,,,,,,,,,,,,
RESTRICTOR CEM FOR 10/11MM P.F.C.,SUP-2253282,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
PLATE BNE L THK0.8MM 4X6 H L BILAT CRANIOMAXILLOFACIAL G TI,SUP-2181713,CDM,C1713,HCPCS,0278,RC,,,,both,,,1197.91,778.64,,,,,,,,,,,,,
MILRINONE LACTATE 50 MG/50ML IV SOLN,RX-123638,CDM,J2260,HCPCS,0636,RC,00143-9708-01,NDC,,both,50,ML,115.00,74.75,,,,,,,,,,,,,
AIRWAY LARYN MASK SGL USE SZ 3 SYR AND LUB 7MM CUF ET TUBE,SUP-2384107,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
KIT CATH 16GA L12IN CTRL VEN POLYUR SIDE H INTEGR SUT WNG,SUP-2383268,CDM,C1751,HCPCS,0278,RC,,,,both,,,70.34,45.72,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN 53MML HLX4 STNLSS STEEL RCNSTRCTN F/,SUP-2500646,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.55,780.36,,,,,,,,,,,,,
IMMOBILIZER ORTH 3 PNL 2XL 22 IN KNEE BRTRC ADJ FOAM,SUP-2194906,CDM,L1830,CPT,0272,RC,,,,both,,,57.46,37.35,,,,,,,,,,,,,
BIT DRL L 120/50 MM DIA1.5 MM SCREW DIA2 MM CALIB AO QC CLR,SUP-2908280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.50,501.47,,,,,,,,,,,,,
CATHETER DRNGE 18FR L40CM GWIRE 0.038IN 6 SIDEPRT STD,SUP-2168761,CDM,C1729,HCPCS,0272,RC,,,,both,,,265.02,172.26,,,,,,,,,,,,,
SCREW BONE L80MM OD6.5MM STD CANC NONCANNULATED NONLOCKING,SUP-2343750,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.91,38.29,,,,,,,,,,,,,
BIT DRL M DIA2MM MED P2 DST P3 STP ADD ON DISP FOR IM SMRT,SUP-2379293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER URETH STR 6 FRX80 CM OPN W/O EYE OLYCATH,SUP-2798127,CDM,C1758,HCPCS,0278,RC,,,,both,,,53.91,35.04,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 13 X 38 X 3 MM POLYETHYL BLOCK STRL DISP,SUP-2935174,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
FIBER LASER 200 MH N TAPR POLISHED TIP HOLM ACCUMAX 5/BX,SUP-2537761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1150.31,747.70,,,,,,,,,,,,,
CANNULA ART SHT 13 FR UNCOATED HLS,SUP-2663474,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.10,630.56,,,,,,,,,,,,,
COLLAR CERV FIRM DENS AD 3IN 19IN L,SUP-2276591,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.66,4.33,,,,,,,,,,,,,
COIL EMB L4CM DIA3MM 0.0165IN PLAT NYL FBR DETACH STRTCH,SUP-2296669,CDM,C1889,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
MESH BIO BOV TISS FEN MTRX WND 4CM LEN 4CM W PRIMTRX,SUP-2366724,CDM,C9359,HCPCS,0278,RC,,,,both,,,2619.86,1702.91,,,,,,,,,,,,,
PLATE STRNL CLOSURE 6 H TI O CONCV NS STERNALOCK EZ,SUP-2894519,CDM,C1713,HCPCS,0278,RC,,,,both,,,1902.84,1236.85,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE LG 11 CC CORTICOCANCELLOUS VIABLE,SUP-2932993,CDM,C1762,CPT,0278,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
CATHETER EP LG CRV 2-5-2 MM 6 FRX110 CM STEER,SUP-2126972,CDM,C1730,HCPCS,0272,RC,,,,both,,,463.81,301.48,,,,,,,,,,,,,
SCREW SPNL SACR AND SACROILIAC TI 7.0MMX35MM COLORADO 2,SUP-2290595,CDM,C1713,HCPCS,0278,RC,,,,both,,,3369.22,2189.99,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRUT CORT CANC STRUCTURAL 40MM,SUP-2307182,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.33,627.46,,,,,,,,,,,,,
GUIDEWIRE VASC STR 11 CM 0.035 INX260 CM 4 CM LUNDERQUIST(ORDER BY 5EA),SUP-2170064,CDM,C1769,HCPCS,0272,RC,,,,both,,,363.61,236.35,,,,,,,,,,,,,
FIBER LASER FLAT TIP 600 MH ASMBLY HOLM,SUP-2226000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
INSERT TIB TOT CNDYL SM/SM+/SM++ 8MM ORTHOLOC II,SUP-2397017,CDM,C1776,CPT,0278,RC,,,,both,,,5878.08,3820.75,,,,,,,,,,,,,
HC Asp Inj Intermediate Joint,PX-3612060500,CDM,20605,CPT,0361,RC,,,,inpatient,,,358.00,232.70,,,,,,,,,,,,,
GUIDEPIN ORTH BAL KNEE TEMP,SUP-2315861,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
SET INTRO M.DRAIN L 20 CM SHTH 6 FR TIP L 60 CM GUIDEWIRE,SUP-2761905,CDM,C1894,HCPCS,0272,RC,,,,both,,,45.84,29.80,,,,,,,,,,,,,
COMPONENT HIP POR FEM W/ COCR HD AND XLPE LNR CEMENTLESS,SUP-2347945,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
PLATE BNE SM NON-BIOASORB STRL X-PLATE STRATUM,SUP-2656716,CDM,C1713,HCPCS,0278,RC,,,,both,,,2969.00,1929.85,,,,,,,,,,,,,
NEEDLE BNE MAR RECOVERY 8 GA THRD CLOSED TIP STRL BONESYNC,SUP-2859822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
KIT CATHETER STD 270ML X2ML PER HR ON Q PAINBUSTER,SUP-2236818,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 1/8X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150460,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.61,10.15,,,,,,,,,,,,,
GRAFT BNE 4.8 MM 5 CC OSTEOSET XR,SUP-2498595,CDM,C1713,HCPCS,0278,RC,,,,both,,,1833.76,1191.94,,,,,,,,,,,,,
BASEPLATE TIB REV KNEE,SUP-2366000,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.425,SUP-2859989,CDM,C1713,HCPCS,0278,RC,,,,both,,,40190.43,26123.78,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10 MM DIA 9 MM CATH L 120 CM,SUP-2558723,CDM,C1768,CPT,0278,RC,,,,both,,,10748.22,6986.34,,,,,,,,,,,,,
SPACER TIB H5MM L PROX ENDO MOD M IMPL,SUP-2265092,CDM,C1776,CPT,0278,RC,,,,both,,,3262.46,2120.60,,,,,,,,,,,,,
SEALER ENDOSCP BPLR VATS STRL AQUAMANTYS ENDO VS 8.7R LF,SUP-2865744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1960.68,1274.44,,,,,,,,,,,,,
SPLINT ELBW STRP W 0.625 IN SM FOAM INF PADDED HK LOOP,SUP-2930100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15.67,10.19,,,,,,,,,,,,,
BUR SURG 6MM DMND CORNERSTONE,SUP-2363388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1174.14,763.19,,,,,,,,,,,,,
SYSTEM EXT DRNGE COMPLT W/ 700ML GRAD COLLCTN BG 62IN TBNG 2,SUP-2243798,CDM,C1729,HCPCS,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
TAP BNE DIA 375MM PEDCL SCR SLD QUIK CONN,SUP-2290724,CDM,C1713,HCPCS,0278,RC,,,,both,,,1171.94,761.76,,,,,,,,,,,,,
PIN COMPR NEXFIX 3.5X30MM NS,SUP-2420188,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
GRAFT BNE 10 CC OSTEOSURGE 300,SUP-2641802,CDM,C1713,HCPCS,0278,RC,,,,both,,,5722.65,3719.72,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit W Pta,PX-3613690200,CDM,36902,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
BOLT EXT FIX RUS WIRE NS DISP MONK RING,SUP-2898988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.47,331.16,,,,,,,,,,,,,
LEVEL CMF ST PLATE ORBTL FLOOR SMART LEFT 15 MM SCRW35 X 35,SUP-2707414,CDM,C1713,HCPCS,0278,RC,,,,both,,,4365.23,2837.40,,,,,,,,,,,,,
ADAPTER TIB TY OFFSET SCR BAL REV SYS,SUP-2315557,CDM,C1776,CPT,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
PLATE BNE L158MM 6 H ST R DST HUM EXTRA ARTC S STL LOK,SUP-2177168,CDM,C1713,HCPCS,0278,RC,,,,both,,,4102.47,2666.61,,,,,,,,,,,,,
ALLOGRAFT DERMAL 4X8 CMX3-3.3 MM DERMASPAN ACD,SUP-2866896,CDM,Q4126,HCPCS,0636,RC,,,,both,,,4939.85,3210.90,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING 8MM DIA 45CM LEN GORTX,SUP-2396013,CDM,C1768,CPT,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
DRILL SURG FLX FOR 2.3MM CRV SUT ANCHR SYS,SUP-2341871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,563.72,366.42,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 20 CC,SUP-2335643,CDM,C1713,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
ADAPTER CANN ARTHSCP HIP FLO PRT II REUSE,SUP-2366735,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
BIT DRL TAPR HD 6 MMX9 IN BADGER,SUP-2765765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,594.43,386.38,,,,,,,,,,,,,
CONNECTOR ROD M XLNK FOR VERTEX RECON SYS,SUP-2289103,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
HC Alpha-Fetoprotein Serum,PX-3018210500,CDM,82105,CPT,0301,RC,,,,both,,,202.00,131.30,,,,,,,,,,,,,
PLATE BONE L136MM 18 H STRL S STL LCK COMPR FOR 2.7MM SCR,SUP-2349620,CDM,C1713,HCPCS,0278,RC,,,,both,,,4842.82,3147.83,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 70 CM OD 5 FR GUIDEWIRE 0.038 IN,SUP-2168824,CDM,C1894,HCPCS,0272,RC,,,,both,,,152.29,98.99,,,,,,,,,,,,,
CATHETER ATHRCTMY L130CM OD7FR TIP OD0.066IN ECCENTRICTRIC,SUP-2353048,CDM,C1724,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
STEM HUM ALTIVATE REV STD SHELL 12 X 220MM,SUP-2890873,CDM,C1776,CPT,0278,RC,,,,both,,,36653.22,23824.59,,,,,,,,,,,,,
CAP SPNL POST FACET JT LOK FOR INTEGR ROD REDUC CREO MIS,SUP-2228804,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA XT DR 36.5 CC 68 GM TI POLYUR SIL,SUP-2282395,CDM,C1721,HCPCS,0275,RC,,,,both,,,36313.47,23603.76,,,,,,,,,,,,,
GRAFT HUM TISS ACHILLES TEND ACHILLES] US TISSUE AND CELL],SUP-2391732,CDM,C1713,HCPCS,0278,RC,,,,both,,,4628.36,3008.43,,,,,,,,,,,,,
N S BIPOLAR BAYONET 20MM,SUP-2703460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1921.77,1249.15,,,,,,,,,,,,,
PLATE BONE 6 H MAND STR W/ BAR,SUP-2365233,CDM,C1713,HCPCS,0278,RC,,,,both,,,2577.41,1675.32,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS STD 13X25MMX120CM BA IMPREG OPN END,SUP-2284394,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.49,261.62,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO 5FR 55CM 2 LUMAN RVS TAPR PWR,SUP-2613394,CDM,C1751,HCPCS,0278,RC,,,,both,,,475.21,308.89,,,,,,,,,,,,,
ALLOGRAFT BNE GRAN 8 CC CHIP DRY MIX DBM CORTICAL CANC G2,SUP-2538800,CDM,C1889,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CATHETER HD TENCK 42 CM 2 CUF KT ARGY,SUP-2626784,CDM,C1750,HCPCS,0278,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
TRIAL SPACER LG FEM MOLD SURESPACE,SUP-2433927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.530,SUP-2860211,CDM,C1713,HCPCS,0278,RC,,,,both,,,35653.76,23174.94,,,,,,,,,,,,,
SPACER SPNL W32XH15MM D26MM 8DEG ANT LUM INTBDY FUS BLU PEEK,SUP-2182849,CDM,C1821,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
DEVICE SEAL 30 DEG 5 MMX28 CM ANGLE JAW AMBI LIGASURE,SUP-2174897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1474.48,958.41,,,,,,,,,,,,,
HC So Hepatitis B Surface Ag,PX-3068734066,CDM,87340,CPT,0306,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S3193108D,SUP-2632837,CDM,C1751,HCPCS,0278,RC,,,,both,,,594.06,386.14,,,,,,,,,,,,,
CATHETER DIAG 2.4X1.7FR L150CM ID0.0165IN 90DEG MIC,SUP-2367863,CDM,C1725,HCPCS,0272,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
PLATE BNE L 403 MM SCREW DIA 3.5/4.5 MM 18 H RT TROCHANTERIC 72586218N,SUP-2933065,CDM,C1713,HCPCS,0278,RC,,,,both,,,21967.44,14278.84,,,,,,,,,,,,,
ENDCAP ORTH 12 MM 15 MM EXTN XL40 RECESS FOR FEM NAIL TI GRN,SUP-2789367,CDM,C1889,HCPCS,0278,RC,,,,both,,,599.17,389.46,,,,,,,,,,,,,
SHEARS LAPSCP L35CM DIA5MM PSTL GRP BLNT CVD ACT BLDE ENDO,SUP-2257662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
CATHETER SUPP TRAILBLAZER L 90 CM DIA 0.034 IN SHTH 4 FR,SUP-2720107,CDM,C1887,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF 115CM 8FR BD NAVIGATION,SUP-2248525,CDM,C1732,HCPCS,0272,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
CATHETER SUPRPUB 16FR L25CM 10ML BAL ORNG PVC 3 FACET TRCR,SUP-2384291,CDM,C2627,HCPCS,0272,RC,,,,both,,,108.46,70.50,,,,,,,,,,,,,
SURFACE ARTC 7-10 GH THK28MM AP50MM ML82MM UNIV BLU UHMWPE,SUP-2201843,CDM,C1776,CPT,0278,RC,,,,both,,,5673.98,3688.09,,,,,,,,,,,,,
NARROW PLT STERILIZER 4.5X167 MM 10 HL,SUP-2818129,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.55,1061.16,,,,,,,,,,,,,
SCREW BNE 4/PK L 6 MM DIA2.2 MM PLA GLYCOLIDE CRANIOMAXILLOFACIAL,SUP-2884155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.29,749.64,,,,,,,,,,,,,
HC Iliac Angiogram Nonselective,PX-4810027800,CDM,G0278,CPT,0481,RC,,,,inpatient,,,391.00,254.15,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 0 DEG 8 MM LORDTC ILLIAC CREST BIO,SUP-2637031,CDM,C1713,HCPCS,0278,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
CAGE SPINL EXCEED INTERBODY DEVICE 22 MM L X 10 MM W X 11 MM H 8DEG LORDOTIC,SUP-2934668,CDM,C1889,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
CURETTE SURG MIKAEEL 18 RVS STR,SUP-2484830,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.34,412.32,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.5 % EX OINT,RX-8119,CDM,6370000000,HCPCS,0637,RC,45802-0049-35,NDC,,both,15,GR,38.90,25.28,,,,,,,,,,,,,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML PO SUSR,RX-9902,CDM,340b,HCPCS,0637,RC,68180-0657-01,NDC,,both,20,ML,27.40,17.81,,,,,,,,,,,,,
TAP SURGICAL SCREW DIAMETER 8MM,SUP-2842795,CDM,C1713,HCPCS,0278,RC,,,,both,,,1870.15,1215.60,,,,,,,,,,,,,
BUR SURG UNIV TAPR NONFLUTED,SUP-2252816,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
BASEPLATE TIB CEM 1 KNEE,SUP-2391453,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PIN EXT FIX HALF 4X100 MM 20 MM BLNT BLU XTRAFIX,SUP-2465629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
PLATE BNE MESHED 3.5X75X2 MM 14X14 HOLE RESRB,SUP-2484972,CDM,C1713,HCPCS,0278,RC,,,,both,,,3193.38,2075.70,,,,,,,,,,,,,
PLATE EXT FIX L155MM LNG S STL 8 H CONN COMP IMP ILIZ,SUP-2342268,CDM,C1713,HCPCS,0278,RC,,,,both,,,2083.33,1354.16,,,,,,,,,,,,,
INTRODUCER INFUSION PMP SHT 14 FR IMPELLA,SUP-2431911,CDM,C1892,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SUPPORT ORTHOT CUST RNG MOL PLAS LTHR,SUP-2435582,CDM,L1110,HCPCS,0274,RC,,,,both,,,901.46,585.95,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST THOR CTRL LAT SUPP UPR,SUP-2435693,CDM,L2680,HCPCS,0274,RC,,,,both,,,414.26,269.27,,,,,,,,,,,,,
HC Syphilis Test Non-Treponemal Antibody Qual,PX-3028659200,CDM,86592,CPT,0302,RC,,,,both,,,72.00,46.80,,,,,,,,,,,,,
LINER ACET ID28MM E 0DEG HIP CONSTRN FOR A-SERIES ACUMATCH,SUP-2222086,CDM,C1776,CPT,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
PLATE BNE L95MM 3 H TI R FIBULAR LOK COMPR PROX BULL TIP,SUP-2413692,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.97,1381.88,,,,,,,,,,,,,
METHOTREXATE ECTOPIC PREGNANCY SYRINGE|DISCARDED DRUG NOT ADMINISTE,RX-4081729,CDM,J9260,HCPCS,0636,RC,00143-9519-10,NDC,JW,both,2,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT DURA REP L7 X W 7 CM THK 0.4 MM ELECTROSPUN FIBER ART7706,SUP-2904067,CDM,C1763,HCPCS,0278,RC,,,,both,,,4592.25,2984.96,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RADIA L 95 CM DIA 7 FR SPC 2-14-2,SUP-2142361,CDM,C1731,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BONE L165MM 9 H RT PROX HUM LCK FOR 3.5MM SCR PERI-LOC,SUP-2348556,CDM,C1713,HCPCS,0278,RC,,,,both,,,13919.31,9047.55,,,,,,,,,,,,,
ONDANSETRON HCL 4 MG/5ML PO SOLN,RX-18877,CDM,Q0162,HCPCS,0637,RC,00054-0064-47,NDC,,both,5,ML,37.80,24.57,,,,,,,,,,,,,
EXTENSION STEM FEM 4 MM KNEE OFFSET OPTETRAK LOGIC,SUP-2432777,CDM,C1776,CPT,0278,RC,,,,both,,,897.88,583.62,,,,,,,,,,,,,
SYS HEMORRHAGE CNTRL INTRAUT VACM IND JADA MUST ORDER IN INCREMENTS OF 3 EACH,SUP-2854226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
BASEPLATE GLEN SZ 8 MM MOD TAPR KT NEUT STRL ALTIVATE RVS,SUP-2904162,CDM,C1776,CPT,0278,RC,,,,both,,,18794.47,12216.41,,,,,,,,,,,,,
PIN FIX 2X40MM RESRB REUNITE,SUP-2408519,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6.5X9 CM TEND REINF MTRX PURAFORCE,SUP-2716035,CDM,C1765,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 0.094X9.25 IN THRD STRL,SUP-2846265,CDM,C1769,HCPCS,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
ROD EXT FIX FOR MR CONDITIONAL L MULTIPIN CLMP,SUP-2188489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1108.67,720.64,,,,,,,,,,,,,
KIT GUID INTRO L63CM DIA8.5FR GWIRE 0.032IN TRANSSEPTAL 407358] ST JUDE MEDICAL INC],SUP-2357230,CDM,C1894,HCPCS,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
UPCHARGE KNEE ATTUNE REVISION TRAY DEPUY SYNTHES,SUP-2501360,CDM,C1776,CPT,0278,RC,,,,both,,,2992.42,1945.07,,,,,,,,,,,,,
K PL L SUBCONDYLAR FRACT PL10MM LCKNG,SUP-2681867,CDM,C1713,HCPCS,0278,RC,,,,both,,,2842.39,1847.55,,,,,,,,,,,,,
JOINT TOE GREAT LG NS HEMI LTX REUSE,SUP-2857509,CDM,C1776,CPT,0278,RC,,,,both,,,5626.88,3657.47,,,,,,,,,,,,,
MGII KNEE TIB ART SURF A/P LIP EF/ GREEN 9MM,SUP-2501956,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
PLATE BNE W101XL224MM THK35MM 16 H BILAT TI STR RIG LOK,SUP-2191092,CDM,C1713,HCPCS,0278,RC,,,,both,,,2255.49,1466.07,,,,,,,,,,,,,
GUIDEWIRE ORTH MULT HOLE PERC NS TFN-ADVANCED,SUP-2799743,CDM,C1769,HCPCS,0272,RC,,,,both,,,3435.60,2233.14,,,,,,,,,,,,,
ELECTRODE ES FOR BOVIE X-10 GENRTR,SUP-2313740,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
NEEDLE SUT CAPSULECLOSE SCORPION,SUP-2121460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
PHACOEMULSIFICATION PACK SS PREMIERE LF REUSE,SUP-2478302,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1505.32,978.46,,,,,,,,,,,,,
PLATE BNE L106MM 7 H NONSTERILE L ANTLAT DST TIB S STL LO,SUP-2185948,CDM,C1713,HCPCS,0278,RC,,,,both,,,4055.12,2635.83,,,,,,,,,,,,,
DIAZEPAM 10 MG/2ML IJ SOLN,RX-163217,CDM,2500000003,HCPCS,0250,RC,76045-0204-20,NDC,,both,2,ML,141.50,91.97,,,,,,,,,,,,,
IBUPROFEN 400 MG PO TABS,RX-3843,CDM,6370000000,HCPCS,0637,RC,00904-5853-61,NDC,,both,1,UN,0.60,0.39,,,,,,,,,,,,,
GEL LIFTING SUBMUCOSAL SYR TWIN PK ORISE,SUP-2436449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SUPPORT ORTHOT THOR ANTR CUST DEROTATION,SUP-2435589,CDM,L1260,HCPCS,0272,RC,,,,both,,,267.03,173.57,,,,,,,,,,,,,
THEOPHYLLINE ER 300 MG PO TB12,RX-12098,CDM,6370000000,HCPCS,0637,RC,62332-0025-31,NDC,,both,1,UN,5.90,3.83,,,,,,,,,,,,,
GUIDEWIRE VASC L 100 CM DIA 0.035 IN CRV RAD 10 MM SS REUT,SUP-2167578,CDM,C1769,HCPCS,0272,RC,,,,both,,,183.38,119.20,,,,,,,,,,,,,
HOLDER HK SPNL ANTR COLORADO 2,SUP-2290541,CDM,C1894,HCPCS,0272,RC,,,,both,,,7482.62,4863.70,,,,,,,,,,,,,
PROBE CARD ABLATION CRYOICE L 10 CM ALUM SMTH MALL,SUP-2124441,CDM,C9808,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2500679,CDM,C1768,CPT,0278,RC,,,,both,,,580.37,377.24,,,,,,,,,,,,,
HC So Sirolimus,PX-3018019566,CDM,80195,CPT,0301,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
COVER BURR H BASE SUPPORT CLP STRL SENSIGHT,SUP-2882962,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI TRI FLO ACTE 11.5FR DIA SM LUMAN 12CM,SUP-2610530,CDM,C1752,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
SHUNT L250MM 0-20CM H2O CEREBROSPINAL FLUID WITH PEDIATRIC C,SUP-2843223,CDM,C1889,HCPCS,0278,RC,,,,both,,,18708.65,12160.62,,,,,,,,,,,,,
TUBE GASTROSTMY 24FR 34 CM,SUP-2149750,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
SPLINT THUMB WRIST L AD L8IN L D RNG ABD FIRM SUPP W STAY,SUP-2194734,CDM,L3807,HCPCS,0274,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
PLATE FUSION VA LCP 1ST MTP 2.4/2.7MM MED 10 DEG RT TI STRL,SUP-2546976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2938.10,1909.76,,,,,,,,,,,,,
LOOP CUT SM 24X26FR YEL ANG FOR 24 28FR RESECTSCP SHTH THMS,SUP-2261186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.63,276.66,,,,,,,,,,,,,
BIT DRL DIA4.3MM CALIB ANK COMPR NAILING SYS,SUP-2316003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.47,446.86,,,,,,,,,,,,,
CLOBETASOL PROPIONATE 0.05 % EX SOLN,RX-9632,CDM,6370000000,HCPCS,0637,RC,00168-0269-50,NDC,,both,50,ML,216.00,140.40,,,,,,,,,,,,,
RETRACTOR THMB 15DEG A CRV TAB THMBLE ACCSRY NANOFX,SUP-2123632,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA15MM BITE 4 55MM COMPR SCR,SUP-2315941,CDM,C1769,HCPCS,0272,RC,,,,both,,,252.99,164.44,,,,,,,,,,,,,
HC Ot Adl Training 15 Min,PX-4309753500,CDM,97535,CPT,0430,RC,,,,both,,,131.00,85.15,,,,,,,,,,,,,
PLATE T DSTL RAD DRSL 2.4MM 3H HD 3H SHFT TI VA LCP STRL,SUP-2546754,CDM,C1713,HCPCS,0278,RC,,,,both,,,2379.74,1546.83,,,,,,,,,,,,,
GUIDEWIRE ORTH L28IN DIA2.2MM S STL DISP FOR VERSANAIL HUM,SUP-2413205,CDM,C1769,HCPCS,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
COVER BURR HOLE CONTOURED 18X0.3 MM 5 TI STRL LEVEL 1 NEURO,SUP-2458279,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.72,651.12,,,,,,,,,,,,,
BUR SURG HUB I CRANIOTOME CUT STR STRL DISP HI-LINE XS,SUP-2928998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
COIL EMB L14CM LOOP DIA10MM 0.018IN PLAT HYDRGEL POLYMER,SUP-2385393,CDM,C1889,HCPCS,0278,RC,,,,both,,,1099.03,714.37,,,,,,,,,,,,,
IMMOBILIZER ORTH CLOSED PAT UNIV AD 12 IN 24 IN CANVS,SUP-2194466,CDM,L1830,CPT,0274,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP SEMITENDINOSUS,SUP-2867229,CDM,C1762,CPT,0278,RC,,,,both,,,5053.20,3284.58,,,,,,,,,,,,,
HC So Hepatitis a Ab Total (Havab),PX-3028670867,CDM,86708,CPT,0302,RC,,,,both,,,21.00,13.65,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4 H L HND STR NONCOMPRESSION GRID FOR,SUP-2267873,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.17,431.06,,,,,,,,,,,,,
LEADWIRE NERVE STIM 70 CM SURG KT SURPS-C,SUP-2481871,CDM,C1883,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
ANCHOR SUT ETHIB FASTIN RC W/O 2-0,SUP-2525522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
MESH HERN 15X15 CM N ABSRB INGUINAL MACROPOROUS PARIETENE,SUP-2752193,CDM,C1781,HCPCS,0278,RC,,,,both,,,244.07,158.65,,,,,,,,,,,,,
HC So Mycophenolate Level,PX-3018018066,CDM,80180,CPT,0301,RC,,,,both,,,129.00,83.85,,,,,,,,,,,,,
FEEDING TUBE KIT LP 12 FRX1 CM BLLN BUTTON SIL CLR MINI 1,SUP-2754568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,914.87,594.67,,,,,,,,,,,,,
PLATE BONE THK1.5MM 32 H LEV 1 THOR TI LCK FOR 2.3MM SCR,SUP-2262534,CDM,C1713,HCPCS,0278,RC,,,,both,,,4113.09,2673.51,,,,,,,,,,,,,
PLATE BNE RECON 120 DEG 2.7X3 MM MAND 8 HOLE ANGLED FRAC TI,SUP-2475141,CDM,C1713,HCPCS,0278,RC,,,,both,,,3506.91,2279.49,,,,,,,,,,,,,
PLATE BONE L177MM 9 H S STL BROAD NONLOCKING COMPR CNTOUR,SUP-2348972,CDM,C1713,HCPCS,0278,RC,,,,both,,,2418.37,1571.94,,,,,,,,,,,,,
SHEATH INTRO ACQGUIDE MINI-S 90 DEG L 65 CM OD 12 FR ID 8.5,SUP-2845249,CDM,C1887,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CATHETER IVUS REVOLUTION L 135 CM OUTER SHFT DIA 3.5 FR,SUP-2327234,CDM,C1753,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
HC CT Facial Bones W/ Contrast,PX-3517048700,CDM,70487,CPT,0351,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
HC Excision Up to 15 Skin Tags,PX-4501120000,CDM,11200,CPT,0450,RC,,,,both,,,633.00,411.45,,,,,,,,,,,,,
ULTRASONIC SET CRV TIP LNG 1.6 MM MIC TUBE SONASTAR,SUP-2434136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
BIT DRL DIA 4.5 MM CANN AO QC LG SYS STRL DISP EVOS,SUP-2933913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1448.95,941.82,,,,,,,,,,,,,
HC Hemoglobin Glycosylated A1c|NOT REASONABLE AND NECESSARY,PX-3018303600,CDM,83036,CPT,0301,RC,,,GZ,both,,,141.00,91.65,,,,,,,,,,,,,
CLAMP EXT FIX S STL 4 H PIN ILIZ,SUP-2340704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.08,1732.30,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC HANSSON 2.4MM 300MM THREADED STERILE,SUP-2696004,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.76,123.99,,,,,,,,,,,,,
PLATE BNE M L14MM ID4.2MM 0DEG NONLOCKING COMPR FOR L MT,SUP-2321448,CDM,C1713,HCPCS,0278,RC,,,,both,,,5198.27,3378.88,,,,,,,,,,,,,
CATHETER GUID MP 1 SIDE H 8FR WISEGUID,SUP-2139637,CDM,C1887,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
CAGE SPNL EXPANDABLE LG 0 DEG 30X10X12-18 MM,SUP-2737675,CDM,C1713,HCPCS,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED POROUS STEJH2] STRYKER CORP],SUP-2365935,CDM,C1776,CPT,0278,RC,,,,both,,,14211.64,9237.57,,,,,,,,,,,,,
RABIES IMMUNE GLOBULIN 300 UNIT/2ML IJ SOLN,RX-141161,CDM,90377,HCPCS,0636,RC,76125-0150-02,NDC,,both,2,ML,2199.60,1429.74,,,,,,,,,,,,,
SUTURE NONABSORBABLE SZ 0 L24IN DBL ARMED CL V 20 SC 6 D/A 8886258963,SUP-2174189,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
PROBE PEDCL L165MM CANN W/ MOD JAMSH NDL NO2 MOD MOD,SUP-2354607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
BIT DRL DIA2.9MM DISP FOR VERSANAIL HUM UNIV NAILING SYS,SUP-2412817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
GRAFT HUM TISS 500 MG PURAPLY MZ,SUP-2849177,CDM,C1763,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
RETRACTOR FAN 15IN 5 FINGER 10MM,SUP-2243665,CDM,C1713,HCPCS,0278,RC,,,,both,,,3254.80,2115.62,,,,,,,,,,,,,
HC Midline Placement 3yr or >,PX-3613641000,CDM,36410,CPT,0361,RC,,,,both,,,1195.00,776.75,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA 8 FR DIL L 20 CM GUIDEWIRE,SUP-2167827,CDM,C1892,HCPCS,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
PLATE BNE SM LT DBL LISFRANC STRATUM,SUP-2458796,CDM,C1713,HCPCS,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
PLATE BONE THK0.8MM 4 H HND STR TRILOK FOR 1.5MM SCR APTUS,SUP-2267903,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.99,1036.74,,,,,,,,,,,,,
CROWN DENT 3L ANTR LOWER CUSPID PRIMARY REFILL SS UNITEK,SUP-2322234,CDM,D6783,CPT,0278,RC,,,,both,,,18.68,12.14,,,,,,,,,,,,,
KIT EEG ELECTRD L 33.5 MM 10 CONTACT RF PRB STRL DISP EVO,SUP-2936569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3347.24,2175.71,,,,,,,,,,,,,
HC So Phenobarbital,PX-3018018466,CDM,80184,CPT,0301,RC,,,,both,,,113.00,73.45,,,,,,,,,,,,,
COMPONENT FEM L 100MM TROCHANTERIC HIP CO CHROM MOD REV,SUP-2404491,CDM,C1776,CPT,0278,RC,,,,both,,,2947.99,1916.19,,,,,,,,,,,,,
CAGE SPNL W8XH24XL34MM 8DEG KT MLX,SUP-2310438,CDM,C1889,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,0636,RC,00517-9702-25,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CALCIUM SULF CALCIUM PHOSPHATE LO,SUP-2890197,CDM,C1713,HCPCS,0278,RC,,,,both,,,21050.56,13682.86,,,,,,,,,,,,,
BLADE OPHTH 19GA L1.6MM CORNEAL SCLER BLNT DEL STR HNDL,SUP-2110018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,60.29,39.19,,,,,,,,,,,,,
PLATE BNE THK0.6MM 5MM BAR 5 H 100DEG UNIV,SUP-2366307,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.01,418.61,,,,,,,,,,,,,
PLATE BONE MESH SCREEN 1.3X30X40X0.2 MM TITANIUM,SUP-2838350,CDM,C1713,HCPCS,0278,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
MODULE FEM,SUP-2364662,CDM,C1776,CPT,0278,RC,,,,both,,,6536.70,4248.85,,,,,,,,,,,,,
PROSTHESIS OSS GROTE MED 14X13X18 MM CNL WALL POROUS HA,SUP-2637869,CDM,L8613,CPT,0278,RC,,,,both,,,1416.20,920.53,,,,,,,,,,,,,
WAND ARTHSCP SHFT DIA3.75MM TIP DIA3MM 50DEG COBLATION,SUP-2342006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,729.42,474.12,,,,,,,,,,,,,
DEVICE TISS CLOSURE L 195 CM OPENING W 15 CM CHANNEL 3.2 MM,SUP-2880955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SCREW BNE L32MM DIA4MM STD CANC TI ST LOK FULL THRD BLNT SM,SUP-2413607,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.47,348.71,,,,,,,,,,,,,
SCREW BONE L19MM OD2.0MM CRANIO MAXILLOFACIAL HD TI MINI,SUP-2262659,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.75,64.19,,,,,,,,,,,,,
PLATE BONE L25MM THK1.4MM SHFT W6MM 4 H STRL FLX FOR 2.4MM,SUP-2349672,CDM,C1713,HCPCS,0278,RC,,,,both,,,4218.43,2741.98,,,,,,,,,,,,,
GUIDEPIN ORTH L 248 MM DIA 3.2 MM HUM THRD TIP STRL DISP,SUP-2933552,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.73,243.57,,,,,,,,,,,,,
DEVICE FIX TIB 11 MM WITH PRELOADED TUNNELOC,SUP-2664002,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.45,1218.39,,,,,,,,,,,,,
KIT CATH 20GA L1.75IN RAD ART POLYUR RADPQ THN WALL INTRO,SUP-2383259,CDM,C1894,HCPCS,0272,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
SCREW BNE LAG 75 MM HIP FIX TI STRL CHIMAERA HFS,SUP-2646693,CDM,C1713,HCPCS,0278,RC,,,,both,,,2070.67,1345.94,,,,,,,,,,,,,
GRAFT DERM CLLGN SURG PROC HUM RECTANG IMPL L20XW6CM,SUP-2125864,CDM,C1781,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
CATHETER HD STR EXTN 13.5 FRX30 CM DL HI FLO MAHRK ELITE,SUP-2626879,CDM,C1752,HCPCS,0278,RC,,,,both,,,155.18,100.87,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-103555,CDM,2580000003,HCPCS,0258,RC,00264-7800-10,NDC,JW,both,250,ML,14.90,9.68,,,,,,,,,,,,,
SUPPORT ORTHOT HIP KNEE ANK CUST UNILAT TORSON BALL BEAR,SUP-2435645,CDM,L2090,HCPCS,0274,RC,,,,both,,,1407.69,915.00,,,,,,,,,,,,,
BLADE SURG OMNI CUT 4.2 MM RESECT STRL FMS VUE DISP,SUP-2624799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
COMPONENT TIB STEM OPT NXGN SZ 6+,SUP-2201538,CDM,C1776,CPT,0278,RC,,,,both,,,8289.60,5388.24,,,,,,,,,,,,,
SCREW SPNL IL SACR AND SACROIL S STL 7.0MMX55MM COLORADO 2,SUP-2290484,CDM,C1713,HCPCS,0278,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
CATHETER VENTRICULAR L25CM DIAMETER 2.5MM SILICONE WITH DEFL,SUP-2825624,CDM,C1729,HCPCS,0272,RC,,,,both,,,1033.91,672.04,,,,,,,,,,,,,
JOINT GREAT TOE 1 REG LPT,SUP-2399100,CDM,C1776,CPT,0278,RC,,,,both,,,4644.06,3018.64,,,,,,,,,,,,,
PLATE BNE L262MM 14 H ST L LAT PROX TIB S STL LOK COMPR LO,SUP-2185728,CDM,C1713,HCPCS,0278,RC,,,,both,,,4801.03,3120.67,,,,,,,,,,,,,
CATHETER GUID FL6 MOD SIDE H MOD WG 8FR 100CM .086IN,SUP-2140493,CDM,C1887,HCPCS,0272,RC,,,,both,,,664.42,431.87,,,,,,,,,,,,,
SCREW BONE L90MM DIA4.5MM THRD L40MM MALL S STL ST SELF DRL,SUP-2184561,CDM,C1713,HCPCS,0278,RC,,,,both,,,101.11,65.72,,,,,,,,,,,,,
BLADE SHAVER ARTHSCP 3X120 MM STR FULL RAD DRILLCUTX RED,SUP-2602787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.42,341.52,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 5 HOLE COMPR STRL ALPS LTX,SUP-2861814,CDM,C1713,HCPCS,0278,RC,,,,both,,,815.02,529.76,,,,,,,,,,,,,
EXTRACTOR SURG EASYOUT 2 MM QR ACUTRK,SUP-2857691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
SET ORTH INSTR SZ 3.5 MM OSSIFIED BIOINTEGRATIVE COMPR SCREW,SUP-2904308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
STENT BILI PALMAZ L 39 MM DIA 4-9 MM MED SS TRNSHEP BALLOON,SUP-2158991,CDM,C1877,HCPCS,0278,RC,,,,both,,,3146.28,2045.08,,,,,,,,,,,,,
CATHETER PERI L120CM OD2.2MM ID1MM SIL BA IMPREG MEDOS,SUP-2257150,CDM,C1729,HCPCS,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
JOINT EXT FIX UNIV,SUP-2197242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 5000RPM SNUS SERR NONROTATABLE STR,SUP-2284143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,751.59,488.53,,,,,,,,,,,,,
SD BLADE 1.5MM XD 80MM 1.5MM DRIVER WIDE DIA,SUP-2676717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,720.69,468.45,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC DBM CRUNCH,SUP-2913370,CDM,C1713,HCPCS,0278,RC,,,,both,,,2725.52,1771.59,,,,,,,,,,,,,
MESH SURG W5.4XL7IN OMEGA 3 FATTY ACIDS NAT BIORESORBABLE,SUP-2265965,CDM,C1781,HCPCS,0278,RC,,,,both,,,1767.82,1149.08,,,,,,,,,,,,,
BIT DRL L110MM DIA1.8MM QUIK CPL CALIB W/O STP REUSE,SUP-2187295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.96,266.47,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM DIA28 MM POLYESTER BOV CLLGN,SUP-2227238,CDM,C1768,CPT,0278,RC,,,,both,,,1389.89,903.43,,,,,,,,,,,,,
CATHETER DRAINAGE SAFETY 4 FRX10 CM STRL SKATER LTX,SUP-2876591,CDM,C1729,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,6370000000,HCPCS,0637,RC,00536-1362-23,NDC,,both,1,UN,1.90,1.23,,,,,,,,,,,,,
COMPONENT FEM REV RT BEAD VITALLIUMXL DURAC,SUP-2364837,CDM,C1776,CPT,0278,RC,,,,both,,,7857.85,5107.60,,,,,,,,,,,,,
EXPANDER TISS BRST 9.5 CM PROJCT 11X11 CM 500 CC RND,SUP-2328141,CDM,C1789,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
NAIL IM L480MM DIA13MM L LAT FEM LT GRN TI CANN LOK CRV,SUP-2179784,CDM,C1713,HCPCS,0278,RC,,,,both,,,5203.26,3382.12,,,,,,,,,,,,,
PATCH BIO TISS W10XL16CM BOV PERICARD CROSS LINKED,SUP-2130367,CDM,C1768,CPT,0278,RC,,,,both,,,2836.71,1843.86,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC OSTEOSPARX,SUP-2641788,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
KIT INTRO EXCALIBUR L 35 MM DIA 3 FR NDL 19 GA PERC ART VEN,SUP-2125566,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.73,48.57,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 5 MM EPTFE STR STD WALL,SUP-2396178,CDM,C1768,CPT,0278,RC,,,,both,,,1290.54,838.85,,,,,,,,,,,,,
SPACER SPNL 18 DEG 60X27X14 MM OLIF PIVOX OLIF25,SUP-2627900,CDM,C1889,HCPCS,0278,RC,,,,both,,,17599.70,11439.80,,,,,,,,,,,,,
SEGMENTAL FEMORAL HINGE SERVICE KIT SIZE B,SUP-2502431,CDM,C1776,CPT,0278,RC,,,,both,,,5666.13,3682.98,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT MENIS W/ TIB PLATEAU HUM TISS LT,SUP-2307287,CDM,C1776,CPT,0278,RC,,,,both,,,18683.00,12143.95,,,,,,,,,,,,,
SPACER FEM SZ 1 THICKNESS 5MM TI LT MEDL KNEE PRI PRESSFIT,SUP-2208353,CDM,C1776,CPT,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
BUSHING TIB 0MM OFFSET REV NEUT PROVEN GEN-FLEX,SUP-2359210,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER EXT INTMED SZ 32MM CLR SELF ADH POLYTECH,SUP-2239737,CDM,C1758,HCPCS,0278,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
PLATE BNE STR 1 MM 22 HOLE STRL RESORB X,SUP-2487123,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.26,622.22,,,,,,,,,,,,,
INTRODUCER LD 5 FRX13 CM 20 CM HEMOSTATIC VLV SAFSHTH TEARWY,SUP-2302616,CDM,C1893,HCPCS,0272,RC,,,,both,,,143.81,93.48,,,,,,,,,,,,,
ROD EXT FIX L400MM S STL THRD TELSCP ORIG CIR FOR TAY SPAT,SUP-2342308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.56,326.66,,,,,,,,,,,,,
PLATE BNE RECON SM 2-2.3X2.8 MM LT PRESHAPED SMRT TI NS,SUP-2457935,CDM,C1713,HCPCS,0278,RC,,,,both,,,9513.67,6183.89,,,,,,,,,,,,,
PLATE BNE L25MM 2 H BILAT S STL CNTOUR 2 COMPR FOR 35MM SCR,SUP-2411329,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.15,195.10,,,,,,,,,,,,,
SPLINT HND M ULN DEVIATION RT NEOPRNE WRP ARND W/ THMB H ADJ,SUP-2324909,CDM,L3906,HCPCS,0274,RC,,,,both,,,28.01,18.21,,,,,,,,,,,,,
HC Biliary Duct Dilat W/Out Stent,PX-3614755500,CDM,47555,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
COLLAR EXTRIC AD 35IN FOR 11 23IN FR 1 PC FLAT LOK TAB CLS,SUP-2194415,CDM,L0120,HCPCS,0274,RC,,,,both,,,16.52,10.74,,,,,,,,,,,,,
PLATE BNE LCK 2.7X141 MM 12 HOLE CNTOUR 2 COMPR SS STRL,SUP-2461862,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.75,726.54,,,,,,,,,,,,,
CATHETER EP SM 2-7-2 MM 7 FRX95 CM ORBITER ST,SUP-2487169,CDM,C1730,HCPCS,0272,RC,,,,both,,,3086.62,2006.30,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 72 MM ANTR LUMBOSACRAL TI CITADEL,SUP-2584620,CDM,C1713,HCPCS,0278,RC,,,,both,,,10927.20,7102.68,,,,,,,,,,,,,
PLATE BONE LAPIDUS RIGHT PETITE TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878149,CDM,C1713,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
SHEATH INTRO 7FR L45CM STEER TOURGUIDE,SUP-2298497,CDM,C1894,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
RING EXT FIX DIA200MM HALF FOR TRUELOK RNG FIX SYS,SUP-2316182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1890.94,1229.11,,,,,,,,,,,,,
SYSTEM IMPL 38X28X12 DEG 11MM LUM INTEGR FUS PLSM COAT STRL,SUP-2419775,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
ROD EXT FIX L638MM DIA8MM SPAN L499MM 135DEG C FBR CVD,SUP-2188723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1510.69,981.95,,,,,,,,,,,,,
EXTENSION GUIDEWIRE TRUEPATH L 160 CM DIA 0.018 IN STR STRL,SUP-2145954,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GUIDEWIRE ORTH BALL NOSE HUM NS AFFIXUS,SUP-2606190,CDM,C1769,HCPCS,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
PROSTHESIS OSS L4MM OD0.4X1MM TI PIST BCKT HNDL 2,SUP-2312801,CDM,L8613,CPT,0278,RC,,,,both,,,653.53,424.79,,,,,,,,,,,,,
PLATE BNE STD NEUT LT MTC MEDIALMAX,SUP-2315910,CDM,C1713,HCPCS,0278,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
SCREW BNE SPARE,SUP-2486613,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.75,67.44,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PHOTON U DR 29 J 37 ML 74 GM 2 CHMBR STRL,SUP-2320137,CDM,C1721,HCPCS,0275,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
CEMENT BNE W/ HA RADPQ FOR KYPHOPLASTY KYPHON ACTIVOS 10,SUP-2293455,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
DEVICE TISS FIX PUSHLOCK ANCHR DIA2.9 MM LNT SYS STRL HD,SUP-2910497,CDM,C1713,HCPCS,0278,RC,,,,both,,,2818.94,1832.31,,,,,,,,,,,,,
COMPONENT FEM PROX TROCHANTERIC HIP NEUT MOD REPL SYS GMRS,SUP-2364666,CDM,C1776,CPT,0278,RC,,,,both,,,12003.44,7802.24,,,,,,,,,,,,,
SCREW BONE L7MM OD2.3MM TI6AL4V LCK DRL FRE STRNL MAX DRV,SUP-2262551,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.49,177.77,,,,,,,,,,,,,
PLATE SPNL FIX 5.5X28 MM SS CROSSLINK,SUP-2660208,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
ALLOGRAFT BNE STRP SM FD ASEP IL CREST,SUP-2867019,CDM,C1762,CPT,0278,RC,,,,both,,,2201.45,1430.94,,,,,,,,,,,,,
PORT SYS ATTACH TI INTRA-ARTERY BEAD SIL 7FR,SUP-2332931,CDM,C1788,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
FORCEP ENDOSCP BX 7.5 FRX50 CM 2.4 MM STR FRMBL SS JAWZ LTX,SUP-2876081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SET NEPHROSTOMY MCOT DSTL L 20 CM PROX L 30 CM DIA24/7 FR,SUP-2168889,CDM,C1729,HCPCS,0272,RC,,,,both,,,266.77,173.40,,,,,,,,,,,,,
PLATE BNE STR 3.5X261 MM 22 HOLE RECON FOR SCR SS NS,SUP-2479543,CDM,C1713,HCPCS,0278,RC,,,,both,,,1883.62,1224.35,,,,,,,,,,,,,
GRAFT NRV L30MM DIA4-5MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124854,CDM,C1762,CPT,0278,RC,,,,both,,,14035.80,9123.27,,,,,,,,,,,,,
STENT GRFT VASC AFX L 95 MM UNCOVERED L 20 MM DIA 25 MM,SUP-2217595,CDM,C1768,CPT,0278,RC,,,,both,,,11727.90,7623.13,,,,,,,,,,,,,
HC So Renin,PX-3018424466,CDM,84244,CPT,0301,RC,,,,both,,,602.00,391.30,,,,,,,,,,,,,
FILLER BONE VOID 5ML HA SYNTH CA PHOS PUTTY TISS IMPL CEM,SUP-2194290,CDM,C1713,HCPCS,0278,RC,,,,both,,,4660.07,3029.05,,,,,,,,,,,,,
PLATE LO PROF 4 H MINI 20 MOD TI 06MM REG,SUP-2262929,CDM,C1713,HCPCS,0278,RC,,,,both,,,272.93,177.40,,,,,,,,,,,,,
PAD ORTHOT LAT TROCHANTERIC CUST,SUP-2435592,CDM,L1290,HCPCS,0272,RC,,,,both,,,219.99,142.99,,,,,,,,,,,,,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT,RX-7331,CDM,6370000000,HCPCS,0637,RC,00536-1253-91,NDC,,both,3.5,GR,46.20,30.03,,,,,,,,,,,,,
GRAFT BNE W20 70MM FEM HD W TROCH FRZN NO ANG R SIDE,SUP-2307308,CDM,C1713,HCPCS,0278,RC,,,,both,,,9784.24,6359.76,,,,,,,,,,,,,
HC So Cbc W/O Diff|NOT REASONABLE AND NECESSARY,PX-3058502766,CDM,85027,CPT,0305,RC,,,GZ,both,,,79.00,51.35,,,,,,,,,,,,,
SCREW BONE LOCKING 3.5/2.7MM DIA 48MML STERILE,SUP-2588235,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.15,195.10,,,,,,,,,,,,,
PLATE BONE ANGLED THICK 2.5 MM MANDIBLE PATIENT SPECIFIC ANG,SUP-2838601,CDM,C1713,HCPCS,0278,RC,,,,both,,,26237.53,17054.39,,,,,,,,,,,,,
HC Elec Alys Implt Smpl Cn Npgt Prgrmg,PX-9209597600,CDM,95976,CPT,0920,RC,,,,outpatient,,,121.00,78.65,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM PEEK STRL FIBERTAK ACHILLES,SUP-2910480,CDM,C1713,HCPCS,0278,RC,,,,both,,,9215.12,5989.83,,,,,,,,,,,,,
BELT MOD SM MED 14 V,SUP-2356010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
KIT ACCS 10ML SYR CATH ALC PD PLEURX,SUP-2133744,CDM,C1729,HCPCS,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
PROSTHESIS PENILE L25CM DIA11MM HYDRPHLC MAL TAIL CAP TRIM,SUP-2165370,CDM,C1813,HCPCS,0278,RC,,,,both,,,30147.14,19595.64,,,,,,,,,,,,,
EXPANDER BRST TISS 500CC W13.5XH13.5CM P6.6CM SIL SMOOTH HI,SUP-2301020,CDM,C1789,HCPCS,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
MESH CRAN L 120 X W 120 MM THK 0.8 MM SCREW DIA1.5/1.7 MM LG,SUP-2883419,CDM,C1713,HCPCS,0278,RC,,,,both,,,28309.61,18401.25,,,,,,,,,,,,,
BLADE SAW L 51 X W 15 MM D 20 MM THK MATERIAL 0.5 MM CUT 6,SUP-2928910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.27,292.03,,,,,,,,,,,,,
APPLIER INT CLP LAP MED 10 MMX33 CM ROT KNOB,SUP-2852432,CDM,C1889,HCPCS,0278,RC,,,,both,,,3243.31,2108.15,,,,,,,,,,,,,
SCREW INTRF SHT THRD 8X23 MM KNEE CRUC DRVR BIOSTEON,SUP-2366519,CDM,C1713,HCPCS,0278,RC,,,,both,,,739.00,480.35,,,,,,,,,,,,,
PLATE BONE L98MM 7 H RT POST DSTL TIB LCK FOR 3.5MM SCR,SUP-2349805,CDM,C1713,HCPCS,0278,RC,,,,both,,,9518.13,6186.78,,,,,,,,,,,,,
PLATE BNE W8XL20MM THK2MM 0DEG 2 H BILAT S STL STR RIG DYN,SUP-2186174,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.96,250.22,,,,,,,,,,,,,
WIRE EXT FIX L385MM DIA1.8MM S STL DRL TIP W/ STPR FOR ILIZ,SUP-2340793,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8497.78,5523.56,,,,,,,,,,,,,
COIL NEUROVASCULAR HELIPAQ 18 L 30 CM DIA14 MM WORKING L 190,SUP-2458318,CDM,C1889,HCPCS,0278,RC,,,,both,,,2797.17,1818.16,,,,,,,,,,,,,
COIL EMB L6CM DIA3MM EXTRA SFT PUSH DSGN USE ACE TRK,SUP-2323529,CDM,C1889,HCPCS,0278,RC,,,,both,,,5620.60,3653.39,,,,,,,,,,,,,
DRESSING HUM TISS SZ 2 X 2 CM UMB TISS SKIN LYOPRESERVED,SUP-2905485,CDM,Q4133,HCPCS,0636,RC,,,,both,,,2780.47,1807.31,,,,,,,,,,,,,
PLATE RAD HD NECK 2.4MM 4H TI LCP,SUP-2549714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2018.67,1312.14,,,,,,,,,,,,,
HC X-Ray Spine 1 View,PX-3207202000,CDM,72020,CPT,0320,RC,,,,inpatient,,,233.00,151.45,,,,,,,,,,,,,
TRAY NERVE BLOCK ST300C OPM BPSK STRL LF DISP DESIGN OPTIONS,SUP-2936633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,37.84,24.60,,,,,,,,,,,,,
HC Hands Bone Age Study,PX-3207707200,CDM,77072,CPT,0320,RC,,,,outpatient,,,252.00,163.80,,,,,,,,,,,,,
DRILL TWIST DIA7MM CANNULATED PROXIMAL,SUP-2878274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
STEM HIP SZ 6 NK L25MM M-HA OMFLX,SUP-2364204,CDM,C1776,CPT,0278,RC,,,,both,,,13031.00,8470.15,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VISIA AF VR W 51 X H 66 MM D 13 MM,SUP-2282418,CDM,C1722,HCPCS,0275,RC,,,,both,,,36115.31,23474.95,,,,,,,,,,,,,
PLATE BNE W10XL77MM THK3.3MM HK D15MM 8 H R CLAV S STL LOK,SUP-2185834,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.48,1426.41,,,,,,,,,,,,,
PLATE 4 H 2.3 TRAUM MOD TI 1.5MM MED,SUP-2262994,CDM,C1713,HCPCS,0278,RC,,,,both,,,801.39,520.90,,,,,,,,,,,,,
REAMER SURG 16 MM CUP,SUP-2319071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CUP LNR XLPE G7,SUP-2212417,CDM,C1776,CPT,0278,RC,,,,both,,,6772.98,4402.44,,,,,,,,,,,,,
BASEPLATE GLEN HD DIA50MM REG BILAT UHMWPE PEGGED PRESSFIT,SUP-2193842,CDM,C1776,CPT,0278,RC,,,,both,,,3739.68,2430.79,,,,,,,,,,,,,
PLATE BNE W10XL89MM THK1.5MM 90DEG 7X4 H BILAT S STL T SHP,SUP-2185877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1398.56,909.06,,,,,,,,,,,,,
ATOVAQUONE-PROGUANIL HCL 250-100 MG PO TABS,RX-23814,CDM,6370000000,HCPCS,0637,RC,66993-0060-02,NDC,,both,1,UN,27.30,17.74,,,,,,,,,,,,,
GRAFT BNE SUB 60CC 1.7MM-10MM CHIP FRZ DRY CANC,SUP-2307079,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.22,1373.59,,,,,,,,,,,,,
PLATE BNE L74MM 3X5 H S STL T LOK COMPR OBLQ L ANG FOR,SUP-2186027,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.41,676.27,,,,,,,,,,,,,
SHUNT SURG W/ ANCHR CLP UNI-SHUNT,SUP-2666570,CDM,C1889,HCPCS,0278,RC,,,,both,,,354.29,230.29,,,,,,,,,,,,,
CATHETER VENTRICULAR FIN 15 CM STR CONN RT ANGLE GUIDE,SUP-2851484,CDM,C1729,HCPCS,0272,RC,,,,both,,,570.26,370.67,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.015 IN STR FLX SFT TIP FIX COR,SUP-2167845,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
HC So Parvo,PX-3028674766,CDM,86747,CPT,0302,RC,,,,both,,,223.00,144.95,,,,,,,,,,,,,
OSS SEG DSTL FEM 8.5CM LT,SUP-2506417,CDM,C1776,CPT,0278,RC,,,,both,,,20064.60,13041.99,,,,,,,,,,,,,
"HC So Immunoglobulin,Ige",PX-3018278566,CDM,82785,CPT,0301,RC,,,,both,,,143.00,92.95,,,,,,,,,,,,,
CLIP SURG L8MM M L POLYGLY ACID POLYGLY LAP ABSRB RAD,SUP-2172325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.41,353.22,,,,,,,,,,,,,
PLATE BNE PUBIC SYMPHYSIS PELV 6 HOLE,SUP-2518370,CDM,C1713,HCPCS,0278,RC,,,,both,,,3494.82,2271.63,,,,,,,,,,,,,
ELECTRODE ES 24FR YEL KNF MPLR DISP,SUP-2313985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.09,288.01,,,,,,,,,,,,,
GUIDE SURG PLN NYL LP CUSTOMIZABLE BNDL RECON VSP,SUP-2883952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,23864.00,15511.60,,,,,,,,,,,,,
PROSTHESIS HIPXSM 12/14 MAYO,SUP-2203724,CDM,C1776,CPT,0278,RC,,,,both,,,15164.63,9857.01,,,,,,,,,,,,,
KIT INTRO ELITE HV SHTH L 7 CM DIA 4 FR GUIDEWIRE L 45 CM,SUP-2125280,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.96,41.57,,,,,,,,,,,,,
GUIDEWIRE VASC APPRCH CTO L135CM 0.014IN L18CM 12GM STR SHRT,SUP-2638729,CDM,C1769,HCPCS,0272,RC,,,,both,,,395.95,257.37,,,,,,,,,,,,,
BRACE WLK L SHOE MAN 10 13 WOMAN 11 15 EXTRA PNEUMAT SEMI,SUP-2196363,CDM,L4361,HCPCS,0274,RC,,,,both,,,224.82,146.13,,,,,,,,,,,,,
HC So Chemiluminescent Assay,PX-3018239766,CDM,82397,CPT,0301,RC,,,,inpatient,,,230.00,149.50,,,,,,,,,,,,,
GUN BNE CEM INJ 2 SPD,SUP-2366768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1987.62,1291.95,,,,,,,,,,,,,
CURETTE SURG 11IN NO 6 STR ST COBB DAWSON YUHL,SUP-2160983,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.91,222.24,,,,,,,,,,,,,
HC Perq Trluml Revsc Chrnc Tot Occls 1 C Art Antgrd,PX-4819294300,CDM,92943,CPT,0481,RC,,,,both,,,21763.00,14145.95,,,,,,,,,,,,,
COIL EMB H 2 MM DIA 7 MM STRL WEB17 SL,SUP-2915263,CDM,C1889,HCPCS,0278,RC,,,,both,,,51794.30,33666.29,,,,,,,,,,,,,
ANALYZER COAG 2 TUBE 2 PLT RICH FBRN MTRX AUTOLGS PLT SYS,SUP-2307547,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
PROSTHESIS OSS L15MM HD L3MM DST END DIA117MM HA FRISBEE PAR,SUP-2436531,CDM,L8613,CPT,0278,RC,,,,both,,,1138.88,740.27,,,,,,,,,,,,,
CATHETER CONT CARD OUTPT 7.5F,SUP-2214038,CDM,C1751,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE L196MM 7 H NONSTERILE R DST FEM TI LOK COMPR FOR,SUP-2190723,CDM,C1713,HCPCS,0278,RC,,,,both,,,4833.59,3141.83,,,,,,,,,,,,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,J7620,HCPCS,0637,RC,00487-0201-01,NDC,,both,3,ML,2.70,1.75,,,,,,,,,,,,,
SCREW ST 120MM 3.5MM CRTX,SUP-2183609,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.12,50.78,,,,,,,,,,,,,
STEM FEM SZ 11 L145MM HIP TI POR STD OFFSET CEMENTLESS PRI,SUP-2344406,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X354 MM LT PROX 11 HOLE STRL VALCP,SUP-2789592,CDM,C1713,HCPCS,0278,RC,,,,both,,,9098.84,5914.25,,,,,,,,,,,,,
PLATE FUSION VA LCP 1ST MTP 2.4/2.7MM REV 0 DEG LT TI STRL,SUP-2546981,CDM,C1713,HCPCS,0278,RC,,,,both,,,4865.43,3162.53,,,,,,,,,,,,,
FIBERS CORTICAL DEMIN 10CC INNOVASIS BB76100,SUP-2847028,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
HC So Vitamin C,PX-3018218066,CDM,82180,CPT,0301,RC,,,,both,,,461.00,299.65,,,,,,,,,,,,,
SYSTEM TISS GLUE 10ML KT BIOLOGIC FBRN SEAL TISSEEL VALUPAK,SUP-2129972,CDM,C9250,HCPCS,0636,RC,,,,both,,,1659.80,1078.87,,,,,,,,,,,,,
PATCH VASC KNIT N VEL ULT THN N TAPR END CLLGN POLY FINESSE,SUP-2227661,CDM,C1768,CPT,0278,RC,,,,both,,,398.84,259.25,,,,,,,,,,,,,
PLATE BNE L128MM 8 H NONSTERILE R PROX BILAT TIB S STL NEUT,SUP-2184305,CDM,C1713,HCPCS,0278,RC,,,,both,,,3877.52,2520.39,,,,,,,,,,,,,
TIP SONOPET 12CM iQ MICRO,SUP-2752127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2835.36,1842.98,,,,,,,,,,,,,
BIT DRL OD1.7MM SLD INTOSS FIX SYS,SUP-2400073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
BIT DRL L110MM WRK L20MM DIA1.6MM CLR DEPTH MRK FOR,SUP-2364186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1293.84,841.00,,,,,,,,,,,,,
PIN FIX L1IN KNEE SYS HD TOT STBL DURAC,SUP-2378554,CDM,C1776,CPT,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BLADE SHV OD4.5MM ENDO BOXED CONCV INCIS,SUP-2341410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
BIT DRL FLUT 5.3X362 MM VERSANAIL,SUP-2606669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.57,418.32,,,,,,,,,,,,,
PLATE BNE 3.5X41 MM 3 HOLE SS LC-DCP,SUP-2569225,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.70,124.60,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER NAV L 115 CM 4 MM D-F CRV,SUP-2248520,CDM,C1732,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GRAFT AMNIOFIX AMNIOTIC MEMBRANE 20MG,SUP-2866798,CDM,C1762,CPT,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GUIDE WIRE 32 MM X 400MM,SUP-2477386,CDM,C1769,HCPCS,0272,RC,,,,both,,,529.88,344.42,,,,,,,,,,,,,
JOINT FNGR MP 50 SIL STRL,SUP-2464926,CDM,C1776,CPT,0278,RC,,,,both,,,3372.36,2192.03,,,,,,,,,,,,,
TRAY HAD CHRNC W18GA INTRDCR NDLE JFLX GDWRE TEAR AWAY SHT,SUP-2729590,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
GRAFT BNE SUB W1XL5CM POSTEROLATERAL CERV DEMIN BNE MTRX,SUP-2293965,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
STEM RADIAL DIA 6.5 MM PEEK TI ALLOY ELBW CEM TOT ARTHPLSTY,SUP-2902231,CDM,C1776,CPT,0278,RC,,,,both,,,9225.32,5996.46,,,,,,,,,,,,,
GRAFT EVAR DST BODY L76MM LEG L28MM IPSILATERAL DIA12MM SHTH,SUP-2170129,CDM,C1874,HCPCS,0278,RC,,,,both,,,18839.97,12245.98,,,,,,,,,,,,,
MESH BONE HOLEX12 07MM THK LATEX FREE MAXILLOFACIAL,SUP-2707283,CDM,C1713,HCPCS,0278,RC,,,,both,,,5111.32,3322.36,,,,,,,,,,,,,
DEVICE PROSTHETIC TYP BK SOCKET MOLD,SUP-2388180,CDM,L2350,HCPCS,0274,RC,,,,both,,,2452.91,1594.39,,,,,,,,,,,,,
DISTRACTOR SURG L 30 MM 3 X 3 H RT MANDIBULAR PED NS,SUP-2883396,CDM,C1713,HCPCS,0278,RC,,,,both,,,23612.80,15348.32,,,,,,,,,,,,,
MESH HERN 12X115CM RND COMP VENTRAL REABSORBABLE CLLGN,SUP-2174708,CDM,C1781,HCPCS,0278,RC,,,,both,,,2085.27,1355.43,,,,,,,,,,,,,
PLATE BNE PATELLAR 2.7 MM LAT RIM VA LCK TI STRL,SUP-2789408,CDM,C1713,HCPCS,0278,RC,,,,both,,,7486.39,4866.15,,,,,,,,,,,,,
PLATE BNE DBL Y LG 1.5X19X1 MM MIDFACE 6 HOLE W/ TAB TI NS,SUP-2478356,CDM,C1713,HCPCS,0278,RC,,,,both,,,884.91,575.19,,,,,,,,,,,,,
BIT DRL DIA2.75MM 0.066 CANN FOR GLEN BNE LOSS SET,SUP-2122055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CUTTER FNGR RNG ECON NICKEL PLT,SUP-2382309,CDM,C1776,CPT,0278,RC,,,,both,,,100.01,65.01,,,,,,,,,,,,,
OSTEOTOME CVD .50MMX120MM HRIS,SUP-2364384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.79,510.76,,,,,,,,,,,,,
PLATE BNE CRV 3.5X213 MM 18 HOLE RECON FOR SCR SS NS,SUP-2482146,CDM,C1713,HCPCS,0278,RC,,,,both,,,1635.22,1062.89,,,,,,,,,,,,,
SCREW BNE DSTL 4.3X22 MM SHLDR PUR NS AEQUALIS,SUP-2715424,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
HC Mammo Screening Incl Cad if Perf,PX-4037706700,CDM,77067,CPT,0403,RC,,,,outpatient,,,480.00,312.00,,,,,,,,,,,,,
PLATE BNE L97MM 8 H BILAT S STL 1/3 TBLR FOR 3.5MM SCR,SUP-2411345,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.35,141.28,,,,,,,,,,,,,
PLATE BONE L77MM 6 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1066.03,692.92,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN,RX-5474,CDM,6370000000,HCPCS,0637,RC,24208-0790-62,NDC,,both,10,ML,229.80,149.37,,,,,,,,,,,,,
DRILL SURGICAL 4.5MM CANNULATED VERSITOMIC,SUP-2589312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1192.79,775.31,,,,,,,,,,,,,
LORDOTIC 8MM,SUP-2309709,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GRAFT DURA REP L 5 X W 5 CM THK 0.4 MM ELECTROSPUN FIBER ART5506,SUP-2904066,CDM,C1763,HCPCS,0278,RC,,,,both,,,3122.73,2029.77,,,,,,,,,,,,,
SCREW BNE L76MM DIA4.5MM CORT TI ST NONCANNULATED,SUP-2190484,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.79,81.76,,,,,,,,,,,,,
COUNTERSINK SURG CANN W/ S CPLR FOR SM FRAG PLATING SYS,SUP-2211520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1094.29,711.29,,,,,,,,,,,,,
PLATE BONE L47MM 6 H S STL 1/4 TBLR QTR SLGHT CONCV W/O CLLR,SUP-2186072,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
SPACER KNEE 22 MM VANGUARD,SUP-2446703,CDM,C1776,CPT,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX150 CM RADIFOCUS GLIDEWIRE,SUP-2385261,CDM,C1769,HCPCS,0272,RC,,,,both,,,118.44,76.99,,,,,,,,,,,,,
RING EXT FIX FULL 180 MM CARBON DFS DYNAFIX,SUP-2534571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
PHILADEPHIA CLLR 1-PIECE - RIG EXTRIC TALL,SUP-2194491,CDM,L0172,HCPCS,0272,RC,,,,both,,,25.62,16.65,,,,,,,,,,,,,
BRACE WLK L 105 12MM M 115 13MM FEM STD TWO LAYR MEM FOAM,SUP-2195488,CDM,L4360,HCPCS,0272,RC,,,,both,,,82.30,53.49,,,,,,,,,,,,,
GRAFT BNE SUB 90CC 1 4MM CANC CRUSH CHIP READIGRFT,SUP-2264829,CDM,C1713,HCPCS,0278,RC,,,,both,,,3354.12,2180.18,,,,,,,,,,,,,
PLATE PL DSTL HUM LAT SUPP 3.5MM 3H RT 65MM LCP STRL,SUP-2547560,CDM,C1713,HCPCS,0278,RC,,,,both,,,2905.19,1888.37,,,,,,,,,,,,,
CATHETER CV 5 FRX55 CM PWR INJ MAX BARR NURSING KT XCELA,SUP-2734862,CDM,C1751,HCPCS,0278,RC,,,,both,,,126.23,82.05,,,,,,,,,,,,,
FIBER LASER FLAT TIP 200 MH ASMBLY HOLM MF200BH] GALLAGHER MEDICAL PRODUCTS LLC],SUP-2225998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
SPLINT WRST L R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326139,CDM,L3908,HCPCS,0274,RC,,,,both,,,63.71,41.41,,,,,,,,,,,,,
IMPLANT WR JT L37MM 9MM TAPR CRPL PLT MAESTRO,SUP-2407357,CDM,C1713,HCPCS,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
BRACE ORTH FRAC FEM CAST MOLD KAFO L2126] TIDEWATER PROSTHETICS],SUP-2388170,CDM,L2126,HCPCS,0274,RC,,,,both,,,3243.18,2108.07,,,,,,,,,,,,,
SET INTRO L2IN OD6FR PERC HEMSTAS VLV PRT TIP MRK DUST CAP,SUP-2383422,CDM,C1894,HCPCS,0272,RC,,,,both,,,865.48,562.56,,,,,,,,,,,,,
CAGE SPINAL W14XH8XL16MM 8DEG ZERO PROFILE TOMCAT,SUP-2550522,CDM,C1889,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
BIT DRL DIA4MM FOR FOOTPRINT ANCHR SL SYS,SUP-2341887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.93,338.60,,,,,,,,,,,,,
PLATE BONE THK2MM 4X20X4 H MAND TI X LCKING DBL ANG FOR 2MM,SUP-2191275,CDM,C1713,HCPCS,0278,RC,,,,both,,,8910.69,5791.95,,,,,,,,,,,,,
PLATE BNE SUPER ELASTIC W/ SCREW FOR MOTOCLIP DYNAFORCE,SUP-2431539,CDM,C1713,HCPCS,0278,RC,,,,both,,,3946.98,2565.54,,,,,,,,,,,,,
MESH HERN W20XL30CM THK1MM PTCH RECT 2 SIDE FOR VENTRAL,SUP-2125802,CDM,C1781,HCPCS,0278,RC,,,,both,,,6018.44,3911.99,,,,,,,,,,,,,
BUMPER KNEE REV HINGE NEUT STRL TRIATHLON,SUP-2890083,CDM,C1776,CPT,0278,RC,,,,both,,,2959.45,1923.64,,,,,,,,,,,,,
SCREW BNE CANC 6.5X140 MM FT HEX HD SS NS,SUP-2457545,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.48,86.11,,,,,,,,,,,,,
PLATE BNE L 312 MM SCREW DIA 3.5/4.5 MM 14 H UTIL NS EVOS,SUP-2932827,CDM,C1713,HCPCS,0278,RC,,,,both,,,17347.72,11276.02,,,,,,,,,,,,,
PLATE BNE L20MM UNICOMPRESSION INTERAXIS UNI CLIP,SUP-2243463,CDM,C1713,HCPCS,0278,RC,,,,both,,,3358.39,2182.95,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 2.9 MM PEEK OPTMA LINK CLEAT EYELET,SUP-2431668,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 11 MM OSTEOCHNDRL,SUP-2866831,CDM,C1762,CPT,0278,RC,,,,both,,,12140.81,7891.53,,,,,,,,,,,,,
HC Skeletal Survey Large Bone,PX-3207707400,CDM,77074,CPT,0320,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 0.8X100 MM NS,SUP-2789081,CDM,C1769,HCPCS,0272,RC,,,,both,,,759.25,493.51,,,,,,,,,,,,,
CLIP HEMSTAS 90 DEG 8.5 MM LNG LIG ARM YEL STRL EZ CLP LF,SUP-2865652,CDM,C1889,HCPCS,0278,RC,,,,both,,,187.65,121.97,,,,,,,,,,,,,
HC Cervical Disc/Inj Each Level,PX-3616229100,CDM,62291,CPT,0361,RC,,,,outpatient,,,2224.00,1445.60,,,,,,,,,,,,,
CLAMP 3 D LG BL,SUP-2460235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1749.07,1136.90,,,,,,,,,,,,,
MARKER MOLLI RE.MARKABLE 12CM,SUP-2875966,CDM,A4648,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
FENTANYL CITRATE-NACL 1-0.9 MG/100ML-% IJ SOLN,RX-155623,CDM,J3010,HCPCS,0636,RC,69374-0523-10,NDC,,both,100,ML,135.20,87.88,,,,,,,,,,,,,
PIN HALF THRD 5X120 MM 35 MM SELF DRILLING APEX,SUP-2363228,CDM,C1713,HCPCS,0278,RC,,,,both,,,201.24,130.81,,,,,,,,,,,,,
PROTECTOR TISS SHTH L 14 CM INCISION 2.5-8 CM SM ORTH RIGID,SUP-2929746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
VALVE VENT REG POLYPR SIL PERF LEV 05 ELASTMR LO FLSH RESVR,SUP-2284400,CDM,C1713,HCPCS,0278,RC,,,,both,,,3473.56,2257.81,,,,,,,,,,,,,
TUBE ET OD8.8MM ID6MM 2 CHN REINF DISP FOR EMG NIM,SUP-2284326,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1228.24,798.36,,,,,,,,,,,,,
HC Blood Occult Peroxidase Actv Qual Other Sources,PX-3018227100,CDM,82271,CPT,0301,RC,,,,both,,,67.00,43.55,,,,,,,,,,,,,
NAIL FEM RG 13.5MMX380MM,SUP-2405541,CDM,C1713,HCPCS,0278,RC,,,,both,,,6961.38,4524.90,,,,,,,,,,,,,
IMPLANT FEM L29MM DIA9MM INSRT APERFIX AM,SUP-2402620,CDM,C1713,HCPCS,0278,RC,,,,both,,,3175.67,2064.19,,,,,,,,,,,,,
PLATE BONE 10 H ANTR BOW LAT PROX FOR 3.5 SCR,SUP-2349060,CDM,C1713,HCPCS,0278,RC,,,,both,,,930.85,605.05,,,,,,,,,,,,,
MESH 16X12 L ANAT,SUP-2172954,CDM,C1781,HCPCS,0278,RC,,,,both,,,1490.50,968.82,,,,,,,,,,,,,
GUIDEWIRE VASC ARISTOTLE 24 L 200 CM DIA 0.024 IN SFT,SUP-2656738,CDM,C1769,HCPCS,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
CAGE SPNL 12-17 MM BLK CALIB,SUP-2229227,CDM,C1889,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
ESUCTION COLONIC 3BOX,SUP-2677575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,829.18,538.97,,,,,,,,,,,,,
LOCKING MNDBLR ANGLE PLATE 4X4 NON CMPRSSN 20MM THICK T 6L,SUP-2694219,CDM,C1713,HCPCS,0278,RC,,,,both,,,2614.08,1699.15,,,,,,,,,,,,,
STENT CORONARY MAGIC WSTNT STRL,SUP-2140982,CDM,C1876,HCPCS,0278,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
PORT INFUS CATH DIA9.6FR TI ATTCH SIL PEEL APART INTRO SGL,SUP-2127726,CDM,C1788,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SCREW SET FOR GUID BLOCK,SUP-2653726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
SYSTEM BREATHING ADULT 22MM HME AND MR,SUP-2850079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1529.12,993.93,,,,,,,,,,,,,
PLATE BNE L69MM 3 H L SUP ANT CLAV S STL LOK COMPR W/ LAT,SUP-2184128,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.95,1659.42,,,,,,,,,,,,,
CAP NAIL L 8 MM DIA11 MM TIB LOWER EXTREMITY STRL PICCOLO,SUP-2930791,CDM,C1713,HCPCS,0278,RC,,,,both,,,286.02,185.91,,,,,,,,,,,,,
SET INTRO PERFRMR L 5.5 CM DIA 4 FR GUIDEWIRE L 30 CM DIA,SUP-2169705,CDM,C1894,HCPCS,0272,RC,,,,both,,,104.41,67.87,,,,,,,,,,,,,
BLADE CHSL SM W10XL120MM THK1MM LNG STR DISP FOR KNEE EXTR,SUP-2341199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.70,304.00,,,,,,,,,,,,,
GRAFT BNE INJ 5 CC REGENERATIVE PRO-DENSE,SUP-2759598,CDM,C1713,HCPCS,0278,RC,,,,both,,,5216.61,3390.80,,,,,,,,,,,,,
PLATE BURR H L 22.63 DIA18.5 MM SLOT 4.5 MM SCREW DIA1.5 MM,SUP-2936847,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
SCREW BNE L70MM DIA4MM HEX HD DIA62MM CORT DST FEM TI ST,SUP-2205007,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 20MMW X 60MML SPNL MSCLE NRRW RGGLS RDM,SUP-2462358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1624.60,1055.99,,,,,,,,,,,,,
HC So Dna/Rna Amplified Probe,PX-3008715066,CDM,87150,CPT,0300,RC,,,,both,,,173.00,112.45,,,,,,,,,,,,,
AUGMENT TIB SZ 4 THK5MM RT MEDL LT LAT KNEE CO CHROM TOT,SUP-2363802,CDM,C1776,CPT,0278,RC,,,,both,,,3895.92,2532.35,,,,,,,,,,,,,
PLATE CRAN THK 0.3 MM SCREW DIA1.5 MM MASTOID NS DISP,SUP-2936857,CDM,C1713,HCPCS,0278,RC,,,,both,,,2885.66,1875.68,,,,,,,,,,,,,
ORTHOPEDIC KIT GLENOSPHERE 46 MM EXP EXT LCK CAP,SUP-2451423,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
DEVICE MENIS REP SEQUENT CRV 3 IMPLANTS,SUP-2167207,CDM,C1713,HCPCS,0278,RC,,,,both,,,2309.41,1501.12,,,,,,,,,,,,,
ALLOGRAFT BNE HUM SHFT 160X2 MM FRZN,SUP-2717864,CDM,C1762,CPT,0278,RC,,,,both,,,4563.83,2966.49,,,,,,,,,,,,,
BAR ARCH OVERALL 5IN DENT,SUP-2160755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,59.25,38.51,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 5000RPM STR SNUS M4 ROT OFFSET CUT,SUP-2284144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,768.17,499.31,,,,,,,,,,,,,
TECH SURGICAL BOSTON ENDO,SUP-2114054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
TUBE FEED OD14FR ID9FR SIL JEJUSTMY TRIM DST TIP SUT WNG,SUP-2124616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.04,388.08,,,,,,,,,,,,,
PIN FIX L40MM DIA3.5MM PROV TARGETER FOR 3.5MM LAT PROX TIB,SUP-2343986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1541.17,1001.76,,,,,,,,,,,,,
INTRODUCER KYPHOPLASTY SZ 3 8GA 42MM BVL OSTEO KYPHON 1 STP,SUP-2281650,CDM,C1894,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 2X2X3 CM PRESERVON CANC READIGRAFT,SUP-2740812,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
SHEATH ACCS 18 FRX16 CM OPQ AMPLATZ,SUP-2835768,CDM,C1894,HCPCS,0272,RC,,,,both,,,93.73,60.92,,,,,,,,,,,,,
GRAFT BONE SUB 22X45MM ILIUM TRICORT STRP,SUP-2281639,CDM,C1762,CPT,0278,RC,,,,both,,,5986.57,3891.27,,,,,,,,,,,,,
SCREW SPNL STV HELIX,SUP-2311049,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
BRACE ANK LACE UP X LG ELASTIC CUF CLOSURE SPRT ORTHOSIS NYL,SUP-2336333,CDM,L4350,HCPCS,0272,RC,,,,both,,,33.69,21.90,,,,,,,,,,,,,
TUBE VENT 1.02 MM GRMMT W/ TAB SIL,SUP-2535078,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.83,19.39,,,,,,,,,,,,,
SCREW BNE L28MM DIA4MM DST FIBULAR NONLOCKING PARTIALLY THRD,SUP-2400216,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
SCREW SPNL CANC 6.5X50 MM LUMBAR SD FIX THRD TI SPINELINK,SUP-2468598,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.88,131.87,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X161 MM 9 HOLE SS LCP,SUP-2569362,CDM,C1713,HCPCS,0278,RC,,,,both,,,611.36,397.38,,,,,,,,,,,,,
PLATE BNE L159MM 6 H L CNDYL S STL VAR ANG LOK COMPR,SUP-2184325,CDM,C1713,HCPCS,0278,RC,,,,both,,,5380.04,3497.03,,,,,,,,,,,,,
CARTILAGE ALLOGRAFT MATRIX CAM,SUP-2726033,CDM,C1762,CPT,0278,RC,,,,both,,,1975.37,1283.99,,,,,,,,,,,,,
HC Splint App Long Leg,PX-4502950500,CDM,29505,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
SCREW +50MM L55MMCANNULATED COMPR,SUP-2364825,CDM,C1713,HCPCS,0278,RC,,,,both,,,4279.51,2781.68,,,,,,,,,,,,,
GUIDEWIRE VASC TEFCOR L 145 CM 0.038 IN 10 CM CRV RAD 3 MM,SUP-2167805,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.66,29.68,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK L 70 CM DIA 3.5 FR 3 CM 5 MM,SUP-2659381,CDM,C1725,HCPCS,0272,RC,,,,both,,,1684.30,1094.79,,,,,,,,,,,,,
BRACE ORTHOPEDIC PADDED UNIV ANK STIRRUP,SUP-2306212,CDM,L4350,HCPCS,0272,RC,,,,both,,,75.05,48.78,,,,,,,,,,,,,
RING FIX OVL 180MM IMP DNE,SUP-2197263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
GUIDEWIRE ORTH 600 MM STRL,SUP-2609518,CDM,C1769,HCPCS,0272,RC,,,,both,,,335.57,218.12,,,,,,,,,,,,,
HC Canalith Repositioning Proc|OP PT SERVICES,PX-4209599200,CDM,95992,CPT,0420,RC,,,GP,outpatient,,,333.00,216.45,,,,,,,,,,,,,
NAIL IM PERITROCHANTERIC PTN,SUP-2606675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1896.56,1232.76,,,,,,,,,,,,,
VALVE NEUROSURGICAL OD1.9MM CATHETERL90CM 40CM VERTICAL WATE,SUP-2825677,CDM,C1889,HCPCS,0278,RC,,,,both,,,6978.84,4536.25,,,,,,,,,,,,,
SET SCR SPNL L32MM DIA6.35MM TI LOK BRK OFF DBL HEX SOCK,SUP-2289649,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.01,226.86,,,,,,,,,,,,,
STEM HUM DIA11MM SHLDR PRI PRESSFIT EQUINOXE,SUP-2223279,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 5FR 45CML SIL RADPQ SHERLOCK MAG 9827505,SUP-2632708,CDM,C1751,HCPCS,0278,RC,,,,both,,,385.40,250.51,,,,,,,,,,,,,
BUR SURG CYL 8X13.5 MM 14 CM FLUT CORNERSTONE MIDAS REX 8,SUP-2664600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.87,314.52,,,,,,,,,,,,,
LENS IOL BCNVX 16+ DIOPT 6X13 MM ANTR CHMBR SIL,SUP-2112386,CDM,V2632,HCPCS,0276,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
HC So2 Islet Cell Antibody,PX-3028634168,CDM,86341,CPT,0302,RC,,,,both,,,55.00,35.75,,,,,,,,,,,,,
PIN TEMP FIX AVTR,SUP-2532810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
HC US Retroperitoneal Limited,PX-4027677500,CDM,76775,CPT,0402,RC,,,,both,,,964.00,626.60,,,,,,,,,,,,,
FOOTPLATE EXT FIX 120 MM PVC FREE TRUELOK +,SUP-2645678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1349.92,877.45,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5CM 11MM 120CM HEPARIN,SUP-2396581,CDM,C1874,HCPCS,0278,RC,,,,both,,,11008.84,7155.75,,,,,,,,,,,,,
BLADE RETRACTOR 64 MM HIP FIX STRT CUPX,SUP-2242469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SYSTEM ICD CRT VR-T W/ HOME MON LUMAX 340,SUP-2138125,CDM,C1722,HCPCS,0275,RC,,,,both,,,53986.93,35091.50,,,,,,,,,,,,,
INSERT TIB SULCUS 5+ 12 MM LT RT TOT ANK POLYETH INBONE II,SUP-2850362,CDM,C1776,CPT,0278,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ LOOP LOK W STAY FIRM SUPP,SUP-2276658,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.45,10.69,,,,,,,,,,,,,
PLATE BNE L36MM 6 H BILAT TI STR RIG NONCOMPRESSION FOR,SUP-2191469,CDM,C1713,HCPCS,0278,RC,,,,both,,,1213.55,788.81,,,,,,,,,,,,,
SCREW BNE MULT DIRECTION 3.5X12MM T15 COBALT CHROM NS ALPS,SUP-2457271,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.03,302.27,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 6X4 CM PLCNTA BASE MEMBRN AMNIOEFFECT,SUP-2871500,CDM,C1762,CPT,0278,RC,,,,both,,,8079.22,5251.49,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 4.01-5.0 MCI STRL ADVANTAGE 2029ELS1] ISOAID LLC],SUP-2247269,CDM,C2642,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
DRESSING BIO L 20 X W 7 CM SZ 200 UM PORCINE SM INTEST,SUP-2905516,CDM,Q4103,HCPCS,0636,RC,,,,both,,,5412.58,3518.18,,,,,,,,,,,,,
PLATE BONE L115MM RIB RIBLOC U+,SUP-2107918,CDM,C1713,HCPCS,0278,RC,,,,both,,,4722.56,3069.66,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST LIFT ELEVATION PER INCH,SUP-2435719,CDM,L3334,HCPCS,0272,RC,,,,both,,,107.95,70.17,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 20X12 - 13 MM FRZ DRY,SUP-2294106,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
PLATE SPNL CERV 8 DEG 24X26X12 MM GRN ZUMA,SUP-2245546,CDM,C1713,HCPCS,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
PROSTHESIS OSS GRATE 1.15X1.78X4.7 MM MALL TO STAPE STRUT,SUP-2637861,CDM,L8613,CPT,0278,RC,,,,both,,,714.88,464.67,,,,,,,,,,,,,
SPLINT ANK FT XL L POST LEAF LTWT SEMI RIG ROLYAN,SUP-2326014,CDM,L4396,HCPCS,0274,RC,,,,both,,,140.08,91.05,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 100 CM DIA 8 MM EPTFE STR TW REINF,SUP-2498187,CDM,C1768,CPT,0278,RC,,,,both,,,1788.36,1162.43,,,,,,,,,,,,,
PROBE THERMOMETER ORL ADLT 4FT CRD F/ COVIDIEN FILAC 3000 LT,SUP-2613010,CDM,C1751,HCPCS,0278,RC,,,,both,,,113.13,73.53,,,,,,,,,,,,,
THORACOLUMBAR STPL SYS GRPHC CA,SUP-2232367,CDM,C1713,HCPCS,0278,RC,,,,both,,,8845.38,5749.50,,,,,,,,,,,,,
GRAFT HUM TISS DIA15MM OSTEOCHNDRL CHONDROFIX,SUP-2200261,CDM,C1713,HCPCS,0278,RC,,,,both,,,12183.20,7919.08,,,,,,,,,,,,,
INSERT TIB SZ 1 THICKNESS 11MM UNIV POLYETH PRI NEUT UNI,SUP-2342172,CDM,C1776,CPT,0278,RC,,,,both,,,1893.42,1230.72,,,,,,,,,,,,,
PACEMAKER CARD INVIVE W 1.75 X H 2.4 IN THK 0.76 CM 34 GM,SUP-2149292,CDM,C2621,HCPCS,0275,RC,,,,both,,,24178.00,15715.70,,,,,,,,,,,,,
HEAD HUM DIA40MM SHT FOR TOT SHLDR ARTHROPLASTY GLOB,SUP-2250013,CDM,C1776,CPT,0278,RC,,,,both,,,4574.35,2973.33,,,,,,,,,,,,,
KIT INT FIX EL DST BICEP TEND GUID PIN MAXBRAID SUT DEV,SUP-2212944,CDM,C1713,HCPCS,0278,RC,,,,both,,,5903.20,3837.08,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE|DOCUMENTATION ON FILE,PX-4409712900,CDM,97129,CPT,0440,RC,,,GN|KX,both,,,186.00,120.90,,,,,,,,,,,,,
INSERT ACET SZ F OD54-56MM ID28MM 0DEG UHMWPE CONSTRN,SUP-2344625,CDM,C1776,CPT,0278,RC,,,,both,,,7466.92,4853.50,,,,,,,,,,,,,
PLATE SPNL CERV ANT UNIV 2 LEV 24MM LEN STD SPIDER,SUP-2402149,CDM,C1713,HCPCS,0278,RC,,,,both,,,4518.46,2937.00,,,,,,,,,,,,,
SPEEDBRG IMP SYS W/BIO-COMP SWVLK,SUP-2812573,CDM,C1713,HCPCS,0278,RC,,,,both,,,5997.40,3898.31,,,,,,,,,,,,,
STEM HUM L 150 MM DIA 7 MM CLLR DIA 34 MM SZ 2 XLN PLASMA,SUP-2912558,CDM,C1776,CPT,0278,RC,,,,both,,,23588.62,15332.60,,,,,,,,,,,,,
PLATE BNE L22MM 8 H R S STL EXT H SHP LO PROF RIG NEUT LOK,SUP-2186294,CDM,C1713,HCPCS,0278,RC,,,,both,,,1275.75,829.24,,,,,,,,,,,,,
SPACER SPNL H12MM ASMBLY PRIMALOK SP,SUP-2319813,CDM,C1713,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
SCREW BNE L40MM DIA3MM THRD L18MM G CORT TI ALLY ST SELF,SUP-2189784,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.36,355.78,,,,,,,,,,,,,
BAR THRD 80MM FOR SHEFFIELD STRL TY SYS,SUP-2316264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.02,224.26,,,,,,,,,,,,,
GRAFT BNE SUB L W10XH7XL50MM COMPRESSIBLE SPNG STRP PROVIDE,SUP-2138507,CDM,C1713,HCPCS,0278,RC,,,,both,,,7322.10,4759.36,,,,,,,,,,,,,
KIT INTRO VSI L 5.5 CM DIA 5 FR GUIDEWIRE L 40 CM DIA 0.018,SUP-2120552,CDM,C1894,HCPCS,0272,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
CICLOPIROX OLAMINE 0.77 % EX CREA,RX-9598,CDM,6370000000,HCPCS,0637,RC,51672-1318-01,NDC,,both,15,GR,83.70,54.40,,,,,,,,,,,,,
SURGICAL INSTRUMENT KIT 3 MM MINIMALLY INVASIVE PONTO BK UP,SUP-2430322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,811.06,527.19,,,,,,,,,,,,,
CANNULA ENDOSCP DIA 7/8 MM SHRT REDUCER 5 MM DIL RADIALLY,SUP-2896314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.05,279.53,,,,,,,,,,,,,
FLORANEX PO PACK,RX-93352,CDM,6370000000,HCPCS,0637,RC,71351-0013-12,NDC,,both,1,UN,7.40,4.81,,,,,,,,,,,,,
CATHETER URET 6FR L70CM OPN END FOR DRNGE RG PYELOGRAM,SUP-2171216,CDM,C1758,HCPCS,0278,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
CANNULA ENDOSCP ZERO TUBE STRL DISP PARALLELPORTAL,SUP-2908750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
INSERT ACET OD52MM ID28MM HIP ULTAMET LCK RNG ALTERNATIVE,SUP-2250325,CDM,C1776,CPT,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6 MM L 50 CM STR TW,SUP-2396314,CDM,C1768,CPT,0278,RC,,,,both,,,4072.58,2647.18,,,,,,,,,,,,,
HC Diag Lumbar Spinal Puncture W/Fluor or CT,PX-3616232800,CDM,62328,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
MESH CRAN W90XL90MM PROF H0.6MM MIC UP FACE,SUP-2366218,CDM,C1713,HCPCS,0278,RC,,,,both,,,4478.33,2910.91,,,,,,,,,,,,,
ANCHOR SUT ROT CUF W/ ORTHOCORD 2 SUT QUICKANCHR +,SUP-2256679,CDM,C1713,HCPCS,0278,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
SCISSORS SURG METZ DISECT STD BLNT SERR S STL CRV 9IN,SUP-2382454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,62.11,40.37,,,,,,,,,,,,,
GRAFT BNE SUB 25CC 2MM GRAN ALLOGENIC MORPHOGENETIC PROT W,SUP-2138495,CDM,C1713,HCPCS,0278,RC,,,,both,,,2075.92,1349.35,,,,,,,,,,,,,
PROGUIDE 36CM BASIC KIT HOLES 16F PLWAY SHTH 18 G INTRDCR ND,SUP-2676389,CDM,C1894,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
COUPLER EXT FIX PENNIG II,SUP-2875763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1707.85,1110.10,,,,,,,,,,,,,
PLATE BROAD Y 7 SHAFT HL,SUP-2702911,CDM,C1713,HCPCS,0278,RC,,,,both,,,4325.66,2811.68,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT DIA29 MM BOV PERICARD COCR,SUP-2214059,CDM,C1889,HCPCS,0278,RC,,,,both,,,19436.60,12633.79,,,,,,,,,,,,,
SYSTEM DILATOR ENDOSCOPIC XPRESS LOPROFILE 6MM BALLOON 8MM,SUP-2900183,CDM,C1726,HCPCS,0272,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
SUPPORT ORTHOT ANK PEDIATRIC KNEE CUST PLAS,SUP-2435637,CDM,L2035,HCPCS,0274,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
GRAFT BNE DWL FRZ DRY UNICORTICAL L 14-40MM OD 15MM,SUP-2307088,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
IMPLANT NSL 1 SYS ABSRB LATERA,SUP-2354995,CDM,C1889,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SCREW BNE L64MM DIA4.5MM HD DIA6.5MM CANC S STL ST SELF DRL,SUP-2184472,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.75,318.99,,,,,,,,,,,,,
PLATE BONE LNG THK0.6MM 100DEG 4X6 H MIDFACE SLV TI LT L SHP,SUP-2135896,CDM,C1713,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
PLATE BNE 4X2 H LOK GRID TRAP FOR 2MM SCR H DIA,SUP-2267948,CDM,C1713,HCPCS,0278,RC,,,,both,,,2077.42,1350.32,,,,,,,,,,,,,
GUIDEWIRE ORTH L20IN DIA2MM S STL BLNT TIP POLARUS 3,SUP-2106880,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
MATRIX HUM TISS L 4 X W 10 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909315,CDM,Q4122,HCPCS,0636,RC,,,,both,,,9678.42,6290.97,,,,,,,,,,,,,
HC Repair Wound/Lesion +,PX-4501315300,CDM,13153,CPT,0450,RC,,,,both,,,792.00,514.80,,,,,,,,,,,,,
CATHETER KIT 0.018 INX17.75 IN AD 4 FRX50 CM BLU FLEXTIP,SUP-2384053,CDM,C1751,HCPCS,0278,RC,,,,both,,,145.26,94.42,,,,,,,,,,,,,
CUTTER BNE 2.5MM AGG SM JT J LOK JTCUT,SUP-2366551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,128.14,83.29,,,,,,,,,,,,,
HC Temporary External Pacing,PX-4809295300,CDM,92953,CPT,0480,RC,,,,outpatient,,,1976.00,1284.40,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 260 CM DIA 0.025 IN FLX TIP L 7 CM,SUP-2157231,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
PLATE BNE L55-65MM TROCHANTERIC HIP MALLORY-HEAD TI 2 PC,SUP-2405219,CDM,C1713,HCPCS,0278,RC,,,,both,,,1371.55,891.51,,,,,,,,,,,,,
SCREW SPNL SD 4X11 MM MINIP DIVERGENCE,SUP-2632032,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST W/NONTORSION JT PREFABRICATED,SUP-2435786,CDM,L3929,HCPCS,0274,RC,,,,both,,,235.31,152.95,,,,,,,,,,,,,
STRAP BITE BLOCK CLAV HVY DUTY,SUP-2148720,CDM,L3650,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BIT DRL 2MM INTOSS FIX SYS SLD,SUP-2315897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.22,370.64,,,,,,,,,,,,,
NERVE STIMULATOR KIT INSUL DIL STRL SAFEOP,SUP-2726377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD UNI,SUP-2351346,CDM,C1776,CPT,0278,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
CARBON FIBER ROD 5.0MMX250MM,SUP-2810995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
COIL VASC VORTX-35 L 35 MM UNRESTRAINED L 4.5 MM DIA 5 MM,SUP-2142386,CDM,C1889,HCPCS,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
DEVICE CONTAINMENT FOR SYS TISS EXTR PNEUMOLINER,SUP-2313602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
COMPONENT ARTC SURF 1 9 MM KNEE,SUP-2200487,CDM,C1776,CPT,0278,RC,,,,both,,,1661.37,1079.89,,,,,,,,,,,,,
GELFOAM SZ 100 SPNG,SUP-2326434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1048.76,681.69,,,,,,,,,,,,,
IMPLANT BIO TISS W6XL6CM REGEN PORCINE CLLGN SQ XENMATRIX,SUP-2126236,CDM,C1781,HCPCS,0278,RC,,,,both,,,3460.59,2249.38,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 15CML IN 5496150,SUP-2632895,CDM,C1752,HCPCS,0278,RC,,,,both,,,592.52,385.14,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4 FR 40 CM 0.018IN 7CM NIT SHFT STIFF,SUP-2615950,CDM,C1894,HCPCS,0272,RC,,,,both,,,113.29,73.64,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 145 CM DIA 0.035 IN TAPR L 15 CM SS,SUP-2169719,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.31,24.90,,,,,,,,,,,,,
HEAD FEM SKIRTED 40 MM HIP OFFSET COCR,SUP-2308969,CDM,C1776,CPT,0278,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
PROBE ABLATN MICROWAVE 14 GAX270 MM AMICA,SUP-2303522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
TIP ASPIR L4.53IN ID0.05IN DISP FOR ULTRASONIC SURG ASPIR,SUP-2243960,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE STP 4 H 2 SLOT DISPLC CALCNL TI MATING SCR 35MM,SUP-2243234,CDM,C1713,HCPCS,0278,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
BRACE KNEE POSTOP COOL PROCARE TROM ADV,SUP-2195713,CDM,L1810,HCPCS,0274,RC,,,,both,,,226.68,147.34,,,,,,,,,,,,,
COIL VASC MREYE FLIPPER EMBOLUS L 3 CM DIA 3 MM CATH DIA,SUP-2170592,CDM,C1889,HCPCS,0278,RC,,,,both,,,275.54,179.10,,,,,,,,,,,,,
BASEPLATE TIB STD UNIV PRI STEM CEM NP PC 46 A/PX67MM M/L,SUP-2200381,CDM,C1776,CPT,0278,RC,,,,both,,,9834.48,6392.41,,,,,,,,,,,,,
GRAFT HUM TISS CHORION FREE THN 4X4 CM AMNIO ACTISHIELD CF,SUP-2759452,CDM,C1762,CPT,0278,RC,,,,both,,,6292.56,4090.16,,,,,,,,,,,,,
VALVE SPEAK W/ O2 PRT PHONATE,SUP-2283884,CDM,L8501,HCPCS,0272,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
ENDCAP SPNL DIA13MM,SUP-2415362,CDM,C1889,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SET HAD CATH AD 11.5FR L20CM SIL PERIPH ACUTE 2 LUMN TAPR,SUP-2267078,CDM,C1752,HCPCS,0278,RC,,,,both,,,347.91,226.14,,,,,,,,,,,,,
BUTTON ENEMA CECOSTOMY 14 FRX6 CM BLLN MINIACE,SUP-2119469,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BIT DRL CANN ADD ON CPL FOR 5MM ASNS III SCR,SUP-2365000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1569.37,1020.09,,,,,,,,,,,,,
ROD IM ALIGN TIB LEGEND II,SUP-2454377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1849.46,1202.15,,,,,,,,,,,,,
RING EXT FIX 200 MM 5/8 MR SAFE TI NS,SUP-2863456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2381.28,1547.83,,,,,,,,,,,,,
ALLOGRAFT BNE MED 3.5-4X1-2 CMX 1.8-2.2 MM FD STRL PROF LF,SUP-2465430,CDM,C1889,HCPCS,0278,RC,,,,both,,,2144.78,1394.11,,,,,,,,,,,,,
STEM HUM CEM 9X210 MM SHLDR REVERSED AEQUALIS,SUP-2715592,CDM,C1776,CPT,0278,RC,,,,both,,,8806.13,5723.98,,,,,,,,,,,,,
LEAD PACE 2.6FR L50CM UPLR TEMP ATR NONSTEROID ELUT PIN,SUP-2282230,CDM,C1786,HCPCS,0275,RC,,,,both,,,43.18,28.07,,,,,,,,,,,,,
PUSHER KNOT ENDOSCP OPN TIP REUSE 5MM DIA 40CM LEN APPEL,SUP-2243658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.19,344.62,,,,,,,,,,,,,
MICROCATHETER INFUSION MAESTRO 150CM 2.8/2.4FR TRUEFORM,SUP-2462621,CDM,C1887,HCPCS,0272,RC,,,,both,,,1642.06,1067.34,,,,,,,,,,,,,
BOLT EXT FIX 6.5X190 MM SALVATION,SUP-2484347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 6H 118MM LEFT STERILE,SUP-2549635,CDM,C1713,HCPCS,0278,RC,,,,both,,,5012.66,3258.23,,,,,,,,,,,,,
SCREW SPNL OD5.5MM PEDCL LUM THRD STRT H TOP CLSR,SUP-2415297,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
HC US Abdominal Limited,PX-4027670500,CDM,76705,CPT,0402,RC,,,,both,,,1336.00,868.40,,,,,,,,,,,,,
KIT INDIR DCOMPR SYS W/ DRVR INSRTR AND INTERSPINOUS GA,SUP-2392704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ANCHOR SUTURE SFT LNG SINGLE LD WHT BLU JUGGERKNOT,SUP-2745509,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS REDUCTION UNIAXIAL STRL CD,SUP-2926604,CDM,C1713,HCPCS,0278,RC,,,,both,,,2841.70,1847.10,,,,,,,,,,,,,
BIT DRL CANN 10X150 MM QR CALIB BUD NS POLARUS 2 DISP,SUP-2518653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
CATHETER VENTRICULAR 13 CM IMPL OSV II,SUP-2666643,CDM,C1729,HCPCS,0272,RC,,,,both,,,9286.05,6035.93,,,,,,,,,,,,,
ALLOGRAFT BNE CART 2-5.9X1 CM NACL COSTAL,SUP-2717801,CDM,C1762,CPT,0278,RC,,,,both,,,3837.05,2494.08,,,,,,,,,,,,,
SCREW BNE PERC COMPR BUTTERFLY GOTFRIED,SUP-2644773,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.50,246.02,,,,,,,,,,,,,
WASHER ORTH DIA65MM TI RND FOR 3MM CANN SCR,SUP-2190560,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.16,46.90,,,,,,,,,,,,,
STEM R120 MOD CEM SZ 2,SUP-2217519,CDM,C1776,CPT,0278,RC,,,,both,,,10977.44,7135.34,,,,,,,,,,,,,
SENSOR PRSSRE WTRNSDCR WTH BFRCTD PRSSRE LINES WTH VAMP SST,SUP-2696594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1103.77,717.45,,,,,,,,,,,,,
PLATE BNE FIBULAR 7 HOLE COMP LCK STRL ALPS LTX,SUP-2861800,CDM,C1713,HCPCS,0278,RC,,,,both,,,601.56,391.01,,,,,,,,,,,,,
HC Interoperative U/S Guid Rd Mat,PX-4027696500,CDM,76965,CPT,0402,RC,,,,both,,,1167.00,758.55,,,,,,,,,,,,,
PPICC PROVENA SOLO SP 4F DL MAX,SUP-2613540,CDM,C1751,HCPCS,0278,RC,,,,both,,,672.15,436.90,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX19 CM SIDE H SPRT PK W/ STYL SYMETREX,SUP-2627494,CDM,C1750,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
GENII TIB BSPL SZ3 LT HA COAT,SUP-2822759,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.8 MM THOR 11 HOLE LCK JLT NS LEVEL 1,SUP-2869245,CDM,C1713,HCPCS,0278,RC,,,,both,,,914.05,594.13,,,,,,,,,,,,,
TACTRA MALL PENILE PROS 9.5MMX14-23 CM,SUP-2417952,CDM,C2622,HCPCS,0278,RC,,,,both,,,27993.10,18195.51,,,,,,,,,,,,,
TAP BNE 3.5 MM,SUP-2319068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
CHANNELSCOPE 30K 21.6 CM SHAFT WC DIAMETER 2 MM,SUP-2854429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
ALLOGRAFT BNE 10 MM,SUP-2736781,CDM,C1713,HCPCS,0278,RC,,,,both,,,8193.92,5326.05,,,,,,,,,,,,,
INTRO SHEATH TRANSSEPTAL 8.5FRX71CM,SUP-2357282,CDM,C1894,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
WIRE FIX BLNT 1.4 MM KIRSCHNER,SUP-2211135,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 1.6X220 MM NS,SUP-2789084,CDM,C1769,HCPCS,0272,RC,,,,both,,,1036.83,673.94,,,,,,,,,,,,,
IMPLANT OSS L4MM PIST DIA0.6MM STAP PLAT S STL RBBN LOOP,SUP-2312543,CDM,L8613,CPT,0278,RC,,,,both,,,380.94,247.61,,,,,,,,,,,,,
PLATE BONE L82MM 7 H STRL S STL 1/3 TBLR LCK FOR 3.5MM SCR,SUP-2419095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1035.57,673.12,,,,,,,,,,,,,
GRAFT BNE W6-21XL14-25MM THK19-21MM TRICORT IL FRZ DRY,SUP-2307145,CDM,C1713,HCPCS,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
MESH SURG W26XL34CM THK2MM EPTFE FOR CHST WALL RECON,SUP-2395338,CDM,C1781,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
EXTENSION STEM GTT DN PLUG FOR TIB PLT NXGN MIS,SUP-2208589,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BONE LT ILIUM WHL TRAD FRZN,SUP-2294152,CDM,C1713,HCPCS,0278,RC,,,,both,,,15345.18,9974.37,,,,,,,,,,,,,
SHUNT CV 10FR L31CM POLYUR OUTLYING FLEX KINK RESIST W/ T,SUP-2264212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
SHOE POSTOP SM 7-9 LO PROF FOAM/NYLON MESH M LOOP LOK CLSR,SUP-2197104,CDM,L4387,HCPCS,0274,RC,,,,both,,,15.13,9.83,,,,,,,,,,,,,
SCREW BONE PROX LCK S STL CONQ FN 7.5MMX100MM,SUP-2341202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2040.69,1326.45,,,,,,,,,,,,,
FILTER VASC VENATECH LP L 56 CM DIA 9 FR VENA CAVA CARTRIDGE,SUP-2498261,CDM,C1880,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
PIN 12 SELF DRILL 10MM THRD 3X80MM,SUP-2705304,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.03,242.47,,,,,,,,,,,,,
HC Complex Interstitial Appl,PX-3337777800,CDM,77778,CPT,0333,RC,,,,both,,,2421.00,1573.65,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE,RX-8121,CDM,2500000003,HCPCS,0250,RC,00713-0655-40,NDC,,both,5,GR,290.20,188.63,,,,,,,,,,,,,
HC So RBC Pretreatment Serum,PX-3028697866,CDM,86978,CPT,0302,RC,,,,inpatient,,,351.00,228.15,,,,,,,,,,,,,
IMPLANT CAPPED HIP H2 TOT ADV REV MH,SUP-2916302,CDM,C1776,CPT,0278,RC,,,,both,,,19841.35,12896.88,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM COMP AMNIO MEM MTRX SHT AMNIOFIX,SUP-2305708,CDM,V2790,HCPCS,0274,RC,,,,both,,,7071.28,4596.33,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.27 MM INNR FLANGE DIA2.75 MM TYTAN,SUP-2901978,CDM,L8699,HCPCS,0278,RC,,,,both,,,130.56,84.86,,,,,,,,,,,,,
BLADE SHV L8MM DIA2MM PUR SM JT HOOD ABRASION BUR FRMLA,SUP-2366890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,241.47,156.96,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH SPIRAL-Z L 107 MM DIA11 MM SHTH 14 FR,SUP-2171073,CDM,C1768,CPT,0278,RC,,,,both,,,10801.60,7021.04,,,,,,,,,,,,,
KIT TRACH TB L755MM OD119MM ID8MM PERC DIL FULL COMP BLU,SUP-2351758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.70,566.60,,,,,,,,,,,,,
TUBE ET OD10.4MM ID7MM EVAC ORAL MURPHY EYE TAPERGUARD CUF,SUP-2172241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,75.71,49.21,,,,,,,,,,,,,
RING EXT FIX 160 MM HINDFOOT W/ H SALVATION,SUP-2846118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2207.42,1434.82,,,,,,,,,,,,,
INSTRUMENT KIT PLN PT SPEC MAND RECON W/O MODEL,SUP-2860260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8257.89,5367.63,,,,,,,,,,,,,
EXTRACTOR SURG SM EZ OUT REMOVAL TOOL AO QC FOR FIBULAR NAIL,SUP-2909105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
GRAFT VASC PERIPH BYPS STR THN WALL N RING 6MM DIA 80CM LEN,SUP-2126680,CDM,C1768,CPT,0278,RC,,,,both,,,3422.60,2224.69,,,,,,,,,,,,,
ATTUNE RP TIB BASE SZ 1 POR,SUP-2251405,CDM,C1776,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
VITRECTOMY PACK 23 GA PRB CASSETTE DRN BG ACCURUS TOT +,SUP-2424302,CDM,C1713,HCPCS,0278,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
PLATE BNE L154MM 8 H ST L LAT PROX TIB S STL LOK COMPR LO,SUP-2185717,CDM,C1713,HCPCS,0278,RC,,,,both,,,4647.11,3020.62,,,,,,,,,,,,,
PROBE LITHO 5FR L60CM EHL DISP,SUP-2313970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,630.86,410.06,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CONQ L 75 CM BALLOON L 40 MM DIA 7 MM,SUP-2128031,CDM,C1725,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
CATHETER VALVULOPLASTY AORT ENDOCLAMP,SUP-2214465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9021.22,5863.79,,,,,,,,,,,,,
SCREW ACET 6.5X40 MM CANC HIP LOGICAL,SUP-2322445,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
INSERT TIB SZ 1 THK8MM CONSTRN BAL REV SYS,SUP-2315567,CDM,C1776,CPT,0278,RC,,,,both,,,3190.24,2073.66,,,,,,,,,,,,,
SCREW BNE LCK SHT THRD 4X20 MM NS FITBONE TAA LTX,SUP-2875096,CDM,C1713,HCPCS,0278,RC,,,,both,,,707.76,460.04,,,,,,,,,,,,,
HC So Assay of Psa Total|NOT REASONABLE AND NECESSARY,PX-3018415366,CDM,84153,CPT,0301,RC,,,GZ,outpatient,,,338.00,219.70,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5X50X50X0.8 MM MESH RAPID RESORBABLE S,SUP-2838584,CDM,C1713,HCPCS,0278,RC,,,,both,,,4916.93,3196.00,,,,,,,,,,,,,
BEAM ANK FUS L110MM DIA7MM 11MM PROX SALVATION,SUP-2400783,CDM,C1713,HCPCS,0278,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
COLLAR CERV CNTOUR LG 22.5X4.5 IN 15-20 IN MED FOAM PROCARE,SUP-2196862,CDM,L0180,HCPCS,0272,RC,,,,both,,,9.01,5.86,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX COMPASS L 3.5 CM LOOP DIA2.5 MM,SUP-2305148,CDM,C1889,HCPCS,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX4 T SHAPED LEFT DORSAL DISTAL,SUP-2721080,CDM,C1713,HCPCS,0278,RC,,,,both,,,2930.19,1904.62,,,,,,,,,,,,,
BUNDLE CASE MICROTIA VSP,SUP-2862837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10154.76,6600.59,,,,,,,,,,,,,
PIN FIX L9IN OD1/8IN S STL STYL 4 SMOOTH PLN SHANK TRCR,SUP-2398010,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.77,218.90,,,,,,,,,,,,,
PLATE RECON THRDLCK TS ANGLE ANGLE 27 MM SCREW 30 HOLE T30,SUP-2679089,CDM,C1713,HCPCS,0278,RC,,,,both,,,4889.64,3178.27,,,,,,,,,,,,,
KIT INTRO MICROEZ L 35 CM CATH 5 FR NDL L 6 CM SS GUIDEWIRE,SUP-2126204,CDM,C1894,HCPCS,0272,RC,,,,both,,,98.60,64.09,,,,,,,,,,,,,
INTRODUCER CATH BRITE TIP RADIANZ GUIDING 6FR 110CM RADIAL,SUP-2855186,CDM,C1894,HCPCS,0272,RC,,,,both,,,807.77,525.05,,,,,,,,,,,,,
PLATE BNE L98MM 8 H POST LAT S STL 1/3 TBLR LOK COMPR FOR,SUP-2349797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2576.75,1674.89,,,,,,,,,,,,,
GRAFT BIO TISS W10XL20CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2112983,CDM,Q4130,HCPCS,0636,RC,,,,both,,,19229.36,12499.08,,,,,,,,,,,,,
VERAPAMIL HCL ER 120 MG PO TBCR,RX-13184,CDM,6370000000,HCPCS,0637,RC,75834-0320-01,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
SHEATH INTRO LIEBERMAN L 37 CM DIA 6.5 FR GUIDEWIRE 0.038 IN,SUP-2168786,CDM,C1894,HCPCS,0272,RC,,,,both,,,127.86,83.11,,,,,,,,,,,,,
ATROPINE SULFATE 1 MG/10ML IJ SOSY,RX-137355,CDM,J0462,HCPCS,0636,RC,64253-0400-91,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE VASC COMET L 185 CM DIA 0.014 IN COCR PLAT TIP,SUP-2146961,CDM,C1769,HCPCS,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
STRAP CLAV M BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194671,CDM,L3670,HCPCS,0274,RC,,,,both,,,14.73,9.57,,,,,,,,,,,,,
CATHETER CARD ABLATION CELSIUS L 115CM DIA 7FR J SHP BRAIDED,SUP-2257450,CDM,C1733,HCPCS,0272,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP APRON,SUP-2435539,CDM,L0457,HCPCS,0272,RC,,,,both,,,2815.80,1830.27,,,,,,,,,,,,,
LEVEL 1 THOR STRL PLT RIB LCK Z SHP 2.3 MM SCR 32 H T=1.5 MM,SUP-2262532,CDM,C1713,HCPCS,0278,RC,,,,both,,,4113.09,2673.51,,,,,,,,,,,,,
PLATE BNE 3X5 H L DST RAD VOLAR S STL LO PROF RIG,SUP-2186103,CDM,C1713,HCPCS,0278,RC,,,,both,,,2736.26,1778.57,,,,,,,,,,,,,
SLING INCONT TRNS OBTURATOR TAPE ARIS,SUP-2165222,CDM,C1771,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
ELEVATOR SURG L95IN 13X22MM BLDE SPNL CRV HEX HNDL COBB,SUP-2160975,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.52,240.19,,,,,,,,,,,,,
HC Revision/Relocat Skin Pocket-I,PX-4813322300,CDM,33223,CPT,0481,RC,,,,both,,,6021.00,3913.65,,,,,,,,,,,,,
BIT DRL DIA 3.7 MM SHRT QC W/ AO STRL DISP EVOS,SUP-2931295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,884.22,574.74,,,,,,,,,,,,,
CATHETER BILI 16FR SIL SFT SIDE H RADPQ TANT MRK PLAS,SUP-2134680,CDM,C1875,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PROBE SURG HATCHED TUBESET NEXUS SONICONE OR,SUP-2745903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1530.75,994.99,,,,,,,,,,,,,
GRAFT BNE SUB W14-18MMXL8CM FIB SHFT FRZ DRY,SUP-2307195,CDM,C1776,CPT,0278,RC,,,,both,,,2055.35,1335.98,,,,,,,,,,,,,
KIT SONIC ANCHOR FORCE FIB 2.5X10MM 0,SUP-2474715,CDM,C1776,CPT,0278,RC,,,,both,,,1016.36,660.63,,,,,,,,,,,,,
ANCHOR SUT L36IN SZ 2 ETHBND GRN POLY BRAID DBL ARMED EXCEL,SUP-2256635,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
PLATE BNE W16XL124MM BLDE L60MM THK4.8MM 95DEG 7 H,SUP-2185500,CDM,C1713,HCPCS,0278,RC,,,,both,,,2828.23,1838.35,,,,,,,,,,,,,
SCREW BNE CRTX 2.4X12 MM PLUSDRIVE RECESS LCK CRUCFRM STRL,SUP-2569984,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.17,40.41,,,,,,,,,,,,,
STENT COR 16MM 2.75MM CATH L144CM PLAT CHROM ALLOY SELF,SUP-2145084,CDM,C1874,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 18 CM ART CUF SET BIOFLX TESIO,SUP-2627153,CDM,C1750,HCPCS,0278,RC,,,,both,,,162.78,105.81,,,,,,,,,,,,,
PLATE BNE L 113 MM 8 H SCREW DIA 3.5 MM SS LL PROX TIB SM,SUP-2931134,CDM,C1713,HCPCS,0278,RC,,,,both,,,6877.70,4470.50,,,,,,,,,,,,,
COIL EMB L25CM OD0.020IN NIT J STRTCH RESIST FILL SFT STBL,SUP-2323423,CDM,C1889,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
HC Remv & Replc Pm Gen Sing,PX-4813322700,CDM,33227,CPT,0481,RC,,,,outpatient,,,28682.00,18643.30,,,,,,,,,,,,,
PLATE BNE L 179 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 13 72466413,SUP-2932847,CDM,C1713,HCPCS,0278,RC,,,,both,,,5937.74,3859.53,,,,,,,,,,,,,
SCREW BONE L24MM DIA3.5MM S STL LCK WSHR SURFIX,SUP-2243355,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
CANN SCRW THD 3.0X22MM,SUP-2586789,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.01,294.46,,,,,,,,,,,,,
VALVE SHUNT CTRL FLO BUTTON PRESSURE LO,SUP-2628268,CDM,C1889,HCPCS,0278,RC,,,,both,,,2690.35,1748.73,,,,,,,,,,,,,
RING EXT FIX 180 MM 5/8 MR SAFE TI NS,SUP-2863455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2307.27,1499.73,,,,,,,,,,,,,
PLATE BNE L LNG 2.4/2.7X62 MM LT 1ST MTP 2X2 HOLE VA LP LCK,SUP-2181252,CDM,C1713,HCPCS,0278,RC,,,,both,,,3306.39,2149.15,,,,,,,,,,,,,
ADAPTER CARD PACE L174CM BPLR IS 1 VS 1 CONN SIL INSUL,SUP-2356134,CDM,C1883,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE MIC 120 CM W/ RICKHAM RESERVOIR 2 CM,SUP-2863643,CDM,C1889,HCPCS,0278,RC,,,,both,,,16873.07,10967.50,,,,,,,,,,,,,
NAIL INDICATED FOR THE TREAT OF STBL AND UNSTBL PROX FEM,SUP-2152591,CDM,C1713,HCPCS,0278,RC,,,,both,,,4353.77,2829.95,,,,,,,,,,,,,
PLATE BNE L 2-2.5X44X1 MM 28 MM RT 2X2 HOLE TLTS BSSO TI,SUP-2463273,CDM,C1713,HCPCS,0278,RC,,,,both,,,1292.90,840.38,,,,,,,,,,,,,
DEFIBRILLATOR CARD C HD W/ RIATA ATLS + CR,SUP-2356522,CDM,C1722,HCPCS,0275,RC,,,,both,,,64881.82,42173.18,,,,,,,,,,,,,
HC Bx Bone Trocar/Needle Deep,PX-3612022500,CDM,20225,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SPLINT REST HND ADL L S DRBLUE BROAD,SUP-2165486,CDM,L3807,HCPCS,0274,RC,,,,both,,,140.26,91.17,,,,,,,,,,,,,
STIMULATOR BONE GROWTH ELEC NONINVASIVE FOR OSTEOGENESIS,SUP-2137435,CDM,E0749,HCPCS,0278,RC,,,,both,,,7842.15,5097.40,,,,,,,,,,,,,
KIT BASIC 4FRX18GAX65CM PICC AND INTRO SGL LUMN SIL W/,SUP-2120072,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HEAD HUM SHLDR CUF TEAR ARTHROPATHY,SUP-2249601,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
K WIRE FIX L228MM DIA2MM S STL SMOOTH DBL END DBL SHRP TIP,SUP-2398088,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX1.7 CM BLLN BUTTON SIL MINI 1,SUP-2754574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.11,338.07,,,,,,,,,,,,,
HC X-Ray Low Ext Infant Min 2 Views,PX-3207359200,CDM,73592,CPT,0320,RC,,,,both,,,274.00,178.10,,,,,,,,,,,,,
DUTASTERIDE 0.5 MG PO CAPS,RX-34089,CDM,6370000000,HCPCS,0637,RC,42806-0549-09,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE W11XL208MM THK42MM 13 H MTPHSEAL S STL LOK COMPR,SUP-2185266,CDM,C1713,HCPCS,0278,RC,,,,both,,,3387.62,2201.95,,,,,,,,,,,,,
COMPONENT CTRL BODY EXT FIX STD PROCALLUS,SUP-2316280,CDM,C1776,CPT,0278,RC,,,,both,,,3087.19,2006.67,,,,,,,,,,,,,
SET HAD CATH AD 14FR L30CM BASIC DBL LUMN DIL SCALP,SUP-2266999,CDM,C1751,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
STENT ENDOPROS L2.5CM DIA8MM CATH 8FR L75CM BAL DIA8MM,SUP-2396561,CDM,C1874,HCPCS,0278,RC,,,,both,,,8697.80,5653.57,,,,,,,,,,,,,
BIT DRL LANX 12MM,SUP-2207867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
BOLT SPNL L25MM DIA5.5MM ANTR THORLUM LAT PLT SYSTEMXLP +,SUP-2311333,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SPACER TIB SCREW N-K II,SUP-2449004,CDM,C1776,CPT,0278,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
STIMULATOR BONE GROWTH SGL COIL SZ 2,SUP-2196351,CDM,E0749,HCPCS,0278,RC,,,,both,,,7959.90,5173.93,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ATLNTS SR PRO L 135 CM DIA 3.2,SUP-2139920,CDM,C1753,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
IMPLANT NSL M W1.1XL4.4CM THK0.35CM SIL MID DORS AUG FOR,SUP-2242099,CDM,2780000010,LOCAL,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
RING EXT FIX HALF 120 MM CIR SIDEKCK,SUP-2850516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
PORTX-PORT MRI W/ 8FR CHRONOFLEX C,SUP-2127760,CDM,C1788,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
"HC Repair Trnscath Mitral Valve, Addit Prosthesis",PX-3603341900,CDM,33419,CPT,0360,RC,,,,inpatient,,,8530.00,5544.50,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 6 MM DEL SHTH,SUP-2934603,CDM,C1713,HCPCS,0278,RC,,,,both,,,5592.34,3635.02,,,,,,,,,,,,,
PLATE BONE THK1.8MM 6 H ANG FOR 2.4MM SCR LORENZ,SUP-2136638,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
HC Selective Lv La Angiocard Cath,PX-4819356500,CDM,93565,CPT,0481,RC,,,,both,,,620.00,403.00,,,,,,,,,,,,,
SCREW BNE L 110 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931867,CDM,C1713,HCPCS,0278,RC,,,,both,,,184.16,119.70,,,,,,,,,,,,,
SYSTEM DISTR PRPLE FRGD EXTRNL DISTR RED II 51 580 00 04,SUP-2679227,CDM,C1713,HCPCS,0278,RC,,,,both,,,24260.08,15769.05,,,,,,,,,,,,,
ANCHOR SUTURE 20 12.7X3 MM HIP FIBERWIRE KNOTLESS BIOCOMPOSI,SUP-2836433,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
KIT ARTHSCP LAT ANK ARTHROBROSTROM REP,SUP-2122948,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
NAIL IM L340MM DIA11MM 130DEG LNG LT FEM TI ALLOY CANN LCK,SUP-2362343,CDM,C1713,HCPCS,0278,RC,,,,both,,,5407.39,3514.80,,,,,,,,,,,,,
GUIDEWIRE VASC VICTORY 14 L 195 CM DIA 0.014 IN TIP L 2.5 CM,SUP-2140820,CDM,C1769,HCPCS,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
RING ANNULPLSTY HAART 300 DIA21 MM TI CVR DACRON AORT VLV,SUP-2878072,CDM,C1889,HCPCS,0278,RC,,,,both,,,19405.20,12613.38,,,,,,,,,,,,,
PATCH BIO BOV PERICARD PTCH PERICARD 8CM LEN 6CM W CARDIOFIX,SUP-2352647,CDM,C1768,CPT,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
PLATE BNE TIB LT DSTL MEDL 9 HOLE LCK MERCURY-FREE PVC-FREE,SUP-2463196,CDM,C1713,HCPCS,0278,RC,,,,both,,,4389.00,2852.85,,,,,,,,,,,,,
LEAD PACE L78CM TRNSVEN LT VENTRIC DEXMETHSON ACETT ELUT,SUP-2419407,CDM,C1900,HCPCS,0275,RC,,,,both,,,6049.40,3932.11,,,,,,,,,,,,,
STAPLE BNE COMPR 20 MM 15 MM CONT 2 LEG BME ELITE,SUP-2564468,CDM,C1713,HCPCS,0278,RC,,,,both,,,4433.08,2881.50,,,,,,,,,,,,,
BLADE SCREWDRIVER 1.5 MM FOR ANGULUS X DRV LEVEL 1,SUP-2461306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.99,304.19,,,,,,,,,,,,,
STRAP CLAV SM 3 W HK,SUP-2428149,CDM,L3650,HCPCS,0272,RC,,,,both,,,17.62,11.45,,,,,,,,,,,,,
CANNULA ARTHSCP INFLO N SCP INTEL 3MM,SUP-2341417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.77,662.20,,,,,,,,,,,,,
RING EXT FIX L200MM FULL SIDEKCK,SUP-2400662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
SCREW BNE DRILL-FREE 1.5X4 MM TI STRL MAXDRIVE LEVEL 1 NEURO,SUP-2470682,CDM,C1713,HCPCS,0278,RC,,,,both,,,214.56,139.46,,,,,,,,,,,,,
PLATE BNE 28 PLTTM 4-HOLE STR LOK 1.5MM,SUP-2321440,CDM,C1713,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
BURR BALL FLUTED 2.0MM EXTENDED ANSPACH S2BG1,SUP-2843309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.05,236.63,,,,,,,,,,,,,
ALLOGRAFT BNE 8-15X100 MM FIBULAR SHFT STRL BIO LF DISP,SUP-2632316,CDM,C1762,CPT,0278,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
HALF PIN 5X180MM 50MM CON,SUP-2818453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1005.11,653.32,,,,,,,,,,,,,
HC Leukaphoresis,PX-7613651100,CDM,36511,CPT,0761,RC,,,,inpatient,,,4768.00,3099.20,,,,,,,,,,,,,
CATHETER GUIDE OUTER SLITTABLE CPS DIRECT SL,SUP-2665286,CDM,C1887,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BONE S STL FOR 5MM SCR PERIARTC SYS LCP,SUP-2177076,CDM,C1713,HCPCS,0278,RC,,,,both,,,110469.53,71805.19,,,,,,,,,,,,,
SYSTEM KNEE FLX NXGN,SUP-2212150,CDM,C1776,CPT,0278,RC,,,,both,,,11972.82,7782.33,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 70 CM DIA 6 MM POLYESTER BOV CLLGN UTHN,SUP-2491527,CDM,C1768,CPT,0278,RC,,,,both,,,2113.94,1374.06,,,,,,,,,,,,,
VALVE TRACH AD OD22MM ID15MM AQUA PLAS SWALLOWING SPEAK W/,SUP-2134640,CDM,L8501,HCPCS,0274,RC,,,,both,,,294.06,191.14,,,,,,,,,,,,,
CATHETER CV SET 032 10 FRX25 CM 5 LUMEN QUINT SPECTRUM,SUP-2759769,CDM,C1751,HCPCS,0278,RC,,,,both,,,493.64,320.87,,,,,,,,,,,,,
PLATE BNE CLAV CS3 2.7 MM RT LAT VA LCK COMPR TI NS VA-LCP,SUP-2758164,CDM,C1713,HCPCS,0278,RC,,,,both,,,3628.08,2358.25,,,,,,,,,,,,,
SHEATH INTRO L 81 CM DIA 9.5 FR AD STRL,SUP-2141175,CDM,C1753,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
MESH HERN L DIA8CM VENTRAL POLYPR EPTFE CIR SELF EXP PTCH,SUP-2125721,CDM,C1781,HCPCS,0278,RC,,,,both,,,1768.13,1149.28,,,,,,,,,,,,,
PLATE BNE 4 H LT DSTL MEDL TIB NS,SUP-2896828,CDM,C1713,HCPCS,0278,RC,,,,both,,,5334.86,3467.66,,,,,,,,,,,,,
COMPONENT KNEE FOR PKG 5200 ZUK,SUP-2212674,CDM,C1776,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.540,SUP-2860057,CDM,C1713,HCPCS,0278,RC,,,,both,,,48793.40,31715.71,,,,,,,,,,,,,
PROCESSOR MAIN MOD BLK NUCLS FRDM,SUP-2164926,CDM,L8614,HCPCS,0278,RC,,,,both,,,16131.75,10485.64,,,,,,,,,,,,,
PLATE BNE THK0.5MM 8MM BAR 6 H 100DEG UNIV,SUP-2366246,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
PROSTHESIS OSS 0.83X7X1.5X1.5 MM GROTE INCUS PARTIALLY CANN,SUP-2648919,CDM,L8613,CPT,0278,RC,,,,both,,,1397.14,908.14,,,,,,,,,,,,,
HC Perq Plmt Bile Duct Stent W/O Bili Cath,PX-3614753900,CDM,47539,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
HC Replac Central Tun Cath W/Pump,PX-3613658300,CDM,36583,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
BLOM-SINGER INDWL LO PRSS VOICE PROS REPL KT SER 8MM,SUP-2246404,CDM,L8509,HCPCS,0274,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
BIT DRL SEGMENTED ADJ STP SONICWELD RX DISP,SUP-2457788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.53,280.49,,,,,,,,,,,,,
PLATE BNE AD BLDE L60MM THK48MM DISPLC 10MM 100DEG 4 H,SUP-2185551,CDM,C1713,HCPCS,0278,RC,,,,both,,,2764.58,1796.98,,,,,,,,,,,,,
PLATE BNE FIBULAR LT 10 HOLE LCK ANAT STRL ALPS LTX,SUP-2861808,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.13,2245.18,,,,,,,,,,,,,
PLATE BONE L92MM 5 H S STL BROAD SELF COMPR,SUP-2198604,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.04,239.88,,,,,,,,,,,,,
GUIDEWIRE .035X7 ST,SUP-2639688,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
STENT NEPHURET COPE L 28 CM DIA 8.5 FR UTHANE UPJ STRL,SUP-2168172,CDM,C2625,HCPCS,0278,RC,,,,both,,,345.43,224.53,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 6 CM DIA 6 FR 2.5 CM 0.038 IN,SUP-2385187,CDM,C1894,HCPCS,0272,RC,,,,both,,,93.42,60.72,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT MAXBARR 4FR 0.033IN 60CM 1 LUMAN RV,SUP-2613421,CDM,C1751,HCPCS,0278,RC,,,,both,,,427.67,277.99,,,,,,,,,,,,,
NEEDLE VERTEBROPLASTY 10GA L4.721IN YEL DMND TIP RADPQ,SUP-2179486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1237.16,804.15,,,,,,,,,,,,,
PLATE BNE L104MM BLDE L90MM 130DEG 6 H ST PROX FEM BILAT S,SUP-2185524,CDM,C1713,HCPCS,0278,RC,,,,both,,,2755.70,1791.20,,,,,,,,,,,,,
LOCKING PLATE T10MM L SHAPE L7 HOLES,SUP-2679031,CDM,C1713,HCPCS,0278,RC,,,,both,,,1009.92,656.45,,,,,,,,,,,,,
LEVEL NEURO ST MESH 3D ULTRNE NEURO SCRW49 MM DIA T06 MM CP,SUP-2707387,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.23,949.15,,,,,,,,,,,,,
VALVE MITRAL 29MM MITRIS RESILIA,SUP-2854411,CDM,C1889,HCPCS,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX HUMERUS LONG 5H SHAFT 142MM STER,SUP-2549715,CDM,C1713,HCPCS,0278,RC,,,,both,,,5255.36,3415.98,,,,,,,,,,,,,
VALVE AORT KONECT RESILIA TISS ANNULUS 29 MM SEW RNG DIA 40,SUP-2624864,CDM,C1889,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
COIL EMB L10CM LOOP DIA6MM PERIPH SELF EXP HYDRGEL POLYMER,SUP-2385398,CDM,C1889,HCPCS,0278,RC,,,,both,,,3710.57,2411.87,,,,,,,,,,,,,
ROD EXT FIX THRD 115 MM SS,SUP-2162670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.90,257.98,,,,,,,,,,,,,
RESERVOIR EXT DRNGE 0.6ML BUR H DIA12MM CSF CONV,SUP-2284529,CDM,C1889,HCPCS,0278,RC,,,,both,,,894.62,581.50,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR FIX CEM STEM,SUP-2365425,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
BAR REDUCER EXTN NS OSCAR 3 LTX,SUP-2875729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
PLATE BONE L193MM 30 H CRANIOMAXILLOFACIAL TI ADAPTATION,SUP-2191267,CDM,C1713,HCPCS,0278,RC,,,,both,,,2070.52,1345.84,,,,,,,,,,,,,
HOOK SPNL L TI OFFSET FOR 5.5MM ROD CDH LEG,SUP-2287877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM DIA PROX/DSTL 34/34 MM NIT,SUP-2396402,CDM,C1768,CPT,0278,RC,,,,both,,,48670.00,31635.50,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM AMNIO MEMBRN TRNSLUC GRID PAT SGL,SUP-2113884,CDM,Q4154,HCPCS,0636,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
ADAPTER LD L 45 CM DIA 32 MM IS1 OR 3.2 MM LP BPLR TO IS1,SUP-2148921,CDM,C1883,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
KWIRE FIX L4IN DIA11MM SMOOTH DBL TRCR PNT 13463NS] STRYKER CORP],SUP-2361629,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.48,10.06,,,,,,,,,,,,,
PLATE BONE L74MM 9 H TI RT LAT DSTL POST HUM LO PROF RIG,SUP-2411719,CDM,C1713,HCPCS,0278,RC,,,,both,,,3661.24,2379.81,,,,,,,,,,,,,
PLATE BNE 12 H NONSTERILE BILAT MANUBRIUM STRNL TI LOK STAR,SUP-2192439,CDM,C1713,HCPCS,0278,RC,,,,both,,,3138.74,2040.18,,,,,,,,,,,,,
PIN SURG L20MM OD2.4MM DRL TIP THRD SHLDR STAR,SUP-2365262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
PIN FIX L9IN DIA24MM ST S STL 3 SIDE DBL TRCR BOTH END PNT,SUP-2150520,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.72,16.72,,,,,,,,,,,,,
CONDUIT CV SZ 33MM L10CM ASCEND AORT CARBOMEDICS CARBO SEAL,SUP-2352742,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
LENS POST CHMBR 3 PC ACRYL 21.5 ANTR ASYM BCNVX 6.0MM OPT,SUP-2110491,CDM,V2632,HCPCS,0276,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
STAPLER INT REINF 45 MM BIODESIGN EZ 45,SUP-2737225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.446,SUP-2860010,CDM,C1713,HCPCS,0278,RC,,,,both,,,55099.46,35814.65,,,,,,,,,,,,,
ROD SPNL L140MM DIA5.5MM POST PEDCL TI LORDOSED VIPER 2,SUP-2256307,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
TUBE EXT FIX L250MM OD25MM RED C FOR UNILAT MONOTB TRIAX,SUP-2372615,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PIN EXT FIX L20MM DIA4MM TI HALF HEX FIX CIR RANCHO ILIZ,SUP-2342554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1663.01,1080.96,,,,,,,,,,,,,
FULLY TH CANC SCREW 6.5 145MM,SUP-2818872,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.93,386.05,,,,,,,,,,,,,
SLEEVE ORTH SUSP ANK PELV CTRL,SUP-2388213,CDM,L5695,HCPCS,0272,RC,,,,both,,,500.23,325.15,,,,,,,,,,,,,
SIROLIMUS 1 MG PO TABS,RX-28958,CDM,J7520,HCPCS,0636,RC,00904-7248-04,NDC,,both,1,UN,44.20,28.73,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4 FR 40 CM 0.018IN 4CM NIT SHFT STD,SUP-2125283,CDM,C1894,HCPCS,0272,RC,,,,both,,,92.60,60.19,,,,,,,,,,,,,
SCREW BNE 7X14 MM BOLT TENDESIS QUATTRO,SUP-2608896,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.27,921.23,,,,,,,,,,,,,
PATIENT ADMISSION KIT BRSH 3 MM PT SUPP,SUP-2356002,CDM,C1713,HCPCS,0278,RC,,,,both,,,38700.50,25155.32,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|ADJ,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|CQ|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
SPACER FEM KNEE M 64MM ANTIBIO TREAT REMEDY,SUP-2319840,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
PLATE BNE CRESCENT 1.25 MM 2X2 HOLE TI NS MATRIXMANDIBLE,SUP-2181767,CDM,C1713,HCPCS,0278,RC,,,,both,,,1773.79,1152.96,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X231 MM 14 HOLE SS DCP,SUP-2569180,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
MENISCAL REPAIR SET RVS CRV INSRTR NDL BENDR FAST-FIX FLX,SUP-2835337,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
REAMER SURG 2.5 MM,SUP-2175003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
BLADE OSTEOTOM L12MM CVD FLEX W/ BLDE AND DETACH HNDL,SUP-2364282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.13,230.83,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA26 MM POLYESTER GEL,SUP-2385047,CDM,C1768,CPT,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
VALVE AORT CARP EDW TISS ANNULUS 25MM 31MM 21MM PERICARD,SUP-2214048,CDM,C1889,HCPCS,0278,RC,,,,both,,,17301.40,11245.91,,,,,,,,,,,,,
BIT DRL L300MM DIA13MM CANN W/O STP CALIB QUIK CPL,SUP-2188079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1676.29,1089.59,,,,,,,,,,,,,
GUIDE SURG REUSE DRL TAP SCR,SUP-2279325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3411.42,2217.42,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 6 MM RNG L 60 CM EPTFE STR STD,SUP-2396096,CDM,C1768,CPT,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
TOLVAPTAN 15 MG PO TABS,RX-97802,CDM,6370000000,HCPCS,0637,RC,49884-0768-54,NDC,,both,1,UN,270.00,175.50,,,,,,,,,,,,,
STEM FEM L260MM DIA15MM STD CLLR R HIP CO CHROME POR REV,SUP-2345245,CDM,C1776,CPT,0278,RC,,,,both,,,18714.40,12164.36,,,,,,,,,,,,,
PLATE BNE W24.4XL56.6MM STD L DST DORS VOLAR RAD T ANAT DBL,SUP-2414018,CDM,C1713,HCPCS,0278,RC,,,,both,,,2193.29,1425.64,,,,,,,,,,,,,
NAIL IM LNG 130 DEG 11X420 MM RT HIP AFFIXUS,SUP-2460731,CDM,C1713,HCPCS,0278,RC,,,,both,,,6992.78,4545.31,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 10 HOLE-STERILE,SUP-2546100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1773.00,1152.45,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 0.018 IN 5 FRX60 CM 65 CM TURBO FLO,SUP-2168805,CDM,C1751,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
CATHETER CV KT 7 FRX20 CM 3L PRESSURE INJ ARROWG+ARD BLU +,SUP-2763331,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.75,220.84,,,,,,,,,,,,,
PLATE LOQTEQ DISTAL LATERAL HUMERUS 3H LT,SUP-2753224,CDM,C1713,HCPCS,0278,RC,,,,both,,,4561.85,2965.20,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH DIA28 MM CONTRALATERAL LIMB L 74 MM SS,SUP-2169810,CDM,C1768,CPT,0278,RC,,,,both,,,25785.68,16760.69,,,,,,,,,,,,,
DRILL SURG 7 MM FOR BNE GRFT ASMBLY,SUP-2857903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5394.52,3506.44,,,,,,,,,,,,,
SIGMOIDOSCOPE FLX W/ OBTURATOR GRP STRL DISP,SUP-2800975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
KIT LEAD TINED 4 CYL ELECTRODE,SUP-2563685,CDM,C1897,HCPCS,0278,RC,,,,both,,,10223.84,6645.50,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT FRZN ASEP ACHILLES TEND,SUP-2867035,CDM,C1762,CPT,0278,RC,,,,both,,,6228.50,4048.52,,,,,,,,,,,,,
HC CT Cryo Ablation Renal,PX-3615059300,CDM,50593,CPT,0361,RC,,,,both,,,10438.00,6784.70,,,,,,,,,,,,,
PLATE BNE L W135XL206MM THK42MM 11 H BILAT TI NAR RIG NEUT,SUP-2190822,CDM,C1713,HCPCS,0278,RC,,,,both,,,1734.54,1127.45,,,,,,,,,,,,,
EXTENSION STEM L40MM PROX FEM MOD PC GMRS,SUP-2376556,CDM,C1776,CPT,0278,RC,,,,both,,,7254.34,4715.32,,,,,,,,,,,,,
SYSTEM INFUSION 4 FRX90 CM 10 CM PULSESPRAY,SUP-2752579,CDM,C1751,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
CATHETERIZATION KIT AD 8 FRX5-1/8 IN ARROWG+ARD BLU +,SUP-2383333,CDM,C1751,HCPCS,0278,RC,,,,both,,,184.79,120.11,,,,,,,,,,,,,
PLATE BNE SM W11XL116MM THK3.3MM 0DEG 9 H BILAT TI STR,SUP-2190782,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.44,420.84,,,,,,,,,,,,,
PLATE BNE L60MM 4 H NONSTERILE L PROX TIB S STL LO PROF,SUP-2185810,CDM,C1713,HCPCS,0278,RC,,,,both,,,3677.73,2390.52,,,,,,,,,,,,,
GRAFT VASC 7 MMX25/15X70 CMX0.35 MM 30 CM STR HEMGRD,SUP-2466435,CDM,C1768,CPT,0278,RC,,,,both,,,3057.26,1987.22,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 25X15 CM RECON TISS MTRX STRATTICE,SUP-2492100,CDM,Q4130,HCPCS,0636,RC,,,,both,,,37127.36,24132.78,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX60 CM SS TURBO-JECT UPICS40CT1111,SUP-2759820,CDM,C1751,HCPCS,0278,RC,,,,both,,,328.57,213.57,,,,,,,,,,,,,
NEEDLE ASPIR 25GA SHTH DIA1.4MM CHN 2MM PULM EB US,SUP-2149679,CDM,C1713,HCPCS,0278,RC,,,,both,,,598.33,388.91,,,,,,,,,,,,,
SYSTEM STNT INTRO CATH PUSH 9FR GUID 5.5FR L195CM 0.035IN,SUP-2170076,CDM,C1874,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X196 MM 11 HOLE SS LC-DCP,SUP-2569270,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.11,287.37,,,,,,,,,,,,,
ROD ORTH STR TEND APTO KT,SUP-2399191,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
GRAFT HUM TISS L230MM DIA4MM TEND HAMSTRING SEMI TENDINOSUS,SUP-2264788,CDM,C1713,HCPCS,0278,RC,,,,both,,,4014.40,2609.36,,,,,,,,,,,,,
GRAFT BNE DEMIN BNE MTRX BIO DBM,SUP-2364713,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
KETOCONAZOLE 2 % EX SHAM,RX-14132,CDM,6370000000,HCPCS,0637,RC,45802-0465-64,NDC,,both,120,ML,99.40,64.61,,,,,,,,,,,,,
BLADE TONGUE RUSSEL DAVIS 40MMW 92MML,SUP-2705822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
FIBER LASER ENDOBEAM W/ VMC ULTRA RACK,SUP-2798175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,99186.45,64471.19,,,,,,,,,,,,,
MESH MAND CUSTOMIZED + STRL MEDPOR LTX,SUP-2862749,CDM,C1713,HCPCS,0278,RC,,,,both,,,27202.45,17681.59,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC MAXBARR 5FR 55CM 1 LUMAN RVS TAPR P,SUP-2613367,CDM,C1751,HCPCS,0278,RC,,,,both,,,787.51,511.88,,,,,,,,,,,,,
KIT INFUS PMP 400ML 5IN SOAK CATH NONNARCOTIC ELASTOMERIC,SUP-2236781,CDM,E0783,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CAGE SPNL 60X10MM LORDTC LUM INTBDY FUS DUO,SUP-2418102,CDM,C1889,HCPCS,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
MICROCATHETER INFUSION RAPIDTRANSIT L 150 CM L 50CM 1 MARKER,SUP-2158104,CDM,C1887,HCPCS,0272,RC,,,,both,,,3206.41,2084.17,,,,,,,,,,,,,
PEEK CANN B,SUP-2417907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
INTRODUCER FLEX URETEROSCOPY 11FRX40CM,SUP-2171263,CDM,C1894,HCPCS,0272,RC,,,,both,,,316.51,205.73,,,,,,,,,,,,,
BUR SURG DIAMOND LNG 4 MM 7.5 CM BALL MIDAS REX LEGEND,SUP-2630541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.91,345.09,,,,,,,,,,,,,
ANCHOR SUTURE DIA1.4 MM SUTURE SZ 2 HA COAT 1 STRND XBRAID S,SUP-2908769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
GRAFT CORNEAL W1.5XL2CM THK50-100UM BIO TRANSPLANTATION,SUP-2135257,CDM,V2790,HCPCS,0274,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
PROBE ENDOSCP SUCTION 3.5 MM CNTOUR SERFAS,SUP-2361319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BNE FUSION LT FT MEDL CLMN STRL A.L.P.S,SUP-2466806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2881.33,1872.86,,,,,,,,,,,,,
PLATE BNE L37MM 3 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT DYN,SUP-2185923,CDM,C1713,HCPCS,0278,RC,,,,both,,,396.64,257.82,,,,,,,,,,,,,
BRACE ANKLEXL AD FOR 11.5-13IN UNIV VLY CNTOUR STL STAY,SUP-2197935,CDM,L4350,HCPCS,0272,RC,,,,both,,,30.21,19.64,,,,,,,,,,,,,
SET INTRO SAFSHTH ULTRA L 13 CM DIA11 FR DIL L 18 CM,SUP-2159470,CDM,C1892,HCPCS,0272,RC,,,,both,,,689.29,448.04,,,,,,,,,,,,,
PLATE BONE L17MM THK0.9MM 5MM OFFSET 0DEG 4 H BILAT CHIN,SUP-2191215,CDM,C1713,HCPCS,0278,RC,,,,both,,,975.91,634.34,,,,,,,,,,,,,
SAW SURG COMPLETE IM,SUP-2448360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,25151.40,16348.41,,,,,,,,,,,,,
PLATE BNE L140MM 7 H R PROX HUM HI ALPS,SUP-2411643,CDM,C1713,HCPCS,0278,RC,,,,both,,,7360.16,4784.10,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 0.5 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-29464,CDM,J2274,HCPCS,0636,RC,00641-6020-01,NDC,JW,both,5,ML,83.30,54.14,,,,,,,,,,,,,
IMPLANT HUM TISS L 35 X W 25 MM THK 4 MM ACHILLES TEND RC,SUP-2932950,CDM,C1762,CPT,0278,RC,,,,both,,,7440.10,4836.06,,,,,,,,,,,,,
COMPONENT FNGR JT SZ 40 DST MP PYROCARBON SIL SPCR,SUP-2244239,CDM,C1776,CPT,0278,RC,,,,both,,,4681.74,3043.13,,,,,,,,,,,,,
SCREW BNE CANN 4X36 MM ASNS III,SUP-2362426,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
SCREW BNE CANN 4X12 MM LP TI CAPTURE,SUP-2609544,CDM,C1713,HCPCS,0278,RC,,,,both,,,1006.18,654.02,,,,,,,,,,,,,
GRAFT BNE GEL 5 CC SYR DBM DYNAGRAFT II,SUP-2641739,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BONE L67MM 6 H C FBR 1/3 TBLR,SUP-2152587,CDM,C1713,HCPCS,0278,RC,,,,both,,,1335.29,867.94,,,,,,,,,,,,,
STEM FEM SZ 0 L105MM 130DEG CO CHROM POR BILAT SH NK CEM,SUP-2210811,CDM,C1776,CPT,0278,RC,,,,both,,,10030.42,6519.77,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC MICROINTRODU 5904230,SUP-2632974,CDM,C1750,HCPCS,0278,RC,,,,both,,,1803.46,1172.25,,,,,,,,,,,,,
RESERVOIR PENILE PROS 75CC CLVRLF W/ LOK OUT VLV TI,SUP-2165443,CDM,C1813,HCPCS,0278,RC,,,,both,,,8895.62,5782.15,,,,,,,,,,,,,
PLATE BNE L127MM 4 H R PROX PERIARTC HUM S STL LOK COMPR,SUP-2177804,CDM,C1713,HCPCS,0278,RC,,,,both,,,4805.46,3123.55,,,,,,,,,,,,,
FIBER LASER 200 MH BALL TIP SOLTIVE DISP,SUP-2540081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1993.30,1295.64,,,,,,,,,,,,,
DEVICE SUT TEND ACHILLON SYS,SUP-2242921,CDM,C1713,HCPCS,0278,RC,,,,both,,,3747.87,2436.12,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM NONABSORBABLE OUTER SHELL INNR PLUG ROT,SUP-2341789,CDM,C1713,HCPCS,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
GRAFT NRV L50MM DIA1-2MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124848,CDM,C1763,HCPCS,0278,RC,,,,both,,,21160.46,13754.30,,,,,,,,,,,,,
GRAFT BNE STRP 5 CC AUGMATRIX,SUP-2495205,CDM,C1768,CPT,0278,RC,,,,both,,,2989.28,1943.03,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM 2 ERGO HNDL LSR BND W/O NDL DBL END HA,SUP-2366671,CDM,C1713,HCPCS,0278,RC,,,,both,,,1336.70,868.85,,,,,,,,,,,,,
PROSTHESIS OSS 1.5-5.6 MM 1.5X2.5 MM 1.45 MM PART HA TI SIL,SUP-2483418,CDM,L8613,CPT,0278,RC,,,,both,,,1256.09,816.46,,,,,,,,,,,,,
HC Perq Device Breast Add Image,PX-3611928200,CDM,19282,CPT,0361,RC,,,,both,,,1593.00,1035.45,,,,,,,,,,,,,
HEAD RMR DIA16.5MM MDLLRY,SUP-2188099,CDM,C1713,HCPCS,0278,RC,,,,both,,,727.98,473.19,,,,,,,,,,,,,
SCREW BONE CANNULATED 6.5X105 MM PROXIMAL FEMUR LOCKING STAI,SUP-2837589,CDM,C1713,HCPCS,0278,RC,,,,both,,,2083.33,1354.16,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 45CM 6FR COAT L 5CM HS,SUP-2385270,CDM,C1894,HCPCS,0272,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
CATHETER NAVI-STAR J CRV SFT TIP 7FR,SUP-2248475,CDM,C1732,HCPCS,0272,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
HEAD HUM H13.5MM OD37MM STD OFFSET PRI NECKLESS SHLDR CO,SUP-2388624,CDM,C1776,CPT,0278,RC,,,,both,,,7091.69,4609.60,,,,,,,,,,,,,
GRAFT HUM TISS M W4XL8CM ACELLULAR DERM ALLGRFT FLOWERDERM,SUP-2225420,CDM,Q4179,HCPCS,0636,RC,,,,both,,,11853.50,7704.77,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7030,HCPCS,0250,RC,00338-0049-04,NDC,,both,250,ML,10.70,6.95,,,,,,,,,,,,,
CATHETER CARD ABLATION INTELLANAV XP L 110 CM DIA 7 FR STR,SUP-2141815,CDM,C1733,HCPCS,0272,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
IMPLANT SYNTH L 88 X W 86 MM THK 15 MM MED POLYETHYL,SUP-2883438,CDM,C1713,HCPCS,0278,RC,,,,both,,,5009.24,3256.01,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 2",PX-7619920200,CDM,99202,CPT,0761,RC,,,,both,,,363.00,235.95,,,,,,,,,,,,,
WASHER SPNL DIA17MM TI BTTRS SYS FIX,SUP-2292220,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.20,427.18,,,,,,,,,,,,,
MESH HERN W8XL8CM POLY ABSRB CLLGN FLM COMP HRT SHP FOR,SUP-2752146,CDM,C1781,HCPCS,0278,RC,,,,both,,,2063.64,1341.37,,,,,,,,,,,,,
GLUCAGON HCL (DIAGNOSTIC) 1 MG IJ SOLR,RX-130194,CDM,J1611,HCPCS,0636,RC,63323-0596-03,NDC,,both,1,UN,1453.00,944.45,,,,,,,,,,,,,
KIT SCREW ANTR LUMBAR INTERFIXATION APREVO,SUP-2912128,CDM,C1713,HCPCS,0278,RC,,,,both,,,1674.66,1088.53,,,,,,,,,,,,,
CATHETER HD PRECRV 11.5 FRX12 CM DL W/ 2 SUTURE WNG DUOFLO,SUP-2627379,CDM,C1752,HCPCS,0278,RC,,,,both,,,36.14,23.49,,,,,,,,,,,,,
BIT DRILL 8MML BIT ANT CRVCL JACOB CHUCK END RGGLS RDMND ST,SUP-2670333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,472.26,306.97,,,,,,,,,,,,,
IMPLANT BEDROCK GRANITE IFUSE 10.5MM X 70MM,SUP-2858678,CDM,C1737,HCPCS,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
BLADE TREPHINE 17.5MM ID X 8IN,SUP-2515462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
ROD ORTH THRD 30 MM PILLAR,SUP-2749915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
VALVE SHUNT SM NSC ADJ W/ BIOGLDE STRATA,SUP-2631419,CDM,C1889,HCPCS,0278,RC,,,,both,,,12531.96,8145.77,,,,,,,,,,,,,
ALLOGRAFT BNE LG FRZN 1/3 HEMI PELVIS,SUP-2736961,CDM,C1762,CPT,0278,RC,,,,both,,,8919.26,5797.52,,,,,,,,,,,,,
PIN DRL DIA4MM ACL CLS EYELET FOR FEM FIX SYS TIGHTROPE,SUP-2121411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BLADE IM L70MM DIA12.5MM ST TI CANN FR CUT EDGE SPRL FOR RG,SUP-2180042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1719.15,1117.45,,,,,,,,,,,,,
HC Insertion/Rplcmt Iims Implantable Mntr Only,PX-4810527000,CDM,0527T,CPT,0481,RC,,,,outpatient,,,26264.00,17071.60,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM HA,SUP-2365937,CDM,C1776,CPT,0278,RC,,,,both,,,5617.46,3651.35,,,,,,,,,,,,,
ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP,RX-353,CDM,340b,HCPCS,0637,RC,00536-0091-85,NDC,,both,5,ML,0.70,0.45,,,,,,,,,,,,,
GRAFT HUM TISS L 200 MM FOLDED DIA 4.5 MM SINGLE STRND DIA 3,SUP-2913411,CDM,C1762,CPT,0278,RC,,,,both,,,5554.66,3610.53,,,,,,,,,,,,,
PLATE EXT FIX BRAC LOK NUT FOR SIDEKCK STLTH FIX REARFOOT,SUP-2400644,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
SCREW BNE L55MM OD6.5MM THRD L16MM TI CALCNL CANN HD COMPR,SUP-2401070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SHAFT BONE GRAFT ULNA SHAFT RT FZ ASP,SUP-2875972,CDM,C1762,CPT,0278,RC,,,,both,,,13563.70,8816.40,,,,,,,,,,,,,
PIN FIX L5MM DIA16MM CNTR FOR REDUC JOYSTICK 27MM VAR ANG,SUP-2179087,CDM,C1713,HCPCS,0278,RC,,,,both,,,425.50,276.57,,,,,,,,,,,,,
SAVI PROCEDURE KIT,SUP-2702116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,89.46,58.15,,,,,,,,,,,,,
GUIDEWIRE VASC MAGIC TORQUE L 260 CM DIA 0.035 IN TIP 5 CM,SUP-2142699,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.84,85.05,,,,,,,,,,,,,
HC I&D Abscess Peritonsillar,PX-4504270000,CDM,42700,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
INSTRUMENT KIT 7 MM DISP,SUP-2200252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
WEDGE TIB TY FULL,SUP-2252431,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 74X50X14 MM VENTRIC RST ATLAS+ VR,SUP-2356528,CDM,C1722,HCPCS,0275,RC,,,,both,,,67510.00,43881.50,,,,,,,,,,,,,
SHEATH INTRO DIREX 50 DEG L 71 CM DIA 8.5 FR SM CRV 17 MM,SUP-2424651,CDM,C1766,CPT,0272,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
COUNTERSINK SURG DRL 3-4 MM,SUP-2390553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
HC CT Lower Ext W/O Cont,PX-3527370000,CDM,73700,CPT,0352,RC,,,,both,,,2077.00,1350.05,,,,,,,,,,,,,
PROBE NERVE STIM MONOPOLAR PNMI0275] PRECISION MEDICAL INC],SUP-2329783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
DYNACLIP FORTE DISPOSABLE PROCEDURE PACK STERILE,SUP-2878960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
SCREW BNE ST 1X7 MM CRTX EMGCY W/ FLUT TIP TI MTRX GLD NS LF,SUP-2189079,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.17,219.16,,,,,,,,,,,,,
SLEEVE INSULATING TIP CRYOSURGICAL,SUP-2171528,CDM,C1894,HCPCS,0272,RC,,,,both,,,43.68,28.39,,,,,,,,,,,,,
CONTROLLER DETACH AZUR PERIPH HELCL PUSHABLE 18 SYS STRL,SUP-2385394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,595.03,386.77,,,,,,,,,,,,,
GRAFT TIB DST L ALLGRFT,SUP-2335299,CDM,C1713,HCPCS,0278,RC,,,,both,,,21964.30,14276.79,,,,,,,,,,,,,
STAPLER INT AD L L25MM DIA12MM INTLUMN WHT TI CIR CUT 2 ROW,SUP-2283256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4686.17,3046.01,,,,,,,,,,,,,
DEVICE TISS REMOVINGXL 17OZ L25.25IN DIA4MM ROD LENS,SUP-2239919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4223.30,2745.14,,,,,,,,,,,,,
CANNULA ARTHRO ENDOTRAC SLOTTED LASER MARKED,SUP-2461080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.43,1010.38,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY L12CM OD18GA PRELD STRL,SUP-2247286,CDM,C2638,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
TRAY CTRL VEN L70CM OD5FR 2 LUMN CATH BASIC MICROINTRODUCER,SUP-2125538,CDM,C1751,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SUPPORT ORTH HIP CIRC 28-48 IN SM MED SZ 2 ALUM,SUP-2915082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.52,504.09,,,,,,,,,,,,,
PLATE BNE W17.5XL206MM THK5.2MM 11 H BILAT S STL BROAD LOK,SUP-2185296,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.56,1173.61,,,,,,,,,,,,,
BONE MARROW TRAY STD STRL T-LOK LF,SUP-2876732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.49,220.02,,,,,,,,,,,,,
HYBRID HUM CUP EPI36 D42 +9MM,SUP-2513009,CDM,C1776,CPT,0278,RC,,,,both,,,5783.88,3759.52,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 100 MG 1 YR SHLF LIFE VIADISC NP,SUP-2740077,CDM,C1762,CPT,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
DRILL SURG 15MM SHT MINI QUIK CONN VLP MINI MOD,SUP-2351108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.39,405.85,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR DIA 900-1200 UM 2 ML PVA,SUP-2140326,CDM,C1889,HCPCS,0278,RC,,,,both,,,805.10,523.31,,,,,,,,,,,,,
PLATE BNE L131MM 7 H NONSTERILE L DST LAT FIBULAR S STL VAR,SUP-2177727,CDM,C1713,HCPCS,0278,RC,,,,both,,,2658.92,1728.30,,,,,,,,,,,,,
OSS AVL TIBIAL LOCK RING,SUP-2506413,CDM,C1776,CPT,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|CQ|XU,both,,,144.00,93.60,,,,,,,,,,,,,
TRAY TIB SZ 1 MOD OFFSET BKS,SUP-2315561,CDM,C1776,CPT,0278,RC,,,,both,,,6707.04,4359.58,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK CD 2 TI CRT 3 CHMBR LV1 IS1 UPLR,SUP-2140442,CDM,C1722,HCPCS,0275,RC,,,,both,,,71202.64,46281.72,,,,,,,,,,,,,
MESH HERN ANAT XL 16X12 CM LT PRESHAPED MONOFILAMENT DEXTILE,SUP-2752176,CDM,C1781,HCPCS,0278,RC,,,,both,,,893.46,580.75,,,,,,,,,,,,,
BLADE OSTEOTOM L 100 MM DIA12 MM GOUGE CRV RND TIP,SUP-2898696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.63,1339.41,,,,,,,,,,,,,
SYSTEM GYN ANTR PELV FLR MESH PELV RECON GYNECARE PROSIMA,SUP-2219811,CDM,C1781,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
HC I&D Deep Abscess Upper Leg,PX-4502730100,CDM,27301,CPT,0450,RC,,,,both,,,2779.00,1806.35,,,,,,,,,,,,,
IMPLANT LARYN L10MM DIA16FR INDWL RADPQ RNG CLASS,SUP-2242367,CDM,L8509,HCPCS,0274,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ANCHOR SUT SZ 4.5MM BLU PEEK UHMWPE BRAID FLAT PERMATAPE,SUP-2417593,CDM,C1713,HCPCS,0278,RC,,,,both,,,1205.76,783.74,,,,,,,,,,,,,
ROD DISTR VRTCL 150MML CRBN F/RGD EXTRNL DISTR RED II,SUP-2489602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1221.62,794.05,,,,,,,,,,,,,
GRAFT HUM TISS W15 40 4 30XL30 40MM THK24 26MM IL CREST WDG,SUP-2307418,CDM,C1713,HCPCS,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-129586,CDM,J0714,HCPCS,0636,RC,00456-2700-10,NDC,,both,1,UN,2388.40,1552.46,,,,,,,,,,,,,
RAKE HOOKS LONE STAR RETRCT SYS BLNT END SM CRV 4-FINGER E,SUP-2171548,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.71,28.41,,,,,,,,,,,,,
DEFIBRILLATOR CARD CRT-D BIVENTRICULAR DF4/LV1 CONN DYNAGEN,SUP-2149214,CDM,C1882,HCPCS,0275,RC,,,,both,,,46274.18,30078.22,,,,,,,,,,,,,
MARKER FIDUCIAL 0.35 MMX1 CM PRELD NDL CARR COIL VISICOIL,SUP-2430920,CDM,A4648,CPT,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20-40X10-30 MM FD ILIUM BICORTICAL,SUP-2717882,CDM,C1762,CPT,0278,RC,,,,both,,,3447.97,2241.18,,,,,,,,,,,,,
CATHETER US 10FR L90CM 3D SOUNDSTAR FOR SIEMENS,SUP-2248955,CDM,C1753,HCPCS,0278,RC,,,,both,,,7843.72,5098.42,,,,,,,,,,,,,
MESH BONE 162MM DIA 2512MML 15MM THK RSRB X SM GRID LATEX,SUP-2694435,CDM,C1713,HCPCS,0278,RC,,,,both,,,10705.80,6958.77,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0250,RC,00338-0049-11,NDC,,both,250,ML,123.30,80.14,,,,,,,,,,,,,
CATHETER PERI DLYS L120CM OD2.5MM ID1.3MM STD BA IMPREG OPN,SUP-2284393,CDM,C1750,HCPCS,0278,RC,,,,both,,,402.49,261.62,,,,,,,,,,,,,
ALLOGRAFT BNE PROX FEM 10 CM FRZN RT HD,SUP-2717955,CDM,C1762,CPT,0278,RC,,,,both,,,24178.00,15715.70,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|ADJ|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,ADJ|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
HC Pt Iontophoresis per 15 Min,PX-4209703300,CDM,97033,CPT,0420,RC,,,,both,,,221.00,143.65,,,,,,,,,,,,,
PAD TRACH STOMA 3 45X38 MM INNOVATIVE CUSH SIL.FLEX,SUP-2352876,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.87,351.57,,,,,,,,,,,,,
PHENYLEPHRINE HCL 0.125 % NA SOLN,RX-36952,CDM,6370000000,HCPCS,0637,RC,56184-0121-05,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
DEVICE TISS FIX FIBERTAG TIGHTROPE II INTERNALBRACE ACL DRL,SUP-2910477,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.79,1939.46,,,,,,,,,,,,,
ELECTRODE ELECSURG STR VES SEAL BRAISED PK SUPERPLUSE DISP,SUP-2312849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,792.22,514.94,,,,,,,,,,,,,
SEALER EPI VEIN 15DEG SEAL BPLR TIP AQUAMANTYS,SUP-2281804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.59,1339.38,,,,,,,,,,,,,
CONNECTOR SHUNT 1X1.9X11 MM RT ANGLE PLAS STRL ACCU-FLO,SUP-2666412,CDM,C1889,HCPCS,0278,RC,,,,both,,,304.86,198.16,,,,,,,,,,,,,
KIT CATHETER DRNGE LNG L864CM INTRO NDL 16GA L114CM SPNL,SUP-2280045,CDM,C1755,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
ELECTRODE ELECSURG BICOAGULATION 2 MMX105 CM MONOPOLAR,SUP-2477704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.24,428.51,,,,,,,,,,,,,
STENT PERIPH EVERFLEX L 150 MM DIA 7 MM CATH L 120 CM SHTH 5,SUP-2716352,CDM,C1876,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
CATHETER KIT 3L 5 FR PWR 3CG PLCMNT,SUP-2126773,CDM,C1751,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
STAPLE BONE FIXATION W14XH14XL14MM SUPERELASTIC ERGONOMIC LOW PROFILE BROAD BRIDGE DYNACLIP,SUP-2878338,CDM,C1713,HCPCS,0278,RC,,,,both,,,7394.70,4806.55,,,,,,,,,,,,,
ROD SPNL L50MM OD6MM TI ANT POST SMOOTH MAX RAD IMPL XIA,SUP-2380138,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
IMPLANT OTO L5.8MM HD DIA3.5MM HA MALL CNTR PORP RICHARD,SUP-2312811,CDM,L8613,CPT,0278,RC,,,,both,,,1236.16,803.50,,,,,,,,,,,,,
STEM FEM SZ 13.5 RT HIP HA STD BODY DSTL TEXT APR,SUP-2211003,CDM,C1776,CPT,0278,RC,,,,both,,,16817.84,10931.60,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 15 CC PRESERVON CANC READIGRAFT,SUP-2740807,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.55,534.66,,,,,,,,,,,,,
PLATE BNE L236MM 16 H ST POST DST TIB S STL T LOK COMPR FOR,SUP-2177441,CDM,C1713,HCPCS,0278,RC,,,,both,,,4880.94,3172.61,,,,,,,,,,,,,
CATHETER DRNGE 8FR L40CM GWIRE 0.038IN BILI W/ LCK PGTL,SUP-2120142,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
ANCHOR SUT W/ ETHBND SZ 4-0 P-3 NDL TAPERCUT MIC QUICKANCHR,SUP-2249378,CDM,C1713,HCPCS,0278,RC,,,,both,,,2609.34,1696.07,,,,,,,,,,,,,
DEVICE TISS REMOVING L25.25IN OD4MMXL HYSTEROSCOPIC SGL USE,SUP-2239920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2892.98,1880.44,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SOUNDSTAR ECO 3D DIA10 FR FOR,SUP-2699992,CDM,C1759,HCPCS,0272,RC,,,,both,,,3596.40,2337.66,,,,,,,,,,,,,
CANNULA ARTHSCP ROTATABLE 70 DEG 4X160 MM 13.7 TRUEVIEW II,SUP-2747491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3101.19,2015.77,,,,,,,,,,,,,
GUIDE PIN ORTHOPEDIC 12X190 MM,SUP-2193795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
TAP SURG DIA 4 MM SINGLE LD AO QC FOR FIBULAR NAIL NS DISP,SUP-2909095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
DELIVERY SYS VLV REP MITRACLIP 2 CLP CATH STEER SLV STRL,SUP-2106213,CDM,C1889,HCPCS,0278,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
CABLE PACE L 2 FT FOR 3105 BIOTRONIK PSA SYS,SUP-2494552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP ANTR TIBIALIS,SUP-2867227,CDM,C1762,CPT,0278,RC,,,,both,,,6828.09,4438.26,,,,,,,,,,,,,
GRAFT SKIN N MESHED CRYOPRESERVED ALLGRFT 232CM2,SUP-2165550,CDM,C1762,CPT,0278,RC,,,,both,,,1406.72,914.37,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X218 MM 18 HOLE SS DCP,SUP-2569158,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
ILLUMINATOR RETRACTOR CANYON TL DISP,SUP-2869070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Appl Mltlayr Compres Sys Uparm Lwarm Hand&Finger,PX-7612958400,CDM,29584,CPT,0761,RC,,,,both,,,414.00,269.10,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE MESHED 4X4CM,SUP-2905484,CDM,Q4128,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
COLLAR CERV M H3XL17IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335996,CDM,L0180,HCPCS,0274,RC,,,,both,,,12.21,7.94,,,,,,,,,,,,,
SHEATH ENDOSCP 17 GAX12 IN,SUP-2361475,CDM,C1894,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
COMPONENT PATELLAR 3 PEG 26 MM DOMED ROUNDED EXP VIT E,SUP-2390477,CDM,C1776,CPT,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
VPAP II ST-A BI-LEVEL CPAP DEV,SUP-2331924,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
COMPONENT TIB CRUCFRM BEAD 1 MED IMPL PERIAPATITE HA POROUS,SUP-2377177,CDM,C1776,CPT,0278,RC,,,,both,,,6737.18,4379.17,,,,,,,,,,,,,
BIT DRILL SLD STP T2 RECON,SUP-2701848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.00,564.85,,,,,,,,,,,,,
SCISSOR SURG PECK-JOSEPH 5.5 IN 4.9 CM CRV SHRP/SHRP BLADE,SUP-2872580,CDM,C1889,HCPCS,0278,RC,,,,both,,,257.17,167.16,,,,,,,,,,,,,
BRACE WRIST/THUMB AD L7IN UNIV LT SFT IMMOB JT LACE STAY,SUP-2324010,CDM,L3931,HCPCS,0274,RC,,,,both,,,31.27,20.33,,,,,,,,,,,,,
SCREW BONE L140MM DIA8MM STD CORT TI ST SELF DRL CANN,SUP-2343508,CDM,C1713,HCPCS,0278,RC,,,,both,,,2052.87,1334.37,,,,,,,,,,,,,
PLATE BONE L41MM 5 H S STL QTR TBLR ECT,SUP-2198591,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.41,93.87,,,,,,,,,,,,,
CATHETER PICC 5FR L55CM 17.5/17.5GA PEELABLE SHEATH/DILATOR,SUP-2118816,CDM,C1751,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
CATHETER PICC L 30 CM DIA1.4 FR POLYUR SINGLE LUMEN STRL,SUP-2904957,CDM,C1751,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
GUIDE WIRE 16 MM PILOT PENNIG DYN WRST FIX,SUP-2644598,CDM,C1769,HCPCS,0272,RC,,,,both,,,231.73,150.62,,,,,,,,,,,,,
SYSTEM THROMCTMY POUNCE L 128 CM WORKING L 90 CM SHTH 10 FR,SUP-2913965,CDM,C1757,HCPCS,0272,RC,,,,both,,,21823.00,14184.95,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 20 A 2 PEDIATRIC WITH SHUNT ASSISTANT PR,SUP-2821856,CDM,C1889,HCPCS,0278,RC,,,,both,,,10012.96,6508.42,,,,,,,,,,,,,
GRAFT BIO TISS OASIS ULTRA 3LAYER MATRIX 5X7CM MESHED,SUP-2341246,CDM,Q4124,HCPCS,0636,RC,,,,both,,,1394.03,906.12,,,,,,,,,,,,,
SYRINGE MED CONE TIP 150 CC 3 RNG CTRL AUTOCLV FOR UROLOGY,SUP-2747412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1702.79,1106.81,,,,,,,,,,,,,
STENT COR 15MM 35MM CATHETER L140CM 0014IN CO CHROME RAP,SUP-2138319,CDM,C1876,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
IMMOBILIZER KNEE L23IN UNIV AD WRP ARND OPN PAT WIND ADJ,SUP-2136226,CDM,L1830,CPT,0272,RC,,,,both,,,112.41,73.07,,,,,,,,,,,,,
SCREW BNE 10 DEG SM TI SLD ANGLED STRL PHALINX,SUP-2900663,CDM,C1713,HCPCS,0278,RC,,,,both,,,4744.54,3083.95,,,,,,,,,,,,,
PLATE BONE L63MM 4 H T OBLQ STRL SM FRAG,SUP-2348451,CDM,C1713,HCPCS,0278,RC,,,,both,,,2016.32,1310.61,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA 3.5 MM TI CANN HDLSS NS LEOS,SUP-2932587,CDM,C1713,HCPCS,0278,RC,,,,both,,,856.25,556.56,,,,,,,,,,,,,
GRAFT BONE SUB 16X14MM DWL CANC AND CORT FRZ DRY,SUP-2294050,CDM,C1713,HCPCS,0278,RC,,,,both,,,1626.52,1057.24,,,,,,,,,,,,,
AUGMENT ACET OD62MM ID64MM THK15MM 6 H TRITANIUM BULK FOAM,SUP-2363289,CDM,C1776,CPT,0278,RC,,,,both,,,5101.87,3316.22,,,,,,,,,,,,,
PACEMAKER CARD W52XH44MM THK6MM PERM 2 CHMBR STD,SUP-2357346,CDM,C1785,HCPCS,0275,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
CATHETER KIT 0.018 INX17.75 IN AD 5 FRX50 CM BLU FLEXTIP,SUP-2384054,CDM,C1751,HCPCS,0278,RC,,,,both,,,848.18,551.32,,,,,,,,,,,,,
SYSTEM SPNL FIX 16 MM TI STRL COFIX LTX,SUP-2867269,CDM,C1889,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
BIT DRL 3 FLUT W/ QUIK CPL 4.0MMX250MM LEN,SUP-2204931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
PLATE BONE W17.5XL214MM THK5.2MM 12 H TI BROAD LIMIT CNTCT,SUP-2190852,CDM,C1713,HCPCS,0278,RC,,,,both,,,2024.99,1316.24,,,,,,,,,,,,,
TRAZODONE HCL 150 MG PO TABS,RX-8084,CDM,6370000000,HCPCS,0637,RC,00904-7212-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT DURA W2XL2IN ULTRAPURE DURAGN + EA,SUP-2244006,CDM,C1763,HCPCS,0278,RC,,,,both,,,1609.41,1046.12,,,,,,,,,,,,,
SCREW BNE L16MM DIA2.7MM TI ST VAR ANG NONCANNULATED LOK,SUP-2181185,CDM,C1713,HCPCS,0278,RC,,,,both,,,479.32,311.56,,,,,,,,,,,,,
HOOK SPNL BLDE W5MM LT LAM TI OFFSET OPN FOR 5.5MM ROD MOSS,SUP-2254450,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
BRACE ORTH EXTN ORTHOSIS WRST CTRL,SUP-2388193,CDM,L3908,HCPCS,0274,RC,,,,both,,,162.43,105.58,,,,,,,,,,,,,
CONNECTOR AX TI 50MMX55MM CDH M8,SUP-2631254,CDM,C1713,HCPCS,0278,RC,,,,both,,,3944.41,2563.87,,,,,,,,,,,,,
KIT BNE CEM PREP PLUG BRSH CURET SPNG W/ RESTRIC FOR FEM,SUP-2253093,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
STRAP ORTHOT HIP KNEE ANK CUST TORSON BILATERAL ROT,SUP-2435640,CDM,L2040,HCPCS,0272,RC,,,,both,,,572.74,372.28,,,,,,,,,,,,,
SM FRAG PLT STERILIZER 3.5X37 MM 3 HL,SUP-2818396,CDM,C1713,HCPCS,0278,RC,,,,both,,,944.20,613.73,,,,,,,,,,,,,
PIN FIX L9IN OD1/8IN S STL TYP D STNMN,SUP-2342716,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.16,136.60,,,,,,,,,,,,,
GRAFT EVAR L40X70CM DIA8X8MM AXILLOBIFEMORAL FULL RNGD STD,SUP-2395787,CDM,C1768,CPT,0278,RC,,,,both,,,11680.80,7592.52,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD 15.5FR L28CM CHRONIC BASIC KT W/,SUP-2116517,CDM,C1750,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
CATHETER IRRIGATION 4 FRX80 CM OCCL,SUP-2264265,CDM,C2628,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STEM HUM CEM 140 DEG 6.5X115 MM SHLDR AEQUALIS,SUP-2715535,CDM,C1776,CPT,0278,RC,,,,both,,,10131.21,6585.29,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 13 MM 33 CC 71 GM EPIC II VR V158ROPT] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356510,CDM,C1722,HCPCS,0275,RC,,,,both,,,69865.00,45412.25,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 6X16 CMX1-2 MM PROLAYER EDM,SUP-2717799,CDM,C1763,HCPCS,0278,RC,,,,both,,,22568.75,14669.69,,,,,,,,,,,,,
COMPONENT TOT KNEE STD W/TS STEM INSRT,SUP-2379198,CDM,C1776,CPT,0278,RC,,,,both,,,15307.50,9949.87,,,,,,,,,,,,,
BIT DRILL CALIB 4.3MM,SUP-2491960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5CM 10MM 120CM 0.035 IN,SUP-2719582,CDM,C1768,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
BASKET SPEC RETRV OLYPERCX PCNL,SUP-2798155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.01,494.01,,,,,,,,,,,,,
COUPLER EXT FIX 2 MM TIB W/SL OFFSET GEN II,SUP-2435052,CDM,C1776,CPT,0278,RC,,,,both,,,4056.88,2636.97,,,,,,,,,,,,,
RING EXT FIX ALUM ROCK FOR ILIZ TAY SPAT FRME SYS,SUP-2343002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5695.65,3702.17,,,,,,,,,,,,,
HC Admin Hepatitis B Vaccine,PX-7710001000,CDM,G0010,HCPCS,0771,RC,,,,outpatient,,,116.00,75.40,,,,,,,,,,,,,
PACEMAKER CARD CONSULTA W 59 X H 57 MM D 6 MM 15 CC 26 GM TI,SUP-2282345,CDM,C2621,HCPCS,0275,RC,,,,both,,,19417.73,12621.52,,,,,,,,,,,,,
GRAFT DURAMATRIX CLLGN DURA SUB MEM 1 IN X 1 IN ST FR TYOE 1,SUP-2165119,CDM,C1763,HCPCS,0278,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
BOLT EXT FIX WIRE SIDEKCK EZ FRAME EF1500PK,SUP-2484070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7517.16,4886.15,,,,,,,,,,,,,
RECON PLATE 18X214MM 3.5MM,SUP-2818477,CDM,C1713,HCPCS,0278,RC,,,,both,,,4979.88,3236.92,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 5 MM RNG L 2.5 CM EPTFE STR TW,SUP-2396148,CDM,C1768,CPT,0278,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
ALLOGRAFT BNE SHT 3 CMX3 MM FD CIR CANC STRL ENHANCE LF DISP,SUP-2468377,CDM,C1889,HCPCS,0278,RC,,,,both,,,1513.32,983.66,,,,,,,,,,,,,
BIT DRL L160MM DIA3.5MM ST CANN QUIK CPL NONRADIOLUCENT ADJ,SUP-2187340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1243.53,808.29,,,,,,,,,,,,,
GRAFT HUM TISS L 5 X W 4 CM SZ 20 SQCM AMNION-CHORION-AMNION,SUP-2909286,CDM,Q4137,HCPCS,0636,RC,,,,both,,,9764.49,6346.92,,,,,,,,,,,,,
MATRIX BIO L 25 X W 20 CM FET BOV DERM DERMAL MESHED STRL,SUP-2909317,CDM,Q4110,HCPCS,0636,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
WIRE EXT FIX OLV 1.6 MM,SUP-2749722,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
PLATE BNE RECON 3.5X118 MM 10 HOLE TI NS,SUP-2191078,CDM,C1713,HCPCS,0278,RC,,,,both,,,1670.89,1086.08,,,,,,,,,,,,,
PERI-LOC VLP 3.5MM S-T LOCK SCREW 42MM,SUP-2821049,CDM,C1713,HCPCS,0278,RC,,,,both,,,880.24,572.16,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1193108D4,SUP-2632795,CDM,C1751,HCPCS,0278,RC,,,,both,,,1100.44,715.29,,,,,,,,,,,,,
PAMIDRONATE DISODIUM 90 MG/10ML IV SOLN,RX-32855,CDM,J2430,HCPCS,0636,RC,67457-0446-10,NDC,,both,10,ML,185.60,120.64,,,,,,,,,,,,,
PROBE ELECSURG MIC ANG TEMP CTRL TACS,SUP-2341610,CDM,C1713,HCPCS,0278,RC,,,,both,,,1167.14,758.64,,,,,,,,,,,,,
NEEDLE PLACEMENT 18 GA X 25 CM WITH POLYMARK MARKER,SUP-2665288,CDM,A4648,CPT,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
CONNECTOR SHUNT 1X1.9X17.8 MM STR PLAS STRL ACCU-FLO,SUP-2666411,CDM,C1889,HCPCS,0278,RC,,,,both,,,280.12,182.08,,,,,,,,,,,,,
SNARE VASC PET PLT RADPQ MRK BND STRAIN RELF HUB EVAR 1 SNR,SUP-2303142,CDM,C1773,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BONE W17.5XL229MM THK5.2MM 12 H STRL BILAT S STL BROAD,SUP-2185300,CDM,C1713,HCPCS,0278,RC,,,,both,,,2106.00,1368.90,,,,,,,,,,,,,
AUGMENT ACET DIA 66 MM THK 15 MM,SUP-2888597,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER DRNGE 10FR L25CM HYDRPHLC ORIGIN STIFFNESS W/ LCK,SUP-2391577,CDM,C1729,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
PLATE BNE L 120 X W 8 MM THK 3.2 MM SCREW DIA2.7 MM 15 H SS 72440115N,SUP-2933437,CDM,C1713,HCPCS,0278,RC,,,,both,,,2976.25,1934.56,,,,,,,,,,,,,
COIL NEUROVASCULAR MICRUSFRAME S 18 L 47 CM DIA14 MM PRIMARY,SUP-2249250,CDM,C1889,HCPCS,0278,RC,,,,both,,,12825.58,8336.63,,,,,,,,,,,,,
NAIL IM TIB UNIV 10 MMX42 CM TI NAT NAIL,SUP-2461339,CDM,C1713,HCPCS,0278,RC,,,,both,,,4864.24,3161.76,,,,,,,,,,,,,
TRAY CATH 5FR INTRO NDL CHLOROPREP FUTURA SCALP SYR CAP,SUP-2133891,CDM,C1729,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
CATHETER HD PRECRV 12.5 FRX32 CM LT DL STP TIP SIL HEMCATH,SUP-2627319,CDM,C1750,HCPCS,0278,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
CATHETER NEPHROSTOMY 22FR 5CC MALECOT,SUP-2858159,CDM,C1729,HCPCS,0272,RC,,,,both,,,299.12,194.43,,,,,,,,,,,,,
BLOCK CUT KNEE PT SPEC INSTRUMENT FOR CAPPED,SUP-2212491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC So Cebpa Gene Full Sequence,PX-3108121866,CDM,81218,CPT,0310,RC,,,,both,,,384.00,249.60,,,,,,,,,,,,,
INTRODUCER KT MINI ACCS N VASC 6FRX20CM 4FR W DIL AND,SUP-2303018,CDM,C1894,HCPCS,0272,RC,,,,both,,,189.81,123.38,,,,,,,,,,,,,
SCREW BNE CANN 3.5X23 MM COMPR LP TRNSVRS TI LAPIPLASTY,SUP-2422332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PACK VITRECTOMY DIA25 GA SURG PROC,SUP-2905473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1959.36,1273.58,,,,,,,,,,,,,
PROBE 2 CHAN PH PRB F/ ACID REFLX COMFORTEC M11 18CM DISP,SUP-2336772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT HUM TISS W10MM BISECTED PAT LIG FRZN FLEXIGRFT,SUP-2264727,CDM,C1762,CPT,0278,RC,,,,both,,,7441.33,4836.86,,,,,,,,,,,,,
SLEEVE CNTR L8MM PMMA FOR FEM HIP FX,SUP-2406635,CDM,C1776,CPT,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
CATHETER INFUSION ENDOVASC DEV 12 FRX106 CM US COR EKOSONIC,SUP-2214798,CDM,C1887,HCPCS,0272,RC,,,,both,,,18887.10,12276.61,,,,,,,,,,,,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,6370000000,HCPCS,0637,RC,43598-0436-35,NDC,,both,1,UN,95.20,61.88,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPLR CEM ENDO HD ST LD/FX,SUP-2212085,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
WASHER ORTH T6 FOR 2.3 MM SCREW NS VARIAX 2 MINI FRAG,SUP-2902164,CDM,C1713,HCPCS,0278,RC,,,,both,,,214.78,139.61,,,,,,,,,,,,,
POST EXT FIX SLT SM,SUP-2162667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BASEPLATE TIB SZ 1 BIOFOAM SCR H ADV,SUP-2304791,CDM,C1776,CPT,0278,RC,,,,both,,,8044.68,5229.04,,,,,,,,,,,,,
HC MRI-Upper Ext W Cont,PX-6107321900,CDM,73219,CPT,0610,RC,,,,outpatient,,,4976.00,3234.40,,,,,,,,,,,,,
CATHETER THERMOABLATION CLOSUREPLUS L 60 CM DIA 6 FR,SUP-2393081,CDM,C1888,HCPCS,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
GUIDE PIN TIP THRD 3.2X300MM,SUP-2820853,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.95,213.82,,,,,,,,,,,,,
INSERT TIB H16MM M/M+ DURAMER ADVTM LSI,SUP-2304384,CDM,C1776,CPT,0278,RC,,,,both,,,6559.77,4263.85,,,,,,,,,,,,,
SYSTEM NEUROPROTECTION ENROUTE GUIDEWIRE 0.035 IN,SUP-2890430,CDM,C1884,HCPCS,0278,RC,,,,both,,,11727.90,7623.13,,,,,,,,,,,,,
STEM FEM L165MM OD11MM 100% POR PLSM SPRY DSTL CALCAR MOD,SUP-2404002,CDM,C1776,CPT,0278,RC,,,,both,,,5915.76,3845.24,,,,,,,,,,,,,
IMMOBILIZER SHLDR L FOR 40-44IN RIB FOAM WRST NYL HUM CUF E,SUP-2196922,CDM,L3650,HCPCS,0272,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
TOOL EMBDNG FOR TEMPORARILY EMBED EXT PORTION OF PERI DLYS,SUP-2303481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR REACTIV8 L 65 CM SUTURE SLV STRL,SUP-2877968,CDM,C1730,HCPCS,0272,RC,,,,both,,,8945.86,5814.81,,,,,,,,,,,,,
PLATE BNE W22XL66MM STD 6X4 H ST L DST RAD VOLAR TI VAR ANG,SUP-2180850,CDM,C1713,HCPCS,0278,RC,,,,both,,,2735.10,1777.81,,,,,,,,,,,,,
CATHETER GUID BATES 2 0.091 INX8 FRX55 CM W/ 2 SH PTFE MACH1,SUP-2147723,CDM,C1887,HCPCS,0272,RC,,,,both,,,295.44,192.04,,,,,,,,,,,,,
LINER ACET OD36MM ID22MM THK5.1MM 10DEG STD HIP POLYETH MOD,SUP-2202086,CDM,C1776,CPT,0278,RC,,,,both,,,2514.51,1634.43,,,,,,,,,,,,,
RING ANNULPLSTY CG FUTURE ID 24 MM OD 28.9 MM STIFFENER ID,SUP-2282739,CDM,C1889,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT 35X10 MM FRZN HALF PATELLAR TEND,SUP-2866892,CDM,C1762,CPT,0278,RC,,,,both,,,6479.08,4211.40,,,,,,,,,,,,,
PAD ORTHOT LUMBAR CUST DEROTATION,SUP-2435587,CDM,L1240,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA5MM HALF QUIK CONN FOR RNG FIX SYS,SUP-2316103,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.96,283.37,,,,,,,,,,,,,
NEEDLE JAMSH BVL I-PASS III,SUP-2310419,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
DRESSING KIT 13 CM PREVENA,SUP-2113633,CDM,C1781,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
NEEDLE EPIDURAL L 6 IN STRL DISP PHARM COUD,SUP-2917193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SPECULUM VGNL AUVRD 1 1/2NW X 2 3/4NL BLADE 2.5LB CPCTY WGHT,SUP-2473602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.82,328.78,,,,,,,,,,,,,
DISTRACTION INTRNL EXTN CRDNC ACT ARM16 MM T 6L 4V QT001 EA,SUP-2494961,CDM,C1713,HCPCS,0278,RC,,,,both,,,3174.41,2063.37,,,,,,,,,,,,,
PLATE BNE CALCANEAL CUBOID LG TI RIVAL VW,SUP-2645295,CDM,C1713,HCPCS,0278,RC,,,,both,,,4837.17,3144.16,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL PREFABRICATED LSO,SUP-2388147,CDM,L0627,HCPCS,0272,RC,,,,both,,,1058.59,688.08,,,,,,,,,,,,,
KIT RETRIEVAL SINGLE LOOP SNARE,SUP-2715944,CDM,C1773,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
IMPLANT STRNL CLSR PEEK W NDL ZIPFIX,SUP-2182839,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.23,298.50,,,,,,,,,,,,,
SPLINT WRST FA AD L11IN UNIV BLU CANVS TRICOT LNR STRP ON,SUP-2194375,CDM,L3908,HCPCS,0272,RC,,,,both,,,20.79,13.51,,,,,,,,,,,,,
FLAT WASHER 8.0MM STERILE,SUP-2586885,CDM,C1713,HCPCS,0278,RC,,,,both,,,140.58,91.38,,,,,,,,,,,,,
GRAFT HUM TISS L 6 X W 2 CM AMNION-CHORION-AMNION LAYR,SUP-2909269,CDM,Q4140,HCPCS,0636,RC,,,,both,,,9889.71,6428.31,,,,,,,,,,,,,
CAGE SPNL 0 DEG H 14X8X8 MM COALITION AGX R,SUP-2424050,CDM,C1889,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CATHETER GUID VERIPATH L 50 CM OD 8 FR ID 0.088 IN INNR PTFE,SUP-2101518,CDM,C1887,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
FELT VASC W6XL6IN THK2.87MM PTFE,SUP-2127686,CDM,C1768,CPT,0278,RC,,,,both,,,1428.39,928.45,,,,,,,,,,,,,
COIL VASC INTERLOCK-35 L 40 CM DIA20 MM GUIDEWIRE 0.035 IN,SUP-2148129,CDM,C1889,HCPCS,0278,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
KIT THROMCTMY JET 7 L 132 CM PROX/DSTL OD 6 FR/2.16 MM,SUP-2880228,CDM,C1757,HCPCS,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
BRACE ANK LACE UP FIGURE 8 X L,SUP-2276709,CDM,L4350,HCPCS,0274,RC,,,,both,,,23.55,15.31,,,,,,,,,,,,,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,0636,RC,25021-0184-82,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE L64MM 4 H LT PROX POSTEROMEDIAL VAR ANG LCK FOR,SUP-2349800,CDM,C1713,HCPCS,0278,RC,,,,both,,,9167.86,5959.11,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH LG 0.4 MM CRESCENT BLU STRL,SUP-2859904,CDM,C1713,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 5 FR CANN L 5.5 CM POLYUR PLAS SS,SUP-2156061,CDM,C1894,HCPCS,0272,RC,,,,both,,,23.71,15.41,,,,,,,,,,,,,
PASSER SUT 70DEG SHT MIC NIT LOOP PERIPH ULN TRIANG,SUP-2122327,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 80 MM DIA26/28 MM,SUP-2168755,CDM,C1874,HCPCS,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
SET URET STENT MARD L 24 CM DIA 4.8 FR GUIDEWIRE 0.035 IN,SUP-2139048,CDM,C2617,HCPCS,0278,RC,,,,both,,,450.75,292.99,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 5.5 MM SCR IN TI WHT BLU BLK V-LOX,SUP-2762301,CDM,C1713,HCPCS,0278,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
IMMUNE GLOBULIN (FLEBOGAMMA) 10%|DISCARDED DRUG NOT ADMINISTE,RX-4081761,CDM,J1459,HCPCS,0636,RC,44206-0436-05,NDC,JW,both,50,ML,2830.00,1839.50,,,,,,,,,,,,,
PLATE BNE L 192 X W 10 MM THK 2 MM SCREW DIA2.7/3.5 MM 14 H 72465314N,SUP-2933506,CDM,C1713,HCPCS,0278,RC,,,,both,,,5947.47,3865.86,,,,,,,,,,,,,
VALVE HEMOSTAS DBL PLAY LUMEN DIA 9 FR POLYCARB INSRTN TOOL,SUP-2303045,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.05,40.33,,,,,,,,,,,,,
CONNECTOR VENT DRNGE OD1.8MM ID1.2MM S STL 3 W Y SHP,SUP-2243837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,517.35,336.28,,,,,,,,,,,,,
CATHETER EP 4FR L110CM 2-5-2MM SPC 1MM BND ELECTRD M CRV,SUP-2357643,CDM,C1730,HCPCS,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
PLATE BNE HK 2.7X12 MM RT CLAV BUTTON LCK COMPR STRL VA-LCP,SUP-2750827,CDM,C1713,HCPCS,0278,RC,,,,both,,,4189.76,2723.34,,,,,,,,,,,,,
CANNULA SURG W/O STOPCOCK 70 MM 3.2 MM FOR IRRIGATION,SUP-2794081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,475.87,309.32,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA 6 MM EPTFE STR STD WALL,SUP-2396183,CDM,C1768,CPT,0278,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
STAPLER INT CARTRIDGE EXTRA THICK 80 MM TRI-STAPLE BLK GIA,SUP-2787700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1185.82,770.78,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 95 CM BALLOON L 20 MM RX COMPLIANT,SUP-2141002,CDM,C1725,HCPCS,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
WIRE ILLUMINATION SINUS RELIEVA LUMA,SUP-2106380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
BLADE SURG FOR ADENOTOMES WT540601,SUP-2649904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1126.79,732.41,,,,,,,,,,,,,
FILTER VASC ACCUNET SZ 4.5 MM SHTH 6 FR GUIDEWIRE L 300 MM,SUP-2104681,CDM,C1889,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
CATH BLLN INTRA AORTIV LINEAR 7.5FRX40CC,SUP-2481924,CDM,C1725,HCPCS,0272,RC,,,,both,,,2543.31,1653.15,,,,,,,,,,,,,
IMPLANT TOE 3.4X3X26MM TWO STEP FOR HAMMER TOE,SUP-2878124,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
BEAM FIX L65MM DIA4.5MM ARTH,SUP-2223926,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCREW INTRF L23MM DIA7MM KNEE PLLA CANN BIOABSRB THRD WDG,SUP-2362043,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.88,335.97,,,,,,,,,,,,,
PORT IMPL INFUSION STR 26X60 MM SS,SUP-2232156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.032IN TAPR 6 CM FLPY TIP 2 CM,SUP-2167654,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.74,19.98,,,,,,,,,,,,,
CATHETER EP DIAG MAP M CRV OCTAPOLAR 2-5-2MM SPC 2MM TIP,SUP-2356864,CDM,C1730,HCPCS,0272,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
GRAFT VASC L80CM DIA8MM PTFE CBAS HEP SURF THN WALLED REM,SUP-2395824,CDM,C1768,CPT,0278,RC,,,,both,,,8983.54,5839.30,,,,,,,,,,,,,
PLATE BNE LG TI MIDFACE 3D PRNT NS DISP ACCUPLATE,SUP-2934723,CDM,C1713,HCPCS,0278,RC,,,,both,,,38920.30,25298.19,,,,,,,,,,,,,
KIT PIN AND RMR SALTO TALARIS,SUP-2244122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3780.56,2457.36,,,,,,,,,,,,,
GUIDEWIRE VASC CLOSUREFAST L 150 CM DIA 0.025 IN TIP L 1.5,SUP-2393089,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.92,27.25,,,,,,,,,,,,,
PROLONG TIBIAL INSERT SZ 5 2,SUP-2720345,CDM,C1776,CPT,0278,RC,,,,both,,,4281.39,2782.90,,,,,,,,,,,,,
PLATE BNE 6 H R CLOVER COMPR LISFRANC GORILLA,SUP-2321539,CDM,C1713,HCPCS,0278,RC,,,,both,,,4651.13,3023.23,,,,,,,,,,,,,
ENDCAP SPNL RND 0 DEG 16X14 MM PARL TI X-CORE MINI,SUP-2559841,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
STAPLE SPNL RSTRL 23 MM CD HORZ,SUP-2278987,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
RING ANNULPLSTY PHY 24MM CARP EDW 4450M24] EDWARDS LIFESCIENCES CORP],SUP-2214165,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
CATHETER BLLN DIL L17MM DIA6MM SPHENOID EM SKR NUVENT,SUP-2284115,CDM,C1726,HCPCS,0272,RC,,,,both,,,1309.69,851.30,,,,,,,,,,,,,
SCREW BONE L12MM DIA2.8MM NONLOCKING SLD FOR PLATING SYS,SUP-2223996,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SUPPORT ORTHOT FNGR CUST ADJ W/O JT FABRICATED SFT INTFACE,SUP-2435789,CDM,L3933,HCPCS,0274,RC,,,,both,,,549.78,357.36,,,,,,,,,,,,,
TM TIBIAL CONE LARGE 51 X 34 RIGHT,SUP-2502240,CDM,C1776,CPT,0278,RC,,,,both,,,9558.16,6212.80,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 20X17 MM FD PAT,SUP-2717925,CDM,C1762,CPT,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
GUIDEWIRE VASC STR 2 CM 0.038 INX145 CM FIX COR SS SAFE-T-J,SUP-2167664,CDM,C1769,HCPCS,0272,RC,,,,both,,,24.74,16.08,,,,,,,,,,,,,
BLADE RETRACTOR HOHMN 21 CMX29 MM,SUP-2659986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2436.36,1583.63,,,,,,,,,,,,,
DIANEAL PD-2/1.5% DEXTROSE 346 MOSM/L IP SOLN,RX-15434,CDM,A4722,HCPCS,0250,RC,00941-0426-52,NDC,,both,1000,ML,74.80,48.62,,,,,,,,,,,,,
BAND ARM AD UNIV GEL ELAS STRP BILAT,SUP-2324557,CDM,L3702,HCPCS,0274,RC,,,,both,,,48.17,31.31,,,,,,,,,,,,,
GRIP CBL SM L115MM TROCHANTERIC HIP 3 CBL ACCORD,SUP-2345201,CDM,C1776,CPT,0278,RC,,,,both,,,5444.76,3539.09,,,,,,,,,,,,,
IMPLANT BIO TISS 4X7CM SM SURG TEND INTEGRA REINF MTRX,SUP-2244429,CDM,C1781,HCPCS,0278,RC,,,,both,,,7195.75,4677.24,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 10MM SMOOTH DISPOSABLE WITH TA,SUP-2804215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.85,421.75,,,,,,,,,,,,,
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY|DISCARDED DRUG NOT ADMINISTE,RX-157660,CDM,J1650,HCPCS,0636,RC,63323-0559-93,NDC,JW,both,0.3,ML,54.10,35.16,,,,,,,,,,,,,
HINGE EXT FIX M,SUP-2365313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
HC Renal Arteriogram Bilat,PX-3233625200,CDM,36252,CPT,0323,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
PEG BONE FIX L9MM DIA2.5MM DSTL VOLAR RAD CANC NONLOCKING,SUP-2414170,CDM,C1713,HCPCS,0278,RC,,,,both,,,286.37,186.14,,,,,,,,,,,,,
PACEMAKER CARD PHILOS II DR-T TI EPOXY RESIN 2 CHMBR MOB,SUP-2138059,CDM,C1785,HCPCS,0275,RC,,,,both,,,16017.14,10411.14,,,,,,,,,,,,,
PROGRAMMER PT 128GM H6.8XL10.77CM THK2.6CM SPNL CRD W/,SUP-2355983,CDM,C1787,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
GRAFT HUM TISS DIA20MM DISC VIABLE OSTEOCHNDRL ALLGRFT,SUP-2120738,CDM,C1713,HCPCS,0278,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
PLATE BONE FUSION 3.5X104 MM LEFT ANKLE HINDFOOT 5 HOLE UTIL,SUP-2837553,CDM,C1713,HCPCS,0278,RC,,,,both,,,7416.52,4820.74,,,,,,,,,,,,,
SCREW BNE L40MM DIA43MM TI ALLY SELF DRL ST VAR LAG DSGN FOR,SUP-2242833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1409.33,916.06,,,,,,,,,,,,,
TRAY TIB SZ 2 TI L MED R LAT CEM OFFSET PFC,SUP-2253955,CDM,C1776,CPT,0278,RC,,,,both,,,7167.99,4659.19,,,,,,,,,,,,,
BIT SURG DRL L17MM DIA2MM CANN W/ COUNTSINK FIXOS,SUP-2366052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.63,510.66,,,,,,,,,,,,,
CATHETER ART LN L8CM OD20GA .018IN GWIRE POLYETH SET SGL,SUP-2167834,CDM,C1751,HCPCS,0278,RC,,,,both,,,164.54,106.95,,,,,,,,,,,,,
PLATE BNE LP 1.5X0.6 MM NEURO 4X2 HOLE LADDER SQ SEG TI STRL,SUP-2472995,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.06,557.09,,,,,,,,,,,,,
CATHETER VENT L15CM BA ACCU-FLO,SUP-2243777,CDM,C1729,HCPCS,0272,RC,,,,both,,,702.92,456.90,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L500CM DIA0.035IN SUP STIFF TAPR DISP FOR,SUP-2149331,CDM,C1769,HCPCS,0272,RC,,,,both,,,358.56,233.06,,,,,,,,,,,,,
SCREW SPNL TALL CLOSE BODY PHOENIX,SUP-2316624,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ALLOGRAFT BNE WHL FIB FRZN LT,SUP-2717942,CDM,C1762,CPT,0278,RC,,,,both,,,9514.20,6184.23,,,,,,,,,,,,,
IMPLANT SYNTH 82 X 105 MM THK 20 MM LG POLYETHYL LT TEMPORAL,SUP-2883601,CDM,C1713,HCPCS,0278,RC,,,,both,,,5317.09,3456.11,,,,,,,,,,,,,
TRAY PNEUMOPERICARDIAL DRNGE CATH 8FR L15CM NDL 18GA L7CM,SUP-2171104,CDM,C1729,HCPCS,0272,RC,,,,both,,,608.85,395.75,,,,,,,,,,,,,
SCREW BNE L 155 MM DIA 6.5 MM THRD L 40 MM SS ST SD CANN RVS,SUP-2900934,CDM,C1713,HCPCS,0278,RC,,,,both,,,1302.28,846.48,,,,,,,,,,,,,
SPACER SPINE WDG TI 12DEG 18MM M ICI VANGUARD EBI SOLITAIRE,SUP-2414767,CDM,C1821,HCPCS,0278,RC,,,,both,,,15561.84,10115.20,,,,,,,,,,,,,
SCREW BNE L34MM DIA5MM CORT TI ST NONCANNULATED LOK FULL,SUP-2190246,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.63,281.86,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 16H LEFT 322MM,SUP-2549626,CDM,C1713,HCPCS,0278,RC,,,,both,,,3541.57,2302.02,,,,,,,,,,,,,
SHEATH ENDOSCP L20CM DIA3MM SGL ACT JAW OUTER W FRCP INSRT,SUP-2261267,CDM,C1894,HCPCS,0272,RC,,,,both,,,2672.77,1737.30,,,,,,,,,,,,,
PROBE LAP DIA8GA STEREOTACTIC DISP MAMTOM MR,SUP-2195659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,720.32,468.21,,,,,,,,,,,,,
SCREW BNE L32MM OD4.5MM TI CANN SHT THRD HD COMPR DARCO,SUP-2401021,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
NAIL IM L90MM OD11MM HIP SUBTROCHANTERIC ZCKL II,SUP-2364782,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.20,553.93,,,,,,,,,,,,,
SCREW INTRF L23MM DIA7MM PEEK VENT BIO-TENODESIS,SUP-2121353,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
ESTROGENS CONJUGATED 0.625 MG/GM VA CREA,RX-159331,CDM,6370000000,HCPCS,0637,RC,00046-0872-21,NDC,,both,30,GR,2073.90,1348.03,,,,,,,,,,,,,
COMPONENT RADIAL CRPL XS LT WRST UNIV 2,SUP-2610331,CDM,C1776,CPT,0278,RC,,,,both,,,21325.44,13861.54,,,,,,,,,,,,,
SHELL ACET PRESSFIT PRI 48 MM OD UNIV CLUS H TRABECULAR MTL,SUP-2202627,CDM,C1776,CPT,0278,RC,,,,both,,,6449.56,4192.21,,,,,,,,,,,,,
BIT DRL QC 2.5X240 MM 150 MM CALIB STRL,SUP-2563753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.27,321.28,,,,,,,,,,,,,
PIN EXTERNAL FIXATION W55XH6XL200MM GREEN HALF XTRAFIX,SUP-2499237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
PLATE BONE SHAFT 146MML HLX10 STRGHT NRRW NON CNTCT BRDGE PO,SUP-2721083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1728.38,1123.45,,,,,,,,,,,,,
CATHETER BLLN DIL 6 FRX320 CM 16 MMX8 CM QUANTUM TTC,SUP-2759284,CDM,C1726,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE 3 CRPL FOR WRST ARTHROPLAST TI STRL FRDM,SUP-2851941,CDM,C1713,HCPCS,0278,RC,,,,both,,,13902.22,9036.44,,,,,,,,,,,,,
NEEDLE VENTRICULAR CONE 18 GAX3.5 IN 2 HOLE MIRROR FINISH,SUP-2868950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.23,282.25,,,,,,,,,,,,,
PROBE SURG LIG PASS 4.5 MMX7.25 IN MICROSURGERY RT ANGLED TI,SUP-2458023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1225.79,796.76,,,,,,,,,,,,,
IMPL KNEE RECON RAD 6MM COLLAR SZ 2,SUP-2706514,CDM,C1776,CPT,0278,RC,,,,both,,,9354.69,6080.55,,,,,,,,,,,,,
SCREW BNE SD 1.5X5 MM NS UNIV NEURO III LTX,SUP-2862784,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
BLADE MACINTOSH FBR OPT LARYNSCP NO 4 155MMX15MM HEINE CLASS,SUP-2238180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.57,391.67,,,,,,,,,,,,,
BRACE CERV HRD CUST,SUP-2388135,CDM,L0174,HCPCS,0274,RC,,,,both,,,1074.63,698.51,,,,,,,,,,,,,
SCREW SPNL L 55 MM DIA 7.5 MM CFR-PEEK PEDCL FEN STRL,SUP-2883111,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
NEEDLE ENDO OD22GA ODSEC5.2FR TAPR BVL STYL TIP US STRL DISP,SUP-2169440,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SHELL ACET OD56MM ID24MM UNIV TI MH RINGLOC,SUP-2403543,CDM,C1776,CPT,0278,RC,,,,both,,,4684.88,3045.17,,,,,,,,,,,,,
ANTEROLATERAL PILON FUSION PLATE 9H LT,SUP-2815227,CDM,C1713,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
SLOTTED SCREW F/CONDYLAR HEAD,SUP-2823038,CDM,C1889,HCPCS,0278,RC,,,,both,,,580.27,377.18,,,,,,,,,,,,,
GRAFT BNE 8MM TISS WDG COT,SUP-2321662,CDM,C1776,CPT,0278,RC,,,,both,,,4519.09,2937.41,,,,,,,,,,,,,
ELECTRODE ENDO L36CM DIA5FR MPLR NDL,SUP-2218057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1178.94,766.31,,,,,,,,,,,,,
PLATE CRAN 120X100X40 MM PT SPEC IMPL PEEK,SUP-2860146,CDM,C1713,HCPCS,0278,RC,,,,both,,,36717.59,23866.43,,,,,,,,,,,,,
SET CLLR SZ P1 SORBATEX EXTRA PD ANTIBACT MIAMI JR,SUP-2276576,CDM,L0120,HCPCS,0272,RC,,,,both,,,187.68,121.99,,,,,,,,,,,,,
SCREW BNE L24MM OD3MM CANN LO PROF IMPL CAPTURE,SUP-2243894,CDM,C1713,HCPCS,0278,RC,,,,both,,,914.56,594.46,,,,,,,,,,,,,
ALLOGRAFT DERMAL SM MED 1.6/0.4 MM CNTOUR RDY TO USE ALLDERM,SUP-2458322,CDM,Q4116,HCPCS,0636,RC,,,,both,,,9002.38,5851.55,,,,,,,,,,,,,
GUIDEWIRE ORTH L18IN DIA1.2MM FOR ACL PCL FIX SYS BIOSURE,SUP-2341765,CDM,C1769,HCPCS,0272,RC,,,,both,,,144.66,94.03,,,,,,,,,,,,,
PACEMAKER CARD PHILOS II DR-T W 44 X H 51 MM D 6 MM TI,SUP-2138036,CDM,C1785,HCPCS,0275,RC,,,,both,,,19157.14,12452.14,,,,,,,,,,,,,
STEM FEM NO 2 L203MM OD14MM TI HA POR HIP REV STR NEUT CEM,SUP-2375244,CDM,C1776,CPT,0278,RC,,,,both,,,14064.69,9142.05,,,,,,,,,,,,,
PIN IM SZ E L152MM DIA3.2MM S STL FOR ROD RUSH,SUP-2211448,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
FIBER LASER FLAT TIP 200 MH ASMBLY HOLM CMH1020FL] MEDWEST ASSOCIATES INC],SUP-2300073,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SCREW BNE L18MM DIA4.2MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321218,CDM,C1713,HCPCS,0278,RC,,,,both,,,479.64,311.77,,,,,,,,,,,,,
HC Compatibility Test Incubate Ea Unit,PX-3008692100,CDM,86921,CPT,0300,RC,,,,both,,,187.00,121.55,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 22 CM DIA2.9 MM SPD 500-1500 RPM ENT,SUP-2901920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
DISC INTERVERTEBRAL W16XH7MM D14MM CERV CO CHROM MOLYBDENUM,SUP-2231424,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PATCH CV IVENA L 75 X W 10 MM PTFE ARW SHP,SUP-2763171,CDM,C1768,CPT,0278,RC,,,,both,,,716.61,465.80,,,,,,,,,,,,,
TUBE TRACH AD L40MM KISTNER,SUP-2383846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,159.83,103.89,,,,,,,,,,,,,
PLATE BNE L57MM 8 H L CNDYL TI RIG NONCOMPRESSION FOR 2.4MM,SUP-2191475,CDM,C1713,HCPCS,0278,RC,,,,both,,,1735.98,1128.39,,,,,,,,,,,,,
NAIL IM L340MM OD11MM 125DEG LNG TIM LT HIP AG CANN LCK,SUP-2211477,CDM,C1713,HCPCS,0278,RC,,,,both,,,9872.16,6416.90,,,,,,,,,,,,,
DEFIBRILLATOR ICD 2 CHMBR W/ LANDLINE HM LUMAX 740 DR T,SUP-2138199,CDM,C1721,HCPCS,0275,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
SUPPORT WRST PUL LACE CLOSURE UNIV RT PROCARE QUICK-FIT,SUP-2195779,CDM,L3931,HCPCS,0274,RC,,,,both,,,35.11,22.82,,,,,,,,,,,,,
PLATE BONE MEDIALMAX POCKETLOCK NEUT B,SUP-2400134,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,2500000003,HCPCS,0250,RC,00781-6153-95,NDC,,both,1,UN,265.00,172.25,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 L 10 CM DIA 4 MM MICROCATHETER,SUP-2365656,CDM,C1889,HCPCS,0278,RC,,,,both,,,1514.42,984.37,,,,,,,,,,,,,
NAIL IM L230MM DIA7.5MM 120DEG ST BLU L/R HUM TI CANN LOK,SUP-2192487,CDM,C1713,HCPCS,0278,RC,,,,both,,,4982.61,3238.70,,,,,,,,,,,,,
BUTTON FIX FOR IMPL SYS FIBERTAK,SUP-2423989,CDM,C1713,HCPCS,0278,RC,,,,both,,,2477.46,1610.35,,,,,,,,,,,,,
PROSTHESIS OSS 6 MM 1.12 MM 3 MM CENTERED PART TILT OTOSIL,SUP-2468981,CDM,L8613,CPT,0278,RC,,,,both,,,1235.24,802.91,,,,,,,,,,,,,
INTRODUCER SHTH 8.5FR L81CM 8.5FR DIL L85CM 0.032IN,SUP-2357267,CDM,C1893,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
LEAD DEFIB COR SINUS OVR THE WIRE QP S-75 SENTUS,SUP-2138437,CDM,C1900,HCPCS,0275,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
TBO-FILGRASTIM 480 MCG/0.8ML SC SOSY,RX-124232,CDM,J1447,HCPCS,0636,RC,63459-0912-11,NDC,,both,0.8,ML,1179.70,766.80,,,,,,,,,,,,,
CENTRALIZER STEM DIA9MM DST,SUP-2314440,CDM,C1776,CPT,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
STAPLE BNE AKIN 10X10 MM,SUP-2223275,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
HC Venography Extremity Bilateral,PX-3207582200,CDM,75822,CPT,0320,RC,,,,outpatient,,,1284.00,834.60,,,,,,,,,,,,,
PLATE BNE 100 DEG L 3.8 CM THK 1 MM SCREW DIA2 MM 6X8 H TI,SUP-2936471,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
DEVICE FUS OBLQ LAT LUMBER INTBDY 9MMX28MMX15MM ZEUS O,SUP-2115748,CDM,C1713,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
BIT DRL M DIA4.3MM FOR CALCNL SCR ARTH NAIL SYS PANTA,SUP-2243631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,698.08,453.75,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 8 MM EPTFE STR STD WALL N RING,SUP-2396430,CDM,C1768,CPT,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
PI PICC KIT 3-L 6 FR X 55 CM AGBA/TIPTRACKER,SUP-2565198,CDM,C1751,HCPCS,0278,RC,,,,both,,,743.02,482.96,,,,,,,,,,,,,
PLATE BONE L86MM 7 H POST LAT S STL 1/3 TBLR LCK COMPR FOR,SUP-2349796,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.31,1526.40,,,,,,,,,,,,,
DRILL SURG 2 MMX6 IN,SUP-2607264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.08,329.60,,,,,,,,,,,,,
STABILIT MX FRACTURE KIT BASE SHRT,SUP-2702593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
SCREW CORTICAL 2.5X26MM,SUP-2719777,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.60,174.59,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK WAIST BELT WEB,SUP-2388212,CDM,L5688,HCPCS,0272,RC,,,,both,,,160.55,104.36,,,,,,,,,,,,,
HC Eeg Extended More Than 1 Hour,PX-7409581300,CDM,95813,CPT,0740,RC,,,,inpatient,,,3429.00,2228.85,,,,,,,,,,,,,
ROD SPNL ANTR RT CVD SMOOTH S STL 5.0MM DIA 50MM LEN,SUP-2290499,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
PLATE BONE L18MM THK0.6MM 2X3 H MIDFACE TI RECTANG MTRX FOR,SUP-2402891,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.32,383.71,,,,,,,,,,,,,
GRAFT BNE STRP 100X10X8 MM 16 CC DBM,SUP-2644339,CDM,C1713,HCPCS,0278,RC,,,,both,,,8974.12,5833.18,,,,,,,,,,,,,
PLATE BNE L 234 MM SCREW DIA 4.5 MM 14 H BOW COMPR LCK STRL,SUP-2933391,CDM,C1713,HCPCS,0278,RC,,,,both,,,4472.93,2907.40,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X209 MM RT LAT DSTL 13 HOLE STRL VALCP,SUP-2789779,CDM,C1713,HCPCS,0278,RC,,,,both,,,3868.10,2514.26,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5 FR NIT MANDREL TUNGSTEN TIP REG,SUP-2120524,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
STAPLE BONE FIX L8XW9MM IMP SUPERELASTIC NIT STAPIX,SUP-2365917,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
CATHETER HD 11.5 FRX24 CM FULL TY KINK RESISTANCE,SUP-2267021,CDM,C1750,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
SPACER SPNL W11XH8XL14MM CERV PEEK ANAT,SUP-2279108,CDM,C1889,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
HEAD RADIAL 0+ MM 10X22 MM 7.5 MM ELBW STRL,SUP-2789482,CDM,C1776,CPT,0278,RC,,,,both,,,9249.81,6012.38,,,,,,,,,,,,,
PROBE BRST BX 13GA US VAC ASST MAMTOM ELITE,SUP-2195645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1165.07,757.30,,,,,,,,,,,,,
PRESSURIZER BONE CEM L PROX FEM CNL W/O HUB FOR HI VAC INJ,SUP-2361847,CDM,C1713,HCPCS,0278,RC,,,,both,,,60.16,39.10,,,,,,,,,,,,,
BODY HUM L50MM R DST SHLDR SCR FOR SEG REV SYS COMPHSVE,SUP-2435912,CDM,C1776,CPT,0278,RC,,,,both,,,11176.83,7264.94,,,,,,,,,,,,,
BIT DRL DIA2.5MM FOR REV SHLDR SYS,SUP-2208231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
KIT CRUCE ACC 2.4MM DRL TIP GUID WIRE 2.7MM DRL TIP PASS,SUP-2341590,CDM,C1769,HCPCS,0272,RC,,,,both,,,815.02,529.76,,,,,,,,,,,,,
PLATE BONE L26MM 10 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413747,CDM,C1713,HCPCS,0278,RC,,,,both,,,930.79,605.01,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR CHARGING MINI EON,SUP-2356753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3518.37,2286.94,,,,,,,,,,,,,
DISTRACTION PIN 2.0MM X 42MM 7MM CTTNG SHAFT 2/PKG T 6L 4V S,SUP-2499460,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.77,292.35,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 8 MM EPTFE FLX STD WALL RING,SUP-2761447,CDM,C1768,CPT,0278,RC,,,,both,,,1868.21,1214.34,,,,,,,,,,,,,
RING EXT FIX 160MM HALF,SUP-2197251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
CHEST TUBE PLEURAFLOW 32FR RT ANGLE ACT SYS WITH FLOWGLIDE,SUP-2655659,CDM,C1729,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
HC Temp Pacer Insertion,PX-3613321000,CDM,33210,CPT,0361,RC,,,,inpatient,,,1599.00,1039.35,,,,,,,,,,,,,
IMPLANT WR JT CRPL POLY INSRT SZ 1 4MM,SUP-2243505,CDM,C1776,CPT,0278,RC,,,,both,,,4275.58,2779.13,,,,,,,,,,,,,
PROSTHESIS OSS CENTERED 5.5 MM HA TI WILDCAT PRO,SUP-2457307,CDM,L8613,CPT,0278,RC,,,,both,,,1173.92,763.05,,,,,,,,,,,,,
CLASSIC CHS PL 14 SLOT 135 DEG,SUP-2818351,CDM,C1713,HCPCS,0278,RC,,,,both,,,7279.46,4731.65,,,,,,,,,,,,,
ORTHOLOC SPS 185MM STANDARD10 HOLE PLATE,SUP-2822320,CDM,C1713,HCPCS,0278,RC,,,,both,,,8597.32,5588.26,,,,,,,,,,,,,
SCREW BNE L 21 MM DIA2 MM TI ST LCK T6 DRV NS VLP,SUP-2931579,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.46,288.25,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM THCK PTCH UMB CRD DERIVATIVE AMNION,SUP-2393049,CDM,Q4170,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
FORCEPS ES L33CM DIA5MM CUT ERGO CUT BLDE TRIG HND ACT,SUP-2313979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2530.84,1645.05,,,,,,,,,,,,,
SHEATH INTRO L28CM DIA18FR POLYETH HYDRPHLC W/O CRV HEMSTAT,SUP-2396257,CDM,C1894,HCPCS,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
PLATE BNE L173MM THK3MM 11 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185344,CDM,C1713,HCPCS,0278,RC,,,,both,,,2030.29,1319.69,,,,,,,,,,,,,
DRILL SURG RETRACTABLE,SUP-2684214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
LIP BALM EX OINT,RX-18885,CDM,6370000000,HCPCS,0637,RC,83078-0113-14,NDC,,both,10,GR,4.20,2.73,,,,,,,,,,,,,
ENDOSCOPIC PACK RAP PAC LF,SUP-2848564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.30,572.19,,,,,,,,,,,,,
PIN FIX L9IN DIA3/32IN BAYNT PT SMOOTH,SUP-2252369,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
NICARDIPINE HCL IN NACL 20-0.86 MG/200ML-% IV SOLN,RX-94219,CDM,J2404,HCPCS,0636,RC,44567-0850-01,NDC,,both,200,ML,155.30,100.94,,,,,,,,,,,,,
ELECTRODE ELECSURG THERMOPAD DISPER RITA,SUP-2752472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
POSTERIOR PILON FUSION PLATE 12H,SUP-2817643,CDM,C1713,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
LEAD NERVE STIM KT STRL ENTERRA LTX,SUP-2866566,CDM,C1778,HCPCS,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
ALLOSYNC CANCELLOUS CUBES 30CC,SUP-2811231,CDM,C1713,HCPCS,0278,RC,,,,both,,,2020.59,1313.38,,,,,,,,,,,,,
PLATE BONE TUBULAR 37 MM 3 HOLE 1/3 WITH COLLAR STERILE TC10,SUP-2836661,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.60,285.09,,,,,,,,,,,,,
HC Simualtion Complex,PX-3337729000,CDM,77290,CPT,0333,RC,,,,both,,,2899.00,1884.35,,,,,,,,,,,,,
BASEPLATE TIB STD UNIV PRI STEM PRESSFIT POR CO CHROM SZ 1,SUP-2200366,CDM,C1776,CPT,0278,RC,,,,both,,,11570.27,7520.68,,,,,,,,,,,,,
CATHETER EP A CRV 2-5-2 MM 6 FRX65 CM UNIDIR,SUP-2356803,CDM,C1730,HCPCS,0272,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
SCREW BONE L48MM HDLSS MIS,SUP-2201525,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.67,151.24,,,,,,,,,,,,,
BASEPLATE HUM TRABECULAR MTL REV,SUP-2199139,CDM,C1776,CPT,0278,RC,,,,both,,,7624.74,4956.08,,,,,,,,,,,,,
SET URET STENT MARD L 26 CM DIA 6 FR GUIDEWIRE 0.038 IN,SUP-2139052,CDM,C2617,HCPCS,0278,RC,,,,both,,,521.37,338.89,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY VIK L 115 CM DIA 5 FR COURNAND,SUP-2460154,CDM,C1730,HCPCS,0272,RC,,,,both,,,132.67,86.24,,,,,,,,,,,,,
CLAMP EXT FIX PIN 5 HOLE,SUP-2749992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3381.78,2198.16,,,,,,,,,,,,,
RESERVOIR VENT L S STL BASE FOR 9.5MM BUR H HOLTER RICKHAM,SUP-2243789,CDM,C1729,HCPCS,0272,RC,,,,both,,,1007.94,655.16,,,,,,,,,,,,,
CATHETER DIAG L132CM DIA0.06IN DST ACCS AXS CATLYST 6,SUP-2368076,CDM,C1887,HCPCS,0272,RC,,,,both,,,6629.80,4309.37,,,,,,,,,,,,,
SCREW BONE L95MM OD3.5MM 6 CRUCFRM COARSE THRD WDRUFF,SUP-2362310,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.17,18.31,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA XT VR DELIVERED ENERGY 36 J 35 CC,SUP-2282420,CDM,C1722,HCPCS,0275,RC,,,,both,,,38016.51,24710.73,,,,,,,,,,,,,
APPLICATOR DURASEAL 15 CM ST DISP,SUP-2243103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,650.64,422.92,,,,,,,,,,,,,
LINER ACET SZ G OD58-60MM ID32MM 10DEG ECC BEAR TECHNOLOGY,SUP-2377152,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
EXTRACTOR BILI RX RETRV BAL 9-12MM BELOW,SUP-2141493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
ROD REPROC EXT FIX CARBN FIBR 4X200MM,SUP-2467587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,49.20,31.98,,,,,,,,,,,,,
TROCAR SURG 2.5 MM,SUP-2483025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE CRV MIC 1.5X0.6 MM NEURO 5X2 HOLE LADDER SQ SEG,SUP-2487369,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.13,591.58,,,,,,,,,,,,,
PLATE DSTL VOLAR RT NAR 22 MMX52 MM,SUP-2361545,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 50 X W 13.5 MM MYRIAD HNDPC L 13 NN-3003,SUP-2930299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22302.92,14496.90,,,,,,,,,,,,,
PLATE MXLFCL 06MM THK MED CMMRCLLY PURE TTNM CHRI MLFRMTN M,SUP-2681399,CDM,C1713,HCPCS,0278,RC,,,,both,,,4472.40,2907.06,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 12X8 MM FD IL CREST,SUP-2860948,CDM,C1713,HCPCS,0278,RC,,,,both,,,5761.90,3745.23,,,,,,,,,,,,,
KIT TKR CEM FEM TIB CPS VIT E SURF AND PAT PERSONA,SUP-2212229,CDM,C1776,CPT,0278,RC,,,,both,,,16054.82,10435.63,,,,,,,,,,,,,
HC MRI Brain WO Ctrst,PX-6117055100,CDM,70551,CPT,0611,RC,,,,both,,,5059.00,3288.35,,,,,,,,,,,,,
MELOXICAM 7.5 MG PO TABS,RX-20566,CDM,6370000000,HCPCS,0637,RC,50268-0525-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Group Exercise Pt|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209715000,CDM,97150,CPT,0420,RC,,,GP|CQ,outpatient,,,135.00,87.75,,,,,,,,,,,,,
IMPLANT RAD SZ 1 RT,SUP-2243498,CDM,C1776,CPT,0278,RC,,,,both,,,21706.73,14109.37,,,,,,,,,,,,,
CROWN DENT LR4 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176710,CDM,D6783,CPT,0278,RC,,,,both,,,25.43,16.53,,,,,,,,,,,,,
STENT PANCREATIC GEENEN L 13 CM DIA 3 FR GUIDEWIRE 0.018 IN,SUP-2737457,CDM,C2617,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
PLATE BNE 5 H R CLOVER COMPR LISFRANC GORILLA,SUP-2321538,CDM,C1713,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.1X150 MM FOR CANN SCREW NS 0333301104,SUP-2789096,CDM,C1769,HCPCS,0272,RC,,,,both,,,1031.93,670.75,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT W/ NDL ABSRB POLY L LACTIDE ACID W/ DIL,SUP-2341053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
CAGE SPNL PARL 17X14X9 MM MP DIVERGENCE,SUP-2632024,CDM,C1889,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
RETENTION PLTS RD DVCE 15MM THICK 15MM SSTM,SUP-2681289,CDM,C1713,HCPCS,0278,RC,,,,both,,,2801.82,1821.18,,,,,,,,,,,,,
BIT DRILL 2PK 3.2MM,SUP-2890890,CDM,C1776,CPT,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
MESH SURG 20 X 25 CM SUTURE SZ 5-0 OVINE PLGA REINF TISS,SUP-2914811,CDM,C1781,HCPCS,0278,RC,,,,both,,,25211.06,16387.19,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA3.2MM THRD TRCR PNT,SUP-2347053,CDM,C1769,HCPCS,0272,RC,,,,both,,,469.05,304.88,,,,,,,,,,,,,
DRESSING BIO L 10 X W 7 CM FISH SKIN 21 PRE MESHED STRL,SUP-2909162,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12393.58,8055.83,,,,,,,,,,,,,
IMATINIB MESYLATE 100 MG PO TABS,RX-32979,CDM,6370000000,HCPCS,0637,RC,59651-0240-90,NDC,,both,1,UN,5.50,3.57,,,,,,,,,,,,,
CATHETER HAD AD 14FR L20CM ADMIN BASIC KT DBL LUMN POLYUR,SUP-2266969,CDM,C1752,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
CUP ACET OD48MM ID28MM TI ALLY POLY TRABECULAR MTL POR 1 PC,SUP-2202898,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
KIT STRNL CLOSURE DBL CABLE PLATE STRL THORECON,SUP-2894327,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
GRAFT BONE 6MM IMPL HUM TISS SEMITENDINOSUS TEND,SUP-2402807,CDM,C1713,HCPCS,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
GUIDE SURG FRAMELESS FOR NEURO NAVIGATION 6000022000] STRYKER CORP],SUP-2364148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1355.22,880.89,,,,,,,,,,,,,
HC So Liver Ds Alys 3 Bmrk Srm Alg,PX-3108151766,CDM,81517,CPT,0310,RC,,,,outpatient,,,465.00,302.25,,,,,,,,,,,,,
GRAFT BNE SPNG 10X10X10 MM BLOCK CANC DBM,SUP-2354409,CDM,C1713,HCPCS,0278,RC,,,,both,,,4587.54,2981.90,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 60 CM DIA 6 MM EPTFE STR TW N RING,SUP-2396342,CDM,C1768,CPT,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
IMPLANT OPHTH 2.75X7.5X80MM SIL RETIN STYL 511 SPNG HALF,SUP-2213501,CDM,C1784,HCPCS,0278,RC,,,,both,,,202.22,131.44,,,,,,,,,,,,,
SCREW BNE L18MM DIA4.5MM COMPR FOR GLEN BASEPLT,SUP-2388920,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.64,172.67,,,,,,,,,,,,,
HC So1 Chromosome Analysis 20-25,PX-3118826467,CDM,88264,CPT,0311,RC,,,,both,,,227.00,147.55,,,,,,,,,,,,,
BIT DRL DIA3MM CANN FOR ANK FUS PLATING SYS,SUP-2123203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SCREW BONE L65MM DIA4.7MM STRL S STL PARTIALLY THRD FOR,SUP-2349607,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.05,304.88,,,,,,,,,,,,,
ELECTRODE ENDOSCP L3.75MM 90DEG XL TURBOVAC 90 AS133601] SMITH AND NEPHEW ENDOSCOPY],SUP-2341990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.14,673.49,,,,,,,,,,,,,
TUBE MYR OD1MM ID004IN SIL UNIQUE DSGN COLLAPSIBLE FLAP SHEA,SUP-2312636,CDM,L8699,HCPCS,0278,RC,,,,both,,,62.77,40.80,,,,,,,,,,,,,
SPLINT THMB STRTCH LOOP STRP MED LG RT LIGHTWEIGHT SPICA BLK,SUP-2336216,CDM,L3931,HCPCS,0274,RC,,,,both,,,36.27,23.58,,,,,,,,,,,,,
CLAMP TI 16MM CRANOFIX,SUP-2108407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.57,234.37,,,,,,,,,,,,,
RELOAD STPL L60MM DIA3.5MM UNIV ROTIC ENDO GIA,SUP-2174520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1270.00,825.50,,,,,,,,,,,,,
KICKSTAND EXT FIX 175 X 210 MM ALUM PIN TO BAR NS DISP MONK,SUP-2909053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3272.67,2127.24,,,,,,,,,,,,,
KWIRE FIX L229MM DIA0.9MM STYL 6 S STL DBL DMND PNT 6PK,SUP-2412583,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.48,86.11,,,,,,,,,,,,,
BIT DRL TWST 1.1X50 MM 7 MM W/ STP CYL ATTCH SS LEVEL 1 DISP,SUP-2482124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.08,278.25,,,,,,,,,,,,,
CATHETER THOR DRNGE 28FR PVC TRCR L10IN PLEUR-EVAC,SUP-2384362,CDM,C1729,HCPCS,0272,RC,,,,both,,,93.20,60.58,,,,,,,,,,,,,
GUIDEWIRE TROCAR TIP NIT 18 INCH INVICTUS,SUP-2114056,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
CUFF URETH L6CM OCCL W/ INHIBZN FOR URIN CTRL SYS AMS 800,SUP-2138953,CDM,C1815,HCPCS,0278,RC,,,,both,,,19739.61,12830.75,,,,,,,,,,,,,
KNIFE SRGCL BLLNGR 3MM BLADE 8NL BNT SWVL LATEX FREE,SUP-2494303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.46,270.70,,,,,,,,,,,,,
MATRIX 1.4MM TROCAR BIT DRILL,SUP-2823266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1028.54,668.55,,,,,,,,,,,,,
TAP SURG SCR SLD BONE SPNL CLR CODE 4.5MM DYNALOK,SUP-2290322,CDM,C1713,HCPCS,0278,RC,,,,both,,,1470.56,955.86,,,,,,,,,,,,,
GUIDEWIRE ORTH 1ST METATRSL LAPIDUS CLMP SYS NS LF,SUP-2881124,CDM,C1769,HCPCS,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
CATHETER GUID SKR L 135 CM SHTH 4 FR GUIDEWIRE 0.014 IN,SUP-2128481,CDM,C1887,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BONE W19.5XL55.5MM THK1.65MM 13 H TI T Y LCK LO PROF,SUP-2411748,CDM,C1713,HCPCS,0278,RC,,,,both,,,1476.59,959.78,,,,,,,,,,,,,
COUPLER EXT FIX ADD A BAR MRI SAFE JET-X,SUP-2342895,CDM,C1776,CPT,0278,RC,,,,both,,,1221.37,793.89,,,,,,,,,,,,,
GUIDEWIRE ORTH 600 MM STR,SUP-2162704,CDM,C1769,HCPCS,0272,RC,,,,both,,,281.34,182.87,,,,,,,,,,,,,
CATHETER PICC L55CM DIA4FR SGL LUMN MAX BARR KT W/ PASV VLV,SUP-2118888,CDM,C1751,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
BIT DRL L380MM DIA5MM TWST,SUP-2187861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.87,989.87,,,,,,,,,,,,,
PLATE BNE L29MM THK1MM MINI 6 H CP TI CRV TLTS FOR 2 25MM,SUP-2262965,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.48,733.51,,,,,,,,,,,,,
FIBER LASER 272 MH HOLM REUSE EMPFBX272HRC,SUP-2540072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3761.88,2445.22,,,,,,,,,,,,,
HC Brachytx Isodose Intermed,PX-3337731700,CDM,77317,CPT,0333,RC,,,,outpatient,,,1096.00,712.40,,,,,,,,,,,,,
ANCHOR SUTURE RETROGRADE 2-0 24 IN W/ NDL WHT ULTRABRAID,SUP-2848655,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.53,47.14,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309714000,CDM,97140,CPT,0430,RC,,,GO|CO,both,,,194.00,126.10,,,,,,,,,,,,,
SUPPORT ORTH HIP CIRC 28-48 IN SM MED SZ 2,SUP-2915041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.05,475.18,,,,,,,,,,,,,
TAP SURG DIA3.5MM GLD FOR CRTX BONE PLATING SYS TC-100,SUP-2343959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
PROBE SPNL PEDCL NRV STIMULATING HNDPC NEUROVISION,SUP-2309802,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840053,CDM,2580000003,HCPCS,0258,RC,00338-0043-03,NDC,JW,both,250,ML,19.20,12.48,,,,,,,,,,,,,
SPLINT THMB L FOR 8-9IN WRST L ADJ STAY SPICA 3 DIM MOLDING,SUP-2334802,CDM,L3908,HCPCS,0272,RC,,,,both,,,74.10,48.16,,,,,,,,,,,,,
HC Insert Tunneled Perit Cath,PX-3614941800,CDM,49418,CPT,0361,RC,,,,both,,,11344.00,7373.60,,,,,,,,,,,,,
INTRODUCER SHTH GUID 0.038 IN 7 FRX45 CM DIL PINNACLE,SUP-2141015,CDM,C1894,HCPCS,0272,RC,,,,both,,,357.18,232.17,,,,,,,,,,,,,
MESH SURG 170X138X1 MM 3D TI STRL LEVEL 1 NEURO ULTRAONE,SUP-2486320,CDM,C1713,HCPCS,0278,RC,,,,both,,,14157.63,9202.46,,,,,,,,,,,,,
SCREW BONE 2MM DIA 12MML TTNM ALLOY MXDRVE 8MM THRDD F/MLTDR,SUP-2493880,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.40,203.06,,,,,,,,,,,,,
PLATE BONE W10XL82MM THK2.8MM 7 H S STL STR NONCOMPRESSION,SUP-2343764,CDM,C1713,HCPCS,0278,RC,,,,both,,,3289.46,2138.15,,,,,,,,,,,,,
HC So1 Hiv-1 Amplified Probe Tech,PX-3068753567,CDM,87535,CPT,0306,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
CUP ACET DIA44MM RESTORIS PST,SUP-2369632,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 8 MM STR TW REINF,SUP-2525452,CDM,C1768,CPT,0278,RC,,,,both,,,974.84,633.65,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET L 140 CM DIA 5 FR RHEOLYTIC STRL,SUP-2277419,CDM,C1757,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,6370000000,HCPCS,0637,RC,00378-9119-98,NDC,,both,1,UN,73.10,47.51,,,,,,,,,,,,,
UTIRA-C 81.6 MG PO TABS,RX-81885,CDM,6370000000,HCPCS,0637,RC,12539-0144-01,NDC,,both,1,UN,7.90,5.13,,,,,,,,,,,,,
PLERIXAFOR 24 MG/1.2ML SC SOLN,RX-95849,CDM,J2562,HCPCS,0636,RC,70121-1694-02,NDC,,both,1.2,ML,752.60,489.19,,,,,,,,,,,,,
GRAFT HUM TISS W30XH7MM D10-11MM TRANSFORAMINAL POST LUM,SUP-2306925,CDM,C1713,HCPCS,0278,RC,,,,both,,,14737.09,9579.11,,,,,,,,,,,,,
SCREW SACROILIAC 10X30MM JT FIX CANN THRD TI SI-LOK,SUP-2229755,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
PLATE BNE HUM 202 MM RT PROX LAT 12 HOLE,SUP-2365891,CDM,C1713,HCPCS,0278,RC,,,,both,,,5034.99,3272.74,,,,,,,,,,,,,
CATHETER ETER URET 4FR WHSTL TIP WVN L DRNGE LUMN REUSE,SUP-2126129,CDM,C1758,HCPCS,0278,RC,,,,both,,,245.45,159.54,,,,,,,,,,,,,
STENT COR 30MM 4MM CO CHROM ALLY RX BARE MTL LO,SUP-2295436,CDM,C1876,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
DEVICE PESSARY SZ 2 RNG W KNOB AND SUPP,SUP-2305664,CDM,A4562,HCPCS,0274,RC,,,,both,,,200.05,130.03,,,,,,,,,,,,,
SOLUTION IV 500ML 0.9% SODIUM CHLORIDE INJ USP,SUP-2900295,CDM,C1713,HCPCS,0278,RC,,,,both,,,7.25,4.71,,,,,,,,,,,,,
PACEMAKER CARD W 6.68 X H 20.27 CM D 4.14 CM SINGLE CHMBR,SUP-2419405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12293.41,7990.72,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT MINI #7 BAYONET 9MM 201833,SUP-2844635,CDM,C1889,HCPCS,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
NAIL IM L15CM DIA11.5MM 5DEG TROCHANTERIC BLU TI CANN LCK,SUP-2347226,CDM,C1713,HCPCS,0278,RC,,,,both,,,11574.04,7523.13,,,,,,,,,,,,,
KIT CEM MIXING/DELIVERY 10CC RADPQ NDL 10GA L5IN W/O CEM PCD,SUP-2367026,CDM,C1713,HCPCS,0278,RC,,,,both,,,1457.84,947.60,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK ULT TI CARBON FIBER,SUP-2388221,CDM,L5940,HCPCS,0272,RC,,,,both,,,1318.45,856.99,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-3612060600,CDM,20606,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE 20 H NONSTERILE STRNL TI STR LO PROF NEUT LOK,SUP-2192433,CDM,C1713,HCPCS,0278,RC,,,,both,,,6809.40,4426.11,,,,,,,,,,,,,
LINER ACET OD64MM ID28MM HIP MARATHON NEUT SNAP IN REV PINN,SUP-2250347,CDM,C1776,CPT,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
TIGHTROPE ABS OBLONG BUTTON,SUP-2811992,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
SCREW SPNL L20MM DIA4MM ANTR CERV TI ST VAR ANG FULL THRD,SUP-2255137,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE BNE STD RT 18 HOLE FOR ORTH FIX STRL POLARUS 3,SUP-2518202,CDM,C1713,HCPCS,0278,RC,,,,both,,,6948.82,4516.73,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 20X9 CM PLCNTA MEMBRN AMNIOEFFECT,SUP-2872722,CDM,C1762,CPT,0278,RC,,,,both,,,41140.28,26741.18,,,,,,,,,,,,,
RESERVOIR VENTRICULAR SM 14 MM HOLTER,SUP-2666416,CDM,C1889,HCPCS,0278,RC,,,,both,,,1271.57,826.52,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA3MM THRD L35MM TI NITRIDE FOR SIDEKCK,SUP-2400688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
BIT DRL 2.5 MM FRAG-LOC,SUP-2857696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
SPACER SPNL H8MM ASSEMB PRIMALOK SP,SUP-2319811,CDM,C1889,HCPCS,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
SHELL ACET DIA48MM GRP 1 UNIV TI CERAMIC PLSM COAT CLUS H,SUP-2221985,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
PLATE BNE TBLR 3.5X42 MM 3 HOLE 1/3 2 COMPR LCK FOR SCR TI,SUP-2473465,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.01,558.36,,,,,,,,,,,,,
RESERVOIR 60ML W/ LOK OUT VLV TI,SUP-2165354,CDM,C1813,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
NEEDLE LOC LESION BRST MOD KOP MREYE,SUP-2168710,CDM,C1819,HCPCS,0278,RC,,,,both,,,133.45,86.74,,,,,,,,,,,,,
SHEET IMPL 38X50X3MM BIOMATERIAL,SUP-2366498,CDM,C1713,HCPCS,0278,RC,,,,both,,,3476.33,2259.61,,,,,,,,,,,,,
COMPONENT TIB CR 0 11 MM RT KNEE PRIMARY STEM CEM NP UCONG,SUP-2209405,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BLADE SAW W9MM THK0.4MM S TYP FOR ULN OSTEOTMY COMPR PLT,SUP-2389620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
MESH HERN RECTANGULAR 20X20 CM PREPERITONEAL ENFORM,SUP-2459009,CDM,C1781,HCPCS,0278,RC,,,,both,,,16711.08,10862.20,,,,,,,,,,,,,
LEAD STIM TST NRV EXT FORE BILAT PLCMNT SACR,SUP-2284414,CDM,C1897,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA20 MM RNG L 30 CM EPTFE STR STD,SUP-2396035,CDM,C1768,CPT,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
GUIDEWIRE VASC SENS + L 175 CM DIA 0.025 IN TIP 3 MM SS SIL,SUP-2521855,CDM,C1769,HCPCS,0272,RC,,,,both,,,124.82,81.13,,,,,,,,,,,,,
NAIL IM END CAP PHOENIX,SUP-2606358,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SPLINT ORTHOPEDIC THMB ABDUCTED UNIV LTHR,SUP-2336237,CDM,L3931,HCPCS,0272,RC,,,,both,,,14.60,9.49,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT + DIA29 MM BOV PERICARD COCR,SUP-2214287,CDM,C1889,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
HMRL BEARING 36 MM STD VITE,SUP-2505943,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HANDPIECE LASER CRV SHFT,SUP-2713751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1918.54,1247.05,,,,,,,,,,,,,
SCREW BNE L32MM DIA4.5MM CORT PROX FEM ANK S STL ST FULL,SUP-2350201,CDM,C1713,HCPCS,0278,RC,,,,both,,,215.34,139.97,,,,,,,,,,,,,
GRAFT BNE SUB 5ML DBM PSTE GRFTON,SUP-2281667,CDM,C1713,HCPCS,0278,RC,,,,both,,,2716.10,1765.46,,,,,,,,,,,,,
PLATE BONE L27MM 100DEG 3X4 H LT CRANIOMAXILLOFACIAL TEAL TI,SUP-2191160,CDM,C1713,HCPCS,0278,RC,,,,both,,,1081.42,702.92,,,,,,,,,,,,,
CPT SPNL W/Q NDL,SUP-2125210,CDM,C1713,HCPCS,0278,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
PROSTHESIS VOICE 22.5FR 12.5MM RADPQ VLV SEAT ENLD ESOPH,SUP-2124411,CDM,L8509,HCPCS,0272,RC,,,,both,,,1060.22,689.14,,,,,,,,,,,,,
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,6370000000,HCPCS,0637,RC,72603-0192-01,NDC,,both,5,ML,67.50,43.87,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT ILIUM STRP BICORT ASEP 6CM,SUP-2307132,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.88,1466.97,,,,,,,,,,,,,
PLATE BNE MESHED 52X52X0.8 MM SM GRID PLLA-PGA STRL,SUP-2458090,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.08,2038.45,,,,,,,,,,,,,
DILATOR SURG URET 16FR,SUP-2141688,CDM,C1894,HCPCS,0272,RC,,,,both,,,249.76,162.34,,,,,,,,,,,,,
TUBING CATH L6FT S STL STRT UP CUST LUER W/ INTEGR AIR TRAP,SUP-2416151,CDM,C1751,HCPCS,0278,RC,,,,both,,,664.42,431.87,,,,,,,,,,,,,
SLEEVE SURG DRL 1.5 MM LCK FOR TCP SYS,SUP-2319064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC URLGCL 0.025MM DIA 150CML 3CML ANGLD TIP R,SUP-2471771,CDM,C1769,HCPCS,0272,RC,,,,both,,,137.09,89.11,,,,,,,,,,,,,
MESH HERN RECTANGULAR 3 15X10 CM MONOFILAMENT VERSATEX,SUP-2752214,CDM,C1781,HCPCS,0278,RC,,,,both,,,475.40,309.01,,,,,,,,,,,,,
SCREW BNE CRTX 3.5X26 MM LP ST HD HEXDRIVE TI NS,SUP-2758233,CDM,C1713,HCPCS,0278,RC,,,,both,,,95.86,62.31,,,,,,,,,,,,,
BLADE RTRCTR 14MMW X 45MML SPNL BALL SNAP CNTR F/MCRO LMBR D,SUP-2492000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1040.50,676.32,,,,,,,,,,,,,
NEEDLE BNE MAR LG 8 GA,SUP-2384767,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
RESERVOIR 20MM WITHOUT SHUNT ASSISTANT HYDRO VORKAMMER PROGA,SUP-2826083,CDM,C1889,HCPCS,0278,RC,,,,both,,,6534.94,4247.71,,,,,,,,,,,,,
SCREW BNE L 18 MM DIA 3 MM TI CANN HDLSS NS LEOS,SUP-2932615,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.87,615.47,,,,,,,,,,,,,
GRAFT VASC PTCH 10X1 CM BOV PERICARD TAPR BIOLOGIC XENOSURE,SUP-2424199,CDM,C1768,CPT,0278,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.7MM MTPHSEAL S STL ST FULL THRD T8,SUP-2177753,CDM,C1713,HCPCS,0278,RC,,,,both,,,139.60,90.74,,,,,,,,,,,,,
Z DUP USE 2111319 LENS INTOCU +21.5 DIOPT CYL PWR +3.75 DIOPT 119 A CONSTANT,SUP-2111825,CDM,V2787,HCPCS,0276,RC,,,,both,,,495.00,321.75,,,,,,,,,,,,,
POST EXT FIX CIR FEMALE 2 HOLE,SUP-2400667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,380.73,247.47,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.018IN TIP L5CM 15DEG ANG NIT,SUP-2172968,CDM,C1769,HCPCS,0272,RC,,,,both,,,162.24,105.46,,,,,,,,,,,,,
RING FIX HALF,SUP-2197268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3320.55,2158.36,,,,,,,,,,,,,
LINEAR HIP STEM STD OFFSET SZ 5 ** SPEC ORD ONLY,SUP-2216864,CDM,C1776,CPT,0278,RC,,,,both,,,13125.20,8531.38,,,,,,,,,,,,,
FIXATION BEAM 4.5 X120 MM,SUP-2604350,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FULL CORSET,SUP-2435564,CDM,L0974,HCPCS,0274,RC,,,,both,,,494.74,321.58,,,,,,,,,,,,,
HC Tcath Plmt Xtrc Vert Car Stent Rs&I Ea Add Vsl,PX-3600076000,CDM,0076T,CPT,0360,RC,,,,both,,,3205.00,2083.25,,,,,,,,,,,,,
STRUT EXT FIX MED NS DISP ACUTE QC,SUP-2932994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4991.56,3244.51,,,,,,,,,,,,,
PIN HALF 45X100X30MM,SUP-2704542,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LIFT ELEVATION INSIDE SHOE UP TO 1 HALF,SUP-2435718,CDM,L3332,HCPCS,0272,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X5 MM SHEA CUP PLAT FLROPLAS,SUP-2637823,CDM,L8613,CPT,0278,RC,,,,both,,,405.78,263.76,,,,,,,,,,,,,
Z DISCONTINUED USE 2884904 STENT TRACHBRONCH L38MM DIA6MM CATH 7FR L80CM S STL PTFE,SUP-2227447,CDM,C1874,HCPCS,0278,RC,,,,both,,,7824.53,5085.94,,,,,,,,,,,,,
SCREW BONE L74MM OD7MM THRD L17MM PUR HINDFOOT ANK CANN SH,SUP-2320951,CDM,C1713,HCPCS,0278,RC,,,,both,,,2724.42,1770.87,,,,,,,,,,,,,
GRAFT BONE SUB 10ML SYR DEMIN MTRX INJ MOLD OPTECURE,SUP-2223575,CDM,C1713,HCPCS,0278,RC,,,,both,,,5086.80,3306.42,,,,,,,,,,,,,
REAMER SURG DIA10MM TIB CANN COR W/ CLLRD PIN FOR TUNN GRFT,SUP-2120899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN TIP L8CM LNG TAPR STR NIT,SUP-2385567,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.96,71.47,,,,,,,,,,,,,
WIRE FIX L304.8MM DIA1MM S STL BEAD ISOLA,SUP-2255706,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
INTRODUCER PACE LD AGILIS 85 DIA 8. 5 FR SM CURL STEER STRL,SUP-2357281,CDM,C1766,CPT,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BONE RT DORS DSTL VOLAR RAD WR CROSSLOCK,SUP-2205428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
DISTAL POSTERIOR MEDIAL HUMERUS TRIAL 10 HOLELEFT,SUP-2704782,CDM,C1713,HCPCS,0278,RC,,,,both,,,877.44,570.34,,,,,,,,,,,,,
SCREW BONE L80MM DIA5MM CO CHROM MOLYBDENUM ALLOY ST LCK,SUP-2183043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1034.32,672.31,,,,,,,,,,,,,
PROBE BX 10GX140MM VACORA,SUP-2127050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.93,386.05,,,,,,,,,,,,,
FILLER DERMAL JUVEDERM ULTRA XC 1ML,SUP-2900488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
BIT DRL L280MM DIA4.3MM STP W/O NONRADIOPAQUE,SUP-2188851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1253.52,814.79,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,0636,RC,00409-7337-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PASSER SUT FOR OMNISPAN MENIS REP SYS CHIA PERCPASS,SUP-2249384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,633.02,411.46,,,,,,,,,,,,,
HC Nephrostogram/Urography Antegrade,PX-3207442500,CDM,74425,CPT,0320,RC,,,,inpatient,,,1485.00,965.25,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM OD 6 FR ID 2 MM GUIDEWIRE L 25 CM,SUP-2168571,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.59,67.33,,,,,,,,,,,,,
NERVE STIMULATOR KIT 50 CM TRL INFINION,SUP-2765587,CDM,C1883,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
IMPL SYS HIP LABRAL RECON,SUP-2814003,CDM,C1713,HCPCS,0278,RC,,,,both,,,6176.38,4014.65,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1173108D3,SUP-2632787,CDM,C1751,HCPCS,0278,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
CHIP CANC BONE 90CC LG MTF+,SUP-2307410,CDM,C1713,HCPCS,0278,RC,,,,both,,,7059.22,4588.49,,,,,,,,,,,,,
COMPONENT FEM E AP51.5MM ML24MM UNI PC PRI CEM STEMLESS R 584201501] ZIMMER BIOMET INC],SUP-2208539,CDM,C1776,CPT,0278,RC,,,,both,,,11498.21,7473.84,,,,,,,,,,,,,
SYSTEM VENTRICULAR DRAINAGE SP0234 W/ 910121 LUMBAR CATH,SUP-2883453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1149.11,746.92,,,,,,,,,,,,,
HC Alpha-1-Antitrypsin Total,PX-3018210300,CDM,82103,CPT,0301,RC,,,,both,,,208.00,135.20,,,,,,,,,,,,,
PLATE BNE L142MM THK3.4MM 11 H BILAT S STL STR LIMIT CNTCT,SUP-2185143,CDM,C1713,HCPCS,0278,RC,,,,both,,,1095.17,711.86,,,,,,,,,,,,,
PRESSURE MONITORING KIT INTCRAN VENTRICULAR CATH CAMINO,SUP-2851495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2977.51,1935.38,,,,,,,,,,,,,
DEFIBRILLATOR IMPL AMPLIA MRI QUAD SURESCAN W 51 X H 74 MM D,SUP-2282415,CDM,C1882,HCPCS,0275,RC,,,,both,,,59934.31,38957.30,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 6 CM THK 0.2 MM HUM AMNIO MEMBRN,SUP-2909416,CDM,Q4282,HCPCS,0636,RC,,,,both,,,19625.00,12756.25,,,,,,,,,,,,,
HEAD HUM H17MM OD46MM OFFSET 3.5MM HI TI SHLDR ANAT ECC,SUP-2399869,CDM,C1776,CPT,0278,RC,,,,both,,,10792.18,7014.92,,,,,,,,,,,,,
HC Rep Lac Smp Face 5.1-7.5 Cm,PX-4501201400,CDM,12014,CPT,0450,RC,,,,both,,,861.00,559.65,,,,,,,,,,,,,
CATHETER THROMCTMY OASIS L 65 CM DIA 6 FR STRL,SUP-2141171,CDM,C1757,HCPCS,0272,RC,,,,both,,,1818.06,1181.74,,,,,,,,,,,,,
SCREW BNE L115MM DIA65MM CANC S STL ST CANN NONLOCKING FULL,SUP-2199306,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.22,80.74,,,,,,,,,,,,,
STRIP BONE GRAFT 22MM X 45/60MM TRICORTICAL ILIUM FD,SUP-2863675,CDM,C1713,HCPCS,0278,RC,,,,both,,,9542.46,6202.60,,,,,,,,,,,,,
COMPONENT FEM XSM L KNEE REV CEM CRUCE RET STEM NONBEADED,SUP-2377030,CDM,C1776,CPT,0278,RC,,,,both,,,7201.37,4680.89,,,,,,,,,,,,,
MODULE DISPLAY LVAD,SUP-2356036,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
GRAFT BNE 5 CC INJ HA CALCIUM PHOSPHATE HYDROSET DISP,SUP-2374938,CDM,C1713,HCPCS,0278,RC,,,,both,,,4411.70,2867.60,,,,,,,,,,,,,
BLADE SCRWDRVR 2MM2.3MM DIA 16MML RIGHT ANGLD CROSS DRIVE,SUP-2707277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,598.64,389.12,,,,,,,,,,,,,
HC So Hemolysins/Agglutinins Auto,PX-3008694066,CDM,86940,CPT,0300,RC,,,,both,,,62.00,40.30,,,,,,,,,,,,,
STENT NEPHURET L 26 CM DIA 8 FR PERCFLX HYDRPHLC 2 PIGTL N,SUP-2147765,CDM,C2617,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE L 153 MM SCREW DIA2 MM 20 SHFT H SS ADPT COMB VA,SUP-2907742,CDM,C1713,HCPCS,0278,RC,,,,both,,,4007.52,2604.89,,,,,,,,,,,,,
PLATE BNE L66MM 4 H NAR 2 COMPR FOR 45MM SCR,SUP-2411387,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
ALLOGRAFT DERMAL THCK 18X6 CM RDY TO USE TISS MTRX ALLDERM,SUP-2113013,CDM,Q4116,HCPCS,0636,RC,,,,both,,,11702.78,7606.81,,,,,,,,,,,,,
PLATE BNE LO BEND 3.5X206 MM RT PROX TIB 14 HOLE SS NS LCP,SUP-2184312,CDM,C1713,HCPCS,0278,RC,,,,both,,,4152.81,2699.33,,,,,,,,,,,,,
GRAFT HUM TISS 2X6CM AMNIOFIX,SUP-2305725,CDM,V2790,HCPCS,0278,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
"HC Debrid,Musc/Fasc,Ea Add 20sqcm",PX-3611104600,CDM,11046,CPT,0361,RC,,,,both,,,315.00,204.75,,,,,,,,,,,,,
ANCHOR SUT OD4.75MM BLU BIOCOMP FIBERTAPE LOOP MULTFI,SUP-2121694,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
PLATE BNE CHIN 8 MM ORTHOGNATHIC GENIOPLASTY FOR SCR TI,SUP-2468183,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.37,377.24,,,,,,,,,,,,,
BONE MARROW ASPIRATION 11GA 15CM W/ SIDEHOLES-STERILE,SUP-2550438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,291.55,189.51,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 4.5 CM FLPY TIP,SUP-2167811,CDM,C1769,HCPCS,0272,RC,,,,both,,,35.04,22.78,,,,,,,,,,,,,
SET PNEUMORTHORAX MP 10FR 30CM,SUP-2168512,CDM,C1894,HCPCS,0272,RC,,,,both,,,311.90,202.73,,,,,,,,,,,,,
BIT DRL DIA4MM FOR BONE HALF PIN,SUP-2342941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2235.62,1453.15,,,,,,,,,,,,,
GRAFT HUM TISS NEO L7.5IN FORESKIN PROC APLIGRAF,SUP-2314094,CDM,Q4101,HCPCS,0636,RC,,,,both,,,14051.50,9133.47,,,,,,,,,,,,,
CURETTE SURG L229MM SZ 1 BNE STR OVL CUP RUGGLES,SUP-2161387,CDM,C1713,HCPCS,0278,RC,,,,both,,,727.54,472.90,,,,,,,,,,,,,
CATHETER URET 3FR L70CM RT PVC WHSTL TIP USED FOR DRNGE RG,SUP-2168869,CDM,C1758,HCPCS,0278,RC,,,,both,,,37.52,24.39,,,,,,,,,,,,,
CANNULA PERFSN L 9.5 IN EFFECTIVE L 6 IN DIA16 FR CONN 3/8,SUP-2881165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,694.16,451.20,,,,,,,,,,,,,
STRUT SPNL W6XL200MM THK3-15MM TIB CORT THIRDS ALLGRFT FRZN,SUP-2307374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2288.71,1487.66,,,,,,,,,,,,,
TREPHINE SURG OD8MM COR SL DISPOSABLE,SUP-2212797,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
TUBE ET OD9.8MM ID6.5MM EVAC ORAL MURPHY EYE TAPERGUARD CUF,SUP-2172240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,48.01,31.21,,,,,,,,,,,,,
EXTENSION STEM FLUT 10X80 MM KNEE REV BKS,SUP-2434300,CDM,C1776,CPT,0278,RC,,,,both,,,2327.68,1512.99,,,,,,,,,,,,,
BLADE SURG 11CM 4MM SURG SHV 60DEG AGG ANG,SUP-2363538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.57,303.27,,,,,,,,,,,,,
DRILL SURG FLIPCUTTER III,SUP-2418778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
GRAFT TISS FRZN SHFT TIB STRUCTURAL ALLGRFT 150MM LEN,SUP-2307367,CDM,C1713,HCPCS,0278,RC,,,,both,,,4394.43,2856.38,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 80 CM DIA 7 MM EPTFE TRMPT GRAD WALL,SUP-2695238,CDM,C1768,CPT,0278,RC,,,,both,,,5279.50,3431.67,,,,,,,,,,,,,
SET URET STENT ENDO-SOF L 24 CM DIA 7 FR POLYMER AQ 2 PIGTL,SUP-2835780,CDM,C2617,HCPCS,0278,RC,,,,both,,,395.99,257.39,,,,,,,,,,,,,
TRAY CATH PICC Q CATH PLU INTERMED 5FR 65CM 2 LUMAN W/ACCSSR,SUP-2613416,CDM,C1751,HCPCS,0278,RC,,,,both,,,300.81,195.53,,,,,,,,,,,,,
PLATE BNE DISTRCTN SHT 1.5-1.8 MM 2 HOLE BUTTRESS LEFORT 1,SUP-2463961,CDM,C1713,HCPCS,0278,RC,,,,both,,,3288.93,2137.80,,,,,,,,,,,,,
HC Mra Pelvis W/W/O Contrast,PX-6107219800,CDM,72198,CPT,0610,RC,,,,both,,,3953.00,2569.45,,,,,,,,,,,,,
HC So Bilirubin Total,PX-3018224766,CDM,82247,CPT,0301,RC,,,,inpatient,,,38.00,24.70,,,,,,,,,,,,,
STENT PERIPH 12FR L5CM DIA13MM CATH L120CM VES DIA10.6-12MM,SUP-2396588,CDM,C1874,HCPCS,0278,RC,,,,both,,,11228.64,7298.62,,,,,,,,,,,,,
DISSECTOR ELECTROCAUTERY L 165 CM JAW L6 MM CHANNEL DIA2.8,SUP-2881909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
KIT CAGE SPINAL APREVO 3-LEVEL,SUP-2912824,CDM,C1889,HCPCS,0278,RC,,,,both,,,119320.00,77558.00,,,,,,,,,,,,,
PROBE COAG 9.6FR L2.2M CONVENIENT BLT IN FLTR 2200A FIAPC,SUP-2217935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
GRAFT BIOLOGIC BLK CORLN HA 12MMX30MMX30MM PRO OSTEON 500,SUP-2413076,CDM,C1713,HCPCS,0278,RC,,,,both,,,4984.59,3239.98,,,,,,,,,,,,,
GRAFT EVAR L124MM DIA16X16MM CATH 14FR LIMB DST DSGN C DEL,SUP-2295250,CDM,C1768,CPT,0278,RC,,,,both,,,15464.50,10051.92,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.9X16 MM LOCKING TITANIUM MATRIXMAN,SUP-2837743,CDM,C1713,HCPCS,0278,RC,,,,both,,,670.83,436.04,,,,,,,,,,,,,
ENDCAP ORTH DIA12MM EXTN 10MM LAT FEM GRY TI CANN T40,SUP-2188987,CDM,C1713,HCPCS,0278,RC,,,,both,,,638.64,415.12,,,,,,,,,,,,,
ANCHOR SUT OD5.5MM 2 BLK WHT BLU NONABSORBABLE PEEK OPTMA,SUP-2341842,CDM,C1713,HCPCS,0278,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
STRATTICE RCNSTRCTVE TSSUE MTRX PRFRTD 10 20 FIRM,SUP-2676522,CDM,Q4130,HCPCS,0636,RC,,,,both,,,19800.84,12870.55,,,,,,,,,,,,,
HC Ot Contrast Bath Therapy,PX-4309703400,CDM,97034,CPT,0430,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
KIT TISS EXP W/ 10ML LUERLOCK SYR 108CM TRNSF SET 2W CK VLV,SUP-2113308,CDM,C1789,HCPCS,0278,RC,,,,both,,,34.01,22.11,,,,,,,,,,,,,
TIP THRMCPL LG 4 MM CRV,SUP-2357671,CDM,C1733,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
GRAFT VASC 20 MMX9.5 CM EXCLUDER,SUP-2395968,CDM,C1768,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
LENS INTOCU 6.5MM DIAM 13.25MM LEN 3DEG 5.2MM DEPTH + 10,SUP-2129469,CDM,V2632,HCPCS,0276,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
NUT EXT FIX DIA10MM FOR SALVATION EXT FIX,SUP-2401146,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
"HC Occl Dev in Vein Art, Angioseal, Vasc Plug",PX-3610026900,CDM,G0269,CPT,0361,RC,,,,both,,,305.00,198.25,,,,,,,,,,,,,
TOTAL KNEE IMPL NXGN PROVIDE THE ABIL TO WLK SIT OR,SUP-2212255,CDM,C1776,CPT,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.551,SUP-2860068,CDM,C1713,HCPCS,0278,RC,,,,both,,,62937.53,40909.39,,,,,,,,,,,,,
NAIL IM 6X140 MM FEM AG,SUP-2208078,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
KIT CTRL VEN CATHETER L20CM OD85FR QUAD LUMN NONCOATED INJ,SUP-2270273,CDM,C1751,HCPCS,0278,RC,,,,both,,,242.88,157.87,,,,,,,,,,,,,
HC Eval Speech Sound Lang Comprhension,PX-4449252300,CDM,92523,CPT,0444,RC,,,,both,,,484.00,314.60,,,,,,,,,,,,,
HC Ablate Pulm Tumor Perq Crybl,PX-3613299400,CDM,32994,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
CAP END PLUS ANKLE 10MM PHOENIX,SUP-2485267,CDM,C1889,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
LENS INTOCU 16.5 DIOPT 1.5 DIOPT CYL PWR L13MM DIA6MM 0DEG,SUP-2248249,CDM,V2788,HCPCS,0276,RC,,,,both,,,967.00,628.55,,,,,,,,,,,,,
BIT DRL DIA3.2MM CANN FOR 4.5MM SCR,SUP-2179104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1053.69,684.90,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA 7 MM EPTFE STR TW N RING STRL,SUP-2396702,CDM,C1768,CPT,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
HC Removal Biliary Drng Cath,PX-3614753700,CDM,47537,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GUIDEWIRE ORTH L15IN DIA1.1MM NIT FOR ANT CRUCE LIG RECON,SUP-2249554,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.43,130.28,,,,,,,,,,,,,
GRAFT HUM TISS DIA20 70MM FRZN ALLGRFT FEM HD W TROCH L,SUP-2307307,CDM,C1713,HCPCS,0278,RC,,,,both,,,9657.64,6277.47,,,,,,,,,,,,,
IMPLANT ANK JT 42MM MED MALL SLED,SUP-2389600,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
STENT PERIPH VEN WSTNT L 90 MM DIA18 MM CATH L 75 CM DIA11,SUP-2558959,CDM,C1876,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SET SCREW SPNL R 45 MM CARBON FIBER PEDCL LCK ELEMENT FOR,SUP-2883022,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 24 MM DIA 5 MM CATH L 75 CM DIA 6 FR,SUP-2159204,CDM,C1876,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
PACLITAXEL 100 MG/16.7ML IV CONC,RX-31096,CDM,J9267,HCPCS,0636,RC,61703-0342-22,NDC,,both,16.7,ML,81.20,52.78,,,,,,,,,,,,,
SCREWDRIVER SURG CANN QC COUNTSINK FOR 6.5/7/7.5 SCR NS,SUP-2486948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1034.94,672.71,,,,,,,,,,,,,
HOOK PHLEBECTOMY RAMELET 1 3-7/8 IN RT SS,SUP-2473579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.40,236.86,,,,,,,,,,,,,
TRAB METAL FEMORAL CONE AGMT MEDIUM 50MM RIGHT,SUP-2502252,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
BIT DRILL JLATCH 1.5X88 MM 24 MM,SUP-2841960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.35,320.03,,,,,,,,,,,,,
CATHETER EP MED SWP 2-5-2 MM 2 MM 6 FRX115 CM,SUP-2867397,CDM,C1730,HCPCS,0272,RC,,,,both,,,2804.02,1822.61,,,,,,,,,,,,,
PLATE HOCKEY 5HOLE LT RS,SUP-2653978,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
TUBE ET L40CM DIA8MM LSR RESIST FOAM SURROUND MAGILL CUF,SUP-2383547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.89,205.98,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5 FRX36 CM LT DL FULL SET TITAN HD,SUP-2627364,CDM,C1750,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
KIT THYROPLASTY M SGL PROC MONT,SUP-2141840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
MESH SURG DIA20CM PARASTOMAL RND W/ CTRL BND NO H,SUP-2174730,CDM,C1781,HCPCS,0278,RC,,,,both,,,2120.41,1378.27,,,,,,,,,,,,,
BIT DRL L 100/30 MM DIA1.5 MM SCREW DIA2 MM CALIB AO QC CLR,SUP-2908123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,764.90,497.18,,,,,,,,,,,,,
TUBE JEJU 9 FRX60 CM FLO 20,SUP-2737405,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
INSERT TIB BEAR POST STBL III 7493-0112,SUP-2452087,CDM,C1776,CPT,0278,RC,,,,both,,,2421.57,1574.02,,,,,,,,,,,,,
STEM FEM L90MM OD17MM STR TI POR IM REV CEM NEUT MOD LNG,SUP-2405715,CDM,C1776,CPT,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED SM KT MEDPOR PTERIONAL +,SUP-2862740,CDM,C1713,HCPCS,0278,RC,,,,both,,,38243.44,24858.24,,,,,,,,,,,,,
BRACE ORTHOPEDIC AFO PLAS,SUP-2388166,CDM,L1970,HCPCS,0274,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
RAIL EXT FIX MINI 2.75 IN SYS RX-FIX,SUP-2517151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8107.48,5269.86,,,,,,,,,,,,,
ESTRADIOL 1 MG PO TABS,RX-9967,CDM,6370000000,HCPCS,0637,RC,70954-0565-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 61 CM DIA 8.5 FR DIL L 67 CM,SUP-2357148,CDM,C1893,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
STEM FEM SZ 0 CO CHROM NP OFFSET NATURAL-HIP,SUP-2210871,CDM,C1776,CPT,0278,RC,,,,both,,,9470.24,6155.66,,,,,,,,,,,,,
SHELL ACET PLSM COAT W/ HA 48MM NOVATION CERAMIC AHS,SUP-2221998,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
GRAFT BNE SUB 7.2CC W15XL50MM MINERALIZED CLLGN SCFLD,SUP-2138524,CDM,C9362,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC MRI-Upper Ext Jnt WO Cont,PX-6107322100,CDM,73221,CPT,0610,RC,,,,both,,,3764.00,2446.60,,,,,,,,,,,,,
IMPLANT BRST W13XH135CM 450 475ML P53CM NACL STYL 468 FULL,SUP-2113354,CDM,C1789,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
GRAFT HUM TISS 2ML 160MG AMNIO MEM PARTICULATE INJ AMNIOFIX,SUP-2305721,CDM,V2790,HCPCS,0274,RC,,,,both,,,6265.87,4072.82,,,,,,,,,,,,,
RETRACTOR SURG ORTH PROTECTOR MED LG 17 CM 5-13 CM FLX STRL,SUP-2864522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
LENS IO +130 DIOPT CYL PWR +300 DIOPT L13MM DIA6MM 0DEG,SUP-2111727,CDM,V2787,HCPCS,0276,RC,,,,both,,,595.00,386.75,,,,,,,,,,,,,
SET URET STENT SALLE L 12-18 CM DIA 4.7 FR CONN TUBE L 30 CM,SUP-2826998,CDM,C2625,HCPCS,0278,RC,,,,both,,,282.91,183.89,,,,,,,,,,,,,
HC So Leptospira Ab's,PX-3028672066,CDM,86720,CPT,0302,RC,,,,both,,,375.00,243.75,,,,,,,,,,,,,
IMPLANT OTO DIA3MM EAR TI STR HEX HD FLNG FIX FOR VISTAFIX,SUP-2164937,CDM,L8614,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
GRAFT HUM TISS 2X12CM STD THK1-2MM REGENERATIVE TISS MTRX,SUP-2399083,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6408.74,4165.68,,,,,,,,,,,,,
HC So Iron|NOT REASONABLE AND NECESSARY,PX-3018354066,CDM,83540,CPT,0301,RC,,,GZ,both,,,521.00,338.65,,,,,,,,,,,,,
CEMENT FLX FEM/CEM TIB/STD SURF/NO PAT,SUP-2212159,CDM,C1776,CPT,0278,RC,,,,both,,,10771.93,7001.75,,,,,,,,,,,,,
WAND ABLAT LOPRO 90DEG ICW W/O SUCT 3.6MM,SUP-2341975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
PLATE BNE SQ MINI 2X0.6 MM 4X2 HOLE FOR SCREW NS 250240809,SUP-2472575,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.12,483.68,,,,,,,,,,,,,
PLATE BONE THK 0.75MM 8 H RESRB POLYMER TI,SUP-2364979,CDM,C1713,HCPCS,0278,RC,,,,both,,,522.09,339.36,,,,,,,,,,,,,
SLEEVE FEM -3.5MM SH NK TI HIP DYNASTY,SUP-2304513,CDM,C1776,CPT,0278,RC,,,,both,,,2418.59,1572.08,,,,,,,,,,,,,
HC Cta Heart W/WO Calcium,PX-3507557400,CDM,75574,CPT,0480,RC,,,,both,,,2388.00,1552.20,,,,,,,,,,,,,
STENT EVAR L79MM DIA8-11MM CATH L80CM INTRO SHTH 8FR,SUP-2395678,CDM,C1874,HCPCS,0278,RC,,,,both,,,11049.66,7182.28,,,,,,,,,,,,,
PLATE SPNL POLYAX 11 MM SCREW HOLE POLYETH CNPY,SUP-2228533,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
IMPLANT GYN W8XL12CM DERM TUTOPLAST PROC ALLGRFT TISS FOR,SUP-2165391,CDM,C1762,CPT,0278,RC,,,,both,,,9115.42,5925.02,,,,,,,,,,,,,
PLATE CRAN 200X100X40 MM PT SPEC IMPL PEEK,SUP-2860150,CDM,C1713,HCPCS,0278,RC,,,,both,,,45360.13,29484.08,,,,,,,,,,,,,
PLATE BNE 10 H S STL LOK STR FOR ANK FRAC MGMT,SUP-2123030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 23CM 4FR 80 CM NDL 2.5 CM PLAS,SUP-2677191,CDM,C1894,HCPCS,0272,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
PLATE BNE FIBULAR LT 4 HOLE LCK ANAT STRL ALPS LTX,SUP-2861805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2522.68,1639.74,,,,,,,,,,,,,
PLATE BNE L 100 MM 7 H SS LT DSTL VOLAR ULN STD STRL EVOS,SUP-2931154,CDM,C1713,HCPCS,0278,RC,,,,both,,,5256.36,3416.63,,,,,,,,,,,,,
GRAFT VASC GORTX L 110 CM DIA 6 MM RNG L 60 CM EPTFE STR TW,SUP-2396125,CDM,C1768,CPT,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 13MMW X90MML 1.37MM THK COARSE MIDMIDDLEB,SUP-2605770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,202.28,131.48,,,,,,,,,,,,,
SHELL ACET OD54MM LNR DMG DBL MOBILITY MPACT,SUP-2267372,CDM,C1776,CPT,0278,RC,,,,both,,,7567.40,4918.81,,,,,,,,,,,,,
HC Treat Ankle Fx,PX-4502778600,CDM,27786,CPT,0450,RC,,,,both,,,444.00,288.60,,,,,,,,,,,,,
KIT PROS SPHIN CONN CUF SZR BLNT NDL TBNG IMP,SUP-2140265,CDM,C1815,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PLATE BNE TIB RT DP 7 HOLE,SUP-2351455,CDM,C1713,HCPCS,0278,RC,,,,both,,,16280.90,10582.58,,,,,,,,,,,,,
PLATE BNE L52MM 6 H S STL COMPR FOR 27MM SCR MINI FRAG SYS,SUP-2199360,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.34,275.82,,,,,,,,,,,,,
BASE GLEN SM COMPHSVE MOD HYBRID,SUP-2404685,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM PLCNTA MEM CRYOPRESERVED CHORION,SUP-2319169,CDM,Q4132,HCPCS,0636,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
DEVICE REATTACHMENT W23XL232MM GTR TROCH TIV 4 H EXT W/ 4,SUP-2410265,CDM,C1713,HCPCS,0278,RC,,,,both,,,9831.97,6390.78,,,,,,,,,,,,,
PLATE BNE SZ 2.8 MM MIDFACE PMI NS DISP ACCUPLATE,SUP-2935861,CDM,C1713,HCPCS,0278,RC,,,,both,,,56585.94,36780.86,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ FIT STRP W/OUT JT FABRICATED,SUP-2435756,CDM,L3702,HCPCS,0272,RC,,,,both,,,744.02,483.61,,,,,,,,,,,,,
CATHETER PH MONITORING 2 CHANNEL 6 FRX25 CM VERSAFLEX LPR,SUP-2173700,CDM,C1713,HCPCS,0278,RC,,,,both,,,4016.06,2610.44,,,,,,,,,,,,,
INTRODUCER SHTH J 9 FRX23 CM DBL DSTL W/O OBTURATOR KT,SUP-2431326,CDM,C1887,HCPCS,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
DILATOR ENDOSCP 6 FRX180 CM 4X20 MM BILI CATH MAXPASS DISP,SUP-2312951,CDM,C1725,HCPCS,0272,RC,,,,both,,,692.24,449.96,,,,,,,,,,,,,
RETRACTOR SURG L10IN BLDE W125IN S STL COBRA SMOOTH TIP PLN,SUP-2161266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.14,240.59,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT MINI BEAD FAST SET CA SULF RESRB OD,SUP-2400546,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
FLUCONAZOLE 40 MG/ML PO SUSR,RX-14233,CDM,340b,HCPCS,0637,RC,16714-0696-01,NDC,,both,2.5,ML,18.40,11.96,,,,,,,,,,,,,
TUNNELER SHTH 11GAX8IN ON-Q,SUP-2236801,CDM,C2626,HCPCS,0278,RC,,,,both,,,149.31,97.05,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X324 MM 18 HOLE SS LCP,SUP-2569379,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.00,744.25,,,,,,,,,,,,,
PLATE BNE L 100 DEG STD 1.7X5X0.55 MM RT 5 HOLE BAR MALL,SUP-2366245,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.95,414.67,,,,,,,,,,,,,
TRUMATCH CT PIN GUIDE TIBIAL L,SUP-2823307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
FLUVOXAMINE MALEATE 25 MG PO TABS,RX-20634,CDM,6370000000,HCPCS,0637,RC,60505-0164-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER GUID NEURON L 115 CM DSTL FLX ZONE 12 CM,SUP-2323601,CDM,C1887,HCPCS,0272,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 30 CM DIA16 FR GUIDEWIRE 0.038 IN,SUP-2167892,CDM,C1894,HCPCS,0272,RC,,,,both,,,162.84,105.85,,,,,,,,,,,,,
KIT INTRO L 11 CM DIA 6FR TUOHY BORST INTEGR HEMOSTATIC VLV,SUP-2601058,CDM,C1894,HCPCS,0272,RC,,,,both,,,82.27,53.48,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 12.5CM PCED 2,SUP-2613271,CDM,C1752,HCPCS,0278,RC,,,,both,,,859.58,558.73,,,,,,,,,,,,,
MESH HERN W3XL6IN RECTANG COMP POLYMER MACROPOROUS NAT,SUP-2219767,CDM,C1781,HCPCS,0278,RC,,,,both,,,1139.47,740.66,,,,,,,,,,,,,
CATHETER EP LG 2-8-2 MM 7 FRX95 CM LIVEWIRE,SUP-2355235,CDM,C1731,HCPCS,0278,RC,,,,both,,,4577.18,2975.17,,,,,,,,,,,,,
STAPLER ENDOSCP BIOABSORBABLE STPL LN REINF ENDOPATH SEAMGRD,SUP-2395279,CDM,C1781,HCPCS,0278,RC,,,,both,,,493.23,320.60,,,,,,,,,,,,,
COVER PLATE MOD LG LAT 1 HOLE ASMBLY TI TIMBERLINE MPF,SUP-2690202,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
NAIL FEMORAL RETROGRADE D11X340MM,SUP-2761707,CDM,C1713,HCPCS,0278,RC,,,,both,,,11194.10,7276.16,,,,,,,,,,,,,
ROD SPNL L45MM DIA6.35MM RT ANTR TI STR SMOOTH MNRCH,SUP-2254517,CDM,C1713,HCPCS,0278,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
VITAMIN D3 1.25 MG (50000 UT) PO CAPS,RX-108700,CDM,6370000000,HCPCS,0637,RC,75834-0020-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDE SURG CUT AO CUST CT DERIVED,SUP-2741997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
STENT PERIPH PALMAZ GEN L 29 MM DIA10 MM SHTH 8 FR GUIDE 10,SUP-2159241,CDM,C1877,HCPCS,0278,RC,,,,both,,,3975.24,2583.91,,,,,,,,,,,,,
CEMENT LUTING GLS IONOMER FOR SGL UNIT KETAC-CEM APLICAP,SUP-2238639,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.65,378.07,,,,,,,,,,,,,
PIN EXT FIX HALF CIR FIX OD5MM L180MM L40MM THRD SIDEKCK,SUP-2400701,CDM,C1776,CPT,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
HC Fresh Plasma 24hrs,PX-3900905900,CDM,P9059,HCPCS,0390,RC,,,,outpatient,,,491.00,319.15,,,,,,,,,,,,,
IMPLANT OTO L5.5MM DIA1.14MM HA HD PLASTIPORE SHFT FULL,SUP-2313678,CDM,L8613,CPT,0278,RC,,,,both,,,1147.86,746.11,,,,,,,,,,,,,
POST EXT FIX 1 H M CONN FOR SIDEKCK EZ FRME EXT FIX FREE,SUP-2400617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
CATHETER ABLATN F CRV CONTACT FORC SENSORENABLED TACTICATH,SUP-2574333,CDM,C1725,HCPCS,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
SCREW BNE ST 3.5X20 MM CRTX PELV SS NS,SUP-2183545,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.93,59.10,,,,,,,,,,,,,
NAIL IM 130 DEG L 24 CM DIA11.5 MM FEM STRL INTERTAN,SUP-2931206,CDM,C1713,HCPCS,0278,RC,,,,both,,,6848.18,4451.32,,,,,,,,,,,,,
PPICC PROVENA SOLO 3F SLEEVE BASIC TL,SUP-2613556,CDM,C1751,HCPCS,0278,RC,,,,both,,,571.07,371.20,,,,,,,,,,,,,
SCREW BONE L70MM OD5.5MM CORT SLD FULL THRD STRL,SUP-2413183,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.36,351.23,,,,,,,,,,,,,
SHELL ACET SPIK 66 MM HIP REFLECTION,SUP-2434761,CDM,C1776,CPT,0278,RC,,,,both,,,5815.28,3779.93,,,,,,,,,,,,,
DEFIBRILLATOR CARD SGL CHMBR ATLS VR,SUP-2357750,CDM,C1722,HCPCS,0275,RC,,,,both,,,50554.00,32860.10,,,,,,,,,,,,,
SYSTEM BILI STENT DEL OASIS 1 ACT GUIDE CATH L 318 CM DIA 5,SUP-2169522,CDM,C1894,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 4-6 MM SHRT TAPR REINF,SUP-2495531,CDM,C1768,CPT,0278,RC,,,,both,,,729.11,473.92,,,,,,,,,,,,,
URETEROSCOPE FLX DIGITAL MODEL D RVS DEFLECTION STRL DISP,SUP-2894008,CDM,C1747,HCPCS,0272,RC,,,,both,,,2483.74,1614.43,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L145CM DIA0.035IN TIP L3CM S STL PTFE FLX,SUP-2171225,CDM,C1769,HCPCS,0272,RC,,,,both,,,63.30,41.14,,,,,,,,,,,,,
CATHETER EP 7FR L95CM 2-10-2MM SPC SM CRV SPR COR SHFT W/,SUP-2141252,CDM,C1731,HCPCS,0278,RC,,,,both,,,3086.62,2006.30,,,,,,,,,,,,,
CATHETER DRAINAGE SHUNT 13X25 MMX90 CM MED PRESSURE PUDENZ,SUP-2244297,CDM,C1729,HCPCS,0272,RC,,,,both,,,509.53,331.19,,,,,,,,,,,,,
GRAFT BNE SPNG 12X12X12 MM DBM CANC,SUP-2641780,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
EXPEL APDL 8.3/25 K,SUP-2652759,CDM,C1729,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
BIT DRILL EX LONG CALIBRATED 4.3MM,SUP-2741119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
DX FIBERTAK SUTURE ANCHOR #2 MTS WITH NDL,SUP-2815354,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK0.1-.2MM AMNIO MEM 2 LAYR,SUP-2421276,CDM,Q4150,HCPCS,0636,RC,,,,both,,,12541.16,8151.75,,,,,,,,,,,,,
PLATE BNE CLAV CS1 2.7 MM LT VA LCK COMPR SS STRL VA-LCP,SUP-2750791,CDM,C1713,HCPCS,0278,RC,,,,both,,,3502.36,2276.53,,,,,,,,,,,,,
BIT DRL TWST 1.1X50 MM 17 MM W/ STP J NOTCH STRL LEVEL 1,SUP-2468061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.89,295.03,,,,,,,,,,,,,
SET VASC ACCS 4FR L10CM S STL PLAT TIP 0018IN NDL 21GA,SUP-2170554,CDM,C1894,HCPCS,0272,RC,,,,both,,,117.28,76.23,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR DIA19 MM BOV PERICARD COCR,SUP-2214067,CDM,C1889,HCPCS,0278,RC,,,,both,,,13863.10,9011.01,,,,,,,,,,,,,
SCREW EXT FIX L200MM DIA6.2MM THRD L55MM S STL 2 COR SCHNZ,SUP-2187005,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK1.8-3.9MM ULT THCK HYDRATED,SUP-2307495,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4697.44,3053.34,,,,,,,,,,,,,
COMPONENT TALAR SZ 4 ANK CO CHROME POR CEM BASE PLT REV AGIL,SUP-2252061,CDM,C1776,CPT,0278,RC,,,,both,,,9187.64,5971.97,,,,,,,,,,,,,
STAPLER ROBOTIC DIA30MM GRY ENDOWRIST DA VINCI XI,SUP-2246808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,563.38,366.20,,,,,,,,,,,,,
CUP ACET CEM 32 MM HIP HW W/ PLATE,SUP-2447857,CDM,C1776,CPT,0278,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
PLATE BNE L70MM HK D12MM 4 H R CLAV S STL LOK COMPR FOR,SUP-2185840,CDM,C1713,HCPCS,0278,RC,,,,both,,,3146.41,2045.17,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM PEEK DL KNOTLESS STRL CRKSCR,SUP-2930432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.02,1060.81,,,,,,,,,,,,,
PROSTHESIS INDWL VOICE L FLNG T AND E 20F 14MM,SUP-2242419,CDM,L8509,HCPCS,0274,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ENDPLATE SPNL DISK 9DEG M UNIV INTERVERTEBRAL THORACO LUM,SUP-2205504,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
CANNULA SURG FOR DRL GUIDE,SUP-2762143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
BUR SURG L14CM DIA3MM LEGEND PROX MTCH HD MIDAS REX CLRVW,SUP-2281566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
SPLINT WR AD L GREATER THAN W4IN RT MCP DLX KAY-SPLNT III,SUP-2324562,CDM,L3906,HCPCS,0274,RC,,,,both,,,82.80,53.82,,,,,,,,,,,,,
BAND GAST CRV ADJ DISECT REALIZE ENDO-SURGERY,SUP-2219869,CDM,C1889,HCPCS,0278,RC,,,,both,,,9071.46,5896.45,,,,,,,,,,,,,
SCREW BNE PART THRD 5X40 MM CANN STRL,SUP-2471330,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
FENOFIBRATE 48 MG PO TABS,RX-40009,CDM,6370000000,HCPCS,0637,RC,51079-0599-20,NDC,,both,1,UN,5.70,3.70,,,,,,,,,,,,,
PLATE BONE W7XL47MM THK1MM 6 H S STL QTR TBLR NONCOMPRESSION,SUP-2343852,CDM,C1713,HCPCS,0278,RC,,,,both,,,688.35,447.43,,,,,,,,,,,,,
GRAFT INFORCE TISS 5CMX5CM PORCINE,SUP-2244086,CDM,C1763,HCPCS,0278,RC,,,,both,,,10110.80,6572.02,,,,,,,,,,,,,
PLATE BNE L18MM THK03MM 6 H CRANIOMAXILLOFACIAL TI DBL Y FOR,SUP-2136524,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
NEEDLE SET 0.038 IN 20 GA 5 FRX15 CM MP PIG CATH 8 SP,SUP-2167985,CDM,C1729,HCPCS,0272,RC,,,,both,,,204.89,133.18,,,,,,,,,,,,,
NAIL IM DSTL TIB GRY 10MMX32CM,SUP-2347129,CDM,C1713,HCPCS,0278,RC,,,,both,,,2973.55,1932.81,,,,,,,,,,,,,
SCREW TI METAPHYSEAL 2.7MM SLF-TPNG/T8 STRDRV 75MM - STER,SUP-2546830,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.15,178.20,,,,,,,,,,,,,
PLATE BONE W10XL53MM THK1.5MM 3X3 H NEUT BILAT S STL T SHP,SUP-2185883,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.27,546.83,,,,,,,,,,,,,
STAPLER INT BIOABSRB REINF ECHELON ENDOPATH 60,SUP-2395280,CDM,C1781,HCPCS,0278,RC,,,,both,,,521.49,338.97,,,,,,,,,,,,,
PIN FIX L61MM DIA10MM PROV SH THRD TC-100,SUP-2343744,CDM,C1713,HCPCS,0278,RC,,,,both,,,752.31,489.00,,,,,,,,,,,,,
HC So1 Chemiluminescent Assay,PX-3018239767,CDM,82397,CPT,0301,RC,,,,both,,,84.00,54.60,,,,,,,,,,,,,
PLATE BONE CRANIAL 5 HOLE STRAIGHT 21.4X3.4MM TITANIUM NEURO,SUP-2825989,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BONE SM THK2MM TI BLU MAND DBL ANG STR MID GRD 2,SUP-2136807,CDM,C1713,HCPCS,0278,RC,,,,both,,,5906.34,3839.12,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 5X3 CM PLCNTA BASE MEMBRN AMNIOEFFECT,SUP-2872720,CDM,C1762,CPT,0278,RC,,,,both,,,6713.32,4363.66,,,,,,,,,,,,,
RADIOFREQUENCY ABLATION KIT LNG 5/10 CM W/ POWERCURVE STAR,SUP-2487603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11717.44,7616.34,,,,,,,,,,,,,
BIT DRILL AO  SHORT  3.8MM,SUP-2750030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
FILGRASTIM-AAFI 480 MCG/1.6ML IJ SOLN,RX-145106,CDM,Q5110,HCPCS,0636,RC,00069-0294-10,NDC,,both,1.6,ML,2014.80,1309.62,,,,,,,,,,,,,
CORTICAL BONE SCR 2.7X16MM,SUP-2397913,CDM,C1713,HCPCS,0278,RC,,,,both,,,220.43,143.28,,,,,,,,,,,,,
CAGE SPNL L16XW16XH10MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317741,CDM,C1889,HCPCS,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
SPACER SPNL 9X9X26MM 4 DEG L NAR IMPACTED PEEK COROENT,SUP-2310782,CDM,C1821,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
PLATE BNE L66MM THK1.25MM 3X10 H BILAT S STL T SHP ST LO,SUP-2186373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.34,752.27,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 24CM 1,SUP-2613277,CDM,C1750,HCPCS,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
GUIDEWIRE VASC L 15 CM DIA 0.025 IN SS SAFE-T-J STR FIX COR,SUP-2760069,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.37,29.49,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB UNIV L,SUP-2276645,CDM,L3931,HCPCS,0272,RC,,,,both,,,15.92,10.35,,,,,,,,,,,,,
KIT AUTOTRANSFUSION FILTER 150 UM 225 ML COLLCTN RESERVOIR 3,SUP-2905512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,927.65,602.97,,,,,,,,,,,,,
PLATE BNE LCK 5.5X189 MM LT PROX LAT TIB 10 HOLE COMPR SS,SUP-2198439,CDM,C1713,HCPCS,0278,RC,,,,both,,,3974.20,2583.23,,,,,,,,,,,,,
SLING ORTH CHST CIRC 32-36IN SM BLK UNIV HUM CUF SHLDR SUPP,SUP-2324515,CDM,L3675,HCPCS,0274,RC,,,,both,,,79.47,51.66,,,,,,,,,,,,,
SLEEVE FEM SM SZ 18-19 TI STIKTITE HA HIP REV MOD REDAPT,SUP-2421235,CDM,C1776,CPT,0278,RC,,,,both,,,5262.64,3420.72,,,,,,,,,,,,,
BELT ORTHOT RIB THOR CUST FABRICATED,SUP-2435536,CDM,L0220,HCPCS,0274,RC,,,,both,,,365.75,237.74,,,,,,,,,,,,,
RIVASTIGMINE TARTRATE 1.5 MG PO CAPS,RX-28278,CDM,6370000000,HCPCS,0637,RC,65862-0648-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PATCH CV HEMACAROTID L 75XW 8MM THK0.41MM POLYESTER BOV PK10,SUP-2227505,CDM,C1781,HCPCS,0278,RC,,,,both,,,348.19,226.32,,,,,,,,,,,,,
SCREW BONE L65MM DIA4MM CANC T20 FULL THRD SM FRAG PLATING,SUP-2350003,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.17,184.71,,,,,,,,,,,,,
PLATE NAVICULAR 2.4/2.7MM LT TI VA LCK STRL,SUP-2546963,CDM,C1713,HCPCS,0278,RC,,,,both,,,4384.41,2849.87,,,,,,,,,,,,,
LEVEL NEURO ST MESH STNDRD ULTRNE NEURO SCRW83 X 47 MM T035,SUP-2676760,CDM,C1713,HCPCS,0278,RC,,,,both,,,3368.81,2189.73,,,,,,,,,,,,,
JIG SURG REDUC FX CAGE PH,SUP-2167383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SCREW SPNL L55MM DIA5.5MM TI ST VAR TIMBERLINE MPF,SUP-2415819,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
SLEEVE CATH CATH-GARD L 80 CM DIA 7.5 FR TWISTLOCK ADPT,SUP-2127034,CDM,C1750,HCPCS,0278,RC,,,,both,,,37.81,24.58,,,,,,,,,,,,,
ROD SPNL 50 MM,SUP-2415851,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
STEM FEM SZ 12 L225MM HIP CO CHROM STD CLLR CEM NEUT REV,SUP-2344470,CDM,C1776,CPT,0278,RC,,,,both,,,13439.20,8735.48,,,,,,,,,,,,,
LENS IOL MN60AC,SUP-2110511,CDM,V2632,HCPCS,0276,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
TAP BNE SPNL ANT CERV,SUP-2286471,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.16,328.35,,,,,,,,,,,,,
GRAFT BLGCL TSSUE W16XL20CM PRCNE DRMS MTRX RCNSTRCTVE PLBLE,SUP-2675761,CDM,C1781,HCPCS,0278,RC,,,,both,,,30765.72,19997.72,,,,,,,,,,,,,
MIS TRAB METAL FLEX SCREW,SUP-2822709,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE W16XL158MM THK5MM 7 H R CNDYL FEM S STL BTTRS DYN,SUP-2185805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2366.05,1537.93,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM RT MAND 26 HOLE ANGLED FIX TI STRL,SUP-2500268,CDM,C1713,HCPCS,0278,RC,,,,both,,,9294.12,6041.18,,,,,,,,,,,,,
CLIP ANEURYSM OPENING W2.3MM BLADE L5MM MICRO PHYNOX STRAIGH,SUP-2825388,CDM,C1889,HCPCS,0278,RC,,,,both,,,801.05,520.68,,,,,,,,,,,,,
CATHETER PERITONEAL SHUNT 1.3X2.5 MMX90 CM MED PUDENZ,SUP-2852590,CDM,C1729,HCPCS,0272,RC,,,,both,,,639.34,415.57,,,,,,,,,,,,,
RING FOOT LNG 155MM,SUP-2481005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5950.93,3868.10,,,,,,,,,,,,,
SCREW BNE L16MM DIA45MM PUR CANN GUID GROWTH EIGHT PLATE,SUP-2316384,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.90,326.88,,,,,,,,,,,,,
OYSTER SHELL CALCIUM W/D 500-5 MG-MCG PO TABS,RX-160103,CDM,6370000000,HCPCS,0637,RC,10006-0700-38,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT EVAR L100MM DIA46X46MM CATH 25FR THOR CLS WEB STR DST,SUP-2281720,CDM,C1768,CPT,0278,RC,,,,both,,,51009.30,33156.04,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5.5X60 MM CANN EXT TAB VOYAGER 4.75,SUP-2629435,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BASKET STONE 19FR L90CM 10MM 3 WIR HELI SURLOK,SUP-2312746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.93,280.10,,,,,,,,,,,,,
PINN CAN BONE SCREW 6.5MMX8MM,SUP-2512745,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
GRAFT BNE CUBE FRZ DRY CANC L 10MMXW 10MMXH 10MM 40CC,SUP-2264687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1556.00,1011.40,,,,,,,,,,,,,
HEAD HUM STEMLESS SHT 41 MM SHLDR ALPHA EQUINOXE,SUP-2451396,CDM,C1776,CPT,0278,RC,,,,both,,,4266.63,2773.31,,,,,,,,,,,,,
GRAFT BNE 10 CC CELLULAR BNE MTRX V92,SUP-2742072,CDM,C1713,HCPCS,0278,RC,,,,both,,,16406.50,10664.22,,,,,,,,,,,,,
HC Gonadotropin Luteinizing Hormone,PX-3018300200,CDM,83002,CPT,0301,RC,,,,inpatient,,,443.00,287.95,,,,,,,,,,,,,
BIT DRL CANN 5.5 MM KNEE SINGLE FLUT MTO,SUP-2849077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2411.52,1567.49,,,,,,,,,,,,,
PLATE BNE L 129 MM SCREW DIA 4.5 MM 6 H RT PROX LAT TIB NS,SUP-2932772,CDM,C1713,HCPCS,0278,RC,,,,both,,,9368.98,6089.84,,,,,,,,,,,,,
RETRACTOR SURG RNG DIA 9 CM LG INTERCOSTAL INCISION SFT TISS,SUP-2890026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.43,742.58,,,,,,,,,,,,,
CANNULA EXTN 20 CM FOR UNIV HNDL STR,SUP-2470940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,746.88,485.47,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135 CM DIA 4 FR SLT PAT L 40 CM,SUP-2117042,CDM,C1751,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
CATHETER PULM ART 7FR BLLN 1.25CC L110CM DIA11MM DBL LUMN,SUP-2383245,CDM,C1887,HCPCS,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
RING ANNULPLSTY EDW MC3 26MM TI ALLOY POLYESTER SIL RUBBER,SUP-2214214,CDM,C1889,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
BUR SURG HUDSON BRAC 16 MM MCKENZ ENLARGING,SUP-2476367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
CATHETER NEPHROSTOMY SET 10 FRX19.5 CM COPE LOOP,SUP-2835666,CDM,C1729,HCPCS,0272,RC,,,,both,,,840.89,546.58,,,,,,,,,,,,,
ASPIRATION KIT BNE MAR 120 ML,SUP-2223568,CDM,C1713,HCPCS,0278,RC,,,,both,,,7567.40,4918.81,,,,,,,,,,,,,
HC So Hbv Dna W/Reflex to Geno,PX-3068751767,CDM,87517,CPT,0306,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0736,HCPCS,0636,RC,00781-3290-91,NDC,,both,50,ML,83.40,54.21,,,,,,,,,,,,,
MICROCATHETER VASC MC18 + STRL,SUP-2367766,CDM,C1757,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
JACKET ORTHOT CUST POST OPERATIVE BODY,SUP-2435594,CDM,L1310,HCPCS,0274,RC,,,,both,,,5082.28,3303.48,,,,,,,,,,,,,
CATHETER ETER DLYS 135FR 16CM IC STR EXTN MAHRK ELITE,SUP-2613219,CDM,C1752,HCPCS,0278,RC,,,,both,,,283.51,184.28,,,,,,,,,,,,,
CATHETER PICC L90CM 0.035IN 30DEG ANG TIP S STL DBL BRAID,SUP-2385620,CDM,C1887,HCPCS,0272,RC,,,,both,,,700.53,455.34,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP 0.1MM DIA TIP 3.2MML TIP STRGHT TIP SHFT R,SUP-2637603,CDM,C1769,HCPCS,0272,RC,,,,both,,,320.12,208.08,,,,,,,,,,,,,
DAKINS (FULL STRENGTH) 0.5 % EX SOLN,RX-148149,CDM,6370000000,HCPCS,0637,RC,00436-0946-16,NDC,,both,473,ML,51.10,33.21,,,,,,,,,,,,,
PLATE BONE L163MM 12 H NONSTERILE RT PROX TIB S STL LO PROF,SUP-2185817,CDM,C1713,HCPCS,0278,RC,,,,both,,,3708.21,2410.34,,,,,,,,,,,,,
SCREW BNE MAXILLOMANDIBULAR 2X12 MM 8 MM SS MAXDRIVE,SUP-2469567,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.69,239.00,,,,,,,,,,,,,
HC Fibrin Dgradj Products D-Dimer Quantitative,PX-3058537900,CDM,85379,CPT,0305,RC,,,,both,,,340.00,221.00,,,,,,,,,,,,,
PLATE BNE MED TI MANDIBULAR 3D PRNT NS DISP ACCUPLATE,SUP-2934721,CDM,C1713,HCPCS,0278,RC,,,,both,,,29032.44,18871.09,,,,,,,,,,,,,
CATHETER HD DL 14.5X23 CM ADMIN BASIC KT LT STR HEMOSTAR,SUP-2126528,CDM,C1750,HCPCS,0278,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
GRAFT VASC SEALPTFE L 50 CM DIA 6 MM GEL SEAL EPTFE STD WALL,SUP-2392561,CDM,C1768,CPT,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PROSTHESIS VOICE LO PRSS 16FR SZ 18MM BLOM SINGER,SUP-2242312,CDM,L8509,HCPCS,0274,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM OD0038IN TAPR L3CM J TIP ZIPWIRE,SUP-2148214,CDM,C1769,HCPCS,0272,RC,,,,both,,,83.18,54.07,,,,,,,,,,,,,
PURAPLYAM (4.0X4.0) 16 sq cm,SUP-2635402,CDM,Q4196,HCPCS,0636,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
SUPPORT EXT FIX FT LEG ALIGN STRL TRUELOK LTX,SUP-2875383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.30,266.69,,,,,,,,,,,,,
HC So Myoglobin,PX-3018387466,CDM,83874,CPT,0301,RC,,,,both,,,320.00,208.00,,,,,,,,,,,,,
IMPLANT BRST 620 645CC P65CM W154XH13CM NACL STYL 363LF,SUP-2113316,CDM,C1789,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L6MM L FLNG INDWL 2 VLV BLOM-SINGER,SUP-2242330,CDM,L8509,HCPCS,0274,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
PATCH BIO W7XL10CM PORCINE 4 PLY FOR INTCARD REP,SUP-2172037,CDM,C1768,CPT,0278,RC,,,,both,,,3199.03,2079.37,,,,,,,,,,,,,
TRAY THORCENT CATH 8FR 3ML CHLORAPREP NDL STRW FLTR FN TIP,SUP-2133920,CDM,C1729,HCPCS,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
GRAFT DURA ABSRB CLLGN BASE ST 2IN 2IN DURAMATRIX,SUP-2165120,CDM,C1763,HCPCS,0278,RC,,,,both,,,1643.26,1068.12,,,,,,,,,,,,,
BIT DRL FOR SH 2.9MM PUSHLOCK,SUP-2121760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE SPNL THK2MM 32 H THOR RIB CP TITANIUMXSHAPED LCK FOR,SUP-2262535,CDM,C1713,HCPCS,0278,RC,,,,both,,,5400.80,3510.52,,,,,,,,,,,,,
CATHETER DRAINAGE LCK PIG 10 FRX40 CM POLYURETHANE,SUP-2303561,CDM,C1729,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
KNEE IMMOB 20 IN SM,SUP-2195246,CDM,L1830,CPT,0274,RC,,,,both,,,36.71,23.86,,,,,,,,,,,,,
LASER SURG 1CM INDIGO DIFFUSER TIP FBROPT TEMP SENS OPT,SUP-2257669,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
CATHETER HD STR 12.5 FRX32 CM LT DL STP BASIC SET HEMCATH,SUP-2627317,CDM,C1750,HCPCS,0278,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
ROD EXT FIX L200MM DIA8MM DSTL RAD ELBW C FBR REUSE FOR,SUP-2188739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115 CM F-J BLK,SUP-2248508,CDM,C1732,HCPCS,0272,RC,,,,both,,,4411.70,2867.60,,,,,,,,,,,,,
DYNANITE 1.1 DBL TIP NITI G-WIRE 2 ZONE,SUP-2812885,CDM,C1769,HCPCS,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
PLATE BONE W15XL200MM THK2MM 10 H BILAT TI THN BLDE RIG,SUP-2190987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1808.45,1175.49,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0250,RC,00264-7510-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 6 FRX10 CM 18 GA SAFETY ACCEL,SUP-2659270,CDM,C1729,HCPCS,0272,RC,,,,both,,,70.18,45.62,,,,,,,,,,,,,
OVERTUBE ENDOSCP L25CM OD19.5MM ID16.7MM SCP DIA8.6-10MM,SUP-2360645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,528.09,343.26,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WOVEN L 110 CM DIA 6 FR SPC 2-4-2,SUP-2142305,CDM,C1731,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
SCREW BONE PET L70MM DIA7.7MM THRD,SUP-2315920,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.67,745.99,,,,,,,,,,,,,
PLASMA-LYTE A IV SOLN,RX-6331,CDM,2580000003,HCPCS,0258,RC,00338-0221-03,NDC,,both,500,ML,80.50,52.32,,,,,,,,,,,,,
INTRODUCER SHTH 45 CM 8 FRX13 CM 20 CM SSV SPLIT GUIDEWIRE,SUP-2424644,CDM,C1894,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Mra Abdomen W&W/O Contrast,PX-6187418502,CDM,C8902,CPT,0618,RC,,,,outpatient,,,2826.00,1836.90,,,,,,,,,,,,,
HC So Aso Titer,PX-3028606066,CDM,86060,CPT,0302,RC,,,,inpatient,,,129.00,83.85,,,,,,,,,,,,,
SHEATH INTRF SCR DIA6-7MM,SUP-2122017,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
GRAFT HUM TISS W25MMXW10CM FASC LATA FRZ DRY TUTOPLAST,SUP-2307100,CDM,C1762,CPT,0278,RC,,,,both,,,714.70,464.55,,,,,,,,,,,,,
WEDGE TIB SZ 5-6 7DEG STD FULL PRI GEN II,SUP-2345775,CDM,C1776,CPT,0278,RC,,,,both,,,2949.25,1917.01,,,,,,,,,,,,,
HAMMER SURG QUISLING 7 IN INTNSL PADGETT,SUP-2484783,CDM,C1713,HCPCS,0278,RC,,,,both,,,695.07,451.80,,,,,,,,,,,,,
CATHETER CTRL VEN 12FR 16CM LEN 3 LUMN N TUNNELED BASIC SET,SUP-2120626,CDM,C1751,HCPCS,0278,RC,,,,both,,,192.80,125.32,,,,,,,,,,,,,
CAGE SPNL PARL 17X14X8 MM MP DIVERGENCE,SUP-2632023,CDM,C1889,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM SUTURE TAPE W 1.4 MM BIOCOMP 2,SUP-2907016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
SCREW BNE SD 3 MM SHFT 3-2.5X70 MM 15 MM CORTICAL,SUP-2646756,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.00,182.65,,,,,,,,,,,,,
ELECTRODE ES RESECT W/ HF CBL PLSM BTTN,SUP-2314007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1406.88,914.47,,,,,,,,,,,,,
MESH SURG W10XL15CM POLY ANAT FOR R INGUINAL HERN PARIETEX,SUP-2174784,CDM,C1781,HCPCS,0278,RC,,,,both,,,377.71,245.51,,,,,,,,,,,,,
CONNECTOR CATH Y 1X2 MM RADIOPAQUE POLYPR STRL,SUP-2851299,CDM,C1729,HCPCS,0272,RC,,,,both,,,3295.34,2141.97,,,,,,,,,,,,,
DRILL SURG DIA4.5MM CANN,SUP-2256847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
MESH SURG 26X4X3CM POLYPR Y FOR SACROCOLPOPEXY VERTESSA LT,SUP-2152281,CDM,C1781,HCPCS,0278,RC,,,,both,,,2964.16,1926.70,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA10 MM POLYESTER GEL,SUP-2385013,CDM,L8670,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
INSERT TIB CR T1/1+ 12 MM KNEE GLIDING SURF DP DSH POLYETH,SUP-2422121,CDM,C1776,CPT,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PLATE HOCKEY 8H LT RS,SUP-2653979,CDM,C1713,HCPCS,0278,RC,,,,both,,,2504.15,1627.70,,,,,,,,,,,,,
HEMIN 350 MG IV SOLR,RX-139180,CDM,J1640,HCPCS,0636,RC,55292-0702-55,NDC,,both,1,UN,33016.80,21460.92,,,,,,,,,,,,,
PLUG BNE POLY PLUG MDLLRY 13MM,SUP-2205393,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
ALLOGRAFT TISS 3X6 CM MTRX REGENERATIVE,SUP-2393053,CDM,Q4170,HCPCS,0636,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BONE THK0.3MM CRANIOFACIAL ORBIT TI MESH MALL FOR,SUP-2190685,CDM,C1713,HCPCS,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
BIT DRILL 2MM DIA 216MML 420AB 455 STNLSS STEEL QCK CNNCT C,SUP-2722083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
SCREW BONE LAG 10MM DIA 105MML FNAIL,SUP-2723147,CDM,C1713,HCPCS,0278,RC,,,,both,,,1688.25,1097.36,,,,,,,,,,,,,
GRAFT BNE 15 CC CELLULAR BNE MTRX OSSEOGEN,SUP-2858502,CDM,C1713,HCPCS,0278,RC,,,,both,,,12446.18,8090.02,,,,,,,,,,,,,
BALLOON DIL 30-33-36FR L8CM INFLATED DIA10-11-12MM 2-4-6ATM,SUP-2170091,CDM,C1726,HCPCS,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
ANCHOR SUT SZ 2 L93CM WHT N ABSRB BRAID POLYETH RAPPEL LINE,SUP-2399081,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
GRAFT BNE MATCHSTICK 3-6X60 MM CANC CORTICAL PUREBONE,SUP-2424610,CDM,C1713,HCPCS,0278,RC,,,,both,,,2299.89,1494.93,,,,,,,,,,,,,
SHELL ACET OD44MM SPIK TIV ALLY POR TOT HIP PRI PRESSFIT,SUP-2202339,CDM,C1776,CPT,0278,RC,,,,both,,,8038.40,5224.96,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0 X 20MM HD CANN SHT THRD SCR,SUP-2320534,CDM,C1713,HCPCS,0278,RC,,,,both,,,642.92,417.90,,,,,,,,,,,,,
MESH CRAN W100XL100MM THK0.6MM SLV TI CNTOUR FOR 1.5MM,SUP-2402667,CDM,C1781,HCPCS,0278,RC,,,,both,,,5956.58,3871.78,,,,,,,,,,,,,
CATHETER KIT 0.018 INX17.75 IN 5 FRX40 CM DL BLU FLEXTIP,SUP-2384052,CDM,C1751,HCPCS,0278,RC,,,,both,,,259.49,168.67,,,,,,,,,,,,,
HEAD HUM H15MM OD40MM STD CO CHROM SHLDR PRI REV TOT BPLR,SUP-2404692,CDM,C1776,CPT,0278,RC,,,,both,,,4989.46,3243.15,,,,,,,,,,,,,
ALLOGRAFT BNE PWD 10 CC FD ASEP CORTICAL,SUP-2867134,CDM,C1762,CPT,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
COMPONENT PART KNEE CAPPED K1ZIMMER] ZIMMER BIOMET INC],SUP-2212585,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
PROXILOCK HA TI STEM 9MM 01-220-09241,SUP-2198953,CDM,C1776,CPT,0278,RC,,,,both,,,17326.21,11262.04,,,,,,,,,,,,,
PROSTHESIS OSS STD 0.6X0.9X4.25 MM CLASSIC STAP TI,SUP-2638175,CDM,L8613,CPT,0278,RC,,,,both,,,706.72,459.37,,,,,,,,,,,,,
PACEMAKER CARD PULSAR MAX DR TI 2 CHMBR IS1 COMPATIBLE CONN,SUP-2148601,CDM,C1785,HCPCS,0275,RC,,,,both,,,17882.30,11623.49,,,,,,,,,,,,,
CEMENT BNE PASTE 25 GM SOURC,SUP-2371940,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 4 MM EPTFE STR STD WALL N RING,SUP-2396414,CDM,C1768,CPT,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
COVER BUR H L14MM DIA0.6MM DOMED W/ TAB,SUP-2365228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
CATHETER HAD ADMIN BASIC KT SGL LUMN POLYUR PRECRV HYDRPHLC,SUP-2117396,CDM,C1750,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
SCREW BONE L65MM DIA6.5MM UNIV CORT FEM ST FT DRV END,SUP-2411531,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT EMBOL-X SLIM DIA24 FR OBTURATOR SM,SUP-2214484,CDM,C1884,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
STEM FEM L121MM DIA11MM HIP EXT OFFSET REDUC NK LEN MEDL,SUP-2137013,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BUR 23MM TAPERED ROUTER,SUP-2431337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,454.17,295.21,,,,,,,,,,,,,
BASEPLATE TIB CLLRLSS STD KNEE ASMBLY BIMTRC,SUP-2448787,CDM,C1776,CPT,0278,RC,,,,both,,,1851.03,1203.17,,,,,,,,,,,,,
HC Ot Re-Eval Est Plan Care,PX-4349716800,CDM,97168,CPT,0434,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
SET LD INTRO PEELWY L 30 CM OD 14 FR GUIDEWIRE 0.038 IN,SUP-2167898,CDM,C1892,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
SET INTRO SCOUTPRO L 45 CM DIA 7 FR GUIDEWIRE 0.038 IN NDL,SUP-2138045,CDM,C1894,HCPCS,0272,RC,,,,both,,,2003.32,1302.16,,,,,,,,,,,,,
PLATE BNE Y 0.6 MM FACE,SUP-2262678,CDM,C1713,HCPCS,0278,RC,,,,both,,,784.56,509.96,,,,,,,,,,,,,
GRAFT SFT TISS PRE SAT 155 MM ANK LAT FRZN TEND,SUP-2427793,CDM,C1762,CPT,0278,RC,,,,both,,,4091.26,2659.32,,,,,,,,,,,,,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-4501312000,CDM,13120,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
PLATE BNE W10.2XL169MM THK2.7MM 13 H BILAT S STL STR LO,SUP-2186200,CDM,C1713,HCPCS,0278,RC,,,,both,,,1700.50,1105.32,,,,,,,,,,,,,
LINER ACET HIP ARCM FOR KM3,SUP-2136660,CDM,C1776,CPT,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 180 CM TIP L 6 CM DIA 0.035 IN SS,SUP-2148177,CDM,C1769,HCPCS,0272,RC,,,,both,,,568.72,369.67,,,,,,,,,,,,,
MESH PARIETEX TWO DIM 20 CM X 20 CM,SUP-2174776,CDM,C1781,HCPCS,0278,RC,,,,both,,,381.26,247.82,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 150 MM DIA 7 MM DEL SYS L 190 CM,SUP-2866204,CDM,C1725,HCPCS,0272,RC,,,,both,,,5704.81,3708.13,,,,,,,,,,,,,
KIT OPHTH 7ML PERFLUOROCARBON LIQ PROC PERFLUORON,SUP-2110016,CDM,C1784,HCPCS,0278,RC,,,,both,,,4475.38,2909.00,,,,,,,,,,,,,
CATHETER NEPHSTMY 22FR BAL 5CC SIL SH TIP COUNCL STYL BAL,SUP-2129042,CDM,C1729,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
DARBEPOETIN ALFA 500 MCG/ML IJ SOSY,RX-131234,CDM,J0881,HCPCS,0636,RC,55513-0032-01,NDC,,both,1,ML,11416.50,7420.72,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 360 DEG L 4 CM DIA2 MM,SUP-2362410,CDM,C1889,HCPCS,0278,RC,,,,both,,,3.80,2.47,,,,,,,,,,,,,
EXTENSION GUIDEWIRE STRTCH L 150 CM DIA 0.014 IN STRL,SUP-2664346,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC ED Closed Tx Tmj Dislocation,PX-4502148000,CDM,21480,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
"HC So Cytomegalovirus,Igm Antibody",PX-3028664566,CDM,86645,CPT,0302,RC,,,,both,,,179.00,116.35,,,,,,,,,,,,,
WASHER ORTHOPEDIC 1.5MM X 15MM DYNANAIL HELIX,SUP-2878685,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
DEVICE REVASCULARIZATION 3D L 26 MM WORKING L 20 MM DIA 4.5,SUP-2323630,CDM,C1757,HCPCS,0272,RC,,,,both,,,16296.60,10592.79,,,,,,,,,,,,,
PLATE BNE T 4.5X91 MM 4 HOLE LCP,SUP-2569409,CDM,C1713,HCPCS,0278,RC,,,,both,,,556.09,361.46,,,,,,,,,,,,,
BURR DIAMOND BALL 3.0MM S3DG1,SUP-2843311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.52,231.74,,,,,,,,,,,,,
SAW SURG JOS 190 LT BAYNT SHP CRV,SUP-2649605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.39,299.90,,,,,,,,,,,,,
CATHETER HD TRPL LUMEN 12 FRX24 CM HI PRESSURE CRV EXT MAHRK,SUP-2283988,CDM,C1750,HCPCS,0278,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
HC L Heart Vgram W Graft,PX-4819345900,CDM,93459,CPT,0481,RC,,,,both,,,16603.00,10791.95,,,,,,,,,,,,,
GUIDEWIRE ORTH TAPERED TIP 3X330 MM LATERAL ACCESS DISP,SUP-2731938,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PROPYLTHIOURACIL 50 MG PO TABS,RX-6662,CDM,6370000000,HCPCS,0637,RC,68084-0964-95,NDC,,both,1,UN,12.60,8.19,,,,,,,,,,,,,
SET DRNGE 5FR 0.035IN NSL PANCREAS STR W/ FLAP FOR TEMP,SUP-2169040,CDM,C1729,HCPCS,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
PROBE PACE BPLR TEMP COBRA AFFIRM DISP,SUP-2124414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
KIT INFUS PMP 270ML 2M/HR SOAK CATH L2.5IN N NARC ON-Q,SUP-2236825,CDM,C9804,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 60 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2486125,CDM,C1768,CPT,0278,RC,,,,both,,,1341.60,872.04,,,,,,,,,,,,,
RING REPROC HALF,SUP-2488432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,961.91,625.24,,,,,,,,,,,,,
CATHETER EP 4FR L110CM SPC 2MM M CRV DECAPOLAR STEER,SUP-2357444,CDM,C1730,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GUIDEWIRE VASC MORPHEUS L 130 CM DIA 0.018 IN PLAT TIP,SUP-2117374,CDM,C1769,HCPCS,0272,RC,,,,both,,,182.43,118.58,,,,,,,,,,,,,
PIN 5X160X35MM YL,SUP-2483733,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
KIT THR TRABECULAR MTL POR STEM CUP VIT E LNR AND STD HD,SUP-2212131,CDM,C1776,CPT,0278,RC,,,,both,,,18683.00,12143.95,,,,,,,,,,,,,
STYLET ABLAT 6FR L12CM 0.035IN ENDOVENOUS RF COMPATIBLE W/,SUP-2393095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
NEEDLE ASPIR ENDOSCP ULTRASOUND 25 GA 2.4 MM MIN CHANNEL,SUP-2141500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
NEEDLE OPHTH DIX SPUD FB W/ SLIDING HNDL SS,SUP-2497610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.13,383.58,,,,,,,,,,,,,
GUIDEWIRE ORTH L152MM DIA32MM SMOOTH SHRP TIP,SUP-2251211,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
SLEEVE TIB L5CM PROX KNEE FOR ORTH SALV SYS,SUP-2406464,CDM,C1776,CPT,0278,RC,,,,both,,,8463.87,5501.52,,,,,,,,,,,,,
CATHETER ANGIO PGTL COR W/ SIDE H W/OUT HYDRPHLC COAT AD,SUP-2116593,CDM,C1725,HCPCS,0272,RC,,,,both,,,60.38,39.25,,,,,,,,,,,,,
PLATE BONE 10 H TI LCK STR,SUP-2123457,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM BIOCOMP FLAG MIS CC STRL FIBERTAK,SUP-2910465,CDM,C1713,HCPCS,0278,RC,,,,both,,,10533.92,6847.05,,,,,,,,,,,,,
PLATE BONE L142MM 12 H STRL BILAT S STL NONCOMPRESSION RECON,SUP-2348447,CDM,C1713,HCPCS,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
PLATE SPNL BX 14X14 MM ULTRA LO PROF TI LIGHT GRN NS,SUP-2423200,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.61,542.50,,,,,,,,,,,,,
CUFF TRNQT 8IN CIRC 1 PRT 1 BLDR PED NONSTERILE PNEUMAT,SUP-2208886,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.75,263.09,,,,,,,,,,,,,
PLATE BNE L 176 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 16 H 72440916,SUP-2933333,CDM,C1713,HCPCS,0278,RC,,,,both,,,2262.84,1470.85,,,,,,,,,,,,,
SPACER SPNL 8MM LONESTAR,SUP-2317851,CDM,C1821,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
CATHETER CV KT 8 FRX20 CM DL PRESSURE INJ GUIDEWIRE DIL,SUP-2763386,CDM,C1751,HCPCS,0278,RC,,,,both,,,438.97,285.33,,,,,,,,,,,,,
COIL VASC 10MM DIA 30CM LEN 018IN GWIRE STRTCH DETACH HELI,SUP-2365710,CDM,C1889,HCPCS,0278,RC,,,,both,,,1828.74,1188.68,,,,,,,,,,,,,
PROBE ELECTROSURG PERCUTANEOUS COOLED RF COOLIEF,SUP-2736734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
DEVICE THERM REG SIL ESOPH MLTI LUMEN CLIK-TITE CONN 5 DEG,SUP-2882141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2668.22,1734.34,,,,,,,,,,,,,
STEM HUM L150 MM SM LATITUDE EV RT,SUP-2396773,CDM,C1776,CPT,0278,RC,,,,both,,,29535.31,19197.95,,,,,,,,,,,,,
BIT DRL L248MM DIA2.8MM QUIK CPL W/O STP CALIB,SUP-2187458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.67,303.99,,,,,,,,,,,,,
FOSPHENYTOIN 50 MG PE/ML IJ SOLN (MIXTURES ONLY),RX-430014,CDM,Q2009,HCPCS,0636,RC,00069-5471-02,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
MEPIVACAINE HCL (PF) 1 % IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-106537,CDM,J0670,HCPCS,0636,RC,63323-0260-37,NDC,JW,both,2,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HIPCAP3000] STRYKER CORP],SUP-2365534,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
HC Iaad Ia Clostridium Difficile Toxin,PX-3068732400,CDM,87324,CPT,0306,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
CABLE ORTHOT HIP KNEE ANK CUST UNILAT TORSON,SUP-2435644,CDM,L2080,LOCAL,0274,RC,,,,both,,,1056.52,686.74,,,,,,,,,,,,,
SYRINGE BNE GRFT,SUP-2430776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
FOOT ARCH EXT FIX D 180 MM RX STRL TRUELOK EVO LTX,SUP-2875622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7054.01,4585.11,,,,,,,,,,,,,
DEVICE REM 183GM W7.1XH11.4CM D5.1CM TRAK BK II,SUP-2326855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SUTURE LASSO NDL QTY 5 AR4560,SUP-2121866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
COMPONENT FEM L11MM KNEE HNG BOLT W/ SL LEGION,SUP-2346259,CDM,C1776,CPT,0278,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L115CM 6FR 1MM 10MM FIX L CRV,SUP-2462747,CDM,C1730,HCPCS,0272,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
MESH HERN W5XL10CM SYNTH INGUINAL N ABSRB PRESHAPED KEYHOLE,SUP-2265907,CDM,C1781,HCPCS,0278,RC,,,,both,,,125.29,81.44,,,,,,,,,,,,,
PIN FIX L9IN DIA32MM NONSTERILE S STL 3 SIDE SGL TRCR 1,SUP-2150445,CDM,C1713,HCPCS,0278,RC,,,,both,,,64.87,42.17,,,,,,,,,,,,,
PLATE SPNL FIX 31 MM LP TI CD HORZ X10 CROSSLINK,SUP-2289539,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 300 HF-T 55 X 66MM 12MM 30J BPLR,SUP-2138112,CDM,C1882,HCPCS,0275,RC,,,,both,,,84962.12,55225.38,,,,,,,,,,,,,
SCREW BONE LOCKING 2.9X12 MM MANDIBULAR SELFTAPPING 20/PK TI,SUP-2842345,CDM,C1713,HCPCS,0278,RC,,,,both,,,591.26,384.32,,,,,,,,,,,,,
SCREW SPNL THN 7.5X55 MM TSRH 3DX OSTEOGRIP,SUP-2279941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SYSTEM FIX 30 ABSRB FAST OPTIFIX,SUP-2125764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM STR TW HELIX,SUP-2525453,CDM,C1768,CPT,0278,RC,,,,both,,,1340.37,871.24,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL MED TI RIVAL VW,SUP-2645185,CDM,C1713,HCPCS,0278,RC,,,,both,,,5457.32,3547.26,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX8 MM INDWL ESOPH FLANGE BLOM-SINGER,SUP-2242399,CDM,L8509,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PASSER SUT STR FIRSTPASS MINI,SUP-2349225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.95,600.57,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 TI LCK SCREW 95MM S-T,SUP-2819242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1245.73,809.72,,,,,,,,,,,,,
BOOT ORTHOT L VASC CLASS ROOKE,SUP-2319144,CDM,L4386,HCPCS,0272,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
PLATE BONE W5XL32MM THK1MM 6 H BILAT TI STR RIG NEUT DYN,SUP-2191043,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.52,559.34,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0250,RC,00264-1800-32,NDC,,both,250,ML,57.40,37.31,,,,,,,,,,,,,
SCREW BNE L 18 MM DIA 3 MM HD,SUP-2909472,CDM,C1713,HCPCS,0278,RC,,,,both,,,991.86,644.71,,,,,,,,,,,,,
PUMP INFUSION PAIN SINGLE AUTO,SUP-2361461,CDM,C2626,HCPCS,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
BUTTON FIX DIA17MM SUT ACL PCL FOR GRFT DELRIN,SUP-2341304,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.15,147.65,,,,,,,,,,,,,
PLATE BONE 6 H STRL MANUBRIUM STRNL TI STAR SHP LCK FOR 3MM,SUP-2192438,CDM,C1713,HCPCS,0278,RC,,,,both,,,3182.70,2068.75,,,,,,,,,,,,,
SYRINGE IRRIGATION CONE TIP 150 CC FIX,SUP-2747413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1571.82,1021.68,,,,,,,,,,,,,
NAIL IM L320MM DIA11MM 125DEG L LNG FOR HIP FRAC SYS,SUP-2316363,CDM,C1713,HCPCS,0278,RC,,,,both,,,5370.62,3490.90,,,,,,,,,,,,,
KIT INSRTN CATH OD8FR 25ML FIDELITY,SUP-2227322,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 80 CM BALLOON L 60 MM DIA 7,SUP-2141871,CDM,C1725,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BIT DRL 5X24 MM NCB,SUP-2862214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.13,2245.18,,,,,,,,,,,,,
SCREW SPNL L34MM OD4MM ANTR CERV CANN CANC LAG TI UCSS,SUP-2417481,CDM,C1713,HCPCS,0278,RC,,,,both,,,3777.42,2455.32,,,,,,,,,,,,,
SEGMENTAL TM COLLAR FOR 9-16MM 25MM,SUP-2502454,CDM,C1776,CPT,0278,RC,,,,both,,,6231.33,4050.36,,,,,,,,,,,,,
WIRE SMOOTH 0.62X9IN K,SUP-2303780,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.84,11.60,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 5.0CM X 5.0CM,SUP-2874120,CDM,A2007,HCPCS,0636,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
COLLAR CERV 4IN 24IN M XLN M DENS AD CNTOUR HK AND LOOP CLSR,SUP-2194441,CDM,L0120,HCPCS,0272,RC,,,,both,,,11.05,7.18,,,,,,,,,,,,,
PEG BNE FIX L16MM DIA2.5MM DST VOLAR CORT RAD CO CHROM,SUP-2411662,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.90,263.18,,,,,,,,,,,,,
PLATE BNE W17.5XL336MM THK5.2MM 18 H NONSTERILE BILAT S STL,SUP-2185318,CDM,C1713,HCPCS,0278,RC,,,,both,,,2956.97,1922.03,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 40 CM DIA 8 MM EPTFE CARBON FLX,SUP-2761448,CDM,C1768,CPT,0278,RC,,,,both,,,1977.73,1285.52,,,,,,,,,,,,,
BIT DRL OD90MM TIB CANN TOGGLELOC,SUP-2212946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH WORLEY L 90 CM DIA 9 FR,SUP-2138007,CDM,C1892,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
CATHETER DRNGE L25CM DIA10.2FR 0.038IN 3 H CRV UTHANE,SUP-2168614,CDM,C1729,HCPCS,0272,RC,,,,both,,,186.58,121.28,,,,,,,,,,,,,
MESH HERN 5X10CM POLYPR W/ POLYDIOXANONE PROCEED RECT TISS,SUP-2219759,CDM,C1781,HCPCS,0278,RC,,,,both,,,875.21,568.89,,,,,,,,,,,,,
CABLE ORTH 2X900 MM ASMBLY 2 LEADER STRL,SUP-2563690,CDM,C1713,HCPCS,0278,RC,,,,both,,,1474.07,958.15,,,,,,,,,,,,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,2500000003,HCPCS,0250,RC,00143-9391-01,NDC,,both,1,UN,352.20,228.93,,,,,,,,,,,,,
PATCH CV 5X75CMX08MM,SUP-2395309,CDM,C1768,CPT,0278,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
PERC INSRT KT FOR 3.0 MM KNOTLESS ST,SUP-2121613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
ADAPTER DRL BIT CIR FOR VERTEX MAX,SUP-2286731,CDM,C1713,HCPCS,0278,RC,,,,both,,,2321.43,1508.93,,,,,,,,,,,,,
GRAFT BONE SUB 30ML CORTICOCANCELLOUS FRZN,SUP-2165566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SPACER SPNL 16-22MM COR DIA16MM TI FOR SELF EXP VBR SYS,SUP-2311131,CDM,C1821,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
STENT PERIPH L2.5CM DIA5MM CATH 6FR L120CM BAL DIA5MM,SUP-2396626,CDM,C1874,HCPCS,0278,RC,,,,both,,,9482.80,6163.82,,,,,,,,,,,,,
EXPANDER BRST 450CC W12.7XH10.8CM P7CM M HT CNTOUR PROF W/,SUP-2300696,CDM,C1789,HCPCS,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
HC Cta Abdominal Aorta W Runoffs,PX-3527563500,CDM,75635,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
BLADE ARTHSCP OD4.5MM AGG + CUT ANG FRMLA,SUP-2361325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
TAP SURG DIA45MM THOR LUM S STL FOR SPNL DEFORMITY CDH LEG,SUP-2290726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1247.15,810.65,,,,,,,,,,,,,
KIT SUTURING DEVICE M-CLOSE,SUP-2707531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.57,183.67,,,,,,,,,,,,,
SCREW BNE ST STD 7X40 MM CANC CANN NLCK HEX HD SS,SUP-2183954,CDM,C1713,HCPCS,0278,RC,,,,both,,,826.07,536.95,,,,,,,,,,,,,
SYSTEM SPNL CEMENT FOR VERTEBROPLASTY STRL DISP HI V,SUP-2883108,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PROSTHESIS INCUS STAP HA 0.76MM DIA 10MM LEN GROTE,SUP-2313673,CDM,L8613,CPT,0278,RC,,,,both,,,944.79,614.11,,,,,,,,,,,,,
CATHETER ETER EP DIAG MAP L CRV QPLR 2 5 2MM SPC 5MM TIP BI DIR,SUP-2356987,CDM,C1733,HCPCS,0272,RC,,,,both,,,2188.58,1422.58,,,,,,,,,,,,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN (MIXTURES ONLY),RX-430067,CDM,J2597,HCPCS,0636,RC,55566-2200-00,NDC,,both,0.25,ML,116.70,75.85,,,,,,,,,,,,,
RASP SURG GLEN HANDHELD SGL END COARSE CRSS CUT ANG TAPR,SUP-2120944,CDM,C1776,CPT,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
GRAFT HUM TISS L 1 X W 1 CM AMNION PLCNTA MEMBRN 2 LAYR,SUP-2913216,CDM,C1762,CPT,0278,RC,,,,both,,,2895.08,1881.80,,,,,,,,,,,,,
MESH SURG DIA1.7 IN SM POLY-4-HYDROXYBUTYRATE POLYGLY ACD,SUP-2937423,CDM,C1781,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
TUBE SURG NOSE 13 CM CRV MIS NS LTX,SUP-2859727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5216.64,3390.82,,,,,,,,,,,,,
CAGE SPNL W8XL36MM PEEK MECH CAPSTONE,SUP-2293986,CDM,C1889,HCPCS,0278,RC,,,,both,,,17298.26,11243.87,,,,,,,,,,,,,
HEAD HUM DIA45MM THK21MM SHLDR CO CHROM PRI STD OFFSET NK 53504521] STRYKER ORTHOPEDICS HOWM],SUP-2372838,CDM,C1776,CPT,0278,RC,,,,both,,,4467.91,2904.14,,,,,,,,,,,,,
WASHER ORTH DIA20 MM SPIK STRL TRIGEN MAX,SUP-2932749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
ROD EXT FIX CARBON FIBER,SUP-2362751,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
GRAFT VASC BIFUR 16X8 MMX50 CM WOVEN POLYESTER INTERGARD,SUP-2246476,CDM,C1768,CPT,0278,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
SYSTEM  EUSTACHIAN TUBE DILATION,SUP-2749727,CDM,C1726,HCPCS,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
PIN EXT FIX L 50 MM DIA 5 MM SHRT TIN HALF STRL DISP JET-X,SUP-2933162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,714.38,464.35,,,,,,,,,,,,,
DILATOR RENAL AMPLATZ TYP 20 FR X 35CM,SUP-2139233,CDM,C1726,HCPCS,0272,RC,,,,both,,,145.98,94.89,,,,,,,,,,,,,
TIBIAL NAIL INSTRUMENTS,SUP-2811209,CDM,C1713,HCPCS,0278,RC,,,,both,,,104860.30,68159.19,,,,,,,,,,,,,
SCREW BONE L14MM DIA2MM HND VAR ANG LCK FLOWERCUBE,SUP-2225442,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.07,273.70,,,,,,,,,,,,,
PLATE BONE TITANIUMXSHAPED ULT LO PROF MATRIXNEURO,SUP-2181543,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.61,542.50,,,,,,,,,,,,,
GRAFT HUM TISS DIA19MM THK20MM MT RESTORING DISC,SUP-2321678,CDM,C1776,CPT,0278,RC,,,,both,,,10142.20,6592.43,,,,,,,,,,,,,
DISC INTERVERTEBRAL ARTIFICIAL LG 6 MM CERV SIMPLIFY,SUP-2751696,CDM,C1713,HCPCS,0278,RC,,,,both,,,15662.32,10180.51,,,,,,,,,,,,,
GRAFT HUM TISS W5XL12CM THCK ALLDERM,SUP-2113078,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5793.30,3765.64,,,,,,,,,,,,,
HC Thromb Mech W/Oth Interv,PX-3613718600,CDM,37186,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE 4X8CM,SUP-2307620,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4860.72,3159.47,,,,,,,,,,,,,
ASCENT DST AUG MED 16MM LM/RL,SUP-2408818,CDM,C1776,CPT,0278,RC,,,,both,,,2568.52,1669.54,,,,,,,,,,,,,
HC So T Helper Cell Cd4,PX-3028636166,CDM,86361,CPT,0302,RC,,,,both,,,165.00,107.25,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 8.5 FRX25 CM BILI SET 6 HOLE UTHANE,SUP-2168130,CDM,C1729,HCPCS,0272,RC,,,,both,,,272.33,177.01,,,,,,,,,,,,,
GUIDEPIN ORTH L248MM DIA3.2MM TIP THRD TRIGEN,SUP-2348122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.27,746.38,,,,,,,,,,,,,
COMPONENT FEM SZ B L KNEE SEG,SUP-2200498,CDM,C1776,CPT,0278,RC,,,,both,,,22480.83,14612.54,,,,,,,,,,,,,
STABILIT MX FRACTURE KIT LNG,SUP-2702136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9061.26,5889.82,,,,,,,,,,,,,
GRAFT TIB SHFT FRZ DRY ALLGRFT,SUP-2165589,CDM,C1762,CPT,0278,RC,,,,both,,,1890.28,1228.68,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 25 MM EXPANSION DIA10-12 MM SHTH 8,SUP-2159233,CDM,C1877,HCPCS,0278,RC,,,,both,,,3749.16,2436.95,,,,,,,,,,,,,
GRAFT HUM TISS W30MMXL15CM FASC LATA FRZ DRY,SUP-2307099,CDM,C1762,CPT,0278,RC,,,,both,,,946.14,614.99,,,,,,,,,,,,,
CEFUROXIME 1.5 G IV SOLN (MIXTURES ONLY),RX-430023,CDM,J0697,HCPCS,0636,RC,00143-9567-25,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PLATE BONE L250MM 25 H HUM LNG DSTL POST LAT LCK RT,SUP-2136233,CDM,C1713,HCPCS,0278,RC,,,,both,,,7609.32,4946.06,,,,,,,,,,,,,
COLLAR CERV 2.5X22 IN,SUP-2194374,CDM,L0120,HCPCS,0272,RC,,,,both,,,11.34,7.37,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 18X1.5X0.6 MM W/ DRN HOLE FLAT TI NS,SUP-2481193,CDM,C1713,HCPCS,0278,RC,,,,both,,,783.05,508.98,,,,,,,,,,,,,
PLATE BNE SM R CALCNL LOK,SUP-2413700,CDM,C1713,HCPCS,0278,RC,,,,both,,,2248.87,1461.77,,,,,,,,,,,,,
GUIDEWIRE 1.35MM,SUP-2423331,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
PLATE BNE L59.5MM 12 H L DST RAD VOLAR S STL LOK COMPR CLMN,SUP-2184082,CDM,C1713,HCPCS,0278,RC,,,,both,,,2418.27,1571.88,,,,,,,,,,,,,
BIT DRL 3.5 MM,SUP-2319111,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
BUR SHV L19CM DIA5MM 8 FLUT HIP LEN RND COOLCUT,SUP-2121983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
EXTRACTION KIT BNE MAR 3.5S AUTOCELL CELLXTRACT,SUP-2420671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2621.62,1704.05,,,,,,,,,,,,,
DRILL SURG STEM 18 MM FEM REV NXGN LCCK CRA,SUP-2438212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
HC So1 H.Pylori. Serum,PX-3028667767,CDM,86677,CPT,0302,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,0636,RC,00641-6044-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
NEEDLE BX INTRO DISP 18GA 12CM,SUP-2139372,CDM,C1894,HCPCS,0272,RC,,,,both,,,104.28,67.78,,,,,,,,,,,,,
SYSTEM PACEMKR MICRA AV L 105 CM DIA23 FR DSTL SHFT L 5.8 CM,SUP-2516497,CDM,C1786,HCPCS,0275,RC,,,,both,,,76302.00,49596.30,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4X38 MM OCCIPITOCERVICAL UPPER THOR,SUP-2632001,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
SUTURE ORTHOCORD SZ 2-0 VLT BLU MO-7 NDL MULTIPAK 223114,SUP-2249457,CDM,C1713,HCPCS,0278,RC,,,,both,,,245.17,159.36,,,,,,,,,,,,,
CATHETER SET CECOSTOMY 10.2 FRX20 CM 0.6 CM CHAIT NDL CANN,SUP-2168770,CDM,C1729,HCPCS,0272,RC,,,,both,,,1225.42,796.52,,,,,,,,,,,,,
HC So1 Drg Scrn Class List A,PX-3018030767,CDM,80307,CPT,0301,RC,,,,both,,,147.00,95.55,,,,,,,,,,,,,
SHEAR HARMONIC VES SEAL 360 DEG SHFT L 45 MM DIA 5 MM JAW L,SUP-2889527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1514.23,984.25,,,,,,,,,,,,,
BAND SURG DISECT CALIB TUBE GI TRACT REALIZE,SUP-2219870,CDM,C1713,HCPCS,0278,RC,,,,both,,,10261.49,6669.97,,,,,,,,,,,,,
CATHETER GUID CS-EH STR RT 2.21X2.7 MMX63 CM EASYTRAK,SUP-2149015,CDM,C1887,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
BRACE KNEE RT L ORTHOPRO HYPEREX,SUP-2324014,CDM,L1810,HCPCS,0272,RC,,,,both,,,277.04,180.08,,,,,,,,,,,,,
BIT DRL L305MM DIA4MM TIB REUSE RUSS TAY,SUP-2342369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.64,219.47,,,,,,,,,,,,,
TUBE TYMPANOSTOMY VENT,SUP-2312869,CDM,L8699,HCPCS,0278,RC,,,,both,,,142.56,92.66,,,,,,,,,,,,,
PLATE BNE W5XL22MM THK1MM 4 H BILAT TI STR RIG NEUT DYN,SUP-2191041,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.48,541.76,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2.5 MM RECON PT SPEC,SUP-2860103,CDM,C1713,HCPCS,0278,RC,,,,both,,,29866.42,19413.17,,,,,,,,,,,,,
FORCEP SURG RANEY SCALP CLP,SUP-2863555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1270.82,826.03,,,,,,,,,,,,,
PLATE BNE L172MM 8 H L ANTEROMEDIAL DST TIB S STL VAR ANG,SUP-2177661,CDM,C1713,HCPCS,0278,RC,,,,both,,,5625.59,3656.63,,,,,,,,,,,,,
HC So Plasminogen Activator,PX-3058541566,CDM,85415,CPT,0305,RC,,,,outpatient,,,544.00,353.60,,,,,,,,,,,,,
CATHETER OCCL BLLN L11MM DIA4MM DST TIP L5MM EXTRA,SUP-2305410,CDM,C2628,HCPCS,0272,RC,,,,both,,,5524.83,3591.14,,,,,,,,,,,,,
PIN BNE FIX L16MM DIA15MM PLA BIORESORBABLE NONCOLLAGENOUS,SUP-2166732,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.43,386.38,,,,,,,,,,,,,
UNIT COMPR DISTR CLICKER STD EXT TO 4CM,SUP-2316061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1429.01,928.86,,,,,,,,,,,,,
MASK CPAP SM NSL 2 FLAP CUSH CMFRT FULL 2 W/ PREM HDGEAR,SUP-2326709,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
COMPONENT FEM DIA3.5MM HIP CKPT RESTORIS MCK,SUP-2368441,CDM,C1776,CPT,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY II DR W 44 X H 52 MM THK 7 MM 28.7,SUP-2148605,CDM,C1785,HCPCS,0275,RC,,,,both,,,16312.30,10602.99,,,,,,,,,,,,,
DEVICE DRNGE CLR TUTOPLAST 1/3 CORNEA SCLER,SUP-2247190,CDM,V2785,HCPCS,0810,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
STENT BILI ZILVER 635 L 12 CM DIA 8 MM INTRO L 200 CM DIA 6,SUP-2169477,CDM,C1876,HCPCS,0278,RC,,,,both,,,5331.72,3465.62,,,,,,,,,,,,,
CATHETER VENTRICULAR F 9 CM SNAP SHUNT ENDOVENT INNERVISION,SUP-2628505,CDM,C1729,HCPCS,0272,RC,,,,both,,,639.15,415.45,,,,,,,,,,,,,
ALLOGRAFT BNE FD ASEP RIB CART,SUP-2867025,CDM,C1762,CPT,0278,RC,,,,both,,,1494.48,971.41,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL SLNG,SUP-2435681,CDM,L2580,HCPCS,0272,RC,,,,both,,,1228.62,798.60,,,,,,,,,,,,,
SCREW BNE L80MM DIA15.8MM LAG FREE LOK L THRD,SUP-2197713,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
PIN EXT FIX L60MM OD20MM RX FIX MINIRAIL,SUP-2396845,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
HC Thromb Mech 1st Vssl,PX-3613718400,CDM,37184,CPT,0361,RC,,,,inpatient,,,10740.00,6981.00,,,,,,,,,,,,,
PLATE CRAN XL PEEK NS DISP ACCUSHAPE,SUP-2936894,CDM,C1713,HCPCS,0278,RC,,,,both,,,30772.00,20001.80,,,,,,,,,,,,,
PLATE BNE OSTEOTMY 5 MM MEDL 2 HOLE WEDGED MAXLOCK EXTRM,SUP-2388614,CDM,C1713,HCPCS,0278,RC,,,,both,,,3354.15,2180.20,,,,,,,,,,,,,
CANNULATED DRL 7X185MM,SUP-2417662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1982.22,1288.44,,,,,,,,,,,,,
PIN DISTRACTOR L14MM FOR SECURE-C CERV ARTIFICIAL,SUP-2232197,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
ROD CONIC EXTR M 13 MM UNIV NAIL EXTR DEV,SUP-2361785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
FRAG LOC COMPRESSION SCREW LNG,SUP-2639435,CDM,C1776,CPT,0278,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
HC Heinz Bodies Direct,PX-3058544100,CDM,85441,CPT,0305,RC,,,,both,,,328.00,213.20,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB III ROSEN STRL REUSE HI-LINE,SUP-2928960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.64,274.07,,,,,,,,,,,,,
ELECTRODE ENDO 24FR MPLR LOOP ELECTRD REUSE CUT STR,SUP-2361450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,306.90,199.48,,,,,,,,,,,,,
GRAFT BONE PRO DENS 2CC,SUP-2399145,CDM,C1713,HCPCS,0278,RC,,,,both,,,2284.73,1485.07,,,,,,,,,,,,,
CATHETER INFUSION 2.8 FRX130 CM 16 FR STR DIREXION HIFLO,SUP-2139702,CDM,C1887,HCPCS,0272,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1385108D3,SUP-2632822,CDM,C1751,HCPCS,0278,RC,,,,both,,,1131.81,735.68,,,,,,,,,,,,,
HC 2d Echo Without Contrast - With Dop/Color Flow,PX-4839330601,CDM,93306,CPT,0483,RC,,,,both,,,3365.00,2187.25,,,,,,,,,,,,,
BLADE SHAVER 4.2 MM PREBENT ULTRACUT,SUP-2765853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.25,340.76,,,,,,,,,,,,,
GRASPER ARTHSCP SHFT L15CM 15DEG GRY SUT MGMT IDEAL,SUP-2256808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT FEM DSTL TRAD LT,SUP-2294159,CDM,C1713,HCPCS,0278,RC,,,,both,,,10597.50,6888.37,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY 26MM 30.7MM 24.9MM 325SQMM FLX2,SUP-2214157,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
HC Chest Tube Insertion,PX-7613255100,CDM,32551,CPT,0761,RC,,,,inpatient,,,4942.00,3212.30,,,,,,,,,,,,,
CANNULA ARTHSCP L2CM DIA8MM PASSPRT BTTN,SUP-2122040,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
FEEDING TUBE KIT LP 20 FRX2.5 CM BLLN BUTTON,SUP-2754599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,638.42,414.97,,,,,,,,,,,,,
K WIRE FIX L105MM DIA1.1MM CO CHROM,SUP-2136627,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.18,37.17,,,,,,,,,,,,,
RADICAL PIN PLT,SUP-2389685,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SPACER KNEE PART KNEE ALIGN TWR PERSONA,SUP-2448188,CDM,C1776,CPT,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
MORETZ VENT TUBE WTAB 1.27MM ID BLUE TITANIUM 10 PACK,SUP-2695100,CDM,L8699,HCPCS,0278,RC,,,,both,,,66.57,43.27,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CERM ON CERM CHIPSNEPHCERCER] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351335,CDM,C1776,CPT,0278,RC,,,,both,,,20052.04,13033.83,,,,,,,,,,,,,
SCREW ACET LP UNIV 6.5X70 MM HIP DOMED 2 MOBILITY STRL G7,SUP-2403208,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
STENT PERIPH PALMAZ GEN L 15 MM DIA 4 MM CATH L 80 CM,SUP-2159105,CDM,C1877,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.3X200 MM SS,SUP-2646005,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.16,55.35,,,,,,,,,,,,,
HC Biopsy-Pleura Needle,PX-3613240000,CDM,32400,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
IDENTIFIER BX SITE 12GA ATEC TRIMARK3612] SUROS SURGICAL SYSTEMS],SUP-2382014,CDM,A4648,CPT,0278,RC,,,,both,,,243.66,158.38,,,,,,,,,,,,,
ALLOGRAFT BNE 200X25 MM FRZN LT DSTL FEM CONDYLE SHFT,SUP-2866854,CDM,C1762,CPT,0278,RC,,,,both,,,11649.40,7572.11,,,,,,,,,,,,,
CURETTE KYPHOPLASTY SZ 3 DIA8MM T TIP FOR VERTPLSTY EXPR,SUP-2293446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,532.70,346.25,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 15 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120666,CDM,C1768,CPT,0278,RC,,,,both,,,6433.86,4182.01,,,,,,,,,,,,,
SCREW BNE BLNT PT 6X250 MM 40 MM THRD SCHNZ TI STRL,SUP-2789434,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.39,334.35,,,,,,,,,,,,,
CATHETER CV KT 9 FRX11.5 CM DL FOR 7.5-8 FR INTRO NDL MAC,SUP-2763354,CDM,C1751,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PATELLA AUG 19MM M CONTINUUM KNEE SYS,SUP-2200593,CDM,C1776,CPT,0278,RC,,,,both,,,8779.44,5706.64,,,,,,,,,,,,,
SCREW COMPR REPL LAPIDUS INCORE,SUP-2473658,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.83,79.19,,,,,,,,,,,,,
PLATE BNE L 332 MM SCREW DIA 4.5 MM 20 H BOW COMPR LCK NS,SUP-2933182,CDM,C1713,HCPCS,0278,RC,,,,both,,,5431.42,3530.42,,,,,,,,,,,,,
MATRIX DERM BOV TISS FEN PRIMTRX 6CM X 6CM,SUP-2366725,CDM,C9359,HCPCS,0278,RC,,,,both,,,5831.29,3790.34,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 110 CM 7FR DUODECAPOLAR,SUP-2538101,CDM,C1731,HCPCS,0278,RC,,,,both,,,1617.73,1051.52,,,,,,,,,,,,,
HYDROCOD POLI-CHLORPHE POLI ER 10-8 MG/5ML PO SUER,RX-161224,CDM,340b,HCPCS,0637,RC,09999-9900-35,NDC,,both,5,ML,11.30,7.34,,,,,,,,,,,,,
PLATE SPNL POST 10 MM COR,SUP-2430746,CDM,C1713,HCPCS,0278,RC,,,,both,,,16915.18,10994.87,,,,,,,,,,,,,
SCREW BNE T6 DRV 2X20 MM VARIAX,SUP-2435328,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.63,264.31,,,,,,,,,,,,,
ELECTRODE NDL CANN L15CM ARRY DIA5CM FOR OPN AND PERC RF,SUP-2149340,CDM,C1713,HCPCS,0278,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
GRAFT VASC GORTX L 100 CM DIA 6 MM RNG L 50 CM EPTFE STR TW,SUP-2396160,CDM,C1768,CPT,0278,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COBALT XT HF MRI SURESCAN W 51 X H 71 MM,SUP-2601069,CDM,C1882,HCPCS,0275,RC,,,,both,,,43646.00,28369.90,,,,,,,,,,,,,
PIN FIX L20MM OD1.5MM LACTOSORB COPOLYMER ABSRB SGL USE,SUP-2212967,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PUSHER ENDOSCP KNOT 5 MMX45 CM,SUP-2171745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.18,620.22,,,,,,,,,,,,,
NEEDLE MRK L30CM OD17GA STD SFT TISS STRL,SUP-2164650,CDM,A4648,CPT,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
SCREW BNE L36MM DIA3.5MM EL TI LOK MULTDIR FOR ALPS FRAC,SUP-2413772,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
COUNTERSINK SURG OD3.5MM HDLSS DISP MONSTER,SUP-2320971,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
COMPONENT HUM STD LNG STEM DST STR L SOLAR,SUP-2372325,CDM,C1776,CPT,0278,RC,,,,both,,,23410.58,15216.88,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH XP L 100 CM DIA 5 FR 1.22 MM ANGLED,SUP-2385165,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.52,112.79,,,,,,,,,,,,,
SCREW BONE L65MM DIA5MM PARTIALLY THRD OSTEOPENIA PERI-LOC,SUP-2348507,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.48,409.81,,,,,,,,,,,,,
COMPONENT GLEN OD23MM SZ 1 REG POLYETH SHLDR CEM PEGGED ULT,SUP-2351227,CDM,C1776,CPT,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 1-4 MM 90 CC FD IRRADIATED CANC,SUP-2866922,CDM,C1762,CPT,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
PLATE BNE W19XL30MM 10 H RAD HD EL SYS BTTRS FOR 2MM SCR,SUP-2267953,CDM,C1713,HCPCS,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
GRAFT SKIN AUTOGRFT EPICEL,SUP-2227096,CDM,2780000010,LOCAL,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 40 X W 15 X H 3 MM MED DBM STRP SPNG,SUP-2904100,CDM,C1713,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
PLATE BNE L349MM 14 H ST PROX FEM S STL HK LO PROF LOK,SUP-2186065,CDM,C1713,HCPCS,0278,RC,,,,both,,,5558.77,3613.20,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 60 CM DIA 3 FR BALLOON DIA 3 MM SIL,SUP-2168563,CDM,C1725,HCPCS,0272,RC,,,,both,,,640.37,416.24,,,,,,,,,,,,,
LIDO-RACEPINEPHRINE-TETRACAINE 4-0.05-0.5 % EX GEL,RX-165078,CDM,6370000000,HCPCS,0637,RC,70092-1135-44,NDC,,both,3,ML,54.70,35.55,,,,,,,,,,,,,
IMPLANT TOE HEMIPROSTHESIS CANN NO 3 19 X 17MM COCR,SUP-2392720,CDM,L8630,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
FRACTURE KIT FULL LNG 10 ML W/ PWR CRV STABILIT MX,SUP-2484122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9548.58,6206.58,,,,,,,,,,,,,
ARROWGARD BLUE PSI KIT CATH GARD 7.5-8 FR CATH 8.5FRX10CM,SUP-2660676,CDM,C1894,HCPCS,0272,RC,,,,both,,,385.84,250.80,,,,,,,,,,,,,
HC X-Ray Exam Chest 4+ Views,PX-3247104800,CDM,71048,CPT,0324,RC,,,,both,,,1066.00,692.90,,,,,,,,,,,,,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,0636,RC,70436-0089-55,NDC,,both,1,UN,253.00,164.45,,,,,,,,,,,,,
SYSTEM THROMCTMY POUNCE LP L 150 CM DIA 7 FR GUIDEWIRE 0.018,SUP-2913917,CDM,C1757,HCPCS,0272,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
CABLE NAVIGATION TRUDI,SUP-2418308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
ANCHOR SUT L14.7MM DIA5.5MM BIOCOMPOSITE FULL THRD W/ 2,SUP-2121547,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
KIT STRT 1000ML PT DISCHRG BTL DSG GZ PD BLU WRAPPING INFO,SUP-2133737,CDM,C1729,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SET BNE BX NDL W DMND TIP INTRO REDUC TRAUM MULT SPEC COLL,SUP-2168280,CDM,C1713,HCPCS,0278,RC,,,,both,,,970.07,630.55,,,,,,,,,,,,,
CATHETER HD STR 9 FRX20 CM CATH INTRO NDL DUOFLO,SUP-2627102,CDM,C1752,HCPCS,0278,RC,,,,both,,,6.75,4.39,,,,,,,,,,,,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSY,RX-173406,CDM,J3376,HCPCS,0636,RC,58160-0826-52,NDC,,both,1,ML,387.70,252.00,,,,,,,,,,,,,
CLINIMIX/DEXTROSE (5/15) 5 % IV SOLN,RX-25752,CDM,2500000003,HCPCS,0250,RC,00338-1099-04,NDC,,both,2000,ML,460.00,299.00,,,,,,,,,,,,,
INFINITY POLY SZ 5 6MM TOTAL ANKLE,SUP-2827698,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
PLATE BNE RECON 3.5X214 MM 18 HOLE SS,SUP-2569092,CDM,C1713,HCPCS,0278,RC,,,,both,,,557.82,362.58,,,,,,,,,,,,,
ALLOGRAFT BNE SYRINGE LG 8 CC DBM FIBER OSTEOSTRAND PLUS,SUP-2731819,CDM,C1713,HCPCS,0278,RC,,,,both,,,13282.20,8633.43,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 260 MM DIA15 MM DEL SHTH,SUP-2934499,CDM,C1713,HCPCS,0278,RC,,,,both,,,19350.72,12577.97,,,,,,,,,,,,,
SET SCR SPNL L225MM DIA14MM ANTR PEDCL S STL BRK OFF FOR 2,SUP-2279972,CDM,C1713,HCPCS,0278,RC,,,,both,,,223.73,145.42,,,,,,,,,,,,,
SEALER VES BPLR FOR DA VINCI XI ENDOWRIST,SUP-2246797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
SET SCR SPNL DIA5.5MM IL TI HEX BRK OFF CDH SOLERA,SUP-2287852,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 190 CM DIA 0.014 IN SS SIL STR LNG,SUP-2148333,CDM,C1769,HCPCS,0272,RC,,,,both,,,332.75,216.29,,,,,,,,,,,,,
PROSTHESES BTTN SEPT OD.06MM 20FR OESOPHAGUS TRACH LARYN,SUP-2242394,CDM,L8509,HCPCS,0274,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
SCREW BNE ST 2X22 MM CRTX FT W/ FLUT TIP TI NS,SUP-2189377,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.05,134.58,,,,,,,,,,,,,
JOINT TOE CANN SCR 6.5 MM PLANAR W/ BLADE PRO-TOE VO,SUP-2486951,CDM,C1776,CPT,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
PLATE TOT WR FUS STD LT,SUP-2107017,CDM,C1713,HCPCS,0278,RC,,,,both,,,5859.24,3808.51,,,,,,,,,,,,,
HC Path Consltj Surg 1st Blk Frozen Sctj 1st Spec,PX-3128833100,CDM,88331,CPT,0312,RC,,,,both,,,330.00,214.50,,,,,,,,,,,,,
BLADE SAW L 13X70MM LAT MALL PROTECTED W/ RBBN RETRCT SALTO,SUP-2388889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CATHETER CV SET 032 REG 8 FRX20 CM 12 GA DL J TIP SPECTRUM,SUP-2759724,CDM,C1751,HCPCS,0278,RC,,,,both,,,439.88,285.92,,,,,,,,,,,,,
SYSTEM INFUS MATCHING OCCL WIRE CK RELF VLV PASS HEMSTAS VLV,SUP-2302564,CDM,C1751,HCPCS,0278,RC,,,,both,,,379.63,246.76,,,,,,,,,,,,,
COMPONENT FEM SM UNIV POST KNEE CO CHROM NP MOD CEM MONO,SUP-2364838,CDM,C1776,CPT,0278,RC,,,,both,,,5080.27,3302.18,,,,,,,,,,,,,
SCREW BNE L34MM DIA5MM TIB TI DBL LD FOR PHOENIX NAIL SYS,SUP-2412120,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
MATRIX BIO L 2 X W 2 CM SZ 7 SQCM FISH SKIN DERMAL PREMESHED,SUP-2909222,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2835.42,1843.02,,,,,,,,,,,,,
COMPONENT 6X100MM HUMERAL ELBOW FLANGED C LEFT DISCOVERY,SUP-2879152,CDM,C1776,CPT,0278,RC,,,,both,,,15002.92,9751.90,,,,,,,,,,,,,
ANCHOR SUTURE PIN 4 MM SUTURE SZ 2 FIBERLINK STRL DISP,SUP-2882172,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
BRACE ORTH CUST FABRICATED RIGID W/O INTFACE LNR PLAS,SUP-2388142,CDM,L0482,HCPCS,0272,RC,,,,both,,,4080.59,2652.38,,,,,,,,,,,,,
PORT INFUS 8FR ATTCH GROSH CATHETER TI W SIL FILL SUT H AND,SUP-2126311,CDM,C1788,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
KIT INSTR DEL COR DCOMPR FOR IO BIOPLASTY,SUP-2120743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1624.95,1056.22,,,,,,,,,,,,,
PLATE BNE LAT ANT PLT L ANK FUS TIBIAXYS,SUP-2242997,CDM,C1713,HCPCS,0278,RC,,,,both,,,6001.33,3900.86,,,,,,,,,,,,,
PIN DRL QUIK HI PERF FOR SIG SYS,SUP-2253438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 60 CM DIA 6 MM EPTFE CARBON PERIPH STR,SUP-2126811,CDM,C1768,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PHENYLEPHRINE HCL 10 MG/ML SOLN (MIXTURES ONLY),RX-430013,CDM,J2371,HCPCS,0636,RC,00641-6142-25,NDC,,both,0.01,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT FEM L60MM INTLOK RT KNEE REV CEM POST STBL STEM,SUP-2405606,CDM,C1776,CPT,0278,RC,,,,both,,,14827.08,9637.60,,,,,,,,,,,,,
MICROFREE HIGH SPEED DRILL,SUP-2605742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,23480.29,15262.19,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 10X20X8 MM FD SPNG CANC READIGRAFT BLX,SUP-2740889,CDM,C1713,HCPCS,0278,RC,,,,both,,,2030.20,1319.63,,,,,,,,,,,,,
CATHETER IVUS VERISIGHT PRO DEFLECTION 120 DEG L 90 CM DIA 9,SUP-2904261,CDM,C1753,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
NAIL INTRMDLLRY L180MM D13MM 130DG LNG HIP TIMAX CNNLTD LOK,SUP-2460190,CDM,C1776,CPT,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
ELECTRODE MONOPOLAR COAG 24 FRX3 MM BALL,SUP-2360971,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
PLATE BNE H0.6MM 10X10 H UP FACE G TI 3D LEIBINGER UNIV 2,SUP-2366271,CDM,C1713,HCPCS,0278,RC,,,,both,,,3885.03,2525.27,,,,,,,,,,,,,
MESH SURG DIA12CM WHT POLY CLLGN FLM RND MFIL BIOABSRB,SUP-2283397,CDM,C1781,HCPCS,0278,RC,,,,both,,,1340.31,871.20,,,,,,,,,,,,,
NEXGEN STRAIGHT STEM EXT 15MM DIA X 200MM(155MM),SUP-2503202,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC US Dup Scn Aorta Ivc Ltd,PX-9219397900,CDM,93979,CPT,0921,RC,,,,inpatient,,,1888.00,1227.20,,,,,,,,,,,,,
HANDPIECE MORCELLATION L 21.5 CM DIA19 GA FOR AESCULAP,SUP-2930235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13672.60,8887.19,,,,,,,,,,,,,
TREPHINE SURG 55IN DIA17MM,SUP-2252781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1679.12,1091.43,,,,,,,,,,,,,
ELECTRODE ENDSCPC URLGY 24FR DIA 12DG CTTNG LOOP HF RSCTN LA,SUP-2730095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1011.02,657.16,,,,,,,,,,,,,
TROCH NAIL 10X15 BLUE,SUP-2818907,CDM,C1713,HCPCS,0278,RC,,,,both,,,8193.20,5325.58,,,,,,,,,,,,,
BRACE WALKING 14-17 IN XL CUSH LP NYL PROCARE MAXTRAX,SUP-2197143,CDM,L4360,HCPCS,0272,RC,,,,both,,,83.15,54.05,,,,,,,,,,,,,
PLATE BONE L56MM 4 H LT OLECRANON S STL LCK FOR 2.7/3.5MM,SUP-2348705,CDM,C1713,HCPCS,0278,RC,,,,both,,,11162.86,7255.86,,,,,,,,,,,,,
CLOBETASOL PROPIONATE 0.05 % EX GEL,RX-13203,CDM,6370000000,HCPCS,0637,RC,51672-1294-01,NDC,,both,15,GR,161.20,104.78,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM SHTH L L23MM TIB BIOCRYL RAPIDE,SUP-2249569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2885.66,1875.68,,,,,,,,,,,,,
PIN FIX L225MM DIA6MM S STL FOR L EXT FIX SET,SUP-2187000,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.90,228.08,,,,,,,,,,,,,
BUR SURG BALL 5 MM 10 CM FN FLUT SM BOR MIDAS REX 8 LEGEND,SUP-2664500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,363.99,236.59,,,,,,,,,,,,,
CATHETER VENTRICULAR 13X25 MMX15 CM STD STR BA IMPREG,SUP-2277969,CDM,C1729,HCPCS,0272,RC,,,,both,,,483.47,314.26,,,,,,,,,,,,,
TUBE VENT 1.27 MM 3 MM BAXTER BVL BOB TAPR FLROPLAS BLU,SUP-2477705,CDM,L8699,HCPCS,0278,RC,,,,both,,,31.53,20.49,,,,,,,,,,,,,
GUIDEWIRE ORTH J TIP 0.025 INX260 CMX3 MM FIX COR,SUP-2610679,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.74,45.33,,,,,,,,,,,,,
STAPLE INT BIOABSORBABLE REINF LN SUREFORM 60 GRN SEAMGRD,SUP-2650426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.34,340.17,,,,,,,,,,,,,
KIT GRAFTMAG GRAFT DELIVERY SYSTEM DISPOSABLE EX,SUP-2934650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
ROD IM DSTL CUT GUIDE MICROPLASTY ELITE,SUP-2446195,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
EXTERNAL FIXATION SET HYBRID LIGHTWEIGHT PVC FREE STRL,SUP-2646341,CDM,C1713,HCPCS,0278,RC,,,,both,,,9071.02,5896.16,,,,,,,,,,,,,
SCREW BNE COMPR 7X90 MM MULTI-USE,SUP-2399614,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
TI SPHERICAL WASHER LRG ROUND FOR 6.5/7.3MM CANN SCREW-STER,SUP-2549384,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.68,292.29,,,,,,,,,,,,,
CAGE SPNL L14MM W10MM H50MM TI INTBDY ANT THORLUM OVL,SUP-2291981,CDM,C1889,HCPCS,0278,RC,,,,both,,,17301.40,11245.91,,,,,,,,,,,,,
BAR SUPP ANK DISTRACTOR SYS,SUP-2340727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 40 CM DIA26 MM BRANCH SIDE L 15 CM,SUP-2894614,CDM,C1768,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
KIT SUTURE ANCHR L 20 MM DIA 4.75 MM DYN KNOTLESS PRELD PASS,SUP-2899199,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
DRESSING WND MULTLYR CLLGN MTRX 7X10 CM SHT MATRISTEM,SUP-2106526,CDM,Q4166,HCPCS,0636,RC,,,,both,,,3855.92,2506.35,,,,,,,,,,,,,
MATRIX BIO SZ 300 SQCM FISH SKIN DERMAL SLD INTACT STRL,SUP-2909288,CDM,Q4158,HCPCS,0636,RC,,,,both,,,27977.40,18185.31,,,,,,,,,,,,,
PLATE BONE L90MM THK3.5-4.5MM 4 H NONSTERILE LT MEDL TI DSTL,SUP-2190913,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.53,2704.34,,,,,,,,,,,,,
MATRIX PLCNTA FLOWABLE CYROPRESERVED CRYOMTRX 2.0CC,SUP-2340462,CDM,C1762,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
HC Perc Transhep Port W/Hemo Eval,PX-3207588500,CDM,75885,CPT,0320,RC,,,,outpatient,,,7130.00,4634.50,,,,,,,,,,,,,
GUIDEWIRE ORTH L300MM DIA2.5MM CO CHROM DRL TIP FOR LCP,SUP-2179013,CDM,C1769,HCPCS,0272,RC,,,,both,,,189.44,123.14,,,,,,,,,,,,,
NERVE STIMULATOR KIT IMPLANTABLE PULSE GENERATOR VERCISE PC,SUP-2836322,CDM,C1767,HCPCS,0278,RC,,,,both,,,56206.00,36533.90,,,,,,,,,,,,,
COIL EMB HNDL DETACH SMRT COIL,SUP-2323708,CDM,C1889,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
HC So Onc Pan-Tumor Dna&Rna Next-Generation Sequencing,PX-3100211066,CDM,0211U,CPT,0310,RC,,,,both,,,8878.00,5770.70,,,,,,,,,,,,,
INSERT TIB L59MM THK12MM UNIV KNEE PRI POST STBL NEUT ASCNT,SUP-2407029,CDM,C1776,CPT,0278,RC,,,,both,,,3234.20,2102.23,,,,,,,,,,,,,
MESH SURG 50X16 MM 1007703,SUP-2565359,CDM,C1781,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
RING EXT FIX DIA130MM FULL FOR TRUELOK RNG FIX SYS,SUP-2316168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2707.72,1760.02,,,,,,,,,,,,,
IMPLANT BIO TISS W18 25XL250MM THCK CLLGN DERM MTRX XENMTRX,SUP-2126244,CDM,C1781,HCPCS,0278,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
CRANIAL ACCESS KIT W/ NO DRUG 2 DRL BIT NO RAZOR,SUP-2852688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1308.19,850.32,,,,,,,,,,,,,
GRAFT BONE SUB 3CC CA PHOS INJ VOID FIL FOR SUBCHONDROPLASTY,SUP-2136563,CDM,C1713,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
TROCAR ENDOSCP DIA2/3 MM DIL RADIALLY EXPANDABLE SLV STRL,SUP-2896341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.24,262.76,,,,,,,,,,,,,
CATHETER INFUSION PMP 2 ML/HR 2.5 IN 275 CC,SUP-2365199,CDM,C2626,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
PLATE BONE L292MM 22 H LCK COMPR WAISTED FOR 4MM SCR,SUP-2371970,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.67,661.49,,,,,,,,,,,,,
WIRE FIX L9IN OD0.062IN TRCR PNT BOTH END,SUP-2303784,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.62,8.20,,,,,,,,,,,,,
TIP ASPIR L4.6IN L OD2.47MM ID1.92MM SFT TISS STR FOR,SUP-2363700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10738.42,6979.97,,,,,,,,,,,,,
NAIL IM CORTICAL 4X20 MM HUM STRL AFFIXUS NAT NAIL,SUP-2606859,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|CQ|XU,both,,,191.00,124.15,,,,,,,,,,,,,
LINER ACET OD48MM ID28MM +4MM OFFSET 10DEG HIP GVF POLYETH,SUP-2250247,CDM,C1776,CPT,0278,RC,,,,both,,,9693.81,6300.98,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING MINI 1.8X32 MM NON STERILE,SUP-2837996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
INSTRUMENT PACK PIN WIRE PAC D FOR MENIS REP SYS STRL LF,SUP-2877955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,827.55,537.91,,,,,,,,,,,,,
SYSTEM OCCL DEL L60CM CATHETER 160CM SHTH 4FR 90DEG CRV CBL,SUP-2357479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2524.31,1640.80,,,,,,,,,,,,,
HC US Breast Comp,PX-4027664100,CDM,76641,CPT,0402,RC,,,,inpatient,,,1082.00,703.30,,,,,,,,,,,,,
PLATE BNE L 257 MM SCREW DIA 4.5 MM 14 H NAR COMPR NLCK NS,SUP-2933676,CDM,C1713,HCPCS,0278,RC,,,,both,,,2689.10,1747.91,,,,,,,,,,,,,
PROBE BX 14 GAX138 MM W/ INTEGR COAX CANN VACORA,SUP-2759180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.93,386.05,,,,,,,,,,,,,
PACEMAKER CARD INTICA PROMRI DX TI HSNG EPOXY RESIN HEADER,SUP-2138470,CDM,C1722,HCPCS,0275,RC,,,,both,,,66725.00,43371.25,,,,,,,,,,,,,
TROCAR CANN FOR SINOSCOPY FEN BEAK LEN OF THE CANN 8.5CM O.D,SUP-2261352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,586.49,381.22,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X394 MM 22 HOLE TI NS LC-DCP,SUP-2568786,CDM,C1713,HCPCS,0278,RC,,,,both,,,3970.22,2580.64,,,,,,,,,,,,,
PLATE BONE L49MM THK1.6MM 6 H WR TI TRILOK SM FRAG FOR 2.5MM,SUP-2267969,CDM,C1713,HCPCS,0278,RC,,,,both,,,2534.33,1647.31,,,,,,,,,,,,,
SPACER SPNL W9XH7XL22MM TI CONVX LO PROF EXP 8 WAF,SUP-2354692,CDM,C1821,HCPCS,0278,RC,,,,both,,,19066.08,12392.95,,,,,,,,,,,,,
PLATE BNE MEDL LT ANTR TIBIAXYS,SUP-2609011,CDM,C1713,HCPCS,0278,RC,,,,both,,,4581.13,2977.73,,,,,,,,,,,,,
WEDGE TIB L SZ 2 THK10MM TI L KNEE PRI PRESSFIT FULL FLUT,SUP-2377102,CDM,C1776,CPT,0278,RC,,,,both,,,1943.72,1263.42,,,,,,,,,,,,,
PLATE BNE MISC BIN FRAG SYS NS F3 LTX,SUP-2861300,CDM,C1713,HCPCS,0278,RC,,,,both,,,1047.88,681.12,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH DIA 7 FR LNG HEMOSTATIC VLV SIDEPRT,SUP-2355556,CDM,C1894,HCPCS,0272,RC,,,,both,,,43.18,28.07,,,,,,,,,,,,,
COMPONENT FEM 10X35 MM KNEE W/ INSRTR APERFIX,SUP-2431667,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
NEEDLE EP003994S BRCKNBRGH AD,SUP-2282432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BONE MARROW ASPIRATION KIT CLOSED 8 GA CPRP ACD-A STRL LTX,SUP-2859799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3475.98,2259.39,,,,,,,,,,,,,
COMPONENT FEM KNEE POST STABILIZING LT UNISX PRI N POR CEM,SUP-2201894,CDM,C1776,CPT,0278,RC,,,,both,,,10289.78,6688.36,,,,,,,,,,,,,
KIT INFL SYR TBNG L13IN 20ML PRSS 30ATM BAR CLR POLYCARB,SUP-2257637,CDM,C1894,HCPCS,0272,RC,,,,both,,,163.22,106.09,,,,,,,,,,,,,
COMPONENT COMPR PED 0 62CM FOR LIMB RECON SYS DISTR UNIT EXT,SUP-2316144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1202.43,781.58,,,,,,,,,,,,,
SPACER KNEE 5MM SM-ML DSTL POST DURAC,SUP-2364866,CDM,C1776,CPT,0278,RC,,,,both,,,1896.09,1232.46,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L20MM IBT ADD FRAC KYPHON,SUP-2293663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
CATHETER ATHRCTMY WILDCAT L 110 CM OD 6 FR ID 0.038 JUICEBOX,SUP-2124797,CDM,C1769,HCPCS,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
SPLINT ANK STRRP AIR AND FOAM TRAINER,SUP-2276707,CDM,L4350,HCPCS,0272,RC,,,,both,,,40.47,26.31,,,,,,,,,,,,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,0636,RC,50242-0041-64,NDC,,both,1,UN,1064.80,692.12,,,,,,,,,,,,,
CONNECTOR SPNL 5.5MM OPN 5.5MM CLOSE 90DEG W ROD-ROD ASF,SUP-2311869,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
LOCK SCREW SQ DRIVE 2.7MM X 24MM STER,SUP-2587130,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX15 CM 51 IN SPIN-LOCK ACCEL,SUP-2659276,CDM,C1729,HCPCS,0272,RC,,,,both,,,136.72,88.87,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN PC THE FIRM L 260 CM 0.035IN 3CM ANGLED,SUP-2168416,CDM,C1769,HCPCS,0272,RC,,,,both,,,117.22,76.19,,,,,,,,,,,,,
HC Venous Sel Cath Plcmt 1st Ord,PX-3613601100,CDM,36011,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SPACER SPNL TRAPEZIUM LG 20X15X15 MM MTCRPL CMC,SUP-2120679,CDM,C1821,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,0636,RC,67457-0675-02,NDC,,both,0.5,ML,737.50,479.37,,,,,,,,,,,,,
SCREW SPNL L32MM DIA3.5MM MINI CANC POST OCCIPITAL CERV THOR,SUP-2254411,CDM,C1713,HCPCS,0278,RC,,,,both,,,3121.16,2028.75,,,,,,,,,,,,,
GUIDEWIRE UROLOGY STR 0.038 INX150 CM HYBRID MOTN,SUP-2835990,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.65,130.42,,,,,,,,,,,,,
PLATE BONE MESHED 1.5X100X100X0.25 MM CRANIOFACIAL ORBITAL C,SUP-2838565,CDM,C1713,HCPCS,0278,RC,,,,both,,,10948.24,7116.36,,,,,,,,,,,,,
TRAY ADPT FX SHLDR SYS,SUP-2223411,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
SYSTEM W/FLUSHING RESV 4/24,SUP-2821790,CDM,C1729,HCPCS,0272,RC,,,,both,,,6315.83,4105.29,,,,,,,,,,,,,
PLATE BNE L 184 MM SCREW DIA2.7 MM 18 SHFT H SS STR VA SLV,SUP-2907595,CDM,C1713,HCPCS,0278,RC,,,,both,,,4935.61,3208.15,,,,,,,,,,,,,
PLATE BNE L 75 MM 7 H RT VOLAR DSTL RADIAL STD NS VARIAX,SUP-2902194,CDM,C1713,HCPCS,0278,RC,,,,both,,,5202.76,3381.79,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 6MM STR TW REMOVABLE RNG,SUP-2396290,CDM,C1768,CPT,0278,RC,,,,both,,,2719.24,1767.51,,,,,,,,,,,,,
C WIRE FIX L5IN DIA0.062IN DBL END SPADE TIP,SUP-2166344,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.89,14.23,,,,,,,,,,,,,
PLATE BNE THK 1 MM BAR 4 MM SCREW DIA2 MM 6 H MINI CRV,SUP-2883221,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.69,600.40,,,,,,,,,,,,,
HC Collection Venous Blood Venipuncture,PX-3003641500,CDM,36415,CPT,0300,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
HC Thyroid Stimulating Hormone,PX-3018444300,CDM,84443,CPT,0301,RC,,,,both,,,293.00,190.45,,,,,,,,,,,,,
KIT TUBING RAPIDPORT EZ,SUP-2119236,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PROCESSER HEARING AID RT MOCCA BRN FOR PONTO + PWR SYS,SUP-2319908,CDM,L8691,HCPCS,0274,RC,,,,both,,,14114.30,9174.29,,,,,,,,,,,,,
STENT BILI DYNALINK L 28 MM DIA 5 MM CATH L 120 CM GUIDEWIRE,SUP-2104138,CDM,C1876,HCPCS,0278,RC,,,,both,,,4232.72,2751.27,,,,,,,,,,,,,
SCREW BNE L11MM DIA1.2MM TI ST CRSS FIT MOD PROFYLE,SUP-2366389,CDM,C1713,HCPCS,0278,RC,,,,both,,,1828.27,1188.38,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA MRI XT SURESCAN W 51 X H 66 MM D 13,SUP-2282398,CDM,C1721,HCPCS,0275,RC,,,,both,,,35042.40,22777.56,,,,,,,,,,,,,
BRACE ORTH AD XSM L6.5IN FOR 7.25-8IN HND L WRST BLK BOA LOK,SUP-2196532,CDM,L3931,HCPCS,0274,RC,,,,both,,,193.55,125.81,,,,,,,,,,,,,
GRAFT BIO TISS W3.1XL3.1IN PORCINE DERM RIFAMPIN,SUP-2125833,CDM,C1781,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY NAR M-L BRIM CUST FIT,SUP-2435676,CDM,L2526,HCPCS,0272,RC,,,,both,,,1813.22,1178.59,,,,,,,,,,,,,
SCREW BONE L70MM DIA3.5MM CORT DSTL TIB TI NONCANNULATED,SUP-2413384,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.05,108.58,,,,,,,,,,,,,
GRAFT NRV REP L4CM DIA3MM TYP 1 CLLGN ABSRB SEMIPERMEABLE,SUP-2244317,CDM,C9352,HCPCS,0278,RC,,,,both,,,4642.84,3017.85,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE STARCLOSE DIA 8 FR FEM ART INTVASC,SUP-2105645,CDM,C1760,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CANNULA ENDOSCP 6 MMX10.5 CM W/O INSUFFLATION STOPCOCK,SUP-2767776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1322.85,859.85,,,,,,,,,,,,,
SCREW BONE L34MM DIA3MM PARTIALLY THRD HD M CANN FLOWERCUBE,SUP-2225324,CDM,C1713,HCPCS,0278,RC,,,,both,,,727.00,472.55,,,,,,,,,,,,,
PLATE BNE L W135XL404MM THK42MM 22 H BILAT TI NAR RIG NEUT,SUP-2190839,CDM,C1713,HCPCS,0278,RC,,,,both,,,4115.79,2675.26,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 6 H TI O LP NS STERNALOCK EZ,SUP-2894444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
SCREW BNE L72MM DIA5MM CORT GRN TI ST LOK FULL THRD TRCR,SUP-2192346,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.14,334.19,,,,,,,,,,,,,
COLLAR CERV AND PD SET CAPITAL ENH,SUP-2336001,CDM,L0174,HCPCS,0272,RC,,,,both,,,112.88,73.37,,,,,,,,,,,,,
CATHETER HEMO DYLS L 33 CM DIA14.5 FR PRECIS SI SLV,SUP-2905042,CDM,C1750,HCPCS,0278,RC,,,,both,,,1250.38,812.75,,,,,,,,,,,,,
BUR SURG PRECIS 5 MMX13 CM RND LILAC STRL LTX,SUP-2859517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,762.02,495.31,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0250,RC,00264-7520-00,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
BUR SURG HOLE SAW 10.8X24.1 MM 9 CM LG BOR MIDAS REX LEGEND,SUP-2631877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
RING PESSARY RNG 5 KNOB SIL,SUP-2171733,CDM,A4562,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
COMPONENT HUM SHOULDERXLPE CONSTRUCT COMPHSVE,SUP-2408804,CDM,C1776,CPT,0278,RC,,,,both,,,25905.00,16838.25,,,,,,,,,,,,,
BUR SURGICAL OD4MM TUNGSTEN CARBIDE ROSEN DISPOSABLE FOR HANDPIECE I HI LINE XS,SUP-2108767,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.40,220.61,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 0.025 IN 6 FRX25 CM BILI SET UTHANE,SUP-2168619,CDM,C1729,HCPCS,0272,RC,,,,both,,,248.53,161.54,,,,,,,,,,,,,
COMPONENT TRAPEZIUM SZ 2 FNGR 1 PC FLX SWNSN,SUP-2397776,CDM,C1776,CPT,0278,RC,,,,both,,,5347.42,3475.82,,,,,,,,,,,,,
HC Dest Botox-Ea Add Ext 1-4 Musc,PX-5106464300,CDM,64643,CPT,0510,RC,,,,outpatient,,,2154.00,1400.10,,,,,,,,,,,,,
SCREW SQ FIT 2.0X12MM,SUP-2363524,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
HC So Magnesium|NOT REASONABLE AND NECESSARY,PX-3018373566,CDM,83735,CPT,0301,RC,,,GZ,both,,,58.00,37.70,,,,,,,,,,,,,
PHENYLEPHRINE HCL-NACL 50-0.9 MG/250ML-% IV SOLN,RX-137288,CDM,J2371,HCPCS,0636,RC,76154-0855-15,NDC,,both,250,ML,126.50,82.22,,,,,,,,,,,,,
STRUT EXT FIX QUIK ADJ LG 160-250 MM MOD CONN,SUP-2749905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4323.78,2810.46,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,J7060,HCPCS,0258,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
CANNULA SURG LNG MULTI-TIP ROTATABLE FIXATED LEVEL 1,SUP-2458830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1883.84,1224.50,,,,,,,,,,,,,
INSERT TIB L79/83MM THK10MM UNIV KNEE UHMWPE PRI POST STBL,SUP-2407050,CDM,C1776,CPT,0278,RC,,,,both,,,2775.76,1804.24,,,,,,,,,,,,,
HC Sc Ther Infusion Up to 1 Hr,PX-2609636900,CDM,96369,CPT,0260,RC,,,,both,,,267.00,173.55,,,,,,,,,,,,,
DOXYCYCLINE MONOHYDRATE 50 MG PO CAPS,RX-9901,CDM,6370000000,HCPCS,0637,RC,50268-0280-11,NDC,,both,1,UN,4.00,2.60,,,,,,,,,,,,,
STIMULATOR KIT SPINE ACCSRY CRD,SUP-2356681,CDM,C1822,CPT,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
RING EXT FIX DIA105 MM 2/3 RED NS DISP SMRT TSF,SUP-2933118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4587.60,2981.94,,,,,,,,,,,,,
PROBE DISCECTOMY L3IN DIA19GA PERC STR INTRO CANN BLNT STYL,SUP-2367004,CDM,C1713,HCPCS,0278,RC,,,,both,,,5874.81,3818.63,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL CTRL LAT,SUP-2435554,CDM,L0635,HCPCS,0272,RC,,,,both,,,2828.95,1838.82,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL CABLE PLAS,SUP-2435686,CDM,L2627,HCPCS,0274,RC,,,,both,,,6050.84,3933.05,,,,,,,,,,,,,
PLATE BNE W17.5XL278MM THK5.2MM 12 H NONSTERILE L CNDYL FEM,SUP-2185029,CDM,C1713,HCPCS,0278,RC,,,,both,,,4422.16,2874.40,,,,,,,,,,,,,
HC Pain Minor,PX-3600007514,CDM,3600007514,LOCAL,0360,RC,,,,inpatient,,,2101.00,1365.65,,,,,,,,,,,,,
SYSTEM BONE MAR ASPIR 60ML CONC ACCELERATE,SUP-2223566,CDM,C1713,HCPCS,0278,RC,,,,both,,,5542.10,3602.36,,,,,,,,,,,,,
BASKET RETRV L1950MM DIA22MM MIN WRK CHN 28MM SFT BULL SHP,SUP-2313133,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.53,765.39,,,,,,,,,,,,,
INTRODUCER SHTH 9.5FR L14CM GWIRE L50CM DIA0.038IN W/ 3MM J,SUP-2357063,CDM,C1892,HCPCS,0272,RC,,,,both,,,27.63,17.96,,,,,,,,,,,,,
PLATE BNE L 100 DEG 1.7X2 MM RT 6 HOLE BAR TI GLD NS,SUP-2366305,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.68,406.69,,,,,,,,,,,,,
ALLOGRAFT BNE WDG FRZN ASEP IL CREST,SUP-2867034,CDM,C1762,CPT,0278,RC,,,,both,,,2362.54,1535.65,,,,,,,,,,,,,
CATHETER CV TY 018 5 FRX60 CM 1 LUMEN TURBO-FLO,SUP-2759990,CDM,C1751,HCPCS,0278,RC,,,,both,,,366.41,238.17,,,,,,,,,,,,,
IMPLANT ORBIT DIA20 MM HDPE QUADRO PRT TUNN SPHR ENUC INTRO,SUP-2882658,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
MINI PLATE STRAIGHT 20 HOLE ADAPTION 10MM CP TITANIUM,SUP-2675815,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.46,287.60,,,,,,,,,,,,,
SCREW BNE L30MM DIA35MM S STL LOK SURFIX,SUP-2243400,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.92,733.80,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF XSHORT 5X40 MM TITANIUM NITRIDE S,SUP-2836780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1157.40,752.31,,,,,,,,,,,,,
PLATE BNE NAR 3.5X197 MM 11 HOLE SS LCP,SUP-2569355,CDM,C1713,HCPCS,0278,RC,,,,both,,,585.45,380.54,,,,,,,,,,,,,
GUIDEWIRE ORTH PART THRD 2.8X300 MM,SUP-2319443,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
STEM FEM HIP PRSS FIT COCR HA COAT TI STD OFFSET 160MM SZ,SUP-2375302,CDM,C1776,CPT,0278,RC,,,,both,,,14120.58,9178.38,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0258,RC,00264-7520-00,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
HEAD CASS DIA14MM DISP FOR SELF EXP SM VERT BODY REPL,SUP-2390801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X135 MM 8 HOLE SS DCP,SUP-2569176,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.58,252.58,,,,,,,,,,,,,
PLATE BNE L229MM 12 H S STL LOK COMPR BROAD CRV FOR 4.5/5MM,SUP-2185299,CDM,C1713,HCPCS,0278,RC,,,,both,,,1915.09,1244.81,,,,,,,,,,,,,
SET PUMP VENTRICULAR ASSIST 2.5FR DIA IMPELLA,SUP-2652613,CDM,C1889,HCPCS,0278,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
GRAFT DURA W3XL3IN THK0.6MM PURIFIED TYP 1 CLLGN HIGHLY,SUP-2365423,CDM,C1763,HCPCS,0278,RC,,,,both,,,2468.79,1604.71,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X2 H BILAT HND RECTANG NAR,SUP-2267885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
ALLOGRAFT BNE 20 MM PRESERVON FIBULAR SHFT MATRIGRAFT,SUP-2740989,CDM,C1762,CPT,0278,RC,,,,both,,,1491.12,969.23,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO BK W/ SHLDR SHUT,SUP-2265010,CDM,L0454,HCPCS,0274,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
PLATE BNE L142MM 6 H R ANTEROMEDIAL DST TIB S STL VAR ANG,SUP-2177658,CDM,C1713,HCPCS,0278,RC,,,,both,,,5571.77,3621.65,,,,,,,,,,,,,
SUTURE ANCHOR KIT 4.5 MM PEEK STRL LTX,SUP-2857592,CDM,C1713,HCPCS,0278,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
PLATE RINGFIX SYS 3 HL ALUM,SUP-2704792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND EAGLE EYE PLAT ST L 150 CM DIA 5,SUP-2900263,CDM,C1753,HCPCS,0278,RC,,,,both,,,1360.81,884.53,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV UNIV CONTACT CLOSURE NYL PROCARE,SUP-2196992,CDM,L3650,HCPCS,0272,RC,,,,both,,,21.76,14.14,,,,,,,,,,,,,
GUIDEPIN ORTH DIA2MM FOR HEMI CAP IMPL,SUP-2123522,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BONE SUB 5CC DEMIN BONE MTRX ORTHOBLEND FOR SM DEFCT,SUP-2294019,CDM,C1713,HCPCS,0278,RC,,,,both,,,3746.02,2434.91,,,,,,,,,,,,,
PLATE EXT FIX RETENTION TLTS T LNG LCK FOR 2.0-2.3 MM RED II,SUP-2481643,CDM,C1713,HCPCS,0278,RC,,,,both,,,4102.41,2666.57,,,,,,,,,,,,,
STENT PERIPH PULSAR-18 L 100 MM DIA 4 MM CATH L 135 CM PROX,SUP-2227261,CDM,C1876,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PLATE BNE MED,SUP-2101217,CDM,C1713,HCPCS,0278,RC,,,,both,,,2411.71,1567.61,,,,,,,,,,,,,
SCREW SS REVERE SM DIAM,SUP-2232364,CDM,C1713,HCPCS,0278,RC,,,,both,,,8116.90,5275.98,,,,,,,,,,,,,
LOOP LENS GILLS-WELSH 4.75 IN 7X5 MM OLV TIP ON OPPOSITE END,SUP-2872025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.27,423.33,,,,,,,,,,,,,
SCREW INTRF L12MM OD3.5MM HDLSS BLNT THRD TENODESIS,SUP-2321045,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
CAGE SPNL H6.5MM AP D12MM 6DEG TAPR LORDOSIS ANTR CERV PEEK,SUP-2163179,CDM,C1889,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
EASYFUSE STAPLE 25X25 NITINOL 2-LEG,SUP-2830238,CDM,C1713,HCPCS,0278,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
TRIAL KNEE SZ 4-6 L60MM TIB STEM EXTN PFC,SUP-2253329,CDM,C1776,CPT,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
CATHETER 7 INDIGO 130CM XTORQ + LIGHTNING ASPIRATION TUBING,SUP-2655648,CDM,C1757,HCPCS,0272,RC,,,,both,,,17238.60,11205.09,,,,,,,,,,,,,
PLATE BONE L94MM 4 H NONSTERILE RT LAT PROX TIB LCK FOR,SUP-2348466,CDM,C1713,HCPCS,0278,RC,,,,both,,,11391.29,7404.34,,,,,,,,,,,,,
KIT ELBOW BEARING ORTHOPAEDIC ULNAR XSMALL DISCOVERY,SUP-2879197,CDM,C1776,CPT,0278,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 4 FR SS 7 CM 21 GA MANDREL TIP SIL,SUP-2763442,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.74,41.43,,,,,,,,,,,,,
SUPPORT ORTHOT SACROILIAC PELV CUST W/PANEL STRP PENDULOUS,SUP-2435553,CDM,L0623,HCPCS,0274,RC,,,,both,,,501.05,325.68,,,,,,,,,,,,,
LINER ACET ID32MM 0DEG HIP UHMWPE CONSTRN W/ RNG L SER,SUP-2420916,CDM,C1776,CPT,0278,RC,,,,both,,,6060.20,3939.13,,,,,,,,,,,,,
STENT ES L7CM DIA18MM PROX FLARE DIA23MM NONCOVERED DST REL,SUP-2149379,CDM,C1876,HCPCS,0278,RC,,,,both,,,5110.04,3321.53,,,,,,,,,,,,,
CATHETER ANGIO ZOOM L 137 CM DIA 6 FR DSTL OD 5 FR PROX ID,SUP-2913687,CDM,C1757,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
MESH SYNTH ABD N ABSRB RECT POLYPR OBLONG OVL 12CM LEN 8CM,SUP-2265963,CDM,C1781,HCPCS,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X40 MM WRST LCK CAP STRL FRDM,SUP-2852841,CDM,C1713,HCPCS,0278,RC,,,,both,,,1502.52,976.64,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN RT FULL BONE-PATELLAR TENDON-BONE,SUP-2867033,CDM,C1762,CPT,0278,RC,,,,both,,,10643.34,6918.17,,,,,,,,,,,,,
SHOULDER IMMOB ELAS XLG,SUP-2195042,CDM,L3650,HCPCS,0274,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
HC Leg Bones Lengthening Study,PX-3207707300,CDM,77073,CPT,0320,RC,,,,outpatient,,,802.00,521.30,,,,,,,,,,,,,
CATHETER THORACENTESIS SET 14 FRX29 CM PNEUMOTHORAX WAYNE,SUP-2759796,CDM,C1729,HCPCS,0272,RC,,,,both,,,600.02,390.01,,,,,,,,,,,,,
COIL NEUROVASCULAR HYDROFRAME 18 L 19 CM LOOP DIA 6 MM,SUP-2305269,CDM,C1889,HCPCS,0278,RC,,,,both,,,8540.80,5551.52,,,,,,,,,,,,,
PLATE BNE MID FUS RECON SM L ST,SUP-2401268,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
IMPLANT BIO TISS W16XL20CM REINF BIOSCAFFOLDS PERM OVITEX 1S,SUP-2383095,CDM,C1781,HCPCS,0278,RC,,,,both,,,18086.40,11756.16,,,,,,,,,,,,,
WASHER SPNL 7X18 MM FOR SCREW TI NS,SUP-2592002,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
CATHETER ASPIR 4.2FR XTRCT,SUP-2327203,CDM,C1757,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER GUID L100CM OD7FR GEOMETRIC L 4.5 W/O HYDRPHLC,SUP-2103127,CDM,C1887,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
DRESSING WND REP 15X7.5 IN GRAPHIX,SUP-2391509,CDM,Q4133,HCPCS,0636,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB XLI ROSEN STRL REUSE HI-LINE,SUP-2928876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.13,399.83,,,,,,,,,,,,,
PLATE BNE M L64MM ST R CALCNL S STL VAR ANG LOK FOR 27MM SCR,SUP-2178422,CDM,C1713,HCPCS,0278,RC,,,,both,,,3338.35,2169.93,,,,,,,,,,,,,
SCREW LCKING HDLSS LP F/IM NAIL XL 25/S 5X44MM,SUP-2761695,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.78,506.21,,,,,,,,,,,,,
KIT PI PICC 2-L 5 FRX55 CM WITH PRELO,SUP-2826671,CDM,C1751,HCPCS,0278,RC,,,,both,,,886.89,576.48,,,,,,,,,,,,,
IMPLANT ANK JT SZ 2 TIB COMP CO CHROM SALTO TALARIS,SUP-2244137,CDM,C1776,CPT,0278,RC,,,,both,,,18775.32,12203.96,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM 0.018 IN L 5 CM NIT MANDREL SS COIL,SUP-2823946,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.84,42.15,,,,,,,,,,,,,
INTRODUCER SHTH HEMSTAS 7FRX23CM W/ .038IN GWIRE 7FR DILATO,SUP-2355393,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-106958,CDM,J0712,HCPCS,0636,RC,00456-0600-10,NDC,,both,1,UN,1480.40,962.26,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VIVA QUAD S W 51 X H 74 MM D 13 MM,SUP-2282408,CDM,C1882,HCPCS,0275,RC,,,,both,,,54200.26,35230.17,,,,,,,,,,,,,
GRAFT BNE SUB W6XH24XL14MM FT ANK PRESHAPED ALLGRFT FOR COT,SUP-2370448,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MR L 75 CM DIA 5.2 FR BALLOON L 2 CM DIA,SUP-2139652,CDM,C1725,HCPCS,0272,RC,,,,both,,,736.80,478.92,,,,,,,,,,,,,
GRAFT HUM TISS AMBIENT 1 CC FLOWABLE PLCNTA TISS VIAFLOW,SUP-2759478,CDM,C1762,CPT,0278,RC,,,,both,,,6093.67,3960.89,,,,,,,,,,,,,
BIT DRL DIA8MM ACL CANN TRANSTIBIAL,SUP-2120876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
PLATE BNE W22XL75MM STD 6X5 H ST R DST RAD VOLAR S STL VAR,SUP-2177305,CDM,C1713,HCPCS,0278,RC,,,,both,,,2603.66,1692.38,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL COMPLX + PEEK,SUP-2862814,CDM,C1713,HCPCS,0278,RC,,,,both,,,48883.58,31774.33,,,,,,,,,,,,,
HC Portal Film,PX-3337741700,CDM,77417,CPT,0333,RC,,,,inpatient,,,756.00,491.40,,,,,,,,,,,,,
SET INTRO L 14 CM DIA12 FR GUIDEWIRE 0.038 IN PTFE TEARWY,SUP-2226012,CDM,C1894,HCPCS,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
GUIDEWIRE ORTH L350MM DIA2.8MM S STL THRD TRCR PNT,SUP-2188202,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.59,75.78,,,,,,,,,,,,,
HC Donor Lymphocyte Infusion,PX-3623824200,CDM,38242,CPT,0362,RC,,,,both,,,1519.00,987.35,,,,,,,,,,,,,
PLATE 95 DEG CONDYLAR 7 HOLES 40MM 124MM STERILE,SUP-2547715,CDM,C1713,HCPCS,0278,RC,,,,both,,,3653.96,2375.07,,,,,,,,,,,,,
PLATE BONE 10 H LT DSTL MEDL TIB LCK W/O TAB FOR 3.5MM SCR,SUP-2349082,CDM,C1713,HCPCS,0278,RC,,,,both,,,3376.60,2194.79,,,,,,,,,,,,,
MARKER BRST BX IDENTIFIER SITE COMPATIBLE FOR STEREOTACTIC,SUP-2240033,CDM,A4648,CPT,0278,RC,,,,both,,,200.18,130.12,,,,,,,,,,,,,
ROD EXT FIX L 550 MM DIA11 MM LG CARBON FIBRE MR CONDITIONAL,SUP-2908139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.21,618.94,,,,,,,,,,,,,
SCREW BNE L 105 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2931880,CDM,C1713,HCPCS,0278,RC,,,,both,,,118.94,77.31,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM EL TI ST LOK MULTDIR FOR ALPS,SUP-2413761,CDM,C1713,HCPCS,0278,RC,,,,both,,,519.01,337.36,,,,,,,,,,,,,
HC Pulm Art Balloon Angioplasty; Single Vessel,PX-4819299700,CDM,92997,CPT,0481,RC,,,,both,,,35312.00,22952.80,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 33 CM DIA26 FR BODY DIA 9.5 MM,SUP-2395738,CDM,C1894,HCPCS,0272,RC,,,,both,,,1654.78,1075.61,,,,,,,,,,,,,
TUBE PEG L17CM OD18FR LO PROF PUSH KT ENDOVIVE 1 STP BTTN,SUP-2149752,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
BUR SURG DIA05MM DMND RND FLUT FOR ELITE SABER SHANK,SUP-2367567,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.55,240.21,,,,,,,,,,,,,
COMPONENT FEM 9X3X1.5MM KNEE UNI OFFSET,SUP-2123706,CDM,C1776,CPT,0278,RC,,,,both,,,11869.20,7714.98,,,,,,,,,,,,,
BASKET RETRV MEM HRD WIRE 4W 1.5 CMX3.5 CM BSKT,SUP-2169082,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
CATHETER CV QUAD LUMEN 8.5 FRX20 CM ARROWG+ARD BLU,SUP-2383394,CDM,C1751,HCPCS,0278,RC,,,,both,,,369.17,239.96,,,,,,,,,,,,,
SCREW BNE LCK 5X30 MM SLD,SUP-2433777,CDM,C1713,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE STRGHT 2 HOLE MED CP TTNM,SUP-2680998,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.03,208.67,,,,,,,,,,,,,
TI LOW PROFILE NEURO,SUP-2823424,CDM,C1713,HCPCS,0278,RC,,,,both,,,2225.00,1446.25,,,,,,,,,,,,,
PLATE BONE 5 H LT LAPIDUS OMNI,SUP-2224013,CDM,C1713,HCPCS,0278,RC,,,,both,,,4399.14,2859.44,,,,,,,,,,,,,
TUBE TRACH SZ 14 L118MM DIA14X11MM SIL CLR N ADH THOR 5200,SUP-2138751,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
BASEPLATE GLEN AUG REVERSED 8 DEG SM RT POST SHLDR EQUINOXE,SUP-2451448,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
HC So Fta-Abs,PX-3028678066,CDM,86780,CPT,0302,RC,,,,both,,,116.00,75.40,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12 DEG 55X18X11 MM LAT ELEMAX,SUP-2739106,CDM,C1713,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
GRAFT BONE PUTTY SYR DEMINERALISED BONE MTRX 5CC TREL-XPRESS,SUP-2244477,CDM,C9359,HCPCS,0278,RC,,,,both,,,2365.99,1537.89,,,,,,,,,,,,,
LEVEL CMF PLATE FRAC TLTS CVD 20 25 MM SCRW6 HOLE 31 MM T1,SUP-2694190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1778.50,1156.02,,,,,,,,,,,,,
DISTRACTION INTRNL TUBE ADJ MDFCE BTTRSS 1.5 MM MXDRVE SET S,SUP-2489570,CDM,C1713,HCPCS,0278,RC,,,,both,,,6495.12,4221.83,,,,,,,,,,,,,
BOUGIE ESOPH HURST TUNGSTEN FIL 38FR SIL,SUP-2383705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.88,298.92,,,,,,,,,,,,,
MESH HERNIAXL W7XL9IN OBLONG OVL ABD O3FA COAT POLYPR STR,SUP-2265987,CDM,C1781,HCPCS,0278,RC,,,,both,,,2791.46,1814.45,,,,,,,,,,,,,
PLATE BNE LCK 2.7X95 MM 8 HOLE CNTOUR 2 COMPR SS STRL,SUP-2493379,CDM,C1713,HCPCS,0278,RC,,,,both,,,962.50,625.62,,,,,,,,,,,,,
SHAVER SURG 10MM W/ SIDE CUT IO-FLEX MICROBLADE,SUP-2115832,CDM,C1713,HCPCS,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 180CM 0.035IN TIP L 1 CM ANGLED,SUP-2385107,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.31,84.70,,,,,,,,,,,,,
RAIL INT FIX NEW AD 150 MM,SUP-2517842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3366.08,2187.95,,,,,,,,,,,,,
INSERT TIB L71/75MM THK14MM UNIV STD KNEE PRI POST STBL,SUP-2407084,CDM,C1776,CPT,0278,RC,,,,both,,,4169.92,2710.45,,,,,,,,,,,,,
PLATE TI VA-LCKNG CALCANEAL W/TABS LG 2.7MM 64MM RGHT-STER,SUP-2547005,CDM,C1713,HCPCS,0278,RC,,,,both,,,3373.65,2192.87,,,,,,,,,,,,,
KIT STIMULATOR NERVE LD L65CM 565 SPC MRI COMPATIBLE,SUP-2631822,CDM,C1767,HCPCS,0278,RC,,,,both,,,19954.70,12970.55,,,,,,,,,,,,,
STENT BILI FLEXXUS L 4 CM DIA10 MM CATH L 190 CM DIA 7.5 FR,SUP-2166290,CDM,C1876,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CATHETER CV 3L 6 FRX60 CM SET PRO-LINE MD28036301,SUP-2626374,CDM,C1751,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
LASER SURG ULTRAPULSE DUO,SUP-2713804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468645.00,304619.25,,,,,,,,,,,,,
SHEATH INTRO STR 8 FRX60 CM SMOOTH TAPR SS PTFE BLU COMPASS,SUP-2846737,CDM,C1894,HCPCS,0272,RC,,,,both,,,292.08,189.85,,,,,,,,,,,,,
SCREW BNE L18MM DIA3.5MM TOT WRST FUS SYS SURFIX,SUP-2243389,CDM,C1713,HCPCS,0278,RC,,,,both,,,1217.63,791.46,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2.5 MM RT MAND 26 HOLE ANGLED LCK TI,SUP-2539580,CDM,C1713,HCPCS,0278,RC,,,,both,,,5614.54,3649.45,,,,,,,,,,,,,
GRAFT VASC ULTRAMAX L 40 CM DIA14 X 7 MM POLYESTER GEL,SUP-2265941,CDM,C1768,CPT,0278,RC,,,,both,,,1496.78,972.91,,,,,,,,,,,,,
HC US Guidance for Needle Place - Anes Block|UNUSUAL NON-OVERLAPPING SERVICE,PX-4027694201,CDM,76942,CPT,0402,RC,,,XU,both,,,978.00,635.70,,,,,,,,,,,,,
COIL EMB L2CM DIA2MM 0.01IN MICROCOIL SFT FINISH HELCL,SUP-2249137,CDM,C1889,HCPCS,0278,RC,,,,both,,,3106.72,2019.37,,,,,,,,,,,,,
BLADE SAW RECIP KEEL FOR STRYKR SYS,SUP-2408500,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CATHETER HD DL 10 FRX15 CM VLV INTRO GLIDEPATH AIRGUARD,SUP-2627018,CDM,C1750,HCPCS,0278,RC,,,,both,,,2027.66,1317.98,,,,,,,,,,,,,
ELECTRODE EMG L 25 MM TIP 3 MM WIRE L 1 M SIL COAT TIP GRN,SUP-2901976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
"HC So Hiv-1, Amplified Probe Tech",PX-3068753566,CDM,87535,CPT,0306,RC,,,,both,,,293.00,190.45,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X20 MM WRST LCK CAP STRL FRDM,SUP-2852842,CDM,C1713,HCPCS,0278,RC,,,,both,,,1451.62,943.55,,,,,,,,,,,,,
CAPSULE ENDO L26MM DIA11MM 145DEG EC TYP 1 ANT LD CVR ACT,SUP-2313257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
COMPONENT XVS STERILE COMPONENTS,SUP-2756517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
PLATE BNE L 226 MM SCREW DIA 4.5 MM 9 H PROX FEM STRL EVOS,SUP-2931141,CDM,C1713,HCPCS,0278,RC,,,,both,,,10068.41,6544.47,,,,,,,,,,,,,
NAIL R 11MMX360MM LNG GAM,SUP-2370050,CDM,C1713,HCPCS,0278,RC,,,,both,,,6918.05,4496.73,,,,,,,,,,,,,
LINER ACET HI RIM RINGLOK 0 DEG 22MM ID SZ 20,SUP-2403374,CDM,C1776,CPT,0278,RC,,,,both,,,2756.92,1792.00,,,,,,,,,,,,,
CABLE ELECTROTHERAPY LD 1X16 IN,SUP-2141962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
FIBER LASER HOLMIUM 1S0 SUREFLEE,SUP-2885274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
IMMOBILIZER SHLDR L W8XL18IN COT ADJUSTABLE  SHLDR STRP W  A,SUP-2431841,CDM,L3670,HCPCS,0274,RC,,,,both,,,53.51,34.78,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 5 FRX11 CM 21 GAX4 CM GRY PRELUDE,SUP-2303267,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.55,87.46,,,,,,,,,,,,,
INSERT SURG 0.3 MM TETH TRANSLACE,SUP-2732730,CDM,C1776,CPT,0278,RC,,,,both,,,1802.36,1171.53,,,,,,,,,,,,,
SCREW BNE CANN 11X30 MM 7 MM RCI STRL,SUP-2849113,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.69,293.60,,,,,,,,,,,,,
HC So Lipid Cascade,PX-3018006168,CDM,80061,CPT,0301,RC,,,,both,,,66.00,42.90,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 25X50-80 MM FD 1/3 SHFT ILIUM,SUP-2717843,CDM,C1762,CPT,0278,RC,,,,both,,,10010.35,6506.73,,,,,,,,,,,,,
HC Blood Culture Multiplex Pcr 2|REPEAT CLINICAL DIAGNOSTIC LABORATORY TEST|NOT REASONABLE AND NECESSARY,PX-3008715400,CDM,87154,CPT,0300,RC,,,91|GZ,both,,,524.00,340.60,,,,,,,,,,,,,
OSTEOTOME SURG L9 1 2IN BLDE W1 4IN STR HIBBS,SUP-2161301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,299.68,194.79,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZN ALLGRFT FEM L MED STRUT BNE 250MM,SUP-2307419,CDM,C1713,HCPCS,0278,RC,,,,both,,,2795.26,1816.92,,,,,,,,,,,,,
DRIVER SURG T15 FEMALE TENOTAC,SUP-2749819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
INSTRUMENT ORTH SKR TAB LAPIDUS SYS IO FRDM,SUP-2865098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
PLATE BONE W53XL85MM THK0.6MM MH TI SM GRID PNL FOR 1.5MM,SUP-2402902,CDM,C1713,HCPCS,0278,RC,,,,both,,,3585.88,2330.82,,,,,,,,,,,,,
BUR SURG L92MM DIA2MM S STL RND FN DMND NONFLUTED VISAO,SUP-2284235,CDM,C1713,HCPCS,0278,RC,,,,both,,,837.94,544.66,,,,,,,,,,,,,
GRAFT VASCULAR PATCH 1X14CM TAPERED,SUP-2713906,CDM,C1768,CPT,0278,RC,,,,both,,,1409.86,916.41,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA12MM BLDELSS OBT RADLUC STBL SL,SUP-2218264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,644.92,419.20,,,,,,,,,,,,,
GRAFT BNE SUB 10CC B TRICALCIUM PHSPTE VERSATILE ULT POR,SUP-2370374,CDM,C1713,HCPCS,0278,RC,,,,both,,,9127.98,5933.19,,,,,,,,,,,,,
INSERT TIB 0 THK8MM UHMWPE RT SALTO TALARIS,SUP-2400120,CDM,C1776,CPT,0278,RC,,,,both,,,5344.28,3473.78,,,,,,,,,,,,,
CATHETER EP DIAG MAP HISSER CRV QPLR 5MM SPC 1MM TIP UNI M004814830] ABBOTT],SUP-2102301,CDM,C1730,HCPCS,0272,RC,,,,both,,,1461.67,950.09,,,,,,,,,,,,,
MARKER TISS W4XL4CM RADIOGRAPHIC HAS BIOABSRB SPCR BIOZORB,SUP-2225564,CDM,A4648,CPT,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
PLATE BONE W5XL39MM THK1.2MM 7 H RT CNDYL S STL,SUP-2343842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2272.17,1476.91,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2MM S STL SGL END SMOOTH SGL SHRP TIP (MUST BE ORDERED IN MULTIPLES OF 10 EACH),SUP-2371660,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.75,58.99,,,,,,,,,,,,,
CROWN DENT LR5 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176711,CDM,D6783,CPT,0278,RC,,,,both,,,22.67,14.74,,,,,,,,,,,,,
PLATE BNE L154MM 10 H NONSTERILE R PROX BILAT TIB S STL,SUP-2184308,CDM,C1713,HCPCS,0278,RC,,,,both,,,3920.45,2548.29,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,J7060,HCPCS,0250,RC,00264-7510-10,NDC,,both,500,ML,34.00,22.10,,,,,,,,,,,,,
SCREW SPNL TI BRK OFF CLOSE CD HORZ ENGAGE,SUP-2293323,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
CONNECTOR SPNL L40MM ADJACENT LEV DEV W/ HALF JOG OFFSET FOR,SUP-2354917,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.430,SUP-2859994,CDM,C1713,HCPCS,0278,RC,,,,both,,,42540.09,27651.06,,,,,,,,,,,,,
EXTRACTOR SURG L4.5-5.5 MMXTRACT ALL DISP FOR 4.5-5.5 MM,SUP-2337713,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
HC X-Ray Exam Bil Hips W/Pelvis 2 Views,PX-3207352100,CDM,73521,CPT,0320,RC,,,,both,,,676.00,439.40,,,,,,,,,,,,,
IMPLANT TISS FIX ADJ LOOP BTTN STRL PROCINCH QUADCINCH,SUP-2908646,CDM,C1713,HCPCS,0278,RC,,,,both,,,1544.88,1004.17,,,,,,,,,,,,,
COMPONENT FEM L80MM R KNEE CONN PC GMRS,SUP-2376553,CDM,C1713,HCPCS,0278,RC,,,,both,,,10533.92,6847.05,,,,,,,,,,,,,
RESTRICTOR CEM DIA5-8MM HUM ELBW REVERSED AEQUALIS,SUP-2399877,CDM,C1713,HCPCS,0278,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
KIT SHTH CONVOY 90 DEG L 79.4 CM DIA 8.5 FR SFT TIP ADV DEL,SUP-2141298,CDM,C1894,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CANNULA ENDOSCP TERMANIAN ENDOTIP 11 MMX4 CM THRD,SUP-2775615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,878.35,570.93,,,,,,,,,,,,,
HC Apply Hand/Wrist Cast,PX-4502908500,CDM,29085,CPT,0450,RC,,,,both,,,320.00,208.00,,,,,,,,,,,,,
TAP SURG DIA2.2 MM DELT,SUP-2883303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.12,365.38,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0250,RC,00338-0023-02,NDC,,both,125,ML,26.60,17.29,,,,,,,,,,,,,
KIT INFUS PMP L 20GA L6.4CM VOL TBNG EPI CATH 2 DY NDL SYR,SUP-2363211,CDM,C2626,HCPCS,0278,RC,,,,both,,,420.85,273.55,,,,,,,,,,,,,
SHUNT VENTRICULAR L2.3CM OD13.8FR ODSEC4.6MM VERTICAL 40CM H,SUP-2825656,CDM,C1889,HCPCS,0278,RC,,,,both,,,6701.64,4356.07,,,,,,,,,,,,,
PLATE BNE REARFOOT INTERPOSITION W O STEM,SUP-2243221,CDM,C1713,HCPCS,0278,RC,,,,both,,,4223.05,2744.98,,,,,,,,,,,,,
SCREW BNE L46MM DIA6MM CANC TIB TI NONCANNULATED NONLOCKING,SUP-2212917,CDM,C1713,HCPCS,0278,RC,,,,both,,,685.78,445.76,,,,,,,,,,,,,
GRAFT ENDOPROS LN L5CM UNLN L2CM ID8-10MM SHTH 10FR 0.035IN,SUP-2395933,CDM,C1874,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
BIT DRILL SURG DIA 3.5 MM SM AO QC ATTACH EVOS,SUP-2931404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.18,394.02,,,,,,,,,,,,,
SUPPORT EL NEOPRENE11 13IN L,SUP-2276611,CDM,L3702,HCPCS,0272,RC,,,,both,,,10.61,6.90,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,J2004,HCPCS,0636,RC,00409-3178-02,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 14 H TI DBL T LP NS,SUP-2894433,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SCREW IM LCK CORT TI DIAM 5.0MM LEN 70MM,SUP-2363498,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
BEARING TIB SZ 1 LT ANK POLYETH FIX VANTAGE,SUP-2223476,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB X L UNIV R,SUP-2276647,CDM,L3931,HCPCS,0272,RC,,,,both,,,28.42,18.47,,,,,,,,,,,,,
ENDCAP IM NAIL 2MM FEM AG RG EXTN,SUP-2364649,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.66,153.18,,,,,,,,,,,,,
ELECTRODE LOOP L WITH CABLE 30DEG TELESCOPE,SUP-2721001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.83,1040.54,,,,,,,,,,,,,
TUNNELER SURG DIA6MM BULL TIP KELLY-WICK,SUP-2128314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,143.40,93.21,,,,,,,,,,,,,
STEM HUM L125MM OD15.5MM TI POR IMP BI-ANGULAR,SUP-2404703,CDM,C1776,CPT,0278,RC,,,,both,,,11690.22,7598.64,,,,,,,,,,,,,
KIT SHTH DESTINO REACH L 75 CM DIA12 FR CRV BEND 50 MM DIL,SUP-2616173,CDM,C1766,CPT,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PLATE BNE THK13MM DORS HND TI 6 H LOK COMPR MAL FOR 23MM,SUP-2107089,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
PLATE BONE SM W10XL53MM THK1.5MM 3X3 H S STL DSTL OBLQ T SHP,SUP-2343784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1888.40,1227.46,,,,,,,,,,,,,
PLATE BONE L78MM NONSTERILE RT MEDL S STL CLMN FUS VAR ANG,SUP-2420165,CDM,C1713,HCPCS,0278,RC,,,,both,,,4803.16,3122.05,,,,,,,,,,,,,
JETD REPERFUSION CATHETER,SUP-2500569,CDM,C1887,HCPCS,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
GRAFT PSTE SYN CA PHSPTE BONESOURCE BVF 10GM,SUP-2374936,CDM,C1713,HCPCS,0278,RC,,,,both,,,2962.59,1925.68,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD HD MINI MONSTER 3.5 X 28MM,SUP-2320502,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
HC CT Soft Tissue Neck W/WO Contrast,PX-3517049200,CDM,70492,CPT,0351,RC,,,,both,,,2388.00,1552.20,,,,,,,,,,,,,
EPINEPHRINE 1 MG/10ML IJ SOSY,RX-143088,CDM,J0169,HCPCS,0636,RC,00409-4921-34,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
BRINZOLAMIDE 1 % OP SUSP,RX-22953,CDM,6370000000,HCPCS,0637,RC,66758-0085-70,NDC,,both,10,ML,2113.70,1373.90,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME LT KNEE COMBINED INSTABILITY,SUP-2915075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1145.85,744.80,,,,,,,,,,,,,
STEM HUM SZ 4B L78MM 132.5DEG STD SHLDR TI PRESSFIT,SUP-2388550,CDM,C1776,CPT,0278,RC,,,,both,,,12117.26,7876.22,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.525,SUP-2860042,CDM,C1713,HCPCS,0278,RC,,,,both,,,43647.88,28371.12,,,,,,,,,,,,,
PROPOFOL 200 MG/20ML IV EMUL,RX-133090,CDM,J2704,HCPCS,0636,RC,00069-0209-01,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
SET DRN RND SIL TRCR 10FRX6IN FULL CHANNELS 10FRX20CM,SUP-2155580,CDM,C1729,HCPCS,0272,RC,,,,both,,,41.92,27.25,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.6 MM PERC NS LCP,SUP-2799836,CDM,C1769,HCPCS,0272,RC,,,,both,,,3210.05,2086.53,,,,,,,,,,,,,
INSERT TIB THK9MM S STL UHMWPE PRI MOB SLDE COR STAR PGT,SUP-2362578,CDM,C1776,CPT,0278,RC,,,,both,,,3664.38,2381.85,,,,,,,,,,,,,
WIRE FIX DIA2.4MM S STL DRL PNT FOR CRUCE RECON K,SUP-2212936,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.34,386.32,,,,,,,,,,,,,
CATHETER HD DL 15.5 FRX12 CM PRECRV TAPR TIP DUOFLO,SUP-2267102,CDM,C1750,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CONNECTOR ROD L50 MM OD6 MM SPINETUNE TL STR STRL FEATURING,SUP-2416059,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BONE PREFORMED MEDIUM 2.5 MM LEFT MANDIBLE RECONSTRUCT,SUP-2837779,CDM,C1713,HCPCS,0278,RC,,,,both,,,10625.13,6906.33,,,,,,,,,,,,,
CATHETER GUID SELECTSITE L 43 CM OD 8.4 FR ID 5.7 FR INTRO 9,SUP-2419408,CDM,C1887,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
BLADE SURG 7 LT MIDLN,SUP-2631600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
PLATE BNE MESHED 206X1023X6 MM TI,SUP-2136553,CDM,C1713,HCPCS,0278,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
TIP ASPIR L4.5IN DIA0.08IN STD EXT FLUE CRV DISP CUSA EXCEL,SUP-2172368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2194.67,1426.54,,,,,,,,,,,,,
HC Med Nutr Ther Group Init/Fu 30 Min,PX-9429780400,CDM,97804,CPT,0942,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
LONGEVITY 10 DEG ELEVATED FACE CUP 28X55,SUP-2504682,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC So Mycoplasma Igg,PX-3028673866,CDM,86738,CPT,0302,RC,,,,inpatient,,,218.00,141.70,,,,,,,,,,,,,
HC Echo Cong Anom Complete W/Ctrst,PX-4839330301,CDM,C8921,HCPCS,0483,RC,,,,both,,,1724.00,1120.60,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ACHILLES TEND W/ BONE BLK FOR LIGMNT REP,SUP-2113891,CDM,C1713,HCPCS,0278,RC,,,,both,,,9842.74,6397.78,,,,,,,,,,,,,
SHEATH INTRO FLX BLKN L 40 CM OD 6 FR GUIDEWIRE 0.038 IN,SUP-2170113,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.20,95.03,,,,,,,,,,,,,
INSERT SCIS SZ 5MM L36CM FOR HK SGL ACT JAW NOT CROSSING,SUP-2261301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1604.60,1042.99,,,,,,,,,,,,,
CATHETER CENTESIS 5FR L7CM 1 STP,SUP-2303193,CDM,C1729,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
INSERT TIB OFFSET,SUP-2405432,CDM,C1776,CPT,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
IMPLANT BIO TISS CLLGN TEND WRP TENOMEND,SUP-2223610,CDM,C1713,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
DEVICE ABLATN ENDOMET,SUP-2239886,CDM,C1886,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
PLATE BNE 100DEG 2X3 H R CRANIOMAXILLOFACIAL G TI L SHP,SUP-2191156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1090.21,708.64,,,,,,,,,,,,,
NAIL IM HIP SCR 10DEG AG 130,SUP-2349037,CDM,C1713,HCPCS,0278,RC,,,,both,,,9237.88,6004.62,,,,,,,,,,,,,
SCREW BNE L9MM OD2.7MM LOK FOR PLT TUFFNEK TECHNOLOGY,SUP-2321095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1248.15,811.30,,,,,,,,,,,,,
SPACER SPNL 65X20X10-17 MM ELSA,SUP-2732362,CDM,C1889,HCPCS,0278,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
GRAFT 10MM WDG,SUP-2244474,CDM,C1713,HCPCS,0278,RC,,,,both,,,6006.73,3904.37,,,,,,,,,,,,,
PLATE BNE STR 15X0.6 MM NEURO 2 HOLE TI NS LEVEL 1 251521209,SUP-2518094,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.63,221.41,,,,,,,,,,,,,
PLATE BNE L132MM THK3MM 7 H BILAT S STL STR LOK COMPR RECON,SUP-2185337,CDM,C1713,HCPCS,0278,RC,,,,both,,,1451.84,943.70,,,,,,,,,,,,,
SHANK SPNL SCREW L 40 MM DIA 6.5 MM NANO OSTEOGRIP STRL CD,SUP-2926396,CDM,C1713,HCPCS,0278,RC,,,,both,,,2593.64,1685.87,,,,,,,,,,,,,
CATHETER KIT 2 LUMEN 5 FR 60M161562] ANGIODYNAMICS INC],SUP-2117190,CDM,C1751,HCPCS,0278,RC,,,,both,,,628.69,408.65,,,,,,,,,,,,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,6370000000,HCPCS,0637,RC,51672-1300-09,NDC,,both,400,GR,243.00,157.95,,,,,,,,,,,,,
PLATE BNE L27MM 100DEG 3X4 H R CRANIOMAXILLOFACIAL TI L SHP,SUP-2191161,CDM,C1713,HCPCS,0278,RC,,,,both,,,1167.14,758.64,,,,,,,,,,,,,
HEAD HUM DIA54MM THK23MM SHLDR CO CHROM REPL PROS AEQUALIS,SUP-2388634,CDM,C1776,CPT,0278,RC,,,,both,,,7917.51,5146.38,,,,,,,,,,,,,
BUR ENDOSCP SHAVER 40 DEG L 13 CM DIA 3 MM ENT FRONTAL,SUP-2901950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1074.29,698.29,,,,,,,,,,,,,
BUR H 26MM SELF-CLOSING,SUP-2137635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 30 J TI EPOXY RESIN SIL SINGLE,SUP-2138115,CDM,C1722,HCPCS,0275,RC,,,,both,,,62583.34,40679.17,,,,,,,,,,,,,
BLADE IM L100MM DIA11MM STRL GLD TI HNDL HELCL FOR,SUP-2192550,CDM,C1713,HCPCS,0278,RC,,,,both,,,3899.88,2534.92,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.4MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189475,CDM,C1713,HCPCS,0278,RC,,,,both,,,949.85,617.40,,,,,,,,,,,,,
CORKSCREW SURG 7.5 IN T HNDL,SUP-2138731,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
SEALANT FISS PIT LO VISC KT PEARLESCENT,SUP-2322099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,97.09,63.11,,,,,,,,,,,,,
KIT 4.75MM LOOP N TAK BICEP,SUP-2781309,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 15 CC FD IRRADIATED CORTICAL CANC,SUP-2867209,CDM,C1762,CPT,0278,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
MODEL ANAT RECON VIRTUAL PLN NO GUIDE VSP,SUP-2883528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
COLLAR CERV SFT BABY FIRM DENS NO NK STFFNK SN6] PENNCARE],SUP-2323344,CDM,L0140,HCPCS,0272,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
CAGE IM SM 73MM NIT SELF EXP 3 DIM FX MGMT,SUP-2167473,CDM,C1889,HCPCS,0278,RC,,,,both,,,15370.30,9990.69,,,,,,,,,,,,,
PLATE BONE THICKNESS1.8MM STRNL LCK PLT 10 H STR,SUP-2262582,CDM,C1713,HCPCS,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
BUR SURG L10CM DIA4MM BALL FLUT SM BOR MIDAS REX LEGEND,SUP-2277611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.35,225.78,,,,,,,,,,,,,
COIL NEUROVASCULAR HELIPAQ 10 L 6 CM DIA2 MM WORKING L 190,SUP-2457847,CDM,C1889,HCPCS,0278,RC,,,,both,,,3486.47,2266.21,,,,,,,,,,,,,
BUR SURG RND 3X80 MM W/ LAT PROTCT GOLF BLU STRL DISP,SUP-2599840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.04,256.13,,,,,,,,,,,,,
PROBE VITRCTMY 25GA L27MM 10000CPM CONSTELLATION ULTRAVIT,SUP-2109976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4445.30,2889.44,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.25MM TI TRCR PNT,SUP-2193144,CDM,C1776,CPT,0278,RC,,,,both,,,284.14,184.69,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40 CM DIA18 X 9 MM POLYESTER BOV,SUP-2494374,CDM,C1768,CPT,0278,RC,,,,both,,,2364.67,1537.04,,,,,,,,,,,,,
INTRA-AORTIC PUMP KIT 7.5 FR 30 CC BLLN CATH WAPA MEGA,SUP-2525604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2857.87,1857.62,,,,,,,,,,,,,
CANN SCREW THD 5.0X44MM,SUP-2586818,CDM,C1713,HCPCS,0278,RC,,,,both,,,468.65,304.62,,,,,,,,,,,,,
KIT PERICARDCENT PERIVAC STR CATH W/ CLP STRL,SUP-2885610,CDM,C1729,HCPCS,0272,RC,,,,both,,,487.74,317.03,,,,,,,,,,,,,
MESH HERN W6XL6IN POLYPR MID WT MFIL SQ RND FLAT SHT STR,SUP-2227328,CDM,C1781,HCPCS,0278,RC,,,,both,,,97.84,63.60,,,,,,,,,,,,,
ROD SPNL S STL STR L150MM L150MM OD5.5MM REVERE,SUP-2185225,CDM,C1713,HCPCS,0278,RC,,,,both,,,5175.44,3364.04,,,,,,,,,,,,,
ANCHOR SUT L16.3MM D5.5MM TI NO2 FIBERWIRE ORDER MULT OF 5EA,SUP-2121574,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
SMALL SQC CANN COUNTERSINK CANNULATED SCREW SYSTEM,SUP-2487743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
PROFIX NONPOR CR W/ NP CR TIB AND PROFLX INSRT,SUP-2348006,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SIMETHICONE 125 MG PO CAPS,RX-11361,CDM,6370000000,HCPCS,0637,RC,00067-6275-72,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.6MM TI SELF DRL FOR CRAN CLSR SYS,SUP-2243981,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.04,99.48,,,,,,,,,,,,,
BIT DRL 12 MM CERV FOR ACP STD DISP,SUP-2430716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
NAIL IM L380MM DIA8MM ST DK BLU TIB TI LOK UNREAMED SLD W/,SUP-2192763,CDM,C1713,HCPCS,0278,RC,,,,both,,,5558.74,3613.18,,,,,,,,,,,,,
IMMOBILIZER ORTH 3 PNL 2XL 22 IN KNEE BRTRC ADJ FOAM,SUP-2194906,CDM,L1830,CPT,0274,RC,,,,both,,,57.46,37.35,,,,,,,,,,,,,
FERROUS SULFATE ER 45 MG PO TBCR,RX-167216,CDM,6370000000,HCPCS,0637,RC,10006-0730-13,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
FIBER LASER 550 MH SMOOTH TIP LUMENIS HOLM SLM LN 200 DFL,SUP-2478182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1194.02,776.11,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SPICA MED LG LT THMB HK LOOP CLOSURE VLY 0005785000000] ALIMED INC],SUP-2112560,CDM,L3924,HCPCS,0274,RC,,,,both,,,96.56,62.76,,,,,,,,,,,,,
PLATE BNE L 221 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 18 H,SUP-2936269,CDM,C1713,HCPCS,0278,RC,,,,both,,,7579.96,4926.97,,,,,,,,,,,,,
GRAFT BONE SUB L DEFCT 15ML ORTHOBLEND JR DEMIN BONE MTRX,SUP-2293915,CDM,C1713,HCPCS,0278,RC,,,,both,,,3800.66,2470.43,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 35 CM DIA 5 MM CLLGN BOV CAR ART,SUP-2120662,CDM,C1768,CPT,0278,RC,,,,both,,,3984.66,2590.03,,,,,,,,,,,,,
IMMUNE GLOBULIN (PRIVIGEN) 10%,RX-4081762,CDM,J1459,HCPCS,0636,RC,44206-0437-10,NDC,,both,100,ML,5659.90,3678.93,,,,,,,,,,,,,
CATHETER HD KT 0.035 IN 12 FRX25 CM 3L INTRO NDL SHRP SAFETY,SUP-2762983,CDM,C1752,HCPCS,0278,RC,,,,both,,,331.58,215.53,,,,,,,,,,,,,
PLATE BNE L W13.5XL160MM THK4.2MM 9 H BILAT TI STR RIG,SUP-2190817,CDM,C1713,HCPCS,0278,RC,,,,both,,,622.85,404.85,,,,,,,,,,,,,
PLATE BNE L 3.5X60 MM RT PROX TIB 4 HOLE SS STRL,SUP-2421869,CDM,C1713,HCPCS,0278,RC,,,,both,,,4186.81,2721.43,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 12.9 MM 32 CC 69 GM VENTRIC EPIC + VR V196ROPT] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356531,CDM,C1722,HCPCS,0275,RC,,,,both,,,52657.80,34227.57,,,,,,,,,,,,,
STEM FEM SZ 6 L125MM STD HIP INSITU,SUP-2308958,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
BIT DRILL 18/4X24 MM J LATCH COUPLING STOP NON STERILE MATRI,SUP-2837607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.85,532.90,,,,,,,,,,,,,
CATHETER GUID L100CM OD5FR ID0.056IN S STL NYL PTFE AL3 AL1,SUP-2159373,CDM,C1887,HCPCS,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
COMPONENT TIB UNI 32MM X 6.5MM REPICCI II,SUP-2212779,CDM,C1776,CPT,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1395108D2,SUP-2632827,CDM,C1751,HCPCS,0278,RC,,,,both,,,1166.57,758.27,,,,,,,,,,,,,
SHEATH URET ACC 14FR L35CM HYDRPHLC FOR ESTABLISH A CONDUIT,SUP-2169834,CDM,C1894,HCPCS,0272,RC,,,,both,,,644.01,418.61,,,,,,,,,,,,,
NAIL IM CANN 11X360 MM RT TROCHANTERIC FIX TI STRL,SUP-2192195,CDM,C1713,HCPCS,0278,RC,,,,both,,,4421.12,2873.73,,,,,,,,,,,,,
PHENYLEPHRINE HCL 0.5 % NA SOLN,RX-6244,CDM,2500000003,HCPCS,0250,RC,00225-0805-47,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 INX150 CM 3 CM 7 FRX26 CM POLARIS,SUP-2537625,CDM,C2617,HCPCS,0278,RC,,,,both,,,702.26,456.47,,,,,,,,,,,,,
STEM FEM NO 4 L165MM OD16MM TI HA POR HIP REV STR NEUT CEM,SUP-2375231,CDM,C1776,CPT,0278,RC,,,,both,,,13689.14,8897.94,,,,,,,,,,,,,
GUIDEWIRE ORTH MINI 1.4MM MTP POCKETLOCK MAXLOCK EXTRM,SUP-2400513,CDM,C1769,HCPCS,0272,RC,,,,both,,,600.37,390.24,,,,,,,,,,,,,
IMPLANT PAT RND PRI 9 MM THCK CEM N POR STD WITHOUTXRAY WIRE,SUP-2200482,CDM,C1776,CPT,0278,RC,,,,both,,,1554.68,1010.54,,,,,,,,,,,,,
SIZER SURG WIRE MINI ACUTRK,SUP-2525731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CAP NAIL DIA 0 MM STRL TRIGEN MAX,SUP-2933053,CDM,C1713,HCPCS,0278,RC,,,,both,,,670.70,435.95,,,,,,,,,,,,,
SCREW BNE L5MM DIA2MM CRANIOMAXILLOFACIAL TI SELF RET,SUP-2262831,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.59,216.83,,,,,,,,,,,,,
PLATE BNE SEMI TBLR 55 MM 3 HOLE FOR LG FRAG SYS SS NS,SUP-2461521,CDM,C1713,HCPCS,0278,RC,,,,both,,,165.60,107.64,,,,,,,,,,,,,
SYSTEM BONE MAR ASPIR NDL SYR LESS INVASIVE L15CM DIA11GA,SUP-2194029,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GRAFT BNE 13 MM CUBE Q-PACK CONFORM,SUP-2264597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2255.15,1465.85,,,,,,,,,,,,,
SPLINT THMB M+ LT CARPOMETACARPAL JT RESTRICT ELAS SUPP,SUP-2324211,CDM,L3931,HCPCS,0274,RC,,,,both,,,64.24,41.76,,,,,,,,,,,,,
SCREW BNE SCHNZ 4X125 MM DISP,SUP-2605953,CDM,C1713,HCPCS,0278,RC,,,,both,,,306.15,199.00,,,,,,,,,,,,,
PLATE BNE H 3.5/4 MM 15 HOLE NS FPS LTX,SUP-2856880,CDM,C1713,HCPCS,0278,RC,,,,both,,,2662.72,1730.77,,,,,,,,,,,,,
PROBE PENCIL 8MHZ CONTOURED  RSFH ONLY,SUP-2862967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
WIRE BNE FIX DIA2 MM NS LEOS KIRSCHNER,SUP-2933365,CDM,C1713,HCPCS,0278,RC,,,,both,,,151.66,98.58,,,,,,,,,,,,,
CATHETER VENTRICULAR PUDENZ STD 18 CM 1.3X2.5 MM BA STRIPE,SUP-2244289,CDM,C1729,HCPCS,0272,RC,,,,both,,,352.75,229.29,,,,,,,,,,,,,
OXINIUM UNI FEM IMPL SM,SUP-2344262,CDM,C1776,CPT,0278,RC,,,,both,,,8684.46,5644.90,,,,,,,,,,,,,
RING FIX FULL SZ 180MM ALUMINUM MAXFRAME,SUP-2179157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3540.07,2301.05,,,,,,,,,,,,,
PLATE BNE 6 H NONSTERILE BILAT MIDFOOT TALUS S STL MAL LO,SUP-2177140,CDM,C1713,HCPCS,0278,RC,,,,both,,,2253.99,1465.09,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM TRCR PNT FOR PERI-LOC VAR ANG,SUP-2343917,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.40,190.06,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S1173108PD,SUP-2632790,CDM,C1751,HCPCS,0278,RC,,,,both,,,906.20,589.03,,,,,,,,,,,,,
SCREW SPNL L30MM OD5.5MM S STL CANC PEDCL ST FIX ANG,SUP-2288872,CDM,C1713,HCPCS,0278,RC,,,,both,,,2398.18,1558.82,,,,,,,,,,,,,
IMPLANT OTO L5.13MM DIA0.76MM SH HA INCUS STAPE KARTUSH,SUP-2312560,CDM,L8613,CPT,0278,RC,,,,both,,,927.15,602.65,,,,,,,,,,,,,
RESERVOIR SHUNT 14MM SMALL TITANIUM RADIOPAQUE BUR HOLE VENT,SUP-2825622,CDM,C1729,HCPCS,0272,RC,,,,both,,,2231.35,1450.38,,,,,,,,,,,,,
CATHETER CV 3L 5.5 FRX8 CM BASIC KT ARROWG+ARD,SUP-2383321,CDM,C1751,HCPCS,0278,RC,,,,both,,,243.66,158.38,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0258,RC,00409-7101-02,NDC,,both,250,ML,48.90,31.78,,,,,,,,,,,,,
HC So Clot Inhibit Protein C Antigen,PX-3058530266,CDM,85302,CPT,0305,RC,,,,both,,,151.00,98.15,,,,,,,,,,,,,
PLATE BONE THK0.5MM 6 H NEURO DBL Y,SUP-2365075,CDM,C1713,HCPCS,0278,RC,,,,both,,,1730.01,1124.51,,,,,,,,,,,,,
TITANIUM MESH PANEL REG GRID 85MM X 55MM 6MM 20MM SYS CP T,SUP-2707374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2195.05,1426.78,,,,,,,,,,,,,
BASEPLATE GLEN DIA36MM +5MM STD TI SHLDR PROMOS +,SUP-2351195,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
PLATE SPNL 20 MM ALIF51 DIVERGENCE-L,SUP-2422249,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
KNIFE ENDOSCP 9.5 FR HK BLADE SCKL TIP FOR OPT URETHROTM,SUP-2430220,CDM,C1713,HCPCS,0278,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL PLASTAZOTE EQL,SUP-2435702,CDM,L3002,HCPCS,0274,RC,,,,both,,,457.25,297.21,,,,,,,,,,,,,
KNIFE SURG FUKUSHIMA CHEN 7.5 INX1 MM RND RUGGLES-REDMOND,SUP-2476692,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.60,302.64,,,,,,,,,,,,,
RETRIEVER SURG 0.015 IN 3X32 MM TREVO NXT PROVUE,SUP-2551050,CDM,C1757,HCPCS,0272,RC,,,,both,,,22518.20,14636.83,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 7 PACK,SUP-2855641,CDM,C2642,HCPCS,0278,RC,,,,both,,,16597.13,10788.13,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CANC 1 4MM CRUSH CHIP READIGRFT,SUP-2264816,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.99,500.49,,,,,,,,,,,,,
GRAFT HUM TISS W3XL6CM MINIMALLY PROC UMB CRD SFT TISS MEM,SUP-2124870,CDM,C1762,CPT,0278,RC,,,,both,,,11853.50,7704.77,,,,,,,,,,,,,
PLATE BNE L 52 MM SCREW DIA2 MM 7 SHFT H SS STR VA OPTIMIZED NS,SUP-2908861,CDM,C1713,HCPCS,0278,RC,,,,both,,,2428.26,1578.37,,,,,,,,,,,,,
PLATE BONE 4 H RT TI PREBENT TENS BND MINI FOR 2MM SCR LCK,SUP-2191246,CDM,C1713,HCPCS,0278,RC,,,,both,,,1784.78,1160.11,,,,,,,,,,,,,
BENDING TEMPLATE FOR 3.5MM LCP(TM) PILON PLATES,SUP-2548485,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.90,292.43,,,,,,,,,,,,,
GUIDEWIRE SYNCHRO SELECT SOFT PRE-SHAPED 0.014IN X 300 CM,SUP-2855165,CDM,C1769,HCPCS,0272,RC,,,,both,,,2907.64,1889.97,,,,,,,,,,,,,
ROD REPROC EXT FIX HYBRID CARBN 11X450MM,SUP-2736202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.03,263.27,,,,,,,,,,,,,
PLATE BNE L208MM 14 H NONSTERILE R POSTEROLAT DST HUM S STL,SUP-2185918,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.85,2144.25,,,,,,,,,,,,,
FOOTPLATE BONE ELEVATED RIGHT ANTERIOR MIDFACIAL FOR DISTRAC,SUP-2838453,CDM,C1713,HCPCS,0278,RC,,,,both,,,3382.72,2198.77,,,,,,,,,,,,,
SUPPORT EL NEOPRENE 7 9IN SM,SUP-2276612,CDM,L3702,HCPCS,0274,RC,,,,both,,,9.36,6.08,,,,,,,,,,,,,
PLATE BNE L62MM 3 H S STL LOK COMPR HK FOR 3.5MM SCR LCP,SUP-2177457,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.44,1275.59,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ALTRUA 60 TI SINGLE CHMBR BATTERY PWR,SUP-2149104,CDM,C1786,HCPCS,0275,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 4 H TI V LP NS STERNALOCK EZ,SUP-2894502,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
STENT NEURO LVIS EVO UNDEPLOYED L 44 MM LABELED L 24 MM DIA,SUP-2905256,CDM,C1876,HCPCS,0278,RC,,,,both,,,22466.70,14603.35,,,,,,,,,,,,,
PLATE BNE L 118 X W 9 MM THK 1.1 MM SCREW DIA 3.5 MM 10 H SS,SUP-2933749,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.47,230.41,,,,,,,,,,,,,
CATHETER HD RAULERSON 13 FRX20 CM IJ SHT TERM DUO-SPLIT,SUP-2627188,CDM,C1752,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 50X10X5 MM,SUP-2225966,CDM,C1889,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
OBTURATOR TROCAR TRAINGULAR 5X60 MM BLNT REUSE,SUP-2850119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.54,213.55,,,,,,,,,,,,,
MORPHINE SULFATE 4 MG/ML IV SOLN,RX-155570,CDM,J2270,HCPCS,0636,RC,00641-6125-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CAGE SPNL ANGLED 0 DEG 12X10-13 MM TI SM VBR,SUP-2431555,CDM,C1889,HCPCS,0278,RC,,,,both,,,23393.00,15205.45,,,,,,,,,,,,,
BOOT ORTHOT L VASC CLASS ROOKE,SUP-2319144,CDM,L4386,HCPCS,0274,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
PLATE BNE L120MM 7 H ST R SUP CLAV S STL LOK COMPR W/ LAT,SUP-2177374,CDM,C1713,HCPCS,0278,RC,,,,both,,,3010.26,1956.67,,,,,,,,,,,,,
PLATE SLIM STR 3 HL T8,SUP-2702873,CDM,C1713,HCPCS,0278,RC,,,,both,,,3362.94,2185.91,,,,,,,,,,,,,
GUIDEWIRE ENDOSCOPIC 1.6 MM JETX,SUP-2836760,CDM,C1769,HCPCS,0272,RC,,,,both,,,7355.61,4781.15,,,,,,,,,,,,,
SCREW BNE L 15 MM DIA2 MM TI INTERMAXILLARY FIX SYS NS DISP,SUP-2935002,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.06,245.74,,,,,,,,,,,,,
PLATE BONE LOW PRFLE 0.6MM THK HLX3X2 TTNM SQRE F/1.5MM SCRE,SUP-2494474,CDM,C1713,HCPCS,0278,RC,,,,both,,,711.90,462.73,,,,,,,,,,,,,
SCREW BONE L130MM DIA12MM HIP NAIL LAG FOR TRAUM GAM,SUP-2370996,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.36,882.93,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH ATTCH TO SHOE LONGITUDINAL,SUP-2435709,CDM,L3090,HCPCS,0274,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
CEMENT BNE SLO CURING RADIOPAQUE GENTAMICIN PALACOS,SUP-2602137,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.038 IN SS PTFE STR FIX COR N,SUP-2116518,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.83,19.39,,,,,,,,,,,,,
PLATE BNE RECON NAR,SUP-2363457,CDM,C1713,HCPCS,0278,RC,,,,both,,,2054.69,1335.55,,,,,,,,,,,,,
STENT BILI LIFESTENT NT L 40 MM DIA 6 MM CATH L 120 CM,SUP-2214606,CDM,C1876,HCPCS,0278,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
ANCHOR SUT 0 DIA3.7MM PLLA ABSRB DBL ARMED W/ NDL RAPTORMITE,SUP-2341796,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.93,564.15,,,,,,,,,,,,,
MEMBRANE REGENERATIVE MED 15X20 IN RESOLUT XT,SUP-2396734,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 59 MM DIA 7 MM CATH L 120 CM,SUP-2884906,CDM,C1874,HCPCS,0278,RC,,,,both,,,8735.83,5678.29,,,,,,,,,,,,,
FIXATION EXT 4 H FN WIRE RNG CLMP KT,SUP-2316279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.72,430.12,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND ESOPH 6 SHOT SAEED,SUP-2737554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
GRAFT BNE SUB W25XH4XL100MM THK4MM 10ML B TRICALCIUM PHSPTE,SUP-2368173,CDM,C1713,HCPCS,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
HUMERAL TRAY REVERSED +10 MM 49 MM SHLDR,SUP-2431686,CDM,C1776,CPT,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
HC Unscheduled/Emerg OP Dialysis,PX-8299093500,CDM,G0257,HCPCS,0829,RC,,,,both,,,810.00,526.50,,,,,,,,,,,,,
SLEEVE KNEE NEOPRENE OPN PAT BLK SM 1 8IN,SUP-2319239,CDM,L1810,HCPCS,0274,RC,,,,both,,,19.15,12.45,,,,,,,,,,,,,
STEM FEM SZ 16 STD HIP CLLR MOD ENTRADA,SUP-2315497,CDM,C1713,HCPCS,0278,RC,,,,both,,,10465.62,6802.65,,,,,,,,,,,,,
HC Amniocentesis Any Method,PX-3615900000,CDM,59000,CPT,0361,RC,,,,both,,,924.00,600.60,,,,,,,,,,,,,
TECHNETIUM TC 99M EXAMETAZIME-WBC IV SOLN,RX-4082704,CDM,A9569,HCPCS,0343,RC,17156-0022-05,NDC,,both,1,UN,4265.40,2772.51,,,,,,,,,,,,,
TUBE ENDOSCP 50 CM LEN 19.5 MM OD 16.7 MM ID W/ TAPR TIP,SUP-2391609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.19,412.87,,,,,,,,,,,,,
MARKER RAD L20MM DIA0.9MM NIT LUNG COIL FIDUCIAL SUPERLOCK,SUP-2381755,CDM,A4648,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BNE LADDER 23X0.6 MM NEURO 3X2 HOLE CRV TI NS LEVEL 1,SUP-2477039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.61,656.90,,,,,,,,,,,,,
PLATE BNE RADIAL DSTL,SUP-2859842,CDM,C1713,HCPCS,0278,RC,,,,both,,,129085.40,83905.51,,,,,,,,,,,,,
PLATE BNE L33MM PROF 15MM 4 H TI MINI PATTEN THREADLOCK TS,SUP-2262962,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.65,726.47,,,,,,,,,,,,,
BIT DRL DIA4MM FOR 55MM CANN SCR,SUP-2343598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2793.00,1815.45,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR ADJ CUST FIT STRP W/OUT JT FABRICATED,SUP-2435751,CDM,L3671,HCPCS,0274,RC,,,,both,,,2321.65,1509.07,,,,,,,,,,,,,
PLATE BNE RECON 2.5 MM 20 HOLE RECON PT SPEC,SUP-2860089,CDM,C1713,HCPCS,0278,RC,,,,both,,,18162.07,11805.35,,,,,,,,,,,,,
SPLINT FT AD SM SZ 3-6 UNISX LT PREFABRICATED POST LEAF,SUP-2325044,CDM,L4398,HCPCS,0274,RC,,,,both,,,82.08,53.35,,,,,,,,,,,,,
FORCEPS SURG SUT TISS 4.75 IN REUSE NONSTERILE AD ADSN,SUP-2412590,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
ALLOGRAFT BNE PASTE 8 CC DEMINERALIZED BNE MTRX + CANC,SUP-2717767,CDM,C1713,HCPCS,0278,RC,,,,both,,,4979.44,3236.64,,,,,,,,,,,,,
SYSTEM DEL EUS 19 GA FLX ENDOSCP W/ BX NDL PRE LD NIT BEAC,SUP-2427166,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN TIP L 3 MM PTFE J STR,SUP-2301941,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.43,16.53,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST ADJ FIT STRP W/O JT FABRICATED,SUP-2435773,CDM,L3906,HCPCS,0272,RC,,,,both,,,1305.74,848.73,,,,,,,,,,,,,
RONGEUR SURG LEMPERT 6.5 IN 10X2 MM LIGHT MODEL SLENDER JAW,SUP-2159922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.16,290.00,,,,,,,,,,,,,
BLADE SHV 4.0MM DIA MICROENDOSCOPY SHRP EDGE FRMLA FOR,SUP-2361331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.33,240.06,,,,,,,,,,,,,
SCREW BNE L34MM DIA4.5MM THRD L13MM CORT TI ST SELF DRL,SUP-2190380,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.37,37.29,,,,,,,,,,,,,
HC Assay of Haptoglobin Quantitative,PX-3018301000,CDM,83010,CPT,0301,RC,,,,both,,,339.00,220.35,,,,,,,,,,,,,
IMMOBILIZER KNEE L23IN UNIV AD WRP ARND OPN PAT WIND ADJ,SUP-2136226,CDM,L1830,CPT,0274,RC,,,,both,,,112.41,73.07,,,,,,,,,,,,,
PLATE BNE L130MM 11 H BILAT TI RIG LO PROF NONCOMPRESSION,SUP-2191079,CDM,C1713,HCPCS,0278,RC,,,,both,,,1929.91,1254.44,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA100-300 UN 20 ML PVA STRL,SUP-2140324,CDM,C1889,HCPCS,0278,RC,,,,both,,,825.41,536.52,,,,,,,,,,,,,
COMPONENT FEM SZ 3 LT KNEE POR PRI NAR ADV STAT,SUP-2304648,CDM,C1776,CPT,0278,RC,,,,both,,,19471.14,12656.24,,,,,,,,,,,,,
HC CT Brain W/WO Contrast,PX-3517047000,CDM,70470,CPT,0351,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
PLATE BNE DBL Y 0.5 MM 6 HOLE TI BLU NS MATRIXMIDFACE,SUP-2181684,CDM,C1713,HCPCS,0278,RC,,,,both,,,1131.97,735.78,,,,,,,,,,,,,
SCREW BNE DRILL-FREE 2X15 MM 10 MM HEX HD ETCHED TI LEVEL 1,SUP-2477383,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.63,387.16,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST PER EXTN BAR,SUP-2435695,CDM,L2760,HCPCS,0274,RC,,,,both,,,160.86,104.56,,,,,,,,,,,,,
NAIL IM L480MM DIA10MM 130DEG ST GRN FEM TI CANN LOK AG RG,SUP-2192609,CDM,C1713,HCPCS,0278,RC,,,,both,,,4428.53,2878.54,,,,,,,,,,,,,
TRAY CATH DRNGE 65FR DIA 0038N GDWRE 25CML HDRPHLC CTD PGT,SUP-2705581,CDM,C1729,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CANNULA ART SHT 15 FR BIOLINE COATED HLS,SUP-2663457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.69,694.00,,,,,,,,,,,,,
PLATE BNE RADIAL XLN RT DSTL VOLAR LCK STRL DVR EPAK LTX,SUP-2861557,CDM,C1713,HCPCS,0278,RC,,,,both,,,8169.59,5310.23,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA26 MM POLYESTER GEL,SUP-2385478,CDM,L8670,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
VALVE CSF REG PERF LEVEL 1.5 W/ BIOGLDE DELT,SUP-2631430,CDM,C1889,HCPCS,0278,RC,,,,both,,,4271.03,2776.17,,,,,,,,,,,,,
BIT DRL TWST 1.2X4 MM 7 CM SM BOR MIDAS REX 8,SUP-2664817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,293.65,190.87,,,,,,,,,,,,,
CATHETER ETER DIL 75FR L180CM BLLN L3CM DIA8 9 10MM 0035IN,SUP-2141555,CDM,C1726,HCPCS,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
STEM HUM FRAC R 7MM EQUINOXE,SUP-2223294,CDM,C1776,CPT,0278,RC,,,,both,,,7181.18,4667.77,,,,,,,,,,,,,
GRAFT BIO TISS W3.9XL11IN PORCINE DERM RIFAMPIN MINOCYCLINE,SUP-2125837,CDM,C1781,HCPCS,0278,RC,,,,both,,,29842.56,19397.66,,,,,,,,,,,,,
PLATE BONE THK0.6MM 4 H GRN ORBIT TI CVD HX FOR 1.5MM SCR,SUP-2135903,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 8 FR B CRV RED,SUP-2492474,CDM,C1732,HCPCS,0272,RC,,,,both,,,7762.08,5045.35,,,,,,,,,,,,,
PLATE BNE L63MM THK1.3MM 2X8 H L MTCRPL TI L SHP COMPR FOR,SUP-2267920,CDM,C1713,HCPCS,0278,RC,,,,both,,,909.34,591.07,,,,,,,,,,,,,
BRACE ANK XL FOR 14 15IN BLK W O STAY GAMEDAY,SUP-2319318,CDM,L4350,HCPCS,0274,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
COVER BUR H DIA17MM 6 H CRANIOMAXILLOFACIAL BLU TI,SUP-2181546,CDM,C1713,HCPCS,0278,RC,,,,both,,,796.93,518.00,,,,,,,,,,,,,
WASHER ORTH L1MM FOR SIDEKCK EZ FRME EXT FIX,SUP-2400673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SAW HAND JSPH 6 7/8NL 38MML BLADE STRGHT W/THMB REST PDGTT N,SUP-2492156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.45,256.39,,,,,,,,,,,,,
BIT DRL L150MM DIA4MM 3 FLUT QUIK CPL RADPQ BRAD PNT W/O,SUP-2193806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,811.38,527.40,,,,,,,,,,,,,
NUT ORTH DIA5/16IN RT HND FOR SPNL FIX DEV,SUP-2255599,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
GRAFT BNE FRSH STORED REFRIGERATED L LAT FEM HEMICONDYLE,SUP-2335302,CDM,C1713,HCPCS,0278,RC,,,,both,,,24649.00,16021.85,,,,,,,,,,,,,
HANDPIECE SURG PWR MINIMALLY INVASIVE HNDPC AO CONN STRL LF,SUP-2881083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3384.92,2200.20,,,,,,,,,,,,,
PLATE SPNL AFFIX III 50 MM POST SIDE,SUP-2561438,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
MESH HERN W3XL4.75IN L PLA PRECUT FLAP STYL PARTIALLY ABSRB,SUP-2174790,CDM,C1781,HCPCS,0278,RC,,,,both,,,785.41,510.52,,,,,,,,,,,,,
ASCORBIC ACID 25000 MG/50ML IV SOLN,RX-142248,CDM,340B,HCPCS,0250,RC,67157-0101-50,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
HEAD FEM DISASSEMBLY HIP ATTCH PLAS,SUP-2440396,CDM,C1776,CPT,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
GUIDEWIRE VASC BENT L 180 CM DIA 0.018 IN TAPR L 16 CM FLPY,SUP-2167993,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.73,27.12,,,,,,,,,,,,,
CATHETER GLDE ANG 4FRX65CM,SUP-2141097,CDM,C1887,HCPCS,0272,RC,,,,both,,,151.44,98.44,,,,,,,,,,,,,
STEM FEM SZ 2 STD SHT NK HIP HA QUADRA H,SUP-2267225,CDM,C1776,CPT,0278,RC,,,,both,,,8289.60,5388.24,,,,,,,,,,,,,
INSUFFLATION TBNG ROBOT SURG SET HI FLO DA VINCI 5,SUP-2884189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
STAPLER INT STPL SZ 35MM L21MM DIA5MM TI CIR CUT ECHELON,SUP-2283241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3758.39,2442.95,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X40 MM FEN SOLERA 5.5/6,SUP-2629693,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BUR OVAL FLUSHCUT RETR 8 FLUT 5.0MMX13C,SUP-2814158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
"HC Insert Picc Cath, <5 Yrs",PX-3613656800,CDM,36568,CPT,0361,RC,,,,both,,,4942.00,3212.30,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC BULL TIP 3 MMX100 CM SMOOTH IM FIX ZMS,SUP-2207940,CDM,C1769,HCPCS,0272,RC,,,,both,,,224.20,145.73,,,,,,,,,,,,,
KIT MIDLN 18GA L8CM FLO RATE 7ML/SEC MIDLN PWR INJ FULL TY,SUP-2125660,CDM,C1751,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
WASHER ORTH BOLT SPIK OSS,SUP-2441741,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
ARM EXT FIX LNG ARTC 3 ARTH FOR SIDEKCK STLTH REARFOOT FIX,SUP-2400634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2226.26,1447.07,,,,,,,,,,,,,
SPACER HUM 9+ MM TI HUMELOCK II,SUP-2741761,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
WASHER ORTH 3.5 MM FOR 4MM SCR,SUP-2559086,CDM,C1713,HCPCS,0278,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
KIT INTRO VSI RADIAL SHTH L 12 CM DIA 6 FR GUIDEWIRE L 45 CM,SUP-2383182,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
TUBE ET AD OD12.7/14.5MM ID9MM SIL SGL LUMN CUF HI VOL LO,SUP-2383581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM W/ 2 3 COBRAID BLU BLK ULTRABRAID SUT,SUP-2341878,CDM,C1713,HCPCS,0278,RC,,,,both,,,1222.53,794.64,,,,,,,,,,,,,
DEVICE FIX TI ANK SYNDEMOSIS ZIPLOOP TECHNOLOGY ZIPTIGHT,SUP-2137180,CDM,C1713,HCPCS,0278,RC,,,,both,,,2215.58,1440.13,,,,,,,,,,,,,
TUBE VENT ID127MM SIL BLU FOR MYR CLLR BTTN,SUP-2313713,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.65,25.12,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 8X8X8 MM FD DEMINERALIZED CANC LIFEFLEX,SUP-2866836,CDM,C1762,CPT,0278,RC,,,,both,,,781.55,508.01,,,,,,,,,,,,,
WIRE ORTH THRD SGL SHRP TIP S STL 0.9MM DIA 102MM K,SUP-2363716,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
CAGE SPNL MESH 33X26X70 MM 6 LOBE,SUP-2602092,CDM,C1889,HCPCS,0278,RC,,,,both,,,20133.68,13086.89,,,,,,,,,,,,,
KASSAM SCREEN MESH PANEL 2MM CP TITANIUM,SUP-2680902,CDM,C1713,HCPCS,0278,RC,,,,both,,,798.44,518.99,,,,,,,,,,,,,
BUTTON GASTMY L 2.3 CM DIA14 FR SIL ENFIT LP GLO GRN,SUP-2915190,CDM,C1889,HCPCS,0278,RC,,,,both,,,425.03,276.27,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM 8 IN RT WRST CNTOUR,SUP-2124889,CDM,L3931,HCPCS,0274,RC,,,,both,,,45.53,29.59,,,,,,,,,,,,,
CATHETER URET 4FR L70CM 0.025IN OPN END FOR DRNGE RG,SUP-2171215,CDM,C1758,HCPCS,0278,RC,,,,both,,,50.15,32.60,,,,,,,,,,,,,
HC Pulse Oximetry Continuous,PX-4609476200,CDM,94762,CPT,0460,RC,,,,outpatient,,,452.00,293.80,,,,,,,,,,,,,
ANCHOR SUTURE STRL TILINK-P,SUP-2937212,CDM,C1713,HCPCS,0278,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
PLATE BNE L109MM 14 H L FIBULAR TIM LOK COMPR ANAT FOR,SUP-2413688,CDM,C1713,HCPCS,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
IMPLANT CAPSULAR TENS RNG COMPR 13-11 MM PMMA PRELD INJ FLX,SUP-2884219,CDM,L8699,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ABACAVIR SULFATE 300 MG PO TABS,RX-24438,CDM,6370000000,HCPCS,0637,RC,68084-0021-11,NDC,,both,1,UN,39.80,25.87,,,,,,,,,,,,,
SPACER SPNL W12XH12XL14MM 5DEG PEEK OPTMA INTERVERTEBRAL,SUP-2211878,CDM,C1821,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
TIP ASPIR CLAW 1.7X2.8 MM 12 CM FOR BNE CUT SONOPET IQ DISP,SUP-2791056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3040.78,1976.51,,,,,,,,,,,,,
CODMAN ACCU-FLO STR CONN S STL,SUP-2249013,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.86,252.76,,,,,,,,,,,,,
REMOVABLE END CAP,SUP-2823037,CDM,C1889,HCPCS,0278,RC,,,,both,,,1549.59,1007.23,,,,,,,,,,,,,
CUBE EXTERNAL FIXATION 3 HOLE STAINLESS STEEL,SUP-2586502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,724.05,470.63,,,,,,,,,,,,,
STENT BILI L20MM DIA7MM CATH L80CM LIFESTNT,SUP-2420396,CDM,C1876,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
FIBER LASER SURG FIBER 365 MH HOLM SMARTSCOPE DISP,SUP-2337026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION 12-30 DEG PLASMA-OVALBUTTON,SUP-2467542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.44,1220.34,,,,,,,,,,,,,
TUBE VENT 0.97 MM 2.3 MM BAXTER BVL BOB TAPR FLROPLAS,SUP-2535148,CDM,L8699,HCPCS,0278,RC,,,,both,,,33.06,21.49,,,,,,,,,,,,,
PLATE BNE LCK 189 MM LT DSTL LAT TIB PERIARTICULAR 14 HOLE,SUP-2492343,CDM,C1713,HCPCS,0278,RC,,,,both,,,4491.68,2919.59,,,,,,,,,,,,,
SCREW BNE CANN 9X65 MM FEN TI STRL FIREBIRD SI,SUP-2738376,CDM,C1713,HCPCS,0278,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
BIT DRL L110MM DIA4MM SLD,SUP-2321597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
CUTTER ENDOSCP L340MM LIN ARTC SGL STROKE FIRING ENDOPATH,SUP-2218776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,766.32,498.11,,,,,,,,,,,,,
ENDCAP SPNL 8 DEG 30 MM FOR PLATE T2 STRATOSPHERE,SUP-2423826,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR THEON 25MM 32MM 17MM PERICARD,SUP-2214083,CDM,C1889,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
PLATE BONE THK1MM 8 H CRANIOMAXILLOFACIAL ORAL GRN SLV TI,SUP-2181765,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.67,1375.84,,,,,,,,,,,,,
HC Ventilator Initial Day,PX-4109400200,CDM,94002,CPT,0410,RC,,,,inpatient,,,1570.00,1020.50,,,,,,,,,,,,,
DRAIN SURG 10FR SIL RND HUBLESS RADPQ W O TRCR BLAK,SUP-2256673,CDM,C1729,HCPCS,0272,RC,,,,both,,,120.51,78.33,,,,,,,,,,,,,
ROD EXT FIX L220MM WRST C FBR W 4 25MM SCHNZ SCR,SUP-2179122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2980.65,1937.42,,,,,,,,,,,,,
GRASPER HYSTEROSCOPIC L 33 CM DIA 3 MM HND ACTUATED STRL,SUP-2913667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
CATHETER PRESSURE MEAS ENDOFLIP L 8 CM GI NSL TIP INTEGR,SUP-2749619,CDM,C1726,HCPCS,0272,RC,,,,both,,,1450.05,942.53,,,,,,,,,,,,,
SET INTRO S-MAK L 10 CM DIA 4 FR L 40 CM SS STIFF DIL MINI,SUP-2889705,CDM,C1894,HCPCS,0272,RC,,,,both,,,98.66,64.13,,,,,,,,,,,,,
CONNECTOR SPNL SM TI TSRH-3DX,SUP-2289709,CDM,C1713,HCPCS,0278,RC,,,,both,,,3020.68,1963.44,,,,,,,,,,,,,
MESH CRAN W38XL45MM DIA0.6MM TI CNTOUR RIG PNK MATRIXNEURO,SUP-2255853,CDM,C1781,HCPCS,0278,RC,,,,both,,,4457.54,2897.40,,,,,,,,,,,,,
GRAFT NRV L70MM DIA2-3MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124851,CDM,C1762,CPT,0278,RC,,,,both,,,26859.56,17458.71,,,,,,,,,,,,,
IMPLANT SACROILIAC JT FUS L65MM DIA7MM TI POR PLSM SPRY,SUP-2337790,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
PLATE BNE 5 DEG SM RT METATARSOPHALANGEAL REV NS LEOS,SUP-2931335,CDM,C1713,HCPCS,0278,RC,,,,both,,,4498.05,2923.73,,,,,,,,,,,,,
MAXFRAME QA Strut Long,SUP-2548604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3399.49,2209.67,,,,,,,,,,,,,
PROSTHESIS OSS EAR LG 2.5 MM APPLBM,SUP-2313845,CDM,L8613,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
VALVE SHUNT SYSTEM WITH DIFFERENTIAL PRESSURE UNIT 0CM AND D,SUP-2821804,CDM,C1889,HCPCS,0278,RC,,,,both,,,12471.73,8106.62,,,,,,,,,,,,,
GUIDEWIRE VASC PRIMEWIRE PRESTIGE L 185 CM SS GLYDX HYDRPHLC,SUP-2393125,CDM,C1769,HCPCS,0272,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
GUIDEWIRE HEP COAT FIX COR DBL END STR J TIP 3MM 035INX150CM,SUP-2302743,CDM,C1769,HCPCS,0272,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
GUIDEWIRE ORTH TRCR PT 1 END 2.8X220 MM STRL,SUP-2789093,CDM,C1769,HCPCS,0272,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
CARBAMAZEPINE 100 MG/5ML PO SUSP,RX-1356,CDM,340b,HCPCS,0637,RC,70954-0240-10,NDC,,both,5,ML,3.60,2.34,,,,,,,,,,,,,
CATHETER BLLN DIL SET 5 FRX65 CM 5 MMX4 CM URET,SUP-2835669,CDM,C1758,HCPCS,0278,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
NEEDLE INTRO BX COAX 15 GX10.6 CM W/INTRO,SUP-2120162,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
STEM FEM VERSYS 7.5 IN BEADED FC +20 CALCAR 15.0X170MM STR,SUP-2504255,CDM,C1776,CPT,0278,RC,,,,both,,,13376.40,8694.66,,,,,,,,,,,,,
BLADE SAW L 85 MM L 27 MM THK MATERIAL 0.25 MM CUT 0.35 MM,SUP-2928985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,789.49,513.17,,,,,,,,,,,,,
DEFIBRILLATOR CRD 5.37X7.36X0.99 CM DF4 CONN RESONATE EL VR,SUP-2424813,CDM,C1722,HCPCS,0275,RC,,,,both,,,43768.46,28449.50,,,,,,,,,,,,,
SCREW BNE ST 1X10 MM CRUCFRM HD TI NS,SUP-2189086,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
CATHETER EMB 2.2-2.2FR L150CM BLLN L10MM DIA4MM OCCL,SUP-2172471,CDM,C2628,HCPCS,0272,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
PIN FIX L120MM DIA4MM THRD L30MM CORT S STL HALF SELF DRL,SUP-2372420,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
STEM HIP PATIENT SPEC,SUP-2165897,CDM,C1776,CPT,0278,RC,,,,both,,,7818.60,5082.09,,,,,,,,,,,,,
PROBE LITHO RENAL BLDR DISP,SUP-2313962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE L 13 CM DIL L 20 CM OD 6 FR ID 2 FR,SUP-2168723,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.19,76.82,,,,,,,,,,,,,
STABILIZER FEM 2XL DURAC LT KNEE MOD MONO IMP,SUP-2364848,CDM,C1776,CPT,0278,RC,,,,both,,,6506.08,4228.95,,,,,,,,,,,,,
CATHETER THROMCTMY ESPERANCE L 115 CM DIA 6 FR SHFT,SUP-2892525,CDM,C1757,HCPCS,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
IMPLANT TOE SZ 20 FOREFOOT PRIMUS GREAT W/ GRMMT FUTURA,SUP-2399909,CDM,C1776,CPT,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.014IN TIP L5CM 15DEG G TUNGSTEN,SUP-2172962,CDM,C1769,HCPCS,0272,RC,,,,both,,,308.76,200.69,,,,,,,,,,,,,
GRAFT BIO W5XL5CM FOR OTO REP BIODESIGN,SUP-2170502,CDM,C1763,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
PLATE BNE MINI MED 4 HOLE LCK 2 BRK AWAY TAB TLTS TI LEVEL 1,SUP-2482350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1118.22,726.84,,,,,,,,,,,,,
CLAV ANT NRW 11H 90MM NS,SUP-2721206,CDM,C1713,HCPCS,0278,RC,,,,both,,,4248.42,2761.47,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA 0.76 MM INNR FLANGE DIA1 MM FLROPLAS,SUP-2901953,CDM,L8699,HCPCS,0278,RC,,,,both,,,71.91,46.74,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR TRL NRV MULTIPROGRAM,SUP-2356139,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK MINI L 65 CM 2.5 FR 2 CM 8 MM,SUP-2659640,CDM,C1725,HCPCS,0272,RC,,,,both,,,1668.88,1084.77,,,,,,,,,,,,,
CAP SCR SHLDR LCK AEQUALIS FLX REVIVE,SUP-2417740,CDM,C1776,CPT,0278,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
REPAIR KIT KNOTLESS AC IMPL STRL LTX,SUP-2859826,CDM,C1713,HCPCS,0278,RC,,,,both,,,4936.08,3208.45,,,,,,,,,,,,,
GRAFT HUMAN TSSUE SGMNT LG 6MML BRCHMTTRSL FRZE DRIED IRRDTD,SUP-2726036,CDM,C1762,CPT,0278,RC,,,,both,,,3733.15,2426.55,,,,,,,,,,,,,
SCREW BNE L80MM OD5MM STD CORT LOK RECON FOR FEM NAIL,SUP-2342533,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.26,176.32,,,,,,,,,,,,,
TRAY HUM THK+0MM 0MM OFFSET CNTR REVERSED AEQUALIS ASCEND,SUP-2388720,CDM,C1776,CPT,0278,RC,,,,both,,,4661.33,3029.86,,,,,,,,,,,,,
BIT DRL CEM 15.7 MM TIB PERSONA,SUP-2448191,CDM,2720000010,LOCAL,0272,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 50 X 61 MM POLYETHYL RT HELCL RIM STRL,SUP-2935272,CDM,C1713,HCPCS,0278,RC,,,,both,,,2427.22,1577.69,,,,,,,,,,,,,
PLATE BNE L94MM 6 H ST L SUP ANT CLAV S STL LOK COMPR FOR,SUP-2177340,CDM,C1713,HCPCS,0278,RC,,,,both,,,2934.80,1907.62,,,,,,,,,,,,,
LEVETIRACETAM 250 MG PO TABS,RX-26816,CDM,6370000000,HCPCS,0637,RC,00904-7123-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT HUM TISS W15 18XL100MM RADIUS ULNA SHFT FRZ DRY,SUP-2307203,CDM,C1713,HCPCS,0278,RC,,,,both,,,2410.70,1566.95,,,,,,,,,,,,,
PLATE BNE MESHED 11 XL 0.6 MM RT CONTOURED TI NS,SUP-2478126,CDM,C1713,HCPCS,0278,RC,,,,both,,,17154.54,11150.45,,,,,,,,,,,,,
ENDCAP ORTH UNIV FLSH FOR VERSANAIL TIB NAILING SYS,SUP-2412386,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 6 MM EPTFE STR TW N RING STRL,SUP-2396696,CDM,C1768,CPT,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
SCREW BNE NLCK 2X15 MM TI NS BABY GORILLA,SUP-2750072,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.70,298.80,,,,,,,,,,,,,
WRAP ELBW BREATHABLE UNIV FOREARM FOAM 2 ADJ STRAP PROCARE,SUP-2196799,CDM,L3702,HCPCS,0272,RC,,,,both,,,44.37,28.84,,,,,,,,,,,,,
PLATE BNE MED MALL,SUP-2399842,CDM,C1713,HCPCS,0278,RC,,,,both,,,3708.34,2410.42,,,,,,,,,,,,,
CATHETER ENDOVENOUS 7FR L100CM W/O PK RF MIS-7F11 CLSR FAST,SUP-2393086,CDM,C1888,HCPCS,0272,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
PLATE BNE L148MM 8 H BILAT S STL T NONCOMPRESSION LO PROF,SUP-2185757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1786.03,1160.92,,,,,,,,,,,,,
STRUT EXT FIX L163 300MM LNG ACUTE ADJ LOK UNIV HNG ON BOTH,SUP-2316068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2908.43,1890.48,,,,,,,,,,,,,
PLATE BNE L85MM HK D15MM 5 H R CLAV S STL LOK COMPR FOR,SUP-2185851,CDM,C1713,HCPCS,0278,RC,,,,both,,,3291.47,2139.46,,,,,,,,,,,,,
SPLINT REST HND ADL R DRBLUE BROAD,SUP-2165489,CDM,L3807,HCPCS,0272,RC,,,,both,,,124.82,81.13,,,,,,,,,,,,,
LENS IOL 1 PC 17.5 DIOPT 6X13.75 MM ANTR CHMBR PMMA,SUP-2129206,CDM,V2630,CPT,0276,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
NUT SPNL W11MM UNIV PEDCL THORLUM TI ALLY FLAT SM STAT USS,SUP-2193398,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SCREW BONE L4MM DIA1MM CORT CRANIOMAXILLOFACIAL GLD TI ST,SUP-2189035,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.40,225.16,,,,,,,,,,,,,
COMPONENT KNEE CEM STD FEM TIB PATELLAR OPT PROLONG LPS-FLEX,SUP-2212329,CDM,C1776,CPT,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.25MM PEDCL TI POLYAX MNRCH,SUP-2254491,CDM,C1713,HCPCS,0278,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
KIT SCREW GLENOID FIXATION REVERSE TORQUE DEFINING,SUP-2512469,CDM,C1776,CPT,0278,RC,,,,both,,,5581.66,3628.08,,,,,,,,,,,,,
PLATE BONE MESHED 1.3 MM MANDIBLE C TYPE FOR CRANIOMAXILLOFA,SUP-2837650,CDM,C1713,HCPCS,0278,RC,,,,both,,,3286.01,2135.91,,,,,,,,,,,,,
KIT INTRO ARW THMS DIA 9 FR GUIDEWIRE 0.035 IN POLYUR PERC,SUP-2383288,CDM,C1894,HCPCS,0272,RC,,,,both,,,104.88,68.17,,,,,,,,,,,,,
ELECTRODE ENDOSCP MPLR DISPOSABLE  NDL 37CM MCCARTHY,SUP-2436272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
TUBE VENT PAPARELLA 1.27 MM W/ TAB SIL STRL,SUP-2470798,CDM,L8699,HCPCS,0278,RC,,,,both,,,23.83,15.49,,,,,,,,,,,,,
PLATE EXT FIX 120 DEG 180 MM FEM ARCH CARBON FIBER NS,SUP-2800193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2712.80,1763.32,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 50 CM DIA 7 MM EPTFE STR STD WALL,SUP-2227645,CDM,C1768,CPT,0278,RC,,,,both,,,1386.91,901.49,,,,,,,,,,,,,
SCREW BONE L16MM THRD DIA2MM HD DIA3.3MM COR DIA1.3MM PITCH,SUP-2349378,CDM,C1713,HCPCS,0278,RC,,,,both,,,645.71,419.71,,,,,,,,,,,,,
GUIDE SURG TI VSP,SUP-2883357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
RETRACTOR SURG MAS TLIF HOOP SHIM DISP MAXCESS,SUP-2310435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT BONE FEM SHFT SPL FRZ DRY,SUP-2165576,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
FIBER LASER HOLM 11046] FORTEC MEDICAL INC],SUP-2418108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PIN FIX DISP SM FRAG PLATING SYS L12MM,SUP-2413865,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.36,312.88,,,,,,,,,,,,,
HC Abscess Catheter Injection,PX-3614942400,CDM,49424,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
POST EXT FIX 5.9 MMX28 MM LT TI INCORE LAPIDUS,SUP-2485803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7303.83,4747.49,,,,,,,,,,,,,
ENDCAP ORTH 5 MM EBA 1,SUP-2719864,CDM,C1889,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE BAR 4 MM 4 H MINI LT MIDFACE L SHP MALL,SUP-2883295,CDM,C1713,HCPCS,0278,RC,,,,both,,,1638.14,1064.79,,,,,,,,,,,,,
HC Change of Ureterostomy Tube,PX-3615068800,CDM,50688,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
KIT PICC PI 1-L 4FR X 55 CM TIPTRACKER,SUP-2855517,CDM,C1751,HCPCS,0278,RC,,,,both,,,598.96,389.32,,,,,,,,,,,,,
GRFT CHIPS CORT CANC 1-4MM 4.59MM 30CC PUROS,SUP-2693920,CDM,C1713,HCPCS,0278,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
TUBE TYMPANOSTOMY SM L4.5MM DIA1.27MM INNR EAR CLR SIL T,SUP-2284013,CDM,L8699,HCPCS,0278,RC,,,,both,,,104.12,67.68,,,,,,,,,,,,,
GRAFT BONE SUB W25XH8XL50MM 10CC STRP BIOACTIVE BIOLOGIC,SUP-2232307,CDM,C9362,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
CANNULA GRFT DEL SYS X3 PREFILLED,SUP-2740841,CDM,C1713,HCPCS,0278,RC,,,,both,,,5735.84,3728.30,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 20 MM DIA 6 MM DEL SYS L 190 CM,SUP-2866200,CDM,C1725,HCPCS,0272,RC,,,,both,,,3422.88,2224.87,,,,,,,,,,,,,
CATHETER VASC DIAG COBRA 2 PERIPH .038 W/O HYDRPHLC COAT AD,SUP-2141098,CDM,C1887,HCPCS,0272,RC,,,,both,,,154.77,100.60,,,,,,,,,,,,,
HC Splint App/Short Leg,PX-4502951500,CDM,29515,CPT,0450,RC,,,,inpatient,,,497.00,323.05,,,,,,,,,,,,,
APPLIER CLP CRV MED LG 8 IN MANUAL LOAD LCK LIG HEM-O-LOK,SUP-2656804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
CRADLE SPNL RAD 220MM SUP CRAN GLD TI ALLOY NEUT FOR RIB,SUP-2193283,CDM,C1889,HCPCS,0278,RC,,,,both,,,5915.76,3845.24,,,,,,,,,,,,,
BIT DRL AO SHFT 4.5 MM OVR SCR NS DISP,SUP-2489681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.68,602.34,,,,,,,,,,,,,
HC Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq,PX-3068763700,CDM,87637,CPT,0306,RC,,,,inpatient,,,300.00,195.00,,,,,,,,,,,,,
GRAFT BIO TISS RECON FIRM CRUC INCIS STRATTICE PORCINE IMP,SUP-2113359,CDM,Q4116,HCPCS,0636,RC,,,,both,,,3271.88,2126.72,,,,,,,,,,,,,
STEM HUM L100MM DIA8MM IM SHLDR MOD SEG REV SYS W/ SCR,SUP-2402759,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
EXTERNAL FIXATION KIT SET FT SUPP COMPLETE GALAXY FIX GEM,SUP-2875640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7043.71,4578.41,,,,,,,,,,,,,
DRILL SURG DIA27MM STD CANN PERIARTC,SUP-2410859,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
ALLOGRAFT DERMAL 2X3 CM DERMAPURE,SUP-2388441,CDM,Q4152,HCPCS,0636,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
DRILL SURG UNIV SHFT COMPHSVE,SUP-2443504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4041.18,2626.77,,,,,,,,,,,,,
PLATE BNE L106MM 4 H L MED PROX TIB S STL LOK COMPR LO PROF,SUP-2185669,CDM,C1713,HCPCS,0278,RC,,,,both,,,4536.11,2948.47,,,,,,,,,,,,,
PLATE PROX MEDIAL TIB 3.5 RT 3H,SUP-2854928,CDM,C1713,HCPCS,0278,RC,,,,both,,,6999.44,4549.64,,,,,,,,,,,,,
TI NARROW 2 HOLE PLATE 26MM,SUP-2704879,CDM,C1713,HCPCS,0278,RC,,,,both,,,224.20,145.73,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX9 TTNM RCNSTRCTN F3.5MM LOK SCRE,SUP-2724005,CDM,C1713,HCPCS,0278,RC,,,,both,,,1630.04,1059.53,,,,,,,,,,,,,
CONNECTOR SHUNT OD1.9MM TITANIUM STEP DOWN L HYDROCEPHALUS M,SUP-2821782,CDM,C1889,HCPCS,0278,RC,,,,both,,,869.12,564.93,,,,,,,,,,,,,
KIT TKR KNEE CRUCE RET CEM STD INSRT VERILAST LEGION GEN II,SUP-2348028,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
KIT HYSTEROSCOPIC PROC INFLO OUTFLO TUBE SET W/ SVC,SUP-2341625,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
EZ SHOT 3 PLUS 22 G ASP NEEDLE,SUP-2707138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
BIT DRILL AO CALIBRATED 3.8MM,SUP-2750031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
SYSTEM OCCL DEL SHTH 7FR L60CM 45DEG SEPT S STL PTFE,SUP-2355731,CDM,C1894,HCPCS,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
HC Needle Biopsy Muscle,PX-3612020600,CDM,20206,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM 22MM POLYESTER BOV CLLGN STR,SUP-2265916,CDM,C1768,CPT,0278,RC,,,,both,,,1014.09,659.16,,,,,,,,,,,,,
MESH SURG 100X100X1 MM 3D TI LEVEL 1 NEURO,SUP-2465193,CDM,C1713,HCPCS,0278,RC,,,,both,,,5758.07,3742.75,,,,,,,,,,,,,
SYSTEM ORTH REV MOD TIB TAPE 63 LNG OSS,SUP-2441800,CDM,C1776,CPT,0278,RC,,,,both,,,9170.37,5960.74,,,,,,,,,,,,,
SCREW BONE L24MM DIA2MM TI CANC ST SELF DRL CANN LAG,SUP-2319500,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PLATE BONE STRAIGHT FRAGMENT,SUP-2492073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
SET URET STENT C FLX L 8 CM CATH L 70 CM DIA 3.7 FR,SUP-2171247,CDM,C2617,HCPCS,0278,RC,,,,both,,,632.71,411.26,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 7 FRX22-30 CM 6 FR STIFF CNTOUR,SUP-2470186,CDM,C2617,HCPCS,0278,RC,,,,both,,,604.26,392.77,,,,,,,,,,,,,
GRAFT BNE 5 CC VOID FILL SYNTH,SUP-2430785,CDM,C1889,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY LG 20 IN PERF WRP ARND FOAM,SUP-2194894,CDM,L1830,CPT,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
PATCH DURAL SYNTHETIC NON ABSORBABLE SUBSTITUTE NON IMMUNOGE,SUP-2825551,CDM,C1763,HCPCS,0278,RC,,,,both,,,1413.60,918.84,,,,,,,,,,,,,
STAPLE BNE 12X12 MM FOREFOOT PK NIT DYNAFORCE MOTOCLIP MAX,SUP-2175167,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
ANCHOR SUT OD5MM L36IN 2 VIO BLU MO-7 NDL TI SFT TISS BRAID,SUP-2256683,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
BOJRAB UNIVERSAL,SUP-2680148,CDM,L8613,CPT,0278,RC,,,,both,,,1401.70,911.10,,,,,,,,,,,,,
HEAD FEM DIA50MM CO CHROM POR CEM HEMI RESURF BIRMINGHAM,SUP-2350876,CDM,C1776,CPT,0278,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
MONITOR CARD ASSERT-IQ 3 L 9.4 X H 46.5 MM THK 3.1 MM 1.2 ML,SUP-2873672,CDM,C1764,HCPCS,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
SHEATH INTRO ARW FLX L 7 CM DIA 9 FR TIP ID 2.9 MM OBTURATOR,SUP-2383498,CDM,C1894,HCPCS,0272,RC,,,,both,,,31.31,20.35,,,,,,,,,,,,,
VALVE TRACH SPEAK SHILEY,SUP-2516374,CDM,L8501,HCPCS,0272,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
IMPLANT BIO TISS W19XL35CM REGEN PORCINE CLLGN RECT,SUP-2125849,CDM,C1781,HCPCS,0278,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
INTRODUCER TUBE SET 6.5/7/7.5/8 MM MULTI PERC W/O TRACH TUBE,SUP-2759705,CDM,C1769,HCPCS,0272,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
CLIP INT USE W 11 MM WORKING CHANNEL 136 MM DIA2.5 MM CAP D,SUP-2881910,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BLADE SAW SAG 9.5MMW X25.5MML 0.6MM/0.6MM THK CUT SM BNE FN,SUP-2605396,CDM,2720000010,LOCAL,0272,RC,,,,both,,,95.90,62.33,,,,,,,,,,,,,
IMPULSE TIG45 SGL,SUP-2664316,CDM,C1887,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
STRUT EXT FIX LNG TRNSPRT NS DISP ILIZ,SUP-2933872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6696.02,4352.41,,,,,,,,,,,,,
DRESSING WND TALYMED L 3 X W 3 CM POLY-N-ACETYL GLUCOSAMINE,SUP-2266132,CDM,Q4127,HCPCS,0636,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
PLATE BNE T NEURO ULTRA LO PROF W/ TAB TI LEVEL 1 LF,SUP-2462737,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.76,489.94,,,,,,,,,,,,,
DEVICE BNE ACCS SZ 2 10GA DIA3.4MM DMND AND BVL OSTEO INTRO,SUP-2293707,CDM,C1894,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X167 MM 10 HOLE SS DCP,SUP-2569178,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.12,275.03,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 MEDL LAT PRI GEN II,SUP-2346050,CDM,C1776,CPT,0278,RC,,,,both,,,2530.84,1645.05,,,,,,,,,,,,,
CATHETER INFUS 5FR L65CM 5CM GWIRE 0.035IN MEWISSEN,SUP-2141149,CDM,C1725,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
CALCITRIOL 0.5 MCG PO CAPS,RX-9351,CDM,6370000000,HCPCS,0637,RC,64380-0724-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE W11XL151MM THK33MM 11 H BILAT MTPHSEAL TI LOK,SUP-2190765,CDM,C1713,HCPCS,0278,RC,,,,both,,,2856.36,1856.63,,,,,,,,,,,,,
RETRACTOR OMNI-TRACT POST LUM COMPLT,SUP-2305866,CDM,C1713,HCPCS,0278,RC,,,,both,,,39727.28,25822.73,,,,,,,,,,,,,
NUT EXT FIX SPD STRL TRUELOK EVO LTX,SUP-2875632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.63,133.01,,,,,,,,,,,,,
GUIDEWIRE ORTH L220MM DIA3.2MM STD S STL SMOOTH DRL TIP FOR,SUP-2410861,CDM,C1769,HCPCS,0272,RC,,,,both,,,107.64,69.97,,,,,,,,,,,,,
CATHETER UROLOGICAL PHILIPS 14 FR FOR FILIFORM BOUGIES 27576,SUP-2768118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.36,219.28,,,,,,,,,,,,,
WRX DISTAL RADIUS NAIL 5X70MM STERILE,SUP-2816191,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
ROD SPNL ANTR RT SMOOTH S STL 5.0MM DIA 200MM LEN COLORADO,SUP-2290510,CDM,C1713,HCPCS,0278,RC,,,,both,,,2091.24,1359.31,,,,,,,,,,,,,
COMPONENT FEM SZ 6 R KNEE OXINIUM BI CRUCE STBL JOURNEY II,SUP-2350341,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
DRESSING BIO W2XL4CM CLLGN SH 0.1% POLYHEXMETHYLENEBIGUANIDE,SUP-2314088,CDM,Q4196,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PATCH BIO W9XL14CM THK1MM BOV PERICARD,SUP-2355779,CDM,C1768,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
COLLAR CERV FIRM 4X22IN UNIV,SUP-2276587,CDM,L0120,HCPCS,0274,RC,,,,both,,,7.69,5.00,,,,,,,,,,,,,
ANCHOR SUT DIA2.8MM NO2 SUT TI ULTRABRAID TWINFIX,SUP-2341666,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.38,498.80,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ABDUCTN ROT BAR W/O SHOE,SUP-2435712,CDM,L3150,HCPCS,0274,RC,,,,both,,,230.48,149.81,,,,,,,,,,,,,
KIT INTRO SHTH L 10 CM DIA 5.5 FR TEARWY ACCSRY STRL,SUP-2627294,CDM,C1894,HCPCS,0272,RC,,,,both,,,20.22,13.14,,,,,,,,,,,,,
BIT OVERDRILL DIA 3.5 MM AO QC SM TARGETER SYS STRL DISP,SUP-2932962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1316.45,855.69,,,,,,,,,,,,,
BLADE URETHROTOME STR SACHSE,SUP-2261208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.77,572.50,,,,,,,,,,,,,
SCREW BNE L 40 MM DIA 4 MM TI ST SD CANN PARTIALLY THRD,SUP-2900619,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
IMPLANT TOE JT DORS MTP ULTRA LP STD RAPID COMPR STRL,SUP-2908878,CDM,C1713,HCPCS,0278,RC,,,,both,,,11671.38,7586.40,,,,,,,,,,,,,
STENT VASC L40MM DIA6MM CATH L80CM SHTH 8FR FLR HELI DSGN,SUP-2418862,CDM,C1874,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307586,CDM,Q4128,HCPCS,0636,RC,,,,both,,,21056.06,13686.44,,,,,,,,,,,,,
KIT POS BEACH CHAIR DISP ADAPTABLE,SUP-2908606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STENT PERIPH L60MM DIA7MM CATH L135CM IL LIFESTAR,SUP-2420437,CDM,C1876,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
COMPONENT HIP PRSS FT H7 HD X3 MTL CERM MDM,SUP-2379154,CDM,C1776,CPT,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE MED ECON BUCK,SUP-2336328,CDM,L4398,HCPCS,0272,RC,,,,both,,,28.29,18.39,,,,,,,,,,,,,
PLATE BNE L85MM THK3.4MM 6 H BILAT S STL STR LOK COMPR FOR,SUP-2185133,CDM,C1713,HCPCS,0278,RC,,,,both,,,839.13,545.43,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X13 MM 6 LOBE,SUP-2602072,CDM,C1889,HCPCS,0278,RC,,,,both,,,8079.22,5251.49,,,,,,,,,,,,,
BIT DRL L19MM DIA1.6MM DENT SHFT END FOR 2/2.3X8MM,SUP-2366426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.72,233.82,,,,,,,,,,,,,
KIT REP BRDG TECH FOR TRANSTEND REP OF PART ARTC SIDE,SUP-2121601,CDM,C1713,HCPCS,0278,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
SEALER BPLR L5.74MM DIA3.48MM SPC 6MM 30DEG MAL W/ LT BLK,SUP-2281805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 5 FR 0.035 IN 7 CM 18 GA SS,SUP-2700276,CDM,C1894,HCPCS,0272,RC,,,,both,,,38.37,24.94,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 90 CM 4 FR 0.038 IN STR NONBRAIDED,SUP-2118165,CDM,C1887,HCPCS,0272,RC,,,,both,,,108.68,70.64,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 180 CM DIA 0.035 IN TAPR L 15 CM FLPY,SUP-2167871,CDM,C1769,HCPCS,0272,RC,,,,both,,,89.36,58.08,,,,,,,,,,,,,
PLATE BNE 22 H ST BILAT S STL NAR CRV LOK COMPR FOR 45MM SCR,SUP-2178068,CDM,C1713,HCPCS,0278,RC,,,,both,,,5165.11,3357.32,,,,,,,,,,,,,
NERVE STIMULATOR KIT W/ PULSE GENRTR PERC LD,SUP-2563687,CDM,C1883,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
INTRODUCER SUPRPUB CATH 16FR SHTH 20FR L17CM TRCR L20CM FOR,SUP-2171356,CDM,C1894,HCPCS,0272,RC,,,,both,,,400.98,260.64,,,,,,,,,,,,,
MESH SURG DIA20-25CM WHT POLY CLLGN FLM RECT MFIL BIOABSRB,SUP-2283402,CDM,C1781,HCPCS,0278,RC,,,,both,,,5338.44,3469.99,,,,,,,,,,,,,
PLATE BONE THK1MM 2X2 H RT BILAT CRANIOMAXILLOFACIAL ORAL TI,SUP-2181779,CDM,C1713,HCPCS,0278,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE 3 PNL CANVS 12 IN LTX FREE,SUP-2336073,CDM,L1830,CPT,0274,RC,,,,both,,,56.24,36.56,,,,,,,,,,,,,
ALLOGRAFT DERMAL MED 6X18 CMX1.6/0.4 MM RDY TO USE ALLDERM,SUP-2465996,CDM,Q4116,HCPCS,0636,RC,,,,both,,,12622.80,8204.82,,,,,,,,,,,,,
GUIDEWIRE ZBR ANG .035X450CM,SUP-2141514,CDM,C1769,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SET URET STENT KWART RETRO INJ SOFFLX L 22-32 CM DIA 4.7 FR,SUP-2168903,CDM,C2617,HCPCS,0278,RC,,,,both,,,396.39,257.65,,,,,,,,,,,,,
CATHETER NEUROVASC GUID 4.3FR L130CM DIA0.044IN DST ACCS W/,SUP-2367786,CDM,C1887,HCPCS,0272,RC,,,,both,,,3391.39,2204.40,,,,,,,,,,,,,
STOCKING COMPR ARM BUTLER APPL AID DEV W/ STD LEN,SUP-2724359,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.58,74.48,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO STR PLT 1 PK STRL,SUP-2935351,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
WRAP ELBW BREATHABLE UNIV FOREARM FOAM 2 ADJ STRAP PROCARE,SUP-2196799,CDM,L3702,HCPCS,0274,RC,,,,both,,,44.37,28.84,,,,,,,,,,,,,
STENT PERIPH L20MM OD4MM CATH L135CM OD3.5FR GWIRE L300CM,SUP-2368140,CDM,C1876,HCPCS,0278,RC,,,,both,,,21073.80,13697.97,,,,,,,,,,,,,
SYSTEM LOADING VALVE EVOLUT 23MM,SUP-2501424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
COMPONENT FEM XSM L DST CO CHROM CEM PRI POST STBL STEMLESS,SUP-2252626,CDM,C1776,CPT,0278,RC,,,,both,,,23761.01,15444.66,,,,,,,,,,,,,
GRAFT HUM TISS L 8 X W 4 CM AMNIO MEMBRN CUST STRL,SUP-2913440,CDM,Q4173,HCPCS,0636,RC,,,,both,,,18243.40,11858.21,,,,,,,,,,,,,
PROBE HATCHED TIP DEB TI SONIC 1,SUP-2305955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1178.13,765.78,,,,,,,,,,,,,
LEAD DEFIB RELIANCE SG L 64 CM SIL EPTFE ENDOCARD RT,SUP-2148558,CDM,C2628,HCPCS,0272,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
SUPPORT ORTH L8IN M NEOPRENE EL CNTCT CLSR STRP D RNG GOLFER,SUP-2196836,CDM,L3702,HCPCS,0274,RC,,,,both,,,20.85,13.55,,,,,,,,,,,,,
TUBE VENT POPE 1.14 MM 1 MM 2.5 PHOSPHORYLCHOLINE COAT SIL,SUP-2535108,CDM,L8699,HCPCS,0278,RC,,,,both,,,50.21,32.64,,,,,,,,,,,,,
"HC So1 Ag Detect Nos, Eia Multi Step",PX-3068744967,CDM,87449,CPT,0306,RC,,,,both,,,384.00,249.60,,,,,,,,,,,,,
PROBE NERVE STIM MONOPOLAR STD PRASS HNDL FLSH TIP STRL DISP,SUP-2902005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.70,274.10,,,,,,,,,,,,,
HC Bx Breast 1st Lesion US Img,PX-3611908300,CDM,19083,CPT,0361,RC,,,,outpatient,,,7265.00,4722.25,,,,,,,,,,,,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,J2003,HCPCS,0636,RC,00409-4276-02,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
COIL VASC EMBOLD L 6 CM DIA2 MM CATH LUMEN DIA 0.021 IN PLAT,SUP-2753942,CDM,C1889,HCPCS,0278,RC,,,,both,,,3209.08,2085.90,,,,,,,,,,,,,
DEVICE FIX BIOABSORBABLE 3.5 MM W/ DRL BIT INSRTN TOOL,SUP-2760657,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.11,563.62,,,,,,,,,,,,,
GRAFT HUM TISS L 3 X W 2 CM AMNION-CHORION-AMNION LAYR,SUP-2909271,CDM,Q4140,HCPCS,0636,RC,,,,both,,,7066.88,4593.47,,,,,,,,,,,,,
FRAME ORTH L200MM ASSEMB SALVATION,SUP-2401159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22783.84,14809.50,,,,,,,,,,,,,
BLADE SHV PLAT 5.5MM DYONICS INCIS +,SUP-2341135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.49,211.57,,,,,,,,,,,,,
IMPLANT OTO L4MM PIST DIA0.5MM NIT FLROPLAS SMRT,SUP-2313862,CDM,2780000010,LOCAL,0278,RC,,,,both,,,950.48,617.81,,,,,,,,,,,,,
PLATE BNE L111MM THK3.4MM 8 H BILAT S STL STR LOK COMPR FOR,SUP-2185137,CDM,C1713,HCPCS,0278,RC,,,,both,,,914.62,594.50,,,,,,,,,,,,,
HC CT Guidance Needle Placement,PX-3507701200,CDM,77012,CPT,0350,RC,,,,both,,,621.00,403.65,,,,,,,,,,,,,
PLATE BNE L 208 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 18 H,SUP-2932967,CDM,C1713,HCPCS,0278,RC,,,,both,,,3416.63,2220.81,,,,,,,,,,,,,
MICROSPHERE EMB EMBOSPHERE DIA 40-120 UM 2 CC 20 CC SYR ORN,SUP-2303394,CDM,C1889,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
TUBING KIT RF COOLED FLUID 2 PRB IV SPIKE STRL COOLIEF LTX,SUP-2859189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.67,388.49,,,,,,,,,,,,,
CATHETER ABLATN MED CRV XLS 4/8 MM 2-5-2 MM 7 FRX115 CM,SUP-2356982,CDM,C1733,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
KIT VENTCULSTMY LUERLOCK HUB APPL DRP GZ SPNG FCPS MRK PEN,SUP-2243738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
INTRODUCER SHTH DBL CRV 12X14 FR ACCS W/ DIL,SUP-2424701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CATHETER ABLATN SM CRV 7 FR,SUP-2141287,CDM,C1733,HCPCS,0272,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
SUPPORT ORTHOT METATRSL CUST BAR WDG ROCKER,SUP-2435726,CDM,L3400,HCPCS,0272,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
HC Tips Revision,PX-3613718300,CDM,37183,CPT,0361,RC,,,,inpatient,,,15457.00,10047.05,,,,,,,,,,,,,
BUPROPION HCL ER (SR) 150 MG PO TB12,RX-18386,CDM,6370000000,HCPCS,0637,RC,00904-7465-61,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
SCREW BONE LOK 27MM DIA UNVRSL 14MML TTNM ST,SUP-2720367,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.10,252.26,,,,,,,,,,,,,
PLATE VA VLP CONDYLAT TI CRVD 12H RRT 266MM,SUP-2744544,CDM,C1713,HCPCS,0278,RC,,,,both,,,5923.23,3850.10,,,,,,,,,,,,,
STENT BILI NITI-S D L 6 CM DIA 8 MM DEL SYS L 180 CM DIA 8,SUP-2737106,CDM,C2617,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
HC Sterno-Clavicular Jt Min 3 Views,PX-3207113000,CDM,71130,CPT,0320,RC,,,,both,,,781.00,507.65,,,,,,,,,,,,,
SCREW ACET THMB ASMBLY INSTRUMENT,SUP-2449670,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
TUBE VENT 7 MM 1.14 MM 2.3 MM STR FLROPLAS STRL 520082,SUP-2535135,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.41,13.92,,,,,,,,,,,,,
HC So Ferritin|NOT REASONABLE AND NECESSARY,PX-3018272866,CDM,82728,CPT,0301,RC,,,GZ,both,,,79.00,51.35,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR TEMP PULSE GENRTR DDDDDD 500DVIVDDD00,SUP-2138031,CDM,C1713,HCPCS,0278,RC,,,,both,,,13878.80,9021.22,,,,,,,,,,,,,
TWIST DRILL MRRSN/KLS MRTN1.9MMX105MM AO ATTCH LEV1 TRCR,SUP-2500242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,821.68,534.09,,,,,,,,,,,,,
SHEATH INNR W STPCOCK PRSS SENS FOR 87K FLD MGMT SYS,SUP-2166833,CDM,C1894,HCPCS,0272,RC,,,,both,,,3073.87,1998.02,,,,,,,,,,,,,
EXTERNAL FIXATION KIT A FLD STRL HOFFMANN 3,SUP-2431371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14579.33,9476.56,,,,,,,,,,,,,
PLATE BNE LCK 349 MM LT DSTL LAT FEM 18 HOLE SS STRL,SUP-2466893,CDM,C1713,HCPCS,0278,RC,,,,both,,,4740.05,3081.03,,,,,,,,,,,,,
KIT PLATELET CONCENTRATION CARDIAMP 60ML F/CELL SEPARATOR,SUP-2866981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.82,476.98,,,,,,,,,,,,,
HC So2 Cardiolipin Antibody,PX-3028614768,CDM,86147,CPT,0302,RC,,,,both,,,30.00,19.50,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM DIA0.014IN NIT HYDRPHLC STR TIP,SUP-2148152,CDM,C1769,HCPCS,0272,RC,,,,both,,,398.18,258.82,,,,,,,,,,,,,
PROGRAMMER PT DBS ACTIVA,SUP-2665158,CDM,C1787,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
LISINOPRIL 10 MG PO TABS,RX-10449,CDM,6370000000,HCPCS,0637,RC,00904-6798-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ LOOP LOK W STAY E SUPP COT,SUP-2276650,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.64,6.27,,,,,,,,,,,,,
ENDPLATE SPNL DISK H6MM 11X12MM FOOTPRINT 6DEG CO CHROM,SUP-2232282,CDM,C1713,HCPCS,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
DUAL PKT 36MM ALPHA H PLATE,SUP-2400568,CDM,C1713,HCPCS,0278,RC,,,,both,,,4744.54,3083.95,,,,,,,,,,,,,
HC Calcium Total,PX-3018231000,CDM,82310,CPT,0301,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
BASEPLATE TIB N BEAD SM KNEE ASMBLY KINEMAX +,SUP-2452024,CDM,C1776,CPT,0278,RC,,,,both,,,5069.22,3294.99,,,,,,,,,,,,,
PLATE BNE W10XL77MM THK3.3MM HK D18MM 8 H L CLAV S STL LOK,SUP-2185837,CDM,C1713,HCPCS,0278,RC,,,,both,,,2266.83,1473.44,,,,,,,,,,,,,
GUIDEWIRE SURG STRL AFFIRM,SUP-2598527,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
SLEEVE EXT FIX DIA 4/5 MM CENTERING,SUP-2898477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SCREW INTRF RND HD 8X25MM COMPOSITCP 30,SUP-2212840,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
ALLODERM THIN FENESTRATED 4X8,SUP-2827478,CDM,Q4116,HCPCS,0636,RC,,,,both,,,8644.42,5618.87,,,,,,,,,,,,,
ADAPTER LD 5 32MM BPLR BIFUR,SUP-2355667,CDM,C1883,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
CLAMP EXT FIX DIA56MM BAR TO PIN MINI FRDM,SUP-2342866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4142.29,2692.49,,,,,,,,,,,,,
STAPLER INT L L33MM DIA5MM GI YEL TI BARIATRIC CIR CUT 2,SUP-2421062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4498.90,2924.28,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ANGLED 3 CM 0.038 INX150 CM NIT SENSOR,SUP-2139366,CDM,C1769,HCPCS,0272,RC,,,,both,,,147.05,95.58,,,,,,,,,,,,,
ROD SPNL L31CM DIA635MM QTR UNIT,SUP-2289676,CDM,C1713,HCPCS,0278,RC,,,,both,,,3881.04,2522.68,,,,,,,,,,,,,
SHUNT VLV PRECHAMBER PEDIATRIC 15 CM H2O ADJ PROGAV 2.0,SUP-2846932,CDM,C1889,HCPCS,0278,RC,,,,both,,,9218.35,5991.93,,,,,,,,,,,,,
SIZER BRST 325CC DIA11.9CM P4.1CM SIL GEL RND SMOOTH MOD +,SUP-2300937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM CRANIOMAXILLOFACIAL SELF DRL CROSS,SUP-2363330,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.58,108.93,,,,,,,,,,,,,
HC Rfa Renal Tumor(S),PX-3615059200,CDM,50592,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
STENT BILI ABS L 20 MM UNCONSTRAINED DIA 6 MM CATH L 135 CM,SUP-2101748,CDM,C1876,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
UREA 15 G PO PACK,RX-136732,CDM,6370000000,HCPCS,0637,RC,62530-0000-11,NDC,,both,1,UN,16.40,10.66,,,,,,,,,,,,,
BODY FEM L13.5MM HIP MOD ENCORE,SUP-2217197,CDM,C1776,CPT,0278,RC,,,,both,,,10314.90,6704.68,,,,,,,,,,,,,
IMPLANT HUM TISS L 21-30 CM OD 4-10 MM FEM ART CRYOPRESERVED,SUP-2931135,CDM,C1762,CPT,0278,RC,,,,both,,,20498.11,13323.77,,,,,,,,,,,,,
KIT INFLATION DEV PRIORITY PK INFLATED 30 ATM VLV ID 0.096,SUP-2103552,CDM,C1894,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 5 CC DBM FIBER NEVOS,SUP-2762317,CDM,C1713,HCPCS,0278,RC,,,,both,,,1771.90,1151.73,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 10 IN WRST FOREARM LT,SUP-2336335,CDM,L3809,HCPCS,0274,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
HC Elec Alys Implt Smpl Cn Npgt Prgrmg,PX-9209597600,CDM,95976,CPT,0920,RC,,,,inpatient,,,121.00,78.65,,,,,,,,,,,,,
CORE OSTEOCHONDRAL FS/A 15MM,SUP-2876043,CDM,C1762,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
HC Assay of Magnesium|NOT REASONABLE AND NECESSARY,PX-3018373500,CDM,83735,CPT,0301,RC,,,GZ,both,,,122.00,79.30,,,,,,,,,,,,,
DRESSING POST OPERATIVE RIGID BULK N WET BEAR,SUP-2388204,CDM,L5460,HCPCS,0274,RC,,,,both,,,1662.85,1080.85,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 340 HF-T TI EPOXY RESIN SIL,SUP-2138122,CDM,C1882,HCPCS,0275,RC,,,,both,,,76582.72,49778.77,,,,,,,,,,,,,
IMMOBILIZER KNEE PREMIER PRO TRI PNL 22INCH FOAM TIETEX PAT,SUP-2336077,CDM,L1830,CPT,0274,RC,,,,both,,,38.78,25.21,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP RT PROX HUM,SUP-2867026,CDM,C1762,CPT,0278,RC,,,,both,,,15812.88,10278.37,,,,,,,,,,,,,
REUSABLE NS SINGLE-ANGLE BRKT W/ ACCUSITE NDL GUID 5,SUP-2164637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
INSERT ACET ALPHA GG STD 48 MM 28 MM HIP METASUL ALLOFIT,SUP-2204500,CDM,C1776,CPT,0278,RC,,,,both,,,5909.17,3840.96,,,,,,,,,,,,,
CONNECTOR SPNL D SHP BAR 5.5 MM SACR STD ASMBLY OPN EXPEDIUM,SUP-2590528,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CAP T2 RECON NAIL 10MM END,SUP-2700929,CDM,C1889,HCPCS,0278,RC,,,,both,,,675.89,439.33,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US,PX-5102060500,CDM,20605,CPT,0510,RC,,,,both,,,908.00,590.20,,,,,,,,,,,,,
HEAD FEM DIA22MM +0MM CO CHROME,SUP-2314550,CDM,C1776,CPT,0278,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
DRILL BNE ACCS 10 GA STRL SYNFLATE,SUP-2758541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
TRAY MAXIMAL BARR PICC CATH SGL LUMN 5 FR 55 CM LEN N COAT N,SUP-2118885,CDM,C1751,HCPCS,0278,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
BUR SURG BALL 3 MMX12 CM SYMMETRI MIDAS REX LEGEND,SUP-2627646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.11,273.72,,,,,,,,,,,,,
CATHETER NASOBILIARY 8.5FR L250CM STL TEF W/ GWIRE DISP,SUP-2148628,CDM,C1898,HCPCS,0275,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT VASC SZ 24 MM SPEC 3 BRANCH,SUP-2535444,CDM,C1768,CPT,0278,RC,,,,both,,,6206.43,4034.18,,,,,,,,,,,,,
BIT DRL DIA11MM TRIFLAT FOR ZEPHIR ANT CERV PLT SYS,SUP-2291211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
CARTRIDGE GRFT DEL GEL 5 CC STRL INSTAFILL SIGNIFY LTX,SUP-2865332,CDM,C1713,HCPCS,0278,RC,,,,both,,,5746.20,3735.03,,,,,,,,,,,,,
COUNTERSINK SURG HDLSS 3X3 MM,SUP-2175119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
SYSTEM ORTHOPEDIC 5.5 MM FDL,SUP-2431994,CDM,C1776,CPT,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
GRAFT SKIN 1.6 CM ANTIMICROBIAL DISC PURAPLY,SUP-2314114,CDM,Q4196,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ANCHOR SUT L19.1MM DIA5.5MM BIOCOMPOSITE FULL THRD KNOTLESS,SUP-2121683,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
LEAD ANAS CPLR EXT FLO CPLR,SUP-2900199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.58,354.63,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 8 MM EPTFE STR TW N RING,SUP-2396350,CDM,C1768,CPT,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
TWIST DRILL MRRSN/KLS MRTN2.0MMX105MM CYL LEV1 TRCR,SUP-2499281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
GUIDEWIRE VASC TORQ-FLEX L 40 CM DIA 0.018 IN FLX TIP L 8 CM,SUP-2168207,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.07,47.50,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM F CRV UNIDIR,SUP-2248942,CDM,C1732,HCPCS,0272,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
DEXRAZOXANE HCL 500 MG IV SOLR,RX-145117,CDM,J1190,HCPCS,0636,RC,72266-0101-01,NDC,,both,1,UN,569.40,370.11,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 60 CM DIA 5 FR SPC 2-8-2 MM TIP,SUP-2486634,CDM,C1730,HCPCS,0272,RC,,,,both,,,356.55,231.76,,,,,,,,,,,,,
DISTRACTOR SURG X TRACK FOR ORTHOLOC 3DI,SUP-2398324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4769.66,3100.28,,,,,,,,,,,,,
PATCH HERN SM DIA1.7IN CIR W/ STRP SEPRA TECHNOLOGY ABSRB,SUP-2125891,CDM,C1781,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
GRAFT HUM TISS W27-32XH11XL21-26MM 8DEG FRZN ANTR LUM INTBDY,SUP-2177053,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GRAFT BIO TISS W20XL25CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113037,CDM,Q4130,HCPCS,0636,RC,,,,both,,,48070.26,31245.67,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 5 MM LOW PROFILE NEURO TITANIUM NON,SUP-2838226,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.04,154.73,,,,,,,,,,,,,
SUMATRIPTAN SUCCINATE 50 MG PO TABS,RX-15328,CDM,6370000000,HCPCS,0637,RC,62756-0521-69,NDC,,both,1,UN,8.00,5.20,,,,,,,,,,,,,
COIL EMB L57CM OD0.020IN LOOP OD15MM STD NIT COMPLX FRME,SUP-2323380,CDM,C1889,HCPCS,0278,RC,,,,both,,,7470.06,4855.54,,,,,,,,,,,,,
METAL CANNULA 5.0MM,SUP-2812609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
ROCKER EXT FIX SHRT FT NS DISP MONK RING,SUP-2899189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4308.87,2800.77,,,,,,,,,,,,,
DRILL REAMER COMBINATION,SUP-2475333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
RING 58 RINGFIX SYS ALUM 180MM,SUP-2696085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3362.94,2185.91,,,,,,,,,,,,,
DRILL SURG BUSHING 2.5 MM TRABECULAR MTL BIGLIANI/FLATOW,SUP-2436806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.19,578.62,,,,,,,,,,,,,
ELECTRODE ELECSURG NDL 90 DEG PEDIATRIC 10 FR HF RESECT STRL,SUP-2464387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
BLADE SHAVER STR STD 4.8 MM TYP A STRL DISP,SUP-2638421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 16MM DISK,SUP-2905491,CDM,Q4151,HCPCS,0636,RC,,,,both,,,1371.43,891.43,,,,,,,,,,,,,
RING EXT FIX DIA180 MM 1/2 PNK NS DISP SPAT FRME TSF,SUP-2933314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3807.31,2474.75,,,,,,,,,,,,,
SCREW BNE LCK 5X18 MM PERIPROSTHETIC ST OPTILINK NS VALCP,SUP-2789486,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.32,383.71,,,,,,,,,,,,,
RESERVOIR EXT DRNGE L15CM S STL PLAS SIL RUB BASE 9.5MM BUR,SUP-2243786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.57,826.52,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED BICOMPARTMENTAL ONLAY RESTORIS MCK,SUP-2265789,CDM,C1776,CPT,0278,RC,,,,both,,,15747.10,10235.61,,,,,,,,,,,,,
SCREW SPNL MONOAX 5.5X40 MM 4.5 MM SS,SUP-2630570,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.82,2883.93,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV BSC 4FR 55CM 2 LUMAN RVS 3274118,SUP-2632664,CDM,C1751,HCPCS,0278,RC,,,,both,,,513.77,333.95,,,,,,,,,,,,,
RING EXT FIX DIA105 MM ACCSRY SINGLE ROW 2/3 NS DISP TSF,SUP-2932865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4858.77,3158.20,,,,,,,,,,,,,
PLATE BNE 5 DEG 7 DEG RT VALGUS MOD,SUP-2438048,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
BLADE SCREWDRIVER 1MM DIA 61MML CENTRE DRIVE,SUP-2676783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.76,255.94,,,,,,,,,,,,,
LEVEL CMF ST PLATE RECON TLTS STR 20 25 MM SCRW20 HOLE 158,SUP-2669748,CDM,C1713,HCPCS,0278,RC,,,,both,,,3896.68,2532.84,,,,,,,,,,,,,
HC ED Clsd Tx Finger Fx W Manip,PX-4502672500,CDM,26725,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SYSTEM VEIN HARV ENDOSCP INCL DISECT AND HARVER ROD TRCR,SUP-2385158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2102.23,1366.45,,,,,,,,,,,,,
STABILIZER SURG MECH AXIUS,SUP-2141846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
KIT REPL FOR CHARGE PAK BTTRY CHRG 2 SET ELECTRD LFEPK CR +,SUP-2327704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.25,476.61,,,,,,,,,,,,,
STENT GRFT VASC TAG L 15 CM UNCOVERED L 4 MM PROX/DSTL,SUP-2423919,CDM,C1768,CPT,0278,RC,,,,both,,,63255.30,41115.94,,,,,,,,,,,,,
CATHETER ANGIO OD4FR L65CM 0.035IN AD FLUSHED PGTL RADPQ,SUP-2116581,CDM,C1887,HCPCS,0272,RC,,,,both,,,325.93,211.85,,,,,,,,,,,,,
CONFORMER OPHTH W/ HOLE MED 23X20 MM,SUP-2261402,CDM,L8610,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
GUIDEWIRE ORTH MULTIPLE 2.8 MM NS,SUP-2789128,CDM,C1769,HCPCS,0272,RC,,,,both,,,4663.28,3031.13,,,,,,,,,,,,,
SHEARS LAPSCP L34CM DIA10MM PSTL GRP UCIS REPROC HARM,SUP-2257661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1073.16,697.55,,,,,,,,,,,,,
PIN FIX L180MM DIA3.5MM S STL SGL END SHRP TIP CTRL THRD,SUP-2186930,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.33,163.36,,,,,,,,,,,,,
SPACER SPNL W12XH5XL14MM 5DEG PEEK OPTMA INTERVERTEBRAL,SUP-2211875,CDM,C1821,HCPCS,0278,RC,,,,both,,,3432.65,2231.22,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS L 120 CM BALLOON L 4 CM DIA20 MM,SUP-2127925,CDM,C1725,HCPCS,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
ULTRABAG/DIANEAL/4.25% DEX 483 MOSM/L IP SOLN,RX-32721,CDM,2580000003,HCPCS,0250,RC,00941-0433-53,NDC,,both,1000,ML,74.80,48.62,,,,,,,,,,,,,
SNARE SURG OVL 230 CM 25 GAX3 MM ISNARE,SUP-2736641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
STEM FEM SZ 2 135DEG TI HA HIP POR PLSM SPR PROX REV,SUP-2408341,CDM,C1776,CPT,0278,RC,,,,both,,,16252.64,10564.22,,,,,,,,,,,,,
RELOAD STPLR X THN 60 MM REINF FOR SIGNIA LD TRI-STAPLE 2.0,SUP-2858006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1530.09,994.56,,,,,,,,,,,,,
MESH CRAN L 90 X W 80 MM THK 0.8 MM SCREW DIA1.5/1.7 MM MED,SUP-2883650,CDM,C1713,HCPCS,0278,RC,,,,both,,,6230.80,4050.02,,,,,,,,,,,,,
CANNULA ENDOSCP INSUL 25 MMX23 CM MONOPOLAR LARYNGEAL,SUP-2776942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,512.92,333.40,,,,,,,,,,,,,
PORT INFUS 8FR POLYUR ATTCH CHRONOFLEX CATHETER TI OPN SUT H,SUP-2126310,CDM,C1788,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
IB KIT PEEK NON-COLLAGEN COATED,SUP-2812060,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.547,SUP-2860228,CDM,C1713,HCPCS,0278,RC,,,,both,,,50072.64,32547.22,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0250,RC,00264-7520-10,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
DRILL SURG KT STRL MINIBUNION,SUP-2432224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
PLATE COLINK AFX ONE THIRD TUBULAR 5 HOLE,SUP-2741109,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PLATE BNE 1ST MTP/MPJ SM 2.7 MM RT NS FPS LTX,SUP-2856856,CDM,C1713,HCPCS,0278,RC,,,,both,,,5438.48,3535.01,,,,,,,,,,,,,
BRACE KNEE N SLIP 2XL COMFORTABLE BREATHABLE DONJOY RX WEB,SUP-2196495,CDM,L1812,HCPCS,0272,RC,,,,both,,,228.31,148.40,,,,,,,,,,,,,
NUT EXT FIX DIA10MM FLNG FOR SALVATION EXT FIX,SUP-2401145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
BARRIER ADH TISS SM 3X5 IN INCISION ABSORBABLE SEPRAFILM,SUP-2336787,CDM,C1765,HCPCS,0278,RC,,,,both,,,855.56,556.11,,,,,,,,,,,,,
STYLET NERVE STIM ENHANCED 30 CM KT W/ STEERING CAP STIFF,SUP-2464114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX2/5 T SHPD F/2.7MM SCREW UNVRSL L,SUP-2495529,CDM,C1713,HCPCS,0278,RC,,,,both,,,1003.92,652.55,,,,,,,,,,,,,
STEM FEM LAT 9/13 MAG NK W/ TRUNNION GENERATION 4,SUP-2443999,CDM,C1776,CPT,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
CATHETER ART SET LN POLYETH FEM 0.028INX2 GWIRE 18GA 15CM,SUP-2167842,CDM,C1751,HCPCS,0278,RC,,,,both,,,130.66,84.93,,,,,,,,,,,,,
IMPLANT BIO TISS W25XL40MM THK3MM ABD BOV CLLGN SURGIMEND,SUP-2383082,CDM,C1781,HCPCS,0278,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
PEG BNE FIX L18MM DIA2MM DST VOLAR RAD LOK SMOOTH FOR ANAT,SUP-2414131,CDM,C1776,CPT,0278,RC,,,,both,,,359.78,233.86,,,,,,,,,,,,,
PLATE BNE TIB 4.5/6.5X109 MM LT PROX 5 HOLE SS EPI UNION,SUP-2461237,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
STENT NEURO FRED L 28/22 MM WORKING L 22/14 MM DIA 5.5 MM,SUP-2738105,CDM,C1876,HCPCS,0278,RC,,,,both,,,39901.55,25936.01,,,,,,,,,,,,,
NEBULIZER RESP C6ML SM VOL INHAL AD W/ MOUTHPC O2 TBNG,SUP-2227412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2273.83,1477.99,,,,,,,,,,,,,
SCREW BONE CONDYLE FASTENING F/TEMP ADJ DEV LEIBINGER UNIV 2PK,SUP-2363870,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.33,266.06,,,,,,,,,,,,,
BLADE RETRACTOR ANKENEY AD 1-3/8X2 IN STRNL SUTURE HOLDING,SUP-2485540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3237.91,2104.64,,,,,,,,,,,,,
STENT URET SOF-CURL 360 DEG L 30 CM DIA 7 FR TECOFLEX NYL,SUP-2460737,CDM,C2617,HCPCS,0278,RC,,,,both,,,211.17,137.26,,,,,,,,,,,,,
TUBE MYR ID127MM VENT TI MORETZ,SUP-2313694,CDM,L8699,HCPCS,0278,RC,,,,both,,,92.63,60.21,,,,,,,,,,,,,
SCREW BNE LCK 2.3X12 MM,SUP-2691426,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.10,319.21,,,,,,,,,,,,,
OSTEOTOME SURG L120MM DIA12MM FLXIBLE OSTEO FLX,SUP-2375013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1072.00,696.80,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7184,SUP-2499897,CDM,C1769,HCPCS,0272,RC,,,,both,,,905.58,588.63,,,,,,,,,,,,,
PLATE BNE L 146 MM 12 H SS RADIAL SHFT STRL EVOS,SUP-2933112,CDM,C1713,HCPCS,0278,RC,,,,both,,,3290.09,2138.56,,,,,,,,,,,,,
CUBE EXT FIX 2 HOLE RANCHO,SUP-2749947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK FULL THRD W/ FORC FBR INTRALINE,SUP-2366675,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.37,487.74,,,,,,,,,,,,,
SCREW BNE L75MM DIA6MM TI CANC ST LOK PARTIALLY THRD LO,SUP-2282070,CDM,C1713,HCPCS,0278,RC,,,,both,,,110.75,71.99,,,,,,,,,,,,,
FORCEP SPEC RETRV GRASPING 5 FRX40 CM 20 MM,SUP-2835653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,572.27,371.98,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FD ASEP WHL FASC LATA,SUP-2867004,CDM,C1762,CPT,0278,RC,,,,both,,,3299.20,2144.48,,,,,,,,,,,,,
SLEEVE DRL DIA27MM SGL END DISPOSABLE,SUP-2193799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.99,312.64,,,,,,,,,,,,,
PLATE BONE NON LOCKING SMALL 3.5X41 MM CORTICAL 2 HOLE COMPR,SUP-2837373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.68,764.19,,,,,,,,,,,,,
BIT DRILL RM 4 MM ACL CROSSPIN,SUP-2212874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1290.54,838.85,,,,,,,,,,,,,
PEG BNE FIX L18MM DIA2.5MM DST VOLAR RAD PARTIALLY THRD FOR,SUP-2414243,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
BLOCK TIB AUG 4 10 MM,SUP-2201702,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SET IMPL 3.5MM LO PROF PELV SYS,SUP-2177061,CDM,C1713,HCPCS,0278,RC,,,,both,,,136236.06,88553.44,,,,,,,,,,,,,
NAIL IM L26CM OD10MM GLD FEM TIB KNEE LCK CANN BENT RG AG,SUP-2347081,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
THYROID 120 MG PO TABS,RX-7938,CDM,6370000000,HCPCS,0637,RC,62559-0744-01,NDC,,both,1,UN,5.80,3.77,,,,,,,,,,,,,
HC So1 Collagen Cross-Link N-Telopep,PX-3018252367,CDM,82523,CPT,0301,RC,,,,both,,,215.00,139.75,,,,,,,,,,,,,
SCREW SPNL MONOAX 5.5X45 MM FOR 4.5 MM ROD SS SHILLA,SUP-2630571,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.82,2883.93,,,,,,,,,,,,,
NAIL IM L300MM DIA10MM 130DEG NONSTERILE GRN FEM TI CANN,SUP-2192590,CDM,C1713,HCPCS,0278,RC,,,,both,,,4431.42,2880.42,,,,,,,,,,,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,J7608,HCPCS,0636,RC,70069-0019-01,NDC,,both,4,ML,71.10,46.21,,,,,,,,,,,,,
BLOCK TIB AUG L67MM THK6MM KNEE TI ALLY CEM VANGUARD,SUP-2405486,CDM,C1776,CPT,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
RING EXT FIX MED 180 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29967.16,19478.65,,,,,,,,,,,,,
SCREW BONE 3.5MMX65MM LCK T20 ST PERI-LOC,SUP-2349993,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.51,843.38,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 7FRX12CM SHTH W/ 0.038 IN GWIRE,SUP-2355482,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 0.025 INX260 CM RND STIFF JAGWIRE,SUP-2457436,CDM,C1729,HCPCS,0272,RC,,,,both,,,314.38,204.35,,,,,,,,,,,,,
KIT CATH 1.9FR X 25CM 1-LUMEN POLYURETH PICC 30GA MOD INTRO,SUP-2874172,CDM,C1751,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
GUIDEWIRE ORTH L800MM DIA2.2MM S STL SMOOTH TIP FOR T2 HUM,SUP-2368577,CDM,C1769,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CATHETER KIT BUNDLED 16 CM CV,SUP-2214467,CDM,C1751,HCPCS,0278,RC,,,,both,,,349.07,226.90,,,,,,,,,,,,,
HC COMPRESSION HEAD STD 7.6MM,SUP-2841248,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19.5MMW X80MML 0.9MM THK 0.9MM THK CUT LG,SUP-2605477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,81.45,52.94,,,,,,,,,,,,,
PACEMAKER 2 CHMBR MRI SAFE ACCENT DR,SUP-2357691,CDM,C1785,HCPCS,0275,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv,PX-3606441800,CDM,64418,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
GUIDEWIRE ORTH L 16 IN DIA2 MM LG TROCAR TIP STRL DISP,SUP-2934484,CDM,C1769,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
FULL TIB WDG W/O SCR SZ 2,SUP-2359307,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
STEM FEM HIP CEM REV NEUT CALCAR 10.5MM DIA 175MM LEN,SUP-2211495,CDM,C1776,CPT,0278,RC,,,,both,,,17613.83,11448.99,,,,,,,,,,,,,
MESH HERN ELLIPSE 10X8 IN POLYPR VENTRALIGHT ST,SUP-2126517,CDM,C1781,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.021 IN TIP L 6 MM PTFE J FIX,SUP-2301926,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.42,18.47,,,,,,,,,,,,,
PLATE BNE L205MM 6 H PROX FEM S STL HK LOK COMPR LO PROF,SUP-2186056,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.95,2884.02,,,,,,,,,,,,,
COIL EMB L30CM DIA12MM 00135IN SFT HELI DETACH STRTCH,SUP-2173301,CDM,C1889,HCPCS,0278,RC,,,,both,,,3686.36,2396.13,,,,,,,,,,,,,
STRM STRAIGHT PLATE 6 HOLE,SUP-2488253,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.88,2144.27,,,,,,,,,,,,,
DELIVERY SYR SCP 5-PACK,SUP-2205791,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PIN HALF THRD 6X200 MM 25 MM EXT FIX SS HA,SUP-2343011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 10 IN WRST FOREARM RT,SUP-2336334,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
PLATE BNE COMPR NAR 14 HOLE,SUP-2205651,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.67,354.69,,,,,,,,,,,,,
IMPL SUBTALAR SUBFIX 8MM,SUP-2476855,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
IMPLANT ANK JT TALAR COMP R FLAT CUT CO CHROM SALTO TALARIS,SUP-2244182,CDM,C1776,CPT,0278,RC,,,,both,,,31045.18,20179.37,,,,,,,,,,,,,
DEVICE FIXATION LADDER PLATE WIDE 14 HOLES,SUP-2719531,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
"HC So Systemic Lupus a, Dna Ab",PX-3028622567,CDM,86225,CPT,0302,RC,,,,both,,,28.00,18.20,,,,,,,,,,,,,
PLATE BNE STD RT 22 HOLE FOR ORTH FIX STRL POLARUS 3,SUP-2518204,CDM,C1713,HCPCS,0278,RC,,,,both,,,7284.80,4735.12,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X200 MM FRZN GAM SEMITENDINOSUS,SUP-2866909,CDM,C1762,CPT,0278,RC,,,,both,,,2720.50,1768.32,,,,,,,,,,,,,
PLATE BONE L W7XL34MM THK1MM 3 H LT TI OBLQ RIG,SUP-2191007,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.50,132.27,,,,,,,,,,,,,
SPLINT ORTH SUPP MED YTH WRST FOREARM RT ALUM FOAM,SUP-2194488,CDM,L3808,HCPCS,0274,RC,,,,both,,,12.15,7.90,,,,,,,,,,,,,
STEM FEM ARCOS 15X115MM CYL DIST,SUP-2506043,CDM,C1776,CPT,0278,RC,,,,both,,,9382.32,6098.51,,,,,,,,,,,,,
SPACER SPNL LORDTC 5 DEG 11 MM LUMBAR OBLQ VERTIGRAFT II,SUP-2264977,CDM,C1713,HCPCS,0278,RC,,,,both,,,9878.38,6420.95,,,,,,,,,,,,,
GRAFT DURA REP L 4 X W 3 CM THK 0.4 MM ELECTROSPUN FIBER,SUP-2904021,CDM,C1763,HCPCS,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
SCREW BNE FT 4X26 MM 12 MM CANC SM HEX SOCKET SS NS LCP,SUP-2183724,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.76,35.59,,,,,,,,,,,,,
IMMOBILIZER ORTH 2 AXIS SHT 17 IN 36 IN KNEERANGER II,SUP-2197133,CDM,L3702,HCPCS,0272,RC,,,,both,,,105.28,68.43,,,,,,,,,,,,,
SCREW BNE L65MM OD5.5MM YEL TI LO EXT ST SELF DRL CANN FIX,SUP-2242848,CDM,C1713,HCPCS,0278,RC,,,,both,,,1484.31,964.80,,,,,,,,,,,,,
PLATE BNE W17.5XL260MM THK5.2MM 14 H BILAT S STL BROAD LOK,SUP-2185304,CDM,C1713,HCPCS,0278,RC,,,,both,,,2131.15,1385.25,,,,,,,,,,,,,
SCREW INTERFERENCE L35MM DIAMETER 9MM CANNULATED,SUP-2842784,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.29,269.29,,,,,,,,,,,,,
PIN FIX L9IN DIA48MM S STL 3 SIDE SGL TRCR 1 END PNT STYL,SUP-2150447,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.11,53.37,,,,,,,,,,,,,
PACK PROC 6FT IVTM DISP STRT UP KT ICY,SUP-2416138,CDM,C1751,HCPCS,0278,RC,,,,both,,,12803.16,8322.05,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|ADJ,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|CQ|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE BNE LCK 34 MM LT RADIAL PERIARTICULAR 3 HOLE STYLOID,SUP-2461202,CDM,C1713,HCPCS,0278,RC,,,,both,,,1465.09,952.31,,,,,,,,,,,,,
STENT BILI SYM L 22 MM DIA 7 FR CATH L 75 CM DIA 6 MM NIT AD,SUP-2141179,CDM,C1876,HCPCS,0278,RC,,,,both,,,3808.82,2475.73,,,,,,,,,,,,,
CATHETER BASIC DWELL ENDURNC KIT ARROW 22GAX8,SUP-2744559,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
ANCHOR SUT FOR SPNL CRD STIM SWIFT-LOCK,SUP-2355908,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
ROD SPNL L420MM DIA35 55MM OCCIPITOCERVICAL UP THOR TAPR,SUP-2285471,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
SCREW 4X38MM,SUP-2678040,CDM,C1713,HCPCS,0278,RC,,,,both,,,746.54,485.25,,,,,,,,,,,,,
PLATFORM ACCS L45CM DIA4CM TRANSANAL 5 10MM OBT 10MM RETRCT,SUP-2119684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2363.01,1535.96,,,,,,,,,,,,,
MICROCATHETER GUID MIRAFLEX L 135 CM OD 2.5 FR ID 0.021 IN,SUP-2170451,CDM,C1887,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 7/64X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150470,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.69,8.25,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X1 MM 6 HOLE FRAC LCK TI LEVEL 1,SUP-2484699,CDM,C1713,HCPCS,0278,RC,,,,both,,,875.24,568.91,,,,,,,,,,,,,
SCREW BNE L24MM DIA3.5MM S STL SELF DRL NONCANNULATED LOK,SUP-2397385,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SHELL ACET 46 MM FEM HIP MTL,SUP-2202535,CDM,C1776,CPT,0278,RC,,,,both,,,8314.72,5404.57,,,,,,,,,,,,,
HC Immunofluorescence per Spec 1st Single Antb Stn,PX-3128834600,CDM,88346,CPT,0312,RC,,,,both,,,443.00,287.95,,,,,,,,,,,,,
GRAFT BONE SUB DIA6CM CIR SHP DEMIN BONE MTRX GRFTON A-FLEX,SUP-2293902,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.02,2591.56,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ANGLED 3 CM 0.038 INX150 CM 66802091,SUP-2862344,CDM,C1769,HCPCS,0272,RC,,,,both,,,115.71,75.21,,,,,,,,,,,,,
PROBE LASER 25GA ILLUMINATED FLX CRV W/ RFID,SUP-2109955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.78,445.76,,,,,,,,,,,,,
BIT DRL L46MM DIA1MM 4MM STP STRYKR END DISP FOR 1.2MM SCR,SUP-2366398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,397.68,258.49,,,,,,,,,,,,,
LINER ACET LAT F 35 DEG 32X54-56 MM HIP XLPE REFLECTION,SUP-2434806,CDM,C1776,CPT,0278,RC,,,,both,,,6926.84,4502.45,,,,,,,,,,,,,
PLATE SPNL L72-79.5MM THORLUM COMPR TRUSS,SUP-2230329,CDM,C1713,HCPCS,0278,RC,,,,both,,,10801.60,7021.04,,,,,,,,,,,,,
COUNTERSINK SURG CONDYLE T2 ALPHA SYS STRL DISP,SUP-2902692,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
SHELL ACET OD76MM TI POR PLSM SPR HIP LIMIT H RAD FIN,SUP-2406532,CDM,C1776,CPT,0278,RC,,,,both,,,4733.55,3076.81,,,,,,,,,,,,,
PLATE BNE THK0.8MM 4X2 H HND TI TRAP GRID TRILOK TECHNOLOGY,SUP-2267909,CDM,C1713,HCPCS,0278,RC,,,,both,,,2374.78,1543.61,,,,,,,,,,,,,
PUMP PAIN PROGRAMMABLE FOR PRE MRI PROC FLOWONIX PROMETRA II,SUP-2225540,CDM,E0783,HCPCS,0278,RC,,,,both,,,31714.00,20614.10,,,,,,,,,,,,,
MESH HERN W12XL15CM RECT PREPERI BIOMATERIAL COMP POLYPR,SUP-2395760,CDM,C1781,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
DOPPLER VASC W 8MHZ PRB DGT DISPLAY ALK BATTERIES ART PRSS,SUP-2308197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3047.84,1981.10,,,,,,,,,,,,,
CATHETER INFUSION SPEEDLYSER L 15 CM DIA 5 FR SLT PAT L 10,SUP-2118522,CDM,C1757,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLUG RMR DIA 14MM SPNL LUM TAPR FUS SGL BRL L CAGE,SUP-2291611,CDM,C1713,HCPCS,0278,RC,,,,both,,,297.48,193.36,,,,,,,,,,,,,
HC Iadna Streptococcus Group B Amplified Probe Tq,PX-3068765300,CDM,87653,CPT,0306,RC,,,,both,,,105.00,68.25,,,,,,,,,,,,,
BLADE SAW W8XL75MM THK1MM RECIP,SUP-2363317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1058.02,687.71,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH ULTRA L 13 CM DIA 7 FR GUIDEWIRE L,SUP-2159474,CDM,C1892,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BONE TUBULAR 26 MM 2 HOLE 1/3 STERILE PERILOC,SUP-2837388,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.37,318.74,,,,,,,,,,,,,
HC Acute Hepatitis Panel,PX-3018007400,CDM,80074,CPT,0301,RC,,,,both,,,416.00,270.40,,,,,,,,,,,,,
HC Inj's Anes/Steroid Pudental Nerve,PX-3616443000,CDM,64430,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
KIT PROC W IMPL STP DRL PHALANX REAMERS BNE HLDR IMPL HNDL,SUP-2137578,CDM,C1713,HCPCS,0278,RC,,,,both,,,4388.97,2852.83,,,,,,,,,,,,,
GRAFT VASC MAXIFLO L 50 CM DIA 6 MM EPTFE SEAL PTFE TW STRL,SUP-2392562,CDM,C1768,CPT,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
STEM FEM L250MM DIA15MM BEAD 10IN CO CHROM HIP REV NEUT,SUP-2203216,CDM,C1776,CPT,0278,RC,,,,both,,,19042.53,12377.64,,,,,,,,,,,,,
MESH 16X12 R ANAT,SUP-2172955,CDM,C1781,HCPCS,0278,RC,,,,both,,,1490.50,968.82,,,,,,,,,,,,,
COMPONENT FEM M L KNEE REV CEM CRUCE RET STEM NONBEADED CO 66300315] STRYKER ORTHOPEDICS HOWM],SUP-2377047,CDM,C1776,CPT,0278,RC,,,,both,,,10876.96,7070.02,,,,,,,,,,,,,
GRAFT BNE INJ 10 CC REGENERATIVE PRO-DENSE,SUP-2759449,CDM,C1713,HCPCS,0278,RC,,,,both,,,9254.15,6015.20,,,,,,,,,,,,,
PLATE BONE WITHOUT ANGLE THICK 2.5 MM MANDIBLE PATIENT SPECI,SUP-2838603,CDM,C1713,HCPCS,0278,RC,,,,both,,,18588.49,12082.52,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CALCIUM SULF CALCIUM PHOSPHATE LO,SUP-2890267,CDM,C1713,HCPCS,0278,RC,,,,both,,,11872.34,7717.02,,,,,,,,,,,,,
SAW SURG 1-2 KNEE MOD POST CAPTURE ATTUNE,SUP-2454798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 5-6 EF 20 MM KNEE GRN NXGN LPS,SUP-2208736,CDM,C1776,CPT,0278,RC,,,,both,,,3679.45,2391.64,,,,,,,,,,,,,
FORCEP BX 1 MMX286 CM FOR MAX ACCSRY DEV SPYBITE,SUP-2423800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1641.53,1066.99,,,,,,,,,,,,,
NAIL FEM RG 13.5MMX420MM,SUP-2405542,CDM,C1713,HCPCS,0278,RC,,,,both,,,8700.94,5655.61,,,,,,,,,,,,,
SCREW BNE L75MM DIA5MM PROX FEM S STL SELF DRL ST CONIC HD,SUP-2184729,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.42,341.52,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY DEMIN CANC CORT 4MM-10MM RANG 60CC,SUP-2294044,CDM,C1713,HCPCS,0278,RC,,,,both,,,2191.72,1424.62,,,,,,,,,,,,,
SCREW BONE 4.5X100MM MALLEOLUS ARSENAL,SUP-2878254,CDM,C1713,HCPCS,0278,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
ANCHOR SUT ROT CUF W/ ETHBND QUICKANCHR +,SUP-2249345,CDM,C1713,HCPCS,0278,RC,,,,both,,,2078.68,1351.14,,,,,,,,,,,,,
APPLICATOR SURG 7 CM LOCALIZER 22,SUP-2137815,CDM,A4648,CPT,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
CATHETER CTRL VEN 0.62ML 5FR CUF POS 5CM POLYUR GRAV FLO,SUP-2127764,CDM,C1887,HCPCS,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
PLATE BNE L 56 MM 4 H SS RT DSTL RADIAL VOLAR STD STRL EVOS,SUP-2931336,CDM,C1713,HCPCS,0278,RC,,,,both,,,3144.08,2043.65,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR DD,SUP-2248604,CDM,C1732,HCPCS,0278,RC,,,,both,,,9730.86,6325.06,,,,,,,,,,,,,
BELT STBL SM 100759] ST JUDE MED THORATEC],SUP-2355989,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
MESH HERN W15XH15CM POLYPR NONABSORBABLE SYN SQ PROL,SUP-2219795,CDM,C1781,HCPCS,0278,RC,,,,both,,,281.44,182.94,,,,,,,,,,,,,
SCREW BNE CANC 150MM THRD LEN 30MM OD 6MM XCALIBER ST,SUP-2316314,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.84,276.15,,,,,,,,,,,,,
BLADE ENDOSCP CUBITAL TUNN RELEASE SYS ENDORELEASE LTXFRDM,SUP-2604359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2353.40,1529.71,,,,,,,,,,,,,
CROSSLINK SPNL TITLE 2 IMP T LINK 50MM GLDN GATE,SUP-2205496,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
DRESSING BIO L 2 X W 4 CM PORCINE CLLGN SINGLE LAYR FEN SHT,SUP-2909412,CDM,Q4195,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UNI CKNEEBIOUNI] ZIMMER BIOMET INC],SUP-2137380,CDM,C1776,CPT,0278,RC,,,,both,,,9423.14,6125.04,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RX 014 12 ATM 6 FRX140 CM 4X15 MM CUT,SUP-2141221,CDM,C1725,HCPCS,0272,RC,,,,both,,,2584.91,1680.19,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC DBM,SUP-2913398,CDM,C1713,HCPCS,0278,RC,,,,both,,,2282.78,1483.81,,,,,,,,,,,,,
PLATE BNE 10 H 98DEG SUPCONDYLAR S STL BILAT LOK RIG SHT,SUP-2370901,CDM,C1713,HCPCS,0278,RC,,,,both,,,4052.96,2634.42,,,,,,,,,,,,,
PLATE BNE L 45 MM SCREW DIA2 MM 3 HD 6 SHFT H TI T SHP MINI,SUP-2907575,CDM,C1713,HCPCS,0278,RC,,,,both,,,2830.46,1839.80,,,,,,,,,,,,,
CATHETER EP STEER SM 5 MM SPC 6 FR INQUIRY,SUP-2357432,CDM,C1730,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CANNULA TANDEMHEART 72CM TRANSSEPTAL,SUP-2862988,CDM,C1889,HCPCS,0278,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ADV 14LP L 110 CM BALLOON L 6 CM DIA2 MM,SUP-2168966,CDM,C1725,HCPCS,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
SCREW INTRF L25MM DIA9MM 1 TI CANN FLX NONABSORBABLE TAPR HD,SUP-2342264,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
HC So Tissue Culture Tumor,PX-3118823966,CDM,88239,CPT,0311,RC,,,,both,,,267.00,173.55,,,,,,,,,,,,,
NOZZLE BNE CEM R ANG FOR VAC MIX SYS OPTVAC,SUP-2216842,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.86,189.71,,,,,,,,,,,,,
STRUT EXT FIX MED RX W/ DYNA STRL TRUELOK EVO LTX,SUP-2875634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
GRAFT ENDOVASC L108MM PROX L37MM DSTL L71MM DIA24X12MM SHTH,SUP-2170308,CDM,C1874,HCPCS,0278,RC,,,,both,,,19860.50,12909.32,,,,,,,,,,,,,
PIN FIX L9IN DIA24MM ST S STL 2 SIDE SGL DMND 1 END PNT,SUP-2150478,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.22,8.59,,,,,,,,,,,,,
ANCHOR SUT W/ ORTHOCORD KNOTLESS FOR ROT CUF REP VERSALOK,SUP-2249331,CDM,C1713,HCPCS,0278,RC,,,,both,,,2750.64,1787.92,,,,,,,,,,,,,
SCREW SYS DEPTH G DRL 100 MM 2.7 MM OD 4.5 MM SCRS,SUP-2392913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.10,595.46,,,,,,,,,,,,,
SCREW BNE PART THRD 5X90 MM PANTA,SUP-2423786,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.58,627.63,,,,,,,,,,,,,
SCREW BNE 1.5X4 MM DRILL-FREE TI STRL ONEDRIVE 251530471,SUP-2460469,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.68,155.79,,,,,,,,,,,,,
PLATE BNE W33XL173MM 12 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185115,CDM,C1713,HCPCS,0278,RC,,,,both,,,4331.88,2815.72,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG ACUTE 13.5FR DIA 20CML IN 5575200,SUP-2632905,CDM,C1752,HCPCS,0278,RC,,,,both,,,608.53,395.54,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-110987,CDM,J0650,HCPCS,0636,RC,70710-1833-01,NDC,,both,1,UN,543.40,353.21,,,,,,,,,,,,,
SPHERE OPHTH DIA20MM EYE PMMA LTWT PERM,SUP-2129496,CDM,L8610,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
SET PICC 2L 5FR X 55CM W BP,SUP-2887054,CDM,C1751,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
GUIDEPIN ORTH L358MM OD3.2MM FULL THRD CANN,SUP-2344063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2083.33,1354.16,,,,,,,,,,,,,
SET PERICARDCENT L 22 CM DIA 7 FR GUIDEWIRE L 70 CM DIA,SUP-2760017,CDM,C1729,HCPCS,0272,RC,,,,both,,,482.40,313.56,,,,,,,,,,,,,
SCREW SPNL L12MM S STL ST THRD UNIV BULL SHP HD DISTR PIN,SUP-2274176,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.75,42.74,,,,,,,,,,,,,
SCREW BNE L 95 MM DIA 4 MM SS CANC PART THRD T15 STARDRV,SUP-2905725,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.70,430.75,,,,,,,,,,,,,
CANNULA ENDOSCP FLX W/ NDL INJ,SUP-2747281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,915.62,595.15,,,,,,,,,,,,,
CATHETER PICC ARROWG+ARD BLU ADV L 55 CM DIA 4.5 FR,SUP-2827500,CDM,C1751,HCPCS,0278,RC,,,,both,,,310.23,201.65,,,,,,,,,,,,,
SACUBITRIL-VALSARTAN 49-51 MG PO TABS,RX-130695,CDM,6370000000,HCPCS,0637,RC,70377-0032-12,NDC,,both,1,UN,37.10,24.11,,,,,,,,,,,,,
BOOT TRAC M L20IN FOR 15.5IN CALF CONVOLUTED FOAM LNR STAY,SUP-2196869,CDM,L4387,HCPCS,0274,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
SCREW SPNL L 85 MM DIA10.5 MM TI PEDCL THORLUM POLYAXL CANN,SUP-2885872,CDM,C1713,HCPCS,0278,RC,,,,both,,,1529.18,993.97,,,,,,,,,,,,,
HEALICOIL KNOTLESS RG ST,SUP-2823680,CDM,C1713,HCPCS,0278,RC,,,,both,,,1605.70,1043.70,,,,,,,,,,,,,
SCREW SPNL L 6 MM BLACKARMOR CARBON PEEK THORLUM M8 STRL,SUP-2917073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
SCREW SPNL 2PK SD 4X11 MM FIX ANGLE STRL ATLNTS ESSENTIALS,SUP-2632022,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
CATHETER HD RT STR AD 62.5 CM SWAN NK CURL CATH KT ARYGLE,SUP-2283992,CDM,C1750,HCPCS,0278,RC,,,,both,,,816.71,530.86,,,,,,,,,,,,,
ENDOTRACHEAL TUBE KIT 39 FR LT DL BLT IN VID CAM VIVASIGHT 2,SUP-2752996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
OCCLUDER CV WATCHMAN DIA21 MM SHTH L 75 CM DIA14 FR DEL SYS,SUP-2141820,CDM,C1889,HCPCS,0278,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
PLATE BNE STD L DORS FIX ANG LOK K WIRE JOYSTICK H ACU-LOC,SUP-2106932,CDM,C1713,HCPCS,0278,RC,,,,both,,,3039.52,1975.69,,,,,,,,,,,,,
PLATE BNE STR 0.6 MM LT 4 HOLE C-TUBE HK FOR 6MM BRIDGE TI,SUP-2458997,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.77,750.60,,,,,,,,,,,,,
DILATOR ENDOSCP L240CM BLLN L5.5CM DIA10X11X12MM CATH 7.5FR,SUP-2141551,CDM,C1726,HCPCS,0272,RC,,,,both,,,690.39,448.75,,,,,,,,,,,,,
PLATE BONE 6 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413750,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.73,702.47,,,,,,,,,,,,,
OPES 90 ABLATOR TOOTHBRUSH,SUP-2815764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
VALVE MI ORIFICE DIA261MM TISS ANNULUS DIA37MM 85DEG LEAFLET,SUP-2355167,CDM,C1889,HCPCS,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
BUR SURG CANN 6 MM,SUP-2598331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2882.52,1873.64,,,,,,,,,,,,,
ROD EXTERNAL FIXATION L200MM STAINLESS STEEL THREADED,SUP-2586508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.98,282.74,,,,,,,,,,,,,
NAIL CPHLMDLLRY L215CM OD115MM 130DG SM SHRT TTNM RIGHT CCD,SUP-2462052,CDM,C1713,HCPCS,0278,RC,,,,both,,,4450.26,2892.67,,,,,,,,,,,,,
PLATE BONE STRUT 1.5 MM 2 HOLE RAPID RESORBABLE STERILE RAPI,SUP-2838554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.90,1211.53,,,,,,,,,,,,,
TUBE TRACH CUF 6 MM SINGLE CANN,SUP-2264507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
INTRODUCER REPROC SHTH SM CURL 0.032 IN 8.5 FRX71 CM AGILIS NXT,SUP-2357284,CDM,C1766,CPT,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
ENDPLATE SPNL LOWER L12MM 15X18MM FOOTPRINT 7DEG VERT BODY,SUP-2229978,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CABLE EP CATH L 2.5 M 10 PIN MODEL 1910-S DIAG CONN GUID,SUP-2887273,CDM,C1732,HCPCS,0278,RC,,,,both,,,472.57,307.17,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.7 MM SM PATELLAR MESH STRL EVOS,SUP-2933646,CDM,C1713,HCPCS,0278,RC,,,,both,,,6575.16,4273.85,,,,,,,,,,,,,
STENT URTRL 6FR DIA 28CML SLCNE TCFLX OPEN END WPSH CATH UR,SUP-2727156,CDM,C2617,HCPCS,0278,RC,,,,both,,,429.90,279.43,,,,,,,,,,,,,
SCREW BONE L30MM OD3.5MM TI CORT T15 ST,SUP-2101289,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.38,52.25,,,,,,,,,,,,,
PLATE BONE CRANIO FACE MAND FULL SEC RECON 6 H TI W/ TEMPLT,SUP-2363755,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.83,2847.54,,,,,,,,,,,,,
CATHETER GUID SPEX 35 L 50 CM OD 0.035 IN ID 0.063 IN,SUP-2227749,CDM,C1887,HCPCS,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
MESH HERN ANAT LG 15X10 CM RT PRESHAPED MONOFILAMENT DEXTILE,SUP-2752175,CDM,C1781,HCPCS,0278,RC,,,,both,,,827.30,537.74,,,,,,,,,,,,,
RING EXT FIX ID180MM ANK FT FULL FOR TRUELOK FRME ASSEMB,SUP-2316173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3359.05,2183.38,,,,,,,,,,,,,
PLATE 22MM UNIV FOREFOOT,SUP-2243220,CDM,C1713,HCPCS,0278,RC,,,,both,,,5303.30,3447.14,,,,,,,,,,,,,
DEVICE PROSTHETIC SHRINKER BK 5] SOUTHERN PROSTHETIC SUPPLY],SUP-2352853,CDM,L8440,HCPCS,0274,RC,,,,both,,,168.18,109.32,,,,,,,,,,,,,
HOLDER NDLE CSTRVJO 8 1/2NL TNGSTN CRBDE STRGHT SRRTD JAW DL,SUP-2482021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.47,285.66,,,,,,,,,,,,,
PLATE BNE MIC THK0.4MM 18 H BILAT CRANIOMAXILLOFACIAL BLU,SUP-2181676,CDM,C1713,HCPCS,0278,RC,,,,both,,,2384.83,1550.14,,,,,,,,,,,,,
CATHETERIZATION KIT ART 025 20 GAX12 CM 18/25 GA 5 CC FEP LF,SUP-2865584,CDM,C1751,HCPCS,0278,RC,,,,both,,,316.51,205.73,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 1 CC DBM PTTY OSTEOINDUCTIVE STRL,SUP-2883879,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
PORT VEN ACC UNASSEMBLED SGL LUMN POLYSULFONE TI ULT LCK,SUP-2352177,CDM,C1788,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DEVICE REVASCULARIZATION EMBOTRAP III L 22 MM DIA 5 MM NIT 3,SUP-2525506,CDM,C1889,HCPCS,0278,RC,,,,both,,,28501.31,18525.85,,,,,,,,,,,,,
FIBER LASER 550 MICRON 3/PKG STERILE INCLUDES 1,SUP-2574064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1169.74,760.33,,,,,,,,,,,,,
SET INFUS L100CM OD5FR CATH SEG L7CM GWIRE OD0.035IN 14,SUP-2418550,CDM,C1751,HCPCS,0278,RC,,,,both,,,282.69,183.75,,,,,,,,,,,,,
GRAFT BNE PASTE 2 CC SUBSTITUTE OPTEFORM,SUP-2223558,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
STAPLER INT AD L30MM DIA4.8MM TI STR PRELD DISP ROTIC,SUP-2283031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1920.36,1248.23,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0258,RC,00990-7984-20,NDC,,both,25,ML,29.20,18.98,,,,,,,,,,,,,
LEAD PACE RENEWAL TR EASYTRAK 2/3 STRL,SUP-2149120,CDM,C1895,HCPCS,0275,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
CATHETER HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 20 5551200,SUP-2632899,CDM,C1752,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SCREW BNE L60MM DIA3.7MM CORT S STL ST DRL CANN LOK FULL,SUP-2178754,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.31,322.60,,,,,,,,,,,,,
COUPLER EXT FIX PIN TO ROD DELT FOR HOFFMANN III MOD SYS,SUP-2372219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1947.43,1265.83,,,,,,,,,,,,,
PLATE BNE RECON 2.7X241 MM 20 HOLE LCK STR SS STRL,SUP-2469129,CDM,C1713,HCPCS,0278,RC,,,,both,,,2580.89,1677.58,,,,,,,,,,,,,
CATHETER URET 6/10FR L50CM INJ LUMN DIA0.05IN AQ 2 LUMN,SUP-2171300,CDM,C1758,HCPCS,0278,RC,,,,both,,,136.28,88.58,,,,,,,,,,,,,
RING 12 RINGFIX SYS ALUM 160MM,SUP-2696084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3747.28,2435.73,,,,,,,,,,,,,
IMPLANT GLEN SM PEGGED ALPHA EQUINOXE,SUP-2223348,CDM,C1776,CPT,0278,RC,,,,both,,,3918.72,2547.17,,,,,,,,,,,,,
MESH HERN OVL 14X12 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855275,CDM,C1781,HCPCS,0278,RC,,,,both,,,57132.30,37135.99,,,,,,,,,,,,,
IMMOBOLIZER SHLDR SUPP UNIV UNISX M,SUP-2136721,CDM,L3660,HCPCS,0274,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
TRAY CATHETER 5FR L135CM S STL 2 LUMN W GWIRE,SUP-2126388,CDM,C1751,HCPCS,0278,RC,,,,both,,,381.20,247.78,,,,,,,,,,,,,
CEMENT BNE VOID 2 GM,SUP-2402962,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
PROBE ABLATN RF XL 180 MM 50-S W/ INTEGR CABLE HND SERFAS,SUP-2557500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1893.20,1230.58,,,,,,,,,,,,,
COMPONENT TIB L150MM L7CM THK9MM PROX N MOD CEM STEM 1 PC,SUP-2405790,CDM,C1776,CPT,0278,RC,,,,both,,,21463.47,13951.26,,,,,,,,,,,,,
MANIFOLD ANGIO 200PSI ANGIO 4 VLV M PRSS ON HNDL PRT REG RT,SUP-2118875,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
BUSHING FEM SET POLYETH OSS AVL,SUP-2441789,CDM,C1776,CPT,0278,RC,,,,both,,,1031.49,670.47,,,,,,,,,,,,,
ANCHOR SUT SZ 4.5MM WHT BLU PEEK UHMWPE BRAID FLAT PERMATAPE,SUP-2417594,CDM,C1713,HCPCS,0278,RC,,,,both,,,1720.72,1118.47,,,,,,,,,,,,,
BIT DRL DIA4.5MM CANN DISP,SUP-2412628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1339.84,870.90,,,,,,,,,,,,,
WIRE EXT FIX L100MM DIA2MM THRD L15MM THRDED,SUP-2316466,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.00,212.55,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2931471,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.74,88.23,,,,,,,,,,,,,
ALLOGRAFT BNE 2 CC,SUP-2264599,CDM,C1889,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
NAIL IM L270MM DIA7.5MM 120DEG STRL BLU L/R HUM TI CANN LCK,SUP-2192494,CDM,C1713,HCPCS,0278,RC,,,,both,,,5991.37,3894.39,,,,,,,,,,,,,
PEG BNE FIX DST FEM KNEE CO CHROM MOLYBDENUM ALLY VANGUARD,SUP-2407475,CDM,C1776,CPT,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
INSERT TIB SZ 5 THICKNESS 12MM CO CHROM UHMWPE KNEE PRI POST,SUP-2365100,CDM,C1776,CPT,0278,RC,,,,both,,,2121.86,1379.21,,,,,,,,,,,,,
TRAY NERVE BLOCK CANN DIA20 GA BPSK SNB400OPM STRL LF DISP,SUP-2936628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,57.34,37.27,,,,,,,,,,,,,
STENT URET SILHOUETTE COMFORT L 26 CM DIA 4.6 FR NIT SYNTH,SUP-2119484,CDM,C2617,HCPCS,0278,RC,,,,both,,,391.12,254.23,,,,,,,,,,,,,
PLATE BNE L208MM THK34MM 16 H BILAT S STL STR LIMIT CNTCT,SUP-2185154,CDM,C1713,HCPCS,0278,RC,,,,both,,,1944.66,1264.03,,,,,,,,,,,,,
BIT DRL L65MM DIA3.5MM S STL W/O STP NONRADIOPAQUE DISP FOR,SUP-2318878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,674.35,438.33,,,,,,,,,,,,,
RETRACTOR W21MM H15MM L5CM TUBE D.6IN OD12MM SELF RET MEDL,SUP-2393992,CDM,C1894,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PRAZOSIN HCL 1 MG PO CAPS,RX-6468,CDM,6370000000,HCPCS,0637,RC,00904-7020-61,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
INTRODUCER CATHETER 10FR L8IN FOR CHOLGM CATHETER TAUT,SUP-2384042,CDM,C1894,HCPCS,0272,RC,,,,both,,,115.68,75.19,,,,,,,,,,,,,
CATHETER THOR 32FR DIA10.7MM POLYVI CHL TRCR TIP STR SFT,SUP-2384356,CDM,C1729,HCPCS,0272,RC,,,,both,,,20.72,13.47,,,,,,,,,,,,,
BENDING PIN FOR LOCKING ATTACHMENT PLATES,SUP-2548486,CDM,C1713,HCPCS,0278,RC,,,,both,,,936.85,608.95,,,,,,,,,,,,,
SCREW BNE L20MM DIA7MM ANT POST KNEE TI HEX DRV RND HD FOR,SUP-2341527,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.91,280.74,,,,,,,,,,,,,
PIN FIX L9IN DIA4MM ST S STL 3 SIDE SGL TRCR 1 END PNT STYL,SUP-2150452,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.59,12.73,,,,,,,,,,,,,
GUIDEWIRE VASC TAD II L 260 CM DIA 0.035 IN MICROGLIDE,SUP-2104859,CDM,C1769,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
ALLOGRAFT HUM TISS BLOCK ASEP ACHILLES TEND,SUP-2257908,CDM,C1762,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
PISTON OTOLARYN L3.75MM OD.6MM S STL FLROPLAS INCUS PIST,SUP-2312534,CDM,L8613,CPT,0278,RC,,,,both,,,300.03,195.02,,,,,,,,,,,,,
PIN BNE FIX L25MM OD2MM N LOK RESRB POLY L LACTIDE ACID,SUP-2166475,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.38,303.15,,,,,,,,,,,,,
GRAFT BONE PUTTY SYR DEMINERALISED BONE MTRX 2.5CC,SUP-2244479,CDM,C9359,HCPCS,0278,RC,,,,both,,,1248.15,811.30,,,,,,,,,,,,,
IMMOBILIZER KNEE L20IN AD 1 SZ FIT MOST UNIV WRP ARND OPN,SUP-2196742,CDM,L1830,CPT,0274,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 8 FR LP X-PORT ISP,SUP-2126616,CDM,C1788,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
SCREW CVR TI CONIC USED FOR BAHA TWO STG SURG BI300,SUP-2164965,CDM,2780000010,LOCAL,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES PATTEN BTM TYP,SUP-2435606,CDM,L1755,HCPCS,0272,RC,,,,both,,,5069.15,3294.95,,,,,,,,,,,,,
BAR SACRAL THRD 6X260MM,SUP-2547746,CDM,C1713,HCPCS,0278,RC,,,,both,,,1851.44,1203.44,,,,,,,,,,,,,
BIT DRL TAPR HD 5 MMX9 IN BADGER,SUP-2765764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.21,576.69,,,,,,,,,,,,,
BIT DRL DIA4MM SH ADD ON FIT FOR TRIGEN SURESHOT DSTL,SUP-2347935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.23,787.95,,,,,,,,,,,,,
MATRIX BIO L 8 X W 10 CM SZ 144 SQCM FISH SKIN DERMAL BX/10,SUP-2909360,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9316.07,6055.45,,,,,,,,,,,,,
BIT DRILL SURG W/ NEEDLE FOR Q-FIX STRL DISP,SUP-2882970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1259.93,818.95,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 6CMD SPNL MSCLE MULTI TTHD BLACK FNSH U,SUP-2494073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.35,405.18,,,,,,,,,,,,,
GRAFT HUM TISS M 30X150MM FASC LATA FRZ DRY READIGRFT,SUP-2264780,CDM,C1762,CPT,0278,RC,,,,both,,,3003.57,1952.32,,,,,,,,,,,,,
HC CT Upper Extremity W/ Contrast,PX-3527320100,CDM,73201,CPT,0352,RC,,,,both,,,4472.00,2906.80,,,,,,,,,,,,,
GRAFT BNE SUB 10ML HA SYN TISS CLLGN MTRX STRP RESRB HEALOS,SUP-2255627,CDM,C9362,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
PATCH VASC VASCU-GUARD L 8 X W 0.8 CM BOV PERICARD FOR,SUP-2130383,CDM,C1768,CPT,0278,RC,,,,both,,,771.12,501.23,,,,,,,,,,,,,
BIT DRL CANN 5X150 MM,SUP-2606631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
SCREW CORTICAL LOQTEQ VA 2.5X26MM,SUP-2719778,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
BAG WND LAV 1L CLR ETH ACET ACID SOD ACETT BENZALKONIUM CHL,SUP-2204123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
STEM FEM PRSS FT HIP CERM ON POLYETH OXIN R3,SUP-2351410,CDM,C1776,CPT,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
BIT DRL CHK END BNE ACL PLUG SUTURE JCBS STRL DISP,SUP-2608081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.75,204.59,,,,,,,,,,,,,
BIT DRL HEXA 3.5 MM POWERBIT TRINKLE END OMEGA +,SUP-2457452,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.92,568.05,,,,,,,,,,,,,
PIN EXT FIX L25MM OD5MM HA SALVATION,SUP-2401149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
MATRIX BIO L 7 X W 20 CM FISH SKIN DERMAL SLD INTACT STRL,SUP-2909291,CDM,Q4158,HCPCS,0636,RC,,,,both,,,13627.60,8857.94,,,,,,,,,,,,,
PROBE LITHOTROPIC ELECTRD 9 FR,SUP-2332789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,595.34,386.97,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 20MMX6X110CM BAL DIL PTV NUCLEUSX,SUP-2309686,CDM,C1725,HCPCS,0272,RC,,,,both,,,2681.78,1743.16,,,,,,,,,,,,,
PLATE BNE Y 1.5X29X1 MM MIDFACE 7 HOLE W/ TAB TI STRL,SUP-2480848,CDM,C1713,HCPCS,0278,RC,,,,both,,,845.92,549.85,,,,,,,,,,,,,
CUBITAL TUNNEL BLADE 5 PACK,SUP-2604360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11766.90,7648.48,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 5-8 MM EPTFE LNG TAPR STD,SUP-2681171,CDM,C1768,CPT,0278,RC,,,,both,,,1162.02,755.31,,,,,,,,,,,,,
PLATE BONE L56MM LNG NONSTERILE LT ANTEROLATERAL CALCNL S,SUP-2178430,CDM,C1713,HCPCS,0278,RC,,,,both,,,2907.83,1890.09,,,,,,,,,,,,,
BIT DRL CANN LG 14 MM QC NS,SUP-2799308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1454.76,945.59,,,,,,,,,,,,,
SCREW SPNL 6.5X50 MM EXPEDIUM VERSE,SUP-2256230,CDM,C1713,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
ES TROCH NAIL LEFT 10MMX39CM X125 DEGREE,SUP-2828767,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
INTRODUCER SHTH TRANSSEPTAL 032 8 FRX60 CM 67 CM MULLINS,SUP-2464325,CDM,C1893,HCPCS,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
STENT URET STR 0.035 IN 4.8 FRX22-30 CM 6 FR BENSTON CNTOUR,SUP-2472708,CDM,C2617,HCPCS,0278,RC,,,,both,,,367.54,238.90,,,,,,,,,,,,,
KIT OTOLOGICAL INSTR BKUP INCLUDE CANN WNING DRL DISP FOR,SUP-2319922,CDM,C1713,HCPCS,0278,RC,,,,both,,,787.36,511.78,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.018 IN TAPR L 7 CM FLPY TIP L,SUP-2167840,CDM,C1769,HCPCS,0272,RC,,,,both,,,158.60,103.09,,,,,,,,,,,,,
POURCHEZXPRESSO/SAFETRAC COMB KT TIP TO HUB LEN 32 CM IMPL,SUP-2354976,CDM,C1752,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRIPPER SURGICAL RETRACTOR DISP,SUP-2427782,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
GRAFT BNE STRP SM 50X25X6 MM 15 CC SCAFFOLD ATTRAX,SUP-2736497,CDM,C1713,HCPCS,0278,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
SLING GYN TENS FRE VAG TAPE W/ SECUR SYS GYNECARE TVT,SUP-2257820,CDM,C1771,HCPCS,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
COMPONENT TIB TY 5 ANK INFIN,SUP-2397011,CDM,C1776,CPT,0278,RC,,,,both,,,17147.54,11145.90,,,,,,,,,,,,,
VALVE CSF PERF LEVEL 2 SM EXTRACTED DELT,SUP-2628542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4967.54,3228.90,,,,,,,,,,,,,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,2500000003,HCPCS,0250,RC,00338-1123-04,NDC,,both,2000,ML,494.50,321.42,,,,,,,,,,,,,
INTRODUCER ENDO OD3.07MM ID2.48MM S STL SGL USE,SUP-2239408,CDM,C1894,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
FORCEP SPEC RETRV STONE 3 FRX120 CM RETRACTING PRNG TRICEP,SUP-2473736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.86,350.26,,,,,,,,,,,,,
GRAFT AMNIO MEMBRN W2XL3CM DEHYDR AMNIOEXCEL,SUP-2194318,CDM,Q4137,HCPCS,0636,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
GRAFT INFLUX SPARC 10CC,SUP-2615610,CDM,C1713,HCPCS,0278,RC,,,,both,,,14852.20,9653.93,,,,,,,,,,,,,
CABLE SPNL DIA12MM ST S STL SGL LOOP W BAR CRMP SONGER,SUP-2255760,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
GRAFT DERMAL MESH 8X8 CM FEN + WND MTRX MIRODERM,SUP-2431552,CDM,Q4175,HCPCS,0636,RC,,,,both,,,12449.47,8092.16,,,,,,,,,,,,,
LINER ACET 40X26 MM SCR IN +5 RINGLOC+ MAX-ROM,SUP-2447214,CDM,C1776,CPT,0278,RC,,,,both,,,2472.75,1607.29,,,,,,,,,,,,,
HUMERAL HEAD CTA 54X23,SUP-2815448,CDM,C1776,CPT,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.018IN TIP L3CM NIT HYDRPHLC STD,SUP-2385560,CDM,C1769,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
ELECTRODE ES 6FR BUGBEE,SUP-2436271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.75,322.89,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 3.0 X 26MM H,SUP-2320885,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.33,478.61,,,,,,,,,,,,,
LETROZOLE 2.5 MG PO TABS,RX-21509,CDM,6370000000,HCPCS,0637,RC,50268-0476-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER GUID 7X5FR L68CM WRK L65CM 90DEG CRV PEBAX INNR,SUP-2356396,CDM,C1887,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE COMPR LNG 3.5/4 MM 3 HOLE STR NS LTX,SUP-2857067,CDM,C1713,HCPCS,0278,RC,,,,both,,,5598.62,3639.10,,,,,,,,,,,,,
PLATE BNE L 193 MM 16 H SS RADIAL SHFT STRL EVOS,SUP-2933262,CDM,C1713,HCPCS,0278,RC,,,,both,,,4497.11,2923.12,,,,,,,,,,,,,
COMPONENT TIB MOD NEUT LG 75 MM KNEE ENDO-MODEL SL,SUP-2423701,CDM,C1776,CPT,0278,RC,,,,both,,,13453.39,8744.70,,,,,,,,,,,,,
PROBE OPHTH VITRECTOMY 20 GA CRV ENDOPROBE,SUP-2225655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BIT DRILL CANN 24X14MM F/26MM PIN,SUP-2700935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.85,251.45,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM AMNIO MEMBRN TRNSLUC GRID PAT SGL,SUP-2113885,CDM,Q4154,HCPCS,0636,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
STEM HUM SZ 13 DIA13MM PROX SHLDR TI HYDROXYAPETITE RM,SUP-2379015,CDM,C1776,CPT,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
PLATE BONE 5 H STR MOTOBAND CP,SUP-2174980,CDM,C1713,HCPCS,0278,RC,,,,both,,,6485.67,4215.69,,,,,,,,,,,,,
WIRE FIX DIA1.6MM K,SUP-2267995,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.82,44.08,,,,,,,,,,,,,
TRIAL NERVE STIM KT INSTRUMENT STIM BLDR AFT ADV,SUP-2435498,CDM,C1820,HCPCS,0278,RC,,,,both,,,37306.34,24249.12,,,,,,,,,,,,,
GRAFT BNE INJ 20 CC PRO-DENSE,SUP-2759541,CDM,C1713,HCPCS,0278,RC,,,,both,,,15427.01,10027.56,,,,,,,,,,,,,
KIT JEJUSTMY TB 22FR BLLN 7-10ML JEJU L45CM TRANSGASTRIC,SUP-2124614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1074.95,698.72,,,,,,,,,,,,,
SCREW CRTX 5.0MM DIA 35MM LGTH FT SELF TAP F/BIOMET - 5.0MM,SUP-2136670,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
COLLAR CERV 3IN 12 24IN L TRACH OPN W  CHIN SUPP ADJUSTABLE,SUP-2431856,CDM,L0174,HCPCS,0274,RC,,,,both,,,182.91,118.89,,,,,,,,,,,,,
PAD ORTHOT LUMBAR CUST DEROTATION,SUP-2435587,CDM,L1240,HCPCS,0274,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
STENT URET SET SFT MFIL TETH 5FRX22CM UNIVERSA,SUP-2169458,CDM,C2617,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
SPHERE GLEN 2X25 MM ECC FOR AEQUALIS COCR,SUP-2431493,CDM,C1776,CPT,0278,RC,,,,both,,,9628.81,6258.73,,,,,,,,,,,,,
PLATE BNE STR 2.3X30 MM MAND 4 HOLE COMPR FRAC TI LEVEL 1 LF,SUP-2470388,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.99,500.49,,,,,,,,,,,,,
PROSTHESIS VOICE 2 VLV 20 FRX8 MM NS BLOM-SINGER,SUP-2242333,CDM,L8509,HCPCS,0274,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
HC Veeg by Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-7409571600,CDM,95716,CPT,0740,RC,,,,both,,,5500.00,3575.00,,,,,,,,,,,,,
FOOTPLATE EXT FIX 160 MM 12224100] CAROMED INTL],SUP-2162653,CDM,C1713,HCPCS,0278,RC,,,,both,,,5144.58,3343.98,,,,,,,,,,,,,
CUP ACET OD42MM ID22MM UHMWPE COMPR MOLD PVT BPLR,SUP-2314497,CDM,C1776,CPT,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
SUTURE ENDOSCP L165CM DIA2.8MM TISS HELIX F/ OVERSTITCH 6/BX,SUP-2119262,CDM,C1768,CPT,0278,RC,,,,both,,,677.71,440.51,,,,,,,,,,,,,
STYLET LD STR EXT TAPR BALL TIP PUR KNOB 55CM OD.016IN,SUP-2282080,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BUR SURG RND 6 MM 8 MM FLUT CARBIDE MSD AM33 STRL ULTRA PWR,SUP-2166779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,187.87,122.12,,,,,,,,,,,,,
PLATE BNE BAR L8MM THK1MM 4 H CRANIOMAXILLOFACIAL TI MINI,SUP-2366314,CDM,C1713,HCPCS,0278,RC,,,,both,,,510.00,331.50,,,,,,,,,,,,,
PLUG BNE VIT APCL ACET CUP,SUP-2376078,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.63,204.51,,,,,,,,,,,,,
BIT DRL 7 MM SHLDR FOR SILK FIX SCR NS DISP,SUP-2762096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
PROBE VITRCTMY ANT ATIOP LEG EVEREST,SUP-2109630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.49,304.52,,,,,,,,,,,,,
HC Add Lt Vent Pacing Lead to Pcm,PX-3613322400,CDM,33224,CPT,0361,RC,,,,outpatient,,,35488.00,23067.20,,,,,,,,,,,,,
CANDESARTAN CILEXETIL 16 MG PO TABS,RX-23231,CDM,6370000000,HCPCS,0637,RC,00378-3231-93,NDC,,both,1,UN,4.70,3.05,,,,,,,,,,,,,
HINGE EXT FIX UNIV TRUELOK,SUP-2316167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
DISTRACTOR SURG L 20 MM 3 X 3 H LT MANDIBULAR PED NS,SUP-2883552,CDM,C1713,HCPCS,0278,RC,,,,both,,,22874.90,14868.68,,,,,,,,,,,,,
NAIL IM L380MM DIA13MM ST AQUA L/R DST FEM TI LOK SLD DYN,SUP-2191819,CDM,C1713,HCPCS,0278,RC,,,,both,,,7336.30,4768.59,,,,,,,,,,,,,
NEEDLE ASPIR 20 GAX1.8X15 MM ALWAYS ON TIP TRACKED DISP,SUP-2392609,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
GRAFT STRP BNE MTRX TISS SYN 5CMX5CM INQU,SUP-2247318,CDM,C1713,HCPCS,0278,RC,,,,both,,,5206.12,3383.98,,,,,,,,,,,,,
TUBE SET ASPIR PRECIS TIP CYL SHAVER NEXUS SONASTAR,SUP-2748596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4217.52,2741.39,,,,,,,,,,,,,
HC Mra Abdomen W&W/O Contrast,PX-6187418502,CDM,C8902,CPT,0618,RC,,,,inpatient,,,2826.00,1836.90,,,,,,,,,,,,,
MESH HERN SM W5XL30CM POLYPR NONABSORBABLE SYN RECT PROL,SUP-2219802,CDM,C1781,HCPCS,0278,RC,,,,both,,,252.46,164.10,,,,,,,,,,,,,
SPLINT THMB M+ LT CARPOMETACARPAL JT RESTRICT ELAS SUPP,SUP-2324211,CDM,L3931,HCPCS,0272,RC,,,,both,,,64.24,41.76,,,,,,,,,,,,,
SYSTEM IMPL DEL GRFT ANCHR,SUP-2122601,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GRAFT HUM TISS L 3 X W 2 CM AMNIO MEMBRN RESRB AIR DRY STRL,SUP-2913449,CDM,Q4173,HCPCS,0636,RC,,,,both,,,5843.54,3798.30,,,,,,,,,,,,,
CATHETER PICC 3FR L45CM SGL LUMN SHERLOCK STYL MAXIMAL BARR,SUP-2125506,CDM,C1751,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
SYSTEM EUSTACHIAN DIL L 20 MM DIA 5 MM BALLOON INFLATION SYR,SUP-2900137,CDM,C1726,HCPCS,0272,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
UNILATERAL BAHA KIT-CONFIRMING PONO 1356915 FOR BOTH LN,SUP-2165015,CDM,L8614,HCPCS,0278,RC,,,,both,,,20221.60,13144.04,,,,,,,,,,,,,
ROD SPNL PRECUT 40 MM LUMBAR,SUP-2256248,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.89,826.73,,,,,,,,,,,,,
PATCH BIO TISS W60XL80MM BOV PERICARD GLUTARHYD CROSS LINKED,SUP-2130365,CDM,C1768,CPT,0278,RC,,,,both,,,1806.85,1174.45,,,,,,,,,,,,,
CORT BONE SCW 4.5MMX22MM,SUP-2510198,CDM,C1776,CPT,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SCREW INTFR L25MM DIA10MM ANT CRUCE LIG TI CANN,SUP-2366525,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.68,198.69,,,,,,,,,,,,,
HC Replace of Peg Tube Flu Guid,PX-4504945000,CDM,49450,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
SUTURE ORTHOCORD SZ 2-0 W/ DBL ARM MENIS NDL 228144,SUP-2256746,CDM,C1713,HCPCS,0278,RC,,,,both,,,689.54,448.20,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 80 CM 5 FR 0.035 IN SOS OMNI2 SFT,SUP-2116772,CDM,C1887,HCPCS,0272,RC,,,,both,,,59.03,38.37,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 180 CM STIFF SHT TAPR AQUATRACK,SUP-2158675,CDM,C1769,HCPCS,0272,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
STERILE WATER FOR INJECTION (MIXTURES ONLY),RX-430028,CDM,2500000003,HCPCS,0250,RC,00264-7850-00,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
SHEATH INTRO STEADYSHEATH EVOLUTION L 11.2 CM DIA 9 FR,SUP-2170084,CDM,C1893,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BIT DRL DIA49MM SHT CANN CALIB FOR NAT NAIL AG FEM SYS,SUP-2198669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1097.05,713.08,,,,,,,,,,,,,
TUBE MYR DIAM 4.5MM LEN 1.32MM T SHP SIL,SUP-2312838,CDM,L8699,HCPCS,0278,RC,,,,both,,,46.03,29.92,,,,,,,,,,,,,
CATHETER INTRAAORTIC BLLN 7.5 FR 25 CC,SUP-2227326,CDM,C1725,HCPCS,0272,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
HEYMAN FOLLOWERS STR TIP COMPLT SET (10-24FR.),SUP-2128929,CDM,C1726,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
ADAPTER OTOLARYN DIA4.5MM ABUTMENT DIA6MM 3MM W PREMOUNTED,SUP-2319915,CDM,L8690,HCPCS,0278,RC,,,,both,,,9982.06,6488.34,,,,,,,,,,,,,
NEEDLE ASPIR 21GA L20-40MM WRK L700MM CHN 2MM DST END ADJ,SUP-2313394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.92,243.70,,,,,,,,,,,,,
GUIDEWIRE VASC SAFARI L 260 CM DIA 0.035 IN SS LUBRIGREEN,SUP-2140840,CDM,C1769,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HOOK SPNL DIA4.5MM CERVICOTHORACIC LAM VERTEX MAX,SUP-2286783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CANN 3.9 FRX20 MM 0.025 IN TRUETOME,SUP-2141617,CDM,C1769,HCPCS,0272,RC,,,,both,,,917.16,596.15,,,,,,,,,,,,,
BIT DRL L100MM DIA2MM ST QUIK CPL NONRADIOPAQUE W/O STP,SUP-2187201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.45,243.39,,,,,,,,,,,,,
ROD EXT FIX THRD 200 MM,SUP-2197272,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
HC Chemo Im Inject Hormonal,PX-3319640200,CDM,96402,CPT,0331,RC,,,,both,,,279.00,181.35,,,,,,,,,,,,,
SCREW SPNL L40MM DIA5.5MM HA VAR ANG INTERCONTINENTAL,SUP-2230588,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT SYN H6XL17MM MIDFOOT WDG BIOFOAM,SUP-2397871,CDM,C1713,HCPCS,0278,RC,,,,both,,,5356.84,3481.95,,,,,,,,,,,,,
PATCH SURG FIBRIN SEAL 4.8X4.8 CM ABSORBABLE TACHOSIL,SUP-2130296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1429.83,929.39,,,,,,,,,,,,,
REMDESIVIR 100 MG/20 ML (MIXTURES ONLY),RX-4081838,CDM,J0248,HCPCS,0636,RC,61958-2901-02,NDC,,both,1,UN,2600.00,1690.00,,,,,,,,,,,,,
BUR SURG RND 3 MM TELSCP FOR STRYKR SIGN ELITE ATTCH STRL,SUP-2877760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.80,257.27,,,,,,,,,,,,,
SPLINT ANK FT XL R POST LEAF LTWT SEMI RIG ROLYAN,SUP-2326016,CDM,L4397,HCPCS,0272,RC,,,,both,,,113.89,74.03,,,,,,,,,,,,,
FORCEPS SURG UNIV PLT,SUP-2364410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.12,412.18,,,,,,,,,,,,,
PLATE BNE 2.7X63 MM 7 HOLE SS LCP,SUP-2569308,CDM,C1713,HCPCS,0278,RC,,,,both,,,371.31,241.35,,,,,,,,,,,,,
GRAFT BNE SUB 4CC CA SULF CA PHSPTE INJ REGEN PRO-DENSE,SUP-2399152,CDM,C1713,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
PLATE BNE L86MM 6 H BILAT MTPHSEAL S STL LOK COMPR LO PROF,SUP-2185099,CDM,C1713,HCPCS,0278,RC,,,,both,,,2390.17,1553.61,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE|DOCUMENTATION ON FILE|UNUSUAL NON-OVERLAPPING SERVICE,PX-4409712900,CDM,97129,CPT,0440,RC,,,GN|KX|XU,both,,,186.00,120.90,,,,,,,,,,,,,
PACEMAKER CARD EVIA SR-T TI SINGLE CHMBR HOME MONITORING MOB,SUP-2138288,CDM,C1786,HCPCS,0275,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
SEALER TISS L35CM DIA5MM CRV JAW ARTC ADV BPLR ENSEAL G2,SUP-2219729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4287.39,2786.80,,,,,,,,,,,,,
HC Revision/Reloc of Skin Pocket,PX-3613322200,CDM,33222,CPT,0361,RC,,,,both,,,6424.00,4175.60,,,,,,,,,,,,,
WIRE FIX 150MM 1.6MM TI K,SUP-2193147,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.65,16.02,,,,,,,,,,,,,
ROD SPNL L300MM DIA5.5MM STR MULT ANG PERC SNIPER,SUP-2354878,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PERICARDIOCENTESIS SET 8.5 FRX22 CM,SUP-2760013,CDM,C1729,HCPCS,0272,RC,,,,both,,,701.01,455.66,,,,,,,,,,,,,
KIT REP FOR 9.6FR SGL LUMN CTRL VEN CATH HCKMN,SUP-2127719,CDM,C1751,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
MESH SURG L6XW6IN 6MM THICKNESS POLY RIG KNIT RND CORNERS,SUP-2174778,CDM,C1781,HCPCS,0278,RC,,,,both,,,209.44,136.14,,,,,,,,,,,,,
CATHETER INFUSION MEWEISSEN L 65 CM DIA 5 FR SEG 10 CM,SUP-2141151,CDM,C1887,HCPCS,0272,RC,,,,both,,,237.16,154.15,,,,,,,,,,,,,
WIRE FIX TRCR PT 0.9X100 MM SINGLE END SMOOTH RND KIRSCHNER,SUP-2321714,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
DISTRACTOR SURG L150MM EXT FIX LIMB RECON ANGULAR TRUELOK,SUP-2316083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3238.22,2104.84,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
DEVICE PESSARY RNG W/ SUPP FLD 3IN SZ 5,SUP-2171738,CDM,A4562,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
CONDUIT NRV L20MM ID4MM PROVEN CHOICE GRFT NEUROTUBE,SUP-2382609,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
SET SCR SPNL M6 CONN MAS RECON SYS VERTEX,SUP-2289105,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.12,262.68,,,,,,,,,,,,,
SPACER SPNL INTBDY ANTR LUM LTX FRE,SUP-2101158,CDM,C1821,HCPCS,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
GRAFT BONE SUB 15CC MG BASE COMPND INJ MOLD BIOCOMPATIBLE,SUP-2418112,CDM,C1713,HCPCS,0278,RC,,,,both,,,13894.50,9031.42,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 9-13 MM FD ILIUM TRICORT,SUP-2717913,CDM,C1713,HCPCS,0278,RC,,,,both,,,3661.11,2379.72,,,,,,,,,,,,,
SCREW INTRF BIOABSORBABLE 2.7X24 MM FT,SUP-2166519,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.20,286.78,,,,,,,,,,,,,
BIT DRL L320MM DIA4.3MM CALIB FOR PHOENIX SYS,SUP-2412960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,478.54,311.05,,,,,,,,,,,,,
PLATE BNE LCK 5.5X189 MM RT PROX LAT TIB 10 HOLE SS STRL,SUP-2478081,CDM,C1713,HCPCS,0278,RC,,,,both,,,3974.20,2583.23,,,,,,,,,,,,,
BUR SURG 45MMX19CM PREBENT SPHR HIP PRESERVATION SYS,SUP-2167162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.01,503.11,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2.5MM FOR ORTHOLOC 3DI SYS,SUP-2398333,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 150 GM AMNIO MEMBRN PARTICULATE NEOX FLO,SUP-2648691,CDM,Q4155,HCPCS,0636,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 13 CM DIA 7 FR PTFE PERC LNG T,SUP-2127716,CDM,C1894,HCPCS,0272,RC,,,,both,,,239.86,155.91,,,,,,,,,,,,,
TUBE MYR L7MM POLY FOR VENT,SUP-2312523,CDM,L8699,HCPCS,0278,RC,,,,both,,,20.54,13.35,,,,,,,,,,,,,
SCREW BNE CORTICAL 1.5X11 MM 3 MM ST SS NS,SUP-2459129,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.43,118.58,,,,,,,,,,,,,
IMMOBILIZER ORTH XSM SHLDR,SUP-2196914,CDM,L3660,HCPCS,0272,RC,,,,both,,,12.59,8.18,,,,,,,,,,,,,
CLAMP CRAN L 12 MM NEURO CRANIOTOMY LN STRL DISP LORENZ,SUP-2935329,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK2-3.5MM ACELLULAR DERM MTRX,SUP-2402521,CDM,Q4126,HCPCS,0636,RC,,,,both,,,7410.40,4816.76,,,,,,,,,,,,,
STRAP CLAV STD L,SUP-2276600,CDM,L3650,HCPCS,0274,RC,,,,both,,,14.19,9.22,,,,,,,,,,,,,
PLATE BNE SM L53MM 3X3 H BILAT TI T OBLQ LIMIT CNTCT DYN,SUP-2190941,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.56,535.31,,,,,,,,,,,,,
CATHETER INFUSION MEWEISSEN L 100 CM DIA 5 FR SEG 15 CM,SUP-2141166,CDM,C1751,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
GRAFT BONE H10MM PARA NAR CERV PRESERVON VERTIGRFT VG 2,SUP-2264954,CDM,C1713,HCPCS,0278,RC,,,,both,,,3624.97,2356.23,,,,,,,,,,,,,
BIT DRL L70MM DIA27MM CANN DST CUT FOR EL STBL SYS IJS,SUP-2340229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1116.27,725.58,,,,,,,,,,,,,
CARTRIDGE SAW W25XH1.27XL105MM STD OSC TIP FALC EVOLVE,SUP-2367669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
HALOPERIDOL 10 MG PO TABS,RX-3580,CDM,6370000000,HCPCS,0637,RC,51079-0431-01,NDC,,both,1,UN,7.60,4.94,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L115CM 6FR 4MM QPLR CURL,SUP-2494656,CDM,C1730,HCPCS,0272,RC,,,,both,,,504.32,327.81,,,,,,,,,,,,,
SHUNT CAR 9 FRX15 CM PRUITT-INAHARA,SUP-2264210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
ASSEMBLY GWIRE DIA0035IN PARA FOR MIC ACUTRK 2,SUP-2107280,CDM,C1769,HCPCS,0272,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
GRAFT SKIN GRAFIX PRIME 1.5X2CM CYROPRESERVED,SUP-2319165,CDM,Q4132,HCPCS,0636,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
SCOPE ENDOSCP NANONEEDLE 125 MM,SUP-2849266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1689.32,1098.06,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 12 DEG L 11 CM DIA 3.5 MM SPD 5000 RPM,SUP-2902021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,630.51,409.83,,,,,,,,,,,,,
CLAMP ENDOSCP 3 TO 9CM TB POST MTRX,SUP-2292892,CDM,C1713,HCPCS,0278,RC,,,,both,,,4304.97,2798.23,,,,,,,,,,,,,
HC Fetal Bio W/O Nonstress Test,PX-4027681900,CDM,76819,CPT,0402,RC,,,,both,,,904.00,587.60,,,,,,,,,,,,,
IMPLANT TOP HAT LATARJET STRL,SUP-2256894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
PLATE BNE CLAV 2.7 MM LT SHFT VA LCK COMPR TI STRL VALCP,SUP-2789383,CDM,C1713,HCPCS,0278,RC,,,,both,,,3869.74,2515.33,,,,,,,,,,,,,
SCREW BNE ALIGN HIPLOC,SUP-2466135,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 6 FR ATTCH POLYURETHANE MRI,SUP-2126178,CDM,C1788,HCPCS,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
POUCH DISP PLAS ADD PROTCT PREVENT TAMPERING TEMP,SUP-2281987,CDM,2780000010,LOCAL,0278,RC,,,,both,,,197.88,128.62,,,,,,,,,,,,,
BRACE ORTH LNR 3 SHELL TLSO,SUP-2388140,CDM,L0462,HCPCS,0274,RC,,,,both,,,3215.55,2090.11,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN AMBRIO2,SUP-2247194,CDM,V2790,HCPCS,0274,RC,,,,both,,,1983.32,1289.16,,,,,,,,,,,,,
LINER ACET +5 MM NEUT 36 MM HIP E1 G7,SUP-2422197,CDM,C1776,CPT,0278,RC,,,,both,,,5681.83,3693.19,,,,,,,,,,,,,
BLADE SAW KNEE 25.4MM CUT EDGE 90MM CUT DEPTH 1.27MM CUT THI,SUP-2605584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
CATHETER HEMODIALYSI TITAN HD CHRONIC 15.5FR DIA 55CM INTRNL,SUP-2610633,CDM,C1750,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
INTRODUCER NEUROSTIMULATOR LD FOR URIN CTRL INTERSTIM,SUP-2284431,CDM,C1894,HCPCS,0272,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
CATHETER PULM ART 5FR L60CM INTRO 5FR INFLATED BAL 0.75CC,SUP-2383930,CDM,C1725,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
LP PLATE L SH RT LNG EXTENDED BAYS STY,SUP-2676715,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.84,267.05,,,,,,,,,,,,,
PROBE LAP WRK L28CM DIA10MM HND CTRL W/ CRD L10FT DISP,SUP-2166158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.46,309.70,,,,,,,,,,,,,
SPLINT THMB AD SM FOR 4.75-6.25IN RT WR REG TRIOXON LINING,SUP-2324737,CDM,L3931,HCPCS,0274,RC,,,,both,,,59.72,38.82,,,,,,,,,,,,,
NEEDLE BX 18GA L15CM ASAP DELT CUT,SUP-2141132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.125X9 IN RND END SS NS STEINMANN,SUP-2791620,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.62,11.45,,,,,,,,,,,,,
LINER TIB THK 11 MM SZ D1-2 POLYETHYL MTL BK KNEE CR STRL,SUP-2914452,CDM,C1776,CPT,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
COIL EMB L50CM DIA14MM 360DEG STD DETACH TARGET XL,SUP-2367730,CDM,C1889,HCPCS,0278,RC,,,,both,,,7294.69,4741.55,,,,,,,,,,,,,
PLATE STRNL LG 4 H TI SQ NS MATRIXSTERNUM,SUP-2904226,CDM,C1713,HCPCS,0278,RC,,,,both,,,1812.78,1178.31,,,,,,,,,,,,,
IMPLANT HUM TISS DIA16 MM SM THOR AORT REDUC THROMBOSIS,SUP-2933163,CDM,C1762,CPT,0278,RC,,,,both,,,25248.43,16411.48,,,,,,,,,,,,,
PEG FIX LCK 1.8X28 MM PERIARTICULAR STRL,SUP-2525164,CDM,C1713,HCPCS,0278,RC,,,,both,,,186.30,121.09,,,,,,,,,,,,,
HC So Prothrombin Time|NOT REASONABLE AND NECESSARY,PX-3058561066,CDM,85610,CPT,0305,RC,,,GZ,both,,,36.00,23.40,,,,,,,,,,,,,
BLADE DISP MILLER CH FBR OPT SZ 2 153MMX12MM GRNLN,SUP-2381518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30.08,19.55,,,,,,,,,,,,,
CATHETER DRNGE 20FR 4 WNG DISP FOR NEPHSTMY MALECOTS,SUP-2129075,CDM,C2627,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
PLATE BNE THK 0.75 MM PANEL 1.7 MM 2 X 21 H MAXILLOFCL,SUP-2909645,CDM,C1713,HCPCS,0278,RC,,,,both,,,7286.53,4736.24,,,,,,,,,,,,,
MESH SURG TOT PELV GUID CANN REP KT PROLIFT,SUP-2219786,CDM,C1781,HCPCS,0278,RC,,,,both,,,8977.26,5835.22,,,,,,,,,,,,,
HC Aspiration of Bladder W/Ins,PX-3615110200,CDM,51102,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
BIT DRL MINI FOR 3MM SH HALF PIN JET-X,SUP-2342888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
SCREW BONE 1.3X8MM CORT N LCK ALPS,SUP-2411750,CDM,C1713,HCPCS,0278,RC,,,,both,,,187.36,121.78,,,,,,,,,,,,,
GRAFT BONE ALLGRFT DEMIN 1CC MTRX GRFTON,SUP-2115989,CDM,C9359,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
GRAFT CERV ALLOGRAFT 6MM,SUP-2490652,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
BUR SURG DIAMOND 0.5 MM FOR STAP NS REUSE,SUP-2638246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.62,220.10,,,,,,,,,,,,,
PLATE BNE SM W11XL137MM THK34MM 10 H BILAT TI RIG NEUT LOK,SUP-2190785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.38,702.25,,,,,,,,,,,,,
PLATE BNE H08MM 30 H TI STR REG LEIBINGER UNIV 2,SUP-2366330,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.81,1036.63,,,,,,,,,,,,,
PLATE BNE R MT CX CROSSCHECK,SUP-2399298,CDM,C1713,HCPCS,0278,RC,,,,both,,,6543.76,4253.44,,,,,,,,,,,,,
HC Cta Heart W/WO Calcium|WAIVER OF LIABILITY ON FILE|REDUCED SERVICES,PX-3507557400,CDM,75574,CPT,0480,RC,,,GA|52,both,,,2388.00,1552.20,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER LNG 30X11X13 MM BIO AVS UNILIF,SUP-2637047,CDM,C1713,HCPCS,0278,RC,,,,both,,,7928.50,5153.52,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 22GA 8CM WNG 1 LUMA F122088PT,SUP-2632747,CDM,C1751,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
CLAMP EXT FIX DIA4MM DSTL RAD TI ALLOY ADJ FOR SCHNZ SCR,SUP-2188540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1588.84,1032.75,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|ADJ,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|CO|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
HC 2-D-Echo-Lmt - MRI,PX-6100893400,CDM,C8934,CPT,0610,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
PLATE BONE L146MM 6 H RT MEDL DSTL TIB LCK W/O TAB FOR 3.5MM,SUP-2349084,CDM,C1713,HCPCS,0278,RC,,,,both,,,3313.49,2153.77,,,,,,,,,,,,,
STENT ESOPH ALIMAXX-ES L 70 MM DIA18 MM DEL SYS L 67 MM,SUP-2700428,CDM,C1874,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
TAP SURG BONE SCR SELF DRL DELT SYS 1.7MM,SUP-2365068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.49,372.77,,,,,,,,,,,,,
GRAFT SFT TISS FASC LATA MED 10 CM,SUP-2307536,CDM,C1762,CPT,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
AUGMENT PAT M THK19.5MM STD UNIV TRABECULAR MTL CEM PRI BLK,SUP-2200589,CDM,C1776,CPT,0278,RC,,,,both,,,7108.96,4620.82,,,,,,,,,,,,,
RING ACET LCK 260 HIP RINGLOK,SUP-2449971,CDM,C1776,CPT,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
REAMER SURG OD9.5MM FULL FLUT,SUP-2256781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
PLATE BONE 253MML HLX20 STNLSS STEEL BTTRSS F/3.5MM/4MM CRTC,SUP-2499035,CDM,C1713,HCPCS,0278,RC,,,,both,,,2525.28,1641.43,,,,,,,,,,,,,
OLANZAPINE 10 MG PO TBDP,RX-28160,CDM,6370000000,HCPCS,0637,RC,13668-0088-30,NDC,,both,1,UN,16.30,10.59,,,,,,,,,,,,,
MESH BONE 30MM DIA 30MMW X 30MML 0.6MM THK RSRB X TRNGLR LAT,SUP-2496475,CDM,C1713,HCPCS,0278,RC,,,,both,,,2397.64,1558.47,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X250 MM 14 HOLE SS LC-DCP,SUP-2569272,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.74,317.68,,,,,,,,,,,,,
HC Cbc|NOT REASONABLE AND NECESSARY,PX-3058502500,CDM,85025,CPT,0305,RC,,,GZ,both,,,180.00,117.00,,,,,,,,,,,,,
IMPLANT PLAS BRST 300 CC FILL VOL SIL MOD PROF 3 CM PROJCT,SUP-2300405,CDM,C1789,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BONE L12MM OD3.5MM CORT DSTL VOLAR RAD PRECIS SELF DRL,SUP-2361530,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.83,194.24,,,,,,,,,,,,,
BUR SURG L21CM DIA6MM BALL FLUT L BOR MIDAS REX LEGEND,SUP-2284388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.21,271.19,,,,,,,,,,,,,
GRAFT VASC STD WALLED INTEGR RNG IMPL L20CM L5CM ID6MM,SUP-2395833,CDM,C1768,CPT,0278,RC,,,,both,,,2050.42,1332.77,,,,,,,,,,,,,
GRAFT BNE PTTY 2 CC DBM INTERGRO,SUP-2136618,CDM,C9359,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.506,SUP-2860023,CDM,C1713,HCPCS,0278,RC,,,,both,,,35308.67,22950.64,,,,,,,,,,,,,
HC Bedside Swallowing Eval|OP SPEECH LANGUAGE SERVICE,PX-4449261000,CDM,92610,CPT,0444,RC,,,GN,both,,,355.00,230.75,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK0.9-1.99MM ACELLULAR DERM MTRX,SUP-2402514,CDM,Q4126,HCPCS,0636,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
GRAFT HUM TISS CHORION FREE THN 8X4 CM AMNIO ACTISHIELD CF,SUP-2759543,CDM,C1762,CPT,0278,RC,,,,both,,,10085.68,6555.69,,,,,,,,,,,,,
ORTHOPAEDIC INSTRUMENT KIT IM IMPL SCR STRL MINIBUNION LTX,SUP-2866375,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CATHETER CTRL VEN L8CM OD5FR DBL LUMN POLYUR SET,SUP-2167975,CDM,C1751,HCPCS,0278,RC,,,,both,,,227.65,147.97,,,,,,,,,,,,,
BODY VERT H 19-23 MM DIA19 MM 2XS BLACKARMOR CARBON PEEK,SUP-2917109,CDM,C1889,HCPCS,0278,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
ELEVATOR ENDOSCP 10 CM NANOSCOPE,SUP-2849183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP PT MATCHED LT MEDL HALF MENIS,SUP-2866992,CDM,C1762,CPT,0278,RC,,,,both,,,8304.67,5398.04,,,,,,,,,,,,,
MARKER RAD 1X5MM NDL L20CM OD18GA GLD FIDUCIAL PROST SEED,SUP-2164652,CDM,A4648,CPT,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X3 CM CRYOPRESERVED AMNIOX CLARIX CRD 1K,SUP-2648675,CDM,Q4148,HCPCS,0636,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
MARKER SURG FIDUCIAL 2X2 CM SPACER CLP SFT TISS STRL BIOZORB,SUP-2716281,CDM,A4648,CPT,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 25 CM 5 FR SS HYDRPHLC PERIPHERAL,SUP-2385665,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.26,52.82,,,,,,,,,,,,,
GRAFT BNE SUB 25MM IL CREST WDG TREAT W PRESERVON,SUP-2264841,CDM,C1713,HCPCS,0278,RC,,,,both,,,3326.74,2162.38,,,,,,,,,,,,,
ALLOGRAFT BNE 2 CC DEMINERALIZED BONE MTRX ALLOCRAFT,SUP-2636995,CDM,C1713,HCPCS,0278,RC,,,,both,,,1126.07,731.95,,,,,,,,,,,,,
MESH CRAN W40XL40MM THK0.3MM CRANIOFACIAL TI DYN MAL FOR,SUP-2366216,CDM,C1713,HCPCS,0278,RC,,,,both,,,4173.66,2712.88,,,,,,,,,,,,,
PLATE BNE W5XL42MM THK1.5MM 8 H BILAT TI STR RIG NEUT DYN,SUP-2191045,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.36,759.43,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA10 MM EXTERNALLY SUPP,SUP-2478251,CDM,C1768,CPT,0278,RC,,,,both,,,8213.08,5338.50,,,,,,,,,,,,,
SCREW BNE L16MM OD45MM S STL CANN,SUP-2316413,CDM,C1713,HCPCS,0278,RC,,,,both,,,537.19,349.17,,,,,,,,,,,,,
SHUNT CAR 9FR L31CM W/ T PRT REG TEMP W/OUT RESVR,SUP-2264217,CDM,C1889,HCPCS,0278,RC,,,,both,,,1692.46,1100.10,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 40 CM DIA 7 MM CLLGN BOV CAR ART,SUP-2120672,CDM,C1768,CPT,0278,RC,,,,both,,,7815.46,5080.05,,,,,,,,,,,,,
PLATE BNE L105MM 5 H ST L DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177720,CDM,C1713,HCPCS,0278,RC,,,,both,,,2653.87,1725.02,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX10 T SHAPED RIGHT DORSAL DISTAL,SUP-2721391,CDM,C1713,HCPCS,0278,RC,,,,both,,,3318.29,2156.89,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 16X6 CM PLCNTA MEMBRN AMNIOEFFECT,SUP-2871501,CDM,C1762,CPT,0278,RC,,,,both,,,26925.50,17501.57,,,,,,,,,,,,,
GRAFT EVAR L49MM DIA32X32MM EXTN FREE FLO CLS WEB FOR ABD,SUP-2295233,CDM,C1768,CPT,0278,RC,,,,both,,,14365.50,9337.57,,,,,,,,,,,,,
RESERVOIR VENT 0.3ML DIA18MM CATH SM L23CM CSF BA IMPREG RT,SUP-2284525,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.62,581.50,,,,,,,,,,,,,
HC Treat Finger Fx Each,PX-4502672000,CDM,26720,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN,RX-122343,CDM,J2710,HCPCS,0636,RC,00641-6149-10,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BNE SM 15 CC PRO OSTEON 200R,SUP-2685765,CDM,C1713,HCPCS,0278,RC,,,,both,,,5058.54,3288.05,,,,,,,,,,,,,
SPACER SPNL 7 DEG H A/P 9/8 MM A/P 11.5 MM M/L 12.5 MM SM,SUP-2881928,CDM,C1713,HCPCS,0278,RC,,,,both,,,2721.38,1768.90,,,,,,,,,,,,,
SADDLE CABLE DIA 4.5 MM SS STRL EVOS,SUP-2931177,CDM,C1713,HCPCS,0278,RC,,,,both,,,1170.91,761.09,,,,,,,,,,,,,
STEM RADIAL STR 6X24 MM ELBW TI STRL,SUP-2564336,CDM,C1713,HCPCS,0278,RC,,,,both,,,4861.82,3160.18,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX19 CM SLV PALINDROMIC HSI,SUP-2283948,CDM,C1750,HCPCS,0278,RC,,,,both,,,1046.34,680.12,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM DIA 6 FR GUIDEWIRE 0.035 IN,SUP-2168285,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.47,47.11,,,,,,,,,,,,,
CARRIER LT TYP 30R,SUP-2383873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.44,608.04,,,,,,,,,,,,,
PLATE STRNL 7 H TI T SHP NS MATRIXSTERNUM,SUP-2904242,CDM,C1713,HCPCS,0278,RC,,,,both,,,2385.24,1550.41,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.035 IN L 3 MM SS PTFE J UNIFORMITY,SUP-2763689,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.78,16.76,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5 CC FIBER PLIAFX PRIM,SUP-2741025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.04,775.48,,,,,,,,,,,,,
IMPLANT ANK JT 3 LT TALUS IMPLABLE,SUP-2199170,CDM,C1776,CPT,0278,RC,,,,both,,,13074.11,8498.17,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 5FR 55CML PU PWR INJ RADPQ PEEL 3275110,SUP-2632669,CDM,C1751,HCPCS,0278,RC,,,,both,,,413.22,268.59,,,,,,,,,,,,,
NEEDLE VENTRICULAR TOUHY 14 GAX3.5 IN NS,SUP-2666370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,933.77,606.95,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit W Stent,PX-3613690300,CDM,36903,CPT,0361,RC,,,,both,,,11772.00,7651.80,,,,,,,,,,,,,
INSERT TIB SZ 7 THICKNESS 10MM UHMWPE KNEE PRI NEUT UNIV,SUP-2365103,CDM,C1776,CPT,0278,RC,,,,both,,,2150.15,1397.60,,,,,,,,,,,,,
MONO T1 NEUT STEM 6X18MM,SUP-2364449,CDM,C1776,CPT,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
SHEATH URET ACCS 10.7 FRX20 CM DIL FLX PARL RAPID RELEASE,SUP-2835981,CDM,C1894,HCPCS,0272,RC,,,,both,,,431.06,280.19,,,,,,,,,,,,,
CATHETER ETER EP 5FR L110CM 5MM SPC 4 ELECTRD A CRV AUTO ID,SUP-2248856,CDM,C1730,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER INTVASC OCCL ASCNT L 150 CM 2.9 FR 0.0170 IN 10 MM,SUP-2459180,CDM,C2628,HCPCS,0272,RC,,,,both,,,6208.72,4035.67,,,,,,,,,,,,,
PLATE BONE L120MM 6 H S STL T SHP,SUP-2198574,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.95,315.87,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.7MM NONSTERILE CORT S STL ST,SUP-2183157,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.51,257.08,,,,,,,,,,,,,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,6370000000,HCPCS,0637,RC,00378-9104-93,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
INTRODUCER BX 12GA FOR 12 DEV CELERO,SUP-2240008,CDM,C1894,HCPCS,0272,RC,,,,both,,,67.20,43.68,,,,,,,,,,,,,
TUBING STBL DIA12MM DISPOSABLE CARDIOVAC DA VINCI ENDOWRIST,SUP-2246649,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
SPLINT ARM MP LG,SUP-2274800,CDM,L3809,HCPCS,0272,RC,,,,both,,,40.73,26.47,,,,,,,,,,,,,
SCREW INTFR L25MM DIA9MM UNIV TI CANN BLNT NONABSORBABLE,SUP-2366617,CDM,C1713,HCPCS,0278,RC,,,,both,,,520.46,338.30,,,,,,,,,,,,,
GRAFT BNE 1 CC CELLULAR BNE MTRX V92,SUP-2434349,CDM,C1889,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SYSTEM EMB L 190 CM RVD 5-6 MM CAR STENTING FLX TIP PEELWY,SUP-2101765,CDM,C1876,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
HC Med Nut Therapy Ind Init 15 Min,PX-9429780200,CDM,97802,CPT,0942,RC,,,,both,,,95.00,61.75,,,,,,,,,,,,,
GUIDEWIRE ORTH L100MM DIA0.8MM S STL FOR 2.4MM CANN SCR SYS,SUP-2186881,CDM,C1769,HCPCS,0272,RC,,,,both,,,367.51,238.88,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7030,HCPCS,0258,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
DEVICE COAG 3 CM GUID 6130 EPISENSE (only avail by Each),SUP-2424447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
PLATE BONE L142MM THK3.7MM 6 H LT DSTL MEDL TIB TI LCK COMPR,SUP-2190882,CDM,C1713,HCPCS,0278,RC,,,,both,,,4351.41,2828.42,,,,,,,,,,,,,
ISOSORBIDE MONONITRATE ER 30 MG PO TB24,RX-24521,CDM,6370000000,HCPCS,0637,RC,13668-0104-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STAPLE BNE BLNT SET,SUP-2478384,CDM,C1713,HCPCS,0278,RC,,,,both,,,1668.91,1084.79,,,,,,,,,,,,,
SHEATH ENDOSCP 3.5 MMX20 CM OUTER INSUL FOR CLN 31100,SUP-2768531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1181.58,768.03,,,,,,,,,,,,,
PROSTHESIS STAP L425MM DIA05MM BND LOOP W05MM PURE TI MTRX,SUP-2263282,CDM,L8613,CPT,0278,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
DRILL SURG CANN 10 MM HND JCBS CHK UNIV SS NS REUSE,SUP-2491113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2981.37,1937.89,,,,,,,,,,,,,
ROD EXT FIX 11X300MM C FBR,SUP-2188661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,813.73,528.92,,,,,,,,,,,,,
SCREW BONE L6MM DIA1.5MM BRNZ CORT TI ST NONCANNULATED,SUP-2181613,CDM,C1713,HCPCS,0278,RC,,,,both,,,319.15,207.45,,,,,,,,,,,,,
TACK SPNL FOR HALLMARK ANTR CERV PLATING SYS,SUP-2317499,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
KIT INTRO MINI STK II L 5 CM DIA 3 FR GUIDEWIRE L 45 CM DIA,SUP-2734848,CDM,C1894,HCPCS,0272,RC,,,,both,,,24.49,15.92,,,,,,,,,,,,,
ROD SPNL L400MM DIA5.5MM POST TI STR SMOOTH SILVERTON-D,SUP-2211121,CDM,C1713,HCPCS,0278,RC,,,,both,,,881.71,573.11,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.018IN TIP L3CM 45DEG GLD HYDRPHLC,SUP-2385556,CDM,C1769,HCPCS,0272,RC,,,,both,,,600.53,390.34,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE GAUNTLET PREFABRICATED OFF THE SHLF,SUP-2435622,CDM,L1902,HCPCS,0272,RC,,,,both,,,211.32,137.36,,,,,,,,,,,,,
HC So Hiv1 Probe,PX-3068753568,CDM,87535,CPT,0306,RC,,,,outpatient,,,118.00,76.70,,,,,,,,,,,,,
INTRODUCER SHTH 7FR (min order 10 eaches)L12CM DIA0.038IN HEMSTAS CLOSE TOL,SUP-2357132,CDM,C1894,HCPCS,0272,RC,,,,both,,,5.65,3.67,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 22X1 MM SLGHT CONTOURED PDLLA STRL,SUP-2462761,CDM,C1713,HCPCS,0278,RC,,,,both,,,1087.88,707.12,,,,,,,,,,,,,
GRAFT BNE DEMINERALIZED BNE MTRX 5 ML RT ALTIVA,SUP-2391500,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
TREPHINE OPHTHALMIC TERRY 7.5MM W/GUARD LATEX FREE,SUP-2473112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.51,890.18,,,,,,,,,,,,,
BLOCKER BRONCH AD 9FR 8ML L610MM POLYUR STL MESH SIL HI VOL,SUP-2115125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
"HC So1 Detect, Agnt Mult, Dna Ampli",PX-3068780167,CDM,87801,CPT,0306,RC,,,,both,,,498.00,323.70,,,,,,,,,,,,,
BRACE ORTH LUMBAR X SM LT EVERGREEN,SUP-2123875,CDM,L0626,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WEBST L 110 CM DIA 5 FR TIP 1 MM,SUP-2248859,CDM,C1730,HCPCS,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
CATHETER CTRL VEN L70CM OD5X6FR IDSEC15.5GA 55CM NIT WIRE,SUP-2118835,CDM,C1751,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SCREW BNE L36MM DIA3MM PROSTEP MICA,SUP-2398119,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
HC Intro Cath Rt Hrt or Main Pulm,PX-3613601300,CDM,36013,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
APPLIER CLP L33MM DIA5MM 20 M/L TI CLP ENDO MULT ROT LIGACLP,SUP-2257549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.78,263.76,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESHED THN 12X8 CM MTRX SOMAGEN,SUP-2434143,CDM,C1762,CPT,0278,RC,,,,both,,,17290.79,11239.01,,,,,,,,,,,,,
"HC So Cytomegalovirus, Igg Antibody",PX-3028664466,CDM,86644,CPT,0302,RC,,,,both,,,179.00,116.35,,,,,,,,,,,,,
HC Ligation of Hemorrhoid(S),PX-4504622100,CDM,46221,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
BIT DRL CANN 2.5 MM FOR FRDM WRST ARTHROPLAST,SUP-2852121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.97,561.58,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT STEM HD SHELL TRAB MEL CERM,SUP-2212728,CDM,C1776,CPT,0278,RC,,,,both,,,16128.61,10483.60,,,,,,,,,,,,,
VEST TRAC L98CM DIA72MM SYNTH LNR SH VERSATILE VAC FRM TOOL,SUP-2255763,CDM,L0810,HCPCS,0274,RC,,,,both,,,5165.30,3357.44,,,,,,,,,,,,,
PEG 3350 17 G PO PACK,RX-100115,CDM,6370000000,HCPCS,0637,RC,00904-6931-86,NDC,,both,1,UN,6.30,4.09,,,,,,,,,,,,,
ANCHOR SUT DIA3.7MM BIOABSRB TAG WDG,SUP-2341290,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.46,602.20,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ BVL TAB 1.14 MM ID SIL STRL,SUP-2277938,CDM,L8699,HCPCS,0278,RC,,,,both,,,140.04,91.03,,,,,,,,,,,,,
HEAD RMR MINI WRST FUS PLT,SUP-2107837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
PLATE DISTL LAT 3 H RT HUM,SUP-2467090,CDM,C1713,HCPCS,0278,RC,,,,both,,,6690.71,4348.96,,,,,,,,,,,,,
PLATE LCK STRNL 14 H,SUP-2262584,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
PLATE BONE 18 H BILAT MAND TI STR RIG NONCOMPRESSION,SUP-2191408,CDM,C1713,HCPCS,0278,RC,,,,both,,,3918.72,2547.17,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBM GEL FRZ DRY OPTIUM,SUP-2264858,CDM,C1713,HCPCS,0278,RC,,,,both,,,2749.82,1787.38,,,,,,,,,,,,,
PLATE BNE L336MM 16 H ST R CNDYL S STL CRV LOK COMPR VAR,SUP-2177864,CDM,C1713,HCPCS,0278,RC,,,,both,,,7014.73,4559.57,,,,,,,,,,,,,
BIT DRL QC 2.5X170 MM 80 MM CALIB NS,SUP-2563750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.57,272.72,,,,,,,,,,,,,
RETRACTOR KIT FOR INTERCONTINENTAL PLATE SPACER SYS MARS 3V,SUP-2232230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC DBM GRFT,SUP-2294011,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
SCREW BNE L30MM DIA4.5MM LNG THRD L12MM S STL SELF DRL CANN,SUP-2185056,CDM,C1713,HCPCS,0278,RC,,,,both,,,861.58,560.03,,,,,,,,,,,,,
SPACER TIB SM L8MM DURAMER SL GRDIAN,SUP-2304388,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
GUIDEWIRE ORTH L 150 MM DIA1.1 MM SCREW DIA2.5/3 MM TROCAR,SUP-2907653,CDM,C1769,HCPCS,0272,RC,,,,both,,,270.54,175.85,,,,,,,,,,,,,
SET PERF L203CM 12IN RED AND BLU AORT ROOT MULT SLIP CONN,SUP-2282554,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.81,42.78,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 24 MM DIA 6 MM CATH TOT L 160,SUP-2142749,CDM,C1876,HCPCS,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
TRIAL NERVE STIM EXT,SUP-2568742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 12 HOLES,SUP-2549475,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.47,1947.06,,,,,,,,,,,,,
STEM HUM SZ 10 DIA10MM PROX SHLDR TI HYDROXYAPETITE REUNION,SUP-2379012,CDM,C1776,CPT,0278,RC,,,,both,,,11869.20,7714.98,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM BIOCOMP KNOTLESS SWIVELOCK STRL HD,SUP-2910049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
SCREW BNE CORTICAL LG 2.7X20 MM FUSION HEX DRV SS STRL,SUP-2852008,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.11,278.27,,,,,,,,,,,,,
HC Perq Plmt Bile Duct Stent W/ Bili Cath Plmt,PX-3614754000,CDM,47540,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
POST HUM L30MM DIA9MM SHLDR TAPR HEMICAP,SUP-2123525,CDM,C1713,HCPCS,0278,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
SYSTEM STENT GRFT OVATION IX L 80 MM DIA 34 MM DEL CATH 15,SUP-2217722,CDM,C1768,CPT,0278,RC,,,,both,,,39246.86,25510.46,,,,,,,,,,,,,
BIT DRILL J LATCH 1.8X88 MM 22 MM WITH STOP TITANIUM NON STE,SUP-2837620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.82,417.18,,,,,,,,,,,,,
PLATE BONE L2.7MM 7 H LCK COMPR PEDILOC,SUP-2318664,CDM,C1713,HCPCS,0278,RC,,,,both,,,2293.52,1490.79,,,,,,,,,,,,,
HINGE HALF,SUP-2488353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CLAMP BAR-TO-BARXTRAFIX,SUP-2205433,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1724.65,1121.02,,,,,,,,,,,,,
STEM HUM 13X17 MM DSTL SHLDR,SUP-2363645,CDM,C1776,CPT,0278,RC,,,,both,,,9529.27,6194.03,,,,,,,,,,,,,
COMPONENT OUTER 28/28 MM SFC,SUP-2389700,CDM,C1776,CPT,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
INTRODUCER ENDOSCP MINOP DIA22-19 FR RND BLNT OBTURATOR SHTH,SUP-2821661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.81,534.83,,,,,,,,,,,,,
TIP ULTRSNC ASPIR L 37 CM WORKING L 32.2 CM OD 2.52 MM ID,SUP-2883138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7055.58,4586.13,,,,,,,,,,,,,
GRAFT VASC L60CM DIA8MM STD L60CM THN WALLED INTEGR RNG,SUP-2395861,CDM,C1768,CPT,0278,RC,,,,both,,,6942.54,4512.65,,,,,,,,,,,,,
PERI-LOC 4.5MM S-T CRTX SCREW 42MM,SUP-2819168,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.93,126.70,,,,,,,,,,,,,
LENS INTOCU +33.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111085,CDM,V2632,HCPCS,0276,RC,,,,both,,,421.11,273.72,,,,,,,,,,,,,
IMPLANT SPNL MOD TULIP PRECEPT,SUP-2312140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BONE THK0.6MM 14 H MIDFACE GLD TI CVD RIG GRD 4 FOR,SUP-2135917,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
CUTTER ENDOSCP 10 MM STRL FLIPCUTTER AR1204F] ARTHREX INC],SUP-2120832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 18 MM DIA 9 MM CATH TOT L 100,SUP-2142750,CDM,C1876,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
SCREW SPNL L10MM DIA3.5MM MINI CANC POST OCCIPITAL CERV THOR,SUP-2256183,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.70,2365.80,,,,,,,,,,,,,
PLATE BNE HUM 166 MM RT DSTL MEDL 17 HOLE STRL A.L.P.S,SUP-2463056,CDM,C1713,HCPCS,0278,RC,,,,both,,,3143.14,2043.04,,,,,,,,,,,,,
ALLOGRAFT BNE 9X220 MM POST TIBIALIS,SUP-2866886,CDM,C1762,CPT,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
SPACER PROX CNTRLZR HIP 12/13MM VLIGN VERSYS,SUP-2203475,CDM,C1776,CPT,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
TRANEXAMIC ACID 1000 MG IN 100 ML NS (PREMIX) IVPB,RX-4082238,CDM,2500000003,HCPCS,0250,RC,09999-0150-10,NDC,,both,100,ML,558.40,362.96,,,,,,,,,,,,,
COUNTERSINK SURG M DISP FOR INTOSS FIXATIONX-POST IOFIX 2.0,SUP-2223764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
HOOK SPNL SM W7.5XH6.4XL9.5MM S STL PEDCL LO PROF REVERE,SUP-2230933,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PASSER SUT REUSE VIPER,SUP-2121177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
SCREW BNE LCK 1.5X18 MM ST VA W/ T4 STARDRV RECESS SS NS,SUP-2178001,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.91,233.94,,,,,,,,,,,,,
UB BLADE FENCE RIGID 4IN X 5IN,SUP-2674215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.67,775.89,,,,,,,,,,,,,
NEUROSTIMULATOR AXONICS 4101,SUP-2853157,CDM,C1820,HCPCS,0278,RC,,,,both,,,34715.84,22565.30,,,,,,,,,,,,,
CATHETER HD DL 14 FRX30 CM ADMIN FULL KT STR TAPR TIP,SUP-2267003,CDM,C1752,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
PLATE BNE L205MM THK3MM 13 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185348,CDM,C1713,HCPCS,0278,RC,,,,both,,,2263.06,1470.99,,,,,,,,,,,,,
PLATE RETEN AUTOCAPTURE + LD TOOL USED W E3AC+ FLX SUT PASS,SUP-2256895,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.54,142.05,,,,,,,,,,,,,
CATHETER 0.018 IN 130 CM 5X300 MM LUTONIX,SUP-2650212,CDM,C2623,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
SCREW HIP CMPNNT CNNLTD LAG 10.5MM DIA 75MML TIMAX PRXML FMR,SUP-2588695,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.24,1211.11,,,,,,,,,,,,,
PLATE BNE L106MM BLDE W9.2XL35MM 90DEG 8 H BILAT S STL LOK,SUP-2185372,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.11,2442.77,,,,,,,,,,,,,
SPLINT FNGR M 3IN WIRE FOAM EXTN ASST BROAD CRV DORS CNTR PD,SUP-2194873,CDM,L3933,HCPCS,0274,RC,,,,both,,,60.26,39.17,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC DBM TENSIX,SUP-2759483,CDM,C1713,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
MESH PARIETEX COMP RND 8CM SKIRTED,SUP-2174725,CDM,C1781,HCPCS,0278,RC,,,,both,,,1157.53,752.39,,,,,,,,,,,,,
CATHETER PERI DLYS L62CM 2 CUF CURLED ARGY,SUP-2283891,CDM,C1750,HCPCS,0278,RC,,,,both,,,189.94,123.46,,,,,,,,,,,,,
GUIDE PIN ORTH TROCAR PT 1 END 3.2X330 MM AOS,SUP-2766034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
GRAFT BONE POSTEROLATERAL 2.5CMX5CM MAGNIFUSE,SUP-2293967,CDM,C1713,HCPCS,0278,RC,,,,both,,,9784.24,6359.76,,,,,,,,,,,,,
RESERVOIR CSF EXT MINI 1.5X2.7 MM 1.2X2.2 MM 0.023 CC,SUP-2852565,CDM,C1889,HCPCS,0278,RC,,,,both,,,1635.59,1063.13,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX14 LEFT LATERAL DISTAL FEMORAL,SUP-2588185,CDM,C1713,HCPCS,0278,RC,,,,both,,,4533.06,2946.49,,,,,,,,,,,,,
GRAFT EVAR L82MM DIA16X28MM PROX DST IL CONTRALATERAL LIMB,SUP-2295268,CDM,C1768,CPT,0278,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
SCREW SPNL ROD DIA 5.5/6 MM SS UNIAXIAL STRL CD HORZ MODULEX 2PK,SUP-2928046,CDM,C1713,HCPCS,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
IMMOBILIZER SLNG LOOP CLOSURE UNIV UNISX SHLDR PROCARE,SUP-2196933,CDM,L3660,HCPCS,0272,RC,,,,both,,,21.26,13.82,,,,,,,,,,,,,
HC MR Sfty Implt&/FB Asmt Stf 1st 15 Min,PX-6107601400,CDM,76014,CPT,0610,RC,,,,both,,,77.00,50.05,,,,,,,,,,,,,
SPLINT CLAV L AD W2.75XL34.5IN BCKL CLSR PD MCLEOD,SUP-2197365,CDM,L3650,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
CATHETER ETER DLYS 28CM PALINDROME,SUP-2283923,CDM,C1750,HCPCS,0278,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 10X2.5 CM FIBER KORE,SUP-2736960,CDM,C1713,HCPCS,0278,RC,,,,both,,,10303.13,6697.03,,,,,,,,,,,,,
PRIMIDONE 50 MG PO TABS,RX-11129,CDM,6370000000,HCPCS,0637,RC,68084-0202-11,NDC,,both,1,UN,3.70,2.40,,,,,,,,,,,,,
KIT CATH 14FR L9IN PERC CAV DRNGE ASMBLY CVD BLU FLEXTIP,SUP-2383257,CDM,C1729,HCPCS,0272,RC,,,,both,,,378.68,246.14,,,,,,,,,,,,,
BUR SHV DIA5.5MM BRN STR TIP FOR ARTHSCP RESECT DYONIC,SUP-2341736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
GRAFT VASC VECTRA L 50 CM DIA 5 MM WALL THK 1 MM POLYUR HEMO,SUP-2127770,CDM,C1768,CPT,0278,RC,,,,both,,,3686.36,2396.13,,,,,,,,,,,,,
PLATE BONE THK1MM 6 H MIDFACE GLD BSSO FOR 2MM SCR LORENZ,SUP-2402952,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
PLATE BNE H1MM BAR L8MM 4 H MAND BLU TI MINI STR LOK,SUP-2366339,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.17,273.76,,,,,,,,,,,,,
INTRODUCER CATH L1.9CM PUR SHLD FOR PICC AND MIDLN CATH,SUP-2133168,CDM,C1894,HCPCS,0272,RC,,,,both,,,147.42,95.82,,,,,,,,,,,,,
ANCHOR SUT DIA1.4MM SFT SHT NDL SGL LD JUGGERKNOT,SUP-2212957,CDM,C1713,HCPCS,0278,RC,,,,both,,,1301.22,845.79,,,,,,,,,,,,,
PLATE BNE L246MM THK3.7MM 14 H NONSTERILE R DST MED TIB S,SUP-2185536,CDM,C1713,HCPCS,0278,RC,,,,both,,,3954.64,2570.52,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 20X12 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838615,CDM,C1763,HCPCS,0278,RC,,,,both,,,22274.53,14478.44,,,,,,,,,,,,,
PLATE BONE 8 H TI PRECONTOURED FOR 8 AND 9 RT RIB MATRIXRIB,SUP-2181511,CDM,C1713,HCPCS,0278,RC,,,,both,,,4189.55,2723.21,,,,,,,,,,,,,
SCREW BONE L16MM DIA3MM GRN TI ALLOY ST SELF DRL CANN,SUP-2399806,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
GRAFT HUM TISS 2CC PLCNTA TISS MTRX FLOWERFLO,SUP-2225379,CDM,C1713,HCPCS,0278,RC,,,,both,,,17144.40,11143.86,,,,,,,,,,,,,
AUGMENT TIB SZ 3 THK10MM UNIV DST KNEE POR WDG STP PRESSFIT,SUP-2250966,CDM,C1776,CPT,0278,RC,,,,both,,,4500.25,2925.16,,,,,,,,,,,,,
SET INTRO CATH 5FR L15CM GWIRE L60CM DIA0.018IN NDL 21GA,SUP-2168211,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.37,45.74,,,,,,,,,,,,,
HC Treatment Devices Inter,PX-3337733300,CDM,77333,CPT,0333,RC,,,,both,,,1471.00,956.15,,,,,,,,,,,,,
PROSTHESIS OSS CNTR CONCISE PART,SUP-2420195,CDM,L8613,CPT,0278,RC,,,,both,,,1153.48,749.76,,,,,,,,,,,,,
GRAFT BONE 5MM-20MM RANG 45ML L VOL TISS FRZN CORT CANC,SUP-2307409,CDM,C1713,HCPCS,0278,RC,,,,both,,,3812.34,2478.02,,,,,,,,,,,,,
INTRODUCER ENGAGE TR 4FRX12CM SHTH W/ COAT CANN 0.025 IN,SUP-2355815,CDM,C1894,HCPCS,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
CEMENT B1 70GM HI VISC ALL IN 1 SYS RALLY,SUP-2340807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SET SUPRPUB CATH 12FR L25CM W/ MAC-LOC CLR CONN TB 1 W,SUP-2171360,CDM,C2627,HCPCS,0272,RC,,,,both,,,508.37,330.44,,,,,,,,,,,,,
SHEATH GUID R2P DESTINATION SLENDER L 154CM L149CM 6FR 2.5MM,SUP-2540721,CDM,C1894,HCPCS,0272,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
INSERT TIB THK10MM STD UNIV MENIS POLYETH PRI NEUT ROT,SUP-2250758,CDM,C1776,CPT,0278,RC,,,,both,,,4726.33,3072.11,,,,,,,,,,,,,
SCREW BNE L165MM DIA7.3MM HD DIA8.2MM NONSTERILE CANC S STL,SUP-2183991,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.10,412.81,,,,,,,,,,,,,
PLATE BNE DBL Y 0.6 MM FACE,SUP-2262676,CDM,C1713,HCPCS,0278,RC,,,,both,,,850.88,553.07,,,,,,,,,,,,,
SET PLUG 0.6X9.5CM FOR ANORECT FIST BIODESIGN,SUP-2171027,CDM,C1763,HCPCS,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
CATHETER GUID CXI L 135 CM DIA 2.3 FR 0.014 IN SS STR TIP,SUP-2638641,CDM,C1887,HCPCS,0272,RC,,,,both,,,659.37,428.59,,,,,,,,,,,,,
BURR SURG 4MM DIA HD MED MIC 48MML 10MML HD SM BNE DIAMOND D,SUP-2605559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.39,45.10,,,,,,,,,,,,,
PIN DISTRACTOR L12MM S STL FOR ANTR CERV INTBDY FUS,SUP-2176864,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
CATHETER ENDOVASC 10.7FRX65CM C CTRL,SUP-2327390,CDM,C1733,HCPCS,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
COLLAR BK SZ UNIV VISTA,SUP-2196895,CDM,L0120,HCPCS,0274,RC,,,,both,,,61.51,39.98,,,,,,,,,,,,,
ANCHOR BONE BTB TIGHTROPE 2,SUP-2741981,CDM,C1776,CPT,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
COMPONENT ARTC SURF PS 5-6 EF UNIV 15 MM CNDYL FIX CONSTRN,SUP-2201186,CDM,C1776,CPT,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
HOOK SPNL TI THOR LAM R ANG BLDE FOR 5.5MM ROD CDH LEG,SUP-2287874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
ROD DOLPHIX DELTA KIT TITANIUM,SUP-2717567,CDM,C1713,HCPCS,0278,RC,,,,both,,,26062.00,16940.30,,,,,,,,,,,,,
CEMENT BONE 25GM 17.25CC CA PHOS HA INJ PUTTY SYNTH TISS,SUP-2402964,CDM,C1713,HCPCS,0278,RC,,,,both,,,9658.64,6278.12,,,,,,,,,,,,,
HC US Guidance for Needle Place - Anes Block|SEPARATE PRACTITIONER,PX-4027694201,CDM,76942,CPT,0402,RC,,,XP,both,,,978.00,635.70,,,,,,,,,,,,,
MESH SURG SM THK0.4MM SLV TI MASTOID MALL CNTOUR LO PROF,SUP-2181584,CDM,C1781,HCPCS,0278,RC,,,,both,,,2485.00,1615.25,,,,,,,,,,,,,
GRAFT HUMAN TSSUE FIRM 16X10 CM RCNSTRCTVE TSSUE MTRX STRTTC,SUP-2483681,CDM,Q4130,HCPCS,0636,RC,,,,both,,,15844.44,10298.89,,,,,,,,,,,,,
NAIL IM FEM 13 MMX43 CM TRIGEN META-NAIL,SUP-2347433,CDM,C1713,HCPCS,0278,RC,,,,both,,,5295.92,3442.35,,,,,,,,,,,,,
PORT INFUS CATH 6FR TI SGL LUMN INTMED KT W/ ATTCH OPN END,SUP-2127741,CDM,C1788,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
STEM HUM L133MM DIA8MM 135DEG LNG SHLDR TI ARTHROPLASTY,SUP-2250044,CDM,C1776,CPT,0278,RC,,,,both,,,21634.60,14062.49,,,,,,,,,,,,,
SHOE ORTHOT CUST SLD STIRRUP TRANSFER NEW,SUP-2435748,CDM,L3630,HCPCS,0274,RC,,,,both,,,284.45,184.89,,,,,,,,,,,,,
DRIVER SURG HDLSS 2 MM HEX FOR 3MM,SUP-2175118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
NEEDLE INJ 5 6CM LARYN OROTRACHEAL DISPOSABLE,SUP-2243034,CDM,C1713,HCPCS,0278,RC,,,,both,,,96.08,62.45,,,,,,,,,,,,,
STEM HUM DIA9MM 132.5DEG STD SHLDR PROX BODY AEQUALIS FLX,SUP-2417741,CDM,C1776,CPT,0278,RC,,,,both,,,13489.44,8768.14,,,,,,,,,,,,,
SCREW BONE L30MM DIA3.5MM MIDFOOT VAR ANG COMPR 1ST RAY,SUP-2420144,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.17,325.11,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE STRL SELD MAXBARR 20GA 10CM 1 LUM,SUP-2613569,CDM,C1751,HCPCS,0278,RC,,,,both,,,487.74,317.03,,,,,,,,,,,,,
BIT DRL L110MM DIA2MM CANN W/ QUIK CONN FOR SM SCR,SUP-2344062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1809.21,1175.99,,,,,,,,,,,,,
PLATE BONE L109MM 9 H S STL SELF COMPR FOR 3.5MM SCR ECT,SUP-2198566,CDM,C1713,HCPCS,0278,RC,,,,both,,,293.40,190.71,,,,,,,,,,,,,
PLATE BNE W14XL101MM THK3.8MM 90DEG 5 H R TIB L BTTRS L ANG,SUP-2185767,CDM,C1713,HCPCS,0278,RC,,,,both,,,1783.21,1159.09,,,,,,,,,,,,,
DRILL SURGICAL DIA2.5MM CALIBRATED PILOT,SUP-2878398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
TWIST DRILL 2.7MM,SUP-2818384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
CATHETER ANGIOPLSTY METACROSS 135 CM 5.4 FR 40 MM 4 MM OTW,SUP-2761781,CDM,C1725,HCPCS,0272,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
COIL SZ 1 OL1000 SGL ELECTR BNE ST,SUP-2196350,CDM,E0749,HCPCS,0278,RC,,,,both,,,7959.90,5173.93,,,,,,,,,,,,,
BUR SURG L 54.5 MM HD L 4 MM DIA 4 MM 24 FLUT RND POL STRL,SUP-2898832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,150.12,97.58,,,,,,,,,,,,,
EXTENSION NEUROSTIMULATOR L60CM SPNL CRD OCTAPOLAR 1X8,SUP-2284456,CDM,C1883,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
PLATE BONE COMPRESSION 3.5 MM 7 HOLE SMALL FRAGMENT SET FOR,SUP-2836958,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.74,853.28,,,,,,,,,,,,,
MICROCATHETER ETER DIAG 25 2FR 160CM 11MM WDG,SUP-2418959,CDM,C1725,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP MED 8 IN LT WRST COCK UP ELASTIC,SUP-2108132,CDM,L3809,HCPCS,0274,RC,,,,both,,,41.61,27.05,,,,,,,,,,,,,
SCREW BONE CANNULATED 7X140 MM 16 MM SELFDRILLING PARTIAL TH,SUP-2836842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.88,1377.92,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC DBM OPTIUM,SUP-2264863,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.41,1051.32,,,,,,,,,,,,,
DISTRACTION INTRNL DIST ALVLR TRACK 1.0 END DRV 1.0 1.2 MM S,SUP-2488046,CDM,C1713,HCPCS,0278,RC,,,,both,,,2807.76,1825.04,,,,,,,,,,,,,
SPLINT THMB UNIV NEOPRENE PERF W DORS RAD PALMAR STAY PKT,SUP-2196849,CDM,L3923,HCPCS,0274,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 6 MM RNG L 12 CM EPTFE STR TW,SUP-2396151,CDM,C1768,CPT,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
GRAFT BONE SUB 5CC PASTE DEMIN MTRX VIAGRAF,SUP-2348208,CDM,C1713,HCPCS,0278,RC,,,,both,,,2078.68,1351.14,,,,,,,,,,,,,
CLAMP EXT FIX 10.5MM BAR TO 5MM PIN FRDM MR SAFE JET-X,SUP-2342892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4614.39,2999.35,,,,,,,,,,,,,
BIAFINE EX EMUL,RX-43655,CDM,2500000003,HCPCS,0250,RC,58980-0960-31,NDC,,both,90,GR,169.80,110.37,,,,,,,,,,,,,
SCREW BONE STD 22MM ACUTRK 2,SUP-2107282,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 4H 127MM RT STRL,SUP-2546843,CDM,C1713,HCPCS,0278,RC,,,,both,,,5767.43,3748.83,,,,,,,,,,,,,
STAPLER INT REINF 60 MM BRTRC BIODESIGN ECHELON 60 CSLRASC60,SUP-2737229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
DRESSING CELLERATE RX 5 GM SURG PWD HYDROLYZED CLLGN,SUP-2422826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
SET CANN SM AD BIOLINE COAT HLS ADV 5,SUP-2266040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,42583.24,27679.11,,,,,,,,,,,,,
GRAFT BNE SUTURABLE 6X8 CM BOV PERICARD,SUP-2624227,CDM,C1763,HCPCS,0278,RC,,,,both,,,1578.79,1026.21,,,,,,,,,,,,,
BIT DRL L150MM DIA39X42MM 3 FLUT QUIK CPL FOR 5MM SCR,SUP-2178951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,582.41,378.57,,,,,,,,,,,,,
PACEMAKER CARD INVIVE W 44.5 X H 61 MM THK 7.5 MM CRT-P 3,SUP-2149291,CDM,C2621,HCPCS,0275,RC,,,,both,,,21540.40,14001.26,,,,,,,,,,,,,
COMPONENT FEM ROTATIONAL LG 25 MM LT PROS W/ ANTI-LUXATION,SUP-2265097,CDM,C1776,CPT,0278,RC,,,,both,,,15180.33,9867.21,,,,,,,,,,,,,
WIRE EXT FIX L 546 MM DIA1.8 MM XL OLV NS DISP ILIZ,SUP-2932755,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.27,389.53,,,,,,,,,,,,,
MAND ANGLE PLATE T.S.LCKNG RT X LNG 3 X 3 2.3MM SSTM T 6L 4V,SUP-2496207,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.97,986.03,,,,,,,,,,,,,
PLATE BNE 16 H CRANIOMAXILLOFACIAL TI STR LO PROF W/O BAR,SUP-2366198,CDM,C1713,HCPCS,0278,RC,,,,both,,,918.58,597.08,,,,,,,,,,,,,
STENT PERIPH L5CM DIA6MM CATH L120CM 0.035IN HEP BIOACTIVE,SUP-2396597,CDM,C1874,HCPCS,0278,RC,,,,both,,,9391.74,6104.63,,,,,,,,,,,,,
BLADE IM L100MM DIA1035MM PROX FEM G TI CANN HELI TFN ADV,SUP-2180757,CDM,C1713,HCPCS,0278,RC,,,,both,,,2023.07,1315.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY UTHN L 75 CM BALLOON L 40 MM DIA 9 MM,SUP-2141831,CDM,C1725,HCPCS,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
COMPONENT GLEN L 40MM STD SHLDR UHMWPE COFIELD2,SUP-2344311,CDM,C1776,CPT,0278,RC,,,,both,,,3037.95,1974.67,,,,,,,,,,,,,
SCREW BNE L24MM DIA3MM THRD L8MM CANC S STL ST SELF DRL,SUP-2184994,CDM,C1713,HCPCS,0278,RC,,,,both,,,796.08,517.45,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 1 MESH KT NS FACE ID,SUP-2909638,CDM,C1713,HCPCS,0278,RC,,,,both,,,34573.57,22472.82,,,,,,,,,,,,,
BIT DRILL CANN 3.3MMD QUICK COUPLING,SUP-2482353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,931.45,605.44,,,,,,,,,,,,,
SYSTEM CARD MONITORING ARRHYTHMIA BIOMONITOR III,SUP-2422776,CDM,C1764,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
GUIDEWIRE SUPP L185CM DIA0014IN STR TIP SAVION FLX,SUP-2140938,CDM,C1769,HCPCS,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
SPACER HIP 46MM SH 1 PC SLD POLY METH METHACRYLATE S STL,SUP-2223673,CDM,C1713,HCPCS,0278,RC,,,,both,,,8650.70,5622.95,,,,,,,,,,,,,
HC Thromb Mech Vein,PX-3613718700,CDM,37187,CPT,0361,RC,,,,outpatient,,,7160.00,4654.00,,,,,,,,,,,,,
PLATE BONE NC FUS 1.5MM THICKNESS LT SM,SUP-2321508,CDM,C1713,HCPCS,0278,RC,,,,both,,,6143.41,3993.22,,,,,,,,,,,,,
WRENCH SURG 8 11MM PT FOR DISTR OSTEOGENESIS RNG SYS,SUP-2176962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,710.39,461.75,,,,,,,,,,,,,
MESH CRAN W60XL60MM PROF H0.1MM MIC UP FACE,SUP-2366214,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.99,1082.24,,,,,,,,,,,,,
ALENDRONATE SODIUM 70 MG PO TABS,RX-29048,CDM,6370000000,HCPCS,0637,RC,16714-0633-01,NDC,,both,1,UN,5.10,3.31,,,,,,,,,,,,,
CLAMP EXTERNAL FIXATION 45MML BLUE F/PIN XTRAFIX,SUP-2475525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1645.58,1069.63,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR H54XL54MM 2 CHN DEV RECHRG BTTRY,SUP-2284467,CDM,C1820,HCPCS,0278,RC,,,,both,,,84466.00,54902.90,,,,,,,,,,,,,
PACEMAKER CARD TRIL SR + SINGLE CHMBR STRL,SUP-2320133,CDM,C1786,HCPCS,0275,RC,,,,both,,,13172.30,8561.99,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM GENDER SPEC FLX POLYETH,SUP-2212703,CDM,C1776,CPT,0278,RC,,,,both,,,12776.69,8304.85,,,,,,,,,,,,,
BIT DRL L215MM DIA3.2MM CALIB L82MM STRL 3 FLUT QUIK CPL,SUP-2188198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,808.61,525.60,,,,,,,,,,,,,
BIT DRL FISH TAIL UNIV 30 MM SOLITAIRE,SUP-2685254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
MESH HERN W10XL15CM THK1MM EPTFE ABD VENTRAL NONABSORBABLE,SUP-2125741,CDM,C1781,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
CATHETER EP JSN 2-5-2 MM 6 FRX120 CM SUPREME,SUP-2355185,CDM,C1730,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
REAMER MTP 21MM FEM SH CUST,SUP-2320320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
VALVE AORT DIA25MM MECH SEW RNG ROT STD CUF,SUP-2356709,CDM,C1889,HCPCS,0278,RC,,,,both,,,15018.62,9762.10,,,,,,,,,,,,,
COIL EMB L12MM DIA2.5MM NEUROVASC BRAID DSGN FLXIBLE,SUP-2296687,CDM,C1889,HCPCS,0278,RC,,,,both,,,43925.46,28551.55,,,,,,,,,,,,,
EXTRACTOR SURG SZ 1.6 MM SCREW DIA 3.4-4 MM STRL DISP,SUP-2913642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1923.82,1250.48,,,,,,,,,,,,,
CAGE SPNL W17XH88XL22MM ANT CERV THORLUM TI OBLONG,SUP-2193230,CDM,C1889,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
DEVICE COAG 3CM GUID 6130 FOR EPICARD ABLAT EPI-SENSE,SUP-2124438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE MED ECON BUCK,SUP-2336328,CDM,L4398,HCPCS,0274,RC,,,,both,,,28.29,18.39,,,,,,,,,,,,,
IMMOBILIZER KNEE SIZED CANVS 19 IN 2XL,SUP-2336067,CDM,L1830,CPT,0272,RC,,,,both,,,39.66,25.78,,,,,,,,,,,,,
PLATE BNE L84MM 4 H BILAT S STL T SHP LO PROF NEUT,SUP-2185752,CDM,C1713,HCPCS,0278,RC,,,,both,,,1565.35,1017.48,,,,,,,,,,,,,
PLATE BNE RECON 2-2.7X3 MM RT MAND 26 HOLE ANGLED TI NS,SUP-2469924,CDM,C1713,HCPCS,0278,RC,,,,both,,,6179.49,4016.67,,,,,,,,,,,,,
HEAD RMR DIA8.5MM MDLLRY FR CUT,SUP-2188127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.11,571.42,,,,,,,,,,,,,
"HC So Herpes Simplex, Type 1",PX-3028669566,CDM,86695,CPT,0302,RC,,,,both,,,108.00,70.20,,,,,,,,,,,,,
ANCHOR SUT L19.1MM DIA4.75MM BIOCOMPOSITE FULL THRD,SUP-2121695,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
PACEMAKER CRD SINGLE CHMBR LD CABLE INTRO,SUP-2357726,CDM,C1786,HCPCS,0275,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
CATHETER GUID AD L45CM DIA7FR PERIPH W/O HYDRPHLC HOCK STK,SUP-2139612,CDM,C1894,HCPCS,0272,RC,,,,both,,,357.18,232.17,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 45 CM DIA 8 FR HYDRPHLC,SUP-2383414,CDM,C1894,HCPCS,0272,RC,,,,both,,,375.42,244.02,,,,,,,,,,,,,
INTRODUCER CARD LD PLCMNT STR 9FRX47CM W/O HEMSTAT VLV COR,SUP-2357292,CDM,C1887,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE W6.3XL40MM THK1.6MM 3X3 H R DST RAD VOLAR S STL T,SUP-2186099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1694.56,1101.46,,,,,,,,,,,,,
SCREW BONE EMERGENCY 1.2X8 MM CORTEX CRANIOMAXILLOFACIAL WIT,SUP-2838160,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.07,238.60,,,,,,,,,,,,,
PLATE BNE L 56 MM 7 H TI LT DSTL DORS ULN STRL EVOS,SUP-2931301,CDM,C1713,HCPCS,0278,RC,,,,both,,,3835.20,2492.88,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 45FR DIA DST TIP 15MML TIP 20MML CUT,SUP-2707127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.69,378.10,,,,,,,,,,,,,
HC Shoulder Complete Min 2 Views,PX-3207303000,CDM,73030,CPT,0320,RC,,,,both,,,425.00,276.25,,,,,,,,,,,,,
SCREW BONE L6MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI SELF,SUP-2189359,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
COMPONENT CRPL SM 1+ MM WRST POLYETH UNIV 2 262301,SUP-2610327,CDM,C1776,CPT,0278,RC,,,,both,,,3528.79,2293.71,,,,,,,,,,,,,
CATHETER SPNL OD1MM ODSEC17GA ID.5MM TI POLYUR KT INTEGR,SUP-2257114,CDM,C1889,HCPCS,0278,RC,,,,both,,,2439.78,1585.86,,,,,,,,,,,,,
IMPLANT OTO L3.75MM PIST DIA0.5MM NIT FLROPLAS SMRT,SUP-2312821,CDM,2780000010,LOCAL,0278,RC,,,,both,,,939.58,610.73,,,,,,,,,,,,,
GRAFT EVAR L49MM DIA36X36MM EXTN FREE FLO CLS WEB FOR ABD,SUP-2295234,CDM,C1768,CPT,0278,RC,,,,both,,,14679.50,9541.67,,,,,,,,,,,,,
CORD ELECSURG BPLR PWR IRRIGATOR NS LTX,SUP-2859250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,385.47,250.56,,,,,,,,,,,,,
VISE EXT FIX INSUL MINI HM29,SUP-2517251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.05,390.03,,,,,,,,,,,,,
APPLICATOR ELECSURG STR 6X65 MM W/ SUCTION DISP,SUP-2734131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
CATHETER HD STR 20 CM 15 CM BIOFLO DURAMAX,SUP-2487143,CDM,C1750,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
KIT ACC 10GA 3ML SYR BVL TIP SIDE OPN RADPQ W/O CEM SYNFLATE,SUP-2255821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HEAD FEM DIA36MM NK L+7MM 12/14 TAPR HIP CO CHROM CEM PRI 80183604] ZIMMER BIOMET ETEX CORP],SUP-2402792,CDM,C1776,CPT,0278,RC,,,,both,,,2670.35,1735.73,,,,,,,,,,,,,
PATCH CV FOR CARD PED 05MM NOM THICKNESSX3CM NOM WIDTHX3CM,SUP-2395327,CDM,C1768,CPT,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
DRILL SURG OD4.4MM CALIB NONSTERILE JCBS,SUP-2412781,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
HC Debride Skin and Subcu,PX-4501104200,CDM,11042,CPT,0450,RC,,,,both,,,1247.00,810.55,,,,,,,,,,,,,
CATHETER GUID VL3.5 6 FR,SUP-2139791,CDM,C1887,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
CATHETER CARD ABLATION CELSIUS FLTR L 115 CM 7.5 FR TIP 8 MM,SUP-2248634,CDM,C1733,HCPCS,0272,RC,,,,both,,,2383.26,1549.12,,,,,,,,,,,,,
DEVICE FIX 5.5X20MM XTENDOBUTTON,SUP-2341700,CDM,C1776,CPT,0278,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
HC So Pregnenolone,PX-3018414066,CDM,84140,CPT,0301,RC,,,,outpatient,,,55.00,35.75,,,,,,,,,,,,,
SCREW BNE L30MM OD6.5MM TIV KNEE ST MG II NXGN,SUP-2199568,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.52,330.54,,,,,,,,,,,,,
FORCEPS STONE RETRV L120CM DIA8MM SHTH 2.6FR NIT 2 PRNG,SUP-2139240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.66,413.18,,,,,,,,,,,,,
GUIDEWIRE UROLOGY STR 0.035 INX145 CM 3 CM STD BODY RDRUN PC,SUP-2835779,CDM,C1769,HCPCS,0272,RC,,,,both,,,152.76,99.29,,,,,,,,,,,,,
KIT CATH AD L36CM DIA14.5FR 1.6ML SIL DBL LUMN CVD SYMMETRIC,SUP-2174230,CDM,C1750,HCPCS,0278,RC,,,,both,,,1700.37,1105.24,,,,,,,,,,,,,
STAPLE BNE 25X20X20 MM SUPER ELASTIC NIT MEMOFIX,SUP-2423401,CDM,C1713,HCPCS,0278,RC,,,,both,,,5736.84,3728.95,,,,,,,,,,,,,
PLATE BNE W10XL142MM THK3.6MM 12 H BILAT S STL CRV RIG CLLR,SUP-2186256,CDM,C1713,HCPCS,0278,RC,,,,both,,,2378.30,1545.89,,,,,,,,,,,,,
PLATE BNE W10.3XL111.6MM THK3.7MM 8 H TI LOK COMPR LO PROF,SUP-2413708,CDM,C1713,HCPCS,0278,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
FIBER LASER HOLM 10609] FORTEC MEDICAL INC],SUP-2225649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OVR THE WIRE 0.018 IN 150 CM 2.5X220 MM,SUP-2140761,CDM,C1725,HCPCS,0272,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
RELOAD STPLR ARTICULATING LINEAR 45 MM END CUT ENDOPATH ETS,SUP-2257558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.69,297.50,,,,,,,,,,,,,
DEVICE LAPSCP L DIA9CM HND ASST LAP-DISC,SUP-2257668,CDM,C1788,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
GRAFT BNE L230MM DIA4MM GRACILIS TEND HAMSTRING FRZN FOR,SUP-2264762,CDM,C1762,CPT,0278,RC,,,,both,,,3634.96,2362.72,,,,,,,,,,,,,
GRAFT VASC HEMGRD BODY/BRANCH L 100/60 CM DIA 8 X 8 MM,SUP-2478763,CDM,C1768,CPT,0278,RC,,,,both,,,2569.96,1670.47,,,,,,,,,,,,,
KIT INTRO MINI STK MAX L 10 CM DIA 5 FR 7 CM ECHOGENIC STIFF,SUP-2118824,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
STENT BILI MGLNK L 18 MM DIA 6 FR EXP DIA 8 MM SS AD BALLOON,SUP-2103531,CDM,C1877,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PACEMAKER CARD CYLOS DR W 42 X H 57 MM D 6 MM TI POLYUR SIL,SUP-2138038,CDM,C1785,HCPCS,0275,RC,,,,both,,,13812.86,8978.36,,,,,,,,,,,,,
ALLOGRAFT BNE SPNG 20X15X5 MM BLOCK DBM CANC H-GENIN,SUP-2225961,CDM,C1889,HCPCS,0278,RC,,,,both,,,3717.76,2416.54,,,,,,,,,,,,,
FIXATOR EXT FIX COMPR DISTRCTN STATIC XCALIBER PVC FREE STRL,SUP-2646338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,965.55,627.61,,,,,,,,,,,,,
SHEATH ENDO OD2.7MM EXCHG FOR 30DEG TELSCP 8672.422,SUP-2332865,CDM,C1894,HCPCS,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
AXICABTAGENE CILOLEUCEL 200000000 CELLS IV SUSP,RX-155561,CDM,Q2041,HCPCS,0891,RC,71287-0119-01,NDC,,both,1,UN,3525060.00,2291289.00,,,,,,,,,,,,,
SHEARS SEAL L20CM DIA5MM ULTRASONIC CRV TIP HARM HD 1000I,SUP-2219111,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1864.72,1212.07,,,,,,,,,,,,,
DISPOSABLES KIT FOR 3.5 MM HIP PUSHLOCK,SUP-2812329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
IMMOBILIZER ORTH T BAR UNIV 19 IN KNEE CANVS BLU REUSE,SUP-2336063,CDM,L1830,CPT,0274,RC,,,,both,,,38.12,24.78,,,,,,,,,,,,,
SCREW BNE L28MM OD3MM TI LO EXT ST SELF DRL CANN FIX STBL,SUP-2242812,CDM,C1713,HCPCS,0278,RC,,,,both,,,1285.36,835.48,,,,,,,,,,,,,
VALVE HYDROCEPHALUS PEDIATRIC WITH BURR HOLE RESERVOIR PROGA,SUP-2826123,CDM,C1889,HCPCS,0278,RC,,,,both,,,7946.46,5165.20,,,,,,,,,,,,,
SPLINT FNGR W1 2IN 3PP BUDDY LOOP,SUP-2112615,CDM,L3933,HCPCS,0272,RC,,,,both,,,8.35,5.43,,,,,,,,,,,,,
POLARCUP Anchoring Peg (2 each),SUP-2511217,CDM,C1776,CPT,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
CATHETER NEPHROSTOMY PIG 6.5 FRX30 CM TOT ABSCESSION,SUP-2752473,CDM,C1729,HCPCS,0272,RC,,,,both,,,224.13,145.68,,,,,,,,,,,,,
PROBE VITRCTMY 27GA L27MM 10000CPM CONSTELLATION ULTRAVIT,SUP-2109977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,736.90,478.98,,,,,,,,,,,,,
MESH HERN 14X14IN POLY 4 HYDROXYBUTYRATE SYN SQ WVN,SUP-2125878,CDM,C1781,HCPCS,0278,RC,,,,both,,,51684.40,33594.86,,,,,,,,,,,,,
CATHETERIZATION KIT 8.5 FRX16 CM CV BNDL VANTEX,SUP-2744705,CDM,C1751,HCPCS,0278,RC,,,,both,,,423.87,275.52,,,,,,,,,,,,,
KIT BNE PLATE SCREW DIA2 MM TI MANDIBULAR PRIMARY RECON HEMI,SUP-2883331,CDM,C1713,HCPCS,0278,RC,,,,both,,,30991.80,20144.67,,,,,,,,,,,,,
METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR,RX-162820,CDM,J2919,HCPCS,0636,RC,00009-0047-26,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
SPLINT RNG PIP FLX EXTN FNGR 3/4IN SM,SUP-2324608,CDM,L3808,HCPCS,0274,RC,,,,both,,,45.81,29.78,,,,,,,,,,,,,
COMPONENT FEM 1.5 KNEE 3 IN 1 SIG,SUP-2456217,CDM,C1776,CPT,0278,RC,,,,both,,,8308.44,5400.49,,,,,,,,,,,,,
BIT DRL L270MM DIA12MM NONSTERILE LNG CANN L QUIK CPL FOR,SUP-2178906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1368.35,889.43,,,,,,,,,,,,,
NEEDLE BNE MAR SET 11 GAX152 MM BX SYS ONCONTROL,SUP-2766673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.09,271.11,,,,,,,,,,,,,
PLATE BNE W7XL32MM THK1.2MM 3 H S STL T SHP MAL FOR 2.7MM,SUP-2186088,CDM,C1713,HCPCS,0278,RC,,,,both,,,1065.56,692.61,,,,,,,,,,,,,
HC Continous Inhale Tx 1st Hour,PX-4109464400,CDM,94644,CPT,0410,RC,,,,inpatient,,,660.00,429.00,,,,,,,,,,,,,
WASHER ORTH FOR COUNT TORQUE ARM TRABECULAR MTL,SUP-2437279,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
LEVEL NEURO ST PLATE MICRO LDDR 15 MM SCRW2 X 2 HOLES 12 MM,SUP-2707406,CDM,C1713,HCPCS,0278,RC,,,,both,,,559.83,363.89,,,,,,,,,,,,,
STABILIZER FEM SM CO CHROM DURAC NP RT KNEE REV POST STBL,SUP-2364839,CDM,C1776,CPT,0278,RC,,,,both,,,7147.80,4646.07,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST DBL UPR PREFABRICATED OFF THE SHLF,SUP-2435619,CDM,L1852,HCPCS,0272,RC,,,,both,,,2371.58,1541.53,,,,,,,,,,,,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,0636,RC,00641-1495-31,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L142MM 8 H NONSTERILE L ANTEROMEDIAL DST TIB S,SUP-2177676,CDM,C1713,HCPCS,0278,RC,,,,both,,,5189.98,3373.49,,,,,,,,,,,,,
PIN FIX L240MM DIA4MM S STL TRCR SMOOTH SHRP TIP,SUP-2341351,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
PLATE BNE L232MM 12 H ST R MED DST TIB S STL VAR ANG LOK,SUP-2177645,CDM,C1713,HCPCS,0278,RC,,,,both,,,6318.47,4107.01,,,,,,,,,,,,,
TREPHINE BONE BX L8IN DIA11MM RMR FOR FEM REV PROC,SUP-2136782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GAUGE DEPTH FOR RECON SYS VERTEX MAX,SUP-2286802,CDM,C1713,HCPCS,0278,RC,,,,both,,,1176.43,764.68,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.539,SUP-2860220,CDM,C1713,HCPCS,0278,RC,,,,both,,,42225.78,27446.76,,,,,,,,,,,,,
WRAP KNEE INSRT ICE W/2 DURA SFT,SUP-2197214,CDM,L1820,HCPCS,0274,RC,,,,both,,,98.63,64.11,,,,,,,,,,,,,
CATHETER URODYN BLLN 7.4 FRX30 CM,SUP-2835714,CDM,C1726,HCPCS,0272,RC,,,,both,,,131.28,85.33,,,,,,,,,,,,,
PROSTHESIS PENILE PARYLENE INFL NONCONNECTED W/ INHIBIZONE,SUP-2140296,CDM,C1813,HCPCS,0278,RC,,,,both,,,8556.50,5561.72,,,,,,,,,,,,,
BIT DRL CANN 2 MM AO SHFT STRL DISP,SUP-2469804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.80,423.67,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 5 FRX130 CM 4X100 MM LUTONIX BSLX3513041005F] BARD PERIPHERAL VASCULAR],SUP-2127967,CDM,C2623,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
BENZOCAINE-DOCUSATE SODIUM 20-283 MG RE ENEM,RX-111264,CDM,6370000000,HCPCS,0637,RC,17433-9877-05,NDC,,both,5,ML,9.30,6.04,,,,,,,,,,,,,
EXTENSION STEM STR 18X175 MM KNEE REV PERSONA,SUP-2508772,CDM,C1776,CPT,0278,RC,,,,both,,,4044.32,2628.81,,,,,,,,,,,,,
CEFAZOLIN SODIUM 3 G IJ SOLR,RX-166584,CDM,J3376,HCPCS,0636,RC,60505-6266-00,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0018IN TIP L20CM SIL NIT IMAG ANG,SUP-2172971,CDM,C1769,HCPCS,0272,RC,,,,both,,,225.04,146.28,,,,,,,,,,,,,
GRAFT BNE STRP 50 MM 10 CC,SUP-2430786,CDM,C1889,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
HC So Immunology Procedure,PX-3028684966,CDM,86849,CPT,0302,RC,,,,inpatient,,,27.00,17.55,,,,,,,,,,,,,
CATHETER CV 3L 6 FR PASV VLV MAX BARR NURSING KT BIOFLO,SUP-2734869,CDM,C1751,HCPCS,0278,RC,,,,both,,,183.38,119.20,,,,,,,,,,,,,
BUR SURG RND 4.5X130 MM W/ LAT PROTCT GOLF BLU STRL DISP,SUP-2599843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.30,232.24,,,,,,,,,,,,,
HC Immunofluorescence PR Spec Ea Add Singl Antb Stn,PX-3128835000,CDM,88350,CPT,0312,RC,,,,both,,,369.00,239.85,,,,,,,,,,,,,
CATHETER CTRL VEN 8FR NONPOWER INJ SGL LUMN W/ TISS,SUP-2127894,CDM,C1751,HCPCS,0278,RC,,,,both,,,1970.41,1280.77,,,,,,,,,,,,,
PLATE BNE 2.7X44 MM 5 HOLE SS DCP,SUP-2569127,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.32,167.26,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00990-7922-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
PORT INFUS 8FR SIL PWR INJ ATTCH POLYUR CATH INTMED KT,SUP-2126306,CDM,C1788,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC EXCHANGE 14.5 5397230 - ORDER UOM IS CA,SUP-2632953,CDM,C1750,HCPCS,0278,RC,,,,both,,,1341.88,872.22,,,,,,,,,,,,,
STENT CORONARY XIENCE PRIM LL L 28 MM DIA2.25 MM SYS L 143,SUP-2104685,CDM,C1874,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
ROD SPNL L 190 MM DIA 6 MM CARBON FIBER PEDCL S SHP TYP 1,SUP-2883100,CDM,C1713,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
NEEDLE ASPIR 22 GA EZ SHOT 3,SUP-2434182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,827.77,538.05,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP FEM SHFT,SUP-2867012,CDM,C1762,CPT,0278,RC,,,,both,,,5100.93,3315.60,,,,,,,,,,,,,
HIP H3 TOT ADV DUAL MOBILITY IMPL CAPPED H3 OD,SUP-2431851,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED FRAC,SUP-2212723,CDM,C1776,CPT,0278,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW CLASSIC 36MM OD 41.2MM MITRL,SUP-2214147,CDM,C1889,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
PIN EXT FIX L 30 MM DIA 6 MM HA HALF STRL DISP,SUP-2932756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.52,423.49,,,,,,,,,,,,,
PLATE BNE W22XL54MM STD 6X3 H NONSTERILE R DST RAD VOLAR TI,SUP-2180846,CDM,C1713,HCPCS,0278,RC,,,,both,,,2379.65,1546.77,,,,,,,,,,,,,
CATHETER GUID TURNPIKE L 150 CM SHFT DIA PROX/DSTL,SUP-2383151,CDM,C1887,HCPCS,0272,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX12 CM 16 GA 3L RIFAMPIN SPECTRUM,SUP-2759744,CDM,C1751,HCPCS,0278,RC,,,,both,,,435.17,282.86,,,,,,,,,,,,,
INSULIN ASPART PROT & ASPART (70-30) 100 UNIT/ML SC SUSP,RX-33666,CDM,J1815,HCPCS,0637,RC,00169-3685-12,NDC,,both,10,ML,57.90,37.63,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY POLYCENTRIC,SUP-2435665,CDM,L2387,HCPCS,0274,RC,,,,both,,,540.46,351.30,,,,,,,,,,,,,
PLATE BNE CLMN ARCH LG 2 MM LT MEDL TI GORILLA,SUP-2751074,CDM,C1713,HCPCS,0278,RC,,,,both,,,5016.15,3260.50,,,,,,,,,,,,,
GRAFT 160MG 20CC INJ MICRONIZED ALLGRFT EPIFIX,SUP-2305739,CDM,Q4145,HCPCS,0636,RC,,,,both,,,9107.57,5919.92,,,,,,,,,,,,,
KIT LD INTRO INTROFLEX DIA 9 FR J BPLR INSRTN FOR TEMP PACE,SUP-2214543,CDM,C1894,HCPCS,0272,RC,,,,both,,,83.96,54.57,,,,,,,,,,,,,
PLATE BNE W10XL190MM THK3.6MM 16 H BILAT S STL CRV RIG CLLR,SUP-2186259,CDM,C1713,HCPCS,0278,RC,,,,both,,,2853.38,1854.70,,,,,,,,,,,,,
BALLOON ENT SINUS DIL SYS VENTERA,SUP-2341432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
CATHETER HD STR EXTN 12.5 FRX28 CM LT DL STP TIP SIL HEMCATH,SUP-2627314,CDM,C1750,HCPCS,0278,RC,,,,both,,,20.22,13.14,,,,,,,,,,,,,
SCREW BNE L 46 MM DIA 4.5 MM CORTICAL ST STRL EVOS,SUP-2931158,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.16,115.15,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED FEM HD,SUP-2867201,CDM,C1762,CPT,0278,RC,,,,both,,,4000.20,2600.13,,,,,,,,,,,,,
GRAFT BNE W14.5XH6X8XL12MM 7DEG CERV INTBDY FUS LORD,SUP-2264946,CDM,C1713,HCPCS,0278,RC,,,,both,,,3665.32,2382.46,,,,,,,,,,,,,
SET URET STENT CNTOUR L 24 CM DIA 4.8 FR PTFE GUIDEWIRE SLV,SUP-2462210,CDM,C2617,HCPCS,0278,RC,,,,both,,,465.41,302.52,,,,,,,,,,,,,
ALLOGRAFT BNE BI-COMPARTMENT REFRIGERATED LT MEDL TROCHLEA,SUP-2740878,CDM,C1762,CPT,0278,RC,,,,both,,,57907.91,37640.14,,,,,,,,,,,,,
IMPL TOE JT 0 DEG XS CANN STR STRL PHALINX,SUP-2900773,CDM,C1713,HCPCS,0278,RC,,,,both,,,5099.36,3314.58,,,,,,,,,,,,,
JOINT TOE HAMRTOE 10 DEG 3.3 MM KT TOE-LEGIT,SUP-2749829,CDM,C1776,CPT,0278,RC,,,,both,,,4888.98,3177.84,,,,,,,,,,,,,
PLATE BNE L 105 X W 8 MM THK 2.4 MM SCREW DIA2.7 MM 6 H SS,SUP-2933934,CDM,C1713,HCPCS,0278,RC,,,,both,,,2783.92,1809.55,,,,,,,,,,,,,
HC Pulse Ox Multiple Determine,PX-4609476100,CDM,94761,CPT,0460,RC,,,,inpatient,,,406.00,263.90,,,,,,,,,,,,,
SHEATH INTRO 4.5IN/11CM PERC LD SPNL CRD STIM SYS,SUP-2141925,CDM,C1892,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HEAD FEM DIA47MM UPLR CO CHROM MOD 12/14 TAPR LEG,SUP-2207880,CDM,C1776,CPT,0278,RC,,,,both,,,968.38,629.45,,,,,,,,,,,,,
CANFIELD TONSIL KNF 8 12,SUP-2669734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.56,285.06,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM TIP L8MM 2.5MM SPC QPLR L CRV,SUP-2141344,CDM,C1732,HCPCS,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED BROAD LCP TM 26 HOLES 479MM STERILE,SUP-2549502,CDM,C1713,HCPCS,0278,RC,,,,both,,,5545.46,3604.55,,,,,,,,,,,,,
BIT DRL STP STRT PFC ULT,SUP-2456005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY DS VR W 6.1 X H 6.6 CM D 1.1 CM,SUP-2149283,CDM,C1722,HCPCS,0275,RC,,,,both,,,49665.38,32282.50,,,,,,,,,,,,,
GRAFT BNE FEN 15X100 MM DEMINERALIZED CORTICAL FENFLEX,SUP-2742006,CDM,C1713,HCPCS,0278,RC,,,,both,,,3151.78,2048.66,,,,,,,,,,,,,
CENTRALIZER DSTL HUM 6.5 MM DIA TI MOSAIC,SUP-2403514,CDM,C1776,CPT,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 150 CM DIA 0.025 IN NIT HYDRPHLC,SUP-2141138,CDM,C1769,HCPCS,0272,RC,,,,both,,,174.27,113.28,,,,,,,,,,,,,
ALLOSYNC DBM STRIP 19X26X7MM,SUP-2811276,CDM,C1713,HCPCS,0278,RC,,,,both,,,4903.11,3187.02,,,,,,,,,,,,,
SCREW DARTFIRE EDGE SNAP OFF D2420012,SUP-2849011,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.36,1375.63,,,,,,,,,,,,,
TROCAR SURG RETROGRADE 8 MM FEM TRI FLUT,SUP-2495675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.32,544.91,,,,,,,,,,,,,
PIN POS 5MM TI CRMP FOR ORTH CBL SYS,SUP-2181298,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.33,487.71,,,,,,,,,,,,,
DEVICE VES SEAL OD 15 FR ID 10-12 FR PERC FEM VEN ACCS SITE,SUP-2927663,CDM,C1760,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
TIP ULTRASONIC L280MM TIP L12.8MM OD1.95MM ID1.50MM REPL,SUP-2243012,CDM,C1713,HCPCS,0278,RC,,,,both,,,2927.11,1902.62,,,,,,,,,,,,,
COLLAR HUM DIA40MM ECC SUT FOR SHLDR ARTHROPLASTY SYS GLOB,SUP-2249860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.70,911.10,,,,,,,,,,,,,
PLATE BNE L109MM 4 H NONSTERILE R MED DST TIB S STL LO BEND,SUP-2184169,CDM,C1713,HCPCS,0278,RC,,,,both,,,3695.50,2402.07,,,,,,,,,,,,,
HC Njx Px Cntrst Kne Arthg Cntrst Enhncd CT/MRI Kne,PX-3612736900,CDM,27369,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW INTFR L16MM DIA8MM BOLT TENODESIS FOR PROX BICEPS REP,SUP-2417350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.27,921.23,,,,,,,,,,,,,
SCREW INTFR L30MM DIA8MM KNEE FULL THRD RND HD FOR ACL FIX,SUP-2136090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1244.95,809.22,,,,,,,,,,,,,
GRAFT 6CMWX16CMLX18 25MM ULT THCK DERM PLIABLE BIL BRST KT,SUP-2307592,CDM,Q4128,HCPCS,0636,RC,,,,both,,,15794.99,10266.74,,,,,,,,,,,,,
NAIL IM TIB 8X330 MM STRL T2 ALPHA,SUP-2461254,CDM,C1713,HCPCS,0278,RC,,,,both,,,8091.53,5259.49,,,,,,,,,,,,,
STENT URET STR 0.038 IN 3 CM 7 FRX26 CM 6 FRX150 CM CNTOUR,SUP-2459842,CDM,C2617,HCPCS,0278,RC,,,,both,,,537.00,349.05,,,,,,,,,,,,,
BLADE RTRCTR SCVLLE MRDNG SM MED 2INW X 3 12ND SRRTD TIP UL,SUP-2667621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.21,210.74,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 3 FR BASIC TY W/ SAFETY INTRO GROSH,SUP-2126613,CDM,C1751,HCPCS,0278,RC,,,,both,,,232.99,151.44,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR CUST FIT,SUP-2435674,CDM,L2520,HCPCS,0272,RC,,,,both,,,1521.74,989.13,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq Ea Addl 15 Min,PX-4209755100,CDM,97551,CPT,0420,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 15X0 CM GENTRIX MATRIX PLUS,SUP-2106483,CDM,Q4166,HCPCS,0636,RC,,,,both,,,12487.78,8117.06,,,,,,,,,,,,,
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,2580000003,HCPCS,0258,RC,00409-1775-10,NDC,,both,10,ML,175.10,113.81,,,,,,,,,,,,,
ORTHOSIS ANK FT SM SZ M 6-7.5 WOM 7.5-9 RT CLOSE HEEL DLX,SUP-2195190,CDM,L1930,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT VASC IMPRA L 35 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761265,CDM,C1768,CPT,0278,RC,,,,both,,,1384.43,899.88,,,,,,,,,,,,,
BLADE SHAVER CRV 15 DEG 4.8 MM SERRATED HEMOSTATIC CONVX,SUP-2638103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC DBM B201005P] FRONTIER MEDICAL PRODUCTS INC],SUP-2225959,CDM,C9359,HCPCS,0278,RC,,,,both,,,3378.64,2196.12,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X41 MM 5 HOLE 1/4 SS,SUP-2536105,CDM,C1713,HCPCS,0278,RC,,,,both,,,358.27,232.88,,,,,,,,,,,,,
HC So Hiv-2 Ab,PX-3028670266,CDM,86702,CPT,0302,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
ARFORMOTEROL TARTRATE 15 MCG/2ML IN NEBU,RX-77581,CDM,J7605,HCPCS,0636,RC,60687-0770-79,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
HOLDER PLT DIA2X2.4MM THRD FOR HND PLATING SYS TAK,SUP-2319569,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
MESH SURG L 30 X W 30 CM POLYPRO POLYLACTIC ACD GRP,SUP-2901781,CDM,C1781,HCPCS,0278,RC,,,,both,,,5408.90,3515.78,,,,,,,,,,,,,
FIBER LASER 200U 50W ETFE SIL FLEXSHIELD HI PWR POLISHED OUTPT,SUP-2141810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1174.27,763.28,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 260 CM DIA 0.035 IN TAPR L 15 CM FLPY,SUP-2167872,CDM,C1769,HCPCS,0272,RC,,,,both,,,135.43,88.03,,,,,,,,,,,,,
SALVATION  C WASHER 2.5MM 6PK MULTIPACK,SUP-2493481,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
PLATE CRAN 140X140X40 MM PT SPEC IMPL PEEK,SUP-2860156,CDM,C1713,HCPCS,0278,RC,,,,both,,,44496.31,28922.60,,,,,,,,,,,,,
BUR SURG RND LG 4 MM,SUP-2521572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
ENDCAP ROD FIB SONOMA,SUP-2352594,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CANISTER PMP MAX ARTEMIS,SUP-2461989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
SPACER SPNL MED 29-39 MM CNTRL BODY STRL XLR,SUP-2592008,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE STR WTAB 1.5 MM SCRW4 HOLE 18 MM T,SUP-2676829,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.70,298.80,,,,,,,,,,,,,
CATHETER DRNGE L120CM OD2.2MM ID1MM SIL PERI IMPREG BA,SUP-2243806,CDM,C1729,HCPCS,0272,RC,,,,both,,,1525.10,991.31,,,,,,,,,,,,,
PATCH BIOLOGICAL L 8 X W 6 CM BOVINE PERICARDIUM STERILE XENOSURE,SUP-2264268,CDM,C1768,CPT,0278,RC,,,,both,,,2069.26,1345.02,,,,,,,,,,,,,
SHEATH DIL OD16.3FR ID14.1FR CXL WHT POLYPR LD EXTR TELSCP,SUP-2169008,CDM,C1893,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
STEM FEM MOD 12/14 TAPR NK 35MM 8 CERASIV,SUP-2216774,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT BONE SUB BONE GRFT 1ML GEL TRANZGRFT,SUP-2353937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CONE TIB DIA24MM SHT LEGION,SUP-2349175,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
PROBE SURG SCR PEDCL DISP,SUP-2852927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2.5 MM RECON MAXILLA PT SPEC,SUP-2860101,CDM,C1713,HCPCS,0278,RC,,,,both,,,30345.59,19724.63,,,,,,,,,,,,,
CRYOABLATION PROC KT - VAR (6X CVA2400 6X CRYO-55-F 1X,SUP-2885436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13031.00,8470.15,,,,,,,,,,,,,
HC Apheresis W/ Affinity Column,PX-9403651600,CDM,36516,CPT,0940,RC,,,,both,,,13545.00,8804.25,,,,,,,,,,,,,
PLATE BONE ADJUSTABLE SLIDER 0.7X33 MM SAGITTAL SPLIT TITANI,SUP-2842388,CDM,C1713,HCPCS,0278,RC,,,,both,,,1951.82,1268.68,,,,,,,,,,,,,
TAP SURG L150MM THRD CANN QUIK CONN W/O HNDL FOR 7MM SCR,SUP-2187433,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2099.59,1364.73,,,,,,,,,,,,,
GUIDEWIRE URO L150CM 0035IN 3CM STR TIP PTFE FLATWIRE WRP,SUP-2312642,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.15,46.25,,,,,,,,,,,,,
GRAFT HUM TISS W1.5XL1.5CM AMNIO MEMBRN ALLGRFT FULL RESRB,SUP-2194316,CDM,Q4137,HCPCS,0636,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
CATHETER GUID LT HRT ATTAIN COMMND SUREVALVE,SUP-2282221,CDM,C1887,HCPCS,0272,RC,,,,both,,,980.62,637.40,,,,,,,,,,,,,
IMPLANT FNGR JT SZ 3 PROX INTERPHALANGEAL PRI SWNSN,SUP-2397895,CDM,C1776,CPT,0278,RC,,,,both,,,3488.54,2267.55,,,,,,,,,,,,,
BLADE ARTHSCP CRV HIP SHRP TIP,SUP-2608319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,882.78,573.81,,,,,,,,,,,,,
ANCHOR SUT OD2.9MM PEEK OPTMA POLYMER PRETIED KNOT ST KINSA,SUP-2341712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
COMPRESSION SCREW SET,SUP-2841429,CDM,C1713,HCPCS,0278,RC,,,,both,,,38465.00,25002.25,,,,,,,,,,,,,
PROSTHESIS PENILE INFLATABLE 0 DEG 16 CM SCROT TITAN TCH LF,SUP-2848013,CDM,C1813,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM DIA28MM SMOOTH FOR 65MM SCR,SUP-2319464,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
PLATE BNE L50.5MM 12 H R DST RAD VOLAR S STL LOK COMPR CLMN,SUP-2184073,CDM,C1713,HCPCS,0278,RC,,,,both,,,2345.74,1524.73,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X150X150X0.5 MM RAPID RESORBABLE,SUP-2838568,CDM,C1713,HCPCS,0278,RC,,,,both,,,18454.41,11995.37,,,,,,,,,,,,,
GRAFT VASC LIFESPAN L 80 CM DIA 8 MM EPTFE STR TW STRL,SUP-2264308,CDM,C1768,CPT,0278,RC,,,,both,,,2113.28,1373.63,,,,,,,,,,,,,
BIT DRL DIA 3.1 MM MEDIALIZED MOD STRL DISP INVICTUS,SUP-2886560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SCREW BNE L17MM DIA2MM MANDIBULOMAXILLARY IM FIX ORTHOANCHOR,SUP-2262926,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
SPACER SPNL SM W26XH14MM THORLUM PEEK FLAT INTBDY FUS ADD,SUP-2291502,CDM,C1889,HCPCS,0278,RC,,,,both,,,13056.12,8486.48,,,,,,,,,,,,,
BUR SURG L21CM HD L35.1MM DIA3MM TAPR L BOR MIDAS REX,SUP-2284390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.21,249.74,,,,,,,,,,,,,
GRAFT BONE 4-10MM 30ML CANC CUBE,SUP-2293754,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
ANCHOR SUT SFT TISS NO 2 POLY SUT ABSRB GLEN 3MM DIA,SUP-2366663,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.72,319.62,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM MED CP TI MANDIBULAR FULL,SUP-2883712,CDM,C1713,HCPCS,0278,RC,,,,both,,,17216.34,11190.62,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 45 MM DIA22 MM SHTH 11 FR CATH L,SUP-2142679,CDM,C1876,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 90 CM DIA 0.035 IN TAPR L 11 CM,SUP-2170672,CDM,C1769,HCPCS,0272,RC,,,,both,,,173.64,112.87,,,,,,,,,,,,,
SCREW BONE CNNLTD 6.5MM DIA 45MML TIMAX 16MML THRDD NON ST,SUP-2586826,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.19,477.22,,,,,,,,,,,,,
PROBE ENDOSCP DISECT 90 DEG 28.5 CM SHFT FOR NEUROENDOSCOPE,SUP-2665081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1222.40,794.56,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 112 MCG PO TABS,RX-10404,CDM,6370000000,HCPCS,0637,RC,00904-6954-61,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
BIT DRL L500MM DIA6X9MM CANN STP L QUIK CPL FOR DH DC TFN,SUP-2178964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1590.60,1033.89,,,,,,,,,,,,,
LINER ACET SZ DMD OD48MM ID28MM YEL HIP HIGHCROSS DBL,SUP-2267317,CDM,C1776,CPT,0278,RC,,,,both,,,5465.80,3552.77,,,,,,,,,,,,,
SLING ORTH 9X14IN 4X44IN SZ UNIV SM ENV IMMOB SWTH SLDE,SUP-2196952,CDM,L3660,HCPCS,0274,RC,,,,both,,,21.89,14.23,,,,,,,,,,,,,
STENT ESOPH NITI-S L 6 CM 18 MM 180 CM 10.5 FR FULL CVR,SUP-2425038,CDM,C1874,HCPCS,0278,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
ANCHOR SOFT TISSUE 7X30MM CARTRIDGE TIBIAL ANGLED KNURLED EX,SUP-2824094,CDM,C1713,HCPCS,0278,RC,,,,both,,,1387.88,902.12,,,,,,,,,,,,,
SYSTEM ATHRCTMY ROTLNK ADV ROT PRE CONN STRL,SUP-2147025,CDM,C1894,HCPCS,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
CATHETER ANGIOPLSTY PFLX PRO L 135 CM BALLOON L 120 MM DIA 4,SUP-2156762,CDM,C1725,HCPCS,0272,RC,,,,both,,,617.95,401.67,,,,,,,,,,,,,
PRESSURIZER BONE CEM 45DEG ACET HD NK,SUP-2408414,CDM,C1713,HCPCS,0278,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
GUIDEWIRE VASC CENTURION L 60 CM DIA 0.032 IN TIP L 3 MM J,SUP-2764052,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.29,30.74,,,,,,,,,,,,,
COUNTERBORE DRILL BIO-POST,SUP-2811826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
HC OP Traction Intermittent|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701200,CDM,97012,CPT,0420,RC,,,GP|CQ,outpatient,,,292.00,189.80,,,,,,,,,,,,,
PLATE BNE THK 2.6 MM SCREW DIA2/2.3 MM LG GRD II TI,SUP-2936149,CDM,C1713,HCPCS,0278,RC,,,,both,,,5661.42,3679.92,,,,,,,,,,,,,
ARROW COCR CNTR HUM HD .40 - 15,SUP-2224499,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
GUIDE SURG LT RVS SHLDR AUGMENTED COMPHSVE,SUP-2613651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
AUGMENT FEM M THK10MM STD UNIV DST BLK PRI PRESSFIT ROT HNG,SUP-2253242,CDM,C1776,CPT,0278,RC,,,,both,,,1857.62,1207.45,,,,,,,,,,,,,
PIN BONE FIX L50MM CROSS CANN L15 AXL,SUP-2137196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE DISC OR DIAL LCK FOR ADJ KNEE FLX,SUP-2435669,CDM,L2425,HCPCS,0274,RC,,,,both,,,405.85,263.80,,,,,,,,,,,,,
EXEMESTANE 25 MG PO TABS,RX-26551,CDM,6370000000,HCPCS,0637,RC,69097-0316-02,NDC,,both,1,UN,7.60,4.94,,,,,,,,,,,,,
BIT DRL 12 MM,SUP-2420187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3733.46,2426.75,,,,,,,,,,,,,
MESH SURG L 8 X W 3 CM D 1 MM PORCINE DERMAL CLLGN ABD HERN,SUP-2901722,CDM,C9364,HCPCS,0278,RC,,,,both,,,1965.26,1277.42,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 1.2X100 MM SMOOTH FOR 3 MM SCREW TI,SUP-2372175,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WEBST COMPLI L 115 CM DIA 5 FR,SUP-2248851,CDM,C1733,HCPCS,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
PLATE BONE W12XL71MM 4 H SEMI TBLR ECT,SUP-2198536,CDM,C1713,HCPCS,0278,RC,,,,both,,,142.12,92.38,,,,,,,,,,,,,
TRAY BONE LESION BX NDL 11GA L10CM ACC L6CM PWR ONCONTROL,SUP-2383235,CDM,C1713,HCPCS,0278,RC,,,,both,,,1325.08,861.30,,,,,,,,,,,,,
BURR SURG 8.5MM DIA HD LG BNE CONTOURED FLUTEX8 FLFRVSNS SUR,SUP-2605420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,400.70,260.45,,,,,,,,,,,,,
GRAFT VASC IMPRA L 90 CM DIA 8 MM EPTFE STR TW N RING HEMO,SUP-2761376,CDM,C1768,CPT,0278,RC,,,,both,,,3383.44,2199.24,,,,,,,,,,,,,
CATHETER DIAG L90CM OD0.044X0.03IN TIP OD1.8FR 15MM SPC,SUP-2353125,CDM,C1887,HCPCS,0272,RC,,,,both,,,501.52,325.99,,,,,,,,,,,,,
SCREW BNE 2/PK L 10 MM DIA2.6 MM PLA GLYCOLIDE,SUP-2884159,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.77,721.35,,,,,,,,,,,,,
LEVOFLOXACIN 5 MG/ML SYRINGE (PED) <50 ML,RX-4090160,CDM,J1956,HCPCS,0636,RC,25021-0132-81,NDC,,both,50,ML,33.60,21.84,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS MAXXEUS SEMIT W GRACLIS FZ,SUP-2875992,CDM,C1762,CPT,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
SYSTEM GRFT PREP 30MM LNG GRN WHT W HI STRENGTH SUT FOR KNEE,SUP-2256713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
KIT ACC 10GA 3ML SYR BVL TIP END OPN RADPQ W/O CEM SYNFLATE,SUP-2255820,CDM,2720000010,LOCAL,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
PLATE BNE RADIAL-ULNAR 30 DSTL WRST ASMBLY,SUP-2421734,CDM,C1713,HCPCS,0278,RC,,,,both,,,12864.58,8361.98,,,,,,,,,,,,,
PLATE BONE L102MM 3 H PROX HUM FOR PICCOLO COMP PLT SYS,SUP-2152595,CDM,C1713,HCPCS,0278,RC,,,,both,,,3054.03,1985.12,,,,,,,,,,,,,
STENT URET CNTOUR VL L 22-30 CM DIA 4.8 FR CATH 6 FR,SUP-2139128,CDM,C2617,HCPCS,0278,RC,,,,both,,,581.90,378.23,,,,,,,,,,,,,
PLATE BNE LO BEND 3.5X135 MM RT DSTL MEDL TIB 6 HOLE SS NS,SUP-2184171,CDM,C1713,HCPCS,0278,RC,,,,both,,,3736.91,2428.99,,,,,,,,,,,,,
BRACE ORTH JEWETT,SUP-2138672,CDM,L0472,HCPCS,0272,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X4 CMX0.76-1.25 MM DECELL DERM ORACELL,SUP-2741069,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
CABLE ORTH L750MM DIA2MM HIP VIT DALL-M,SUP-2377585,CDM,C1776,CPT,0278,RC,,,,both,,,649.35,422.08,,,,,,,,,,,,,
PLATE BNE RECON 3 MM MAND 32 HOLE ANGLED-ANGLED LCK TI,SUP-2457346,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.60,140.79,,,,,,,,,,,,,
PLATE BNE THK0.6MM BAR L2MM 100DEG 5 H L,SUP-2366295,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.93,360.05,,,,,,,,,,,,,
SAW SURG IM SPOOL DRV,SUP-2448361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
DRILL PLATING 2.5X14MM CERV SPIDER,SUP-2402185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
HC Angiogram F/U Study,PX-3237589800,CDM,75898,CPT,0323,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
INSTRUMENT OPHTH 20GA W/ BRSH NDL PASS ASPIR DISP,SUP-2213460,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.63,222.06,,,,,,,,,,,,,
TROCAR ARTHSCP N THRD N OPT VW BLDELSS BLNT TIP W HNDL W OUT,SUP-2166824,CDM,C1894,HCPCS,0272,RC,,,,both,,,632.14,410.89,,,,,,,,,,,,,
PLATE BONE LOK 133MML HLX10 STNLSS STEEL 1/3 TBLR NON ST,SUP-2588604,CDM,C1713,HCPCS,0278,RC,,,,both,,,535.37,347.99,,,,,,,,,,,,,
SPLINT ANK FT L R POST LEAF LTWT SEMI RIG ROLYAN,SUP-2324822,CDM,L4397,HCPCS,0272,RC,,,,both,,,98.56,64.06,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN BNE MTRX INJ FRZ DRY,SUP-2307005,CDM,C9359,HCPCS,0278,RC,,,,both,,,2623.60,1705.34,,,,,,,,,,,,,
PLATE BNE PARASYMPHYSIS 2/2.5X27X12X1 MM 8 HOLE NS LEVEL 1,SUP-2469043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.48,940.86,,,,,,,,,,,,,
PACEMAKER LEADLESS VR PM 19.5F 38.5MM RV,SUP-2880906,CDM,C1786,HCPCS,0275,RC,,,,both,,,25748.00,16736.20,,,,,,,,,,,,,
SEALANT FIBRIN 4 CC FRZN PRE FILLED SYR TISSEEL,SUP-2130314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,850.44,552.79,,,,,,,,,,,,,
CATHETER NEPHSTMY DIA34FR 4 WNG AMB REINF TIP NO MRK DISP,SUP-2128995,CDM,C1729,HCPCS,0272,RC,,,,both,,,76.74,49.88,,,,,,,,,,,,,
BRACE KNEE HNG WRP M,SUP-2276701,CDM,L1820,HCPCS,0272,RC,,,,both,,,53.73,34.92,,,,,,,,,,,,,
DRILL SURG DISCOVERY,SUP-2256729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
GUIDEPIN FIX DIA3MM THRD ITST,SUP-2410483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.70,282.55,,,,,,,,,,,,,
CATHETER EP LG CRV 2-5-2 MM 6 FRX110 CM QPLR 81404] ST JUDE MEDICAL INC],SUP-2357435,CDM,C1730,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
IMPLANT CRANIALXL PEEK PRIORITY CUSTOMIZED,SUP-2365151,CDM,C1763,HCPCS,0278,RC,,,,both,,,64879.06,42171.39,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.503,SUP-2860020,CDM,C1713,HCPCS,0278,RC,,,,both,,,33943.71,22063.41,,,,,,,,,,,,,
SET INSTR IMPL SCR DIA3MM CANN GRPHC CASES INSTR EXTR DEV,SUP-2183058,CDM,C1713,HCPCS,0278,RC,,,,both,,,74912.11,48692.87,,,,,,,,,,,,,
SCREW FIX BUNION CORRECTION SYS 15X6 MM KT STRL RE+LN,SUP-2457367,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.83,1375.94,,,,,,,,,,,,,
SCREW BNE L30MM DIA4MM LO PROF HD COMPR,SUP-2315946,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.34,569.62,,,,,,,,,,,,,
RELOAD STPLR L45MM GRN ENDOWRIST,SUP-2246811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SHELL ACET OD56MM ID24MM +5MM TI POR UNIV HIP FULL HMSPHR,SUP-2403300,CDM,C1776,CPT,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
KIT BNE GRFT SUB 25CC BEAD STD CURE RESRB INCL 2 MOLD,SUP-2399034,CDM,C1713,HCPCS,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
CONNECTOR VLV METERING LN DIA 0.5 MM SPEC INFUSION STRL DISP,SUP-2930212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.75,238.39,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM OD 6 FR ID 2 MM GUIDEWIRE 0.038,SUP-2168358,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.35,47.03,,,,,,,,,,,,,
SPACER KNEE 5MMXSM DSTL POST DURAC,SUP-2364865,CDM,C1776,CPT,0278,RC,,,,both,,,1387.88,902.12,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X50 MM CANN PEEK CD HORZ LEG,SUP-2279494,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
ORTHOSES THERMOPLASTIC WRST HND COCKUP,SUP-2319134,CDM,L3908,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L22IN FOAM WRP ARND UNIV CLS PAT,SUP-2195242,CDM,L1830,CPT,0272,RC,,,,both,,,23.99,15.59,,,,,,,,,,,,,
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111050,CDM,J3424,HCPCS,0636,RC,50633-0310-11,NDC,,both,1,UN,3091.60,2009.54,,,,,,,,,,,,,
ALBUMIN HUMAN-KJDA 25 % IV SOLN,RX-144449,CDM,P9047,HCPCS,0636,RC,64208-2512-07,NDC,,both,50,ML,402.50,261.62,,,,,,,,,,,,,
GRAFT BNE 20ML CORT CANC DEMIN,SUP-2264716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.57,686.12,,,,,,,,,,,,,
BIT DRL L130MM DIA3.2MM ST TI JCBS CHK NONRADIOPAQUE W/O,SUP-2187258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.20,230.88,,,,,,,,,,,,,
STYLET NAVIGATION ELECTROMAGNETIC DISP,SUP-2910365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2584.22,1679.74,,,,,,,,,,,,,
GRAFT BNE H18XL25MM FRZ DRY CALCNL WDG MATRIGRFT,SUP-2264846,CDM,C1713,HCPCS,0278,RC,,,,both,,,1533.70,996.90,,,,,,,,,,,,,
HOOK SPNL BLDE W5.5MM RT TI SUPRALAMINAR ANG OPN FOR 5.5MM,SUP-2254447,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
GUIDEWIRE URO L150CM L3CM OD0035IN 3CM TIP FLX TIP FIX COR,SUP-2141736,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.21,58.64,,,,,,,,,,,,,
TRIAL HIP OD45MM 127DEG NK C TAPR SGL PT USE FOR REST HA REV,SUP-2375986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1049.39,682.10,,,,,,,,,,,,,
TRACHEOTOMY TY,SUP-2277144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.27,283.58,,,,,,,,,,,,,
PLATE BNE W31.5XL62.7MM R 2 TIER STD FAST GUID TECHNOLOGY,SUP-2414027,CDM,C1713,HCPCS,0278,RC,,,,both,,,2295.34,1491.97,,,,,,,,,,,,,
SCREW BONE L80MM DIA6.35MM FULL THRD LCK GS KEMPF,SUP-2362425,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.33,163.36,,,,,,,,,,,,,
GRAFT HUM TISS FN PARTICULATE 200 MG MICRONIZED MICROMATRIX,SUP-2106477,CDM,Q4118,HCPCS,0636,RC,,,,both,,,2191.72,1424.62,,,,,,,,,,,,,
PIN CLAMP 5 HOLE,SUP-2853455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.08,1732.30,,,,,,,,,,,,,
PLATE BNE L72MM 6 H LOK 2 COMPR FOR 27MM SCR UNIV LOK SYS,SUP-2199367,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.32,544.91,,,,,,,,,,,,,
STEM FEM CONSTRN 21X225 MM HIP MOD,SUP-2364542,CDM,C1776,CPT,0278,RC,,,,both,,,12173.78,7912.96,,,,,,,,,,,,,
PROSTHESIS VOICE 16 FRX20 CM DUCKBILL SIL,SUP-2242272,CDM,L8509,HCPCS,0272,RC,,,,both,,,277.58,180.43,,,,,,,,,,,,,
NAIL IM LCK 9X300 MM ANK STRL PHOENIX LTX DISP,SUP-2861152,CDM,C1713,HCPCS,0278,RC,,,,both,,,9702.60,6306.69,,,,,,,,,,,,,
KIT SUTURE LG HS FIBER SUTURE ORTH SURG NDL FOR OPN SFT TISS,SUP-2906617,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SHEATH INTRO SAFSHTH L 13 CM DIA 7 FR STR VLV ACCS HEMOSTAS,SUP-2148970,CDM,C1894,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
LEAD DEFIB 59 CM ENDOCARD 2 COIL DF4-LLHH ENDOTK RELIANCE G,SUP-2148578,CDM,C1895,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
SCREW BNE CANN 6.5X30 MM SD FT SS,SUP-2409889,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.22,437.59,,,,,,,,,,,,,
EVOS RADIAL SHAFT PLATE 16H 193MM,SUP-2820203,CDM,C1713,HCPCS,0278,RC,,,,both,,,7035.80,4573.27,,,,,,,,,,,,,
PLATE BNE L 297 MM SCREW DIA 3.5/4.5 MM 14 H RT DSTL FEM,SUP-2931264,CDM,C1713,HCPCS,0278,RC,,,,both,,,19247.42,12510.82,,,,,,,,,,,,,
SALVATION  6X35MM HALF PIN HA STERILE,SUP-2488401,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
HC Rpr F/E/E/N/L/M >30.0 Cm,PX-4501201800,CDM,12018,CPT,0450,RC,,,,both,,,1445.00,939.25,,,,,,,,,,,,,
GRAFT VASC HYBRID L 50 CM DIA 6 MM REINF SECT L 10 CM DIA 9,SUP-2395261,CDM,C1768,CPT,0278,RC,,,,both,,,8729.20,5673.98,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 10 IN WRST FOREARM RT,SUP-2336334,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 8 H MAXILLOFCL STR,SUP-2909644,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.58,448.88,,,,,,,,,,,,,
SCREW BNE L6MM DIA2.7MM HD DIA5MM SM STD CORT TI ST,SUP-2189690,CDM,C1713,HCPCS,0278,RC,,,,both,,,102.84,66.85,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM 0.035 IN TIP L 3 MM PTFE J MOVEABLE,SUP-2118928,CDM,C1769,HCPCS,0272,RC,,,,both,,,18.87,12.27,,,,,,,,,,,,,
GRAFT OPHTH W1XL4CM EYELID SPCR 12 LAYR TARSYS,SUP-2261522,CDM,C1763,HCPCS,0278,RC,,,,both,,,1178.00,765.70,,,,,,,,,,,,,
BIT DRL DIA2MM REUSE FOR SM FRAG PLATING SYS,SUP-2413954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.54,239.55,,,,,,,,,,,,,
SHELL ACET TOT HIP PRI PRESSFIT CLUS H UNIV A SER 52MM OD,SUP-2221792,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE W13.5XL206MM THK4.2MM 11 H BILAT S STL NAR LIMIT,SUP-2185246,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.28,1054.48,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,2580000003,HCPCS,0258,RC,00264-7520-00,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
FILLER BNE GRFT 5 ML GENTAMICIN SULF HA CALCIUM SULF INJ,SUP-2893107,CDM,C1602,HCPCS,0278,RC,,,,both,,,12943.08,8413.00,,,,,,,,,,,,,
NEEDLE BX 18GA L15CM ORNG S STL PLAS HNDL AUTO PROGRAMMABLE,SUP-2133807,CDM,C1894,HCPCS,0272,RC,,,,both,,,156.97,102.03,,,,,,,,,,,,,
HC Repair Vad,PX-3613657500,CDM,36575,CPT,0361,RC,,,,both,,,706.00,458.90,,,,,,,,,,,,,
BIT DRL DIA4MM CANN FOR 6.7MM SCR FOR FT ANK FUS MINI,SUP-2123192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
STAPLE BONE FIX W20XL20MM NIT COMPR W/ INSTRMT LO PROF FOR,SUP-2418418,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
CATHETER ETER MEDSTN 9MM EYE ON SIDE HYDRAGLIDE COAT SIL,SUP-2265912,CDM,C1729,HCPCS,0272,RC,,,,both,,,48.20,31.33,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 12 CM DIA 4 FR GUIDEWIRE L 50 CM,SUP-2357139,CDM,C1894,HCPCS,0272,RC,,,,both,,,8.16,5.30,,,,,,,,,,,,,
PLATE BNE L 92 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 4 H SS RT 72467204,SUP-2933662,CDM,C1713,HCPCS,0278,RC,,,,both,,,5450.88,3543.07,,,,,,,,,,,,,
PLATE BNE RECTANGULAR LG 1.5X0.2 MM SCRN MESH JANNETTA TI NS,SUP-2466981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.11,678.67,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE W/ INS0001 SYS INS0001 CATH SET,SUP-2883507,CDM,C1729,HCPCS,0272,RC,,,,both,,,963.48,626.26,,,,,,,,,,,,,
BUTTON SUT L10.9MM DIA2.6MM FOR PECTORALIS REP,SUP-2121667,CDM,C1776,CPT,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM DIA 7 FR SPC 2-6-2,SUP-2476144,CDM,C1730,HCPCS,0272,RC,,,,both,,,1901.24,1235.81,,,,,,,,,,,,,
HC Gbl Wheelchair Training per 15 Min,PX-9829754200,CDM,97542,CPT,0982,RC,,,,both,,,247.00,160.55,,,,,,,,,,,,,
TRACH EXCHANGE SET WEINMANN-MULTI,SUP-2718703,CDM,C1769,HCPCS,0272,RC,,,,both,,,668.35,434.43,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST OFF-THE-SHELF W/MTL JT ELASTIC,SUP-2435757,CDM,L3710,HCPCS,0274,RC,,,,both,,,367.91,239.14,,,,,,,,,,,,,
STIMULATOR NERVE PT PRGMR PRODIGY MRI,SUP-2615546,CDM,C1787,HCPCS,0278,RC,,,,both,,,2933.39,1906.70,,,,,,,,,,,,,
STENT ESOPH NITI-S L 6 CM 16 MM 70 CM 16 FR FULL CVR,SUP-2737333,CDM,C1874,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
PLATE BNE 4 H ST S STL LOK COMPR ATTCH FOR 35 45MM SCR LCP,SUP-2177781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1613.18,1048.57,,,,,,,,,,,,,
COIL EMB L6CM DIA3MM DETACH TARGET 3D,SUP-2368049,CDM,C1889,HCPCS,0278,RC,,,,both,,,6286.28,4086.08,,,,,,,,,,,,,
PATCH CV HEMACAROTID L 120 X W 8 MM THK 0.41 MM POLYESTER,SUP-2525482,CDM,C1768,CPT,0278,RC,,,,both,,,827.11,537.62,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 12 CM DIA AORTIC/ILIAC 23/12,SUP-2738001,CDM,C1768,CPT,0278,RC,,,,both,,,36279.56,23581.71,,,,,,,,,,,,,
GRAFT BONE H10.75MM ANTEROPOSTERIOR DIA23-27MM MEDIOLATERAL,SUP-2264888,CDM,C1713,HCPCS,0278,RC,,,,both,,,9592.89,6235.38,,,,,,,,,,,,,
STEM FEM L150MM OD18MM UNIV STD TI KNEE REV CEM FLUT STR,SUP-2406974,CDM,C1776,CPT,0278,RC,,,,both,,,4468.22,2904.34,,,,,,,,,,,,,
BINDER SUBMALAR FACE IMPL SIL L 4.9 CMX2.0 CMX0.57 CMX1.2 CM,SUP-2242096,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY NAR M-L BRIM CUST FIT,SUP-2435676,CDM,L2526,HCPCS,0274,RC,,,,both,,,1813.22,1178.59,,,,,,,,,,,,,
FILLER BNE VOID 5 CC CORTICAL BNE SODIUM HYALURONATE KOLOSIS,SUP-2927230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
CARTRIDGE BNE CEM MIX UNIV TWR VAC ROTOR BRK OFF NOZ W/O,SUP-2253063,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB W/ NL850500V INS8420,SUP-2883558,CDM,C1729,HCPCS,0272,RC,,,,both,,,866.55,563.26,,,,,,,,,,,,,
SUTURE ANCHR TI ANCHR TWINFIX TI 5.0 MM SUT ANCHR W/ TWO,SUP-2341673,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.38,498.80,,,,,,,,,,,,,
PLATE BNE L W10.1XL84MM THK3.5MM 6 H BILAT S STL STR RIG,SUP-2186211,CDM,C1713,HCPCS,0278,RC,,,,both,,,1339.40,870.61,,,,,,,,,,,,,
PLATE BNE 135DEG FEM TRL DHS,SUP-2187955,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.90,581.03,,,,,,,,,,,,,
GRAFT BNE SUB 1.2CC SIL SOD CA PHOS OXIDE FOAM PK RECT CONT,SUP-2368181,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.17,558.46,,,,,,,,,,,,,
SEALANT TISS 2 CC FIBRIN VISTASEAL,SUP-2427766,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.08,239.90,,,,,,,,,,,,,
KYPHOPLASTY KIT ACCS 10 GA OSSEOFLEX,SUP-2500683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,853.04,554.48,,,,,,,,,,,,,
BUR ORTH L 20 MM DIA 3.1 MM SHANNON RECTA 3 LG STRL DISP,SUP-2896797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
SET ORTH GRPHC CA W/ BILAT GUID FOR 4.5MM CVD CNDYL PLT,SUP-2177059,CDM,C1713,HCPCS,0278,RC,,,,both,,,62181.36,40417.88,,,,,,,,,,,,,
SPACER SPNL BLK W6XH14XL14MM ANTR CERV INTBDY FUS,SUP-2293956,CDM,C1713,HCPCS,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
INTRODUCER SHTH L12CM 13FR AD .038IN GWIRE W/ L LUMN,SUP-2355410,CDM,C1894,HCPCS,0272,RC,,,,both,,,44.75,29.09,,,,,,,,,,,,,
SET URET STENT SOFFLX L 10 CM DIA 3.0 FR GUIDEWIRE L 60 CM,SUP-2707492,CDM,C2617,HCPCS,0278,RC,,,,both,,,556.09,361.46,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM TI MANDIBULAR PRIMARY RECON HEMI,SUP-2883261,CDM,C1713,HCPCS,0278,RC,,,,both,,,28778.10,18705.76,,,,,,,,,,,,,
MESH SURG 24X18 CMX1 MM DLMC,SUP-2395333,CDM,C1781,HCPCS,0278,RC,,,,both,,,4213.88,2739.02,,,,,,,,,,,,,
MICRO BONE PLATE 4 X 4 HOLES RCTNGLR SGMNTS .6MM 1.0MM SSTM,SUP-2496429,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.45,788.09,,,,,,,,,,,,,
DRILL TWST L 105 MM DIA1.1 MM STP 18 MM SCREW DIA1.5 MM NS,SUP-2883836,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GRAFT EVAR L155MM DIA28MM 16MM PROX DST AAA INTUITRAK,SUP-2217577,CDM,C1768,CPT,0278,RC,,,,both,,,31243.00,20307.95,,,,,,,,,,,,,
NAIL IM L240MM DIA9MM UNIV HUM BLU TI CANN LOK RND CRSS,SUP-2179637,CDM,C1713,HCPCS,0278,RC,,,,both,,,4877.61,3170.45,,,,,,,,,,,,,
KIT PERICARDCENT L 40 CM DIA 8.3 FR STR 7 SPIRALING DRAINAGE,SUP-2880384,CDM,C1729,HCPCS,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
Z INACTIVE USE 2305833 HANDPIECE ELECSURG THERM ABLATN DISP,SUP-2305832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
KIT INSRTN INTRO L 6 IN CATH DIA 7.5 FR 30/40 CC PACKAGED,SUP-2908613,CDM,C1894,HCPCS,0272,RC,,,,both,,,420.70,273.45,,,,,,,,,,,,,
CONTROLLER DETACH V-GRIP FOR V-TRAK DEL SYS STRL,SUP-2305470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
PROSTHESIS PENILE 15CM PRECONN PENOSCROTAL APPRCH LGX MS,SUP-2139021,CDM,C1813,HCPCS,0278,RC,,,,both,,,26523.58,17240.33,,,,,,,,,,,,,
HC So Assay Anti-Mullerian Horm,PX-3018216666,CDM,82166,CPT,0301,RC,,,,both,,,165.00,107.25,,,,,,,,,,,,,
WASHER ORTH 4 MM CRV SEG HIP SYS TRABECULAR MTL,SUP-2437240,CDM,C1713,HCPCS,0278,RC,,,,both,,,3405.33,2213.46,,,,,,,,,,,,,
HC Vasc Embolize Occlude Bleed,PX-3613724400,CDM,37244,CPT,0361,RC,,,,inpatient,,,11772.00,7651.80,,,,,,,,,,,,,
SCREW BONE L30 MM L9 MM OD3.5 MM ST SELF DRL CANN PARTIALLY,SUP-2321034,CDM,C1713,HCPCS,0278,RC,,,,both,,,585.77,380.75,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK MAMMOGRAPHIC LOC MAMMO LOC PK,SUP-2495484,CDM,A4648,CPT,0278,RC,,,,both,,,58.72,38.17,,,,,,,,,,,,,
INSERT TIB M L SZ 2/2 DIA13MM MOD ROT HNG MONOGRAM,SUP-2376384,CDM,C1776,CPT,0278,RC,,,,both,,,2768.07,1799.25,,,,,,,,,,,,,
PLATE 13 TUB 3HL L35MM,SUP-2695629,CDM,C1713,HCPCS,0278,RC,,,,both,,,1189.12,772.93,,,,,,,,,,,,,
SCREW BONE 4MM DIA 32MML CANCELLOUS SELF TAPPING,SUP-2720920,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.43,75.68,,,,,,,,,,,,,
NAIL IM L210MM OD14MM 130DEG STD CANN LCK COMPR,SUP-2351368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
SYSTEM DRAINAGE VENTRICULAR CATH SHUNT FOR EDS III,SUP-2308153,CDM,C1729,HCPCS,0272,RC,,,,both,,,954.34,620.32,,,,,,,,,,,,,
STEM RAD DIA7.5MM + 2 UNIV CO CHROM STR PRSS FIT DISP,SUP-2397983,CDM,C1776,CPT,0278,RC,,,,both,,,7030.46,4569.80,,,,,,,,,,,,,
NEEDLE BX 8 GA ASPIR BNE MAR TARGET,SUP-2430778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
TAMP BNE INFLATABLE 2 15 MM KYPHON EXPRESS II,SUP-2664464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
SCREW PEDCL PIROUETTE TIMED POLYAX TI 5.5MM DIA 55MML,SUP-2205099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BONE 29X47MM THK0.3MM TEMPORAL SKULL BASE MALL FOR,SUP-2363573,CDM,C1713,HCPCS,0278,RC,,,,both,,,2627.36,1707.78,,,,,,,,,,,,,
SYSTEM PRP FACILITATES RAP PREP OF AUTOLGS FR A SM SAMP OF,SUP-2120722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
GUIDEWIRE ORTH L6IN DIA0.035IN DBL TRCR FOR MIC COMPR SCR,SUP-2107169,CDM,C1769,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
VALVE SWALLOING AND SPEAK OD23MM ID15MM CLR LO PROF LTWT,SUP-2322023,CDM,L8501,HCPCS,0272,RC,,,,both,,,365.68,237.69,,,,,,,,,,,,,
STENT BILI WSTNT L 24 MM DIA10 MM CATH L 155 MM SHTH 6 FR,SUP-2141197,CDM,C1876,HCPCS,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
ALLOGRAFT BNE TIB SHFT 160X2 MM FRZN 31024269,SUP-2717866,CDM,C1762,CPT,0278,RC,,,,both,,,5140.59,3341.38,,,,,,,,,,,,,
SYSTEM MENIS REP VERSATILE LO PROF ROBUST W/ PEEK IMPL,SUP-2249485,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.56,1743.01,,,,,,,,,,,,,
PLATE BNE W11XL99MM THK33MM 7 H BILAT MTPHSEAL TI LOK COMPR,SUP-2190761,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.72,1743.12,,,,,,,,,,,,,
BLADE SHV L11CM DIA2MM SNUS STR SHFT ELEV FOR SUBMUCOSAL,SUP-2284120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,860.61,559.40,,,,,,,,,,,,,
SCREW BNE CANN 7X8 MM,SUP-2315921,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
HC So Carbohydrate Antigen 19-9,PX-3028630166,CDM,86301,CPT,0302,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
ROD EXT FIX L80MM THRD,SUP-2197305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CATHETER DRNGE L25CM OD8FR NEPHSTMY TIGHT PGTL,SUP-2118772,CDM,C1729,HCPCS,0272,RC,,,,both,,,221.06,143.69,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X49 MM 6 HOLE 1/4 SS,SUP-2536107,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.45,248.59,,,,,,,,,,,,,
SNARE ENDO W25XL40MM SHTH DIA3MM NDL 25GA L5MM HEX DISP FOR,SUP-2360307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE CONN 90 DEG 5 HOLE OFFSET NS,SUP-2800152,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.89,244.33,,,,,,,,,,,,,
MPF Shell Revision 48/39,SUP-2511138,CDM,C1776,CPT,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
BRACE WALKING LP MED 5.5-10 IN 6.5-11 IN WOMEN MAXTRAX AIR,SUP-2428155,CDM,L4360,HCPCS,0272,RC,,,,both,,,97.50,63.37,,,,,,,,,,,,,
KIT PENILE PROS STD ASSEMB TI,SUP-2165367,CDM,C1813,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
RESERVOIR VENTRICULAR DRAINAGE 18CM CATHETER LENGTH 20MM DIA,SUP-2830489,CDM,C1729,HCPCS,0272,RC,,,,both,,,1681.94,1093.26,,,,,,,,,,,,,
ROD ORTH OD2.5MM SIL FLEX DBL STEM SPCR KT ORTHOFLEX,SUP-2396952,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.409,SUP-2859973,CDM,C1713,HCPCS,0278,RC,,,,both,,,33866.78,22013.41,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM 0.035IN L 9.5CM 3CM HEPARIN AMPLTZ STR,SUP-2168521,CDM,C1769,HCPCS,0272,RC,,,,both,,,63.43,41.23,,,,,,,,,,,,,
PLATE BONE INF BLDE L42MM DISPLC 12MM 90DEG 3 H NONSTERILE,SUP-2185417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1409.61,916.25,,,,,,,,,,,,,
PLATE BONE W8XL100MM THK2MM 0DEG 12 H BILAT TI STR RIG DYN,SUP-2191075,CDM,C1713,HCPCS,0278,RC,,,,both,,,1980.56,1287.36,,,,,,,,,,,,,
SCREW BNE THERMO SCARF 3 MM EMP BX BAROUK,SUP-2486548,CDM,C1713,HCPCS,0278,RC,,,,both,,,1239.64,805.77,,,,,,,,,,,,,
CATHETERIZATION KIT 13-1/8 IN 5 FRX55 CM DL BLU FLEXTIP,SUP-2383374,CDM,C1751,HCPCS,0278,RC,,,,both,,,463.21,301.09,,,,,,,,,,,,,
PLATE BONE LUHR STR 40MM,SUP-2364679,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
PLATE BNE TIB LT PROX TARGETING ARM,SUP-2766313,CDM,C1713,HCPCS,0278,RC,,,,both,,,16940.30,11011.19,,,,,,,,,,,,,
PLATE BNE M 12 H SIL TI MESH CNTOUR MAL FOR 1.5MM SCR,SUP-2181553,CDM,C1713,HCPCS,0278,RC,,,,both,,,2566.01,1667.91,,,,,,,,,,,,,
SUPPORT ORTHOT CUST RNG FLANGE PLAS LTHR,SUP-2435581,CDM,L1100,HCPCS,0274,RC,,,,both,,,537.66,349.48,,,,,,,,,,,,,
SPLINT THMB AD M L BGE L MCP CMC JT PREFRM PERF FLX BASE LAM,SUP-2326182,CDM,L3908,HCPCS,0272,RC,,,,both,,,70.21,45.64,,,,,,,,,,,,,
EXTERNAL FIXATION KIT MOTN ELBW,SUP-2645942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4599.32,2989.56,,,,,,,,,,,,,
MICROCATHETER DIAG NAVVUS L 335 CM WORKING L 150 CM DSTL,SUP-2150030,CDM,C1887,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE BNE L 98 MM 8 H SS RADIAL SHFT STRL EVOS,SUP-2932808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2404.30,1562.79,,,,,,,,,,,,,
PLATE BNE MED TI MANDIBULAR PMI ORTHOGNATHIC 3D PRNT NS DISP,SUP-2934809,CDM,C1713,HCPCS,0278,RC,,,,both,,,24309.88,15801.42,,,,,,,,,,,,,
CONNECTOR NRV L15MM DIA3MM PORCINE EXTRACELLULAR MTRX,SUP-2124866,CDM,C1763,HCPCS,0278,RC,,,,both,,,6889.16,4477.95,,,,,,,,,,,,,
PASSER SUTURE ARTH 5.5 MM ANCHR OGDEN TITAN,SUP-2174635,CDM,C1713,HCPCS,0278,RC,,,,both,,,77.97,50.68,,,,,,,,,,,,,
CATHETER MVS MC212150S HEADWAY 21 STR,SUP-2305465,CDM,C1887,HCPCS,0272,RC,,,,both,,,2345.58,1524.63,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA 3.5 MM MINERAL FIBER MTRX CANN COMPR,SUP-2904309,CDM,C1713,HCPCS,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
PLATE BONE 6 H FOREFOOT TI Y COMPR FOR 1.5/2/2.4MM SCR,SUP-2225437,CDM,C1713,HCPCS,0278,RC,,,,both,,,2509.49,1631.17,,,,,,,,,,,,,
ALUM HYDROXIDE-MAG CARBONATE 160-105 MG PO CHEW,RX-9016,CDM,6370000000,HCPCS,0637,RC,00904-5365-60,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
CATHETER ENDOSCP L135CM W7.5XL15.7MM DIA2.8MM FLX RFA,SUP-2172452,CDM,C1888,HCPCS,0272,RC,,,,both,,,6327.10,4112.61,,,,,,,,,,,,,
SCREW BONE 4.5X25MM MALL CORT S STL ECT,SUP-2198324,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.60,38.74,,,,,,,,,,,,,
PLATE BNE RESECT + 1 MM NS VANGUARD MICROPLASTY SLIDEX,SUP-2446444,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP LOOP TIP STRL LTX DISP,SUP-2877793,CDM,C1769,HCPCS,0272,RC,,,,both,,,642.92,417.90,,,,,,,,,,,,,
ANCHOR SUTURE FULL THRD DIL 4.75 MM REGENESORB REUSE,SUP-2848635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1580.61,1027.40,,,,,,,,,,,,,
HC So Antibody Titer,PX-3028688666,CDM,86886,CPT,0302,RC,,,,both,,,281.00,182.65,,,,,,,,,,,,,
CATHETER ETER INFUS L130CM OD084X61MM ID053X046MM DST L40CM,SUP-2417577,CDM,C1887,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
GRAFT BNE H25MM IL CREST WDG FRZ DRY MATRIGRFT,SUP-2264802,CDM,C1713,HCPCS,0278,RC,,,,both,,,2571.69,1671.60,,,,,,,,,,,,,
BIT DRL SURG 1.6MM SURG W/ 26MM STP IQ SER,SUP-2136986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.29,286.19,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR REACTIV8 L 45 CM SUTURE SLV STRL,SUP-2877967,CDM,C1730,HCPCS,0272,RC,,,,both,,,8656.98,5627.04,,,,,,,,,,,,,
PLATE VA LCP CLAV SHAFT XL LT 2.7MM ST,SUP-2740107,CDM,C1713,HCPCS,0278,RC,,,,both,,,3517.05,2286.08,,,,,,,,,,,,,
CATHETER DRAINAGE NAGARAJA 7 FR NSL BILI,SUP-2737323,CDM,C1729,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
IMPLANT OTO L4.25MM PIST DIA0.5MM NIT FLROPLAS SMRT,SUP-2313863,CDM,2780000010,LOCAL,0278,RC,,,,both,,,831.06,540.19,,,,,,,,,,,,,
PLATE BNE L22MM THK1.5MM 8MM SPCR TI REARFOOT LAT CLMN,SUP-2399636,CDM,C1713,HCPCS,0278,RC,,,,both,,,3086.62,2006.30,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 1S 20X20CM,SUP-2383097,CDM,C1781,HCPCS,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
LEAD DEFIB TRANSVENE L 52 CM DIA 7.5 FR SIL POLYUR TRNSVEN,SUP-2282253,CDM,C1896,HCPCS,0275,RC,,,,both,,,1856.87,1206.97,,,,,,,,,,,,,
STEM FEM ARCOS 14X210MM BRCH BODY STD,SUP-2506144,CDM,C1776,CPT,0278,RC,,,,both,,,16629.44,10809.14,,,,,,,,,,,,,
RESORB XG ST MESH SPCLTY SUN PTTRN PRTL FOIL 101 X 101 MM T0,SUP-2694981,CDM,C1713,HCPCS,0278,RC,,,,both,,,14870.29,9665.69,,,,,,,,,,,,,
MODEL ANAT SINGLE JAW SPLNT ORTHOGNATHIC VSP,SUP-2884204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2270.06,1475.54,,,,,,,,,,,,,
PLATE BONE BAR L2.9MM THK1.5MM 4 H MINI,SUP-2365231,CDM,C1713,HCPCS,0278,RC,,,,both,,,2080.28,1352.18,,,,,,,,,,,,,
HC Lumbar Diskography,PX-3207229500,CDM,72295,CPT,0320,RC,,,,both,,,3334.00,2167.10,,,,,,,,,,,,,
COMP SHRT ST/RGX GLD/STD HD,SUP-2212465,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
PLATE TIBIA DISTAL 3.5MM TI LCP LOW BEND MEDIAL 8H RIGHT 161MM,SUP-2549696,CDM,C1713,HCPCS,0278,RC,,,,both,,,4046.24,2630.06,,,,,,,,,,,,,
CAGE SPNL HYPERLORDOTIC STD 16 MM ENDOSKELETON TAS NANOLOCK,SUP-2730360,CDM,C1889,HCPCS,0278,RC,,,,both,,,21666.00,14082.90,,,,,,,,,,,,,
COLLAR CERV MED DENS UNIV 24X4 IN CNTOUR PROCARE LF,SUP-2195755,CDM,L0180,HCPCS,0274,RC,,,,both,,,7.10,4.61,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SONICATH ULTRA FREQ 20 MHZ STRL,SUP-2141112,CDM,C1753,HCPCS,0278,RC,,,,both,,,1643.01,1067.96,,,,,,,,,,,,,
GRAFT BNE FEM SHFT 11 CM FD,SUP-2321805,CDM,C1713,HCPCS,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
GRFT CRUSH CANC 1-4MM 15CC PUROS,SUP-2693925,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
KIT INSRT INTAORT CATH 9.5FR 40ML 650MM 90 SER EXT 0.30IN,SUP-2227306,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
IMPLANT GAIT M,SUP-2397258,CDM,C1776,CPT,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
BUR SURG DIAMOND 3 MM 5 CM BALL MIDAS REX 8 CLRVW LP,SUP-2664912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.00,510.90,,,,,,,,,,,,,
CRANIAL ACCESS KIT 3.97 MM 5.31X6.35 MM MULTIPLE DRL BITS,SUP-2666729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.81,586.83,,,,,,,,,,,,,
STEM FEM L267MM OD13MM BOW TRI SLOT PLSM SPRAYED HA DST HIP,SUP-2375898,CDM,C1776,CPT,0278,RC,,,,both,,,9397.39,6108.30,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.059 MM TROCAR PT 1 END,SUP-2107891,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY OPTRELL SM D-F CRV TRUEREF,SUP-2880079,CDM,C1732,HCPCS,0278,RC,,,,both,,,9014.94,5859.71,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|DOCUMENTATION ON FILE",PX-4209711000,CDM,97110,CPT,0420,RC,,,GP|CQ|KX,both,,,195.00,126.75,,,,,,,,,,,,,
HC Perq Dev Soft Tiss 1st Imag,PX-3611003500,CDM,10035,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
TIP SUCT EXT YANK BLB FOR LT IRRIG GYN PLAS SURG VIT VUE,SUP-2172324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.77,338.50,,,,,,,,,,,,,
SEALER REPROC VES 37 CM MARYLAND JAW LIGASURE,SUP-2418777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,915.03,594.77,,,,,,,,,,,,,
GRAFT VASC TW 6 MMX100 CM RNG SFT WRP TUNN ATTCH ADVANTA VXT,SUP-2469020,CDM,C1768,CPT,0278,RC,,,,both,,,3441.25,2236.81,,,,,,,,,,,,,
BURR DIAMOND MATCHSTICK 3.2MM L8NSDG1,SUP-2843296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.84,292.40,,,,,,,,,,,,,
PLATE BNE GENIOPLASTY 2X0.6 MM 4 MM GRIFFIN W/ MIDLN TI,SUP-2459394,CDM,C1713,HCPCS,0278,RC,,,,both,,,608.28,395.38,,,,,,,,,,,,,
HC Adult Sleep Study (Polysomnogram),PX-9209581000,CDM,95810,CPT,0920,RC,,,,inpatient,,,5628.00,3658.20,,,,,,,,,,,,,
PLATE BNE R ANT TIBIOTALAR ANK FUS,SUP-2123207,CDM,C1713,HCPCS,0278,RC,,,,both,,,6515.50,4235.07,,,,,,,,,,,,,
SCREW BNE SD 150 MM 6-5.6X30 MM CORTICAL FLUT NS XCALIBER,SUP-2645910,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.65,249.37,,,,,,,,,,,,,
SLING ORTH 9X14IN 4X44IN SZ UNIV SM ENV IMMOB SWTH SLDE,SUP-2196952,CDM,L3660,HCPCS,0272,RC,,,,both,,,21.89,14.23,,,,,,,,,,,,,
POSACONAZOLE 40 MG/ML PO SUSP,RX-77371,CDM,340b,HCPCS,0637,RC,00254-1016-36,NDC,,both,2.5,ML,123.40,80.21,,,,,,,,,,,,,
WIRE 1.8MM W/OLIVE DIA PT,SUP-2497301,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
MICROCATHETER INFUSION MARKSMAN L 160 CM OD PROX/DSTL,SUP-2280932,CDM,C1887,HCPCS,0272,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
IMPLANT CRAN THK 5 MM SZ 174 X 133 MM HDPE POROUS RT HMSPHR,SUP-2934326,CDM,C1713,HCPCS,0278,RC,,,,both,,,27252.06,17713.84,,,,,,,,,,,,,
NAIL IM L340MM DIA10MM THK1.5MM 1.5M CURVATURE RAD UNIV FEM,SUP-2186405,CDM,C1713,HCPCS,0278,RC,,,,both,,,3674.27,2388.28,,,,,,,,,,,,,
RASP SURG CRV TN SAW CONCV R25 STRYKR STRL,SUP-2898443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
PENTAMIDINE ISETHIONATE 300 MG IJ SOLR,RX-27430,CDM,J2516,HCPCS,0636,RC,63323-0113-10,NDC,,both,1,UN,959.70,623.80,,,,,,,,,,,,,
CUP ACET DIA56MM 5 H DP PROF GRIPTION REV PINN,SUP-2250150,CDM,C1776,CPT,0278,RC,,,,both,,,9546.86,6205.46,,,,,,,,,,,,,
INSTRUMENT KIT EXTREMITY,SUP-2175009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
PI PICC KIT 2-L 5 FR X 55 CM TIPTRACKER,SUP-2565191,CDM,C1751,HCPCS,0278,RC,,,,both,,,570.44,370.79,,,,,,,,,,,,,
LOOP N TACK 3.9 TENODESIS SYS,SUP-2737931,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
TUBE ENDOTRACHEAL 7 MM EVOKE,SUP-2137892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
KIT INTRO ONESTIC L 11 CM DIA 5 FR GUIDEWIRE L 45 CM DIA,SUP-2876546,CDM,C1894,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
KIT BX DIA2.2MM PASS NDL DISP,SUP-2284363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2058.21,1337.84,,,,,,,,,,,,,
PROBE SUCT DIA2.5MM MIC BRSH FOR SM JT SERFAS ENERGY,SUP-2366561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.94,289.86,,,,,,,,,,,,,
SCREW TEMP FIX THOR REDUC FOR RIBFIX BLU SYS,SUP-2413089,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
SCREW AX MULT 3605535 55 X 35MM,SUP-2285536,CDM,C1713,HCPCS,0278,RC,,,,both,,,2535.55,1648.11,,,,,,,,,,,,,
SCREW BNE CANN 7.3X105 MM PERI ARTC LCK SS NS LCP,SUP-2184763,CDM,C1713,HCPCS,0278,RC,,,,both,,,783.08,509.00,,,,,,,,,,,,,
BALLOON SINUPLASTY 6X16 MM SYS RELIEVA SPINPLUS,SUP-2106369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8000.72,5200.47,,,,,,,,,,,,,
SCREW BNE L9MM DIA13MM G CORT TI ALLY ST SELF RET W T4,SUP-2180964,CDM,C1713,HCPCS,0278,RC,,,,both,,,137.91,89.64,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR HI RL CUF,SUP-2435679,CDM,L2550,HCPCS,0274,RC,,,,both,,,963.29,626.14,,,,,,,,,,,,,
INSERT TIB SZ 4-5 FEM 3-4 TIB THK9MM CONSTRN LEGION,SUP-2349162,CDM,C1776,CPT,0278,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
ALLOGRAFT NERVE 2-3X15 MM PROC STRL AVANCE LTX,SUP-2753344,CDM,C1762,CPT,0278,RC,,,,both,,,8499.98,5524.99,,,,,,,,,,,,,
CAGE ACET CUP DIA64MM THK2MM LT COMMERCIALLY PURE TI MOD,SUP-2405115,CDM,C1776,CPT,0278,RC,,,,both,,,8930.16,5804.60,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR LACER,SUP-2435678,CDM,L2540,HCPCS,0274,RC,,,,both,,,1284.79,835.11,,,,,,,,,,,,,
COIL VASC I-ED COIL PRIMARY L 30 CM DIA 0.012 IN SECONDARY,SUP-2865311,CDM,C1889,HCPCS,0278,RC,,,,both,,,5824.70,3786.05,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.035IN TIP 3CM PTFE NIT,SUP-2139369,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.95,94.87,,,,,,,,,,,,,
SET ATHRCTMY ROTAREX L 135 CM DIA 6 FR GUIDEWIRE L 320 CM,SUP-2739179,CDM,C1724,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SYSTEM RADAR LOC DEL 15 GAX12.3 CM REFLCT STRL SCOUT BX LTX,SUP-2864535,CDM,C1819,HCPCS,0278,RC,,,,both,,,1450.68,942.94,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE L 90 CM OD 5 FR GUIDEWIRE 0.038 IN,SUP-2170003,CDM,C1894,HCPCS,0272,RC,,,,both,,,341.13,221.73,,,,,,,,,,,,,
DEVICE ANEUR NK RECON 4MM 10MM Y SHP ARCH PULSERIDER,SUP-2893543,CDM,C1876,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
SCREW BNE L25MM OD10.5MM DISP ACL MULCH,SUP-2212889,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
CATHETER HEMODLYS 14.5FR TOT L72CM INSRT L55CM CARBOTHANE,SUP-2283939,CDM,C1750,HCPCS,0278,RC,,,,both,,,1037.20,674.18,,,,,,,,,,,,,
PLATE BNE L399MM 19 H L LAT DST FEM S STL LOK FOR 4.5MM SCR,SUP-2348214,CDM,C1713,HCPCS,0278,RC,,,,both,,,15350.83,9978.04,,,,,,,,,,,,,
SPACER TEND NO5 W5XH2.5XL24MM SIL SWNSN HUNTER,SUP-2397188,CDM,C1776,CPT,0278,RC,,,,both,,,3133.72,2036.92,,,,,,,,,,,,,
MATRIX WND SM AMNIO FLD CVR NUCEL,SUP-2309716,CDM,C1713,HCPCS,0278,RC,,,,both,,,2076.51,1349.73,,,,,,,,,,,,,
HC Inj Proc for Retro Cystography,PX-3615161000,CDM,51610,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
TROCAR ENDOPATH BASX BLDELSS W STBL SL 12MMX100MM DISPOSABLE,SUP-2220020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.10,286.06,,,,,,,,,,,,,
CABLE LIGHT PLIF MAS STRL MAXCESS,SUP-2434164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
JOINT FNGR X-TYPE 0 DEG LG UNIV 22.5X7 MM PRIMARY PRSS FT,SUP-2431397,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
JOINT TOE CLASSIC GREAT TOE 60 SIL GRAY/WHITE,SUP-2609610,CDM,L8642,HCPCS,0278,RC,,,,both,,,4353.20,2829.58,,,,,,,,,,,,,
PLATE BNE W4XL44MM THK1MM 3X8 H BILAT S STL T SHP LO PROF,SUP-2186290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1166.20,758.03,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 360DEG ROT SERR STR SHFT,SUP-2277869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.55,483.31,,,,,,,,,,,,,
WALKER SM SHT LEG NONSKID,SUP-2276712,CDM,L4387,HCPCS,0272,RC,,,,both,,,80.60,52.39,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 45CM 6FR COAT L 5CM LIMA,SUP-2385280,CDM,C1894,HCPCS,0272,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
GRAFT BNE INJ 6 CC DEMINERALIZED FIBER GRFT,SUP-2574345,CDM,C1776,CPT,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 8 MM EPTFE FLX TW SM BEAD RING,SUP-2761428,CDM,C1768,CPT,0278,RC,,,,both,,,1141.01,741.66,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X66X23X1.8 MM THOR 26 HOLE LADDER LEVEL 1,SUP-2869246,CDM,C1713,HCPCS,0278,RC,,,,both,,,2517.75,1636.54,,,,,,,,,,,,,
PLATE BNE L 25.17 X W 25.22 MM THK 0.6 MM ADV 6 MM SCREW,SUP-2935752,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING REG PEDIATRIC INF 1.25 IN PROCARE,SUP-2195748,CDM,L0180,HCPCS,0274,RC,,,,both,,,80.01,52.01,,,,,,,,,,,,,
SHUNT VENTRICULAR L1.5CM DIAMETER 2.5MM CATHETER L18CM DISTA,SUP-2825682,CDM,C1889,HCPCS,0278,RC,,,,both,,,2517.90,1636.63,,,,,,,,,,,,,
CATHETER HEMO DYLS ULTRASTREAM L 32 CM DIA15.5 FR,SUP-2120057,CDM,C1881,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
IMPLANT FACE SZ 40 X 52 MM THK 2.3 MM POLYETHYL ORBIT BARR,SUP-2883690,CDM,C1713,HCPCS,0278,RC,,,,both,,,3154.07,2050.15,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST SACH CUSH TYP,SUP-2435731,CDM,L3450,HCPCS,0274,RC,,,,both,,,298.77,194.20,,,,,,,,,,,,,
FORCEPS BPLR L33CM L5MM TWO TIER SERR FN ROUNDED TIP TAPR,SUP-2312660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
BUTTON FIXATION 4.5X14MM CORTICAL FEMORAL ADJUSTABLE BTB GRA,SUP-2825173,CDM,C1713,HCPCS,0278,RC,,,,both,,,1119.98,727.99,,,,,,,,,,,,,
THROMBIN 20000 UNITS EX SOLR,RX-11547,CDM,2500000003,HCPCS,0250,RC,60793-0217-20,NDC,,both,1,UN,1718.50,1117.02,,,,,,,,,,,,,
KIT PROCEDURE 16X13MM STAPLE SYSTEM PROCEDURE ARCUS,SUP-2477375,CDM,C1713,HCPCS,0278,RC,,,,both,,,2649.85,1722.40,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 18H RT 275MM-STER,SUP-2549593,CDM,C1713,HCPCS,0278,RC,,,,both,,,5329.37,3464.09,,,,,,,,,,,,,
RHS SHORT RADIAMETERL STEM DIAMETER 8MM NECK 16MM,SUP-2822290,CDM,C1776,CPT,0278,RC,,,,both,,,8939.58,5810.73,,,,,,,,,,,,,
HC So2 Heparin Assoc Platelet Antibo,PX-3028602268,CDM,86022,CPT,0302,RC,,,,both,,,728.00,473.20,,,,,,,,,,,,,
GRAFT DERM ULT THN ACELLULAR DERM IMP L2XW1CM THICKNESS .2,SUP-2307504,CDM,Q4128,HCPCS,0636,RC,,,,both,,,356.26,231.57,,,,,,,,,,,,,
SYRINGE MED CONE TIP 100 CC CLMP 3 RNG AUTOCLV FOR UROLOGY,SUP-2747411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1440.82,936.53,,,,,,,,,,,,,
PLATE BNE THK1MM 0DEG 6 H STR BILAT TI CRANIOMAXILLOFACIAL,SUP-2262765,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.15,169.75,,,,,,,,,,,,,
BIT DRL STP 6.5 MM STRL VERSANAIL,SUP-2606670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.02,444.61,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM 0.035 IN L 6 CM SAFE-T-J CRV FIX COR,SUP-2638697,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.57,21.82,,,,,,,,,,,,,
SUPPORT ORTHOT CUST FULL SOLE HEEL WDG BTWN SOLE,SUP-2435728,CDM,L3420,HCPCS,0272,RC,,,,both,,,154.83,100.64,,,,,,,,,,,,,
SCREW BNE ZURICH 1.5X5 MM 5 MM MXLFCL X DRV DRILL-FREE TI,SUP-2459240,CDM,C1713,HCPCS,0278,RC,,,,both,,,425.44,276.54,,,,,,,,,,,,,
PLATE BNE L112MM 5 H R PROX LAT HUM S STL LOK FOR 4MM SCR,SUP-2372104,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
PLATE SPNL 16MM POST WIDE BODY,SUP-2415551,CDM,C1713,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
HC X-Ray Ac Joints,PX-3207305000,CDM,73050,CPT,0320,RC,,,,both,,,675.00,438.75,,,,,,,,,,,,,
BLADE RETRACTOR HOHMN 18 CMX29 MM OLIF,SUP-2627605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2436.36,1583.63,,,,,,,,,,,,,
DRIVER POWER CANN 1.8MM,SUP-2489130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
LINER ACET 42X54 MM HIP 2 MOBILITY XLPE OR3O,SUP-2434985,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
KIT INSTR DRL AND SPEAR TRCR DISP FOR 3MM SUTURETAK,SUP-2121597,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SCREW BNE LCK 4X14 MM VA FOR MEDL CLMN FUSION PLATE SOLE LTX,SUP-2875515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1453.19,944.57,,,,,,,,,,,,,
BIT DRL OD4.5MM CORT OPENER LOK AO FIT FOR SM FRAG SYS,SUP-2377972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,762.71,495.76,,,,,,,,,,,,,
CATHETER BLLN OCCL 0.010 IN 2.2FRX150MM 5X30MM HYPERGLIDE,SUP-2172479,CDM,C2628,HCPCS,0272,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
PATCH DURA REGEN MTRX CLLGN BASE ST 1 IN X 3 IN DURAGN +,SUP-2244010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.47,730.91,,,,,,,,,,,,,
SCREW BONE L5MM DIA2X-DRIVE TRAUMAONE,SUP-2415398,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.97,428.98,,,,,,,,,,,,,
INSERT TIB SZ 4 THK16MM STD UNIV PRI CONSTRN NEUT ANAT MOD,SUP-2252397,CDM,C1776,CPT,0278,RC,,,,both,,,4178.71,2716.16,,,,,,,,,,,,,
CATHETER URET 5FR L70CM 0.038IN OPN END FOR DRNGE RG,SUP-2171200,CDM,C1758,HCPCS,0278,RC,,,,both,,,75.08,48.80,,,,,,,,,,,,,
CALCIUM POLYCARBOPHIL 625 MG PO TABS,RX-11046,CDM,6370000000,HCPCS,0637,RC,00536-4306-05,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KNEE VNGD TI FEM SSK 70MM RT,SUP-2510699,CDM,C1713,HCPCS,0278,RC,,,,both,,,17671.92,11486.75,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX6 TTNM CNTRD F/3.5MM LOK SCREW ST,SUP-2488123,CDM,C1713,HCPCS,0278,RC,,,,both,,,1610.63,1046.91,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 70X0.4 MM NEURO TI BLU NS,SUP-2859909,CDM,C1713,HCPCS,0278,RC,,,,both,,,5017.09,3261.11,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM THK0.1MM PERICARD BIOCOMPATIBLE,SUP-2395372,CDM,C1768,CPT,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
BIT DRL TWST 1.6X100 MM 45 MM SEGMENTED STP SS SONICWELD RX,SUP-2462055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.53,280.49,,,,,,,,,,,,,
BIT DRL DIA2.4MM FOR VERTEX SEL OCCIPITAL RECON SYS,SUP-2289128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SHELL ACET PRESSFIT PRI 48 MM OD UNIV MULT H TRABECULAR MTL,SUP-2202626,CDM,C1776,CPT,0278,RC,,,,both,,,5204.55,3382.96,,,,,,,,,,,,,
HALOPERIDOL LACTATE 2 MG/ML PO CONC,RX-3585,CDM,340b,HCPCS,0637,RC,00121-0581-05,NDC,,both,1,ML,3.20,2.08,,,,,,,,,,,,,
VITAMIN B-12 1000 MCG PO TABS,RX-8654,CDM,6370000000,HCPCS,0637,RC,20555-0006-00,NDC,,both,1,UN,1.60,1.04,,,,,,,,,,,,,
ANCHOR SUT OD14MM SHT SFT FOR LAT EPICONDYLITIS REP,SUP-2137228,CDM,C1713,HCPCS,0278,RC,,,,both,,,2215.58,1440.13,,,,,,,,,,,,,
GRAFT BNE PARTICULATE 5 CC DBM CORTICAL,SUP-2861447,CDM,C1713,HCPCS,0278,RC,,,,both,,,4233.57,2751.82,,,,,,,,,,,,,
CLAV SUP PLT RT 8H 90MM NS,SUP-2720907,CDM,C1713,HCPCS,0278,RC,,,,both,,,4367.74,2839.03,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT 35-10 MM FRZN HALF PATELLAR TEND,SUP-2866905,CDM,C1762,CPT,0278,RC,,,,both,,,5939.15,3860.45,,,,,,,,,,,,,
BLADE IM NAIL HELCL 90X11 MM IMPL TI,SUP-2191875,CDM,C1713,HCPCS,0278,RC,,,,both,,,2216.09,1440.46,,,,,,,,,,,,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97699,CDM,J3260,HCPCS,0636,RC,63323-0306-30,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
KIT STPL SZ 15 X 15 X 15 MM NIT TIB FIBULAR STR PRELD RIGID,SUP-2880922,CDM,C1713,HCPCS,0278,RC,,,,both,,,4318.60,2807.09,,,,,,,,,,,,,
MATRIX BIO L 10 X W 8 IN BOV TEND CLLGN GLYCOSAMINOGLYCAN,SUP-2909320,CDM,Q4105,HCPCS,0636,RC,,,,both,,,42631.75,27710.64,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 90 MM DIA 6 MM CATH TOT L 100,SUP-2148369,CDM,C1876,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
SLEEVE K WIRE 1.6MM/2MM TISS PROTCT FOR CONVENTUS CAGE SYS,SUP-2167376,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SPLINT ORTH M HND THMS SUSP,SUP-2112602,CDM,L3807,HCPCS,0272,RC,,,,both,,,96.96,63.02,,,,,,,,,,,,,
COVER SPNL LCK 14 MM ZUMA,SUP-2245580,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE NEURO ULTRA LOW PRFLE STRGHT W/TAB HLX18 LATEX FREE,SUP-2492847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.58,665.98,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0.025IN BILI STD HYDRPHLC HI,SUP-2149310,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.38,204.35,,,,,,,,,,,,,
PLATE BNE FIBULAR LT LAT ANK 9 HOLE NS,SUP-2518405,CDM,C1713,HCPCS,0278,RC,,,,both,,,5570.36,3620.73,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL STANDARDXL W200XL200MM THK0.6MM,SUP-2419462,CDM,C1713,HCPCS,0278,RC,,,,both,,,21055.40,13686.01,,,,,,,,,,,,,
PLATE BONE MAND PRI CRANIO FACE MAND RECON TI STR 17 H FOR,SUP-2363732,CDM,C1713,HCPCS,0278,RC,,,,both,,,1696.86,1102.96,,,,,,,,,,,,,
SHEATH INTRO 30 DEG L 60 CM DIA 9.5 FR CRV,SUP-2141303,CDM,C1894,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CATHETER BRONCHSCP L 145 CM WORKING L 72 CM BALLOON DIA13 MM,SUP-2930256,CDM,C2628,HCPCS,0272,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
PLATE BONE LT DSTL FIB TI LCK,SUP-2419540,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
TM MODULAR CUP 60MM MULTI-HOLE REVISION,SUP-2503640,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PIN FIX L120MM DIA45MM S STL SGL END SMOOTH SHRP TIP FOR,SUP-2186913,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.02,130.01,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM XK CHRONIC STD 16FR DIA 36CM,SUP-2613306,CDM,C1750,HCPCS,0278,RC,,,,both,,,1453.82,944.98,,,,,,,,,,,,,
DRILL SURG 1.8 MM 2.8 MM FOR ANCHR TI TWINFIX,SUP-2849117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.72,246.82,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 175 CM DIA 0.035 IN J L 3 MM PTFE X,SUP-2383456,CDM,C1769,HCPCS,0272,RC,,,,both,,,108.58,70.58,,,,,,,,,,,,,
CUP ACET OD47MM ID22MM MTL ON POLYETH NEUT PRI CEM W/ SPCR,SUP-2203596,CDM,C1776,CPT,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,2500000003,HCPCS,0250,RC,51754-1007-01,NDC,,both,10,ML,544.60,353.99,,,,,,,,,,,,,
IMPLANT TOE 1.6 MM 9.34X4.5X6.04 MM LG KT,SUP-2564343,CDM,C1776,CPT,0278,RC,,,,both,,,4170.49,2710.82,,,,,,,,,,,,,
STAPLER INT 12 MM 2.5 MM TI MULTFI ENDO TA LF DISP,SUP-2787746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2307.12,1499.63,,,,,,,,,,,,,
PLATE BONE SM W10XL121MM THK3.4MM 10 H UNIV DSTL HUM RAD ULN,SUP-2343772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.43,926.53,,,,,,,,,,,,,
STEM POROUS 16.5X220MM BOWED,SUP-2505117,CDM,C1776,CPT,0278,RC,,,,both,,,10248.96,6661.82,,,,,,,,,,,,,
INSERT TIB 3 H8MM POLYETH ANK INFIN,SUP-2397294,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
BLADE SHAVER STR 4.2 MM SERRATED HEMOSTATIC DIEGO,SUP-2638101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.46,390.30,,,,,,,,,,,,,
CLASSIC CHS PL 10 SLOT 145 DEG,SUP-2818262,CDM,C1713,HCPCS,0278,RC,,,,both,,,5741.33,3731.86,,,,,,,,,,,,,
OSS SMOOTH STM W/SRW 90ST-10,SUP-2510685,CDM,C1776,CPT,0278,RC,,,,both,,,4018.57,2612.07,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2 CHMBR CONTAK RENEWAL TR H121 BSC CRM,SUP-2149219,CDM,C1721,HCPCS,0275,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
HC So1 Heparin Asso1c Platelet Antibo,PX-3028602267,CDM,86022,CPT,0302,RC,,,,outpatient,,,465.00,302.25,,,,,,,,,,,,,
TROCAR SURG DIA2.8MM FOR 6.5/7.3MM CANN SCR,SUP-2177036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.17,341.36,,,,,,,,,,,,,
CYSTOSCOPY KIT FLX CANN STRL DRP ENDOSEE,SUP-2755376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BNE FRAG NS MOD LTX,SUP-2861299,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.23,1034.30,,,,,,,,,,,,,
BIT DRL L225MM DIA3.2MM NONSTERILE QUIK CPL NONRADIOPAQUE,SUP-2187166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.83,296.29,,,,,,,,,,,,,
STYLET PACE L 80 CM DIA 0.016 IN STR STD STEER WHT KNOB/CAP,SUP-2148812,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE 2.7X20 MM 2 HOLE SS DCP,SUP-2569125,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.69,149.30,,,,,,,,,,,,,
SCREW BNE M3.5X0.6 MM 2X12 MM LCK MIC-THRD TI CONTOURS VPS-3,SUP-2646763,CDM,C1713,HCPCS,0278,RC,,,,both,,,272.93,177.40,,,,,,,,,,,,,
NEEDLE HLDR 475IN DERF CARB BITE,SUP-2244530,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
MESH PTCH SYN ABD N ABSRB RECT EXP POLYTETRAFLUROETHYLENE,SUP-2395289,CDM,C1781,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
BIT DRL L180MM OD1.8-4.2MM FOR 5.5MM SCR,SUP-2242912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.07,532.40,,,,,,,,,,,,,
SCREW BONE CRTX CRANIO MAXILLOFACIAL TI ALLOY SELF DRL TAP,SUP-2363331,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.45,86.74,,,,,,,,,,,,,
IMPLANT NASAL LATERA 24MM,SUP-2739008,CDM,C1889,HCPCS,0278,RC,,,,both,,,6144.98,3994.24,,,,,,,,,,,,,
HC So2 Alpha Fetoprotein,PX-3018210568,CDM,82105,CPT,0301,RC,,,,both,,,163.00,105.95,,,,,,,,,,,,,
INSERT TIB SM THK11MM STD UNIV KNEE DUR MTL PRI NEUT,SUP-2376454,CDM,C1776,CPT,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
SHEATH INTRO AFX L 45 CM GUIDEWIRE 0.035 IN PTFE 55D PEBAX,SUP-2217717,CDM,C1894,HCPCS,0272,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
SCREW BNE L95MM DIA5MM S STL ST VAR ANG LOK FULL THRD T25,SUP-2178723,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.70,461.30,,,,,,,,,,,,,
HC MRI Breast W/O Contrast Bilateral,PX-6107704700,CDM,77047,CPT,0610,RC,,,,both,,,5019.00,3262.35,,,,,,,,,,,,,
GRAFT HUM TISS W6XL150-200MM THK3-15MM TIB CORT FRZN STRUT,SUP-2307370,CDM,C1713,HCPCS,0278,RC,,,,both,,,2450.49,1592.82,,,,,,,,,,,,,
HC Hepatitis B Core Antibody Hbcab Igm Antibody,PX-3028670500,CDM,86705,CPT,0302,RC,,,,both,,,763.00,495.95,,,,,,,,,,,,,
MIXER BNE CEM 40GM MAX CAP SGL MIX OPTVAC VAC SYS,SUP-2216857,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.69,281.25,,,,,,,,,,,,,
ANCHOR SUTURE UHMWPE POLYESTER POLYPRO OR PPL TI BTTN WASHER ST 2PK,SUP-2905470,CDM,C1713,HCPCS,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
DEVICE TRACTION FOREARM HANDSTAND DISP,SUP-2846769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SCREW BONE PEG 2.5X40 MM FOOT DRIVER,SUP-2588904,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.03,148.87,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC LOOP LCK 5.5-6.5 IN SM 7.5 IN LT PROCARE,SUP-2197046,CDM,L3931,HCPCS,0274,RC,,,,both,,,20.44,13.29,,,,,,,,,,,,,
INSERT TIB CR XS STD 11 MM KNEE DURAC,SUP-2377508,CDM,C1776,CPT,0278,RC,,,,both,,,6364.15,4136.70,,,,,,,,,,,,,
RETRACTOR SURG SCREW KT REDDICK SAYE,SUP-2264236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1332.74,866.28,,,,,,,,,,,,,
PROBE ABLAT 50DEG ASPIR MULTIPORT BPLR RF 1 PC ELECTRD ERGO,SUP-2123448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.426,SUP-2859990,CDM,C1713,HCPCS,0278,RC,,,,both,,,35546.06,23104.94,,,,,,,,,,,,,
SCREW BNE L80MM DIA4MM ST BLU CORT TI ST NONCANNULATED LOK,SUP-2192303,CDM,C1713,HCPCS,0278,RC,,,,both,,,843.40,548.21,,,,,,,,,,,,,
HC Multiple Sleep Latency or Maintenance Wakefulness Test,PX-9209580500,CDM,95805,CPT,0920,RC,,,,outpatient,,,6931.00,4505.15,,,,,,,,,,,,,
HEAD FEM UNIV 36 MM HIP BIOLOX DELT,SUP-2364694,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STEM FEM SZ 10 STD HIP TI PLSM SPR OVATION,SUP-2314395,CDM,C1776,CPT,0278,RC,,,,both,,,9852.38,6404.05,,,,,,,,,,,,,
PIN KIT EXTN BND 1.5X20 MM SS,SUP-2107848,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
PLATE SPNL L31MM 3 H ANT OCCIPITOCERVICAL TI INVRT Y,SUP-2255349,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
HC Tmj Open/Closed Mouth Bilateral,PX-3207033000,CDM,70330,CPT,0320,RC,,,,both,,,902.00,586.30,,,,,,,,,,,,,
HC Glucose Body Fluid Other Than Blood,PX-3018294500,CDM,82945,CPT,0301,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
OLMESARTAN MEDOXOMIL 20 MG PO TABS,RX-32762,CDM,6370000000,HCPCS,0637,RC,33342-0179-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
INSERT MGII AC TIB ART SURF CDD+ YEL 17MM,SUP-2199632,CDM,C1776,CPT,0278,RC,,,,both,,,6011.22,3907.29,,,,,,,,,,,,,
HC So Trg Gene Rearrangement,PX-3108134266,CDM,81342,CPT,0310,RC,,,,both,,,374.00,243.10,,,,,,,,,,,,,
MIRTAZAPINE 15 MG PO TABS,RX-17466,CDM,6370000000,HCPCS,0637,RC,68084-0119-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L 221 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 18 H 72463118N,SUP-2932917,CDM,C1713,HCPCS,0278,RC,,,,both,,,7884.54,5124.95,,,,,,,,,,,,,
IMPLANT PAT DIA32MM THK10MM X3 ASYM TRIATHLON,SUP-2373615,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
LINER ACET OD39MM ID22MM HIPXLPE BPLR TNDM,SUP-2344605,CDM,C1776,CPT,0278,RC,,,,both,,,3692.64,2400.22,,,,,,,,,,,,,
PLATE BNE PLNTR 2.8X42X16 MM RT 6 HOLE TI TRILOK TMT-1,SUP-2427834,CDM,C1713,HCPCS,0278,RC,,,,both,,,6257.71,4067.51,,,,,,,,,,,,,
PLATE BONE L40-50MM TROCHANTERIC HIP MALLORY-HEAD TI 2 PC,SUP-2405215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
TAP SHORT MODULAR INTERFERENCE SCREW 9-10MM GENESYS MATRYX,SUP-2842818,CDM,C1713,HCPCS,0278,RC,,,,both,,,1226.14,796.99,,,,,,,,,,,,,
MARKER BRST BX 15GA TI OPN COIL RIG NDL W/ RADPQ CLP W/IN,SUP-2195597,CDM,A4648,CPT,0278,RC,,,,both,,,246.18,160.02,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SOUNDSTAR ECO L 90 CM DIA10 FR,SUP-2912452,CDM,C1759,HCPCS,0272,RC,,,,both,,,3157.43,2052.33,,,,,,,,,,,,,
IMPLANT TOE SZ 30 FOREFOOT CLASS GREAT KT FUTURA,SUP-2388611,CDM,C1776,CPT,0278,RC,,,,both,,,3907.20,2539.68,,,,,,,,,,,,,
GUIDEWIRE VASC ARISTOTLE COLOSSUS L 200 CM DIA 0.035 IN,SUP-2884435,CDM,C1769,HCPCS,0272,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
NYSTATIN 500000 UNITS PO TABS,RX-5752,CDM,6370000000,HCPCS,0637,RC,23155-0051-01,NDC,,both,1,UN,4.60,2.99,,,,,,,,,,,,,
PLATE BNE T MIDFACE CRANIOMAXILLOFACIAL 4 HOLE ARNETT W/ TAB,SUP-2465628,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.12,492.13,,,,,,,,,,,,,
SYSTEM BONE CEMENT PCD W/VERTAPLEX HV LONG 90DEG EXT TUBE,SUP-2875969,CDM,C1713,HCPCS,0278,RC,,,,both,,,2222.05,1444.33,,,,,,,,,,,,,
CROWN DENT STRP L3 PEDIATRIC LOWER CUSPID,SUP-2119364,CDM,D6783,CPT,0278,RC,,,,both,,,13.78,8.96,,,,,,,,,,,,,
GRAFT BONE SUB 20ML CANC CORT DBM CHIP RM TEMP FRZ DRY,SUP-2223564,CDM,C1762,CPT,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
CONNECTOR CATH 3 WAY PUDENZ,SUP-2847006,CDM,C1889,HCPCS,0278,RC,,,,both,,,379.09,246.41,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SEMITENDINOSUS TEND N SUTURED DBL STRND,SUP-2418411,CDM,C1762,CPT,0278,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
BUR SURG 16.8 MM TREPHINE FOR OTO SPINE,SUP-2607579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.18,314.07,,,,,,,,,,,,,
SPLINT THMB STRTCH LOOP STRP MED LG RT LIGHTWEIGHT SPICA BLK,SUP-2336216,CDM,L3931,HCPCS,0272,RC,,,,both,,,36.27,23.58,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED KIT INSRT 18GA 8CM CATH BASIC PWR GLDE PRO,SUP-2125659,CDM,C1751,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
DICYCLOMINE HCL 10 MG PO CAPS,RX-2418,CDM,6370000000,HCPCS,0637,RC,00904-6987-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 3X4CM,SUP-2307622,CDM,Q4151,HCPCS,0636,RC,,,,both,,,3224.78,2096.11,,,,,,,,,,,,,
STEM FEM MOD E HIP FOR KINECTIV TECHNOLOGY NK IMPL,SUP-2439200,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
LGN CONST INSRT SZ3-4 TIB SZ4-5 FEM 13MM,SUP-2822788,CDM,C1776,CPT,0278,RC,,,,both,,,6939.40,4510.61,,,,,,,,,,,,,
MESH SURG DIA4.5IN CIR W/ ECHO 2 POS SYS VENTRALIGHT,SUP-2125926,CDM,C1781,HCPCS,0278,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
KIT TRACH AD TB L70MM OD8.7MM ID6MM SIL W/ OBT SIDEPRT,SUP-2352455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.13,208.73,,,,,,,,,,,,,
COLLAR CERV ATLS REG PD5 PEDIATRIC 3-6 YR OCPTL SUPP STRP,SUP-2420905,CDM,L0172,HCPCS,0272,RC,,,,both,,,149.09,96.91,,,,,,,,,,,,,
HC So Vma,PX-3018458566,CDM,84585,CPT,0301,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
PLEDGET SURG L 75 CM 3/4 X 5/16 X 1/16 IN PTFE SFT DA,SUP-2904099,CDM,C1768,CPT,0278,RC,,,,both,,,37.43,24.33,,,,,,,,,,,,,
SCREW LAG FOR AFFIXUS HIP FX NAIL SYS IMP L80MM OD10.5MM,SUP-2211483,CDM,C1713,HCPCS,0278,RC,,,,both,,,1976.32,1284.61,,,,,,,,,,,,,
NEXGEN LPS-FLEX OPTION FEMORAL SIZE E-LT,SUP-2502889,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER INTVASC LITHO C2PLUS L 138 CM 5 FR L 12 DIA 2.5 MM,SUP-2877801,CDM,C1761,CPT,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
NAIL IM L460MM DIA9MM RT LAT FEM LT GRN TI CANN LCK CVD,SUP-2179694,CDM,C1713,HCPCS,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
PLATE BNE L W13.5XL134MM THK4.2MM 7 H BILAT TI NAR RIG NEUT,SUP-2190814,CDM,C1713,HCPCS,0278,RC,,,,both,,,1337.89,869.63,,,,,,,,,,,,,
IMMOBILIZER KNEE 1 SZ FITS MOST WRP ARND ABV KNEE OPN PAT,SUP-2324216,CDM,L1830,CPT,0272,RC,,,,both,,,76.08,49.45,,,,,,,,,,,,,
WASHER ORTH DIA 7 MM FOR CANN SCREW SYS NS LEOS,SUP-2933760,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.73,222.77,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 4 PACK,SUP-2855638,CDM,C2642,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
PLATE BNE L23MM 4 H S STL COMPR FOR 2MM SCR SM MINI FRAG,SUP-2411312,CDM,C1713,HCPCS,0278,RC,,,,both,,,186.30,121.09,,,,,,,,,,,,,
PAD THER UNIV HYDRGEL GEL TWO CHST LEG NONINVASIVE H2O,SUP-2127456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,J2003,HCPCS,0636,RC,55150-0252-20,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
BOLT ORTHOPEDIC 125 MM FEM TI STRL FNS,SUP-2432246,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.99,721.49,,,,,,,,,,,,,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-3613622300,CDM,36223,CPT,0361,RC,,,,both,,,5589.00,3632.85,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST ADJ FIT STRP W/O JT FABRICATED,SUP-2435773,CDM,L3906,HCPCS,0274,RC,,,,both,,,1305.74,848.73,,,,,,,,,,,,,
CROWN DENT 4 PLAS PRI UP LT CTRL PREFABRICATED TRNSPAR ANTR,SUP-2100384,CDM,D6783,CPT,0278,RC,,,,both,,,23.27,15.13,,,,,,,,,,,,,
GRAFT BNE PLNTR WDG CANC COT 7MMX14MMX10MMX25MM,SUP-2321718,CDM,C1713,HCPCS,0278,RC,,,,both,,,4097.70,2663.50,,,,,,,,,,,,,
SHEATH URET L 40 CM OD 14 FR ID 12 FR STRL DISP CLEARPETRA,SUP-2937284,CDM,C1894,HCPCS,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
BEAM FIX L80MM DIA5.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223939,CDM,C1776,CPT,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
CUTTER PACE LD ACUITY UNIV STRL,SUP-2148943,CDM,C1876,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
STENT URTRL 45FR DIA 20CML TCFLX OPEN END FLXBLE LUBRI FLEX,SUP-2721958,CDM,C2617,HCPCS,0278,RC,,,,both,,,214.31,139.30,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL 22GA L56CM 50DEG TRNSLUC HUB HEARTSPAN,SUP-2302569,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.13,267.88,,,,,,,,,,,,,
EXTENSION STEM L100MM DST FEM MOD PC GMRS,SUP-2376561,CDM,C1776,CPT,0278,RC,,,,both,,,7254.34,4715.32,,,,,,,,,,,,,
DRILL SURG XL 1.7 MM SUTUREFIX ULTRA DISP,SUP-2848657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,537.41,349.32,,,,,,,,,,,,,
VALVE SPEAK W/ O2 PRT PHONATE,SUP-2283884,CDM,L8501,HCPCS,0274,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
PLATE BNE L 221 MM SCREW DIA 4.5 MM 12 H NAR COMPR NLCK NS,SUP-2933846,CDM,C1713,HCPCS,0278,RC,,,,both,,,2468.79,1604.71,,,,,,,,,,,,,
BIT DRL 1.7 MM FOR SM SCR FIX SYS LACTOSORB REUNITE,SUP-2608841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.90,326.88,,,,,,,,,,,,,
IMPLANT NSL L 30 X H 28 MM THK 7 MM LG POLYETHYL RT,SUP-2883382,CDM,C1889,HCPCS,0278,RC,,,,both,,,1503.18,977.07,,,,,,,,,,,,,
SILVER NITRATE-POT NITRATE 75-25 % EX MISC,RX-11359,CDM,6370000000,HCPCS,0637,RC,09999-9909-98,NDC,,both,10,UN,12.70,8.25,,,,,,,,,,,,,
MATRIX BIO L 4.7 X W 3.2 IN SZ 98.4 SQCM PORCINE TEND,SUP-2909275,CDM,A2008,HCPCS,0636,RC,,,,both,,,8923.88,5800.52,,,,,,,,,,,,,
MATRIX TISS REGEN GRFTJKT NOW THCK 4CM X 8CM,SUP-2399087,CDM,Q4107,HCPCS,0636,RC,,,,both,,,10107.60,6569.94,,,,,,,,,,,,,
PLATE BONE L20MM THK0.3MM 6 H CRANIOMAXILLOFACIAL TI Y FOR,SUP-2136525,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
GRAFT BNE SUB M 5ML CANC DBM FRMBL CELLULAR VIVIGEN,SUP-2264670,CDM,C1713,HCPCS,0278,RC,,,,both,,,9052.24,5883.96,,,,,,,,,,,,,
TUBE LO PROF GASTSTMY 20FR 3.4CM,SUP-2169496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
HC Extremity Arteriogram Unilateral,PX-3237571000,CDM,75710,CPT,0323,RC,,,,both,,,3608.00,2345.20,,,,,,,,,,,,,
HC Nasotracheal Catheter Aspiration,PX-7613172000,CDM,31720,CPT,0761,RC,,,,outpatient,,,99.00,64.35,,,,,,,,,,,,,
RESERVOIR 75ML W/ LCK OUT VLV TI,SUP-2165356,CDM,C1813,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
PLATE BONE TI OD6 MM MAXILLOFACIAL DBL ROW 2 MM SCR,SUP-2319373,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
"HC So1 Quantation of Therapuetic Drug, Nes",PX-3018037567,CDM,G0480,CPT,0301,RC,,,,both,,,225.00,146.25,,,,,,,,,,,,,
HC Dx Breast Tomo Bil,PX-4017706200,CDM,G0279,HCPCS,0401,RC,,,,inpatient,,,99.00,64.35,,,,,,,,,,,,,
PLATE L DSTL RAD DRSL 2.4MM -20D 3H HD 3H SHFT TI STRL,SUP-2546757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.39,1183.90,,,,,,,,,,,,,
KIT CATH HAD CHRNC LNG TERM LMNX2 155FR DIA 48CML RBST PLST,SUP-2729584,CDM,C1750,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
PLATE BNE LO BEND 3.5X135 MM LT MEDL DSTL TIB 6 HOLE LCK TI,SUP-2180904,CDM,C1713,HCPCS,0278,RC,,,,both,,,4111.36,2672.38,,,,,,,,,,,,,
BLADE SURG SAFETY SZ 21 STAINLES STL BARD PARKER LTXFRDM STR,SUP-2605893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2.79,1.81,,,,,,,,,,,,,
ROD EXT FIX L120MM DIA8MM DSTL RAD ELBW C FBR REUSE,SUP-2188736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
TISSUE BIO MATRIDERM 5.2 X 7.4CM 1MM SM,SUP-2866499,CDM,A2027,HCPCS,0636,RC,,,,both,,,9143.49,5943.27,,,,,,,,,,,,,
GRAFT BONE 10.0ML ALLGRFT PUTTY DBM MAXXEUS,SUP-2165614,CDM,C9359,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
GUIDEWIRE URO L260CM DIA0.018IN STR TIP STD DISP NAVIPRO,SUP-2141536,CDM,C1769,HCPCS,0272,RC,,,,both,,,305.58,198.63,,,,,,,,,,,,,
RING EXT FIX FULL 140 MM TI NS,SUP-2800050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2541.11,1651.72,,,,,,,,,,,,,
CEMENT BNE 3 CC DEMINERALIZED BONE MATRIX STRL TRABEXUS LTX,SUP-2855698,CDM,C1713,HCPCS,0278,RC,,,,both,,,11093.62,7210.85,,,,,,,,,,,,,
BRUSH CYTO L2.5CM DIA3MM CATH 6FR ACCSRY CHAN 3.2MM 0.035IN,SUP-2170661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
DEVICE HEARING AD SZ 4MM W/ 6MM ABUTMENT COMP INSTR DISP FOR,SUP-2319875,CDM,L8690,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
SCREW BONE L24MM DIA1.5MM CO CHROM CORT ST NONLOCKING FULL,SUP-2411775,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.30,176.34,,,,,,,,,,,,,
RING FIX SM FOR 16-21IN OPN BK BAIL HALO,SUP-2328128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
HEAD HUM STD PRI NECKLESS CO CHROM TOT 38MM OD 17MM HT,SUP-2217314,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
BUR SURG RND CUT 3.0 MM DIAM FLUT,SUP-2367535,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.36,249.18,,,,,,,,,,,,,
SCREW BNE L11MM DIA2.3MM THOR STRNL TI LOK DRL FREE LEV 1,SUP-2262555,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.04,52.03,,,,,,,,,,,,,
DEVICE COIL DETACH EDG V4 ELECTRO DETACH GENRTR RET ELECTRD,SUP-2865280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BNE VOLAR XLN 24X125 MM LT LCK STRL DVR,SUP-2481183,CDM,C1713,HCPCS,0278,RC,,,,both,,,3884.18,2524.72,,,,,,,,,,,,,
SET SHTH DESTINO L 87 CM L 67 CM 10FR CRV BEND 50 MM 50 DEG,SUP-2616102,CDM,C1766,CPT,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
EXTERNAL FIXATION SET ANCIL SUBFIX,SUP-2467210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10413.81,6768.98,,,,,,,,,,,,,
PIN FIX L 60 MM DIA 3.5 MM PROV COMPR STRL EVOS,SUP-2933621,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.65,441.77,,,,,,,,,,,,,
COMPONENT FEM L7CM R PROX HIP TI MOD FINN STYL OSS,SUP-2405808,CDM,C1776,CPT,0278,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA 28 MM L 15CM 8 MM ANTE FLO,SUP-2894825,CDM,C1768,CPT,0278,RC,,,,both,,,6550.04,4257.53,,,,,,,,,,,,,
MEGESTROL ACETATE 40 MG/ML PO SUSP,RX-10521,CDM,6370000000,HCPCS,0637,RC,00121-0945-10,NDC,,both,5,ML,9.50,6.17,,,,,,,,,,,,,
PROBE UTER SOUNDING DEV NOVASURE/SURESOUND,SUP-2239967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4183.52,2719.29,,,,,,,,,,,,,
PROBE ELECSURG THERM MOD VULCAN,SUP-2848571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1211.98,787.79,,,,,,,,,,,,,
ENDCAP ORTH TIB NAIL STRL LTX,SUP-2861517,CDM,C1889,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
KIT VENT ASST CTRL L,SUP-2282556,CDM,Q0481,HCPCS,0272,RC,,,,both,,,22451.00,14593.15,,,,,,,,,,,,,
BAR EXT FIX L 600 MM DIA11 MM STRL DISP MAV,SUP-2933431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
MICROCATHETER ETER VASC DST 25FR PROX 28FR L154CM TIP,SUP-2418600,CDM,C1887,HCPCS,0272,RC,,,,both,,,4136.95,2689.02,,,,,,,,,,,,,
BUR DENT 7X70 MM CARBIDE STRL PM2 80K,SUP-2134831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
HC Iadna S Aureus Amplified Probe Tq,PX-3068764000,CDM,87640,CPT,0306,RC,,,,both,,,105.00,68.25,,,,,,,,,,,,,
BINDER ABD UNIV H9IN WAIST 45-62IN E SFT COT PREM 3 PNL,SUP-2197075,CDM,L0450,HCPCS,0272,RC,,,,both,,,20.72,13.47,,,,,,,,,,,,,
RESERVOIR 20MM W/ HYDR SPRUNG PROGAV 2.0,SUP-2108739,CDM,C1729,HCPCS,0272,RC,,,,both,,,7388.26,4802.37,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL STRUT FD,SUP-2391735,CDM,C1889,HCPCS,0278,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L45CM DIA13MM ELECTRD L6MM SPC 18MM,SUP-2278244,CDM,C1778,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
LEAD NERVE STIM 50 CM W/ PLANTLOCK ARTISAN,SUP-2765588,CDM,C1883,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PLATE BONE NARROW 4.5X55 MM 3 HOLE FOR SCREW STERILE TC100,SUP-2836675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1075.17,698.86,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309712900,CDM,97129,CPT,0430,RC,,,GN|XU,outpatient,,,186.00,120.90,,,,,,,,,,,,,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-155612,CDM,90677,HCPCS,0636,RC,00005-2000-01,NDC,,both,.5,ML,1120.50,728.32,,,,,,,,,,,,,
SHEATH INTRO SAFSHTH ULTRA LT L 13 CM DIA 8.5 FR DIL L 18 CM,SUP-2118987,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.25,85.31,,,,,,,,,,,,,
PLATE BONE LOK 85MML HLX46 HDSHFT T SHPD ST,SUP-2730177,CDM,C1713,HCPCS,0278,RC,,,,both,,,1338.96,870.32,,,,,,,,,,,,,
GUIDEWIRE VASC MINI HYDRPHLC HYBRID X SFT TRAXCESS,SUP-2305452,CDM,C1769,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
HC Cystourethroscopy (Separate Procedure),PX-4505200000,CDM,52000,CPT,0450,RC,,,,both,,,706.00,458.90,,,,,,,,,,,,,
GRAFT HUM TISS L 22 X W 22 X H 6/4 MM IL CREST UNICORTICAL,SUP-2913420,CDM,C1762,CPT,0278,RC,,,,both,,,6427.58,4177.93,,,,,,,,,,,,,
SCREW BNE ABSORBABLE 5X40 MM LP PART THRD REUNITE,SUP-2466225,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET XPEEDIOR L 120 CM DIA 6 FR,SUP-2277420,CDM,C1757,HCPCS,0272,RC,,,,both,,,3234.20,2102.23,,,,,,,,,,,,,
ALIGNRITE WRIST BLK LNG RGHT XS,SUP-2458402,CDM,L3906,HCPCS,0272,RC,,,,both,,,55.95,36.37,,,,,,,,,,,,,
BASKET SPEC RETRV 7 FR 1.5X3.5 CM FOR REMOVAL BILI STONE MEM,SUP-2422798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
STIMULATOR NERVE 7.5 AMP IMPL PULSE GENRTR DL QUAT PROCLAIM,SUP-2355965,CDM,C1767,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
CATHETER GRFT POS DIA26-45 MM POLYUR THOR TRILOBE DESIGN,SUP-2395623,CDM,C1725,HCPCS,0272,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
HC J Tube Plcmt,PX-3614944100,CDM,49441,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
HEAD FEM BPLR 22X38 MM HIP RINGLOK,SUP-2449889,CDM,C1776,CPT,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
PLATE BNE VOLAR NAR SHT LT 3 HOLE ANAT STRL DVR,SUP-2462388,CDM,C1713,HCPCS,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 6 MM EPTFE STR TW,SUP-2481324,CDM,C1768,CPT,0278,RC,,,,both,,,1119.22,727.49,,,,,,,,,,,,,
SET CBL SL SM DIA2MM VIT FOR RECON AND TRAUM SYS DALL-M,SUP-2377565,CDM,C1776,CPT,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 25CM 7MM 120CM 7FR RADIOPAQUE,SUP-2396655,CDM,C1874,HCPCS,0278,RC,,,,both,,,20052.04,13033.83,,,,,,,,,,,,,
SHEATH INTRO 16GA L12IN TUNN DISP ON-Q,SUP-2236804,CDM,C1894,HCPCS,0272,RC,,,,both,,,85.09,55.31,,,,,,,,,,,,,
HC So Chromosome Anal 15-20,PX-3118826266,CDM,88262,CPT,0311,RC,,,,both,,,463.00,300.95,,,,,,,,,,,,,
SET CIRC BRTH AD L180CM COAX FLOW EXPIRATORY VLV PRESSEMBLED,SUP-2237224,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.36,91.88,,,,,,,,,,,,,
GUIDEWIRE ORTH CRV 8.75 IN,SUP-2459873,CDM,C1769,HCPCS,0272,RC,,,,both,,,570.79,371.01,,,,,,,,,,,,,
BRACE SHLDR SM FA L115 13IN UNIV AIRMESH BRTH SLNG 15DEG,SUP-2150867,CDM,L3650,HCPCS,0272,RC,,,,both,,,171.16,111.25,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT HUM WHL R W/ CUF,SUP-2307340,CDM,C1776,CPT,0278,RC,,,,both,,,26498.46,17224.00,,,,,,,,,,,,,
METHYLPHENIDATE HCL 10 MG PO TABS,RX-4986,CDM,6370000000,HCPCS,0637,RC,68084-0823-21,NDC,,both,1,UN,7.50,4.87,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE CYL W/ INTEGR CONN HAKIM,SUP-2666808,CDM,C1889,HCPCS,0278,RC,,,,both,,,16069.58,10445.23,,,,,,,,,,,,,
GRAFT VASC GRAD WALL 5-8 MMX35 CM STR TRMPT TAPR FLIXENE,SUP-2470335,CDM,C1768,CPT,0278,RC,,,,both,,,3599.66,2339.78,,,,,,,,,,,,,
SET ENDOSCP W/ 8-9MM CLLRD PIN DISP FOR OSTEOCHNDRL,SUP-2121635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1410.17,916.61,,,,,,,,,,,,,
FAMOTIDINE 2 MG/ML IN NS INJ SOLN (PED-NEO),RX-4090131,CDM,J1308,HCPCS,0636,RC,09999-9906-54,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
STYLET PACE L58CM REACH L40MM RAD 14MM 0016IN DEFL ENABLES,SUP-2356063,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BUR SURG L14CM HD L36MM DIA25MM MTCH HD TELSCP MIDAS REX,SUP-2281645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.65,240.92,,,,,,,,,,,,,
PLATE BNE THK 1 MM ADV 2 MM SCREW DIA2 MM MINI RT,SUP-2883174,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.82,1072.38,,,,,,,,,,,,,
SET DEL CARDPLG W ARREST AGNT ADD CASS TBL LN 50ML 6FT,SUP-2330952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
INSERT TIB CR 3 12 MM KNEE BEAR TECHNOLOGY X3 TRIATHLON,SUP-2431363,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER GUID OD7FR ID5.4FR L40CM C315,SUP-2282340,CDM,C1894,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CABLE ORTHPDC 1.3MM DIA 889MML CBLT CHRMM W/NDLE CRIMP CABLE,SUP-2500488,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.37,565.09,,,,,,,,,,,,,
COVER BURR H DIA13 MM PROF THK 0.6 MM THK 0.5 MM SCREW DIA2,SUP-2883873,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 26MM POLYESTER BOV CLLGN STR,SUP-2265930,CDM,C1768,CPT,0278,RC,,,,both,,,1985.48,1290.56,,,,,,,,,,,,,
LINER ACET ID28MM HOOD,SUP-2359079,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 60 CM DIA 6MM STR TW REMOVABLE RNG,SUP-2396293,CDM,C1768,CPT,0278,RC,,,,both,,,3557.62,2312.45,,,,,,,,,,,,,
BASEPLATE TIB L62XW37MM UNIV DURAC KNEE CRUCFRM BEAD IMPL,SUP-2377157,CDM,C1776,CPT,0278,RC,,,,both,,,9077.74,5900.53,,,,,,,,,,,,,
DOPAMINE HCL 40 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-2595,CDM,J1265,HCPCS,0636,RC,00409-9104-20,NDC,JW,both,10,ML,54.10,35.16,,,,,,,,,,,,,
COLLAR CERV 2.5X22 IN,SUP-2194374,CDM,L0120,HCPCS,0274,RC,,,,both,,,11.34,7.37,,,,,,,,,,,,,
PLATE BNE L69MM SHT 1 H ST L MED DST HUM S STL VAR ANG FOR,SUP-2177579,CDM,C1713,HCPCS,0278,RC,,,,both,,,4128.79,2683.71,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 280 MM DIA15 MM DEL SHTH,SUP-2934434,CDM,C1713,HCPCS,0278,RC,,,,both,,,20211.65,13137.57,,,,,,,,,,,,,
BLADE SAW OSCILLATING 9.5MMW X25MML FLUORIDEFSTRYKER,SUP-2605445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,72.91,47.39,,,,,,,,,,,,,
KNIFE SRGCL JRDN 45DG ANGLD TPRD BLADE FSTPDCTMY LATEX FREE,SUP-2673269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.47,208.96,,,,,,,,,,,,,
STEM FEM VERSYS 10 IN BEADED FC +10CALCAR 18.0X240MM BWD RT,SUP-2504288,CDM,C1776,CPT,0278,RC,,,,both,,,15599.52,10139.69,,,,,,,,,,,,,
KIT PERICARDCENT NDL L 8 CM DIA18 GA CATH L 40 CM DIA 8.3 FR,SUP-2760071,CDM,C1729,HCPCS,0272,RC,,,,both,,,684.24,444.76,,,,,,,,,,,,,
BIT DRILL NON QUICK COUPLING 1.1X45 MM JACOBS CHUCK END STER,SUP-2837041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.82,510.78,,,,,,,,,,,,,
GRAFT ENDOVASC L2.5CM OD5MM CATH L120CM STENT FEM IL AV ACC,SUP-2396628,CDM,C1874,HCPCS,0278,RC,,,,both,,,10267.80,6674.07,,,,,,,,,,,,,
CANNULA ENDOSCP W/O VLV 11 MMX15 CM GRN RED,SUP-2768547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1006.50,654.22,,,,,,,,,,,,,
HC Phys Performnce Test Ea 15 Min,PX-4209775000,CDM,97750,CPT,0420,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
MARKER FIDUCIAL STERIL GOLD W/DEL NEEDLES 1.2MM X 3MM (PK/3),SUP-2874150,CDM,A4648,CPT,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
STEM FEM SZ 6 L159MM HI OFFSET CEMENTLESS PLATFRM,SUP-2351066,CDM,C1776,CPT,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
KIT PROC 2 CP910 AND CP920 NUCLS 6 SYS,SUP-2165007,CDM,L8614,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY L20CM DIA18GA APPL SEEDWITH ULT SHRP,SUP-2129081,CDM,C1715,HCPCS,0272,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
PROBE LITHO L330MM DIA3.8MM KID URETER BLDR ULTSOUND,SUP-2139434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1725.62,1121.65,,,,,,,,,,,,,
TUBE FIX FOR CORETRAK ARTC FIX,SUP-2399884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
EMTRICITABINE 200 MG PO CAPS,RX-36252,CDM,6370000000,HCPCS,0637,RC,65862-0301-30,NDC,,both,1,UN,72.40,47.06,,,,,,,,,,,,,
PLATE BONE L128MM 7 H S STL T SHP BTTRS LO PROF RIG,SUP-2185759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1750.61,1137.90,,,,,,,,,,,,,
TRAY PICC SUBCL 1/L 5FR 60CML PU RADPQ PEEL AWAY INT 3155115,SUP-2632644,CDM,C1751,HCPCS,0278,RC,,,,both,,,294.22,191.24,,,,,,,,,,,,,
HC Ep Tx Atrial Fib Pul Vn Isolat,PX-4819365600,CDM,93656,CPT,0481,RC,,,,both,,,32110.00,20871.50,,,,,,,,,,,,,
SET CLLR SZ P1 SORBATEX EXTRA PD ANTIBACT MIAMI JR,SUP-2276576,CDM,L0120,HCPCS,0274,RC,,,,both,,,187.68,121.99,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq Ea Addl 15 Min,PX-4309755100,CDM,97551,CPT,0430,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
KIT BNE GRFT SUB 15CC MINI INVASIVE INJ MIIG OSTEOSET,SUP-2399040,CDM,C1713,HCPCS,0278,RC,,,,both,,,4232.50,2751.12,,,,,,,,,,,,,
SCREW BONE 1.5X3MM STERILE CROSS DRIVE SELF DRILLING TITANIU,SUP-2821670,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.68,37.49,,,,,,,,,,,,,
AGBA PICC/DELTA KIT: 1-L 4.5 FRX40 CM,SUP-2822087,CDM,C1751,HCPCS,0278,RC,,,,both,,,981.78,638.16,,,,,,,,,,,,,
HC Duplex Scan Artl Infl&Ven O/F Hemo Compl Uni Std,PX-9219398600,CDM,93986,CPT,0921,RC,,,,inpatient,,,920.00,598.00,,,,,,,,,,,,,
COIL EMB L30CM OD10MM 360DEG STD STRTCH RESIST BIG LOOP,SUP-2365749,CDM,C1889,HCPCS,0278,RC,,,,both,,,8515.05,5534.78,,,,,,,,,,,,,
PLATE BNE L83MM 5 H ST R DST LAT FIBULAR VAR ANG LOK FOR,SUP-2349839,CDM,C1713,HCPCS,0278,RC,,,,both,,,5817.48,3781.36,,,,,,,,,,,,,
CAP SPNL LCK RAD,SUP-2543612,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SCREW BONE L100MM DIA5MM CANC TIM CANN ANTIROTATION,SUP-2137177,CDM,C1713,HCPCS,0278,RC,,,,both,,,795.61,517.15,,,,,,,,,,,,,
HEAD FEM DIA 32 MM NK -3 MM COCR HIP 12/14 TAPR STRL FRDM,SUP-2887730,CDM,C1776,CPT,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
SCREWDRIVER BLADE 2/2.3X94 MM CROSS DRV TERM SS STRL,SUP-2466553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.71,215.61,,,,,,,,,,,,,
BIT DRL L45MM MOD FLEX DISP FOR ACET CUP SCR,SUP-2204019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.22,370.64,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336039,CDM,L3809,HCPCS,0274,RC,,,,both,,,18.46,12.00,,,,,,,,,,,,,
KIT SGL USE W/ PRE FIL LIDO SYR 24FR SAFT PEG PUL ENDOVIVE,SUP-2141589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PUSHER KNOT SUT CUT CVD STRL DISP FAST FIX,SUP-2341635,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.20,236.08,,,,,,,,,,,,,
BLADE SCREWDRVR DIA1.5MM SH CNTR DRV FOR 1.5/2MM MIDFACE,SUP-2402899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
PIN FIX L9IN DIA2.4MM NONSTERILE S STL 3 SIDE SGL TRCR 1,SUP-2150449,CDM,C1713,HCPCS,0278,RC,,,,both,,,51.84,33.70,,,,,,,,,,,,,
INSERT TIB TI OFFSET NEUT LOK,SUP-2405433,CDM,C1776,CPT,0278,RC,,,,both,,,526.58,342.28,,,,,,,,,,,,,
LEAD PACE CAPSUR VDD2 L 52 CM DIA 9 FR SIL INSUL STEROID RT,SUP-2281960,CDM,C1779,HCPCS,0275,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
TRIAL SPNL 14MM IMPL ALLGRFT DANEK,SUP-2292301,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.39,669.10,,,,,,,,,,,,,
GUN BX 14 GAX115 MM AUTO,SUP-2327305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 5X40 MM TITANIUM NITRIDE NON STER,SUP-2836779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1629.50,1059.17,,,,,,,,,,,,,
SET CLLR AD H3IN FOR 13-21IN NK REG ORNG PLAS HK AND LOOP,SUP-2124216,CDM,L0172,HCPCS,0274,RC,,,,both,,,90.87,59.07,,,,,,,,,,,,,
DEVICE BNE FILL SZ 3,SUP-2279566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.49,585.97,,,,,,,,,,,,,
COMPONENT FEM 4 KNEE NXGN,SUP-2201240,CDM,C1776,CPT,0278,RC,,,,both,,,6286.28,4086.08,,,,,,,,,,,,,
SHEATH INTRO SILHOUETTE PEELWY L 30 CM DIA16 FR GUIDEWIRE,SUP-2168321,CDM,C1894,HCPCS,0272,RC,,,,both,,,154.65,100.52,,,,,,,,,,,,,
"HC Cult,Pathognic Orgnsms,Screen",PX-3008708100,CDM,87081,CPT,0300,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
PLATE BNE L49MM THK3.3MM 4 H BILAT S STL RIG STR DYN COMPR,SUP-2186328,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.83,554.99,,,,,,,,,,,,,
BISOPROLOL FUMARATE 5 MG PO TABS,RX-18288,CDM,6370000000,HCPCS,0637,RC,70954-0455-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX23 CM SLV PALINDROMIC HSI,SUP-2283945,CDM,C1750,HCPCS,0278,RC,,,,both,,,1478.97,961.33,,,,,,,,,,,,,
PLATE BONE 6 H T SHP BTTRS ECT,SUP-2198572,CDM,C1713,HCPCS,0278,RC,,,,both,,,667.03,433.57,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HICKMAN CHRONIC 13.5FR DIA 23CM 40CML I,SUP-2613307,CDM,C1751,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2X14 MM MANDIBULAR 20/PK TITANIUM NON,SUP-2842280,CDM,C1713,HCPCS,0278,RC,,,,both,,,224.20,145.73,,,,,,,,,,,,,
TRAY CATH PICC LUMENX2 5FR DIA 60CML POLYURETHANE 0.55ML PRI,SUP-2613391,CDM,C1751,HCPCS,0278,RC,,,,both,,,227.02,147.56,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.552,SUP-2860233,CDM,C1713,HCPCS,0278,RC,,,,both,,,57759.04,37543.38,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE L 15 CM DIA 4 FR GUIDEWIRE 0.018 IN,SUP-2168210,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.50,38.67,,,,,,,,,,,,,
COLLAR CERV SM PED W25XL14IN FOAM M DENS BRTH COT STOCK LNR,SUP-2194384,CDM,L0120,HCPCS,0274,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
PACEMAKER CARD CYLOS DR-T TI POLYUR SIL 2 CHMBR STD NOT MRI,SUP-2138083,CDM,C1785,HCPCS,0275,RC,,,,both,,,17238.60,11205.09,,,,,,,,,,,,,
PLATE BONE L18MM THK0.8MM 0DEG 2 H CRAN ADPT STR RAP RESRB,SUP-2194070,CDM,C1713,HCPCS,0278,RC,,,,both,,,487.96,317.17,,,,,,,,,,,,,
PLATE BNE FEM DSTL SET PERI-LOC,SUP-2351349,CDM,C1713,HCPCS,0278,RC,,,,both,,,6719.60,4367.74,,,,,,,,,,,,,
PLATE BNE POST ELBW,SUP-2525761,CDM,C1713,HCPCS,0278,RC,,,,both,,,3460.28,2249.18,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC OSTEOSURGE 300C,SUP-2644326,CDM,C1713,HCPCS,0278,RC,,,,both,,,6612.84,4298.35,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 4.5X221 MM 14 HOLE FOR SCREW STERI,SUP-2836649,CDM,C1713,HCPCS,0278,RC,,,,both,,,4340.27,2821.18,,,,,,,,,,,,,
HC Puncture Aspir Cyst-Breast,PX-3611900000,CDM,19000,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
CORMET HD SIZE: 6/48MM,SUP-2363937,CDM,C1776,CPT,0278,RC,,,,both,,,16623.16,10805.05,,,,,,,,,,,,,
PLATE BNE SM L238MM 20 H BILAT S STL LO PROF RIG LIMIT,SUP-2186216,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.23,1694.05,,,,,,,,,,,,,
BLOOD PUMP KIT CANN 31 FRX28 CM 18 FRX51 CM VENOUS LIFESPARC,SUP-2570700,CDM,C1889,HCPCS,0278,RC,,,,both,,,67510.00,43881.50,,,,,,,,,,,,,
CATHETER EMB 7FR CTRL FLO EPS PROXIS,SUP-2356605,CDM,C1884,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CUP ACET 2 HOLE 46 MM HIP I-HIP,SUP-2240792,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
IMPLANT TOE JT L16MM DIA4MM BLDE W5XL7.85IN 0DEG S STL THRD,SUP-2397823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
PLATE BNE 8 H CORT WRST TI STD BEND SM FRAG SYS FOR,SUP-2191033,CDM,C1713,HCPCS,0278,RC,,,,both,,,3545.94,2304.86,,,,,,,,,,,,,
PLATE BONE TCP STR 25MM,SUP-2396851,CDM,C1713,HCPCS,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7040,HCPCS,0250,RC,00264-7800-10,NDC,,both,250,ML,14.90,9.68,,,,,,,,,,,,,
PLATE BNE L 197 MM SCREW DIA 4.5 MM 9 H RT DSTL FEM ST LCK,SUP-2931330,CDM,C1713,HCPCS,0278,RC,,,,both,,,11070.07,7195.55,,,,,,,,,,,,,
PROSTHESIS KNEE M W65MM LT FEM TIB ENDODUR POREX MOD,SUP-2265093,CDM,C1776,CPT,0278,RC,,,,both,,,81734.20,53127.23,,,,,,,,,,,,,
ELECTRODE ES RESECT W/ HF CBL PLSM OVL BTTN,SUP-2313592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1936.16,1258.50,,,,,,,,,,,,,
SYSTEM FIX STD FEM W/ SHTH 9MM SCR L23MM DIA9-10MM INTRAFIX,SUP-2256827,CDM,C1776,CPT,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
GRAFT BNE SUB 1 8MM 20ML CANC CORT CHIP FRZ DRY READIGRFT,SUP-2264694,CDM,C1713,HCPCS,0278,RC,,,,both,,,705.43,458.53,,,,,,,,,,,,,
PLATE BONE L72.6MM SM THK3.7MM 0DEG 5 H TI HYBRID LCK COMPR,SUP-2421386,CDM,C1713,HCPCS,0278,RC,,,,both,,,862.09,560.36,,,,,,,,,,,,,
SLEEVE IM RESRB FOR 5MM ANGULAR STBL LOK SCR,SUP-2182837,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.66,366.38,,,,,,,,,,,,,
Z DISCONTINUED USE 2283564 DEVICE TISS SEAL L35CM BPLR CRV TIP ENSEAL TRIO,SUP-2257600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1362.10,885.36,,,,,,,,,,,,,
MESH SURG W8XL10IN ELLIPSE W/ ECHO PS POS SYS FOR LAP,SUP-2125920,CDM,C1781,HCPCS,0278,RC,,,,both,,,4838.74,3145.18,,,,,,,,,,,,,
GUIDEWIRE FIX COR DSGN N STRL W/ J TIP 0.035 INX150CM STD,SUP-2355594,CDM,C1769,HCPCS,0272,RC,,,,both,,,4.40,2.86,,,,,,,,,,,,,
STEM TIB L75MM DIA18MM KNEE EXTN STABILIZING PRI FLUT,SUP-2253315,CDM,C1713,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
PLATE BONE W9XL37MM CRPL FOR MAESTRO WR RECON SYS,SUP-2136459,CDM,C1713,HCPCS,0278,RC,,,,both,,,4908.61,3190.60,,,,,,,,,,,,,
PLATE BNE L74MM 6 H BILAT 1/3 TBLR NONCOMPRESSION RIG FOR,SUP-2348957,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.48,409.81,,,,,,,,,,,,,
CANNULA RF 20 GAUGEX100MM 10MM,SUP-2236629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
PLATE BONE L91MM 6 H STRL RT LAT PROX TIB S STL PART ARTC,SUP-2349712,CDM,C1713,HCPCS,0278,RC,,,,both,,,7142.40,4642.56,,,,,,,,,,,,,
SCREW BNE L5MM DIA2MM CORT CRANIOMAXILLOFACIAL G TI ST 5PK,SUP-2366116,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.25,106.76,,,,,,,,,,,,,
ALLOGRAFT BNE WHL HUM 10 CM FRZN W/ ROT CUF LT,SUP-2717944,CDM,C1762,CPT,0278,RC,,,,both,,,23198.32,15078.91,,,,,,,,,,,,,
CATHETER BLLN OCCL 2.8/2.5 FRX150 CM 4X7 MM HYPERFORM,SUP-2465947,CDM,C2628,HCPCS,0272,RC,,,,both,,,5630.02,3659.51,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST W/NONTORSION JT,SUP-2435788,CDM,L3931,HCPCS,0274,RC,,,,both,,,537.22,349.19,,,,,,,,,,,,,
APPLIER ANEURYSM CLIP L8IN STANDARD BAYONET STRAIGHT REUSABL,SUP-2825295,CDM,C1889,HCPCS,0278,RC,,,,both,,,4702.62,3056.70,,,,,,,,,,,,,
BUTTON FIX OVL LG 15X21 MM 10 MM PEG STRL XTENDOBUTTON LTX,SUP-2877816,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
SPLINT ARM L W25XL14IN FOR 8-21IN LIMB TRNSLUC FAB POLYSTYR,SUP-2328638,CDM,L3702,HCPCS,0272,RC,,,,both,,,31.53,20.49,,,,,,,,,,,,,
KIT THROMCTMY ANGIOJET ULTRA PWR PULSE Y STRL,SUP-2142029,CDM,C1757,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
NAIL IM HUM PICCOLO 8.5MMX22CM,SUP-2152629,CDM,C1713,HCPCS,0278,RC,,,,both,,,6932.49,4506.12,,,,,,,,,,,,,
"HC Debrid,Subq Ea Addt'l 20sqcm",PX-3611104500,CDM,11045,CPT,0361,RC,,,,outpatient,,,207.00,134.55,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM DIA 0.035 IN TIP L 10 CM,SUP-2701662,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.29,22.29,,,,,,,,,,,,,
CATHETER EP L100CM DIA6FR SPC 5MM TIP L5MM STD CRV MAP EP,SUP-2140176,CDM,C1730,HCPCS,0272,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
PUMP INFUSION ELASTOMERIC 270 CC 2 ML/HR FIX FLO STRL ON-Q,SUP-2424459,CDM,C9804,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED ADV OXIN NP JOURNEY II,SUP-2348066,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
MIDAZOLAM-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN,RX-153672,CDM,J2250,HCPCS,0636,RC,44567-0611-01,NDC,,both,100,ML,172.50,112.12,,,,,,,,,,,,,
LEAD DEFIB 7FR L65CM TIP TO PROX COIL 17CM SIL OPTIM EXT,SUP-2356224,CDM,C1895,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
SLEEVE TIB H40MM AP31MM ML53MM MTPHSEAL KNEE TI PORCOAT POR,SUP-2250950,CDM,C1776,CPT,0278,RC,,,,both,,,6886.65,4476.32,,,,,,,,,,,,,
COMPONENT FEM L7CM 1/3 RT PROX HIP TYP 1 TAPR FINN,SUP-2407261,CDM,C1776,CPT,0278,RC,,,,both,,,12082.72,7853.77,,,,,,,,,,,,,
NEURO FLAP FIX KIT 2 HOLE STRAIGHT PLATES SCREWS,SUP-2677534,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.99,662.34,,,,,,,,,,,,,
BRUSH CYTO CHN SZ 1.2MM L115CM DIA2MM BRIST DIA0.064MM THCK,SUP-2312963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,110.97,72.13,,,,,,,,,,,,,
REDUCER SCREW 4 IN BIRD ZYG,SUP-2492875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.39,324.60,,,,,,,,,,,,,
MESH SURG L 4 X W 1 CM D 1 MM PORCINE DERMAL CLLGN ABD HERN,SUP-2901701,CDM,C9364,HCPCS,0278,RC,,,,both,,,327.53,212.89,,,,,,,,,,,,,
PLATE BNE L 131 MM SCREW DIA 4.5 MM 7 H NAR COMPR NLCK NS,SUP-2932891,CDM,C1713,HCPCS,0278,RC,,,,both,,,1597.48,1038.36,,,,,,,,,,,,,
WIRE TRL OD1.5MM SH PROV,SUP-2351111,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.24,312.81,,,,,,,,,,,,,
HEAD FEM OD28MM -3.5MM 12/14 TAPR LO WR FRAC TOUGH PLT TYP,SUP-2222423,CDM,C1776,CPT,0278,RC,,,,both,,,4644.69,3019.05,,,,,,,,,,,,,
BEARING TIB MED 3 MM RT KNEE,SUP-2136405,CDM,C1776,CPT,0278,RC,,,,both,,,4763.38,3096.20,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED SM 8 IN RT WRST FOREARM THMB,SUP-2276639,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.26,14.47,,,,,,,,,,,,,
SET SCR SPNL SM SILVERTON-D,SUP-2415754,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
SCREW BNE CORTICAL LNG 4X70 MM TI TIBIAXYS,SUP-2243008,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.99,585.64,,,,,,,,,,,,,
KNIFE SURG ANNULOTOMY BAYNT DISP MAXCESS,SUP-2310424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
COIL EMB L14CM LOOP DIA10MM 0.035IN PLAT HYDRGEL POLYMER,SUP-2385377,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PACEMAKER CARD MERID SR 10.5 CC TI POLYUR SINGLE CHMBR IS1,SUP-2148595,CDM,C1786,HCPCS,0275,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
BALLOON IMPL LIMB SALV L 80 CM DIA18/22 MM SHTH 7 MM 65 ML,SUP-2883004,CDM,C1713,HCPCS,0278,RC,,,,both,,,16271.48,10576.46,,,,,,,,,,,,,
PERI-LOC 2.7MM S-T LOCK SCREW 28MM,SUP-2819441,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.11,609.77,,,,,,,,,,,,,
CATHETER ATRSEPTSTMY Z-5 TIP 35 DEG L 50 CM DIA 4 FR BALLOON,SUP-2125232,CDM,C1725,HCPCS,0272,RC,,,,both,,,994.85,646.65,,,,,,,,,,,,,
PLATE BNE STR NAR NS NCB,SUP-2862093,CDM,C1713,HCPCS,0278,RC,,,,both,,,8926.39,5802.15,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAG CTRL SFT ANTR APRON,SUP-2435541,CDM,L0466,HCPCS,0272,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
DEFIBRILLATOR IMPL AURORA EV-ICD MRI SURESCAN W 51 X H 64 MM,SUP-2891565,CDM,C1722,HCPCS,0275,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
CATHETERIZATION KIT 13-1/8 IN 4 FRX40 CM BLU FLEXTIP,SUP-2383368,CDM,C1751,HCPCS,0278,RC,,,,both,,,506.17,329.01,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE INJ VOID FILL FOR,SUP-2414251,CDM,C1713,HCPCS,0278,RC,,,,both,,,10248.96,6661.82,,,,,,,,,,,,,
CATHETER CV DL 7.8 FR KT ACCS W/ INTEGR HEMSTAS VLV,SUP-2383945,CDM,C1751,HCPCS,0278,RC,,,,both,,,317.77,206.55,,,,,,,,,,,,,
MALLET 3714104 LUCAE,SUP-2705130,CDM,C1713,HCPCS,0278,RC,,,,both,,,415.33,269.96,,,,,,,,,,,,,
HC MRI-Chest W & WO Contrast,PX-6107155200,CDM,71552,CPT,0610,RC,,,,inpatient,,,4696.00,3052.40,,,,,,,,,,,,,
HC Iadna Mycoplasma Genitalium Amplified Probe Tech,PX-3068756300,CDM,87563,CPT,0306,RC,,,,both,,,120.00,78.00,,,,,,,,,,,,,
SCREW BONE L65MM DIA2.7MM STD CORT FULL THRD CANN ST LCK S,SUP-2348735,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.95,213.82,,,,,,,,,,,,,
SCREW BONE L4MM NEURO TI SELF DRL LO PROF,SUP-2189298,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.08,189.20,,,,,,,,,,,,,
GUIDEWIRE ORTH L12IN DIA1.2MM NIT SMOOTH BLNT TIP FOR ACL,SUP-2341059,CDM,C1769,HCPCS,0272,RC,,,,both,,,127.01,82.56,,,,,,,,,,,,,
CLAMP SURG PED STR CTRL FOR LIMB RECON SYS,SUP-2316145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.10,830.11,,,,,,,,,,,,,
KIT TUNN TOOL L30CM IMPL NRV STIM SYS DRG MOD PROCLAIM,SUP-2357686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
LINER ACET CEM HIP HYBIRD HXLPE,SUP-2379162,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
CURETTE SURG 0 9.5 IN CERV LUMBAR BKWRD STR RUGGLES-REDMOND,SUP-2470975,CDM,C1776,CPT,0278,RC,,,,both,,,425.06,276.29,,,,,,,,,,,,,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,0636,RC,50242-0044-13,NDC,,both,1,UN,25301.10,16445.71,,,,,,,,,,,,,
SET ENDOSCP DISP FOR 8MM OSTEOCHNDRL HYALINE CART CYL HARV,SUP-2121640,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
COIL VASC AZUR CX L 24 CM DIA13 MM MICROCATHETER 0.035 IN,SUP-2385444,CDM,C1889,HCPCS,0278,RC,,,,both,,,4308.08,2800.25,,,,,,,,,,,,,
BIT DRILL DIA5.5MM CANNULATED PILOT,SUP-2878723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
PLATE CRAN 140X40X40 MM PT SPEC IMPL PEEK,SUP-2860126,CDM,C1713,HCPCS,0278,RC,,,,both,,,26279.29,17081.54,,,,,,,,,,,,,
BIT DRL L445MM DIA07MM STP 6MM L14MM NONSTERILE,SUP-2187621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.28,251.08,,,,,,,,,,,,,
DEFIBRILLATOR CARD V-196 W/ RIATA ST OPTIM EPIC VR,SUP-2356532,CDM,C1721,HCPCS,0275,RC,,,,both,,,66586.84,43281.45,,,,,,,,,,,,,
GRAFT BLK TRI CORT BONE FRZ DRY ALLGRFT 1.5-1.9CM,SUP-2165561,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
BIT DRL L 152 MM DIA2 MM AO NS DISP LEOS,SUP-2933573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.40,454.61,,,,,,,,,,,,,
CATHETER BAL DIL HYDR+ COAT BAL 4MMX4CM TIP LEN 4CM,SUP-2139718,CDM,C1726,HCPCS,0272,RC,,,,both,,,867.43,563.83,,,,,,,,,,,,,
ALLOGRAFT DERMAL 25X30 MM MATRACELL DECELL DERM ARTHROFLEX,SUP-2740767,CDM,Q4125,HCPCS,0636,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
KIT CATH 7FR L6IN CTRL VEN POLYUR 3 LUMN BLU FLEXTIP W/,SUP-2383291,CDM,C1751,HCPCS,0278,RC,,,,both,,,82.27,53.48,,,,,,,,,,,,,
ARTESUNATE 110 MG IV SOLR,RX-154445,CDM,J0391,HCPCS,0636,RC,73607-0011-11,NDC,,both,1,UN,15866.60,10313.29,,,,,,,,,,,,,
PROBE NERVE STIM MONOPOLAR SLIM PRASS FLSH TIP STRL DISP,SUP-2902112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.21,240.64,,,,,,,,,,,,,
WIRE FIX THRD OLV,SUP-2400242,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
PIN FIX L9IN DIA5/64IN SMOOTH SGL TRCR PT STNMN,SUP-2304035,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.70,57.00,,,,,,,,,,,,,
KIT INT FIX ACL INLINE DRL BIT DRL PNT K WIRE GUID WIRE TRCR,SUP-2136097,CDM,C1713,HCPCS,0278,RC,,,,both,,,4571.84,2971.70,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4409753000,CDM,97530,CPT,0440,RC,,,KX|CQ|XU,both,,,191.00,124.15,,,,,,,,,,,,,
OSS ARCOS IM FEMUR ROD 20CM,SUP-2506346,CDM,C1776,CPT,0278,RC,,,,both,,,7714.98,5014.74,,,,,,,,,,,,,
SCREW SPNL PEDCL 4.5X30 MM TI,SUP-2175366,CDM,C1713,HCPCS,0278,RC,,,,both,,,5551.52,3608.49,,,,,,,,,,,,,
STENT BILI EPIC L 100 MM DIA10 MM CATH L 220 CM DIA 6 FR,SUP-2436475,CDM,C1876,HCPCS,0278,RC,,,,both,,,4835.13,3142.83,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 0.035 IN X150 CM MOVABLE COR FLX,SUP-2469005,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.54,65.35,,,,,,,,,,,,,
SYSTEM SHUNT BURR HOLE STD 120-170 MM H2O HI PRESSURE BRN,SUP-2851279,CDM,C1729,HCPCS,0272,RC,,,,both,,,3591.88,2334.72,,,,,,,,,,,,,
STENT PERIPH FORMULA 418 L 12 MM DIA 5 MM CATH L 80 CM DIA 6,SUP-2171177,CDM,C1876,HCPCS,0278,RC,,,,both,,,2774.98,1803.74,,,,,,,,,,,,,
BUR SURG HD L19.1MM DIA3.1MM LNG STR ROUTER ELITE TPS,SUP-2363374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
SCREW KIT LNG CANC SCR STRL GALAXY UNYCO,SUP-2646396,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.36,346.68,,,,,,,,,,,,,
PLATE BNE L 90 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 7 H,SUP-2936380,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.78,475.66,,,,,,,,,,,,,
GRAFT SYNTHECEL DURA REPAIR 1X3IN,SUP-2717544,CDM,C1763,HCPCS,0278,RC,,,,both,,,1570.79,1021.01,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.156X9 IN 3 SHANK END SS NS STEINMANN,SUP-2791607,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.76,35.59,,,,,,,,,,,,,
GUIDEWIRE ORTH LAIN DIA0.062IN LNG DISP,SUP-2122967,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
DEVICE ORTHOT ADDITION TO LO EXT LIMIT ANK MOTN EA JT,SUP-2388175,CDM,L2200,HCPCS,0274,RC,,,,both,,,117.31,76.25,,,,,,,,,,,,,
GRAFT BNE SUB 15GM GRN CA COMPND PTTY AND SILICATE BASE INJ,SUP-2138530,CDM,C9359,HCPCS,0278,RC,,,,both,,,5310.53,3451.84,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA 6 MM EPTFE STR TW N RING STRL,SUP-2396692,CDM,C1768,CPT,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|ADJ,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|CO|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,KX|CO,both,,,195.00,126.75,,,,,,,,,,,,,
APPLIER CLP L33CM SHFT DIA11MM 8 SUT ABSRB RELD REUSE LAPRA,SUP-2219515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2732.74,1776.28,,,,,,,,,,,,,
COIL DETACH 3MM DIA 4CM 1.2MM THER DIA NXT HELIX SFT 10,SUP-2173006,CDM,C1889,HCPCS,0278,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
SET INTRO SHTH L 15 CM DIA 7 FR TEARWY VLV PEELABLE STRL,SUP-2627272,CDM,C1894,HCPCS,0272,RC,,,,both,,,12.56,8.16,,,,,,,,,,,,,
PLATE BONE L67MM THK3.4MM 4 H BILAT NONLOCKING COMPR FOR,SUP-2348947,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
PLATE BNE EIGHT 16 MM TI STRL GUID GROWTH,SUP-2646457,CDM,C1713,HCPCS,0278,RC,,,,both,,,1766.25,1148.06,,,,,,,,,,,,,
CROWN DENT E7 2ND PRIMARY M UPPER LT SS 7770625] 3M],SUP-2100305,CDM,D6783,CPT,0278,RC,,,,both,,,20.60,13.39,,,,,,,,,,,,,
IMPLANT HEARING 4MM TI ABUTMENT FOR FLNG FIX BAHA BA210,SUP-2164964,CDM,L8690,HCPCS,0278,RC,,,,both,,,7429.24,4829.01,,,,,,,,,,,,,
ANCHOR SUTURE 5MM WITH 2 NO 2 SUTURES AND WITHOUT NEEDLE SUP,SUP-2824874,CDM,C1713,HCPCS,0278,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
NERVE STIMULATOR KIT 90 CM 1X8 SUBCOMPACT VECTRIS SURESCAN,SUP-2280219,CDM,C1778,HCPCS,0278,RC,,,,both,,,7529.72,4894.32,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR AIRPLANE DESIGN W/W O NONTORSION JT,SUP-2435754,CDM,L3674,HCPCS,0272,RC,,,,both,,,3045.61,1979.65,,,,,,,,,,,,,
CATHETER GUID NAVICROSS L 135 CM DIA 1.39 MM L 40 CM ANGLED,SUP-2385614,CDM,C1887,HCPCS,0272,RC,,,,both,,,700.53,455.34,,,,,,,,,,,,,
PLATE BONE L LT GLD 3D ORBIT FLR FOR 1.2MM SCR,SUP-2363679,CDM,C1713,HCPCS,0278,RC,,,,both,,,4038.73,2625.17,,,,,,,,,,,,,
END BONE TRANSPORT STRUT,SUP-2494142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
HOOK RETRCT 7CM BLDE MCCULLOCH,SUP-2161662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,302.73,196.77,,,,,,,,,,,,,
BOOT CAST L AD UNISX OPN TOE VELC CLSR TCC-EZ,SUP-2194357,CDM,L4386,HCPCS,0272,RC,,,,both,,,259.33,168.56,,,,,,,,,,,,,
SCREW BONE L30MM DIA3MM CO CHROM POLYAX LCK CANN FOR PROX,SUP-2340276,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
SIDECUTTING BUR LNG TAPERED QTY 5,SUP-2605575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,70.93,46.10,,,,,,,,,,,,,
CLAMP EXTERNAL FIXATION MULTI VECTOR DISTRACTOR FOR CARBON F,SUP-2838086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2835.42,1843.02,,,,,,,,,,,,,
CATHETER URETH SPRL FILIFORM TIP 5 FRX70 CM WOVEN BLASUCCI,SUP-2126133,CDM,C1758,HCPCS,0278,RC,,,,both,,,266.27,173.08,,,,,,,,,,,,,
KIT INTRO MICROEZ L 50 CM CATH 4.5 FR NDL L 5 CM PTFE ORN,SUP-2125498,CDM,C1894,HCPCS,0272,RC,,,,both,,,193.02,125.46,,,,,,,,,,,,,
BLADE SURG FASCIAL INVICTUS,SUP-2728785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE 95 DEG L ANT TALAR HI NK,SUP-2399163,CDM,C1713,HCPCS,0278,RC,,,,both,,,4116.54,2675.75,,,,,,,,,,,,,
PROBE ARTHRO 60DEG 3.0MM WAND ABLAT BPLR W/ SUCT ENLARGED,SUP-2341639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT HUM TISS FEM HD W/O CART FRZN ALLGRFT,SUP-2113900,CDM,C1776,CPT,0278,RC,,,,both,,,3940.70,2561.45,,,,,,,,,,,,,
COMPONENT TIB 10.6MM SM TAPR POST UNI UNICAP,SUP-2123718,CDM,C1776,CPT,0278,RC,,,,both,,,1555.43,1011.03,,,,,,,,,,,,,
SNARE ENDO 35MM ELITE EXPRO,SUP-2104767,CDM,C1773,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE SM L94MM 8 H BILAT S STL LO PROF RIG LIMIT CNTCT,SUP-2186228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1465.19,952.37,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK TRICORT 800125,SUP-2743366,CDM,C1713,HCPCS,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
"HC E/M Crit Care,ER, 1st 30-74min",PX-4509929100,CDM,99291,CPT,0450,RC,,,,outpatient,,,4946.00,3214.90,,,,,,,,,,,,,
HC Transcatheter Dlvr Enhncd Fixation Devices Rs&I,PX-3603471200,CDM,34712,CPT,0360,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
NEXGEN PRECOAT AGMT BLOCK POSTERIOR SIZE E 5MM,SUP-2503284,CDM,C1776,CPT,0278,RC,,,,both,,,2499.44,1624.64,,,,,,,,,,,,,
TOOL EXT FIX T MINI RAIL SYS RX-FIX,SUP-2517154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
STRAP ELBW TENNIS 8 IN BANDIT,SUP-2325152,CDM,L3702,HCPCS,0274,RC,,,,both,,,68.92,44.80,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM 0.025 IN L 7 CM 3 CM AMPLTZ X STIFF,SUP-2638700,CDM,C1769,HCPCS,0272,RC,,,,both,,,249.32,162.06,,,,,,,,,,,,,
BLADE CANN SCRDRVR SELF HLD 2.2,SUP-2267812,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1997.35,1298.28,,,,,,,,,,,,,
PLATE FT 120MM DBL H FOR CIR FIX FRDM SIDEKCK,SUP-2400632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,0636,RC,00003-0494-20,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER GUID 7X5FR L62CM WRK L59CM 90DEG CRV PEBAX INNR,SUP-2356395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
FIBER LASER HPS/XPS,SUP-2225586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
STEM HUM L122MM DIA8MM SHLDR PPS FOR FRAC SYS COMPHSVE,SUP-2404913,CDM,C1776,CPT,0278,RC,,,,both,,,7749.52,5037.19,,,,,,,,,,,,,
GAUGE DEPTH FOR 5MM LOK SCR TI TROCHANTERIC NAIL FIX,SUP-2188233,CDM,C1713,HCPCS,0278,RC,,,,both,,,2073.44,1347.74,,,,,,,,,,,,,
GRAFT BIO TISS W15XL25CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113031,CDM,Q4130,HCPCS,0636,RC,,,,both,,,36053.48,23434.76,,,,,,,,,,,,,
COMPONENT FEM SZ 4 NAR LT POST STBL CEM GMK,SUP-2267604,CDM,C1776,CPT,0278,RC,,,,both,,,8438.75,5485.19,,,,,,,,,,,,,
ELECTRODE MPLR 22FR 30DEG 0.014IN CUT LOOP RESECTOSCOPIC,SUP-2361454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.75,267.64,,,,,,,,,,,,,
SYSTEM NAVIGATION 180DEG FIRM EXT WRK CHAN EDGE,SUP-2381740,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
FIBER LASER 600 MH FOR USE W/ KTP/YAG,SUP-2225628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
PLATE BONE L235MM 13 H NONSTERILE RT MEDL DSTL TIB LCK FOR,SUP-2348489,CDM,C1713,HCPCS,0278,RC,,,,both,,,13310.15,8651.60,,,,,,,,,,,,,
BUR SHAVER L19CM OD5.5/6MM STRAIGHT HPS SHEATH,SUP-2825161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,472.51,307.13,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VIVA XT DELIVERED ENERGY 36 J 35 CC 80 GM,SUP-2282401,CDM,C1882,HCPCS,0275,RC,,,,both,,,46972.80,30532.32,,,,,,,,,,,,,
CEFUROXIME AXETIL 250 MG PO TABS,RX-9495,CDM,6370000000,HCPCS,0637,RC,65862-0699-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA IR 3FR 55CM 1 LUMA S3173355,SUP-2632835,CDM,C1751,HCPCS,0278,RC,,,,both,,,382.73,248.77,,,,,,,,,,,,,
CHLORPROMAZINE HCL 50 MG/2ML IJ SOLN,RX-131208,CDM,J3230,HCPCS,0250,RC,00641-1398-35,NDC,,both,0.4,ML,54.10,35.16,,,,,,,,,,,,,
OSS 5CM TAPERED DIAPH SEGMENT,SUP-2506337,CDM,C1776,CPT,0278,RC,,,,both,,,14356.08,9331.45,,,,,,,,,,,,,
BLADE SHV L13CM DIA4.3MM STR LNG SHFT IRRIG TBNG FOR,SUP-2284161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,801.83,521.19,,,,,,,,,,,,,
COMPONENT FEM SZ 2 LT KNEE POST STBL NP REV CEM FOUNDATION,SUP-2215576,CDM,C1776,CPT,0278,RC,,,,both,,,13256.58,8616.78,,,,,,,,,,,,,
SCREW BNE ST 2.4X8 MM CRTX MXLFCL,SUP-2189489,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
STEM HUM L175MM DIA6MM UNIV SHLDR PRI CEM RSP,SUP-2217363,CDM,C1776,CPT,0278,RC,,,,both,,,11401.06,7410.69,,,,,,,,,,,,,
BIT DRL L160MM DIA3.5MM CANN QUIK CPL NONRADIOLUCENT W/ ADJ,SUP-2187339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1098.09,713.76,,,,,,,,,,,,,
PROTECTOR TISS 2X2 IN 1 CC FLAT DRY SHT TRNSLUC VERSAWRAP,SUP-2740208,CDM,C1889,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA2 MM TI MANDIBULAR UNIV FIX SYS LCK,SUP-2883997,CDM,C1713,HCPCS,0278,RC,,,,both,,,240.74,156.48,,,,,,,,,,,,,
SCREW BONE L57MM OD3.5MM 6 CRUCFRM COARSE THRD WDRUFF,SUP-2362304,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.75,16.74,,,,,,,,,,,,,
CONNECTOR CATH STEPDOWN 0.8X1.5-1.8 MM RADIOPAQUE POLYPR,SUP-2851301,CDM,C1729,HCPCS,0272,RC,,,,both,,,2866.85,1863.45,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0.035IN BILI STD HI PERF STR,SUP-2149657,CDM,C1769,HCPCS,0272,RC,,,,both,,,551.38,358.40,,,,,,,,,,,,,
KIT BONE MAR ASPIRATE 10ML,SUP-2384754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
RING ACET OD53MM ID49MM MTL REINF CNTOUR,SUP-2345094,CDM,C1776,CPT,0278,RC,,,,both,,,5545.24,3604.41,,,,,,,,,,,,,
COMPONENT TIB KNEE TY CRUC RET POR STEM MEDL LEFT/LAT RT,SUP-2199626,CDM,C1776,CPT,0278,RC,,,,both,,,15659.81,10178.88,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX40 CM LT DL VASCPAK KT DURAFLO 2,SUP-2472810,CDM,C1750,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
STEM FEM PRSS FT 18X150 MM REV SLT GEN II,SUP-2435049,CDM,C1776,CPT,0278,RC,,,,both,,,5074.24,3298.26,,,,,,,,,,,,,
SEGMENT FEM OD21MM 5DEGXSM TRAPEZOIDAL FLARE COMP SCR FORGED,SUP-2222170,CDM,C1713,HCPCS,0278,RC,,,,both,,,6004.94,3903.21,,,,,,,,,,,,,
KIT ARTHSCP MINI W/ INSRTR FOR HALLUX VALGUS MINI TIGHTROPE,SUP-2122786,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MED VIABLE AMNION MTRX ESSENCE,SUP-2538798,CDM,C1762,CPT,0278,RC,,,,both,,,6848.34,4451.42,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COGNIS TI CRT BPLR RV IS1 LV DF1 CONN,SUP-2149259,CDM,C1882,HCPCS,0275,RC,,,,both,,,82268.00,53474.20,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EPIC + DR 30 J TI 2 CHMBR STD LD BPLR,SUP-2357753,CDM,C1721,HCPCS,0275,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
GRAFT BNE 5ML B TCP TYP 1 BOV CLLGN PTTY BIOLOGIC SUB,SUP-2316223,CDM,C9359,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 16 CM DIA 7 FR GUIDEWIRE L 80,SUP-2740618,CDM,C1892,HCPCS,0272,RC,,,,both,,,184.63,120.01,,,,,,,,,,,,,
CATHETER ETER URET 4FR L70CM POLYUR OPN TIP W ADPT,SUP-2129002,CDM,C1758,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,6370000000,HCPCS,0637,RC,84389-0111-38,NDC,,both,28.4,GR,54.10,35.16,,,,,,,,,,,,,
GRAFT ENDOVASC L3.3CM DIA28.5MM AORT EXT ENDOPROS EXCLUDER,SUP-2395940,CDM,C1768,CPT,0278,RC,,,,both,,,7416.68,4820.84,,,,,,,,,,,,,
MESH ULTRAPRO ADVANCED 6CM 12CM,SUP-2740092,CDM,C1781,HCPCS,0278,RC,,,,both,,,394.79,256.61,,,,,,,,,,,,,
SCREW BONE L16MM DIA2.4MM CORT TI ST NONCANNULATED,SUP-2189552,CDM,C1713,HCPCS,0278,RC,,,,both,,,215.81,140.28,,,,,,,,,,,,,
GRAFT VASC IMPRA L 20 CM DIA 8 MM EPTFE STR TW N RING HEMO,SUP-2761258,CDM,C1768,CPT,0278,RC,,,,both,,,1004.08,652.65,,,,,,,,,,,,,
GUIDEWIRE VASC PRESSUREWIRE X L 175 CM DIA 0.014 IN HYDRPHLC,SUP-2357540,CDM,C1769,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
LINER ACET SZ 44-48 DIA28MM 5/15DEG MCS GXL,SUP-2221661,CDM,C1776,CPT,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
PLATE BNE L23MM 4 H NONSTERILE TI LOK COMPR W SHT THRD DRL,SUP-2180909,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.69,518.50,,,,,,,,,,,,,
GRAFT BONE 11CM FEM SHFT FRZ DRY,SUP-2165571,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
PLATE BNE L370MM 18 H ST R CNDYL S STL CRV LOK COMPR VAR,SUP-2177867,CDM,C1713,HCPCS,0278,RC,,,,both,,,7468.80,4854.72,,,,,,,,,,,,,
BIT DRL TWST 1.5X70 MM 7 MM W/ STP HEX ATTCH BOS LEVEL 1,SUP-2463038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.58,300.68,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.433,SUP-2859997,CDM,C1713,HCPCS,0278,RC,,,,both,,,38649.63,25122.26,,,,,,,,,,,,,
CONE TIB SHT 18 KNEE LEGION,SUP-2349172,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
PLATE BNE L244MM 90DEG 12 H BILAT S STL SUPCNDYL TB STD BRL,SUP-2342591,CDM,C1713,HCPCS,0278,RC,,,,both,,,6182.97,4018.93,,,,,,,,,,,,,
DRAINAGE KIT STD 100 CM W/ ICP CUP CATH 10-20 CM TIP EXAFLOW,SUP-2666662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,475.52,309.09,,,,,,,,,,,,,
HC MRI Lower Ext Jnt W&W/O Cont,PX-6107372300,CDM,73723,CPT,0610,RC,,,,both,,,4220.00,2743.00,,,,,,,,,,,,,
MARKER FIDUCIAL CONCL 1.27 MM FOR IMAGE REG PINPT,SUP-2863141,CDM,A4648,CPT,0278,RC,,,,both,,,9.61,6.25,,,,,,,,,,,,,
SYSTEM PRP DBL SYR W/ CAP FOR AUTOLGS PLSM SYS ACP,SUP-2120720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE M THK0.3MM STD G UP FACE TI ORBIT FLR BASIC FOR,SUP-2366222,CDM,C1713,HCPCS,0278,RC,,,,both,,,2577.72,1675.52,,,,,,,,,,,,,
BUSHING TIB STD DUR KINEMATIC,SUP-2376411,CDM,C1776,CPT,0278,RC,,,,both,,,733.35,476.68,,,,,,,,,,,,,
GRAFT BONE 14X20 MECH GIC58 THR DWL FRO MDII,SUP-2293889,CDM,C1713,HCPCS,0278,RC,,,,both,,,11278.88,7331.27,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DECANAV L 115 CM 7 FR 2 MM F CRV,SUP-2248952,CDM,C1732,HCPCS,0278,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
SPLINT CLAV HVY PD 24 - 30IN SZ SM,SUP-2196988,CDM,L3650,HCPCS,0272,RC,,,,both,,,17.24,11.21,,,,,,,,,,,,,
HC Cardiopulm Resuscitation,PX-4509295000,CDM,92950,CPT,0450,RC,,,,inpatient,,,424.00,275.60,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR THEON DIA27 MM SEW RNG DIA 35,SUP-2488176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13863.10,9011.01,,,,,,,,,,,,,
CRANIAL ACCESS KIT 6.35 MM MULTIPLE DRL BITS,SUP-2666730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,845.32,549.46,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.4MM THRD L6MM CANC S STL SELF DRL ST,SUP-2185009,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.18,518.17,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 60 CC FRZN IRRADIATED CANC,SUP-2867072,CDM,C1762,CPT,0278,RC,,,,both,,,2765.24,1797.41,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|DOCUMENTATION ON FILE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|CQ|KX,both,,,144.00,93.60,,,,,,,,,,,,,
WASHER ORTH OD10MM ID4.7MM S STL RND TC-100,SUP-2343823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.52,1022.79,,,,,,,,,,,,,
HC Njx Sel Hrt Art/Grft Congenital Hrt Cath W/S&I,PX-4819356400,CDM,93564,CPT,0481,RC,,,,both,,,620.00,403.00,,,,,,,,,,,,,
IMMOBILIZER ORTH M TIETEX SHLDR,SUP-2195526,CDM,L3650,HCPCS,0274,RC,,,,both,,,11.43,7.43,,,,,,,,,,,,,
TROCAR SURG TRANSBUCCAL 70 MM,SUP-2470658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.22,454.49,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 80 CM DIA 8 MM EPTFE TRMPT GRAD WALL,SUP-2525474,CDM,C1768,CPT,0278,RC,,,,both,,,3906.82,2539.43,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM 26MM POLYESTER BOV CLLGN STR,SUP-2265918,CDM,C1768,CPT,0278,RC,,,,both,,,1358.36,882.93,,,,,,,,,,,,,
ROD FOR GALAXY FIX SYS 12MM 250MM,SUP-2316297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,858.54,558.05,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1-4 MM 15 CC CORTICOCANCELLOUS PROX,SUP-2913190,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.32,1710.36,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 68 CM DIA 0.025 IN SS PERIPH MARKED,SUP-2838740,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
IMPLANT SPNL L65MM DIA7MM POR TI PLSM SPR SACROILIAC TRIANG,SUP-2337789,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GUIDEWIRE VASC IMAG L40CM OD0018IN NIT COR PALLADIUM TIP STR,SUP-2303015,CDM,C1769,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX XSMALL 10X15 CM PLASTIC MATRISTEM,SUP-2106512,CDM,Q4166,HCPCS,0636,RC,,,,both,,,12611.03,8197.17,,,,,,,,,,,,,
RIGHTADIOLUCENT TARIGHTGET ARIGHTM CALC PLATE RIGHT XS,SUP-2811174,CDM,C1713,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
INSERT TIB L THK9MM STD L KNEE POLYETH NEUT REV MOD PCA,SUP-2377642,CDM,C1776,CPT,0278,RC,,,,both,,,5575.38,3624.00,,,,,,,,,,,,,
BRACE ORTH 2X UPR KNEE,SUP-2388161,CDM,L1845,HCPCS,0274,RC,,,,both,,,2397.89,1558.63,,,,,,,,,,,,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,6370000000,HCPCS,0637,RC,00904-2533-21,NDC,,both,177,ML,6.40,4.16,,,,,,,,,,,,,
EXTENSION DRL BIT LNG DIA6MM CARB REUSE,SUP-2179280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.43,722.43,,,,,,,,,,,,,
KIT FIX W/ K WIRE GRFT PASS PIN 2 DRL BIT BNE PLUG MRK PEN,SUP-2212938,CDM,C1713,HCPCS,0278,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THK.9-1.99MM ACELLULAR DERM MTRX,SUP-2402512,CDM,Q4126,HCPCS,0636,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PROSTHESIS TESTICULAR L W2.9XL4.5CM NACL MENTR,SUP-2165398,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
COMPONENT TIB TY 6 7 MM LT ANK HINTERMANN SER H2,SUP-2751905,CDM,C1776,CPT,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
HC Lymphangiogram Bilat S&I,PX-3207580300,CDM,75803,CPT,0320,RC,,,,both,,,2550.00,1657.50,,,,,,,,,,,,,
PLATE BONE W12XL39MM THK1MM 2 H BILAT TI SEMI TBLR LO PROF,SUP-2190700,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.08,138.50,,,,,,,,,,,,,
SHEATH ENDOSCP CYSTOURETHROSCOPE 17 FRX20.6 CM FOR CHANNELX1,SUP-2313967,CDM,C1894,HCPCS,0272,RC,,,,both,,,2263.63,1471.36,,,,,,,,,,,,,
SCREW BNE L20MM DIA1.5MM THRD L6MM NONSTERILE CORT S STL ST,SUP-2178688,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.00,412.10,,,,,,,,,,,,,
SCREW BNE DRILL-FREE 1.5X5 MM MIDFACIAL SELF RET NS MAXDRIVE,SUP-2459684,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.01,120.26,,,,,,,,,,,,,
DRILL SURG STP 8 MM IM ANTR REF ASCNT,SUP-2444933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1229.31,799.05,,,,,,,,,,,,,
BLADE RTRCTR SM 24MMW X 110MML TTNM SPNL TTHX3 THIN PRPLE LM,SUP-2478743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1018.02,661.71,,,,,,,,,,,,,
ROD SPNL L480MM DIA5.5MM TI STR HEX END EXPEDIUM,SUP-2254713,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
TUBE VENT ID1.14MM SIL DONALDSON,SUP-2284009,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.52,32.19,,,,,,,,,,,,,
PIN FIX L60MM OD2MM LACTOSORB COPOLYMER ABSRB SGL USE,SUP-2212969,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
TRAY BX L102MM OD11GA S STL NDL PWR BNE ACCS ONCONTROL,SUP-2383230,CDM,C1830,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
DEXTROSE 20 % IV SOLN,RX-2359,CDM,2580000003,HCPCS,0250,RC,00990-7935-19,NDC,,both,500,ML,123.30,80.14,,,,,,,,,,,,,
GRAFT BNE SUB W15 18XL40MM RAD ULN SHFT FRZ DRY,SUP-2307200,CDM,C1713,HCPCS,0278,RC,,,,both,,,1957.19,1272.17,,,,,,,,,,,,,
LEAD EXTENSION KIT 60 CM BLU,SUP-2457569,CDM,C1883,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
WIRE FIX SMOOTH 1.6X150 MM KIRSCHNER,SUP-2321715,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SLING LIFT PCH W13XL19IN SWTH W5XL54IN UNIV PERF FOAM ADJ,SUP-2194775,CDM,L3650,HCPCS,0272,RC,,,,both,,,21.70,14.10,,,,,,,,,,,,,
PLATE BNE HLS STR 1.0MM 6-HOLE LT,SUP-2247338,CDM,C1713,HCPCS,0278,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
PLATE BONE LOCKING 2.7/3.5 MM 8 HOLE RECONSTRUCTION PERILOC,SUP-2837488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2786.91,1811.49,,,,,,,,,,,,,
PLATE BONE CONTOUR MESH 100X100X0.6 MM RECONSTRUCTION TITANI,SUP-2837712,CDM,C1713,HCPCS,0278,RC,,,,both,,,7645.27,4969.43,,,,,,,,,,,,,
VANCOMYCIN HCL 750 MG IV SOLR,RX-97281,CDM,J3373,HCPCS,0636,RC,00409-6531-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
ENDCAP ORTH 10 MM TI STRL AGILE NAIL,SUP-2646466,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.58,342.28,,,,,,,,,,,,,
BUR SURG DIA 4 MM HUB II BRL SOFTCUT STRL DISP HI-LINE XS,SUP-2929245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.55,275.31,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0250,RC,00990-7983-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
SCREW BNE L16MM DIA2.7MM LNG CORT FT ANK S STL ST,SUP-2411018,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.25,43.06,,,,,,,,,,,,,
PLATE BNE FIBULAR 3.5X59 MM LT LAT DSTL 3 HOLE EVOS,SUP-2349741,CDM,C1713,HCPCS,0278,RC,,,,both,,,3898.62,2534.10,,,,,,,,,,,,,
GUIDEWIRE ORTHPDC D32MM STNDRD STNLSS STEEL DRILL TIP SMOOTH,SUP-2481465,CDM,C1769,HCPCS,0272,RC,,,,both,,,161.46,104.95,,,,,,,,,,,,,
SCREW BONE CORT 1.3 MM DIAM 10 MM LEN N CANN FULL THRD TI ST,SUP-2189057,CDM,C1713,HCPCS,0278,RC,,,,both,,,277.89,180.63,,,,,,,,,,,,,
BIT DRL L100MM DIA17MM CANN QUIK CPL FOR 24MM SCR,SUP-2179009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1293.49,840.77,,,,,,,,,,,,,
BLADE RTRCTR BLFR 2 58NW X 10 34NL X 2 34ND SPRPBC CNTR J,SUP-2701371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.99,300.29,,,,,,,,,,,,,
PROCESSOR SND SYS N5SP1,SUP-2141842,CDM,L8691,HCPCS,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X30 MM WRST LCK CAP STRL FRDM,SUP-2852843,CDM,C1713,HCPCS,0278,RC,,,,both,,,1533.76,996.94,,,,,,,,,,,,,
PLUG BONE 9MM FD IRR,SUP-2875984,CDM,C1713,HCPCS,0278,RC,,,,both,,,1798.75,1169.19,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM FULL TY EXCALIBUR INTRO GROSH NXT,SUP-2126670,CDM,C1751,HCPCS,0278,RC,,,,both,,,391.02,254.16,,,,,,,,,,,,,
SYSTEM SEAL W/ DEL DEV LOADER 3.8MM AORT CUT HEARTSTRING,SUP-2227561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1750.83,1138.04,,,,,,,,,,,,,
CONNECTOR VENTILATOR SW ALRM OUTPT SERVO-I,SUP-2747001,CDM,C1713,HCPCS,0278,RC,,,,both,,,564.63,367.01,,,,,,,,,,,,,
BOLT EXT FIX WIRE SIDEKCK EZ FRAME EF001500,SUP-2850507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SET SCR SPNL TI INNR FOR 5.5MM ROD MOSS MIAMI,SUP-2254435,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SCREW BONE L45MM DIA4MM HDLSS COMPR M CANN FLOWERCUBE,SUP-2225513,CDM,C1713,HCPCS,0278,RC,,,,both,,,1178.13,765.78,,,,,,,,,,,,,
LENS IOL BCNVX 6.5+ DIOPT 12.5 MM PMMA PLEXIGLAS,SUP-2129731,CDM,V2630,CPT,0276,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
BEARING HUM CROSSLINKED 45 MM SHLDR POLYETH VIVACIT-E,SUP-2431692,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
SET URET STENT L 20 CM DIA 8.5 FR GUIDEWIRE 0.035 IN UTHANE,SUP-2168517,CDM,C2625,HCPCS,0278,RC,,,,both,,,347.16,225.65,,,,,,,,,,,,,
SCREW BNE LAG 10.5X70 MM FOR CEPHALOMEDULLARY NAIL,SUP-2463591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1542.09,1002.36,,,,,,,,,,,,,
EXPANDER BRST W14.6XH12.6CM P7.6CM 650CC W/ SUT TAB M HT,SUP-2300656,CDM,C1789,HCPCS,0278,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
HC Antistreptolysin O Titer,PX-3028606000,CDM,86060,CPT,0302,RC,,,,both,,,120.00,78.00,,,,,,,,,,,,,
GRAFT VASC L 5 CM DIA20 MM WOVEN EXTRALUMINAL STRL,SUP-2139654,CDM,C1768,CPT,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
NEEDLE SUT SZ 2 SURG 3 FRE STRND SGL PASS MENIS LOOP W/ WIRE,SUP-2256747,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
GUIDEWIRE SOLO HYDRO 0.035 WITH STRAIGHT TIP,SUP-2655879,CDM,C1769,HCPCS,0272,RC,,,,both,,,101.55,66.01,,,,,,,,,,,,,
BIT DRILL 2MM REUSABLE NON,SUP-2824802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,630.48,409.81,,,,,,,,,,,,,
PACK ORTH INSTR OVR DRL COMPR SLV RECTANGULAR DRVR FOR 5 MM,SUP-2902310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1702.19,1106.42,,,,,,,,,,,,,
ROD EXT FIX JT UNIV GRV,SUP-2491187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2085.90,1355.83,,,,,,,,,,,,,
GUIDEWIRE SURG,SUP-2644722,CDM,C1769,HCPCS,0272,RC,,,,both,,,494.36,321.33,,,,,,,,,,,,,
STRUT FEM CORT TRAD ALLGRFT 60 MM 4 EA FRZ DRY,SUP-2294113,CDM,C1713,HCPCS,0278,RC,,,,both,,,6430.72,4179.97,,,,,,,,,,,,,
PLATE BONE L124MM 6 H S STL NAR NONLOCKING COMPR CNTOUR FOR,SUP-2348962,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.89,946.33,,,,,,,,,,,,,
ROD INSRTR FEM STP PIN REUSE RIGIDFIX,SUP-2256612,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
"HC Repair Trnscath Mitral Valve, Initial Prosthesis",PX-3603341800,CDM,33418,CPT,0360,RC,,,,inpatient,,,44486.00,28915.90,,,,,,,,,,,,,
SIZER BRST 700CC DIA15.8CM P4.9CM SIL GEL MOD + PROF RND,SUP-2300897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
TAP 7-8MM FIXED FOR GENESYS MATRYX INTERFERENCE SCREW,SUP-2842816,CDM,C1713,HCPCS,0278,RC,,,,both,,,1993.08,1295.50,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX 7X15 CM PLASTIC MATRISTEM,SUP-2106493,CDM,Q4166,HCPCS,0636,RC,,,,both,,,4063.16,2641.05,,,,,,,,,,,,,
MINOXIDIL 2.5 MG PO TABS,RX-5115,CDM,6370000000,HCPCS,0637,RC,00591-5642-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE TUBULAR BROAD 4.5 MM 9 HOLE PROVISIONAL FIXATION,SUP-2836965,CDM,C1713,HCPCS,0278,RC,,,,both,,,2668.12,1734.28,,,,,,,,,,,,,
DILATOR UROLOGICAL SET 6-18 FRX37 CM FASCIAL PTFE,SUP-2835676,CDM,C2627,HCPCS,0272,RC,,,,both,,,996.64,647.82,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.452,SUP-2860016,CDM,C1713,HCPCS,0278,RC,,,,both,,,63333.17,41166.56,,,,,,,,,,,,,
DRILL TWST FOR 13MM 5MM AND 6MM SCR,SUP-2365066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,275.91,179.34,,,,,,,,,,,,,
PROBE SURG PEDCL STR SGL END W O EYE VERTEX SEL,SUP-2286790,CDM,C1713,HCPCS,0278,RC,,,,both,,,1408.79,915.71,,,,,,,,,,,,,
BUR DIAMOND RND 5MM,SUP-2736215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1103.62,717.35,,,,,,,,,,,,,
CATHETER CV DL 5 FR SHERLOCK 3CG TPS STYL BASIC TY POWERPICC,SUP-2759202,CDM,C1751,HCPCS,0278,RC,,,,both,,,1096.27,712.58,,,,,,,,,,,,,
LENS BILL IOL 60005,SUP-2881901,CDM,V2787,HCPCS,0276,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE L69MM 1 H ST POST MED PROX TIB S STL LOK COMPR,SUP-2177791,CDM,C1713,HCPCS,0278,RC,,,,both,,,3344.73,2174.07,,,,,,,,,,,,,
PLATE BNE L68.5MM 14 H R DST RAD VOLAR S STL LOK COMPR CLMN,SUP-2184077,CDM,C1713,HCPCS,0278,RC,,,,both,,,2489.30,1618.04,,,,,,,,,,,,,
CALIPER SURG SPNL CROSS CONN REVERE,SUP-2232146,CDM,C1713,HCPCS,0278,RC,,,,both,,,2446.06,1589.94,,,,,,,,,,,,,
PLATE BNE L 44 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 4 H 72440604N,SUP-2932879,CDM,C1713,HCPCS,0278,RC,,,,both,,,1837.03,1194.07,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 16CM 6FR 80CM NDL 4CM NIT PLAT,SUP-2483446,CDM,C1894,HCPCS,0272,RC,,,,both,,,151.66,98.58,,,,,,,,,,,,,
ALLOGRAFT BNE WDG LG FRZN IRRADIATED IL CREST,SUP-2867217,CDM,C1762,CPT,0278,RC,,,,both,,,3946.51,2565.23,,,,,,,,,,,,,
BRA SURG SUPP LG 38-40 IN ZIPPER,SUP-2213721,CDM,L8000,HCPCS,0272,RC,,,,both,,,125.41,81.52,,,,,,,,,,,,,
SUBSTITUTE BONE GRAFT SM PROPEL PUTTY,SUP-2546000,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BUR SURG OD3MM LNG DMND RND N FLUT FOR TPS MIDAS REX UPWR,SUP-2367482,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.49,223.92,,,,,,,,,,,,,
BOLT EXT FIX AUG STEM HSNG COCR VANGUARD,SUP-2441906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
SEVELAMER CARBONATE 800 MG PO TABS,RX-89201,CDM,J0601,HCPCS,0637,RC,60687-0328-33,NDC,,both,1,UN,24.60,15.99,,,,,,,,,,,,,
HEAD HUM LO OFFSET 15X41 MM 1.5 MM SHLDR AEQUALIS ASCEND FLX,SUP-2390580,CDM,C1776,CPT,0278,RC,,,,both,,,13098.51,8514.03,,,,,,,,,,,,,
CATHETER ANGIO DIA 4 FR COBRA STRL,SUP-2383189,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COMPONENT CNDYL RT TEMP PROS,SUP-2363872,CDM,C1776,CPT,0278,RC,,,,both,,,3157.71,2052.51,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 9 FRX20 CM 3L STRL,SUP-2759923,CDM,C1751,HCPCS,0278,RC,,,,both,,,470.12,305.58,,,,,,,,,,,,,
PROBE LITHO 9FR L120CM EHL,SUP-2313968,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.69,616.65,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.032 IN STR TIP STRL,SUP-2214527,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.50,16.57,,,,,,,,,,,,,
KIT INTRO BILI STNT PUSH CATH 7FR,SUP-2149475,CDM,C2625,HCPCS,0278,RC,,,,both,,,230.19,149.62,,,,,,,,,,,,,
ALLOGRAFT BNE SPNG 2X5X0.5 CM 10 CC CRBNT APATITE VENADO,SUP-2718019,CDM,C1713,HCPCS,0278,RC,,,,both,,,1993.87,1296.02,,,,,,,,,,,,,
PATCH ABSRB CLLGN WND DRSG PLUG FOR ORAL WND PROTCT HEALING,SUP-2204810,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.69,18.00,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT TI KT SHLDR FIX QUIK T KNOT PUSH SUT CUT,SUP-2341071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
CATHETER URET CONE TIP 10 FR POLYURETHANE,SUP-2129015,CDM,C1758,HCPCS,0278,RC,,,,both,,,46.88,30.47,,,,,,,,,,,,,
CATHETER GUID BNCHMRK 071 L 95 CM OD 6 FR ID 0.071 IN SEL,SUP-2323569,CDM,C1887,HCPCS,0272,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
STENT BILI L80MM DIA6MM CATH L80CM LIFESTNT,SUP-2420395,CDM,C1876,HCPCS,0278,RC,,,,both,,,10346.30,6725.09,,,,,,,,,,,,,
HC Repair Forearm Tendon/Muscle Prim 1 Ea Tdn,PX-4502527000,CDM,25270,CPT,0450,RC,,,,both,,,3319.00,2157.35,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4.5MM CANC ANTR CERV TI ST LCK VAR ANG,SUP-2254600,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
ABLATOR ENDOSCP COAG TEF BALL TIP 23 MM DIAM 300 CM LEN 1 PC,SUP-2360707,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM PRECIS SPECTR INFINION 16 LD SPNL,SUP-2138787,CDM,C1778,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
NKII REV CSTI POROUS FEMORAL LT SIZE 00,SUP-2509648,CDM,C1776,CPT,0278,RC,,,,both,,,20008.08,13005.25,,,,,,,,,,,,,
HC MRI-Angio Neck WO & W Contra,PX-6157054900,CDM,70549,CPT,0615,RC,,,,both,,,4932.00,3205.80,,,,,,,,,,,,,
SCREW BNE L6MM DIA2.4MM TEAL TI ST EMGCY BLU,SUP-2189409,CDM,C1713,HCPCS,0278,RC,,,,both,,,247.06,160.59,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.449,SUP-2860013,CDM,C1713,HCPCS,0278,RC,,,,both,,,55824.80,36286.12,,,,,,,,,,,,,
TRAY HAD FULL SHT TERM 3 LUMN 15.5FRX24CM T-3,SUP-2266987,CDM,C1752,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
ROD SPNL L300MM DIA5.5MM TI Z SHP EXPEDIUM,SUP-2254759,CDM,C1713,HCPCS,0278,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
FOUNDATION PRI INSRT SZ 1 9 MM ** SPEC ORD ONLY,SUP-2216226,CDM,C1776,CPT,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
SCREW BNE CANC 4X22 MM PERIARTICULAR FT HEX HD STRL,SUP-2459346,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.02,57.86,,,,,,,,,,,,,
PLATE BNE CLAV 3.5 MM RT DSTL 16 HOLE FOR SCREW STRL,SUP-2518243,CDM,C1713,HCPCS,0278,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
CATHETER IVL SHOCKWAVE INTRAVACULAR LITHOTRIPSY M5+ 135CM 5.0X60MM,SUP-2850096,CDM,C1725,HCPCS,0272,RC,,,,both,,,108.33,70.41,,,,,,,,,,,,,
SCREW BNE SD 1.5X5 MM CRTX W/ PLUSDRIVE RECESS TI MTRX SLV,SUP-2188937,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.15,181.45,,,,,,,,,,,,,
KNIFE SURG OPHTH 45 DEG 3.5 MM CORNEA ANGLED DBL BVL,SUP-2133070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,52.81,34.33,,,,,,,,,,,,,
GRAFT BIO TISS MESH 8X8 CM MIROMATRIX MIROMESH,SUP-2115022,CDM,C1781,HCPCS,0278,RC,,,,both,,,5805.86,3773.81,,,,,,,,,,,,,
BUSPIRONE HCL 15 MG PO TABS,RX-17464,CDM,6370000000,HCPCS,0637,RC,00904-6899-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY HALO XP L 110 CM DIA 7 FR LOOP,SUP-2248784,CDM,C1731,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
GUIDEWIRE VASC L450CM TIP L5CM 025FR STR RND TIP TUNGSTEN FI,SUP-2436464,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.81,357.38,,,,,,,,,,,,,
CYCLOPHOSPHAMIDE 50 MG PO CAPS,RX-126701,CDM,J8530,HCPCS,0636,RC,62332-0619-31,NDC,,both,1,UN,13.20,8.58,,,,,,,,,,,,,
SCREW 20MM CC FEM AUG BLK STK,SUP-2223077,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
TAP SURG L 70 MM DIA2.6 MM DELT,SUP-2883225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.32,520.21,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.14 MM 1.6 MM 2.3 MM FLROPLAS 520121,SUP-2535139,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.49,15.92,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE STR WTAB NEURO SCRW6 HOLE 27 MM,SUP-2707451,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.96,505.02,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 25CM 5MM 120CM 7FR HEPARIN,SUP-2719623,CDM,C1768,HCPCS,0278,RC,,,,both,,,19778.86,12856.26,,,,,,,,,,,,,
SEGMENTAL TM PROX FEM BODY 38MM OFFSET,SUP-2502394,CDM,C1776,CPT,0278,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
CATHETER CV DL 8 FRX16 CM PRESSURE INJ BLU FLEXTIP,SUP-2383384,CDM,C1751,HCPCS,0278,RC,,,,both,,,324.05,210.63,,,,,,,,,,,,,
HC So Abl1 Gene,PX-3108117066,CDM,81170,CPT,0310,RC,,,,both,,,641.00,416.65,,,,,,,,,,,,,
KIT KYPHOPLASTY L 12 CM DIA10 GA LNG ACCSRY DIAMOND BVL TIP,SUP-2930354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
DEVICE FIX ARTICULATING RELD W/ 8 DP PURCH RELIATACK,SUP-2752199,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.93,288.55,,,,,,,,,,,,,
GUIDEWIRE VASC WISEWIRE L 180 CM DIA 0.035 IN STR TIP DEV,SUP-2148142,CDM,C1769,HCPCS,0272,RC,,,,both,,,1579.01,1026.36,,,,,,,,,,,,,
KIT VASC CLOSURE VASOSEAL CLLGN MEDIATED EXTRAVASCULAR STRL,SUP-2227422,CDM,C1760,HCPCS,0278,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
BRACE WRST AND FA R CIRC LESS THAN 13IN LEN 10IN SZ UNIV,SUP-2197069,CDM,L3931,HCPCS,0274,RC,,,,both,,,25.28,16.43,,,,,,,,,,,,,
TUBE COMPRSS DISTRACTION,SUP-2468926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CRANIAL ACCESS KIT W/ NO DRUG 2 DRL BIT RAZOR,SUP-2852689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1333.59,866.83,,,,,,,,,,,,,
DEVICE REVASCULARIZATION EMBOTRAP II L 21 MM DIA 5 MM NIT 2,SUP-2163306,CDM,C1889,HCPCS,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
PUMP SET INFLATABLE 10 CM INFPUB NAR BASE CYL TITAN OTR,SUP-2165402,CDM,C1813,HCPCS,0278,RC,,,,both,,,21552.96,14009.42,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR LACER,SUP-2435678,CDM,L2540,HCPCS,0272,RC,,,,both,,,1284.79,835.11,,,,,,,,,,,,,
OCCLUDER CV HEMOCOAT LT ATR APPENDAGE CLOSURE RADIOPAQUE,SUP-2905475,CDM,C1889,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 5 MM EPTFE STR TW N RING STRL,SUP-2396688,CDM,C1768,CPT,0278,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
CLAMP CRAN TEXT 11 MM FLAPFIX FOR EXT FIX TI STRL LF,SUP-2431411,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.62,764.15,,,,,,,,,,,,,
GRAFT VASC GELSFT L 15 CM DIA14 MM POLYESTER GEL ABD PERIPH,SUP-2384932,CDM,C1768,CPT,0278,RC,,,,both,,,774.39,503.35,,,,,,,,,,,,,
INSERT TIB THK8MM BEAR ONLAY X3,SUP-2368702,CDM,C1776,CPT,0278,RC,,,,both,,,2620.33,1703.21,,,,,,,,,,,,,
TROCAR VERSPRT + W/SHLD 5-10MM,SUP-2283195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.04,282.13,,,,,,,,,,,,,
PLATE BNE L156MM 5 H NONSTERILE R DST FEM TI LOK COMPR FOR,SUP-2190721,CDM,C1713,HCPCS,0278,RC,,,,both,,,4737.38,3079.30,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL LNG RT FORE FT FUSION,SUP-2609104,CDM,C1713,HCPCS,0278,RC,,,,both,,,6755.49,4391.07,,,,,,,,,,,,,
GRAFT BONE SUB M REG RESRB MOLD MINERALIZED PLEXUR M,SUP-2293948,CDM,C1713,HCPCS,0278,RC,,,,both,,,4250.78,2763.01,,,,,,,,,,,,,
WEDGE HEEL 3/4 2.5X9/16 HAPAD,SUP-2325445,CDM,L3350,HCPCS,0274,RC,,,,both,,,12.91,8.39,,,,,,,,,,,,,
EMPAGLIFLOZIN 10 MG PO TABS,RX-127132,CDM,6370000000,HCPCS,0637,RC,00597-0152-37,NDC,,both,1,UN,94.50,61.42,,,,,,,,,,,,,
INSERT TIB THK 7 MM SZ 1 UHMWPE RT ANK TOT ANAT NEUT STRL,SUP-2931410,CDM,C1776,CPT,0278,RC,,,,both,,,8102.93,5266.90,,,,,,,,,,,,,
BLADE REPROC LARYNSCP GLIDESCOPE SPECTRM DVM SZ 3,SUP-2653266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,89.18,57.97,,,,,,,,,,,,,
PLATE BNE SM W10XL87MM THK15MM 90DEG 3X7 H TI T SHP R ANG,SUP-2190937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1542.12,1002.38,,,,,,,,,,,,,
GRAFT ILIAC CREST STRIP MED 70-90MM FD,SUP-2863663,CDM,C1762,CPT,0278,RC,,,,both,,,10418.52,6772.04,,,,,,,,,,,,,
SHEATH GUID SUBLIME L 150 CM 5 FR 2.3 MM ID 1.9 MM 0.035 IN,SUP-2913951,CDM,C1894,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
BOLT BONE L80MM DIA10MM GLD TI ALLOY FOR FEM NK SYS,SUP-2181052,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.99,721.49,,,,,,,,,,,,,
COIL EMB 10 L1CM OD2MM COMPLX STRTCH RESIST FNSH V-TRAK SFT,SUP-2305134,CDM,C1889,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM XS 22X14MM TI,SUP-2549730,CDM,C1713,HCPCS,0278,RC,,,,both,,,2570.72,1670.97,,,,,,,,,,,,,
MESH SURG XL W4.8XL6.7IN R L PORE LTWT FOR INGUINAL HERN,SUP-2125798,CDM,C1781,HCPCS,0278,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
GRAFT BNE SUB 5CC INJ FOR BNE AUG CORTOSS,SUP-2379531,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
STEM HUM L200MM DIA8MM REV M TAPR FOUNDATION,SUP-2217335,CDM,C1776,CPT,0278,RC,,,,both,,,8980.40,5837.26,,,,,,,,,,,,,
ATTUNE RP TIB BASE SZ 1 CEM,SUP-2251437,CDM,C1776,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC FLX SM AD LT FNGR ORTHOSIS FLX BRAC,SUP-2325138,CDM,L3807,HCPCS,0272,RC,,,,both,,,243.51,158.28,,,,,,,,,,,,,
GUIDEWIRE ORTH L6IN DIA0.054IN S STL SGL TRCR FOR ACU-LOC 2,SUP-2107894,CDM,C1769,HCPCS,0272,RC,,,,both,,,8.04,5.23,,,,,,,,,,,,,
COIL VASC HILAL MICROCOIL EMBOLUS L 6 CM DIA 7 MM CATH DIA,SUP-2168196,CDM,C1889,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
CATHETER ETER OCCL 22 28FR L150CM BLLN L15MM DIA5MM TIP L4MM,SUP-2172477,CDM,C2628,HCPCS,0272,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
GUIDEWIRE ORTH TRCR PT 1 END 1.6X220 MM STRL,SUP-2789091,CDM,C1769,HCPCS,0272,RC,,,,both,,,1356.86,881.96,,,,,,,,,,,,,
PLATE BNE MED TI RL FIBULAR NS UNITE,SUP-2896969,CDM,C1713,HCPCS,0278,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
BUTTON SUTURE BNE TUNN TUNNELPRO,SUP-2908824,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
KIT INTRO MAK L 10 CM DIA 5 FR 40 CM 0.018 IN NIT COAX STD,SUP-2303005,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.12,45.58,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 50 X W 11 MM MYRIAD HNDPC L 13 CM NN-3000,SUP-2930297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22037.27,14324.23,,,,,,,,,,,,,
PLATE SPNL ANTR UNIV BEND 22MM STD LEN TECHTONIX,SUP-2362808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
PLATE BNE L220MM BRL L15IN 130DEG PELVIS BILAT S STL STD 10,SUP-2342437,CDM,C1713,HCPCS,0278,RC,,,,both,,,5573.81,3622.98,,,,,,,,,,,,,
PLATE BNE L50MM THK1.3MM 8 H HND TI STR LOK COMPR FOR 2MM,SUP-2267937,CDM,C1713,HCPCS,0278,RC,,,,both,,,2901.36,1885.88,,,,,,,,,,,,,
SPACER SPNL SM 12 DEG 32X23X18 MM,SUP-2630947,CDM,C1889,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
GUIDEWIRE ORTH MED,SUP-2400567,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
CATHETER DIAG L135CM OD0.059X0.052IN TIP OD3.2FR 50MM SPC,SUP-2353140,CDM,C1887,HCPCS,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
AWL SURG DIA 4 MM CANN STR GRN,SUP-2934448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
EPINEPHRINE 0.125 MG/ACT IN AERO,RX-144803,CDM,6370000000,HCPCS,0637,RC,17270-0553-00,NDC,,both,11.7,GR,126.90,82.48,,,,,,,,,,,,,
INTRODUCER PERC INTRO FLX,SUP-2272870,CDM,C1894,HCPCS,0272,RC,,,,both,,,167.46,108.85,,,,,,,,,,,,,
KIT INFUS PRT 8FR ATTCH GROSH CATH SIL PLAS INJ SGL LUMN,SUP-2420320,CDM,C1788,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SET SUPRPUB CATH 8FR L15CM PERC POLYETH MCOT W/ NDL OBT,SUP-2171290,CDM,C2627,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
BASEPLATE GLEN DIA25MM POST 15MM FOR CONV SHLDR SYS,SUP-2388675,CDM,C1776,CPT,0278,RC,,,,both,,,6389.59,4153.23,,,,,,,,,,,,,
PLATE BNE STR 4 HOLE 15411400,SUP-2864950,CDM,C1713,HCPCS,0278,RC,,,,both,,,3491.68,2269.59,,,,,,,,,,,,,
GRAFT BNE STRP 5X2X0.5 CM DBM ACCELL TBM,SUP-2641756,CDM,C1713,HCPCS,0278,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
SCREW BNE L75MM DIA6.5MM THRD L16MM S STL CANN HEX SOCK,SUP-2183840,CDM,C1713,HCPCS,0278,RC,,,,both,,,619.55,402.71,,,,,,,,,,,,,
CANISTER ASPIR ZOOM,SUP-2739216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
BIT DRL TWST 1.8X36.5 MM 2.75 IN,SUP-2136230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
KIT ARTHSCP FIX W/ DRL GUID OBT DISP FOR 2.8MM Q-FIX,SUP-2341381,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.97,365.28,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENESTRATED ADULT  UNCUFFED ADAPTER OBTURA,SUP-2793424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.21,270.54,,,,,,,,,,,,,
HC Assay of Gammaglobulin Ige,PX-3018278500,CDM,82785,CPT,0301,RC,,,,both,,,644.00,418.60,,,,,,,,,,,,,
GRAFT BNE SUB 5CC BOV TYP I SYN TISS CLLGN MTRX STRP RESRB,SUP-2255626,CDM,C9362,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
RELOAD STPL 3.8MM L90MM S STL SGL USE LD UNIT GIA 90 PREM,SUP-2283066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1482.52,963.64,,,,,,,,,,,,,
BRACE ORTH SLD ANK FT,SUP-2388165,CDM,L1960,HCPCS,0274,RC,,,,both,,,1458.81,948.23,,,,,,,,,,,,,
SCREW SPNL THRD 2X12 MM 8 MM SS MAXDRIVE MMF LF,SUP-2483529,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.04,205.43,,,,,,,,,,,,,
K WIRE FIX L6IN THK0.045IN FOR FT PLATING SYS EXTREMILOCK,SUP-2319433,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
ELECTRODE RF DIA23MM WDG DISPOSABLE FOR SM JT VAPR,SUP-2256731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
RING EXT FIX OPN 120 MM ALUM HOFFMANN,SUP-2460473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3762.98,2445.94,,,,,,,,,,,,,
PLATE BONE L104MM 7 H STRL RT POSTEROMEDIAL PROX TIB S STL T,SUP-2349730,CDM,C1713,HCPCS,0278,RC,,,,both,,,8634.84,5612.65,,,,,,,,,,,,,
PLATE BNE W16XL235MM BLDE L50MM THK48MM 95DEG 14 H ST BILAT,SUP-2185475,CDM,C1713,HCPCS,0278,RC,,,,both,,,5316.05,3455.43,,,,,,,,,,,,,
CAGE SPNL 18X28-41 MM TI X-CORE 2,SUP-2561292,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
BRACE ORTH CRUC RIGID TLSO PLAS,SUP-2388141,CDM,L0472,HCPCS,0272,RC,,,,both,,,997.58,648.43,,,,,,,,,,,,,
PACK DEL SYS ANCHR SUT L15MM DIA4.5MM CONVENIENCE ACHILLES,SUP-2122830,CDM,C1713,HCPCS,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
COVER BUR H DIA12MM 6 H TI FOR 1.3MM PLUSDRIVE SCR,SUP-2190677,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
KIT CTRL VEN CATH PED L8CM DIA5FR POLYUR ANTIMIC DBL LUMN,SUP-2383320,CDM,C1751,HCPCS,0278,RC,,,,both,,,246.80,160.42,,,,,,,,,,,,,
IMPLANT COCHLEAR SLIM STR ELECTRD NUCLS CI422,SUP-2165045,CDM,L8614,HCPCS,0278,RC,,,,both,,,67845.98,44099.89,,,,,,,,,,,,,
ATTACHMENT HNDPC L12.6CM STR INSTR SYS BLK MAX,SUP-2176911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1770.96,1151.12,,,,,,,,,,,,,
PLATE BONE SM TIM LCK INLINE LO PROF CNTOUR SMOOTH FUS ALPS,SUP-2419525,CDM,C1713,HCPCS,0278,RC,,,,both,,,2535.55,1648.11,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 7 HOLES 132MM,SUP-2549507,CDM,C1713,HCPCS,0278,RC,,,,both,,,1598.39,1038.95,,,,,,,,,,,,,
HC Insert Ivc Filter,PX-3613719100,CDM,37191,CPT,0361,RC,,,,outpatient,,,16763.00,10895.95,,,,,,,,,,,,,
SYSTEM TROCAR SHT SYR PRT BLNT TIP,SUP-2241159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CROWN FORM DENT STRP U2 PRIMARY ANTR UPPER LT LAT PLAS,SUP-2322246,CDM,D6783,CPT,0278,RC,,,,both,,,43.30,28.14,,,,,,,,,,,,,
GRAFT DBM PUTTY 2.5CC INFLUX,SUP-2737866,CDM,C1713,HCPCS,0278,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
MARKER SFT TISS L3MM DIA0.9MM GLD FIDUCIAL W/ 18GA L12CM ETW,SUP-2164654,CDM,A4648,CPT,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
STAPLER INT L37CM STPL 25MM CIR ENDOSCP CRV INTLUMN B FRM,SUP-2218994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1060.88,689.57,,,,,,,,,,,,,
BRACE KNEE N SLIP 2XL COMFORTABLE BREATHABLE DONJOY RX WEB,SUP-2196495,CDM,L1812,HCPCS,0274,RC,,,,both,,,228.31,148.40,,,,,,,,,,,,,
SLEEVE TROCAR L150MM DIAMETER 10MM SMOOTH DISPOSABLE WITH TA,SUP-2804216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.81,476.33,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT HD CERM,SUP-2212730,CDM,C1776,CPT,0278,RC,,,,both,,,12988.61,8442.60,,,,,,,,,,,,,
CATHETER BRACHYTHERAPY MULT LUMEN 4.5 CM BLLN CONTURAFLEX,SUP-2239950,CDM,C1726,HCPCS,0272,RC,,,,both,,,8223.66,5345.38,,,,,,,,,,,,,
SCREW BONE LOK 6.5MM DIA 40MML TIMAX CNCLLS HXGNL HEAD 22MML,SUP-2588746,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.52,88.09,,,,,,,,,,,,,
INSERT TIB SZ 5-6 THICKNESS 17MM UNIV STRP GRN PROLONG PRI,SUP-2201295,CDM,C1776,CPT,0278,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,6370000000,HCPCS,0637,RC,72888-0077-15,NDC,,both,10,ML,67.50,43.87,,,,,,,,,,,,,
PLATE BNE W12XL160MM THK25MM LNG 6 H NONSTERILE BILAT PROX,SUP-2190991,CDM,C1713,HCPCS,0278,RC,,,,both,,,5006.76,3254.39,,,,,,,,,,,,,
CATHETER GUID L 30 CM OD 7 FR ID 1.8 MM J SHP FIX HK DEL,SUP-2665331,CDM,C1887,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
VORICONAZOLE 200 MG PO TABS,RX-33009,CDM,6370000000,HCPCS,0637,RC,00904-7024-04,NDC,,both,1,UN,99.10,64.41,,,,,,,,,,,,,
GUIDEWIRE VASC TRANSEND 300 L 300 CM 0.014 IN 2CM STR TIP X,SUP-2367925,CDM,C1769,HCPCS,0272,RC,,,,both,,,1834.39,1192.35,,,,,,,,,,,,,
SCREW BNE L25MM DIA4.75MM CORT FIX ANG NONCANNULATED,SUP-2407396,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
SET PNEUMOTHOR LESS TRAUMATIC FOR PERC ASPIR,SUP-2383243,CDM,C1729,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CUP 1 PC ACET POR CO CHROM PRESSFIT FLR RIM POR PLSM SPRY,SUP-2136394,CDM,C1776,CPT,0278,RC,,,,both,,,19793.62,12865.85,,,,,,,,,,,,,
SUTURE ANCHOR 5.0X14MM WITH TWO NUMBER 2 POLYESTER SUTURES P,SUP-2824808,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.59,344.23,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN CTRL SEMI FLX,SUP-2435597,CDM,L1630,HCPCS,0274,RC,,,,both,,,598.11,388.77,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.109X9 IN 3 SHANK END SS NS STEINMANN,SUP-2791375,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.04,13.68,,,,,,,,,,,,,
SHEATH INTRO AIRGUARD L 15 CM DIA13 FR POLYUR VLV LCK CLLR,SUP-2127827,CDM,C1894,HCPCS,0272,RC,,,,both,,,1544.88,1004.17,,,,,,,,,,,,,
PACEMAKER CARD 10.4ML W50XH47MM THK6MM IS-1 CONN 2 CHMBR,SUP-2356464,CDM,C1785,HCPCS,0275,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
TRANSITION BUMPER 15MM STRL,SUP-2231441,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
KNIFE ENDOSCP CORR SERRATED EDGE URETHROTOMY LF,SUP-2472077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,931.29,605.34,,,,,,,,,,,,,
BIT DRL L95MM DIA3.5MM ST JCBS CHK NONRADIOPAQUE W/O STP,SUP-2187265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 7 28X26X14 MM ALIF CORTICAL ALLOQUENT,SUP-2736914,CDM,C1713,HCPCS,0278,RC,,,,both,,,13878.80,9021.22,,,,,,,,,,,,,
PROTECTOR NERVE L 8 X W 3 CM PORCINE SODIUM HYALURONATE,SUP-2890392,CDM,C1763,HCPCS,0278,RC,,,,both,,,15970.04,10380.53,,,,,,,,,,,,,
DRILL SURG 3.9 MM FOR 5 MM PIN SALVATION 2,SUP-2521581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
STEM FEM L185MM OD21MM 135DEG STD TI PRESSFIT POR HIP PRI,SUP-2409380,CDM,C1776,CPT,0278,RC,,,,both,,,28731.00,18675.15,,,,,,,,,,,,,
ENDCAP SPNL MONOLITH 5991450,SUP-2567554,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 5000RPM M4 360DEG ROT 60DEG CRV SHFT,SUP-2277873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,766.66,498.33,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GAX12.5 CM HAWKINS II,SUP-2120051,CDM,C1819,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SET NEPHROSTOMY NEFF D AGOSTINO MOD STRL,SUP-2638485,CDM,C1769,HCPCS,0272,RC,,,,both,,,431.69,280.60,,,,,,,,,,,,,
CATHETER CV DL 7 FRX16 CM BASIC KT ARROWG+ARD,SUP-2383329,CDM,C1751,HCPCS,0278,RC,,,,both,,,172.39,112.05,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CONNECTOR SHUNT OD1.8-1.5MM ID0.8MM S STL F8-F5 STEPDOWN,SUP-2243839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.84,454.90,,,,,,,,,,,,,
PLATE LCP 2.7MM 16HL /148MM ST,SUP-2761692,CDM,C1713,HCPCS,0278,RC,,,,both,,,1385.15,900.35,,,,,,,,,,,,,
RING EXT FIX DIA210MM LNG FT C FBR FOR HOFF LRF SYS,SUP-2363178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6694.79,4351.61,,,,,,,,,,,,,
PLATE BNE L103MM THK3.4MM 8 H BILAT S STL STR LIMIT CNTCT,SUP-2185136,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.74,636.83,,,,,,,,,,,,,
RAIL EXT FIX SPD FRAME,SUP-2197309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
HC CT C-Spine W/ Contrast,PX-3527212600,CDM,72126,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
PLATE SPNL FIX 28 MM 6.35 MM LP FOR ROD SS X10 CROSSLINK,SUP-2289429,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
GRAFT BONE 10ML IMPL HUM TISS DEMIN PUTTY BONE ALLGRFT DBM,SUP-2414011,CDM,C1713,HCPCS,0278,RC,,,,both,,,4750.82,3088.03,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM OD 5 FR ID 1.7 MM GUIDEWIRE L 30 CM,SUP-2168553,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.46,67.25,,,,,,,,,,,,,
PROSTHESIS OSS L2 56MM HD OD15X2MM DST END CUP OD145MM TI HA,SUP-2232508,CDM,L8613,CPT,0278,RC,,,,both,,,651.49,423.47,,,,,,,,,,,,,
PLATE BNE L90MM 4 H L LAT PROX PERIARTC HUM LOK COMPR,SUP-2410730,CDM,C1713,HCPCS,0278,RC,,,,both,,,4201.89,2731.23,,,,,,,,,,,,,
GRAFT BIO TISS 2X4CM THK04 10MM PROLAYER,SUP-2362226,CDM,C1763,HCPCS,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
SUPPORT ORTHOT BK PREPARATORY NO CVR SACH FT PREFABRICATED,SUP-2694035,CDM,L5535,HCPCS,0274,RC,,,,both,,,5487.28,3566.73,,,,,,,,,,,,,
MESH HERN W9XL14CM POLY HYDRPHLC OVL MFIL SELF FIXATING,SUP-2174791,CDM,C1781,HCPCS,0278,RC,,,,both,,,1314.22,854.24,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 3 X 21 H PLL,SUP-2883163,CDM,C1713,HCPCS,0278,RC,,,,both,,,17478.62,11361.10,,,,,,,,,,,,,
HEAD UPLR DIA38MM FEM SOLITUDE,SUP-2314465,CDM,C1776,CPT,0278,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
PLATE BONE W17.5XL314MM THK5.2MM 17 H BILAT S STL BROAD LCK,SUP-2185313,CDM,C1713,HCPCS,0278,RC,,,,both,,,3382.78,2198.81,,,,,,,,,,,,,
METRONIDAZOLE (FLAGYL) IVPB,RX-4081086,CDM,J1836,HCPCS,0636,RC,00338-1055-48,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 1.9/2.7 FRX139 CM 2X6 MM EMPIRA NC RX,SUP-2158281,CDM,C1725,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
GRAFT BNE PLUG 12 MM CLOWARD DWL FD ASEP,SUP-2693956,CDM,C1713,HCPCS,0278,RC,,,,both,,,5193.56,3375.81,,,,,,,,,,,,,
GUIDEWIRE VASC COUGAR XT L 190 CM DIA 0.014 IN TIP L 3 CM,SUP-2295072,CDM,C1769,HCPCS,0272,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
GRAFT HUM TISS L 115 X W 11 MM PLGA DBM RESRB STRL,SUP-2928389,CDM,Q4118,HCPCS,0636,RC,,,,both,,,13753.20,8939.58,,,,,,,,,,,,,
PIN EXT FIX L30MM OD5MM HA SALVATION,SUP-2401150,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
SYNPOR SMOOTH FAN PLATE,SUP-2827982,CDM,C1713,HCPCS,0278,RC,,,,both,,,2457.36,1597.28,,,,,,,,,,,,,
SPLINT WR FRARM RIGHTXL INSTABILITY INJ W/ STAY FIRM SUPP,SUP-2195253,CDM,L3931,HCPCS,0272,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
BIT DRL L 140/45 MM DIA2.5 MM CALIB AO QC STRL DISP V,SUP-2907613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.35,489.68,,,,,,,,,,,,,
JIG SURG REDUCTION ACCS N GUID LP,SUP-2167401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CLIP HEMSTAS ROTATABLE 11 MM REPOSITIONABLE COAT STRL DISP,SUP-2791191,CDM,C1889,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.1MM S STL NTHRD FOR 3MM CANN SCR,SUP-2186885,CDM,C1769,HCPCS,0272,RC,,,,both,,,68.83,44.74,,,,,,,,,,,,,
ONDANSETRON HCL 40 MG/20ML IJ SOLN,RX-103563,CDM,J2405,HCPCS,0636,RC,00641-6079-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
KIT INTRO STIFFEN FLUENT L 10 CM DIA 5 FR GUIDEWIRE L 40 CM,SUP-2164808,CDM,C1894,HCPCS,0272,RC,,,,both,,,130.47,84.81,,,,,,,,,,,,,
PREDNISONE 2.5 MG PO TABS,RX-6495,CDM,J7512,HCPCS,0637,RC,00054-8740-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Ephys Eval Subq Implantable Defibrillator,PX-3619364400,CDM,93644,CPT,0361,RC,,,,both,,,9405.00,6113.25,,,,,,,,,,,,,
CLAMP SURG ROD TO ROD WIDE 6.35-6.35 MM SS REVERE,SUP-2585149,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
GRAFT DURA W1XL1IN REABSORBABLE MTRX SUB FOR SFT TISS REP ID1105] INTEGRA LIFESCIENCES CORP],SUP-2244078,CDM,C1763,HCPCS,0278,RC,,,,both,,,396.52,257.74,,,,,,,,,,,,,
PLATE BNE T 148 MM 8 HOLE SS,SUP-2569109,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.39,249.20,,,,,,,,,,,,,
GRAFT VASC TAPR SHT 7-4 MMX40 CM STD WALL EPTFE CARBOFLO,SUP-2761272,CDM,C1768,CPT,0278,RC,,,,both,,,1740.41,1131.27,,,,,,,,,,,,,
CATHETER HD STR 15.5 FRX24 CM DL UNCUF BASIC SET HEM-FLO XF,SUP-2269536,CDM,C1881,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
STEM FEM SZ 00 STD SH NK HIP HA QUADRA H,SUP-2267241,CDM,C1776,CPT,0278,RC,,,,both,,,16145.13,10494.33,,,,,,,,,,,,,
HC I&D Breast Abscess Deep,PX-4501902000,CDM,19020,CPT,0450,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
CATHETER KIT AGBA PICC 1-LUMEN 4.5 FR X 55CM,SUP-2655671,CDM,C1751,HCPCS,0278,RC,,,,both,,,626.74,407.38,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR PRODIGY MRI,SUP-2615541,CDM,C1820,HCPCS,0278,RC,,,,both,,,40898.50,26584.02,,,,,,,,,,,,,
AUGMENT TIB SZ 6 THK5MM HNG SCREWED GMK,SUP-2267640,CDM,C1776,CPT,0278,RC,,,,both,,,4485.49,2915.57,,,,,,,,,,,,,
Cystourethroscopy With Biopsy|SEPARATE STRUCTURE,CASE-52204,LOCAL,52204,CPT,,,,,XS,outpatient,,,26984.53,16190.72,,,,,,,,,,,,,
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs|RIGHT SIDE|PO,CASE-25115,LOCAL,25115,CPT,,,,,RT|PO,outpatient,,,20045.78,12027.47,,,,,,,,,,,,,
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms|RIGHT SIDE,CASE-27696,LOCAL,27696,CPT,,,,,RT,outpatient,,,37793.42,22676.05,,,,,,,,,,,,,
Ligj & Div Short Saph Vein Saphenopop Junct Spx,CASE-37780,LOCAL,37780,CPT,0360,RC,,,,outpatient,,,39737.47,23842.48,,,,,,,,,,,,,
HC Stent Place Initial Artery Ang|LEFT SIDE,CASE-37236,LOCAL,37236,CPT,0360,RC,,,LT,outpatient,,,38664.35,23198.61,,,,,,,,,,,,,
Unlisted Procedure Femur/Knee|LEFT SIDE,CASE-27599,LOCAL,27599,CPT,,,,,LT,outpatient,,,20260.72,12156.43,,,,,,,,,,,,,
"HC ED Avulsion Nail Plate Single|LEFT FOOT, GREAT TOE|PO",CASE-11730,LOCAL,11730,CPT,0450,RC,,,TA|PO,outpatient,,,22059.40,13235.64,,,,,,,,,,,,,
Synovectomy Metatarsophalangeal Joint Each,CASE-28072,LOCAL,28072,CPT,0360,RC,,,,outpatient,,,23775.28,14265.17,,,,,,,,,,,,,
Open Treatment of Ulnar Shaft Fracture|RIGHT SIDE,CASE-25545,LOCAL,25545,CPT,0360,RC,,,RT,outpatient,,,33527.12,20116.27,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE|PO,CASE-24342,LOCAL,24342,CPT,0360,RC,,,LT|PO,outpatient,,,29631.38,17778.83,,,,,,,,,,,,,
Tnols Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|RIGHT SIDE|PO,CASE-25295,LOCAL,25295,CPT,0360,RC,,,RT|PO,outpatient,,,18778.17,11266.90,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,LOCAL,58662,CPT,0360,RC,,,RT,outpatient,,,67691.60,40614.96,,,,,,,,,,,,,
Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,CASE-26125,LOCAL,26125,CPT,0360,RC,,,,outpatient,,,16072.42,9643.45,,,,,,,,,,,,,
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE,CASE-27405,LOCAL,27405,CPT,,,,,LT,outpatient,,,31537.33,18922.40,,,,,,,,,,,,,
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,LOCAL,43237,CPT,0360,RC,,,,outpatient,,,14313.12,8587.87,,,,,,,,,,,,,
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu,CASE-25260,LOCAL,25260,CPT,0360,RC,,,,outpatient,,,13068.78,7841.27,,,,,,,,,,,,,
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-54840,LOCAL,54840,CPT,0360,RC,,,LT|XU,outpatient,,,35814.02,21488.41,,,,,,,,,,,,,
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE,CASE-27685,LOCAL,27685,CPT,0360,RC,,,LT,outpatient,,,52734.25,31640.55,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE,CASE-29807,LOCAL,29807,CPT,,,,,RT,outpatient,,,40724.82,24434.89,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,LOCAL,38510,CPT,0360,RC,,,LT,outpatient,,,38020.08,22812.05,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,LOCAL,52356,CPT,,,,,50,outpatient,,,44452.18,26671.31,,,,,,,,,,,,,
"HC Bx,Vulva/Perineum,Addl Lesion",CASE-56606,LOCAL,56606,CPT,0361,RC,,,,outpatient,,,19681.45,11808.87,,,,,,,,,,,,,
STENT PERIPH LIFESTREAM L 58 MM DIA 7 MM CATH L 135 CM,SUP-2128344,CDM,C1874,HCPCS,0278,RC,,,,both,,,7567.40,4918.81,,,,,,,,,,,,,
STENT COR 12MM 2.25MM RADPQ MRK RX MICROTRAC DEL,SUP-2296910,CDM,C1874,HCPCS,0278,RC,,,,both,,,2103.80,1367.47,,,,,,,,,,,,,
CATHETER PICC DIA4FR PLCMNT WIRE INTEGR NDL PROTCT SHRP SAFT,SUP-2383475,CDM,C1751,HCPCS,0278,RC,,,,both,,,236.25,153.56,,,,,,,,,,,,,
HC Rsf Lab Ecmc - Autopsy,PX-9900000125,CDM,9900000125,LOCAL,0990,RC,,,,both,,,503.00,326.95,,,,,,,,,,,,,
SIZER SURG POLARUS 3,SUP-2525728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2408.38,1565.45,,,,,,,,,,,,,
BOLT EXT FIX L6MM HALF PIN FOR TAY SPAT FRME ILIZ,SUP-2342272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7690.65,4998.92,,,,,,,,,,,,,
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,LOCAL,52317,CPT,0360,RC,,,,outpatient,,,27597.97,16558.78,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2|RIGHT SIDE|PO,CASE-29822,LOCAL,29822,CPT,,,,,RT|PO,outpatient,,,26409.28,15845.57,,,,,,,,,,,,,
Musc Myocutaneous/Fasciocutaneous Flap Trunk,CASE-15734,LOCAL,15734,CPT,0360,RC,,,,outpatient,,,78216.28,46929.77,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE|PO,CASE-15823,LOCAL,15823,CPT,0360,RC,,,50|PO,outpatient,,,70250.82,42150.49,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE|PO,CASE-24342,LOCAL,24342,CPT,,,,,LT|PO,outpatient,,,29631.38,17778.83,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26525,LOCAL,26525,CPT,,,,,F7|PO,outpatient,,,15631.72,9379.03,,,,,,,,,,,,,
"HC Debrid,Musc/Fasc,Ea Add 20sqcm",CASE-11046,LOCAL,11046,CPT,0361,RC,,,,outpatient,,,16502.73,9901.64,,,,,,,,,,,,,
Vulvectomy Simple Partial,CASE-56620,LOCAL,56620,CPT,,,,,,outpatient,,,19672.25,11803.35,,,,,,,,,,,,,
Optx Greater Humeral Tuberosity Fx W/Int Fixj|RIGHT SIDE,CASE-23630,LOCAL,23630,CPT,0360,RC,,,RT,outpatient,,,57059.65,34235.79,,,,,,,,,,,,,
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE|PO,CASE-25447,LOCAL,25447,CPT,0360,RC,,,RT|PO,outpatient,,,18976.62,11385.97,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28124,LOCAL,28124,CPT,,,,,T4|PO,outpatient,,,15256.77,9154.06,,,,,,,,,,,,,
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28313,LOCAL,28313,CPT,0360,RC,,,XS|T3|PO,outpatient,,,57075.62,34245.37,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE|PO,CASE-29827,LOCAL,29827,CPT,0360,RC,,,RT|PO,outpatient,,,51622.62,30973.57,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64415,LOCAL,64415,CPT,0360,RC,,,XU|RT|PO,outpatient,,,41098.85,24659.31,,,,,,,,,,,,,
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,LOCAL,45330,CPT,,,,,,outpatient,,,8601.45,5160.87,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26123,LOCAL,26123,CPT,0360,RC,,,F9|PO,outpatient,,,13675.87,8205.52,,,,,,,,,,,,,
MIDAZOLAM HCL 5 MG/5ML IJ SOLN,RX-93518,CDM,J2250,HCPCS,0636,RC,00641-6059-10,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE SM L145MM 12 H TI 1/3 TBLR,SUP-2190924,CDM,C1713,HCPCS,0278,RC,,,,both,,,148.37,96.44,,,,,,,,,,,,,
SCREW INTRF L8MM DIA3MM W/ HNDL INSRTR BIO-TENODESIS,SUP-2121326,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
BIT DRILL 3.8MM 50MM,SUP-2514440,CDM,C1776,CPT,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
POST EXT FIX 3 H WIRE MR CONDITIONAL FOR DISTR OSTEOGENESIS,SUP-2176967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,694.10,451.16,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO SPLIT ACTE 13FR DIA 30CM STRGHT 2L,SUP-2610503,CDM,C1752,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
PLATE BNE L 287 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 24 HL LT,SUP-2937393,CDM,C1713,HCPCS,0278,RC,,,,both,,,8672.99,5637.44,,,,,,,,,,,,,
NEEDLE ASPIR 11GA L250MM BONE MAR,SUP-2384766,CDM,C1713,HCPCS,0278,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
"HC Debrid,Bone Ea Addl 20sqcm",PX-3611104700,CDM,11047,CPT,0361,RC,,,,both,,,840.00,546.00,,,,,,,,,,,,,
PLATE SPNL L84MM UNIV CERV ANT 4 LEV TI STD REFLX,SUP-2380885,CDM,C1713,HCPCS,0278,RC,,,,both,,,6022.52,3914.64,,,,,,,,,,,,,
PLATE BNE L262MM 19 H R ANTLAT DST TIB TI LOK COMPR FOR 35MM,SUP-2190974,CDM,C1713,HCPCS,0278,RC,,,,both,,,4900.19,3185.12,,,,,,,,,,,,,
Cysto W/Removal of Lesions Small,CASE-52224,LOCAL,52224,CPT,0360,RC,,,,outpatient,,,24001.32,14400.79,,,,,,,,,,,,,
Ant Vesicourethropexy/Urethropexy Smpl,CASE-51840,LOCAL,51840,CPT,,,,,,outpatient,,,92091.05,55254.63,,,,,,,,,,,,,
Laparoscopy Surg Pyeloplasty|RIGHT SIDE,CASE-50544,LOCAL,50544,CPT,,,,,RT,outpatient,,,102769.62,61661.77,,,,,,,,,,,,,
Open Repair of Rotator Cuff Chronic,CASE-23412,LOCAL,23412,CPT,,,,,,outpatient,,,52273.90,31364.34,,,,,,,,,,,,,
Partial Excision Bone Fibula|LEFT SIDE|PO,CASE-27641,LOCAL,27641,CPT,0360,RC,,,LT|PO,outpatient,,,32962.88,19777.73,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,LOCAL,64483,CPT,0360,RC,,,RT,outpatient,,,3987.63,2392.58,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO,CASE-27601,LOCAL,27601,CPT,0360,RC,,,LT|PO,outpatient,,,37078.38,22247.03,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE|PO",CASE-28292,LOCAL,28292,CPT,0360,RC,,,TA|PO,outpatient,,,22850.50,13710.30,,,,,,,,,,,,,
HC Special Stain Group 1 Microorganisms I&R,PX-3128831200,CDM,88312,CPT,0312,RC,,,,both,,,219.00,142.35,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY 24 IN,SUP-2336082,CDM,L1830,CPT,0274,RC,,,,both,,,37.21,24.19,,,,,,,,,,,,,
MICROCATHETER INFUSION PROWLER SEL LP-ES L 150CM 5CM STR TIP,SUP-2499396,CDM,C1887,HCPCS,0272,RC,,,,both,,,4134.19,2687.22,,,,,,,,,,,,,
COIL EMB 3MMX4CM MIC NEUROVASC XSFT MIC NEUROVASC GALAXY G3,SUP-2249164,CDM,C1889,HCPCS,0278,RC,,,,both,,,7481.58,4863.03,,,,,,,,,,,,,
COVER IMPL LCK 6-7 MM CERV NO PROF SHORELINE ACS,SUP-2245866,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
HC Dialysis Circuit Embolj,PX-3613690900,CDM,36909,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
PUMP PAIN 400ML FLO RATE 2-14ML/HR SEL A FLO ON-Q,SUP-2236812,CDM,C9804,HCPCS,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
HC Clsd Tx Hip Dislo Postarth,PX-4502726500,CDM,27265,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
KIT INTRO INTRACLUDE DIA19 FR HEMOSTATIC STRL,SUP-2214548,CDM,C1894,HCPCS,0272,RC,,,,both,,,1624.95,1056.22,,,,,,,,,,,,,
MESH HERN SM W6XL7CM PTFE FOR REP OF HIATAL PARAESOPHAGEAL,SUP-2126071,CDM,C1781,HCPCS,0278,RC,,,,both,,,817.44,531.34,,,,,,,,,,,,,
TRAY CHST TB 28FR L41CM 4 SIDEPRT THAL QUIK W/ 80CM GWIRE,SUP-2167997,CDM,C1729,HCPCS,0272,RC,,,,both,,,725.65,471.67,,,,,,,,,,,,,
PLATE BNE TIB 3.5X216 MM RT MEDL DSTL PERI ARTC 14 HOLE SS,SUP-2422117,CDM,C1713,HCPCS,0278,RC,,,,both,,,2463.17,1601.06,,,,,,,,,,,,,
TRIAL PLATE HK 1.3 MM ROLANDO FRAC,SUP-2525718,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % PO SOLN,RX-9828,CDM,Q9963,HCPCS,0636,RC,00270-0445-35,NDC,,both,5,ML,2.30,1.49,,,,,,,,,,,,,
Mastectomy Partial W/Axillary Lymphadenectomy,CASE-19302,LOCAL,19302,CPT,,,,,,outpatient,,,47697.25,28618.35,,,,,,,,,,,,,
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE|PO,CASE-24073,LOCAL,24073,CPT,0360,RC,,,LT|PO,outpatient,,,15900.18,9540.11,,,,,,,,,,,,,
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, FOURTH DIGIT|PO",CASE-26080,LOCAL,26080,CPT,0360,RC,,,F3|PO,outpatient,,,14915.00,8949.00,,,,,,,,,,,,,
Removal Implant Deep,CASE-20680,LOCAL,20680,CPT,0360,RC,,,,outpatient,,,22707.67,13624.60,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE|PO,CASE-29826,LOCAL,29826,CPT,,,,,LT|PO,outpatient,,,55425.58,33255.35,,,,,,,,,,,,,
Trluml Balo Angiop Ctr Dialysis Seg W/Img S&I,CASE-36907,LOCAL,36907,CPT,,,,,,outpatient,,,35016.12,21009.67,,,,,,,,,,,,,
Debridement Bone Each Additional 20 Sq Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-11047,LOCAL,11047,CPT,,,,,XU,outpatient,,,29271.23,17562.74,,,,,,,,,,,,,
Dstrj Lesion Anus Simple Laser Surg,CASE-46917,LOCAL,46917,CPT,0360,RC,,,,outpatient,,,25809.12,15485.47,,,,,,,,,,,,,
Surg Tx Anal Fistula Intersphincteric,CASE-46275,LOCAL,46275,CPT,,,,,,outpatient,,,18372.90,11023.74,,,,,,,,,,,,,
CROWN REFIL 1ST M 41104108 D-UR-3,SUP-2322185,CDM,D6783,CPT,0278,RC,,,,both,,,33.60,21.84,,,,,,,,,,,,,
CEMENT FLX FEM/CEM TIB/PRLNGSURF/STD PAT/TAPER PLUG,SUP-2212157,CDM,C1776,CPT,0278,RC,,,,both,,,15219.52,9892.69,,,,,,,,,,,,,
POWDER MED TALCUM FOR TREAT OF MALIG PLEUR EFFUS,SUP-2138763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,613.87,399.02,,,,,,,,,,,,,
PLATE BONE MED RIGHT F/METATARSOPHALANGEAL FUSION JOINT,SUP-2586521,CDM,C1713,HCPCS,0278,RC,,,,both,,,6388.90,4152.78,,,,,,,,,,,,,
KIT PARACENT 8FR L5IN POLYUR 18GAX7.5IN RND WALL NDL 3 W,SUP-2383253,CDM,C1729,HCPCS,0272,RC,,,,both,,,256.44,166.69,,,,,,,,,,,,,
PROBE OPHTH LASER FLEX NIT TAPR TIP ILLUMINATED MIDFIELD LT,SUP-2129228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.99,284.04,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 26-50 MMX0.3 CM FD,SUP-2717847,CDM,C1762,CPT,0278,RC,,,,both,,,3515.67,2285.19,,,,,,,,,,,,,
GUIDEWIRE VASC SPYGLS DISCOVER JAGWIRE L 180 CM TIP L 5 CM,SUP-2754406,CDM,C1769,HCPCS,0272,RC,,,,both,,,404.28,262.78,,,,,,,,,,,,,
PLATE BNE ORBIT FLR SM 1.5X0.4 MM RT SMRT 3D TI STRL LEVEL 1,SUP-2518088,CDM,C1713,HCPCS,0278,RC,,,,both,,,3735.00,2427.75,,,,,,,,,,,,,
CATHETER CV KT 5 FRX16 CM 16 GA JUG PUNC SPRING WIRE GUIDE,SUP-2763319,CDM,C1751,HCPCS,0278,RC,,,,both,,,57.78,37.56,,,,,,,,,,,,,
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE|PO,CASE-29891,LOCAL,29891,CPT,0360,RC,,,RT|PO,outpatient,,,61983.88,37190.33,,,,,,,,,,,,,
Excision Malignant Lesion F/E/E/N/L >4.0 Cm,CASE-11646,LOCAL,11646,CPT,,,,,,outpatient,,,18469.32,11081.59,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,LOCAL,26055,CPT,,,,,F6,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|RIGHT SIDE|PO,CASE-27675,LOCAL,27675,CPT,0360,RC,,,RT|PO,outpatient,,,38224.85,22934.91,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT HAND, FOURTH DIGIT",CASE-28285,LOCAL,28285,CPT,0360,RC,,,F8,outpatient,,,32022.20,19213.32,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|LEFT HAND, FIFTH DIGIT|PO",CASE-26440,LOCAL,26440,CPT,0360,RC,,,F4|PO,outpatient,,,10585.43,6351.26,,,,,,,,,,,,,
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28645,LOCAL,28645,CPT,0360,RC,,,T8|PO,outpatient,,,60113.25,36067.95,,,,,,,,,,,,,
Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins|LEFT SIDE|PO,CASE-25320,LOCAL,25320,CPT,0360,RC,,,LT|PO,outpatient,,,39268.60,23561.16,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE|PO,CASE-25111,LOCAL,25111,CPT,,,,,RT|PO,outpatient,,,13785.72,8271.43,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,LOCAL,52287,CPT,0360,RC,,,XU,outpatient,,,25913.65,15548.19,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,LOCAL,52353,CPT,0360,RC,,,LT,outpatient,,,24393.20,14635.92,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-38792,LOCAL,38792,CPT,0361,RC,,,XU|LT,outpatient,,,47436.78,28462.07,,,,,,,,,,,,,
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB|PO",CASE-64831,LOCAL,64831,CPT,0360,RC,,,F5|PO,outpatient,,,18985.28,11391.17,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28820,LOCAL,28820,CPT,0360,RC,,,T5,outpatient,,,17197.70,10318.62,,,,,,,,,,,,,
ACCESS KIT 20 GAX0.018 IN AXERA RX,SUP-2424407,CDM,C1769,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
EVOS LG TGTR 3.7MM R DRL,SUP-2931387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1549.59,1007.23,,,,,,,,,,,,,
PLATE BNE 3X8 H TI T SHP ADPT DYN COMPR FOR 1.3MM SCR,SUP-2190692,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.40,726.31,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00264-1510-32,NDC,,both,100,ML,21.30,13.84,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA5MM THRD L40MM HALF,SUP-2197300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
NAIL TIBIAL -ADVANCED 9MMX 345MM ST,SUP-2718104,CDM,C1713,HCPCS,0278,RC,,,,both,,,4336.47,2818.71,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 4.5-6.5 MM EPTFE TAPR STD WALL,SUP-2396445,CDM,C1768,CPT,0278,RC,,,,both,,,1890.28,1228.68,,,,,,,,,,,,,
BIT REPROC DRL REPROC 3/32 0.093X5 IN HI PERF TIP GRY,SUP-2538337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.87,296.97,,,,,,,,,,,,,
INBONE  POLY SZ 1 16MM SULCUS TOTAL ANKLE,SUP-2459939,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
INSERT TIB XL THK11MM AP58MM ML82MM UNIV CNDYL KNEE NEUT,SUP-2377420,CDM,C1776,CPT,0278,RC,,,,both,,,2526.76,1642.39,,,,,,,,,,,,,
PLATE BNE L100MM 6 H ST ANT ANK S STL LOK COMPR FOR ARTH,SUP-2177142,CDM,C1713,HCPCS,0278,RC,,,,both,,,4399.61,2859.75,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY L20CM OD18G 5X10 PREWAXED SEED,SUP-2129061,CDM,C1715,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
EXPANDER TISS NACL 6.7 CM PROJCT 13X11 CM 400 CC SHT HT STRL,SUP-2873911,CDM,C1889,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
Repair Primary Open/Prq Ruptured Achilles Tendon|PO,CASE-27650,LOCAL,27650,CPT,0360,RC,,,PO,outpatient,,,19709.95,11825.97,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,LOCAL,G0260,CPT,0360,RC,,,LT,outpatient,,,4422.92,2653.75,,,,,,,,,,,,,
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl,CASE-37232,LOCAL,37232,CPT,0360,RC,,,,outpatient,,,124503.83,74702.30,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE|PO,CASE-23515,LOCAL,23515,CPT,,,,,RT|PO,outpatient,,,38878.82,23327.29,,,,,,,,,,,,,
Open Treatment Calcaneal Fracture|RIGHT SIDE|PO,CASE-28415,LOCAL,28415,CPT,0360,RC,,,RT|PO,outpatient,,,35375.77,21225.46,,,,,,,,,,,,,
"Tenolysis Extensor Tendon Hand/Finger Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26445,LOCAL,26445,CPT,0360,RC,,,F7|PO,outpatient,,,15631.72,9379.03,,,,,,,,,,,,,
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE|PO,CASE-64405,LOCAL,64405,CPT,0450,RC,,,RT|PO,outpatient,,,3549.32,2129.59,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE|PO,CASE-27427,LOCAL,27427,CPT,0360,RC,,,RT|PO,outpatient,,,41942.65,25165.59,,,,,,,,,,,,,
HC >= 12 Lead Ekg,CASE-93005,LOCAL,93005,CPT,0730,RC,,,,outpatient,,,44595.73,26757.44,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28289,LOCAL,28289,CPT,,,,,T5|PO,outpatient,,,21771.18,13062.71,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,LOCAL,52332,CPT,,,,,LT|XU,outpatient,,,21644.35,12986.61,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE,CASE-29825,LOCAL,29825,CPT,,,,,RT,outpatient,,,48673.63,29204.18,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj 1st Metar|SEPARATE STRUCTURE|LEFT SIDE,CASE-28306,LOCAL,28306,CPT,,,,,XS|LT,outpatient,,,119772.13,71863.28,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,LOCAL,49651,CPT,0360,RC,,,LT,outpatient,,,39248.22,23548.93,,,,,,,,,,,,,
"Ostc Prtl Exostc/Condylc Metar Head|LEFT FOOT, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28288,LOCAL,28288,CPT,,,,,T1|XU,outpatient,,,22918.45,13751.07,,,,,,,,,,,,,
HC Carotid Stent W Eps,PX-3613721500,CDM,37215,CPT,0361,RC,,,,both,,,3458.00,2247.70,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM SNAP OFF FOR FRAC REP AND FIX,SUP-2175086,CDM,C1713,HCPCS,0278,RC,,,,both,,,1201.05,780.68,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ILIUM BICORT STRP ASEP 22MML 55CM,SUP-2307123,CDM,C1713,HCPCS,0278,RC,,,,both,,,2930.50,1904.82,,,,,,,,,,,,,
INSERT TIB TOT STBL 11/9 STD 10 MM FEM ARTC KNEE CONSTRN FLX,SUP-2378401,CDM,C1776,CPT,0278,RC,,,,both,,,4587.54,2981.90,,,,,,,,,,,,,
ALLOGRAFT BNE PROX FEM 10 CM FRZN LT W/O HD,SUP-2717958,CDM,C1762,CPT,0278,RC,,,,both,,,9985.20,6490.38,,,,,,,,,,,,,
BUR SURG ACROMIONIZER 5.5X130 MM W/ LAT PROTCT VIO STRL DISP,SUP-2599846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.07,252.25,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 7.5X170-225 MM POST TEND FLEXIGRAFT,SUP-2740867,CDM,C1762,CPT,0278,RC,,,,both,,,3632.82,2361.33,,,,,,,,,,,,,
DILATOR ENDOSCP DIA11 13MM BLLN L80MM ES FIX WIRE BLLN DISPO,SUP-2436491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,756.74,491.88,,,,,,,,,,,,,
ACETAMINOPHEN 120 MG RE SUPP,RX-103,CDM,6370000000,HCPCS,0637,RC,51672-2115-00,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
DEVICE FIX MOTORIZED PUSH BTTN FIRING MECHANISM TACK INLINE,SUP-2902724,CDM,C1713,HCPCS,0278,RC,,,,both,,,3258.22,2117.84,,,,,,,,,,,,,
TI LCP PROX LATERAL TIBIA PL 11 HOLES/260MM/LEFT-STERILE,SUP-2549444,CDM,C1713,HCPCS,0278,RC,,,,both,,,4886.88,3176.47,,,,,,,,,,,,,
BLADE SURG BABY SZ SGL USE THROW-AWAY OMNI-TRACT,SUP-2243523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,105.19,68.37,,,,,,,,,,,,,
SPACER ANTR CERV 14X17X8MM 5 DEG PEEK,SUP-2211542,CDM,C1821,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
ROD SPNL TRNS 3.5-5.5X400 MM C-T TI INVICTUS,SUP-2553928,CDM,C1713,HCPCS,0278,RC,,,,both,,,1406.72,914.37,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X4.75 MM MCGEE SS,SUP-2637764,CDM,L8613,CPT,0278,RC,,,,both,,,262.79,170.81,,,,,,,,,,,,,
LENS INTOCU +1.0 DIOPT L13MM DIA6MM 5DEG HAPTIC ANG POST,SUP-2110618,CDM,V2632,HCPCS,0276,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
BUR SURG MED 9.9 MM COR TOOL FOR HD-G1,SUP-2848303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1066.78,693.41,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FOURTH DIGIT|PO",CASE-28232,LOCAL,28232,CPT,0360,RC,,,T3|PO,outpatient,,,21238.90,12743.34,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THIRD DIGIT|PO",CASE-26860,LOCAL,26860,CPT,0360,RC,,,F2|PO,outpatient,,,28192.65,16915.59,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, THIRD DIGIT|PO",CASE-28270,LOCAL,28270,CPT,0360,RC,,,XS|T2|PO,outpatient,,,27333.98,16400.39,,,,,,,,,,,,,
Open Treatment Calcaneal Fracture|RIGHT SIDE|PO,CASE-28415,LOCAL,28415,CPT,,,,,RT|PO,outpatient,,,35375.77,21225.46,,,,,,,,,,,,,
Transurethral Waterjet Ablation Prostate Compl,CASE-0421T,LOCAL,0421T,CPT,,,,,,outpatient,,,42803.42,25682.05,,,,,,,,,,,,,
Blepharoplasty Lower Eyelid|BILATERAL PROCEDURE,CASE-15820,LOCAL,15820,CPT,0360,RC,,,50,outpatient,,,36231.00,21738.60,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-29827,LOCAL,29827,CPT,0360,RC,,,73,outpatient,,,17170.50,10302.30,,,,,,,,,,,,,
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, SECOND DIGIT|PO",CASE-26080,LOCAL,26080,CPT,,,,,F6|PO,outpatient,,,16814.63,10088.78,,,,,,,,,,,,,
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36247,LOCAL,36247,CPT,0361,RC,,,LT|XU,outpatient,,,33843.90,20306.34,,,,,,,,,,,,,
Blepharoplasty Lower Eyelid Herniated Fat Pad|BILATERAL PROCEDURE|PO,CASE-15821,LOCAL,15821,CPT,,,,,50|PO,outpatient,,,43856.37,26313.82,,,,,,,,,,,,,
Laparoscopy Surgical Jejunostomy,CASE-44186,LOCAL,44186,CPT,,,,,,outpatient,,,53552.30,32131.38,,,,,,,,,,,,,
BUR SURG 2 FLUT 3 MM CYL UPWR,SUP-2166784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
TIOTROPIUM BROMIDE 2.5 MCG/ACT IN AERS,RX-173421,CDM,6370000000,HCPCS,0637,RC,00597-0100-51,NDC,,both,4,GR,337.50,219.37,,,,,,,,,,,,,
SPHERE GLEN +3 MM 42 MM SHLDR REVERSED LAT AEQUALIS PERFORMA,SUP-2421800,CDM,C1776,CPT,0278,RC,,,,both,,,8437.02,5484.06,,,,,,,,,,,,,
INSERT ACET OD44MM ID22MM 20DEG UHMWPE HIP COMP SER I OMFIT,SUP-2369977,CDM,C1776,CPT,0278,RC,,,,both,,,884.91,575.19,,,,,,,,,,,,,
HEAD FEM REV MTL ON POLY CO CHROM 32MM DIA +16 NK LEN LFIT,SUP-2364463,CDM,C1776,CPT,0278,RC,,,,both,,,1170.59,760.88,,,,,,,,,,,,,
THE CROSSROADS SCR SYS IS INDICATED FOR FRAC REP AND FIX,SUP-2175127,CDM,C1776,CPT,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
STEM FEM SZ 5 SH TAPR HIP TI POR PLSM SPRY HI OFFSET,SUP-2349070,CDM,C1776,CPT,0278,RC,,,,both,,,13784.60,8959.99,,,,,,,,,,,,,
PLATE BONE W15XL120MM THK2MM 5 H BILAT TI THN BLDE RIG,SUP-2190983,CDM,C1713,HCPCS,0278,RC,,,,both,,,1346.78,875.41,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 0.035 INX260 CM STD NIT GLIDEWIRE,SUP-2385574,CDM,C1769,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
Syndactylization Toes|RIGHT SIDE|PO,CASE-28280,LOCAL,28280,CPT,0360,RC,,,RT|PO,outpatient,,,42596.50,25557.90,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE|PO,CASE-64635,LOCAL,64635,CPT,0360,RC,,,RT|PO,outpatient,,,11960.10,7176.06,,,,,,,,,,,,,
Thorcoscpy W/Mediastinl & Regionl Lymphdenectomy,CASE-32674,LOCAL,32674,CPT,,,,,,outpatient,,,96443.17,57865.90,,,,,,,,,,,,,
Brnchsc Brushing/Protected Brushings,CASE-31623,LOCAL,31623,CPT,0360,RC,,,,outpatient,,,22274.95,13364.97,,,,,,,,,,,,,
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,LOCAL,64585,CPT,0360,RC,,,,outpatient,,,14001.53,8400.92,,,,,,,,,,,,,
Unlisted Procedure Arthroscopy,CASE-29999,LOCAL,29999,CPT,0360,RC,,,,outpatient,,,48468.53,29081.12,,,,,,,,,,,,,
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,LOCAL,43253,CPT,,,,,,outpatient,,,37023.45,22214.07,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE|PO,CASE-29879,LOCAL,29879,CPT,,,,,RT|PO,outpatient,,,28355.38,17013.23,,,,,,,,,,,,,
Revj/Rmvl Prosthetic Vaginal Graft Vaginal App,CASE-57295,LOCAL,57295,CPT,0360,RC,,,,outpatient,,,32711.57,19626.94,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT|PO",CASE-26727,LOCAL,26727,CPT,,,,,F4|PO,outpatient,,,6212.92,3727.75,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, THIRD DIGIT",CASE-28308,LOCAL,28308,CPT,,,,,T2,outpatient,,,19207.23,11524.34,,,,,,,,,,,,,
Open Tx Fracture Phalanx/Phalanges Not Great Toe,CASE-28525,LOCAL,28525,CPT,0360,RC,,,,outpatient,,,15785.70,9471.42,,,,,,,,,,,,,
COIL EMB L13CM OD0.020IN LOOP OD5MM NIT STRTCH RESIST FILL,SUP-2323397,CDM,C1889,HCPCS,0278,RC,,,,both,,,7165.48,4657.56,,,,,,,,,,,,,
PORT MRI PLAS HRD BASE SGL LUMN 96FR PRE ATTCH OPN END SIL,SUP-2126592,CDM,C1788,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
NAIL IM L200MM DIA13MM SHT FEM TIB KNEE G TI CANN LOK RG,SUP-2347111,CDM,C1713,HCPCS,0278,RC,,,,both,,,12716.22,8265.54,,,,,,,,,,,,,
MIS LOCK CALC PLT SM RT,SUP-2586883,CDM,C1713,HCPCS,0278,RC,,,,both,,,2062.01,1340.31,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 23 CM DIA 8 FR DIL DIA 5.8 FR,SUP-2357111,CDM,C1894,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
SCREW BNE L 32 MM DIA2 MM NANO HDLSS COMPR NS ACUTRK 3,SUP-2912746,CDM,C1713,HCPCS,0278,RC,,,,both,,,3004.98,1953.24,,,,,,,,,,,,,
TI LCP VOLR CLMN DSTL RADIUS PL 7H HEAD/4H SHAFT/LT-STERILE,SUP-2546661,CDM,C1713,HCPCS,0278,RC,,,,both,,,3071.77,1996.65,,,,,,,,,,,,,
HC Comprehensive Metabolic Panel|REPEAT CLINICAL DIAGNOSTIC LABORATORY TEST|ADJ,PX-3018005300,CDM,80053,CPT,0301,RC,,,91|ADJ,both,,,380.00,247.00,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC BALL NOSE 8 CM DISP,SUP-2252857,CDM,C1769,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.018IN TIP L3CM STD PERIPH SUP E,SUP-2385100,CDM,C1769,HCPCS,0272,RC,,,,both,,,255.50,166.07,,,,,,,,,,,,,
CATHETER PAIN PMP 25 CM 5 CC T PEEL NDL ON-Q SILVERSOAKER,SUP-2424454,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT BNE GEL 10 CC SYR DBM DYNAGRAFT II,SUP-2641740,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ROD SPNL L36MM OD5.5MM POST LORDOSED LEV 2 TRANSITION,SUP-2230036,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
WASHER ORTHOPEDIC DIA 9.5 MM NS LF DISP ADVANTAGERIB,SUP-2908965,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
MARKER RADIOGRAPHIC MAXFRAME,SUP-2255817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.73,1502.62,,,,,,,,,,,,,
PLATE BNE T 3.5X78X1.2 MM 4X6 HOLE FOR SCR SM FRAG SYS SS NS,SUP-2470183,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.34,275.82,,,,,,,,,,,,,
NEEDLE BX ECHOGENIC TIP 18 GAX25 CM SAMPLE NOTCH TRU-CORE II,SUP-2876677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE,CASE-19120,LOCAL,19120,CPT,,,,,RT,outpatient,,,16668.48,10001.09,,,,,,,,,,,,,
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>|RIGHT SIDE|PO,CASE-25071,LOCAL,25071,CPT,0360,RC,,,RT|PO,outpatient,,,11090.38,6654.23,,,,,,,,,,,,,
Suture Infrapatellar Tendon Primary|RIGHT SIDE|PO,CASE-27380,LOCAL,27380,CPT,,,,,RT|PO,outpatient,,,40396.35,24237.81,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO,CASE-62323,LOCAL,62323,CPT,0360,RC,,,PO,outpatient,,,4115.68,2469.41,,,,,,,,,,,,,
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|LEFT FOOT, SECOND DIGIT|PO",CASE-28313,LOCAL,28313,CPT,0360,RC,,,T1|PO,outpatient,,,14876.03,8925.62,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB|PO",CASE-26540,LOCAL,26540,CPT,,,,,F5|PO,outpatient,,,18309.60,10985.76,,,,,,,,,,,,,
Claviculectomy Partial|RIGHT SIDE|PO,CASE-23120,LOCAL,23120,CPT,0360,RC,,,RT|PO,outpatient,,,38318.80,22991.28,,,,,,,,,,,,,
Removal Implant Deep|SEPARATE STRUCTURE,CASE-20680,LOCAL,20680,CPT,0360,RC,,,XS,outpatient,,,25125.32,15075.19,,,,,,,,,,,,,
Rpr Nonunion/Malunion Radius/Ulna W/Autograft|LEFT SIDE|PO,CASE-25405,LOCAL,25405,CPT,0360,RC,,,LT|PO,outpatient,,,30707.65,18424.59,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, THIRD DIGIT|PO",CASE-26123,LOCAL,26123,CPT,,,,,F7|PO,outpatient,,,13286.83,7972.10,,,,,,,,,,,,,
Cysto impl 4 or more,CASE-C9740,LOCAL,C9740,CPT,0360,RC,,,,outpatient,,,39779.78,23867.87,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27601,LOCAL,27601,CPT,,,,,LT|PO|CG,outpatient,,,25385.63,15231.38,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE,CASE-27691,LOCAL,27691,CPT,,,,,LT,outpatient,,,23360.38,14016.23,,,,,,,,,,,,,
"Arthrodesis Great Toe Interphalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28755,LOCAL,28755,CPT,0360,RC,,,TA|PO,outpatient,,,16439.88,9863.93,,,,,,,,,,,,,
STAPLE BNE FIX W20XL20MM LEG L20MM SPD TI DRL BIT KT WIRE,SUP-2194273,CDM,C1713,HCPCS,0278,RC,,,,both,,,3983.75,2589.44,,,,,,,,,,,,,
PIN FIX FOR ZEPHIR ANT CERV PLATING SYS,SUP-2291191,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.88,131.87,,,,,,,,,,,,,
STAPLE INT W9XH7MM WIRE OD1.5X1.5MM HND WRST COMPR,SUP-2194248,CDM,C1713,HCPCS,0278,RC,,,,both,,,2301.49,1495.97,,,,,,,,,,,,,
SCREW BNE 16 MM TIP 2-3/4 IN DISTRCTN FOR RUGGLES REDMOND NS,SUP-2460932,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR W48XH53CM D11MM RECHRG PROTG MRI IPG,SUP-2356757,CDM,C1820,HCPCS,0278,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
PROBE TEMP TRPL LUMEN COMPLETE BRAIN PRB KT W/ TEMP PRB,SUP-2666700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.02,394.56,,,,,,,,,,,,,
PLATE BONE L75MM CRANIOMAXILLOFACIAL MAND MOD 3 DIM MCS LUHR,SUP-2364676,CDM,C1713,HCPCS,0278,RC,,,,both,,,1172.82,762.33,,,,,,,,,,,,,
INTRODUCER ENDO 17GA CVD,SUP-2362639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BASKET STONE STR 1.9 FR 12 MMX120 CM 4 WIR W/O TIP NIT STRL,SUP-2767534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1260.46,819.30,,,,,,,,,,,,,
SUPPORT WRST PUL LACE CLOSURE UNIV LT PROCARE QUICK-FIT,SUP-2195780,CDM,L3931,HCPCS,0272,RC,,,,both,,,34.32,22.31,,,,,,,,,,,,,
GRAFT VASC GELSFT L 15 CM DIA10 MM POLYESTER GEL ABD PERIPH,SUP-2384930,CDM,C1768,CPT,0278,RC,,,,both,,,751.25,488.31,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.404,SUP-2859968,CDM,C1713,HCPCS,0278,RC,,,,both,,,30903.88,20087.52,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|PO,CASE-27695,LOCAL,27695,CPT,0360,RC,,,LT|PO,outpatient,,,41161.53,24696.92,,,,,,,,,,,,,
Bx Prostate Strtctc Saturation Sampling Img Gid,CASE-55706,LOCAL,55706,CPT,0360,RC,,,,outpatient,,,13079.40,7847.64,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L >4.0 Cm,CASE-11406,LOCAL,11406,CPT,0360,RC,,,,outpatient,,,16509.78,9905.87,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,LOCAL,52332,CPT,0360,RC,,,50|XU,outpatient,,,23949.20,14369.52,,,,,,,,,,,,,
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE,CASE-28120,LOCAL,28120,CPT,0360,RC,,,RT,outpatient,,,33279.22,19967.53,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,LOCAL,64493,CPT,,,,,50,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Fasciotomy Foot&/Toe|RIGHT SIDE|PO,CASE-28008,LOCAL,28008,CPT,,,,,RT|PO,outpatient,,,10617.18,6370.31,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,LOCAL,23430,CPT,,,,,LT,outpatient,,,30594.10,18356.46,,,,,,,,,,,,,
Proctosgmdsc Rgd Dx W/WO Collj Spec Br/Wa Spx,CASE-45300,LOCAL,45300,CPT,0360,RC,,,,outpatient,,,12411.63,7446.98,,,,,,,,,,,,,
Open Treatment Calcaneal Fracture|LEFT SIDE,CASE-28415,LOCAL,28415,CPT,,,,,LT,outpatient,,,36105.75,21663.45,,,,,,,,,,,,,
Grafting of Autologous Fat by Lipo 25 Cc or Less|PO,CASE-15773,LOCAL,15773,CPT,,,,,PO,outpatient,,,39270.40,23562.24,,,,,,,,,,,,,
BUR SURG DIAMOND 1.3 MM FOR STAP NS REUSE,SUP-2638252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.26,221.82,,,,,,,,,,,,,
BIT DRL DIA3.5MM QUIK CONN FOR PERI-LOC PERIARTC LOCKED,SUP-2343999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1245.73,809.72,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X300 MM FOR CANN SCREW NS 03333015,SUP-2789107,CDM,C1769,HCPCS,0272,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
SCREW BNE HD 2X10 MM DART-FIRE,SUP-2399800,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
TRAY PICC 6FR POLYUR TRIM LEN DBL LUMN PWR INJ PASV VLV CT,SUP-2126393,CDM,C1751,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
INTRODUCER SHTH 10.5FR L12CM 0.038IN L50CM L LUMN HEMSTAS,SUP-2355412,CDM,C1894,HCPCS,0272,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
RING 5/8 160MM FOR TRUELOK FIX SYS,SUP-2316184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1982.85,1288.85,,,,,,,,,,,,,
STENT GRFT VASC AFX L 80 MM UNCOVERED L 20 MM DIA,SUP-2217613,CDM,C1768,CPT,0278,RC,,,,both,,,15558.70,10113.15,,,,,,,,,,,,,
HC Remove Aortic Assist Device,PX-3603396800,CDM,33968,CPT,0360,RC,,,,inpatient,,,5920.00,3848.00,,,,,,,,,,,,,
"RABIES VACCINE, PCEC IM SUSR",RX-22120,CDM,90675,HCPCS,0636,RC,50632-0010-01,NDC,,both,1,UN,1955.80,1271.27,,,,,,,,,,,,,
PLATE BONE L215MM 16 H NONSTERILE RT PROX TIB S STL LO PROF,SUP-2185821,CDM,C1713,HCPCS,0278,RC,,,,both,,,4008.71,2605.66,,,,,,,,,,,,,
PLATE BNE L25MM THK3.3MM 2 H BILAT S STL RIG STR DYN COMPR,SUP-2186326,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.13,268.53,,,,,,,,,,,,,
GRAFTON MTRX 2.5CMX10CM 2 EA,SUP-2307031,CDM,C1713,HCPCS,0278,RC,,,,both,,,3951.69,2568.60,,,,,,,,,,,,,
NEEDLE ASPIR 19GA L80MM WRK L1400MM INSRT PORTION DIA185MM,SUP-2313397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,683.83,444.49,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 56 MM DIA14 MM SHTH 16 FR SS,SUP-2170643,CDM,C1768,CPT,0278,RC,,,,both,,,9686.90,6296.48,,,,,,,,,,,,,
NARROW PLT STERILIZER 4.5X87 MM 5 HL,SUP-2818127,CDM,C1713,HCPCS,0278,RC,,,,both,,,1123.90,730.53,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,LOCAL,38510,CPT,,,,,LT,outpatient,,,38020.08,22812.05,,,,,,,,,,,,,
Chemodenervation Internal Anal Sphincter,CASE-46505,LOCAL,46505,CPT,0360,RC,,,,outpatient,,,15789.58,9473.75,,,,,,,,,,,,,
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE|PO,CASE-27822,LOCAL,27822,CPT,,,,,LT|PO,outpatient,,,41260.75,24756.45,,,,,,,,,,,,,
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|BILATERAL PROCEDURE,CASE-38570,LOCAL,38570,CPT,,,,,50,outpatient,,,64971.32,38982.79,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only,CASE-27601,LOCAL,27601,CPT,,,,,,outpatient,,,34921.98,20953.19,,,,,,,,,,,,,
Tenolysis Extensor Tendon Hand/Finger Each,CASE-26445,LOCAL,26445,CPT,0360,RC,,,,outpatient,,,13068.78,7841.27,,,,,,,,,,,,,
Revasc lithotrip tibi/perone|LEFT SIDE,CASE-C9772,LOCAL,C9772,CPT,,,,,LT,outpatient,,,71722.93,43033.76,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE|PO,CASE-29879,LOCAL,29879,CPT,0360,RC,,,RT|PO,outpatient,,,28355.38,17013.23,,,,,,,,,,,,,
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,LOCAL,58552,CPT,,,,,,outpatient,,,32085.30,19251.18,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE,CASE-27524,LOCAL,27524,CPT,,,,,RT,outpatient,,,31014.30,18608.58,,,,,,,,,,,,,
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE,CASE-28740,LOCAL,28740,CPT,,,,,LT,outpatient,,,65701.70,39421.02,,,,,,,,,,,,,
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>|RIGHT SIDE|PO,CASE-25071,LOCAL,25071,CPT,,,,,RT|PO,outpatient,,,11090.38,6654.23,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,LOCAL,28825,CPT,0360,RC,,,T1,outpatient,,,12560.27,7536.16,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|BILATERAL PROCEDURE|PO,CASE-28308,LOCAL,28308,CPT,,,,,50|PO,outpatient,,,21352.17,12811.30,,,,,,,,,,,,,
Excision/Curettage Cyst/Tumor Femur|RIGHT SIDE,CASE-27355,LOCAL,27355,CPT,0360,RC,,,RT,outpatient,,,33172.63,19903.58,,,,,,,,,,,,,
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, THIRD DIGIT|PO",CASE-26531,LOCAL,26531,CPT,0360,RC,,,F2|PO,outpatient,,,19127.25,11476.35,,,,,,,,,,,,,
CATHETER EP L115CM OD7FR SPC 2-8-2MM BLU D CRV DECAPOLAR,SUP-2248704,CDM,C1732,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
DRILL TWST L50MM OD1.5MM W/ STP NONRADIOLUCENT,SUP-2361103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
KIT INTRO ARW FLX SHTH L 10 CM DIA 8.5 FR GUIDEWIRE 0.035 IN,SUP-2763400,CDM,C1892,HCPCS,0272,RC,,,,both,,,224.82,146.13,,,,,,,,,,,,,
WASHER ORTHOPEDIC SPIKE NONSTERILE LATEX GRIDLOCK,SUP-2880180,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PROSTHESIS OSS 2 MM 4X3.25 MM 1.45 MM DORNHOFFER PART HA TI,SUP-2469813,CDM,L8613,CPT,0278,RC,,,,both,,,1293.65,840.87,,,,,,,,,,,,,
STAPLER INT CIR EXTRA THICK 28 MM W/ TRI-STAPLE LF,SUP-2787716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3427.15,2227.65,,,,,,,,,,,,,
PLATE BONE L49MM 6 H S STL QTR TBLR ECT,SUP-2198592,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.45,104.29,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 200 CM BALLOON L 150 MM DIA 5 MM SHTH,SUP-2890494,CDM,C1725,HCPCS,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
HC Revasc Intra Lithotrip-Ather,CASE-C9766,LOCAL,C9766,CPT,0481,RC,,,,outpatient,,,109921.02,65952.61,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,LOCAL,62323,CPT,,,,,,outpatient,,,3968.35,2381.01,,,,,,,,,,,,,
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,LOCAL,43237,CPT,,,,,,outpatient,,,14313.12,8587.87,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvic/Le 1st Ord|LEFT SIDE,CASE-36245,LOCAL,36245,CPT,0361,RC,,,LT,outpatient,,,29879.18,17927.51,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27601,LOCAL,27601,CPT,0360,RC,,,LT|PO|CG,outpatient,,,25385.63,15231.38,,,,,,,,,,,,,
HC Hdr Vaginal Cyl Insertion,CASE-57156,LOCAL,57156,CPT,0333,RC,,,,outpatient,,,36237.50,21742.50,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,LOCAL,29879,CPT,0360,RC,,,LT,outpatient,,,35525.72,21315.43,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,LOCAL,49505,CPT,0360,RC,,,LT,outpatient,,,29999.58,17999.75,,,,,,,,,,,,,
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, GREAT TOE|PO",CASE-28160,LOCAL,28160,CPT,,,,,T5|PO,outpatient,,,15739.18,9443.51,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB|PO",CASE-26418,LOCAL,26418,CPT,0360,RC,,,FA|PO,outpatient,,,12573.62,7544.17,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FOURTH DIGIT|PO",CASE-26765,LOCAL,26765,CPT,,,,,F3|PO,outpatient,,,24888.02,14932.81,,,,,,,,,,,,,
Tenolysis Extensor Foot Single Tendon,CASE-28225,LOCAL,28225,CPT,0360,RC,,,,outpatient,,,21325.52,12795.31,,,,,,,,,,,,,
"Tenolysis Extensor Tendon Hand/Finger Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26445,LOCAL,26445,CPT,0360,RC,,,F8|PO,outpatient,,,13068.78,7841.27,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, GREAT TOE",CASE-28810,LOCAL,28810,CPT,0360,RC,,,T5,outpatient,,,52733.95,31640.37,,,,,,,,,,,,,
Partial Excision Bone Talus/Calcaneus|LEFT SIDE|PO,CASE-28120,LOCAL,28120,CPT,0360,RC,,,LT|PO,outpatient,,,35935.35,21561.21,,,,,,,,,,,,,
Blepharoplasty Lower Eyelid Herniated Fat Pad|BILATERAL PROCEDURE|PO,CASE-15821,LOCAL,15821,CPT,0360,RC,,,50|PO,outpatient,,,43856.37,26313.82,,,,,,,,,,,,,
Laparoscopy Nephrectomy W/Partial Ureterect,CASE-50546,LOCAL,50546,CPT,,,,,,outpatient,,,97230.95,58338.57,,,,,,,,,,,,,
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,LOCAL,57250,CPT,0360,RC,,,,outpatient,,,51931.27,31158.76,,,,,,,,,,,,,
Syndactylization Toes,CASE-28280,LOCAL,28280,CPT,0360,RC,,,,outpatient,,,21840.08,13104.05,,,,,,,,,,,,,
Arthrt Elbow Capsular Excision Capsular Rls Spx|RIGHT SIDE|PO,CASE-24006,LOCAL,24006,CPT,,,,,RT|PO,outpatient,,,16276.97,9766.18,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 10 CM DIA 7 MM EPTFE CARBON STR,SUP-2761241,CDM,C1768,CPT,0278,RC,,,,both,,,596.35,387.63,,,,,,,,,,,,,
CAGE SPNL VERT BONE REPL CENTERPIECE IMP H40 TO 62MM OD20MM,SUP-2390809,CDM,C1889,HCPCS,0278,RC,,,,both,,,51656.14,33576.49,,,,,,,,,,,,,
SCREW BONE 9X25MM INTRF BIOABSRB STRL ENDO-FIX,SUP-2341349,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM NOM THK2MM MAXFORC EXTRM HUM DERM,SUP-2399139,CDM,Q4107,HCPCS,0636,RC,,,,both,,,9231.60,6000.54,,,,,,,,,,,,,
HC Surgery Level 1 Base,PX-3600000001,CDM,3600000001,LOCAL,0360,RC,,,,both,,,1052.00,683.80,,,,,,,,,,,,,
IMPL NAIL FEMORAL PF LT 13X340MM,SUP-2701287,CDM,C1713,HCPCS,0278,RC,,,,both,,,10746.34,6985.12,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 90 CM SHTH 6 FR GUIDEWIRE,SUP-2155677,CDM,C1887,HCPCS,0272,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26735,LOCAL,26735,CPT,0360,RC,,,F4|PO,outpatient,,,20553.30,12331.98,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node,CASE-38792,LOCAL,38792,CPT,0361,RC,,,,outpatient,,,10382.68,6229.61,,,,,,,,,,,,,
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, FOURTH DIGIT",CASE-28234,LOCAL,28234,CPT,,,,,T3,outpatient,,,11454.52,6872.71,,,,,,,,,,,,,
Anesthesia Combined Upper&Lower GI Endoscopic Px,CASE-00813,LOCAL,00813,CPT,0370,RC,,,,outpatient,,,15300.02,9180.01,,,,,,,,,,,,,
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE,CASE-27339,LOCAL,27339,CPT,,,,,LT,outpatient,,,17545.02,10527.01,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Extensive,CASE-11771,LOCAL,11771,CPT,,,,,,outpatient,,,19303.15,11581.89,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,LOCAL,60220,CPT,0360,RC,,,LT,outpatient,,,45409.38,27245.63,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-28270,LOCAL,28270,CPT,0360,RC,,,XS|TA|PO,outpatient,,,19110.18,11466.11,,,,,,,,,,,,,
Ostectomy Complete 5th Metatarsal Head|LEFT SIDE|PO,CASE-28113,LOCAL,28113,CPT,0360,RC,,,LT|PO,outpatient,,,21781.68,13069.01,,,,,,,,,,,,,
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms,CASE-27696,LOCAL,27696,CPT,,,,,,outpatient,,,48843.65,29306.19,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,LOCAL,52005,CPT,0360,RC,,,50,outpatient,,,16162.92,9697.75,,,,,,,,,,,,,
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,LOCAL,20526,CPT,0510,RC,,,50,outpatient,,,3566.22,2139.73,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-12032,LOCAL,12032,CPT,0450,RC,,,XU,outpatient,,,22455.33,13473.20,,,,,,,,,,,,,
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,LOCAL,30520,CPT,0360,RC,,,,outpatient,,,20894.78,12536.87,,,,,,,,,,,,,
Claviculectomy Partial|LEFT SIDE,CASE-23120,LOCAL,23120,CPT,,,,,LT,outpatient,,,38909.32,23345.59,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, SECOND DIGIT|PO",CASE-26860,LOCAL,26860,CPT,0360,RC,,,F6|PO,outpatient,,,18675.95,11205.57,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|SEPARATE PRACTITIONER,CASE-64415,LOCAL,64415,CPT,0360,RC,,,RT|XP,outpatient,,,40540.52,24324.31,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|PO",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F6|PO,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,LOCAL,64635,CPT,,,,,RT,outpatient,,,12778.57,7667.14,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,LOCAL,52005,CPT,0360,RC,,,XU,outpatient,,,24893.75,14936.25,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|PO,CASE-64634,LOCAL,64634,CPT,,,,,PO,outpatient,,,12094.77,7256.86,,,,,,,,,,,,,
REAMER SURG SZ 22 MM MTP STRL ORTHOLOC 3DI,SUP-2900519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
GRAFT BIO TISS W8XL12CM FET BOV SIL FEN ANTIMIC PRIMATRIX,SUP-2243712,CDM,Q4110,HCPCS,0636,RC,,,,both,,,10399.68,6759.79,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CC FD DBM FIBERFUSE,SUP-2736947,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PIN POS L3.5MM S STL CERCLAGE THRD FOR LOK COMPR PLT,SUP-2187038,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.76,324.19,,,,,,,,,,,,,
DRIVER SURG OD2X35MM HEX ARTC FOR FIX SYS CORETRAK SIDEKCK,SUP-2399886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
CLIP HEMSTAS W16MMXL230CM MIN WRK CHAN 2.8MM REPLAY,SUP-2418595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GRAFT HUM TISS OD43MM FEM HD OSTEOARTC ALLGRFT FRZN,SUP-2264751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3444.11,2238.67,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X65 MM 8 HOLE 1/4 TI,SUP-2536112,CDM,C1713,HCPCS,0278,RC,,,,both,,,446.19,290.02,,,,,,,,,,,,,
RESERVOIR SHUNT 20MM TITANIUM INTEGRATED CATHETER L600MM FLU,SUP-2830493,CDM,C1889,HCPCS,0278,RC,,,,both,,,1314.91,854.69,,,,,,,,,,,,,
SCREW FOR BKWALT RETRCT 50-4637,SUP-2382093,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.32,65.21,,,,,,,,,,,,,
BUR SURG DIAMOND MIC XLN 2 MM HVY GRIT MICROPOWER MIC 100,SUP-2607498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L115CM 7/20FR 6MM,SUP-2248628,CDM,C1732,HCPCS,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
HC Fresh Frozen Plasma Thawing,PX-3008692700,CDM,86927,CPT,0300,RC,,,,outpatient,,,247.00,160.55,,,,,,,,,,,,,
PLATE BNE W7XL47MM THK1MM 6 H BILAT TI 1/4 TBLR RIG,SUP-2191004,CDM,C1713,HCPCS,0278,RC,,,,both,,,1063.02,690.96,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.501,SUP-2860018,CDM,C1713,HCPCS,0278,RC,,,,both,,,33123.86,21530.51,,,,,,,,,,,,,
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,LOCAL,46945,CPT,0360,RC,,,,outpatient,,,20061.38,12036.83,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,LOCAL,52352,CPT,0360,RC,,,RT,outpatient,,,19597.77,11758.66,,,,,,,,,,,,,
Revj Total Knee Arthrp W/WO Algrft 1 Component,CASE-27486,LOCAL,27486,CPT,0360,RC,,,,outpatient,,,35968.07,21580.84,,,,,,,,,,,,,
Arthrotomy W/Meniscus Repair Knee|LEFT SIDE,CASE-27403,LOCAL,27403,CPT,0360,RC,,,LT,outpatient,,,63869.23,38321.54,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|RIGHT SIDE|PO,CASE-11422,LOCAL,11422,CPT,0360,RC,,,RT|PO,outpatient,,,10974.90,6584.94,,,,,,,,,,,,,
SIZER SURG W14XH14.6CM 555ML P5.9CM SIL GEL BRST 332 STYL,SUP-2300828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1X4 MM CRANIOMAXILLOFACIAL EMERGENCY,SUP-2837651,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.01,392.61,,,,,,,,,,,,,
STAPLER INT 60 48MM AUTO SGL USE RELD GIA,SUP-2787663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1250.63,812.91,,,,,,,,,,,,,
PLATE BNE ORBIT RIM 47X40 MM RT SIDE EXTN MEDPOR,SUP-2328473,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
NAIL-EX FEM RECON LAT ENTRY 16X300MM LT TI STRL,SUP-2546287,CDM,C1713,HCPCS,0278,RC,,,,both,,,4288.64,2787.62,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE,CASE-23515,LOCAL,23515,CPT,0360,RC,,,RT,outpatient,,,38268.27,22960.96,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,LOCAL,58662,CPT,0360,RC,,,LT,outpatient,,,45159.50,27095.70,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, THIRD DIGIT|PO",CASE-26860,LOCAL,26860,CPT,,,,,F7|PO,outpatient,,,11771.20,7062.72,,,,,,,,,,,,,
Revsc Opn/Prq Tib/Pero W/Athrc/Angiop Uni Ea Vsl|RIGHT SIDE,CASE-37233,LOCAL,37233,CPT,,,,,RT,outpatient,,,53548.50,32129.10,,,,,,,,,,,,,
Arteriovenous Anastomosis Open Direct,CASE-36821,LOCAL,36821,CPT,0360,RC,,,,outpatient,,,34207.47,20524.48,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,LOCAL,64721,CPT,,,,,LT,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|PO,CASE-64493,LOCAL,64493,CPT,0360,RC,,,PO,outpatient,,,4354.35,2612.61,,,,,,,,,,,,,
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs,CASE-25116,LOCAL,25116,CPT,0360,RC,,,,outpatient,,,31099.67,18659.80,,,,,,,,,,,,,
Revasc lithotrip tibi/perone,CASE-C9772,LOCAL,C9772,CPT,,,,,,outpatient,,,89370.43,53622.26,,,,,,,,,,,,,
Rhinp Prim Lat&Alar Crtlgs&/Elvtn Nasal Ti|BILATERAL PROCEDURE|PO,CASE-30400,LOCAL,30400,CPT,0360,RC,,,50|PO,outpatient,,,64500.27,38700.16,,,,,,,,,,,,,
Sesamoidectomy First Toe Spx|BILATERAL PROCEDURE|PO,CASE-28315,LOCAL,28315,CPT,,,,,50|PO,outpatient,,,26572.58,15943.55,,,,,,,,,,,,,
Rpr Nonunion/Malunion Radius/Ulna W/Autograft,CASE-25405,LOCAL,25405,CPT,0360,RC,,,,outpatient,,,30707.65,18424.59,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 120 CM BA STRP,SUP-2666786,CDM,C1889,HCPCS,0278,RC,,,,both,,,23991.61,15594.55,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN BNE MTRX EXPONENT,SUP-2138518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1707.47,1109.86,,,,,,,,,,,,,
PREPARATION KIT BNE CEMENT SM 14 FR FEM BOWL SPATULA STRL,SUP-2408545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
HC Wedge Excision Skin Nail Fold,PX-4501176500,CDM,11765,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
NEEDLE KYPHOPLASTY 11GA L7.48IN NIT VERTICAL AUG CRV TIP W/,SUP-2367079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1779.16,1156.45,,,,,,,,,,,,,
BIT DRL L279MM DIA3.5MM LNG HIP GRAD BRAD PNT,SUP-2347931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.88,239.12,,,,,,,,,,,,,
HC I & D Simple,PX-4501006000,CDM,10060,CPT,0450,RC,,,,outpatient,,,632.00,410.80,,,,,,,,,,,,,
POSTERIOR PILON FUSION PLATE 9H,SUP-2815016,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein|RIGHT SIDE,CASE-37249,LOCAL,37249,CPT,0360,RC,,,RT,outpatient,,,27259.98,16355.99,,,,,,,,,,,,,
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu,CASE-25260,LOCAL,25260,CPT,,,,,,outpatient,,,13068.78,7841.27,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, THIRD DIGIT|PO",CASE-26860,LOCAL,26860,CPT,0360,RC,,,F7|PO,outpatient,,,11771.20,7062.72,,,,,,,,,,,,,
Partial Excision Bone Tibia|LEFT SIDE|PO,CASE-27640,LOCAL,27640,CPT,0360,RC,,,LT|PO,outpatient,,,35793.97,21476.38,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE,CASE-52005,LOCAL,52005,CPT,0360,RC,,,LT,outpatient,,,13374.02,8024.41,,,,,,,,,,,,,
Rpr 1st Fem Hernia Any Age Incarcerated,CASE-49553,LOCAL,49553,CPT,0360,RC,,,,outpatient,,,33815.97,20289.58,,,,,,,,,,,,,
HC Cv Cath Plac W/Port Tun >5|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-36561,LOCAL,36561,CPT,0361,RC,,,73,outpatient,,,16140.68,9684.41,,,,,,,,,,,,,
Arthroplasty Ankle W/Implant|RIGHT SIDE,CASE-27702,LOCAL,27702,CPT,,,,,RT,outpatient,,,84455.38,50673.23,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT FOOT, GREAT TOE|PO",CASE-28297,LOCAL,28297,CPT,,,,,TA|PO,outpatient,,,44565.32,26739.19,,,,,,,,,,,,,
Destruction Lesions Vulva Extensive,CASE-56515,LOCAL,56515,CPT,0360,RC,,,,outpatient,,,15469.13,9281.48,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THUMB|PO",CASE-26055,LOCAL,26055,CPT,0360,RC,,,FA|PO,outpatient,,,10333.88,6200.33,,,,,,,,,,,,,
SET STRL FOR 4.5MM 90DEG NONSTERILE CANN LC ANG BLDE INSTR,SUP-2183072,CDM,C1713,HCPCS,0278,RC,,,,both,,,12986.26,8441.07,,,,,,,,,,,,,
SET VASC ACCS PEELWY L 15.5 CM INTRO L 20 CM DIA14 FR,SUP-2168021,CDM,C1892,HCPCS,0272,RC,,,,both,,,127.80,83.07,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.018 IN TIP LOAD 3,SUP-2909313,CDM,C1769,HCPCS,0272,RC,,,,both,,,118.25,76.86,,,,,,,,,,,,,
SCREW BONE L14MM OD2.5MM TI CORT SM HD T8 ST,SUP-2101274,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.73,218.22,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 4H 81MM LEFT-STER,SUP-2549540,CDM,C1713,HCPCS,0278,RC,,,,both,,,3427.59,2227.93,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 30X20X20 MM FD CANC,SUP-2792178,CDM,C1713,HCPCS,0278,RC,,,,both,,,3074.69,1998.55,,,,,,,,,,,,,
PLATE BNE DSTL RAD OPTILOCK,SUP-2606601,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.78,55.76,,,,,,,,,,,,,
ROD EXT FIX L500MM DIA11MM C CONN MOD MRI SAFE FOR HOFFMANN,SUP-2372233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1490.24,968.66,,,,,,,,,,,,,
UNIT PRASS PR EMG 12.5MM 2 CHAN SM,SUP-2284325,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.24,279.66,,,,,,,,,,,,,
PLATE BNE VOLAR UNIV DSTL RADIAL 7 HOLE OPTILOCK,SUP-2466822,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
HC So Thyroglobin Ab,PX-3028680068,CDM,86800,CPT,0302,RC,,,,both,,,32.00,20.80,,,,,,,,,,,,,
GRAFT SOFT TISSUE CANN 11X30 MM TIB WITH DRIVER APERFIX II,SUP-2664013,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
COVER BURR H DIA10 MM THK 0.5 MM CRANIOFACIAL FOR 1.7 MM,SUP-2883561,CDM,C1713,HCPCS,0278,RC,,,,both,,,1867.04,1213.58,,,,,,,,,,,,,
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE|PO,CASE-26615,LOCAL,26615,CPT,,,,,RT|PO,outpatient,,,19728.23,11836.94,,,,,,,,,,,,,
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,LOCAL,58573,CPT,,,,,,outpatient,,,77235.17,46341.10,,,,,,,,,,,,,
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE|PO,CASE-25628,LOCAL,25628,CPT,0360,RC,,,LT|PO,outpatient,,,20715.72,12429.43,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THIRD DIGIT|PO",CASE-26765,LOCAL,26765,CPT,,,,,F2|PO,outpatient,,,6199.00,3719.40,,,,,,,,,,,,,
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf,CASE-36825,LOCAL,36825,CPT,,,,,,outpatient,,,47193.40,28316.04,,,,,,,,,,,,,
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,LOCAL,64772,CPT,,,,,,outpatient,,,18678.83,11207.30,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,LOCAL,28289,CPT,0360,RC,,,TA,outpatient,,,19476.55,11685.93,,,,,,,,,,,,,
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,LOCAL,46922,CPT,,,,,,outpatient,,,22101.17,13260.70,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO,CASE-29881,LOCAL,29881,CPT,0360,RC,,,LT|PO,outpatient,,,21036.48,12621.89,,,,,,,,,,,,,
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26125,LOCAL,26125,CPT,,,,,F8|PO,outpatient,,,13286.83,7972.10,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE|PO,CASE-29827,LOCAL,29827,CPT,0360,RC,,,LT|PO,outpatient,,,52895.18,31737.11,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB|PO",CASE-26418,LOCAL,26418,CPT,,,,,FA|PO,outpatient,,,12573.62,7544.17,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26123,LOCAL,26123,CPT,,,,,F9|PO,outpatient,,,13675.87,8205.52,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins,PX-4309712900,CDM,97129,CPT,0430,RC,,,,outpatient,,,186.00,120.90,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 20X8 CMX1.8 MM FLEXHD,SUP-2307484,CDM,Q4128,HCPCS,0636,RC,,,,both,,,14248.57,9261.57,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 22 MM 4 CHANNEL TWISTED PR GRN WHT,SUP-2902010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
MESH SURG DIA70MM THK0.4MM SLV CRANIOFACIAL TI MALL CNTOUR,SUP-2181579,CDM,C1713,HCPCS,0278,RC,,,,both,,,5301.58,3446.03,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2 CHMBR 40 J 4X7.1X1.4 CM 35 CC 75 CC,SUP-2356287,CDM,C1721,HCPCS,0275,RC,,,,both,,,63585.00,41330.25,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.4X6 MM CORTICAL MANDIBULAR CRANIOFACI,SUP-2838272,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
PLATE 12HL LT,SUP-2470214,CDM,C1713,HCPCS,0278,RC,,,,both,,,3994.90,2596.68,,,,,,,,,,,,,
CATHETER ABLATN 4 MM SPC LNG REACH CELSIUS D7BTG5L,SUP-2468224,CDM,C1732,HCPCS,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
TRAY PICC SUBCL 1/L 5FR 55CML SIL PWR INJ RADPQ PEEL 7918518,SUP-2632685,CDM,C1751,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 40 CM DIA 6 MM EPTFE STR STD WALL,SUP-2227642,CDM,C1768,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
COMPONENT FEM SZ 1 LT KNEE NP PRI CEM STEM ROT HNG MEDL PVT,SUP-2304625,CDM,C1776,CPT,0278,RC,,,,both,,,14732.88,9576.37,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,LOCAL,64415,CPT,0360,RC,,,RT|XU,outpatient,,,37768.25,22660.95,,,,,,,,,,,,,
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,LOCAL,49329,CPT,,,,,,outpatient,,,48028.78,28817.27,,,,,,,,,,,,,
Arthroplasty Interphalangeal Jt W/Prosthetic Ea,CASE-26536,LOCAL,26536,CPT,0360,RC,,,,outpatient,,,22471.93,13483.16,,,,,,,,,,,,,
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|RIGHT SIDE,CASE-27675,LOCAL,27675,CPT,0360,RC,,,RT,outpatient,,,35280.80,21168.48,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT|PO",CASE-26951,LOCAL,26951,CPT,0360,RC,,,F2|PO,outpatient,,,15455.88,9273.53,,,,,,,,,,,,,
Repair Brow Ptosis,CASE-67900,LOCAL,67900,CPT,0360,RC,,,,outpatient,,,36231.00,21738.60,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,LOCAL,29888,CPT,,,,,RT,outpatient,,,45851.97,27511.18,,,,,,,,,,,,,
Rhytidectomy Neck W/Platysmal Tightening|PO,CASE-15825,LOCAL,15825,CPT,,,,,PO,outpatient,,,60933.83,36560.30,,,,,,,,,,,,,
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE|PO,CASE-29891,LOCAL,29891,CPT,,,,,LT|PO,outpatient,,,31467.45,18880.47,,,,,,,,,,,,,
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE,CASE-29875,LOCAL,29875,CPT,,,,,LT,outpatient,,,27637.02,16582.21,,,,,,,,,,,,,
IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS,RX-41142,CDM,6370000000,HCPCS,0637,RC,00597-0087-17,NDC,,both,12.9,GR,1380.80,897.52,,,,,,,,,,,,,
SEALER ENDOSCP 3 MM 5 MMX25 CM CRV VES CUT TISS ENSEAL TRIO,SUP-2257599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1084.43,704.88,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INOGEN MINI 28.5 CC TI 2 CHMBR DF1 CONN,SUP-2140378,CDM,C1721,HCPCS,0275,RC,,,,both,,,57462.00,37350.30,,,,,,,,,,,,,
DHS TRIPLE REAMER-COMPLETE FOR DHS PLATES-SHORT BARREL,SUP-2548674,CDM,C1713,HCPCS,0278,RC,,,,both,,,4715.21,3064.89,,,,,,,,,,,,,
KIT BNE PLATE SCREW DIA2.8 MM TI MANDIBULAR SECONDARY RECON FULL,SUP-2884161,CDM,C1713,HCPCS,0278,RC,,,,both,,,34681.30,22542.84,,,,,,,,,,,,,
BOLT ORTH L 50 MM DIA 4.9 MM TI ST LCK NS,SUP-2907996,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.00,360.75,,,,,,,,,,,,,
END CAP SCREWS,SUP-2830111,CDM,C1889,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
OSTEOTOME SURG OD 8MM LNG BLDE THN FLX,SUP-2408600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
COIL EMB L6CM OD0.020IN LOOP OD3MM NIT STRTCH RESIST FILL,SUP-2323431,CDM,C1889,HCPCS,0278,RC,,,,both,,,6760.42,4394.27,,,,,,,,,,,,,
BUR SURG L13CM OD3MM 40DEG ENT BULL DMND 30K,SUP-2277859,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1454.61,945.50,,,,,,,,,,,,,
HC Neonatal Head,PX-4027650600,CDM,76506,CPT,0402,RC,,,,both,,,836.00,543.40,,,,,,,,,,,,,
HC I&D Cyst Abscess Mouth Simple,PX-4504080000,CDM,40800,CPT,0450,RC,,,,both,,,730.00,474.50,,,,,,,,,,,,,
KIT EXT FIX WRST MULTIPIN CLMP 200X15MM C CONN ROD,SUP-2372629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
Mastectomy Partial W/Axillary Lymphadenectomy|RIGHT SIDE,CASE-19302,LOCAL,19302,CPT,,,,,RT,outpatient,,,47697.25,28618.35,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,LOCAL,28825,CPT,,,,,T7,outpatient,,,20449.32,12269.59,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,LOCAL,29826,CPT,,,,,LT,outpatient,,,46233.03,27739.82,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,LOCAL,29846,CPT,,,,,,outpatient,,,29451.92,17671.15,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE|PO",CASE-28292,LOCAL,28292,CPT,,,,,TA|PO,outpatient,,,22850.50,13710.30,,,,,,,,,,,,,
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,LOCAL,43274,CPT,0360,RC,,,,outpatient,,,37200.60,22320.36,,,,,,,,,,,,,
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,LOCAL,46255,CPT,,,,,,outpatient,,,17499.95,10499.97,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB|PO",CASE-26540,LOCAL,26540,CPT,0360,RC,,,FA|PO,outpatient,,,21626.93,12976.16,,,,,,,,,,,,,
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT SIDE,CASE-28289,LOCAL,28289,CPT,0360,RC,,,RT,outpatient,,,17062.68,10237.61,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE|PO,CASE-29825,LOCAL,29825,CPT,0360,RC,,,RT|PO,outpatient,,,33578.62,20147.17,,,,,,,,,,,,,
Colsc Flx With Directed Submucosal Njx Any Sbst|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45381,LOCAL,45381,CPT,,,,,XU,outpatient,,,17031.87,10219.12,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE|PO,CASE-29828,LOCAL,29828,CPT,0360,RC,,,RT|PO,outpatient,,,52209.17,31325.50,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,LOCAL,64415,CPT,0360,RC,,,XU,outpatient,,,44536.62,26721.97,,,,,,,,,,,,,
Arthroscopy Knee Removal Loose/Foreign Body,CASE-29874,LOCAL,29874,CPT,,,,,,outpatient,,,18525.75,11115.45,,,,,,,,,,,,,
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|LEFT SIDE,CASE-37722,LOCAL,37722,CPT,,,,,LT,outpatient,,,29073.12,17443.87,,,,,,,,,,,,,
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,LOCAL,64561,CPT,0360,RC,,,,outpatient,,,48818.20,29290.92,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE|PO,CASE-G0260,LOCAL,G0260,CPT,,,,,50|PO,outpatient,,,4478.50,2687.10,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, THUMB|PO",CASE-26525,LOCAL,26525,CPT,,,,,FA|PO,outpatient,,,10433.33,6260.00,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28750,LOCAL,28750,CPT,,,,,TA|PO,outpatient,,,38243.75,22946.25,,,,,,,,,,,,,
PAD CLLR CERV UNIV AD REPL,SUP-2124221,CDM,L0172,HCPCS,0272,RC,,,,both,,,31.78,20.66,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2 MM 12 HOLE PRECONTOURED TITANIUM LIGHT,SUP-2837752,CDM,C1713,HCPCS,0278,RC,,,,both,,,3488.23,2267.35,,,,,,,,,,,,,
MODEL ANAT MANDIBULAR/MAXILLARY RECON CASE BNDL W/ MTL INSRT,SUP-2883644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21018.91,13662.29,,,,,,,,,,,,,
PLATE BNE W10XL52MM THK15MM 3X3 H R TI T SHP OBLQ LO PROF,SUP-2190917,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.87,679.17,,,,,,,,,,,,,
SCREW BNE L32MM DIA5MM CORT DST ST FULL THRD FOR AFFIXUS,SUP-2413333,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.37,522.19,,,,,,,,,,,,,
LINER ACET SZ 6 ID28MM 0DEG ARCM HIP LCK RNG HI RIM WALL SUP,SUP-2405917,CDM,C1776,CPT,0278,RC,,,,both,,,4684.88,3045.17,,,,,,,,,,,,,
PLATE BONE 51MML HLX2 STNLSS STEEL BTTRSS F/2.7MM/3.5MM SCRE,SUP-2477601,CDM,C1713,HCPCS,0278,RC,,,,both,,,1503.90,977.53,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE STR WTAB NEURO SCRW4 HOLE 22 MM,SUP-2676758,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.42,321.37,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 8 HOLE BOX CAR 24MM TITANIUM,SUP-2825444,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.08,198.30,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 7 FRX4 CM 21 GAX4 CM ORNG PRELUDE,SUP-2303314,CDM,C1893,HCPCS,0272,RC,,,,both,,,103.46,67.25,,,,,,,,,,,,,
GRAFT BIO TISS STD PORCINE MTRX PEYRONIES REP BIODESIGN,SUP-2170533,CDM,C1763,HCPCS,0278,RC,,,,both,,,1548.02,1006.21,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 1.1-2.0 Cm,CASE-11402,LOCAL,11402,CPT,,,,,,outpatient,,,25564.22,15338.53,,,,,,,,,,,,,
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|PO,CASE-26160,LOCAL,26160,CPT,,,,,PO,outpatient,,,10855.00,6513.00,,,,,,,,,,,,,
Syndactylization Toes|LEFT SIDE|PO,CASE-28280,LOCAL,28280,CPT,0360,RC,,,LT|PO,outpatient,,,21840.08,13104.05,,,,,,,,,,,,,
Repair Dislocating Peroneal Tendon W/Fib Osteot,CASE-27676,LOCAL,27676,CPT,,,,,,outpatient,,,28524.17,17114.50,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|PO,CASE-64483,LOCAL,64483,CPT,,,,,PO,outpatient,,,3914.52,2348.71,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2,CASE-29822,LOCAL,29822,CPT,0360,RC,,,,outpatient,,,26409.28,15845.57,,,,,,,,,,,,,
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,LOCAL,54405,CPT,,,,,,outpatient,,,89454.92,53672.95,,,,,,,,,,,,,
Unlisted Procedure Femur/Knee,CASE-27599,LOCAL,27599,CPT,0360,RC,,,,outpatient,,,21539.80,12923.88,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE|PO,CASE-25111,LOCAL,25111,CPT,0360,RC,,,RT|PO,outpatient,,,13785.72,8271.43,,,,,,,,,,,,,
"Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn|RIGHT HAND, THIRD DIGIT|PO",CASE-26145,LOCAL,26145,CPT,,,,,F7|PO,outpatient,,,23079.30,13847.58,,,,,,,,,,,,,
Cysto W/Simple Removal Stone & Stent,CASE-52310,LOCAL,52310,CPT,0360,RC,,,,outpatient,,,21743.25,13045.95,,,,,,,,,,,,,
Implnt Bio Implnt for Soft Tissue Reinforcement,CASE-15777,LOCAL,15777,CPT,0360,RC,,,,outpatient,,,97810.18,58686.11,,,,,,,,,,,,,
Repair Dislocating Peroneal Tendon W/Fib Osteot|LEFT SIDE,CASE-27676,LOCAL,27676,CPT,0360,RC,,,LT,outpatient,,,28524.17,17114.50,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE|PO,CASE-29828,LOCAL,29828,CPT,0360,RC,,,LT|PO,outpatient,,,54366.32,32619.79,,,,,,,,,,,,,
SET INTRO FLX L 13 CM OD 7 FR ID 2.5 MM GUIDEWIRE L 40 CM,SUP-2168669,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
HANDPIECE SURG 6 IN BEND-A-BEAM ABC,SUP-2225595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE MESHED 6 STD 0.6 MM CRAN PRECONTR TI STRL LF,SUP-2479676,CDM,C1713,HCPCS,0278,RC,,,,both,,,8732.43,5676.08,,,,,,,,,,,,,
BUR SURG TAPR 2.3X15.9 MM 7 CM FOOTED SM BOR MIDAS REX 8,SUP-2664898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BUR SURG 51X23MM RND CUT NONFLUTED CARB ST MICROFRANCE,SUP-2278143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.36,380.48,,,,,,,,,,,,,
PROSTHESIS OTO L375MM SHFT OD05MM NIT MID EAR STAP PIST,SUP-2232483,CDM,L8613,CPT,0278,RC,,,,both,,,975.35,633.98,,,,,,,,,,,,,
LINER ACET E1 2 MOBILITY ACT ARTC CP G7 SYS,SUP-2417506,CDM,C1776,CPT,0278,RC,,,,both,,,11344.82,7374.13,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1173108D1,SUP-2632785,CDM,C1751,HCPCS,0278,RC,,,,both,,,768.23,499.35,,,,,,,,,,,,,
NAIL IM CANN 10X340 MM LT TROCHANTERIC SS STRL,SUP-2186378,CDM,C1713,HCPCS,0278,RC,,,,both,,,4100.84,2665.55,,,,,,,,,,,,,
INTRODUCER TUBE 24/26/28FR L100CM PERC FOR TRACH CIAGLIA BLU,SUP-2168764,CDM,C1894,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
NAIL IM L260MM DIA11MM L R HUM BLU TI AG RG BENT CANN LOK,SUP-2179654,CDM,C1713,HCPCS,0278,RC,,,,both,,,5042.27,3277.48,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 6.5MM WITH THREE NO2 HI FI 17MM NEEDL,SUP-2824899,CDM,C1713,HCPCS,0278,RC,,,,both,,,1468.89,954.78,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-40840052,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN L 300 CM DIA 0.018 IN TAPR L 7 CM FLPY,SUP-2168250,CDM,C1769,HCPCS,0272,RC,,,,both,,,299.87,194.92,,,,,,,,,,,,,
NEURO MD SCRWS 15MM DIA X 4MM 5/PKG T 6L 4V TTNM ALLOY,SUP-2682079,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.71,122.66,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-29881,LOCAL,29881,CPT,,,,,LT|PO|XS,outpatient,,,60209.02,36125.41,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,LOCAL,52351,CPT,,,,,RT|XU,outpatient,,,21972.27,13183.36,,,,,,,,,,,,,
"Inject Nerv Blck,Paravert Sympath|PO",CASE-64520,LOCAL,64520,CPT,0360,RC,,,PO,outpatient,,,5780.23,3468.14,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt,CASE-28309,LOCAL,28309,CPT,,,,,,outpatient,,,50809.40,30485.64,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|PO,CASE-28308,LOCAL,28308,CPT,,,,,RT|PO,outpatient,,,27135.67,16281.40,,,,,,,,,,,,,
"Arthrodesis Great Toe Interphalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28755,LOCAL,28755,CPT,,,,,TA|PO,outpatient,,,16439.88,9863.93,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THIRD DIGIT|PO",CASE-26860,LOCAL,26860,CPT,,,,,F2|PO,outpatient,,,28192.65,16915.59,,,,,,,,,,,,,
Hrhc 2/> Col/Grp W/Fstulectmy Incl Fssrectmy,CASE-46262,LOCAL,46262,CPT,,,,,,outpatient,,,19581.88,11749.13,,,,,,,,,,,,,
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|RIGHT SIDE|PO,CASE-29884,LOCAL,29884,CPT,,,,,RT|PO,outpatient,,,45972.65,27583.59,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid W/Excessive Skin,CASE-15823,LOCAL,15823,CPT,,,,,,outpatient,,,62659.03,37595.42,,,,,,,,,,,,,
Excision Tumor Soft Tiss Face/Scalp Subq 2 Cm/>,CASE-21012,LOCAL,21012,CPT,0360,RC,,,,outpatient,,,13868.62,8321.17,,,,,,,,,,,,,
Open Treatment Calcaneal Fracture|LEFT SIDE,CASE-28415,LOCAL,28415,CPT,0360,RC,,,LT,outpatient,,,36105.75,21663.45,,,,,,,,,,,,,
HC Rt Bronch Dx Clear Airway,CASE-31645,LOCAL,31645,CPT,0361,RC,,,,outpatient,,,27635.07,16581.04,,,,,,,,,,,,,
Rhytidectomy Neck W/Platysmal Tightening,CASE-15825,LOCAL,15825,CPT,0360,RC,,,,outpatient,,,36231.00,21738.60,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 2 CHMBR IS-1 DF-1 CONN RST EPIC II DR,SUP-2356558,CDM,C1721,HCPCS,0275,RC,,,,both,,,57305.00,37248.25,,,,,,,,,,,,,
PSN REV STRAIGHT SPLINE STEM EXT 15X175MM,SUP-2508792,CDM,C1776,CPT,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
HC Fingers Min 2 Views,PX-3207314000,CDM,73140,CPT,0320,RC,,,,both,,,397.00,258.05,,,,,,,,,,,,,
PLATE SPNL L 26 MM TI ANTR CERV LEVEL 2 NS SONOMA,SUP-2887248,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.34,37.27,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA1.5 MM COCR CORTICAL HND ST TIP LCK SQ,SUP-2885044,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.67,176.59,,,,,,,,,,,,,
STIMULATOR NERVE 4.32 MM PERC EXTN KT INTERSTIM QUAD,SUP-2550568,CDM,C1883,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
CATHETER ATHRCTMY KITTYCAT L 140 CM DIA 5 FR GUIDEWIRE 0.014,SUP-2124798,CDM,C1769,HCPCS,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCREW IM NAIL L 70 MM DIA 5 MM TI CORTICAL HINDFOOT HDLSS NS,SUP-2930399,CDM,C1713,HCPCS,0278,RC,,,,both,,,1961.72,1275.12,,,,,,,,,,,,,
IFOSFAMIDE 1 GM/20ML IV SOLN,RX-87925,CDM,J9208,HCPCS,0636,RC,00143-9531-01,NDC,,both,20,ML,105.90,68.83,,,,,,,,,,,,,
SEALANT TISS GLUE 2.5 ML LIQUIC TOP MICROBIAL STRL LF DISP,SUP-2906583,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|LEFT FOOT, GREAT TOE|PO",CASE-28092,LOCAL,28092,CPT,0360,RC,,,TA|PO,outpatient,,,19025.68,11415.41,,,,,,,,,,,,,
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE,CASE-27698,LOCAL,27698,CPT,,,,,RT,outpatient,,,32572.72,19543.63,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE|PO,CASE-25608,LOCAL,25608,CPT,,,,,RT|PO,outpatient,,,28201.32,16920.79,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,LOCAL,43239,CPT,,,,,XS,outpatient,,,92380.78,55428.47,,,,,,,,,,,,,
Removal Shoulder Foreign Body Deep Subfascial/Im,CASE-23333,LOCAL,23333,CPT,,,,,,outpatient,,,14326.22,8595.73,,,,,,,,,,,,,
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites,CASE-31625,LOCAL,31625,CPT,0360,RC,,,,outpatient,,,18592.38,11155.43,,,,,,,,,,,,,
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>|LEFT SIDE,CASE-23071,LOCAL,23071,CPT,,,,,LT,outpatient,,,17042.67,10225.60,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,LOCAL,58661,CPT,0360,RC,,,RT,outpatient,,,33821.88,20293.13,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE|PO,CASE-29826,LOCAL,29826,CPT,0360,RC,,,RT|PO,outpatient,,,52209.17,31325.50,,,,,,,,,,,,,
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,LOCAL,31629,CPT,,,,,,outpatient,,,20478.97,12287.38,,,,,,,,,,,,,
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE|PO,CASE-28200,LOCAL,28200,CPT,,,,,LT|PO,outpatient,,,40088.18,24052.91,,,,,,,,,,,,,
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-24341,LOCAL,24341,CPT,,,,,74,outpatient,,,10923.90,6554.34,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28270,LOCAL,28270,CPT,0360,RC,,,XS|T3|PO,outpatient,,,27333.98,16400.39,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE|PO,CASE-29880,LOCAL,29880,CPT,0360,RC,,,50|PO,outpatient,,,21233.00,12739.80,,,,,,,,,,,,,
COMPONENT EXT FIX UPPER PART MULT DIR FOR RED II,SUP-2460125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7156.47,4651.71,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.078X9 IN SS NS STEINMANN,SUP-2791274,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.02,7.16,,,,,,,,,,,,,
CONNECTOR SPNL HD OFFSET 36 MM CREO 5.5,SUP-2731844,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CATHETER HD J STR 23 CM 2 CUF TY INTRO GUIDEWIRE INJ,SUP-2283902,CDM,C1750,HCPCS,0278,RC,,,,both,,,804.63,523.01,,,,,,,,,,,,,
HC Tee Cong Anom,PX-4839331500,CDM,93315,CPT,0483,RC,,,,both,,,2549.00,1656.85,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,LOCAL,24342,CPT,,,,,LT,outpatient,,,25187.08,15112.25,,,,,,,,,,,,,
Excision/Curettage Cyst/Tumor Phalanx Finger,CASE-26210,LOCAL,26210,CPT,,,,,,outpatient,,,10788.45,6473.07,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28825,LOCAL,28825,CPT,0360,RC,,,T5,outpatient,,,18774.05,11264.43,,,,,,,,,,,,,
Dilat Rct Strix Spx Under Anes Oth/Thn Local,CASE-45910,LOCAL,45910,CPT,0360,RC,,,,outpatient,,,16099.63,9659.78,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28299,LOCAL,28299,CPT,,,,,TA|PO,outpatient,,,25037.65,15022.59,,,,,,,,,,,,,
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE,CASE-23700,LOCAL,23700,CPT,,,,,LT,outpatient,,,17623.45,10574.07,,,,,,,,,,,,,
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|RIGHT SIDE,CASE-27130,LOCAL,27130,CPT,0360,RC,,,RT,outpatient,,,53800.60,32280.36,,,,,,,,,,,,,
Tx Missed Abortion First Trimester Surgical,CASE-59820,LOCAL,59820,CPT,,,,,,outpatient,,,16636.97,9982.18,,,,,,,,,,,,,
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,LOCAL,26437,CPT,,,,,,outpatient,,,15589.47,9353.68,,,,,,,,,,,,,
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE,CASE-27822,LOCAL,27822,CPT,0360,RC,,,LT,outpatient,,,33550.63,20130.38,,,,,,,,,,,,,
Cysto W/Removal of Lesions Small,CASE-52224,LOCAL,52224,CPT,,,,,,outpatient,,,24001.32,14400.79,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE|PO",CASE-64491,LOCAL,64491,CPT,,,,,50|PO,outpatient,,,4722.57,2833.54,,,,,,,,,,,,,
Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated,CASE-49596,LOCAL,49596,CPT,,,,,,outpatient,,,61194.60,36716.76,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids,CASE-60500,LOCAL,60500,CPT,,,,,,outpatient,,,44699.83,26819.90,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|PO,CASE-25111,LOCAL,25111,CPT,,,,,PO,outpatient,,,11520.57,6912.34,,,,,,,,,,,,,
Lig&Div Long Saph Vein Saphfem Junct/Interrupj|LEFT SIDE,CASE-37700,LOCAL,37700,CPT,0360,RC,,,LT,outpatient,,,23884.98,14330.99,,,,,,,,,,,,,
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE,CASE-27829,LOCAL,27829,CPT,,,,,LT,outpatient,,,34840.13,20904.08,,,,,,,,,,,,,
Insertion Intrauterine Device Iud,CASE-58300,LOCAL,58300,CPT,0360,RC,,,,outpatient,,,18809.37,11285.62,,,,,,,,,,,,,
SEMI-TUB PLT STERILIZER 103 MM LENGTH 6 HL,SUP-2818491,CDM,C1713,HCPCS,0278,RC,,,,both,,,539.11,350.42,,,,,,,,,,,,,
PLATE BONE L342MM 15 H LT PROX FEM LCK FOR 4.5MM SCR,SUP-2351129,CDM,C1713,HCPCS,0278,RC,,,,both,,,14787.36,9611.78,,,,,,,,,,,,,
PLATE BNE L 125.73 X W 5.08 MM THK 1 MM 20 H TI STR NS DISP,SUP-2936479,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
ANCHOR SUT ARTHSCP HNDL INSRTR NO 2 SUT TI 3.5MM DIA TWINFIX,SUP-2341070,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
KIT INSTR W/ 2.4MM STP DRL GUID FOR SM JT DISP SUTURETAK,SUP-2122904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
HC R&L Heart Cath WO Graft,PX-4819345300,CDM,93453,CPT,0481,RC,,,,outpatient,,,9718.00,6316.70,,,,,,,,,,,,,
KNIFE SURG DISCECTOMY 190 MM BAYNT,SUP-2277784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1664.51,1081.93,,,,,,,,,,,,,
PLATE BNE 7 H FIB FLX,SUP-2896543,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms,CASE-27696,LOCAL,27696,CPT,0360,RC,,,,outpatient,,,48843.65,29306.19,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,LOCAL,64446,CPT,0360,RC,,,RT|XU|PO,outpatient,,,48106.08,28863.65,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,LOCAL,49651,CPT,0360,RC,,,50,outpatient,,,60107.72,36064.63,,,,,,,,,,,,,
Mastectomy Gynecomastia|BILATERAL PROCEDURE,CASE-19300,LOCAL,19300,CPT,,,,,50,outpatient,,,17751.60,10650.96,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE|PO,CASE-64635,LOCAL,64635,CPT,0360,RC,,,50|PO,outpatient,,,12211.98,7327.19,,,,,,,,,,,,,
Dir Rpr Aneurysm Axil-Brachial Arm Incision,CASE-35011,LOCAL,35011,CPT,0360,RC,,,,outpatient,,,51788.87,31073.32,,,,,,,,,,,,,
Suture Quadriceps/Hamstring Rupture Primary|LEFT SIDE,CASE-27385,LOCAL,27385,CPT,0360,RC,,,LT,outpatient,,,29254.98,17552.99,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,LOCAL,62321,CPT,0360,RC,,,,outpatient,,,4358.25,2614.95,,,,,,,,,,,,,
Excision/Curettage Bone Cyst/Tumor Tibia/Fibula|SEPARATE STRUCTURE|RIGHT SIDE,CASE-27635,LOCAL,27635,CPT,,,,,XS|RT,outpatient,,,36064.92,21638.95,,,,,,,,,,,,,
Cysto W/Removal of Tumors Small,CASE-52234,LOCAL,52234,CPT,0360,RC,,,,outpatient,,,23999.48,14399.69,,,,,,,,,,,,,
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, THIRD DIGIT|PO",CASE-28645,LOCAL,28645,CPT,,,,,T7|PO,outpatient,,,29334.38,17600.63,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,LOCAL,52351,CPT,,,,,RT,outpatient,,,15814.95,9488.97,,,,,,,,,,,,,
Split Agrft T/a/L Ea 100 Cm/Ea 1% Bdy Inft/Chld,CASE-15101,LOCAL,15101,CPT,,,,,,outpatient,,,28702.92,17221.75,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,LOCAL,64636,CPT,,,,,RT,outpatient,,,12778.57,7667.14,,,,,,,,,,,,,
Cystourethroscopy W/Dil Bladder General Anesth,CASE-52260,LOCAL,52260,CPT,,,,,,outpatient,,,18956.38,11373.83,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT",CASE-28270,LOCAL,28270,CPT,,,,,XS|T7,outpatient,,,40956.73,24574.04,,,,,,,,,,,,,
BOOT CAST XL L13.5IN TOE W6IN BLK CANVS NONSLIP ROCK SOLE,SUP-2196785,CDM,L4631,HCPCS,0274,RC,,,,both,,,14.85,9.65,,,,,,,,,,,,,
AUGMENT FEM M THK4MM STD UNIV R MED L LAT DST KNEE CEM BLK,SUP-2406993,CDM,C1776,CPT,0278,RC,,,,both,,,3356.66,2181.83,,,,,,,,,,,,,
HEAD FEM DIA38MM CODE D L DIAM METASUL,SUP-2204639,CDM,C1776,CPT,0278,RC,,,,both,,,4673.89,3038.03,,,,,,,,,,,,,
CAGE SPNL L12XW12XH16MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317733,CDM,C1889,HCPCS,0278,RC,,,,both,,,7108.96,4620.82,,,,,,,,,,,,,
LEVOFLOXACIN 5 MG/ML SYRINGE (PED) <50 ML,RX-4090160,CDM,J1956,HCPCS,0636,RC,00143-9316-24,NDC,,both,50,ML,11.00,7.15,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 500-700 UM 1 ML PVA PREFIL SYR,SUP-2148449,CDM,C1889,HCPCS,0278,RC,,,,both,,,445.69,289.70,,,,,,,,,,,,,
CATHETER DIAG 6FR L125CM DST L9CM SIM CRV S STL BRAID SEL,SUP-2323618,CDM,C1887,HCPCS,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 55 MM PROX/DSTL 20 MM SHTH,SUP-2171050,CDM,C1768,CPT,0278,RC,,,,both,,,6101.02,3965.66,,,,,,,,,,,,,
INTERTAN SET SCREW,SUP-2821023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1647.78,1071.06,,,,,,,,,,,,,
STRAP LCK NS SIDEKCK EZ FRAME,SUP-2850513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3055.22,1985.89,,,,,,,,,,,,,
FIBER LASER HOLM 273 M FOR USE W/ H-30 RED SMARTSYNC DISP,SUP-2835945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1232.04,800.83,,,,,,,,,,,,,
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE|PO,CASE-27822,LOCAL,27822,CPT,0360,RC,,,RT|PO,outpatient,,,38444.12,23066.47,,,,,,,,,,,,,
Excision Lesion Tendon Sheath/Capsule Leg&/Ank|RIGHT SIDE,CASE-27630,LOCAL,27630,CPT,0360,RC,,,RT,outpatient,,,24787.32,14872.39,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,LOCAL,26160,CPT,,,,,F7,outpatient,,,13875.43,8325.26,,,,,,,,,,,,,
"Open Tx Fracture Great Toe/Phalanx/Phalanges|LEFT FOOT, GREAT TOE",CASE-28505,LOCAL,28505,CPT,0360,RC,,,TA,outpatient,,,40869.75,24521.85,,,,,,,,,,,,,
Crtj Arven Fstl Xcp Dir Arven Anast Nonautog Grf,CASE-36830,LOCAL,36830,CPT,0360,RC,,,,outpatient,,,41583.48,24950.09,,,,,,,,,,,,,
Revascularization Iliac Art Angiop Ea Ipsi Vsl|LEFT SIDE,CASE-37222,LOCAL,37222,CPT,,,,,LT,outpatient,,,56908.88,34145.33,,,,,,,,,,,,,
HC Intro Catheter Aorta|RIGHT SIDE,CASE-36200,LOCAL,36200,CPT,0361,RC,,,RT,outpatient,,,52733.95,31640.37,,,,,,,,,,,,,
Dir Rpr Aneurysm Axil-Brachial Arm Incision|RIGHT SIDE,CASE-35011,LOCAL,35011,CPT,,,,,RT,outpatient,,,51788.87,31073.32,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT|PO",CASE-28124,LOCAL,28124,CPT,0360,RC,,,T2|PO,outpatient,,,56989.27,34193.56,,,,,,,,,,,,,
HC Intro Catheter Aorta|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36200,LOCAL,36200,CPT,0361,RC,,,XU,outpatient,,,60596.37,36357.82,,,,,,,,,,,,,
"Arthrodesis Iphal Jt W/WO Int Fixj Ea Iphal Jt|RIGHT HAND, THIRD DIGIT|PO",CASE-26861,LOCAL,26861,CPT,,,,,F7|PO,outpatient,,,18675.95,11205.57,,,,,,,,,,,,,
Corrj Hallux Valgus W/Sesmdc W/2 Osteot,CASE-28299,LOCAL,28299,CPT,,,,,,outpatient,,,25142.88,15085.73,,,,,,,,,,,,,
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,LOCAL,52354,CPT,0360,RC,,,LT,outpatient,,,22753.05,13651.83,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit W Pta|LEFT SIDE,CASE-36902,LOCAL,36902,CPT,0361,RC,,,LT,outpatient,,,22774.38,13664.63,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE|PO,CASE-23515,LOCAL,23515,CPT,,,,,LT|PO,outpatient,,,47339.70,28403.82,,,,,,,,,,,,,
GRAFT BONE SUB 5CC DBM W/ RPM PUROS,SUP-2415799,CDM,C1713,HCPCS,0278,RC,,,,both,,,2232.54,1451.15,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 6 FR SS HYDRPHLC PERIPHERAL,SUP-2385669,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.62,19.90,,,,,,,,,,,,,
PLATE 10HL 146MM,SUP-2479428,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.13,1157.08,,,,,,,,,,,,,
BIT DRL OD2.4MM DISP FOR VERTEX MAX SYS,SUP-2280206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2207.42,1434.82,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DEMIN CELLULAR MTRX VIVIGEN,SUP-2264614,CDM,C1713,HCPCS,0278,RC,,,,both,,,10513.19,6833.57,,,,,,,,,,,,,
ANCHOR SUT NDL DX FIBERTAK,SUP-2123221,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
COMPONENT ACET AUG BLADE 50 MM HIP REDAPT,SUP-2434892,CDM,C1776,CPT,0278,RC,,,,both,,,6851.48,4453.46,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 20 CM CRV RAD,SUP-2638702,CDM,C1769,HCPCS,0272,RC,,,,both,,,229.31,149.05,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID 1 CC AMNIO PLCNTA MEMBRN PRO3-FA,SUP-2742036,CDM,C1762,CPT,0278,RC,,,,both,,,6951.18,4518.27,,,,,,,,,,,,,
CALCITRIOL 1 MCG/ML PO SOLN,RX-16218,CDM,340b,HCPCS,0637,RC,64980-0447-15,NDC,,both,0.25,ML,30.10,19.56,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X98 MM 8 HOLE SS DCP,SUP-2569150,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.68,198.69,,,,,,,,,,,,,
SHUNT CV 3 MMX15 CMX4.3 MM CAR HALLIN ENDRTRMY,SUP-2633892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3082.95,2003.92,,,,,,,,,,,,,
PROCESSOR SND KT MAG 345 AD,SUP-2165019,CDM,L8691,HCPCS,0274,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 20X20 CM RECON TISS MTRX STRATTICE,SUP-2484629,CDM,Q4130,HCPCS,0636,RC,,,,both,,,39604.82,25743.13,,,,,,,,,,,,,
SUPPORT ORTHOT CUST HEEL WDG,SUP-2435721,CDM,L3350,HCPCS,0272,RC,,,,both,,,64.75,42.09,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|LEFT SIDE,CASE-50081,LOCAL,50081,CPT,,,,,LT,outpatient,,,70093.62,42056.17,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent,CASE-52332,LOCAL,52332,CPT,0360,RC,,,,outpatient,,,37858.80,22715.28,,,,,,,,,,,,,
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,LOCAL,43235,CPT,0360,RC,,,,outpatient,,,10139.13,6083.48,,,,,,,,,,,,,
Open Treatment Fracture Distal Tibia & Fibula|LEFT SIDE|PO,CASE-27828,LOCAL,27828,CPT,,,,,LT|PO,outpatient,,,42721.33,25632.80,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE,CASE-28090,LOCAL,28090,CPT,0360,RC,,,LT,outpatient,,,19625.32,11775.19,,,,,,,,,,,,,
"HC Excis Nail Matrix Perm Rmvl|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-11750,LOCAL,11750,CPT,0450,RC,,,XS|T5|PO,outpatient,,,18454.12,11072.47,,,,,,,,,,,,,
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,LOCAL,53445,CPT,0360,RC,,,,outpatient,,,107642.93,64585.76,,,,,,,,,,,,,
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE|PO,CASE-27829,LOCAL,27829,CPT,,,,,RT|PO,outpatient,,,38444.12,23066.47,,,,,,,,,,,,,
Inject Platelet Rich Plasma W/Img Harvest/Preparatoin,CASE-0232T,LOCAL,0232T,CPT,0360,RC,,,,outpatient,,,28755.95,17253.57,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, GREAT TOE",CASE-28270,LOCAL,28270,CPT,,,,,TA,outpatient,,,19625.32,11775.19,,,,,,,,,,,,,
HC Insrt Aortic Balloon Thru ASC Aort,PX-3603397300,CDM,33973,CPT,0360,RC,,,,both,,,15176.00,9864.40,,,,,,,,,,,,,
PLATE BNE HK 4.5X128 MM 4 HOLE SS NS DCP,SUP-2185800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2204.56,1432.96,,,,,,,,,,,,,
PLATE BONE THK0.6MM SH 2X2 H LT CRANIOMAXILLOFACIAL TI L,SUP-2191173,CDM,C1713,HCPCS,0278,RC,,,,both,,,918.76,597.19,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 4MM 10MM RANG 60CC READIGRFT,SUP-2264739,CDM,C1713,HCPCS,0278,RC,,,,both,,,2124.90,1381.18,,,,,,,,,,,,,
ROD IM BAL 3 DEG FEM SIG HP,SUP-2456314,CDM,C1713,HCPCS,0278,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
CATHETER VALVULOPLASTY NUCLEUS-X L 110 CM DIA 9 FR 5 CM 28MM,SUP-2659661,CDM,C1725,HCPCS,0272,RC,,,,both,,,2981.84,1938.20,,,,,,,,,,,,,
IMPLANT NSL SIL ANAT 4.4X2.7X1.00X0.79X0.95X0.42X0.70X0.50CM,SUP-2242094,CDM,2780000010,LOCAL,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BONE L125MM 135DEG 6 H HIP BILAT S STL STD BRL LEN RIG,SUP-2197817,CDM,C1713,HCPCS,0278,RC,,,,both,,,891.67,579.59,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 7CMD SPNL MSCLE BLACK FNSH HOOK ULTRA,SUP-2672370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.55,270.76,,,,,,,,,,,,,
DEVICE MENIS REP STR ZIPLOOP TECHNOLOGY MAXFIRE MARXMEN,SUP-2212786,CDM,C1776,CPT,0278,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
PICC KIT CHLOROGUARD 4.5 FR VPS PRECIS ARROWG+ARD BLU +,SUP-2763312,CDM,C1751,HCPCS,0278,RC,,,,both,,,824.78,536.11,,,,,,,,,,,,,
CATHETER INTVASC OCCL EQL L 100 CM DIA 7 FR BALLOON DIA 33,SUP-2147471,CDM,C2628,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
Excision Malignant Lesion F/E/E/N/L >4.0 Cm,CASE-11646,LOCAL,11646,CPT,0360,RC,,,,outpatient,,,18469.32,11081.59,,,,,,,,,,,,,
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49594,LOCAL,49594,CPT,,,,,XU,outpatient,,,32599.72,19559.83,,,,,,,,,,,,,
Fth/Gft Fr W/Dir Clsr S/a/L Ea Addl 20 Cm/<,CASE-15221,LOCAL,15221,CPT,,,,,,outpatient,,,39572.23,23743.34,,,,,,,,,,,,,
Laparoscopy Nephrectomy W/Partial Ureterect|RIGHT SIDE,CASE-50546,LOCAL,50546,CPT,,,,,RT,outpatient,,,97230.95,58338.57,,,,,,,,,,,,,
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,LOCAL,64450,CPT,0450,RC,,,LT,outpatient,,,4333.55,2600.13,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,LOCAL,64483,CPT,0360,RC,,,LT,outpatient,,,3983.85,2390.31,,,,,,,,,,,,,
Laparoscopy Surg Pyeloplasty,CASE-50544,LOCAL,50544,CPT,,,,,,outpatient,,,75551.85,45331.11,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|LEFT SIDE,CASE-49507,LOCAL,49507,CPT,,,,,LT,outpatient,,,24059.18,14435.51,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26735,LOCAL,26735,CPT,,,,,F4|PO,outpatient,,,20553.30,12331.98,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|LEFT SIDE|PO,CASE-23430,LOCAL,23430,CPT,0360,RC,,,LT|PO,outpatient,,,40714.32,24428.59,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 2.6-7 Cm,CASE-12032,LOCAL,12032,CPT,0450,RC,,,,outpatient,,,15943.30,9565.98,,,,,,,,,,,,,
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,LOCAL,57520,CPT,0360,RC,,,,outpatient,,,22066.28,13239.77,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvic/Le 1st Ord,CASE-36245,LOCAL,36245,CPT,0361,RC,,,,outpatient,,,42243.20,25345.92,,,,,,,,,,,,,
Unlisted Px Skin Muc Membrane & Subq Tissue|PO,CASE-17999,LOCAL,17999,CPT,0360,RC,,,PO,outpatient,,,38630.25,23178.15,,,,,,,,,,,,,
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,LOCAL,57260,CPT,,,,,,outpatient,,,29078.93,17447.36,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE|BILATERAL PROCEDURE,CASE-52005,LOCAL,52005,CPT,,,,,XU|50,outpatient,,,14294.82,8576.89,,,,,,,,,,,,,
Cysto impl 4 or more,CASE-C9740,LOCAL,C9740,CPT,,,,,,outpatient,,,39779.78,23867.87,,,,,,,,,,,,,
CONE TIB AUG ASYM C RL/LM KNEE REV TRITANIUM TRIATHLON,SUP-2373584,CDM,C1776,CPT,0278,RC,,,,both,,,12950.77,8418.00,,,,,,,,,,,,,
ANCHOR SUTURE L10.75MM DIAMETER 2.9MM DOUBLE LOADED WITH NO,SUP-2842793,CDM,C1713,HCPCS,0278,RC,,,,both,,,1101.79,716.16,,,,,,,,,,,,,
HC Calcium Ionized,PX-3018233000,CDM,82330,CPT,0301,RC,,,,both,,,172.00,111.80,,,,,,,,,,,,,
WASHER ORTH DIA13MM FOR CANN SCR,SUP-2184681,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.45,49.04,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY CUST OFFSET,SUP-2435666,CDM,L2390,HCPCS,0274,RC,,,,both,,,289.79,188.36,,,,,,,,,,,,,
PROBE LASER ASPIR 20 GA STR PRECIS FIBER CENTERING,SUP-2466332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,542.59,352.68,,,,,,,,,,,,,
SCREW SNAP OFF DIAM A 27MM LEN B 13MM NEXFIX,SUP-2400543,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GUIDE WIRE AND DRL 250=LENGTH 20=DIAMETER SGL TRCR OPT FOR,SUP-2392815,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BONE L42MM 6 H BILAT MAXILLOFACIAL MAND ORAL TI STR,SUP-2191325,CDM,C1713,HCPCS,0278,RC,,,,both,,,1415.51,920.08,,,,,,,,,,,,,
BASEPLATE TIB SZ 6 RT PRI NP CEM FIX COMPARTMENTAL CA KEELED,SUP-2304601,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER DRAINAGE SINGLE PIG 8.5 FRX250 CM TUBE NIT FLEXIMA,SUP-2478590,CDM,C1729,HCPCS,0272,RC,,,,both,,,333.12,216.53,,,,,,,,,,,,,
PLATE BNE 3.5X157 MM 12 HOLE SS LCP,SUP-2569325,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
ANCHOR SUTURE BIOCOMP 4.75X22 MM DBL LD WHT SWIVELOCK C,SUP-2121693,CDM,C1713,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
COLLAR CERV FLAT REG 3 IN 1 PC IMMOB REHAB ORNG PROCARE,SUP-2196864,CDM,L0190,HCPCS,0274,RC,,,,both,,,25.47,16.56,,,,,,,,,,,,,
HC Fetal Eval 1st Tri Sgl Gest,PX-4027680100,CDM,76801,CPT,0402,RC,,,,inpatient,,,1288.00,837.20,,,,,,,,,,,,,
INFINITY EVERLAST SZ 2 8MM TOTAL ANKLE,SUP-2822432,CDM,C1776,CPT,0278,RC,,,,both,,,5878.08,3820.75,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FIFTH DIGIT",CASE-26951,LOCAL,26951,CPT,0360,RC,,,F4,outpatient,,,22434.18,13460.51,,,,,,,,,,,,,
"HC Debrid,Bone,1st 20sqcm or Less|SEPARATE STRUCTURE",CASE-11044,LOCAL,11044,CPT,0361,RC,,,XS,outpatient,,,101045.98,60627.59,,,,,,,,,,,,,
Unlisted Px Skin Muc Membrane & Subq Tissue,CASE-17999,LOCAL,17999,CPT,,,,,,outpatient,,,34777.38,20866.43,,,,,,,,,,,,,
Osteotomy Radius Distal Third|LEFT SIDE|PO,CASE-25350,LOCAL,25350,CPT,0360,RC,,,LT|PO,outpatient,,,37307.13,22384.28,,,,,,,,,,,,,
Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT SIDE|PO,CASE-28160,LOCAL,28160,CPT,,,,,RT|PO,outpatient,,,18216.12,10929.67,,,,,,,,,,,,,
Laparoscopy Surg Partial Nephrectomy|RIGHT SIDE,CASE-50543,LOCAL,50543,CPT,,,,,RT,outpatient,,,112424.60,67454.76,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Recurrent|LEFT SIDE|PO,CASE-25112,LOCAL,25112,CPT,,,,,LT|PO,outpatient,,,13513.90,8108.34,,,,,,,,,,,,,
Rcnstj Angular Dfrm Toe Soft Tiss Px Only|LEFT SIDE|PO,CASE-28313,LOCAL,28313,CPT,,,,,LT|PO,outpatient,,,21723.10,13033.86,,,,,,,,,,,,,
PLATE BNE TI RT POST TTC FUSION NS,SUP-2896800,CDM,C1713,HCPCS,0278,RC,,,,both,,,6433.86,4182.01,,,,,,,,,,,,,
PLATE BONE L THK1.5MM 4X20X4 H MAND TI DBL ANG LCKING FOR,SUP-2191268,CDM,C1713,HCPCS,0278,RC,,,,both,,,8499.67,5524.79,,,,,,,,,,,,,
MOLD CEM SPCR DIA65MM UNIV FEM SIL CRUCE SACRIFICING AGC,SUP-2408623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3717.76,2416.54,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE STRL SELD MAXBARR 18GA 10CM 1 LUM,SUP-2613566,CDM,C1751,HCPCS,0278,RC,,,,both,,,487.74,317.03,,,,,,,,,,,,,
STENT NEPHURET L 24 CM DIA 8 FR PERCFLX LCK PIGTL GUIDEWIRE,SUP-2141080,CDM,C2617,HCPCS,0278,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
PLATE BROAD STR 6HL,SUP-2702875,CDM,C1713,HCPCS,0278,RC,,,,both,,,4004.76,2603.09,,,,,,,,,,,,,
INSERT TIB SZ 5 THICKNESS 15MM UHMWPE KNEE PRI NEUT UNIV,SUP-2365101,CDM,C1776,CPT,0278,RC,,,,both,,,1934.33,1257.31,,,,,,,,,,,,,
SCREW BONE L130MM DIA6.5MM STD CORT TI ST SELF DRL CANN,SUP-2343336,CDM,C1713,HCPCS,0278,RC,,,,both,,,1696.51,1102.73,,,,,,,,,,,,,
EXTENDER BTTN FOOTPRINT 20X5MM SLT FOR ACL RECON TIGHTROPE,SUP-2121402,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE CNDYL 95 DEG 70X92 MM 5 HOLE SS STRL,SUP-2185488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2949.59,1917.23,,,,,,,,,,,,,
CATHETER INFUS 5FR L135CM INFUS L50CM 0.038IN SGL LUMN VLV,SUP-2172526,CDM,C1751,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BRACE ANK DORSIFLEXION ASST PLNTR,SUP-2388176,CDM,L2210,HCPCS,0274,RC,,,,both,,,169.78,110.36,,,,,,,,,,,,,
HC So Vitamin E,PX-3018444666,CDM,84446,CPT,0301,RC,,,,both,,,382.00,248.30,,,,,,,,,,,,,
STAPLE BNE FIX SZ 23 X 20 MM RAPID COMPR STRL LAPIPLASTY,SUP-2893065,CDM,C1713,HCPCS,0278,RC,,,,both,,,11379.36,7396.58,,,,,,,,,,,,,
TARGETING SLEEVE KNOB,SUP-2900823,CDM,C1713,HCPCS,0278,RC,,,,both,,,5798.95,3769.32,,,,,,,,,,,,,
CATHETER ATHRCTMY KITTYCAT 2 L 150 CM DIA 5 FR GUIDEWIRE,SUP-2124799,CDM,C1769,HCPCS,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
Colorectal Scrn; Hi Risk Ind,CASE-G0105,LOCAL,G0105,CPT,0360,RC,,,,outpatient,,,9888.12,5932.87,,,,,,,,,,,,,
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|RIGHT SIDE,CASE-52354,LOCAL,52354,CPT,0360,RC,,,RT,outpatient,,,25609.22,15365.53,,,,,,,,,,,,,
Debridement Bone Each Additional 20 Sq Cm,CASE-11047,LOCAL,11047,CPT,0360,RC,,,,outpatient,,,19365.23,11619.14,,,,,,,,,,,,,
Hysteroscopy Endometrial Ablation,CASE-58563,LOCAL,58563,CPT,,,,,,outpatient,,,31240.57,18744.34,,,,,,,,,,,,,
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm/1pct,CASE-15002,LOCAL,15002,CPT,,,,,,outpatient,,,22521.73,13513.04,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28296,LOCAL,28296,CPT,0360,RC,,,TA|PO,outpatient,,,19493.02,11695.81,,,,,,,,,,,,,
Incision & Drainage Leg/Ankle Abscess/Hematoma|LEFT SIDE,CASE-27603,LOCAL,27603,CPT,0360,RC,,,LT,outpatient,,,20212.50,12127.50,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE|PO,CASE-29888,LOCAL,29888,CPT,0360,RC,,,RT|PO,outpatient,,,54845.65,32907.39,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|LEFT SIDE,CASE-29825,LOCAL,29825,CPT,0360,RC,,,LT,outpatient,,,23587.90,14152.74,,,,,,,,,,,,,
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, THIRD DIGIT|PO",CASE-26080,LOCAL,26080,CPT,0360,RC,,,F7|PO,outpatient,,,16814.63,10088.78,,,,,,,,,,,,,
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE,CASE-27570,LOCAL,27570,CPT,,,,,RT,outpatient,,,13218.02,7930.81,,,,,,,,,,,,,
Ostectomy Prtl 5th Metar Head Spx|RIGHT SIDE|PO,CASE-28110,LOCAL,28110,CPT,0360,RC,,,RT|PO,outpatient,,,15830.75,9498.45,,,,,,,,,,,,,
Split Agrft T/a/L 1st 100 Cm/&/1% Bdy Inft/Chld,CASE-15100,LOCAL,15100,CPT,0360,RC,,,,outpatient,,,23548.95,14129.37,,,,,,,,,,,,,
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt,CASE-38570,LOCAL,38570,CPT,,,,,,outpatient,,,50863.18,30517.91,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 1.1-2.0 Cm,CASE-11402,LOCAL,11402,CPT,0360,RC,,,,outpatient,,,25564.22,15338.53,,,,,,,,,,,,,
Revis Shoulder Arthrplsty Humeral&Glenoid Compnt|RIGHT SIDE,CASE-23474,LOCAL,23474,CPT,,,,,RT,outpatient,,,104345.23,62607.14,,,,,,,,,,,,,
Cystectomy Partial Simple,CASE-51550,LOCAL,51550,CPT,,,,,,outpatient,,,45487.02,27292.21,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64446,LOCAL,64446,CPT,0360,RC,,,XU|LT,outpatient,,,47460.68,28476.41,,,,,,,,,,,,,
Unlisted Laparoscopic Procedure Liver,CASE-47379,LOCAL,47379,CPT,0360,RC,,,,outpatient,,,29847.77,17908.66,,,,,,,,,,,,,
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE,CASE-27654,LOCAL,27654,CPT,,,,,LT,outpatient,,,49796.85,29878.11,,,,,,,,,,,,,
HC Epidural Blood Patch - Anes,PX-3706227300,CDM,62273,CPT,0370,RC,,,,both,,,1586.00,1030.90,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE GTT LCK L2182] TIDEWATER PROSTHETICS],SUP-2388173,CDM,L2182,HCPCS,0274,RC,,,,both,,,245.23,159.40,,,,,,,,,,,,,
BLADE SHV OD4.5MM STR CUT BOXED ARTHROBLDE SYNOVATOR,SUP-2341398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,184.95,120.22,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 15 CC FD ASEP CORTICAL CANC,SUP-2867040,CDM,C1762,CPT,0278,RC,,,,both,,,2013.53,1308.79,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE|ADJ,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|CQ|XU|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
SENNA-DOCUSATE SODIUM 8.6-50 MG PO TABS,RX-33357,CDM,6370000000,HCPCS,0637,RC,63739-0432-02,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
FIBER LASER 1000 MH N TAPR POLISHED TIP HOLM ACCUMAX 5/BX,SUP-2537765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2116.11,1375.47,,,,,,,,,,,,,
STAPLE SURG 10X10X10MM,SUP-2390575,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
MATRIX BONE GRFT SUB DEMIN TREL-XPRESS 300 10 ML PUTTY,SUP-2244482,CDM,C9359,HCPCS,0278,RC,,,,both,,,10942.90,7112.88,,,,,,,,,,,,,
MASK CPAP MED ELBW CAPSTRAP,SUP-2429260,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.60,229.84,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,LOCAL,28825,CPT,0360,RC,,,T7,outpatient,,,20449.32,12269.59,,,,,,,,,,,,,
Transoral Lower Esophageal Myotomy,CASE-43497,LOCAL,43497,CPT,,,,,,outpatient,,,47585.13,28551.08,,,,,,,,,,,,,
Bone Graft Any Donor Area Major/Large,CASE-20902,LOCAL,20902,CPT,0360,RC,,,,outpatient,,,85871.93,51523.16,,,,,,,,,,,,,
Nerve Repair W/Conduit Each Nerve|LEFT SIDE|PO,CASE-64910,LOCAL,64910,CPT,0360,RC,,,LT|PO,outpatient,,,56748.52,34049.11,,,,,,,,,,,,,
Ostectomy Complete 5th Metatarsal Head,CASE-28113,LOCAL,28113,CPT,0360,RC,,,,outpatient,,,21781.68,13069.01,,,,,,,,,,,,,
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE,CASE-28300,LOCAL,28300,CPT,,,,,RT,outpatient,,,57269.77,34361.86,,,,,,,,,,,,,
Conv Prev Hip Tot Hip Arthrp W/WO Agrft/Algrft|RIGHT SIDE,CASE-27132,LOCAL,27132,CPT,,,,,RT,outpatient,,,82195.42,49317.25,,,,,,,,,,,,,
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT SIDE|PO,CASE-26160,LOCAL,26160,CPT,0360,RC,,,LT|PO,outpatient,,,8596.35,5157.81,,,,,,,,,,,,,
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|SEPARATE STRUCTURE|PO,CASE-14040,LOCAL,14040,CPT,,,,,XS|PO,outpatient,,,16315.30,9789.18,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,LOCAL,G0121,CPT,0360,RC,,,,outpatient,,,9867.32,5920.39,,,,,,,,,,,,,
Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea,CASE-28092,LOCAL,28092,CPT,0360,RC,,,,outpatient,,,12964.35,7778.61,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T9|PO,outpatient,,,18154.98,10892.99,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,LOCAL,52352,CPT,,,,,,outpatient,,,16787.03,10072.22,,,,,,,,,,,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,0636,RC,00641-0493-25,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE WR 4.5X35 MM FRDM,SUP-2610391,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.92,558.95,,,,,,,,,,,,,
PLATE RINGFIX SYS 90DEG 1X2,SUP-2500596,CDM,C1713,HCPCS,0278,RC,,,,both,,,381.51,247.98,,,,,,,,,,,,,
ROD IM VANGUARD GLOB,SUP-2441397,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
BASEPLATE GLEN SM UNIV SHLDR CAP COAT UNIVERSE REVERS,SUP-2123259,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
BIT DRL TWST 1.6X40 MM 7 MM BOD COUNTSINK SONICWELD RX,SUP-2477353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.38,535.85,,,,,,,,,,,,,
BURR SURG 1.2MM DIA HD LNG MIC 2.3MML HD SM BNE TAPR CROS CT,SUP-2605572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,89.90,58.43,,,,,,,,,,,,,
ADAPTER LD L 17 CM SIL INSUL UPLR LV1 RECEPTACLE IS1 CONN,SUP-2616253,CDM,C1883,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PHENYLEPHRINE HCL 10 MG/ML SOLN (MIXTURES ONLY),RX-430013,CDM,J2371,HCPCS,0636,RC,00781-3466-70,NDC,,both,0.01,ML,54.10,35.16,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IPERIA 7 HF-T W 56 X H 65 MM D 11 MM 40 J,SUP-2138368,CDM,C1882,HCPCS,0275,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
BUR SURG FLUT 4.2 MM BRL SUCTION IRRIGATING STR,SUP-2638216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.88,413.32,,,,,,,,,,,,,
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-157664,CDM,J1650,HCPCS,0636,RC,00075-0623-00,NDC,,both,1,ML,142.90,92.88,,,,,,,,,,,,,
SPLINT THMB SM FOR 6-7IN RT CARPOMETACARPAL JT RESTRICT ELAS,SUP-2324695,CDM,L3931,HCPCS,0272,RC,,,,both,,,57.56,37.41,,,,,,,,,,,,,
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,LOCAL,43282,CPT,,,,,,outpatient,,,125917.75,75550.65,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,LOCAL,64634,CPT,,,,,LT,outpatient,,,11775.07,7065.04,,,,,,,,,,,,,
"Arthrodesis Iphal Jt W/WO Int Fixj Ea Iphal Jt|RIGHT HAND, THIRD DIGIT|PO",CASE-26861,LOCAL,26861,CPT,0360,RC,,,F7|PO,outpatient,,,18675.95,11205.57,,,,,,,,,,,,,
"Synovectomy Metatarsophalangeal Joint Each|LEFT FOOT, SECOND DIGIT",CASE-28072,LOCAL,28072,CPT,,,,,T1,outpatient,,,31016.42,18609.85,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT HAND, FIFTH DIGIT",CASE-28308,LOCAL,28308,CPT,0360,RC,,,F9,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
HC N Block Inj Intercost Sng|BILATERAL PROCEDURE|PO,CASE-64420,LOCAL,64420,CPT,0360,RC,,,50|PO,outpatient,,,5101.95,3061.17,,,,,,,,,,,,,
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|LEFT SIDE,CASE-27130,LOCAL,27130,CPT,,,,,LT,outpatient,,,54770.73,32862.44,,,,,,,,,,,,,
CATHETER ABLATN MED 2-5-2 4 MM 7 FRX110 1304-7-25-M-TH THER,SUP-2487902,CDM,C1733,HCPCS,0272,RC,,,,both,,,2044.14,1328.69,,,,,,,,,,,,,
STYLET LD EXTRACTION LIBERATOR BEAC TIP L 140 CM ACTIVE L 70,SUP-2169593,CDM,C1773,HCPCS,0272,RC,,,,both,,,1745.81,1134.78,,,,,,,,,,,,,
PIN FIX SKULL RADLUC STRL DISP,SUP-2150244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.26,455.82,,,,,,,,,,,,,
BLADE SURG 4MM 30DEG E DISPOSABLE FOR PLNTR FASCIITIS,SUP-2399188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8000.72,5200.47,,,,,,,,,,,,,
PLATEXRAY SZ 2 STOR PHOSPHOR SCANX,SUP-2238750,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.85,451.00,,,,,,,,,,,,,
AM PICC SET: 2-L 5.5FRX55CM 80CM HYDRO,SUP-2827503,CDM,C1751,HCPCS,0278,RC,,,,both,,,413.44,268.74,,,,,,,,,,,,,
RING FIX 10-12.3MM CAPSULAR TENS EXP COMPRESSIBLE REFORM,SUP-2110078,CDM,L8610,HCPCS,0278,RC,,,,both,,,696.08,452.45,,,,,,,,,,,,,
CONE BODY STEM STD OFFSET AA 75 MM 40X35 MM FEM HIP ZMR,SUP-2439864,CDM,C1776,CPT,0278,RC,,,,both,,,11228.64,7298.62,,,,,,,,,,,,,
IMPLANT HUM TISS L 10 X W 6 CM AMNION/CHORION MEMBRN DEHYDR,SUP-2905525,CDM,C1762,CPT,0278,RC,,,,both,,,13875.66,9019.18,,,,,,,,,,,,,
ANCHOR SUTURE L 12 MM DIA 3 MM TI STRL GRAPPLER,SUP-2881102,CDM,C1713,HCPCS,0278,RC,,,,both,,,1112.97,723.43,,,,,,,,,,,,,
PLATE BNE L56MM 4 H L DST DORS PERIARTC RAD S STL T SHP LOK,SUP-2198467,CDM,C1713,HCPCS,0278,RC,,,,both,,,2463.17,1601.06,,,,,,,,,,,,,
COIL VASC VORTX-18 L 58 MM UNRESTRAINED L 5.5 MM DIA 5 MM,SUP-2148150,CDM,C1889,HCPCS,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
CONNECTOR SPNL DIA5.5MM SIDE LD CLS CDH SOLERA,SUP-2289159,CDM,C1713,HCPCS,0278,RC,,,,both,,,2775.76,1804.24,,,,,,,,,,,,,
BLADE RETRACTOR THERAPON MORSE 30X28 MM SET INSTRUMENT ULTRA,SUP-2480817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1495.21,971.89,,,,,,,,,,,,,
KIT CATH 8FR L16CM CTRL VEN DBL LUMN W/ BLU FLEXTIP CATH,SUP-2120606,CDM,C1751,HCPCS,0278,RC,,,,both,,,170.82,111.03,,,,,,,,,,,,,
SYSTEM PAIN RELF 600ML W/ SEL A FLO 2-14ML/HR ON-Q,SUP-2236813,CDM,C9804,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,LOCAL,28270,CPT,,,,,T6|PO,outpatient,,,15248.78,9149.27,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28232,LOCAL,28232,CPT,,,,,T9|PO,outpatient,,,12145.77,7287.46,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,LOCAL,64494,CPT,,,,,RT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, FIFTH DIGIT|PO",CASE-26531,LOCAL,26531,CPT,0360,RC,,,F4|PO,outpatient,,,26296.00,15777.60,,,,,,,,,,,,,
Capsulectomy/Capsulotomy Mtcarphlngl Joint Each|LEFT SIDE|PO,CASE-26520,LOCAL,26520,CPT,0360,RC,,,LT|PO,outpatient,,,15418.95,9251.37,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|RIGHT FOOT, GREAT TOE|PO",CASE-28297,LOCAL,28297,CPT,0360,RC,,,T5|PO,outpatient,,,46038.33,27623.00,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T6|PO,outpatient,,,29334.38,17600.63,,,,,,,,,,,,,
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,LOCAL,50543,CPT,,,,,LT,outpatient,,,88882.22,53329.33,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,LOCAL,29879,CPT,0360,RC,,,RT,outpatient,,,31663.63,18998.18,,,,,,,,,,,,,
Aspiration Bladder Insert Suprapubic Catheter|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51102,LOCAL,51102,CPT,,,,,XU,outpatient,,,28249.65,16949.79,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26418,LOCAL,26418,CPT,0360,RC,,,F7|PO,outpatient,,,12888.95,7733.37,,,,,,,,,,,,,
Ercp Dx Collection Specimen Brushing/Washing|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43260,LOCAL,43260,CPT,0360,RC,,,74,outpatient,,,23073.50,13844.10,,,,,,,,,,,,,
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE|PO,CASE-26615,LOCAL,26615,CPT,0360,RC,,,LT|PO,outpatient,,,19276.60,11565.96,,,,,,,,,,,,,
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,LOCAL,46607,CPT,,,,,,outpatient,,,17539.27,10523.56,,,,,,,,,,,,,
"Sesamoidectomy First Toe Spx|LEFT FOOT, GREAT TOE|PO",CASE-28315,LOCAL,28315,CPT,0360,RC,,,TA|PO,outpatient,,,22178.83,13307.30,,,,,,,,,,,,,
HC So Hpv Dna Amp Probe,PX-3068762466,CDM,87624,CPT,0306,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
VALVE AORT EVOLUT FX + DIA26 MM ANNULUS 20-23 MM PORCINE,SUP-2898735,CDM,C1889,HCPCS,0278,RC,,,,both,,,100480.00,65312.00,,,,,,,,,,,,,
PLATE BONE 135DEG 10 H SUPCNDYL S STL COMPR FRELOK,SUP-2205403,CDM,C1713,HCPCS,0278,RC,,,,both,,,1376.26,894.57,,,,,,,,,,,,,
PLATE BNE L190MM 10 H ST L LAT PROX TIB S STL LOK COMPR LO,SUP-2185721,CDM,C1713,HCPCS,0278,RC,,,,both,,,4695.93,3052.35,,,,,,,,,,,,,
BINDER ABD XL W15IN 62 74IN CIRC UNISX 5 PNL E CNTCT CLSR,SUP-2197130,CDM,L3650,HCPCS,0274,RC,,,,both,,,70.18,45.62,,,,,,,,,,,,,
ROD SPNL 3X120 MM,SUP-2564515,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.35,43.78,,,,,,,,,,,,,
NAIL IM HUM 8 7MMX30CM,SUP-2348164,CDM,C1713,HCPCS,0278,RC,,,,both,,,3952.00,2568.80,,,,,,,,,,,,,
PLATE BONE LOW PRFLE HLX3X2 06MM THK TTNM CRVD SQRE SGMNT P,SUP-2676648,CDM,C1713,HCPCS,0278,RC,,,,both,,,792.85,515.35,,,,,,,,,,,,,
PROX TIB LOCK PLATE RT 15H ST,SUP-2587100,CDM,C1713,HCPCS,0278,RC,,,,both,,,2806.41,1824.17,,,,,,,,,,,,,
WAND ABLAT DIA3.75MM 50DEG THRMCPL TECHNOLOGY W/ INTEGR,SUP-2342018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STRAP CLAV FOAM PADDED 42-48 IN X LG BCKL CLOSURE PROCARE,SUP-2195760,CDM,L3650,HCPCS,0272,RC,,,,both,,,15.57,10.12,,,,,,,,,,,,,
Removal Implant Deep,CASE-20680,LOCAL,20680,CPT,,,,,,outpatient,,,22707.67,13624.60,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|PO,CASE-G0260,LOCAL,G0260,CPT,,,,,PO,outpatient,,,4478.50,2687.10,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|LEFT SIDE,CASE-27524,LOCAL,27524,CPT,0360,RC,,,LT,outpatient,,,31537.33,18922.40,,,,,,,,,,,,,
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,LOCAL,52281,CPT,,,,,,outpatient,,,18464.57,11078.74,,,,,,,,,,,,,
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,LOCAL,58550,CPT,,,,,,outpatient,,,69732.95,41839.77,,,,,,,,,,,,,
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|BILATERAL PROCEDURE,CASE-38570,LOCAL,38570,CPT,0360,RC,,,50,outpatient,,,64971.32,38982.79,,,,,,,,,,,,,
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,LOCAL,45331,CPT,0360,RC,,,,outpatient,,,11428.40,6857.04,,,,,,,,,,,,,
Claviculectomy Partial|LEFT SIDE|PO,CASE-23120,LOCAL,23120,CPT,,,,,LT|PO,outpatient,,,38630.25,23178.15,,,,,,,,,,,,,
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE,CASE-54840,LOCAL,54840,CPT,0360,RC,,,LT,outpatient,,,18442.88,11065.73,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,LOCAL,60220,CPT,0360,RC,,,RT,outpatient,,,46464.52,27878.71,,,,,,,,,,,,,
HC Intro Catheter Aorta,CASE-36200,LOCAL,36200,CPT,0361,RC,,,,outpatient,,,28809.40,17285.64,,,,,,,,,,,,,
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt,CASE-27602,LOCAL,27602,CPT,,,,,,outpatient,,,20832.28,12499.37,,,,,,,,,,,,,
HC Intrvasc US Noncoronary Addl|RIGHT SIDE,CASE-37253,LOCAL,37253,CPT,0361,RC,,,RT,outpatient,,,27259.98,16355.99,,,,,,,,,,,,,
MESH SYNTH STRP SCAFFOLD TEND LIGMNT REP ABSRB RECT,SUP-2388578,CDM,C1781,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + LG PRIORITY STRL MEDPOR,SUP-2862759,CDM,C1713,HCPCS,0278,RC,,,,both,,,64996.02,42247.41,,,,,,,,,,,,,
GRAFT BIO TISS MESH 10X10 CM MIROMATRIX MIROMESH,SUP-2115024,CDM,C1781,HCPCS,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
ORTHOSES THERMOPLASTIC ACROMIOCLAVICULAR SHLDR PREFABRICATED,SUP-2319133,CDM,L3670,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 18 MM 2 CHANNEL PRASS PR SM HUB STRL,SUP-2902089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.24,274.46,,,,,,,,,,,,,
SPACER SPNL 4 DEG 14X20 MM,SUP-2362886,CDM,C1889,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
INSERT TIB 5 12 MM TOT ANK POLYETH PROPHECY INFIN,SUP-2462779,CDM,C1776,CPT,0278,RC,,,,both,,,6619.12,4302.43,,,,,,,,,,,,,
CATHETER CV PICC 5.5 FRX50 CM DL PRESSURE ARROWG+ARD BLU ADV,SUP-2846972,CDM,C1751,HCPCS,0278,RC,,,,both,,,310.23,201.65,,,,,,,,,,,,,
HC Sp Eval Non-Speech-Gen Device,PX-4449260500,CDM,92605,CPT,0444,RC,,,,both,,,498.00,323.70,,,,,,,,,,,,,
PACK VITRCTMY POST CASS ILLUM DLX,SUP-2129358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3009.12,1955.93,,,,,,,,,,,,,
GRAFT 1CC DBM GEL ALLOFUSE,SUP-2415844,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
COMPONENT ULN L75MM 4MM OFFSET BOND COAT RT ELBW BEAR DISCVR,SUP-2136204,CDM,C1776,CPT,0278,RC,,,,both,,,13831.70,8990.60,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.540,SUP-2860221,CDM,C1713,HCPCS,0278,RC,,,,both,,,44166.61,28708.30,,,,,,,,,,,,,
CATHETER GUID 7.62FR L62CM WRK L59CM QUARTET CRV INNR,SUP-2356402,CDM,C1751,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
RETRACTOR ENDOSCP L 300 MM HRT W 80 MM TROCAR DIA 5 MM LIV,SUP-2905614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.15,330.30,,,,,,,,,,,,,
BIT DRL L170MM WRK L139MM DIA45MM 3 FLUT REPL S STL TWST,SUP-2150441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,493.33,320.66,,,,,,,,,,,,,
SET INTRO PEELWY ECHOTIP L 9 CM DIA 4.5 FR GUIDEWIRE L 65 CM,SUP-2168660,CDM,C1894,HCPCS,0272,RC,,,,both,,,202.22,131.44,,,,,,,,,,,,,
UNIT IPAS III BVL SPRINGLESS STRL,SUP-2310411,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE NAR 3.5X161 MM 9 HOLE SS LCP,SUP-2569353,CDM,C1713,HCPCS,0278,RC,,,,both,,,535.37,347.99,,,,,,,,,,,,,
IMPLANT SLNG SWVL SCR 39CM POLY SUT,SUP-2140291,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.93,921.00,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 5 FR L 7 CM NIT,SUP-2633280,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.09,46.86,,,,,,,,,,,,,
CUTTER ARTHSCP 6 MM RETROCUTTER,SUP-2120847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE BNE L66MM 5 H NONSTERILE CNTOUR LOK 2 COMPR FOR 3.5MM,SUP-2411368,CDM,C1713,HCPCS,0278,RC,,,,both,,,848.68,551.64,,,,,,,,,,,,,
GRAFT SFT TISS BOV CLLGN 2.0 SQ 20CMX20CM SURGIMEND,SUP-2243684,CDM,C9360,HCPCS,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
STENT OPHTH L EYE TRABECULAR MIC BYPS ISTNT,SUP-2227949,CDM,C1783,HCPCS,0278,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
SCREW BONE FIX L26MM DIA2.2MM DSTL VOLAR RAD SMOOTH LCK PEG,SUP-2136242,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
SPACER SPNL 30X11X13 MM BIO AVS TL,SUP-2850810,CDM,C1889,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
SET TUBING THERMOABLATION GENESYS HTA PROCERVA HYSTEROSCOPIC ENDOMETRIAL W/CASSETTE DRAIN BAG SHEATH 5ST/BX,SUP-2138889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4828.69,3138.65,,,,,,,,,,,,,
DEVICE SUCTION 5 MM CAUT SPATULA TIP W/O TBNG SURGIWAND II,SUP-2787742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.12,275.03,,,,,,,,,,,,,
HC MRI-Upper Ext W & WO Cont,PX-6107322000,CDM,73220,CPT,0610,RC,,,,both,,,5578.00,3625.70,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THK200UM AMNIO MEMBRN DEHYDR CHORION,SUP-2421218,CDM,C1762,CPT,0278,RC,,,,both,,,13530.26,8794.67,,,,,,,,,,,,,
ROD SPNL Z 5.5X100 MM TI MARINER OUTRIG,SUP-2709841,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
CABLE SPNL L100MM LUM SULENE POLYCARB TEREPHTHALATE FOR DYN,SUP-2414262,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SCREW SPNL POLYAX MOD TULIP ADV FOR 5.5MM ROD CREO,SUP-2228673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CONNECTOR TBNG OD10.5MM ID9.0MM STR,SUP-2281985,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN PC NIMB L 145 CM DIA 0.035 IN TAPR L,SUP-2168471,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.39,56.80,,,,,,,,,,,,,
LENS IOL BCNVX 26.5+ DIOPT 5X11.5 MM CRYSTALENS AT50AO2650] VALEANT BAUSCH AND LOMB SURGICAL],SUP-2392058,CDM,V2788,HCPCS,0276,RC,,,,both,,,950.00,617.50,,,,,,,,,,,,,
PLATE BNE FLAT T PLT SPEC 3X3 H,SUP-2401264,CDM,C1713,HCPCS,0278,RC,,,,both,,,2788.32,1812.41,,,,,,,,,,,,,
EXTENDER BNE GRFT 2 MM 10 CC GRAN GROWTH FACTOR OSTEOAMP,SUP-2138492,CDM,C1713,HCPCS,0278,RC,,,,both,,,5548.69,3606.65,,,,,,,,,,,,,
GRAFT CANC CUBE 30CC,SUP-2115982,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COLLAR CERV L18IN H3.25IN L TRACH OPN AD PHIL,SUP-2195258,CDM,L0180,HCPCS,0272,RC,,,,both,,,39.94,25.96,,,,,,,,,,,,,
HAT-TRICK PIP FUS 4.2MM PROX10DEG4MM+MID,SUP-2819243,CDM,C1713,HCPCS,0278,RC,,,,both,,,4995.11,3246.82,,,,,,,,,,,,,
PLATE BNE STR NEUT 18.5X6X1 MM 4 HOLE SAG SPLIT NC MALL TI,SUP-2181837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1433.10,931.51,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 6 FR 0.025 IN 4 CM 20 GA SS,SUP-2677275,CDM,C1894,HCPCS,0272,RC,,,,both,,,67.26,43.72,,,,,,,,,,,,,
SCREW BNE L28MM DIA6.5MM SHLDR CNTR FOR RSA REUNION,SUP-2373751,CDM,C1713,HCPCS,0278,RC,,,,both,,,501.14,325.74,,,,,,,,,,,,,
TACK POS TROCAR TIP CERV,SUP-2601878,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
JOINT SUBTALAR 11.5 MM ANK,SUP-2318978,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
PLEDGET CV L 5.1 X W 0.6 CM THK 1.65 MM PTFE FELT BTTRS STRL,SUP-2761357,CDM,C1768,CPT,0278,RC,,,,both,,,76.08,49.45,,,,,,,,,,,,,
CETAPHIL GENTLE CLEANSER EX LIQD,RX-133961,CDM,6370000000,HCPCS,0637,RC,00299-0110-22,NDC,,both,473,ML,49.00,31.85,,,,,,,,,,,,,
SCREW SPNL 3.5X30 MM CORRIDOR,SUP-2593515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1196.34,777.62,,,,,,,,,,,,,
ALTEPLASE (ACTIVASE) 100 MG VIAL IV BOLUS,RX-4081200,CDM,J2997,HCPCS,0636,RC,50242-0085-27,NDC,,both,1,UN,50602.10,32891.36,,,,,,,,,,,,,
PLATE BONE L131MM 10 HOLE RCNSTRCTN 35MM SCREW UNVRSL LOK SS,SUP-2498306,CDM,C1713,HCPCS,0278,RC,,,,both,,,1552.42,1009.07,,,,,,,,,,,,,
PLATE BONE 4.5MM OFFSET SHLDR REPLICATOR EQUINOXE,SUP-2223289,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE POS QUADANG 110 DEG/90 DEG/90 DEG/70 DEG,SUP-2548637,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.67,231.84,,,,,,,,,,,,,
SHEATH ACCS 30 FRX16 CM OPQ AMPLATZ,SUP-2835767,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.51,52.98,,,,,,,,,,,,,
"HC Blood Typing, Rh(D)",PX-3008690100,CDM,86901,CPT,0300,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
PLATE BNE LNG TI ALLOY WR NAR SPANNING STRL ACU-LOC 2,SUP-2913024,CDM,C1713,HCPCS,0278,RC,,,,both,,,7422.96,4824.92,,,,,,,,,,,,,
CROWN DENT LR3 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176709,CDM,D6783,CPT,0278,RC,,,,both,,,22.04,14.33,,,,,,,,,,,,,
SET INTRO PEELWY NIT DENNY MOD STRL,SUP-2168398,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.83,95.44,,,,,,,,,,,,,
POST ORTHOPEDIC 2 HOLE W/ 12MM BOLT TRUELOK,SUP-2316108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X4 MM 0.97 MM LT EAR SHEA CUP,SUP-2637796,CDM,L8613,CPT,0278,RC,,,,both,,,457.03,297.07,,,,,,,,,,,,,
MESH SURG W7XL10CM SEPRA TECHNOLOGY RECT PHASIX,SUP-2125881,CDM,C1781,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
BRACE ORTH CLOSURE SM AD BK SHLDR BLK QUIKDRAW PRO,SUP-2123908,CDM,L0628,HCPCS,0274,RC,,,,both,,,165.64,107.67,,,,,,,,,,,,,
TUBE SURG FLR EXCHG FOR IM NAIL EXTR,SUP-2410278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
GUIDEWIRE VASC STRT L 260 CM DIA 0.035 IN TIP L 15 CM SS,SUP-2148281,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.61,32.25,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min,PX-4209753000,CDM,97530,CPT,0420,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
SUGAMMADEX SODIUM 200 MG/2ML IV SOLN,RX-132570,CDM,2500000003,HCPCS,0250,RC,00006-5423-12,NDC,,both,2,ML,782.90,508.88,,,,,,,,,,,,,
KIT INT FIX IMPL INSTR SYNDESMOTIC FIX DEV W/ BLNT GWIRE,SUP-2399135,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 5 HOLE Y-PLATE 17MM TITANIUM,SUP-2825442,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.71,105.76,,,,,,,,,,,,,
CEMENT DENT CAPSULE RESIN REINF SELF CURE YEL GC FUJI +,SUP-2238653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.11,325.72,,,,,,,,,,,,,
GRAFT HUM TISS 40MG WHL MICRONIZED ALLGRFT AMNION CHORION,SUP-2305737,CDM,Q4186,HCPCS,0636,RC,,,,both,,,2345.61,1524.65,,,,,,,,,,,,,
KIT 2.7MM 2.4MM DRL TIP GWIRE 4.5MM CANN ACL BONE FIX PLUG,SUP-2341041,CDM,C1769,HCPCS,0272,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UPCHARGE BIOMETKNEUP] ZIMMER BIOMET INC],SUP-2137344,CDM,C1776,CPT,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE VARIAX POLYAX NAVICULAR LK LT,SUP-2703202,CDM,C1713,HCPCS,0278,RC,,,,both,,,4892.75,3180.29,,,,,,,,,,,,,
SPACER SPNL LG 12 DEG 14 MM PEEK PERIMETER,SUP-2629067,CDM,C1889,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
SITAGLIPTIN PHOSPHATE 50 MG PO TABS,RX-77616,CDM,6370000000,HCPCS,0637,RC,00006-0112-01,NDC,,both,1,UN,49.50,32.17,,,,,,,,,,,,,
PIN EXT FIX L95MM DIA4MM THRD L30MM SH ORTH RECON HALF S,SUP-2342905,CDM,C1713,HCPCS,0278,RC,,,,both,,,855.87,556.32,,,,,,,,,,,,,
ANCHOR SFT TISS 2.8 MM SINGLE W/O SUTURE OR NDL TI TWINFIX,SUP-2877961,CDM,C1713,HCPCS,0278,RC,,,,both,,,619.84,402.90,,,,,,,,,,,,,
INTRODUCER HEMSTAS 8FR L85CM GWIRE 0.038IN 7CM J W/ DIL FAST,SUP-2355579,CDM,C1894,HCPCS,0272,RC,,,,both,,,167.99,109.19,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 20X20 CM,SUP-2383091,CDM,C1781,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
STEM FEM SZ 7 L155MM OD11MM TI HA HIP STR REV NEUT CEM CLLR,SUP-2374170,CDM,C1776,CPT,0278,RC,,,,both,,,17590.28,11433.68,,,,,,,,,,,,,
T-PLT RIGHT ANGLE 50MM STERIGHT HEAD 3HL SHAFT 3HL,SUP-2818500,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.38,621.65,,,,,,,,,,,,,
DOXAZOSIN MESYLATE 4 MG PO TABS,RX-9896,CDM,6370000000,HCPCS,0637,RC,68084-0862-11,NDC,,both,1,UN,4.10,2.66,,,,,,,,,,,,,
TRIAL HIP OD54MM ID36MM +4MM 20DEG CROSSLINKED POLYETH LNR,SUP-2345757,CDM,C1776,CPT,0278,RC,,,,both,,,2295.15,1491.85,,,,,,,,,,,,,
STEM FEM PRSS FT -30 MM 8 14X205 MM CALCAR HIP RESECT REST,SUP-2374307,CDM,C1776,CPT,0278,RC,,,,both,,,18052.49,11734.12,,,,,,,,,,,,,
CANNULA BYPS TANDEMHEART BLD PMP KIT LIFESPARC,SUP-2665309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
ORTHOLOC SPS 2.0MM BIT DRILL,SUP-2827731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
COMPONENT TIB CRUCE RET R PRI STEM CEM NP POLYETH ULT CONG,SUP-2209426,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
ORTHOPAEDIC KIT HIP PART HD LNR CERAMAX,SUP-2254033,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
PLATE CRAN 140X120X40 MM PT SPEC IMPL PEEK,SUP-2860152,CDM,C1713,HCPCS,0278,RC,,,,both,,,41900.47,27235.31,,,,,,,,,,,,,
PLATE BONE L140MM 8 H S STL BROAD SELF COMPR,SUP-2198607,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.27,292.03,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.3MM CORT FOR WRST FIX SYS,SUP-2389724,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
SYRINGE KIT 60 CC,SUP-2418960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
STEM DSTL MOD 19MM DIA 250MML POR RL HARDENED W/SLOT,SUP-2404201,CDM,C1776,CPT,0278,RC,,,,both,,,10107.66,6569.98,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 90 CM OD 6 FR ID 0.067 IN NYL,SUP-2158731,CDM,C1887,HCPCS,0272,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
PLATE SPNL 19X10MM 5.5 PLT TI POST FIX XLNK,SUP-2289520,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
HEAD FEM DIA36MM NK L+16MM OXIDIZED ZIRCONIUM 12/14 TAPR PRI,SUP-2345373,CDM,C1776,CPT,0278,RC,,,,both,,,6000.54,3900.35,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 10 CM OD 6 FR ID 0.087 IN SPRING,SUP-2385326,CDM,C1893,HCPCS,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
CALCITRIOL 0.25 MCG PO CAPS,RX-9350,CDM,6370000000,HCPCS,0637,RC,60687-0345-11,NDC,,both,1,UN,3.60,2.34,,,,,,,,,,,,,
COMPONENT TOE DIA15MM 1.5X4.5MM OFFSET MT CE ARTC TOE2,SUP-2123613,CDM,C1776,CPT,0278,RC,,,,both,,,9438.84,6135.25,,,,,,,,,,,,,
SEALANT TISS FIBRIN 4 CC HUM 4 PK KT VISTASEAL,SUP-2738900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2460.98,1599.64,,,,,,,,,,,,,
HC Cisternal or Lat Cervical Punc,PX-3616105500,CDM,61055,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0250,RC,00264-1800-32,NDC,,both,1000,ML,229.50,149.17,,,,,,,,,,,,,
DUODENOSCOPE STRL SNGLE USE EXALT CNTRLR BX 2,SUP-2498379,CDM,C1748,HCPCS,0278,RC,,,,both,,,9200.20,5980.13,,,,,,,,,,,,,
SYSTEM LOCATING NERVE CHECKPOINT GEMINI BIPOLAR,SUP-2854484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
CONNECTOR SPNL TOP SIDE 4.5-5 MM CORTICAL CD HORZ MODULEX,SUP-2854491,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L130CM BAL L250MM DIA4MM GWIRE 0.035IN,SUP-2280384,CDM,C2623,HCPCS,0278,RC,,,,both,,,6374.20,4143.23,,,,,,,,,,,,,
CATHETER ETER EP QPLR LIVEWIRE L115CM OD5FR L2MM,SUP-2356881,CDM,C1730,HCPCS,0272,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
PRELUDE SHRT SHTH INTRDCR 8FR 4CM .035X50CM STNLSS STEEL 3MM,SUP-2463174,CDM,C1894,HCPCS,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
VEST TRAC L98CM DIA72MM SYNTH LNR SH VERSATILE VAC FRM TOOL,SUP-2255763,CDM,L0810,HCPCS,0272,RC,,,,both,,,5165.30,3357.44,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 10 CM DIA 7 FR 2.5 CM ETFE,SUP-2385644,CDM,C1894,HCPCS,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
PLATE BONE LT DSTL RAD STD SGL PT USE,SUP-2225425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
COMPONENT FEM DSTL E 8.5 CM RT KNEE POROUS MAK RS OSS,SUP-2449861,CDM,C1776,CPT,0278,RC,,,,both,,,18128.79,11783.71,,,,,,,,,,,,,
CARVEDILOL 25 MG PO TABS,RX-15748,CDM,6370000000,HCPCS,0637,RC,00904-7308-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.438,SUP-2860002,CDM,C1713,HCPCS,0278,RC,,,,both,,,47437.24,30834.21,,,,,,,,,,,,,
PLATE BNE L 329 MM SCREW DIA 3.5/4.5 MM H 16 LT PROX FEM,SUP-2931257,CDM,C1713,HCPCS,0278,RC,,,,both,,,20318.16,13206.80,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CANN 3.9 FRX260 CM 0.025 IN JAGTOME,SUP-2420156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.07,847.00,,,,,,,,,,,,,
PLATE BONE SM L65MM 8 H S STL STR ECT,SUP-2198583,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.62,207.10,,,,,,,,,,,,,
ELECTRODE ELECTROTHERAPY NIT MPLR L200MM VENOM,SUP-2366968,CDM,C1713,HCPCS,0278,RC,,,,both,,,6452.01,4193.81,,,,,,,,,,,,,
PARTICLE EMB BEAR NSPVA DIA150-250 UM 100 MG PVA HYDRPHLC,SUP-2482241,CDM,C1889,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
INTRODUCER TUBE CATH 8 FRX35 CM STIFFENING STYL INTUB FROVA,SUP-2760026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.22,221.79,,,,,,,,,,,,,
BLADE SURG SHT MOD STBL ISCHIAL SCR,SUP-2403456,CDM,C1776,CPT,0278,RC,,,,both,,,3543.18,2303.07,,,,,,,,,,,,,
RING EXT FIX ID115MM TI C FBR HYBRID 3 4 FOR DST TIB FRME,SUP-2188608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1182.49,768.62,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X209 MM RT LAT DSTL 13 HOLE NS VA-LCP,SUP-2758205,CDM,C1713,HCPCS,0278,RC,,,,both,,,3523.58,2290.33,,,,,,,,,,,,,
BLADE SAW SAG 190110127SS] ZIMMER BIOMET INC],SUP-2205533,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
HC So Hla Class II Typing Ea|UNUSUAL NON-OVERLAPPING SERVICE,PX-3108138266,CDM,81382,CPT,0310,RC,,,XU,both,,,203.00,131.95,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 7 CM DIA10 MM CATH DIA 0.018 IN,SUP-2170984,CDM,C1889,HCPCS,0278,RC,,,,both,,,338.68,220.14,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE W/ NL850500V 951303 CATH,SUP-2883567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,899.89,584.93,,,,,,,,,,,,,
ESUCTION ESOPH 3/BOX,SUP-2419431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.41,442.92,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X185 MM 14 HOLE SS LCP,SUP-2569340,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.46,343.50,,,,,,,,,,,,,
SCREW BONE PED L14MM DIA4.5MM LT RT CORT PROX FEM S STL LCK,SUP-2318598,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.36,585.23,,,,,,,,,,,,,
COMPONENT TOT KNEE BICOMPARTMENTAL MEDL LT W/O PAT RESURF,SUP-2165958,CDM,C1776,CPT,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
GRAFT BNE BLOCK LG TRICORT,SUP-2759482,CDM,C1713,HCPCS,0278,RC,,,,both,,,6369.77,4140.35,,,,,,,,,,,,,
STENT PERIPH PALMAZ L 29 MM DIA IL 6-8 MM SHTH 6-7 FR SS MED,SUP-2158986,CDM,C1877,HCPCS,0278,RC,,,,both,,,3146.28,2045.08,,,,,,,,,,,,,
SYSTEM LAP MED 18 CM INCISION CAP FOR SPEC EXTRACTION ALEXIS,SUP-2859553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE BNE W10.2XL104MM THK2.7MM 8 H BILAT S STL STR LO PROF,SUP-2186195,CDM,C1713,HCPCS,0278,RC,,,,both,,,1435.55,933.11,,,,,,,,,,,,,
GRIP CBL SM DIA1.6MM HIP VIT COMPHSVE RECON TRAUM DALL-M,SUP-2377579,CDM,C1776,CPT,0278,RC,,,,both,,,1274.84,828.65,,,,,,,,,,,,,
PIN EXTERNAL FIXATION 5 MM FOR PROTECTIVE CAP BLACK STERILE,SUP-2836757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,127.92,83.15,,,,,,,,,,,,,
TM TOTAL ANKLE RIGHT TALUS SIZE 6,SUP-2459324,CDM,C1776,CPT,0278,RC,,,,both,,,13074.11,8498.17,,,,,,,,,,,,,
STAPLE BONE FIXATION W22XH20XL22MM SUPERELASTIC ERGONOMIC LOW PROFILE BROAD BRIDGE DYNACLIP,SUP-2878406,CDM,C1713,HCPCS,0278,RC,,,,both,,,7991.30,5194.34,,,,,,,,,,,,,
PPICC PROVENA SOLO 3F SLEEVE MAX TL,SUP-2613554,CDM,C1751,HCPCS,0278,RC,,,,both,,,681.32,442.86,,,,,,,,,,,,,
STEM FEM L100MM DIA10MM KNEE CO CHROM ALLY PORCOAT STR CEM,SUP-2252656,CDM,C1776,CPT,0278,RC,,,,both,,,10385.55,6750.61,,,,,,,,,,,,,
BLADE SURG DIA4MM C STL HIP ARTHRO SHRP SHP DISP,SUP-2341875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
DEFIBRILLATOR CARD 41CC 14MM 36J LD W5CM BPLR DF4 IS1 CONN,SUP-2357760,CDM,C1882,HCPCS,0275,RC,,,,both,,,67510.00,43881.50,,,,,,,,,,,,,
SUPPORT ORTH HIP CIRC 48-60 IN LARGE/XL SZ 4 LUMSACR LP,SUP-2914959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.00,208.65,,,,,,,,,,,,,
SET INTRO 5FR L13CM ID1.7MM W/ 0.018IN GWIRE NDL MICPUNC,SUP-2168724,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.03,76.72,,,,,,,,,,,,,
HC Injection Im Sub Q,PX-2609637200,CDM,96372,CPT,0260,RC,,,,both,,,102.00,66.30,,,,,,,,,,,,,
IMPLANT HUM TISS RT ANK WHL OSTEOARTICULAR CUST MATCHED FRZN,SUP-2932942,CDM,C1762,CPT,0278,RC,,,,both,,,25586.92,16631.50,,,,,,,,,,,,,
PROSTHESIS PENILE L18CM TBNG L10CM IFP PARYLENE INFL,SUP-2138991,CDM,C1813,HCPCS,0278,RC,,,,both,,,39969.69,25980.30,,,,,,,,,,,,,
PLATE BNE SM L31MM THK1MM CENTRE SPACE 2.5MM 4 H MAND TI,SUP-2191207,CDM,C1713,HCPCS,0278,RC,,,,both,,,1523.21,990.09,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN MICRO 8SQCM,SUP-2909376,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
DEVICE ENDO L200CM SHTH OD1.9MM GRSP HYBRID JAW,SUP-2391615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.69,233.80,,,,,,,,,,,,,
PROBE SUCT DIA35MM CNTOUR W INTEGR CBL HND CTRL SERFAS,SUP-2367325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.24,262.76,,,,,,,,,,,,,
KIT INSRT AD PED VEN GWIRE L180CM DIA0038IN STP VES DIL 8FR,SUP-2282870,CDM,C1769,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
KIT CATH PALINDROME IMPL DL,SUP-2174248,CDM,C1881,HCPCS,0278,RC,,,,both,,,1267.68,823.99,,,,,,,,,,,,,
PLATE BONE 4 H S STL LT L SHP BTTRS,SUP-2198569,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.96,351.62,,,,,,,,,,,,,
NAPROXEN 500 MG PO TABS,RX-5393,CDM,6370000000,HCPCS,0637,RC,60687-0491-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT NSL DESIGN A LG 8X66 MM DORSUM SHP MEDPOR LF,SUP-2366464,CDM,C1889,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
ANCHOR SUT TI UP EXT ST W/ CIR TAPR NDL 2 STRANDS FULL THRD,SUP-2366679,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.57,567.17,,,,,,,,,,,,,
GRAFT BNE INJ 15 CC INDUCTIVE PRO-STIM,SUP-2759468,CDM,C1713,HCPCS,0278,RC,,,,both,,,17621.68,11454.09,,,,,,,,,,,,,
HC Capsule Endoscopy,PX-3609019000,CDM,3609019000,LOCAL,0750,RC,,,,both,,,3214.00,2089.10,,,,,,,,,,,,,
KIT DISPOSABLE 9MM,SUP-2200253,CDM,C1713,HCPCS,0278,RC,,,,both,,,1849.46,1202.15,,,,,,,,,,,,,
ROD EXT FIX SM L156MM DIA4MM 120DEG UNIV C FBR CRV CONN,SUP-2188718,CDM,C1713,HCPCS,0278,RC,,,,both,,,583.10,379.01,,,,,,,,,,,,,
NUT ORTH LCK 10 MM HEX QR,SUP-2749958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 17X0.3 MM LP C3 FOR NEURO SCR TI NS,SUP-2485895,CDM,C1713,HCPCS,0278,RC,,,,both,,,1702.38,1106.55,,,,,,,,,,,,,
PLATE BNE L97MM 12 H NONSTERILE STR RECON FOR 27MM SCR UNIV,SUP-2402650,CDM,C1713,HCPCS,0278,RC,,,,both,,,1304.04,847.63,,,,,,,,,,,,,
HC E/M Crit Care Each Addit 30min,PX-4509929200,CDM,99292,CPT,0450,RC,,,,inpatient,,,362.00,235.30,,,,,,,,,,,,,
DEFIBRILLATOR IMPL DYNAGEN MINI W 5.23 X H 6.71 CM D 0.99 CM,SUP-2149164,CDM,C1722,HCPCS,0275,RC,,,,both,,,29245.96,19009.87,,,,,,,,,,,,,
KIT PENILE PROS 30CM ACCSRY CONN BLNT NDL CVD KEITHTUBING,SUP-2165368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
BLADE REPROC CUTTER FULL RAD FORMULA SM JOINT 2.5MM,SUP-2653129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,104.44,67.89,,,,,,,,,,,,,
CATHETER GUID MERCI L 80 CM OD 8 FR ID 0.078 IN SS POLYUR,SUP-2367774,CDM,C1887,HCPCS,0272,RC,,,,both,,,3741.00,2431.65,,,,,,,,,,,,,
PLATE BNE 10 H ST BILAT S STL NAR CRV LOK COMPR FOR 45MM SCR,SUP-2178056,CDM,C1713,HCPCS,0278,RC,,,,both,,,2317.63,1506.46,,,,,,,,,,,,,
GRAFT BONE SUB 5ML PUTTY CA PHOS SYNTH GRAN BIOABSRB ATTRAX,SUP-2310453,CDM,C1763,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
STENT VASC L12MM BAL L15MM OD7MM DEL SYS L80CM 0.018IN M S,SUP-2159086,CDM,C1877,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
SCREW BNE PEDIATRIC 1 IN,SUP-2469167,CDM,C1713,HCPCS,0278,RC,,,,both,,,1528.40,993.46,,,,,,,,,,,,,
CATHETER CARD ABLATION COBRA FUSION 150 L 150 MM POLYUR,SUP-2124417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21509.00,13980.85,,,,,,,,,,,,,
PLATE BNE 9 H R DST CLAV LOK FOR 3.5MM SCR,SUP-2420259,CDM,C1713,HCPCS,0278,RC,,,,both,,,3384.92,2200.20,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 180 CM DIA 0.035 IN SS PTFE J STD,SUP-2157299,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
ALOE VESTA PROTECTIVE EX OINT,RX-22029,CDM,6370000000,HCPCS,0637,RC,83078-0113-14,NDC,,both,10,GR,4.20,2.73,,,,,,,,,,,,,
LEAD DEFIB INTRO 7FR L60X65X75CM OPTIM SGL COIL TRUE BPLR,SUP-2357377,CDM,C1777,HCPCS,0275,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
PROCEDURE PACK 4.5 MM DRL GUIDE STRL MORPHIX DISP,SUP-2277447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
INSERTION KIT ARTVEN PED BIO-MEDICUS NEXTGEN,SUP-2480656,CDM,C1769,HCPCS,0272,RC,,,,both,,,248.69,161.65,,,,,,,,,,,,,
GUIDEWIRE ENDO L600CM DIA0.035IN HYDRPHLC COAT L5CM TIP L5CM,SUP-2170824,CDM,C1769,HCPCS,0272,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
PACK HARV VEIN ENDOSCP VASOVIEW,SUP-2227757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.93,253.45,,,,,,,,,,,,,
CATHETER HD DL 14.5 FRX28 CM STR SHTH INTRO HEMO-FLOW XF,SUP-2269537,CDM,C1881,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
TUNNELER SURG AV SHTH KT 120DEG ROD 23.5CM,SUP-2127966,CDM,C1713,HCPCS,0278,RC,,,,both,,,1091.97,709.78,,,,,,,,,,,,,
STAPLER INT AD L55MM DIA5MM THCK TISS TI LIN 2 ROW STR,SUP-2283029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2009.03,1305.87,,,,,,,,,,,,,
INTRODUCER SHTH 5FR L4CM SHT GRY HUB W S STL DBL END GWIRE,SUP-2303307,CDM,C1893,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
HC Portal Vein Catheterization,PX-3613648100,CDM,36481,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
ALLOGRAFT DERMAL 10X40X0.8-1.8 MM DERM TISS MTRX PUROS,SUP-2210629,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH MED 7X5 CM ACELLULAR HYDRATED DERM,SUP-2321756,CDM,C1713,HCPCS,0278,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
HC So1 Hla Class II Typing Ea|UNUSUAL NON-OVERLAPPING SERVICE,PX-3108138267,CDM,81382,CPT,0310,RC,,,XU,outpatient,,,144.00,93.60,,,,,,,,,,,,,
RING TRNSJUG INTRAHEPATIC 18GA NDL L55CM 7FR INTRO PED ACCS,SUP-2168279,CDM,C1894,HCPCS,0272,RC,,,,both,,,1671.27,1086.33,,,,,,,,,,,,,
BUR SURG SYMTRC 6 MM 7.5 CM FOR DISECT TOOL MIDAS REX LEGEND,SUP-2630552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.56,301.96,,,,,,,,,,,,,
PLATE BNE CRANIOFACIAL N COMPR I R TI 30MM SCR H DIA 11 H,SUP-2366357,CDM,C1713,HCPCS,0278,RC,,,,both,,,1071.21,696.29,,,,,,,,,,,,,
ELECTRODE BALL 5FR L36CM FOR BPLR ELECSURG SYS GYNECARE,SUP-2218055,CDM,C1713,HCPCS,0278,RC,,,,both,,,1178.94,766.31,,,,,,,,,,,,,
SHELL ACET SPIK 42 MM HIP REFLECTION,SUP-2434759,CDM,C1776,CPT,0278,RC,,,,both,,,5645.72,3669.72,,,,,,,,,,,,,
CAP BNE CEM COMPR FEM,SUP-2368422,CDM,L8690,HCPCS,0278,RC,,,,both,,,303.95,197.57,,,,,,,,,,,,,
BRACE ANK SPRAIN AND TRAUM AND CHRONIC DISORD 1 SZ FIT MOST,SUP-2319275,CDM,L4350,HCPCS,0274,RC,,,,both,,,41.67,27.09,,,,,,,,,,,,,
BIT DRL L145MM DIA3.2MM ST HUM 3 FLUT QUIK CPL NDL PNT FOR,SUP-2178875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,689.54,448.20,,,,,,,,,,,,,
CATHETER SET TWO LUMEN 035 IN 12 FRX20 CM STR LG BOR PUR A+G,SUP-2627063,CDM,C1752,HCPCS,0278,RC,,,,both,,,222.59,144.68,,,,,,,,,,,,,
LOCKING RCNSTRCTN PLATE ANGLE ANGLE 34 HOLE 30MM THCK27MM,SUP-2680246,CDM,C1713,HCPCS,0278,RC,,,,both,,,7347.47,4775.86,,,,,,,,,,,,,
PAD THER CRYO L R SHLDR SL AD NONSTERILE W STRP ACCELERATED,SUP-2324440,CDM,L3650,HCPCS,0272,RC,,,,both,,,162.65,105.72,,,,,,,,,,,,,
HEAD HUM FX RT ANAT SHLDR SYS 40MM,SUP-2204878,CDM,C1776,CPT,0278,RC,,,,both,,,4917.24,3196.21,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X2 H BILAT HND RECTANG NONCOMPRESSION,SUP-2267884,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.10,421.26,,,,,,,,,,,,,
TRACKER PT NAVIGATE SPINPERC VPAD,SUP-2392604,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BLADE RTRCTR 60MMW X 70MML TTNM SPNL WIDE PRNGX6 DARK BLUE L,SUP-2457651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.71,567.91,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PTCH FD ASEP FASC LATA,SUP-2867079,CDM,C1762,CPT,0278,RC,,,,both,,,2192.51,1425.13,,,,,,,,,,,,,
MESH HERN W15.9XL26.1CM VENTRAL POLYPR EPTFE OVL,SUP-2125815,CDM,C1781,HCPCS,0278,RC,,,,both,,,2774.50,1803.42,,,,,,,,,,,,,
PLATE BNE LCK 10 MM 6 HOLE BAR CRV SAG SPLIT SMARTLOC,SUP-2421796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1458.69,948.15,,,,,,,,,,,,,
PLATE BONE W12XL119MM 7 H SEMI TBLR ECT,SUP-2198539,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.50,114.72,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT CRANIOTOMY INCL 14 MM DISP PERF,SUP-2257408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.25,493.51,,,,,,,,,,,,,
DEFIBRILLATOR LUMAX740 VR T HI ENERGY SYS W/ TI W/ CELLULAR,SUP-2138415,CDM,C1722,HCPCS,0275,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
GRFT CRUSH CANC 1-4MM 30CC PUROS,SUP-2693926,CDM,C1713,HCPCS,0278,RC,,,,both,,,3096.04,2012.43,,,,,,,,,,,,,
HC Red Blood Cells Each Unit,PX-3900902100,CDM,P9021,CPT,0390,RC,,,,both,,,1275.00,828.75,,,,,,,,,,,,,
DEVICE PROSTHETIC SHRINKER BK L8440] TIDEWATER PROSTHETICS],SUP-2388226,CDM,L8440,HCPCS,0274,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
PROSTHESIS PENILE CYLINDER/PUMP 16 CM,SUP-2165358,CDM,C1813,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT ENDOSCP CANN XL TIP PLAS ARTHSCP ATRAUM ACCS RADIOPAQUE,SUP-2882278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PROSOURCE TF PO LIQD,RX-126124,CDM,6370000000,HCPCS,0637,RC,70074-0583-02,NDC,,both,237,ML,10.70,6.95,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.025IN L 7CM 2.5CM SAFE-T-J FIX COR,SUP-2167593,CDM,C1769,HCPCS,0272,RC,,,,both,,,46.19,30.02,,,,,,,,,,,,,
HC Rep Lac Simple Face 20.1-30.0c,PX-4501201700,CDM,12017,CPT,0450,RC,,,,both,,,1445.00,939.25,,,,,,,,,,,,,
SCREW BNE FT 4X85 MM CANC STRL PERI-LOC,SUP-2348413,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.87,296.97,,,,,,,,,,,,,
HC Carboxyhemoglobin Quantitative,PX-3018237500,CDM,82375,CPT,0301,RC,,,,outpatient,,,120.00,78.00,,,,,,,,,,,,,
GRAFT BNE SUB W05XH05XL05CM 15ML CANC HYDRPHLC FRZ DRY,SUP-2264689,CDM,C1713,HCPCS,0278,RC,,,,both,,,616.70,400.85,,,,,,,,,,,,,
HC NM Thyroid Uptake Measurement,PX-3417801200,CDM,78012,CPT,0341,RC,,,,both,,,1380.00,897.00,,,,,,,,,,,,,
BAR EXT FIX L75MM DIA6MM COMP FOR JET-X FIX SYS,SUP-2342911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.99,475.14,,,,,,,,,,,,,
SCREW BNE CRTX 2.7X75 MM ST T8 STARDRV RECESS TI NS,SUP-2758221,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.07,102.75,,,,,,,,,,,,,
NEEDLE CUT REV B SER SZ 4 0 WIRE 043MM LEN 1307M,SUP-2109785,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SHELL ACET NEUT 28X42 MM HIP,SUP-2315329,CDM,C1776,CPT,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
BIT DRL L330MM DIA3.2MM CALIB L100MM ST 3 FLUT QUIK CPL FOR,SUP-2178853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,903.75,587.44,,,,,,,,,,,,,
WAVE CALCANEAL FRACTURE PLATE DRILL MODEL 2.7X160MM,SUP-2830339,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
MARKER BRST BX 8GA BOWTIE SHP MAMTOM,SUP-2195651,CDM,A4648,CPT,0278,RC,,,,both,,,358.27,232.88,,,,,,,,,,,,,
IMMOBILIZER ELBW SM L7IN FOR 7-9IN BICEP 6-8IN WR COT W/O,SUP-2269055,CDM,L3650,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
CATHETER THROMCTMY SOLITAIRE X TOT L 47 MM L 40 MM DIA 6 MM,SUP-2418751,CDM,C1757,HCPCS,0272,RC,,,,both,,,21125.92,13731.85,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAG CTRL STRP STAY PENDULOUS,SUP-2435558,CDM,L0649,HCPCS,0274,RC,,,,both,,,811.85,527.70,,,,,,,,,,,,,
SCREW CRTX FT SELF TAP HEX HD 4.5MM DIA 44MML,SUP-2342661,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.63,34.86,,,,,,,,,,,,,
CATHETER IV DL 5 FR DOT KT MBP BIOP PC NG POWERMIDLINE,SUP-2626740,CDM,C1751,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
SMALL ACP PLATE 27 8 HOLES L 68,SUP-2706086,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.83,265.74,,,,,,,,,,,,,
PLATE BNE L267MM THK3.4MM 20 H BILAT S STL STR LOK COMPR,SUP-2185158,CDM,C1713,HCPCS,0278,RC,,,,both,,,2262.87,1470.87,,,,,,,,,,,,,
STENT BILI PRECIS L 30 MM DIA 9 MM CATH L 135 CM DIA 6 FR,SUP-2155713,CDM,C1876,HCPCS,0278,RC,,,,both,,,5829.10,3788.91,,,,,,,,,,,,,
GRAFT BIO TISS W8XL8CM FET BOV SIL FEN ANTIMIC PRIMATRIX AG,SUP-2243713,CDM,Q4110,HCPCS,0636,RC,,,,both,,,7149.78,4647.36,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 18GA 8CM WNGD 1 LUMA F218081T,SUP-2632749,CDM,C1751,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
CATHETER CV KT AD 14 GAX16 CM SINGLE LUMEN N TUNNELED,SUP-2763391,CDM,C1751,HCPCS,0278,RC,,,,both,,,69.71,45.31,,,,,,,,,,,,,
GRAFT BNE L25MM DIA10MM ACL PCL CANC REV DWL FLEXIGRFT,SUP-2264648,CDM,C1713,HCPCS,0278,RC,,,,both,,,3161.45,2054.94,,,,,,,,,,,,,
GUIDEPIN ARTHSCP L15IN DIA2.4MM EYELET DRL TIP DISP FOR,SUP-2341575,CDM,C1769,HCPCS,0272,RC,,,,both,,,400.73,260.47,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID 0.25 CC AMNIO PLCNTA MEMBRN PRO3-F,SUP-2742030,CDM,C1762,CPT,0278,RC,,,,both,,,3022.25,1964.46,,,,,,,,,,,,,
GRAFT VASC PTCH 150X25X0.65 MM RVS LOCKNIT CLLGN COAT HEMGRD,SUP-2535424,CDM,C1768,CPT,0278,RC,,,,both,,,538.10,349.76,,,,,,,,,,,,,
PLATE SPNL 3 LEVEL WIDE 52 MM ANTR CERV ARCHON,SUP-2563408,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SCREW BNE L 28 MM DIA2 MM TI CANN HDLSS NS LEOS,SUP-2932634,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.43,450.08,,,,,,,,,,,,,
HANDPIECE SURG ANGLED UNIV REPL NOSE CONE CVR SONOPET,SUP-2791043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3254.33,2115.31,,,,,,,,,,,,,
PLATE BNE LT 12 HOLE SS NS,SUP-2177459,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.53,3214.59,,,,,,,,,,,,,
PLATE BNE MESHED PEDIATRIC 0.6 MM RT NEURO SMRT PTERIONAL,SUP-2481055,CDM,C1713,HCPCS,0278,RC,,,,both,,,9430.55,6129.86,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 15X30 MM FD PERIO FASC LATA ORAGRAFT,SUP-2740985,CDM,C1762,CPT,0278,RC,,,,both,,,247.09,160.61,,,,,,,,,,,,,
CANNULA PERF ARTRL 14N ACCPTNCE 12FR DIA 9INL CRMDA BCTVE C,SUP-2726388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.24,304.36,,,,,,,,,,,,,
HC US Guidance or Line Place W/ Permanent Image - Anes,PX-4027693701,CDM,76937,CPT,0402,RC,,,,both,,,791.00,514.15,,,,,,,,,,,,,
WIRE PASS DRL 1.3MM S,SUP-2361699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,100.07,65.05,,,,,,,,,,,,,
CATHETER PTCA L145CM BLLN L10MM DIA1.5MM DIA1.9X2.6FR,SUP-2158452,CDM,C1725,HCPCS,0272,RC,,,,both,,,516.75,335.89,,,,,,,,,,,,,
HC Perq Dev Breast Add MR Guide,PX-3611928800,CDM,19288,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
AUGMENT TIB THK 5 MM SZ EF TRABECULAR MTL LT MEDL HALF BLOCK,SUP-2887382,CDM,C1776,CPT,0278,RC,,,,both,,,4745.33,3084.46,,,,,,,,,,,,,
DRAIN CHN 19FR L0.25IN DIA6.3MM SIL RND HUBLESS FULL FLUT,SUP-2152753,CDM,C1729,HCPCS,0272,RC,,,,both,,,44.46,28.90,,,,,,,,,,,,,
FERROUS GLUCONATE 240 (27 FE) MG PO TABS,RX-25938,CDM,6370000000,HCPCS,0637,RC,00904-6403-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC So Lipid Panel,PX-3018006166,CDM,80061,CPT,0301,RC,,,,outpatient,,,43.00,27.95,,,,,,,,,,,,,
VALVE AORT BIOPROSTHESIS 25 MM 505 HANCOCK II CINCH II ULTRA,SUP-2429969,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE LDDR NEURO SCRW4 X 2 HOLES 30 MM,SUP-2707442,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.61,745.95,,,,,,,,,,,,,
COMPONENT GLEN FIX SM EDGE 4X6.8MM 8DEG LT POST AUG SHLDR,SUP-2223355,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PLATE BNE T LG 1.5X27X1 MM MIDFACE 8 HOLE W/ TAB TI STRL,SUP-2518115,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.31,535.15,,,,,,,,,,,,,
ELECTRODE ELECSURG DISPER RITA,SUP-2752471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
HC Ftl Fibronectin Cervicovag Secretions Semi-Quan,PX-3018273100,CDM,82731,CPT,0301,RC,,,,both,,,771.00,501.15,,,,,,,,,,,,,
HC So1 Herpes Simplex Type 1,PX-3028669567,CDM,86695,CPT,0302,RC,,,,both,,,28.00,18.20,,,,,,,,,,,,,
STAPLER INT 60 UNIV BLK W TRI STAPLE TECHNOLOGY ULT FOR 4,SUP-2395285,CDM,C1781,HCPCS,0278,RC,,,,both,,,550.29,357.69,,,,,,,,,,,,,
FRACTURE KIT 2ND SHT W/ POWERCURVE STABILIT,SUP-2497209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
FIBER LASER 1000 MH N TAPR POLISHED TIP HOLM ACCUMAX,SUP-2458813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1991.58,1294.53,,,,,,,,,,,,,
SCREW 4.0MMX38MM HEADLESS,SUP-2857923,CDM,C1713,HCPCS,0278,RC,,,,both,,,2750.64,1787.92,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X3 CM NUSHIELD,SUP-2314109,CDM,Q4160,HCPCS,0636,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE 2 CLMN DSTL VLR RAD 2.4MM 7H HD 4H SHFT LT STRL TI,SUP-2546712,CDM,C1713,HCPCS,0278,RC,,,,both,,,2738.52,1780.04,,,,,,,,,,,,,
HOOK SPNL DIA6.5MM BILAT PEDCL TI NEUT THRT W BLDE OPN FOR,SUP-2254523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
ALLOGRAFT BNE DURA MATER 8-30 SC PTCH ETO,SUP-2867076,CDM,C1763,HCPCS,0278,RC,,,,both,,,1291.64,839.57,,,,,,,,,,,,,
ENDOSCOPE NEURO 8X100 MM STRL AURORA SURGISCOPE LTX DISP,SUP-2863638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
PROSTHESIS OSS VENT TUBE 1.27X0.050X1.65 MM BUTTON FLROPLAS,SUP-2312804,CDM,L8699,HCPCS,0278,RC,,,,both,,,19.81,12.88,,,,,,,,,,,,,
SUPPORT ORTHOT HIP BILATERAL CUST COMBINATION,SUP-2435602,CDM,L1690,HCPCS,0274,RC,,,,both,,,5474.75,3558.59,,,,,,,,,,,,,
GRAFT BONE GEL IRRADIATED DEMINERLIZED BONE MTRX 10CC GRFTON,SUP-2307525,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.88,2024.67,,,,,,,,,,,,,
REDAPT SLVLS MONO STEM 240MM SZ 12 SO,SUP-2345577,CDM,C1776,CPT,0278,RC,,,,both,,,18136.64,11788.82,,,,,,,,,,,,,
PACK IMPL SM DIA3.2MM INCLUDE PROX DSTL SCR TAPR LCK PIN,SUP-2123610,CDM,C1713,HCPCS,0278,RC,,,,both,,,5645.72,3669.72,,,,,,,,,,,,,
IMPLANT PENILE 18CM CYL INFL MINOCYCLINE RIFAMPIN INHIBIZONE,SUP-2140280,CDM,C1813,HCPCS,0278,RC,,,,both,,,15527.30,10092.74,,,,,,,,,,,,,
AM PICC SET: 1-L 4.5FRX55CM 130CM HYDR,SUP-2822097,CDM,C1751,HCPCS,0278,RC,,,,both,,,425.31,276.45,,,,,,,,,,,,,
BONE MARROW KIT 5 PRT 11 GAX4 CM 10 CC W/ ASPIR NDL BMAX,SUP-2759688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
ELECTRODE ELECSURG 3 MMX40 CM NDL INSRT,SUP-2313616,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
COMPONENT TIB TY 1.5 KNEE TRUMATCH,SUP-2452944,CDM,C1776,CPT,0278,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
GRAFT HUM TISS M W11XL20CM THK0.7-1.4MM THN ACELLULAR,SUP-2307604,CDM,Q4128,HCPCS,0636,RC,,,,both,,,11417.04,7421.08,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 90CM 7FR COAT 15CM MP XCUT,SUP-2385204,CDM,C1894,HCPCS,0272,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
LONG DRL 3.0X30 10/PK KIT0733,SUP-2266525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
FRACTURE KIT 2ND LNG STABILIT,SUP-2458952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PLATE ORTH LNG ATCS STRL DISP 5 PER PK,SUP-2930431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1071.53,696.49,,,,,,,,,,,,,
WIRE FIX L100MM DIA16MM K,SUP-2243138,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.50,314.27,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT REUT BOB W/ FLNG H M 1.14 MM ID TI S,SUP-2284032,CDM,L8699,HCPCS,0278,RC,,,,both,,,71.28,46.33,,,,,,,,,,,,,
GRAFT HUM TISS W30XL40MM THK0.5MM ACELLULAR DERM RM TEMP,SUP-2264667,CDM,Q4125,HCPCS,0636,RC,,,,both,,,2910.43,1891.78,,,,,,,,,,,,,
HC Ins/Repl of Ppm/Vent.Only,PX-3613320700,CDM,33207,CPT,0361,RC,,,,both,,,9141.00,5941.65,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 10 H TI BX JUNCTION LP NS,SUP-2894524,CDM,C1713,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
GRAFT HUM TISS 9.5SQCM AMNIO MEMBRN MESH ALLGRFT DEHYDR N,SUP-2305742,CDM,Q4186,HCPCS,0636,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE DRILLABLE FAST SET PTTY NORIAN,SUP-2182829,CDM,C9359,HCPCS,0278,RC,,,,both,,,3695.50,2402.07,,,,,,,,,,,,,
FIBER LASER 550UM HOLM SMRT ID SYS REUSE FOR ALL LUMENIS LASER,SUP-2141791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1659.74,1078.83,,,,,,,,,,,,,
SCREW BNE L10MM DIA35MM ST CORT S STL ST FULL THRD HEX DRV,SUP-2178108,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.35,170.53,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 6 FR 0.025IN SS,SUP-2385483,CDM,C1894,HCPCS,0272,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
COVER BURR HOLE ULTRA LOW PRFLE 25MM DIA LG HLX2X3 03MM THK,SUP-2681383,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.63,591.91,,,,,,,,,,,,,
INTRODUCER SHTH LAMP 135 0.032 IN 3 MM 8 FRX63 CM 8 FRX67 CM,SUP-2357237,CDM,C1893,HCPCS,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
PIN FIX FOR SM FRAG SYS STRL A.L.P.S,SUP-2467661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
INSERT SNUS TARSI HYPERPRONATION FT HYPROCURE 8,SUP-2236087,CDM,C1776,CPT,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
BASEPLATE GLEN OD29MM STD TI POR SHLDR LAT AEQUALIS PERFORM,SUP-2388799,CDM,C1713,HCPCS,0278,RC,,,,both,,,5237.52,3404.39,,,,,,,,,,,,,
IMPLANT OTO W4MM W/ 9MM ABUTMENT DISP PONTO SYS,SUP-2319888,CDM,L8690,HCPCS,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
DEVICE FIX CRV ULT FAST-FIX AB,SUP-2341777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1164.78,757.11,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 5MM THREADED DISPOSABLE WITH T,SUP-2803690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.49,266.17,,,,,,,,,,,,,
DRILL GUIDE 23OVERDRILL 25NEUT CENTR,SUP-2695628,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
GUIDEWIRE VASC COPE L 60 CM DIA 0.018 IN TAPR L 7.25 CM FLPY,SUP-2168340,CDM,C1769,HCPCS,0272,RC,,,,both,,,92.60,60.19,,,,,,,,,,,,,
STAPLE BONE LEG W1.8XL18MM INTERAXIS L15MM CLP THK2.7MM BRDG,SUP-2175181,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
KIT CRAN ACCS RAZ SYR NDL FEN DRP W BARR WHT ABSRB TWL GZ,SUP-2244099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
ACET RECONSTRUCTION CAGE 58MM OD X54MM ID LT,SUP-2504592,CDM,C1776,CPT,0278,RC,,,,both,,,6983.36,4539.18,,,,,,,,,,,,,
PLATE BNE 24 H CRANIOMAXILLOFACIAL TI ADPT FOR 1.3MM,SUP-2190625,CDM,C1713,HCPCS,0278,RC,,,,both,,,2587.05,1681.58,,,,,,,,,,,,,
SCREW BNE L 48 MM DIA2.4 MM TI CORTICAL ST T7 DRV NS VLP,SUP-2931509,CDM,C1713,HCPCS,0278,RC,,,,both,,,212.77,138.30,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L70CM PERC PRELD ENH STYL,SUP-2138785,CDM,C1778,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
MESH SURGICAL CONTOURABLE 1.5X100X0.8 MM STERILE RAPIDSORB,SUP-2838579,CDM,C1713,HCPCS,0278,RC,,,,both,,,11530.71,7494.96,,,,,,,,,,,,,
CATHETER ABLATN LG CURL 2-5-2 MM SPC 7 FRX110 CM SAPHIRE BLU,SUP-2357498,CDM,C2630,CPT,0272,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
SET CBL GRP L DIA1.6MM VIT FOR HOWMEDICA OSTEONICS DALL-M,SUP-2377562,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.81,1402.58,,,,,,,,,,,,,
PLATE BNE STR REINF BAR 4 H MINI FOR 2MM UNIV FIX SYS,SUP-2366349,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.14,754.74,,,,,,,,,,,,,
PLATE BONE LOCKING MINI 2 MM MANDIBULAR 8 HOLE STRUT MALLEAB,SUP-2838413,CDM,C1713,HCPCS,0278,RC,,,,both,,,2349.66,1527.28,,,,,,,,,,,,,
SCREW BNE ST 3.5X24 MM W/ T15 STARDRV RECESS LCK FT TI NS,SUP-2190210,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.89,244.33,,,,,,,,,,,,,
TRAY CATH PICC LUMENX3 6FR OD POLYURETHANE SUBCLAV MAXIMAL B,SUP-2613373,CDM,C1751,HCPCS,0278,RC,,,,both,,,784.06,509.64,,,,,,,,,,,,,
HC Intracardiac Ecg (Ice),PX-4819366200,CDM,93662,CPT,0481,RC,,,,both,,,9073.00,5897.45,,,,,,,,,,,,,
HC Inj Anes/Steroid L/S Facet Sg,PX-3616449300,CDM,64493,CPT,0361,RC,,,,both,,,4864.00,3161.60,,,,,,,,,,,,,
GRAFT VASC GORTX L 45 CM DIA 6 MM RNG L 5 CM EPTFE STR TW,SUP-2396150,CDM,C1768,CPT,0278,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
PLATE BONE L194MM 6X24X6 H BILAT MAND ORAL MAXILLOFACIAL TI,SUP-2191433,CDM,C1713,HCPCS,0278,RC,,,,both,,,10702.06,6956.34,,,,,,,,,,,,,
TUBE TRACH AD L110MM OD92MM ID6MM SIL CUF ADJUSTABLE NK FLNG,SUP-2352022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,929.41,604.12,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY W PAT STRP 20IN,SUP-2195122,CDM,L1830,CPT,0274,RC,,,,both,,,58.69,38.15,,,,,,,,,,,,,
CATHETER BLLN DIL 7.5 FRX180 CM 15-18 MMX5.5 CM CRE RX,SUP-2417343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
ELECTRODE ES URLGY 24FR DIA 12DG CTTNG LOOP HF RSCTN ST DSPS,SUP-2720512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.86,443.86,,,,,,,,,,,,,
PROBE LASER 25GA PRECIS FBR CNTR PLAS HND PC STR DISP RFID,SUP-2109915,CDM,C1713,HCPCS,0278,RC,,,,both,,,3509.14,2280.94,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED LG PRIORITY + PEEK NS LTX,SUP-2862817,CDM,C1713,HCPCS,0278,RC,,,,both,,,59393.10,38605.51,,,,,,,,,,,,,
HC L Heart Vgram W Graft|UNUSUAL NON-OVERLAPPING SERVICE,PX-4819345900,CDM,93459,CPT,0481,RC,,,XU,both,,,16603.00,10791.95,,,,,,,,,,,,,
TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS,RX-31684,CDM,6370000000,HCPCS,0637,RC,00904-6821-04,NDC,,both,1,UN,21.30,13.84,,,,,,,,,,,,,
DILTIAZEM HCL ER 60 MG PO CP12,RX-14100,CDM,6370000000,HCPCS,0637,RC,00378-6060-01,NDC,,both,1,UN,11.50,7.47,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA5MM S STL BLNT TRCR PNT MR,SUP-2186953,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.18,151.57,,,,,,,,,,,,,
CONE TIP URETERAL CATHETER,SUP-2827459,CDM,C1758,HCPCS,0278,RC,,,,both,,,38.56,25.06,,,,,,,,,,,,,
BLADE REPROC SAW SAG FINE FLAT 5.5X18.5X0.4MM,SUP-2652955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.81,42.78,,,,,,,,,,,,,
SALVATION  BEAM 7.0 X 110MM THREAD,SUP-2459140,CDM,C1713,HCPCS,0278,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
PLATE BONE LOCKING 4.5X255 MM RIGHT LATERAL PROXIMAL TIBIAL,SUP-2837468,CDM,C1713,HCPCS,0278,RC,,,,both,,,11909.08,7740.90,,,,,,,,,,,,,
BUR SURG LNG WAVED SPRL FOR CRANIOTOME HNDPC STRL DISP,SUP-2937208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
MESH SYN ABD N ABSRB RECT POLYPR W EXP,SUP-2126098,CDM,C1781,HCPCS,0278,RC,,,,both,,,6053.92,3935.05,,,,,,,,,,,,,
INQUIRY H CURVE STEER DUO DEC 1120 7 5 HL,SUP-2698839,CDM,C1731,HCPCS,0278,RC,,,,both,,,3969.59,2580.23,,,,,,,,,,,,,
PLATE BNE 40 H SCREW DIA1.5 MM TI CMF REG STR NS LORENZ,SUP-2883777,CDM,C1713,HCPCS,0278,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
BLOCKER EB 7FR L75MM Y SHP BIFUR DST END 1 LUNG VENT EZ,SUP-2384373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.09,607.81,,,,,,,,,,,,,
PLATE BNE L116MM 4 H ST L OLECRANON TI LO PROF VAR ANG LOK,SUP-2180820,CDM,C1713,HCPCS,0278,RC,,,,both,,,3886.63,2526.31,,,,,,,,,,,,,
BLADE RTRCTR BLFR 2 34NW X 9 12NL X 2 34ND SPRPBC CNTR,SUP-2706029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,205.83,133.79,,,,,,,,,,,,,
KIT INFUS PMP 270ML 4ML/HR 2ML/SITE SOAK CATH L2.5IN,SUP-2236828,CDM,C9804,HCPCS,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
STAPLE SPNL TI THOR RSTRL 2 PRNG IMPL VANTAGE,SUP-2292685,CDM,C1713,HCPCS,0278,RC,,,,both,,,3068.97,1994.83,,,,,,,,,,,,,
GRAFT BONE PUTTY SYR FRZ DRY DEMIN BONE MTRX 1CC,SUP-2136835,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
SHEATH INTRO 30 DEG 8.5 FRX60 CM HEARTSPAN,SUP-2464534,CDM,C1894,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
BLOCK TIB PLT HALF MEDL RT LAT LT W/ 2 SCR SZ 2 10MM THCK,SUP-2359282,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
INSERT TIB SZ 4 THK14MM POST STBL FIX GMK,SUP-2267511,CDM,C1776,CPT,0278,RC,,,,both,,,2452.65,1594.22,,,,,,,,,,,,,
GRAFT BNE 166 202MM FEM SHFT FRZN BIOCLEANSE STRL,SUP-2335566,CDM,C1713,HCPCS,0278,RC,,,,both,,,8013.28,5208.63,,,,,,,,,,,,,
DRIVER NAV2024 SOLERA 475 STD MAS,SUP-2281197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2806.38,1824.15,,,,,,,,,,,,,
POST EXT FIX FEMALE 4 HOLE,SUP-2471881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ALLOGRAFT TISS 3X4 CM MTRX REGENERATIVE,SUP-2393052,CDM,Q4170,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SUPPORT EL NEOPRENE 7 9IN SM,SUP-2276612,CDM,L3702,HCPCS,0272,RC,,,,both,,,9.36,6.08,,,,,,,,,,,,,
HC Drug Screen Quantitative Gentamicin,PX-3018017000,CDM,80170,CPT,0301,RC,,,,inpatient,,,147.00,95.55,,,,,,,,,,,,,
SEALANT TISS 4 CC FIBRIN VISTASEAL,SUP-2421675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.48,477.41,,,,,,,,,,,,,
SCREW BNE 2.4MM DIA 12MML STAINLES STL HEXDRVR SPIDER,SUP-2604356,CDM,C1713,HCPCS,0278,RC,,,,both,,,294.16,191.20,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-40840056,CDM,J3490,HCPCS,0258,RC,00338-0085-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 51-150 MMX0.3 CM FRZN,SUP-2717852,CDM,C1762,CPT,0278,RC,,,,both,,,4749.41,3087.12,,,,,,,,,,,,,
GUIDEWIRE 1.2MMX9IN BX OF 5 STRL,SUP-2341058,CDM,C1769,HCPCS,0272,RC,,,,both,,,121.20,78.78,,,,,,,,,,,,,
NAIL IM L48CM OD13MM GLD TIB KNEE RG AG LCK CANN TRIGEN,SUP-2347124,CDM,C1713,HCPCS,0278,RC,,,,both,,,5636.93,3664.00,,,,,,,,,,,,,
CROWN DENT 1 S STL SEC PRI M UP LT ANTR CUSPID PREFABRICATED,SUP-2238912,CDM,D6783,CPT,0278,RC,,,,both,,,21.48,13.96,,,,,,,,,,,,,
PLATE BNE L135MM 8 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185274,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
INSERT SCRDRVR TORX STARDRV T6 FOR SCREW STRL DISP OPERACE,SUP-2913550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1923.82,1250.48,,,,,,,,,,,,,
SCREW BONE L65MM DIA5MM PARTIALLY THRD FOR ARTH NAIL SYS,SUP-2417660,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.78,1220.56,,,,,,,,,,,,,
PLATE BNE L 33 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 4 H SS,SUP-2933117,CDM,C1713,HCPCS,0278,RC,,,,both,,,1364.55,886.96,,,,,,,,,,,,,
SCREW BNE CANN 3.5X10 MM SD FT SS,SUP-2409798,CDM,C1713,HCPCS,0278,RC,,,,both,,,542.59,352.68,,,,,,,,,,,,,
INSERT TIB L83MM THK18MM UNIV KNEE PRI ANTR STBL NEUT ASCNT,SUP-2407235,CDM,C1776,CPT,0278,RC,,,,both,,,3114.88,2024.67,,,,,,,,,,,,,
BUR SURG BALL 4 MMX10 CM FLUT SM BOR MIDAS REX LEGEND,SUP-2627621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.29,205.59,,,,,,,,,,,,,
PROSOURCE NO CARB PO LIQD,RX-102212,CDM,6370000000,HCPCS,0637,RC,94688-0114-44,NDC,,both,45,ML,5.70,3.70,,,,,,,,,,,,,
PLATE BONE L94MM 4 H RT LAT PROX TIB S STL LCK FOR 4.5MM SCR,SUP-2348227,CDM,C1713,HCPCS,0278,RC,,,,both,,,14665.53,9532.59,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 0 DEG 9 MM LORDTC TRICORT STRL BIO DISP,SUP-2632311,CDM,C1713,HCPCS,0278,RC,,,,both,,,3026.96,1967.52,,,,,,,,,,,,,
SPLINT COLLES W FOAM L ARM PERF ALUMINIUM XR LUCENT TAN AD,SUP-2336083,CDM,L3908,HCPCS,0274,RC,,,,both,,,12.18,7.92,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK45UM AMNIO MEMBRN DEHYDR OMNI DIR,SUP-2340455,CDM,C1762,CPT,0278,RC,,,,both,,,11709.06,7610.89,,,,,,,,,,,,,
BIT DRL 0.125 INX35 MM FLX,SUP-2397076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
COMPONENT 6X200MM HUMERAL ELBOW FLANGED C RIGHT DISCOVERY,SUP-2879138,CDM,C1776,CPT,0278,RC,,,,both,,,17091.02,11109.16,,,,,,,,,,,,,
HYALURONIDASE BOVINE 15 UNITS/ML IJ SYRINGE,RX-40891037,CDM,J3470,HCPCS,0636,RC,09999-9917-18,NDC,,both,0.2,ML,64.20,41.73,,,,,,,,,,,,,
GRAFT SYNTHETIC TISSUE GRANULE 1.42.8 MM 2.5 CC BETA TRICALC,SUP-2838533,CDM,C1713,HCPCS,0278,RC,,,,both,,,1149.55,747.21,,,,,,,,,,,,,
BIT DRL L 295 MM DIA 5 MM LNG CANN QC STRL REUSE,SUP-2905576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2429.76,1579.34,,,,,,,,,,,,,
RING EXT FIX ID230MM ALUM 2/3 W/ 7 H MSTR TAB TAY SPAT FRME,SUP-2343036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7279.46,4731.65,,,,,,,,,,,,,
PLATE BNE RECON LG 2-2.3X2.8 MM RT PRESHAPED SMRT TI NS,SUP-2481226,CDM,C1713,HCPCS,0278,RC,,,,both,,,10230.87,6650.07,,,,,,,,,,,,,
DISTRACTION INTRNL DIST ALVLR TRACK 15 END DRV 15 18 MM S,SUP-2680407,CDM,C1713,HCPCS,0278,RC,,,,both,,,2976.22,1934.54,,,,,,,,,,,,,
PEG SUBTALAR FT DEFORMITY STA PEG SM,SUP-2397143,CDM,C1713,HCPCS,0278,RC,,,,both,,,6926.84,4502.45,,,,,,,,,,,,,
HEAD FEM OD28MM +0MM 12/14 TAPR LO WR FRAC TOUGH PLT TYP,SUP-2222420,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
HC NM Cardiac Muga Scan Gated Restin,PX-3417847200,CDM,78472,CPT,0341,RC,,,,both,,,1924.00,1250.60,,,,,,,,,,,,,
DRESSING NSL EPISTAXIS L 4 X W 2.4 CM THK 0.3 CM POLYETHYL,SUP-2900166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
CASE GRFT ENDURANT II NIT POLYESTER 4 PC AORTO-UNI-ILIAC,SUP-2873752,CDM,C1768,CPT,0278,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
PLATE CRAN W200XL200MM NONSTERILE TI RECTANG RIG CNTOUR MESH,SUP-2190623,CDM,C1713,HCPCS,0278,RC,,,,both,,,28608.54,18595.55,,,,,,,,,,,,,
BAR XTRAFIX 11MM CRBN 250,SUP-2495831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.02,423.81,,,,,,,,,,,,,
SCREW BONE L90/85MM LAG COMPR INTEGR KT META-TAN,SUP-2340868,CDM,C1713,HCPCS,0278,RC,,,,both,,,4096.60,2662.79,,,,,,,,,,,,,
KIT UPHOLD SLNG,SUP-2141765,CDM,C1763,HCPCS,0278,RC,,,,both,,,6075.90,3949.33,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6 MM EPTFE STR STD WALL,SUP-2396189,CDM,C1768,CPT,0278,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
GUIDEWIRE SPNL K TRCR TIP 1.6X500MM NIT,SUP-2354587,CDM,C1769,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 7 FRX15 CM 13 GA 3L SPECTRUM,SUP-2759868,CDM,C1751,HCPCS,0278,RC,,,,both,,,476.62,309.80,,,,,,,,,,,,,
COVER BURR H DIA24 MM THK 0.75 MM CRANIOFACIAL CIR,SUP-2883439,CDM,C1713,HCPCS,0278,RC,,,,both,,,2608.37,1695.44,,,,,,,,,,,,,
PLATE BNE L238MM BLDE W58XL38MM 130DEG 14 H NONSTERILE BILAT,SUP-2186589,CDM,C1713,HCPCS,0278,RC,,,,both,,,2786.81,1811.43,,,,,,,,,,,,,
BIT DRL 12 MM OPENING FOR SUPRAPATELLAR INSTRUMENT T2,SUP-2488136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,982.82,638.83,,,,,,,,,,,,,
PEG 4.0MM X 25.0MM THRD S STL S3 PROX HUM PLATING SYS,SUP-2414223,CDM,C1776,CPT,0278,RC,,,,both,,,360.44,234.29,,,,,,,,,,,,,
BUR SURG L 9 CM DIA 3 MM MTCH SYM TRI DISECT TOOL STRL DISP,SUP-2930042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
NEEDLE SUTURE KNOTLESS IMPL SYS MULTFI SWIVELOCK C SCORPION,SUP-2845509,CDM,C1713,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 8 FR B-B CRV,SUP-2727177,CDM,C2630,CPT,0272,RC,,,,both,,,4920.38,3198.25,,,,,,,,,,,,,
CATHETER DRAINAGE INTRO 17 FRX18 CM RET FLEX BIO-MEDICUS LS,SUP-2745333,CDM,C1729,HCPCS,0272,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM WHL MEM AMNIO SHT NO ANG AMINOFIX,SUP-2305724,CDM,C1762,CPT,0278,RC,,,,both,,,3463.42,2251.22,,,,,,,,,,,,,
PLATE BNE CLAV STD 3.5X110 MM LT 10 HOLE SUP NS A.L.P.S,SUP-2471021,CDM,C1713,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
CATHETER EP LG CURL 2-4-2 MM SPC 2 MM TIP,SUP-2867388,CDM,C1730,HCPCS,0272,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
BUR SURG OD40MM LNG DMND ECOARSE RND N FLUT ST FOR TPS,SUP-2363361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.51,205.08,,,,,,,,,,,,,
BRACE KNEE BLEDSOE BRAC II,SUP-2341214,CDM,L1810,HCPCS,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
PIN FIX DIA3.2MM FOR GLOB AP SHLDR ARTHROPLASTY SYS,SUP-2252797,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
CAGE SPNL L10XW10XH15MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317726,CDM,C1889,HCPCS,0278,RC,,,,both,,,5790.16,3763.60,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 7 MM DEL SHTH,SUP-2934157,CDM,C1713,HCPCS,0278,RC,,,,both,,,6550.04,4257.53,,,,,,,,,,,,,
SYSTEM DEL CATH 14FR WRK L107CM CAP DIA6MM W/ 30CM INLINE,SUP-2419637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
GRAFT BNE R OSTEOCHNDRL TROCHLEA FRSH STORED,SUP-2335301,CDM,C1713,HCPCS,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
BIT DRL DIA3 4MM OVERDRL FOR TC CANN SCR SYS CAPTURE,SUP-2243906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,728.76,473.69,,,,,,,,,,,,,
INSERT TIB CS 4 11 MM KNEE TRIATHLON,SUP-2363730,CDM,C1776,CPT,0278,RC,,,,both,,,4966.38,3228.15,,,,,,,,,,,,,
GRAFT BNE INJ 7 CC INDUCTIVE PRO-STIM,SUP-2759438,CDM,C1713,HCPCS,0278,RC,,,,both,,,10161.04,6604.68,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZ DRY CANC STRL 1-10MM 15CC,SUP-2165536,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
PROCESSOR SND SYS,SUP-2141841,CDM,L8691,HCPCS,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
GRAFT BONE SUB 5CC CA PHOS VIT E ACETT HEMSTAT COHESIVE,SUP-2106300,CDM,C1713,HCPCS,0278,RC,,,,both,,,5491.86,3569.71,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 4 HOLE,SUP-2518361,CDM,C1713,HCPCS,0278,RC,,,,both,,,2901.36,1885.88,,,,,,,,,,,,,
CATHETER INTVASC OCCL L 80 CM DIA2 FR BALLOON L 7 CM DIA 7,SUP-2141027,CDM,C2628,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122220,CDM,J7168,HCPCS,0636,RC,63833-0386-02,NDC,,both,1,UN,4395.50,2857.07,,,,,,,,,,,,,
DISC CERV H6MM DIA14MM TI CERAMIC PROS PRESTIGE LP,SUP-2286936,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SET PERICARDCENT CATH 8.3FR L40CM GWIRE L70CM DIA0.038IN 6,SUP-2167856,CDM,C1729,HCPCS,0272,RC,,,,both,,,459.07,298.40,,,,,,,,,,,,,
LINER ACET OD52MM ID28MMXLPE HIP CEM ANTEVERTED REDAPT,SUP-2345493,CDM,C1776,CPT,0278,RC,,,,both,,,3292.29,2139.99,,,,,,,,,,,,,
BIT DRL L50MM DIA1MM 6MM STP FOR 1.2MM SCR UP FACE,SUP-2366399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.82,251.43,,,,,,,,,,,,,
PLATE BONE L55MM THK3.8MM 3 H BILAT S STL NAR DYN COMPR FOR,SUP-2185202,CDM,C1713,HCPCS,0278,RC,,,,both,,,627.37,407.79,,,,,,,,,,,,,
CANNULA VOID FIL DEL L 450 MM DIA 7.8 MM ERGO T HNDL UNIV LL,SUP-2893104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
STRAP CLAV FOAM PADDED 42-48 IN X LG BCKL CLOSURE PROCARE,SUP-2195760,CDM,L3650,HCPCS,0274,RC,,,,both,,,15.57,10.12,,,,,,,,,,,,,
SENSOR OXMTR PTCH TISS DISP,SUP-2392934,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
PLATE BONE W6.3XL66MM THK1.6MM 5X5 H LT DSTL VOLAR RAD TI,SUP-2191011,CDM,C1713,HCPCS,0278,RC,,,,both,,,2033.06,1321.49,,,,,,,,,,,,,
BLADE SAW W9XL31MM THK038MM CUT THK064MM REPL S STL SAG,SUP-2150759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,27.19,17.67,,,,,,,,,,,,,
OSTEOTOME SURG STRL DISP TRITOME,SUP-2893054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE L 90 MM SCREW DIA2.7/3.5 MM 7 H LL DSTL HUM STRL,SUP-2931162,CDM,C1713,HCPCS,0278,RC,,,,both,,,5042.21,3277.44,,,,,,,,,,,,,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.7 MG/125ML-% IV SOLN,RX-148148,CDM,2500000003,HCPCS,0250,RC,69374-0997-15,NDC,,both,125,ML,82.70,53.75,,,,,,,,,,,,,
BUR SURG DIA 8 MM HUB I ROSEN STRL REUSE HI-LINE,SUP-2929616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,261.41,169.92,,,,,,,,,,,,,
BLADE SCRDRVR ASSEMB W/ GRSP SL FOR MAND FX,SUP-2364413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3111.36,2022.38,,,,,,,,,,,,,
LEAD NERVE STIM 4.32 MM INTERSTIM SURESCAN,SUP-2550571,CDM,C1778,HCPCS,0278,RC,,,,both,,,11508.10,7480.26,,,,,,,,,,,,,
APPLIER CLP XL 10 MMX32 CM MANUAL LOAD HEM-O-LOK ENDO10,SUP-2656814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3256.18,2116.52,,,,,,,,,,,,,
HC So Igk Rearrangeabn Clonal Pop,PX-3108126466,CDM,81264,CPT,0310,RC,,,,both,,,445.00,289.25,,,,,,,,,,,,,
GUIDEWIRE VASC STYL S52ZYJD,SUP-2616264,CDM,C1769,HCPCS,0272,RC,,,,both,,,67.51,43.88,,,,,,,,,,,,,
SCREW BNE EMGCY 2X17 MM CNTRDRV,SUP-2262657,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.75,64.19,,,,,,,,,,,,,
INSERT HUM OD36MM THK+6MM SHLDR POLY CONSTRN AEQUALIS,SUP-2388688,CDM,C1776,CPT,0278,RC,,,,both,,,6397.75,4158.54,,,,,,,,,,,,,
HALF PIN 5MMX90MM,SUP-2818080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1126.95,732.52,,,,,,,,,,,,,
KNIFE FREER ANG SEPT 7IN,SUP-2162137,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.02,258.06,,,,,,,,,,,,,
CABLE SPNL NERVE MONITORING LG RETRACTOR SYS CLARITY,SUP-2713115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
EPIFIX DISC 18MM,SUP-2305747,CDM,Q4186,HCPCS,0636,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
IMPLANT STAP LOOP PIST FLROPLAS S STL 06MM DIA 525MM LEN,SUP-2313659,CDM,C1769,HCPCS,0272,RC,,,,both,,,300.03,195.02,,,,,,,,,,,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,0636,RC,63323-0286-35,NDC,,both,15,ML,65.00,42.25,,,,,,,,,,,,,
NAIL IM BLNT TIP 4X40 MM HUM STRL AFFIXUS NAT NAIL,SUP-2606842,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
TRIAL BONE PLT 5 H T SHP TC-100 SM FRAG SYS,SUP-2343728,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.08,997.80,,,,,,,,,,,,,
HC Scs Analysis W/O Program,PX-9209597000,CDM,95970,CPT,0920,RC,,,,both,,,418.00,271.70,,,,,,,,,,,,,
METHOCARBAMOL 1000 MG/10ML IJ SOLN,RX-129226,CDM,J2800,HCPCS,0636,RC,71288-0716-11,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L W135XL152MM THK42MM 8 H BILAT TI NAR RIG NEUT,SUP-2190816,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.84,921.60,,,,,,,,,,,,,
EXTRACTOR SURG L5 MMXTRACT ALL DISP FOR 4.5-6 MM BROKEN SCR,SUP-2337707,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX HUMERUS LONG 12H SHAFT 268MM STER,SUP-2549719,CDM,C1713,HCPCS,0278,RC,,,,both,,,6088.59,3957.58,,,,,,,,,,,,,
GRAFT HUM TISS W8XL260MM STRUT SEMITENDINOSUS W/ GRACILIS,SUP-2137076,CDM,C1713,HCPCS,0278,RC,,,,both,,,5410.22,3516.64,,,,,,,,,,,,,
CATHETER VENT DRNGE L45CM OD1.3MM ID0.8MM SIL DST ATR TYP A,SUP-2243793,CDM,C1729,HCPCS,0272,RC,,,,both,,,144.13,93.68,,,,,,,,,,,,,
FIBER LASER DVDF DVI-SC W/ WALL PLATE,SUP-2798107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2234.42,1452.37,,,,,,,,,,,,,
IMPL KWIRES TROCAR 3813 2 090,SUP-2707054,CDM,C1713,HCPCS,0278,RC,,,,both,,,110.69,71.95,,,,,,,,,,,,,
CATHETER INTRAAORTIC BLLN 7.5FR 30CC L25.3IN SHTH L6IN CTRL,SUP-2383464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX11 TTNM RCNSTRCTN F/3.5MM SCREW U,SUP-2492990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA 4.7 MM SS FT LCK OSTEOPENIA STRL EVOS,SUP-2931486,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.61,389.75,,,,,,,,,,,,,
SLEEVE FEM NK L 3MM UPLR HIP 10 12 TAPR EXT ADPT ULT,SUP-2253259,CDM,C1776,CPT,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840052,CDM,2580000003,HCPCS,0258,RC,00264-7800-09,NDC,JW,both,250,ML,6.40,4.16,,,,,,,,,,,,,
SCREW INTFR L30MM DIA9MM BIOSURE REGENESORB,SUP-2341923,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.31,752.25,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 15 CM FLPY TIP L,SUP-2167810,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.41,30.82,,,,,,,,,,,,,
CATHETER CTRL VEN PED 6.6FR 0.3ML L71CM SGL LUMN SURECUF,SUP-2126153,CDM,C1751,HCPCS,0278,RC,,,,both,,,491.10,319.21,,,,,,,,,,,,,
SCREW BNE CANN 2.5X8 MM LP TI CAPTURE,SUP-2609528,CDM,C1713,HCPCS,0278,RC,,,,both,,,825.41,536.52,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THCK AMNIO BARR MEM CHORION BASE,SUP-2399182,CDM,C1762,CPT,0278,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZ DRY CANC 4MM 10MM RANG 15CC,SUP-2264674,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.03,438.12,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH THCK 5X4 CM ACELLULAR HYDRATED DERM,SUP-2321761,CDM,C1713,HCPCS,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 145 CM DIA 0.035 IN TAPR 11 CM,SUP-2170673,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.79,94.76,,,,,,,,,,,,,
GRAFT BNE CRUSH 15 CC,SUP-2137585,CDM,C1734,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BIT DRL L45MM 15MM FLUT WIRE PASS,SUP-2166389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,107.17,69.66,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS PAT W/ EXT MECHANISM IRR,SUP-2875982,CDM,C1762,CPT,0278,RC,,,,both,,,13050.63,8482.91,,,,,,,,,,,,,
HC So Lactic Acid,PX-3018360566,CDM,83605,CPT,0301,RC,,,,both,,,124.00,80.60,,,,,,,,,,,,,
CASSETTE ANALGESIC PMP FILTER APC SYS NS LF DISP AMBIT,SUP-2892644,CDM,C9806,HCPCS,0272,RC,,,,both,,,820.33,533.21,,,,,,,,,,,,,
CATHETER CTRL VEN 7FR POLYUR DBL LUMN INDWL RADPQ W/ BLU,SUP-2383473,CDM,C1751,HCPCS,0278,RC,,,,both,,,79.44,51.64,,,,,,,,,,,,,
PLATE BNE SPCR 0MM 4 H NONSTERILE MIDFOOT TI VAR ANG LOK OPN,SUP-2181212,CDM,C1713,HCPCS,0278,RC,,,,both,,,3387.12,2201.63,,,,,,,,,,,,,
CONNECTOR ROD 6.35X21.5MM SPINE TRNSVRS TI SYNERGY,SUP-2415610,CDM,C1713,HCPCS,0278,RC,,,,both,,,1387.28,901.73,,,,,,,,,,,,,
PLATE BNE L235MM 10 H ST R PERIARTC PROX HUM S STL LOK LO,SUP-2177815,CDM,C1713,HCPCS,0278,RC,,,,both,,,6004.25,3902.76,,,,,,,,,,,,,
MESH HERN RECT 8X4 IN FULL RESRB FOR SFT TISS PHASIX ST,SUP-2855260,CDM,C1781,HCPCS,0278,RC,,,,both,,,10996.28,7147.58,,,,,,,,,,,,,
COIL NEUROVASCULAR DELTAMAXX CERECYTE L 33 CM DIA 7 MM,SUP-2460527,CDM,C1889,HCPCS,0278,RC,,,,both,,,7605.80,4943.77,,,,,,,,,,,,,
NAIL IM ZCKL II SUBTROCHANTERIC 17MMX350MM ROD RT,SUP-2364778,CDM,C1713,HCPCS,0278,RC,,,,both,,,4858.68,3158.14,,,,,,,,,,,,,
BLADE SCREWDRIVER ANGLED FOR 2 MM SCR SS LEVEL 1 ANGULUS 2,SUP-2470545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.07,273.70,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB W/ 10150 SYS 10520 CATH,SUP-2883581,CDM,C1729,HCPCS,0272,RC,,,,both,,,661.03,429.67,,,,,,,,,,,,,
PLATE BNE 4 H L MINI SM W TAB FOR PINIFORM RIM AND ZYG BTTRS,SUP-2262739,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.12,492.13,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 10MMW X 13MML 0.4MM THK 0.6MM THK CUT SM,SUP-2586281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.12,42.33,,,,,,,,,,,,,
CANNULA ENDOSCP 11GA L120MM SIDE DEL ACCUPORT,SUP-2414252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1494.64,971.52,,,,,,,,,,,,,
SHEATH GUID HALO 1 L 70 CM DIA 5 FR DIL L 77.5 CM GUIDEWIRE,SUP-2890321,CDM,C1887,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
SLEEVE CBL M VIT FOR USE W/ 2MM CBL DALL-M,SUP-2377578,CDM,C1776,CPT,0278,RC,,,,both,,,453.42,294.72,,,,,,,,,,,,,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,6370000000,HCPCS,0637,RC,16714-0496-01,NDC,,both,15,GR,98.70,64.15,,,,,,,,,,,,,
GUIDEWIRE 21038 TEFLON COATED 100CM,SUP-2277902,CDM,C1769,HCPCS,0272,RC,,,,both,,,205.51,133.58,,,,,,,,,,,,,
BIT DRL SURG 25 MM SLD W/ STP DISP,SUP-2223991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
BRAIN STIMULATOR KIT REMOT CTRL 3 VERCISE,SUP-2845267,CDM,C1787,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
COMPONENT HUM SM L4IN UNIV DST EL TIV PLSM INTERCHANGEABLE,SUP-2205912,CDM,C1776,CPT,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
SIZER SURG 295 CC BRST STYL SSZ FULL PROF NATRELLE INSPIRA,SUP-2753001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
FIBER HOLM LSR SIDE FIRING,SUP-2225717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
CATHETER DRAINAGE EXT 35 CM CSF VENTRICULAR,SUP-2257147,CDM,C1729,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 IN 3 CM 5 FRX14 CM STIFF SHFT,SUP-2463614,CDM,C2617,HCPCS,0278,RC,,,,both,,,589.44,383.14,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH 48 DEG L 110 CM DIA 7 FR GUIDEWIRE,SUP-2355529,CDM,C1894,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
GRAFT VASC IMPRA L 25 CM DIA19 MM EPTFE FLEXLG DIAMETER RING,SUP-2761436,CDM,C1768,CPT,0278,RC,,,,both,,,1922.97,1249.93,,,,,,,,,,,,,
HC Resuscitation,PX-4809295000,CDM,92950,CPT,0480,RC,,,,inpatient,,,424.00,275.60,,,,,,,,,,,,,
HC Rfl&Main Implt Pmp/Rsvr Dlvr Spi/Brn Phy/Qhp,PX-5109599100,CDM,95991,CPT,0510,RC,,,,outpatient,,,908.00,590.20,,,,,,,,,,,,,
DISSECTOR ENDOSCP L21CM TIP CURVATURE 40DEG FN CRV JAW VES,SUP-2172419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1599.45,1039.64,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT SHFT FEM STRUCTURAL 100MM,SUP-2307347,CDM,C1762,CPT,0278,RC,,,,both,,,3309.75,2151.34,,,,,,,,,,,,,
CATHETER CV DL 8 FRX16 CM FULL KT ARROWG+ARD BLU +,SUP-2383383,CDM,C1751,HCPCS,0278,RC,,,,both,,,239.90,155.93,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 65 CM DIA 8.5 FR CRV BEND 17 MM DIL,SUP-2616236,CDM,C1766,CPT,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
HC Right Heart Cath,PX-4819345100,CDM,93451,CPT,0481,RC,,,,both,,,6610.00,4296.50,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA 3 MM EPTFE TW PED SHUNT STRL,SUP-2396677,CDM,C1768,CPT,0278,RC,,,,both,,,1576.28,1024.58,,,,,,,,,,,,,
DISTAL LATERAL TIBIA PLATE JIG LEFT,SUP-2726642,CDM,C1713,HCPCS,0278,RC,,,,both,,,1272.99,827.44,,,,,,,,,,,,,
DART PIP L30MM DIA25MM 10DEG PEEK,SUP-2420293,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
NAIL IM L270MM DIA11MM UNIV TIB TI CANN LOK BENT UNREAMED,SUP-2192815,CDM,C1713,HCPCS,0278,RC,,,,both,,,4275.17,2778.86,,,,,,,,,,,,,
GRAFT HUM TISS PARTICULATE 50 MG CONNECTIVE TISS INTERFYL,SUP-2845978,CDM,Q4171,HCPCS,0636,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
IMPLANT FACE L 93 X W 75 MM RT COMPLETE ORBIT OCULOPLASTIC,SUP-2883656,CDM,C1713,HCPCS,0278,RC,,,,both,,,14633.47,9511.76,,,,,,,,,,,,,
SHEATH INTRO BRAIDED COR 0.035 IN JUMBO 9 FRX40 CM WORLEY,SUP-2329849,CDM,C1892,HCPCS,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
GUIDEWIRE VASC L 70 CM DIA 0.035 IN TIP L 3 MM DEPTH MARKING,SUP-2117326,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
TOLNAFTATE 1 % EX POWD,RX-8021,CDM,6370000000,HCPCS,0637,RC,57896-0199-45,NDC,,both,45,GR,13.80,8.97,,,,,,,,,,,,,
MESH HERN L W5.4XL7IN POLYPR EPTFE OVL SELF EXP PTCH,SUP-2125711,CDM,C1781,HCPCS,0278,RC,,,,both,,,2847.04,1850.58,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 16X20 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838616,CDM,C1763,HCPCS,0278,RC,,,,both,,,29697.18,19303.17,,,,,,,,,,,,,
SET URET STENT SMITH L 80 CM DIA 8 FR PERCFLX PIGTL FLX TIP,SUP-2171206,CDM,C2617,HCPCS,0278,RC,,,,both,,,705.37,458.49,,,,,,,,,,,,,
BRACE WRIST/THUMB AD L7IN UNIV LT SFT IMMOB JT LACE STAY,SUP-2324010,CDM,L3931,HCPCS,0272,RC,,,,both,,,31.27,20.33,,,,,,,,,,,,,
DENOSUMAB-BBDZ 120 MG/1.7ML SC SOLN,RX-172039,CDM,Q5136,HCPCS,0636,RC,61314-0228-94,NDC,,both,1.7,ML,9464.40,6151.86,,,,,,,,,,,,,
BIOTENE PBF DRY MOUTH MT LIQD,RX-82596,CDM,A9154,HCPCS,0636,RC,48582-0003-30,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 0.5 CC DBM FLOWABLE FIBER AMBIENT STOR,SUP-2933169,CDM,C1762,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KIT BONE CEM MX AND DEL RADPQ VERT AUG W/ TY AVAMAX,SUP-2367083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
FIXATOR EXT FIX OBLQ SUPP MR SAFE,SUP-2187906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1660.53,1079.34,,,,,,,,,,,,,
BLADE SURG L130MM DIA125MM NONSTERILE S STL HELIX TROCH FOR,SUP-2186790,CDM,C1776,CPT,0278,RC,,,,both,,,1065.56,692.61,,,,,,,,,,,,,
PLATE TI LOCKING 1.3MM STRAIGHT 6 HOLES STERILE,SUP-2546878,CDM,C1713,HCPCS,0278,RC,,,,both,,,1404.30,912.79,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM HEX HD DIA2.5MM CANC BIODUR 108C,SUP-2411044,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 30 CC FD IRRADIATED CANC,SUP-2867069,CDM,C1762,CPT,0278,RC,,,,both,,,1422.89,924.88,,,,,,,,,,,,,
COMPONENT PAT KINEMATIC KNEE IMPL L,SUP-2376465,CDM,C1776,CPT,0278,RC,,,,both,,,2138.34,1389.92,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.038IN TIP L3CM URO FLX ANG,SUP-2139364,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.03,123.52,,,,,,,,,,,,,
ANCHOR SUT SZ 4.5MM WHT BLU BIOCRYL RAPIDE UHMWPE BRAID FLAT,SUP-2256667,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
HC Sarscov-2 Ag/Flu Ab (Sophia),PX-3008724800,CDM,87428,CPT,0300,RC,,,,both,,,211.00,137.15,,,,,,,,,,,,,
RING ANNULPLSTY SZ 24 OD30MM ID22MM AP136MM MI VLV TI RIG,SUP-2355847,CDM,C1713,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
DISC NEUROSURGICAL N PROGRAMMABLE SET W/O RESERVOIR PROGAV,SUP-2846929,CDM,C1889,HCPCS,0278,RC,,,,both,,,3099.05,2014.38,,,,,,,,,,,,,
SCREW INTRF 5X10 MM PEEK GRAPPLER TENODESIS,SUP-2749764,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.18,1096.02,,,,,,,,,,,,,
BUTTON SUT L12MM DIA4MM FEM SFT TISS FOR SGL INCIS BNE TO,SUP-2341291,CDM,C1713,HCPCS,0278,RC,,,,both,,,586.87,381.47,,,,,,,,,,,,,
AUGMENT FEM M THK8MM STD UNIV RT MEDL LT LAT DSTL KNEE CEM,SUP-2406999,CDM,C1776,CPT,0278,RC,,,,both,,,2603.06,1691.99,,,,,,,,,,,,,
SCREW BONE EMERGENCY 1.2X6 MM WITH PLUSDRIVE RECESS TITANIUM,SUP-2838157,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.63,238.31,,,,,,,,,,,,,
NEEDLE SUTURE L 48 MM LOOP 10 MM CTX TAPR PT 1/2 CIR SHUTTLE,SUP-2906016,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
THERASKIN 2.5X2.5CM 6SQ CM,SUP-2264656,CDM,Q4121,HCPCS,0636,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
HC So Cystatin C,PX-3018261066,CDM,82610,CPT,0301,RC,,,,inpatient,,,80.00,52.00,,,,,,,,,,,,,
CATHETER INTVASC OCCL FOGARTY L 40 CM DIA 3 FR BALLOON DIA,SUP-2214267,CDM,C2628,HCPCS,0272,RC,,,,both,,,153.23,99.60,,,,,,,,,,,,,
SYSTEM VENTRICULAR DRAINAGE W/ CATH ACCUDRAIN,SUP-2883455,CDM,C1729,HCPCS,0272,RC,,,,both,,,629.73,409.32,,,,,,,,,,,,,
COMPONENT PAT L STD TI POLYETH 3 PEG RND REV PRESSFIT POR,SUP-2250831,CDM,C1776,CPT,0278,RC,,,,both,,,1848.52,1201.54,,,,,,,,,,,,,
INTRODUCER CATHETER 8FR L35IN PERI FOR CHOLGM CATHETER TAUT,SUP-2384691,CDM,C1894,HCPCS,0272,RC,,,,both,,,122.33,79.51,,,,,,,,,,,,,
KIT CVC 66FR FOR SGL LUMN CATHETER BRVC,SUP-2126560,CDM,C1894,HCPCS,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
TRAY CATH 5FR 2 LUMN MAXIMAL BARR STD W/ SHERLOCK STYL,SUP-2125639,CDM,C1751,HCPCS,0278,RC,,,,both,,,680.66,442.43,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X20X6 MM FD SPNG CANC READIGRAFT BLX,SUP-2741073,CDM,C1713,HCPCS,0278,RC,,,,both,,,2627.30,1707.74,,,,,,,,,,,,,
DEVICE FIX 4X90 MM CLAV CRX,SUP-2431209,CDM,C1713,HCPCS,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
BIOPSY KIT 18 GAX60 CM 7 FR 5 FRX65 CM TRNSJUG LIV TLAB,SUP-2876887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
PHENYLEPHRINE HCL 0.25 % NA SOLN,RX-6243,CDM,6370000000,HCPCS,0637,RC,00225-0800-47,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
SET CV THRD PROTECTOR STRL DISP HEARTMATE 3,SUP-2895267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
PLATE BNE L 102 MM SCREW DIA 4.5 MM 6 H COMPR LCK STRL EVOS,SUP-2932859,CDM,C1713,HCPCS,0278,RC,,,,both,,,2884.09,1874.66,,,,,,,,,,,,,
ACETAMINOPHEN 500 MG PO TABS,RX-102,CDM,6370000000,HCPCS,0637,RC,50580-0491-10,NDC,,both,1,UN,0.60,0.39,,,,,,,,,,,,,
BLADE SCREWDRIVER 2MM DIA F/X FIX MOLINA PIN,SUP-2497084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.36,576.78,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART DIA 8.5 FR SLITTER L 16 CM DIA 7,SUP-2126573,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SET SCR SPNL S STL BRKOFF FOR 6.35MM ROD CDH LEG,SUP-2288807,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.14,295.84,,,,,,,,,,,,,
SPHERE GLEN TILTED 10 DEG 39 MM 29 MM SHLDR COCR AEQUALIS,SUP-2715797,CDM,C1776,CPT,0278,RC,,,,both,,,9438.84,6135.25,,,,,,,,,,,,,
PLATE LCK NAVICULAR 2.4/2.7MM SS STRL,SUP-2546014,CDM,C1713,HCPCS,0278,RC,,,,both,,,2578.10,1675.76,,,,,,,,,,,,,
MATRIX BIO L 12 X W 8 CM FET BOV DERM IONIC SLV DERMAL SLD,SUP-2909232,CDM,Q4110,HCPCS,0636,RC,,,,both,,,10399.68,6759.79,,,,,,,,,,,,,
SCREW BNE L 48 MM DIA2.4 MM TI ST LCK T7 DRV NS VLP,SUP-2931518,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.54,244.10,,,,,,,,,,,,,
PLATE HEAD LCKNG PHALANGEAL 1.3MM RIGHT-STERILE,SUP-2546065,CDM,C1713,HCPCS,0278,RC,,,,both,,,1621.24,1053.81,,,,,,,,,,,,,
KIT CATH 2 LUMN 7 F,SUP-2120581,CDM,C1751,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
PROBE ARTHSCP BLU INTEGR CBL DYONIC EFLEX TACS,SUP-2341731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
SPLINT WR AD SM FOR 5.5-6.5IN STRP L4IN VENT ELAS,SUP-2324483,CDM,L3908,HCPCS,0272,RC,,,,both,,,43.27,28.13,,,,,,,,,,,,,
PLATE SPINAL 9 MM 2 HOLE LOW PROFILE STRAIGHT CONTOURABLE NE,SUP-2838352,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
ORTHOLOC SPS 3.5X38MM CORTICAL NON-LOCKING SCREW,SUP-2822324,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
MODEL ANAT FULL SKULL PED UPTO 5YR 3D CT BASE SEL CLR VITAL,SUP-2883637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15657.74,10177.53,,,,,,,,,,,,,
ANTEROLATERAL PILON FUSION PLATE 15H RT,SUP-2815201,CDM,C1713,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
PLATE BNE L25MM 2 H TI 1 3 TBLR W CLLR SM FRAG SET SPS,SUP-2364394,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.52,198.59,,,,,,,,,,,,,
AUG PAT 3-PEG ROT POR 177975000] JNJ DEPUY SYNTHES ORTHOPEDICS],SUP-2252416,CDM,C1776,CPT,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
BUR SURG DIA3MM NEURO PRECIS,SUP-2365188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.26,243.92,,,,,,,,,,,,,
SYSTEM FIX BNE TEND BNE W/ 10MM FLIPCUTTER II TIGHTROPE,SUP-2121385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX12 CM 3L CUTLM501JRSCABRMHC,SUP-2759859,CDM,C1751,HCPCS,0278,RC,,,,both,,,362.86,235.86,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 45 CM DIA 7 FR HYDRPHLC,SUP-2383408,CDM,C1894,HCPCS,0272,RC,,,,both,,,237.92,154.65,,,,,,,,,,,,,
SHEATH ORTHOPEDIC PASS TEND HUNTER,SUP-2422192,CDM,C1763,HCPCS,0278,RC,,,,both,,,5190.42,3373.77,,,,,,,,,,,,,
SPOON BOB VENT TB,SUP-2312806,CDM,L8699,HCPCS,0278,RC,,,,both,,,31.56,20.51,,,,,,,,,,,,,
SYSTEM INTRO ACUSTK II SS WIRE W/O GUIDEWIRE RADIOPAQUE,SUP-2147742,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CLAMP TRANSFIXING PIN FOR ORTHOFIX PREFIX FIX,SUP-2316288,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.75,441.84,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 24CML I 5624240,SUP-2632913,CDM,C1752,HCPCS,0278,RC,,,,both,,,750.90,488.08,,,,,,,,,,,,,
DRESSING NSL L4CM SYN PROPRIETARY POLYMER FOAM FIRM,SUP-2367517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.03,221.02,,,,,,,,,,,,,
KIT BNE SCR L26MM DIA4.5MM GLEN SHLDR ORNG COMPR LOK CAP,SUP-2223389,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
ALLOGRAFT BNE CLOWARD DWL 11X15 MM CERV FD MATRIGRAFT,SUP-2264806,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
DEVICE EMB CATERPILLAR DEL WIRE L 155 CM CATH 0.056 IN RVD,SUP-2655907,CDM,C1889,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PLATE PROFYLE M ROTATIONAL 23MM,SUP-2695492,CDM,C1713,HCPCS,0278,RC,,,,both,,,1470.62,955.90,,,,,,,,,,,,,
BIT DRL SLD 3 MM STRL DISP,SUP-2194151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
BIT DRL DIA2.5MM STP L16MM NONRADIOPAQUE REUSE,SUP-2187838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
DIST LAT HUM LCK PLATE 15,SUP-2476723,CDM,C1713,HCPCS,0278,RC,,,,both,,,3146.25,2045.06,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC FLX SM AD LT FNGR ORTHOSIS FLX BRAC,SUP-2325138,CDM,L3807,HCPCS,0274,RC,,,,both,,,243.51,158.28,,,,,,,,,,,,,
AID HEARING SM 31.5 CM NS BAHA LTX,SUP-2858120,CDM,L8690,HCPCS,0278,RC,,,,both,,,151.19,98.27,,,,,,,,,,,,,
BIT DRL DIA61MM FOR THRD HD SCR ANK COMPR NAIL SYS,SUP-2316001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.57,595.77,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC BIOACTIVE MTRX STRL BONESYNC LTX,SUP-2859806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2371.01,1541.16,,,,,,,,,,,,,
GUIDEWIRE VASC SKR L 175 CM DIA16 IN FLX X SUPP STRL,SUP-2141240,CDM,C1769,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
GRAFT HUM TISS W50XL90MM THK15MM ACELLULAR DERM RM TEMP,SUP-2264601,CDM,C1713,HCPCS,0278,RC,,,,both,,,9077.46,5900.35,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 40 CM DIA28 MM L 15 CM DIA 8 MM AG FLO,SUP-2385037,CDM,C1768,CPT,0278,RC,,,,both,,,3381.09,2197.71,,,,,,,,,,,,,
ENDCAP SPNL 0 DEG 18X18X60 MM TI X-CORE 2,SUP-2560273,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
KIT SHLDR SUPENSION DISP ISOTAC,SUP-2342837,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.24,87.26,,,,,,,,,,,,,
DRILL SURG 9 MM FOR MINI PLATE SYS DIVERGENCE,SUP-2630667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.23,333.60,,,,,,,,,,,,,
PLATE BONE L72MM 5 H LT POST DSTL TIB LCK FOR 3.5MM SCR,SUP-2349804,CDM,C1713,HCPCS,0278,RC,,,,both,,,6304.81,4098.13,,,,,,,,,,,,,
CATHETER IVUS EAGLE EYE GLD CORONARY,SUP-2327216,CDM,C1753,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
NEEDLE SHRP STR 3 MMX23 CM DEL TAPR SHFT,SUP-2775073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.13,315.98,,,,,,,,,,,,,
SPLINT HND AD L115IN L DK BLU HEADLINER BROAD CLTH REST,SUP-2165488,CDM,L3807,HCPCS,0272,RC,,,,both,,,211.04,137.18,,,,,,,,,,,,,
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN,RX-134058,CDM,2500000003,HCPCS,0250,RC,70756-0611-82,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE THK10MM 10DEG SUPCNDYL N COMPR SUP AUG,SUP-2223381,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
BRACE ORTH LACE CLOSURE SM 5.5X6.25 IN WRST LT SPECTR,SUP-2319267,CDM,L3906,HCPCS,0272,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
HC Plmt Biliary Drainage Cath External,PX-3614753300,CDM,47533,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
GRAFT BNE SUB 90ML 01 4MM CANC CRUSH CHIP MORSELIZED FRZ,SUP-2307067,CDM,C1713,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 300 CM DIA 0.014 IN TIP LOAD 3,SUP-2909280,CDM,C1769,HCPCS,0272,RC,,,,both,,,441.01,286.66,,,,,,,,,,,,,
NUT ORTH LCK FOR 9-12 MM UNIV FEM NAIL,SUP-2548734,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.71,253.96,,,,,,,,,,,,,
HC Group Caregiver Training Strategies & Technique,PX-4409755200,CDM,97552,CPT,0440,RC,,,,both,,,56.00,36.40,,,,,,,,,,,,,
PLATE BONE M SZ 12MM 2 H STR FOR NEURO USE LORENZ,SUP-2402909,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM DIA 0.035 IN TAPR L 7.5 CM,SUP-2665433,CDM,C1769,HCPCS,0272,RC,,,,both,,,146.95,95.52,,,,,,,,,,,,,
STAPLE BONE L SCAPHOID,SUP-2351301,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
HOOK RETRCT 25 MM 7.75 IN NERVE ANGLED BALL TIP TI NS REUSE,SUP-2457483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.59,173.28,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS II SHT 5.3X4.1X1.6X3.5 MM 0.9 MM HA,SUP-2638126,CDM,L8613,CPT,0278,RC,,,,both,,,1258.23,817.85,,,,,,,,,,,,,
MESH HERN W8XH6IN INT ABD OMEGA 3 FATTY ACID POLYPR OBLONG,SUP-2265985,CDM,C1781,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 40X14 - 18 MM FRZ DRY,SUP-2294103,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
CANNULA SUCTION L8 7/8IN WORKING L65MM DIAMETER 3.5MM FOR NE,SUP-2804634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1031.96,670.77,,,,,,,,,,,,,
CRANIAL ACCESS KIT 5.31 MM W/ DRUG DRL BIT NO RAZOR,SUP-2852686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1231.98,800.79,,,,,,,,,,,,,
LEAD PACE SELECTSECURE L 59 CM DIA 4.1 FR POLYUR SIL INSUL,SUP-2281896,CDM,C1898,HCPCS,0275,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY KNEE CTRL FULL KNEECAP,SUP-2435698,CDM,L2795,HCPCS,0274,RC,,,,both,,,232.17,150.91,,,,,,,,,,,,,
MESH SURG W200XL200MM THK0.4MM NONSTERILE BLU CRANIOFACIAL,SUP-2181573,CDM,C1781,HCPCS,0278,RC,,,,both,,,26545.56,17254.61,,,,,,,,,,,,,
PLATE BNE CLAV 2.7 MM RT MEDL VA LCK COMPR SS NS VA-LCP,SUP-2757613,CDM,C1713,HCPCS,0278,RC,,,,both,,,3967.70,2579.00,,,,,,,,,,,,,
HC Iadna Streptococcus Group a Amplified Probe Tq,PX-3068765100,CDM,87651,CPT,0306,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR,RX-31177,CDM,340b,HCPCS,0637,RC,09999-9917-93,NDC,,both,5,ML,4.20,2.73,,,,,,,,,,,,,
CATHETER ABLAT L160CM DIA4MM BPLR ELECTRD W10XL15MM FOC,SUP-2172351,CDM,C1886,HCPCS,0278,RC,,,,both,,,6301.98,4096.29,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC 0035N OD STNDRD 260CML NTNL BLRY ROUND AN,SUP-2676533,CDM,C1729,HCPCS,0272,RC,,,,both,,,551.38,358.40,,,,,,,,,,,,,
HC So H.Pylori. Serum,PX-3028667766,CDM,86677,CPT,0302,RC,,,,both,,,59.00,38.35,,,,,,,,,,,,,
LENS INTOCU +27.0 DIOPT L13.5MM DIA6MM AC D5.2MM 5DEG UV,SUP-2247701,CDM,V2632,HCPCS,0276,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC STD 14.5FR DIA 19CM,SUP-2613298,CDM,C1750,HCPCS,0278,RC,,,,both,,,1615.53,1050.09,,,,,,,,,,,,,
PIN DRL 2.5X125 MM LAPIDUS SYS IO FRDM DISP,SUP-2864892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
GUIDEWIRE 8MM 0.062X15IN SURTAC,SUP-2195799,CDM,C1769,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
DRESSING WND FEN 10X15 CM SHT EXTRACELLULAR MTRX MATRISTEM,SUP-2106524,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2497.05,1623.08,,,,,,,,,,,,,
KNIFE SRGCL LTHRP 10/25MM BLADE 8 3/4NL TNSL CRVD BNT SHPD J,SUP-2496303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,310.26,201.67,,,,,,,,,,,,,
PSN REV CCK ART SURF VE 18MM R 11-13 GH,SUP-2508538,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
KIT STBL POS SHLDR SPIDER 2 EXCEPTIONAL LIMB CTRL,SUP-2341137,CDM,L3650,HCPCS,0272,RC,,,,both,,,519.70,337.80,,,,,,,,,,,,,
SORBITOL 70 % SOLN,RX-93927,CDM,340b,HCPCS,0637,RC,46287-0500-30,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO CAT PENUMBRA 140CM RX L LUMN ASPIR TBNG,SUP-2323580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
ADAPTER SPNL LAT 10 MM OFFSET CENTURION,SUP-2658908,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
HC Forearm 2 Views,PX-3207309000,CDM,73090,CPT,0320,RC,,,,both,,,565.00,367.25,,,,,,,,,,,,,
APPLIER CLP M-L L55.6CM JAW L2.1CM DIA8MM 0-35DEG OPN ANG,SUP-2246686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
COMPONENT TIB L79MM CO CHROM POR KNEE FIN HIGHLY POLISHED,SUP-2405415,CDM,C1776,CPT,0278,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
SCREW BNE MINI 2X7 MM CROSS DRV CNTRDRV,SUP-2262634,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
HEAD FEM BPLR CO CHROM BPLR SYS 28MMX45MM,SUP-2359154,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
BIT DRL L15MM DIA3.2MM ACET SCR FLEX REFLCT,SUP-2345714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC HF 5FR 55CM 3 LUMAN RVRSE 3385108Q,SUP-2632679,CDM,C1751,HCPCS,0278,RC,,,,both,,,597.57,388.42,,,,,,,,,,,,,
CATHETER CV DL 8.5 FRX20 CM MULT MED HI FLO HEPARIN,SUP-2214563,CDM,C1751,HCPCS,0278,RC,,,,both,,,170.78,111.01,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THCK 4CMX12CM,SUP-2306912,CDM,C1762,CPT,0278,RC,,,,both,,,4461.34,2899.87,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 4-7 MM EPTFE TAPR STD,SUP-2396217,CDM,C1768,CPT,0278,RC,,,,both,,,3133.72,2036.92,,,,,,,,,,,,,
SCREW BNE CANC 6.5X35 MM FT TI NS ISO,SUP-2460481,CDM,C1713,HCPCS,0278,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
STENT ENDOPROS L2.5CM DIA6MM CATH 7FR L120CM 0.035IN VES,SUP-2396595,CDM,C1874,HCPCS,0278,RC,,,,both,,,9715.16,6314.85,,,,,,,,,,,,,
INTRODUCER SET TRANSSEPTAL 10FRX12CM LEN AD ULTIMUM,SUP-2355595,CDM,C1894,HCPCS,0272,RC,,,,both,,,36.90,23.98,,,,,,,,,,,,,
INTRODUCER VASC 3.5FR L35CM S STL W/OUT CRV W/OUT HEMSTAT,SUP-2126203,CDM,C1894,HCPCS,0272,RC,,,,both,,,98.60,64.09,,,,,,,,,,,,,
HANDPIECE IRRIG DIA2.2MM FRONTAL SNUS FIX 80 ARTC DISP,SUP-2284173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,977.64,635.47,,,,,,,,,,,,,
PLATE BNE CONTOURED LT SUBMUSCULAR 14 HOLE SMPLE,SUP-2490494,CDM,C1713,HCPCS,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
BENDING TEMPLATE FOR LOCKING CALCANEAL PLATE-MINI,SUP-2548481,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.29,154.89,,,,,,,,,,,,,
TAPE SUTURE UHMWPE SMTH LP N ABSRB STRL DISP XBRAID TT,SUP-2906851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
HC So Aspergillus Antibody,PX-3028660666,CDM,86606,CPT,0302,RC,,,,both,,,119.00,77.35,,,,,,,,,,,,,
TRANEXAMIC ACID 100 MG/ML FOR NEBULIZATION,RX-4082649,CDM,2500000003,HCPCS,0250,RC,81284-0612-10,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BONE L16MM DIA3MM STRNL TI SELF DRL LCK 5 PER PK,SUP-2181536,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.37,357.09,,,,,,,,,,,,,
IMIPRAMINE HCL 25 MG PO TABS,RX-3861,CDM,6370000000,HCPCS,0637,RC,69315-0134-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER GUID ANGLED 0.018 IN 65 CM SUPP 3 MARKER NAVICROSS,SUP-2435365,CDM,C1887,HCPCS,0272,RC,,,,both,,,680.12,442.08,,,,,,,,,,,,,
PLATE OLECRANON 3.5MM 2H LT 86MM SS LCP STRL,SUP-2547481,CDM,C1713,HCPCS,0278,RC,,,,both,,,3168.61,2059.60,,,,,,,,,,,,,
HC Perq Art M-Thrombect &/Nfs,PX-3616164500,CDM,61645,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
CATHETER EP CRD 2 5-5 MM 4 FRX120 CM SUPREME,SUP-2356936,CDM,C1730,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
BLADE SAW RECIPROCATOR 76X12.5X0.9 MM,SUP-2607451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,99.85,64.90,,,,,,,,,,,,,
SPLINT FLX HND ADL NVY TERRY,SUP-2165484,CDM,L3807,HCPCS,0272,RC,,,,both,,,153.77,99.95,,,,,,,,,,,,,
SCREW BONE POLYAX PEDCL OPN TI EXT TAB ROD 5.5MM 4.5MMX25MM,SUP-2109190,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BONE L22MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190374,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.30,35.94,,,,,,,,,,,,,
GRAFT ALLGRFT TEND PAT WHL FRZN,SUP-2335546,CDM,C1713,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
LCS PW TIB SHIM SM/SM+ 12.5,SUP-2513619,CDM,C1776,CPT,0278,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
SCREW BNE OSTEOPENIA 5X18 MM,SUP-2348610,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
PACEMAKER CARD EVIA DR 2 CHMBR STRL,SUP-2138257,CDM,C1785,HCPCS,0275,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
CATHETER INTRAAORTIC BAL 8FR 30CC L25.3IN SHTH L6IN CTRL,SUP-2383457,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
PEG FIX LCK 2.2X10 MM SMOOTH NS DVR,SUP-2462037,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2436519,CDM,Q4128,HCPCS,0636,RC,,,,both,,,7316.83,4755.94,,,,,,,,,,,,,
REINFORCEMENT STPL LN SUREFORM BLK SEAMGRD 1BSGXI60BK,SUP-2762592,CDM,C1781,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
BUR SURG M L8MM DIA4MM EGG CUT FLUT ELITE TPS 51201540] STRYKER INSTRUMENT DIV],SUP-2367476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,275.54,179.10,,,,,,,,,,,,,
PLATE BNE L 112 MM SCREW DIA 3.5/4.5 MM 1 H SS RT,SUP-2931280,CDM,C1713,HCPCS,0278,RC,,,,both,,,20110.92,13072.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L135CM BAL L15MM DIA4MM HYDROPHOBIC RAP,SUP-2101617,CDM,C1725,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 40 MM DIA16 MM SHTH 10 FR CATH L,SUP-2142677,CDM,C1876,HCPCS,0278,RC,,,,both,,,3221.48,2093.96,,,,,,,,,,,,,
KNEE VNGD TI FEM PS 60MM RT,SUP-2510720,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/ELASTIC FNGR CTRL PREFABRICATED,SUP-2435774,CDM,L3912,HCPCS,0274,RC,,,,both,,,271.45,176.44,,,,,,,,,,,,,
HC Feeding Tube Placement,PX-3207434000,CDM,74340,CPT,0320,RC,,,,both,,,1184.00,769.60,,,,,,,,,,,,,
PROBE ENDOSCP ELECTROCAUTERY L 2.3 M DIA2.6 MM ELECTRD L 2,SUP-2901675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GRAFT BNE SUB 15CC 01 2MM CORT CANC MIX MORSELIZED GRAN FRZ,SUP-2307060,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.80,627.77,,,,,,,,,,,,,
STEM FEM CEM POLISHED SZ 9 125MM INTRIGUE,SUP-2406814,CDM,C1776,CPT,0278,RC,,,,both,,,9451.40,6143.41,,,,,,,,,,,,,
CARRIER ATTCH 13MM FOR SM BNE FIX SYS STAPLIZER,SUP-2167242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2824.74,1836.08,,,,,,,,,,,,,
LK RECON PLATE 14HL 222MM,SUP-2702819,CDM,C1713,HCPCS,0278,RC,,,,both,,,2834.48,1842.41,,,,,,,,,,,,,
SCREW BNE L 70 MM DIA2.7 MM TI LCK T8 STARDRV AQUA STRL V,SUP-2905735,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.27,828.28,,,,,,,,,,,,,
ROD IM 15X380MM FEM TI ALTA,SUP-2363485,CDM,C1713,HCPCS,0278,RC,,,,both,,,3272.19,2126.92,,,,,,,,,,,,,
SCREW BNE L105MM DIA10.5MM LAG FOR AFFIXUS HIP FRAC NAIL,SUP-2413330,CDM,C1713,HCPCS,0278,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
GRAFT BONE ASEP MTRX DEMIN GRFTON,SUP-2307032,CDM,C9359,HCPCS,0278,RC,,,,both,,,2139.91,1390.94,,,,,,,,,,,,,
HC Reposition Gastric Tube Duod,PX-3614376100,CDM,43761,CPT,0361,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
PLATE BNE L 180 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 14 72466614,SUP-2933040,CDM,C1713,HCPCS,0278,RC,,,,both,,,6297.90,4093.63,,,,,,,,,,,,,
STAPLE SPNL ANTR ANTR SYS TI COLORADO 2,SUP-2290620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
MOLD FEM SPCR SM AP37MM ML60MM PMMA URETHANE GENT KASM,SUP-2315774,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE HUM LNG 3.5X302 MM RT DSTL X ARTC 14 HOLE SS NS,SUP-2184046,CDM,C1713,HCPCS,0278,RC,,,,both,,,5271.65,3426.57,,,,,,,,,,,,,
COLLAR CERV PD REG INF BK PANEL REPL,SUP-2124226,CDM,L0174,HCPCS,0274,RC,,,,both,,,56.14,36.49,,,,,,,,,,,,,
SCREW SPNL LCK 4.5 MM GROWTH DIRECTING CLLRD SS SHILLA,SUP-2630596,CDM,C1713,HCPCS,0278,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
STENT ESOPH L15CM DIA18MM PROX FLARE DIA23MM CVR L12CM,SUP-2139596,CDM,C1874,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
EVOS VOL PLATE 3H LEFT STD TI 48MM NS,SUP-2818637,CDM,C1713,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
PLATE BNE TOD BLDE L26MM DISPLC 4MM 90DEG ST S STL CANN,SUP-2185394,CDM,C1713,HCPCS,0278,RC,,,,both,,,2367.94,1539.16,,,,,,,,,,,,,
COIL EMB 10 L1CM OD2MM HELCL STRTCH RESIST HYDRGEL V-TRAK,SUP-2305133,CDM,C1889,HCPCS,0278,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L2700MM DIA0025IN ANG DST TIP EXCELLENT,SUP-2313168,CDM,C1769,HCPCS,0272,RC,,,,both,,,709.36,461.08,,,,,,,,,,,,,
PORT INFUS CATH 7FR LO PROF 2 SLIMPRT PEEL APART PERC INTRO,SUP-2127736,CDM,C1788,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
TRIAL CRUC RET ARTC SURF PROV BLU 10MM NXGN,SUP-2201311,CDM,C1776,CPT,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
STENT TRANSCAROTID X ACT L 20 MM DIA 7 MM ICA DIA 5.5-6.4 MM,SUP-2925087,CDM,C1876,HCPCS,0278,RC,,,,both,,,6562.60,4265.69,,,,,,,,,,,,,
PLATE BNE T 80 MM 4 HOLE BUTTRESS TI NS,SUP-2569057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1933.77,1256.95,,,,,,,,,,,,,
GUIDE SURG PLN TI LP DISTRCTN CUSTOMIZABLE BILATERAL VSP,SUP-2883944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21584.99,14030.24,,,,,,,,,,,,,
BIT DRL CALIB STP 5/6.5 MM AOS,SUP-2766046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
PATCH BIO LYOPLANT L 10 X W 4 CM BOV PERICARD STRL,SUP-2821556,CDM,C1763,HCPCS,0278,RC,,,,both,,,731.84,475.70,,,,,,,,,,,,,
PLATE CRAN 100X100X40 MM PT SPEC IMPL PEEK,SUP-2860145,CDM,C1713,HCPCS,0278,RC,,,,both,,,34559.15,22463.45,,,,,,,,,,,,,
PLATE BNE W24XL31MM 5 H NONSTERILE BILAT MIDFOOT HINDFOOT TI,SUP-2191455,CDM,C1713,HCPCS,0278,RC,,,,both,,,2635.84,1713.30,,,,,,,,,,,,,
PATCH DURA SUB N BIO EPTFE STRL CRAN TUMOR TRAUM 4X4CM 0.3MM,SUP-2395376,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
KIT DRAINAGE ASPIRA PERITONEAL,SUP-2676359,CDM,C1729,HCPCS,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
HC >= 12 Lead Ekg,PX-7309300500,CDM,93005,CPT,0730,RC,,,,both,,,517.00,336.05,,,,,,,,,,,,,
SET DRNGE FUHRMAN PLEUR STRL,SUP-2167973,CDM,C1729,HCPCS,0272,RC,,,,both,,,472.88,307.37,,,,,,,,,,,,,
ANCHOR SUT DIA2.8MM WHT KNOTLESS W/ PERFECT PASS MAG WIRE,SUP-2342111,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
STENT BILI ROYAL L 14 MM DIA 9 MM AD STRL,SUP-2141183,CDM,C1876,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
KIT PERICARDCENT L 40 CM DIA 8.3 FR PIGTL 7 SPIRALING,SUP-2482977,CDM,C1729,HCPCS,0272,RC,,,,both,,,373.57,242.82,,,,,,,,,,,,,
GRAFT ALLODERM DERMAL MATRIX 16CM X 20CM EXTRA THICK,SUP-2848898,CDM,Q4116,HCPCS,0636,RC,,,,both,,,32260.36,20969.23,,,,,,,,,,,,,
GRAFT HUM TISS W20MM QUAD L6CM WHL PAT W EXTRA QUAD FRZN,SUP-2264794,CDM,C1713,HCPCS,0278,RC,,,,both,,,11990.37,7793.74,,,,,,,,,,,,,
CORT SCREW 70MM 3.5,SUP-2818702,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.31,195.20,,,,,,,,,,,,,
PLATE BNE STR MINI MED 2X1 MM 4 HOLE FOR SCR TI NS LEVEL 1,SUP-2476756,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.69,166.20,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST COUNT REINF LTHR,SUP-2435730,CDM,L3440,HCPCS,0274,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
KIT PRB L440MM DIA3.9MM BLU SWISS LITHOCLAST TRIL,SUP-2141780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2806.78,1824.41,,,,,,,,,,,,,
CATHETER HD STR 55 CM 50 CM 2 VLV BASIC KT BIOFLO DURAMAX,SUP-2457543,CDM,C1750,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
TUBE VENT MOD 1.27 MM 6 MM 7.6 MM PHOSPHORYLCHOLINE COAT SIL,SUP-2467729,CDM,L8699,HCPCS,0278,RC,,,,both,,,59.60,38.74,,,,,,,,,,,,,
STIMULATOR BONE GROWTH 60UA CATHODE WAVE SPF + MINI,SUP-2414471,CDM,C1713,HCPCS,0278,RC,,,,both,,,21328.45,13863.49,,,,,,,,,,,,,
SPACER FEM XL THK5MM L MED DST DURAC,SUP-2377208,CDM,C1776,CPT,0278,RC,,,,both,,,2483.11,1614.02,,,,,,,,,,,,,
COLLAR CERV SERP CNTOUR L235XH5IN L,SUP-2276596,CDM,L0120,HCPCS,0274,RC,,,,both,,,8.51,5.53,,,,,,,,,,,,,
PACK AUTOGRFT CONVENIENCE IMPL GRAFTLINK,SUP-2121384,CDM,C1776,CPT,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
SCREW BNE TOT WR 2.7X12 MM SURFIX,SUP-2610346,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.80,564.07,,,,,,,,,,,,,
STEM FEM L60MM DIA14MM KNEE TI ALLY CRSS SLT PRESSFIT REV,SUP-2251488,CDM,C1776,CPT,0278,RC,,,,both,,,3761.72,2445.12,,,,,,,,,,,,,
PLATE BNE L60MM 4 H NONSTERILE R PROX TIB S STL LO PROF,SUP-2185809,CDM,C1713,HCPCS,0278,RC,,,,both,,,3536.27,2298.58,,,,,,,,,,,,,
PLATE BONE 16 H RT RIB 4 5 ROSE RED TI PRECONTOURED,SUP-2181506,CDM,C1713,HCPCS,0278,RC,,,,both,,,6144.20,3993.73,,,,,,,,,,,,,
OXYGENATOR PERF PRF FIBER HPRNHDRPHLC CTD 270ML PRIME VLME,SUP-2722904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1109.33,721.06,,,,,,,,,,,,,
CATHETER GUID SPEX 35 L 135 CM OD 0.035 IN ID 0.063 IN,SUP-2227751,CDM,C1887,HCPCS,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 CM DIA 6 MM FEM VEIN COMPETENT VLV,SUP-2933507,CDM,C1762,CPT,0278,RC,,,,both,,,18835.54,12243.10,,,,,,,,,,,,,
MESH CRAN THK 0.6 MM SCREW DIA1.5 MM TI GRD II RT PARIETL,SUP-2935054,CDM,C1713,HCPCS,0278,RC,,,,both,,,18337.60,11919.44,,,,,,,,,,,,,
SCREW BNE L90MM DIA12.7MM STD S STL CANC ST CANN LAG,SUP-2410201,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.12,598.73,,,,,,,,,,,,,
GRAFT BNE GRAN 0.5 CC VI RESRB CERM MASTERGRAFT,SUP-2743368,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
PLATE BONE LOK 53MML HLX4 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2588596,CDM,C1713,HCPCS,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
MESH HERN L6XW4IN POLY SKIRTED KNIT W/ CLLGN BARR IMPL FOR,SUP-2174710,CDM,C1781,HCPCS,0278,RC,,,,both,,,1548.49,1006.52,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES ORTHOSIS TORONTO TYP,SUP-2435603,CDM,L1700,HCPCS,0272,RC,,,,both,,,4404.76,2863.09,,,,,,,,,,,,,
TRAY HUM STD FOR COMPHSVE REV SHLDR SYS,SUP-2418442,CDM,C1776,CPT,0278,RC,,,,both,,,5146.46,3345.20,,,,,,,,,,,,,
GRAFT VASC GELSFT L 40 CM DIA 6 MM POLYESTER GEL ABD PERIPH,SUP-2384961,CDM,C1768,CPT,0278,RC,,,,both,,,1074.88,698.67,,,,,,,,,,,,,
GRAFT VASC W6XL12CM THK0.1MM PERICARD EPTFE MEM PRECL,SUP-2395368,CDM,C1768,CPT,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS,RX-7557,CDM,6370000000,HCPCS,0637,RC,65162-0271-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ROD SPNL L240MM DIA3.2MM R POST TI SMOOTH FOR VERTEX MAX,SUP-2286683,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PROBE THERMOABLATION COBRA COOLED SS 5 ELECTRD INSUL TIP,SUP-2124415,CDM,C1713,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
BALLOON ENDOSCP EUS CUF US FOR GFUM20 JFUM20 GFUM130Q130 (Order by Box),SUP-2313284,CDM,C1753,HCPCS,0278,RC,,,,both,,,88.99,57.84,,,,,,,,,,,,,
PLATE BONE MESH RSRBBLE 31MMW X 106MML 1MM THK RSRB X RCTNGL,SUP-2669319,CDM,C1713,HCPCS,0278,RC,,,,both,,,4798.33,3118.91,,,,,,,,,,,,,
PLATE QUIKFLAP BURR 14MM SD AXS,SUP-2718052,CDM,C1713,HCPCS,0278,RC,,,,both,,,10051.14,6533.24,,,,,,,,,,,,,
PLATE BNE CALCANEAL 3.5/4X58 MM LT NS LTX,SUP-2857056,CDM,C1713,HCPCS,0278,RC,,,,both,,,6590.86,4284.06,,,,,,,,,,,,,
EXTRACTOR SURG EASYOUT 2.5 MM QR ACUTRK,SUP-2857692,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM BAL L20MM OD4MM DIL RX MRAIL,SUP-2140565,CDM,C1725,HCPCS,0272,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
HC Rmvl Perm Intraperitneal Cath,PX-3614942200,CDM,49422,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
TUBE CHST SET 20 FRX41 CM 1 LUMEN 4 SIDEPRT THAL-QUICK,SUP-2760080,CDM,C1729,HCPCS,0272,RC,,,,both,,,572.42,372.07,,,,,,,,,,,,,
PLATE BNE L20MM 2 H COMPR LO PROF FIX ANG MAL NONLOCKING,SUP-2397372,CDM,C1713,HCPCS,0278,RC,,,,both,,,2455.48,1596.06,,,,,,,,,,,,,
GRAFT BNE BLOCK MED TRICORT,SUP-2759547,CDM,C1713,HCPCS,0278,RC,,,,both,,,5907.69,3840.00,,,,,,,,,,,,,
SPLINT ANK REG UNIV STRRP AIR AND GEL FOR CLD THER,SUP-2276708,CDM,L4350,HCPCS,0274,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
REAMER SURG DIA4.6MM FOR INTOSS FIX IOFIX PLUSX-POST,SUP-2223757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC FD FIBER PLIAFX PRIM,SUP-2740842,CDM,C1713,HCPCS,0278,RC,,,,both,,,3149.95,2047.47,,,,,,,,,,,,,
PASSER SUT L15MM DIA10X12MM CONE SHP PILOT GUID DISP CARTER,SUP-2171686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.90,322.33,,,,,,,,,,,,,
MESH SURG W30XL30CM DIA5MM POLYPR SQ FLAT FOR SFT TISS REP,SUP-2219797,CDM,C1781,HCPCS,0278,RC,,,,both,,,1161.39,754.90,,,,,,,,,,,,,
COMPONENT FEM PS CEM HI FLX SZ 0 LT,SUP-2223180,CDM,C1776,CPT,0278,RC,,,,both,,,12760.96,8294.62,,,,,,,,,,,,,
STENT BILI SYM L 44 MM DIA 8 MM CATH L 75 CM DIA 7 FR NIT AD,SUP-2140190,CDM,C1874,HCPCS,0278,RC,,,,both,,,3196.77,2077.90,,,,,,,,,,,,,
SCREW BNE NLCK 4.5X30 MM DBL STRT THRD STRL JPS LTX,SUP-2875290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1411.27,917.33,,,,,,,,,,,,,
CONNECTOR EXT FIX OBLQ AD ILIZ,SUP-2340732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5436.75,3533.89,,,,,,,,,,,,,
GRAFT VASC 6 MMX70 CM 30 CM RNG GORTX,SUP-2396006,CDM,C1768,CPT,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L60CM OD0035IN TIP L7CM NIT HYDRPHLC SLIP,SUP-2168946,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.87,130.57,,,,,,,,,,,,,
LINER ACET OD68MM ID26MM CO CHROM FEM BPLR ASMBLY IMP,SUP-2207820,CDM,C1776,CPT,0278,RC,,,,both,,,3356.03,2181.42,,,,,,,,,,,,,
STAPLE BONE M SCAPHOID,SUP-2351302,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
COMPONENT KNEE FOR PK 4800,SUP-2212673,CDM,C1776,CPT,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
WIRE TEMP FIX 28 MM DIAM S STL DBL END SMOOTH DBL SHRP TIP,SUP-2342714,CDM,C1713,HCPCS,0278,RC,,,,both,,,201.02,130.66,,,,,,,,,,,,,
RING EXT FIX ID140MM ANK FT FULL FOR TRUELOK FRME ASSEMB,SUP-2316169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
HC Ins Cd Gen Only Dual,PX-4813323000,CDM,33230,CPT,0481,RC,,,,outpatient,,,81065.00,52692.25,,,,,,,,,,,,,
STENT ESOPH WALLFLEX L 15 CM DIA18 FR DIA PROX/DSTL 20,SUP-2140977,CDM,C1876,HCPCS,0278,RC,,,,both,,,6480.96,4212.62,,,,,,,,,,,,,
BEAM FIX L80MM DIA7.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223954,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
ROD EXT FIX L450MM DIA11MM C CONN FOR HOFFMANN III MRI SYS,SUP-2372232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1305.61,848.65,,,,,,,,,,,,,
LINER ACET OD56MM ID32MM +4MM OFFSET 10DEG HIP GVF POLYETH,SUP-2250264,CDM,C1776,CPT,0278,RC,,,,both,,,10927.20,7102.68,,,,,,,,,,,,,
SUTURE 5 L36IN NONABSORBABLE WHT OS-8 L40MM 1/2 CIR SIL D9212,SUP-2218946,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.48,273.31,,,,,,,,,,,,,
IOBP HIP CLOSED TIP PROCEDURE KIT,SUP-2811226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 1 or 2 Muscles,PX-4202056000,CDM,20560,CPT,0420,RC,,,,both,,,42.00,27.30,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 4.5 MM REELX STT,SUP-2362564,CDM,C1713,HCPCS,0278,RC,,,,both,,,1613.96,1049.07,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 60 MM DIA 7 MM DEL SHTH 3.3ML,SUP-2936811,CDM,C1713,HCPCS,0278,RC,,,,both,,,10241.11,6656.72,,,,,,,,,,,,,
DRILL SURG BUSHING 2.5 OFFSET TRABECULAR MTL BIGLIANI/FLATOW,SUP-2436807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1370.61,890.90,,,,,,,,,,,,,
SPACER SPNL INTBDY FUS C RNG FOR 6.35MM ROD,SUP-2293078,CDM,C1889,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
HC Cv Cath Plac W/Port Tun <5,PX-3613656000,CDM,36560,CPT,0361,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
PLATE BONE 4X18 HOLE RIGHT RECONSTRUCTION WITH CONDYLAR HEAD,SUP-2838421,CDM,C1713,HCPCS,0278,RC,,,,both,,,17715.88,11515.32,,,,,,,,,,,,,
HEAD PIN 2.5X100MM 10 PK KIT0758,SUP-2266535,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE W5XL50MM THK1-1.2MM 4X9 H BILAT TI T SHP RIG,SUP-2191058,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.25,561.11,,,,,,,,,,,,,
DEFIBRILLATOR IMPL RESONATE X4 W 5.37 X H 8.18 CM D 0.99 CM,SUP-2149888,CDM,C1882,HCPCS,0275,RC,,,,both,,,61408.98,39915.84,,,,,,,,,,,,,
SCREW LOW-PROF CORTICAL 03.5 X 57.5,SUP-2741992,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.512,SUP-2860029,CDM,C1713,HCPCS,0278,RC,,,,both,,,35587.82,23132.08,,,,,,,,,,,,,
"HC So Albumin Other Source, Quan Ea",PX-3078204266,CDM,82042,CPT,0307,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
RAIL EXT FIX MINI 4 IN SYS RX-FIX,SUP-2517152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9360.34,6084.22,,,,,,,,,,,,,
Z DUP USE 2282180 CATHETER GUID INNER L57MM OD2.4MM 130DEG ATTAIN SEL II,SUP-2719773,CDM,C1887,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM TAPE 1.8/1.4 MM PEEK NONSLIDING,SUP-2882659,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
HALF PIN EXT FIX L20MM DIA3MM DSTL RAD FOR JET-X MINI EXT,SUP-2342887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1251.82,813.68,,,,,,,,,,,,,
PLATE BONE L71MM 4 H STR SEMITUBULAR FOR 4.5MM,SUP-2343802,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.20,354.38,,,,,,,,,,,,,
GRAFT ENDOVASC L108MM PROX L37MM DIA32MM DSTL L71MM DIA12MM,SUP-2171097,CDM,C1874,HCPCS,0278,RC,,,,both,,,21066.26,13693.07,,,,,,,,,,,,,
ANCHOR SUT 5 MM DIA NO 2 SUT,SUP-2341588,CDM,C1713,HCPCS,0278,RC,,,,both,,,653.62,424.85,,,,,,,,,,,,,
PLATE BNE L12MM GRN GUID GROWTH EIGHT PLT,SUP-2316387,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.94,586.91,,,,,,,,,,,,,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,0636,RC,43598-0387-11,NDC,,both,1,UN,185.50,120.57,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 98 CM OD 7 FR ID 2.3 MM GUIDEWIRE,SUP-2168591,CDM,C1894,HCPCS,0272,RC,,,,both,,,177.44,115.34,,,,,,,,,,,,,
BOOT TRAC L L20IN FOR 18IN CALF CONVOLUTED FOAM LNR STAY,SUP-2196870,CDM,L4631,HCPCS,0274,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
NAIL IM L160MM DIA9MM STRL AQUA L/R DSTL FEM TI LCK SLD DYN,SUP-2191690,CDM,C1713,HCPCS,0278,RC,,,,both,,,5458.14,3547.79,,,,,,,,,,,,,
PARADIGM EZ SWITCH SYSTEM UNIVERSAL,SUP-2824687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
PROTECTOR TEND W2XL2IN SHT BOV CLLGN GLYCOSAMINOGLYCAN POR,SUP-2244459,CDM,C1776,CPT,0278,RC,,,,both,,,9873.01,6417.46,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.405,SUP-2859969,CDM,C1713,HCPCS,0278,RC,,,,both,,,31372.05,20391.83,,,,,,,,,,,,,
HC So2 Detect Agent Nos Dna Amp,PX-3068779868,CDM,87798,CPT,0306,RC,,,,both,,,855.00,555.75,,,,,,,,,,,,,
CARRIER LT L16CM FBR OPT FOR DST ILLUMINATION LARYNSCP,SUP-2261375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2116.30,1375.59,,,,,,,,,,,,,
SCISSOR SURG METZ 5.75 IN DISECT CRV DEL SHRP/SHRP NS VITAL,SUP-2872581,CDM,C1889,HCPCS,0278,RC,,,,both,,,198.48,129.01,,,,,,,,,,,,,
CONNECTOR ROD OD35X55MM POST CERV PARA DBL SIERRA,SUP-2245452,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.28,55.43,,,,,,,,,,,,,
CATHETER VALVULOPLASTY 4FR L70CM BAL L2CM DIA7MM 0.021IN MIC,SUP-2125234,CDM,C1725,HCPCS,0272,RC,,,,both,,,1684.30,1094.79,,,,,,,,,,,,,
SCREW BNE CANN SHRT THRD 4.5X20 MM 7 MM MIDFOOT HD COMPR SS,SUP-2609305,CDM,C1713,HCPCS,0278,RC,,,,both,,,1184.53,769.94,,,,,,,,,,,,,
EXPANDER TISS 3X5CM P3CM 36CC RECT SMOOTH INTEGRA,SUP-2328137,CDM,C1789,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
IMPLANT OTO L4MM PIST DIA0.6MM WELL DIA1MM FLROPLAS RICHARDS,SUP-2312589,CDM,L8613,CPT,0278,RC,,,,both,,,323.26,210.12,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 25 CM DIA 8 FR GUIDEWIRE 0.038 IN,SUP-2139633,CDM,C1894,HCPCS,0272,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE SILHOUETTE 10CM SS PLAT MALLINCKRODT,SUP-2170538,CDM,C1894,HCPCS,0272,RC,,,,both,,,88.33,57.41,,,,,,,,,,,,,
AUGMENT DPHSEAL SM CONE SYMM STRL EMPOWR,SUP-2929664,CDM,C1776,CPT,0278,RC,,,,both,,,19887.50,12926.87,,,,,,,,,,,,,
EXTRACTOR SURG L2 MMXTRACT ALL DISP FOR 2-2.5 MM BROKEN SCR,SUP-2337704,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
GRAFT BONE SUB 5CC DBM PURE PUTTY,SUP-2340465,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
RELOAD STPL SZ 2 H2.5MM TAN CRV TIP VASCULAR/MEDIUM,SUP-2283353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.05,436.18,,,,,,,,,,,,,
SCREW BONE CORT MALL 4.5X35 MM,SUP-2184386,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.60,35.49,,,,,,,,,,,,,
GRAFT BNE SUB SM CANC FRZN MORSELIZED W/ VIABLE CELL,SUP-2307239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
PLATE BNE L 342 MM SCREW DIA 4.5 MM 17 H DSTL FEM STRL EVOS,SUP-2931144,CDM,C1713,HCPCS,0278,RC,,,,both,,,12771.17,8301.26,,,,,,,,,,,,,
DRILL TWST L 54 MM DIA1 MM STP 13.8 MM DENT SHFT NS DISP,SUP-2883327,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.47,238.21,,,,,,,,,,,,,
COMPONENT FEM NP HIP POST STBL CONS LEGION,SUP-2348022,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
BUR SURG ACORN 6X7.7 MM 7 CM FLUT SM BOR LEGEND MEDNEXT,SUP-2630994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.38,204.35,,,,,,,,,,,,,
PLATE BONE 18 H ANTR BOW LAT PROX FOR 3.5 SCR,SUP-2349064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1135.49,738.07,,,,,,,,,,,,,
VALVE TRACH SPEAK SHILEY,SUP-2516374,CDM,L8501,HCPCS,0274,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
NAIL IM L340MM DIA13MM UNIV FEM TI SLV BENT AG NONLOCKING,SUP-2408509,CDM,C1713,HCPCS,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
PERI SCR 4.0MMX50MM,SUP-2461082,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.24,100.91,,,,,,,,,,,,,
WASHER SPNL LT OCCIPITAL CERV THOR TI HI ANG LCK DEV FOR TIB,SUP-2254386,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
SYSTEM KNEE FEM W/ PC TIB OPT NXGN LCCK,SUP-2212337,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE L151MM THK3.8MM 9 H BILAT S STL NAR DYN COMPR FOR,SUP-2185209,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.01,979.56,,,,,,,,,,,,,
CATHETER INTRAAORTIC BLLN 10.5 FR 50 CC,SUP-2227269,CDM,C1725,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
WIRE GUID 5MM TEMP NIT ANGIOGUARD XP 5FR INTRO 300CM,SUP-2157305,CDM,C1769,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X118 MM LT LAT DSTL 6 HOLE NS VA-LCP,SUP-2758198,CDM,C1713,HCPCS,0278,RC,,,,both,,,2834.54,1842.45,,,,,,,,,,,,,
SPACER SPNL 6DEG H10MM 55X22MM LAT TRUSS SYS,SUP-2101173,CDM,C1889,HCPCS,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
INSERT TIB SZ 1 THK6MM LT ANK FIX BEAR VANTAGE,SUP-2223483,CDM,C1776,CPT,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 152 MM DIA 46 MM NIT POLYPRO,SUP-2750375,CDM,C1768,CPT,0278,RC,,,,both,,,53955.97,35071.38,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,2500000003,HCPCS,0250,RC,00990-7972-08,NDC,,both,500,ML,17.00,11.05,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM DIA12 FR GUIDEWIRE 0.038 IN,SUP-2168247,CDM,C1894,HCPCS,0272,RC,,,,both,,,174.21,113.24,,,,,,,,,,,,,
PLATE BONE M MEDL MIDFT OFFSET H ANAT SHP HIND FT ARW MEDLIS,SUP-2321015,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
HC Postural Drainage Sub,PX-4109466800,CDM,94668,CPT,0410,RC,,,,inpatient,,,109.00,70.85,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST TURNBUCKLE W/NONTORSION JT,SUP-2435777,CDM,L3916,HCPCS,0272,RC,,,,both,,,1369.64,890.27,,,,,,,,,,,,,
HEAD HUM RESURF MACROBOND SZ 3 COPELAND EAS,SUP-2403995,CDM,C1776,CPT,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
PLATE BNE L40MM THK1MM 3X7 H NONSTERILE HND TI T SHP LOK VAR,SUP-2181004,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.79,1021.01,,,,,,,,,,,,,
SPLINT EL M,SUP-2276616,CDM,L3702,HCPCS,0274,RC,,,,both,,,29.01,18.86,,,,,,,,,,,,,
OSTEOTOME SURG W44XL205MM RT CVD RT W/ GRD ANDERSON-NEIVERT,SUP-2129696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 7.5CM X 7.5CM,SUP-2874121,CDM,A2007,HCPCS,0636,RC,,,,both,,,10597.50,6888.37,,,,,,,,,,,,,
REAMER SURG COMB ASSEMB OMEGA,SUP-2365041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3952.00,2568.80,,,,,,,,,,,,,
HALF PIN 5MMX55MM,SUP-2818216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1663.01,1080.96,,,,,,,,,,,,,
KIT INSRTN INTRO L 6 IN CATH DIA 7 FR 34/40 CC PACKAGED STRL,SUP-2908751,CDM,C1894,HCPCS,0272,RC,,,,both,,,455.17,295.86,,,,,,,,,,,,,
MESH SURG Y SHP 24X4 CM POLYPR RESTORELLE Y,SUP-2425006,CDM,C1781,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
TITANIUM 3D MESH 80MM X 80MM 1MM THICK 15MM SYSTEM,SUP-2707392,CDM,C1713,HCPCS,0278,RC,,,,both,,,4888.38,3177.45,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 6 H TI BRIDGE H LP BLU NS,SUP-2894489,CDM,C1713,HCPCS,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
LEAD PACE COROX OTW L 87 CM DIA1.8 MM POLYUR IRIDIUM OXIDE,SUP-2138066,CDM,C1900,HCPCS,0275,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
EVOS 2.7/3.5MM M-D HUMERIGHTUS PL 9H RIGHT 146MM,SUP-2820153,CDM,C1713,HCPCS,0278,RC,,,,both,,,8787.13,5711.63,,,,,,,,,,,,,
GRAFT BONE 100X25MM DEMIN BOAT CORT 3DEMIN,SUP-2125438,CDM,C1713,HCPCS,0278,RC,,,,both,,,13737.50,8929.37,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 4-7 MM LNG REINF SLDE GDS,SUP-2681799,CDM,C1768,CPT,0278,RC,,,,both,,,823.97,535.58,,,,,,,,,,,,,
SCREW BNE L 55 MM DIA 4.5 MM THRD L 22 MM TI ST SD PARTIALLY,SUP-2905555,CDM,C1713,HCPCS,0278,RC,,,,both,,,1801.45,1170.94,,,,,,,,,,,,,
BRACE ORTH CRUC RIGID TLSO PLAS,SUP-2388141,CDM,L0472,HCPCS,0274,RC,,,,both,,,997.58,648.43,,,,,,,,,,,,,
STENT GRFT VASC BODY L 110 MM DIA20 MM LIMB L 30 MM DIA20 MM,SUP-2217662,CDM,C1768,CPT,0278,RC,,,,both,,,37052.00,24083.80,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC SYR DBM ACCELL EVO3C,SUP-2641763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
HC Pt Estim-Manual Each 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209703200,CDM,97032,CPT,0420,RC,,,GO|CO,both,,,206.00,133.90,,,,,,,,,,,,,
HC Chest Tube Insertion,PX-3613255100,CDM,32551,CPT,0361,RC,,,,inpatient,,,4942.00,3212.30,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC PREHYDRATED DBM TENSIX,SUP-2489190,CDM,C1713,HCPCS,0278,RC,,,,both,,,7479.48,4861.66,,,,,,,,,,,,,
ROD SPNL ADJ 3.5X100 MM OCCIPITOCERVICAL COCRMOLY INFIN,SUP-2631926,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
ANCHOR SUT OD5MM 2 3 MAXBRAID TI SCR PERM DBL LD ROT CUF,SUP-2212815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1266.05,822.93,,,,,,,,,,,,,
METAL CANNULA 4.5MM WITH DAM,SUP-2812618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2552.82,1659.33,,,,,,,,,,,,,
HEADLESS COMPRESSION SCREW SYSTEM2.5/3.0,SUP-2841404,CDM,C1713,HCPCS,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
BRIDGE TELSCP W/ 2 LOK CHAN,SUP-2261152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2577.91,1675.64,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 4.5-6.5 MM EPTFE TAPR STD WALL,SUP-2396443,CDM,C1768,CPT,0278,RC,,,,both,,,1325.08,861.30,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.44/2.16 MM PAPARELLA W/ TAB 510043C,SUP-2535085,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.07,26.05,,,,,,,,,,,,,
PLATE BNE LAT EXT RIGHT/INTERNAL LT FOR OSTEOTMY TIBIAXYS,SUP-2609012,CDM,C1713,HCPCS,0278,RC,,,,both,,,4229.93,2749.45,,,,,,,,,,,,,
COIL VASC I-ED COIL L 10 CM DIA 0.012 IN SECONDARY 5 MM,SUP-2865308,CDM,C1889,HCPCS,0278,RC,,,,both,,,4914.10,3194.16,,,,,,,,,,,,,
TISSUE BIO MATRIDERM 21 X 29.7CM 2MM LG,SUP-2866496,CDM,A2027,HCPCS,0636,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE L195MM 8 H ST L CNDYL S STL CRV LOK COMPR VAR ANG,SUP-2177851,CDM,C1713,HCPCS,0278,RC,,,,both,,,6034.23,3922.25,,,,,,,,,,,,,
CATHETER IMAGING DRAGONFLY OPSTAR LENS TO TIP DISTANCE 23 MM,SUP-2574355,CDM,C1753,HCPCS,0278,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
PLATE BONE L 5 H TI PROX RAD LCK COMPR FOR 2.5MM SCR ALPS,SUP-2411726,CDM,C1713,HCPCS,0278,RC,,,,both,,,2155.30,1400.94,,,,,,,,,,,,,
CAP END TIB NAIL S STL,SUP-2402618,CDM,C1769,HCPCS,0272,RC,,,,both,,,1188.68,772.64,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM CART ARAGONITE 5PK,SUP-2913425,CDM,C1763,HCPCS,0278,RC,,,,both,,,21509.00,13980.85,,,,,,,,,,,,,
PLATE EXT FIX L 55 MM 4 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.10,353.66,,,,,,,,,,,,,
ALLOGRAFT BNE PASTE 1 CC DEMINERALIZED BNE MTRX + CANC,SUP-2717765,CDM,C1713,HCPCS,0278,RC,,,,both,,,870.53,565.84,,,,,,,,,,,,,
GRAFT BNE KT 5 CC W/ BEAD MOLD TY GENEX,SUP-2867001,CDM,C1713,HCPCS,0278,RC,,,,both,,,6418.16,4171.80,,,,,,,,,,,,,
KIT OLV WIRE M ADV W/ GWIRE SCRDRVR PLATING DEPTH GA E-KT,SUP-2225377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.05,618.83,,,,,,,,,,,,,
GRAFT BONE FEM HEMI CONDYLE RT MEDL FRSH STORED,SUP-2335224,CDM,C1713,HCPCS,0278,RC,,,,both,,,34524.30,22440.79,,,,,,,,,,,,,
STAPLER PWR JAW L 23 CM STPL H 1.2-2.2 MM GASTRC 6 ROW N,SUP-2901853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
SYSTEM KNEE LT STRL MISHA,SUP-2930733,CDM,C1776,CPT,0278,RC,,,,both,,,49455.00,32145.75,,,,,,,,,,,,,
ANCHOR SUT L36IN SZ 2 ETHBND POLY L LACTIDE 2 ABSRB GRN WHT,SUP-2184247,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.90,317.78,,,,,,,,,,,,,
KIT BONE MAR ASPIR,SUP-2415886,CDM,C1713,HCPCS,0278,RC,,,,both,,,1831.56,1190.51,,,,,,,,,,,,,
WIRE FIX TELLURIDE K FOR MIS SPNL FIX SYS,SUP-2211174,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
KIT EXT FIX MULTAXL CORRECTION SYS HEXAPOD FULL AUTO NS DISP,SUP-2905656,CDM,C1713,HCPCS,0278,RC,,,,both,,,23635.22,15362.89,,,,,,,,,,,,,
ACCESS KIT ECHO ENHANCED TIP MINI 5 FRX10 CM COAX INTRO MAX,SUP-2303004,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.46,49.70,,,,,,,,,,,,,
RAIL EXT FIX STR 5.5X500 MM 4D COBALT CHROM,SUP-2517553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6343.05,4122.98,,,,,,,,,,,,,
HC IV Inf 1st Hour Ea New Drug,PX-2609636700,CDM,96367,CPT,0260,RC,,,,both,,,98.00,63.70,,,,,,,,,,,,,
TUBE ET NSL STRL NAZ-AL 7.5MM,SUP-2383858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,984.11,639.67,,,,,,,,,,,,,
HANDLE INSTRUMENT RASPATORY 5 MM SLGHT CRV,SUP-2487332,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.17,286.76,,,,,,,,,,,,,
HEMOFILTER SET EXCORP CIRC PRISMAFLEX M100,SUP-2129944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.38,502.05,,,,,,,,,,,,,
CATHETER DRAINAGE 0.035 IN 10 FRX30 CM LCK RESOLV +,SUP-2303334,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.25,136.66,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ARMDA 35 L 80 CM BALLOON L 20 MM DIA 9,SUP-2106109,CDM,C1725,HCPCS,0272,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
SPACER FEM L DIA17MM DST HIP CO CHROM RNG STYL FOR SZ 6 AND,SUP-2368388,CDM,C1776,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
COMPONENT PAT RESURF CUST IDUO RT MEDL,SUP-2165959,CDM,C1776,CPT,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 85 CM OD 8 FR ID 2.6 MM GUIDEWIRE,SUP-2168368,CDM,C1894,HCPCS,0272,RC,,,,both,,,213.21,138.59,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA2 MM TI CANN HD NS LEOS,SUP-2932604,CDM,C1713,HCPCS,0278,RC,,,,both,,,729.61,474.25,,,,,,,,,,,,,
MESH BONE 190X140MM MAXILLOFACIAL PRE-FORMED,SUP-2365220,CDM,C1781,HCPCS,0278,RC,,,,both,,,56019.33,36412.56,,,,,,,,,,,,,
ASSEMBLY EXT FIX LG KT SIDEKCK EZ FRAME,SUP-2851069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
GENERATOR PLSE W502XH668MM 135MM SPNL CRD MRI COMPATIBLE,SUP-2101982,CDM,C1767,HCPCS,0278,RC,,,,both,,,45530.00,29594.50,,,,,,,,,,,,,
VOLAR PLATE 4 HOLES LEFT 28MM,SUP-2830159,CDM,C1713,HCPCS,0278,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
COIL EMB L4CM OD2MM MICROCATHETER COMPATIBILITY 0.0165IN,SUP-2296666,CDM,C1889,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
NAIL IM 3X130 MM RT FIBULAR,SUP-2432019,CDM,C1713,HCPCS,0278,RC,,,,both,,,8374.38,5443.35,,,,,,,,,,,,,
BUR SURG MATCHSTICK SHT 3 MM FLUT FOR QD8/QD8-G1/QD8-S,SUP-2848458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.34,262.82,,,,,,,,,,,,,
BREAST LESION LOC WIRE SET GHIATAS BEAD SILK MAMM GLAND 19,SUP-2242571,CDM,C1819,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
LEAD PACE BPLR 59 CM IS-1 CONN W/ INSUL SWEET PICOTIP RX,SUP-2148638,CDM,C1898,HCPCS,0275,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 9 FR HYDRPHLC,SUP-2120624,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
BIT DRL 4.5 MM W/ PENETRATION STP PREP OF TUNN MPFL RECON GA,SUP-2776114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
HC So Immunoassay,PX-3018351666,CDM,83516,CPT,0301,RC,,,,both,,,100.00,65.00,,,,,,,,,,,,,
RETRIEVER THROMCTMY MERCI L6 L 180 CM DIA2.7 MM DIA 4.5 MM,SUP-2367768,CDM,C1757,HCPCS,0272,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
SCREW BNE L55MM DIA5MM CORT TI ST LOK FULL THRD HD W/ HEX,SUP-2190321,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.21,373.24,,,,,,,,,,,,,
STEM FEM STD OFFSET 133 DEG 18-24 MM TYPE1 TRUNNION TAPRLOK,SUP-2448381,CDM,C1776,CPT,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
PROBE LITHO 1.5X440 MM TRIL KT SWISS LITHOCLAST DISP,SUP-2520664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2806.78,1824.41,,,,,,,,,,,,,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,2500000003,HCPCS,0250,RC,00316-0225-30,NDC,,both,85,GR,24.90,16.18,,,,,,,,,,,,,
ROD SPNL L240MM DIA3.2MM POST TI THRD LEG VERTEX MAX,SUP-2286756,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
BIT DRL 3.6 MM STRL INCORE LAPIDUS DISP,SUP-2476184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 TI LCK SCREW 46MM S-T,SUP-2819240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.18,785.97,,,,,,,,,,,,,
INTRODUCER SHTH 16 FRX14 CM SET CS ACCS W/O CRV PEELWY,SUP-2357073,CDM,C1892,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
PAPARELLA VT WTAB SI 1.14MM,SUP-2680278,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.15,20.90,,,,,,,,,,,,,
COLLAR CERV PED SM EXTRIC 1 PC TRACH OPN W CHIN REST MINI,SUP-2115115,CDM,L0140,HCPCS,0274,RC,,,,both,,,35.36,22.98,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC 4FR 55CM 1 LUMAN RVS TAPR PWR INJ W,SUP-2613365,CDM,C1751,HCPCS,0278,RC,,,,both,,,721.07,468.70,,,,,,,,,,,,,
PIN EXT FIX 2 MM,SUP-2198651,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.30,176.34,,,,,,,,,,,,,
AWL SURG SQ TAPR,SUP-2934604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
TUBE CONN OUTER END TELLURIDE FOR MIS SPNL FIX SYS,SUP-2211189,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2415.29,1569.94,,,,,,,,,,,,,
SYSTEM PAIN RELF 400ML W/ SEL A FLO 2-14ML/HR ON-Q,SUP-2236810,CDM,C9804,HCPCS,0272,RC,,,,both,,,859.70,558.80,,,,,,,,,,,,,
OXYGENATOR PERFSN 215 ML SOFTLINE COAT AD DIFFUS MEMBRN,SUP-2908624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3919.57,2547.72,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC CORTICOCANCELLOUS ALLGRFT FRZN,SUP-2933209,CDM,C1762,CPT,0278,RC,,,,both,,,1423.33,925.16,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.37XH7.79CM D0.99CM 2 CHMBR DR IS-1,SUP-2149169,CDM,C1721,HCPCS,0275,RC,,,,both,,,53361.16,34684.75,,,,,,,,,,,,,
CONNECTOR SPNL SM SZ 4 L26-27MM STD POST LUM THOR TI SCR,SUP-2254359,CDM,C1713,HCPCS,0278,RC,,,,both,,,3546.63,2305.31,,,,,,,,,,,,,
KIT SCR TORQ DEFINING,SUP-2223286,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
HC Sclerotherapy Multiple Veins,PX-3613647100,CDM,36471,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER INFUSION STR 0.018 IN 160 CM 15 CMX6 CM PHENOM 21,SUP-2418136,CDM,C1887,HCPCS,0272,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM CLAVICLE 4H RT-15MM HOOK DEPTH-STER,SUP-2549658,CDM,C1713,HCPCS,0278,RC,,,,both,,,3461.63,2250.06,,,,,,,,,,,,,
PLATE BNE L 333 MM SCREW DIA 3.5/4.5 MM 16 H SS DSTL FEM,SUP-2931170,CDM,C1713,HCPCS,0278,RC,,,,both,,,19791.42,12864.42,,,,,,,,,,,,,
PATCH BIO W4XL6CM BOV PERICARDIUMXENOSURE,SUP-2264300,CDM,C1713,HCPCS,0278,RC,,,,both,,,1755.26,1140.92,,,,,,,,,,,,,
COLLAR CERV L H3.25X23IN M DENS FOAM COT STOCK CVR LO,SUP-2196890,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.96,7.12,,,,,,,,,,,,,
LEAD DEFIB L90CM ENDOCARD SGL COIL PASS NO CHRG RELIANCE S,SUP-2139493,CDM,C1779,HCPCS,0275,RC,,,,both,,,21116.50,13725.72,,,,,,,,,,,,,
GRAFT BNE CHIP 4-10 MM 60 CC FRZN COARSE CORTICAL CANC,SUP-2307433,CDM,C1713,HCPCS,0278,RC,,,,both,,,5831.01,3790.16,,,,,,,,,,,,,
VORICONAZOLE 50 MG PO TABS,RX-33008,CDM,6370000000,HCPCS,0637,RC,00904-6596-04,NDC,,both,1,UN,36.50,23.72,,,,,,,,,,,,,
MESH PTCH MK W POSIFLEX OVL 3 IN X 5 IN SM,SUP-2126069,CDM,C1781,HCPCS,0278,RC,,,,both,,,337.55,219.41,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/NONTORSION ELASTIC PREFABRICATED,SUP-2435787,CDM,L3930,HCPCS,0272,RC,,,,both,,,235.31,152.95,,,,,,,,,,,,,
PED CHS PLATE - 100 DEG,SUP-2818376,CDM,C1713,HCPCS,0278,RC,,,,both,,,7599.27,4939.53,,,,,,,,,,,,,
"HC So Osmolality, Urine",PX-3018393566,CDM,83935,CPT,0301,RC,,,,both,,,28.00,18.20,,,,,,,,,,,,,
CANNULA DEL L120MM THK11GA 5CC END KNEE KT FOR SCP ACCUPORT,SUP-2206136,CDM,C1713,HCPCS,0278,RC,,,,both,,,11351.10,7378.21,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA SULF HA INJ BIPHASIC OSTEOCONDUCTIVE,SUP-2402599,CDM,C1713,HCPCS,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
CATHETER SUPP QUICK-CROSS EXTRM L 150 CM DIA 4 FR 0.018 IN,SUP-2823590,CDM,C1887,HCPCS,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
BIT DRL REUSE NONSTERILE 160MM,SUP-2291551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3347.84,2176.10,,,,,,,,,,,,,
CYGNUS ANTR CERV PLTE FIX PIN,SUP-2664217,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
BIT DRL 4.5 MM,SUP-2862306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
BEAM FUS L135MM DIA5.4MM FT ANK S STL G-BEAM,SUP-2417461,CDM,C1713,HCPCS,0278,RC,,,,both,,,5400.80,3510.52,,,,,,,,,,,,,
BIT DRILL L4MM DIA15MM SUBCHONDRAL,SUP-2589363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,199.23,129.50,,,,,,,,,,,,,
CATHETER DRNGE L60CM DIA10.2FR 0.038IN TRCR STYL NDL,SUP-2169797,CDM,C1729,HCPCS,0272,RC,,,,both,,,398.81,259.23,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 61 CM DIA 8.5 FR NDL L 71 CM STL,SUP-2516627,CDM,C1893,HCPCS,0272,RC,,,,both,,,75.83,49.29,,,,,,,,,,,,,
PLATE BNE L121MM 4 H L PROX LAT TIB S STL LOK FOR 3.5/4MM,SUP-2372127,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
STAPLE COMPRESSION 8MMX8MM TITANIUM,SUP-2652943,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CANNULA ARTHSCP L35IN DIA63MM INNR PRSS SENS FOR 87K FLD,SUP-2166826,CDM,C1894,HCPCS,0272,RC,,,,both,,,1491.31,969.35,,,,,,,,,,,,,
BRACE TRACTION HALO VEST 2XL,SUP-2328124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
PLATE BNE REPLICATOR 0 MM SHT SHLDR OFFSET FIX ANGLE KT TI,SUP-2451382,CDM,C1713,HCPCS,0278,RC,,,,both,,,3494.19,2271.22,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE T SHP WTAB 1.5 MM SCRW8 HOLE T0.6,SUP-2677544,CDM,C1713,HCPCS,0278,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL BND BELT UNILAT,SUP-2435688,CDM,L2630,HCPCS,0272,RC,,,,both,,,655.51,426.08,,,,,,,,,,,,,
CONNECTOR SPNL OD23MM TI MONOBLOCK MULTIAXIAL MAC LX,SUP-2379879,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PROBE ABLATN,SUP-2225695,CDM,C2618,HCPCS,0272,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL FREE,SUP-2435682,CDM,L2600,HCPCS,0272,RC,,,,both,,,603.82,392.48,,,,,,,,,,,,,
HC Assay of Troponin Quantitative,PX-3018448400,CDM,84484,CPT,0301,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
GRAFT HUM TISS ACELLULAR DERM THK.4-.8 MM OD4 CM X 8 CM N,SUP-2366753,CDM,Q4126,HCPCS,0636,RC,,,,both,,,9815.55,6380.11,,,,,,,,,,,,,
BIT DRL L280MM DIA17MM L QUIK CPL CANN,SUP-2178841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1824.91,1186.19,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 14MM DISK,SUP-2905493,CDM,Q4151,HCPCS,0636,RC,,,,both,,,800.64,520.42,,,,,,,,,,,,,
ANCHOR SUT 2-0 DIA5.5MM BLU COBRAID BLK REGENESORB PRELD,SUP-2349212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.50,816.72,,,,,,,,,,,,,
STEM FEM SZ 4 L165MM DIA15MM HIP CO CHROME CLLRD PRESSFIT,SUP-2252027,CDM,C1776,CPT,0278,RC,,,,both,,,3500.47,2275.31,,,,,,,,,,,,,
IMPLANT BREAST 625ML HIGH PROFILE SALINE SMOOTH ROUND,SUP-2745924,CDM,C1789,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GRAFT BNE 2.5 CC DEMINERALIZED BNE FIBER PROGRAFT,SUP-2858504,CDM,C1713,HCPCS,0278,RC,,,,both,,,1219.89,792.93,,,,,,,,,,,,,
STENT GRFT VASC AFX2 VELA L 80 MM UNCOVERED L 20 MM DIA 34mm,SUP-2217612,CDM,C1874,HCPCS,0278,RC,,,,both,,,13690.40,8898.76,,,,,,,,,,,,,
PROVENTM REV KNEE SYS DSTL FEM AUG SZ 1 THRU 5 5,SUP-2359326,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
UNIT HEARING AID XPRESS,SUP-2430336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
GRAFT BIO TISS W20XL40CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113041,CDM,Q4130,HCPCS,0636,RC,,,,both,,,76914.30,49994.29,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X237 MM 18 HOLE SS LCP,SUP-2569344,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.36,385.03,,,,,,,,,,,,,
SYSTEM IV INFUSION 4 FRX45 CM 20 CM 20 CC SQUIRT FLUID DEL,SUP-2740491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
WIRE FIX DIAMOND PT 2 END 0.062X6 IN SS NS KIRSCHNER,SUP-2791248,CDM,C1713,HCPCS,0278,RC,,,,both,,,9.23,6.00,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC L 370 MM DIA 3 MM TROCAR TIP NS LF DISP,SUP-2930398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
CATHETER CV DL 6 FRX55 CM PWR INJ MAX BARR NURSING KT XCELA,SUP-2734864,CDM,C1751,HCPCS,0278,RC,,,,both,,,132.51,86.13,,,,,,,,,,,,,
GRAFT DERMAL MESH 4X4 CM FEN + WND MTRX MIRODERM,SUP-2431543,CDM,Q4175,HCPCS,0636,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
HC Iadna Sars-Cov-2-19 Amp Probe Tq,PX-3068763500,CDM,87635,CPT,0306,RC,,,,both,,,110.00,71.50,,,,,,,,,,,,,
PLATE BONE LOCKING 4.5X444 MM 24 HOLE COMPRESSION,SUP-2837372,CDM,C1713,HCPCS,0278,RC,,,,both,,,12807.59,8324.93,,,,,,,,,,,,,
TRAY PICC CATH 5FR POLYUR BASIC TRIM LEN SGL LUMN IR PWR,SUP-2125534,CDM,C1751,HCPCS,0278,RC,,,,both,,,371.46,241.45,,,,,,,,,,,,,
HEAD FEM LFIT 0+ 40 MM HIP COCR V40,SUP-2364575,CDM,C1776,CPT,0278,RC,,,,both,,,3686.99,2396.54,,,,,,,,,,,,,
IMMOBILIZER SHLDR L STRP 43IN,SUP-2324219,CDM,L3650,HCPCS,0272,RC,,,,both,,,19.75,12.84,,,,,,,,,,,,,
CUTTER SUTURE MENIS REP DEV JUGGERSTITCH DISP,SUP-2421745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.23,303.70,,,,,,,,,,,,,
SOCKS PROSTHETIC SINGLE PLY FIT LF,SUP-2388228,CDM,L8470,HCPCS,0272,RC,,,,both,,,17.55,11.41,,,,,,,,,,,,,
OXCARBAZEPINE 300 MG/5ML PO SUSP,RX-30479,CDM,340b,HCPCS,0637,RC,50268-0649-05,NDC,,both,5,ML,37.60,24.44,,,,,,,,,,,,,
BOLT SPINAL 5MM X 20MM ALIF FIX MODULUS STRL,SUP-2863084,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
HC So Mopath Procedure Level 4,PX-3108140366,CDM,81403,CPT,0310,RC,,,,both,,,463.00,300.95,,,,,,,,,,,,,
HC Ia Infectious Agt Antibody Qual/Semiq 1step Meth,PX-3028631800,CDM,86318,CPT,0302,RC,,,,both,,,41.00,26.65,,,,,,,,,,,,,
ASPIRIN 81 MG PO TBEC,RX-688,CDM,6370000000,HCPCS,0637,RC,77333-0031-25,NDC,,both,1,UN,1.00,0.65,,,,,,,,,,,,,
PLATE SPNL 17 MM ZEVO,SUP-2278039,CDM,C1713,HCPCS,0278,RC,,,,both,,,5081.78,3303.16,,,,,,,,,,,,,
GUIDEWIRE ENDO L450CM OD0.035IN NIT HYDRPHLC TORQUEABLE,SUP-2141513,CDM,C1769,HCPCS,0272,RC,,,,both,,,337.55,219.41,,,,,,,,,,,,,
TRIAL CBL MULTILD FOR DIR LD INFIN IPG,SUP-2101969,CDM,C1883,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.7 MM LG PATELLAR MESH STRL EVOS,SUP-2932791,CDM,C1713,HCPCS,0278,RC,,,,both,,,6669.36,4335.08,,,,,,,,,,,,,
IMPACTOR SURG ANG FOR GRFT PYRAMETRIX,SUP-2292626,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.98,898.94,,,,,,,,,,,,,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-4839335500,CDM,93355,CPT,0483,RC,,,,both,,,2093.00,1360.45,,,,,,,,,,,,,
CATHETER EP SINGLE 2-2-2MM 7FRX90CM MARINR,SUP-2281827,CDM,C1730,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SHEATH INTRO TORFLEX 90 DEG L 63 CM DIA 8 FR GUIDEWIRE L 180,SUP-2131516,CDM,C1893,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
KIT ELBOW BEARING ORTHOPAEDIC CONDYLAR HEXALOBULAR,SUP-2879195,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
KNIFE SURG SCHKNT ROLLER 15 90 DEG 6 INX3 MM MICROFRANCE,SUP-2477075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.76,354.74,,,,,,,,,,,,,
MARKER GRFT SCANLAN A/C LOC,SUP-2336955,CDM,A4648,CPT,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
SCREW BNE NLCK 2.7X22 MM,SUP-2363510,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.83,130.54,,,,,,,,,,,,,
PLATE BNE 12 H ST BILAT S STL NAR CRV LOK COMPR FOR 45MM SCR,SUP-2178058,CDM,C1713,HCPCS,0278,RC,,,,both,,,2674.31,1738.30,,,,,,,,,,,,,
MOLD CEM SPCR HD DIA48MM HIP SIL S STL FOR MAKING TEMP HEMI,SUP-2408601,CDM,C1776,CPT,0278,RC,,,,both,,,2298.48,1494.01,,,,,,,,,,,,,
BAR EXT FIX 11X300 MM CARBON,SUP-2749997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.7MM TI CORT ST EMER LCK HDED THRD HD 5PK,SUP-2363333,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.41,124.42,,,,,,,,,,,,,
DILTIAZEM HCL ER 120 MG PO CP12,RX-11892,CDM,6370000000,HCPCS,0637,RC,00378-6120-01,NDC,,both,1,UN,17.10,11.11,,,,,,,,,,,,,
GUIDEWIRE VASC SION L 300 CM DIA 0.014 IN RADIOPAQUE L 3 CM,SUP-2123809,CDM,C1769,HCPCS,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
PUMP PAIN 400ML FLO RATE 5ML/HR FIX FOR NRV BLK ON-Q,SUP-2236807,CDM,C9804,HCPCS,0272,RC,,,,both,,,616.88,400.97,,,,,,,,,,,,,
FLUORESCEIN SODIUM 1 MG OP STRP,RX-27663,CDM,6370000000,HCPCS,0637,RC,51801-0009-40,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BELT RIB XL 6 IN M ELASTIC VELCRO CLOSURE,SUP-2194761,CDM,L0220,HCPCS,0272,RC,,,,both,,,22.95,14.92,,,,,,,,,,,,,
CABLE LT,SUP-2310428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CLIP ENDOSCP 235CM RESOL 360 ORDER UOM IS EACH,SUP-2149428,CDM,C1889,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
GRAFT CORNEAL PROC FEE,SUP-2164746,CDM,V2785,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
NEEDLE HLDR LPRSCPY SELF RGHTNG 3.5MMX32CM NON INSLTD CRVD S,SUP-2473473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2831.71,1840.61,,,,,,,,,,,,,
INSTRUMENT SCREW BNE L48MM CONSTRN CNDYL KNEE HEX HD STEM FOR LEG NXGN,SUP-2201524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
GUIDEPIN ORTH L 350 MM DIA 3.2 MM DRL TIP LG TARGETER STRL,SUP-2931157,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
GRAFT SPINE AND GEN ORTH TISS FRZ DRY STRP SHAFTS ILIUM,SUP-2307131,CDM,C1713,HCPCS,0278,RC,,,,both,,,1970.48,1280.81,,,,,,,,,,,,,
GRAFT ALLGRFT TEND PAT PRE SHP MACHINED FRZN 10MM MAXXEUS,SUP-2165608,CDM,C1713,HCPCS,0278,RC,,,,both,,,9313.24,6053.61,,,,,,,,,,,,,
ORTHO ANCHRGE PLATE 4 HLE STRGHT 30MM BRDGE CP TTNM,SUP-2497257,CDM,C1713,HCPCS,0278,RC,,,,both,,,814.39,529.35,,,,,,,,,,,,,
COUNTERSINK SURG FOR 1.5-2MM CORT SCR MINI FRAG SYS,SUP-2187351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.56,476.16,,,,,,,,,,,,,
PROSTHESIS TORP 084MM DIAM 4MM LEN CNTR HD HA,SUP-2313674,CDM,L8613,CPT,0278,RC,,,,both,,,1186.04,770.93,,,,,,,,,,,,,
HC So Haptoglobin,PX-3018301066,CDM,83010,CPT,0301,RC,,,,inpatient,,,38.00,24.70,,,,,,,,,,,,,
REAMER SURG OD46MM S STL ACET SPHR CUTTINGEDGE,SUP-2361870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
AUGMENT TIB SZ 5/4+ THK5MM NP PRI CEM BLK BASE ADV,SUP-2304780,CDM,C1776,CPT,0278,RC,,,,both,,,3111.74,2022.63,,,,,,,,,,,,,
HC Blood Count Hemoglobin|NOT REASONABLE AND NECESSARY,PX-3058501800,CDM,85018,CPT,0305,RC,,,GZ,both,,,59.00,38.35,,,,,,,,,,,,,
STENT GRFT VASC AFX COCR STRATA IL INFRARENAL SELF EXPND,SUP-2217644,CDM,C1768,CPT,0278,RC,,,,both,,,34398.70,22359.15,,,,,,,,,,,,,
BIT DRL DIA6MM DSTL RAD ULN CANN,SUP-2119913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,478.85,311.25,,,,,,,,,,,,,
INSERT TIB BEAR 12MM UHMWPE FINN - 12MM,SUP-2406086,CDM,C1776,CPT,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
GRAFT EVAR L50MM DIAM 8MM TRNSJUG INTRAHEPATIC VIATORR,SUP-2395921,CDM,C1874,HCPCS,0278,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-JEJUNAL 18 FRX45 CM 7-10 CC FOR SURG,SUP-2764469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1049.23,682.00,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 5.25X5.25 IN FNGR W/ BLB RADLUC,SUP-2276774,CDM,L3933,HCPCS,0274,RC,,,,both,,,5.21,3.39,,,,,,,,,,,,,
Z DUP USE 2111317 LENS INTOCU +18.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111318,CDM,V2632,HCPCS,0276,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
WASHER ORTH BOWL 7 MM MONSTER,SUP-2742355,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.16,246.45,,,,,,,,,,,,,
SCREW INTRF L12MM DIA8MM BIO-TENODESIS,SUP-2121452,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BONE W60XL60MM THK0.6MM TI DYN MESH FOR COMP CRAN CLSR,SUP-2243968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.10,881.46,,,,,,,,,,,,,
LEAD PACEMKR LT VENT COR VEN SYS QUICKFLEX,SUP-2356053,CDM,C1900,HCPCS,0275,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
MESH SURG W8XL8CM FLAT SHT BIO-A,SUP-2395750,CDM,C1781,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KIT ART CATH 0.021INCH 40CENTIMETER GWIRE 21GAUGE 2INCH NDL,SUP-2120112,CDM,C1751,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
KIT DRN 600ML 1/4IN 6IN POST AUTOTRNS PVC TRCR HEMVAC,SUP-2205662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.99,278.84,,,,,,,,,,,,,
DEVICE INFLATION BALLOON L 3 CM DIA24/18 FR PACLITAXEL COAT,SUP-2881841,CDM,C1889,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
CATHETER VALVULOPLASTY COEFFICIENT L 75 CM 3.5 FR 4 CM 4 MM,SUP-2659438,CDM,C1725,HCPCS,0272,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
BLADE ARTHSCP D4.5MM GRAY SHVR ANGLD TMCT SM JOINT FRMLA,SUP-2589383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,216.60,140.79,,,,,,,,,,,,,
TUBE SET DIL DISP,SUP-2750391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SCREW BNE NLCK 4.5X34 MM DBL STRT THRD SS JPS,SUP-2645473,CDM,C1713,HCPCS,0278,RC,,,,both,,,1126.63,732.31,,,,,,,,,,,,,
ENDCAP ORTH GRN TI FOR 3-4MM E NAIL SYS,SUP-2192721,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.84,152.00,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM DIA 6 FR TIP DIA1 MM SPC,SUP-2526801,CDM,C1730,HCPCS,0272,RC,,,,both,,,359.15,233.45,,,,,,,,,,,,,
HC Therapeutic Prophylactic/Dx Njx Intra-Arterial,PX-2609637300,CDM,96373,CPT,0260,RC,,,,both,,,267.00,173.55,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RX 3X15 MM VOYAGER,SUP-2424269,CDM,C1725,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
"HC So Blood Typing, Rh(D)",PX-3008690166,CDM,86901,CPT,0302,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
MTOSCR.INTF NON-CAN 7X20 N/S,SUP-2341306,CDM,C1713,HCPCS,0278,RC,,,,both,,,289.04,187.88,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 6H 163MM RT STRL,SUP-2546845,CDM,C1713,HCPCS,0278,RC,,,,both,,,6079.73,3951.82,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309753000,CDM,97530,CPT,0430,RC,,,KX|CQ|XU,both,,,144.00,93.60,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS,RX-33228,CDM,6370000000,HCPCS,0637,RC,60687-0803-11,NDC,,both,1,UN,11.00,7.15,,,,,,,,,,,,,
GRAFT HUM TISS M W9.2XL19.2CM CORTIVA 1MM TAILORED ALLGRFT,SUP-2335289,CDM,C1762,CPT,0278,RC,,,,both,,,10762.10,6995.36,,,,,,,,,,,,,
GRAFT DERM HUM TISS HYDRATED THCK ACELLULAR DERM IMPL,SUP-2307459,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2315.81,1505.28,,,,,,,,,,,,,
MESH SURG CONTOURED SM 0.3 MM ORBIT FLR SPEC BOWLES TI,SUP-2458003,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.81,765.58,,,,,,,,,,,,,
SCREW BNE L11MM OD2MM S STL IMPL FRAC CORRECTIVE OSTEOTMY,SUP-2361633,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.33,496.16,,,,,,,,,,,,,
HEAD FEM MOD 4- MM SHT 54 MM HIP BIRMINGHAM HIPTM RESURF,SUP-2435180,CDM,C1776,CPT,0278,RC,,,,both,,,11511.24,7482.31,,,,,,,,,,,,,
LOOP SURG BILLEAU FIG 1 16.5 CM EAR SS,SUP-2501190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,171.66,111.58,,,,,,,,,,,,,
NAIL IM L440MM DIA4MM FEM TIB TI CANN RG BENT E FLX DSGN,SUP-2192734,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.41,676.27,,,,,,,,,,,,,
ENVELOPE CV DEVICEXL W6.9XL9.5CM PORCINE DERIVED,SUP-2172041,CDM,C1889,HCPCS,0278,RC,,,,both,,,3030.10,1969.56,,,,,,,,,,,,,
INTRODUCER SHTH 12FR L30CM 0.038IN HEMSTAS VLV L LUMN GWIRE,SUP-2355435,CDM,C1894,HCPCS,0272,RC,,,,both,,,270.83,176.04,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6MM STR REINF SLDE GDS,SUP-2681784,CDM,C1768,CPT,0278,RC,,,,both,,,1948.87,1266.77,,,,,,,,,,,,,
GRAFT HUMAN TSSUE L12XW6CM RGNRTVE TSSUE MTRX THN READY USE,SUP-2491359,CDM,Q4116,HCPCS,0636,RC,,,,both,,,7963.04,5175.98,,,,,,,,,,,,,
DISSECTOR ENDOSCP L18CM ARTC W/ TRNSF TAPE LUMITIP,SUP-2124450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR 16 CHANNEL PRODIGY MRI,SUP-2615540,CDM,C1820,HCPCS,0278,RC,,,,both,,,49592.44,32235.09,,,,,,,,,,,,,
BAND FET MONITOR 11 YDX10 IN WHT,SUP-2735407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.89,214.43,,,,,,,,,,,,,
SCREW SYNDESMOTIC L 42 MM DIA 4 MM TI ANK HEXALOBE HD LP -RSFH,SUP-2881305,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
MIDAZOLAM HCL (PF) 5 MG/ML IJ SOLN,RX-147440,CDM,J2250,HCPCS,0636,RC,00409-2308-01,NDC,,both,0.4,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L35MM 6 H BILAT S STL STR LO PROF NEUT,SUP-2186299,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.50,888.87,,,,,,,,,,,,,
SCREW INTRF 12X25 MM FT TI,SUP-2762233,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.444,SUP-2860008,CDM,C1713,HCPCS,0278,RC,,,,both,,,45382.11,29498.37,,,,,,,,,,,,,
GUIDEWIRE VASC VICTORY 18 L 300 CM DIA 0.018 IN TIP 2.5 CM,SUP-2140827,CDM,C1769,HCPCS,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
BIO-UNI DISPOSABLE CUTTING KIT L17,SUP-2811436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
CONNECTOR ST 360 BLU 10-15MM S,SUP-2205087,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
EXTENSION ORTHOT LAT THOR CUST,SUP-2435585,CDM,L1210,HCPCS,0274,RC,,,,both,,,692.68,450.24,,,,,,,,,,,,,
SHAVERDRILL SUTURETAK DISPOSABLES KT,SUP-2419463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GRAFT BNE COTTON WDG 20X15X6 MM STRL RIPTIDE LTX,SUP-2866941,CDM,C1713,HCPCS,0278,RC,,,,both,,,9099.72,5914.82,,,,,,,,,,,,,
BRACE TRACTION HALO VEST LG,SUP-2328123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
DRILL SURG STP 3.9 MM FOR 5 MM PIN SALVATION 2,SUP-2850525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
ENALAPRIL MALEATE 10 MG PO TABS,RX-9924,CDM,6370000000,HCPCS,0637,RC,23155-0772-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 1ML GEL MIXED WITH PRP DERIVED FROM WHOLE BLOOD OR BONE MARROW STIMUBLAST,SUP-2120746,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
AUGMENT TIB SM KNEE CRUCE RET REV VANGUARD 360,SUP-2408089,CDM,C1776,CPT,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X251 MM LT PROX 8 HOLE STRL VALCP,SUP-2789591,CDM,C1713,HCPCS,0278,RC,,,,both,,,7703.27,5007.13,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.527,SUP-2860208,CDM,C1713,HCPCS,0278,RC,,,,both,,,34662.46,22530.60,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH CANC 130816034,SUP-2165601,CDM,C1889,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
ELECTRODE ELECSURG ANGLED LOOP 12 DEG 30 24-28 FR 0.02 IN,SUP-2472699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
GRAFT BNE 15 CC HI VISC MIIG X3,SUP-2486754,CDM,C1713,HCPCS,0278,RC,,,,both,,,10098.24,6563.86,,,,,,,,,,,,,
PLATE BNE PENTAGON 1.5X0.2 MM NEURO SCRN MESH JANNETTA TI NS,SUP-2463225,CDM,C1713,HCPCS,0278,RC,,,,both,,,890.57,578.87,,,,,,,,,,,,,
PIN FIX 1.5MM BIODEGRADABLE KT INION FREEDOMPIN,SUP-2417694,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
ROD EXT FIX W50XL110MM DIA4MM UNIV C FBR ANG T BAR,SUP-2188719,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.43,700.33,,,,,,,,,,,,,
BRACE ELBW C SHP REINF ADJ COUNTERFORCE VISCOELASTIC POLYMER,SUP-2324053,CDM,L3702,HCPCS,0274,RC,,,,both,,,137.66,89.48,,,,,,,,,,,,,
PLATE BNE CRV MIC 1.5 MM ORBIT CRANIOMAXILLOFACIAL 8 HOLE TI,SUP-2478119,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.37,377.24,,,,,,,,,,,,,
PLATE BONE L74MM 6 H DSTL ANTR TIB VAR ANG LCK FOR 3.5MM SCR,SUP-2349813,CDM,C1713,HCPCS,0278,RC,,,,both,,,8695.76,5652.24,,,,,,,,,,,,,
CATHETER DIAG L90CM OD0.059X0.052IN TIP OD3.2FR 50MM SPC,SUP-2353138,CDM,C1887,HCPCS,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
BUR SURG DIA25.4 MM CARBIDE 3MC FOR MTL CUT HNDPC STRL DISP,SUP-2937257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
APPLIER CLP 12FR L114CM W/ ENDOANCHOR CASS 10 IMPL FOR,SUP-2280985,CDM,C1713,HCPCS,0278,RC,,,,both,,,19518.24,12686.86,,,,,,,,,,,,,
SYSTEM CAST 4 IN TOT CONTACT W/ X LG BOOT TCC-EZ,SUP-2268427,CDM,L4386,HCPCS,0274,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
DRESSING BIO CIRC 14 MM ACELLULAR FISH SKIN OMEGA 3 SLD CIR,SUP-2883716,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1385108D4,SUP-2632823,CDM,C1751,HCPCS,0278,RC,,,,both,,,884.54,574.95,,,,,,,,,,,,,
PLATE BNE TBLR SS NS,SUP-2185994,CDM,C1713,HCPCS,0278,RC,,,,both,,,3159.47,2053.66,,,,,,,,,,,,,
BLADE OPHTH STRL LTX FREE DISP,SUP-2314056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.13,225.63,,,,,,,,,,,,,
GUIDEWIRE SURG L407MM DIA1.6MM S STL FLEX SMOOTH BALL TIP,SUP-2256597,CDM,C1769,HCPCS,0272,RC,,,,both,,,246.18,160.02,,,,,,,,,,,,,
PLATE BNE TIB 3.5X185 MM RT PROX LAT 12 HOLE LOQTEQ,SUP-2691243,CDM,C1713,HCPCS,0278,RC,,,,both,,,5595.48,3637.06,,,,,,,,,,,,,
SCREW SET BRK OFF STRL CD HORZ MODULEX 559200009,SUP-2849987,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
COMPONENT HUM FLNG 3.5X84 MM LT SHLDR BOND COAT MOSAIC STRL,SUP-2215485,CDM,C1776,CPT,0278,RC,,,,both,,,11451.58,7443.53,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM DIA0.014IN RADPQ L30CM MICROGLIDE STR,SUP-2105897,CDM,C1769,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
BLADE ENDOSCP SHV DIA4MM 15DEG ANG SNUS CRV SERR CONCAVE,SUP-2313826,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.47,255.11,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX60 CM SET PRO-LINE MD28035101,SUP-2626367,CDM,C1751,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
INSERT ACET 32X57 MM HIP METASUL,SUP-2205432,CDM,C1776,CPT,0278,RC,,,,both,,,5157.32,3352.26,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.018 IN TIP L 6 MM PTFE J FIX,SUP-2301925,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.72,25.82,,,,,,,,,,,,,
STENT BILI L 7 CM DIA 7 FR GUIDEWIRE 0.035 IN PERCFLX,SUP-2149459,CDM,C2617,HCPCS,0278,RC,,,,both,,,155.59,101.13,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40CM 12X7MM POLYESTER BOV BIFURCATE,SUP-2266067,CDM,C1768,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SET INT FIX 2 H MED TI NEURO PLATE ST SCREW STRL DISP LORENZ,SUP-2936148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
KIT INTRO DIL DIA24 FR LAPSCP FOR GASTMY FEED TUBE STRL,SUP-2764615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.94,471.86,,,,,,,,,,,,,
SET DRNGE 12FR 30CM 038IN 14FR SUMP GUID WIRE J TIP CONN,SUP-2168235,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.38,357.75,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 130 CM OD 0.07 IN ID 0.058 IN FLX,SUP-2522809,CDM,C1887,HCPCS,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM PTC 14 GAX4 IN 20 IN PMI DISP,SUP-2330478,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.17,48.86,,,,,,,,,,,,,
STEM FEM SZ 2 L KNEE POST STBL CONGRUENCY 121928160] JNJ DEPUY SYNTHES ORTHOPEDICS],SUP-2250362,CDM,C1776,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER ANGIOPLSTY AVTR L 135 CM BALLON L 15 MM DIA 4 MM,SUP-2156426,CDM,C1725,HCPCS,0272,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
GRAFT BONE ALIF SPCR ANTR APPRCH FRZ DRY H 11MM,SUP-2306897,CDM,C1713,HCPCS,0278,RC,,,,both,,,14184.95,9220.22,,,,,,,,,,,,,
ALLOGRAFT DERMAL N MESHED MED STD 2X4 CM FLOWERDERM,SUP-2225419,CDM,C1713,HCPCS,0278,RC,,,,both,,,2974.21,1933.24,,,,,,,,,,,,,
COMPONENT FEM 38MM OFFSET PROX ZMLY SEG BASIC,SUP-2200518,CDM,C1776,CPT,0278,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
COVER BURR HOLE CONTOURED 18X0.3 MM 5 HOLE TI LEVEL 1 NEURO,SUP-2493732,CDM,C1713,HCPCS,0278,RC,,,,both,,,801.20,520.78,,,,,,,,,,,,,
PLATE BNE L199MM 12 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185278,CDM,C1713,HCPCS,0278,RC,,,,both,,,1841.42,1196.92,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 10X10X10 MM DEMINERALIZED CANC LIFEFLEX,SUP-2866837,CDM,C1762,CPT,0278,RC,,,,both,,,939.65,610.77,,,,,,,,,,,,,
LEVEL CMF PLATE MDFCE LDDR WTAB 1.5 MM SCRW2 X 2 HOLES 12 M,SUP-2677538,CDM,C1713,HCPCS,0278,RC,,,,both,,,808.24,525.36,,,,,,,,,,,,,
PLATE BONE L98MM 6 H RT ANTEROLATERAL MEDL DSTL TIB LCK FOR,SUP-2348481,CDM,C1713,HCPCS,0278,RC,,,,both,,,16888.96,10977.82,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL THCK 16X4 CMX0.8-1.7 MM BRST FLEXHD,SUP-2307508,CDM,Q4128,HCPCS,0636,RC,,,,both,,,10649.09,6921.91,,,,,,,,,,,,,
CAGE SPINE CERV ANTR RECT GEO 9X9X21,SUP-2414456,CDM,C1889,HCPCS,0278,RC,,,,both,,,9881.58,6423.03,,,,,,,,,,,,,
GRAFT HUM TISS RT TALUS OSTEOCHNDRL REFRIGERATED CART RECON,SUP-2307434,CDM,C1713,HCPCS,0278,RC,,,,both,,,12936.80,8408.92,,,,,,,,,,,,,
MATRIX HEMOSTATIC BOV DERIVED 10 CC GEL APPL TIP FLOSEAL,SUP-2424551,CDM,C1713,HCPCS,0278,RC,,,,both,,,814.80,529.62,,,,,,,,,,,,,
PLATE 2 CLMN DSTL VLR RAD 2.4MM 7H HD 5H SHFT LT STRL TI,SUP-2546714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2842.55,1847.66,,,,,,,,,,,,,
IMPLANT BRST 1030 CC SIL GEL SMTH ULTRA HI PROF STRL,SUP-2927331,CDM,C1789,HCPCS,0278,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1.6 MM 2.3 MM SHEP GRMMT TAB PC SIL STRL,SUP-2535076,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
SET CLLR AD H2 1/4IN FOR 13-21IN NK SHT BLU PLAS HK AND,SUP-2124215,CDM,L0172,HCPCS,0272,RC,,,,both,,,96.96,63.02,,,,,,,,,,,,,
CUP ACET CEM NEUT STD 32X60X11 MM HIP PRIMARY HW W/ PEG,SUP-2406740,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC CT Lower Ext W&W/O Cont,PX-3527370200,CDM,73702,CPT,0352,RC,,,,both,,,2769.00,1799.85,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG SM 4.5X104 MM 80 MM 6 STRL,SUP-2653587,CDM,C1713,HCPCS,0278,RC,,,,both,,,2283.19,1484.07,,,,,,,,,,,,,
GRAFT BIO TISS OASIS WND MATRIX 3X7CM FEN,SUP-2341252,CDM,Q4102,HCPCS,0636,RC,,,,both,,,719.25,467.51,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5X25 MM CANN FOR 4.5 MM ROD SHILLA,SUP-2630580,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW BNE SELF RET MIC 1.5X5 MM MAND DRILL-FREE CENTRE-DRIVE,SUP-2496571,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.54,120.60,,,,,,,,,,,,,
NEEDLE PHACO 30 DEG 2.75 MM TIP MICROFLOW REUSE,SUP-2487420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.19,225.02,,,,,,,,,,,,,
BRACE ORTHOPEDIC CTRL KNEE POS LIN,SUP-2315981,CDM,L1833,HCPCS,0274,RC,,,,both,,,360.47,234.31,,,,,,,,,,,,,
UNIT SIERRA II SIERRA SER CTRL SER 6200A CONSTANT CURRENT,SUP-2152237,CDM,C1767,HCPCS,0278,RC,,,,both,,,730.05,474.53,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2.7X6 MM CORTEX FOREFOOT MIDFOOT FULL,SUP-2837199,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.21,138.59,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX12 CM DL TAPR TIP BASIC SET DUOFLO,SUP-2627382,CDM,C1752,HCPCS,0278,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM SHFT OD5.8FR BAL L4CM OD10MM OVR,SUP-2139691,CDM,C1725,HCPCS,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
PROSTHESIS PENILE 21X12 CM PRECONN MOMENTARY SQUEEZE PS CX,SUP-2862190,CDM,C1813,HCPCS,0278,RC,,,,both,,,34498.55,22424.06,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0250,RC,00990-7984-20,NDC,,both,250,ML,291.20,189.28,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7040,HCPCS,0250,RC,00264-7800-10,NDC,,both,1000,ML,59.50,38.67,,,,,,,,,,,,,
SMALL CURVE BX5,SUP-2573317,CDM,C1769,HCPCS,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SYSTEM BONE REPL 5G QUICKSET MIMIX,SUP-2402960,CDM,C1713,HCPCS,0278,RC,,,,both,,,2047.28,1330.73,,,,,,,,,,,,,
SCREW BNE CANN 4X10 MM CANC LAG STRL ALPS LTX,SUP-2861636,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.75,365.79,,,,,,,,,,,,,
VANCOMYCIN HCL 2 G IV SOLR,RX-168631,CDM,J3374,HCPCS,0636,RC,72078-0066-50,NDC,,both,1,UN,246.20,160.03,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 6 MM CUBE 3 PACK,SUP-2547191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.47,676.31,,,,,,,,,,,,,
PLATE SPNL L30MM CEPHALIC TO CAUD 22MM 5 H GLD ANTR BILAT,SUP-2193034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PUNCH AORT 3.8MM 5 3/4IN DISP PSTL GRP HNDL CONE TIP CUT,SUP-2227559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CATHETER EP 6FR L110CM 5MM SPC 2MM BND M CRV QPLR STEER,SUP-2357633,CDM,C1730,HCPCS,0272,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-104434,CDM,J1956,HCPCS,0636,RC,25021-0132-82,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
CONNECTOR SPNL INLINE 6.25 MM ROD ASF16T ARMDA,SUP-2562367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
IBAL TKA FEM IMP PS CEMENTED SZ 5 LFT,SUP-2813066,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
ORTHOTIC FT BOOT SM UNISX UNIV AD TAN,SUP-2332644,CDM,L4396,HCPCS,0274,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
COMPONENT TIB L150MM L5CM THK9MM PROX N MOD CEM STEM 1 PC,SUP-2405786,CDM,C1776,CPT,0278,RC,,,,both,,,20135.25,13087.91,,,,,,,,,,,,,
STRUT CORT TRAD ALLGRFT L 60X20 MM FRZ DRY,SUP-2294112,CDM,C1713,HCPCS,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
GRAFT DWL PRECIS MACHINED ALLGRFT MAJ DIAM 5.5MM,SUP-2309708,CDM,C1713,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
STERILE WATER FOR INJECTION (MIXTURES ONLY),RX-430028,CDM,2500000003,HCPCS,0250,RC,63323-0185-50,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L 159 MM SCREW DIA 3.5 MM 9 H SS PROX HUM STR STRL,SUP-2933589,CDM,C1713,HCPCS,0278,RC,,,,both,,,7787.20,5061.68,,,,,,,,,,,,,
EXTENSION STEM L65MM OD10MM FEM HIP REV CEM ADV CCK,SUP-2304746,CDM,C1776,CPT,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
HEAD FEM 28 MM HIP BIOLOX DELT,SUP-2448637,CDM,C1776,CPT,0278,RC,,,,both,,,12420.27,8073.18,,,,,,,,,,,,,
CATHETER OCCL BAL OCCL 26FR BAL 5FRX100CM CATH,SUP-2139720,CDM,C2628,HCPCS,0272,RC,,,,both,,,411.47,267.46,,,,,,,,,,,,,
SEED BRACHYTHERAPY STRND,SUP-2247310,CDM,C2642,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
PLATE BONE L38MM THK1.4MM SHFT W7.5MM 5 H STRL STR TINE FOR,SUP-2349703,CDM,C1713,HCPCS,0278,RC,,,,both,,,4873.28,3167.63,,,,,,,,,,,,,
CRIMP SPNL 2 PK ASCNT POCT,SUP-2601976,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSTAR CHRONIC STD 14.5FR DIA 20CM 15,SUP-2613296,CDM,C1750,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
PIN FIX TIB 6 LT KNEE REF OFFSET ROSA REUSE,SUP-2656956,CDM,C1713,HCPCS,0278,RC,,,,both,,,1730.14,1124.59,,,,,,,,,,,,,
CISPLATIN 50 MG/50ML IV SOLN,RX-88376,CDM,J9060,HCPCS,0636,RC,00703-5747-11,NDC,,both,50,ML,58.10,37.76,,,,,,,,,,,,,
GRAFT HUM TISS 15MM DISK ALLGRFT AMNIOEXCEL,SUP-2194315,CDM,Q4137,HCPCS,0636,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
SCREW SPNL L8MM DIA35MM CANC POST CERVICOTHORACIC TI FULL,SUP-2189828,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
DRILL SURG QR CHK VANGUARD GLOB,SUP-2441422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
PLATE BNE W17.5XL300MM THK5.2MM 16 H ST BILAT S STL BROAD,SUP-2185312,CDM,C1713,HCPCS,0278,RC,,,,both,,,2848.95,1851.82,,,,,,,,,,,,,
BLADE SAW D64MM CUT EDGE 35MM MAT THK1.1MM SAG 2 CUT,SUP-2361900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,149.81,97.38,,,,,,,,,,,,,
PLATE SPNL L14MM STD ANTR BILAT CERV TI LCK SLIM PROF LEV 1,SUP-2255523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2800.88,1820.57,,,,,,,,,,,,,
PLATE BNE L DST RAD VOLAR S STL LO PROF RIG NONCOMPRESSION,SUP-2186102,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.37,1466.64,,,,,,,,,,,,,
SCREW BONE L19MM OD3.5MM CRUCFRM,SUP-2362293,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.16,13.75,,,,,,,,,,,,,
COIL VASC AZUR CX L 24 CM DIA 8 MM MICROCATHETER 0.035 IN,SUP-2385442,CDM,C1889,HCPCS,0278,RC,,,,both,,,3821.38,2483.90,,,,,,,,,,,,,
PACEMAKER CARD SENSIA DR W 47.9 X H 44.7 MM D 7.5 MM TI 2,SUP-2282481,CDM,C1785,HCPCS,0275,RC,,,,both,,,7899.14,5134.44,,,,,,,,,,,,,
IMPLANT NSL W 3 MM ID 15 X 21 MM NEODYMIUM MAG COAT SIL SEPT,SUP-2887848,CDM,C1889,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
PLATE BNE TIB 3.5X95 MM RT PROX LAT 5 HOLE NS LOQTEC,SUP-2101268,CDM,C1713,HCPCS,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
CATH BLLN SCORING 6X40MM X 137CM OTW PTA ANGIOSCULPT,SUP-2353199,CDM,C1725,HCPCS,0272,RC,,,,both,,,3367.65,2188.97,,,,,,,,,,,,,
SYSTEM EXTR 14CM W/ BG SR GELPOINT ADV ACCS PLATFRM,SUP-2119761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
SCREW BNE L48MM DIA5MM HD DIA8MM TI ST ANGULAR STBL LOK,SUP-2180293,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.21,398.59,,,,,,,,,,,,,
ELECTRODE ECG MEDI-TRACE 3,SUP-2835250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1216.66,790.83,,,,,,,,,,,,,
DISSECTOR ULTRASONIC SONICISION 7 5MM 39CM CURVED JAW CORDLESS,SUP-2863658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
SPACER KNEE XL 84X61X90 MM GENTAMICIN INTERSPACE LTX,SUP-2866824,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
GUIDEWIRE BALL TIP L1000MM DIA2.5MM DISP,SUP-2152524,CDM,C1769,HCPCS,0272,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
HC US 3d Independent Workstation,PX-3207637700,CDM,76377,CPT,0320,RC,,,,both,,,1344.00,873.60,,,,,,,,,,,,,
GUIDEWIRE VASC J 15 MM 0.035 INX150 CM CRV STD FIX COR STRL,SUP-2302702,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
SCREW BNE L48MM DIA4.5MM THRD L13MM CORT TI ST SELF DRL,SUP-2190387,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.87,41.52,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + LG MEDPOR PTERIONAL +,SUP-2862746,CDM,C1713,HCPCS,0278,RC,,,,both,,,57720.39,37518.25,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR ATLS + C-HD,SUP-2356524,CDM,C1722,HCPCS,0275,RC,,,,both,,,64134.50,41687.42,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT CART DST FEM OSTEOCHNDRL MED R,SUP-2307437,CDM,C1762,CPT,0278,RC,,,,both,,,21854.40,14205.36,,,,,,,,,,,,,
PLATE BNE L104MM 4 H BILAT S STL CLVRLF FOR 35MM SCR,SUP-2411335,CDM,C1713,HCPCS,0278,RC,,,,both,,,786.57,511.27,,,,,,,,,,,,,
FENTANYL 50 MCG/ML PCA (DISCRETE DOSING),RX-4081981,CDM,J7999,HCPCS,0636,RC,71266-9170-05,NDC,,both,30,ML,202.40,131.56,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA2.5 MM TI CANN HDLSS NS LEOS,SUP-2932617,CDM,C1713,HCPCS,0278,RC,,,,both,,,760.98,494.64,,,,,,,,,,,,,
STAPLER ENDOSCP STD TISS LNAR CUT STPL LN 6 ROW TI N ABSRB,SUP-2257548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.15,688.45,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 9/64X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150472,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.32,9.96,,,,,,,,,,,,,
SHUNT CSF 0-20CM H2O WITH DISTAL CATHETER PROGAV 2 PROSA,SUP-2821879,CDM,C1889,HCPCS,0278,RC,,,,both,,,17562.84,11415.85,,,,,,,,,,,,,
SHELL BPLR OD52MM ID36MM ACET 1 PC GLADIATOR,SUP-2304609,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SCREW BNE CANN 5X40 MM CONCL TI NS,SUP-2190594,CDM,C1713,HCPCS,0278,RC,,,,both,,,513.55,333.81,,,,,,,,,,,,,
LINER ACET CONSTRN 0 DEG 4+ MM NEUT 44X70 MM HIP LCK GVF TI,SUP-2250290,CDM,C1776,CPT,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
COIL EMB L1CM OD0.010IN LOOP OD2MM PLAT TUNGSTEN HELCL,SUP-2249136,CDM,C1889,HCPCS,0278,RC,,,,both,,,3076.26,1999.57,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC PILLING L 15 CM CUT 2 MM CUT HD AG,SUP-2384630,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COMPONENT FEM AUG 100 MM KNEE LIGMNT,SUP-2448358,CDM,C1776,CPT,0278,RC,,,,both,,,2981.43,1937.93,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 20X16 MM FD PAT,SUP-2717924,CDM,C1762,CPT,0278,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
CATHETER EP L110CM OD8FR L10MM 2.5MM SPC QPLR STR TIP BLZR,SUP-2141270,CDM,C1733,HCPCS,0272,RC,,,,both,,,4794.78,3116.61,,,,,,,,,,,,,
SCREW BNE L110MM DIA6.5MM THRD L30MM ST LAT FEM HIP G TI ST,SUP-2179685,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.10,434.26,,,,,,,,,,,,,
SCREW SPNL HEX 1.2X9 MM 7 MM THRD MAXDRIVE ZURICH 503480909,SUP-2460177,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
DISP INSTR KIT FOR TENO SCRW,SUP-2811900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER EDI 6FR L49CM PHT FRE,SUP-2266012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
SYSTEM KNEE POD GUIDANCE IASSIST,SUP-2212348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER APPL DL 17 CM 25 CM DUPLOCATH,SUP-2129874,CDM,C1751,HCPCS,0278,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
PLATE BNE L73MM 6 H BILAT S STL COMPR FOR 3.5MM SCR,SUP-2411338,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.95,248.92,,,,,,,,,,,,,
SCREW INTFR L24MM DIA3MM PLLA BIO-COMPRESSION,SUP-2121891,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PLATE BNE MINI RT CRANIOMAXILLOFACIAL L-Y SHP PREBENT,SUP-2883169,CDM,C1713,HCPCS,0278,RC,,,,both,,,1257.73,817.52,,,,,,,,,,,,,
FAMCICLOVIR 250 MG PO TABS,RX-16081,CDM,6370000000,HCPCS,0637,RC,33342-0025-07,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MESH SURG DIA9CM WHT POLY CLLGN FLM RND MFIL BIOABSRB,SUP-2283406,CDM,C1781,HCPCS,0278,RC,,,,both,,,977.29,635.24,,,,,,,,,,,,,
PROSTHESIS OTO L9MM SHFT OD0.8MM FLNG OD4MM MID EAR OSS TOT,SUP-2312578,CDM,L8613,CPT,0278,RC,,,,both,,,887.84,577.10,,,,,,,,,,,,,
ALLOGRAFT CELLENTRA ADV 10CC,SUP-2208254,CDM,C1713,HCPCS,0278,RC,,,,both,,,15888.40,10327.46,,,,,,,,,,,,,
CATHETER ETER URET L65CM OD5FR OLV TIP,SUP-2384604,CDM,C1758,HCPCS,0278,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
BASKET SPEC RETRV 50 CM 30 CM ANGLED PROX SHFT RNG HNDL FB,SUP-2772708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4315.08,2804.80,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2477016,CDM,C1768,CPT,0278,RC,,,,both,,,758.03,492.72,,,,,,,,,,,,,
BIT DRL OD2.9MM OCCIPITAL FOR 4.5MM SCR,SUP-2108737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.31,492.90,,,,,,,,,,,,,
PROBE SUCT 50-S XL L180MM DIA3.5MM MAX CUT LEV 11,SUP-2366564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,429.30,279.04,,,,,,,,,,,,,
CLIP ANEUR BLDE L13MM FEN DIA5MM OPN 55MM CLS FORC 180GM,SUP-2108702,CDM,C1889,HCPCS,0278,RC,,,,both,,,6682.71,4343.76,,,,,,,,,,,,,
KNIFE 3714171 JOSEPH BUTTON END STR,SUP-2705672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.91,322.99,,,,,,,,,,,,,
STAPLE SURG W11XL8MM OSSTPL,SUP-2194213,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE BONE LOK NON CMPRSSN HLX12 25MM THK TTNM STRGHT LVLX1,SUP-2679055,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.01,1910.36,,,,,,,,,,,,,
VALVE SHUNT L24MM 9-24CM H2O PRESSURE TITANIUM 2 CONNECTION,SUP-2821791,CDM,C1889,HCPCS,0278,RC,,,,both,,,5263.17,3421.06,,,,,,,,,,,,,
SCREW HEADLESS DART FIRE EDGE 3.0 X30MM,SUP-2855463,CDM,C1713,HCPCS,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
KIT ELECTROPHYSIOLOGY ENSITE X EP SURF ELECTRD X PTCH NS,SUP-2873707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3843.36,2498.18,,,,,,,,,,,,,
KIT THR HIP LO DEMAND FRAC UPLR PROS,SUP-2212086,CDM,C1776,CPT,0278,RC,,,,both,,,5052.64,3284.22,,,,,,,,,,,,,
BLADE OPHTH DIA3MM PHACO ANG CRESC PNT DEL SATIN SLT BLDE,SUP-2110065,CDM,C1776,CPT,0278,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.524,SUP-2860041,CDM,C1713,HCPCS,0278,RC,,,,both,,,42340.07,27521.05,,,,,,,,,,,,,
BIT DRL DIA15/64IN PERIPH SHLDR ANTIROTATION PEG QUIK REL,SUP-2411554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.13,357.58,,,,,,,,,,,,,
IMPLANT SYNTH L 150 X W 180 MM THK 4 MM POLYETHYL CRAN DOME,SUP-2883473,CDM,C1713,HCPCS,0278,RC,,,,both,,,15537.47,10099.36,,,,,,,,,,,,,
BUCKLE SCLER RETINAL 2.5 MM EYE TIRE STYL 220,SUP-2213514,CDM,C1784,HCPCS,0278,RC,,,,both,,,45.84,29.80,,,,,,,,,,,,,
IMPLANT SUBTALAR 10MM TWST,SUP-2390487,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SPINDLE INT FIX SM 12MM 400LB M FORC FEM POR INTFACE CPS,SUP-2406896,CDM,C1776,CPT,0278,RC,,,,both,,,9806.22,6374.04,,,,,,,,,,,,,
SCREW BNE L10MM OD3.2MM CORT NONCANNULATED NONLOCKING THRD,SUP-2397519,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
ANCHOR SUT W/ ETHBND SZ 2-0 PLA GRN ROT CUF 2 LOOP,SUP-2249367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1387.88,902.12,,,,,,,,,,,,,
EXTENSION STEM L30MM DIA20MM KNEE CEM BAL REV SYS,SUP-2315639,CDM,C1776,CPT,0278,RC,,,,both,,,2625.04,1706.28,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 60 MM DIA 6 MM DEL SHTH,SUP-2934515,CDM,C1713,HCPCS,0278,RC,,,,both,,,8048.01,5231.21,,,,,,,,,,,,,
CATHETER ETER EP 7FR 120CM 2 15 1MM 2MM TIP UNIDIR M CRV STEER,SUP-2356883,CDM,C1730,HCPCS,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
DRILL SURG L220MM 75MM COUNTSINK,SUP-2396985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
DRAIN SURG 3/16 IN 5 IN 400 CC KIT INF CTRL PVC HEMVAC,SUP-2431702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3328.40,2163.46,,,,,,,,,,,,,
COUNTERSINK SURG FOR NEXFIX NCS SYS 4.5 MM SCREW,SUP-2400526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.63,222.06,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED 11 MM FRSH PROCHONDRIX CR,SUP-2717803,CDM,C1762,CPT,0278,RC,,,,both,,,11628.05,7558.23,,,,,,,,,,,,,
RASP SURG CRV MTP SAW CONCV R14 STRYKR CONN,SUP-2883377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
MARKER RAD L7MM DIA4MM NIT COIL SUPERLOCK,SUP-2381758,CDM,A4648,CPT,0278,RC,,,,both,,,858.48,558.01,,,,,,,,,,,,,
CATHETER GUID 0.035 IN 0.058 INX5 FR BARE NDL SS GRY RAILWAY,SUP-2653858,CDM,C1887,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
VALVE CSF STD FLAT BTM MED PRESSURE CATH GUIDE LPV II DISP,SUP-2244308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2089.39,1358.10,,,,,,,,,,,,,
BOLT SPNL L175MM DIA5MM TI FIX ANG FOR LUM INTBDY FUS BASE,SUP-2417111,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE L W135XL242MM THK42MM 13 H BILAT TI NAR RIG NEUT,SUP-2190826,CDM,C1713,HCPCS,0278,RC,,,,both,,,1799.63,1169.76,,,,,,,,,,,,,
CONTOURED PLATE 18 HOLE LEFT,SUP-2474531,CDM,C1713,HCPCS,0278,RC,,,,both,,,4559.28,2963.53,,,,,,,,,,,,,
STENT BILI C FLX L 15 CM DIA 7 FR PLAS DBL PIGTL AD BLU STRL,SUP-2149443,CDM,C2617,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
INTRODUCER TUBE SET 6 FR PERC SET CIAGLIA BLU RHINO SHILEY,SUP-2760031,CDM,C1769,HCPCS,0272,RC,,,,both,,,1206.14,783.99,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 130 CM DIA 0.018 IN SS SIL J SHRT,SUP-2148317,CDM,C1769,HCPCS,0272,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
RXG 3D ORB FLR RT T06MM,SUP-2681863,CDM,C1713,HCPCS,0278,RC,,,,both,,,3233.32,2101.66,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM FOR EXTREMILOCK ANK PLATING SYS,SUP-2319589,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
TUBE UTER TRNSVAG 35 MM MCCARTNEY,SUP-2247548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE L38MM 5 H BILAT TI LO PROF RIG NEUT LOK COMPR MINI,SUP-2420780,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.22,493.49,,,,,,,,,,,,,
SCREW BNE LCK 2X6 MM SELF RET TI MAXDRIVE THREADLOCK TS,SUP-2469560,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.50,238.22,,,,,,,,,,,,,
BLADE SAW 6 MM GRFT HARV TRITON,SUP-2628263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
PASSER SURG L38CM CATH DISP,SUP-2284614,CDM,C1751,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
BUR SURG DIAMOND 2.5 MM 12 CM MTCH HD PROX MIDAS REX 8 CLRVW,SUP-2632183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX6 MM INDWL ESOPH FLANGE BLOM-SINGER,SUP-2242390,CDM,L8509,HCPCS,0274,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
CATHETER GUID ENVOY L 100 CM OD 6 FR ID 0.07 IN MPC,SUP-2461470,CDM,C1887,HCPCS,0272,RC,,,,both,,,1710.08,1111.55,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH DIA 9 FR HYDROPHOBIC VLV HEMOSTATIC,SUP-2193984,CDM,C1892,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE CANC 4X20 MM SELF TAPPING,SUP-2465094,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.44,123.79,,,,,,,,,,,,,
COIL VASC EMBOLD L 50 CM DIA10 MM CATH LUMEN DIA 0.021 IN,SUP-2753954,CDM,C1889,HCPCS,0278,RC,,,,both,,,4411.70,2867.60,,,,,,,,,,,,,
HC Pooling Blood Platelets,PX-3008696500,CDM,86965,CPT,0300,RC,,,,both,,,361.00,234.65,,,,,,,,,,,,,
PLATE BNE L 132 MM 20 H SCREW DIA2.4 MM PROF MINI FRAG NS,SUP-2902325,CDM,C1713,HCPCS,0278,RC,,,,both,,,2814.70,1829.55,,,,,,,,,,,,,
PLATE HLS 1MM T 3HL 215053,SUP-2247341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
IMPLANT BRST W13.2CM OD2.9CM 275ML FILL VOL PLAS SIL MOD,SUP-2300403,CDM,C1789,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
PLATE BNE L 50 MM 10 H SCREW DIA2.7 MM BROAD LCK T8 FOR MINI,SUP-2900597,CDM,C1713,HCPCS,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
INTRODUCER SHTH SET REINF 75FR 6IN AND DIL FOR SENS 7FR IAB,SUP-2265879,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.53,102.39,,,,,,,,,,,,,
PLATE BONE MESHED 100X0.6 MM CRANIAL RECONSTRUCTION RIGID TI,SUP-2837716,CDM,C1713,HCPCS,0278,RC,,,,both,,,7385.28,4800.43,,,,,,,,,,,,,
GRAFT HUM TISS MEDL RT MENIS ALLGRFT,SUP-2335264,CDM,C9361,HCPCS,0278,RC,,,,both,,,21964.30,14276.79,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.025 IN CRV RAD 3 MM SS SAFE-T-J,SUP-2760118,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.39,40.55,,,,,,,,,,,,,
CATHETER GUID STROKE FAST PK AXS CATLYST 5 L 132 CM PEBAX,SUP-2884423,CDM,C1887,HCPCS,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
KIT NEUROMODULATION NEXT GENERATION ANCHR CLIK,SUP-2138813,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
BIT DRL L 115 MM WORKING L 35 MM DIA1.6 MM STRYKR END,SUP-2883257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.27,504.58,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR STRL PROCLAIM + 5 LTX,SUP-2858407,CDM,C1767,HCPCS,0278,RC,,,,both,,,68295.00,44391.75,,,,,,,,,,,,,
COUPLER ANAS DIA2MM 20MHZ POLYETH PRB FLO DOPP VASC ASMBLY,SUP-2382619,CDM,C1889,HCPCS,0278,RC,,,,both,,,3444.58,2238.98,,,,,,,,,,,,,
INTRODUCER SHTH L12CM OD5FR ODSEC.038IN GUID WIRE STD FEM,SUP-2355793,CDM,C1894,HCPCS,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
STENT AXIOS ELECTROCAUTERY-ENHANCED 8MMX8MM,SUP-2855125,CDM,C2617,HCPCS,0278,RC,,,,both,,,16154.83,10500.64,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD SET AG LNG TERM ACC 15FRX42CM,SUP-2120628,CDM,C1750,HCPCS,0278,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
BUPIVACAINE HCL 0.25 % IJ SOLN (MIXTURES ONLY),RX-430037,CDM,J0665,HCPCS,0636,RC,00409-1159-02,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
BLADE SCRDRIVER CRUCFRM HLD SL FOR 1MM SCR,SUP-2187564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3504.59,2277.98,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM 4 FR NIT TUNGSTEN TIP SIL STIFFEN DIL,SUP-2763434,CDM,C1894,HCPCS,0272,RC,,,,both,,,68.77,44.70,,,,,,,,,,,,,
BRACE ANK L L9-10IN MAX CALF FOR 17IN BLU FT BRTH ANTIMIC,SUP-2332638,CDM,L4396,HCPCS,0274,RC,,,,both,,,272.61,177.20,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4.6 MMX72 CM CRYOVEIN,SUP-2264649,CDM,C1762,CPT,0278,RC,,,,both,,,21022.30,13664.49,,,,,,,,,,,,,
CATHETER SET 14 DIA. 65 CM LEN .038IN GWIRE W/ TEMP FEEDBACK,SUP-2327250,CDM,C1733,HCPCS,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
INSERT TIB THK13MM DST KNEE POLY MOD ROT HNG GMRS,SUP-2376379,CDM,C1776,CPT,0278,RC,,,,both,,,2745.46,1784.55,,,,,,,,,,,,,
ADAPTER EXT FIX QUIK CPL FOR 4MM SELDRILL SCHNZ SCR,SUP-2188582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.13,617.58,,,,,,,,,,,,,
PLATE BNE SZ 2 L45MM 10DEG 5 H L C SHP FOR HALLU LOCK MTP,SUP-2243425,CDM,C1713,HCPCS,0278,RC,,,,both,,,4550.61,2957.90,,,,,,,,,,,,,
PLATE BNE MESHED 52X31X1 MM SM GRID PDLLA RESORB X STRL,SUP-2478483,CDM,C1713,HCPCS,0278,RC,,,,both,,,2215.30,1439.94,,,,,,,,,,,,,
COVER BURR HOLE 17MM DIA 03MM THK CMMRCLLY PURE TTNM CNTRD,SUP-2677365,CDM,C1713,HCPCS,0278,RC,,,,both,,,713.44,463.74,,,,,,,,,,,,,
PIN EXT FIX TEMP PLATE,SUP-2468404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
MESH SURG DIA4.6CM POLY PGLA CLLGN FLM RIG ABSRB EXP SEMI,SUP-2283993,CDM,C1781,HCPCS,0278,RC,,,,both,,,1636.16,1063.50,,,,,,,,,,,,,
SCREW BNE L40MM DIA4.75MM HD DIA3.5MM CORT FIX ANG,SUP-2407406,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
CONNECTOR SPNL DIA5.5X5.5MM PARA ROD TOP LD FOR DEFORMITY,SUP-2316092,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CATHETER CV 3L 0.035 IN 12 FRX8 IN SILK SUTURE KT,SUP-2120586,CDM,C1751,HCPCS,0278,RC,,,,both,,,337.24,219.21,,,,,,,,,,,,,
CATHETER DRUG DEL L12.5CM 270MLX5ML/HR 2.25 DAY N NARC ON Q,SUP-2236780,CDM,C2626,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BNE L283MM 10 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186046,CDM,C1713,HCPCS,0278,RC,,,,both,,,4780.30,3107.19,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.9X120 MM PLN TROCAR PT 1 END DISP,SUP-2243907,CDM,C1769,HCPCS,0272,RC,,,,both,,,98.09,63.76,,,,,,,,,,,,,
PLATE BNE RT ANTR TI AXSOS 3,SUP-2550579,CDM,C1713,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
COUPLING REPROC EXT FIX PIN TO ROD STR4920-1-020,SUP-2496949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.18,288.07,,,,,,,,,,,,,
BURR SURG 3MM DIA HD 4MML HD CARBIDE CYL MICROPOWER MCR100 S,SUP-2605544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.68,45.29,,,,,,,,,,,,,
CATHETER HD CRV EXTN 12 FRX15 CM CATH NDL DUOFLO,SUP-2627072,CDM,C1752,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PIN GUIDE L 450 MM DIA 3.2 MM STRL DISP INTERTAN RAPID TAN,SUP-2933059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,767.20,498.68,,,,,,,,,,,,,
PLATE BNE 50X20X0.1 MM MEMBRN PDLLA STRL RESORB X LF,SUP-2474269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1437.37,934.29,,,,,,,,,,,,,
SCREW BNE L44MM DIA2.7MM MTPHSEAL TAN ST LO PROF COMPR T8,SUP-2180943,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.74,100.58,,,,,,,,,,,,,
K WIRE FIX L70MM DIA0.6MM S STL W/ TRCR PNT,SUP-2186855,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.11,138.52,,,,,,,,,,,,,
PLATE BONE W38XL45MM THK1.5MM NONSTERILE TI RECTANG CNTOUR,SUP-2191099,CDM,C1713,HCPCS,0278,RC,,,,both,,,4384.07,2849.65,,,,,,,,,,,,,
GRAFT HUM TISS 1CC PLCNTA MTRX FLOWABLE IMMUNOSUPPRESSIVE W/,SUP-2340456,CDM,C1762,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE L250MM 12 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185683,CDM,C1713,HCPCS,0278,RC,,,,both,,,4914.98,3194.74,,,,,,,,,,,,,
RAIL EXT FIX 4IN MINI RX FIX,SUP-2396841,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
STEM ULN L 125 MM MED TI PLASMA SPRY RT ELBW TOT ARTHPLSTY,SUP-2902180,CDM,C1776,CPT,0278,RC,,,,both,,,23073.51,14997.78,,,,,,,,,,,,,
SCREW BONE L12MM DIA2.7MM FULL THRD STP FOR OLECRANON,SUP-2177098,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.87,305.42,,,,,,,,,,,,,
BUR SURG DIA3MM FLUT MTCH TRANSNASAL,SUP-2284699,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
HC US Guidance for Needle Place,PX-4027694200,CDM,76942,CPT,0402,RC,,,,both,,,733.00,476.45,,,,,,,,,,,,,
SPACER KNEE 3-10 4 MM DSTL SYS REV GUIDE ATTUNE,SUP-2454496,CDM,C1776,CPT,0278,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
PLATE BONE LOK WEDGE MED TIMAX ANTMCL LTRL CLMN LNGTHNNG ALP,SUP-2588781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.15,1228.60,,,,,,,,,,,,,
SAW SURG AIR PWR STRNM FTPLT GRD FOR VETERINARY INSTRUMENT,SUP-2486851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19601.76,12741.14,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 145 CM DIA 0.035 IN TAPR L 7 CM TIP,SUP-2301899,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.74,23.88,,,,,,,,,,,,,
HC So1 Delta Aminolevulinic Acid,PX-3018213567,CDM,82135,CPT,0301,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
SYSTEM FIX 15 FAST ABSRB PERMA FIX,SUP-2125762,CDM,C1713,HCPCS,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
HEAD FEM MOD 8- MM 46 MM HIP BIRMINGHAM HIPTM RESURF,SUP-2435176,CDM,C1776,CPT,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 25X20 CM RND SKIRTED PARIETEX,SUP-2752189,CDM,C1781,HCPCS,0278,RC,,,,both,,,5670.59,3685.88,,,,,,,,,,,,,
LENS MX60USP 125MM +0100,SUP-2392381,CDM,V2787,HCPCS,0276,RC,,,,both,,,150.00,97.50,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 6 FRX23 CM 21 GAX4 CM GRN PRELUDE,SUP-2303285,CDM,C1894,HCPCS,0272,RC,,,,both,,,168.18,109.32,,,,,,,,,,,,,
SCREW BNE L30MM DIA4MM CORT TI ST NONCANNULATED LOK FULL,SUP-2192251,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
NAIL IM CANN 10X440 MM LT TROCHANTERIC FIX TI STRL,SUP-2192127,CDM,C1713,HCPCS,0278,RC,,,,both,,,6016.68,3910.84,,,,,,,,,,,,,
GRAFT BIO TISS 2X4CM THK10 20MM THCK PROLAYER,SUP-2362229,CDM,C1763,HCPCS,0278,RC,,,,both,,,2717.98,1766.69,,,,,,,,,,,,,
GRAFT BNE CHIP 4-10 MM 15 CC CANC PUREBONE,SUP-2424603,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.94,447.16,,,,,,,,,,,,,
CAGE ACET DIA61MM L HIP TI REV PROTRUSIO RECVRY,SUP-2403960,CDM,C1776,CPT,0278,RC,,,,both,,,10638.32,6914.91,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 5 FRX11 CM VLV GRY HUB PRELUDE,SUP-2303268,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.05,19.53,,,,,,,,,,,,,
CATHETER ANGIO PERFORMA L 125 CM 5 FR CRV 4 CM ULT4 1 SIDE H,SUP-2665522,CDM,C1887,HCPCS,0272,RC,,,,both,,,74.29,48.29,,,,,,,,,,,,,
SYSTEM THREADED SEPARATOR 5MMX100MM,SUP-2119549,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.05,253.53,,,,,,,,,,,,,
MORPHINE SULFATE 1 MG/ML PCA (DISCRETE DOSING),RX-77005,CDM,J2270,HCPCS,0636,RC,70092-1519-48,NDC,,both,30,ML,57.00,37.05,,,,,,,,,,,,,
DILATOR BLLN CHN SZ 37MM L1950MM DST TIP L7MM DIA44FR 0035IN,SUP-2312966,CDM,C1726,HCPCS,0272,RC,,,,both,,,1569.47,1020.16,,,,,,,,,,,,,
THERA-GESIC EX CREAM,RX-103864,CDM,6370000000,HCPCS,0637,RC,41167-0060-06,NDC,,both,85,GR,9.60,6.24,,,,,,,,,,,,,
CATHETER HD SET 15 FRX55 CM RETROGRADE REPL HUB VECTORFLOW,SUP-2763048,CDM,C1750,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SLEEVE SURG OD4MM ID25MM THRD DRL SGL END FOR AO ASIF M EXT,SUP-2188759,CDM,C1713,HCPCS,0278,RC,,,,both,,,664.52,431.94,,,,,,,,,,,,,
HEMO CATHETER CATHETER TRAY,SUP-2610540,CDM,C1752,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
TUBE VENT ID127MM WHT ST PACIFIC COAT FLROPLAS MYR,SUP-2313857,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
ANCHOR SUTURE 2.1MM WITH ONE STRAND NUMBER 2 HI-FI GENESYS P,SUP-2824682,CDM,C1713,HCPCS,0278,RC,,,,both,,,1943.91,1263.54,,,,,,,,,,,,,
GRAFT HUM TISS DIA12 MM AMNION PLCNTA MEMBRN 2 LAYR PROTCT,SUP-2913160,CDM,C1762,CPT,0278,RC,,,,both,,,2603.06,1691.99,,,,,,,,,,,,,
LINER BPLR OD52-56MM ID28MM POLYETH CONVENE,SUP-2345766,CDM,C1776,CPT,0278,RC,,,,both,,,442.90,287.88,,,,,,,,,,,,,
SCREW BNE ST 6.5X45 MM ACET TRIL,SUP-2202544,CDM,C1713,HCPCS,0278,RC,,,,both,,,387.79,252.06,,,,,,,,,,,,,
CATHETER CV SET 14 GAX16 CM SINGLE LUMEN BLU FLEXTIP,SUP-2763398,CDM,C1751,HCPCS,0278,RC,,,,both,,,52.12,33.88,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.7MM CORT CRANIOMAXILLOFACIAL TI EMER W/,SUP-2189198,CDM,C1713,HCPCS,0278,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 3 MESH NS FACE ID,SUP-2909650,CDM,C1713,HCPCS,0278,RC,,,,both,,,32381.78,21048.16,,,,,,,,,,,,,
SPLINT FT AD SM SZ 3-6 UNISX RT PREFABRICATED POST LEAF,SUP-2325043,CDM,L4398,HCPCS,0274,RC,,,,both,,,79.44,51.64,,,,,,,,,,,,,
SCREW BNE L12MM DIA13MM GRN CORT TI ALLY ST SELF RET W T4,SUP-2180979,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.96,237.22,,,,,,,,,,,,,
CATHETER EP JSN 1 CRV 5-10-5 MM 4 FR FIX CRV,SUP-2357395,CDM,C1730,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 3X6CM THICK AMNIOTIC UMBILICAL CORD PRO3C,SUP-2741749,CDM,C1762,CPT,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
HC So1 Nephelometry Ea Analyte Nes,PX-3018388367,CDM,83883,CPT,0301,RC,,,,both,,,88.00,57.20,,,,,,,,,,,,,
PLATE BNE DORS VOLAR FRAG Y SHP DVR 131217103] ZIMMER BIOMET TRAUMA],SUP-2411677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.00,1173.25,,,,,,,,,,,,,
STAPLER INT H44X15MM DIA55MM 0DEG TI UNIV 6 ROW CART,SUP-2693602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,159.98,103.99,,,,,,,,,,,,,
WIRE EXT FIX L 400 MM DIA2 MM TI REDUCTION HALF PT NS DISP,SUP-2899056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.20,319.93,,,,,,,,,,,,,
GRAFT BONE SUB SM 4CC BIOACTIVE GLS PUTTY,SUP-2330555,CDM,C9359,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
HC Ins Cath Ren Art 1st Unilat,PX-3613625100,CDM,36251,CPT,0361,RC,,,,outpatient,,,10063.00,6540.95,,,,,,,,,,,,,
CANNULA PERF 15FR L17CM FEM ART W/ 10FR INTRO TANDEMHEART,SUP-2152640,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W8XL16CM THK1.04 2.28MM THICK RGNRTVE TSSU,SUP-2466662,CDM,Q4116,HCPCS,0636,RC,,,,both,,,13869.38,9015.10,,,,,,,,,,,,,
NEEDLE ENDO ELMNT WORKING INJCTN,SUP-2747577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8408.89,5465.78,,,,,,,,,,,,,
PIN FIX L50MM DIA2.5MM ELBW CO CHROM AXIS FOR STBL SYS IJS,SUP-2340232,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
BI MENTUM PFR REVISION CUP 47MM,SUP-2540587,CDM,C1776,CPT,0278,RC,,,,both,,,9305.70,6048.70,,,,,,,,,,,,,
SCREW SPNL L35MM DIA7MM CANC SACR TI POLYAX NONCANNULATED,SUP-2254432,CDM,C1713,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
STENT URET 4.8 FRX22-30 CM 6 FR INJ FLEXIMA STRTCH VL DISP,SUP-2468573,CDM,C2617,HCPCS,0278,RC,,,,both,,,413.10,268.51,,,,,,,,,,,,,
SCREW BNE ST 2.4X22 MM CRTX T8 STARDRV RECESS SS STRL,SUP-2423821,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.02,133.91,,,,,,,,,,,,,
GRAFT SURG 7CMX6CM AMNIOFIX,SUP-2305731,CDM,V2790,HCPCS,0274,RC,,,,both,,,7231.42,4700.42,,,,,,,,,,,,,
ALLOGRAFT BNE HEMI PELVIS FRZN,SUP-2321868,CDM,C1713,HCPCS,0278,RC,,,,both,,,21308.04,13850.23,,,,,,,,,,,,,
SCREW SPNL FIX ANGLE 5X30 MM CANN FOR 5.5 MM ROD SHILLA,SUP-2630635,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.82,2883.93,,,,,,,,,,,,,
PLATE BONE L65MM THK0.3MM 16 H CRANIOMAXILLOFACIAL TI STR,SUP-2136519,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
TWIST DRILL 11MM DIA X 30MM STOP DNTL LATCH SNGLE USE,SUP-2680266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.70,290.35,,,,,,,,,,,,,
PACEMAKER CARD PULSAR MAX II SR SINGLE CHMBR IS1 CONN UPLR,SUP-2148596,CDM,C1786,HCPCS,0275,RC,,,,both,,,14842.78,9647.81,,,,,,,,,,,,,
SPLINT WR AD SM FOR 2.5-3IN RT MCP REG FIRM OUTER FAB HND,SUP-2324879,CDM,L3809,HCPCS,0274,RC,,,,both,,,51.75,33.64,,,,,,,,,,,,,
CATHETER CARD ABLATION MARINR MC L 112 CM DIA 7 FR TIP L 4,SUP-2282284,CDM,C1733,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
BLADE COAG SHR L14CM DIA5MM CVD W/ GRP AND PROTCT SL DISP,SUP-2257621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.36,321.33,,,,,,,,,,,,,
PLATE BNE STR NEURO 8 HOLE ULTRA LO PROF W/ TAB TI LEVEL 1,SUP-2525643,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.31,459.10,,,,,,,,,,,,,
HEMOSTASIS VALVE KIT ADVANTAGE+ WATCHDOG,SUP-2798393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,601.62,391.05,,,,,,,,,,,,,
SCREW SPNL POLYAX 4.5X25 MM THORLUM PEDCL TRPL LD PREF 2,SUP-2175464,CDM,C1713,HCPCS,0278,RC,,,,both,,,4775.94,3104.36,,,,,,,,,,,,,
MATRIXNEURO EMER SCR 1.8 MM ST LEN 3 MM TI ALLOY TAN PK OF,SUP-2181597,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
WEDGE FT 0 DEG 4 MM LAPIDUS,SUP-2908986,CDM,C1713,HCPCS,0278,RC,,,,both,,,5557.80,3612.57,,,,,,,,,,,,,
CATHETER GUID DIA2.7 MM VER VID STRL,SUP-2165192,CDM,C1887,HCPCS,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
KIT HIP IMPL CAPPED H2 ADV OTH HD H2ZIMMERBIOMET,SUP-2431795,CDM,C1776,CPT,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
SCREW SPNL THN SHT 5.5X60 MM TSRH 3DX OSTEOGRIP MPA,SUP-2631176,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
ALLOGRAFT BNE W/O HD WHL FEM,SUP-2321807,CDM,C1713,HCPCS,0278,RC,,,,both,,,12123.54,7880.30,,,,,,,,,,,,,
PLATE CRAN 180X160X40 MM PT SPEC IMPL PEEK,SUP-2860161,CDM,C1713,HCPCS,0278,RC,,,,both,,,49984.72,32490.07,,,,,,,,,,,,,
SHELL ACET DIA54MM GRP E BIOFOAM TI MTL FOAM HIP PRESSFIT,SUP-2304548,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE L143MM 9 H R DST POSTEROLATERAL HUM S STL LOK,SUP-2185897,CDM,C1713,HCPCS,0278,RC,,,,both,,,3033.93,1972.05,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ORBITER ST L 95 CM DIA 7 FR SPC 2,SUP-2142353,CDM,C1731,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
ANCHOR SUT DIA55MM W NDL 2 STRND BIOSTEON INTRALINE FORC,SUP-2362555,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.01,707.21,,,,,,,,,,,,,
HC MRI-Angio Head WO Contrast,PX-6157054400,CDM,70544,CPT,0615,RC,,,,both,,,3209.00,2085.85,,,,,,,,,,,,,
COIL EMB L9CM LOOP OD5MM OD0.020IN NIT STRTCH RESIST FILL,SUP-2323396,CDM,C1889,HCPCS,0278,RC,,,,both,,,7049.30,4582.04,,,,,,,,,,,,,
COIL VASC AZUR CX L 20 CM DIA 6 MM MICROCATHETER 0.018 IN,SUP-2385235,CDM,C1889,HCPCS,0278,RC,,,,both,,,2824.43,1835.88,,,,,,,,,,,,,
DEVICE SUTURING CUF OPUS AUTO,SUP-2342055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 63 CM DIL L 67 CM DIA10 FR,SUP-2357206,CDM,C1894,HCPCS,0272,RC,,,,both,,,1086.44,706.19,,,,,,,,,,,,,
CATHETERIZATION KIT ART 018 20 GAX3.81 CM 18/25 GA 3 CC LF,SUP-2865588,CDM,C1751,HCPCS,0278,RC,,,,both,,,57.78,37.56,,,,,,,,,,,,,
CETIRIZINE-PSEUDOEPHEDRINE ER 5-120 MG PO TB12,RX-31239,CDM,6370000000,HCPCS,0637,RC,51660-0940-24,NDC,,both,1,UN,3.40,2.21,,,,,,,,,,,,,
SYSTEM IBV VLV INCLUDE LD TY AIRWY SZ KT W/ CALIB GA 5000,SUP-2313519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Iaadiadoo Respiratory Synctial Virus,PX-3068780700,CDM,87807,CPT,0306,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
STENT PERIPH S.M.A.R.T. CTRL L 20 MM DIA12 MM DEL SYS L 120,SUP-2158635,CDM,C1876,HCPCS,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD STRYKNEES] STRYKER CORP],SUP-2365997,CDM,C1776,CPT,0278,RC,,,,both,,,10971.16,7131.25,,,,,,,,,,,,,
PLATE BNE ORBIT FLR LG 1.5X40X35X0.5 MM RT SMRT TI NS,SUP-2487018,CDM,C1713,HCPCS,0278,RC,,,,both,,,4120.21,2678.14,,,,,,,,,,,,,
KIT DBS EXT TST CABLE STRL DISP SENSIGHT,SUP-2882983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200000 IJ SOLN,RX-169110,CDM,J2004,HCPCS,0636,RC,00409-3183-11,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
DEVICE RESECT ENDOSCP MUCOSAL FOR L GASTROSCP CAPTIVATOR,SUP-2141570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.12,683.23,,,,,,,,,,,,,
PIN DISTR SPNL DISP CASPR,SUP-2310540,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PLATE BNE L RT 4 HOLE,SUP-2864957,CDM,C1713,HCPCS,0278,RC,,,,both,,,3887.32,2526.76,,,,,,,,,,,,,
SPLINT FNGR W325XL325IN ALUMINUM LN W FOAM PLASTALUME RADLUC,SUP-2276771,CDM,L3933,HCPCS,0272,RC,,,,both,,,3.17,2.06,,,,,,,,,,,,,
SCREW SPNL STD OPN BODY PHOENIX,SUP-2316620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ADAPTER LD L 17 CM LT VENTRICULAR FOR OSCOR BIS/BIS-17 EXT,SUP-2498643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
GUIDEWIRE VSCLR 0.035N DIA 150CML NTNL PRPHRL QTTRO,SUP-2492911,CDM,C1769,HCPCS,0272,RC,,,,both,,,164.66,107.03,,,,,,,,,,,,,
BIT DRL FOR 5MM LNG HALF PIN JET-X,SUP-2342944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2235.62,1453.15,,,,,,,,,,,,,
ALLOGRAFT BNE DSTL HUM FRZN LT,SUP-2717952,CDM,C1762,CPT,0278,RC,,,,both,,,9938.10,6459.76,,,,,,,,,,,,,
PROGRAMMER COMMUNICATION W/HANDSET F/SACRAL NERVE STIMULATORS,SUP-2550572,CDM,C1787,HCPCS,0278,RC,,,,both,,,5787.02,3761.56,,,,,,,,,,,,,
CROWN FORM DENT STRP U4 PRIMARY ANTR UPPER RT LAT PLAS,SUP-2322251,CDM,D6783,CPT,0278,RC,,,,both,,,37.11,24.12,,,,,,,,,,,,,
VALVE SHUNT MR CONDITIONAL ADJ STRATA,SUP-2631432,CDM,C1889,HCPCS,0278,RC,,,,both,,,13634.29,8862.29,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309712900,CDM,97129,CPT,0430,RC,,,GO|CO,outpatient,,,186.00,120.90,,,,,,,,,,,,,
PIN EXT FIX ARTC BAR OFFSET CONVERGING TOMAHAWK MINI FIX,SUP-2400613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
SPACER SPNL ENDPIECE B 0 DEG RT VBR,SUP-2430768,CDM,C1889,HCPCS,0278,RC,,,,both,,,10453.06,6794.49,,,,,,,,,,,,,
MONTELUKAST SODIUM 10 MG PO TABS,RX-22509,CDM,6370000000,HCPCS,0637,RC,00904-6808-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TALQUETAMAB-TGVS 3 MG/1.5ML SC SOLN,RX-165050,CDM,J3055,HCPCS,0636,RC,57894-0469-01,NDC,,both,1.5,ML,2495.50,1622.07,,,,,,,,,,,,,
PLATE EXT FIX SHT 180 MM FT RNG CARBON FIBER NS,SUP-2799576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2302.84,1496.85,,,,,,,,,,,,,
SCREW SPNL L35MM OD5.5MM S STL CANC PEDCL VAR ANG 76645535] MEDTRONIC SOFAMOR DANEK],SUP-2288922,CDM,C1713,HCPCS,0278,RC,,,,both,,,3404.39,2212.85,,,,,,,,,,,,,
DEVICE FIX 20MM LOOP DYNEEMA PURITY BRAID CONT FOR ACL PCL,SUP-2366526,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.22,918.59,,,,,,,,,,,,,
BIT DRL CANN 4.5X233 MM 130 MM QC JCBS CHK SS STRL DISP,SUP-2187343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1220.24,793.16,,,,,,,,,,,,,
GUIDEPIN ORTH FOR L SET TRUMATCH,SUP-2252965,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT AMNIOTIC MEMBRANE FLOWERAMNIOPATCH 16MM DISC SIZE,SUP-2866792,CDM,Q4178,HCPCS,0636,RC,,,,both,,,4793.21,3115.59,,,,,,,,,,,,,
BRACE ORTH THGH CIRC 15.5-18.5 IN STD SM SZ 2 ALUMINIUM FRME,SUP-2915023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,843.44,548.24,,,,,,,,,,,,,
SCREW BNE LCK 3.5X12 MM POLYAX MOTOBAND,SUP-2432221,CDM,C1713,HCPCS,0278,RC,,,,both,,,730.05,474.53,,,,,,,,,,,,,
SPLINT ORTH 10IN KNEE BASIC,SUP-2197150,CDM,L1830,CPT,0274,RC,,,,both,,,30.52,19.84,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.177X9 IN RND END SS NS STEINMANN,SUP-2791273,CDM,C1713,HCPCS,0278,RC,,,,both,,,40.69,26.45,,,,,,,,,,,,,
PROBE KIT DECOMPRESSOR 17 GAX9 IN STR PERC,SUP-2366998,CDM,C1713,HCPCS,0278,RC,,,,both,,,5874.81,3818.63,,,,,,,,,,,,,
LENS INTOCU +3.0 DIOPT DIA13MM A CONSTANT 118.7 PMMA BCNVX,SUP-2129753,CDM,V2632,HCPCS,0276,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
CATHETER EP D 6 MM 20 MMX7 FRX115 CM DUO,SUP-2465282,CDM,C1732,HCPCS,0272,RC,,,,both,,,8245.64,5359.67,,,,,,,,,,,,,
PROBE ARTHSCP HK L3.4MM TIP W/ 5MM MRK FOR MENIS REP,SUP-2120783,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
BEARING TIB FIX 4 RT KNEE PLATE,SUP-2223482,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
GRAFT BONE SUB W2.5XL10CM TROUGH MTRX GRFTON,SUP-2294007,CDM,C1713,HCPCS,0278,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
TOOL RELEASE REACTIV8,SUP-2877975,CDM,C1730,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ANCHOR SUT OD4.5MM FULL THRD TI PRELD W/ FORC FBR INSITE,SUP-2396984,CDM,C1713,HCPCS,0278,RC,,,,both,,,889.25,578.01,,,,,,,,,,,,,
NEEDLE ASPIR 11 GAX11 CM STRL MAR CELLUTION 11CSTS,SUP-2743329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
HC So Egfr Gene,PX-3108123566,CDM,81235,CPT,0310,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BRACE WR ADULTXL LT INSTABILITY INJ,SUP-2198769,CDM,L3809,HCPCS,0274,RC,,,,both,,,69.39,45.10,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR TW REINF,SUP-2525450,CDM,C1768,CPT,0278,RC,,,,both,,,978.42,635.97,,,,,,,,,,,,,
HC Sel Cath Pulmonary Art,PX-3613601400,CDM,36014,CPT,0361,RC,,,,outpatient,,,13613.00,8848.45,,,,,,,,,,,,,
SCREW BNE L15MM DIA2.7MM LOK FOR R3CON PLATING SYS GORILLA,SUP-2321277,CDM,C1713,HCPCS,0278,RC,,,,both,,,572.27,371.98,,,,,,,,,,,,,
BUR SURG L10CM HD L113MM DIA6MM CYL BRL SM BOR MIDAS REX,SUP-2277619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
EVOS TI 3.5MMX15MM LCK SCREW T15 S-T,SUP-2820423,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.72,463.27,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 9MM FENESTRATED STRAIGHT 201686,SUP-2848947,CDM,C1889,HCPCS,0278,RC,,,,both,,,795.61,517.15,,,,,,,,,,,,,
METFORMIN HCL 850 MG PO TABS,RX-14719,CDM,6370000000,HCPCS,0637,RC,00904-7163-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 20 MM DIA 7 MM CATH TOT L 160,SUP-2148372,CDM,C1876,HCPCS,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
BUR SURG 6 MM 500 MM,SUP-2599992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,598.01,388.71,,,,,,,,,,,,,
FIXATOR EXT FIX SHRT HND N BRDG FRACTR STRL DISP NBX,SUP-2909408,CDM,C1713,HCPCS,0278,RC,,,,both,,,9027.50,5867.87,,,,,,,,,,,,,
BIT DRL 2.9X308 MM STRL VERSANAIL,SUP-2606672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,992.71,645.26,,,,,,,,,,,,,
PLATE BONE L120MM 6 H BILAT S STL SPN LCK COMPR LO PROF RIG,SUP-2185732,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.63,749.21,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 21-26X27-32X21 MM FRZN ANTR LUMINARY-CC,SUP-2737047,CDM,C1713,HCPCS,0278,RC,,,,both,,,16051.99,10433.79,,,,,,,,,,,,,
STRAW NEOCONNECT 6 IN LG BORE SAMPLING W/ENFIT CONN PUR,SUP-2110451,CDM,V2632,HCPCS,0276,RC,,,,both,,,2.73,1.77,,,,,,,,,,,,,
ROD SPNL L75MM OD5.5MM CVD CONE TIP AUXILIARY MARS,SUP-2229650,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
INSERT TOE 01 2.5MM OFFSET THK3.6MM MOD TOEMOTION,SUP-2123619,CDM,C1776,CPT,0278,RC,,,,both,,,7818.60,5082.09,,,,,,,,,,,,,
ROD EXT FIX 85 MM 1 LEVEL HALF MAND BENT TI,SUP-2423209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1610.57,1046.87,,,,,,,,,,,,,
PLATE POSTLAT DSTL HUM 3.5MM 9H LT 143MM LCP STRL,SUP-2547559,CDM,C1713,HCPCS,0278,RC,,,,both,,,3338.82,2170.23,,,,,,,,,,,,,
HEADBAND EEG MEDIUM ADLT SINGLE PT USE,SUP-2740085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CONTROLLER STIM SYS MY SCS GO THER,SUP-2905201,CDM,C1787,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
COMPONENT HUM 46X42MM ARTC OFFSET OVOMOTION,SUP-2123588,CDM,C1776,CPT,0278,RC,,,,both,,,18249.68,11862.29,,,,,,,,,,,,,
GRAFT PASTE SYNTH CLLGN COPIOS BVF 5CC,SUP-2197452,CDM,C1713,HCPCS,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
HC So Antibody; Mumps,PX-3028673566,CDM,86735,CPT,0302,RC,,,,outpatient,,,104.00,67.60,,,,,,,,,,,,,
PLATE BNE L301MM 20 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185663,CDM,C1713,HCPCS,0278,RC,,,,both,,,5045.23,3279.40,,,,,,,,,,,,,
INFUSION PUMP KIT PAIN 1 IN CTRL CATH PAINBUSTER ON-Q PM035] HALYARD SALES LLC FKA I-FLOW],SUP-2236843,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ARTHROSCOPIC SET POSTLESS HIP DISTRCTN SYS DISP,SUP-2845688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA1.8MM SMOOTH MRI SAFE FOR DISTR,SUP-2179128,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.54,141.40,,,,,,,,,,,,,
FUROSEMIDE 40 MG PO TABS,RX-3295,CDM,6370000000,HCPCS,0637,RC,00054-8299-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BONE PUTTY DEMINERLIZED BONE MTRX 2.5CC DYNAGRFT II,SUP-2242677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1030.92,670.10,,,,,,,,,,,,,
SCREW BNE SELF RET MINI 2X7 MM MAND DRILL-FREE CENTRE-DRIVE,SUP-2462733,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.06,109.89,,,,,,,,,,,,,
BIT DRL CANN 3 MM STRL VERTEX SEL,SUP-2630218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.62,586.05,,,,,,,,,,,,,
COLLAR CERV PED SM EXTRIC 1 PC TRACH OPN W CHIN REST MINI,SUP-2115115,CDM,L0140,HCPCS,0272,RC,,,,both,,,35.36,22.98,,,,,,,,,,,,,
GRAFT VSCLR STRGHT WOVEN DBLE VLR 24MM DX15CM L HMSHLD PLTNM,SUP-2472257,CDM,C1768,CPT,0278,RC,,,,both,,,1330.14,864.59,,,,,,,,,,,,,
PAPILLOTOME ENDO CATH L200CM OD5FR 0.035IN CUT WIRE L7MM,SUP-2169183,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
KWIRE FIX L100MM DIA11MM FOR TOT FT SYS 2,SUP-2243137,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.51,73.13,,,,,,,,,,,,,
KYPHOPLASTY KIT 1ST FRAC 20/3 IBT KYPHON OSTEO INTRO,SUP-2743796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
CATHETER BLLN DIL 5.8FR L75CM BLLN 18FR L4CM 0.038IN HYDR+,SUP-2139191,CDM,C1726,HCPCS,0272,RC,,,,both,,,831.82,540.68,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY DS DR H 5.9 CM D 1.1 CM DEL,SUP-2149281,CDM,C1721,HCPCS,0275,RC,,,,both,,,58090.00,37758.50,,,,,,,,,,,,,
PLATE BONE W9XL61MM THK1.1MM 5 H DSTL ULN FIBULAR S STL 1/3,SUP-2343776,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.58,457.33,,,,,,,,,,,,,
NAIL CEPHALOMEDULLARY SM L34CM DIA10MM 130DEG LNG TI R CCD,SUP-2208148,CDM,C1713,HCPCS,0278,RC,,,,both,,,6685.75,4345.74,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X358 MM 20 HOLE TI NS LC-DCP,SUP-2568785,CDM,C1713,HCPCS,0278,RC,,,,both,,,4136.23,2688.55,,,,,,,,,,,,,
PLATE BNE W9XL93MM THK1MM 8 H TI 1/3 TBLR W/ CLLR LOK COMPR,SUP-2190954,CDM,C1713,HCPCS,0278,RC,,,,both,,,537.22,349.19,,,,,,,,,,,,,
PROSTHESIS ANK SZ 2 CLP LOK,SUP-2420826,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.25,271.86,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 100 CM 4 FR SIM2 NONBRAIDED SFT,SUP-2116696,CDM,C1725,HCPCS,0272,RC,,,,both,,,41.45,26.94,,,,,,,,,,,,,
SCREW BNE L6MM DIA1MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189078,CDM,C1713,HCPCS,0278,RC,,,,both,,,1685.87,1095.82,,,,,,,,,,,,,
KIT ACCSRY SHTH 20 FR DIL DIA12/16 FR PEELWY Y ADPT 1W,SUP-2175238,CDM,C1892,HCPCS,0272,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
HEAD RAD H12MM DIA24MM ELBW CO CHROM LO PROF DSTL EDGE L2L,SUP-2418599,CDM,C1776,CPT,0278,RC,,,,both,,,5457.32,3547.26,,,,,,,,,,,,,
PLATE BNE THK1MM M 4 H TI LOK FOR 2.7MM SCR 2MM MINI SYS,SUP-2262829,CDM,C1713,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
INSERT TIB HD CONSTRAINT N-K,SUP-2449035,CDM,C1776,CPT,0278,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
ENVELOPE PACEMKR M W2.5XL2.7IN ABSRB ANTIBACT TYRX,SUP-2282347,CDM,C1889,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SYSTEM OCCL DEL AMPLATZER 45 DEG L 60 CM SHTH 8 FR NIT MESH,SUP-2116321,CDM,C1894,HCPCS,0272,RC,,,,both,,,2047.28,1330.73,,,,,,,,,,,,,
PIN FIX L9IN OD5/32IN S STL TYP D STNMN,SUP-2342724,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.12,178.18,,,,,,,,,,,,,
PLATE BONE L W13.5XL232MM THK4.2MM 13 H BILAT TI STR RIG,SUP-2190825,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.08,601.95,,,,,,,,,,,,,
CANNULA KIT UNI PEDICULAR 10 GA CEMENT DEL,SUP-2846424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT HUM TISS SZ 9 MM TRICORT WDG,SUP-2913402,CDM,C1762,CPT,0278,RC,,,,both,,,5991.12,3894.23,,,,,,,,,,,,,
PLATE BNE LCK 2 MM STRNL 6 HOLE BODY 2402540] KLS MARTIN LP],SUP-2262571,CDM,C1713,HCPCS,0278,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
SCREW IM NAIL L 110 MM DIA 3.7/4 MM FIBULAR,SUP-2896866,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
SCREW BONE SELF DRL MINI TI NS 2.0MMX7MM MAXDRIVE,SUP-2262881,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.80,100.62,,,,,,,,,,,,,
COMPONENT FEM SZ 5 KNEE CEM UNI PRESERVATION,SUP-2251254,CDM,C1776,CPT,0278,RC,,,,both,,,8390.08,5453.55,,,,,,,,,,,,,
TRAY CATH MIDLN POWERMIDLINE MAXBARR 4FR 20CM 2 LUMAN RVS TA,SUP-2613519,CDM,C1751,HCPCS,0278,RC,,,,both,,,568.53,369.54,,,,,,,,,,,,,
ALLOGRAFT BNE FD IRRADIATED FEM HD 920495,SUP-2867052,CDM,C1762,CPT,0278,RC,,,,both,,,4537.14,2949.14,,,,,,,,,,,,,
COIL EMB L4CM OD3MM 360DEG HELI SFT STRTCH RESIST BIG LOOP,SUP-2365739,CDM,C1889,HCPCS,0278,RC,,,,both,,,8172.16,5311.90,,,,,,,,,,,,,
CATHETER DIAG L65CM OD0.063X0.05IN TIP OD3.1FR 50MM SPC,SUP-2353135,CDM,C1887,HCPCS,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
COIL EMB L20CM DIA5MM 0.02IN PERIPH COMPLX STD FRME,SUP-2323661,CDM,C1889,HCPCS,0278,RC,,,,both,,,4678.60,3041.09,,,,,,,,,,,,,
PLATE BNE T 4.5X127 MM 6 HOLE LCP,SUP-2569410,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.72,391.77,,,,,,,,,,,,,
PLATE BNE L W13.5XL214MM THK4.2MM 12 H BILAT TI STR RIG,SUP-2190823,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.70,528.90,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 1 MED AD 135X20 MM SS GRNLN,SUP-2393643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.47,153.06,,,,,,,,,,,,,
PLATE BNE W11XL262MM THK42MM 16 H MTPHSEAL S STL LOK COMPR,SUP-2185268,CDM,C1713,HCPCS,0278,RC,,,,both,,,3634.80,2362.62,,,,,,,,,,,,,
ANCHOR VERSALOOP 1.8MM DL TAPE,SUP-2756501,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
PLATE BONE L153.5MM 8 H LT MEDL DSTL TIB TI FOR,SUP-2225376,CDM,C1713,HCPCS,0278,RC,,,,both,,,5021.49,3263.97,,,,,,,,,,,,,
TRAY CTRL VEN POLYUR DBL LUMN STR J TIP GWIRE SCALP DIL,SUP-2167998,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BUR SURG RND MED 4.8 MM 68 MM FLUT FOR DRL SYS SS,SUP-2628955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,214.40,139.36,,,,,,,,,,,,,
BIT DRL QC 2.5X135 MM 45 MM CALIB STRL,SUP-2563749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.84,254.05,,,,,,,,,,,,,
SCREW BNE ST 4.5X42 MM CORTICAL ACCORD,SUP-2344026,CDM,C1713,HCPCS,0278,RC,,,,both,,,8528.24,5543.36,,,,,,,,,,,,,
PIN GUID ORTH OBLQ NTHRD,SUP-2292223,CDM,C1713,HCPCS,0278,RC,,,,both,,,315.44,205.04,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.544,SUP-2860225,CDM,C1713,HCPCS,0278,RC,,,,both,,,46755.86,30391.31,,,,,,,,,,,,,
DRONEDARONE HCL 400 MG PO TABS,RX-98239,CDM,6370000000,HCPCS,0637,RC,00024-4142-60,NDC,,both,1,UN,60.80,39.52,,,,,,,,,,,,,
CATHETER GUID L 110 CM DIA 7 FR CORONARY JL4 MOD,SUP-2139697,CDM,C1887,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BENDER PLT CERV,SUP-2207788,CDM,C1713,HCPCS,0278,RC,,,,both,,,2362.54,1535.65,,,,,,,,,,,,,
MICROCATHETER GUID PLATO 17 45 DEG USABLE L 160 CM COAT L 90,SUP-2909733,CDM,C1887,HCPCS,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SPLINT WR FRARM SM AD L11IN BLU L FOAM FOR INSTABILITY INJ,SUP-2195162,CDM,L3908,HCPCS,0274,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
INFUSION PUMP KIT PAINBUSTER 2.5 IN 400 CC ON-Q SILVERSOAKER,SUP-2236829,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
BLADE SHV FULL RAD LNG STR 5.5MM 18CM DYONICS PWR EP-1,SUP-2341433,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.11,483.02,,,,,,,,,,,,,
PLATE BNE L W135XL224MM THK42MM 12 H BILAT TI NAR RIG NEUT,SUP-2190824,CDM,C1713,HCPCS,0278,RC,,,,both,,,1864.75,1212.09,,,,,,,,,,,,,
GRAFT TISSUE HUMAN THERASKIN 4.0 X 6.5,SUP-2745400,CDM,Q4121,HCPCS,0636,RC,,,,both,,,3763.29,2446.14,,,,,,,,,,,,,
SCREW BNE CRANIO MAXILLOFACIAL HD TI 2.3MMX11MM CENTRE DRV,SUP-2262628,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.77,74.60,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH CSG WORLEY L 45 CM DIA 9 FR,SUP-2329851,CDM,C1892,HCPCS,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE FREE MOLD PLAS,SUP-2435638,CDM,L2037,HCPCS,0274,RC,,,,both,,,4694.99,3051.74,,,,,,,,,,,,,
HC Smr Prim Src Wet Mount Nfct Agt,PX-3008721001,CDM,87210,CPT,0300,RC,,,,inpatient,,,208.00,135.20,,,,,,,,,,,,,
SYSTEM DISPNS MED MAIN 2 DRAW 3500 MEDSTATION,SUP-2126362,CDM,C1781,HCPCS,0278,RC,,,,both,,,1316.60,855.79,,,,,,,,,,,,,
KIT BNE FIX L16MM OD15MM FRAC NAIL SMRT,SUP-2166909,CDM,C1713,HCPCS,0278,RC,,,,both,,,582.97,378.93,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 6CMD STNLSS STEEL SPNL MSCLE NRRW BLACK,SUP-2464799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.39,265.45,,,,,,,,,,,,,
TUBE EXT FIX CARBON 20X350 MM,SUP-2539886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.23,609.85,,,,,,,,,,,,,
BIT REPROC DRL CANN 4.9MM W/LG AO 6.5/8MM,SUP-2653175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.19,382.97,,,,,,,,,,,,,
KIT SCR L15MM DIA8MM W/ BICEPTOR BIOSURE,SUP-2341825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1283.66,834.38,,,,,,,,,,,,,
ELECTRODE ES 24X26FR DIA5MM YEL COAG BRL SHP FOR 24/28FR,SUP-2261196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,429.14,278.94,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 X W 20 MM THK 5 MM ACHILLES TEND RC,SUP-2933845,CDM,C1762,CPT,0278,RC,,,,both,,,6187.81,4022.08,,,,,,,,,,,,,
COLLAR CERV UNIV 13 19INCH VISTA TX,SUP-2196896,CDM,L0172,HCPCS,0274,RC,,,,both,,,128.43,83.48,,,,,,,,,,,,,
CATHETER HD TWO LUMEN 12 FRX20 CM LG BOR ARROWG+ARD BLU,SUP-2627043,CDM,C1752,HCPCS,0278,RC,,,,both,,,447.14,290.64,,,,,,,,,,,,,
SHEATH TUNN L20.5IN DIA12MM BLU POLYMER RADPQ DISP FOR 10MM,SUP-2336986,CDM,C1894,HCPCS,0272,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
INTRODUCER VASC 8.5FR LUMN L81CM CURL 168MM SHTH 85FR L61CM,SUP-2357597,CDM,C1766,CPT,0272,RC,,,,both,,,2656.13,1726.48,,,,,,,,,,,,,
BRACE ORTHOPEDIC SIMP 22-34 IN UNIV KNEE,SUP-2269750,CDM,2740000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BNE UTIL 2 HOLE CROSSCHECK PLATING SYS,SUP-2399370,CDM,C1713,HCPCS,0278,RC,,,,both,,,5140.18,3341.12,,,,,,,,,,,,,
HC Ot Work Conditioning 15 Min,PX-4309753700,CDM,97537,CPT,0430,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
TAMP BNE SZ 3 L20MM BNE INFL BLLN KYPHX XPANDER,SUP-2281086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
COMPONENT TIB L65MM THK8MM TI UHMWPE MEDL LAT POST STBL AGC,SUP-2406190,CDM,C1776,CPT,0278,RC,,,,both,,,7658.46,4978.00,,,,,,,,,,,,,
KIT INTRO DIL DIA20 FR LAPSCP FOR GASTMY FEED TUBE STRL,SUP-2764618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.59,493.08,,,,,,,,,,,,,
DRESSING WND SGL LAYR MTRX ST DISP L2XW2IN,SUP-2243645,CDM,Q4108,HCPCS,0636,RC,,,,both,,,5545.24,3604.41,,,,,,,,,,,,,
KIT DRNGE LUM 700ML L80CM BA IMPREG CONN FIX TAB BLNT TUOHY,SUP-2284548,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.80,427.57,,,,,,,,,,,,,
PIN HALF SD 150X30 MM 5 MM THRD,SUP-2372342,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
KNIFE ANNULOTOMY RETRCT,SUP-2329745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1607.68,1044.99,,,,,,,,,,,,,
GALILEO TROCH NAIL 9MMX20CMX125 DEGREE,SUP-2828801,CDM,C1713,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
RING SPNL HALF CLS CRADLE END FOR RIB SUPP TI NS VEPTR,SUP-2193300,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BIT DRILL CANN 4.9MM,SUP-2497212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
PLATE SPNL 4X10 MM LT MOUTH SINGLE,SUP-2708740,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BAR EXT FIX 11X200 MM CARBON XTRAFIX,SUP-2481563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
BIT DRL 4.5 MMX9 IN FOR HDLSS SCR SYS NS LTX,SUP-2862179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1552.42,1009.07,,,,,,,,,,,,,
SET SZ SM M L BLU GRY GRN UHMWPE ANG STA-PEG,SUP-2397145,CDM,C1713,HCPCS,0278,RC,,,,both,,,3287.58,2136.93,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SFT LN ACTE 11.5FR DIA 20CM IN T118IJ2,SUP-2633028,CDM,C1752,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
PLATE SURFACE 3.5MM QUADRILATERAL LONG STERILE,SUP-2546016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1981.15,1287.75,,,,,,,,,,,,,
SHUNT PERI L120CM OD25MM ID13MM REG CATHETER OPN END W WALL,SUP-2278391,CDM,C1889,HCPCS,0278,RC,,,,both,,,13586.18,8831.02,,,,,,,,,,,,,
HC Perq Transcath Cls Paravalvr Leak 1 Aortic Valve,PX-4819359100,CDM,93591,CPT,0481,RC,,,,both,,,56457.00,36697.05,,,,,,,,,,,,,
LORATADINE-PSEUDOEPHEDRINE ER 10-240 MG PO TB24,RX-27521,CDM,6370000000,HCPCS,0637,RC,51660-0724-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT BNE 2.7X18 MM PIP STRL TENFUSE,SUP-2423166,CDM,C1889,HCPCS,0278,RC,,,,both,,,4229.58,2749.23,,,,,,,,,,,,,
CATHETER HD TWO LUMEN 14 FRX6 IN LG BOR KT STR ARW,SUP-2627029,CDM,C1752,HCPCS,0278,RC,,,,both,,,180.93,117.60,,,,,,,,,,,,,
SCREW BNE ST 4.5X85 MM CORTICAL LG HEX SOCKET SS NS LCP DCP,SUP-2184409,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.64,137.57,,,,,,,,,,,,,
CONNECTOR SPNL ROD 5.5X70 MM STR TI CD HORZ,SUP-2631077,CDM,C1713,HCPCS,0278,RC,,,,both,,,4713.14,3063.54,,,,,,,,,,,,,
HC Mandible Mandible Min 4 Views,PX-3207011000,CDM,70110,CPT,0320,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COMPONENT SHLDR CAPPED SHT FEM HIP ST COV UPLR CEM JEAD GLD,SUP-2421718,CDM,C1776,CPT,0278,RC,,,,both,,,26847.00,17450.55,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO BASIC 22GA 8CM WNG 1 F122087T,SUP-2632746,CDM,C1751,HCPCS,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
NEEDLE PRE WAXED 0.50MM X 01.0CM 21 GAUGE 15CM,SUP-2716306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.66,315.03,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 1.6X220 MM TROCAR PT 1 END,SUP-2424097,CDM,C1769,HCPCS,0272,RC,,,,both,,,246.55,160.26,,,,,,,,,,,,,
EXTENSION STEM L205MM OD13MM HIP FEM MOD PLSM SPRY IMP,SUP-2217205,CDM,C1776,CPT,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
CATHETER PERI DLYS COILED L V NK W/ DBL CUF SET 63CM,SUP-2267005,CDM,C1752,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
GUIDEWIRE ORTH 12X100 MM SMOOTH SINGLE END TROCAR TIP,SUP-2321617,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
SHUNT SURG SM 120 CM STRATA II INNERVISION,SUP-2628623,CDM,C1729,HCPCS,0272,RC,,,,both,,,16980.18,11037.12,,,,,,,,,,,,,
PLATE BONE L145MM THK3.4MM 10 H BILAT NONLOCKING COMPR FOR,SUP-2348953,CDM,C1713,HCPCS,0278,RC,,,,both,,,1611.23,1047.30,,,,,,,,,,,,,
CONNECTOR VLV SELF ADJUSTING CSF PRESSURE SIL ANTISIPHON,SUP-2243846,CDM,C1729,HCPCS,0272,RC,,,,both,,,9115.48,5925.06,,,,,,,,,,,,,
CATHETER PICC L55CM OD4FR DBL LUMN,SUP-2120641,CDM,C1751,HCPCS,0278,RC,,,,both,,,391.24,254.31,,,,,,,,,,,,,
GUIDEPIN SURG PAT KNEE,SUP-2351422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
GRAFT FRZ DRY ALLGRFT 1-24CM2,SUP-2165567,CDM,C1762,CPT,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SCREW BNE L90MM DIA3.5MM STD CORT S STL NONCANNULATED FULL,SUP-2183522,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.078X9 IN RND END SS NS STEINMANN,SUP-2791599,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.93,7.75,,,,,,,,,,,,,
SEED BRACHYTHERAPY I-125 IOD LOOSE VI PRECONN NDL,SUP-2129001,CDM,C2638,HCPCS,0278,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
ALLOGRAFT BNE PROX TIB W/O PAT LIGMNT,SUP-2321913,CDM,C1713,HCPCS,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
PROSTHESIS OSS 3-7 MM 2.2X3 MM 0.8 MM MORETZ DELT HA TI SIL,SUP-2461911,CDM,L8613,CPT,0278,RC,,,,both,,,1217.72,791.52,,,,,,,,,,,,,
DEVICE CRD DRV MECHANISM ACTIVATOR II,SUP-2717311,CDM,C1713,HCPCS,0278,RC,,,,both,,,3995.05,2596.78,,,,,,,,,,,,,
BRACE WRST SUPP LG 7.5-8.5 IN RT STABILIZING,SUP-2196519,CDM,L3931,HCPCS,0272,RC,,,,both,,,26.72,17.37,,,,,,,,,,,,,
PLATE BNE W5XL37MM THK1.5MM 7 H BILAT TI STR RIG NEUT DYN,SUP-2191044,CDM,C1713,HCPCS,0278,RC,,,,both,,,968.00,629.20,,,,,,,,,,,,,
GRAFT BONE SUB SM 7MM 5DEG LORDOSIS RAMP POST SPNL GRFTECH,SUP-2294224,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SPHERE GLEN DIA36MM +6MM OFFSET CO CHROM SHLDR REV SYS,SUP-2404721,CDM,C1776,CPT,0278,RC,,,,both,,,3937.56,2559.41,,,,,,,,,,,,,
GRAFT BNE SUB 5CC 1GM BIOACTIVE SYN GRAN INTFACE,SUP-2138522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1609.25,1046.01,,,,,,,,,,,,,
ROD STR SPINE SMOOTH TI TENOR SPINE 5.5X210MM,SUP-2289295,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
UNIT THER COMB CRYO W PD SHLDR W TB PWR OPERATED W OUT BD,SUP-2150932,CDM,C1713,HCPCS,0278,RC,,,,both,,,355.64,231.17,,,,,,,,,,,,,
PIN FXTN 32MM DIA 70MML 13MM THRD F/EXTRNL FXTN SSTM X FIX,SUP-2681413,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.45,430.59,,,,,,,,,,,,,
IMPLANT BIO TISS 5X10CM SM SURG TEND INTEGRA REINF MTRX,SUP-2244430,CDM,C1763,HCPCS,0278,RC,,,,both,,,8109.43,5271.13,,,,,,,,,,,,,
"HC So1 Immunofix Electphoresis,Othfld",PX-3028633567,CDM,86335,CPT,0302,RC,,,,both,,,182.00,118.30,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR PT HND HELD CA WR STRP BTTRY FOR,SUP-2279560,CDM,C1787,HCPCS,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
GRAFT BIO TISS OASIS WND MATRIX 3X3.5CM FEN,SUP-2341251,CDM,Q4102,HCPCS,0636,RC,,,,both,,,359.81,233.88,,,,,,,,,,,,,
HC Plmt Ureteral Stent Prq,PX-3615069500,CDM,50695,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
GRAFT BNE SUB 25ML POLYMER HYALURONIC ACID BASE PSTE MIX,SUP-2247320,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
CATHETER CARD ABLATION LASSO 2515 NAV ECO L 115CM SPC2-6-2MM,SUP-2248612,CDM,C1732,HCPCS,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
PLUG HERN SM W1XL1.35IN INGUINAL POLYPR REP PRESHAPED ONLAY,SUP-2125754,CDM,C1781,HCPCS,0278,RC,,,,both,,,389.67,253.29,,,,,,,,,,,,,
SET INTRO PEELWY ECHOTIP L 9 CM DIA 5.5 FR GUIDEWIRE L 65 CM,SUP-2168658,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.87,92.22,,,,,,,,,,,,,
MESH HERN L14XW10IN POLYPR EPTFE ABD NONABSORBABLE RECTANG,SUP-2125804,CDM,C1781,HCPCS,0278,RC,,,,both,,,4614.54,2999.45,,,,,,,,,,,,,
STEM FEM CALCAR 13 30 MM HIP STR POROUS ECHELON,SUP-2450577,CDM,C1776,CPT,0278,RC,,,,both,,,10016.60,6510.79,,,,,,,,,,,,,
TUBE CABLE PASS L 400 MM SURG WIRE STRL LF DISP,SUP-2905585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,764.24,496.76,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,PX-3606444600,CDM,64446,CPT,0360,RC,,,XU,both,,,2895.00,1881.75,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN FULL KT DBL LUMN POLYUR STR,SUP-2283927,CDM,C1750,HCPCS,0278,RC,,,,both,,,576.22,374.54,,,,,,,,,,,,,
DEVICE CARD MONITOR MYLUX MOB FOR LUX-DX II+ INSERTABLE SYS,SUP-2880201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
BUR SURG L71MM DIA25MM LNG S STL RND FN DMND NONFLUTED,SUP-2278118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.51,307.78,,,,,,,,,,,,,
BUTTON 9X16MM 7MM FIXATION OVAL SMALL XTENDOBUTTON,SUP-2880377,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
PLATE 8 H 1 3RD TBLR,SUP-2243249,CDM,C1713,HCPCS,0278,RC,,,,both,,,5747.30,3735.74,,,,,,,,,,,,,
IMPLANT FIX 2 TETHERED TWINLOCK,SUP-2342081,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
DRILL SURG CLLRD 8 MM ARTHSCP MENIS TRANSPLANTATION,SUP-2608073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
SCREW DISTR PIN L16MM ANT CERV AGG,SUP-2417447,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.86,40.86,,,,,,,,,,,,,
BODY FEM 19MM UNIV PROX SHAL MILLED MOD RESTR REV HIP SYS,SUP-2375564,CDM,C1713,HCPCS,0278,RC,,,,both,,,9808.10,6375.26,,,,,,,,,,,,,
DRILL SURG 30 MM SPARE PART KT SPEEDGUIDE,SUP-2491651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.73,304.02,,,,,,,,,,,,,
PLATE BNE CONN 3 HOLE FOR DISTRCTN OSTEOGENESIS RNG SYS,SUP-2179149,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.04,166.43,,,,,,,,,,,,,
SCREW CORT FT SELF TAP HEX HD 4.5MM DIA 16MML,SUP-2342647,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
PLATE BNE STD 1 H ST S STL QUADRILATERAL SURF RECON LO PROF,SUP-2177158,CDM,C1713,HCPCS,0278,RC,,,,both,,,1799.50,1169.67,,,,,,,,,,,,,
PLATE BNE L 115 MM SCREW DIA2.7/3.5 MM 7 H SS LT DSTL,SUP-2931412,CDM,C1713,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
BASKET STONE RETRV L120CM OD20MM SHTH OD3FR 4W NO TIP DISP,SUP-2141703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
JOINT TEMPOROMANDIBULAR UNILAT CRAN,SUP-2565227,CDM,C1776,CPT,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
STENT COR OTW 2.5X8 MM 5 FRX143 CM XIENCE V,SUP-2104431,CDM,C1874,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.549,SUP-2860066,CDM,C1713,HCPCS,0278,RC,,,,both,,,59286.65,38536.32,,,,,,,,,,,,,
HC Veno Adrenal Unilat Sel S&I Rt,PX-3207584000,CDM,75840,CPT,0320,RC,,,,both,,,3165.00,2057.25,,,,,,,,,,,,,
DRAINAGE KIT CUST,SUP-2302899,CDM,C1729,HCPCS,0272,RC,,,,both,,,423.81,275.48,,,,,,,,,,,,,
HC Clsd Tx Cmc Disl WO Anesth,PX-4502667000,CDM,26670,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 11 HOLES,SUP-2549474,CDM,C1713,HCPCS,0278,RC,,,,both,,,2320.59,1508.38,,,,,,,,,,,,,
MESH CRAN W100XL100MM THK05MM STR ROW PLT RESRB ORTHOMESH,SUP-2257162,CDM,C1781,HCPCS,0278,RC,,,,both,,,6100.42,3965.27,,,,,,,,,,,,,
SET VASC NDL 15GA L15MM IO S STL WRISTBAND SHRP BLK EZ IO,SUP-2383216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.92,278.80,,,,,,,,,,,,,
CAGE SPNL L10XW10XH8MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317723,CDM,C1889,HCPCS,0278,RC,,,,both,,,3990.94,2594.11,,,,,,,,,,,,,
SCREW BNE L85MM DIA12.7MM STD S STL CANC ST LAG CANN LOK,SUP-2197702,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
CATHETER DIL CORONARY 1.2X12 MM MINI TREK,SUP-2848025,CDM,C1725,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PLATE BNE L 146 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 9 H 72465509N,SUP-2933122,CDM,C1713,HCPCS,0278,RC,,,,both,,,5295.30,3441.94,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE X LG SHT ANK ROCKER BTM INLINE,SUP-2336134,CDM,L4361,HCPCS,0274,RC,,,,both,,,93.29,60.64,,,,,,,,,,,,,
CONNECTOR SPNL L55MM THORLUM TI SIDELOAD FOR 5.5MM ROD CDH,SUP-2289154,CDM,C1713,HCPCS,0278,RC,,,,both,,,3169.74,2060.33,,,,,,,,,,,,,
GRAFT BONE SUB H12MM CANC CORT FIBULAR RNG PLUG WDG MECH FEE,SUP-2293803,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
TRIAL HIP M LT ACET FLNG PROV RINGLOK PAR 5,SUP-2403447,CDM,C1776,CPT,0278,RC,,,,both,,,2223.12,1445.03,,,,,,,,,,,,,
PLATE BNE LEFORT 0.6 MM RT FLAT LINDORF MOD TI,SUP-2458751,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.73,621.87,,,,,,,,,,,,,
SCREW BONE CANN SYS 2.0MMX8MM SM QFX,SUP-2343082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1324.92,861.20,,,,,,,,,,,,,
BLADE SCALP TRIANG (MUST BE ORDERED IN MULTIPLES OF 6 EA),SUP-2370408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
BRACE ORTH SHELL ADJ 2XS AD 9-10 IN BILATERAL REUSE,SUP-2319320,CDM,L4350,HCPCS,0274,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
PIN FIX DIA1.8MM PROV,SUP-2344033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.60,587.99,,,,,,,,,,,,,
SCREW BNE FEN N FORCE 73MM X 100MM,SUP-2414077,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
OPACIFIER BONE CEM 5GM RADPQ TRACERS,SUP-2342140,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.33,172.46,,,,,,,,,,,,,
PLATE MESH 2.4/2.7MM 5X12H TI VA LCK STRL,SUP-2546966,CDM,C1713,HCPCS,0278,RC,,,,both,,,6173.84,4013.00,,,,,,,,,,,,,
PLATE LOK STRGHT XLRG6H T10MM 1MM MARKS W/TAB CP TTNM,SUP-2694192,CDM,C1713,HCPCS,0278,RC,,,,both,,,1753.44,1139.74,,,,,,,,,,,,,
GRAFT CORNEA HUMAN,SUP-2738102,CDM,V2785,HCPCS,0810,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430078,CDM,Q5135,HCPCS,0636,RC,65219-0590-04,NDC,,both,4,ML,1155.50,751.07,,,,,,,,,,,,,
BUR SURG TAPR 1.7X15.8 MM 7 CM SM BOR MIDAS REX 8 LEGEND,SUP-2664809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.30,211.44,,,,,,,,,,,,,
SPACER SPNL 2XL W18XH7MM D15MM 7DEG ANTR CERV PEEK LORDTC,SUP-2231256,CDM,C1821,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
CARRIER LT REPL RT LNG 180MM,SUP-2383877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,927.90,603.13,,,,,,,,,,,,,
WALKER PT L DIAB,SUP-2276715,CDM,L4387,HCPCS,0272,RC,,,,both,,,257.67,167.49,,,,,,,,,,,,,
PLATE BONE L144MM 4 H LT PROX FEM LCK FOR 4.5MM SCR PERI-LOC,SUP-2351168,CDM,C1713,HCPCS,0278,RC,,,,both,,,11452.21,7443.94,,,,,,,,,,,,,
COIL VASC AZUR L 50 CM DIA20 MM MICROCATHETER 0.018 IN LOOP,SUP-2385437,CDM,C1889,HCPCS,0278,RC,,,,both,,,2854.61,1855.50,,,,,,,,,,,,,
BASKET SPEC RETRV L120CM OD12MM PTFE PULM DISPOSABLE ZEROTIP,SUP-2141361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,809.24,526.01,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 8 MM EPTFE STR TW N RING STRL,SUP-2396714,CDM,C1768,CPT,0278,RC,,,,both,,,2179.16,1416.45,,,,,,,,,,,,,
ENDCAP ORTH FEM DSTL FOR NAIL TI,SUP-2564342,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.88,370.42,,,,,,,,,,,,,
LEAD DEFIB PERM VENT LD PACE BPLR ACT FIX SJ4 CONN 75CM LEN,SUP-2357375,CDM,C1895,HCPCS,0275,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
WIRE ORTHOPEDIC SMOOTH 1.4 MM OLV BABY GORILLA,SUP-2321633,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
SPHERE OPHTH DIA18 MM ORBIT OCULOPLASTIC POROUS,SUP-2883446,CDM,L8610,HCPCS,0278,RC,,,,both,,,1663.45,1081.24,,,,,,,,,,,,,
GRAFT BONE 3-6MM 30ML CANC CHIP FRZ DRY,SUP-2294036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
SPHERE EMBOLIZATION 45 150 MUM 100 MGVIAL BEARING NSPVA,SUP-2677311,CDM,C1889,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BONE L100MM 5 H BILAT S STL SPN LCK COMPR LO PROF RIG,SUP-2185731,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.41,702.27,,,,,,,,,,,,,
HC Insertion/Rplcmt Iims Implantable Mntr Only,PX-4810527000,CDM,0527T,CPT,0481,RC,,,,inpatient,,,26264.00,17071.60,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN LG 22X13 CMX0.7-1.4 MM SHP FLEXHD,SUP-2307612,CDM,Q4128,HCPCS,0636,RC,,,,both,,,16707.00,10859.55,,,,,,,,,,,,,
PEG FEM AUG THK10MM KNEE VANGUARD,SUP-2407853,CDM,C1776,CPT,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CONNECTOR SPNL POSTED SCREW SM VERTEX SEL,SUP-2630683,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
GRAFT HUM TISS DERMACELL POROUS 1.75X1.75CM 3SQCM,SUP-2909323,CDM,Q4122,HCPCS,0636,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SPRAY ENDODONTIC FORMOCRESOL 1 OZ,SUP-2322059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.79,272.86,,,,,,,,,,,,,
CATHETER PET TI SGL LUMN PRT W/ 6.5FR DETACHED SIL AND,SUP-2169588,CDM,C1788,HCPCS,0278,RC,,,,both,,,1261.12,819.73,,,,,,,,,,,,,
PLATE BONE L198MM 16 HOLE RIGHT LTRL DST PRRTCLR FBLR STNLSS,SUP-2494903,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.00,1385.80,,,,,,,,,,,,,
PLATE BNE UPPER SYMPHYSIS 2.3 MM FRAC SMRT TI LEVEL 1,SUP-2462430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1614.68,1049.54,,,,,,,,,,,,,
PIN FIX DIA4MM FOR FEM HD REM SCHNZ,SUP-2304385,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
JOINT TOE SUBTALAR 14 MM MBA,SUP-2609514,CDM,C1776,CPT,0278,RC,,,,both,,,6941.63,4512.06,,,,,,,,,,,,,
APPLIER INT CLP LAP SM 5 MMX31 CM YEL DS,SUP-2850608,CDM,C1889,HCPCS,0278,RC,,,,both,,,3175.29,2063.94,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CHARGER L 135 CM BALLOON L 200 MM DIA 3,SUP-2140057,CDM,C1725,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
COIL EMB DETACHABLE STD 10 MMX35 CM FRAME COMPLX RUBY,SUP-2323650,CDM,C1889,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 25 CM DIA 9 FR DIL PROTRUDING,SUP-2385199,CDM,C1894,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
INSERT BONE SPNL IMPLANTXPANSE R SM 20 MM LX5 MM WX8 MM H,SUP-2294191,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
BRACE WLK SM M GRY LO PROF ANK LEG ROCK SOLE 5 LOOP LCK STRP,SUP-2334818,CDM,L4361,HCPCS,0274,RC,,,,both,,,171.13,111.23,,,,,,,,,,,,,
PLATE BONE L142MM 6 H RT MEDL DSTL TIB TIM LCK COMPR FOR,SUP-2137059,CDM,C1713,HCPCS,0278,RC,,,,both,,,4608.74,2995.68,,,,,,,,,,,,,
INCOBOTULINUMTOXINA 200 UNITS IM SOLR,RX-132854,CDM,J0588,HCPCS,0636,RC,00259-1620-01,NDC,,both,1,UN,3014.90,1959.68,,,,,,,,,,,,,
PAD PWR,SUP-2162146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.40,381.81,,,,,,,,,,,,,
PLATE BNE 20 H NONSTERILE BILAT S STL NAR CRV LOK COMPR FOR,SUP-2178051,CDM,C1713,HCPCS,0278,RC,,,,both,,,3028.03,1968.22,,,,,,,,,,,,,
STENT PERIPH ZILVER PTX L 40 MM DIA 8 MM CATH L 125 CM SHTH,SUP-2170408,CDM,C1874,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
DISPOSABLE KIT FOR DX SWIVELOCK 4.75 MM,SUP-2815353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 6.5MM KNOTLESS DT WITH NO2 HI-FI CROS,SUP-2824880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
STEM HUM PRSS FT SHLDR PART,SUP-2379209,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
CAGE SPNL LORDTC 7 DEG 16X13X8 MM CERV INTBDY TI CASCADIA,SUP-2520140,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
WALKER PT M DIAB,SUP-2276716,CDM,L4387,HCPCS,0274,RC,,,,both,,,242.66,157.73,,,,,,,,,,,,,
BURR SURG 1MM DIA HD MIC CARBIDE SM BNE RND FLUTEX6 MICROPOW,SUP-2605577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,143.59,93.33,,,,,,,,,,,,,
DEVICE FIX 55 MM STRL ENDOBUTTON CL BTB,SUP-2848581,CDM,C1713,HCPCS,0278,RC,,,,both,,,985.80,640.77,,,,,,,,,,,,,
HC Stress Echo W Contrast,PX-4839335000,CDM,C8928,HCPCS,0483,RC,,,,outpatient,,,1944.00,1263.60,,,,,,,,,,,,,
IMPLANT HUM TISS H 10 MM SUBTALAR PRO-SPEC WDG,SUP-2933226,CDM,C1762,CPT,0278,RC,,,,both,,,4836.20,3143.53,,,,,,,,,,,,,
CATHETER PICC L55CM OD5FR KT SGL LUMN NRS FULL TY W/,SUP-2125621,CDM,C1751,HCPCS,0278,RC,,,,both,,,677.30,440.24,,,,,,,,,,,,,
LENS INTOCU +21.5 DIOPT L13.5MM DIA6MM AC D5.2MM 5DEG UV,SUP-2247690,CDM,V2632,HCPCS,0276,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
SCREW BNE L 130 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2932197,CDM,C1713,HCPCS,0278,RC,,,,both,,,181.84,118.20,,,,,,,,,,,,,
GUIDEWIRE ORTH L400MM DIA1.8MM S STL OLV DRL PNT RINGFIX,SUP-2372158,CDM,C1769,HCPCS,0272,RC,,,,both,,,984.70,640.05,,,,,,,,,,,,,
RELOAD STPL L60MM 3X25MM OPN 1MM CLSR WHT TI NONABSORBABLE,SUP-2283039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.23,303.05,,,,,,,,,,,,,
DRAIN SURG L49IN DIA1/8IN 10IN H SIL W/O TRCR END PERF,SUP-2127115,CDM,C1729,HCPCS,0272,RC,,,,both,,,13.03,8.47,,,,,,,,,,,,,
BLADE RETRACTOR MCCULLOCH NAR 30 MM MUSCLE TI,SUP-2489447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.91,230.69,,,,,,,,,,,,,
PHYTONADIONE 10 MG/ML IJ SOLN,RX-11023,CDM,J3430,HCPCS,0636,RC,69097-0708-31,NDC,,both,0.2,ML,54.10,35.16,,,,,,,,,,,,,
NAIL IM L260MM DIA10MM ST AQUA L/R DST FEM TI LOK CANN DYN,SUP-2191737,CDM,C1713,HCPCS,0278,RC,,,,both,,,5527.06,3592.59,,,,,,,,,,,,,
TIRE SCLER OD7MM ID2.5MM SIL CNVX SYMMETRICAL STYL,SUP-2213479,CDM,L8610,HCPCS,0278,RC,,,,both,,,70.96,46.12,,,,,,,,,,,,,
HC So Assay of Psa Total,PX-3018415366,CDM,84153,CPT,0301,RC,,,,inpatient,,,338.00,219.70,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.3MM CORT CRANIOMAXILLOFACIAL SIL TI,SUP-2189063,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.66,216.88,,,,,,,,,,,,,
KIT CATHETER PICC LN 2 LUMN,SUP-2384048,CDM,C1751,HCPCS,0278,RC,,,,both,,,177.16,115.15,,,,,,,,,,,,,
MESH HERN RND 15 CM OPTIMIZED COMP PARIETEX,SUP-2174712,CDM,C1781,HCPCS,0278,RC,,,,both,,,1594.84,1036.65,,,,,,,,,,,,,
GRAFT VASC 30 MMX15 CM 38X30 MM 10 MM AORT CLLGN CARDIOROOT,SUP-2471281,CDM,C1768,CPT,0278,RC,,,,both,,,6586.09,4280.96,,,,,,,,,,,,,
SCREW BNE CANN 2X48 MM DIGITAL FUSION TI CAPTURE,SUP-2609565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1214.49,789.42,,,,,,,,,,,,,
SHEATH VASC ACCS WATCHMAN L 75 CM DIA14 FR PTFE PEBAX SINGLE,SUP-2141817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE L163MM 8 H R MED DST HUM S STL VAR ANG FOR,SUP-2177596,CDM,C1713,HCPCS,0278,RC,,,,both,,,4039.64,2625.77,,,,,,,,,,,,,
COMPONENT THMB MOD 2+ 13 MM HD,SUP-2137781,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
KIT CLEANING EARTIP ADAPTER SANIBEL,SUP-2719739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11.93,7.75,,,,,,,,,,,,,
PLATE BNE DIA13 MM THK 0.5 MM SCREW DIA1.7 MM MAXILLOFCL,SUP-2909529,CDM,C1713,HCPCS,0278,RC,,,,both,,,2099.44,1364.64,,,,,,,,,,,,,
COIL EMB L15CM OD5MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305171,CDM,C1889,HCPCS,0278,RC,,,,both,,,4647.20,3020.68,,,,,,,,,,,,,
CATHETER GUID HEARTRAIL III L 100 CM 6 FR IL3.75 2 SIDE H,SUP-2522834,CDM,C1887,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HC Inj Anesth Celiac Plexus,PX-3616453000,CDM,64530,CPT,0361,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
ANCHOR SUTURE 6.5 MM 2 SUTURE W/ NDL BIOSTEON INTRALINE,SUP-2608441,CDM,C1713,HCPCS,0278,RC,,,,both,,,1094.48,711.41,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ARCH N REMOVABLE ATTCH TO SHOE,SUP-2435707,CDM,L3070,HCPCS,0274,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
PLATE 3.5MM TI CURVED NARROW LCP 12 HOLE-STERILE,SUP-2546919,CDM,C1713,HCPCS,0278,RC,,,,both,,,2326.52,1512.24,,,,,,,,,,,,,
LEAD PACE ATTAIN STARFIX L 88 CM DIA 5.3 FR POLYUR INSUL,SUP-2278327,CDM,C1900,HCPCS,0275,RC,,,,both,,,5392.95,3505.42,,,,,,,,,,,,,
TRUELOK RNG FIX SYS FT PLT EXTN 7-HOLE,SUP-2316201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.15,360.85,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 56 MM DIA16 MM SHTH 16 FR SS,SUP-2170645,CDM,C1874,HCPCS,0278,RC,,,,both,,,9686.90,6296.48,,,,,,,,,,,,,
CATHETER DLYS L61CM INSRT L44CM RADPQ DISP PRECIS,SUP-2174247,CDM,C1750,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
COMPONENT TIB SZ 1 RT FIX CEM GMK,SUP-2267562,CDM,C1776,CPT,0278,RC,,,,both,,,4279.07,2781.40,,,,,,,,,,,,,
BLADE SAW OSC OXFORD STRYKR 6 HUB,SUP-2136846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SCREW BNE L28MM OD4.5MM STD CORT ST N LOK,SUP-2342653,CDM,C1713,HCPCS,0278,RC,,,,both,,,26.28,17.08,,,,,,,,,,,,,
PIN CLAMP 105MM,SUP-2494702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2059.56,1338.71,,,,,,,,,,,,,
SCREW ST 50MM 2.4MM CRTX,SUP-2417892,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.59,105.68,,,,,,,,,,,,,
COMPONENT FEM SZ 00 UNIV POST STBL REV CEM STEM MOD UNISX,SUP-2209328,CDM,C1776,CPT,0278,RC,,,,both,,,871.66,566.58,,,,,,,,,,,,,
PLATE BNE W22XL66MM STD 6X4 H NONSTERILE L DST RAD VOLAR TI,SUP-2180849,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.80,1630.72,,,,,,,,,,,,,
DIANEAL PD-2/4.25% DEXTROSE 485 MOSM/L IP SOLN,RX-15436,CDM,2580000003,HCPCS,0258,RC,00941-0415-07,NDC,,both,1000,ML,57.50,37.37,,,,,,,,,,,,,
SPACER SPNL W14XH32MM D12MM 6DEG VERT BODY REPL HAWKEYE,SUP-2164232,CDM,C1889,HCPCS,0278,RC,,,,both,,,15960.62,10374.40,,,,,,,,,,,,,
STEM FEM HIP PRSS FIT REV LT 13.5MM DIA 250MM LEN PRECEDENT,SUP-2211522,CDM,C1776,CPT,0278,RC,,,,both,,,18511.87,12032.72,,,,,,,,,,,,,
GRAFT BNE SUB 9 -10MM 35-45MM BTB PRESHAPED,SUP-2335537,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
NAIL IM LENGTHENING FOR TAA0960-F-220 SYS NS FITBONE TAA LTX,SUP-2875094,CDM,C1713,HCPCS,0278,RC,,,,both,,,70775.60,46004.14,,,,,,,,,,,,,
GRAFT BIO TISS MESH 16X8 CM MIROMATRIX MIROMESH,SUP-2115023,CDM,C1781,HCPCS,0278,RC,,,,both,,,11342.18,7372.42,,,,,,,,,,,,,
TROCAR TIP NIT GWIRE 320MM,SUP-2114088,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
PLATE BNE L 137 MM SCREW DIA 3.5 MM 7 H SS PROX HUM STR STRL,SUP-2933110,CDM,C1713,HCPCS,0278,RC,,,,both,,,7300.50,4745.32,,,,,,,,,,,,,
INSERTER SURG CRV FLX RVS STRL FAST-FIX LTX,SUP-2880224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1711.14,1112.24,,,,,,,,,,,,,
HEAD FEM DIA28MM NK L+0MM STD CO CHROM V40 TAPR PRI LFIT 62645128] STRYKER CORP],SUP-2364465,CDM,C1776,CPT,0278,RC,,,,both,,,1046.25,680.06,,,,,,,,,,,,,
PLATE BNE L301MM 20 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185662,CDM,C1713,HCPCS,0278,RC,,,,both,,,4586.44,2981.19,,,,,,,,,,,,,
CATHETER INFUSION PMP 4 ML/HR 2X2.5 IN 275 CC,SUP-2361464,CDM,C1751,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
BASEPLATE GLENOID HALF AUGMENT 25 DEGREE 2+ MM 28 MM OBLIQUE,SUP-2836575,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
HC Veeg by Tech Ea Incr 12-26 Hr Unmonitored,PX-7409571400,CDM,95714,CPT,0740,RC,,,,both,,,2592.00,1684.80,,,,,,,,,,,,,
BUR SURG MATCHSTICK LNG 3 MM FLUT FOR HD/HD-G1,SUP-2848171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,397.96,258.67,,,,,,,,,,,,,
GRAFT HUM TISS DISC 17 MM SZ 2 SQCM AMNION-CHORION-AMNION,SUP-2909327,CDM,Q4137,HCPCS,0636,RC,,,,both,,,2109.61,1371.25,,,,,,,,,,,,,
KNEE K1 TOT HEMI STD CEM IMPL CAPPED K1 SN,SUP-2431877,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
RESURFACING CAGE 30MM,SUP-2512433,CDM,C1776,CPT,0278,RC,,,,both,,,1694.34,1101.32,,,,,,,,,,,,,
POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN,RX-149327,CDM,2500000003,HCPCS,0250,RC,00409-7295-01,NDC,,both,15,ML,85.10,55.31,,,,,,,,,,,,,
REPLACEMENT PD F VISTA CERV CLLR ADLT,SUP-2196894,CDM,L0120,HCPCS,0274,RC,,,,both,,,52.19,33.92,,,,,,,,,,,,,
IONOMER GLASS VITREBOND LIQUID 6.4G,SUP-2714083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.67,418.39,,,,,,,,,,,,,
CATHETER ETER URET 12FR L70CM SHFT 7FR WVN CONE TIP REUSE,SUP-2126137,CDM,C1758,HCPCS,0278,RC,,,,both,,,253.77,164.95,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM OD20FR TRACHEOESOPHAGEAL INDWL L FLNG,SUP-2242406,CDM,L8509,HCPCS,0274,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
BASKET SPEC RETRV STONE 1.3 FRX90 CM THMB WHL SM OPTIFLEX,SUP-2487951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,735.29,477.94,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 35 WITH SHUNT ASSISTANT AND CONTROL RESE,SUP-2821860,CDM,C1889,HCPCS,0278,RC,,,,both,,,9775.61,6354.15,,,,,,,,,,,,,
STENT NEURO ENTRP 2 L 30MM 4FR MICROCATHETER 0.021IN NO DSTL,SUP-2498179,CDM,C1876,HCPCS,0278,RC,,,,both,,,28918.83,18797.24,,,,,,,,,,,,,
HC 2-D-Echo-Lmt,PX-4839330800,CDM,93308,CPT,0483,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BONE L45MM THK1.6MM 14DEG 7 H LT 1ST,SUP-2137079,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.15,1228.60,,,,,,,,,,,,,
SCREW INTRF L35MM,SUP-2414760,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HEAD FEM SM 12/14 28 MM,SUP-2440579,CDM,C1776,CPT,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X103 MM 6 HOLE SS DCP,SUP-2569174,CDM,C1713,HCPCS,0278,RC,,,,both,,,355.76,231.24,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 7 FRX26.5 CM 3L STD,SUP-2759919,CDM,C1751,HCPCS,0278,RC,,,,both,,,367.00,238.55,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.6X0.5 MM 2 HOLE TITANIUM NON STERILE L,SUP-2838351,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
CATHETER EMB NOVASIL L 40 CM DIA2 FR BALLOON DIA 4 MM 0.05,SUP-2424165,CDM,C1757,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
ANCHOR SUTURE 5.5 MM W/ 1MM HI-FI RIBBON ARGO KNOTLESS,SUP-2846779,CDM,C1713,HCPCS,0278,RC,,,,both,,,2347.97,1526.18,,,,,,,,,,,,,
HC Rep Lac Smp Not Face <2.5cm,PX-4501200100,CDM,12001,CPT,0450,RC,,,,inpatient,,,421.00,273.65,,,,,,,,,,,,,
INSERT TIB SZ 2 THK12MM STD R KNEE POLYETH CRUCE RET PRI,SUP-2304696,CDM,C1776,CPT,0278,RC,,,,both,,,3067.78,1994.06,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PUNCTUA W 6.17 X H 7.95 CM D 0.99 CM 32.5,SUP-2149258,CDM,C1882,HCPCS,0275,RC,,,,both,,,52158.54,33903.05,,,,,,,,,,,,,
NEEDLE ENDOSCP SPNL 0 DEG 18 MMX25 CM NEURO W/O BITE,SUP-2768605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,491.60,319.54,,,,,,,,,,,,,
PLATE BNE L87MM THK3.8MM 5 H BILAT S STL NAR DYN COMPR FOR,SUP-2185205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.40,722.41,,,,,,,,,,,,,
"HC So Transferrin, Carbohydrate Dfct",PX-3018237366,CDM,82373,CPT,0301,RC,,,,outpatient,,,146.00,94.90,,,,,,,,,,,,,
SLING GYN ANTR PELV MESH RECON TRNSVAG POLYPR PROLIFT,SUP-2219783,CDM,C1781,HCPCS,0278,RC,,,,both,,,5711.66,3712.58,,,,,,,,,,,,,
KIT ENOFIX SYNDESMOSIS REPAIR,SUP-2878958,CDM,C1713,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
DEXMEDETOMIDINE HCL 1000 MCG/10ML IV SOLN,RX-135710,CDM,2500000003,HCPCS,0250,RC,44567-0601-04,NDC,,both,10,ML,766.10,497.96,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 6CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2674040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.29,265.39,,,,,,,,,,,,,
PLATE BNE LAPIDUS LT DORS MEDL STRATUM,SUP-2459144,CDM,C1713,HCPCS,0278,RC,,,,both,,,5627.51,3657.88,,,,,,,,,,,,,
PLUG BONE DIA12X16MM POLY W/ DISP INSRTR ALLEN,SUP-2203668,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.48,209.61,,,,,,,,,,,,,
WIRE ORTH TOT FT SYS DISP L100MM OD1.1MM K,SUP-2243135,CDM,C1713,HCPCS,0278,RC,,,,both,,,93.98,61.09,,,,,,,,,,,,,
BI MENTUM PFR CEMENTED CUP 55MM,SUP-2540599,CDM,C1776,CPT,0278,RC,,,,both,,,5351.82,3478.68,,,,,,,,,,,,,
HGH DMD HP SYS(LG HD,SUP-2212057,CDM,C1776,CPT,0278,RC,,,,both,,,13186.87,8571.47,,,,,,,,,,,,,
SCALPEL SURG CRV 10 MM FOR HRD TISS REMOVAL SIL DISP,SUP-2305939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1257.57,817.42,,,,,,,,,,,,,
KIT CATH L11.5CM DIA9FR CTRL VEN POLYUR ANTIMIC COAT DBL,SUP-2383305,CDM,C1751,HCPCS,0278,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
PLATE BNE L84MM 4 H S STL T LOK COMPR FOR 4.5/5MM SCR,SUP-2185753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1627.96,1058.17,,,,,,,,,,,,,
NEEDLE INTRO 17GA L11.8CM BNE MAR BX OPT ECHOGENIC COAX MCXS1815BP] ARGON MEDICAL DEVICES INC],SUP-2120167,CDM,C1894,HCPCS,0272,RC,,,,both,,,62.74,40.78,,,,,,,,,,,,,
STENT URET 6FR L26CM 0.038IN 360DEG HYDRPHLC SOF-CURL,SUP-2313809,CDM,C2617,HCPCS,0278,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 180CM 0.025IN TIP L 3 CM ANGLED,SUP-2385606,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.52,130.34,,,,,,,,,,,,,
PLATE BNE L 179.25 MM SCREW DIA2 MM 9 H LG TI RAMUS ANGLED,SUP-2936440,CDM,C1713,HCPCS,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
PLATE BONE CALCANEUS UNIVERSAL SLIDE TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878176,CDM,C1713,HCPCS,0278,RC,,,,both,,,7002.20,4551.43,,,,,,,,,,,,,
SYSTEM SKIN CLSR 60CM 2-OCTYL CYNOACRLT W/ MESH DISPNS,SUP-2218877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.47,301.91,,,,,,,,,,,,,
CATHETER CV JACC 4.5 FRX35 CM SINGLE LUMEN PRESSURE INJ ADV,SUP-2763380,CDM,C1751,HCPCS,0278,RC,,,,both,,,642.66,417.73,,,,,,,,,,,,,
GUAIFENESIN 100 MG/5ML PO LIQD,RX-13748,CDM,2500000003,HCPCS,0250,RC,81033-0102-05,NDC,,both,5,ML,7.90,5.13,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1173108D4,SUP-2632788,CDM,C1751,HCPCS,0278,RC,,,,both,,,799.63,519.76,,,,,,,,,,,,,
SYSTEM BNE FIX 18MM LC B CP LAPIDUS W PLT SCR FOR FRSH FRAC,SUP-2175174,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
BLADE ARTHRO 4MM 60DEG DBL EDGE HOE TIP CRV SHRP ALL ARND S,SUP-2570496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,54.04,35.13,,,,,,,,,,,,,
HC Arthrogram Knee Flouro X-Ray,PX-3227358000,CDM,73580,CPT,0322,RC,,,,both,,,666.00,432.90,,,,,,,,,,,,,
BOOT CAST SM FOR WMN 55 8 SQ TOE DSGN UNIV FOREFOOT CLSR,SUP-2176232,CDM,L4386,HCPCS,0274,RC,,,,both,,,27.38,17.80,,,,,,,,,,,,,
COMPONENT TIB UNI SM 15 MM LL/RM KNEE ONLAY GEN,SUP-2344217,CDM,C1776,CPT,0278,RC,,,,both,,,5133.12,3336.53,,,,,,,,,,,,,
BONE CEMENT MIXING KIT KYPHOPLASTY,SUP-2765275,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
CLAMP EXT FIX QUIK 6MM TO 4MM,SUP-2342954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3167.63,2058.96,,,,,,,,,,,,,
SCREW BONE 4.0X100 MM TIBIAXYS,SUP-2243001,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
HC Eval of Speech Production,PX-4449252200,CDM,92522,CPT,0444,RC,,,,outpatient,,,693.00,450.45,,,,,,,,,,,,,
GUIDEWIRE TEF COAT 038INX145CM,SUP-2294351,CDM,C1769,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
SINUS SCTN BURR ANGLD 15DGRS DMND BURR D5MM SHFT4MMX12CM 5/P,SUP-2574175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.53,471.59,,,,,,,,,,,,,
BLADE SURG SGL PK DISPOSABLE FOR PLNTR FASCIITIS,SUP-2399187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
MATRIX DERM ACELLULAR DERMAMTRX THCK 0.8-1.7,SUP-2306905,CDM,C1762,CPT,0278,RC,,,,both,,,206.96,134.52,,,,,,,,,,,,,
MILL BNE BWL W/ 2 BLDE DISP LEGEND MIDAS REX,SUP-2284675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER INTVENT COR CTO CROSSING CROSSBOSS,SUP-2147016,CDM,C1725,HCPCS,0272,RC,,,,both,,,5187.28,3371.73,,,,,,,,,,,,,
REAMER SURG SM GLEN AUGMENTED MGS STRL DISP VIP UNIVERS,SUP-2933959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
STAPLE BONE FIX 1.5X1.5MM A11 B8 C8 WIRE OSSTPL,SUP-2190914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
ALLOGRAFT DERMAL 10X20 CMX2.4/0.4 MM RDY TO USE ALLDERM,SUP-2469959,CDM,Q4116,HCPCS,0636,RC,,,,both,,,23377.30,15195.24,,,,,,,,,,,,,
GRAFT HUM TISS W7XL30-59MM COSTAL CART FRZN,SUP-2417976,CDM,C1762,CPT,0278,RC,,,,both,,,1568.43,1019.48,,,,,,,,,,,,,
HC So Antiepileptic Nos 1-3,PX-3018033966,CDM,G0480,CPT,0301,RC,,,,both,,,253.00,164.45,,,,,,,,,,,,,
SCREW BONE L14MM DIA2MM CORT TI ST LCK COARSE PITCH STARDRV,SUP-2189634,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.98,133.89,,,,,,,,,,,,,
CONNECTOR SPNL M SZ 7 L37-45MM STD POST LUM THOR TI SCR,SUP-2254362,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS L 75 CM BALLOON L 4 CM DIA24 MM,SUP-2127942,CDM,C1725,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
INTRODUCER SHTH 7FR L11CM CLSR FAST SET,SUP-2393094,CDM,C1894,HCPCS,0272,RC,,,,both,,,95.77,62.25,,,,,,,,,,,,,
PLATE BNE 2X22X1 MM 4 HOLE SS DCP,SUP-2569119,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
CATHETER ETER HAD 155FR L32CM 3 LUMN STR EXTN SHT TERM T 3,SUP-2269525,CDM,C1752,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
KIT THROMCTMY RED 72 L 132 CM PTFE SS NIT COIL,SUP-2880247,CDM,C1887,HCPCS,0272,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
BRACE WR CLUTCH DORS STAY VELSTRETCH WRP RT CIRC 6 1/2-8,SUP-2323980,CDM,L3906,HCPCS,0272,RC,,,,both,,,50.84,33.05,,,,,,,,,,,,,
GUIDE COR SNUS 9FR SHTH L40CM 3MM 0.035IN R SIDE DSGN W/,SUP-2303507,CDM,C1892,HCPCS,0272,RC,,,,both,,,1273.58,827.83,,,,,,,,,,,,,
CATHETER PTCA L135CM BLLN L20MM DIA6MM SHTH 6FR 0.018IN,SUP-2148517,CDM,C1725,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
STEM FEM SZ 9 L155MM DIA15MM HIP TI ALLY HA REV RESTR,SUP-2374175,CDM,C1776,CPT,0278,RC,,,,both,,,13795.90,8967.33,,,,,,,,,,,,,
RING ACET DIA36MM FOR MOD CUP REPL LCK,SUP-2503584,CDM,C1776,CPT,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
CATHETER THORACENTESIS DRY SET 8.5 FRX6 CM 15 GA EMGCY,SUP-2759991,CDM,C1729,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
WIRE GUID PRSS PRIMEWIRE LNG J TIP .014INX300CM PRESTIGE,SUP-2327227,CDM,C1769,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
RESERVOIR KIT 24 MM W/ 1 BA VENTRICULAR CATH STR ACCU-FLO,SUP-2666534,CDM,C1729,HCPCS,0272,RC,,,,both,,,1796.14,1167.49,,,,,,,,,,,,,
TUBE SUCTION COOLEY 12 IN 6 MM TIP VASC SS,SUP-2500196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.97,251.53,,,,,,,,,,,,,
CATHETER THROMCTMY RED 43 L 138 CM PTFE SS NIT COIL REDGLIDE,SUP-2880243,CDM,C1887,HCPCS,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|CO,both,,,144.00,93.60,,,,,,,,,,,,,
SCREW BNE L150MM DIA4.5MM STD CORT S STL HEX SOCK,SUP-2184421,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.29,154.89,,,,,,,,,,,,,
COMPONENT FEM 0 LT POR ASYM POST STBL OPTETRAK HI FLX,SUP-2223216,CDM,C1776,CPT,0278,RC,,,,both,,,12377.88,8045.62,,,,,,,,,,,,,
GRAFT DERMAL ULTRA THCK 4X1 CM ACELLULAR DERM DERMAMATRIX,SUP-2306985,CDM,C1762,CPT,0278,RC,,,,both,,,492.51,320.13,,,,,,,,,,,,,
CATHETER GUID 3DRC 0.070 INX6 FRX100 CM VISTA BRT TIP,SUP-2422843,CDM,C1887,HCPCS,0272,RC,,,,both,,,474.20,308.23,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L 115 CM 7/15 FR D,SUP-2248625,CDM,C1732,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
LEVEL NEURO ST KIT CRNTMY FLAP 25 975 04 71 6 01 302 13 71 3,SUP-2677536,CDM,C1713,HCPCS,0278,RC,,,,both,,,2611.44,1697.44,,,,,,,,,,,,,
"HC Acetone, Serum",PX-3078200900,CDM,82009,CPT,0307,RC,,,,inpatient,,,275.00,178.75,,,,,,,,,,,,,
WIRE EXT FIX DIA1.2 MM SMTH FOR SM BNE FIX STRL DISP TSF,SUP-2933519,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.94,233.96,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB GUIDEPIN K3AARTHREX] ARTHREX INC],SUP-2123481,CDM,C1776,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HC Cardiac Stress Test,PX-4829301700,CDM,93017,CPT,0482,RC,,,,both,,,1474.00,958.10,,,,,,,,,,,,,
BIT DRL DIA14MM CANN FLX FOR L QUIK CPL,SUP-2178961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2601.74,1691.13,,,,,,,,,,,,,
OSSEOFLEX SB STRAIGHT BLLN 10GA4ML,SUP-2677175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
PLATE BNE L26MM L DORS DST RAD CONG,SUP-2107766,CDM,C1713,HCPCS,0278,RC,,,,both,,,1450.68,942.94,,,,,,,,,,,,,
SUPPORT ORTHOT SACROILIAC PELV CUST FLX STRP PREFABRICATED,SUP-2435551,CDM,L0621,HCPCS,0274,RC,,,,both,,,244.10,158.66,,,,,,,,,,,,,
GRAFT BNE BLOCK 6.25X2X0.4 CM 10 CC PLATFORM CM,SUP-2691581,CDM,C1713,HCPCS,0278,RC,,,,both,,,6232.90,4051.38,,,,,,,,,,,,,
CONNECTOR ST 360 SLV 12-18MM,SUP-2205091,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|KX|CO,both,,,144.00,93.60,,,,,,,,,,,,,
"HC So Folic Acid, RBC",PX-3018274766,CDM,82747,CPT,0301,RC,,,,inpatient,,,108.00,70.20,,,,,,,,,,,,,
CAPSAICIN 0.025 % EX CREA,RX-1350,CDM,6370000000,HCPCS,0637,RC,00536-2525-25,NDC,,both,60,GR,31.40,20.41,,,,,,,,,,,,,
PLATE BNE L211MM 14 H ST R LAT PROX TIB S STL LOK COMPR LO,SUP-2185623,CDM,C1713,HCPCS,0278,RC,,,,both,,,4414.78,2869.61,,,,,,,,,,,,,
SHEATH VASC L12CM OD9FR 0.038IN GWIRE W/ LUER LCK HUB,SUP-2355398,CDM,C1894,HCPCS,0272,RC,,,,both,,,66.73,43.37,,,,,,,,,,,,,
SPACER SPNL W28XH10MM 6DEG NAR TI ANTR INTBDY FUS LORDTC,SUP-2414740,CDM,C1713,HCPCS,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
SCREW SPNL TULIP HD FOR 5.5MM ROD SPHERX PPS,SUP-2311520,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE W8XL48MM THK3.3MM 6 H ST BILAT PELV S STL,SUP-2186233,CDM,C1713,HCPCS,0278,RC,,,,both,,,1148.61,746.60,,,,,,,,,,,,,
SCREW BNE LCK 5X26 MM LP FOR IM NAIL TI NS RFN-ADVANCED,SUP-2758088,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.83,431.49,,,,,,,,,,,,,
NAIL IM HUM UNIV 7X180 MM STRL VERSANAIL LTX,SUP-2861168,CDM,C1713,HCPCS,0278,RC,,,,both,,,5860.37,3809.24,,,,,,,,,,,,,
GRAFT BNE FIBER 15 CC DBM CORTICAL PUREBONE,SUP-2424609,CDM,C1713,HCPCS,0278,RC,,,,both,,,5060.49,3289.32,,,,,,,,,,,,,
NAIL IM L150MM DIA7.5MM ST HUM TI CANN LOK PROX BEND S2,SUP-2192537,CDM,C1713,HCPCS,0278,RC,,,,both,,,5186.34,3371.12,,,,,,,,,,,,,
HEAD FEM DIA 36 MM OFFSET 0 MM COCR 12/14 TAPR STRL FRDM,SUP-2887428,CDM,C1776,CPT,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
STEM FEM PRSS FT HIP BPLR/UPLR CEM,SUP-2249581,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
PLATE BONE DOUBLE ANGLE THICK 2 MM MANDIBLE PATIENT SPECIFIC,SUP-2838605,CDM,C1713,HCPCS,0278,RC,,,,both,,,29796.09,19367.46,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.035IN S STL COR SLX STEER SFT,SUP-2157313,CDM,C1769,HCPCS,0272,RC,,,,both,,,261.88,170.22,,,,,,,,,,,,,
PLATE BNE 2 HK 3.5/4X116 MM 7 HOLE SS,SUP-2569191,CDM,C1713,HCPCS,0278,RC,,,,both,,,493.92,321.05,,,,,,,,,,,,,
PROPOFOL 1000 MG/100ML IV EMUL,RX-133092,CDM,J2704,HCPCS,0636,RC,16714-0690-01,NDC,,both,100,ML,124.20,80.73,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM DIA 0.035 IN PTFE PERIPH,SUP-2301911,CDM,C1769,HCPCS,0272,RC,,,,both,,,102.05,66.33,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR LACER N MOLD,SUP-2435677,CDM,L2530,HCPCS,0274,RC,,,,both,,,678.96,441.32,,,,,,,,,,,,,
ANCHOR SUT 51MM NO2 GRN QUICKWHIP,SUP-2277455,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CATHETER HD SET 0.035 INX60 CM 12 FRX13 CM DL DRP YOU-BEND,SUP-2763038,CDM,C1752,HCPCS,0278,RC,,,,both,,,198.95,129.32,,,,,,,,,,,,,
GRAFT BONE 0.1-4MM 120ML CANC CRUSH CHIP FRZ DRY,SUP-2294028,CDM,C1713,HCPCS,0278,RC,,,,both,,,5017.72,3261.52,,,,,,,,,,,,,
COIL EMB L10CM DIA4MM 0.02IN PERIPH COMPLX STD FRME,SUP-2323655,CDM,C1889,HCPCS,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 30 MM DIA24 MM SHTH 16 FR SS,SUP-2168963,CDM,C1874,HCPCS,0278,RC,,,,both,,,5922.04,3849.33,,,,,,,,,,,,,
KIT PROC SM NS DISP PVT GRDIAN,SUP-2906451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
SCREW BONE L45MM DIA3.5MM CORT VOLAR S ST NONCANNULATED LCK,SUP-2348539,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.38,174.45,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 115 CM OD 0.084 IN ID 0.072 IN DSTL 8,SUP-2522811,CDM,C1887,HCPCS,0272,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
TUBE CALIB REALIZE GAST ASYMMETRICAL,SUP-2219866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
KIT SUT FIBERWIRE FOR LARGER COMPLX SFT TISS APPROXIMATION,SUP-2122089,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
COMPONENT SPNL ASMBLY 6 MM PRIMALOK SP,SUP-2319810,CDM,C1776,CPT,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 4.5X24 MM HDLSS NS MONSTER,SUP-2742611,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.48,665.26,,,,,,,,,,,,,
MEGESTROL ACETATE 40 MG PO TABS,RX-4871,CDM,6370000000,HCPCS,0637,RC,64380-0159-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT CONDYLE SCREW DIA2.4 MM LT LCK ADDON RECON SYS NS,SUP-2936480,CDM,C1713,HCPCS,0278,RC,,,,both,,,4414.84,2869.65,,,,,,,,,,,,,
SYSTEM OCCL DEL SHTH 7FR L80CM 180DEG POLYMER PTFE REINF LO,SUP-2355730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
PLATE BNE THK15MM M 6 H TI LOK FOR 27MM SCR 2MM MINI SYS,SUP-2262963,CDM,C1713,HCPCS,0278,RC,,,,both,,,1630.48,1059.81,,,,,,,,,,,,,
KIT HEMO DYLS OR HD 13FR L12.5CM CVD EXTN LEG SH TERM 3 LUMN,SUP-2126514,CDM,C1752,HCPCS,0278,RC,,,,both,,,853.92,555.05,,,,,,,,,,,,,
TROCAR ENDOSCP L102MM DIA10MM STD CANN BLNT TIP W/ FIX BLLN,SUP-2283312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.00,412.75,,,,,,,,,,,,,
TUBING CNTRST DEL EXCITE L 100 CM 2.59CC NYL POLYUR AIRLESS,SUP-2302640,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.28,12.53,,,,,,,,,,,,,
PLATE BNE VOLAR LT DORS DSTL RADIAL 2 HOLE OPTILOCK,SUP-2522086,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
SET INTRO 10GM MRI PRB VAC ASST BRST BX ENCOR,SUP-2126856,CDM,C1894,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
STAPLER INT INTRALUMINAL 28 MM 35 MM TILT TOP EEA DST SER,SUP-2283245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,896.00,582.40,,,,,,,,,,,,,
MESH SPNL W22XH90XL28MM TI OVL,SUP-2254373,CDM,C1713,HCPCS,0278,RC,,,,both,,,18858.84,12258.25,,,,,,,,,,,,,
WIRE FIX L102MM OD1.1MM S STL SMOOTH TRCR PT TWO END SHRP,SUP-2304018,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.56,8.81,,,,,,,,,,,,,
STEM RAD L30X19MM DIA8MM NK OFFSET 4MM TI ALIGN,SUP-2340147,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5 FR GUIDEWIRE L 60CM DIA 0.018 IN,SUP-2383166,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.31,67.15,,,,,,,,,,,,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,6370000000,HCPCS,0637,RC,61314-0143-05,NDC,,both,5,ML,45.00,29.25,,,,,,,,,,,,,
PACEMAKER CRD 2 CHMBR 44X52X7 MM 28.7 GM PULSAR MAX,SUP-2148603,CDM,C1785,HCPCS,0275,RC,,,,both,,,16321.72,10609.12,,,,,,,,,,,,,
IMPLANT UROLOGICAL MESH ELEV POST INTEXEN LP,SUP-2140248,CDM,C1781,HCPCS,0278,RC,,,,both,,,6249.39,4062.10,,,,,,,,,,,,,
INSERT NDLHLDR SINGLE ACT 5 MMX13 IN RT 3 PC CRV CARB-BITE,SUP-2472874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1466.91,953.49,,,,,,,,,,,,,
KIT INFUS PMP 400ML 5ML/HR SOAK CATH L5IN N NARC ON-Q,SUP-2236837,CDM,C9804,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
ROD EXT FIX L300MM S STL THRD TELSCP ORIG CIR FOR TAY SPAT,SUP-2342306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.18,267.27,,,,,,,,,,,,,
STAPLER INT W4MM BLU TI FOR RELD HERN MESH FIX MULTFI ENDO,SUP-2283144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,123.68,80.39,,,,,,,,,,,,,
STENT COR 8MM 2.25MM PACLITAXEL ELUT COAT CO CHROM ALLY,SUP-2105591,CDM,C1874,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PACEMAKER CRD SINGLE CHAMBERED CLOSED LOOP EVIA SR-T,SUP-2138087,CDM,C1786,HCPCS,0275,RC,,,,both,,,15574.40,10123.36,,,,,,,,,,,,,
GRAFT HUM TISS W6XL10CM PLCNTA AMNIO MEM EPIXL,SUP-2305763,CDM,Q4186,HCPCS,0636,RC,,,,both,,,14020.13,9113.08,,,,,,,,,,,,,
STEM FEM L9IN DIA13.5MM PLATFRM 2.25CM STD 12/14 TAPR L HIP,SUP-2252184,CDM,C1776,CPT,0278,RC,,,,both,,,20628.54,13408.55,,,,,,,,,,,,,
HC So Infectious Agent Ab Quant,PX-3028631766,CDM,86317,CPT,0302,RC,,,,inpatient,,,118.00,76.70,,,,,,,,,,,,,
HC So Cytoplasmic Tech Comp,PX-3118818566,CDM,88185,CPT,0311,RC,,,,both,,,55.00,35.75,,,,,,,,,,,,,
CATHETER KIT DL 4 FR PLCMNT POWERPICC PROVENA,SUP-2126779,CDM,C1751,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PIN HALF FIX M4 L200MM THRD L40MM S STL,SUP-2242953,CDM,C1713,HCPCS,0278,RC,,,,both,,,506.58,329.28,,,,,,,,,,,,,
CATHETER DRNGE ABSC J CRV SET INCL INSRT .038IN GWIRE 2 DIL,SUP-2168139,CDM,C1729,HCPCS,0272,RC,,,,both,,,303.86,197.51,,,,,,,,,,,,,
K WIRE FIX L450MM DIA3.2MM S STL DBL SHRP TIP SMOOTH FOR,SUP-2368453,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
BIT DRL L10-24MM DIA2.4MM DISP FOR VERTEX MAX RECON SYS,SUP-2286795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.81,441.88,,,,,,,,,,,,,
LENS IOL TORIC PANOPTIX CLAREON CNWTT5 10.0D,SUP-2752034,CDM,V2788,HCPCS,0276,RC,,,,both,,,1015.00,659.75,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA12MM BLDELSS SMOOTH SL ENDOPATH,SUP-2218784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,670.70,435.95,,,,,,,,,,,,,
KIT CATHETER REV SEG W ATTCH SUTURELESS PMP CONN 2 CLLT RUL,SUP-2280046,CDM,C1755,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
FORCEPS BOWEL MTL HNDL 5MMX43CM,SUP-2261299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3915.80,2545.27,,,,,,,,,,,,,
BIT DRL DIA4MM SHT S STL FOR AG IM NAIL TRIGEN,SUP-2347047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
BLADE SHV DIA4.8MM STR SERR HEMSTAT W/ PK TECHNOLOGY FOR,SUP-2312777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.71,330.66,,,,,,,,,,,,,
KIT PICC CATH 4FR L40CM GWIRE L17.75IN 0.018IN POLYUR SGL,SUP-2384051,CDM,C1751,HCPCS,0278,RC,,,,both,,,256.91,166.99,,,,,,,,,,,,,
BOOT CAST OPN TOE 2XS 5.5X3 IN OPN HEEL PROCARE,SUP-2196779,CDM,L4387,HCPCS,0272,RC,,,,both,,,15.42,10.02,,,,,,,,,,,,,
HC Drug Screen Quantitative Tobramycin,PX-3018020000,CDM,80200,CPT,0301,RC,,,,inpatient,,,322.00,209.30,,,,,,,,,,,,,
PLATE BNE W17.5XL170MM THK5.2MM 6 H L CNDYL FEM S STL LOK,SUP-2185016,CDM,C1713,HCPCS,0278,RC,,,,both,,,4103.95,2667.57,,,,,,,,,,,,,
CATHETER URODYN 481100101] ENDOCARE INC],SUP-2217537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
CATHETER KIT 8.5 FR CV MULT LUMEN,SUP-2383955,CDM,C1751,HCPCS,0278,RC,,,,both,,,245.55,159.61,,,,,,,,,,,,,
COMPONENT KNEE FEM PT SPEC INSTRUMENT GENDER SOL,SUP-2212607,CDM,C1776,CPT,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
PLATE BNE L79MM 3 H R LAT DST FIBULAR S STL VAR ANG LOK,SUP-2177710,CDM,C1713,HCPCS,0278,RC,,,,both,,,2203.15,1432.05,,,,,,,,,,,,,
VALACYCLOVIR HCL 500 MG PO TABS,RX-13133,CDM,6370000000,HCPCS,0637,RC,63739-0077-10,NDC,,both,1,UN,6.20,4.03,,,,,,,,,,,,,
PLATE BNE 2 H MED TI ALLOY STR LCK NS LEOS,SUP-2933601,CDM,C1713,HCPCS,0278,RC,,,,both,,,2934.33,1907.31,,,,,,,,,,,,,
COLLAR CERV L H3XL20IN M DENS FOAM COT STOCK LNR,SUP-2194404,CDM,L0120,HCPCS,0274,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
NUT AND WSHR FOR SHEFFIELD STERILISATION TY SYS,SUP-2316259,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.31,152.30,,,,,,,,,,,,,
PSN REV TM TIB PERIPHERALCONE SZ LRG L,SUP-2508676,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
PLATE BNE L31MM THK1.2MM 5 H BILAT HINDFT MIDFT S STL,SUP-2186126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2057.17,1337.16,,,,,,,,,,,,,
CATHETER DEL CARR L 152 CM LG COMP HYDRPHLC 1 LUMEN VAR PK10,SUP-2933998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
WIRE ORTH THRD PART DBL SHRP TIP S STL NONSTERILE 1.6MM DIA,SUP-2316517,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.12,58.58,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ISMUS L 115 CM DIA 7 FR SPC,SUP-2248780,CDM,C1730,HCPCS,0272,RC,,,,both,,,3165.12,2057.33,,,,,,,,,,,,,
GRAFT BNE MAR L CONC,SUP-2163080,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 14 IN 12-24 IN ADJ FOAM,SUP-2194895,CDM,L1830,CPT,0272,RC,,,,both,,,34.95,22.72,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT IR 5FR 55CM 2 LUMAN RVS 3275335F,SUP-2632670,CDM,C1751,HCPCS,0278,RC,,,,both,,,282.88,183.87,,,,,,,,,,,,,
SCREW BONE L65MM THRD DIA2.4MM HD DIA3.8MM COR DIA1.6MM,SUP-2349429,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.18,483.07,,,,,,,,,,,,,
CLIP HEMSTAS 2.8 MM 155 CM 11 MM OPENING DEV STRL RESOL 360,SUP-2495512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.61,312.40,,,,,,,,,,,,,
CEMENT BNE 20 GM HI VISC RADIOPAQUE VERTAPLEX HV,SUP-2423940,CDM,C1713,HCPCS,0278,RC,,,,both,,,3268.49,2124.52,,,,,,,,,,,,,
APPLIER CLP M L8CM 1.1MM CLP CLSR SYS ANASTOCLP GC,SUP-2264244,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
INTRODUCER SET BLUE RHINO G2-MULTI PDT,SUP-2718704,CDM,C1769,HCPCS,0272,RC,,,,both,,,1559.64,1013.77,,,,,,,,,,,,,
PLATE BNE L211MM 6 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186041,CDM,C1713,HCPCS,0278,RC,,,,both,,,3868.64,2514.62,,,,,,,,,,,,,
PLATE BNE RECON 3.5X143 MM 11 HOLE W/ WIDE ANGLE STR LP NS,SUP-2799242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.42,988.92,,,,,,,,,,,,,
DEVICE FIX FULL MESH ABSORBABLE W/ ARTICULATING OPTIFIX AT,SUP-2858041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
WAND ABLAT DIA4.7MM 50DEG THRMCPL TECHNOLOGY RASP DSGN RIG,SUP-2342017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
STRIPPER SURG 550UM HOLM LASER FBR REM FBR JKT SLM LN EZ,SUP-2141787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,683.11,444.02,,,,,,,,,,,,,
PLATE BNE L 172.82 X W 8.26 MM THK 2.8 MM SCREW DIA2/2.3 MM,SUP-2936980,CDM,C1713,HCPCS,0278,RC,,,,both,,,11206.66,7284.33,,,,,,,,,,,,,
BLADE SAW KNEE 25.4MM CUT EDGE 90MM CUT DEPTH 1.47MM CUT THI,SUP-2605513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,155.81,101.28,,,,,,,,,,,,,
PROBE HAINES STYLE5,SUP-2677556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1320.12,858.08,,,,,,,,,,,,,
NAIL IM 10 MM CAPPED,SUP-2208223,CDM,C1713,HCPCS,0278,RC,,,,both,,,650.98,423.14,,,,,,,,,,,,,
CHUCK DRL QR AGC,SUP-2445376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
PACEMAKER CARD ASSURITY MRI W 50 X H 47 MM THK 6 MM 10.4 ML,SUP-2657217,CDM,C1785,HCPCS,0275,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24,RX-29272,CDM,6370000000,HCPCS,0637,RC,60687-0206-01,NDC,,both,1,UN,3.70,2.40,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 50X25X8 MM FD DEMINERALIZED CANC LIFEFLEX,SUP-2866839,CDM,C1762,CPT,0278,RC,,,,both,,,2452.03,1593.82,,,,,,,,,,,,,
FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN,RX-133093,CDM,J3010,HCPCS,0636,RC,00409-9094-22,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PROCESSOR HEARING AID SND L CHROMA BGE PONTO PRO PWR,SUP-2319884,CDM,L8691,HCPCS,0274,RC,,,,both,,,14051.50,9133.47,,,,,,,,,,,,,
SAW HAND JSPH 7 1/2NL 37MML BLADE NASAL RGHT ANGLD BNT PDGTT,SUP-2468502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.37,297.29,,,,,,,,,,,,,
DICYCLOMINE HCL 10 MG/5ML PO SOLN,RX-42119,CDM,340b,HCPCS,0637,RC,00054-0622-63,NDC,,both,5,ML,5.50,3.57,,,,,,,,,,,,,
SCREW BNE CORT HND TI L9MM OD1.2MM APTUS HEXADRIVE 4,SUP-2268009,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 7 MM RNG L 30 CM,SUP-2227613,CDM,C1768,CPT,0278,RC,,,,both,,,3149.58,2047.23,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.5-3 MM 15 CC FD CRUSH CORTICAL CANC,SUP-2743395,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
GRAFT BNE SUB SM 1ML CRYOPRESERVED VIABLE CORT CANC BNE,SUP-2264669,CDM,C1713,HCPCS,0278,RC,,,,both,,,1992.02,1294.81,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 4X20 MM STAINLESS STEEL NON STERI,SUP-2836768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,855.87,556.32,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM DIA 31 MM SHTH 22 FR THOR AORT,SUP-2396363,CDM,C1768,CPT,0278,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
SNARE ENDOSCP WIRE 6 FRX6-10 MMX120 CM VASC RETRV,SUP-2120087,CDM,C1773,HCPCS,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
SUPPORT ORTHOT FNGR CUST ADJ W/O JT FABRICATED SFT INTFACE,SUP-2435789,CDM,L3933,HCPCS,0272,RC,,,,both,,,549.78,357.36,,,,,,,,,,,,,
K WIRE FIX L6IN DIA0.045IN S STL DBL TRCR HND BMT 6PK,SUP-2412237,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
LENS INTOCU +2.0 DIOPT L13MM DIA6MM 5DEG HAPTIC ANG POST,SUP-2110621,CDM,V2632,HCPCS,0276,RC,,,,both,,,439.79,285.86,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ PROCEED 25 DEG L 300 CM DIA 0.014 IN,SUP-2893018,CDM,C1769,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
TIP CONICAL SYSTEM GRFT DEL NSTAFILL,SUP-2865330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 6 CM OD 6 FR ID 2 MM 0.035IN,SUP-2168595,CDM,C1894,HCPCS,0272,RC,,,,both,,,67.92,44.15,,,,,,,,,,,,,
STEM EXTN LIMB SALV LO BODY ELEOS CEM 10MMX100MM,SUP-2314048,CDM,C1776,CPT,0278,RC,,,,both,,,5680.26,3692.17,,,,,,,,,,,,,
INTRODUCER INFUSION PMP ACCS AX KIT INSRTN IMPELLA 5.0,SUP-2431910,CDM,C1892,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW BONE L9MM DIA1.5MM MIC CRANIOMAXILLOFACIAL TI,SUP-2262597,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.49,53.62,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM OD5-12MM PLAS BLADED BLNT TIP N THRD,SUP-2283179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.99,274.94,,,,,,,,,,,,,
HC X-Ray Exam Abdomen 2 Views,PX-3207401900,CDM,74019,CPT,0320,RC,,,,both,,,890.00,578.50,,,,,,,,,,,,,
SCREW BNE SM L6MM DIA17MM CANC CORT HND TI ST NONLOCKING,SUP-2364054,CDM,C1713,HCPCS,0278,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
STEM RADIAL MED 5.5 ULN WRST MOD COCR 1ST CHOICE,SUP-2852858,CDM,C1776,CPT,0278,RC,,,,both,,,14251.02,9263.16,,,,,,,,,,,,,
SCREW BONE L7MM OD1.5MM ST TI CORT T4 DRV VLP,SUP-2350899,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.72,178.57,,,,,,,,,,,,,
CATHETER GUID JL5 8 FRX90 CM LG LUMEN FLX SH NYL LAUNCHER,SUP-2429824,CDM,C1887,HCPCS,0272,RC,,,,both,,,91.15,59.25,,,,,,,,,,,,,
COMPONENT GLEN FIX 48 HAP CONVX MTL BK BASE ARW,SUP-2224547,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
PLATE BONE L DSTL VOLAR RAD ADAPTIVE II TRILOK 2.5,SUP-2267958,CDM,C1713,HCPCS,0278,RC,,,,both,,,4094.56,2661.46,,,,,,,,,,,,,
SPACER FEM CO CHROM MOLYBDENUM ALLOY L20MM PROX STRL,SUP-2397016,CDM,C1776,CPT,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
GUIDEWIRE ORTH L8IN,SUP-2137780,CDM,C1769,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
STAPLER INT CIR XLN X THCK 33 MM 4/4.5/5 MM TRI-STAPLE EEA,SUP-2858018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5308.70,3450.65,,,,,,,,,,,,,
DRESSING WND CARE W7XL10CM ACELLULAR FISH SKIN OMEGA3,SUP-2261686,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
TAP SURG L95MM DIA1.7MM SELF DRL,SUP-2365076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2148.55,1396.56,,,,,,,,,,,,,
SCREW CRTX FT SELF TAP HEX HD 4.5MM DIA 48MML,SUP-2342664,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.82,35.63,,,,,,,,,,,,,
CATHETER ABLAT 8FR L115CM TIP ELECTRD L4MM F-J CRV 1-4-1,SUP-2355751,CDM,C2630,CPT,0272,RC,,,,both,,,7588.12,4932.28,,,,,,,,,,,,,
CATHETER BLLN DIL 6 MMX4 CM URETH URETSCP UROFORCE,SUP-2126691,CDM,C1726,HCPCS,0272,RC,,,,both,,,972.96,632.42,,,,,,,,,,,,,
HOOK SPNL LIP LG 6.35 MM LAM NAR BLADE SS CD HORZ LEG,SUP-2288838,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
LEAD DEFIB 65CM IS-1 DF-1 CONN DURATA,SUP-2356246,CDM,C1895,HCPCS,0275,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
STEM FNGR JT SZ 3 PROX INTERPHALANGEAL SIL NONCOATED,SUP-2250680,CDM,L8630,HCPCS,0278,RC,,,,both,,,3755.44,2441.04,,,,,,,,,,,,,
RING EXT FIX CIR 5/8 140 MM SIDEKCK,SUP-2485922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
IMMOBILIZER SHLDR M PCH W8XL16.5IN UNIV TIETEX FOAM STRP,SUP-2195497,CDM,L3650,HCPCS,0274,RC,,,,both,,,15.39,10.00,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0258,RC,00264-1800-32,NDC,,both,1000,ML,229.50,149.17,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC DBM GRFT,SUP-2294009,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,GO|CO,both,,,195.00,126.75,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM GLD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189659,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.69,162.30,,,,,,,,,,,,,
TISSUE BNE 8MMX36MM CAPSTONE,SUP-2293987,CDM,C1713,HCPCS,0278,RC,,,,both,,,17298.26,11243.87,,,,,,,,,,,,,
SPONGE BCKL 4X80MM NO504 RND SIL,SUP-2213487,CDM,L8610,HCPCS,0278,RC,,,,both,,,141.61,92.05,,,,,,,,,,,,,
DRILL SURG GLEN INVERSE ANAT SHLDR,SUP-2440739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
PLATE BNE SM W11XL25MM THK3.3MM 0DEG 2 H BILAT TI STR RIG,SUP-2190770,CDM,C1713,HCPCS,0278,RC,,,,both,,,463.87,301.52,,,,,,,,,,,,,
TROCAR LAPSCP 10 MM DIA 70 MM LEN BLDELSS BAL,SUP-2383785,CDM,C1788,HCPCS,0278,RC,,,,both,,,293.43,190.73,,,,,,,,,,,,,
HEAD HUM DIA40MM THK18MM SHLDR CO CHROM PRI STD OFFSET NK 53524018] STRYKER ORTHOPEDICS HOWM],SUP-2372863,CDM,C1776,CPT,0278,RC,,,,both,,,5650.12,3672.58,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X2 CM AMNIO WND MTRX BIOSKIN,SUP-2759487,CDM,C1762,CPT,0278,RC,,,,both,,,4567.54,2968.90,,,,,,,,,,,,,
GUIDEWIRE VASC SPECTRE L 300 CM DIA 0.014 IN RADIOPAQUE TIP,SUP-2763459,CDM,C1769,HCPCS,0272,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
SCREW BNE L6MM DIA2.3MM CRANIOMAXILLOFACIAL PUR ST EMGCY 5PK,SUP-2366170,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.10,141.76,,,,,,,,,,,,,
CLIP ANEURYSM OPENING W1.5MM BLADE L2MM MICRO CURVED CLOSING,SUP-2825694,CDM,C1889,HCPCS,0278,RC,,,,both,,,833.23,541.60,,,,,,,,,,,,,
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,PX-4506445000,CDM,64450,CPT,0450,RC,,,,both,,,2232.00,1450.80,,,,,,,,,,,,,
STEM FEM STD OFFSET A MAG NK W/ TRUNNION ARCOS,SUP-2443216,CDM,C1776,CPT,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
STENT URET POLARIS L 22 CM DIA 8 FR SENSOR GUIDEWIRE L 150,SUP-2754286,CDM,C2617,HCPCS,0278,RC,,,,both,,,550.32,357.71,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0258,RC,00264-7520-10,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
SCREWDRIVER BLADE MED 1.5X58 MM FOR PLATING SYS MAXDRIVE,SUP-2463409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.96,300.92,,,,,,,,,,,,,
PLATE BNE X 2.3X1.5 MM 15 MM THOR RIB 14 HOLE LCK LEVEL 1,SUP-2869167,CDM,C1713,HCPCS,0278,RC,,,,both,,,3641.77,2367.15,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|KX|CO,both,,,144.00,93.60,,,,,,,,,,,,,
SLING GYN UNIV POLYPR TRNSVAG MIDURETHRAL MESH ASSEMB HALO,SUP-2139446,CDM,C1771,HCPCS,0278,RC,,,,both,,,5890.55,3828.86,,,,,,,,,,,,,
GRAFT BNE INJ 12 CC INDUCTIVE PRO-STIM,SUP-2759445,CDM,C1713,HCPCS,0278,RC,,,,both,,,14682.64,9543.72,,,,,,,,,,,,,
PLATE BNE LG LT MIS HV REV,SUP-2897010,CDM,C1713,HCPCS,0278,RC,,,,both,,,5962.86,3875.86,,,,,,,,,,,,,
COIL EMB L6CM OD2MM 0.01IN SFT HELCL STRTCH RESIST DETACH,SUP-2365654,CDM,C1889,HCPCS,0278,RC,,,,both,,,2139.91,1390.94,,,,,,,,,,,,,
CATHETER CV 5 FRX55 CM 2 LUMEN PWR INJ XCELA,SUP-2117121,CDM,C1751,HCPCS,0278,RC,,,,both,,,366.75,238.39,,,,,,,,,,,,,
CATHETER BLLN OCCL 2.8FR L150CM ID0.053IN BLLN L10MM DIA4MM,SUP-2368108,CDM,C2628,HCPCS,0272,RC,,,,both,,,4622.08,3004.35,,,,,,,,,,,,,
GRAFT SURG 1MM PROC HUM DERM CLLGN RECTANG 8CMX20CM ALLOMAX,SUP-2126262,CDM,C1781,HCPCS,0278,RC,,,,both,,,11101.16,7215.75,,,,,,,,,,,,,
FOUNDATION ALL POLY TIB SZ 2 9 MM LT,SUP-2216303,CDM,C1776,CPT,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
OSTEOTOME SURG OD12MM BLDE THN FLX,SUP-2408595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
ELECTRODE WAND ABLAT 3MM 50DEG AMBIENT COVAC 50 IFS,SUP-2342013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.19,578.62,,,,,,,,,,,,,
STAPLE BNE FIX BRIDGE L 18 X 18 X W 4 MM MAX NIT LP NS REFLX,SUP-2896875,CDM,C1713,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
GRAFT NRV L30MM DIA2-3MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124849,CDM,C1762,CPT,0278,RC,,,,both,,,14035.80,9123.27,,,,,,,,,,,,,
INTRODUCER VLV PROGRAMMABLE 21.8 CM STRL MEDOS DISP,SUP-2666466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1175.46,764.05,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-HC OP SUSP,RX-19631,CDM,6370000000,HCPCS,0637,RC,61314-0641-75,NDC,,both,7.5,ML,673.60,437.84,,,,,,,,,,,,,
CLAMP EXT FIX NS,SUP-2188499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2123.74,1380.43,,,,,,,,,,,,,
BRACE ORTHOPEDIC PUL ON 1 XS 12-15 IN KNEE FULL CIR STRP,SUP-2150965,CDM,L1810,HCPCS,0272,RC,,,,both,,,299.09,194.41,,,,,,,,,,,,,
HC MRI-Chest W Contrast,PX-6107155100,CDM,71551,CPT,0610,RC,,,,both,,,4190.00,2723.50,,,,,,,,,,,,,
MESH SURG DIA8IN CIR VENTRALIGHT,SUP-2126543,CDM,C1781,HCPCS,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
NAIL IM L460MM DIA10MM NK 135DEG GRN L FEM TI TROCHANTERIC,SUP-2191990,CDM,C1713,HCPCS,0278,RC,,,,both,,,5304.21,3447.74,,,,,,,,,,,,,
DEVICE EMB L25MM OD4.5MM 55DEG SFT DST TIP BRAID 4 FLX,SUP-2296758,CDM,C1884,HCPCS,0278,RC,,,,both,,,46982.25,30538.46,,,,,,,,,,,,,
CATHETER EP LG CRV 5 FRX115 CM QPLR FIX,SUP-2356875,CDM,C1730,HCPCS,0272,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
PLATE BONE BUR H CVR FAN BLDE STD TI 11MM TIMESH CRAN,SUP-2277538,CDM,C1713,HCPCS,0278,RC,,,,both,,,651.11,423.22,,,,,,,,,,,,,
BUR SURG ROUTER 1.5 MM SPRL GRN RED NS SIGN LTX,SUP-2859282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.05,241.18,,,,,,,,,,,,,
BIT DRL DIA 3.2 MM LNG FOR HALF PIN NS DISP,SUP-2933791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1440.79,936.51,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00264-7510-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
SCREW BNE L120MM DIA6MM THRD L20MM CORT OSTEOTITE,SUP-2316311,CDM,C1713,HCPCS,0278,RC,,,,both,,,427.42,277.82,,,,,,,,,,,,,
CANNULATED DRL 9X185MM,SUP-2417664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1985.30,1290.44,,,,,,,,,,,,,
CATHETER HD CRV EXTN 11 FRX10 CM CATH NDL DUOFLO,SUP-2627067,CDM,C1752,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
METHYLPHENIDATE HCL 5 MG PO TABS,RX-4988,CDM,6370000000,HCPCS,0637,RC,68084-0805-21,NDC,,both,1,UN,9.30,6.04,,,,,,,,,,,,,
WASHER MULT AX SPNL TI CDH LEG,SUP-2289643,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
SHUNT CV SUNDT L 30 CM DSTL TBNG OD 4 MM ID 2 MM PROX TBNG,SUP-2308225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2093.53,1360.79,,,,,,,,,,,,,
PLATE BNE T SM 1.2 MM 3X5 HOLE OBLQ NS LTX,SUP-2861952,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.35,353.18,,,,,,,,,,,,,
KIT BNE VOID FILL 5ML INJ CALLOS,SUP-2106910,CDM,C1713,HCPCS,0278,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
VISE EXT FIX MOD 3 HOLE W/ 2 ROD,SUP-2467496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1144.53,743.94,,,,,,,,,,,,,
HANDLE SRGCL KNIFE SIZE 3KL 5 78NL STNLSS STEEL MATTE FNSH,SUP-2700741,CDM,2720000010,LOCAL,0272,RC,,,,both,,,85.88,55.82,,,,,,,,,,,,,
BLADE OPHTH SZ 0.8 MM GONIOTOMY 2 TRAPEZOIDAL SERRATED,SUP-2881876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1409.86,916.41,,,,,,,,,,,,,
PLATE BNE L73MM 3 H ST L LAT DST FIBULAR S STL LOK COMPR,SUP-2177412,CDM,C1713,HCPCS,0278,RC,,,,both,,,1866.26,1213.07,,,,,,,,,,,,,
IMPLANT PENILE 21CM CYL INFL MINOCYCLINE RIFAMPIN INHIBIZONE,SUP-2140277,CDM,C1815,HCPCS,0278,RC,,,,both,,,9215.90,5990.33,,,,,,,,,,,,,
BLADE ES DIA4MM 90DEG ANG CONCAVE WIND CRV DIEGO,SUP-2313839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.79,252.06,,,,,,,,,,,,,
STAPLE SPNL WASHER FOR ANTR STPL SYS ARI,SUP-2538505,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 7-10 EF 12 MM KNEE STRP BLU NXGN LPS,SUP-2208738,CDM,C1776,CPT,0278,RC,,,,both,,,2469.92,1605.45,,,,,,,,,,,,,
HEAD FEM OD32MM +8 NK LEN 12/14 TAPR CO CHROM MTL ON POLY,SUP-2205557,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
MESH HERN W10.5XL15.9CM VENTRAL POLYPR EPTFE OVL,SUP-2125814,CDM,C1781,HCPCS,0278,RC,,,,both,,,1032.43,671.08,,,,,,,,,,,,,
ANCHOR SFT TISS L10MM IMPL MENIS ARW,SUP-2137751,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CYCLOSPORINE MODIFIED 25 MG PO CAPS,RX-28842,CDM,J7515,HCPCS,0636,RC,00074-3108-32,NDC,,both,1,UN,8.30,5.39,,,,,,,,,,,,,
SYSTEM STENT GRFT OVATION PRIM L 100 MM DIA PROX/DSTL,SUP-2217738,CDM,C1713,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X40X2 MM CORTICAL FLEXIGRAFT,SUP-2740839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1612.20,1047.93,,,,,,,,,,,,,
SALINE TEXT MAGNASITE ANATOMICIN EXP STYL 133 FILL VOL,SUP-2113320,CDM,C1789,HCPCS,0278,RC,,,,both,,,32.47,21.11,,,,,,,,,,,,,
LORATADINE 10 MG PO TABS,RX-10466,CDM,6370000000,HCPCS,0637,RC,45802-0650-78,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
BLOCK TIB AUG HALF 5X20 MM TAPR NXGN,SUP-2201701,CDM,C1776,CPT,0278,RC,,,,both,,,3369.22,2189.99,,,,,,,,,,,,,
SCREW BONE L5MM OD2.0MM EMER CROSS DRV,SUP-2262631,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.95,56.52,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX L 30 CM LOOP DIA14 MM,SUP-2305217,CDM,C1889,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
PIN HLD PLT PREFIXATION THRD DISP TRINICA,SUP-2414371,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
Z DUP USE 2111568 LENS INTOCU +20.5 DIOPT CYL PWR +1.50 DIOPT L13MM DIA6MM,SUP-2111569,CDM,V2787,HCPCS,0276,RC,,,,both,,,390.00,253.50,,,,,,,,,,,,,
BLADE SURG DISP FOR PLNTR FASCTMY KOBYGUARD,SUP-2319777,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10CM 10MM 120CM 8FR HEPARIN,SUP-2610467,CDM,C1768,CPT,0278,RC,,,,both,,,10748.22,6986.34,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SAPPHIRE II PRO 1.25MM X 8MM,SUP-2858145,CDM,C1725,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
BUR SURG HD DIA3MM CARB MTCH,SUP-2367603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.08,474.55,,,,,,,,,,,,,
CURETTE SURG KORNER WESTERMANN 2 8 IN SINUS,SUP-2473446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.95,214.47,,,,,,,,,,,,,
MESH CRAN L 190 X W 140 MM THK 0.6 MM SCREW DIA1.5/1.7 MM XL,SUP-2883534,CDM,C1713,HCPCS,0278,RC,,,,both,,,57009.75,37056.34,,,,,,,,,,,,,
PLATE BONE 4 H RT OLECRANON,SUP-2364577,CDM,C1713,HCPCS,0278,RC,,,,both,,,3373.62,2192.85,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 4 T TAIL KT STRL DISP EVO,SUP-2934742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2565.38,1667.50,,,,,,,,,,,,,
COLLAR CERV L18IN H3.25IN L TRACH OPN AD PHIL,SUP-2195258,CDM,L0180,HCPCS,0274,RC,,,,both,,,39.94,25.96,,,,,,,,,,,,,
FILLER BNE VOID 2 ML CALCIUM SULF CALCIUM PHOSPHATE INJ,SUP-2902295,CDM,C1713,HCPCS,0278,RC,,,,both,,,10522.14,6839.39,,,,,,,,,,,,,
SCREW BONE CORT FULL THRD N CANN ST N LCK S STL NSTERILE,SUP-2198232,CDM,C1713,HCPCS,0278,RC,,,,both,,,41.26,26.82,,,,,,,,,,,,,
GOUGE SPNL RND KNURLED HNDL STR CRV 11IN COBB,SUP-2244790,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.15,202.90,,,,,,,,,,,,,
PROSTHESIS 5X45MM DAPAT PLATTI,SUP-2284072,CDM,L8613,CPT,0278,RC,,,,both,,,772.94,502.41,,,,,,,,,,,,,
PLATE BNE 2.7X73 MM 8 HOLE SS LC-DCP,SUP-2569217,CDM,C1713,HCPCS,0278,RC,,,,both,,,297.04,193.08,,,,,,,,,,,,,
ADAPTER STEM 4MM OFFSET W/ JAM NUT FOR SCORP SGL AXIS TOT,SUP-2376320,CDM,C1776,CPT,0278,RC,,,,both,,,2287.08,1486.60,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL VIT 1.3MM DIA 4MML,SUP-2364630,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.88,103.27,,,,,,,,,,,,,
TAP SURG L 130 MM DIA2.2 MM SD HEX FOR 3-4 MM SCREW DELT,SUP-2883159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.37,1339.24,,,,,,,,,,,,,
PLATE BNE 90 DEG L 17 MM THK 0.6 MM SCREW DIA2 MM 2X2 H REG,SUP-2936506,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
COMPONENT FEM L200MM DIA11MM RT HIP TI POR REV BOW REACH,SUP-2406564,CDM,C1776,CPT,0278,RC,,,,both,,,19279.60,12531.74,,,,,,,,,,,,,
PLATE BNE CUT DSTL FEM KNEE REV NXGN LEG,SUP-2438072,CDM,C1713,HCPCS,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
SET DRNGE OD5FR PLEUR NEO PNEUMOPERICARDIAL FUHRMAN,SUP-2171102,CDM,C1729,HCPCS,0272,RC,,,,both,,,391.90,254.73,,,,,,,,,,,,,
GRAFT HUM TISS W3XL4CM PLCNTA MEM CRYOPRESERVED CHORION,SUP-2319167,CDM,Q4132,HCPCS,0636,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
PACEMAKER CARD STD PERM SGL CHMBR UPLR IS1 CONN INTEGRITY,SUP-2357331,CDM,C1786,HCPCS,0275,RC,,,,both,,,14742.30,9582.49,,,,,,,,,,,,,
GRAFT HUM TISS NAT MESH 5 MMX65 CM BIOGRAFT TRELEX,SUP-2129886,CDM,C1762,CPT,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,0636,RC,00143-9689-10,NDC,,both,10,ML,146.80,95.42,,,,,,,,,,,,,
KIT AUTOTRNS ATF 40 FAST STRT W/ 1 AT1 AUTOTRNS SET 1 ATR 40,SUP-2385069,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
STEM HUM CMNTLS 9X100 MM SHLDR REVERSED AEQUALIS,SUP-2715663,CDM,C1776,CPT,0278,RC,,,,both,,,7785.63,5060.66,,,,,,,,,,,,,
HC X-Ray Exam Abdomen 3+ Views,PX-3207402100,CDM,74021,CPT,0320,RC,,,,both,,,827.00,537.55,,,,,,,,,,,,,
PLATE BONE L55MM THK1.4MM SHFT W6MM HD 12.3MM 2X8 H STRL T,SUP-2349669,CDM,C1713,HCPCS,0278,RC,,,,both,,,4111.83,2672.69,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM BIOCRYL RAPIDE ABSRB 2 PERMACORD SZ 2,SUP-2256701,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
PLATE BNE HUM 147 MM LT DSTL PL 17 HOLE STRL A.L.P.S,SUP-2462751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3262.46,2120.60,,,,,,,,,,,,,
ALLOGRAFT SPCR CERV TRIAD BIPORTAL,SUP-2311769,CDM,C1713,HCPCS,0278,RC,,,,both,,,7143.50,4643.27,,,,,,,,,,,,,
ANTEGRADE FEM NAIL RIGHT 14MMX30CM,SUP-2811055,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,6370000000,HCPCS,0637,RC,69238-1534-05,NDC,,both,15,GR,65.70,42.70,,,,,,,,,,,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,0636,RC,00143-9729-05,NDC,,both,0.5,ML,86.30,56.09,,,,,,,,,,,,,
GRAFT DERM CLLGN SURG PROC HUM RECTANG IMPL L20XW4CM,SUP-2125860,CDM,C1762,CPT,0278,RC,,,,both,,,6367.92,4139.15,,,,,,,,,,,,,
DRILL SURG LUG SM HI PERF SIG,SUP-2456283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
GLYCOPYRROLATE-FORMOTEROL 9-4.8 MCG/ACT IN AERO,RX-134596,CDM,6370000000,HCPCS,0637,RC,09999-9913-89,NDC,,both,.08916,GR,9.90,6.43,,,,,,,,,,,,,
SCREW BONE L50MM DIA4.5MM HD NONLOCKING LO PROF FOR INTOSS,SUP-2223849,CDM,C1713,HCPCS,0278,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
LEFLUNOMIDE 10 MG PO TABS,RX-23872,CDM,6370000000,HCPCS,0637,RC,70748-0129-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 20CML I 5623200,SUP-2632910,CDM,C1752,HCPCS,0278,RC,,,,both,,,375.54,244.10,,,,,,,,,,,,,
CATHETER ABLATN J-J 2-5-2 MM 3.5 MM 8 FRX115 CM THERMOCOOL,SUP-2248539,CDM,C1732,HCPCS,0272,RC,,,,both,,,7583.10,4929.01,,,,,,,,,,,,,
GENESIS II CR HYBRID W/ CEM TIB,SUP-2347968,CDM,C1776,CPT,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
PLATE BNE MESHED 51X51X1 MM SM GRID PLLA-PGA STRL RESORB XG,SUP-2457929,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.08,2038.45,,,,,,,,,,,,,
BOLT LOCKING HUMERAL ROD F/POLARUS HUMERAL ROD SYSTEM,SUP-2639961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
CATHETER EMB 6FR 2ML L80CM BLLN DIA13MM INTRO 7FR ART SIL S – SEE COMMENT,SUP-2214002,CDM,C1757,HCPCS,0272,RC,,,,both,,,186.99,121.54,,,,,,,,,,,,,
GRAFT VASC L 40 CM DIA12 X 6 MM POLYESTER THOR ABD AORT,SUP-2227626,CDM,C1768,CPT,0278,RC,,,,both,,,2289.69,1488.30,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH THCK 10X5 CM ACELLULAR HYDRATED DERM,SUP-2321760,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
SET URET STENT SOFFLX L 75 CM CATH 6.0 FR GUIDEWIRE L 100 CM,SUP-2168924,CDM,C2617,HCPCS,0278,RC,,,,both,,,498.00,323.70,,,,,,,,,,,,,
HC X-Ray Bile Duct Endoscopy,PX-3207432800,CDM,74328,CPT,0320,RC,,,,inpatient,,,859.00,558.35,,,,,,,,,,,,,
WIRE SMTH 1.8X400MM,SUP-2477089,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW BNE L 145 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2932536,CDM,C1713,HCPCS,0278,RC,,,,both,,,228.15,148.30,,,,,,,,,,,,,
PLATE BNE RECON 3.5X46 MM 4 HOLE SS,SUP-2569079,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.40,212.16,,,,,,,,,,,,,
SHEATH URET ACC 12FR L28CM HYDRPHLC FLX,SUP-2168991,CDM,C1894,HCPCS,0272,RC,,,,both,,,625.17,406.36,,,,,,,,,,,,,
PLATE BNE L18MM 10 H CRPL PEEK FUS CUP XPODE,SUP-2389449,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
GUIDEWIRE ENDO L480CM OD0.035IN AQUA COAT SHORTER TAPR,SUP-2169526,CDM,C1769,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
PLATE BNE SM W11XL176MM THK34MM 13 H BILAT TI RIG NEUT LOK,SUP-2190790,CDM,C1713,HCPCS,0278,RC,,,,both,,,1371.93,891.75,,,,,,,,,,,,,
RESIN DENT ADH SELF ETCH 7TH GENERATION LT CURE SGL COMP,SUP-2100155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,519.67,337.79,,,,,,,,,,,,,
FOOT PLATE EXT FIX DIA180 MM SHRT NS DISP MONK RING,SUP-2881110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4999.67,3249.79,,,,,,,,,,,,,
HC Veeg by Tech 2-12 Hours Unmonitored,PX-7409571100,CDM,95711,CPT,0740,RC,,,,both,,,1990.00,1293.50,,,,,,,,,,,,,
TROCAR ENDOSCP CONVERTERLESS THRD BLUNTPORT + DISP,SUP-2283194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,997.01,648.06,,,,,,,,,,,,,
CATHETERIZATION KIT 4 FRX50 CM SINGLE LUMEN PWR INJ,SUP-2383976,CDM,C1751,HCPCS,0278,RC,,,,both,,,522.65,339.72,,,,,,,,,,,,,
CATHETER PICC DBL LUMN BASIC KT INTVENT RAD PWR INJ POLYUR,SUP-2125546,CDM,C1751,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
GRAFT BONE SUB 1CC DBM PUTTY W/ RPM,SUP-2415792,CDM,C9359,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
KIT SHTH DESTINO L 81 CM DIA 8.5 FR CRV BEND L 22 MM DIL 50,SUP-2616121,CDM,C1766,CPT,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
CATHETER HD CRV 12.5 FRX13 CM TRPL LUMEN IC TY MAHRK ELITE,SUP-2626956,CDM,C1752,HCPCS,0278,RC,,,,both,,,297.67,193.49,,,,,,,,,,,,,
SYSTEM INTRO SAFSHTH II L 23 CM DIA 9 FR DIL 28.5 CM BLK,SUP-2419358,CDM,C1892,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STARTER KIT INJECTABLE POLYMER SYSTEM STERILE RAPIDSORB,SUP-2838538,CDM,C1713,HCPCS,0278,RC,,,,both,,,8356.80,5431.92,,,,,,,,,,,,,
CATHETER VASC GUID STR PERIPH W/ HYDRPHLC COAT AD,SUP-2139771,CDM,C1725,HCPCS,0272,RC,,,,both,,,757.21,492.19,,,,,,,,,,,,,
BLADE SAW W8XL70MM THK1.27MM OSC,SUP-2363318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1024.02,665.61,,,,,,,,,,,,,
PLATE BNE MESHED 246X11X1 MM 2 HOLE CONTOURED SM GRID STRL,SUP-2467924,CDM,C1713,HCPCS,0278,RC,,,,both,,,5907.47,3839.86,,,,,,,,,,,,,
GRAFT DURA ABSRB CLLGN BASE ST SUB SPNL CRAN DURAPLASTY,SUP-2165121,CDM,C1763,HCPCS,0278,RC,,,,both,,,2085.46,1355.55,,,,,,,,,,,,,
"HC So1 Electron Microscopy, Diag",PX-3128834867,CDM,88348,CPT,0312,RC,,,,both,,,920.00,598.00,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X26 MM FUSION HEX DRV YEL WRST SS NS,SUP-2852114,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.81,437.98,,,,,,,,,,,,,
BIT DRL CINCHLOCK FLX DISP,SUP-2663980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.98,520.64,,,,,,,,,,,,,
PLATE BNE L391MM 16 H R PROX FEM S STL LOK COMPR FOR,SUP-2186144,CDM,C1713,HCPCS,0278,RC,,,,both,,,5120.68,3328.44,,,,,,,,,,,,,
PHILADEPHIA CLLR 1-PIECE - RIG EXTRIC TALL,SUP-2194491,CDM,L0172,HCPCS,0274,RC,,,,both,,,25.62,16.65,,,,,,,,,,,,,
WIRE FIX SMOOTH 1.3X70 MM OLV BABY GORILLA KIRSCHNER,SUP-2421737,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X288 MM 16 HOLE SS LCP,SUP-2569377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.29,669.04,,,,,,,,,,,,,
CLIP ANEURYSM L9MM 90DEG STANDARD TITANIUM PERMANENT YASARGI,SUP-2821770,CDM,C1889,HCPCS,0278,RC,,,,both,,,6646.25,4320.06,,,,,,,,,,,,,
EPICORD 3X5CM 15SQ CM,SUP-2305733,CDM,Q4187,HCPCS,0636,RC,,,,both,,,11099.90,7214.93,,,,,,,,,,,,,
PROSTHESIS OTO L10MM OD4/2.1MM HA AND S STL MID EAR OSS TOT,SUP-2284052,CDM,L8613,CPT,0278,RC,,,,both,,,1251.23,813.30,,,,,,,,,,,,,
ANCHOR SUTURE L14MM DIAMETER 5MM PRELOADED ON DRIVER WITH NO,SUP-2825017,CDM,C1713,HCPCS,0278,RC,,,,both,,,702.54,456.65,,,,,,,,,,,,,
KIT REP ANCHR LISFRANC INTERNALBRACE,SUP-2121457,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
PLATE BNE 3D PRNT MINI MIDFACE MAND TI TRUMATCH,SUP-2860363,CDM,C1713,HCPCS,0278,RC,,,,both,,,9655.81,6276.28,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST FT PLATE STIRRUP ATTCH,SUP-2435655,CDM,L2250,HCPCS,0272,RC,,,,both,,,945.67,614.69,,,,,,,,,,,,,
COMPONENT FEM SLT 55 MM M KNEE SEG TAPR ANTIROTATION TAB TI,SUP-2252619,CDM,C1776,CPT,0278,RC,,,,both,,,4720.83,3068.54,,,,,,,,,,,,,
SCREW BONE 6.5MM DIA 115MML STNLSS STEEL CNCLLS SOLID DRIVE,SUP-2586755,CDM,C1713,HCPCS,0278,RC,,,,both,,,909.50,591.17,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED + MED COMPLX + PEEK NS LTX,SUP-2862811,CDM,C1713,HCPCS,0278,RC,,,,both,,,44820.36,29133.23,,,,,,,,,,,,,
PLATE BONE DSTL RAD TRL,SUP-2225432,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
EPINEPHRINE 1 MG/ML IJ SOLN,RX-123230,CDM,J0169,HCPCS,0636,RC,54288-0119-01,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC THRD 1.4 MM,SUP-2315873,CDM,C1769,HCPCS,0272,RC,,,,both,,,42.70,27.75,,,,,,,,,,,,,
DRESSING WND 4X5IN MTRX BOV CLLGN SGL,SUP-2243649,CDM,Q4108,HCPCS,0636,RC,,,,both,,,18431.80,11980.67,,,,,,,,,,,,,
SPLINT FINGER SIZE 5.5 STAX,SUP-2895961,CDM,L3933,HCPCS,0272,RC,,,,both,,,5.50,3.57,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RINGER BALLOON L 20 MM DIA 4.5 MM,SUP-2910485,CDM,C1725,HCPCS,0272,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
EXPANDER BRST TISS 350CC W10XH10CM P7CM SIL SMOOTH ULT HI,SUP-2421121,CDM,C1789,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
PIN FIX L9IN DIA2MM ST S STL 2 SIDE SGL DMND 1 END PNT STYL,SUP-2150482,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.53,8.79,,,,,,,,,,,,,
BIT DRL L107MM OD1.5MM 20MM STP SHFT END NONRADIOLUCENT FOR,SUP-2366414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,554.90,360.68,,,,,,,,,,,,,
DRILL TWST L 38 MM DIA1 MM STP 3.5 MM SCREW DIA1.5 MM MRG3,SUP-2883877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FULL CORSET,SUP-2435564,CDM,L0974,HCPCS,0272,RC,,,,both,,,494.74,321.58,,,,,,,,,,,,,
CANNULA INJ FOR TFNA SYS STRL TRAUMACEM V+,SUP-2382592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1025.59,666.63,,,,,,,,,,,,,
KIT THERMOABLATION 6MM ENDOMET DEV NOVASURE - SEE COMMENT,SUP-2239892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
INSTRUMENT BX 16GA L20CM PEN D22MM ACTUATOR BTTN PUR COR,SUP-2127776,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.77,53.80,,,,,,,,,,,,,
HC IV Dop Vel&/Press C/Flo Rsrv Meas Ea Addl Vsl,PX-4819357200,CDM,93572,CPT,0480,RC,,,,both,,,614.00,399.10,,,,,,,,,,,,,
MIS POR ST-NK/ POR CUP/ MET LINER/ MET HD,SUP-2212115,CDM,C1776,CPT,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
SPLINT ORTH M L13IN 6-17IN GRY ELBW BILAT ZIP OPN NYL LOOP,SUP-2324194,CDM,L3702,HCPCS,0272,RC,,,,both,,,64.40,41.86,,,,,,,,,,,,,
AUGMENT FEM 2XL THK4MM STD RT POST KNEE TI CEM BLK PRESSFIT,SUP-2406984,CDM,C1776,CPT,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
HEAD HUM 36 MM RT SHLDR SLIM ANAT SHLDR,SUP-2440652,CDM,C1776,CPT,0278,RC,,,,both,,,3942.27,2562.48,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 8 FR POLYPRO TBNG,SUP-2474125,CDM,C1894,HCPCS,0272,RC,,,,both,,,68.92,44.80,,,,,,,,,,,,,
BIT DRILL SURG 2.5 MM ALPS DISP,SUP-2607153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.11,252.92,,,,,,,,,,,,,
GUIDEWIRE ORTH L304MM OD1.1MM SMOOTH CANN BLNT TIP FLX,SUP-2341320,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.76,40.14,,,,,,,,,,,,,
MESH SURG W6XL11CM RECT PARTIALLY ABSRB FLAT FOR SFT TISS,SUP-2220107,CDM,C1781,HCPCS,0278,RC,,,,both,,,414.61,269.50,,,,,,,,,,,,,
CATHETER HD FULL SAFETY TY 035 12 FRX25 CM DL TURBO-FLO HD,SUP-2759837,CDM,C1752,HCPCS,0278,RC,,,,both,,,478.72,311.17,,,,,,,,,,,,,
MESH HERN 12X12IN POLY 4 HYDROXYBUTYRATE SYN SQ WVN,SUP-2126266,CDM,C1781,HCPCS,0278,RC,,,,both,,,36863.60,23961.34,,,,,,,,,,,,,
STEM EXTN L65MM DIA16MM KNEE CEMENTLESS FLUT GMK,SUP-2267626,CDM,C1776,CPT,0278,RC,,,,both,,,5708.52,3710.54,,,,,,,,,,,,,
PLATE BONE SM W11XL181MM THK3.3MM 0DEG 14 H BILAT TI STR RIG,SUP-2190791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1182.87,768.87,,,,,,,,,,,,,
PACK EYE CUST DR YOUNG,SUP-2424303,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.04,260.03,,,,,,,,,,,,,
PLATE BNE L 243 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 20 H 72463220N,SUP-2932753,CDM,C1713,HCPCS,0278,RC,,,,both,,,7981.88,5188.22,,,,,,,,,,,,,
PLATE 3.5MM SPRING PLATE 1 HOLE-STERILE,SUP-2546015,CDM,C1713,HCPCS,0278,RC,,,,both,,,1104.06,717.64,,,,,,,,,,,,,
PLATE BNE T 2X3 HOLE COMPR NS LTX,SUP-2855828,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 1.7-10MM CANC CHIP MORSELIZED FRZ DRY,SUP-2307078,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
PATCH VASC HEMGRD L 75 X W 25 MM THK 0.65 MM POLYESTER BOV,SUP-2535427,CDM,C1768,CPT,0278,RC,,,,both,,,443.21,288.09,,,,,,,,,,,,,
NEEDLE 20GAX5CM BREAST MAMMO,SUP-2120042,CDM,C1819,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
HEAD ULN DIA17.5 MM STEM SZ 6.5 MM COCR WR STD 1PC PART DRUJ,SUP-2933190,CDM,C1776,CPT,0278,RC,,,,both,,,20370.53,13240.84,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 90 MM DIA13/10 MM DEL,SUP-2934300,CDM,C1713,HCPCS,0278,RC,,,,both,,,15886.74,10326.38,,,,,,,,,,,,,
CONNECTOR SPNL TOP LD 5.5X5.5 MM SIDE BY SIDE SFS,SUP-2582942,CDM,C1713,HCPCS,0278,RC,,,,both,,,2813.44,1828.74,,,,,,,,,,,,,
CLAMP REPROC MULTI PIN HII MRI 10 HL,SUP-2700102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,899.17,584.46,,,,,,,,,,,,,
KIT KYPHOPLASTY CEM MX AND TRNSF PK FORTRESS +,SUP-2232194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
CATHETER ETER 24CM STD ALPHACURVE GLIDEPATH,SUP-2126479,CDM,C1881,HCPCS,0278,RC,,,,both,,,1374.85,893.65,,,,,,,,,,,,,
CONNECTOR SPNL L35.5MM-40MM SM CROSS ROD ADJ TI,SUP-2415637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.98,746.19,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ PISTON 0.6X4.50 MM SS FLROPLAS,SUP-2638111,CDM,L8613,CPT,0278,RC,,,,both,,,313.18,203.57,,,,,,,,,,,,,
HEAD HUM H27MM DIA50MM CURVATURE DIA50MM SHLDR CO CHROM,SUP-2404505,CDM,C1776,CPT,0278,RC,,,,both,,,5287.76,3437.04,,,,,,,,,,,,,
HC MRI-Spine Thoracic W Contrast,PX-6127214700,CDM,72147,CPT,0612,RC,,,,both,,,4146.00,2694.90,,,,,,,,,,,,,
GRAFT BIO W38XL50MM THK0.85MM MEDPOR,SUP-2366459,CDM,C1713,HCPCS,0278,RC,,,,both,,,1406.91,914.49,,,,,,,,,,,,,
SYSTEM PACEMKR CARD ZEPHYRXL DR 2 CHMBR RATE RESPON,SUP-2356219,CDM,C1785,HCPCS,0275,RC,,,,both,,,17332.80,11266.32,,,,,,,,,,,,,
IMPLANT BONE STRP MOLD IL CREST MTRX 90MM FRZN OSTEOFIL ICM,SUP-2284711,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
COMPONENT TIB AUG FLANGE 3.5 MM ANTR OSS,SUP-2441731,CDM,C1776,CPT,0278,RC,,,,both,,,2225.48,1446.56,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DRN STRL,SUP-2381495,CDM,L8699,HCPCS,0278,RC,,,,both,,,60.29,39.19,,,,,,,,,,,,,
FIBER LASER 164 FT KRA-CPAOCHXL HDMI,SUP-2798084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1524.22,990.74,,,,,,,,,,,,,
HC Perq P-Art Revsc St 1st Nml Native Connj Bi,PX-4813390100,CDM,33901,CPT,0481,RC,,,,inpatient,,,35474.00,23058.10,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 4.4FR TIP L5MM CUT WIRE 30MM 0.035IN,SUP-2149569,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.75,437.94,,,,,,,,,,,,,
SHEATH INTRO TORFLEX 45 DEG L 63 CM DIA 8 FR GUIDEWIRE L 180,SUP-2131514,CDM,C1893,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TOTAL KNEE REPLACEMENT KIT PRIMARY E-PLUS,SUP-2217514,CDM,C1776,CPT,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM DIA20 MM POLYESTER BOV CLLGN,SUP-2227720,CDM,C1768,CPT,0278,RC,,,,both,,,2732.52,1776.14,,,,,,,,,,,,,
CATHETER INT AORT BAL REDIGUARD FLEX 50CC 8.0FR,SUP-2744830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
PLATE SPNL 14 MM,SUP-2163891,CDM,C1713,HCPCS,0278,RC,,,,both,,,5039.70,3275.80,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7 MM STR STD WALL HELIX,SUP-2525462,CDM,C1768,CPT,0278,RC,,,,both,,,1968.43,1279.48,,,,,,,,,,,,,
KIT TKR KNEE CRUCE RET NAR CEM NP TIB INSRT VERILAST LEGION,SUP-2348042,CDM,C1776,CPT,0278,RC,,,,both,,,13031.00,8470.15,,,,,,,,,,,,,
CATHETER VENTRICULAR 14 CM W/ CM MRK STR 1 STYL MEDOS,SUP-2666799,CDM,C1729,HCPCS,0272,RC,,,,both,,,609.69,396.30,,,,,,,,,,,,,
PLATE SPNL L35MM UNIV TI POST LUM PREBENT STD OFFSET BILAT,SUP-2293344,CDM,C1713,HCPCS,0278,RC,,,,both,,,4201.73,2731.12,,,,,,,,,,,,,
COMPONENT SHLDR SHT GLEN ST REVERSED 1ST XLPE COMPHSVE,SUP-2212458,CDM,C1776,CPT,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED REVERSED W/ POST BASEPLT,SUP-2212512,CDM,C1776,CPT,0278,RC,,,,both,,,26828.16,17438.30,,,,,,,,,,,,,
HC So Assay of Vit B-2,PX-3018425266,CDM,84252,CPT,0301,RC,,,,both,,,165.00,107.25,,,,,,,,,,,,,
LEAD DEFIB PAMIRA PROMRI S L 60 CM DF4 TRIPOLAR CONN MR,SUP-2887116,CDM,C1898,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
EVOS VOLARIGHT PLATE 5H RIGHT WDE 78MM,SUP-2820167,CDM,C1713,HCPCS,0278,RC,,,,both,,,7751.56,5038.51,,,,,,,,,,,,,
TRAY TIB KNEE 2T3F FOR MODULAR/REVISION SYS PROVEN GEN-FLEX,SUP-2359219,CDM,C1776,CPT,0278,RC,,,,both,,,9498.50,6174.02,,,,,,,,,,,,,
PLATE BNE W10.3XL98.6MM THK3.7MM 7 H TI LOK COMPR LO PROF,SUP-2413707,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLATE BNE RIM SM LT,SUP-2402824,CDM,C1713,HCPCS,0278,RC,,,,both,,,3243.62,2108.35,,,,,,,,,,,,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,0636,RC,10019-0953-01,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
FORCEP ENDOSCP 4 MMX230 CM 3.2 HEMSTAS ANTI SLIP COAGRASPER,SUP-2501312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.69,544.50,,,,,,,,,,,,,
EPOPROSTENOL SODIUM 1.5 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-15898,CDM,J1325,HCPCS,0636,RC,62756-0060-40,NDC,JW,both,1,UN,255.90,166.33,,,,,,,,,,,,,
BIT DRL L85MM DIA2MM JCBS CHK REUSE,SUP-2410945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
PLATE STR 6H SS STRL VAL,SUP-2546091,CDM,C1713,HCPCS,0278,RC,,,,both,,,1690.20,1098.63,,,,,,,,,,,,,
SCREW BNE 4.5X55 MM N LCK,SUP-2606638,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.35,124.38,,,,,,,,,,,,,
SET URET STENT MARD L 28 CM DIA 8 FR ZIPWIRE 0.035 IN,SUP-2721561,CDM,C2617,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
TAP SURG L8MM QUIK CONN FOR SREW INTRF BIOCOMP,SUP-2121645,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 120 MM DIA 6 MM DEL SYS L 190 CM,SUP-2866189,CDM,C1876,HCPCS,0278,RC,,,,both,,,5046.55,3280.26,,,,,,,,,,,,,
PIN TEMP FIX L 40 MM DIA 3.5 MM LG TARGETER PROV STRL DISP,SUP-2931298,CDM,C1713,HCPCS,0278,RC,,,,both,,,1991.39,1294.40,,,,,,,,,,,,,
IMPLANT BRST NACL SMOOTH RND ADJ SPECTRUM,SUP-2748610,CDM,C1789,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE L172MM 10 H NONSTERILE L ANTEROMEDIAL DST TIB S,SUP-2177680,CDM,C1713,HCPCS,0278,RC,,,,both,,,5235.42,3403.02,,,,,,,,,,,,,
GRAFT EVAR L75MM DIA25MM STNT L20MM DEL SYS 19FR AORT EXT,SUP-2217571,CDM,C1768,CPT,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
ALLOGRAFT BNE FEM FRZN TISS WHL W/O HD,SUP-2165578,CDM,C1889,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
TAP BNE PLT FOR 3.5MM SCR,SUP-2107127,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST THOR CTRL BND,SUP-2435691,CDM,L2660,HCPCS,0274,RC,,,,both,,,507.27,329.73,,,,,,,,,,,,,
BIT DRL SM PK ANTR CHMFR RMR TALAR KEEL MILL FOR STAR MOB,SUP-2361516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SCREW BNE RESCUE 12 MM,SUP-2207856,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 0.5 MG/ML IJ SOLN,RX-29464,CDM,J2274,HCPCS,0636,RC,00641-6020-01,NDC,,both,5,ML,83.30,54.14,,,,,,,,,,,,,
STENT URET CNTOUR VL L 22-30 CM DIA 6 FR TIP L 3 CM SENSOR,SUP-2522230,CDM,C2617,HCPCS,0278,RC,,,,both,,,550.79,358.01,,,,,,,,,,,,,
HEMOSTATIC KIT POLYSACCHARIDE 230 CM 2.8 MM 3 GM ENDOCLOT,SUP-2865642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
LINER ACET OD48MM ID28MM GG METASUL HIP ALPHA UNCEMENTED,SUP-2204556,CDM,C1776,CPT,0278,RC,,,,both,,,5184.14,3369.69,,,,,,,,,,,,,
IMPLANT THYROPLASTY SZ 8 SIL FOR FEM PT MONT,SUP-2138770,CDM,C1878,HCPCS,0278,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
HC So Antinomyces Antibody,PX-3028660266,CDM,86602,CPT,0302,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
RAIL ORTH 2 TRANSITION 5.5X600 MM 200 MM MESA,SUP-2732254,CDM,C1713,HCPCS,0278,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
BLADE SURG ANGLED HK STRL,SUP-2481821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.26,273.17,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM UNIV SELF DRL CRSS PIN,SUP-2366491,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.69,144.75,,,,,,,,,,,,,
K WIRE FIX L450MM DIA16MM NIT BLNT TIP,SUP-2232215,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
COIL OCCL L30CM DIA325 4MM 002IN POD 4 SYS,SUP-2323697,CDM,C1889,HCPCS,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
HALOPERIDOL 2 MG PO TABS,RX-3581,CDM,6370000000,HCPCS,0637,RC,58657-0902-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L20CM 13.5FR AD ADMIN ACUTE COMP,SUP-2126509,CDM,C1752,HCPCS,0278,RC,,,,both,,,297.04,193.08,,,,,,,,,,,,,
SCREW BNE 2X13 MM,SUP-2321701,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.63,408.61,,,,,,,,,,,,,
CATHETER CTRL VEN DBL LUMN N TUNNELED BASIC KT POLYUR N COAT,SUP-2383396,CDM,C1751,HCPCS,0278,RC,,,,both,,,98.34,63.92,,,,,,,,,,,,,
SCREW BNE CANN 7X60 MM 16 MM THRD SS NS,SUP-2183893,CDM,C1713,HCPCS,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 10 MM FD IRRADIATED,SUP-2867103,CDM,C1762,CPT,0278,RC,,,,both,,,1897.19,1233.17,,,,,,,,,,,,,
RETRACTOR EXTENDED WEAR PANNICULUS SM,SUP-2880686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
STEM FEM SHT EM KNEE W/ BODY VANGUARD PREMIER,SUP-2446340,CDM,C1776,CPT,0278,RC,,,,both,,,3447.72,2241.02,,,,,,,,,,,,,
KIT RING FIX TC 555 50PC SET,SUP-2326378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.26,507.82,,,,,,,,,,,,,
DISPOSABLE OSABLES KT FOR BIOUNI,SUP-2120770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
BASKET EXTR 5MMX1.3CM SHTH 5FR ACCSRY CHAN 2MM MINI FOR ENDO,SUP-2169104,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
SET LD EXTRACTION EVOLUTION SHORTIE L 13.6 CM OD 19 FR ID 11,SUP-2170682,CDM,C1773,HCPCS,0272,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
GRAFT VASC STD WALL 5 MMX90 CM STR RNG REINF ADVANTA VXT,SUP-2471651,CDM,C1768,CPT,0278,RC,,,,both,,,2055.54,1336.10,,,,,,,,,,,,,
PLATE BNE SPCR 3MM 4 H NONSTERILE MIDFOOT TI VAR ANG LOK OPN,SUP-2181214,CDM,C1713,HCPCS,0278,RC,,,,both,,,3294.65,2141.52,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CALF CUST SLD STIRRUP,SUP-2435630,CDM,L1980,HCPCS,0274,RC,,,,both,,,1143.12,743.03,,,,,,,,,,,,,
AMPLATZ RENAL DILATOR SET,SUP-2826946,CDM,C1726,HCPCS,0272,RC,,,,both,,,870.31,565.70,,,,,,,,,,,,,
STEM TIB L65MM DIA11MM KNEE PRI GMK,SUP-2267618,CDM,C1776,CPT,0278,RC,,,,both,,,4309.65,2801.27,,,,,,,,,,,,,
GRAFT SYNTH TISS 10ML VI GRAN BONE IMPL HA PRO OSTEON 500,SUP-2413078,CDM,C1713,HCPCS,0278,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
HC So Hemoglobin Electrophoresis,PX-3018302066,CDM,83020,CPT,0301,RC,,,,both,,,42.00,27.30,,,,,,,,,,,,,
DEVICE BNE FILL SZ 2 DIR DEL SYS KYPHX KYPHON EXPR,SUP-2293567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2 CHMBR 51X69X12 MM 31 CC 71 GM GALLANT DR,SUP-2707576,CDM,C1721,HCPCS,0275,RC,,,,both,,,43313.16,28153.55,,,,,,,,,,,,,
MESH HERN RECT 12X6 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855253,CDM,C1781,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
AGENT HEMOSTATIC 3 ML SYNTH FOR MILD MOD BLEED STRL PURASTAT,SUP-2881769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
HC Peri-Proc Eval and Prog Icd,PX-4809328700,CDM,93287,CPT,0480,RC,,,,both,,,132.00,85.80,,,,,,,,,,,,,
TUBE VENT ID1MM FLNG NO H FLROPLAS REUT BOB,SUP-2313688,CDM,L8699,HCPCS,0278,RC,,,,both,,,27.82,18.08,,,,,,,,,,,,,
LONG CALIBRATED DRILL 49MM,SUP-2720866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.57,511.27,,,,,,,,,,,,,
SET NEUROSURGICAL CK DEV NEURO W/ WIRE IO-FLEX,SUP-2115836,CDM,C1713,HCPCS,0278,RC,,,,both,,,2788.32,1812.41,,,,,,,,,,,,,
TUBING SET PRTBL ARTHRO DISPOSABLE APEX,SUP-2166982,CDM,C1713,HCPCS,0278,RC,,,,both,,,245.86,159.81,,,,,,,,,,,,,
STEM HUM W/ ALIGN H STD 9X115 BIO-MOD,SUP-2136162,CDM,C1776,CPT,0278,RC,,,,both,,,9704.96,6308.22,,,,,,,,,,,,,
SOUND PROCESSOR KIT 2 BAHA 6 MAX,SUP-2858111,CDM,L8690,HCPCS,0278,RC,,,,both,,,19422.19,12624.42,,,,,,,,,,,,,
PLATE BNE M CALCNL MESH VARIAX,SUP-2371664,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BNE CHIN 1.7X4 MM 6 HOLE PRE-BENT ADV GLD NS LTX,SUP-2862767,CDM,C1713,HCPCS,0278,RC,,,,both,,,686.69,446.35,,,,,,,,,,,,,
CONNECTOR RMR FEM ACCURIS,SUP-2344214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.74,606.28,,,,,,,,,,,,,
OBTURATOR BRACHYTHERAPY BLNT STRL SAVI BRACHY LF,SUP-2858442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT TUBE 11MM,SUP-2812121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC PREFABRIC,SUP-2388197,CDM,L4360,HCPCS,0272,RC,,,,both,,,759.16,493.45,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST REINF SLD STIRRUP,SUP-2435656,CDM,L2260,HCPCS,0274,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF SHORT 5X30 MM TITANIUM NITRIDE ST,SUP-2836774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.41,795.87,,,,,,,,,,,,,
KIT BNE FIX PEEK STPL PLGA TACK CADDY STRL INTEGRITY,SUP-2902006,CDM,C1713,HCPCS,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
STENT NEURO SURPS EVOLVE L 40 MM DIA 4.5 MM COCR PLAT FLO,SUP-2541460,CDM,C1876,HCPCS,0278,RC,,,,both,,,46654.12,30325.18,,,,,,,,,,,,,
SYSTEM CAST 4 IN TOT CONTACT W/ X LG BOOT TCC-EZ,SUP-2268427,CDM,L4386,HCPCS,0272,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX L 30 CM LOOP DIA 7 MM,SUP-2305209,CDM,C1889,HCPCS,0278,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 80 MM DIA 8 MM DEL SYS L 120 CM,SUP-2155365,CDM,C1876,HCPCS,0278,RC,,,,both,,,4713.14,3063.54,,,,,,,,,,,,,
GUIDEWIRE VASC L 30 CM DIA 0.018 IN SS SAFE-T-J STR FIX COR,SUP-2167843,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.31,67.15,,,,,,,,,,,,,
GUIDEWIRE ORTH L300MM DIA2.8MM S STL THRD SHRP TRCR TIP FOR,SUP-2186893,CDM,C1769,HCPCS,0272,RC,,,,both,,,112.13,72.88,,,,,,,,,,,,,
SCREW 75 L100 THREAD LENGTH 16 CANNULATED,SUP-2586591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1484.91,965.19,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM 5 H TI LOWER EXTREMITY STR NS,SUP-2905696,CDM,C1713,HCPCS,0278,RC,,,,both,,,2403.92,1562.55,,,,,,,,,,,,,
PLATE BONE L108MM 6 H S STL NAR SELF COMPR,SUP-2198598,CDM,C1713,HCPCS,0278,RC,,,,both,,,277.36,180.28,,,,,,,,,,,,,
SCREW SPNL UNIAXIAL 4X15 MM PEDCL COCR CD HORZ SOLERA 5.5/6,SUP-2730580,CDM,C1713,HCPCS,0278,RC,,,,both,,,6622.26,4304.47,,,,,,,,,,,,,
PATCH CV HEMSHLD L 3 X W 2 IN THK 0.76 MM POLYESTER BOV,SUP-2485400,CDM,C1768,CPT,0278,RC,,,,both,,,538.10,349.76,,,,,,,,,,,,,
GRAFT HUM TISS 1CC FLOWABLE PLCNTA TISS MTRX VIAFLOW,SUP-2399189,CDM,C1713,HCPCS,0278,RC,,,,both,,,6093.67,3960.89,,,,,,,,,,,,,
GRASPER ARTHSCP PROX FOR HAMRTOE CORR NEXTRA,SUP-2137584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,647.09,420.61,,,,,,,,,,,,,
GRAFT HUM TISS 49SQCM DEHYDR HUM AMNION CHORION MEM MESH,SUP-2305757,CDM,Q4186,HCPCS,0636,RC,,,,both,,,32712.52,21263.14,,,,,,,,,,,,,
NAIL IM 5X28 MM TIB W/ T25 STARDRV FOR LCK SCREW TI NS,SUP-2179924,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.71,487.31,,,,,,,,,,,,,
BIT DRL DIA2.4MM CANN W/ AO FIT FOR 4MM SCR,SUP-2136104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SPLINT WRST XSM AD L8IN FOR 5 65IN R NYL LN FOAM PUL ON,SUP-2276666,CDM,L3908,HCPCS,0274,RC,,,,both,,,18.21,11.84,,,,,,,,,,,,,
HEAD HUM 15X44 MM SHLDR RESURF TITAN,SUP-2244070,CDM,C1776,CPT,0278,RC,,,,both,,,15119.10,9827.41,,,,,,,,,,,,,
BUNDLE CASE SINGLE STG CRAN VSP,SUP-2862824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,32861.58,21360.03,,,,,,,,,,,,,
PLATE BNE 6 H RT LAPIDUS FT SLOTLOCK TECHNOLOGY,SUP-2883731,CDM,C1713,HCPCS,0278,RC,,,,both,,,5692.82,3700.33,,,,,,,,,,,,,
SCREW CONN 4MM W COCHLEAR W/ ABUTMENT 6MM PREMOUNTED PONTO,SUP-2319887,CDM,C1713,HCPCS,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
ANCHOR SUTURE OD3.5MM PRE THREADED BIO ANCHOR,SUP-2828531,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.14,299.74,,,,,,,,,,,,,
RING ACET SZ 48 HIP LCK REPLACEMENTXRAY RNGLOC RX90,SUP-2404765,CDM,C1776,CPT,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SHELL ACET SZ A DIA42MM RIM 8 H HIP TI W ARC DEPOSIT SURF,SUP-2372525,CDM,C1776,CPT,0278,RC,,,,both,,,5352.44,3479.09,,,,,,,,,,,,,
GRAFT EVAR IL BRANCH COMP L10CM DIA14.5MM NIT EPTFE FEP,SUP-2395718,CDM,C1768,CPT,0278,RC,,,,both,,,33337.38,21669.30,,,,,,,,,,,,,
BRACE WLK XL 13+ M 15+ WOM ANK FOAM PNEUMAT SEMI RIG SHELL,SUP-2196362,CDM,L4361,HCPCS,0274,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
PROSTHESIS OSS STAPE 0.6X0.6X4.5 MM CUP,SUP-2313686,CDM,L8613,CPT,0278,RC,,,,both,,,343.83,223.49,,,,,,,,,,,,,
STENT BILI SELF EXPANDABLE 0.035 IN 12X40 MM 6 FRX80 CM SMRT,SUP-2158642,CDM,C1876,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
DILATOR SET CURET TY NS IO-FLEX LTX DISP,SUP-2855687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLUG HERN BIOABSRB TYP 1 CLLGN 3-D SCFLD BIO-A,SUP-2395804,CDM,C1781,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
Needle Biopsy Craig Vertebral Body 24-2506,SUP-2853278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
HC IV Dop Vel&/Press C/Flo Rsrv Meas 1st Vessel,PX-4819357100,CDM,93571,CPT,0481,RC,,,,both,,,7672.00,4986.80,,,,,,,,,,,,,
HC So Diabetes Autoimmune Profile (First Cpt),PX-3028633767,CDM,86337,CPT,0302,RC,,,,both,,,187.00,121.55,,,,,,,,,,,,,
PAIN CTRL DEV,SUP-2196461,CDM,C1772,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CAGE SPNL 18X41 TO 65MM EXPANDABLEXCORE,SUP-2310742,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
DRILL TWST SZ 2.5 L91MM DIA2MM STP 40MM AO QUIK CPL,SUP-2267867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.23,303.70,,,,,,,,,,,,,
NEEDLE ASPIR 22GA L80MM PREASSEMBLED PRESTERILIZED DISP,SUP-2313393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.25,332.31,,,,,,,,,,,,,
BIT DRL HUDSON END 28 CM HND COMPLETE DISP,SUP-2481291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5672.35,3687.03,,,,,,,,,,,,,
"HC So Spectrophotometry, Analyte Nes",PX-3018431166,CDM,84311,CPT,0301,RC,,,,inpatient,,,298.00,193.70,,,,,,,,,,,,,
HC Lymph Vessel X-Ray Trunk,PX-3207580700,CDM,75807,CPT,0320,RC,,,,outpatient,,,2864.00,1861.60,,,,,,,,,,,,,
COMPONENT PAT SZ 35MM POLYETH RND RESURF RESTORIS MCK,SUP-2368534,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KIT IMPL L450MM DIA2MM TIM IM AND ENDCAP THE NANCY NAIL,SUP-2253249,CDM,C1713,HCPCS,0278,RC,,,,both,,,782.17,508.41,,,,,,,,,,,,,
PLATE BNE LEFORT 11X0.6 MM LT LINDORF MOD TI,SUP-2473255,CDM,C1713,HCPCS,0278,RC,,,,both,,,836.06,543.44,,,,,,,,,,,,,
TIP IRRIG DIA03MM ASPIR STR ULTRAFLOW,SUP-2110005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN AMNIOEXCEL,SUP-2194321,CDM,Q4137,HCPCS,0636,RC,,,,both,,,3149.42,2047.12,,,,,,,,,,,,,
BIT DRL CANN 11 MM KNEE SINGLE FLUT MTO,SUP-2849087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2238.82,1455.23,,,,,,,,,,,,,
CROWN DENT 4 S STL PRI ANTR UP RT CTRL PREFABRICATED,SUP-2100354,CDM,D6783,CPT,0278,RC,,,,both,,,28.76,18.69,,,,,,,,,,,,,
HC Wound Debridement Tis 20 Cm/<,PX-4509759700,CDM,97597,CPT,0450,RC,,,,both,,,413.00,268.45,,,,,,,,,,,,,
HC Trluml Perip Athrc Renal Art,PX-3610234000,CDM,0234T,HCPCS,0361,RC,,,,both,,,10136.00,6588.40,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM CORT CLAV TI LOK,SUP-2107527,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
CATHETER HAD 2 LUMN,SUP-2127694,CDM,C1750,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
KIT PERITONEAL DLYS TUNN TOOL PLUG STRL DISP RITUS,SUP-2882201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
INSERT TIB SZ 1 THK10MM POST STBL FIX GMK,SUP-2267459,CDM,C1776,CPT,0278,RC,,,,both,,,2341.37,1521.89,,,,,,,,,,,,,
ANCHOR SUT NO2 DIA5.5MM PEEK FULL THRD W/ FORC FBR,SUP-2366678,CDM,C1713,HCPCS,0278,RC,,,,both,,,839.01,545.36,,,,,,,,,,,,,
CATHETER HD DL 14.5X28 CM 45 CM SYMMETRICAL TIP PALINDROME,SUP-2283926,CDM,C1750,HCPCS,0278,RC,,,,both,,,1297.13,843.13,,,,,,,,,,,,,
FIBER LASER 70 DEG INFRATOME,SUP-2225608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PRECISION CONNECTOR M1 70 CM,SUP-2700482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GRAFT BNE WDG 10 DEG 10 MM LAPIDUS,SUP-2321727,CDM,C1713,HCPCS,0278,RC,,,,both,,,6341.23,4121.80,,,,,,,,,,,,,
PROBE 25GA ENH STANDALONE VITRCTMY,SUP-2109927,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
TI MSH STR BEALS STY RGD BLU2 H20 SYS,SUP-2677461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.37,1083.14,,,,,,,,,,,,,
DEVICE PESSARY TNDM CUBE 7-5 2.25X1.75 IN PROCIDENTIA MILEX,SUP-2755566,CDM,A4562,HCPCS,0274,RC,,,,both,,,301.60,196.04,,,,,,,,,,,,,
COLLAR CERV FLX N ADJ PREFABRICATED OFF THE SHLF BRAC,SUP-2388131,CDM,L0120,HCPCS,0274,RC,,,,both,,,71.59,46.53,,,,,,,,,,,,,
ROD SPNL 11X350 MM,SUP-2205342,CDM,C1713,HCPCS,0278,RC,,,,both,,,704.15,457.70,,,,,,,,,,,,,
BUR SURG L26CM HD L351MM DIA3MM TAPR L BOR MIDAS REX,SUP-2277966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
DRILL TWST L72MM DIA1.2MM STP 10MM FOR 1.2MM LAG SCR DENT,SUP-2267817,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.34,245.92,,,,,,,,,,,,,
SCREW BNE L8MM DIA3MM CORT TI ST NONCANNULATED LOK FULL THRD,SUP-2190331,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.66,413.18,,,,,,,,,,,,,
INVISION  TIBIAL TRAY SZ 2 4MM UNIVERSAL LNG,SUP-2477326,CDM,C1776,CPT,0278,RC,,,,both,,,18199.44,11829.64,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X131 MM RT LAT DSTL 7 HOLE STRL VALCP,SUP-2789392,CDM,C1713,HCPCS,0278,RC,,,,both,,,3267.23,2123.70,,,,,,,,,,,,,
BUR SURG DIA1 MM HUB II ROSEN STRL DISP HI-LINE XS,SUP-2928849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.76,205.24,,,,,,,,,,,,,
VALVE CSF M PRSS W/ ASD,SUP-2308212,CDM,C1889,HCPCS,0278,RC,,,,both,,,5226.22,3397.04,,,,,,,,,,,,,
TUBE VENT L6MM ID1.14MM C FLX T TYP,SUP-2284037,CDM,L8699,HCPCS,0278,RC,,,,both,,,270.64,175.92,,,,,,,,,,,,,
HC So Molecular Path Level 2,PX-3108140166,CDM,81401,CPT,0310,RC,,,,both,,,391.00,254.15,,,,,,,,,,,,,
MESH HERN L15XW23CM OBLONG INTRAABDOMINAL PLCMNT PROLITE,SUP-2265986,CDM,C1781,HCPCS,0278,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
SEAL BONE CEM SZ 4-7 FEM DEF PRSS FIT,SUP-2375361,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
SCREW BNE L32MM DIA3.5MM UNIV CORT S STL ST NONCANNULATED,SUP-2411075,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.62,49.80,,,,,,,,,,,,,
ANCHOR SUT 4 FBR SZ 2 SUT TI OD6.5MM INTRALINE,SUP-2421260,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.59,420.93,,,,,,,,,,,,,
PIN FIX L35MM SET CBL RDY,SUP-2410276,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.75,514.64,,,,,,,,,,,,,
PLATE CRAN L 20 MM THK 0.4 MM SCREW DIA1.5 MM TI SHUNT LP,SUP-2883648,CDM,C1713,HCPCS,0278,RC,,,,both,,,1227.65,797.97,,,,,,,,,,,,,
SHAFT IMPL INSRT SPNL MESH CATLYST,SUP-2285271,CDM,C1713,HCPCS,0278,RC,,,,both,,,479.32,311.56,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1173108D2,SUP-2632786,CDM,C1751,HCPCS,0278,RC,,,,both,,,793.35,515.68,,,,,,,,,,,,,
SCREW INTFR 8MMX25MM GENESYS MATRYX,SUP-2166540,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.83,733.74,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA12 MM STD OPT FIX CANN DOLPHIN,SUP-2896173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.88,310.62,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 88 MM DIA DSTL 12 MM SHTH 14 FR SS,SUP-2168731,CDM,C1768,CPT,0278,RC,,,,both,,,8732.34,5676.02,,,,,,,,,,,,,
COMPONENT ARTC L35MM 8X8MM OFFSET FEM HD CO CHROM ALLOY,SUP-2123650,CDM,C1776,CPT,0278,RC,,,,both,,,19939.00,12960.35,,,,,,,,,,,,,
KIT DRL BIT DIA3MM LOC PIN TAMP K WIRE CORRESPONDING,SUP-2254036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.59,561.33,,,,,,,,,,,,,
CLIP ANEUR T BAR 45 DEG 9 MM PERM TI STRL YASRG,SUP-2108699,CDM,C1889,HCPCS,0278,RC,,,,both,,,5960.19,3874.12,,,,,,,,,,,,,
BIT DRILL DIA4MM WITH STOP WRIST FREEDOM ARTHROPLASTY SYSTEM,SUP-2586702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,859.92,558.95,,,,,,,,,,,,,
COMPONENT ARTC 8.5X5MM OFFSET TROCHLEAR HEMICAP,SUP-2123687,CDM,C1776,CPT,0278,RC,,,,both,,,16673.40,10837.71,,,,,,,,,,,,,
STEM FEM EPOCH TIV HA/TCP COAT SZ 11 LT,SUP-2210194,CDM,C1776,CPT,0278,RC,,,,both,,,21966.50,14278.22,,,,,,,,,,,,,
MIS LOCK CALC PLT LG EXD 3H RT,SUP-2586882,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.81,1827.68,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.511,SUP-2860193,CDM,C1713,HCPCS,0278,RC,,,,both,,,29479.58,19161.73,,,,,,,,,,,,,
IMPLANT DERM W100XL100MM CLLGN SQ SHT ALLOMAX,SUP-2125857,CDM,C1781,HCPCS,0278,RC,,,,both,,,9922.40,6449.56,,,,,,,,,,,,,
INQUIRY LUMA STEER 1102 L 7 5 L,SUP-2698837,CDM,C1730,HCPCS,0272,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
CATHETER ABLATN D-F CRV N NAVIGATIONAL EZ STEER THERMOCOOL,SUP-2257365,CDM,C1732,HCPCS,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PLATE L DSTL RAD DRSL 2.4MM -90D 2H HD 5H SHFT TI STRL,SUP-2546749,CDM,C1713,HCPCS,0278,RC,,,,both,,,2421.76,1574.14,,,,,,,,,,,,,
HC Fluoro Xray Venogram Ext Unil,PX-3207582000,CDM,75820,CPT,0320,RC,,,,both,,,1017.00,661.05,,,,,,,,,,,,,
ALLOGRAFT BNE HEMI CONDYLE FEM FRZN,SUP-2321812,CDM,C1713,HCPCS,0278,RC,,,,both,,,30615.00,19899.75,,,,,,,,,,,,,
GUIDEWIRE VASC TAPR STD XL 0.014 INX300 CM 42 CM NEUROSCOUT,SUP-2492092,CDM,C1769,HCPCS,0272,RC,,,,both,,,2850.15,1852.60,,,,,,,,,,,,,
TAP SURG FIX FOR SNOWMASS ANTR CERV PLT SYS,SUP-2207792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,983.45,639.24,,,,,,,,,,,,,
VOLAR DR AIMING BLOCK INTERMEDIATE RIGHT 7 HOLES,SUP-2702832,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
GRAFT BNE WDG 0 DEG 30X12X10 MM FIBULAR,SUP-2860939,CDM,C1713,HCPCS,0278,RC,,,,both,,,7473.20,4857.58,,,,,,,,,,,,,
HC ED Clsd Tx Radial Head/Neck Fx Manip,PX-4502465500,CDM,24655,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
BLADE SAW L 111 MM L 33 MM THK MATERIAL 0.4 MM CUT 0.6 MM,SUP-2929133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,557.10,362.11,,,,,,,,,,,,,
GRAFT SYN DIA10MM MT CART DURABLE BIOCOMPATIBLE,SUP-2162878,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PLATE BNE CNDYL 2X39 MM RT 7 HOLE FOR SCR MINI FRAG SYS SS,SUP-2489734,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR L4MM PRELD IN SMRT INSRTR AND BRSH,SUP-2124396,CDM,L8509,HCPCS,0274,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
INSERT TIB SZ 1 THK7MM POST STBL BAL SYS,SUP-2314694,CDM,C1776,CPT,0278,RC,,,,both,,,2800.88,1820.57,,,,,,,,,,,,,
PACK VENT ASST L SHLDR BG PT PERS SUPP,SUP-2282574,CDM,Q0498,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
METOCLOPRAMIDE HCL 10 MG/10ML PO SOLN,RX-77710,CDM,6370000000,HCPCS,0637,RC,00121-1576-10,NDC,,both,5,ML,9.20,5.98,,,,,,,,,,,,,
KIT INTRO AXCESS L 11 CM DIA 7 FR GUIDEWIRE 0.035-0.038 IN,SUP-2119988,CDM,C1894,HCPCS,0272,RC,,,,both,,,43.18,28.07,,,,,,,,,,,,,
SLEEVE IM 120DEG LT BLU TI FOR SPRL BLDE FEM NAIL,SUP-2192714,CDM,C1713,HCPCS,0278,RC,,,,both,,,1339.52,870.69,,,,,,,,,,,,,
CLIP MED L235CM L2.8MM 11MM OPN HEMSTAT FIX RESOL,SUP-2149433,CDM,C1889,HCPCS,0278,RC,,,,both,,,480.61,312.40,,,,,,,,,,,,,
HC Prog Eval Multi Lead Icd,PX-4809328400,CDM,93284,CPT,0480,RC,,,,both,,,132.00,85.80,,,,,,,,,,,,,
PLATE BNE L220MM 9 H NONSTERILE L LAT PROX TIB TI LOK COMPR,SUP-2190716,CDM,C1713,HCPCS,0278,RC,,,,both,,,4395.50,2857.07,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM 2 WHT BLU PEEK OPTMA FULL THRD AWL,SUP-2341784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
COLLAGENASE 250 UNIT/GM EX OINT,RX-9682,CDM,6370000000,HCPCS,0637,RC,50484-0010-30,NDC,,both,30,GR,1428.60,928.59,,,,,,,,,,,,,
BIT DRL L110MM DIA27MM 3 FLUT QUIK CPL NONRADIOPAQUE W O,SUP-2187587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.88,222.22,,,,,,,,,,,,,
GUIDEWIRE URO L150CM 0038IN S STL PTFE STR TIP SMOOTH FLAT,SUP-2312597,CDM,C1769,HCPCS,0272,RC,,,,both,,,113.07,73.50,,,,,,,,,,,,,
RELOAD STPL 45MM CRV TIP ARTC FOR MEDIUM/THICK TISS,SUP-2283355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.03,564.87,,,,,,,,,,,,,
HC Feeding Tube Plcmt W Fluoro,PX-3614375200,CDM,43752,CPT,0361,RC,,,,inpatient,,,1485.00,965.25,,,,,,,,,,,,,
DEVICE RESECTING SMOL 2.9 MM AVETA DISP,SUP-2739121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CABLE CNTOUR 3.5MM SERFAS,SUP-2362166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.03,267.17,,,,,,,,,,,,,
LEVOFLOXACIN 5 MG/ML IVPB (PED) >/= 50 ML,RX-4090161,CDM,J1956,HCPCS,0250,RC,00143-9317-24,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
BUR SURG SHANK L13CM DIA3MM LILAC COARSE DMND RND,SUP-2365190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.59,394.28,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 13 HOLES/316MM/RIGHT-STERILE,SUP-2549455,CDM,C1713,HCPCS,0278,RC,,,,both,,,5594.29,3636.29,,,,,,,,,,,,,
STEM FEM OD13MM +0MM SH TI HIP REV POLISHED EMPERION,SUP-2344349,CDM,C1776,CPT,0278,RC,,,,both,,,8145.16,5294.35,,,,,,,,,,,,,
GRAFT VASC L40CM DIA28MM STR STD WALL N RING WVN VASCUTEK,SUP-2385011,CDM,L8670,HCPCS,0278,RC,,,,both,,,8383.80,5449.47,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 12.9 MM 32 CC 69 GM VENTRIC EPIC + VR V196RST] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356533,CDM,C1722,HCPCS,0275,RC,,,,both,,,64903.80,42187.47,,,,,,,,,,,,,
DRILL SURG HD 30 MM HIP GRIPTION TF PINNACLE,SUP-2453608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
CHOICE INTERMEDIATE 182CM MAG 5PK,SUP-2664362,CDM,C1729,HCPCS,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
IMMOBILIZER KNEE PERF-VINYL FOAM MEDL LAT POST STAY LOOP LCK,SUP-2197967,CDM,L1830,CPT,0272,RC,,,,both,,,98.78,64.21,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.038IN L3CM STD SM VES NIT GR3803] TERUMO MEDICAL CORP],SUP-2385578,CDM,C1769,HCPCS,0272,RC,,,,both,,,134.20,87.23,,,,,,,,,,,,,
SEEDS 2.0 MCI -3.0 MCI LD IN COMS PLAQ 1-125,SUP-2247264,CDM,C2642,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PROBE ELECSURG 7FR L270CM DISP ABC FLX,SUP-2166129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,707.44,459.84,,,,,,,,,,,,,
IMPL CAPPED H4 HEMI UNI/BIPOLAR EXACTECH,SUP-2435984,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
CONNECTOR SPNL SM SIDE/FRONT LD,SUP-2317815,CDM,C1713,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L 115 CM 7 FR 6MM D,SUP-2457296,CDM,C1730,HCPCS,0272,RC,,,,both,,,2583.44,1679.24,,,,,,,,,,,,,
SHIM SPNL SZ 25 MM INTDISC INSRTN MONITORING NS DISP,SUP-2886317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
HC Antigen Typing,PX-3008690500,CDM,86905,CPT,0300,RC,,,,both,,,170.00,110.50,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6 MM 20 CM STR STD WALL,SUP-2396265,CDM,C1768,CPT,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
PLATE BONE SQUARE SHEET 50X50X3 MM STERILE SYNPOR,SUP-2837794,CDM,C1713,HCPCS,0278,RC,,,,both,,,3154.13,2050.18,,,,,,,,,,,,,
WALKER LEG DLX BLK SHT L,SUP-2276713,CDM,L4387,HCPCS,0274,RC,,,,both,,,87.64,56.97,,,,,,,,,,,,,
IMPLANT FEM SZ 4 LT REV PROVEN,SUP-2359377,CDM,C1776,CPT,0278,RC,,,,both,,,6738.44,4379.99,,,,,,,,,,,,,
GRAFT BNE 100X25X4 MM 10 CC CALCIUM PHOSPHATE NANOSS 3D +,SUP-2731722,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM BIOCRYL RAPIDE ABSRB MILAGRO,SUP-2249524,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
TITANIUM MESH PANEL SML GRID 83MM X 50MM 3MM 10MM SYS CP T,SUP-2681327,CDM,C1713,HCPCS,0278,RC,,,,both,,,2651.86,1723.71,,,,,,,,,,,,,
STRUT EXT FIX MED MULTAXL CORRECTION SYS HEXAPOD FULL AUTO,SUP-2905641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6720.60,4368.39,,,,,,,,,,,,,
ELECTRODE ENDOSCP MPLR BAYNT W  INTERCHANGEABLE TIP CONIC,SUP-2436275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1746.47,1135.21,,,,,,,,,,,,,
HC Transesophageal Echo,PX-4839331200,CDM,93312,CPT,0483,RC,,,,both,,,1699.00,1104.35,,,,,,,,,,,,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,0636,RC,00409-1163-01,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
RXG PLATE STR 10 HOLE T06MM,SUP-2694976,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.03,560.97,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 15 HOLE/356MM RIGHT-STERILE,SUP-2546859,CDM,C1713,HCPCS,0278,RC,,,,both,,,5524.74,3591.08,,,,,,,,,,,,,
STENT URTRL 85FR DIA 20CML TCFLX DBLE PGTL ST SNGLE USE,SUP-2721831,CDM,C2617,HCPCS,0278,RC,,,,both,,,190.47,123.81,,,,,,,,,,,,,
DRILL SURG 7.5X25 MM TRABECULAR MTL RVS +,SUP-2436864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
CATHETER HD FULL SAFETY TY 035 12 FRX25 CM DRY TURBO-FLO HD,SUP-2759840,CDM,C1752,HCPCS,0278,RC,,,,both,,,447.64,290.97,,,,,,,,,,,,,
BRA SURG SUPP LG 38-40 IN ZIPPER,SUP-2213721,CDM,L8000,HCPCS,0274,RC,,,,both,,,125.41,81.52,,,,,,,,,,,,,
TIP LSR FBR CONCL LT TCH,SUP-2164904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SPACER SPNL CERV 14X11X7 MM GRAFTECH,SUP-2279905,CDM,C1889,HCPCS,0278,RC,,,,both,,,2499.44,1624.64,,,,,,,,,,,,,
SHEATH DELIVERY STEERABLE AMPLATZER 14F,SUP-2858706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE 6 MM ANK GALAXY FIX GEM LTX,SUP-2875648,CDM,C1713,HCPCS,0278,RC,,,,both,,,33898.50,22034.02,,,,,,,,,,,,,
PATCH CV ULTRAMAX L 7.6 X W 2.5 CM POLYESTER GEL KNITTED DBL,SUP-2265998,CDM,C1768,CPT,0278,RC,,,,both,,,346.19,225.02,,,,,,,,,,,,,
HEAD FEM 0+ MM 12/14 40 MM HIP TAPR CERM,SUP-2449612,CDM,C1776,CPT,0278,RC,,,,both,,,4846.59,3150.28,,,,,,,,,,,,,
PROSTHESIS PENILE L15CM INFL IFP APPRCH PRECONN W/ MS PMP,SUP-2138977,CDM,C1813,HCPCS,0278,RC,,,,both,,,30591.45,19884.44,,,,,,,,,,,,,
PLATE BNE L100MM 5 H BILAT S STL T NONCOMPRESSION LO PROF,SUP-2185754,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.58,542.48,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 10 CM FLPY TIP 3,SUP-2167686,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.90,24.63,,,,,,,,,,,,,
PLATE BONE OFFSET 4MM THK0.7MM 5 H BILAT CHIN MAXILLOFACIAL,SUP-2181839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.16,888.65,,,,,,,,,,,,,
PLATE BNE LCK UNIV 2.7X49 MM 4 HOLE CONTOURED 2 COMPR,SUP-2462601,CDM,C1713,HCPCS,0278,RC,,,,both,,,786.57,511.27,,,,,,,,,,,,,
GRAFT HUMAN TSSUE MTRX 192SQCM THICK 12CMW X 16CML 23 33MM,SUP-2676529,CDM,Q4116,HCPCS,0636,RC,,,,both,,,20802.50,13521.62,,,,,,,,,,,,,
PLATE BNE L90MM BRL L25MM 150DEG 4 H NONSTERILE BILAT PELV,SUP-2186833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1454.35,945.33,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST DBL UPR W/AIR OFF THE SHLF,SUP-2435616,CDM,L1848,HCPCS,0274,RC,,,,both,,,1628.40,1058.46,,,,,,,,,,,,,
GRAFT BNE 20CC W/ BIOACTIVE GLS MOLD MTRX PLATFORM,SUP-2719784,CDM,C1713,HCPCS,0278,RC,,,,both,,,22765.00,14797.25,,,,,,,,,,,,,
TROCAR ENDOSCOPIC L100MM DIA12MM THREADED FIRST ENTRY FOR ABDOMINAL ACCESS SYSTEM KII FIOS,SUP-2119664,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.14,470.04,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK 6 FR INSPIRE,SUP-2265138,CDM,C1713,HCPCS,0278,RC,,,,both,,,1859.67,1208.79,,,,,,,,,,,,,
PLATE BNE CRV 3.5 MM 12 HOLE RECON,SUP-2197687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1245.95,809.87,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM OD 7 FR ID 2.3 MM GUIDEWIRE,SUP-2168418,CDM,C1894,HCPCS,0272,RC,,,,both,,,89.18,57.97,,,,,,,,,,,,,
PLATE BONE L92MM 4 H STRL LT PROX HUM S STL CVD FOR 3.5MM,SUP-2349773,CDM,C1713,HCPCS,0278,RC,,,,both,,,8863.28,5761.13,,,,,,,,,,,,,
HEAD MOD RAD SZ 20S,SUP-2244260,CDM,C1776,CPT,0278,RC,,,,both,,,8058.03,5237.72,,,,,,,,,,,,,
CATHETER EP STD 2-8-2 MM 6 FRX105 CM POLARIS,SUP-2148487,CDM,C1730,HCPCS,0272,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
ATOVAQUONE 750 MG/5ML PO SUSP,RX-14953,CDM,340b,HCPCS,0637,RC,00904-7459-41,NDC,,both,5,ML,66.70,43.35,,,,,,,,,,,,,
GRAFT HUM TISS W10-30MMXL3-10CM THK3-20MM COSTAL CART FRZN,SUP-2307298,CDM,C1713,HCPCS,0278,RC,,,,both,,,2022.47,1314.61,,,,,,,,,,,,,
ROD SPNL STR END SPOOL CRD STRL TRANSITION,SUP-2230050,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER EP CRD 10 MM 5 FRX120 CM SUPREME,SUP-2356933,CDM,C1730,HCPCS,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
GRAFT VASC STD WALL 6 MMX10 CM STR RNG REINF ADVANTA VXT,SUP-2469231,CDM,C1768,CPT,0278,RC,,,,both,,,570.85,371.05,,,,,,,,,,,,,
MARKER SURG TEND FOR BIOINDUCTIVE IMPL REGENETEN,SUP-2848906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
FIBER LASER 200UM DUST THULIUM,SUP-2885377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
HC Open/Perq Place Stent Ea Add A,PX-3603723700,CDM,37237,CPT,0360,RC,,,,inpatient,,,15457.00,10047.05,,,,,,,,,,,,,
PLATE BONE THK1.5MM 12 H CRANIOMAXILLOFACIAL ORAL SLV TI STR,SUP-2181770,CDM,C1713,HCPCS,0278,RC,,,,both,,,3044.23,1978.75,,,,,,,,,,,,,
HC So Microsomal Antibody,PX-3028637666,CDM,86376,CPT,0302,RC,,,,both,,,237.00,154.05,,,,,,,,,,,,,
GRAFT BONE 2.5CC HCT/P 361 REGULATED VIABLE CELLULAR,SUP-2419111,CDM,C1713,HCPCS,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
CLAMP ANSTMSS CLEY SRRTD 6 1/2NL 3/4NL X 1/4ND JAW DBLE CRVD,SUP-2473939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,862.31,560.50,,,,,,,,,,,,,
CATHETER INFUSION 3X2.4 FRX130 CM 0.021 INX180 CM DIREXION,SUP-2141060,CDM,C1887,HCPCS,0272,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
HC Tips Revision,PX-3613718300,CDM,37183,CPT,0361,RC,,,,outpatient,,,15457.00,10047.05,,,,,,,,,,,,,
PLATE BNE LAT CLMN FUSION SM RT BABY GORILLA,SUP-2751118,CDM,C1713,HCPCS,0278,RC,,,,both,,,4702.15,3056.40,,,,,,,,,,,,,
IMPLANT SUBTALAR DIA 9 MM TI CONCL SFT THRD STRL TALAR-FIT,SUP-2913152,CDM,C1776,CPT,0278,RC,,,,both,,,7350.74,4777.98,,,,,,,,,,,,,
GRAFT NRV L30MM DIA3-4MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124852,CDM,C1763,HCPCS,0278,RC,,,,both,,,14035.80,9123.27,,,,,,,,,,,,,
CENTRALIZER MS 30 PROX/STAN SZ 10,SUP-2204700,CDM,C1776,CPT,0278,RC,,,,both,,,419.50,272.67,,,,,,,,,,,,,
RING EXT FIX 140 MM 5/8 CARBON FIBER NS,SUP-2799525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1672.36,1087.03,,,,,,,,,,,,,
PLATE BNE H1.5MM 6 H MAND G TI LO PROF FRAC W/ BAR FOR,SUP-2366365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1467.95,954.17,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 8X6 CM PLCNTA BASE MEMBRN AMNIOEFFECT,SUP-2872721,CDM,C1762,CPT,0278,RC,,,,both,,,16155.30,10500.94,,,,,,,,,,,,,
PLATE BNE THK0.5MM 6X6 H UNIV CRANIOMAXILLOFACIAL TI 3D MAL,SUP-2366234,CDM,C1713,HCPCS,0278,RC,,,,both,,,2975.56,1934.11,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|CQ|XU|KX,both,,,144.00,93.60,,,,,,,,,,,,,
STEM HUM 9.5X125MM MOD II,SUP-2408649,CDM,C1776,CPT,0278,RC,,,,both,,,8176.56,5314.76,,,,,,,,,,,,,
BRACE WALKING LP MED 5.5-10 IN 6.5-11 IN AD M MAXTRAX AIR,SUP-2427327,CDM,L4360,HCPCS,0272,RC,,,,both,,,93.76,60.94,,,,,,,,,,,,,
SUTURE TAPE,SUP-2907276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
DRESSING WND MTRX 7X20 CM MESHED STR STRL OASIS,SUP-2341253,CDM,Q4102,HCPCS,0636,RC,,,,both,,,21901.50,14235.97,,,,,,,,,,,,,
CATHETER BLLN DIL 200 CM 5-20 MMX70 CM SAVARY-GILLIARD,SUP-2759272,CDM,C1769,HCPCS,0272,RC,,,,both,,,11329.12,7363.93,,,,,,,,,,,,,
ALLOGRAFT CORT RING 12 DIA X 7 H X 4 MM,SUP-2863665,CDM,C1713,HCPCS,0278,RC,,,,both,,,6110.44,3971.79,,,,,,,,,,,,,
DRILL SURG 24X33MM PROX SL,SUP-2400089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BONE W5.4XL30MM THK1.5MM 6 H RT FOREFOOT TI T FOR,SUP-2225450,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.81,1402.58,,,,,,,,,,,,,
GRAFT VASC 8X30 MM AORT ARCH SINGLE BRANCH WOVEN,SUP-2472450,CDM,C1768,CPT,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
PLATE BNE W8XL160MM THK3.3MM 20 H NONSTERILE BILAT PELV S,SUP-2186247,CDM,C1713,HCPCS,0278,RC,,,,both,,,2659.27,1728.53,,,,,,,,,,,,,
PLATE BONE 5 HOLE 2X27 MM TITANIUM NON STERILE DCP,SUP-2838375,CDM,C1713,HCPCS,0278,RC,,,,both,,,1241.87,807.22,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 4-7 MM SHRT TAPR REINF,SUP-2669626,CDM,C1768,CPT,0278,RC,,,,both,,,1481.45,962.94,,,,,,,,,,,,,
HC So Drug Assay Itraconazole,PX-3018018966,CDM,80189,CPT,0301,RC,,,,both,,,399.00,259.35,,,,,,,,,,,,,
PROMETHAZINE HCL 25 MG PO TABS,RX-6622,CDM,Q0169,HCPCS,0637,RC,00904-7304-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 1-4 MM 30 CC FRZN IRRADIATED CANC,SUP-2866925,CDM,C1762,CPT,0278,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
MESH SURG 20 X 20.5 CM SUTURE SZ 6-0 OVINE PGA REINF TISS,SUP-2914816,CDM,C1781,HCPCS,0278,RC,,,,both,,,23179.48,15066.66,,,,,,,,,,,,,
CATHETER KIT 2 LUMEN 5 FR ASK04052SEH] TELEFLEX INC],SUP-2383959,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.67,286.44,,,,,,,,,,,,,
PLATE BURR H L 54.8 MM DIA 48 MM THK 0.51 MM TI NS DISP,SUP-2935927,CDM,C1713,HCPCS,0278,RC,,,,both,,,2191.72,1424.62,,,,,,,,,,,,,
COMPONENT HUMERALXSM L6IN UNIV DSTL ELBW TIV PLSM,SUP-2205921,CDM,C1776,CPT,0278,RC,,,,both,,,11417.04,7421.08,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 12.6-20,PX-4501203500,CDM,12035,CPT,0450,RC,,,,both,,,1674.00,1088.10,,,,,,,,,,,,,
CATHETER DIL UROMX ULTRA L 75 CM DIA21 FR BALLOON L 4 CM DIA,SUP-2139199,CDM,C1726,HCPCS,0272,RC,,,,both,,,864.54,561.95,,,,,,,,,,,,,
LIFT HEEL MED ADJLFT,SUP-2394117,CDM,L3334,HCPCS,0274,RC,,,,both,,,38.31,24.90,,,,,,,,,,,,,
LENS IOL 12.0 DIOPT CYL 1.5 DIOPT L 13 MM DIA 6 MM,SUP-2881506,CDM,V2787,HCPCS,0276,RC,,,,both,,,505.00,328.25,,,,,,,,,,,,,
BOWL BONE CEM MX W/ SPAT SUMMIT,SUP-2304362,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
PROSTHESIS OSS MANGHAM PISTON 0.6X5 MM FLROPLAS PLAT,SUP-2638201,CDM,L8613,CPT,0278,RC,,,,both,,,510.63,331.91,,,,,,,,,,,,,
DRILL TWST DIA4MM ADPT RADLUC TARGETING DEV,SUP-2408641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
STIMULATOR NERVE PERIPH SUNSTIM LF,SUP-2381625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1118.63,727.11,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.513,SUP-2860030,CDM,C1713,HCPCS,0278,RC,,,,both,,,36330.74,23614.98,,,,,,,,,,,,,
CATHETER EP CSL 2-8-2 MM 5 FRX120 MM SUPREME,SUP-2355231,CDM,C1730,HCPCS,0272,RC,,,,both,,,1414.35,919.33,,,,,,,,,,,,,
Z DISCONTINUED USE 2903995 CATHETER GUID AD 7FR L100CM COR PERIPH ORNG NYL PTFE XB L,SUP-2158386,CDM,C1887,HCPCS,0272,RC,,,,both,,,112.10,72.86,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED TUBE VENT L12MM ID1.14X2.2MM EAR FLROPLAS SPL FEUERSTEIN,SUP-2381506,CDM,L8699,HCPCS,0278,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
NERVE STIMULATOR KIT PROC EMG/NMJ SURFACE/SSEP SURF ELECTRD,SUP-2725217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PACK VITRCTMY 20GA STR ENDOILLUMINATOR CONSTELLATION TOT +,SUP-2109924,CDM,C1713,HCPCS,0278,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|KX|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
MESH SURG W20XL30CM PTFE RECT KNIT FLM PARTIALLY ABSRB,SUP-2395757,CDM,C1781,HCPCS,0278,RC,,,,both,,,13888.22,9027.34,,,,,,,,,,,,,
PACEMAKER CARD ESTELLA DR-T 2 CHMBR HOME MONITORING,SUP-2138294,CDM,C1785,HCPCS,0275,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 55 CM DIA 7 FR CRV BEND 9 MM DIL 73,SUP-2604662,CDM,C1887,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE 3 H 7 PEG STD L VOLAR S STL FIX ANG,SUP-2389779,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
PLATE BNE STR REG CRANIOFACIAL NEURO 4 HOLE LP CONTOURED NS,SUP-2470400,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.01,188.51,,,,,,,,,,,,,
CONNECTOR 7 MM 7.5 DEG TEAL TI FOR IMPLATE SYS,SUP-2340251,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
BIT DRL DIA73MM LNG CANN REUSE,SUP-2319441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UNI STEJK4] STRYKER CORP],SUP-2365945,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
BRACE LUMBOSACRALXL 15DEG BK HK RECV MAT SFT BRTH LNR RIG,SUP-2195547,CDM,L0625,HCPCS,0274,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
BUNDLE CASE DISTRCTN CRAN MXLFCL 1 FULL SKULL RECON VSP,SUP-2862825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16149.59,10497.23,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 8 FR AIRGUARD POWERPORT ISP,SUP-2126309,CDM,C1788,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
STAPLE CAUD TI 19MM SM CD HORZ,SUP-2290268,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PROCESSOR HEARING AID CHROMA BGE LT EAR SND PROC CHAN WIND,SUP-2319859,CDM,L8690,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
IMMOBILIZER SHOULDERXL FOR 42-48IN CHST ELAS W/O NK STRP M,SUP-2197392,CDM,L3660,HCPCS,0274,RC,,,,both,,,70.02,45.51,,,,,,,,,,,,,
REVISION TIB BUSHING 4 MM OFFSET,SUP-2359214,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HEMOSTATIC KIT POLYSACCHARIDE 230 CM 2.8 MM 5 GM ENDOCLOT,SUP-2865644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X1 CMX1.27 3.30 MM TISSUE MATRIX ALLODERM,SUP-2459017,CDM,Q4116,HCPCS,0636,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
KNIFE SURG JANNETTA SM 7.5 IN ANGLED LF,SUP-2485564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.86,214.41,,,,,,,,,,,,,
KIT HEMO DYLS OR HD CATH 15.5FR L24CM STD CHRONIC PEEL AWAY,SUP-2120052,CDM,C1751,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM DIA26 MM SHTH 20 FR AORT,SUP-2396365,CDM,C1713,HCPCS,0278,RC,,,,both,,,40035.00,26022.75,,,,,,,,,,,,,
RELOAD STPL 40MM H1.5-3.5MM WIRE 0.2MM REG TISS BLU CRV,SUP-2716237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.13,578.58,,,,,,,,,,,,,
SCREWDRIVER BLADE 2 MM RT ANGLED W/ DENT LATCH SS MAXDRIVE,SUP-2461284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.30,270.59,,,,,,,,,,,,,
PIN EXT FIX HALF 6X250 MM 85 MM GRY XTRAFIX,SUP-2534566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
SYSTEM PRP 60ML FOR GENTLE CENTRIFUGATION ACT HI YLD,SUP-2223569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
PLATE BONE PREFORMED LARGE 2.5 MM RIGHT MANDIBLE RECONSTRUCT,SUP-2837780,CDM,C1713,HCPCS,0278,RC,,,,both,,,11003.19,7152.07,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR FJ,SUP-2248607,CDM,C1732,HCPCS,0272,RC,,,,both,,,9730.86,6325.06,,,,,,,,,,,,,
SPACER SPNL CORPECTOMY MED LG 0 DEG 30X25X3946 MM XPANDR,SUP-2740411,CDM,C1889,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
NEEDLE OPHTH DIX SPUD FB W/ REVERSIBLE SCREW HNDL SS,SUP-2486999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.95,316.52,,,,,,,,,,,,,
KIT CATH CATH CTRL VEN SET POLYUR SGL LUMN WITHINTEGRAL EXTN,SUP-2120634,CDM,C1751,HCPCS,0278,RC,,,,both,,,46.06,29.94,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA3MM THRD L35MM HALF FOR SIDEKCK STLTH,SUP-2400687,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
KIT INSTR ANTI-DRIFTBOLT REAMER PK OUT STRL DISP MOTOBAND CP,SUP-2893329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
HC Ultrasound Procedure Unlisted,PX-4027699900,CDM,76999,CPT,0402,RC,,,,outpatient,,,276.00,179.40,,,,,,,,,,,,,
SYSTEM POS STBL BUND ACROBAT I,SUP-2227773,CDM,C1713,HCPCS,0278,RC,,,,both,,,5959.15,3873.45,,,,,,,,,,,,,
SPLINT KNEE UNIV FOR LESS THAN 36IN L24IN FOAM LAM ELAS CNTCT,SUP-2197156,CDM,L3650,HCPCS,0274,RC,,,,both,,,45.34,29.47,,,,,,,,,,,,,
ROD SPNL DIA 6 MM CARBON FIBER PEDCL PT SPEC CRV STRL,SUP-2883041,CDM,C1713,HCPCS,0278,RC,,,,both,,,49455.00,32145.75,,,,,,,,,,,,,
GRAFT MESHED W5XL5CM PRIMATRIX DERM REP SCAFFOLD,SUP-2243704,CDM,Q4110,HCPCS,0636,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PEG BNE FIX DST FEM MOD TRIATHLON,SUP-2373755,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SPACER KNEE BLOCK CUT 10 MM DSTL FEM SLT SPEC 2,SUP-2456665,CDM,C1776,CPT,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
MESH HERN RECTANGULAR 10X16 CM INTRAPERITONEAL ENFORM,SUP-2539548,CDM,C1781,HCPCS,0278,RC,,,,both,,,9291.26,6039.32,,,,,,,,,,,,,
SHEATH INTRO TISS STBL 11 FRX11.2 CM 16.2X19.4 FR EVOLUTION,SUP-2638746,CDM,C1893,HCPCS,0272,RC,,,,both,,,779.47,506.66,,,,,,,,,,,,,
BLADE SHAVER CRV 15 DEG 4.8 MM SERRATED HEMOSTATIC CONCV,SUP-2648914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.80,380.77,,,,,,,,,,,,,
PLATE BNE L78MM BLDE W5.8XL38MM 130DEG 4 H NONSTERILE BILAT,SUP-2186597,CDM,C1713,HCPCS,0278,RC,,,,both,,,1579.11,1026.42,,,,,,,,,,,,,
PLATE BONE CRANIAL SHORT 6 HOLE GAP 28.8X14.5X0.4MM TITANIUM,SUP-2827183,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.09,343.91,,,,,,,,,,,,,
CLIP IMPL BLADE L 7.5/6.7 MM MAXIMAL OPENING 5 MM CLS FORC,SUP-2929097,CDM,C1889,HCPCS,0278,RC,,,,both,,,1331.58,865.53,,,,,,,,,,,,,
SCREW ATTCH TIB STEM EXACTECH,SUP-2222987,CDM,C1713,HCPCS,0278,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
CLAMP EXT FIX SZ 6-4 MM SWVL NS DISP MAV MINI,SUP-2932874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
PROBE LASER ASPIR 25 GA CRV PRECIS FIBER CENTERING,SUP-2466730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.68,229.24,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5X131 MM 10 HOLE CONTOURED 2 COMPR,SUP-2476460,CDM,C1713,HCPCS,0278,RC,,,,both,,,1034.94,672.71,,,,,,,,,,,,,
MESH SURG SZ 20 X 25 IN POLYDIOXANONE MACROPOROUS MONOFILAME,SUP-2881031,CDM,C1781,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
PORT INFUS CATH 6.6FR TI LO PROF W/ PREATTACH OPN END SIL,SUP-2127724,CDM,C1788,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
NAIL IM 9X360MM TIB HUM N LCK SLD PROX BEND TI ALTA,SUP-2363492,CDM,C1713,HCPCS,0278,RC,,,,both,,,2153.73,1399.92,,,,,,,,,,,,,
PROSTHESIS VOICE 12 MM LO PRESSURE KT,SUP-2246405,CDM,L8509,HCPCS,0274,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
INSERT FEM NK +3MM HIP CO CHROM MOLYBDENUM ALLY TAPR 1 ENDO,SUP-2405244,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
ROCKER SURG 4.75 MM RMAS EXT CD HORZ SOLERA 4.75,SUP-2629398,CDM,C1713,HCPCS,0278,RC,,,,both,,,2052.02,1333.81,,,,,,,,,,,,,
PLATE BONE L36MM THK1.2MM SHFT W5MM HD 10.2MM 2X6 H STRL T,SUP-2349645,CDM,C1713,HCPCS,0278,RC,,,,both,,,3228.55,2098.56,,,,,,,,,,,,,
NEEDLE PHACOEMULSIFICATION 19GA 30DEG STERILE LATEX FREE,SUP-2493028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1241.27,806.83,,,,,,,,,,,,,
HC So Nephelometry Ea Analyte Nes,PX-3018388366,CDM,83883,CPT,0301,RC,,,,outpatient,,,53.00,34.45,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 50-80X9X15 MM FD IRRADIATED IL CREST,SUP-2866877,CDM,C1762,CPT,0278,RC,,,,both,,,4164.27,2706.78,,,,,,,,,,,,,
HC MRI Breast W Cont Bilateral,PX-6107704901,CDM,77049,CPT,0610,RC,,,,both,,,5019.00,3262.35,,,,,,,,,,,,,
CLAMP SURG DIA16MM CRAN TI RAP SAFE HEALING LO PROF,SUP-2108414,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.59,327.33,,,,,,,,,,,,,
PROMETHAZINE HCL 6.25 MG/5ML PO SOLN,RX-6620,CDM,Q0169,HCPCS,0637,RC,09999-9911-77,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED LG PRIORITY STRL MEDPOR,SUP-2862752,CDM,C1713,HCPCS,0278,RC,,,,both,,,61889.43,40228.13,,,,,,,,,,,,,
LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),RX-430042,CDM,J2003,HCPCS,0636,RC,00409-4282-02,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO SQ PLATE 12 PK STRL,SUP-2935684,CDM,C1713,HCPCS,0278,RC,,,,both,,,18730.10,12174.56,,,,,,,,,,,,,
IMPLANT BIO TISS W2XL9CM BOV PERICARD BIOCOMPATIBLE STR,SUP-2264298,CDM,C1781,HCPCS,0278,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
BAR EXT FIX 11X150 MM CARBON,SUP-2749994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.035IN STR PTFE MOV COR,SUP-2139327,CDM,C1769,HCPCS,0272,RC,,,,both,,,46.75,30.39,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP RT RAD SHFT,SUP-2867045,CDM,C1762,CPT,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
CEMENT BNE 40GM W/ GENT HI VISC RADPQ FOR REV SURG,SUP-2403494,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BNE W12XL39MM THK1MM 2 H BILAT S STL SEMI TBLR LO,SUP-2184863,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.94,124.11,,,,,,,,,,,,,
SUTURE N ABSRB BRAIDED 5-0 24 IN 49 MM GRN NICELOOP SMSL50101,SUP-2401165,CDM,C1713,HCPCS,0278,RC,,,,both,,,391.84,254.70,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.02 MM INNR FLANGE DIA2.5 MM MICROGEL,SUP-2901932,CDM,L8699,HCPCS,0278,RC,,,,both,,,79.35,51.58,,,,,,,,,,,,,
TUBE DCOMPR L48IN DIA16FR RADIOPQ OPQ RUB FUN END LEVIN,SUP-2127563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,59.28,38.53,,,,,,,,,,,,,
STENT BILI WSTNT L 21 MM DIA 8 MM CATH L 155 CM SHTH 5 FR,SUP-2140233,CDM,C1876,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PLU MAXBARR 4FR 55CM 1 LU 1174108D1,SUP-2632625,CDM,C1751,HCPCS,0278,RC,,,,both,,,947.84,616.10,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH BSC 5FR 0.034IN 60CM 2 LU 3255105,SUP-2632660,CDM,C1751,HCPCS,0278,RC,,,,both,,,213.77,138.95,,,,,,,,,,,,,
TIP ASPIR 1.57X19.27 CM EXCEL EXT STRL MICROTIP + DISP,SUP-2427659,CDM,C1713,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
ENDOSCOPIC KIT COLON W/ 1.1 OZ LUBE HYDR ORCA W/O BRSH,SUP-2472601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,44.81,29.13,,,,,,,,,,,,,
REAMER SURG DIA4MM CANN HD,SUP-2120846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
ROD SPNL POST CRV PREBENT SMOOTH TI ALLY OD5.5MM L40MM EBI,SUP-2415868,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.62,662.75,,,,,,,,,,,,,
PLATE BONE W7XL39MM THK1MM 5 H S STL QTR TBLR NONCOMPRESSION,SUP-2343851,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.39,405.85,,,,,,,,,,,,,
PLATE BNE L 80 MM SCREW DIA2.7/3.5MM 3 H SS RT MEDL DSTL HUM,SUP-2931372,CDM,C1713,HCPCS,0278,RC,,,,both,,,4458.17,2897.81,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN TAPR 3CM HYDRPHLC NIT ANG,SUP-2148166,CDM,C1769,HCPCS,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X24 MM TOT WR SS STRL,SUP-2610371,CDM,C1713,HCPCS,0278,RC,,,,both,,,429.61,279.25,,,,,,,,,,,,,
FIBER LASER 30 W SM FLX POWERFUL ENERGY FOR COAG HOLM,SUP-2462704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,155301.26,100945.82,,,,,,,,,,,,,
KIT FIX DEV KNEE AC JT TOGGLELOC PUSH PLUNG BRTH PIN CANN,SUP-2212834,CDM,C1776,CPT,0278,RC,,,,both,,,2851.12,1853.23,,,,,,,,,,,,,
PLATE BNE L L103MM 4 H POST TIBIOTALOCALCANEAL ANK TI,SUP-2398510,CDM,C1713,HCPCS,0278,RC,,,,both,,,6261.16,4069.75,,,,,,,,,,,,,
BOLT ORTH TI INSRT FOR CANN TIB NAIL,SUP-2188192,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.67,520.44,,,,,,,,,,,,,
FIBER LASER HOLM 200 M FOR USE W/ SMA-905 RED SMARTSYNC,SUP-2835953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1108.83,720.74,,,,,,,,,,,,,
SEG TM HIP FLAT 7MM WASHE,SUP-2502393,CDM,C1776,CPT,0278,RC,,,,both,,,3405.33,2213.46,,,,,,,,,,,,,
LEAD DEFIB OPTISURE L 52 CM DIA 8 FR POLYUR SIL ENDOCARD 2,SUP-2356417,CDM,C1895,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2X18 MM WITH PLUSDRIVE RECESS TITANIUM,SUP-2838135,CDM,C1713,HCPCS,0278,RC,,,,both,,,246.18,160.02,,,,,,,,,,,,,
DART SURG L18MM FOR ARTHSCP MENIS KNEE REP SYS,SUP-2121788,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
TUBE TRACH PED L104MM OD67MM ID45MM SIL CUF STR NK FLNG W,SUP-2352029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.39,538.45,,,,,,,,,,,,,
OBTURATOR VERSPRT + RT 12MM BLUNTPORT OBT W/ 5MM + SEAL AND,SUP-2283210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.25,217.26,,,,,,,,,,,,,
BIT DRILL 3.2MM DIAMETER FOR ULTRAFIX RC SUTURE ANCHOR,SUP-2824086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.35,316.13,,,,,,,,,,,,,
CATHETER DRNGE PERI DSTL BA OPN END,SUP-2243794,CDM,C1729,HCPCS,0272,RC,,,,both,,,834.99,542.74,,,,,,,,,,,,,
STEM TIB L127MM OD9MM PRI STABILIZING EXTN W O BODY MRS,SUP-2376469,CDM,C1776,CPT,0278,RC,,,,both,,,6634.04,4312.13,,,,,,,,,,,,,
POR ST/OSS CP/LGXL/LG HD,SUP-2212425,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
KIT INTRO DIA 6 FR PERC TUOHY BORST 1 PC STRL,SUP-2876527,CDM,C1894,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
PLATE BNE L 242 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 22 HL,SUP-2936834,CDM,C1713,HCPCS,0278,RC,,,,both,,,3923.74,2550.43,,,,,,,,,,,,,
BIT DRL 2 MM FOR TOT WRST FUSION DISP,SUP-2851929,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.29,544.89,,,,,,,,,,,,,
HC So1 Thrombin Time Plasma,PX-3058567067,CDM,85670,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
DISTRACTOR SURG CLVRLF 25 MM END DRV 4 PLATE TI ZURICH II,SUP-2473793,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15859.67,10308.79,,,,,,,,,,,,,
SHEATH DIL BYRD 10.4 FR TELSCP SS,SUP-2638738,CDM,C1893,HCPCS,0272,RC,,,,both,,,1095.29,711.94,,,,,,,,,,,,,
CATHETER HD FULL SAFETY TY 12 FRX15 CM DL TURBO-FLO HD,SUP-2759884,CDM,C1752,HCPCS,0278,RC,,,,both,,,851.76,553.64,,,,,,,,,,,,,
CATHETER URETH L29CM DIA7FR BLLN L18CM DIA8.7MM PTFE S STL,SUP-2171310,CDM,C1726,HCPCS,0272,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
DEVICE PROSTHETIC GRAPHITE LAMINATED CARBON,SUP-2388185,CDM,L2755,HCPCS,0272,RC,,,,both,,,336.45,218.69,,,,,,,,,,,,,
SHUNT CAR W/O RESVR N PROGRAMMABLE 10FR 31CM,SUP-2264213,CDM,C1889,HCPCS,0278,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
STYLET 24MM,SUP-2722365,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
COMPONENT SHLDR LAT AUG BASEPLT AEQUALIS REVERSED FX ASCEND,SUP-2419085,CDM,C1776,CPT,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
STENT PERIPH L50MM DIAM 6MM CATH L120CM VASC,SUP-2396484,CDM,C1874,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
HEAD HUM 48X44 MM OFFSET HEMICAP OVO,SUP-2776724,CDM,C1776,CPT,0278,RC,,,,both,,,12625.94,8206.86,,,,,,,,,,,,,
BIT DRL DIA2.9MM SH FOR PEDINAIL PED FEM NAIL SYS,SUP-2318887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.11,329.62,,,,,,,,,,,,,
FORCEPS 25GA TIP SGL USE MAXGRIP ADV DSP,SUP-2109721,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.07,319.85,,,,,,,,,,,,,
CUBE EXT FIX 1 H S STL RANCHO FOR ILIZ TAY SPAT FRME EXT,SUP-2342332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1084.30,704.79,,,,,,,,,,,,,
EDOXABAN TOSYLATE 30 MG PO TABS,RX-128772,CDM,6370000000,HCPCS,0637,RC,65597-0202-30,NDC,,both,1,UN,68.90,44.78,,,,,,,,,,,,,
PLATE BONE L48MM 5 H TI MIDFOOT STR W/ SLOT FOR,SUP-2225436,CDM,C1713,HCPCS,0278,RC,,,,both,,,4092.05,2659.83,,,,,,,,,,,,,
PLATE BONE 7 H 7 PEG STD RT VOLAR S STL BEAR,SUP-2389759,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
TOOL TUNN LNG 35 CM PRECIS,SUP-2141928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COMPONENT FEM SM AP62MM ML66MM R CO CHROM NP CEM REV MOD,SUP-2253238,CDM,C1776,CPT,0278,RC,,,,both,,,15127.26,9832.72,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.411,SUP-2859975,CDM,C1713,HCPCS,0278,RC,,,,both,,,33150.24,21547.66,,,,,,,,,,,,,
IMPLANT SACROILIAC JT L 40 MM DIA 9.5 MM TI STRL IFUSE,SUP-2889903,CDM,C1737,HCPCS,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
PLATE TI LOCKING 1.3MM STRUT 8 HOLES OBLIQUE RT-STERILE,SUP-2546885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.35,795.83,,,,,,,,,,,,,
CAP END TIB TI NAIL LO PROF UNIFLEX,SUP-2412893,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
BUTTON GAST ACC AD 28FR L1.5CM NONBLLN NONOBTRUSIVE,SUP-2125949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.2MM S STL TRCR TIP K APTUS,SUP-2267988,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
BASKET EXTR STONE REM .021IN MULTIFILAMENT DBL LUMN 4W L4CM,SUP-2169335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PI PICC KIT 1-L 4 FR X 55 CM TIPTRACKER,SUP-2565189,CDM,C1751,HCPCS,0278,RC,,,,both,,,539.04,350.38,,,,,,,,,,,,,
ASCOPE 5 BRONCHO HD 5.6/2.8 SAMPLER SET,SUP-2882182,CDM,C1601,HCPCS,0272,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRUT CORT TRAD 100X20MM,SUP-2294114,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM DIA 6 FR TIP 1 MM SPC 10,SUP-2248671,CDM,C1733,HCPCS,0272,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
DISTALDORSO-ULNARDORSO-RADIALL-PLATESR4H,SUP-2816178,CDM,C1713,HCPCS,0278,RC,,,,both,,,2716.10,1765.46,,,,,,,,,,,,,
BIT DRL L195MM DIA6MM ST QUIK CPL NONRADIOPAQUE W/O STP,SUP-2187324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.91,412.69,,,,,,,,,,,,,
Z DUP USE 2305332 COIL EMB 0.010 IN 8 MMX25 CM V-TRAK ADV DEL SYS COSMOS 10,SUP-2530390,CDM,C1889,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
PIN FXTN STNMNN 332MM DIA 9INL THRDD TRCR POINT,SUP-2723589,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.37,37.94,,,,,,,,,,,,,
COMPONENT FIX DF P HEMICAPDF P,SUP-2123623,CDM,C1776,CPT,0278,RC,,,,both,,,3997.22,2598.19,,,,,,,,,,,,,
SPLINT WR AD SM UPTO W3.5IN RT MCP DLX KAY-SPLNT III,SUP-2324558,CDM,L3906,HCPCS,0274,RC,,,,both,,,75.96,49.37,,,,,,,,,,,,,
CLAMP SPNL MONOBLOC TENOR SPNL SYS,SUP-2289280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
FOOTPLATE EXT FIX 180 MM FULL DBL ROW STRL TRUELOK TL-HEX,SUP-2875382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6084.38,3954.85,,,,,,,,,,,,,
HC N Block Paravert Thoracic 1st|BILATERAL PROCEDURE,PX-3606449000,CDM,64490,CPT,0360,RC,,,50,both,,,4864.00,3161.60,,,,,,,,,,,,,
PLATE BNE L 133 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 9 H 72467409N,SUP-2932954,CDM,C1713,HCPCS,0278,RC,,,,both,,,3251.16,2113.25,,,,,,,,,,,,,
SCALPEL SURG JACKSON 2 IN 6.5 IN TRACH PRB TIP CRV BLADE,SUP-2478298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.82,222.18,,,,,,,,,,,,,
GRAFT BNE 450556,SUP-2838801,CDM,C1713,HCPCS,0278,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
NEXGEN A/P WEDGED PRCT TIBIAL PLATE SZ 3,SUP-2503116,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
BLADE RETRACTOR SHT TEETH 65X20 MM PUR FLEXI-SPINE,SUP-2467750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.94,586.91,,,,,,,,,,,,,
PLATE LOQTEQ NARROW 7 HOLE,SUP-2749487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3503.80,2277.47,,,,,,,,,,,,,
METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-117354,CDM,J9250,HCPCS,0636,RC,00143-9519-10,NDC,JW,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
KIT THROMCTMY ACE60 HI FLO L 132 CM OD/ID PROX 6 FR/ 0.068,SUP-2323552,CDM,C1887,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
HEAD ELBW 16 MM 4.5 MM ULN STEM FOR PART REPL 1ST CHOICE,SUP-2852832,CDM,C1776,CPT,0278,RC,,,,both,,,18473.34,12007.67,,,,,,,,,,,,,
ANCHOR SUT KNOTLESS BIORAPTOR,SUP-2341830,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.76,885.14,,,,,,,,,,,,,
PLATE BONE LNG 4X6 H MIDFACE GLD TI LT L SHP RIG TI GRD 4,SUP-2135916,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
COMPONENT FEM KNEE POST STABILIZING UNISX REV PRESSFIT STEM,SUP-2199742,CDM,C1776,CPT,0278,RC,,,,both,,,23821.30,15483.84,,,,,,,,,,,,,
HC Splint App/Short Leg,PX-4502951500,CDM,29515,CPT,0450,RC,,,,outpatient,,,497.00,323.05,,,,,,,,,,,,,
EXPANDER BRST W10.7XH9.3CM P6.2CM 275CC SIL NACL TEXT SURF,SUP-2300652,CDM,C1789,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT ALLGRFT BLK CANC DEMIN FRZ DRY IMPL 20MMX20MMX30MM,SUP-2264683,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.91,901.49,,,,,,,,,,,,,
PLATE BNE L 144 X W 12 MM THK 0.75 MM SCREW DIA1.7 MM PLL,SUP-2883143,CDM,C1713,HCPCS,0278,RC,,,,both,,,13445.48,8739.56,,,,,,,,,,,,,
WIRE FIX 250 MM KIRSCHNER,SUP-2243647,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
K-WIRE .045X12 PT DM,SUP-2818088,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.65,71.27,,,,,,,,,,,,,
STEM HUM 16X170 MM SHLDR RVS TRABECULAR MTL,SUP-2436915,CDM,C1776,CPT,0278,RC,,,,both,,,13720.23,8918.15,,,,,,,,,,,,,
FIBER LASER W/ 200 EXCALIBUR,SUP-2225718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
PLATE BNE L52MM THK2.3MM 8 H NONCOMPRESSION FRAC,SUP-2262990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.15,763.85,,,,,,,,,,,,,
THORACENTESIS TRAY PGTL 6 FRX16 CM LIDO SAFE-T-CENTESIS LF,SUP-2428006,CDM,C1729,HCPCS,0272,RC,,,,both,,,168.99,109.84,,,,,,,,,,,,,
ALLOGRAFT DERMAL HUM TISS SM X THCK 2X1 CMX2.3-3.3 MM,SUP-2463948,CDM,Q4116,HCPCS,0636,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 4 CM DIA 5 FR GUIDEWIRE L 50 CM DIA,SUP-2476900,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.51,52.98,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 4.75MM PEEK THREADED PATTERN KNOTLESS,SUP-2828574,CDM,C1713,HCPCS,0278,RC,,,,both,,,1345.43,874.53,,,,,,,,,,,,,
GRAFT ENDOVASC L15CM DIA5MM CATH L120CM BAL DIA5MM 0.035IN,SUP-2396543,CDM,C1874,HCPCS,0278,RC,,,,both,,,11523.80,7490.47,,,,,,,,,,,,,
PLATE BONE L255MM 13 H RT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348231,CDM,C1713,HCPCS,0278,RC,,,,both,,,15411.75,10017.64,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH 10CM 5FR 7CM NIT PLAT ECHOGENIC,SUP-2170487,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.47,38.66,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 1 CC LECITHIN CARR DBM NS REGENEROSS +,SUP-2862036,CDM,C1713,HCPCS,0278,RC,,,,both,,,520.71,338.46,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM THK200UM AMNIO MEMBRN DEHYDR CHORION,SUP-2340449,CDM,C1762,CPT,0278,RC,,,,both,,,15031.18,9770.27,,,,,,,,,,,,,
CATHETER URET 5FR L70CM TIP 8FR OPN END CONE TIP INJ HUB,SUP-2139292,CDM,C1758,HCPCS,0278,RC,,,,both,,,656.23,426.55,,,,,,,,,,,,,
STAPLER XL L26CM ULT UNIV HNDL ENDO GIA,SUP-2283271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1163.84,756.50,,,,,,,,,,,,,
CLIP SURG LG 25X21X14 MM LAT PEEK SANTORINI,SUP-2517398,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BRACE KNEE SZ 4 16-17INXL MID PAT Q FR CLSR IN 2SL BIOSKIN,SUP-2174972,CDM,L1820,HCPCS,0274,RC,,,,both,,,181.96,118.27,,,,,,,,,,,,,
PROBE NEUROMONITORING 4MM STERILE,SUP-2538830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
GUIDEPIN SURG OD45MM CALIB SPADE TIP TOGGLELOC,SUP-2136098,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.72,370.32,,,,,,,,,,,,,
LINER ACET SZ B OD42MM ID22MM 20DEGXLPE CONSTRN PRI REFLCT,SUP-2348090,CDM,C1776,CPT,0278,RC,,,,both,,,2816.58,1830.78,,,,,,,,,,,,,
INSERT TIB L59MM THK8MM MEDL LAT KNEE ARTC CRUC RET MOLD,SUP-2406271,CDM,C1776,CPT,0278,RC,,,,both,,,1934.24,1257.26,,,,,,,,,,,,,
NAIL LONG LEFT D 10X340 MM,SUP-2854225,CDM,C1713,HCPCS,0278,RC,,,,both,,,8888.02,5777.21,,,,,,,,,,,,,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3244,HCPCS,0636,RC,71288-0019-10,NDC,,both,1,UN,148.10,96.26,,,,,,,,,,,,,
STIMULATOR COCHLEAR BILATERAL PEDIATRIC SLEEPER BAHA,SUP-2165016,CDM,L8614,HCPCS,0278,RC,,,,both,,,34665.60,22532.64,,,,,,,,,,,,,
PROBE SUCT DIA2MM 60DEG BLK VULCAN ABLATOR-S DYONICS,SUP-2341618,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.90,360.03,,,,,,,,,,,,,
CONNECTOR ROD DIA6.35MM TI TRNSVRS SPINE W/ CNTR NUT ISOLA,SUP-2255603,CDM,C1713,HCPCS,0278,RC,,,,both,,,3275.02,2128.76,,,,,,,,,,,,,
LEAD BRAIN STIM L40CM DIA1.27MM BLK MRK BND ELECTRD L1.5MM,SUP-2357356,CDM,C1767,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
GRAFT DURA 1.57IN 1.57IN BOV PERICARD ENDURA,SUP-2244038,CDM,C1763,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
FIBER LASER SURG FIBER 1000 MH RND TIP HOLM SMARTSCOPE DISP,SUP-2337025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1133.54,736.80,,,,,,,,,,,,,
SPLINT THMB AD M FOR 6.5-7.5IN RT WR REG TRIOXON LINING,SUP-2324738,CDM,L3931,HCPCS,0272,RC,,,,both,,,60.95,39.62,,,,,,,,,,,,,
PLATE BNE L76MM THK2MM LNG L CALCNL S STL LOK COMPR FOR,SUP-2185991,CDM,C1713,HCPCS,0278,RC,,,,both,,,2107.47,1369.86,,,,,,,,,,,,,
CATHETER DRNGE 26FR 2 EYE PROPORTIONATE HD DISP FOR,SUP-2128981,CDM,C1729,HCPCS,0272,RC,,,,both,,,23.17,15.06,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 6 CM DIA 3 MM STD,SUP-2323353,CDM,C1889,HCPCS,0278,RC,,,,both,,,6832.64,4441.22,,,,,,,,,,,,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,0636,RC,67457-0994-05,NDC,,both,5,ML,172.50,112.12,,,,,,,,,,,,,
CATHETER ART THERMODILUTION .035 IN 7 FRX110 CM PULM 2 LUMEN,SUP-2662685,CDM,C1751,HCPCS,0278,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
TOCILIZUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430062,CDM,J3262,HCPCS,0636,RC,50242-0136-01,NDC,,both,10,ML,3917.40,2546.31,,,,,,,,,,,,,
PLATE BNE L20MM 4 H FT COMPR INTERAXIAL UNI-CP,SUP-2243488,CDM,C1713,HCPCS,0278,RC,,,,both,,,6387.23,4151.70,,,,,,,,,,,,,
CLIP ENDOSCOPIC L162CM TIP DIA9.5-11MM BIOCOMPATIBLE FOR SCOOP PADLOCK CLIP,SUP-2119263,CDM,C1760,HCPCS,0278,RC,,,,both,,,1378.15,895.80,,,,,,,,,,,,,
PLATE BONE L177MM THK6MM 7 H LT FEM CNDYL TI BTTRS RIG CLLR,SUP-2190901,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.57,1922.42,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST ABDUCTN BAR JOINTED ADJ,SUP-2435658,CDM,L2300,HCPCS,0274,RC,,,,both,,,712.75,463.29,,,,,,,,,,,,,
CONNECTOR VENT STEPDOWN BA IMPREG,SUP-2284391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,199.20,129.48,,,,,,,,,,,,,
SLING URETH PRECIS MINIARC 443378,SUP-2140110,CDM,C1771,HCPCS,0278,RC,,,,both,,,4025.35,2616.48,,,,,,,,,,,,,
COIL EMB L15CM OD4MM 0.018IN HYDRGEL PERIPH DETACH 18 SYS,SUP-2385412,CDM,C1889,HCPCS,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
COUNTERSINK SURG AO SCREW QC FOR FIBULAR NAIL NS DISP,SUP-2909072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
BUR SURG DIA1.4 MM HUB II DIAMOND STRL REUSE HI-LINE,SUP-2929234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,622.00,404.30,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 12X30-35 MM PRESERVON XLNG CANC FLEXIGRAFT,SUP-2264646,CDM,C1762,CPT,0278,RC,,,,both,,,3783.32,2459.16,,,,,,,,,,,,,
BUTTON SUT DIA19MM POLY FOR PCL AND MULT KNEE LIG RECON,SUP-2212823,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
ROD CONN CONT THRD 21 MM,SUP-2862041,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
PLEDGET SURG DEVICE HAART AORTIC ANNULOPLASTY POLYESTER,SUP-2878063,CDM,C1768,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM 0.035IN L 3 MM SS PTFE J FIX COR STD,SUP-2733978,CDM,C1769,HCPCS,0272,RC,,,,both,,,15.20,9.88,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM DIA 7 FR D CRV,SUP-2880105,CDM,C1732,HCPCS,0272,RC,,,,both,,,4282.96,2783.92,,,,,,,,,,,,,
PLATE BNE L190MM 10 H R OLECRANON S STL LOK COMPR FOR 3.5MM,SUP-2185430,CDM,C1713,HCPCS,0278,RC,,,,both,,,3287.01,2136.56,,,,,,,,,,,,,
SUTURE ULTRATAPE SZ 2 NONABSORBABLE BLU COBRAID 72203897,SUP-2341899,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
SYSTEM CATH INTRO L60CM 0.018IN N VASC DISP FOR PERC DRNGE,SUP-2167940,CDM,C1769,HCPCS,0272,RC,,,,both,,,230.88,150.07,,,,,,,,,,,,,
LEVEL CMF SCREW CRSSDRVE TNTNG DRILL FR15 X 4 MM THD TTL7 M,SUP-2707278,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.61,185.00,,,,,,,,,,,,,
PLATE BNE L123MM 7 H ST R SUP ANT CLAV TI LOK COMPR W LAT,SUP-2180869,CDM,C1713,HCPCS,0278,RC,,,,both,,,3285.51,2135.58,,,,,,,,,,,,,
GUIDEPIN ORTHOPAEDIC 3.2X230 MM DRILL TIP,SUP-2837052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.59,241.53,,,,,,,,,,,,,
PIN FIX STEINMAN 9/64 IN,SUP-2150397,CDM,C1713,HCPCS,0278,RC,,,,both,,,9.42,6.12,,,,,,,,,,,,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-157657,CDM,J1815,HCPCS,0637,RC,00002-7510-01,NDC,,both,10,ML,53.20,34.58,,,,,,,,,,,,,
BIT DRL L195MM DIA4MM QUIK CPL 3 FLUT W/O STP REUSE FOR TIB,SUP-2187605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.59,301.98,,,,,,,,,,,,,
KIT PLT CONC SYS MINI W/ ACD A AND BD SEP TB TRNQT ALC PREP,SUP-2402586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ORTHOPAEDIC KIT PELV STRL HOFFMANN II,SUP-2495342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16418.18,10671.82,,,,,,,,,,,,,
CATHETER VENTRICULAR 1.5X3.1X15.7X4X6 MM STRL HOLTER,SUP-2666419,CDM,C1729,HCPCS,0272,RC,,,,both,,,1614.87,1049.67,,,,,,,,,,,,,
GUIDEWIRE 20X150MM TRCR TIP PLN,SUP-2243908,CDM,C1769,HCPCS,0272,RC,,,,both,,,140.14,91.09,,,,,,,,,,,,,
PLATE BNE 1/3 TBLR 61 MM 5 HOLE NS LTX,SUP-2861941,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.05,126.13,,,,,,,,,,,,,
ENDCAP ORTH DIA8MM 5MM EXTN NONSTERILE DK PUR TI ALLY CANN,SUP-2180315,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.47,289.56,,,,,,,,,,,,,
PLUG HERN M DIA7CM POLYPR TILENE INGUNIAL ONLAY PTCH LT,SUP-2402566,CDM,C1781,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CATHETER DRNGE 75FR OD 250CML NTNL NSBLRY SNGLE PGTL W/CNNC,SUP-2676504,CDM,C2625,HCPCS,0278,RC,,,,both,,,333.12,216.53,,,,,,,,,,,,,
ANCHOR SUTURE 1-0 SHT 1.4X1 MM SINGLE LD BLK WHT JUGGERKNOT,SUP-2745511,CDM,C1776,CPT,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SCREW 5.0MM TI DUAL CORE LCKNG T25 STRDRV 62MM F IM NAIL STE,SUP-2546350,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.98,464.74,,,,,,,,,,,,,
SCREW BNE 5.5X45 MM FOR ROD TI,SUP-2256218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0035IN TIP L23CM PTFE BENT STR FIX,SUP-2302721,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.90,23.98,,,,,,,,,,,,,
NAIL IM L200MM OD11.5MM 130DEG AG FOR INTERTROCHANTERIC FX,SUP-2347569,CDM,C1713,HCPCS,0278,RC,,,,both,,,5581.35,3627.88,,,,,,,,,,,,,
STEM FEM L167MM OD19MM BOW TI ALLY PLSM SPRAYED HA DST HIP,SUP-2375657,CDM,C1776,CPT,0278,RC,,,,both,,,8764.37,5696.84,,,,,,,,,,,,,
HEAD RAD H14MM OD20MM UNIV CO CHROM ANT DST EL STR MOD,SUP-2404361,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SCREW BNE L90MM OD7MM THRD L17MM PUR HINDFOOT ANK CANN SHT,SUP-2320793,CDM,C1713,HCPCS,0278,RC,,,,both,,,1514.42,984.37,,,,,,,,,,,,,
PLATE BONE L41MM 6 H BILAT MAXILLOFACIAL MAND ORAL TI CVD,SUP-2191328,CDM,C1713,HCPCS,0278,RC,,,,both,,,1657.29,1077.24,,,,,,,,,,,,,
ANKLE FUSION PLATE ANTERIOR TT RIGHT 5H STRL,SUP-2815095,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SENSOR OXMTR O2 FOR AESTIVA EXCEL SE 7100 7900,SUP-2226989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.10,315.31,,,,,,,,,,,,,
CATHETER ETER 7FR 5FR REFLEXION SPRL,SUP-2357500,CDM,C1730,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
IMPLANT HUM TISS SZ 2 X 3 CM THK 2000 UM PLCNTA MEMBRN FRSH,SUP-2913439,CDM,C1762,CPT,0278,RC,,,,both,,,13907.06,9039.59,,,,,,,,,,,,,
ANCHOR SUT DIA5MM PLLA W/ PRELD ULTRABRAID SUT TWINFIX,SUP-2341744,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.91,536.19,,,,,,,,,,,,,
PLATE BNE L436MM 19 H R DST FEM S STL LOK COMPR FOR 45MM SCR,SUP-2177828,CDM,C1713,HCPCS,0278,RC,,,,both,,,5209.48,3386.16,,,,,,,,,,,,,
KIT ACC TRANSRADIAL POLYMER COAT WIRE RADIALSOURCE RED,SUP-2157411,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.27,65.83,,,,,,,,,,,,,
PLATE BNE L84MM 0DEG 7 H ANK TI BILAT 1 3 TBLR STR LOK COMPR,SUP-2398344,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SUPPORT WR L AD RT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324890,CDM,L3931,HCPCS,0272,RC,,,,both,,,47.51,30.88,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK PRIZM 2 DR W 6.5 X H 6.5 CM D 1.2,SUP-2148621,CDM,C1721,HCPCS,0275,RC,,,,both,,,74104.00,48167.60,,,,,,,,,,,,,
CATHETER OCCL 2.8FR L150CM ID0.053IN BLLN L30MM DIA4MM,SUP-2368111,CDM,C2628,HCPCS,0272,RC,,,,both,,,4622.08,3004.35,,,,,,,,,,,,,
SCREW BNE LCK 3X44 MM DBL STRT THRD STRL JPS LTX,SUP-2875324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1341.41,871.92,,,,,,,,,,,,,
KIT CATHETER CTRL VEN 145X23CM DOUBEL LUMN SYMMETRICAL TOP W,SUP-2283918,CDM,C1750,HCPCS,0278,RC,,,,both,,,2378.49,1546.02,,,,,,,,,,,,,
TAP SURG SPNL SCR BONE DELT SYS 1.7MM,SUP-2365067,CDM,C1713,HCPCS,0278,RC,,,,both,,,513.96,334.07,,,,,,,,,,,,,
EXTRACTOR SURG SZ 2.6 MM SCREW DIA2.3-6 MM STRL DISP OPERACE,SUP-2913608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.63,1339.41,,,,,,,,,,,,,
CAGE SPNL SQ LNG 12X65 MM CERV VU MESH FOOT PRINT VUMESH,SUP-2707701,CDM,C1889,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
PLATE BNE L64MM 7 H TI R LAT DST HUM LO PROF RIG ALPS,SUP-2411713,CDM,C1713,HCPCS,0278,RC,,,,both,,,4735.12,3077.83,,,,,,,,,,,,,
ATTACHMENT TOOL L8CM RED STR SM BOR MTCH HD DMND LEGEND,SUP-2284667,CDM,C1713,HCPCS,0278,RC,,,,both,,,2994.74,1946.58,,,,,,,,,,,,,
CATHETER EP F 3-3-3-3-7 MM 6 FRX115 CM 6,SUP-2248461,CDM,C1730,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
STENT ENDOPROS L15CM DIA5MM CATH 7FR L120CM BAL DIA5MM,SUP-2396494,CDM,C1874,HCPCS,0278,RC,,,,both,,,10864.40,7061.86,,,,,,,,,,,,,
BLADE LARYNSCP MACINTOSH SZ 4 FBROPT UPSHER 1019040,SUP-2301145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.39,244.00,,,,,,,,,,,,,
PLATE BNE L120MM 6 H RIG SPN FOR 45MM SCR L FRAG SYS,SUP-2411402,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.77,457.45,,,,,,,,,,,,,
WIRE FIX DIA062IN REUNITE K,SUP-2137299,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.97,132.58,,,,,,,,,,,,,
PLATE BNE L56MM THK1.3MM 2X8 H HND TI T SHP LOK TRILOK FOR,SUP-2267941,CDM,C1713,HCPCS,0278,RC,,,,both,,,3198.72,2079.17,,,,,,,,,,,,,
PASSER SUT 16MM STR MULTFI SCORPION,SUP-2121203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
SET SHTH DESTINO REACH L 75 CM DIA12 FR CRV BEND 22 MM DIL,SUP-2616170,CDM,C1766,CPT,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
LEAD DBS L 42 CM DIA 0.5 MM DIRECTIONAL W/ MARKER STRL DISP,SUP-2883087,CDM,C1883,HCPCS,0278,RC,,,,both,,,12006.58,7804.28,,,,,,,,,,,,,
HC So Dihydrotestosterone (Dht),PX-3018264266,CDM,82642,CPT,0301,RC,,,,both,,,78.00,50.70,,,,,,,,,,,,,
GRAFT HUM TISS 05CC FLOWABLE PLCNTA TISS MTRX VIAFLX,SUP-2417202,CDM,C1713,HCPCS,0278,RC,,,,both,,,3425.74,2226.73,,,,,,,,,,,,,
COIL VASC RETRACTA L 14 CM DIA12 MM CATH 0.035 IN LOOP 3.7,SUP-2570698,CDM,C1889,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
SCREW BNE L4MM DIA17MM CORT CRANIOFACIAL STD NONLOCKING LO 4/EA,SUP-2364992,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.47,879.76,,,,,,,,,,,,,
GRAFT HUM TISS FRZN COSTAL CART IMPL ALLGRFT L15XW10 TO 30MM,SUP-2307299,CDM,C1762,CPT,0278,RC,,,,both,,,1181.27,767.83,,,,,,,,,,,,,
GRAFT BNE 100X25X8 MM 20 CC POROUS COLLAGEN MATRIX SIGNAFUSE,SUP-2731802,CDM,C1713,HCPCS,0278,RC,,,,both,,,10621.05,6903.68,,,,,,,,,,,,,
COMPONENT FEM HIP NP CEM,SUP-2347967,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
STENT PERIPHERAL L40MM DIAMETER 6MM CATHETER L80CM FLARED VASCULAR,SUP-2128214,CDM,C1874,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
DIST CRANIAL15 LG SPDL50MM END DRVN,SUP-2694398,CDM,C1713,HCPCS,0278,RC,,,,both,,,19439.39,12635.60,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 6 CM DIA 6 FR 2.5 CM ETFE,SUP-2385639,CDM,C1894,HCPCS,0272,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,2580000003,HCPCS,0250,RC,00264-7520-10,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
TROCAR SURG TRANSFIXING PIN FIX SYS BLK XTRAFIX,SUP-2199736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
IMPLANT BRST GEL 335 CC SMOOTH RND MOD PROF NATRELLE INSPIRA,SUP-2113709,CDM,C1789,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
BUTTON FIX UHMWPE ATTCH SYS FOR ACL RECON TIGHTROPE,SUP-2121399,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
GUIDEWIRE ORTH L 450 MM DIA2.8 MM FLUT TIP FOR CANN COMPR,SUP-2907626,CDM,C1769,HCPCS,0272,RC,,,,both,,,624.04,405.63,,,,,,,,,,,,,
ANCHOR SUT DIA1.3MM MIC W/ SZ 4-0 ETHBND EXCEL C-1 TAPERCUT,SUP-2249377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
LEVEL NEURO PLATE ULTRNE LDDR CVD NEURO SCRW5 X 2 HOLES 43 M,SUP-2676747,CDM,C1713,HCPCS,0278,RC,,,,both,,,1108.58,720.58,,,,,,,,,,,,,
HC Manual Spirometry 1 Time,PX-4609415000,CDM,94150,CPT,0460,RC,,,,both,,,46.00,29.90,,,,,,,,,,,,,
DEVICE CLIPPING HEMSTAT 155CM,SUP-2141393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.46,339.60,,,,,,,,,,,,,
PIN ORTH SPARE CNTR FOR HLLW RMR EXT FIX 309.035,SUP-2187147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.67,231.84,,,,,,,,,,,,,
SPHERE GLEN STD TI ECCENTER DSGN SHLDR EPOCA,SUP-2193868,CDM,C1776,CPT,0278,RC,,,,both,,,1995.28,1296.93,,,,,,,,,,,,,
JOINT EXT FIX BALL W/ ROD NS DISP,SUP-2885173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1746.47,1135.21,,,,,,,,,,,,,
SCREW BNE L 30 MM DIA2.5 MM TI CANN HD NS LEOS,SUP-2932602,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.80,521.82,,,,,,,,,,,,,
ENDCAP ORTH DIA15MM EXTN 0MM LT BLU FEM TI FOR SPRL BLDE,SUP-2192139,CDM,C1713,HCPCS,0278,RC,,,,both,,,677.49,440.37,,,,,,,,,,,,,
SET DIL 8/10FR PTFE GRADUAL TAPR SMOOTH TRANSITION SFTY,SUP-2139236,CDM,C1894,HCPCS,0272,RC,,,,both,,,147.23,95.70,,,,,,,,,,,,,
SHUNT PERI 7FR 90CM M SM W O RESVR CSF ASSEMB FLOW CTRL VLV,SUP-2278386,CDM,C1889,HCPCS,0278,RC,,,,both,,,2447.66,1590.98,,,,,,,,,,,,,
PATCH HERN L W5.4XL7IN UNCOATED MFIL PROPYLENE OVL ABSRB,SUP-2125898,CDM,C1781,HCPCS,0278,RC,,,,both,,,2984.88,1940.17,,,,,,,,,,,,,
BARRIER AND CVR SZ 2 SORDEX OPTIME,SUP-2238672,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.07,234.70,,,,,,,,,,,,,
CATHETER ANGIO 5FR L100CM 0.038IN S STL HYDRPHLC ANG TAPR,SUP-2139769,CDM,C1725,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE BONE L144MM 7 H RT PROX HUM LCK FOR 4.5MM SCR PERI-LOC,SUP-2348276,CDM,C1713,HCPCS,0278,RC,,,,both,,,15274.69,9928.55,,,,,,,,,,,,,
STENT LARYNGEAL MONTGOMERY L 12 X W 10 X H 40 MM MED SIL,SUP-2138742,CDM,C1875,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
PATCH CV 20CMX140CMX04MM,SUP-2395306,CDM,C1768,CPT,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
PIN FIX ANCHR 4X40 MM GUIDEPIN ORTH FOR SURG NAVIGATION SYS,SUP-2657177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1478.41,960.97,,,,,,,,,,,,,
CONNECTOR SPNL DIA5.5X5.5MM TI CLOSED/OPEN AX CDH LEG,SUP-2289158,CDM,C1713,HCPCS,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
GUIDEWIRE ARTHSCP L381MM DIA24MM SMOOTH DRL TIP,SUP-2137215,CDM,C1769,HCPCS,0272,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
FIBER LASER SINGLE 200 MH FLEXIVA ID,SUP-2458969,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.39,707.45,,,,,,,,,,,,,
SPLINT FNGR AD M JT EXTN TUBE DGT DYN,SUP-2325054,CDM,L3933,HCPCS,0274,RC,,,,both,,,46.91,30.49,,,,,,,,,,,,,
BIT DRL DIA22MM REUSE LINDERMANN,SUP-2367598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.17,269.86,,,,,,,,,,,,,
BLADE REPROC SAW MAKO NARROW 2MM,SUP-2653056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,214.96,139.72,,,,,,,,,,,,,
REAMER SURG DIA2.5 MM LNG STRL DISP MOTOBAND CP DYNAFORCE,SUP-2893464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
CABLE ORTH SWAGE 2 MM RCS COCR 745320,SUP-2450891,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
SCREW BONE L54MM DIA4MM STRL BLU CORT TI ST NONCANNULATED,SUP-2192277,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.32,481.21,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 135 CM 5.5X60 MM STERLING MRAIL,SUP-2140039,CDM,C1725,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
HC Prog Eval Single Lead Icd,PX-4809328200,CDM,93282,CPT,0480,RC,,,,both,,,132.00,85.80,,,,,,,,,,,,,
SLEEVE POS DIA13MM UNIV SHLDR CO CHROM PRI CEM FOR COMPHSVE,SUP-2404535,CDM,C1776,CPT,0278,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
PLATE BNE L109MM THK3.3MM 9 H BILAT S STL RIG STR DYN COMPR,SUP-2186333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1065.87,692.82,,,,,,,,,,,,,
MESH SURG L15XW10CM POLYFORM MACROPOROUS POLYPR SYN,SUP-2139413,CDM,C1781,HCPCS,0278,RC,,,,both,,,1867.70,1214.00,,,,,,,,,,,,,
DILATOR FILFRM SPRL TIP 4FR HEYMAN,SUP-2126290,CDM,C1758,HCPCS,0278,RC,,,,both,,,26.38,17.15,,,,,,,,,,,,,
GRAFT BNE FIBER 2.5 CC DBM CORTICAL PUREBONE,SUP-2424607,CDM,C1713,HCPCS,0278,RC,,,,both,,,1233.77,801.95,,,,,,,,,,,,,
DRILL 25MM,SUP-2841576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
ANCHOR SUT MINILOK QUIK ANCHR W/ NO 0 ORTHOCORD OS-2 NDL AND,SUP-2256606,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
PLATE BNE MTP MED 0 DEG RT FUSION,SUP-2397256,CDM,C1713,HCPCS,0278,RC,,,,both,,,4016.06,2610.44,,,,,,,,,,,,,
PLATE BNE L116MM 4 H NONSTERILE R MED DST TIB S STL LOK,SUP-2185578,CDM,C1713,HCPCS,0278,RC,,,,both,,,4081.78,2653.16,,,,,,,,,,,,,
GRAFT BNE W14XL24MM THK25X6MM BICORT COT WDG FOR OSTEOTMY,SUP-2399092,CDM,C1713,HCPCS,0278,RC,,,,both,,,5105.64,3318.67,,,,,,,,,,,,,
SCREW BNE STYLOID 2X22 MM ST HI ANGLE T5 DRV,SUP-2462038,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.59,101.78,,,,,,,,,,,,,
SCREW MTO SFT SLK STRL 11MM X 25MM,SUP-2754805,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.92,987.95,,,,,,,,,,,,,
CATHETER GUID BNCHMRK 071 L 95 CM OD 6 FR ID 0.071 IN IN SEL,SUP-2323567,CDM,C1887,HCPCS,0272,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
BIT DRL PED DIA3.2MM SH PEDINAIL,SUP-2318888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1016.42,660.67,,,,,,,,,,,,,
PROBE ABLATOR VULCAN 90 DEG HP,SUP-2850058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,526.83,342.44,,,,,,,,,,,,,
PLATE BNE L124MM THK3.4MM 9 H BILAT S STL STR LOK COMPR FOR,SUP-2185139,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.08,619.50,,,,,,,,,,,,,
BLADE RETRCT W2.5XL3IN RT LT SACR CUTOUT SELF RET UNIV,SUP-2382322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1317.45,856.34,,,,,,,,,,,,,
PLATE BNE 18 H ST BILAT S STL NAR CRV LOK COMPR FOR 35MM SCR,SUP-2178050,CDM,C1713,HCPCS,0278,RC,,,,both,,,3002.84,1951.85,,,,,,,,,,,,,
CANNULA IRRIGATION STROBEL 5 MMX14.5 CM LAT OUTFLO,SUP-2767090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.00,293.80,,,,,,,,,,,,,
BLADE LARYNSCP SZ 4 STD GRN S STL FBR OPT MACINTOSH,SUP-2394599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.53,216.14,,,,,,,,,,,,,
JOINT SHOULDER HUMERAL FIXATION RING EQUINOXE 18.5MM,SUP-2855528,CDM,C1776,CPT,0278,RC,,,,both,,,3500.32,2275.21,,,,,,,,,,,,,
DRESSING WND NEG PRESSURE HYDROPHOBIC HND SHP SENSATRAC DISP,SUP-2262347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.79,231.26,,,,,,,,,,,,,
CONNECTOR SHUNT OD1.9MM TITANIUM L HYDROCEPHALUS MIETHKE,SUP-2825886,CDM,C1889,HCPCS,0278,RC,,,,both,,,771.72,501.62,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.025 % EX CREA,RX-8112,CDM,6370000000,HCPCS,0637,RC,45802-0063-35,NDC,,both,15,GR,16.20,10.53,,,,,,,,,,,,,
PASSER SUT 45DEG SLINGSHOT CHAMPION,SUP-2365419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,253.21,164.59,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-7 MM SHRT TAPR SLDE GDS,SUP-2681787,CDM,C1768,CPT,0278,RC,,,,both,,,1541.61,1002.05,,,,,,,,,,,,,
PIN FIX L254MM OD3MM S STL BLNT TIP RND BVL PT SMOOTH,SUP-2342643,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
BUTTON FIX DIA25MM BNE TO BNE ENDOBTTN CL,SUP-2341035,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 8 MM EPTFE STR TW,SUP-2525454,CDM,C1768,CPT,0278,RC,,,,both,,,1340.81,871.53,,,,,,,,,,,,,
HC Pelvis Min 3 Views,PX-3207219000,CDM,72190,CPT,0320,RC,,,,inpatient,,,513.00,333.45,,,,,,,,,,,,,
STEM FEM L260MM DIA19MM STD CLLR L HIP CO CHROME POR REV,SUP-2345240,CDM,C1776,CPT,0278,RC,,,,both,,,24713.37,16063.69,,,,,,,,,,,,,
MARKER BRST BX L12CM OD18GA NITINOLXSHAPE INTRO FRE HND FOR,SUP-2239914,CDM,A4648,CPT,0278,RC,,,,both,,,2588.93,1682.80,,,,,,,,,,,,,
SLEEVE COMPR SUSP,SUP-2388182,CDM,L2397,HCPCS,0272,RC,,,,both,,,300.78,195.51,,,,,,,,,,,,,
COUNTERSINK DRL DIA2.7MM CANN FOR HDLSS COMPR SCR SYS REDUCT,SUP-2340176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 7 MM DEL SHTH 2.9ML,SUP-2936810,CDM,C1713,HCPCS,0278,RC,,,,both,,,8571.10,5571.21,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 3 Y SHP XLN PLATE 12 PK,SUP-2936715,CDM,C1713,HCPCS,0278,RC,,,,both,,,53916.94,35046.01,,,,,,,,,,,,,
PROBE ENDOSCP ULTRASOUND W/ BLLN SHTH,SUP-2467078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,560.80,364.52,,,,,,,,,,,,,
KNIFE SURG SCHKNT ROLLER 90 DEG 7.5 IN 3 MM HORIZONTAL LF,SUP-2460558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.70,243.55,,,,,,,,,,,,,
BUR DIAMONDS 811 037 MAXIMA,SUP-2238962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,95.30,61.94,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM GRAFIX COR,SUP-2319168,CDM,Q4132,HCPCS,0636,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
STYLET PACE L75CM OD0.012IN LD PLCMNT ATR LT VENT FIRM CPS,SUP-2356389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
NAIL IM L28CM DIA7.5-9MM LNG PROX HUM LOK AG BEND TRIGEN,SUP-2348198,CDM,C1713,HCPCS,0278,RC,,,,both,,,11787.25,7661.71,,,,,,,,,,,,,
HC Operative Cholangiogram,PX-3207430000,CDM,74300,CPT,0320,RC,,,,outpatient,,,1415.00,919.75,,,,,,,,,,,,,
HC So Insulin,PX-3018352566,CDM,83525,CPT,0301,RC,,,,both,,,402.00,261.30,,,,,,,,,,,,,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,6370000000,HCPCS,0637,RC,60505-0823-06,NDC,,both,3.7,ML,430.50,279.82,,,,,,,,,,,,,
REAMER SURG DIA2.7MM CANN FOR 4MM SCR,SUP-2342388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3152.40,2049.06,,,,,,,,,,,,,
PLATE BNE Y 2.3X1.5 MM THOR RIB 40 HOLE LCK LEVEL 1,SUP-2869166,CDM,C1713,HCPCS,0278,RC,,,,both,,,5915.76,3845.24,,,,,,,,,,,,,
NAIL IM L420MM DIA13MM 125DEG LT LAT FEM TI CANN LCK AG ANG,SUP-2361814,CDM,C1713,HCPCS,0278,RC,,,,both,,,5898.80,3834.22,,,,,,,,,,,,,
DISPENSER GRFT DEL SYS X1,SUP-2740846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
DRILL TWST L27MM DIA1.4MM W/O STP NONRADIOLUCENT DENT END,SUP-2374212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
COLLAR CERV SFT DENS UNIV 24X4.5 IN HK LOOP CLOSURE,SUP-2336316,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.46,6.80,,,,,,,,,,,,,
PUTTY W/ CHIP 5.0CC DBM W/ RPM,SUP-2415803,CDM,C9359,HCPCS,0278,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
PACEMAKER CARD 20GM 10.4CC W50XH47MM THK6MM SGL CHMBR IS1,SUP-2356457,CDM,C1786,HCPCS,0275,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
BIT DRL FLUT 0.6X148 MM 15 MM HOUGH STAPEDIAL SS MICROFRANCE,SUP-2475155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.85,273.55,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X12 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851926,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.99,505.04,,,,,,,,,,,,,
GRAFT BONE 10ML DEMIN BONE MTRX BONUS II,SUP-2136834,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SCREW LK F/IM NAIL 5X30MM XL25,SUP-2718107,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.13,353.03,,,,,,,,,,,,,
HC CT Pelvis W/WO Contrast,PX-3527219400,CDM,72194,CPT,0352,RC,,,,inpatient,,,2630.00,1709.50,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR CHRG AND CHARGING ANT OLD EON,SUP-2356750,CDM,C1767,HCPCS,0278,RC,,,,both,,,2591.29,1684.34,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX2 T SHAPED LEFT DORSAL DISTAL,SUP-2723523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2658.51,1728.03,,,,,,,,,,,,,
SCREW BONE L36MM DIA4MM HEADLESS COMPRESSION,SUP-2633879,CDM,C1713,HCPCS,0278,RC,,,,both,,,992.24,644.96,,,,,,,,,,,,,
HC Operative Cholangiogram,PX-3207430000,CDM,74300,CPT,0320,RC,,,,inpatient,,,1415.00,919.75,,,,,,,,,,,,,
BARREL SPNL L8MM STD PEEK ASMBLY SPFIX,SUP-2231412,CDM,C1821,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
CLIP DYN STIM L,SUP-2310409,CDM,E0749,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
COMPONENT ACET TRIFLANGED 24 MM HIP,SUP-2137599,CDM,C1776,CPT,0278,RC,,,,both,,,35168.00,22859.20,,,,,,,,,,,,,
CATHETER KIT STATLOK PICC,SUP-2384066,CDM,C1751,HCPCS,0278,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
IMPLANT BRST DIA14.4CM P4.4CM 550CC SIL GEL FILL SHELL RND,SUP-2300619,CDM,C1789,HCPCS,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
CATHETER CV SET 035 9 FRX20 CM 3L POLYURETHANE,SUP-2759979,CDM,C1751,HCPCS,0278,RC,,,,both,,,304.64,198.02,,,,,,,,,,,,,
WASHER ORTH DIA16MM SFT SPIK RND FOR ARTHROTEK WSHRLOC,SUP-2212894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1920.17,1248.11,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 7X7 CM AMNIO MEMBRN MTRX NEOX,SUP-2135263,CDM,Q4148,HCPCS,0636,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK PRIZM DR HE DEL ENERGY 41 J TI 2,SUP-2139662,CDM,C1721,HCPCS,0275,RC,,,,both,,,77244.00,50208.60,,,,,,,,,,,,,
PLATE BNE STR LG 1.5X28X1 MM MIDFACE 6 HOLE W/ TAB STRL,SUP-2518114,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.29,345.34,,,,,,,,,,,,,
SET ACCS CATH 4FR L10CM NDL 21GA L7CM GWIRE L40CM,SUP-2170544,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.58,48.48,,,,,,,,,,,,,
GUIDEWIRE ORTH L320MM DIA3.2MM ENTRY DISP FOR ANK ARTH NAIL,SUP-2412145,CDM,C1769,HCPCS,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
HC Fna Bx W/Fluor Gdn 1st Les,PX-3611000700,CDM,10007,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
ATENOLOL 100 MG PO TABS,RX-716,CDM,6370000000,HCPCS,0637,RC,51079-0685-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.523,SUP-2860040,CDM,C1713,HCPCS,0278,RC,,,,both,,,41065.23,26692.40,,,,,,,,,,,,,
PLATE BNE ORTHOGNATHIC STRP STD 2 MM 3X10 HOLE MESHED TI NS,SUP-2467959,CDM,C1713,HCPCS,0278,RC,,,,both,,,758.50,493.02,,,,,,,,,,,,,
SHELL ACET OD65MM UNIV CSTI HIP RIM FLARE MULTIH REV,SUP-2208487,CDM,C1776,CPT,0278,RC,,,,both,,,9137.40,5939.31,,,,,,,,,,,,,
CATHETER EXT M SZ 29MM CLR SELF ADH POLYTECH,SUP-2239736,CDM,C1758,HCPCS,0278,RC,,,,both,,,9.42,6.12,,,,,,,,,,,,,
BIT DRL DIA16MM CANN FOR PROX FEM NAILING SYS TFN ADV,SUP-2178966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2608.18,1695.32,,,,,,,,,,,,,
BOOT ORTHOSIS FOR 11-13IN ANK FOAM STATIC FOR POS AND PRSS,SUP-2194764,CDM,L4387,HCPCS,0274,RC,,,,both,,,138.54,90.05,,,,,,,,,,,,,
ANCHOR SUTURE PRSS FIT,SUP-2663508,CDM,C1776,CPT,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X131 MM RT LAT DSTL 7 HOLE NS VA-LCP,SUP-2758199,CDM,C1713,HCPCS,0278,RC,,,,both,,,2974.96,1933.72,,,,,,,,,,,,,
DRILL SURG CALIB 2.5X95 MM AO STYL,SUP-2766122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE L585MM THK32MM 4 H SYMPHYSIS PUBIS S STL RAD 75,SUP-2362713,CDM,C1713,HCPCS,0278,RC,,,,both,,,3692.64,2400.22,,,,,,,,,,,,,
ELEVATOR ENDOSCP 7 CM NANOSCOPE,SUP-2849184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT BNE SUB SM HIGHLY PURIFIED TYP I CLLGN HA B,SUP-2310445,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
SCREW BONE LOK 3.5MM DIA UNVRSL 80MML TTNM CRTCL SELF TPPNG,SUP-2588595,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.40,45.76,,,,,,,,,,,,,
BOLT ORTH L 85 MM DIA 6.5 MM PT INTLOK,SUP-2898422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
STENT DUODENAL L120MM DIA22MM CATH L230CM 10FR 0.035IN NIT,SUP-2149875,CDM,C1876,HCPCS,0278,RC,,,,both,,,7716.80,5015.92,,,,,,,,,,,,,
LEAD NERVE STIM 16C 60 CM LAMITRODE TRIPOLE,SUP-2615509,CDM,C1778,HCPCS,0278,RC,,,,both,,,12968.20,8429.33,,,,,,,,,,,,,
COLLAR HUM DIA56MM SUT FOR SHLDR ARTHROPLASTY SYS GLOB UNITE,SUP-2249867,CDM,C1713,HCPCS,0278,RC,,,,both,,,1245.95,809.87,,,,,,,,,,,,,
SPACER SPNL LIMB RECON SYS,SUP-2646834,CDM,C1889,HCPCS,0278,RC,,,,both,,,1263.79,821.46,,,,,,,,,,,,,
HC So Ammonia,PX-3018214066,CDM,82140,CPT,0301,RC,,,,both,,,72.00,46.80,,,,,,,,,,,,,
HC Cltx Medial Ankle Fx,PX-4502776000,CDM,27760,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
LIOTHYRONINE SODIUM 25 MCG PO TABS,RX-4504,CDM,6370000000,HCPCS,0637,RC,70377-0115-12,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
INSERT MOBILITY DUAL BH 48/28MM,SUP-2511107,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
STENT CAR 7X40 MM ENROUTE,SUP-2431179,CDM,C1884,HCPCS,0278,RC,,,,both,,,8098.06,5263.74,,,,,,,,,,,,,
BRACE KNEE OFF THE SHLF W ACCUTRAC TECHNOLOGY STD PCL MOD L,SUP-2319280,CDM,L1810,HCPCS,0274,RC,,,,both,,,1125.94,731.86,,,,,,,,,,,,,
SYSTEM FIX DIA7-7.5MM FEM HRD SCR SHTH INTRAFIX,SUP-2256823,CDM,C1713,HCPCS,0278,RC,,,,both,,,2059.84,1338.90,,,,,,,,,,,,,
BIT DRL EL FIX KT 180MMX48MM STP UNIT 48MM ALLEN WRNCH,SUP-2315966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.94,256.06,,,,,,,,,,,,,
SPLINT WRST WRP ARND UNIV 8 IN FOREARM RT COOL BLU,SUP-2336238,CDM,L3908,HCPCS,0274,RC,,,,both,,,15.57,10.12,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 6 MM DEL SHTH 2.1ML,SUP-2936808,CDM,C1713,HCPCS,0278,RC,,,,both,,,7106.39,4619.15,,,,,,,,,,,,,
TIRE SCLER SIL CONVX STYL 287,SUP-2213515,CDM,C1784,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 5 FRX150 MM 17 GAX70 MM KT CAREFLOW,SUP-2516612,CDM,C1751,HCPCS,0278,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
SCREW BONE 4MM DIA 45MML CNCLLS FLLY THRDD 47464004501,SUP-2721560,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.65,113.52,,,,,,,,,,,,,
STE TALAR NECK PLATE ASSY SM,SUP-2588800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2843.05,1847.98,,,,,,,,,,,,,
MATRIX BNE SUB OSTEOCONDUCTIVE SCFLD STRP MOZAIK 10ML,SUP-2244488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CATHETER THROMCTMY FOGARTY L 80 CM DIA 6 FR MEMBRN DIA,SUP-2214029,CDM,C1757,HCPCS,0272,RC,,,,both,,,1156.09,751.46,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN LT SCAPULA,SUP-2740913,CDM,C1762,CPT,0278,RC,,,,both,,,15177.50,9865.37,,,,,,,,,,,,,
SCREW BNE SPADE PT 6X160 MM BLNT TROCAR SS HA STRL SCHNZ,SUP-2422830,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.80,346.32,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 10MM DISK,SUP-2905500,CDM,Q4151,HCPCS,0636,RC,,,,both,,,457.78,297.56,,,,,,,,,,,,,
EXPANDER PUPIL 7 MM STRL MALYUGIN RNG,SUP-2304866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.47,305.81,,,,,,,,,,,,,
TAP BNE 65MM FOR DANEK FEN RATCH SCRDRVR,SUP-2289243,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.18,203.57,,,,,,,,,,,,,
COIL DETACH 360 STD SR 13MM BIG LOOP OD 30CM INTRO GDC 10,SUP-2365679,CDM,C1889,HCPCS,0278,RC,,,,both,,,5858.93,3808.30,,,,,,,,,,,,,
CATHETER GUID L45CM L COR 3D INTEGR HEMSTAS ATTAIN COMMND,SUP-2282207,CDM,C1887,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PLATE OLECRANON 3.5MM 10H LT 190MM SS LCP STRL,SUP-2547488,CDM,C1713,HCPCS,0278,RC,,,,both,,,3614.08,2349.15,,,,,,,,,,,,,
SPLINT ORTH L4IN STD PLAS FNGR MLLT W/O PD STAX,SUP-2205660,CDM,L3913,HCPCS,0274,RC,,,,both,,,5.28,3.43,,,,,,,,,,,,,
HC Perc D-E Cor Revasc T Cabg B,PX-4810960500,CDM,C9605,CPT,0481,RC,,,,inpatient,,,9327.00,6062.55,,,,,,,,,,,,,
SHEATH URO 13 15FRX46CM UROPS,SUP-2312761,CDM,C1894,HCPCS,0272,RC,,,,both,,,427.13,277.63,,,,,,,,,,,,,
CATHETER PTCA L135CM BLLN L40MM DIA4MM GWIRE 0.014IN CHOC,SUP-2280610,CDM,C1725,HCPCS,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
HC IV Inf Thera Concurrent,PX-2609636800,CDM,96368,CPT,0260,RC,,,,both,,,83.00,53.95,,,,,,,,,,,,,
ROD SPNL 5.5X30 MM LORDTC TI RELINE-O,SUP-2310170,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
WIRE FIXATION .9MM 22.9CM TROCAR POINT,SUP-2474399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,35.61,23.15,,,,,,,,,,,,,
HUMERAL NAIL 11/9.5MMX24CM,SUP-2818963,CDM,C1713,HCPCS,0278,RC,,,,both,,,7386.07,4800.95,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DECANAV L 115 CM 7 FR 2 MM F CRV,SUP-2248952,CDM,C1732,HCPCS,0272,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
CLAMP SURG MULT SCR FOR ORTHOFIX GALAXY FIX SYS,SUP-2316295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2059.84,1338.90,,,,,,,,,,,,,
KIT CATH HYDRPHLC CO2 CVD ATTAIN COMMND SYS,SUP-2282194,CDM,C1887,HCPCS,0272,RC,,,,both,,,1993.43,1295.73,,,,,,,,,,,,,
GUIDEWIRE SURG DIA2.4MM DISP FOR 4.5MM SCR PEDILOC PEDIFRAG,SUP-2318884,CDM,C1769,HCPCS,0272,RC,,,,both,,,815.14,529.84,,,,,,,,,,,,,
PLEDGET CV EDW L 15.2 X W 15.2 CM THK 0.91 MM PTFE FABRIC,SUP-2761344,CDM,C1768,CPT,0278,RC,,,,both,,,949.32,617.06,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 200 MG/10ML IV SOLN,RX-167519,CDM,Q5135,HCPCS,0636,RC,65219-0592-10,NDC,,both,10,ML,2888.70,1877.65,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq 1st 30 Minutes,PX-4409755000,CDM,97550,CPT,0440,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
CATHETER ECRP 5.5-3.5FR L200CM 0.021IN LNG TAPR TIP FOR CANN,SUP-2169268,CDM,C1757,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
GUIDEWIRE ORTH,SUP-2247391,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
DRILL TWST L87MM OD21MM CANN AO QUIK CPL SHFT END FOR K WIRE,SUP-2267871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.25,1105.81,,,,,,,,,,,,,
DISTRACTOR SURG LG STD SET ACCS FEE,SUP-2432346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.39,333.70,,,,,,,,,,,,,
SHEATH INTRO L 30 CM DIA15 FR GUIDEWIRE 0.038 IN LNG PTFE X,SUP-2615913,CDM,C1894,HCPCS,0272,RC,,,,both,,,148.05,96.23,,,,,,,,,,,,,
FIBER LSR FLEXIVA PULSE 242,SUP-2717687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1244.29,808.79,,,,,,,,,,,,,
GUIDEWIRE SURG FOR PNCH FORCEP,SUP-2649719,CDM,C1769,HCPCS,0272,RC,,,,both,,,56.14,36.49,,,,,,,,,,,,,
BUPIVACAINE HCL 0.5 % IJ SOLN (MIXTURES ONLY),RX-430038,CDM,J0665,HCPCS,0636,RC,00409-1162-01,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
VANCOMYCIN HCL 1.25 G IV SOLR,RX-144941,CDM,J3374,HCPCS,0636,RC,39822-0460-01,NDC,,both,1,UN,86.30,56.09,,,,,,,,,,,,,
DRAINAGE SET ABSC 038 14 FRX41 CM 18 GAX15 CM J THAL QUIK,SUP-2168352,CDM,C1729,HCPCS,0272,RC,,,,both,,,303.86,197.51,,,,,,,,,,,,,
DRILL SURG 6 MM PATELLO FEM JT IM GENDER SOL,SUP-2437878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PIN EXT FIX THRD 4X80 MM 7 MM MXLFCL LF,SUP-2481897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.45,430.59,,,,,,,,,,,,,
LEVEL NEURO PLATE ULTRNE LDDR NEURO SCRW4 X 2 HOLES 30 MM T0,SUP-2707417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1043.27,678.13,,,,,,,,,,,,,
MIDAZOLAM HCL 2 MG/2ML IJ SOLN,RX-40872,CDM,J2250,HCPCS,0636,RC,00641-6057-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
STENT URET MULT LEN 6FR 22-28CM GWIRE PTFE FLX .035,SUP-2313749,CDM,C2617,HCPCS,0278,RC,,,,both,,,271.67,176.59,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X222X2 MM 32 HOLE ANGLED-ANGLED TI,SUP-2539586,CDM,C1713,HCPCS,0278,RC,,,,both,,,7790.91,5064.09,,,,,,,,,,,,,
KIT DISP NEUROVISION,SUP-2310413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1770.96,1151.12,,,,,,,,,,,,,
RONGEUR SURG FRIEDMAN 5.5 IN SS,SUP-2238709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.79,536.76,,,,,,,,,,,,,
AMLODIPINE BESYLATE 2.5 MG PO TABS,RX-9070,CDM,6370000000,HCPCS,0637,RC,00904-6369-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DEVICE SUTURING N ABSRB 3-0 8 IN LD UNIT ENDOSTCH DISP,SUP-2787734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,239.61,155.75,,,,,,,,,,,,,
RETRACTOR SURG L 50/30 X W 15/20 MM CRDLS INTEGR MULTILED,SUP-2914857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,855.65,556.17,,,,,,,,,,,,,
PLATE BNE L 279 MM SCREW DIA 3.5/4.5 MM 12 H UTIL NS EVOS,SUP-2933281,CDM,C1713,HCPCS,0278,RC,,,,both,,,17019.59,11062.73,,,,,,,,,,,,,
COMPONENT FEM L200MM KNEE TOT SEG IMP MOST OPTIONS,SUP-2208268,CDM,C1776,CPT,0278,RC,,,,both,,,11671.38,7586.40,,,,,,,,,,,,,
PLATE BNE T 3.5X67 MM 3X5 HOLE RT ANGLED SS LCP,SUP-2569405,CDM,C1713,HCPCS,0278,RC,,,,both,,,511.19,332.27,,,,,,,,,,,,,
KIT REP FOR 10FR CATHETER ETERS BRVC HCKMN AND LNRD,SUP-2126563,CDM,C1751,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
GRAFT SPNL 10MM26MM26MM 8DEG ANTR FRZN PRECIS,SUP-2293921,CDM,C1713,HCPCS,0278,RC,,,,both,,,12154.94,7900.71,,,,,,,,,,,,,
FILTER VASC TRAPEASE L 90 CM DIA 6 FR CAVA DIA 30 MM NIT AC,SUP-2157010,CDM,C1880,HCPCS,0278,RC,,,,both,,,3560.76,2314.49,,,,,,,,,,,,,
STERILE WATER FOR INJECTION (MIXTURES ONLY),RX-430028,CDM,2500000003,HCPCS,0250,RC,00338-0013-06,NDC,,both,2000,ML,54.10,35.16,,,,,,,,,,,,,
FIBER LASER 200 MH N TAPR POLISHED TIP HOLM ACCUMAX,SUP-2465399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.39,707.45,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7116,SUP-2484389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
IMPLANT ANK FT TARSOMETATARSAL STD FUSION REFLX HYBRID,SUP-2897071,CDM,C1713,HCPCS,0278,RC,,,,both,,,7532.86,4896.36,,,,,,,,,,,,,
PLATE BNE RECON 3.5X178 MM 15 HOLE SS,SUP-2569090,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.65,309.82,,,,,,,,,,,,,
IMPLANT OP RM LAPIDUS PLT 5 AND 8MM GRA,SUP-2321487,CDM,C1713,HCPCS,0278,RC,,,,both,,,4074.15,2648.20,,,,,,,,,,,,,
RELOAD STPL 2.5MM L60MM 0DEG VASC TISS TAN TI 6 ROW LIN,SUP-2283265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1188.24,772.36,,,,,,,,,,,,,
PLATE BONE 2X8 H TI T SHP FOR 1.5MM SCR VLP MINI-MOD SM BONE,SUP-2351070,CDM,C1713,HCPCS,0278,RC,,,,both,,,3548.36,2306.43,,,,,,,,,,,,,
PLATE BNE STD Y SHP 3X2 H TI FOR 1MM SCR 2MM MINI MOD,SUP-2262770,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
AMK TIB TY SZ 3+,SUP-2251229,CDM,C1776,CPT,0278,RC,,,,both,,,7991.30,5194.34,,,,,,,,,,,,,
RING OPEN ALUM DIA155MM,SUP-2701756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4233.35,2751.68,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 4 FR PWR INJ N COAT POWERPICC,SUP-2126700,CDM,C1751,HCPCS,0278,RC,,,,both,,,564.73,367.07,,,,,,,,,,,,,
PLATE SPNL L39MM UNIV CERV ANT 3 LEV TI STD REFLX,SUP-2380868,CDM,C1713,HCPCS,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
INSTRUMENT 25MM IMPLANT TO TRIAL ADAPTER,SUP-2515580,CDM,C1776,CPT,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
COMPONENT TIB PS MOLD ON MTL BK 11MM SZ 1,SUP-2222989,CDM,C1776,CPT,0278,RC,,,,both,,,9545.60,6204.64,,,,,,,,,,,,,
SCREW BNE LAG 12.7X105 MM,SUP-2314153,CDM,C1713,HCPCS,0278,RC,,,,both,,,2001.75,1301.14,,,,,,,,,,,,,
ELECTRODE NDL CANN L25CM ARRY DIA4CM FOR OPN AND PERC RF,SUP-2139751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
HAGIE PIN 3.16X6X11.2,SUP-2818443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.57,673.12,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST REINF SLD STIRRUP,SUP-2435656,CDM,L2260,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
HC Assay of Total Estradiol,PX-3018267000,CDM,82670,CPT,0301,RC,,,,both,,,638.00,414.70,,,,,,,,,,,,,
COMPONENT FEM B A/P 48.5MM M/L58MM ZMLY LT KNEE PRI CRUC RET,SUP-2200872,CDM,C1776,CPT,0278,RC,,,,both,,,13327.73,8663.02,,,,,,,,,,,,,
CATHETER CV KT AD 9 FRX11.5 CM DL N TUNNELED 7.5-8 FR MAC,SUP-2763351,CDM,C1751,HCPCS,0278,RC,,,,both,,,378.68,246.14,,,,,,,,,,,,,
STENT PERIPH EVERFLEX L 120 MM DIA 6 MM CATH L 80 CM SHTH 5,SUP-2866784,CDM,C1876,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HEAD FEM ENDOPROSTHESIS 12-14 56 MM HIP,SUP-2203057,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC So Beta-2-Microglobulin,PX-3018223266,CDM,82232,CPT,0301,RC,,,,outpatient,,,426.00,276.90,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE TIB CUST FRAC SFT,SUP-2435648,CDM,L2112,HCPCS,0274,RC,,,,both,,,1428.32,928.41,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5FR NIT TUNGSTEN TIP SIL ECHOGENIC,SUP-2763446,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.34,45.72,,,,,,,,,,,,,
MINOXIDIL 10 MG PO TABS,RX-5114,CDM,6370000000,HCPCS,0637,RC,00591-5643-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
LINER ACET HOOD HIP METASUL EPSILON,SUP-2448624,CDM,C1776,CPT,0278,RC,,,,both,,,50486.49,32816.22,,,,,,,,,,,,,
GRAFT BONE SUB 5CC GEL GRFTON,SUP-2307524,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC Extracranial Bilat Study,PX-9219388000,CDM,93880,CPT,0921,RC,,,,both,,,1104.00,717.60,,,,,,,,,,,,,
STENT BILI PRECIS L 20 MM DIA 8 MM CATH L 135 CM DIA 6 FR,SUP-2158922,CDM,C1876,HCPCS,0278,RC,,,,both,,,5598.49,3639.02,,,,,,,,,,,,,
RETRIEVER STONE REM W4XL5.5CM SHTH DIA2.5MM UNIV SPR LIKE,SUP-2360676,CDM,C1713,HCPCS,0278,RC,,,,both,,,299.81,194.88,,,,,,,,,,,,,
PROBE ABLATN 40 MM FLX VASC,SUP-2427439,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
COLLAR EXTRIC AD REG 2 PC TRACH OPN VELC CLSR W/ CHIN SUPP,SUP-2194469,CDM,L0180,HCPCS,0272,RC,,,,both,,,61.83,40.19,,,,,,,,,,,,,
BUR SURG L4MM OD5.1MM DMND NEURO DRL W/O STP N RADLUC FOR,SUP-2364016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.17,269.86,,,,,,,,,,,,,
KIT JET7 AND PENUMBRA HI FLOW ASPIR TBNG AND 3D,SUP-2323587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,28212.90,18338.38,,,,,,,,,,,,,
CANNULA IV 3/8 IN 18 CM 17 FRX12.5 IN BIO-MEDICUS,SUP-2465291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.67,626.39,,,,,,,,,,,,,
DRESSING WND SURG MTRX THCK 7X10 CM MATRISTEM,SUP-2106496,CDM,Q4166,HCPCS,0636,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
BLADE RETRACTOR RICHARDSON 1X1.25 IN BOOKWALTER,SUP-2468019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1026.40,667.16,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5 MM 6 HOLE CONTOURED 2 COMPR RECON,SUP-2486637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1324.73,861.07,,,,,,,,,,,,,
APPLIER INT CLP REMOVER 12.5 MMX35 CM ARTICULATING BULLDOG,SUP-2852476,CDM,C1889,HCPCS,0278,RC,,,,both,,,6810.94,4427.11,,,,,,,,,,,,,
PLATE CRAN 60X20X20 MM PT SPEC IMPL PEEK,SUP-2860167,CDM,C1713,HCPCS,0278,RC,,,,both,,,21795.37,14166.99,,,,,,,,,,,,,
BRACE ANK L H10IN RIG THERMOPLASTIC SHELL ADJ HEEL STRP W/,SUP-2197171,CDM,L4350,HCPCS,0272,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
"HC So Compatibility Test, Immed.Spin",PX-3008692066,CDM,86920,CPT,0300,RC,,,,outpatient,,,359.00,233.35,,,,,,,,,,,,,
PLATE BNE L 44.45 X W 6.99 MM THK 2 MM SCREW DIA2/2.3 MM 6 H,SUP-2937040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
MENISCAL ALLOGRAFT DISPOSABLE KIT,SUP-2812465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
HEAD FEM DIA36MM -3.5MM SHT NK CO CHROM SUFIKITA SUP FINISH,SUP-2304426,CDM,C1776,CPT,0278,RC,,,,both,,,4388.15,2852.30,,,,,,,,,,,,,
PLATE BNE L288MM 21 H NONSTERILE R ANTLAT DST TIB S STL LO,SUP-2185974,CDM,C1713,HCPCS,0278,RC,,,,both,,,4499.12,2924.43,,,,,,,,,,,,,
STEM TIB MID 12 MM R/L TOT ANK PLASMA COAT INBONE II,SUP-2850811,CDM,C1776,CPT,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
HC Cast Short Leg,PX-4502940500,CDM,29405,CPT,0450,RC,,,,both,,,848.00,551.20,,,,,,,,,,,,,
FORCEPS OPHTH 23GA ILM DISP GRIESHABER REVOLUTION DSP,SUP-2109703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SCREW BNE L85MM DIA3.7MM THRD L25MM S STL CANN CONIC,SUP-2185199,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.81,280.03,,,,,,,,,,,,,
KIT SPRY COAX 2 TIP PLT CONC SYS,SUP-2402582,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
KIT PICC CATH AD 7FR L76CM POLYUR DBL LUMN BASIC NPOWER INJ,SUP-2125581,CDM,C1751,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
PLATE BONE CONDYLAR 5 HOLE QUARTER TUBULAR STAINLESS STEEL S,SUP-2836700,CDM,C1713,HCPCS,0278,RC,,,,both,,,566.52,368.24,,,,,,,,,,,,,
GRAFT VASC IMPRA L 15 CM DIA 4-7 MM EPTFE STP STD WALL N,SUP-2761528,CDM,C1768,CPT,0278,RC,,,,both,,,830.66,539.93,,,,,,,,,,,,,
HC I&D Abcess Complic Multiple,PX-4501006100,CDM,10061,CPT,0450,RC,,,,inpatient,,,405.00,263.25,,,,,,,,,,,,,
KIT HAD CATH L45CM INSRT L28CM CARBOTHANE SYMMETRIC TIP 2,SUP-2283952,CDM,C1881,HCPCS,0278,RC,,,,both,,,917.76,596.54,,,,,,,,,,,,,
NEEDLE BRST LOC NON-REPOSITIONABLE 20 GAX12.5 CM WIRE HAWK3,SUP-2874185,CDM,C1819,HCPCS,0278,RC,,,,both,,,102.05,66.33,,,,,,,,,,,,,
SHEATH ROT CF INNR G 25.6FR,SUP-2313077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5082.22,3303.44,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H XLN TI NEURO DBL Y SHP PLATE,SUP-2935833,CDM,C1713,HCPCS,0278,RC,,,,both,,,21879.52,14221.69,,,,,,,,,,,,,
SCREW BNE 2.7X24 MM FOR THRD STP SS STRL,SUP-2178276,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.87,322.97,,,,,,,,,,,,,
SPLINT WR AD M L6.25IN FOR 6.5-7.5IN LT REG W/ STAY ELAS,SUP-2309139,CDM,L3808,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER VENTRICULAR 1.3X2.5 MMX15 CM IMPREG STRIPE TRNSLUC,SUP-2631853,CDM,C1729,HCPCS,0272,RC,,,,both,,,693.28,450.63,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 60 CM DIA22 MM THK 0.38 MM POLYESTER,SUP-2694162,CDM,C1768,CPT,0278,RC,,,,both,,,1805.94,1173.86,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X10 MM 6 LOBE,SUP-2602069,CDM,C1889,HCPCS,0278,RC,,,,both,,,6766.70,4398.35,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 11 CM DIA 4 FR IV CATH L 2.5 CM,SUP-2740573,CDM,C1892,HCPCS,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
HC So Chromium Serum,PX-3018249566,CDM,82495,CPT,0301,RC,,,,outpatient,,,60.00,39.00,,,,,,,,,,,,,
LEAD NERVE STIM 2.16 MM INTERSTIM SURESCAN,SUP-2550570,CDM,C1778,HCPCS,0278,RC,,,,both,,,12305.66,7998.68,,,,,,,,,,,,,
BIT DRL CANN,SUP-2218773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.20,1018.03,,,,,,,,,,,,,
SYSTEM BOOT TOT CNTCT CAST REG FOR MEDE-KAST TCC-EZ,SUP-2194356,CDM,L4386,HCPCS,0274,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
VALVE AORT ON-X TISS ANNULUS 19 MM ORIFICE 17.4 MM FLARE,SUP-2175254,CDM,C1889,HCPCS,0278,RC,,,,both,,,15696.86,10202.96,,,,,,,,,,,,,
PIN STBL 170MM ENDORING,SUP-2291689,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
INTRODUCER GUID REDUC RAD SSR4 8FRX60CM 038IN SWARTZ,SUP-2357182,CDM,C1893,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
BLADE ULTRASONIC L20MM BLNT W/ SIL SL SHT EXTN DISP FOR HRD,SUP-2305941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.66,770.68,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 45 CM DIA14 FR GUIDEWIRE 0.038 IN,SUP-2169787,CDM,C1894,HCPCS,0272,RC,,,,both,,,305.77,198.75,,,,,,,,,,,,,
CAGE 9X15MM ADJ RVS STEM AEQUALIS,SUP-2419739,CDM,C1889,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
KIT ELBW JT ULN PIN BUSHING COONRAD/MORREY,SUP-2205923,CDM,C1776,CPT,0278,RC,,,,both,,,1902.21,1236.44,,,,,,,,,,,,,
RING ANNULPLSTY CARPENTIER MCCARTHY ADAMS IMR ETLOGIX DIA28,SUP-2214131,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
GRAFT VASC IMPRA L 15 CM DIA 5 MM EPTFE FLX TW SM BEAD RING,SUP-2761430,CDM,C1768,CPT,0278,RC,,,,both,,,1271.83,826.69,,,,,,,,,,,,,
INSERTER SURG GUIDEPIN INLINE NS FLAREHAWK 7 LTX,SUP-2871312,CDM,C1889,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PROBE PERIODONTAL N 22 T,SUP-2936970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 100 GM AMNIO MEMBRN PARTICULATE NEOX FLO,SUP-2648690,CDM,Q4155,HCPCS,0636,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
HC Blood Draw per Port,PX-7613659100,CDM,36591,CPT,0510,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.045 MM PERIPH AMPLTZ DEV DEL,SUP-2167809,CDM,C1769,HCPCS,0272,RC,,,,both,,,40.57,26.37,,,,,,,,,,,,,
CLIP SURG DIL STRL,SUP-2710541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE EXT FIX L180MM FT DBL H FOR SIDEKCK FREE CIR FIX,SUP-2400658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
CLAMP SURG 4.5-6 MM ASMBLY RAIL G2 NILE,SUP-2734571,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
INSERT HUM DIA36MM THK+9MM 7.5DEG REVERSED SHLDR FOR CONV,SUP-2388716,CDM,C1776,CPT,0278,RC,,,,both,,,6572.02,4271.81,,,,,,,,,,,,,
ASSEMBLY EXT FIX STD KT SIDEKCK EZ FRAME,SUP-2469742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18262.24,11870.46,,,,,,,,,,,,,
DRILL SURG TORQUE LIMITING ATTCH,SUP-2497856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3446.37,2240.14,,,,,,,,,,,,,
CATHETER EP H CRV 7 FR 1X9 MM 10 INQUIRY,SUP-2102300,CDM,C1731,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SEED BRACHYTHERAPY PD-103 PALLADIUM W/ SOURCELINK CONN,SUP-2129043,CDM,C2640,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
NAIL IM L340MM DIA13MM FEM NONLOCKING CANN,SUP-2205960,CDM,C1713,HCPCS,0278,RC,,,,both,,,14312.12,9302.88,,,,,,,,,,,,,
PLATE LOK STRGHT LRG4H T10MM 1MM MARKS W/TAB CP TTNM,SUP-2679030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1712.46,1113.10,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 15 CC PRESERVON CANC READIGRAFT,SUP-2740806,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.67,550.99,,,,,,,,,,,,,
BASKET RETRV L1950MM DIA22MM MIN WRK CHN 28MM SFT WIRE BULL,SUP-2313137,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.56,246.06,,,,,,,,,,,,,
CATHETER VENTRICULAR L25CM OD2.5MM GRADUATED WITH STYLET WIT,SUP-2825903,CDM,C1729,HCPCS,0272,RC,,,,both,,,749.24,487.01,,,,,,,,,,,,,
ELECTRODE ES DIA3MM 50DEG WAND POWERFUL ANG FOR FREE,SUP-2341993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE 25 GA CUST,SUP-2110951,CDM,C1713,HCPCS,0278,RC,,,,both,,,1824.18,1185.72,,,,,,,,,,,,,
PLATE BNE MESH PANEL STD 1.5X85X53X0.3 MM SM GRID TI NS,SUP-2483303,CDM,C1713,HCPCS,0278,RC,,,,both,,,2816.86,1830.96,,,,,,,,,,,,,
HANDPIECE LASER THER MNL FBR STEER SOLOGRIP III,SUP-2175247,CDM,C2618,HCPCS,0272,RC,,,,both,,,18698.70,12154.15,,,,,,,,,,,,,
BIT DRL TWST 2.5X76 MM W/ NOTCH LEVEL 1 DISP,SUP-2457973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.56,233.06,,,,,,,,,,,,,
KIT RFA MULTI COOLED PROBE ADVANCED 100,SUP-2745224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
SCREW BNE 2/PK L 4 MM DIA1.7 MM PLA GLYCOLIDE CRANIOMAXILLOFACIAL,SUP-2884150,CDM,C1713,HCPCS,0278,RC,,,,both,,,909.53,591.19,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,J7030,HCPCS,0258,RC,79672-0613-50,NDC,,both,1000,ML,425.00,276.25,,,,,,,,,,,,,
GRANISETRON HCL 1 MG PO TABS,RX-14720,CDM,Q0166,HCPCS,0637,RC,69452-0350-92,NDC,,both,1,UN,4.80,3.12,,,,,,,,,,,,,
GUIDEWIRE VASC L 160 CM DIA 0.063 IN HEPARIN MJ6.5,SUP-2147063,CDM,C1769,HCPCS,0272,RC,,,,both,,,124.41,80.87,,,,,,,,,,,,,
GRAFT BNE INJ 20 CC INDUCTIVE PRO-STIM,SUP-2759469,CDM,C1713,HCPCS,0278,RC,,,,both,,,13979.28,9086.53,,,,,,,,,,,,,
CATHETER DIAG 6FR L95CM DST L6CM 0.035/0.038IN S STL MP,SUP-2323595,CDM,C1887,HCPCS,0272,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ PISTON 0.6X4.5 MM SHORTENED SMRT,SUP-2638168,CDM,L8613,CPT,0278,RC,,,,both,,,1130.24,734.66,,,,,,,,,,,,,
HC US Scrotum & Contents,PX-4027687000,CDM,76870,CPT,0402,RC,,,,both,,,1745.00,1134.25,,,,,,,,,,,,,
CEFDINIR 250 MG/5ML PO SUSR,RX-39522,CDM,340b,HCPCS,0637,RC,67877-0548-98,NDC,,both,60,ML,45.10,29.31,,,,,,,,,,,,,
PLATE BONE TIBIAL 2.7X32 MM MEDIAL DISTAL 4 HOLE STRAIGHT LO,SUP-2836534,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
PLATE BNE HEVANS LNG 24MM L,SUP-2321481,CDM,C1713,HCPCS,0278,RC,,,,both,,,5077.38,3300.30,,,,,,,,,,,,,
CONDYLAR PLATE RIGHT 7X158MM,SUP-2818527,CDM,C1713,HCPCS,0278,RC,,,,both,,,7218.55,4692.06,,,,,,,,,,,,,
GRAFT HUM TISS 2X2CM AMNIO MEM VERSASHIELD,SUP-2316033,CDM,C1762,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SET INTRO L 5 CM DIA 5.5 FR GUIDEWIRE L 45 CM DIA 0.018 IN,SUP-2267052,CDM,C1894,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
STENT ENDOPROS L15CM DIA8MM CATH 8FR L120CM 0.035IN VES,SUP-2396623,CDM,C1874,HCPCS,0278,RC,,,,both,,,12261.70,7970.10,,,,,,,,,,,,,
CANNULA SUCTION MONOPOLAR 3 MMX20 CM COAG INSUL,SUP-2767731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,930.13,604.58,,,,,,,,,,,,,
SCREW INTRF L25MM DIA10MM KNEE PLLA HA BIOABSRB FOR ACL PCL,SUP-2341580,CDM,C1713,HCPCS,0278,RC,,,,both,,,762.61,495.70,,,,,,,,,,,,,
SYSTEM TOE JT GREAT HEMI TOT PROX MOV W 183 HT 132 STEM LEN,SUP-2244253,CDM,L8659,HCPCS,0278,RC,,,,both,,,7768.64,5049.62,,,,,,,,,,,,,
DRIVER SHFT SURG FLAT BLDE NONCANNULATED SPARE MMF LEIBINGER,SUP-2361548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.97,536.23,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,J2004,HCPCS,0636,RC,00409-0147-01,NDC,,both,1.7,ML,54.10,35.16,,,,,,,,,,,,,
DEVICE SPNL INTBDY POST COR OCTAVE 8MM,SUP-2264522,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
KIT INSTR MIS LAT STRL DISP MINMN,SUP-2911990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
STENT BILI PALMAZ XL L 40 MM DIA10 MM SHTH 10 FR SS TRNSHEP,SUP-2158992,CDM,C1877,HCPCS,0278,RC,,,,both,,,3264.03,2121.62,,,,,,,,,,,,,
TUNNELER NERVE STIM,SUP-2225542,CDM,C1894,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
WIRE FIX L300MM DIA2MM PICCOLO COMP DSTL FEM PLT SYS K,SUP-2152506,CDM,C1713,HCPCS,0278,RC,,,,both,,,209.12,135.93,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM SCREW DIA2 MM 4 H XLN TI,SUP-2936171,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
SCREW BNE L20MM DIA27MM LOK,SUP-2315954,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.78,475.66,,,,,,,,,,,,,
POR ST/OSS CP/E1 AA DM LN/STD,SUP-2212430,CDM,C1776,CPT,0278,RC,,,,both,,,19665.82,12782.78,,,,,,,,,,,,,
PLATE BONE L183MM THK3.4MM 12 H BILAT S STL LCK COMPR NEUT,SUP-2348988,CDM,C1713,HCPCS,0278,RC,,,,both,,,3837.71,2494.51,,,,,,,,,,,,,
HC MRI-Spine Cervical WO Contrast,PX-6127214100,CDM,72141,CPT,0612,RC,,,,both,,,3143.00,2042.95,,,,,,,,,,,,,
COLLAR EXTRIC AD 2IN 17IN XSH TWO PC TRACH OPN VELC CLSR W,SUP-2194464,CDM,L0172,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Exc Face-Mm B9+Marg 0.5 Cm/<,PX-4501144000,CDM,11440,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 8 IN WRST FOREARM RT,SUP-2336336,CDM,L3809,HCPCS,0274,RC,,,,both,,,20.63,13.41,,,,,,,,,,,,,
OXAZEPAM 10 MG PO CAPS,RX-5930,CDM,6370000000,HCPCS,0637,RC,62584-0812-11,NDC,,both,1,UN,10.80,7.02,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING PEDIATRIC CH TODDLER 2 IN PROCARE,SUP-2195749,CDM,L0180,HCPCS,0274,RC,,,,both,,,81.01,52.66,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN MEDL TO LAT HALF FEM CONDYLE,SUP-2866852,CDM,C1762,CPT,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
PLATE BNE L69MM 1 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177790,CDM,C1713,HCPCS,0278,RC,,,,both,,,3041.34,1976.87,,,,,,,,,,,,,
HOOK SPNL PROTEX CT,SUP-2593195,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT EVAR L49MM DIA23X23MM CATH 18FR AORT EXTN W/ FREE FLO,SUP-2295230,CDM,C1768,CPT,0278,RC,,,,both,,,13109.50,8521.17,,,,,,,,,,,,,
ANCHOR SUT 27MM MAINSTAY ZIP,SUP-2362541,CDM,C1713,HCPCS,0278,RC,,,,both,,,107.83,70.09,,,,,,,,,,,,,
LOOP ELECSURG TUMOR RESECT 24 FR BLDR FOR ACMI USA ELITE SYS,SUP-2754293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.27,1124.68,,,,,,,,,,,,,
PLATE BNE SM L58MM NONSTERILE L CALCNL S STL VAR ANG LOK FOR,SUP-2178420,CDM,C1713,HCPCS,0278,RC,,,,both,,,3013.77,1958.95,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 15ML CANC CUBE,SUP-2212019,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
TUBING ASPIR PUMP/CANISTER,SUP-2748589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.82,285.23,,,,,,,,,,,,,
HC Replace Single/Dual Cd Gen Only,PX-4813324000,CDM,33240,CPT,0481,RC,,,,both,,,76255.00,49565.75,,,,,,,,,,,,,
CATHETER HD KT 15 FRX23 CM DL LNG TERM ACCS CANNON II +,SUP-2763010,CDM,C1750,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
INBONE EVERLAST SZ 2+ 14MM TOTAL ANKLE,SUP-2822258,CDM,C1776,CPT,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 26.5-29.5 IN CTR 19-21 IN CALF 20-22 IN,SUP-2914906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.45,571.64,,,,,,,,,,,,,
WEDGE COT 16X65 TI BNE,SUP-2244445,CDM,C1713,HCPCS,0278,RC,,,,both,,,8496.21,5522.54,,,,,,,,,,,,,
PLATE BNE L140MM 5 H NONSTERILE L LAT PROX TIB TI LOK COMPR,SUP-2190712,CDM,C1713,HCPCS,0278,RC,,,,both,,,4217.90,2741.63,,,,,,,,,,,,,
IMPLANT SYNTH 13 X 38 MM THK 3 MM POLYETHYL CRANIOFACIAL,SUP-2883218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.92,941.15,,,,,,,,,,,,,
TUBE VENT ID102MM SIL BLU PAPARELLA TYP W TAB FOR MYR,SUP-2313877,CDM,L8699,HCPCS,0278,RC,,,,both,,,39.75,25.84,,,,,,,,,,,,,
STAPLER INT AD L30MM STPL SZ 2.5MM 1MM CLSR WHT TI STD TISS,SUP-2283032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2081.85,1353.20,,,,,,,,,,,,,
SAMPLER SET BRONCHSCP REG 85 DEG CLOSED LOOP GRN ASCOPE 4,SUP-2752994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
TUNNELER SURG L 600 MM LG RIGID NO RNG MARKING STRL DISP 10/PK,SUP-2928804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4628.14,3008.29,,,,,,,,,,,,,
ANCHOR SUTURE L 16.3 MM DIA 5.5 MM TI SUTURETAPEN FT STRL,SUP-2930502,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.13,621.48,,,,,,,,,,,,,
DEVICE SEAL BLNT TIP NANO COAT HND AND FT ACT LIGASURE,SUP-2283559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1355.57,881.12,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.4MM TI ST LOK FULL THRD STARDRV RECESS,SUP-2190276,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.79,226.06,,,,,,,,,,,,,
STEM FEM L165MM DIA15MM 12/14 TAPR HIP 5/8 POR TRIANG STD,SUP-2252068,CDM,C1776,CPT,0278,RC,,,,both,,,5435.34,3532.97,,,,,,,,,,,,,
VALVE CSF PERF LEVEL 1 NEONATE 90 CM DELT,SUP-2628519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3473.56,2257.81,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/ELASTIC FNGR CTRL PREFABRICATED,SUP-2435774,CDM,L3912,HCPCS,0272,RC,,,,both,,,271.45,176.44,,,,,,,,,,,,,
HEAD FEM 44 MM HIP CERM SEL,SUP-2449662,CDM,C1776,CPT,0278,RC,,,,both,,,6344.37,4123.84,,,,,,,,,,,,,
RESORB X TAP FRICTION STOP 100MM LGTH 21MM 15MM,SUP-2679316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.25,369.36,,,,,,,,,,,,,
SPLINT WRST BLK XS 8 IN L,SUP-2336048,CDM,L3809,HCPCS,0274,RC,,,,both,,,18.68,12.14,,,,,,,,,,,,,
CATHETER PERITONEAL 110 CM RADIOPAQUE W/ 16 SLT,SUP-2851310,CDM,C1729,HCPCS,0272,RC,,,,both,,,397.05,258.08,,,,,,,,,,,,,
CATHETER ETER URET OPN END 5 FR,SUP-2312755,CDM,C1758,HCPCS,0278,RC,,,,both,,,86.66,56.33,,,,,,,,,,,,,
TROCAR ENDOSCP BLDELSS 5X75 MM STBL SL ENDOPATH BASX,SUP-2857943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.16,277.00,,,,,,,,,,,,,
HC So Lamotrigine,PX-3018017566,CDM,80175,CPT,0301,RC,,,,outpatient,,,96.00,62.40,,,,,,,,,,,,,
CEMENT BONE 20GM RADPQ ORTHOSET,SUP-2304363,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HEAD RADIAL LNG STEM 4 ELBW MOD,SUP-2852853,CDM,C1776,CPT,0278,RC,,,,both,,,10237.19,6654.17,,,,,,,,,,,,,
VASOPRESSIN 20 UNIT/ML IV SOLN,RX-128198,CDM,J2598,HCPCS,0636,RC,42023-0164-10,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
MESH CRAN L 52.37 X W 31.01 MM THK 0.61 MM TI EXT CHIARI,SUP-2935988,CDM,C1713,HCPCS,0278,RC,,,,both,,,5454.18,3545.22,,,,,,,,,,,,,
FEM TRL LT SZ4 N-K,SUP-2209579,CDM,C1713,HCPCS,0278,RC,,,,both,,,2609.34,1696.07,,,,,,,,,,,,,
CATHETER PTCA L150CM BLLN L8CM DIA3MM SHTH 4FR GWIRE,SUP-2128518,CDM,C1725,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
BIT DRL L270MM DIA3.2MM PICCOLO COMP DSTL FEM PLT SYS,SUP-2152507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.59,437.18,,,,,,,,,,,,,
HC Replace Icd Sgl Lead System,PX-3613326200,CDM,33262,CPT,0361,RC,,,,inpatient,,,7823.00,5084.95,,,,,,,,,,,,,
GRAFT BNE SUB 10CC 50X15X7MM DEMIN BNE MTRX 3D SCFLD STRP,SUP-2335645,CDM,C9362,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PLATE BNE COMPR BROAD 137 MM 7 HOLE,SUP-2362722,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.23,345.95,,,,,,,,,,,,,
CAGE SPNL STACKABLE 4 DEG 9 MM BTM BENGAL,SUP-2530169,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
COMPONENT BPLR OD54MM ID26MM FEM CO CHROM ASSEMB,SUP-2207812,CDM,C1776,CPT,0278,RC,,,,both,,,4219.75,2742.84,,,,,,,,,,,,,
HC So Calprotectin Fecal,PX-3018399366,CDM,83993,CPT,0301,RC,,,,both,,,480.00,312.00,,,,,,,,,,,,,
CABLE RIB GUIDE NS ADVANTAGERIB,SUP-2908964,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
BLADE SAW L 73 X W 7 MM L 12.5 MM BROAD RASP SM RECIP FOR,SUP-2929559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,821.80,534.17,,,,,,,,,,,,,
PLATE BNE RIBBON UNIV 3.5X45 MM FOR RECON SYS NS LTX DISP,SUP-2861124,CDM,C1713,HCPCS,0278,RC,,,,both,,,1241.93,807.25,,,,,,,,,,,,,
MIDAZOLAM 100 MG/100ML IV SOLN,RX-151967,CDM,J2250,HCPCS,0636,RC,09999-9917-23,NDC,,both,100,ML,126.50,82.22,,,,,,,,,,,,,
SCREW IM L 52 MM DIA 3.5 MM TI CORTICAL T15 DRVR GLD STRL,SUP-2900419,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GRAFT DURA W2XL2IN CLLGN SUTURELESS HIGHLY CNFRM RESTR,SUP-2165125,CDM,C1763,HCPCS,0278,RC,,,,both,,,1667.56,1083.91,,,,,,,,,,,,,
PACEMAKER CARD EVIA DR-T TI HOME MONITORING MOB STRL,SUP-2138285,CDM,C1785,HCPCS,0275,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
CATHETER CTRL VEN 6FR 2 LUMN POLYUR BASIC PROC TY POWERHOHN,SUP-2125478,CDM,C1751,HCPCS,0278,RC,,,,both,,,840.45,546.29,,,,,,,,,,,,,
NAIL IM TRIM 2.4X30 MM 2 IMPL BIO INTEGRATIVE OSSIOFIBER,SUP-2641886,CDM,C1713,HCPCS,0278,RC,,,,both,,,5488.72,3567.67,,,,,,,,,,,,,
CROWN DENT SZ UR1 UP RT CTRL PRI M S STL THCK OCCLUSAL SURF,SUP-2238825,CDM,D6783,CPT,0278,RC,,,,both,,,110.34,71.72,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM ADV 3 MM SCREW DIA2 MM 4 H MINI CHIN,SUP-2883148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.33,785.41,,,,,,,,,,,,,
PIN FIX L16.8CM DIA4.8MM CORT S STL SELF TAP DRL,SUP-2409697,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.95,248.92,,,,,,,,,,,,,
COIL VASC EMBOLUS L 3 CM DIA 5 MM GUIDEWIRE 0.038 IN,SUP-2167813,CDM,C1889,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
HC NM Bone Limited,PX-3417830000,CDM,78300,CPT,0341,RC,,,,outpatient,,,1898.00,1233.70,,,,,,,,,,,,,
PLATE SPNL L37.5MM UNIV TI ANT CERV LOK ALLY ATLNTS,SUP-2293160,CDM,C1713,HCPCS,0278,RC,,,,both,,,2585.60,1680.64,,,,,,,,,,,,,
CATHETER EXT VENT L33CM OD2.8MM ID1.5MM TRNSLUC W/ BA STRP,SUP-2284571,CDM,C1729,HCPCS,0272,RC,,,,both,,,737.81,479.58,,,,,,,,,,,,,
SYSTEM VAC MIX SGL DBL CLEARMIX 1 PER CA,SUP-2408543,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
BLADE SAW W15MM CUT EDGE THK0.51MM D30MM OSC CRESC TPS,SUP-2367309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
PLATE FT 180 DBL H IMP,SUP-2197261,CDM,C1713,HCPCS,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
TISS HUM IMPL W6XL6CM AMNIO MEMBRN ALLGRFT BIOVANCE,SUP-2113889,CDM,Q4154,HCPCS,0636,RC,,,,both,,,11852.24,7703.96,,,,,,,,,,,,,
CATHETER TRAY THORACENTESIS 14 GA 17 GAX6 IN NDL TEF CURITY,SUP-2153994,CDM,C1729,HCPCS,0272,RC,,,,both,,,125.69,81.70,,,,,,,,,,,,,
DRILL SURG 4.5MM CANN DISP FOR 4.5/8.5MM BEAMING SYS,SUP-2223914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT EVAR L13.5CM DIA18MM CONTRALATERAL LEG ENDOPROS USED,SUP-2395954,CDM,C1768,CPT,0278,RC,,,,both,,,11837.80,7694.57,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 8 MM RNG L 40 CM EPTFE,SUP-2396303,CDM,C1768,CPT,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
RACEPINEPHRINE HCL 2.25 % IN NEBU,RX-114658,CDM,6370000000,HCPCS,0637,RC,00487-5901-99,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
FULL TIB WDG W/O SCR SZ 1,SUP-2359306,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
MESH SPNL H50XL12MM TI RND,SUP-2254464,CDM,C1713,HCPCS,0278,RC,,,,both,,,13420.36,8723.23,,,,,,,,,,,,,
PLATE BNE L172MM 8 H ST L DST MED TIB S STL VAR ANG LOK,SUP-2177640,CDM,C1713,HCPCS,0278,RC,,,,both,,,5361.52,3484.99,,,,,,,,,,,,,
GRAFT DERMAL RECT 9.8X11.8 IN ANTIBACT XENMATRIX AB,SUP-2855244,CDM,C1781,HCPCS,0278,RC,,,,both,,,78811.49,51227.47,,,,,,,,,,,,,
SHUNT CSF SM SNAP ASSEMB W BLNT NDL 16GA VENTCULSTMY RESVR,SUP-2277982,CDM,C1889,HCPCS,0278,RC,,,,both,,,14729.14,9573.94,,,,,,,,,,,,,
WASHER ORTH SCREW DIA 4.5 MM DBL NS EVOS,SUP-2933074,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
DULOXETINE HCL 20 MG PO CPEP,RX-39275,CDM,6370000000,HCPCS,0637,RC,68180-0294-07,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L170MM WRST STR SPANNING LO PROF FOR 2.4MM CORT,SUP-2194239,CDM,C1713,HCPCS,0278,RC,,,,both,,,4897.36,3183.28,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX24 CM SHT TERM DL SET SOFT-LINE,SUP-2627336,CDM,C1752,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
RELOAD STPLR 45 MM FOR SIGNIA INTELLIGENT LD UNIT,SUP-2858009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1762.95,1145.92,,,,,,,,,,,,,
CUTTER SURG LT MEDL RT LAT FEM ACCURIS STRL,SUP-2344212,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.35,626.18,,,,,,,,,,,,,
SCREW BNE CANN 5X38 MM PART THRD TIM NS,SUP-2467197,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
PLATE SPNL W16XL53MM THK1.9MM 6 H LEV 2 ANTR CERV TI SNOWCAP,SUP-2207836,CDM,C1713,HCPCS,0278,RC,,,,both,,,4035.53,2623.09,,,,,,,,,,,,,
BIT DRL 230/200MM CALIB DIA3.2MM 3 FLUT QUIK CPL,SUP-2187618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.29,443.49,,,,,,,,,,,,,
RING EXT FIX DIA180MM ANT ALUMINUM HALF,SUP-2242955,CDM,C1713,HCPCS,0278,RC,,,,both,,,4336.09,2818.46,,,,,,,,,,,,,
MESH SURG 16X10 CM BIOMATERIAL PREPERITONEAL ENFORM,SUP-2435399,CDM,C1781,HCPCS,0278,RC,,,,both,,,6685.06,4345.29,,,,,,,,,,,,,
BLADE SAW W16.5XL34.5MM THK0.38MM CUT THK0.43MM REPL SAG,SUP-2150716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,27.19,17.67,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM CORT CRANIOMAXILLOFACIAL TI SELF,SUP-2188934,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.71,181.16,,,,,,,,,,,,,
PATCH DURA W10XL12CM ELASTOMERIC INNR LAYR PRECL MVP,SUP-2395357,CDM,C1763,HCPCS,0278,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
SCREW BNE L8MM DIA2MM CORT HND S STL ST NONLOCKING LO PROF,SUP-2183285,CDM,C1713,HCPCS,0278,RC,,,,both,,,111.00,72.15,,,,,,,,,,,,,
CATHETER CRYOABLATION 28 MM ARCTIC FRONT ADVANCED,SUP-2460587,CDM,C1733,HCPCS,0272,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
SCREW BONE L8MM OD1.3MM CRANIOMAXILLOFACIAL VIT LUHR PAN FIX,SUP-2364633,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.65,79.72,,,,,,,,,,,,,
WEDGE FEM L SZ 1-2 THK5MM STD UNIV POST KNEE CO CHROM PRI,SUP-2346032,CDM,C1776,CPT,0278,RC,,,,both,,,1965.64,1277.67,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTAPOLAR DEFLECTABLE STRL,SUP-2516515,CDM,C1730,HCPCS,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
PAD ORTHOT SCOLIOSIS CUST TENS BASE FIT ADJ,SUP-2435569,CDM,L1005,HCPCS,0274,RC,,,,both,,,9061.47,5889.96,,,,,,,,,,,,,
FEMORAL L RT CO CHROM MOLYBDENUM NP PRI UNI OXFORD,SUP-2136402,CDM,C1776,CPT,0278,RC,,,,both,,,11118.74,7227.18,,,,,,,,,,,,,
SYSTEM PLATELET CONC 30 CC,SUP-2431545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BONE L65MM 8 H S STL QTR TBLR ECT,SUP-2198594,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.92,111.75,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK08 17MM DERM HUM ACELLULAR,SUP-2307047,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4329.12,2813.93,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE PRE THN XL 26X23 CMX0.7-1.4 MM FLEXHD,SUP-2430131,CDM,Q4128,HCPCS,0636,RC,,,,both,,,42564.02,27666.61,,,,,,,,,,,,,
PLATE BNE L1 2X130X0.5 MM CRANIOMAXILLOFACIAL 9 HOLE TI STRL,SUP-2498809,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.92,779.95,,,,,,,,,,,,,
PROBE SURG SCR PEDCL STRL PHANTOM XL DISP,SUP-2851753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
KIT SUT PASS W/ SZ 2 TIGERLOOP SZ 2 FIBERLOOP CRV MIC,SUP-2122152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 8 H TI V LP NS STERNALOCK EZ,SUP-2894512,CDM,C1713,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
KIT BAL KYPHOPLASTY NDL 10GA L15MM SGL IVAS ELITE,SUP-2361506,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4264.31,2771.80,,,,,,,,,,,,,
MESH SURG CONTOURED LG 0.3 MM ORBIT FLR SPEC BOWLES TI,SUP-2485125,CDM,C1713,HCPCS,0278,RC,,,,both,,,1372.49,892.12,,,,,,,,,,,,,
HC Revise/Remove Spinal Cord Stim,PX-3600007521,CDM,3600007521,LOCAL,0360,RC,,,,both,,,482.00,313.30,,,,,,,,,,,,,
CUFF CO CIRC 43-71 MM FNGR AD SELF COILING N INVAS NS DISP,SUP-2885379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
BUR SURG OD2.3MM BLU RED SPRL ROUTER CUT SIGN,SUP-2367528,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.59,272.08,,,,,,,,,,,,,
ALLOGRAFT BNE PROX TIB W/ TUBEROSITY,SUP-2321914,CDM,C1713,HCPCS,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
CATHETER INTVASC 9.3FR L38CM POLYUR APPLAUSE HEAT EXCHG FLX,SUP-2416149,CDM,C1751,HCPCS,0278,RC,,,,both,,,2998.57,1949.07,,,,,,,,,,,,,
SCREW SPNL L35MM OD7.5MM FOR 5.5MM ROD VAR ANG N CANN THRD,SUP-2230086,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
PLATE BONE L37MM 7 H S STL 1/3 TBLR ECT,SUP-2198533,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.24,87.91,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY 45 DEG L 110 CM DIA 7 FR,SUP-2474742,CDM,C1730,HCPCS,0272,RC,,,,both,,,1697.83,1103.59,,,,,,,,,,,,,
GRAFT BIO TISS W20XL30CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113039,CDM,Q4130,HCPCS,0636,RC,,,,both,,,57684.94,37495.21,,,,,,,,,,,,,
SCREW BONE CORT DIAM 2.0MM L10MM CROSS PIN LCK,SUP-2363439,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.68,127.19,,,,,,,,,,,,,
SCREW BNE L22MM DIA3.5MM EL TI POLYAX NONLOCKING COMPR FOR,SUP-2340299,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
SCREW SPNL POST THORLUM TI CLS LOK ARMDA,SUP-2311943,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
HC Iadna Nos Amplified Probe Tq Each Organism,PX-3068779800,CDM,87798,CPT,0306,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
CLINDAMYCIN HCL 150 MG PO CAPS,RX-1740,CDM,6370000000,HCPCS,0637,RC,00904-5959-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MESH HERN W10XL15CM THK2MM EPTFE PTCH OVL 2 SIDE FOR,SUP-2125742,CDM,C1781,HCPCS,0278,RC,,,,both,,,2514.83,1634.64,,,,,,,,,,,,,
FIBER ENT HOLM LSR 200 MIC STRL LTX FRE,SUP-2417255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
STEM FEM CEM SZ 17 165MM LGTH INTRIGUE - SZ 17 165MM LEN,SUP-2406817,CDM,C1776,CPT,0278,RC,,,,both,,,8773.16,5702.55,,,,,,,,,,,,,
PREDNISONE 50 MG PO TABS,RX-6498,CDM,J7512,HCPCS,0637,RC,00054-0019-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE L24MM TIP DIA4MM 2.5MM HEX STD ST ST FULL THRD,SUP-2107343,CDM,C1713,HCPCS,0278,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
"HC So Encephalitis, Western Equine",PX-3028665466,CDM,86654,CPT,0302,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
THEOPHYLLINE 80 MG/15ML PO ELIX,RX-7820,CDM,340b,HCPCS,0637,RC,00121-4820-15,NDC,,both,18.75,ML,56.50,36.72,,,,,,,,,,,,,
PLATE BNE L310MM 14X5 H S STL R DST LAT PERIARTC FEM LOK FOR,SUP-2362735,CDM,C1713,HCPCS,0278,RC,,,,both,,,7396.27,4807.58,,,,,,,,,,,,,
EXPANDER BRST TISS 375CC W12XH12CM P6.4CM SIL SMOOTH HI,SUP-2421120,CDM,C1789,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT STEM EPOCH,SUP-2212732,CDM,C1776,CPT,0278,RC,,,,both,,,15029.61,9769.25,,,,,,,,,,,,,
PLATE BNE L29MM THK075MM 14 H NONSTERILE HND S STL WEB LOK,SUP-2417426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1370.67,890.94,,,,,,,,,,,,,
HC Hdr Brachy Seed IR 192,PX-2780171701,CDM,C1717,HCPCS,0278,RC,,,,both,,,1859.00,1208.35,,,,,,,,,,,,,
PLATE SPNL ANCHR 37 MM OCPTL ASCNT POCT,SUP-2601971,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.88,2024.67,,,,,,,,,,,,,
STEM FEM REV 14X245 MM MONOBLOC ALTEON,SUP-2432431,CDM,C1776,CPT,0278,RC,,,,both,,,19035.78,12373.26,,,,,,,,,,,,,
CATHETER DRAINAGE INTRO 25 FRX38 CM MULT BIO-MEDICUS LS,SUP-2745345,CDM,C1729,HCPCS,0272,RC,,,,both,,,1678.64,1091.12,,,,,,,,,,,,,
GRAFT VASC L 30 MM ID 5 MM CLLGN BOV CAR ART WOVEN,SUP-2880948,CDM,C1768,CPT,0278,RC,,,,both,,,8255.06,5365.79,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST PATTEN BTM,SUP-2435662,CDM,L2370,HCPCS,0274,RC,,,,both,,,906.08,588.95,,,,,,,,,,,,,
PLATE BNE W10XL77MM THK1.5MM 90DEG 6X3 H BILAT S STL T SHP,SUP-2185874,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.88,749.37,,,,,,,,,,,,,
STENT URET L 24 CM DIA 4.8 FR PERCFLX 2 PIGTL LP FIRM SHFT,SUP-2722599,CDM,C2617,HCPCS,0278,RC,,,,both,,,260.87,169.57,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5 CM DIA10 MM CATH L 75 CM NIT,SUP-2396461,CDM,C1876,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
SPLINT WRST SM L6IN R CANVS LACE UP FIRM SUPP REM MAL PALMAR,SUP-2194831,CDM,L3908,HCPCS,0274,RC,,,,both,,,29.36,19.08,,,,,,,,,,,,,
SPACER ORTH SUBTALAR 6.5 MM,SUP-2482068,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 8 DEG 20X45X15 MM ANGLED FD ORACLE,SUP-2736777,CDM,C1713,HCPCS,0278,RC,,,,both,,,19424.61,12626.00,,,,,,,,,,,,,
SCREWDRIVER SURG T6 LIN DRVR SHFT W/ AO QUIK CPLR,SUP-2417067,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
PLATE BNE W24XL31MM 5 H ST BILAT MIDFOOT HINDFOOT TI RIG LOK,SUP-2191456,CDM,C1713,HCPCS,0278,RC,,,,both,,,2874.07,1868.15,,,,,,,,,,,,,
GRAFT FEM SHFT ALLGRFT FRZ DRY 100MM MATRIGRFT,SUP-2264749,CDM,C1713,HCPCS,0278,RC,,,,both,,,2570.47,1670.81,,,,,,,,,,,,,
SNARE SURG SAGE 25 GAX9 IN TONSIL SS NS,SUP-2496822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1278.39,830.95,,,,,,,,,,,,,
MESH HERN RECTANGULAR 30X40 CM PREPERITONEAL ENFORM,SUP-2539551,CDM,C1781,HCPCS,0278,RC,,,,both,,,50136.38,32588.65,,,,,,,,,,,,,
SCREW BNE LCK 2.7X66 MM ST T8 SS NS,SUP-2183388,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.88,255.37,,,,,,,,,,,,,
STYLET LD POS L75/86CM OD0.014IN ID0.012IN LV LD LUMN,SUP-2357579,CDM,C1769,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC STRP LG ELBW TENNNIS NEOPRNE,SUP-2136949,CDM,L3702,HCPCS,0272,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
DEVICE SUT QUIK LOAD PK COR-KNOT,SUP-2265302,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
CATHETER VENT DRNGE L91CM OD2.54MM ID1.27CM 90DEG CLS PRSS,SUP-2243779,CDM,C1729,HCPCS,0272,RC,,,,both,,,843.94,548.56,,,,,,,,,,,,,
BONE REDUCTION CLAMP BLUNT LAG SCREW SYSTEM,SUP-2473871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,770.81,501.03,,,,,,,,,,,,,
POST EXT FIX RT ANGLE NS MAXFRAME,SUP-2758007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1218.45,791.99,,,,,,,,,,,,,
CANNULA ENDOSCP 30 CM W/ GUIDE KT TORQ CAP VAC PRT GUIDEWIRE,SUP-2866236,CDM,C1769,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SURFACE ARTC 1-2 AB THK17MM AP40MM ML58MM PUR PROLONG KNEE,SUP-2211957,CDM,C1776,CPT,0278,RC,,,,both,,,4633.07,3011.50,,,,,,,,,,,,,
SYSTEM ROD BONE 150MML TTNM WGRVE FRGD EXTRNL DISTR LATEX,SUP-2679223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1221.62,794.05,,,,,,,,,,,,,
GRAFT DURA PTCH MED 8X10 CM DURAMATER,SUP-2321733,CDM,C1713,HCPCS,0278,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
GUIDEWIRE ORTH 125X150 MM THRD TIP RAD PLATE SYS SS,SUP-2184108,CDM,C1769,HCPCS,0272,RC,,,,both,,,648.06,421.24,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 30 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120667,CDM,C1768,CPT,0278,RC,,,,both,,,7721.26,5018.82,,,,,,,,,,,,,
STIMULATOR NERVE 5.02X6.68 CM,SUP-2637208,CDM,C1767,HCPCS,0278,RC,,,,both,,,57335.18,37267.87,,,,,,,,,,,,,
LINER ACET CONSTRN E 36 MM PROV FRDM G7,SUP-2440187,CDM,C1776,CPT,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
CATHETER ABLAT 7FR TIP L4MM 2.5MM SPC QPLR SM CRV STD LEN,SUP-2140147,CDM,C1733,HCPCS,0272,RC,,,,both,,,2798.37,1818.94,,,,,,,,,,,,,
TRAY HEMO DYLS OR HD CATH AD 14.5FR L36CM INSRTN L16CM,SUP-2174213,CDM,C1751,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PANCRELIPASE (LIP-PROT-AMYL) 10000-32000 UNITS PO CPEP,RX-142032,CDM,6370000000,HCPCS,0637,RC,73562-0110-01,NDC,,both,1,UN,19.00,12.35,,,,,,,,,,,,,
PLATE BONE L37MM 3 H S STL 1/3 TBLR ECT,SUP-2198530,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.90,75.98,,,,,,,,,,,,,
BLADE SURG L75MM ST S STL HELIX FOR LCP DHHS SYS,SUP-2186778,CDM,C1713,HCPCS,0278,RC,,,,both,,,1172.13,761.88,,,,,,,,,,,,,
HC MRI-Spine Cervical W & WO Cont,PX-6127215600,CDM,72156,CPT,0612,RC,,,,both,,,3486.00,2265.90,,,,,,,,,,,,,
MICROCATHETER INFUSION APOLLO ONYX TOT L 165 CM OD,SUP-2459734,CDM,C1887,HCPCS,0272,RC,,,,both,,,6242.32,4057.51,,,,,,,,,,,,,
PLATE BNE 12 H BILAT ORBIT RIM TI LO PROF RIG NEUT,SUP-2191242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1059.44,688.64,,,,,,,,,,,,,
SCREW INTFR L25MM DIA7MM CANN 1MM KNEE N ABSRB TI TAPR HD,SUP-2341312,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
SET SCR SPNL DEV FOR CLOSE CLMP CD HORZ LEG,SUP-2289305,CDM,C1713,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
CATHETER BLLN 1.25 X 6MM SPRINTER OTW,SUP-2282975,CDM,C1725,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
HC CT Guide for Stereotactic Loca,PX-3507701100,CDM,77011,CPT,0350,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT BNE SUB 60ML 05 5MM CORT CANC GRAN MORSELIZED FRZ DRY,SUP-2307057,CDM,C1713,HCPCS,0278,RC,,,,both,,,2450.27,1592.68,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,6370000000,HCPCS,0637,RC,76204-0300-03,NDC,,both,3,ML,2.70,1.75,,,,,,,,,,,,,
GRAFT BONE SUB 5ML TRICALCIUM PHOS GRAN CONT RESRB CONDUIT,SUP-2256851,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
SPLINT FT AD SM SZ 3-6 UNISX LT PREFABRICATED POST LEAF,SUP-2325044,CDM,L4398,HCPCS,0272,RC,,,,both,,,82.08,53.35,,,,,,,,,,,,,
SEGMENTAL FEM/TIB MALE-FEMALE 30MM,SUP-2502403,CDM,C1776,CPT,0278,RC,,,,both,,,9269.28,6025.03,,,,,,,,,,,,,
KIT INTRODUCER GASTROSTOMY FEEDING TUBE 16FR,SUP-2124619,CDM,C1894,HCPCS,0272,RC,,,,both,,,766.19,498.02,,,,,,,,,,,,,
COMPONENT FEM 5 CM LT KNEE RESURF OSS RS,SUP-2441727,CDM,C1776,CPT,0278,RC,,,,both,,,17747.28,11535.73,,,,,,,,,,,,,
STAPLER INT INSTRUMENT 45 MM ENDOWRIST XI SUREFORM DISP,SUP-2246799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
SCREW BNE L70MM DIA5.5MM S STL CORT PERIARTC ST CANN LOK,SUP-2410841,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
BIT DRL 16 MM DISP,SUP-2243020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
GRAFT BNE W5XL60MM FIB FRZN SHFT,SUP-2307378,CDM,C1713,HCPCS,0278,RC,,,,both,,,2071.24,1346.31,,,,,,,,,,,,,
PLATE BNE H0.5MM 24 H UP FACE BLU TI STR COND MAL LEIBINGER,SUP-2366238,CDM,C1713,HCPCS,0278,RC,,,,both,,,1669.35,1085.08,,,,,,,,,,,,,
PLATE BNE STR 6 MM LT HK BRIDGE TI NS LEVEL 1 ORTHOANCHOR LF,SUP-2481307,CDM,C1713,HCPCS,0278,RC,,,,both,,,911.64,592.57,,,,,,,,,,,,,
RESERVOIR DRNGE 6MM BUR H W/ NYL BASE SALM,SUP-2243787,CDM,C1729,HCPCS,0272,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
VALVE HEMOSTAS DBL PLAY LUMEN DIA 9 FR POLYCARB TORQUE DEV,SUP-2303046,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.71,37.51,,,,,,,,,,,,,
SET FIX PIN BI PHS BONE SCR 1 7/8IN TI,SUP-2135873,CDM,C1713,HCPCS,0278,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF LONG 6X45 MM TITANIUM NITRIDE STE,SUP-2836809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1251.82,813.68,,,,,,,,,,,,,
HC C-Reactive Protein High Sensitivity,PX-3028614100,CDM,86141,CPT,0302,RC,,,,inpatient,,,192.00,124.80,,,,,,,,,,,,,
HC So Catecholamines Fractionated,PX-3018238466,CDM,82384,CPT,0301,RC,,,,both,,,174.00,113.10,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE MOM,SUP-2212689,CDM,C1776,CPT,0278,RC,,,,both,,,6824.79,4436.11,,,,,,,,,,,,,
TRILOGY PROV LNR 20 DEG 50/52/54X32,SUP-2202552,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE CRAN 120X40X20 MM PT SPEC IMPL PEEK,SUP-2860178,CDM,C1713,HCPCS,0278,RC,,,,both,,,25639.67,16665.79,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM GRAVITATIONAL L 12 MM CATH DSTL L 900 FX549T,SUP-2932716,CDM,C1729,HCPCS,0272,RC,,,,both,,,16003.92,10402.55,,,,,,,,,,,,,
GRAFT BIO TISS W15XL10CM THK2MM NONDENATURED BOV CLLGN,SUP-2243681,CDM,C9360,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
FLEXIBLE DRILL FIBERTAK 1.9MM,SUP-2812671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE L17MM 2 H R S STL L SHP RIG NEUT NONCOMPRESSION,SUP-2186157,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.78,123.36,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ACHILLES TEND PRESHAPED,SUP-2321866,CDM,C1713,HCPCS,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION 12-30 DEG PLASMABAND DISP,SUP-2459184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.83,1040.54,,,,,,,,,,,,,
SCREW BONE DIA7MM IL S STL CANC ISOLA,SUP-2255714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2516.71,1635.86,,,,,,,,,,,,,
GRAFT BNE 5 CC OSTEOSURGE 100,SUP-2641798,CDM,C1713,HCPCS,0278,RC,,,,both,,,2234.90,1452.68,,,,,,,,,,,,,
NANOBITER STRAIGHT TIP AR10911D1,SUP-2843604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BONE 3 MM STP THK1.6 MM TI IMP F 3.5 MM SCR LAPIDUS,SUP-2321011,CDM,C1713,HCPCS,0278,RC,,,,both,,,5224.96,3396.22,,,,,,,,,,,,,
PLATE BNE L 90 DEG 6X0.5 MM 2X2 HOLE REVERSIBLE TI BLU NS LF,SUP-2431401,CDM,C1713,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
DIANEAL PD-2/1.5% DEXTROSE 346 MOSM/L IP SOLN,RX-15434,CDM,A4722,HCPCS,0250,RC,00941-0411-11,NDC,,both,1000,ML,63.30,41.14,,,,,,,,,,,,,
PLATE BNE CALCANEAL 90X22 MM LAT TIBIOTALAR ANK HI MODEL,SUP-2399179,CDM,C1713,HCPCS,0278,RC,,,,both,,,3802.54,2471.65,,,,,,,,,,,,,
ROD EXT FIX HOFF CARBON FIBER 6MMX120MM,SUP-2463769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,205.98,133.89,,,,,,,,,,,,,
BIT DRILL STRYKER J LATCH 1.25X125 MM CRANIOMAXILLOFACIAL 2,SUP-2837626,CDM,2720000010,LOCAL,0272,RC,,,,both,,,670.39,435.75,,,,,,,,,,,,,
PROTECTOR NERVE L 2 X W 2 CM PORCINE SODIUM HYALURONATE,SUP-2890377,CDM,C1763,HCPCS,0278,RC,,,,both,,,8380.66,5447.43,,,,,,,,,,,,,
KIT CHOLGM POLYUR W/ KARLAN BLLN CATH 4FR L60CM 5MM INTRO,SUP-2383431,CDM,C1729,HCPCS,0272,RC,,,,both,,,234.87,152.67,,,,,,,,,,,,,
KIT TUBE RETEN SYS CONVENIENCE L43IN OD12FR NG CORTRAK,SUP-2236655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.70,273.45,,,,,,,,,,,,,
CANNULA SUCTION BRINER 4.5 MMX11 CM BPLR ANGULAR INSUL,SUP-2774762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2751.86,1788.71,,,,,,,,,,,,,
SCREW BNE CANN 2.8X28 MM PARTIALLY THRD STRL BIODRIVE LTX,SUP-2861399,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.83,554.99,,,,,,,,,,,,,
GRAFT VASC GORTX L 60 CM DIA 4-7 MM EPTFE TAPR STD WALL N,SUP-2396453,CDM,C1768,CPT,0278,RC,,,,both,,,2019.02,1312.36,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 215CM 0.014IN SEG 35CM SOFR PRESHAPED,SUP-2717702,CDM,C1769,HCPCS,0272,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
STENT BILI 6FR L40MM DIA10MM USABLE L120CM NIT OVR THE WIRE,SUP-2173493,CDM,C1876,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PLATE BNE L 76 MM SCREW DIA2.4 MM 10 H T SHP LCK NAR NS,SUP-2900512,CDM,C1713,HCPCS,0278,RC,,,,both,,,4046.83,2630.44,,,,,,,,,,,,,
BASEPLATE TIB REV 2/3 14+ MM RT KNEE POROUS N-K II,SUP-2449002,CDM,C1776,CPT,0278,RC,,,,both,,,9760.06,6344.04,,,,,,,,,,,,,
GRAFT BNE 1 4MM 60ML CANC CRUSH CHIP FRZN,SUP-2264738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2616.12,1700.48,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC DBM TENSIX,SUP-2759605,CDM,C1713,HCPCS,0278,RC,,,,both,,,2868.67,1864.64,,,,,,,,,,,,,
GUIDEWIRE VASC L450MM NIT BLNT CDH LONGITUDE,SUP-2279589,CDM,C1769,HCPCS,0272,RC,,,,both,,,221.94,144.26,,,,,,,,,,,,,
ADAPTER UPLR FEM 12 14 TAPR +0MM OFFSET SOLITUDE,SUP-2314488,CDM,C1776,CPT,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
HEAD RADIAL H 0.712 IN DIA 0.945 IN SZ 24L COCR ALLOY ELBW,SUP-2932780,CDM,C1776,CPT,0278,RC,,,,both,,,10699.36,6954.58,,,,,,,,,,,,,
CATHETER IRRIG 2 LUMN DST ST 11MM 5FR 40CM LEN,SUP-2264231,CDM,C1757,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
SCREW BNE TI REDUC EXTN SL 635MM 635MMX7MM CDH LEG,SUP-2287821,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.61,491.80,,,,,,,,,,,,,
DILTIAZEM HCL 30 MG PO TABS,RX-2475,CDM,6370000000,HCPCS,0637,RC,50228-0481-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
REAMER SURG 11 MM METATRSL MTP,SUP-2423328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
SPACER SPNL L58-84MM 0DEG ANTR THORLUM TI CTRL BODY NONSCREW,SUP-2182820,CDM,C1821,HCPCS,0278,RC,,,,both,,,20273.72,13177.92,,,,,,,,,,,,,
UNIT RECV ENTRL ACCS SYS CORTRAK,SUP-2764716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2953.17,1919.56,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 5 FR GUIDEWIRE 45 CM,SUP-2383425,CDM,C1894,HCPCS,0272,RC,,,,both,,,142.87,92.87,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X263 MM 16 HOLE SS DCP,SUP-2569181,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.74,342.38,,,,,,,,,,,,,
PROSTHESIS OSSCLR DRNHFFR 09MM DIA SHAFT TTNM STPS SHOE FTP,SUP-2669514,CDM,L8613,CPT,0278,RC,,,,both,,,405.91,263.84,,,,,,,,,,,,,
SHEATH INTRO L 60 CM DIA 8.5 FR SL25 CRV,SUP-2357185,CDM,C1894,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SCISSORS SURG 25GA CRV GRIESHABER,SUP-2109699,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0035IN FLPY TIP EXTN COMPATIBLE STR,SUP-2281742,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SET CATH 4FR 12CM CTRL VEN SGL LUMN N TUNNELED N COAT N PWR,SUP-2167833,CDM,C1751,HCPCS,0278,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
ANCHOR SUTURE W/ INSRTR 1.4 MM NANOTACK,SUP-2608554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.26,826.32,,,,,,,,,,,,,
CATHETER ABSC APD LOOP ALL PURP PERCFLX 20FRX25CM,SUP-2139709,CDM,C1729,HCPCS,0272,RC,,,,both,,,201.49,130.97,,,,,,,,,,,,,
SLING GYN L 12 X W 1.1 CM POLYPRO MONOFILAMENT SHRT,SUP-2929641,CDM,C1771,HCPCS,0278,RC,,,,both,,,3874.76,2518.59,,,,,,,,,,,,,
WIRE FIX 1.5X20 MM KIT SIMP SAFE RESRB SOL K,SUP-2166910,CDM,C1713,HCPCS,0278,RC,,,,both,,,582.97,378.93,,,,,,,,,,,,,
CANNULA ENDOSCP ENDOTIP 11 MMX10.5 CM W/O VLV THRD,SUP-2767350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1899.29,1234.54,,,,,,,,,,,,,
SCREW BNE CRANIOFACIAL RESRB 17MMX6MM DELT SYS 4/EA,SUP-2364994,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.12,420.63,,,,,,,,,,,,,
GUIDEWIRE ENDO L80CM 20DEG SINUS RELIEVA VIGOR,SUP-2106357,CDM,C1769,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE BONE TUBULAR NARROW 4.5 MM 5 HOLE PROVISIONAL FIXATION,SUP-2836971,CDM,C1713,HCPCS,0278,RC,,,,both,,,1443.71,938.41,,,,,,,,,,,,,
BRONCHOSCOPES MONARCH,SUP-2736193,CDM,C1601,HCPCS,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
SCREW BNE L44MM DIA5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412125,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
SHEET PROTCT BIORESORBABLE 130MMX200MMX0.02MM CARDIOWRAP,SUP-2175202,CDM,C1768,CPT,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
STAPLER INT STR 3.5X45 MM RELD BIOABSORBABLE BLU WHT SEAMGRD,SUP-2485773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.43,334.38,,,,,,,,,,,,,
PLATE BNE ADV 7 MM RT CRANIOMAXILLOFACIAL LEFORT I,SUP-2883175,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.00,1271.40,,,,,,,,,,,,,
KIT L90CM OD12FR CATHETER CTRL VEN DBL LUMN TUNNELED BASIC,SUP-2126156,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.02,321.11,,,,,,,,,,,,,
TRAY PICC SUBCL 1/L 5FR 55CML SIL PWR INJ RADPQ PEEL 9918518,SUP-2632711,CDM,C1751,HCPCS,0278,RC,,,,both,,,651.24,423.31,,,,,,,,,,,,,
BIT DRILL L220MM DIA44MM CS 65 CANNULATED HUDSON,SUP-2586586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.06,501.19,,,,,,,,,,,,,
GRAFT STENT THOR 46X46X200 MM 25 FR PROX FREEFLO STR VALIANT,SUP-2298558,CDM,C1768,CPT,0278,RC,,,,both,,,61214.30,39789.29,,,,,,,,,,,,,
PLATE BNE LP 14X0.6 MM NEURO 2X2 HOLE LADDER SQ FOR SCR TI,SUP-2480794,CDM,C1713,HCPCS,0278,RC,,,,both,,,702.01,456.31,,,,,,,,,,,,,
SYSTEM DRAINAGE MONITORR SP0017,SUP-2666838,CDM,C1729,HCPCS,0272,RC,,,,both,,,587.43,381.83,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING MINI 0.76X19 MM 5 MM WITH STOP NON,SUP-2837981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.28,370.03,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE|DOCUMENTATION ON FILE,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|CQ|XU|KX,both,,,191.00,124.15,,,,,,,,,,,,,
FILTER SMK EVAC SMARTFLTR,SUP-2166751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.12,305.58,,,,,,,,,,,,,
DISTRACTOR MLNA MNDBLR BDRCTNL LG RGHT 76 X 40 MM,SUP-2669819,CDM,C1713,HCPCS,0278,RC,,,,both,,,16063.93,10441.55,,,,,,,,,,,,,
MESH T SLNG 1CM W,SUP-2152280,CDM,C1771,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BONE 1.7X18 MM EMERGENCY RECESS TITANIUM NON STERILE P,SUP-2838180,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.25,195.16,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 10 H TI MANUBRIUM LP NS,SUP-2894547,CDM,C1713,HCPCS,0278,RC,,,,both,,,3843.36,2498.18,,,,,,,,,,,,,
GRAFT DERM L20XW12CM CLLGN RECTANG IMPL ALLOMAX,SUP-2125866,CDM,C1781,HCPCS,0278,RC,,,,both,,,19103.76,12417.44,,,,,,,,,,,,,
MESH SURG 30X30CM PREPERI ENFORM,SUP-2419665,CDM,C1781,HCPCS,0278,RC,,,,both,,,37601.50,24440.97,,,,,,,,,,,,,
WIRE CADDY ACC RETRV UNOBTRUSTIVE,SUP-2367019,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.29,128.89,,,,,,,,,,,,,
CATHETER DRNGE L120CM DIA2.5MM PERI KINK RESIST SLT WALLED,SUP-2308216,CDM,C1729,HCPCS,0272,RC,,,,both,,,895.06,581.79,,,,,,,,,,,,,
SHEATH INTRO 50 DEG 0.038 INX180 CM 8.5 FRX63 CM HEARTSPAN,SUP-2464796,CDM,C1893,HCPCS,0272,RC,,,,both,,,448.39,291.45,,,,,,,,,,,,,
LINER CROSS LINK LNR NEUT 22X44MM,SUP-2267710,CDM,C1776,CPT,0278,RC,,,,both,,,2970.44,1930.79,,,,,,,,,,,,,
CHARGER BTTRY FOR VENT ASST DEV HEARTWARE,SUP-2282565,CDM,Q0495,HCPCS,0274,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
CARTILAGINATOR SURG FLAT SINGLE SIDE SAW RASP STRL,SUP-2898459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
CATHETER EP D 6 MM 20 MMX7 FRX115 CM DUO,SUP-2465282,CDM,C1732,HCPCS,0278,RC,,,,both,,,8245.64,5359.67,,,,,,,,,,,,,
WIRE FIX 0.8 IN KIRSCHNER,SUP-2433961,CDM,C1713,HCPCS,0278,RC,,,,both,,,145.38,94.50,,,,,,,,,,,,,
COMPONENT HIP UNIPOLAR/BIPOLAR H4 HEMI,SUP-2431151,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PLATE BSSO SLIDING COLOGNE40MM,SUP-2676897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.52,1066.34,,,,,,,,,,,,,
ORTHOANCHOR SCREW XD DF15 X8MM THRD20MM TSSUE CLLR RCTNGLR,SUP-2681000,CDM,C1713,HCPCS,0278,RC,,,,both,,,437.59,284.43,,,,,,,,,,,,,
PROBE CRYOABLATION SLIMLINE ROUND ICE 1.7MM,SUP-2716311,CDM,C2618,HCPCS,0272,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
HEAD FEM DIA36MM +9MM OFFSET HIP CO CHROM TYP 12/14 TAPR,SUP-2405363,CDM,C1776,CPT,0278,RC,,,,both,,,3315.84,2155.30,,,,,,,,,,,,,
STIMULATOR PACEMKR SINGLE CHMBR EXT,SUP-2138027,CDM,C1786,HCPCS,0275,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
HC So Histochemical Identification,PX-3128831966,CDM,88319,CPT,0312,RC,,,,both,,,349.00,226.85,,,,,,,,,,,,,
STAPLE COMPRESSION 25MMX20MM TITANIUM,SUP-2652948,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-15882,CDM,J7042,HCPCS,0258,RC,00264-7610-00,NDC,JW,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
PLATE BONE L51MM 6 H MAND TI STR ECC LIMIT CNTCT DYN COMPR,SUP-2191400,CDM,C1713,HCPCS,0278,RC,,,,both,,,2956.31,1921.60,,,,,,,,,,,,,
GRAFT BNE SUB 1CC DEMIN BNE MTRX PTTY OSTEOINDUCTIVE INJ,SUP-2306994,CDM,C9359,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
INQUIRY H CURVE STEER DEC 110 6 291 HL,SUP-2698825,CDM,C1731,HCPCS,0278,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
GATIFLOXACIN 0.5 % OP SOLN,RX-103346,CDM,6370000000,HCPCS,0637,RC,61314-0672-25,NDC,,both,2.5,ML,212.80,138.32,,,,,,,,,,,,,
SAW SURG HOLE 10.8X33 MM 9 CM LG BOR MIDAS REX 8,SUP-2664882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.96,369.17,,,,,,,,,,,,,
PLATE BNE L 172.82 MM THK 1.6 MM LG WIDE TI ANGLED NS DISP,SUP-2936414,CDM,C1713,HCPCS,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG 1.14 MM ID STRL DONALDSON,SUP-2277593,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.10,13.71,,,,,,,,,,,,,
HANDPIECE THERMOABLATION RF STRL DISP SONATA,SUP-2882680,CDM,C1886,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
GUIDEWIRE FEM CENTRONAIL STRL PACKAGED INSTRMT W/O OLV DIAM,SUP-2316304,CDM,C1769,HCPCS,0272,RC,,,,both,,,599.93,389.95,,,,,,,,,,,,,
CAP PROTCT 4MM RED FOR THRD PIN JETX,SUP-2342834,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
CLAMP EXT FIX PIN 8 HOLE,SUP-2749993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,6370000000,HCPCS,0637,RC,33342-0333-15,NDC,,both,15,GR,19.60,12.74,,,,,,,,,,,,,
SCREW SPINAL RETAIN 3.5X14MM,SUP-2256930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1676.76,1089.89,,,,,,,,,,,,,
CORTEX HEX SCREW S-T 3.5X22 MM STRL,SUP-2818133,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.57,149.87,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC LOWER SPINE ADJUSTABLE VISTA 637 LSO,SUP-2427925,CDM,L0637,HCPCS,0274,RC,,,,both,,,679.12,441.43,,,,,,,,,,,,,
SCREW BNE CANC 6.5X20 MM FT TI STRL,SUP-2569922,CDM,C1713,HCPCS,0278,RC,,,,both,,,50.08,32.55,,,,,,,,,,,,,
GUIDEWIRE ORTH L5IN DIA0.059IN S STL SGL TRCR FOR MOD HND,SUP-2107897,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
DRILL DISK DIA7MM 3 ULTSONIC DISP ULT DRV,SUP-2408562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
GRAFT VASC STD WALL 8 MMX50 CM STR TWO LAYR ADVANTA VXT,SUP-2468368,CDM,C1768,CPT,0278,RC,,,,both,,,1511.66,982.58,,,,,,,,,,,,,
BUR SURG L13CM DIA3MM RND PRECIS LILAC BND,SUP-2365189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1618.86,1052.26,,,,,,,,,,,,,
HC Flouro X-Ray Barium Enema,PX-3207427000,CDM,74270,CPT,0320,RC,,,,both,,,1401.00,910.65,,,,,,,,,,,,,
KIT INTRO 18FR PRELD SAFE T PEXY T FASTENERS LOKING POLYUR,SUP-2124698,CDM,C1894,HCPCS,0272,RC,,,,both,,,690.71,448.96,,,,,,,,,,,,,
GRAFT DERM MTRX HUM TISS FLD HYDRATED THN KT BILAT BRST,SUP-2307579,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4403.85,2862.50,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 22-24X27-32X9 MM FD ALIF ANTR APPRCH,SUP-2736757,CDM,C1713,HCPCS,0278,RC,,,,both,,,14184.95,9220.22,,,,,,,,,,,,,
PLATE BNE L39MM THK1.2MM 0DEG 6 H BILAT S STL STR RIG LIMIT,SUP-2186169,CDM,C1713,HCPCS,0278,RC,,,,both,,,1132.19,735.92,,,,,,,,,,,,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,0636,RC,00143-9006-01,NDC,,both,1,UN,189.80,123.37,,,,,,,,,,,,,
NAIL IM L300MM DIA8.5MM TIB KNEE GRY TI CANN LOK RG BENT,SUP-2347448,CDM,C1713,HCPCS,0278,RC,,,,both,,,11741.56,7632.01,,,,,,,,,,,,,
HC So Candida Dna Amp Probe,PX-3068748166,CDM,87481,CPT,0306,RC,,,,outpatient,,,101.00,65.65,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 100 CM 4 FR OMNI NONBRAIDED SFT,SUP-2116674,CDM,C1725,HCPCS,0272,RC,,,,both,,,49.67,32.29,,,,,,,,,,,,,
PROCESSOR SND BGE NEUT BAHA CORDELLE II,SUP-2165022,CDM,L8614,HCPCS,0278,RC,,,,both,,,9357.20,6082.18,,,,,,,,,,,,,
MESH HERN W11XL15CM POLYPR INGUINAL NONABSORBABLE FOR LAP,SUP-2126054,CDM,C1781,HCPCS,0278,RC,,,,both,,,99.44,64.64,,,,,,,,,,,,,
BASKET RETRIEVAL DISCOVER SPYGLASS,SUP-2713870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
PLATE BONE W23XL54MM THK2MM 13 H LT DSTL RAD TI ADAPTIVE FOR,SUP-2267974,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
FILTER BACT INT 0.2 MIC,SUP-2255904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
ALLOGRAFT BNE 0.5 CC FD DBM GRFT,SUP-2787760,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.11,227.57,,,,,,,,,,,,,
SIDEPLATE SHRT BARL 150 DEG 3H STRL LCP DHHS,SUP-2547710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1578.16,1025.80,,,,,,,,,,,,,
BIT DRL DIA4.5MM DISP FOR TOGGLELOC FEM FIX DEV,SUP-2212826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1005.80,653.77,,,,,,,,,,,,,
PLATE BNE 3 X 4 H CRANIOMAXILLOFACIAL REG DISTRCTN NS,SUP-2883212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1834.51,1192.43,,,,,,,,,,,,,
CATHETER KIT 1 LUMEN 4 FR W/ PASV PWR INJ XCELA,SUP-2117187,CDM,C1751,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
CANNULA ARTHSCP SPNL NANO KT DISP,SUP-2937189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
SET INTRO V-STICK DIA 4 FR 7 CM NIT COAX NONECHOGENIC STIFF,SUP-2876223,CDM,C1894,HCPCS,0272,RC,,,,both,,,124.03,80.62,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN TIP L 3 MM SS PTFE J,SUP-2733979,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.17,14.41,,,,,,,,,,,,,
INTRODUCER IV CATH NEOMAGIC CATH 1.9/2 FR VEN BRKWY NDL,SUP-2874176,CDM,C1894,HCPCS,0272,RC,,,,both,,,108.33,70.41,,,,,,,,,,,,,
COMPONENT TOT SHLDR RT GUIDE BNE MODEL COMPHSVE,SUP-2435449,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6MM STR STD WALL SLDE GDS,SUP-2525440,CDM,C1768,CPT,0278,RC,,,,both,,,1801.61,1171.05,,,,,,,,,,,,,
PLATE BNE W135XL404MM THK42MM 22 H BILAT S STL NAR LOK,SUP-2185260,CDM,C1713,HCPCS,0278,RC,,,,both,,,3741.37,2431.89,,,,,,,,,,,,,
NICOTINE 7 MG/24HR TD PT24,RX-27860,CDM,6370000000,HCPCS,0637,RC,43598-0446-70,NDC,,both,1,UN,18.10,11.76,,,,,,,,,,,,,
SET SCR SPNL OD4MM TI BRK OFF VERTEX XLNK,SUP-2286943,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
SINUS SUCTION BURR STERILE,SUP-2574170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,645.71,419.71,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 15 MM OSTEOCHNDRL,SUP-2866832,CDM,C1762,CPT,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
SCREW N LOK 24X35MM,SUP-2400447,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
SYSTEM DELIVERY 23-29 MM  EVOLUT FX,SUP-2854099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15605.80,10143.77,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X158 MM 13 HOLE SS DCP,SUP-2569155,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.12,237.98,,,,,,,,,,,,,
QUICK RELEASE GLENOID DRILL SHORT 6MM,SUP-2841532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
TUBE GAST JEJU 14FR L15CM STOMA L1CM G GRN TECHNOLOGY LO,SUP-2119808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
GRAFT SFT TISS FASC LATA SLNG L3CMXW2CM TUTOPLAST,SUP-2247187,CDM,C1762,CPT,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM MAND 34 HOLE FULL MAND LCK STRL,SUP-2486611,CDM,C1713,HCPCS,0278,RC,,,,both,,,8266.65,5373.32,,,,,,,,,,,,,
SHEATH INTRO DRNGE CATH BAN PEEL 12FR 15MM,SUP-2141070,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.41,85.42,,,,,,,,,,,,,
PLATE BONE SM L54MM 4 HOLE LEFT DST VOLAR PRRTCLR RDL,SUP-2470134,CDM,C1713,HCPCS,0278,RC,,,,both,,,1852.57,1204.17,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM DIA 7 FR SPC 4 MM,SUP-2538037,CDM,C1730,HCPCS,0272,RC,,,,both,,,1087.48,706.86,,,,,,,,,,,,,
INTRODUCER NDL BX 7 FR 18 GAX60 CM SET LIV ACCS,SUP-2432217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.88,1106.22,,,,,,,,,,,,,
DEVICE GRFT DEL BIOLOGICS,SUP-2861976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.35,353.18,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 3",PX-7619920300,CDM,99203,CPT,0761,RC,,,,outpatient,,,321.00,208.65,,,,,,,,,,,,,
MATRIX HUM TISS L 3 X W 3 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909223,CDM,Q4122,HCPCS,0636,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
BUR SURG NEURO 31 MM CUT TUNGSTEN CARBIDE HI-LINE XS DISP,SUP-2108778,CDM,C1713,HCPCS,0278,RC,,,,both,,,507.02,329.56,,,,,,,,,,,,,
GUIDEWIRE VASC NEUROSCOUT 14 L 205 CM DSTL TIP L 42 CM DIA,SUP-2676242,CDM,C1769,HCPCS,0272,RC,,,,both,,,2315.72,1505.22,,,,,,,,,,,,,
SEALANT HEMSTAT 2ML HUM FBRNGN THROM PREFIL SYR EVICEL 10,SUP-2256933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6150.44,3997.79,,,,,,,,,,,,,
DRIVER SURG ENDCAP LCK SCREWX-CORE 2,SUP-2311088,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
KIT BAL DIL 16X40MM RELIEVA TRACT,SUP-2417596,CDM,C1726,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
KIT KYPHOPLASTY IVAS ELITE BALLOON L 10 MM NDL 10 GA SINGLE,SUP-2653969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4264.31,2771.80,,,,,,,,,,,,,
PLATE BNE L UNIV 2.7 MM RT 3 HOLE 2 COMPR LCK OBLQ FOR SCR,SUP-2464969,CDM,C1713,HCPCS,0278,RC,,,,both,,,890.06,578.54,,,,,,,,,,,,,
WIRE ORTH SMOOTH DBL SHRP TIP S STL SMOOTH OLV TIP ORTHOFIX,SUP-2315991,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.13,137.23,,,,,,,,,,,,,
HC NM Kidney Image W/O Pharmacologic,PX-3417870700,CDM,78707,CPT,0341,RC,,,,both,,,2078.00,1350.70,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 80 MG/4ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-167520,CDM,Q5135,HCPCS,0636,RC,65219-0590-04,NDC,JW,both,4,ML,1155.50,751.07,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE|DOCUMENTATION ON FILE|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309712900,CDM,97129,CPT,0430,RC,,,GN|KX|XU,outpatient,,,186.00,120.90,,,,,,,,,,,,,
PLATE BONE 5 H TI LCK 3RD TBLR,SUP-2419534,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE BNE W11XL190MM THK33MM 14 H BILAT MTPHSEAL TI LOK,SUP-2190767,CDM,C1713,HCPCS,0278,RC,,,,both,,,3806.50,2474.22,,,,,,,,,,,,,
PLATE BNE L53MM THK1.2MM 2X8 H T SHP FOR 2MM SCR PRO-PAK,SUP-2186300,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.34,680.12,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 2.8X300 MM NS,SUP-2789102,CDM,C1769,HCPCS,0272,RC,,,,both,,,1719.34,1117.57,,,,,,,,,,,,,
GRAFT 4MM 10MM RANG 90CC CHIP CRUSH CANC FRZN ALLGRFT,SUP-2264742,CDM,C1713,HCPCS,0278,RC,,,,both,,,3105.08,2018.30,,,,,,,,,,,,,
SCREW SPNL L35MM DIA6.25MM CANC PEDCL S STL NO CUT ISOLA VSP,SUP-2255681,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
CEMENT BNE FULL DOSE 20 CC TOBRA SIMPLEX P -SINGLE PK,SUP-2636351,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
WIRE FIX DIAMOND PT 2 END 0.045X5 IN SS NS KIRSCHNER,SUP-2791344,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.42,5.47,,,,,,,,,,,,,
GRAFT STENT 36X180 MM 6 FR DISECT ENDOVASC ZENITH,SUP-2423996,CDM,C1768,CPT,0278,RC,,,,both,,,47542.74,30902.78,,,,,,,,,,,,,
LEGION TIBIAL WEDGE LUG 10MM,SUP-2822935,CDM,C1776,CPT,0278,RC,,,,both,,,636.79,413.91,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 1.20 CC FD MINERALIZED ORAGRAFT,SUP-2740966,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.95,141.67,,,,,,,,,,,,,
SPLINT KNEE L24IN FOR 32IN THGH UNIV FOAM 3 PC DSGN TRIMMED,SUP-2196755,CDM,L1830,CPT,0272,RC,,,,both,,,46.69,30.35,,,,,,,,,,,,,
SAXAGLIPTIN HCL 5 MG PO TABS,RX-98424,CDM,6370000000,HCPCS,0637,RC,65862-0826-30,NDC,,both,1,UN,8.90,5.78,,,,,,,,,,,,,
SCREW BNE L36MM DIA35MM LAG CROSSCHECK ORTHOLOC 3DI,SUP-2398216,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 1 5436150,SUP-2632891,CDM,C1752,HCPCS,0278,RC,,,,both,,,656.57,426.77,,,,,,,,,,,,,
CANNULA SUCTION KLEINSASSER 5 MMX26 CM COAG UPLR INSUL,SUP-2775055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1106.10,718.96,,,,,,,,,,,,,
PROSTHESIS OTO L 3X5MM PART MALL FLX H/A,SUP-2277549,CDM,L8613,CPT,0278,RC,,,,both,,,2634.65,1712.52,,,,,,,,,,,,,
SCREW INTFR L30MM DIA7-9MM TIB TAPR NONABSORBABLE FOR SFT,SUP-2249557,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
PLATE BNE L41MM -90DEG 2X3 H NONSTERILE L DST DORS RAD R,SUP-2184184,CDM,C1713,HCPCS,0278,RC,,,,both,,,2065.24,1342.41,,,,,,,,,,,,,
HOOK DISECT 10MM HARM,SUP-2257471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.94,365.91,,,,,,,,,,,,,
NAIL INTRAMEDULLARY L25MM OD2.4MM 96L/4D PLA RESORBABLE SMAR,SUP-2824707,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.43,386.38,,,,,,,,,,,,,
HC MRI-Spine Cervical W Contrast,PX-6127214200,CDM,72142,CPT,0612,RC,,,,both,,,4190.00,2723.50,,,,,,,,,,,,,
HC So Crp,PX-3028614066,CDM,86140,CPT,0302,RC,,,,both,,,17.00,11.05,,,,,,,,,,,,,
PLATE BNE L 440 MM SCREW DIA 3.5/4.5 MM 20 H PERIPROSTHETIC,SUP-2931405,CDM,C1713,HCPCS,0278,RC,,,,both,,,22183.32,14419.16,,,,,,,,,,,,,
CHIPS BONE GRAFT CANC MORS 30CC 1-4MM FD ASP,SUP-2875980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1288.66,837.63,,,,,,,,,,,,,
PORT INFUS 9.6FR CATH SIL POLYUR PRT PLAS SGL LUMN INTERMED,SUP-2127751,CDM,C1788,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
ELECTRODE 3MM THERM VAPOUR FOR THERM MOD SUCT SL 2,SUP-2256726,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.48,35.41,,,,,,,,,,,,,
SCREW BNE L60MM DIA5MM PROX FEM S STL ST SELF DRL CANN,SUP-2184743,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.69,302.05,,,,,,,,,,,,,
BUNDLE CASE MICROTIA ADD TEMP VSP,SUP-2862838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12924.24,8400.76,,,,,,,,,,,,,
HC So Drug Assay Amiodarone,PX-3018015166,CDM,80151,CPT,0301,RC,,,,inpatient,,,189.00,122.85,,,,,,,,,,,,,
PLATE EXT FIX SHT 100 MM FT RNG CARBON FIBER NS,SUP-2800194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1920.99,1248.64,,,,,,,,,,,,,
HC Tcat Removal Perm Leadless Pm Right Ventr W/Img,PX-4813327500,CDM,33275,CPT,0481,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
CATHETER PUSH STENT CONN CLR PUR 11FR LEN 170CM,SUP-2169264,CDM,C1729,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
INSTRUMENT SET TOT WRST LT HND,SUP-2490035,CDM,C1776,CPT,0278,RC,,,,both,,,31281.94,20333.26,,,,,,,,,,,,,
SCREW WRIST 18MM,SUP-2500462,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.02,411.46,,,,,,,,,,,,,
PLATE BONE CMPRSSN 204MML HLX11 STNLSS STEEL 95DG ANGLD TUBE,SUP-2726374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2076.36,1349.63,,,,,,,,,,,,,
SCREW SPNL L20MM OD4MM MONOAX REDUC REVERE,SUP-2231808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
HC So Dna Antibody,PX-3028622566,CDM,86225,CPT,0302,RC,,,,both,,,397.00,258.05,,,,,,,,,,,,,
CATHETER HD STR EXTN 12.5 FRX30 CM TRPL LUMEN MAHRK ELITE,SUP-2626948,CDM,C1752,HCPCS,0278,RC,,,,both,,,208.90,135.78,,,,,,,,,,,,,
GUIDEWIRE VASC J 0.035 INX50 CM FIX COR HEPARIN SS SAFE-T-J,SUP-2167611,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.65,25.12,,,,,,,,,,,,,
ALLOGRAFT BNE LORDTC 5 DEG 23-27X23-30X14.75X5-6 MM LAT VG1,SUP-2740831,CDM,C1713,HCPCS,0278,RC,,,,both,,,9592.89,6235.38,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL RT ANTR CONTOURED BABY GORILLA,SUP-2751222,CDM,C1713,HCPCS,0278,RC,,,,both,,,6208.57,4035.57,,,,,,,,,,,,,
GRAFT HUM TISS L 6 X W 4 CM XL AMNIO MEMBRN RESRB AIR DRY,SUP-2913443,CDM,Q4173,HCPCS,0636,RC,,,,both,,,9790.52,6363.84,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA1.8 MM CRANIOMAXILOFACIAL HI TORQUE XDRV,SUP-2935482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3177.68,2065.49,,,,,,,,,,,,,
SCREW BONE JONES 5.5MM,SUP-2719494,CDM,C1713,HCPCS,0278,RC,,,,both,,,6512.36,4233.03,,,,,,,,,,,,,
COIL EMB L2CM DIA3-2MM CATH DIA0.018IN FOR AV MALFORMATION,SUP-2168310,CDM,C1889,HCPCS,0278,RC,,,,both,,,366.88,238.47,,,,,,,,,,,,,
TWIST DRILL MRRSNKLS MRTN1.5MMX105MM WNTCH SGTTL SPLIT LEV,SUP-2676882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
SPLINT KNEE L12IN UNIV WRP ARND OPN PAT WIND CLS POPLITEAL,SUP-2196739,CDM,L1830,CPT,0272,RC,,,,both,,,33.00,21.45,,,,,,,,,,,,,
SHOE ORTHOT ADDITION CONVERT INSTEP VELCRO CLOSURE,SUP-2435742,CDM,L3580,HCPCS,0272,RC,,,,both,,,183.63,119.36,,,,,,,,,,,,,
GRAFT BNE SUB 30ML 01 2MM CORT CANC GRAN MORSELIZED FRZ DRY,SUP-2307061,CDM,C1713,HCPCS,0278,RC,,,,both,,,1379.72,896.82,,,,,,,,,,,,,
PACK OPHTH US BASIC VISN SYS INFIN,SUP-2109873,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
LCKNG EMERGENCY SCR MD31X11MM5/PKG,SUP-2668810,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.27,317.38,,,,,,,,,,,,,
SPHERE GLEN DIA38MM +4MM OFFSET LAT SHLDR FOR RVS EXP SYS,SUP-2223374,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 67X50X14 MM 38 CC 78 GM ATLS + DR V243RST] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356554,CDM,C1721,HCPCS,0275,RC,,,,both,,,70022.00,45514.30,,,,,,,,,,,,,
PIN FIX 7/64X9 IN DBL BAY NS STEINMANN DISP,SUP-2861164,CDM,C1713,HCPCS,0278,RC,,,,both,,,252.27,163.98,,,,,,,,,,,,,
HC So Plasma Cryofibrinogen,PX-3018258566,CDM,82585,CPT,0301,RC,,,,both,,,255.00,165.75,,,,,,,,,,,,,
ANCHOR SUT DIA1.4MM W/ NDL 1 STRND NO2 FORC FBR,SUP-2366689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1828.52,1188.54,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.5MM CRANIOMAXILLOFACIAL TI SELF DRL,SUP-2181588,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.86,168.26,,,,,,,,,,,,,
DRESSING GERM W5XL6IN HELIX COMP LAYR JUMPSTART,SUP-2123477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,114.61,74.50,,,,,,,,,,,,,
BIT DRL SPRL FLX,SUP-2449499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
BIT DRL TWST 1.6X50 MM 10 MM W/ STP NOTCH STRL SONICWELD RX,SUP-2459005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.14,363.44,,,,,,,,,,,,,
GRIP CBL L265MM STD TROCHANTERIC HIP 11 CBL ACCORD,SUP-2345209,CDM,C1776,CPT,0278,RC,,,,both,,,9683.76,6294.44,,,,,,,,,,,,,
CATHETER EP DAO CRV 10 MM 6 FRX120 CM SUPREME,SUP-2356852,CDM,C1730,HCPCS,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
CATHETER ABLATN D-D 1-7-4 MM 8MM 7 FRX115 CM EZ STEER LF,SUP-2248511,CDM,C1732,HCPCS,0272,RC,,,,both,,,7074.42,4598.37,,,,,,,,,,,,,
SCREW BNE CANN 6.5X35 MM ST SD TI STRL ASNS III,SUP-2374351,CDM,C1713,HCPCS,0278,RC,,,,both,,,830.84,540.05,,,,,,,,,,,,,
PLATE BONE W6XL33MM 12 H VIT LADDER STRUT FOR 1.3MM SCR,SUP-2364703,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
GRAFT HUM TISS W20XL15MM THK12MM FRZ DRY ALLGRFT BLK CANC,SUP-2307119,CDM,C1713,HCPCS,0278,RC,,,,both,,,2511.50,1632.47,,,,,,,,,,,,,
GRAFT HUM TISS L 3 X W 0.7-0.9 CM THK 3 MM LG COSTAL CART,SUP-2895218,CDM,C1762,CPT,0278,RC,,,,both,,,1894.46,1231.40,,,,,,,,,,,,,
PLATE BNE 2X37X1.5 MM 7 HOLE SS DCP,SUP-2569123,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.86,189.71,,,,,,,,,,,,,
CATHETER THORACENTESIS SET 9 FRX20 CM PNEUMOTHORAX PETERS,SUP-2760076,CDM,C1729,HCPCS,0272,RC,,,,both,,,600.12,390.08,,,,,,,,,,,,,
SCREW BNE L16MM DIA3MM FT BLU SELF DRL ST CANN DST THRD CYL,SUP-2396798,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.65,250.02,,,,,,,,,,,,,
IMPLANT HUM TISS L 2 X W 2 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905494,CDM,Q4184,HCPCS,0636,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CHISEL SURG EXTRACTION TIP NS,SUP-2800142,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.42,413.67,,,,,,,,,,,,,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,0636,RC,65649-0551-02,NDC,,both,0.4,ML,651.40,423.41,,,,,,,,,,,,,
TRAY THORCENT L4.75IN DIA8FR SFTY COMP PRECIS TURKEL,SUP-2154964,CDM,C1729,HCPCS,0272,RC,,,,both,,,258.27,167.88,,,,,,,,,,,,,
SPADE TIP DRILL FOR 3.9MM SWIVELOCK,SUP-2812532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
HOOK ELECTRD L243MM BLDE L35MM L SHP PARTIALLY INSUL R ANG,SUP-2243729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,622.91,404.89,,,,,,,,,,,,,
CAGE SPNL L W14XH20XL16MM 0DEG CERV THORLUM C FBR POLYMER,SUP-2256203,CDM,C1889,HCPCS,0278,RC,,,,both,,,3030.23,1969.65,,,,,,,,,,,,,
SCREW INTRF L10MM OD3MM LACTOSORB COPOLYMER POLY L LACTIC,SUP-2137286,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
PROSTHESIS PENILE SCROT ALPHA 1 CYL,SUP-2300754,CDM,C1813,HCPCS,0278,RC,,,,both,,,18196.30,11827.59,,,,,,,,,,,,,
CATHETER ABLAT L160CM DIA4MM BPLR ELECTRD W13XL20MM FOC,SUP-2172349,CDM,C1888,HCPCS,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
IMPLANT ANK JT HYBRID SUBTALAR TI AND POLYETH HORZ 9MM,SUP-2137775,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
STEM FEM L140MM DIA12MM HIP L MTPHSEAL BODY STR NK TIV,SUP-2210352,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
KNIFE 3722040 TYMPAN 7MM CVD BLADE,SUP-2702665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.54,261.00,,,,,,,,,,,,,
IMPLANT HUM TISS 20CML TISS FRZN TIBIALIS ANTR TEND,SUP-2307034,CDM,C1713,HCPCS,0278,RC,,,,both,,,5026.36,3267.13,,,,,,,,,,,,,
STRATOGEN MEM 2 X 6 CM,SUP-2164200,CDM,Q4139,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
COLLAR CERV CNTOUR UNIV 3 IN MED DENS FOAM PROCARE,SUP-2196897,CDM,L0180,HCPCS,0272,RC,,,,both,,,7.82,5.08,,,,,,,,,,,,,
HC Perq Dev Breast 1st US Image,PX-3611928500,CDM,19285,CPT,0361,RC,,,,inpatient,,,2124.00,1380.60,,,,,,,,,,,,,
STEM FEM HI OFFSET A MAG NK W/ TRUNNION ARCOS,SUP-2443221,CDM,C1776,CPT,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 175 CM DIA 4-8 MM,SUP-2120067,CDM,C1773,HCPCS,0272,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
GRAFT HUM TISS W12-13XL100MM FRZ DRY ALLGRFT FIB SHFT BNE,SUP-2307198,CDM,C1762,CPT,0278,RC,,,,both,,,2201.20,1430.78,,,,,,,,,,,,,
FEE PROC LIMFLOW SYS,SUP-2902910,CDM,C1757,HCPCS,0272,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
REAMER EXTRACTION SZ 5.8 MM SCREW DIA 4.7-5.8 MM STRL DISP,SUP-2913564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3160.19,2054.12,,,,,,,,,,,,,
COMPONENT HUM SM L8IN ELBW INTERCHANGEABLE LNG FLNG ASMBLY,SUP-2205926,CDM,C1776,CPT,0278,RC,,,,both,,,12490.92,8119.10,,,,,,,,,,,,,
HC Bladder Scan,PX-7615179800,CDM,51798,CPT,0761,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
BOLT EEG ELECTRD L 25 MM OD 2.4 MM ID 0.9 MM ANCHR BLU STRL,SUP-2936470,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM ACELLULAR DERM CLLGN RECTANG,SUP-2125862,CDM,C1781,HCPCS,0278,RC,,,,both,,,9545.60,6204.64,,,,,,,,,,,,,
SPACER KNEE 3-10 12 MM DSTL SYS REV GUIDE ATTUNE,SUP-2454500,CDM,C1776,CPT,0278,RC,,,,both,,,1717.58,1116.43,,,,,,,,,,,,,
SCREW INTRF L30MM DIA9MM PEEK FOR INTRAFIX ADV TIB FAST SYS,SUP-2256832,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
SCREW 3.5MMX44MM HEADLESS DART-FIRE,SUP-2857922,CDM,C1713,HCPCS,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
SCISSORS OPHTH 41IN KERATOPLASTY CRV R DEL BLNT CASTRO,SUP-2129397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.03,518.72,,,,,,,,,,,,,
CYCLOBENZAPRINE HCL 10 MG PO TABS,RX-2017,CDM,6370000000,HCPCS,0637,RC,69097-0846-07,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE HI COMPRESSIVE STRENGTH RADPQ,SUP-2106908,CDM,C1713,HCPCS,0278,RC,,,,both,,,4681.74,3043.13,,,,,,,,,,,,,
CATHETER ETER EP MAP DIAG 5FR 110CM LEN M CRV OCTAPOLAR 2MM SPC 1MM,SUP-2357653,CDM,C1730,HCPCS,0272,RC,,,,both,,,1117.84,726.60,,,,,,,,,,,,,
PLUG TIB TI KNEE HNG STRL MOST OPTIONS,SUP-2208388,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.81,382.08,,,,,,,,,,,,,
CATHETER CHOLGM 4FR L50CM NDL INTRO REDDICK SCOOP TIP,SUP-2264235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
BIT DRILL DIAMETER 4MM SHOULDER DISPOSABLE FOR KNOTLESS SUTU,SUP-2825106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.93,475.75,,,,,,,,,,,,,
SCREW SPNL 5.5X35 MM SHANK OSTEOGRIP NS CD HORIZON,SUP-2737981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
COMPONENT ARTC 35X17MM CURVATURE 15MM CAPITATE WRISTMOTION,SUP-2123590,CDM,C1776,CPT,0278,RC,,,,both,,,25104.30,16317.79,,,,,,,,,,,,,
STENT URET 45FR L22CM POLYMER HYDRPHLC OPN TIP RADPQ MRK,SUP-2313776,CDM,C2617,HCPCS,0278,RC,,,,both,,,376.42,244.67,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO SEP 8 L 150 CM DSTL DIA 0.072 IN,SUP-2765592,CDM,C1757,HCPCS,0272,RC,,,,both,,,5824.70,3786.05,,,,,,,,,,,,,
CATHETER SET 12 FRX25 CM SUPRAPUBIC MAC-LOC SCALPEL UTHANE,SUP-2169838,CDM,C2627,HCPCS,0272,RC,,,,both,,,251.64,163.57,,,,,,,,,,,,,
PLATE BNE L50MM 6 H BILAT ORAL MAXILLOFACIAL TI CRESC SHP,SUP-2191403,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.24,1827.31,,,,,,,,,,,,,
BIT DRL CANN 4.8X155 MM TRAPEZIUM NS,SUP-2863449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,889.34,578.07,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 109 MM DIA28 MM SHTH 16 FR RVD,SUP-2170227,CDM,C1874,HCPCS,0278,RC,,,,both,,,51634.16,33562.20,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 15% HYDROXYAPATITE/85% B-TCP GRAN POR,SUP-2288534,CDM,C1713,HCPCS,0278,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
PLATE BNE CLAV CS1 2.7 MM LT LAT VA LCK COMPR TI NS VA-LCP,SUP-2758159,CDM,C1713,HCPCS,0278,RC,,,,both,,,3681.96,2393.27,,,,,,,,,,,,,
PIN EXT FIX MINI CLMP CONVERGING FOR CORRECTIVE OSTEOTMY,SUP-2400612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
PROBE TEMP CTRL BLU SENS MALL SHFT TACS,SUP-2341021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1015.48,660.06,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W3XL7CM THK1.04 2.28MM THICK RGNRTVE TSSUE,SUP-2483327,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2738.08,1779.75,,,,,,,,,,,,,
GUIDEWIRE ORTH MULT HOLE,SUP-2644805,CDM,C1769,HCPCS,0272,RC,,,,both,,,2595.90,1687.33,,,,,,,,,,,,,
SCREW BNE L10MM DIA5MM CORT S STL ST NONCANNULATED LOK FULL,SUP-2178473,CDM,C1713,HCPCS,0278,RC,,,,both,,,713.35,463.68,,,,,,,,,,,,,
BIT DRILL STRYKER 6015620,SUP-2855427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.32,826.36,,,,,,,,,,,,,
ENDPLATE CAGE W 18 MM D 18 MM DIA16 MM FOOTPRINT DIA18 MM VA,SUP-2928057,CDM,C1889,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
FILTER VASC TRAPEASE L 55 CM DIA 6 FR CAVA DIA 30 MM NIT JUG,SUP-2865606,CDM,C1880,HCPCS,0278,RC,,,,both,,,3372.36,2192.03,,,,,,,,,,,,,
PLATE BNE W13.5XL160MM THK4.2MM 9 H BILAT S STL NAR LIMIT,SUP-2185241,CDM,C1713,HCPCS,0278,RC,,,,both,,,1387.47,901.86,,,,,,,,,,,,,
ANCHOR SUTURE 4.5MM WITH 2 SUTURES HI-FI NEEDLE GENESYS CROS,SUP-2825102,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.09,1020.56,,,,,,,,,,,,,
PACEMAKER CARD ADAPTA VDD W 42.9 X H 44.7 MM D 7.5 MM TI 2,SUP-2282317,CDM,C2619,HCPCS,0275,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
PLATE BNE STR 3.5X131 MM 10 HOLE RECON LCK SS STRL,SUP-2477073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.39,988.90,,,,,,,,,,,,,
ANCHOR SUT DIA1.4MM TAPE 1 STRND INTELLIBRAID TECHNOLOGY,SUP-2366687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1762.45,1145.59,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.532,SUP-2860049,CDM,C1713,HCPCS,0278,RC,,,,both,,,47180.07,30667.05,,,,,,,,,,,,,
ACETYLCHOLINE CHLORIDE 20 MG IO SOLR,RX-76641,CDM,2500000003,HCPCS,0250,RC,24208-0539-20,NDC,,both,1,UN,750.80,488.02,,,,,,,,,,,,,
PLATE BNE SZ 20MM 2 H COMPR,SUP-2243484,CDM,C1713,HCPCS,0278,RC,,,,both,,,5659.38,3678.60,,,,,,,,,,,,,
BODY HUM L40MM SHLDR M FEM TAPR COMP MRS,SUP-2376475,CDM,C1776,CPT,0278,RC,,,,both,,,6584.58,4279.98,,,,,,,,,,,,,
"HC Culture, Fungus Blood",PX-3008710300,CDM,87103,CPT,0300,RC,,,,outpatient,,,454.00,295.10,,,,,,,,,,,,,
PLATE BNE L 367 MM SCREW DIA 3.5/4.5 MM 16 H LT TROCHANTERIC 72586116N,SUP-2932742,CDM,C1713,HCPCS,0278,RC,,,,both,,,21760.20,14144.13,,,,,,,,,,,,,
MAGNESIUM SULFATE 2 GM/50ML IV SOLN,RX-131192,CDM,J3475,HCPCS,0636,RC,63323-0106-02,NDC,,both,50,ML,73.90,48.03,,,,,,,,,,,,,
SCREW BNE L44MM OD45MM STD S STL CORT N ST NCANNULATED,SUP-2362351,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.49,75.72,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 45 CM DIA 7 MM CLLGN BOV CAR ART,SUP-2120673,CDM,C1768,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
GUIDEWIRE 2MM 15IN SCR SMOOTH BLNT TIP STRL CANNFLX,SUP-2340981,CDM,C1769,HCPCS,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
HC NM Parathyroid Scan,PX-3417807000,CDM,78070,CPT,0341,RC,,,,both,,,3888.00,2527.20,,,,,,,,,,,,,
DIREXION HI-FLO/FATHOM/027/BERN/1RO/155,SUP-2652843,CDM,C1887,HCPCS,0272,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
LINER ACET OD66-68MM ID28MM +4MM 20DEGXLPE REFLCT,SUP-2344762,CDM,C1776,CPT,0278,RC,,,,both,,,2918.63,1897.11,,,,,,,,,,,,,
LINER ACET CUP NEUT REV SNAP IN MTL ON POLY POLYETH ECC 64MM,SUP-2202277,CDM,C1776,CPT,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
MARKER BRST BX MOLLI L 8 CM DIA14 GA PRELD MR CONDITIONAL,SUP-2875963,CDM,A4648,CPT,0278,RC,,,,both,,,2610.38,1696.75,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN FLX FREJKA TYP W/CVR,SUP-2435595,CDM,L1600,HCPCS,0272,RC,,,,both,,,364.81,237.13,,,,,,,,,,,,,
BLADE BLUNT 20MM MIS W/SHTH AND TUBE SET NEXUS,SUP-2716354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2321.46,1508.95,,,,,,,,,,,,,
VEST TRAC L112CM DIA76MM SYNTH LNR TALL COMPATIBLE ADV,SUP-2255764,CDM,L0810,HCPCS,0274,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET AVX L 50 CM DIA 6 FR RX,SUP-2277422,CDM,C1757,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC Rmvl FB Corneal W Slit Lamp,PX-4506522200,CDM,65222,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM SL FOOTPRINT ULT PK,SUP-2341886,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
DRILL SURG CEM 1.5-3 FBT HI PERF SIG,SUP-2456271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1560.58,1014.38,,,,,,,,,,,,,
PLATE BNE L99MM 5 H ST L LAT DST FIBULAR S STL LOK COMPR,SUP-2177417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1923.97,1250.58,,,,,,,,,,,,,
BEAM FIX L100MM DIA8.5MM ARTH,SUP-2223961,CDM,C1713,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
BIT DRL CANN 4.5X100 MM QC,SUP-2392914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
TAP SURG DIA2.2 MM SD DELT,SUP-2883248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.45,512.49,,,,,,,,,,,,,
KIT INSRTN INTRO L 6 IN CATH DIA 8 FR 50 CC PACKAGED STRL,SUP-2908670,CDM,C1894,HCPCS,0272,RC,,,,both,,,379.31,246.55,,,,,,,,,,,,,
COMPONENT TALAR SZ 3 BILAT ANK POLY SULCUS DOME POR CEM,SUP-2397153,CDM,C1776,CPT,0278,RC,,,,both,,,9583.28,6229.13,,,,,,,,,,,,,
SCREW BNE L10MM DIA2MM PUR TI ALLY THRD AND ROUNDED CONIC HD,SUP-2181024,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.06,267.84,,,,,,,,,,,,,
HC So Chylmd Trach Dna Amp Probe,PX-3068749166,CDM,87491,CPT,0306,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
HC Rheumatoid Factor Quantitative,PX-3028643100,CDM,86431,CPT,0302,RC,,,,both,,,347.00,225.55,,,,,,,,,,,,,
IMPLANT TOE JT 2.7 MM METATRSL LESSER SHORTNG SLOT STRL,SUP-2898968,CDM,C1776,CPT,0278,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
ANCHOR SUT ORTHOCORD 4-0 DRL BIT OD1.3MM NDL C-1 TAPERPOINT,SUP-2256601,CDM,C1713,HCPCS,0278,RC,,,,both,,,1896.56,1232.76,,,,,,,,,,,,,
SET BNE BX AND INFUS W COAX CRV 10G 10MM INTRO NDL AND 13G,SUP-2168818,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7104,SUP-2493071,CDM,C1769,HCPCS,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 5FR 0.042N 60CM 1 LUMAN RVRSE TAP,SUP-2613428,CDM,C1751,HCPCS,0278,RC,,,,both,,,429.55,279.21,,,,,,,,,,,,,
STENT URET L 90 CM DIA 7 FR SIL BRAIDED DIV HYDRO-GLIDE,SUP-2128997,CDM,C2617,HCPCS,0278,RC,,,,both,,,315.60,205.14,,,,,,,,,,,,,
STEM FEM PRSS FT 13 HIP SYNERGY,SUP-2344424,CDM,C1776,CPT,0278,RC,,,,both,,,8135.30,5287.94,,,,,,,,,,,,,
SCREW BNE DRILL-FREE 1.5X13 MM 8 MM 2 MM CLLR ORTHOANCHOR,SUP-2458349,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.57,222.67,,,,,,,,,,,,,
SPACER SPNL 6-45MM FUS UNIV DYNESYS,SUP-2414261,CDM,C1889,HCPCS,0278,RC,,,,both,,,7363.30,4786.14,,,,,,,,,,,,,
GRAFT HUM TISS L 10ML BONE MTRX CELLULAR OSTEOCEL PRO,SUP-2310457,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
SET INTRO SHTH 6FR L2IN PERC POLYUR W/ INTEGR HAEMOSTASIS,SUP-2383421,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.73,35.57,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 25.4MMW X90MML 1.5MM THK 1.5MM THK CUT ME,SUP-2605471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,102.21,66.44,,,,,,,,,,,,,
SLEEVE CBL SM DIA1.6MM VIT HIP BEAD DALL-M,SUP-2377564,CDM,C1776,CPT,0278,RC,,,,both,,,790.02,513.51,,,,,,,,,,,,,
CATHETER ATHRCTMY SILVERHAWK L 135 CM EFFECTIVE L 129 CM TIP,SUP-2173083,CDM,C1714,HCPCS,0272,RC,,,,both,,,8619.30,5602.54,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH CSTA L 60 CM DIA 8 FR GUIDEWIRE L 145,SUP-2357180,CDM,C1894,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
BUTTON CBL 3.5MM HIP S STL HEX USE W/ 1.3MM/1.8MM CBL,SUP-2410259,CDM,C1776,CPT,0278,RC,,,,both,,,248.41,161.47,,,,,,,,,,,,,
SET HAD CATHETER 9FR L12CM STR INTRO NDL GWIRE DIL BASIC,SUP-2269568,CDM,C1752,HCPCS,0278,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
KIT DISECT 6 7 8.5 10 12MM MOD RNG HNDL VOLLMAR,SUP-2264255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
U RNG DIA180MM SPD FRME,SUP-2197265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB GUIDEPIN K3AMEDACTA] MEDACTA USA],SUP-2267793,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ANCHOR SUT 13MM HIP W 1 NO Y KNOT FLX,SUP-2167267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1678.08,1090.75,,,,,,,,,,,,,
PIN FIX TARGETER 3.5X40 MM,SUP-2351294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.06,280.19,,,,,,,,,,,,,
RELOAD STPL L45MM H15 35MM REG TISS BLU 6 ROW B FRM NAT,SUP-2218985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.53,309.74,,,,,,,,,,,,,
PLATE BNE L9MM THK0.4MM 2 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181554,CDM,C1713,HCPCS,0278,RC,,,,both,,,201.59,131.03,,,,,,,,,,,,,
CRANIAL ACCESS KIT 5.31 MM W/O PREP SOL BIT,SUP-2666738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,790.71,513.96,,,,,,,,,,,,,
INSERT ACET SZ P5 OD58-60MM ID28MM THK10MM 0DEG X FRE CO,SUP-2376202,CDM,C1776,CPT,0278,RC,,,,both,,,2751.90,1788.73,,,,,,,,,,,,,
PLATE BNE LCK 30 MM RT DSTL RADIAL VOLAR LAT 2 HOLE CLMN,SUP-2494167,CDM,C1713,HCPCS,0278,RC,,,,both,,,2152.69,1399.25,,,,,,,,,,,,,
KIT THROMCTMY TREVO XP PROVUE L 180 CM RETRV L 32 MM DIA 4,SUP-2367764,CDM,C1757,HCPCS,0272,RC,,,,both,,,21964.30,14276.79,,,,,,,,,,,,,
SHUNT SURG 4 MM LUMBO-PERITONEAL,SUP-2666434,CDM,C1729,HCPCS,0272,RC,,,,both,,,1649.13,1071.93,,,,,,,,,,,,,
SPLINT WR PED M THK1/8IN LT WRP ARND DSGN D RNG STRP ROLYAN,SUP-2324210,CDM,L3809,HCPCS,0274,RC,,,,both,,,51.68,33.59,,,,,,,,,,,,,
HC So Suscept Macrobroth Dilution Ea,PX-3008718866,CDM,87188,CPT,0300,RC,,,,both,,,256.00,166.40,,,,,,,,,,,,,
MATRIX BIO L 8 X W 10 CM SZ 144 SQCM FISH SKIN DERMAL,SUP-2909206,CDM,Q4158,HCPCS,0636,RC,,,,both,,,14164.54,9206.95,,,,,,,,,,,,,
MESH SYN ABD BIOMATERIAL N ABSRB EXP POLYTETRAFLUROETHYLENE 1DLMCPH04] WL GORE AND ASSOCIATES INC],SUP-2395349,CDM,C1781,HCPCS,0278,RC,,,,both,,,3030.10,1969.56,,,,,,,,,,,,,
MESH HERN W20XL25CM POLY ABD RECT COMP OPN SKRT PARIETEX,SUP-2172433,CDM,C1781,HCPCS,0278,RC,,,,both,,,5051.51,3283.48,,,,,,,,,,,,,
BOLT EXT FIX 16.5 MM STRL TRUELOK EVO LTX,SUP-2875627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,90.81,59.03,,,,,,,,,,,,,
HC Straight Cath - Residual Urine,PX-7615170100,CDM,51701,CPT,0761,RC,,,,both,,,204.00,132.60,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO FIX DUODECAPOLAR 20 POLE,SUP-2490042,CDM,C1731,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
PLATE BONE TENSION BAND BROAD MINI 1 MM 3X3 HOLE MALLEABLE T,SUP-2837764,CDM,C1713,HCPCS,0278,RC,,,,both,,,1857.31,1207.25,,,,,,,,,,,,,
PROBE COAG 6.9FR L2.2M CONV SIDE FIRE BLT IN FLTR 2200SC FIAPC,SUP-2217947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.93,518.00,,,,,,,,,,,,,
BUR SURG L 130 MM DIA 4 MM MH COARSE DIAMOND TUBE FOR SLIM,SUP-2937176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
MESH HERN ELLIPSE 14X12 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855267,CDM,C1781,HCPCS,0278,RC,,,,both,,,52595.00,34186.75,,,,,,,,,,,,,
COMPONENT NEG PRSS WND THER STRP M NO PRSS RANG SNAP,SUP-2261608,CDM,C1776,CPT,0278,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
GRAFT BNE SUB 15ML 1.7-10MM CANC CHIP MORSELIZED FRZ DRY,SUP-2307077,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
PUNCH AORT 4.8MM 203MM LNG TIP DISP,SUP-2330985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.03,54.62,,,,,,,,,,,,,
PLATE BNE LO BEND 3.5X180 MM LT PROX TIB 12 HOLE SS NS LCP,SUP-2184311,CDM,C1713,HCPCS,0278,RC,,,,both,,,4108.38,2670.45,,,,,,,,,,,,,
KIT SHLDR PROS STEMLESS INHANCE,SUP-2884233,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SYSTEM NAVIGATION PALM SZ PRECIS ALIGN TECHNOLOGY DISP FOR,SUP-2314152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
SCREW BNE ST 2X6 MM CRTX COARSE PITCH TI GLD PLUSDRIVE LF,SUP-2189327,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.96,172.87,,,,,,,,,,,,,
PLATE BNE W5XL100MM THK1MM 20 H BILAT S STL STR RIG NEUT,SUP-2186151,CDM,C1713,HCPCS,0278,RC,,,,both,,,808.30,525.39,,,,,,,,,,,,,
VITAMIN E 180 MG (400 UNIT) PO CAPS,RX-154146,CDM,6370000000,HCPCS,0637,RC,57896-0752-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,6370000000,HCPCS,0637,RC,60505-0826-01,NDC,,both,15,ML,81.00,52.65,,,,,,,,,,,,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,0636,RC,00169-7201-01,NDC,,both,1,UN,8289.50,5388.17,,,,,,,,,,,,,
PLATE BONE MINI L27MM CVD,SUP-2364913,CDM,C1713,HCPCS,0278,RC,,,,both,,,311.55,202.51,,,,,,,,,,,,,
CROWN DENT E7 2ND PRIMARY M UPPER LT SS 5009568] PATTERSON DENTAL SUPPLY],SUP-2322218,CDM,D6783,CPT,0278,RC,,,,both,,,33.35,21.68,,,,,,,,,,,,,
AGENT BONDING 5ML UNIV LT CURE NAT ELEGANCE,SUP-2238467,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.97,102.03,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN FLX FREJKA CVR ONLY,SUP-2435596,CDM,L1610,HCPCS,0272,RC,,,,both,,,154.96,100.72,,,,,,,,,,,,,
VITAMIN D 25 MCG (1000 UT) PO TABS,RX-147710,CDM,6370000000,HCPCS,0637,RC,80681-0169-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE W14XL149MM THK3.8MM 7 H R LAT TIB HD BTTRS S STL,SUP-2185777,CDM,C1713,HCPCS,0278,RC,,,,both,,,4101.22,2665.79,,,,,,,,,,,,,
BAR EXT FIX L400MM DIA10.5MM C COMP UNILAT KNEE RND CROSS,SUP-2342878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1854.89,1205.68,,,,,,,,,,,,,
GUIDEWIRE SURG L14IN DIA2.4MM CALIB DRL TIP DISP APERFIX,SUP-2416415,CDM,C1769,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE BNE L 162 MM SCREW DIA2.7/3.5MM 12 H LT MEDL DSTL TIB,SUP-2931149,CDM,C1713,HCPCS,0278,RC,,,,both,,,7858.64,5108.12,,,,,,,,,,,,,
TRAY CHST TUBE 32 FR TRCR TIP STR SFT 10.7 MM DIA 4,SUP-2168202,CDM,C1729,HCPCS,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
NEEDLE PHACO 45 DEG STD 19 GA 2.75 MM TAPR TIP REUSE,SUP-2463468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
CAGE SPNL W11XH8XL14MM LUM LORD INTBDY FUS TRIAD CC,SUP-2310536,CDM,C1889,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
STEM FNGR JT SZ 50 MP SIL CEMENTLESS PRI PRESSFIT NEUFLEX,SUP-2250688,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE 130 DEG SHFT L 60 MM BLADE L 50 MM SCREW DIA 3.5,SUP-2908315,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.69,1071.65,,,,,,,,,,,,,
LOCKING SCR T8 FT 2.7MM / L15MM,SUP-2364743,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
GRAFT VASC DYNAFLO L 80 CM DIA 8 MM EPTFE CARBON PERIPH STR,SUP-2126825,CDM,C1768,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
HC Clsd Tx Cmc Disl Thumb W/Man,PX-4502664100,CDM,26641,CPT,0450,RC,,,,both,,,729.00,473.85,,,,,,,,,,,,,
PATCH CV HEMSHLD PLAT FINESSE L 1.2 X W 4.6 CM THK 0.635 MM,SUP-2266059,CDM,C1768,CPT,0278,RC,,,,both,,,532.23,345.95,,,,,,,,,,,,,
CADDY SCR POLYAX 3.5X34 MM VA VIRAGE,SUP-2684938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 15 CC CELLENTRA ADV,SUP-2866899,CDM,C1713,HCPCS,0278,RC,,,,both,,,15105.91,9818.84,,,,,,,,,,,,,
PLATE BNE 10 H ST BILAT S STL NAR CRV LOK COMPR FOR 35MM SCR,SUP-2178042,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.53,935.04,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE FIBERGRAFT 11CC,SUP-2741935,CDM,C1713,HCPCS,0278,RC,,,,both,,,16321.72,10609.12,,,,,,,,,,,,,
MARKER BRST BX X SHP 9 GA FOR EVIVA TI SENOMARK,SUP-2759167,CDM,A4648,CPT,0278,RC,,,,both,,,188.84,122.75,,,,,,,,,,,,,
SYSTEM CARD ICD SYS 2 CHMBR W/ RIATA SYS FOR V-243 ATLS + DR,SUP-2356555,CDM,C1721,HCPCS,0275,RC,,,,both,,,66520.90,43238.58,,,,,,,,,,,,,
BURR SURG 6MM DIA HD XLN MIC SM BNE RND DIAMOND HVY COARSE G,SUP-2605576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,161.02,104.66,,,,,,,,,,,,,
GRAFT STENT 10X40 MM 9 FRX117 CM,SUP-2126902,CDM,C1874,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
ACTUATOR EXT FIX COMPR STD 4 CM DISTRCTN EXT TUBE PROCALLUS,SUP-2645889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1251.35,813.38,,,,,,,,,,,,,
IMPLANT FACE 45 X 41 X 4 MM POLYETHYL GENIOMANDIBULAR,SUP-2883172,CDM,C1713,HCPCS,0278,RC,,,,both,,,1342.92,872.90,,,,,,,,,,,,,
GRAFT HUM TISS DERMACELL POROUS 3X4CM 12SQCM,SUP-2909303,CDM,Q4122,HCPCS,0636,RC,,,,both,,,2719.24,1767.51,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZ DRY CANC 5CC,SUP-2120709,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
HC Psa Screening,PX-3010010300,CDM,G0103,HCPCS,0301,RC,,,,both,,,343.00,222.95,,,,,,,,,,,,,
BIT DRILL CANN 3.8MM,SUP-2470844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
GUIDEWIRE ORTH SHRP FOR GRANITE IMPL NIT IFUSE BEDROCK,SUP-2864562,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 8 MM EPTFE FLX STD WALL SM BEAD,SUP-2761486,CDM,C1768,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
NEEDLE REPROC INTRO 98CM 18G 30DEG BRK1 XS S STL TRANSSEPTAL,SUP-2877985,CDM,C1893,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC Pt Manual Therapy Ea 15|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209714000,CDM,97140,CPT,0420,RC,,,GP|CQ,both,,,194.00,126.10,,,,,,,,,,,,,
PLATE BNE THK0.5MM 5MM BAR 5 H 100DEG UNIV,SUP-2366244,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.95,414.67,,,,,,,,,,,,,
SPACER SPNL 45X12X10 MM INTBDY FUSION DEV CRESCENT,SUP-2281753,CDM,C1713,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
IMPLANT GREAT TOE BIOACTION METATRSL SM NEUT CO CHROM TI,SUP-2303800,CDM,C1776,CPT,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
GUIDEWIRE VASC VICTORY 14 L 300 CM DIA 0.014 IN TIP L 2.5 CM,SUP-2146038,CDM,C1769,HCPCS,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN (MIXTURES ONLY),RX-430040,CDM,2500000003,HCPCS,0250,RC,63323-0462-17,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SHUNT CAR ENDART 3X4 MM STR SUNDT,SUP-2308219,CDM,C1713,HCPCS,0278,RC,,,,both,,,2424.33,1575.81,,,,,,,,,,,,,
MODEL ANAT FULL SKULL AD 3D CT BASE SEL CLR VITAL STRUCT,SUP-2883375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17974.68,11683.54,,,,,,,,,,,,,
STENT URET 7FR L26CM NYL COAT DBL PGTL BRAID HYDRPHLC OPN,SUP-2312731,CDM,C2617,HCPCS,0278,RC,,,,both,,,176.15,114.50,,,,,,,,,,,,,
BRACE ORTH L 16.5 IN WAIST CIRC 55 IN SHRT HIP UNIV ADV ROM,SUP-2914999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.18,722.27,,,,,,,,,,,,,
PLATE BONE L165MM 8 H LT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348223,CDM,C1713,HCPCS,0278,RC,,,,both,,,12777.13,8305.13,,,,,,,,,,,,,
SOCKET PROS TST,SUP-2388206,CDM,L5620,HCPCS,0272,RC,,,,both,,,730.74,474.98,,,,,,,,,,,,,
COMPONENT FEM KNEE OXINIUM LAT TROCHLEAR GRV,SUP-2347981,CDM,C1776,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
PLATE BNE L132MM 9 H R ANTLAT DST TIB S STL LOK COMPR LO,SUP-2185950,CDM,C1713,HCPCS,0278,RC,,,,both,,,4096.57,2662.77,,,,,,,,,,,,,
CATHETER ANGIOPLSTY VASCUTRAK L 80 CM BALLOON L 8 CM DIA 7,SUP-2128769,CDM,C1725,HCPCS,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PLATE BNE L 31.8 X W 5.1 MM THK 1 MM SCREW DIA2 MM 5 H GRD,SUP-2936044,CDM,C1713,HCPCS,0278,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
ROD EXT FIX L60MM S STL THRD TELSCP ORIG CIR FOR TAY SPAT,SUP-2342299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,183.97,119.58,,,,,,,,,,,,,
GUIDE L 70MM SPD FOR 35MM T10,SUP-2378000,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
BRACE WALKING N PNEUMATIC PRE FABRIC,SUP-2388198,CDM,L4386,HCPCS,0274,RC,,,,both,,,440.07,286.05,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA 6 FR HYDRPHLC,SUP-2383403,CDM,C1894,HCPCS,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
PATCH HERN MIDLN W6.1XL10.1IN UNCOATED MFIL PROPYLENE ABSRB,SUP-2125899,CDM,C1781,HCPCS,0278,RC,,,,both,,,4916.30,3195.59,,,,,,,,,,,,,
GRAFT BIO TISS W8XL8CM MESHED FET BOV ACELLULAR DERM MTRX,SUP-2243707,CDM,Q4110,HCPCS,0636,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
GRAFT HUM TISS FIB SHFT BNE FRZN ALLGRFT 50MM LEN 8 15MM W,SUP-2264755,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.19,1122.67,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX48 CM LT DL BASIC KT DURAFLO 2,SUP-2464722,CDM,C1750,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
BETHANECHOL CHLORIDE 25 MG PO TABS,RX-1044,CDM,6370000000,HCPCS,0637,RC,00832-0512-01,NDC,,both,1,UN,4.20,2.73,,,,,,,,,,,,,
DRILL SURG L101.6MM DIA2MM TWST CAPTURE,SUP-2419616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1056.70,686.85,,,,,,,,,,,,,
KNIFE SURG 9.5 IN VERTICAL TRNSSPHND BAYNT RUGGLES-REDMOND,SUP-2486550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,418.97,272.33,,,,,,,,,,,,,
HC So1 Sgot (Ast),PX-3018445067,CDM,84450,CPT,0301,RC,,,,both,,,15.00,9.75,,,,,,,,,,,,,
GRAFT TEND PAT W/ SHTH FRZN ALLGRFT,SUP-2388443,CDM,C1713,HCPCS,0278,RC,,,,both,,,13608.76,8845.69,,,,,,,,,,,,,
GRAFT VASC FLX 8 MMX70 CM STD WALL SM BEAD EPTFE CARBOFLO,SUP-2761487,CDM,C1768,CPT,0278,RC,,,,both,,,3608.58,2345.58,,,,,,,,,,,,,
PORT BURR HOLE RESERVOIR VENTRICULAR DRAINAGE 18CM CATHETER,SUP-2830491,CDM,C1889,HCPCS,0278,RC,,,,both,,,1460.95,949.62,,,,,,,,,,,,,
PROBE ELECSURG 90DEG BPLR INSUL COOLBACK SHFT JWL CUT NOTCH,SUP-2341623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
BASEPLATE TIB UNI LT MEDL RT LAT PRI PEG CEM 38MM A/PXSM GEN,SUP-2349782,CDM,C1776,CPT,0278,RC,,,,both,,,3979.95,2586.97,,,,,,,,,,,,,
CATHETER CV SET 018 PEDIATRIC 4 FRX5 CM DL J TIP POLYETH,SUP-2760004,CDM,C1751,HCPCS,0278,RC,,,,both,,,278.24,180.86,,,,,,,,,,,,,
SCREW BNE L10MM DIA2MM HD DIA3.5MM CORT S STL NONCANNULATED,SUP-2183177,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.73,69.37,,,,,,,,,,,,,
HC Spleenoportography S&I,PX-3207581000,CDM,75810,CPT,0320,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
COMPONENT FEM ALL POLY NP TIB GEN II,SUP-2347964,CDM,C1776,CPT,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 4FR 60CML PU RADPQ STYL SFTY EXC 3254105,SUP-2632658,CDM,C1751,HCPCS,0278,RC,,,,both,,,289.82,188.38,,,,,,,,,,,,,
GRAFT HUM TISS W12XL20CM THK18 4MM ACELLULAR DERM MTRX,SUP-2307486,CDM,Q4128,HCPCS,0636,RC,,,,both,,,22838.57,14845.07,,,,,,,,,,,,,
SPHERE GLEN 40 MM,SUP-2199145,CDM,C1776,CPT,0278,RC,,,,both,,,4954.42,3220.37,,,,,,,,,,,,,
SCREW SYS DEPTH GAUGES DRL 150 MM 4.5 MM OD 6.5 MM SCRS,SUP-2392915,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
BIT DRILL PILOT TIP SHORT 3.2 MMX6 IN QUICK CONNECT FOR ANTE,SUP-2837090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.28,314.78,,,,,,,,,,,,,
PLATE BONE L101MM 8 H TI LT CLAV SHFT FOR 3.5MM SCR LOQTEQ,SUP-2417630,CDM,C1713,HCPCS,0278,RC,,,,both,,,2655.18,1725.87,,,,,,,,,,,,,
PLATE BNE W12XL230MM THK2.5MM LNG 10 H NONSTERILE BILAT,SUP-2190993,CDM,C1713,HCPCS,0278,RC,,,,both,,,5397.44,3508.34,,,,,,,,,,,,,
PROBE LASER 23GA 45DEG STEEPED ANG FLX TIP DISP ENDOPRB,SUP-2247216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.06,394.59,,,,,,,,,,,,,
DEFIBRILLATOR CRD 63X51X12 MM 30 CC 69 GM SYS DF4 GALLANT VR,SUP-2876023,CDM,C1722,HCPCS,0275,RC,,,,both,,,50767.52,32998.89,,,,,,,,,,,,,
SCREW BONE SHLDR ASMBLY AEQUALIS FLX REVIVE,SUP-2417739,CDM,C1713,HCPCS,0278,RC,,,,both,,,2697.26,1753.22,,,,,,,,,,,,,
INTRODUCER SHTH 9FR BRT TIP REPROC,SUP-2156053,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
BIT DRILL NAV LONG 4.0MM,SUP-2711624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1806.63,1174.31,,,,,,,,,,,,,
GRAFT TUBE 7MM,SUP-2812116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HC So2 Encephalitis St.Louis,PX-3028665368,CDM,86653,CPT,0302,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 10 SYS W/ SHUNT ASST SPRUNG RESVR PROGAV,SUP-2108745,CDM,C1729,HCPCS,0272,RC,,,,both,,,10002.97,6501.93,,,,,,,,,,,,,
BIT DRL CALIB 2.7X160 MM DISP,SUP-2606595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.97,208.63,,,,,,,,,,,,,
GRAFT VASC PERIPH BYPS STR STD WALL N RING EPTFE 6MM DIA,SUP-2126225,CDM,C1768,CPT,0278,RC,,,,both,,,453.35,294.68,,,,,,,,,,,,,
SPACER 56301010 12W 30MM X 10MM 10 DG TI,SUP-2417156,CDM,C1889,HCPCS,0278,RC,,,,both,,,15660.75,10179.49,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.7MM CORT GLD TI FOR MINI FRAG SYS,SUP-2189692,CDM,C1713,HCPCS,0278,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
GUIDEPIN SURG L11IN OD2.4MM TRCR TIP PASS W/ EYELET FOR,SUP-2341318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450395805,SUP-2844126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2169.11,1409.92,,,,,,,,,,,,,
INSERT TIB SZ 3 THK20MM STD CNDYL KNEE CONSTRN REV ADV II,SUP-2304730,CDM,C1776,CPT,0278,RC,,,,both,,,726.91,472.49,,,,,,,,,,,,,
CEMENT BONE 40GM LO VISC PALACOS LV,SUP-2239058,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
SCREW SET MULTAXL SS STRL CD HORZ MODULEX,SUP-2849984,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BNE CUT SUP LAT SHLDR DELTA-XTEND,SUP-2454178,CDM,C1713,HCPCS,0278,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
CEMENT ST/POR CP/LGXL/LG HD,SUP-2212365,CDM,C1776,CPT,0278,RC,,,,both,,,13545.96,8804.87,,,,,,,,,,,,,
CLOVERLEAF PLT STERILIZER 88 MM 3 HL,SUP-2820744,CDM,C1713,HCPCS,0278,RC,,,,both,,,2266.08,1472.95,,,,,,,,,,,,,
CUBE EXT FIX OD5MM 4 H SALVATION,SUP-2401122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CATHETER HD PRECRV 14 FRX12 CM SHT TERM DUOFLO 400XL,SUP-2627164,CDM,C1752,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
EPIFIX MESHED 3.5X3.5CM 8SQ CM,SUP-2305741,CDM,Q4186,HCPCS,0636,RC,,,,both,,,4248.42,2761.47,,,,,,,,,,,,,
IMPLANT MASTOID SM 45X36X1 MM POLYETH POROUS,SUP-2366485,CDM,C1713,HCPCS,0278,RC,,,,both,,,2399.12,1559.43,,,,,,,,,,,,,
MODIFIED MAXDRIVE SCREW TENTING STYLE 15 X 5MM 5/PKG,SUP-2669679,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.56,186.91,,,,,,,,,,,,,
SCREW BNE NLCK 2X5 MM SELF DRILLING CROSS DRV TI NS,SUP-2754967,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
VANCOMYCIN HCL 50 MG/ML PO SOLR,RX-11630,CDM,340b,HCPCS,0637,RC,67877-0751-81,NDC,,both,2.5,ML,11.10,7.21,,,,,,,,,,,,,
PLATE BNE STD CNTOUR FLAT L 2ND 3RD TARSOMETATARSAL TI IMPL,SUP-2401382,CDM,C1776,CPT,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
DRILL SURG STP 2.4X140 MM CANN,SUP-2749972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SYSTEM IMPL 3.5 MM SHLDR ELBW RC AUG SYS TISSUETAK TEND,SUP-2910342,CDM,C1713,HCPCS,0278,RC,,,,both,,,10055.85,6536.30,,,,,,,,,,,,,
SPACER SPNL W14XH7XL18MM 5DEG PEEK OPTMA ANTR CERV LORDTC LO,SUP-2211889,CDM,C1821,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
ROD SPNL 2 5.5-4.75X450 MM TI NS MONARCH,SUP-2583131,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SHUNT KIT NEONATAL VENTRICULOPERITONEAL HI PRESSURE ULTRA VS,SUP-2852574,CDM,C1889,HCPCS,0278,RC,,,,both,,,3890.08,2528.55,,,,,,,,,,,,,
KIT PACE STYL L 46 CM STR STD WIDE NAR J CLP ON/IMPLANT TOOL,SUP-2356345,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
SET INT FIX DIA18.5 MM TI NEURO 12 PK STRL DISP LORENZ,SUP-2935326,CDM,C1713,HCPCS,0278,RC,,,,both,,,23631.64,15360.57,,,,,,,,,,,,,
MOLD CEM SPCR DIA60MM UNIV FEM SIL CRUCE SACRIFICING AGC,SUP-2408622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3830.80,2490.02,,,,,,,,,,,,,
BOOT CHARCOT TCC EZ EXTRA L,SUP-2194343,CDM,L4387,HCPCS,0272,RC,,,,both,,,312.27,202.98,,,,,,,,,,,,,
STEM FEM L70MM 15DEG 38MM OFFSET PROX KNEE TI POR FEM TAPR,SUP-2252620,CDM,C1776,CPT,0278,RC,,,,both,,,13025.03,8466.27,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COGNIS TI CRT 2 CHMBR 2 LD HI ENERGY STRL,SUP-2149056,CDM,C1721,HCPCS,0275,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
ALLOGRAFT BNE 11X11X8 MM CORTICAL CANC CORNERSTONE L-ASR,SUP-2293883,CDM,C1713,HCPCS,0278,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 8 DEG 23-27X24-32X21 MM FD ANGLED FRA,SUP-2736756,CDM,C1713,HCPCS,0278,RC,,,,both,,,13658.40,8877.96,,,,,,,,,,,,,
PROBE ABLATN MICROWAVE 14 GAX150 MM AMICA,SUP-2303520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
BODY HUM PROXIMAGE 62 MM COMPHSVE SEG REV SYSTEML LAR,SUP-2136571,CDM,L3809,HCPCS,0272,RC,,,,both,,,11360.52,7384.34,,,,,,,,,,,,,
PLATE CRANIO-FACIAL T DBL 1.5MM 6 H 24MML TI,SUP-2402935,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
SCREW SPNL L50MM DIA5.5MM CANC PEDCL TI FIX ANG,SUP-2287931,CDM,C1713,HCPCS,0278,RC,,,,both,,,2579.82,1676.88,,,,,,,,,,,,,
CHRONOS(TM) BETA-TCP WEDGE 14 DEG/RECTANGULAR-STERILE,SUP-2550433,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.09,1266.91,,,,,,,,,,,,,
HC Fna Bx W/CT Gdn 1st Les,PX-3611000900,CDM,10009,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PISTON L4MM SHFT L1.25MM OD0.5MM STR PLAT TI KARTUSH,SUP-2284070,CDM,L8613,CPT,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,KX|CO,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE SPNL LUMBAR 65 DEG 45 MM TRINICA,SUP-2414401,CDM,C1713,HCPCS,0278,RC,,,,both,,,13408.59,8715.58,,,,,,,,,,,,,
HC Urinalysis Qual/Semiquant Except Immunoassays,PX-3078100500,CDM,81005,CPT,0307,RC,,,,both,,,113.00,73.45,,,,,,,,,,,,,
ALLOGRAFT BNE PASTE 3 CC CANC PUROS,SUP-2692417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
BLADE RETRACTOR HOHMN 11 CMX29 MM,SUP-2659978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2037.42,1324.32,,,,,,,,,,,,,
HC Tcat Rmvl&Rplcmt Perm 1chmbr Ldls Pm R Atrial,PX-4810825000,CDM,0825T,CPT,0481,RC,,,,both,,,56457.00,36697.05,,,,,,,,,,,,,
MARKER 1.2MM 1 MRK PER NDL 30CM 17GA FIDUCIAL GLD SFT TISS 4,SUP-2164651,CDM,A4648,CPT,0278,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
GRAFT HUM TISS W 10 MM BNE DWL TIB L 23 MM DIA10-10.5 MM,SUP-2913330,CDM,C1762,CPT,0278,RC,,,,both,,,18623.34,12105.17,,,,,,,,,,,,,
SCREW BONE L75MM OD3.5MM STD TI CORT ST NONCANNULATED,SUP-2413385,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.02,130.01,,,,,,,,,,,,,
BIT DRL SHT 4X90 MM S3 FAST GUIDE,SUP-2606606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.15,517.50,,,,,,,,,,,,,
LEAD PACING UFM W 26MM HCIR 64MM KN,SUP-2850071,CDM,C1898,HCPCS,0275,RC,,,,both,,,42.77,27.80,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-15852,CDM,J2274,HCPCS,0636,RC,00409-3815-12,NDC,JW,both,10,ML,120.70,78.45,,,,,,,,,,,,,
BOLT BNE FIX L145MM DIA5MM PROX L10MM DST L22MM MIDFOOT FUS,SUP-2400755,CDM,C1713,HCPCS,0278,RC,,,,both,,,4826.18,3137.02,,,,,,,,,,,,,
LINER BPLR OD57-60MM ID28MM UNIV FEM ACET,SUP-2344603,CDM,C1776,CPT,0278,RC,,,,both,,,436.93,284.00,,,,,,,,,,,,,
SUTURE NONABSORBABLE BRAID 1/2 CIR TAPR PT WHT BLU 39IN OM9054,SUP-2342109,CDM,C1769,HCPCS,0272,RC,,,,both,,,82.90,53.88,,,,,,,,,,,,,
KIT PAIN PMP 400ML 4ML/HR ELASTOMERIC NONNARCOTIC 2 ON-Q,SUP-2236775,CDM,C9804,HCPCS,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
COMPONENT ACET AUG SM 58 MM HIP REGENEREX PT110158,SUP-2449936,CDM,C1776,CPT,0278,RC,,,,both,,,6118.29,3976.89,,,,,,,,,,,,,
PLATE BNE STR 5 HOLE THRD FIX FOR R.E.D II DEV TI,SUP-2467444,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.18,262.72,,,,,,,,,,,,,
BIT DRL PAT OVL RESURF PEG,SUP-2346876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
BOLT CONN DIA6MM FOR FEM KNEE SYS MAXM,SUP-2405662,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
STEM TOE M METATRSL,SUP-2319769,CDM,C1776,CPT,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1294108D5,SUP-2632813,CDM,C1751,HCPCS,0278,RC,,,,both,,,1134.36,737.33,,,,,,,,,,,,,
PACEMAKER CARD PACE 101H SZ 45 X 60 X 115 X 20 MM 6.5 OZ,SUP-2616258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
GRAFT BNE STRP 16 CC ISOTIS PURE,SUP-2644344,CDM,C1713,HCPCS,0278,RC,,,,both,,,8974.12,5833.18,,,,,,,,,,,,,
SPACER SPNL LAT 10X11X11 MM PRT VERTE-STACK CORNERSTONE PSR,SUP-2286381,CDM,C1821,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR W/O ATR LD TIERED THER ADAPTIVE,SUP-2236355,CDM,C1721,HCPCS,0275,RC,,,,both,,,83900.80,54535.52,,,,,,,,,,,,,
HC IR Plmt Uret Stent Prq New WO,PX-3615069400,CDM,50694,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BNE STD LT 14 HOLE FOR ORTH FIX STRL POLARUS 3,SUP-2518199,CDM,C1713,HCPCS,0278,RC,,,,both,,,6603.42,4292.22,,,,,,,,,,,,,
CANNULATED DRILL 4.0MM,SUP-2841288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PEG BNE FIX L22MM DIA2.5MM DST VOLAR RAD NONLOCKING FULL,SUP-2414180,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
GRAFT W7XL10CM ENT REP BIODESIGN,SUP-2170298,CDM,C1763,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HC Duplex Av Dialysis Shunt,PX-9219399000,CDM,93990,CPT,0921,RC,,,,outpatient,,,1222.00,794.30,,,,,,,,,,,,,
KIT EEG ELECTRD L 32.5 MM 10 CONTACT STRL DISP EVO,SUP-2936744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
BOLT FEM AUG KNEE VANGUARD,SUP-2407855,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR 6 MMX0.2 CM FD CROSS SECT,SUP-2717740,CDM,C1762,CPT,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
HC So Drg Scrn Class List A|NOT REASONABLE AND NECESSARY,PX-3018030766,CDM,80307,CPT,0301,RC,,,GZ,outpatient,,,79.00,51.35,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 4.75MM PEEK LATERAL ROW DUAL THREADED,SUP-2825108,CDM,C1713,HCPCS,0278,RC,,,,both,,,2060.15,1339.10,,,,,,,,,,,,,
SEALER TISS L25CM SHFT DIA5MM 360DEG ROT CVD JAW TAPR TIP,SUP-2219739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1424.87,926.17,,,,,,,,,,,,,
SET INTRO L 15 CM CATH 5/7.5 FR REINF HEMOSTATIC VLV DIL FOR,SUP-2517605,CDM,C1894,HCPCS,0272,RC,,,,both,,,124.85,81.15,,,,,,,,,,,,,
KYPHOPLASTY KIT BLLN 11 GAX30 MM FRAC 2ND,SUP-2864568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4164.83,2707.14,,,,,,,,,,,,,
FORCEP TISS MICRO-TYING LG 23 GAX10 MM AHMED CRV DISP,SUP-2304861,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
BLADE SURG MULT XL 4.2 MM + STRL FMS VUE DISP,SUP-2624802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
GRAFT HUM TISS 6 10MM 30CC CANC CUBE,SUP-2293752,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
ALLOGRAFT DERMAL 16X20 CMX2.4/0.4 MM RDY TO USE ALLDERM,SUP-2488336,CDM,Q4116,HCPCS,0636,RC,,,,both,,,37406.82,24314.43,,,,,,,,,,,,,
PROSTHETIC KIT IMPL PT DISP,SUP-2304849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PROBE DTECT MARGIN F/LUMPECTOMY,SUP-2213366,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
PLATE BONE 6MM OFFSET 90DEG 3 H PROX FEM LCK FOR 3.5MM SCR,SUP-2318548,CDM,C1713,HCPCS,0278,RC,,,,both,,,6828.09,4438.26,,,,,,,,,,,,,
BAR EXT FIX DIA6MM V JET-X,SUP-2342914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1602.09,1041.36,,,,,,,,,,,,,
STENT PERIPH L150MM DIA10MM CATH L120CM DIA11FR 0.035IN NIT,SUP-2396578,CDM,C1874,HCPCS,0278,RC,,,,both,,,12261.70,7970.10,,,,,,,,,,,,,
TRANSFER SET 6 LD VENTED PREASSEMBLED BARCODED STRL PINNACLE,SUP-2774377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1520.07,988.05,,,,,,,,,,,,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,2500000003,HCPCS,0250,RC,00409-5555-11,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
GENTAMICIN SULFATE 2 MG/ML SYRINGE (PED-NEO) <50 ML|DISCARDED DRUG NOT ADMINISTE,RX-4090289,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,JW,both,50,ML,54.10,35.16,,,,,,,,,,,,,
PLEDGET CV DEBAKEY L 10 X W 10 CM THK 0.25 MM POLYESTER,SUP-2126027,CDM,C1768,CPT,0278,RC,,,,both,,,326.40,212.16,,,,,,,,,,,,,
RELOAD STPL L45MM EXTRA THCK REINF FOR SIGNIA STPLR,SUP-2283375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2806.47,1824.21,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 4 FR FULL W/ MI DOT POWERPICC SOLO 2,SUP-2126372,CDM,C1751,HCPCS,0278,RC,,,,both,,,503.84,327.50,,,,,,,,,,,,,
GUIDEWIRE VASC ADX L 180 CM 0.035IN L15CM PTFE WORKHORSE TIP,SUP-2657248,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.45,26.94,,,,,,,,,,,,,
PLATE NEURO T 6L 4V TTNM ALLOY ULTRA LOW PRFLE STRGHT WTAB,SUP-2676568,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.49,292.17,,,,,,,,,,,,,
HC Cholecystostomy,PX-3614749000,CDM,47490,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PLUG STEM TIV FLX TAPR FOR MG II ST BNE SCR NXGN,SUP-2201054,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
TUBE ET ID6.5MM PVC NSL ORAL SGL LUMN LO PRSS CUF TAPR,SUP-2383844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
TERAZOSIN HCL 5 MG PO CAPS,RX-14553,CDM,6370000000,HCPCS,0637,RC,59746-0385-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST W/NONTORSION JT PREFABRICATED,SUP-2435776,CDM,L3915,HCPCS,0274,RC,,,,both,,,1369.64,890.27,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 30 CC FRZN IRRADIATED CANC,SUP-2867071,CDM,C1762,CPT,0278,RC,,,,both,,,1583.97,1029.58,,,,,,,,,,,,,
PIN FIX APEX HALF STD 5X150MM,SUP-2363229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.76,235.14,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL THCK 16X6 CMX0.8-1.7 MM BRST FLEXHD,SUP-2307510,CDM,Q4128,HCPCS,0636,RC,,,,both,,,16401.95,10661.27,,,,,,,,,,,,,
COVER BUR H 14MM W TAB,SUP-2365223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.25,676.16,,,,,,,,,,,,,
CUP ACET HIP RESURF BIRMINGHAM,SUP-2348009,CDM,C1776,CPT,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
KIT BNE MAR CONC MINI W/O ACDA BIOCUE,SUP-2884250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4122.82,2679.83,,,,,,,,,,,,,
SPLINT ANK STRRP AIR AND FOAM TRAINER,SUP-2276707,CDM,L4350,HCPCS,0274,RC,,,,both,,,40.47,26.31,,,,,,,,,,,,,
SHEATH URETH ACC 54 CM,SUP-2312759,CDM,C1894,HCPCS,0272,RC,,,,both,,,367.51,238.88,,,,,,,,,,,,,
ACETAZOLAMIDE ER 500 MG PO CP12,RX-8962,CDM,6370000000,HCPCS,0637,RC,16729-0331-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NEEDLE BX L15CM OD14GA ADJUSTABLE COAX TEMNO,SUP-2302403,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.68,67.39,,,,,,,,,,,,,
STENT URET INLAY OPTMA L 26 CM DIA 6 FR POLYMER BLEND,SUP-2126657,CDM,C2617,HCPCS,0278,RC,,,,both,,,782.68,508.74,,,,,,,,,,,,,
ROD EXT FIX W110XL120MM DIA4MM UNIV C FBR ANG T BAR,SUP-2188720,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.34,680.12,,,,,,,,,,,,,
ROPINIROLE HCL 2 MG PO TABS,RX-21690,CDM,6370000000,HCPCS,0637,RC,68462-0256-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE CRAN THK0.2MM CRANIOFACIAL TI ORBIT B MESH MALL FOR,SUP-2190684,CDM,C1713,HCPCS,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
BODY HUM SZ 90MM SHLDR INTERCALARY PROX LAT SEG REV W/ SCR,SUP-2402756,CDM,C1776,CPT,0278,RC,,,,both,,,17450.55,11342.86,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST ADJ W/JT FABRICATED,SUP-2435766,CDM,L3806,HCPCS,0274,RC,,,,both,,,1170.37,760.74,,,,,,,,,,,,,
HC Rep Cpx Face H Ft 2.6-7.5cm,PX-4501313200,CDM,13132,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
BIT DRL CANN 5 MM,SUP-2518592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
SCREW SPNL MULTAXL 10.5X70 MM CANC CD HORZ TCS,SUP-2628343,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
GRAFT HUM TISS 9MM OSTEOCHNDRL CHONDROFIX,SUP-2200259,CDM,C1713,HCPCS,0278,RC,,,,both,,,10898.94,7084.31,,,,,,,,,,,,,
MARKER SFT TISS L3MM DIA0.9MM GLD FIDUCIAL W/ 18GA L20CM ETW,SUP-2164656,CDM,A4648,CPT,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UPCHARGE GENDER SPEC,SUP-2212679,CDM,C1776,CPT,0278,RC,,,,both,,,1761.54,1145.00,,,,,,,,,,,,,
HEAD FEM MOD ANTIBIO REMEDY L 60MM,SUP-2319832,CDM,C1776,CPT,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL RT 6 HOLE REV,SUP-2525795,CDM,C1713,HCPCS,0278,RC,,,,both,,,4807.34,3124.77,,,,,,,,,,,,,
SPLINT COLLES W FOAM L ARM PERF ALUMINIUM XR LUCENT TAN AD,SUP-2336083,CDM,L3908,HCPCS,0272,RC,,,,both,,,12.18,7.92,,,,,,,,,,,,,
PLATE BNE TIB WIDE 3.5 MM RT MEDL 3 HOLE SS JPS 5434002R,SUP-2645626,CDM,C1713,HCPCS,0278,RC,,,,both,,,12999.60,8449.74,,,,,,,,,,,,,
GRAFT HUM TISS FIRM 8X8 CM RECON TISS MTRX PORCINE STRATTICE,SUP-2112977,CDM,Q4130,HCPCS,0636,RC,,,,both,,,6590.86,4284.06,,,,,,,,,,,,,
MESH HERN W10XL15CM RIG TWO DIM FLAT SHT PARIETEX,SUP-2174777,CDM,C1781,HCPCS,0278,RC,,,,both,,,184.63,120.01,,,,,,,,,,,,,
SCREW CADDY 2.7MM,SUP-2841456,CDM,C1713,HCPCS,0278,RC,,,,both,,,4647.20,3020.68,,,,,,,,,,,,,
DEVICE ABLAT FOR EPICOR CARD ABLAT SYS ULTRAWAND LP,SUP-2355886,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
"HC Est Pt, E/M Level 2",PX-5109921200,CDM,99212,CPT,0510,RC,,,,both,,,202.00,131.30,,,,,,,,,,,,,
URETERORENOSCOPE VID DIA 6.3 FR ADJ ANGLE KNOB ULTRASLIM,SUP-2934025,CDM,C1747,HCPCS,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
SCREW SPNL OPEN 6MM DIA 50MML 475MM THK STNLSS STEEL PDCLE,SUP-2721329,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
EXTRACTOR STONE BSKT 0.6 MM 3 WIR STRL DISP,SUP-2771971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1011.17,657.26,,,,,,,,,,,,,
COUNTERSINK SURG L 50 MM DIA1.8 MM NS DISP DELT,SUP-2909648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.49,453.37,,,,,,,,,,,,,
SCREW BNE 4MM 70 20 FOR GALAXY FIX SYS,SUP-2316041,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.13,204.18,,,,,,,,,,,,,
PLATE BONE L3MM THK0.6MM 4 H ORAL MAXILLOFACIAL TI NEUT N,SUP-2262499,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
GRAFT HUMAN TISSUE BIOLOGICAL TISSUE MATRIX THICK 30X20 CM NON CROSSLINKED SCAFFOLD NATURALLY OCCURRING PORCINE STERILE GENTRIX DISPOSABLE,SUP-2106503,CDM,Q4166,HCPCS,0636,RC,,,,both,,,51009.30,33156.04,,,,,,,,,,,,,
TUBE VENT ID1.14MM SIL MICROGEL PAPARELLA NOTCH TAB FOR MYR,SUP-2284014,CDM,L8699,HCPCS,0278,RC,,,,both,,,85.78,55.76,,,,,,,,,,,,,
PLATE BNE L12MM THK2MM TI TARSAL ISOLATED FUS AFP DARCO MRS,SUP-2399640,CDM,C1713,HCPCS,0278,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
SYSTEM BX ASPIR TRANSPERINEAL PRECISIONPOINT,SUP-2884258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BIT DRILL EXTRACTION SZ 2 MM SCREW DIA1.5-2 MM STRL DISP,SUP-2913631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2472.75,1607.29,,,,,,,,,,,,,
SCREW INTRF L15MM DIA5.5MM DISP DRVR BIO-TENODESIS,SUP-2121341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY 24 IN,SUP-2336082,CDM,L1830,CPT,0272,RC,,,,both,,,37.21,24.19,,,,,,,,,,,,,
PROSTHESIS PENILE 65ML INFL RESVR ULTREX AMS 700,SUP-2140279,CDM,C1813,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
SET URET STENT L 20 CM DIA 6 FR GUIDEWIRE 0.038 IN BLK SIL,SUP-2168909,CDM,C2617,HCPCS,0278,RC,,,,both,,,434.07,282.15,,,,,,,,,,,,,
CATHETER ETER BRACHYTHERAPY 5 6CM MULTILUMEN BLLN CONTURA,SUP-2239949,CDM,C1726,HCPCS,0272,RC,,,,both,,,8375.95,5444.37,,,,,,,,,,,,,
GRAFT BIO W6XL10CM THK18 25MM PORCINE CLLGN RECT REGEN,SUP-2126237,CDM,C1781,HCPCS,0278,RC,,,,both,,,5778.86,3756.26,,,,,,,,,,,,,
PROSTHESIS OSS 7 MM 4/3.25 MM 0.8 MM BOJRAB UNIV FLROPLAS,SUP-2464978,CDM,L8613,CPT,0278,RC,,,,both,,,1264.45,821.89,,,,,,,,,,,,,
CATHETER HD DL 13 FRX24 CM ACUTE STR SPLIT TIP DUO-SPLIT,SUP-2269520,CDM,C1752,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
BLADE SCREWDRIVER 2/2.3X140 MM CENTRE DRV LEVEL 1,SUP-2471285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,799.44,519.64,,,,,,,,,,,,,
PLATE BONE L49MM 4 H S STL SELF COMPR FOR 3.5MM SCR ECT,SUP-2198563,CDM,C1713,HCPCS,0278,RC,,,,both,,,231.51,150.48,,,,,,,,,,,,,
GRAFT BNE MTRX XL 20 CC STRL FIBERGRAFT AERIDYAN 59000200,SUP-2874926,CDM,C1713,HCPCS,0278,RC,,,,both,,,19216.80,12490.92,,,,,,,,,,,,,
HC Prog Stim/Pac Aft IV Drug Addon,PX-4819362300,CDM,93623,CPT,0481,RC,,,,both,,,17124.00,11130.60,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE UNIV KNEE WARRIOR RECOVERY,SUP-2336061,CDM,L1810,HCPCS,0274,RC,,,,both,,,210.22,136.64,,,,,,,,,,,,,
SCREW SPNL MULTAXL 7.5X65 MM CANN EXT TAB VOYAGER 4.75,SUP-2629443,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE H1.5MM 6 H MAND G TI TEMPLT COMPR LO PROF FOR 2MM,SUP-2366372,CDM,C1713,HCPCS,0278,RC,,,,both,,,1388.67,902.64,,,,,,,,,,,,,
PLATE BNE T 84 MM 4 HOLE SS,SUP-2569106,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
RASP SURG PYRAMETRIX ADV,SUP-2292624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1798.34,1168.92,,,,,,,,,,,,,
ANVIL F/BROAD PLATES,SUP-2548475,CDM,C1713,HCPCS,0278,RC,,,,both,,,645.27,419.43,,,,,,,,,,,,,
PIN FIX L229MM DIA3.6MM S STL STYL 6 STNMN,SUP-2409664,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.05,20.18,,,,,,,,,,,,,
CATHETER CTRL VEN AD 9.5FR DBL LUMN SURECUF TISS INGROWTH,SUP-2127899,CDM,C1751,HCPCS,0278,RC,,,,both,,,2666.65,1733.32,,,,,,,,,,,,,
GRAFT HUM TISS D EYE AMINOGRFT,SUP-2135255,CDM,V2790,HCPCS,0274,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
HEAD ALUMINA 32MM 0MM 5-40,SUP-2364457,CDM,C1776,CPT,0278,RC,,,,both,,,2754.57,1790.47,,,,,,,,,,,,,
SHELL ACET 46 MM HIP NO HOLE HA REFLECTION,SUP-2434738,CDM,C1776,CPT,0278,RC,,,,both,,,6053.92,3935.05,,,,,,,,,,,,,
INBONE  POLY SZ 1 10MM SULCUS TOTAL ANKLE,SUP-2476135,CDM,C1776,CPT,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
SCREW SPINAL 4X32MM TITANIUM CANNULATED CORTICAL UCSS,SUP-2290869,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCREW BNE L8MM DIA2MM CRANIOMAXILLOFACIAL TI SELF DRL LOK 5PK,SUP-2366137,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.68,296.84,,,,,,,,,,,,,
GRAFT BNE GRAN 3 CC VI RESRB CERM MASTERGRAFT,SUP-2743370,CDM,C1713,HCPCS,0278,RC,,,,both,,,992.24,644.96,,,,,,,,,,,,,
CATHETER DRAINAGE 2 EYE 38 FR RETENTION HD REINF TIP PEZ,SUP-2126195,CDM,C2627,HCPCS,0272,RC,,,,both,,,63.18,41.07,,,,,,,,,,,,,
PLATE BONE W6.3XL48MM THK1.6MM 5X3 H LT DSTL VOLAR RAD TI,SUP-2191010,CDM,C1713,HCPCS,0278,RC,,,,both,,,2587.23,1681.70,,,,,,,,,,,,,
LEVETIRACETAM 100 MG/ML PO SOLN,RX-36590,CDM,340b,HCPCS,0637,RC,00904-7265-41,NDC,,both,2.5,ML,7.20,4.68,,,,,,,,,,,,,
COLLAR CERV 4.25IN 12IN SM TRACH OPN AD PHIL,SUP-2195257,CDM,L0180,HCPCS,0274,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
PLATE BNE STR 140 DEG PEDIATRIC 3.5X70X19 MM HIP 3 HOLE SS,SUP-2546026,CDM,C1713,HCPCS,0278,RC,,,,both,,,2601.80,1691.17,,,,,,,,,,,,,
SCREW 5.0MM SELF DRILLING SCHANZ 150MM HA COATING STERILE,SUP-2547745,CDM,C1713,HCPCS,0278,RC,,,,both,,,861.33,559.86,,,,,,,,,,,,,
SCREW BNE ST 3.5X50 MM LCK SS NS,SUP-2184252,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.40,275.86,,,,,,,,,,,,,
BIT DRL UNIV 24 MM SL INTER-LOCK CROSS PIN FOR SCREW INTLOK,SUP-2608241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.26,277.72,,,,,,,,,,,,,
BUR SURG MTL CUT 3X17.9 MM 14 CM LG BOR MIDAS REX 8 LEGEND,SUP-2664607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.62,368.95,,,,,,,,,,,,,
SCREW SPNL COMPR 6X50 MM HA STRL ZYFUSE,SUP-2593511,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM TRL W/ PRELD ENH STYL,SUP-2141907,CDM,C1778,HCPCS,0278,RC,,,,both,,,3693.90,2401.03,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 10X10X10 MM 1 CC PRO OSTEON 500R,SUP-2684309,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
FIBER LASER OTO MICROLASE REUSE,SUP-2713746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8854.80,5755.62,,,,,,,,,,,,,
TACK PLT FOR POLYAX COMPR PLATING SYS CLAW II,SUP-2397477,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
TUBE VENT ID1MM INNR FLNG 1MM FLROPLAS W/O H FOR MYR REUT,SUP-2312596,CDM,L8699,HCPCS,0278,RC,,,,both,,,15.89,10.33,,,,,,,,,,,,,
BUTTON FIX TI SHLDR FOR MULTIPLE FIBERTAPE STRL AC DOG BNE,SUP-2121671,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HEAD HUM ECC 1.5 MM 39X14 MM SHLDR ANAT LOW OFFSET TI,SUP-2715720,CDM,C1776,CPT,0278,RC,,,,both,,,11779.71,7656.81,,,,,,,,,,,,,
PUMP HEART IMPELLA 5.5 W/SMART ASSIST S2,SUP-2853216,CDM,C1889,HCPCS,0278,RC,,,,both,,,141300.00,91845.00,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US|RIGHT SIDE,PX-5102060500,CDM,20605,CPT,0510,RC,,,RT,both,,,908.00,590.20,,,,,,,,,,,,,
SOLE EXT FIX WALKING ATTACH,SUP-2898587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
APPLICATOR TISS GLUE L15CM SIL EXT TIP DURA SEAL,SUP-2243106,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.69,294.25,,,,,,,,,,,,,
PATCH CV HEMACAROTID L 120 X W 6 MM THK 0.41 MM POLYESTER,SUP-2227498,CDM,C1768,CPT,0278,RC,,,,both,,,454.01,295.11,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 50 MM DIA14 MM CATH TOT L 116 CM,SUP-2140226,CDM,C1874,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
ROD RM 3X950 MM W/ BALL TIP SS STRL,SUP-2188114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.02,334.76,,,,,,,,,,,,,
CAGE SPNL STACKABLE 4 DEG LG 14X16X11 MM ANTR LUMBAR BENGAL,SUP-2256207,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
SCREW BONE L30MM OD2MM ST LAG CROSS PIN SLD LO PROF 5PK,SUP-2363611,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.98,129.34,,,,,,,,,,,,,
BLADE SHAVER SUPERFICIAL 18 DEG 4X270 MM LARYNGEAL DBL BEND,SUP-2638097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.06,663.04,,,,,,,,,,,,,
HC Njx Px Nfrosgrm &/Urtrgrm,PX-3615043000,CDM,50430,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
HC So Myelin Basic Protein,PX-3018387366,CDM,83873,CPT,0301,RC,,,,inpatient,,,992.00,644.80,,,,,,,,,,,,,
HC Electrophysiology Evaluation,PX-4809362100,CDM,93621,CPT,0480,RC,,,,both,,,3541.00,2301.65,,,,,,,,,,,,,
PLATE BONE L123MM 6 H S STL BROAD NONLOCKING COMPR CNTOUR,SUP-2348969,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.27,1265.08,,,,,,,,,,,,,
IMPLANT SUBTALAR 9MM TI HORZ,SUP-2137778,CDM,2780000010,LOCAL,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LIFT ELEVATION MTL EXTN,SUP-2435717,CDM,L3330,HCPCS,0272,RC,,,,both,,,1602.25,1041.46,,,,,,,,,,,,,
HC Carcinoembryonic Antigen Cea|NOT REASONABLE AND NECESSARY,PX-3018237800,CDM,82378,CPT,0301,RC,,,GZ,both,,,334.00,217.10,,,,,,,,,,,,,
CANNULA IRRIGATION L32CM DIAMETER 10MM REUSABLE POOLE SUCTIO,SUP-2843213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,519.80,337.87,,,,,,,,,,,,,
MESH HERN M CLR PLUG AND PTCH SURGPRO HERN-MATE,SUP-2173557,CDM,C1781,HCPCS,0278,RC,,,,both,,,563.41,366.22,,,,,,,,,,,,,
LEAD PACE 7FR L58CM ULTRATHIN CARD SIL STEROID TI NITRIDE,SUP-2356101,CDM,C1898,HCPCS,0275,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
DRILL SURG FOR KNOTLESS SUTURETAK VERY HRD BONE,SUP-2121609,CDM,C1776,CPT,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
LEVEL CMF PLATE SMRT3D TRMA TLTS PRSMPHSS 20 25 MM SCRW12,SUP-2676833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1601.78,1041.16,,,,,,,,,,,,,
TAP SURG L30MM DIA4.5MM CANN THRD TELLURIDE FOR MIS SPNL,SUP-2211176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK ZIP W/ NDL (ORDER MUTLIPLES OF 5 EACH),SUP-2366666,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.71,478.86,,,,,,,,,,,,,
PROSTHESIS OSS 0.8X37 MM MID EAR TI HA BOJRAB ALTO,SUP-2232500,CDM,L8613,CPT,0278,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
PLATE BONE 6 H TI 1/3 TBLR,SUP-2319672,CDM,C1713,HCPCS,0278,RC,,,,both,,,2075.54,1349.10,,,,,,,,,,,,,
CONNECTOR SHUNT DIAMETER 1.9MM T SHAPE TITANIUM HYDROCEPHALU,SUP-2825580,CDM,C1889,HCPCS,0278,RC,,,,both,,,872.86,567.36,,,,,,,,,,,,,
PLATE BNE H0.5MM 20 H MID FACE BLU TI STR COND MAL,SUP-2366239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.03,1071.22,,,,,,,,,,,,,
PACK INSTR L INCLUDE DRL SCR DRVR THIMBLE FOR HAMRTOE CORR,SUP-2123607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1485.22,965.39,,,,,,,,,,,,,
SHEET FACE IMPL N REINF NOM THICKNESS 1MM W6 6.5X6.5,SUP-2395378,CDM,C1771,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GRAFT HUM TISS BIOINTEGRATIVE 30X30 MM W/ INTRO LAT TAPESTRY,SUP-2867248,CDM,C1763,HCPCS,0278,RC,,,,both,,,4427.40,2877.81,,,,,,,,,,,,,
HC So Cryptococcus Antibody,PX-3028664166,CDM,86641,CPT,0302,RC,,,,both,,,233.00,151.45,,,,,,,,,,,,,
COMPONENT TOT HIP CEM,SUP-2365521,CDM,C1776,CPT,0278,RC,,,,both,,,10558.69,6863.15,,,,,,,,,,,,,
KIT ANGIO XCELA DIA 5 FR STRL,SUP-2117191,CDM,C1751,HCPCS,0278,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
CATHETER PD COILED AD 62 CM 16 CM 23 CM KT 3 CUF EXT,SUP-2516624,CDM,C1750,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
STENT URET L22CM DIA5FR URETEROPELVIC JUNCTION BRAID TETH,SUP-2171028,CDM,C2617,HCPCS,0278,RC,,,,both,,,349.80,227.37,,,,,,,,,,,,,
STAPLE BNE FIX L15MM LEG W1.8XL15MM RMR 3.2MM BRDG H1.7MM,SUP-2175180,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
BALLOON DIL 54 57 60FR L55CM INFLATED DIA18 19 20MM 2 4 6ATM,SUP-2170846,CDM,C1726,HCPCS,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
HC Inj's Anes/Steroid Pudental Nerve,PX-3616443000,CDM,64430,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PROBE BX 14 GAX138 MM ULTRASOUND W/ INTEGR COAX CANN VACORA,SUP-2759181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,694.44,451.39,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
COLLAR CERV H3XL15IN SM AD TRACH CLS HK AND LOOP CLSR W CHIN,SUP-2276593,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.56,4.26,,,,,,,,,,,,,
BUR SURG M L8MM DIA4MM S STL OVL DMND FOR SM BONE,SUP-2166714,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.72,229.92,,,,,,,,,,,,,
BLADE SURG 6 RT MIDLN 9563186,SUP-2631616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
GRAFT STRUT CORT FEM STRUCTURAL ALLGRFT FRZ DRY 100MM LX20MM,SUP-2307185,CDM,C1713,HCPCS,0278,RC,,,,both,,,1702.60,1106.69,,,,,,,,,,,,,
JIG SURG RT TIB KNEE AREF ROT PT SPEC DISP PERSONA,SUP-2205589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE CATLYST III DIA 5.7 FR FEM ART MANUAL,SUP-2159549,CDM,C1760,HCPCS,0278,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
ANCHOR SOFT TISSUE 11X21MM FEMORAL WITH DISPOSABLE GUN EXOSH,SUP-2824100,CDM,C1713,HCPCS,0278,RC,,,,both,,,2677.79,1740.56,,,,,,,,,,,,,
PROBE SUCT DIA3.5MM 90-S AGG W/ INTEGR CBL HND CTRL SERFAS,SUP-2366833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.43,342.83,,,,,,,,,,,,,
LENS IOL HYDROPHOBIC ACRYL POST CHMBR EXT VISION CLR,SUP-2880950,CDM,V2788,HCPCS,0276,RC,,,,both,,,915.00,594.75,,,,,,,,,,,,,
HC Stab Phlebectomy >20,PX-3613776600,CDM,37766,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
CATHETER EMB SYNTEL L 40 CM DIA 4 FR INFLATED DIA 9 MM 0.75,SUP-2119456,CDM,C1757,HCPCS,0272,RC,,,,both,,,162.97,105.93,,,,,,,,,,,,,
JOINT WRST 1 LT RADIAL COCR MOLYBDENUM FRDM,SUP-2851944,CDM,C1776,CPT,0278,RC,,,,both,,,25281.62,16433.05,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED S3WRIGHT] WRIGHT MEDICAL TECHNOLOGY INC],SUP-2400713,CDM,C1776,CPT,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
TIP HNDPC SONICFUSION,SUP-2489378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
CATHETER GUID FLOWGATE L 95 CM OD 8 FR ID 0.084 IN 60 CC SYR,SUP-2367796,CDM,C2628,HCPCS,0272,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN TIP L3IN NIT COR POLYUR,SUP-2385568,CDM,C1769,HCPCS,0272,RC,,,,both,,,143.62,93.35,,,,,,,,,,,,,
STEM FEM L190MM OD51MM STR REG HIP FEN ASTN MOORE,SUP-2377805,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PIN FIXATION THREADED 3X355 MM,SUP-2472906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
ANCHOR SUTURE 5.5MM WITH 2 NO 2 SUTURES WITHOUT NEEDLE CROSS,SUP-2824426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
FIBER LASER DIA550UM HOLM SIDE FIRING DISP BPH DUOTOME,SUP-2139444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2320.55,1508.36,,,,,,,,,,,,,
PIN EXT FIX THRD L15MM DIA3MM SHANK L65MM DIA4MM SH TI,SUP-2342885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.68,504.84,,,,,,,,,,,,,
GRAFT BONE FRZN LT TALUS IMP OSTEOCHNDRL,SUP-2307316,CDM,C1713,HCPCS,0278,RC,,,,both,,,11275.74,7329.23,,,,,,,,,,,,,
DISTRACTION INTRNL ACT ARM RIGID RMTE DTCH33 MM T 6L 4V QT00,SUP-2669787,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.66,1922.48,,,,,,,,,,,,,
STENT NEPHURET L 26 CM DIA10 FR PERCFLX INTERNAL/EXTERNAL,SUP-2147756,CDM,C2617,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
CUTTER SUT TENSIONER,SUP-2121615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BRACE WALKING LP MED 5.5-10 IN 6.5-11 IN AD M MAXTRAX AIR,SUP-2427327,CDM,L4360,HCPCS,0274,RC,,,,both,,,93.76,60.94,,,,,,,,,,,,,
SET CARDPLG 50ML TBL LN L10FT DIA3/16IN STD DEL W/ ARREST,SUP-2330951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 0.5CC PUTTY GRFTON,SUP-2307526,CDM,C9359,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BONE LCK L CRV LT 15 H TI PROX TIB PLATING SYS ALPS,SUP-2413719,CDM,C1713,HCPCS,0278,RC,,,,both,,,4203.68,2732.39,,,,,,,,,,,,,
SCREW KIT CANC STRL GALAXY UNYCO,SUP-2646384,CDM,C1713,HCPCS,0278,RC,,,,both,,,884.26,574.77,,,,,,,,,,,,,
ARTHROFLEX 50X90X1.5MM,SUP-2811354,CDM,Q4125,HCPCS,0636,RC,,,,both,,,10956.40,7121.66,,,,,,,,,,,,,
CONNECTOR SPINE SPNL SYS TI TSRH 3D ROD 635MM L,SUP-2290001,CDM,C1713,HCPCS,0278,RC,,,,both,,,4179.34,2716.57,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS INCUS MED 3.3X2.1X2.5 MM SINGLE NOTCH,SUP-2637873,CDM,L8613,CPT,0278,RC,,,,both,,,1195.59,777.13,,,,,,,,,,,,,
COIL EMB L10CM LOOP DIA4MM PERIPH SELF EXP HYDRGEL POLYMER 45480410] TERUMO MEDICAL CORP],SUP-2385411,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
FIBER LASER KIT 600 MIC FOR KTP,SUP-2225704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE 8 H MIC TI NONSTERILE 1.5MM SCR .6MM,SUP-2262682,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.50,123.17,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.021 IN TAPR L 7 CM FLPY TIP L,SUP-2167769,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.29,34.64,,,,,,,,,,,,,
DEFIBRILLATOR CARD W/ RIATA EPIC II DR,SUP-2356559,CDM,C1721,HCPCS,0275,RC,,,,both,,,71121.00,46228.65,,,,,,,,,,,,,
DRILL SURG 4/5 SLD DENS ACUTRK,SUP-2107226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 150CM 0.038IN TIP L 3 CM STIFF STR,SUP-2385593,CDM,C1769,HCPCS,0272,RC,,,,both,,,155.24,100.91,,,,,,,,,,,,,
PLATE BNE L59MM 12 H NONSTERILE S STL ADPT LOK COMPR W/ SHT,SUP-2177474,CDM,C1713,HCPCS,0278,RC,,,,both,,,1229.84,799.40,,,,,,,,,,,,,
SCREW BNE PART THRD 2.7X26 MM LCK,SUP-2363947,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.16,148.95,,,,,,,,,,,,,
BIT DRL DIA4MM CANN W/ CALIB DEPTH MRK FOR STD TWO INCIS,SUP-2120844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS 2 CUF STD AD 62 CM 6 CM 6 CC ARC,SUP-2302486,CDM,C1750,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BLADE RTRCTR HIBBS 2INW X 3INL PRONG F/HMI LMNCTMY RGGLS RDM,SUP-2501131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.72,221.47,,,,,,,,,,,,,
ANCHOR SUTURE L14MM DIAMETER 5MM TITANIUM SELF PUNCHING SELF,SUP-2824260,CDM,C1713,HCPCS,0278,RC,,,,both,,,826.35,537.13,,,,,,,,,,,,,
CATHETER BERN 4FR 100CM,SUP-2116854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,108.64,70.62,,,,,,,,,,,,,
SCREWDRIVER SURG OD15MM NONCANNULATED DRL FREE CENTRE DRV,SUP-2262791,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.44,114.69,,,,,,,,,,,,,
CATHETER ABLATN LG CRV 2-5-2 MM 4 MM TIP 7 FRX110 CM THER,SUP-2102283,CDM,C1733,HCPCS,0272,RC,,,,both,,,1890.28,1228.68,,,,,,,,,,,,,
PLATE SPNL L48MM 8 H TI ANT CERV 3 LEV FIX STD LOK MAXAN,SUP-2414951,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
CARBON FIBER BAR 6MM X 65MM,SUP-2730000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
BUSULFAN 6 MG/ML IV SOLN,RX-24695,CDM,J0594,HCPCS,0636,RC,71288-0116-11,NDC,,both,10,ML,331.20,215.28,,,,,,,,,,,,,
BIT DRL L8MM DIA1.8MM W/O STP FOR LAMINOPLASTY SYS,SUP-2186835,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
ENDCAP ORTH L0MM DIA8MM ST FEM TI NAIL EXTN,SUP-2191864,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
STENT URET 6FR L24CM LUBRICIOUS HYDRPHLC TAPR TIP SMOOTH,SUP-2126625,CDM,C2617,HCPCS,0278,RC,,,,both,,,685.71,445.71,,,,,,,,,,,,,
IMPLANT FACE L 100 X W 76 MM THK 1.5 MM POLYETHYL EMBEDDED,SUP-2883632,CDM,C1713,HCPCS,0278,RC,,,,both,,,8977.92,5835.65,,,,,,,,,,,,,
COVER BUR H L10MM DIA0.6MM DOMED W/ TAB,SUP-2365227,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.91,796.19,,,,,,,,,,,,,
PACK PROCEDURE UNIVERSAL STAPLE DYNACLIP,SUP-2878341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-103564,CDM,J0665,HCPCS,0636,RC,00409-1159-01,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-157662,CDM,J1650,HCPCS,0636,RC,71288-0434-84,NDC,,both,0.6,ML,54.10,35.16,,,,,,,,,,,,,
TAP BNE SPNL POST 12MM DIA,SUP-2291532,CDM,C1713,HCPCS,0278,RC,,,,both,,,2518.25,1636.86,,,,,,,,,,,,,
WIRE FIX TRCR PT 1.4X150 MM RND KIRSCHNER,SUP-2321689,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
BLADE SHV L27.5CM DIA4MM 60-500RPM DBL CRV LO PROF ANG,SUP-2284156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1529.81,994.38,,,,,,,,,,,,,
DEVICE CLSR TRCR PRT,SUP-2171688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,272.55,177.16,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 49 5FR OD DST TIP 20MML CUT WIRE BLR,SUP-2676818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
Gender PFJ FEMORAL COMP CEMENTED SIZE 4-LT,SUP-2502683,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ISMUS L 110 CM DIA 7 FR 2-12-2 MM,SUP-2726705,CDM,C1731,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
DRAINAGE KIT SUBDURAL EVACUATING PRT SYS W/ LIDO,SUP-2665012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4912.69,3193.25,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM STD BASIC KT POWERPICC,SUP-2126384,CDM,C1751,HCPCS,0278,RC,,,,both,,,279.77,181.85,,,,,,,,,,,,,
OXYGENATOR PERF AD W HS RESVR PRIMO2X,SUP-2265154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
AWL SURG 52 DEG DIA 6 MM CANN CRV OBTURATOR,SUP-2934623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
ROD EXT FIX L220MM DIA8MM UNIV C FBR CONN REUSE FOR M FIX,SUP-2188740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.09,284.76,,,,,,,,,,,,,
FIXATOR EXT L220MM DIA2.8MM DST RAD S STL SELF DRL SCHNZ,SUP-2179166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7469.40,4855.11,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC DBM PTTY FIBER XCITE -RSFH,SUP-2881378,CDM,C1713,HCPCS,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
GRAFT BNE SUB W25XH4XL50MM 5ML B TRICALCIUM PHSPTE FOAM,SUP-2368175,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER DRAINAGE STR 8 FRX10 CM FIX LUER SELF CLS 1 STP,SUP-2430083,CDM,C1729,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PROBE ENDO CALIB ABLAT FOR ACL RECON COOLCUT,SUP-2123444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CLAMP CONN 6.5 TO 6.5MM PARA REVERE,SUP-2230107,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
CATHETER PTCA L80CM BLLN L4CM DIA8MM SHTH 5FR GWIRE 0.035IN,SUP-2170947,CDM,C1725,HCPCS,0272,RC,,,,both,,,348.85,226.75,,,,,,,,,,,,,
TEMPLATE SZ 3 DIM LG 27X60X0.6 MM MXLFCL RT ORBIT RESORB-X,SUP-2489741,CDM,C1713,HCPCS,0278,RC,,,,both,,,2823.08,1835.00,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA2 161 MM 36 MM SHTH 18 FR TAPR,SUP-2911984,CDM,C1889,HCPCS,0278,RC,,,,both,,,66894.56,43481.46,,,,,,,,,,,,,
GUIDEWIRE VASC SENS L 55 CM DIA 0.035 IN TIP 3 MM SS SIL,SUP-2521857,CDM,C1769,HCPCS,0272,RC,,,,both,,,161.58,105.03,,,,,,,,,,,,,
COLLAR CERV SFT 375X15IN SM,SUP-2276590,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.12,3.98,,,,,,,,,,,,,
KIT PROTCT SYS EMBOL-X GLIDE L 11 IN LG 2 FILTER 1 ART CANN,SUP-2214493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.42,979.82,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA 75 UM 2 ML HYDRGEL POLYZENE MIC WHT,SUP-2139572,CDM,C1889,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
TUBE CONN INNR END TELLURIDE FOR MIS SPNL FIX SYS,SUP-2211190,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
CATHETER ATHRCTMY FRONTRUNNER XP L 140 CM DIA 3.1 FR SHTH 6,SUP-2158727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3573.32,2322.66,,,,,,,,,,,,,
PIN FIX SM 22 MM REINF EMPOWR VVC,SUP-2634253,CDM,C1776,CPT,0278,RC,,,,both,,,2681.65,1743.07,,,,,,,,,,,,,
CATHETER ANGIOPLSTY DORADO L 135 CM BALLOON L 15 CM DIA 6 MM,SUP-2126836,CDM,C1725,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
SET PICC L 20CM DIA 5FR SHTH L 7CM DIA 5FR PR-32052-BAS,SUP-2887214,CDM,C1751,HCPCS,0278,RC,,,,both,,,308.35,200.43,,,,,,,,,,,,,
CANNULA ENDO L195CM OD2.5FR CHAN 3.2MM GWIRE OD0.018IN MTL,SUP-2313499,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.08,585.05,,,,,,,,,,,,,
CATHETER THERMOABLATION HABIB ENDOHPB L 180 CM DIA 8 FR BILI,SUP-2141352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5158.55,3353.06,,,,,,,,,,,,,
CATHETER DIL PTA P3 8MM X 2CM PWRFLX,SUP-2156155,CDM,C1725,HCPCS,0272,RC,,,,both,,,586.11,380.97,,,,,,,,,,,,,
BUR SURG DIA 4.5 MM FRONT CUT FLX,SUP-2934309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
CATHETER US 5FR L150CM GWIRE 0.014IN PLAT GLYDX HYDRPHLC,SUP-2327228,CDM,C1753,HCPCS,0278,RC,,,,both,,,2469.61,1605.25,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA16 MM POLYESTER GEL,SUP-2894631,CDM,C1889,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
KIT ANCHOR SUTURE MINI 1.8 MM Q-FIX DISP,SUP-2341946,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.01,354.26,,,,,,,,,,,,,
DVR LOCK EXTRA EXTRA LNG R ST,SUP-2587119,CDM,C1713,HCPCS,0278,RC,,,,both,,,4075.72,2649.22,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP MED 8 IN LT WRST COCK UP ELASTIC,SUP-2108132,CDM,L3809,HCPCS,0272,RC,,,,both,,,41.61,27.05,,,,,,,,,,,,,
DRIVER NDL ST GRAV,SUP-2399114,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
FIBER LASER 200UM FLX HOLM DISPOSABLE,SUP-2313984,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HC CT Upper Extremity W/O Contrast,PX-3527320000,CDM,73200,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
PAD CERV CLLR REPL FOR VISTA,SUP-2123902,CDM,L0190,HCPCS,0274,RC,,,,both,,,23.20,15.08,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM GRAVITATIONAL L 12 MM PRESSURE ADJ FX645T,SUP-2931040,CDM,C1729,HCPCS,0272,RC,,,,both,,,14971.05,9731.18,,,,,,,,,,,,,
INTRODUCER PERI L46CM S STL OBT W/ SUT H BULL SHP TIP REUSE,SUP-2243831,CDM,C1894,HCPCS,0272,RC,,,,both,,,305.71,198.71,,,,,,,,,,,,,
PLATE BNE L62MM 3 H STD L DST RAD VOLAR S STL LOK FOR,SUP-2348737,CDM,C1713,HCPCS,0278,RC,,,,both,,,7629.73,4959.32,,,,,,,,,,,,,
CAP SCR DIA8MM HEX DIA3.5MM DST FEM TI LOK NCB,SUP-2411465,CDM,C1776,CPT,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
"HC So Sugars, Single, Quant",PX-3018437866,CDM,84378,CPT,0301,RC,,,,inpatient,,,74.00,48.10,,,,,,,,,,,,,
PIN FIX L22MM DIA1.8MM S STL BTTRS VAR ANG LOK T8 STARDRV,SUP-2178302,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.31,245.90,,,,,,,,,,,,,
PLATE BNE L 46 MM SCREW DIA 3.5 MM 4 SHFT H SS RECON VA,SUP-2907617,CDM,C1713,HCPCS,0278,RC,,,,both,,,2720.03,1768.02,,,,,,,,,,,,,
CANNULA PERF AD 23FR L50CM FEM VEN W/ INTRO 0.5IN NVENT,SUP-2282858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,787.92,512.15,,,,,,,,,,,,,
HEAD FEM DISASSEMBLY HIP ATTCH MTL,SUP-2440394,CDM,C1776,CPT,0278,RC,,,,both,,,579.33,376.56,,,,,,,,,,,,,
JOINT SACROILIAC 7X55 MM IFUSE-3D,SUP-2337786,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
GENTAMICIN SULFATE 0.1 % EX CREA,RX-3423,CDM,6370000000,HCPCS,0637,RC,45802-0056-35,NDC,,both,15,GR,177.80,115.57,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL TIP 23 FRX40 CM STRL PALINDROMIC,SUP-2174234,CDM,C1750,HCPCS,0278,RC,,,,both,,,1700.37,1105.24,,,,,,,,,,,,,
HANDPIECE PHACO ULTRASONIC USED W/ INFIN VISION SYS,SUP-2109879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
HC So Alpha 1 Antitrypsin,PX-3018210366,CDM,82103,CPT,0301,RC,,,,both,,,69.00,44.85,,,,,,,,,,,,,
HC So Magnesium,PX-3018373566,CDM,83735,CPT,0301,RC,,,,both,,,58.00,37.70,,,,,,,,,,,,,
HC Renal Art 1st Order Bil,PX-4813625200,CDM,36252,CPT,0481,RC,,,,inpatient,,,10063.00,6540.95,,,,,,,,,,,,,
PLATE T PROFYLE HAND WD 8 HL 23MM,SUP-2703009,CDM,C1713,HCPCS,0278,RC,,,,both,,,982.19,638.42,,,,,,,,,,,,,
PROSTHESIS OSSCLR TOTAL 2MM/2.5MM DIA HEAD 0.8MM DIA DST END,SUP-2493782,CDM,L8613,CPT,0278,RC,,,,both,,,1191.44,774.44,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE CUTAWAY CNTOUR 22INCH COOL BLU,SUP-2336081,CDM,L1830,CPT,0274,RC,,,,both,,,81.73,53.12,,,,,,,,,,,,,
SOTALOL HCL 120 MG PO TABS,RX-15723,CDM,6370000000,HCPCS,0637,RC,69584-0842-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
RING FULL 220MM FOR TRUELOK FIX SYS,SUP-2316175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3976.21,2584.54,,,,,,,,,,,,,
COIL EMB 10 L6CM OD2MM HELCL STRTCH RESIST FNSH HYDRGEL,SUP-2305144,CDM,C1889,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW BONE L6MM DIA2MM MAND SLV NONLOCKINGXDRIVE FOR LORENZ,SUP-2136746,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
PLATE BNE L 150 X W 15 MM THK 0.75 MM SCREW DIA1.7 MM 8 H,SUP-2883187,CDM,C1713,HCPCS,0278,RC,,,,both,,,29162.03,18955.32,,,,,,,,,,,,,
PACEMAKER CARD W42.9XH40.2MM D7.5MM GENRTR SGL CHMBR ADAPTA,SUP-2282314,CDM,C1786,HCPCS,0275,RC,,,,both,,,9518.13,6186.78,,,,,,,,,,,,,
INTRODUCER PACE LD L 60 CM DIA 7 FR PEELABLE FOR TRNSVEN,SUP-2282101,CDM,C1894,HCPCS,0272,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
SCREW SPNL L17MM DIA4MM FIX ANG ANT CERV CANC TI ST,SUP-2293231,CDM,C1713,HCPCS,0278,RC,,,,both,,,1326.27,862.08,,,,,,,,,,,,,
CENTESIS CATH 4F 12CM PGTL SLIP FIT 20GA INTRDCR NDLE 4 HOLE,SUP-2702112,CDM,C1729,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
CATHETER ENDOSCP FOR URETHROTM,SUP-2747469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3222.21,2094.44,,,,,,,,,,,,,
PLATE BNE L SHT 0.6 MM RT,SUP-2262734,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE L20MM DIA24MM TI VAR ANG LOK ST STARDRV RECESS TB,SUP-2418149,CDM,C1713,HCPCS,0278,RC,,,,both,,,460.29,299.19,,,,,,,,,,,,,
BONESYNC STRIP 10CC,SUP-2811324,CDM,C1713,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
SCREW BNE L60MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413586,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.99,253.49,,,,,,,,,,,,,
SCREW BNE CANN 6.5X50 MM 16 MM THRD AXSOS 3,SUP-2613620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
PLATE BNE THK 0.5 MM 2 X 21 H POLY L-LACTIDE POLY D-LACTIDE,SUP-2883133,CDM,C1713,HCPCS,0278,RC,,,,both,,,11652.41,7574.07,,,,,,,,,,,,,
SPLINT ANK FT XL R POST LEAF LTWT SEMI RIG ROLYAN,SUP-2326016,CDM,L4397,HCPCS,0274,RC,,,,both,,,113.89,74.03,,,,,,,,,,,,,
PLATE MIS PLANTARPOWER,SUP-2652617,CDM,C1713,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
BUR SURG L14CM HD L351MM DIA3MM TAPR L BOR MIDAS REX,SUP-2277726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.81,237.13,,,,,,,,,,,,,
PLATE BONE L80MM 7 H STRL LT POSTEROLATERAL DSTL FIBULAR S,SUP-2349721,CDM,C1713,HCPCS,0278,RC,,,,both,,,3974.77,2583.60,,,,,,,,,,,,,
PACK PROC BILAT HAT-TRICK MTP,SUP-2349216,CDM,C1776,CPT,0278,RC,,,,both,,,4248.89,2761.78,,,,,,,,,,,,,
MESH CRAN L 90 X W 90 MM SCREW DIA2 MM TI PANEL NS DISP,SUP-2936495,CDM,C1713,HCPCS,0278,RC,,,,both,,,3840.22,2496.14,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 180 CM DIA 0.018 IN TIP,SUP-2385541,CDM,C1769,HCPCS,0272,RC,,,,both,,,892.39,580.05,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR STRP W/O JT PREFABRICATED INTFACE,SUP-2435783,CDM,L3924,HCPCS,0272,RC,,,,both,,,248.88,161.77,,,,,,,,,,,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,0636,RC,00703-4502-91,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L MOD BAL REV SYS,SUP-2315529,CDM,C1776,CPT,0278,RC,,,,both,,,12359.04,8033.38,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM DST VOLAR RAD LOK FULL THRD SQ DRV,SUP-2411792,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
CHEEK RETRACTOR FOR PEDIATRIC,SUP-2823218,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.28,225.73,,,,,,,,,,,,,
HC Radium Ra223 Dichloride Ther (Non-Pmm),PX-2780960601,CDM,A9606,CPT,0278,RC,,,,both,,,470.00,305.50,,,,,,,,,,,,,
SET THAL QUIK CHST TUBE 28 FR CATH LEN 41CM SIDEPORTS 4 SET,SUP-2167989,CDM,C1729,HCPCS,0272,RC,,,,both,,,748.58,486.58,,,,,,,,,,,,,
SCREW SPNL L14MM DIA4MM SELF DRL VUELOCK,SUP-2415576,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE DIA 35 MM THK 0.5 MM SCREW DIA1.7 MM MAXILLOFCL,SUP-2909620,CDM,C1713,HCPCS,0278,RC,,,,both,,,5740.96,3731.62,,,,,,,,,,,,,
TIP SONOPET IQ STANDARD 20CM,SUP-2755026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3267.67,2123.99,,,,,,,,,,,,,
STENT COR 23MM 3MM DEL SYS 145CM 0.014IN CO CHROM,SUP-2105455,CDM,C1874,HCPCS,0278,RC,,,,both,,,2225.26,1446.42,,,,,,,,,,,,,
CATHETER GUID WINGMAN 35 L 65 CM OD 0.06 IN TIP DIA 0.050 IN,SUP-2227768,CDM,C1887,HCPCS,0272,RC,,,,both,,,2028.44,1318.49,,,,,,,,,,,,,
GUIDE PIN CALIB STYL SIX 2.4MM X 229MM,SUP-2409631,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.56,42.61,,,,,,,,,,,,,
GRAFT BNE SUB W30XL35MM THK12 16MM ILIUM BICORT STRP FRZ DRY,SUP-2307133,CDM,C1713,HCPCS,0278,RC,,,,both,,,2408.07,1565.25,,,,,,,,,,,,,
KIT ANEUROPLASTIC CEM 30GM 2 MTRX BG 2 VI LIQ STRL DISP,SUP-2256971,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.59,292.88,,,,,,,,,,,,,
LENS IOL BCNVX 7.5+ DIOPT POST CHMBR ACRYL AKREOS,SUP-2129300,CDM,V2632,HCPCS,0276,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HC Arthrocent/Aspiration Maj Jnt|BILATERAL PROCEDURE|PO,PX-3612061000,CDM,20610,CPT,0361,RC,,,50|PO,both,,,1245.00,809.25,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC EXCHANGE 16 5327350,SUP-2632949,CDM,C1750,HCPCS,0278,RC,,,,both,,,7088.55,4607.56,,,,,,,,,,,,,
PLATE BONE L25MM THK1MM 4 H MAND TI TENS BND FOR 2MM SCR FIX,SUP-2191211,CDM,C1713,HCPCS,0278,RC,,,,both,,,1907.86,1240.11,,,,,,,,,,,,,
HC So Nephelometry Ea Analyte Nes,PX-3018388366,CDM,83883,CPT,0301,RC,,,,inpatient,,,53.00,34.45,,,,,,,,,,,,,
ROD EXT FIX 250X9.5 MM ALUM VISION,SUP-2517870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
CATHETER CTRL VEN OD4.2FR 1 LUMN SURCUF BASIC TY STYL NDL,SUP-2126548,CDM,C1751,HCPCS,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
SP PLASMA OVALBUTTON LNG,SUP-2722877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1843.97,1198.58,,,,,,,,,,,,,
DEVICE SPEC REMOVING L 12.6 IN OD 3 MM HYSTEROSCOPIC STRL,SUP-2913647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2856.96,1857.02,,,,,,,,,,,,,
TROCAR ENDOSCP DIA12 MM SZ 5/ 7/8 MM POLYUR BALLOON BLNT TIP,SUP-2896154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.68,445.69,,,,,,,,,,,,,
SYRINGE MED 1 CC DEFLUX PREFIL 1092203] MCKESSON GENERAL MEDICAL],SUP-2266607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5964.27,3876.78,,,,,,,,,,,,,
PLATE BONE L33MM 4 H SEMI COMPR,SUP-2319390,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
DEVICE SUT KNOTLESS INSRTR HNDL MAG WIRE SUT CART FOR LABRAL,SUP-2342083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SL POWERMIDLINE CATHETER KIT W/GUARDIVA,SUP-2613517,CDM,C1751,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
PLATE BNE L 110 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 10 H,SUP-2936286,CDM,C1713,HCPCS,0278,RC,,,,both,,,2463.49,1601.27,,,,,,,,,,,,,
PLATE BONE 70MML STNLSS STEEL F3.5MM SCREW SM FRGMNT SSTM N,SUP-2721912,CDM,C1713,HCPCS,0278,RC,,,,both,,,1272.99,827.44,,,,,,,,,,,,,
FIBER LASER HOLMIUM 272 LONG,SUP-2885396,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CATHETER SET 7 FR RAPID INFUSION EXCHANGE DIL,SUP-2120642,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.94,25.96,,,,,,,,,,,,,
PLATE BONE COMPRESSION 2 MM MANDIBULAR 4 HOLE INTERMEDIATE L,SUP-2838406,CDM,C1713,HCPCS,0278,RC,,,,both,,,1481.45,962.94,,,,,,,,,,,,,
ALLOGRAFT BNE GRAN 6 CC HA/TCP CANC STRL VENADO,SUP-2718012,CDM,C1713,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
COMPONENT TIB SZ 2 LT FIX CEM GMK,SUP-2267563,CDM,C1776,CPT,0278,RC,,,,both,,,5436.94,3534.01,,,,,,,,,,,,,
SLING KNOTLESS INCONT MESH,SUP-2308304,CDM,C1781,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BRUSH CLN 1.25 MM,SUP-2492060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,765.88,497.82,,,,,,,,,,,,,
HC Repr Smp Not Face 20.1-30cm,PX-4501200600,CDM,12006,CPT,0450,RC,,,,both,,,1445.00,939.25,,,,,,,,,,,,,
KIT INTRO L 10CM 5FR NIT WIRE TUNGSTEN TIP MIC B BVL CLR HUB,SUP-2117382,CDM,C1894,HCPCS,0272,RC,,,,both,,,78.09,50.76,,,,,,,,,,,,,
DRAINAGE KIT PLEURAL ESSENTIAL INSRTN TY CATH ASPIRA,SUP-2301576,CDM,C1729,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
COMPONENT TIB AUG UNIV 55X59X10 MM KNEE OSS RS RD122061,SUP-2449994,CDM,C1776,CPT,0278,RC,,,,both,,,2444.49,1588.92,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 63 CM DIA 8.5 FR NDL L 71 CM ML2,SUP-2516628,CDM,C1893,HCPCS,0272,RC,,,,both,,,13.03,8.47,,,,,,,,,,,,,
CATHETER DIAG TRACSTAR L 95 CM DIA 0.088 IN HYDRPHLC LG DSTL,SUP-2739208,CDM,C1887,HCPCS,0272,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
SHELL ACET DIA40MM F/M TI ALLOY POR SPIK W/O H PRI REV UNIV,SUP-2202330,CDM,C1776,CPT,0278,RC,,,,both,,,4612.66,2998.23,,,,,,,,,,,,,
CATHETER HD PRECRV AD 15.5 FRX32 CM LT DL SH STRL DURAFLO 2,SUP-2462957,CDM,C1750,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 035X480 15 CM MOVEABLE PUR TRCE HYBRID,SUP-2759262,CDM,C1769,HCPCS,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
BONE MARROW TRAY SAFETY 11 GAX4 IN W/ BX NDL STRL T-LOK LF,SUP-2876737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
PLATE BONE L227MM 14 H RT PROX HUM LO ALPS,SUP-2418355,CDM,C1713,HCPCS,0278,RC,,,,both,,,8807.70,5725.00,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X40X3-6 MM SPNG FD CANC,SUP-2717783,CDM,C1713,HCPCS,0278,RC,,,,both,,,5165.30,3357.44,,,,,,,,,,,,,
BRACE KNEE BIOSKIN Q PAT TRK M,SUP-2174970,CDM,L1820,HCPCS,0272,RC,,,,both,,,165.67,107.69,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE SQRE .6MM 1.5MM SYS CP TTNM ST,SUP-2497791,CDM,C1713,HCPCS,0278,RC,,,,both,,,639.30,415.54,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE MED SHT ANK ROCKER BTM INLINE,SUP-2336132,CDM,L4361,HCPCS,0272,RC,,,,both,,,79.35,51.58,,,,,,,,,,,,,
RING EXT FIX SEG 120 MM CARBON HOFFMANN,SUP-2470768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4300.54,2795.35,,,,,,,,,,,,,
REAMER SURG FLX KNEE VERSITOMIC OD4.5MM,SUP-2366801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4518.46,2937.00,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX12 CM SHT TERM DL SET SOFT-LINE,SUP-2627326,CDM,C1752,HCPCS,0278,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSPLIT XK CHRONIC STD 16FR D 5685270,SUP-2632960,CDM,C1750,HCPCS,0278,RC,,,,both,,,1425.56,926.61,,,,,,,,,,,,,
ELECTRODE MONOPOLAR COAG 24 FR PT FOR COLLIN KNIFE YEL STRL,SUP-2360969,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-6 MM SHRT TAPR REINF,SUP-2525446,CDM,C1768,CPT,0278,RC,,,,both,,,797.28,518.23,,,,,,,,,,,,,
HC Extrem Low Ankle Arthrogram,PX-3227361500,CDM,73615,CPT,0322,RC,,,,both,,,1013.00,658.45,,,,,,,,,,,,,
CATHETER EP CIR 1-4-5-1 MM 7 FRX110 CM OPTMA,SUP-2102280,CDM,C1731,HCPCS,0278,RC,,,,both,,,4819.90,3132.93,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN BNE MTRX PTTY GRFTON,SUP-2294016,CDM,C1713,HCPCS,0278,RC,,,,both,,,2879.38,1871.60,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLUENCY + L 40 MM DIA 7 MM CATH L 80 CM,SUP-2128256,CDM,C1874,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
CURETTE SURG W10MMXL17IN FOR CEMENTLESS HIP REV SYS MORELAND,SUP-2253224,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CONTROLLER DETACHMENT FOR ANEURYSM EMBOLIZATION SYSTEM WEB W,SUP-2836320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
Z INACTIVE PER BARD CARTRIDGE IMPL 30 Q-RING SALUTE 18CM,SUP-2126057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KIT INTELLIS SENSOR MRI PERC,SUP-2882877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,81696.52,53102.74,,,,,,,,,,,,,
PLATE BNE L45MM THK12MM 0DEG 7 H BILAT S STL STR RIG LIMIT,SUP-2186170,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.10,787.86,,,,,,,,,,,,,
STENT URETERAL STENOSTENT 24CM,SUP-2848797,CDM,C2617,HCPCS,0278,RC,,,,both,,,925.36,601.48,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM COR DIA2.7MM TROCHANTERIC TI LOK,SUP-2410874,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.15,195.10,,,,,,,,,,,,,
MESH HERN SM DIA8CM INGUINAL CIR SELF EXP PTCH KUGEL,SUP-2125977,CDM,C1781,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
HC Mandible Partial Less Than 4 Views,PX-3207010000,CDM,70100,CPT,0320,RC,,,,both,,,759.00,493.35,,,,,,,,,,,,,
SHEATH INTRO CHARIOT L 90 CM DIA 7 FR STR TIP XCUT LG LUMEN,SUP-2140082,CDM,C1894,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SLXACUTE 14FR DIA 30CM STRGHT TAPR TIP,SUP-2610566,CDM,C1752,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL BND BELT BILATERAL,SUP-2435689,CDM,L2640,HCPCS,0272,RC,,,,both,,,889.62,578.25,,,,,,,,,,,,,
CANISTER SUCTION ASPIR NS DISP ZOOM DUOPORT,SUP-2930264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
GRAFT HUMAN TSSUE FIRM 20X16 CM RCNSTRCTVE TSSUE MTRX STRTTC,SUP-2483526,CDM,Q4130,HCPCS,0636,RC,,,,both,,,31685.74,20595.73,,,,,,,,,,,,,
DRAINAGE KIT 80 CM LUMBAR OPN TIP BA IMPREG SIL,SUP-2666765,CDM,C1729,HCPCS,0272,RC,,,,both,,,432.03,280.82,,,,,,,,,,,,,
PLATE BONE SM LT GLD 3D ORBIT FLR FOR 1.2MM SCR,SUP-2363678,CDM,C1713,HCPCS,0278,RC,,,,both,,,4292.44,2790.09,,,,,,,,,,,,,
HINGE EXT FIX MONOTUBE,SUP-2480614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1101.20,715.78,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE 3 PNL CANVS 16INCH LTX FREE,SUP-2336075,CDM,L1830,CPT,0274,RC,,,,both,,,45.44,29.54,,,,,,,,,,,,,
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,6370000000,HCPCS,0637,RC,00096-0732-04,NDC,,both,120,ML,67.00,43.55,,,,,,,,,,,,,
TRIAMTERENE-HCTZ 37.5-25 MG PO TABS,RX-8132,CDM,6370000000,HCPCS,0637,RC,60505-2656-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INCEPTA DR W 6.17 X H 6.9-7.4 CM D 0.99,SUP-2149202,CDM,C1721,HCPCS,0275,RC,,,,both,,,40926.76,26602.39,,,,,,,,,,,,,
VLP 2.5MM TALUS PLT MDL L RIGHT 11X20MM ST,SUP-2820182,CDM,C1713,HCPCS,0278,RC,,,,both,,,5954.54,3870.45,,,,,,,,,,,,,
HC Inject Peritoneal Cavity,PX-3614940000,CDM,49400,CPT,0361,RC,,,,both,,,455.00,295.75,,,,,,,,,,,,,
POLYETHYLENE GLYCOL 3350 17 G PO PACK,RX-25424,CDM,6370000000,HCPCS,0637,RC,57896-0490-01,NDC,,both,1,UN,5.80,3.77,,,,,,,,,,,,,
SYRINGE MED 11 N BCA ETHIODIZED OIL NEUROVASC EMB LIQ FOR,SUP-2249001,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
GRAFT HUM TISS VEIN 3MM OD 61 70CML SAPHENOU CRYOPRESERVED A,SUP-2607339,CDM,C1762,CPT,0278,RC,,,,both,,,29069.65,18895.27,,,,,,,,,,,,,
SHELL ACET PRESSFIT PRI 40 MM OD UNIV SPIK NO H CERAMIC,SUP-2210214,CDM,C1776,CPT,0278,RC,,,,both,,,5469.88,3555.42,,,,,,,,,,,,,
SET CATH RAP INFUS EXCHG W/ 8.5FR SHTH TISS DIL SPR WIRE,SUP-2383492,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.06,24.74,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SLIP ON SM AD 7.5 IN WRST COMFORTFORM,SUP-2197051,CDM,L3931,HCPCS,0274,RC,,,,both,,,42.77,27.80,,,,,,,,,,,,,
ANCHOR SUT BIOABSRB IMPL W/ ORTHOCORD LUPINE BR,SUP-2249329,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
HC Pre-Pooled Cryoprecipitate,PX-3900901200,CDM,P9012,CPT,0390,RC,,,,inpatient,,,384.00,249.60,,,,,,,,,,,,,
KIT ACC 10GA 3ML SYR DMND TIP END OPN RADPQ W/O CEM SYNFLATE,SUP-2255819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
NAIL IM CCD ANGLE 130 DEG L 170 MM DIA12 MM TROCHANTERIC,SUP-2900581,CDM,C1713,HCPCS,0278,RC,,,,both,,,7134.24,4637.26,,,,,,,,,,,,,
CATHETER GUID L100CM OD7FR JUDKINS L 4 W/ SIDE H W/OUT,SUP-2103712,CDM,C1887,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 4 FR GUIDEWIRE L 60 CM DIA 0.018,SUP-2383171,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
PIN FIX DIA1.2MM FOR SM BNE PLATING SYS ORTHOLOC 3DI,SUP-2399749,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
COLLAR CERV LO DENS LG 15-20 IN,SUP-2197207,CDM,L0120,HCPCS,0272,RC,,,,both,,,17.18,11.17,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X33X1.25 MM 4 HOLE FRAC TI LEVEL 1,SUP-2457057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.30,1193.59,,,,,,,,,,,,,
TUBE VENT 1.14 MM 1 MM 2.7 MM BOB FLROPLAS STRL,SUP-2535122,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.45,14.59,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X120 MM 9 HOLE SS LCP,SUP-2569335,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.47,294.11,,,,,,,,,,,,,
TUBE SET 2.6 MM MACR ST NEXUS SONASTAR,SUP-2748598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
TIGERTAPE STERNAL CLOSURE WITH CUTTING NDL,SUP-2814145,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GRAFT HUM TISS SZ C W3.5XL3.5CM FRZN ALLGRFT OCU AMNIO MEM,SUP-2135259,CDM,V2790,HCPCS,0274,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
KIT CATH HEMODIALYSI PWR TRIALYSI SLIM CATH ACTE 12FR DIA 12,SUP-2613259,CDM,C1752,HCPCS,0278,RC,,,,both,,,886.89,576.48,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 125 CM DIA 0.032 IN CRV RAD 3 MM,SUP-2157272,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
PLATE BNE 6 H CRANIOMAXILLOFACIAL TI LO PROF DBL Y W/ BAR,SUP-2366208,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.80,364.52,,,,,,,,,,,,,
PLUG MESH M ANCHR 4CM RIM 5CM SYN POLYPR POLIGLECAPRONE 25,SUP-2220112,CDM,C1781,HCPCS,0278,RC,,,,both,,,613.09,398.51,,,,,,,,,,,,,
HC So Q Fever Antibody,PX-3028663866,CDM,86638,CPT,0302,RC,,,,outpatient,,,423.00,274.95,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 4 10MM CORT CANC CHIP COARSE FRZN,SUP-2307430,CDM,C1713,HCPCS,0278,RC,,,,both,,,3824.87,2486.17,,,,,,,,,,,,,
ARCOS CAL SZ D +0 HI 60MM,SUP-2506013,CDM,C1776,CPT,0278,RC,,,,both,,,15159.92,9853.95,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 6.25X2X0.8 CM 10 CC CRBNT APATITE VENADO,SUP-2718021,CDM,C1713,HCPCS,0278,RC,,,,both,,,2563.56,1666.31,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT RAD DST STRUCTURAL L,SUP-2307319,CDM,C1713,HCPCS,0278,RC,,,,both,,,4878.46,3171.00,,,,,,,,,,,,,
SCREW SET FITBONE,SUP-2645706,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.79,418.46,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL SLNG,SUP-2435681,CDM,L2580,HCPCS,0274,RC,,,,both,,,1228.62,798.60,,,,,,,,,,,,,
PIN FIX L25MM OD2MM FT PROV PERI-LOC VLP,SUP-2344025,CDM,C1713,HCPCS,0278,RC,,,,both,,,944.20,613.73,,,,,,,,,,,,,
GRAFT HUM TISS FEM HD FRZN,SUP-2281651,CDM,C1713,HCPCS,0278,RC,,,,both,,,5187.28,3371.73,,,,,,,,,,,,,
GRAFT BNE SUB L20CM STRP MASTERGRFT,SUP-2289162,CDM,C1713,HCPCS,0278,RC,,,,both,,,9256.72,6016.87,,,,,,,,,,,,,
CAGE SPNL 0 DEG 14X12X8 MM ANTR CERV INTBDY TI MATISSE TICRO,SUP-2578054,CDM,C1889,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SCREW BONE 3.5MM X 55MM NON LOCKING HEXALOBE STR,SUP-2639373,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL HEEL PD,SUP-2435736,CDM,L3480,HCPCS,0274,RC,,,,both,,,176.41,114.67,,,,,,,,,,,,,
RING EXT FIX 5/8 180 MM SALVATION,SUP-2459697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
BIT DRILL CALIBRATED 3.5 MM WITH QUICK CONNECT STERILE PERIL,SUP-2837016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,928.97,603.83,,,,,,,,,,,,,
NAIL IM CANN 125 DEG 11X440 MM LT TROCHANTERIC FIX TI GRN NS,SUP-2192025,CDM,C1713,HCPCS,0278,RC,,,,both,,,6765.07,4397.30,,,,,,,,,,,,,
STENT DIVERTER FLOW FREDX 21 3.0MM X 14 / 19,SUP-2855011,CDM,C1876,HCPCS,0278,RC,,,,both,,,46227.08,30047.60,,,,,,,,,,,,,
TRAY NERVE BLOCK CANN DIA22 GA SNB300OPM BPSK STRL LF DISP,SUP-2936665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,57.09,37.11,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA20 MM EPTFE STRL,SUP-2396442,CDM,C1768,CPT,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
GRAFT BNE GRAN 5 CC CLLGN HA B TRICALCIUM FORMAGRAFT,SUP-2567398,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.25,943.96,,,,,,,,,,,,,
GRAFT HUM TISS W20 25XL150MM HUM SHFT FRZN,SUP-2307376,CDM,C1713,HCPCS,0278,RC,,,,both,,,2845.66,1849.68,,,,,,,,,,,,,
NEEDLE SPNL DMND SPRINGLESS BVL TIP ST I-PAS III,SUP-2310405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 3FR 55CM 1 LUMAN R S3173108,SUP-2632831,CDM,C1751,HCPCS,0278,RC,,,,both,,,473.07,307.50,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0258,RC,00338-0049-11,NDC,,both,50,ML,24.70,16.05,,,,,,,,,,,,,
GRAFT ENDOVASC L16CM AORT DIA26MM IL DIA14.5MM ABD EXCLUDER,SUP-2396079,CDM,C1768,CPT,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
PERFORATOR SURG DRL BNE FEN,SUP-2321585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
ROD ORTH THRD 120 MM,SUP-2123508,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZN ALLGRFT FIB CORT STRUT BNE 150MM,SUP-2307372,CDM,C1713,HCPCS,0278,RC,,,,both,,,4717.98,3066.69,,,,,,,,,,,,,
GRAFT BONE SUB 1CC DEMIN BONE MTRX PUTTY INJ SYR PUROS,SUP-2205385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
SHELL ACET SZ 48MM GRP 1 UNIV BRN TI CLUS H PRI REV,SUP-2222500,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
BUR SURG TAPR 1.7X16 MM ROUTER M ATTCH MIDAS REX UPWR TPS,SUP-2363340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,238.42,154.97,,,,,,,,,,,,,
IMMOBILIZER KNEE 3 PNL 19 IN,SUP-2336076,CDM,L1830,CPT,0272,RC,,,,both,,,37.65,24.47,,,,,,,,,,,,,
"HC Trans, Esb, L/S, Single",PX-3606448300,CDM,64483,CPT,0360,RC,,,,both,,,2817.00,1831.05,,,,,,,,,,,,,
DISSECTOR ENDOSCP PREPERI KID SHP DISTENSION BLLN SPCMKR,SUP-2283311,CDM,C1727,CPT,0278,RC,,,,both,,,744.34,483.82,,,,,,,,,,,,,
CLAMP EXT FIX SM TI ALLOY COMB MR CONDITIONAL CLP ON SELF,SUP-2188536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
BEARING HUM DIA36-44MM +3MM OFFSET ARCOMXL FOR COMPHSVE REV,SUP-2409554,CDM,C1776,CPT,0278,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
HC 25 Hydroxy Includes Fractions if Performed,PX-3018230600,CDM,82306,CPT,0301,RC,,,,both,,,233.00,151.45,,,,,,,,,,,,,
BIT DRL L70MM DIA2.6MM FOR CLAVICULAR LOK PLT SYS,SUP-2378012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
COMPONENT FEM CNDYL KNEE MOD ROTATIONAL PROS REPL ENDO-MODEL,SUP-2423131,CDM,C1776,CPT,0278,RC,,,,both,,,23195.18,15076.87,,,,,,,,,,,,,
SCREW BNE LCK 2.7X10 MM CANC,SUP-2397416,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.84,726.60,,,,,,,,,,,,,
POST EXT FIX 1 H FEM CONN SIDEKCK FREE CIR FIX,SUP-2400618,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
PLATE BNE CHAMPY MINI 110 DEG 2-2.5X1 MM LT MAND 6 HOLE TI,SUP-2470980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1338.96,870.32,,,,,,,,,,,,,
PLATE SPINE SACR RT COLORADO 2 SACR AND SACROILIAC S STL,SUP-2290564,CDM,C1713,HCPCS,0278,RC,,,,both,,,7369.58,4790.23,,,,,,,,,,,,,
MICROCATHETER GUID TREVO TRAK 21 L 162 CM PROX/DSTL OD,SUP-2551054,CDM,C1887,HCPCS,0272,RC,,,,both,,,2195.49,1427.07,,,,,,,,,,,,,
TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS,RX-130239,CDM,6370000000,HCPCS,0637,RC,00597-0155-70,NDC,,both,4,GR,337.50,219.37,,,,,,,,,,,,,
DEVICE COAG 3 CM GUID NO CANN FOR EPICARD ABLATN EPISENSE,SUP-2424446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
SET DIL CATH 7FR L65CM BAL L4CM DIA6MM 60PSI URET INFL PRSS,SUP-2171204,CDM,C1726,HCPCS,0272,RC,,,,both,,,845.29,549.44,,,,,,,,,,,,,
ALLOGRAFT BNE CAGE 2 CC DBM VESUVIUS,SUP-2717990,CDM,C1713,HCPCS,0278,RC,,,,both,,,2127.51,1382.88,,,,,,,,,,,,,
MESALAMINE ER 250 MG PO CPCR,RX-10533,CDM,6370000000,HCPCS,0637,RC,54092-0189-81,NDC,,both,1,UN,13.70,8.90,,,,,,,,,,,,,
TRAY CATH CNTRL VENOU LUMENX3 6FR DIA SUBCLAV W/SHRLCK 3CG S,SUP-2613374,CDM,C1751,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
LEVEL CMF ST PLATE RECON TLTS ANGLE LFT 20 25 MM SCRW26 HO,SUP-2679060,CDM,C1713,HCPCS,0278,RC,,,,both,,,5662.55,3680.66,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 5.5/6 MM MULTAXL STRL CD HORZ 4PK,SUP-2928657,CDM,C1713,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
SHEET CRANIOFACIAL W50XL76MM THK0.85MM ULT THN BIOMATERIAL,SUP-2366461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.18,1096.02,,,,,,,,,,,,,
GRAFT HUM TISS GRACILIS TEND FRZ DRY,SUP-2137247,CDM,C1762,HCPCS,0278,RC,,,,both,,,2589.24,1683.01,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336042,CDM,L3809,HCPCS,0274,RC,,,,both,,,17.93,11.65,,,,,,,,,,,,,
DEVICE PESSARY NO5 DIA1.75IN SIL CUBE VAULT TRIMO SAN JEL,SUP-2171732,CDM,A4562,HCPCS,0274,RC,,,,both,,,112.79,73.31,,,,,,,,,,,,,
CUTTER VITRCTMY 20GA HI SPD FOR WHITESTAR SIGN SYS,SUP-2247709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED 20X1 MM PROCHONDRIX,SUP-2361155,CDM,C1889,HCPCS,0278,RC,,,,both,,,21666.00,14082.90,,,,,,,,,,,,,
GRAFT BNE W22XL20MM THK75X12MM BICORT EVANS WDG FOR,SUP-2399096,CDM,C1734,HCPCS,0278,RC,,,,both,,,6204.64,4033.02,,,,,,,,,,,,,
STEM NONCEMENTED FEM/TIB 12X80MM,SUP-2359181,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CONE TIB AUG MED 25 MM KNEE REGENEREX POROUS TI,SUP-2441909,CDM,C1776,CPT,0278,RC,,,,both,,,2501.01,1625.66,,,,,,,,,,,,,
PORT INFUS CATH 8FR TI ATTACH OPN END SGL LUMN CHRONOFLEX,SUP-2127756,CDM,C1788,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
DEVICE THROMCTMY ARROW-TREROTOLA PTD DIA 7 FR PWR 3000 RPM,SUP-2384058,CDM,C1757,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GUIDE NDL ULTRASOUND 14-18 GA KT SINGLE ANGLE ACCUSITE,SUP-2164710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
KNIFE NDLE ENDSCPC 5FR OD DST TIP 5MML 170CML WRKNG PRCRVD T,SUP-2675533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.01,455.66,,,,,,,,,,,,,
GRAFT HUM TISS 60-69CM SAPH VEIN,SUP-2417193,CDM,C1768,CPT,0278,RC,,,,both,,,30925.86,20101.81,,,,,,,,,,,,,
GUIDEWIRE GLDEWIRE STIFF SHFT ANG FLEX TIP 0.025INX150CM,SUP-2141741,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.51,112.13,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS PEDCL REDUCTION UNIAXIAL,SUP-2926861,CDM,C1713,HCPCS,0278,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
SYSTEM RAP DEL DRL 4 S STL GUIDWIRE DEL INSTR ANG OVL HD,SUP-2341624,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.60,357.89,,,,,,,,,,,,,
HALF RING 220 MM INT DIAM,SUP-2818152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11619.73,7552.82,,,,,,,,,,,,,
PLATE BONE L54MM THK1.4MM SHFT W7.5MM HD 19.8MM 6 H STRL,SUP-2349709,CDM,C1713,HCPCS,0278,RC,,,,both,,,5101.72,3316.12,,,,,,,,,,,,,
REMOVER CLP L15CM L APPRX SPAN BEFORE CLSR 1.7MM DISP,SUP-2264251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7313.06,4753.49,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 6 MM RNG L 20 CM EPTFE,SUP-2396310,CDM,C1768,CPT,0278,RC,,,,both,,,3821.38,2483.90,,,,,,,,,,,,,
SCREW PEDCL SPNL LCK VAR TI 6.5MMDIA 45MML,SUP-2415531,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
PLATE BNE L 70 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 6 H 72440706N,SUP-2932860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.16,885.40,,,,,,,,,,,,,
PUMP PAIN 400ML 1 PRT 1 FIX HUB PROGRAMMABLE PRTABLE RESVR,SUP-2361479,CDM,C2626,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 100 CM OD 5 FR ID 0.056 IN LNG,SUP-2155873,CDM,C1887,HCPCS,0272,RC,,,,both,,,94.95,61.72,,,,,,,,,,,,,
PROBE SURG FLAT 3.5X20 MM NSL INSUL,SUP-2853207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1455.08,945.80,,,,,,,,,,,,,
CUP ACET DIA54MM HIP POLY IMPCT FOR 48MM HD BIRMINGHAM,SUP-2350863,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
BIT DRL 2.2 MM,SUP-2175115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM 125DEG R TROCHANTERIC FEM HIP TI R2,SUP-2370530,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
PORT INFUS SGL LUMN ATTCH POLYUR OPN END CATH 8FR POWERPRT,SUP-2126513,CDM,C1788,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
SCREW BNE L25MM DIA5MM PARTIALLY THRD PANTSA XL,SUP-2243622,CDM,C1713,HCPCS,0278,RC,,,,both,,,1176.97,765.03,,,,,,,,,,,,,
BAND SCLER BCKL L 120 MM 3.5 X 0.75 MM SIL TYP 41 SFT ELAS,SUP-2930289,CDM,C1784,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
GUIDE SURG 10 CC CORTOSS CARTRIDGE CEM,SUP-2379533,CDM,C1713,HCPCS,0278,RC,,,,both,,,3999.73,2599.82,,,,,,,,,,,,,
CATHETER EXTR DBL LUMN 6FRX14CM,SUP-2260396,CDM,C1887,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM SFT REGEN MTRX REP REPLFRM,SUP-2139392,CDM,C1762,CPT,0278,RC,,,,both,,,5162.95,3355.92,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 35X35X0.8 MM SMOOTH STERILE SYNPOR,SUP-2837803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
GAUGE DEPTH CANN NCB-PH/PT,SUP-2472987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-4504908300,CDM,49083,CPT,0450,RC,,,73,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 4-7 MM SHRT TAPR SLDE GDE,SUP-2525465,CDM,C1768,CPT,0278,RC,,,,both,,,2279.45,1481.64,,,,,,,,,,,,,
ALLOGRAFT GRAFTLINK: D=8.0 L=67 MM,SUP-2816062,CDM,C1762,CPT,0278,RC,,,,both,,,6963.26,4526.12,,,,,,,,,,,,,
PIN FIX L20MM FEM TRNSVRS AUXILIARY MINI COMPR,SUP-2406910,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.92,111.75,,,,,,,,,,,,,
GRAFT BNE SUB 5CC SZ 17 7MM DEMIN CANC CHIP FRZ DRY FOR,SUP-2307252,CDM,C1713,HCPCS,0278,RC,,,,both,,,720.63,468.41,,,,,,,,,,,,,
PATCH EXT REF SZ 100 MM FOR CARTO 3 PMP SYS NS,SUP-2248584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
ALLOGRAFT BNE 30X10 MM FRZN IRRADIATED COSTAL CART,SUP-2866969,CDM,C1762,CPT,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7608,SUP-2525342,CDM,C1769,HCPCS,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
PLATE BONE SM RT MEDL CLMN LO PROF FOR 3.5MM SCR,SUP-2123111,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
BIT DRL 4X152 MM PRECICE,SUP-2312225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
SCREW BNE 6.5X85 MM RECON T25 STARDRV RECESS TI NS,SUP-2188991,CDM,C1713,HCPCS,0278,RC,,,,both,,,520.83,338.54,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 70X0.4 MM NEURO TI BLU STRL,SUP-2859910,CDM,C1713,HCPCS,0278,RC,,,,both,,,5184.77,3370.10,,,,,,,,,,,,,
GRAFT HUM TISS 7X5 CM GENTRIX MTRX +,SUP-2106480,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
PATCH BIOLOGICAL BOVINE PERICARDIUM NERVE 10CM LENGTH 2CM WI,SUP-2821558,CDM,C1763,HCPCS,0278,RC,,,,both,,,326.62,212.30,,,,,,,,,,,,,
SHUNT SURG DENV DBL VLV,SUP-2153836,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2766.34,1798.12,,,,,,,,,,,,,
SHEATH URET ACCS L45CM DIA107FR HYDRPHLC FLX,SUP-2170222,CDM,C1894,HCPCS,0272,RC,,,,both,,,603.51,392.28,,,,,,,,,,,,,
MESH HERN M W1.3XL1.6IN INGUINAL POLYPR NONABSORBABLE,SUP-2125790,CDM,C1781,HCPCS,0278,RC,,,,both,,,479.16,311.45,,,,,,,,,,,,,
ANCHOR SUTURE 5.5MM WITH 3 NO 2 SUTURES HI-FI NEEDLE CROSSFT,SUP-2824898,CDM,C1713,HCPCS,0278,RC,,,,both,,,1545.32,1004.46,,,,,,,,,,,,,
SET CATH CATH L 20 CM DIA 5 FR GUIDEWIRE 0.018 IN NDL L 7 CM,SUP-2884236,CDM,C1751,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BONE L MINI 2 MM RIGHT MANDIBULAR LOCKING MALLEABLE TI,SUP-2838416,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.37,738.64,,,,,,,,,,,,,
GRAFT VASC DYNAFLO L 80 CM DIA 7 MM EPTFE CARBON PERIPH STR,SUP-2126824,CDM,C1768,CPT,0278,RC,,,,both,,,6369.80,4140.37,,,,,,,,,,,,,
CLIP ANEUR MIC STR 9MM TEMP - 9MM,SUP-2243952,CDM,C1889,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
KIT HAD ADMIN CHRONIC SIDE H INTRO NDL J STR GWIRE SHTH INJ,SUP-2283955,CDM,C1881,HCPCS,0278,RC,,,,both,,,691.46,449.45,,,,,,,,,,,,,
SCREW BNE LCK 3.5X40 MM ST SS NS,SUP-2184250,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.99,295.74,,,,,,,,,,,,,
PLATE BONE CONTOUR MESH 200X200X0.6 MM RECONSTRUCTION TITANI,SUP-2837714,CDM,C1713,HCPCS,0278,RC,,,,both,,,15821.83,10284.19,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM CORT DST VOLAR RAD TI LOK FULL,SUP-2340168,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.58,155.73,,,,,,,,,,,,,
SURFACE ARTC THK10MM KNEE PUR UHMWPE CRUC RET MOLD REG,SUP-2201264,CDM,C1776,CPT,0278,RC,,,,both,,,3714.62,2414.50,,,,,,,,,,,,,
PACK PROC TX2 ULTRASONIC SURG ASPIR TISS REM SYS,SUP-2384733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
HC Revasc Lithotr-Ather Tib/Per,PX-4810977400,CDM,C9774,CPT,0481,RC,,,,both,,,57405.00,37313.25,,,,,,,,,,,,,
PLATE BNE TIB NEUT 4.5X82 MM LT LAT PROX 4 HOLE LCK LP STRL,SUP-2185711,CDM,C1713,HCPCS,0278,RC,,,,both,,,4539.06,2950.39,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA28 MM POLYESTER GEL,SUP-2385054,CDM,C1768,CPT,0278,RC,,,,both,,,1591.51,1034.48,,,,,,,,,,,,,
COMPONENT FEM KNEE UNI UNISX PRI CEM STEMLESS N POR N BEAD,SUP-2208918,CDM,C1776,CPT,0278,RC,,,,both,,,7470.06,4855.54,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X25X1.5 MM 4 HOLE FRAC TI LEVEL 1,SUP-2469689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1337.86,869.61,,,,,,,,,,,,,
HC Sacrum and Coccyx Min 2 Views,PX-3207222000,CDM,72220,CPT,0320,RC,,,,both,,,665.00,432.25,,,,,,,,,,,,,
STYLET GUID PRECALIBRATED INCORPORATED PASS MRK PLT DISP,SUP-2150267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CARD AIRBAG W 67 X H 55 MM D 13 MM 30 J,SUP-2138012,CDM,C1721,HCPCS,0275,RC,,,,both,,,56303.34,36597.17,,,,,,,,,,,,,
GUIDEWIRE ORTH L9MM DIA1MM 15DEG D9MM BNE CHN NIT DISP FOR,SUP-2123633,CDM,C1769,HCPCS,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
PLATE BONE L134MM 10 H STRL RT LAT PROX TIB S STL FOR 3.5MM,SUP-2349727,CDM,C1713,HCPCS,0278,RC,,,,both,,,11330.38,7364.75,,,,,,,,,,,,,
SEED BRACHYTHERAPY STRND PROST C4 MRK,SUP-2247305,CDM,C2642,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
POST ORTH MOD TRABECULAR MTL ALLIANCE,SUP-2450139,CDM,C1776,CPT,0278,RC,,,,both,,,1116.27,725.58,,,,,,,,,,,,,
BRIDGE RIB FIX POST L 23 MM SHRT LCK NS ADVANTAGERIB,SUP-2908966,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SCREWDRIVER SURG AO SHFT T2 RECON,SUP-2484859,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
BIT DRL L125MM OD1.6MM PILOT TWST CHK END DISP FOR 2MM LAG,SUP-2366419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.04,332.18,,,,,,,,,,,,,
SCREW BNE L50MM DIA6MM CORT ST NONCANNULATED NONLOCKING,SUP-2377556,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.78,565.36,,,,,,,,,,,,,
PLATE BONE L246MM 15 H RT PROX HUM LCK FOR 4.5MM SCR,SUP-2348280,CDM,C1713,HCPCS,0278,RC,,,,both,,,17421.98,11324.29,,,,,,,,,,,,,
SHEATH INTRO FUBUKI XF L 80 CM 2.70 MM 2.28 MM L 8 CM STR,SUP-2879073,CDM,C1887,HCPCS,0272,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
CONNECTOR SHLDR IMPL,SUP-2204887,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SYSTEM DRAINAGE 50-80 MM H2O 290-400 MM H2O TALL BRN,SUP-2851475,CDM,C1729,HCPCS,0272,RC,,,,both,,,4206.12,2733.98,,,,,,,,,,,,,
PUNCH AORT L8IN DIA4MM S STL THERMOPLASTIC ROT CUT ACT,SUP-2330983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,82.43,53.58,,,,,,,,,,,,,
PLATE FIXATION STERNAL HEX 6 HOLES,SUP-2849060,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.73,898.12,,,,,,,,,,,,,
PLATE BONE L86MM 5 H W RT DSTL RAD VOLAR S STL LCK FOR,SUP-2348744,CDM,C1713,HCPCS,0278,RC,,,,both,,,8086.60,5256.29,,,,,,,,,,,,,
STEM FEM L255MM DIA13X18MM NK L36+21+8MM XLN L HIP BOW TI,SUP-2253198,CDM,C1776,CPT,0278,RC,,,,both,,,18071.33,11746.36,,,,,,,,,,,,,
ALLOGRAFT BNE PWD 30 CC FD IRRADIATED CANC,SUP-2867089,CDM,C1762,CPT,0278,RC,,,,both,,,1369.20,889.98,,,,,,,,,,,,,
PLATE BNE ORBIT FLR SM 3D,SUP-2363658,CDM,C1713,HCPCS,0278,RC,,,,both,,,4281.36,2782.88,,,,,,,,,,,,,
HIP IMPLANT SYSTEM 4.75MM SPEEDBRIDGE,SUP-2816786,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
COLLAR EXTRIC AD ADJUSTABLE STFFNK SEL,SUP-2120410,CDM,L0172,HCPCS,0272,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
PLATE LOCK NARROW 10 HOLES,SUP-2757493,CDM,C1713,HCPCS,0278,RC,,,,both,,,4340.74,2821.48,,,,,,,,,,,,,
DIPHENHYDRAMINE HCL 25 MG PO CAPS,RX-2509,CDM,6370000000,HCPCS,0637,RC,71399-1027-01,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
CAP ORTH H15MM TIB NAIL,SUP-2208071,CDM,C1776,CPT,0278,RC,,,,both,,,620.97,403.63,,,,,,,,,,,,,
KIT SUT DEV RELD ENDOSCP FAST COMB COR-KNOT MINI,SUP-2265308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
STAPLER INT L80MM OPN 3X385MM B SHP CLSR 15MM BLU TI 2 DBL,SUP-2283285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.94,256.06,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 4-7 MM OFFSET RNG L 50 CM EPTFE,SUP-2396108,CDM,C1768,CPT,0278,RC,,,,both,,,3604.72,2343.07,,,,,,,,,,,,,
GRAFT BNE HEMI PAT TISS,SUP-2391737,CDM,C1713,HCPCS,0278,RC,,,,both,,,4838.74,3145.18,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC,SUP-2382018,CDM,L4360,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SUPPORT ORTHOT ANK PEDIATRIC KNEE CUST PLAS,SUP-2435637,CDM,L2035,HCPCS,0272,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
STENT TRACHBRONCH UFLX EXP L 20 MM DIA 8 MM COMPR DIA 7 MM,SUP-2149825,CDM,C1876,HCPCS,0278,RC,,,,both,,,7875.28,5118.93,,,,,,,,,,,,,
KNIFE SURG HOUGH WHIRLYBIRD 2 LT LIGHT CRV MICROFRANCE,SUP-2461334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.58,253.88,,,,,,,,,,,,,
KYPHOPLASTY TRAY 20/3 1 STP OSTEO INTRO CDS KYPHOPAK XPANDER,SUP-2665123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12898.49,8384.02,,,,,,,,,,,,,
KIT CATHETER 135FR 13CM PRECRV MAHRK ELITE,SUP-2174262,CDM,C1750,HCPCS,0278,RC,,,,both,,,237.67,154.49,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X14 MM ST STRL LTX,SUP-2861158,CDM,C1713,HCPCS,0278,RC,,,,both,,,252.27,163.98,,,,,,,,,,,,,
BIT DRL TWST 0.25 IN 6.4 MM,SUP-2455477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
SAW SURG STD HUM DST SOLAR,SUP-2372593,CDM,C1713,HCPCS,0278,RC,,,,both,,,2090.74,1358.98,,,,,,,,,,,,,
WASHER ORTHOPEDIC LG 7.3 MM 13 MM OSTEOPOROTIC BNE SCREW TI,SUP-2468587,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.76,162.34,,,,,,,,,,,,,
BLOCK CUT SZ 4 DST FEM R MED CT APPRCH NONSTERILE MYKNEE,SUP-2267755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STAPLE BNE FIX W11XH10XL10MM DIA1.5MM NIT FIX LO EXT 2 PRNG,SUP-2190916,CDM,C1713,HCPCS,0278,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
ARMSTRONG R VENT TUBE 1.14 MM ID FLUOROPLASTIC 50 PACK,SUP-2491362,CDM,L8699,HCPCS,0278,RC,,,,both,,,36.80,23.92,,,,,,,,,,,,,
COMPONENT FEM SZ C KNEE POLYETH SEG SYS,SUP-2200505,CDM,C1776,CPT,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
ROD IM 25 CM FEM OSS ARCOS,SUP-2441767,CDM,C1713,HCPCS,0278,RC,,,,both,,,7714.98,5014.74,,,,,,,,,,,,,
ROD SPNL 2 MM W/ SPACER SZR GRN ORTHOFLEX,SUP-2319095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
FORCEPS SURG L7 3 4IN TISS HEMSTAT INSUL LOVELACE,SUP-2161919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.28,331.03,,,,,,,,,,,,,
HEAD FEM DIA32MM +9MM OFFSET 12/14 TAPR HIP CERAMIC TI SL,SUP-2251105,CDM,C1776,CPT,0278,RC,,,,both,,,5646.98,3670.54,,,,,,,,,,,,,
CATHETER ETER ACCURACY FULL BA VENT INTRODUCING ROD 15CM,SUP-2243869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9122.55,5929.66,,,,,,,,,,,,,
CATHETER CARD ABLATION LASSO 2515 NAV ECO L 115CM SPC2-6-2MM,SUP-2248612,CDM,C1732,HCPCS,0272,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
KIT HAD L40CM (SUB OPTION 2283941) CATH SYMMETRIC TIP 2 LUMN CATH SFTY SHTH TISS,SUP-2283920,CDM,C1750,HCPCS,0278,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
SET SCR IMPL HDLSS COMPR 3.0 MM,SUP-2177075,CDM,C1713,HCPCS,0278,RC,,,,both,,,93264.66,60622.03,,,,,,,,,,,,,
STEM FEM STD OFFSET 0 12/14 105 MM HIP PROS TAPR COCR CPT,SUP-2439514,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
NEEDLE BX REUSE FRANK SILVERMAN 18GA 15CM,SUP-2161880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.40,275.86,,,,,,,,,,,,,
SHEATH DIL TAPR 20 FRX17 CM KINK-RESISTANT PTFE AMPLATZ,SUP-2481236,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.74,87.58,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 1000 MG MATRISTEM MICROMATRIX,SUP-2106479,CDM,Q4118,HCPCS,0636,RC,,,,both,,,8330.42,5414.77,,,,,,,,,,,,,
PATCH HERN SM DIA3IN UNCOATED MFIL PROPYLENE CIR ABSRB BARR,SUP-2125894,CDM,C1781,HCPCS,0278,RC,,,,both,,,1253.80,814.97,,,,,,,,,,,,,
KIT BNE CEMENT KNEE MIXING SYS CANC NOZ TIB PRESSURIZER TIP,SUP-2884226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.99,215.79,,,,,,,,,,,,,
STRAP SPLNT 2INX18IN WHT NYL D RNG HK AND LOOP ROLYAN,SUP-2324781,CDM,L3908,HCPCS,0272,RC,,,,both,,,9.73,6.32,,,,,,,,,,,,,
SPONGE GRV SIL 3.0MMX5.0MMX80MM,SUP-2213496,CDM,L8610,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
COUPLER EXT FIX ROD TO TB COMPR DISTR COMP SYS HOFFMANN II,SUP-2372254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CATHETER ART L110CM OD7.5FR HPRN VIP LUMN THRMDIL BAL INFL,SUP-2214324,CDM,C1751,HCPCS,0278,RC,,,,both,,,538.89,350.28,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 35 A WITH CONTROL RESERVOIR SHUNT ASSIST,SUP-2821857,CDM,C1889,HCPCS,0278,RC,,,,both,,,9171.37,5961.39,,,,,,,,,,,,,
ANCHOR SUTURE L 14.7 MM DIA 5.5 MM PEEK SUTURETAPE FT STRL,SUP-2930462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1038.56,675.06,,,,,,,,,,,,,
PACEMAKER CARD W44XH43MM THK6MM PERM 2 CHMBR STD,SUP-2357345,CDM,C1785,HCPCS,0275,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
MESH HERN RECT 18X12 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855256,CDM,C1781,HCPCS,0278,RC,,,,both,,,56206.00,36533.90,,,,,,,,,,,,,
MATRIX BIO DIA 30 MM FISH SKIN SIL DERMAL ADH CIR FEN INTACT,SUP-2909249,CDM,Q4158,HCPCS,0636,RC,,,,both,,,18538.56,12050.06,,,,,,,,,,,,,
LEAD PACE MYOPORE BP 54 L 54 CM SIL BODY EPICARD BPLR,SUP-2138181,CDM,C1895,HCPCS,0275,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
PERIPHERAL ROTAPRO 1.25MM,SUP-2887219,CDM,C1724,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
DEVICE TORQ DIA0.018-0.038IN GRN ERGO 1 HND FOR PTFE GWIRE,SUP-2303480,CDM,C1769,HCPCS,0272,RC,,,,both,,,13.35,8.68,,,,,,,,,,,,,
PIN SPNL TEMP FIX SHORELINE ACS,SUP-2709643,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
HC NM Acute GI Bleed Study,PX-3417827800,CDM,78278,CPT,0341,RC,,,,outpatient,,,2106.00,1368.90,,,,,,,,,,,,,
HC So1 Mgmt Methylation Analysis,PX-3108128767,CDM,81287,CPT,0310,RC,,,,both,,,979.00,636.35,,,,,,,,,,,,,
KIT MON DETACH MPLR PRB EXTN CBL BALL TIP PRB DISP,SUP-2415825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SCREW BNE PEGGED 2.5X14 MM STRL LTX,SUP-2861113,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.89,214.43,,,,,,,,,,,,,
INSERT INTERSPINOUS FUS UNILINK 8MM TI,SUP-2205254,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
GRAFT BONE L50XW7XH5MM 1.75ML CANC DEMIN STRP STRL,SUP-2125420,CDM,C1713,HCPCS,0278,RC,,,,both,,,686.88,446.47,,,,,,,,,,,,,
PUTTY BONE GRAFT FACTOR 2.5ML PEPTIDE ENHANCED W/SYRINGE,SUP-2693633,CDM,C1713,HCPCS,0278,RC,,,,both,,,3601.58,2341.03,,,,,,,,,,,,,
LASER SURG VISION 1/SMART 532 FC SMRT LIO,SUP-2713732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,38370.80,24941.02,,,,,,,,,,,,,
HC Njx Aa&/Strd Ntrcost Nrv 1|BILATERAL PROCEDURE|PO,PX-3616442000,CDM,64420,CPT,0361,RC,,,50|PO,both,,,2230.00,1449.50,,,,,,,,,,,,,
IMP SYS BTB T-ROPE W/10.0MM FLIPCUTR II,SUP-2811951,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
FILTER SHUNT ID1.5MM 3.9U LN OUTLT PRT 2 HOLTER,SUP-2243796,CDM,C1729,HCPCS,0272,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
PLATE BNE L189MM THK3MM 10 H BILAT S STL STR LOK COMPR RECON,SUP-2185343,CDM,C1713,HCPCS,0278,RC,,,,both,,,1712.30,1112.99,,,,,,,,,,,,,
KIT SURG DRL KT STRL DISP UDRV 3,SUP-2883772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3343.16,2173.05,,,,,,,,,,,,,
ROD EXT FIX CONN MIC 35 MM HOFFMAN,SUP-2363267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
BUR SURG BALL LNG 3.2 MM FLUT FOR HD/HD-G1,SUP-2848162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.47,327.26,,,,,,,,,,,,,
PLATE BNE L107MM 3X8 H R S STL T SHP OBLQ ANG LOK COMPR FOR,SUP-2185848,CDM,C1713,HCPCS,0278,RC,,,,both,,,1220.99,793.64,,,,,,,,,,,,,
CASSETTE PHACO W/O TIP MAXVAC,SUP-2109639,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
SLING GYN TRNSVAG FIT OD2.7MM ADVNTG,SUP-2141794,CDM,C1771,HCPCS,0278,RC,,,,both,,,2424.71,1576.06,,,,,,,,,,,,,
BIO MEDICUS 15FR,SUP-2727840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.58,665.33,,,,,,,,,,,,,
BIT DRL RG NAILING SYS KT REQ FOR SH NAIL 4MM LEN 310MM,SUP-2315972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.79,252.06,,,,,,,,,,,,,
"HC Injection, Incobotulinumtoxin a, I Unit",PX-6360058800,CDM,J0588,CPT,0636,RC,,,,both,,,17.00,11.05,,,,,,,,,,,,,
DEVICE SUT W/ DEL TOOL KNOT PUSH DISP FIXATE,SUP-2138771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
MARKER ROBOTIC SYS PASS DISP FOR EXCELSIUSGPS ROBOTIC,SUP-2232050,CDM,A4648,CPT,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
CATHETER EP QPLR 4 MM TIP 7 FR,SUP-2356977,CDM,C1733,HCPCS,0272,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE DIA 7.5 MM SZ 2 CART ARAGONITE POROUS,SUP-2913229,CDM,C1763,HCPCS,0278,RC,,,,both,,,20724.00,13470.60,,,,,,,,,,,,,
BUR SURG DIAMOND X COARSE 4 MMX12 CM BALL SM BOR LEGEND,SUP-2627649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.46,266.15,,,,,,,,,,,,,
CATHETER ART 0.025 IN 7.5 FRX110 CM STD 5 LUMEN HEPCOAT LTX,SUP-2662678,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR TIP 035X4500 HYDRPHLC ZBR,SUP-2791202,CDM,C1769,HCPCS,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
EXPANDER TISS 2.6X1.7X0.8 IN KT CONT EXT DERMACLOSE XL,SUP-2391439,CDM,C1789,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
SCISSORS SURG L4.5IN BLK IRIS OPHTH SUP CUT RAZ EDGE,SUP-2162148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,478.13,310.78,,,,,,,,,,,,,
SCREW SPNL L12MM DIA3.5MM MINI CANC POST OCCIPITAL CERV,SUP-2254388,CDM,C1713,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
CAGE ACET DIA50MM RT TOT HIP TI REV CEM BURCH-SCHNEIDER,SUP-2212040,CDM,C1776,CPT,0278,RC,,,,both,,,8458.85,5498.25,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.4X5.5 MM PISTON TI,SUP-2457610,CDM,L8613,CPT,0278,RC,,,,both,,,540.24,351.16,,,,,,,,,,,,,
LP PLATE 4 X 4 HOLES SQRE SGMNTS 6MM 20MM SSTM CP TTNM,SUP-2681102,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.79,592.01,,,,,,,,,,,,,
ALLOGRAFT BNE 1CC MTRX VIABLE BIO4,SUP-2362223,CDM,C1889,HCPCS,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST STD NEW LTHR,SUP-2435732,CDM,L3455,HCPCS,0274,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
BASKET STONE 22 MM 2Q MECH LITHO,SUP-2475444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.41,353.87,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 40 CM DIA 8 MM EPTFE POLYESTER,SUP-2669797,CDM,C1768,CPT,0278,RC,,,,both,,,4498.02,2923.71,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA10 MM RNG L 30 CM EPTFE STR TW,SUP-2396172,CDM,C1768,CPT,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
ALLOGRAFT BNE 150 MM FD IRRADIATED TIB SHFT,SUP-2866918,CDM,C1762,CPT,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
STEM HUM CMNTLS 6.5X180 MM SHLDR REVERSED AEQUALIS,SUP-2715661,CDM,C1776,CPT,0278,RC,,,,both,,,10121.79,6579.16,,,,,,,,,,,,,
IMPLANT BIO TISS L2.5CM ID4MM PERIPH NRV CLLGN,SUP-2378819,CDM,C9353,HCPCS,0278,RC,,,,both,,,3849.64,2502.27,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 14X11X5 MM FD LORDTC CORTICAL GRAFTECH,SUP-2791133,CDM,C1713,HCPCS,0278,RC,,,,both,,,3166.63,2058.31,,,,,,,,,,,,,
ASSEMBLY SHUNT SNAP NEONATAL 1.5 LT RESERVOIR DOME NDL DELT,SUP-2664458,CDM,C1889,HCPCS,0278,RC,,,,both,,,5038.10,3274.76,,,,,,,,,,,,,
PLATE BONE WALL 1.5X0.6 MM MEDIAL RIGHT TITANIUM NON STERILE,SUP-2838378,CDM,C1713,HCPCS,0278,RC,,,,both,,,4171.80,2711.67,,,,,,,,,,,,,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML PO SOLN,RX-141223,CDM,340b,HCPCS,0637,RC,75834-0280-30,NDC,,both,30,ML,1495.60,972.14,,,,,,,,,,,,,
CATHETER GUID GUIDELINER V3 L 150 CM DIA 6 FR RX L 25 CM,SUP-2383144,CDM,C1887,HCPCS,0272,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
LINER KERAMOS REPL POLY 28MMX48/50 MM,SUP-2217228,CDM,C1776,CPT,0278,RC,,,,both,,,3818.24,2481.86,,,,,,,,,,,,,
CATHETER DRAINAGE VENTRICULAR 10 FRX1.9 MMX35 CM CEREBROFLO,SUP-2427663,CDM,C1713,HCPCS,0278,RC,,,,both,,,2392.08,1554.85,,,,,,,,,,,,,
BLADE REPROC SHV GREAT WHITE LG HUB 4.8MM,SUP-2652963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,104.44,67.89,,,,,,,,,,,,,
HC So Arsenic,PX-3018217566,CDM,82175,CPT,0301,RC,,,,outpatient,,,125.00,81.25,,,,,,,,,,,,,
SPLINT DORSAL AFO SPLNT X RT W STRP,SUP-2163840,CDM,L4396,HCPCS,0274,RC,,,,both,,,97.28,63.23,,,,,,,,,,,,,
VISE EXT FIX INSUL MINI HM32,SUP-2517252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.03,326.97,,,,,,,,,,,,,
PLATE BNE L76MM BLDE W11.7XL30MM 90DEG 4 H ST BILAT S STL,SUP-2185434,CDM,C1713,HCPCS,0278,RC,,,,both,,,3363.69,2186.40,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 10.5 CM DIA 4.5 FR PTFE PERC,SUP-2127714,CDM,C1894,HCPCS,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
ADAPTER FEM SL +0MM OFFSET MTPHSEAL TI PORCOAT FOR PRESSFIT,SUP-2252607,CDM,C1776,CPT,0278,RC,,,,both,,,1544.41,1003.87,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X107 MM 6 HOLE SS LCP,SUP-2569359,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.64,346.87,,,,,,,,,,,,,
BAG BLD TRNSFUS CONSOLIDATED RT VENTRICULAR ASST DEV,SUP-2356016,CDM,Q0508,HCPCS,0272,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
GUIDE SURG LAPIDUS KT CUT NS DISP LAPIPLASTY,SUP-2893062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 20X20X4MM DEMIN CANC FILL MTRX CNFRM,SUP-2307023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1866.73,1213.37,,,,,,,,,,,,,
TRIAL PLATE STR 0.8 MM 10 HOLE,SUP-2525716,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
CATHETER DIAG 2.4FR ID0.017IN L150CM HYDRPHLC COAT MICCATH,SUP-2305460,CDM,C1887,HCPCS,0272,RC,,,,both,,,2755.35,1790.98,,,,,,,,,,,,,
PROBE RF L150MM ACT TIPL4MM OD17GA DISP COOLIEF,SUP-2237178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
GRAFT BNE MAR SM CONC,SUP-2163085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT FRZN IRRADIATED ACHILLES TEND,SUP-2867083,CDM,C1762,CPT,0278,RC,,,,both,,,4939.85,3210.90,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR CARDIOVERTER STD W/ 1 ACT FIX LD,SUP-2236357,CDM,C1721,HCPCS,0275,RC,,,,both,,,88610.80,57597.02,,,,,,,,,,,,,
SEGMENTAL VSS STEM 15MM X 190MM BOWED,SUP-2502504,CDM,C1776,CPT,0278,RC,,,,both,,,11812.68,7678.24,,,,,,,,,,,,,
BIT DRL QC 2.7X125 MM STRL,SUP-2563755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.53,221.34,,,,,,,,,,,,,
PLATE BNE L199MM 12 H BROAD COMPR RIG FOR 4.5MM SCR L FRAG,SUP-2411424,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA 75 UM 3 ML HYDRGEL POLYZENE MIC WHT,SUP-2139506,CDM,C1889,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X240 MM FRZN GAM PERONEUS LONGUS TEND,SUP-2866907,CDM,C1762,CPT,0278,RC,,,,both,,,3066.52,1993.24,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH 115CM 8FR D CRV,SUP-2248609,CDM,C1732,HCPCS,0278,RC,,,,both,,,9457.68,6147.49,,,,,,,,,,,,,
PLATE BONE L190MM NAR 9 H DPHSEAL PICCOLO COMP PLT SYS,SUP-2152550,CDM,C1713,HCPCS,0278,RC,,,,both,,,2619.64,1702.77,,,,,,,,,,,,,
GUIDEWIRE VASC SENTAI FIGHTER L 190 CM SPRING COIL L 18 CM,SUP-2140868,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND FNGR W/JT ELASTIC FABRICATED,SUP-2435765,CDM,L3766,HCPCS,0274,RC,,,,both,,,3498.56,2274.06,,,,,,,,,,,,,
WALKER PT M DIAB,SUP-2276716,CDM,L4387,HCPCS,0272,RC,,,,both,,,242.66,157.73,,,,,,,,,,,,,
GRAFT BNE CUBE 6X6X6 MM DBM CANC CONFORM FLX Q-PACK,SUP-2307018,CDM,C1713,HCPCS,0278,RC,,,,both,,,579.33,376.56,,,,,,,,,,,,,
SHUNT VENTRICULAR PUMP CHAMBER 5/30CM WATER WITHOUT RESERVOI,SUP-2821796,CDM,C1889,HCPCS,0278,RC,,,,both,,,7008.83,4555.74,,,,,,,,,,,,,
GRAFT BNE INJ 4 CC EXTREMITY PRO-DENSE,SUP-2759540,CDM,C1713,HCPCS,0278,RC,,,,both,,,4583.80,2979.47,,,,,,,,,,,,,
SCREW BNE NLCK 3X26 MM DBL STRT THRD STRL JPS LTX,SUP-2875249,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.35,217.98,,,,,,,,,,,,,
SHEATH INTRO BASE CAMP SS POLYMER 1 LUMEN ROTATING,SUP-2878101,CDM,C1887,HCPCS,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
STEM FEMORAL 115X17MM CONICAL TI DISTAL REVISION,SUP-2880911,CDM,C1776,CPT,0278,RC,,,,both,,,9185.44,5970.54,,,,,,,,,,,,,
CATHETER GUID L 90 CM DIA 6 FR MPC STRL,SUP-2154150,CDM,C1887,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
GRAFT BNE SCAFFOLD 1 CC OSTEOINDUCTIVE DBM EXPONENT,SUP-2424596,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
PLATE BNE BURR HOLE 1.5X18X0.5 MM CVR CONTOURED W/ DRN HOLE,SUP-2480056,CDM,C1713,HCPCS,0278,RC,,,,both,,,669.95,435.47,,,,,,,,,,,,,
COMPONENT FEM SZ 8 L POST KNEE NP PRI BICRUCIATE CEM STBL,SUP-2350309,CDM,C1776,CPT,0278,RC,,,,both,,,10487.60,6816.94,,,,,,,,,,,,,
CATHETER ETER CTRL VEN L90CM OD96FR ODSEC32MM ID16MM 1 LUMN,SUP-2126549,CDM,C1751,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
SPLINT WRST FA 6IN UNIV BLU L LOOP LOK W STAY COCK UP CANVS,SUP-2194434,CDM,L3809,HCPCS,0274,RC,,,,both,,,35.86,23.31,,,,,,,,,,,,,
GUIDEWIRE VASC L 220 CM DIA 0.035 IN TAPR L 4.5 CM FLPY TIP,SUP-2167796,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.28,25.53,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 90 CM DIA 8.5 FR CRV BEND 17 MM DIL,SUP-2616238,CDM,C1766,CPT,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RX 018 5/7 FRX135 CM 7X60 MM STERLING,SUP-2142544,CDM,C1725,HCPCS,0272,RC,,,,both,,,507.74,330.03,,,,,,,,,,,,,
HC Group Exercise (P),PX-4100023900,CDM,G0239,CPT,0410,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
COMPONENT SUBTALAR SZ 12MM BILAT ANK JT PLLA NONPOLYETHYLENE,SUP-2242688,CDM,C1776,CPT,0278,RC,,,,both,,,8089.90,5258.43,,,,,,,,,,,,,
BOLT EXT FIX CANN POST MT SCR SCHNZ FOR DISTRCTN,SUP-2179137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.01,503.11,,,,,,,,,,,,,
PLATE BONE COMPRESSION 2 MM MANDIBULAR 6 HOLE INTERMEDIATE L,SUP-2838408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1732.02,1125.81,,,,,,,,,,,,,
BIT DRL L L385MM DIA15.5MM W/O STP FLX QUIK CPL,SUP-2188303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1237.13,804.13,,,,,,,,,,,,,
SCREW SPNL FIX ANGLE 6.5X20 MM CANN FOR 5.5 MM ROD SHILLA,SUP-2630647,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.82,2883.93,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 3ML CA PHSPTE HA INJ CEM CRANIO,SUP-2366469,CDM,C1713,HCPCS,0278,RC,,,,both,,,2956.18,1921.52,,,,,,,,,,,,,
MIKAEEL 10 STRONG SICKLE KNIFE 26CM TTL,SUP-2707305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.97,549.23,,,,,,,,,,,,,
SCREW BONE L30MM DIA4.5MM PARTIALLY THRD HD M CANN,SUP-2225342,CDM,C1713,HCPCS,0278,RC,,,,both,,,772.22,501.94,,,,,,,,,,,,,
HANDPIECE ELECSURG ACESSA PROVU,SUP-2765141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL FLEXCATH CROSS L 65 CM DIA12 FR ACCS DIL,SUP-2882553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE L286MM 14 H L LAT DST PERIARTC FEM S STL LOK FOR,SUP-2410724,CDM,C1713,HCPCS,0278,RC,,,,both,,,4533.06,2946.49,,,,,,,,,,,,,
CATHETER VENTRICULAR BA IMPREG HERM,SUP-2666764,CDM,C1729,HCPCS,0272,RC,,,,both,,,374.04,243.13,,,,,,,,,,,,,
GUIDEWIRE ORTH TRCR PT 1 END 1.1X150 MM STRL,SUP-2789089,CDM,C1769,HCPCS,0272,RC,,,,both,,,1079.28,701.53,,,,,,,,,,,,,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,6370000000,HCPCS,0637,RC,16864-0680-03,NDC,,both,85,GR,26.10,16.96,,,,,,,,,,,,,
SUPPORT LO PROF LUM LSO VISTA 631,SUP-2123915,CDM,L0631,HCPCS,0272,RC,,,,both,,,629.41,409.12,,,,,,,,,,,,,
BLADE SHV L22.5CM DIA4MM 1500RPM LNG DBL CRV ANG TIP,SUP-2284158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1651.23,1073.30,,,,,,,,,,,,,
BLADE SCREWDRIVER LG 1.5X80 MM CROSS DRV LEVEL 1,SUP-2467370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,506.83,329.44,,,,,,,,,,,,,
HC CT Orbit/Ear/Fossa W/WO Contrast,PX-3517048200,CDM,70482,CPT,0351,RC,,,,inpatient,,,2630.00,1709.50,,,,,,,,,,,,,
KIT CATH W/ 4X20 TREVO XP RETRV AND CATLYST 6 CATH STROKE,SUP-2367910,CDM,C1757,HCPCS,0272,RC,,,,both,,,28295.80,18392.27,,,,,,,,,,,,,
COMPONENT STERILE LATEX TALAR XXSMALL RIGHT VERSION STAR,SUP-2879208,CDM,C1776,CPT,0278,RC,,,,both,,,20158.96,13103.32,,,,,,,,,,,,,
PENTOSAN POLYSULFATE SODIUM 100 MG PO CAPS,RX-12912,CDM,6370000000,HCPCS,0637,RC,50458-0098-01,NDC,,both,1,UN,53.90,35.03,,,,,,,,,,,,,
PLATE BNE L38MM THK33MM 3 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185125,CDM,C1713,HCPCS,0278,RC,,,,both,,,784.40,509.86,,,,,,,,,,,,,
GUAIFENESIN 200 MG PO TABS,RX-10144,CDM,6370000000,HCPCS,0637,RC,00904-5154-60,NDC,,both,1,UN,0.30,0.19,,,,,,,,,,,,,
PLATE BNE L77MM THK3MM 5 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1495.77,972.25,,,,,,,,,,,,,
GRAFT SYNTH TISS 10MMX20MMX50MM BLK BONE IMPL CA PHOS HA PRO,SUP-2413075,CDM,C1713,HCPCS,0278,RC,,,,both,,,5878.08,3820.75,,,,,,,,,,,,,
MESH BONE PTTSBRGH SM 03MM THK TTNM LATEX FREE MXLFCL,SUP-2676688,CDM,C1713,HCPCS,0278,RC,,,,both,,,1443.33,938.16,,,,,,,,,,,,,
SHAFT RMR L885MM MOD TRINKLE BIXCUT,SUP-2368274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1804.56,1172.96,,,,,,,,,,,,,
PLATE BONE L 2X2 H BX LO PROF W/ TAB FOR 1.5MM SCR CRAN FIX,SUP-2363625,CDM,C1713,HCPCS,0278,RC,,,,both,,,1025.02,666.26,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX THICK 20X20 CM MATRISTEM,SUP-2106501,CDM,Q4166,HCPCS,0636,RC,,,,both,,,33629.40,21859.11,,,,,,,,,,,,,
SET ART LN CATH 4FR L12CM 0.021IN POLY STR NDL HUB W/,SUP-2167819,CDM,C1751,HCPCS,0278,RC,,,,both,,,126.76,82.39,,,,,,,,,,,,,
STAPLER INT W25MM WHT TRNSOR CIR ANVIL W/ ADVANCING PROX,SUP-2283248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1119.63,727.76,,,,,,,,,,,,,
HC Inf Ea Add'l Hour Hyd,PX-2609636100,CDM,96361,CPT,0260,RC,,,,both,,,87.00,56.55,,,,,,,,,,,,,
IMPLANT HUM TISS L20-80CM DIA3-6MM SAPH VEIN CRYOPRESERVED,SUP-2175273,CDM,C1762,CPT,0278,RC,,,,both,,,30263.32,19671.16,,,,,,,,,,,,,
SCREW BONE SPNL POLYAX REVERE 4X25 MM,SUP-2228088,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 80 MM DIA 8 MM DEL SHTH 5ML,SUP-2936835,CDM,C1713,HCPCS,0278,RC,,,,both,,,11184.68,7270.04,,,,,,,,,,,,,
HC Fluoro Guidance for Needl Plac,PX-3207700200,CDM,77002,CPT,0320,RC,,,,both,,,936.00,608.40,,,,,,,,,,,,,
PIN SKULL DISPOSIBLE CH STL 36/BX,SUP-2243874,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.20,22.88,,,,,,,,,,,,,
WIRE FIX 1.25 MM 80 MM TROCAR TIP SS KIRSCHNER,SUP-2653534,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.52,36.09,,,,,,,,,,,,,
ALLOGRAFT BNE XS 1 CC DBM FIBER OSTEOSTRAND,SUP-2731812,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 7 FR SPC 2-8-2 MM,SUP-2877986,CDM,C1730,HCPCS,0272,RC,,,,both,,,639.78,415.86,,,,,,,,,,,,,
STRIP INT STPL CLLGN MTRX W/ VERIT PSD 6 FIRING COMPATIBLE,SUP-2130379,CDM,C1713,HCPCS,0278,RC,,,,both,,,541.37,351.89,,,,,,,,,,,,,
PROBE SURG JAKO 2 MM 300 MM LARYNGEAL STR,SUP-2458295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.58,312.38,,,,,,,,,,,,,
SYSTEM IMPL TEND 4.75MM SWIVELOCK BAN SUT LASSO W/ NIT WIRE,SUP-2122836,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
CATHETER CV KT 0.018 IN PEDIATRIC 4 FRX8 CM DL STR SFT TIP,SUP-2763362,CDM,C1751,HCPCS,0278,RC,,,,both,,,387.48,251.86,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSOSTAR NAV L 115 CM DIA 7 FR,SUP-2248923,CDM,C1732,HCPCS,0278,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
BODY RAD SZ 1 12MM RT WR FOR FX SYS MAESTRO,SUP-2407361,CDM,C1776,CPT,0278,RC,,,,both,,,11282.02,7333.31,,,,,,,,,,,,,
NEEDLE ASPIR 25 GAX80 MM ROUNDED W/O A SIDE HOLE EZ SHOT 3 +,SUP-2460303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
SET INTRO 12FR L37CM SHTH L32CM UROLOGY 2 KNB PEEL AWAY,SUP-2171217,CDM,C1894,HCPCS,0272,RC,,,,both,,,176.34,114.62,,,,,,,,,,,,,
HEAD HUM H17MM DIA48MM TI STD OFFSET PRI FOR SHLDR FX SYS,SUP-2123279,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
COIL EMB COMPLX 7 MMX30 CM DETACHABLE COMPLX ORBIT GALAXY,SUP-2427713,CDM,C1713,HCPCS,0278,RC,,,,both,,,6208.35,4035.43,,,,,,,,,,,,,
MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN,RX-137341,CDM,J3475,HCPCS,0636,RC,44567-0410-24,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
KIT ACC W/ QUIK CONN SUTURELESS WIND CONNOR L30CM TBNG BLNT,SUP-2138899,CDM,C1815,HCPCS,0278,RC,,,,both,,,4507.47,2929.86,,,,,,,,,,,,,
ALLOGRAFT BNE FD IRRADIATED HUM SHFT,SUP-2867170,CDM,C1762,CPT,0278,RC,,,,both,,,7731.94,5025.76,,,,,,,,,,,,,
BLADE RETRACTOR 3 IN HIP STD T BAR HNDL SELF RET,SUP-2242479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1094.92,711.70,,,,,,,,,,,,,
DEFIBRILLATOR CARD RESYNCH THER X4 CRT-D VIGILANT,SUP-2149218,CDM,C1882,HCPCS,0275,RC,,,,both,,,61638.20,40064.83,,,,,,,,,,,,,
CATHETER NEPHSTMY 24FR L12CM SHTH L17CM PTFE HI PRSS LO PROF,SUP-2139712,CDM,C1729,HCPCS,0272,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
GRAFT BIO TISS 4X4CM THK04 10MM UNMESHED ACELLULAR DERM,SUP-2362227,CDM,C1763,HCPCS,0278,RC,,,,both,,,4657.25,3027.21,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 13 MM DIA 5 MM CATH L 80 CM DIA 8 FR,SUP-2159094,CDM,C1877,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC L Hrt Cath Trnsptl Puncture,PX-4819346200,CDM,93462,CPT,0481,RC,,,,outpatient,,,27322.00,17759.30,,,,,,,,,,,,,
BRACE KNEE 17 27IN R L UNIV FIT UPTO 305IN THGH T SCP,SUP-2150870,CDM,L1810,HCPCS,0274,RC,,,,both,,,290.23,188.65,,,,,,,,,,,,,
SCREW BNE 4.5X55 MM 5TH METATRSL JONES UNION SYS,SUP-2610083,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
PLATE BNE T 2.7 MM 6 HOLE NS FPS LTX,SUP-2856837,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0258,RC,00264-7520-00,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
GRAFT NRV L15MM DIA1-2MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124846,CDM,C1763,HCPCS,0278,RC,,,,both,,,8499.98,5524.99,,,,,,,,,,,,,
PPICC PROVENA SOLO 3F SLEEVE,SUP-2613533,CDM,C1751,HCPCS,0278,RC,,,,both,,,535.87,348.32,,,,,,,,,,,,,
SUTURE ULTRATAPE SZ 2 NONABSORBABLE BLU 72203896,SUP-2341898,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.73,136.97,,,,,,,,,,,,,
TRAY CATH L20CM OD7FR 3 LUMN CTRL VEN CATH VES DIL GWIRE,SUP-2383948,CDM,C1751,HCPCS,0278,RC,,,,both,,,167.46,108.85,,,,,,,,,,,,,
SCREW SPNL TRANSITION RAIL 4.5X500 MM TI MESA RAIL 4D,SUP-2538576,CDM,C1713,HCPCS,0278,RC,,,,both,,,6929.51,4504.18,,,,,,,,,,,,,
SCREW BNE L45MM OD5MM TI LO PROF IMPL FOR BASEPLT VERSO,SUP-2404643,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BNE STR 4 HOLE STRATUM,SUP-2475976,CDM,C1713,HCPCS,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
COVER BUR H DIA10MM CRANIOMAXILLOFACIAL PLT LO PROF W/ TAB,SUP-2366205,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.49,436.47,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA2.7 MM NLCK NS LEOS,SUP-2931322,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.89,222.88,,,,,,,,,,,,,
COIL VASC AZUR L 20 CM DIA 8 MM MICROCATHETER 0.018 IN LOOP,SUP-2385434,CDM,C1889,HCPCS,0278,RC,,,,both,,,2426.44,1577.19,,,,,,,,,,,,,
PLATE BNE RT PELV QUADRILATERAL SURF,SUP-2518355,CDM,C1713,HCPCS,0278,RC,,,,both,,,3890.46,2528.80,,,,,,,,,,,,,
MARKER BREAST TUMARK PROFESS Q FOR BREVERA STD,SUP-2662948,CDM,A4648,CPT,0278,RC,,,,both,,,245.61,159.65,,,,,,,,,,,,,
HC Coronary Artery Cath WO Graft,PX-4819345400,CDM,93454,CPT,0481,RC,,,,both,,,10999.00,7149.35,,,,,,,,,,,,,
ANCHOR SUTURE 4.5 MM ACHILLES REP KT CSL FOOTPRINT ULTRA PK,SUP-2848637,CDM,C1713,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
HC Assay of Magnesium,PX-3018373500,CDM,83735,CPT,0301,RC,,,,both,,,122.00,79.30,,,,,,,,,,,,,
SCREW BNE 2X7 MM CNTRDRV,SUP-2262661,CDM,C1713,HCPCS,0278,RC,,,,both,,,118.44,76.99,,,,,,,,,,,,,
PLATE BNE 50 MM CAGE TCP,SUP-2538160,CDM,C1713,HCPCS,0278,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
SPACER SPNL W20XH7-14XL60MM ELSA,SUP-2228771,CDM,C1821,HCPCS,0278,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
COLLAR TRACH H2 1/4IN SM PHIL,SUP-2120429,CDM,L0172,HCPCS,0274,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
MESH SURG W15XL19CM THK1MM EPTFE BIOMATERIAL OVL ANTIMIC,SUP-2395341,CDM,C1781,HCPCS,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
PEAK FX PLATE 3 HOLE NS,SUP-2487949,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
LINAGLIPTIN 5 MG PO TABS,RX-108630,CDM,6370000000,HCPCS,0637,RC,00597-0140-61,NDC,,both,1,UN,78.80,51.22,,,,,,,,,,,,,
CLASSIC SPCNDR PL 90 10SL,SUP-2820713,CDM,C1713,HCPCS,0278,RC,,,,both,,,5497.67,3573.49,,,,,,,,,,,,,
CATHETER EP H LG CRV 5 MM 1 MM 7 FRX110 CM,SUP-2357429,CDM,C1730,HCPCS,0272,RC,,,,both,,,1858.85,1208.25,,,,,,,,,,,,,
HC Pt Estim-Manual Each 15 Min,PX-4209703200,CDM,97032,CPT,0420,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
SHUNT VALVE M BLUE  ZERO GRAVITATIONAL,SUP-2665172,CDM,C1889,HCPCS,0278,RC,,,,both,,,13354.01,8680.11,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM CRANIOMAXILOFACIAL LNG DOG BNE 15-730,SUP-2936399,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
DILATOR VASC DIA0.145IN ROT SHTH DISP TIGHTRAIL SUB-C,SUP-2353167,CDM,C1894,HCPCS,0272,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 2 215CM 0.014IN SEG 35CM STR PLAT,SUP-2716233,CDM,C1769,HCPCS,0272,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
CONNECTOR SPNL FOR 55 6MM ROD TETHERING SYS TRANSLACE,SUP-2417656,CDM,C1713,HCPCS,0278,RC,,,,both,,,3877.90,2520.63,,,,,,,,,,,,,
ARM EXT FIX ACTIVATION 60 MM SNAKE SS TI RESORB XG,SUP-2489183,CDM,C1713,HCPCS,0278,RC,,,,both,,,3646.61,2370.30,,,,,,,,,,,,,
PLATE BNE 2.7X52 MM 6 HOLE SS DCP,SUP-2569128,CDM,C1713,HCPCS,0278,RC,,,,both,,,272.87,177.37,,,,,,,,,,,,,
KIT HEMO DYLS OR HD ADMIN CATH 2 LUMN POLYUR CHRONIC HI FLO,SUP-2174239,CDM,C1894,HCPCS,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BNE L160MM 8 H L MED DST HUM S STL VAR ANG FOR,SUP-2177586,CDM,C1713,HCPCS,0278,RC,,,,both,,,3918.56,2547.06,,,,,,,,,,,,,
CATHETER ENDO M-110S TIP SINUS GUID RELIEVA,SUP-2106356,CDM,C1887,HCPCS,0272,RC,,,,both,,,981.25,637.81,,,,,,,,,,,,,
STENT NEURO SURPS EVOLVE L 12 MM DIA 5 MM COCR PLAT FLO,SUP-2745358,CDM,C1889,HCPCS,0278,RC,,,,both,,,42898.68,27884.14,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA10 MM EPTFE STR STD WALL N RING,SUP-2396439,CDM,C1768,CPT,0278,RC,,,,both,,,2753.78,1789.96,,,,,,,,,,,,,
PLATE BONE MINI L37MM STR,SUP-2364911,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.52,184.94,,,,,,,,,,,,,
PLATE BONE THK0.8MM HND H LCK COMPR BILAT MALL FOR 1.5/2.3MM,SUP-2107079,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
BIT DRL L7IN DIA0.25IN N RADPQ W/O STP REUSE,SUP-2412568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.77,590.05,,,,,,,,,,,,,
VITAMIN A 3 MG (10000 UT) PO CAPS,RX-149955,CDM,6370000000,HCPCS,0637,RC,00904-2085-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SAW SURG JOS 7.5 INX38 MM NSL STR MICROFRANCE,SUP-2464445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.79,391.81,,,,,,,,,,,,,
BLADE RETRCT W2.5XL5 5/8IN HARR BKWALT,SUP-2382390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1393.75,905.94,,,,,,,,,,,,,
PLATE BONE 2.7/3MM SCR H DIA 45MM LEN YEL N COMPR C RT 5 H,SUP-2242906,CDM,C1713,HCPCS,0278,RC,,,,both,,,2180.01,1417.01,,,,,,,,,,,,,
GRAFT BIO TISS W16XL20CM THK18 4MM ACELLULAR DERM MTRX ULT,SUP-2307500,CDM,Q4128,HCPCS,0636,RC,,,,both,,,29660.25,19279.16,,,,,,,,,,,,,
CATHETER ART LN 5.5FR L15CM 2 LUMN MIDLN PRSS INJ ARROWG+ARD,SUP-2120617,CDM,C1751,HCPCS,0278,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
SCREW BNE LNG THRD 5.5X55 MM,SUP-2315911,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
CEMENT BNE 40 GM RADIOPAQUE CONCORD,SUP-2595682,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
SCRAPER MEMBRN 27 CVD DISP GRIESHABER VITREOUS,SUP-2109657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
WEDGE TOE IMPL W20XH10XL20MM FT TI PEEK FOR EVANS OSTEOTMY,SUP-2417148,CDM,C1713,HCPCS,0278,RC,,,,both,,,5986.82,3891.43,,,,,,,,,,,,,
PLATE BNE L91MM 2 H NONSTERILE L PROX PERIARTC HUM S STL,SUP-2184283,CDM,C1713,HCPCS,0278,RC,,,,both,,,4666.35,3033.13,,,,,,,,,,,,,
ECHOTIP OPEN-END URETERAL CATHETER,SUP-2826943,CDM,C1758,HCPCS,0278,RC,,,,both,,,63.80,41.47,,,,,,,,,,,,,
KIT STPL BRDG 25MM 4 LEG 20MM MAX CLSR 7.1MM BME ELITE,SUP-2254043,CDM,C1713,HCPCS,0278,RC,,,,both,,,4574.92,2973.70,,,,,,,,,,,,,
SCREW BONE LOCKING 3.5MM DIA 85MML,SUP-2588247,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
THREADLOCK TRANSPORT DIST 50MM PREBENT RIGHT TI 6AL 4V,SUP-2669833,CDM,C1713,HCPCS,0278,RC,,,,both,,,17792.37,11565.04,,,,,,,,,,,,,
CATHETER THROMCTMY CLOTTRIEVER L 80 CM DIA11 FR DEPLOYED L,SUP-2417092,CDM,C1757,HCPCS,0272,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
EXTENSION NEUROSTIMULATOR L40CM OD38MM ID15MM 43MM SPC SGL,SUP-2278215,CDM,C1883,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
DEVICE FIX W 30 N ABSRB FASTENERS LAP PERMAFIX,SUP-2125763,CDM,C1713,HCPCS,0278,RC,,,,both,,,5432.20,3530.93,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 40 CM DIA 6 MM EPTFE CARBON STR N,SUP-2128778,CDM,C1768,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER GUID IMA 6 FRX55 CM RENAL SET VISTA BRT TIP,SUP-2659328,CDM,C1887,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
IMPLANT HUM TISS L 8 X W 4 CM AMNION/CHORION MEMBRN DEHYDR,SUP-2905524,CDM,C1762,CPT,0278,RC,,,,both,,,9429.42,6129.12,,,,,,,,,,,,,
CATHETER HD STR EXTN 12.5 FRX16 CM 3L TY MAHRK ELITE,SUP-2283972,CDM,C1752,HCPCS,0278,RC,,,,both,,,595.41,387.02,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7538,SUP-2525332,CDM,C1769,HCPCS,0272,RC,,,,both,,,675.95,439.37,,,,,,,,,,,,,
DRILL SURG CANN 2.7 MM PILOT QR NS LTX,SUP-2857935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
SPLINT HND RT REG FUNC POS ABDUCTN OPPOS THMB FIRM SUPP,SUP-2324560,CDM,L3906,HCPCS,0272,RC,,,,both,,,81.33,52.86,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 2 Y SHP XLN PLATE 12 PK,SUP-2936651,CDM,C1713,HCPCS,0278,RC,,,,both,,,48377.98,31445.69,,,,,,,,,,,,,
ORTHOPAEDIC INSTRUMENT KIT GEN II STRL DYNABUNION LTX,SUP-2866340,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INSRTN L 115 CM DIA 5 FR SPC,SUP-2475199,CDM,C1730,HCPCS,0272,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
CATHETER DRNGE 8.5FR L25CM GWIRE 0.038IN SGL LUMN HYDRPHLC,SUP-2168475,CDM,C1729,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STENT ESOPH EVOLUTION L 8 CM BODY DIA20 MM FLANGE DIA25 MM,SUP-2170564,CDM,C1874,HCPCS,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
PROBE LASER PRECIS 20 GA FIBER HND PC CRV PLAS EYELITE,SUP-2109737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2509.49,1631.17,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TAPR L 7 CM FLX TIP 2,SUP-2167729,CDM,C1769,HCPCS,0272,RC,,,,both,,,44.46,28.90,,,,,,,,,,,,,
GRAFT HUM TISS DIA16MM AMNIO TISS MEM DISK SHT AMNIOFIX,SUP-2305722,CDM,V2790,HCPCS,0274,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
CROWN DENT M PRI 3M DLR2 LO RT S STL,SUP-2322179,CDM,D6783,CPT,0278,RC,,,,both,,,19.28,12.53,,,,,,,,,,,,,
SHEATH INTRO 6FR L45CM NYL PTFE S STL HYDROPHILLIC STR CRSS,SUP-2385263,CDM,C1894,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
HEX DRIVER SHRT 2MM 6,SUP-2473819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
SET PMP CYL L22CM 0DEG BIOFLX SIL SCROT PENILE SYS INFL TCH,SUP-2165447,CDM,C1813,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
PLATE BNE L79MM 10 H OLECRANON TIM LO PROF MULTIPLANAR ARM,SUP-2411728,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 10 CM OD 6FR ID 0.087IN 0.035IN,SUP-2384840,CDM,C1894,HCPCS,0272,RC,,,,both,,,144.75,94.09,,,,,,,,,,,,,
CATHETER INTVASC 9.3FR L22CM RADPQ POLYUR FLX HEAT EXCHG,SUP-2416148,CDM,C1751,HCPCS,0278,RC,,,,both,,,1880.61,1222.40,,,,,,,,,,,,,
KIT INTRODUCER 9F INTROFLEX MAX BARRIER,SUP-2866712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.45,354.54,,,,,,,,,,,,,
SURGICAL LSR FBR 600/300 CONCL TIP W/ HNDPC W/ 2.5 CM EXTN,SUP-2164903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE DBL HK 1.5 MM 18 MM RT STELNICKI/MARCHETTO TI NS,SUP-2471608,CDM,C1713,HCPCS,0278,RC,,,,both,,,2583.00,1678.95,,,,,,,,,,,,,
GUIDEPIN ORTH L343MM DIA3.2MM FOR TRIGEN INTERTAN PROX LOK,SUP-2347058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,986.84,641.45,,,,,,,,,,,,,
SENNOSIDES 8.8 MG/5ML PO SYRP,RX-15168,CDM,340b,HCPCS,0637,RC,48433-0219-40,NDC,,both,5,ML,9.00,5.85,,,,,,,,,,,,,
BEAM FIX L75MM DIA6.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223945,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,PX-3606232300,CDM,62323,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
CURETTE SZ 6 MCELROY,SUP-2342356,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PASSER CATH L36CM SHT MAL DISP FOR HYDROCEPHALUS SYS,SUP-2243782,CDM,C1894,HCPCS,0272,RC,,,,both,,,377.21,245.19,,,,,,,,,,,,,
TUBE T SUP SFT SIL 12MM,SUP-2381504,CDM,L8699,HCPCS,0278,RC,,,,both,,,153.29,99.64,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7030,HCPCS,0258,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
DEVICE FIX 5MM BTTN DIR W/O LOOP FEM ENDOBTTN,SUP-2341083,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM LT VA LCK COMPR SS STRL VA-LCP,SUP-2750793,CDM,C1713,HCPCS,0278,RC,,,,both,,,3397.86,2208.61,,,,,,,,,,,,,
BRACE KNEE T SCP POSTOP MEAS TAKEN 6IN ABV MID PAT 27-35IN,SUP-2150859,CDM,L1810,HCPCS,0272,RC,,,,both,,,303.95,197.57,,,,,,,,,,,,,
NAIL IM FEM STD SHT SET ITST,SUP-2861288,CDM,C1713,HCPCS,0278,RC,,,,both,,,24217.69,15741.50,,,,,,,,,,,,,
GRAFT BONE SUB 2.5CC DBM PUTTY W/ RPM,SUP-2415793,CDM,C9359,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
HC Assay of Osmolality Blood,PX-3018393000,CDM,83930,CPT,0301,RC,,,,outpatient,,,216.00,140.40,,,,,,,,,,,,,
NITROFURANTOIN MACROCRYSTAL 100 MG PO CAPS,RX-5593,CDM,6370000000,HCPCS,0637,RC,50268-0624-11,NDC,,both,1,UN,13.00,8.45,,,,,,,,,,,,,
HC Perq Trluml Coronary Mchnl Aspir Thrombectomy,PX-4819297300,CDM,92973,CPT,0481,RC,,,,outpatient,,,828.00,538.20,,,,,,,,,,,,,
SCREW BONE L26MM DIA5.7MM TI CANC NONCANNULATED LCK FULL,SUP-2106784,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
PLATE BNE T 2X18 MM 2 HOLE SS,SUP-2569097,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.71,87.56,,,,,,,,,,,,,
INJECTOR INTOCU LENS HNDPC MNRCH II,SUP-2110041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 45 CM OD 7 FR ID 2.3 MM GUIDEWIRE,SUP-2168689,CDM,C1894,HCPCS,0272,RC,,,,both,,,132.70,86.25,,,,,,,,,,,,,
GRAFT TISS FRZ DRY FIB WDG ACF 12 22MML 9 13MM 8MM THICKNESS,SUP-2307149,CDM,C1713,HCPCS,0278,RC,,,,both,,,1870.97,1216.13,,,,,,,,,,,,,
DOCUSATE SODIUM 100 MG PO CAPS,RX-2566,CDM,6370000000,HCPCS,0637,RC,00904-7183-61,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
STENT BILI L24MM 6FR 75CM CATH LEN 4MM DIAM AD GEN,SUP-2159196,CDM,C1876,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
PLATE BONE 1.5 MM CRANIOFACIAL REINFORCED FAN WITH EXPOSED F,SUP-2837806,CDM,C1713,HCPCS,0278,RC,,,,both,,,4648.77,3021.70,,,,,,,,,,,,,
BRACE ORTHOPEDIC ABDUCTN HIP,SUP-2388159,CDM,L1686,HCPCS,0272,RC,,,,both,,,4779.08,3106.40,,,,,,,,,,,,,
SEED BRACHYTHERAPY PALLADIUM-103 LD MICK CART THERASEED,SUP-2127063,CDM,C2641,HCPCS,0278,RC,,,,both,,,114.61,74.50,,,,,,,,,,,,,
PLATE BNE THK0.8MM 8 H HND T SHP TRILOK FOR 1.5MM SCR APTUS,SUP-2267904,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
RING CATRCT PMMA TYP 14C AX L24-28MM FOR NRML MYOPIC EYE,SUP-2224372,CDM,L8610,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X92 MM LT LAT DSTL 4 HOLE STRL VALCP,SUP-2789391,CDM,C1713,HCPCS,0278,RC,,,,both,,,2795.35,1816.98,,,,,,,,,,,,,
PLATE BNE L 167 MM SCREW DIA 4.5 MM 9 H NAR COMPR NLCK NS,SUP-2933752,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.22,1157.14,,,,,,,,,,,,,
INTRODUCER HOWELL BILI PUR 6FRX200CM,SUP-2169442,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
BASEPLATE TIB SZ 2 OXINIUM LT KNEE FEM TAPR HNG CEM LEGION,SUP-2346245,CDM,C1776,CPT,0278,RC,,,,both,,,14337.24,9319.21,,,,,,,,,,,,,
SHEATH TRANSSEPTAL L 72 CM DIA 8.5 FR CRV L 22 MM DIL L 95,SUP-2913158,CDM,C1766,HCPCS,0272,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
STENT GRFT VASC AFX L 88 MM DIA 16 MM IL LIMB EXT AAA,SUP-2217705,CDM,C1768,CPT,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
STEM RAD L20MM OD8MM 3 2MM CLLR LAT STD CLLR ASSEMB PGT,SUP-2370437,CDM,C1776,CPT,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
CLAMP REPROC TUBE TUBE MRI SAFE FIXATION,SUP-2679119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.64,286.42,,,,,,,,,,,,,
CATHETER HD STR 14 FRX20 CM SHT TERM 400 XL PRE CRV TAPR TIP,SUP-2266966,CDM,C1752,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SYSTEM EXTR BG 3400ML RNG DIA14CM BLLN L100MM DIA12MM,SUP-2119763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
COLLAR CERV H325XL19IN M TRACH CLS VELC CLSR CNTOUR LO DENS,SUP-2196900,CDM,L0120,HCPCS,0274,RC,,,,both,,,8.54,5.55,,,,,,,,,,,,,
PIN FIX L STR BILAT AXLE,SUP-2372339,CDM,C1713,HCPCS,0278,RC,,,,both,,,6975.45,4534.04,,,,,,,,,,,,,
PLATE BNE CRV MINI 28X14 MM CRANIOFACIAL 6 HOLE TRI SHP SAG,SUP-2460012,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.22,408.99,,,,,,,,,,,,,
SET SCR SPNL DIA5.5MM POST THORLUM TI BRK OFF FOR,SUP-2289459,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.06,293.19,,,,,,,,,,,,,
PLATE BNE L 77 MM 7 H RT DSTL VOLAR RADIAL NAR EXT STRL,SUP-2902421,CDM,C1713,HCPCS,0278,RC,,,,both,,,6498.01,4223.71,,,,,,,,,,,,,
INTRODUCER SET CARD LD PLCMNT STR 13CM LEN 10.5FR HEMSTAT,SUP-2280993,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
SCREW BNE CANN 6.5X55 MM 22 MM PARTIALLY THRD TI,SUP-2343351,CDM,C1713,HCPCS,0278,RC,,,,both,,,1873.17,1217.56,,,,,,,,,,,,,
INSERT TALAR SZ 4 THK13MM ANK POLYETH FOR PROPHECY INBONE 2,SUP-2397178,CDM,C1776,CPT,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
STEM TIB L150MM OD18MM TI KNEE PRI IMP GEN II,SUP-2346012,CDM,C1776,CPT,0278,RC,,,,both,,,3275.81,2129.28,,,,,,,,,,,,,
PLATE BNE ORTHODONTIC TRAUM CRSS DRV W WIRE ANCHR TI,SUP-2262927,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.57,222.67,,,,,,,,,,,,,
DEVICE ABLAT HIFU EMITTING TRANSDUCERS LO CELL PROF,SUP-2355880,CDM,C1713,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
LINER ACET OD56MM ID36MM CERAMIC PRI SNAP IN US BIOLOX FORTE,SUP-2345187,CDM,C1776,CPT,0278,RC,,,,both,,,5571.93,3621.75,,,,,,,,,,,,,
BLADE RETRACTOR ABD 4 IN BALFOUR FEN WIRE BLDE,SUP-2462089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.25,331.66,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 30 CM DIA 6 MM EPTFE CARBON STR,SUP-2761263,CDM,C1768,CPT,0278,RC,,,,both,,,1448.29,941.39,,,,,,,,,,,,,
PLATE BONE L64MM 7 HOLE LEFT LTRL DST HMRL TTNM LOW PRFLE RI,SUP-2487661,CDM,C1713,HCPCS,0278,RC,,,,both,,,3020.68,1963.44,,,,,,,,,,,,,
GRAFT SFT TISS BOV CLLGN 2.0 RECT 16CMX20CM SURGIMEND,SUP-2243682,CDM,C9360,HCPCS,0278,RC,,,,both,,,18086.40,11756.16,,,,,,,,,,,,,
PATCH VASC HEMGRD L 100 X W 100 MM THK 0.65 MM POLYESTER BOV,SUP-2535415,CDM,C1768,CPT,0278,RC,,,,both,,,790.34,513.72,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE 30X15X1 MM PRESERVON CORTICAL ORAGRAFT,SUP-2740943,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.60,745.29,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WEBST INSRTN L 115 CM DIA 5 FR,SUP-2248588,CDM,C1730,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
TRAY PICC MAXIMAL BARR 5FR 3 LUMN CATHETER W BIOPATCH PROTCT S1395108D5,SUP-2125700,CDM,C1751,HCPCS,0278,RC,,,,both,,,1138.60,740.09,,,,,,,,,,,,,
SHOULDER IMMOB ELAS XLG,SUP-2195042,CDM,L3650,HCPCS,0272,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
TAP BNE 4.5 MM FOR IMAGE GUID TSRH 3D,SUP-2290727,CDM,C1713,HCPCS,0278,RC,,,,both,,,2035.00,1322.75,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X4.5 MM 0.97 MM LT EAR SHEA CUP,SUP-2637797,CDM,L8613,CPT,0278,RC,,,,both,,,456.05,296.43,,,,,,,,,,,,,
KIT INSTR NDL 2 BVL ASSEMB PEDCL XPAK,SUP-2290651,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.23,316.05,,,,,,,,,,,,,
CLAMP CRAN L 20 MM LG NEURO BURR H STRL DISP LORENZ,SUP-2935434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
SCREW BNE 2.1X7 MM PDLLA STRL RESORB RX 520212704,SUP-2478188,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.58,130.38,,,,,,,,,,,,,
ROD SPNL THRD LNG 250 MM MR SAFE NS,SUP-2863452,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.21,134.69,,,,,,,,,,,,,
STAPLE BNE 50X10X13 MM EASYCLIP,SUP-2365477,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM AMNION PLCNTA MEMBRN 2 LAYR,SUP-2913329,CDM,C1762,CPT,0278,RC,,,,both,,,3950.12,2567.58,,,,,,,,,,,,,
GRAFT BNE SUB 5CC VI DIA48MM CA SULF PELLET RESRB PRELD,SUP-2399033,CDM,C1713,HCPCS,0278,RC,,,,both,,,1481.23,962.80,,,,,,,,,,,,,
CONNECTOR ADJ TRNSVRS,SUP-2415594,CDM,C1713,HCPCS,0278,RC,,,,both,,,680.81,442.53,,,,,,,,,,,,,
PLATE BNE L53MM THK1.2MM 2X8 H TI T FOR 2MM SCR,SUP-2191243,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.41,748.42,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 X W 4 CM PLCNTA MTRX MEMBRN MINIMALLY,SUP-2905502,CDM,C1762,CPT,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
PLATE BONE W12XL151MM THK1MM 9 H BILAT TI SEMI TBLR LO PROF,SUP-2190707,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.67,227.29,,,,,,,,,,,,,
GRAFT DURA W3XL3IN PURIFIED CLLGN MTRX REGEN DURAGN SECUR,SUP-2244020,CDM,C1713,HCPCS,0278,RC,,,,both,,,2651.64,1723.57,,,,,,,,,,,,,
CATHETER CV PRESSURE MONITORING TY 018 PEDIATRIC 3 FRX5 CM,SUP-2760024,CDM,C1751,HCPCS,0278,RC,,,,both,,,215.78,140.26,,,,,,,,,,,,,
FIXATOR BNE L LNG BNE ADJ,SUP-2188577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11104.20,7217.73,,,,,,,,,,,,,
HC Tcat Insj/Rpl Perm Ldls Pm,PX-3613327400,CDM,33274,CPT,0361,RC,,,,inpatient,,,56457.00,36697.05,,,,,,,,,,,,,
IMMOBILIZER SHLDR SLNG M,SUP-2276607,CDM,L3660,HCPCS,0274,RC,,,,both,,,10.52,6.84,,,,,,,,,,,,,
PACEMAKER CARD ELECTRD SPC 18 MM 0.8 CC VDD LEADLESS AUTO AV,SUP-2882756,CDM,C1786,HCPCS,0275,RC,,,,both,,,38370.80,24941.02,,,,,,,,,,,,,
PIN MXLFCL 1.6X7 MM PDLLA STRL SONICPIN RX,SUP-2457240,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.63,174.61,,,,,,,,,,,,,
SCREW BNE ANK 4X60 MM FOR COMPR FCPS TIBIAXYS,SUP-2609024,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.30,283.59,,,,,,,,,,,,,
CANN SCREW WASHER 10.0MM OD X 4.6MM ID,SUP-2639526,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PLATE BNE L77MM THK3.3MM 6 H BILAT S STL STR LIMIT CNTCT,SUP-2185131,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.32,583.91,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 4-7 MM LNG TAPR REINF,SUP-2525448,CDM,C1768,CPT,0278,RC,,,,both,,,704.27,457.78,,,,,,,,,,,,,
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,RX-4995,CDM,J1010,HCPCS,0636,RC,00009-3073-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH RENU L 54 MM DIA 36 MM SHTH 22 FR RVD,SUP-2170458,CDM,C1874,HCPCS,0278,RC,,,,both,,,16864.94,10962.21,,,,,,,,,,,,,
KIT PICC MAX BARR ANTIMICR/ANITTHROM PRELOAD 4.5FR X 55CM 1L,SUP-2864581,CDM,C1751,HCPCS,0278,RC,,,,both,,,823.72,535.42,,,,,,,,,,,,,
MESH HERN L24XW18CM THICKNESS 1MM EPTFE INTRA-ABDOMINAL,SUP-2125801,CDM,C1781,HCPCS,0278,RC,,,,both,,,2910.78,1892.01,,,,,,,,,,,,,
COUNTERSINK DRL SHT MINI EXTRM MTP PKT MASXLOCK,SUP-2400512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PLATE BONE 12 H BILAT MAND TI STR RIG NONCOMPRESSION,SUP-2191406,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
GRAFT DERM L10XW5CM THCKNESS 8 17MM ACELLULAR DERM HYDRATED,SUP-2307472,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4484.92,2915.20,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM 0.025 IN TIP L 3 MM PTFE FIX,SUP-2301917,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.23,18.35,,,,,,,,,,,,,
PLATE BONE W9XL37MM THK1.1MM 3 H DSTL ULN FIBULAR S STL 1/3,SUP-2343774,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.24,312.81,,,,,,,,,,,,,
STAPLER INT CIR 45 MM RELD BIOABSORBABLE REINF LN SEAMGRD,SUP-2485991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
HC Mech Rem/Obst GI Tube,PX-3614946000,CDM,49460,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
KIT CATH AD CTRL VEN CATH 7FR L6IN GWIRE 0.025IN POLYUR 3,SUP-2383292,CDM,C1751,HCPCS,0278,RC,,,,both,,,132.13,85.88,,,,,,,,,,,,,
POST EXT FIX CIR FEMALE 1 HOLE,SUP-2400606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.27,227.68,,,,,,,,,,,,,
PIN FIX SMOOTH TIP 2.5X200 MM STRL AEQUALIS PERFORM DISP,SUP-2715617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM SZ 4 CART ARAGONITE,SUP-2913320,CDM,C1763,HCPCS,0278,RC,,,,both,,,25591.00,16634.15,,,,,,,,,,,,,
BIT DRL TWST 1X30 MM 5 MM W/ STP DENT SS SONICWELD RX,SUP-2461242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.30,270.59,,,,,,,,,,,,,
KIT BNE GRFT SUB 5CC MINI BEAD RESRB OSTEOSET,SUP-2399041,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 5-6 CD 12 MM KNEE STRP GRN NXGN LPS,SUP-2201961,CDM,C1776,CPT,0278,RC,,,,both,,,2411.52,1567.49,,,,,,,,,,,,,
HC Neg Pressure Wnd <= 50 Sq Cm Disposable,PX-7619760700,CDM,97607,CPT,0761,RC,,,,outpatient,,,813.00,528.45,,,,,,,,,,,,,
BLADE STRPR L10MM KNEE FOR QUAD TEND GRFT CUT GUID DISP,SUP-2121715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
RESERVOIR VENTRICULAR DRAINAGE 8.5CM CATHETER LENGTH 14MM DI,SUP-2826645,CDM,C1889,HCPCS,0278,RC,,,,both,,,1681.94,1093.26,,,,,,,,,,,,,
GRAFT BNE L7CMXW3CM REGEN MTRX 3 REPLFRM,SUP-2139389,CDM,C1762,CPT,0278,RC,,,,both,,,2698.89,1754.28,,,,,,,,,,,,,
NAIL IM L380MM DIA12MM TI ALLY RG CORELOCK TECHNOLOGY,SUP-2405540,CDM,C1713,HCPCS,0278,RC,,,,both,,,6757.28,4392.23,,,,,,,,,,,,,
MARKER TISS 8GA FOR MAMTOM PRB MICROMARK II,SUP-2195631,CDM,A4648,CPT,0278,RC,,,,both,,,281.97,183.28,,,,,,,,,,,,,
PLATE BNE THK1MM 6X2 H BLU MAND TI 3D CRV FOR LEIBINGER,SUP-2366348,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.29,813.34,,,,,,,,,,,,,
SET PERI DLYS CATH L63CM DIA15FR BASIC SIL STR COILED R V,SUP-2267006,CDM,C1752,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
BUR DENT HD DIA1MM CARB CRSS CUT FISS RND NONFLUTED,SUP-2367590,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.45,265.49,,,,,,,,,,,,,
GASTROSTOMY SET PUL METHOD 24 FRX150 CM 5.5 FR FEN DRP PEG24,SUP-2738238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.440,SUP-2860004,CDM,C1713,HCPCS,0278,RC,,,,both,,,45146.92,29345.50,,,,,,,,,,,,,
HC So Ova and Parasites,PX-3008717766,CDM,87177,CPT,0300,RC,,,,both,,,103.00,66.95,,,,,,,,,,,,,
TUBE ESOPH AD 20FR L8.25X1.5IN SPEC DISP FOR GI TRACT,SUP-2126706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
KIT TORQ WRNCH REUSE FOR NEUROSTIM,SUP-2418484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
COMPONENT HUM 52X48MM ARTC OFFSET OVOMOTION,SUP-2123589,CDM,C1776,CPT,0278,RC,,,,both,,,13611.90,8847.73,,,,,,,,,,,,,
PLATE BNE NAR 4.5X183 MM 11 HOLE SS DCP,SUP-2569169,CDM,C1713,HCPCS,0278,RC,,,,both,,,343.67,223.39,,,,,,,,,,,,,
CARBOPLATIN 600 MG/60ML IV SOLN,RX-40055,CDM,J9045,HCPCS,0636,RC,55150-0386-01,NDC,,both,60,ML,144.50,93.92,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM S STL CANN PARTIALLY THRD HD HEX,SUP-2183622,CDM,C1713,HCPCS,0278,RC,,,,both,,,440.79,286.51,,,,,,,,,,,,,
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24,RX-29270,CDM,6370000000,HCPCS,0637,RC,60687-0195-01,NDC,,both,1,UN,3.70,2.40,,,,,,,,,,,,,
PIN DRL HDLSS 3.2X75 MM HEX END TRCR PT,SUP-2760758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.90,241.08,,,,,,,,,,,,,
DEFIBRILLATOR CARD W6.70XH6.70CM D1.20CM 30J 20SEC 9YR SGL,SUP-2138061,CDM,C1721,HCPCS,0275,RC,,,,both,,,40082.10,26053.36,,,,,,,,,,,,,
PLATE BNE THK 0.8 MM SCREW DIA1.7 MM 4 H LG TI GRA,SUP-2883633,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.22,561.09,,,,,,,,,,,,,
PLATE BNE L39MM THK1.5MM 6 H MAND BILAT TI RIG ORAL,SUP-2262988,CDM,C1713,HCPCS,0278,RC,,,,both,,,1034.63,672.51,,,,,,,,,,,,,
SCREW BNE 3X12 MM SNAP-OFF,SUP-2608923,CDM,C1713,HCPCS,0278,RC,,,,both,,,1248.78,811.71,,,,,,,,,,,,,
GRAFT HUM TISS L12SQCM DEHYDR AMNION CHORION MEM MESH,SUP-2305753,CDM,Q4186,HCPCS,0636,RC,,,,both,,,8145.16,5294.35,,,,,,,,,,,,,
REAMER SURG L20MM MT CUP GENERATION 2,SUP-2398416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
CANNULA ENDOSCP VERY LO PROF 6 MMX15 CM N THRD SMOOTH BLK,SUP-2768225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,810.31,526.70,,,,,,,,,,,,,
CANNULA ENDOSCP 2 MMX22 CM CVS OPENING RT 1 LUER LCK ADPT,SUP-2773336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.83,423.69,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA10 MM AX COMPLIANCE,SUP-2694230,CDM,C1768,CPT,0278,RC,,,,both,,,6655.42,4326.02,,,,,,,,,,,,,
TRACHEOSTOMY KIT PEDIATRIC 17 GA 5 MMX5.8 CM CRICOTHYROTOMY,SUP-2846610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.45,358.44,,,,,,,,,,,,,
SHUNT VENTRICULOPERTIONEAL 6FR 90CM M SM W SNAP RESVR CSF,SUP-2278381,CDM,C1889,HCPCS,0278,RC,,,,both,,,3784.64,2460.02,,,,,,,,,,,,,
PUMP PAIN FILL VOL 400ML FLO RATE 1-7ML/HR 5ML BOL,SUP-2236811,CDM,C9804,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
KIT BLLN KYPHOPLASTY 8GA 20MM,SUP-2863096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8450.02,5492.51,,,,,,,,,,,,,
"HC So Lipoprotein,Bld,by Nmr",PX-3018370466,CDM,83704,CPT,0301,RC,,,,inpatient,,,76.00,49.40,,,,,,,,,,,,,
ELTROMBOPAG OLAMINE 50 MG PO TABS,RX-94580,CDM,2500000003,HCPCS,0250,RC,00078-0686-55,NDC,,both,1,UN,2124.50,1380.92,,,,,,,,,,,,,
BONESYNC PUTTY 15CC,SUP-2811423,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
GRAFT VASC HEMGRD BODY/BRANCH L 85/55 CM L 35/20 CM 8X6X6MM,SUP-2480579,CDM,C1768,CPT,0278,RC,,,,both,,,5221.19,3393.77,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-40840052,CDM,J7040,HCPCS,0250,RC,00264-7800-10,NDC,,both,250,ML,14.90,9.68,,,,,,,,,,,,,
ANTENNA SURG ABLATN 17 CM MICROWAVE EVIDENT,SUP-2174872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
ANCHOR BNE FOR REGENETEN BIOINDUCTIVE IMPL,SUP-2341377,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SHEATH DIL SM 12FR L43CM OD5.5MM ID4.2MM PEBAX TEF ROBUST,SUP-2353112,CDM,C1893,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK08 17MM DERM ACELLULAR THCK HUM,SUP-2307468,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4969.68,3230.29,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.447,SUP-2860011,CDM,C1713,HCPCS,0278,RC,,,,both,,,55233.54,35901.80,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 90 CC FD IRRADIATED CORTICAL CANC,SUP-2867129,CDM,C1762,CPT,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
SHEARS ULTRSNC SHFT L 23 CM DIA 5 MM JAW L 14 MM APER 15 MM,SUP-2889594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1206.98,784.54,,,,,,,,,,,,,
LEAD PACE COROX OTW-L L 87 CM DIA1.8 MM POLYUR IRIDIUM OXIDE,SUP-2138260,CDM,C1900,HCPCS,0275,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
CATHETER PERI STD L91CM OD2.3MM ID1.1MM SIL ELASTMR OPN END,SUP-2243863,CDM,C1752,HCPCS,0278,RC,,,,both,,,375.10,243.81,,,,,,,,,,,,,
WASHER ORTH OD13MM ID6.6MM S STL RND BONE FIX,SUP-2343820,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.84,187.10,,,,,,,,,,,,,
HEAD FEMORAL COCR 12/14 36MM +0,SUP-2504653,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CUP ACET HIP TRITANIUM,SUP-2366003,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER VENTRICULAR TYP E 48 CM SHUNT ATR IFU BA HOLTER,SUP-2423585,CDM,C1729,HCPCS,0272,RC,,,,both,,,745.78,484.76,,,,,,,,,,,,,
PLATE BNE L139MM 2 H ST PROX FEM S STL HK LO PROF LOK COMPR,SUP-2420803,CDM,C1713,HCPCS,0278,RC,,,,both,,,4740.33,3081.21,,,,,,,,,,,,,
CATHETER INFUS L20CM OD6FR 3 LUMN JACC,SUP-2120621,CDM,C1751,HCPCS,0278,RC,,,,both,,,763.96,496.57,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE TIB CUST FRAC MOLD TO PT,SUP-2435647,CDM,L0220,HCPCS,0274,RC,,,,both,,,3254.80,2115.62,,,,,,,,,,,,,
GRAFT VASC TAPR 8-5 MMX70 CM TW N RING EPTFE CARBOFLO,SUP-2761340,CDM,C1768,CPT,0278,RC,,,,both,,,3602.52,2341.64,,,,,,,,,,,,,
GRAFT SFT TISS W9XL20CM NAT BARR OPTIMIZE SURG PERF,SUP-2305728,CDM,V2790,HCPCS,0278,RC,,,,both,,,29644.74,19269.08,,,,,,,,,,,,,
BENDER PLT CERV MSPAN X10 XLNK,SUP-2289443,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.18,769.07,,,,,,,,,,,,,
VALVE CSF FIXED 130 MM PRECIS CYL HI HAKIM,SUP-2666471,CDM,C1889,HCPCS,0278,RC,,,,both,,,3171.71,2061.61,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA20 GA NDL DIA18 GA CE18TKON 1 FULL,SUP-2936473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,79.22,51.49,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840054,CDM,2580000003,HCPCS,0258,RC,00264-7610-00,NDC,JW,both,250,ML,8.50,5.52,,,,,,,,,,,,,
SEALANT TISS 10ML FIBRIN PREFIL SYR PRIMA FRZN W 1 DUPLOJET,SUP-2130408,CDM,C1713,HCPCS,0278,RC,,,,both,,,2280.49,1482.32,,,,,,,,,,,,,
CATHETER BLLN 85 CM GUIDE EMBOGUARD,SUP-2854946,CDM,C2628,HCPCS,0272,RC,,,,both,,,8042.51,5227.63,,,,,,,,,,,,,
SCREW BNE COMPR 32 MM HIP TALON,SUP-2391511,CDM,C1713,HCPCS,0278,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
SCREW BNE L50MM DIA5MM UNICORTICAL FEM TI ST LOK 2 COR FULL,SUP-2180157,CDM,C1713,HCPCS,0278,RC,,,,both,,,716.30,465.59,,,,,,,,,,,,,
BIT DRILL L200MM D7MM CNNLTD REAM SBTLR TBTLR ARTCLR SRFCS 3,SUP-2465713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.30,423.99,,,,,,,,,,,,,
WIRE BNE FIX L 110 MM DIA2.4 MM FLUT NS BABY GORILLA/GORILLA,SUP-2899025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,293.59,190.83,,,,,,,,,,,,,
GRAFT BONE SUB 10CC CA PHOS PUTTY FOR NORIAN CRS FAST SET,SUP-2193977,CDM,C1713,HCPCS,0278,RC,,,,both,,,6314.54,4104.45,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PERSONA,SUP-2212184,CDM,C1776,CPT,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
KNIFE SRGCL BLLNGR 4MM BLADE 8NL BNT SWVL LATEX FREE,SUP-2494181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.59,241.53,,,,,,,,,,,,,
STEM SEG LIMB SALV LO BODY CEM STR FLUT ELEOS 25MM,SUP-2314046,CDM,C1776,CPT,0278,RC,,,,both,,,12073.30,7847.64,,,,,,,,,,,,,
PLATE BNE L L70MM NONSTERILE R CALCNL S STL VAR ANG LOK FOR,SUP-2178424,CDM,C1713,HCPCS,0278,RC,,,,both,,,3057.48,1987.36,,,,,,,,,,,,,
PLATE BNE L157MM 9 H ST L DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177732,CDM,C1713,HCPCS,0278,RC,,,,both,,,3052.46,1984.10,,,,,,,,,,,,,
BUR SURG DR LNG 7.6X28.6 MM FLUT FOR HD/HD-G1,SUP-2848176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,799.26,519.52,,,,,,,,,,,,,
BRACE KNEE POSTOP LNG UNIV UNISX WRP ARND HNG T SCP 10DEG,SUP-2150857,CDM,L1845,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC So Hla Dqb1 06:02 Genotype,PX-3108138366,CDM,81383,CPT,0310,RC,,,,inpatient,,,276.00,179.40,,,,,,,,,,,,,
PACEMAKER CARD SENSIA SR W 42.9 X H 40.2 MM D 7.5 MM TI,SUP-2282484,CDM,C1786,HCPCS,0275,RC,,,,both,,,7373.51,4792.78,,,,,,,,,,,,,
PLATE BNE 145DEG 4 H S STL HIP LOK BILAT COMPR RIG SHT BRL,SUP-2370866,CDM,C1713,HCPCS,0278,RC,,,,both,,,1806.76,1174.39,,,,,,,,,,,,,
HOOK SPNL PEDCL SM 5.5 MM 259000210] CTL AMEDICA US SPINE],SUP-2175458,CDM,C1713,HCPCS,0278,RC,,,,both,,,2816.58,1830.78,,,,,,,,,,,,,
SPLINT WR LT L INSTABILITY INJ 6 IN LOOP LCK W/ STAY COCK UP,SUP-2194853,CDM,L3931,HCPCS,0272,RC,,,,both,,,18.71,12.16,,,,,,,,,,,,,
NAIL IM L160MM DIA8MM L PROX HUM BLU TI STR RND CANN LOK,SUP-2180168,CDM,C1713,HCPCS,0278,RC,,,,both,,,5832.24,3790.96,,,,,,,,,,,,,
GRAFT HUM TISS 3X5CM AMNIOCORD,SUP-2305710,CDM,Q4187,HCPCS,0636,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE DIA 7.5 MM SZ 4 CART ARAGONITE POROUS,SUP-2913168,CDM,C1763,HCPCS,0278,RC,,,,both,,,22451.00,14593.15,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 187MML HLX16 STNLSS STEEL CNTRD,SUP-2588591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.29,813.99,,,,,,,,,,,,,
DRILL SURG 2 TRIGGER MOD HALL TITAN,SUP-2607717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,26682.15,17343.40,,,,,,,,,,,,,
HC So1 Assay of Manganese,PX-3018378567,CDM,83785,CPT,0301,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
SENNA 8.8 MG/5ML PO SYRP,RX-28961,CDM,6370000000,HCPCS,0637,RC,57237-0310-05,NDC,,both,5,ML,11.70,7.60,,,,,,,,,,,,,
CANNULA SURGICAL L250MM UTERINE SELF RETAINING WITH SPRING C,SUP-2809560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,858.57,558.07,,,,,,,,,,,,,
COIL VASC 3D SFT 6MM DIA 12CM LEN .010IN GWIRE STRTCH,SUP-2173668,CDM,C1889,HCPCS,0278,RC,,,,both,,,3432.02,2230.81,,,,,,,,,,,,,
ENDCAP ORTH L15MM DIA11MM ST BLU TI EXTN FOR SLD TIB IM,SUP-2192165,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.06,612.34,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 100X0.6 MM RIGID TI SLV STRL,SUP-2859916,CDM,C1713,HCPCS,0278,RC,,,,both,,,5900.69,3835.45,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.402,SUP-2859966,CDM,C1713,HCPCS,0278,RC,,,,both,,,30009.29,19506.04,,,,,,,,,,,,,
PLATE BNE L338MM BLDE W48XL25MM 95DEG 20 H NONSTERILE HIP S,SUP-2186769,CDM,C1713,HCPCS,0278,RC,,,,both,,,4330.37,2814.74,,,,,,,,,,,,,
CABLE ELECSURG BPLR GENERATOR/IRRIGATOR INTERCONNECT NS LTX,SUP-2859253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1509.74,981.33,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 4 FRX15 CM 18 GA DL SPECTRUM,SUP-2759892,CDM,C1751,HCPCS,0278,RC,,,,both,,,563.13,366.03,,,,,,,,,,,,,
HC Iadna Respiratry Probe & Rev Trnscr 12-25 Target|NOT REASONABLE AND NECESSARY,PX-3068763300,CDM,87633,CPT,0306,RC,,,GZ,both,,,683.00,443.95,,,,,,,,,,,,,
COMPONENT PAT DIA35MM DST KNEE POLY OVL DOME 3 PEG NP CEM,SUP-2253503,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BLU MAX 20 L 75 CM BALLOON L 4 CM DIA 8,SUP-2147231,CDM,C1725,HCPCS,0272,RC,,,,both,,,313.97,204.08,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X2 H STD CRANIOMAXILLOFACIAL G TI 3D SQ,SUP-2366268,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.47,438.41,,,,,,,,,,,,,
MESH SURG W10XL15CM GYN NONABSORBABLE PROL,SUP-2219079,CDM,C1781,HCPCS,0278,RC,,,,both,,,1624.92,1056.20,,,,,,,,,,,,,
GRAFT BIO TISS MARIGEN EXPANSE 4X4CM MESHED,SUP-2909363,CDM,Q4158,HCPCS,0636,RC,,,,both,,,5243.80,3408.47,,,,,,,,,,,,,
HC Thromb Mech Vein Sub Day,PX-3613718800,CDM,37188,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
SCREW W CABLE LLIF STRL LT TIP,SUP-2114090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
INSERT ACET OD54MM ID36MM HIP ULTAMET COBAL CHROME ARTC MOD,SUP-2250300,CDM,C1776,CPT,0278,RC,,,,both,,,6497.92,4223.65,,,,,,,,,,,,,
NAIL IM L205MM DIA7.5MM 120DEG UNIV HUM TI BENT SLD RG AND,SUP-2192484,CDM,C1713,HCPCS,0278,RC,,,,both,,,5211.40,3387.41,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 10 MM,SUP-2741811,CDM,C1762,CPT,0278,RC,,,,both,,,7606.65,4944.32,,,,,,,,,,,,,
HANDPIECE LASER 300 MM MALL FIBERLASE ACUPULSE,SUP-2713714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
TAG HUGS WI-FI,SUP-2873712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,683.08,444.00,,,,,,,,,,,,,
WAND IFS COBLATION TOPAZ EZ MICRODEBRIDER,SUP-2341987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1404.99,913.24,,,,,,,,,,,,,
HC So Human Epididymis Prot 4 (He4),PX-3028630566,CDM,86305,CPT,0302,RC,,,,both,,,477.00,310.05,,,,,,,,,,,,,
CLIP INT LIG LG TI RED,SUP-2757598,CDM,C1889,HCPCS,0278,RC,,,,both,,,70.74,45.98,,,,,,,,,,,,,
CUBE 3 HOLE SALVATION,SUP-2401121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
PLATE BNE L142MM 9 H NONSTERILE R POSTEROLAT DST HUM S STL,SUP-2185905,CDM,C1713,HCPCS,0278,RC,,,,both,,,3386.18,2201.02,,,,,,,,,,,,,
PLATE BNE L202MM 10 H ST L MED DST TIB S STL VAR ANG LOK,SUP-2177643,CDM,C1713,HCPCS,0278,RC,,,,both,,,5415.34,3519.97,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL FIX COR 15 CM 0.038 INX145 CM BENT,SUP-2835677,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.73,47.92,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH LG 0.4 MM MASTOID TI BLU NS,SUP-2859917,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
NEEDLE NERVE BLOCK INSUL 23 GAX2.75 IN,SUP-2125386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,839.95,545.97,,,,,,,,,,,,,
SCREW BNE L95MM DIA5MM CANN LOK,SUP-2184923,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.09,403.71,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 45 CM DIA 4-7 MM EPTFE SHRT TAPR STD,SUP-2227652,CDM,C1768,CPT,0278,RC,,,,both,,,1475.42,959.02,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.141X9 IN RND END SS NS STEINMANN,SUP-2791374,CDM,C1713,HCPCS,0278,RC,,,,both,,,33.10,21.51,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MED 60-149 MM FD FASC LATA,SUP-2792179,CDM,C1762,CPT,0278,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
DEVICE DEL L180CM SHTH DIA2.5MM FOR 23.5-26.5MM VID CAP,SUP-2391606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
NAIL IM HUM 8 7MMX18CM,SUP-2348158,CDM,C1713,HCPCS,0278,RC,,,,both,,,9853.16,6404.55,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED SM 8 IN RT WRST FOREARM THMB,SUP-2276639,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.26,14.47,,,,,,,,,,,,,
PLUG VASC 6FR L8MM DIA16MM CATH 8FR L100CM NIT SGL LAYR,SUP-2355747,CDM,C1713,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
VALVE CSF H SM CSF FLOW CTRL X HI PRESSURE,SUP-2628538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3311.70,2152.60,,,,,,,,,,,,,
CANNULA ENDOSCP L 70 MM DIA11 MM SHRT BLDELSS TROCAR SLV,SUP-2896328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.15,283.50,,,,,,,,,,,,,
LINER ACET NEUT HIP METASUL EPSILON,SUP-2448623,CDM,C1776,CPT,0278,RC,,,,both,,,50995.17,33146.86,,,,,,,,,,,,,
"HC Culture,Anaerobic",PX-3008707500,CDM,87075,CPT,0300,RC,,,,both,,,245.00,159.25,,,,,,,,,,,,,
DEVICE THRD L50MM DIA12MM TI ALLY L FEN CANN FOR SACROILIAC,SUP-2279554,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM DIA2MM VAGUS NRV SIL BPLR HELI,SUP-2265173,CDM,C1778,HCPCS,0278,RC,,,,both,,,27497.29,17873.24,,,,,,,,,,,,,
GUIDEWIRE ORTH TRCR PT 1 END 1.4X150 MM STRL,SUP-2789090,CDM,C1769,HCPCS,0272,RC,,,,both,,,1244.19,808.72,,,,,,,,,,,,,
CATHETER THOR 36FR L23IN PVC R ANG 5 EYE TAPR CONN TIP SFT,SUP-2227440,CDM,C1729,HCPCS,0272,RC,,,,both,,,34.98,22.74,,,,,,,,,,,,,
HC So Albumin,PX-3078204066,CDM,82040,CPT,0307,RC,,,,both,,,35.00,22.75,,,,,,,,,,,,,
SHELL ACET MH 25 62 MM HIP REGENEREX RINGLOK,SUP-2365888,CDM,C1776,CPT,0278,RC,,,,both,,,7919.08,5147.40,,,,,,,,,,,,,
GUIDE MARKING ORTHOGNATHIC MAND IPS,SUP-2433938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
INSERT ACET SZ P4 OD54-56MM ID32MM 10DEG OFFSET +4MM DUR CO,SUP-2376193,CDM,C1776,CPT,0278,RC,,,,both,,,2410.26,1566.67,,,,,,,,,,,,,
BLADE ENDOSCP COEQUAL LP ASMBLY SMARTRELEASE ONYX,SUP-2760601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
APPLIER ANEURYSM CLIP L3.5IN EXTRA SMALL STANDARD FINGER TIP,SUP-2821649,CDM,C1889,HCPCS,0278,RC,,,,both,,,4495.22,2921.89,,,,,,,,,,,,,
SET PICC CATHETER TAPR TRIM PERIPH W TRIM,SUP-2384056,CDM,C1751,HCPCS,0278,RC,,,,both,,,269.04,174.88,,,,,,,,,,,,,
GRAFT BNE SUB 5ML MTRX CELLULAR OSTEOCEL +,SUP-2310449,CDM,C1713,HCPCS,0278,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
INTRODUCER US ATEC,SUP-2239944,CDM,C1894,HCPCS,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
PLATE BNE L 246 MM SCREW DIA 3.5/4.5 MM H 10 UTIL NS EVOS,SUP-2931239,CDM,C1713,HCPCS,0278,RC,,,,both,,,22430.59,14579.88,,,,,,,,,,,,,
GAUGE DEPTH 2MM K WIRE STNMN PIN,SUP-2212972,CDM,C1776,CPT,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
RING EXT FIX 3/4 210 MM MONOTUBE,SUP-2462892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1769.39,1150.10,,,,,,,,,,,,,
GRAFT BNE L12XW12XH7MM 5DEG UNIV PEEK TI COMP SPCR ANT CERV,SUP-2317027,CDM,C1713,HCPCS,0278,RC,,,,both,,,8842.24,5747.46,,,,,,,,,,,,,
TINY TRIUNE VT SI 0.76MM,SUP-2492046,CDM,L8699,HCPCS,0278,RC,,,,both,,,51.43,33.43,,,,,,,,,,,,,
ANCHOR SUT L19.1MM DIA4.75MM BIOCOMPOSITE CLS EYELET,SUP-2121699,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GAUGE DEPTH CANN 120 MM PERC VERSAFX II MAGNA-FX,SUP-2473823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.91,787.09,,,,,,,,,,,,,
SET CATH L35CM OD3.4MM ID1.9MM VENT BACTISEAL STYL CONN CAP,SUP-2243802,CDM,C1729,HCPCS,0272,RC,,,,both,,,2308.12,1500.28,,,,,,,,,,,,,
SLEEVE RMR +1 JOURNEY,SUP-2347044,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
STEM WAGNER SL REVISION 135 NK ANGLE 17MM X 190MM,SUP-2505398,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
GRAFT DERMAL MICROPERFORATED 6X16 CMX0.6-1.05 MM DERMACELL,SUP-2777421,CDM,Q4122,HCPCS,0636,RC,,,,both,,,8305.30,5398.44,,,,,,,,,,,,,
HC Pt Vasopneumatic Device Therapy,PX-4209701600,CDM,97016,CPT,0420,RC,,,,inpatient,,,206.00,133.90,,,,,,,,,,,,,
GRAFT HUM TISS L HUM WHL W CUF FRZN,SUP-2307321,CDM,C1713,HCPCS,0278,RC,,,,both,,,28938.24,18809.86,,,,,,,,,,,,,
SAW SURG 3-5 KNEE MOD POST CAPTURE ATTUNE,SUP-2454799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
SYSTEM BNE BX PERF 11 GAX10 CM W/ DRL MADISON,SUP-2491183,CDM,C1894,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TIP 3 MM PTFE J,SUP-2147066,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.55,19.86,,,,,,,,,,,,,
SCREW BNE L10MM OD2.7MM S STL CORT ST NONCANNULATED LOK,SUP-2348635,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.68,504.84,,,,,,,,,,,,,
GRAFT HUM TISS W2XL5CM THK08 17MM DERM HUM ACELLULAR,SUP-2307045,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1633.43,1061.73,,,,,,,,,,,,,
WRAP WR UNIV LT COMPR GEL,SUP-2324362,CDM,L3931,HCPCS,0274,RC,,,,both,,,99.91,64.94,,,,,,,,,,,,,
IMPLANT BRST GEL 5.7 CM PROJCT 12X11.1 CM 325 GM NATRELLE,SUP-2113335,CDM,C1789,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0035IN TAPR L7CM FLPY TIP L3CM HEP,SUP-2167921,CDM,C1769,HCPCS,0272,RC,,,,both,,,65.19,42.37,,,,,,,,,,,,,
PLATE BNE XSM L24MM 4 H NONSTERILE BILAT FOREFOOT TI X SHP,SUP-2181208,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.34,2193.97,,,,,,,,,,,,,
SCREW BNE FEM NAIL HOLDING S2,SUP-2492719,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
PROBE MPLR LNG,SUP-2211620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC So Chimerism Anal W/Cell Select,PX-3018126866,CDM,81268,CPT,0301,RC,,,,inpatient,,,329.00,213.85,,,,,,,,,,,,,
SPHERE GLEN REVERSED 42 MM SHLDR CENTERED FOR 29 MM BASEPLT,SUP-2715706,CDM,C1776,CPT,0278,RC,,,,both,,,11738.89,7630.28,,,,,,,,,,,,,
STIRRUP POS H10IN STD UNIV ANK AIR BLDR RIG MED LAT SHELLS,SUP-2195184,CDM,L4350,HCPCS,0272,RC,,,,both,,,41.86,27.21,,,,,,,,,,,,,
BRACE WR AD UNIV LT AND RT ELAS SUPP STRP FOAM CUSH WRP ARND,SUP-2309133,CDM,L3931,HCPCS,0274,RC,,,,both,,,52.09,33.86,,,,,,,,,,,,,
POLISHER CAPSULE 45 DEG 20 GA 0.3 MM ANGLED TIP MTL,SUP-2462199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1030.71,669.96,,,,,,,,,,,,,
GUIDEWIRE ANGIO CATH RETRV TIP 6MM QUIK CRSS CAPTURE,SUP-2353171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM DIA 0.038 IN SS PTFE PERIPH AMPLTZ X,SUP-2760087,CDM,C1769,HCPCS,0272,RC,,,,both,,,163.22,106.09,,,,,,,,,,,,,
SPACER SPNL PEEK PILLAR SA 7DEG 37X32X22MM,SUP-2317184,CDM,C1821,HCPCS,0278,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
PLATE BNE L 43 MM PROF H 1.7 MM SHRT RT DSTL ULNA STR BASE,SUP-2900507,CDM,C1713,HCPCS,0278,RC,,,,both,,,3457.64,2247.47,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM 0.025 IN L 7 CM FLPY TIP 2CM STR TIP,SUP-2638694,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.44,21.09,,,,,,,,,,,,,
PLATE BONE TIBIAL RIGHT PROXIMAL LATERAL 4 HOLE LOCKING,SUP-2836983,CDM,C1713,HCPCS,0278,RC,,,,both,,,8162.74,5305.78,,,,,,,,,,,,,
HC Hysterosalpingogram,PX-3207474000,CDM,74740,CPT,0320,RC,,,,outpatient,,,686.00,445.90,,,,,,,,,,,,,
HEAD HUM 16X40 MM SHLDR RESURF TITAN,SUP-2244069,CDM,C1776,CPT,0278,RC,,,,both,,,15269.82,9925.38,,,,,,,,,,,,,
"HC So Peptide,C",PX-3018468166,CDM,84681,CPT,0301,RC,,,,both,,,1561.00,1014.65,,,,,,,,,,,,,
PLATE BONE L25MM 4 H CRANIOMAXILLOFACIAL STR LO PROF,SUP-2191106,CDM,C1713,HCPCS,0278,RC,,,,both,,,165.79,107.76,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 025 5 FRX5 CM 16 GA 3L SPECTRUM,SUP-2759897,CDM,C1751,HCPCS,0278,RC,,,,both,,,569.41,370.12,,,,,,,,,,,,,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL FILM,RX-106574,CDM,J0572,HCPCS,0636,RC,47781-0355-11,NDC,,both,1,UN,10.10,6.56,,,,,,,,,,,,,
GRAFT BNE FRZN PROX FEM HD IMPL ALLGRFT MATRIGRFT,SUP-2264784,CDM,C1713,HCPCS,0278,RC,,,,both,,,13358.85,8683.25,,,,,,,,,,,,,
SPACER SPNL 30X11 MM CRESCENT,SUP-2631449,CDM,C1889,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
EVOS 2.7/3.5MM EA-D HUM PL 12H RIGHT 151MM,SUP-2819910,CDM,C1713,HCPCS,0278,RC,,,,both,,,9411.52,6117.49,,,,,,,,,,,,,
LINER ACET SZ I OD66-68MM ID40MM 0DEG POLYETHYLENEX3 HIP FOR,SUP-2364436,CDM,C1776,CPT,0278,RC,,,,both,,,6452.23,4193.95,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL VIT 2.0MM DIA 18MML,SUP-2364642,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.40,76.31,,,,,,,,,,,,,
PLATE BNE L81MM THK3.5MM XLN R CALCNL S STL LOK COMPR FOR,SUP-2185992,CDM,C1713,HCPCS,0278,RC,,,,both,,,2179.98,1416.99,,,,,,,,,,,,,
FLUPHENAZINE HCL 2.5 MG PO TABS,RX-3220,CDM,6370000000,HCPCS,0637,RC,70954-0274-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE L34MM DIA4.5MM TI LOK LO PROF FOR ANK FUS PLATING,SUP-2122238,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 6 HOLE STR STRL LTX,SUP-2861617,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.40,479.31,,,,,,,,,,,,,
MESH CRAN THK 0.2 MM SCREW DIA1/1.5 MM LG TRAP NS DISP,SUP-2936931,CDM,C1713,HCPCS,0278,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
CATHETER KIT DL 5 FR PWR 3CG PLCMNT,SUP-2126772,CDM,C1751,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
GUIDEWIRE ENDO L145CM OD0.038IN 14FR INTRO SUP STIFF AMPLTZ,SUP-2141747,CDM,C1769,HCPCS,0272,RC,,,,both,,,111.78,72.66,,,,,,,,,,,,,
MESH HERN LG 15.7X10.2 CM W/ POCKET ONFLEX,SUP-2858043,CDM,C1781,HCPCS,0278,RC,,,,both,,,797.78,518.56,,,,,,,,,,,,,
STEM FEM SZ 5 L130MM NK L37MM +44MM OFFSET 132DEG STD HIP,SUP-2374326,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
BUTTON SUTURE SZ 12 X 8 MM OD THK 1.6 MM TUNN SZ 4-7 MM FLAT,SUP-2906257,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
GRAFT HUM TISS 5X8CM THK0.4-1MM ACELLULAR DERM MTRX MESHED,SUP-2225422,CDM,Q4179,HCPCS,0636,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
BIT DRL L 205/110 MM DIA2.5 MM CALIB AO QC NS REUSE V,SUP-2908171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,868.78,564.71,,,,,,,,,,,,,
ACTIDOSE WITH SORBITOL 25 GM/120ML PO SUSP,RX-159884,CDM,6370000000,HCPCS,0637,RC,00574-0520-74,NDC,,both,120,ML,60.00,39.00,,,,,,,,,,,,,
STENT COLON UFLX PRECIS L 87 MM WORKING L 100 CM DIA25 MM,SUP-2149676,CDM,C1876,HCPCS,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
SCREW LCKING MAXFRAME HDLESS /XL25/X 5.0X26MM,SUP-2752096,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.78,506.21,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .014P L 150 CM SHTH 5 FR GUIDE CATH,SUP-2898637,CDM,C1753,HCPCS,0278,RC,,,,both,,,1672.05,1086.83,,,,,,,,,,,,,
PLATE BNE L 60 MM TI INTRATHORACIC PREBENT NS RIBFIX TITAN,SUP-2905468,CDM,C1713,HCPCS,0278,RC,,,,both,,,11555.20,7510.88,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 4",PX-7619921400,CDM,99214,CPT,0761,RC,,,,inpatient,,,313.00,203.45,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT INTERMED 5FR 0.026IN 55CM 2 LUMAN R,SUP-2613425,CDM,C1751,HCPCS,0278,RC,,,,both,,,421.39,273.90,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM TAP IN DSGN FOR SFT TISS FIX FOOTPRINT,SUP-2341862,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.36,882.93,,,,,,,,,,,,,
GUIDEWIRE VASC MORPHEUS L 80 CM DIA 0.018 IN PLAT TIP PERIPH,SUP-2116532,CDM,C1769,HCPCS,0272,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
CANNULA ENDOSCP TERNAMIAN ENDOTIP 11 MMX10.5 CM STOPCOCK,SUP-2767278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2545.76,1654.74,,,,,,,,,,,,,
HC Neg Pressure Wnd > 50 Sq Cm Disposable,PX-7619760800,CDM,97608,CPT,0761,RC,,,,both,,,813.00,528.45,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 40 CM DIA 8 MM EPTFE STR STD WALL,SUP-2227643,CDM,C1768,CPT,0278,RC,,,,both,,,1063.99,691.59,,,,,,,,,,,,,
HC Cardiac Rehab Outpatient,PX-9439379800,CDM,93798,CPT,0943,RC,,,,inpatient,,,412.00,267.80,,,,,,,,,,,,,
SET NEPHSTMY SHTH L20CM OD4FR NDL L15CM OD21GA GWIRE L60CM,SUP-2168588,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.21,173.04,,,,,,,,,,,,,
BIT DRL HLLW CANN PERC 16MM STRL,SUP-2546209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2945.57,1914.62,,,,,,,,,,,,,
PIN EXT FIX 4 MM,SUP-2197281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
PLATE BNE THK 2.8 MM SM DBL ANGLE STR NS DISP TRAUMAONE,SUP-2937019,CDM,C1713,HCPCS,0278,RC,,,,both,,,10095.10,6561.81,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + L,SUP-2195533,CDM,L1830,CPT,0274,RC,,,,both,,,61.32,39.86,,,,,,,,,,,,,
CONNECTOR SPNL 55 55MM OPN SIDE CDH DOMINO,SUP-2279961,CDM,C1713,HCPCS,0278,RC,,,,both,,,2439.78,1585.86,,,,,,,,,,,,,
GUIDEWIRE URLGCL 0035N DIA 150CML PTFE CTD J WIRE MVBLE COR,SUP-2724971,CDM,C1769,HCPCS,0272,RC,,,,both,,,60.54,39.35,,,,,,,,,,,,,
CATHETER EP 6FR L105CM 5MM SPC DECAPOLAR 270DEG STD CRV,SUP-2141318,CDM,C1732,HCPCS,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
PLATE BONE L186MM 13 H LT ANTEROLATERAL MEDL DSTL TIB LCK,SUP-2348480,CDM,C1713,HCPCS,0278,RC,,,,both,,,17300.14,11245.09,,,,,,,,,,,,,
POST EXT FIX CIR M 5 HOLE,SUP-2400703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
PLATE BNE MESHED LG 0.6 MM MXLFCL NEURO STD PAT OUSIDE HOLE,SUP-2477844,CDM,C1713,HCPCS,0278,RC,,,,both,,,4600.85,2990.55,,,,,,,,,,,,,
MARKER BRST BX MOLLI L 12 CM DIA14 GA PRELD MR CONDITIONAL,SUP-2875964,CDM,A4648,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
INTRODUCER SHTH SL1 0.032 IN 8 FRX63 CM DIL SWARTZ SL,SUP-2464195,CDM,C1893,HCPCS,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
GUIDEWIRE VASC L 230 MM DIA1.4 MM FOR TERRA NOVAL MI,SUP-2734732,CDM,C1769,HCPCS,0272,RC,,,,both,,,279.77,181.85,,,,,,,,,,,,,
HC OP Traction Intermittent|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701200,CDM,97012,CPT,0420,RC,,,KX|CQ,outpatient,,,292.00,189.80,,,,,,,,,,,,,
CUBE EXT FIX 3 H S STL RANCHO FOR ILIZ TAY SPAT FRME EXT,SUP-2342334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1388.88,902.77,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5X25 MM 6.35 MM PEDCL FOR ROD RED LEG,SUP-2288980,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
APPLIER CLP M/L SHFT DIA5MM 15 LIG LIGAMAX 5,SUP-2218998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.24,219.21,,,,,,,,,,,,,
SCREW BNE EMGCY 2X7 MM CRUCFRM HD FT ST FLUT TIP TI NS,SUP-2189256,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.10,158.01,,,,,,,,,,,,,
GRAFT HUM TISS W6XL12CM THK8 17MM DERM ACELLULAR HYDRATED,SUP-2307475,CDM,Q4128,HCPCS,0636,RC,,,,both,,,6667.13,4333.63,,,,,,,,,,,,,
SHELL BPLR DIA44MM UNIV ACET CONVENE,SUP-2342602,CDM,C1776,CPT,0278,RC,,,,both,,,3039.52,1975.69,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L33CM DIA1.27MM ELECTRD SPC 1.5MM QPLR,SUP-2284491,CDM,C1778,HCPCS,0278,RC,,,,both,,,11162.70,7255.75,,,,,,,,,,,,,
SET TBNG 23KHZ MFLD EXCEL CUSA,SUP-2243953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS COILED 63 CM LT V NK DBL X-SERIES,SUP-2269531,CDM,C1752,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
BUSHING FEM DSTL HIP GMRS,SUP-2364955,CDM,C1776,CPT,0278,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
VALVE AORT MSTR SER CUF DIA20 MM TISS ANNULUS DIA15 MM,SUP-2894049,CDM,C1889,HCPCS,0278,RC,,,,both,,,29651.02,19273.16,,,,,,,,,,,,,
DEVICE GRFT FIX 4.75X19.1 MM ANCHR IMPL BIOCOMP SWIVELOCK,SUP-2423812,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6 MM STR STD WALL HELIX,SUP-2458479,CDM,C1768,CPT,0278,RC,,,,both,,,2455.67,1596.19,,,,,,,,,,,,,
PLUG BONE 12MM CEM RESTRIC SWNSN DSGN,SUP-2304516,CDM,C1776,CPT,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
LENS INTOCU +11.0 DIOPT L13MM DIA6MM 118.7 A CONSTANT SLM-2,SUP-2247790,CDM,V2632,HCPCS,0276,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GRAFT BNE SYR 5 CC DBM ACCELL CONNEXUS,SUP-2641754,CDM,C1713,HCPCS,0278,RC,,,,both,,,2234.90,1452.68,,,,,,,,,,,,,
WIRE BNE FIX L 152 MM DIA 0.9 MM DBL END TROCAR TIP NS LEOS,SUP-2933124,CDM,C1713,HCPCS,0278,RC,,,,both,,,92.94,60.41,,,,,,,,,,,,,
CAGE SPNL L12XW12XH9MM 4 LOBE MESH L ANAT FOOTPRINT MOD IMP,SUP-2317729,CDM,C1889,HCPCS,0278,RC,,,,both,,,5036.56,3273.76,,,,,,,,,,,,,
CLAMP EXT FIX TWO HOLE K WIRE,SUP-2645880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,563.88,366.52,,,,,,,,,,,,,
GRAFT HUM TISS BIOINTEGRATIVE 40X30 MM INTRO ANTR TAPESTRY,SUP-2867251,CDM,C1763,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
PLATE BNE W16XL299MM BLDE L70MM THK48MM 95DEG 18 H ST BILAT,SUP-2185510,CDM,C1713,HCPCS,0278,RC,,,,both,,,6221.78,4044.16,,,,,,,,,,,,,
PLATE BNE TIB RT DSTL MEDL 15 HOLE LCK STRL A.L.P.S,SUP-2466121,CDM,C1713,HCPCS,0278,RC,,,,both,,,4556.52,2961.74,,,,,,,,,,,,,
DEVICE SUT LAPROSCOPIC RD180 SP,SUP-2265296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
INSERT TIB SM L64MM THK8MM AP40MM RT MEDL LAT ARTC CRUC RET,SUP-2344078,CDM,C1776,CPT,0278,RC,,,,both,,,3347.24,2175.71,,,,,,,,,,,,,
HC Plmt Biliary Drainage Cath Internal-External,PX-3614753400,CDM,47534,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER NEPHSTMY DIA24FR 2 EYE DRNGE PROPORTIONATE HD DISP,SUP-2128980,CDM,C1729,HCPCS,0272,RC,,,,both,,,25.34,16.47,,,,,,,,,,,,,
DRILL SURG 11 GA HND OPTABLATE,SUP-2864575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1282.16,833.40,,,,,,,,,,,,,
HEPARIN (PORK) 100 UNIT/ML IV SOLN - (MIXTURES ONLY),RX-430068,CDM,J1642,HCPCS,0636,RC,64253-0333-35,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER EP ADOL AD 9FR L90CM TEMP SGL HND SELF LOK 4 W TIP,SUP-2357566,CDM,C1759,HCPCS,0272,RC,,,,both,,,6246.90,4060.48,,,,,,,,,,,,,
CONNECTOR FEM L40-50MM LAT TROCHANTERIC CALCAR HIP,SUP-2403673,CDM,C1776,CPT,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
PLATE BNE SM TI MIDFACE 3D PRNT NS DISP ACCUPLATE,SUP-2934754,CDM,C1713,HCPCS,0278,RC,,,,both,,,26752.80,17389.32,,,,,,,,,,,,,
ALLOGRAFT DERMAL HUM TISS SM 4X1 CMX0.23-0.51 MM ALLDERM,SUP-2468452,CDM,Q4116,HCPCS,0636,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
HC Bx Bone Trocar/Needle Superfic,PX-3612022000,CDM,20220,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
HEAD FEM OD28MM +7MM 12/14 TAPR LO WR FX TOUGH PLT TYP CRYS,SUP-2222422,CDM,C1776,CPT,0278,RC,,,,both,,,6028.80,3918.72,,,,,,,,,,,,,
PLATE BNE TBLR 49 MM 4-HOLE 1/3,SUP-2518434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PROBE NSL STR,SUP-2713678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT FEM PROX W O HD L,SUP-2307311,CDM,C1713,HCPCS,0278,RC,,,,both,,,11101.72,7216.12,,,,,,,,,,,,,
ENVELOPE DEFIB BIOENVELOPE LG FIVE PK STRL,SUP-2138483,CDM,C1713,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
FIXATOR EXT CALCNL OSTEOTMY MINIRAIL,SUP-2316505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4392.61,2855.20,,,,,,,,,,,,,
HC Mech Removal Intracath S&I,PX-3207590200,CDM,75902,CPT,0320,RC,,,,both,,,3098.00,2013.70,,,,,,,,,,,,,
PIN FIX AXIS STD GMRS,SUP-2452012,CDM,C1776,CPT,0278,RC,,,,both,,,2355.47,1531.06,,,,,,,,,,,,,
PUMP CNTRFUG W CARMD BIOACTIVE SURF BIO PMP + BPX 80,SUP-2282914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
LINER TIB KNEE HYBIRD XLPE PREMIER STRYK4] STRYKER ORTHOPEDICS HOWM],SUP-2379181,CDM,C1776,CPT,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
KIT REP FOR CLAVICULAR PLT SYS ACU-SINCH,SUP-2106900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3130.58,2034.88,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.539,SUP-2860056,CDM,C1713,HCPCS,0278,RC,,,,both,,,46386.59,30151.28,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0250,RC,00264-1510-32,NDC,,both,100,ML,21.30,13.84,,,,,,,,,,,,,
BLADE REPROC TURBINATE INFERIOR W/O TUBE 2MM,SUP-2653212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.48,171.26,,,,,,,,,,,,,
DEVICE ELECSURG CORECATH 2.7S DISP,SUP-2381722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
PLATE BONE L4MM THK0.9MM 4X7 H BILAT TI T SHP RIG NEUT,SUP-2191131,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
ALLOGRAFT GRAN LESS THAN 2MM 15CC,SUP-2138493,CDM,C1713,HCPCS,0278,RC,,,,both,,,7853.14,5104.54,,,,,,,,,,,,,
SET SCREW BONE M6,SUP-2491828,CDM,C1713,HCPCS,0278,RC,,,,both,,,92.94,60.41,,,,,,,,,,,,,
FIBER LASER RECV DDX 102 RX DVI,SUP-2748366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5162.69,3355.75,,,,,,,,,,,,,
SUTUREFIX CRVD AHR X-LARGE 1 #2 UB STRAIGHT BL,SUP-2823708,CDM,C1713,HCPCS,0278,RC,,,,both,,,1308.09,850.26,,,,,,,,,,,,,
BIT DRL OD22MM DISPOSABLE FOR SM SCR FIX SYS REUNITE,SUP-2137298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.57,281.17,,,,,,,,,,,,,
CATHETER DRAINAGE 0.038 IN 12 FRX25 CM 6 SP NDL DIL CANN SET,SUP-2168550,CDM,C1729,HCPCS,0272,RC,,,,both,,,432.13,280.88,,,,,,,,,,,,,
AGENT HEMSTAT 8ML FLX TIP MTRX + DISP SURGIFLO,SUP-2218262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.48,243.41,,,,,,,,,,,,,
COIL EMB L12CM DIA6MM 0020IN PERIPH L VOL COMPLX STD FRME,SUP-2323663,CDM,C1889,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
COLLAR CERV M AD H225XL13 16IN TRACH CLS 2 PC RIG POLYETH,SUP-2196882,CDM,L0120,HCPCS,0272,RC,,,,both,,,42.01,27.31,,,,,,,,,,,,,
BUR SURG 13 MM FLOWER PLATE AO ATTCH,SUP-2488395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1820.82,1183.53,,,,,,,,,,,,,
PLATE BNE CLAV CS3 2.7 MM LT LAT VA LCK COMPR TI STRL VALCP,SUP-2789381,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.56,2593.86,,,,,,,,,,,,,
RING EXT FIX FULL 140 MM NS TRUELOK LTX,SUP-2875055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1772.47,1152.11,,,,,,,,,,,,,
GUIDEWIRE VASC TRANSEND L 190 CM DIA 0.014 IN TIP 2 CM,SUP-2148244,CDM,C1769,HCPCS,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SCREW BNE L16MM DIA13MM GRN CORT TI ALLY ST SELF RET W T4,SUP-2180983,CDM,C1713,HCPCS,0278,RC,,,,both,,,309.45,201.14,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 25GM 14ML NONRECHARGEABLE PRGMR,SUP-2265160,CDM,C1767,HCPCS,0278,RC,,,,both,,,42864.14,27861.69,,,,,,,,,,,,,
CATHETER URET 6FR L70CM 0.038IN OPN END FLEXITIP FOR DRNGE,SUP-2171249,CDM,C1758,HCPCS,0278,RC,,,,both,,,61.58,40.03,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.535,SUP-2860052,CDM,C1713,HCPCS,0278,RC,,,,both,,,46155.80,30001.27,,,,,,,,,,,,,
VALVE VENT ULT SM L20MM DIA11MM THK4MM POLYPR SIL ELASTMR LO,SUP-2278340,CDM,C1889,HCPCS,0278,RC,,,,both,,,2064.61,1342.00,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM DIA18 MM POLYESTER BOV CLLGN,SUP-2488967,CDM,C1768,CPT,0278,RC,,,,both,,,1364.83,887.14,,,,,,,,,,,,,
TUBE VENT DIA1.14MM INNR FLNG DIA2.6MM INTERFLNG DISTANCE,SUP-2284022,CDM,L8699,HCPCS,0278,RC,,,,both,,,164.13,106.68,,,,,,,,,,,,,
PLATFORM GELPOINT V PATH TRANSVAGINAL ACCEES,SUP-2848990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE SPNL L42MM ANTR BILAT CERV LO PROF LEV 2 UNIPLT,SUP-2256434,CDM,C1713,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
KERECIS OMEGA3 SURIBLIND,SUP-2909169,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9815.64,6380.17,,,,,,,,,,,,,
HEMODIALYSIS KIT RAD FREQ DEL DEV STRL REZUM,SUP-2424811,CDM,C1713,HCPCS,0278,RC,,,,both,,,4033.02,2621.46,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 20 FR 7-10 CC SECUR-LOK EXT ENFIT MIC,SUP-2764437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.55,278.56,,,,,,,,,,,,,
SPLINT ORTHOPEDIC PADDED FOAM PERF ALUM,SUP-2195267,CDM,L3931,HCPCS,0274,RC,,,,both,,,27.82,18.08,,,,,,,,,,,,,
VALVE 15 WITH PEDIATRIC PRECHAMBER MININAV,SUP-2821802,CDM,C1889,HCPCS,0278,RC,,,,both,,,1592.77,1035.30,,,,,,,,,,,,,
PLATE BNE L405MM 20 H R CNDYL S STL CRV LOK COMPR VAR ANG,SUP-2177870,CDM,C1713,HCPCS,0278,RC,,,,both,,,8353.44,5429.74,,,,,,,,,,,,,
AGENT HEMSTAT 3GM OXIDIZED REGENERATED CELOS ABSRB FOR CONT (ORDER MULTIPLES OF 5EA),SUP-2218277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,454.61,295.50,,,,,,,,,,,,,
DEVICE FIX KNOTLESS 3 MM HIP ARTHCARE PEEK IMPL SPEEDLOCK,SUP-2848538,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
CATHETER ANGIOPLSTY STERLING L 150 CM BALLOON L 220 MM DIA 5,SUP-2140769,CDM,C1725,HCPCS,0272,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
GRAFT NERVE REP L 6 X W 3 CM AMNIO MEMBRN MULTLYRED MTRX,SUP-2914053,CDM,C1762,CPT,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
COMPONENT TIB L9CM PROX MOD BODY ORTH SALV SYS,SUP-2405794,CDM,C1776,CPT,0278,RC,,,,both,,,17676.63,11489.81,,,,,,,,,,,,,
BLADE SHV DIA4MM 40DEG CRV SERR DISECT CONCAVE WIND FOR,SUP-2313828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.24,219.21,,,,,,,,,,,,,
MATRIX BIO L 4 X W 4 CM SZ 29 SQCM FISH SKIN DERMAL,SUP-2909208,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4195.04,2726.78,,,,,,,,,,,,,
BAR EXT FIX CRV 11X175 MM CARBON XTRAFIX,SUP-2472619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1707.66,1109.98,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 130 CM DIA 0.018 IN SS SIL J LNG,SUP-2148319,CDM,C1769,HCPCS,0272,RC,,,,both,,,273.93,178.05,,,,,,,,,,,,,
KIT INFUS PRT L76CM DIA10FR PLAS ATTCH SIL 2 LUMN OPN END,SUP-2127743,CDM,C1788,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
LEAD DEFIB ENDOTK ENDUR EZ L 64 CM DIA11 FR SIL PTIR STEROID,SUP-2148552,CDM,C1895,HCPCS,0275,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
PERI-LOC 2.5MM S-T LOCK SCREW 14MM,SUP-2819439,CDM,C1713,HCPCS,0278,RC,,,,both,,,804.09,522.66,,,,,,,,,,,,,
PLATE BNE L94MM THK3MM 5 H BILAT S STL STR LOK COMPR RECON,SUP-2185333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.95,843.67,,,,,,,,,,,,,
SPLINT WRST L L THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326138,CDM,L3908,HCPCS,0272,RC,,,,both,,,63.05,40.98,,,,,,,,,,,,,
RASP SURG M L18.3MM DIA3.2MM HELICOIDAL,SUP-2367457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.33,227.71,,,,,,,,,,,,,
STAPLE BNE FIX SZ 28 X 17 X 14 MM ANAT QUAD RAPID COMPR STRL,SUP-2893066,CDM,C1713,HCPCS,0278,RC,,,,both,,,11771.86,7651.71,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 8 MM EPTFE STR TW REINF 2,SUP-2501038,CDM,C1768,CPT,0278,RC,,,,both,,,349.98,227.49,,,,,,,,,,,,,
GRAFT VASC GORTX L 90 CM DIA 8 MM RNG L 70 CM EPTFE STR TW,SUP-2396138,CDM,C1768,CPT,0278,RC,,,,both,,,3645.54,2369.60,,,,,,,,,,,,,
GUIDE DRILL 3.5MM 90 DEG CANN LC-ANGLED BLADE PLATE,SUP-2548615,CDM,C1713,HCPCS,0278,RC,,,,both,,,3056.38,1986.65,,,,,,,,,,,,,
PLATE BNE L 186 MM SCREW DIA 3.5/4.5 MM 6 H LT TROCHANTERIC 72586106N,SUP-2933170,CDM,C1713,HCPCS,0278,RC,,,,both,,,20905.34,13588.47,,,,,,,,,,,,,
PLATE SPNL L 22 MM TI ANTR CERV LEVEL 1 NS SONOMA,SUP-2887221,CDM,C1713,HCPCS,0278,RC,,,,both,,,93.38,60.70,,,,,,,,,,,,,
BUR SURG L64MM OD14MM NONFLUTED CARB ACORN CUT,SUP-2278089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.51,341.58,,,,,,,,,,,,,
TRANSFER SET 9 LD VENTED MANIFOLD STRL PINNACLE LF,SUP-2774414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2021.38,1313.90,,,,,,,,,,,,,
BUNDLE CASE DISTRCTN CRAN MXLFCL 2 FULL SKULL RECON VSP,SUP-2862826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,20163.89,13106.53,,,,,,,,,,,,,
BUR SURG DIAMOND 15 DEG 3 MMX12.5 CM MTCH HD DSTL BEND IBUR,SUP-2859508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
PLATE BONE W15XL15MM 4 H TI CRAN BX SHP RIG FOR 2MM SCR,SUP-2191323,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
MESH HERN 16X12CM L POLY CLLGN COAT ANAT W LAT SLT,SUP-2752161,CDM,C1781,HCPCS,0278,RC,,,,both,,,739.38,480.60,,,,,,,,,,,,,
BIT DRL L100MM DIA2MM AO FOR HALLU-LOCK MTP ARTH SYS,SUP-2243439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,727.16,472.65,,,,,,,,,,,,,
PIN BTTRS L20MM DIA1.8MM DST RAD S STL LOK STARDRV T8,SUP-2183129,CDM,C1713,HCPCS,0278,RC,,,,both,,,315.22,204.89,,,,,,,,,,,,,
COMPONENT PATELLAR ASYM 40X11 MM SUP INFERIOR KNEE BEAD,SUP-2373635,CDM,C1776,CPT,0278,RC,,,,both,,,3011.89,1957.73,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 5 MM EPTFE TW PED SHUNT STRL,SUP-2396686,CDM,C1768,CPT,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 2X2CM,SUP-2905501,CDM,Q4151,HCPCS,0636,RC,,,,both,,,2576.31,1674.60,,,,,,,,,,,,,
CATHETER INTRAUTERINE BALLOON L 4 CM DIA 9 FR 5 ML SYR SIL,SUP-2168944,CDM,C2628,HCPCS,0272,RC,,,,both,,,118.41,76.97,,,,,,,,,,,,,
PLATE BONE MINI L38MM CVD,SUP-2364914,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
INTRODUCER CATH 8.5FR L71CM 8.5FR DIL L180CM DIA0.032IN W/,SUP-2357599,CDM,C1894,HCPCS,0272,RC,,,,both,,,3395.75,2207.24,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 80 CM DIA10 FR HYDRPHLC,SUP-2894394,CDM,C1894,HCPCS,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
MASK LARYN PED SZ 5 40ML AIRWY DEV ONLY REINF REUSE LMA,SUP-2383564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.86,568.01,,,,,,,,,,,,,
BARRIER ADH REDUCTION SOLUTION 1.5 LT FLX PVC CLR STRL ADEPT,SUP-2130305,CDM,C1765,HCPCS,0278,RC,,,,both,,,765.53,497.59,,,,,,,,,,,,,
TUNNELER SURG 17 GAX12 IN,SUP-2361474,CDM,C1894,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CLAMP PIN XTRAFIX 2 BAR 45MM BL,SUP-2459420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3932.79,2556.31,,,,,,,,,,,,,
PLATE EXT FIX 3 H SIDEKCK FREE CIR FIX,SUP-2400678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
SHEATH INTRO ARW GLIDETHRU L 7 CM DIA 5 FR DIL 5 FR POLYUR,SUP-2887199,CDM,C1894,HCPCS,0272,RC,,,,both,,,46.16,30.00,,,,,,,,,,,,,
SLING GYN L45XW1CM UNIV FLAT TAPE ANTR VAG POLYPR FOR URETH,SUP-2165318,CDM,C1771,HCPCS,0278,RC,,,,both,,,3194.95,2076.72,,,,,,,,,,,,,
KIT ACC TRANSRADIAL SPR WIRE RADIALSOURCE RED 4FRX6.5CM MINI,SUP-2157406,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.27,65.83,,,,,,,,,,,,,
CARBACHOL 0.01 % IO SOLN,RX-19704,CDM,6370000000,HCPCS,0637,RC,00065-0023-15,NDC,,both,.5,ML,89.10,57.91,,,,,,,,,,,,,
MESH SZ 4X16CM IMPL FOR HUM ALLGRFT ACELLULAR DERM CLLGN,SUP-2300710,CDM,C1713,HCPCS,0278,RC,,,,both,,,5761.90,3745.23,,,,,,,,,,,,,
CATHETER INTVASC OCCL SCEPTER MINI L 165 CM PROX/DSTL,SUP-2753241,CDM,C2628,HCPCS,0272,RC,,,,both,,,9594.27,6236.28,,,,,,,,,,,,,
NEEDLE ASPRIRATION 25GA EXPECT PULMONARY,SUP-2855142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3078.77,2001.20,,,,,,,,,,,,,
CEFAZOLIN SODIUM 3 G SOLR (MIXTURES ONLY),RX-430080,CDM,J0688,HCPCS,0636,RC,00143-9140-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
NAIL IM L210MM OD10MM 130DEG CANN LOK MEDIOLATERAL BENT,SUP-2343921,CDM,C1713,HCPCS,0278,RC,,,,both,,,1708.79,1110.71,,,,,,,,,,,,,
COIL VASC NIT-OCCLUD L 3.5 MM DIA DSTL/PROX 6/5 MM,SUP-2659225,CDM,C1889,HCPCS,0278,RC,,,,both,,,8425.53,5476.59,,,,,,,,,,,,,
ALLOGRAFT DERMAL 60-90X7 MM FRZN COSTAL CART DERM ORACELL,SUP-2741029,CDM,C1762,CPT,0278,RC,,,,both,,,1879.29,1221.54,,,,,,,,,,,,,
GRAFT BNE DRILLABLE 5 CC VOID FILL STRL LTX,SUP-2865883,CDM,C1713,HCPCS,0278,RC,,,,both,,,6604.05,4292.63,,,,,,,,,,,,,
MATERIAL TRANSPLANT FECAL MICROBIOTA,SUP-2866781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
PLATE BNE VA NEUT 2.7/3.5X202 MM RT DSTL TIB 12 HOLE LCK LP,SUP-2177682,CDM,C1713,HCPCS,0278,RC,,,,both,,,5943.42,3863.22,,,,,,,,,,,,,
BUR SURG L10CM DIA3MM MTCH HD FLUT SM BOR MIDAS REX LEGEND,SUP-2277620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,296.89,192.98,,,,,,,,,,,,,
PIN FIX DPLX HD 1/8X2.5 IN,SUP-2361949,CDM,C1713,HCPCS,0278,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
CAGE SPNL 12 DEG 12X45X22 MM CLYDESDALE,SUP-2277990,CDM,C1889,HCPCS,0278,RC,,,,both,,,11514.38,7484.35,,,,,,,,,,,,,
PLATE TIB SZ 5 POR STEM NXGN,SUP-2201518,CDM,C1713,HCPCS,0278,RC,,,,both,,,8878.35,5770.93,,,,,,,,,,,,,
MANOMETER ET INFL BLB AIR VENT BTTN CUFFLATOR,SUP-2328646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1047.03,680.57,,,,,,,,,,,,,
SPACER SPNL W12XH7XL14MM 5DEG PEEK OPTMA INTERVERTEBRAL,SUP-2137142,CDM,C1821,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 3 Y SHP XLN PLATE 1 PK,SUP-2936712,CDM,C1713,HCPCS,0278,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
HC So Dgp Antibody Each Ig Class,PX-3028625866,CDM,86258,CPT,0302,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
KIT INTRO 10.5FR L14CM XTW NDL 18GA GWIRE L50CM 0.038IN SYR,SUP-2357066,CDM,C1892,HCPCS,0272,RC,,,,both,,,27.63,17.96,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA MRI XT SURESCAN W 51 X H 68 MM D 13,SUP-2282399,CDM,C1721,HCPCS,0275,RC,,,,both,,,35168.00,22859.20,,,,,,,,,,,,,
PUSHER COIL L 177 CM DIA 0.016 IN CATH 0.018 IN STRL,SUP-2142674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
WIRE FIX 2X150 MM TROCAR PT ON BOTH ENDS SS NS KIRSCHNER,SUP-2186879,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.07,188.55,,,,,,,,,,,,,
HANDPIECE BX SAVI SCOUT DISP,SUP-2517638,CDM,C1819,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT HUM TISS W13-10MMXL8-14CM PAT TEND BONE HEMI SHP BLK,SUP-2307033,CDM,C1713,HCPCS,0278,RC,,,,both,,,4191.90,2724.73,,,,,,,,,,,,,
BUR SURG BALL 5 MMX10 CM SYMMETRI MIDAS REX LEGEND,SUP-2627625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,498.07,323.75,,,,,,,,,,,,,
PLATE TI VA-LOCKING CALCANEAL LARGE 2.7MM 70MM RGHT STRL,SUP-2547003,CDM,C1713,HCPCS,0278,RC,,,,both,,,3667.99,2384.19,,,,,,,,,,,,,
GRAFT VASC 4 CC AMNIO VERESHIELD,SUP-2307531,CDM,C1762,CPT,0278,RC,,,,both,,,6845.20,4449.38,,,,,,,,,,,,,
PATCH CV 0.6X10CMX0.4MM,SUP-2395304,CDM,C1768,CPT,0278,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 X W 20 MM THK 4 MM ACHILLES TEND RC,SUP-2932778,CDM,C1762,CPT,0278,RC,,,,both,,,4714.52,3064.44,,,,,,,,,,,,,
PLATE EXT FIX L 65 MM 5 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.70,380.70,,,,,,,,,,,,,
CATHETER PICC AD 5FR 18GA L55CM 2 LUMN NRS PWR INJ N COAT,SUP-2125640,CDM,C1751,HCPCS,0278,RC,,,,both,,,635.79,413.26,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 50 CM DIA12 X 6 MM THK 0.49 MM POLYESTER,SUP-2227287,CDM,C1768,CPT,0278,RC,,,,both,,,2567.70,1669.00,,,,,,,,,,,,,
ROD EXT FIX PRE BENT XL CRANIOMAXILLOFACIAL FULL MAND TI,SUP-2460030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2455.35,1595.98,,,,,,,,,,,,,
SCREW BNE COMPR 13X14 MM NOTCH TI UNI-CLIP,SUP-2609072,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.57,1939.32,,,,,,,,,,,,,
RING EXT FIX 160 MM 5/8 MR SAFE TI NS,SUP-2863408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1986.11,1290.97,,,,,,,,,,,,,
STEM FEM SZ 0 L N CLLRD POR NAT HIP,SUP-2210731,CDM,C1776,CPT,0278,RC,,,,both,,,24680.40,16042.26,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 6.6 FRX90 CM PEEL APART INTRO BRVC,SUP-2127698,CDM,C1751,HCPCS,0278,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
PLATE STRUT 2MM 12H TI STRL VAL,SUP-2546913,CDM,C1713,HCPCS,0278,RC,,,,both,,,2164.46,1406.90,,,,,,,,,,,,,
BAR EXTRNL FXTN 11MM DIA 380MML CRBN FIBER CRVD XTRFX,SUP-2722165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1852.57,1204.17,,,,,,,,,,,,,
BUTTON ARTHSCP W/ DRL GWIRE PASS PIN BONE TUNN PLUG ULT PAC,SUP-2341856,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.68,726.49,,,,,,,,,,,,,
PLATE BNE L112MM 4 H L OLECRANON S STL LOK COMPR FOR 3.5MM,SUP-2185424,CDM,C1713,HCPCS,0278,RC,,,,both,,,3005.83,1953.79,,,,,,,,,,,,,
GUIDEWIRE THREADED TROCAR TIP,SUP-2714101,CDM,C1769,HCPCS,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
ANCHOR SUTURE BIOCOMP W/ 3 STRANDS W/ 3 STRANDS STRL,SUP-2907515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
PLATE BNE L33MM THK1MM 2X6 H HND 316L S STL VAR ANG LOK ROT,SUP-2178016,CDM,C1713,HCPCS,0278,RC,,,,both,,,2024.86,1316.16,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR STD WALL REINF,SUP-2525439,CDM,C1768,CPT,0278,RC,,,,both,,,992.65,645.22,,,,,,,,,,,,,
BRACE ORTH SZ M 5 TO 7 WOM 6 TO 8 SM WLK LOEST PROF X LO,SUP-2195484,CDM,L4386,HCPCS,0272,RC,,,,both,,,221.84,144.20,,,,,,,,,,,,,
SCREW BNE L14MM DIA35MM LOK ST T20 FOR SM FRAG PLATING SYS,SUP-2350129,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.85,728.55,,,,,,,,,,,,,
HEAD FEM DIA26MM NK L0MM STD CERAMIC ZIRCONIA 12/14 TAPR PRI,SUP-2344550,CDM,C1776,CPT,0278,RC,,,,both,,,4684.10,3044.66,,,,,,,,,,,,,
OCCLUDER CV AMPLATZER PICCOLO WAIST DIA 3 MM BTWN DISC L 2,SUP-2904254,CDM,C1889,HCPCS,0278,RC,,,,both,,,28888.00,18777.20,,,,,,,,,,,,,
PLATE RECON THRDLCK TS ANGLE ANGLE 27 MM SCREW 28 HOLE T30,SUP-2679088,CDM,C1713,HCPCS,0278,RC,,,,both,,,5260.98,3419.64,,,,,,,,,,,,,
SCREW BNE L17MM DIA2.7MM LOK FOR R3CON PLATING SYS GORILLA,SUP-2321279,CDM,C1713,HCPCS,0278,RC,,,,both,,,573.84,373.00,,,,,,,,,,,,,
SNARE VASC 1 SNR L 200 CM LOOP DIA 7 MM CATH L 175 CM,SUP-2303151,CDM,C1773,HCPCS,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
HARVESTER BNE GRFT CLOSED 4.75 MM KNEE TEND NS REUSE,SUP-2762177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG 1.14 MM ID SIL STRL BLU GOODE,SUP-2381505,CDM,L8699,HCPCS,0278,RC,,,,both,,,155.49,101.07,,,,,,,,,,,,,
CEFAZOLIN IN SODIUM CHLORIDE 2-0.9 GM/100ML-% IV SOLN,RX-135152,CDM,J0690,HCPCS,0636,RC,99990-0043-19,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA 3.2 MM MANDIBULAR XDRV EMER DISP,SUP-2934872,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
CEMENT BNE 20ML 40GM HALF DOSE PMMA W/ 0.5GM GENT HI VISC,SUP-2197462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1338.68,870.14,,,,,,,,,,,,,
GUIDEWIRE SURG LNG DIA25MM SPHR VAR ANG FOR 5MM CANN SCR LCP,SUP-2179119,CDM,C1769,HCPCS,0272,RC,,,,both,,,2433.56,1581.81,,,,,,,,,,,,,
SCALPEL SURG SAFETY SZ 10 STAINLES STL W/LNG LCK BARD PARKER,SUP-2605891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4.99,3.24,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK08 17MM THCK HYDRATED ACELLULAR,SUP-2307471,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4259.72,2768.82,,,,,,,,,,,,,
PLATE BONE W8XL36MM 2 H TI DYN COMPR FOR 2.7MM SCR,SUP-2191068,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.87,696.07,,,,,,,,,,,,,
IMPLANT TOE SZ 40 FOREFOOT PRIMUS GREAT W/ GRMMT FUTURA,SUP-2399911,CDM,C1776,CPT,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
PLATE BONE L59MM 10 H SUBCONDYLAR FT TI FX FUS FOR 2.7MM SCR,SUP-2319674,CDM,C1713,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
CAGE SPNL 14X23-32MM 2-5 DEG GIZA,SUP-2362882,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
SPACER FEM M/L THK5MM R MED DST DURAC,SUP-2377201,CDM,C1776,CPT,0278,RC,,,,both,,,39.53,25.69,,,,,,,,,,,,,
DRILL SURG L4.5MM FT CANN FOR MOV GREAT TOE SYS,SUP-2244013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,820.51,533.33,,,,,,,,,,,,,
URETHRAL DILATION BLLN CATHETER,SUP-2827463,CDM,C1726,HCPCS,0272,RC,,,,both,,,606.65,394.32,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CER GRAN TYPE-I BOV CLLGN RPM,SUP-2930811,CDM,C1763,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
TUBE VENT NO3 DIA1.50MM SIL PAPARELLA TUPE III,SUP-2312787,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.04,26.03,,,,,,,,,,,,,
TM SHT FLANGE CAGE LT 66/68/70 SHELL/58 LINER,SUP-2503954,CDM,C1776,CPT,0278,RC,,,,both,,,7121.52,4628.99,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CORTICAL FIBER,SUP-2898991,CDM,C1713,HCPCS,0278,RC,,,,both,,,3065.43,1992.53,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CAP5100] ZIMMER BIOMET INC],SUP-2212487,CDM,C1776,CPT,0278,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO-2 L 200 CM DIA 0.014 IN SS NIT,SUP-2148473,CDM,C1769,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SLING URETH SINGLE INCISION SYS BLU SOLYX,SUP-2424699,CDM,C1771,HCPCS,0278,RC,,,,both,,,6233.21,4051.59,,,,,,,,,,,,,
CATHETER GUID 5FR L70CM 0.038IN W/O HYDRPHLC COAT RADPQ,SUP-2117057,CDM,C1887,HCPCS,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
SET DCOMPR CATH OD8.5FR GWIRE L480CM OD0.035IN PUR BROD,SUP-2169139,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ACHILLES TEND FRZN W/O BNE NO-RAD,SUP-2321829,CDM,C1762,CPT,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
PLATE BNE L 200 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 16 H 72463116,SUP-2933390,CDM,C1713,HCPCS,0278,RC,,,,both,,,7412.76,4818.29,,,,,,,,,,,,,
FIXATION KIT BNE DART FOR ALLOSYNC PIP DISP,SUP-2423624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1342.35,872.53,,,,,,,,,,,,,
TIBIAL NAIL D15XL405,SUP-2703049,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 3X3X3 MM 15 CC PTTY STRL OSTEOSTRUX,SUP-2731805,CDM,C1713,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
SPLINT WRST SM L11IN L FA BLU CANVS HK AND LOOP PREMIERPRO,SUP-2336038,CDM,L3809,HCPCS,0274,RC,,,,both,,,18.65,12.12,,,,,,,,,,,,,
PERMETHRIN 1 % EX LIQD,RX-10918,CDM,6370000000,HCPCS,0637,RC,63736-0120-02,NDC,,both,59,ML,40.10,26.06,,,,,,,,,,,,,
KIT BNE CEM PREP FEM W O RESTRIC BRSH CURET NOZ AND SPNG,SUP-2257057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
IMPLANT TALAR SZ 1 ANK LT VANTAGE,SUP-2223466,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
HOOK RETRCT 3 MM 90 DEG 9.5 IN NERVE ANGLED RUGGLES-REDMOND,SUP-2475862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.49,274.62,,,,,,,,,,,,,
BIT DRL L190MM DIA11MM 2.7MM CANN QUIK CPL,SUP-2188296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1688.63,1097.61,,,,,,,,,,,,,
CLAMP SURG L11MM CRAN TI CRANIOFIX 2,SUP-2108413,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
SHELL ACET THRD 37 MM ALTERNATE BEAR,SUP-2442607,CDM,C1776,CPT,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
SCREW BNE L85MM OD5MM THRD L30MM DK PUR CORT FEM TI ST CANN,SUP-2180325,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.57,307.82,,,,,,,,,,,,,
COMPONENT TOE JT W5XL15MM L PROX DST X TYP HAMMERLOCK 2,SUP-2194198,CDM,C1776,CPT,0278,RC,,,,both,,,2398.39,1558.95,,,,,,,,,,,,,
PLATE BNE L286MM 14 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185686,CDM,C1713,HCPCS,0278,RC,,,,both,,,4515.38,2935.00,,,,,,,,,,,,,
KIT PROC CLR GLDE EVH,SUP-2266078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
BLADE RTRCTR BLFR 4ND ABDMNL WIRE LTRL JARIT NON ST,SUP-2485511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,867.49,563.87,,,,,,,,,,,,,
BLADE RTRCTR 1 12NW X 2 14ND STNLSS STEEL GRRTT JARIT LATE,SUP-2703326,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.15,466.80,,,,,,,,,,,,,
SCREW ADAPT LAG OMEGA,SUP-2468054,CDM,C1713,HCPCS,0278,RC,,,,both,,,1213.30,788.64,,,,,,,,,,,,,
CLIP SURG L155CM CHN DIA2.8MM OPN W11IN RESOL 360 1/BX,SUP-2141392,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
PLATE BNE L46MM 7 H DST ULN S STL LOK COMPR FOR 2MM SCR,SUP-2186125,CDM,C1713,HCPCS,0278,RC,,,,both,,,2122.29,1379.49,,,,,,,,,,,,,
PLATE BNE THK0.5MM 12MM BAR 6 H 100DEG UNIV,SUP-2366248,CDM,C1713,HCPCS,0278,RC,,,,both,,,677.64,440.47,,,,,,,,,,,,,
GRAFT HUM TISS L 22 X W 22 X H 8/5 MM IL CREST UNICORTICAL,SUP-2913406,CDM,C1762,CPT,0278,RC,,,,both,,,7598.80,4939.22,,,,,,,,,,,,,
DEVICE GRFT DEL FOR BONE VOID FIL NORIAN,SUP-2419206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.99,240.49,,,,,,,,,,,,,
MESH CS LEFT MEDIUM 8 CM X 14 CM,SUP-2655636,CDM,C1781,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SALVATION 160MM TAB FT RNG,SUP-2401134,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
CABLE SPNL L470MM DIA1MM TI SGL LD CRMP,SUP-2193140,CDM,C1889,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
HC So Fructosamine,PX-3018298566,CDM,82985,CPT,0301,RC,,,,outpatient,,,274.00,178.10,,,,,,,,,,,,,
GRAFT VASC GELSFT + L 50 CM DIA22 MM POLYESTER GEL,SUP-2384965,CDM,C1768,CPT,0278,RC,,,,both,,,1181.21,767.79,,,,,,,,,,,,,
SET DRNAGE 16FR L18CM 0038IN LOK LOOP SUMP TO DRN,SUP-2168260,CDM,C1729,HCPCS,0272,RC,,,,both,,,495.34,321.97,,,,,,,,,,,,,
SCREW BONE L40MM DIA3.5MM HD DIA6MM STD CORT TI ST SM HEX,SUP-2189860,CDM,C1713,HCPCS,0278,RC,,,,both,,,49.83,32.39,,,,,,,,,,,,,
SEALER TISS L25CM ADV BPLR STR RND TIP LAP APPRCH ENSEAL,SUP-2257690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5727.71,3723.01,,,,,,,,,,,,,
NAIL IM FEM UNIV LNG 11.5 MMX28 CM RETROGRADE TI NAT NAIL,SUP-2459942,CDM,C1713,HCPCS,0278,RC,,,,both,,,6313.16,4103.55,,,,,,,,,,,,,
BUTTON GASTROSTMY CONT FEED TUBE 24 FRX24 IN NON-BLLN NS,SUP-2166552,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
SCREW SPNL L45MM DIA5.5MM SUPLMNT CANC TI FIX ST TOP LEV,SUP-2137272,CDM,C1713,HCPCS,0278,RC,,,,both,,,2326.36,1512.13,,,,,,,,,,,,,
BLADE SHAVER 4.2 MMX10.5 CM STR IRRIG XTRASHRP MICROXCISOR,SUP-2607703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,287.94,187.16,,,,,,,,,,,,,
EVOS 2.7/3.5MM EA-D HUM PL 20H RIGHT 239MM,SUP-2819911,CDM,C1713,HCPCS,0278,RC,,,,both,,,9929.31,6454.05,,,,,,,,,,,,,
IMPLANT HUM TISS DIA16 MM SM PA CONDUIT NONVALVED REDUC,SUP-2932799,CDM,C1762,CPT,0278,RC,,,,both,,,24891.03,16179.17,,,,,,,,,,,,,
PLATE BNE L80MM 5 H NONSTERILE L ANTLAT DST TIB S STL LO,SUP-2185944,CDM,C1713,HCPCS,0278,RC,,,,both,,,4143.92,2693.55,,,,,,,,,,,,,
BUR NEUROSURGICAL CUT RND FLUT S STL TAPR 11MM 160MM,SUP-2284385,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.43,181.63,,,,,,,,,,,,,
TUBE SZ DIA10MM FOR BONE GRFT ACUFEX ACL PCL RECON DRL GUID,SUP-2340724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
KIT MICROINTRODUCER 4FR GWIRE L40CM DIA0.018IN ECHOGENIC NDL,SUP-2120522,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.61,92.05,,,,,,,,,,,,,
ROD W/ HEX 40MM TI ALLOY CVD,SUP-2415261,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.56,926.61,,,,,,,,,,,,,
CATHETER CARD ABLATION L 5 MM DIA 6 FR STD CRV QPLR STEER,SUP-2141243,CDM,C1730,HCPCS,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-107187,CDM,J1453,HCPCS,0636,RC,31722-0165-31,NDC,JW,both,1,UN,69.80,45.37,,,,,,,,,,,,,
HC Tips,PX-3613718200,CDM,37182,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 20 CM DIA20 MM 0.035 IN,SUP-2761719,CDM,C1889,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
ATTACHMENT HNDPC L14CM DIA32MM STR L BOR MIDAS REX LEGEND,SUP-2284669,CDM,C1713,HCPCS,0278,RC,,,,both,,,3977.69,2585.50,,,,,,,,,,,,,
OR INTVENT PK,SUP-2155845,CDM,C1894,HCPCS,0272,RC,,,,both,,,484.41,314.87,,,,,,,,,,,,,
INTRODUCER SHTH BLLST 088 L 100 CM DIA 0.088 IN LNG HYDRPHLC,SUP-2717621,CDM,C1894,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
PLATE BNE SUP SACROILIAC PELV 4 HOLE,SUP-2518371,CDM,C1713,HCPCS,0278,RC,,,,both,,,4430.54,2879.85,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COGNIS RF HE TI CRT RF HI ENERGY STRL,SUP-2149059,CDM,C1722,HCPCS,0275,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
PIN EXT FIX L 160 M DIA 5 MM THRD L 35 MM SS HALF UNILAT NS,SUP-2931402,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.20,589.03,,,,,,,,,,,,,
PLATE BONE L162MM 4X20X4 H BILAT MAND ORAL MAXILLOFACIAL TI,SUP-2191431,CDM,C1713,HCPCS,0278,RC,,,,both,,,9607.46,6244.85,,,,,,,,,,,,,
BLADE SHAVER CUT 4.5X120 MM AGGRESSIVE DK GRY GRN UNIDRIVE,SUP-2585904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,243.35,158.18,,,,,,,,,,,,,
STEM FEM SEG 9 CM DPHSEAL KNEE TAPR OSS,SUP-2441750,CDM,C1776,CPT,0278,RC,,,,both,,,14356.08,9331.45,,,,,,,,,,,,,
GRAFT BNE SUB M GRN CA CRBNT PTTY INJ RESRB SIGNAFUSE,SUP-2138528,CDM,C9359,HCPCS,0278,RC,,,,both,,,1448.33,941.41,,,,,,,,,,,,,
HC So Drvvt,PX-3058561366,CDM,85613,CPT,0305,RC,,,,both,,,116.00,75.40,,,,,,,,,,,,,
COMPONENT TIB SZ 4 RT ANK TI POR CEM AGIL,SUP-2252063,CDM,C1776,CPT,0278,RC,,,,both,,,11156.42,7251.67,,,,,,,,,,,,,
SET ORTHOPEDIC INSTR LISFRANC SYS STRL DISP TRUAIM,SUP-2900810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
SCREW BNE EMGCY 2.5X13 MM STRNL LEVEL 1 MAXDRIVE 240241361,SUP-2869205,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.04,52.03,,,,,,,,,,,,,
PLATE BNE SM 10 H MAXILLOMANDIBULAR TI MATRIXWAVE,SUP-2181782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.02,700.06,,,,,,,,,,,,,
GRAFT BNE LORDTC 5 MM CERV MONOLITHIC CORTICAL ALLOQUENT,SUP-2601443,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
DRIVER SURG 2.5MM HEX,SUP-2123644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
NEEDLE INJ BNE GRFT 11 GAX6 IN IMBIBE 20909028,SUP-2531428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
KIT FIX DIA10 MM TIB TUNN STRL QUADLINK,SUP-2930404,CDM,C1713,HCPCS,0278,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
GRAFT BNE L150-200XW6MM THICKNESS 3-15MM CORT TIB FRZN,SUP-2307371,CDM,C1713,HCPCS,0278,RC,,,,both,,,4370.57,2840.87,,,,,,,,,,,,,
BUTTON GASTROSTOMY 24FR DIA 2.4INL PULL STEP,SUP-2457354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.26,353.77,,,,,,,,,,,,,
PACK 155F X 19CM SYMETREX SPRT,SUP-2269561,CDM,C1750,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PASSER SUT L48IN 70DEG ANG UP 1 MFIL SHUTTLE ST DISP FOR,SUP-2341714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.07,289.95,,,,,,,,,,,,,
MESH SYNTH ABD N ABSRB RECT EXP POLYTETRAFLUROETHYLENE 24CM,SUP-2395832,CDM,C1781,HCPCS,0278,RC,,,,both,,,3742.88,2432.87,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.517,SUP-2860199,CDM,C1713,HCPCS,0278,RC,,,,both,,,30851.13,20053.23,,,,,,,,,,,,,
CATHETER DIL BLLN L16MM DIA7MM HI PERF SFT TIP SMOOTH PASS,SUP-2106322,CDM,C1726,HCPCS,0272,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
DILATOR SURG L14CM OD1-5MM SH SGL END VASC MALL SHFT REUSE,SUP-2384418,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
HC So1 Porphobilinogenurine Quant,PX-3018411067,CDM,84110,CPT,0301,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
SPACER SPNL LG 12 DEG 16 MM PEEK PERIMETER,SUP-2629068,CDM,C1889,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
SET URET STENT SOFFLX L 75 CM DIA 8.4FR GUIDEWIRE L 100CM RT,SUP-2835726,CDM,C2617,HCPCS,0278,RC,,,,both,,,221.24,143.81,,,,,,,,,,,,,
PLATE BNE L74MM 3X5 H OBLQ T SHP FOR 3.5MM SCR,SUP-2411364,CDM,C1713,HCPCS,0278,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
GRAFT BONE SUB W6.5XH25XL20MM 10DEG B TRICALCIUM PHOS GRAN,SUP-2194022,CDM,C1713,HCPCS,0278,RC,,,,both,,,3081.60,2003.04,,,,,,,,,,,,,
PLATE BNE DELT 117 MM RT DSTL DORS RADIAL 8 HOLE LCK SS NS,SUP-2476105,CDM,C1713,HCPCS,0278,RC,,,,both,,,2649.47,1722.16,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.9MM CORT CRANIOMAXILLOFACIAL PUR S STL 5PK,SUP-2366109,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.50,123.82,,,,,,,,,,,,,
CUP ACET CRV FOR ALLOFIT TI,SUP-2449523,CDM,C1776,CPT,0278,RC,,,,both,,,2218.41,1441.97,,,,,,,,,,,,,
GUIDEROD ORTH BALL TIPPED 3X550 MM HINDFOOT FOR NAIL PHANTOM,SUP-2749692,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
PATCH HERN M DIA2.5IN CIR W/ STRP SEPRA TECHNOLOGY ABSRB,SUP-2125892,CDM,C1781,HCPCS,0278,RC,,,,both,,,1316.60,855.79,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ALTRUA20 TI SINGLE CHMBR BATTERY PWR STRL,SUP-2149106,CDM,C1722,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2127892,CDM,C1768,CPT,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
SHUTTLE SUT STR CRESC W CHIA IDEAL,SUP-2256806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
NAIL IM L170MM DIA10MM 125DEG TROCHANTERIC FEM TI CANN LOK,SUP-2370458,CDM,C1713,HCPCS,0278,RC,,,,both,,,4819.90,3132.93,,,,,,,,,,,,,
PLATE BNE L138MM 6 H NONSTERILE L OLECRANON S STL LOK COMPR,SUP-2185427,CDM,C1713,HCPCS,0278,RC,,,,both,,,3097.58,2013.43,,,,,,,,,,,,,
LEAD DEFIB ENDOTK ENDUR RX L 70 CM SIL STEROID ENDOCARD,SUP-2148550,CDM,C1895,HCPCS,0275,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
HC So Hemoglobin Fetal,PX-3058546066,CDM,85460,CPT,0305,RC,,,,both,,,479.00,311.35,,,,,,,,,,,,,
CLAMP MULT PIN FOR JET-X EXT FIX SYS,SUP-2342865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2646.80,1720.42,,,,,,,,,,,,,
SCREW CORK L STRYKR INSTR T HNDL CORN SEVERS EXTR FEM HD,SUP-2361588,CDM,C1713,HCPCS,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
TRAY APPL BRACHYTHERAPY SAVI 6-1 MINI,SUP-2164402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
STEM FEM PRSS FT 1 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267795,CDM,C1776,CPT,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
DRILL TWST FOR BOS HEX ATTCH 23MMXL 19X70MM,SUP-2262986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.58,300.68,,,,,,,,,,,,,
FLEXHD PLIABLE SHAPED THICK MED 11CM,SUP-2676607,CDM,Q4128,HCPCS,0636,RC,,,,both,,,11607.32,7544.76,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED RESURF S1EXACTECH] EXACTECH INC],SUP-2223655,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
WASHER ORTH FOR 3 MM CANN SCREW NS,SUP-2788645,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
SCREW CONN S STL STARDRV FOR LOK ATTCH PLT,SUP-2177788,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.52,287.64,,,,,,,,,,,,,
IMPLANT BRST 30ML 2W CK VLV FIL SYR TBNG KT,SUP-2113307,CDM,C1789,HCPCS,0278,RC,,,,both,,,34.01,22.11,,,,,,,,,,,,,
INTRODUCER SHTH STR 0.018 IN 6 FRX11 CM 21 GAX4 CM PRELUDE,SUP-2303222,CDM,C1894,HCPCS,0272,RC,,,,both,,,126.60,82.29,,,,,,,,,,,,,
TRAY CTRL VEN OD6FR 3 LUMN CATH NRS PWR INJ REV TAPR DSGN,SUP-2125556,CDM,C1751,HCPCS,0278,RC,,,,both,,,709.01,460.86,,,,,,,,,,,,,
MESH HERN W20X20IN SFT POLYPR OPN WV PROL SURGPRO,SUP-2744748,CDM,C1781,HCPCS,0278,RC,,,,both,,,2328.09,1513.26,,,,,,,,,,,,,
BRACE ORTH LUMBAR W/O RIGID STAY LSO,SUP-2388148,CDM,L0628,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
BLADE CARROLL GIRARD 38 708 02 07,SUP-2668410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,860.55,559.36,,,,,,,,,,,,,
CONTOURED MESH UNIV CENTER06MM PROFILE,SUP-2677393,CDM,C1713,HCPCS,0278,RC,,,,both,,,14468.74,9404.68,,,,,,,,,,,,,
SET URET STENT KWART RETRO INJ L22-32 CM DIA 6 FR INSRTR L,SUP-2835751,CDM,C2617,HCPCS,0278,RC,,,,both,,,403.18,262.07,,,,,,,,,,,,,
LEAD NRV STIM L90CM SPNL CRD TRL,SUP-2308600,CDM,C1897,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
MESH PLUG ULTRAPRO 3CM ANCHR 5CM RIM SM,SUP-2220113,CDM,C1781,HCPCS,0278,RC,,,,both,,,697.90,453.63,,,,,,,,,,,,,
COMPONENT PAT STANDARD+ POLYETH CRUCFRM MOB BEAR REPL NP,SUP-2250806,CDM,C1776,CPT,0278,RC,,,,both,,,1880.23,1222.15,,,,,,,,,,,,,
"DYNACLIP STAPLE, 4-LEG, QUATTRO, 22MM X 16MM X 16MM STERILE, PRELOADED (INSERTER)",SUP-2878451,CDM,C1713,HCPCS,0278,RC,,,,both,,,11194.10,7276.16,,,,,,,,,,,,,
RING SEGMENT CARBON FIBER 210MM,SUP-2457135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4300.54,2795.35,,,,,,,,,,,,,
RING TRAC L 22-24IN CERV CLOSE BK W/ 2.5IN SKULL AND POS PIN,SUP-2328118,CDM,L0810,HCPCS,0272,RC,,,,both,,,5510.70,3581.95,,,,,,,,,,,,,
SCREW BNE LAG 110 MM CANC SLD,SUP-2607101,CDM,C1713,HCPCS,0278,RC,,,,both,,,140.70,91.45,,,,,,,,,,,,,
BIT DRL QC 2.7X125 MM CALIB NS,SUP-2757823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,308.91,200.79,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE ZRCH 2 NYU END DRV RTCH 1.5 1,SUP-2495564,CDM,C1713,HCPCS,0278,RC,,,,both,,,16969.66,11030.28,,,,,,,,,,,,,
GRAFT DERM L20CMXW16CM THCKNESS 8 17MM ACELLULAR HYDRATED,SUP-2307477,CDM,Q4128,HCPCS,0636,RC,,,,both,,,25820.22,16783.14,,,,,,,,,,,,,
CATHETER HD KT 15 FRX50 CM DL AG HEMOSTATIC SHTH EDGE,SUP-2763035,CDM,C1750,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ADV CUP LNR G7 E1,SUP-2419008,CDM,C1776,CPT,0278,RC,,,,both,,,8364.96,5437.22,,,,,,,,,,,,,
BIT DRILL SURG DIA 3.5 MM MINI FOOTPRINT,SUP-2882964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.89,320.38,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN ADJ,SUP-2435599,CDM,L1650,HCPCS,0272,RC,,,,both,,,698.18,453.82,,,,,,,,,,,,,
HC Perq Dev Breast Add Strtctc,PX-3611928400,CDM,19284,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
REAMER SURG OD51MM S STL ACET SPHR CUTTINGEDGE,SUP-2361874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.27,683.33,,,,,,,,,,,,,
POLIOVIRUS VACCINE INACTIVATED IJ SUSP,RX-173415,CDM,J3376,HCPCS,0636,RC,49281-0860-10,NDC,,both,.5,ML,201.30,130.84,,,,,,,,,,,,,
CATHETER DLYS L62.5CM L SWAN NK 2 CUF ARGY CURL CATH,SUP-2283989,CDM,C1750,HCPCS,0278,RC,,,,both,,,560.84,364.55,,,,,,,,,,,,,
SET INT FIX BURR H PLATE DIA18.5 MM SCREW DIA1.5 MM 15-7382,SUP-2936401,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
BIT DRL CANN 2X115 MM QC,SUP-2221711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL SHLF,SUP-2435544,CDM,L0469,HCPCS,0272,RC,,,,both,,,1346.15,875.00,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO BASIC 18GA 10CM WNGD F118100T,SUP-2632723,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.73,159.07,,,,,,,,,,,,,
FOOTPLATE EXT FIX LNG 160 MM SET HEX RNG STRUT TRUELOK EVO,SUP-2875600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36721.04,23868.68,,,,,,,,,,,,,
ELECTRODE PRB HEMSTAS DSTL IRR 30CM BICAP,SUP-2312982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
STAPLE BNE FIX 30X7MM BRDG 4 20MM LEG Y SHP IMPL,SUP-2194192,CDM,C1713,HCPCS,0278,RC,,,,both,,,5748.84,3736.75,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE VASCADE DIA 5 FR CLLGN PTCH NIT DISC,SUP-2537979,CDM,C1760,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
BUR ENDOSCP BRL SEMI HOOD DK GRY PNK STRL UNIDRIVE DISP,SUP-2585909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,273.34,177.67,,,,,,,,,,,,,
BIT DRL DIA49MM SHT CALIB FOR NAT NAIL SYS,SUP-2198667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X30 MM PRESERVON STRUCTURAL ORAGRAFT,SUP-2741053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1269.19,824.97,,,,,,,,,,,,,
INSERT TIB 5 THK18MM KNEE BEAR SER II OMFIT,SUP-2370405,CDM,C1776,CPT,0278,RC,,,,both,,,2123.90,1380.53,,,,,,,,,,,,,
SHEATH TUNN L12CM DIA9MM REPROC FOR SUBQ GRFT,SUP-2336990,CDM,C1894,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
SYSTEM BOOT TOT CNTCT CAST REG FOR MEDE-KAST TCC-EZ,SUP-2194356,CDM,L4386,HCPCS,0272,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
SET URO 20 FR SUPRPUB ACC 12 CM LEN PEEL AWAY W/O OBT,SUP-2168916,CDM,C2627,HCPCS,0272,RC,,,,both,,,303.89,197.53,,,,,,,,,,,,,
DEVICE FIX BIOABSORBABLE 4.5 MM MIDFACE SUSP ENDOTINE,SUP-2760656,CDM,C1713,HCPCS,0278,RC,,,,both,,,1071.53,696.49,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA100 UM SM 2 ML PREFIL SYR HYDRGEL WHT,SUP-2139507,CDM,C1889,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
ALLOGRAFT BNE FOAM STRP 25X50X4 MM VITOSS BA,SUP-2319139,CDM,C1889,HCPCS,0278,RC,,,,both,,,4732.45,3076.09,,,,,,,,,,,,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-155550,CDM,2500000003,HCPCS,0250,RC,00264-4460-30,NDC,,both,100,ML,62.10,40.36,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 THK5MM RT MEDL LT LAT KNEE HNG REV HEMI STP,SUP-2346700,CDM,C1776,CPT,0278,RC,,,,both,,,5080.52,3302.34,,,,,,,,,,,,,
GRAFT BNE PASTE 1 CC GRFT,SUP-2307041,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
MESH HERN OPN 25X15 CM FLX COMP PHYSIOMESH,SUP-2257748,CDM,C1781,HCPCS,0278,RC,,,,both,,,4983.18,3239.07,,,,,,,,,,,,,
SCREW BNE L40MM DIA5MM CORT TI SELF DRL LOK HEX RECESS,SUP-2190749,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.15,377.10,,,,,,,,,,,,,
BRACE WLK FULL SHELL WLK M M SHOE SZ 7 10 FEM SHOE SZ 8,SUP-2336093,CDM,L4360,HCPCS,0272,RC,,,,both,,,128.61,83.60,,,,,,,,,,,,,
TUBE VENT ARMSTR R 1.14 PHOSPHORYLCHOLINE COAT SIL 510286C,SUP-2486581,CDM,L8699,HCPCS,0278,RC,,,,both,,,48.51,31.53,,,,,,,,,,,,,
CATHETER CV DL 0.018 IN 5 FR RAD BASIC TY SS POWERPICC 2,SUP-2125542,CDM,C1751,HCPCS,0278,RC,,,,both,,,261.12,169.73,,,,,,,,,,,,,
TRIAL SURG FORXPLATE FLOWERCUBE,SUP-2225464,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR EPIC DR V233ROPTSYS] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356539,CDM,C1721,HCPCS,0275,RC,,,,both,,,69036.04,44873.43,,,,,,,,,,,,,
CATHETER HD STR 13 FRX12 CM BASIC SET SHT TERM DUO-SPLIT,SUP-2269517,CDM,C1752,HCPCS,0278,RC,,,,both,,,225.39,146.50,,,,,,,,,,,,,
TROCAR SURG DIA3/16MM TI INSTR W/O CNTR NUT ISOLA,SUP-2255602,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER DIAG 180DEG FIRM TIP EWC EDGE 180 SDK4000FT] SUPERDIMENSION INC],SUP-2381765,CDM,C1887,HCPCS,0272,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
NAIL IM L 25 CM DIA11 MM TI L TIBL STRL TRIGEN MAX,SUP-2931459,CDM,C1713,HCPCS,0278,RC,,,,both,,,6691.97,4349.78,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 145 CM TIP L 12 CM DIA 0.035 IN SS,SUP-2148180,CDM,C1769,HCPCS,0272,RC,,,,both,,,553.68,359.89,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE LG FRZN ASEP FEM,SUP-2867060,CDM,C1762,CPT,0278,RC,,,,both,,,2469.92,1605.45,,,,,,,,,,,,,
HC CT Abdomen W/O Cont,PX-3527415000,CDM,74150,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
MESH GYN POLYPR ULT LTWT SMARTMESH TECHNOLOGY FOR ANT PELV,SUP-2165311,CDM,C1781,HCPCS,0278,RC,,,,both,,,4122.82,2679.83,,,,,,,,,,,,,
COMPONENT CARPOMETACARPAL 40 LG NUGRIP,SUP-2610447,CDM,C1776,CPT,0278,RC,,,,both,,,7501.15,4875.75,,,,,,,,,,,,,
PLATE BONE W53XL85MM THK0.3MM CRANIOMAXILLOFACIAL TI PNL,SUP-2402754,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
BLADE OSTEO PNEUMATIC MEDL VERSADRIVER,SUP-2877750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.63,1339.41,,,,,,,,,,,,,
POST EXT FIX L 3 H S STL FEM ILIZ,SUP-2342289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1050.80,683.02,,,,,,,,,,,,,
PLATE BONE STD RT ANTR PROC POST TUBEROSITY PERC CALCNL FX,SUP-2123138,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
EXPANDER BRST TISS TALL 930-1445 CC SIL SMTH SUTURE TAB,SUP-2927323,CDM,C1889,HCPCS,0278,RC,,,,both,,,6546.90,4255.48,,,,,,,,,,,,,
PROSTHESIS PENILE 12CM PRECONNECT PENOSCROTAL APPRCH CX MS,SUP-2139008,CDM,C1813,HCPCS,0278,RC,,,,both,,,26058.86,16938.26,,,,,,,,,,,,,
PLATE ATTACHMENT 3.5MM TI LCKNG PL F4.5MM LCP 4H-STER,SUP-2546834,CDM,C1713,HCPCS,0278,RC,,,,both,,,1761.16,1144.75,,,,,,,,,,,,,
CANNULA SUCTION MONOPOLAR 5 MMX28 CM COAG TUBE DSTL ANGLED,SUP-2775812,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1069.42,695.12,,,,,,,,,,,,,
NAIL IM FEM SLD TI NS,SUP-2192569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2059.84,1338.90,,,,,,,,,,,,,
CATHETER ABLATN STD 2-5 MM 4.5 MM 7.5 FRX110 CM INTELLATIP,SUP-2424671,CDM,C1732,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
BUR SURG L3.8MM DIA3MM EXT PRECIS NEURO MTCH HD,SUP-2363484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.09,331.56,,,,,,,,,,,,,
ANCHOR SUTURE L12MM OD4MM ID1.8MM PRETHREADED WITH TWO SIZE,SUP-2824223,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.07,469.35,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR FJ,SUP-2248607,CDM,C1732,HCPCS,0278,RC,,,,both,,,9730.86,6325.06,,,,,,,,,,,,,
CONNECTOR SHUNT DIA1.9 MM TI Y SHP STRL DISP MIETHKE,SUP-2929396,CDM,C1889,HCPCS,0278,RC,,,,both,,,709.33,461.06,,,,,,,,,,,,,
CATHETER THROMCTMY 8FR L80CM DIA13MM 2.25ML LIQ 4.5ML GAS,SUP-2214114,CDM,C1757,HCPCS,0272,RC,,,,both,,,266.49,173.22,,,,,,,,,,,,,
SHELL HUM SOCKET NEUT SHLDR TURON RSP,SUP-2634910,CDM,C1776,CPT,0278,RC,,,,both,,,5151.04,3348.18,,,,,,,,,,,,,
BLADE SURG 6 LT MIDLN,SUP-2631599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
SMALL FRAGMENT WASHER,SUP-2829381,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 7 FR LOOP DIA 60 MM,SUP-2248707,CDM,C1730,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
CLIP ANEURYSM BLADE L30MM OPENING 19MM PHYNOX LONG PERMANENT,SUP-2821641,CDM,C1889,HCPCS,0278,RC,,,,both,,,1591.45,1034.44,,,,,,,,,,,,,
BAR EXT FIX L 60 MM DIA 6 MM TI STRL DISP JET-X,SUP-2932947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.57,294.82,,,,,,,,,,,,,
PLATE CRANIOFACIAL W1.5MM 7X7 H TI MESH NONCOMPRESSION SH,SUP-2365887,CDM,C1713,HCPCS,0278,RC,,,,both,,,3644.66,2369.03,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.2 MM XDRV EMER NS DISP LORENZ,SUP-2934828,CDM,C1713,HCPCS,0278,RC,,,,both,,,221.06,143.69,,,,,,,,,,,,,
PLATE BNE L199MM THK3.8MM 12 H BILAT S STL NAR DYN COMPR,SUP-2185213,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC Nonvascular Shunt X-Ray,PX-3207580900,CDM,75809,CPT,0320,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
BASEPLATE TIB STD UNIV PRI PEG PRESSFIT POR PUR SZ A 58MM,SUP-2199508,CDM,C1776,CPT,0278,RC,,,,both,,,14001.89,9101.23,,,,,,,,,,,,,
VALVE MITRL ON-X TISS ANNULUS 23 MM ORIFICE 21.4 MM SZ 23,SUP-2175261,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
MESH BIO PORCINE MTRX ABD 10CM LEN 20CM W 1.5MM THICKNESS P151020] MEDTRONIC COVIDIEN US SURGICAL],SUP-2174700,CDM,C9364,HCPCS,0278,RC,,,,both,,,13756.78,8941.91,,,,,,,,,,,,,
AWL SURG DIA 4 MM CANN CRV GRN,SUP-2934153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
CATHETER ANGIO ARW BERMAN L 60 CM DIA 6 FR BALLOON DIA10 MM,SUP-2383951,CDM,C1725,HCPCS,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
GRAFT BONE SUB 10CC CA PHOS SYNTH PUTTY FIL IMPACTION FRMLA,SUP-2319791,CDM,C1713,HCPCS,0278,RC,,,,both,,,7953.62,5169.85,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X224 MM 17 HOLE SS LCP,SUP-2569343,CDM,C1713,HCPCS,0278,RC,,,,both,,,578.55,376.06,,,,,,,,,,,,,
HEAD HUM H20MM DIA51MM 4MM OFFSET SHLDR CO CHROM HI SFT,SUP-2388770,CDM,C1776,CPT,0278,RC,,,,both,,,9817.21,6381.19,,,,,,,,,,,,,
KIT NEG PRSS 7 DY THER W 250ML ISOLYZER CANSTR AC POWERCORD,SUP-2262385,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2387.03,1551.57,,,,,,,,,,,,,
KIT PT PRGM FOR SPNL CRD STIM SYS PRECIS NOVI,SUP-2138828,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER CARD ABLATION FREEZOR L 108 CM 7 FR L 4 MM SHRT RED,SUP-2175197,CDM,C1733,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE L171MM 10 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3917.46,2546.35,,,,,,,,,,,,,
KIT LOCATION REFERENCE PATCH RHYTHMIA MAPPING SYSTEM,SUP-2424681,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
TROCAR ENDOSCP SHFT L100MM DIA5MM DIL TIP ENDOPATH XCEL,SUP-2218918,CDM,2720000010,LOCAL,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
K WIRE FIX DIA1.6MM U SHP MED MALL PIN PLT,SUP-2389603,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GUIDEWIRE HYDRPHLC STR TIP 038INX260CM ZIPWIRE,SUP-2148173,CDM,C1769,HCPCS,0272,RC,,,,both,,,131.91,85.74,,,,,,,,,,,,,
HC Laryngoscopy W FB Removal,PX-4503153000,CDM,31530,CPT,0450,RC,,,,both,,,1754.00,1140.10,,,,,,,,,,,,,
SCREW BLNT PT SCHANZ 5.0X35MM,SUP-2737900,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.17,389.46,,,,,,,,,,,,,
CLINIMIX/DEXTROSE (8/14) 8 % IV SOLN,RX-151973,CDM,2500000003,HCPCS,0250,RC,00338-0184-01,NDC,,both,2000,ML,655.50,426.07,,,,,,,,,,,,,
MESH SPNL W22XH50XL28MM TI OVL,SUP-2254372,CDM,C1713,HCPCS,0278,RC,,,,both,,,13957.30,9072.24,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC INJ DBM BEAST,SUP-2742042,CDM,C1713,HCPCS,0278,RC,,,,both,,,1683.83,1094.49,,,,,,,,,,,,,
IRINOTECAN HCL 100 MG/5ML IV SOLN,RX-91054,CDM,J9206,HCPCS,0636,RC,60505-6128-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
Z DISCONTINUED USE 2718075 PIN FIX L50MM DIA5MM SFT TISS KNEE AMORPHOUS PLLA FOR ACL,SUP-2121112,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
SPLINT FA WRST PED 6 IN L,SUP-2336053,CDM,L3908,HCPCS,0274,RC,,,,both,,,14.79,9.61,,,,,,,,,,,,,
CLIP INT USE L 235 CM DIA2.8 MM SS CAPSULE COCR YOKE STYRENE 20/BX,SUP-2905532,CDM,C1889,HCPCS,0278,RC,,,,both,,,1145.16,744.35,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W12MM LEG L12X15MM WIRE DIA1.5X1.5MM S,SUP-2194216,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
CYGNUS ANTR CERV 72MM PLTE MTI LVL,SUP-2664210,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
CEMENT BONE 5CC CA PHOS HA INJ FAST SET ISOTHERMIC RADPQ,SUP-2365155,CDM,C1713,HCPCS,0278,RC,,,,both,,,6522.97,4239.93,,,,,,,,,,,,,
CATHETER KIT BUNDLED 20 CM CV,SUP-2214468,CDM,C1751,HCPCS,0278,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
NAIL IM L310MM DIA9MM UNIV TIB TI ALLY CANN LOK CORELOCK,SUP-2412950,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.16,69.00,,,,,,,,,,,,,
CATHETER KIT PICC ANTIMICROBIAL/ANTITHROMBOGENIC,SUP-2655669,CDM,C1751,HCPCS,0278,RC,,,,both,,,626.74,407.38,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST LIMIT RANG OF MOTN,SUP-2435653,CDM,L2184,HCPCS,0272,RC,,,,both,,,327.94,213.16,,,,,,,,,,,,,
PLATE BONE L81MM 5 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349756,CDM,C1713,HCPCS,0278,RC,,,,both,,,4751.45,3088.44,,,,,,,,,,,,,
CATHETER ANGIO SOS OMNI SEL 2 5 FRX65 CM N BRAIDED,SUP-2117141,CDM,C1725,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
COMP SHRT ST/CONV GLD/STDHD,SUP-2212453,CDM,C1776,CPT,0278,RC,,,,both,,,22137.00,14389.05,,,,,,,,,,,,,
GUIDEWIRE VASC PHOENIX L 300 CM DIA 0.014 IN SS COR SIL FLPY,SUP-2823718,CDM,C1769,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
COMPONENT GLEN KEELED 90 DEG SHLDR STR ALL POLYETH BI-ANG,SUP-2431679,CDM,C1776,CPT,0278,RC,,,,both,,,5256.36,3416.63,,,,,,,,,,,,,
CATHETER CTRL VEN 7FR 30CM LEN 3 LUMN N TUNNELED BASIC SET,SUP-2383434,CDM,C1751,HCPCS,0278,RC,,,,both,,,63.80,41.47,,,,,,,,,,,,,
NEEDLE CRYOABLATION ICEROD 1.5MM +,SUP-2225662,CDM,C2618,HCPCS,0272,RC,,,,both,,,4121.25,2678.81,,,,,,,,,,,,,
SLING URETH TRNS OBTURATOR SYS OBTRYX II,SUP-2141814,CDM,C1771,HCPCS,0278,RC,,,,both,,,3074.06,1998.14,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 12 MM BLB DIA1.5 MM SIL RUBBER,SUP-2130325,CDM,C1760,HCPCS,0278,RC,,,,both,,,218.70,142.15,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM BIOCRYL RAPIDE ABSRB KNOTLESS HEALIX,SUP-2249440,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
INTRODUCER PACE LD L 25 CM DIA 9 FR PERC PEELABLE STRL,SUP-2282127,CDM,C1894,HCPCS,0272,RC,,,,both,,,112.26,72.97,,,,,,,,,,,,,
KNOWLES PIN 1.8X4 1.4,SUP-2818101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1069.08,694.90,,,,,,,,,,,,,
ROD SPNL CAPPED 4.75X35 MM CCM CD HORZ SOLERA VOYAGER,SUP-2278971,CDM,C1713,HCPCS,0278,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
SCREW BNE L10MM OD2.4MM TI MAXILLOMANDIBULAR NONLOCKING HI,SUP-2403057,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
PLATE BNE L41MM THK13MM 2X6 H NONSTERILE HND TI ROT CORR LOK,SUP-2181044,CDM,C1713,HCPCS,0278,RC,,,,both,,,2482.33,1613.51,,,,,,,,,,,,,
PROBLE SURG 8IN INSUL TRANSCONTINENTAL,SUP-2417903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
NIPPER NAIL CONCV CHROM 5 1/2IN,SUP-2243050,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
IMPLANT TOE JT SM SZ 4S FLX HNG GRMMT SWNSN,SUP-2399923,CDM,C1776,CPT,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 6.01-7.0 MCI NS ADVANTAGE,SUP-2247277,CDM,C2643,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC Iaad Ia Not Otherwise Specified Each Organism,PX-3068744900,CDM,87449,CPT,0306,RC,,,,both,,,66.00,42.90,,,,,,,,,,,,,
HC Thrmbc/Nfs Dialysis W Stent,PX-3613690600,CDM,36906,CPT,0361,RC,,,,both,,,18820.00,12233.00,,,,,,,,,,,,,
RITUXIMAB-ABBS (TRUXIMA) 10 MG/ML IV SOLN (MIXTURES ONLY),RX-1150545,CDM,Q5115,HCPCS,0636,RC,63459-0103-10,NDC,,both,10,ML,2435.20,1582.88,,,,,,,,,,,,,
NAIL IM L160MM DIA13MM FEM GRN TI RG UNIV STR FLUT CANN LOK,SUP-2180121,CDM,C1713,HCPCS,0278,RC,,,,both,,,4778.89,3106.28,,,,,,,,,,,,,
BLADE SHAVER SERRATED CLOSED ROTATABLE STRL DISP,SUP-2648980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.22,437.59,,,,,,,,,,,,,
GRASPER SUT 30DEG SHRP TIP LO PROF FOR RAP ACCS IN SHLDR,SUP-2249549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
BUR SURG L8CM HD L15.9MM DIA2.3MM SM BOR TAPR FOOTED LEGEND,SUP-2284683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.43,181.63,,,,,,,,,,,,,
KIT INTRO ACCS 4FR L10CM GWIRE 0018IN NDL 21GA L4CM MINI S,SUP-2302998,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.46,49.70,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 6 CM LOOP DIA 3 MM PRIMARY,SUP-2249263,CDM,C1889,HCPCS,0278,RC,,,,both,,,3807.25,2474.71,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 60 MM DIA 6 MM DEL SHTH 2.7ML,SUP-2937071,CDM,C1713,HCPCS,0278,RC,,,,both,,,6160.68,4004.44,,,,,,,,,,,,,
PLATE BNE L MINI LNG 2-2.5 MM RT 3X2 HOLE LCK PEREZ TI,SUP-2464369,CDM,C1713,HCPCS,0278,RC,,,,both,,,1451.09,943.21,,,,,,,,,,,,,
SHEATH INTRO PRELUDE SNAP L 13CM DIA10 FR NO SIDEPRT FUCHSIA,SUP-2743278,CDM,C1769,HCPCS,0272,RC,,,,both,,,102.21,66.44,,,,,,,,,,,,,
SPACER SPNL PARL 0 DEG 23X10X8 MM SLD TRABECULAR MTL TM-500,SUP-2414293,CDM,C1889,HCPCS,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 5 MM DEL SHTH,SUP-2934268,CDM,C1713,HCPCS,0278,RC,,,,both,,,5272.06,3426.84,,,,,,,,,,,,,
PLATE BNE L132MM 9 H R ANTLAT DST TIB TI LOK COMPR FOR,SUP-2190964,CDM,C1713,HCPCS,0278,RC,,,,both,,,4506.50,2929.22,,,,,,,,,,,,,
DEVICE ENDOSCP DIA9.5-13MM 7FR SHTH 1.5X2.5CM SNR 6 BNDS,SUP-2170143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
KIT PICC CATH 5FR L55CM POLYUR NRS DBL LUMN INDWL BLU,SUP-2383476,CDM,C1751,HCPCS,0278,RC,,,,both,,,175.31,113.95,,,,,,,,,,,,,
PLATE BNE STD BRL 130 DEG 4.5X60 MM BILATERAL PELV 2 HOLE SS,SUP-2342573,CDM,C1713,HCPCS,0278,RC,,,,both,,,3517.90,2286.63,,,,,,,,,,,,,
HC Iadna Cytomegalovirus Amplified Probe Tq,PX-3068749600,CDM,87496,CPT,0306,RC,,,,both,,,88.00,57.20,,,,,,,,,,,,,
DISTRACTOR SURG L 35 MM MIDFACE NS,SUP-2883653,CDM,C1713,HCPCS,0278,RC,,,,both,,,12418.73,8072.17,,,,,,,,,,,,,
"HC So1 Molecular Pathology, Unlisted",PX-3108147967,CDM,81479,CPT,0310,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
ALLOGRAFT TISS CRYOPRESERVED 2X2 CM STRAVIX,SUP-2319185,CDM,Q4133,HCPCS,0636,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
CATHETER GUID L 90 CM DIA 6 FR 2 LUMEN WDG PRESSURE LL SYR,SUP-2148864,CDM,C2628,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
ENDCAP SPNL PARL 14X22X19 MM MONOLITH,SUP-2567550,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT HUM TISS 7.5-9.5X170-220 MM PERONEUS TEND FLEXIGRAFT,SUP-2740793,CDM,C1762,CPT,0278,RC,,,,both,,,3560.29,2314.19,,,,,,,,,,,,,
AUGMENTED VAULTLOCK MEDIUM 25L,SUP-2815155,CDM,C1776,CPT,0278,RC,,,,both,,,9655.50,6276.07,,,,,,,,,,,,,
LINER ACET SNAP IN NEUT STD 28X49 MM HIP INTOP PRIMARY NS,SUP-2207586,CDM,C1776,CPT,0278,RC,,,,both,,,5265.78,3422.76,,,,,,,,,,,,,
GRAFT BNE SUB 2.5CC FOAM PK VERSATILE COMPR RESIST VITOSS,SUP-2368194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
HC So Allergen Specific,PX-3058600366,CDM,86003,CPT,0305,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4 H MIC STR L TI NONSTERILE FOR 1.5MM,SUP-2262672,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.69,166.20,,,,,,,,,,,,,
PLATE BNE T 12 HOLE,SUP-2205649,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.94,722.76,,,,,,,,,,,,,
SHEATH INTRO INPUT PS L 11 CM DIA 6 FR GUIDEWIRE 0.038 IN,SUP-2277550,CDM,C1894,HCPCS,0272,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
PLATE BONE TUBE 135 DEGREE 5 HOLE KEYLESS VERSA FX II,SUP-2463451,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.17,908.16,,,,,,,,,,,,,
IMPLANT WR OD15MM ID7MM +2MM CRPL HD MAESTRO,SUP-2407290,CDM,C1776,CPT,0278,RC,,,,both,,,3410.04,2216.53,,,,,,,,,,,,,
SCREW BNE L 6 MM DIA2.6 MM PLA GLYCOLIDE CRANIOMAXILLOFACIAL,SUP-2883434,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.34,377.87,,,,,,,,,,,,,
PROLAYERXENOGRAFT 2 CMX5 CM,SUP-2418460,CDM,C1763,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
BENDING TEMPLATE FOR CALCANEAL Y-PLATES 87MM,SUP-2548480,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.41,73.07,,,,,,,,,,,,,
SPHERE EMB LC BEAD LUMI DIA 40-90 UM M0 RADIOPAQUE STRL,SUP-2664294,CDM,C1889,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 90 CM DIA 4 FR SLT PAT L 10 CM,SUP-2117045,CDM,C1751,HCPCS,0278,RC,,,,both,,,356.70,231.85,,,,,,,,,,,,,
HC N Block Inj Intercost Mlt,PX-3606442100,CDM,64421,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L115CM 7/20FR 6MM D,SUP-2248627,CDM,C1732,HCPCS,0278,RC,,,,both,,,3990.94,2594.11,,,,,,,,,,,,,
DISTRACTOR SHRT BTTRSS TUBE BI DRCTNL MXLLRY DVCE T 6L 4V,SUP-2497669,CDM,C1713,HCPCS,0278,RC,,,,both,,,6228.63,4048.61,,,,,,,,,,,,,
STEM FEM SZ 10.5 RT HIP OVRSZ DSTL TEXT APR,SUP-2210921,CDM,C1776,CPT,0278,RC,,,,both,,,16266.77,10573.40,,,,,,,,,,,,,
PLATE BNE CRV 2-2.5X34X1 MM LT 4 HOLE ELEV HOLE FRAC TI,SUP-2470230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1819.76,1182.84,,,,,,,,,,,,,
BUR ENDOSCP SHAVER 60 DEG SHFT DIA 4 MM ENT CRV DBL SERRATED,SUP-2885540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SET CERV PD4 FOR 35 45IN 2 5YRS PED L89 114CM W REPL PD,SUP-2123894,CDM,L0190,HCPCS,0272,RC,,,,both,,,219.08,142.40,,,,,,,,,,,,,
COIL DETACH 10MM ID 30CM RESTRAINED NEXUS HELIX SUPERSOFT,SUP-2173641,CDM,C1889,HCPCS,0278,RC,,,,both,,,4461.94,2900.26,,,,,,,,,,,,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,0636,RC,72266-0160-10,NDC,,both,1,UN,188.60,122.59,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH TRL LD CHANNEL,SUP-2917080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 75 X W 13.5 MM MYRIAD HNDPC L 13 NN-3009,SUP-2930303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22480.23,14612.15,,,,,,,,,,,,,
SHEATH DIL L20CM ID30FR PTFE RENAL AMPLATZ,SUP-2139478,CDM,C1894,HCPCS,0272,RC,,,,both,,,130.97,85.13,,,,,,,,,,,,,
PLATE BNE SM W11XL189MM THK34MM 14 H BILAT TI RIG NEUT LOK,SUP-2190792,CDM,C1713,HCPCS,0278,RC,,,,both,,,1786.31,1161.10,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 8.01-9.0 MCI STRL ADVANTAGE 2029ILS1] ISOAID LLC],SUP-2247281,CDM,C2642,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
RING OPHTH L24-28 MM MORCHER CAPSULAR TENS FOR CATRCT SURG,SUP-2224365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
HC Revasc Intra Lithotrip-Ather,PX-4810976600,CDM,C9766,CPT,0481,RC,,,,inpatient,,,57405.00,37313.25,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L4MM ESOPH TRACH INDWL W/ L FLNG,SUP-2242385,CDM,L8509,HCPCS,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
PLATE BONE ANGLED THICK 2 MM MANDIBLE PATIENT SPECIFIC ANGLE,SUP-2838604,CDM,C1713,HCPCS,0278,RC,,,,both,,,24378.02,15845.71,,,,,,,,,,,,,
SYSTEM SUT POLYPR POLYDIOXANONE SGL HND CINCHE DSGN RELD,SUP-2119259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
PLATE BNE L 56 MM SCREW DIA2.4 MM 6 H SS HK NS V,SUP-2905706,CDM,C1713,HCPCS,0278,RC,,,,both,,,2992.04,1944.83,,,,,,,,,,,,,
PROSTHESIS OSS 6.1 MM 1.12 MM 3 MM STRASNICK TILT-TOP OTOSIL,SUP-2475021,CDM,L8613,CPT,0278,RC,,,,both,,,1159.32,753.56,,,,,,,,,,,,,
STAPLE SPNL 10-10X10X1.5X1.2 MM,SUP-2365483,CDM,C1713,HCPCS,0278,RC,,,,both,,,5699.10,3704.41,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY GLUTEAL ISCHIAL WT BEAR,SUP-2435672,CDM,L2500,HCPCS,0274,RC,,,,both,,,885.95,575.87,,,,,,,,,,,,,
BIT DRILL FOR 22MM ALL SUTURE ANCHOR SURELOCK,SUP-2589290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
HC Iadna Respiratry Probe & Rev Trnscr 12-25 Target,PX-3068763300,CDM,87633,CPT,0306,RC,,,,both,,,683.00,443.95,,,,,,,,,,,,,
PLATE BONE ANKLE 12 HOLE 1/3 TUBULAR TITANIUM GRIDLOCK VLC PLATING SYSTEM FOR 2.4/3/4MM SCREW,SUP-2878204,CDM,C1713,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
TRIAL SURG SCREW DIA1.3-5 MM RECESS HEX SOCKET STRL DISP,SUP-2913515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.57,714.72,,,,,,,,,,,,,
RELOAD STPL M SZ 2 THK30MM PUR THCK TRI STPL,SUP-2283350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1608.21,1045.34,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL AD 18GA L71CM 50DEG S STL BVL BRK1 CRV,SUP-2357222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
COMPONENT TIB KNEE HNG ASMBLY ROTATIONAL STP PIN GRDIAN,SUP-2304393,CDM,C1776,CPT,0278,RC,,,,both,,,5746.20,3735.03,,,,,,,,,,,,,
SHEATH INTRO L45CM DIA4FR 10ML ECHOGENIC NDL DIA19-21GA W/,SUP-2385250,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
PLATE BNE TI LT TT FUSION PRIMARY PILON NS,SUP-2897778,CDM,C1713,HCPCS,0278,RC,,,,both,,,7218.86,4692.26,,,,,,,,,,,,,
COMPONENT TIB W22XH11MM OD45MM UHMWPE KNEE SLED W/O MTL PD,SUP-2397007,CDM,C1776,CPT,0278,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
DRILL HAND HUDSON BRACE PRECISION SNAP LOCK JARIT STERILE,SUP-2705663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.59,688.73,,,,,,,,,,,,,
IMPLANT FNGR JT MOD THMB HD CO CHROM 14MM,SUP-2137771,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BONE SZ 1.5MM REG 6 H SLV DBL Y SHP TRAUMAONE LORENZ,SUP-2402884,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
ECLIPSE TRUNION 47 MM TPS CTD,SUP-2815661,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL,SUP-2435543,CDM,L0468,HCPCS,0272,RC,,,,both,,,1346.15,875.00,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 40 CM DIA 8 FR GUIDEWIRE 0.038 IN,SUP-2355554,CDM,C1894,HCPCS,0272,RC,,,,both,,,55.74,36.23,,,,,,,,,,,,,
NUCLEUS PROFILE PLUS W/ SLIM STRAIGHT ELECTRODE (CI622),SUP-2858188,CDM,L8614,HCPCS,0278,RC,,,,both,,,71662.65,46580.72,,,,,,,,,,,,,
ALLOGRAFT DRML THICK 6X16 CM READY USE TSSUE MTRX ALLDRM,SUP-2491846,CDM,Q4116,HCPCS,0636,RC,,,,both,,,10399.68,6759.79,,,,,,,,,,,,,
CATHETER GUID 5.2FR L115CM ID0.057IN PTFE LNR S STL BRAID,SUP-2367783,CDM,C1887,HCPCS,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
STIMULATOR NERVE DBS SPINE PT CTRL,SUP-2357363,CDM,C1787,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
PARTIALLY THRD SCREW-6.5X100MM,SUP-2417724,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS L 120 CM BALLOON L 4 CM DIA12 MM,SUP-2127917,CDM,C1725,HCPCS,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
ARCOS 18X200MM INTLKNG DIST,SUP-2506099,CDM,C1776,CPT,0278,RC,,,,both,,,10562.96,6865.92,,,,,,,,,,,,,
STENT URET RESONANCE L 24 CM CATH L 71.5 CM DIA 6 FR SHTH L,SUP-2171370,CDM,C2625,HCPCS,0278,RC,,,,both,,,4339.79,2820.86,,,,,,,,,,,,,
PLATE BONE EVANS TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878969,CDM,C1713,HCPCS,0278,RC,,,,both,,,5997.40,3898.31,,,,,,,,,,,,,
PLATE BNE W6XL42MM 24 H CRANIOMAXILLOFACIAL TI STRUT FOR,SUP-2190569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2270.53,1475.84,,,,,,,,,,,,,
SPACER TIB SZ 3.5 H8MM PROX WDG OPTETRAK LOGIC,SUP-2220974,CDM,C1776,CPT,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
PLATE BNE 3X7 H BILAT TI Y SHP LO PROF RIG NEUT LOK COMPR,SUP-2191256,CDM,C1713,HCPCS,0278,RC,,,,both,,,1280.18,832.12,,,,,,,,,,,,,
SET SCR SPNL TI POST THORACOLUMBOSACRAL MULTIAXIAL LO PROF,SUP-2289494,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA 4FR 20CM 2 LUMAN RVS TAPR P S4254108,SUP-2632862,CDM,C1751,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
KIT INTRO VSI L 15 CM DIA 5 FR GUIDEWIRE L 60 CM DIA 0.018,SUP-2763489,CDM,C1892,HCPCS,0272,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
METRONIDAZOLE 0.75 % EX CREA,RX-19805,CDM,6370000000,HCPCS,0637,RC,00168-0323-46,NDC,,both,45,GR,321.20,208.78,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY SR TI SINGLE CHMBR 5/6 MM CONN UPLR,SUP-2148594,CDM,C1785,HCPCS,0275,RC,,,,both,,,12170.64,7910.92,,,,,,,,,,,,,
BLADE SHV L18CM DIA2.9MM 15DEG AIRWY M4 ROT ANG TIP LNG DBL,SUP-2277857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2032.21,1320.94,,,,,,,,,,,,,
GRAFT HUM TISS L 40 MM DIA10 MM FIB SHFT LYOPH STRL,SUP-2913284,CDM,C1762,CPT,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
SCREW BONE L38MM DIA2MM STD CORT S STL NONCANNULATED FULL,SUP-2248962,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.22,102.19,,,,,,,,,,,,,
GRAFT HUM TISS W3XL7CM THK2-3.5MM ACELLULAR DERM MTRX,SUP-2402520,CDM,Q4126,HCPCS,0636,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6 MM 50 CM STR STD WALL,SUP-2396268,CDM,C1768,CPT,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
BASEPLATE TIB SZ 1 UNIV KNEE PRI CEM MOD KEEL IMP NXGN,SUP-2201004,CDM,C1776,CPT,0278,RC,,,,both,,,3041.09,1976.71,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5 DEG 14 MM LORDTC PLIF BULL TIP STRL,SUP-2632320,CDM,C1713,HCPCS,0278,RC,,,,both,,,9383.95,6099.57,,,,,,,,,,,,,
OSTEOTOME SURG L8IN BLDE W95MM CRV SMITH PETERSON,SUP-2161289,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.36,172.48,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 3X7CM FEN,SUP-2909200,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3928.14,2553.29,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L90CM 4 CHMBR PERC PERM QUATTRODE,SUP-2356727,CDM,C1778,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HMRS/G I-II CIRCLIPS,SUP-2512640,CDM,C1776,CPT,0278,RC,,,,both,,,811.06,527.19,,,,,,,,,,,,,
SLEEVE FEM L31MM UNIV MTPHSEAL FULL POR LPS,SUP-2250939,CDM,C1776,CPT,0278,RC,,,,both,,,7900.24,5135.16,,,,,,,,,,,,,
SURFACE ARTC SZ EF 7-10 H12MM AP50MM ML82MM UHMWPE BLU STRP,SUP-2208724,CDM,C1776,CPT,0278,RC,,,,both,,,7561.12,4914.73,,,,,,,,,,,,,
DIREXION HI FLO/SINGLE/027/J/1RO/105,SUP-2652834,CDM,C1887,HCPCS,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,PX-4506445000,CDM,64450,CPT,0450,RC,,,XU|RT,both,,,2232.00,1450.80,,,,,,,,,,,,,
GRAFT HUM TISS 20ML DEMIN MTRX PASTE OSTEOFIL RT,SUP-2293737,CDM,C1713,HCPCS,0278,RC,,,,both,,,6245.46,4059.55,,,,,,,,,,,,,
GRAFT HUM TISS DERMACELL POROUS 2X3CM 6SQCM,SUP-2909262,CDM,Q4122,HCPCS,0636,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA1.9 MM COMPR FULL THRD SNAP OFF NS,SUP-2930417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GRAFT BONE SUB SM 5CC CA SULF RAP CURE KT SYNTHECURE,SUP-2124551,CDM,C1713,HCPCS,0278,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
PLATE BNE RECON 2.7 MM MAND 27 HOLE FULL FOR SCR TI LEVEL 1,SUP-2460886,CDM,C1713,HCPCS,0278,RC,,,,both,,,4156.76,2701.89,,,,,,,,,,,,,
CATHETER VENTRICULAR H 11 CM SNAP SHUNT ENDOVENT INNERVISION,SUP-2628507,CDM,C1729,HCPCS,0272,RC,,,,both,,,633.12,411.53,,,,,,,,,,,,,
PATELLA SUTPLT II STAR M STRL,SUP-2811474,CDM,C1713,HCPCS,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SLIP ON LG 8.5 IN WRST COMFORTFORM,SUP-2197053,CDM,L3906,HCPCS,0272,RC,,,,both,,,42.77,27.80,,,,,,,,,,,,,
CATHETER EMB TUFTEX L 80 CM DIA 5.5 FR BALLOON DIA12 MM,SUP-2264192,CDM,C1757,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
KIT EXT FIX ID BND CAP STRL DISP SMRT FX,SUP-2933429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,779.16,506.45,,,,,,,,,,,,,
GRAFT BONE SUB 10CC DEMIN BONE MTRX INJ FRZ DRY,SUP-2307006,CDM,C9359,HCPCS,0278,RC,,,,both,,,4011.07,2607.20,,,,,,,,,,,,,
SET EXTN OD10FR RED ART TESIO,SUP-2269528,CDM,C1881,HCPCS,0278,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
HC So Microdissection Laser,PX-3128838066,CDM,88380,CPT,0312,RC,,,,both,,,1298.00,843.70,,,,,,,,,,,,,
ARTICULAR SURF TIB H 18 MM SZ TIB G-H FEM 10-12 VIVACIT-E RT,SUP-2894089,CDM,C1889,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BONE L180MM 6 H LT PROX FEM LCK FOR 4.5MM SCR PERI-LOC,SUP-2351169,CDM,C1713,HCPCS,0278,RC,,,,both,,,11665.41,7582.52,,,,,,,,,,,,,
PLATE BNE W5XL42MM THK1.5MM 0DEG 8 H BILAT S STL STR RIG,SUP-2186166,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.88,421.12,,,,,,,,,,,,,
GUIDEWIRE VASC L 125 CM DIA 0.025 IN TAPR L 7 CM FLPY TIP L,SUP-2167649,CDM,C1769,HCPCS,0272,RC,,,,both,,,26.63,17.31,,,,,,,,,,,,,
CLAMP ABLAT L10CM PRB DISPOSABLE CRYOFLEX,SUP-2124490,CDM,C2618,HCPCS,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
CATHETER DRAINAGE 0.76X1.65 MMX46 CM LUERLOCK CONN,SUP-2308151,CDM,C1729,HCPCS,0272,RC,,,,both,,,590.54,383.85,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 4FR 55CM 2 LUMAN R S9274108,SUP-2632874,CDM,C1751,HCPCS,0278,RC,,,,both,,,594.03,386.12,,,,,,,,,,,,,
EXTRACTOR STONE TIPLSS 4.5 FRX65 CM NIT NCIRCLE,SUP-2835756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.31,331.05,,,,,,,,,,,,,
DISC SCR ST PRE LD UNIV 1.5X4MM NEURO 2,SUP-2362176,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.83,300.19,,,,,,,,,,,,,
MESH HERN L13XW10IN POLYPR EPTFE ABD NONABSORBABLE ELP,SUP-2125803,CDM,C1781,HCPCS,0278,RC,,,,both,,,4385.32,2850.46,,,,,,,,,,,,,
LINER TIB CEM KNEE CR XLPE PREMIER STRYK7] STRYKER ORTHOPEDICS HOWM],SUP-2379184,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
KIT STRNL CLOSURE X CABLE PLATE KT INCLUDE SCREW CABLE STRL,SUP-2894323,CDM,C1713,HCPCS,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
PLATE BONE SHFT L428MM BLDE L70MM THK4.8MM 95DEG 26 H BILAT,SUP-2185472,CDM,C1713,HCPCS,0278,RC,,,,both,,,4003.88,2602.52,,,,,,,,,,,,,
SCREW INTFR L20MM DIA2.7MM PLLA BIOCOMPRESSION,SUP-2121889,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
COIL EMB L15CM OD0.020IN NIT J STRTCH RESIST FILL SFT STBL,SUP-2323422,CDM,C1889,HCPCS,0278,RC,,,,both,,,7570.54,4920.85,,,,,,,,,,,,,
PLATE BONE L21MM BLDE L17MM THK0.9MM SH 2X2 H RT,SUP-2191300,CDM,C1713,HCPCS,0278,RC,,,,both,,,896.78,582.91,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 5MM 120CM 6FR RADIOPAQUE,SUP-2719624,CDM,C1768,HCPCS,0278,RC,,,,both,,,10741.94,6982.26,,,,,,,,,,,,,
BUR SURG OVL LNG 4 MMX10 CM MIDAS REX LEGEND,SUP-2627642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.10,230.81,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6MM STR TW HELIX SLDE GDS,SUP-2681203,CDM,C1768,CPT,0278,RC,,,,both,,,2180.23,1417.15,,,,,,,,,,,,,
CANNULA ARTHSCP 6.5MM OUTER SPD LCK W/ 2 ROT STPCOCK,SUP-2361389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1724.55,1120.96,,,,,,,,,,,,,
SHUNT SURG DELT ASMBLY 2 REG SPNL CEREB FLUID,SUP-2284559,CDM,C1889,HCPCS,0278,RC,,,,both,,,4013.05,2608.48,,,,,,,,,,,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-4504376200,CDM,43762,CPT,0450,RC,,,,outpatient,,,935.00,607.75,,,,,,,,,,,,,
MATRIX BIO L 7 X W 7 CM SZ 300 SQCM ACELLULAR FISH SKIN,SUP-2909197,CDM,Q4158,HCPCS,0636,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
STRAP CLAV DLX COT L,SUP-2276604,CDM,L3650,HCPCS,0274,RC,,,,both,,,23.93,15.55,,,,,,,,,,,,,
CATHETER NEPHSTMY DIA20FR 2 EYE DRNGE PROPORTIONATE HD DISP,SUP-2128978,CDM,C1729,HCPCS,0272,RC,,,,both,,,62.49,40.62,,,,,,,,,,,,,
PLATE BNE T METATRSL FORE FT 6 HOLE LESSER ORTHOLOC,SUP-2398013,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BIT DRL 9.5 MMX7 IN JCBS CHK END,SUP-2457948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,752.31,489.00,,,,,,,,,,,,,
BIT DRL OD4.7MM BLU CANN COUNTSINK,SUP-2399463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC CORTICOCANCELLOUS ALLGRFT,SUP-2932969,CDM,C1762,CPT,0278,RC,,,,both,,,53128.80,34533.72,,,,,,,,,,,,,
KNIFE NDL CATH L200CM 7-5FR 0.035IN TAPR TIP 3 LUMN FOR,SUP-2169505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
PROBE BPLR 7FR L350CM TIP 6.5MM YEL MULT ELECTRD FOR,SUP-2166261,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW ACET LP 6.5X110 MM HIP SYS TI RINGLOK,SUP-2449908,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
PLATE BNE L35MM 4 H TI STR,SUP-2262999,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.46,420.20,,,,,,,,,,,,,
SET CATH INTRO 9FR L12CM VEN J STR TIP W/ DIL,SUP-2355253,CDM,C1894,HCPCS,0272,RC,,,,both,,,33.76,21.94,,,,,,,,,,,,,
KNIFE OPHTH DIAMOND 4.7 INX2-2.4 MM ANGLED TRAP TRU-SIZE,SUP-2465484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6300.57,4095.37,,,,,,,,,,,,,
PROBE SURG JAKO 90 DEG 2 MM 295 MM LARYNGEAL ANGLED,SUP-2459205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.17,321.21,,,,,,,,,,,,,
ANCHOR SUT L17MM OD5MM HD BIOABSRB CRKSCR,SUP-2121504,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BIT DRL L8IN DIA0.125IN GRY TIP JCBS CHK END DISP,SUP-2373942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PROBE PEDCL STR,SUP-2211137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.27,377.18,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.436,SUP-2860000,CDM,C1713,HCPCS,0278,RC,,,,both,,,45593.11,29635.52,,,,,,,,,,,,,
KIT SURG WIRE ACROMIOCLAVICULAR STRL CERCLAGE,SUP-2910464,CDM,C1713,HCPCS,0278,RC,,,,both,,,7114.93,4624.70,,,,,,,,,,,,,
STEM ULN L70MM SM STD PLSM COAT CO CHROM RT PRI CEM,SUP-2396772,CDM,C1776,CPT,0278,RC,,,,both,,,20305.91,13198.84,,,,,,,,,,,,,
PLATE BNE W8XL76MM THK2MM 0DEG 9 H BILAT S STL STR RIG DYN,SUP-2186181,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
HEAD HUM H21MM DIA48MM SHLDR ECC LO PROF MED FIN H FOR,SUP-2249940,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
KIT CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 15CM STRGHT 2L,SUP-2613262,CDM,C1752,HCPCS,0278,RC,,,,both,,,672.75,437.29,,,,,,,,,,,,,
COMPOUND RESTORATIVE 1.7GM NANOFILLED LT CURE M VISC,SUP-2238523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.61,359.20,,,,,,,,,,,,,
SCREW BNE SET 7 MM CANN FT EXT TAB,SUP-2861033,CDM,C1713,HCPCS,0278,RC,,,,both,,,3803.42,2472.22,,,,,,,,,,,,,
COLLAR CERV M DENS AD VELC CLSR FOAM W/ STOCK 3.5IN 23.5IN M,SUP-2198742,CDM,L0120,HCPCS,0274,RC,,,,both,,,16.58,10.78,,,,,,,,,,,,,
ALLOGRAFT BNE SHFT SPLIT FD FEM,SUP-2321795,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
BUR SURG DIA1.5 MM HUB XLI TWST DRL ACTIV C STRL DISP,SUP-2929146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.72,272.82,,,,,,,,,,,,,
BLOCK CRANIOFACIAL SQ 63X38X3 MM SMOOTH SHELL SIL MEDPOR,SUP-2366444,CDM,C1713,HCPCS,0278,RC,,,,both,,,3358.26,2182.87,,,,,,,,,,,,,
HC Cytology Consult.,PX-3118810400,CDM,88104,CPT,0311,RC,,,,both,,,146.00,94.90,,,,,,,,,,,,,
DEVICE FIX W5MM 12 ABSRB STRP DISP SECURESTRP,SUP-2219934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1317.64,856.47,,,,,,,,,,,,,
PLATE BONE W14XL162MM THK3.8MM 90DEG 9 H LT TIB S STL L SHP,SUP-2185784,CDM,C1713,HCPCS,0278,RC,,,,both,,,2062.51,1340.63,,,,,,,,,,,,,
GRAFT BNE PTTY SYR FRZ DRY DEMIN BNE MTRX CANC 1CC I C GRFT,SUP-2264797,CDM,C1713,HCPCS,0278,RC,,,,both,,,1502.65,976.72,,,,,,,,,,,,,
GRAFT EVAR L3.3CM DIA32MM AORT EXT ENDOPROS EXCLUDER,SUP-2395941,CDM,C1768,CPT,0278,RC,,,,both,,,9027.50,5867.87,,,,,,,,,,,,,
BLADE SURG L80MM S STL HELIX FOR LCP DHHS SYS,SUP-2186779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.98,673.39,,,,,,,,,,,,,
BRACE ANKLE FOOT ORTHOSIS,SUP-2421821,CDM,L4396,HCPCS,0274,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.5MM SLV CORT TI SELF DRL NONCANNULATED,SUP-2181626,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.62,212.30,,,,,,,,,,,,,
BOOT FT FLEECE X LG ANK CONTRACTURE W/ OUT SOLE,SUP-2336235,CDM,L4396,HCPCS,0274,RC,,,,both,,,120.20,78.13,,,,,,,,,,,,,
ANCHOR SUT PEEK OD4.5MM ORTHOCORD HEALIX ADV FORC FBR,SUP-2249462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
BASEPLATE GLEN FIX SHLDR RVS CNTRL SCREW 1 LCK CAP KT STRL,SUP-2908866,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
STAPLE BONE W10XH10XL10MM NIT SUPERELASTIC FIX DYNACLIP,SUP-2418089,CDM,C1713,HCPCS,0278,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
STENT URETERAL IMAJIN SILICONE W/ POSITIONER,SUP-2848795,CDM,C2617,HCPCS,0278,RC,,,,both,,,439.29,285.54,,,,,,,,,,,,,
HC NM Cisternography,PX-3417863000,CDM,78630,CPT,0341,RC,,,,outpatient,,,3207.00,2084.55,,,,,,,,,,,,,
SCREW BNE L20MM DIA3MM CORT S STL ST LOK FULL THRD T8 DRV LO,SUP-2371474,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.27,155.53,,,,,,,,,,,,,
BUTTON CBL VIT SYS GRV DALL M,SUP-2377581,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.06,449.84,,,,,,,,,,,,,
SCREW BONE L6MM TI SELF DRL ORTHODONTIC ANCHR,SUP-2181500,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
INSTRUMENT EXT FIX UNIV MINI TOOL TOMAHAWK SIDEKCK,SUP-2400711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 20 CC PRESERVON CANC READIGRAFT,SUP-2740805,CDM,C1713,HCPCS,0278,RC,,,,both,,,705.40,458.51,,,,,,,,,,,,,
PLATE BNE 3.5X194 MM 16 HOLE SS DCP,SUP-2569145,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.76,255.94,,,,,,,,,,,,,
SCREW SPNL ST 4X13 MM MINIP DIVERGENCE,SUP-2632043,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
VALVE SHUNT L2.8CM OD1.9MM D.6CM VERTICAL 30CM HORIZONTAL 10,SUP-2821784,CDM,C1889,HCPCS,0278,RC,,,,both,,,6829.03,4438.87,,,,,,,,,,,,,
DISTRACTOR SURG 25 MM 1-1.2 MM MAND 36 HOLE INT TI ZURICH II,SUP-2473868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16969.66,11030.28,,,,,,,,,,,,,
LINER ACET CONSTRN C 32 MM PROV FRDM G7,SUP-2440185,CDM,C1776,CPT,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
CONVERTER GRAFT 22X113MM 18FR 7.1MM,SUP-2751318,CDM,C1874,HCPCS,0278,RC,,,,both,,,21000.32,13650.21,,,,,,,,,,,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,0636,RC,63323-0162-00,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
HEAD FEM DIA32MM NK L+0MM 12/14 TAPR HIP OXINIUM PRI REV,SUP-2345362,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
WAND ABLAT L157MM DIA1.07MM 17GA NDL L6IN CRWFRD PLSM ABLAT,SUP-2342057,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
"HC Inj Proc for Myelogram/CT, Lumbar",PX-3616228400,CDM,62284,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
COMPONENT KNEE 2 SPECIALITY KNEE2ZI1800] ZIMMER BIOMET INC],SUP-2212598,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
HC Pulse Ox Multiple Determine,PX-4609476100,CDM,94761,CPT,0460,RC,,,,outpatient,,,406.00,263.90,,,,,,,,,,,,,
PLATE BNE MESHED PEDIATRIC 0.6 MM RT NEURO SMRT TI LEVEL,SUP-2459854,CDM,C1713,HCPCS,0278,RC,,,,both,,,16354.12,10630.18,,,,,,,,,,,,,
PRE 20MM 035 GW STR BX20,SUP-2679397,CDM,C1769,HCPCS,0272,RC,,,,both,,,28875.44,18769.04,,,,,,,,,,,,,
STAPLE BNE FIX L 28 X W 13 X H 11 MM TI ALLOY TOE COMPR LCK,SUP-2893046,CDM,C1713,HCPCS,0278,RC,,,,both,,,10242.68,6657.74,,,,,,,,,,,,,
TEMPLATE CLMP PEDIATRIC SANDWICH,SUP-2875762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
SCREW BONE L11MM DIA2.5MM CO CHROM MULTDIR LCK THRD PEGGED,SUP-2411658,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.03,318.52,,,,,,,,,,,,,
RELOAD STPL L45MM M THICK TISS PUR REINF ARTC INTELLIGENCE,SUP-2283374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,955.09,620.81,,,,,,,,,,,,,
INTRODUCER SHTH 0.021 IN 4 FRX11 CM STR FLPY PRELUDE IDEAL,SUP-2798465,CDM,C1894,HCPCS,0272,RC,,,,both,,,190.41,123.77,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L60CM 8 ELECTRD 4MM SPC TUNN TOOL TORQ,SUP-2355955,CDM,C1778,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
CENTRALIZER DSTL 12MM F/INSIDE STEM F/SMITH,SUP-2344466,CDM,C1776,CPT,0278,RC,,,,both,,,13935.32,9057.96,,,,,,,,,,,,,
ELECTRODE LAP MNPLR 35MM DIA 33CML L HOOK RGHT ANGLD TIP PR,SUP-2675803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,617.14,401.14,,,,,,,,,,,,,
BIT DRL L102MM OD1.9MM STP D20.0MM N RADLUC NSTERILE REUSE,SUP-2366432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,782.71,508.76,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA2.3 MM CRANIOFACIAL CROSS PIN HD EMER 5PK,SUP-2884169,CDM,C1713,HCPCS,0278,RC,,,,both,,,2192.98,1425.44,,,,,,,,,,,,,
KIT ORTH TENODESIS DISP FOR 3X8MM SCR SYS,SUP-2121328,CDM,C1769,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
STABILIZER SURG HRT OFF PMP STD PLT XPOSE 4+ ACROBAT SUV,SUP-2227772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 17X3X1.5 MM LP CONTOURED TI NS,SUP-2539567,CDM,C1713,HCPCS,0278,RC,,,,both,,,724.77,471.10,,,,,,,,,,,,,
BOOT WALKING CUST FABRIC ANK FT,SUP-2237265,CDM,L4631,HCPCS,0272,RC,,,,both,,,4492.59,2920.18,,,,,,,,,,,,,
IMPL CAPPED KNEE GS FX CM FMTB STSUR NO PAT,SUP-2212252,CDM,C1776,CPT,0278,RC,,,,both,,,14541.81,9452.18,,,,,,,,,,,,,
STENT ESOPH OTW 19X150 MM 24 FRX90 CM FULL CVR ENDOMAXX,SUP-2467319,CDM,C1874,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
EXTENSION GUIDEWIRE L 145 CM DIA 0.014/0.018 IN SS POLYMER,SUP-2105889,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
IMMOBILIZER KNEE PERF FOAM 12 IN T BAR ADJ MEDL BLK CUTAWAY,SUP-2336323,CDM,L1830,CPT,0272,RC,,,,both,,,43.93,28.55,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 10CC DEMINERALIZED BONE MATRIX PUTTY REVERSE PHASE M STIMUBLAST CB,SUP-2120750,CDM,C1713,HCPCS,0278,RC,,,,both,,,3659.67,2378.79,,,,,,,,,,,,,
MESH HERN ELLIPSE 13X10 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855266,CDM,C1781,HCPCS,0278,RC,,,,both,,,42201.60,27431.04,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.445,SUP-2860009,CDM,C1713,HCPCS,0278,RC,,,,both,,,51978.30,33785.89,,,,,,,,,,,,,
GUIDEWIRE VASC PRELUDE L 80 CM DIA 0.038 IN TIP L 3 MM SS,SUP-2303471,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.97,16.88,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 16H 237MM RIGHT-STER,SUP-2549561,CDM,C1713,HCPCS,0278,RC,,,,both,,,3748.78,2436.71,,,,,,,,,,,,,
SCREW KNEE ARTHROPLASTY FEM DST VIT ST DURAC 10MML,SUP-2377244,CDM,C1713,HCPCS,0278,RC,,,,both,,,186.89,121.48,,,,,,,,,,,,,
PLATE BNE X SM 2.4/2.7X24X18 MM LCK SS STRL,SUP-2863363,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.73,1646.92,,,,,,,,,,,,,
MESH HERN SM 1X1.35IN INGUINAL WHT POLYPR MFIL PLUG,SUP-2125750,CDM,C1781,HCPCS,0278,RC,,,,both,,,642.13,417.38,,,,,,,,,,,,,
KIT INTRO MINI STK II L 7 CM DIA 6 FR GUIDEWIRE L 60 CM DIA,SUP-2117129,CDM,C1892,HCPCS,0272,RC,,,,both,,,74.95,48.72,,,,,,,,,,,,,
INSERT TIB H12MM S STL UHMWPE KNEE REV MOB SLDE COR STAR PGT,SUP-2365352,CDM,C1776,CPT,0278,RC,,,,both,,,6468.40,4204.46,,,,,,,,,,,,,
BLADE SURG BLNT 25 MM TUBESET NEXUS BONESCALPEL,SUP-2745899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1723.23,1120.10,,,,,,,,,,,,,
STAR PSI STANDARD BUNDLE WITH ANATOMICAL MODELS,SUP-2878302,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
SPLINT FNGR M 3IN DYN KNCK BENDR RVS SGL DGT WIRE FOAM RUB,SUP-2324851,CDM,L3809,HCPCS,0272,RC,,,,both,,,41.95,27.27,,,,,,,,,,,,,
PROSTHESIS VOICE 16 FRX4 MM INDWL SFT VLV NS BLOM-SINGER,SUP-2242283,CDM,L8509,HCPCS,0274,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
PLATE BNE STR 1.5X100 MM 20 HOLE,SUP-2569070,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
PLATE BNE L77MM 3 H R POSTEROLATERAL DST FIBULAR S STL LOK,SUP-2177379,CDM,C1713,HCPCS,0278,RC,,,,both,,,1679.77,1091.85,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL AD 18GA L89CM S STL BRK CRV STYL BVL ANG,SUP-2357226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
COMPONENT ARTC SURF UNI 4 11 MM KNEE UHMWPE PHYSICA ZUK,SUP-2342192,CDM,C1776,CPT,0278,RC,,,,both,,,1868.05,1214.23,,,,,,,,,,,,,
PLATE BONE L14MM RT MAX TI T SHP FOR 1.3MM SCR,SUP-2190661,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
SCREW BNE L32MM OD23MM TI CORT DST RAD NONLOCKING,SUP-2372665,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.29,362.89,,,,,,,,,,,,,
CATHETERIZATION KIT 0.032 IN 7 FRX8 IN 3L ARROWG+ARD +,SUP-2383335,CDM,C1751,HCPCS,0278,RC,,,,both,,,181.46,117.95,,,,,,,,,,,,,
STEM FEM L75MM DIA14MM UNIV KNEE FLUT PRESSFIT FOR ROT HNG,SUP-2253332,CDM,C1776,CPT,0278,RC,,,,both,,,3686.36,2396.13,,,,,,,,,,,,,
BIT DRILL TWIST 2.7 QUICK COUPLING SCALED,SUP-2713858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,826.61,537.30,,,,,,,,,,,,,
SYSTEM SFT TISS FIX STRL LF DISP GRAFTLINK CP 2,SUP-2882176,CDM,C1713,HCPCS,0278,RC,,,,both,,,6138.70,3990.15,,,,,,,,,,,,,
CATHETER PICC L 55 CM DIA 5.5 FR 2 LUMEN PRESSURE INJ VPS,SUP-2886215,CDM,C1751,HCPCS,0278,RC,,,,both,,,1046.66,680.33,,,,,,,,,,,,,
PLATE BONE L119MM THK3.4MM 8 H BILAT NONLOCKING COMPR FOR,SUP-2348951,CDM,C1713,HCPCS,0278,RC,,,,both,,,1559.45,1013.64,,,,,,,,,,,,,
NORTRIPTYLINE HCL 25 MG PO CAPS,RX-5675,CDM,6370000000,HCPCS,0637,RC,75907-0070-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ENVELOPE DEFIB BIOENVELOPE 2XL SINGLE PK STRL,SUP-2138482,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
RING EXT FIX DIA 300 MM HALF NS DISP TSF,SUP-2933826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7847.05,5100.58,,,,,,,,,,,,,
STENT URET 4.5FR L26CM CLASS DBL PGTL COAT OPN END TECOFLEX,SUP-2313803,CDM,C2617,HCPCS,0278,RC,,,,both,,,172.39,112.05,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM ID 7-4 MM EPTFE SHRT TAPR STD WALL,SUP-2126425,CDM,C1768,CPT,0278,RC,,,,both,,,4195.98,2727.39,,,,,,,,,,,,,
STAPLER INT L340MM VASC THN TISS ARTC LIN CUT W/ WHT RELD,SUP-2257357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,676.64,439.82,,,,,,,,,,,,,
ROD SPNL 2X30 MM,SUP-2564510,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.63,30.31,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM DIA24 MM POLYESTER BOV CLLGN,SUP-2265917,CDM,C1768,CPT,0278,RC,,,,both,,,1430.14,929.59,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0250,RC,00264-7510-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 30 CM EPTFE STR TW,SUP-2396156,CDM,C1768,CPT,0278,RC,,,,both,,,3253.04,2114.48,,,,,,,,,,,,,
BLADE SURG HNDL CRV ATRAUM CAPSLTMY STRL DISP SAFECUT,SUP-2910489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.31,492.90,,,,,,,,,,,,,
KIT KYPHOPLASTY BALLOON L 25 MM UNIPEDICULAR STRL DISP,SUP-2930330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
PLATE BNE LCK 2.7 MM 16 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2472662,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.19,773.62,,,,,,,,,,,,,
PLATE STR 1.5MM 12H TI STRL VAL,SUP-2546889,CDM,C1713,HCPCS,0278,RC,,,,both,,,1713.75,1113.94,,,,,,,,,,,,,
HC Hemoglobin Methemoglobin Quantitative,PX-3018305000,CDM,83050,CPT,0301,RC,,,,outpatient,,,89.00,57.85,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.035IN PTFE NIT HYDRPHLC STR TIP,SUP-2139367,CDM,C1769,HCPCS,0272,RC,,,,both,,,140.45,91.29,,,,,,,,,,,,,
CATHETER CRICO 5MMX9CM SET EMER INTRO NDL CVD DIL CUF AIRWY,SUP-2169801,CDM,C1713,HCPCS,0278,RC,,,,both,,,1165.88,757.82,,,,,,,,,,,,,
PLATE BNE LNG THK1MM 4 H TI FOR 2MM MINI MOD,SUP-2262768,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
TUBE GASTROSTMY ENTRL FEED 18 FR 15 CC ENFIT CONN COMPAT,SUP-2309463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,57.21,37.19,,,,,,,,,,,,,
SHEATH UROLOGICAL X-FORCE L 22 CM DIA10 MM RENAL CLR STRL,SUP-2655873,CDM,C1729,HCPCS,0272,RC,,,,both,,,116.49,75.72,,,,,,,,,,,,,
HEAD STEPTECH APG 52+5MM RIGHT,SUP-2512730,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
HEAD FEM +0MM DIA36MM ALUM OXIDE ZIRCONIA STRONTIUM OXIDE,SUP-2222429,CDM,C1776,CPT,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
DEVICE FIX DIA9-10MM STD FEM FOR 35-50MM TUNN EZLOC,SUP-2212828,CDM,C1713,HCPCS,0278,RC,,,,both,,,2240.20,1456.13,,,,,,,,,,,,,
PLATE BONE L93MM 8 H STRL S STL LCK COMPR FOR 3.5MM SCR EVOS,SUP-2349631,CDM,C1713,HCPCS,0278,RC,,,,both,,,2439.69,1585.80,,,,,,,,,,,,,
BLADE SAW NO2 W11.5XL12MM INT ORAL S STL UTTING DRL ACC,SUP-2367265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.26,214.02,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.4MM S STL ST LOK FULL THRD T8 STARDRV,SUP-2184344,CDM,C1713,HCPCS,0278,RC,,,,both,,,315.22,204.89,,,,,,,,,,,,,
CATHETER DRAINAGE MP STYL LOOP 038 12X35 CM 16 CM MAC LCK,SUP-2638508,CDM,C1729,HCPCS,0272,RC,,,,both,,,240.96,156.62,,,,,,,,,,,,,
TIP UNTRASONIC HNDPC SEL 24KHZ STD TIP 5 FLUE DISP ST,SUP-2243015,CDM,C1713,HCPCS,0278,RC,,,,both,,,1115.99,725.39,,,,,,,,,,,,,
STEM FEM SZ 1 STD OFFSET HIP ENDUR,SUP-2251937,CDM,C1776,CPT,0278,RC,,,,both,,,8531.38,5545.40,,,,,,,,,,,,,
COUNTERSINK SURG DIA3MM SCR CANN,SUP-2187347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1025.93,666.85,,,,,,,,,,,,,
HC US OB 1st Tr Fetal Translu Sgl,PX-4027681300,CDM,76813,CPT,0402,RC,,,,both,,,806.00,523.90,,,,,,,,,,,,,
KNIFE SURG SZ 15 CART NEUT S STL STRL DISP SMILLIE,SUP-2342363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
MARKER BRST BX 8GA TI OPN COIL HYDROMARK,SUP-2195590,CDM,A4648,CPT,0278,RC,,,,both,,,246.49,160.22,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 300 DR-T 55 X 66MM 12MM 30J DDDRV,SUP-2138073,CDM,C1721,HCPCS,0275,RC,,,,both,,,44544.04,28953.63,,,,,,,,,,,,,
STENT URET 0.035 IN 6 FRX30 CM 6 FR DBL PGTL PERCFLX POLARIS,SUP-2468915,CDM,C2617,HCPCS,0278,RC,,,,both,,,578.36,375.93,,,,,,,,,,,,,
CATHETER ABLAT 7FR L60CM HEAT ELEMENT L7CM 0.025IN,SUP-2172372,CDM,C1888,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SYSTEM LT VISN RFID CHANDELIER CONSTELLATION,SUP-2109950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.50,275.92,,,,,,,,,,,,,
PISTON 08MM DIAM 45MM LEN MALL SHEA LOOP FLROPLAS SHEA,SUP-2313663,CDM,L8613,CPT,0278,RC,,,,both,,,298.68,194.14,,,,,,,,,,,,,
STAPLE BONE FIX W15XL14-14MM COMPR,SUP-2223979,CDM,C1713,HCPCS,0278,RC,,,,both,,,3001.84,1951.20,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 35X35X1.5 MM POROUS POLYETHYLENE ST,SUP-2837799,CDM,C1713,HCPCS,0278,RC,,,,both,,,2035.35,1322.98,,,,,,,,,,,,,
HC So Homocystine,PX-3018309066,CDM,83090,CPT,0301,RC,,,,both,,,402.00,261.30,,,,,,,,,,,,,
GRAFT RECON BLDR REPLFRM 2X4CM,SUP-2139387,CDM,C1762,CPT,0278,RC,,,,both,,,1754.63,1140.51,,,,,,,,,,,,,
SCR MD MICRO15X35MM FLAT TIP,SUP-2678144,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.24,105.46,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,J7030,HCPCS,0250,RC,79672-0613-50,NDC,,both,1000,ML,425.00,276.25,,,,,,,,,,,,,
WALKER FT SM M SHOE SZ 3 65 FEM 4 75 STD CLS HEEL ROCK SOLE,SUP-2195218,CDM,L4386,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SET BLD PMP CANN 32FR 10MM BIVENT SUPP SYS 5000 BVS VENT,SUP-2106276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
NEEDLE KIT BVL TIP,SUP-2737856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PIN FIX DIA2.7MM BIOCRYL FEM TIB BNE TEND BNE CRSS RIGIDFIX,SUP-2249334,CDM,C1713,HCPCS,0278,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
BRACE KNEE AD ALUM FOAM FULL UNIV HNG STRP CLSR ADJ X-ACT,SUP-2196492,CDM,L1833,HCPCS,0272,RC,,,,both,,,315.07,204.80,,,,,,,,,,,,,
SET CATH JEJUSTMY STRL BARONE,SUP-2168836,CDM,C1769,HCPCS,0272,RC,,,,both,,,478.57,311.07,,,,,,,,,,,,,
PLATE BNE L 99 MM SCREW DIA2 MM 14 SHFT H TI STR MINI FRAG,SUP-2908088,CDM,C1713,HCPCS,0278,RC,,,,both,,,3643.19,2368.07,,,,,,,,,,,,,
GRAFT BIO TISS W7.5XL11IN RECT XENMATRIX,SUP-2125848,CDM,C1781,HCPCS,0278,RC,,,,both,,,33598.00,21838.70,,,,,,,,,,,,,
PLATE BONE 6 H CLAV LCK,SUP-2247333,CDM,C1713,HCPCS,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
PLATE BONE L214MM 14 H BILAT LCK COMPR RIG FOR 3.5MM SCR,SUP-2348453,CDM,C1713,HCPCS,0278,RC,,,,both,,,5908.85,3840.75,,,,,,,,,,,,,
CATHETER URET 4.8FR L70CM 8FR CONE TIP W/ OPN END FOR RG,SUP-2171240,CDM,C1758,HCPCS,0278,RC,,,,both,,,63.62,41.35,,,,,,,,,,,,,
CLIP INT L235CM OPN 11MM WRK CHN 2.8MM LOK MECHANISM MR,SUP-2436451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.46,339.60,,,,,,,,,,,,,
SUPPORT WR SM LNG LEN RT FRARM WVN COT RUB FAB BGE FIRM W/,SUP-2324893,CDM,L3931,HCPCS,0274,RC,,,,both,,,41.01,26.66,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA 30 MM L 15CM 10 MM ANTE FLO,SUP-2385050,CDM,C1768,CPT,0278,RC,,,,both,,,2772.40,1802.06,,,,,,,,,,,,,
GUIDEWIRE VASC IQ L 300 CM DIA 0.014 IN SIL STR TIP STRL,SUP-2140696,CDM,C1769,HCPCS,0272,RC,,,,both,,,52.12,33.88,,,,,,,,,,,,,
BALLOON NSL EPISTAXIS STRL,SUP-2261407,CDM,C1726,HCPCS,0272,RC,,,,both,,,233.93,152.05,,,,,,,,,,,,,
PIN DRL L15IN DIA2.4MM CALIB FOR ARTHSCP ANTR CRUC LIGMNT,SUP-2256828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
SCREWDRIVER ASD MAXDRIVE 20 ST,SUP-2262987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.07,315.95,,,,,,,,,,,,,
HEAD HUM H18MM DIA48MM CO CHROM ALLY BPLR STD OFFSET REV,SUP-2193860,CDM,C1776,CPT,0278,RC,,,,both,,,7659.40,4978.61,,,,,,,,,,,,,
CATHETER ETER CTRL VEN L55CM OD4FR POLYUR 1 LUMN,SUP-2384046,CDM,C1751,HCPCS,0278,RC,,,,both,,,151.60,98.54,,,,,,,,,,,,,
SCREW BONE L20MM DIA4MM NONSTERILE BLU CORT TI ST,SUP-2192241,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.07,383.55,,,,,,,,,,,,,
STEM HUM L175MM DIA8MM LNG SHLDR REV,SUP-2223309,CDM,C1776,CPT,0278,RC,,,,both,,,11006.33,7154.11,,,,,,,,,,,,,
GUIDEWIRE VASC L195CM OD0.012IN LD L VENT FIRM CPS DUO,SUP-2356391,CDM,C1769,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
COMPONENT PATELLAR KNEE SCORP,SUP-2378449,CDM,C1776,CPT,0278,RC,,,,both,,,1701.25,1105.81,,,,,,,,,,,,,
SLING ORTHOT CERV THOR LUMBAR SACR CUST AX,SUP-2435570,CDM,L1010,HCPCS,0274,RC,,,,both,,,236.88,153.97,,,,,,,,,,,,,
GRAFT BNE SUB 1.5CC W10XL15MM MINERALIZED CLLGN SCFLD,SUP-2138523,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
Vivacit-E Art Surf Sz 1 8mm,SUP-2510951,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CUP ACET OD53MM ID32MM LONGEVITY CEM SNAP IN SPCR PRI ZCA,SUP-2203802,CDM,C1776,CPT,0278,RC,,,,both,,,8551.79,5558.66,,,,,,,,,,,,,
TRIAL SURG INSTR 22X22X12MM BIOFOAM EVANS,SUP-2397869,CDM,C1776,CPT,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
SHEATH CATH INTRO 11FR L12CM HEMSTAS VLV SIDEPRT DIL DBL,SUP-2355403,CDM,C1894,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
STEM ENDO MODEL MOD CONICAL CMNTLSS 135X16MM,SUP-2665193,CDM,C1776,CPT,0278,RC,,,,both,,,6995.92,4547.35,,,,,,,,,,,,,
SPLINT FRARM AD SM/M RT NEOPRNE TERRY LNR BASE CVA/TBI DGT,SUP-2324472,CDM,L3809,HCPCS,0274,RC,,,,both,,,375.98,244.39,,,,,,,,,,,,,
HC Revasc Intra Lithotrip-Ather,PX-4810976600,CDM,C9766,CPT,0481,RC,,,,outpatient,,,57405.00,37313.25,,,,,,,,,,,,,
CATHETER CV SET 025 PEDIATRIC 5 FRX5 CM 3L POLYURETHANE,SUP-2759969,CDM,C1751,HCPCS,0278,RC,,,,both,,,234.68,152.54,,,,,,,,,,,,,
LEAD PACE SIL ENDOCARD RT ATRIOVENTRICULAR ACTIVE SCREW FIX,SUP-2139480,CDM,C1898,HCPCS,0275,RC,,,,both,,,3133.72,2036.92,,,,,,,,,,,,,
PLATE BNE 2X6 H ST CNDYL S STL LOK COMPR W SHT THRD DRL GUID,SUP-2177486,CDM,C1713,HCPCS,0278,RC,,,,both,,,1667.94,1084.16,,,,,,,,,,,,,
PLATE BNE DORS MED RT MID FT,SUP-2609050,CDM,C1713,HCPCS,0278,RC,,,,both,,,5109.44,3321.14,,,,,,,,,,,,,
IMPLANT BRST SMOOTH MOD PROF X,SUP-2748658,CDM,C1889,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
RING EXT FIX L180MM 2 H FT FOR SIDEKCK FREE CIR FIX,SUP-2400659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 20 MM DIA 3.5 MM SS RX,SUP-2142464,CDM,C1876,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
GRAFT DERMACELL DERMAL 16CM MATRIX X MICROPERFORATED,SUP-2777445,CDM,Q4122,HCPCS,0636,RC,,,,both,,,28888.00,18777.20,,,,,,,,,,,,,
SCREW BNE L38MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190354,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.17,35.86,,,,,,,,,,,,,
STAPLER INT USE DIA21 MM STPL H 3/3.5/4 MM MEDIUM/THICK CIR,SUP-2896339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2995.69,1947.20,,,,,,,,,,,,,
PASSER WIRE AC STRL DISP,SUP-2910486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
PLATE BNE L MED LT 6 HOLE W/ INTERMED SPACE STRL RESORB X,SUP-2468652,CDM,C1713,HCPCS,0278,RC,,,,both,,,680.69,442.45,,,,,,,,,,,,,
COMPONENT FEM SZ 4 L KNEE OXINIUM REV CEM LEGION,SUP-2346188,CDM,C1776,CPT,0278,RC,,,,both,,,20070.88,13046.07,,,,,,,,,,,,,
STEM FEM 04 L250MM OD20X16.5MM TILASTAN MICROPOROUS HIP,SUP-2397014,CDM,C1776,CPT,0278,RC,,,,both,,,7300.50,4745.32,,,,,,,,,,,,,
GRAFT HUM TISS L 250 MM DIA 8 MM ANTR TIBIALIS TEND FRZN,SUP-2913240,CDM,C1762,CPT,0278,RC,,,,both,,,10515.86,6835.31,,,,,,,,,,,,,
GRAFT BNE SUB 1CC 2MM GRAN ALLOGENIC MORPHOGENETIC PROT W,SUP-2138490,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
TRAY BX SZ 2 BLLN L15MM IBT ADD FRAC KYPHON EXPR KYPHON,SUP-2293627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5331.72,3465.62,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM THRD L15MM S STL TRCR PNT,SUP-2186902,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.31,297.25,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,J2004,HCPCS,0636,RC,63323-0482-27,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
KIT SPLNT CSTNG TCC EZ 4INW FIBERGLAS 1 PC WOVEN OP TCC24005,SUP-2194348,CDM,L4386,HCPCS,0274,RC,,,,both,,,371.96,241.77,,,,,,,,,,,,,
GRAFT HUM TISS R LAT W HEMI PLATEAU FRZN MENIS RECON,SUP-2307291,CDM,C1713,HCPCS,0278,RC,,,,both,,,18103.83,11767.49,,,,,,,,,,,,,
GRAFT BIO TISS W4XL4CM DERM REP SCFLD FEN PRIMATRIX,SUP-2243692,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
ELECTRODE ES URLGY 24FR DIA SM 12DG ANGLD CTTNG LOOP HF RSCT,SUP-2722829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1410.39,916.75,,,,,,,,,,,,,
PLATE BNE L158MM 11 H ST R ANTLAT DST TIB S STL LO PROF,SUP-2185955,CDM,C1713,HCPCS,0278,RC,,,,both,,,4547.94,2956.16,,,,,,,,,,,,,
PROSTHESIS OSS 0.4X3.65X4.5 MM EAR,SUP-2313854,CDM,L8613,CPT,0278,RC,,,,both,,,464.09,301.66,,,,,,,,,,,,,
COUNTERSINK SURG MINI MAXLOCK EXTRM ISO,SUP-2400510,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
GRAFT HUM TISS 10MM DISC CRYOPRESERVED VIABLE OSTEOCHNDRL,SUP-2120737,CDM,C1713,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
CURETTE SRGCL 8 1/2NL CRVCL CRTCL BONE ANGLD FRWRD F/MCRDSCC,SUP-2499391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1233.17,801.56,,,,,,,,,,,,,
IMPLANT BRST GEL 4.8 CM PROJCT 12.8 CM 405 CC RND MEMORYGEL,SUP-2758613,CDM,C1789,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
FLUOXETINE HCL 10 MG PO CAPS,RX-10069,CDM,6370000000,HCPCS,0637,RC,00904-7345-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
LEAD ICD RT VENT BPLR 21CM SPC A,SUP-2357380,CDM,C1895,HCPCS,0275,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
HC So Everolimus Level,PX-3018016966,CDM,80169,CPT,0301,RC,,,,both,,,231.00,150.15,,,,,,,,,,,,,
FORCEPS BPLR AD PED L8IN TIP DIA15MM STD NONSTICK DISPOSABLE,SUP-2364929,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1191.44,774.44,,,,,,,,,,,,,
ROD SPNL INLINE 6.35 MM ASF16S,SUP-2559406,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CLIP ANEUR BLDE W7MM DIA2.5MM S STL GRFT SLIM-LINE,SUP-2243081,CDM,C1713,HCPCS,0278,RC,,,,both,,,5598.62,3639.10,,,,,,,,,,,,,
HC Bone Marrow Biopsy-CT,PX-3613822100,CDM,38221,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
INSERT HUM ECC 2+ MM 12+ MM 42 MM SHLDR AEQUALIS REVERSED II,SUP-2715615,CDM,C1776,CPT,0278,RC,,,,both,,,4173.06,2712.49,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 8 H SCREW DIA2 MM TI MIDFACE ANGLED,SUP-2883741,CDM,C1713,HCPCS,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
SHUNT SURG 53 CM 2-5 CM W/ RESERVOIR KT LO CLS UNI-SHUNT,SUP-2666558,CDM,C1889,HCPCS,0278,RC,,,,both,,,5017.69,3261.50,,,,,,,,,,,,,
PLATE BNE HUM 3.5X163 MM RT PERIARTICULAR PROX 6 HOLE LCK LP,SUP-2177807,CDM,C1713,HCPCS,0278,RC,,,,both,,,5573.56,3622.81,,,,,,,,,,,,,
GRAFT HUM TISS CRYOPRESERVED 1 CC FLOWABLE PLCNTA VIAFLOW C,SUP-2759479,CDM,C1762,CPT,0278,RC,,,,both,,,4420.81,2873.53,,,,,,,,,,,,,
"HC So1 Dna Quantification, Each",PX-3068779967,CDM,87799,CPT,0306,RC,,,,both,,,503.00,326.95,,,,,,,,,,,,,
COMPONENT GLEN 40 MM SHLDR TRABECULAR MTL BIGLIANI/FLATOW,SUP-2436899,CDM,C1776,CPT,0278,RC,,,,both,,,3786.84,2461.45,,,,,,,,,,,,,
HC Total Protein,PX-3018415500,CDM,84155,CPT,0301,RC,,,,both,,,152.00,98.80,,,,,,,,,,,,,
PLATE BNE STR 2 MM 6 HOLE LCK TI NS LTX,SUP-2856947,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.22,1373.59,,,,,,,,,,,,,
PLATE BNE THK3MM REG 20 H TI L FOR 27MM SCR THREADLOCK,SUP-2262978,CDM,C1713,HCPCS,0278,RC,,,,both,,,4004.54,2602.95,,,,,,,,,,,,,
VALVE AORT MT DIA23MM BOV PERICARD STNT CO CHROM ALLY,SUP-2214105,CDM,C1889,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
KEY ORTH VERSE CORRECTION EXPEDIUM,SUP-2719352,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
IMMOBILIZER SHLDR L10.5-17IN D7IN SLNG W/ 15DEG ABD PLLW,SUP-2196388,CDM,L3650,HCPCS,0274,RC,,,,both,,,106.92,69.50,,,,,,,,,,,,,
GUIDEWIRE ORTH L800MM DIA3MM BALL TIP,SUP-2316305,CDM,C1769,HCPCS,0272,RC,,,,both,,,604.04,392.63,,,,,,,,,,,,,
MAGIC MOUTHWASH WITH NYSTATIN SIMPLE,RX-4081628,CDM,6370000000,HCPCS,0637,RC,09999-9917-22,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,2500000003,HCPCS,0250,RC,00338-0004-04,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE SYNDESMOSIS FOR ANK FRAC SYS ORTHOLOC 3DI,SUP-2398373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER HEMODIALYSI TRI FLO ACTE 11.5FR DIA 24CM STRGHT TAP,SUP-2610640,CDM,C1752,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
CATHETER HAD ADMIN FULL TY SHT TERM STR 11.5FRX12CM DUO FLO,SUP-2267016,CDM,C1752,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
GUIDEWIRE VASC STR 5 CM 0.014 INX80 CM FLX ILLUMAX NIT-VU,SUP-2117336,CDM,C1769,HCPCS,0272,RC,,,,both,,,176.56,114.76,,,,,,,,,,,,,
SCREW SPNL L 30 MM DIA 5.5 MM SHANK MDX OSTEOGRIP NS CD HORZ,SUP-2925161,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
KIT CATH HEMODIALYSI AHDC SAFETY 12FR DIA 25CM 3 LUMAN INDWL,SUP-2613324,CDM,C1751,HCPCS,0278,RC,,,,both,,,447.14,290.64,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR 16 CNTCT L50CM TRL INFINION,SUP-2138788,CDM,C1778,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
APPLIER CLP L L1.7MM DISP FOR VCS VES CLSR SYSTEMXENOSURE,SUP-2264245,CDM,C1713,HCPCS,0278,RC,,,,both,,,396.68,257.84,,,,,,,,,,,,,
PROSTHESIS OSS STAP DIA1.17 MM INCUS DIA 0.8 MM MED FLX H/A,SUP-2901942,CDM,L8613,CPT,0278,RC,,,,both,,,1689.95,1098.47,,,,,,,,,,,,,
DISTRACTOR SURG FAST PRECICE,SUP-2312262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
BASEPLATE 24MM 10* FULL AUGMENT,SUP-2749342,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
PLATE BONE LOK 285MML HLX12 PRTSL 64 NON CNTCT BRDGE POLYAX,SUP-2495217,CDM,C1713,HCPCS,0278,RC,,,,both,,,4098.39,2663.95,,,,,,,,,,,,,
CATHETER THROMCTMY AXS VECTA 74 L 115 CM PROX/DSTL OD,SUP-2551066,CDM,C1757,HCPCS,0272,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DYN TIP L 110 CM DIA 6 FR SPC 10,SUP-2142176,CDM,C1730,HCPCS,0272,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
KIT ACC HD EXT PLSE GENRTR,SUP-2355922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
NEEDLE SURG CRV W/O CANN FOR BLLN SYS STRL AVAFLEX,SUP-2864563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1556.37,1011.64,,,,,,,,,,,,,
CATHETER EP 4FR L120CM SPC 2-5-2MM 1MM BND JSN CRV QPLR,SUP-2356959,CDM,C1730,HCPCS,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
GRAFT BONE SUB L50-90MM FLD FEM DIA7-12MM TIB 7.0-12MM FRZN,SUP-2417748,CDM,C1762,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
INTRODUCER TUBE SET 6 FR PERC ADV CIAGLIA BLU RHINO G2,SUP-2759752,CDM,C1769,HCPCS,0272,RC,,,,both,,,1352.24,878.96,,,,,,,,,,,,,
SCREW BNE L30MM OD4.5MM STD CORT LOK,SUP-2342546,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.83,61.64,,,,,,,,,,,,,
SCREW VA LCK OPTILINK SLF TP 5.0X42MM,SUP-2720103,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.21,356.34,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 30 CC FD ASEP CANC,SUP-2867132,CDM,C1762,CPT,0278,RC,,,,both,,,1610.82,1047.03,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM REGEN MTRX REPLFRM,SUP-2139390,CDM,C1762,CPT,0278,RC,,,,both,,,3190.59,2073.88,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE W/ SIPHONGUARD BACTISEAL CERTAS +,SUP-2666587,CDM,C1889,HCPCS,0278,RC,,,,both,,,15969.54,10380.20,,,,,,,,,,,,,
EVOS 2.7/3.5 OLCRNN PL W/TNS 13H L 179MM,SUP-2819864,CDM,C1713,HCPCS,0278,RC,,,,both,,,9853.16,6404.55,,,,,,,,,,,,,
APPLICATOR TRAY GAM MINI 6-1 STRL SAVI BRACHY LF,SUP-2858444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SET PERFSN DIA18/20 20/22 22.24 FR GUIDEWIRE L 100 CM DIA,SUP-2908836,CDM,C1769,HCPCS,0272,RC,,,,both,,,289.95,188.47,,,,,,,,,,,,,
PLATE BNE W10XL56MM THK1.5MM 4X4 H BILAT S STL T R ANG LOK,SUP-2185867,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.12,569.48,,,,,,,,,,,,,
CLIP BNE FIX HIP SCR AMBI,SUP-2342406,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.27,530.58,,,,,,,,,,,,,
OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS,RX-5940,CDM,6370000000,HCPCS,0637,RC,00904-7093-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE 0DEG 6 H BILAT HND S STL STR LO PROF RIG,SUP-2184848,CDM,C1713,HCPCS,0278,RC,,,,both,,,939.77,610.85,,,,,,,,,,,,,
HC Pulse Oximetry Continuous,PX-4609476200,CDM,94762,CPT,0460,RC,,,,inpatient,,,452.00,293.80,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 2S 20X20 CM,SUP-2383100,CDM,C1781,HCPCS,0278,RC,,,,both,,,30144.00,19593.60,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR MODEL 2104 BAROSTIM NEO2,SUP-2881052,CDM,C1767,HCPCS,0278,RC,,,,both,,,98910.00,64291.50,,,,,,,,,,,,,
CAGE SPNL L14XW14XH30MM 4 LOBE LORDTC END CAP IMP NGAGE,SUP-2317739,CDM,C1889,HCPCS,0278,RC,,,,both,,,13175.44,8564.04,,,,,,,,,,,,,
SCREW BONE L130MM OD8MM STD S STL CORT ST SELF DRL CANN,SUP-2343422,CDM,C1713,HCPCS,0278,RC,,,,both,,,1760.47,1144.31,,,,,,,,,,,,,
BIT DRL L413MM DIA4.3MM FOR FEM NK SYSTEN,SUP-2179055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1219.32,792.56,,,,,,,,,,,,,
STEM HUM INTERCALARY 120 MM SHLDR REV SEG W/ SCREW COMPHSVE,SUP-2442427,CDM,C1776,CPT,0278,RC,,,,both,,,17634.24,11462.26,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BLADE LARYNSCP MILLER CH AD FBR OPT SZ 2 SM 152MMX13MM HEINE,SUP-2238187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 18 ATM 4 FRX190 CM 2.5X100 MM SABERX,SUP-2866067,CDM,C1725,HCPCS,0272,RC,,,,both,,,1014.97,659.73,,,,,,,,,,,,,
BUR ENDOSCP SHAVER 15 DEG DIA2.9 MM SPD 6000 RPM CRV DIAMOND,SUP-2901928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.73,643.32,,,,,,,,,,,,,
MICROCATHETER GUID TELEPORT CTRL L 135 CM DIA PROX 2.7/2.1,SUP-2159487,CDM,C1887,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,0636,RC,43066-0993-24,NDC,,both,50,ML,61.60,40.04,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 7X7 CM AMNION/CHORION MEMBRN EPIFIX,SUP-2305764,CDM,Q4186,HCPCS,0636,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
KETAMINE HCL 30 MG/3ML IJ SOSY,RX-143111,CDM,2500000003,HCPCS,0250,RC,69374-0982-33,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER ETER DIAG L25MM ACHVE MAP,SUP-2281884,CDM,C1730,HCPCS,0272,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-7 MM SHRT TAPR STR,SUP-2669696,CDM,C1768,CPT,0278,RC,,,,both,,,1130.27,734.68,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM 0.018 IN L 5 CM SS MANDREL STR FIX,SUP-2828287,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.25,37.86,,,,,,,,,,,,,
CATH ABLATION TACTIFLEX SE BID CURVE D-F,SUP-2874130,CDM,C2630,CPT,0272,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML CO SUSP,RX-167835,CDM,340b,HCPCS,0637,RC,46287-0006-60,NDC,,both,60,ML,111.60,72.54,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 360 DEG L 6 CM DIA 3 MM,SUP-2362411,CDM,C1889,HCPCS,0278,RC,,,,both,,,6143.41,3993.22,,,,,,,,,,,,,
CLAMP SURG IN LN EXTN 200 MM 6-6.5 MM RT 6.35 MM ROD,SUP-2584891,CDM,C1713,HCPCS,0278,RC,,,,both,,,8333.56,5416.81,,,,,,,,,,,,,
DILATOR VASC L 12.5 CM DIA 3 FR SS STIFF STRL,SUP-2615885,CDM,C1894,HCPCS,0272,RC,,,,both,,,53.07,34.50,,,,,,,,,,,,,
JOINT SACROILIAC 7X80 MM IFUSE-3D,SUP-2423223,CDM,C1889,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
PLATE SPNL LCK 9 MM THRD CVR SHORELINE ACS,SUP-2750400,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
CATHETER CV SET 032 8 FRX20 CM DL J TIP POLYURETHANE,SUP-2759961,CDM,C1751,HCPCS,0278,RC,,,,both,,,237.79,154.56,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 12 MM 39 CC 78 GM 2 CHMBR ATLS II DR V268ROPT] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356571,CDM,C1721,HCPCS,0275,RC,,,,both,,,72691.00,47249.15,,,,,,,,,,,,,
BURR BALL FLUTED 4.0MM ANSPACH S4BG1,SUP-2843314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.16,268.55,,,,,,,,,,,,,
REGULATOR ENDO AERO VENT,SUP-2402576,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
BOWL BNE CEM MIX SPAT CURET SMARTMIX CTS,SUP-2253061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
MESH SURG L 4 X W 2 CM D 1 MM PORCINE DERMAL CLLGN ABD HERN,SUP-2901706,CDM,C9364,HCPCS,0278,RC,,,,both,,,655.10,425.81,,,,,,,,,,,,,
ENDCAP ORTH L0MM DIA3.5MM ST TI NAIL SPRL BLDE EXTN HUM,SUP-2192475,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
COIL EMB L30CM OD12MM 0.018IN 2D HELCL STRTCH DETACH GDC-18,SUP-2365711,CDM,C1889,HCPCS,0278,RC,,,,both,,,1829.99,1189.49,,,,,,,,,,,,,
SYSTEM BONE CEM MX UNIV SGL VAC ROTOR W/O NOZ PRSSZR RESTRIC,SUP-2199461,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 10 HOLE,SUP-2518364,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
GRAFT BONE STRUT CORT ALLGRFT SZ 2X15CM,SUP-2113894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
CARBIDOPA-LEVODOPA 10-100 MG PO TABS,RX-9406,CDM,6370000000,HCPCS,0637,RC,00093-9701-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 25 CM 7 FR SS HYDRPHLC PERIPHERAL,SUP-2385676,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.58,48.48,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 0.035 INX180 CM STD NIT GLIDEWIRE,SUP-2385573,CDM,C1769,HCPCS,0272,RC,,,,both,,,142.87,92.87,,,,,,,,,,,,,
GRAFT HUM TISS W11XH5XL14MM CANC CORT LORD SPNL SPCR,SUP-2293952,CDM,C1713,HCPCS,0278,RC,,,,both,,,3450.86,2243.06,,,,,,,,,,,,,
HC Lactoferrin Fecal Qualitative,PX-3018363000,CDM,83630,CPT,0301,RC,,,,both,,,123.00,79.95,,,,,,,,,,,,,
CUP ACET DIA58MM HIP HOLED ANODIZED INSITU,SUP-2308979,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CUTTER SUT STD TENS PROCINCH,SUP-2361153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 74X50X14 MM VENTRIC CROPT ATLAS+ VR,SUP-2356521,CDM,C1722,HCPCS,0275,RC,,,,both,,,51307.60,33349.94,,,,,,,,,,,,,
CATHETER MAP D CRV 1-4-1 MM SPC 8 FRX117 CM CIR ADVISOR VL,SUP-2867439,CDM,C1730,HCPCS,0272,RC,,,,both,,,5843.54,3798.30,,,,,,,,,,,,,
INTRODUCER HEMSTAS 7FRX45CM 30 DEG CRV .038IN GWIRE FAST,SUP-2355580,CDM,C1894,HCPCS,0272,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
HC Electrophys Map 3d Add-On,PX-4819361300,CDM,93613,CPT,0481,RC,,,,both,,,13089.00,8507.85,,,,,,,,,,,,,
INTRODUCER BRST BX CELERO,SUP-2239957,CDM,C1894,HCPCS,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
PLATE BNE L 150 X W 15 MM THK 1.4 MM SCREW DIA2.2 MM 8 H PLL,SUP-2883306,CDM,C1713,HCPCS,0278,RC,,,,both,,,35034.96,22772.72,,,,,,,,,,,,,
HC Cardiac MRI for Velocity Flow Mapping,PX-6147556500,CDM,75565,CPT,0614,RC,,,,both,,,714.00,464.10,,,,,,,,,,,,,
PATIENT MNL AND MAG,SUP-2357364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CEFTRIAXONE SODIUM-DEXTROSE 2-2.22 GM-%(50ML) IV SOLR,RX-143624,CDM,J0696,HCPCS,0636,RC,00264-3155-11,NDC,,both,1,UN,150.90,98.08,,,,,,,,,,,,,
GRAFT BIO TISS W10XL16CM THK18 4MM ACELLULAR DERM MTRX ULT,SUP-2307480,CDM,Q4128,HCPCS,0636,RC,,,,both,,,14253.81,9264.98,,,,,,,,,,,,,
ANCHOR STRE 2.9MM DIA JGGRLC SOFT TSSUE NON BBSRBLE,SUP-2589046,CDM,C1713,HCPCS,0278,RC,,,,both,,,1783.02,1158.96,,,,,,,,,,,,,
DILATOR VES L17CM OD5FR 0.038IN GRY INTRO SHTH INPUT TS,SUP-2294506,CDM,C1894,HCPCS,0272,RC,,,,both,,,12.06,7.84,,,,,,,,,,,,,
TREPHINE SURG OD7MM COR SL DISPOSABLE,SUP-2212796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SCREW 7.0X75MM LNG THRD CANN MAXTORQUE MSD0107075L] WRIGHT MEDICAL TECHNOLOGY INC],SUP-2400352,CDM,C1713,HCPCS,0278,RC,,,,both,,,818.91,532.29,,,,,,,,,,,,,
DRILL SURG 2 MM PERC W/ TIP NS INION OTPS LTX REUSE,SUP-2857869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
SYSTEM CLOSURE 6 FR CLINCHER KNOT TYNG,SUP-2240296,CDM,C1760,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
STEM FEM L170MM DIA13MM HIP CO CHROM INTLOK PRI CEM TAPR,SUP-2403348,CDM,C1776,CPT,0278,RC,,,,both,,,4584.40,2979.86,,,,,,,,,,,,,
STENT URET DBL PGTL 0.038 IN 3 CM 8 FRX30 CM 6 FR POLARIS,SUP-2459383,CDM,C2617,HCPCS,0278,RC,,,,both,,,496.97,323.03,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 15 CC FD CANC,SUP-2205398,CDM,C1889,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X20 MM FOR 4.75 MM ROD ATS,SUP-2629325,CDM,C1713,HCPCS,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 5.5/6 MM REDUCTION UNIAXIAL STRL CD,SUP-2926665,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
BRACE WR THMB LT MCP CMC JT ELAS SUPP NEOPRNE WRP AD 1 SZ,SUP-2309135,CDM,L3908,HCPCS,0272,RC,,,,both,,,81.33,52.86,,,,,,,,,,,,,
SCREW BNE AD PED L7MM DIA2MM CORT TI SELF DRL SELF RET,SUP-2262825,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.30,74.29,,,,,,,,,,,,,
SUPPORT ORTH HIP CIRC 48-60 IN LARGE/XL SZ 4,SUP-2915156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.27,503.93,,,,,,,,,,,,,
POST FIX 2 H M,SUP-2197275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
STRUT EXT FIX L158 318MM LNG QUIK ADJ FOR RNG FIX SYS,SUP-2316070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3664.00,2381.60,,,,,,,,,,,,,
"HC Transcath Stent Cerv,Carotid W/O Eps",PX-3603721600,CDM,37216,CPT,0360,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
LITHIUM CARBONATE ER 300 MG PO TBCR,RX-10454,CDM,6370000000,HCPCS,0637,RC,00054-0021-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L 185 MM SCREW DIA 4.5 MM 10 H SS NAR COMPR NLCK,SUP-2933634,CDM,C1713,HCPCS,0278,RC,,,,both,,,2042.07,1327.35,,,,,,,,,,,,,
GRAFT BONE CLOWARD DWL FRZ DRY,SUP-2165558,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
BAG LEFT CARRY CONSLDTD F/HEARTMATE II,SUP-2356023,CDM,Q0508,HCPCS,0274,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.4X10 MM MANDIBULAR LOCKING FOR REC,SUP-2838465,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
SYSTEM FIX DIA9-10MM FEM HRD SCR SHTH INTRAFIX,SUP-2256826,CDM,C1776,CPT,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
SUPPORT ORTHOT METATRSL CUST BAR WDG ROCKER,SUP-2435726,CDM,L3400,HCPCS,0274,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
RELOAD STPL L45MM EXTRA THCK TISS BLK ARTC INTELLIGENCE FOR,SUP-2283354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,814.39,529.35,,,,,,,,,,,,,
PLATE BONE L238MM THK4.5MM 11 H LT LAT TIB HD BTTRS TI RIG,SUP-2190896,CDM,C1713,HCPCS,0278,RC,,,,both,,,3070.20,1995.63,,,,,,,,,,,,,
BAND LAPAROSCOPY GASTRIC 11 CM ADJUSTABLE STERILE LAP-BAND VG,SUP-2119232,CDM,C1889,HCPCS,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
BLADE SURG FOR ADENOTOMES WT540603,SUP-2649906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1101.45,715.94,,,,,,,,,,,,,
KIT CATHETER ARTERIAL ARROW SAFETY 20GA 3.8CM RADIAL,SUP-2865690,CDM,C1751,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
KIT HAD CATH L32CM DIA15FR TIP TO CUF 27CM TWO LUMN LNG,SUP-2383443,CDM,C1750,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
CATHETER EP 6FR L115CM 2-5-2MM SPC M CRV DECAPOLAR MAP UNI,SUP-2356858,CDM,C1730,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
HEAD HUM 3+ MM 40 MM GLEN SHLDR TI COMPHSVE VERSA-DIAL,SUP-2441519,CDM,C1776,CPT,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
ALLOGRAFT HUM TISS TEND 8-12.5X77-95 MM JRF GRAFTLINK XL,SUP-2264640,CDM,C1713,HCPCS,0278,RC,,,,both,,,8101.20,5265.78,,,,,,,,,,,,,
SIDEKICK STLTH REARFOOT FIX HALF PIN 3 MMX180 MM 40 MM THRD,SUP-2400689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
BAR SPNL L15MM UNIV THORLUM TI CLS TRNSVRS SM STAT USS,SUP-2193447,CDM,C1713,HCPCS,0278,RC,,,,both,,,1705.02,1108.26,,,,,,,,,,,,,
IMPLANT CRANIOFACIAL L 40 X W 40 MM THK 2.5/0.73 MM LG,SUP-2909502,CDM,C1713,HCPCS,0278,RC,,,,both,,,2204.06,1432.64,,,,,,,,,,,,,
CAGE SPNL D 25 MM EXPANDABLE CORPECTOMY T2 STRATOSPHERE,SUP-2423825,CDM,C1889,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
CONDUIT CV CONTEGRA ID 12 MM BOV JUG VEIN FLX THN VERSATILE,SUP-2429904,CDM,C1713,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
CATHETERIZATION KIT 8.5 FRX20 CM ARROWG+ARD BLU +,SUP-2383395,CDM,C1751,HCPCS,0278,RC,,,,both,,,459.07,298.40,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST MULTILIGAMENTOUS PREFABRICATED,SUP-2435624,CDM,L1906,HCPCS,0274,RC,,,,both,,,318.33,206.91,,,,,,,,,,,,,
GUIDEWIRE VASC L 45 CM DIA 0.018 IN NIT MARKED RADIOPAQUE,SUP-2269548,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123853,CDM,J9041,HCPCS,0636,RC,63020-0049-01,NDC,,both,1,UN,4616.70,3000.85,,,,,,,,,,,,,
PROSTHESIS LARYN 10MM LO AIRFLO RESISTANCE EZ MAINT FOR,SUP-2124339,CDM,L8509,HCPCS,0274,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
KIT INSTR DISP FOR MIC BIO SUTURETAK,SUP-2121001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PROSTHESIS OSS L4.5MM OD1.65MM INCUS SGL NOTCH IMP WEHRS,SUP-2312814,CDM,L8613,CPT,0278,RC,,,,both,,,1177.12,765.13,,,,,,,,,,,,,
BASEPLATE TIB SZ 4 LT KNEE TI PRI CEM STEM GEN II,SUP-2346611,CDM,C1776,CPT,0278,RC,,,,both,,,5612.75,3648.29,,,,,,,,,,,,,
PLATE BNE L 37 MM SCREW DIA1.6 MM TI LT CNDYL 2 COMPR LCK LP,SUP-2912894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1321.94,859.26,,,,,,,,,,,,,
SCREW INTRF PEEK INTRAFIX ADV 7MMX30MM,SUP-2176895,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
SYSTEM ENDOSCOPIC 235CM PROFILE TACKING HELIX LOW XTACK,SUP-2878001,CDM,C1889,HCPCS,0278,RC,,,,both,,,5363.12,3486.03,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X1 CM FD DBM GRFT,SUP-2787764,CDM,C1713,HCPCS,0278,RC,,,,both,,,7603.82,4942.48,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 12 DEG L 11 CM DIA 4 MM SPD 1500 RPM,SUP-2902118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.64,427.47,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN TIP L3IN NIT COR POLYUR,SUP-2385569,CDM,C1769,HCPCS,0272,RC,,,,both,,,155.84,101.30,,,,,,,,,,,,,
SHUNT VENTRICULAR OD2.5MM CATHETER L25CM AND L120CM 5CM WATE,SUP-2821801,CDM,C1889,HCPCS,0278,RC,,,,both,,,2601.84,1691.20,,,,,,,,,,,,,
PLATE BONE CONDYLAR 6 HOLE QUARTER TUBULAR STAINLESS STEEL S,SUP-2836701,CDM,C1713,HCPCS,0278,RC,,,,both,,,627.43,407.83,,,,,,,,,,,,,
KIT PD 5.8FT-6.3FT M STRNL BRAC PT TLSO,SUP-2123924,CDM,L0462,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
DEVICE FIX DIA10MM CONT LOOP FOR ACL FIX ENDOBUTTON CL ULT,SUP-2341876,CDM,C1713,HCPCS,0278,RC,,,,both,,,1052.75,684.29,,,,,,,,,,,,,
PLATE BNE R DST RAD VOLAR TI FOR 1.8/2.4/2.7MM SCR,SUP-2191014,CDM,C1713,HCPCS,0278,RC,,,,both,,,2241.43,1456.93,,,,,,,,,,,,,
KWIRE FIX L6IN DIA11MM S STL 3 SIDE DBL TRCR BOTH END PNT,SUP-2150335,CDM,C1713,HCPCS,0278,RC,,,,both,,,7.50,4.87,,,,,,,,,,,,,
DUR BANTAM 10D 22.225X38 LINER,SUP-2512907,CDM,C1776,CPT,0278,RC,,,,both,,,2136.46,1388.70,,,,,,,,,,,,,
ALLOGRAFT BNE HUM SHFT 160X2 MM FD,SUP-2717863,CDM,C1762,CPT,0278,RC,,,,both,,,4463.54,2901.30,,,,,,,,,,,,,
CATH URET L 20 IN DIA 10 FRY ADLT DUAL LUM RADI ST LF DISP,SUP-2914403,CDM,C1758,HCPCS,0278,RC,,,,both,,,277.48,180.36,,,,,,,,,,,,,
TUBE TELSCP T14 ANG LEGEND,SUP-2281700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2532.54,1646.15,,,,,,,,,,,,,
GRAFT BNE 10CC BLU N-FORCE,SUP-2421384,CDM,C1713,HCPCS,0278,RC,,,,both,,,13527.12,8792.63,,,,,,,,,,,,,
DOXEPIN HCL 150 MG PO CAPS,RX-2610,CDM,6370000000,HCPCS,0637,RC,49884-0222-03,NDC,,both,1,UN,3.60,2.34,,,,,,,,,,,,,
COMPONENT FEM L5CM L DST KNEE RESURF ORTH SALV SYS,SUP-2405704,CDM,C1776,CPT,0278,RC,,,,both,,,18383.13,11949.03,,,,,,,,,,,,,
STEM FEM L30MM OD16MM UNIV CSTI POR KNEE PRI CEM FLUT IMP,SUP-2208275,CDM,C1776,CPT,0278,RC,,,,both,,,13621.32,8853.86,,,,,,,,,,,,,
HC Insertion Uterine Tandem&/Vaginal Ovoids,PX-3425715500,CDM,57155,CPT,0342,RC,,,,inpatient,,,2249.00,1461.85,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L19IN FOR UP TO 27IN THGH UNIV FOAM NYL,SUP-2205521,CDM,L1830,CPT,0274,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1295108FD4,SUP-2632817,CDM,C1751,HCPCS,0278,RC,,,,both,,,1010.58,656.88,,,,,,,,,,,,,
INSERT TIBIALXL L80MM THK15MM AP51MM LT MEDL LAT ARTC CRUC,SUP-2344109,CDM,C1776,CPT,0278,RC,,,,both,,,2673.71,1737.91,,,,,,,,,,,,,
"HC Debride Skin,Non-Selective",PX-4209760200,CDM,97602,CPT,0420,RC,,,,both,,,253.00,164.45,,,,,,,,,,,,,
PROBE SPNL CRV BALL HNDL TSRH 3D,SUP-2289780,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.75,748.64,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS IMPLANTATION STYL INF 42 CM STYL,SUP-2475475,CDM,C1769,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
SCREW BNE SZ 4.0MMX40MM CANN,SUP-2243598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.43,760.13,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 220 CM 0.035 IN TAPR L 22 CM ANGLED,SUP-2170345,CDM,C1769,HCPCS,0272,RC,,,,both,,,89.65,58.27,,,,,,,,,,,,,
LEAD DEFIB ST SIL ENDOCARD 7FR ST. JUDE MED RIATA,SUP-2357365,CDM,C1895,HCPCS,0275,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
CATHETER HD STR 15.5 FRX15 CM SHT TERM 3L T-3 CT,SUP-2627213,CDM,C1752,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
DEVICE REATTACHMENT W22.1XL50.8MM SHT GREATER TROCHANTERIC,SUP-2410261,CDM,C1776,CPT,0278,RC,,,,both,,,2235.49,1453.07,,,,,,,,,,,,,
SCREW SYS PARTIALLY THRD LAG SCRS TI THRD 35 MM CANN 09 MM,SUP-2392907,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.63,366.36,,,,,,,,,,,,,
IMPLANT BRST 460CC P5.9CM DIA11.4CM SFT COHESIVE SIL GEL,SUP-2113345,CDM,C1789,HCPCS,0278,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
INTRODUCER SHTH 6 FRX20 CM 21 GAX15 CM COAX DIL NDL MAK-NV,SUP-2469319,CDM,C1894,HCPCS,0272,RC,,,,both,,,143.44,93.24,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE BUR HOLE RT ANGLE UNITZ DSTL CATH,SUP-2666486,CDM,C1889,HCPCS,0278,RC,,,,both,,,16468.70,10704.65,,,,,,,,,,,,,
STAPLE BNE FIX SM W10XL10.5MM DIA1MM S STL BARB LEG LO PROF,SUP-2122331,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CAUTERY ROBOTIC DIA5MM SPAT TIP DA VINCI,SUP-2246577,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE L301MM 14 H NONSTERILE L CNDYL S STL CRV LOK,SUP-2177861,CDM,C1713,HCPCS,0278,RC,,,,both,,,6252.87,4064.37,,,,,,,,,,,,,
BOLT ORTH L 36 MM DIA 3.5 MM TI ANTI-DRIFT FT STRL MOTOBAND,SUP-2893272,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SCREW BNE L45MM DIA4.5MM THRD L22MM HD DIA8MM MALL S STL,SUP-2184553,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
PLATE BNE W12XL140MM THK25MM LNG 5 H NONSTERILE BILAT PROX,SUP-2190990,CDM,C1713,HCPCS,0278,RC,,,,both,,,4817.33,3131.26,,,,,,,,,,,,,
BLADE SAW L 115 MM L 37 MM THK MATERIAL 0.4 MM CUT 0.6 MM,SUP-2929358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.67,443.74,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME L 120 CM DIA 5 FR SPC 2-5,SUP-2489220,CDM,C1730,HCPCS,0272,RC,,,,both,,,124.34,80.82,,,,,,,,,,,,,
SLEEVE DRL OD2MM FOR 2.7MM UNIV GUID,SUP-2194068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.31,67.15,,,,,,,,,,,,,
SEED BRACHYTHERAPY FOR RADIOACTIVE ADVANTAGE IOD I 125,SUP-2423883,CDM,C2638,HCPCS,0278,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY POLARIS X 270DEG L 110 CM DIA 6,SUP-2700079,CDM,C1732,HCPCS,0272,RC,,,,both,,,380.10,247.06,,,,,,,,,,,,,
SET VITALFLOW DISP W/BALANCE BIOSURFACE,SUP-2909521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30301.00,19695.65,,,,,,,,,,,,,
COVER BURR HOLE ULTRA LO PROF 15 MM 5 HOLE STR NEUT TAB TI,SUP-2262589,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.63,591.91,,,,,,,,,,,,,
WIRE FIX L450MM OD15MM ORTH ETCHED OLV HOFFMANN II,SUP-2372242,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE L24MM 4 H CRANIOFACIAL TI STR,SUP-2262763,CDM,C1713,HCPCS,0278,RC,,,,both,,,231.95,150.77,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED + LG COMPLX + PEEK NS LTX,SUP-2862812,CDM,C1713,HCPCS,0278,RC,,,,both,,,52946.81,34415.43,,,,,,,,,,,,,
PLATE BNE L20MM S STL FT 4 H COMPR FOR 3.5MM SCR CHARLOTTE,SUP-2397368,CDM,C1713,HCPCS,0278,RC,,,,both,,,2615.62,1700.15,,,,,,,,,,,,,
CATHETER DIAG 6FR L145CM WIRE CTRL VENTURE,SUP-2356654,CDM,C1887,HCPCS,0272,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
CLAMP REPROC MINI BAR BAR MR SAFE JET X 6MM 10.5MM,SUP-2465455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.56,335.11,,,,,,,,,,,,,
HC Dilate Nephrost Ureter Urethra,PX-3207448500,CDM,74485,CPT,0320,RC,,,,outpatient,,,1668.00,1084.20,,,,,,,,,,,,,
KIT STPL BRDG 18MM LEG 18MM MAX CLSR 10.4MM BME ELITE,SUP-2254041,CDM,C1713,HCPCS,0278,RC,,,,both,,,4104.51,2667.93,,,,,,,,,,,,,
PLATE BNE L103MM THK3.8MM 6 H BILAT S STL NAR DYN COMPR FOR,SUP-2185206,CDM,C1713,HCPCS,0278,RC,,,,both,,,1176.87,764.97,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM 0.018 IN L 5CM SS MANDREL STR FIX FLX,SUP-2828289,CDM,C1769,HCPCS,0272,RC,,,,both,,,67.45,43.84,,,,,,,,,,,,,
PLATE BONE L88MM 3 H S STL CLVRLF,SUP-2198576,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.70,324.80,,,,,,,,,,,,,
COMPONENT GLEN SHLDR HEMI TO RVS TRABECULAR MTL,SUP-2212298,CDM,C1776,CPT,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
KIT EXP NDL L6IN SOAK CATH L5IN T PEEL ON-Q,SUP-2236831,CDM,C2626,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 BLLN L10MM IBT ADD FRAC KYPHON EXPR,SUP-2293637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SCREW BNE DISTRCTN 12 MM STRL,SUP-2430773,CDM,C1713,HCPCS,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
HC So Ld Isoenzyme Referred,PX-3018362566,CDM,83625,CPT,0301,RC,,,,both,,,374.00,243.10,,,,,,,,,,,,,
PLATE SPNL L43MM 6 H LEV 2 ANTR BILAT CERV TI LCK LO PROF,SUP-2254587,CDM,C1713,HCPCS,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
PROCESSOR SND SYS N5SP2,SUP-2141843,CDM,L8690,HCPCS,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 60 CM DIA 8.5 FR CRV DIA28 MM,SUP-2357213,CDM,C1894,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
KIT INTRO MICROEZ L 35 CM CATH 5 FR NDL L 10 CM SS GUIDEWIRE,SUP-2125476,CDM,C1751,HCPCS,0278,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
SPONGE SCLER L5XW2.5MM HALF RND STYL 510 SIL ST,SUP-2213500,CDM,C1784,HCPCS,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
SCREW ACET 140 DEG 100 MM HIP NS,SUP-2251193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
PLATE BONE LOK HLX3 MED CLMN RIGHT DST VOLAR RDL,SUP-2724782,CDM,C1713,HCPCS,0278,RC,,,,both,,,2716.73,1765.87,,,,,,,,,,,,,
PLATE SPINE OCCIPITAL M LINEUM OCT,SUP-2205462,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX9 TTNM CNTRD F3.5MM LOK SCREW ST,SUP-2724127,CDM,C1713,HCPCS,0278,RC,,,,both,,,1785.28,1160.43,,,,,,,,,,,,,
SCREW BNE CANN 7X50 MM,SUP-2420820,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 025 5 FRX8 CM 16 GA 3L SPECTRUM,SUP-2759895,CDM,C1751,HCPCS,0278,RC,,,,both,,,571.95,371.77,,,,,,,,,,,,,
FRAME EXT FIX BRDG BX ANK DELT STRL GALAXY UNYCO LTX,SUP-2875638,CDM,C1713,HCPCS,0278,RC,,,,both,,,32361.47,21034.96,,,,,,,,,,,,,
LINER ACET PROV A 10 DEG 28 MM G7,SUP-2440257,CDM,C1776,CPT,0278,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
BUR SURG RND 1.8X1 MM CARBIDE BRN S2 MINI,SUP-2859298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,625.86,406.81,,,,,,,,,,,,,
SYSTEM INTRO 8FR L13CM STD BLU CAP HEMSTAT SPLITTABLE,SUP-2302495,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.07,55.95,,,,,,,,,,,,,
FILTER VASC L 150 CM DIA 0.035 IN SS TEF VENA CAVA FEM,SUP-2113960,CDM,C1880,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
MANIPULATOR SURG IOL STR W/ GRD LESTER,SUP-2261483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,664.17,431.71,,,,,,,,,,,,,
PLATE BONE DOUBLE BEND 2 MM 6 MM LEFT CHIN 4 HOLE ADVANCEMEN,SUP-2838393,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.29,651.49,,,,,,,,,,,,,
MESH SURG XS OPTIMESH,SUP-2536959,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
VERTEBRAL BODY DEV 36MMX13MMX12DEG STALIF,SUP-2320303,CDM,C1889,HCPCS,0278,RC,,,,both,,,28244.30,18358.79,,,,,,,,,,,,,
BLADE SURG 7 LT MIDLN MAST MIDLF,SUP-2631589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
GRAFT BONE LT FEM WHL W/O HD TRAD FRZN,SUP-2294156,CDM,C1713,HCPCS,0278,RC,,,,both,,,14695.20,9551.88,,,,,,,,,,,,,
REAMER SURG OD36MM S STL ACET SPHR CUTTINGEDGE,SUP-2361866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.28,429.83,,,,,,,,,,,,,
COIL EMB L8CM OD3MM 0.01IN 2D HELCL DETACH GDC-10,SUP-2365655,CDM,C1889,HCPCS,0278,RC,,,,both,,,1520.07,988.05,,,,,,,,,,,,,
LINER ACET PRSS FT HIP POROUS MTL CERM,SUP-2304817,CDM,C1776,CPT,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
HC Microsomal Antibodies Each,PX-3028637600,CDM,86376,CPT,0302,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
"HC Ultrasound, Fetal Biophys",PX-4027681800,CDM,76818,CPT,0402,RC,,,,both,,,1022.00,664.30,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED BIOMET8000] ZIMMER BIOMET INC],SUP-2137329,CDM,C1776,CPT,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
SET URET STENT MARD L 28 CM DIA 8 FR ZIPWIRE 0.038 IN,SUP-2457680,CDM,C2617,HCPCS,0278,RC,,,,both,,,566.02,367.91,,,,,,,,,,,,,
BLADE DRIVER T8,SUP-2704916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1017.67,661.49,,,,,,,,,,,,,
PROMETHAZINE HCL 25 MG RE SUPP,RX-11144,CDM,6370000000,HCPCS,0637,RC,00713-0526-06,NDC,,both,1,UN,51.20,33.28,,,,,,,,,,,,,
PLATE BNE L 2.7 MM RT LCK 5 HOLE SHFT NS LTX,SUP-2861509,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.12,782.03,,,,,,,,,,,,,
HEAD RADIAL MOD 22 LNG ELBW,SUP-2610426,CDM,C1776,CPT,0278,RC,,,,both,,,9236.25,6003.56,,,,,,,,,,,,,
KIT VASC SEAL 4 ML HUM SER ALB POLYETHYL GLYCOL APPL SPRY,SUP-2930546,CDM,C1762,CPT,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA18MM REDUC MR SAFE,SUP-2255809,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
DRILL F 6MM SCR 1.3X79MM,SUP-2364180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.43,296.03,,,,,,,,,,,,,
PLATE BUR H L 17 MM THK 0.5 MM SZ 24.2 X 21.2 MM TI RT,SUP-2934753,CDM,C1713,HCPCS,0278,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
HARVESTER SURG W2.5XL2.5CM EPIDERMAL AUTO PRECIS CELLUTOME,SUP-2262291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
KNEE TOTAL PERSONA ZIMMER BIOMET,SUP-2909906,CDM,C1776,CPT,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
BASEPLATE TIB,SUP-2265739,CDM,C1776,CPT,0278,RC,,,,both,,,2488.23,1617.35,,,,,,,,,,,,,
PLATE BNE SQ 1.5X0.6 MM CRANIOFACIAL NEURO 4 HOLE LADDER NS,SUP-2485041,CDM,C1713,HCPCS,0278,RC,,,,both,,,614.18,399.22,,,,,,,,,,,,,
PIN EXT FIX BLNT 6X250 MM 90 MM THRD HA SS STRL APEX,SUP-2460751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CAP ENDOSCP SEAL H2O RESIST FOR GIF-H180,SUP-2472706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1047.38,680.80,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4MM MINI CANC POST OCCIPITAL CERV THOR,SUP-2254393,CDM,C1713,HCPCS,0278,RC,,,,both,,,2923.34,1900.17,,,,,,,,,,,,,
NEEDLE PUNC SPNL 0 DEG 17 MMX18 CM NEURO W/O BITE WIDTH,SUP-2770066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.11,248.37,,,,,,,,,,,,,
DRILL SUT ANCHR MICRORAPTOR SHLDR,SUP-2419183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
STRAP ORTHOT HIP KNEE ANK CUST TORSON BILATERAL ROT,SUP-2435640,CDM,L2040,HCPCS,0274,RC,,,,both,,,572.74,372.28,,,,,,,,,,,,,
CAGE SPNL H24-40MM OD16MM 6DEG SM TI ANT THORLUM INTBDY FUS,SUP-2390798,CDM,C1889,HCPCS,0278,RC,,,,both,,,28194.06,18326.14,,,,,,,,,,,,,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR|DISCARDED DRUG NOT ADMINISTE,RX-6086,CDM,J2540,HCPCS,0636,RC,00049-0520-22,NDC,JW,both,1,UN,54.10,35.16,,,,,,,,,,,,,
SCREW PEDCL SPNL POST THORACO LUM 5.5MM DIA SAG ADJUSTING W/,SUP-2291260,CDM,C1713,HCPCS,0278,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
CANNULA ENDOSCP SLT,SUP-2477717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1141.20,741.78,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 10%|DISCARDED DRUG NOT ADMINISTE,RX-430005,CDM,J1459,HCPCS,0636,RC,44206-0437-10,NDC,JW,both,100,ML,5659.90,3678.93,,,,,,,,,,,,,
SIDEPLATE STD BARL 130 DEG 14H STRL LCP DHHS,SUP-2547648,CDM,C1713,HCPCS,0278,RC,,,,both,,,3087.25,2006.71,,,,,,,,,,,,,
PLATE BNE W10XL50MM THK1.2MM 90DEG 3X3 H BILAT S STL T SHP,SUP-2185863,CDM,C1713,HCPCS,0278,RC,,,,both,,,980.56,637.36,,,,,,,,,,,,,
PIOGLITAZONE HCL 15 MG PO TABS,RX-25528,CDM,6370000000,HCPCS,0637,RC,33342-0054-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE SM W11XL111MM THK34MM 8 H BILAT TI RIG NEUT LOK,SUP-2190781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1007.88,655.12,,,,,,,,,,,,,
BIT DRILL ARTHSCP RETROCUTTER 10.5MM,SUP-2120854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
CATHETER CV FULL TY 032 10 FRX20 CM 10 GA 5 LUMEN SPECTRUM,SUP-2759735,CDM,C1751,HCPCS,0278,RC,,,,both,,,617.70,401.50,,,,,,,,,,,,,
CLAMP EXT FIX DIA8/11MM COMB CLP ON SELF HLD,SUP-2188531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1780.41,1157.27,,,,,,,,,,,,,
BIT DRL CPL END 6X195 MM,SUP-2795979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.38,205.00,,,,,,,,,,,,,
BIT DRL L485MM DIA4.5/6.5MM TI STP L QUIK CPL FOR INFERIOR 03010078] DEPUY SYNTHES USA],SUP-2178865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1583.91,1029.54,,,,,,,,,,,,,
STEM FEM L150MM STD OFFSET L HIP CO CHROM PROSTALAC,SUP-2251990,CDM,C1776,CPT,0278,RC,,,,both,,,9377.30,6095.24,,,,,,,,,,,,,
INSERT TIB SZ 9 THICKNESS 8MM CRUC RET NEUT UNIV PRI SCORP,SUP-2365097,CDM,C1776,CPT,0278,RC,,,,both,,,2027.66,1317.98,,,,,,,,,,,,,
KIT HEMTLGY CONC SYS CBMA MAR0 MAX QUICKDRAW W/ LIGHTNING,SUP-2247323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
GUIDEWIRE PTFE COAT FIX COR STIFF BODIED 0038INX150CM J TIP,SUP-2139320,CDM,C1769,HCPCS,0272,RC,,,,both,,,42.67,27.74,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.413,SUP-2859977,CDM,C1713,HCPCS,0278,RC,,,,both,,,32879.88,21371.92,,,,,,,,,,,,,
WIRE EXT FIX L370MM DIA1.8MM S STL BAYNT PNT FOR ILIZ TAY,SUP-2342295,CDM,C1769,HCPCS,0272,RC,,,,both,,,5263.14,3421.04,,,,,,,,,,,,,
LINER HUM 0+ MM 60 DEG 40 MM VIVACIT-E,SUP-2436931,CDM,C1776,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
CATHETER DRAINAGE LCK 038 LG 14 FRX14 CM 5 CM STAYFIX RESOLV,SUP-2464587,CDM,C1729,HCPCS,0272,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SCREW BONE L ACET LNR MULT H VIT E,SUP-2212341,CDM,C1713,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
VALVE PERITONEAL L90CM OD1.4MM 30CM VERTICAL WATER PRESSURE,SUP-2821786,CDM,C1889,HCPCS,0278,RC,,,,both,,,7301.00,4745.65,,,,,,,,,,,,,
FEBUXOSTAT 40 MG PO TABS,RX-97047,CDM,6370000000,HCPCS,0637,RC,33342-0274-07,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE L242MM THK3.3MM 20 H BILAT S STL RIG STR DYN,SUP-2186339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1696.45,1102.69,,,,,,,,,,,,,
PLATE BNE MINI 15 MM MIDFOOT 4 HOLE MOTOBAND CP SCP,SUP-2866408,CDM,C1713,HCPCS,0278,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
SCREW SPNL L20MM DIA5.5MM CANC ANTR THORLUM GRN TI ALLOY ST,SUP-2193078,CDM,C1713,HCPCS,0278,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
BLADE SHAVER RESECT 5.5X130 MM SMOOTH DISP,SUP-2661217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.04,256.13,,,,,,,,,,,,,
URELLE 81 MG PO TABS,RX-33126,CDM,6370000000,HCPCS,0637,RC,00037-6321-90,NDC,,both,1,UN,42.40,27.56,,,,,,,,,,,,,
PIN EXT FIX L 25 MM DIA 3 MM TIN HALF STRL DISP JET-X MAV,SUP-2933684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.35,396.73,,,,,,,,,,,,,
HC M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb,PX-3128837700,CDM,88377,CPT,0312,RC,,,,inpatient,,,1050.00,682.50,,,,,,,,,,,,,
HC Assay of Lipoprotein,PX-3018371800,CDM,83718,CPT,0301,RC,,,,inpatient,,,216.00,140.40,,,,,,,,,,,,,
WEDGE OSTEOTOM ORTH FOR TIB SYS,SUP-2121032,CDM,C1713,HCPCS,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
BIT DRL DIA2.4MM TRIFLAT ADJ FOR ATLNTS ANT CERV PLT SYS,SUP-2291125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.69,443.10,,,,,,,,,,,,,
GRAFT SPNL W8XL26MM CORT CAPSTONE,SUP-2293985,CDM,C1713,HCPCS,0278,RC,,,,both,,,13838.61,8995.10,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7533,SUP-2525329,CDM,C1769,HCPCS,0272,RC,,,,both,,,705.43,458.53,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135CM 4FR SLT 20CM 0.035IN BALL,SUP-2117049,CDM,C1725,HCPCS,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
HC Endoven Ther Chem Adhes 1st,PX-3613648200,CDM,36482,CPT,0361,RC,,,,both,,,16763.00,10895.95,,,,,,,,,,,,,
POST EXT FIX 1 H WIRE MR CONDITIONAL FOR DISTR OSTEOGENESIS,SUP-2179148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.79,418.46,,,,,,,,,,,,,
PLATE BNE W14XL118MM THK3.8MM 90DEG 5 H L TIB S STL L SHP,SUP-2185789,CDM,C1713,HCPCS,0278,RC,,,,both,,,4020.11,2613.07,,,,,,,,,,,,,
ANCHOR SUTURE BIOWIRE 4 IN KNOTLESS WHT SUTURETAK,SUP-2122130,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
HEAD CASS 12MM DISP FOR VBR EXP ADDPLUS,SUP-2390800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
WIRE FIX OLV 1.6 MM KIRSCHNER,SUP-2267997,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.98,440.04,,,,,,,,,,,,,
COIL NEUROVASCULAR MICRUSPHERE XL 18 L 27 CM DIA 9 MM,SUP-2249294,CDM,C1889,HCPCS,0278,RC,,,,both,,,4858.05,3157.73,,,,,,,,,,,,,
CLAMP EXT FIX CLP ON SELF HLD MAG RESONANCE CONDITIONAL,SUP-2188500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1433.28,931.63,,,,,,,,,,,,,
PLATE BONE W100XL100MM 4MM H SPC CRAN TI MESH FOR 1/1.5MM,SUP-2190573,CDM,C1713,HCPCS,0278,RC,,,,both,,,7411.66,4817.58,,,,,,,,,,,,,
PLATE BNE L MED 1 MM RT LCK TI,SUP-2477583,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.17,597.46,,,,,,,,,,,,,
BIT DRL SLD 3.8X127 MM SS ALPS,SUP-2487351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
KIT COR DCOMPR 15CC FOR INJ REGEN GRFT PRO DENSE,SUP-2399156,CDM,C1713,HCPCS,0278,RC,,,,both,,,15944.92,10364.20,,,,,,,,,,,,,
CATHETER DRAINAGE 4 FRX15 CM FLUID ASPIR SM VOL NDL M DRN,SUP-2761902,CDM,C1729,HCPCS,0272,RC,,,,both,,,5.34,3.47,,,,,,,,,,,,,
PIN LOCATING DIA2MM,SUP-2878596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
BLADE SURG 26 MM LIF-PTP,SUP-2736616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
NEEDLE ENDOSCP LARYNGEAL 23 CM CRV RT KLEINSASSER F8597 HNDL,SUP-2775006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,677.93,440.65,,,,,,,,,,,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-18195,CDM,J2795,HCPCS,0636,RC,63323-0286-23,NDC,JW,both,15,ML,71.30,46.34,,,,,,,,,,,,,
SCREW LOCKING 1.6X7MM,SUP-2741717,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
GRAFT VASC FLX 7-4 MMX70 CM TW TAPR SM BEAD EPTFE CARBOFLO,SUP-2761493,CDM,C1768,CPT,0278,RC,,,,both,,,4308.39,2800.45,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE HD CERM,SUP-2212677,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT BONE L16MM DIA11MM CANC PLUG W/O CART FLEXIGRFT,SUP-2264647,CDM,C1713,HCPCS,0278,RC,,,,both,,,1972.92,1282.40,,,,,,,,,,,,,
PLATE BNE L 79.8 X W 17.4 MM THK 1.65 MM SCREW DIA2.5 MM TIM,SUP-2885133,CDM,C1713,HCPCS,0278,RC,,,,both,,,2115.17,1374.86,,,,,,,,,,,,,
CLIP ANEUR NO51 L15.8MM OPN 9MM HNDL L7MM 0.69N STD TI T2,SUP-2306119,CDM,C1889,HCPCS,0278,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 30 CM DIA 5 MM EPTFE STR STD WALL,SUP-2695231,CDM,C1768,CPT,0278,RC,,,,both,,,444.66,289.03,,,,,,,,,,,,,
PLATE STRNL 4 H TI STR NS MATRIXSTERNUM,SUP-2904256,CDM,C1713,HCPCS,0278,RC,,,,both,,,1778.43,1155.98,,,,,,,,,,,,,
COMPONENT PAT SZ 0 10MM POLYETH NTRL KN FLX,SUP-2200039,CDM,C1776,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
RAMIPRIL 5 MG PO CAPS,RX-11261,CDM,6370000000,HCPCS,0637,RC,65862-0476-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ELECTRODE ELECSURG L 30.2 CM INSUL DIA1.72 MM TIP DIA1.37 MM,SUP-2936945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.84,577.10,,,,,,,,,,,,,
NAIL IM L200MM DIA12MM UNIV FEM BENT RG LCK CANN,SUP-2412884,CDM,C1713,HCPCS,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-40840052,CDM,J7030,HCPCS,0250,RC,00264-7800-09,NDC,,both,250,ML,6.40,4.16,,,,,,,,,,,,,
SYSTEM REP KNOTLESS AC,SUP-2121712,CDM,C1713,HCPCS,0278,RC,,,,both,,,5372.54,3492.15,,,,,,,,,,,,,
COIL VASC HELCL SFT 10MM ID 20CM LEN .0135IN GWIRE STRTCH,SUP-2173640,CDM,C1889,HCPCS,0278,RC,,,,both,,,3416.32,2220.61,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 5 FR NDL L 7 CM NIT WIRE PLAT TIP A,SUP-2116528,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
CATHETER CV DL 19 FRX30 CM PROC KT PWR INJ ARGY,SUP-2173949,CDM,C1751,HCPCS,0278,RC,,,,both,,,221.28,143.83,,,,,,,,,,,,,
PEG BNE FIX L14MM DIA2MM VOLAR SMOOTH LOK FOR ANAT PLATING,SUP-2414129,CDM,C1776,CPT,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
PLATE L FUSION VA LCP 2.4/2.7MM LNG RT TI STRL,SUP-2546994,CDM,C1713,HCPCS,0278,RC,,,,both,,,3609.12,2345.93,,,,,,,,,,,,,
ANCHOR SUTURE 3 2 5 MM TI MAXBRAID ALLTHREAD,SUP-2194148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.014IN NIT HYDRPHLC STR TIP,SUP-2148154,CDM,C1769,HCPCS,0272,RC,,,,both,,,505.41,328.52,,,,,,,,,,,,,
"HC So Mononuclear Cell Antigen,Quan",PX-3028635666,CDM,86356,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
TRAY CATH 12FR L20CM STR EXTN 2 LUMN DISP MAHRK ELITE,SUP-2417750,CDM,C1752,HCPCS,0278,RC,,,,both,,,358.12,232.78,,,,,,,,,,,,,
SNARE NSL KRAUSE 10.25 IN 4-1/3 IN SATIN FINISH STD SMOOTH,SUP-2161593,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.32,281.01,,,,,,,,,,,,,
TAMP BNE BLLN 4CC L10MM 400 PRSS INFL FOR FRAC REDUC EXPR,SUP-2293621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT BNE CHIP FRZ DRY CANC CORT 1MM 8MM RANG 30CC READIGRFT,SUP-2264695,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.14,720.94,,,,,,,,,,,,,
PIN BONE FIX L90MM DIA4MM,SUP-2368492,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.96,284.02,,,,,,,,,,,,,
GUIDEWIRE VASC J 3 MM AD 0.021 INX260 CM PTFE COAT SAFE-T-J,SUP-2167589,CDM,C1769,HCPCS,0272,RC,,,,both,,,51.21,33.29,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 2.01-3.0 MCI NS ADVANTAGE,SUP-2247265,CDM,C2643,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
GUIDE RESECT HUM NK SOLAR,SUP-2374005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1104.02,717.61,,,,,,,,,,,,,
TROCAR SURG PERC,SUP-2459398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SYSTEM LD INTRO SELECTRA L 45 CM DIA 7 FR EXT HK CRV,SUP-2424591,CDM,C1893,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE CRAN 100X40X40 MM PT SPEC IMPL PEEK,SUP-2860124,CDM,C1713,HCPCS,0278,RC,,,,both,,,28083.85,18254.50,,,,,,,,,,,,,
SYSTEM BONE HEALING EXT OSTEOGENESIS STIM EBI,SUP-2137326,CDM,E0749,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-137259,CDM,J3370,HCPCS,0636,RC,71506-0019-59,NDC,,both,500,ML,195.50,127.07,,,,,,,,,,,,,
KIT SURG PWR MINIMALLY INVASIVE PROC OPN STRL LF DISP,SUP-2881103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
IMPLANT HUM TISS M W4XL7CM SKIN REGEN MTRX FRZ DRY ASEP,SUP-2112991,CDM,Q4116,HCPCS,0636,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
FORCEPS ES AD PED L7IN DIA15MM STD BPLR NONSTICK DISPOSABLE,SUP-2364926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1191.44,774.44,,,,,,,,,,,,,
DEVICE FAT PROC TISS COLLCTN REVOLVE RV0004] ALLERGAN USA - LIFECELL],SUP-2113064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
SHEATH INTRO PINNACLE TIF TIP L 10 CM DIA 5 FR 0.038 IN,SUP-2384798,CDM,C1894,HCPCS,0272,RC,,,,both,,,41.07,26.70,,,,,,,,,,,,,
CATHETER CV SET 032 10 FRX20 CM 10 GA 5 LUMEN QUINT SPECTRUM,SUP-2759732,CDM,C1751,HCPCS,0278,RC,,,,both,,,423.08,275.00,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 11CM 7FR 45 CM 0.021IN HYDRPHLC,SUP-2485357,CDM,C1894,HCPCS,0272,RC,,,,both,,,154.96,100.72,,,,,,,,,,,,,
COMPONENT TIB SZ A L MED KNEE UHMWPE ALPHA UNI FIX BEAR,SUP-2406147,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BONE NONSTERILE CRANIOMAXILLOFACIAL TEAL TI SM ARC,SUP-2191109,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.32,1710.36,,,,,,,,,,,,,
STEM HUM DIA4MM FRAC IMPL COMPHSVE SHLDR SYS,SUP-2403966,CDM,C1776,CPT,0278,RC,,,,both,,,11194.10,7276.16,,,,,,,,,,,,,
HC So Urinalysis Routine,PX-3078100366,CDM,81003,CPT,0307,RC,,,,both,,,11.00,7.15,,,,,,,,,,,,,
PLATE BNE W8XL52MM THK2MM 0DEG 6 H BILAT S STL STR RIG DYN,SUP-2186177,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.26,349.87,,,,,,,,,,,,,
JOINT FNGR 30 SM 10.2X20.2X8.9 MM 10.1 MM PYROCARBON NUGRIP,SUP-2852960,CDM,C1776,CPT,0278,RC,,,,both,,,11097.39,7213.30,,,,,,,,,,,,,
WRENCH SURG FIX BOLT ILIZ,SUP-2340712,CDM,C1898,HCPCS,0275,RC,,,,both,,,4411.70,2867.60,,,,,,,,,,,,,
TUBE CHST SET 24 FRX41 CM 1 LUMEN 4 SIDEPRT THAL-QUICK,SUP-2760050,CDM,C1729,HCPCS,0272,RC,,,,both,,,584.67,380.04,,,,,,,,,,,,,
SUPPORT KNEE XSM FOR 12 15IN THGH NEOPRENE,SUP-2150840,CDM,L1812,HCPCS,0274,RC,,,,both,,,32.03,20.82,,,,,,,,,,,,,
REAMER NC FUS,SUP-2321411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,868.21,564.34,,,,,,,,,,,,,
COMPONENT KNEE PT SPEC INSTRUMENT TRAB MEL GENDER SOL,SUP-2212606,CDM,C1776,CPT,0278,RC,,,,both,,,9247.30,6010.74,,,,,,,,,,,,,
INSERT TIB 0 10 MM RT ANK POLYETH SALTO TALARIS,SUP-2244133,CDM,C1776,CPT,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SLXACUTE 14FR DIA LG 15CM STRGHT TAPR,SUP-2610563,CDM,C1752,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
STENT PERIPH EPIC L 50 MM DIA 6 MM CATH L 120 CM NOM DIA,SUP-2145778,CDM,C1876,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PROSTHESIS OSS CLASSIC STAP 4X0.9 MM 0.4 MM TI,SUP-2638171,CDM,L8613,CPT,0278,RC,,,,both,,,701.26,455.82,,,,,,,,,,,,,
HC So Assay of Hydroxyindolacetic Acid 5-Hiaa,PX-3018349766,CDM,83497,CPT,0301,RC,,,,both,,,324.00,210.60,,,,,,,,,,,,,
SET PANCREATIC STENT ZMMN L 4 CM 5 FR 0.035 IN POLYETHYL,SUP-2169294,CDM,C2625,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
PROTECTOR PLT SM M PAT TRIATHLON,SUP-2364729,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
CATHETER URET 3FR 70CM LEN WVN OLV TIP REUSE,SUP-2129048,CDM,C1729,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
BOLT EXT FIX 0.37 IN TIB LCK DOVE,SUP-2314017,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST FULL CORSET,SUP-2435565,CDM,L0976,HCPCS,0274,RC,,,,both,,,423.30,275.14,,,,,,,,,,,,,
PLATE BNE 1/3 TBLR 31 MM 4 HOLE NS LTX,SUP-2861928,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.24,100.91,,,,,,,,,,,,,
TAP SURG L 50 MM DIA2.2 MM SCREW 6 MM SD DENT NS LF DISP,SUP-2883129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1226.48,797.21,,,,,,,,,,,,,
GENERATOR CARD Q TRAK ELECTRD SUBQ ICD STRL,SUP-2140374,CDM,C1882,HCPCS,0275,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
PLATE BONE L160MM 9 H S STL T SHP BTTRS LO PROF RIG,SUP-2185760,CDM,C1713,HCPCS,0278,RC,,,,both,,,1912.39,1243.05,,,,,,,,,,,,,
NAIL RFNA 10DEG BEND 10X200MM STERILE,SUP-2744545,CDM,C1713,HCPCS,0278,RC,,,,both,,,5975.92,3884.35,,,,,,,,,,,,,
RESERVOIR VENT STD S STL BASE FOR 6MM BUR H HOLTER RICKHAM,SUP-2243788,CDM,C1713,HCPCS,0278,RC,,,,both,,,1314.28,854.28,,,,,,,,,,,,,
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-154731,CDM,J0668,HCPCS,0636,RC,47426-0501-02,NDC,,both,14,ML,1825.10,1186.31,,,,,,,,,,,,,
PLATE BONE L W13.5XL178MM THK4.2MM 10 H BILAT TI STR RIG,SUP-2190819,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.95,516.72,,,,,,,,,,,,,
GUIDEWIRE DYNANITE 1.6DBL TIP NITI 2ZONE (MULTIPLES OF FIVE),SUP-2657205,CDM,C1769,HCPCS,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
MESH SURG 25X33CM W/ POS SYS ECHO 2 VENTRALIGHT ST,SUP-2125931,CDM,C1781,HCPCS,0278,RC,,,,both,,,6421.30,4173.84,,,,,,,,,,,,,
SHUNT SURG REG ASMBLY VENTRICULOSTOMY RESERVOIR STRATA NSC,SUP-2628620,CDM,C1729,HCPCS,0272,RC,,,,both,,,15162.59,9855.68,,,,,,,,,,,,,
TIROFIBAN HCL IN NACL 12.5-0.9 MG/250ML-% IV SOLN,RX-135453,CDM,J3246,HCPCS,0636,RC,55150-0430-01,NDC,,both,250,ML,1305.30,848.44,,,,,,,,,,,,,
PLATE BONE 72MM 5 H MALL 3.5 LO PROF AVOID BEND,SUP-2321042,CDM,C1713,HCPCS,0278,RC,,,,both,,,3677.25,2390.21,,,,,,,,,,,,,
BRACE SHLDR L FA L15 16IN UNIV AIRMESH BRTH SLNG 15DEG ABD,SUP-2150869,CDM,L3650,HCPCS,0274,RC,,,,both,,,171.16,111.25,,,,,,,,,,,,,
CATHETER HD LG LUMEN 16 FRX32 CM LT STR HEMOSTAR XK,SUP-2127869,CDM,C1750,HCPCS,0278,RC,,,,both,,,1575.65,1024.17,,,,,,,,,,,,,
NEEDLE LOC BRST REPOSITIONAL HOMER FLX J CRV WIRE 20 G X 3,SUP-2120040,CDM,C1819,HCPCS,0278,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
SLEEVE POS DIA10MM UNIV SHLDR CO CHROM CEM PRI FOR HUM FRAC,SUP-2404532,CDM,C1776,CPT,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
COMPONENT RADIAL IM XL DSTL WRST MICRONAIL,SUP-2538186,CDM,C1776,CPT,0278,RC,,,,both,,,7231.42,4700.42,,,,,,,,,,,,,
LENS VITRCTMY FLAT DISP,SUP-2213462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,148.84,96.75,,,,,,,,,,,,,
GRAFT BONE L26XW26XH14MM CORT RNG MACHINED FRZ DRY,SUP-2293911,CDM,C1713,HCPCS,0278,RC,,,,both,,,12154.94,7900.71,,,,,,,,,,,,,
SCREW BNE L5MM DIA15MM TI SELF DRL FULL THRD CRSS PIN COR,SUP-2366091,CDM,C1713,HCPCS,0278,RC,,,,both,,,209.19,135.97,,,,,,,,,,,,,
CABLE SPNL LAT LIGHT TIMBERLINE,SUP-2690629,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC So West Nile Ab,PX-3028678966,CDM,86789,CPT,0302,RC,,,,outpatient,,,49.00,31.85,,,,,,,,,,,,,
WASHER ORTH DIA2 MM FOR CANULATED SCREW SYS NS,SUP-2913312,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
MICROCATHETER GUID CORSAIR PRO L 150 CM DIA GUIDEWIRE 0.014,SUP-2123834,CDM,C1887,HCPCS,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
REAMER SURG 16 MM PHLANG,SUP-2432016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE UPR W/O KA PLAS,SUP-2435636,CDM,L2034,HCPCS,0272,RC,,,,both,,,5751.38,3738.40,,,,,,,,,,,,,
HC So Urine Cult/Colony Count|NOT REASONABLE AND NECESSARY,PX-3008708666,CDM,87086,CPT,0300,RC,,,GZ,both,,,101.00,65.65,,,,,,,,,,,,,
PLATE BNE GRP LG 160 MM TROCHANTERIC SS DALL-M,SUP-2451638,CDM,C1713,HCPCS,0278,RC,,,,both,,,3919.98,2547.99,,,,,,,,,,,,,
SCREW INTRF 7X20 MM PEEK OPTMA BIOSURE PK,SUP-2848613,CDM,C1713,HCPCS,0278,RC,,,,both,,,774.80,503.62,,,,,,,,,,,,,
SET SCR SPNL L50MM DIA6.5MM THORLUM TI THRD MULTAXL 30,SUP-2137297,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
GRAFT HUM TISS 15ML FRMBL CELLULAR BNE MTRX CRYOPRESERVED,SUP-2264616,CDM,C1713,HCPCS,0278,RC,,,,both,,,20103.03,13066.97,,,,,,,,,,,,,
SCREW INTRF L12MM DIA6MM BIOCRYL RAPIDE ABSRB MILAGRO,SUP-2256772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
GRAFT 10CMX15CM 300CMSQ SLNT CLLGN MTRX SEMIOVAL SURGIMEND,SUP-2243675,CDM,C9360,HCPCS,0278,RC,,,,both,,,7517.16,4886.15,,,,,,,,,,,,,
PLATE BNE GAP 1.5/0.5X50 MM NEURO,SUP-2403039,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
BONE SPCR ANTR CERV PUROS 0DEG 11X11,SUP-2414404,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PACK PROC TOT SHLDR PROMOS,SUP-2347962,CDM,C1776,CPT,0278,RC,,,,both,,,19243.49,12508.27,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CORONAL CTRL PREFABRICATED,SUP-2388152,CDM,L0640,HCPCS,0274,RC,,,,both,,,2694.81,1751.63,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 7FR L350CM WRK CHN 2.8MM G PRB STD,SUP-2149702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
BUR SURG SHANNON STYL 3 MM BNE NS,SUP-2751459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
COIL EMB L40CM OD0.020IN LOOP OD14MM NIT STRTCH RESIST FILL,SUP-2323418,CDM,C1889,HCPCS,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
FEARON MODIFIED UPPER RED II,SUP-2669814,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.00,2593.50,,,,,,,,,,,,,
CATHETER ABLATN THERMASTAR BLU,SUP-2248465,CDM,C1733,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW LOCKING FOR IM NAIL 5X54MM XL25,SUP-2739168,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.13,353.03,,,,,,,,,,,,,
TUBE SET DECOMPRESSION BLADE SHAVER BONESCALPEL MIS,SUP-2748601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCREW BONE L20MM DIA6.5MM FOR NOVATION CRWN CUP ACET SHELL,SUP-2222487,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.55,219.41,,,,,,,,,,,,,
ANCHOR SUTURE SHOE 1.4MML SOFT W/NEEDLE JUGGERKNOT,SUP-2589267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1250.22,812.64,,,,,,,,,,,,,
BIT DRL L270MM DIA12MM ST LNG CANN L QUIK CPL FOR,SUP-2178907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1512.95,983.42,,,,,,,,,,,,,
SUPPORT SHLDR M L36-40IN UNIV CHST NEOPRENE BLK HUM CUF 61460601] PERFORMANCE HEALTH INC],SUP-2324516,CDM,L3675,HCPCS,0272,RC,,,,both,,,160.45,104.29,,,,,,,,,,,,,
SET INTRO FLX PEELWY L 11 CM DIA23 FR GUIDEWIRE L 150 CM DIA,SUP-2889625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
BUTTON CBL 2.5MM TI HEX DRV FOR NCB POLYAX LOK PLT SYS,SUP-2413015,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA26 MM BRANCH SZ 10 MM,SUP-2227364,CDM,C1768,CPT,0278,RC,,,,both,,,4510.42,2931.77,,,,,,,,,,,,,
STEM HUM L125MM OD6.5MM UNIV CO CHROM SHLDR PRI CEM IMP,SUP-2404713,CDM,C1776,CPT,0278,RC,,,,both,,,15583.82,10129.48,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR QAUDRI LAT BRIM,SUP-2435673,CDM,L2510,HCPCS,0272,RC,,,,both,,,2283.35,1484.18,,,,,,,,,,,,,
PLATE BNE CRANIOMAXILLOFACIAL THK06MM DBL Y SHP PROF MIDFACE,SUP-2262677,CDM,C1713,HCPCS,0278,RC,,,,both,,,884.91,575.19,,,,,,,,,,,,,
COMPONENT PATELLAR DOMED 35 MM KNEE W/ CENTER PEG,SUP-2253967,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,6370000000,HCPCS,0637,RC,60505-0827-01,NDC,,both,15,ML,162.00,105.30,,,,,,,,,,,,,
BIT DRL DIA4MM OSTEOCHNDRL DEFCT FOR COR CART REP,SUP-2249553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
PLUG BNE CEM SM POLYETH FOR 8-10MM IM CNL,SUP-2405150,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 8 MM STR STD WALL HELIX,SUP-2494777,CDM,C1768,CPT,0278,RC,,,,both,,,1026.56,667.26,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 130 CM DIA 0.018 IN PERIPH MARKED,SUP-2887217,CDM,C1729,HCPCS,0272,RC,,,,both,,,132.51,86.13,,,,,,,,,,,,,
BLADE SAW DIA9MM S STL CASPR,SUP-2363307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
TW DRL F/COLE RAD DRL 3.2MM,SUP-2819559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1760.47,1144.31,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.02 MM 1.6 MM 2.3 MM FLROPLAS 520112,SUP-2535138,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.08,15.65,,,,,,,,,,,,,
PLATE BNE THK2MM 32 H MAND TI ANG LOK RECON FOR 23MM SCR,SUP-2262974,CDM,C1713,HCPCS,0278,RC,,,,both,,,6214.91,4039.69,,,,,,,,,,,,,
INTRODUCER SHTH SLR3 0.032 IN 8 FRX63 CM 8 FRX67 CM SWARTZ,SUP-2357258,CDM,C1893,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
BLADE OSTEO W16MM S STL MRI RAD DISPOSABLE,SUP-2435929,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
BIT DRL 2X200 MM K WIRE VARIAX,SUP-2537991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.03,445.92,,,,,,,,,,,,,
SCREW BNE L65MM DIA6.5MM THRD L16MM STD CANC S STL,SUP-2373835,CDM,C1713,HCPCS,0278,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
SCALPEL SURG LCK STRL T2 ALPHA GAMMA4,SUP-2900711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1901.21,1235.79,,,,,,,,,,,,,
BUR SURG 2 FLUT 2.2X16 MM SIDE CUT UPWR,SUP-2166802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLUG VASC UNCONSTRAINED L18MM DIA22MM CATH 9FR L100CM NIT,SUP-2355718,CDM,C1889,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
IMPLANT BRST MOD PROF SIL 510 CC FILL VOL 155 CM PROJCT,SUP-2113103,CDM,C1789,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR L4MM PROVOX VEGA,SUP-2124378,CDM,L8509,HCPCS,0272,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
HC Ammonia,PX-3018214000,CDM,82140,CPT,0301,RC,,,,both,,,301.00,195.65,,,,,,,,,,,,,
JOINT EXT FIX UNIV NS DISP MONK RING,SUP-2899260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.87,555.67,,,,,,,,,,,,,
PLATE BONE L171MM 6 H NONSTERILE RT MEDL DSTL TIB LCK FOR,SUP-2348487,CDM,C1713,HCPCS,0278,RC,,,,both,,,12990.34,8443.72,,,,,,,,,,,,,
ASSEMBLY SEAL CAP DEXTRUS ENDOPATH,SUP-2219097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2152.44,1399.09,,,,,,,,,,,,,
COVER BUR H DIA7MM UNIV CRANIOMAXILLOFACIAL TI MALL LO PROF,SUP-2366287,CDM,C1713,HCPCS,0278,RC,,,,both,,,780.98,507.64,,,,,,,,,,,,,
BLADE SAW SAG 20X12X0.4 MM STD TOOTH STRL,SUP-2432341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
CATHETER ANGIO 9FR L45CM PLCMNT CUT AWAY COR SNUS ACCS,SUP-2149039,CDM,C1887,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
HC CT Orbit/Ear/Fossa W/O Contrast,PX-3517048000,CDM,70480,CPT,0351,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
PROSOURCE TF PO LIQD,RX-126124,CDM,6370000000,HCPCS,0637,RC,94688-0114-76,NDC,,both,30,ML,6.10,3.96,,,,,,,,,,,,,
STENT URET 7FR L20CM NYL COAT DBL PGTL BRAID HYDRPHLC OPN,SUP-2313806,CDM,C2617,HCPCS,0278,RC,,,,both,,,453.54,294.80,,,,,,,,,,,,,
CONNECTOR ROD DIA5.5/6X5.5/6MM LAT HYBRID 2 SCR IL VITALITY,SUP-2402703,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER GUID SIM2 AD 6 FRX90 CM ENVOY,SUP-2154327,CDM,C1887,HCPCS,0272,RC,,,,both,,,1710.08,1111.55,,,,,,,,,,,,,
WASHER SPNL OD5.5MM FOR STPL SYS REVERE ANTR,SUP-2229628,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PASSER SUT RT CVD FIRSTPASS MINI,SUP-2419530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.68,589.34,,,,,,,,,,,,,
PLATE BNE T 3.5X87 MM 3X7 HOLE RT ANGLED SS LCP,SUP-2569407,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.63,420.96,,,,,,,,,,,,,
TUBE TYMPANOSTOMY ID1.27MM FL9.5MM L3MM INNR EAR MYR VENT,SUP-2277939,CDM,L8699,HCPCS,0278,RC,,,,both,,,135.65,88.17,,,,,,,,,,,,,
BRACE THMB XSM AD FOR 725 LESS THAN 8IN L9IN R WRST BLK,SUP-2196550,CDM,L3931,HCPCS,0274,RC,,,,both,,,279.18,181.47,,,,,,,,,,,,,
SPACER SPNL W9XH25XL9MM STD TRL POST LUM INTBDY FUS JAGUAR,SUP-2253223,CDM,C1821,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 6 MM OFFSET RNG L 7 CM,SUP-2396281,CDM,C1768,CPT,0278,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
RELOAD STPLR ARTICULATING LINEAR 60 MM END CUT INSTRUCTION,SUP-2257588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.31,275.80,,,,,,,,,,,,,
IMPLANT KNEE ANTERIOR CRUCIATE BEAR,SUP-2857997,CDM,C1763,HCPCS,0278,RC,,,,both,,,15778.50,10256.02,,,,,,,,,,,,,
IMPLANT BRST GEL 4.9 CM PROJCT 11.1 CM 320-340 CC NATRELLE SZHP63320] ALLERGAN USA INC],SUP-2113784,CDM,C1789,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BNE 2.5X1.6 MM LT DORS WRST 11 HOLE RSL FUSION PL,SUP-2423737,CDM,C1713,HCPCS,0278,RC,,,,both,,,4838.11,3144.77,,,,,,,,,,,,,
PLATE RAD HD RIM 2.4MM 2H LT TI LCP,SUP-2549707,CDM,C1713,HCPCS,0278,RC,,,,both,,,1926.92,1252.50,,,,,,,,,,,,,
TRAY CATH PICC Q CATH PLU INTERMED 5FR 65CM 1 LUMAN W/ACCSSR,SUP-2613414,CDM,C1751,HCPCS,0278,RC,,,,both,,,145.70,94.70,,,,,,,,,,,,,
PLATE BONE L100MM 5 H BILAT TI SPN LCK COMPR LO PROF RIG FOR,SUP-2190887,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.25,709.96,,,,,,,,,,,,,
CANNULA ART PERF L 1 CM INSRTN L 15 CM CATH DIA13 GA CONN,SUP-2908651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1556.53,1011.74,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM THN SGL LAYR AMNION SOLO CYGNUS,SUP-2393054,CDM,Q4170,HCPCS,0636,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CYLINDER PENILE PROS L20CM DIA14MM CONCEALABLE SPECTR,SUP-2138898,CDM,C2622,HCPCS,0278,RC,,,,both,,,36101.21,23465.79,,,,,,,,,,,,,
SHEARS SURG L36CM DIA5MM CRV BLDE W/ PSTL HNDLE HND CTRL,SUP-2257348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1308.60,850.59,,,,,,,,,,,,,
SEGMENT FEM SZ 1 H20MM LT LAT TILASTAN FOR W60MM COMP,SUP-2265082,CDM,C1776,CPT,0278,RC,,,,both,,,5680.26,3692.17,,,,,,,,,,,,,
WASHER INSET N FORCE 73MM,SUP-2414094,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
HC Evacuation of Hematoma,PX-3611014000,CDM,10140,CPT,0361,RC,,,,outpatient,,,4946.00,3214.90,,,,,,,,,,,,,
HC Ot Sensory Integrate 15 Min,PX-4309753300,CDM,97533,CPT,0430,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
BRACE ORTH FRAC FEM CAST MOLD KAFO L2126] TIDEWATER PROSTHETICS],SUP-2388170,CDM,L2126,HCPCS,0272,RC,,,,both,,,3243.18,2108.07,,,,,,,,,,,,,
PANEL DS RESORB BLNK 55X55MM,SUP-2364987,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.23,1459.40,,,,,,,,,,,,,
TRAY TIB SZ 0F/0T CEM FIN OPTETRAK LOGIC,SUP-2220920,CDM,C1776,CPT,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
HEAD ULN 16 WRST MOD COCR 1ST CHOICE,SUP-2852953,CDM,C1776,CPT,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
STEM FEM 12/14 TAPR STD NEUT MOD NK CO CHROM,SUP-2345381,CDM,C1776,CPT,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 15 DEG 38X25X12 MM ALIF NS TRIAD DISP,SUP-2716880,CDM,C1889,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
IMPLANT PROST NIT TEMPORARILY IMPLD SNR MINIMALLY INVASIVE,SUP-2915763,CDM,C1889,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
TROCAR SURG DBL SL 4X120 MM ASMBLY,SUP-2517246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 100 CM DIA 6 MM POLYESTER BOV CLLGN STR,SUP-2227525,CDM,C1768,CPT,0278,RC,,,,both,,,1927.11,1252.62,,,,,,,,,,,,,
"HC Pulm Angiogrm Inject, Heart Cath",PX-4819356800,CDM,93568,CPT,0481,RC,,,,both,,,705.00,458.25,,,,,,,,,,,,,
PLATE BONE REDUCTION INSTRUMENT 27/35MM,SUP-2497339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1697.33,1103.26,,,,,,,,,,,,,
BIT DRL L L90 120MM CANN DENS FOR HDLSS COMPR SCR ACUTRK,SUP-2107245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
PROBE COAG 6.9FR L3M CONVENIENT BLT IN FLTR 3000A FIAPC,SUP-2217946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X1.02X4.5 MM 0.97 MM RT EAR SHEA,SUP-2637805,CDM,L8613,CPT,0278,RC,,,,both,,,455.58,296.13,,,,,,,,,,,,,
BRACE THMB AD SM FOR 3.875-9.5IN IP TO WR CREASE LNG LT CMC,SUP-2324971,CDM,L3931,HCPCS,0274,RC,,,,both,,,62.58,40.68,,,,,,,,,,,,,
PORT INFUS OD9.5FR VEN 2 LUMN VLV ATTCH CATH INTMED KT OPN,SUP-2127754,CDM,C1788,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
AUGMENT FEM L72.5MM THICKNESS 5MM LT MEDL RT LAT KNEE,SUP-2407760,CDM,C1776,CPT,0278,RC,,,,both,,,2917.06,1896.09,,,,,,,,,,,,,
GUIDEWIRE VASC IQ L 185 CM DIA 0.014 IN SIL WORKHORSE J W/,SUP-2140695,CDM,C1769,HCPCS,0272,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
GRAFT EVAR L10CM DIA5MM CATH L120CM BLLN DIA5MM 0.035IN HEP,SUP-2396542,CDM,C1874,HCPCS,0278,RC,,,,both,,,12318.22,8006.84,,,,,,,,,,,,,
PLATE BNE RECON UNIV 2.7 MM 14 HOLE 2 COMPR FOR SCR TI NS,SUP-2464918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1335.10,867.81,,,,,,,,,,,,,
BRACE ORTHOPEDIC AFO ANK PREFABRICATED SPRL,SUP-2265016,CDM,L1951,HCPCS,0272,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
PLATE BNE DBL Y MIC LNG 1.5 MM TI,SUP-2480965,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.29,422.04,,,,,,,,,,,,,
PLATE BONE LOK 5.5MM DIA HLX8 RIGHT LTRL PRXML TBL,SUP-2496334,CDM,C1713,HCPCS,0278,RC,,,,both,,,3932.79,2556.31,,,,,,,,,,,,,
SODIUM CHLORIDE 3% IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-4082505,CDM,2580000003,HCPCS,0258,RC,00338-0054-03,NDC,JW,both,100,ML,11.10,7.21,,,,,,,,,,,,,
HC Intro Needle/Cath Ext Art,PX-3613614000,CDM,36140,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.035 IN TAPR L 10 CM FLPY TIP L,SUP-2167577,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.02,41.61,,,,,,,,,,,,,
MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN,RX-117786,CDM,340b,HCPCS,0637,RC,09999-9900-26,NDC,,both,0.125,ML,2.70,1.75,,,,,,,,,,,,,
CAPSAICIN 0.075 % EX CREA,RX-9399,CDM,6370000000,HCPCS,0637,RC,00536-1118-25,NDC,,both,57,GR,21.10,13.71,,,,,,,,,,,,,
HC So Ptt / Thromboplastin Subs,PX-3058573266,CDM,85732,CPT,0305,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
KIT BNE FIX STPL BRIDGE L 20 X 20 MM ULTRA NIT ANK FT ULTRA,SUP-2896847,CDM,C1713,HCPCS,0278,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
PLATE BNE Y LNG 1.5 MM NEURO LP FOR SCREW TI NS LEVEL 1 LF,SUP-2470292,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.89,419.18,,,,,,,,,,,,,
KIT BNE PLT L54MM HD DIA22MM 6X3 H L VOLAR DST RAD S STL VAR,SUP-2177300,CDM,C1713,HCPCS,0278,RC,,,,both,,,4148.94,2696.81,,,,,,,,,,,,,
NEEDLE SPNL 1 BVL TRCR TIP CDH SEXTANT DISP,SUP-2290630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.60,502.19,,,,,,,,,,,,,
OCCLUDER CV WATCHMAN NIT POLYETHYL TEREPHTHALATE PTFE PEBAX,SUP-2142003,CDM,C1894,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
BLADE RETRACTOR GELPI UNIV ABD RNG,SUP-2465675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.63,626.36,,,,,,,,,,,,,
STAPLER INT 15X15X15 MM NIT MEMOFIX,SUP-2609677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4586.63,2981.31,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT TI DURABRAID W/ 38IN USPNO 2.8MM DIA,SUP-2341044,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
PLATE BNE ACET PELV 3 HOLE SPRING,SUP-2518349,CDM,C1713,HCPCS,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
BIT DRL DIA7MM ENTRY FOR ANK COMPR NAILING SYS,SUP-2316004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.65,607.52,,,,,,,,,,,,,
APPLIER CLP LG 10 MMX34 CM MANUAL LOAD HEM-O-LOK ENDO10,SUP-2656818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
GUIDEWIRE VASC L 300 CM DIA 0.018 IN RADIOPAQUE TIP L 2 CM,SUP-2101938,CDM,C1769,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE L236MM 17 H L ANTLAT DST TIB TI LOK COMPR FOR,SUP-2190973,CDM,C1713,HCPCS,0278,RC,,,,both,,,4863.20,3161.08,,,,,,,,,,,,,
PLATE BNE L 23 MM SCREW DIA 3.5 MM 2 SHFT H TI 1/3 TUBLR NS,SUP-2907645,CDM,C1713,HCPCS,0278,RC,,,,both,,,1668.28,1084.38,,,,,,,,,,,,,
DILATOR ENDOSCP L180CM CATH 6FR BLLN L8CM INFLATED M00558360,SUP-2420683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,605.89,393.83,,,,,,,,,,,,,
PIN FIX ANTR CERV THRD SMOOTH TEMP EAGLE + SWIFT +,SUP-2252862,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
ISOLYTE-S IV SOLN,RX-4014,CDM,2580000003,HCPCS,0258,RC,00264-7703-00,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
SHEATH INTRO L 14 CM DIA14 FR GUIDEWIRE 0.038 IN PTFE X TW,SUP-2615904,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.76,56.39,,,,,,,,,,,,,
URETEROSCOPE RIGID ASPIR SYS STRL DISP CVAC  MIN ORDER 2BX,SUP-2904956,CDM,C1747,HCPCS,0272,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
"HC Transluminal Peripheral Atherectomy, Abdominal Aorta",PX-3610236000,CDM,0236T,HCPCS,0361,RC,,,,both,,,10136.00,6588.40,,,,,,,,,,,,,
TIP ENDO SUCT ANG 6 MM DIAM 30 CM LEN N COAG SIDE VENT PLAS,SUP-2152101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 37X28 CM RND POLYESTER PARIETEX,SUP-2752186,CDM,C1781,HCPCS,0278,RC,,,,both,,,8994.47,5846.41,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 5 FRX130 CM 4X150 MM LUTONIX BSLX3513041505F] BARD PERIPHERAL VASCULAR],SUP-2127969,CDM,C2623,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
RESERVOIR VENTRICULAR W/ PLAS BASE FOR 6MM BUR HOLE HOLTER,SUP-2666804,CDM,C1889,HCPCS,0278,RC,,,,both,,,1095.83,712.29,,,,,,,,,,,,,
HANDPIECE HYDROSURGERY TIP L14MM 45DEG EXACT DISP FOR MAX,SUP-2351651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 280 MM DIA17 MM DEL SHTH,SUP-2934598,CDM,C1713,HCPCS,0278,RC,,,,both,,,20857.32,13557.26,,,,,,,,,,,,,
NAIL IM L420MM DIA8MM ST DK BLU TIB TI LOK UNREAMED SLD W/,SUP-2192767,CDM,C1713,HCPCS,0278,RC,,,,both,,,5705.69,3708.70,,,,,,,,,,,,,
PLATE BNE 24.5 CM THOR WAND HOLDING STERNOTOMY HEMI NS LTX,SUP-2869209,CDM,C1713,HCPCS,0278,RC,,,,both,,,4747.93,3086.15,,,,,,,,,,,,,
BIT SCRWDRVR T8 AO QUICK CPL,SUP-2489670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115 CM D-D CRV,SUP-2248505,CDM,C2630,CPT,0272,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
NAIL IM 130 DEG 10 MMX40 CM RT IMHS,SUP-2349039,CDM,C1713,HCPCS,0278,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
HANDPIECE INCIS FOC 0.2 MM LENS CELL BRL,SUP-2713596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4772.74,3102.28,,,,,,,,,,,,,
OXYCODONE HCL ER 20 MG PO T12A,RX-123651,CDM,6370000000,HCPCS,0637,RC,59011-0420-20,NDC,,both,1,UN,48.80,31.72,,,,,,,,,,,,,
BASEPLATE GLEN SM POROUS,SUP-2535492,CDM,C1713,HCPCS,0278,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
CATHETER PULM ART 10.5FR L100CM 0.038IN INTRAAORTIC 3 LUMN,SUP-2214546,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
GRAFT 0.5CC BONE PUTTY DBM PUROS,SUP-2335222,CDM,C9359,HCPCS,0278,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
TITANIUM FXTN SCREW KNRLD HEAD 55MM RD II DVCE,SUP-2676923,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.42,346.07,,,,,,,,,,,,,
KIT PEG 20FR STD NONSAFETY PUL PLCMNT TECH PONSKY,SUP-2127663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2611.29,1697.34,,,,,,,,,,,,,
REAMER SURG OD14.5MM PAT INTERCHANGEABLE HD W/ PILOT NOSE,SUP-2343591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
COMPONENT PATELLAR 35 MM KNEE RESTORIS MCK,SUP-2265748,CDM,C1776,CPT,0278,RC,,,,both,,,2652.20,1723.93,,,,,,,,,,,,,
PACK SAW BLDE 68MM D424MM CUT EDGE 10MM THK12MM FOR PWR,SUP-2365144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
PLATE BONE L W13.5XL116MM THK4.2MM 6 H BILAT TI STR RIG,SUP-2190811,CDM,C1713,HCPCS,0278,RC,,,,both,,,611.92,397.75,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.156X9 IN RND END SS NS STEINMANN,SUP-2791817,CDM,C1713,HCPCS,0278,RC,,,,both,,,38.94,25.31,,,,,,,,,,,,,
HC Malaria Prep,PX-3008720700,CDM,87207,CPT,0300,RC,,,,both,,,229.00,148.85,,,,,,,,,,,,,
CROWN DENT NODLL4 1ST PRI M LO L S STL REFIL,SUP-2322193,CDM,D6783,CPT,0278,RC,,,,both,,,32.22,20.94,,,,,,,,,,,,,
CANNULA PERF PED 12FR L19CM TIP L11CM 1/4IN NVENT CONN,SUP-2282881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.07,421.90,,,,,,,,,,,,,
CROWN DENT LR7 1ST PRI M INDIV SPACE MAINTAINER,SUP-2176685,CDM,D6783,CPT,0278,RC,,,,both,,,22.92,14.90,,,,,,,,,,,,,
KIT BNE CEM 80GM DBL MIX SHT CART EXT W/ BRKWY NOZ OPTVAC,SUP-2216858,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-159347,CDM,J1720,HCPCS,0636,RC,00009-0016-12,NDC,,both,1,UN,502.80,326.82,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM AMNIO MEMBRN AXOGRFT,SUP-2125455,CDM,C1762,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SPLINT ORTHOPEDIC BOUTONNIERE 4 FNGR BEAUTY STRENGTH,SUP-2325004,CDM,L3927,HCPCS,0272,RC,,,,both,,,250.76,162.99,,,,,,,,,,,,,
MELATONIN 3 MG PO TABS,RX-16830,CDM,6370000000,HCPCS,0637,RC,50268-0524-15,NDC,,both,1,UN,1.00,0.65,,,,,,,,,,,,,
CATHETER HD SET 14 FRX20 CM DL N COAT BLU FLEXTIP,SUP-2763025,CDM,C1752,HCPCS,0278,RC,,,,both,,,177.19,115.17,,,,,,,,,,,,,
STEM BPLR HIP POR SYS,SUP-2212079,CDM,C1776,CPT,0278,RC,,,,both,,,8143.06,5292.99,,,,,,,,,,,,,
SHEATH INTRO L 14 CM DIA 4 FR GUIDEWIRE 0.028 IN PTFE X TW,SUP-2615923,CDM,C1894,HCPCS,0272,RC,,,,both,,,79.13,51.43,,,,,,,,,,,,,
PREDNISONE 20 MG PO TABS,RX-6496,CDM,J7512,HCPCS,0637,RC,60687-0925-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ADAPTER FEM L-4MM UPLR NEUT NK,SUP-2207893,CDM,C1776,CPT,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
BUR SURG DIAMOND COARSE 6 MMX14 CM BALL LG BOR LEGEND,SUP-2627686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.05,253.53,,,,,,,,,,,,,
PLATE BNE W10.1XL180MM THK3.5MM 16 H S STL CRV LOK COMPR,SUP-2186266,CDM,C1713,HCPCS,0278,RC,,,,both,,,2743.64,1783.37,,,,,,,,,,,,,
PLATE BNE L15MM XSM 2 H S STL FT ANK BILAT POLYAX COMPR LO,SUP-2397455,CDM,C1713,HCPCS,0278,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
INSERT TIB SZ 5 THK17.5MM GVF POLYETH ROT PLATFRM STBL PFC,SUP-2253727,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
KIT PAIN PMP 270ML 5ML/HR NONNARCOTIC ELASTOMERIC ACUTE AMB,SUP-2236834,CDM,C9804,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
PLATE BNE L278MM 12 H ST L CNDYL S STL LOK COMPR CRV FOR,SUP-2177081,CDM,C1713,HCPCS,0278,RC,,,,both,,,4916.46,3195.70,,,,,,,,,,,,,
COLLAR TRACHEOTOMY M H3.25IN FOR 13-16IN NK POLY FOAM TWO,SUP-2196876,CDM,L0120,HCPCS,0274,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X285 MM RT PROX 9 HOLE STRL VALCP,SUP-2789284,CDM,C1713,HCPCS,0278,RC,,,,both,,,8169.43,5310.13,,,,,,,,,,,,,
IMPLANT HYB KN-LPS FLX TIV CEM FEM/MIS TM TIB/PRLG SUR/PAT,SUP-2212336,CDM,C1776,CPT,0278,RC,,,,both,,,14492.29,9419.99,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX15 CM 20 GA ECHOGENIC NDL ACCEL,SUP-2659252,CDM,C1729,HCPCS,0272,RC,,,,both,,,68.33,44.41,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT ENDOSCP OUTPT CUST,SUP-2217545,CDM,C1729,HCPCS,0272,RC,,,,both,,,21.07,13.70,,,,,,,,,,,,,
PLATE BNE LCK 1.5X23 MM 4 HOLE TI NS LCP,SUP-2799632,CDM,C1713,HCPCS,0278,RC,,,,both,,,667.47,433.86,,,,,,,,,,,,,
STRIP INT STPL DRY VERIT BOV PERICARD PSD-V TISS CLLGN MTRX,SUP-2130378,CDM,C9354,HCPCS,0278,RC,,,,both,,,739.60,480.74,,,,,,,,,,,,,
CURVED RECON 3.5MM 18X214MM,SUP-2818482,CDM,C1713,HCPCS,0278,RC,,,,both,,,5375.84,3494.30,,,,,,,,,,,,,
PLATE BONE THK1.5MM 4 H MINI STR FOR 2/2.3MM SCR,SUP-2365230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.54,1234.70,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN L8CM LNG TAPR SM VES NIT,SUP-2385572,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.02,75.41,,,,,,,,,,,,,
RXG BURR HOLE COVER SLIGHT CONTOURED 1MM 17MM DIA,SUP-2679390,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.61,742.70,,,,,,,,,,,,,
CLIP OCCL ATRICLIP FLEX-V L 45 MM TI POLYETHYL TEREPHTHALATE,SUP-2424444,CDM,C1889,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
HC Insert Verterbral Stent Init,PX-3600075000,CDM,0075T,CPT,0360,RC,,,,both,,,11440.00,7436.00,,,,,,,,,,,,,
SCISSOR SURG CASTANARES 6.25 IN FACELIFT NS LTX,SUP-2872583,CDM,C1889,HCPCS,0278,RC,,,,both,,,282.07,183.35,,,,,,,,,,,,,
CYLINDER PENILE PROS L20CM 0DEG SCROT PMP SET TI TCH,SUP-2165446,CDM,C1813,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
ACTIVATOR PATIENT REACTIV8,SUP-2877969,CDM,C1730,HCPCS,0272,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.2MM S STL ST SELF DRL CANN NONLOCKING,SUP-2397537,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2.7X36 MM CANCELLOUS FULLY THREADED H,SUP-2836896,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.28,55.43,,,,,,,,,,,,,
GRAFT HUM TISS M THK2-2.79MM RDY TO USE CNTOUR ALLDERM,SUP-2113440,CDM,C1713,HCPCS,0278,RC,,,,both,,,15429.96,10029.47,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT MAXBARR 5FR 55CM 2 LUM 1275108FD,SUP-2632636,CDM,C1751,HCPCS,0278,RC,,,,both,,,813.17,528.56,,,,,,,,,,,,,
GUIDEWIRE VASC L 300 CM DIA 0.014 IN DSTL TIP L 7 CM IT TIP,SUP-2154042,CDM,C1769,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
BTB IB TIGHTROPE W FLIPCUTTER III DRILL,SUP-2811641,CDM,C1713,HCPCS,0278,RC,,,,both,,,3563.90,2316.53,,,,,,,,,,,,,
PLATE BONE W13.5XL358MM THK4.2MM 20 H BILAT S STL NAR LIMIT,SUP-2185258,CDM,C1713,HCPCS,0278,RC,,,,both,,,3526.31,2292.10,,,,,,,,,,,,,
STAPLE BNE 15X15X15MM HND FT NIT SUP E FOR OSTEOTMY ARTH,SUP-2175097,CDM,C1713,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
SPACER SPNL W22XH8XL28MM 4DEG PEEK ANT LUM INTBDY FUS LORD,SUP-2380486,CDM,C1713,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 6 CM FLX TIP L,SUP-2167608,CDM,C1769,HCPCS,0272,RC,,,,both,,,57.52,37.39,,,,,,,,,,,,,
GUIDEWIRE VASC VSI TRU-TORQUE L 260 CM DIA 0.035 IN PTFE MOD,SUP-2763464,CDM,C1769,HCPCS,0272,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
HC Intraosseous Needle Placement,PX-7613668000,CDM,36680,CPT,0761,RC,,,,outpatient,,,954.00,620.10,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE X LG SHT ANK ROCKER BTM INLINE,SUP-2336134,CDM,L4361,HCPCS,0272,RC,,,,both,,,93.29,60.64,,,,,,,,,,,,,
CATHETER SUBCLAV 8FRX20CM W/ REM Y ADPT,SUP-2267029,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE LOK 51MML HLX33 HDSHFT T SHPD RIGHT OBLQUE ST,SUP-2726043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.31,756.80,,,,,,,,,,,,,
GRAFT HUM TISS 16CM W/O STRUT FRZN IRRADIATED ACHILLES,SUP-2137249,CDM,C1763,HCPCS,0278,RC,,,,both,,,4739.99,3080.99,,,,,,,,,,,,,
DRAIN SURG 19FR SIL RND HUBLESS RADPQ W/O TRCR BLAK,SUP-2218223,CDM,C1729,HCPCS,0272,RC,,,,both,,,306.53,199.24,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ 8IN LOOP LOK W STAY FIRM SUPP,SUP-2276657,CDM,L3808,HCPCS,0272,RC,,,,both,,,16.23,10.55,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST ROCKER BTM CONTACT,SUP-2435654,CDM,L2232,HCPCS,0272,RC,,,,both,,,275.03,178.77,,,,,,,,,,,,,
CEMENT BONE TRCE ADTV,SUP-2342072,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
HC Noncontact R-T Fluor Wnd Img 1st Anatomic Site,PX-3200598000,CDM,0598T,CPT,0320,RC,,,,both,,,1010.00,656.50,,,,,,,,,,,,,
COMPONENT HUM SUPEROLATERAL RESECT UNIVERS REVERS,SUP-2845821,CDM,C1776,CPT,0278,RC,,,,both,,,5118.36,3326.93,,,,,,,,,,,,,
MESH SRGCL 06MM THK TTNM ALLOY LEFT FRNTTMPRL PRTL CRNL CNT,SUP-2676602,CDM,C1713,HCPCS,0278,RC,,,,both,,,16876.12,10969.48,,,,,,,,,,,,,
ROD SPNL 4.75X50 MM PERC CCM CD HORZ SOLERA,SUP-2278963,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
SCREW BNE NLCK 2.7X18 MM LP STRL STRATUM,SUP-2423343,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA 3 MM TI CANN HD NS LEOS,SUP-2932588,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.63,549.01,,,,,,,,,,,,,
SET LD INTRO PEELWY L 24 CM ID 10 FR GUIDEWIRE 0.038 IN NDL,SUP-2169807,CDM,C1892,HCPCS,0272,RC,,,,both,,,186.52,121.24,,,,,,,,,,,,,
CAGE SPNL 3D 15 DEG 28X11X17 MM WAVEFORM,SUP-2711485,CDM,C1889,HCPCS,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
ANCHOR SUTURE WITH TWO NO 2 HI FI SUTURES 17MM LENGTH 5.5MM,SUP-2824896,CDM,C1713,HCPCS,0278,RC,,,,both,,,1437.49,934.37,,,,,,,,,,,,,
KIT BRST BX MRK WIRE,SUP-2240024,CDM,A4648,CPT,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
STEM FEM SEG LG 3 CM DPHSEAL KNEE ELLIP OSS,SUP-2445716,CDM,C1776,CPT,0278,RC,,,,both,,,2359.71,1533.81,,,,,,,,,,,,,
CONNECTOR SPNL CROSS SZ CRD,SUP-2211133,CDM,C1713,HCPCS,0278,RC,,,,both,,,146.95,95.52,,,,,,,,,,,,,
DEVICE TISS FIX FIBERTAG TIGHTROPE II INTERNALBRACE FLX ACL,SUP-2910478,CDM,C1713,HCPCS,0278,RC,,,,both,,,3214.58,2089.48,,,,,,,,,,,,,
CATHETER PERI DLYS L60CM DIA7FR PERC PACE INTRO LD AXIA RSN,SUP-2283892,CDM,C1750,HCPCS,0278,RC,,,,both,,,249.69,162.30,,,,,,,,,,,,,
SET URET STENT UTHANE L 26 CM POS L 46 CM DIA 7.0 FR SLV L,SUP-2168927,CDM,C2617,HCPCS,0278,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
PLATE BONE SM L104MM 8 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348995,CDM,C1713,HCPCS,0278,RC,,,,both,,,1504.63,978.01,,,,,,,,,,,,,
GRAFT SPNL SPCR W14.5XH8XL12MM 7DEG CERV LORDOSIS FRZ DRY,SUP-2264910,CDM,C1713,HCPCS,0278,RC,,,,both,,,2919.89,1897.93,,,,,,,,,,,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,0636,RC,63323-0064-11,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE LNG PROX HUM S STL FOR 3.5MM SCR SM FRAG SYS LCP,SUP-2177063,CDM,C1713,HCPCS,0278,RC,,,,both,,,23769.89,15450.43,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC,SUP-2382018,CDM,L4360,HCPCS,0274,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BALLOON 34CC 9.5,SUP-2227309,CDM,C1725,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
GRAFT HUMAN TSSUE GRTR EQUAL 16CML 1/10MM THK QDRCPS TNDN FR,SUP-2573323,CDM,C1762,CPT,0278,RC,,,,both,,,6104.16,3967.70,,,,,,,,,,,,,
BURR SURG 1.7MM DIA HD LNG MIC 70MML 12MML HD CARBIDE SM BNE,SUP-2605562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.74,45.33,,,,,,,,,,,,,
GRAFT VASC W3XL3CM THK04MM CV PTCH GOR TX,SUP-2395307,CDM,C1768,CPT,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
CATHETER TY PERIPHERALLY INSERTED CTRL VEN 5FR LEN 60CM TWIN,SUP-2168844,CDM,C1751,HCPCS,0278,RC,,,,both,,,312.93,203.40,,,,,,,,,,,,,
NEOSTIGMINE-GLYCOPYRROLATE 3-0.6 MG/3ML IV SOSY,RX-163605,CDM,J2711,HCPCS,0636,RC,42023-0269-01,NDC,,both,3,ML,122.20,79.43,,,,,,,,,,,,,
STENT GRFT VASC OVATION IX L 100 MM 145 MM 14/10 MM 10/12 FR,SUP-2217732,CDM,C1768,CPT,0278,RC,,,,both,,,14126.86,9182.46,,,,,,,,,,,,,
PIN FIX L180MM DIA4MM S STL SGL END SHRP TIP CTRL THRD,SUP-2420759,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.18,203.57,,,,,,,,,,,,,
BUR SURG L12CM DIA2.5MM MTCH HD TELSCP LNG MIDAS REX LEGEND,SUP-2281644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
PLATE CRAN 200X120X40 MM PT SPEC IMPL PEEK,SUP-2860155,CDM,C1713,HCPCS,0278,RC,,,,both,,,44217.17,28741.16,,,,,,,,,,,,,
DRAINAGE SET 5 FRX80 CM NEEDLE-FREE LDS LUMBAR DRAINAGE CLMP,SUP-2666661,CDM,C1729,HCPCS,0272,RC,,,,both,,,832.16,540.90,,,,,,,,,,,,,
GRAFT VASC L45CM ID4-7MM TAPR ACUSEAL,SUP-2395748,CDM,C1768,CPT,0278,RC,,,,both,,,4719.42,3067.62,,,,,,,,,,,,,
MASK CPAP MED NSL HEADGEAR CONN DREAMWISP,SUP-2423093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,463.97,301.58,,,,,,,,,,,,,
PLATE BNE M ST L CALCNL FOR 35MM SCR VLP,SUP-2349962,CDM,C1713,HCPCS,0278,RC,,,,both,,,6289.58,4088.23,,,,,,,,,,,,,
PROPAFENONE HCL ER 225 MG PO CP12,RX-37643,CDM,6370000000,HCPCS,0637,RC,16714-0825-01,NDC,,both,1,UN,23.90,15.53,,,,,,,,,,,,,
CLIP SURG 1.4MM M TI ANAS VES CLSR ST DISP ANASTOCLP VCS,SUP-2264238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 250 MG AMINIOFILL,SUP-2305713,CDM,C1762,CPT,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
DILATOR URETH OD26FR BAL L180XOD8.7MM SHFT L30CMXOD7FR COUDE,SUP-2141678,CDM,C1726,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
COMPONENT IMPLANT SHLDR CAP S2 HEMI,SUP-2797210,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK 3 ORTHOCORD SZ 2 L36IN VLT BLU,SUP-2249412,CDM,C1713,HCPCS,0278,RC,,,,both,,,1306.24,849.06,,,,,,,,,,,,,
SCREW BONE L110MM DIA10.5MM HIP LAG FOR AFFIXUS FX NAIL SYS,SUP-2137050,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.24,1211.11,,,,,,,,,,,,,
PLATE BNE HK LNG 2.7X12 MM RT CLAV VA LCK STRL VALCP,SUP-2789385,CDM,C1713,HCPCS,0278,RC,,,,both,,,4214.26,2739.27,,,,,,,,,,,,,
CATHETER ANGIO AD PED 5FR L100CM GWIRE 0.038IN PERIPH PGTL,SUP-2139761,CDM,C1758,HCPCS,0278,RC,,,,both,,,30.71,19.96,,,,,,,,,,,,,
MESH HERN SELF FIXATING 15X10 CM LAP PK BILATERAL ANAT LF,SUP-2752178,CDM,C1781,HCPCS,0278,RC,,,,both,,,1117.87,726.62,,,,,,,,,,,,,
BUR SURG DIA3MM CUT RND FLUT ZYPHR ELITE,SUP-2367562,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.12,215.88,,,,,,,,,,,,,
BODY ASSEMBLY KIT SELF ALIGNING STD ARTICULATED PROCALLUS,SUP-2645901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10415.07,6769.80,,,,,,,,,,,,,
GRAFT VASC SEALPTFE L 40 CM DIA 6 MM EPTFE GEL STD WALL STR,SUP-2385216,CDM,C1768,CPT,0278,RC,,,,both,,,1519.04,987.38,,,,,,,,,,,,,
PLATE BNE W6.3XL66MM THK1.6MM 5X5 H R DST EXTRAARTICULAR,SUP-2186090,CDM,C1713,HCPCS,0278,RC,,,,both,,,2430.11,1579.57,,,,,,,,,,,,,
ALLODERM SELECT 1X2 MEDIUM 1.2-2.0,SUP-2822071,CDM,Q4116,HCPCS,0636,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
BASKET RETRV 20MM SEGR,SUP-2141356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
IMPLANT PTERIONAL W43XL44MM L SMOOTH,SUP-2365257,CDM,C1889,HCPCS,0278,RC,,,,both,,,7112.10,4622.86,,,,,,,,,,,,,
GRAFT BNE CORT STRUT ALLGRFT FRZN IMPL L200XW20MM MATRIGRFT,SUP-2264744,CDM,C1713,HCPCS,0278,RC,,,,both,,,1440.51,936.33,,,,,,,,,,,,,
CATHETER URET OLV TIP 4FRX70CM FLEXIMA,SUP-2139297,CDM,C1758,HCPCS,0278,RC,,,,both,,,29.67,19.29,,,,,,,,,,,,,
PIN FIX CLLRD 50 MM KNEE THRD REV BKRS,SUP-2434339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1053.16,684.55,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED XL PRIORITY STRL MEDPOR,SUP-2862753,CDM,C1713,HCPCS,0278,RC,,,,both,,,72157.86,46902.61,,,,,,,,,,,,,
BLADE SHV DIA4MM 60DEG CRV SERR DISECT CONCAVE WIND FOR,SUP-2313829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.90,245.63,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2MM S STL TRCR TIP DISP FOR EVOS MINI,SUP-2343918,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.89,124.73,,,,,,,,,,,,,
GRAFT BNE SUB W1.75XL5CM POSTEROLATERAL MAGNIFUSE,SUP-2293962,CDM,C1713,HCPCS,0278,RC,,,,both,,,8203.25,5332.11,,,,,,,,,,,,,
ROD SPNL 2 5.5-6.35X450 MM TI NS MONARCH,SUP-2583132,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
DRESSING POST OPERATIVE RIGID ANK,SUP-2388202,CDM,L5420,HCPCS,0272,RC,,,,both,,,3995.27,2596.93,,,,,,,,,,,,,
SCREW BNE HD SHT THRD 4X42 MM CANN MINI-MONSTER,SUP-2320562,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
CARMUSTINE 100 MG IV SOLR,RX-28911,CDM,J9050,HCPCS,0636,RC,70710-1525-09,NDC,,both,1,UN,2160.00,1404.00,,,,,,,,,,,,,
SHEATH ARTHSCP 6MM DIA STD LEN N THRD N OPT VW BLDELSS OBLQ,SUP-2341421,CDM,C1713,HCPCS,0278,RC,,,,both,,,2443.08,1588.00,,,,,,,,,,,,,
PROSTHESIS PENILE L15CM TBNG L9CM PS PARYLENE INFL PRECONN,SUP-2138986,CDM,C1813,HCPCS,0278,RC,,,,both,,,39969.69,25980.30,,,,,,,,,,,,,
BUR SURG L98MM OD5MM RND DMND CRV NONFLUTED VISAO,SUP-2284231,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.49,504.07,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 16 HOLE,SUP-2518367,CDM,C1713,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
NAIL IM L160MM DIA11.5MM LT HINDFOOT CANN LCK RG BENT,SUP-2347961,CDM,C1713,HCPCS,0278,RC,,,,both,,,18107.28,11769.73,,,,,,,,,,,,,
SAW SURG OSCILLATING HALL TITAN PRO9300B,SUP-2607718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21972.15,14281.90,,,,,,,,,,,,,
HEAD RAD M THK15MM WRST CO CHROM SOLAR,SUP-2377863,CDM,C1776,CPT,0278,RC,,,,both,,,11759.30,7643.54,,,,,,,,,,,,,
SHEATH URET 18 FRX17 CM W/ RADIOPAQUE STRIPE CLR AMPLATZ,SUP-2835995,CDM,C2627,HCPCS,0272,RC,,,,both,,,155.02,100.76,,,,,,,,,,,,,
HC Chloride Other Source,PX-3018243800,CDM,82438,CPT,0301,RC,,,,both,,,166.00,107.90,,,,,,,,,,,,,
NAIL IM L24CM OD9MM 20DEG HUM CANN LCK RUSS TAY,SUP-2342553,CDM,C1713,HCPCS,0278,RC,,,,both,,,8339.84,5420.90,,,,,,,,,,,,,
BLADE SAW SAG 16.5X10 MM 20 MM GRFT HARVESTING W/ STP SS,SUP-2166092,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.51,221.98,,,,,,,,,,,,,
PLATE BONE SHFT L204MM BLDE L50MM THK4.8MM 95DEG 12 H STRL,SUP-2185460,CDM,C1713,HCPCS,0278,RC,,,,both,,,3550.46,2307.80,,,,,,,,,,,,,
STENT NEURO SURPS STREAMLINE L 50 MM DIA 5 MM COCR INTCRAN,SUP-2884375,CDM,C1876,HCPCS,0278,RC,,,,both,,,49455.00,32145.75,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 30 CM DIA12 FR GUIDEWIRE 0.038 IN,SUP-2355550,CDM,C1894,HCPCS,0272,RC,,,,both,,,60.45,39.29,,,,,,,,,,,,,
TAP BONE MMF FOR LAG SCR LEIBINGER UNIV FIX SYS 2.0MM,SUP-2364416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
HC So Sugars Qual,PX-3018437766,CDM,84377,CPT,0301,RC,,,,both,,,81.00,52.65,,,,,,,,,,,,,
STENT BILI PRECIS L 40 MM DIA 9 MM CATH L 135 CM DIA 8 FR,SUP-2158929,CDM,C1876,HCPCS,0278,RC,,,,both,,,5829.10,3788.91,,,,,,,,,,,,,
PLATE BNE K MINI 2/2.5X1 MM RT 9 HOLE TI NS 253840909,SUP-2500998,CDM,C1713,HCPCS,0278,RC,,,,both,,,2707.75,1760.04,,,,,,,,,,,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-4504908300,CDM,49083,CPT,0450,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE NS SEEDSNS] BIOCOMPATIBLES INC],SUP-2135321,CDM,C2639,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
PLATE BNE L138MM 6 H ST R OLECRANON S STL LOK COMPR FOR 35MM,SUP-2185426,CDM,C1713,HCPCS,0278,RC,,,,both,,,3408.38,2215.45,,,,,,,,,,,,,
COMPONENT FEM SEG 8.5 CM RT KNEE REDUC RESECT OSS RS,SUP-2441808,CDM,C1776,CPT,0278,RC,,,,both,,,19287.45,12536.84,,,,,,,,,,,,,
PLUG ACET DOME H PLUG CONVERGE,SUP-2207429,CDM,C1776,CPT,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SEALANT HEMSTAT 5ML HUM FIBRIN THROM 2 VI APPL DEV EVICEL,SUP-2218326,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1415.07,919.80,,,,,,,,,,,,,
SYSTEM FRAC REDUC AGEE WRISTJACK,SUP-2237245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
HC So Nk Cell Total,PX-3028635766,CDM,86357,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
BASEPLATE TIB AUG CASE UNIVERS REVERS,SUP-2845850,CDM,C1776,CPT,0278,RC,,,,both,,,15307.50,9949.87,,,,,,,,,,,,,
PLATE BNE L31MM 4 H BILAT S STL LOK COMPR LO PROF FOR 2MM,SUP-2186302,CDM,C1713,HCPCS,0278,RC,,,,both,,,688.19,447.32,,,,,,,,,,,,,
GENTAMICIN IN SALINE 2-0.9 MG/ML-% IV SOLN,RX-15912,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE L202MM THK4.5MM 9 H RT LAT TIB HD BTTRS TI RIG,SUP-2190893,CDM,C1713,HCPCS,0278,RC,,,,both,,,3309.12,2150.93,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.,PX-4309714000,CDM,97140,CPT,0430,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
HEAD HUM H19MM OD48MM SHLDR CHOICE SHLDR SYS IMPL BIO MOD,SUP-2404656,CDM,C1776,CPT,0278,RC,,,,both,,,6754.14,4390.19,,,,,,,,,,,,,
NAIL IM L72MM DIA1.8MM ANK FT THRD SPHR WIRE FOR LAPIDUS,SUP-2321641,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.65,250.02,,,,,,,,,,,,,
PROBE SURG DEPTH 0.035 IN,SUP-2535242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
CATHETER VENT DRNGE L15CM OD3.1MM ID1.5MM S STL SIL BA,SUP-2243792,CDM,C1729,HCPCS,0272,RC,,,,both,,,143.12,93.03,,,,,,,,,,,,,
IRBESARTAN 150 MG PO TABS,RX-21848,CDM,6370000000,HCPCS,0637,RC,31722-0730-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
FORCEPS OPHTH 23GA BLNT DST END MICROTEXTURED BROAD GRSP,SUP-2109700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.75,310.54,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 4.5 FRX170 CM 2.8X30 MM TRPL LUMEN,SUP-2313224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.71,590.01,,,,,,,,,,,,,
BSS IO SOLN,RX-37579,CDM,2500000003,HCPCS,0250,RC,00065-0795-15,NDC,,both,15,ML,72.80,47.32,,,,,,,,,,,,,
BLADE OSTEOTOM W10XL140MM S STL FLEX THN,SUP-2342367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
PLATE BNE RECON LNG LT NON-CROSS,SUP-2399292,CDM,C1713,HCPCS,0278,RC,,,,both,,,5846.68,3800.34,,,,,,,,,,,,,
PLATE BONE SM 95MML HLX8 STNLSS STEEL BTTRSS ST LEFT DST VOL,SUP-2496870,CDM,C1713,HCPCS,0278,RC,,,,both,,,2007.81,1305.08,,,,,,,,,,,,,
TRIAL BONE PLT 5 H T SHP OBLQ TC-100 SM FRAG SYS,SUP-2343731,CDM,C1713,HCPCS,0278,RC,,,,both,,,2159.47,1403.66,,,,,,,,,,,,,
SCREW BONE L105MM DIA6.5MM THRD L20MM CANN GUID ASNS 2,SUP-2362442,CDM,C1713,HCPCS,0278,RC,,,,both,,,971.52,631.49,,,,,,,,,,,,,
FORCEPS STONE REM 2.5FR L115CM GRSP DIA10MM FOR RETRIEVE,SUP-2171235,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.78,378.16,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM BALL FOR MIA16-G1/MIA16,SUP-2848318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.95,290.52,,,,,,,,,,,,,
HC So1 Assay of Volatiles,PX-3018460067,CDM,84600,CPT,0301,RC,,,,both,,,173.00,112.45,,,,,,,,,,,,,
HANDPIECE BX VAC ASST SPR LD COR DEV,SUP-2240007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
IMPLANT TOE JT L13MM DIA2MM BLDE W4XL635IN 10DEG S STL THRD,SUP-2397816,CDM,C1776,CPT,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
FA-PYRIDOXINE-CYANOCOBALAMIN 2.5-25-2 MG PO TABS,RX-91043,CDM,6370000000,HCPCS,0637,RC,51991-0384-90,NDC,,both,1,UN,3.50,2.27,,,,,,,,,,,,,
GUIDE SURG K WIRE DEPTH,SUP-2232163,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE BNE SZ 2.8 MM TI MANDIBULAR STR NS DISP ACCUPLATE,SUP-2934743,CDM,C1713,HCPCS,0278,RC,,,,both,,,40110.36,26071.73,,,,,,,,,,,,,
BUR SURG SZ 3 235MM TUNGSTEN CARB SIDE CUT,SUP-2108789,CDM,C1713,HCPCS,0278,RC,,,,both,,,448.58,291.58,,,,,,,,,,,,,
HC Urine Cult./Colony Count|NOT REASONABLE AND NECESSARY,PX-3008708600,CDM,87086,CPT,0300,RC,,,GZ,both,,,150.00,97.50,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMOS VR-T W 67 X H 55 MM D 12 MM 32 CC,SUP-2138086,CDM,C1722,HCPCS,0275,RC,,,,both,,,53163.34,34556.17,,,,,,,,,,,,,
PLATE BONE 1.5MM 4 H W/ BAR STR UNIV NEURO III,SUP-2363628,CDM,C1713,HCPCS,0278,RC,,,,both,,,434.80,282.62,,,,,,,,,,,,,
NAIL IM L190MM DIA7.5MM 120DEG NONSTERILE BLU L/R HUM TI,SUP-2192482,CDM,C1713,HCPCS,0278,RC,,,,both,,,5515.50,3585.07,,,,,,,,,,,,,
SIMPLE SYRUP PO SYRP,RX-7242,CDM,340b,HCPCS,0637,RC,00395-2661-16,NDC,,both,473,ML,66.00,42.90,,,,,,,,,,,,,
PLATE BNE TI LT LAPIDUS 2 MODE COMPR FOR HALLUX VALGUS NS,SUP-2896849,CDM,C1713,HCPCS,0278,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
SCREW BNE L34MM OD43MM TI LO EXT ST SELF DRL CANN FIX STBL,SUP-2242827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.21,759.99,,,,,,,,,,,,,
PLATE BNE L63MM THK1.5MM 4 H R S STL T OBLQ ANG LOK COMPR,SUP-2185825,CDM,C1713,HCPCS,0278,RC,,,,both,,,993.06,645.49,,,,,,,,,,,,,
TRIANGLETIPJ UPPER LENGTH 1 UNIT EA,SUP-2677728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4802.32,3121.51,,,,,,,,,,,,,
COLLAR CERV MED DENS X LG 24X4.5 IN FRM FIT COTTON PROCARE,SUP-2195746,CDM,L0120,HCPCS,0274,RC,,,,both,,,9.86,6.41,,,,,,,,,,,,,
HC Inj N Block Hypogas Plxs,PX-3616451700,CDM,64517,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
IMPLANT HUM TISS 4X6CM MEMBRN AMNIO DEHYDR ALLGRFT,SUP-2225383,CDM,C1713,HCPCS,0278,RC,,,,both,,,9247.30,6010.74,,,,,,,,,,,,,
CATHETER ANGIOPLSTY STERLING MR L 135 CM BALLOON L 4 MM DIA2,SUP-2140052,CDM,C1725,HCPCS,0272,RC,,,,both,,,1197.28,778.23,,,,,,,,,,,,,
DILATOR SHTH 11FR L47.5CM ID3.7MM ROT LD EXTR TIGHTRAIL,SUP-2353157,CDM,C1894,HCPCS,0272,RC,,,,both,,,7865.70,5112.70,,,,,,,,,,,,,
HC Antb Severe Aqt Respir Synd Sars-Cov-2 Covid-19,PX-3028676900,CDM,86769,CPT,0302,RC,,,,both,,,82.00,53.30,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.018IN PTFE SIL STR VENT ASST DEV,SUP-2106270,CDM,C1769,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CAGE SPNL L12XW12XH10MM 4 LOBE MESH L ANAT FOOTPRINT MOD,SUP-2317730,CDM,C1889,HCPCS,0278,RC,,,,both,,,5614.32,3649.31,,,,,,,,,,,,,
WAND ABLAT P 50 HND CTRL VAPR,SUP-2256752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
HC Assay of Urea Nitrogen Quantitative,PX-3018452000,CDM,84520,CPT,0301,RC,,,,outpatient,,,92.00,59.80,,,,,,,,,,,,,
HC Ot Electricl Stim Attended 15|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309703200,CDM,97032,CPT,0430,RC,,,GO|CO,outpatient,,,206.00,133.90,,,,,,,,,,,,,
SUTURE NOVAFIL SZ 0 L18IN NONABSORBABLE BLU HSG-22 L27MM 8886446063,SUP-2174602,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.30,155.54,,,,,,,,,,,,,
SMRT KNE-PSN IQ STM W/HBS,SUP-2879113,CDM,C1776,CPT,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
N S BIPOLAR STRAIGHT ANGLED 03MM,SUP-2703459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1613.11,1048.52,,,,,,,,,,,,,
MESH HERN W12.3XL6.3IN OMEGA 3 FATTY ACID COAT POLYPR,SUP-2265990,CDM,C1781,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
BIT DRL L6-18MM DIA3.5MM ST GRY CORT DISP FOR VERTEX MAX,SUP-2286798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.75,574.44,,,,,,,,,,,,,
SCREW BONE TI LCK THRD CANC TRIFLANGE ACET COMP L15MM,SUP-2137414,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.25,493.51,,,,,,,,,,,,,
PLATE EXT FIX BRDG 150 MM FOR 5/8 RNG ALUM NS MAXFRAME,SUP-2799531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3821.29,2483.84,,,,,,,,,,,,,
DISTRACTOR EXT FIX 20 MM 1 - 1.2 MM 9 MM END DRIVEN SQ MESH,SUP-2477760,CDM,C1713,HCPCS,0278,RC,,,,both,,,19739.26,12830.52,,,,,,,,,,,,,
IMMUNE GLOBULIN (FLEBOGAMMA) 10%,RX-4081761,CDM,J1459,HCPCS,0636,RC,44206-0439-40,NDC,,both,400,ML,22639.50,14715.67,,,,,,,,,,,,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,0636,RC,63323-0012-11,NDC,,both,0.3,ML,54.10,35.16,,,,,,,,,,,,,
INSTRUMENT TRAY 3X15 MM INFLATABLE BNE TAMP KYPHON XPANDER,SUP-2293650,CDM,C1894,HCPCS,0272,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
PLATE BNE L172MM 8 H NONSTERILE L DST MED TIB S STL VAR ANG,SUP-2177639,CDM,C1713,HCPCS,0278,RC,,,,both,,,4873.81,3167.98,,,,,,,,,,,,,
HC So Preg Assoc Plasma Prot-a Pappa,PX-3018416366,CDM,84163,CPT,0301,RC,,,,both,,,49.00,31.85,,,,,,,,,,,,,
IMPL CAPPED KNEE LPS FXTICMFMTBPRLSRPATPLG,SUP-2212334,CDM,C1776,CPT,0278,RC,,,,both,,,17421.54,11324.00,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 12 H TI NAR Y LP NS,SUP-2894473,CDM,C1713,HCPCS,0278,RC,,,,both,,,3560.76,2314.49,,,,,,,,,,,,,
SYSTEM ENDOSCP ULTRASOUND DEL 19 GA PRE LD NDL BEAC DSF1901] MEDTRONIC COVIDIEN GIVEN IMAGING],SUP-2173691,CDM,A4648,CPT,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
ELECTRODE ELECSURG NDL 45 DEG TURIS CABLE PLASMA BUTTON,SUP-2313584,CDM,C1713,HCPCS,0278,RC,,,,both,,,1596.88,1037.97,,,,,,,,,,,,,
WEDGE FEM SZ 1 DIA4MM DST GMK,SUP-2267560,CDM,C1776,CPT,0278,RC,,,,both,,,3854.35,2505.33,,,,,,,,,,,,,
DRAIN CHN 24FR L8MM SIL RND HUBLESS FULL FLUT DEPTH MRK,SUP-2127338,CDM,C1729,HCPCS,0272,RC,,,,both,,,43.93,28.55,,,,,,,,,,,,,
ENDCAP ORTH L10MM DIA12MM NONSTERILE GRN FEM TI NAIL EXTN,SUP-2192363,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.19,395.97,,,,,,,,,,,,,
COMPONENT FEM 2 LT PRI CEM RESURF UNISX GRDIAN,SUP-2304403,CDM,C1776,CPT,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
HC So Lidocaine,PX-3018017666,CDM,80176,CPT,0301,RC,,,,inpatient,,,387.00,251.55,,,,,,,,,,,,,
COIL EMB 10 L6CM OD4MM COMPLX STRTCH RESIST FNSH V-TRAK SFT,SUP-2305161,CDM,C1889,HCPCS,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA1.8 MM TI NEURO XDRV EMER 12 PK STRL,SUP-2935285,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
TWIST DR W/SUT HL 2.4X127,SUP-2818449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.75,378.14,,,,,,,,,,,,,
SET HAD CATH 12.5FR L24CM STR DIL GWIRE ADH DSG INTRO NDL,SUP-2267004,CDM,C1752,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
IMPLANT BRST 525CC P5.8CM W14.5XH13.2CM HIGHLY COHESIVE SIL,SUP-2113497,CDM,C1789,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
DEVICE TNSLCTMY OPN SEAL DIV BIZACT,SUP-2172364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10 CM DIA13 MM CATH L 110 CM,SUP-2396473,CDM,C1874,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
CATHETER IABP AD 7.5FR L230MM 30CC POLYUR S STL FBROPT,SUP-2383463,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
CAGE SPNL LORDTC 10 DEG 30X24X14 MM ALIF EXPANDABLE SAHARA,SUP-2532986,CDM,C1889,HCPCS,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
SYSTEM PRSS MON W/ RADPQ SENS FOR PULM ART IN HRT FAILURE CM2000] ST JUDE MEDICAL INC],SUP-2357560,CDM,C2624,HCPCS,0278,RC,,,,both,,,59660.00,38779.00,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM SCREW PIN POLYETH,SUP-2212715,CDM,C1713,HCPCS,0278,RC,,,,both,,,12131.77,7885.65,,,,,,,,,,,,,
PLATE BNE LCK UNIV 2X2.3X1.5 MM 4 HOLE BAR SCREW TI GLD NS,SUP-2366363,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.60,749.84,,,,,,,,,,,,,
GRAFT BNE SUB THK16-18MM CALCANEUS CRSS SECT FRZ DRY,SUP-2307163,CDM,C1713,HCPCS,0278,RC,,,,both,,,2423.95,1575.57,,,,,,,,,,,,,
HC ED Layer Clos Face 12.6-20,PX-4501205500,CDM,12055,CPT,0450,RC,,,,both,,,1904.00,1237.60,,,,,,,,,,,,,
BLADE RTRCTR CHRNLEY SHRT 1INW X 2 3/8NL X 4IND F/INTL INCSN,SUP-2497092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.17,252.96,,,,,,,,,,,,,
ROD SPNL 5.5X85 MM CD HORZ LEG,SUP-2631281,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR STD 0.018 INX400 CM FIX COR SAFE-T-J,SUP-2738258,CDM,C1769,HCPCS,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
WRENCH TORQUE REACTIV8,SUP-2877971,CDM,C1730,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
NAIL IM L34.5CM OD10MM TIB CANN LCK DELT RUSS TAY,SUP-2342519,CDM,C1713,HCPCS,0278,RC,,,,both,,,1855.74,1206.23,,,,,,,,,,,,,
PLATE BNE VOLAR NAR LT FT BABY,SUP-2137318,CDM,C1713,HCPCS,0278,RC,,,,both,,,3212.22,2087.94,,,,,,,,,,,,,
GRAFT BNE BLOCK 7 MM ILLIUM TRICORT,SUP-2162595,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
PIN FIX 2X50 MM STRL INION OTPS LTX DISP,SUP-2857901,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
STIMULATOR BNE XL 8CM MESH CATHODE 40UA DEV SPF,SUP-2414468,CDM,E0749,HCPCS,0278,RC,,,,both,,,17638.95,11465.32,,,,,,,,,,,,,
PLATE BNE RECON 3.5X154 MM 13 HOLE SS,SUP-2569088,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.75,292.99,,,,,,,,,,,,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA,RX-10434,CDM,6370000000,HCPCS,0637,RC,81033-0025-05,NDC,,both,5,GR,36.90,23.98,,,,,,,,,,,,,
TUBE VENT V-T GROMMET 1.27MM,SUP-2656690,CDM,L8699,HCPCS,0278,RC,,,,both,,,81.73,53.12,,,,,,,,,,,,,
COMPONENT FEM SZ 2 L NP CRUCE RET BKS TRIMAX,SUP-2314952,CDM,C1776,CPT,0278,RC,,,,both,,,7372.72,4792.27,,,,,,,,,,,,,
NEEDLE INTOSS AD FAST L25MM OD15GA EZ-IO,SUP-2120556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
MICROCATHETER INFUSION PROGREAT L 130 CM DIA2.7 FR COAT 70,SUP-2385153,CDM,C1887,HCPCS,0272,RC,,,,both,,,1862.96,1210.92,,,,,,,,,,,,,
WALKER PT STD XL 11-16 13 + CLOSED HEEL SHOE PACESETTER II,SUP-2195219,CDM,L4386,HCPCS,0274,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
BIT DRL 2.2X16 MM JCBS ANTR CERV PLATE SYS SKYLINE,SUP-2591625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HC Fetal Eval Follow-Up/Repeat,PX-4027681600,CDM,76816,CPT,0402,RC,,,,both,,,1269.00,824.85,,,,,,,,,,,,,
GRAFT HUM TISS DIA11MM OSTEOCHNDRL CHONDROFIX,SUP-2200260,CDM,C1713,HCPCS,0278,RC,,,,both,,,11564.62,7517.00,,,,,,,,,,,,,
IMPLANT FUS TI PLSM SPR COAT IFUSE 7MM X 45MM,SUP-2337778,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,0250,RC,00264-7751-00,NDC,,both,1000,ML,25.50,16.57,,,,,,,,,,,,,
HC Simulation Intermediate,PX-3337728500,CDM,77285,CPT,0333,RC,,,,both,,,1230.00,799.50,,,,,,,,,,,,,
TAP SURG L11MM OD4MM THRD,SUP-2293253,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.24,305.01,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST DBL UPR EXTN FLX ASST FABRICATED,SUP-2435758,CDM,L3730,HCPCS,0272,RC,,,,both,,,2335.16,1517.85,,,,,,,,,,,,,
ROPIVACAINE ELASTOMERIC INFUSION 0.2%,RX-4081819201,CDM,C9804,HCPCS,0636,RC,09999-9917-29,NDC,,both,100,ML,75.40,49.01,,,,,,,,,,,,,
RING EXTERNAL FIXATION DIA160MM ALUMINUM FULL,SUP-2586492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4336.09,2818.46,,,,,,,,,,,,,
BIT DRL L150MM WRK L50MM DIA2MM 3 FLUTEREPLACEMENT S STL,SUP-2150426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,493.33,320.66,,,,,,,,,,,,,
GRAFT ENDOVASC L3.3CM DIA26MM AORT EXT ENDOPROS EXCLUDER,SUP-2395939,CDM,C1768,CPT,0278,RC,,,,both,,,8509.40,5531.11,,,,,,,,,,,,,
ANAGRELIDE HCL 0.5 MG PO CAPS,RX-20446,CDM,6370000000,HCPCS,0637,RC,13668-0453-01,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
CATHETER ATR FIX PRESSURE FULL 46 CM SHUNT FULL BA,SUP-2243867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.36,205.63,,,,,,,,,,,,,
CATHETER VENTRICULAR STD 1.5 MMX35 CM INTCRAN BA STRIPE CLR,SUP-2851441,CDM,C1729,HCPCS,0272,RC,,,,both,,,414.26,269.27,,,,,,,,,,,,,
OXYGENATOR PERF 0.5-5LPM 4000ML HLLW FBR HARDSHELL RESVR,SUP-2384843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
HC N Block Paravert Lumbar 1st,PX-3606449300,CDM,64493,CPT,0360,RC,,,,both,,,4864.00,3161.60,,,,,,,,,,,,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,J2440,HCPCS,0636,RC,54288-0142-01,NDC,,both,1,ML,93.50,60.77,,,,,,,,,,,,,
PLATE BONE NONSTERILE UNIV CRAN ORBIT TI FLR LO PROF,SUP-2190646,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
ALLOGRAFT BNE INSRT MED 9 8X6X9 MM FD CYL DBM XPANSE,SUP-2787771,CDM,C1713,HCPCS,0278,RC,,,,both,,,1597.63,1038.46,,,,,,,,,,,,,
PLATE BONE MESHED 99X66 MM LEFT PREFORMED TEMPORAL TITANIUM,SUP-2837717,CDM,C1713,HCPCS,0278,RC,,,,both,,,10751.99,6988.79,,,,,,,,,,,,,
HC Surgery Hybrid Base,PX-3600000007,CDM,3600000007,LOCAL,0360,RC,,,,both,,,9658.00,6277.70,,,,,,,,,,,,,
PLATE BONE L90MM THK3.5-4.5MM 4 H STRL RT MEDL TI DSTL FEM,SUP-2190912,CDM,C1713,HCPCS,0278,RC,,,,both,,,4408.34,2865.42,,,,,,,,,,,,,
BOLT ORTH TROCHANTERIC CALCAR HIP MLRY HD 1 PC POLY PLUG,SUP-2403608,CDM,C1776,CPT,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
WIRE FIX 2X150 MM TI NS KIRSCHNER,SUP-2432340,CDM,C1713,HCPCS,0278,RC,,,,both,,,30.62,19.90,,,,,,,,,,,,,
SCREW SPNL L40MM DIA8MM CANC PEDCL TI VAR ANG NONCANNULATED,SUP-2193324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1661.06,1079.69,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA11MM STBL SL BLDELSS DISP ENDOPATH,SUP-2218781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,650.86,423.06,,,,,,,,,,,,,
HYDROMORPHONE HCL 0.2 MG/ML IV SOLN,RX-151804,CDM,J1171,HCPCS,0636,RC,71266-5035-01,NDC,,both,100,ML,177.10,115.11,,,,,,,,,,,,,
SCREW BNE L100MM DIA12MM HIP NAIL LAG FOR TRAUM GAM,SUP-2370992,CDM,C1713,HCPCS,0278,RC,,,,both,,,924.73,601.07,,,,,,,,,,,,,
PROTECTOR TISS 8 MM FOR DRL,SUP-2167397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE STR 3.5X49.2 MM 4 HOLE RECON FOR SM FRAG SYS TI NS,SUP-2475381,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.42,542.37,,,,,,,,,,,,,
CATHETER VENTRICULAR DRAINAGE L 35 CM OD 10 FR ID 1.9 MM,SUP-2883345,CDM,C1729,HCPCS,0272,RC,,,,both,,,2392.08,1554.85,,,,,,,,,,,,,
NAIL IM L22CM OD35MM 8DEG SIL S STL TIM PROX HUM TIB END,SUP-2342807,CDM,C1713,HCPCS,0278,RC,,,,both,,,3533.13,2296.53,,,,,,,,,,,,,
CUP ACET OD52MM ID46MM CO CHROM HIP HMSPHR PRI PRSS FIT LO,SUP-2304483,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
REAMER PLUG SPNL LUM TAPR FUS DEV LT CAGE SGL BRL SHFT,SUP-2291601,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.97,386.73,,,,,,,,,,,,,
CANNULA ENDOSCP W/O VLV 3.5 MMX6 CM W/ INSUFFLATION STOPCOCK,SUP-2767480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,654.53,425.44,,,,,,,,,,,,,
CAGE SPNL H16-25MM DIA14MM 6DEG ANT TI VBR DISTR DEV ADD,SUP-2390793,CDM,C1889,HCPCS,0278,RC,,,,both,,,23393.00,15205.45,,,,,,,,,,,,,
GRAFT BNE BIPHASIC 9 CC 1 STRP OSTEOMATRIX +,SUP-2517943,CDM,C1713,HCPCS,0278,RC,,,,both,,,4270.78,2776.01,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 15CM 10MM 120CM RADIOPAQUE,SUP-2610468,CDM,C1768,CPT,0278,RC,,,,both,,,12261.70,7970.10,,,,,,,,,,,,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,0636,RC,71351-0022-02,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
SHUNT SURG REG 60 CM ASMBLY STRATA II BIOGLDE,SUP-2628594,CDM,C1729,HCPCS,0272,RC,,,,both,,,13928.95,9053.82,,,,,,,,,,,,,
PSN PK ART SURF INS TIP,SUP-2508585,CDM,C1776,CPT,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
STENT NEURO ENTRP 2 L 39 MM 4 FR MICROCATHETER .021 IN RECON,SUP-2518822,CDM,C1874,HCPCS,0278,RC,,,,both,,,28918.83,18797.24,,,,,,,,,,,,,
FORCEP ELECSURG BPLR 1.2 MM 19 CM IRRIGATING SILVERGLIDE,SUP-2859625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3740.62,2431.40,,,,,,,,,,,,,
KIT SUT ANCHR BTTN PLT OPT ASMBLY,SUP-2401368,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
DEVICE TISS FIX FIBERTAPE SUTURE FOR INTERNALBRACE TECH STRL,SUP-2882174,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
CABLE SURG L750MM DIA1.7MM S STL W/ CRMP,SUP-2187031,CDM,C1776,CPT,0278,RC,,,,both,,,13282.73,8633.77,,,,,,,,,,,,,
GRAFT BNE SUB M CANC FRZN MORSELIZED W/ VIABLE CELL TRINITY,SUP-2307240,CDM,C1713,HCPCS,0278,RC,,,,both,,,5658.28,3677.88,,,,,,,,,,,,,
SCREW BNE NLCK 5X40 MM OSTEOPENIA PARTIALLY THRD NS PERI-LOC,SUP-2348498,CDM,C1713,HCPCS,0278,RC,,,,both,,,220.74,143.48,,,,,,,,,,,,,
PROSTHESIS 16F 5MM SPEC LEN LG ESOPH FLNG INDWL VOICE,SUP-2242345,CDM,L8509,HCPCS,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
GRAFT VASC GELSFT L 60 CM DIA 8 MM POLYESTER GEL ABD PERIPH,SUP-2384966,CDM,C1768,CPT,0278,RC,,,,both,,,1451.31,943.35,,,,,,,,,,,,,
GUIDEWIRE VASC COPE L 40 CM DIA 0.018 IN TAPR L 7 CM FLPY,SUP-2168469,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.51,56.23,,,,,,,,,,,,,
PHYTONADIONE 1 MG/ML ORAL SOLUTION,RX-4082399,CDM,6370000000,HCPCS,0637,RC,09999-9158-05,NDC,,both,2.5,ML,35.40,23.01,,,,,,,,,,,,,
GENERATOR PACEMKR CYLOS DR 2 CHMBR ADV DDDR IS1 BPLR CONN,SUP-2138178,CDM,C1785,HCPCS,0275,RC,,,,both,,,17552.60,11409.19,,,,,,,,,,,,,
CLAMP EXT FIX ADJ WIRE PIN,SUP-2188591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2316.16,1505.50,,,,,,,,,,,,,
ALLOGRAFT BNE WHL TIB,SUP-2321917,CDM,C1713,HCPCS,0278,RC,,,,both,,,19311.00,12552.15,,,,,,,,,,,,,
PLATE BSSO SLIDING COLOGNE30MM STERILE,SUP-2676896,CDM,C1713,HCPCS,0278,RC,,,,both,,,1861.74,1210.13,,,,,,,,,,,,,
PLATE BONEXL THK2MM 12 H MAND TI STR FOR 2MM PLUSDRIVE SCR,SUP-2191271,CDM,C1713,HCPCS,0278,RC,,,,both,,,3521.20,2288.78,,,,,,,,,,,,,
RESERVOIR VENT CATH L7CM OD3.1MM ID1.5MM 5 H SIL S STL STYL,SUP-2243791,CDM,C1729,HCPCS,0272,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
PEN ABLAT CARD RF SYS CARDIOBLATE,SUP-2278863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,0636,RC,00409-5921-16,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
LINER ACET SZ E OD54X56MM ID32MM THK7.9MM 10DEG HIP X3,SUP-2375151,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
WIRE BNE FIX METATRSL SHORTNG PILOT H 2.25 NS,SUP-2899209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
NAIL IM L400MM DIA10MM 130DEG LNG R PROX FEM GRN TI CANN,SUP-2180498,CDM,C1713,HCPCS,0278,RC,,,,both,,,6454.80,4195.62,,,,,,,,,,,,,
SET INTRO FLX BLKN L 55 CM OD 7 FR CKFLO VLV STRL,SUP-2168572,CDM,C1894,HCPCS,0272,RC,,,,both,,,212.67,138.24,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7030,HCPCS,0250,RC,00338-0049-04,NDC,,both,250,ML,10.70,6.95,,,,,,,,,,,,,
SUCTION TUBE 8 UPMC GARDNER STYLE,SUP-2495017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1741.16,1131.75,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK FORK STRP,SUP-2388211,CDM,L5684,HCPCS,0272,RC,,,,both,,,126.48,82.21,,,,,,,,,,,,,
HC So1 Protein Electrophoresis Serum,PX-3018416567,CDM,84165,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
ANGIOGRAPHY KIT,SUP-2302859,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.41,30.17,,,,,,,,,,,,,
HC Endo Level 1 Addl 15 Min,PX-3600007511,CDM,3600007511,LOCAL,0360,RC,,,,both,,,1968.00,1279.20,,,,,,,,,,,,,
PLATE BNE L63MM 4 H BILAT S STL STR NONCOMPRESSION RECON,SUP-2410175,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.43,585.28,,,,,,,,,,,,,
REAMER SURG 10MM NONSTERILE FOR HAMRTOE HTR IMPL SYS,SUP-2390551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
HC Unlisted Proc Lungs and Pleura,PX-3613299900,CDM,32999,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BNE T 2.7/3.5X85 MM 7 HOLE SS,SUP-2569104,CDM,C1713,HCPCS,0278,RC,,,,both,,,385.12,250.33,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 5X5 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651378,CDM,Q4154,HCPCS,0636,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
DRILL SURG L25MM FLEX PEG R3,SUP-2345727,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
OSSEOFLEX SB 10 GAUGE4ML STRAIGHT SYSTEM CONVENIENCE PACK,SUP-2702594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2841.70,1847.10,,,,,,,,,,,,,
GUIDEWIRE VASC PULSE SPRY L 154 CM DIA 0.035 IN FLPY TIP L 2,SUP-2118469,CDM,C1769,HCPCS,0272,RC,,,,both,,,241.15,156.75,,,,,,,,,,,,,
SPECULUM 3714691 BECKMAN NASAL SZ2 MED,SUP-2494947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.87,488.07,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 4.5/5.5 MM FOR 10314 10315,SUP-2762151,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
GUIDEWIRE VASC SENTAI SAMURAI RC L 190 CM SPRING COIL L 24,SUP-2140871,CDM,C1769,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PLATE BNE 3D PRNT LG MIDFACE MAND TI TRUMATCH,SUP-2860368,CDM,C1713,HCPCS,0278,RC,,,,both,,,27035.40,17573.01,,,,,,,,,,,,,
CATHETER DRAINAGE SINGLE PIG 6 FRX250 CM TUBE NIT FLEXIMA,SUP-2480145,CDM,C1729,HCPCS,0272,RC,,,,both,,,333.12,216.53,,,,,,,,,,,,,
IMPLANT BIO TISS L25CM ID4MM PERIPH NRV CLLGN CONDUIT,SUP-2378814,CDM,C1713,HCPCS,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
GRAFT DURA L 1 X W 1 IN THK 0.6 MM TYP I CLLGN BOV ACHILLES,SUP-2889758,CDM,C1763,HCPCS,0278,RC,,,,both,,,957.39,622.30,,,,,,,,,,,,,
PLATE BNE 1ST MTP/MPJ 2.7 MM RT PRIMARY NS FPS LTX,SUP-2856860,CDM,C1713,HCPCS,0278,RC,,,,both,,,5115.06,3324.79,,,,,,,,,,,,,
KIT IMAGING SYS RIGID W/SNGL USE KITX6 FLUORESCENT F/ENDOSCOPE PINPOINT DISP SPY-MIS PACK,SUP-2424109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,638.96,415.32,,,,,,,,,,,,,
CONNECTOR SHUNT OD1.9MM STR TI HYDROCEPHALUS 1 PC,SUP-2108706,CDM,C1729,HCPCS,0272,RC,,,,both,,,277.23,180.20,,,,,,,,,,,,,
SET URET STENT L 24 CM DIA 6 FR GUIDEWIRE 0.038 IN SIL VLY,SUP-2171281,CDM,C2617,HCPCS,0278,RC,,,,both,,,463.15,301.05,,,,,,,,,,,,,
PLATE BNE L 62.7 X W 17.3 MM THK 0.6 MM SCREW DIA1.65 MM 18,SUP-2936419,CDM,C1713,HCPCS,0278,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
CAGE SPNL PARL 9X7X23 MM LUMBAR CONCORDE,SUP-2255217,CDM,C1889,HCPCS,0278,RC,,,,both,,,11704.35,7607.83,,,,,,,,,,,,,
HC Cold Agglutinin Titer,PX-3028615700,CDM,86157,CPT,0302,RC,,,,both,,,421.00,273.65,,,,,,,,,,,,,
DARATUMUMAB-HYALURONIDASE-FIHJ 1800-30000 MG-UT/15ML SC SOLN,RX-150615,CDM,J9144,HCPCS,0636,RC,57894-0503-01,NDC,,both,15,ML,30447.00,19790.55,,,,,,,,,,,,,
GUIDEPIN SURG TRANSTIBIAL SUT EYE RETRODRILL,SUP-2120916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
BLADE SHVR ARTHSCP 3MM DIA 120MML 65DG CRVD RCTNGLR WNDW RDS,SUP-2574166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,814.52,529.44,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LNR POLYETH H2SN] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351356,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
GRAFT VASC L90X40CM DIA8X8MM AXILLOBIFEMORAL PTFE CBAS HEP,SUP-2395788,CDM,C1768,CPT,0278,RC,,,,both,,,13806.58,8974.28,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 10H LEFT 214MM,SUP-2549614,CDM,C1713,HCPCS,0278,RC,,,,both,,,3426.15,2227.00,,,,,,,,,,,,,
TEMPLATE DERM REGEN W4XL10IN BOV TEND CLLGN,SUP-2244244,CDM,Q4105,HCPCS,0636,RC,,,,both,,,35400.36,23010.23,,,,,,,,,,,,,
FIBER LASER 400UM HOLM LT GUID,SUP-2313981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1346.53,875.24,,,,,,,,,,,,,
PLATE BNE L423MM 26 H BROAD COMPR RIG FOR 45MM SCR L FRAG,SUP-2411436,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.65,955.27,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 48 CM DIA 4-6 MM EPTFE TAPR STD,SUP-2396210,CDM,C1768,CPT,0278,RC,,,,both,,,1893.42,1230.72,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES ORTHOSIS SCOTTISH R,SUP-2435605,CDM,L1730,HCPCS,0272,RC,,,,both,,,3525.84,2291.80,,,,,,,,,,,,,
PLATE BNE L122MM 4 H ST R DST HUM EXTRA ARTC S STL LOK,SUP-2177167,CDM,C1713,HCPCS,0278,RC,,,,both,,,3587.45,2331.84,,,,,,,,,,,,,
HALF PIN EXT FIX L110MM DIA5MM THRD L35MM DIA5MM SH TI,SUP-2342925,CDM,C1713,HCPCS,0278,RC,,,,both,,,1206.14,783.99,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1193108D3,SUP-2632794,CDM,C1751,HCPCS,0278,RC,,,,both,,,1127.57,732.92,,,,,,,,,,,,,
GUIDE SURG SZ 03-02 MOD SET FOR TOT KNEE ARTHROPLASTY SIGN,SUP-2136775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
MESH GYN W4XL27CM Y PRESHAPED UNIDIR POLYPR FOR,SUP-2165309,CDM,C1781,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
PLATE BNE L116MM 6 H BILAT S STL T NONCOMPRESSION LO PROF,SUP-2185755,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
TAP MAND LCK BONE SCR FIX MOD NONSTERILE REUSE LEIBINGER,SUP-2364415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.02,351.66,,,,,,,,,,,,,
EXPANDER TISS BRST TEXT SURF + LO POLE FULL HT 600-720CC FIL,SUP-2353025,CDM,C1789,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CATHETER AIRWY EXCHANGE SET 038X160 CM 14 FRX70 CM ARNDT,SUP-2760019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.72,255.27,,,,,,,,,,,,,
BLADE RETRCT SZ 5 L MOUTH GAG RNG DAVIS,SUP-2243545,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.78,404.16,,,,,,,,,,,,,
BLADE REPROC SHV TRICUT STR SHAFT 11CM W/O TUBE 4MM,SUP-2653216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,218.32,141.91,,,,,,,,,,,,,
SILVERSTEIN TOTAL SHAFT WFOOTPLATE TACK,SUP-2680306,CDM,L8613,CPT,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
HC ED Clsd Tx Prox Ulnar Fx Manip,PX-4502467500,CDM,24675,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
TI LCP VOLAR COLUMN DISTAL RADIUS PL 8H HEAD/5H SHAFT/LT,SUP-2549121,CDM,C1713,HCPCS,0278,RC,,,,both,,,2898.94,1884.31,,,,,,,,,,,,,
LINER ACET OD60MM ID28MM 0DEG MARATHON HIP REV LIP PINN,SUP-2250377,CDM,C1776,CPT,0278,RC,,,,both,,,2362.54,1535.65,,,,,,,,,,,,,
INSERT TIB ARTC CRUCE RET MOD CNDYL STABILIZING NEUT UNIV,SUP-2376286,CDM,C1776,CPT,0278,RC,,,,both,,,2917.06,1896.09,,,,,,,,,,,,,
SPACER SPNL H5MM INTBDY LORDTC A-CIFT SOLOFUSE,SUP-2353558,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
MOLD TIB SPCR M AP45MM ML70MM PMMA URETHANE GENT KASM,SUP-2315778,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BNE PRI L SZ 2,SUP-2388825,CDM,C1713,HCPCS,0278,RC,,,,both,,,3105.46,2018.55,,,,,,,,,,,,,
SHELL ACET SZ 22 OD48MM POR REV PRESSFIT MULT H FLNG LCK,SUP-2403715,CDM,C1776,CPT,0278,RC,,,,both,,,5790.16,3763.60,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X220 MM GRACILIS TEND,SUP-2866885,CDM,C1762,CPT,0278,RC,,,,both,,,2171.62,1411.55,,,,,,,,,,,,,
SPLINT ARM M L13IN FOR 5 17IN ARM POLY FAB MP MACH WSH,SUP-2274801,CDM,L3809,HCPCS,0274,RC,,,,both,,,29.99,19.49,,,,,,,,,,,,,
BUR SURG HD DIA5MM S STL STR RND FLUT AGG,SUP-2367559,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.49,266.82,,,,,,,,,,,,,
CATHETER NEPHROSTOMY LCK LOOP 8 FRX26 CM TAPR TIP PERCFLX,SUP-2481343,CDM,C1729,HCPCS,0272,RC,,,,both,,,266.71,173.36,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRICE,SUP-2212488,CDM,C1776,CPT,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
BIT DRL DIA7MM ASSEMB BNE GRFT FOR UNIV PLATTER,SUP-2107742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
GRAFT BNE PAT TEND TISS HEMI ALLGRFT,SUP-2335536,CDM,C1762,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
EXPANDER TISS 8.3X5.5 CM 17 CM 100-120 CC TEXT SOFTSPAN,SUP-2459472,CDM,C1889,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
STIMULATOR BNE GROWTH PHYSIO-STIM,SUP-2316032,CDM,E0749,HCPCS,0278,RC,,,,both,,,7840.58,5096.38,,,,,,,,,,,,,
ANCHOR SUTURE STRL SUTURELOC AR-4551-1,SUP-2910535,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.17,312.76,,,,,,,,,,,,,
SUPPORT ANK UNIV LG PLAS,SUP-2330385,CDM,L4350,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STIMULATOR NERVE CHARGING SYS,SUP-2568741,CDM,C1820,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
GRAFT 5ML PUTTY NOVABONE,SUP-2307533,CDM,C9359,HCPCS,0278,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
PROSTHESIS OTO 2 10MM TI CNTR TORP ADJUSTABLE MIC,SUP-2313847,CDM,L8613,CPT,0278,RC,,,,both,,,961.25,624.81,,,,,,,,,,,,,
AUGMENT FEM 3 4 MM POST,SUP-2610720,CDM,C1776,CPT,0278,RC,,,,both,,,3067.15,1993.65,,,,,,,,,,,,,
PLATE BONE W13.5XL242MM THK4.2MM 13 H BILAT S STL NAR LCK,SUP-2185251,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
MESH BIO TISS W40XL50MM PORCINE CLLGN MTRX BIO-GIDE,SUP-2416357,CDM,C1713,HCPCS,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
GUIDEWIRE FIX 24MMX70CM HUM BULL TIP S STL M DN,SUP-2410450,CDM,C1769,HCPCS,0272,RC,,,,both,,,132.48,86.11,,,,,,,,,,,,,
CATHETER PRB GLD DIR 10FR,SUP-2141559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
KIT IMPL KNEE CUST EXACTECHGPS,SUP-2223587,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,J2004,HCPCS,0636,RC,63323-0482-01,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
IMPLANT HUM TISS W20CMXL25MM FASC LATA FRZ DRY TUTOPLAST,SUP-2307101,CDM,C1762,CPT,0278,RC,,,,both,,,1309.85,851.40,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL ADJ FLX,SUP-2435685,CDM,L2622,HCPCS,0274,RC,,,,both,,,900.87,585.57,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN 90 DEG L 81 CM DIA 8.5 FR NDL L 89 CM,SUP-2460734,CDM,C1893,HCPCS,0272,RC,,,,both,,,448.39,291.45,,,,,,,,,,,,,
CATHETER INTRAAORTIC BLLN 75 FR 25 CC W/ KONTRON LINEAR,SUP-2227230,CDM,C1725,HCPCS,0272,RC,,,,both,,,2543.31,1653.15,,,,,,,,,,,,,
BLADE SAW KYOCERA ORTHOSTAR 90X13MM,SUP-2222799,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
PROBE PRESSURE MONITOR MIC FOR O2 LICOX,SUP-2883662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.20,707.33,,,,,,,,,,,,,
BLADE SHAVER BPLR STD STR SERRATED CLOSED STRL DISP,SUP-2648960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.14,325.74,,,,,,,,,,,,,
GRAFT HUMAN TISSUE PELVIC FLOOR MATRIX 15X10 CM MATRISTEM,SUP-2106488,CDM,C1763,HCPCS,0278,RC,,,,both,,,14836.50,9643.72,,,,,,,,,,,,,
GUIDEWIRE ORTH L190CM DIA1.6MM TIB PARTIALLY THRD SHRP TIP,SUP-2204945,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.11,40.37,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + MED MEDPOR PTERIONAL +,SUP-2862745,CDM,C1713,HCPCS,0278,RC,,,,both,,,48861.98,31760.29,,,,,,,,,,,,,
HC Pentamidine Treatment,PX-4109464200,CDM,94642,CPT,0410,RC,,,,both,,,322.00,209.30,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 L15MM IBT KYPHON EXPR OSTEO INTRO SYS,SUP-2293638,CDM,C1894,HCPCS,0272,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
ANCHOR SUTURE NO 2 L12MM DIAMETER 4MM POLYESTER PRETHREADED,SUP-2824801,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.12,288.03,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 360 DEG L 13 CM DIA 4 MM SPD 7500 RPM,SUP-2902043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,739.03,480.37,,,,,,,,,,,,,
HC So Hla I Typing 1 Antigen Lr,PX-3108137466,CDM,81374,CPT,0310,RC,,,,outpatient,,,153.00,99.45,,,,,,,,,,,,,
APIXABAN 2.5 MG PO TABS,RX-120067,CDM,6370000000,HCPCS,0637,RC,00003-0893-31,NDC,,both,1,UN,45.50,29.57,,,,,,,,,,,,,
SET O2 FLO MODULATOR 6FR L7.5CM ID2MM TRANSTRACHEAL KINK,SUP-2168722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.93,271.00,,,,,,,,,,,,,
SHAFT SCRDRVR L520MM FOR RMR IRRIG ASPIR,SUP-2187571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13213.18,8588.57,,,,,,,,,,,,,
PROSTHESIS LARYN L6MM OD17FR INDWL LO AIRFLO RESISTANCE FOR,SUP-2124302,CDM,L8509,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
KIT CATHETER 14GA L8IN POLYUR RADPQ SIDE H INTEGR SUT WNG,SUP-2383273,CDM,C1751,HCPCS,0278,RC,,,,both,,,58.40,37.96,,,,,,,,,,,,,
HC Treat Radius Fx,PX-4502465000,CDM,24650,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
BASEPLATE TIB SZ 0/1 THK14MM STD POR LT STEM PRESSFIT REV,SUP-2209327,CDM,C1776,CPT,0278,RC,,,,both,,,10010.32,6506.71,,,,,,,,,,,,,
SPACER SPNL W14XH11XL8MM 4DEG PEEK OPTMA ANT CERV INTBDY,SUP-2286397,CDM,C1821,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
PLATE BNE THK 1 MM SCREW DIA2 MM 2 X 2 H MINI 3D TRAP,SUP-2883194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.71,998.21,,,,,,,,,,,,,
GUIDEWIRE VASC L40CM DIA0018IN NDL 21GA L7CM Z S STL MAK,SUP-2302986,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.54,40.00,,,,,,,,,,,,,
CATHETER URET 5FR TIP 14FR L70CM UNIV WDG FOR RG PYELOGRAM,SUP-2171185,CDM,C1758,HCPCS,0278,RC,,,,both,,,39.91,25.94,,,,,,,,,,,,,
DILATOR ES 60FR 20MM OVR THE GWIRE FLX SAFEGUIDE,SUP-2277393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,773.70,502.90,,,,,,,,,,,,,
COMPONENT CARPAL LG ST,SUP-2696159,CDM,C1776,CPT,0278,RC,,,,both,,,11430.86,7430.06,,,,,,,,,,,,,
PLATE BONE 130DEG 6 H PROX FEM LCK FOR 3.5MM SCR PEDILOC,SUP-2318558,CDM,C1713,HCPCS,0278,RC,,,,both,,,7899.61,5134.75,,,,,,,,,,,,,
MATRIX DERM W8XL8CM BOV TISS N PERF PRIMTRX,SUP-2366726,CDM,Q4110,HCPCS,0636,RC,,,,both,,,8653.84,5625.00,,,,,,,,,,,,,
PLATE BNE L180MM 7 H NONSTERILE R PROX LAT TIB S STL LOK,SUP-2184879,CDM,C1713,HCPCS,0278,RC,,,,both,,,3911.56,2542.51,,,,,,,,,,,,,
PLATE BONE PREBENT 10MM STP LT MAX 1.6MM SCR OSA SYS,SUP-2319387,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
SET URET STENT C FLX L 21-32 CM DIA 3.7 FR SS POLYUR,SUP-2826629,CDM,C2617,HCPCS,0278,RC,,,,both,,,360.72,234.47,,,,,,,,,,,,,
APPLICATOR ABLATN 29 CM FOR MICROWAVE TISS SYS SOLERO,SUP-2752480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
GRAFT BNE FN 1-4 MM 90 CC FRZN CANC,SUP-2766764,CDM,C1713,HCPCS,0278,RC,,,,both,,,5445.70,3539.70,,,,,,,,,,,,,
CATHETER ANGIOPLSTY UTHN ST L 150 CM BALLOON L 2 CM DIA 8 MM,SUP-2147259,CDM,C1725,HCPCS,0272,RC,,,,both,,,646.71,420.36,,,,,,,,,,,,,
CATHETER ANGIO MOD HK 035 5 FRX100 CM 6 SP PERFORMA,SUP-2301643,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.63,246.76,,,,,,,,,,,,,
GRAFT BNE GRAN 15X15X1-2 MM 2.6 CC SUBSTITUTE SHP ACTIFUSE,SUP-2129869,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
CATHETER EP 4 MM 7 FRX110 4 FRX20 MM INQUIRY,SUP-2538007,CDM,C1731,HCPCS,0278,RC,,,,both,,,5133.90,3337.03,,,,,,,,,,,,,
PACK SURG CUST AV FISTULA JEWISH,SUP-2711641,CDM,C1713,HCPCS,0278,RC,,,,both,,,708.10,460.26,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.502,SUP-2860019,CDM,C1713,HCPCS,0278,RC,,,,both,,,33471.14,21756.24,,,,,,,,,,,,,
CATHETER THERMOABLAT DIA18-31MM BLLN L8CM ELECTRD L4CM 16,SUP-2172284,CDM,C1888,HCPCS,0272,RC,,,,both,,,8003.86,5202.51,,,,,,,,,,,,,
PLATE BONE LOK 185MML HLX14 STNLSS STEEL 1/3 TBLR ST,SUP-2588608,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
STENT PERIPH ELUVIA L 100 MM DIA 6 MM CATH L 130 CM DIA 6 FR,SUP-2140847,CDM,C1874,HCPCS,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
SCREW EXT FIX L150MM DIA4.5MM THRD L18MM CORT S STL STR,SUP-2186966,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.73,133.72,,,,,,,,,,,,,
STEM RADIAL LG 6.5 ULN WRST MOD COCR 1ST CHOICE,SUP-2852822,CDM,C1776,CPT,0278,RC,,,,both,,,15205.23,9883.40,,,,,,,,,,,,,
ALLOGRAFT CHIP CORT CANC DEMIN 2MM - 4MM RANG 15CC,SUP-2414281,CDM,C1889,HCPCS,0278,RC,,,,both,,,760.67,494.44,,,,,,,,,,,,,
SHELL ACET SZ H DIA66MM 13 H HIP TRITANIUM HMSPHR TRIDENT,SUP-2419423,CDM,C1776,CPT,0278,RC,,,,both,,,7630.20,4959.63,,,,,,,,,,,,,
PLATE BONE LOK SM TIMAX ANTMCL ALPS LEFT NVCLR FOOT,SUP-2588780,CDM,C1713,HCPCS,0278,RC,,,,both,,,1562.12,1015.38,,,,,,,,,,,,,
RESERVOIR SHUNT LG LUMPERITON CSF 2 MTL CONN SPETZLER,SUP-2851455,CDM,C1889,HCPCS,0278,RC,,,,both,,,1109.55,721.21,,,,,,,,,,,,,
NEEDLE SUT C-13 L36.6MM 1/2 CIR REV CUT W/ NIT LOOP FOR,SUP-2122138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
MODIFIED KLS MRTN RD II PRPLE SCRWS O/R S/D SNGLE USE,SUP-2681290,CDM,C1713,HCPCS,0278,RC,,,,both,,,22563.32,14666.16,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X216 MM LT PROX 7 HOLE STRL VALCP,SUP-2789281,CDM,C1713,HCPCS,0278,RC,,,,both,,,7238.52,4705.04,,,,,,,,,,,,,
GRAFT VASC UNIV 6 MM DIAM 700 MM LEN THN WALL N TAPR N RING,SUP-2265858,CDM,C1768,CPT,0278,RC,,,,both,,,2549.68,1657.29,,,,,,,,,,,,,
DEVICE REVASCULARIZATION EMBOTRAP II L 33 MM DIA 5 MM NIT 2,SUP-2163307,CDM,C1889,HCPCS,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
CATHETER HD 2 LUMEN 14 FRX24 CM,SUP-2159456,CDM,C1750,HCPCS,0278,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
JOINT TOE 9.5 MM STS,SUP-2318976,CDM,C1776,CPT,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
KIT ACCS PRT 0 10ML GAST LO PROF APS AVG BND LAP BND,SUP-2119226,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PIN FIX ENDOBROW 2.1X5 MM STRL SONICWELD RX,SUP-2487082,CDM,C1713,HCPCS,0278,RC,,,,both,,,334.28,217.28,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2 MM 20 HOLE STAINLESS STEEL STERILE TC1,SUP-2836686,CDM,C1713,HCPCS,0278,RC,,,,both,,,1730.01,1124.51,,,,,,,,,,,,,
CATHETER ATHRCTMY L110CM OD2.5MM .018IN OVR THE WIRE LSR,SUP-2353101,CDM,C1885,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
SCREW BONE LOCKING 5.7X110 MM CORTICAL SELFDRILLING SELFTAPP,SUP-2837336,CDM,C1713,HCPCS,0278,RC,,,,both,,,2400.09,1560.06,,,,,,,,,,,,,
STEM FEM L115MM DIA13MM DST HIP TI POR STR BULL TIP MOD REV,SUP-2422100,CDM,C1776,CPT,0278,RC,,,,both,,,20849.60,13552.24,,,,,,,,,,,,,
HC US Pelvis Limited,PX-4027685700,CDM,76857,CPT,0402,RC,,,,both,,,1220.00,793.00,,,,,,,,,,,,,
CATHETER KIT 4 IN CV DL HEMSTAS VLV NDL,SUP-2120579,CDM,C1751,HCPCS,0278,RC,,,,both,,,283.23,184.10,,,,,,,,,,,,,
STEM HUM L 107 MM DSTL DIA10 MM CLLR DIA 38 MM SZ 3 TYP,SUP-2894282,CDM,C1776,CPT,0278,RC,,,,both,,,16016.14,10410.49,,,,,,,,,,,,,
CANNULA ART LNG 15 FR UNCOATED HLS,SUP-2663469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.74,619.28,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 200 CM BALLOON L 60 MM DIA 6 MM SHTH 5,SUP-2890466,CDM,C2623,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
"HC NM Lymphatics,Lymph Gland Imaging",PX-3417819500,CDM,78195,CPT,0341,RC,,,,both,,,2453.00,1594.45,,,,,,,,,,,,,
HC Revasc Lithotrip-Stent-Ather,PX-4810976700,CDM,C9767,CPT,0481,RC,,,,both,,,54207.00,35234.55,,,,,,,,,,,,,
DEVICE SUT SHFT L34CM DIA 10MM 2 JAW LD UNIT ENDOSTCH,SUP-2283124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.89,414.63,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 0.035 INX220 CM STD HYDRPHLC LAUREATE,SUP-2472876,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
BIT DRL DIA9.5MM IM FEM GEN II,SUP-2346858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,642.92,417.90,,,,,,,,,,,,,
SCREW BNE REPL BEAL TYP,SUP-2466960,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.89,113.03,,,,,,,,,,,,,
BASE CALIB REUSE VIP 5D,SUP-2123499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BIFUR 115 DEG 30MM/5MM STRL,SUP-2547478,CDM,C1713,HCPCS,0278,RC,,,,both,,,1437.05,934.08,,,,,,,,,,,,,
CAGE SPNL 17X14X5MM 5 DEG CERV LORDOSIS ZEUS,SUP-2115255,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CEMENT BNE 80GM DBL DOSE PMMA W O ANTIBIO M VISC N RADPQ LNG,SUP-2252880,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.65,394.32,,,,,,,,,,,,,
PLATE FOOT RINGFIX SYS ALUM LNG 160MM,SUP-2467928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
IMMOBILIZER SHLDR M STRP 39IN,SUP-2324218,CDM,L3650,HCPCS,0274,RC,,,,both,,,19.12,12.43,,,,,,,,,,,,,
GRAFT BNE FRZN HUM HD IMPL ALLGRFT OD43MM MATRIGRFT,SUP-2264764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2950.31,1917.70,,,,,,,,,,,,,
BUR SURG X COARSE DIAMOND 7 MM 14 CM BALL LG BOR MIDAS REX 8,SUP-2664575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,458.94,298.31,,,,,,,,,,,,,
AUGMENT ACET PART HMSPHR SZ 50 MM 20 MM THCK MULT H POR,SUP-2199311,CDM,C1776,CPT,0278,RC,,,,both,,,9168.80,5959.72,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 201-250 CM FASC,SUP-2321783,CDM,C1762,CPT,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
BUR SURG OD3MM WHT SPRL ROUTER CUT SIGN,SUP-2367529,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.45,244.69,,,,,,,,,,,,,
REAMER SURG 520 MM KIT TBNG ROD SEAL STRL RIA 2,SUP-2432237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8046.44,5230.19,,,,,,,,,,,,,
HC Unlisted Procedure Vascular Surgery,PX-3603779900,CDM,37799,CPT,0360,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
SCREW BNE STD 2.3X15 MM TI NS MAXDRIVE LEVEL 1,SUP-2464155,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.85,133.15,,,,,,,,,,,,,
PROBE ABLAT XL L180MM DIA3.5MM MAX CUT LEV 11 90-S RF AGG,SUP-2366563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
GUIDEWIRE VASC NEUROSCOUT 14 L 300 CM DSTL TIP L 43 CM DIA,SUP-2699306,CDM,C1769,HCPCS,0272,RC,,,,both,,,2850.15,1852.60,,,,,,,,,,,,,
HC Perc Balloon Valvuloplasty; Pulm Valve,PX-4819299000,CDM,92990,CPT,0481,RC,,,,both,,,15337.00,9969.05,,,,,,,,,,,,,
CATHETER CTRL VEN 5.5FR 20CM LEN SGL LUMN N TUNNELED BASIC,SUP-2383312,CDM,C1751,HCPCS,0278,RC,,,,both,,,86.04,55.93,,,,,,,,,,,,,
SCREW BNE L10MM DIA5MM S STL ST VAR ANG LOK FOR,SUP-2178690,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.17,614.36,,,,,,,,,,,,,
PLATE BNE L64MM 3 H ST DST TIB S STL T LOK COMPR FOR 35MM,SUP-2177433,CDM,C1713,HCPCS,0278,RC,,,,both,,,2209.62,1436.25,,,,,,,,,,,,,
CUBE EXT FIX UNIV 1 HOLE SALVATION,SUP-2465040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
RETRACTOR ENDOSCOPIC HAND FREE INTRACORPOREAL DUO,SUP-2880419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PURAPLY AM 6X9 CM 54SQ CM,SUP-2314119,CDM,Q4196,HCPCS,0636,RC,,,,both,,,16108.20,10470.33,,,,,,,,,,,,,
HALF PIN EXTRNL FXTN 3MM DIA SHRT 100MML STNLSS STEEL 15MML,SUP-2721920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
PLATE BONE L202MM 16 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349642,CDM,C1713,HCPCS,0278,RC,,,,both,,,2923.97,1900.58,,,,,,,,,,,,,
DILATOR ENDO BAL L8CM DIA30MM CATH L75CM DIA16FR 0.038IN,SUP-2169511,CDM,C1726,HCPCS,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
MATRIX PARTICULATE AMNIOBAND 80MG,SUP-2719486,CDM,Q4168,HCPCS,0636,RC,,,,both,,,6085.32,3955.46,,,,,,,,,,,,,
HC So Vitamin A,PX-3018459066,CDM,84590,CPT,0301,RC,,,,both,,,354.00,230.10,,,,,,,,,,,,,
PLATE BNE W17.5XL124MM THK5.2MM 7 H TI BROAD LIMIT CNTCT,SUP-2190842,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.03,616.22,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED REVERSED S3LIMA] LIMA USA],SUP-2265057,CDM,C1776,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
STEM HUM L165MM DIA10MM LNG UNIV SHLDR CO CHROM CEM REV,SUP-2193877,CDM,C1776,CPT,0278,RC,,,,both,,,11224.97,7296.23,,,,,,,,,,,,,
SPACER FEM THK10MM POST HALF DURAC,SUP-2377240,CDM,C1776,CPT,0278,RC,,,,both,,,2483.11,1614.02,,,,,,,,,,,,,
ROD SPNL THORLUM CRV PREBENT TI OD5.5MM L65MM SILVERTON,SUP-2415729,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
STEM FEM SLT 13.5X220 MM HIP BOW MOD TIV POROUS PLASMA SPRY,SUP-2204348,CDM,C1776,CPT,0278,RC,,,,both,,,12572.56,8172.16,,,,,,,,,,,,,
PLATE CRAN 200X180X40 MM PT SPEC IMPL PEEK,SUP-2860164,CDM,C1713,HCPCS,0278,RC,,,,both,,,55743.48,36233.26,,,,,,,,,,,,,
NAIL INTRAMEDULLARY SUBTALAR 7X75MM HEADLESS DYNANAIL HELIX,SUP-2878162,CDM,C1713,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
HC Cath/Intro Sal Cont Hyst,PX-3615834000,CDM,58340,CPT,0361,RC,,,,inpatient,,,445.00,289.25,,,,,,,,,,,,,
DILATOR ENDOSCP HI PRESSURE 6X20 MM BILI RADIOPAQUE MAXPASS,SUP-2460754,CDM,C1726,HCPCS,0272,RC,,,,both,,,899.08,584.40,,,,,,,,,,,,,
BIT DRILL T2 TRIFLAT 42 X 260MM,SUP-2704166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
GRAFT BNE H10MM IL CREST WDG FRZ DRY MATRIGRFT,SUP-2264642,CDM,C1762,CPT,0278,RC,,,,both,,,2061.98,1340.29,,,,,,,,,,,,,
CATHETER INFUS L135CM OD1.8FR .014IN RADPQ GLD MRK BND DSTL,SUP-2327205,CDM,C1887,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC Perc D-E Cor Revasc W Ami S,PX-4810960600,CDM,C9606,CPT,0481,RC,,,,inpatient,,,31210.00,20286.50,,,,,,,,,,,,,
BASKET STONE REMV L115CM DIA10MM SHFT 24FR URO NIT SHFT 4,SUP-2126141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,806.79,524.41,,,,,,,,,,,,,
KNIFE SURG FOR APCL COR,SUP-2356018,CDM,C1713,HCPCS,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE SM IN-LINE SEPARABLE CATH CERTAS +,SUP-2666578,CDM,C1889,HCPCS,0278,RC,,,,both,,,11914.89,7744.68,,,,,,,,,,,,,
KNOT PUSHER/ PORTAL SKID,SUP-2741731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
STAPLE BNE FIX BRIDGE L 25 X 20 X W 5 MM ULTRA NIT LP STRL,SUP-2897132,CDM,C1713,HCPCS,0278,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 3 CM SZ 12 SQCM AMNION-CHORION-AMNION,SUP-2909294,CDM,Q4137,HCPCS,0636,RC,,,,both,,,6543.67,4253.39,,,,,,,,,,,,,
TUBE VENT L7.6MM DIA1.14MM FLROPLAS PLN END BVL FOR MYR,SUP-2313661,CDM,L8699,HCPCS,0278,RC,,,,both,,,53.22,34.59,,,,,,,,,,,,,
BIT DRL CANN 8 MM FULL FLUT FOR LARDING WIRE,SUP-2767543,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.33,589.11,,,,,,,,,,,,,
HYDROCORTISONE 10 MG PO TABS,RX-3733,CDM,6370000000,HCPCS,0637,RC,60687-0582-11,NDC,,both,1,UN,7.60,4.94,,,,,,,,,,,,,
CAGE SPNL W9XH13XL21MM C FBR REINF POLYMER POST LUM INTBDY,SUP-2256177,CDM,C1889,HCPCS,0278,RC,,,,both,,,12321.93,8009.25,,,,,,,,,,,,,
BIT DRILL DIA3.5MM CANNULATED 5MM SCREW,SUP-2465630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
RONGEUR SURG KERRISON 1 MM SHRP THN FTPLT DISP,SUP-2481830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST ADJ FIT STRP W/O JT FABRICATED,SUP-2435775,CDM,L3913,HCPCS,0272,RC,,,,both,,,697.80,453.57,,,,,,,,,,,,,
TEMPLATE SURG M W5XL14MM 0DEG IM CHT FIX SYS PET ANG SZ NIT,SUP-2194205,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
INFINITY EVERLAST SZ 2 12MM TOTAL ANKLE,SUP-2822275,CDM,C1776,CPT,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
PLATE BNE SET FOR LG LOWER EXTREMITY PERI-LOC,SUP-2351391,CDM,C1713,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT CLLR BTTN FLNG L 2.1 MM LEN 1.27 MM,SUP-2381507,CDM,L8699,HCPCS,0278,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
BRACE ORTH 2X UPR SLD STIR AFO,SUP-2388168,CDM,L1990,HCPCS,0272,RC,,,,both,,,1099.75,714.84,,,,,,,,,,,,,
KIT MIC INTRO 9.5FR 2 LUMN POLYUR CATH W/ SURECUF INGROWTH,SUP-2127769,CDM,C1751,HCPCS,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
CATHETER THORACENTESIS SET 8.5 FRX15 CM 8 SIDEPRT,SUP-2760036,CDM,C1729,HCPCS,0272,RC,,,,both,,,801.77,521.15,,,,,,,,,,,,,
SCREW INTRF L35MM DIA9MM KNEE PLLA HA BIOABSRB FOR ACL PCL,SUP-2341561,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.46,602.20,,,,,,,,,,,,,
ROD IM ALIGN LCS HP,SUP-2454019,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
VALVE SHUNT CTRL FLO BUTTON PRESSURE LOW-LOW,SUP-2628267,CDM,C1889,HCPCS,0278,RC,,,,both,,,2690.35,1748.73,,,,,,,,,,,,,
PLATE BNE L21MM THK0.6MM 8MM OFFSET 5 H BILAT CHIN ORAL,SUP-2191219,CDM,C1713,HCPCS,0278,RC,,,,both,,,1213.30,788.64,,,,,,,,,,,,,
MANIFOLD 200PSI 2 PORTS R ORIENTATION AND ROT LUER SIDE OFF,SUP-2301351,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.22,8.59,,,,,,,,,,,,,
WIRE EXT FIX DLC,SUP-2473320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
CEMENT BNE 40GM PCH HI VISC CO,SUP-2196556,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
NAIL IM 10X320 MM ANK ARTH PHOENIX,SUP-2416998,CDM,C1713,HCPCS,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
SET INTRO 4FR L10CM NDL 21GA L7CM GWIRE 0018IN NIT COR,SUP-2302995,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.04,61.13,,,,,,,,,,,,,
RESERVOIR CSF FOLTZ 19 MM SINGLE DOME REINF FLAT BTM,SUP-2852580,CDM,C1889,HCPCS,0278,RC,,,,both,,,1571.48,1021.46,,,,,,,,,,,,,
TM FEM DIAPHYSEAL CONE 30 LARGE RIGHT,SUP-2502263,CDM,C1776,CPT,0278,RC,,,,both,,,10605.04,6893.28,,,,,,,,,,,,,
SWANSON TI GREAT TOE IMPL HEMI ARTHROPLASTY CLR CODE SZ SET,SUP-2397936,CDM,C1776,CPT,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
VALVE ENDOSCP ASPIR FOR BRONCHOSCOPES OES 20,SUP-2313339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,454.95,295.72,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 4H /110MM/60MM,SUP-2547501,CDM,C1713,HCPCS,0278,RC,,,,both,,,2330.95,1515.12,,,,,,,,,,,,,
RIGHT X SM DISTAL RADIAL COMP STERILE,SUP-2696160,CDM,C1776,CPT,0278,RC,,,,both,,,12012.38,7808.05,,,,,,,,,,,,,
COLLAR CERV DEFINITIVE PEDIATRIC 8-11X2 IN 2 PC,SUP-2428148,CDM,L0172,HCPCS,0272,RC,,,,both,,,173.83,112.99,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK UNIV STRL,SUP-2418088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KNIFE SURGICAL LEBSCHE STERNAL LATEX FREE,SUP-2675687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.49,287.62,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 035 IN 5 FRX130 CM 6X150 MM LP LUTONIX,SUP-2127981,CDM,C2623,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GUIDEWIRE ORTH SMOOTH 0.062X4 IN FOR SM JT,SUP-2609663,CDM,C1769,HCPCS,0272,RC,,,,both,,,203.79,132.46,,,,,,,,,,,,,
LEVEL NEURO PLATE ULTRNE X SHP WTAB NEURO SCRW4 HOLE 14 MM,SUP-2676749,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.59,535.33,,,,,,,,,,,,,
PLATE BONE LOK NON CMPRSSN HLX24 15MM THK TTNM STRGHT LVLX1,SUP-2679059,CDM,C1713,HCPCS,0278,RC,,,,both,,,2725.30,1771.44,,,,,,,,,,,,,
DESMOPRESSIN ACETATE SPRAY 0.01 % NA SOLN,RX-21135,CDM,6370000000,HCPCS,0637,RC,60505-0815-00,NDC,,both,5,ML,554.10,360.16,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 130 MM H2O HI RANG BACTISEAL,SUP-2666826,CDM,C1889,HCPCS,0278,RC,,,,both,,,8578.54,5576.05,,,,,,,,,,,,,
BLADE SAW 62.5X11.5 MM 0.64 MM 25 MM 8.7 CM LG SECT SS,SUP-2632335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.94,237.86,,,,,,,,,,,,,
LIFT HEEL MED ADJLFT,SUP-2394117,CDM,L3334,HCPCS,0272,RC,,,,both,,,38.31,24.90,,,,,,,,,,,,,
DEFIBRILLATOR IMPL GALLANT HF L 79 X W 51 X H 12 MM 37 CC 81,SUP-2889718,CDM,C1882,HCPCS,0275,RC,,,,both,,,43646.00,28369.90,,,,,,,,,,,,,
RELOAD STPLR 20 CMX5 MM JUSTRIGHT,SUP-2427768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KNIFE SURG 10MM GRFT DISP FOR ACL RECON,SUP-2249532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.21,750.89,,,,,,,,,,,,,
PLATE BNE ORBIT MED GLD,SUP-2135898,CDM,C1713,HCPCS,0278,RC,,,,both,,,2112.72,1373.27,,,,,,,,,,,,,
MORPHINE SULFATE ER 15 MG PO TBCR,RX-120979,CDM,6370000000,HCPCS,0637,RC,63304-0450-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 80 MM DIA 8 MM DEL SHTH,SUP-2934160,CDM,C1713,HCPCS,0278,RC,,,,both,,,14631.30,9510.34,,,,,,,,,,,,,
BLADE SAW THK0.015IN CUT EDGE L0.8IN D1.6IN MIC OSC AND SAG,SUP-2363669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,155.40,101.01,,,,,,,,,,,,,
SCREW CNCLLS LOK 5.3MM DIA 20MML FLLY THRDD TTNM ST ACMD,SUP-2639948,CDM,C1713,HCPCS,0278,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
PLATE BONE 90MM STR PAN FIX COND VIT,SUP-2364699,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
PLATE BNE MINI CRANIOMAXILLOFACIAL STR DBL STRP,SUP-2883254,CDM,C1713,HCPCS,0278,RC,,,,both,,,5353.01,3479.46,,,,,,,,,,,,,
STENT BILI SENTINOL L 40 MM DIA 8 MM CATH L 135 CM NIT SELF,SUP-2144563,CDM,C1876,HCPCS,0278,RC,,,,both,,,3990.16,2593.60,,,,,,,,,,,,,
CEMENT BNE 3 CC STRL FORTERA LTX,SUP-2855701,CDM,C1713,HCPCS,0278,RC,,,,both,,,5598.62,3639.10,,,,,,,,,,,,,
CATHETER EP 7FR 2-10-2MM SPC DUODECAPOLAR BIDIR SUP L CRV,SUP-2141250,CDM,C1731,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SCREW SPNL 5.5/8.2X60 MM TP OH,SUP-2175727,CDM,C1713,HCPCS,0278,RC,,,,both,,,5937.74,3859.53,,,,,,,,,,,,,
MEXILETINE HCL 150 MG PO CAPS,RX-10595,CDM,6370000000,HCPCS,0637,RC,62559-0820-01,NDC,,both,1,UN,2.90,1.88,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 75 CM OD 5 FR ID 1.7 MM 0.025IN,SUP-2633273,CDM,C1894,HCPCS,0272,RC,,,,both,,,234.53,152.44,,,,,,,,,,,,,
LEAD DEFIB 5.6FR 65CM TRNSVEN ACT FIX BPLR PERM STEROID ELUT,SUP-2356669,CDM,C1895,HCPCS,0275,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
SET INTRO PEELWY L 13 CM DIA24 FR DIL L 20 CM GUIDEWIRE,SUP-2168026,CDM,C1892,HCPCS,0272,RC,,,,both,,,183.66,119.38,,,,,,,,,,,,,
GRAFT WEDGE BNE EVANS 6MM 20X25MM BONUS,SUP-2656710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1837.53,1194.39,,,,,,,,,,,,,
HC So T Helper/Supressor Lymph,PX-3028636067,CDM,86360,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
UNIT ELECSURG 10 CM RIGID ANT 1,SUP-2105410,CDM,C1713,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
CATHETER CTRL VEN L20CM OD5FR .032IN GWIRE KT SGL LUMN N AK04212] ARROW INTERNATIONAL],SUP-2120573,CDM,C1751,HCPCS,0278,RC,,,,both,,,49.61,32.25,,,,,,,,,,,,,
PLATE BNE RECON MED 2-2.3X169X2.8 MM RT 22 HOLE TI STRL,SUP-2460103,CDM,C1713,HCPCS,0278,RC,,,,both,,,10215.68,6640.19,,,,,,,,,,,,,
ASSEMBLY NDL CVD FOR FAST-FIX MENIS REP SYS,SUP-2341568,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.27,555.28,,,,,,,,,,,,,
BLADE SAW THK0.51MM CUT EDGE L18MM D30MM CRESC OSC TPS COR,SUP-2367525,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.37,212.14,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 20X15 CM RND POLYESTER PARIETEX,SUP-2752191,CDM,C1781,HCPCS,0278,RC,,,,both,,,3847.07,2500.60,,,,,,,,,,,,,
NEEDLE SPNL 14GA L9CM DISPOSABLE TUOHY PS MED IMPL AND THER,SUP-2284399,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.53,169.99,,,,,,,,,,,,,
PAD ORTHOT LUMBAR CUST BOLSTER,SUP-2435573,CDM,L1030,HCPCS,0274,RC,,,,both,,,221.68,144.09,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 11CM 4FR 45 CM NDL 2.5 CM HYDRPHLC,SUP-2457140,CDM,C1894,HCPCS,0272,RC,,,,both,,,154.96,100.72,,,,,,,,,,,,,
NEEDLE 45DEG R ORTH SLDE,SUP-2366699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.61,572.40,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK0.4-2.4MM REGEN TISS MTRX PERF,SUP-2113012,CDM,Q4116,HCPCS,0636,RC,,,,both,,,38524.66,25041.03,,,,,,,,,,,,,
HC X-Ray Knee Standing Ap,PX-3207356500,CDM,73565,CPT,0320,RC,,,,outpatient,,,599.00,389.35,,,,,,,,,,,,,
HC Map Tachycardia Add-On,PX-4809360900,CDM,93609,CPT,0480,RC,,,,both,,,7809.00,5075.85,,,,,,,,,,,,,
CATHETER NEPHROSTOMY SET 20 FRX30 CM MCOT EXCHANGE UNIVERSA,SUP-2836212,CDM,C1729,HCPCS,0272,RC,,,,both,,,142.59,92.68,,,,,,,,,,,,,
HC Cpap/Bipap Daily,PX-4109466000,CDM,94660,CPT,0410,RC,,,,both,,,831.00,540.15,,,,,,,,,,,,,
FLUCONAZOLE 50 MG PO TABS,RX-10046,CDM,6370000000,HCPCS,0637,RC,16714-0694-01,NDC,,both,1,UN,3.60,2.34,,,,,,,,,,,,,
CARDIOPLEGIA DEL NIDO FORMULA PF SOLN,RX-148227,CDM,2500000003,HCPCS,0250,RC,71285-0202-01,NDC,,both,1052.8,ML,865.90,562.83,,,,,,,,,,,,,
KIT HIP IMPL CAPPED H3 ADV 2 MOBILITY VE LNR H3VEZIMMERBIOMET,SUP-2894032,CDM,C1776,CPT,0278,RC,,,,both,,,16171.00,10511.15,,,,,,,,,,,,,
GRAFT BIO TISS W10XL10CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2112979,CDM,Q4130,HCPCS,0636,RC,,,,both,,,9614.68,6249.54,,,,,,,,,,,,,
HC Fluid Pressure Muscle,PX-4502095000,CDM,20950,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
KIT STRNL CLOSURE NDL CUT L CONVENTIONAL 36 IN FREE 60 MM,SUP-2930413,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
HC Rp Loclzj Tum Plnr 1 Area Single Day Imaging,PX-3417880000,CDM,78800,CPT,0341,RC,,,,outpatient,,,1691.00,1099.15,,,,,,,,,,,,,
PLATE BNE 24 DEG L 48 X W 8.5 MM THK 1.6 MM 3 H SS RT DSTL,SUP-2932758,CDM,C1713,HCPCS,0278,RC,,,,both,,,3056.48,1986.71,,,,,,,,,,,,,
HANDPIECE 9GAX10CM 12MM PET DISPOSABLE EVIVA,SUP-2240011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.55,423.51,,,,,,,,,,,,,
PLUG TIB TY OFFSET ADPT TY,SUP-2405431,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CUSHION HEEL W/ BLU DOT S,SUP-2151867,CDM,L3334,HCPCS,0272,RC,,,,both,,,48.36,31.43,,,,,,,,,,,,,
PROCESSOR HEARING AID BLK CP910 NUCLS 6,SUP-2165047,CDM,L8690,HCPCS,0278,RC,,,,both,,,25104.30,16317.79,,,,,,,,,,,,,
HC Clsd Tx Shdr Disl W Neck Fx,PX-4502367500,CDM,23675,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
SCREW BONE L50MM DIA6MM CORT TI ST CANN LCK FULL THRD HEX HD,SUP-2191836,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.05,410.18,,,,,,,,,,,,,
BRACE KNEE WOM AD SM 6IN ABV MID PAT 15-18IN 6IN BELOW,SUP-2151050,CDM,L3660,HCPCS,0274,RC,,,,both,,,891.57,579.52,,,,,,,,,,,,,
KIT CATH HEMODIALYSI PWR TRIALYSI ACUTE 13FR DIA 30CML INSER,SUP-2613247,CDM,C1752,HCPCS,0278,RC,,,,both,,,896.78,582.91,,,,,,,,,,,,,
PLATE BONE L93MM 16 H CRANIOFACIAL VIT STR COND FOR 1.3MM,SUP-2364695,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PROBE LITHOTRIPSY DISPOSABLE 9FR PNEUMATIC AUTOLITH IEHL,SUP-2722576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,633.24,411.61,,,,,,,,,,,,,
STENT GRFT LPS THOR EXTEN,SUP-2277641,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.06,280.84,,,,,,,,,,,,,
HC Air Contrast Barium Enema,PX-3207428000,CDM,74280,CPT,0320,RC,,,,both,,,1815.00,1179.75,,,,,,,,,,,,,
CAGE SPNL L22XW8XH9MM 5DEG PEEK OPTMA POST LUM INTBDY FUS L,SUP-2353261,CDM,C1889,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
COMBO KT CONSISTS OF 10 150 INS 5010,SUP-2242729,CDM,C1713,HCPCS,0278,RC,,,,both,,,661.60,430.04,,,,,,,,,,,,,
PIN BONE FIX L3IN HDLSS W/O FLUT TRIATHLON,SUP-2364725,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.36,745.78,,,,,,,,,,,,,
HC Neutralizing Antibody Sars-Cov-2 Screen,PX-3008640866,CDM,86408,CPT,0300,RC,,,,both,,,82.00,53.30,,,,,,,,,,,,,
GUIDEWIRE VASC TORQ-FLEX L 150 CM DIA 0.018 IN FLX TIP L 8,SUP-2170117,CDM,C1769,HCPCS,0272,RC,,,,both,,,138.85,90.25,,,,,,,,,,,,,
COMPONENT FEM PROX KNEE STD NEUT V40 TAPR GLOB MOD REPL SYS,SUP-2376504,CDM,C1776,CPT,0278,RC,,,,both,,,12003.44,7802.24,,,,,,,,,,,,,
CANNULA ENDOSCP W/O VLV 11 MMX8.5 CM W/ INSUFFLATION GRN WHT,SUP-2767244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.72,607.57,,,,,,,,,,,,,
BIT DRILL CANNULATED AO 20X80MM,SUP-2723518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,268.03,174.22,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.035IN TIP L23CM PTFE BENT STR FIX,SUP-2302724,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.19,20.92,,,,,,,,,,,,,
MATRIX HUM TISS DIA20 MM DECELL PLCNTA MEMBRN TROPHOBLAST,SUP-2909227,CDM,Q4201,HCPCS,0636,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BNE L 2.35 X W 0.36 CM THK 0.5 MM SCREW DIA1.5 MM 6 H,SUP-2936497,CDM,C1713,HCPCS,0278,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
CATHETER EP MED CRV 7 FR THER COOL PATH,SUP-2459519,CDM,C2630,CPT,0272,RC,,,,both,,,4361.46,2834.95,,,,,,,,,,,,,
SEALER TISS L45CM ADV BPLR STR RND TIP LAP APPRCH ENSEAL,SUP-2257695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6725.94,4371.86,,,,,,,,,,,,,
PIN FIX TROCAR PT 1 END 9/64X9 IN 1 PT STYL SMOOTH PLN STRL,SUP-2150458,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.73,10.22,,,,,,,,,,,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,0636,RC,70436-0030-82,NDC,,both,10,ML,64.70,42.05,,,,,,,,,,,,,
IMPLANT HAMRTOE 35MM MID PHALANX 32MM PROX ST NEXTRA,SUP-2137577,CDM,C1713,HCPCS,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
SCREW BNE SD 1.5X4 MM CRAN STARDRV RECESS TI NS,SUP-2189245,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
DEVICE PESSARY SZ 3 SIL FIT RNG MILEX,SUP-2171769,CDM,A4562,HCPCS,0274,RC,,,,both,,,228.75,148.69,,,,,,,,,,,,,
SPLINT WRST SM L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276627,CDM,L3809,HCPCS,0272,RC,,,,both,,,23.20,15.08,,,,,,,,,,,,,
HC ER Level 2,PX-4509928200,CDM,99282,CPT,0450,RC,,,,outpatient,,,987.00,641.55,,,,,,,,,,,,,
"HC So1 N.Gonorrhea, Dna, Amp Probe",PX-3068759167,CDM,87591,CPT,0306,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
PLATE BNE MESHED MED 1.5X26X0.8 MM MIDFACE 6X2 W/ TAB STRL,SUP-2518107,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.11,695.57,,,,,,,,,,,,,
PLATE BONE L180MM 135DEG 8 H PELVIS BILAT S STL STD BRL RIG,SUP-2342588,CDM,C1713,HCPCS,0278,RC,,,,both,,,4934.20,3207.23,,,,,,,,,,,,,
ANCHOR SUT DIA55MM PEEK OPTMA POLYMER 3 NO2 MAXBRAID W O,SUP-2212837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
STAPLER INT STPL L53MM 4X6.6MM 4.3MM CLSR TAN LACTOMER STD,SUP-2283019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.63,1106.06,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 7FR 0.035IN POLYPRO TBNG SS,SUP-2677200,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X79 MM RT LAT DSTL 3 HOLE STRL VALCP,SUP-2789386,CDM,C1713,HCPCS,0278,RC,,,,both,,,2694.12,1751.18,,,,,,,,,,,,,
NAIL INTRMDLLRY 9MM DIA 320MML TTNM ALLOY FMRL RTRGRDE TRGTN,SUP-2587317,CDM,C1713,HCPCS,0278,RC,,,,both,,,5446.74,3540.38,,,,,,,,,,,,,
COMPONENT KNEE FEMORAL PERSONA CEMENTED UNICOMPARTMENTAL CONSTRAINED,SUP-2212240,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM BIOCRYL RAPIDE ABSRB 3 DYNACORD SZ 2,SUP-2256651,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
BUR SURG ACORN 5 MMX10 CM FLUT SM BOR MIDAS REX LEGEND,SUP-2627608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.99,211.89,,,,,,,,,,,,,
CAGE SPNL L12XW12XH30MM 4 LOBE LORDTC END CAP IMP NGAGE,SUP-2317734,CDM,C1889,HCPCS,0278,RC,,,,both,,,12377.88,8045.62,,,,,,,,,,,,,
CATHETER URET PED 3FR L70CM,SUP-2168914,CDM,C1758,HCPCS,0278,RC,,,,both,,,189.66,123.28,,,,,,,,,,,,,
BUR SURG DIA 5 MM HUB II TUNGSTEN CARBIDE ROSEN STRL DISP,SUP-2929580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.44,314.89,,,,,,,,,,,,,
CATHETER TRAY SINGLE LUMEN 4 FR MAXIMAL BARR PRB POWERPICC,SUP-2125508,CDM,C1751,HCPCS,0278,RC,,,,both,,,1015.66,660.18,,,,,,,,,,,,,
SCREW BNE DISTRCTN 14 MM STRL,SUP-2430771,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5 ML BIOACTIVE FOAM PK VITOSS BA BIMODAL,SUP-2637054,CDM,C1889,HCPCS,0278,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
FLANGE ACET PAR 5 SH W,SUP-2403454,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SPLINT ORTH COTATION HUM ARM,SUP-2388194,CDM,L3980,HCPCS,0272,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
PUSHER KNOT SUT CUT SLED DISP AIR,SUP-2372186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,839.95,545.97,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR ENTERRA II,SUP-2930513,CDM,C1767,HCPCS,0278,RC,,,,both,,,52595.00,34186.75,,,,,,,,,,,,,
LEAD PACE L90CM 2X8 SPEC SURESCAN MRI,SUP-2284651,CDM,C1778,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
HC Electron Microscopy Diagnostic,PX-3128834800,CDM,88348,CPT,0312,RC,,,,both,,,1815.00,1179.75,,,,,,,,,,,,,
PIN HALF FIXATION M5 L200MM THREAD L30MM STAINLESS STEEL,SUP-2586487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.38,366.85,,,,,,,,,,,,,
SET APPLICATOR LOCALIZER-S 20 5 CM,SUP-2657246,CDM,A4648,CPT,0278,RC,,,,both,,,17741.00,11531.65,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-JEJUNAL 16 FRX30 CM 1.5 CM 3-5 CC,SUP-2764494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1055.20,685.88,,,,,,,,,,,,,
HC Imm Admn Sarscov2 Vaccine 1st/Only Component,PX-7719048000,CDM,90480,CPT,0771,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
HC Blood Type Antigen Donor Ea,PX-3008690200,CDM,86902,CPT,0300,RC,,,,both,,,153.00,99.45,,,,,,,,,,,,,
JOINT FNGR CRPL LUNATE 4 TI SWNSN,SUP-2535900,CDM,C1776,CPT,0278,RC,,,,both,,,11159.56,7253.71,,,,,,,,,,,,,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-135985,CDM,Q5103,HCPCS,0636,RC,00069-0809-01,NDC,,both,1,UN,2791.60,1814.54,,,,,,,,,,,,,
SCREW BNE CANN 60 MM CANC SCFE NS LTX,SUP-2861118,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.42,542.37,,,,,,,,,,,,,
HC Peritoneal Lavage W/WO Imaging Guidance,PX-4504908400,CDM,49084,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
GRAFT HUM TISS L 150 MM FIB SHFT LYOPH,SUP-2913308,CDM,C1762,CPT,0278,RC,,,,both,,,5115.06,3324.79,,,,,,,,,,,,,
BUR ENDOSCP RND SITELINE STRL UNIDRIVE DISP,SUP-2585908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,254.62,165.50,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.4MM PARTIALLY THRD HD SM CANN,SUP-2225320,CDM,C1713,HCPCS,0278,RC,,,,both,,,619.84,402.90,,,,,,,,,,,,,
CANNULA SUCTION L245MM DIAMETER 3MM DEBAKEY TIP,SUP-2806702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.48,248.61,,,,,,,,,,,,,
PLATE BNE W7XL39MM THK1MM 5 H BILAT TI 1/4 TBLR RIG,SUP-2191003,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.92,214.45,,,,,,,,,,,,,
HC So Lysozyme,PX-3058554966,CDM,85549,CPT,0305,RC,,,,both,,,614.00,399.10,,,,,,,,,,,,,
KIT INSTR DRL STRL DISP MINIBUNION,SUP-2893454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
INVISION  TIBIAL TRAY TRIAL SZ 3 4MM,SUP-2469798,CDM,C1776,CPT,0278,RC,,,,both,,,1557.44,1012.34,,,,,,,,,,,,,
REAMER SURG DIA25MM PAT BLDE BIT PFC SIG,SUP-2253897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 1 PLATE CUSTOMIZED FACE ID,SUP-2883364,CDM,C1713,HCPCS,0278,RC,,,,both,,,32394.47,21056.41,,,,,,,,,,,,,
IRRIGATOR SURG DIA8MM SUCT ENDOWRIST,SUP-2246796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.96,568.07,,,,,,,,,,,,,
SCREW BNE L16MM DIA13MM G CORT TI ALLY ST SELF RET W T4,SUP-2180970,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.72,76.52,,,,,,,,,,,,,
INTRODUCER 10FR PEEL AWAY 6091] ABBOTT VASCULAR],SUP-2105937,CDM,C1892,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SET VASC ACCS 4FR L10CM S STL PLAT TIP 0.018IN NDL 21GA,SUP-2170543,CDM,C1894,HCPCS,0272,RC,,,,both,,,68.36,44.43,,,,,,,,,,,,,
GUIDEWIRE VASC TORX L 80 CM DIA 0.018 IN TIP 5 CM NIT PERIPH,SUP-2226011,CDM,C1769,HCPCS,0272,RC,,,,both,,,311.68,202.59,,,,,,,,,,,,,
STRAP CLAV SM 3 W HK,SUP-2428149,CDM,L3650,HCPCS,0274,RC,,,,both,,,17.62,11.45,,,,,,,,,,,,,
BIT DRL L40MM DIA2MM SLD SIDE CUT FOR GEMINUS VOLAR DST RAD,SUP-2340179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
TIP FLO PHACO 30DEG CVD INF SL 20GA LAM,SUP-2247715,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
HC Pt Prosthetic Training 15 Min,PX-4209776100,CDM,97761,CPT,0420,RC,,,,inpatient,,,135.00,87.75,,,,,,,,,,,,,
HOLDER PIN 16X11CM M TRAC BOHLER STNMN,SUP-2197324,CDM,C1713,HCPCS,0278,RC,,,,both,,,493.92,321.05,,,,,,,,,,,,,
BLADE LARYNSCP UNIV EMER CLD LT DORGES,SUP-2261361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SCREW BNE SELF DRILLING 1.2X5 MM,SUP-2435296,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.19,140.52,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 110 CM DIA 7 FR SPC,SUP-2356887,CDM,C1730,HCPCS,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
FIBER LASER FOR YAG,SUP-2225711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
HC Allo Stem Cell Collection,PX-8153820500,CDM,38205,CPT,0815,RC,,,,both,,,4740.00,3081.00,,,,,,,,,,,,,
PACEMAKER CARD PERCEPTA QUAD MRI SURESCAN W 46.5 X H 59 MM D,SUP-2282510,CDM,C2621,HCPCS,0275,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 0 PREMI NEONATAL FIBEROPTIC MRI,SUP-2309344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GRAFT BNE WDG 12X20 MM CORTICAL TANGENT,SUP-2335445,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
BRACE ORTHOPEDIC MED FT SPLNT MULT PODUS,SUP-2332643,CDM,L4396,HCPCS,0274,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
WEDGE TIB SZ 5-6 10MM KNEE REV FULL STP LEGION,SUP-2346593,CDM,C1776,CPT,0278,RC,,,,both,,,4603.24,2992.11,,,,,,,,,,,,,
SHEATH INTRO CHARIOT L 65 CM DIA 7 FR STR TIP XCUT LG LUMEN,SUP-2140079,CDM,C1894,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
SCREW BONE L15MM DIA2.3MM CRANIOMAXILLOFACIAL TI CROSSDRIVE,SUP-2262621,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.72,55.07,,,,,,,,,,,,,
SPACER TIB L12MM SM DURAMER SL GRDIAN,SUP-2304390,CDM,C1776,CPT,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
CABLE CONN THER 2 8,SUP-2357459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC So Immunoassayanalytenos,PX-3018352066,CDM,83520,CPT,0301,RC,,,,both,,,170.00,110.50,,,,,,,,,,,,,
FIB NAIL 1503185,SUP-2843405,CDM,C1713,HCPCS,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
BUR SURG L 125 MM DIA2.35 MM HD DIA 4 MM DIAMOND NS REUSE,SUP-2929276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.70,218.85,,,,,,,,,,,,,
SHUNT SURG SM 90 CM PERF LEVEL 1.0 SNAP DELT,SUP-2665033,CDM,C1729,HCPCS,0272,RC,,,,both,,,5954.54,3870.45,,,,,,,,,,,,,
CATHETER SURG RETRV OD7-6FR BAL OD9-12MM GWIRE 0.035IN INJ,SUP-2141491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
BIT DRL L195MM DIA3.2MM 3 FLUT QUIK CPL W/O STP REUSE FOR E,SUP-2187593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.45,265.49,,,,,,,,,,,,,
NEEDLE NAVIGATION SPINE TRCR TIP K WIRE INSRT CANNUALTED,SUP-2364162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.46,624.30,,,,,,,,,,,,,
SYSTEM BECKER W BLUE STRIPED TBNG AND SMRTSITE NDLLSS INJ,SUP-2284408,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.88,348.97,,,,,,,,,,,,,
PLATE RAD HD RIM 2.4MM 4H RT TI LCP,SUP-2549710,CDM,C1713,HCPCS,0278,RC,,,,both,,,2017.20,1311.18,,,,,,,,,,,,,
PLATE BNE H0.6MM 8 H STD UP FACE G TI STR LEIBINGER UNIV 2,SUP-2366266,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.68,543.19,,,,,,,,,,,,,
WEDGE OSTEOTMY L6CM W3CM H1.75CM ASEP FRZ DRY,SUP-2320325,CDM,C1776,CPT,0278,RC,,,,both,,,4678.60,3041.09,,,,,,,,,,,,,
NCB PP DF PLATE PROVISION 912H,SUP-2720671,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
ROCURONIUM BROMIDE 50 MG/5ML IV SOSY,RX-135030,CDM,2500000003,HCPCS,0250,RC,71266-2002-01,NDC,,both,5,ML,58.50,38.02,,,,,,,,,,,,,
Z DUP USE 2111325 LENS INTOCU +20.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111326,CDM,V2632,HCPCS,0276,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
KIT INTRO MAK L 10 CM DIA 4 FR COAX DIL PR STRL,SUP-2303002,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
BASKET RETRV 7 FRX65 CM URETHRA,SUP-2139588,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
BOOT ORTHOT M SMOOTH IN BD AFO SOFTPRO,SUP-2324237,CDM,L4387,HCPCS,0274,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
COVER BURR H DIA 7 MM THK 0.5 MM SCREW DIA1.7 MM CRAN STRL,SUP-2909602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1659.80,1078.87,,,,,,,,,,,,,
SCREW BNE L85MM DIA10.5MM LAG FOR AFFIXUS HIP FRAC NAIL SYS,SUP-2413328,CDM,C1713,HCPCS,0278,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
ELECTRODE ENDO MPLR KNF DISP 27FR,SUP-2261171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.71,288.41,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 40MM X 20MM X 5MM,SUP-2547188,CDM,C1713,HCPCS,0278,RC,,,,both,,,3347.30,2175.74,,,,,,,,,,,,,
VALVE AORT SUTURELESS PERCEVAL,SUP-2352662,CDM,C1889,HCPCS,0278,RC,,,,both,,,28888.00,18777.20,,,,,,,,,,,,,
CATHETER INTVASC OCCL L 65 CM DIA 8 FR BALLOON DIA27 MM SHTH,SUP-2141026,CDM,C1725,HCPCS,0272,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
SYSTEM SPNL SEAL 3ML EXACT DURASEAL,SUP-2243115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2459.06,1598.39,,,,,,,,,,,,,
PLATE BNE L 147 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 10 72466410,SUP-2932978,CDM,C1713,HCPCS,0278,RC,,,,both,,,5665.19,3682.37,,,,,,,,,,,,,
ELECTRODE ABLAT STARBURST 15,SUP-2118717,CDM,C1819,HCPCS,0278,RC,,,,both,,,5818.42,3781.97,,,,,,,,,,,,,
DEVICE TARGET FT ANK RADLUC,SUP-2371636,CDM,C1713,HCPCS,0278,RC,,,,both,,,789.08,512.90,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 28CM 2,SUP-2613278,CDM,C1750,HCPCS,0278,RC,,,,both,,,7418.25,4821.86,,,,,,,,,,,,,
INSERT TIB THK 11 MM SZ 3 HINGE REV STRL TRIATHLON,SUP-2889771,CDM,C1776,CPT,0278,RC,,,,both,,,7986.43,5191.18,,,,,,,,,,,,,
MESH HERN L15.2XW7.6CM POLYPR ABD ABSRB RECTANG SEPRAMESH,SUP-2125922,CDM,C1781,HCPCS,0278,RC,,,,both,,,644.64,419.02,,,,,,,,,,,,,
SET FILTER DEL VENATECH LP L 96 CM DIA 9 FR GUIDEWIRE 0.038,SUP-2492090,CDM,C1894,HCPCS,0272,RC,,,,both,,,794.39,516.35,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM THK.8-1.4MM ACELLULAR DERM MTRX,SUP-2402519,CDM,Q4126,HCPCS,0636,RC,,,,both,,,8022.70,5214.75,,,,,,,,,,,,,
TUBE FEED 18FR CLR SIL GASTRO ENTERIC EXT RETEN RNG JEJU,SUP-2124601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.92,367.20,,,,,,,,,,,,,
DRILL SURG 1.8MM FLEX DISP FOR Q-FIX ALL-SUTURE ANCHR,SUP-2341146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,566.83,368.44,,,,,,,,,,,,,
TROCAR LAP TIP L12MM BLNT DISP SPCMKR,SUP-2283315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.24,351.81,,,,,,,,,,,,,
CROWN DENT LR2 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176708,CDM,D6783,CPT,0278,RC,,,,both,,,23.33,15.16,,,,,,,,,,,,,
GRAFT HUM TISS HUM SHFT STRUCTURAL FRZ DRY,SUP-2165582,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
PLATE BNE L165MM 14 H BILAT S STL STR RECON NONLOCKING,SUP-2197679,CDM,C1713,HCPCS,0278,RC,,,,both,,,1345.43,874.53,,,,,,,,,,,,,
STEM HUM L100MM DIA9MM LNG UNIV SHLDR CO CHROM HA CEM PRI,SUP-2388646,CDM,C1776,CPT,0278,RC,,,,both,,,8082.36,5253.53,,,,,,,,,,,,,
BURR FLUTED MATCHSTICK 3.0MM ANSPACH MA158NS,SUP-2843305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.83,398.34,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CMNTLS DURAC SCORP,SUP-2365624,CDM,C1776,CPT,0278,RC,,,,both,,,14974.82,9733.63,,,,,,,,,,,,,
TRIAL SPNL L21MM ANTR LUM INSTR,SUP-2291673,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
TWIST DRILL 2.2MM DIA X 70MM CYLINDRICAL,SUP-2491655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.09,263.31,,,,,,,,,,,,,
LINER ACET OD58MM ID32MM 10DEG 6MM OFFSET ECC HIP POLYETH,SUP-2379047,CDM,C1776,CPT,0278,RC,,,,both,,,1371.14,891.24,,,,,,,,,,,,,
GRAFT BNE TISS DBM SYNERGENT 6300001] EXACTECH INC],SUP-2223570,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC BONEPLAST,SUP-2424581,CDM,C1713,HCPCS,0278,RC,,,,both,,,2546.54,1655.25,,,,,,,,,,,,,
STAPLE KIT 20X20 MM STRL INSTAFIX LTX DISP,SUP-2857583,CDM,C1713,HCPCS,0278,RC,,,,both,,,4625.22,3006.39,,,,,,,,,,,,,
HC Remove Vad Different Session,PX-3603399200,CDM,33992,CPT,0360,RC,,,,inpatient,,,5261.00,3419.65,,,,,,,,,,,,,
SET VASC SNR MULTI-SNARE L 125 CM DIA10 MM INTRO L 105 CM,SUP-2125281,CDM,C1773,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SUPPORT ORTHOT CUST RNG MOL PLAS LTHR,SUP-2435582,CDM,L1110,HCPCS,0272,RC,,,,both,,,901.46,585.95,,,,,,,,,,,,,
DEVICE SUCT TBNG L244CM IRRIG LN L61CM DIR OLY FUJINON,SUP-2360653,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.25,225.71,,,,,,,,,,,,,
CATHETER ABLATN 4 MM SPC LNG REACH CELSIUS D7BTG5L,SUP-2468224,CDM,C1732,HCPCS,0272,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
HEAD FEM STD 42 MM COCR,SUP-2217242,CDM,C1776,CPT,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
PLATE CUTTING PLIERS XS S M L,SUP-2695625,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
PLATE BNE THK15MM REG 6 H LOK ANG FOR 27MM SCR THREADLOCK,SUP-2262969,CDM,C1713,HCPCS,0278,RC,,,,both,,,2578.94,1676.31,,,,,,,,,,,,,
NAIL IM L26CM DIA12MM TIBIOTALOCALCANEAL NIT DYNANAILXL,SUP-2277458,CDM,C1713,HCPCS,0278,RC,,,,both,,,58859.30,38258.54,,,,,,,,,,,,,
TRAY GLEN SM SHLDR POR MOD BIOMOD,SUP-2404669,CDM,C1776,CPT,0278,RC,,,,both,,,4465.08,2902.30,,,,,,,,,,,,,
PAIN PMP,SUP-2363223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
GRAFT BNE SUB 1CC DBM FRZ DRY PTTY GRFTON,SUP-2294014,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 135 CM BALLOON L 100 MM DIA10 MM,SUP-2140536,CDM,C1725,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH LG 0.6 MM CRESCENT SLV NS,SUP-2859907,CDM,C1713,HCPCS,0278,RC,,,,both,,,3779.30,2456.54,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0250,RC,00990-7922-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
PLATE BNE L44MM THK1.3MM 2X6 H CNDYL HND 316L S STL VAR ANG,SUP-2178038,CDM,C1713,HCPCS,0278,RC,,,,both,,,1784.40,1159.86,,,,,,,,,,,,,
GRAFT FIBULA SEGMENT ALLOGRAFT FROZEN,SUP-2863661,CDM,C1762,CPT,0278,RC,,,,both,,,6236.04,4053.43,,,,,,,,,,,,,
MORCELLATOR HYSTEROSCOPIC 10MM CUT WIND 5MM DST FOR 80 SYS,SUP-2172310,CDM,C1782,HCPCS,0272,RC,,,,both,,,2383.95,1549.57,,,,,,,,,,,,,
INSERT TIB SZ 4 THK20MM KNEE GVF POLYETH STBL ROT PLATFRM,SUP-2253721,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR ROPT EPIC DR,SUP-2356538,CDM,C1721,HCPCS,0275,RC,,,,both,,,53270.10,34625.56,,,,,,,,,,,,,
HC Intraosseous Needle Placement (ED),PX-4503668000,CDM,36680,CPT,0450,RC,,,,both,,,954.00,620.10,,,,,,,,,,,,,
CROWN DENT STRP L2 PEDIATRIC LOWER CUSPID,SUP-2119363,CDM,D6783,CPT,0278,RC,,,,both,,,12.53,8.14,,,,,,,,,,,,,
MESH HERN 15X15CM MACROPOROUS ULTRAPRO ADV,SUP-2257824,CDM,C1781,HCPCS,0278,RC,,,,both,,,361.57,235.02,,,,,,,,,,,,,
ANCHOR SUTURE PRE LD 2-0 6.5 MM TWO STRND POLYESTER,SUP-2608438,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.46,283.05,,,,,,,,,,,,,
DISTRACTION INTRNL DIST LFRT 1 ZRCH 2 LFT 1.5 1.8 MM SCRW20,SUP-2499089,CDM,C1713,HCPCS,0278,RC,,,,both,,,15052.19,9783.92,,,,,,,,,,,,,
CATHETER GUID MP1 AD 0.071 INX6 FRX55 CM LG LUMEN LAUNCHER,SUP-2281127,CDM,C1887,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H XLN TI NEURO STR PLT SD HI,SUP-2935804,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
DYNAFORCE IS A NIT SUPERELASTIC BONE STPL FOR USE IN SURG,SUP-2175163,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE BNE 5MM MED OSTEOTMY WDG,SUP-2400259,CDM,C1713,HCPCS,0278,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
STEM FEM CEM LO OFFSET FORGED CO CHROM SZ 1 ACUMATCH C SER,SUP-2221723,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PLATE BONE LOK SHRT 74MML HLX3 PRPLE ST LEFT MED DST HMRL,SUP-2463028,CDM,C1713,HCPCS,0278,RC,,,,both,,,2401.10,1560.71,,,,,,,,,,,,,
CUTTER SURG L8CM OD4MM AGG MICRODEBRIDER ESSX,SUP-2363535,CDM,2720000010,LOCAL,0272,RC,,,,both,,,402.52,261.64,,,,,,,,,,,,,
PACEMAKER CARD INSIGNIA I ULTRA W 4.45 X H 5.02 CM THK 0.75,SUP-2148606,CDM,C1785,HCPCS,0275,RC,,,,both,,,19254.48,12515.41,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X52 MM 6 HOLE TI,SUP-2464010,CDM,C1713,HCPCS,0278,RC,,,,both,,,380.25,247.16,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 76 X 61 X 19 MM SM POLYETHYL LT TEMPORAL,SUP-2934456,CDM,C1713,HCPCS,0278,RC,,,,both,,,6126.14,3981.99,,,,,,,,,,,,,
BLADE SAW COARSE TOOTH MIC 55X27X0.4 MM SAG,SUP-2607441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
WALKER POSTOP SM AD F ANK BILAT FIX UNISX TRAUM MAXTRAX,SUP-2197140,CDM,L4350,HCPCS,0272,RC,,,,both,,,83.15,54.05,,,,,,,,,,,,,
PLATE BNE L370MM BLDE W48XL25MM 95DEG 22 H ST HIP S STL RIG,SUP-2186776,CDM,C1713,HCPCS,0278,RC,,,,both,,,4975.68,3234.19,,,,,,,,,,,,,
DEVICE INT FIX 50 MM POLYURETHANE ENDOBUTTON CL,SUP-2341709,CDM,C1713,HCPCS,0278,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
CAGE SPINE VBR PEEK SMALL 9MM,SUP-2665180,CDM,C1889,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
PLATE BNE 5MM R CRANIOMAXILLOFACIAL CP TI 1 LEV FOR 2MM SCR,SUP-2262503,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.68,563.99,,,,,,,,,,,,,
FOLLOWER URETH 12FR L35.5CM DIL W/O SIDEPRT PHILIPS,SUP-2171273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,106.70,69.35,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION LNG CABLE ANGLED PLASMALOOP,SUP-2470110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1593.55,1035.81,,,,,,,,,,,,,
CAGE SPNL INTBDY 7 DEG 18X15X12 MM NS SHORELINE ACS,SUP-2245768,CDM,C1889,HCPCS,0278,RC,,,,both,,,2151.31,1398.35,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.509,SUP-2860026,CDM,C1713,HCPCS,0278,RC,,,,both,,,37328.63,24263.61,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA 8 MM EPTFE FLX TW RING HEMO,SUP-2126889,CDM,C1768,CPT,0278,RC,,,,both,,,2353.37,1529.69,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 135 CM BALLOON L 20 MM DIA 6,SUP-2141992,CDM,C1725,HCPCS,0272,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
AGENT HEMSTAT W4XL4IN OXIDIZED REGENERATED CELOS STRUCTURED,SUP-2218215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.23,227.00,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL HEARTSPAN DIA18 GA STRL,SUP-2457165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X76 MM 9 HOLE TI,SUP-2536118,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.81,280.03,,,,,,,,,,,,,
DOUBLE DRILL GUIDE COMPR/NEUTR 32MM,SUP-2705030,CDM,C1713,HCPCS,0278,RC,,,,both,,,2924.22,1900.74,,,,,,,,,,,,,
HC Ins Cath Ren Art 1st Unilat,PX-3613625100,CDM,36251,CPT,0361,RC,,,,inpatient,,,10063.00,6540.95,,,,,,,,,,,,,
ANCHOR SUT 5.5MM PEEK SELF PUNCHING HEALIX ADV SP,SUP-2418578,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 9X2 CM ROUNDED BOV PERICARD PHOTOFIX LTX,SUP-2859716,CDM,C1768,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ENDCAP SPNL EXT 0 DEG 20X30 MM T2 STRATOSPHERE,SUP-2423277,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
BASKET STONE RETRV L90CM DIA12MM SHTH 2.4FR NIT POLYIMIDE,SUP-2139277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.94,416.61,,,,,,,,,,,,,
CATHETER HD SWAN NK PEDIATRIC 43 CM CURL CATH 2 CUF ARGY,SUP-2626971,CDM,C1750,HCPCS,0278,RC,,,,both,,,321.44,208.94,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 7 FRX22 CM 6 FR DBL PGTL CNTOUR,SUP-2490283,CDM,C2617,HCPCS,0278,RC,,,,both,,,415.08,269.80,,,,,,,,,,,,,
PLATE BNE L 311 MM SCREW DIA 3.5/4.5 MM 12 H LT,SUP-2931217,CDM,C1713,HCPCS,0278,RC,,,,both,,,21708.39,14110.45,,,,,,,,,,,,,
PLATE BNE W4XL50MM THK1MM 3X9 H BILAT TI T SHP RIG,SUP-2191142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1329.13,863.93,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 7 CM DIA12 MM SHTH L 45 CM,SUP-2395801,CDM,C1768,CPT,0278,RC,,,,both,,,9460.82,6149.53,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK4-5MM EXTRA ULT THCK HYDRATED,SUP-2307503,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5159.18,3353.47,,,,,,,,,,,,,
HC Hemoglobin Glycosylated A1c,PX-3018303600,CDM,83036,CPT,0301,RC,,,,both,,,141.00,91.65,,,,,,,,,,,,,
TUBE TRACH AD SZ 6 SPECIALIZED CUF SHILEY,SUP-2172420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CATHETER DIAG SHFT L70CM DIA5FR 0.035IN SEG 2CM PLAT BND,SUP-2118525,CDM,C1887,HCPCS,0272,RC,,,,both,,,74.70,48.55,,,,,,,,,,,,,
HC Remove FB Foot,PX-4502819300,CDM,28193,CPT,0450,RC,,,,both,,,1649.00,1071.85,,,,,,,,,,,,,
GRAFT HUM TISS 132 SQ CM THK2-2.8MM THCK M PERF CNTOUR ACELLULAR DERM,SUP-2113057,CDM,Q4116,HCPCS,0636,RC,,,,both,,,15891.54,10329.50,,,,,,,,,,,,,
PLATE BNE L42MM STD 2X2 H NONSTERILE BILAT 1ST MTP FUS S,SUP-2184832,CDM,C1713,HCPCS,0278,RC,,,,both,,,2852.31,1854.00,,,,,,,,,,,,,
FIBER LASER L3050MM COR DIA750UM GRN LT MOXY,SUP-2139479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4974.67,3233.54,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM DIA 0.018 IN TIP L 3 MM PTFE,SUP-2301920,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.53,21.14,,,,,,,,,,,,,
PLATE BNE L 71 MM SCREW DIA 3.5 MM 4 H SS RT PROX,SUP-2931194,CDM,C1713,HCPCS,0278,RC,,,,both,,,4213.57,2738.82,,,,,,,,,,,,,
CATHETER EP 6FR L125CM 5MM SPC POLYUR QPLR FIX 200574,SUP-2142208,CDM,C1725,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
FEEDING TUBE KIT LP 16 FRX4 CM BLLN BUTTON MINI1,SUP-2754598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.61,423.55,,,,,,,,,,,,,
STEM FEM SZ 8 STD HIP HA AMISTEM-H,SUP-2267266,CDM,C1776,CPT,0278,RC,,,,both,,,12434.40,8082.36,,,,,,,,,,,,,
PLATE BONE W7XL63MM THK1MM 8 H S STL QTR TBLR NONCOMPRESSION,SUP-2343853,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.54,498.90,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT REMOVABLE UCB TYP BERK SHELL,SUP-2435700,CDM,L3000,HCPCS,0272,RC,,,,both,,,889.37,578.09,,,,,,,,,,,,,
MESH SURG W20XL25CM SEPRA TECHNOLOGY RECT PHASIX,SUP-2125884,CDM,C1781,HCPCS,0278,RC,,,,both,,,23675.60,15389.14,,,,,,,,,,,,,
PLATE BONE SZ 10 DSTL RADIOULNAR JT LCK ASMBLY,SUP-2119921,CDM,C1713,HCPCS,0278,RC,,,,both,,,15502.18,10076.42,,,,,,,,,,,,,
CLIP ANEUR W3MM DIA5MM GRFT SLIM LN,SUP-2183272,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.49,113.42,,,,,,,,,,,,,
WEDGE FEM SZ 5 THK5MM STD UNIV DST KNEE PRI PRESSFIT CEM,SUP-2346329,CDM,C1776,CPT,0278,RC,,,,both,,,3774.28,2453.28,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4409753000,CDM,97530,CPT,0440,RC,,,GO|KX|CO|XU,both,,,191.00,124.15,,,,,,,,,,,,,
PLATE BNE THK0.6MM BAR L8MM 100DEG 5 H R,SUP-2366300,CDM,C1713,HCPCS,0278,RC,,,,both,,,607.37,394.79,,,,,,,,,,,,,
GRAFT BNE L40MM OD24MM CORT FRZ DRY PIN IMPL ALLOFIX,SUP-2307227,CDM,C1713,HCPCS,0278,RC,,,,both,,,805.63,523.66,,,,,,,,,,,,,
INQUIRY 6F STEER OCT 1108 6 25 L1 BD TE2BE1SOFT,SUP-2698831,CDM,C1730,HCPCS,0272,RC,,,,both,,,1576.28,1024.58,,,,,,,,,,,,,
BLADE SURG NO64 S STL SATIN FINISH MINIATURE EDGE ROUNDED,SUP-2161434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,27.51,17.88,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 7 FRX20 CM 3L DRY SPECTRUM,SUP-2759881,CDM,C1751,HCPCS,0278,RC,,,,both,,,506.92,329.50,,,,,,,,,,,,,
GRAFT HUM TISS D EYE AMINOGRFT,SUP-2135255,CDM,V2790,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X92 MM LT LAT DSTL 4 HOLE NS VA-LCP,SUP-2758194,CDM,C1713,HCPCS,0278,RC,,,,both,,,2545.54,1654.60,,,,,,,,,,,,,
BIT DRL DIA2.4MM DISP FOR GRIDLOCK SCR,SUP-2390570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
AMINO ACID 15 % IV SOLN,RX-23068,CDM,2500000003,HCPCS,0250,RC,00338-0502-06,NDC,,both,2000,ML,759.00,493.35,,,,,,,,,,,,,
APPLICATOR THERMOABLATION L14CM 140W SLD STATE GENRTR INTEGR,SUP-2118730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11423.32,7425.16,,,,,,,,,,,,,
SCREW BN MTRXMDF 2X6MM SLFTP,SUP-2837732,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
PLATE BNE L168MM THK3.7MM 8 H NONSTERILE R DST MED TIB S,SUP-2185529,CDM,C1713,HCPCS,0278,RC,,,,both,,,3820.88,2483.57,,,,,,,,,,,,,
COLLAR CERV XL H3XL20IN AD CLS TRACH HK AND LOOP CLSR CNTOUR,SUP-2194433,CDM,L0120,HCPCS,0272,RC,,,,both,,,17.87,11.62,,,,,,,,,,,,,
PIN NAVIGATION L100MM OD3MM S STL STRL DISP,SUP-2364170,CDM,C1713,HCPCS,0278,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
HINGE EXT FIX INLINE 100 MM NS TRUELOK LTX,SUP-2875015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.31,565.05,,,,,,,,,,,,,
BOLT IM L42MM DIA3.9MM BLU TI ALUM NIOBIUM TRCR TIP ST LOK,SUP-2192196,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.02,389.36,,,,,,,,,,,,,
CATH GD MP1 SH 7FR 100CM WSGD,SUP-2142141,CDM,C1887,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA10.5 FR MULTPURP STRL,SUP-2168536,CDM,C1892,HCPCS,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
REAMER SURG DIA7MM PILOTED HD FOR ALL ARTHSCP PROX BICEP,SUP-2121314,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
CUBE EXT FIX 40 MM UBER,SUP-2898449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
COMPONENT HIP 24 MM LT TRIFLANGE,SUP-2212615,CDM,C1776,CPT,0278,RC,,,,both,,,34226.00,22246.90,,,,,,,,,,,,,
CATHETER THERMODILUTION 7.5 FRX110 CM CO SVO2 SWN GZ,SUP-2214318,CDM,C1751,HCPCS,0278,RC,,,,both,,,623.51,405.28,,,,,,,,,,,,,
TUBE EXT FIX DIA20MM BLU DYN FOR MONOTB TRIAX SYS,SUP-2372604,CDM,C1713,HCPCS,0278,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
GRAFT HUM TISS SPACER 22X8X13/10.6 MM FRZN POST LUMBAR,SUP-2306881,CDM,C1713,HCPCS,0278,RC,,,,both,,,8193.92,5326.05,,,,,,,,,,,,,
INTRODUCER PEEL AWAY 9FRX45CM,SUP-2357106,CDM,C1892,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
NUT ORTH 5 MM CORTICAL SCR HEX SOCKET NS LCP,SUP-2184944,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.63,281.86,,,,,,,,,,,,,
HC X-Ray Specimen,PX-3207609800,CDM,76098,CPT,0320,RC,,,,outpatient,,,566.00,367.90,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W12XL12CM THK1.04 2.28MM THICK RGNRTVE TSS,SUP-2466201,CDM,Q4116,HCPCS,0636,RC,,,,both,,,15360.88,9984.57,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.1MM S STL THRD FOR 3MM CANN SCR,SUP-2186884,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.29,47.64,,,,,,,,,,,,,
DIAZEPAM 5 MG PO TABS,RX-2405,CDM,6370000000,HCPCS,0637,RC,51079-0285-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE SUB 1 8MM 20ML CANC CHIP FRZN ALLGRFT,SUP-2264731,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.36,580.68,,,,,,,,,,,,,
NAIL IM L280MM DIA12MM UNIV L R DST FEM TI CANN LOK RG DYN,SUP-2191777,CDM,C1713,HCPCS,0278,RC,,,,both,,,6847.40,4450.81,,,,,,,,,,,,,
URETEROSCOPE FLX DIGITAL AXIS DISP,SUP-2432369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2471.18,1606.27,,,,,,,,,,,,,
SPHERE EMB LAVA-18 6 ML EVA TANTALUM PWDR PERIPH VASC LIQ,SUP-2899666,CDM,C1889,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
ROD SPNL 5.5X500 MM 50 MM MESA RAIL 811H55500T50,SUP-2732253,CDM,C1713,HCPCS,0278,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
NAIL IM L180MM OD9MM 130DEG SH TIM HIP AG CANN LCK AFFIXUS,SUP-2402794,CDM,C1713,HCPCS,0278,RC,,,,both,,,7075.52,4599.09,,,,,,,,,,,,,
CATHETER EP LG 5 MM 1 MM 5 FRX110 INQUIRY,SUP-2483880,CDM,C1730,HCPCS,0272,RC,,,,both,,,1405.90,913.83,,,,,,,,,,,,,
GUIDE PIN ORTHOPEDIC 2 MM,SUP-2242698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,92.63,60.21,,,,,,,,,,,,,
STEM FEM L240MM DIA16MM 135DEG STD OFFSET DST HIP BILAT,SUP-2252570,CDM,C1776,CPT,0278,RC,,,,both,,,9472.75,6157.29,,,,,,,,,,,,,
AUTOTRANSFUSION KIT 120 MH FAST STRT AT1 FOR CATS +,SUP-2429401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
LIFT HEEL SM WOM SUEDE LTHR TOP CVR ADJ A-LIFT,SUP-2227854,CDM,L3310,HCPCS,0274,RC,,,,both,,,16.23,10.55,,,,,,,,,,,,,
SET THROMCTMY ANGIOJET XPEEDIOR L 120 CM DIA 6 FR SHTH 6 FR,SUP-2142031,CDM,C1757,HCPCS,0272,RC,,,,both,,,3940.70,2561.45,,,,,,,,,,,,,
NAIL IM L360MM DIA10MM UNIV L R DST FEM TI CANN LOK RG DYN,SUP-2191721,CDM,C1713,HCPCS,0278,RC,,,,both,,,6646.75,4320.39,,,,,,,,,,,,,
SCREWDRIVER BLADE 7 1.5 MM SCR HD SOCKET CENTRE DRV,SUP-2459619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.59,275.33,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.44/2.16 MM PAPARELLA TAB SIL 510041,SUP-2535081,CDM,L8699,HCPCS,0278,RC,,,,both,,,44.84,29.15,,,,,,,,,,,,,
LIDOCAINE HCL 1% INJ (MIXTURES ONLY),RX-430017,CDM,J2003,HCPCS,0636,RC,00409-4276-02,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE STR MINI REG 2 MM RT ORBIT 14 HOLE TI LEVEL 1,SUP-2473951,CDM,C1713,HCPCS,0278,RC,,,,both,,,795.83,517.29,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 10X4 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871495,CDM,C1762,CPT,0278,RC,,,,both,,,9712.02,6312.81,,,,,,,,,,,,,
SCREW BNE L10MM DIA1.5MM HD DIA3MM CORT S STL NONCANNULATED,SUP-2183108,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
GRAFT BONE SUB 10CC INJ KT BETA-BSM,SUP-2218020,CDM,C1713,HCPCS,0278,RC,,,,both,,,8231.35,5350.38,,,,,,,,,,,,,
POST EXT FIX 3 HOLE STRL TRUELOK EVO LTX,SUP-2875629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.58,976.68,,,,,,,,,,,,,
COMPONENT FEM SZ 2 R KNEE NP PRI CEM STEM ROT HNG MED PVT,SUP-2304628,CDM,C1776,CPT,0278,RC,,,,both,,,16701.66,10856.08,,,,,,,,,,,,,
REVOWAVE 0035 450CM ANG ULT HRD,SUP-2418531,CDM,C1769,HCPCS,0272,RC,,,,both,,,514.93,334.70,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX200 MM 16 GAX70 MM W/ EXTN TY 3 CAREFLOW,SUP-2494069,CDM,C1751,HCPCS,0278,RC,,,,both,,,78.37,50.94,,,,,,,,,,,,,
BUPIVACAINE 0.375% ELASTOMERIC INFUSION,RX-4082489,CDM,J0665,HCPCS,0636,RC,09999-9917-85,NDC,,both,300,ML,67.30,43.74,,,,,,,,,,,,,
APPLIER ANEURYSM CLIP YASARGIL STANDARD BAYONET REUSABLE 9IN,SUP-2825557,CDM,C1889,HCPCS,0278,RC,,,,both,,,4831.36,3140.38,,,,,,,,,,,,,
SCREW BNE L 75 MM DIA 3.5 MM THRD L 19 MM TI CANN COMPR,SUP-2906100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1673.15,1087.55,,,,,,,,,,,,,
BUR SURG PRECIS 15 DEG 2.5MMX12.5 CM MTCH HD PROX ORNG IBUR,SUP-2859514,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1125.56,731.61,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 29 X 19 X 6 MM POLYETHYL LT PARANASAL,SUP-2935830,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
IMPLANT TOE JT L21.5MM PROF HD DIA2.4MM METATARSOPHALANGEAL,SUP-2123309,CDM,C1776,CPT,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE BNE W10.2XL78MM THK2.7MM 6 H BILAT S STL STR LO PROF,SUP-2186193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1314.22,854.24,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 40 X 40 X 2.7 X 0.7 MM LG POLYETHYL,SUP-2935647,CDM,C1713,HCPCS,0278,RC,,,,both,,,2687.84,1747.10,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THK15 22MM THCK ACELLULAR HYDRATED,SUP-2307568,CDM,Q4128,HCPCS,0636,RC,,,,both,,,8480.36,5512.23,,,,,,,,,,,,,
COLLAR CERV PED 3IN 16IN M HEADMASTER,SUP-2324112,CDM,L0180,HCPCS,0272,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
CATHETER HD 16 FRX21 CM TIP TO CUF HEMOSPLIT,SUP-2269495,CDM,C1881,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HC US Duplex Abd/Pelvis/Scrotum Comp,PX-9219397500,CDM,93975,CPT,0921,RC,,,,both,,,2625.00,1706.25,,,,,,,,,,,,,
GUIDEWIRE STRL DISP STD WIRE STR TIP NO TORQ VISE,SUP-2166276,CDM,C1769,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
WIRE FIX K TRCR TIP RND END 1X100MM,SUP-2320980,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 6 MESH NS FACE ID,SUP-2909576,CDM,C1713,HCPCS,0278,RC,,,,both,,,39178.28,25465.88,,,,,,,,,,,,,
PLATE BNE L55MM 7 H S STL 1/4 TBLR CLLRD FOR 2.7MM SCR,SUP-2411326,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
CATHETER DRNGE SIL RUB FOR BARTH CYST ABSC,SUP-2171591,CDM,C1729,HCPCS,0272,RC,,,,both,,,69.43,45.13,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR 10MM LESS STRAINED SPEAK VLV PROVOX,SUP-2124387,CDM,L8509,HCPCS,0272,RC,,,,both,,,912.70,593.25,,,,,,,,,,,,,
SHEATH INTRO PED 6FR L44CM DIL L52CM 0025IN PTFE FIX CRV,SUP-2294358,CDM,C1893,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM 32 HOLE ANGLED-ANGLED LCK TI NS,SUP-2474984,CDM,C1713,HCPCS,0278,RC,,,,both,,,6864.48,4461.91,,,,,,,,,,,,,
CANNULA UTER KAHN TRIG L7 3/8IN 2 FLX,SUP-2160514,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.31,1054.50,,,,,,,,,,,,,
SCREW BNE L 80 MM DIA 4.5 MM CORTICAL ST STRL EVOS,SUP-2931188,CDM,C1713,HCPCS,0278,RC,,,,both,,,146.80,95.42,,,,,,,,,,,,,
CAP ORTH FOR LOK HUM ROD POLARUS +,SUP-2107687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
BRACE WRST LEN 7 3 4IN CIRC OVR 8 3 4IN XL R REG D RNG W,SUP-2326029,CDM,L3908,HCPCS,0272,RC,,,,both,,,80.35,52.23,,,,,,,,,,,,,
SCREW BNE L10MM DIA3.5MM TI BLNT TIP HEXALOBE DRV FOR,SUP-2321360,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.32,341.46,,,,,,,,,,,,,
GRAFT BNE BIO DBM BOAT SHT SGL UNIT,SUP-2364714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 157 MM DIA 46 MM NIT POLYPRO,SUP-2751294,CDM,C1874,HCPCS,0278,RC,,,,both,,,53955.97,35071.38,,,,,,,,,,,,,
SHEATH GUID HALO 1 L 45 CM DIA 5 FR DIL L 52.5 CM GUIDEWIRE,SUP-2431945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 100 MM H2O MED HI RANG BACTISEAL,SUP-2666825,CDM,C1889,HCPCS,0278,RC,,,,both,,,5659.32,3678.56,,,,,,,,,,,,,
MESH SURG 43CM LEN 15CM W SYN ABD N ABSRB OVL,SUP-2126075,CDM,C1781,HCPCS,0278,RC,,,,both,,,146.32,95.11,,,,,,,,,,,,,
COVER BUR H DIA15MM BILAT TI CNTOUR RIG NONCOMPRESSION LO,SUP-2190698,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.98,506.99,,,,,,,,,,,,,
HC Mra Abdomen W/ Contrast,PX-6187418500,CDM,C8900,CPT,0618,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
NEEDLE BX LIV 14G/15CM,SUP-2236350,CDM,C1786,HCPCS,0275,RC,,,,both,,,19311.00,12552.15,,,,,,,,,,,,,
SET CLLR AD H3IN FOR 13-21IN NK REG ORNG PLAS HK AND LOOP,SUP-2124216,CDM,L0172,HCPCS,0272,RC,,,,both,,,90.87,59.07,,,,,,,,,,,,,
GRAFT VASC L80CM DIA6MM PTFE CBAS HEP SURF THN WALLED REM,SUP-2395814,CDM,C1768,CPT,0278,RC,,,,both,,,8719.78,5667.86,,,,,,,,,,,,,
PLATE BNE W8XL176MM THK3.3MM 22 H NONSTERILE BILAT PELV S,SUP-2186249,CDM,C1713,HCPCS,0278,RC,,,,both,,,3094.47,2011.41,,,,,,,,,,,,,
ONDANSETRON HCL 4 MG PO TABS,RX-10778,CDM,Q0162,HCPCS,0637,RC,68084-0220-01,NDC,,both,1,UN,3.40,2.21,,,,,,,,,,,,,
BLADE RTRCTR MRDNG MED 1INW X 3 1/3NL TTNM F / UNVRSL RING U,SUP-2498731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,976.13,634.48,,,,,,,,,,,,,
GRAFT HUM TISS 2000MG PLCNTA TISS AMNIOFILL,SUP-2305717,CDM,C1762,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
SHEATH INTRO CLOTTRIEVER L 15 CM DIA13 FR DEPLOYED FUNNEL,SUP-2417093,CDM,C1894,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LG UPCHARGE HD CERM,SUP-2212686,CDM,C1776,CPT,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
INSERT ACET OD54-56MM ID32MM 10DEG X FRE CO CHROM HIP CUP,SUP-2370106,CDM,C1776,CPT,0278,RC,,,,both,,,1201.33,780.86,,,,,,,,,,,,,
NAIL IM L255MM DIA8MM UNIV DK BLU PROX TIB TI BEND CANN LOK,SUP-2180381,CDM,C1713,HCPCS,0278,RC,,,,both,,,4592.41,2985.07,,,,,,,,,,,,,
SCREW SPNL 4.5X22 MM SYM,SUP-2539618,CDM,C1713,HCPCS,0278,RC,,,,both,,,3545.06,2304.29,,,,,,,,,,,,,
SUTURE NONABSORBABLE MONOFILAMENT 7-0 BV-1 24 IN PROLENE D8228,SUP-2218935,CDM,C1713,HCPCS,0278,RC,,,,both,,,650.17,422.61,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS,RX-33227,CDM,6370000000,HCPCS,0637,RC,00093-2274-34,NDC,,both,1,UN,6.40,4.16,,,,,,,,,,,,,
CATHETER EP CSL CRV 2-2-2 MM 6 FRX120 CM,SUP-2356843,CDM,C1730,HCPCS,0272,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
GRAFT DERMAL ANTIMICROBIAL 4.91X4.91 CM 24.1 SC PURAPLYAM XT,SUP-2866270,CDM,Q4197,HCPCS,0636,RC,,,,both,,,8870.50,5765.82,,,,,,,,,,,,,
PACEMAKER CARD ADAPTA SR W 42.9 X H 43.3 MM D 7.5 MM 11 CC,SUP-2282316,CDM,C1786,HCPCS,0275,RC,,,,both,,,7268.63,4724.61,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM CRYOPRESERVED AMNIO MEM LO PROF FOR,SUP-2116284,CDM,Q4148,HCPCS,0636,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
IMPL KWIRE SMTH VARIAX 1.4X100MM,SUP-2492765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
SET SPRUNG RESVR W/ DSTL CATH,SUP-2108710,CDM,C1729,HCPCS,0272,RC,,,,both,,,1940.49,1261.32,,,,,,,,,,,,,
ADAPTER ORTH 5 CM OSS COMPRESS,SUP-2441844,CDM,C1776,CPT,0278,RC,,,,both,,,2303.19,1497.07,,,,,,,,,,,,,
PIN EXT FIX COLL FOR SIDEKCK STLTH REARFOOT FIX,SUP-2400628,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
QUADLINK IMPLANT SYSTEM 9MM,SUP-2811463,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
CATHETER ETER EP 6FR L115CM 2MM SPC A CRV POLE 8 FIX,SUP-2248893,CDM,C1730,HCPCS,0272,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
PLATE BNE HYBRID MMF SMARTLOCK 2PK,SUP-2366228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1047.76,681.04,,,,,,,,,,,,,
SLEEVE INSRT SZ 8-11 E FOR T2 NAILING SYS,SUP-2368596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
JOINT FNGR CARPOMETACARPAL 40 SPHR PYROSPHERE DISP,SUP-2610450,CDM,C1776,CPT,0278,RC,,,,both,,,7699.56,5004.71,,,,,,,,,,,,,
INSERT TIB SM SZ 1 2 THK10MM R KNEE POLYETH PRI NEUT,SUP-2350389,CDM,C1776,CPT,0278,RC,,,,both,,,5586.85,3631.45,,,,,,,,,,,,,
CATHETER EP LG4 10 MM 6 FRX110 CM HEXA DYN XT,SUP-2462285,CDM,C1730,HCPCS,0272,RC,,,,both,,,2103.80,1367.47,,,,,,,,,,,,,
UPCHARGE KNEE X3 PATELLA STRYKER,SUP-2501352,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SMALL PLATE 14X169MM 3.5MM,SUP-2818478,CDM,C1713,HCPCS,0278,RC,,,,both,,,2990.98,1944.14,,,,,,,,,,,,,
THUMBWHEEL EXT FIX XTRAFIX,SUP-2517828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.64,396.92,,,,,,,,,,,,,
PLATE BONE 13 H LT DSTL LAT FEM LCK COMPR FOR 4.5MM SCR,SUP-2343751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3555.42,2311.02,,,,,,,,,,,,,
STENT TRACH L30MM DIA12MM WRK L62CM 16FR POLYUR OVR THE WIRE,SUP-2302396,CDM,C1874,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP LT MEDL MENIS W/ BNE,SUP-2867143,CDM,C1762,CPT,0278,RC,,,,both,,,9688.78,6297.71,,,,,,,,,,,,,
SYSTEM FAT TRANSFER LIPOASPIRATE WSH STRL VIALITY LTX,SUP-2869230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HI DEMAND 2 POROUS STRYKERH2POR] STRYKER CORP],SUP-2365974,CDM,C1776,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 15 CM SEG FEM,SUP-2321804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2216.84,1440.95,,,,,,,,,,,,,
SHOE ORTHOT CUST DENNIS BRN SPLNT,SUP-2435749,CDM,L3640,HCPCS,0272,RC,,,,both,,,122.49,79.62,,,,,,,,,,,,,
FRACTURE STEM SYS W MPLR CUP,SUP-2212072,CDM,C1776,CPT,0278,RC,,,,both,,,6157.54,4002.40,,,,,,,,,,,,,
HC Elec Alys Implt Cplx Cn Npgt Prgrmg,PX-9209597700,CDM,95977,CPT,0920,RC,,,,inpatient,,,298.00,193.70,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO V4 L 138 CM 5.5FR 5FR 0.014IN 30CC,SUP-2120488,CDM,C1757,HCPCS,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
PLATE BNE CLAV CS1 2.7 MM LT LAT VA LCK COMPR TI STRL VALCP,SUP-2789772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.98,2633.14,,,,,,,,,,,,,
PLATE BONE L160MM 8 H LT MEDL DSTL TIB LCK FOR 3.5MM SCR,SUP-2348245,CDM,C1713,HCPCS,0278,RC,,,,both,,,16782.36,10908.53,,,,,,,,,,,,,
GRAFT HUM TISS REGENERATIVE THCK 5X7 CM  GRAFTJACKET NOW,SUP-2858158,CDM,Q4107,HCPCS,0636,RC,,,,both,,,31396.86,20407.96,,,,,,,,,,,,,
MECLIZINE HCL 12.5 MG PO TABS,RX-12024,CDM,6370000000,HCPCS,0637,RC,50268-0522-11,NDC,,both,1,UN,4.20,2.73,,,,,,,,,,,,,
GREAT TOE METATRSL SZ 1 RT CO CHROM KINETIKOS,SUP-2242671,CDM,C1776,CPT,0278,RC,,,,both,,,5301.89,3446.23,,,,,,,,,,,,,
HEAD FEM 54MM MOD ST REMEDY HIP SPCR,SUP-2319833,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CATHETER PICC 5FR 3 LUMN MAXIMAL BARR TY W/ TPS STYL,SUP-2125514,CDM,C1751,HCPCS,0278,RC,,,,both,,,942.66,612.73,,,,,,,,,,,,,
HC So Islet Cell Antibody,PX-3028634166,CDM,86341,CPT,0302,RC,,,,outpatient,,,698.00,453.70,,,,,,,,,,,,,
SCREW IM NAIL DIA 5 MM SZ 60 PARTIALLY THRD C NS PANTA2,SUP-2931277,CDM,C1713,HCPCS,0278,RC,,,,both,,,1760.88,1144.57,,,,,,,,,,,,,
KIT PMP LT VENT ASST DEV W/ PKT CTRL HEARTMATE II,SUP-2356046,CDM,C1713,HCPCS,0278,RC,,,,both,,,249630.00,162259.50,,,,,,,,,,,,,
CATHETER ABLATN DD CRV CONTACT FORC BIDIR TACTICATH,SUP-2470992,CDM,C2630,CPT,0272,RC,,,,both,,,8771.02,5701.16,,,,,,,,,,,,,
BELT ORTHOT RIB THOR CUST FABRICATED,SUP-2435536,CDM,L0220,HCPCS,0272,RC,,,,both,,,365.75,237.74,,,,,,,,,,,,,
STEM FEM L300MM OD11MM BOW TI POR IM REV CEM NEUT MOD LNG,SUP-2405728,CDM,C1776,CPT,0278,RC,,,,both,,,5016.15,3260.50,,,,,,,,,,,,,
GRAFT STENT 7X2.5 MM 75 CM SUPERFICIAL FEM ART W/O HEPARIN,SUP-2396502,CDM,C1874,HCPCS,0278,RC,,,,both,,,7017.90,4561.63,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN S STL PULM STR JAGWIRE,SUP-2149399,CDM,C1769,HCPCS,0272,RC,,,,both,,,386.53,251.24,,,,,,,,,,,,,
COLLAR CERV SEMI RIGID BRAC ADJ,SUP-2265009,CDM,L0140,HCPCS,0274,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
ABRASOR DIAMOND COARSE 320MM X 3.5MM X 3.4MM BALL TIP JOIMAX,SUP-2848826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
SCREW BONE L14MM DIA2.7MM MIDFOOT VAR ANG COMPR 1ST RAY,SUP-2417629,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.93,194.30,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC DBM BONUS TRIAD,SUP-2607051,CDM,C1889,HCPCS,0278,RC,,,,both,,,12363.75,8036.44,,,,,,,,,,,,,
CATHETER CV DL PEDIATRIC 7 FRX65 CM CUF W/ STYL BRVC,SUP-2126157,CDM,C1751,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
DEVICE VASCULAR CLOSURE CELT ACD PLUS 5FR,SUP-2933944,CDM,C1760,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
DEVICE FIXATION 8MM IMPLANT ARTHROSCOPY BIOABSORBABLE STERIL,SUP-2824301,CDM,C1713,HCPCS,0278,RC,,,,both,,,270.20,175.63,,,,,,,,,,,,,
WIRE FIX COUNTSINK FOR INTROSSEOUS SYS,SUP-2400067,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
STEM HUM L140MM DIA8.5MM 132.5DEG R SHLDR TI ALLY CEM PRI,SUP-2223304,CDM,C1776,CPT,0278,RC,,,,both,,,7862.56,5110.66,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL BRK XS CRV S STL AD 18AGX89CM BRK,SUP-2357592,CDM,C1713,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
PLATE BNE GRP 2.7 MM CLAV A LEVEL NS ALPS FAST DISP,SUP-2499404,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
PLATE BNE THK1.25MM 11 H BILAT MIDFOOT S STL CUBOID ST LO,SUP-2186374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.61,1532.45,,,,,,,,,,,,,
KIT ACCSRY PMP FOR INFLATABLE PENILE PROS STRL DISP AMS 700,SUP-2930702,CDM,C1813,HCPCS,0278,RC,,,,both,,,2848.61,1851.60,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STEM XLPE,SUP-2212518,CDM,C1776,CPT,0278,RC,,,,both,,,10996.28,7147.58,,,,,,,,,,,,,
SHEATH URO L16CM OD16FR RENAL OPQ FOR NEPHSTMY TRACT AMPLTZ,SUP-2171312,CDM,C1894,HCPCS,0272,RC,,,,both,,,102.49,66.62,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE BDB L 95 CM DIA 7 FR SPC,SUP-2356918,CDM,C1731,HCPCS,0278,RC,,,,both,,,3981.52,2587.99,,,,,,,,,,,,,
TUBE VENT 1.27 MM 1 MM 2.7 MM BOB TI GLD STRL,SUP-2535064,CDM,L8699,HCPCS,0278,RC,,,,both,,,67.35,43.78,,,,,,,,,,,,,
VLP 2.7MM S-T LOCK SCREW 46MM STER,SUP-2819997,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.78,552.36,,,,,,,,,,,,,
PLATE BUR H L 22 MM SCREW DIA1.5 MM MALL NS DISP,SUP-2935005,CDM,C1713,HCPCS,0278,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
ROD EXT FIX 4X160 MM,SUP-2187109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2364.99,1537.24,,,,,,,,,,,,,
CATHETER ABLATN SM 2-5-2 4 MM 7 FRX110 CM 1304-7-25-S THER,SUP-2491363,CDM,C1733,HCPCS,0272,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
BIT DRILL SCALED AO 25X450MM,SUP-2695997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1301.22,845.79,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4.5X200-219 MM SEMITENDINOSUS,SUP-2866880,CDM,C1762,CPT,0278,RC,,,,both,,,2881.58,1873.03,,,,,,,,,,,,,
CATHETER PA L 110 CM DIA 6 FR 4 LUMEN 1.5 CC POLYUR,SUP-2893601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
GRAFT BONE SUB OSTEOCONDUCTIVE SCAFFOLD PUTTY,SUP-2244117,CDM,C1713,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
GUIDEPIN SURG DIA3MM NONCANNULATED RETRODRILL,SUP-2120915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
STAPLE NITI SUPERMX W/INSTRS 20W X 15L,SUP-2745057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
PLATE BNE L158MM 11 H NONSTERILE R ANTLAT DST TIB S STL LO,SUP-2185954,CDM,C1713,HCPCS,0278,RC,,,,both,,,4133.56,2686.81,,,,,,,,,,,,,
SCREW BONE L30MM OD9.5MM 60DEG MAG UNIF COMPR STBL FIX REINF,SUP-2223910,CDM,C1713,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
ANCHOR SUT TI WDG 5MM W TWO STRANDS OF FORCEFIBER,SUP-2362550,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.02,479.06,,,,,,,,,,,,,
RING ADPT BOLT STLTH REARFOOT FIX,SUP-2400664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
SCREW BNE AD PED L7MM DIA23MM CRANIOMAXILLOFACIAL TI SELF,SUP-2262835,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.75,268.29,,,,,,,,,,,,,
CUTTER ORTH PLATE STRL DISP STERNALOCK XP,SUP-2894466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PERICARD 7X2 CM M THN PROC TUTOPLAST,SUP-2847987,CDM,C1762,CPT,0278,RC,,,,both,,,3491.68,2269.59,,,,,,,,,,,,,
RAIL EXT FIX LNG BODY COMPLT,SUP-2197293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
VALVE SPEAK TRACH,SUP-2138739,CDM,L8501,HCPCS,0274,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX12 TTNM CNTRD F3.5MM LOK SCREW S,SUP-2724799,CDM,C1713,HCPCS,0278,RC,,,,both,,,1901.71,1236.11,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN IRRADIATED GRACILIS TEND,SUP-2867226,CDM,C1762,CPT,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
BRACE ORTH SZ 1 RT THMB CMC PUSH METAGRIP,SUP-2324629,CDM,L3924,HCPCS,0274,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
WIRE ORTH SMOOTH DBL SHRP TIP S STL NONSTERILE 3.0MM DIA,SUP-2362539,CDM,C1769,HCPCS,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
IMPLANT OSS M L3.9MM DIA1.17MM SHT INCUS STAP HA FULL CANN,SUP-2313672,CDM,L8613,CPT,0278,RC,,,,both,,,905.26,588.42,,,,,,,,,,,,,
PLATE BNE PROF THK 0.6 MM 16 H SCREW DIA2 MM TI MIDFACE STR,SUP-2883898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
ARM TARGET DEV DSTL 2 MM RT,SUP-2484798,CDM,C1713,HCPCS,0278,RC,,,,both,,,8389.33,5453.06,,,,,,,,,,,,,
PLATE BNE L106MM 4 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185666,CDM,C1713,HCPCS,0278,RC,,,,both,,,4123.20,2680.08,,,,,,,,,,,,,
SCREW BNE L34MM TIP DIA4MM HEX 2.5MM STD HND FT ST CANN,SUP-2107353,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.84,828.65,,,,,,,,,,,,,
PROBE CRYOABLATION SLIMLINE 1.7MM,SUP-2716314,CDM,C2618,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSOSTAR NAV L 115 CM DIA 7 FR,SUP-2248923,CDM,C1732,HCPCS,0272,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
CATHETER VENTRICULAR 1.5X3.1X15.7X3X6 MM STRL HOLTER,SUP-2666418,CDM,C1729,HCPCS,0272,RC,,,,both,,,1548.96,1006.82,,,,,,,,,,,,,
COMPONENT HIP RESURF H6,SUP-2123624,CDM,C1776,CPT,0278,RC,,,,both,,,21509.00,13980.85,,,,,,,,,,,,,
VALVE SHUNT STRATA II STRATA NSC,SUP-2628603,CDM,C1889,HCPCS,0278,RC,,,,both,,,15936.60,10358.79,,,,,,,,,,,,,
FILTER VASC 65CM 9FR INTRO 30MM PERM RETRIEVABLE MRI SAFE,SUP-2169013,CDM,C1880,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE W11XL112MM THK3.3MM 8 H BILAT MTPHSEAL TI LOK,SUP-2190762,CDM,C1713,HCPCS,0278,RC,,,,both,,,2718.71,1767.16,,,,,,,,,,,,,
CATHETER SUPRPUB 14FR L23CM 1 OBT STYL CONN TUBE SET RETEN,SUP-2171259,CDM,C2627,HCPCS,0272,RC,,,,both,,,173.33,112.66,,,,,,,,,,,,,
PLATE BNE SM L131MM 2X2X2 H L MT TI POLYAX LOK COMPR LO,SUP-2398504,CDM,C1713,HCPCS,0278,RC,,,,both,,,5890.64,3828.92,,,,,,,,,,,,,
MESH SURG STRUT THK0.4MM SLV CRANIOFACIAL TI MALL CNTOUR LO,SUP-2181552,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
SET PICC L 1 9/16 IN DIA18 GA SHTH L 1 1/4 IN DIA 5 FR,SUP-2887113,CDM,C1769,HCPCS,0272,RC,,,,both,,,70.02,45.51,,,,,,,,,,,,,
PLATE BONE W100XL100MM CRANIOMAXILLOFACIAL TI SCRN FOR 1.3MM,SUP-2190683,CDM,C1713,HCPCS,0278,RC,,,,both,,,5029.02,3268.86,,,,,,,,,,,,,
PLATE BONE 8 H TI Y SHP FOR 1.5MM SCR VLP MINI-MOD SM BONE,SUP-2351068,CDM,C1713,HCPCS,0278,RC,,,,both,,,4705.76,3058.74,,,,,,,,,,,,,
LEAD NERVE STIM 90 CM EXCLAIM,SUP-2615512,CDM,C1778,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
RUSSELL-TAYLOR FEMORAL NAIL 15MMX42CM,SUP-2818215,CDM,C1713,HCPCS,0278,RC,,,,both,,,8254.12,5365.18,,,,,,,,,,,,,
RELOAD INT DIA3.5MM BLU 6 ROW ENDOWRIST DA VINCI SI,SUP-2246599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SEGMENT FEM COMP L SZ 3 W75XH50MM LT DSTL TILASTAN,SUP-2265084,CDM,C1776,CPT,0278,RC,,,,both,,,4791.64,3114.57,,,,,,,,,,,,,
NEEDLE PROC TRANSSEPTAL 86 DEG 18 GAX71 CM HEARTSPAN,SUP-2472120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
GRAFT PUTTY NOVABONE,SUP-2307532,CDM,C9359,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
CATHETER EP 1 MM 7 FRX110 10 MM STEER INQUIRY,SUP-2473019,CDM,C1730,HCPCS,0272,RC,,,,both,,,3356.66,2181.83,,,,,,,,,,,,,
TI LCP VOLR CLMN DSTL RADIUS PL 6H HEAD/3H SHAFT/LT-STERILE,SUP-2546653,CDM,C1713,HCPCS,0278,RC,,,,both,,,2979.39,1936.60,,,,,,,,,,,,,
BRACE ANK H85IN SM AD BILAT STRP CLSR OPN HEEL TOE RIG W,SUP-2195185,CDM,L4350,HCPCS,0272,RC,,,,both,,,71.72,46.62,,,,,,,,,,,,,
DISC SPNL DP MED 6 MM FOR TOT DISC REPL STRL PRODISC C,SUP-2163160,CDM,C1889,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
CROWN DENT 2U ANTR UPPER CUSPID PRIMARY REFILL SS UNITEK,SUP-2322228,CDM,D6783,CPT,0278,RC,,,,both,,,26.34,17.12,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM THCK THK2-3.3MM REGENERATIVE TISS MTRX,SUP-2399086,CDM,Q4107,HCPCS,0636,RC,,,,both,,,7272.05,4726.83,,,,,,,,,,,,,
PLATE BNE L210MM BLDE W4.8XL25MM 95DEG 12 H ST HIP S STL,SUP-2186757,CDM,C1713,HCPCS,0278,RC,,,,both,,,3392.08,2204.85,,,,,,,,,,,,,
"HC E/M Crit Care,ER, 1st 30-74min",PX-4509929100,CDM,99291,CPT,0450,RC,,,,inpatient,,,4946.00,3214.90,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 90 MM DIA25 MM LIMB L 30 MM DIA20,SUP-2217641,CDM,C1768,CPT,0278,RC,,,,both,,,34398.70,22359.15,,,,,,,,,,,,,
SPLINT RST PAN MIT SP S RT,SUP-2163831,CDM,L3807,HCPCS,0274,RC,,,,both,,,81.29,52.84,,,,,,,,,,,,,
RING BPLR DIA53-57MM HIP REPL RNGLOC,SUP-2404324,CDM,C1776,CPT,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
PLANER SURG STANDARD STANDARD+ PAT BSKT PLT REPL LCS,SUP-2252798,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
HC Perc Balloon Valvuloplasty; Aortic Valve,PX-4819298600,CDM,92986,CPT,0481,RC,,,,outpatient,,,15337.00,9969.05,,,,,,,,,,,,,
SET CATH HEMODIALYSI SPLIT STRM CHRONIC BASIC 14FR DIA 28CM,SUP-2610542,CDM,C1750,HCPCS,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
SCREW INTRF 10X20 MM 1.5 MM GUIDEWIRE MTO STRL SOFTSILK LTX,SUP-2879282,CDM,C1713,HCPCS,0278,RC,,,,both,,,1295.72,842.22,,,,,,,,,,,,,
COMPONENT FEM L CO CHROM KNEE NP PRI STEMLESS UNI NONBEADED,SUP-2409238,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
STENT PERIPH L100MM DIA7MM CATH L135CM NIT SELF EXP RADPQ,SUP-2104821,CDM,C1876,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
DRILL SURG 0.25 IN DSTL W/ STP MAXM,SUP-2444379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
INSERT TIB SZ 2 THK11MM UNIV KNEE POST STBL CONSTRN REV NEUT,SUP-2216434,CDM,C1776,CPT,0278,RC,,,,both,,,3513.00,2283.45,,,,,,,,,,,,,
ALUMINUM RENAL ABH BLADE 1 X 8,SUP-2703359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1476.52,959.74,,,,,,,,,,,,,
GUIDEWIRE SURG TI MH FOR EXPERT RG FEM NAIL,SUP-2178927,CDM,C1769,HCPCS,0272,RC,,,,both,,,2288.06,1487.24,,,,,,,,,,,,,
COLLAR CERV FIRM DENS AD HK AND LOOP CLSR FOAM W COT CVR,SUP-2276586,CDM,L0120,HCPCS,0274,RC,,,,both,,,7.03,4.57,,,,,,,,,,,,,
GUIDE PIN ORTHOPEDIC THRD 3.2X300 MM TIP,SUP-2342843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,202.00,131.30,,,,,,,,,,,,,
SCREW WR INTEGRA FRDM ARTHROPLASTY CRPL PLT IS USED IN AN,SUP-2243494,CDM,C1713,HCPCS,0278,RC,,,,both,,,12018.57,7812.07,,,,,,,,,,,,,
CATHETER PICC L50CM OD5FR DBL LUMN BASIC,SUP-2383963,CDM,C1751,HCPCS,0278,RC,,,,both,,,1515.30,984.94,,,,,,,,,,,,,
FRAME EXT FIX OD180MM CIR ASSEMB SIDEKCK,SUP-2400709,CDM,C1713,HCPCS,0278,RC,,,,both,,,14701.48,9555.96,,,,,,,,,,,,,
HC Surgery Level 1 Addtl 15min,PX-3600000011,CDM,3600000011,LOCAL,0360,RC,,,,both,,,622.00,404.30,,,,,,,,,,,,,
BUR ENDOSCP SHAVER L 12.5 CM DIA 4.5 MM SPD 12000 RPM ENT,SUP-2902001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.54,707.55,,,,,,,,,,,,,
TIP ULTRSNC DEV 3 DEG L 180 MM CRV EXT M/F ULTRSNC STRL DISP,SUP-2883553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2931.69,1905.60,,,,,,,,,,,,,
OXYGENATOR PERF 43ML FLO RATE 0.1-1.5LPMXCOATING HARDSHELL,SUP-2384817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 200 CM DIA 0.035 IN TIP L 3 MM PTFE,SUP-2301923,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
BLADE SHV PED L11CM DIA4MM 40DEG 1500RPM CRV FOR,SUP-2284148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.59,420.28,,,,,,,,,,,,,
STEM FEM SZ 8 STD HIP CLLRLSS MOD ENTRADA,SUP-2315476,CDM,C1776,CPT,0278,RC,,,,both,,,10738.80,6980.22,,,,,,,,,,,,,
SHUNT SURG VENTRICULOPERITONEAL UNI-SHUNT NS0104,SUP-2666778,CDM,C1889,HCPCS,0278,RC,,,,both,,,2254.80,1465.62,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X140-200 MM TEND FLEXIGRAFT CONN EXT,SUP-2740961,CDM,C1762,CPT,0278,RC,,,,both,,,3348.94,2176.81,,,,,,,,,,,,,
HEAD HUM MOD STD PRI STD NK 38MM OD 15MM HT,SUP-2408632,CDM,C1776,CPT,0278,RC,,,,both,,,5859.24,3808.51,,,,,,,,,,,,,
HC Pt Elec Stim Unattended|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701400,CDM,G0283,HCPCS,0420,RC,,,GP|CQ,both,,,206.00,133.90,,,,,,,,,,,,,
OXYBUTYNIN CHLORIDE 5 MG PO TABS,RX-5938,CDM,6370000000,HCPCS,0637,RC,00832-0038-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
RING EXT FIX FULL 160 MM SINGLE ROW,SUP-2749869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4135.38,2688.00,,,,,,,,,,,,,
GRAFT BONE 30ML CORT CANC CHIP FRZ DRY IRRADIATED,SUP-2113893,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
NAIL COMPR L200MM DIA12MM ANK TI CANN,SUP-2316335,CDM,C1713,HCPCS,0278,RC,,,,both,,,8343.61,5423.35,,,,,,,,,,,,,
SCREW INTRF L 6 MM DIA2.5 MM PEEK TENODESIS W/ HNDL INSRTR,SUP-2882224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS TEND FRZN,SUP-2137250,CDM,C1762,CPT,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
PROBE CRYOSURGICAL GRN MALL SHFT ANG FOR RESECT ABLAT,SUP-2341617,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.25,319.31,,,,,,,,,,,,,
STAPLE BNE COMPR 3X2 MM,SUP-2223645,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
GUIDEWIRE URO TAPR RADPQ STR STIFF TIP POLYUR TUNGSTEN NIT,SUP-2385259,CDM,C1769,HCPCS,0272,RC,,,,both,,,614.81,399.63,,,,,,,,,,,,,
CATHETER CV 3L 6 FR STYL BASIC TY POLY RADPICC,SUP-2126398,CDM,C1751,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
PLATE STRNL CLOSURE 4 H TI BX CONVX NS STERNALOCK EZ,SUP-2894456,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
KNIFE SURG KLEINSASSER 9.75 INX8 MM CRV PT MICROFRANCE LF,SUP-2485002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,575.62,374.15,,,,,,,,,,,,,
ROD ORTH 10X135 MM AVASCULAR NECROSIS,SUP-2861956,CDM,C1713,HCPCS,0278,RC,,,,both,,,4249.74,2762.33,,,,,,,,,,,,,
MESH SURG L 22 X W 10 CM POLYPRO SHT,SUP-2929632,CDM,C1781,HCPCS,0278,RC,,,,both,,,2804.02,1822.61,,,,,,,,,,,,,
COMPONENT TIB 3 8 MM KNEE,SUP-2200489,CDM,C1776,CPT,0278,RC,,,,both,,,1980.84,1287.55,,,,,,,,,,,,,
PLATE BNE RECON 3.5X143 MM 11 HOLE LCK LP SS NS,SUP-2184031,CDM,C1713,HCPCS,0278,RC,,,,both,,,2412.37,1568.04,,,,,,,,,,,,,
COIL DELTAPLUSH STRETCH RESIST 1.5MMX1CM,SUP-2466226,CDM,C1889,HCPCS,0278,RC,,,,both,,,5209.70,3386.30,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 14 X 7 MM STD WALL TRUNK,SUP-2396238,CDM,C1768,CPT,0278,RC,,,,both,,,2634.46,1712.40,,,,,,,,,,,,,
GRAFT BONE SUB 0.5CC PUTTY,SUP-2307522,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
PASSER SUTURE SHRP TIP 60 DEG ARTHSCP UP RVS TIP SPEEDSNARE,SUP-2745451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
PLATE BNE W16XL190MM THK5MM 9 H R CNDYL FEM S STL BTTRS DYN,SUP-2185806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2560.14,1664.09,,,,,,,,,,,,,
CONNECTOR SPNL S STL END TO END FOR 6.35/6.35MM ROD ISOLA,SUP-2255713,CDM,C1713,HCPCS,0278,RC,,,,both,,,2593.64,1685.87,,,,,,,,,,,,,
SHOE ORTHOT CALIP PLATE EXISTING TRANSFER,SUP-2435745,CDM,L3600,HCPCS,0274,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
RESERVOIR VENTRICULAR L18CM OD20MM ODSEC2.5MM D5.65MM EXTERN,SUP-2825620,CDM,C1889,HCPCS,0278,RC,,,,both,,,1824.34,1185.82,,,,,,,,,,,,,
SCREW BNE L25MM DIA5MM FULL THRD CORT PANTA,SUP-2243611,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.28,744.43,,,,,,,,,,,,,
PLATE BONE SM THK0.3MM MULT H ORBIT FLR TI MESH PREFRM FOR,SUP-2135899,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
CERAMIC BALL HD 12/14 28 IN3.5 S,SUP-2267743,CDM,C1776,CPT,0278,RC,,,,both,,,2875.46,1869.05,,,,,,,,,,,,,
GRAFT BIO TISS OASIS ULTRA 3LAYER MATRIX 3X3.5CM FEN,SUP-2341247,CDM,Q4124,HCPCS,0636,RC,,,,both,,,706.37,459.14,,,,,,,,,,,,,
SCREW BNE L50MM DIA5MM CANC TI ST CANN LOK FULL THRD TRIGEN,SUP-2348149,CDM,C1713,HCPCS,0278,RC,,,,both,,,1407.16,914.65,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 30 CM DIA 4-7 MM SHRT TAPR REINF,SUP-2669625,CDM,C1768,CPT,0278,RC,,,,both,,,607.18,394.67,,,,,,,,,,,,,
BAR SPNL SZ 8 L74.5MM RAD 220MM SUP INFERIOR CRAN GLD TI,SUP-2193295,CDM,C1713,HCPCS,0278,RC,,,,both,,,7878.26,5120.87,,,,,,,,,,,,,
ANCHOR SUT NO 0 MINI DRL BIT QUICKANCHR + ORTHOCORD,SUP-2256599,CDM,C1713,HCPCS,0278,RC,,,,both,,,2782.04,1808.33,,,,,,,,,,,,,
CATHETER ANGIO 6FR L110CM 0.038IN SARAH RAD 4.0 NYL POLYUR,SUP-2385357,CDM,C1887,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SPLINT WRST M R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326137,CDM,L3908,HCPCS,0274,RC,,,,both,,,73.51,47.78,,,,,,,,,,,,,
SNARE ENDOSCP POLYP LOOP OVL ASMBLY SHTH WIRE COLONSCP,SUP-2463221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1435.70,933.20,,,,,,,,,,,,,
SCREW BONE LOCKING 2X6 MM SELFDRILLING TITANIUM NON STERILE,SUP-2837731,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.15,318.60,,,,,,,,,,,,,
PATCH ABD W20XL40CM RECT POLYAMIDE FBR NONABSORBABLE,SUP-2358736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19782.00,12858.30,,,,,,,,,,,,,
BASKET SPCMN RTRVL 22MMW OPNNG 195CML WRKNG BLLT SHPD TIP ST,SUP-2679347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.53,765.39,,,,,,,,,,,,,
CLINDAMYCIN (CLEOCIN) 6 MG/ML SYRINGE (PED/NEO),RX-4090063,CDM,J0737,HCPCS,0636,RC,00338-3410-24,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE VA 2 MM 6 HOLE LCK FRAC TI NS,SUP-2190286,CDM,C1713,HCPCS,0278,RC,,,,both,,,2509.24,1631.01,,,,,,,,,,,,,
CATHETER SUPRPUB 14FR L15CM FADER TIP SET W/ LCK PGTL AND,SUP-2140100,CDM,C2627,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SCREW BNE 36 MM LATARJET SS NS,SUP-2256866,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
INTRODUCER PACE LD L 60 CM DIA 8 FR PEELABLE FOR TRNSVEN,SUP-2282112,CDM,C1894,HCPCS,0272,RC,,,,both,,,179.95,116.97,,,,,,,,,,,,,
CATHETER INFUSION PMP 5 ML/HR 2.5 IN 275 CC,SUP-2361466,CDM,C1751,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
BRACE ANK SM H875IN L SEMI RIG ANATOMICALLY DESIGNED SHELL,SUP-2196369,CDM,L4350,HCPCS,0274,RC,,,,both,,,61.80,40.17,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|DOCUMENTATION ON FILE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|CQ|KX,both,,,144.00,93.60,,,,,,,,,,,,,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,2500000003,HCPCS,0250,RC,67457-0438-00,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
BIT DRL 25X60 MM FOR SALVATION 3DI PLATING SYS DISP,SUP-2401182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
SCREW ILIOSACRAL TI 7.0MMDIA 50MML,SUP-2290579,CDM,C1713,HCPCS,0278,RC,,,,both,,,3686.36,2396.13,,,,,,,,,,,,,
COMPONENT TOE L10MM DIA3.4X3MM TI ST SELF DRL THRD SPADE TWO,SUP-2390525,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ 10IN LOOP LOK FIRM SUPP VYN,SUP-2276620,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.01,10.41,,,,,,,,,,,,,
KIT EVAC BLB 7MM 100CC SIL FLAT LO LEV SUCT DISPOSABLE,SUP-2126599,CDM,C1729,HCPCS,0272,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
SPACER SPNL TRAPEZIUM 10X10X10 MM MTCRPL CMC,SUP-2120681,CDM,C1821,HCPCS,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
IMPLANT FACE L 45 X H 47 MM PROJCT 5 MM MED POLYETHYL CHIN,SUP-2883660,CDM,C1713,HCPCS,0278,RC,,,,both,,,1560.39,1014.25,,,,,,,,,,,,,
BRIVARACETAM 50 MG/5ML IV SOLN,RX-133987,CDM,2500000003,HCPCS,0250,RC,50474-0970-63,NDC,,both,2.5,ML,181.50,117.97,,,,,,,,,,,,,
SCREW SPNL ROD DIA 5.5/6 MM SS UNIAXIAL STRL CD HORZ MODULEX,SUP-2926483,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
CATHETER CV SET 035 PEDIATRIC 5 FRX5 CM 1 LUMEN J TIP,SUP-2760011,CDM,C1751,HCPCS,0278,RC,,,,both,,,143.00,92.95,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.8X4 MM 0.6 MM PISTON FLROPLAS,SUP-2478087,CDM,L8699,HCPCS,0278,RC,,,,both,,,286.18,186.02,,,,,,,,,,,,,
CLIP LIG HORZ TANT M 6/CR - M,SUP-2383510,CDM,C1889,HCPCS,0278,RC,,,,both,,,18.15,11.80,,,,,,,,,,,,,
TRAY PARACENT 5FR L10CM STR 1 STP CENTESIS CATHETER SLIP FIT,SUP-2303451,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
SCREW BNE LCK 5X30 MM CANN TI NS,SUP-2863427,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.62,378.05,,,,,,,,,,,,,
SPLINT ORTH AD L24IN FOR 29IN THGH UNIV KNEE FOAM,SUP-2196749,CDM,L1830,CPT,0272,RC,,,,both,,,47.19,30.67,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 3.5 MM EPTFE STR STD WALL N,SUP-2761273,CDM,C1768,CPT,0278,RC,,,,both,,,1576.09,1024.46,,,,,,,,,,,,,
SCISSORS OPHTH 25GA CRV DISP GRIESHABER REVOLUTION DSP,SUP-2109698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,617.20,401.18,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 5X7CM,SUP-2909170,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4513.75,2933.94,,,,,,,,,,,,,
COMPONENT FEM 6X2MM OFFSET UNICAP,SUP-2123699,CDM,C1776,CPT,0278,RC,,,,both,,,13993.47,9095.76,,,,,,,,,,,,,
KIT AIRFLOW SENS PRSS TRNSDUC PTAF LT FOR ALICE 5 PRO TECH,SUP-2327534,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
HC Wound Cautery-Chemical,PX-3611725000,CDM,17250,CPT,0361,RC,,,,inpatient,,,280.00,182.00,,,,,,,,,,,,,
BIT DRL 10 MM LUER,SUP-2364442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.95,205.37,,,,,,,,,,,,,
SPLINT RST PAN MIT SP M LF,SUP-2163832,CDM,L3807,HCPCS,0274,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
BIT DRL L120MM DIA2.3MM RED PROX FIX TOT WRST FUS PLT,SUP-2389437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
STEM FEM L230MM DIA14MM RT HIP CVD REV CLLRLSS U2,SUP-2391365,CDM,C1776,CPT,0278,RC,,,,both,,,19946.85,12965.45,,,,,,,,,,,,,
HC Thrmbc/Nfs Dialysis Circuit,PX-3613690400,CDM,36904,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
BUTTON FIX L14MM CLLR 7MM RND CONCAVE TWO PC FOR ACL RECON,SUP-2121396,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X219 MM LT LAT 18 HOLE BUTTRESS SS,SUP-2459691,CDM,C1713,HCPCS,0278,RC,,,,both,,,2297.60,1493.44,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY DIA 6 FR SPC 2-5-2 MM JSN,SUP-2538000,CDM,C1730,HCPCS,0272,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
TRAY KYPHOPLASTY BAL 2ML L10MM DIA11.6MM NDL 10GA SYR 20ML,SUP-2367061,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
BONESYNC PUTTY 5.0CC,SUP-2811322,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM DORS EZ FRAME,SUP-2490034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2395.82,1557.28,,,,,,,,,,,,,
CATHETER PI AGBA PICC KIT 2-L 5.5 FR X 50CM,SUP-2655670,CDM,C1751,HCPCS,0278,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
KIT INSTR SCR DISP FOR PIP JT ARTH RETROFUSION,SUP-2121841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW BONE L10MM DIA2MM HND VAR ANG LCK FLOWERCUBE,SUP-2225441,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.29,243.29,,,,,,,,,,,,,
BLADE RETRACTOR 17 CMX20 MM VES THN OLIF,SUP-2627586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1933.05,1256.48,,,,,,,,,,,,,
PLATE BONE FEMORAL 4.5X234 MM LEFT PROXIMAL 9 HOLE LOCKING F,SUP-2837598,CDM,C1713,HCPCS,0278,RC,,,,both,,,11726.33,7622.11,,,,,,,,,,,,,
TRIAL KNEE DIA38MM THK11MM ASYM TOT STBL TRIATHLON,SUP-2363808,CDM,C1776,CPT,0278,RC,,,,both,,,395.95,257.37,,,,,,,,,,,,,
HC So Trichomonas Vaginalis Amplif,PX-3068766166,CDM,87661,CPT,0306,RC,,,,both,,,120.00,78.00,,,,,,,,,,,,,
PLATE BNE L62MM 6 H ST ULN S STL LOK COMPR FOR 27MM SCR,SUP-2177321,CDM,C1713,HCPCS,0278,RC,,,,both,,,3395.06,2206.79,,,,,,,,,,,,,
GRAFT BNE 1MM 4MM RANG 30CC CHIP CRUSH FRZN CANC ALLGRFT,SUP-2264736,CDM,C1713,HCPCS,0278,RC,,,,both,,,1498.85,974.25,,,,,,,,,,,,,
NAIL IM L400MM OD11MM 130DEG LNG TI LT FEM CANN LCK GAMMA3,SUP-2362345,CDM,C1713,HCPCS,0278,RC,,,,both,,,3102.32,2016.51,,,,,,,,,,,,,
PROSTHESIS OSS BELL 1.75-4.5X0.75-3.50 MM 0.2 MM TTP-VARIO,SUP-2266603,CDM,L8613,CPT,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
PLATE LCK STRNL 8-H LAD T 1.8MM,SUP-2262585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1098.65,714.12,,,,,,,,,,,,,
CATHETER VAXCEL TUNNELED VENUS 6FR,SUP-2141137,CDM,C1751,HCPCS,0278,RC,,,,both,,,796.71,517.86,,,,,,,,,,,,,
GRASPER LAP SHFT DIA24MM WHT STL W MINIGRIP HNDL REUSE,SUP-2384376,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.07,489.50,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 4.8 FRX22-30 CM FLX STRTCH VL,SUP-2486689,CDM,C2617,HCPCS,0278,RC,,,,both,,,427.79,278.06,,,,,,,,,,,,,
KIT PERI DRNGE CATH 15.5FR BG 1000ML VLV CAP SLDE CLMP WIPE,SUP-2126463,CDM,C1729,HCPCS,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PASSER SUT NDL CAPTURE 1ST PASS,SUP-2341370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.97,327.58,,,,,,,,,,,,,
PLATE BONE L61MM 14MM 4 H DYN COMPR FOR 4.5MM SCR,SUP-2185204,CDM,C1713,HCPCS,0278,RC,,,,both,,,1450.59,942.88,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X50X0.25 MM RAPID RESORBABLE STE,SUP-2838564,CDM,C1713,HCPCS,0278,RC,,,,both,,,5088.37,3307.44,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX14 MM INDWL HRD VLV NS BLOM-SINGER,SUP-2242282,CDM,L8509,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
GUIDEWIRE 100CM FLPY SINUS RELIEVA,SUP-2106358,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-106534,CDM,2500000003,HCPCS,0250,RC,00409-1541-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PROBE SRGCL MCCLLCH 9 12NL 4MM TIP ANGLD FMNPLTN,SUP-2676451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.47,212.86,,,,,,,,,,,,,
LASER SURG SELECTA TRIO,SUP-2713770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298300.00,193895.00,,,,,,,,,,,,,
PASSER SUTURE DRAGON TNGE DEV COSURE CAPSULAR,SUP-2745457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED SET INTRO 8FR HYDRPHLC PERC FOR TRACH CIAGLIA BLU RHINO,SUP-2168708,CDM,C1769,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
BIOPSY KIT 19 GAX60 CM 7 FR TRNSJUG LIV FLX TIP 4 SWAB TLAB,SUP-2876888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
GRAFT HUM TISS 5CM OR SMER FIB SEG STRUCTURAL FRZN,SUP-2165545,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
GUIDEWIRE ENDO L360CM S STL PROG FLEX TIP TO INTRODUCE DIL,SUP-2169232,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
MESH BIO BOV MTRX WND TISS N PERF 6CM LEN 6CM W 1MM,SUP-2364669,CDM,C9359,HCPCS,0278,RC,,,,both,,,5610.05,3646.53,,,,,,,,,,,,,
SPHERE OPHTH DIA21MM BIOCOMPATIBLE W/ INSRT MEDPOR,SUP-2366489,CDM,C1713,HCPCS,0278,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
BOOT CAST OPN TOE 2XS 5.5X3 IN OPN HEEL PROCARE,SUP-2196779,CDM,L4387,HCPCS,0274,RC,,,,both,,,15.42,10.02,,,,,,,,,,,,,
PASSER SURG L 36 CM DISP,SUP-2883600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1850.59,1202.88,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CERM ON CERM CHIPZIMCERCER] ZIMMER BIOMET INC],SUP-2212520,CDM,C1776,CPT,0278,RC,,,,both,,,21022.30,13664.49,,,,,,,,,,,,,
BAR EXT FIX SM 1,SUP-2460173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3622.30,2354.49,,,,,,,,,,,,,
ELECTRODE LARYNGEAL MAGSTIM SIZE 6/7,SUP-2844648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
CATHETER ANGIO L70CM OD6FR GWIRE OD0.014IN 90DEG CRV PLCMNT,SUP-2356638,CDM,C1751,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
KIT CATH 5FR L91CM GWIRE INTRO SHTH SET SYR STPCOCK BRDG,SUP-2353170,CDM,C2628,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
HEAD FEM 5 MM HIP ALUMINIUM,SUP-2364874,CDM,C1776,CPT,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
SUTURE ETHIBOND N ABSRB L 30 IN SZ 3-0 NDL L 17 MM POLYESTER GRN,SUP-2881365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,144.60,93.99,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LIFT LOOP FOR GTT LCK RNG,SUP-2435671,CDM,L2492,HCPCS,0272,RC,,,,both,,,332.06,215.84,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.3 MM STP INSTR JUGGERLOC,SUP-2608603,CDM,C1769,HCPCS,0272,RC,,,,both,,,478.28,310.88,,,,,,,,,,,,,
CATH REPROC EP SUPREME FIX CRD 4POL 2/5/2 5FR,SUP-2526067,CDM,C1730,HCPCS,0272,RC,,,,both,,,180.49,117.32,,,,,,,,,,,,,
SCREW BNE RVS THRD 9X25 MM BIORCI,SUP-2848558,CDM,C1713,HCPCS,0278,RC,,,,both,,,623.73,405.42,,,,,,,,,,,,,
HC Pt Prosthetic Training 15 Min,PX-4209776100,CDM,97761,CPT,0420,RC,,,,outpatient,,,135.00,87.75,,,,,,,,,,,,,
PLATE CRPL 9X43MM 14MM AUG TAPR MAESTRO,SUP-2407334,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SPACER SPNL LG 25 DEG 39X29X19 MM 5.3 CC ALIF INDEPENDENCE,SUP-2733342,CDM,C1889,HCPCS,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
HC US Duplex Scan of Aorta Complt,PX-9219397800,CDM,93978,CPT,0921,RC,,,,outpatient,,,2518.00,1636.70,,,,,,,,,,,,,
DRESSING NSL L 8 CM POLYMER X FIRM BIORESORBABLE STRL DISP,SUP-2900113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.38,439.00,,,,,,,,,,,,,
PLATE BNE L 70 MM SCREW DIA2.4/2.7 MM 6 HD 4 SHFT H LT DSTL,SUP-2913554,CDM,C1713,HCPCS,0278,RC,,,,both,,,5913.19,3843.57,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2.5 MM RECON PT SPEC TI,SUP-2860099,CDM,C1713,HCPCS,0278,RC,,,,both,,,22092.10,14359.86,,,,,,,,,,,,,
PLATE BONE W12XL199MM THK1MM 11 H BILAT S STL SEMI TBLR LO,SUP-2256650,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
HINGE EXT FIX OUTBOARD 100 MM NS TRUELOK LTX,SUP-2875016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1423.21,925.09,,,,,,,,,,,,,
NEEDLE ENDOSCP 21 MMX15 CM LL SPRING LD ADIPOSE PT EMPLOYING,SUP-2769559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.33,474.71,,,,,,,,,,,,,
COMPONENT ARTC 3X3MM OFFSET PATELLOFEMORAL HEMICAP,SUP-2123663,CDM,C1776,CPT,0278,RC,,,,both,,,18648.46,12121.50,,,,,,,,,,,,,
COMPONENT FEM SZ 7 CO CHROM LT KNEE REV STEMLESS POST STBL,SUP-2346128,CDM,C1776,CPT,0278,RC,,,,both,,,19430.32,12629.71,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE ANTR TIB CUST PREFABRICATED RIGID,SUP-2435628,CDM,L1932,HCPCS,0274,RC,,,,both,,,2526.32,1642.11,,,,,,,,,,,,,
CATHETER GUID PTFE S STL BRAIDING JL 3.5 ECOPAC COR SHP,SUP-2158348,CDM,C1887,HCPCS,0272,RC,,,,both,,,557.35,362.28,,,,,,,,,,,,,
CONNECTOR SPNL 1/4 STD POST S STL UNTHREADED TRNSVRS CONN,SUP-2255598,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
PLATE BNE W7.5XL43MM THK1.6MM 5X3 H L DST VOLAR RAD S STL,SUP-2186106,CDM,C1713,HCPCS,0278,RC,,,,both,,,2293.96,1491.07,,,,,,,,,,,,,
ANCHOR VERSALOOP 1.5MM SL TAPE JNJ210216,SUP-2756509,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
STENT DIVERTER FLOW FREDX 27 4.5MM X 39 / 45,SUP-2855028,CDM,C1876,HCPCS,0278,RC,,,,both,,,41903.30,27237.14,,,,,,,,,,,,,
GENTAMICIN SULFATE 2 MG/ML IVPB (PED-NEO) >/= 50 ML|DISCARDED DRUG NOT ADMINISTE,RX-4090290,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,JW,both,50,ML,54.10,35.16,,,,,,,,,,,,,
PACEMAKER CARD VIVA W 59 X H 57 MM D 6 MM 15 CC 26 GM TI,SUP-2282346,CDM,C2621,HCPCS,0275,RC,,,,both,,,20213.72,13138.92,,,,,,,,,,,,,
BINDER MAMM SURG 3XL X SFT CUP,SUP-2113433,CDM,L8000,HCPCS,0272,RC,,,,both,,,132.82,86.33,,,,,,,,,,,,,
CATHETER NEPHSTMY 24-8FR L52CM PERCFLX STENTING N COAT PGTL,SUP-2147762,CDM,C1729,HCPCS,0272,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
HOOK SPNL BLDE W5.5MM BILAT PEDCL TI NEUT OPN FOR 5.5MM ROD,SUP-2254439,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 30X20MM,SUP-2469973,CDM,C1713,HCPCS,0278,RC,,,,both,,,5601.76,3641.14,,,,,,,,,,,,,
BLADE SCREWDRIVER 27MM DIA QUICK COUPLING CENTRE DRIVE,SUP-2694415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1496.27,972.58,,,,,,,,,,,,,
MORPHINE SULFATE-NACL 100-0.9 MG/100ML-% IV SOLN,RX-138284,CDM,J2270,HCPCS,0636,RC,09999-9912-73,NDC,,both,100,ML,136.30,88.59,,,,,,,,,,,,,
MESH HERN REP DIA15CM P4HB MFIL RESRB RND W HYDRGEL BARR,SUP-2126269,CDM,C1781,HCPCS,0278,RC,,,,both,,,10870.68,7065.94,,,,,,,,,,,,,
PLATE SPNL 1 CENTER SCREW 6X15 MM LAT INTBDY FUSION AMP,SUP-2736574,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
BLOCK FEM SZ 9 THK5MM UNIV POST KNEE CO CHROM TOT STBL FULL,SUP-2378509,CDM,C1776,CPT,0278,RC,,,,both,,,2362.54,1535.65,,,,,,,,,,,,,
BIT DRILL 1.5X90 MM FOR MINI QUICK COUPLING NON STERILE,SUP-2837639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,639.62,415.75,,,,,,,,,,,,,
GRAFT VASC 6MM DIA 20CM LEN 10CM STR STRTCH STD WALL N RNGD,SUP-2395840,CDM,C1768,CPT,0278,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
STENT BILI SELF EXP 5FR CATHETER  219CM CATHETER  LEN AMSDAM,SUP-2436439,CDM,C1876,HCPCS,0278,RC,,,,both,,,4126.84,2682.45,,,,,,,,,,,,,
CEMENT DENT 38 GM PWD ZN OXIDE-EUGENOL IRM,SUP-2176748,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.54,167.40,,,,,,,,,,,,,
NAIL IM HUM PICCOLO 8.5MMX26CM,SUP-2152631,CDM,C1713,HCPCS,0278,RC,,,,both,,,5719.82,3717.88,,,,,,,,,,,,,
DEVICE SUT L32CM OD12MM TRNSVAG STD W/O SUT DISP FOR OPN,SUP-2140345,CDM,C2631,HCPCS,0278,RC,,,,both,,,32.62,21.20,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.3X18 MM SELFTAPPING PLUSDRIVE RECESS T,SUP-2838153,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.94,187.16,,,,,,,,,,,,,
BOLT EXT FIX S STL RUS WIRE FOR ILIZ TAY SPAT FRME EXT FIX,SUP-2342844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1538.13,999.78,,,,,,,,,,,,,
BLADE GRFT HARV W165MM THK04MM CUT THK9MM 20MM DEPTH STP,SUP-2166091,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.51,221.98,,,,,,,,,,,,,
WASHER ORTH 2.7 MM TI NS FPS LTX,SUP-2856621,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
HC So1 Drg Scrn Class List A|NOT REASONABLE AND NECESSARY,PX-3018030767,CDM,80307,CPT,0301,RC,,,GZ,both,,,147.00,95.55,,,,,,,,,,,,,
AMITRIPTYLINE HCL 25 MG PO TABS,RX-435,CDM,6370000000,HCPCS,0637,RC,00904-7410-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT BNE 8-15X40 MM FIBULAR SHFT STRL BIO LF DISP,SUP-2632314,CDM,C1762,CPT,0278,RC,,,,both,,,3026.96,1967.52,,,,,,,,,,,,,
PLEDGET CV DEBAKEY L 15.2 X W 15.2 CM THK 0.57 MM POLYESTER,SUP-2761343,CDM,C1768,CPT,0278,RC,,,,both,,,366.09,237.96,,,,,,,,,,,,,
DRIVER SHFT SURG FLAT BLDE NCANNULATED N STRL REUSE 2.0MM,SUP-2364196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,812.98,528.44,,,,,,,,,,,,,
BRA SURG SUPP MED 34-36 IN ZIPPER,SUP-2213722,CDM,L8000,HCPCS,0274,RC,,,,both,,,120.54,78.35,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.510,SUP-2860027,CDM,C1713,HCPCS,0278,RC,,,,both,,,35983.46,23389.25,,,,,,,,,,,,,
HC MRI-Chest WO Contrast,PX-6107155000,CDM,71550,CPT,0610,RC,,,,outpatient,,,4190.00,2723.50,,,,,,,,,,,,,
INSERT TIB THK 10 MM SZ 3 UHMWPE RT ANK NEUT STRL CADENCE,SUP-2932828,CDM,C1776,CPT,0278,RC,,,,both,,,9478.25,6160.86,,,,,,,,,,,,,
SCREW SPNL L14MM OD4MM VAR ANG SELF DRL TI SNOWCAP,SUP-2136813,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CONNECTOR SPNL IN-LINE 6.5MM TO 6.5MM,SUP-2228082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GRAFT SFT TISS 15X30 MM BOV PERICARD MEMBRN COPIOS,SUP-2335281,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
CATHETER THROMCTMY SYM L 117 CM SHTH 16 FR GUIDEWIRE 0.035,SUP-2887255,CDM,C1757,HCPCS,0272,RC,,,,both,,,22592.30,14684.99,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LIVIAN HE TI BATTERY PWR ACUITY ENDOTK A,SUP-2149048,CDM,C1882,HCPCS,0275,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
PLATE Y 2MM 3H HD 7H SHFT TI STRL VAL,SUP-2546910,CDM,C1713,HCPCS,0278,RC,,,,both,,,1693.56,1100.81,,,,,,,,,,,,,
PLATE BONE L213MM THK6MM 9 H RT FEM CNDYL TI BTTRS RIG CLLR,SUP-2190899,CDM,C1713,HCPCS,0278,RC,,,,both,,,3042.03,1977.32,,,,,,,,,,,,,
PLATE BONE L20MM UNICOMPRESSION INTERAXIS UNI-CLIP,SUP-2243462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1959.36,1273.58,,,,,,,,,,,,,
COMPONENT ARTC SURF FIX BEAR 9 KNEE CR ATTUNE,SUP-2454950,CDM,C1776,CPT,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
STENT GRFT VASC AFX L 55 MM DIA PROX/DSTL 28 MM COCR,SUP-2217598,CDM,C1768,CPT,0278,RC,,,,both,,,16638.86,10815.26,,,,,,,,,,,,,
HYDROXYZINE PAMOATE 50 MG PO CAPS,RX-3778,CDM,6370000000,HCPCS,0637,RC,50268-0399-50,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SINGLE USE RETRIEVAL NITINOL BASKET V,SUP-2675476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1200.27,780.18,,,,,,,,,,,,,
CONNECTOR SPNL L20MM OD5.5MM S STL THORLUM OFFSET REVERE,SUP-2230984,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
SCREW INTFR L30MM DIA6-7MM TIB PLA BIOABSRB TAPR FOR SFT,SUP-2249559,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
SCREW BONE LOK 6.5MM DIA 45MML TIMAX CNCLLS HXGNL HEAD 22MML,SUP-2588747,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.52,88.09,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 100 CM 4 FR 0.038 IN H1 NONBRAIDED,SUP-2116685,CDM,C1887,HCPCS,0272,RC,,,,both,,,41.45,26.94,,,,,,,,,,,,,
HYALURONIDASE BOVINE 15 UNITS/ML IJ SYRINGE,RX-40891037,CDM,J3470,HCPCS,0636,RC,09999-9917-17,NDC,,both,0.2,ML,64.20,41.73,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL 50 DEG 18 GAX89 CM STD CRV LCK STYL TSX,SUP-2424684,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER BLLN DIL 16-17-18 MM FIX WIRE EZDILATE,SUP-2865617,CDM,C1726,HCPCS,0272,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
GRAFT SFT TISS 50 MG PARTICULATE IN VI TISS MTRX INTERFYL,SUP-2651383,CDM,Q4171,HCPCS,0636,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
NEEDLE ASPIR 700X2 MM W/O SYRINGE DISP,SUP-2482118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,814.36,529.33,,,,,,,,,,,,,
GUIDEWIRE VASC L 70 CM DIA 0.035 IN SPRING STRL,SUP-2627228,CDM,C1769,HCPCS,0272,RC,,,,both,,,35.86,23.31,,,,,,,,,,,,,
SCREW BNE L13MM OD2MM TI CORT ST SELF DRL NONLOCKING FULL,SUP-2242874,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.47,740.66,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM TEAL CRANIOMAXILLOFACIAL TI ST FULL,SUP-2188974,CDM,C1713,HCPCS,0278,RC,,,,both,,,247.93,161.15,,,,,,,,,,,,,
MESH SYNTH SM H1.3IN D1.1IN W/ KEYHOLE SLT ONLAY PLUG,SUP-2265957,CDM,C1781,HCPCS,0278,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
GRAFT BNE XS 1 CC DBM FIBER STRND +,SUP-2644300,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
KIT PHLEB W/ 5.5MM BLDE AND TBNG TRANSILLUMINATED PWR SYS,SUP-2264271,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
SYSTEM GASTRIC BANDING L ADJUSTABLE WITH OMNIFORM DESIGN ACCESS PORT I INFLATABLE KINK RESISTANT TUBING END PLUG SEAL FOR MORBID OBESITY LAP-BAND AP,SUP-2119247,CDM,C1889,HCPCS,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
ALLOGRAFT BNE MOLD 1 CC VIABLE BNE MTRX VIBONE,SUP-2731785,CDM,C1762,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
"HC So Culture, Afb",PX-3008711666,CDM,87116,CPT,0300,RC,,,,both,,,155.00,100.75,,,,,,,,,,,,,
PIN FIX L14MM DIA2MM PROV FOR EVOS SM PLATING SYS,SUP-2344052,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.68,504.84,,,,,,,,,,,,,
STEM FEM L200MM CEM MOD,SUP-2265076,CDM,C1776,CPT,0278,RC,,,,both,,,9143.68,5943.39,,,,,,,,,,,,,
CANNULA ENDOSCP TERMANIAN ENDOTIP 13 MMX15 CM STOPCOCK,SUP-2768545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1961.31,1274.85,,,,,,,,,,,,,
HC Remv & Replc Cd Gen Dual,PX-4803326300,CDM,33263,CPT,0480,RC,,,,both,,,76255.00,49565.75,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 60 X W 11 MM MYRIAD HNDPC L 13 CM NN-3001,SUP-2930298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22103.37,14367.19,,,,,,,,,,,,,
SCREW BNE CORTICAL 1.5X10 MM,SUP-2462932,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.01,43.56,,,,,,,,,,,,,
OCCLUDER SEPT L3MM DIA4MM 45DEG CRV SHTH 6FR WAIST NIT,SUP-2355672,CDM,C1817,HCPCS,0278,RC,,,,both,,,20027.92,13018.15,,,,,,,,,,,,,
MOD ARTHRO 5 DEG LCK COLLAR,SUP-2510743,CDM,C1776,CPT,0278,RC,,,,both,,,8831.25,5740.31,,,,,,,,,,,,,
PLATE BNE W10.2XL208MM THK2.7MM 16 H BILAT S STL STR LO,SUP-2186203,CDM,C1713,HCPCS,0278,RC,,,,both,,,1932.86,1256.36,,,,,,,,,,,,,
SIDEPLATE STD BARL 145 DEG 8H STRL LCP DHHS,SUP-2547674,CDM,C1713,HCPCS,0278,RC,,,,both,,,2319.58,1507.73,,,,,,,,,,,,,
CARVEDILOL 6.25 MG PO TABS,RX-15747,CDM,6370000000,HCPCS,0637,RC,68084-0854-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COLLAR SPNL DIA6MM UNIV TI 2 COR USS,SUP-2193399,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT SPNL BNE 8MMX22MM CORT FRZ DRY IMP CAPSTONE,SUP-2293984,CDM,C1713,HCPCS,0278,RC,,,,both,,,9482.80,6163.82,,,,,,,,,,,,,
PUMP CNTRFUG PED BLD 50ML PRIMING 4500RPM CONE BP50 BIO PMP,SUP-2280159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.89,278.13,,,,,,,,,,,,,
TUBE MYR DIA127MM VENT TAB SIL ST ULTRASIL PAPARELLA,SUP-2312836,CDM,L8699,HCPCS,0278,RC,,,,both,,,53.19,34.57,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 27 J TI EPOXY RESIN SIL SINGLE,SUP-2138114,CDM,C1722,HCPCS,0275,RC,,,,both,,,49502.10,32176.36,,,,,,,,,,,,,
STENT ESOPH ENDOMAXX L 100 MM DIA23 MM FLARE DIA28 MM DEL,SUP-2516651,CDM,C1874,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
LEAD NERVE STIM KT,SUP-2568744,CDM,C1778,HCPCS,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
BIT DRILL STOP 1.5X24 MM 88 MM HEXAGONAL COUPLING TITANIUM N,SUP-2841978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
CATHETER PULM ART 8FR L110CM THRMDIL 3 LUMN W/ EXTRA INFUS 4121701] ICU MEDICAL INC],SUP-2241227,CDM,C1751,HCPCS,0278,RC,,,,both,,,186.74,121.38,,,,,,,,,,,,,
STEM FEM SZ 13.5 L HIP CLLRLSS STD BODY DST TEXT APR,SUP-2210973,CDM,C1776,CPT,0278,RC,,,,both,,,28228.60,18348.59,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 5CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2491576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.35,234.23,,,,,,,,,,,,,
HC Drug Assay Cyclosporine,PX-3018015800,CDM,80158,CPT,0301,RC,,,,both,,,326.00,211.90,,,,,,,,,,,,,
KIT CATH PLEUR CHLORAPREP FEN DRP FLTR STRW FOAM CATH PD,SUP-2133738,CDM,C1729,HCPCS,0272,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.054X9 IN SS NS KIRSCHNER,SUP-2791356,CDM,C1713,HCPCS,0278,RC,,,,both,,,10.11,6.57,,,,,,,,,,,,,
CUFF SURG TRNQT 12IN SGL BLDR PRT PNEUMAT ELECTR PED CONIC,SUP-2208887,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.49,274.62,,,,,,,,,,,,,
ROD THRD RINGFIX SYS 80MM,SUP-2460077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA2MM 6.5MM OLV 45MM THRD GEN INSTRMT,SUP-2318882,CDM,C1769,HCPCS,0272,RC,,,,both,,,732.25,475.96,,,,,,,,,,,,,
KIT H CVR UNIV UHMWPE FOR REV ACET SYS REDAPT,SUP-2345484,CDM,C1776,CPT,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,6370000000,HCPCS,0637,RC,75834-0170-01,NDC,,both,28.4,GR,23.70,15.40,,,,,,,,,,,,,
NAIL IM 11X300MM 125DEG LNG W/ 2MM SET SCR GAM SYS,SUP-2370024,CDM,C1713,HCPCS,0278,RC,,,,both,,,6097.25,3963.21,,,,,,,,,,,,,
DRILL SURG N CANN LNG FOR 3.5 MM SCREW,SUP-2598342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
INSERT TIB SZ 6 THK17MM STD FIX GMK,SUP-2267548,CDM,C1776,CPT,0278,RC,,,,both,,,2179.91,1416.94,,,,,,,,,,,,,
SCREW INTRF KNEE CANN ABSRB POLY-L LACTIC ACID TAPR HD 7MM,SUP-2341690,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
TRAY DRAINAGE CATH RESOLV DIA14 FR STAYFIX SECUREMENT DEV,SUP-2461755,CDM,C1729,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BONE CURVED 12 MM 1 MM 6 HOLE TITANIUM NON STERILE,SUP-2837791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.08,945.80,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.4MM S STL CORT PERIARTC CONIC ST,SUP-2410748,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.41,161.47,,,,,,,,,,,,,
PROSTHESIS OSS 1.80X3 MM 1.45X37 MM DSTL END CUP TI HA ALTO,SUP-2232499,CDM,L8613,CPT,0278,RC,,,,both,,,1159.98,753.99,,,,,,,,,,,,,
PLATE BNE L 77 MM SCREW DIA2.4/2.7 MM 6 HD 5 SHFT H LT DSTL,SUP-2913602,CDM,C1713,HCPCS,0278,RC,,,,both,,,6429.15,4178.95,,,,,,,,,,,,,
BLADE SURG W/O HNDL STR ATRAUM CAPSLTMY STRL DISP SAFECUT,SUP-2910463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
EEA CIR STPLR W TRISTAPLE TECHNOLOGY 28MM M THICK,SUP-2172449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1366.97,888.53,,,,,,,,,,,,,
MESH 2X4IN PROL SFT POLYPR SYN ABD NONABSORBABLE RECT SFT,SUP-2219920,CDM,C1781,HCPCS,0278,RC,,,,both,,,4600.82,2990.53,,,,,,,,,,,,,
CANNULA ARTRL EC 14FR DIA 38IN ACCPTNCE CRMDA BCTVE HPRN CT,SUP-2725868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1087.57,706.92,,,,,,,,,,,,,
KIT ORTH DRL DIA 3.5 MM K WIRE DIA1.3 MM CANN STRL DISP,SUP-2913234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 100X100X0.6 MM RIGID SLV NS,SUP-2859897,CDM,C1713,HCPCS,0278,RC,,,,both,,,6556.32,4261.61,,,,,,,,,,,,,
GRAFT BLK CERV CORT ALLGRFT 7MMX14MMX11MM,SUP-2289235,CDM,C1763,HCPCS,0278,RC,,,,both,,,2815.80,1830.27,,,,,,,,,,,,,
BIT DRL CANN 2.9X140 MM STRL,SUP-2607154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,656.29,426.59,,,,,,,,,,,,,
SCREW STEREOTACTIC SYS LNG HD RNG DISP,SUP-2244000,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.98,440.04,,,,,,,,,,,,,
SPACER RAD THER SPACEOAR VUE,SUP-2421823,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
PACK SAW BLDE 64MM D405MM CUT EDGE 10MM THK12MM FOR PWR,SUP-2365142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3176.64,2064.82,,,,,,,,,,,,,
COMPONENT TIB BASEPLT M/L 63MM A/P 41MM PROVEN GEN-FLEX,SUP-2390299,CDM,C1776,CPT,0278,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FR BASIC TY POWERPICC SOLO 2,SUP-2126378,CDM,C1751,HCPCS,0278,RC,,,,both,,,359.15,233.45,,,,,,,,,,,,,
GASTROSCOPE FLEXIBLE ASCOPE  210DEG AUXILIARY,SUP-2844707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
ROD SPNL 4.5X500 MM SS SHILLA,SUP-2630594,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
TEMPLATE SURG LO PROF FIX STD POST XLNK PLT,SUP-2290317,CDM,C1713,HCPCS,0278,RC,,,,both,,,416.46,270.70,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SLOM BALLOON L 24 MM DIA 7 MM DURALYN,SUP-2159226,CDM,C1876,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.025 INX260 CM HYDRPHLC COAT NAVIPRO,SUP-2141537,CDM,C1769,HCPCS,0272,RC,,,,both,,,322.76,209.79,,,,,,,,,,,,,
SCREW BNE 2X8 MM 6 MM DRILL-FREE TI STRL L1 MAXDRIVE,SUP-2540173,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.54,311.05,,,,,,,,,,,,,
QUICKSET ACE GRATER HEAD 39MM,SUP-2514445,CDM,C1776,CPT,0278,RC,,,,both,,,1532.32,996.01,,,,,,,,,,,,,
GRAFT BONE THK5MM FNGR JT LAPIDUS WDG,SUP-2321673,CDM,C1713,HCPCS,0278,RC,,,,both,,,7313.69,4753.90,,,,,,,,,,,,,
BLADE RETRCT L5CM BLK FINISH SHRP HK SPNL MED LAT SELF RET,SUP-2382491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.28,280.98,,,,,,,,,,,,,
RING TRACTIONXSM 14-16IN CERV CLOSE BK W/ 2.5IN SKULL AND,SUP-2328117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
CATHETER PICC ARROWG+ARD BLUE ADVANCE 4.5FR 55CM 1-LUMEN,SUP-2887064,CDM,C1751,HCPCS,0278,RC,,,,both,,,645.80,419.77,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135CM 5FR SLT 5CM 0.035 IN BALL,SUP-2117041,CDM,C1757,HCPCS,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
BIT DRL 2.5 MM W/ MINI-QUICK CONN ALPS,SUP-2606626,CDM,2720000010,LOCAL,0272,RC,,,,both,,,165.29,107.44,,,,,,,,,,,,,
STAPLE BNE FIX 18X18X18MM NIT SUPERPLASTIC DYNAFORCE,SUP-2175184,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
RING EXT FIX FOOT LNG HOFF ALUM 180MM,SUP-2496206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5174.72,3363.57,,,,,,,,,,,,,
HC Mammo Dgx Bilateral Incl Cad if Perf,PX-4017706600,CDM,77066,CPT,0401,RC,,,,inpatient,,,710.00,461.50,,,,,,,,,,,,,
BIT DRL OD25MM CANN LAPIDUS SYS,SUP-2316382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,666.37,433.14,,,,,,,,,,,,,
PLATE BONE L130MM THK4.5MM 5 H LT LAT TIB HD BTTRS TI RIG,SUP-2190894,CDM,C1713,HCPCS,0278,RC,,,,both,,,2506.88,1629.47,,,,,,,,,,,,,
FIBER LASER 200 MH SHTH SCP SAFE FLEXG STRL CALCULASE DISP,SUP-2778002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.70,771.35,,,,,,,,,,,,,
LEAD DEFIB RELIANCE SG ACTIVE FIX STRL,SUP-2139725,CDM,C1777,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
ALLOGRAFT BNE MACHINED 10MMX3IN PLIF PUROS,SUP-2684813,CDM,C1713,HCPCS,0278,RC,,,,both,,,10343.16,6723.05,,,,,,,,,,,,,
IMPLANT TISSUE CONNECTIVE FLOW 4CC,SUP-2880217,CDM,C1762,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 5.01-6.0 MCI NS ADVANTAGE,SUP-2247274,CDM,C2643,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
INSERTER SURG LNR RVS TRABECULAR MTL,SUP-2436883,CDM,C1776,CPT,0278,RC,,,,both,,,4309.65,2801.27,,,,,,,,,,,,,
SLEEVE SURG SFT TISS WORKING CHANNEL,SUP-2460475,CDM,C1713,HCPCS,0278,RC,,,,both,,,2709.82,1761.38,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX7 TTNM F/2.7MM SCREW UNVRSL LOK S,SUP-2493084,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.32,544.91,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 5",PX-7619921500,CDM,99215,CPT,0761,RC,,,,both,,,369.00,239.85,,,,,,,,,,,,,
PUSHER STENT ADVANIX SZ 4/5 FR PANCREATIC OTW STRL,SUP-2141440,CDM,C1889,HCPCS,0278,RC,,,,both,,,157.69,102.50,,,,,,,,,,,,,
TUBE VENT DIA1.4MM INNR FLNG DIA3.5MM SIL BVL ARMSTR GRMMT,SUP-2284006,CDM,L8699,HCPCS,0278,RC,,,,both,,,74.26,48.27,,,,,,,,,,,,,
GUIDEWIRE VASC STRT L 150 CM DIA 0.035 IN TIP L 10 CM DIA15,SUP-2148315,CDM,C1769,HCPCS,0272,RC,,,,both,,,67.29,43.74,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 10 MM CUBE,SUP-2547186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.72,748.62,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST EXT STL SHANK,SUP-2435661,CDM,L2360,HCPCS,0272,RC,,,,both,,,145.98,94.89,,,,,,,,,,,,,
BLADE SAW LG 70X13X1.24 MM STRYKR SALTO TALARIS,SUP-2365910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
GRAFT VASC HERO L 40 CM OD 19 FR ID 5 MM SIL NIT VEN OUTFLO,SUP-2516633,CDM,C1768,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
TWNFX TI 2.8 HS 2 USP NO 2-0,SUP-2341010,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.66,467.78,,,,,,,,,,,,,
MARKER SURG FOR ATEC SECURMARK,SUP-2240034,CDM,A4648,CPT,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
SCREW BONE L12MM OD2.6MM FULL THRD COMPR,SUP-2224034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
BLADE RETRACTOR KOROS 1.25 IN SELF RET,SUP-2444062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
WIRE MANDRIN VAN BUREN CRV 6FR,SUP-2160578,CDM,C1769,HCPCS,0272,RC,,,,both,,,95.90,62.33,,,,,,,,,,,,,
SCREW SPNL HEX 2X17 MM ETCHED DRL FREE TI MMF,SUP-2468626,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.63,387.16,,,,,,,,,,,,,
NEEDLE SPNL TARGETING TELLURIDE,SUP-2687388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
AGENT HEMOSTATIC 4X3 CM SYVEKEXCEL,SUP-2266128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BONE TMT RIGHT,SUP-2427832,CDM,C1713,HCPCS,0278,RC,,,,both,,,6692.91,4350.39,,,,,,,,,,,,,
HC Multiple Sleep Latency or Maintenance Wakefulness Test,PX-9209580500,CDM,95805,CPT,0920,RC,,,,inpatient,,,6931.00,4505.15,,,,,,,,,,,,,
GRAFT BNE PTTY 3 CC MOLD DBM XEMPLIFI +,SUP-2423062,CDM,C9359,HCPCS,0278,RC,,,,both,,,1654.78,1075.61,,,,,,,,,,,,,
SCREW SPNL L14MM S STL ST THRD UNIV BULL SHP HD DISTR PIN,SUP-2274177,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.83,44.74,,,,,,,,,,,,,
KIT CATH 7FR L30CM CTRL VEN POLYUR 3 LUMN ARWGRD + BLU,SUP-2120596,CDM,C1751,HCPCS,0278,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
HEAD HUM OD40MM CO CHROM PROX SHLDR MORSE TAPR MRS,SUP-2376488,CDM,C1776,CPT,0278,RC,,,,both,,,8482.24,5513.46,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PTCH THN 4X8 CM AMNIO TISS MEMBRN CYGNUS,SUP-2422824,CDM,Q4170,HCPCS,0636,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
TI LCP DIA-META VOLAR DISTAL RADIUS PL 15H SHAFT/RT-STERILE,SUP-2546642,CDM,C1713,HCPCS,0278,RC,,,,both,,,5258.34,3417.92,,,,,,,,,,,,,
BIT DRL 2.5X18 MM FOR ACP SYS VAN GOGH,SUP-2661683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
POST EXT FIX 3 H S STL M SUPP FOR ILIZ TAY SPAT FRME SYS,SUP-2342287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,922.88,599.87,,,,,,,,,,,,,
SNARE ENDOVASC L120CM WRK DIA12-20MM COLLAPSED DIA0.055IN,SUP-2302537,CDM,C1773,HCPCS,0272,RC,,,,both,,,978.02,635.71,,,,,,,,,,,,,
INTRODUCER INTUB FROVA,SUP-2169466,CDM,C1894,HCPCS,0272,RC,,,,both,,,233.15,151.55,,,,,,,,,,,,,
BIT DRL L190MM OD3MM TIBIO TALO CALCNL LO EXT FOR 4.5MM SCR,SUP-2243130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME RT KNEE FOURCEPOINT HINGE L/TH,SUP-2914912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1424.74,926.08,,,,,,,,,,,,,
GUIDEPIN SURG L17.5IN DIA3.2MM THRD FOR AFFIXUS HIP FRAC,SUP-2413924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
TRAY HUM DIA44MM +10MM OFFSET CO CHROM FOR REV SHLDR SYS,SUP-2404734,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
BRACE KNEE HNG WRP 2X L,SUP-2276699,CDM,L1820,HCPCS,0274,RC,,,,both,,,55.08,35.80,,,,,,,,,,,,,
CATHETER EP CRD 2-10-2 MM 6 FRX120 CM RESPON,SUP-2356775,CDM,C1730,HCPCS,0272,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
HEAD FEM SKIRTED 15+ MM 14/16 32 MM OFFSET TAPR STD STYL,SUP-2249720,CDM,C1776,CPT,0278,RC,,,,both,,,2013.37,1308.69,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN MICRO 38SQCM,SUP-2909168,CDM,Q4158,HCPCS,0636,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
GRAFT BNE SUB W14XH8XL14MM CORT INTBDY FUS FRZ DRY BLK SPCR,SUP-2293782,CDM,C1713,HCPCS,0278,RC,,,,both,,,2650.16,1722.60,,,,,,,,,,,,,
CATHETER ART PRESSURE MONITORING SET 018 3 FRX5 CM RADIAL,SUP-2760107,CDM,C1751,HCPCS,0278,RC,,,,both,,,144.91,94.19,,,,,,,,,,,,,
PLATE BNE PROF THK 0.6 MM SCREW DIA1. 5 MM TI MIDFACE FLAT,SUP-2883893,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
PLATE BONE L28MM THK0.3MM 6 H CRANIOMAXILLOFACIAL TI STR FOR,SUP-2136520,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
CATHETER GUID TRAPLINER DIA 6 FR RX L 13 CM PUSH ROD 0.02,SUP-2558715,CDM,C1887,HCPCS,0272,RC,,,,both,,,1912.26,1242.97,,,,,,,,,,,,,
CATHETERIZATION KIT ART 018 20 GAX3.8 CM 25 GA 3 CC LF,SUP-2865591,CDM,C1751,HCPCS,0278,RC,,,,both,,,121.83,79.19,,,,,,,,,,,,,
SYSTEM PRESSURE MEAS NDL L 8 CM DIA25 GA SHTH 5.2 FR CONN,SUP-2881797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6170.10,4010.56,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CONSTRN PS VIVACIT-E PERSONA,SUP-2212504,CDM,C1776,CPT,0278,RC,,,,both,,,15464.50,10051.92,,,,,,,,,,,,,
BLOCK CUT PROX TIB KNEE GUID VISIONAIRE GEN II,SUP-2351432,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
KIT PRP BLD PROC 3 CYCL UPTO 180ML PROGRAMMABLE ANGEL,SUP-2120733,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
EXPANDER BRST W10.7XH9.3CM P6.2CM 275CC SIL NACL SHELL RND M,SUP-2300631,CDM,C1789,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
FILTER IVC BIOCONVERTIBLE FOR SENTRY SYS,SUP-2416859,CDM,C1880,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PROBE NSL STR 90 DEG W/ RT HND MIRROR,SUP-2713679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.80,483.47,,,,,,,,,,,,,
GRAFT HUM TISS 6-10MM 15CC CANC CUBE,SUP-2293751,CDM,C1713,HCPCS,0278,RC,,,,both,,,1366.40,888.16,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 14H 262MM RIGHT STERILE,SUP-2549649,CDM,C1713,HCPCS,0278,RC,,,,both,,,5237.58,3404.43,,,,,,,,,,,,,
LEAD TRL L50CM SPNL CRD PERC W ENH STYL IMAG RDY MRI FULL,SUP-2436546,CDM,C1778,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SYSTEM IMPLANT ECLIPSE SPEEDCAP,SUP-2753230,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
MESH HERN L W1.6XL1.9IN INGUINAL WHT POLYPR MFIL PLUG PTCH,SUP-2125752,CDM,C1781,HCPCS,0278,RC,,,,both,,,661.28,429.83,,,,,,,,,,,,,
PLATE BNE 3 H TI ALLOY STR NS LEOS,SUP-2933587,CDM,C1713,HCPCS,0278,RC,,,,both,,,3127.44,2032.84,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 26-50 MMX0.1 CM FRZN,SUP-2717859,CDM,C1762,CPT,0278,RC,,,,both,,,2342.09,1522.36,,,,,,,,,,,,,
GRAFT TEND HUNTER RNG KNOB END ACT LEN 18CM LX4MM W,SUP-2399192,CDM,C1713,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
INSTRUMENT OPHTH OD20 GA BACKFLUSH BLNT NDL NONSTERILE,SUP-2213455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
CLIP ANEUR BLDE L8.3MM MAX OPN 6.8MM 180GM PERM PHYNOX STD,SUP-2108378,CDM,C1889,HCPCS,0278,RC,,,,both,,,1588.15,1032.30,,,,,,,,,,,,,
STEM TIB L75MM DIA10MM KNEE EXTN STABILIZING PRI FLUT,SUP-2253311,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.26,2365.52,,,,,,,,,,,,,
KIT LASER L65CM 0.035IN NEEDLE 21GA 4FR TRE-SHEATH HYDROPHILIC STAINLESS STEEL BRAID INTRODUCER GOLD TIP FIBER ENDOVENOUS PROCEDURE NEVERTOUCH VENACURE,SUP-2116797,CDM,C1888,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BIT DRL L 205/110 MM DIA2.8 MM CALIB AO QC NS REUSE V,SUP-2908491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,858.85,558.25,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO XL BK SPK COMPLETE PANEL QUICKDRAW,SUP-2124228,CDM,L1620,HCPCS,0274,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SPLINT WR AD L 9IN LNG LT COT W/ STAY ELAS SUPP FOR,SUP-2324570,CDM,L3809,HCPCS,0272,RC,,,,both,,,36.86,23.96,,,,,,,,,,,,,
MESH SURG ELLIP 8X6 IN W/ FEN PORCINE COLLAMEND FM,SUP-2126252,CDM,C1781,HCPCS,0278,RC,,,,both,,,10133.57,6586.82,,,,,,,,,,,,,
KIT DISP W/ SPEAR DRL AND TENSIONER CUT FOR KNOTLESS,SUP-2121610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PLATE BONE L W12XL103MM THK1MM 6 H BILAT TI SEMI TBLR LO,SUP-2190704,CDM,C1713,HCPCS,0278,RC,,,,both,,,275.91,179.34,,,,,,,,,,,,,
TAP BONE SPNL COLORADO 2 4.5MM DIA,SUP-2290560,CDM,C1713,HCPCS,0278,RC,,,,both,,,4502.76,2926.79,,,,,,,,,,,,,
Elite H Continuous Compression Implant 20x20x13mm 4 Legs,SUP-2550446,CDM,C1713,HCPCS,0278,RC,,,,both,,,6591.93,4284.75,,,,,,,,,,,,,
PROBE BRST BX DIA10GA VERTICAL ENCOR,SUP-2126859,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BRACE KNEE HNG WRP L,SUP-2276700,CDM,L1820,HCPCS,0272,RC,,,,both,,,56.68,36.84,,,,,,,,,,,,,
PEN ABLAT ELECTRD L30MM BPLR LIN COOLRAIL,SUP-2124462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSPLIT CHRONIC STD 14.5FR DIA LG LUM,SUP-2613295,CDM,C1750,HCPCS,0278,RC,,,,both,,,1486.95,966.52,,,,,,,,,,,,,
GRAFT BNE 30CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264819,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.51,693.88,,,,,,,,,,,,,
DILATOR VASC OD8-10FR PASS,SUP-2141507,CDM,C1726,HCPCS,0272,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
EPIFIX MESHED 4.5X4.5CM  11SQ CM,SUP-2305743,CDM,Q4186,HCPCS,0636,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
SUPPORT ORTHOT CUST OUTRIG,SUP-2435578,CDM,L1080,HCPCS,0272,RC,,,,both,,,148.15,96.30,,,,,,,,,,,,,
MATRIX BIO L 7 X W 7 CM BOV CLLGN CHONDROITIN-6-SULFATE,SUP-2909259,CDM,Q4105,HCPCS,0636,RC,,,,both,,,9178.85,5966.25,,,,,,,,,,,,,
SCREW SPNL L11MM DIA4MM ANT CERV SELF DRL FOR STD ALONE,SUP-2293584,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
ROD ORTH THRD 100 MM PILLAR,SUP-2749918,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
PLATE CRAN 160X80X40 MM PT SPEC IMPL PEEK,SUP-2860142,CDM,C1713,HCPCS,0278,RC,,,,both,,,37796.81,24567.93,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 4 MG/ML IJ SOLN,RX-142448,CDM,J2272,HCPCS,0636,RC,63323-0454-00,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
IMPLANT TOE SZ 30 FOREFOOT PRIMUS GREAT W/ GRMMT FUTURA,SUP-2399910,CDM,C1776,CPT,0278,RC,,,,both,,,3570.18,2320.62,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ TAB 1.27 MM ID STRL MORETZ,SUP-2284047,CDM,L8699,HCPCS,0278,RC,,,,both,,,60.32,39.21,,,,,,,,,,,,,
HARVESTING SET 4.5 MM CHSL TAMP DRL BIT GRN MOSAICPLASTY DP,SUP-2878033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1391.33,904.36,,,,,,,,,,,,,
PLATE BNE L396MM 17 H R DST FEM S STL LOK COMPR FOR 45MM SCR,SUP-2177826,CDM,C1713,HCPCS,0278,RC,,,,both,,,5114.78,3324.61,,,,,,,,,,,,,
CATHETER CV DL 13.5 FR HICKMAN,SUP-2627027,CDM,C1751,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
GRAFT BONE SUB 25GM CA PHOS CRANIOMAXILLOFACIAL FULL DOSE HI,SUP-2365154,CDM,C1713,HCPCS,0278,RC,,,,both,,,7582.63,4928.71,,,,,,,,,,,,,
PROBE COAG L350CM CHN 28MM TIP 7FR 2 PLUG W FIX PIN CONN,SUP-2313020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.90,534.88,,,,,,,,,,,,,
COMPONENT TIB CR 5 UNIV 10 MM NP PRIMARY CEM STEM MONOBLOCK,SUP-2378461,CDM,C1776,CPT,0278,RC,,,,both,,,2859.91,1858.94,,,,,,,,,,,,,
COLLAR CERV MED DENS 2XS PEDIATRIC 14X2 IN FRM FIT PROCARE,SUP-2195744,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.83,7.04,,,,,,,,,,,,,
HC Asp Lum Disc Single/Multi Lev,PX-3616228700,CDM,62287,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
COMPONENT TIB MONOBLOCK UNI UNIV PRI STEM CEM NP POLYETH SZ,SUP-2215732,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
STEM FEM L200MM DIA17MM DSTL CALCAR HIP TI MOD DPHSEAL MLRY,SUP-2403938,CDM,C1776,CPT,0278,RC,,,,both,,,9209.62,5986.25,,,,,,,,,,,,,
PLATE BNE PANCARPAL 2/2.7 MM 11 HOLE ARTH SS LCP,SUP-2569398,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.542,SUP-2860059,CDM,C1713,HCPCS,0278,RC,,,,both,,,52173.93,33913.05,,,,,,,,,,,,,
SPLINT THUMB WRIST L AD L8IN L D RNG ABD FIRM SUPP W STAY,SUP-2194734,CDM,L3807,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
HC So Ca 125,PX-3028630466,CDM,86304,CPT,0302,RC,,,,inpatient,,,221.00,143.65,,,,,,,,,,,,,
PACEMAKER CARD MERID TI 2 CHMBR IS1 COMPATIBLE CONN UPLR,SUP-2139585,CDM,C1785,HCPCS,0275,RC,,,,both,,,14428.30,9378.39,,,,,,,,,,,,,
CATHETER CV SET 018 3 FRX8 CM 1 LUMEN J TIP,SUP-2760114,CDM,C1751,HCPCS,0278,RC,,,,both,,,143.44,93.24,,,,,,,,,,,,,
IMPLANT FACE 76 X 127 MM THK 0.85 MM POLYETHYL CRANIOFACIAL,SUP-2883399,CDM,C1713,HCPCS,0278,RC,,,,both,,,3629.34,2359.07,,,,,,,,,,,,,
PLATE BONE 4 H N COMPR MAND BILAT TI 2.3MM SCR L 30MM,SUP-2262996,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT VASC PROPATEN L 5 CM DIA 3 MM EPTFE CBAS HEPARIN TW,SUP-2655620,CDM,C1768,CPT,0278,RC,,,,both,,,2395.82,1557.28,,,,,,,,,,,,,
PLATE BNE L333MM BLDE W5.8XL38MM 135DEG 20 H ST BILAT PELV,SUP-2186592,CDM,C1713,HCPCS,0278,RC,,,,both,,,3152.34,2049.02,,,,,,,,,,,,,
SCREW BONE L2MM DIA1MM GLD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189033,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.32,230.31,,,,,,,,,,,,,
CATHETER ETER GUID 70DEG TIP F 70 DST SNUS SFT RELIEVA FLX,SUP-2546012,CDM,C1726,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
JOINT FNGR 50 MP SIL,SUP-2852976,CDM,C1776,CPT,0278,RC,,,,both,,,4812.40,3128.06,,,,,,,,,,,,,
STEM FEM SZ 13 L130MM PF VERSYS LD/FX,SUP-2203064,CDM,C1776,CPT,0278,RC,,,,both,,,4257.84,2767.60,,,,,,,,,,,,,
PLATE BNE L391MM 16 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186052,CDM,C1713,HCPCS,0278,RC,,,,both,,,5632.78,3661.31,,,,,,,,,,,,,
COMPONENT FEM AUG DSTL LG KNEE OSSEO TI OSS,SUP-2441762,CDM,C1776,CPT,0278,RC,,,,both,,,5397.66,3508.48,,,,,,,,,,,,,
DRILL SURG DIA3.2MM CORACOID STP FOR BRISTOW LATARJET,SUP-2256872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
SCREW BNE CANN 5.7X75 MM CRTX ST LCK PERI-LOC,SUP-2340940,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.13,81.33,,,,,,,,,,,,,
COMPONENT FEM SZ C L POST STBL NXGN,SUP-2201883,CDM,C1776,CPT,0278,RC,,,,both,,,7853.45,5104.74,,,,,,,,,,,,,
SPLINT ORTH M WRST FA HND R FRAC FIRM SUPP ALUMINUM POLY,SUP-2276769,CDM,L3809,HCPCS,0272,RC,,,,both,,,14.48,9.41,,,,,,,,,,,,,
IMPLANT HUM TISS L 5 X W 5 CM AMNIO MEMBRN LYOPRESERVED,SUP-2905514,CDM,Q4133,HCPCS,0636,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|ADJ|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4409753000,CDM,97530,CPT,0440,RC,,,GP|ADJ|CO,both,,,191.00,124.15,,,,,,,,,,,,,
SHEATH INTRO COMPANION SHTH L 30 CM OD 3.01 MM ID 7 FR,SUP-2889619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BUR 55MM LNG EGG ATTCH,SUP-2363365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.40,504.66,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X1 CM TERMINALLY STRL WND NEOX CRD RT,SUP-2648694,CDM,Q4148,HCPCS,0636,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
MODEL ANAT FULL SKULL AD 3D CT BASE OSTEOVIEW,SUP-2883675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6203.82,4032.48,,,,,,,,,,,,,
"HC NM Tumor Localization,Whole Body",PX-3417880400,CDM,78804,CPT,0341,RC,,,,both,,,5060.00,3289.00,,,,,,,,,,,,,
HC So Chimerism Anal W/Cell Select,PX-3018126866,CDM,81268,CPT,0301,RC,,,,outpatient,,,329.00,213.85,,,,,,,,,,,,,
ROPINIROLE HCL 1 MG PO TABS,RX-21689,CDM,6370000000,HCPCS,0637,RC,60687-0588-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PROVEN REV MOD FEM SZ 1,SUP-2359348,CDM,C1776,CPT,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
SCREW BONE L25MM DIA5MM HD CORT DYNANAIL,SUP-2277461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
GRAFT VASC L60CM DIA6MM PTFE NONRINGED STD CUF FLX SM BEAD,SUP-2128076,CDM,C1768,CPT,0278,RC,,,,both,,,13482.09,8763.36,,,,,,,,,,,,,
BOLT EXT FIX PHOENIX,SUP-2495102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.05,304.88,,,,,,,,,,,,,
COLLAR CERV M AD W3.5XL23.5IN M DENS CNTOUR CNTCT CLSR FOAM,SUP-2197375,CDM,L0120,HCPCS,0272,RC,,,,both,,,17.46,11.35,,,,,,,,,,,,,
STEM FEM CEM -5 MM 5 9X175 MM 25 MM HIP CRV REDUC NK TAPR,SUP-2376613,CDM,C1776,CPT,0278,RC,,,,both,,,15848.21,10301.34,,,,,,,,,,,,,
BOLT EXT FIX S STL LNG WIRE SLT FOR ILIZ TAY SPAT FRME SYS,SUP-2342847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1934.08,1257.15,,,,,,,,,,,,,
GRAFT VASC BEND 4 IN SEAL OUTFLO HEARTMATE II,SUP-2356000,CDM,L8670,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX28 CM SET W/ STYL SYMETREX,SUP-2627450,CDM,C1750,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
INSERT TIB THICKNESS 8.5MM SM UNIV STD POLYETH PRI NEUT IMP,SUP-2200347,CDM,C1776,CPT,0278,RC,,,,both,,,5960.98,3874.64,,,,,,,,,,,,,
PLATE BONE 6X42MM ULN BILAT CROSSLOCK DVR,SUP-2137043,CDM,C1713,HCPCS,0278,RC,,,,both,,,5006.54,3254.25,,,,,,,,,,,,,
IMPL ANKLE SUBFIX 9MM,SUP-2706710,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
BOOT CAST ASMBLY ROCKER BTM,SUP-2162677,CDM,L4361,HCPCS,0272,RC,,,,both,,,4220.16,2743.10,,,,,,,,,,,,,
TRAY KYPHOPLASTY BAL 4ML L10MM DIA18.3MM NDL 10GA SYR 20ML,SUP-2361537,CDM,C1727,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
KIT IM NAIL L150MM DIA10MM PROX HUM LCK,SUP-2412505,CDM,C1713,HCPCS,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 6 HOLE BOX CAR 17MM TITANIUM,SUP-2825715,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.71,181.81,,,,,,,,,,,,,
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-101486,CDM,J1742,HCPCS,0636,RC,00009-3794-01,NDC,,both,10,ML,695.30,451.94,,,,,,,,,,,,,
SYSTEM VLV REP TRICLIP G4 TRICSP VLV TRANSCATHETER EDGE TO,SUP-2895994,CDM,C1889,HCPCS,0278,RC,,,,both,,,122460.00,79599.00,,,,,,,,,,,,,
HC Driver Training 1 Hr,PX-9900000138,CDM,9900000138,LOCAL,0990,RC,,,,both,,,325.00,211.25,,,,,,,,,,,,,
PLATE BNE STR 2 HOLE OMNI,SUP-2610109,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
CEMENT DELIEVERY KIT 13 GA NDL PARALLAX EZ FLO,SUP-2342022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
ANCHOR SUT L15.5MM DIA5MM W/ TWO SZ 2 FIBERWIRE CRKSCR II,SUP-2121501,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CLAMP REPROC PIN HII MRI 5 HL,SUP-2462897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.13,396.58,,,,,,,,,,,,,
ST APG SYNV RASP SM +7 LINV,SUP-2514073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.46,470.25,,,,,,,,,,,,,
K WIRE FIX L6IN DIA0.062IN TRCR PNT 6PK,SUP-2412238,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.57,111.52,,,,,,,,,,,,,
CAP NAIL HUM 8.5X10 MM AG RETROGRADE STRL AFFIXUS NAT NAIL,SUP-2606874,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
GUIDEWIRE VASC PRELUDE L 45 CM DIA 0.025 IN NIT PLAS RADIAL,SUP-2677291,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.11,48.82,,,,,,,,,,,,,
SPHINCTEROTOME WRK CHN 37MM DST TIP DIA44FR GWIRE DIA0035IN,SUP-2313229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,864.35,561.83,,,,,,,,,,,,,
BIT DRL FOR 11MM LAG SCR TRIGEN INTERTAN SYS,SUP-2347571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
RESERVOIR PORT PEDIATRIC SMALL L14MM TITANIUM RADIOPAQUE CSF,SUP-2830490,CDM,C1889,HCPCS,0278,RC,,,,both,,,887.84,577.10,,,,,,,,,,,,,
IMPLANT OPHTH MERIDIONAL 10.5 MM RETINAL STYL 106,SUP-2263421,CDM,L8610,HCPCS,0278,RC,,,,both,,,61.86,40.21,,,,,,,,,,,,,
PLATE BONE LOK 77MML HLX3/6 HD/SHFT STNLSS STEEL T SHPD NON,SUP-2499014,CDM,C1713,HCPCS,0278,RC,,,,both,,,2566.67,1668.34,,,,,,,,,,,,,
BIT DRILL JLATCH 1.7 MM 4 MM WITH STOP FOR RAPIDSORB IPS STE,SUP-2837905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.78,445.76,,,,,,,,,,,,,
PLATE BONE L18MM 6 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413743,CDM,C1713,HCPCS,0278,RC,,,,both,,,811.97,527.78,,,,,,,,,,,,,
PIN FIX POLY LOK OSS,SUP-2405829,CDM,C1776,CPT,0278,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
CATHETER ANGIOPLSTY STELLAREX L 135 CM DIA 6 FR BALLOON L,SUP-2420208,CDM,C2623,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
HC So Morph Analy Insitu Dist Serv,PX-3128836766,CDM,88367,CPT,0312,RC,,,,both,,,110.00,71.50,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 80 MM DIA 7 MM CATH L 130 CM DIA 6,SUP-2128192,CDM,C1876,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PUMP THROMCTMY FOR 3000 SER SYS ANGIOJET,SUP-2277416,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HYDROCORTISONE BUTYRATE 0.1 % EX CREA,RX-10214,CDM,6370000000,HCPCS,0637,RC,51672-4074-01,NDC,,both,15,GR,225.80,146.77,,,,,,,,,,,,,
SYSTEM DRNGE 50ML W BAXTER INTLNK NDLLSS INJECTIN SITES CRD,SUP-2277977,CDM,C1729,HCPCS,0272,RC,,,,both,,,502.93,326.90,,,,,,,,,,,,,
STEM FEM L175MM DIA12MM +30MM OFFSET NEUT CALCAR HIP REV,SUP-2344479,CDM,C1776,CPT,0278,RC,,,,both,,,18064.42,11741.87,,,,,,,,,,,,,
SET BRUSHING L26MM DIA3MM FEM POLY KNEE ROT HNG TOT FINN,SUP-2406067,CDM,C1776,CPT,0278,RC,,,,both,,,1015.95,660.37,,,,,,,,,,,,,
PLATE BNE L216MM 16 H BILAT MTPHSEAL S STL LOK COMPR LO,SUP-2185107,CDM,C1713,HCPCS,0278,RC,,,,both,,,3534.16,2297.20,,,,,,,,,,,,,
CEMENT BNE 15CC CA PHSPTE INJ LIQ PWD HYDROSET,SUP-2366473,CDM,C1713,HCPCS,0278,RC,,,,both,,,12950.58,8417.88,,,,,,,,,,,,,
KIT PROC L70CM OD4FR LSR PRE POSITIONED FBR LCK VARI-LASE,SUP-2120514,CDM,C1894,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,2580000003,HCPCS,0258,RC,00338-0023-02,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
APPLIER CLP HNDPC MULT FIRE MOD M/L-10 REUSE SURG CLP,SUP-2304324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
PLATE BNE RECON UNIV 3.5 MM 8 HOLE 2 COMPR FOR SCR TI NS,SUP-2472100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1448.92,941.80,,,,,,,,,,,,,
HEAD FEM DIA50MM CO CHROM MTL POR HIP CEM FOR DYSPLASIA,SUP-2350857,CDM,C1776,CPT,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
SCREW BNE 3.6X22 MM ANCHORAGE 2 CP,SUP-2362124,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.84,326.85,,,,,,,,,,,,,
BRACE KNEE AD SM SH UNIV FOAM POSTOP UNISX WRP ARND HNG T,SUP-2150853,CDM,L1845,HCPCS,0274,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
SYSTEM BNE CEMENT DEL HYDRLC OSSEOFLEX CD-H,SUP-2460813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
CATHETER THORACENTESIS TY 9 FRX29 CM PNEUMOTHORAX 20 SIDEPRT,SUP-2760152,CDM,C1729,HCPCS,0272,RC,,,,both,,,785.47,510.56,,,,,,,,,,,,,
CATHETER LD DEL ACUITY PRO 90 DEG L 60 CM DIA 7 FR SS PTFE,SUP-2149030,CDM,C1887,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
GRAFT VASC L90CM RNGD L70CM ID5MM EPTFE CBAS HEP SURF THN,SUP-2395808,CDM,C1768,CPT,0278,RC,,,,both,,,9313.24,6053.61,,,,,,,,,,,,,
SET ENDO INSTR GAST RECESSION FOR SFT TISS REL SYS,SUP-2122779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
ELECTRODE ES H24FR L LOOP 12 16DEG PLSM LOOP ESG F RESECTION 5PK,SUP-2313587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1346.24,875.06,,,,,,,,,,,,,
ORTHOLOC SPS 140MM STANDARD7 HOLE PLATE,SUP-2822319,CDM,C1713,HCPCS,0278,RC,,,,both,,,8123.18,5280.07,,,,,,,,,,,,,
NAIL IM L380MM DIA10MM FEM KNEE GLD TI CANN LCK RG BENT,SUP-2347395,CDM,C1713,HCPCS,0278,RC,,,,both,,,12015.68,7810.19,,,,,,,,,,,,,
GRAFT HUM TISS OPN MED MINI 20X26 MM BIOINDUCTIVE REGENETEN,SUP-2848897,CDM,C1781,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0258,RC,00990-7983-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
REAMER SURG 2.2X83 MM STRL CROSSTIE,SUP-2175005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
PLATE BNE L24MM THK1.5MM S STL O SHP CENTRE H FOR 4.5MM SCR,SUP-2318690,CDM,C1713,HCPCS,0278,RC,,,,both,,,2030.45,1319.79,,,,,,,,,,,,,
GUIDEWIRE VASC L 30 CM DIA 0.015 IN CRV RAD 2 MM STR CRV DBL,SUP-2760064,CDM,C1769,HCPCS,0272,RC,,,,both,,,133.26,86.62,,,,,,,,,,,,,
CATHETER KIT 6 FRX70X370 CM FIBEROPTIC EMITTING IRIS,SUP-2366515,CDM,C1758,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE CRAN W100XL100MM 4X4MM H TI MESH FOR USE W/ 1MM SCR,SUP-2190571,CDM,C1713,HCPCS,0278,RC,,,,both,,,7855.65,5106.17,,,,,,,,,,,,,
MESH HERN SQ 1 15X15 CM W/ ORIENTATION MARKING VERSATEX,SUP-2752216,CDM,C1781,HCPCS,0278,RC,,,,both,,,717.58,466.43,,,,,,,,,,,,,
HC So Cellular Stim for Biomarker,PX-3028635266,CDM,86352,CPT,0302,RC,,,,both,,,303.00,196.95,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR UPLR CEM STEM H4DEPUY] JNJ HEALTHCARE],SUP-2257616,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
PROSTHESIS OSS 4 MM 0.6 MM BARTELS BCKT OFFSET,SUP-2490949,CDM,L8613,CPT,0278,RC,,,,both,,,697.93,453.65,,,,,,,,,,,,,
ALLOGRAFT BNE COSTAL CART 5-8 CM,SUP-2321775,CDM,C1762,CPT,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
CATHETER GUID 6FR L150CM GUID SEG L25CM PLAT IRIDIUM HELCL,SUP-2140875,CDM,C1887,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BONE STR 2.0MM 4 H,SUP-2361576,CDM,C1713,HCPCS,0278,RC,,,,both,,,247.02,160.56,,,,,,,,,,,,,
DEVICE ANNULAR CLOSURE 8 MM STRL BARRICAID LTX,SUP-2858409,CDM,C1713,HCPCS,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
COUNTERSINK DRL DIA2.7MM ADD ON QUIK CONN DISP,SUP-2340803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
STEM FEM 12/14 5 STD OFFSET TAPR LPI PRIM,SUP-2222349,CDM,C1776,CPT,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
STENT PERIPH L60MM DIA6MM DEL SYS L125CM SHTH 6FR 0.035IN,SUP-2170397,CDM,C1874,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
LINER ACET ID28MM 20DEG GRP 2 ACS ENDRN,SUP-2249912,CDM,C1776,CPT,0278,RC,,,,both,,,3888.58,2527.58,,,,,,,,,,,,,
BACLOFEN 40 MG/20ML IT SOLN,RX-104431,CDM,J0475,HCPCS,0636,RC,70121-2503-01,NDC,,both,0.0125,ML,271.80,176.67,,,,,,,,,,,,,
BLADE SHV DIA2MM STR SERR TURB DISECT FOR SNUS SURG DIEGO,SUP-2313836,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.72,276.72,,,,,,,,,,,,,
BIT DRL 2.7X127 MM KT DRL STP 3MM ALLEN WRNCH DYN WRST FIX,SUP-2644600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.12,271.13,,,,,,,,,,,,,
CANNULA ARTHSCP 7 MM HIP SHLDR ADJ SHFT HYDRODAM REUSE,SUP-2745448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,773.70,502.90,,,,,,,,,,,,,
STRAP ORTHOT PERONEAL CUST PREFABRICATED OFF THE SHLF,SUP-2435566,CDM,L0980,HCPCS,0272,RC,,,,both,,,48.39,31.45,,,,,,,,,,,,,
BUSHING TIB STD AXLE STD ASMBLY PK STRL TRIATHLON,SUP-2889782,CDM,C1776,CPT,0278,RC,,,,both,,,7719.06,5017.39,,,,,,,,,,,,,
SCREW BONE CNNLTD 7.5MM DIA 115MML TTNM ALLOY PRTLLY THRDD S,SUP-2586462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1925.20,1251.38,,,,,,,,,,,,,
ALLOSYNC INJECTABLE FIBERS 1CC,SUP-2816377,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 8 IN WRST FOREARM LT,SUP-2336337,CDM,L3809,HCPCS,0272,RC,,,,both,,,24.55,15.96,,,,,,,,,,,,,
FOLIC ACID 1 MG PO TABS,RX-3233,CDM,6370000000,HCPCS,0637,RC,00904-7224-61,NDC,,both,1,UN,1.50,0.97,,,,,,,,,,,,,
CATHETER NEPHSTMY L25CM OD14FR DRNGE PGTL TIP RADPQ FLEXIMA,SUP-2139753,CDM,C1729,HCPCS,0272,RC,,,,both,,,264.70,172.05,,,,,,,,,,,,,
PLATE SPNL W16XL106MM STD 2.5 H XLNK POST LUM S STL FIX CONN,SUP-2255574,CDM,C1713,HCPCS,0278,RC,,,,both,,,5044.41,3278.87,,,,,,,,,,,,,
CEMENT BONE 20ML 40GM FULL DOSE POLYMETHYLMETHACRYLATE,SUP-2197441,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.38,137.40,,,,,,,,,,,,,
PLATE BONE L194MM 20 H MAND TI STR LCK COMPR RECON FOR 2.4MM,SUP-2191428,CDM,C1713,HCPCS,0278,RC,,,,both,,,5508.19,3580.32,,,,,,,,,,,,,
CATHETER GUID 2.8X2.3FR L150X20CM ID0.021IN 45DEG PTFE NYL,SUP-2248995,CDM,C1887,HCPCS,0272,RC,,,,both,,,4025.83,2616.79,,,,,,,,,,,,,
PLATE BONE L97X47MM 5X13 H LT MAND ORAL MAXILLOFACIAL TI ANG,SUP-2191467,CDM,C1713,HCPCS,0278,RC,,,,both,,,5475.22,3558.89,,,,,,,,,,,,,
LINER ACET ELEV TRIDENT X3 ECC 0 DEG 32MM OD SZ E,SUP-2376079,CDM,C1776,CPT,0278,RC,,,,both,,,2462.39,1600.55,,,,,,,,,,,,,
CEMENT BNE DAM N-K II,SUP-2448994,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
PLATE BNE DBL Y 2X0.8 MM CHIN GENIOPLASTY FAB W/ TAB TI,SUP-2462306,CDM,C1713,HCPCS,0278,RC,,,,both,,,851.07,553.20,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 5X175X23 MM HIP 9 HOLE SS STRL,SUP-2546039,CDM,C1713,HCPCS,0278,RC,,,,both,,,3264.82,2122.13,,,,,,,,,,,,,
BENDER STEM RAD HD EVOLVE,SUP-2397211,CDM,C1713,HCPCS,0278,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 7 MM EPTFE STR STD WALL N RING,SUP-2396429,CDM,C1768,CPT,0278,RC,,,,both,,,1450.68,942.94,,,,,,,,,,,,,
SCREW BNE LCK 3.5X8 MM SS NS SURFIX,SUP-2609223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.23,724.25,,,,,,,,,,,,,
SCREW INTRF L30MM DIA6-8MM TIB PEEK TAPR INTRAFIX,SUP-2256820,CDM,C1713,HCPCS,0278,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
BLADE SHV L11CM DIA3.5MM 3000RPM CRV SHFT M4 ROT TIP,SUP-2284137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.57,710.82,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.093X9 IN SS NS STEINMANN,SUP-2791595,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.81,8.33,,,,,,,,,,,,,
SCREW BONE L28MM TITANIUMWITH TOP HAT FOR BRISTOW LATARJET,SUP-2256867,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
PLATE BNE HK 5TH METATRSL,SUP-2864970,CDM,C1713,HCPCS,0278,RC,,,,both,,,5614.32,3649.31,,,,,,,,,,,,,
BIT DRL DIA2.5MM LNG W/ AO QUIK CONN DISP FOR SM PLATING,SUP-2344044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.72,463.27,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.018 IN TAPR 7 CM FLPY TIP 2 CM,SUP-2167642,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.77,28.45,,,,,,,,,,,,,
PLATE BONE RT DSTL VOLAR RIM CROSSLOCK TECHNOLOGY EPAK DVR,SUP-2137034,CDM,C1713,HCPCS,0278,RC,,,,both,,,6888.85,4477.75,,,,,,,,,,,,,
PLATE BNE COBRA HD LG 4.5X186 MM 9 HOLE FOR SCR SS NS,SUP-2460108,CDM,C1713,HCPCS,0278,RC,,,,both,,,1376.48,894.71,,,,,,,,,,,,,
PAD EXT FIX DISPOSABLE FOR FEM FT SIDEKCK EZ FRME FIX SYS,SUP-2399882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BUR SURG BALL 5 MM 21 CM FLUT LG BOR MIDAS REX 8 LEGEND,SUP-2664677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,583.79,379.46,,,,,,,,,,,,,
PLATE BNE 2X2 H RECT FOR 15MM CRAN FIX UNIV NEURO III SYS,SUP-2363627,CDM,C1713,HCPCS,0278,RC,,,,both,,,954.47,620.41,,,,,,,,,,,,,
NAIL IM L150MM DIA10MM ANK ARTH PRI N LOK UNIFLEX,SUP-2412888,CDM,C1713,HCPCS,0278,RC,,,,both,,,4169.92,2710.45,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM 1.5 MM CLLR BUTTON SIL STRL 510133,SUP-2535102,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.58,19.23,,,,,,,,,,,,,
BIT DRL L 150 MM DIA 3.5 MM AO QC STRL DISP V,SUP-2908409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,994.06,646.14,,,,,,,,,,,,,
CATHETER W/ OLIGON 7F VANTEX CTRL VEN W/ OLIGON,SUP-2214383,CDM,C1751,HCPCS,0278,RC,,,,both,,,169.81,110.38,,,,,,,,,,,,,
DEVICE HEARING LT CHROMA BGE PONTO,SUP-2319858,CDM,L8690,HCPCS,0278,RC,,,,both,,,9577.00,6225.05,,,,,,,,,,,,,
HC Puncture Drainage of Lesion,PX-4501016000,CDM,10160,CPT,0450,RC,,,,both,,,1386.00,900.90,,,,,,,,,,,,,
INTRODUCER SHTH L90CM OD6FR .038IN PTFE S STL HYDRPHLC,SUP-2385649,CDM,C1894,HCPCS,0272,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
GRAFT BNE 0.5-1 MM POROUS GRAN HA,SUP-2651599,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.79,307.96,,,,,,,,,,,,,
SCREW BNE PARTIALLY THRD 5X110 MM PANTA 511110ND,SUP-2434155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1420.10,923.06,,,,,,,,,,,,,
HC Albumin,PX-3078204000,CDM,82040,CPT,0307,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
HC So Assay of Estrone,PX-3018267966,CDM,82679,CPT,0301,RC,,,,outpatient,,,139.00,90.35,,,,,,,,,,,,,
CATHETER NEPHSTMY 8FR L25CM FLEXIMA KT REG PGTL TIP RADPQ,SUP-2147848,CDM,C1729,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 4 FRX12 CM 18 GA DL SPECTRUM,SUP-2759894,CDM,C1751,HCPCS,0278,RC,,,,both,,,577.57,375.42,,,,,,,,,,,,,
SCREW BNE CANC 4.5X48 MM FT NCB,SUP-2861255,CDM,C1713,HCPCS,0278,RC,,,,both,,,523.94,340.56,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY MED 20 IN KNEE ADJ PERF FOAM,SUP-2194893,CDM,L1830,CPT,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
STENT BILI E-LUMINEXX L 120 MM DIA 6 MM CATH L 135 CM DIA 6,SUP-2128907,CDM,C1876,HCPCS,0278,RC,,,,both,,,4392.86,2855.36,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ 10IN LOOP LOK FIRM SUPP VYN,SUP-2276620,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.01,10.41,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX70 CM HYDRPHLC STYL RADPICC,SUP-2125526,CDM,C1751,HCPCS,0278,RC,,,,both,,,214.46,139.40,,,,,,,,,,,,,
INSERTER SURG T-CONNECTOR SPINE CODE 46,SUP-2232130,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
PLATE BNE L207MM 13 H ST R POSTEROLATERAL DST FIBULAR S STL,SUP-2177403,CDM,C1713,HCPCS,0278,RC,,,,both,,,2140.04,1391.03,,,,,,,,,,,,,
PROBE ARTHSCP HK L5.4MM TIP W/ 5MM MRK,SUP-2120782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
CATHETER DRNGE 5FR OD 250CML NTNL NSBLRY SNGLE PGTL WCNNCTN,SUP-2679097,CDM,C2617,HCPCS,0278,RC,,,,both,,,333.12,216.53,,,,,,,,,,,,,
PROBE NRV STIM BALL TIP DISP M5,SUP-2310417,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
COLLAR PREMIER PRO UNIV ADJ CLS CELL FOAM LNR L TRACH OPN,SUP-2336009,CDM,L0140,HCPCS,0274,RC,,,,both,,,14.32,9.31,,,,,,,,,,,,,
SCREW DIA1.7MM L3MM ABSRB FOR STRYKR LEIBINGER 2/EA,SUP-2364990,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.04,218.43,,,,,,,,,,,,,
MATRIX HUM TISS L 5 X W 9 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909256,CDM,Q4122,HCPCS,0636,RC,,,,both,,,9877.81,6420.58,,,,,,,,,,,,,
SCREW BNE LCK 5X51 MM TI NS,SUP-2192330,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.91,344.44,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.14 MM INNR FLANGE DIA 3.5 MM MICROGEL,SUP-2902004,CDM,L8699,HCPCS,0278,RC,,,,both,,,82.08,53.35,,,,,,,,,,,,,
MESH HERN W10XL12IN RECT FULL RESRB SCFLD MFIL ABSRB - ORDER BY CASE,SUP-2126271,CDM,C1781,HCPCS,0278,RC,,,,both,,,35168.00,22859.20,,,,,,,,,,,,,
CATHETER GUID ZOOM 88 L 100 CM DIA 8 FR DSTL OD/ID 8,SUP-2878007,CDM,C1887,HCPCS,0272,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
IMPLANT TOE L22MM OD2.5MM LCTSRB CPLMR THRDD RSRBBLE HMMRTOE,SUP-2485551,CDM,C1776,CPT,0278,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
SHUNT SURG REG 16 GA SNAP ASMBLY BLNT NDL STRATA NSC,SUP-2628579,CDM,C1729,HCPCS,0272,RC,,,,both,,,13667.29,8883.74,,,,,,,,,,,,,
SCREW BNE L 110 MM DIA 3.5 MM ST LCK NS EVOS,SUP-2931890,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.05,355.58,,,,,,,,,,,,,
HC Inc Thromb Hemorrhoid Ext,PX-4504608300,CDM,46083,CPT,0450,RC,,,,outpatient,,,383.00,248.95,,,,,,,,,,,,,
BIT DRL LNG 4 MM,SUP-2254049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
CANNULA SUCTION 2 MMX23 CM INSUL MONOPOLAR LARYNGEAL,SUP-2775025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,512.92,333.40,,,,,,,,,,,,,
PIN FIX 2X40 MM BIOTRAK 30249] ACUMED LLC],SUP-2106873,CDM,2780000010,LOCAL,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
PLATE BONE 1.3X100X100 MM CONTOURABLE MESH RIGID TITANIUM GO,SUP-2838347,CDM,C1713,HCPCS,0278,RC,,,,both,,,7366.44,4788.19,,,,,,,,,,,,,
GRAFT BIO TISS W6XL6CM FEN FET BOV ACELLULAR DERM MTRX,SUP-2243694,CDM,Q4110,HCPCS,0636,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
INSERT FEM NK L-6MM TAPR HIP CO CHROM MOLYBDENUM ALLY ENDO,SUP-2405247,CDM,C1776,CPT,0278,RC,,,,both,,,222.31,144.50,,,,,,,,,,,,,
SET ORTH L13.5MM DIA3.5MM W/ DRL GUID DRL BIT TAP FOR DX,SUP-2123214,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PADDLE NEUROSTIMULATOR SPNL CRD BLNK WIDE FOR COVEREDGE X,SUP-2138811,CDM,C1778,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
STENT COR 8MM OD2.75MM BARE MTL RX CO CHROM ALLOY,SUP-2104187,CDM,C1876,HCPCS,0278,RC,,,,both,,,2756.92,1792.00,,,,,,,,,,,,,
CATHETER HD CRV 12.5 FRX13 CM  TRPL LUMEN PASS MAHRK ELITE,SUP-2626957,CDM,C1752,HCPCS,0278,RC,,,,both,,,462.55,300.66,,,,,,,,,,,,,
SNARE ENDOSCP POLYP 2.8 MMX230 CM OVL ASMBLY SNAREMASTER +,SUP-2475212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.87,466.62,,,,,,,,,,,,,
BASEPLATE GLEN +10MM OFFSET EXT CAGE,SUP-2223385,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
SHEATH INTRO ARW GLIDETHRU L 7 CM DIA 6 FR DIL 6 FR POLYUR,SUP-2887200,CDM,C1894,HCPCS,0272,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
INSERT TIB BEAR SZ 1 THK11MM KNEE X3 CNDYL STABILIZING,SUP-2373195,CDM,C1776,CPT,0278,RC,,,,both,,,11530.08,7494.55,,,,,,,,,,,,,
KIT IOBP HIP STRL,SUP-2653377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BLADE SHV OD4MM 60DEG STD SERR CLOSE DS ELITE COMPATIBLE,SUP-2313529,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.31,280.35,,,,,,,,,,,,,
CATHETER URET OD6FR 2MM OPN END AXXCESS,SUP-2139306,CDM,C1758,HCPCS,0278,RC,,,,both,,,31.68,20.59,,,,,,,,,,,,,
WASHER T8 T10 SCREWS 24MM/27MM/35MM,SUP-2704874,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
PLATE BNE W3.6MM W/ 5 L12MM DIA2.5MM AND 4 L14MM DIA2.5MM,SUP-2389092,CDM,C1713,HCPCS,0278,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH THCK 2.75-3.25 MM 7X5 CM ACELLULAR,SUP-2321764,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
PLATE BONE L153.5MM 8 H RT MEDL DSTL TIB TI FOR,SUP-2418840,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-104852,CDM,J0706,HCPCS,0636,RC,51754-0500-01,NDC,,both,3,ML,69.00,44.85,,,,,,,,,,,,,
LENS IOL BCNVX 8+ DIOPT 5 DEG 6X13 MM POST CHMBR,SUP-2392232,CDM,V2632,HCPCS,0276,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
SCREW BNE 2.3X27 MM CRANIOMAXILLOFACIAL TI MAXDRIVE LEVEL 1,SUP-2457088,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.92,133.20,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 20H LEFT 301MM,SUP-2549598,CDM,C1713,HCPCS,0278,RC,,,,both,,,3876.05,2519.43,,,,,,,,,,,,,
PACK VITRCTMY VLV CANN VITREOUS DISP CONSTELLATION,SUP-2109957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2324.82,1511.13,,,,,,,,,,,,,
BASEPLATE TIB L STD UNIV KNEE PRESSFIT STEM PRI POR W/ SCR H,SUP-2397050,CDM,C1776,CPT,0278,RC,,,,both,,,16390.80,10654.02,,,,,,,,,,,,,
NAIL IM L28CM DIA8.5MM TIB KNEE GRY TI CANN LCK RG BEND,SUP-2347074,CDM,C1713,HCPCS,0278,RC,,,,both,,,9533.35,6196.68,,,,,,,,,,,,,
DEVICE FIX RND 2 HOLE SS STRL ENDOBUTTON LTX,SUP-2877791,CDM,C1713,HCPCS,0278,RC,,,,both,,,696.48,452.71,,,,,,,,,,,,,
HC So Ca 125|NOT REASONABLE AND NECESSARY,PX-3028630466,CDM,86304,CPT,0302,RC,,,GZ,outpatient,,,221.00,143.65,,,,,,,,,,,,,
MARKER RAD NDL L20CM OD18GA PROC SFT TISS FIDUCIAL KT,SUP-2164653,CDM,A4648,CPT,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN MED 20X11 CMX0.7-1.4 MM BRST FLEXHD,SUP-2307605,CDM,Q4128,HCPCS,0636,RC,,,,both,,,22378.15,14545.80,,,,,,,,,,,,,
STOCKING COMPR TIB SOCK LEN,SUP-2237272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.32,256.31,,,,,,,,,,,,,
PLATE BNE MESHED 9 STD 0.6 MM RT CRAN PRECONTR TI NS LF,SUP-2460590,CDM,C1713,HCPCS,0278,RC,,,,both,,,8430.84,5480.05,,,,,,,,,,,,,
COVER BURR HOLE CONTOURED 18X0.6 MM W/ 3 MM DRN LO PROF,SUP-2475663,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.97,510.88,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8MM STR TW HELIX SLDE GDS,SUP-2525471,CDM,C1768,CPT,0278,RC,,,,both,,,2677.51,1740.38,,,,,,,,,,,,,
DRILL SURG 1.8 MM HRD BNE STRL MICRORAPTOR LTX,SUP-2879944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
NOZZLE SPRY FOR GD450R GD455R GD465 NS REUSE MICRO-LINE,SUP-2929144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.86,257.96,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 8X16 CMX1.25-2 MM SFT DERMACELL,SUP-2427791,CDM,Q4122,HCPCS,0636,RC,,,,both,,,10650.88,6923.07,,,,,,,,,,,,,
GRAFT DERMAL MESH 2X3 CM FEN WND MTRX MIRODERM,SUP-2431547,CDM,Q4175,HCPCS,0636,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
LORAZEPAM 4 MG/ML IJ SOLN,RX-10468,CDM,J2060,HCPCS,0636,RC,00641-6049-25,NDC,,both,0.75,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L5MM DIA1.5MM UNIV SELF DRL CRSS PIN 5/EA,SUP-2366492,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.47,123.81,,,,,,,,,,,,,
PLATE BONE L94MM THK2.8MM 8 H BILAT S STL NONCOMPRESSION,SUP-2348977,CDM,C1713,HCPCS,0278,RC,,,,both,,,3807.25,2474.71,,,,,,,,,,,,,
HC Sel Cath Thor/Brach Init 3rd+,PX-3613621700,CDM,36217,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
STAPLER INT L100MM CUT LN L98MM STPL LN L102MM BLU B FRM 8,SUP-2220038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,653.56,424.81,,,,,,,,,,,,,
INSERT TIB SM 9 MM CAS ELIBRA UNIV,SUP-2442363,CDM,C1776,CPT,0278,RC,,,,both,,,240.21,156.14,,,,,,,,,,,,,
MATRIX BIO L 9.4 X W 4.7 IN SZ 288 SQCM PORCINE TEND DERIVED,SUP-2909292,CDM,A2008,HCPCS,0636,RC,,,,both,,,16309.16,10600.95,,,,,,,,,,,,,
ANCHOR SUT OD5.5MM LACTOSORB L15 COPOLYMER 2 TWO MAXBRAID 905940] ZIMMER BIOMET INC],SUP-2137198,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.44,706.19,,,,,,,,,,,,,
BLADE SURG TRIANG KT HK ENDOTRAC 20566,SUP-2530570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00264-7510-20,NDC,JW,both,250,ML,31.90,20.73,,,,,,,,,,,,,
BASEPLATE TIB SZ 1-2 KNEE PRI CEM STEM MOD IMP,SUP-2201006,CDM,C1776,CPT,0278,RC,,,,both,,,3016.60,1960.79,,,,,,,,,,,,,
SCREW BNE SD 2.7X12 MM TI SNAP-OFF,SUP-2608913,CDM,C1713,HCPCS,0278,RC,,,,both,,,1394.91,906.69,,,,,,,,,,,,,
GUIDE WIRE .052IN X 55CM SAFE-T-J TEFLON COATED FIXED CORE,SUP-2718702,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
RETRACTOR MICRODISCECTOMY 18MM DIA TBLR MTRX,SUP-2292888,CDM,C1713,HCPCS,0278,RC,,,,both,,,1156.24,751.56,,,,,,,,,,,,,
PLATE SPNL ANTR CERV 30 MM 2 LEVEL LORDTC VAN GOGH,SUP-2661655,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
BIT DRL L216MM OD32MM ST SHT NONLOCKING,SUP-2365047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
HC Peripheral Block - Peripheral Nerve or Branch|LEFT SIDE,PX-3606445000,CDM,64450,CPT,0360,RC,,,LT,both,,,2232.00,1450.80,,,,,,,,,,,,,
HC Drain Rectal Abscess,PX-4504500500,CDM,45005,CPT,0450,RC,,,,both,,,1217.00,791.05,,,,,,,,,,,,,
SHEATH INTRO SENTRANT L 64 CM DIA16 FR GUIDEWIRE 0.035 IN,SUP-2749558,CDM,C1894,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
POST EXT FIX 12MM 4 H ASSEMB BOLT FLEX ANK FT NONSTERILE,SUP-2316111,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SCREW BNE L 8 MM DIA2 MM MAXILLOMANDIBULAR LCK SD NS HYBRID,SUP-2909486,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.54,346.15,,,,,,,,,,,,,
MESH HERN W7XL5.4IN OMEGA 3 FATTY ACID COAT POLYPR,SUP-2265984,CDM,C1781,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
GUIDEWIRE VASC ASAHI FIELDER L 180 CM TIP L 3 CM DIA 0.014,SUP-2102218,CDM,C1769,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
DRILL TWST DIA4MM G FOR COLE RADLUC,SUP-2342346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2052.87,1334.37,,,,,,,,,,,,,
PLATE BONE 2 H STR STD GRD 1/3 COMMERCIALLY PURE TI CRAN,SUP-2277531,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CATHETER NEPHROSTOMY BLLN 8 MMX15 CM SET VLY CLR ULTRAXX,SUP-2836029,CDM,C1726,HCPCS,0272,RC,,,,both,,,1281.43,832.93,,,,,,,,,,,,,
GRAFT NRV L2CM ID3MM CLLGN PERIPH SEMI PERM BIOCOMPATIBLE,SUP-2244350,CDM,C9352,HCPCS,0278,RC,,,,both,,,3358.39,2182.95,,,,,,,,,,,,,
BLADE SURG SAW GRFT HARV STRL S STL 20MM LEN 6MM W .4MM THCK,SUP-2166600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
PACEMAKER CARD 24GM 11CC H45XL52MM THK6MM TI PARYLENE EPOXY,SUP-2356210,CDM,C1785,HCPCS,0275,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BNE STR 3.5X209 MM 16 HOLE RECON LCK SS STRL,SUP-2483471,CDM,C1713,HCPCS,0278,RC,,,,both,,,1976.76,1284.89,,,,,,,,,,,,,
ROD EXT FIX THRD 100 MM RINGFIX,SUP-2365334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L150CM 7X20 BAL MRAIL ULT SFT SV,SUP-2140571,CDM,C1725,HCPCS,0272,RC,,,,both,,,1279.71,831.81,,,,,,,,,,,,,
CANNULA ENDOSCP LFRIC 10 CM CARVALHO LP W/O LUER LCK CONN,SUP-2767949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.42,470.22,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 10MM X 10MM X 4MM,SUP-2547189,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.03,365.97,,,,,,,,,,,,,
PUMP PAIN MGMT SYS 400ML 2 SEL A FLO,SUP-2236747,CDM,C9804,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
CATHETER IRR SINUS RELIEVA VORT,SUP-2106359,CDM,C1729,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 17 7MM DEMIN CANC CHIP FRZ DRY,SUP-2307251,CDM,C1713,HCPCS,0278,RC,,,,both,,,1257.07,817.10,,,,,,,,,,,,,
PIN FIX LNG FOR ANT FIX SYS ANTEGRA-T,SUP-2179473,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 29.5-32 IN CTR 21-23 IN CALF 22-24 IN 3XL LT,SUP-2916744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1127.45,732.84,,,,,,,,,,,,,
PLATE CRAN 80X20X20 MM PT SPEC IMPL PEEK,SUP-2860168,CDM,C1713,HCPCS,0278,RC,,,,both,,,22434.99,14582.74,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 10X190 MM ACHILLES TEND,SUP-2866883,CDM,C1762,CPT,0278,RC,,,,both,,,5846.68,3800.34,,,,,,,,,,,,,
HC Remove Eyelid FB,PX-4506793800,CDM,67938,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
HEAD FEM BPLR 28X53 MM HIP,SUP-2322482,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
END CAP ORTH L 10 MM DIA15.5 MM HIP IM NAIL STRL GAMMA4,SUP-2900537,CDM,C1889,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
GRAFT BNE SUB 80CC 1 4MM CANC CRUSH CHIP READIGRFT,SUP-2264827,CDM,C1713,HCPCS,0278,RC,,,,both,,,2988.56,1942.56,,,,,,,,,,,,,
INSTRUMENT SET AM GASTROC EXPRESS,SUP-2473423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2851.12,1853.23,,,,,,,,,,,,,
SET SHTH DESTINO L 87 CM L 67 CM 8.5FRCRV BEND 17 MM,SUP-2616200,CDM,C1766,CPT,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
PROBE BRST BX W/ VAC SET MAMTOM EX,SUP-2195637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.43,466.98,,,,,,,,,,,,,
STENT CORONARY MULTLNK ULTRA L 18 MM DIA 5 MM GUIDE CATH,SUP-2103568,CDM,C1876,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PLATE BNE 3.5X92 MM 7 HOLE,SUP-2198757,CDM,C1713,HCPCS,0278,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
CONFORMER OPHTH L W22XL25MM BILAT CLR VENT ACRYL CUP,SUP-2366503,CDM,L8610,HCPCS,0278,RC,,,,both,,,184.82,120.13,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 5 CM DIA 3 MM EPTFE STR TW N RING,SUP-2396324,CDM,C1768,CPT,0278,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
SET URET STENT CNTOUR L 30 CM DIA 7 FR SENSOR GUIDEWIRE,SUP-2724944,CDM,C2617,HCPCS,0278,RC,,,,both,,,473.86,308.01,,,,,,,,,,,,,
FIBER LASER 2 MM FIBERLASE STC,SUP-2713720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
SCREW BNE L4MM DIA1MM CORT TI ST FULL THRD CRUCFRM RECESS,SUP-2189074,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.17,219.16,,,,,,,,,,,,,
HOOK SPNL 3 MM 4.5X8 MM OFFSET BLADE TI EXPEDIUM,SUP-2583496,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BLADE SAW L 10 MM WORKING L 5 MM NAR RASP RECIP STRL DISP,SUP-2929131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,655.19,425.87,,,,,,,,,,,,,
STIMULATOR NERVE PT PRGMR EXT GENRTR,SUP-2355979,CDM,C1787,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
SCREW BNE L95MM DIA6.5MM THRD L20MM S STL CORT CANN LAG,SUP-2342481,CDM,C1713,HCPCS,0278,RC,,,,both,,,1842.71,1197.76,,,,,,,,,,,,,
KIT STRT TBNG L 7 FT AD HNDHLD SM VOL ERGO VLV MOUTHPIECE T,SUP-2881892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,200.77,130.50,,,,,,,,,,,,,
TUBE OPHTH IMPL .305 MM DIAM 25 MM TUBE LEN SIL POLYPR,SUP-2308661,CDM,C1783,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SHUNT CAR 9FR L31CM BLU LUMN POLYUR T-PORT PRUITT F3-S,SUP-2264220,CDM,C1889,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
BRACE ORTH STUMP SHRINKER AK,SUP-2388227,CDM,L8460,HCPCS,0274,RC,,,,both,,,239.08,155.40,,,,,,,,,,,,,
PLUG VASC AMPLATZER UNCONSTRAINED L 7 MM DIA 6 MM DEL SYS L,SUP-2892937,CDM,C1889,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
BIT DRL L 150 MM DIA 3.5 MM AO QC NS REUSE V,SUP-2907760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.75,467.19,,,,,,,,,,,,,
PLATE BONE DIA70MM NONSTERILE CRAN TI RND CNTOUR MESH MALL,SUP-2190637,CDM,C1713,HCPCS,0278,RC,,,,both,,,5717.94,3716.66,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 20 MM DIA12 MM SHTH 9 FR CATH L,SUP-2147049,CDM,C1876,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SUPPORT WRST XSM L7IN FOR 55IN L HND SUEDE FLANNEL PERF LACE,SUP-2197030,CDM,L3931,HCPCS,0274,RC,,,,both,,,22.61,14.70,,,,,,,,,,,,,
RESERVOIR VENTRICULAR 6 MM CSF SHUNT,SUP-2278366,CDM,C1889,HCPCS,0278,RC,,,,both,,,390.11,253.57,,,,,,,,,,,,,
GRAFT VASC L80CM DIA6MM EPTFE PERIPH BYPS STD WALL,SUP-2128081,CDM,C1768,CPT,0278,RC,,,,both,,,16413.31,10668.65,,,,,,,,,,,,,
SPHERE GLEN SHLDR,SUP-2199131,CDM,C1776,CPT,0278,RC,,,,both,,,4672.32,3037.01,,,,,,,,,,,,,
FRACTURE KIT FULL SHT 10 ML STABILIT MX,SUP-2485944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9061.26,5889.82,,,,,,,,,,,,,
CLIP ENDOSCP WRK L2300MM LO GI TRACT PRECIS ROT ADJ OPN,SUP-2313202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.98,421.84,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19.5MMW X80MML 0.9MM THK 0.9MM THK CUT ME,SUP-2605481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,128.99,83.84,,,,,,,,,,,,,
DRIVER SURG RET STAR 20 FOR ANK FUS PLATING SYS ORTHOLOC,SUP-2398591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP XL 7.5FR MIC NONCOATED BILI NDL KNF,SUP-2149455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.55,292.21,,,,,,,,,,,,,
HC Removal of Artery Clot,PX-3613410100,CDM,34101,CPT,0361,RC,,,,both,,,16763.00,10895.95,,,,,,,,,,,,,
ALLOGRAFT BNE LT HEMI ILIUM FRZN,SUP-2717846,CDM,C1762,CPT,0278,RC,,,,both,,,17307.68,11249.99,,,,,,,,,,,,,
SCREW BONE L6MM DIA2MM HND VAR ANG LCK FLOWERCUBE,SUP-2225439,CDM,C1713,HCPCS,0278,RC,,,,both,,,842.15,547.40,,,,,,,,,,,,,
HOOK SPNL SM PEDCL IMP SFS,SUP-2317417,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
STEM HUM 8 MM SHLDR AFFINITI PC,SUP-2715287,CDM,C1776,CPT,0278,RC,,,,both,,,13169.16,8559.95,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 3/16X9 IN 4 PT STYL SMOOTH PLN STRL,SUP-2150490,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.65,12.12,,,,,,,,,,,,,
TOCILIZUMAB 400 MG/20ML IV SOLN,RX-104372,CDM,J3262,HCPCS,0636,RC,50242-0137-01,NDC,,both,20,ML,7834.70,5092.55,,,,,,,,,,,,,
PLATE BNE STR MINI LNG 2X1 MM 12 MM 4 HOLE BRIDGE TI LEVEL 1,SUP-2483177,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.51,345.48,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 3FR 0.024IN 60CM 1 LUMAN 9153108,SUP-2632689,CDM,C1751,HCPCS,0278,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
HC Ablation 1/> Liver Tumor Perq Cryoablation,PX-3614738300,CDM,47383,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
LGN EXT FLT PRESSFIT STEM 18MMX160MM,SUP-2822621,CDM,C1776,CPT,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
SUTURE NOVAFIL HGS-21 1/2 CIR 37MM TAPERPOINT 5 X 18 IN SZ 8886445463,SUP-2174596,CDM,C1713,HCPCS,0278,RC,,,,both,,,120.07,78.05,,,,,,,,,,,,,
GRAFT BIO TISS W2XL2CM DISC DERM MESHED SCAFFOLD PRIMATRIX,SUP-2243701,CDM,Q4110,HCPCS,0636,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
COIL EMB L1CM DIA2MM 0010IN NYL DETACH 3D SFT STRTCH,SUP-2173062,CDM,C1889,HCPCS,0278,RC,,,,both,,,4618.94,3002.31,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305759,CDM,V2790,HCPCS,0274,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
PLATE BNE THK0.6MM BAR L8MM 5 H STD G MID FACE TI Y LO PROF,SUP-2366251,CDM,C1713,HCPCS,0278,RC,,,,both,,,567.65,368.97,,,,,,,,,,,,,
CATHETER BLLN EXTRACTION 4.5 FR 15X20 MM MULT 3V +,SUP-2312992,CDM,C1726,HCPCS,0272,RC,,,,both,,,499.61,324.75,,,,,,,,,,,,,
TRAY PICC CATH 5FR POLYUR FULL TRIM LEN SGL LUMN NRS PWR INJ,SUP-2126377,CDM,C1751,HCPCS,0278,RC,,,,both,,,493.29,320.64,,,,,,,,,,,,,
SCREW INTFR L20MM DIA9MM TI CANN NONABSORBABLE TAPR HD,SUP-2341313,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
ALLOGRAFT HUM TISS HEMI BTB FRZN COLL-E-STRONG,SUP-2321769,CDM,C1762,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SCREW BNE LCK 2.7X22 MM RADIAL LCK TI,SUP-2363473,CDM,C1713,HCPCS,0278,RC,,,,both,,,296.92,193.00,,,,,,,,,,,,,
BUR SURG DR 5X7.1 MM FLUT STRL ELITE LTX,SUP-2859321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.55,240.21,,,,,,,,,,,,,
PATCH CV HEMGRD L 75 X W 8 MM THK 0.41 MM POLYESTER BOV,SUP-2266052,CDM,C1768,CPT,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
MESH BONE 54MMW X 85MML 02MM THK TTNM F/15MM SCREW LATEX F,SUP-2681104,CDM,C1713,HCPCS,0278,RC,,,,both,,,2008.28,1305.38,,,,,,,,,,,,,
SET URET STENT L 90 CM DIA 7.2 FR GUIDEWIRE 0.038 IN SIL,SUP-2835745,CDM,C2617,HCPCS,0278,RC,,,,both,,,523.41,340.22,,,,,,,,,,,,,
CLAMP EXT FIX DIA8/11MM S STEED DSTL RAD CLP ON MAG,SUP-2188533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.7MM MAND CRANIOMAXILLOFACIAL G ST CRSS 5PK,SUP-2366177,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.40,147.81,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM EL TI LOK MULTDIR FOR ALPS FRAC,SUP-2413762,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.35,506.58,,,,,,,,,,,,,
PLATE BONE 3 H 7 PEG NAR LT VOLAR S STL BEAR,SUP-2389747,CDM,C1713,HCPCS,0278,RC,,,,both,,,3563.90,2316.53,,,,,,,,,,,,,
PATCH DURA REP W4XL4CM BOV PERICARD GLUTARHYD NONPYROGENIC,SUP-2130235,CDM,C1763,HCPCS,0278,RC,,,,both,,,1350.80,878.02,,,,,,,,,,,,,
PLATE BNE FEM 1 HOLE NK SYS TI NS,SUP-2181049,CDM,C1713,HCPCS,0278,RC,,,,both,,,3269.68,2125.29,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 4X16 CMX2-3.3 MM MTRX PROLAYER,SUP-2717809,CDM,C1763,HCPCS,0278,RC,,,,both,,,16602.12,10791.38,,,,,,,,,,,,,
GRAFT VASC L40CM ID6MM FLX KINK RESIST ACUSEAL,SUP-2395744,CDM,C1768,CPT,0278,RC,,,,both,,,4116.54,2675.75,,,,,,,,,,,,,
BLADE SAW OSCILLATING MIC 12X9X0.38-0.53 MM CRESC W/O OFFSET,SUP-2862462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.67,227.29,,,,,,,,,,,,,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,6370000000,HCPCS,0637,RC,00186-0370-28,NDC,,both,6,GR,716.40,465.66,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X49 MM 6 HOLE 1/4 TI,SUP-2536108,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.84,258.60,,,,,,,,,,,,,
GUIDEWIRE T2 RECON 32X400MM,SUP-2704163,CDM,C1769,HCPCS,0272,RC,,,,both,,,883.13,574.03,,,,,,,,,,,,,
CATHETER SUPP QUICK-CROSS SEL L 150 CM DIA 5 FR 0.035 IN,SUP-2823588,CDM,C1887,HCPCS,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
WASHER SPNL 2MM FIX BONE POLYAX TI MNRCH,SUP-2254526,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
KIT STRNL CLOSURE FIBERTAPE L 36 IN DIA2 MM SUTURE X5 BLU,SUP-2930454,CDM,C1713,HCPCS,0278,RC,,,,both,,,3791.55,2464.51,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 100 CM DIA 6 MM EPTFE STR TW,SUP-2525472,CDM,C1768,CPT,0278,RC,,,,both,,,3821.22,2483.79,,,,,,,,,,,,,
POR STD BODY STM LT 10.5MM APR II-T,SUP-2210903,CDM,C1776,CPT,0278,RC,,,,both,,,15290.54,9938.85,,,,,,,,,,,,,
PLATE EXT FIX LNG 180 MM FT RNG TI NS,SUP-2800131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3033.93,1972.05,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST STD RUBBER,SUP-2435733,CDM,L3460,HCPCS,0272,RC,,,,both,,,97.28,63.23,,,,,,,,,,,,,
Z DISCONTINUED SUGGESTED SUBS IN COMMENTS GUIDEWIRE VASC L260CM OD0.035IN S STL PTFE ULT STIFF 2 STR,SUP-2168995,CDM,C1769,HCPCS,0272,RC,,,,both,,,217.60,141.44,,,,,,,,,,,,,
SET INTRO 4FR L10CM NDL 21GA L7CM 0.018IN NIT COR PLAT TIP,SUP-2303432,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
STAPLER INT CARTRIDGE EXTRA THICK 60 MM TRI-STAPLE BLK GIA,SUP-2787696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,812.19,527.92,,,,,,,,,,,,,
CLAMP SURG CASTANEDA MED 18X6 MM,SUP-2187123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1000.34,650.22,,,,,,,,,,,,,
SYSTEM BILI STENT DEL NAVIFLEX L 202.5 CM DIA 8.5 FR PLAS,SUP-2141421,CDM,C1889,HCPCS,0278,RC,,,,both,,,258.64,168.12,,,,,,,,,,,,,
BLADE STERILE RADIUS,SUP-2574100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,305.33,198.46,,,,,,,,,,,,,
SCREW BNE L40MM OD45MM TI CALCNL ANK CANN SHT THRD HD COMPR,SUP-2398951,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
BIT DRL CANN 3.5X140 MM STRL,SUP-2607160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1332.27,865.98,,,,,,,,,,,,,
CARBOPLATIN 10 MG/ML IV SOLN (MIXTURES ONLY),RX-1150452,CDM,J9045,HCPCS,0636,RC,61703-0339-56,NDC,,both,60,ML,170.40,110.76,,,,,,,,,,,,,
PROSTHESIS PENILE 15 CM SCROT,SUP-2140259,CDM,C1813,HCPCS,0278,RC,,,,both,,,12167.50,7908.87,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM CORT VOLAR TI NONCANNULATED LOK,SUP-2413995,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.78,233.86,,,,,,,,,,,,,
PLATE BONE L43MM 6 H MAND TI LCK FOR 2MM SCR,SUP-2191229,CDM,C1713,HCPCS,0278,RC,,,,both,,,2567.26,1668.72,,,,,,,,,,,,,
RING EXT FIX DIA180 MM 2/3 PNK NS DISP TSF,SUP-2933080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4161.50,2704.97,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 90 MM DIA 6 MM CATH TOT L 160,SUP-2148370,CDM,C1876,HCPCS,0278,RC,,,,both,,,6063.34,3941.17,,,,,,,,,,,,,
CATHETER CV DL 12 FRX90 CM LO PROF ADPT SIL HICKMAN,SUP-2126160,CDM,C1751,HCPCS,0278,RC,,,,both,,,1155.02,750.76,,,,,,,,,,,,,
ALLOGRAFT BNE 6.5-8.5X220 MM POST TIBIALIS,SUP-2866881,CDM,C1762,CPT,0278,RC,,,,both,,,3654.18,2375.22,,,,,,,,,,,,,
IMPLANT GYN W6XL8CM FASC LATA TUTOPLAST PROC ALLGRFT TISS,SUP-2421127,CDM,C1762,CPT,0278,RC,,,,both,,,5702.24,3706.46,,,,,,,,,,,,,
CATHETER BLLN OCCL IRRIGATION 6 FRX40 CM 2 CC AORT PRUITT,SUP-2332926,CDM,C2628,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
KIT ARTICULATED ANK COMPLT STRL,SUP-2316324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14422.21,9374.44,,,,,,,,,,,,,
SYSTEM DEL 14FR L107CM REPL W/ INTEGR HNDL FOR 23/26/29MM,SUP-2282430,CDM,2780000006,LOCAL,0278,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
STIMULATOR NERVE CHARGER BELT ANT ADH PD ADPT EON MINI,SUP-2356754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
STABILIZER SURG RIGID STD BLADE ULT,SUP-2102336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
STEM RAD H+0MM DIA9MM TI ELBW SMOOTH BULL TIP FOR HD SYS,SUP-2418598,CDM,C1776,CPT,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
INSERT TIB THK 17 MM SZ 3 POLYETHYL LT ANK FIX XT REV STRL,SUP-2932764,CDM,C1776,CPT,0278,RC,,,,both,,,8271.07,5376.20,,,,,,,,,,,,,
GRAFT BONE SUB H7XL30MM CORT CRESC LORDTC C LN SPCR FRZ DRY,SUP-2293813,CDM,C1713,HCPCS,0278,RC,,,,both,,,17295.12,11241.83,,,,,,,,,,,,,
BLOCK FEM AUG L70MM THK5MM R LAT L MED DST KNEE REV,SUP-2408052,CDM,C1776,CPT,0278,RC,,,,both,,,2964.16,1926.70,,,,,,,,,,,,,
BENAZEPRIL HCL 20 MG PO TABS,RX-9221,CDM,6370000000,HCPCS,0637,RC,43547-0337-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW TENODESIS G FORC 4MMX10MM,SUP-2399116,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING EPTFE STP 5-8MM DIA 45CM LEN,SUP-2127038,CDM,C1768,CPT,0278,RC,,,,both,,,1859.07,1208.40,,,,,,,,,,,,,
PLATE BNE LNG LT PLNTR SYS IMPL INSTRUMENT AXIS,SUP-2610216,CDM,C1713,HCPCS,0278,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
ESTROGENS CONJUGATED 1.25 MG PO TABS,RX-2938,CDM,6370000000,HCPCS,0637,RC,00046-1104-81,NDC,,both,1,UN,31.90,20.73,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 1X150 MM SS NS KIRSCHNER,SUP-2905650,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
CATHETER VENT DRNGE BG EXT 4 W STPCOCK DISP FOR CSF SYS,SUP-2244299,CDM,C1729,HCPCS,0272,RC,,,,both,,,448.42,291.47,,,,,,,,,,,,,
SET SCR SPNL L85MM OD10.5MM TI HIP U BLDE LAG FOR GAMMA3,SUP-2362204,CDM,C1713,HCPCS,0278,RC,,,,both,,,3035.60,1973.14,,,,,,,,,,,,,
CAGE SPNL MESH 22X17X70 MM 6 LOBE,SUP-2602084,CDM,C1889,HCPCS,0278,RC,,,,both,,,18607.64,12094.97,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED MED 8 IN RT WRST FOREARM THMB,SUP-2276638,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.61,14.70,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 25 CM DIA18 MM POLYESTER GEL,SUP-2385007,CDM,C1768,CPT,0278,RC,,,,both,,,1156.78,751.91,,,,,,,,,,,,,
PLATE BNE MED RT PLNTR SYS IMPL INSTRUMENT AXIS,SUP-2610221,CDM,C1713,HCPCS,0278,RC,,,,both,,,8289.60,5388.24,,,,,,,,,,,,,
ROD COUPLER 30  HOFFMANN3 11MM,SUP-2704573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
BRACE KNEE L17-27IN FOR 30.5IN UNIV FOAM HNG STRP CLSR,SUP-2150858,CDM,L1810,HCPCS,0272,RC,,,,both,,,280.25,182.16,,,,,,,,,,,,,
PACEMAKER CARD INSIGNIA I ENTRA TI 2 CHMBR IS1 CONN UPLR,SUP-2148609,CDM,C1785,HCPCS,0275,RC,,,,both,,,17009.38,11056.10,,,,,,,,,,,,,
CATH BLLN SCORING 4X100MM X 137CM OTW PTA ANGIOSCULPT,SUP-2353230,CDM,C1725,HCPCS,0272,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE L 11 CM DIA 7 FR TIP L 3 MM,SUP-2740566,CDM,C1894,HCPCS,0272,RC,,,,both,,,108.80,70.72,,,,,,,,,,,,,
SET THROMCTMY ANGIOJET AVX L 50 CM DIA 6 FR SHTH 6 FR,SUP-2867275,CDM,C1757,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN BASIC KT 3 LUMN SIL STR STD,SUP-2267073,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC So F2 Gene Analysis,PX-3108124066,CDM,81240,CPT,0310,RC,,,,inpatient,,,330.00,214.50,,,,,,,,,,,,,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1171,HCPCS,0636,RC,00641-6151-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INCEPTA W 6.17 X H 7.7 CM D 0.99 CM 32 CC,SUP-2149263,CDM,C1882,HCPCS,0275,RC,,,,both,,,55389.60,36003.24,,,,,,,,,,,,,
BLADE SURG 6 MF6 INSRT TIP,SUP-2423795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE L131MM 7 H ST L DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177728,CDM,C1713,HCPCS,0278,RC,,,,both,,,2919.57,1897.72,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA2.6 MM EMER STRL DELT,SUP-2909658,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.57,799.87,,,,,,,,,,,,,
SET DRNGE 1ML 47-90UM BILI DRY VOL VI PARTIC EMB RNG,SUP-2167939,CDM,C1729,HCPCS,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
PLATE BNE STR 2.5 MM LCK STRL,SUP-2525142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
INSTRUMENT PACK WIREPIN,SUP-2878031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,995.69,647.20,,,,,,,,,,,,,
PLATE BNE L41MM THK13MM 2X6 H HND 316L S STL VAR ANG LOK ROT,SUP-2178040,CDM,C1713,HCPCS,0278,RC,,,,both,,,2288.93,1487.80,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.514,SUP-2860196,CDM,C1713,HCPCS,0278,RC,,,,both,,,28294.85,18391.65,,,,,,,,,,,,,
PLATE BNE L 28.8 X W 5.1 MM THK 1 MM SCREW DIA2/2.3 MM 4 H,SUP-2936179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
BIT DRL OD2.7MM CANN,SUP-2319794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
ELECTRODE SUCTION SPATULA 5 MMX45 CM W/ VLV,SUP-2850571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.78,607.61,,,,,,,,,,,,,
KIT ANK CARE AD H95IN UNIV BILAT W BRAC WRP CLD PK EXER,SUP-2196372,CDM,L4350,HCPCS,0272,RC,,,,both,,,53.91,35.04,,,,,,,,,,,,,
CATHETER DIAG 4FR L135CM 0.014IN S STL HYDRPHLC SPC BRAID,SUP-2353144,CDM,C1887,HCPCS,0272,RC,,,,both,,,59.35,38.58,,,,,,,,,,,,,
SET INTRO NEFF SHTH L 20 CM OD 7 FR ID 4 FR GUIDEWIRE 0.018,SUP-2168031,CDM,C1894,HCPCS,0272,RC,,,,both,,,195.90,127.33,,,,,,,,,,,,,
SUPPORT ORTHOT METATRSL CUST BAR WDG BTWN SOLE,SUP-2435727,CDM,L3410,HCPCS,0274,RC,,,,both,,,262.82,170.83,,,,,,,,,,,,,
BELT BK CRISSCROSS W/ SHLDR STRP CONTAINS VELC CLSR ELAS,SUP-2324538,CDM,L0642,HCPCS,0274,RC,,,,both,,,76.02,49.41,,,,,,,,,,,,,
BRACE ORTH THOR LUMBAR SACR CUST,SUP-2138674,CDM,L0486,HCPCS,0274,RC,,,,both,,,6236.17,4053.51,,,,,,,,,,,,,
KIT INTRO BILI STNT 10FR,SUP-2149476,CDM,C1894,HCPCS,0272,RC,,,,both,,,230.19,149.62,,,,,,,,,,,,,
BIT DRL CANN 2.7X145 MM QC FOR 3.5-4 MM SCREW BLU GRN NS,SUP-2423900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
TRAB METAL FEMORAL CONE AGMT SMALL 50MM LEFT,SUP-2502237,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA2.3 MM TI MAND ST EMER AXS NS UNIV 2.0,SUP-2909554,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.32,222.51,,,,,,,,,,,,,
LAPAROSCOPE RIGID L300MM OD5MM 0DEG WIDE DIRECT VIEW OPERATI,SUP-2808418,CDM,C1776,CPT,0278,RC,,,,both,,,8680.59,5642.38,,,,,,,,,,,,,
HC MRI-Spine Lumbar WO Contrast,PX-6127214800,CDM,72148,CPT,0612,RC,,,,both,,,4976.00,3234.40,,,,,,,,,,,,,
HC CT Ablation Bone,PX-3612098200,CDM,20982,CPT,0361,RC,,,,both,,,7342.00,4772.30,,,,,,,,,,,,,
ZIDOVUDINE 50 MG/5ML PO SYRP,RX-42918,CDM,340b,HCPCS,0637,RC,65862-0048-24,NDC,,both,240,ML,162.00,105.30,,,,,,,,,,,,,
PLATE BNE L 76 MM 5 H SS RT DSTL RADIAL VOLAR STD STRL EVOS,SUP-2931167,CDM,C1713,HCPCS,0278,RC,,,,both,,,4983.81,3239.48,,,,,,,,,,,,,
COMPONENT CRPL XS WRST POLYETH UNIV 2,SUP-2610318,CDM,C1776,CPT,0278,RC,,,,both,,,11733.02,7626.46,,,,,,,,,,,,,
CANNULA SUCTION DIA12 FR PRECALIBRATED CHARR DISP,SUP-2910148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,563.94,366.56,,,,,,,,,,,,,
GRAFT HUM TISS W4-10XH0.009-0.13XL33MM N MESHED DERM TISS,SUP-2112980,CDM,Q4116,HCPCS,0636,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
PLATE BNE 5 DEG 18 MM RT DYNAFORCE MOTOBAND CP,SUP-2431506,CDM,C1713,HCPCS,0278,RC,,,,both,,,7022.61,4564.70,,,,,,,,,,,,,
TRIATHLON CR X3 TIBIAL INSERT,SUP-2431349,CDM,C1776,CPT,0278,RC,,,,both,,,6317.37,4106.29,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0258,RC,00264-7520-10,NDC,,both,125,ML,9.60,6.24,,,,,,,,,,,,,
HEAD UPLR DIA47MM HIP BALL MOD CATHCART SELF CNTR,SUP-2251039,CDM,C1776,CPT,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SOCKS PROSTHETIC SINGLE PLY FIT LF,SUP-2388228,CDM,L8470,HCPCS,0274,RC,,,,both,,,17.55,11.41,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE ZRCH 2 TLTS TRANS HRFRD RGHT,SUP-2694402,CDM,C1713,HCPCS,0278,RC,,,,both,,,18127.38,11782.80,,,,,,,,,,,,,
CUP ACET DIA48MM HIP GRIPTION PRI PINN,SUP-2250219,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
OSS STRAIGHT STEM 9 X 225,SUP-2506328,CDM,C1776,CPT,0278,RC,,,,both,,,4578.12,2975.78,,,,,,,,,,,,,
SERTRALINE HCL 100 MG PO TABS,RX-11350,CDM,6370000000,HCPCS,0637,RC,16714-0613-04,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP L20MM CATH L200CM DIA11.5MM BELOW,SUP-2149502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
PIN EXT FIX SM L150MM DIA3.5MM THRD L25MM MINI ST TRANSFX,SUP-2199168,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.84,114.95,,,,,,,,,,,,,
STRAP SELF ADH BGE 1X18IN D RNG,SUP-2324798,CDM,L3908,HCPCS,0272,RC,,,,both,,,10.86,7.06,,,,,,,,,,,,,
HC Picc With Port <5yr,PX-3613657000,CDM,36570,CPT,0361,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
BLADE ULTRSNC ASPIR WORKING L 100 MM L 10 X W 5 MM THK 0.5,SUP-2889546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
HC Biopsy Liver Percutan Needle|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3614700000,CDM,47000,CPT,0361,RC,,,73,both,,,3707.00,2409.55,,,,,,,,,,,,,
HANDPIECE ELECSURG 23KHZ NOSECONE DISP CUSA EXCEL,SUP-2243964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
COIL VASC INTERLOCK-18 L 20 CM DIA10 MM GUIDEWIRE 0.018 IN,SUP-2142384,CDM,C1889,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
PLATE BNE STR 3.5X183 MM 14 HOLE RECON LCK SS STRL,SUP-2490201,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.51,1183.98,,,,,,,,,,,,,
TUBE VENT ID1.27MM FLROPLAS SHEEHY CLLR BTTN,SUP-2313870,CDM,L8699,HCPCS,0278,RC,,,,both,,,83.96,54.57,,,,,,,,,,,,,
NAIL IM L420MM DIA13MM 130DEG LNG R HIP TIM CANN LOK FOR AG,SUP-2211489,CDM,C1713,HCPCS,0278,RC,,,,both,,,10059.37,6538.59,,,,,,,,,,,,,
PIVOT FIG 4 MLNA ORBTL MALAR DSTRCTR T 6L 4V SNGLE USE,SUP-2679250,CDM,C1713,HCPCS,0278,RC,,,,both,,,1735.16,1127.85,,,,,,,,,,,,,
PIN EXTRNL FXTN L200MM D5MM TRBCLR METAL TOTAL ANKLE SSTM,SUP-2720915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.53,275.94,,,,,,,,,,,,,
STAPLE BONE FIX BRDG W15MM LEG L20X9MM WIRE DIA2MM CALCNL S,SUP-2194221,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
SCREW BNE LAG 105 MM ASMBLY TELSCP KEYLESS,SUP-2415890,CDM,C1713,HCPCS,0278,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
COIL EMB 3D 1 MMX3 CM V-TRAK ADV DEL SYS HYPERSOFT,SUP-2530419,CDM,C1889,HCPCS,0278,RC,,,,both,,,5204.55,3382.96,,,,,,,,,,,,,
JOINT EXT FIX UNIV SS,SUP-2162676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1979.46,1286.65,,,,,,,,,,,,,
HC So1 Immunofluor per Spec Ea Add Ab,PX-3128835067,CDM,88350,CPT,0312,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
PLATE BNE 24 DEG L 141 X W 8.5 MM THK 1.6 MM 10 H TI RT DSTL,SUP-2932928,CDM,C1713,HCPCS,0278,RC,,,,both,,,5918.27,3846.88,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCREW PIN HI FLX HXLPE TI,SUP-2212710,CDM,C1776,CPT,0278,RC,,,,both,,,27240.66,17706.43,,,,,,,,,,,,,
PLATE BNE L159MM 6 H R LAT DST FEM S STL LOK COMPR FOR,SUP-2410718,CDM,C1713,HCPCS,0278,RC,,,,both,,,4077.70,2650.50,,,,,,,,,,,,,
PLATE BNE L105MM 4 H PROX MED POST TIB S STL LOK COMPR FOR,SUP-2177795,CDM,C1713,HCPCS,0278,RC,,,,both,,,3418.74,2222.18,,,,,,,,,,,,,
VALVE CSF FLO BURR HOLE 16 MM CTRL LO PRESSURE DELT,SUP-2665089,CDM,C1889,HCPCS,0278,RC,,,,both,,,2084.65,1355.02,,,,,,,,,,,,,
"HC Neuromuscular Re-Education, Ot|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE",PX-4309711200,CDM,97112,CPT,0430,RC,,,GO|CO|XU,both,,,159.00,103.35,,,,,,,,,,,,,
PLATE TI LCP ULNA OSTEOTOMY 2.7MM 6 HOLES STERILE,SUP-2546717,CDM,C1713,HCPCS,0278,RC,,,,both,,,3704.35,2407.83,,,,,,,,,,,,,
HC Group Exercise Pt,PX-4209715000,CDM,97150,CPT,0420,RC,,,,outpatient,,,135.00,87.75,,,,,,,,,,,,,
BUR 75X5MM LNG BALL FLUT,SUP-2279703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.63,242.86,,,,,,,,,,,,,
STEM RAD DIA9.5MM UNIV CO CHROM STR PRSS FIT DISP EVOLVE,SUP-2397992,CDM,C1776,CPT,0278,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
SYSTEM BLLN DIL L2.4CM OD5MM HI PRSS NONCOMPLIANT ENDOSCP,SUP-2106312,CDM,C1726,HCPCS,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
AUGMENT FEM L65MM THK5MM R LAT L MED DST KNEE TI INTLOK,SUP-2407757,CDM,C1776,CPT,0278,RC,,,,both,,,2549.68,1657.29,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE PRE THN LG 24X21 CMX0.7-1.4 MM FLEXHD,SUP-2422950,CDM,Q4128,HCPCS,0636,RC,,,,both,,,41499.06,26974.39,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 92 MM BLADE L 50 MM SCREW DIA 4.5 MM,SUP-2907583,CDM,C1713,HCPCS,0278,RC,,,,both,,,3966.67,2578.34,,,,,,,,,,,,,
NEEDLE BRST LOC BLNT 20 GAX7.5 CM STRL HAWKINS II LTX,SUP-2876178,CDM,C1819,HCPCS,0278,RC,,,,both,,,171.76,111.64,,,,,,,,,,,,,
HC Left Ventricular Lead Insert,PX-3613322500,CDM,33225,CPT,0361,RC,,,,both,,,470.00,305.50,,,,,,,,,,,,,
ALLOGRAFT BNE DEMINERALIZED CORTICAL 125-710 MIC 10 CC FD,SUP-2717749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1823.96,1185.57,,,,,,,,,,,,,
HC So Chemiluminescent Assay,PX-3018239766,CDM,82397,CPT,0301,RC,,,,outpatient,,,230.00,149.50,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA15 MM DEL SHTH,SUP-2934254,CDM,C1713,HCPCS,0278,RC,,,,both,,,18920.29,12298.19,,,,,,,,,,,,,
IMPLANT OTO L4.9MM DIA1.17MM LNG HA INCUS FULL CANN KARTUSH,SUP-2418998,CDM,L8613,CPT,0278,RC,,,,both,,,1171.09,761.21,,,,,,,,,,,,,
PLATE BNE X 1.5X1 MM 12 MM C-TUBE BRIDGE TI NS LEVEL 1,SUP-2464188,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.99,406.89,,,,,,,,,,,,,
LITHOTRIPTER SURG FIBER SUREFLEX REUSE RLLF200TG] LASER VENTURES],SUP-2263896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
INSTRUMENT KIT PLN PT SPEC MAND RECON,SUP-2860252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13922.13,9049.38,,,,,,,,,,,,,
PLATE BONE L84.5MM 4 H RT DSTL FIB TI ANAT FOR 2.7/3/3.5/4MM,SUP-2225372,CDM,C1713,HCPCS,0278,RC,,,,both,,,4415.47,2870.06,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1MM S STL TRCR PT FOR SM BONE PLATING,SUP-2343914,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.65,71.27,,,,,,,,,,,,,
CAP END DIA15MM EXTN 0MM TI CANN HD FOR LOK SL 13-15MM FEM,SUP-2192716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.19,663.12,,,,,,,,,,,,,
COMPONENT FEM L7CM L PROX HIP TI MOD FINN STYL ORTH SALV,SUP-2405809,CDM,C1776,CPT,0278,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
STAPLER INT L L25MM DIA5MM GI WHT TI BARIATRIC CIR CUT 2,SUP-2283255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3857.62,2507.45,,,,,,,,,,,,,
STENT BILI L40MM 120CM CATH LEN 7MM DIAM AD XCEED,SUP-2105768,CDM,C1876,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
PLATE BNE L27MM 5 H ZYG TI STR DYN COMPR FOR 2MM CRUCFRM,SUP-2191060,CDM,C1713,HCPCS,0278,RC,,,,both,,,1041.85,677.20,,,,,,,,,,,,,
CATHETER KIT NICU PICC PLCMNT,SUP-2270684,CDM,C1751,HCPCS,0278,RC,,,,both,,,81.70,53.10,,,,,,,,,,,,,
PLATE BNE LCK 2 MM STRNL 6 HOLE XIPHOID,SUP-2262562,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PLATE BONE L100MM 4X8 HOLE T SHAPED 35MM SCREW,SUP-2471047,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
KIT NCV TST LD L39IN W/ 2 PREGELLED DISC ELECTRD TOUCHPROOF,SUP-2308049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
GRAFT BNE PTTY DEMINERLIZED BNE MTRX 5CC ALLOFUSE,SUP-2113946,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
INQUIRY AFOCUS II 1120 7 125 SM AF20,SUP-2699062,CDM,C1730,HCPCS,0272,RC,,,,both,,,4361.46,2834.95,,,,,,,,,,,,,
CATHETER CV SET 025 PEDIATRIC 5 FRX5 CM 3L POLYETH,SUP-2760047,CDM,C1751,HCPCS,0278,RC,,,,both,,,233.93,152.05,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + SM PRIORITY STRL MEDPOR,SUP-2862757,CDM,C1713,HCPCS,0278,RC,,,,both,,,47703.88,31007.52,,,,,,,,,,,,,
PLATE BNE CLVRLF 3.5X120 MM 5 HOLE 2 COMPR FOR SCR SS NS,SUP-2473208,CDM,C1713,HCPCS,0278,RC,,,,both,,,983.20,639.08,,,,,,,,,,,,,
SCREW SPNL ROD DIA 5.5/6 MM SS REDUCTION MULTAXL STRL CD 2PK,SUP-2928047,CDM,C1713,HCPCS,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
SEALER/DIVIDER LAP SHFT L37CM JAW APER 11.4MM 315DEG ROT,SUP-2283569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1898.13,1233.78,,,,,,,,,,,,,
SPLINT WR LT L INSTABILITY INJ 6 IN LOOP LCK W/ STAY COCK UP,SUP-2194853,CDM,L3931,HCPCS,0274,RC,,,,both,,,18.71,12.16,,,,,,,,,,,,,
CATHETER EMB REINF 4 FRX40 CM SMOOTH SIL SS LF,SUP-2214227,CDM,C1757,HCPCS,0272,RC,,,,both,,,243.13,158.03,,,,,,,,,,,,,
BUR SURG TREPHINE 13.5 MM CARBIDE UPWR,SUP-2166770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
MESH SURG 9CM OMEGA 3 FATTY ACID POLYPR SEE THRU CLARITY,SUP-2265959,CDM,C1781,HCPCS,0278,RC,,,,both,,,888.40,577.46,,,,,,,,,,,,,
MARKER SURG FIDUCIAL 2X1 CM SPACER CLP SFT TISS STRL BIOZORB,SUP-2716280,CDM,A4648,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GRAFT HUM TISS W76XL200MM N MESHED SKIN CRYOPRESERVED,SUP-2264847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.74,1036.58,,,,,,,,,,,,,
IMMUNE GLOBULIN (FLEBOGAMMA) 10%|DISCARDED DRUG NOT ADMINISTE,RX-4081761,CDM,J1459,HCPCS,0636,RC,44206-0437-10,NDC,JW,both,100,ML,5659.90,3678.93,,,,,,,,,,,,,
HEAD HUM H27MM OD44MM 4MM OFFSET CO CHROM SHLDR PRI TOT,SUP-2404662,CDM,C1776,CPT,0278,RC,,,,both,,,4976.90,3234.98,,,,,,,,,,,,,
PLATE BNE L97MM 4 H R LAT PROX PERIARTC TIB S STL LOK COMPR,SUP-2198433,CDM,C1713,HCPCS,0278,RC,,,,both,,,3808.60,2475.59,,,,,,,,,,,,,
LOCK SCREW SQUARE 3.5X8MM STERILE,SUP-2587138,CDM,C1713,HCPCS,0278,RC,,,,both,,,302.10,196.36,,,,,,,,,,,,,
PROBE ARTHROSCOPIC ENERGY 20DEG BIPOLAR ANGLED HOOK EDGE,SUP-2824215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1002.29,651.49,,,,,,,,,,,,,
GRAFT BNE SUB 10ML 25X50X8MM BA FOAM STRP PREFRM COMPR,SUP-2368187,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
MICROPOWER SAGITTAL SAW,SUP-2605736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9096.08,5912.45,,,,,,,,,,,,,
SCREW BNE L13MM DIA2.7MM NONLOCKING PLT GORILLA R3CON,SUP-2321342,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.23,298.50,,,,,,,,,,,,,
EXTERNAL FIXATION SET LG SELF DRL SCHNZ SCREW SS,SUP-2183084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63940.57,41561.37,,,,,,,,,,,,,
HC Quan MRI Alys Brain W/O Diagnostic MRI Same Sess,PX-6110865000,CDM,0865T,CPT,0611,RC,,,,both,,,1344.00,873.60,,,,,,,,,,,,,
POST EXT FIX M DIA8MM STR CLMP OUTRIG,SUP-2188516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.41,221.27,,,,,,,,,,,,,
PACEMAKER CARD SINGLE CHMBR EXT BATTERY PWR STRL,SUP-2419366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
BIT DRL L280MM DIA11MM W/O STP CANN CONIC QUIK CPL REUSE,SUP-2188235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1441.98,937.29,,,,,,,,,,,,,
COMPONENT PAT DIA35MM THK9MM STD KNEE VIVACIT-E CEM PERSONA,SUP-2207292,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
KIT CLMP WIRE FIX K,SUP-2316278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.16,574.05,,,,,,,,,,,,,
NIACIN ER 500 MG PO TBCR,RX-5545,CDM,6370000000,HCPCS,0637,RC,50268-0583-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW SPNL FT 12X60 MM SACROILIAC LAG FOR FIX SYS HA SI-LOK,SUP-2229813,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
TRIAL BONE PLT 5 H 1/3 TBLR W/ CLLR FOR 3.5MM SCR TC-100 SM,SUP-2343721,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.08,479.10,,,,,,,,,,,,,
PLATE BONE MINI STERNALOCK BLU SYS,SUP-2137636,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
BONE BIOPSY KIT HUNTINGTON GUID 18 GAX10 CM MADISON MINI,SUP-2472852,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,6370000000,HCPCS,0637,RC,47781-0427-11,NDC,,both,1,UN,90.10,58.56,,,,,,,,,,,,,
MESH SURG L 15 X W 10 CM D 1.5 MM PORCINE DERMAL CLLGN ABD,SUP-2901807,CDM,C9364,HCPCS,0278,RC,,,,both,,,10317.60,6706.44,,,,,,,,,,,,,
SET INTUB W/ RAPI-FIT ADPT FOR REPL OF ET TUBE CATH 6FR,SUP-2168499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,642.82,417.83,,,,,,,,,,,,,
CEPHALEXIN 250 MG PO CAPS,RX-9499,CDM,6370000000,HCPCS,0637,RC,67877-0220-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 120 CM DIA 9-15 MM,SUP-2120069,CDM,C1773,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PACK INSTR FOR MINIMALLY INVASIVE FT SURG,SUP-2398132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
HC ED Cltx Distal Radial Fx Manip,PX-4502560500,CDM,25605,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
GUIDEWIRE VASC L 70 CM DIA 0.038 IN J FLX ADV STRL,SUP-2269534,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.58,19.88,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 VR-T 55 X 66MM 13MM 40J REMOT,SUP-2138132,CDM,C1722,HCPCS,0275,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
WEDGE FEM 7X18 MM DSTL GRW PROS,SUP-2452023,CDM,C1776,CPT,0278,RC,,,,both,,,1428.54,928.55,,,,,,,,,,,,,
GRAFT DURA W1XL1IN CLLGN DURAFOAM,SUP-2243763,CDM,C1713,HCPCS,0278,RC,,,,both,,,415.23,269.90,,,,,,,,,,,,,
BIT DRL L331MM DIA3.9X4.2MM CALIB 100MM 3 FLUT QUIK CPL,SUP-2176961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,716.30,465.59,,,,,,,,,,,,,
RAIL EXT FIX STR 5.5X500 MM 4D TI,SUP-2517545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5770.32,3750.71,,,,,,,,,,,,,
DARBEPOETIN ALFA 100 MCG/0.5ML IJ SOSY,RX-131228,CDM,J0881,HCPCS,0636,RC,55513-0025-01,NDC,,both,0.5,ML,2283.30,1484.14,,,,,,,,,,,,,
HC Skull Less Than 4 Views,PX-3207025000,CDM,70250,CPT,0320,RC,,,,both,,,272.00,176.80,,,,,,,,,,,,,
PLATE BONE LOK 280MML HLX19 YELLW ST LEFT PSTRLTRL DST HMRL,SUP-2484907,CDM,C1713,HCPCS,0278,RC,,,,both,,,3767.22,2448.69,,,,,,,,,,,,,
POST FIX 12MM PLNTR COMPR FOR PLATING SYS OMNI PLANTARFIX,SUP-2224009,CDM,C1713,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
HEAD FEM 17X35X160 MM BIMTRC,SUP-2791017,CDM,C1776,CPT,0278,RC,,,,both,,,9834.48,6392.41,,,,,,,,,,,,,
CPT 12/14 COCR REVISION SIZE 3 180MM,SUP-2504692,CDM,C1776,CPT,0278,RC,,,,both,,,11329.12,7363.93,,,,,,,,,,,,,
TEMOZOLOMIDE 100 MG PO CAPS,RX-25894,CDM,J8700,HCPCS,0636,RC,65162-0803-51,NDC,,both,1,UN,118.70,77.15,,,,,,,,,,,,,
STEM FEM SZ 0 132DEG HIP FORGED VIT POR CLLRD TAPR CEM,SUP-2375347,CDM,C1776,CPT,0278,RC,,,,both,,,13680.98,8892.64,,,,,,,,,,,,,
BIT DRL SLD 2.5 MM W/ STP FOR STBL ANK FRAC SYS OMNI DISP,SUP-2865035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
KIT PHLEBECTOMY BLDE L4.5MM W/ TBNG TRANSILLUMINATED PWR,SUP-2264270,CDM,C1713,HCPCS,0278,RC,,,,both,,,626.96,407.52,,,,,,,,,,,,,
SPACER FEM UNI SIG HP,SUP-2453114,CDM,C1776,CPT,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PLATE BNE 4 H FIB RAREFT FOR TOT FT SYS 2,SUP-2243246,CDM,C1713,HCPCS,0278,RC,,,,both,,,6568.31,4269.40,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 215CM 0.014IN SEG 35CM ACCS STD STR,SUP-2866243,CDM,C1769,HCPCS,0272,RC,,,,both,,,2335.06,1517.79,,,,,,,,,,,,,
STENT URET L80CM OD6FR PERCFLX PTFE DIV CLOSE TIP,SUP-2139621,CDM,C2617,HCPCS,0278,RC,,,,both,,,602.38,391.55,,,,,,,,,,,,,
HC Shoulder 1 View,PX-3207302000,CDM,73020,CPT,0320,RC,,,,both,,,238.00,154.70,,,,,,,,,,,,,
STEM FEM SZ 8 L205MM DIA14MM L HIP TI ALLY HA BOW REV RESTR,SUP-2374213,CDM,C1776,CPT,0278,RC,,,,both,,,17148.17,11146.31,,,,,,,,,,,,,
ANCHOR SUTURE ZIP 5.5 MM COBRAID STRANDS PEEK WHT BLU,SUP-2608440,CDM,C1713,HCPCS,0278,RC,,,,both,,,664.11,431.67,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP CANC 800108,SUP-2743350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1661.06,1079.69,,,,,,,,,,,,,
SPHERE GLEN INFERIOR 2.5+ MM 24X36 MM TI,SUP-2845833,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
INTRODUCER GUID 85FRX63CM,SUP-2357214,CDM,C1893,HCPCS,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
BRACE WR THMB LT MCP CMC JT ELAS SUPP NEOPRNE WRP AD 1 SZ,SUP-2309135,CDM,L3908,HCPCS,0274,RC,,,,both,,,81.33,52.86,,,,,,,,,,,,,
PEN ISOLATOR ELECTRD L7MM BPLR PEN 33CM LNG TRANSPOLAR,SUP-2124460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
"HC Est Pt, E/M Level 5",PX-5109921500,CDM,99215,CPT,0510,RC,,,,inpatient,,,369.00,239.85,,,,,,,,,,,,,
PLATE BONE L4.5MM 4 H TI T FOR 4.5/5.5/6.5MM SCR L FRAG,SUP-2412039,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
SCREW BNE L74MM DIA4.5MM CORT PROX FEM ANK S STL ST FULL,SUP-2350222,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.82,251.43,,,,,,,,,,,,,
CLAMP EXT FIX DBL PIN SWVL NS DISP MAV MINI,SUP-2933016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2670.57,1735.87,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 60 X W 13.5 MM MYRIAD HNDPC L 13 NN-2004,SUP-2930267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
BUR SURG ROSEN RND CUT NONFLUTED HI LN XSM TYP I SHT 60MM,SUP-2108770,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.56,246.06,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.032 INX150 CM REG FLX TIP GLIDEWIRE,SUP-2478880,CDM,C1769,HCPCS,0272,RC,,,,both,,,137.09,89.11,,,,,,,,,,,,,
PI PICC KIT 1-L 4 FR X 55 CM AGBA/TIPTRACKER,SUP-2565194,CDM,C1751,HCPCS,0278,RC,,,,both,,,633.12,411.53,,,,,,,,,,,,,
KIT BONE CEM 80GM DBL MX VAC MXING SYS CART 2 NOZ FLTR TBNG,SUP-2136767,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
WALKER FT SM M SHOE SZ 3 65 FEM 4 75 STD CLS HEEL ROCK SOLE,SUP-2195218,CDM,L4386,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COLLAR CERV SFT 3X22IN UNIV,SUP-2276583,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.59,4.28,,,,,,,,,,,,,
GRAFT BIO TISS W6XL6CM FET BOV SIL MESHED ANTIMIC PRIMATRIX,SUP-2243717,CDM,Q4110,HCPCS,0636,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SM LT WRST,SUP-2330434,CDM,L3908,HCPCS,0274,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
SCREW SPNL RECON 4X20 MM POSTED BLU VERTEX SEL,SUP-2630723,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM BIOCRYL RAPIDE ABSRB 3 PERMACORD SZ 2,SUP-2249460,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.78,1381.76,,,,,,,,,,,,,
HALF PIN 4X150MM 35MM THR,SUP-2818388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,895.47,582.06,,,,,,,,,,,,,
HC MRI-Chest W & WO Contrast,PX-6107155200,CDM,71552,CPT,0610,RC,,,,outpatient,,,4696.00,3052.40,,,,,,,,,,,,,
LENGTHENER FIX SHT FOR 32.5MM MINIRAIL SYS,SUP-2316437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3115.51,2025.08,,,,,,,,,,,,,
CATHETER ABLATN STD CRV 2-5-2 MM 4 MM 7 FRX125 CM CELSIUS,SUP-2248581,CDM,C1733,HCPCS,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
MESH SURG L 5 X W 2 CM D 1 MM PORCINE DERMAL CLLGN ABD HERN,SUP-2901774,CDM,C9364,HCPCS,0278,RC,,,,both,,,818.85,532.25,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR NAR M-L BRIM,SUP-2435675,CDM,L2525,HCPCS,0274,RC,,,,both,,,3226.92,2097.50,,,,,,,,,,,,,
PLATE BNE CRV 4.5X159 MM LT CNDYL 6 HOLE VA LCK STRL VALCP,SUP-2789398,CDM,C1713,HCPCS,0278,RC,,,,both,,,5980.41,3887.27,,,,,,,,,,,,,
BIT DRL L 125 MM DIA2 MM SCREW DIA2 MM AO QC NS REUSE V,SUP-2908197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.11,466.12,,,,,,,,,,,,,
SLITTER LD UNIV FOR INNR CATH CPS,SUP-2356361,CDM,C1893,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SIZER BRST 500CC DIA13.6CM P5.5CM COHESIVE I SIL GEL SMOOTH,SUP-2300888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT DERMAL N FEN 8X4 CMX1-2 MM DERMAL MTRX PARADERM,SUP-2742064,CDM,C1763,HCPCS,0278,RC,,,,both,,,7037.53,4574.39,,,,,,,,,,,,,
BASEPLATE TIB SCR FIX LCK FLX MOD NXGN LEG,SUP-2201053,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PROBE ARTHSCP OD3MM GRN MALL SHFT RF LIGMNT CHSL EFLEX,SUP-2341621,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
ANCHOR SUTURE 5.5 MM PEEK-OPTIMA,SUP-2399112,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
SPINDLE ORTH SM SHT 38 MM 400 LB COMPRESS,SUP-2441838,CDM,C1776,CPT,0278,RC,,,,both,,,9212.76,5988.29,,,,,,,,,,,,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,6370000000,HCPCS,0637,RC,59762-0333-02,NDC,,both,2.5,ML,11.30,7.34,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA12 MM STD LAPSCP BLADED SMTH CANN,SUP-2896405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.38,255.70,,,,,,,,,,,,,
GRAFT HUM TISS W8.5XL200MM TEND PRESUTURED DBL STRND,SUP-2123494,CDM,C1762,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
GRAFT BNE FRZN FEM CONDYLE IMPL ALLGRFT L50 TO 70MM,SUP-2264792,CDM,C1713,HCPCS,0278,RC,,,,both,,,8569.06,5569.89,,,,,,,,,,,,,
MESH HERN W6XL8IN ELLIPSE W/ ECHO PS POS SYS VENTRALIGHT ST,SUP-2125917,CDM,C1781,HCPCS,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
DEVICE STRNL CLOSUREXSM D11MM TI TWO LEG SGL VERSION TALON,SUP-2262515,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
IMPLANT FNGR JT SM L13.5MM SCR OD2.8MM BARB L5.5MM OD4MM,SUP-2223969,CDM,C1713,HCPCS,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
LEAD DEFIB TRUE BPLR 21 CM ACTIVE FIX OPTIM INSUL RIATA ST,SUP-2357370,CDM,C1895,HCPCS,0275,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
DRILL SURG ORAL MXLFCL STRGHT HGH SPD PRMNNT LEVER FLFSMLL B,SUP-2605596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17285.83,11235.79,,,,,,,,,,,,,
PUSHER KNOT 5 MMX31 CM EXCORP,SUP-2850164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.81,283.93,,,,,,,,,,,,,
COMPONENT HIP CEM STEMED W/ HD,SUP-2212280,CDM,C1776,CPT,0278,RC,,,,both,,,8249.66,5362.28,,,,,,,,,,,,,
CATHETER INTRO 9X7FR L50.7CM WRK L47CM PEBAX OUTER,SUP-2356363,CDM,C1893,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SYSTEM RE-ENTRY OFFROAD CATH L 70 CM SHFT DIA 5 FR BALLOON,SUP-2145862,CDM,C1725,HCPCS,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
CATHETER ANGIO L54CM OD8FR COR SINUS MPL LV1 EASYTRAK,SUP-2148861,CDM,C1887,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CANNULA ENDOSCP 5MM SHT DIL MINI STP,SUP-2283295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.23,231.55,,,,,,,,,,,,,
TIP ASPIR L38IN CUT W28XL2MM UNIV CLAW DCOMPR FOR SONOPET,SUP-2363702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1788.51,1162.53,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI PWR TRIALYSI SLIM CATH ACTE 12 5855300,SUP-2632932,CDM,C1752,HCPCS,0278,RC,,,,both,,,979.96,636.97,,,,,,,,,,,,,
BLADE SURG STERNALOCK,SUP-2137256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
SCREW KNEE ARTHROPLASTY TI STRL 22MML GEN UNI,SUP-2349781,CDM,C1713,HCPCS,0278,RC,,,,both,,,773.54,502.80,,,,,,,,,,,,,
CLIP INT M L POLYMER LOK LIG HEM O LOK,SUP-2641839,CDM,C1889,HCPCS,0278,RC,,,,both,,,107.42,69.82,,,,,,,,,,,,,
SCREW BNE PART THRD SM 4.3X65 MM STRL PROPELLER HD LTX,SUP-2861172,CDM,C1713,HCPCS,0278,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
ENDOPROSTHESIS BILI VIABIL L 8 CM DIA 8 MM L 200 CM W/O H,SUP-2883825,CDM,C1874,HCPCS,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
COMPONENT TOT KNEE UNIV 45X22 MM 9 MM,SUP-2222198,CDM,C1776,CPT,0278,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
KIT VENT ASST CTRL L,SUP-2282556,CDM,Q0481,HCPCS,0274,RC,,,,both,,,22451.00,14593.15,,,,,,,,,,,,,
KIT INTRO L 7 CM DIA 5 FR GUIDEWIRE L 45 CM DIA 0.018 IN,SUP-2615918,CDM,C1894,HCPCS,0272,RC,,,,both,,,151.35,98.38,,,,,,,,,,,,,
CATHETER INFUSION 2.7 FRX165 CM 3 CM MAGIC SPIF FLO COIL,SUP-2424284,CDM,C1887,HCPCS,0272,RC,,,,both,,,2502.58,1626.68,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM LT LAT VA LCK COMPR SS NS VA-LCP,SUP-2757605,CDM,C1713,HCPCS,0278,RC,,,,both,,,3293.36,2140.68,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.548,SUP-2860065,CDM,C1713,HCPCS,0278,RC,,,,both,,,55917.12,36346.13,,,,,,,,,,,,,
GRAFT BNE SUB 20CC CA SULF CA PHSPTE INJ REGEN PRO-DENSE,SUP-2399154,CDM,C1713,HCPCS,0278,RC,,,,both,,,13778.32,8955.91,,,,,,,,,,,,,
GRAFT VASC W7XL10CM THK01MM PERICARD EPTFE MEM PRECL,SUP-2395367,CDM,C1781,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
CATHETER CV DL 4 FR FULL TY PER-Q-CATH,SUP-2126382,CDM,C1894,HCPCS,0272,RC,,,,both,,,503.97,327.58,,,,,,,,,,,,,
SENNOSIDES 8.6 MG PO TABS,RX-11349,CDM,6370000000,HCPCS,0637,RC,67618-0300-50,NDC,,both,1,UN,1.80,1.17,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 6 DEG 10 MM FRZN ALIF BIGFOOT,SUP-2731733,CDM,C1713,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
PLATE ANK JT FUSION TI RT PILON PRIMARY,SUP-2896558,CDM,C1713,HCPCS,0278,RC,,,,both,,,7218.86,4692.26,,,,,,,,,,,,,
ARTHROSCOPE VID L 125 MM PASSPRT CANN L 4 CM DIA 8 MM,SUP-2930492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.93,1125.10,,,,,,,,,,,,,
MARKER BRST BX XR SITE CLP,SUP-2128487,CDM,A4648,CPT,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BUNDLE VLV REP MITRACLIP MITRL VLV 1 SGC0301,SUP-2106203,CDM,C1889,HCPCS,0278,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
LEAD PACE ACUITY SPRL L 90 CM DIA 6 FR SIL POLYUR ETFE PTIR,SUP-2148699,CDM,C1900,HCPCS,0275,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
PLATE FEM DIST LAT 20 HL 414MM RT,SUP-2705053,CDM,C1713,HCPCS,0278,RC,,,,both,,,10104.52,6567.94,,,,,,,,,,,,,
BIT DRL DIA2.5MM CANN PROF FOR 2.5MM INSTR MAX VPC SCR SYS,SUP-2402760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
BUR SURG DIA4MM RND W/ RIM GLDE TECHNOLOGY PRECIS,SUP-2367541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.03,442.02,,,,,,,,,,,,,
PLATE BNE L90MM THK3.3MM 7 H BILAT S STL STR LIMIT CNTCT,SUP-2185134,CDM,C1713,HCPCS,0278,RC,,,,both,,,932.39,606.05,,,,,,,,,,,,,
SCREW BNE L5MM OD15MM TI CRANIOMAXILLOFACIAL NONCANNULATED,SUP-2262790,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.69,123.95,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM PEEK DBL KNOTLESS SYS STRL OMEGA,SUP-2908722,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.32,1710.36,,,,,,,,,,,,,
PLATE BONE SM W11XL90MM THK3.3MM 0DEG 7 H BILAT TI STR LIMIT,SUP-2190779,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.11,330.27,,,,,,,,,,,,,
LINER ACET CUP FINISHING B 37 MM EZX,SUP-2745661,CDM,C1776,CPT,0278,RC,,,,both,,,529.88,344.42,,,,,,,,,,,,,
GRAFT HUM TISS 3X3 CM REP AMNIO TISS MEMBRN,SUP-2423431,CDM,C1762,CPT,0278,RC,,,,both,,,5375.68,3494.19,,,,,,,,,,,,,
COLLAR CERV XL H4XL20IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335998,CDM,L0120,HCPCS,0274,RC,,,,both,,,13.53,8.79,,,,,,,,,,,,,
PLATE BONE FOIL 11MMW X 1262MML 1MM THK RSRB X LATEX FREE,SUP-2681108,CDM,C1713,HCPCS,0278,RC,,,,both,,,1844.56,1198.96,,,,,,,,,,,,,
SET BONE BX NDL PNCL PT 12GX6.5CM ACKERMANN,SUP-2167931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.07,630.55,,,,,,,,,,,,,
STEM FEM L300MM OD13MM POR DSTL HIP MOD SLOT RL HARDENED,SUP-2404202,CDM,C1776,CPT,0278,RC,,,,both,,,10063.70,6541.40,,,,,,,,,,,,,
NAIL FEMORAL RETROGRADE 13X360MM,SUP-2718056,CDM,C1713,HCPCS,0278,RC,,,,both,,,11195.10,7276.81,,,,,,,,,,,,,
PLATE BNE THK0.8MM BAR L8MM 6 H CRANIOMAXILLOFACIAL GRY TI,SUP-2366263,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.87,491.97,,,,,,,,,,,,,
PLATE BNE L88MM 3 H BILAT S STL CLVRLF FOR 3.5MM SCR,SUP-2411332,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.82,477.63,,,,,,,,,,,,,
PROGRAMMER PT PROCLAIM DRG,SUP-2357383,CDM,C1787,HCPCS,0278,RC,,,,both,,,4596.77,2987.90,,,,,,,,,,,,,
COLLAR CERV CNTOUR LNG NAR 24X2 IN 17-22 IN MED FOAM PROCARE,SUP-2196863,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.71,6.96,,,,,,,,,,,,,
BUR SURG MIC 0.8 MM FOR SALIVARY TELSCP,SUP-2771970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.59,589.93,,,,,,,,,,,,,
HC Voice Prosthesis Eval,PX-4449259700,CDM,92597,CPT,0444,RC,,,,outpatient,,,478.00,310.70,,,,,,,,,,,,,
COLLAR CERV 3 1/4X10-12IN SM TRACH OPN ADJ PHIL,SUP-2195259,CDM,L0120,HCPCS,0274,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
NAIL INTRMDLLRY LOK CNNLTD UNVRSL 7MM DIA 220MML TTNM ALLOY,SUP-2587501,CDM,C1713,HCPCS,0278,RC,,,,both,,,4384.48,2849.91,,,,,,,,,,,,,
CATHETER EP 7FRX115CM F CRV QPLR 1 7 4MM BI DIR DEFL,SUP-2248474,CDM,C1730,HCPCS,0272,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
PUTTY ALLGRFT DEMIN BONE MTRX SYR VOL 2ML ALLOGENIX,SUP-2402965,CDM,C1713,HCPCS,0278,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
SCREW BNE CANC 6.5 MM DIAM 20 MM LEN FULL THRD PEEK BLNT,SUP-2121077,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 204 MM BLADE L 50 MM 12 H SS CNDYL,SUP-2908306,CDM,C1713,HCPCS,0278,RC,,,,both,,,3696.41,2402.67,,,,,,,,,,,,,
IMPLANT FACE W38XL50MM THK1.6MM R MAND ANG MEDPOR,SUP-2366494,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
COMPONENT ULN L100MM STD RT ELBW MRS,SUP-2363215,CDM,C1776,CPT,0278,RC,,,,both,,,9231.60,6000.54,,,,,,,,,,,,,
APPEL TYP KNOT PUSH 5MM 40CM,SUP-2138694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 101-150 CM FASC,SUP-2321781,CDM,C1762,CPT,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
CATH BLLN SCORING 2.5X10MM X 137CM OTW PTCA ANGIOSCULPT,SUP-2353066,CDM,C1725,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
INSERT TIB SZ 4 THK6MM ROT PLATFRM KNEE UHMWPE ANTIOXIDANT,SUP-2251846,CDM,C1776,CPT,0278,RC,,,,both,,,6732.16,4375.90,,,,,,,,,,,,,
NEEDLE BIOPSY 4 12INL GEARBOX CORB LATEX FREE STERILE,SUP-2720333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7317.08,4756.10,,,,,,,,,,,,,
MESH HERN SQ 8X8 IN FULL RESRB FOR SFT TISS RECON PHASIX,SUP-2855254,CDM,C1781,HCPCS,0278,RC,,,,both,,,18902.80,12286.82,,,,,,,,,,,,,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG PO TABS,RX-9081,CDM,6370000000,HCPCS,0637,RC,00555-0972-02,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
SET SCR RET COMPR RET,SUP-2288454,CDM,C1713,HCPCS,0278,RC,,,,both,,,2465.12,1602.33,,,,,,,,,,,,,
PLATE BNE L 135 MM SCREW DIA 4.5 MM 8 H COMPR LCK NS EVOS,SUP-2932914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2987.71,1942.01,,,,,,,,,,,,,
SCREW BNE L16MM DIA4.5MM STD CORT TI ST LOK LO PROF AXSOS,SUP-2704436,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.06,101.44,,,,,,,,,,,,,
PLATE BNE M L150MM THK4MM VIT TROCHANTERIC GRP LO PROF W/ 2,SUP-2377571,CDM,C1713,HCPCS,0278,RC,,,,both,,,3546.94,2305.51,,,,,,,,,,,,,
PLATE BNE PROF H 1.5 MM 8 H SCREW DIA2 MM TI MANDIBULAR STR,SUP-2883150,CDM,C1713,HCPCS,0278,RC,,,,both,,,916.03,595.42,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L24CM OD14.5FR POLYUR 2 LUMN SPL,SUP-2126523,CDM,C1750,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BONE W12XL55MM THK1MM 3 H BILAT TI SEMI TBLR LO PROF,SUP-2190701,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.74,147.38,,,,,,,,,,,,,
CATHETER HD SHT TERM 11.5 FRX15 CM DL TAPR SET SIL HEMCATH,SUP-2627305,CDM,C1752,HCPCS,0278,RC,,,,both,,,30.58,19.88,,,,,,,,,,,,,
SCREW CRAN 10PK L 4 MM DIA2.2 MM PLLA PGA PDLA RESRB STRL DELT,SUP-2883350,CDM,C1713,HCPCS,0278,RC,,,,both,,,2660.84,1729.55,,,,,,,,,,,,,
STENT BILI SENTINOL L 40 MM DIA 6 MM CATH L 75 CM SHTH 6 FR,SUP-2140675,CDM,C1876,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
RITUXIMAB-ABBS (TRUXIMA) 10 MG/ML IV SOLN (MIXTURES ONLY),RX-1150545,CDM,Q5115,HCPCS,0636,RC,63459-0104-50,NDC,,both,50,ML,12176.00,7914.40,,,,,,,,,,,,,
CATHETER SPEC RETRV 035 7-5 FRX200 CM 12 MM BELOW TRI-EX,SUP-2738197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ARCH EXT FIX BOW SHT 90 MM NS TRUELOK LTX,SUP-2875042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1700.15,1105.10,,,,,,,,,,,,,
SPLINT POLYCENTRIC ULN DEVIATION RT SM,SUP-2324606,CDM,L3906,HCPCS,0272,RC,,,,both,,,177.35,115.28,,,,,,,,,,,,,
CATHETER HD ASH SPLIT 14 FRX40 CM,SUP-2269501,CDM,C1750,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
WALKER PT STD XL 11-16 13 + CLOSED HEEL SHOE PACESETTER II,SUP-2195219,CDM,L4386,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
BURR SURG SWNSN REAMER 2MM DIA HD MED MIC 62MML STL SM BNE F,SUP-2605555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,143.72,93.42,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 0.038 INX150 CM GLIDEWIRE UWS6038,SUP-2462933,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.78,98.01,,,,,,,,,,,,,
CANISTER SUCT 1200ML W/ INTERMED TBNG RIPTIDE,SUP-2281163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PLATE BNE SM W11XL85MM THK3.4MM 6 H BILAT TI RIG NEUT LOK,SUP-2420763,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.51,600.28,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SFT LN ACTE 11.5FR DIA 15CM STRGHT TAP,SUP-2610546,CDM,C1752,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
SHEATH INTRO 24FR L28CM ID8.2MM DRYSEAL,SUP-2396260,CDM,C1894,HCPCS,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
INSERT TIB PRIMARY 25 MM PCA,SUP-2451596,CDM,C1776,CPT,0278,RC,,,,both,,,2129.67,1384.29,,,,,,,,,,,,,
IMPLANT BIO TISS W18XL22CM REINF BIOSCAFFOLDS PERM OVITEX 1S,SUP-2383096,CDM,C1781,HCPCS,0278,RC,,,,both,,,22381.92,14548.25,,,,,,,,,,,,,
MESH SYN ABD ABSRB PRESHAPED POLYGLACTIN 910 44CM LEN 30CM,SUP-2220335,CDM,C1781,HCPCS,0278,RC,,,,both,,,2546.48,1655.21,,,,,,,,,,,,,
PIN FIX KNEE S STL HEX HD HLD MG II,SUP-2342143,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 4 MM RNG L 2.5 CM EPTFE STR TW,SUP-2396145,CDM,C1768,CPT,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM GRAVITATIONAL L 12 MM PRESSURE ADJ FX662T,SUP-2928843,CDM,C1889,HCPCS,0278,RC,,,,both,,,15369.04,9989.88,,,,,,,,,,,,,
WASHER ORTH OD35MM S STL MTP LOK SURFIX,SUP-2243052,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.94,327.56,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO BASIC 18GA 10CM WNGD F118107T,SUP-2632728,CDM,C1751,HCPCS,0278,RC,,,,both,,,248.15,161.30,,,,,,,,,,,,,
GUIDE NERVE REP MTRX 1.5 MMX3 CM STRL NEURAGEN 3D LF,SUP-2877624,CDM,C9352,HCPCS,0278,RC,,,,both,,,9919.26,6447.52,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FOX CROSS L 135 CM BALLOON L 20 MM DIA 8,SUP-2101861,CDM,C1725,HCPCS,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
MIDAZOLAM HCL 50 MG/10ML IJ SOLN,RX-93523,CDM,J2250,HCPCS,0636,RC,00641-6060-10,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
NEEDLE FN NDL BX 25GA ENDOBRONCH US,SUP-2418160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.14,746.29,,,,,,,,,,,,,
COMPONENT FEM BASIC PROXIMAL KNEE MOST OPTIONS,SUP-2509217,CDM,C1776,CPT,0278,RC,,,,both,,,11953.98,7770.09,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP PERONEUS LONGUS TEND,SUP-2867232,CDM,C1762,CPT,0278,RC,,,,both,,,5262.01,3420.31,,,,,,,,,,,,,
HC So Alkaloids Nos,PX-3018032366,CDM,G0480,CPT,0301,RC,,,,outpatient,,,64.00,41.60,,,,,,,,,,,,,
RING EXT FIX DIA130 MM LG FT NS DISP TSF,SUP-2933056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4914.10,3194.16,,,,,,,,,,,,,
GUIDEPIN SURG CANN SCREE +,SUP-2398608,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
SYSTEM PAIN PMP 270MLX2ML HR 5ML CTRL ADMIN CATHETER ONDEMAND BOL,SUP-2236852,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
STENT BILI WSTNT L 40 MM DIA10 MM CATH L 194 CM DIA 8 FR,SUP-2141482,CDM,C1876,HCPCS,0278,RC,,,,both,,,5282.05,3433.33,,,,,,,,,,,,,
TIP ASPIR 2.5X3.15 MM 20 CM FOR BNE CUT APEX 360 SONOPET IQ,SUP-2791054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3656.37,2376.64,,,,,,,,,,,,,
KIT EXT FIX AUTO HEXAPOD CTRL MAXFRAME AUTOSTRUT,SUP-2908466,CDM,C1713,HCPCS,0278,RC,,,,both,,,22969.10,14929.91,,,,,,,,,,,,,
TUBING SET SUC IRR FOR ROSI SYS STRL LTX,SUP-2865324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
STENT TRACHBRONCH 9X20 MM NOVATECH BD DUMON,SUP-2309496,CDM,C1875,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PI PICC KIT: 2L 5.5FR 55CM AGBA TIPTRACK,SUP-2827053,CDM,C1751,HCPCS,0278,RC,,,,both,,,799.66,519.78,,,,,,,,,,,,,
GUIDEWIRE ORTH L 450 MM DIA2.8 MM TROCAR FLUT TIP FOR CANN,SUP-2908265,CDM,C1769,HCPCS,0272,RC,,,,both,,,622.66,404.73,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE 3 PNL CANVS 12 IN LTX FREE,SUP-2336073,CDM,L1830,CPT,0272,RC,,,,both,,,56.24,36.56,,,,,,,,,,,,,
BIT DRL CANN LNG 2.3X120 MM AO,SUP-2321603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
SCREW INTFR 9MM 30MM 1MM KNEE FIX CANN N ABSRB TI TAPR HD,SUP-2341315,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
CANN SCREW WASHER 7.0MM ODX3.6MM IMMUNODIFFUSION,SUP-2823117,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
NAIL IM L360MM DIA10MM NK ANG 130DEG LT FEM TI CANN LCK,SUP-2347148,CDM,C1713,HCPCS,0278,RC,,,,both,,,12487.78,8117.06,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN L 145 CM DIA 0.035 IN TAPR L 11.5 CM,SUP-2873667,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 PLU MAXBARR 4FR 55C 1194108D1,SUP-2632629,CDM,C1751,HCPCS,0278,RC,,,,both,,,735.39,478.00,,,,,,,,,,,,,
SCREW BNE SELF DRL GALLERY LAMINOPLASTY SPINE 2.4 MM X 5.0,SUP-2414966,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CANNULA ENDOSCP LUER LCK CONN 3.9 MMX5 CM LIGHTWEIGHT RED,SUP-2767463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1543.31,1003.15,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INTELLAMAP ORION 180 DEG L 115 CM,SUP-2141350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
GUIDEWIRE VASC NIT-VU L 300 CM DIA 0.014 IN TIP L 7 CM NIT,SUP-2117335,CDM,C1769,HCPCS,0272,RC,,,,both,,,220.74,143.48,,,,,,,,,,,,,
HALF PIN 6MMX90MM,SUP-2820673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1197.00,778.05,,,,,,,,,,,,,
CATHETER KT 1IN 2.5CM 100MLX1ML/HR ON-Q PAINBUSTER SOAK,SUP-2236783,CDM,C2626,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
TITANIUM STRAIGHT BAR 101MM,SUP-2679249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1039.31,675.55,,,,,,,,,,,,,
LOCK DIST TIB MED LT 12H STE,SUP-2588832,CDM,C1713,HCPCS,0278,RC,,,,both,,,3874.07,2518.15,,,,,,,,,,,,,
APPLIER INT CLP MULT FIRE SM MED 5X205 MM CHALLENGER REUSE,SUP-2852445,CDM,C1889,HCPCS,0278,RC,,,,both,,,9270.10,6025.56,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM OD 5 FR ID 1.7 MM GUIDEWIRE,SUP-2168655,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.80,45.37,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 1.5 CM AMNION-CHORION-AMNION LAYR,SUP-2909287,CDM,Q4140,HCPCS,0636,RC,,,,both,,,5047.42,3280.82,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0250,RC,00338-0049-11,NDC,,both,50,ML,24.70,16.05,,,,,,,,,,,,,
HC So Cbc W/O Diff,PX-3058502766,CDM,85027,CPT,0305,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
PREGABALIN 150 MG PO CAPS,RX-42166,CDM,6370000000,HCPCS,0637,RC,62332-0123-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MESH HERN L30.5XW5CM THICKNESS 7MM POLYPR INGUINAL,SUP-2125746,CDM,C1781,HCPCS,0278,RC,,,,both,,,206.93,134.50,,,,,,,,,,,,,
STRAP ORTHOT HIP KNEE ANK CUST TORSON UNILAT ROT,SUP-2435643,CDM,L2070,HCPCS,0272,RC,,,,both,,,439.41,285.62,,,,,,,,,,,,,
SPLINT THMB M L8IN LNG RT THERMOPLASTIC INSRT THERMO-FORM,SUP-2324197,CDM,L3931,HCPCS,0272,RC,,,,both,,,57.65,37.47,,,,,,,,,,,,,
MESH SURG 34CM LEN 26CM W THK2MM SYN ABD N ABSRB RECT EXP,SUP-2125810,CDM,C1781,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
STEM FEM L200MM DIA10MM KNEE EXTN OPTETRAK,SUP-2222911,CDM,C1776,CPT,0278,RC,,,,both,,,2420.00,1573.00,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 70 CM OD 8 FR ID 2.87 MM GUIDEWIRE,SUP-2633293,CDM,C1894,HCPCS,0272,RC,,,,both,,,299.56,194.71,,,,,,,,,,,,,
WAND 55-ENT ARTHWAND REFLX ULT,SUP-2342029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X52 MM 6 HOLE SS,SUP-2536115,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.26,240.02,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX5 TTNM RCNSTRCTN F3.5MM LOK SCRE,SUP-2720931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1300.15,845.10,,,,,,,,,,,,,
SHOE CAST SM AD W4.25XL9.25IN W/ ROCK OPN TOE AND OPN HEEL,SUP-2203830,CDM,L4387,HCPCS,0274,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
PLATE BNE NAR 4.5X124 MM 7 HOLE SS LC-DCP,SUP-2569259,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.41,175.12,,,,,,,,,,,,,
CANCELLOUS SCREW STERILIZER 4.0X24 MM F-T,SUP-2818172,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.61,112.85,,,,,,,,,,,,,
SPACER SPNL 35 DEG 14X14 MM THORLUM UPPER ENDPLATE FORTIFYR,SUP-2231200,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BIT DRL L65MM DIA1.1MM STP L40MM STRL MAXILLOFACIAL S STL J,SUP-2187687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.41,374.67,,,,,,,,,,,,,
PLATE 22MM ANT CERV,SUP-2244670,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.93,59.10,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 10 HOLE 2 COMPR LCK FOR SCR TI STRL,SUP-2483579,CDM,C1713,HCPCS,0278,RC,,,,both,,,1490.34,968.72,,,,,,,,,,,,,
COMPONENT FEM SZ 4 R KNEE CO CHROM MOLYBDENUM CEM W/ ASYM,SUP-2251380,CDM,C1776,CPT,0278,RC,,,,both,,,15009.20,9755.98,,,,,,,,,,,,,
FLUTED ACORN 5MM,SUP-2176909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.93,254.10,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-7 MM SHRT TAPR HELIX,SUP-2763161,CDM,C1768,CPT,0278,RC,,,,both,,,1803.05,1171.98,,,,,,,,,,,,,
RING FIX 11-13MM CAPSULAR TENS REFORM,SUP-2110079,CDM,L8610,HCPCS,0278,RC,,,,both,,,675.79,439.26,,,,,,,,,,,,,
METOPROLOL TARTRATE 5 MG/5ML IV SOLN,RX-92079,CDM,J0616,HCPCS,0636,RC,00143-9660-01,NDC,,both,2.5,ML,54.10,35.16,,,,,,,,,,,,,
SYSTEM BNE BX 11 GAX15 CM WESTBROOK,SUP-2479659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BNE TIB LT DSTL POSTEROLATERAL ANK 4 HOLE NS,SUP-2518423,CDM,C1713,HCPCS,0278,RC,,,,both,,,5237.52,3404.39,,,,,,,,,,,,,
SET PERICARDCENT L 40 CM DIA 8.3 FR GUIDEWIRE L 70 CM DIA,SUP-2759900,CDM,C1729,HCPCS,0272,RC,,,,both,,,349.58,227.23,,,,,,,,,,,,,
PLATE BNE CRV 2.3X30 MM FRAC COMPR FOR SCR TI LEVEL 1,SUP-2475936,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.09,616.26,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 60 DEG L 11 CM DIA 3.5 MM SPD 5000 RPM,SUP-2900136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.79,328.76,,,,,,,,,,,,,
GRAFT BNE R HUM HD FRSH,SUP-2264641,CDM,C1713,HCPCS,0278,RC,,,,both,,,22117.09,14376.11,,,,,,,,,,,,,
TRIMMER MESH SPNL PYRAMESH,SUP-2280084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2841.48,1846.96,,,,,,,,,,,,,
PLATE BNE L1865MM THK25MM 12 H PELV S STL STR,SUP-2362702,CDM,C1713,HCPCS,0278,RC,,,,both,,,2635.40,1713.01,,,,,,,,,,,,,
PLATE BNE L 120.7 X W 8.3 MM THK 2.6 MM SCREW DIA2/2.3 MM 16,SUP-2936754,CDM,C1713,HCPCS,0278,RC,,,,both,,,5780.74,3757.48,,,,,,,,,,,,,
SUPPORT ORTH H 9.5 IN UNIV ANK AD DPLX AIRCELL TECHNOLOGY,SUP-2915216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,47.92,31.15,,,,,,,,,,,,,
BLADE RETRACTOR YOUNG 7/16X2 IN 210 MM PROST LAT NOTCH ANTR,SUP-2459083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,490.78,319.01,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413561,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GUIDEWIRE ORTH 2 MMX9 IN FOR HDLSS SCR SYS NS LTX,SUP-2862167,CDM,C1769,HCPCS,0272,RC,,,,both,,,194.05,126.13,,,,,,,,,,,,,
STENT EVAR L50MM DIA8MM CATH 9FR L80CM 0.035IN EPTFE GRFT,SUP-2128230,CDM,C1874,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
GRAFT BLK CERV CORT ALLGRFT 6MMX14MMX11MM,SUP-2289234,CDM,C1713,HCPCS,0278,RC,,,,both,,,2815.80,1830.27,,,,,,,,,,,,,
MANIPULATOR SURG ANDERSON-BARRETT 130 MM DBL END TI,SUP-2473357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.72,476.27,,,,,,,,,,,,,
TUBE VENT 1.14 MM 1.1 MM 2.6X2.6 MM POPE POLYETH STRL 530003,SUP-2483781,CDM,L8699,HCPCS,0278,RC,,,,both,,,43.27,28.13,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 45 CM OD 12 FR ID 4.1 MM GUIDEWIRE,SUP-2171149,CDM,C1894,HCPCS,0272,RC,,,,both,,,167.52,108.89,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SQ 80X80 MM FRZN IRRADIATED FASC LATA,SUP-2866850,CDM,C1762,CPT,0278,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
GRAFT BNE PAT TISS FULL EXTENSOR,SUP-2165600,CDM,2780000010,LOCAL,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
MESH HERN W4XL6IN MFIL RESRB RECT W/ HYDRGEL BARR SCFLD,SUP-2125882,CDM,C1781,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CATHETER VENTRICULAR DRAINAGE TIP L 15 MM DIA 0.021 IN FLX,SUP-2910013,CDM,C1729,HCPCS,0272,RC,,,,both,,,6110.44,3971.79,,,,,,,,,,,,,
HC So Hiv-1antibody,PX-3028670166,CDM,86701,CPT,0302,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
HC Dx Bone Marrow Bx & Aspir,PX-3613822200,CDM,38222,CPT,0361,RC,,,,both,,,8633.00,5611.45,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 11 HOLE INTLOK,SUP-2518368,CDM,C1713,HCPCS,0278,RC,,,,both,,,3727.18,2422.67,,,,,,,,,,,,,
LENS INTOCU +24.0 DIOPT L12.5MM DIA5.5MM D3.39MM 0.5DEG,SUP-2110745,CDM,V2630,CPT,0276,RC,,,,both,,,260.87,169.57,,,,,,,,,,,,,
PIN EXT FIX CIR HALF S STL RANCHO SYS 5 DIAM 25 THRD LEN,SUP-2342569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.18,742.42,,,,,,,,,,,,,
MESH HERN CIR 20 CM W/ ECHO 2 POS SYS POLYPR VENTRALIGHT ST,SUP-2126501,CDM,C1781,HCPCS,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
RING EXT FIX ID165MM TI C FBR HYBRID FIX 1 4 FOR DST TIB,SUP-2188612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1092.22,709.94,,,,,,,,,,,,,
SCREW INTFR BIOSURE REGENESORB 11MM X 25MM,SUP-2341929,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.07,728.05,,,,,,,,,,,,,
SPACER SPNL RND 5 DEG MED 21 MM ENDPLATE STRL XLR,SUP-2592019,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BIT DRL DIA2MM CANN COMPR,SUP-2122159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
PLATE BNE 24X55MM NONSTERILE R VOLAR RIM CROSSLOCK DVR,SUP-2411818,CDM,C1713,HCPCS,0278,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min,PX-4309753000,CDM,97530,CPT,0430,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
CATHETER ETER CTRL VEN L16CM OD5FR 032IN GWIRE KT SGL LUMN N,SUP-2383267,CDM,C1751,HCPCS,0278,RC,,,,both,,,50.18,32.62,,,,,,,,,,,,,
STEM FEM HI OFFSET 4 SHT HIP TAPR POROUS,SUP-2450686,CDM,C1776,CPT,0278,RC,,,,both,,,14205.36,9233.48,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2X3 H TI NEURO RECTANGULAR PLATE,SUP-2936077,CDM,C1713,HCPCS,0278,RC,,,,both,,,23374.16,15193.20,,,,,,,,,,,,,
COMPONENT FEM SZ 6 NP LT KNEE PRI CRUC RET CEM STEMLESS,SUP-2349034,CDM,C1776,CPT,0278,RC,,,,both,,,11351.10,7378.21,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 25CM 5FR 0.074IN SPRING WALL PUNC,SUP-2384823,CDM,C1894,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.5 X 10MM HD CANN SHT THRD SCR,SUP-2320388,CDM,C1713,HCPCS,0278,RC,,,,both,,,682.95,443.92,,,,,,,,,,,,,
STEM RAD L22MM OD5MM UNIV TI POR PLSM SPR ANT DST EL STR,SUP-2404376,CDM,C1776,CPT,0278,RC,,,,both,,,4069.75,2645.34,,,,,,,,,,,,,
HC CT L-Spine W/WO Contrast,PX-3527213300,CDM,72133,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
BLADE RETRACTOR LNG TEETH 45X15X MM SPNL SELF RET BLK,SUP-2457502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,773.95,503.07,,,,,,,,,,,,,
HUMERAL NAIL 11/9.5MMX30CM,SUP-2818964,CDM,C1713,HCPCS,0278,RC,,,,both,,,8756.68,5691.84,,,,,,,,,,,,,
SPACER SPNL LORDTC 6 DEG 30X11X7 MM VALEO TL,SUP-2175318,CDM,C1713,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
STEM EXT 10X120MM,SUP-2221189,CDM,C1776,CPT,0278,RC,,,,both,,,2492.53,1620.14,,,,,,,,,,,,,
SYSTEM BONE CEMENT SPINAL HIGHV+ TEKNIMED,SUP-2717562,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
STENT URTRL 8FR DIA 26CML PRCFLX DBLE PGTL STRGHT TIP FLXBLE,SUP-2726052,CDM,C2617,HCPCS,0278,RC,,,,both,,,630.32,409.71,,,,,,,,,,,,,
BEARING MOD LM RL 8MM REPICCI II,SUP-2136601,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
KIT STPL BNE FIX BRDG 20MM LEG 20MM 8MM OFFSET WIRE 2X2MM,SUP-2194276,CDM,C1713,HCPCS,0278,RC,,,,both,,,3580.73,2327.47,,,,,,,,,,,,,
SCREW SPNL L35MM DIA4.75MM CANC PEDCL S STL NO CUT ISOLA VSP,SUP-2256907,CDM,C1713,HCPCS,0278,RC,,,,both,,,1883.06,1223.99,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 135 CM BALLOON L 60 MM DIA 3,SUP-2141231,CDM,C1725,HCPCS,0272,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
SCREW BNE L54MM L17MM OD5.5MM SHT THRD IMPL MONSTER,SUP-2320681,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
CUP ACET OD50MM ID36MM 0DEG HIP UHMWPE CONSTRN STD FACE,SUP-2403893,CDM,C1776,CPT,0278,RC,,,,both,,,5400.80,3510.52,,,,,,,,,,,,,
MICRO PLATE SQUARE 6MM 15MM SYSTEM CP TITANIUM,SUP-2681099,CDM,C1713,HCPCS,0278,RC,,,,both,,,544.41,353.87,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min|DOCUMENTATION ON FILE,PX-4209711600,CDM,97116,CPT,0420,RC,,,KX,both,,,164.00,106.60,,,,,,,,,,,,,
FELODIPINE ER 5 MG PO TB24,RX-27490,CDM,6370000000,HCPCS,0637,RC,23155-0049-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE W14XL74MM THK3.8MM 4 H RT TIB L BTTRS LT ANG S,SUP-2185766,CDM,C1713,HCPCS,0278,RC,,,,both,,,1768.10,1149.26,,,,,,,,,,,,,
CATHETER BLLN OCCL 4MM TIP 2.2FRX150MM 3X15MM HYPERGLIDE,SUP-2172475,CDM,C2628,HCPCS,0272,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
SHEATH INTRO INPUT PS L 6 CM DIA 6 FR AD W/O HEMOSTATIC VLV,SUP-2141020,CDM,C1894,HCPCS,0272,RC,,,,both,,,35.95,23.37,,,,,,,,,,,,,
SHEATH INTRO L28CM DIA12FR POLYETH HYDRPHLC W/O CRV HEMSTAT,SUP-2396254,CDM,C1894,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE 4 H CRANIOMAXILLOFACIAL TI X SHP FOR 1.3MM SCR,SUP-2190671,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
NAIL IM TIB 10.5X290 MM PROX AG TARGETING ARM CLR CODE TI,SUP-2463978,CDM,C1713,HCPCS,0278,RC,,,,both,,,4954.92,3220.70,,,,,,,,,,,,,
ANCHOR SUT L7.5MM DIA2.4MM W/ 2-0 FIBERWIRE 17.4MM 3/8 CIR,SUP-2121010,CDM,C1713,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
ALLOGRAFT BNE GRAN STRP 1 CC HA/TCP CLLGN VENADO 4815T5011,SUP-2718006,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.24,522.11,,,,,,,,,,,,,
AMNION THICK 3X3,SUP-2811249,CDM,C1762,CPT,0278,RC,,,,both,,,5769.75,3750.34,,,,,,,,,,,,,
MEMBRANE CLLGN DURA REP DURAMATRIX SUTURABLE 1IN X 1IN,SUP-2165128,CDM,C1763,HCPCS,0278,RC,,,,both,,,920.55,598.36,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 65 CM 4 FR 0.035 IN C2 BRAIDED,SUP-2116588,CDM,C1887,HCPCS,0272,RC,,,,both,,,86.60,56.29,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO SQ PLATE 1 PK STRL,SUP-2935608,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.6 MM SM TI CRANIOMAXILLOFACIAL DBL,SUP-2936969,CDM,C1713,HCPCS,0278,RC,,,,both,,,9853.32,6404.66,,,,,,,,,,,,,
NUT EXT FIX WIRE SIDEKCK EZ FRAME EF001600,SUP-2851070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
GUIDEWIRE ORTH L80CM DIA2.6MM S STL PARTIALLY THRD BEAD TIP,SUP-2412142,CDM,C1769,HCPCS,0272,RC,,,,both,,,267.53,173.89,,,,,,,,,,,,,
BRACE EL R ROM TELSCP 4 CUF X ACT,SUP-2196500,CDM,L3702,HCPCS,0274,RC,,,,both,,,294.38,191.35,,,,,,,,,,,,,
COIL EMB L10CM DIA4MM 00115IN DETACH SFT STRTCH RESIST,SUP-2173105,CDM,C1889,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
CATHETER CHOLGM 5.5FR L200CM L100CM MTL CANN TIP STYL REUSE,SUP-2169156,CDM,C1725,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BNE L 108 MM SCREW DIA2 MM 20 SHFT H SS ADPT VA SLV,SUP-2908336,CDM,C1713,HCPCS,0278,RC,,,,both,,,3944.84,2564.15,,,,,,,,,,,,,
SET URET STENT L 24 CM DIA 4.8 FR CATH 6 FR PTFE GUIDEWIRE,SUP-2139093,CDM,C2617,HCPCS,0278,RC,,,,both,,,406.82,264.43,,,,,,,,,,,,,
SCREW SPNL L25MM DIA7.5MM THORLUM LO PROF N THRD LOK REVERE,SUP-2229417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
ADAPTER FEM NEUT KNEE BOLT PFC SIG,SUP-2253595,CDM,C1776,CPT,0278,RC,,,,both,,,699.59,454.73,,,,,,,,,,,,,
COMPONENT GLEN FIX DIA40MM SHLDR XLPE POR ANCHR PEG FOR,SUP-2250030,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY HEXAPOLAR FIX LUMINAL STRL,SUP-2729636,CDM,C1730,HCPCS,0272,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
GRAFT BNE SUB 10CC BEAD 25CC CA SULPHATE RAP SET W/ INDIV,SUP-2135334,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
BRACE CLAV INTO JACKET VEST HALO,SUP-2388153,CDM,L0810,HCPCS,0274,RC,,,,both,,,6444.03,4188.62,,,,,,,,,,,,,
KIT DRNGE CATH DIA8FR VAC EXTN SET W/ HNDL SFTY SCALP PNT,SUP-2133895,CDM,C1729,HCPCS,0272,RC,,,,both,,,152.51,99.13,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BAL L10MM OD2.5MM OVR THE WIRE CUT MRAIL,SUP-2140406,CDM,C1725,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
BB-TAK SMALL THREADED,SUP-2811964,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
ALLOGRAFT PUTTY DBM PUROS 5CC SYR,SUP-2414587,CDM,C9359,HCPCS,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
BRACE KNEE WOM AD SM 6IN ABV MID PAT 15-18IN 6IN BELOW,SUP-2151050,CDM,L3660,HCPCS,0272,RC,,,,both,,,891.57,579.52,,,,,,,,,,,,,
BUR SURG DIAMOND 2.2 MMX10 CM MTCH HD SM BOR LEGEND,SUP-2627638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.24,206.86,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X5.75 MM SCHKNT MALL ATTCH SS,SUP-2637752,CDM,L8613,CPT,0278,RC,,,,both,,,347.22,225.69,,,,,,,,,,,,,
DISCHARGE KIT COPD,SUP-2389143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
GRAFT HUM TISS H5MM CANC PLUG CORT RNG CERV SPCR FIBULAR WDG,SUP-2293796,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
PLATE PL DSTL HUM 2.7/3.5MM 3H LT 75MM SHRT STRL TI VA LCP,SUP-2546788,CDM,C1713,HCPCS,0278,RC,,,,both,,,4503.83,2927.49,,,,,,,,,,,,,
VALVE VENT SM ADJ W/O RESVR STRATA II,SUP-2284520,CDM,C1889,HCPCS,0278,RC,,,,both,,,12366.20,8038.03,,,,,,,,,,,,,
DEVICE GRSP L230CM SHTH DIA2.4MM HYBRID JAW FLX DST WIRE,SUP-2391614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
IMPLANT BIO TISS W12XL25CM THK0.8MM BOV PERICARD CLLGN MTRX,SUP-2130303,CDM,C9354,HCPCS,0278,RC,,,,both,,,21293.97,13841.08,,,,,,,,,,,,,
SYSTEM HARV DISECT HARV ROD TRCR ENDOSCP VES VIRTUOSAPH +,SUP-2385220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3193.38,2075.70,,,,,,,,,,,,,
AGENT HEMSTAT W6XL9IN OXIDIZED REGENERATED CELOS ABSRB FOR,SUP-2218187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,400.95,260.62,,,,,,,,,,,,,
SCREW SET KNEE REPL MG II,SUP-2437015,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.91,64.29,,,,,,,,,,,,,
SPHINCTEROTOME 49 30MM TRUETOME,SUP-2149856,CDM,C1713,HCPCS,0278,RC,,,,both,,,501.30,325.84,,,,,,,,,,,,,
HC CT Heart No Contrast Quant Eval Coronry Calcium|SELF-PAY CT CALCIUM SCORING,PX-3507557100,CDM,75571,CPT,0350,RC,,,CTC,both,,,175.00,175.00,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM ULT THN ACELLULAR DERM FRZ DRY,SUP-2306987,CDM,C1762,CPT,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
PROBE ARTHSCP SUCT DIA2.5MM AARDVARK,SUP-2367324,CDM,C1713,HCPCS,0278,RC,,,,both,,,622.29,404.49,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X40 MM STRL CD HORZ ESSENTIALS,SUP-2660150,CDM,C1713,HCPCS,0278,RC,,,,both,,,3596.24,2337.56,,,,,,,,,,,,,
TRAY SUPRPUB CATH 12FR INTRO 14FR NDL INTRO COUNCL CATH,SUP-2129018,CDM,C1729,HCPCS,0272,RC,,,,both,,,619.21,402.49,,,,,,,,,,,,,
SPHERE EMB LAVA-18 2 ML EVA TANTALUM PWDR PERIPH VASC LIQ,SUP-2899326,CDM,C1889,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
GRAFT BNE W22XH35X8XL20MM BICORT EVANS WDG FOR OSTEOTMY,SUP-2399105,CDM,C1734,HCPCS,0278,RC,,,,both,,,6418.16,4171.80,,,,,,,,,,,,,
PLATE BNE W16XL299MM BLDE L70MM THK48MM 95DEG 18 H,SUP-2185509,CDM,C1713,HCPCS,0278,RC,,,,both,,,5656.46,3676.70,,,,,,,,,,,,,
KIT SUTURE ANCHR L 15 MM DIA 4.5 MM PEEK KNOTLESS DRVR ONLY,SUP-2899027,CDM,C1713,HCPCS,0278,RC,,,,both,,,1217.54,791.40,,,,,,,,,,,,,
SCREW BNE L20MM OD2MM THRD L15MM TI BRK OFF MONSTER BITE,SUP-2321005,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.80,436.67,,,,,,,,,,,,,
KIT INDIR DCOMPR 10MM SUPERION,SUP-2392703,CDM,C1821,HCPCS,0278,RC,,,,both,,,28888.00,18777.20,,,,,,,,,,,,,
HC So2 Hepatitis C Virus Antibody,PX-3028680368,CDM,86803,CPT,0302,RC,,,,both,,,413.00,268.45,,,,,,,,,,,,,
PLUG ORTH DIA4MM LOK SM FRAG CBL AXSOS,SUP-2371466,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
SCREW INTRF 8X50 MM TI CROSS-SCREW,SUP-2608261,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.09,288.01,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X1 CMX0.76-1.25 MM DECELL DERM ORACELL,SUP-2741063,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
CATHETER PERI L62.5CM L SWAN NK CURL DBL CUF ARGY,SUP-2283991,CDM,C1750,HCPCS,0278,RC,,,,both,,,672.09,436.86,,,,,,,,,,,,,
CATHETER ULTRASOUND ACUNAV L 90 CM DIA 8 FR FOR GE SYS,SUP-2525937,CDM,C1759,HCPCS,0272,RC,,,,both,,,2582.78,1678.81,,,,,,,,,,,,,
HC Renal Arteriogram|RIGHT SIDE,PX-3233625100,CDM,36251,CPT,0323,RC,,,RT,both,,,10063.00,6540.95,,,,,,,,,,,,,
PLATE BNE MED IMPL 13 H R TI EL FRAC SYS DST FIB 127MM LNG,SUP-2411734,CDM,C1713,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE SLD STIRRUP W/O JT,SUP-2435633,CDM,L2010,HCPCS,0274,RC,,,,both,,,2470.33,1605.71,,,,,,,,,,,,,
SET URET STENT SOFFLX BANDER L 75 CM DIA 7.2 FR 0.038 IN RT,SUP-2168896,CDM,C2617,HCPCS,0278,RC,,,,both,,,217.04,141.08,,,,,,,,,,,,,
INJECTOR IO LENS FOR LENS MNRCH III IOL DEL SYS,SUP-2110042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
WIRE EXT FIX HALF 1.8X400 MM REDUCTION,SUP-2749890,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
GRAFT VASC FLX 7 MMX80 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761506,CDM,C1768,CPT,0278,RC,,,,both,,,3906.79,2539.41,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT M PROPEL DBM PUTTY,SUP-2310458,CDM,C9359,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
NUT SPNL TI POLYAX MINI OUTER SUMMIT FIX SYS,SUP-2254419,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX12 CM 3L J TIP RIFAMPIN SPECTRUM,SUP-2759971,CDM,C1751,HCPCS,0278,RC,,,,both,,,370.08,240.55,,,,,,,,,,,,,
HC Rh W Coro No Lvgram,PX-4819345600,CDM,93456,CPT,0481,RC,,,,both,,,20941.00,13611.65,,,,,,,,,,,,,
VALSARTAN 40 MG PO TABS,RX-33541,CDM,6370000000,HCPCS,0637,RC,00378-5807-93,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L 241 MM SCREW DIA 4.5 MM 14 H NAR COMPR LCK NS,SUP-2932937,CDM,C1713,HCPCS,0278,RC,,,,both,,,2296.91,1492.99,,,,,,,,,,,,,
ELEVATOR SURG L11IN TIP W25MM S STL SATIN FINISH COBB DAWSON,SUP-2160986,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.91,222.24,,,,,,,,,,,,,
HC Assay of Testosterone Total,PX-3018440300,CDM,84403,CPT,0301,RC,,,,both,,,359.00,233.35,,,,,,,,,,,,,
SET SUPRPUB ACC SHTH L12CM DIA16FR FOR ENDO PROC OBRIEN,SUP-2171272,CDM,C2627,HCPCS,0272,RC,,,,both,,,271.30,176.34,,,,,,,,,,,,,
NAIL IM L440MM DIA2MM 85DEG ST GRN FEM TI CANN NONLOCKING,SUP-2192726,CDM,C1713,HCPCS,0278,RC,,,,both,,,836.18,543.52,,,,,,,,,,,,,
CATHETER IV TY 4 FRX20 CM PICC RADIOPAQUE MIDLN,SUP-2383957,CDM,C1751,HCPCS,0278,RC,,,,both,,,269.91,175.44,,,,,,,,,,,,,
BLADE SHAVER 4.2 MM STLTH FRR,SUP-2765851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE 3 H ORTHODONTIC TRAUM CRSS SHP ANCHR W CURLED END,SUP-2417695,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.27,266.68,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 35 DEG 1 CM 018X180 25 CM GLIDEWIRE,SUP-2851656,CDM,C1769,HCPCS,0272,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
INTRODUCER PACE LD APEEL 115 DEG L 47 CM DIA 8 FR CORONARY,SUP-2357276,CDM,C1894,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
ELECTRODE LAP SPATULA 5 MMX12.5 IN MONOPOLAR W/ VLV OLSEN,SUP-2489544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.06,595.44,,,,,,,,,,,,,
PLATE BNE ANTR BRIM LT PELV 12 HOLE,SUP-2518350,CDM,C1713,HCPCS,0278,RC,,,,both,,,4587.54,2981.90,,,,,,,,,,,,,
HORIZONTAL CROSS BAR 160MM RED DEVICE,SUP-2707225,CDM,C1713,HCPCS,0278,RC,,,,both,,,1270.22,825.64,,,,,,,,,,,,,
PLATE BONE W17.5XL250MM THK5.2MM 14 H TI BROAD LIMIT CNTCT,SUP-2190854,CDM,C1713,HCPCS,0278,RC,,,,both,,,1076.33,699.61,,,,,,,,,,,,,
PLATE BURR H L 17.52 MM DIA13 MM SCREW DIA1.5 MM TI CRAN NS,SUP-2936867,CDM,C1713,HCPCS,0278,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
SCREW COMPR 1.5X13MM HEADLESS TI STRL,SUP-2547163,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.90,496.53,,,,,,,,,,,,,
COMPONENT PAT OD28MM THICKNESS 10MM STD TI POLYETH POR PRI,SUP-2370402,CDM,C1776,CPT,0278,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
PLATE BNE L83MM 6 H L LAT PROX PERIARTC TIB S STL,SUP-2410537,CDM,C1713,HCPCS,0278,RC,,,,both,,,2318.29,1506.89,,,,,,,,,,,,,
CATHETER INTCRAN L105CM OD6FR NIT STR TIP REFLX,SUP-2421067,CDM,C1887,HCPCS,0272,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
PUTTY BONE 10 CC REINFORCED FAST SET STERILE CRANIOS,SUP-2838513,CDM,C1713,HCPCS,0278,RC,,,,both,,,12121.97,7879.28,,,,,,,,,,,,,
DOPPLER US 55X275X13IN 3MHZ PRB 1129OZ DISPLAY GYN EARLY,SUP-2171684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.93,1040.60,,,,,,,,,,,,,
BENDER ROD 5.5MM REVERE,SUP-2232131,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED 13 MM FRSH PROCHONDRIX CR,SUP-2717804,CDM,C1762,CPT,0278,RC,,,,both,,,13184.86,8570.16,,,,,,,,,,,,,
ADAPTER STEM 8MM OFFSET KNEE JAM NUT EXTN TOT STABILIZING,SUP-2376322,CDM,C1776,CPT,0278,RC,,,,both,,,2287.08,1486.60,,,,,,,,,,,,,
DEVICE FAT PROC TISS COLLCTN REVOLVE RV0002] ALLERGAN USA - LIFECELL],SUP-2113063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
PLATE BNE SM L190MM 16 H BILAT S STL LO PROF RIG LIMIT,SUP-2186210,CDM,C1713,HCPCS,0278,RC,,,,both,,,2049.76,1332.34,,,,,,,,,,,,,
COMPONENT FEM 190 MM RT DSTL KNEE GRW,SUP-2452033,CDM,C1776,CPT,0278,RC,,,,both,,,71475.19,46458.87,,,,,,,,,,,,,
PIN ALIGN 3X170 MM AEQUALIS DISP,SUP-2715607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.51,247.98,,,,,,,,,,,,,
BUR SURG BALL MED 3 MM FLUT EXT,SUP-2848202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.32,307.66,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0258,RC,00990-7984-20,NDC,,both,250,ML,291.20,189.28,,,,,,,,,,,,,
MESH HERN W20XL25CM PTFE PGA TMC RECT NONABSORBABLE,SUP-2395756,CDM,C1781,HCPCS,0278,RC,,,,both,,,9834.48,6392.41,,,,,,,,,,,,,
SET PICC L 20CM DIA 4FR SHTH L 7CM DIA 4FR,SUP-2887213,CDM,C1751,HCPCS,0278,RC,,,,both,,,275.69,179.20,,,,,,,,,,,,,
MENISCUS WITH HEMI PLATEAU LATERAL RIGHT FROZEN,SUP-2727842,CDM,C1762,CPT,0278,RC,,,,both,,,18103.83,11767.49,,,,,,,,,,,,,
STAPLER INT CIR XL MED THCK 31 MM 3-4 MM PUR EEA,SUP-2787720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5078.86,3301.26,,,,,,,,,,,,,
TIP CATH FRONTAL F-70 PRECIS SGL HND CTRL DIL IRRIG DURABLE,SUP-2106365,CDM,C1887,HCPCS,0272,RC,,,,both,,,530.38,344.75,,,,,,,,,,,,,
PROBE NERVE STIM BPLR CONCENTRIC STRL DISP,SUP-2901971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.35,306.38,,,,,,,,,,,,,
COMPONENT GLEN PEXSM BIOMET -X-SM,SUP-2403415,CDM,C1776,CPT,0278,RC,,,,both,,,4816.76,3130.89,,,,,,,,,,,,,
STENT PERIPH 6FR L170MM DIA7MM CATH L80CM 0.035IN NIT SELF,SUP-2420404,CDM,C1876,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
IMPLANT STAP L4.5MM DIA0.6MM PIST AND WIRE FLROPLAS S STL,SUP-2312792,CDM,L8613,CPT,0278,RC,,,,both,,,374.73,243.57,,,,,,,,,,,,,
STAPLE FIX W9XH7-7MM WIRE W1.2XL1.2MM BARB OSSTPL BOSS,SUP-2190856,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
HC MRI Lower Ext W/ Cont,PX-6107371900,CDM,73719,CPT,0610,RC,,,,outpatient,,,5019.00,3262.35,,,,,,,,,,,,,
GRAFT BONE SUB 0.25MM-1.0MM 1.0MM CORTICOCANCELLOUS,SUP-2165617,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
MESH SURG W2.54XL10CM POLYPR RECT FLAT FOR SFT TISS REP AND,SUP-2219803,CDM,C1781,HCPCS,0278,RC,,,,both,,,200.30,130.19,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR GUIDEWIRE L 40CM NDL L 7CM SS GLD,SUP-2269689,CDM,C1894,HCPCS,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X22 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851925,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.06,228.84,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME L 120 CM DIA 6 FR SPC 2,SUP-2867396,CDM,C1730,HCPCS,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
SET INTRO S-MAK L 10 CM DIA 5 FR L 40 CM SS COR PLAT TIP,SUP-2303439,CDM,C1893,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
BRACE WRST LEN 7 3 4IN CIRC OVR 8 3 4IN XL R REG D RNG W,SUP-2326029,CDM,L3908,HCPCS,0274,RC,,,,both,,,80.35,52.23,,,,,,,,,,,,,
"HC So Immunofix Electphoresis,Othfld",PX-3028633566,CDM,86335,CPT,0302,RC,,,,outpatient,,,72.00,46.80,,,,,,,,,,,,,
PLATE BONE X LNG OLECRANON ELBW NONCOMPRESSION,SUP-2107789,CDM,C1713,HCPCS,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
PARTICLE EMB EMBOCUBE HYDRATED SZ 5 MM CATH 0.04 IN 50MG,SUP-2501105,CDM,C1889,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
DVR LOCK EXTRA LNG R ST,SUP-2587118,CDM,C1713,HCPCS,0278,RC,,,,both,,,3713.05,2413.48,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S3274108D,SUP-2632841,CDM,C1751,HCPCS,0278,RC,,,,both,,,625.68,406.69,,,,,,,,,,,,,
BUR SURG 6MM BALL,SUP-2361579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,168.15,109.30,,,,,,,,,,,,,
HC Perc D-E Cor Stent Ather S,PX-4810960200,CDM,C9602,CPT,0481,RC,,,,both,,,20807.00,13524.55,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PTCH 2X2 CM 2 LAYR AMNION STERISHIELD II,SUP-2138663,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
SHEATH INTRO 20FR L30CM,SUP-2395873,CDM,C1894,HCPCS,0272,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
NEEDLE BX BRST LOC MAMMALOK + 20 G X 7.5 CM,SUP-2120044,CDM,C1819,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
GRAFT HUM TISS SZ A 2.5X2CM THK50-100UM OPHTH AMNIO MEM STK,SUP-2135258,CDM,V2790,HCPCS,0274,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y PLT 1 PK STRL DISP,SUP-2935673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
CATHETER EP MCXL 2-5-2 MM SPC 110CM MARINR SC,SUP-2277552,CDM,C1887,HCPCS,0272,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN VBX L 29 MM 9/13 MM 135 CM 8 FR,SUP-2395681,CDM,C1874,HCPCS,0278,RC,,,,both,,,9862.74,6410.78,,,,,,,,,,,,,
MARAVIROC 300 MG PO TABS,RX-87999,CDM,6370000000,HCPCS,0637,RC,49702-0224-18,NDC,,both,1,UN,129.80,84.37,,,,,,,,,,,,,
SCREW BNE CORT ANK FUS 4.0MMX46MM 6.0MM HD TIBIAXYS,SUP-2243003,CDM,C1713,HCPCS,0278,RC,,,,both,,,739.88,480.92,,,,,,,,,,,,,
"HC Chlamydia Amp Probe Tech, 1",PX-3068749100,CDM,87491,CPT,0306,RC,,,,both,,,208.00,135.20,,,,,,,,,,,,,
SYSTEM MENIS REP PEEK W/ 24DEG NDL TRUESPAN,SUP-2249486,CDM,C1713,HCPCS,0278,RC,,,,both,,,3023.82,1965.48,,,,,,,,,,,,,
ALLOGRAFT BNE 10X10X16 MM BIOEXPAND,SUP-2637002,CDM,C1713,HCPCS,0278,RC,,,,both,,,3825.65,2486.67,,,,,,,,,,,,,
GUIDEPIN ORTH L 450 MM DIA2.4 MM THRD TIP STRL DISP TRIGEN,SUP-2933356,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.50,526.82,,,,,,,,,,,,,
CATHETER CV DL 4 FRX13 CM BASIC KT ARROWG+ARD,SUP-2383314,CDM,C1751,HCPCS,0278,RC,,,,both,,,154.17,100.21,,,,,,,,,,,,,
RETRACTOR SURG CHARNLEY 2 INX5.1 CM STD BLADE,SUP-2242478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,983.39,639.20,,,,,,,,,,,,,
HC NM Brain With Flow,PX-3417860600,CDM,78606,CPT,0341,RC,,,,inpatient,,,2873.00,1867.45,,,,,,,,,,,,,
CLAMP EXT FIX PIN LG NS,SUP-2188503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
BLADE SAW L 73 X W 5 MM L 10 MM NAR RASP SM RECIP FOR GB130R,SUP-2929229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,572.39,372.05,,,,,,,,,,,,,
NITROGLYCERIN 2 % TD OINT,RX-5606,CDM,6370000000,HCPCS,0637,RC,00281-0326-08,NDC,,both,1,GR,54.10,35.16,,,,,,,,,,,,,
PLATE SPNL L108MM ANT THORLUM TI LOK,SUP-2193103,CDM,C1713,HCPCS,0278,RC,,,,both,,,5699.10,3704.41,,,,,,,,,,,,,
NEEDLE PEDCL ACCS PK1002,SUP-2660653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.81,373.63,,,,,,,,,,,,,
BONE MECH GIC58 6X14X11 CANC BLK,SUP-2293805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME L 65 CM DIA 6 FR SPC,SUP-2356947,CDM,C1730,HCPCS,0272,RC,,,,both,,,2251.38,1463.40,,,,,,,,,,,,,
CATHETER NEPHSTMY 7FR L55CM HI PRSS BLLN 30FR L12CM SHTH,SUP-2138878,CDM,C1726,HCPCS,0272,RC,,,,both,,,842.24,547.46,,,,,,,,,,,,,
SHEATH INTRO POWERLINK DIA12.5 FR TEARWY,SUP-2217701,CDM,C1892,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
ALLOGRAFT BNE TIB SHFT 160X2 MM FRZN 31024268,SUP-2717865,CDM,C1762,CPT,0278,RC,,,,both,,,3631.00,2360.15,,,,,,,,,,,,,
HC Fetal Eval 1st Tri Sgl Gest,PX-4027680100,CDM,76801,CPT,0402,RC,,,,outpatient,,,1288.00,837.20,,,,,,,,,,,,,
HC So Complement Total Ch-50,PX-3028616266,CDM,86162,CPT,0302,RC,,,,both,,,740.00,481.00,,,,,,,,,,,,,
KIT PROC UNILAT W/ 5MM BAL DCR,SUP-2330968,CDM,C1726,HCPCS,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
TROCAR SURG DBL SL 5X180 MM ASMBLY,SUP-2517250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,720.63,468.41,,,,,,,,,,,,,
IMPLANT TIB H 12 MM DIA 9 MM LATTICE 3 MM SZ 1 SHRT LT ANK,SUP-2908998,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PLATE BONE 11 H STR PRI RECON W/ TEMPLT FOR 2/2.3MM SCR,SUP-2365245,CDM,C1713,HCPCS,0278,RC,,,,both,,,8243.16,5358.05,,,,,,,,,,,,,
ROD IM ATTUNE,SUP-2454769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
GUIDEWIRE SURG L735MM DIA1MM ELECTROMAGNETIC SENS ALWAYS-ON,SUP-2392605,CDM,C1769,HCPCS,0272,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
DRILL 5.0MM DEV TARGETING RADLUC,SUP-2371644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
FLEXIGRAFT GRAFTLINK TS: D=10.5 L= 88 MM,SUP-2816261,CDM,C1762,CPT,0278,RC,,,,both,,,7033.91,4572.04,,,,,,,,,,,,,
ALLOGRAFT BNE ULN SHFT 26-50 MM FRZN,SUP-2717871,CDM,C1762,CPT,0278,RC,,,,both,,,2337.10,1519.11,,,,,,,,,,,,,
"HC Tracheostomy, Emergency Procedure",PX-3603160500,CDM,31605,CPT,0360,RC,,,,both,,,743.00,482.95,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L450CM DIA0.035IN STD BILI HYDRPHLC TRIM,SUP-2149669,CDM,C1769,HCPCS,0272,RC,,,,both,,,361.57,235.02,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 45 CM DIA10 FR BODY DIA 4 MM,SUP-2719567,CDM,C1894,HCPCS,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
HC Closed Red Dislocated Lunate,PX-4502569000,CDM,25690,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
CLIP LIG MIC TI TRNSVRS GRV NONABSORBABLE ADH BK PRECIS EZ 6CLIPS/CT,SUP-2383133,CDM,C1751,HCPCS,0278,RC,,,,both,,,12.65,8.22,,,,,,,,,,,,,
PLATE BNE SM 3 HOLE GLD,SUP-2328038,CDM,C1713,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ANK MED,SUP-2330426,CDM,L4350,HCPCS,0274,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
REAMER SURG OD9MM IM MOD HD FORWARD/SIDE CUT DBL WND SHFT,SUP-2368228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ANCHOR SUTURE STRL CITREFIX,SUP-2900523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
BASEPLATE TIB CLLRD STD KNEE ASMBLY BIMTRC,SUP-2448786,CDM,C1776,CPT,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 7 CM DIA12 MM CATH DIA 0.035 IN,SUP-2170988,CDM,C1889,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
WIRE SPNL L30CM DIA0.97MM BEAD LOOP LUQ,SUP-2410237,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.97,76.03,,,,,,,,,,,,,
SCREW GUID FOR AUG RM COMPHSVE RVS SHLDR SYS,SUP-2205384,CDM,C1713,HCPCS,0278,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK ULT TI CARBON FIBER,SUP-2388221,CDM,L5940,HCPCS,0274,RC,,,,both,,,1318.45,856.99,,,,,,,,,,,,,
ROD EXT FIX L850MM DIA11MM 180DEG UNIV C FBR SEMI CIR CRV,SUP-2188641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2019.62,1312.75,,,,,,,,,,,,,
SPACER SPNL W18XH7-14XL40MM 3-15DEG LAT LUM INTBDY FUS TI,SUP-2420848,CDM,C1889,HCPCS,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
BIT DRL L110MM DIA4MM OVR CANN ADD ON,SUP-2321610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.23,298.50,,,,,,,,,,,,,
ALLOGRAFT BNE WHL MAND,SUP-2321827,CDM,C1713,HCPCS,0278,RC,,,,both,,,10399.68,6759.79,,,,,,,,,,,,,
SCREW BNE L36MM DIA3.5MM STD CORT TIM ST CANN NONLOCKING,SUP-2413373,CDM,C1713,HCPCS,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
CLIP BRAIDED 360 CATHETER RESOLUTION ULTRA – UOM BOX OF 10,SUP-2615605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.97,502.43,,,,,,,,,,,,,
CATHETER KIT EXT LUMBAR CEREBROSPINAL FLUID II EDS 3,SUP-2851442,CDM,C1729,HCPCS,0272,RC,,,,both,,,1392.06,904.84,,,,,,,,,,,,,
PLATE BONE L35MM 6 H TI GAP FOR CRAN CLSR SYS,SUP-2243975,CDM,C1713,HCPCS,0278,RC,,,,both,,,429.02,278.86,,,,,,,,,,,,,
TWIST DRILL 1.9MM DIA X 115MM 6MM STOP W/NTCH LEVEL SSTM SNG,SUP-2498808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.22,276.39,,,,,,,,,,,,,
HC Thoracic Fascial Plane Block Bi Injection,PX-3606446800,CDM,64468,CPT,0360,RC,,,,both,,,1238.00,804.70,,,,,,,,,,,,,
SCREW HD THRD 5MMX85MM CENTRONAIL,SUP-2316513,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.55,554.81,,,,,,,,,,,,,
CATHETER INFUSION FOUNTAIN L 135 CM DIA 4 FR TIP L 3 CM SEG,SUP-2303409,CDM,C1751,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BASEPLATE TIB SZ 5 THK10MM UNIV KNEE POLYETH NP CRUCE RET,SUP-2253589,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
CLAMP SURG CORRECTION ANQUIEIR,SUP-2197308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
GENERATOR CARD PLSE SPNL CRD STIM SYS PRECIS NOVI,SUP-2138777,CDM,C1767,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
KIT WRIST SMALL FOR SPIDER 2,SUP-2753243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
HARDWARE ORTH LCK,SUP-2766753,CDM,C1769,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
STENT GRFT VASC RELAYPRO L 200 MM CVR L 190 MM DIA 24 MM,SUP-2894581,CDM,C1768,CPT,0278,RC,,,,both,,,62643.00,40717.95,,,,,,,,,,,,,
SLING GYN L 45 X W 1.1 CM POLYPRO MONOFILAMENT WRP,SUP-2929631,CDM,C1771,HCPCS,0278,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
INTRODUCER RF L100MM OD17GA COOLED,SUP-2237170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.98,230.74,,,,,,,,,,,,,
STENT URTRL 45FR DIA 28CML TCFLX DBLE PGTL ST SNGLE USE,SUP-2722037,CDM,C2617,HCPCS,0278,RC,,,,both,,,189.25,123.01,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA12 MM RNG L 50 CM EPTFE STR STD,SUP-2396028,CDM,C1768,CPT,0278,RC,,,,both,,,4122.82,2679.83,,,,,,,,,,,,,
BRACE KNEE HNG LAT L L OA ADJ 3,SUP-2196482,CDM,L1852,HCPCS,0274,RC,,,,both,,,1314.40,854.36,,,,,,,,,,,,,
CATHETER EP CRD 1 10 MM 5 FRX120 CM SUPREME,SUP-2355172,CDM,C1730,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
APPLIER ANEURYSM CLIP YASARGIL MINI FINGER TIP GRIP STRAIGHT,SUP-2821561,CDM,C1889,HCPCS,0278,RC,,,,both,,,4716.91,3065.99,,,,,,,,,,,,,
MASTOID MESH 06MM THICK LOW PROFILE STYLE CP TITANIUM,SUP-2707276,CDM,C1713,HCPCS,0278,RC,,,,both,,,2536.90,1648.98,,,,,,,,,,,,,
SUTURE D-SPECIAL 3 EBOND GRN BRD D9261,SUP-2218947,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
GRAFT HUM TISS W20XH17.5XL50MM 1ST WDG TIB OSTEOTMY FRZ DRY,SUP-2113924,CDM,C1713,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
HC Njx Noncmpnd Sclrsnt 1 Vein,PX-3613646500,CDM,36465,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
LINER ACET OD76MM ID26MM THK19.3MM STD HIP POLYETH MOD CUP,SUP-2202075,CDM,C1776,CPT,0278,RC,,,,both,,,2393.94,1556.06,,,,,,,,,,,,,
PAD ORTHOT THOR CUST,SUP-2435576,CDM,L1060,HCPCS,0274,RC,,,,both,,,306.62,199.30,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 120 MM DIA13/10 MM DEL 12ML,SUP-2936840,CDM,C1713,HCPCS,0278,RC,,,,both,,,12943.08,8413.00,,,,,,,,,,,,,
BRACE Q LG,SUP-2174971,CDM,L1820,HCPCS,0274,RC,,,,both,,,188.24,122.36,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 80 MM DIA 46 MM SHTH 16 FR RVD 31-38,SUP-2750386,CDM,C1768,CPT,0278,RC,,,,both,,,48234.48,31352.41,,,,,,,,,,,,,
COLLAR CERV AD PLAS FOAM EXTRIC ADJ SET TRACH OPN VELC,SUP-2115114,CDM,L0180,HCPCS,0272,RC,,,,both,,,33.35,21.68,,,,,,,,,,,,,
SPLINT ANK FT M L POST LEAF LTWT SEMI RIG ROLYAN,SUP-2326013,CDM,L4396,HCPCS,0274,RC,,,,both,,,98.22,63.84,,,,,,,,,,,,,
NEEDLE BONE CEMENT DELIVERY 8 GAX10 CM STERILE,SUP-2838508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
BINDER BRST SM,SUP-2223739,CDM,L4386,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0688,HCPCS,0636,RC,00143-9262-25,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PIN GUIDE L 360 MM DIA 3.2 MM THRD TIP TRIGEN MAX,SUP-2933183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
SYSTEM TARGETING 10MM PRECIS SYS W/ PERPENDICULARITY ROD FOR,SUP-2256811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6352.22,4128.94,,,,,,,,,,,,,
BODY FEM SZ 10.5 STD LT DST TEXT APR,SUP-2210915,CDM,C1776,CPT,0278,RC,,,,both,,,16266.77,10573.40,,,,,,,,,,,,,
DRILL SURG DIA4.5MM CANN ENDOBUTTON,SUP-2342262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.70,171.40,,,,,,,,,,,,,
STENT PERIPH COVERA L 40 MM DIA 7 MM CATH L 80 CM SHTH 8 FR,SUP-2418866,CDM,C1874,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
STEM FEM L200MM DIA13MM STD OFFSET RT DSTL HIP CO CHROM STR,SUP-2405134,CDM,C1776,CPT,0278,RC,,,,both,,,14820.80,9633.52,,,,,,,,,,,,,
ATTACHMENT SAG SAW FOR UNIV DRVR,SUP-2362647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5719.04,3717.38,,,,,,,,,,,,,
MICROSPHERE EMB EMBOSPHERE DIA100-300 UM 2 CC 20 CC SYR YEL,SUP-2303401,CDM,C1889,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
BACLOFEN 10 MG/5ML IT SOLN,RX-104430,CDM,J0475,HCPCS,0250,RC,70121-2502-02,NDC,,both,5,ML,1890.30,1228.69,,,,,,,,,,,,,
MORCELLATOR ENDO 15MM OBT DISPOSABLEXCISE,SUP-2265061,CDM,C1782,HCPCS,0272,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
PLATE BONE INF BLDE L35MM 5MM OFFSET 90DEG 3 H LT RT LCK,SUP-2318745,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.53,3265.94,,,,,,,,,,,,,
HC Phase II Recovery - Addtl 15 Min,PX-7100000011,CDM,7100000011,LOCAL,0710,RC,,,,both,,,305.00,198.25,,,,,,,,,,,,,
CROWN DENT UP LT PRI M S STL REFIL,SUP-2322199,CDM,D6783,CPT,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
PLATE BNE L 198 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 18 H 72440918,SUP-2933192,CDM,C1713,HCPCS,0278,RC,,,,both,,,2318.58,1507.08,,,,,,,,,,,,,
PAD ORTHOT CERV THOR LUMBAR SACR CUST KYPHOSIS,SUP-2435571,CDM,L1020,HCPCS,0272,RC,,,,both,,,305.08,198.30,,,,,,,,,,,,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,0636,RC,63833-0616-02,NDC,,both,1,UN,5841.00,3796.65,,,,,,,,,,,,,
SHEATH INTRO TRANSSEPTAL MULLINS,SUP-2280906,CDM,C1894,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 25X20MM,SUP-2466274,CDM,C1713,HCPCS,0278,RC,,,,both,,,6644.24,4318.76,,,,,,,,,,,,,
PLATE BNE L44MM MINI 11 H TI T FOR 1.5MM SCR MOD HND SYS,SUP-2191143,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.65,833.07,,,,,,,,,,,,,
FENTANYL CITRATE-NACL 1-0.9 MG/100ML-% IV SOLN,RX-135017,CDM,J7999,HCPCS,0636,RC,70092-1092-36,NDC,,both,100,ML,127.70,83.00,,,,,,,,,,,,,
PROBE NERVE STIM MONOPOLAR STD PRASS FLSH TIP STRL DISP,SUP-2901969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.19,238.02,,,,,,,,,,,,,
PREGABALIN 75 MG PO CAPS,RX-42164,CDM,6370000000,HCPCS,0637,RC,00904-7000-61,NDC,,both,1,UN,3.50,2.27,,,,,,,,,,,,,
SUPPORT MAMM SURG 48-50 IN 2XL BRA,SUP-2336341,CDM,L8000,HCPCS,0274,RC,,,,both,,,123.50,80.27,,,,,,,,,,,,,
SCREW INTRF 7MM 25MM 1.5MM DIA GWIRE FIX KNEE CANN N ABSRB,SUP-2341645,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.24,398.61,,,,,,,,,,,,,
DRILL TWST L87MM OD22MM CANN AO QUIK CPL SHFT END FOR K WIRE,SUP-2267868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
INSERT TOE 01 25MM OFFSET THK36MM MOD HEMICAPDF P,SUP-2123620,CDM,C1776,CPT,0278,RC,,,,both,,,9633.52,6261.79,,,,,,,,,,,,,
PACEMAKER CARD SINGLE CHMBR TEMP PULSE GENRTR DDDDDD,SUP-2138029,CDM,C1713,HCPCS,0278,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ZIPWIRE L 150 CM DIA 0.035 IN TAPR TIP,SUP-2488003,CDM,C1769,HCPCS,0272,RC,,,,both,,,126.67,82.34,,,,,,,,,,,,,
GUIDEROD L950MM DIA3MM W SMOOTH TIP FOR TI DST FEM NAIL,SUP-2188170,CDM,C1713,HCPCS,0278,RC,,,,both,,,394.98,256.74,,,,,,,,,,,,,
CATHETER EP SM 2-5-2 MM 7 FRX115 CM SAFIRE,SUP-2357030,CDM,C1733,HCPCS,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
HOOK/TRIANGLE BLDE KT -  ORDER BY 6 EACH,SUP-2370410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1433.10,931.51,,,,,,,,,,,,,
CLIP ANEUR DIA7MM 5MM FEN 90DEG MIC,SUP-2243950,CDM,C1889,HCPCS,0278,RC,,,,both,,,1019.75,662.84,,,,,,,,,,,,,
LENS IOL BCNVX 18.5+ DIOPT 6X13 MM TORIC,SUP-2102633,CDM,V2788,HCPCS,0276,RC,,,,both,,,985.00,640.25,,,,,,,,,,,,,
GRAFT VASC L80CM DIA8MM RAD L80CM EPTFE HEP THN WALLED,SUP-2395862,CDM,C1768,CPT,0278,RC,,,,both,,,9247.30,6010.74,,,,,,,,,,,,,
SLEEVE SURG 100DEG ST LT BLU TI LOK FOR 9-12MM FEM NAIL,SUP-2191877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1370.70,890.95,,,,,,,,,,,,,
SUPPORT ORTHOT CUST OUTFLARE WDG,SUP-2435725,CDM,L3390,HCPCS,0272,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
LEAD PACE 8.6FR L62CM DUAL COIL PERM ACT FIX DF4 CONN SPRNT,SUP-2282266,CDM,C1895,HCPCS,0275,RC,,,,both,,,8769.83,5700.39,,,,,,,,,,,,,
ALLOGRAFT DRML MED THICK CNTR READY USE RGNRTVE TSSUE MTRX A,SUP-2460967,CDM,Q4116,HCPCS,0636,RC,,,,both,,,14302.70,9296.75,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ACTICOR 7 PROMRI VR-T W 66.5 X H 60 MM D,SUP-2739243,CDM,C1882,HCPCS,0275,RC,,,,both,,,55590.56,36133.86,,,,,,,,,,,,,
NEEDLE SUTURE 20 SPECTRUM AUTOPASS,SUP-2765862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,996.89,647.98,,,,,,,,,,,,,
CUTTER TDC HIGH SPEED 25G DISP,SUP-2863701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.93,475.10,,,,,,,,,,,,,
GUIDEWIRE URO STD COAT FIX COR STR FLX BENT TYP TIP,SUP-2141735,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.81,59.68,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 15.5 CM DIA16 FR DIL 20 CM GUIDEWIRE,SUP-2167900,CDM,C1894,HCPCS,0272,RC,,,,both,,,109.96,71.47,,,,,,,,,,,,,
CAP ORTH KNEE TAPR REGENEREX,SUP-2136302,CDM,C1776,CPT,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
SYSTEM POS VAG MERID DISP,SUP-2763314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
PLATE CRAN 180X140X40 MM PT SPEC IMPL PEEK,SUP-2860158,CDM,C1713,HCPCS,0278,RC,,,,both,,,51114.49,33224.42,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 4 FRX8 CM 18 GA DL SPECTRUM,SUP-2759891,CDM,C1751,HCPCS,0278,RC,,,,both,,,566.24,368.06,,,,,,,,,,,,,
PLATE BNE W17.5XL242MM THK5.2MM 10 H NONSTERILE L CNDYL FEM,SUP-2185023,CDM,C1713,HCPCS,0278,RC,,,,both,,,4334.83,2817.64,,,,,,,,,,,,,
HC Insertion Epicardial Electrode Endoscopic,PX-3603320300,CDM,33203,CPT,0360,RC,,,,both,,,8901.00,5785.65,,,,,,,,,,,,,
GRAFT HUM TISS ACHILLES TEND W/ BONE FRZN,SUP-2165557,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
PLATE BNE L29MM THK1.3MM 4 H MTCRPL TI STR COMPR FOR,SUP-2267912,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.55,483.31,,,,,,,,,,,,,
RING BPLR DIA58MM HIP REPL RNGLOC,SUP-2404325,CDM,C1776,CPT,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
COMPONENT HUM DIA10.5MM HEMI CAP,SUP-2123524,CDM,C1713,HCPCS,0278,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
SET URET STENT L 16 CM DIA 4.8 FR PTFE GUIDEWIRE 0.035 IN,SUP-2522184,CDM,C2617,HCPCS,0278,RC,,,,both,,,441.52,286.99,,,,,,,,,,,,,
SPACER ORTH HUM 18+ MM,SUP-2715616,CDM,C1776,CPT,0278,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
SUPPORT ORTHOT CERV THOR LUMBAR SACR CUST MILWAUKEE INIT,SUP-2435568,CDM,L1000,HCPCS,0272,RC,,,,both,,,5740.92,3731.60,,,,,,,,,,,,,
PORT INFUS CATH DIA9.6FR TI PREATTACH SIL PEEL APART INTRO,SUP-2127727,CDM,C1788,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
BUR SURG TAPR 1.5X13.1 MM 7 CM FOOTED SM BOR MIDAS REX 8,SUP-2664897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT BNE BLOCK 12X12X9 MM PATELLAR UNICORTICAL,SUP-2860945,CDM,C1713,HCPCS,0278,RC,,,,both,,,4983.18,3239.07,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ FIT STRP W/OUT JT FABRICATED,SUP-2435756,CDM,L3702,HCPCS,0274,RC,,,,both,,,744.02,483.61,,,,,,,,,,,,,
POST PLT WRST TI LOK HUB CAP,SUP-2107845,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
HC Assay of Triiodothyronine T3 Total Tt3,PX-3018448000,CDM,84480,CPT,0301,RC,,,,both,,,331.00,215.15,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7MM STR STD WALL SLDE GDS,SUP-2525458,CDM,C1768,CPT,0278,RC,,,,both,,,1511.66,982.58,,,,,,,,,,,,,
PLATE BONE L46MM THK2.8MM 4 H BILAT S STL NONCOMPRESSION,SUP-2348976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2978.79,1936.21,,,,,,,,,,,,,
BLADE SAW L 11 MM D 7 MM THK MATERIAL 0.4 MM CUT 0.5 MM,SUP-2929143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.47,357.16,,,,,,,,,,,,,
PLATE BNE ANTR MALL 8 HOLE TI,SUP-2525813,CDM,C1713,HCPCS,0278,RC,,,,both,,,3943.84,2563.50,,,,,,,,,,,,,
COMPONENT TOE DIA12MM 1X1.5MM OFFSET MT CE ARTC HEMICAP,SUP-2123595,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
VALVE HEMSTAS W/ GWIRE INSRTN TOOL GRDIAN II NC,SUP-2120549,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
CLOVERLEAF PL 9H 184MM,SUP-2818806,CDM,C1713,HCPCS,0278,RC,,,,both,,,4599.16,2989.45,,,,,,,,,,,,,
GUIDEWIRE ZGR CRM HYD J 180CM,SUP-2282460,CDM,C1769,HCPCS,0272,RC,,,,both,,,356.86,231.96,,,,,,,,,,,,,
KIT TBNG L9FT STRT UP EXT CG 500D EX,SUP-2416152,CDM,C1751,HCPCS,0278,RC,,,,both,,,748.20,486.33,,,,,,,,,,,,,
PLATE BONE L16MM THK0.6MM REG 4 H MIDFACE SLV TI STR FOR,SUP-2402870,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
SHELL ACET OD42MM ID32MM HIP ALL POLY PROSTALAC,SUP-2251996,CDM,C1776,CPT,0278,RC,,,,both,,,1799.85,1169.90,,,,,,,,,,,,,
KIT NURSING PICC CT SINGLE LUM 45CM X 1 MM,SUP-2913463,CDM,C1751,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
NEEDLE BX L25CM S STL 2 CANN DISP FOR CRW SYS NASHOLD,SUP-2244276,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
BLADE ENDOSCP L4MM DETACH FOR CAPSLTMY CAPSULECUT,SUP-2121995,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SET NEUROSURGICAL TISS SCULPTURE TRCR DISP LUM DCOMPR PROC,SUP-2392706,CDM,C1889,HCPCS,0278,RC,,,,both,,,13659.00,8878.35,,,,,,,,,,,,,
GRAFT VASC L200MM W15MM THK01MM PTCH PERICARD MEM UNIV STR,SUP-2395371,CDM,C1781,HCPCS,0278,RC,,,,both,,,4973.76,3232.94,,,,,,,,,,,,,
PLATE BNE L95MM 5 H ST R DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177215,CDM,C1713,HCPCS,0278,RC,,,,both,,,4570.14,2970.59,,,,,,,,,,,,,
KNIFE SURG ROSEN 45-90 DEG 7-5/8 INX193 MM CART DBL END LF,SUP-2498652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.68,233.14,,,,,,,,,,,,,
HC Inj Proc Cysto or Void,PX-3615160000,CDM,51600,CPT,0361,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
NAPROXEN 250 MG PO TABS,RX-5391,CDM,6370000000,HCPCS,0637,RC,50268-0594-15,NDC,,both,1,UN,2.30,1.49,,,,,,,,,,,,,
PLATE BNE SM LT FIBULAR LAT,SUP-2896599,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
GRAFT HUM TISS DERMACELL POROUS 6X7CM 42SQCM,SUP-2909279,CDM,Q4122,HCPCS,0636,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
GRAFT HUM TISS L14MM CONE GRAFIX,SUP-2319160,CDM,Q4132,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CATHETER URET 6FR L70CM GWIRE L145CM 0.035IN 20DEG TAPR ANG,SUP-2171227,CDM,C1758,HCPCS,0278,RC,,,,both,,,172.07,111.85,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.6MM TIB DRL TIP LOK COMPR,SUP-2194143,CDM,C1769,HCPCS,0272,RC,,,,both,,,105.47,68.56,,,,,,,,,,,,,
GRAFT BIO TISS W12XL6CM THK2MM NONDENATURED BOV CLLGN,SUP-2243680,CDM,C9360,HCPCS,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
COMPONENT CNTRL BODY EXTRNL FXTR INNER BODY MALE RTTN FDFS,SUP-2720668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
MARKER SKIN 2 MM SPEE-D-MARK SDM20E,SUP-2323023,CDM,A4648,CPT,0278,RC,,,,both,,,111.38,72.40,,,,,,,,,,,,,
GRAFT HUM TISS W11XL30MM THK11MM FRZ DRY ALLGRFT BLK CANC,SUP-2307113,CDM,C1713,HCPCS,0278,RC,,,,both,,,2662.66,1730.73,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.508,SUP-2860190,CDM,C1713,HCPCS,0278,RC,,,,both,,,26624.37,17305.84,,,,,,,,,,,,,
MESH SURGICAL 7.5CM X 7.5CM RESTRATA,SUP-2874126,CDM,A2007,HCPCS,0636,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336040,CDM,L3809,HCPCS,0272,RC,,,,both,,,23.90,15.53,,,,,,,,,,,,,
"HC Insert Aortic Circulation Assist Device ,Open Approach",PX-4813397000,CDM,33970,CPT,0481,RC,,,,outpatient,,,8382.00,5448.30,,,,,,,,,,,,,
SCREW BNE L11MM DIA15MM PUR TI ALLY THRD AND ROUNDED HD LOK,SUP-2180999,CDM,C1713,HCPCS,0278,RC,,,,both,,,396.90,257.98,,,,,,,,,,,,,
STAPLE INT L15XW12MM S STL COMPR INTERAXIS NONSTERILE IMPL,SUP-2243121,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.57,1939.32,,,,,,,,,,,,,
INJECTOR BNE GRFT SUB 5CC PELLET 4.8MM PRELD PRECIS EFFICIENT,SUP-2399142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.67,1153.54,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SPC 3 MM ATRAUM FIX COURNAND CRV,SUP-2641813,CDM,C1730,HCPCS,0272,RC,,,,both,,,3088.66,2007.63,,,,,,,,,,,,,
STENT BILI WALLFLEX L 100 MM DIA10 MM CATH L 194 CM DIA 9 FR,SUP-2889595,CDM,C1874,HCPCS,0278,RC,,,,both,,,8313.31,5403.65,,,,,,,,,,,,,
WIRE EXT FIX OLV 2X550 MM ANK SPANNING CONSTRUCT,SUP-2457348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
KIT INSRTN INTRO L 6 IN CATH DIA 7.5 FR 34/40 CC PACKAGED,SUP-2908583,CDM,C1769,HCPCS,0272,RC,,,,both,,,379.31,246.55,,,,,,,,,,,,,
WASHER ORTH SH FIX TI ALLOY,SUP-2208302,CDM,C1713,HCPCS,0278,RC,,,,both,,,1449.74,942.33,,,,,,,,,,,,,
INTRODUCER SHTH OD6FR .038IN DIL GWIRE PINN,SUP-2141014,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PLATE BNE CRV 4.5X266 MM RT CNDYL 12 HOLE VA LCK STRL VALCP,SUP-2789641,CDM,C1713,HCPCS,0278,RC,,,,both,,,6515.22,4234.89,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2MM SMOOTH INSRT FOR FEM NAIL PEDINAIL,SUP-2318960,CDM,C1769,HCPCS,0272,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
SLEEVE FEM SM SZ 11 TI STIKTITE HA HIP REV MOD REDAPT,SUP-2345436,CDM,C1776,CPT,0278,RC,,,,both,,,8143.59,5293.33,,,,,,,,,,,,,
SCREW BNE L115MM DIA12.7MM CANC S STL LAG OCTAGONAL RECESS,SUP-2186489,CDM,C1713,HCPCS,0278,RC,,,,both,,,1072.97,697.43,,,,,,,,,,,,,
TRUNION KIT FOR UNIVERS II,SUP-2817691,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CATHETER THORACENTESIS STR 28 FRX23 IN 6 EYELET TAPR TIP LF,SUP-2227432,CDM,C1729,HCPCS,0272,RC,,,,both,,,21.10,13.71,,,,,,,,,,,,,
HC So Androstenedione,PX-3018215766,CDM,82157,CPT,0301,RC,,,,inpatient,,,1352.00,878.80,,,,,,,,,,,,,
CATHETER KIT MULTI-MED 16 CM 3 LT CV MULTI-MED,SUP-2272478,CDM,C1751,HCPCS,0278,RC,,,,both,,,511.38,332.40,,,,,,,,,,,,,
BRUSH NAVIGATION SYS L15MM DIA1.8MM ALWAYS ON TIP TRACKED,SUP-2392610,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
CONNECTOR SPNL PARL WIDE 6.35-6.35 MM SS REVERE,SUP-2594662,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SAW SURG OSCILLATING HALL TITAN PRO9350B,SUP-2607719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29037.15,18874.15,,,,,,,,,,,,,
NAIL IM L170MM DIA11MM 130DEG SHT FEM GRN TI CANN ANAT,SUP-2180536,CDM,C1713,HCPCS,0278,RC,,,,both,,,3997.22,2598.19,,,,,,,,,,,,,
PINSKULL REUSE AD,SUP-2160710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,243.16,158.05,,,,,,,,,,,,,
PLATE BONE THICKNESS 1.5MM TI SAG CVD X LNG PLATTEN PROF,SUP-2262968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1218.76,792.19,,,,,,,,,,,,,
HC So1 Mycoplasma Igg,PX-3028673867,CDM,86738,CPT,0302,RC,,,,inpatient,,,545.00,354.25,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ULTRAVERSE L 120 CM BALLOON L 4 CM DIA 3,SUP-2128654,CDM,C1725,HCPCS,0272,RC,,,,both,,,982.82,638.83,,,,,,,,,,,,,
PLATE BNE STR 2X29 MM 5 HOLE,SUP-2569072,CDM,C1713,HCPCS,0278,RC,,,,both,,,150.25,97.66,,,,,,,,,,,,,
PLATE BNE MINI CRV,SUP-2883198,CDM,C1713,HCPCS,0278,RC,,,,both,,,1069.42,695.12,,,,,,,,,,,,,
PIN GUIDE L 300 MM DIA 3.2 MM DRL TIP LG SYS STRL DISP EVOS,SUP-2933361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1735.64,1128.17,,,,,,,,,,,,,
CATHETER GRFT POS DIA18 FR RVD 26-42 MM POLYUR TRILOBE,SUP-2395624,CDM,C1725,HCPCS,0272,RC,,,,both,,,2050.42,1332.77,,,,,,,,,,,,,
PATCH CV FLUOROPASSIV L 50 X W 10 MM POLYESTER FLUOROPOLYMER,SUP-2385074,CDM,C1768,CPT,0278,RC,,,,both,,,305.11,198.32,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE|ADJ,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|CQ|XU|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
GRAFT DERMAL THCK 16X4 CMX0.8-1.7 MM BRST KT ACELLULAR DERM,SUP-2307008,CDM,C1762,CPT,0278,RC,,,,both,,,10649.09,6921.91,,,,,,,,,,,,,
CROWN FORM DENT STRP U3 PRIMARY ANTR UPPER LT LAT PLAS,SUP-2322247,CDM,D6783,CPT,0278,RC,,,,both,,,40.44,26.29,,,,,,,,,,,,,
PLATE BNE LCK LG EXT LT CALCANEAL 3 HOLE NS A.L.P.S,SUP-2480150,CDM,C1713,HCPCS,0278,RC,,,,both,,,3198.09,2078.76,,,,,,,,,,,,,
CONNECTOR SPNL PARL 3.7-4.5 MM FOR ROD PROTEX CT,SUP-2584540,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CAGE SPINE IMPL AVS ANCHOR-C CERV 14 X 16 FOOTPRINT TI 6 X,SUP-2380431,CDM,C1889,HCPCS,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
EVOS SMALL TGTR 2.5MM DRILL,SUP-2931349,CDM,C1713,HCPCS,0278,RC,,,,both,,,1316.45,855.69,,,,,,,,,,,,,
TUBE VNTLTN RUBE 1.27MM ID LUMEN 1MM DIA INNER FLNGE DSTNCE,SUP-2492679,CDM,L8699,HCPCS,0278,RC,,,,both,,,50.74,32.98,,,,,,,,,,,,,
DISC SCREW SD 1.5X4 MM NS UNIV NEURO III LTX,SUP-2862732,CDM,C1713,HCPCS,0278,RC,,,,both,,,21426.01,13926.91,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-40840054,CDM,J7042,HCPCS,0250,RC,00264-7610-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
LEAD DEFIB RELIANCE SG L 59 CM SIL EPTFE STEROID ENDOCARD RT,SUP-2148614,CDM,C1777,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
BUNDLE ORTHOGNATHIC MOD W ADV GUID VSP,SUP-2366019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12664.06,8231.64,,,,,,,,,,,,,
SPACER SPNL W11XH25XL14MM 4DEG PEEK ANT CERV INTBDY FUS,SUP-2286343,CDM,C1889,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PLATE BNE L29MM 6 H TI STR FOR 1.5MM SCR MOD HND SYS,SUP-2191107,CDM,C1713,HCPCS,0278,RC,,,,both,,,1306.84,849.45,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 X W 4 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881949,CDM,C1762,CPT,0278,RC,,,,both,,,12434.40,8082.36,,,,,,,,,,,,,
COMPONENT TIB 0.0X1MM OFFSET UNICAP,SUP-2123709,CDM,C1776,CPT,0278,RC,,,,both,,,2053.56,1334.81,,,,,,,,,,,,,
MARKER PASS 5X12 FOR ROBOT,SUP-2232049,CDM,A4648,CPT,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
STEM HUM UNIV STD L122MM DIA10MM SHLDR CO CHROM PRI CEM,SUP-2404592,CDM,C1776,CPT,0278,RC,,,,both,,,10949.18,7116.97,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-10 MM 30 CC CANC,SUP-2641778,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BNE PROMO 1 LT BABY GORILLA,SUP-2750992,CDM,C1713,HCPCS,0278,RC,,,,both,,,5444.76,3539.09,,,,,,,,,,,,,
ANCHOR SUTURE PRE LD 2-0 5 MM 2 BRAIDED TWO STRND,SUP-2608437,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.60,323.44,,,,,,,,,,,,,
PROBE MICROWAVE ABLATION L 25 CM DIA13 GA CABLE L 1.4 M STRL,SUP-2908895,CDM,C1886,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
CEMENT BNE 20 GM RADIOPAQUE N RADLUC FORTRESS CONCORD,SUP-2231422,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC Bx Breast Add Lesion US Img,PX-3611908400,CDM,19084,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE L 94 MM TI INTRATHORACIC PREBENT NS RIBFIX TITAN,SUP-2905460,CDM,C1713,HCPCS,0278,RC,,,,both,,,12710.72,8261.97,,,,,,,,,,,,,
PIN GUID DIA2MM TG SGL HEMICAP,SUP-2123526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
TOLTERODINE TARTRATE 2 MG PO TABS,RX-22783,CDM,6370000000,HCPCS,0637,RC,16571-0127-06,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
GRAFT HUM TISS L 60-120 MM DIA25 MM CORTICAL FEM SHFT FD 1PC,SUP-2913407,CDM,C1762,CPT,0278,RC,,,,both,,,4182.48,2718.61,,,,,,,,,,,,,
ANCHOR SUT DIA2MM NO2 SUT TI DURABRAID TWINFIX,SUP-2341075,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
CUBE EXT FIX 1 H RANCHO W/ POST FOR ILIZ TAY SPAT FRME SYS,SUP-2342987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.99,734.49,,,,,,,,,,,,,
KIT ABLAT PRB 17GA L7MM 2 OSTEOCOOL RF,SUP-2293685,CDM,C1886,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
CANNULA SURG 48 MM W/ 2 TEETH TRANSBUCCAL,SUP-2463355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.89,240.43,,,,,,,,,,,,,
DEFEROXAMINE MESYLATE 2 G IJ SOLR,RX-9722,CDM,J0895,HCPCS,0636,RC,00409-2337-25,NDC,,both,1,UN,234.20,152.23,,,,,,,,,,,,,
BRACE WLK L 105 12MM M 115 13MM FEM STD TWO LAYR MEM FOAM,SUP-2195488,CDM,L4360,HCPCS,0274,RC,,,,both,,,82.30,53.49,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.141X9 IN SS NS STEINMANN,SUP-2791275,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.65,20.57,,,,,,,,,,,,,
KIT CATHETER 3FR SGL LUMN POLY FULL MIDLN,SUP-2125576,CDM,C1751,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.414,SUP-2859978,CDM,C1713,HCPCS,0278,RC,,,,both,,,33673.36,21887.68,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DST SEG L45CM DIA0.014IN S STL NIT,SUP-2367846,CDM,C1769,HCPCS,0272,RC,,,,both,,,695.20,451.88,,,,,,,,,,,,,
APPLIER LIG CLP L13IN 10MM PSTL GRP CONTAIN 15 TI L CLP,SUP-2283168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,903.85,587.50,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 13 CM DIA13 GA S3,SUP-2930306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46266.36,30073.13,,,,,,,,,,,,,
PLATE BNE C MINI XL 1X0.8 MM CRANIOMAXILLOFACIAL 4 HOLE,SUP-2469954,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.12,492.13,,,,,,,,,,,,,
STENT LACR L 28 MM DIA 3.5 MM MEDPOR TRIM STRL,SUP-2883451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.11,605.87,,,,,,,,,,,,,
SHELL ACET SLD POR CONSERVE + TOT 6 MM OFFSET 36 MM 42 MM,SUP-2304473,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
COMPONENT ARTC SURF 1 12 MM KNEE VIVACIT-E,SUP-2450541,CDM,C1776,CPT,0278,RC,,,,both,,,3102.32,2016.51,,,,,,,,,,,,,
ROD EXT FIX THRD 150 MM SQ NUT ASMBLY,SUP-2517347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,479.79,311.86,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF L115CM 8FR D,SUP-2248617,CDM,C1732,HCPCS,0272,RC,,,,both,,,8983.54,5839.30,,,,,,,,,,,,,
KNIFE SURG SCKL AD 7.5 IN SHRP CRV RT MICROFRANCE,SUP-2464568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.61,461.25,,,,,,,,,,,,,
PLATE BNE MESH PANEL STD 1.5X100X100X0.3 MM NEURO SM GRID,SUP-2472189,CDM,C1713,HCPCS,0278,RC,,,,both,,,2861.54,1860.00,,,,,,,,,,,,,
STEM FEM SZ 12L L300MM STD CLLR REV CEM ECHELON,SUP-2344519,CDM,C1776,CPT,0278,RC,,,,both,,,15046.88,9780.47,,,,,,,,,,,,,
PROSTHESIS OSS EAR 3X0.5 MM FRISBEE MYRINGOPEXY STAPE TI,SUP-2232497,CDM,L8613,CPT,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BNE CRV L0MM R FLAT MAX PROC TI FOR 15MM MIC SCR,SUP-2262910,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.90,590.13,,,,,,,,,,,,,
KNIFE ELECSURG 0.9X3.9 MM 2.8X230 MM 2.8 MM ITKNIFE NANO,SUP-2477916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2208.21,1435.34,,,,,,,,,,,,,
ROD SPNL L100MM OD5.5MM S STL STR THORLUM REVERE,SUP-2185220,CDM,C1713,HCPCS,0278,RC,,,,both,,,4154.28,2700.28,,,,,,,,,,,,,
HC So Microsomal Ab Ea,PX-3058637668,CDM,86376,CPT,0305,RC,,,,both,,,32.00,20.80,,,,,,,,,,,,,
SHUNT COR L16CM DIA1MM NONPROGRAMMABLE GUIDANT W/O RESVR,SUP-2582813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.33,206.91,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH PERM 8 CONTACT 1 CHAN,SUP-2925125,CDM,C1816,LOCAL,0278,RC,,,,both,,,59660.00,38779.00,,,,,,,,,,,,,
OCCLUDER VASC FLO RST L 12 MM BLB DIA 4.5 MM SIL RUBBER,SUP-2129866,CDM,C1817,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
ALLOGRAFT HUM TISS CRYOPRESERVED 4X2 CM UMB CRD CRYO-CORD,SUP-2740206,CDM,Q4237,HCPCS,0636,RC,,,,both,,,5284.62,3435.00,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 85 CM SAPH VEIN BLD TYP A B AB O,SUP-2884022,CDM,C1768,CPT,0278,RC,,,,both,,,43077.66,28000.48,,,,,,,,,,,,,
STENT URET STR 0.038 IN 3 CM 7 FRX22 CM DBL PGTL PERCFLX,SUP-2493656,CDM,C2617,HCPCS,0278,RC,,,,both,,,398.40,258.96,,,,,,,,,,,,,
FRAME EXT FIX ASMBLY 160MM FOR SALVATION 2 SYS,SUP-2401160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,26410.54,17166.85,,,,,,,,,,,,,
BLADE SURG VES 29 MMX14 CM WIDE,SUP-2629242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
CATHETER THROMCTMY FOGARTY L 80 CM DIA 5 FR MEMBRN DIA,SUP-2214031,CDM,C1757,HCPCS,0272,RC,,,,both,,,813.23,528.60,,,,,,,,,,,,,
GRAFT ENDOVASC L15CM DIA8MM PROF 8FR CATH L75CM 0.035IN,SUP-2396458,CDM,C1874,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
HC Aaa Screening Ultrasound,PX-4027670600,CDM,76706,CPT,0402,RC,,,,inpatient,,,881.00,572.65,,,,,,,,,,,,,
PLATE BNE L260MM THK37MM 20 H BILAT S STL STR LO PROF RIG,SUP-2177150,CDM,C1713,HCPCS,0278,RC,,,,both,,,2982.15,1938.40,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 40X25 CM BIOLOGIC TISSUE MATRIX STERILE X,SUP-2838622,CDM,C1763,HCPCS,0278,RC,,,,both,,,92803.96,60322.57,,,,,,,,,,,,,
HC Fna Bx W/CT Gdn Ea Addl,PX-3611001000,CDM,10010,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BONE L68MM LT CALCNL LCK FOR 3.5MM SCR PERI-LOC,SUP-2348512,CDM,C1713,HCPCS,0278,RC,,,,both,,,5391.07,3504.20,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC LOWER SPINE ADJUSTABLE VISTA 637 LSO,SUP-2427925,CDM,L0637,HCPCS,0272,RC,,,,both,,,679.12,441.43,,,,,,,,,,,,,
SYSTEM SUPP FOR ANTR BIOSYN AVAULTA SOLO,SUP-2126905,CDM,C1771,HCPCS,0278,RC,,,,both,,,2734.88,1777.67,,,,,,,,,,,,,
PATCH CV CORMATRIX SZ 2 X 10 CM PORCINE PERICARD CLOSURE,SUP-2140412,CDM,C1768,CPT,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
NAIL IM L360MM OD12MM TI R FEM RECON AG FLUT T2 R1.5,SUP-2369393,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
SOCKET EXT FIX L60MM S STL THRD FOR ILIZ TAY SPAT FRME,SUP-2342277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
PLATE BONE NEURO RECT,SUP-2402915,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TUBE EXT FIX CARBON 15X300 MM MONOTUBE TRIAX,SUP-2539884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
PROBE LITHO 4.5FR L80CM ELEC HYDRLC CALCUTRIPT,SUP-2261212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.69,255.25,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 1 X 21 H PLL,SUP-2883206,CDM,C1713,HCPCS,0278,RC,,,,both,,,12848.66,8351.63,,,,,,,,,,,,,
PLATE BONE L50MM 9 H GRN S 1 RT LO EXTRM TI NONCOMPRESSION,SUP-2242904,CDM,C1713,HCPCS,0278,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
RING EXT FIX DIA200MM FULL FOR TRUELOK RNG FIX SYS,SUP-2316174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3682.06,2393.34,,,,,,,,,,,,,
HEAD HUM H27MM DIA46MM CURVATURE DIA46MM SHLDR CO CHROM,SUP-2404502,CDM,C1776,CPT,0278,RC,,,,both,,,5617.46,3651.35,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 100 CM OD 6 FR ID 0.070 IN SS,SUP-2154312,CDM,C1887,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
HC Assay of Selenium,PX-3018425500,CDM,84255,CPT,0301,RC,,,,both,,,744.00,483.60,,,,,,,,,,,,,
NEEDLE BRST LOC REPOSITIONAL DISP 20GA 3CM KOP,SUP-2331830,CDM,C1819,HCPCS,0278,RC,,,,both,,,54.07,35.15,,,,,,,,,,,,,
SCREW BONE L65MM THRD DIA3MM HD DIA3.7MM COR DIA1.6MM PITCH,SUP-2349533,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.56,326.66,,,,,,,,,,,,,
GRAFT HUM TISS L PERF THCK REGENERATIVE TISS MTRX CNTOUR,SUP-2113437,CDM,Q4116,HCPCS,0636,RC,,,,both,,,39906.26,25939.07,,,,,,,,,,,,,
PLATE BNE L164MM 8 H NONSTERILE R OLECRANON S STL LOK COMPR,SUP-2185428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3193.79,2075.96,,,,,,,,,,,,,
STEM HUM DIA13MM 132.5DEG STD SHLDR PROX BODY AEQUALIS FLX,SUP-2419077,CDM,C1776,CPT,0278,RC,,,,both,,,12140.50,7891.32,,,,,,,,,,,,,
STEM FEM SM L46MM NK L25MM LNG CEMEX GENT HI REL IMPREG,SUP-2223682,CDM,C1776,CPT,0278,RC,,,,both,,,11994.80,7796.62,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X240 MM FRZN ASEP POST TIBIALIS TEND,SUP-2866982,CDM,C1762,CPT,0278,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
WIRE ORTH POLYETHYL CERCLAGE FOR GLEN BNE LOSS IMPL STRL,SUP-2882230,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 30 CC FD ASEP CANC,SUP-2867039,CDM,C1762,CPT,0278,RC,,,,both,,,1288.66,837.63,,,,,,,,,,,,,
BLADE SCRDRVR SELF RET ADD ON CPL T10 FIT,SUP-2365030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1419.91,922.94,,,,,,,,,,,,,
SCREW BNE L12MM OD3.5MM LOK TUFFNEK TECHNOLOGY FOR PLT,SUP-2321120,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 4 MM STR STD WALL REINF,SUP-2695223,CDM,C1768,CPT,0278,RC,,,,both,,,1109.02,720.86,,,,,,,,,,,,,
PLATE BNE L81MM 6 H L OLECRANON S STL LOK FOR 2.7/3.5MM SCR,SUP-2348706,CDM,C1713,HCPCS,0278,RC,,,,both,,,12183.20,7919.08,,,,,,,,,,,,,
BIT DRL LNG 13 GAX23.6 CM PRESTON,SUP-2464779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
NUSHIELD 2X3CM 6SQ CM,SUP-2314107,CDM,Q4160,HCPCS,0636,RC,,,,both,,,2287.49,1486.87,,,,,,,,,,,,,
PACEMAKER CARD AVEIR VR L 38 MM DIA 6.5 MM TI VENTRICULAR,SUP-2905601,CDM,C1605,HCPCS,0275,RC,,,,both,,,33127.00,21532.55,,,,,,,,,,,,,
STEM FEM M LNG HIP REMEDY,SUP-2319835,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP TEND FLX,SUP-2867090,CDM,C1762,CPT,0278,RC,,,,both,,,2839.82,1845.88,,,,,,,,,,,,,
TISSEEL VHSD 4 ML KT 1504515] BAXTER BIOSURGERY],SUP-2130319,CDM,C9250,HCPCS,0636,RC,,,,both,,,561.65,365.07,,,,,,,,,,,,,
SCREW BNE ST 1.55X3 MM CRANIOFACIAL TI BRNZ NS MATRIXMIDFACE,SUP-2181607,CDM,C1713,HCPCS,0278,RC,,,,both,,,319.15,207.45,,,,,,,,,,,,,
FILTER VASC 300CM 5MM NIT ANGIOGUARDXP,SUP-2157304,CDM,C1769,HCPCS,0272,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 21-26X27-32X17 MM FD ANTR LUMINARY-CC,SUP-2736805,CDM,C1713,HCPCS,0278,RC,,,,both,,,15292.08,9939.85,,,,,,,,,,,,,
SHEATH ROT CF INNR GRY 27.6FR,SUP-2313078,CDM,C1894,HCPCS,0272,RC,,,,both,,,5082.22,3303.44,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM SZ 2-0 NDL L 89 MM SS TEMP WHT,SUP-2116191,CDM,C1786,HCPCS,0275,RC,,,,both,,,32.59,21.18,,,,,,,,,,,,,
SHIM SPNL INTDISC NAR LIF-PTP,SUP-2736562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
MESH TIPATCH 2.75 INX4 IN LT,SUP-2402540,CDM,C1781,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
BLADE SAW THK.93 MM L43 MM X W8 MM RECIPROCATE STERILE LATEX FREE DISPOSABLE,SUP-2880173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
PLATE BNE SZ 2.8 MM TI MANDIBULAR FULL NS DISP ACCUPLATE,SUP-2934819,CDM,C1713,HCPCS,0278,RC,,,,both,,,65767.30,42748.74,,,,,,,,,,,,,
CATHETER ANGIO DIA 5 FR PIG NONBRAIDED MEM TIP STRL,SUP-2117138,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
CATHETER ASPIR 6FR L140CM DIA0.07IN EXPORT ADV,SUP-2294991,CDM,C1757,HCPCS,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
PLATE BONE 6 HOLE 2X10 MM SAGITTAL SPILT BAR CURVED TITANIUM,SUP-2838389,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.33,767.21,,,,,,,,,,,,,
KIT ABLAT PRB 17GA L10MM SGL OSTEOCOOL RF,SUP-2293683,CDM,C1886,HCPCS,0278,RC,,,,both,,,11068.50,7194.52,,,,,,,,,,,,,
CAGE SPNL EXPANDABLE 24X11X9-12 MM INTBDY SET SCREW MOJAVE,SUP-2493773,CDM,C1889,HCPCS,0278,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
CATHETER CV DL 4 FR FULL TY W/ STYL PER-Q-CATH,SUP-2125637,CDM,C1751,HCPCS,0278,RC,,,,both,,,589.69,383.30,,,,,,,,,,,,,
SCREW SPNL L10MM DIA3.5MM 15DEG MINI CANC POST OCCIPITAL,SUP-2254400,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
GUIDEPIN SURG L29MM FEM TIB PREFERRED PT SPEC CR-FLEX DISP,SUP-2201249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
STENT BILI E-LUMINEXX L 40 MM DIA10 MM CATH L 135 CM DIA 6,SUP-2128910,CDM,C1876,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
THEOPHYLLINE ER 200 MG PO CP24,RX-27419,CDM,6370000000,HCPCS,0637,RC,52244-0200-10,NDC,,both,1,UN,25.90,16.83,,,,,,,,,,,,,
POST SURG INTOSS FIX GRN L30MM OD6.6MM 60DEG ANK IOFIX,SUP-2223899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
CLIP HEMSTAT TI CHEVRON SHP INTLOK ATRAUM TEETH MICROCLP,SUP-2382613,CDM,C1760,HCPCS,0278,RC,,,,both,,,32.44,21.09,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 3X2 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651374,CDM,Q4154,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BIT DRL DIA7MM CANN DISP FOR IFUSE IMPL SYS,SUP-2337731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
TIP 90DEG 03MM ULTRAFLOW S P 8000 90DEG 03MM,SUP-2110010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1720.72,1118.47,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 260 MM DIA15 MM DEL SHTH 46ML,SUP-2937084,CDM,C1713,HCPCS,0278,RC,,,,both,,,15448.80,10041.72,,,,,,,,,,,,,
ALLOGRAFT BNE XS 2.5-3X0.7-0.9 CMX 1.8-2.2 MM FD NAR PROF,SUP-2482550,CDM,C1889,HCPCS,0278,RC,,,,both,,,1357.27,882.23,,,,,,,,,,,,,
CONNECTOR SPNL PARL 5.5-5.5X10 MM CREO,SUP-2584321,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
GRAFT HUM TISS 1CC LIQ FLOWABLE AMNION,SUP-2120777,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
VALVE TRACHEOSTOMA ADJ ATSV II STRT KT W/ HUMIDIFILTER CAP,SUP-2242324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,925.04,601.28,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL III RF W 6.6 X H 8.26 CM D,SUP-2149228,CDM,C1882,HCPCS,0275,RC,,,,both,,,85408.00,55515.20,,,,,,,,,,,,,
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,2580000003,HCPCS,0250,RC,00409-1775-10,NDC,,both,10,ML,175.10,113.81,,,,,,,,,,,,,
SPLINT WR AD M L1/8IN FOR 3.5-4.5IN BGE RT FRARM HND PRE FRM,SUP-2324807,CDM,L3906,HCPCS,0272,RC,,,,both,,,94.64,61.52,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 8 FR GUIDEWIRE 45 CM,SUP-2383428,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 300 CM DIA 0.014 IN SS SIL STR LNG,SUP-2148337,CDM,C1769,HCPCS,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
BIT CANNULATED DIA 4.9MM/L240,SUP-2718093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
IMPLANT NSL L 37 X W 22 MM THK 0.5 MM POLYETHYL TIP TOP FLAT,SUP-2883515,CDM,C1889,HCPCS,0278,RC,,,,both,,,1356.32,881.61,,,,,,,,,,,,,
CATHETER THORACENTESIS STR 12 FRX20 IN CLR DRN PVC STRL ARGY,SUP-2428081,CDM,C1729,HCPCS,0272,RC,,,,both,,,26.19,17.02,,,,,,,,,,,,,
DISTRACTION INTRNL DIST LFRT 1 ZRCH TELE RGHT 15 18 MM SCR,SUP-2679166,CDM,C1713,HCPCS,0278,RC,,,,both,,,18646.98,12120.54,,,,,,,,,,,,,
HC X-Ray Exam Hip Uni 2-3 Views,PX-3207350200,CDM,73502,CPT,0320,RC,,,,both,,,368.00,239.20,,,,,,,,,,,,,
PLATE BONE W10XL118MM THK2.8MM 10 H S STL STR NONCOMPRESSION,SUP-2343766,CDM,C1713,HCPCS,0278,RC,,,,both,,,3883.40,2524.21,,,,,,,,,,,,,
PACEMAKER CARD ELUNA 8 PROMRI SR-T SINGLE CHMBR CLOSED LOOP,SUP-2138421,CDM,C1786,HCPCS,0275,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
PHENYLEPHRINE HCL 1 MG/10ML IV SOSY,RX-143164,CDM,J7999,HCPCS,0636,RC,71266-9011-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,2500000003,HCPCS,0250,RC,25021-0686-20,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
BRACE ORTHOPEDIC PRO XL 24-27 IN RT KNEE TRK ORTHOSIS PTO,SUP-2150972,CDM,L1810,HCPCS,0272,RC,,,,both,,,158.82,103.23,,,,,,,,,,,,,
TRAY THORCENT CATH 6FR PGTL DRNGE SYS SAFE T CENTESIS,SUP-2133894,CDM,C1729,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PROBE SRGCL FKSHMA GNNTTA 7 1/4NL BNT BLLT TIP RGGLS RDMND,SUP-2494348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.55,303.91,,,,,,,,,,,,,
PIN GUIDE OMEGA TAP 45MM,SUP-2701917,CDM,C1713,HCPCS,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
HC Endovenous Rf 1st Vein,PX-3613647500,CDM,36475,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
HC So2 Drg Scrn Class List A|NOT REASONABLE AND NECESSARY,PX-3018030768,CDM,80307,CPT,0301,RC,,,GZ,both,,,452.00,293.80,,,,,,,,,,,,,
TUNNELER SURGICAL PLUG BNE CEM CANN DISP FOR 7-12MM TUNN,SUP-2905129,CDM,C1713,HCPCS,0278,RC,,,,both,,,129.05,83.88,,,,,,,,,,,,,
PLATE BONE L5MM 8 H RT DSTL MEDL TIB LCK W/O TAB FOR 3.5MM,SUP-2349085,CDM,C1713,HCPCS,0278,RC,,,,both,,,4109.69,2671.30,,,,,,,,,,,,,
BIT DRL DIA115MM HLLW FOR 95MM MULTILOC PROX HUM NAILING,SUP-2178936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1191.63,774.56,,,,,,,,,,,,,
SEALANT HEMOSTATIC 2 CC SUSP VITAGEL,SUP-2379550,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.65,538.62,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MM 14 CM SYMMETRI PROX MIDAS REX 8 SD/SP,SUP-2664959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,995.25,646.91,,,,,,,,,,,,,
INTRODUCER PACE LD SOLO-TRAK KR XLN KINK RESIST STRL,SUP-2282097,CDM,C1894,HCPCS,0272,RC,,,,both,,,232.27,150.98,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 4.5X40 MM CORTICAL HIP HEXAGONAL HEAD,SUP-2836646,CDM,C1713,HCPCS,0278,RC,,,,both,,,161.27,104.83,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE,PX-4309712900,CDM,97129,CPT,0430,RC,,,GN,outpatient,,,186.00,120.90,,,,,,,,,,,,,
HC Urine Cult./Colony Count,PX-3008708600,CDM,87086,CPT,0300,RC,,,,both,,,150.00,97.50,,,,,,,,,,,,,
PLATE BONE SM L52MM 4 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348991,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
PLATE BNE TWST 2 HOLE,SUP-2481110,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.14,223.69,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 40 MM DIA14 MM NIT SELF,SUP-2158900,CDM,C1876,HCPCS,0278,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
ROD SPNL TEND 3 MMX24.5 CM,SUP-2559087,CDM,C1713,HCPCS,0278,RC,,,,both,,,3554.48,2310.41,,,,,,,,,,,,,
GRAFT BNE L22 30XW9MM THICKNESS 13 15MM PAT FRZ DRY WDG IMPL,SUP-2307177,CDM,C1713,HCPCS,0278,RC,,,,both,,,2962.34,1925.52,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED FRAC ENDO HD,SUP-2212722,CDM,C1776,CPT,0278,RC,,,,both,,,4059.36,2638.58,,,,,,,,,,,,,
CARTRIDGE GRFT DEL 5 CC INSTAFILL,SUP-2865331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE T SHP WTAB 1.5 MM SCRW8 HOLE 27 MM,SUP-2676828,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.37,492.29,,,,,,,,,,,,,
NAIL IM CEPHALOMEDULLARY 125 DEG LNG 13 MMX30 CM RT TI,SUP-2458234,CDM,C1713,HCPCS,0278,RC,,,,both,,,6685.75,4345.74,,,,,,,,,,,,,
HEAD HUM RESURF MACROBOND SZ 6 COPELAND EAS,SUP-2403998,CDM,C1776,CPT,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
IMPLANT ANK JT TIB COMP CO CHROM SALTO TALARIS SZ 0,SUP-2244135,CDM,C1776,CPT,0278,RC,,,,both,,,12393.58,8055.83,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY W PAT STRP 20IN,SUP-2195122,CDM,L1830,CPT,0272,RC,,,,both,,,58.69,38.15,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN FLX TIP L7CM PTFE STR FIX,SUP-2157259,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.62,19.90,,,,,,,,,,,,,
LINER ACET D OD46 48MM ID28MM THK79MM 0DEG POLYETH HA HIP,SUP-2374955,CDM,C1776,CPT,0278,RC,,,,both,,,2390.80,1554.02,,,,,,,,,,,,,
PLATE BNE STD 15 H L OLECRANON,SUP-2107007,CDM,C1713,HCPCS,0278,RC,,,,both,,,4782.22,3108.44,,,,,,,,,,,,,
PLATE BONE L135MM 8 H BILAT COMPR STR BROAD FOR 4.5MM SCR,SUP-2343797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2287.40,1486.81,,,,,,,,,,,,,
AMOXICILLIN 250 MG/5ML PO SUSR,RX-454,CDM,340b,HCPCS,0637,RC,65862-0707-55,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
KLS MARTIN RED III PED,SUP-2679246,CDM,C1713,HCPCS,0278,RC,,,,both,,,23523.56,15290.31,,,,,,,,,,,,,
BLADE SURG 22 CARBON NS PERSONNA +,SUP-2133479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,195.03,126.77,,,,,,,,,,,,,
GUIDEWIRE SURG L220MM DIA1.6MM NTHRD TRCR TIP S STL SMOOTH,SUP-2184963,CDM,C1769,HCPCS,0272,RC,,,,both,,,88.83,57.74,,,,,,,,,,,,,
LINER BPLR OD38-42MM ID26MM UNIV FEM ACET,SUP-2344597,CDM,C1776,CPT,0278,RC,,,,both,,,412.75,268.29,,,,,,,,,,,,,
GUIDEWIRE VASC L 65 CM UNIV,SUP-2148724,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
GRAFT VASC IMPRA L 5 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761310,CDM,C1768,CPT,0278,RC,,,,both,,,286.02,185.91,,,,,,,,,,,,,
RELOAD INT USE SHFT L 24 CM STPL LN L 45 MM OPN LEG H 2.5 MM,SUP-2896192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2540.23,1651.15,,,,,,,,,,,,,
BIT DRL L 115 MM DIA2.4 MM LAG QC NS DISP,SUP-2936421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
SCREW BONE L22MM OD4MM LCTSRB CPLMR SHLDR CNNLTD FLLY THRDD,SUP-2466661,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
KIT CATH URTRL BLLN DLTN 5MM X 4CM URO EZDLTE,SUP-2725734,CDM,C1726,HCPCS,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
GRAFT CORNEAL PROC FEE,SUP-2164746,CDM,V2785,HCPCS,0810,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE BNE RAD STYLOID DIVERGENT ACU-LOC 2,SUP-2107023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2414.66,1569.53,,,,,,,,,,,,,
CLIP INT LIG SM WIDE TI VESOCCLUDE,SUP-2757591,CDM,C1889,HCPCS,0278,RC,,,,both,,,26.38,17.15,,,,,,,,,,,,,
PLATE BNE W17.5XL142MM THK5.2MM 8 H TI BROAD LIMIT CNTCT,SUP-2190844,CDM,C1713,HCPCS,0278,RC,,,,both,,,1052.31,684.00,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 7 FRX20 CM 3L DRY SPECTRUM,SUP-2759882,CDM,C1751,HCPCS,0278,RC,,,,both,,,551.67,358.59,,,,,,,,,,,,,
PLATE BNE L46MM 5 H NONSTERILE DST DORS RAD S STL CLMN LOK,SUP-2177512,CDM,C1713,HCPCS,0278,RC,,,,both,,,1881.93,1223.25,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 40 MM DIA14 MM SHTH 10 FR CATH L,SUP-2142676,CDM,C1876,HCPCS,0278,RC,,,,both,,,3207.73,2085.02,,,,,,,,,,,,,
PROSTHESIS VOICE LO PRESSURE 16 FRX10 MM BLOM-SINGER,SUP-2238267,CDM,L8613,CPT,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE BONE L189MM 14 HOLE RIGHT LTRL DST PRRTCLR TBL STNLSS,SUP-2479174,CDM,C1713,HCPCS,0278,RC,,,,both,,,4491.68,2919.59,,,,,,,,,,,,,
HOOK SPNL SIDE LD SM LAM PEDCL LT TALL BODY SM STAT TI USS,SUP-2193438,CDM,C1713,HCPCS,0278,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
SPLINT TRAC 12IN UNIV 3 PNL KNEE,SUP-2196752,CDM,L1830,CPT,0274,RC,,,,both,,,56.58,36.78,,,,,,,,,,,,,
SHUNT CV L14MM DIA1.75MM IC SIL BLB TIP RADPQ CLRVW,SUP-2282639,CDM,C1889,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
HEAD RAD DIA22MM LT ARH SYS SLIDE-LOC,SUP-2106903,CDM,C1776,CPT,0278,RC,,,,both,,,29588.22,19232.34,,,,,,,,,,,,,
GUIDEWIRE VASC L108CM SL POLYMER TIP S STL STR ATRAUM TIP,SUP-2282440,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CUBE EXT FIX 4 HOLE RANCHO,SUP-2749949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
VALVE DRNGE W/ INTEGR PLAS CONN SIPHONGUARD PRIMING ADPT,SUP-2194061,CDM,C1889,HCPCS,0278,RC,,,,both,,,16468.70,10704.65,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 13 CM DIA26 FR DIL L 20 CM GUIDEWIRE,SUP-2168155,CDM,C1894,HCPCS,0272,RC,,,,both,,,105.16,68.35,,,,,,,,,,,,,
TREPHINE BONE BX L8IN DIA19MM RMR FOR FEM REV PROC,SUP-2136786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
ELEMENT WORKING BPLR IGLESIAS,SUP-2313972,CDM,C1713,HCPCS,0278,RC,,,,both,,,6962.13,4525.38,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5 CC DBM REFICIO,SUP-2731796,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.91,561.54,,,,,,,,,,,,,
CONNECTOR SPNL OPN CBL VERTEX SEL,SUP-2279730,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RNGD EPTFE 5MM DIA 60CM LEN,SUP-2395776,CDM,C1768,CPT,0278,RC,,,,both,,,4970.62,3230.90,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILESTO 7 DR-T W 56 X H 65 MM D 11 MM 32,SUP-2138454,CDM,C1721,HCPCS,0275,RC,,,,both,,,41605.00,27043.25,,,,,,,,,,,,,
DEVICE GUID DBL JT TYP 2 MM 115 CM ROTATABLE STRL LF DISP,SUP-2865624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
CAGE SPNL 19A H19MM DIA19MM CENTERPIECE T2,SUP-2292785,CDM,C1889,HCPCS,0278,RC,,,,both,,,21477.60,13960.44,,,,,,,,,,,,,
MESH SURG L 40 X W 28 CM D 1.5 MM PORCINE DERMAL CLLGN ABD,SUP-2901702,CDM,C9364,HCPCS,0278,RC,,,,both,,,84741.88,55082.22,,,,,,,,,,,,,
STENT URTRL 7FR DIA 16CML TCFLX OPEN WPSH CATH LTHSTNT ST S,SUP-2721364,CDM,C2617,HCPCS,0278,RC,,,,both,,,290.20,188.63,,,,,,,,,,,,,
STENT CORONARY EXPRESS 2 L 8 MM DIA 3 MM GUIDE CATH 5 FR NP,SUP-2139861,CDM,C1876,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER SGL CHMBR 30J PECTORAL BPLR VVEV,SUP-2357749,CDM,C1722,HCPCS,0275,RC,,,,both,,,52124.00,33880.60,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY CUST STR,SUP-2435664,CDM,L2385,HCPCS,0272,RC,,,,both,,,416.02,270.41,,,,,,,,,,,,,
GRAFT BONE SPCR LORDTC FRZ DRY CORT 7DEG L 11MMXW 14MMXH 5MM,SUP-2294196,CDM,C1713,HCPCS,0278,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC GRFT 513102] MUSCULOSKELETAL TRANSPLANT FOUNDATION],SUP-2307521,CDM,C9359,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
SCREW 16MM 22MM LAG PLT,SUP-2243267,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.44,409.14,,,,,,,,,,,,,
MESH HERN W4XL8IN RECTANG COMP POLYMER MACROPOROUS NAT,SUP-2219760,CDM,C1781,HCPCS,0278,RC,,,,both,,,1767.76,1149.04,,,,,,,,,,,,,
PLATE BONE SHFT L397MM BLDE L60MM THK4.8MM 95DEG 24 H BILAT,SUP-2185466,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.78,2367.81,,,,,,,,,,,,,
CATHETER URTRL DLTR 58FR DIA 8MM OD BLLN 24FR DIA INFLTD 75,SUP-2726293,CDM,C1758,HCPCS,0278,RC,,,,both,,,777.28,505.23,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD K1 HA CEM,SUP-2419694,CDM,C1776,CPT,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
LEAD KT STD TRL 8 ELECTRD CONTACTS 30MM SPC 4MM L60CM,SUP-2278240,CDM,C1897,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SCREW BNE L 30 MM DIA 5 MM INTLOK,SUP-2898515,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
BIT DRL L20MM OD3.2MM MULT QUIK CONN NONSTERILE REUSE,SUP-2364319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.10,391.36,,,,,,,,,,,,,
EVOS TI 3.5MMX10MM CTX SCREW T15 S-T,SUP-2820419,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.95,100.07,,,,,,,,,,,,,
PLATE BNE THK0.6MM 6 H MIC SHT TI DBL Y SHP BILAT,SUP-2262706,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.12,202.88,,,,,,,,,,,,,
SPHERE GLEN +3 40 MM SHLDR COMPHSVE VERSE-DIAL,SUP-2418153,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
FIXATION BEAM 7.5 X 105 MM,SUP-2586671,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
STEM HUM 12X200 MM SHLDR RVS NP,SUP-2436922,CDM,C1776,CPT,0278,RC,,,,both,,,13578.93,8826.30,,,,,,,,,,,,,
HC Insert Ureteral Tube,PX-3615069300,CDM,50693,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BNE L91MM 6 H L POSTEROLATERAL DST PERIARTC HUM,SUP-2410658,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.88,1479.97,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.7MM LOK FOR R3CON PLATING SYS GORILLA,SUP-2321270,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.22,412.89,,,,,,,,,,,,,
PLATE BNE L57MM THK1MM 12 H NONSTERILE HND S STL STR LOK,SUP-2178006,CDM,C1713,HCPCS,0278,RC,,,,both,,,1449.71,942.31,,,,,,,,,,,,,
SUPPORT ORTHOT CUST MILWAUKEE TYP SUPERSTRUCTURE,SUP-2435586,CDM,L1230,HCPCS,0272,RC,,,,both,,,1888.71,1227.66,,,,,,,,,,,,,
CATHETER STONE REM OD5FR ANTI RETROPULSION CLR GEL LITHO,SUP-2149868,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
CATHETER ATHRCTMY JETSTREAM SC L 145 CM DIA 7 FR TIP DIA1.6,SUP-2148528,CDM,C1724,HCPCS,0278,RC,,,,both,,,16808.42,10925.47,,,,,,,,,,,,,
BUTTON FIX W8XL12MM TI ATTCH SYS ALLGRFT CONSTRUCT FOR,SUP-2121393,CDM,C1776,CPT,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
CATHETER EP DIAG VIK JOSEPHSON CRV 2MM OCTAPOLAR POLE 6FR,SUP-2142593,CDM,C1730,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
IBAL TKA BEARING IMP PS SZ 7 18MM,SUP-2813186,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
IMPLANT ANK JT L16MM OD10MM TI SUBTALAR SFT THRD CANN CONIC,SUP-2851519,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
ROD RELINE O COCR 5.5X500MM TL,SUP-2880393,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
DRILL TWST L105MM DIA1.9MM ADD ON SHFT END DISP FOR DST RAD,SUP-2374317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ARTHROSCOPIC KIT 2 MM PIN STRL INION OTPS LTX DISP,SUP-2857900,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
GRAFT BNE SUB 10CC 2-4MM GROWTH FACT ALLGRFT OSTEOAMP,SUP-2138498,CDM,C1713,HCPCS,0278,RC,,,,both,,,5799.74,3769.83,,,,,,,,,,,,,
SCREW BNE LAG SHT 12.7X130 MM 17 MM THRD FREE LOK,SUP-2205402,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.22,203.59,,,,,,,,,,,,,
BIT DRL DIA5MM SH FOR EXTRM L CANN SCR INSTR SET,SUP-2349160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.07,770.95,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA1.7 MM POLY L-LACTIDE POLY D-LACTIDE 10PK,SUP-2883349,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
KNIFE SURG W3MM SWVL STR BLDE REUSE S STL BALLENGER,SUP-2161598,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.72,213.02,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7040,HCPCS,0258,RC,00264-7800-10,NDC,,both,1000,ML,59.50,38.67,,,,,,,,,,,,,
GRAFT BNE SUB 40CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264813,CDM,C1713,HCPCS,0278,RC,,,,both,,,1313.34,853.67,,,,,,,,,,,,,
HC So Hepatitis C Virus Genotyping,PX-3068790266,CDM,87902,CPT,0306,RC,,,,inpatient,,,1147.00,745.55,,,,,,,,,,,,,
BUR SURG DR MED 3X9.5 MM FLUT FOR HD-G1 CARBIDE,SUP-2848305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.15,351.75,,,,,,,,,,,,,
DISPENSER GUIDEWIRE 0.9 MMX6 IN,SUP-2607260,CDM,C1769,HCPCS,0272,RC,,,,both,,,506.89,329.48,,,,,,,,,,,,,
PLATE BNE RT 16 HOLE,SUP-2198729,CDM,C1713,HCPCS,0278,RC,,,,both,,,4401.02,2860.66,,,,,,,,,,,,,
CLAMP EXT FIX W1.044XH1.63XL1.344IN ALUM TI S STL USED W/,SUP-2342862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3152.40,2049.06,,,,,,,,,,,,,
ENDCAP ORTH 5MM FOR PEDINAIL PED IM FEM NAIL,SUP-2318890,CDM,C1713,HCPCS,0278,RC,,,,both,,,1038.56,675.06,,,,,,,,,,,,,
IMPLANT FRESH CORNEA LEFT,SUP-2855178,CDM,V2785,HCPCS,0810,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
VALVE CSF CRAN IMPL HYDROCEPHALUS OSV II 9OS702,SUP-2666688,CDM,C1889,HCPCS,0278,RC,,,,both,,,10289.97,6688.48,,,,,,,,,,,,,
CATHETER ANGIOPLSTY DORADO L 120 CM BALLOON L 4 CM DIA 9 MM,SUP-2128101,CDM,C1725,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC CANC CRUSH,SUP-2898985,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.36,1532.28,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.025 IN TIP CRV RAD 3 MM HVY DBL,SUP-2759996,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.91,55.84,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT CRANIOMAXILLOFACIAL TI COARSE,SUP-2189660,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.37,161.44,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN L1.5MM STD SM VES NIT,SUP-2385576,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.44,102.34,,,,,,,,,,,,,
PLATE BNE W17.5XL178MM THK5.2MM 10 H BILAT S STL BROAD,SUP-2185293,CDM,C1713,HCPCS,0278,RC,,,,both,,,1630.82,1060.03,,,,,,,,,,,,,
PLATE BNE 3 H RAD WRST S STL CLMN PIN,SUP-2389682,CDM,C1713,HCPCS,0278,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
KIT TKR KNEE CRUCE RET CEM HI DEMAND INSRT VERILAST LEGION,SUP-2348030,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PIN FIX L60MM DIA15MM POLYLACTIC ACID NONLOAD BEAR IMMOB,SUP-2166474,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.71,292.31,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 50 X 76 X 0.85 MM POLYETHYL ORBIT FLR,SUP-2935301,CDM,C1713,HCPCS,0278,RC,,,,both,,,1595.12,1036.83,,,,,,,,,,,,,
BOLT IM L90MM DIA4.9MM HD DIA8MM CORT TI ST CANN LOK FULL,SUP-2192420,CDM,C1713,HCPCS,0278,RC,,,,both,,,720.06,468.04,,,,,,,,,,,,,
PROPHECY INVISION PATIENT SPECIFIC GUIDES,SUP-2853187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3205.94,2083.86,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR DF,SUP-2248608,CDM,C1732,HCPCS,0272,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 121 MM LEG L 62 MM IPSILATERAL DIA16,SUP-2751286,CDM,C1874,HCPCS,0278,RC,,,,both,,,12132.96,7886.42,,,,,,,,,,,,,
GRAFT HUM TISS W10-20MMXL16-19.4CM ACHILLES TEND W/O,SUP-2307293,CDM,C1713,HCPCS,0278,RC,,,,both,,,6226.24,4047.06,,,,,,,,,,,,,
RING FIX 21-24IN CIRC M OPN BK BAIL HALO,SUP-2328127,CDM,L0859,HCPCS,0274,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 9 FR SIDEPRT,SUP-2763368,CDM,C1892,HCPCS,0272,RC,,,,both,,,381.20,247.78,,,,,,,,,,,,,
BUR SURG L 51 MM DIA2.35 MM HD L 4 MM DIA1.2 MM TUNGSTEN,SUP-2929084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,139.29,90.54,,,,,,,,,,,,,
BAR EXT FIX L 380 MM DIA11 MM CRV NS DISP MAV,SUP-2933083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5859.24,3808.51,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. FLX L 40 MM DIA10 MM DEL SYS L 120 CM,SUP-2159361,CDM,C1876,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
HC Treat Metatarsal Fx,PX-4502847500,CDM,28475,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
RING EXT FIX FULL L140MM SIDEKCK,SUP-2400638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3121.16,2028.75,,,,,,,,,,,,,
BLADE SHAVER 4.2 MMX10.5 CM 45 DEG BEND RHINOTEC CUDA,SUP-2607643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,169.87,110.42,,,,,,,,,,,,,
HC Abdomen Surgery Procedure,PX-3614999900,CDM,49999,CPT,0361,RC,,,,both,,,2802.00,1821.30,,,,,,,,,,,,,
PLATE BNE VOLAR LT GEMINUS,SUP-2340192,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
GRAFT HUM TISS W1XL2CM AMNIO MEMBRN TRNSLUC GRID PAT SGL,SUP-2113882,CDM,Q4154,HCPCS,0636,RC,,,,both,,,1342.35,872.53,,,,,,,,,,,,,
TUBE ENDOTRACHEAL 5 MM CHANGING,SUP-2242618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,32.94,21.41,,,,,,,,,,,,,
DEFIBRILLATOR CARD 15MM 39J SGL CHMBR BPLR REMOT MON ENABLED,SUP-2357741,CDM,C1722,HCPCS,0275,RC,,,,both,,,45530.00,29594.50,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 18GA 10CM WNGD 1 LU F118108PT,SUP-2632730,CDM,C1751,HCPCS,0278,RC,,,,both,,,397.02,258.06,,,,,,,,,,,,,
INTRODUCER TUBE COUDE TIP AD 15 FRX70 CM CALIB POLYETH DISP,SUP-2381630,CDM,C1894,HCPCS,0272,RC,,,,both,,,23.58,15.33,,,,,,,,,,,,,
ROD CONN 5.5 MM FRONT LD FIREBIRD NXG,SUP-2658355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
GRAFT VENTRICULAR ASST DEV SZ 7.6 CM SHRT OUTFLO BEND REL,SUP-2894943,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
MICROFREE MED SPEED DRILL,SUP-2605744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19211.15,12487.25,,,,,,,,,,,,,
DEVICE SUT L26CM DIA5MM TI KNOT TYNG CRMP STD HNDL DISP,SUP-2265298,CDM,C1889,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
COMPONENT FEM M RT KNEE POST STABILIZING REV PRI STEMLESS,SUP-2364855,CDM,C1776,CPT,0278,RC,,,,both,,,19731.76,12825.64,,,,,,,,,,,,,
LINER ACET OD52MM ID40MM 0DEG HIP CO CHROM PRI SNAP IN,SUP-2345308,CDM,C1776,CPT,0278,RC,,,,both,,,11960.26,7774.17,,,,,,,,,,,,,
CATHETER EP L110CM OD4FR 2-5-2MM SPC L DECAPOLAR STEER,SUP-2357644,CDM,C1730,HCPCS,0272,RC,,,,both,,,1610.82,1047.03,,,,,,,,,,,,,
INTRODUCER SHTH 0.078 IN AD 7 FRX55 CM AMPLATZ1 VISTABRT TIP,SUP-2156087,CDM,C1887,HCPCS,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
GRAFT BNE SUB 15CC 15% HYDROXYAPATITE/85% B-TCP GRAN POR,SUP-2288533,CDM,C1713,HCPCS,0278,RC,,,,both,,,1766.25,1148.06,,,,,,,,,,,,,
SPACER THMB CMC 20MMX14MMX14MM L ARTELON,SUP-2361862,CDM,C1776,CPT,0278,RC,,,,both,,,5642.58,3667.68,,,,,,,,,,,,,
BIT DRL L8IN DIA3.8MM DISP FOR TIB NAILING SYS VERSANAIL,SUP-2412809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SCREW BNE L14MM DIA2MM HND 316L S STL ST VAR ANG LOK T6,SUP-2178026,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.04,243.78,,,,,,,,,,,,,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-3729915100,CDM,99151,CPT,0372,RC,,,,both,,,290.00,188.50,,,,,,,,,,,,,
HC Dialysis Other Than Hemo (Crt/Peritoneal),PX-8029094500,CDM,90945,CPT,0881,RC,,,,outpatient,,,1278.00,830.70,,,,,,,,,,,,,
GRAFT BNE SUB 2.5ML SIL SOD CA PHOS OXIDE FOAM PK RECT CONT,SUP-2368190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
NEEDLE CRYOABLATION ICESEED 1.5MM,SUP-2225682,CDM,C2618,HCPCS,0272,RC,,,,both,,,4356.75,2831.89,,,,,,,,,,,,,
SLEEVE CNTR DIA5MM S STL FOR TAY SPAT FRME ILIZ RANCHO,SUP-2342330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,874.14,568.19,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM BIOCRYL RAPIDE ABSRB 3 PERMACORD SZ 2,SUP-2256703,CDM,C1713,HCPCS,0278,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
LENS IOL BCNVX 14+ DIOPT 6X13 MM TORIC,SUP-2102624,CDM,V2788,HCPCS,0276,RC,,,,both,,,984.00,639.60,,,,,,,,,,,,,
DEVICE FIX DIA10MM TIB PRELD TUNNELOC,SUP-2137205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.45,1218.39,,,,,,,,,,,,,
STENT COR 8MM 2.5MM CROSSING 0.037IN BURST 16ATM S STL,SUP-2104182,CDM,C1876,HCPCS,0278,RC,,,,both,,,3231.06,2100.19,,,,,,,,,,,,,
GRAFT BNE SUB 5CC VI DIA3MM CA SULF PELLET RESRB PRELD,SUP-2399037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1458.12,947.78,,,,,,,,,,,,,
GRAFT VASC GORTX L 110 CM DIA 6-8 MM EPTFE TAPR STD WALL N,SUP-2396457,CDM,C1768,CPT,0278,RC,,,,both,,,3290.72,2138.97,,,,,,,,,,,,,
CATHETER PERITONEAL POS XR ID 1.2X2.5 MMX90 CM DSTL HOLTER,SUP-2666429,CDM,C1729,HCPCS,0272,RC,,,,both,,,760.76,494.49,,,,,,,,,,,,,
CANNULA ENDOSCP LT 10X49 MM STRL MONTGOMERY DISP,SUP-2139784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CIPROFLOXACIN HCL 750 MG PO TABS,RX-25120,CDM,6370000000,HCPCS,0637,RC,00143-9929-50,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE 18 H LT ANTEROLATERAL DSTL TIB NS,SUP-2897258,CDM,C1713,HCPCS,0278,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
GRAFT ALLGRFT CHIP CRUSH CANC FRZN RANG 40ML 1MM 8MM,SUP-2264740,CDM,C1713,HCPCS,0278,RC,,,,both,,,3274.17,2128.21,,,,,,,,,,,,,
COIL EMB L10CM OD5MM 2D HELI SFT STRTCH RESIST DETACH,SUP-2365733,CDM,C1889,HCPCS,0278,RC,,,,both,,,6129.12,3983.93,,,,,,,,,,,,,
PLATE 1ST MTCRPL 2MM DORS TI STRL VAL,SUP-2546915,CDM,C1713,HCPCS,0278,RC,,,,both,,,2707.68,1759.99,,,,,,,,,,,,,
PLATE SPNL 1 HOLE 8 MM LCK CVR REGATTA,SUP-2711095,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
GRAFT BNE 4 10MM 5CC CANC CHIP FRZN,SUP-2335542,CDM,C1762,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG,RX-94141,CDM,6370000000,HCPCS,0637,RC,00904-6255-49,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE EL W 4.45 X H 5.88 CM THK 0.75 CM,SUP-2149252,CDM,C1785,HCPCS,0275,RC,,,,both,,,13231.96,8600.77,,,,,,,,,,,,,
GRAFT VASC W6XL6CM THK0.4MM CV PTCH GOR TX,SUP-2395308,CDM,C1768,CPT,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
PLATE BNE X 1.5 MM 12 MM C-TUBE BRIDGE TI NS LEVEL 1,SUP-2471560,CDM,C1713,HCPCS,0278,RC,,,,both,,,334.28,217.28,,,,,,,,,,,,,
HC C-Spine 2-3 Views,PX-3207204000,CDM,72040,CPT,0320,RC,,,,both,,,530.00,344.50,,,,,,,,,,,,,
HC So Immunoperoxidase Stain,PX-3128834266,CDM,88342,CPT,0312,RC,,,,both,,,792.00,514.80,,,,,,,,,,,,,
GRAFT HUMAN TSSUE L W5XL10CM THK0.53 1.02MM DRML TSSUE MTRX,SUP-2496478,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5045.98,3279.89,,,,,,,,,,,,,
BRACE WRST FA HND L INSTABILITY INJ 8IN IMMOB LOOP LOK,SUP-2276635,CDM,L3809,HCPCS,0272,RC,,,,both,,,21.82,14.18,,,,,,,,,,,,,
STENT URET 0.038 IN 6 FRX26 CM SENSOR 2 FLX SET POLARIS LOOP,SUP-2473659,CDM,C2617,HCPCS,0278,RC,,,,both,,,507.42,329.82,,,,,,,,,,,,,
EXTRACTOR SURG SZ 3.5 MM SCREW DIA 3.5-8 MM STRL DISP,SUP-2913544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2199.10,1429.41,,,,,,,,,,,,,
QUICKSET ACE GRATER HEAD 47MM,SUP-2514452,CDM,C1776,CPT,0278,RC,,,,both,,,1532.32,996.01,,,,,,,,,,,,,
SCREW BNE RUL LAG FOR NAILING SYS GAMMA3,SUP-2361613,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
GRAFT BNE CHIP FRZ DRY CANC CORT 1MM 8MM RANG 90CC READIGRFT,SUP-2264697,CDM,C1713,HCPCS,0278,RC,,,,both,,,2926.86,1902.46,,,,,,,,,,,,,
WASHER ORTH DIA31X40MM HIP TROCH FOR MOD SYS S ROM,SUP-2257042,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.30,619.64,,,,,,,,,,,,,
CETIRIZINE HCL 5 MG/5ML PO SOLN,RX-125364,CDM,6370000000,HCPCS,0637,RC,68094-0004-62,NDC,,both,2.5,ML,6.50,4.22,,,,,,,,,,,,,
SCREW BNE L75MM DIA5MM CNDYL S STL ST VAR ANG LOK T25,SUP-2178719,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.00,360.75,,,,,,,,,,,,,
PLATE BNE L20MM M L HEVANS,SUP-2321480,CDM,C1713,HCPCS,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
HC Rmvl FB Conjunctiv Embedded,PX-4506521000,CDM,65210,CPT,0450,RC,,,,both,,,954.00,620.10,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|ADJ,PX-4409753000,CDM,97530,CPT,0440,RC,,,GO|KX|CO|ADJ,both,,,191.00,124.15,,,,,,,,,,,,,
GRAFT EVAR STNT L20MM DIA10MM CATH L75CM SHTH 6FR N COAT,SUP-2142748,CDM,C1876,HCPCS,0278,RC,,,,both,,,3244.00,2108.60,,,,,,,,,,,,,
CONNECTOR SPNL CROSS,SUP-2211058,CDM,C1713,HCPCS,0278,RC,,,,both,,,2817.21,1831.19,,,,,,,,,,,,,
CYLINDER PENILE PROS L16CM DIA12MM CONCEALABLE MAL SPECTR,SUP-2138901,CDM,C1813,HCPCS,0278,RC,,,,both,,,36101.21,23465.79,,,,,,,,,,,,,
CATHETER ABLATN ASYM 4 7 FRX110 CM 2.5 MM INTELLATIP MIFI XP,SUP-2148495,CDM,C1733,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED TIB PATELLAR COMP PERSONA TIBZIMCOMPNTS] ZIMMER BIOMET INC],SUP-2212670,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE L139MM 2 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186037,CDM,C1713,HCPCS,0278,RC,,,,both,,,3719.17,2417.46,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 156 MM BLADE L 50 MM SCREW DIA 4.5,SUP-2908361,CDM,C1713,HCPCS,0278,RC,,,,both,,,4447.31,2890.75,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L 45 CM DIA1.2 MM NIT STRL,SUP-2754756,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CANNULA ENDOSCP N THRD KII SHLD ACCES,SUP-2119605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.25,314.11,,,,,,,,,,,,,
APPLICATOR ENDOCLOT,SUP-2857948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
ALPHAVENT SUTURE ANCHR 4.75MM PEEK SUTURE ANCHR,SUP-2906833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
PLATE BNE BAR L16MM 2 H CRANIOMAXILLOFACIAL TI LO PROF FOR,SUP-2366200,CDM,C1713,HCPCS,0278,RC,,,,both,,,425.25,276.41,,,,,,,,,,,,,
STAPLE INT THK1.8X1.3MM W15XL15-15MM ANK FT NIT SUP E,SUP-2378844,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE XL 16 CC CORTICOCANCELLOUS VIABLE,SUP-2932818,CDM,C1762,CPT,0278,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM DIA14 MM BRANCH SZ 10/10 MM,SUP-2669853,CDM,C1768,CPT,0278,RC,,,,both,,,4895.54,3182.10,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT CLEARVUE BASIC 4FR 0.033N 6 9617405,SUP-2632706,CDM,C1751,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
ANCHOR SUT CRV FOR MENIS REP SYS ULT FAST-FIX,SUP-2341774,CDM,C1713,HCPCS,0278,RC,,,,both,,,1035.26,672.92,,,,,,,,,,,,,
CARTEOLOL HCL 1 % OP SOLN,RX-9417,CDM,6370000000,HCPCS,0637,RC,61314-0238-05,NDC,,both,5,ML,58.30,37.89,,,,,,,,,,,,,
BUPIVACAINE HCL 0.5 % IJ SOLN (MIXTURES ONLY),RX-430038,CDM,J0665,HCPCS,0636,RC,00409-1163-01,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
LEAD PACE CAPSUR L 50 CM SIL INSUL STEROID EPICARD BPLR STRL,SUP-2278400,CDM,C1898,HCPCS,0275,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
STEM FEM L240MM OD13.5MM 10IN BEAD L MTPHSEAL BODY CO CHROM,SUP-2203201,CDM,C1776,CPT,0278,RC,,,,both,,,21838.70,14195.15,,,,,,,,,,,,,
INTRODUCER HEMSTAS 8FRX45CM 30 DEG CRV .038IN GWIRE FAST,SUP-2355586,CDM,C1894,HCPCS,0272,RC,,,,both,,,127.96,83.17,,,,,,,,,,,,,
LINER ACET OD54MM ID32MM +4MM OFFSET HIP GVF POLYETH TI,SUP-2250250,CDM,C1776,CPT,0278,RC,,,,both,,,10459.97,6798.98,,,,,,,,,,,,,
FORCEP ELECSURG BPLR STD 1.2MM 15 CM SEMKIN NS SILVERGLIDE,SUP-2859571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1400.22,910.14,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP KIT ACL DISP,SUP-2608756,CDM,C1769,HCPCS,0272,RC,,,,both,,,1072.62,697.20,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 8 KT STRL DISP EVO,SUP-2934934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
ELECTRODE NDL CANN L25CM ARRY DIA2CM FOR OPN AND PERC RF,SUP-2139750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4163.64,2706.37,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA AVX L 50 CM DIA 6 FR SHTH,SUP-2142030,CDM,C1757,HCPCS,0272,RC,,,,both,,,5243.80,3408.47,,,,,,,,,,,,,
BURR SHVR RPRCSSD ARTHSCP 5.5MM DIA STNDRD ROUND FLTDX12 CYA,SUP-2589372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,179.17,116.46,,,,,,,,,,,,,
DRESSING BIO L 6 X W 9 CM PORCINE CLLGN PHMB CROSS LINKED,SUP-2909399,CDM,C1763,HCPCS,0278,RC,,,,both,,,11190.96,7274.12,,,,,,,,,,,,,
HC So Candida Antibody,PX-3028662866,CDM,86628,CPT,0302,RC,,,,both,,,67.00,43.55,,,,,,,,,,,,,
NEEDLE SPNL Y 100 MM ES2 LT,SUP-2532842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.62,441.10,,,,,,,,,,,,,
KIT INTRO ARW DIA 9 FR SPRING GUIDEWIRE L 17.75 IN DIA 0.035,SUP-2120640,CDM,C1894,HCPCS,0272,RC,,,,both,,,80.70,52.45,,,,,,,,,,,,,
INTRODUCER SHTH 10 FR KT,SUP-2470168,CDM,C1894,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
COLLAR CERV LO DENS LG 15-20 IN,SUP-2197207,CDM,L0120,HCPCS,0274,RC,,,,both,,,17.18,11.17,,,,,,,,,,,,,
FIBER LASER 1000UM DUST THULIUM,SUP-2885327,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
STENT NSL 370UG MOMETASONE FUROATE BIOABSRB IMPL W/ DEL SYS,SUP-2246417,CDM,C2625,HCPCS,0278,RC,,,,both,,,3830.80,2490.02,,,,,,,,,,,,,
SCREW BONE L55MM DIA4MM PARTIALLY THRD HD M CANN FLOWERCUBE,SUP-2225340,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.59,437.18,,,,,,,,,,,,,
GUIDEWIRE BLUNT TIP NIT 18 INCH INVICTUS,SUP-2114057,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
CRANIOPLASTIC RESINOUS 75PPM BONE SUB FOR REPAIRING CRAN,SUP-2243573,CDM,C1889,HCPCS,0278,RC,,,,both,,,4167.00,2708.55,,,,,,,,,,,,,
STAPLE INT STR 12X12 MM ASMBLY,SUP-2751333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3652.92,2374.40,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK FD IRRADIATED IL CREST,SUP-2867054,CDM,C1762,CPT,0278,RC,,,,both,,,2308.84,1500.75,,,,,,,,,,,,,
SMALL RAIL 200MM,SUP-2724393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3523.08,2290.00,,,,,,,,,,,,,
SPLINT ORTH M L13IN 6-17IN GRY ELBW BILAT ZIP OPN NYL LOOP,SUP-2324194,CDM,L3702,HCPCS,0274,RC,,,,both,,,64.40,41.86,,,,,,,,,,,,,
VALVE SHUNT 10 W/ PED BURHOLE RESVR MININAV,SUP-2108731,CDM,C1729,HCPCS,0272,RC,,,,both,,,1592.77,1035.30,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM CLAVICLE 7H LT-15MM HOOK DEPTH-STER,SUP-2549673,CDM,C1713,HCPCS,0278,RC,,,,both,,,3880.47,2522.31,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 6MM STR TW REMOVABLE RNG,SUP-2396298,CDM,C1768,CPT,0278,RC,,,,both,,,4904.68,3188.04,,,,,,,,,,,,,
ANCHOR SUT 3 STRND INTELLIBRAID TECHNOLOGY W/ NO2 FORC FBR,SUP-2366695,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.56,879.81,,,,,,,,,,,,,
TUBE FEED 16FR 108IN 15ML BLLN JEJUSTMY RADPQ CONN W/ DEPTH,SUP-2384673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.48,294.76,,,,,,,,,,,,,
WIRE EXT FIX BAYNT 1.8 MM,SUP-2197297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SET INTRO MICROEZ L 50 CM CATH 5 FR NDL L 7 CM FLEXURA RED,SUP-2125503,CDM,C1769,HCPCS,0272,RC,,,,both,,,140.92,91.60,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BELOW LIMB PREPARATORY,SUP-2388205,CDM,L5530,HCPCS,0272,RC,,,,both,,,4784.51,3109.93,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|ADJ,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|KX|CO|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM NOM THK1.1MM STD HUM DERM REGEN,SUP-2399064,CDM,Q4107,HCPCS,0636,RC,,,,both,,,7523.44,4890.24,,,,,,,,,,,,,
PLATE BONE COMPRESSION SMALL 3.5X158 MM CORTICAL 11 HOLE PER,SUP-2837382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.28,1092.83,,,,,,,,,,,,,
HC Intro Catheter Aorta,PX-3613620000,CDM,36200,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER INFUSION EMB 2.9 FRX100 CM MIC STR EMBOCATH +,SUP-2302530,CDM,C1757,HCPCS,0272,RC,,,,both,,,846.86,550.46,,,,,,,,,,,,,
WIRE FIXATION 30 GAX500 MM NEEDLE TITANIUM STERILE,SUP-2838462,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.92,345.75,,,,,,,,,,,,,
PLATE BNE 16 H R DST CLAV LOK FOR 2.3MM SCR,SUP-2106963,CDM,C1713,HCPCS,0278,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
BRACE KNEE L FOR 21 24IN THGH UNIV NEOPRENE PUL ON ACL PLC,SUP-2151024,CDM,L1810,HCPCS,0274,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
VALVE MI 25MM T6 ANTICALCIFICATION TREAT RADPQ ANNULUS RNG,SUP-2282997,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SPHERE EMB LC BEAD PARTIC SZ 100-300 UM 2 ML SULPHONATE YEL,SUP-2135325,CDM,C1889,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
NEW 24X30 CM DS4000 IMAG PLT,SUP-2303643,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM MULTAXL STRL CD HORZ 2PK,SUP-2928049,CDM,C1713,HCPCS,0278,RC,,,,both,,,3328.40,2163.46,,,,,,,,,,,,,
HC Exam & Select Archive Tissue Molecular Analysi,PX-3108836300,CDM,88363,CPT,0310,RC,,,,both,,,51.00,33.15,,,,,,,,,,,,,
CLARITHROMYCIN 125 MG/5ML PO SUSR,RX-12885,CDM,340b,HCPCS,0637,RC,09999-9917-94,NDC,,both,5,ML,28.00,18.20,,,,,,,,,,,,,
PLATE SPNL L70MM TI ANT CERV LOK LO PROF ATLNTS VISN,SUP-2293173,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.57,1867.82,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE TIB CUST FRAC PLSTR MOLD,SUP-2435646,CDM,L2106,HCPCS,0274,RC,,,,both,,,2231.54,1450.50,,,,,,,,,,,,,
SHELL ACET OD62MM TI-COAT HIP RESTORIS Z KLASSIC HD,SUP-2371083,CDM,C1776,CPT,0278,RC,,,,both,,,8037.74,5224.53,,,,,,,,,,,,,
CANNULA ENDOSCOPIC RIGHT CURVE CROSSBOW,SUP-2824972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1044.80,679.12,,,,,,,,,,,,,
ARTHROFLEX 40X40X1.0 MM,SUP-2816389,CDM,Q4125,HCPCS,0636,RC,,,,both,,,6335.89,4118.33,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 7 MM EPTFE FLX STD WALL RING,SUP-2126872,CDM,C1768,CPT,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
PLATE BNE TALAR 3 MM TRL,SUP-2498025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
SPLINT ANK M SHOE SZ 9-10.5 IN LG POLYPRO PLAS LT FT,SUP-2930190,CDM,L1930,HCPCS,0272,RC,,,,both,,,182.15,118.40,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X2 H CRANIOMAXILLOFACIAL TI SQ 3D PROF,SUP-2366278,CDM,C1713,HCPCS,0278,RC,,,,both,,,685.05,445.28,,,,,,,,,,,,,
PLATE BNE T 210 MM 12 HOLE SS,SUP-2569110,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.66,297.48,,,,,,,,,,,,,
CATHETER VENTRICULAR MED CLS PRESSURE 91 CM SHUNT ACCU-FLO,SUP-2243780,CDM,C1729,HCPCS,0272,RC,,,,both,,,768.01,499.21,,,,,,,,,,,,,
GUIDEWIRE ENDO L400CM DIA0.035IN STD FIX COR STR TIP,SUP-2168864,CDM,C1769,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
COMPONENT TIB M THK8MM RT MEDL LT LAT KNEE UNI NONBEADED CEM,SUP-2364890,CDM,C1776,CPT,0278,RC,,,,both,,,4459.59,2898.73,,,,,,,,,,,,,
STENT URET L 24 CM DIA 8 FR PERCFLX GLDEX USGK DBL PIGTL,SUP-2147803,CDM,C2617,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
BIT DRL SLD 2 MM SPIDER,SUP-2610408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.06,429.69,,,,,,,,,,,,,
BIT DRL L110MM DIA2MM STD RMR ADD ON DISP,SUP-2366053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.22,335.54,,,,,,,,,,,,,
GRAFT VASC L50CM DIA6MM EPTFE STD WALL NONRINGED STR,SUP-2126471,CDM,C1768,CPT,0278,RC,,,,both,,,1770.96,1151.12,,,,,,,,,,,,,
GRAFT HUM TISS L 6 X W 6 CM AMNION-CHORION-AMNION LAYR,SUP-2909302,CDM,Q4140,HCPCS,0636,RC,,,,both,,,18207.95,11835.17,,,,,,,,,,,,,
SCREW BNE L16MM OD2.7MM TI FT ANK CANN SHT THRD HD COMPR,SUP-2400820,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
GRAFT HUM TISS 6X4 CM REP AMNIO TISS MEMBRN,SUP-2422870,CDM,C1762,CPT,0278,RC,,,,both,,,8892.48,5780.11,,,,,,,,,,,,,
INTRODUCER SHTH 7 FRX18 CM PERC SMOOTH TRANSITION SS ORNG LF,SUP-2473518,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.66,56.33,,,,,,,,,,,,,
SYSTEM FLUID DEL STRL DISP MYRIAD,SUP-2930225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,363.24,236.11,,,,,,,,,,,,,
GUIDEWIRE VASC J 1.5 MM 0.035 INX400 CM STIFF SHFT GLIDEWIRE,SUP-2421820,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.93,194.30,,,,,,,,,,,,,
ULTRABAG/DIANEAL/4.25% DEX 483 MOSM/L IP SOLN,RX-32721,CDM,2580000003,HCPCS,0258,RC,00941-0433-53,NDC,,both,1000,ML,74.80,48.62,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 4-7 MM EPTFE TAPR STD WALL N,SUP-2396454,CDM,C1768,CPT,0278,RC,,,,both,,,2442.92,1587.90,,,,,,,,,,,,,
AIRWAY LARYN MASK DISP UNIQUE + SZ 5 W/ SYR AND LUB,SUP-2384091,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
TUBE FEED 18FR L45CM SIL TRANSGASTRIC JEJU EXT RETEN RNG,SUP-2124610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.69,476.90,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LORDTC 7 DEG 12X14.5X8.22X6.75 MM,SUP-2264945,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.35,1892.38,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PROTEGO S W 5 X L 75 CM D 1.3 CM DIA2.6,SUP-2138290,CDM,C1777,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
BIT DRL TWST 1X40 MM 5 MM HEX W/ STP STRL SONICWELD RX DISP,SUP-2483084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.14,363.44,,,,,,,,,,,,,
MINI PLATE LOK 4 HOLE MED T 6L 4V TTNM ALLOY,SUP-2678306,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.55,665.96,,,,,,,,,,,,,
PIN DISTRCTN 14 MM,SUP-2136803,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SCREW SPNL 4.25X16MM CERV VAR SPIDER,SUP-2402175,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.88,481.57,,,,,,,,,,,,,
SCREW BNE L90MM DIA4MM TI ALLY LOK FULL THRD T15 DRV AXSOS 3,SUP-2706304,CDM,C1713,HCPCS,0278,RC,,,,both,,,665.99,432.89,,,,,,,,,,,,,
COVER ORTHOT CUST FOR UPR,SUP-2435583,CDM,L1120,HCPCS,0274,RC,,,,both,,,107.67,69.99,,,,,,,,,,,,,
SET IMPL SCR DISK SELF DRL 1.5MM DIA 4MML,SUP-2362178,CDM,C1713,HCPCS,0278,RC,,,,both,,,1709.73,1111.32,,,,,,,,,,,,,
IMPLANT SYS BIOCOMP ACHILLES SUTRBRIDGE,SUP-2122828,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
MEMO STEP IMPLANT 18 02,SUP-2705874,CDM,C1713,HCPCS,0278,RC,,,,both,,,5327.95,3463.17,,,,,,,,,,,,,
TUBE FEEDING 8FR 36 IRIS ENFIT,SUP-2878013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.03,421.22,,,,,,,,,,,,,
GRAFT EVAR L13.5CM DIA16MM IL LIMB EXCLUDER,SUP-2395951,CDM,C1768,CPT,0278,RC,,,,both,,,10578.66,6876.13,,,,,,,,,,,,,
SCREW SPNL CANN 4.5X22 MM OCT FOR 4 MM REDUC NS SYM,SUP-2590159,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BAXTER BEVELED BOBBIN VT 097MM FLPL,SUP-2680302,CDM,L8699,HCPCS,0278,RC,,,,both,,,33.28,21.63,,,,,,,,,,,,,
SCREW BNE 1.5X4 MM DRL FREE,SUP-2262613,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.00,84.50,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.5MM CRTX ST T7 PERI-LOC,SUP-2350060,CDM,C1713,HCPCS,0278,RC,,,,both,,,187.33,121.76,,,,,,,,,,,,,
MOST CNDYL END R,SUP-2208259,CDM,C1776,CPT,0278,RC,,,,both,,,26649.18,17321.97,,,,,,,,,,,,,
STAPLE BNE FIX W20XL20MM S STL FOREFOOT NTHRD COMPR,SUP-2397616,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
GRAFT VASC W6MMXL80CM BYPS SM CUF DISTAFLO,SUP-2128084,CDM,C1768,CPT,0278,RC,,,,both,,,15631.74,10160.63,,,,,,,,,,,,,
IMPLANT DERM W50XH50XL80MM CLLGN RECTANG SHT ALLOMAX,SUP-2125852,CDM,C1781,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
HEAD HUM 44X18 MM SHAPER GLOB CAP QC,SUP-2453843,CDM,C1776,CPT,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
SCREW BNE L9MM DIA23MM CRANIOMAXILLOFACIAL TI SELF RET CRSS,SUP-2262806,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.92,133.20,,,,,,,,,,,,,
PLATE BONE ADAPTION 1.5X33X5 MM 8 HOLE RAPID RESORBABLE SCAL,SUP-2838547,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
LINER ACET NEUT C 5+ MM 28 MM PROV G7,SUP-2441107,CDM,C1776,CPT,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
PACEMAKER SGL CHMBR ADAPTIVE RATE PULSE GEN SGL DDDR RT A OR,SUP-2357336,CDM,C1785,HCPCS,0275,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
PLATE BNE L 201 MM SCREW DIA 4.5 MM 12 H BOW COMPR LCK NS,SUP-2933379,CDM,C1713,HCPCS,0278,RC,,,,both,,,4162.07,2705.35,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 6 MM RNG L 20 CM,SUP-2227608,CDM,C1768,CPT,0278,RC,,,,both,,,3244.09,2108.66,,,,,,,,,,,,,
DISC INTERVERT PLT VERT BODY REPL RT END PC SZ B 0DEG,SUP-2390786,CDM,C1889,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.6X220 MM FOR CANN SCREW NS 0333301304,SUP-2789100,CDM,C1769,HCPCS,0272,RC,,,,both,,,1299.71,844.81,,,,,,,,,,,,,
STEM FEM L120MM OD12MM 125DEG CO CHROM COMP FULL COAT HIP,SUP-2198927,CDM,C1776,CPT,0278,RC,,,,both,,,29861.40,19409.91,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 28ML W55XL60MM THK11MM 45GM SGL,SUP-2284466,CDM,C1767,HCPCS,0278,RC,,,,both,,,30018.40,19511.96,,,,,,,,,,,,,
PLATE 3.5MM TI LCP EXTRA-ARTICLR DSTL HUM 6H/RT 158MM-STER,SUP-2546619,CDM,C1713,HCPCS,0278,RC,,,,both,,,4475.44,2909.04,,,,,,,,,,,,,
CONNECTOR SPNL S STL STR SLT FOR 6.35MM ROD ISOLA,SUP-2255707,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
CONNECTOR ROD DOMINO 6.35X6.35 IN,SUP-2280181,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1716.07,1115.45,,,,,,,,,,,,,
CATHETER INFUS L15CM OD6FR 3 LUMN JACC,SUP-2120618,CDM,C1751,HCPCS,0278,RC,,,,both,,,736.86,478.96,,,,,,,,,,,,,
HC So Histoplasm,PX-3028669866,CDM,86698,CPT,0302,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
CATHETER THORACENTHESIS STR 32 FRX52 CM FLARED END 6 HOLE,SUP-2265219,CDM,C1729,HCPCS,0272,RC,,,,both,,,17.90,11.63,,,,,,,,,,,,,
COIL VASC TORNADO EMBOLUS L 8 CM DIA12 MM GUIDEWIRE 0.038 IN,SUP-2167755,CDM,C1889,HCPCS,0278,RC,,,,both,,,261.81,170.18,,,,,,,,,,,,,
CATHETER CV KT 0.025 IN 7 FRX16 CM DL INDWELL NDL FLX TIP,SUP-2763359,CDM,C1751,HCPCS,0278,RC,,,,both,,,378.06,245.74,,,,,,,,,,,,,
MATRIX BIO L 4 X W 4 CM BOV CLLGN CHONDROITIN-6-SULFATE,SUP-2909248,CDM,Q4105,HCPCS,0636,RC,,,,both,,,3968.90,2579.78,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM BIOCRYL RAPIDE ABSRB KNOTLESS HEALIX,SUP-2249439,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.88,1922.62,,,,,,,,,,,,,
ROD IM BAL ATTUNE,SUP-2454770,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRP FD IRRADIATED FASC LATA,SUP-2867199,CDM,C1762,CPT,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 8 MM RNG L 20 CM EPTFE STR STD,SUP-2396099,CDM,C1768,CPT,0278,RC,,,,both,,,1708.16,1110.30,,,,,,,,,,,,,
MESH C-QUR EDGE OBLONG OVL 3 INX6 IN,SUP-2265962,CDM,C1781,HCPCS,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
ALLOGRAFT BNE INSRT SM 6X5.2X6 MM FD CYL DBM XPANSE,SUP-2787769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1065.09,692.31,,,,,,,,,,,,,
CEMENT BNE 40GM FULL DOSE PMMA W GENT M VISC RADPQ FAST SET,SUP-2344337,CDM,C1713,HCPCS,0278,RC,,,,both,,,1063.83,691.49,,,,,,,,,,,,,
CAGE SPNL 10 DEG 45X22X10 MM COHERE XLW,SUP-2736463,CDM,C1889,HCPCS,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
GRAFT SYNTHETIC TISSUE GRANULE SMALL 0.71.4 MM 1 CC BETA TRI,SUP-2838531,CDM,C1713,HCPCS,0278,RC,,,,both,,,520.93,338.60,,,,,,,,,,,,,
BIT DRL DIA24MM NAVIGATION FOR VERTEX RECON SYS,SUP-2281198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1803.24,1172.11,,,,,,,,,,,,,
GRAFT VASC STR 4 MMX10 CM TW N RING HD ACCS EPTFE CARBOFLO,SUP-2761233,CDM,C1768,CPT,0278,RC,,,,both,,,1974.68,1283.54,,,,,,,,,,,,,
SCREW BNE SM L25MM AQUA FOR IO FIX X-POST IOFIX 2.0,SUP-2223904,CDM,C1713,HCPCS,0278,RC,,,,both,,,5002.02,3251.31,,,,,,,,,,,,,
STAPLER ROBOT L 30 MM DIA 8 MM CRV TIP STRL DISP SUREFORM DA,SUP-2908883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
IMPLANT MALAR W22XL44MM P3MM POR HDPE RT SHELL SYNTH,SUP-2182846,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
SCREW CP LAG 36X32MM,SUP-2695664,CDM,C1713,HCPCS,0278,RC,,,,both,,,952.36,619.03,,,,,,,,,,,,,
INTRODUCER SHTH L14CM OD8.5FR GWIRE OD0.038IN VASC DI-LOCK,SUP-2357075,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW FIX INF ULT SLNG SYS,SUP-2140330,CDM,C1771,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
IMPLANT BULK AGNT SYR DURASPHERE,SUP-2140370,CDM,L8606,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
NAIL IM L180MM DIA11MM 125DEG SHT FOR HIP FRAC AFFIXUS,SUP-2413324,CDM,C1713,HCPCS,0278,RC,,,,both,,,4994.48,3246.41,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 8MM 120CM 7FR RADIOPAQUE,SUP-2396658,CDM,C1874,HCPCS,0278,RC,,,,both,,,11093.62,7210.85,,,,,,,,,,,,,
INSERT ACET OD48MM ID32MM THK5.9MM 20DEGXLPE MTL ON POLY,SUP-2371337,CDM,C1776,CPT,0278,RC,,,,both,,,7034.26,4572.27,,,,,,,,,,,,,
HC Insj of Subq Implantable Defibrillator Electrode,PX-3613327100,CDM,33271,CPT,0361,RC,,,,both,,,28682.00,18643.30,,,,,,,,,,,,,
CLIP INT L235CM WRK CHAN DIA2.8MM OPN 11MM LCK MECHANISM MR,SUP-2149432,CDM,C1889,HCPCS,0278,RC,,,,both,,,495.18,321.87,,,,,,,,,,,,,
WASHER ORTH OD17MM ID6MM SPIK FOR ACL PCL FIX SYS ACUFEX,SUP-2341563,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
PIN EXT FIX HALF 4X34 MM 120 MM SD SHANK HA COAT STRL,SUP-2749900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
NAIL ELAS SS 2X440MM,SUP-2547600,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.83,512.74,,,,,,,,,,,,,
HC So Tissue Culture Placenta,PX-3118823566,CDM,88235,CPT,0311,RC,,,,both,,,329.00,213.85,,,,,,,,,,,,,
STENT CORONARY MULTLNK TRI L 28 MM DIA 3.5 MM GUIDE CATH,SUP-2101466,CDM,C1876,HCPCS,0278,RC,,,,both,,,6754.14,4390.19,,,,,,,,,,,,,
BASEPLATE TIB L51MM LNG MED LAT KNEE CO CHROM RESURF,SUP-2406482,CDM,C1713,HCPCS,0278,RC,,,,both,,,8633.43,5611.73,,,,,,,,,,,,,
HMRS ROT HINGE TIBIAL ROTATING COMPONENT,SUP-2512643,CDM,C1776,CPT,0278,RC,,,,both,,,13383.94,8699.56,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.4X16 MM TITANIUM MATRIXMANDIBLE,SUP-2837729,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.75,237.74,,,,,,,,,,,,,
LACTASE 3000 UNITS PO TABS,RX-22469,CDM,6370000000,HCPCS,0637,RC,77333-0430-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT XLPE CHIPZIMPRS] ZIMMER BIOMET INC],SUP-2212523,CDM,C1776,CPT,0278,RC,,,,both,,,14877.32,9670.26,,,,,,,,,,,,,
COUNTERSINK DRL CANN FOR 7MM CHARLOTTE MULT USE COMPR SCR,SUP-2397750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
COIL EMB 6.70MM L10CM PRI DIA0.0115IN 2ND DIA6MM INTCRAN,SUP-2295056,CDM,C1889,HCPCS,0278,RC,,,,both,,,3771.14,2451.24,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SABER L 150 CM BALLOON L 80 MM DIA 6 MM,SUP-2909667,CDM,C1725,HCPCS,0272,RC,,,,both,,,744.31,483.80,,,,,,,,,,,,,
ELECTRODE ELECSURG NDL 12-30 DEG 24 FR ANGLED PLASMA BUTTON,SUP-2430218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7051.91,4583.74,,,,,,,,,,,,,
MORCELLATOR HYSTEROSCOPIC DEV DST MRK 5MM FOR USE W 5C SYS,SUP-2172304,CDM,C1782,HCPCS,0272,RC,,,,both,,,1411.27,917.33,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY PRO L 90 CM 5 FR SLT 20CM FLX Y,SUP-2117007,CDM,C1751,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER ASPIR PRIORITYONE AC L 140 CM TIP L 6 MM GUIDE CATH,SUP-2384837,CDM,C1757,HCPCS,0272,RC,,,,both,,,1642.22,1067.44,,,,,,,,,,,,,
SPLINT WRST XL L7IN FOR 85 95IN COT R SLIP ON SFT DURABLE,SUP-2276656,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.73,6.32,,,,,,,,,,,,,
DILATOR VASC L30CM OD20 24FR .035IN HYDRPHLC IL LNG TAPR TIP,SUP-2168829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SALVATION WIRE BOLT 2MM PREASSEMBLED WASHERLESS,SUP-2401136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
KIT ISOLATED ACUSINCH,SUP-2106901,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR RATE RESPON IMP IDENTITY ADX DR,SUP-2356211,CDM,C1785,HCPCS,0275,RC,,,,both,,,16321.72,10609.12,,,,,,,,,,,,,
CROWN DENT NODUL-7 1ST PRI M UP L S STL,SUP-2322214,CDM,D6783,CPT,0278,RC,,,,both,,,156.65,101.82,,,,,,,,,,,,,
STAPLE BONE FIX L21/21MM ARTH MEM,SUP-2137596,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.72,769.42,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1193108D1,SUP-2632792,CDM,C1751,HCPCS,0278,RC,,,,both,,,831.03,540.17,,,,,,,,,,,,,
ANCHOR SUTURE 1 2.3 MM 38 IN 2 ULTRABRAID NDL BLU BIORAPTOR,SUP-2848916,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.75,535.44,,,,,,,,,,,,,
KNIFE SURG FOR MINI CRPL TUNN REL SFGRD,SUP-2242702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
KIT BNE ACCS SZ 3 8GA W/ 1 CANN STYL DRL SPCR OSTEOCOOL,SUP-2293680,CDM,C1894,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER GUID SUPP 035 65 CM CORONARY 45 DEG QUIK CROSS SEL,SUP-2353137,CDM,C1887,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
COIL EMB 10 L15CM OD6MM COMPLX STRTCH RESIST FNSH V TRAK,SUP-2305175,CDM,C1889,HCPCS,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS MULTAXL STRL CD HORZ MODULEX 559200015,SUP-2927811,CDM,C1713,HCPCS,0278,RC,,,,both,,,1.88,1.22,,,,,,,,,,,,,
LEAD PACE FLXTND L 59 CM SIL STEROID ENDOCARD RT,SUP-2140096,CDM,C1779,HCPCS,0275,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BNE X LG 2.4/2.7X36 MM LCK VA FUSION SS NS LCP,SUP-2184804,CDM,C1713,HCPCS,0278,RC,,,,both,,,3156.74,2051.88,,,,,,,,,,,,,
TIP TRANSILLUMINATION SYS DIA40FR FBR OPT BLNT HURST DETACH,SUP-2277401,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CATHETER MAP 8FR L105CM LOOP DIA15MM 3-3-3MM ELECTRD SPC,SUP-2357573,CDM,C1732,HCPCS,0272,RC,,,,both,,,5143.32,3343.16,,,,,,,,,,,,,
EXTRACTOR SURG L2-2.5 MMXTRACT ALL DISP FOR 2-2.5 MM,SUP-2337710,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
STEM FEM L170MM OD18MM 7.5IN BEAD 20MM BUILDUP CALCAR REV,SUP-2203258,CDM,C1776,CPT,0278,RC,,,,both,,,18715.97,12165.38,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X57 MM 7 HOLE 1/4 SS,SUP-2536109,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEJH1] STRYKER CORP],SUP-2365934,CDM,C1776,CPT,0278,RC,,,,both,,,11897.46,7733.35,,,,,,,,,,,,,
KIT INTRO PEEL AWAY 8.5F,SUP-2357064,CDM,C1894,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
BLADE REPROC SAW RECIP 3 MM CONN STRL LTX,SUP-2877811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,964.36,626.83,,,,,,,,,,,,,
PLATE BNE HUM 4.5/6.5X171 MM RT PROX LAT 8 HOLE BUTTRESS,SUP-2472606,CDM,C1713,HCPCS,0278,RC,,,,both,,,2338.99,1520.34,,,,,,,,,,,,,
SCREW BNE FIX 32 MM LIBRA,SUP-2442377,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.91,64.29,,,,,,,,,,,,,
DEVICE MENIS CRV IMPL JUGGER STIT DISP,SUP-2421744,CDM,C1713,HCPCS,0278,RC,,,,both,,,934.46,607.40,,,,,,,,,,,,,
VALVE CSF REG W/ BIOGLDE STRATA II,SUP-2631433,CDM,C1889,HCPCS,0278,RC,,,,both,,,13634.29,8862.29,,,,,,,,,,,,,
CUTTER ENDOSCP L 220 CM DIA2.6 MM CHANNEL DIA2.8 MM BPLR,SUP-2881890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
PLATE BNE L W135XL80MM THK42MM 4 H BILAT TI NAR RIG NEUT,SUP-2190808,CDM,C1713,HCPCS,0278,RC,,,,both,,,1022.67,664.74,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00264-7510-10,NDC,,both,500,ML,34.00,22.10,,,,,,,,,,,,,
BOLT ORTH L34MM DIA6.9MM LAT TROCHANTERIC HIP CO CHROM MOD,SUP-2404492,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
PLATE BONE GORILLA GRIP 20MM THICKNESS LEFT M,SUP-2741754,CDM,C1713,HCPCS,0278,RC,,,,both,,,5487.15,3566.65,,,,,,,,,,,,,
TIP ASPIR CLAW MIC 1.6X2 MM 12 CM FOR BNE CUT SONOPET IQ,SUP-2791055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3288.62,2137.60,,,,,,,,,,,,,
PLATE BNE L145MM 12 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT,SUP-2185940,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.32,345.36,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 16X25 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838617,CDM,C1763,HCPCS,0278,RC,,,,both,,,37122.02,24129.31,,,,,,,,,,,,,
DEVICE VASC CLSR 4FR TO 10FR RAD ART EXT MECH PRSS RADSTAT,SUP-2303324,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
RING EXT FIX MOD 3/8 D 160 MM RX STRL TRUELOK EVO LTX,SUP-2875609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4995.99,3247.39,,,,,,,,,,,,,
DEFIBRILLATOR 2 CHMBR CARDIOVERTER ADV 7.40CM HT 4.00CM W 40,SUP-2356289,CDM,C1721,HCPCS,0275,RC,,,,both,,,49926.00,32451.90,,,,,,,,,,,,,
COIL EMB L5CM DIA0.02IN LOOP DIA3MM COMPLX EXTRA SFT FILL,SUP-2323430,CDM,C1889,HCPCS,0278,RC,,,,both,,,6458.98,4198.34,,,,,,,,,,,,,
PLATE BNE L12MM 4 H MIDFOOT REARFOOT TI BILAT LOK,SUP-2399623,CDM,C1713,HCPCS,0278,RC,,,,both,,,2596.78,1687.91,,,,,,,,,,,,,
ANCHOR SUT TWINLOOP PEEK SGL STRND 2 EYELET UP EXT W NUMBER,SUP-2366681,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
ASSEMBLY SL HLD REVERE,SUP-2232137,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2681.56,1743.01,,,,,,,,,,,,,
IMPLANT DSTL RAD SZ 1,SUP-2418016,CDM,C1776,CPT,0278,RC,,,,both,,,6983.36,4539.18,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5X20 MM 6.35 MM PEDCL FOR ROD RED LEG,SUP-2288979,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
PLATE BNE X 1.5X0.6 MM 6 MM C-TUBE BRIDGE TI NS LEVEL 1,SUP-2485813,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.27,266.68,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM DIA2MM S STL THRD TIP SPADE PNT W/,SUP-2186889,CDM,C1769,HCPCS,0272,RC,,,,both,,,96.59,62.78,,,,,,,,,,,,,
PLATE BONE THK1.5MM 6 H MINI STR FOR 2/2.3MM SCR,SUP-2365232,CDM,C1713,HCPCS,0278,RC,,,,both,,,2535.11,1647.82,,,,,,,,,,,,,
SCREW BNE L90MM DIA4.5MM PROX FEM ANK S STL ST LOK FULL,SUP-2350267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.56,888.91,,,,,,,,,,,,,
AGENT HEMOSTATIC SYR KT ABSORBABLE GEL PWD GEL-FLOW NT,SUP-2326435,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CATHETER GUID MERCI L 180 CM HELIX L 5 MM LOOP DIA2 MM SS,SUP-2365837,CDM,C1887,HCPCS,0272,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
PLATE CRAN 200X60X40 MM PT SPEC IMPL PEEK,SUP-2860137,CDM,C1713,HCPCS,0278,RC,,,,both,,,32682.06,21243.34,,,,,,,,,,,,,
HC Portal Film,PX-3337741700,CDM,77417,CPT,0333,RC,,,,outpatient,,,756.00,491.40,,,,,,,,,,,,,
HC N Block Paravert Lumbar 2nd,PX-3606449400,CDM,64494,CPT,0360,RC,,,,both,,,3892.00,2529.80,,,,,,,,,,,,,
X-CLIP FIX L20MM DIA5.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223943,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SET PICC L 15CM DIA 4.5FR SHTH L 7CM DIA 4.5FR PR-41541-BAS,SUP-2887215,CDM,C1751,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ WINN 200T L 300 CM DIA 0.014 IN TIP,SUP-2105136,CDM,C1769,HCPCS,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
LINER ACET OD68MM ID28MM HIP MARATHON NEUT SNAP IN REV PINN,SUP-2250349,CDM,C1776,CPT,0278,RC,,,,both,,,4320.64,2808.42,,,,,,,,,,,,,
SCREW BNE HDLSS 3X30 MM COMPR FT STRL HCS LTX,SUP-2860987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1144.91,744.19,,,,,,,,,,,,,
PIN DISTR L14MM SELF DRL CASPR,SUP-2108436,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.46,215.45,,,,,,,,,,,,,
SYSTEM CATHETER 16FR L107CM W INTEGR HNDL FOR 23 26 29MM,SUP-2280901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
TISSEEL VHSD 10 ML KT 1501238] BAXTER],SUP-2129974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1726.62,1122.30,,,,,,,,,,,,,
CATHETER ABLATN LG CRV 2-5-2 MM SPC 4 MM TIP 7 FRX110 CM,SUP-2102290,CDM,C1733,HCPCS,0272,RC,,,,both,,,2389.54,1553.20,,,,,,,,,,,,,
IMPLANT OTOLARYN 0.6MM DIAM 3.5MM LEN PLAT STAP PIST,SUP-2312554,CDM,L8613,CPT,0278,RC,,,,both,,,429.99,279.49,,,,,,,,,,,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,0636,RC,00409-2720-03,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RESPON L 120 CM 6FR 2-8-2MM FIX,SUP-2703680,CDM,C1730,HCPCS,0272,RC,,,,both,,,170.47,110.81,,,,,,,,,,,,,
PLATE BNE THK0.8MM UNIV 8 H CRANIOMAXILLOFACIAL TI Y SHP,SUP-2366265,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.57,557.42,,,,,,,,,,,,,
PLATE BNE THK06MM 16 H MIDFACE TI STR LO PROF LEV 1 SIL FOR,SUP-2262718,CDM,C1713,HCPCS,0278,RC,,,,both,,,735.51,478.08,,,,,,,,,,,,,
PLATE BNE MESH PANEL 1X83X50X0.6 MM CRANIOMAXILLOFACIAL,SUP-2468844,CDM,C1713,HCPCS,0278,RC,,,,both,,,2703.57,1757.32,,,,,,,,,,,,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,0636,RC,67457-0430-10,NDC,,both,10,ML,155.30,100.94,,,,,,,,,,,,,
PLATE BNE L322MM 16 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185690,CDM,C1713,HCPCS,0278,RC,,,,both,,,4559.78,2963.86,,,,,,,,,,,,,
STEM RAD L12MM WR MAESTRO,SUP-2407335,CDM,C1776,CPT,0278,RC,,,,both,,,19615.58,12750.13,,,,,,,,,,,,,
SCREW BONE OD2MM 2ND MOD PLT,SUP-2413270,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
CATHETER EP 6FR L105CM 5MM SPC DECAPOLAR 270DEG STD CRV,SUP-2141318,CDM,C1732,HCPCS,0272,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
GRAFT HUM TISS W12XL36MM REV CORES FRZ DRY LIG RECON,SUP-2307073,CDM,C1713,HCPCS,0278,RC,,,,both,,,3314.90,2154.68,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM MED 30X20MM TI STRL,SUP-2549727,CDM,C1713,HCPCS,0278,RC,,,,both,,,2319.11,1507.42,,,,,,,,,,,,,
KIT HEMODLYS REP CATHETER EXTN FOR DLYS SPL,SUP-2269564,CDM,C1769,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
INSERT TIB SZ 2 THK10MM R ANK FIX BEAR VANTAGE,SUP-2420827,CDM,C1776,CPT,0278,RC,,,,both,,,4402.91,2861.89,,,,,,,,,,,,,
CURETTE KYPHOPLASTY SZ 2 DIA7MM T TIP N RADPQ FOR VERTPLSTY,SUP-2293449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
BOLT EXT FIX 12 MM RR1200PK,SUP-2487154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
PLATE BNE NAR 130 MM 10 HOLE TI,SUP-2459103,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.05,252.88,,,,,,,,,,,,,
PLUG FIST TUBE L9CM OD16MM DISK FOR MULT TISS DEFCT REP,SUP-2395749,CDM,C1781,HCPCS,0278,RC,,,,both,,,2643.88,1718.52,,,,,,,,,,,,,
LINER ACET 28X52 MM HIP LIP PROF OPT POLYETH DURALOC ENDRN,SUP-2433912,CDM,C1776,CPT,0278,RC,,,,both,,,2108.82,1370.73,,,,,,,,,,,,,
MARKER BRST BX XR TISS SS MICROMARK II,SUP-2195630,CDM,A4648,CPT,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
SCREW HEADLESS 48MM,SUP-2510901,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GRAFT HUM TISS W3XL2CM THK1MM CRYOPRESERVED UMB CRD AMNIO,SUP-2116288,CDM,Q4148,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
HC ED Clsd Tx Shoulder WO Anes,PX-4502365000,CDM,23650,CPT,0450,RC,,,,inpatient,,,383.00,248.95,,,,,,,,,,,,,
CATHETER HD 12 FRX16 CM DL FLEXTIP KT ARROWG+ARD BLU,SUP-2383376,CDM,C1752,HCPCS,0278,RC,,,,both,,,402.55,261.66,,,,,,,,,,,,,
MARKER BRST BX FOR CELERO,SUP-2240047,CDM,A4648,CPT,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
COMPONENT SHLDR CAPPED SHT GLEN HYBRID ST HD 1ST GLD,SUP-2212463,CDM,C1776,CPT,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
NAIL IM 130DEG 13X380MM RT STER,SUP-2137255,CDM,C1713,HCPCS,0278,RC,,,,both,,,6287.69,4087.00,,,,,,,,,,,,,
SCREW BNE L18MM DIA3.2MM ULN ANK S STL CORT LOK THRD HEX LO,SUP-2389562,CDM,C1713,HCPCS,0278,RC,,,,both,,,3332.98,2166.44,,,,,,,,,,,,,
PLATE BONE L21MM THK1.2MM SHFT W5MM 4 H STRL FLX FOR 2MM SCR,SUP-2349649,CDM,C1713,HCPCS,0278,RC,,,,both,,,3350.38,2177.75,,,,,,,,,,,,,
PLATE BNE SM 2X5 H TI MED MALL LOK COMPR FOR 35 4MM SCR,SUP-2398387,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 90 CM DIA 5.3 FR BALLOON L 20 MM DIA 4,SUP-2141832,CDM,C1725,HCPCS,0272,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19.5MMW X 80MML 0.8MM THK 0.9MM THK CUT M,SUP-2586311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,82.24,53.46,,,,,,,,,,,,,
SLING SHLDR M CHST CIRC 36IN TO 40IN UNIV BLU SUPP NEOPRNE,SUP-2324512,CDM,L3650,HCPCS,0272,RC,,,,both,,,88.67,57.64,,,,,,,,,,,,,
DRESSING NEG PRSS L35CM SYS PREVENA + PEEL AND PLC,SUP-2419100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
DIANEAL PD-2/2.5% DEXTROSE 396 MOSM/L IP SOLN,RX-15435,CDM,2580000003,HCPCS,0250,RC,00941-0413-01,NDC,,both,6000,ML,379.50,246.67,,,,,,,,,,,,,
GRAFT PASTE SYNTH CLLGN 1CC COPIOS BVF,SUP-2197451,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
BIT DRL 4X130 MM MIDFOOT FOR 4.0 HD COMPR SCR SS DISP,SUP-2609255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.11,436.22,,,,,,,,,,,,,
PLATE BNE L114MM THK3MM 6 H TI TIM R DST ANTLAT TIB LOK,SUP-2413679,CDM,C1713,HCPCS,0278,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
STENT URET RESONANCE L 26 CM CATH L 71.5 CM DIA 6 FR SHTH L,SUP-2171371,CDM,C2625,HCPCS,0278,RC,,,,both,,,766.03,497.92,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 10 CC DBM FIBER NEVOS,SUP-2762319,CDM,C1713,HCPCS,0278,RC,,,,both,,,2645.14,1719.34,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PARASPINAL UPR CUST THOR CTRL,SUP-2435692,CDM,L2670,HCPCS,0272,RC,,,,both,,,451.56,293.51,,,,,,,,,,,,,
GUIDEWIRE VASC STR 025X150 STIFF GLIDEWIRE ZIPWIRE,SUP-2140204,CDM,C1769,HCPCS,0272,RC,,,,both,,,154.86,100.66,,,,,,,,,,,,,
PROBE SNR L230CM DIA2.5MM OVL SPRL BRAID FIRM LOOP BEAMER AR,SUP-2166260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 0.062X9 IN RND END SS NS KIRSCHNER,SUP-2791259,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.60,5.59,,,,,,,,,,,,,
PLATE BNE L39MM 5 H S STL QTR TBLR MINI FRAG W/O CLLR,SUP-2186071,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.61,74.50,,,,,,,,,,,,,
BOLT ORTH CONCL 10-12 MM FOR FEM NAIL NS,SUP-2564349,CDM,C1713,HCPCS,0278,RC,,,,both,,,3328.49,2163.52,,,,,,,,,,,,,
BURR SURG 5.5MM DIA HD XLN MIC 10MML CARBIDE SM BNE OVL FLUT,SUP-2605580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,71.25,46.31,,,,,,,,,,,,,
ROD SPNL CRV 5.5X30 MM TITLE,SUP-2415475,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PLATE BONE 7 H FIBULAR STR FOR ANK FX GORILLA,SUP-2321558,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
WIRE FIX L600MM DIA1MM CERCLAGE S STL PRECUT SMOOTH W/,SUP-2186838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.88,222.22,,,,,,,,,,,,,
BRACE ORTHOPEDIC ANK,SUP-2112657,CDM,L1930,HCPCS,0274,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
POST EXT FIX 3 H M,SUP-2898632,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SHOE ROCKER SHRT MED PR,SUP-2459606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5150.57,3347.87,,,,,,,,,,,,,
BUTTERFLY WASHER 21.7MM TI,SUP-2818363,CDM,C1713,HCPCS,0278,RC,,,,both,,,1824.43,1185.88,,,,,,,,,,,,,
SPLINT WRST PADDED LG MTCRPL RT,SUP-2195719,CDM,L3809,HCPCS,0274,RC,,,,both,,,17.46,11.35,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSTAR XK CHRONIC STD 16FR DI 5883350,SUP-2632968,CDM,C1750,HCPCS,0278,RC,,,,both,,,1430.90,930.08,,,,,,,,,,,,,
KIT CVC 7FR POLYURETHAN CTRL VEN CATHETERS EXP,SUP-2214562,CDM,C1751,HCPCS,0278,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
BLOWER FLUID GAS MIX L165CM S STL SHFT MAL AND HNDPC,SUP-2282581,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BNE L36MM 7 H R CNDYL TI STR FOR 1.5MM SCR FIX MOD,SUP-2191170,CDM,C1713,HCPCS,0278,RC,,,,both,,,1472.85,957.35,,,,,,,,,,,,,
ABUTMENT OTO DIA9MM SND PROC DISP FOR PONTO SYS,SUP-2319873,CDM,L8690,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
PLATE BNE LCK 172 MM RT LAT PROX TIB 7 HOLE BRIDGE N CONTACT,SUP-2468693,CDM,C1713,HCPCS,0278,RC,,,,both,,,4036.28,2623.58,,,,,,,,,,,,,
CHISEL SURG EXTRACTION SHFT NS,SUP-2799545,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.42,988.92,,,,,,,,,,,,,
SHUNT CAR L30CM TBNG OD4X5MM ID2X3MM EAE SUNDT,SUP-2308227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2585.04,1680.28,,,,,,,,,,,,,
HC Trach Removal,PX-3600000037,CDM,3600000037,LOCAL,0360,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
GRAFT DERMAL RECT 9.8X15.7 IN ANTIBACT XENMATRIX AB,SUP-2855245,CDM,C1781,HCPCS,0278,RC,,,,both,,,105059.38,68288.60,,,,,,,,,,,,,
GRAFT BIO TISS W4XL4CM FET BOV DERM SLD PRIMATRIX AG,SUP-2243708,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2339.93,1520.95,,,,,,,,,,,,,
STEM HUM L125MM OD14MM UNIV TI POR SHLDR PRI CEM IMP,SUP-2404709,CDM,C1776,CPT,0278,RC,,,,both,,,14720.32,9568.21,,,,,,,,,,,,,
HALF PIN EXTRNL FXTN 3MM DIA SHRT 100MML STNLSS STEEL 25MML,SUP-2720657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
RELOAD STPL LD UNIT 30 MM 2 MM VASC TISS TRISTAPLE DISP,SUP-2283351,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER DRNGE 32FR 4 WNG DISP FOR NEPHSTMY MALECOTS,SUP-2128994,CDM,C1729,HCPCS,0272,RC,,,,both,,,77.31,50.25,,,,,,,,,,,,,
BRACE WR M AD FOR 6.75-7.75IN RT ADJ MALL STAY COCKUP LOOP,SUP-2197947,CDM,L3931,HCPCS,0272,RC,,,,both,,,46.63,30.31,,,,,,,,,,,,,
DEVICE VASC CLOSURE CELT ACD + L 15 CM LUMEN DIA2.4 MM SHTH,SUP-2931108,CDM,C1760,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
PIN EXT FIX L 275 MM DIA 5 MM SS TRANSFIXING UNILAT NS DISP,SUP-2931245,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.71,657.61,,,,,,,,,,,,,
Unlisted Laps Px Hrnap Herniorrhaphy Herniotomy,CASE-49659,LOCAL,49659,CPT,0360,RC,,,,outpatient,,,49022.45,29413.47,,,,,,,,,,,,,
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,LOCAL,43264,CPT,0360,RC,,,,outpatient,,,25821.43,15492.86,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT",CASE-28270,LOCAL,28270,CPT,,,,,XS|T6,outpatient,,,40956.73,24574.04,,,,,,,,,,,,,
"Open Treatment Metatarsal Fracture Each|RIGHT FOOT, FIFTH DIGIT",CASE-28485,LOCAL,28485,CPT,0360,RC,,,T9,outpatient,,,19549.83,11729.90,,,,,,,,,,,,,
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, THIRD DIGIT",CASE-28234,LOCAL,28234,CPT,,,,,T2,outpatient,,,11454.52,6872.71,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FOURTH DIGIT|PO",CASE-28232,LOCAL,28232,CPT,,,,,T3|PO,outpatient,,,21238.90,12743.34,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PO,CASE-20610,LOCAL,20610,CPT,0510,RC,,,RT|PO,outpatient,,,4501.68,2701.01,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, THUMB|PO",CASE-26525,LOCAL,26525,CPT,0360,RC,,,FA|PO,outpatient,,,10433.33,6260.00,,,,,,,,,,,,,
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,LOCAL,27792,CPT,,,,,RT,outpatient,,,33259.40,19955.64,,,,,,,,,,,,,
Ercp Remove Foreign Body/Stent Biliary/Panc Duct|SEPARATE STRUCTURE,CASE-43275,LOCAL,43275,CPT,,,,,XS,outpatient,,,27493.70,16496.22,,,,,,,,,,,,,
Biopsy Vaginal Mucosa Simple,CASE-57100,LOCAL,57100,CPT,,,,,,outpatient,,,17844.23,10706.54,,,,,,,,,,,,,
Arthroscopy Ankle Surgical Debridement Extensive|RIGHT SIDE|PO,CASE-29898,LOCAL,29898,CPT,,,,,RT|PO,outpatient,,,32164.05,19298.43,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|LEFT SIDE|PO,CASE-23430,LOCAL,23430,CPT,,,,,LT|PO,outpatient,,,40714.32,24428.59,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening|RIGHT SIDE|PO,CASE-25390,LOCAL,25390,CPT,0360,RC,,,RT|PO,outpatient,,,37299.03,22379.42,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450394501,SUP-2844115,CDM,C1713,HCPCS,0278,RC,,,,both,,,12721.77,8269.15,,,,,,,,,,,,,
PROSTHESIS 4MM DIAM 7MM LEN RND HD PLASTIPORE TORP CAUSSE,SUP-2312527,CDM,L8613,CPT,0278,RC,,,,both,,,568.40,369.46,,,,,,,,,,,,,
NAIL INTRAMEDULLARY DYNANAIL MINI L70 MM OD8 MM,SUP-2880114,CDM,C1713,HCPCS,0278,RC,,,,both,,,17788.10,11562.26,,,,,,,,,,,,,
IMPLANT FACE L 42 X W 41 MM THK 0.85 MM SCREW DIA 0.5 MM,SUP-2883452,CDM,C1713,HCPCS,0278,RC,,,,both,,,3210.52,2086.84,,,,,,,,,,,,,
HC Chemo Push Each Addt Drug,PX-3319641100,CDM,96411,CPT,0331,RC,,,,inpatient,,,432.00,280.80,,,,,,,,,,,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,0636,RC,63323-0064-23,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV 3FR 45CM 1 LUMAN RVRSE T 9173108,SUP-2632693,CDM,C1751,HCPCS,0278,RC,,,,both,,,647.72,421.02,,,,,,,,,,,,,
SCREW SPNL EXT TAB 12X50 MM SACROILIAC STRL SI-LOK SEL,SUP-2732365,CDM,C1713,HCPCS,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
HC So Pml/Rar Alpha Translocation,PX-3108131566,CDM,81315,CPT,0310,RC,,,,both,,,384.00,249.60,,,,,,,,,,,,,
"HC So Porphobilinogen,Urine Quant",PX-3018411066,CDM,84110,CPT,0301,RC,,,,both,,,646.00,419.90,,,,,,,,,,,,,
ARTHROSCOPE VID L 250 MM HF SHTH,SUP-2930423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1829.84,1189.40,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 5-8 MM EPTFE LNG TAPR TW,SUP-2669695,CDM,C1768,CPT,0278,RC,,,,both,,,2177.28,1415.23,,,,,,,,,,,,,
SYSTEM IMPL MENISCAL ROOT REPAIR W/SWIVELOCK,SUP-2731857,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
CONFORMER OPHTH SM W0.75XH0.22XL0.87IN PMMA HRD CLR PLAS H,SUP-2236381,CDM,L8610,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,LOCAL,43239,CPT,0360,RC,,,74,outpatient,,,14828.12,8896.87,,,,,,,,,,,,,
HC Removal Subcutaneous Cardiac Rhythm Monitor,CASE-33286,LOCAL,33286,CPT,0361,RC,,,,outpatient,,,34993.63,20996.18,,,,,,,,,,,,,
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|RIGHT SIDE,CASE-27680,LOCAL,27680,CPT,,,,,RT,outpatient,,,36064.92,21638.95,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|RIGHT SIDE,CASE-23430,LOCAL,23430,CPT,,,,,RT,outpatient,,,59392.75,35635.65,,,,,,,,,,,,,
Synovectomy Metatarsophalangeal Joint Each,CASE-28072,LOCAL,28072,CPT,,,,,,outpatient,,,23775.28,14265.17,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T9|PO|XU,outpatient,,,26381.72,15829.03,,,,,,,,,,,,,
Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>|LEFT SIDE,CASE-23073,LOCAL,23073,CPT,0360,RC,,,LT,outpatient,,,33501.53,20100.92,,,,,,,,,,,,,
Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt,CASE-26531,LOCAL,26531,CPT,,,,,,outpatient,,,24951.15,14970.69,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,LOCAL,64446,CPT,0360,RC,,,XU,outpatient,,,39959.50,23975.70,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|LEFT SIDE,CASE-19120,LOCAL,19120,CPT,0360,RC,,,LT,outpatient,,,19209.77,11525.86,,,,,,,,,,,,,
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, THIRD DIGIT|PO",CASE-26111,LOCAL,26111,CPT,,,,,F2|PO,outpatient,,,15971.02,9582.61,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28232,LOCAL,28232,CPT,0360,RC,,,T8|PO,outpatient,,,12145.77,7287.46,,,,,,,,,,,,,
PLATE BNE L72MM 4 H ST DST POSTEROLATERAL TIB S STL T SHP,SUP-2177707,CDM,C1713,HCPCS,0278,RC,,,,both,,,3072.65,1997.22,,,,,,,,,,,,,
RELOAD STPL L60MM EXTRA THCK REINF FOR SIGNIA STPLR,SUP-2283377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.06,1220.09,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE + L 135 CM 4.3 FR SLT 15 CM BALL,SUP-2752573,CDM,C1751,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER DRNGE 10FR L35CM GWIRE 0.038IN BILI FLEXIMA REG,SUP-2147832,CDM,C1729,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
IMPLANT OP RM LAPIDUS PLT 1MM STP PL,SUP-2321500,CDM,C1713,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
PLATE BONE NARROW MINI 3X3 HOLE TENSION MALLEABLE TITANIUM N,SUP-2837745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1496.84,972.95,,,,,,,,,,,,,
CLAMP CRAN TEXT 22 MM FLAPFIX FOR EXT FIX TI NS LF,SUP-2431406,CDM,C1713,HCPCS,0278,RC,,,,both,,,805.50,523.57,,,,,,,,,,,,,
BENDER ROD LT CORONAL PLANE,SUP-2232088,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2216.84,1440.95,,,,,,,,,,,,,
SET STONE EXTR L75CM EXPLORATION CATH 5.5FR L70CM 4W FOR,SUP-2167922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
NAIL INTRMDLLRY L340MM D11MM 125DG LNG RIGHT HIP TIMAX CNNLT,SUP-2475691,CDM,C1713,HCPCS,0278,RC,,,,both,,,6992.78,4545.31,,,,,,,,,,,,,
INSERT TIB TOP AUG REV VANGUARD 360,SUP-2448656,CDM,C1776,CPT,0278,RC,,,,both,,,2190.15,1423.60,,,,,,,,,,,,,
GRAFT EVAR L70MM DIA23X23MM C DST DSGN FOR ABD AORT ANEUR,SUP-2295270,CDM,C1768,CPT,0278,RC,,,,both,,,23471.50,15256.47,,,,,,,,,,,,,
PLATE 3.5MM TI CURVED NARROW LCP 16 HOLE-STERILE,SUP-2546921,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.09,1892.21,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-20610,LOCAL,20610,CPT,0510,RC,,,RT|73,outpatient,,,2422.33,1453.40,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm,CASE-11401,LOCAL,11401,CPT,,,,,,outpatient,,,22448.28,13468.97,,,,,,,,,,,,,
"Excision/Curettage Cyst/Tumor Phalanx Finger|RIGHT HAND, SECOND DIGIT|PO",CASE-26210,LOCAL,26210,CPT,0360,RC,,,F6|PO,outpatient,,,10788.45,6473.07,,,,,,,,,,,,,
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE|PO,CASE-27654,LOCAL,27654,CPT,,,,,RT|PO,outpatient,,,34921.98,20953.19,,,,,,,,,,,,,
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,LOCAL,93005,CPT,0730,RC,,,XU,outpatient,,,108706.73,65224.04,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|RIGHT SIDE|PO,CASE-29883,LOCAL,29883,CPT,0360,RC,,,RT|PO,outpatient,,,69267.08,41560.25,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THUMB|PO",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F5|PO,outpatient,,,10294.92,6176.95,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE|PO,CASE-29882,LOCAL,29882,CPT,0360,RC,,,RT|PO,outpatient,,,37790.18,22674.11,,,,,,,,,,,,,
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites,CASE-31625,LOCAL,31625,CPT,,,,,,outpatient,,,18592.38,11155.43,,,,,,,,,,,,,
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, FIFTH DIGIT",CASE-28234,LOCAL,28234,CPT,0360,RC,,,T4,outpatient,,,11454.52,6872.71,,,,,,,,,,,,,
Laparoscopy Proctopexy Prolapse,CASE-45400,LOCAL,45400,CPT,0360,RC,,,,outpatient,,,58571.82,35143.09,,,,,,,,,,,,,
CAGE SPNL H32MM DIA15MM ANT THORLUM TI RND MESH INTBDY FUS,SUP-2193225,CDM,C1889,HCPCS,0278,RC,,,,both,,,6940.81,4511.53,,,,,,,,,,,,,
TIP ASPIR 03MM 45DEG BEND INTERCHANGABLE HNDPC ULTRAFLOW,SUP-2110007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
HC Fecal Leukocytes,PX-3008905500,CDM,89055,CPT,0300,RC,,,,both,,,224.00,145.60,,,,,,,,,,,,,
SCREW SPNL L25MM OD8MM TI CANC ANT THORLUM PEDCL ST FIX ANG,SUP-2292731,CDM,C1713,HCPCS,0278,RC,,,,both,,,4736.69,3078.85,,,,,,,,,,,,,
GRAFT HUM TISS MIN W10MM WHL PAT LIG FRZN FLEXIGRFT,SUP-2264793,CDM,C1762,CPT,0278,RC,,,,both,,,11617.97,7551.68,,,,,,,,,,,,,
STRUT EXT FIX MOTR LNG,SUP-2479661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5908.22,3840.34,,,,,,,,,,,,,
FILTER ASPIR ABS DISP PSI TEC III LYSONIX +,SUP-2152207,CDM,C1880,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,LOCAL,25608,CPT,0360,RC,,,RT,outpatient,,,39858.32,23914.99,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,LOCAL,52005,CPT,,,,,50,outpatient,,,16162.92,9697.75,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE|PO,CASE-24359,LOCAL,24359,CPT,0360,RC,,,RT|PO,outpatient,,,18340.05,11004.03,,,,,,,,,,,,,
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx,CASE-29884,LOCAL,29884,CPT,,,,,,outpatient,,,26503.10,15901.86,,,,,,,,,,,,,
Hemiphalangectomy/Interphalangeal Joint Exc Toe,CASE-28160,LOCAL,28160,CPT,,,,,,outpatient,,,18082.22,10849.33,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|LEFT SIDE,CASE-29825,LOCAL,29825,CPT,,,,,LT,outpatient,,,23587.90,14152.74,,,,,,,,,,,,,
HC Tib per Territory Plasty|RIGHT SIDE,CASE-37228,LOCAL,37228,CPT,0361,RC,,,RT,outpatient,,,56431.38,33858.83,,,,,,,,,,,,,
Excision Tumor Soft Tis Foot/Toe Subq 1.5 Cm/>|RIGHT SIDE|PO,CASE-28039,LOCAL,28039,CPT,0360,RC,,,RT|PO,outpatient,,,13647.15,8188.29,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,LOCAL,28122,CPT,0360,RC,,,LT|XU,outpatient,,,19476.55,11685.93,,,,,,,,,,,,,
Nerve Repair W/Nerve Allograft First Strand|PO,CASE-64912,LOCAL,64912,CPT,,,,,PO,outpatient,,,29029.73,17417.84,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26735,LOCAL,26735,CPT,,,,,F1|PO,outpatient,,,23370.45,14022.27,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO|SEPARATE STRUCTURE,CASE-62323,LOCAL,62323,CPT,,,,,PO|XS,outpatient,,,5330.43,3198.26,,,,,,,,,,,,,
Thrmbc Opn Arven Fstl W/O Revj Dial Grf,CASE-36831,LOCAL,36831,CPT,0360,RC,,,,outpatient,,,73056.27,43833.76,,,,,,,,,,,,,
Arthrodesis Iphal Jt W/WO Int Fixj Ea Iphal Jt,CASE-26861,LOCAL,26861,CPT,,,,,,outpatient,,,18675.95,11205.57,,,,,,,,,,,,,
Arven Anast Opn Upr Arm Basilic Vein Trpos,CASE-36819,LOCAL,36819,CPT,0360,RC,,,,outpatient,,,37621.32,22572.79,,,,,,,,,,,,,
HC Renal Cyst Study Contrast S&I,PX-3207447000,CDM,74470,CPT,0320,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC So Fluor Anti Titer,PX-3028625666,CDM,86256,CPT,0302,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
PACEMAKER CARD PHILOS DR 2 CHMBR IS1 UPLR BPLR CONN DDDR,SUP-2137960,CDM,C1785,HCPCS,0275,RC,,,,both,,,9316.38,6055.65,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 88 MM DIA,SUP-2217557,CDM,C1768,CPT,0278,RC,,,,both,,,8933.30,5806.64,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 13 CM DIA11 GA S3,SUP-2930307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46465.22,30202.39,,,,,,,,,,,,,
KIT STRNL CLOSURE AUXILIARY CABLE PLATE STRL,SUP-2894345,CDM,C1713,HCPCS,0278,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
PLATE BNE L 163 X W 11.4 MM THK 3.5 MM SCREW DIA 3.5 MM 12 H 72464512N,SUP-2932863,CDM,C1713,HCPCS,0278,RC,,,,both,,,3567.04,2318.58,,,,,,,,,,,,,
PRE 20MM 035 GW STR BX10,SUP-2679398,CDM,C1769,HCPCS,0272,RC,,,,both,,,13509.41,8781.12,,,,,,,,,,,,,
KIT INTRO ELITE HV SHTH L 7 CM DIA 3 FR GUIDEWIRE L 40 CM,SUP-2615930,CDM,C1894,HCPCS,0272,RC,,,,both,,,96.05,62.43,,,,,,,,,,,,,
PLATE BNE HK 40 MM 5 HOLE,SUP-2865059,CDM,C1713,HCPCS,0278,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
HEAD FEM EXT 3- MM 10/12 22 MM HIP TAPR OXIN,SUP-2434565,CDM,C1776,CPT,0278,RC,,,,both,,,3654.96,2375.72,,,,,,,,,,,,,
GRAFT BNE SUB 3ML HA FAST SET PTTY FILL BNE VOID CA PHSPTE,SUP-2194285,CDM,C9359,HCPCS,0278,RC,,,,both,,,2837.30,1844.24,,,,,,,,,,,,,
Fasciotomy Foot&/Toe|LEFT SIDE|PO,CASE-28008,LOCAL,28008,CPT,0360,RC,,,LT|PO,outpatient,,,40088.18,24052.91,,,,,,,,,,,,,
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27654,LOCAL,27654,CPT,0360,RC,,,LT|PO|CG,outpatient,,,25385.63,15231.38,,,,,,,,,,,,,
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms|RIGHT SIDE,CASE-27696,LOCAL,27696,CPT,0360,RC,,,RT,outpatient,,,37793.42,22676.05,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvc/Le Init 2nd|LEFT SIDE,CASE-36246,LOCAL,36246,CPT,0361,RC,,,LT,outpatient,,,28040.95,16824.57,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-28308,LOCAL,28308,CPT,0360,RC,,,XS|LT|PO,outpatient,,,57075.62,34245.37,,,,,,,,,,,,,
Ostectomy Complete 1st Metatarsal Head,CASE-28111,LOCAL,28111,CPT,,,,,,outpatient,,,21914.20,13148.52,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn|PO,CASE-62321,LOCAL,62321,CPT,0360,RC,,,PO,outpatient,,,4735.78,2841.47,,,,,,,,,,,,,
GRAFT HUM TISS M PERF THN REGENERATIVE TISS MTRX CNTOUR,SUP-2113438,CDM,Q4116,HCPCS,0636,RC,,,,both,,,32122.20,20879.43,,,,,,,,,,,,,
PROBE SPNL STR ANTR COLORADO 2,SUP-2290554,CDM,C1713,HCPCS,0278,RC,,,,both,,,2819.72,1832.82,,,,,,,,,,,,,
GRAFT BNE CRUSH 10 CC PREHYDRATED PTTY CHIP DBM TENSIX,SUP-2477938,CDM,C1713,HCPCS,0278,RC,,,,both,,,8415.20,5469.88,,,,,,,,,,,,,
HC Stool Culture,PX-3008704500,CDM,87045,CPT,0300,RC,,,,both,,,260.00,169.00,,,,,,,,,,,,,
COMPONENT FEM KNEE OPT PC NXGN,SUP-2201155,CDM,C1776,CPT,0278,RC,,,,both,,,11101.47,7215.96,,,,,,,,,,,,,
INSERT TIB SZ 1 THICKNESS 11MM KNEE SL IMP MOST OPTIONS,SUP-2208281,CDM,C1776,CPT,0278,RC,,,,both,,,6415.02,4169.76,,,,,,,,,,,,,
CATHETER INTVASC OCCL ECLIPSE 2L BALLOON L 9 MM DIA 6 MM TIP,SUP-2895559,CDM,C2628,HCPCS,0272,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
PROBE ES L230CM CHN 3.7MM STR HEMSTAS REUSE HEATPRBS,SUP-2313013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1572.01,1021.81,,,,,,,,,,,,,
BLADE SURG W225XL105IN MATTE FINISH CNTR MAL S STL DIXON,SUP-2162005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.74,376.83,,,,,,,,,,,,,
DISSECTOR ENDOSCP MARYLAND 330 MM 29X10 MM CRV ROTO-CAM,SUP-2492560,CDM,C1713,HCPCS,0278,RC,,,,both,,,2585.16,1680.35,,,,,,,,,,,,,
ILLUMINATOR ELECTROCAUTERY RETRACTED L8IN EXT L11IN DYN,SUP-2247181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
GUIDE WIRE 1.1 MMX18 IN,SUP-2811392,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
Removal Implant Deep|LEFT SIDE,CASE-20680,LOCAL,20680,CPT,,,,,LT,outpatient,,,18251.88,10951.13,,,,,,,,,,,,,
Inguinofem Lmphadec Supfc W/Cloquets Node Spx|RIGHT SIDE,CASE-38760,LOCAL,38760,CPT,0360,RC,,,RT,outpatient,,,33296.82,19978.09,,,,,,,,,,,,,
Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT SIDE|PO,CASE-26111,LOCAL,26111,CPT,0360,RC,,,RT|PO,outpatient,,,8639.88,5183.93,,,,,,,,,,,,,
Thyroidectomy Total/Complete,CASE-60240,LOCAL,60240,CPT,,,,,,outpatient,,,48085.13,28851.08,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,LOCAL,28122,CPT,,,,,LT,outpatient,,,19620.12,11772.07,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|PO,CASE-11422,LOCAL,11422,CPT,,,,,PO,outpatient,,,11119.73,6671.84,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US|LEFT SIDE,CASE-20605,LOCAL,20605,CPT,0510,RC,,,LT,outpatient,,,5662.15,3397.29,,,,,,,,,,,,,
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE|PO,CASE-27698,LOCAL,27698,CPT,0360,RC,,,RT|PO,outpatient,,,38224.85,22934.91,,,,,,,,,,,,,
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,LOCAL,44970,CPT,,,,,XU,outpatient,,,32026.38,19215.83,,,,,,,,,,,,,
HC Extremity Venogram,CASE-36005,LOCAL,36005,CPT,0361,RC,,,,outpatient,,,20233.27,12139.96,,,,,,,,,,,,,
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,LOCAL,43264,CPT,,,,,,outpatient,,,25821.43,15492.86,,,,,,,,,,,,,
Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins|RIGHT SIDE|PO,CASE-25320,LOCAL,25320,CPT,,,,,RT|PO,outpatient,,,18142.28,10885.37,,,,,,,,,,,,,
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE|PO,CASE-64616,LOCAL,64616,CPT,,,,,50|PO,outpatient,,,6312.15,3787.29,,,,,,,,,,,,,
Open Biopsy/Excision Inguinofemoral Nodes|LEFT SIDE,CASE-38531,LOCAL,38531,CPT,,,,,LT,outpatient,,,33336.88,20002.13,,,,,,,,,,,,,
HC Inject Tendon Sheath Ligament,PX-3612055000,CDM,20550,CPT,0361,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
HC So Testosterone Total,PX-3018440366,CDM,84403,CPT,0301,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC DEMINERALIZED BONE MTRX ALLOCRAFT,SUP-2636996,CDM,C1713,HCPCS,0278,RC,,,,both,,,2627.55,1707.91,,,,,,,,,,,,,
IMPLANT OSS L4.75MM OD.5MM NIT FLROPLAS STAP PIST IMPLABLE,SUP-2312822,CDM,L8613,CPT,0278,RC,,,,both,,,799.10,519.41,,,,,,,,,,,,,
EXTERNAL FIXATION KIT DAMAGE CTRL FASTFRAME,SUP-2493135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7598.80,4939.22,,,,,,,,,,,,,
BLADE SURG FOR CAP FIX STRL,SUP-2424043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PROSTHESIS OSS TRL 4 MM TRL REPL SS PORP,SUP-2638069,CDM,L8613,CPT,0278,RC,,,,both,,,475.21,308.89,,,,,,,,,,,,,
POST FIX L35MM OD4.5MM TI KNEE SUT STRL FOR ACL PCL FIX SYS,SUP-2340693,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT FOOT, THIRD DIGIT",CASE-28270,LOCAL,28270,CPT,,,,,XU|T2,outpatient,,,27750.93,16650.56,,,,,,,,,,,,,
HC Rt Bronchoscopy Alveolar Lavage,CASE-31624,LOCAL,31624,CPT,0361,RC,,,,outpatient,,,20538.70,12323.22,,,,,,,,,,,,,
Repair Fibula Nonunion/Malunion W/Int Fixation|LEFT SIDE,CASE-27726,LOCAL,27726,CPT,,,,,LT,outpatient,,,40869.75,24521.85,,,,,,,,,,,,,
Hemiphalangectomy/Interphalangeal Joint Exc Toe,CASE-28160,LOCAL,28160,CPT,0360,RC,,,,outpatient,,,18082.22,10849.33,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F6,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
Excision Multiple External Papillae/Tags Anus,CASE-46230,LOCAL,46230,CPT,,,,,,outpatient,,,18879.13,11327.48,,,,,,,,,,,,,
Transurethral Waterjet Ablation Prostate Compl,CASE-0421T,LOCAL,0421T,CPT,0360,RC,,,,outpatient,,,42803.42,25682.05,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE,CASE-36245,LOCAL,36245,CPT,0361,RC,,,RT,outpatient,,,31024.60,18614.76,,,,,,,,,,,,,
Cysto/Pyeloscopy Rescj Pelvic Tumor|LEFT SIDE,CASE-52355,LOCAL,52355,CPT,,,,,LT,outpatient,,,25111.83,15067.10,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,LOCAL,52351,CPT,,,,,LT,outpatient,,,17316.98,10390.19,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,LOCAL,29824,CPT,,,,,RT,outpatient,,,42758.73,25655.24,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,LOCAL,49650,CPT,0360,RC,,,RT,outpatient,,,42379.33,25427.60,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,LOCAL,58661,CPT,,,,,,outpatient,,,27544.83,16526.90,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE|PO,CASE-29824,LOCAL,29824,CPT,,,,,RT|PO,outpatient,,,52209.17,31325.50,,,,,,,,,,,,,
"Open Tx Fracture Great Toe/Phalanx/Phalanges|LEFT FOOT, GREAT TOE",CASE-28505,LOCAL,28505,CPT,,,,,TA,outpatient,,,40869.75,24521.85,,,,,,,,,,,,,
COIL EMB L6CM DIA0.02IN LOOP DIA3MM COMPLX EXTRA SFT FILL,SUP-2323446,CDM,C1889,HCPCS,0278,RC,,,,both,,,6471.54,4206.50,,,,,,,,,,,,,
HC So Ggtp,PX-3018297766,CDM,82977,CPT,0301,RC,,,,inpatient,,,40.00,26.00,,,,,,,,,,,,,
DEFIBRILLATOR IMPL DYNAGEN MINI W 5.23 X H 7.03 CM D 0.99 CM,SUP-2149166,CDM,C1721,HCPCS,0275,RC,,,,both,,,34408.12,22365.28,,,,,,,,,,,,,
INSTRUMENT 28MM PINN AB IN TR 48,SUP-2514004,CDM,C1776,CPT,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 6 CM DIA 7 FR 2.5 CM 0.038 IN,SUP-2385190,CDM,C1894,HCPCS,0272,RC,,,,both,,,88.14,57.29,,,,,,,,,,,,,
ALLOGRAFT BNE FIBER LG CORTICAL INCITE,SUP-2538792,CDM,C1889,HCPCS,0278,RC,,,,both,,,7149.78,4647.36,,,,,,,,,,,,,
COLLAR CERV FIRM 3X21IN XL,SUP-2276594,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.69,4.35,,,,,,,,,,,,,
STENT CORONARY XIENCE PRIM L 11 MM DIA 3 MM COCR POLYMER,SUP-2106183,CDM,C1874,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
GRAFT HUMAN TSSUE EVANS WEDGE 2MMW X 22MML X 14MMH PRE SHPD,SUP-2573320,CDM,C1713,HCPCS,0278,RC,,,,both,,,2922.56,1899.66,,,,,,,,,,,,,
PUMP PAIN MGMT 400ML 4ML/HR 2 W/ SIL SOAK CATH FOR ABD,SUP-2236838,CDM,C9804,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE SPNL SM FOR LAMINOPLASTY FIX SYS NEWBRIDGE,SUP-2316050,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,LOCAL,64483,CPT,,,,,RT,outpatient,,,3987.63,2392.58,,,,,,,,,,,,,
"Inject Nerv Blck,Paravert Sympath|BILATERAL PROCEDURE|PO",CASE-64520,LOCAL,64520,CPT,,,,,50|PO,outpatient,,,5226.43,3135.86,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,LOCAL,24342,CPT,0360,RC,,,RT,outpatient,,,27644.07,16586.44,,,,,,,,,,,,,
Unlisted Procedure Abdomen Peritoneum & Omentum,CASE-49999,LOCAL,49999,CPT,0360,RC,,,,outpatient,,,78216.28,46929.77,,,,,,,,,,,,,
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE,CASE-28300,LOCAL,28300,CPT,0360,RC,,,RT,outpatient,,,57269.77,34361.86,,,,,,,,,,,,,
Repair Secondary Disrupted Ligament Ankle Coltrl|LEFT SIDE,CASE-27698,LOCAL,27698,CPT,0360,RC,,,LT,outpatient,,,102832.62,61699.57,,,,,,,,,,,,,
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, THIRD DIGIT|PO",CASE-28645,LOCAL,28645,CPT,0360,RC,,,T7|PO,outpatient,,,29334.38,17600.63,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,LOCAL,43239,CPT,0360,RC,,,XU,outpatient,,,11938.77,7163.26,,,,,,,,,,,,,
Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>|RIGHT SIDE,CASE-23073,LOCAL,23073,CPT,,,,,RT,outpatient,,,25669.90,15401.94,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE,CASE-19120,LOCAL,19120,CPT,0360,RC,,,RT,outpatient,,,16668.48,10001.09,,,,,,,,,,,,,
HC Rm Private Oncology,PX-1170000000,CDM,1170000000,LOCAL,,,,,,outpatient,,,4022.42,2413.45,,,,,,,,,,,,,
Excision Lesion Tendon Sheath/Capsule Leg&/Ank|RIGHT SIDE,CASE-27630,LOCAL,27630,CPT,,,,,RT,outpatient,,,24787.32,14872.39,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,LOCAL,64491,CPT,0360,RC,,,,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE|PO,CASE-64493,LOCAL,64493,CPT,,,,,50|PO,outpatient,,,4412.95,2647.77,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE|PO,CASE-29828,LOCAL,29828,CPT,,,,,RT|PO,outpatient,,,52209.17,31325.50,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Mtcarphlngl Joint Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26520,LOCAL,26520,CPT,,,,,F8|PO,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE|PO,CASE-29888,LOCAL,29888,CPT,,,,,LT|PO,outpatient,,,56524.38,33914.63,,,,,,,,,,,,,
Cystourethroscopy With Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52204,LOCAL,52204,CPT,0360,RC,,,XU,outpatient,,,30801.07,18480.64,,,,,,,,,,,,,
Excision/Curettage Bone Cyst/Tumor Tibia/Fibula|SEPARATE STRUCTURE|RIGHT SIDE,CASE-27635,LOCAL,27635,CPT,0360,RC,,,XS|RT,outpatient,,,36064.92,21638.95,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|LEFT SIDE|PO,CASE-25111,LOCAL,25111,CPT,,,,,LT|PO,outpatient,,,11617.85,6970.71,,,,,,,,,,,,,
SUTURE ARTHSCP 90 DEG STR SUTSNARE,SUP-2121952,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
DEFIBRILLATOR CARD 66GM 31CC W51XH68MM THK12MM DF1 IS1 CONN,SUP-2356266,CDM,C1722,HCPCS,0275,RC,,,,both,,,36245.02,23559.26,,,,,,,,,,,,,
CATHETER DRNGE 14FR L35CM DIA4.7MM STD LOOP TIP MULTPURP,SUP-2118775,CDM,C1729,HCPCS,0272,RC,,,,both,,,256.16,166.50,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.521,SUP-2860038,CDM,C1713,HCPCS,0278,RC,,,,both,,,38045.18,24729.37,,,,,,,,,,,,,
ENALAPRILAT 1.25 MG/ML IV SOLN,RX-169136,CDM,2500000003,HCPCS,0250,RC,00143-9786-10,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 75 CM DIA 5 FR BALLOON L 4 CM DIA 5 MM,SUP-2139601,CDM,C1725,HCPCS,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
SET INTRO SKATER SHTH L 18 CM DIA 6 FR DIL 4FR NIT PLAT COAX,SUP-2120118,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
MICROCATHETER INFUSION MAGIC L 165 CM DSTL TIP DIA1.8 FR,SUP-2717637,CDM,C1887,HCPCS,0272,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,LOCAL,52351,CPT,,,,,,outpatient,,,37858.80,22715.28,,,,,,,,,,,,,
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,LOCAL,38571,CPT,,,,,,outpatient,,,107159.30,64295.58,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|LEFT FOOT, SECOND DIGIT|PO",CASE-28124,LOCAL,28124,CPT,0360,RC,,,T1|PO,outpatient,,,56989.27,34193.56,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,LOCAL,38900,CPT,0360,RC,,,,outpatient,,,43563.10,26137.86,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid|BILATERAL PROCEDURE|PO,CASE-15822,LOCAL,15822,CPT,0360,RC,,,50|PO,outpatient,,,36460.77,21876.46,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm|PO,CASE-11404,LOCAL,11404,CPT,,,,,PO,outpatient,,,11027.47,6616.48,,,,,,,,,,,,,
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE|PO,CASE-25607,LOCAL,25607,CPT,0360,RC,,,RT|PO,outpatient,,,31155.25,18693.15,,,,,,,,,,,,,
"Inject Nerv Blck,Paravert Sympath|BILATERAL PROCEDURE|PO",CASE-64520,LOCAL,64520,CPT,0360,RC,,,50|PO,outpatient,,,5226.43,3135.86,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64415,LOCAL,64415,CPT,0360,RC,,,XS|RT|PO,outpatient,,,62063.32,37237.99,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,LOCAL,64491,CPT,0360,RC,,,RT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE|PO,CASE-29846,LOCAL,29846,CPT,0360,RC,,,LT|PO,outpatient,,,28093.25,16855.95,,,,,,,,,,,,,
Sling Opration Corrj Male Urinary Incontinence,CASE-53440,LOCAL,53440,CPT,,,,,,outpatient,,,64755.07,38853.04,,,,,,,,,,,,,
Open Biopsy/Excision Inguinofemoral Nodes|LEFT SIDE,CASE-38531,LOCAL,38531,CPT,0360,RC,,,LT,outpatient,,,33336.88,20002.13,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,LOCAL,52356,CPT,0360,RC,,,50,outpatient,,,44452.18,26671.31,,,,,,,,,,,,,
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, SECOND DIGIT|PO",CASE-28645,LOCAL,28645,CPT,0360,RC,,,T6|PO,outpatient,,,29334.38,17600.63,,,,,,,,,,,,,
Open Treatment Medial Malleolus Fracture|RIGHT SIDE,CASE-27766,LOCAL,27766,CPT,0360,RC,,,RT,outpatient,,,84455.38,50673.23,,,,,,,,,,,,,
Removal Intrauterine Device Iud,CASE-58301,LOCAL,58301,CPT,0360,RC,,,,outpatient,,,19280.30,11568.18,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE,CASE-27695,LOCAL,27695,CPT,,,,,RT,outpatient,,,36064.92,21638.95,,,,,,,,,,,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,0636,RC,44206-0310-25,NDC,,both,250,ML,517.50,336.37,,,,,,,,,,,,,
PLATE SPINE 2 LEV LORDOSED TRANSITION 24MM,SUP-2230030,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X222X2.5 MM 32 HOLE ANGLED-ANGLED LCK,SUP-2477341,CDM,C1713,HCPCS,0278,RC,,,,both,,,7227.59,4697.93,,,,,,,,,,,,,
JOINT WRST 1 4+ MM CRPL UHMWPE FRDM,SUP-2851950,CDM,C1776,CPT,0278,RC,,,,both,,,4178.52,2716.04,,,,,,,,,,,,,
BENDER SURG LG STRL DISP MOTOBAND CP,SUP-2893314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
STENT BILI L 40 MM DIA 7 MM TRNSHEP STRL,SUP-2158580,CDM,C1876,HCPCS,0278,RC,,,,both,,,4132.24,2685.96,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST W/ADJ STP SINGLE UPR,SUP-2435627,CDM,L1920,HCPCS,0274,RC,,,,both,,,1163.06,755.99,,,,,,,,,,,,,
NATURAL-HIP STEM CALC REPL SZ 1/10MM,SUP-2210886,CDM,C1776,CPT,0278,RC,,,,both,,,13695.11,8901.82,,,,,,,,,,,,,
KIT PORTACATH PERI IMP ACCS SYS,SUP-2351828,CDM,C1894,HCPCS,0272,RC,,,,both,,,1093.98,711.09,,,,,,,,,,,,,
CATHETER CARD ABLATION CELSIUS FLTR L 115 CM 7.5 FR TIP 4 MM,SUP-2248636,CDM,C1733,HCPCS,0272,RC,,,,both,,,2615.62,1700.15,,,,,,,,,,,,,
SYSTEM ICD CRT HF-T W/ HOME MON LUMAX 340,SUP-2138124,CDM,C1722,HCPCS,0275,RC,,,,both,,,59663.55,38781.31,,,,,,,,,,,,,
COLLAR EXTRIC 1 PC RIG INF PERFIT,SUP-2389135,CDM,L0190,HCPCS,0272,RC,,,,both,,,18.81,12.23,,,,,,,,,,,,,
CATHETER DRNGE 16FR L40CM GWIRE 0.038IN 6 SIDEPRT STD,SUP-2168760,CDM,C1729,HCPCS,0272,RC,,,,both,,,263.16,171.05,,,,,,,,,,,,,
ROD EXT FIX STR LNG 4X325 MM CRANIOMAXILLOFACIAL TI LEVEL 1,SUP-2490236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2576.90,1674.98,,,,,,,,,,,,,
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE|PO,CASE-27698,LOCAL,27698,CPT,,,,,RT|PO,outpatient,,,38224.85,22934.91,,,,,,,,,,,,,
Mastectomy Partial|RIGHT SIDE,CASE-19301,LOCAL,19301,CPT,,,,,RT,outpatient,,,35850.68,21510.41,,,,,,,,,,,,,
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt,CASE-28291,LOCAL,28291,CPT,,,,,,outpatient,,,26259.73,15755.84,,,,,,,,,,,,,
Open Treatment of Ulnar Shaft Fracture|RIGHT SIDE|PO,CASE-25545,LOCAL,25545,CPT,0360,RC,,,RT|PO,outpatient,,,35323.03,21193.82,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT|PO",CASE-26735,LOCAL,26735,CPT,,,,,F3|PO,outpatient,,,20553.30,12331.98,,,,,,,,,,,,,
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO|SEPARATE STRUCTURE,CASE-14040,LOCAL,14040,CPT,0360,RC,,,PO|XS,outpatient,,,21355.03,12813.02,,,,,,,,,,,,,
HC Vasc Embolize Occlude Artery,CASE-37242,LOCAL,37242,CPT,0361,RC,,,,outpatient,,,58589.22,35153.53,,,,,,,,,,,,,
Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,CASE-58571,LOCAL,58571,CPT,0360,RC,,,,outpatient,,,65813.80,39488.28,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,LOCAL,28122,CPT,0360,RC,,,LT,outpatient,,,19620.12,11772.07,,,,,,,,,,,,,
Partial Excision Bone Tibia|RIGHT SIDE,CASE-27640,LOCAL,27640,CPT,0360,RC,,,RT,outpatient,,,32572.72,19543.63,,,,,,,,,,,,,
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea,CASE-28465,LOCAL,28465,CPT,0360,RC,,,,outpatient,,,39583.60,23750.16,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT|PO",CASE-26735,LOCAL,26735,CPT,0360,RC,,,F3|PO,outpatient,,,20553.30,12331.98,,,,,,,,,,,,,
Prostate Needle Biopsy Any Approach,CASE-55700,LOCAL,55700,CPT,0360,RC,,,,outpatient,,,19624.37,11774.62,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|SEPARATE STRUCTURE|PO,CASE-62323,LOCAL,62323,CPT,,,,,XS|PO,outpatient,,,6176.18,3705.71,,,,,,,,,,,,,
Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-34421,LOCAL,34421,CPT,0360,RC,,,74,outpatient,,,68578.52,41147.11,,,,,,,,,,,,,
Plmt Interstitial Dev Radiat Tx Prostate 1/Mult,CASE-55876,LOCAL,55876,CPT,,,,,,outpatient,,,13437.03,8062.22,,,,,,,,,,,,,
Revasc lithotrip tibi/perone|LEFT SIDE,CASE-C9772,LOCAL,C9772,CPT,0360,RC,,,LT,outpatient,,,71722.93,43033.76,,,,,,,,,,,,,
BOUGIE SURG 36FR TIP L12MM SIL HURST BLNT TIP ULT FLX,SUP-2277387,CDM,C1726,HCPCS,0272,RC,,,,both,,,576.50,374.72,,,,,,,,,,,,,
CATHETER CV DL 6 FR TY W/ MICROINTRODUCER POWERPICC SOLO 2,SUP-2126390,CDM,C1751,HCPCS,0278,RC,,,,both,,,404.37,262.84,,,,,,,,,,,,,
MESH HERN XL W5XL7IN L INGUINAL POLYPR REP CRV SHP SEAL,SUP-2125773,CDM,C1781,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
SCREW INTRF BIO ABSORBABLE 9X22.5 MM KNEE CANN THRD WEDGED,SUP-2608089,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.59,356.58,,,,,,,,,,,,,
CROWN DENT REST M SEC UP LT SZ DUL6 S STL PERM AD,SUP-2322207,CDM,D6783,CPT,0278,RC,,,,both,,,41.13,26.73,,,,,,,,,,,,,
BLADE SAW W7MM CASPR FOR TPS,SUP-2363306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
SCREW BNE SCHNZ 6X250 MM SD HA STRL,SUP-2563702,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.99,312.64,,,,,,,,,,,,,
ANCHOR SUTURE STRL SUTURELOC,SUP-2882171,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SCREW IM NAIL L65MM DIA5MM CALCNL TI THRD HD FOR ANK COMPR,SUP-2316351,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.55,554.81,,,,,,,,,,,,,
ROPINIROLE HCL 0.25 MG PO TABS,RX-21688,CDM,6370000000,HCPCS,0637,RC,00904-6373-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLUG VASC MED 8 MM AZUR,SUP-2853096,CDM,C1889,HCPCS,0278,RC,,,,both,,,6790.25,4413.66,,,,,,,,,,,,,
ANCHOR SUT DIA18MM DBL LD TWO STRND NO2 HI FI Y KNOT,SUP-2167264,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE,CASE-29828,LOCAL,29828,CPT,0360,RC,,,RT,outpatient,,,47018.13,28210.88,,,,,,,,,,,,,
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,LOCAL,45390,CPT,0360,RC,,,XU|PT,outpatient,,,11886.77,7132.06,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T6,outpatient,,,40956.73,24574.04,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE|PO,CASE-64493,LOCAL,64493,CPT,0360,RC,,,LT|PO,outpatient,,,4102.47,2461.48,,,,,,,,,,,,,
Rmvl/Revj Sling Male Urinary Incontinence,CASE-53442,LOCAL,53442,CPT,,,,,,outpatient,,,35272.90,21163.74,,,,,,,,,,,,,
"Synovectomy Metatarsophalangeal Joint Each|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-28072,LOCAL,28072,CPT,0360,RC,,,XS|T5|PO,outpatient,,,23775.28,14265.17,,,,,,,,,,,,,
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy,CASE-27675,LOCAL,27675,CPT,,,,,,outpatient,,,38224.85,22934.91,,,,,,,,,,,,,
Capsulectomy/Capsulotomy Mtcarphlngl Joint Each,CASE-26520,LOCAL,26520,CPT,0360,RC,,,,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
Carpectomy All Bones Proximal Row|LEFT SIDE|PO,CASE-25215,LOCAL,25215,CPT,0360,RC,,,LT|PO,outpatient,,,21219.00,12731.40,,,,,,,,,,,,,
Grafting of Autologous Fat by Lipo 50 Cc or Less,CASE-15771,LOCAL,15771,CPT,,,,,,outpatient,,,78216.28,46929.77,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<|PO,CASE-11420,LOCAL,11420,CPT,0360,RC,,,PO,outpatient,,,8985.38,5391.23,,,,,,,,,,,,,
Colonoscopy Stoma Dx Including Collj Spec Spx,CASE-44388,LOCAL,44388,CPT,,,,,,outpatient,,,9519.78,5711.87,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, THIRD DIGIT|PO",CASE-28270,LOCAL,28270,CPT,,,,,XS|T2|PO,outpatient,,,27333.98,16400.39,,,,,,,,,,,,,
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE,CASE-29891,LOCAL,29891,CPT,,,,,LT,outpatient,,,42163.30,25297.98,,,,,,,,,,,,,
Repair Complex Trunk 1.1-2.5 Cm,CASE-13100,LOCAL,13100,CPT,0360,RC,,,,outpatient,,,35089.77,21053.86,,,,,,,,,,,,,
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-133690,CDM,J1815,HCPCS,0636,RC,00002-8824-27,NDC,,both,3,ML,229.70,149.30,,,,,,,,,,,,,
CATHETER EVD L35CM LUMN ID1.5MM DEPTH MRK 3-15CM FOR EXT,SUP-2249015,CDM,C1729,HCPCS,0272,RC,,,,both,,,2098.05,1363.73,,,,,,,,,,,,,
IMMOBILIZER KNEE PERF FOAM 12 IN T BAR ADJ MEDL BLK CUTAWAY,SUP-2336323,CDM,L1830,CPT,0274,RC,,,,both,,,43.93,28.55,,,,,,,,,,,,,
SHEATH INTRO SUREFLEX L 72 CM DIA 8.5 FR DSTL CRV DIA 50 MM,SUP-2131523,CDM,C1766,CPT,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5 MM 5 HOLE CONTOURED 2 COMPR RECON,SUP-2466320,CDM,C1713,HCPCS,0278,RC,,,,both,,,1159.16,753.45,,,,,,,,,,,,,
CMPLT MICROTIA TEMPLATE SET MOD 59LT PA,SUP-2682131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4461.81,2900.18,,,,,,,,,,,,,
SEALER VES DIA8MM ENDOWRIST DA VINCI SI,SUP-2246595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
ADAPTER FEM SZ E DIA50-52MM UHMWPE CONSTRN REFLCT,SUP-2344634,CDM,C1776,CPT,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,LOCAL,53445,CPT,,,,,,outpatient,,,107642.93,64585.76,,,,,,,,,,,,,
Open Treatment of Ulnar Shaft Fracture,CASE-25545,LOCAL,25545,CPT,,,,,,outpatient,,,33527.12,20116.27,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,LOCAL,G0260,CPT,0360,RC,,,50,outpatient,,,4421.95,2653.17,,,,,,,,,,,,,
Sling Opration Corrj Male Urinary Incontinence,CASE-53440,LOCAL,53440,CPT,0360,RC,,,,outpatient,,,64755.07,38853.04,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,LOCAL,52332,CPT,,,,,50|XU,outpatient,,,23949.20,14369.52,,,,,,,,,,,,,
Sigmoidoscopy Flx Placement of Endoscopic Stent,CASE-45347,LOCAL,45347,CPT,,,,,,outpatient,,,29423.87,17654.32,,,,,,,,,,,,,
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE|POLICY CRITERIA APPLIED,CASE-27570,LOCAL,27570,CPT,0360,RC,,,RT|CG,outpatient,,,12213.62,7328.17,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvc/Le Init 2nd|RIGHT SIDE,CASE-36246,LOCAL,36246,CPT,0361,RC,,,RT,outpatient,,,44899.22,26939.53,,,,,,,,,,,,,
Arthrodesis Subtalar|LEFT SIDE|PO,CASE-28725,LOCAL,28725,CPT,0360,RC,,,LT|PO,outpatient,,,72961.50,43776.90,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0258,RC,00990-7983-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
COIL NEUROVASCULAR DELTAFILL 18 L 42 CM DIA12 MM PRIMARY DIA,SUP-2518798,CDM,C1889,HCPCS,0278,RC,,,,both,,,10687.99,6947.19,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.8X980 MM,SUP-2646016,CDM,C1769,HCPCS,0272,RC,,,,both,,,742.61,482.70,,,,,,,,,,,,,
HC So Fungus ID Yeast,PX-3008710666,CDM,87106,CPT,0300,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
PLATE BONE W9XL73MM THK1.1MM 6 H DSTL ULN FIBULAR S STL 1/3,SUP-2343777,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.93,386.05,,,,,,,,,,,,,
BASKET STONE ERCP 4W FLOWER BSKT ROT 22 MMX195 CM,SUP-2313154,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28285,LOCAL,28285,CPT,,,,,T8|PO,outpatient,,,22059.40,13235.64,,,,,,,,,,,,,
Curtg/Caut Anal Fissure W/Dilat Sphnctr Spx 1st,CASE-46940,LOCAL,46940,CPT,0360,RC,,,,outpatient,,,11531.65,6918.99,,,,,,,,,,,,,
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,LOCAL,30520,CPT,,,,,,outpatient,,,20894.78,12536.87,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,LOCAL,29882,CPT,,,,,LT,outpatient,,,29992.30,17995.38,,,,,,,,,,,,,
HC Rem Central Venous Cath,CASE-36589,LOCAL,36589,CPT,0361,RC,,,,outpatient,,,12607.50,7564.50,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|PO",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F9|PO,outpatient,,,8208.63,4925.18,,,,,,,,,,,,,
HC Revasc Intravasc Lithotripsy,CASE-C9764,LOCAL,C9764,CPT,0481,RC,,,,outpatient,,,98975.00,59385.00,,,,,,,,,,,,,
Colsc Flx With Directed Submucosal Njx Any Sbst|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45381,LOCAL,45381,CPT,0360,RC,,,XU,outpatient,,,17031.87,10219.12,,,,,,,,,,,,,
Repair Brow Ptosis|BILATERAL PROCEDURE|PO,CASE-67900,LOCAL,67900,CPT,,,,,50|PO,outpatient,,,61605.28,36963.17,,,,,,,,,,,,,
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea,CASE-43277,LOCAL,43277,CPT,,,,,,outpatient,,,41987.65,25192.59,,,,,,,,,,,,,
Lig/Banding Angioaccess Arteriovenous Fistula,CASE-37607,LOCAL,37607,CPT,0360,RC,,,,outpatient,,,35362.92,21217.75,,,,,,,,,,,,,
Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins|LEFT SIDE|PO,CASE-25320,LOCAL,25320,CPT,,,,,LT|PO,outpatient,,,39268.60,23561.16,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB|PO",CASE-26160,LOCAL,26160,CPT,,,,,F5|PO,outpatient,,,12467.95,7480.77,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, THIRD DIGIT|PO",CASE-26123,LOCAL,26123,CPT,0360,RC,,,F2|PO,outpatient,,,13228.23,7936.94,,,,,,,,,,,,,
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO,CASE-27654,LOCAL,27654,CPT,,,,,LT|PO,outpatient,,,36741.33,22044.80,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB|PO",CASE-26160,LOCAL,26160,CPT,,,,,FA|PO,outpatient,,,8780.85,5268.51,,,,,,,,,,,,,
Brnchsc Brushing/Protected Brushings,CASE-31623,LOCAL,31623,CPT,,,,,,outpatient,,,22274.95,13364.97,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T2,outpatient,,,27750.93,16650.56,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,LOCAL,52353,CPT,,,,,RT,outpatient,,,24146.30,14487.78,,,,,,,,,,,,,
Laparoscopy Nephrectomy W/Partial Ureterect,CASE-50546,LOCAL,50546,CPT,0360,RC,,,,outpatient,,,97230.95,58338.57,,,,,,,,,,,,,
Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc,CASE-34421,LOCAL,34421,CPT,0360,RC,,,,outpatient,,,68578.52,41147.11,,,,,,,,,,,,,
SET TB L3M HI PRSS DISP KAIRISON,SUP-2108506,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.72,353.42,,,,,,,,,,,,,
CAPTOPRIL 12.5 MG PO TABS,RX-9401,CDM,6370000000,HCPCS,0637,RC,60687-0304-11,NDC,,both,1,UN,6.40,4.16,,,,,,,,,,,,,
SCREW BNE PEGGED 2.5X26 MM THRD MULTIDIRECTIONAL NS,SUP-2861096,CDM,C1713,HCPCS,0278,RC,,,,both,,,446.32,290.11,,,,,,,,,,,,,
ANCHOR SUTURE 2.8 MM DIAMETER BROACHING Y-KNOT RC,SUP-2828687,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.79,604.36,,,,,,,,,,,,,
GRAFT VASC HEMSHLD L 50 CM DIA 30 MM BRANCH SZ 10/10/8/8 MM,SUP-2669856,CDM,C1768,CPT,0278,RC,,,,both,,,5382.53,3498.64,,,,,,,,,,,,,
SCREW BONE L20MM KNEE TIB M/G,SUP-2200344,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.51,409.83,,,,,,,,,,,,,
PLATE BNE L51MM +90DEG 2X5 H NONSTERILE DST DORS RAD TI L,SUP-2190199,CDM,C1713,HCPCS,0278,RC,,,,both,,,2218.28,1441.88,,,,,,,,,,,,,
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27695,LOCAL,27695,CPT,0360,RC,,,LT|XU,outpatient,,,45301.70,27181.02,,,,,,,,,,,,,
Ostectomy Complete 1st Metatarsal Head,CASE-28111,LOCAL,28111,CPT,0360,RC,,,,outpatient,,,21914.20,13148.52,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization,CASE-52005,LOCAL,52005,CPT,,,,,,outpatient,,,15930.88,9558.53,,,,,,,,,,,,,
Implant Neurostim/Receiver,CASE-64590,LOCAL,64590,CPT,,,,,,outpatient,,,59446.15,35667.69,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|PO,CASE-64634,LOCAL,64634,CPT,0360,RC,,,PO,outpatient,,,12094.77,7256.86,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|PO,CASE-28122,LOCAL,28122,CPT,0360,RC,,,RT|PO,outpatient,,,18198.27,10918.96,,,,,,,,,,,,,
Debridement Bone Each Additional 20 Sq Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-11047,LOCAL,11047,CPT,0360,RC,,,XU,outpatient,,,29271.23,17562.74,,,,,,,,,,,,,
Optx Greater Humeral Tuberosity Fx W/Int Fixj,CASE-23630,LOCAL,23630,CPT,0360,RC,,,,outpatient,,,57059.65,34235.79,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,RT|XU,outpatient,,,5650.45,3390.27,,,,,,,,,,,,,
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26125,LOCAL,26125,CPT,0360,RC,,,F9|PO,outpatient,,,16206.85,9724.11,,,,,,,,,,,,,
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,LOCAL,50543,CPT,0360,RC,,,LT,outpatient,,,88882.22,53329.33,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,LOCAL,G0260,CPT,,,,,RT,outpatient,,,4422.92,2653.75,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,LOCAL,24342,CPT,0360,RC,,,LT,outpatient,,,25187.08,15112.25,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, SECOND DIGIT|PO",CASE-26860,LOCAL,26860,CPT,0360,RC,,,F1|PO,outpatient,,,19353.77,11612.26,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,LOCAL,49507,CPT,,,,,RT,outpatient,,,24997.20,14998.32,,,,,,,,,,,,,
HC ED Closed Tx Mtp Dislocation,PX-4502863000,CDM,28630,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE VOLAR WIDE RT DSTL RADIAL VOLAR 3 HOLE NS,SUP-2464207,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 6 FR E CRV,SUP-2148873,CDM,C1732,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT DURA W2XL2IN WHT ABSRB POR NONFRIABLE DBL PEEL CLLGN,SUP-2244082,CDM,C1763,HCPCS,0278,RC,,,,both,,,770.15,500.60,,,,,,,,,,,,,
STENT BILI L38MM DIA7MM CATH L135CM 0.018IN S STEELXCELON,SUP-2101524,CDM,C1876,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
"HC Phlebotomy,Tx",PX-9409919500,CDM,99195,CPT,0940,RC,,,,outpatient,,,330.00,214.50,,,,,,,,,,,,,
LINER ACET SZ DMI OD58MM ID28MM ORNG DBL MOBILITY HIGHCROSS,SUP-2267322,CDM,C1776,CPT,0278,RC,,,,both,,,4547.98,2956.19,,,,,,,,,,,,,
STENT COR 12MM 3MM DEL SYS 145CM 0.014IN CO CHROM,SUP-2105452,CDM,C1874,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
CATHETER GUID MERCI V 2.0 L 180 CM BALLOON L 5 MM DIA2 MM SS,SUP-2367776,CDM,C1773,HCPCS,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
SCREW INTFR L20MM DIA7MM KNEE TI RND BIOABSRB BLNT THRD,SUP-2341569,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
TAP SURG SCR SLD BONE SPNL CLR CODE 3.7MM DYNALOK,SUP-2290320,CDM,C1713,HCPCS,0278,RC,,,,both,,,1589.53,1033.19,,,,,,,,,,,,,
CATHETER ANGIO 4FR 65CM .035IN,SUP-2117140,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
SET PICC L 15 CM DIA 4.5 FR SHTH L 7 CM DIA 4.5 FR,SUP-2887023,CDM,C1751,HCPCS,0278,RC,,,,both,,,525.64,341.67,,,,,,,,,,,,,
PLATE BNE L211MM 14 H NONSTERILE R LAT PROX TIB S STL LOK,SUP-2185622,CDM,C1713,HCPCS,0278,RC,,,,both,,,4013.67,2608.89,,,,,,,,,,,,,
CASE GRFT ENDURANT II NIT POLYESTER 2PC STRL,SUP-2873744,CDM,C1768,CPT,0278,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
HC Surgery Level 6 Addtl 15min,PX-3600000016,CDM,3600000016,LOCAL,0360,RC,,,,both,,,4961.00,3224.65,,,,,,,,,,,,,
PLATE BNE L52MM 7 H T SHP MINUS NCB,SUP-2411489,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.82,843.58,,,,,,,,,,,,,
HYSTEROSCOPE RIGID STRL DISP AVETA OPAL,SUP-2914750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SHUNT PRUITT CAR OUTLYING@,SUP-2264206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1943.66,1263.38,,,,,,,,,,,,,
BUR SURG DIA2.3 MM HUB II NEURO CUT STRL DISP HI-LINE XS,SUP-2929005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.49,223.92,,,,,,,,,,,,,
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, SECOND DIGIT|PO",CASE-26440,LOCAL,26440,CPT,,,,,F6|PO,outpatient,,,10622.82,6373.69,,,,,,,,,,,,,
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE,CASE-28322,LOCAL,28322,CPT,0360,RC,,,LT,outpatient,,,41782.87,25069.72,,,,,,,,,,,,,
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE,CASE-27619,LOCAL,27619,CPT,,,,,LT,outpatient,,,33361.07,20016.64,,,,,,,,,,,,,
Removal Non-Biodegradable Drug Delivery Implant|LEFT SIDE,CASE-11982,LOCAL,11982,CPT,0360,RC,,,LT,outpatient,,,53743.52,32246.11,,,,,,,,,,,,,
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|LEFT SIDE|PO,CASE-28730,LOCAL,28730,CPT,,,,,LT|PO,outpatient,,,76940.20,46164.12,,,,,,,,,,,,,
Suture Infrapatellar Tendon Primary|LEFT SIDE,CASE-27380,LOCAL,27380,CPT,0360,RC,,,LT,outpatient,,,34938.87,20963.32,,,,,,,,,,,,,
Thoracoscopy W/Exc Mediastinal Cyst Tumor/Mass,CASE-32662,LOCAL,32662,CPT,,,,,,outpatient,,,96443.17,57865.90,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,LOCAL,29826,CPT,,,,,RT,outpatient,,,45202.47,27121.48,,,,,,,,,,,,,
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, THIRD DIGIT|PO",CASE-26531,LOCAL,26531,CPT,,,,,F2|PO,outpatient,,,19127.25,11476.35,,,,,,,,,,,,,
Repair Secondary Disrupted Ligament Ankle Coltrl|LEFT SIDE,CASE-27698,LOCAL,27698,CPT,,,,,LT,outpatient,,,102832.62,61699.57,,,,,,,,,,,,,
Arthroscopy Ankle Surgical Debridement Extensive|RIGHT SIDE,CASE-29898,LOCAL,29898,CPT,,,,,RT,outpatient,,,35045.92,21027.55,,,,,,,,,,,,,
"HC Unlisted Procedure, Nervous System|UNUSUAL NON-OVERLAPPING SERVICE",CASE-64999,LOCAL,64999,CPT,0360,RC,,,XU,outpatient,,,125917.75,75550.65,,,,,,,,,,,,,
Rcnstj Angular Dfrm Toe Soft Tiss Px Only|LEFT SIDE|PO,CASE-28313,LOCAL,28313,CPT,0360,RC,,,LT|PO,outpatient,,,21723.10,13033.86,,,,,,,,,,,,,
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26536,LOCAL,26536,CPT,0360,RC,,,F1|PO,outpatient,,,22471.93,13483.16,,,,,,,,,,,,,
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT HAND, FOURTH DIGIT",CASE-28308,LOCAL,28308,CPT,0360,RC,,,F8,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
Open Treatment Calcaneal Fracture|LEFT SIDE|PO,CASE-28415,LOCAL,28415,CPT,0360,RC,,,LT|PO,outpatient,,,38117.17,22870.30,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,LOCAL,45380,CPT,0360,RC,,,PT,outpatient,,,11052.48,6631.49,,,,,,,,,,,,,
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,LOCAL,58558,CPT,,,,,,outpatient,,,19552.00,11731.20,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM 36 HOLE ANGLED-ANGLED LCK TI NS,SUP-2486414,CDM,C1713,HCPCS,0278,RC,,,,both,,,7792.44,5065.09,,,,,,,,,,,,,
SUTURE D SPEC VCRL 2 0 D8876,SUP-2257457,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.83,228.04,,,,,,,,,,,,,
IMPLANT OTO L9MM HD DIA3.25MM SHFT DIA1MM TI HA CAP OFFSET,SUP-2277546,CDM,L8613,CPT,0278,RC,,,,both,,,1607.68,1044.99,,,,,,,,,,,,,
INTERFACE LOWER EXTREMITY SFT AK PLAS,SUP-2388187,CDM,L2830,HCPCS,0274,RC,,,,both,,,231.79,150.66,,,,,,,,,,,,,
KWIRE FIX L230MM DIA23MM SMOOTH SGL END TRCR,SUP-2321625,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.04,56.58,,,,,,,,,,,,,
HC US Transvaginal Obsetrical,PX-4027681700,CDM,76817,CPT,0402,RC,,,,outpatient,,,1263.00,820.95,,,,,,,,,,,,,
SCREW BONE L20MM OD2.7MM MULT DIR LCK,SUP-2136281,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,0636,RC,00781-9404-95,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CATHETER CTRL VEN QUAD LUMN N TUNNELED FULL KT POLYUR CDC42854P1A] TELEFLEX ARROW INTL INC],SUP-2383386,CDM,C1751,HCPCS,0278,RC,,,,both,,,396.27,257.58,,,,,,,,,,,,,
SHEATH MICROINTRODUCER 7FR L7CM CLOSUREFAST,SUP-2172422,CDM,C1894,HCPCS,0272,RC,,,,both,,,95.77,62.25,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 MO-6 5 MM NDL TI WHT BLU V-LOX,SUP-2762297,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
PLATE BNE L 117 MM SCREW DIA 3.5 MM 8 H RT MEDL PROX TIB,SUP-2931258,CDM,C1713,HCPCS,0278,RC,,,,both,,,8802.36,5721.53,,,,,,,,,,,,,
BIT DRILL DIA2.9MM DISTAL RADIAL VOLAR PLATING SYSTEM,SUP-2492337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28820,LOCAL,28820,CPT,0360,RC,,,T2,outpatient,,,17827.43,10696.46,,,,,,,,,,,,,
Arthrodesis Subtalar|LEFT SIDE|PO,CASE-28725,LOCAL,28725,CPT,,,,,LT|PO,outpatient,,,72961.50,43776.90,,,,,,,,,,,,,
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45390,LOCAL,45390,CPT,,,,,XU,outpatient,,,17031.87,10219.12,,,,,,,,,,,,,
Arthrt Glenohmrl Jt W/Jt Expl W/WO Rmvl Loose/FB,CASE-23107,LOCAL,23107,CPT,,,,,,outpatient,,,48915.32,29349.19,,,,,,,,,,,,,
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26536,LOCAL,26536,CPT,,,,,F9|PO,outpatient,,,18730.98,11238.59,,,,,,,,,,,,,
Repair Non/Malunion Humerus W/Iliac/Oth Agrft,CASE-24435,LOCAL,24435,CPT,,,,,,outpatient,,,52858.08,31714.85,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26418,LOCAL,26418,CPT,,,,,F8|PO,outpatient,,,13355.42,8013.25,,,,,,,,,,,,,
Rpr Primary Torn Ligm&/Capsule Knee Collateral|RIGHT SIDE|PO,CASE-27405,LOCAL,27405,CPT,0360,RC,,,RT|PO,outpatient,,,32162.75,19297.65,,,,,,,,,,,,,
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE,CASE-27691,LOCAL,27691,CPT,0360,RC,,,RT,outpatient,,,47822.53,28693.52,,,,,,,,,,,,,
Open Treatment Fracture Distal Tibia & Fibula|RIGHT SIDE,CASE-27828,LOCAL,27828,CPT,0360,RC,,,RT,outpatient,,,45913.63,27548.18,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, SECOND DIGIT|PO",CASE-26356,LOCAL,26356,CPT,,,,,F1|PO,outpatient,,,21815.82,13089.49,,,,,,,,,,,,,
Optx Prox Humeral Fx W/Int Fixj Rpr Tuberosity|LEFT SIDE,CASE-23615,LOCAL,23615,CPT,,,,,LT,outpatient,,,51849.98,31109.99,,,,,,,,,,,,,
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE,CASE-28200,LOCAL,28200,CPT,,,,,RT,outpatient,,,36459.58,21875.75,,,,,,,,,,,,,
Ostc Prtl Exostc/Condylc Metar Head|LEFT SIDE|PO,CASE-28288,LOCAL,28288,CPT,0360,RC,,,LT|PO,outpatient,,,27333.98,16400.39,,,,,,,,,,,,,
Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,CASE-21552,LOCAL,21552,CPT,,,,,,outpatient,,,16781.58,10068.95,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE|PO,CASE-29880,LOCAL,29880,CPT,,,,,RT|PO,outpatient,,,21597.33,12958.40,,,,,,,,,,,,,
HC Peripheral Block - Tap Unilateral Infusion,PX-3606448700,CDM,64487,CPT,0360,RC,,,,both,,,996.00,647.40,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 5.01-6.0 MCI STRL ADVANTAGE 2029FLS1] ISOAID LLC],SUP-2247272,CDM,C2642,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BONE LOCKING SMALL 3.5X272X11X3.4 MM 18 HOLE COMPRESSI,SUP-2837439,CDM,C1713,HCPCS,0278,RC,,,,both,,,7157.63,4652.46,,,,,,,,,,,,,
PIN FIX L42MM DIA3.3MM FEM BIOCRYL CROSS SL ASMBLY INTLOK,SUP-2256592,CDM,C1713,HCPCS,0278,RC,,,,both,,,2703.54,1757.30,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM THK1.04-2.28MM ULT THCK REGENERATIVE,SUP-2113075,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
RETRACTOR SURG L152MM HND HELD DBL END BLNT FARABEUF,SUP-2244666,CDM,C1713,HCPCS,0278,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
PLATE BONE THK1.25MM 12 H CRANIOMAXILLOFACIAL ORAL SLV TI,SUP-2181778,CDM,C1713,HCPCS,0278,RC,,,,both,,,2642.00,1717.30,,,,,,,,,,,,,
CATHETER DRNGE L35CM DIA14FR THOR SUMP LOOP NONCOATED,SUP-2147734,CDM,C1729,HCPCS,0272,RC,,,,both,,,323.45,210.24,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2 CHMBR 36 J 4X7.1X1.4 CM 41 CC 80 GM,SUP-2356284,CDM,C1721,HCPCS,0275,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IPERIA PROMRI DX W 65 X H 55 MM D 11 MM,SUP-2138372,CDM,C1722,HCPCS,0275,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
CATHETER DRN GEN W/ RO MRK TOT ABCESSIONGEN DRNAGE 10FRX30CM,SUP-2117068,CDM,C1729,HCPCS,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
BUR REPROC BARREL 6-FLT BEIGE,SUP-2526058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.83,45.39,,,,,,,,,,,,,
SET THROMCTMY OASIS STRL,SUP-2141172,CDM,C1757,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|RIGHT SIDE,CASE-26121,LOCAL,26121,CPT,0360,RC,,,RT,outpatient,,,14409.52,8645.71,,,,,,,,,,,,,
HC Vasc Embolize Occlude Organ,CASE-37243,LOCAL,37243,CPT,0361,RC,,,,outpatient,,,72480.43,43488.26,,,,,,,,,,,,,
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE|PO,CASE-29898,LOCAL,29898,CPT,,,,,LT|PO,outpatient,,,35793.97,21476.38,,,,,,,,,,,,,
Rpr Recrt Inguinal Hernia Any Age Reducible|LEFT SIDE,CASE-49520,LOCAL,49520,CPT,,,,,LT,outpatient,,,22019.75,13211.85,,,,,,,,,,,,,
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,LOCAL,43246,CPT,,,,,,outpatient,,,37983.45,22790.07,,,,,,,,,,,,,
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28160,LOCAL,28160,CPT,,,,,T3|PO,outpatient,,,21238.90,12743.34,,,,,,,,,,,,,
"Sesamoidectomy First Toe Spx|RIGHT FOOT, GREAT TOE|PO",CASE-28315,LOCAL,28315,CPT,,,,,T5|PO,outpatient,,,18082.22,10849.33,,,,,,,,,,,,,
Excision/Curettage Cyst/Tumor Femur|LEFT SIDE,CASE-27355,LOCAL,27355,CPT,,,,,LT,outpatient,,,17556.60,10533.96,,,,,,,,,,,,,
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|RIGHT SIDE|PO,CASE-24341,LOCAL,24341,CPT,0360,RC,,,RT|PO,outpatient,,,15782.53,9469.52,,,,,,,,,,,,,
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,LOCAL,64450,CPT,0450,RC,,,,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
HC Peripheral Block - Femoral Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,LOCAL,64448,CPT,0360,RC,,,RT|XU,outpatient,,,64227.68,38536.61,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,LOCAL,G0121,CPT,,,,,KX,outpatient,,,10162.85,6097.71,,,,,,,,,,,,,
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE|PO,CASE-27792,LOCAL,27792,CPT,0360,RC,,,RT|PO,outpatient,,,31031.63,18618.98,,,,,,,,,,,,,
RADIUM RA 223 DICHLORIDE 30 MCCI/ML IV SOLN,RX-133995,CDM,A9606,HCPCS,0343,RC,50419-0208-01,NDC,,both,1,UN,435.00,282.75,,,,,,,,,,,,,
PLATE SET SM UPPER EXTREMITY FRAG OUTLIER,SUP-2340933,CDM,C1713,HCPCS,0278,RC,,,,both,,,27161.00,17654.65,,,,,,,,,,,,,
DRILL SURG HI SPD FOR SPINE,SUP-2607500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,28002.52,18201.64,,,,,,,,,,,,,
RESERVOIR VENTRICULAR SINGLE FLAT ACCU-FLO,SUP-2666409,CDM,C1889,HCPCS,0278,RC,,,,both,,,1131.53,735.49,,,,,,,,,,,,,
TUBE ENTRL FEED PUSH METHOD 0.035 IN 20 FRX4.47 MM FLO 20,SUP-2737404,CDM,C1769,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
TUBE LARYNCTMY L55MM DIA8MM CLR SIL STD DISP PROVOX,SUP-2124366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.63,264.31,,,,,,,,,,,,,
CATHETER TEMP PACE L 110 CM DIA 5 FR PROX 1 CM TRNSVEN,SUP-2127503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,689.98,448.49,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 0.035 IN 20 ATM 5 FRX80 CM 4X300 MM,SUP-2865955,CDM,C1725,HCPCS,0272,RC,,,,both,,,511.04,332.18,,,,,,,,,,,,,
COMPONENT FEM SM LT KNEE LIBRA,SUP-2442351,CDM,C1776,CPT,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE,CASE-15823,LOCAL,15823,CPT,0360,RC,,,50,outpatient,,,36231.00,21738.60,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,LOCAL,29807,CPT,,,,,,outpatient,,,40724.82,24434.89,,,,,,,,,,,,,
Bx Prostate Strtctc Saturation Sampling Img Gid,CASE-55706,LOCAL,55706,CPT,,,,,,outpatient,,,13079.40,7847.64,,,,,,,,,,,,,
Laps Surg Esopg/Gstr Fundoplasty,CASE-43280,LOCAL,43280,CPT,0360,RC,,,,outpatient,,,81634.53,48980.72,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,LOCAL,43236,CPT,0360,RC,,,XS,outpatient,,,14351.03,8610.62,,,,,,,,,,,,,
Osteotomy Radius Distal Third,CASE-25350,LOCAL,25350,CPT,0360,RC,,,,outpatient,,,37307.13,22384.28,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64718,LOCAL,64718,CPT,0360,RC,,,XS|RT|PO,outpatient,,,18911.10,11346.66,,,,,,,,,,,,,
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein|RIGHT SIDE,CASE-37249,LOCAL,37249,CPT,,,,,RT,outpatient,,,27259.98,16355.99,,,,,,,,,,,,,
Rhinp Prim Lat&Alar Crtlgs&/Elvtn Nasal Ti|BILATERAL PROCEDURE|PO,CASE-30400,LOCAL,30400,CPT,,,,,50|PO,outpatient,,,64500.27,38700.16,,,,,,,,,,,,,
Transection/Avulsion Oth Spinal Nrv Xdrl|PO,CASE-64772,LOCAL,64772,CPT,,,,,PO,outpatient,,,21425.95,12855.57,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,LOCAL,28308,CPT,,,,,LT,outpatient,,,27750.93,16650.56,,,,,,,,,,,,,
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT SIDE|PO,CASE-26356,LOCAL,26356,CPT,,,,,RT|PO,outpatient,,,15124.93,9074.96,,,,,,,,,,,,,
Crtj Arven Fstl Xcp Dir Arven Anast Nonautog Grf,CASE-36830,LOCAL,36830,CPT,,,,,,outpatient,,,41583.48,24950.09,,,,,,,,,,,,,
Laps Tot Hysterectomy Resj Malignancy W/Omntc,CASE-58575,LOCAL,58575,CPT,0360,RC,,,,outpatient,,,95238.53,57143.12,,,,,,,,,,,,,
GRAFT HUM TISS DISC 15 MM AMNION-CHORION-AMNION LAYR PLCNTA,SUP-2909246,CDM,Q4140,HCPCS,0636,RC,,,,both,,,2800.57,1820.37,,,,,,,,,,,,,
SCREW SPNL 4X20 MM ANTR CERV,SUP-2205440,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
STRATOGEN MEM 2 X 3 CM,SUP-2164198,CDM,Q4139,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
NEEDLE ENDOSCP 0 DEG 3 MMX30 CM MIC BITE BIT ULTRAMICRO,SUP-2767021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1127.64,732.97,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 40 H SCREW DIA2 MM TI MIDFACE NS,SUP-2883813,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
CATHETER HD STR 13 FRX20 CM SHT TERM 3L TY SLIM-CATH,SUP-2125594,CDM,C1752,HCPCS,0278,RC,,,,both,,,638.64,415.12,,,,,,,,,,,,,
VALVE SHUNT SM EXTRACTED STRATA II,SUP-2628591,CDM,C1729,HCPCS,0272,RC,,,,both,,,13380.89,8697.58,,,,,,,,,,,,,
GRAFT BIO TISS W4XL4CM SLD FET BOV ACELLULAR DERM MTRX,SUP-2243685,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA 5 MM AX COMPLIANCE,SUP-2694231,CDM,C1768,CPT,0278,RC,,,,both,,,6230.61,4049.90,,,,,,,,,,,,,
PLATE BNE 2.7X148 MM 16 HOLE TI STRL LCP,SUP-2789464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1523.09,990.01,,,,,,,,,,,,,
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE|SEPARATE STRUCTURE,CASE-27405,LOCAL,27405,CPT,0360,RC,,,LT|XS,outpatient,,,63869.23,38321.54,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,LOCAL,52287,CPT,,,,,,outpatient,,,15300.45,9180.27,,,,,,,,,,,,,
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,LOCAL,45381,CPT,,,,,PT,outpatient,,,15686.23,9411.74,,,,,,,,,,,,,
Rmvl/Revj Sling Male Urinary Incontinence,CASE-53442,LOCAL,53442,CPT,0360,RC,,,,outpatient,,,35272.90,21163.74,,,,,,,,,,,,,
Ostectomy Complete 5th Metatarsal Head|LEFT SIDE|PO,CASE-28113,LOCAL,28113,CPT,,,,,LT|PO,outpatient,,,21781.68,13069.01,,,,,,,,,,,,,
Arven Anast Opn Upr Arm Basilic Vein Trpos|RIGHT SIDE,CASE-36819,LOCAL,36819,CPT,,,,,RT,outpatient,,,48540.40,29124.24,,,,,,,,,,,,,
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|LEFT SIDE|PO,CASE-24341,LOCAL,24341,CPT,0360,RC,,,LT|PO,outpatient,,,46105.48,27663.29,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,LOCAL,52352,CPT,0360,RC,,,LT,outpatient,,,16798.43,10079.06,,,,,,,,,,,,,
"Synovectomy Metatarsophalangeal Joint Each|LEFT FOOT, SECOND DIGIT",CASE-28072,LOCAL,28072,CPT,0360,RC,,,T1,outpatient,,,31016.42,18609.85,,,,,,,,,,,,,
Claviculectomy Partial|RIGHT SIDE|PO,CASE-23120,LOCAL,23120,CPT,,,,,RT|PO,outpatient,,,38318.80,22991.28,,,,,,,,,,,,,
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-54840,LOCAL,54840,CPT,,,,,LT|XU,outpatient,,,35814.02,21488.41,,,,,,,,,,,,,
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|RIGHT SIDE|PO,CASE-25260,LOCAL,25260,CPT,0360,RC,,,RT|PO,outpatient,,,13068.78,7841.27,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM THK45UM AMNIO MEMBRN DEHYDR OMNI DIR,SUP-2340451,CDM,C1762,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BLADE IM L75MM DIA12.5MM FEM G TI CANN SPRL FR CUT EDGE FOR,SUP-2180043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1557.13,1012.13,,,,,,,,,,,,,
GUIDEWIRE URO L145CM DIA0.038IN TIP 5CM DBL FLEX S STL PTFE,SUP-2171450,CDM,C1769,HCPCS,0272,RC,,,,both,,,104.00,67.60,,,,,,,,,,,,,
SCREW BNE L130MM DIA3.5MM STD CORT S STL ST NONCANNULATED,SUP-2183568,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.66,161.63,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X1.12X4.5 MM 1.04 MM LT EAR SHEA,SUP-2637801,CDM,L8613,CPT,0278,RC,,,,both,,,456.34,296.62,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3 CC ADIPOSE MTRX RENUVA HD,SUP-2761881,CDM,C1762,CPT,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,CASE-55866,LOCAL,55866,CPT,,,,,,outpatient,,,112313.43,67388.06,,,,,,,,,,,,,
Arthro/shoul surg; w/spacer,CASE-C9781,LOCAL,C9781,CPT,0360,RC,,,,outpatient,,,78078.60,46847.16,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,LOCAL,29879,CPT,,,,,RT,outpatient,,,31663.63,18998.18,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28270,LOCAL,28270,CPT,,,,,T9|PO,outpatient,,,24033.37,14420.02,,,,,,,,,,,,,
Open Treatment Medial Malleolus Fracture|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27766,LOCAL,27766,CPT,,,,,LT|XU,outpatient,,,45301.70,27181.02,,,,,,,,,,,,,
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE|PO,CASE-23700,LOCAL,23700,CPT,,,,,LT|PO,outpatient,,,12195.95,7317.57,,,,,,,,,,,,,
Capsular Contracture Release|RIGHT SIDE,CASE-23020,LOCAL,23020,CPT,,,,,RT,outpatient,,,48673.63,29204.18,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, SECOND DIGIT|PO",CASE-26055,LOCAL,26055,CPT,,,,,F1|PO,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT|PO",CASE-28820,LOCAL,28820,CPT,0360,RC,,,T1|PO,outpatient,,,10961.68,6577.01,,,,,,,,,,,,,
Syndactylization Toes|LEFT SIDE|PO,CASE-28280,LOCAL,28280,CPT,,,,,LT|PO,outpatient,,,21840.08,13104.05,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,RT,outpatient,,,2581.68,1549.01,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE|PO,CASE-29881,LOCAL,29881,CPT,,,,,LT|XS|PO,outpatient,,,44266.80,26560.08,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,LOCAL,52356,CPT,,,,,LT,outpatient,,,30801.07,18480.64,,,,,,,,,,,,,
INSERT TIB SZ 4 THK14MM LT KNEE CRUC SUB UHMWPE PRI FIX,SUP-2304575,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BONE L32MM 4 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348294,CDM,C1713,HCPCS,0278,RC,,,,both,,,4127.06,2682.59,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L130CM BAL L220MM DIA6MM GWIRE 0.018IN,SUP-2126962,CDM,C2623,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
HEAD RAD STD SZ 24 W24XL13MM BILAT EL JT CO CHROME NONCOATED,SUP-2244261,CDM,C1776,CPT,0278,RC,,,,both,,,6543.76,4253.44,,,,,,,,,,,,,
MOST ELLIPTICAL ALL-POLY PATELLA MEDIUM,SUP-2509223,CDM,C1776,CPT,0278,RC,,,,both,,,2881.11,1872.72,,,,,,,,,,,,,
PATCH AMNION 2 LAYR PROTCT 4 X 8CM STERISHIELD II,SUP-2138666,CDM,C1762,CPT,0278,RC,,,,both,,,7366.44,4788.19,,,,,,,,,,,,,
SCREW BNE LAG 12.7X65 MM HIP COMPR TALON,SUP-2391516,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GRAFT HUM TISS FIB SHFT BNE FRZN ALLGRFT 150MM LEN 8 15MM W,SUP-2264753,CDM,C1713,HCPCS,0278,RC,,,,both,,,2400.88,1560.57,,,,,,,,,,,,,
GRAFT BNE SUB 5CC SZ 05 3MM DEMIN CORT CANC GRAN FRZ DRY,SUP-2307255,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
UNIVERSAL WIRE FIXATION BOLT 17.5MM,SUP-2605901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.52,300.64,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA BASIC 3FR 55CM 1 LUMAN RVS,SUP-2613532,CDM,C1751,HCPCS,0278,RC,,,,both,,,506.98,329.54,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0250,RC,00990-7983-61,NDC,,both,1000,ML,297.50,193.37,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER IMP SGL CHMBR 109G 57ML 39 J DEL,SUP-2357742,CDM,C1722,HCPCS,0275,RC,,,,both,,,46393.50,30155.77,,,,,,,,,,,,,
BLADE SURG SAW STD S STL OSC W/ SERR EDGE DISP,SUP-2367091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT FOOT, GREAT TOE|PO",CASE-28297,LOCAL,28297,CPT,0360,RC,,,TA|PO,outpatient,,,44565.32,26739.19,,,,,,,,,,,,,
Rpr Aa Hernia 1st < 3 Cm Reducible,CASE-49591,LOCAL,49591,CPT,0360,RC,,,,outpatient,,,33015.18,19809.11,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,LOCAL,45380,CPT,,,,,XU|PT,outpatient,,,12009.52,7205.71,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64446,LOCAL,64446,CPT,0360,RC,,,XU|LT|PO,outpatient,,,44292.32,26575.39,,,,,,,,,,,,,
"Arthro, Loose Body + Chondro",CASE-G0289,LOCAL,G0289,CPT,0360,RC,,,,outpatient,,,27637.02,16582.21,,,,,,,,,,,,,
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,LOCAL,38571,CPT,0360,RC,,,,outpatient,,,107159.30,64295.58,,,,,,,,,,,,,
Unlisted Laparoscopic Procedure Liver,CASE-47379,LOCAL,47379,CPT,,,,,,outpatient,,,29847.77,17908.66,,,,,,,,,,,,,
Exc Tumor Soft Tissue Neck/Thorax Subfasc 5 Cm/>,CASE-21554,LOCAL,21554,CPT,0360,RC,,,,outpatient,,,15925.22,9555.13,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|SEPARATE STRUCTURE,CASE-12032,LOCAL,12032,CPT,0450,RC,,,XS,outpatient,,,29842.58,17905.55,,,,,,,,,,,,,
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|LEFT SIDE,CASE-38570,LOCAL,38570,CPT,,,,,LT,outpatient,,,68298.87,40979.32,,,,,,,,,,,,,
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,LOCAL,52240,CPT,0360,RC,,,,outpatient,,,23949.20,14369.52,,,,,,,,,,,,,
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, THUMB|PO",CASE-26445,LOCAL,26445,CPT,,,,,FA|PO,outpatient,,,10433.33,6260.00,,,,,,,,,,,,,
Open Implantation Nea Sacral Nerve,CASE-64581,LOCAL,64581,CPT,,,,,,outpatient,,,84803.77,50882.26,,,,,,,,,,,,,
HC Debrid Wound Tis Addl 20 Cm<,CASE-97598,LOCAL,97598,CPT,0761,RC,,,,outpatient,,,841.75,505.05,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE|PO,CASE-29824,LOCAL,29824,CPT,0360,RC,,,LT|PO,outpatient,,,62784.27,37670.56,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,LOCAL,49650,CPT,,,,,50,outpatient,,,50195.70,30117.42,,,,,,,,,,,,,
Fasciectomy Plantar Fascia Partial Spx|RIGHT SIDE|PO,CASE-28060,LOCAL,28060,CPT,,,,,RT|PO,outpatient,,,10652.72,6391.63,,,,,,,,,,,,,
TRIAL TIB 11MMXL M2 A/P LIP CONSTRN DURAC,SUP-2364862,CDM,C1776,CPT,0278,RC,,,,both,,,483.72,314.42,,,,,,,,,,,,,
COMPONENT FEM LG LT KNEE ZNG LIBRA,SUP-2442358,CDM,C1776,CPT,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
ELECTRODE ELECSURG RF 50 MM SELF GRND NITRODE,SUP-2366981,CDM,C1713,HCPCS,0278,RC,,,,both,,,7503.53,4877.29,,,,,,,,,,,,,
LENS IOL 10.0 TO 30.0 DIOPT IOL PLANE 3.0 CORNEAL,SUP-2880953,CDM,V2787,HCPCS,0276,RC,,,,both,,,415.00,269.75,,,,,,,,,,,,,
IMPLANT HUM TISS L 20 X H 7.5 MM CANC FT COTTON WDG TEXT,SUP-2932831,CDM,C1762,CPT,0278,RC,,,,both,,,5204.33,3382.81,,,,,,,,,,,,,
URETEROSCOPE FLX GLOB RVS 77 FR TIP DIGITAL LITHOVUE,SUP-2141753,CDM,C1747,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW BNE 6X105 MM NS LTX,SUP-2861117,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
DRILL SURG CTRL N CEM MBT HI PERF SIG LCS,SUP-2456250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
VALVE AORT 19.2 MM MSTR HP SER FLX CUF,SUP-2356694,CDM,C1889,HCPCS,0278,RC,,,,both,,,17445.84,11339.80,,,,,,,,,,,,,
DEVICE PESSARY DIA1.75IN SIL FLEX GELLHORN SH STEM FOR 3RD,SUP-2171824,CDM,A4562,HCPCS,0272,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
Removal Implant Deep|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20680,LOCAL,20680,CPT,0360,RC,,,LT|XU,outpatient,,,41782.87,25069.72,,,,,,,,,,,,,
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE,CASE-27698,LOCAL,27698,CPT,0360,RC,,,RT,outpatient,,,32572.72,19543.63,,,,,,,,,,,,,
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs|RIGHT SIDE|PO,CASE-25115,LOCAL,25115,CPT,0360,RC,,,RT|PO,outpatient,,,20045.78,12027.47,,,,,,,,,,,,,
Thyroidectomy Total/Complete,CASE-60240,LOCAL,60240,CPT,0360,RC,,,,outpatient,,,48085.13,28851.08,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|BILATERAL PROCEDURE,CASE-49507,LOCAL,49507,CPT,,,,,50,outpatient,,,30435.68,18261.41,,,,,,,,,,,,,
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,LOCAL,51990,CPT,,,,,,outpatient,,,110018.55,66011.13,,,,,,,,,,,,,
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE|PO,CASE-64624,LOCAL,64624,CPT,0360,RC,,,50|PO,outpatient,,,12974.53,7784.72,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|SEPARATE STRUCTURE|PO,CASE-62323,LOCAL,62323,CPT,0360,RC,,,XS|PO,outpatient,,,6176.18,3705.71,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm|PO,CASE-11401,LOCAL,11401,CPT,0360,RC,,,PO,outpatient,,,13527.90,8116.74,,,,,,,,,,,,,
Destruction Lesions Vulva Extensive,CASE-56515,LOCAL,56515,CPT,,,,,,outpatient,,,15469.13,9281.48,,,,,,,,,,,,,
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26357,LOCAL,26357,CPT,,,,,,outpatient,,,21815.82,13089.49,,,,,,,,,,,,,
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE,CASE-27570,LOCAL,27570,CPT,0360,RC,,,RT,outpatient,,,13218.02,7930.81,,,,,,,,,,,,,
HC Fem Pop Territory Plasty|RIGHT SIDE,CASE-37224,LOCAL,37224,CPT,0361,RC,,,RT,outpatient,,,41087.17,24652.30,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26418,LOCAL,26418,CPT,,,,,F7|PO,outpatient,,,12888.95,7733.37,,,,,,,,,,,,,
CATHETERIZATION TRAY 3 FR SINGLE LUMEN POWERPICC PROVENA,SUP-2127009,CDM,C1751,HCPCS,0278,RC,,,,both,,,382.73,248.77,,,,,,,,,,,,,
POLARUS 3 SCREW CADDY 4.3 MM 18 46 MM,SUP-2639808,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILIVIA NEO 7 DR-T PROMRI TI POLYUR SIL 2,SUP-2739241,CDM,C1721,HCPCS,0275,RC,,,,both,,,58278.40,37880.96,,,,,,,,,,,,,
CATHETER INFUS L20CM DIA5FR POLYUR 2 LUMN RADPQ SH RVS TAPR,SUP-2118841,CDM,C1751,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
GRAFT BONE SUB SM MTRX 3 STRP COLLAGRFT,SUP-2197446,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
TIP EXTRACTOR FOR HINDFOOT TTC/TC INNR NAIL REMOVAL NS DISP,SUP-2909122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,620.15,403.10,,,,,,,,,,,,,
COMPONENT FEM SZ 4 R KNEE OXINIUM CRUCE RET PRI CEM FOR TOT,SUP-2345848,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
HC Cytp Concentration Smears & Interpretation,PX-3118810800,CDM,88108,CPT,0311,RC,,,,both,,,291.00,189.15,,,,,,,,,,,,,
HEAD RAD SZ 1 W7.6XL17MM STD STEM TAPR MDLLRY CNL PRSS FIT,SUP-2244257,CDM,C1776,CPT,0278,RC,,,,both,,,9062.86,5890.86,,,,,,,,,,,,,
SEALER ENDOSCP NANO COAT OPN DIV CRV L JAW LIGASURE IMPACT,SUP-2283567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1859.60,1208.74,,,,,,,,,,,,,
PLATE SPNL L35MM ANT LUM S STL CDH SPIRE,SUP-2292652,CDM,C1713,HCPCS,0278,RC,,,,both,,,10519.00,6837.35,,,,,,,,,,,,,
MESH HERN W15XL20CM OPTIMIZED COMP OPN SKRT PARIETEX,SUP-2174715,CDM,C1781,HCPCS,0278,RC,,,,both,,,2386.18,1551.02,,,,,,,,,,,,,
Chemodenervation Muscle Neck Unilat for Dystonia|RIGHT SIDE|PO,CASE-64616,LOCAL,64616,CPT,,,,,RT|PO,outpatient,,,7170.37,4302.22,,,,,,,,,,,,,
Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|LEFT SIDE|PO,CASE-25290,LOCAL,25290,CPT,0360,RC,,,LT|PO,outpatient,,,12902.80,7741.68,,,,,,,,,,,,,
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,LOCAL,45378,CPT,,,,,74,outpatient,,,9811.63,5886.98,,,,,,,,,,,,,
Repair Non/Malunion Humerus W/O Graft|LEFT SIDE,CASE-24430,LOCAL,24430,CPT,0360,RC,,,LT,outpatient,,,47199.98,28319.99,,,,,,,,,,,,,
"Inject Nerv Blck,Paravert Sympath|RIGHT SIDE",CASE-64520,LOCAL,64520,CPT,0360,RC,,,RT,outpatient,,,3925.23,2355.14,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE|PO,CASE-29882,LOCAL,29882,CPT,0360,RC,,,LT|PO,outpatient,,,53517.53,32110.52,,,,,,,,,,,,,
Ligj Divj & Stripping Short Saphenous Vein,CASE-37718,LOCAL,37718,CPT,0360,RC,,,,outpatient,,,32297.85,19378.71,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,LOCAL,11421,CPT,0360,RC,,,,outpatient,,,24976.52,14985.91,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT FOOT, SECOND DIGIT",CASE-28270,LOCAL,28270,CPT,0360,RC,,,XU|T1,outpatient,,,27750.93,16650.56,,,,,,,,,,,,,
Fasciotomy Foot&/Toe|LEFT SIDE,CASE-28008,LOCAL,28008,CPT,,,,,LT,outpatient,,,16767.93,10060.76,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|RIGHT SIDE,CASE-28308,LOCAL,28308,CPT,,,,,XS|RT,outpatient,,,30270.30,18162.18,,,,,,,,,,,,,
Bone Graft Any Donor Area Minor/Small|RIGHT SIDE,CASE-20900,LOCAL,20900,CPT,,,,,RT,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
HC Inj Trigger Pt 1-2 Musc Grps|PO,CASE-20552,LOCAL,20552,CPT,0510,RC,,,PO,outpatient,,,3533.83,2120.30,,,,,,,,,,,,,
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE,CASE-97605,LOCAL,97605,CPT,0761,RC,,,PBB,outpatient,,,283.83,170.30,,,,,,,,,,,,,
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|RIGHT SIDE|PO,CASE-28465,LOCAL,28465,CPT,,,,,RT|PO,outpatient,,,45080.53,27048.32,,,,,,,,,,,,,
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,LOCAL,52318,CPT,,,,,,outpatient,,,41887.20,25132.32,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-20610,LOCAL,20610,CPT,0510,RC,,,XS|RT|PO,outpatient,,,6055.28,3633.17,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THUMB|PO",CASE-26735,LOCAL,26735,CPT,,,,,FA|PO,outpatient,,,19615.57,11769.34,,,,,,,,,,,,,
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,LOCAL,43248,CPT,,,,,,outpatient,,,11923.00,7153.80,,,,,,,,,,,,,
INSTRUMENT KIT HIP CRV KNOTLESS FIBERTAK DISP,SUP-2423107,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.025 IN TAPR L 8 CM FLPY TIP L,SUP-2167979,CDM,C1769,HCPCS,0272,RC,,,,both,,,57.84,37.60,,,,,,,,,,,,,
WIRE FIX Y 1.28X559 MM ES2 COMPATIBLE LT FC12822B4,SUP-2735811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
STRUT L INFIX 10MM,SUP-2205508,CDM,C1776,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 4 10MM CANC CRUSH CHIP READIGRFT,SUP-2264822,CDM,C1713,HCPCS,0278,RC,,,,both,,,1052.84,684.35,,,,,,,,,,,,,
WASHER ORTH PICKUP STAND PELVIS II,SUP-2496221,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.11,661.77,,,,,,,,,,,,,
PLATE BNE L MINI 2X23 MM OBLQ ANGLED TI,SUP-2536099,CDM,C1713,HCPCS,0278,RC,,,,both,,,270.35,175.73,,,,,,,,,,,,,
BUR SURG TOT L 72 MM CUT L 13 MM DIA 4.3 MM WDG AO STRL LF,SUP-2881101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.73,541.27,,,,,,,,,,,,,
GUIDE DRL HND HELD DISP ISOTAC,SUP-2341301,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.12,100.83,,,,,,,,,,,,,
HC Thromb Mech 2nd Vssl,PX-3613718500,CDM,37185,CPT,0361,RC,,,,outpatient,,,4295.00,2791.75,,,,,,,,,,,,,
HC Allo Hpc Boost,PX-3623824300,CDM,38243,CPT,0362,RC,,,,both,,,1519.00,987.35,,,,,,,,,,,,,
IBAL TKA FEM PS CEMENTED SZ 4 LEFT,SUP-2813386,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
Revascularization Iliac Artery Angiop 1st Vsl|LEFT SIDE,CASE-37220,LOCAL,37220,CPT,,,,,LT,outpatient,,,56908.88,34145.33,,,,,,,,,,,,,
Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc,CASE-34421,LOCAL,34421,CPT,,,,,,outpatient,,,68578.52,41147.11,,,,,,,,,,,,,
Excision Prepatellar Bursa|LEFT SIDE|SEPARATE STRUCTURE,CASE-27340,LOCAL,27340,CPT,0360,RC,,,LT|XS,outpatient,,,30349.03,18209.42,,,,,,,,,,,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,CASE-43762,LOCAL,43762,CPT,0361,RC,,,,outpatient,,,81634.53,48980.72,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,LOCAL,50081,CPT,0360,RC,,,RT,outpatient,,,43049.00,25829.40,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,LOCAL,49651,CPT,0360,RC,,,RT,outpatient,,,42204.82,25322.89,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE|PO,CASE-28308,LOCAL,28308,CPT,,,,,LT|PO,outpatient,,,27333.98,16400.39,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg F/E/E/N/L/M 0.5cm/<|PO,CASE-11440,LOCAL,11440,CPT,,,,,PO,outpatient,,,39029.90,23417.94,,,,,,,,,,,,,
Removal Non-Biodegradable Drug Delivery Implant|LEFT SIDE,CASE-11982,LOCAL,11982,CPT,,,,,LT,outpatient,,,53743.52,32246.11,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26765,LOCAL,26765,CPT,0360,RC,,,F8|PO,outpatient,,,22563.88,13538.33,,,,,,,,,,,,,
Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,CASE-49616,LOCAL,49616,CPT,0360,RC,,,,outpatient,,,68432.20,41059.32,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,LOCAL,52353,CPT,0360,RC,,,RT,outpatient,,,24146.30,14487.78,,,,,,,,,,,,,
Dilation Esophagus Guide Wire,CASE-43453,LOCAL,43453,CPT,,,,,,outpatient,,,15221.77,9133.06,,,,,,,,,,,,,
Open Tx Trimalleolar Ankle Fx W/Fixj Pst Lip|LEFT SIDE|PO,CASE-27823,LOCAL,27823,CPT,0360,RC,,,LT|PO,outpatient,,,35805.08,21483.05,,,,,,,,,,,,,
Open Tx Radial&Ulnar Shaft Fx W/Fixj Radius&Ulna,CASE-25575,LOCAL,25575,CPT,,,,,,outpatient,,,46185.27,27711.16,,,,,,,,,,,,,
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE|PO,CASE-24685,LOCAL,24685,CPT,,,,,LT|PO,outpatient,,,36714.83,22028.90,,,,,,,,,,,,,
KIT EEG ELECTRD L 40.5 MM 12 CONTACT RF PRB STRL DISP EVO,SUP-2936468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2 MM 4 H BROAD LCK MINI FRAG SYS,SUP-2900546,CDM,C1713,HCPCS,0278,RC,,,,both,,,3461.85,2250.20,,,,,,,,,,,,,
SCREW BNE PART CANN 4X60 MM N-FORCE,SUP-2473013,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
KIT DRL PIN L100MM DIA1.5MM ABSRB W/ K WIRE GUID SL BNE,SUP-2121830,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
MICROPHONE HEARING AID CONN LN,SUP-2430270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BIT DRILL D4MM LNG ORNG XTRFX EXTRNL FXTN SSTM,SUP-2472074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
DRILL SURG PEGGED 0.25 IN GLEN STR,SUP-2449762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
"HC Debrid,Musc/Fasc,Ea Add 20sqcm|SEPARATE STRUCTURE",CASE-11046,LOCAL,11046,CPT,0361,RC,,,XS,outpatient,,,39559.38,23735.63,,,,,,,,,,,,,
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|RIGHT SIDE,CASE-52354,LOCAL,52354,CPT,,,,,RT,outpatient,,,25609.22,15365.53,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE",CASE-28299,LOCAL,28299,CPT,,,,,T5,outpatient,,,40956.73,24574.04,,,,,,,,,,,,,
Vaginectomy Partial Removal Vaginal Wall,CASE-57106,LOCAL,57106,CPT,0360,RC,,,,outpatient,,,19746.45,11847.87,,,,,,,,,,,,,
Repair Non/Malunion Humerus W/O Graft|RIGHT SIDE,CASE-24430,LOCAL,24430,CPT,,,,,RT,outpatient,,,70276.58,42165.95,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE|PO,CASE-29888,LOCAL,29888,CPT,,,,,RT|PO,outpatient,,,54845.65,32907.39,,,,,,,,,,,,,
HC Icu Intermediate R&B,PX-2060000000,CDM,2060000000,LOCAL,,,,,,outpatient,,,4022.42,2413.45,,,,,,,,,,,,,
Ostectomy Complete 5th Metatarsal Head|RIGHT SIDE|PO,CASE-28113,LOCAL,28113,CPT,0360,RC,,,RT|PO,outpatient,,,42596.50,25557.90,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, SECOND DIGIT|PO",CASE-26357,LOCAL,26357,CPT,,,,,F1|PO,outpatient,,,21815.82,13089.49,,,,,,,,,,,,,
Excision Olecranon Bursa|RIGHT SIDE|PO,CASE-24105,LOCAL,24105,CPT,,,,,RT|PO,outpatient,,,15782.53,9469.52,,,,,,,,,,,,,
Excision Interdigital Morton Neuroma Single Each|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-28080,LOCAL,28080,CPT,,,,,XU|RT,outpatient,,,44242.73,26545.64,,,,,,,,,,,,,
Chemodenervation Internal Anal Sphincter,CASE-46505,LOCAL,46505,CPT,,,,,,outpatient,,,15789.58,9473.75,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28285,LOCAL,28285,CPT,,,,,T9|PO|XU,outpatient,,,26381.72,15829.03,,,,,,,,,,,,,
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,LOCAL,97605,CPT,0761,RC,,,PBB|XU,outpatient,,,1739.83,1043.90,,,,,,,,,,,,,
METHYLPREDNISOLONE NA SUC (PF) 500 MG IJ SOLR|DISCARDED DRUG NOT ADMINISTE,RX-162821,CDM,J2919,HCPCS,0636,RC,00009-0003-02,NDC,JW,both,1,UN,272.50,177.12,,,,,,,,,,,,,
HC So Viscosity,PX-3058581066,CDM,85810,CPT,0305,RC,,,,both,,,376.00,244.40,,,,,,,,,,,,,
CLINIMIX E/DEXTROSE (4.25/5) 4.25 % IV SOLN,RX-23162,CDM,2500000003,HCPCS,0250,RC,00338-1113-04,NDC,,both,2000,ML,460.00,299.00,,,,,,,,,,,,,
PLATE BNE L107MM 8 H 1 3RD TBLR LOK FOR 3.5MM SCR UNIV LOK,SUP-2411374,CDM,C1713,HCPCS,0278,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
ELECTRODE ELECSURG BND 30 DEG 24 FR HF RESECT CLINCH UROLOGY,SUP-2478335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.71,538.66,,,,,,,,,,,,,
SCREW BNE L38MM DIA5.5MM CORT TI ANK NONLOCKING FULL THRD,SUP-2398574,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
SCREW BONE L8MM DIA2.4MM CORT TI ST LCK FULL THRD HD,SUP-2181750,CDM,C1713,HCPCS,0278,RC,,,,both,,,585.11,380.32,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 65CM 6FR COAT L 35CM XCUT,SUP-2385656,CDM,C1894,HCPCS,0272,RC,,,,both,,,368.95,239.82,,,,,,,,,,,,,
PLATE BONE THK0.5MM 18 H ORBIT GRN TI HX FOR 1.5MM SCR,SUP-2135902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
GORE TAG THORACIC BRANCH ENDOPROSTHESIS 21MMX8MMX10CM 20FR,SUP-2855595,CDM,C1768,CPT,0278,RC,,,,both,,,100480.00,65312.00,,,,,,,,,,,,,
SCREW EDGE COMP DART FIRE,SUP-2857921,CDM,C1713,HCPCS,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
KIT INTRO MAK-NV TROCAR L 15 CM DIA21 GA NONVASCULAR,SUP-2492733,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.62,19.90,,,,,,,,,,,,,
PIN POS L4.5MM S STL CERCLAGE FOR LOK COMPR PLT,SUP-2187039,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.76,324.19,,,,,,,,,,,,,
HC Myoglobin,PX-3018387400,CDM,83874,CPT,0301,RC,,,,both,,,311.00,202.15,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC BALL 2 MM,SUP-2431226,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,LOCAL,38900,CPT,0360,RC,,,LT,outpatient,,,35681.82,21409.09,,,,,,,,,,,,,
"HC Debrid,Subq Ea Addt'l 20sqcm",CASE-11045,LOCAL,11045,CPT,0361,RC,,,,outpatient,,,19833.02,11899.81,,,,,,,,,,,,,
Open Treatment Bimalleolar Ankle Fracture,CASE-27814,LOCAL,27814,CPT,,,,,,outpatient,,,36212.23,21727.34,,,,,,,,,,,,,
Egd Flexible Foreign Body Removal,CASE-43247,LOCAL,43247,CPT,0360,RC,,,,outpatient,,,14682.97,8809.78,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THUMB|PO",CASE-26055,LOCAL,26055,CPT,,,,,F5|PO,outpatient,,,10294.92,6176.95,,,,,,,,,,,,,
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,LOCAL,38531,CPT,0360,RC,,,RT,outpatient,,,32455.47,19473.28,,,,,,,,,,,,,
Excision/Curettage Bone Cyst/Tumor Tibia/Fibula,CASE-27635,LOCAL,27635,CPT,0360,RC,,,,outpatient,,,36064.92,21638.95,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,LOCAL,52352,CPT,0360,RC,,,,outpatient,,,16787.03,10072.22,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE|PO,CASE-24342,LOCAL,24342,CPT,,,,,RT|PO,outpatient,,,17543.07,10525.84,,,,,,,,,,,,,
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26531,LOCAL,26531,CPT,,,,,F6|PO,outpatient,,,35112.83,21067.70,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT|PO",CASE-26951,LOCAL,26951,CPT,,,,,F2|PO,outpatient,,,15455.88,9273.53,,,,,,,,,,,,,
Arven Anast Opn Upr Arm Basilic Vein Trpos|LEFT SIDE,CASE-36819,LOCAL,36819,CPT,,,,,LT,outpatient,,,50418.80,30251.28,,,,,,,,,,,,,
DRESSING WND W4XL10IN 258 SQ CM CROSSLINKED BOV TEND CLLGN,SUP-2243934,CDM,Q4104,HCPCS,0636,RC,,,,both,,,11928.86,7753.76,,,,,,,,,,,,,
STENT BILI L40MM DIA7MM DEL SYS L80CM SHTH 6FR GWIRE,SUP-2257374,CDM,C1876,HCPCS,0278,RC,,,,both,,,5165.30,3357.44,,,,,,,,,,,,,
SPLINT FNGR OVL-8 RNG SZ 4 5PK,SUP-2112610,CDM,L3927,HCPCS,0274,RC,,,,both,,,60.82,39.53,,,,,,,,,,,,,
PIN FIX L110MM DIA3MM EX ANCHR DEV ORTHOLOCK,SUP-2364169,CDM,C1713,HCPCS,0278,RC,,,,both,,,29.52,19.19,,,,,,,,,,,,,
GRAFT ACHILLES PRESHAPE FZ ASP,SUP-2858212,CDM,C1762,CPT,0278,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 3 DOG BNE PLATE XDRV 12,SUP-2935489,CDM,C1713,HCPCS,0278,RC,,,,both,,,26633.48,17311.76,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 60 CM DIA 8.5 FR NDL L 71 CM MP18,SUP-2516625,CDM,C1893,HCPCS,0272,RC,,,,both,,,555.15,360.85,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|PO,CASE-64721,LOCAL,64721,CPT,,,,,RT|PO,outpatient,,,10407.58,6244.55,,,,,,,,,,,,,
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,LOCAL,58260,CPT,,,,,,outpatient,,,40428.58,24257.15,,,,,,,,,,,,,
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,LOCAL,31629,CPT,0360,RC,,,,outpatient,,,20478.97,12287.38,,,,,,,,,,,,,
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, THIRD DIGIT|PO",CASE-26531,LOCAL,26531,CPT,0360,RC,,,F7|PO,outpatient,,,24951.15,14970.69,,,,,,,,,,,,,
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE,CASE-36247,LOCAL,36247,CPT,0361,RC,,,LT,outpatient,,,38936.65,23361.99,,,,,,,,,,,,,
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|LEFT FOOT, SECOND DIGIT|PO",CASE-28092,LOCAL,28092,CPT,,,,,T1|PO,outpatient,,,12995.53,7797.32,,,,,,,,,,,,,
Rpr Aa Hernia Recr > 10 Cm Ncrc8/Strangulated,CASE-49618,LOCAL,49618,CPT,0360,RC,,,,outpatient,,,89154.10,53492.46,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-23430,LOCAL,23430,CPT,0360,RC,,,73,outpatient,,,17170.50,10302.30,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28820,LOCAL,28820,CPT,,,,,T2,outpatient,,,17827.43,10696.46,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,LOCAL,64721,CPT,0360,RC,,,LT,outpatient,,,8150.02,4890.01,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,LOCAL,11404,CPT,,,,,,outpatient,,,22448.28,13468.97,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm|PO,CASE-11401,LOCAL,11401,CPT,,,,,PO,outpatient,,,13527.90,8116.74,,,,,,,,,,,,,
Dcmprn Fasct Leg Ant&/Lat Compartments Only,CASE-27600,LOCAL,27600,CPT,0360,RC,,,,outpatient,,,20812.13,12487.28,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE|PO,CASE-27524,LOCAL,27524,CPT,0360,RC,,,RT|PO,outpatient,,,21598.42,12959.05,,,,,,,,,,,,,
Egd Flexible Foreign Body Removal,CASE-43247,LOCAL,43247,CPT,,,,,,outpatient,,,14682.97,8809.78,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE|PO,CASE-64490,LOCAL,64490,CPT,0361,RC,,,50|PO,outpatient,,,4781.18,2868.71,,,,,,,,,,,,,
Dstrj Lesion Anus Simple Laser Surg,CASE-46917,LOCAL,46917,CPT,,,,,,outpatient,,,25809.12,15485.47,,,,,,,,,,,,,
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,LOCAL,27792,CPT,0360,RC,,,RT,outpatient,,,33259.40,19955.64,,,,,,,,,,,,,
INTRODUCER SHTH L60CM 7FR LAT VEIN HK BRAID SFSHTH WORLEY,SUP-2356597,CDM,C1892,HCPCS,0272,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
MARKER SURG TISS W2XH1XL2CM BIOZORB LO PROF,SUP-2535481,CDM,A4648,CPT,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
IMMOBILIZER KNEE SM L19IN FOR 14 16IN BLU CANVS T BAR STAY,SUP-2336065,CDM,L1830,CPT,0272,RC,,,,both,,,40.07,26.05,,,,,,,,,,,,,
LEAD NERVE STIM L 50 CM KT PERC 16 CONTACT STRL INFINION PRO,SUP-2905209,CDM,C1778,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
KIT FIX EL TI 2 HUM CONDYLE HEXALOBULAR 2 SCR DISCVR,SUP-2215461,CDM,C1776,CPT,0278,RC,,,,both,,,4213.88,2739.02,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ULTRA HI DEMAND CERM ON CERM STRYKERHCERM] STRYKER CORP],SUP-2365977,CDM,C1776,CPT,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 40 CM DIA 4 MM CLLGN BOV CAR ART,SUP-2880937,CDM,C1768,CPT,0278,RC,,,,both,,,11677.66,7590.48,,,,,,,,,,,,,
INSERT TIB 9 5 MM KNEE BEAR,SUP-2365105,CDM,C1776,CPT,0278,RC,,,,both,,,2564.94,1667.21,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM DIA0.014IN PTFE STEER J TIP PRIMEWIRE,SUP-2327235,CDM,C1769,HCPCS,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
PLATE SPNL 21X27X10 MM VU APOD,SUP-2244701,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 60 CM DIA12 MM POLYESTER BOV CLLGN,SUP-2227684,CDM,C1768,CPT,0278,RC,,,,both,,,1897.35,1233.28,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 15 CM DIA15 MM CATH DIA 0.038 IN,SUP-2170435,CDM,C1889,HCPCS,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
PLATE BONE 100DEG 6 H Y SHP STERNALOCK BLU,SUP-2419712,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
PLATE BONE 2 H LNG TI STR FOR CRAN CLSR SYS,SUP-2243970,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.48,111.46,,,,,,,,,,,,,
SHELL ACET OD60MM UNIV HA POR PLSM SPRY HIP REV PRESSFIT,SUP-2408351,CDM,C1776,CPT,0278,RC,,,,both,,,12409.28,8066.03,,,,,,,,,,,,,
PLATE BNE BAR 8MM DBL Y 6 HS FOR 2MM SCR H UNIV FIX SYS,SUP-2366329,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.83,444.49,,,,,,,,,,,,,
Excision Lesion Meniscus/Capsule Knee|LEFT SIDE|PO,CASE-27347,LOCAL,27347,CPT,0360,RC,,,LT|PO,outpatient,,,18525.10,11115.06,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, THIRD DIGIT|PO",CASE-28232,LOCAL,28232,CPT,0360,RC,,,T7|PO,outpatient,,,12145.77,7287.46,,,,,,,,,,,,,
Transurethral Resection Bladder Neck|SEPARATE STRUCTURE,CASE-52500,LOCAL,52500,CPT,,,,,XS,outpatient,,,27597.97,16558.78,,,,,,,,,,,,,
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE,CASE-27650,LOCAL,27650,CPT,0360,RC,,,LT,outpatient,,,26973.92,16184.35,,,,,,,,,,,,,
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|RIGHT SIDE|PO,CASE-25260,LOCAL,25260,CPT,,,,,RT|PO,outpatient,,,13068.78,7841.27,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT|PO",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F2|PO,outpatient,,,8824.37,5294.62,,,,,,,,,,,,,
HC Cv Cath Plac W/Port Tun >5|RIGHT SIDE,CASE-36561,LOCAL,36561,CPT,0361,RC,,,RT,outpatient,,,21895.73,13137.44,,,,,,,,,,,,,
Laparoscopy Surgical Jejunostomy,CASE-44186,LOCAL,44186,CPT,0360,RC,,,,outpatient,,,53552.30,32131.38,,,,,,,,,,,,,
Fasciotomy Foot&/Toe|LEFT SIDE,CASE-28008,LOCAL,28008,CPT,0360,RC,,,LT,outpatient,,,16767.93,10060.76,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,LOCAL,64635,CPT,0360,RC,,,50,outpatient,,,12456.70,7474.02,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,LOCAL,26055,CPT,,,,,FA,outpatient,,,13287.83,7972.70,,,,,,,,,,,,,
Cysto/Pyeloscopy Rescj Pelvic Tumor,CASE-52355,LOCAL,52355,CPT,0360,RC,,,,outpatient,,,23927.88,14356.73,,,,,,,,,,,,,
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|LEFT SIDE,CASE-37225,LOCAL,37225,CPT,0360,RC,,,LT,outpatient,,,55057.63,33034.58,,,,,,,,,,,,,
HC Cath Urethral Simple,CASE-51702,LOCAL,51702,CPT,0761,RC,,,,outpatient,,,10240.53,6144.32,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,LOCAL,52351,CPT,0360,RC,,,RT,outpatient,,,15814.95,9488.97,,,,,,,,,,,,,
Suture Quadriceps/Hamstring Rupture Primary|RIGHT SIDE,CASE-27385,LOCAL,27385,CPT,0360,RC,,,RT,outpatient,,,31734.22,19040.53,,,,,,,,,,,,,
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,LOCAL,54410,CPT,,,,,,outpatient,,,89264.03,53558.42,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|RIGHT SIDE|PO,CASE-29883,LOCAL,29883,CPT,,,,,RT|PO,outpatient,,,69267.08,41560.25,,,,,,,,,,,,,
SCREW BNE L50MM OD6.5MM STD NONSTERILE TI CANC CORT ST SELF,SUP-2374389,CDM,C1713,HCPCS,0278,RC,,,,both,,,1266.05,822.93,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 120 MM DIA 6 MM DEL SYS L 120,SUP-2155353,CDM,C1876,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
HYDROCORTISONE 1 % EX OINT,RX-3731,CDM,6370000000,HCPCS,0637,RC,00168-0020-31,NDC,,both,28.35,GR,29.60,19.24,,,,,,,,,,,,,
DEVICE ATHRCTMY SHFT L 145 CM DIA 0.063 IN CRWN 1.5 MM NOSE,SUP-2892898,CDM,C1724,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 VR-T 55 X 66MM 13MM 40J VVED,SUP-2138191,CDM,C1722,HCPCS,0275,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
PLATE BONE L120MM 5 H BILAT TI SPN LCK COMPR LO PROF RIG FOR,SUP-2190888,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.25,756.76,,,,,,,,,,,,,
MESH HERN W1XL4IN INGUINAL POLYPR MFIL RECTANG,SUP-2125743,CDM,C1781,HCPCS,0278,RC,,,,both,,,76.30,49.59,,,,,,,,,,,,,
PIN HALF FIXATION M4 L200MM THREAD L30MM STAINLESS STEEL,SUP-2586486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,506.58,329.28,,,,,,,,,,,,,
PROSTHESIS 3.25MM DIAM 5MM LEN PORP FULL CANN OFFSET W/,SUP-2312808,CDM,L8613,CPT,0278,RC,,,,both,,,1256.60,816.79,,,,,,,,,,,,,
Cystostomy Cystotomy W/Drainage|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51040,LOCAL,51040,CPT,0360,RC,,,XU,outpatient,,,27232.07,16339.24,,,,,,,,,,,,,
Removal Implant Deep|SEPARATE STRUCTURE|PO,CASE-20680,LOCAL,20680,CPT,0360,RC,,,XS|PO,outpatient,,,35793.97,21476.38,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvic/Le 1st Ord|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,LOCAL,36245,CPT,0361,RC,,,XU,outpatient,,,33676.83,20206.10,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE|PO",CASE-28289,LOCAL,28289,CPT,0360,RC,,,TA|PO,outpatient,,,19110.18,11466.11,,,,,,,,,,,,,
Hysteroscopy Endometrial Ablation,CASE-58563,LOCAL,58563,CPT,0360,RC,,,,outpatient,,,31240.57,18744.34,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64721,LOCAL,64721,CPT,,,,,RT|XS|PO,outpatient,,,27264.38,16358.63,,,,,,,,,,,,,
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|RIGHT SIDE|PO,CASE-29884,LOCAL,29884,CPT,0360,RC,,,RT|PO,outpatient,,,45972.65,27583.59,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE|PO,CASE-29826,LOCAL,29826,CPT,,,,,RT|PO,outpatient,,,52209.17,31325.50,,,,,,,,,,,,,
Syndactylization Toes|BILATERAL PROCEDURE|PO,CASE-28280,LOCAL,28280,CPT,,,,,50|PO,outpatient,,,21355.03,12813.02,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28291,LOCAL,28291,CPT,0360,RC,,,T5|PO,outpatient,,,22995.98,13797.59,,,,,,,,,,,,,
Rpr Aa Hernia Recr > 10 Cm Ncrc8/Strangulated,CASE-49618,LOCAL,49618,CPT,,,,,,outpatient,,,89154.10,53492.46,,,,,,,,,,,,,
Partial Excision Bone Fibula,CASE-27641,LOCAL,27641,CPT,0360,RC,,,,outpatient,,,35935.35,21561.21,,,,,,,,,,,,,
Removal Implant Deep|PO,CASE-20680,LOCAL,20680,CPT,,,,,PO,outpatient,,,21472.18,12883.31,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T3|PO,outpatient,,,25077.23,15046.34,,,,,,,,,,,,,
SYSTEM STENT GRFT OVATION IX L 80 MM DIA29 MM DEL CATH 14 FR,SUP-2217721,CDM,C1768,CPT,0278,RC,,,,both,,,37676.86,24489.96,,,,,,,,,,,,,
SHAFT SURG DRL LEVERAGE LFS DISP 8MM,SUP-2311380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
MESH SURG W20XL30CM THK1MM DUALMESH + BIOMATERIAL EPTFE,SUP-2395343,CDM,C1781,HCPCS,0278,RC,,,,both,,,5444.76,3539.09,,,,,,,,,,,,,
POSITIONER HRT NS STARFISH,SUP-2281002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SET INTRO MICRO-STICK SHTH L 9 CM DIA 5 FR 7 CM NIT REG COAX,SUP-2627288,CDM,C1894,HCPCS,0272,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
HC So Electrophoretic Test,PX-3018266466,CDM,82664,CPT,0301,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
INTRAOSSEOUS FIX SYS TRL SZR FOR 22MM,SUP-2400076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
SPHINCTEROTOME ENDO L200CM OD7FR 4.2MM MFIL PUR CONN DOME,SUP-2170077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
NAIL IM L260MM DIA7MM UNIV HUM TI CANN LCK VERSANAIL,SUP-2412497,CDM,C1713,HCPCS,0278,RC,,,,both,,,3648.68,2371.64,,,,,,,,,,,,,
PLATE BONE SPNL FLR ASPN 10 MM,SUP-2136962,CDM,C1713,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 100 CM DIA10 X 10 MM BRANCH 60CM RT,SUP-2535438,CDM,C1768,CPT,0278,RC,,,,both,,,2569.96,1670.47,,,,,,,,,,,,,
STENT CAR WSTNT UNCONSTRAINED L 24 MM DIA10 MM CATH L 135 CM,SUP-2148434,CDM,C1876,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA11 FR GUIDEWIRE 0.038 IN,SUP-2168430,CDM,C1894,HCPCS,0272,RC,,,,both,,,25.37,16.49,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME 120CM 4FR COURNAND QPLR,SUP-2487482,CDM,C1730,HCPCS,0272,RC,,,,both,,,168.87,109.77,,,,,,,,,,,,,
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64448,LOCAL,64448,CPT,0360,RC,,,XU|LT|PO,outpatient,,,36218.43,21731.06,,,,,,,,,,,,,
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE|PO,CASE-28740,LOCAL,28740,CPT,,,,,LT|PO,outpatient,,,39959.50,23975.70,,,,,,,,,,,,,
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO|SEPARATE STRUCTURE,CASE-14040,LOCAL,14040,CPT,,,,,PO|XS,outpatient,,,21355.03,12813.02,,,,,,,,,,,,,
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|RIGHT SIDE,CASE-27675,LOCAL,27675,CPT,,,,,RT,outpatient,,,35280.80,21168.48,,,,,,,,,,,,,
Removal Implant Deep|SEPARATE STRUCTURE,CASE-20680,LOCAL,20680,CPT,,,,,XS,outpatient,,,25125.32,15075.19,,,,,,,,,,,,,
Excision Tumor Soft Tis Back/Flank Subq 3 Cm/>,CASE-21931,LOCAL,21931,CPT,0360,RC,,,,outpatient,,,21275.58,12765.35,,,,,,,,,,,,,
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,LOCAL,49594,CPT,0360,RC,,,,outpatient,,,54843.77,32906.26,,,,,,,,,,,,,
Capsulectomy/Capsulotomy Mtcarphlngl Joint Each,CASE-26520,LOCAL,26520,CPT,,,,,,outpatient,,,10702.65,6421.59,,,,,,,,,,,,,
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|RIGHT SIDE|PO,CASE-23700,LOCAL,23700,CPT,,,,,RT|PO,outpatient,,,19064.73,11438.84,,,,,,,,,,,,,
Laparoscopic Appendectomy,CASE-44970,LOCAL,44970,CPT,0360,RC,,,,outpatient,,,25927.50,15556.50,,,,,,,,,,,,,
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,LOCAL,55040,CPT,,,,,LT,outpatient,,,21700.47,13020.28,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26123,LOCAL,26123,CPT,,,,,F3|PO,outpatient,,,15717.73,9430.64,,,,,,,,,,,,,
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE,CASE-27601,LOCAL,27601,CPT,0360,RC,,,LT,outpatient,,,26973.92,16184.35,,,,,,,,,,,,,
SCREW BONE LOK 5.5MM DIA 105MML TTNM CRTCL FLLY THRDD SOLID,SUP-2587390,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.32,298.56,,,,,,,,,,,,,
HC Respirator Motion Mgmt Simul,PX-3337729300,CDM,77293,CPT,0333,RC,,,,inpatient,,,4423.00,2874.95,,,,,,,,,,,,,
ANCHOR SUTURE UHMWPE POLYESTER TI BTTN WASHER EXTRATHORACIC ST 1PK,SUP-2905469,CDM,C1713,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
SNARE POLYP 5FR L35CM HYSTEROSCOPIC NIT NCIRCLE,SUP-2168971,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.04,265.23,,,,,,,,,,,,,
WASHER SPNL SS XIA,SUP-2379903,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TAP 20MM CNTRE DRIVE SCRWS W/DPTH GAUGE MRKNGS WORKS W/01 4,SUP-2707274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,397.34,258.27,,,,,,,,,,,,,
PLATE BNE HUM 3.5X109 MM RT PERIARTICULAR PROX 3 HOLE LCK LP,SUP-2177818,CDM,C1713,HCPCS,0278,RC,,,,both,,,5208.00,3385.20,,,,,,,,,,,,,
STIMULATOR BNE MINI MESH CATHODE 60UA DEV SPF +,SUP-2414470,CDM,E0749,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
HC So2 Immunoassay,PX-3018351668,CDM,83516,CPT,0301,RC,,,,both,,,564.00,366.60,,,,,,,,,,,,,
PLATE BONE L207MM 14 H RT DSTL LAT FEM TI FOR 4.5MM SCR,SUP-2101269,CDM,C1713,HCPCS,0278,RC,,,,both,,,4815.50,3130.07,,,,,,,,,,,,,
Dir Rpr Aneurysm Axil-Brachial Arm Incision|RIGHT SIDE,CASE-35011,LOCAL,35011,CPT,0360,RC,,,RT,outpatient,,,51788.87,31073.32,,,,,,,,,,,,,
Rhinoplasty Primary W/Major Septal Repair|PO,CASE-30420,LOCAL,30420,CPT,0360,RC,,,PO,outpatient,,,39029.90,23417.94,,,,,,,,,,,,,
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,LOCAL,94640,CPT,0410,RC,,,,outpatient,,,52994.60,31796.76,,,,,,,,,,,,,
Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent,CASE-36903,LOCAL,36903,CPT,,,,,,outpatient,,,51133.50,30680.10,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,LOCAL,49651,CPT,,,,,RT,outpatient,,,42204.82,25322.89,,,,,,,,,,,,,
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>|RIGHT SIDE,CASE-23071,LOCAL,23071,CPT,,,,,RT,outpatient,,,13689.87,8213.92,,,,,,,,,,,,,
Osteotomy Tarsal Bones Oth/Thn Calcaneus/Talus|LEFT SIDE|PO,CASE-28304,LOCAL,28304,CPT,,,,,LT|PO,outpatient,,,16375.20,9825.12,,,,,,,,,,,,,
Arthroscopy Knee Removal Loose/Foreign Body|LEFT SIDE,CASE-29874,LOCAL,29874,CPT,,,,,LT,outpatient,,,18525.75,11115.45,,,,,,,,,,,,,
COIL EMB L30CM OD0.020IN LOOP OD10MM NIT STRTCH RESIST FILL,SUP-2323410,CDM,C1889,HCPCS,0278,RC,,,,both,,,7655.32,4975.96,,,,,,,,,,,,,
KIT BLWRMSTR CRNRY WTBNG SET F  PUMP BPSS CLRVW,SUP-2722937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.65,335.17,,,,,,,,,,,,,
DRIVER SURG CANN SHFT FEN CREO,SUP-2418318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SHEATH RENAL ACC HYDRPHLC RADIOPQ CONT FLO AMPLTZ OPQ 24,SUP-2168947,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.51,52.98,,,,,,,,,,,,,
FORCEPS BIPOLAR 1.5MM DISPOSABLE,SUP-2760177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
TAP SURG ANTR REVERE OD5.5MM,SUP-2232142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 60 CM DIA 0.032 IN SS PERIPH SFT,SUP-2383361,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.41,21.72,,,,,,,,,,,,,
BURR PTERYGIUM DIAMOND DISK SHAPE 5.5MM,SUP-2471106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.44,208.29,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FOURTH DIGIT|PO",CASE-26765,LOCAL,26765,CPT,0360,RC,,,F3|PO,outpatient,,,24888.02,14932.81,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,LOCAL,64636,CPT,,,,,,outpatient,,,12456.70,7474.02,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26123,LOCAL,26123,CPT,0360,RC,,,F3|PO,outpatient,,,15717.73,9430.64,,,,,,,,,,,,,
Conv Prev Hip Tot Hip Arthrp W/WO Agrft/Algrft,CASE-27132,LOCAL,27132,CPT,,,,,,outpatient,,,82195.42,49317.25,,,,,,,,,,,,,
Prq Skeletal Fix Carpo/Metacarpal Fx Dislc Thumb,CASE-26650,LOCAL,26650,CPT,0360,RC,,,,outpatient,,,10640.50,6384.30,,,,,,,,,,,,,
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|LEFT SIDE,CASE-37232,LOCAL,37232,CPT,,,,,LT,outpatient,,,49148.80,29489.28,,,,,,,,,,,,,
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE|PO,CASE-28120,LOCAL,28120,CPT,,,,,RT|PO,outpatient,,,35852.18,21511.31,,,,,,,,,,,,,
HC Rehab R&B,PX-1280000000,CDM,1280000000,LOCAL,,,,,,outpatient,,,2644.42,1586.65,,,,,,,,,,,,,
HC Extremity Venogram|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,LOCAL,36005,CPT,0361,RC,,,RT|XU,outpatient,,,59463.47,35678.08,,,,,,,,,,,,,
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27654,LOCAL,27654,CPT,,,,,LT|PO|CG,outpatient,,,25385.63,15231.38,,,,,,,,,,,,,
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,LOCAL,43249,CPT,0360,RC,,,,outpatient,,,14344.32,8606.59,,,,,,,,,,,,,
Excision Malignant Lesion S/N/H/F/G 0.6-1.0 Cm,CASE-11621,LOCAL,11621,CPT,,,,,,outpatient,,,17682.82,10609.69,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO|SEPARATE STRUCTURE",CASE-26055,LOCAL,26055,CPT,,,,,F8|PO|XS,outpatient,,,16513.35,9908.01,,,,,,,,,,,,,
Destruction Vaginal Lesions Simple,CASE-57061,LOCAL,57061,CPT,,,,,,outpatient,,,19380.93,11628.56,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular,CASE-27427,LOCAL,27427,CPT,0360,RC,,,,outpatient,,,47575.93,28545.56,,,,,,,,,,,,,
Lig&Div Long Saph Vein Saphfem Junct/Interrupj|LEFT SIDE,CASE-37700,LOCAL,37700,CPT,,,,,LT,outpatient,,,23884.98,14330.99,,,,,,,,,,,,,
Repair Dislocating Peroneal Tendon W/Fib Osteot|LEFT SIDE,CASE-27676,LOCAL,27676,CPT,,,,,LT,outpatient,,,28524.17,17114.50,,,,,,,,,,,,,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],29972.67,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,17127.24,50821.76,All Other Inpatient
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Parathyroid Autotransplantation Add-On,CASE-60512,APC,60512,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv,CASE-64418,APC,64418,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17212.32,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
Tenolysis Extensor Tendon Hand/Finger Each,CASE-26445,APC,26445,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11080.19,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11080.19,32878.30,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11871.54,,"Case rate ($11,871.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,001.85, add-ons for qualifying new technology services are included. If operating cost exceeds $51,547.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,512.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,007.29. The transfer operating threshold is the transfer adjustment factor * $11,001.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.25. The transfer capital threshold is the transfer adjustment factor * $864.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11867.93,11867.93,11867.93,1 through 10,other,11871.54,35778.69,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6699.57,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6637.25,6637.25,6700.52,1 through 10,other,6699.57,24060.08,Inpatient DRG
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13090.16,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12833.49,58980.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,76376.03,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|BILATERAL PROCEDURE,CASE-49507,APC,49507,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9904.85,,"Case rate ($9,433.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,839.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.47. The transfer capital threshold is the transfer adjustment factor * $668.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6531.00,35832.77,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],69736.80,,"Fee schedule rate ($69,736.80). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"IMPLANTABLE HEART ASSIST SYSTEMS,EXTREME",161,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],323068.41,,"Case rate ($323,068.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $121,386, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,323068.41,339221.83,There are no additional notes associated with this service or procedure.
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ligation/Biopsy Temporal Artery|RIGHT SIDE,CASE-37609,APC,37609,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32071.54,,,,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
Mastectomy Simple Complete|RIGHT SIDE,CASE-19303,APC,19303,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],27851.43,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,46419.05,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21074.07,,,,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,10492.66,31134.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Sling Opration Corrj Male Urinary Incontinence,CASE-53440,APC,53440,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12951.54,,"APC Price ($12,513.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12513.57,13139.25,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6518.41,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3935.39,,"Case rate ($3,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,436.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $265.60. The transfer capital threshold is the transfer adjustment factor * $265.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",2515.00,2515.00,2515.00,1 through 10,other,3753.97,11139.15,Inpatient DRG
"OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,EXTREME",253,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],25656.47,,"Case rate ($24,434.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24434.73,25656.47,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
HC Peripheral Block - Femoral Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12225.74,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,11986.02,54149.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9761.89,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9761.89,37873.87,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],31913.70,,"Fee schedule rate ($31,913.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC Rt Bronchoscopy Alveolar Lavage,CASE-31624,APC,31624,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1688.18,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1688.18,1772.59,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14837.11,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14130.58,57770.11,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5618.09,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5507.93,20510.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30818.12,,,,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16865.16,,,,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29912.98,,,,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33483.49,,"Fee schedule rate ($33,483.49). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4564.97,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4564.97,13545.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17691.40,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10109.37,38416.97,All Other Inpatient
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16175.36,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,55581.70,Inpatient DRG
Litholapaxy Smpl/Sm <2.5 Cm|SEPARATE STRUCTURE,CASE-52317,APC,52317,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8.88,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
Arteriovenous Anastomosis Open Direct|LEFT SIDE,CASE-36821,APC,36821,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19210.66,,,,,,0,other,6474.12,19210.66,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14789.23,,,,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
HC Trigger Point 3 or More|LEFT SIDE|PO,CASE-20553,APC,20553,CPT,0510,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],56089.29,,,,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB|PO",CASE-64831,APC,64831,CPT,0360,RC,,,F5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12316.55,,"Case rate ($11,730.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,838.28, add-ons for qualifying new technology services are included. If operating cost exceeds $46,306.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,019.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,881.47. The transfer operating threshold is the transfer adjustment factor * $10,838.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.58. The transfer capital threshold is the transfer adjustment factor * $848.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11730.05,61348.24,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41073.77,,,,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8704.87,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8704.87,25830.00,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14315.62,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13831.52,59770.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>|RIGHT SIDE|PO,CASE-25071,APC,25071,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5349.54,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5094.80,15365.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13014.93,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12395.17,42174.37,Inpatient DRG
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MODERATE",140,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9273.58,,"Case rate ($8,831.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8831.98,9273.58,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],33072.79,,"Case rate ($33,072.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,563.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,392.57. The transfer capital threshold is the transfer adjustment factor * $2,392.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,33072.79,98455.37,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<,CASE-11420,APC,11420,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1621.31,OPPS APC
Split Agrft T/a/L Ea 100 Cm/Ea 1% Bdy Inft/Chld,CASE-15101,APC,15101,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2054.80,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.96,2054.80,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6948.21,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THIRD DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,APC,58661,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"OTHER SMALL AND LARGE BOWEL PROCEDURES,MINOR",223,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4669.27,,"Case rate for a one day stay ($4,446.92). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4446.92,4669.27,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7988.70,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4564.97,13545.65,All Other Inpatient
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14807.87,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14102.73,41847.08,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17771.25,,"Fee schedule rate ($17,771.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14347.61,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13664.39,40546.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Prq Skeletal Fix Carpo/Metacarpal Fx Dislc Thumb|RIGHT HAND, THUMB|PO",CASE-26650,APC,26650,CPT,0360,RC,,,F5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6762.29,,"Case rate ($6,440.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,950.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,418.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,637.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,974.38. The transfer operating threshold is the transfer adjustment factor * $5,950.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $465.91. The transfer capital threshold is the transfer adjustment factor * $465.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6440.28,19110.30,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23624.56,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23624.56,83038.88,Inpatient DRG
Nerve Repair W/Nerve Allograft First Strand|PO,CASE-64912,APC,64912,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8323.61,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8323.61,8739.79,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21850.50,,"Fee schedule rate ($21,850.50). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9717.86,,"Case rate ($9,255.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,827.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.85. The transfer capital threshold is the transfer adjustment factor * $655.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9269.86,37852.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10290.40,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10290.40,42115.80,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6835.51,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6835.51,20283.05,Inpatient DRG
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,APC,58558,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20986.65,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7826.00,90280.33,Inpatient DRG
Removal Implant Deep,CASE-20680,APC,20680,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",2750.01,2750.01,2750.01,1 through 10,other,2755.03,2851.46,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],53205.34,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,30403.05,90685.00,All Other Inpatient
Open Treatment Fracture Distal Tibia Only|RIGHT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],104605.60,,"Fee schedule rate ($104,605.60). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
Fasciectomy Plantar Fascia Partial Spx|RIGHT SIDE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,EXTREME",282,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],31957.04,,"Case rate ($31,957.04). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31957.04,33554.89,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4454.33,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4303.70,14124.38,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6837.50,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6837.50,20288.95,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12560.26,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11962.15,40923.09,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6748.64,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6748.64,20025.28,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16092.51,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15326.20,52511.19,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,APC,43249,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1822.73,1822.73,1822.73,1 through 10,other,1820.02,1911.02,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB|PO",CASE-64831,APC,64831,CPT,0360,RC,,,F5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12006.78,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11600.75,34422.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|RIGHT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18988.45,,"Fee schedule rate ($18,988.45). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,21325.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
Unlisted Procedure Male Genital System,CASE-55899,APC,55899,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],236.97,,"APC Price ($236.97). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,236.97,248.82,OPPS APC
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,APC,43239,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,Zero final payments for the item or service in the 15 months prior to posting the file.
Gastrocnemius Recession|RIGHT SIDE,CASE-27687,APC,27687,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,APC,57520,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8638.55,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8442.00,28788.33,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18587.18,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,18222.73,59942.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22878.60,,"Fee schedule rate ($22,878.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Pilonidal Cyst/Sinus Extensive,CASE-11771,APC,11771,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],70963.13,,,,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5636.41,,"Case rate ($5,368.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,959.91, add-ons for qualifying new technology services are included. If operating cost exceeds $40,427.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,559.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,979.68. The transfer operating threshold is the transfer adjustment factor * $4,959.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $388.34. The transfer capital threshold is the transfer adjustment factor * $388.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5368.01,15928.53,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18042.36,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",18042.37,18042.37,22072.11,1 through 10,other,18042.36,82749.58,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7015.06,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6681.01,19824.58,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],43248.49,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,24713.42,73332.24,All Other Inpatient
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],41577.41,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,23758.52,103116.16,All Other Inpatient
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, SECOND DIGIT|PO",CASE-26356,APC,26356,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8231.45,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7551.60,23262.15,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4470.15,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4257.29,12632.63,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
Rpr Component Inflatable Penile Prosthesis,CASE-54408,APC,54408,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,EXTREME",951,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],54340.24,,"Case rate ($54,340.24). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,544, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,54340.24,57057.25,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10804.92,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10290.40,42115.80,Inpatient DRG
Synovectomy Tendon Sheath Foot Extensor|RIGHT SIDE|PO,CASE-28088,APC,28088,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],31112.60,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31112.60,92731.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33968.35,,"Fee schedule rate ($33,968.35). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15944.28,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",9014.36,9014.36,9014.36,1 through 10,other,3295.00,55581.70,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
HC Cystostomy Tube Change,CASE-51705,APC,51705,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],103171.69,,"Fee schedule rate ($103,171.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17123.00,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8558.00,48389.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Suture Quadriceps/Hamstring Rupture Primary|RIGHT SIDE,CASE-27385,APC,27385,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37423.05,,"Fee schedule rate ($37,423.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13305.64,39481.90,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7826.00,,"Per diem ($7,826). If length of stay < 7.6, first 1 days paid at a per diem of $15,652 instead. Capped at $59,476.09.",,,,0,other,7826.00,90280.33,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Angular Dfrm Toe Soft Tiss Px Only|BILATERAL PROCEDURE|SEPARATE STRUCTURE|PO,CASE-28313,APC,28313,CPT,0360,RC,,,50|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Laparoscopy Surg Partial Nephrectomy|RIGHT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18675.44,,,,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12476.30,,"Case rate ($11,882.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.01. The transfer capital threshold is the transfer adjustment factor * $842.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11901.14,35314.31,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Interdigital Morton Neuroma Single Each|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8925.03,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8925.03,26628.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26465.57,,,,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
Rhytidectomy Neck W/Platysmal Tightening|PO,CASE-15825,APC,15825,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2367.72,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2333.89,2367.72,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT FOOT, GREAT TOE",CASE-28297,APC,28297,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20168.93,,,,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10880.82,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10362.69,29367.82,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FOURTH DIGIT|SEPARATE STRUCTURE",CASE-26440,APC,26440,CPT,0360,RC,,,F8|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3258.56,3258.56,OPPS APC
Open Treatment Ulnar Fracture Proximal End|RIGHT SIDE|PO,CASE-24685,APC,24685,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Debride Subq First 20 Sq Cm|SEPARATE STRUCTURE|PO,CASE-11042,APC,11042,CPT,0361,RC,,,XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE|POLICY CRITERIA APPLIED,CASE-27570,APC,27570,CPT,0360,RC,,,RT|CG,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7421.00,,"Case rate ($7,067.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,540.71, add-ons for qualifying new technology services are included. If operating cost exceeds $42,008.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,671.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,566.78. The transfer operating threshold is the transfer adjustment factor * $6,540.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.84. The transfer capital threshold is the transfer adjustment factor * $500.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7078.89,21005.20,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28299,APC,28299,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11202.05,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5669.00,18994.21,All Other Inpatient
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE|PO,CASE-24073,APC,24073,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2755.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Tibia|RIGHT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11441.81,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11217.46,37366.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21542.42,,"Fee schedule rate ($21,542.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15043.80,,"Fee schedule rate ($15,043.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5308.33,19857.20,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21086.06,,"Case rate ($20,081.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,594.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,423.08. The transfer capital threshold is the transfer adjustment factor * $1,423.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,17274.00,73717.28,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16624.45,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16062.27,48077.57,Inpatient DRG
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,APC,43282,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24074.06,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23602.02,108295.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3536.22,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19971.77,,"Fee schedule rate ($19,971.77). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],107249.77,,"Fee schedule rate ($107,249.77). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10869.06,,"Case rate ($10,351.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,904.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10367.99,37103.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],133731.44,,"Fee schedule rate ($133,731.44). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Bx,Vulva/Perineum,Addl Lesion",CASE-56606,APC,56606,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],873.59,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,873.59,917.27,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7003.94,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7003.94,20782.85,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11434.00,,"Fee schedule rate ($11,434.00). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14139.03,,"Fee schedule rate ($14,139.03). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,5450.78,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20088.06,,"Fee schedule rate ($20,088.06). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],47875.29,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,27357.31,100904.68,All Other Inpatient
"SEIZURE,MAJOR",053,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14663.94,,"Case rate ($13,965.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13965.66,14663.94,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9477.08,,"Fee schedule rate ($9,477.08). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39967.07,,"Fee schedule rate ($39,967.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9373.98,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9056.99,33814.75,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5182.53,,"Case rate ($5,007.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,626.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,094.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,645.03. The transfer operating threshold is the transfer adjustment factor * $4,626.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.24. The transfer capital threshold is the transfer adjustment factor * $362.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5007.28,16142.41,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11778.33,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11217.46,37366.25,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],45758.86,,,,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
Partial Excision Bone Fibula,CASE-27641,APC,27641,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,CASE-36556,APC,36556,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5018.44,2883.68,5018.44,1 through 10,other,2994.77,3144.51,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16320.00,,"Per diem ($16,320). If length of stay < 2.1, first 1 days paid at a per diem of $32,640 instead. Capped at $34,272.79.",,,,0,other,12093.45,40067.60,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9140.11,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8704.87,25830.00,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],97349.99,,,,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE|PO,CASE-27570,APC,27570,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Carpectomy 1 Bone|LEFT SIDE|PO,CASE-25210,APC,25210,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, THIRD DIGIT",CASE-28645,APC,28645,CPT,0360,RC,,,T7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13548.15,,"Fee schedule rate ($13,548.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22878.60,,"Fee schedule rate ($22,878.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",10943.82,10943.82,10943.82,1 through 10,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],129893.46,,"Fee schedule rate ($129,893.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,APC,11404,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11269.65,,"Fee schedule rate ($11,269.65). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",22186.26,22186.26,22186.26,1 through 10,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12179.66,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12179.66,36140.75,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7285.00,,"Per diem ($7,285). If length of stay < 5.4, first 1 days paid at a per diem of $14,570 instead. Capped at $39,337.51.",,,,0,other,7285.00,41187.90,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32406.65,,"Fee schedule rate ($32,406.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],47660.93,,"Fee schedule rate ($47,660.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",39123.22,39123.22,39123.22,1 through 10,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10311.96,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9820.91,29141.64,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8018.15,,"Case rate ($7,636.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,712.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.14. The transfer capital threshold is the transfer adjustment factor * $541.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7648.51,27371.98,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10787.72,,"Case rate ($10,274.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,899.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.05. The transfer capital threshold is the transfer adjustment factor * $728.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10290.40,42115.80,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,32980.62,Estimated amount calculated based on 4 day length of stay.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],36070.49,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,18559.00,141041.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,Zero final payments for the item or service in the 15 months prior to posting the file.
Transurethral Waterjet Ablation Prostate Compl,CASE-0421T,APC,0421T,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4.76,,,,,,0,other,4.76,4.76,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],27539.67,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27539.67,109237.68,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],89469.71,,"Fee schedule rate ($89,469.71). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|RIGHT SIDE,CASE-37225,APC,37225,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],565.88,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12540.27,,"Case rate ($11,943.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.33. The transfer capital threshold is the transfer adjustment factor * $846.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11962.15,40923.09,Inpatient DRG
Excision Malignant Lesion F/E/E/N/L >4.0 Cm,CASE-11646,APC,11646,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13664.39,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13664.39,40546.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5444.94,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",5422.50,5422.50,5422.50,1 through 10,other,5338.18,15839.99,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intravasc Lithotripsy,CASE-C9764,APC,C9764,CPT,0481,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9548.92,,"Case rate ($9,094.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,815.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.45. The transfer capital threshold is the transfer adjustment factor * $644.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",9548.92,7610.96,52657.62,1 through 10,other,9108.71,27028.33,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4517.87,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4517.87,13932.70,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18033.97,,,,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,MAJOR",512,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],32711.35,,"Case rate ($32,711.35). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,32711.35,34346.92,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13664.39,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13664.39,40546.43,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35778.69,,,,,,0,other,11871.54,35778.69,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5648.25,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5379.29,15961.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10886.39,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10367.99,37103.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT SIDE|PO,CASE-26356,APC,26356,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8491.17,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,34379.15,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],9799.00,,"Per diem ($9,799). If length of stay < 2.3, first 1 days paid at a per diem of $19,598 instead. Capped at $22,536.57.",,,,0,other,7952.22,25854.47,Estimated amount calculated based on 4 day length of stay.
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|PREVENTIVE SERVICES,CASE-45385,APC,45385,CPT,0360,RC,,,33,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],37975.33,,"Case rate ($36,166.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,734.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,562.92. The transfer capital threshold is the transfer adjustment factor * $2,562.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",37975.34,37975.34,40243.55,1 through 10,other,36224.65,128473.68,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11217.46,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10824.28,10824.28,10824.28,1 through 10,other,11217.46,37366.25,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12380.83,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11962.15,40923.09,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16817.56,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16817.56,58510.23,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],43128.06,,"Fee schedule rate ($43,128.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],48252.91,,"Fee schedule rate ($48,252.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],41451.86,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,40639.08,120588.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5895.43,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5779.83,17150.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,MODERATE",182,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5981.02,,"Case rate for a one day stay ($5,981.02). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5981.02,6280.07,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18227.38,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18227.38,54086.17,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MODERATE",425,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2502.86,,"Case rate for a one day stay ($2,502.86). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2502.86,2628.00,There are no additional notes associated with this service or procedure.
Open Treatment Bimalleolar Ankle Fracture|RIGHT SIDE|PO,CASE-27814,APC,27814,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13051.67,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13051.67,38728.27,Inpatient DRG
Ercp Dx Collection Specimen Brushing/Washing|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43260,APC,43260,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28442.40,,"Fee schedule rate ($28,442.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Implant Deep|PO,CASE-20680,APC,20680,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenotomy Open Extensor Foot/Toe Each Tendon,CASE-28234,APC,28234,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",6963.55,6963.55,6963.55,1 through 10,other,6882.29,7226.40,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|RIGHT SIDE,CASE-38570,APC,38570,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17467.27,,,,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],64770.78,,,,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4984.06,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4984.06,19757.81,Inpatient DRG
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],45520.40,,"Fee schedule rate ($45,520.40). Adds an outlier to normal pricing equal to the per diem rate ($131,498.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14825.11,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14534.42,59012.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],46830.28,,"Fee schedule rate ($46,830.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia & Fibula,CASE-27828,APC,27828,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31927.90,,,,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4257.29,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4257.29,12632.63,Inpatient DRG
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],33938.10,,"Fee schedule rate ($33,938.10). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26909.70,,"Fee schedule rate ($26,909.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9495.32,42131.77,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28847.26,,"Fee schedule rate ($28,847.26). Adds an outlier to normal pricing equal to the per diem rate ($89,320.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13464.14,,"Case rate ($12,822.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,079.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.68. The transfer capital threshold is the transfer adjustment factor * $908.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13582.24,13582.24,13582.24,1 through 10,other,6965.00,38110.41,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8431.66,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8431.66,25019.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],41117.20,,"Fee schedule rate ($41,117.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5419.59,,"Case rate ($5,161.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,536.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.76. The transfer capital threshold is the transfer adjustment factor * $365.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5169.74,15340.19,Inpatient DRG
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5549.19,16729.39,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27135.21,,"Fee schedule rate ($27,135.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],9242.00,,"Per diem ($9,242). If length of stay < 7.6, first 1 days paid at a per diem of $18,484 instead. Capped at $70,242.60.",,,,0,other,9242.00,76216.30,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],58534.56,,"Fee schedule rate ($58,534.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE,CASE-27650,APC,27650,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9777.90,,"Case rate ($9,312.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,604.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,072.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,638.62. The transfer operating threshold is the transfer adjustment factor * $8,604.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.67. The transfer capital threshold is the transfer adjustment factor * $673.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9312.29,27632.41,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28175.50,,,,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18072.75,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17212.14,64440.06,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28847.26,,"Fee schedule rate ($28,847.26). Adds an outlier to normal pricing equal to the per diem rate ($89,320.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE,CASE-27698,APC,27698,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25830.00,,,,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, THIRD DIGIT",CASE-28234,APC,28234,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1525.13,OPPS APC
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],46234.39,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,26419.65,96304.23,All Other Inpatient
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23270.57,,"Fee schedule rate ($23,270.57). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
Excision Local Lesion Epididymis|RIGHT SIDE,CASE-54830,APC,54830,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],9763.00,,"Per diem ($9,763). If length of stay < 4, first 1 days paid at a per diem of $19,526 instead. Capped at $39,053.73.",,,,0,other,9763.00,48626.00,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],43434.38,,"Fee schedule rate ($43,434.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",43434.38,43434.38,43434.38,1 through 10,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5596.16,,"Case rate ($5,329.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,548.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $377.68. The transfer capital threshold is the transfer adjustment factor * $377.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",5596.16,5596.16,5596.16,1 through 10,other,5338.18,15839.99,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],57135.35,,"Fee schedule rate ($57,135.35). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14118.54,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13446.23,39899.05,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,MINOR",279,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7028.08,,"The inlier payment is calculated as the lesser of the standard DRG payment $6,693.41 and the transfer payment, which is a per diem of $2,253.67. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6693.41,7028.08,Estimated amount calculated based on 1 day length of stay.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],40841.68,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,23338.10,69251.23,All Other Inpatient
Sesamoidectomy First Toe Spx|BILATERAL PROCEDURE|PO,CASE-28315,APC,28315,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],61129.87,,"Fee schedule rate ($61,129.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7826.00,,"Per diem ($7,826). If length of stay < 7.6, first 1 days paid at a per diem of $15,652 instead. Capped at $59,476.09.",,,,0,other,7826.00,90280.33,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],8558.00,,"Per diem ($8,558). If length of stay < 5.4, first 1 days paid at a per diem of $17,116 instead. Capped at $46,215.75.",,,,0,other,8558.00,48389.68,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5499.26,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5237.39,15540.89,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10535.25,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10178.99,36468.17,Inpatient DRG
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MINOR",425,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2727.46,,"Case rate for a one day stay ($2,597.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2597.58,2727.46,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4257.29,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4257.29,12632.63,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15547.45,,"Fee schedule rate ($15,547.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29008.87,,"Fee schedule rate ($29,008.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
Sling Operation Stress Incontinence,CASE-57288,APC,57288,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10434.93,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21880.53,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8940.00,63653.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6371.27,,"Case rate ($6,067.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.99. The transfer capital threshold is the transfer adjustment factor * $429.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6371.27,6371.27,6371.27,1 through 10,other,6077.55,18033.97,Inpatient DRG
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3212.01,3258.56,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15405.10,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,55581.70,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13791.99,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13135.23,38976.20,Inpatient DRG
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, THIRD DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|LEFT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],94720.48,,"Fee schedule rate ($94,720.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],81718.58,,,,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],29129.85,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,29129.85,86437.13,Inpatient DRG
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|BILATERAL PROCEDURE,CASE-38570,APC,38570,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|RIGHT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Syndactylization Toes|LEFT SIDE,CASE-28280,APC,28280,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],39684.68,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10105.00,120252.50,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],115171.02,,"Fee schedule rate ($115,171.02). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16629.05,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16302.99,55737.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
"PEPTIC ULCER AND GASTRITIS,MAJOR",241,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],15772.68,,"Case rate ($15,772.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15772.68,16561.31,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],68639.28,,,,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],51229.93,,"Fee schedule rate ($51,229.93). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15090.78,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15090.78,44778.95,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE|PO,CASE-27570,APC,27570,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11203.52,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6350.00,33244.29,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],20094.74,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19137.85,64589.15,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Metacarpal,CASE-26230,APC,26230,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],91852.39,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10249.47,96445.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11757.91,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11757.91,34889.29,Inpatient DRG
"HC Debrid,Subq Ea Addt'l 20sqcm|PBB CHARGE",CASE-11045,APC,11045,CPT,0361,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10249.98,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9761.89,37873.87,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,APC,64493,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia Only|LEFT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,MAJOR",201,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12045.37,,"Case rate ($12,045.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12045.37,12647.64,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24909.11,,,,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
Bladder Instillation Anticarcinogenic Agent|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51720,APC,51720,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|LEFT SIDE|PO,CASE-24341,APC,24341,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],37794.93,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10105.00,120252.50,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],90878.22,,,,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],40835.64,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,38891.09,169197.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,APC,31654,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,2994.77,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],66888.05,,"Fee schedule rate ($66,888.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.5), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],49902.84,,,,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23582.79,,"Case rate ($23,582.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,789.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,257.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,877.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,876.75. The transfer operating threshold is the transfer adjustment factor * $21,789.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,706.04. The transfer capital threshold is the transfer adjustment factor * $1,706.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",24381.81,24381.81,25202.24,1 through 10,other,23582.79,75543.62,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12843.44,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11781.63,11781.63,11781.63,1 through 10,other,6965.00,38110.41,Inpatient DRG
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13518.78,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5970.00,38757.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],85483.72,,"Fee schedule rate ($85,483.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6054.88,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5766.55,17111.12,Inpatient DRG
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins|LEFT SIDE|PO,CASE-25320,APC,25320,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27753.50,,"Fee schedule rate ($27,753.50). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
"DIVERTICULITIS AND DIVERTICULOSIS,MAJOR",244,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14643.64,,"Case rate ($13,946.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13946.32,14643.64,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16206.75,,"Fee schedule rate ($16,206.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9361.52,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8915.73,26455.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE",CASE-28299,APC,28299,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12745.70,,"Fee schedule rate ($12,745.70). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4201.74,,"Case rate ($4,119.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,806.17, add-ons for qualifying new technology services are included. If operating cost exceeds $39,274.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,821.34. The transfer operating threshold is the transfer adjustment factor * $3,806.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.00. The transfer capital threshold is the transfer adjustment factor * $298.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4119.35,12223.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3816.03,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",3830.30,3830.30,3830.30,1 through 10,other,3209.85,10940.41,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20654.42,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20654.42,69402.59,Inpatient DRG
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18781.54,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7455.00,53076.74,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Cervical Node,CASE-38510,APC,38510,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,XS|T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18988.45,,"Fee schedule rate ($18,988.45). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE,CASE-27405,APC,27405,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9969.47,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9969.47,29582.40,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24097.05,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23624.56,83038.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE|PO,CASE-28200,APC,28200,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],33072.79,,"Case rate ($33,072.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,563.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,392.57. The transfer capital threshold is the transfer adjustment factor * $2,392.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,33072.79,98455.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],185834.07,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,185834.07,195125.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Iliac Territory Plasty Stent,CASE-37221,APC,37221,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],460.53,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25408.95,,"Fee schedule rate ($25,408.95). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MODERATE",344,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],12501.13,,"Case rate ($11,905.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11905.84,12501.13,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx,CASE-29884,APC,29884,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18865.34,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,18227.38,54086.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6773.79,,"Case rate ($6,451.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.16. The transfer capital threshold is the transfer adjustment factor * $457.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6461.52,21772.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3514.75,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3390.91,3390.91,3390.91,1 through 10,other,3395.89,3565.69,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],75976.83,,,,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27943.31,,"Fee schedule rate ($27,943.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11663.65,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11434.95,119072.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14682.53,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7770.00,50313.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,CASE-55866,APC,55866,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",10148.63,10148.63,10148.63,1 through 10,other,10082.05,10586.16,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6286.84,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6074.24,18024.13,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28395.88,,,,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12180.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11600.09,48814.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4976.21,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4878.64,14476.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5104.04,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5003.96,21742.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE|PO,CASE-27698,APC,27698,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24752.04,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",24752.05,24752.05,24752.05,1 through 10,other,23915.01,121205.60,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,EXTREME",192,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],40382.86,,"Case rate ($40,382.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,40382.86,42402.00,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7003.34,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6866.02,27153.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],61348.24,,"Fee schedule rate ($61,348.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],64872.40,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,64872.40,212258.00,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],37131.39,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,18559.00,141041.50,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23582.79,,"Case rate ($23,582.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,789.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,257.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,877.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,876.75. The transfer operating threshold is the transfer adjustment factor * $21,789.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,706.04. The transfer capital threshold is the transfer adjustment factor * $1,706.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,23582.79,75543.62,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1688.18,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1688.18,1772.59,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10687.94,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10178.99,36468.17,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",15553.03,15553.03,15553.03,1 through 10,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27601,APC,27601,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],37679.20,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,36405.02,110499.61,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22695.45,,,,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE|PO,CASE-29826,APC,29826,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8632.81,,"Fee schedule rate ($8,632.81). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27753.50,,"Fee schedule rate ($27,753.50). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16721.04,,"Case rate ($15,924.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,299.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,128.49. The transfer capital threshold is the transfer adjustment factor * $1,128.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15950.19,63458.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,APC,52332,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Drill Osteochondritis Dissecans Grfg,CASE-29885,APC,29885,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Carpectomy 1 Bone|RIGHT SIDE|PO,CASE-25210,APC,25210,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5779.83,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5779.83,17150.47,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],30314.43,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13369.00,88188.38,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31767.69,,"Fee schedule rate ($31,767.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11036.50,33262.00,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Ather,CASE-37229,APC,37229,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],657.88,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],112882.03,,"Fee schedule rate ($112,882.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10818.26,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10818.26,38164.94,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11986.02,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,11986.02,54149.39,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5773.46,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5578.22,18148.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Open/Perq Place Stent Ea Add A,CASE-37237,APC,37237,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28308,APC,28308,CPT,0360,RC,,,RT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Arthroscopy Ankle Surgical Debridement Extensive|RIGHT SIDE,CASE-29898,APC,29898,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
HC Intro Cath Dialysis Circuit W Pta,CASE-36902,APC,36902,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5398.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5293.06,5293.06,5293.06,21,other,5398.26,5668.18,OPPS APC
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15979.02,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15218.11,45156.75,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26999.90,,"Fee schedule rate ($26,999.90). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",7002.11,7002.11,7002.11,1 through 10,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39316.61,,,,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8896.97,,"Case rate ($8,596.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,942.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,410.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,974.25. The transfer operating threshold is the transfer adjustment factor * $7,942.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.86. The transfer capital threshold is the transfer adjustment factor * $621.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8596.11,25507.30,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5942.94,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5942.94,17634.53,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16929.63,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,16929.63,63934.22,Inpatient DRG
Laparoscopy Proctopexy Prolapse,CASE-45400,APC,45400,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN ULCERS,MODERATE",380,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9305.84,,"Case rate ($9,305.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9305.84,9771.13,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20016.13,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],67331.56,,"Fee schedule rate ($67,331.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,APC,52601,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,EXTREME",192,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],40382.86,,"Case rate ($40,382.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,40382.86,42402.00,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE|PO,CASE-28300,APC,28300,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7616.83,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3295.00,37575.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17490.00,,"Per diem ($17,490). If length of stay < 1.2, first 1 days paid at a per diem of $34,980 instead. Capped at $20,988.02.",,,,0,other,7405.81,33747.30,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|RIGHT SIDE|SEPARATE STRUCTURE,CASE-52332,APC,52332,CPT,0360,RC,,,RT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,APC,38900,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11903.13,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11903.13,48838.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12556.78,,"Case rate ($11,958.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,049.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,517.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,093.70. The transfer operating threshold is the transfer adjustment factor * $11,049.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.13. The transfer capital threshold is the transfer adjustment factor * $865.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11958.84,40774.00,Inpatient DRG
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE,CASE-28730,APC,28730,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,APC,29807,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21117.60,,"Fee schedule rate ($21,117.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],23833.38,,"Case rate ($22,698.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,779.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,608.49. The transfer capital threshold is the transfer adjustment factor * $1,608.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22734.65,70806.50,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],26951.04,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25667.66,86123.60,Inpatient DRG
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,APC,60220,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6784.92,,"Case rate ($6,461.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,629.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.91. The transfer capital threshold is the transfer adjustment factor * $457.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6472.13,19204.75,Inpatient DRG
HC >= 12 Lead Ekg|ADJ|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3182.49,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3074.87,3228.61,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT SIDE,CASE-28289,APC,28289,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
Chemodenervation Muscle Neck Unilat for Dystonia|RIGHT SIDE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
Excision Ganglion Wrist Dorsal/Volar Primary|PO,CASE-25111,APC,25111,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surg Tx Anal Fistula Intersphincteric,CASE-46275,APC,46275,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11600.75,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11600.75,34422.94,Inpatient DRG
Rpr Aa Hernia Recr > 10 Cm Ncrc8/Strangulated,CASE-49618,APC,49618,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],201.74,,"APC Price ($201.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,201.74,211.83,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11102.27,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10884.58,32297.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15381.51,,,,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
HC 3rd Order Sel Abd/Lower Ext|RIGHT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,APC,49593,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6355.12,,"APC Price ($6,140.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6140.21,6447.22,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Debridement Bone Each Additional 20 Sq Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-11047,APC,11047,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11341.09,,"Case rate ($10,801.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,936.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $765.40. The transfer capital threshold is the transfer adjustment factor * $765.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",87316.16,87316.16,87316.16,1 through 10,other,10818.26,38164.94,Inpatient DRG
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],64621.61,,"Fee schedule rate ($64,621.61). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,22802.30,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO,CASE-62323,APC,62323,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",463.39,463.39,685.98,1 through 10,other,669.51,702.98,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6940.28,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6940.28,20593.95,Inpatient DRG
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10301.52,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5886.58,17467.27,All Other Inpatient
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16618.15,,"Case rate ($15,826.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.54. The transfer capital threshold is the transfer adjustment factor * $1,121.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15852.04,50518.01,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13937.68,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13664.39,40546.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6910.06,20832.04,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4793.22,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4564.97,13545.65,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18455.85,,"Fee schedule rate ($18,455.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,32980.62,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4506.79,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4418.42,13110.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],38225.27,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36405.02,110499.61,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13405.94,,,,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18227.38,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18227.38,54086.17,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO|UNUSUAL NON-OVERLAPPING SERVICE,CASE-14040,APC,14040,CPT,0360,RC,,,PO|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7744.00,24853.45,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4251.09,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4167.74,12366.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7984.05,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7984.05,23691.11,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|LEFT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24291.03,,"Case rate ($13,880.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,825.31, add-ons for qualifying new technology services are included. If operating cost exceeds $48,293.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,876.42. The transfer operating threshold is the transfer adjustment factor * $12,825.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7285.00,41187.90,All Other Inpatient
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7409.15,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7056.33,28335.74,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
Open Treatment Bimalleolar Ankle Fracture|RIGHT SIDE|PO,CASE-27814,APC,27814,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12536.42,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12536.42,37199.37,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12516.72,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12093.45,40067.60,Inpatient DRG
Excision Tumor Soft Tiss Face/Scalp Subq 2 Cm/>,CASE-21012,APC,21012,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14837.11,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14130.58,57770.11,Inpatient DRG
Synovectomy Metatarsophalangeal Joint Each,CASE-28072,APC,28072,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"HEART FAILURE,EXTREME",194,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],28057.05,,"Case rate ($28,057.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,28057.05,29459.90,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],37072.29,,"Case rate ($35,306.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,673.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,501.97. The transfer capital threshold is the transfer adjustment factor * $2,501.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,18559.00,141041.50,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Surg Tx Anal Fistula Subq,CASE-46270,APC,46270,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit,CASE-36901,APC,36901,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1567.69,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1493.03,1567.69,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22189.86,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21133.20,88801.87,Inpatient DRG
Unlisted Px Skin Muc Membrane & Subq Tissue,CASE-17999,APC,17999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28395.88,,,,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5344.14,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5344.14,15857.69,Inpatient DRG
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6146.79,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,17370.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],195125.77,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,185834.07,195125.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],32637.12,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",32879.94,32879.94,32879.94,1 through 10,other,32637.12,96844.29,Inpatient DRG
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|RIGHT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30977.50,,,,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23714.25,,"Fee schedule rate ($23,714.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level|RIGHT SIDE",CASE-64495,APC,64495,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2|LEFT SIDE|PO,CASE-29822,APC,29822,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12693.58,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12693.58,46577.81,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,1188.00,35040.80,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],183848.16,,"Fee schedule rate ($183,848.16). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
"HC Excis Nail Matrix Perm Rmvl|LEFT FOOT, GREAT TOE|PO",CASE-11750,APC,11750,CPT,0450,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4173.14,,"Case rate ($3,974.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,452.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $281.64. The transfer capital threshold is the transfer adjustment factor * $281.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13054.57,13054.57,13054.57,1 through 10,other,3980.76,11812.10,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],3686.99,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3209.85,10940.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],75545.91,,,,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THUMB|PO",CASE-26055,APC,26055,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16873.59,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16302.99,55737.89,Inpatient DRG
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE|PO,CASE-64421,APC,64421,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10433.69,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10080.86,33310.69,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",40686.73,40686.73,52007.50,1 through 10,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31329.81,,"Fee schedule rate ($31,329.81). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciotomy Foot&/Toe|RIGHT SIDE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],50066.10,,"Fee schedule rate ($50,066.10). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE|PO,CASE-27570,APC,27570,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|RIGHT SIDE,CASE-27680,APC,27680,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12283.14,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11698.23,34712.20,Inpatient DRG
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],40202.74,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,40202.74,148703.60,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],43344.00,,"Fee schedule rate ($43,344.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20986.65,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7826.00,90280.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],58534.56,,"Fee schedule rate ($58,534.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10382.57,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10178.99,36468.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23853.56,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,23385.84,71764.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6858.59,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6724.11,19952.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8021.19,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6495.00,23801.30,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
Fasciectomy Plantar Fascia Radical Spx|RIGHT SIDE,CASE-28062,APC,28062,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19243.94,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19243.94,63510.03,Inpatient DRG
Partial Excision Bone Talus/Calcaneus|LEFT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",128.46,128.46,128.46,1 through 10,other,6882.29,7226.40,OPPS APC
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25267.19,,"Fee schedule rate ($25,267.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],56089.29,,,,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,APC,43248,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],903.26,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",913.91,913.91,913.91,1 through 10,other,860.25,903.26,OPPS APC
Revise/Remove Neurostim/Receiver,CASE-64595,APC,64595,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3315.94,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3315.94,3481.74,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],9799.00,,"Per diem ($9,799). If length of stay < 2.3, first 1 days paid at a per diem of $19,598 instead. Capped at $22,536.57.",,,,0,other,7952.22,25854.47,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43277,APC,43277,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE,CASE-27601,APC,27601,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4795.07,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4795.07,19830.58,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
Lateral Retinacular Release Open,CASE-27425,APC,27425,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18627.00,,"Fee schedule rate ($18,627). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30373.42,,,,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],196.96,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg F/E/E/N/L/M 0.5cm/<|PO,CASE-11440,APC,11440,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5811.28,5895.51,OPPS APC
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27632.41,,,,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21288.16,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20274.44,80940.99,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4463.04,,"Case rate ($4,250.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.20. The transfer capital threshold is the transfer adjustment factor * $301.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",4427.76,4427.76,4427.76,1 through 10,other,4257.29,12632.63,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17233.12,,,,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21172.33,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,12500.00,83592.64,Inpatient DRG
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39792.30,,"Fee schedule rate ($39,792.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5224.00,,"Per diem ($5,224). If length of stay < 2.9, first 1 days paid at a per diem of $10,448 instead. Capped at $15,149.04.",,,,0,other,5224.00,15861.63,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4984.06,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4984.06,19757.81,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|RIGHT SIDE|PO,CASE-29884,APC,29884,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
Rhinp Prim Complete Xtrnl Parts,CASE-30410,APC,30410,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
HC Thromb Mech 1st Vssl,CASE-37184,APC,37184,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],96291.48,,"Case rate ($91,706.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,669.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,498.62. The transfer capital threshold is the transfer adjustment factor * $6,498.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10249.47,96445.01,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],41585.15,,"Fee schedule rate ($41,585.15). Adds an outlier to normal pricing equal to the per diem rate ($65,246.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],96844.29,,,,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE|PO,CASE-24073,APC,24073,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17031.00,,"Fee schedule rate ($17,031). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19230.33,,,,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15914.26,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15156.44,52672.70,Inpatient DRG
"Open Tx Fracture Great Toe/Phalanx/Phalanges|LEFT FOOT, GREAT TOE",CASE-28505,APC,28505,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6558.98,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6558.98,19462.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO,CASE-27654,APC,27654,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"TONSIL AND ADENOID PROCEDURES,MODERATE",097,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4531.56,,"Case rate for a one day stay ($4,531.56). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,4531.56,4758.14,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6393.28,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6088.84,18067.42,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24596.28,,"Fee schedule rate ($24,596.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28847.26,,"Fee schedule rate ($28,847.26). Adds an outlier to normal pricing equal to the per diem rate ($89,320.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE|PO,CASE-27427,APC,27427,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Genicular Nrv Branches W/Img|PO,CASE-64454,APC,64454,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13197.47,,"Fee schedule rate ($13,197.47). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],34393.10,,"Case rate ($32,755.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,492.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,321.16. The transfer capital threshold is the transfer adjustment factor * $2,321.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32807.56,111191.81,Inpatient DRG
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,APC,54410,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20640.96,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,19658.06,20640.96,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",35287.87,23555.50,40196.73,1 through 10,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22831.22,,,,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12169.44,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11757.91,34889.29,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
Brnchsc Brushing/Protected Brushings,CASE-31623,APC,31623,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3536.22,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FIFTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-23430,APC,23430,CPT,0360,RC,,,73,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Gastrostomy W/O Constj Gstr Tube Spx,CASE-43653,APC,43653,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],28696.16,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",27800.83,27800.83,27800.83,1 through 10,other,28696.16,118364.04,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25661.37,,"Fee schedule rate ($25,661.37). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4326.65,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4180.34,14351.57,Inpatient DRG
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7753.46,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7601.43,23918.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10105.00,,"Per diem ($10,105). If length of stay < 10.6, first 1 days paid at a per diem of $20,210 instead. Capped at $107,110.70.",,,,0,other,10105.00,120252.50,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16156.34,,"Fee schedule rate ($16,156.34). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7608.00,,"Case rate ($7,245.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.46. The transfer capital threshold is the transfer adjustment factor * $513.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7257.26,23445.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Bx Prostate Strtctc Saturation Sampling Img Gid,CASE-55706,APC,55706,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6558.98,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6558.98,19462.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, THIRD DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,T7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],46556.99,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,44339.99,131570.26,Inpatient DRG
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|LEFT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17274.00,,"Per diem ($17,274). If length of stay < 3.3, first 1 days paid at a per diem of $34,548 instead. Capped at $57,002.93.",,,,0,other,17274.00,73717.28,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11156.55,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10625.29,39295.53,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29783.11,,,,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21316.71,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20301.63,84714.35,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13110.79,,,,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36247,APC,36247,CPT,0361,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12180.79,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11600.75,34422.94,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21687.14,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20654.42,69402.59,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,MAJOR",201,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12045.37,,"Case rate ($12,045.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12045.37,12647.64,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],36726.64,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7826.00,90280.33,All Other Inpatient
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],104605.60,,"Fee schedule rate ($104,605.60). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33525.67,,,,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10433.69,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10318.17,10318.17,10318.17,1 through 10,other,10080.86,33310.69,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4993.76,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4755.96,21133.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13282.66,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12833.49,58980.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7812.30,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4464.17,13577.72,All Other Inpatient
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS OF UPPER RESPIRATORY TRACT,MAJOR",113,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2290.15,,"Case rate for a one day stay ($2,290.15). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2290.15,2404.66,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21732.40,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20697.52,87921.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17747.81,,"Case rate ($16,902.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,368.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,197.78. The transfer capital threshold is the transfer adjustment factor * $1,197.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,16929.63,63934.22,Inpatient DRG
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9262.54,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,27484.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE,CASE-27695,APC,27695,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19706.40,,"Fee schedule rate ($19,706.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10492.66,,"Case rate ($10,492.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,694.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,162.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,930.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,733.59. The transfer operating threshold is the transfer adjustment factor * $9,694.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.07. The transfer capital threshold is the transfer adjustment factor * $759.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10492.66,31134.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11382.98,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11159.78,39897.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],144298.29,,"Fee schedule rate ($144,298.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",116142.53,116142.53,116142.53,1 through 10,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39792.30,,"Fee schedule rate ($39,792.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],42138.30,,,,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7132.50,,"Case rate ($6,792.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,652.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.36. The transfer capital threshold is the transfer adjustment factor * $481.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5843.00,27370.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|LEFT SIDE|PO,CASE-20550,APC,20550,CPT,0510,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthro/shoul surg; w/spacer,CASE-C9781,APC,C9781,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5160.45,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15997.55,5100.14,55229.08,1 through 10,other,5160.45,15312.64,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|PO,CASE-64454,APC,64454,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Inj Trigger Pt 1-2 Musc Grps|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE|PO,CASE-25607,APC,25607,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
HC Pbb Carpal Tunnel Inj Pmc|LEFT SIDE|PO,CASE-20526,APC,20526,CPT,0510,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1916.92,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surg Tx Anal Fistula Subq,CASE-46270,APC,46270,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],55752.59,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,31858.62,94534.21,All Other Inpatient
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7056.33,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7056.33,28335.74,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26525,APC,26525,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthro/shoul surg; w/spacer|PO,CASE-C9781,APC,C9781,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33132.06,,"Fee schedule rate ($33,132.06). Adds an outlier to normal pricing equal to the per diem rate ($83,058.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",93707.15,93707.15,93707.15,1 through 10,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,APC,26356,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21288.16,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20274.44,80940.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34171.31,,"Fee schedule rate ($34,171.31). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11871.54,35778.69,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC Trigger Point 3 or More|LEFT SIDE|PO,CASE-20553,APC,20553,CPT,0510,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22434.01,,"Case rate ($21,365.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,685.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,514.05. The transfer capital threshold is the transfer adjustment factor * $1,514.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21399.79,63499.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FOURTH DIGIT|PO",CASE-26951,APC,26951,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],43444.85,,,,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
"OTHER DISORDERS OF THE LIVER,MAJOR",283,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14429.85,,"Case rate ($14,429.85). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14429.85,15151.34,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21256.76,,"Fee schedule rate ($21,256.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy With Biopsy|SEPARATE STRUCTURE,CASE-52204,APC,52204,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15896.49,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15896.49,51306.05,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5507.93,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5507.93,5507.93,5507.93,1 through 10,other,5507.93,20510.35,Inpatient DRG
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE,CASE-29891,APC,29891,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24761.93,,"Case rate ($23,582.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,789.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,257.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,877.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,876.75. The transfer operating threshold is the transfer adjustment factor * $21,789.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,706.04. The transfer capital threshold is the transfer adjustment factor * $1,706.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23582.79,75543.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6480.75,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6480.75,29542.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,Zero final payments for the item or service in the 15 months prior to posting the file.
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE|POLICY CRITERIA APPLIED,CASE-27570,APC,27570,CPT,0360,RC,,,RT|CG,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE|PO,CASE-28615,APC,28615,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|RIGHT SIDE,CASE-37765,APC,37765,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO|UNUSUAL NON-OVERLAPPING SERVICE,CASE-14040,APC,14040,CPT,0360,RC,,,PO|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn,CASE-64415,APC,64415,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10806.32,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10291.73,34803.35,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16361.19,,"Fee schedule rate ($16,361.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9685.23,,"Case rate ($9,495.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,773.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,858.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $8,808.40. The transfer operating threshold is the transfer adjustment factor * $8,773.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.92. The transfer capital threshold is the transfer adjustment factor * $686.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9495.32,42131.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5224.00,,"Per diem ($5,224). If length of stay < 2.9, first 1 days paid at a per diem of $10,448 instead. Capped at $15,149.04.",,,,0,other,5224.00,15861.63,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,APC,49593,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6140.21,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6140.21,6447.22,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10467.94,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9969.47,29582.40,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20405.64,,"Fee schedule rate ($20,405.64). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11330.66,,"Case rate ($10,791.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,935.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $764.69. The transfer capital threshold is the transfer adjustment factor * $764.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10808.31,46938.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],96844.29,,,,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Enterolysis Separate Procedure,CASE-44180,APC,44180,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17150.47,,,,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,30966.53,Estimated amount calculated based on 11 day length of stay.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],92493.51,,"Fee schedule rate ($92,493.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.8), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Malignant Lesion S/N/H/F/G 0.6-1.0 Cm,CASE-11621,APC,11621,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],695.15,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,671.64,695.15,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg|ADJ|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3074.87,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3074.87,3228.61,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1283.15,1283.15,1283.15,1 through 10,other,838.89,880.84,OPPS APC
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],36910.99,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36910.99,126842.57,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31058.00,,"Fee schedule rate ($31,058.00). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9988.92,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",9787.13,9787.13,9787.13,1 through 10,other,9793.06,29058.99,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13826.01,,"Fee schedule rate ($13,826.01). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Ostc Prtl Exostc/Condylc Metar Head|LEFT SIDE|PO,CASE-28288,APC,28288,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13292.96,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",13413.27,13413.27,13413.27,1 through 10,other,6965.00,38110.41,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Fem Pop Terr Plasty and Stent,CASE-37226,APC,37226,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],32749.19,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,32749.19,97176.83,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26408.87,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,15090.78,44778.95,All Other Inpatient
Open Tx Tibial Fracture Proximal Unicondylar|LEFT SIDE,CASE-27535,APC,27535,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",6963.55,6963.55,6963.55,1 through 10,other,12177.08,12785.93,OPPS APC
Open Treatment Fracture Distal Tibia Only|LEFT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenolysis Extensor Tendon Hand/Finger Each,CASE-26445,APC,26445,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23596.66,,,,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
Fasciotomy Foot&/Toe|BILATERAL PROCEDURE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17625.30,,"Fee schedule rate ($17,625.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20274.44,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20274.44,80940.99,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11906.46,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5843.00,27370.21,All Other Inpatient
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],26024.99,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9242.00,76216.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26357,APC,26357,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],42145.68,,"Case rate ($40,138.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,015.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,844.37. The transfer capital threshold is the transfer adjustment factor * $2,844.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40202.74,148703.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],33289.86,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,32637.12,96844.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9025.92,,"Case rate ($8,596.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,942.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,410.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,974.25. The transfer operating threshold is the transfer adjustment factor * $7,942.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.86. The transfer capital threshold is the transfer adjustment factor * $621.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8596.11,25507.30,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13245.75,,"Fee schedule rate ($13,245.75). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13780.46,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9763.00,48626.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4363.62,,"Case rate ($4,155.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,465.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $294.50. The transfer capital threshold is the transfer adjustment factor * $294.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,21715.49,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4829.33,,"Case rate ($4,734.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,389.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,934.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,991.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,391.29. The transfer operating threshold is the transfer adjustment factor * $4,389.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.35. The transfer capital threshold is the transfer adjustment factor * $343.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4734.64,14273.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3074.87,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3074.87,3228.61,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",3012.17,3012.17,3012.17,1 through 10,other,3103.39,3258.56,OPPS APC
Open Treatment Proximal Fibula/Shaft Fracture|RIGHT SIDE|PO,CASE-27784,APC,27784,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Shoulder Subfasc <5cm|LEFT SIDE,CASE-23076,APC,23076,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Implnt Bio Implnt for Soft Tissue Reinforcement,CASE-15777,APC,15777,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|SEPARATE STRUCTURE|PO,CASE-14040,APC,14040,CPT,0360,RC,,,XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3212.01,3258.56,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5237.39,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5232.69,5232.69,5232.69,1 through 10,other,5237.39,15540.89,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],50697.38,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13061.00,162464.13,Inpatient DRG
"Open Treatment Metatarsal Fracture Each|RIGHT FOOT, FIFTH DIGIT",CASE-28485,APC,28485,CPT,0360,RC,,,T9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Application Uniplane External Fixation System|PO,CASE-20690,APC,20690,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,CASE-49616,APC,49616,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8.91,,,,,,0,other,8.91,9.04,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],61860.92,,"Fee schedule rate ($61,860.92). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21828.16,93157.39,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19033.08,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,8990.00,80069.53,Inpatient DRG
HC Sel Cath Abd/Pelvic/Le 1st Ord|BILATERAL PROCEDURE,CASE-36245,APC,36245,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11326.23,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6472.13,19204.75,All Other Inpatient
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6950.18,,"Case rate ($6,619.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,117.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $469.35. The transfer capital threshold is the transfer adjustment factor * $469.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6630.72,19989.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12592.92,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12167.07,36103.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|RIGHT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26357,APC,26357,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27601.28,,"Fee schedule rate ($27,601.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,301.32,305.69,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7109.06,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6770.53,20090.22,Inpatient DRG
HC Tib per Territory Ather|RIGHT SIDE,CASE-37229,APC,37229,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],626.55,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
Open Tx Trimalleolar Ankle Fx W/Fixj Pst Lip|LEFT SIDE|PO,CASE-27823,APC,27823,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10467.94,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9969.47,29582.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15261.14,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14534.42,59012.52,Inpatient DRG
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE|PO,CASE-28120,APC,28120,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10669.04,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,31658.33,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22202.30,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8940.00,63653.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",4884.61,4884.61,4884.61,1 through 10,other,5085.49,5339.77,OPPS APC
Cysto Bladder W/Ureteral Catheterization,CASE-52005,APC,52005,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28285,APC,28285,CPT,0360,RC,,,T9|PO|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6816.94,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5520.00,26638.96,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31323.82,,,,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4538.44,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12926.92,12926.92,12926.92,1 through 10,other,4538.44,18815.35,Inpatient DRG
Litholapaxy Smpl/Sm <2.5 Cm|SEPARATE STRUCTURE,CASE-52317,APC,52317,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE|PO,CASE-29898,APC,29898,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE|PO,CASE-28306,APC,28306,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9280.46,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9280.46,39957.56,Inpatient DRG
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12695.38,,"Fee schedule rate ($12,695.38). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
Transperineal Plmt Biodegradable Matrl 1/Mlt Njx,CASE-55874,APC,55874,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8408.84,,"Case rate ($8,008.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.50. The transfer capital threshold is the transfer adjustment factor * $567.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",8408.85,8408.85,8408.85,1 through 10,other,6495.00,23801.30,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11844.40,,"Case rate ($11,280.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.37. The transfer capital threshold is the transfer adjustment factor * $799.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11298.37,44627.23,Inpatient DRG
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|LEFT SIDE|PO,CASE-25260,APC,25260,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5625.00,,"Per diem ($5,625). If length of stay < 2.6, first 1 days paid at a per diem of $11,250 instead. Capped at $14,624.71.",,,,0,other,5160.45,15312.64,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],43610.70,,"Fee schedule rate ($43,610.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6793.95,,"Case rate ($6,470.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,629.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $458.52. The transfer capital threshold is the transfer adjustment factor * $458.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6480.75,29542.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33733.44,,"Fee schedule rate ($33,733.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],8940.00,,"Per diem ($8,940). If length of stay < 6.8, first 1 days paid at a per diem of $17,880 instead. Capped at $60,793.48.",,,,0,other,8940.00,63653.13,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13916.85,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13446.23,39899.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MAJOR",385,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12349.30,,"Case rate ($12,349.30). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12349.30,12966.77,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15540.00,,"Fee schedule rate ($15,540). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9718.72,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,27465.16,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],41585.15,,"Fee schedule rate ($41,585.15). Adds an outlier to normal pricing equal to the per diem rate ($65,246.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14673.67,43541.27,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7981.50,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7601.43,23918.09,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac WO Port>5yr (Tun),CASE-36558,APC,36558,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
Ercp Dx Collection Specimen Brushing/Washing|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43260,APC,43260,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4263.53,,"Case rate ($4,119.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,806.17, add-ons for qualifying new technology services are included. If operating cost exceeds $39,274.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,821.34. The transfer operating threshold is the transfer adjustment factor * $3,806.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.00. The transfer capital threshold is the transfer adjustment factor * $298.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",2722.38,2722.38,2722.38,1 through 10,other,4119.35,12223.35,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4967.82,,"Case rate ($4,870.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,514.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,060.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,001.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,517.21. The transfer operating threshold is the transfer adjustment factor * $4,514.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.19. The transfer capital threshold is the transfer adjustment factor * $353.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4870.41,14682.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
HC Open/Perq Place Stent Ea Add A,CASE-37237,APC,37237,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10949.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VERTIGO AND OTHER LABYRINTH DISORDERS,MODERATE",111,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3454.57,,"Case rate for a one day stay ($3,290.07). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3290.07,3454.57,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],37968.88,,of the excess amount.,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6328.22,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6328.22,27416.36,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38222.57,,,,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7476.69,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,20179.92,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE,CASE-28238,APC,28238,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
Fasciotomy Foot&/Toe|LEFT SIDE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6654.93,,"Case rate ($6,654.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,167.40, add-ons for qualifying new technology services are included. If operating cost exceeds $46,712.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,132.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,170.45. The transfer operating threshold is the transfer adjustment factor * $6,167.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.48. The transfer capital threshold is the transfer adjustment factor * $484.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6654.93,20056.77,Inpatient DRG
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE|PO,CASE-29826,APC,29826,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Musc/Fasc,Ea Add 20sqcm|SEPARATE STRUCTURE",CASE-11046,APC,11046,CPT,0361,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],700.99,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,700.99,725.52,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
"Sesamoidectomy First Toe Spx|RIGHT FOOT, GREAT TOE|PO",CASE-28315,APC,28315,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6693.37,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6230.00,21325.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12319.74,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11903.13,48838.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],71244.51,,,,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MINOR",192,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5362.76,,"Case rate for a one day stay ($5,362.76). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5362.76,5630.90,There are no additional notes associated with this service or procedure.
Open Treatment Fracture Distal Tibia & Fibula|RIGHT SIDE,CASE-27828,APC,27828,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19156.34,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,18508.54,76171.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8111.26,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7952.22,25854.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],36249.82,,"Fee schedule rate ($36,249.82). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9308.98,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,33447.35,Inpatient DRG
"AMPUTATION OF LOWER LIMB EXCEPT TOES,MODERATE",305,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],20098.18,,"Case rate ($20,098.18). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,20098.18,21103.09,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21289.03,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21289.03,76326.34,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41146.57,,,,,,0,other,13866.64,41146.57,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],34386.65,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32749.19,97176.83,Inpatient DRG
Thrmbc Opn Arven Fstl W/O Revj Dial Grf,CASE-36831,APC,36831,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30846.83,,"Fee schedule rate ($30,846.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12843.44,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,38110.41,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23950.83,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23950.83,74869.17,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12235.09,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11652.47,41507.02,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Thrmbc Opn Arven Fstl W/O Revj Dial Grf,CASE-36831,APC,36831,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18994.21,,,,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15896.49,51306.05,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciotomy Foot&/Toe|LEFT SIDE,CASE-28008,APC,28008,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,APC,44970,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],33895.41,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,32749.19,97176.83,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8336.54,,"Case rate ($7,939.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,733.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $562.62. The transfer capital threshold is the transfer adjustment factor * $562.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7952.22,25854.47,Inpatient DRG
HC Debrid Wound Tis Addl 20 Cm<,CASE-97598,APC,97598,CPT,0761,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20954.82,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20954.82,62179.32,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36140.75,,,,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11916.39,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11916.39,58492.48,Inpatient DRG
Arthrp Kne Condyle&Platu Medial&Lat Compartments|LEFT SIDE,CASE-27447,APC,27447,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28832.22,,"Fee schedule rate ($28,832.22). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4795.07,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",23664.87,23664.87,23664.87,1 through 10,other,4795.07,19830.58,Inpatient DRG
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MAJOR",721,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],18480.43,,"Case rate ($17,600.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17600.41,18480.43,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12952.55,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12514.54,37134.43,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],67041.51,,,,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6910.06,20832.04,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21630.93,,,,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4870.01,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4774.52,14406.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21056.36,,,,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24095.40,,"Fee schedule rate ($24,095.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10134.35,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9935.64,29482.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11628.75,,"Fee schedule rate ($11,628.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],37954.97,,,,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16763.25,,"Fee schedule rate ($16,763.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10815.61,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9888.00,40658.63,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],107249.77,,"Fee schedule rate ($107,249.77). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29382.86,,"Fee schedule rate ($29,382.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],86162.15,,"Fee schedule rate ($86,162.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,10625.29,39295.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24863.59,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23679.61,84629.16,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],37843.99,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,37843.99,139522.22,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
HC Remove Retrievable Filter,CASE-37193,APC,37193,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
Cystourethroscopy With Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52204,APC,52204,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24950.10,,"Fee schedule rate ($24,950.10). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE,CASE-28090,APC,28090,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],47661.63,,,,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6785.78,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6785.78,20135.47,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6617.34,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5683.00,19635.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],37180.36,,"Fee schedule rate ($37,180.36). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14465.95,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7308.00,42083.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13713.25,,"Fee schedule rate ($13,713.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],192338.26,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",190287.58,190287.58,190287.58,1 through 10,other,185834.07,195125.77,Inpatient DRG
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],144110.94,,"Fee schedule rate ($144,110.94). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1876.32,1876.32,1876.32,1 through 10,other,1852.10,1944.70,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13867.35,,"Case rate ($13,207). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,107.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $935.89. The transfer capital threshold is the transfer adjustment factor * $935.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13228.06,39251.68,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|PO,CASE-26160,APC,26160,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1525.13,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",30652.85,30652.85,30652.85,1 through 10,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21534.88,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,21112.63,62647.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33727.80,,"Fee schedule rate ($33,727.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cv Cath Plac W/Port Tun >5|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-36561,APC,36561,CPT,0361,RC,,,73,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13704.25,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13051.67,38728.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],39867.32,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE,CASE-28090,APC,28090,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],48779.11,,"Fee schedule rate ($48,779.11). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|LEFT SIDE,CASE-27524,APC,27524,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],11812.10,,,,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],46016.63,,,,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
Litholapaxy Comp/Lg > 2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52318,APC,52318,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33843.71,,of the excess amount. Final payment is multiplied by 175%.,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Lateral Release,CASE-29873,APC,29873,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],43128.05,,,,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6835.51,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6835.51,20283.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE|PO,CASE-64421,APC,64421,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,APC,52318,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],100655.10,,"Fee schedule rate ($100,655.10). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],62824.73,,,,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],35363.23,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,18559.00,141041.50,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvic/Le 1st Ord|LEFT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],57857.48,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",252.98,252.98,252.98,1 through 10,other,55900.95,225294.39,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12405.69,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11814.94,44591.73,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11084.14,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10556.32,32082.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4895.21,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4895.21,14525.56,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7056.33,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7056.33,28335.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7952.22,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7952.22,25854.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9238.13,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",8773.06,8773.06,8773.06,1 through 10,other,9056.99,33814.75,Inpatient DRG
HC Extremity Venogram|LEFT SIDE,CASE-36005,APC,36005,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1567.69,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8192.28,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8192.28,24308.97,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4639.91,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4639.91,13771.19,Inpatient DRG
"ALLERGIC REACTIONS,MODERATE",811,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3002.96,,"Case rate for a one day stay ($2,859.96). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2859.96,3002.96,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4774.52,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4774.52,14406.59,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6553.68,,"Case rate ($6,553.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $6,086.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,276.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,494.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,073.77. The transfer operating threshold is the transfer adjustment factor * $6,086.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.91. The transfer capital threshold is the transfer adjustment factor * $479.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6553.68,20086.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],46750.70,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",29448.28,29448.28,29448.28,1 through 10,other,45834.02,151120.97,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],31090.24,,"Case rate ($30,480.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,163.35, add-ons for qualifying new technology services are included. If operating cost exceeds $63,631.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,376.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,275.59. The transfer operating threshold is the transfer adjustment factor * $28,163.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,205.05. The transfer capital threshold is the transfer adjustment factor * $2,205.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,30480.63,86382.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19413.74,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,8990.00,80069.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17214.39,,"Fee schedule rate ($17,214.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9738.02,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9738.02,28895.67,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],39621.50,,"Case rate ($37,734.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,845.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,674.02. The transfer capital threshold is the transfer adjustment factor * $2,674.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10105.00,120252.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16245.56,,"Case rate ($15,471.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.40. The transfer capital threshold is the transfer adjustment factor * $1,096.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,53945.28,Inpatient DRG
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25267.19,,"Fee schedule rate ($25,267.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn,CASE-64448,APC,64448,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
Destruction Lesions Vulva Extensive,CASE-56515,APC,56515,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2025.45,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.96,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],134001.61,,"Fee schedule rate ($134,001.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],93689.44,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10249.47,96445.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],103171.69,,"Fee schedule rate ($103,171.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7152.15,,"Case rate ($7,011.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,678.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7011.91,27304.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23758.52,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23758.52,103116.16,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
Partial Excision Bone Olecranon Process|RIGHT SIDE|PO,CASE-24147,APC,24147,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3212.01,3258.56,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7826.00,,"Per diem ($7,826). If length of stay < 7.6, first 1 days paid at a per diem of $15,652 instead. Capped at $59,476.09.",,,,0,other,7826.00,90280.33,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23338.10,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23338.10,69251.23,Inpatient DRG
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28892.85,,"Fee schedule rate ($28,892.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",13735.06,13735.06,13735.06,1 through 10,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14062.94,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14062.94,61706.77,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],134001.61,,"Fee schedule rate ($134,001.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Sling Opration Corrj Male Urinary Incontinence,CASE-53440,APC,53440,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12951.54,,"APC Price ($12,513.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12513.57,13139.25,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5102.58,,"Case rate ($4,859.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.37. The transfer capital threshold is the transfer adjustment factor * $344.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4867.35,14442.92,Inpatient DRG
Axillary Lymphadenectomy Complete,CASE-38745,APC,38745,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|PO,CASE-64494,APC,64494,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17111.12,,,,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12521.78,,"Fee schedule rate ($12,521.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9361.52,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8915.73,26455.73,Inpatient DRG
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|BILATERAL PROCEDURE,CASE-37766,APC,37766,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12948.38,,"Fee schedule rate ($12,948.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21542.42,,"Fee schedule rate ($21,542.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,APC,64772,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE|PO,CASE-23515,APC,23515,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15888.93,,"Case rate ($15,132.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,243.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,072.33. The transfer capital threshold is the transfer adjustment factor * $1,072.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15156.44,52672.70,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
Fasciectomy Plantar Fascia Radical Spx|LEFT SIDE|PO,CASE-28062,APC,28062,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],47037.87,,,,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4736.21,,"Case rate ($4,510.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4517.87,13932.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21373.92,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20954.82,62179.32,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24596.28,,"Fee schedule rate ($24,596.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8798.84,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6178.00,25225.91,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22506.55,,,,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],23437.60,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10804.92,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10290.40,42115.80,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16760.18,,"Fee schedule rate ($16,760.18). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8192.28,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8192.28,8077.51,8193.44,1 through 10,other,8192.28,24308.97,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17934.16,,"Fee schedule rate ($17,934.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.1), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17546.22,,"Case rate ($16,710.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,355.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,184.18. The transfer capital threshold is the transfer adjustment factor * $1,184.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",17546.24,17219.79,30853.29,1 through 10,other,16737.33,72192.67,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9549.75,,"Fee schedule rate ($9,549.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17153.91,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",15984.60,15984.60,15984.60,1 through 10,other,16817.56,58510.23,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5342.14,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5237.39,15540.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7957.67,,"Case rate ($7,578.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,708.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $537.06. The transfer capital threshold is the transfer adjustment factor * $537.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7590.81,32847.45,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31767.69,,"Fee schedule rate ($31,767.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11036.50,33262.00,There are no additional notes associated with this service or procedure.
Excision Hidradenitis Axillary Smpl/Intrm Rpr,CASE-11450,APC,11450,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14877.26,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6178.00,25225.91,All Other Inpatient
HC Trluml Balo Angiop 1st Vein,CASE-37248,APC,37248,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5668.18,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5398.26,5668.18,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8601.89,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8192.28,24308.97,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7213.50,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,21404.64,Inpatient DRG
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE|PO,CASE-29898,APC,29898,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5561.91,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",2595.01,2595.01,2595.01,1 through 10,other,5297.06,19049.64,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],47978.53,,"Fee schedule rate ($47,978.53). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE|PO,CASE-29823,APC,29823,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Rpr Tdn/Musc Xtnsr F/Arm&/Wrist Prim 1 Ea Tdn|LEFT SIDE|PO,CASE-25270,APC,25270,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Metatarsal Fracture Each|RIGHT SIDE,CASE-28485,APC,28485,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
HC Wound Vac <=50 Sq Cm Dme|ADJ,CASE-97605,APC,97605,CPT,0761,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12299.85,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11714.14,49460.19,Inpatient DRG
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64418,APC,64418,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
Destruction Lesions Vulva Extensive,CASE-56515,APC,56515,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2025.45,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.96,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6041.52,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5923.06,17575.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11039.73,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6953.00,35389.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8394.53,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8394.53,24909.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],27453.55,,of the excess amount. Final payment is multiplied by 103.5%.,26163.11,26163.11,26163.11,1 through 10,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],91852.39,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10249.47,96445.01,Inpatient DRG
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5854.09,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,17370.86,Inpatient DRG
Suture Quadriceps/Hamstring Rupture Primary|RIGHT SIDE|PO,CASE-27385,APC,27385,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10851.31,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10638.54,40729.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8263.49,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7984.05,33319.56,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14127.58,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8072.90,31159.55,All Other Inpatient
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],60333.05,,"Fee schedule rate ($60,333.05). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Intralesional Up to & Includ 7 Lesions,CASE-11900,APC,11900,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18033.97,,,,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8726.77,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8431.66,25019.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10815.61,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9888.00,40658.63,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],28916.65,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27539.67,109237.68,Inpatient DRG
Open Tx Trimalleolar Ankle Fx W/Fixj Pst Lip|LEFT SIDE|PO,CASE-27823,APC,27823,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],112882.03,,"Fee schedule rate ($112,882.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7597.61,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4341.49,12882.53,All Other Inpatient
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9793.06,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9793.06,29058.99,Inpatient DRG
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],903.26,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,860.25,903.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8638.55,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8442.00,28788.33,Inpatient DRG
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12512.21,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11916.39,58492.48,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
Nerve Repair W/Nerve Allograft First Strand|PO,CASE-64912,APC,64912,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8614.94,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8323.61,8739.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19155.70,,"Fee schedule rate ($19,155.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6654.93,20056.77,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],48779.11,,"Fee schedule rate ($48,779.11). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
Surg Tx Anal Fistula Subq,CASE-46270,APC,46270,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8071.33,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7686.98,22809.58,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4120.09,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3980.76,11812.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10817.50,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10605.39,31469.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intrvasc US Noncoronary 1st,CASE-37252,APC,37252,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],565.88,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16524.47,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16524.47,58465.86,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],27861.95,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27861.95,82674.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],5713.05,,"Fee schedule rate ($5,713.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion S/N/H/F/G 2.1-3.0 Cm,CASE-11623,APC,11623,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8383.25,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7984.05,33319.56,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6401.17,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6401.17,6401.17,6401.17,1 through 10,other,5669.00,18994.21,Inpatient DRG
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8086.83,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,34379.15,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
Cystectomy Partial Simple,CASE-51550,APC,51550,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3460.35,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn|PO,CASE-62321,APC,62321,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",653.31,653.31,653.31,1 through 10,other,669.51,702.98,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6699.57,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6699.57,24060.08,Inpatient DRG
Cysto W/Removal of Tumors Small,CASE-52234,APC,52234,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5142.73,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4968.82,19848.33,Inpatient DRG
HC Cv Cath Plac W/Port Tun >5|RIGHT SIDE,CASE-36561,APC,36561,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
Rpr Primary Torn Ligm&/Capsule Knee Collateral|RIGHT SIDE|PO,CASE-27405,APC,27405,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26540,APC,26540,CPT,0360,RC,,,F6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22325.17,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,21570.21,72041.81,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32876.47,,"Fee schedule rate ($32,876.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6972.22,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6835.51,20283.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
I&D Ischiorct/Intramural Absc W/WO Seton,CASE-46060,APC,46060,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],115171.02,,"Fee schedule rate ($115,171.02). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE|SEPARATE STRUCTURE,CASE-27405,APC,27405,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],22593.41,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22593.41,90908.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12065.11,,"Fee schedule rate ($12,065.11). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12500.00,,"Per diem ($12,500). If length of stay < 4.8, first 1 days paid at a per diem of $25,000 instead. Capped at $60,002.29.",,,,0,other,12500.00,83592.64,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9352.25,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5344.14,15857.69,All Other Inpatient
"HIV WITH MAJOR HIV RELATED CONDITION,EXTREME",892,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],25095.09,,"Case rate ($25,095.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,25095.09,26349.84,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8072.90,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8072.90,31159.55,Inpatient DRG
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11888.55,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11888.55,35276.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28296,APC,28296,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Arthrt Elbow W/Exploration Drainage/Removal FB,CASE-24000,APC,24000,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bone Graft Any Donor Area Major/Large,CASE-20902,APC,20902,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12785.93,12785.93,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16283.27,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15507.88,46016.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27601,APC,27601,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE|PO,CASE-25628,APC,25628,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],31206.03,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13369.00,88188.38,Inpatient DRG
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE|PO,CASE-28322,APC,28322,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE|PO,CASE-28740,APC,28740,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6308.11,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6094.79,22352.66,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13827.53,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",14055.77,14055.77,14055.77,1 through 10,other,13827.53,41030.48,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER DISORDERS OF THE LIVER,MAJOR",283,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15151.34,,"Case rate ($14,429.85). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14429.85,15151.34,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10789.12,,"Case rate ($10,275.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,899.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.15. The transfer capital threshold is the transfer adjustment factor * $728.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10291.73,34803.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14810.25,,"Fee schedule rate ($14,810.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
Carpectomy 1 Bone|RIGHT SIDE|PO,CASE-25210,APC,25210,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Suture Quadriceps/Hamstring Rupture Primary|LEFT SIDE,CASE-27385,APC,27385,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
"OTHER DISORDERS OF NERVOUS SYSTEM,EXTREME",058,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],25660.13,,"Case rate ($25,660.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,25660.13,26943.14,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21830.80,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21830.80,85124.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FOURTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Vasc Embolize Occlude Organ|BILATERAL PROCEDURE,CASE-37243,APC,37243,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18043.98,,"Case rate ($17,184.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,388.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.77. The transfer capital threshold is the transfer adjustment factor * $1,217.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17212.14,64440.06,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13068.09,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,3295.00,37575.69,All Other Inpatient
"MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,MAJOR",248,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14197.76,,"Case rate ($14,197.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14197.76,14907.65,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18988.45,,"Fee schedule rate ($18,988.45). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21421.93,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20697.52,87921.54,Inpatient DRG
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
Cysto W/Simple Removal Stone & Stent,CASE-52310,APC,52310,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,APC,43266,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Lig/Banding Angioaccess Arteriovenous Fistula,CASE-37607,APC,37607,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-54840,APC,54840,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3565.69,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",9800.42,9800.42,9800.42,1 through 10,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",685.98,675.06,685.98,1 through 10,other,669.51,702.98,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19044.40,,"APC Price ($18,400.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,18400.38,19320.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE|SEPARATE STRUCTURE,CASE-27405,APC,27405,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Osteotomy Radius Distal Third|RIGHT SIDE|PO,CASE-25350,APC,25350,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],42695.82,,"Fee schedule rate ($42,695.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,32980.62,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],74873.19,,"Fee schedule rate ($74,873.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.6), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE,CASE-27339,APC,27339,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
Open Treatment Ulnar Fracture Proximal End|RIGHT SIDE|PO,CASE-24685,APC,24685,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10899.16,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10899.16,39746.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER CIRCULATORY SYSTEM DIAGNOSES,MODERATE",207,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8957.70,,"Case rate ($8,957.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8957.70,9405.59,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13789.07,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13789.07,57367.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24679.78,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,14102.73,41847.08,All Other Inpatient
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24585.00,,"Fee schedule rate ($24,585.00). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],36224.65,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36224.65,128473.68,Inpatient DRG
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|LEFT SIDE,CASE-38570,APC,38570,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10434.93,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Stent Place Initial Artery Ang,CASE-37236,APC,37236,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10949.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",10528.13,10528.13,10528.13,1 through 10,other,10949.29,11496.76,OPPS APC
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,MAJOR",174,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8036.29,,"Case rate for a one day stay ($7,653.61). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7653.61,8036.29,There are no additional notes associated with this service or procedure.
"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,MINOR",511,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6203.11,,"Case rate for a one day stay ($6,203.11). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,6203.11,6513.27,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6707.31,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6387.91,18954.85,Inpatient DRG
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],52092.32,,"Fee schedule rate ($52,092.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12065.11,,"Fee schedule rate ($12,065.11). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7231.00,,"Per diem ($7,231). If length of stay < 5.1, first 1 days paid at a per diem of $14,462 instead. Capped at $36,875.62.",,,,0,other,7231.00,38610.21,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,21715.49,Estimated amount calculated based on 9 day length of stay.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30493.52,,"Fee schedule rate ($30,493.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23385.84,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,23385.84,71764.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL CRANIAL AND AUTONOMIC NERVE DISORDERS,MODERATE",048,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10544.29,,"Case rate ($10,042.18). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10042.18,10544.29,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7397.36,,"Case rate ($7,045.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,670.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.24. The transfer capital threshold is the transfer adjustment factor * $499.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",578.74,578.74,578.74,1 through 10,other,7056.33,28335.74,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7482.22,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7335.51,29792.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],44732.44,,"Case rate ($42,602.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,190.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,018.95. The transfer capital threshold is the transfer adjustment factor * $3,018.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",34568.37,34568.37,34568.37,1 through 10,other,42670.25,133443.30,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8227.43,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8227.43,27001.04,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
Open Treatment Metatarsal Fracture Each|RIGHT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],28651.60,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,48444.74,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7435.53,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7289.74,21630.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11832.77,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11600.75,34422.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11965.63,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6837.50,20288.95,All Other Inpatient
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],6569.45,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,3753.97,11139.15,All Other Inpatient
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES SIGNS AND SYMPTOMS,EXTREME",468,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],22461.94,,"Case rate ($22,461.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22461.94,23585.04,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13693.78,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13230.71,39259.55,Inpatient DRG
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|RIGHT SIDE,CASE-27680,APC,27680,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Ganglion Wrist Dorsal/Volar Recurrent,CASE-25112,APC,25112,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24750.60,,"Fee schedule rate ($24,750.60). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5420.70,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5237.39,15540.89,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],82674.88,,,,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11503.68,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7000.00,32980.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33968.35,,"Fee schedule rate ($33,968.35). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Catheter Aorta,CASE-36200,APC,36200,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5555.89,,"Case rate ($5,368.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,959.91, add-ons for qualifying new technology services are included. If operating cost exceeds $40,427.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,559.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,979.68. The transfer operating threshold is the transfer adjustment factor * $4,959.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $388.34. The transfer capital threshold is the transfer adjustment factor * $388.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5368.01,15928.53,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10385.89,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10385.89,32176.55,Inpatient DRG
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|RIGHT SIDE,CASE-27675,APC,27675,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY VASCULAR PROCEDURES,MODERATE",181,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],32578.65,,"Case rate ($31,027.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31027.29,32578.65,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],40072.13,,"Fee schedule rate ($40,072.13). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],36213.17,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,34988.57,110685.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7213.50,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,21404.64,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],45507.56,,"Fee schedule rate ($45,507.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,3295.00,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|BILATERAL PROCEDURE,CASE-37766,APC,37766,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6848.95,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5683.00,19635.68,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11783.04,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11384.58,33781.47,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11134.07,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10915.75,32390.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],903.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,860.25,903.26,OPPS APC
Repair Dislocating Peroneal Tendon W/Fib Osteot|LEFT SIDE|PO,CASE-27676,APC,27676,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Unlisted Procedure Male Genital System,CASE-55899,APC,55899,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],236.97,,"APC Price ($236.97). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,236.97,248.82,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1188.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SMALL AND LARGE BOWEL PROCEDURES,MINOR",223,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4669.27,,"Case rate for a one day stay ($4,446.92). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4446.92,4669.27,There are no additional notes associated with this service or procedure.
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20986.65,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7826.00,90280.33,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Synovectomy Tendon Sheath Foot Extensor,CASE-28088,APC,28088,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6886.93,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6558.98,19462.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12171.73,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11592.12,38954.76,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9102.45,,"Fee schedule rate ($9,102.45). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],45371.94,,"Fee schedule rate ($45,371.94). Adds an outlier to normal pricing equal to the per diem rate ($84,711.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14891.42,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7308.00,42083.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7500.63,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7500.63,22256.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6690.16,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6558.98,19462.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],29270.08,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,28696.16,118364.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20954.82,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20954.82,62179.32,Inpatient DRG
Chemodenervation Internal Anal Sphincter,CASE-46505,APC,46505,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],194815.15,,"Case rate ($185,538.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,319.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,147.88. The transfer capital threshold is the transfer adjustment factor * $13,147.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,185834.07,195125.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39078.16,,"Fee schedule rate ($39,078.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
Excision Ganglion Wrist Dorsal/Volar Primary|PO,CASE-25111,APC,25111,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MODERATE",192,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3832.30,,"Case rate for a one day stay ($3,832.30). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3832.30,4023.92,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21399.79,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21399.79,63499.65,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11652.47,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11652.47,41507.02,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16631.58,,"Fee schedule rate ($16,631.58). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],26181.01,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,25667.66,86123.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6910.06,20832.04,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15547.45,,"Fee schedule rate ($15,547.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8263.49,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",8147.42,8147.42,20841.12,1 through 10,other,7984.05,23691.11,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27138.79,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,15507.88,46016.63,All Other Inpatient
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],41481.09,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,23703.48,110204.98,All Other Inpatient
"KIDNEY AND URINARY TRACT INFECTIONS,MODERATE",463,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8416.15,,"Case rate ($8,416.15). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8416.15,8836.96,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23758.52,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23758.52,103116.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12598.09,,"Fee schedule rate ($12,598.09). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22878.60,,"Fee schedule rate ($22,878.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14551.41,,"Case rate ($13,858.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,825.31, add-ons for qualifying new technology services are included. If operating cost exceeds $48,293.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,153.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,876.42. The transfer operating threshold is the transfer adjustment factor * $12,825.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $982.06. The transfer capital threshold is the transfer adjustment factor * $982.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7285.00,41187.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4941.63,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",3298.86,3298.86,3298.86,1 through 10,other,4774.52,14406.59,Inpatient DRG
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],60160.46,,,,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO,CASE-14040,APC,14040,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.96,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.96,1956.96,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9346.62,,"Case rate ($8,901.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.79. The transfer capital threshold is the transfer adjustment factor * $630.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8915.73,26455.73,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18947.04,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10826.88,32126.64,All Other Inpatient
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,70321.74,Estimated amount calculated based on 17 day length of stay.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Dilat Rct Strix Spx Under Anes Oth/Thn Local,CASE-45910,APC,45910,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Shoulder Foreign Body Deep Subfascial/Im,CASE-23333,APC,23333,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2851.46,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14856.14,,,,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37423.05,,"Fee schedule rate ($37,423.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13305.64,39481.90,There are no additional notes associated with this service or procedure.
Rpr Nonunion/Malunion Radius/Ulna W/Autograft,CASE-25405,APC,25405,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36008.91,,,,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],66169.85,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,64872.40,212258.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],37743.30,,"Fee schedule rate ($37,743.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],22645.02,,of the excess amount.,,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5629.94,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5629.94,16705.77,Inpatient DRG
"TONSIL AND ADENOID PROCEDURES,MODERATE",097,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4758.14,,"Case rate for a one day stay ($4,531.56). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4531.56,4758.14,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
Excision/Curettage Cyst/Tumor Phalanx Finger,CASE-26210,APC,26210,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Partial Excision Bone Talus/Calcaneus|LEFT SIDE|PO,CASE-28120,APC,28120,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],26908.14,,"Case rate ($25,626.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,987.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,816.00. The transfer capital threshold is the transfer adjustment factor * $1,816.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25667.66,86123.60,Inpatient DRG
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4234.02,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,2285.00,12138.74,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L >4.0 Cm|RIGHT SIDE,CASE-11406,APC,11406,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1621.31,1621.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment of Ulnar Shaft Fracture|RIGHT SIDE|PO,CASE-25545,APC,25545,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30658.90,,"Fee schedule rate ($30,658.90). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15392.60,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",90053.56,90053.56,90053.56,1 through 10,other,15090.78,44778.95,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,33843.71,Estimated amount calculated based on 10 day length of stay.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10736.25,,"Fee schedule rate ($10,736.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
Repair Non/Malunion Humerus W/Iliac/Oth Agrft|LEFT SIDE,CASE-24435,APC,24435,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17663.70,,"Case rate ($16,822.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,363.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,192.11. The transfer capital threshold is the transfer adjustment factor * $1,192.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16849.39,49997.29,Inpatient DRG
"Avulsion Nail Plate Partial/Comp Simple Ea Addl|LEFT HAND, FOURTH DIGIT|PO",CASE-11732,APC,11732,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],199.81,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC
Carpectomy All Bones Proximal Row|RIGHT SIDE|PO,CASE-25215,APC,25215,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Bone Graft Any Donor Area Major/Large|SEPARATE STRUCTURE,CASE-20902,APC,20902,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],23437.60,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19917.48,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,19243.94,63510.03,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9774.43,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33447.35,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],93689.50,,"Fee schedule rate ($93,689.50). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8431.66,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8431.66,25019.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,41333.08,Estimated amount calculated based on 10 day length of stay.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4598.45,,"Case rate ($4,442.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.41. The transfer capital threshold is the transfer adjustment factor * $321.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4442.95,13183.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,EXTREME",951,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],54340.24,,"Case rate ($54,340.24). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,544, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,54340.24,57057.25,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13335.48,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",13337.38,13337.38,13337.38,1 through 10,other,13335.48,39570.45,Inpatient DRG
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|RIGHT SIDE|PO,CASE-28119,APC,28119,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12770.37,,,,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
"Inject Nerv Blck,Paravert Sympath|PO",CASE-64520,APC,64520,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|RIGHT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6685.72,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,18893.86,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11202.49,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,31658.33,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Flx W/Endoscopic Mucosal Resection|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MODERATE",720,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11344.94,,"Case rate ($11,344.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11344.94,11912.19,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7601.43,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7601.43,23918.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12640.25,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12212.80,39290.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9929.69,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9456.85,28061.37,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11863.29,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11298.37,44627.23,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],615.80,,"APC Price ($594.98). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,594.98,624.73,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dilation Esophagus Guide Wire,CASE-43453,APC,43453,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15312.64,,,,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19631.82,,"Fee schedule rate ($19,631.82). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MODERATE",425,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2628.00,,"Case rate for a one day stay ($2,502.86). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2502.86,2628.00,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21133.20,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21133.20,88801.87,Inpatient DRG
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE|PO,CASE-27691,APC,27691,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],30630.50,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",17253.76,17253.76,17253.76,1 through 10,other,29594.69,124146.55,Inpatient DRG
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7429.60,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6382.95,21300.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10446.35,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9948.90,46199.76,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12836.55,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12402.46,36801.89,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6529.19,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5669.00,18994.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4369.17,,"Case rate ($4,161.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,466.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $294.87. The transfer capital threshold is the transfer adjustment factor * $294.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4167.74,12366.99,Inpatient DRG
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE|PO,CASE-29826,APC,29826,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>|LEFT SIDE,CASE-23071,APC,23071,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl,CASE-37232,APC,37232,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],180.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16247.30,,,,,,0,other,5389.29,16247.30,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9976.58,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5700.90,30872.02,All Other Inpatient
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4138.67,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4138.67,12473.25,Inpatient DRG
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10632.00,,"Per diem ($10,632). If length of stay < 6.4, first 1 days paid at a per diem of $21,264 instead. Capped at $68,043.82.",,,,0,other,10632.00,103714.29,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],85483.72,,"Fee schedule rate ($85,483.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11336.96,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7000.00,32980.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7405.81,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7405.81,33747.30,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($60,119.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27506.48,,,,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],28837.12,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,27861.95,82674.88,Inpatient DRG
Unlisted Procedure Femur/Knee|RIGHT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],233.96,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,233.96,245.65,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tx Tibl Shft Fx Imed Implt W/WO Screws&/Cercla,CASE-27759,APC,27759,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE,CASE-29891,APC,29891,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($55,128.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MAJOR",192,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],25800.08,,"Case rate ($24,571.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24571.50,25800.08,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12263.59,,"Case rate ($11,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.66. The transfer capital threshold is the transfer adjustment factor * $827.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12077.12,12077.12,12077.12,1 through 10,other,11698.23,34712.20,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15608.37,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8919.07,34453.70,All Other Inpatient
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12948.38,,"Fee schedule rate ($12,948.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT SIDE|PO,CASE-26111,APC,26111,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],45371.94,,"Fee schedule rate ($45,371.94). Adds an outlier to normal pricing equal to the per diem rate ($84,711.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15896.49,51306.05,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
Repair Primary Open/Prq Ruptured Achilles Tendon|RIGHT SIDE|PO,CASE-27650,APC,27650,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Femur/Knee|LEFT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],245.65,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,233.96,245.65,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],25148.37,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23950.83,74869.17,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9793.06,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9793.06,29058.99,Inpatient DRG
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Radial&Ulnar Shaft Fx W/Fixj Radius&Ulna,CASE-25575,APC,25575,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9427.51,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",9519.01,9519.01,9519.01,1 through 10,other,9108.71,27028.33,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12465.12,,"Case rate ($11,871.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,001.85, add-ons for qualifying new technology services are included. If operating cost exceeds $51,547.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,512.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,007.29. The transfer operating threshold is the transfer adjustment factor * $11,001.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.25. The transfer capital threshold is the transfer adjustment factor * $864.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11871.54,35778.69,Inpatient DRG
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Ercp Remove Foreign Body/Stent Biliary/Panc Duct|SEPARATE STRUCTURE,CASE-43275,APC,43275,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",145264.69,145264.69,145264.69,1 through 10,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8953.11,,"Case rate ($8,526.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,902.12, add-ons for qualifying new technology services are included. If operating cost exceeds $48,447.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,268.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $7,906.03. The transfer operating threshold is the transfer adjustment factor * $7,902.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.75. The transfer capital threshold is the transfer adjustment factor * $620.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,25698.16,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21254.28,,"Case rate ($20,242.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,605.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,434.43. The transfer capital threshold is the transfer adjustment factor * $1,434.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20274.44,80940.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7157.79,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5520.00,26638.96,Inpatient DRG
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE|PO,CASE-24342,APC,24342,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,21715.49,Estimated amount calculated based on 9 day length of stay.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7287.29,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6940.28,20593.95,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9733.35,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9269.86,37852.57,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9047.05,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5169.74,15340.19,All Other Inpatient
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
"SICKLE CELL ANEMIA CRISIS,MODERATE",662,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10155.54,,"Case rate ($9,671.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9671.94,10155.54,There are no additional notes associated with this service or procedure.
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE|PO,CASE-27698,APC,27698,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18914.54,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,10808.31,46938.11,All Other Inpatient
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],20679.93,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20274.44,80940.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>,CASE-25071,APC,25071,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13714.70,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5970.00,38757.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],61129.87,,"Fee schedule rate ($61,129.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Bx,Vulva/Perineum,Addl Lesion",CASE-56606,APC,56606,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],917.27,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,873.59,917.27,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],59216.74,,"Fee schedule rate ($59,216.74). Adds an outlier to normal pricing equal to the per diem rate ($89,749.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],32637.12,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,32637.12,96844.29,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17150.47,,,,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],41712.94,,"Fee schedule rate ($41,712.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7179.38,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6837.50,20288.95,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11203.52,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6350.00,33244.29,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|ADJ,CASE-97605,APC,97605,CPT,0761,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Vasc Embolize Occlude Organ,CASE-37243,APC,37243,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",10896.61,10896.61,10896.61,1 through 10,other,10949.29,11496.76,OPPS APC
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Excision Ganglion Wrist Dorsal/Volar Primary|LEFT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],130347.93,,"Fee schedule rate ($130,347.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30254.51,130347.93,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
"DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,MAJOR",042,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],1598.81,,"Case rate for a one day stay ($1,522.68). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1522.68,1598.81,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21256.76,,"Fee schedule rate ($21,256.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7942.27,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4538.44,18815.35,All Other Inpatient
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9702.97,,"Fee schedule rate ($9,702.97). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
HC Extremity Venogram|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9913.38,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9913.38,10409.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Flx W/Endoscopic Mucosal Resection|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|RIGHT SIDE|PO,CASE-23430,APC,23430,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],93678.26,,,,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12943.20,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12326.86,53121.74,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4326.70,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4120.67,13066.56,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7035.25,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6700.24,30254.37,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],144298.29,,"Fee schedule rate ($144,298.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],26525.17,,of the excess amount.,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],65370.90,,"Fee schedule rate ($65,370.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|SEPARATE STRUCTURE,CASE-12032,APC,12032,CPT,0450,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21805.52,,"Fee schedule rate ($21,805.52). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],36505.40,,"Fee schedule rate ($36,505.40). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12881.26,38222.57,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14472.76,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14472.76,56135.46,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
"URETHRAL AND TRANSURETHRAL PROCEDURES,MINOR",446,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5592.77,,"Case rate for a one day stay ($5,592.77). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5592.77,5872.41,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22382.59,,,,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,76376.03,Estimated amount calculated based on 6 day length of stay.
"Tenolysis Extensor Tendon Hand/Finger Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26445,APC,26445,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
Open Tx Trimalleolar Ankle Fx W/Fixj Pst Lip|LEFT SIDE|PO,CASE-27823,APC,27823,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE,CASE-27698,APC,27698,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10109.37,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10109.37,38416.97,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16508.45,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,15950.19,63458.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12395.17,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12395.17,42174.37,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5110.72,,"Case rate ($4,867.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.12. The transfer capital threshold is the transfer adjustment factor * $352.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4867.35,14442.92,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5779.85,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5504.62,16333.88,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6953.28,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5520.00,26638.96,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19988.17,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8972.00,76376.03,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
Unlisted Px Skin Muc Membrane & Subq Tissue|PO,CASE-17999,APC,17999,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7226.40,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE,CASE-29880,APC,29880,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
"DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,MAJOR",042,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],1598.81,,"Case rate for a one day stay ($1,522.68). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1522.68,1598.81,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE|PO,CASE-25607,APC,25607,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25019.31,,,,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],23260.04,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9370.00,65732.99,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5923.06,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5923.06,17575.50,Inpatient DRG
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],57872.02,,,,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
Capsulectomy/Capsulotomy Mtcarphlngl Joint Each,CASE-26520,APC,26520,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE,CASE-27650,APC,27650,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8141.32,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7866.01,25247.47,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18994.21,,,,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
HC Fem Pop Terr Plasty and Stent|LEFT SIDE,CASE-37226,APC,37226,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],491.83,,,,,,0,other,468.41,491.83,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],40183.85,,of the excess amount.,,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],25267.19,,"Fee schedule rate ($25,267.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES SIGNS AND SYMPTOMS,EXTREME",468,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],23585.04,,"Case rate ($22,461.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22461.94,23585.04,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20382.60,,"Fee schedule rate ($20,382.60). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],44474.65,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,43602.60,153667.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6474.12,19210.66,There are no additional notes associated with this service or procedure.
"HC Unlisted Procedure, Nervous System|UNUSUAL NON-OVERLAPPING SERVICE",CASE-64999,APC,64999,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MAJOR",140,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11832.62,,"Case rate ($11,832.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11832.62,12424.25,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21119.68,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,17274.00,73717.28,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27654,APC,27654,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],20445.79,,"Case rate ($19,472.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,551.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,379.87. The transfer capital threshold is the transfer adjustment factor * $1,379.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19503.23,57872.02,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,53945.28,Estimated amount calculated based on 17 day length of stay.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15016.36,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14508.56,59513.03,Inpatient DRG
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Lympho for Sentinal Node|SEPARATE PRACTITIONER,CASE-38792,APC,38792,CPT,0361,RC,,,XP,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8704.81,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8410.44,24956.34,Inpatient DRG
"DIABETES,MINOR",420,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6484.80,,"Case rate ($6,484.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6484.80,6809.04,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],37199.37,,,,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt|RIGHT SIDE|PO,CASE-27602,APC,27602,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"SEPTICEMIA AND DISSEMINATED INFECTIONS,EXTREME",720,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],32886.18,,"Case rate ($31,320.17). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31320.17,32886.18,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13979.96,,"Case rate ($13,314.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,114.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $943.49. The transfer capital threshold is the transfer adjustment factor * $943.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13335.48,39570.45,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11948.42,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11714.14,49460.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3514.75,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, THIRD DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24417.19,,,,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
Arven Anast Opn Upr Arm Basilic Vein Trpos|RIGHT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4263.95,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4180.34,14351.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,APC,54405,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20346.09,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,19658.06,20640.96,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|PO,CASE-28090,APC,28090,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-12032,APC,12032,CPT,0450,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19377.46,,"Fee schedule rate ($19,377.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11993.07,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11757.91,34889.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE,CASE-29891,APC,29891,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5567.57,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5379.29,15961.98,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
Open Treatment Fracture Distal Tibia & Fibula|LEFT SIDE|PO,CASE-27828,APC,27828,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15961.98,,,,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],39668.91,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,38891.09,169197.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],48094.52,,,,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MINOR",192,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5630.90,,"Case rate for a one day stay ($5,362.76). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5362.76,5630.90,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10556.32,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10556.32,32082.48,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",2031.84,2031.84,2031.84,1 through 10,other,1525.13,1601.38,OPPS APC
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5254.16,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5003.96,21742.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11832.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11600.09,48814.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,55581.70,Estimated amount calculated based on 10 day length of stay.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3934.69,,"Case rate ($3,747.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,436.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $265.55. The transfer capital threshold is the transfer adjustment factor * $265.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3753.29,11765.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],48832.41,,,,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],51643.16,,"Fee schedule rate ($51,643.16). Adds an outlier to normal pricing equal to the per diem rate ($161,652.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5985.39,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5985.39,17760.46,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,APC,67900,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],46316.38,,"Fee schedule rate ($46,316.38). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17898.30,,"Fee schedule rate ($17,898.30). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12423.25,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12179.66,36140.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10105.00,,"Per diem ($10,105). If length of stay < 10.6, first 1 days paid at a per diem of $20,210 instead. Capped at $107,110.70.",,,,0,other,10105.00,120252.50,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT|PO",CASE-26951,APC,26951,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6495.00,,"Per diem ($6,495). If length of stay < 3.5, first 1 days paid at a per diem of $12,990 instead. Capped at $22,732.01.",6252.00,6252.00,6252.00,1 through 10,other,6495.00,23801.30,Estimated amount calculated based on 4 day length of stay.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],50750.92,,,,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],108024.76,,,,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14477.85,,"Fee schedule rate ($14,477.85). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|LEFT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17954.98,,"Case rate ($17,099.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,382.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,211.76. The transfer capital threshold is the transfer adjustment factor * $1,211.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17127.24,50821.76,Inpatient DRG
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, SECOND DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],92976.49,,"Fee schedule rate ($92,976.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.5), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Ant&/Lat Compartments Only,CASE-27600,APC,27600,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41847.08,,,,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8131.20,,"Case rate ($7,744). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,731.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $560.22. The transfer capital threshold is the transfer adjustment factor * $560.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7744.00,24853.45,Inpatient DRG
Circumcision Age >28 Days,CASE-54161,APC,54161,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20654.42,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20654.42,69402.59,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19403.03,,"Case rate ($18,479.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,480.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,309.49. The transfer capital threshold is the transfer adjustment factor * $1,309.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18508.54,76171.92,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE,CASE-28200,APC,28200,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11571.55,,"Fee schedule rate ($11,571.55). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
HC Add 2nd/3rd Order Abd/Le|RIGHT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],514.99,,"APC Price ($514.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,514.99,540.74,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28569.12,,"Fee schedule rate ($28,569.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],26024.99,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9242.00,76216.30,Inpatient DRG
Exc Tumor Soft Tissue Abdl Wall Subfascial <5cm,CASE-22900,APC,22900,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],36511.04,,"Fee schedule rate ($36,511.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],8990.00,,"Per diem ($8,990). If length of stay < 6, first 1 days paid at a per diem of $17,980 instead. Capped at $53,939.67.",,,,0,other,8990.00,80069.53,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
Claviculectomy Partial|LEFT SIDE|PO,CASE-23120,APC,23120,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32878.30,,,,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6010.94,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5807.67,17233.12,Inpatient DRG
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13789.07,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13789.07,57367.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9586.73,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,27484.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5217.26,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4968.82,19848.33,Inpatient DRG
Rhytidectomy Neck W/Platysmal Tightening,CASE-15825,APC,15825,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32745.30,,"Fee schedule rate ($32,745.30). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22878.60,,"Fee schedule rate ($22,878.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],30537.65,,"Case rate ($29,083.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,232.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,060.96. The transfer capital threshold is the transfer adjustment factor * $2,060.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29129.85,86437.13,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],102498.90,,"Fee schedule rate ($102,498.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,36167.61,140535.66,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,APC,26437,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula,CASE-27641,APC,27641,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12463.10,,"Case rate ($11,869.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,012.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $841.12. The transfer capital threshold is the transfer adjustment factor * $841.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11888.55,35276.93,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20231.40,,"Fee schedule rate ($20,231.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,28788.33,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8516.76,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8228.75,24417.19,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11500.98,,"Case rate ($10,953.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,947.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.19. The transfer capital threshold is the transfer adjustment factor * $776.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10970.77,32553.63,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5938.97,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5938.97,17858.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Excis Nail Matrix Perm Rmvl|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-11750,APC,11750,CPT,0450,RC,,,XS|T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9969.47,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9969.47,29582.40,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14106.60,,"Fee schedule rate ($14,106.60). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
"SIGNS SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS,MODERATE",861,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],1854.70,,"Case rate for a one day stay ($1,766.38). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1766.38,1854.70,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11714.14,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11714.14,49460.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5648.25,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5379.29,15961.98,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10105.00,,"Per diem ($10,105). If length of stay < 10.6, first 1 days paid at a per diem of $20,210 instead. Capped at $107,110.70.",,,,0,other,10105.00,120252.50,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23415.63,,,,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],28916.65,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27539.67,109237.68,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6377.95,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6074.24,18024.13,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26483.27,,,,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Bi Tot Pel Lmphadec & Pri-Aortic Lymph Bx 1,CASE-38572,APC,38572,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,CASE-58571,APC,58571,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34517.10,,"Fee schedule rate ($34,517.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9725.67,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,27484.83,Inpatient DRG
Surg Tx Anal Fistula Intersphincteric,CASE-46275,APC,46275,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38110.41,,,,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MODERATE",045,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13541.20,,"Case rate ($12,896.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12896.38,13541.20,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,1188.00,27484.83,Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10439.61,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10439.61,34540.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,MINOR",663,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2942.52,,"Case rate for a one day stay ($2,802.40). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2802.40,2942.52,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia Recr > 10 Cm Ncrc8/Strangulated,CASE-49618,APC,49618,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],201.74,,"APC Price ($201.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,201.74,211.83,OPPS APC
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surgical Jejunostomy,CASE-44186,APC,44186,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],29066.85,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4245.71,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3295.00,21715.49,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],129256.37,,"Fee schedule rate ($129,256.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14718.77,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14718.77,51765.74,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10915.75,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10817.10,10817.10,10817.10,1 through 10,other,10915.75,32390.31,Inpatient DRG
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,APC,26356,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64448,APC,64448,CPT,0360,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11593.40,,"Fee schedule rate ($11,593.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,2285.00,12138.74,There are no additional notes associated with this service or procedure.
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrotomy W/Meniscus Repair Knee|LEFT SIDE,CASE-27403,APC,27403,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],3940.95,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3753.29,11765.59,Inpatient DRG
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7182.75,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,21229.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,APC,45381,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt,CASE-38570,APC,38570,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11014.06,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6293.75,21908.95,All Other Inpatient
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24121.65,,"Fee schedule rate ($24,121.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11958.84,40774.00,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],29890.76,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8232.00,84471.39,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14267.55,,"Case rate ($13,588.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,555.10, add-ons for qualifying new technology services are included. If operating cost exceeds $48,023.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,154.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,605.14. The transfer operating threshold is the transfer adjustment factor * $12,555.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $983.00. The transfer capital threshold is the transfer adjustment factor * $983.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13588.14,40320.14,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18378.15,,"Fee schedule rate ($18,378.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18513.23,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7455.00,53076.74,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],28467.39,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",20091.64,20091.64,20091.64,1 through 10,other,8232.00,84471.39,Inpatient DRG
Blepharoplasty Lower Eyelid Herniated Fat Pad,CASE-15821,APC,15821,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.96,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.96,2054.80,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",4884.61,4884.61,5161.43,1 through 10,other,5263.48,5339.77,OPPS APC
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15616.65,,"Fee schedule rate ($15,616.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],33148.67,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,31570.16,98176.71,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10652.43,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,30103.84,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4741.79,,"Case rate ($4,515.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,179.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,647.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,491.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,195.97. The transfer operating threshold is the transfer adjustment factor * $4,179.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $320.02. The transfer capital threshold is the transfer adjustment factor * $320.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4523.19,16536.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|PO,CASE-64494,APC,64494,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5629.94,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5629.94,16705.77,Inpatient DRG
HC Extremity Venogram,CASE-36005,APC,36005,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1493.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1545.29,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],44704.18,,,,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6146.79,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,17370.86,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
Capsulectomy/Capsulotomy Mtcarphlngl Joint Each|LEFT SIDE|PO,CASE-26520,APC,26520,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|ADJ,CASE-97605,APC,97605,CPT,0761,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],20331.48,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19363.31,79918.67,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9269.86,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9269.86,37852.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Hemiphalangectomy/Interphalangeal Joint Exc Toe,CASE-28160,APC,28160,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|PO,CASE-27650,APC,27650,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc,CASE-24341,APC,24341,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,APC,58661,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7476.69,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,20179.92,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6950.18,,"Case rate ($6,619.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,117.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $469.35. The transfer capital threshold is the transfer adjustment factor * $469.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6630.72,19989.86,Inpatient DRG
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32803.53,,,,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6762.29,,"Case rate ($6,440.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,950.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,418.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,637.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,974.38. The transfer operating threshold is the transfer adjustment factor * $5,950.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $465.91. The transfer capital threshold is the transfer adjustment factor * $465.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6440.28,19110.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|BILATERAL PROCEDURE,CASE-49507,APC,49507,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthro, Loose Body + Chondro",CASE-G0289,APC,G0289,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19156.34,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,18508.54,76171.92,Inpatient DRG
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB|PO",CASE-64831,APC,64831,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4288.55,,"Case rate ($4,084.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,460.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $289.43. The transfer capital threshold is the transfer adjustment factor * $289.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2285.00,12138.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],69328.94,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,66027.56,228732.31,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18988.45,,"Fee schedule rate ($18,988.45). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24789.11,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23950.83,74869.17,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8259.31,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7866.01,25247.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],37679.20,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,36405.02,110499.61,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11279.92,,"Case rate ($10,742.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.27. The transfer capital threshold is the transfer adjustment factor * $761.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",28818.50,28818.50,28818.50,1 through 10,other,10759.91,46061.32,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17836.44,,"Fee schedule rate ($17,836.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4971.37,,"Case rate ($4,734.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,389.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,934.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,991.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,391.29. The transfer operating threshold is the transfer adjustment factor * $4,389.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.35. The transfer capital threshold is the transfer adjustment factor * $343.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4734.64,14273.70,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13430.62,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",12925.80,12925.80,12925.80,1 through 10,other,12791.07,43031.63,Inpatient DRG
HC Fem Pop Terr Plasty and Stent,CASE-37226,APC,37226,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],112882.03,,"Fee schedule rate ($112,882.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7736.54,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,33946.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7184.98,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",1759.74,1759.74,1759.74,1 through 10,other,7184.98,21320.03,Inpatient DRG
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5938.30,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5938.30,18621.89,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14002.25,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13335.48,39570.45,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MODERATE",385,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8533.78,,"Case rate ($8,127.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8127.41,8533.78,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea,CASE-28092,APC,28092,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6180.91,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5886.58,17467.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11621.00,,"Per diem ($11,621). If length of stay < 22.4, first 1 days paid at a per diem of $23,242 instead. Capped at $260,309.36.",,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],48779.11,,"Fee schedule rate ($48,779.11). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,APC,43239,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE|PO,CASE-29826,APC,29826,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7369.00,,"Per diem ($7,369). If length of stay < 2.4, first 1 days paid at a per diem of $14,738 instead. Capped at $17,686.09.",,,,0,other,6240.68,18518.02,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14871.78,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,14580.18,57079.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5027.17,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4787.78,20006.29,Inpatient DRG
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|RIGHT SIDE,CASE-26121,APC,26121,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Curtg/Caut Anal Fissure W/Dilat Sphnctr Spx 1st,CASE-46940,APC,46940,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5977.30,,"Case rate ($5,775.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.79. The transfer capital threshold is the transfer adjustment factor * $417.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5950.14,5950.14,5950.14,1 through 10,other,5775.17,17136.70,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],36224.65,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36224.65,128473.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Intercost Sng|RIGHT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,868.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MIGRAINE AND OTHER HEADACHES,MINOR",054,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8272.68,,"Case rate ($7,878.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7878.74,8272.68,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42003.98,,"Fee schedule rate ($42,003.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13768.00,,,,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],61868.44,,"Fee schedule rate ($61,868.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,APC,64585,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3315.94,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3315.94,3481.74,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],34386.65,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32749.19,97176.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11338.31,,"Case rate ($10,798.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,936.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $765.21. The transfer capital threshold is the transfer adjustment factor * $765.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",11155.77,11155.77,11155.77,1 through 10,other,9888.00,40658.63,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],27777.08,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13572.00,108637.77,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
HC Insertion Uterine Tandem&/Vaginal Ovoids,CASE-57155,APC,57155,CPT,0342,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4981.90,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4744.66,4981.90,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11142.86,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,1188.00,18893.86,All Other Inpatient
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20654.42,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20654.42,69402.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|RIGHT SIDE|PO,CASE-29883,APC,29883,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26300.80,,"Fee schedule rate ($26,300.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19824.58,,,,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],3940.95,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3753.29,11765.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|RIGHT SIDE,CASE-27675,APC,27675,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Metatarsophalangeal Joint Dislocation,CASE-28645,APC,28645,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
Arthrt Elbow Capsular Excision Capsular Rls Spx|RIGHT SIDE|PO,CASE-24006,APC,24006,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7354.14,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7003.94,20782.85,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25757.85,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,14718.77,51765.74,All Other Inpatient
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],44691.15,,"Fee schedule rate ($44,691.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE,CASE-15823,APC,15823,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19262.83,,"Fee schedule rate ($19,262.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13557.45,,,,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],45202.80,,"Fee schedule rate ($45,202.80). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Vasc Embolize Occlude Artery,CASE-37242,APC,37242,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO,CASE-27654,APC,27654,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20005.22,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20005.22,74991.64,Inpatient DRG
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38976.20,,,,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19108.28,,"Case rate ($18,198.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,460.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.60. The transfer capital threshold is the transfer adjustment factor * $1,289.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18227.38,54086.17,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17191.57,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17191.57,51012.62,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
"ALLERGIC REACTIONS,MODERATE",811,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2859.96,,"Case rate for a one day stay ($2,859.96). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2859.96,3002.96,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11855.63,,"Case rate ($11,623.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,490.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.89. The transfer capital threshold is the transfer adjustment factor * $842.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,1188.00,35040.80,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],30753.41,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,30150.40,89465.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14523.10,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13831.52,59770.39,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, THUMB|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14442.92,,,,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12383.35,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12140.54,36024.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27135.21,,"Fee schedule rate ($27,135.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
Nerve Repair W/Conduit Each Nerve|LEFT SIDE|PO,CASE-64910,APC,64910,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8614.94,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8323.61,8739.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Femur/Knee,CASE-27599,APC,27599,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],233.96,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,233.96,245.65,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11348.73,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10808.31,46938.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28895.67,,,,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10080.86,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10080.86,33310.69,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],27740.63,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,26419.65,96304.23,Inpatient DRG
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,MODERATE",513,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],17396.85,,"Case rate ($16,568.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16568.43,17396.85,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10528.47,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10528.47,44148.02,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28695.03,,"Fee schedule rate ($28,695.03).",,,,0,other,14182.35,53827.17,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|LEFT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Proctosgmdsc Rgd Dx W/WO Collj Spec Br/Wa Spx,CASE-45300,APC,45300,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9935.64,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9935.64,29482.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8981.78,,"Case rate ($8,981.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,671.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $657.72. The transfer capital threshold is the transfer adjustment factor * $657.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8981.78,27528.12,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE|PO,CASE-64624,APC,64624,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
"DIABETES,MAJOR",420,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13059.61,,"Case rate ($12,437.72). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12437.72,13059.61,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31658.33,,,,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16737.33,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16737.33,72192.67,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13119.35,,"Case rate ($12,494.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,056.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $885.41. The transfer capital threshold is the transfer adjustment factor * $885.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12514.54,37134.43,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17191.57,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",16668.50,16668.50,56571.56,1 through 10,other,17191.57,51012.62,Inpatient DRG
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2,CASE-29822,APC,29822,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt,CASE-25020,APC,25020,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17208.64,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9833.51,45903.36,All Other Inpatient
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6514.03,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6293.75,21908.95,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21373.92,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20954.82,62179.32,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE,CASE-28238,APC,28238,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],49817.93,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8232.00,84471.39,All Other Inpatient
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],71069.39,,,,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, SECOND DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10522.17,,"Case rate ($10,021.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.13. The transfer capital threshold is the transfer adjustment factor * $710.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10037.09,36934.96,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Ablation Renal Cysts|RIGHT SIDE,CASE-50541,APC,50541,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9605.28,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9280.46,39957.56,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5700.90,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5700.90,30872.02,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|RIGHT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],42695.82,,"Fee schedule rate ($42,695.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23950.83,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23950.83,74869.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
HC Tib per Territory Ather,CASE-37229,APC,37229,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],626.55,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
Tenolysis Extensor Foot Single Tendon|LEFT SIDE|PO,CASE-28225,APC,28225,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE,CASE-24685,APC,24685,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],46957.19,,,,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17983.60,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17127.24,50821.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],67775.08,,"Fee schedule rate ($67,775.08). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6216.69,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6094.79,22352.66,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6348.33,,"Case rate ($6,046.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.44. The transfer capital threshold is the transfer adjustment factor * $428.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",3481.00,3481.00,3481.00,1 through 10,other,6055.67,17969.04,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],35466.15,,"Fee schedule rate ($35,466.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],8940.00,,"Per diem ($8,940). If length of stay < 6.8, first 1 days paid at a per diem of $17,880 instead. Capped at $60,793.48.",,,,0,other,8940.00,63653.13,Estimated amount calculated based on 4 day length of stay.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19460.03,,"Case rate ($18,533.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,484.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,313.34. The transfer capital threshold is the transfer adjustment factor * $1,313.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18562.91,73513.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE|PO,CASE-28740,APC,28740,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9346.62,,"Case rate ($8,901.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.79. The transfer capital threshold is the transfer adjustment factor * $630.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8915.73,26455.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Tx Missed Abortion First Trimester Surgical,CASE-59820,APC,59820,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Destruction Lesions Vulva Extensive,CASE-56515,APC,56515,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2054.80,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.96,2054.80,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9262.54,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,27484.83,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24470.88,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7770.00,50313.90,All Other Inpatient
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|RIGHT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],180.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11159.78,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11159.78,39897.21,Inpatient DRG
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Fracture Phalanx/Phalanges Not Great Toe,CASE-28525,APC,28525,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7034.96,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6797.06,20168.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16756.06,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9574.89,28411.62,All Other Inpatient
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8143.73,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7984.05,33319.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16166.30,,"Case rate ($15,396.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.05. The transfer capital threshold is the transfer adjustment factor * $1,091.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15421.03,49137.17,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],20193.62,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19232.02,68941.12,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,37575.69,Estimated amount calculated based on 11 day length of stay.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,APC,29828,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Cystourethroscopy With Biopsy|SEPARATE STRUCTURE,CASE-52204,APC,52204,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],25983.55,,"Case rate ($24,746.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,924.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,753.60. The transfer capital threshold is the transfer adjustment factor * $1,753.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9242.00,76216.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8704.87,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8704.87,25830.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6178.00,,"Per diem ($6,178). If length of stay < 3.9, first 1 days paid at a per diem of $12,356 instead. Capped at $24,092.63.",,,,0,other,6178.00,25225.91,Estimated amount calculated based on 3 day length of stay.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28289,APC,28289,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Tenolysis Flexor Tendon Palm/Finger Each Tendon,CASE-26440,APC,26440,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8938.88,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8513.22,25261.33,Inpatient DRG
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35640.95,,,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
"SKIN ULCERS,EXTREME",380,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],22532.40,,"Case rate ($22,532.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22532.40,23659.02,There are no additional notes associated with this service or procedure.
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MODERATE",721,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11237.67,,"Case rate ($10,702.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10702.54,11237.67,There are no additional notes associated with this service or procedure.
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21292.37,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12167.07,36103.36,All Other Inpatient
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15818.85,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15065.57,53815.71,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],39672.94,,"Case rate ($37,783.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,848.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,677.49. The transfer capital threshold is the transfer adjustment factor * $2,677.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,37843.99,139522.22,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11080.19,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11080.19,32878.30,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24306.10,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13889.20,55846.16,All Other Inpatient
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31790.24,,"Fee schedule rate ($31,790.24). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,11217.46,37366.25,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9076.75,,"Fee schedule rate ($9,076.75). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn|PO,CASE-62321,APC,62321,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",675.06,463.39,685.98,1 through 10,other,669.51,702.98,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5114.41,,"Case rate ($4,870.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.17. The transfer capital threshold is the transfer adjustment factor * $345.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",7344.41,5114.41,7554.01,1 through 10,other,4878.64,14476.37,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21112.63,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21112.63,62647.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],67460.63,,,,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19491.06,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18562.91,73513.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>|LEFT SIDE,CASE-23073,APC,23073,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE|PO,CASE-29875,APC,29875,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12559.96,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12135.23,49469.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23644.46,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23644.46,105789.11,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14574.62,,"Case rate ($13,880.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,825.31, add-ons for qualifying new technology services are included. If operating cost exceeds $48,293.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,876.42. The transfer operating threshold is the transfer adjustment factor * $12,825.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7285.00,41187.90,Inpatient DRG
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35276.93,,,,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10975.11,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10759.91,46061.32,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],89469.71,,"Fee schedule rate ($89,469.71). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17760.46,,,,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20885.18,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20885.18,80720.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39967.07,,"Fee schedule rate ($39,967.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9125.56,,"Case rate ($8,691.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.88. The transfer capital threshold is the transfer adjustment factor * $615.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8704.87,25830.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE|PO,CASE-27524,APC,27524,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Open Tx Metatarsophalangeal Joint Dislocation,CASE-28645,APC,28645,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6393.28,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6088.84,18067.42,Inpatient DRG
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7394.01,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,21229.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30534.77,,,,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],27539.67,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27539.67,109237.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC I & D Simple,CASE-10060,APC,10060,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19609.46,,"Fee schedule rate ($19,609.46). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
Mastectomy Simple Complete|RIGHT SIDE,CASE-19303,APC,19303,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],59216.74,,"Fee schedule rate ($59,216.74). Adds an outlier to normal pricing equal to the per diem rate ($89,749.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5923.82,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",15606.00,5918.62,37236.55,1 through 10,other,5807.67,17233.12,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|RIGHT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],46830.28,,"Fee schedule rate ($46,830.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6334.78,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6033.12,17902.13,Inpatient DRG
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20343.42,,"Fee schedule rate ($20,343.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8165.37,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8005.26,24549.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",675.06,675.06,685.98,1 through 10,other,669.51,702.98,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],86162.15,,"Fee schedule rate ($86,162.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16066.89,,"Case rate ($15,301.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,255.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,084.34. The transfer capital threshold is the transfer adjustment factor * $1,084.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15326.20,52511.19,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16534.40,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6531.00,35832.77,All Other Inpatient
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14442.92,,,,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5942.94,17634.53,Zero final payments for the item or service in the 15 months prior to posting the file.
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SICKLE CELL ANEMIA CRISIS,MINOR",662,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7197.66,,"Case rate ($7,197.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7197.66,7557.54,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19300.28,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18381.22,58579.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],24785.70,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9242.00,76216.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,APC,43239,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12107.00,,"Per diem ($12,107). If length of stay < 2.8, first 1 days paid at a per diem of $24,214 instead. Capped at $33,900.69.",,,,0,other,11962.15,40923.09,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],72742.07,,"Fee schedule rate ($72,742.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
Bladder Instillation Anticarcinogenic Agent|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51720,APC,51720,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],96565.35,,"Fee schedule rate ($96,565.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18381.22,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18381.22,58579.45,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11615.68,,"Case rate ($11,062.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,955.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.93. The transfer capital threshold is the transfer adjustment factor * $783.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",11615.69,11615.69,11615.69,1 through 10,other,11080.19,32878.30,Inpatient DRG
"HEART FAILURE,MINOR",194,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7087.14,,"Case rate ($7,087.14). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7087.14,7441.50,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4976.21,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",4922.54,4922.54,4922.54,1 through 10,other,4878.64,14476.37,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],28005.17,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,28005.17,115392.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10682.39,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10173.70,41194.64,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19871.72,,"Fee schedule rate ($19,871.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23337.09,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13335.48,39570.45,All Other Inpatient
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23602.02,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23602.02,108295.22,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Tumor Soft Tiss Face/Scalp Subq 2 Cm/>,CASE-21012,APC,21012,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
Open Treatment Bimalleolar Ankle Fracture|RIGHT SIDE|PO,CASE-27814,APC,27814,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Fth/Gft Fr W/Dir Clsr F/C/C/M/N/Ax/G/H/F 20 Cm/<|PO,CASE-15240,APC,15240,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2025.45,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.96,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HEART FAILURE,MODERATE",194,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9565.56,,"Case rate ($9,565.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9565.56,10043.84,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12440.40,,"Fee schedule rate ($12,440.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],43444.85,,,,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",1812.87,1812.87,1812.87,1 through 10,other,1852.10,1944.70,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
HC 3rd Order Sel Abd/Lower Ext|BILATERAL PROCEDURE,CASE-36247,APC,36247,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34614.30,,"Fee schedule rate ($34,614.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Fem Hernia Any Age Incarcerated,CASE-49553,APC,49553,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9009.54,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8704.87,25830.00,Inpatient DRG
Rmvl/Revj Sling Male Urinary Incontinence,CASE-53442,APC,53442,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE,CASE-27650,APC,27650,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Inject Platelet Rich Plasma W/Img Harvest/Preparatoin,CASE-0232T,APC,0232T,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15857.69,,,,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35040.80,,,,,,0,other,1188.00,35040.80,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",36215.56,36215.56,36215.56,1 through 10,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10529.78,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10173.70,41194.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy,CASE-44970,APC,44970,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8259.31,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7866.01,25247.47,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9509.84,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9056.99,33814.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18796.76,,"Fee schedule rate ($18,796.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6632.59,19680.94,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33968.35,,"Fee schedule rate ($33,968.35). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,APC,43266,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6045.95,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5758.05,6045.95,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11444.12,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10899.16,39746.35,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8230.55,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7952.22,25854.47,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12120.70,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11710.82,34749.58,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, THUMB|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
Debridement Bone Each Additional 20 Sq Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-11047,APC,11047,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],61868.44,,"Fee schedule rate ($61,868.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18072.75,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17212.14,64440.06,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16682.55,,"Fee schedule rate ($16,682.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE|PO,CASE-27654,APC,27654,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
"OTHER DISORDERS OF NERVOUS SYSTEM,MAJOR",058,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],20257.40,,"Case rate ($19,292.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19292.76,20257.40,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64448,APC,64448,CPT,0360,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24282.18,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23125.89,68621.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12395.17,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12395.17,42174.37,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7759.92,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7759.92,35376.63,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6035.39,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5091.00,22010.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9728.97,,"Case rate ($9,265.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,827.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $656.60. The transfer capital threshold is the transfer adjustment factor * $656.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9280.46,39957.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19110.30,,,,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"MAJOR PANCREAS LIVER AND SHUNT PROCEDURES,MINOR",260,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],23044.93,,"Case rate ($23,044.93). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,23044.93,24197.18,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,28788.33,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13163.24,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12536.42,46998.45,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13140.27,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12514.54,37134.43,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MAJOR",561,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2613.40,,"Case rate for a one day stay ($2,488.95). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2488.95,2613.40,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8605.40,,"Case rate ($8,605.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,951.18, add-ons for qualifying new technology services are included. If operating cost exceeds $43,419.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,982.86. The transfer operating threshold is the transfer adjustment factor * $7,951.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $622.54. The transfer capital threshold is the transfer adjustment factor * $622.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8605.40,42305.71,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],45202.80,,"Fee schedule rate ($45,202.80). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|RIGHT SIDE,CASE-28309,APC,28309,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9411.54,,"Case rate ($8,963.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,653.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $639.31. The transfer capital threshold is the transfer adjustment factor * $639.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8981.78,27528.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6301.06,,"Case rate ($6,001.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,596.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.25. The transfer capital threshold is the transfer adjustment factor * $425.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",5912.33,5912.33,5912.33,1 through 10,other,6010.58,17835.23,Inpatient DRG
Arthro/shoul surg; w/spacer,CASE-C9781,APC,C9781,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17323.07,,"Case rate ($16,498.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,340.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.12. The transfer capital threshold is the transfer adjustment factor * $1,169.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16524.47,58465.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1117.89,1117.89,5875.02,1 through 10,other,5733.99,6020.69,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12303.99,,"Fee schedule rate ($12,303.99). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8562.42,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8394.53,24909.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7492.37,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6308.00,21796.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5368.01,15928.53,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MINOR",192,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5630.90,,"Case rate for a one day stay ($5,362.76). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5362.76,5630.90,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31658.33,,,,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37423.05,,"Fee schedule rate ($37,423.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13305.64,39481.90,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
Sling Opration Corrj Male Urinary Incontinence,CASE-53440,APC,53440,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13139.25,,"APC Price ($12,513.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12513.57,13139.25,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23320.23,,"Fee schedule rate ($23,320.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],36249.82,,"Fee schedule rate ($36,249.82). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Mastectomy Simple Complete|BILATERAL PROCEDURE,CASE-19303,APC,19303,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30204.20,,,,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20954.82,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20954.82,62179.32,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13728.80,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13264.54,50759.39,Inpatient DRG
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT SIDE|PO,CASE-26160,APC,26160,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8285.44,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8005.26,24549.95,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10815.28,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10449.55,43409.67,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],35148.55,,"Fee schedule rate ($35,148.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",35148.55,35148.55,35148.55,1 through 10,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
Fasciectomy Plantar Fascia Radical Spx|RIGHT SIDE,CASE-28062,APC,28062,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Unlisted Procedure Abdomen Peritoneum & Omentum,CASE-49999,APC,49999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11730.05,,"Case rate ($11,730.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,838.28, add-ons for qualifying new technology services are included. If operating cost exceeds $46,306.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,019.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,881.47. The transfer operating threshold is the transfer adjustment factor * $10,838.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.58. The transfer capital threshold is the transfer adjustment factor * $848.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11730.05,61348.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,APC,52318,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8925.03,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8925.03,26628.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11170.47,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10638.54,40729.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8515.39,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8227.43,27001.04,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5169.74,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5169.74,15340.19,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Lateral Release|LEFT SIDE|PO,CASE-29873,APC,29873,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T3,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17072.08,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",16756.86,16756.86,16756.86,1 through 10,other,16737.33,72192.67,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],54261.48,,"Fee schedule rate ($54,261.48). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24863.59,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23679.61,84629.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9957.13,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9761.89,37873.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,5450.78,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
HC Lyr Clos Nk Hnd Ft <2.6cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-12041,APC,12041,CPT,0450,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|BILATERAL PROCEDURE,CASE-52354,APC,52354,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,APC,57260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4910.73,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11519.31,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10970.77,32553.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13842.12,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12440.40,41073.77,Inpatient DRG
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8.46,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9371.99,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5355.42,17067.11,All Other Inpatient
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12650.51,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",12861.31,12861.31,12861.31,1 through 10,other,12402.46,36801.89,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],38916.28,,"Case rate ($38,916.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,957.67, add-ons for qualifying new technology services are included. If operating cost exceeds $71,425.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,986.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $36,100.97. The transfer operating threshold is the transfer adjustment factor * $35,957.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,815.30. The transfer capital threshold is the transfer adjustment factor * $2,815.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",189249.60,189249.60,189249.60,1 through 10,other,38916.28,133824.90,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6235.92,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.97,17858.70,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37423.05,,"Fee schedule rate ($37,423.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13305.64,39481.90,There are no additional notes associated with this service or procedure.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE|PO,CASE-27650,APC,27650,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5254.16,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5003.96,21742.11,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8600.29,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8431.66,25019.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],32616.22,,"Case rate ($31,063.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,372.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,201.24. The transfer capital threshold is the transfer adjustment factor * $2,201.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31112.60,92731.42,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24803.68,,"Fee schedule rate ($24,803.68). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE|PO,CASE-29883,APC,29883,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7109.06,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6770.53,20090.22,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],56880.40,,"Fee schedule rate ($56,880.40). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10569.94,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",73453.33,73453.33,73453.33,1 through 10,other,10362.69,29367.82,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21534.88,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,21112.63,62647.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],29107.79,,"Fee schedule rate ($29,107.79). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34576.42,,,,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14745.18,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14043.03,54637.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24956.34,,,,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17663.70,,"Case rate ($16,822.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,363.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,192.11. The transfer capital threshold is the transfer adjustment factor * $1,192.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",9167.48,9167.48,17663.70,1 through 10,other,16849.39,49997.29,Inpatient DRG
Circumcision Age >28 Days,CASE-54161,APC,54161,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2081.79,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
"SYNCOPE AND COLLAPSE,EXTREME",204,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],18527.40,,"Case rate ($18,527.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,18527.40,19453.77,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6788.54,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6558.98,19462.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],47754.00,,"Fee schedule rate ($47,754). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24074.06,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23602.02,108295.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8953.11,,"Case rate ($8,526.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,902.12, add-ons for qualifying new technology services are included. If operating cost exceeds $48,447.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,268.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $7,906.03. The transfer operating threshold is the transfer adjustment factor * $7,902.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.75. The transfer capital threshold is the transfer adjustment factor * $620.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,25698.16,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10650.56,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10161.45,10161.45,10161.45,1 through 10,other,10290.40,42115.80,Inpatient DRG
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12141.19,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11903.13,48838.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Simple Removal Stone & Stent,CASE-52310,APC,52310,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],34988.57,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,34988.57,110685.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6700.24,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6700.24,30254.37,Inpatient DRG
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,APC,64772,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
Realignment Extensor Tendon Hand Each Tendon|RIGHT SIDE|PO,CASE-26437,APC,26437,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20135.47,,,,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32019.51,,"Fee schedule rate ($32,019.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9262.54,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9262.56,9262.56,9262.56,1 through 10,other,1188.00,27484.83,Inpatient DRG
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10632.00,,"Per diem ($10,632). If length of stay < 6.4, first 1 days paid at a per diem of $21,264 instead. Capped at $68,043.82.",,,,0,other,10632.00,103714.29,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14555.14,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14062.94,61706.77,Inpatient DRG
Synovectomy Metatarsophalangeal Joint Each,CASE-28072,APC,28072,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,APC,43274,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7970.35,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7590.81,32847.45,Inpatient DRG
HC Extremity Venogram|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10260.35,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9913.38,10409.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10385.89,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10385.89,32176.55,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4895.21,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4895.21,14525.56,Inpatient DRG
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10485.30,,"Fee schedule rate ($10,485.30). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvc/Le Init 2nd|LEFT SIDE,CASE-36246,APC,36246,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt,CASE-26531,APC,26531,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|RIGHT SIDE,CASE-27680,APC,27680,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6804.79,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6480.75,29542.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17214.39,,"Fee schedule rate ($17,214.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15979.02,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15218.11,45156.75,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9369.66,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5354.09,15887.21,All Other Inpatient
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],48252.91,,"Fee schedule rate ($48,252.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intravasc Lithotripsy,CASE-C9764,APC,C9764,CPT,0481,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES SIGNS AND SYMPTOMS,EXTREME",468,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],23585.04,,"Case rate ($22,461.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22461.94,23585.04,There are no additional notes associated with this service or procedure.
Amp Mtcrpl W/Finger/Thumb W/WO Inteross Transfer,CASE-26910,APC,26910,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],82423.02,,,,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6862.80,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",6862.80,6862.80,6862.80,1 through 10,other,6630.72,19989.86,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14130.58,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14130.58,57770.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5970.00,,"Per diem ($5,970). If length of stay < 6.2, first 1 days paid at a per diem of $11,940 instead. Capped at $37,016.57.",,,,0,other,5970.00,38757.79,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"Sesamoidectomy First Toe Spx|LEFT FOOT, GREAT TOE|PO",CASE-28315,APC,28315,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9284.75,,"Case rate ($8,842.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,797.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.62. The transfer capital threshold is the transfer adjustment factor * $626.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6972.00,26280.60,Inpatient DRG
HC Joint Injection/Aspir Medium WO US|LEFT SIDE,CASE-20605,APC,20605,CPT,0510,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11265.54,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10884.58,32297.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10168.86,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",28871.53,28871.53,28871.53,1 through 10,other,9969.47,29582.40,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE|PO,CASE-27601,APC,27601,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, SECOND DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvc/Le Init 2nd|RIGHT SIDE,CASE-36246,APC,36246,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3074.87,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3074.87,3182.49,OPPS APC
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],61348.24,,"Fee schedule rate ($61,348.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7950.97,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7795.07,34198.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24490.04,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10632.00,103714.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12573.40,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12326.86,53121.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Radius Distal Third,CASE-25350,APC,25350,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MAJOR",254,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],13805.41,,"Case rate ($13,805.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13805.41,14495.68,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14525.56,,,,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24198.18,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13827.53,41030.48,All Other Inpatient
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
Mastectomy Simple Complete|RIGHT SIDE,CASE-19303,APC,19303,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],20206.14,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19243.94,63510.03,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6553.68,,"Case rate ($6,553.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $6,086.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,276.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,494.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,073.77. The transfer operating threshold is the transfer adjustment factor * $6,086.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.91. The transfer capital threshold is the transfer adjustment factor * $479.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6553.68,20086.28,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6219.21,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5923.06,17575.50,Inpatient DRG
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9839.39,,"Fee schedule rate ($9,839.39). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10669.04,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",853.17,853.17,853.17,1 through 10,other,1188.00,31658.33,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7500.63,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7500.63,22256.65,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15861.63,,,,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
Claviculectomy Partial|RIGHT SIDE|PO,CASE-23120,APC,23120,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Synovectomy Metatarsophalangeal Joint Each|LEFT FOOT, SECOND DIGIT",CASE-28072,APC,28072,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4179.80,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3980.76,11812.10,Inpatient DRG
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13060.40,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12804.31,55145.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7436.45,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7184.98,21320.03,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9255.92,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,27465.16,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9727.58,,"Case rate ($9,264.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,573.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,041.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,827.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,607.86. The transfer operating threshold is the transfer adjustment factor * $8,573.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $656.50. The transfer capital threshold is the transfer adjustment factor * $656.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9279.13,27534.03,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
Destruction Mal Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-17266,APC,17266,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],385.57,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,399.06,OPPS APC
Ostectomy Complete 5th Metatarsal Head,CASE-28113,APC,28113,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"MALFUNCTION REACTION COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE,MAJOR",466,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14418.80,,"Case rate ($13,732.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13732.19,14418.80,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",20127.40,20127.40,20127.40,1 through 10,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],36505.40,,"Fee schedule rate ($36,505.40). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12881.26,38222.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],41837.14,,"Fee schedule rate ($41,837.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],35148.55,,"Fee schedule rate ($35,148.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12402.46,36801.89,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4890.97,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4795.07,19830.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19847.56,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18902.44,56089.29,Inpatient DRG
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm,CASE-12032,APC,12032,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,399.06,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6301.95,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",3390.75,3390.75,3390.75,1 through 10,other,6088.84,18067.42,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13704.25,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13051.67,38728.27,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Gastrocnemius Recession|LEFT SIDE,CASE-27687,APC,27687,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17103.38,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17103.38,50750.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],42012.71,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,40591.99,115037.59,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],20193.62,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19232.02,68941.12,Inpatient DRG
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|LEFT SIDE|PO,CASE-25260,APC,25260,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10815.61,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9888.00,40658.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17813.23,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10178.99,36468.17,All Other Inpatient
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4464.17,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",4389.41,4389.41,4389.41,1 through 10,other,4464.17,13577.72,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11169.08,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10637.22,31563.88,Inpatient DRG
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],37133.12,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,36405.02,110499.61,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,APC,64585,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3432.00,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3315.94,3481.74,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|LEFT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3390.91,3390.91,3390.91,1 through 10,other,3395.89,3565.69,OPPS APC
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7984.05,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7984.05,33319.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8355.45,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8072.90,31159.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4838.84,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4838.84,19587.42,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15517.38,,"Fee schedule rate ($15,517.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5389.29,16247.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36695.64,,,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
Arthrt Elbow Capsular Excision Capsular Rls Spx|LEFT SIDE|PO,CASE-24006,APC,24006,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8716.15,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8716.15,25863.45,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15909.60,,"Fee schedule rate ($15,909.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9929.69,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9456.85,28061.37,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",99916.83,99916.83,99916.83,1 through 10,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],25578.39,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,24713.42,73332.24,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24805.79,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23624.56,83038.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Insertion Uterine Tandem&/Vaginal Ovoids,CASE-57155,APC,57155,CPT,0342,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4981.90,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],37199.37,,,,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-23430,APC,23430,CPT,0360,RC,,,73,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4308.15,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3295.00,21715.49,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22317.90,,"Case rate ($21,255.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,677.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,506.21. The transfer capital threshold is the transfer adjustment factor * $1,506.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21289.03,76326.34,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6503.29,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6503.29,19528.85,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10394.04,,"Fee schedule rate ($10,394.04). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB|PO",CASE-26540,APC,26540,CPT,0360,RC,,,F5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],33422.93,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,33422.93,112824.68,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",144515.52,144515.52,144515.52,1 through 10,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13305.64,,"Case rate ($13,305.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,294.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,761.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,133.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,343.08. The transfer operating threshold is the transfer adjustment factor * $12,294.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.56. The transfer capital threshold is the transfer adjustment factor * $962.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13305.64,39481.90,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17090.89,,"Case rate ($16,277.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,324.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.45. The transfer capital threshold is the transfer adjustment factor * $1,153.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",35700.64,35700.64,35700.64,1 through 10,other,16302.99,55737.89,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16589.65,,"Case rate ($15,799.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,290.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,119.62. The transfer capital threshold is the transfer adjustment factor * $1,119.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15824.86,49371.45,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6176.78,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6055.67,17969.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21595.78,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,12500.00,83592.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5273.13,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",5273.14,5195.52,21725.82,1 through 10,other,5169.74,15340.19,Inpatient DRG
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27601,APC,27601,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12640.25,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12212.80,39290.21,Inpatient DRG
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28308,APC,28308,CPT,0360,RC,,,RT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5256.94,,"Case rate ($5,006.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,625.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,093.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,644.42. The transfer operating threshold is the transfer adjustment factor * $4,625.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.19. The transfer capital threshold is the transfer adjustment factor * $362.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5006.61,14856.14,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5902.03,,"Case rate ($5,620.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.32. The transfer capital threshold is the transfer adjustment factor * $398.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",5891.81,5891.81,5891.81,1 through 10,other,5629.94,16705.77,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],56476.93,,,,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9292.89,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22148.78,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,21399.79,63499.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE,CASE-29806,APC,29806,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21762.07,,"Fee schedule rate ($21,762.07). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7730.10,,"Fee schedule rate ($7,730.10). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level|RIGHT SIDE",CASE-64495,APC,64495,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26297.04,,"Fee schedule rate ($26,297.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,9279.13,27534.03,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cath Urethral Simple,CASE-51702,APC,51702,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],44.41,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,44.41,46.63,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5857.13,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5578.22,18148.00,Inpatient DRG
"HC Excis Nail Matrix Perm Rmvl|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-11750,APC,11750,CPT,0450,RC,,,XS|TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16929.63,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,16929.63,63934.22,Inpatient DRG
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8086.83,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,34379.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8106.00,,"Fee schedule rate ($8,106). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23340.86,,,,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14745.18,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14043.03,54637.47,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15065.57,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15065.57,53815.71,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38110.41,,,,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY SAME PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,76|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],24790.92,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,24790.92,26030.46,OPPS APC
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MAJOR",140,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11832.62,,"Case rate ($11,832.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11832.62,12424.25,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],81177.46,,,,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 1.1-2.0 Cm,CASE-11402,APC,11402,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5934.68,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride Subq First 20 Sq Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-11042,APC,11042,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, FIFTH DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9262.54,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,27484.83,Inpatient DRG
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
HC Tib per Territory Ather,CASE-37229,APC,37229,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],657.88,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],27740.63,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,26419.65,96304.23,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14118.96,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12440.40,41073.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],42212.88,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40202.74,148703.60,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7866.01,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7866.01,25247.47,Inpatient DRG
Excision/Curettage Bone Cyst/Tumor Tibia/Fibula|SEPARATE STRUCTURE|RIGHT SIDE,CASE-27635,APC,27635,CPT,0360,RC,,,XS|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Tot Hysterectomy Resj Malignancy W/Omntc,CASE-58575,APC,58575,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28117.03,,"Fee schedule rate ($28,117.03). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",17441.69,17441.69,17441.69,1 through 10,other,6387.91,18954.85,Estimated amount calculated based on 3 day length of stay.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],79366.60,,"Fee schedule rate ($79,366.60). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE,CASE-27695,APC,27695,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],26732.41,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25459.44,80806.10,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28899.61,,,,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,MAJOR",951,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],33385.18,,"Case rate ($31,795.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31795.41,33385.18,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8078.98,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7694.27,22831.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],72702.37,,"Fee schedule rate ($72,702.37). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14673.67,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",14448.01,3000.47,46125.25,11,other,14673.67,43541.27,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10177.68,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9833.51,45903.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],55900.95,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,55900.95,225294.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6933.00,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6797.06,20168.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE|PO,CASE-27570,APC,27570,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17127.24,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8128.00,8128.00,8128.00,1 through 10,other,17127.24,50821.76,Inpatient DRG
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16817.56,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16817.56,58510.23,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,APC,58558,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3055.06,3055.06,3055.06,1 through 10,other,3070.31,3223.82,OPPS APC
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15373.24,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14641.18,43444.85,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13163.24,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12536.42,37199.37,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4971.19,,"Case rate ($4,734.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.50. The transfer capital threshold is the transfer adjustment factor * $335.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4742.02,14071.02,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29141.64,,,,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10053.63,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9574.89,28411.62,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15953.57,,"Case rate ($15,193.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,247.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,076.69. The transfer capital threshold is the transfer adjustment factor * $1,076.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15218.11,45156.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7492.37,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",16254.67,16254.67,16254.67,1 through 10,other,6308.00,21796.21,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],8232.00,,"Per diem ($8,232). If length of stay < 9.8, first 1 days paid at a per diem of $16,464 instead. Capped at $80,676.47.",,,,0,other,8232.00,84471.39,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],50750.92,,,,,,0,other,3295.00,50750.92,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
Cptr-Asst Surgical Navigation Image-Less,CASE-20985,APC,20985,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17212.32,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16630.26,17212.32,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],38090.20,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36276.38,121107.98,Inpatient DRG
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4962.90,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4795.07,19830.58,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6866.02,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6866.02,27153.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11878.75,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",12135.91,12135.91,12135.91,1 through 10,other,11645.83,37502.92,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4656.27,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4564.97,13545.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13589.22,,"Fee schedule rate ($13,589.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5779.83,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5686.92,1419.10,23681.04,1 through 10,other,5779.83,17150.47,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34180.92,,,,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6828.45,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6728.85,6728.85,6728.85,1 through 10,other,6503.29,19528.85,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10808.31,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,10808.31,46938.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5350.68,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5169.74,15340.19,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5418.47,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5160.45,15312.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35359.57,,,,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13713.25,,"Fee schedule rate ($13,713.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,EXTREME",191,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],29916.56,,"Case rate ($29,916.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,29916.56,31412.39,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9901.84,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,45869.64,Inpatient DRG
Tx Missed Abortion First Trimester Surgical,CASE-59820,APC,59820,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],69251.23,,,,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16549.95,,"Fee schedule rate ($16,549.95). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7076.81,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",7076.81,7076.81,7076.81,1 through 10,other,6837.50,20288.95,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34892.55,,"Fee schedule rate ($34,892.55). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,1188.00,27484.83,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5160.45,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5100.14,5100.14,18579.34,1 through 10,other,5160.45,15312.64,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,21325.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36577.58,,,,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],100096.50,,"Fee schedule rate ($100,096.50). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
Ercp Dx Collection Specimen Brushing/Washing|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43260,APC,43260,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11997.84,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11592.12,38954.76,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13662.46,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7231.00,38610.21,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5465.31,,"Case rate ($5,280.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,879.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,346.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,553.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,898.48. The transfer operating threshold is the transfer adjustment factor * $4,879.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $382.00. The transfer capital threshold is the transfer adjustment factor * $382.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5280.49,17810.78,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],66888.05,,"Fee schedule rate ($66,888.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.5), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4620.42,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4464.17,13577.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12562.13,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6382.95,21300.35,All Other Inpatient
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17137.86,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9793.06,29058.99,All Other Inpatient
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|RIGHT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6350.00,,"Per diem ($6,350). If length of stay < 5, first 1 days paid at a per diem of $12,700 instead. Capped at $31,750.77.",,,,0,other,6350.00,33244.29,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19989.86,,,,,,0,other,6630.72,19989.86,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4724.74,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4564.97,13545.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|LEFT SIDE,CASE-37225,APC,37225,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],538.93,,,,,,0,other,538.93,557.79,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32077.45,,,,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],31858.62,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31858.62,94534.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7249.08,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7003.94,20782.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],37843.99,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,37843.99,139522.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE|PO,CASE-27680,APC,27680,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8940.90,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8442.00,28788.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23149.11,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13228.06,39251.68,All Other Inpatient
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],61972.71,,,,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8285.77,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7891.21,23415.63,Inpatient DRG
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,APC,43248,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenotomy Open Extensor Foot/Toe Each Tendon,CASE-28234,APC,28234,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Catheter Aorta,CASE-36200,APC,36200,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18302.23,,"Fee schedule rate ($18,302.23). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12943.20,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12326.86,53121.74,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],54920.47,,,,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17274.00,,"Per diem ($17,274). If length of stay < 3.3, first 1 days paid at a per diem of $34,548 instead. Capped at $57,002.93.",,,,0,other,17274.00,73717.28,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10080.22,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9739.34,40204.26,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1493.03,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33947.68,,"Fee schedule rate ($33,947.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],60333.05,,"Fee schedule rate ($60,333.05). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],90287.21,,"Fee schedule rate ($90,287.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20.9), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12787.15,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12536.42,37199.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],43523.66,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,42670.25,133443.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
Open Treatment Ulnar Fracture Proximal End|RIGHT SIDE|PO,CASE-24685,APC,24685,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4120.67,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4120.67,13066.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21474.76,,"Fee schedule rate ($21,474.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,7577.56,31445.30,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",16342.80,15906.90,17821.50,1 through 10,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,868.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33285.61,,,,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24824.01,,"Case rate ($23,641.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,846.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,675.35. The transfer capital threshold is the transfer adjustment factor * $1,675.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23679.61,84629.16,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],36287.40,,"Fee schedule rate ($36,287.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],41837.14,,"Fee schedule rate ($41,837.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28086.14,,"Fee schedule rate ($28,086.14). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9910.44,43344.00,Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|LEFT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],180.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,CASE-58571,APC,58571,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11461.54,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10915.75,32390.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12243.00,,"Fee schedule rate ($12,243). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20274.44,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20274.44,80940.99,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],29611.00,,"Fee schedule rate ($29,611.00). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27028.33,,,,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Ablation Renal Cysts|RIGHT SIDE,CASE-50541,APC,50541,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],35579.25,,"Fee schedule rate ($35,579.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,APC,54405,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20640.96,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",19620.88,19620.88,19620.88,1 through 10,other,19658.06,20640.96,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5257.64,,"Case rate ($5,007.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,626.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,094.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,645.03. The transfer operating threshold is the transfer adjustment factor * $4,626.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.24. The transfer capital threshold is the transfer adjustment factor * $362.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5007.28,16142.41,Inpatient DRG
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],36405.02,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36405.02,110499.61,Inpatient DRG
Mastectomy Partial W/Axillary Lymphadenectomy,CASE-19302,APC,19302,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6518.41,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],49902.84,,,,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16166.30,,"Case rate ($15,396.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.05. The transfer capital threshold is the transfer adjustment factor * $1,091.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",10504.38,10504.38,10504.38,1 through 10,other,15421.03,49137.17,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],28749.28,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",217556.31,217556.31,217556.31,1 through 10,other,13572.00,108637.77,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7531.48,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4303.70,14124.38,All Other Inpatient
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12108.97,,"Case rate ($11,871.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,001.85, add-ons for qualifying new technology services are included. If operating cost exceeds $51,547.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,512.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,007.29. The transfer operating threshold is the transfer adjustment factor * $11,001.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.25. The transfer capital threshold is the transfer adjustment factor * $864.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11871.54,35778.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],36249.82,,"Fee schedule rate ($36,249.82). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16361.19,,"Fee schedule rate ($16,361.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15218.11,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15218.11,45156.75,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5923.06,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5923.06,17575.50,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],8232.00,,"Per diem ($8,232). If length of stay < 9.8, first 1 days paid at a per diem of $16,464 instead. Capped at $80,676.47.",,,,0,other,8232.00,84471.39,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Syndactylization Toes,CASE-28280,APC,28280,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13369.00,,"Per diem ($13,369). If length of stay < 6.3, first 1 days paid at a per diem of $26,738 instead. Capped at $84,226.47.",,,,0,other,13369.00,88188.38,Estimated amount calculated based on 5 day length of stay.
Osteotomy Radius Distal Third,CASE-25350,APC,25350,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19133.87,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,18222.73,59942.55,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
Repair Fibula Nonunion/Malunion W/Int Fixation|LEFT SIDE,CASE-27726,APC,27726,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,APC,38571,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",10330.04,10148.63,10330.04,1 through 10,other,10082.05,10586.16,OPPS APC
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],28985.35,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,28005.17,115392.91,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8263.49,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7984.05,23691.11,Inpatient DRG
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
"SICKLE CELL ANEMIA CRISIS,MAJOR",662,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15915.81,,"Case rate ($15,157.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15157.91,15915.81,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7934.97,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7934.97,23545.50,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15324.28,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15023.80,48104.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/Fixj Pst Lip|LEFT SIDE|PO,CASE-27823,APC,27823,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
Partial Excision Bone Fibula|RIGHT SIDE|PO,CASE-27641,APC,27641,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Hidradenitis Axillary Smpl/Intrm Rpr,CASE-11450,APC,11450,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6784.60,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6461.52,21772.28,Inpatient DRG
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],29165.93,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13572.00,108637.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],35148.55,,"Fee schedule rate ($35,148.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12402.46,36801.89,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6685.72,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,18893.86,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5122.57,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4878.64,14476.37,Inpatient DRG
"PERIPHERAL CRANIAL AND AUTONOMIC NERVE DISORDERS,MAJOR",048,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14011.25,,"Case rate ($14,011.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14011.25,14711.81,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16828.39,,"Fee schedule rate ($16,828.39). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9766.39,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9574.89,28411.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10282.71,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9793.06,29058.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8103.90,,"Fee schedule rate ($8,103.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea,CASE-25290,APC,25290,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],70321.74,,of the excess amount. Final payment is multiplied by 175%.,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
Open Treatment Metatarsal Fracture Each|RIGHT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7702.29,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7335.51,29792.90,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14130.58,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14130.58,57770.11,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17191.57,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17191.57,51012.62,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10749.40,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10385.89,32176.55,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4518.89,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4303.70,14124.38,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",675.06,463.39,685.98,19,other,669.51,702.98,OPPS APC
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16092.51,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15326.20,52511.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8147.92,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7759.92,35376.63,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16838.54,,"Case rate ($16,036.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,307.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.42. The transfer capital threshold is the transfer adjustment factor * $1,136.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16062.27,48077.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],43344.00,,"Fee schedule rate ($43,344.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24555.13,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23385.84,71764.93,Inpatient DRG
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],41006.79,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,40202.74,148703.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16633.77,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8558.00,48389.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],110217.19,,"Fee schedule rate ($110,217.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],30121.25,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,17212.14,64440.06,All Other Inpatient
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1822.73,1822.73,1822.73,1 through 10,other,1820.02,1911.02,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],42945.05,,,,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],33734.25,,"Case rate ($33,072.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,563.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,392.57. The transfer capital threshold is the transfer adjustment factor * $2,392.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,33072.79,98455.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25753.26,,,,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|LEFT FOOT, GREAT TOE|PO",CASE-28092,APC,28092,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6098.05,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5807.67,17233.12,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE|PO,CASE-29826,APC,29826,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,APC,52332,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7537.28,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6382.95,21300.35,Inpatient DRG
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,APC,43249,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11714.14,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11714.14,49460.19,Inpatient DRG
Application Uniplane External Fixation System|PO,CASE-20690,APC,20690,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,APC,58542,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6094.79,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6094.79,22352.66,Inpatient DRG
HC Wound Vac <=50 Sq Cm Dme,CASE-97605,APC,97605,CPT,0761,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],199.81,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",193.69,193.69,193.69,1 through 10,other,190.30,199.81,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7712.73,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6308.00,21796.21,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],39668.91,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,38891.09,169197.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10367.99,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10367.99,37103.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15421.03,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15421.03,49137.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11832.77,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11600.75,34422.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],70160.31,,,,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34001.86,,,,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17952.22,,"Fee schedule rate ($17,952.22). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
Open Treatment Calcaneal Fracture|RIGHT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24451.42,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23624.56,83038.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Pilonidal Cyst/Sinus Simple,CASE-11770,APC,11770,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE|PO,CASE-27601,APC,27601,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt,CASE-28309,APC,28309,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE,CASE-27339,APC,27339,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6308.00,,"Per diem ($6,308). If length of stay < 3.3, first 1 days paid at a per diem of $12,616 instead. Capped at $20,817.01.",,,,0,other,6308.00,21796.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5881.88,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5766.55,17111.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
"HC ED Avulsion Nail Plate Single|LEFT FOOT, GREAT TOE|PO",CASE-11730,APC,11730,CPT,0450,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE,CASE-27339,APC,27339,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34422.94,,,,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
"OTHER COMPLICATIONS OF TREATMENT,MODERATE",813,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9991.62,,"Case rate ($9,515.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9515.83,9991.62,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],32495.79,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,31858.62,94534.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10638.72,,"Fee schedule rate ($10,638.72). Adds an outlier to normal pricing equal to the per diem rate ($26,031.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",4361.00,4361.00,4361.00,1 through 10,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
HC Wound Vac <=50 Sq Cm Dme,CASE-97605,APC,97605,CPT,0761,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],199.81,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15928.53,,,,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE|PO,CASE-29823,APC,29823,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7015.06,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6681.01,19824.58,Inpatient DRG
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,46419.05,Estimated amount calculated based on 12 day length of stay.
HC Sel Cath Abd/Pelvc/Le Init 2nd|RIGHT SIDE,CASE-36246,APC,36246,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3182.49,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3074.87,3182.49,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bone Graft Any Donor Area Major/Large|PO,CASE-20902,APC,20902,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11932.19,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11698.23,34712.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,EXTREME",140,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],20855.04,,"Case rate ($19,861.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19861.94,20855.04,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Multiple External Papillae/Tags Anus,CASE-46230,APC,46230,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11550.37,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",11550.38,11550.38,11550.38,1 through 10,other,11159.78,39897.21,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],29405.43,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,28005.17,115392.91,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],82553.89,,"Fee schedule rate ($82,553.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],3829.05,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3753.97,11139.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
"MAJOR ABDOMINAL VASCULAR PROCEDURES,MAJOR",169,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],56659.79,,"Case rate ($53,961.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,53961.70,56659.79,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10764.51,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,30861.41,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,53945.28,Estimated amount calculated based on 17 day length of stay.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32645.32,,"Fee schedule rate ($32,645.32). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11519.18,34180.92,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],45711.64,,,,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],34726.43,,"Case rate ($33,072.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,563.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,392.57. The transfer capital threshold is the transfer adjustment factor * $2,392.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,33072.79,98455.37,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],78395.14,,,,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MODERATE",140,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8831.98,,"Case rate ($8,831.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8831.98,9273.58,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7034.96,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6797.06,20168.93,Inpatient DRG
Tenodesis Long Tendon Biceps|LEFT SIDE|PO,CASE-23430,APC,23430,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12643.07,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",11685.45,11685.45,11685.45,1 through 10,other,12395.17,42174.37,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
HC Rmvl Perm Intraperitneal Cath,CASE-49422,APC,49422,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8066.12,,"Case rate ($7,682.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,715.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.37. The transfer capital threshold is the transfer adjustment factor * $544.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",8006.49,8006.49,20096.49,1 through 10,other,7694.27,22831.22,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, THIRD DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14745.18,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14043.03,54637.47,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21827.79,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,21399.79,63499.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],46750.70,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,45834.02,151120.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11920.65,,"Fee schedule rate ($11,920.65). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20301.63,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20301.63,84714.35,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11645.83,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11899.55,11899.55,11899.55,1 through 10,other,11645.83,37502.92,Inpatient DRG
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6595.05,,"Fee schedule rate ($6,595.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10449.55,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10449.55,43409.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,53945.28,Estimated amount calculated based on 17 day length of stay.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13842.12,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12440.40,41073.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20056.77,,,,,,0,other,6654.93,20056.77,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],43489.95,,"Fee schedule rate ($43,489.95). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx,CASE-29884,APC,29884,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],53377.62,,"Case rate ($50,835.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,773.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,602.40. The transfer capital threshold is the transfer adjustment factor * $3,602.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",116394.17,53377.65,286536.97,1 through 10,other,50916.88,170142.20,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27555.15,,"Fee schedule rate ($27,555.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6724.11,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6724.11,19952.48,Inpatient DRG
HC Debride Subq First 20 Sq Cm|SEPARATE STRUCTURE|PO,CASE-11042,APC,11042,CPT,0361,RC,,,XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10492.66,,"Case rate ($10,492.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,694.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,162.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,930.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,733.59. The transfer operating threshold is the transfer adjustment factor * $9,694.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.07. The transfer capital threshold is the transfer adjustment factor * $759.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10492.66,31134.92,Inpatient DRG
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6933.00,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6797.06,20168.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|PO,CASE-11422,APC,11422,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
Bone Graft Any Donor Area Major/Large|PO,CASE-20902,APC,20902,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],25564.74,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10455.00,90889.11,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23895.30,,"Fee schedule rate ($23,895.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",21020.41,21020.41,21020.41,1 through 10,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE|PO,CASE-29823,APC,29823,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",13606.44,13606.44,13606.44,1 through 10,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
Revasc lithotrip tibi/perone|LEFT SIDE,CASE-C9772,APC,C9772,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11332.76,,"Case rate ($10,793.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,935.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $764.84. The transfer capital threshold is the transfer adjustment factor * $764.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10810.31,32077.45,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15818.34,,,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17958.55,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17103.38,50750.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36556,APC,36556,CPT,0761,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8814.26,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8394.53,24909.11,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12843.44,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,38110.41,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10282.71,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9793.06,29058.99,Inpatient DRG
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",888.72,444.36,888.72,1 through 10,other,882.03,926.14,OPPS APC
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7601.43,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7601.43,23918.09,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
HC Removal FB Skin|PO,CASE-10120,APC,10120,CPT,0450,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC
"MIGRAINE AND OTHER HEADACHES,MODERATE",054,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3263.58,,"Case rate for a one day stay ($3,263.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3263.58,3426.76,There are no additional notes associated with this service or procedure.
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7700.46,,"Case rate ($7,333.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.70. The transfer capital threshold is the transfer adjustment factor * $519.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6308.00,21796.21,Inpatient DRG
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOLIC LIVER DISEASE,EXTREME",280,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],30733.03,,"Case rate ($30,733.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,30733.03,32269.68,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],51131.99,,"Fee schedule rate ($51,131.99). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Crtj Arven Fstl Xcp Dir Arven Anast Nonautog Grf,CASE-36830,APC,36830,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",5407.54,5269.36,5407.54,1 through 10,other,5277.74,5541.62,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4564.97,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4564.97,13545.65,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14321.86,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14041.04,60059.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],82553.89,,"Fee schedule rate ($82,553.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19713.45,,"Fee schedule rate ($19,713.45). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
Arthrp Kne Condyle&Platu Medial&Lat Compartments|LEFT SIDE,CASE-27447,APC,27447,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14448.22,,"Case rate ($14,448.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,349.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,817.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,216.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,402.99. The transfer operating threshold is the transfer adjustment factor * $13,349.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,045.22. The transfer capital threshold is the transfer adjustment factor * $1,045.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6940.00,42872.25,Inpatient DRG
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, THIRD DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26007.09,,,,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31241.17,,,,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
Unlisted Procedure Pelvis/Hip Joint,CASE-27299,APC,27299,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],245.65,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,233.96,245.65,OPPS APC
"SKIN ULCERS,EXTREME",380,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],23659.02,,"Case rate ($22,532.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22532.40,23659.02,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6180.91,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5886.58,17467.27,Inpatient DRG
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs|RIGHT SIDE|PO,CASE-25115,APC,25115,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7436.45,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7184.98,21320.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|BILATERAL PROCEDURE,CASE-37722,APC,37722,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE,CASE-27405,APC,27405,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8940.90,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8442.00,28788.33,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],183848.16,,"Fee schedule rate ($183,848.16). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29008.87,,"Fee schedule rate ($29,008.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",21646.84,21646.84,21646.84,1 through 10,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7553.93,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7405.81,33747.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",76951.68,76951.68,76951.68,1 through 10,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, THIRD DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7700.46,,"Case rate ($7,333.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.70. The transfer capital threshold is the transfer adjustment factor * $519.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",5609.94,591.35,22297.99,1 through 10,other,6308.00,21796.21,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,Zero final payments for the item or service in the 15 months prior to posting the file.
Prostate Needle Biopsy Any Approach|SEPARATE STRUCTURE,CASE-55700,APC,55700,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],27851.43,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Pyeloplasty,CASE-50544,APC,50544,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],75976.83,,,,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
Bx Anorectal Wall Anal Approach,CASE-45100,APC,45100,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],85741.18,,"Fee schedule rate ($85,741.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,30254.51,130347.93,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE|PO,CASE-29883,APC,29883,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FIFTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],67142.93,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,64872.40,212258.00,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE|PO,CASE-25608,APC,25608,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6401.17,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5669.00,18994.21,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5280.49,,"Case rate ($5,280.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,879.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,346.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,553.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,898.48. The transfer operating threshold is the transfer adjustment factor * $4,879.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $382.00. The transfer capital threshold is the transfer adjustment factor * $382.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5280.49,17810.78,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9718.72,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,27465.16,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9413.76,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5379.29,15961.98,All Other Inpatient
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],61348.24,,"Fee schedule rate ($61,348.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],34726.43,,"Case rate ($33,072.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,563.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,392.57. The transfer capital threshold is the transfer adjustment factor * $2,392.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,33072.79,98455.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16289.40,,"Fee schedule rate ($16,289.40). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
Circumcision Age >28 Days,CASE-54161,APC,54161,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26999.90,,"Fee schedule rate ($26,999.90). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9527.16,28269.95,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],40591.99,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,40591.99,115037.59,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5578.22,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5578.22,18148.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12180.79,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11600.75,34422.94,Inpatient DRG
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt,CASE-28291,APC,28291,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc,CASE-34421,APC,34421,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
Ligj Divj & Stripping Short Saphenous Vein,CASE-37718,APC,37718,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO|SEPARATE STRUCTURE",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],81763.50,,"Fee schedule rate ($81,763.50). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10565.10,,"Fee schedule rate ($10,565.10). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($55,128.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4531.81,,"Case rate ($4,442.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.41. The transfer capital threshold is the transfer adjustment factor * $321.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4442.95,13183.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY VASCULAR PROCEDURES,MAJOR",181,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],43856.94,,"Case rate ($41,768.51). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,41768.51,43856.94,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-29827,APC,29827,CPT,0360,RC,,,73,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6590.21,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,18893.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9738.02,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9738.02,28895.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],36287.40,,"Fee schedule rate ($36,287.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Local Lesion Epididymis|RIGHT SIDE,CASE-54830,APC,54830,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|LEFT SIDE|PO,CASE-24341,APC,24341,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17658.44,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16817.56,58510.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE|PO,CASE-64490,APC,64490,CPT,0361,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|RIGHT SIDE|PO,CASE-27675,APC,27675,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE|PO,CASE-28120,APC,28120,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Removal Subcutaneous Cardiac Rhythm Monitor,CASE-33286,APC,33286,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9913.38,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9913.38,10409.05,OPPS APC
HC Intro Cath in Svc or Ivc|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36010,APC,36010,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22524.26,,,,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4090.84,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,2285.00,12138.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE|PO,CASE-29823,APC,29823,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8058.48,,"Case rate ($7,674.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,715.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $543.86. The transfer capital threshold is the transfer adjustment factor * $543.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7686.98,22809.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14336.49,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8192.28,24308.97,All Other Inpatient
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],43434.38,,"Fee schedule rate ($43,434.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15549.63,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",15549.64,15549.64,15549.64,1 through 10,other,15023.80,48104.19,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],88173.00,,"Fee schedule rate ($88,173.00). Adds an outlier to normal pricing equal to the per diem rate ($170,052.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14682.53,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7770.00,50313.90,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],94534.21,,,,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
Open Treatment Fracture Distal Tibia Only|LEFT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9901.84,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,45869.64,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE|PO,CASE-28200,APC,28200,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3536.22,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13948.68,,"Case rate ($13,284.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,294.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,761.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,343.08. The transfer operating threshold is the transfer adjustment factor * $12,294.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.38. The transfer capital threshold is the transfer adjustment factor * $941.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13305.64,39481.90,Inpatient DRG
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],26380.20,,"Fee schedule rate ($26,380.20). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5338.18,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5338.18,15839.99,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Rem Central Venous Cath,CASE-36589,APC,36589,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],615.80,,"APC Price ($594.98). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,594.98,624.73,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs|RIGHT SIDE|PO,CASE-25115,APC,25115,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],43434.38,,"Fee schedule rate ($43,434.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],66951.94,,"Fee schedule rate ($66,951.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11169.08,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10637.22,31563.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MAJOR",192,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],24571.50,,"Case rate ($24,571.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24571.50,25800.08,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10884.58,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10884.58,32297.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],36167.61,,"Case rate ($36,167.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,417.97, add-ons for qualifying new technology services are included. If operating cost exceeds $68,885.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,787.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $33,551.16. The transfer operating threshold is the transfer adjustment factor * $33,417.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,616.46. The transfer capital threshold is the transfer adjustment factor * $2,616.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36167.61,140535.66,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14743.09,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14041.04,60059.69,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],45144.75,,"Fee schedule rate ($45,144.75). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15246.08,,"Fee schedule rate ($15,246.08). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],8990.00,,"Per diem ($8,990). If length of stay < 6, first 1 days paid at a per diem of $17,980 instead. Capped at $53,939.67.",,,,0,other,8990.00,80069.53,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|PREVENTIVE SERVICES,CASE-45385,APC,45385,CPT,0360,RC,,,33,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],39736.19,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,37843.99,139522.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Metatarsal Fracture Each|LEFT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2,CASE-29822,APC,29822,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19824.58,,,,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29886.15,,"Fee schedule rate ($29,886.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13889.20,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13889.20,55846.16,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6240.68,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6240.68,18518.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39198.44,,"Fee schedule rate ($39,198.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf,CASE-36825,APC,36825,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12031.78,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11458.84,42820.42,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7020.54,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7020.54,28431.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11894.86,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6797.06,20168.93,All Other Inpatient
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5139.97,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4895.21,14525.56,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12208.65,,"Case rate ($11,627.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,995.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.95. The transfer capital threshold is the transfer adjustment factor * $823.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11645.83,37502.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,APC,36245,CPT,0361,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8.46,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19183.89,,"Fee schedule rate ($19,183.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,6553.68,20086.28,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciotomy Foot&/Toe|RIGHT SIDE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10170.39,,"Fee schedule rate ($10,170.39). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT SIDE,CASE-28292,APC,28292,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],64778.65,,,,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],32570.75,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31019.76,124854.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4795.07,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4795.07,19830.58,Inpatient DRG
Trluml Balo Angiop Ctr Dialysis Seg W/Img S&I,CASE-36907,APC,36907,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5398.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9151.96,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",3781.30,3781.30,3781.30,1 through 10,other,8716.15,25863.45,Inpatient DRG
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28291,APC,28291,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20110.39,,"Fee schedule rate ($20,110.39). Adds an outlier to normal pricing equal to the per diem rate ($69,590.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7096.13,25801.23,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Trluml Balo Angiop 1st Vein|RIGHT SIDE,CASE-37248,APC,37248,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5668.18,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31980.55,,"Fee schedule rate ($31,980.55). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|PO,CASE-64634,APC,64634,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4797.39,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4568.94,13557.45,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30630.71,,"Fee schedule rate ($30,630.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],112882.03,,"Fee schedule rate ($112,882.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4620.42,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4464.17,13577.72,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12065.11,,"Fee schedule rate ($12,065.11). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],29165.93,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13572.00,108637.77,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5773.19,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5773.19,31196.82,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22594.88,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,21830.80,85124.35,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8522.85,,"Fee schedule rate ($8,522.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5890.67,,"Case rate ($5,775.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.79. The transfer capital threshold is the transfer adjustment factor * $417.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5775.17,17136.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|LEFT SIDE|PO,CASE-28120,APC,28120,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],49664.75,,,,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],82674.88,,,,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],20206.14,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19243.94,63510.03,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],49997.29,,,,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,APC,57250,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16524.47,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16524.47,58465.86,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],59216.74,,"Fee schedule rate ($59,216.74). Adds an outlier to normal pricing equal to the per diem rate ($89,749.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",140832.97,140832.97,140832.97,1 through 10,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22002.56,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20954.82,62179.32,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8625.05,,"Case rate ($8,214.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,753.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $582.10. The transfer capital threshold is the transfer adjustment factor * $582.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8227.43,27001.04,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],94534.21,,,,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
Colsc Flx With Directed Submucosal Njx Any Sbst|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45381,APC,45381,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3117.60,3117.60,3117.60,1 through 10,other,6882.29,7226.40,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Destruction of Lesions,CASE-52214,APC,52214,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,76310.36,Estimated amount calculated based on 21 day length of stay.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
Tx Missed Abortion First Trimester Surgical,CASE-59820,APC,59820,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36556,APC,36556,CPT,0761,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,APC,11424,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],23685.31,,"Case rate ($22,557.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,769.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.50. The transfer capital threshold is the transfer adjustment factor * $1,598.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22593.41,90908.64,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8758.05,,"Fee schedule rate ($8,758.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],28467.39,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",29271.35,29271.35,29271.35,1 through 10,other,8232.00,84471.39,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10629.92,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6074.24,18024.13,All Other Inpatient
Hemiphalangectomy/Interphalangeal Joint Exc Toe,CASE-28160,APC,28160,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE,CASE-29806,APC,29806,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21570.21,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,21570.21,72041.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10810.31,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10810.31,32077.45,Inpatient DRG
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17877.77,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17026.45,50522.67,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6440.28,,"Case rate ($6,440.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,950.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,418.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,637.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,974.38. The transfer operating threshold is the transfer adjustment factor * $5,950.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $465.91. The transfer capital threshold is the transfer adjustment factor * $465.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6440.28,19110.30,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13889.20,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",13544.56,13542.74,13889.21,1 through 10,other,13889.20,55846.16,Inpatient DRG
Rhinp Prim Complete Xtrnl Parts,CASE-30410,APC,30410,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10789.12,,"Case rate ($10,275.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,899.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.15. The transfer capital threshold is the transfer adjustment factor * $728.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10291.73,34803.35,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",26985.97,26985.97,26985.97,1 through 10,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],14842.71,,"Fee schedule rate ($14,842.71). Adds an outlier to normal pricing equal to the per diem rate ($40,567.35) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6974.25,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6837.50,20288.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17754.05,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6965.00,30103.84,All Other Inpatient
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],32668.23,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31112.60,92731.42,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14848.26,,,,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9447.79,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,1188.00,27484.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12304.65,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11888.55,35276.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12727.27,,"Case rate ($12,121.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,030.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.95. The transfer capital threshold is the transfer adjustment factor * $858.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12140.54,36024.65,Inpatient DRG
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],26525.17,,of the excess amount.,49680.32,29798.66,52161.14,1 through 10,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],47660.93,,"Fee schedule rate ($47,660.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MINOR",425,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2597.58,,"Case rate for a one day stay ($2,597.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2597.58,2727.46,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45390,APC,45390,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17350.69,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16524.47,58465.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19133.87,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,18222.73,59942.55,Inpatient DRG
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6630.72,19989.86,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],40693.87,,"Fee schedule rate ($40,693.87). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO|SEPARATE STRUCTURE",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
Carpectomy 1 Bone|RIGHT SIDE|PO,CASE-25210,APC,25210,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, SECOND DIGIT|PO",CASE-26356,APC,26356,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
Revj/Rmvl Prosthetic Vaginal Graft Vaginal App,CASE-57295,APC,57295,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4981.90,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17829.00,,"Fee schedule rate ($17,829). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],29036.74,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8232.00,84471.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE|PO,CASE-29891,APC,29891,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,76376.03,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],53373.60,,"Fee schedule rate ($53,373.60). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8798.84,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6178.00,25225.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Calcaneal Fracture|RIGHT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13238.76,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",12857.37,12857.37,42204.99,1 through 10,other,12791.07,43031.63,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16493.80,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9425.03,27966.92,All Other Inpatient
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|RIGHT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvic/Le 1st Ord,CASE-36245,APC,36245,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12478.39,,"Case rate ($11,884.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.15. The transfer capital threshold is the transfer adjustment factor * $842.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11903.13,48838.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F7|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],109526.12,,,,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28308,APC,28308,CPT,0360,RC,,,RT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5345.47,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5224.00,15861.63,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6630.72,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6630.72,19989.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Inject Nerv Blck,Paravert Sympath|BILATERAL PROCEDURE|PO",CASE-64520,APC,64520,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],27357.31,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27357.31,100904.68,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],37001.91,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,36276.38,121107.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1545.29,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1492.63,1492.63,1492.63,1 through 10,other,1493.03,1567.69,OPPS APC
Tenodesis Long Tendon Biceps|SEPARATE STRUCTURE,CASE-23430,APC,23430,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17461.77,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10164.64,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9820.91,29141.64,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21119.68,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,17274.00,73717.28,Inpatient DRG
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,APC,52318,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX|74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12326.86,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12326.86,53121.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SIGNS SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS,MODERATE",861,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1766.38,,"Case rate for a one day stay ($1,766.38). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1766.38,1854.70,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],38766.74,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9370.00,65732.99,All Other Inpatient
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],61868.44,,"Fee schedule rate ($61,868.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6226.00,,"Case rate ($5,929.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.19. The transfer capital threshold is the transfer adjustment factor * $420.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.97,17858.70,Inpatient DRG
Gastrocnemius Recession|LEFT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],32668.23,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31112.60,92731.42,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13135.23,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",4892.59,4892.59,4892.59,1 through 10,other,13135.23,38976.20,Inpatient DRG
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,APC,58661,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15751.44,,,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
"OPEN EXTRACRANIAL VASCULAR PROCEDURES,MODERATE",024,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7735.83,,"Case rate for a one day stay ($7,367.46). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7367.46,7735.83,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],3940.95,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3753.29,11765.59,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12212.80,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12212.80,39290.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23596.66,,,,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,1188.00,27484.83,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],36910.99,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36910.99,126842.57,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15891.15,,,,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11767.19,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6724.11,19952.48,All Other Inpatient
Fasciotomy Foot&/Toe|BILATERAL PROCEDURE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE|PO,CASE-29826,APC,29826,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12178.75,,"Fee schedule rate ($12,178.75). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],27022.53,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
Claviculectomy Partial|LEFT SIDE,CASE-23120,APC,23120,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11289.75,,"Fee schedule rate ($11,289.75). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7074.80,,"Case rate ($6,737.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,648.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.47. The transfer capital threshold is the transfer adjustment factor * $477.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6748.64,20025.28,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33968.35,,"Fee schedule rate ($33,968.35). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Add 2nd/3rd Order Abd/Le|LEFT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16691.31,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15896.49,51306.05,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
"ALCOHOL ABUSE AND DEPENDENCE,MODERATE",775,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7581.72,,"Case rate ($7,581.72). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7581.72,7960.81,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15852.04,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15852.04,50518.01,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7584.84,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,33946.09,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15454.71,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14718.77,51765.74,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22034.15,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,21289.03,76326.34,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17887.18,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7455.00,53076.74,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt|RIGHT SIDE|PO,CASE-27602,APC,27602,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Radius Distal Third|RIGHT SIDE|PO,CASE-25350,APC,25350,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12861.93,,"Fee schedule rate ($12,861.93). Adds an outlier to normal pricing equal to the per diem rate ($47,786.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",12475.44,12475.44,12475.44,1 through 10,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MODERATE",721,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11237.67,,"Case rate ($10,702.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10702.54,11237.67,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],81161.07,,"Fee schedule rate ($81,161.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,30480.63,86382.02,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18508.54,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18508.54,76171.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Neck/Thorax Subfasc 5 Cm/>,CASE-21554,APC,21554,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33084.25,,"Fee schedule rate ($33,084.25). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],129256.37,,"Fee schedule rate ($129,256.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6921.50,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",6863.86,6863.86,6863.86,1 through 10,other,6785.78,20135.47,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Abdominal Wall Subq <3cm,CASE-22902,APC,22902,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5934.68,6020.69,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],38029.56,,"Case rate ($36,218.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,737.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,566.58. The transfer capital threshold is the transfer adjustment factor * $2,566.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36276.38,121107.98,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],74873.19,,"Fee schedule rate ($74,873.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.6), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4666.41,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4574.91,13575.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9108.77,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8675.02,25741.45,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24888.65,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23703.48,110204.98,Inpatient DRG
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23915.01,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23915.01,121205.60,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28569.12,,"Fee schedule rate ($28,569.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms,CASE-27696,APC,27696,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,APC,52601,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",4955.40,603.82,5210.57,11,other,5085.49,5339.77,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15218.11,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15218.11,45156.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1493.03,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24590.07,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23758.52,103116.16,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8285.77,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7891.21,23415.63,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13307.04,,"Case rate ($12,673.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,069.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $898.08. The transfer capital threshold is the transfer adjustment factor * $898.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12693.58,46577.81,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9425.03,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9425.03,27966.92,Inpatient DRG
Open Treatment Medial Malleolus Fracture|RIGHT SIDE,CASE-27766,APC,27766,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC
Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt,CASE-25020,APC,25020,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4968.82,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4968.82,19848.33,Inpatient DRG
Blepharoplasty Upper Eyelid W/Excessive Skin,CASE-15823,APC,15823,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.80,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2054.80,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Metatarsal Fracture Each|RIGHT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20895.12,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20895.12,99969.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Radius Distal Third,CASE-25350,APC,25350,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21133.20,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21133.20,88801.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27868.14,,"Fee schedule rate ($27,868.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13011.87,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7231.00,38610.21,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11009.52,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10637.22,31563.88,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,Zero final payments for the item or service in the 15 months prior to posting the file.
"CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",165,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],78718.80,,"Case rate ($74,970.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,945, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,74970.29,78718.80,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6940.00,,"Per diem ($6,940). If length of stay < 5.9, first 1 days paid at a per diem of $13,880 instead. Capped at $40,946.19.",,,,0,other,6940.00,42872.25,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5854.09,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,17370.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,APC,43246,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18200.86,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6965.00,30861.41,All Other Inpatient
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35276.93,,,,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8671.32,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6178.00,25225.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11024.48,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",11024.49,11024.49,11024.49,1 through 10,other,10808.31,46938.11,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5365.09,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5183.66,15743.06,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16878.39,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8558.00,48389.68,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8181.61,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",8180.04,8180.04,8180.04,1 through 10,other,6495.00,23801.30,Inpatient DRG
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19300.28,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18381.22,58579.45,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],23935.30,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23125.89,68621.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26874.85,,,,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18024.13,,,,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8513.22,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8513.22,4480.51,88666.91,1 through 10,other,8513.22,25261.33,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],57305.33,,,,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13662.46,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7231.00,38610.21,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9618.93,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,45869.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"HEART FAILURE,MINOR",194,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7441.50,,"Case rate ($7,087.14). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7087.14,7441.50,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11573.27,,"Case rate ($11,022.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,952.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.07. The transfer capital threshold is the transfer adjustment factor * $781.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",11895.83,11895.83,11895.83,1 through 10,other,6953.00,35389.05,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FOURTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19183.89,,"Fee schedule rate ($19,183.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,6553.68,20086.28,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],44924.67,,"Fee schedule rate ($44,924.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14384.78,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14102.73,41847.08,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38728.27,,,,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14534.23,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12440.40,41073.77,Inpatient DRG
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3074.87,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3074.87,3228.61,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11693.81,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11298.37,44627.23,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",16628.10,16628.10,16628.10,1 through 10,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],102660.52,,"Fee schedule rate ($102,660.52). Adds an outlier to normal pricing equal to the per diem rate ($180,358.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35640.95,,,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, THIRD DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7590.81,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7590.81,32847.45,Inpatient DRG
Fasciectomy Plantar Fascia Radical Spx|LEFT SIDE|PO,CASE-28062,APC,28062,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4993.76,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4755.96,21133.33,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28299,APC,28299,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28290.15,,"Fee schedule rate ($28,290.15). Adds an outlier to normal pricing equal to the per diem rate ($7,074.03) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11036.50,33262.00,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15326.20,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15326.20,52511.19,Inpatient DRG
HC Add 2nd/3rd Order Abd/Le,CASE-36248,APC,36248,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10638.54,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10089.40,10089.40,10089.40,1 through 10,other,10638.54,40729.62,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],32616.22,,"Case rate ($31,063.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,372.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,201.24. The transfer capital threshold is the transfer adjustment factor * $2,201.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",66909.74,32523.33,95446.16,1 through 10,other,31112.60,92731.42,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10017.33,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9820.91,29141.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],30163.67,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,30163.67,89504.77,Inpatient DRG
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB|PO",CASE-26540,APC,26540,CPT,0360,RC,,,F5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29162.98,,"Fee schedule rate ($29,162.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6700.24,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6700.24,30254.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13529.83,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13264.54,50759.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5013.25,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4774.52,14406.59,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, SECOND DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6558.98,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6558.98,19462.52,Inpatient DRG
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],35367.69,,"Fee schedule rate ($35,367.69). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|SEPARATE STRUCTURE,CASE-52332,APC,52332,CPT,0360,RC,,,50|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],42145.68,,"Case rate ($40,138.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,015.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,844.37. The transfer capital threshold is the transfer adjustment factor * $2,844.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40202.74,148703.60,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],104605.60,,"Fee schedule rate ($104,605.60). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7891.21,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7891.21,23415.63,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13464.14,,"Case rate ($12,822.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,079.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.68. The transfer capital threshold is the transfer adjustment factor * $908.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,38110.41,Inpatient DRG
Open Tx Fracture Phalanx/Phalanges Not Great Toe,CASE-28525,APC,28525,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE|SEPARATE STRUCTURE,CASE-27405,APC,27405,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|LEFT SIDE|PO,CASE-28306,APC,28306,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",6864.07,6864.07,6864.07,1 through 10,other,6882.29,7123.17,OPPS APC
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36577.58,,,,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,APC,52300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],102807.11,,"Fee schedule rate ($102,807.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, GREAT TOE",CASE-28124,APC,28124,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10920.51,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,30861.41,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10467.94,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9969.47,29582.40,Inpatient DRG
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],53076.74,,,,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13163.24,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12536.42,37199.37,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6055.67,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6055.67,17969.04,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10318.40,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9969.47,29582.40,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5013.25,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4774.52,14406.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7906.27,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4517.87,13932.70,All Other Inpatient
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple,CASE-43239,APC,43239,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21542.42,,"Fee schedule rate ($21,542.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,APC,23430,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16630.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6687.67,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6461.52,21772.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17575.50,,,,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23691.11,,,,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],42842.73,,,,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16573.70,,"Fee schedule rate ($16,573.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6632.59,19680.94,There are no additional notes associated with this service or procedure.
"Exc Tum/Vas Mal Sft Tis Hand/Fngr Subfasc<1.5cm|LEFT HAND, THUMB|PO",CASE-26116,APC,26116,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1621.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29433.60,,"Fee schedule rate ($29,433.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],52698.97,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",71784.02,71784.02,428163.19,1 through 10,other,50916.88,170142.20,Inpatient DRG
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13423.13,,"Case rate ($12,783.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,077.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.91. The transfer capital threshold is the transfer adjustment factor * $905.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12804.31,55145.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15158.86,,"Fee schedule rate ($15,158.86). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],33148.67,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,31570.16,98176.71,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
Open Treatment Fracture Distal Tibia Only|LEFT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Tot Hysterectomy Resj Malignancy W/Omntc,CASE-58575,APC,58575,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4553.45,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",7255.63,7255.63,7255.63,1 through 10,other,4464.17,13577.72,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30493.52,,"Fee schedule rate ($30,493.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],42695.82,,"Fee schedule rate ($42,695.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4303.70,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12255.93,12255.93,12255.93,1 through 10,other,4303.70,14124.38,Inpatient DRG
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28291,APC,28291,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8228.75,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8228.75,24417.19,Inpatient DRG
Unlisted Laparoscopic Procedure Liver,CASE-47379,APC,47379,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,APC,94640,CPT,0410,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,5450.78,16705.77,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15750.74,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15218.11,45156.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8679.02,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8679.02,29908.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,APC,43236,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
"ALTERATION IN CONSCIOUSNESS,MAJOR",052,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14537.61,,"Case rate ($14,537.61). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14537.61,15264.49,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5779.85,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5504.62,16333.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Laps Px Hrnap Herniorrhaphy Herniotomy,CASE-49659,APC,49659,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HEART FAILURE,EXTREME",194,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],28057.05,,"Case rate ($28,057.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,28057.05,29459.90,There are no additional notes associated with this service or procedure.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MAJOR",720,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],18061.22,,"Case rate ($17,201.16). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17201.16,18061.22,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],56694.72,,"Fee schedule rate ($56,694.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|BILATERAL PROCEDURE,CASE-49507,APC,49507,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT FOOT, SECOND DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XU|T1,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],47813.44,,"Case rate ($45,536.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,398.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,226.88. The transfer capital threshold is the transfer adjustment factor * $3,226.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",47813.46,47813.46,47813.46,1 through 10,other,45609.21,211906.58,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10538.94,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10037.09,36934.96,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,MODERATE",663,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9839.31,,"Case rate ($9,370.77). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9370.77,9839.31,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38792,APC,38792,CPT,0361,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Glenohumeral Joint Total Shoulder,CASE-23472,APC,23472,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17461.77,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30103.84,,,,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,XU|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27304.54,,"Fee schedule rate ($27,304.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7342.43,,"Case rate ($6,992.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,666.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.53. The transfer capital threshold is the transfer adjustment factor * $495.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7003.94,20782.85,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10145.17,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,30103.84,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Hdr Vaginal Cyl Insertion,CASE-57156,APC,57156,CPT,0333,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],303.48,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,289.03,303.48,OPPS APC
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11341.09,,"Case rate ($10,801.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,936.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $765.40. The transfer capital threshold is the transfer adjustment factor * $765.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10818.26,38164.94,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38610.21,,,,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12698.12,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,40067.60,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7303.30,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7056.33,28335.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8919.08,,"Fee schedule rate ($8,919.08). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15043.80,,"Fee schedule rate ($15,043.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5308.33,19857.20,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15507.88,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15507.88,46016.63,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24782.12,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23602.02,108295.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5669.00,,"Per diem ($5,669). If length of stay < 3.2, first 1 days paid at a per diem of $11,338 instead. Capped at $18,140.88.",,,,0,other,5669.00,18994.21,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7690.02,,"Case rate ($7,323.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.99. The transfer capital threshold is the transfer adjustment factor * $518.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7335.51,29792.90,Inpatient DRG
"SIGNS SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS,MODERATE",861,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],1854.70,,"Case rate for a one day stay ($1,766.38). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1766.38,1854.70,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10888.24,,"Case rate ($10,888.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,437.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10888.24,32825.17,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6940.00,,"Per diem ($6,940). If length of stay < 5.9, first 1 days paid at a per diem of $13,880 instead. Capped at $40,946.19.",,,,0,other,6940.00,42872.25,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24288.44,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23131.85,76404.43,Inpatient DRG
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",867.84,867.84,867.84,1 through 10,other,838.89,880.84,OPPS APC
Arthrt Elbow W/Exploration Drainage/Removal FB|RIGHT SIDE|PO,CASE-24000,APC,24000,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16536.43,,"Fee schedule rate ($16,536.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],63171.04,,,,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],47205.53,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,45609.21,211906.58,Inpatient DRG
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],67775.08,,"Fee schedule rate ($67,775.08). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],133824.90,,"Fee schedule rate ($133,824.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,38916.28,133824.90,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,APC,11421,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4910.73,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4744.66,4910.73,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12366.99,,,,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15430.11,,"Case rate ($14,695.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,212.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,041.36. The transfer capital threshold is the transfer adjustment factor * $1,041.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14718.77,51765.74,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],29700.53,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,28696.16,118364.04,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3865.18,,"Case rate ($3,681.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.86. The transfer capital threshold is the transfer adjustment factor * $260.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3209.85,10940.41,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Interdigital Morton Neuroma Single Each|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Fem Pop Territory Plasty|RIGHT SIDE,CASE-37224,APC,37224,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],421.27,,,,,,0,other,401.21,421.27,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13632.44,,"Fee schedule rate ($13,632.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4734.64,14273.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Tibia|LEFT SIDE|PO,CASE-27640,APC,27640,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC Fem Pop Terr Plasty and Stent|RIGHT SIDE,CASE-37226,APC,37226,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],468.41,,,,,,0,other,468.41,491.83,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17622.72,,,,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
"OTHER PNEUMONIA,MAJOR",139,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13439.65,,"Case rate ($12,799.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12799.67,13439.65,There are no additional notes associated with this service or procedure.
HC Rem Central Venous Cath,CASE-36589,APC,36589,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],594.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",573.97,573.97,573.97,1 through 10,other,594.98,624.73,OPPS APC
Unlisted Procedure Pelvis/Hip Joint|RIGHT SIDE,CASE-27299,APC,27299,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],245.65,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",5459.79,5459.79,5459.79,1 through 10,other,233.96,245.65,OPPS APC
HC Tib per Territory Ather|RIGHT SIDE,CASE-37229,APC,37229,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],626.55,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12803.67,,"Fee schedule rate ($12,803.67). Adds an outlier to normal pricing equal to the per diem rate ($91,038.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28832.22,,"Fee schedule rate ($28,832.22). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],26566.03,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,25667.66,86123.60,Inpatient DRG
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
Curtg/Caut Anal Fissure W/Dilat Sphnctr Spx 1st,CASE-46940,APC,46940,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7775.16,,"Case rate ($4,442.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.41. The transfer capital threshold is the transfer adjustment factor * $321.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4442.95,13183.59,All Other Inpatient
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],45520.40,,"Fee schedule rate ($45,520.40). Adds an outlier to normal pricing equal to the per diem rate ($131,498.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6480.75,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6480.75,29542.64,Inpatient DRG
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,APC,26080,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15824.86,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15824.86,49371.45,Inpatient DRG
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7543.08,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7543.08,29489.40,Inpatient DRG
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26123,APC,26123,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4406.30,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4257.29,12632.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL CRANIAL AND AUTONOMIC NERVE DISORDERS,MAJOR",048,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14711.81,,"Case rate ($14,011.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14011.25,14711.81,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4418.42,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4418.42,13110.79,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8601.89,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8192.28,24308.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvic/Le 1st Ord|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,APC,36245,CPT,0361,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13.74,,,,,,0,other,13.28,13.94,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],48954.15,,"Fee schedule rate ($48,954.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
"Open Treatment Metatarsal Fracture Each|RIGHT FOOT, FIFTH DIGIT",CASE-28485,APC,28485,CPT,0360,RC,,,T9,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MAJOR",191,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],19490.31,,"Case rate ($19,490.31). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19490.31,20464.83,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13369.00,,"Per diem ($13,369). If length of stay < 6.3, first 1 days paid at a per diem of $26,738 instead. Capped at $84,226.47.",,,,0,other,13369.00,88188.38,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6367.35,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,18893.86,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10178.99,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10178.99,36468.17,Inpatient DRG
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21404.64,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
"DIABETES,EXTREME",420,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],24024.57,,"Case rate ($22,880.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22880.54,24024.57,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6308.00,,"Per diem ($6,308). If length of stay < 3.3, first 1 days paid at a per diem of $12,616 instead. Capped at $20,817.01.",,,,0,other,6308.00,21796.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB EXCEPT TOES,MAJOR",305,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],31032.33,,"Case rate ($29,554.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29554.60,31032.33,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<|PO,CASE-11420,APC,11420,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1621.31,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Treatment Metatarsal Fracture Each|RIGHT FOOT, FIFTH DIGIT",CASE-28485,APC,28485,CPT,0360,RC,,,T9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-20610,APC,20610,CPT,0510,RC,,,RT|73,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,21229.52,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],32157.86,,"Case rate ($30,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,386.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,215.60. The transfer capital threshold is the transfer adjustment factor * $2,215.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30626.53,106200.88,Inpatient DRG
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4654.49,,"Case rate ($4,654.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.72. The transfer capital threshold is the transfer adjustment factor * $336.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4654.49,13811.29,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24834.32,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",119290.62,119290.62,119290.62,1 through 10,other,10455.00,90889.11,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13438.87,,"Fee schedule rate ($13,438.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4971.19,,"Case rate ($4,734.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.50. The transfer capital threshold is the transfer adjustment factor * $335.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4742.02,14071.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12861.93,,"Fee schedule rate ($12,861.93). Adds an outlier to normal pricing equal to the per diem rate ($47,786.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],30150.40,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,30150.40,89465.42,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],27740.63,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,26419.65,96304.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE|PO,CASE-15823,APC,15823,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2367.72,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6461.52,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6461.52,21772.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8227.43,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8227.43,27001.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11859.90,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11458.84,42820.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6459.10,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6240.68,18518.02,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10032.07,,"Case rate ($9,554.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,848.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.05. The transfer capital threshold is the transfer adjustment factor * $677.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9569.58,41116.55,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3228.61,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3074.87,3228.61,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surg Tx Anal Fistula Intersphincteric,CASE-46275,APC,46275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER AFTERCARE AND CONVALESCENCE,MAJOR",862,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9745.02,,"Case rate ($9,280.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9280.97,9745.02,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11380.76,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6503.29,19528.85,All Other Inpatient
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21732.40,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20697.52,87921.54,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],33148.67,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,31570.16,98176.71,Inpatient DRG
Excision Ganglion Wrist Dorsal/Volar Primary|LEFT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],79170.00,,"Fee schedule rate ($79,170). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,38916.28,133824.90,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7109.06,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6770.53,20090.22,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9761.89,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9761.89,37873.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5938.97,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5938.97,17858.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, THUMB|PO",CASE-26445,APC,26445,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],8940.00,,"Per diem ($8,940). If length of stay < 6.8, first 1 days paid at a per diem of $17,880 instead. Capped at $60,793.48.",57800.63,57800.63,57800.63,1 through 10,other,8940.00,63653.13,Estimated amount calculated based on 4 day length of stay.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31790.24,,"Fee schedule rate ($31,790.24). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,11217.46,37366.25,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28832.22,,"Fee schedule rate ($28,832.22). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],40890.77,,,,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23130.31,,,,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4464.17,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4464.17,13577.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,APC,58573,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18872.54,,"Fee schedule rate ($18,872.54). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,33843.71,Estimated amount calculated based on 10 day length of stay.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,APC,58662,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8242.50,,"Fee schedule rate ($8,242.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9787.84,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9456.85,28061.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19056.10,,"Fee schedule rate ($19,056.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14143.97,,"Case rate ($13,866.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,812.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,280.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,174.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,863.50. The transfer operating threshold is the transfer adjustment factor * $12,812.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,003.15. The transfer capital threshold is the transfer adjustment factor * $1,003.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13866.64,41146.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Carpectomy 1 Bone|LEFT SIDE|PO,CASE-25210,APC,25210,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
HC Debride/Musc/Fasc First 20 Sq Cm,CASE-11043,APC,11043,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],725.52,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,700.99,736.04,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],86795.47,,"Fee schedule rate ($86,795.47). Adds an outlier to normal pricing equal to the per diem rate ($211,362.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
Open Treatment Calcaneal Fracture|LEFT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29433.60,,"Fee schedule rate ($29,433.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23758.52,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23758.52,103116.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE|PO,CASE-64405,APC,64405,CPT,0450,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41929.72,,,,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Metatarsal Fracture Each|RIGHT SIDE,CASE-28485,APC,28485,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
"CHOLECYSTECTOMY,MODERATE",263,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],20012.24,,"Case rate ($19,059.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19059.28,20012.24,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10759.91,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11062.86,11062.86,11062.86,1 through 10,other,10759.91,46061.32,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5040.87,,"Case rate ($4,870.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,514.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,060.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,001.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,517.21. The transfer operating threshold is the transfer adjustment factor * $4,514.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.19. The transfer capital threshold is the transfer adjustment factor * $353.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4870.41,14682.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
Excision/Curettage Cyst/Tumor Femur|LEFT SIDE,CASE-27355,APC,27355,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10575.35,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10367.99,37103.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
Litholapaxy Smpl/Sm <2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52317,APC,52317,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,27370.21,Estimated amount calculated based on 3 day length of stay.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23409.73,,,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,APC,57425,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],125659.39,,"Fee schedule rate ($125,659.39). Adds an outlier to normal pricing equal to the per diem rate ($160,041.92) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE|PO,CASE-23700,APC,23700,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12698.12,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,40067.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Ganglion Wrist Dorsal/Volar Primary|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10903.13,,"Case rate ($10,383.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,906.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.84. The transfer capital threshold is the transfer adjustment factor * $735.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13133.14,13133.14,22435.68,1 through 10,other,6965.00,30861.41,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15467.50,,"Fee schedule rate ($15,467.50). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17439.12,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16849.39,49997.29,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16009.89,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16009.89,58554.60,Inpatient DRG
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26123,APC,26123,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],30766.94,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,30163.67,89504.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Extremity Venogram,CASE-36005,APC,36005,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1545.29,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1493.03,1545.29,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|LEFT SIDE,CASE-19120,APC,19120,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23754.07,,,,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6765.24,,"Case rate ($6,632.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,128.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,596.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,650.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,152.78. The transfer operating threshold is the transfer adjustment factor * $6,128.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.82. The transfer capital threshold is the transfer adjustment factor * $479.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6632.59,19680.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
"OTHER DISORDERS OF THE LIVER,EXTREME",283,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],26990.52,,"Case rate ($26,990.52). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,26990.52,28340.05,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,APC,11424,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
Removal Implant Deep|RIGHT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14366.41,,"Case rate ($13,880.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,825.31, add-ons for qualifying new technology services are included. If operating cost exceeds $48,293.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,876.42. The transfer operating threshold is the transfer adjustment factor * $12,825.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7285.00,41187.90,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5888.65,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5773.19,31196.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4787.78,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4787.78,20006.29,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MODERATE",192,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4023.92,,"Case rate for a one day stay ($3,832.30). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3832.30,4023.92,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19061.52,,"Fee schedule rate ($19,061.52). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5237.39,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5237.39,15540.89,Inpatient DRG
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31767.69,,"Fee schedule rate ($31,767.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11036.50,33262.00,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
HC Hdr Vaginal Cyl Insertion,CASE-57156,APC,57156,CPT,0333,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],299.14,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,289.03,303.48,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19262.83,,"Fee schedule rate ($19,262.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],40987.53,,of the excess amount. Final payment is multiplied by 102%.,271403.29,271403.29,271403.29,1 through 10,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9569.58,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9569.58,41116.55,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<,CASE-11420,APC,11420,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1621.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],34467.51,,"Fee schedule rate ($34,467.51). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT SIDE|PO,CASE-26540,APC,26540,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],28090.46,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,27539.67,109237.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19668.75,,"Fee schedule rate ($19,668.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,APC,38900,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],47660.93,,"Fee schedule rate ($47,660.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO|SEPARATE STRUCTURE,CASE-14040,APC,14040,CPT,0360,RC,,,PO|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC
"DIABETES,MAJOR",420,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12437.72,,"Case rate ($12,437.72). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12437.72,13059.61,There are no additional notes associated with this service or procedure.
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, THUMB|PO",CASE-26525,APC,26525,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7177.29,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6835.51,20283.05,Inpatient DRG
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4747.58,,"Case rate ($4,654.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.72. The transfer capital threshold is the transfer adjustment factor * $336.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4654.49,13811.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22091.17,,"Fee schedule rate ($22,091.17). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5700.90,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5700.90,30872.02,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25189.47,,"Fee schedule rate ($25,189.47). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,APC,20526,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
HC Iliac Territory Plasty Stent|RIGHT SIDE,CASE-37221,APC,37221,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],444.96,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10767.45,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10556.32,32082.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21112.63,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21112.63,62647.63,Inpatient DRG
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALFUNCTION REACTION COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE,MODERATE",466,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9225.71,,"Case rate ($9,225.71). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9225.71,9687.00,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13276.20,,"Fee schedule rate ($13,276.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15549.63,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15023.80,48104.19,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16573.70,,"Fee schedule rate ($16,573.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6632.59,19680.94,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",34429.58,34429.58,34429.58,1 through 10,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5451.02,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5344.14,15857.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER CARDIOTHORACIC AND THORACIC CIRCULATORY PROCEDURES,MAJOR",167,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],56246.37,,"Case rate ($53,567.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $47,615, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,53567.97,56246.37,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE|PO,CASE-29806,APC,29806,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, GREAT TOE",CASE-28270,APC,28270,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],27682.71,,of the excess amount.,85273.74,85273.74,85273.74,1 through 10,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
Lig/Banding Angioaccess Arteriovenous Fistula,CASE-37607,APC,37607,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
Arthrt Elbow Capsular Excision Capsular Rls Spx,CASE-24006,APC,24006,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6146.83,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5938.97,17858.70,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THUMB|PO",CASE-26735,APC,26735,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],48389.68,,,,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12496.20,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11901.14,35314.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11903.13,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11903.13,48838.99,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7125.07,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6785.78,20135.47,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8978.65,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8675.02,25741.45,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16810.38,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16009.89,58554.60,Inpatient DRG
Fasciectomy Plantar Fascia Radical Spx|LEFT SIDE|PO,CASE-28062,APC,28062,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Wmhc Perc Implant Stim Lead Ea|PO,CASE-63650,APC,63650,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6346.81,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6044.58,6346.81,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],42577.42,,"Fee schedule rate ($42,577.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],62179.32,,,,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],36947.10,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,21112.63,62647.63,All Other Inpatient
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5183.66,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5183.66,15743.06,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE|PO,CASE-27680,APC,27680,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Manipulation Knee Joint Under General Anesthesia,CASE-27570,APC,27570,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",1485.76,1485.76,1485.76,1 through 10,other,1525.13,1601.38,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,APC,54410,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20346.09,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,19658.06,20640.96,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Prtl 5th Metar Head Spx|RIGHT SIDE|PO,CASE-28110,APC,28110,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms|RIGHT SIDE,CASE-27696,APC,27696,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18067.42,,,,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
HC Removal Subcutaneous Cardiac Rhythm Monitor,CASE-33286,APC,33286,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10409.05,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9913.38,10409.05,OPPS APC
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6721.23,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5669.00,18994.21,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24032.10,,"Fee schedule rate ($24,032.10). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9761.89,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9761.89,37873.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Drill Osteochondritis Dissecans Grfg,CASE-29885,APC,29885,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE|PO,CASE-29823,APC,29823,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12747.57,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12140.54,36024.65,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MINOR",192,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5362.76,,"Case rate for a one day stay ($5,362.76). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5362.76,5630.90,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16849.39,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16849.39,49997.29,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14043.03,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",13761.28,13761.28,13761.28,1 through 10,other,14043.03,54637.47,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10449.55,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10449.55,43409.67,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
Implant Neurostim/Receiver,CASE-64590,APC,64590,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19044.40,,"APC Price ($18,400.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",20604.89,19852.16,20604.89,1 through 10,other,18400.38,19320.40,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20288.95,,,,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9035.67,,"Case rate ($8,605.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,951.18, add-ons for qualifying new technology services are included. If operating cost exceeds $43,419.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,982.86. The transfer operating threshold is the transfer adjustment factor * $7,951.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $622.54. The transfer capital threshold is the transfer adjustment factor * $622.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8605.40,42305.71,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5854.09,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,17370.86,Inpatient DRG
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9227.78,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8915.73,26455.73,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13305.64,39481.90,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6495.00,,"Per diem ($6,495). If length of stay < 3.5, first 1 days paid at a per diem of $12,990 instead. Capped at $22,732.01.",,,,0,other,6495.00,23801.30,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5341.02,,"Case rate ($5,086.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.46. The transfer capital threshold is the transfer adjustment factor * $360.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5094.80,15365.01,Inpatient DRG
"DIABETES,MODERATE",420,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2650.80,,"Case rate for a one day stay ($2,650.80). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2650.80,2783.34,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10887.83,,"Case rate ($10,369.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $734.81. The transfer capital threshold is the transfer adjustment factor * $734.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10385.89,32176.55,Inpatient DRG
Osteotomy Tarsal Bones Oth/Thn Calcaneus/Talus|LEFT SIDE|PO,CASE-28304,APC,28304,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12492.29,,"Case rate ($11,897.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $843.09. The transfer capital threshold is the transfer adjustment factor * $843.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11916.39,58492.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15857.69,,,,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9425.03,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9425.03,27966.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC 3rd Order Sel Abd/Lower Ext,CASE-36247,APC,36247,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8.76,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],91852.39,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10249.47,96445.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11196.90,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10818.26,38164.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11156.45,,"Case rate ($11,156.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,308.28, add-ons for qualifying new technology services are included. If operating cost exceeds $45,776.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,349.36. The transfer operating threshold is the transfer adjustment factor * $10,308.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.09. The transfer capital threshold is the transfer adjustment factor * $807.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11156.45,42003.98,Inpatient DRG
Arven Anast Opn Upr Arm Basilic Vein Trpos,CASE-36819,APC,36819,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5462.46,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit|RIGHT SIDE,CASE-36901,APC,36901,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1545.29,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Debridement Nail Any Method 1-5,CASE-11720,APC,11720,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],55.95,,"APC Price ($55.95). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,55.95,58.75,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1747.26,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1656.96,1656.96,1656.96,1 through 10,other,1688.18,1772.59,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14678.68,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",14263.31,14263.31,14263.31,1 through 10,other,7308.00,42083.20,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13466.94,,,,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],26948.04,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,26419.65,96304.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
"OTHER PNEUMONIA,EXTREME",139,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],19975.22,,"Case rate ($19,975.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19975.22,20973.98,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],102807.11,,"Fee schedule rate ($102,807.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38080.90,,,,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19964.70,,"Fee schedule rate ($19,964.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
HC Trigger Point 3 or More|LEFT SIDE|PO,CASE-20553,APC,20553,CPT,0510,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11603.76,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6630.72,19989.86,All Other Inpatient
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],65344.35,,"Fee schedule rate ($65,344.35). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14906.14,,"Fee schedule rate ($14,906.14). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
HC Fem Pop Terr Plasty and Stent|RIGHT SIDE,CASE-37226,APC,37226,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],468.41,,,,,,0,other,468.41,491.83,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12516.72,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12093.45,35884.94,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],52010.05,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13369.00,88188.38,All Other Inpatient
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|PO,CASE-64494,APC,64494,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
Open Treatment Calcaneal Fracture|LEFT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],44924.67,,"Fee schedule rate ($44,924.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
Optx Greater Humeral Tuberosity Fx W/Int Fixj,CASE-23630,APC,23630,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8.46,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
Partial Excision Bone Talus/Calcaneus|LEFT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14856.14,,,,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,XU|50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Laps Px Hrnap Herniorrhaphy Herniotomy,CASE-49659,APC,49659,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Supracrv Hysterec >250 G Rmvl Tube/Ovary,CASE-58544,APC,58544,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7078.89,21005.20,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],28419.19,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,27861.95,82674.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
Tenolysis Extensor Tendon Hand/Finger Each,CASE-26445,APC,26445,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Laparoscopy Enterolysis Separate Procedure,CASE-44180,APC,44180,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5416.39,5416.39,5416.39,1 through 10,other,5733.99,6020.69,OPPS APC
"Ostc Prtl Exostc/Condylc Metar Head|LEFT FOOT, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28288,APC,28288,CPT,0360,RC,,,T1|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19871.72,,"Fee schedule rate ($19,871.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,7011.91,27304.54,Zero final payments for the item or service in the 15 months prior to posting the file.
Destruction Vaginal Lesions Simple,CASE-57061,APC,57061,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cptr-Asst Surgical Navigation Image-Less,CASE-20985,APC,20985,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17212.32,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],45709.85,,"Case rate ($43,533.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,256.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,084.91. The transfer capital threshold is the transfer adjustment factor * $3,084.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,43602.60,153667.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23804.86,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23338.10,69251.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6240.09,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5942.94,17634.53,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6699.57,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6699.57,24060.08,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit|RIGHT SIDE,CASE-36901,APC,36901,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1493.03,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20288.95,,,,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30683.33,,"Fee schedule rate ($30,683.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE,CASE-27601,APC,27601,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],70023.45,,"Fee schedule rate ($70,023.45). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19912.50,,"Fee schedule rate ($19,912.50). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
Tx Tibl Shft Fx Imed Implt W/WO Screws&/Cercla,CASE-27759,APC,27759,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
"SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,MINOR",361,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3987.92,,"Case rate for a one day stay ($3,798.02). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3798.02,3987.92,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Unlisted Procedure, Nervous System",CASE-64999,APC,64999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MAJOR",710,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],38974.28,,"Case rate ($37,118.36). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,37118.36,38974.28,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11194.16,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9888.00,40658.63,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,MODERATE",663,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9370.77,,"Case rate ($9,370.77). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9370.77,9839.31,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],42577.42,,"Fee schedule rate ($42,577.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|RIGHT SIDE|PO,CASE-28119,APC,28119,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw,CASE-37722,APC,37722,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8887.20,,"Fee schedule rate ($8,887.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|LEFT HAND, FIFTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8890.47,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8716.15,25863.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7439.07,,"Case rate ($7,084.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.06. The transfer capital threshold is the transfer adjustment factor * $502.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7096.13,25801.23,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24805.79,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23624.56,83038.88,Inpatient DRG
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY ANOTHER PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,77|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],31259.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,29771.33,31259.89,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only,CASE-27601,APC,27601,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17018.56,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16208.15,58123.31,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12212.80,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12212.80,39290.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36024.65,,,,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5658.75,,"Case rate ($5,389.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,996, add-ons for qualifying new technology services are included. If operating cost exceeds $45,541.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,038.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,998.47. The transfer operating threshold is the transfer adjustment factor * $4,996.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.82. The transfer capital threshold is the transfer adjustment factor * $390.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5389.29,16247.30,Inpatient DRG
Excision Ganglion Wrist Dorsal/Volar Recurrent,CASE-25112,APC,25112,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto impl 4 or more,CASE-C9740,APC,C9740,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9292.89,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9645.99,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9456.85,28061.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6630.72,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6630.72,19989.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6698.65,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6472.13,19204.75,Inpatient DRG
"SICKLE CELL ANEMIA CRISIS,MAJOR",662,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15915.81,,"Case rate ($15,157.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15157.91,15915.81,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1545.29,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1515.33,1492.63,1515.33,1 through 10,other,1493.03,1567.69,OPPS APC
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5549.19,16729.39,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],57457.72,,"Fee schedule rate ($57,457.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT FOOT, GREAT TOE",CASE-28297,APC,28297,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11670.40,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7000.00,32980.62,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],40281.24,,"Fee schedule rate ($40,281.24). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|LEFT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,EXTREME",720,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],31320.17,,"Case rate ($31,320.17). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31320.17,32886.18,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8369.91,,"Case rate ($7,971.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,736.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.88. The transfer capital threshold is the transfer adjustment factor * $564.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7984.05,33319.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],30537.65,,"Case rate ($29,083.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,232.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,060.96. The transfer capital threshold is the transfer adjustment factor * $2,060.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29129.85,86437.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Ather|LEFT SIDE,CASE-37229,APC,37229,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],657.88,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10556.32,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10556.32,32082.48,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7744.00,24853.45,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],36405.02,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",26082.50,26082.50,26082.50,1 through 10,other,36405.02,110499.61,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6875.97,,"Case rate ($6,548.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,635.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $464.05. The transfer capital threshold is the transfer adjustment factor * $464.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6558.98,19462.52,Inpatient DRG
HC Cath Urethral Simple,CASE-51702,APC,51702,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],44.41,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,44.41,46.63,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33307.89,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,8990.00,80069.53,All Other Inpatient
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],64872.40,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,64872.40,212258.00,Inpatient DRG
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23594.49,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23131.85,76404.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7840.72,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7686.98,22809.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],57263.95,,"Fee schedule rate ($57,263.95). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,APC,58550,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6422.05,,"Case rate ($6,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,620.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.88. The transfer capital threshold is the transfer adjustment factor * $448.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6204.88,19589.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33244.29,,,,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14182.30,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",14182.30,14182.30,14182.30,1 through 10,other,7308.00,42083.20,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6058.98,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,17370.86,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13021.05,,"Fee schedule rate ($13,021.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3753.97,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3753.97,11139.15,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|LEFT SIDE|PO,CASE-25260,APC,25260,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,APC,45331,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],25564.74,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10455.00,90889.11,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",19443.53,19443.53,19443.53,1 through 10,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18914.32,,"Case rate ($18,013.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,447.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,276.51. The transfer capital threshold is the transfer adjustment factor * $1,276.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18042.36,82749.58,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14009.21,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8005.26,24549.95,All Other Inpatient
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38222.57,,,,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11135.66,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10605.39,31469.43,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8596.11,,"Case rate ($8,596.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,942.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,410.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,974.25. The transfer operating threshold is the transfer adjustment factor * $7,942.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.86. The transfer capital threshold is the transfer adjustment factor * $621.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8596.11,25507.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8369.87,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,34379.15,Inpatient DRG
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,APC,43236,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",574.68,574.68,574.68,1 through 10,other,1134.98,1191.72,OPPS APC
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35566.18,,,,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,APC,54405,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19658.06,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19658.06,20640.96,OPPS APC
HC N Block Inj Intercost Sng|LEFT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18049.06,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,30966.53,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,21325.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7898.88,,"Case rate ($7,744). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,731.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $560.22. The transfer capital threshold is the transfer adjustment factor * $560.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7744.00,24853.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7866.01,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7866.01,25247.47,Inpatient DRG
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,APC,54410,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19658.06,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19658.06,20640.96,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7637.70,,"Fee schedule rate ($7,637.70). Adds an outlier to normal pricing equal to the per diem rate ($4,143.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4734.64,14273.70,There are no additional notes associated with this service or procedure.
Revascularization Iliac Artery Angiop 1st Vsl|RIGHT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],361.50,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21256.76,,"Fee schedule rate ($21,256.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE,CASE-23700,APC,23700,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Angular Dfrm Toe Soft Tiss Px Only,CASE-28313,APC,28313,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],40770.64,,"Case rate ($38,829.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,922.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,751.57. The transfer capital threshold is the transfer adjustment factor * $2,751.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,38891.09,169197.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22000.90,,"Case rate ($20,953.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,655.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,484.82. The transfer capital threshold is the transfer adjustment factor * $1,484.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7826.00,90280.33,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5881.88,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5766.55,17111.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8227.43,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8227.43,27001.04,Inpatient DRG
Ant Vesicourethropexy/Urethropexy Smpl,CASE-51840,APC,51840,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|LEFT SIDE,CASE-37765,APC,37765,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],52092.32,,"Fee schedule rate ($52,092.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8133.30,,"Fee schedule rate ($8,133.30). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4389.77,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4303.70,14124.38,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"INTESTINAL OBSTRUCTION,MAJOR",247,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13077.00,,"Case rate ($12,454.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12454.29,13077.00,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,70321.74,Estimated amount calculated based on 17 day length of stay.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24324.30,,"Fee schedule rate ($24,324.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22484.91,,,,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE,CASE-19120,APC,19120,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3899.35,3899.35,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13714.70,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5970.00,38757.79,Inpatient DRG
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34528.24,,"Fee schedule rate ($34,528.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7574.18,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41146.57,,,,,,0,other,13866.64,41146.57,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],30307.66,,"Fee schedule rate ($30,307.66). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],85741.18,,"Fee schedule rate ($85,741.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,30254.51,130347.93,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6044.58,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6700.71,,"Case rate ($6,474.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,981.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,449.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,005.76. The transfer operating threshold is the transfer adjustment factor * $5,981.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.35. The transfer capital threshold is the transfer adjustment factor * $468.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6474.12,19210.66,Inpatient DRG
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27601,APC,27601,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11102.27,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10884.58,32297.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32874.59,,"Fee schedule rate ($32,874.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision/Curettage Bone Cyst/Tumor Tibia/Fibula|SEPARATE STRUCTURE|RIGHT SIDE,CASE-27635,APC,27635,CPT,0360,RC,,,XS|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride Subq First 20 Sq Cm|PBB CHARGE,CASE-11042,APC,11042,CPT,0361,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7287.29,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6940.28,20593.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4138.67,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4138.67,12473.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE|PO,CASE-28300,APC,28300,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|BILATERAL PROCEDURE,CASE-37766,APC,37766,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE|PO,CASE-29875,APC,29875,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19529.62,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11159.78,39897.21,All Other Inpatient
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14825.11,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14534.42,59012.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Arven Anast Opn Upr Arm Basilic Vein Trpos|LEFT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
Gastrocnemius Recession|LEFT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT SIDE|PO,CASE-26160,APC,26160,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4573.06,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4418.42,13110.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ESOPHAGEAL DISORDERS,MAJOR",243,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],13917.31,,"Case rate ($13,917.31). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13917.31,14613.18,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO|SEPARATE STRUCTURE,CASE-62323,APC,62323,CPT,0360,RC,,,PO|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23862.12,,"Fee schedule rate ($23,862.12). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],594.98,,"APC Price ($594.98). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,594.98,624.73,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],69977.32,,,,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15887.21,,,,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4568.94,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4568.94,13557.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THIRD DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7916.21,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7648.51,27371.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],115037.59,,"Fee schedule rate ($115,037.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21.9), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9527.16,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9527.16,28269.95,Inpatient DRG
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,APC,52332,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27156.15,,"Fee schedule rate ($27,156.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12179.66,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12179.66,36140.75,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12843.44,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,38110.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15087.45,,"Fee schedule rate ($15,087.45). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-20610,APC,20610,CPT,0510,RC,,,RT|73,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|BILATERAL PROCEDURE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],24790.92,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,24790.92,26030.46,OPPS APC
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8.76,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1149.34,37.77,1172.33,11,other,1134.98,1191.72,OPPS APC
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16062.27,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16062.27,48077.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6934.05,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6699.57,24060.08,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
Revascularization Iliac Art Angiop Ea Ipsi Vsl|LEFT SIDE,CASE-37222,APC,37222,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],173.90,,,,,,0,other,168.02,176.42,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, SECOND DIGIT|SEPARATE STRUCTURE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T6|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22695.45,,,,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22202.30,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8940.00,63653.13,Inpatient DRG
HC Cv Cath Plac WO Port>5yr (Tun),CASE-36558,APC,36558,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4167.74,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4167.74,12366.99,Inpatient DRG
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26123,APC,26123,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Insertion Intrauterine Device Iud,CASE-58300,APC,58300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27753.50,,"Fee schedule rate ($27,753.50). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33468.92,,"Fee schedule rate ($33,468.92). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
Destruction Mal Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-17266,APC,17266,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],385.57,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,399.06,OPPS APC
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18381.22,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",18381.23,18381.23,18381.23,1 through 10,other,18381.22,58579.45,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10808.31,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,10808.31,46938.11,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],30859.60,,"Case rate ($30,254.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,954.41, add-ons for qualifying new technology services are included. If operating cost exceeds $63,422.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,359.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $28,065.82. The transfer operating threshold is the transfer adjustment factor * $27,954.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,188.69. The transfer capital threshold is the transfer adjustment factor * $2,188.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,30254.51,130347.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT SIDE|PO,CASE-28750,APC,28750,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,APC,20526,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12299.85,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11714.14,49460.19,Inpatient DRG
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2|LEFT SIDE|PO,CASE-29822,APC,29822,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites,CASE-31625,APC,31625,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3713.03,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3536.22,3713.03,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25667.66,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,25667.66,86123.60,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9308.98,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9308.98,9308.98,9308.98,1 through 10,other,6965.00,33447.35,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|RIGHT SIDE,CASE-24073,APC,24073,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
Cysto W/Insert Ureteral Stent|RIGHT SIDE|SEPARATE STRUCTURE,CASE-52332,APC,52332,CPT,0360,RC,,,RT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|RIGHT SIDE,CASE-38570,APC,38570,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14478.52,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13789.07,57367.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30145.85,,"Fee schedule rate ($30,145.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",29750.38,29750.38,29750.38,1 through 10,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],42695.82,,"Fee schedule rate ($42,695.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17274.00,,"Per diem ($17,274). If length of stay < 3.3, first 1 days paid at a per diem of $34,548 instead. Capped at $57,002.93.",,,,0,other,17274.00,73717.28,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29458.80,,"Fee schedule rate ($29,458.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8925.03,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8925.03,26628.31,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7445.33,,"Case rate ($7,090.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.48. The transfer capital threshold is the transfer adjustment factor * $502.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7102.10,21074.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19824.58,,,,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],57534.77,,"Fee schedule rate ($57,534.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13572.00,,"Per diem ($13,572). If length of stay < 5.8, first 1 days paid at a per diem of $27,144 instead. Capped at $78,720.12.",,,,0,other,13572.00,108637.77,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4870.41,,"Case rate ($4,870.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,514.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,060.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,001.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,517.21. The transfer operating threshold is the transfer adjustment factor * $4,514.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.19. The transfer capital threshold is the transfer adjustment factor * $353.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4870.41,14682.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5368.01,,"Case rate ($5,368.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,959.91, add-ons for qualifying new technology services are included. If operating cost exceeds $40,427.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,559.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,979.68. The transfer operating threshold is the transfer adjustment factor * $4,959.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $388.34. The transfer capital threshold is the transfer adjustment factor * $388.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",3834.37,3834.37,3834.37,1 through 10,other,5368.01,15928.53,Inpatient DRG
"HC ED Avulsion Nail Plate Single|LEFT HAND, THIRD DIGIT|PO",CASE-11730,APC,11730,CPT,0450,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],196.96,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,196.96,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Revascularization Iliac Artery Angiop 1st Vsl|LEFT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],361.50,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],40278.35,,"Case rate ($38,916.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,957.67, add-ons for qualifying new technology services are included. If operating cost exceeds $71,425.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,986.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $36,100.97. The transfer operating threshold is the transfer adjustment factor * $35,957.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,815.30. The transfer capital threshold is the transfer adjustment factor * $2,815.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,38916.28,133824.90,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],24956.34,,,,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18251.76,,"Fee schedule rate ($18,251.76). Adds an outlier to normal pricing equal to the per diem rate ($45,948.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6440.28,19110.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10388.39,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10037.09,36934.96,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE|PO,CASE-64490,APC,64490,CPT,0361,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],36224.65,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36224.65,128473.68,Inpatient DRG
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],129256.37,,"Fee schedule rate ($129,256.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7693.94,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7543.08,29489.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11441.81,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11217.46,37366.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30818.12,,,,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6033.12,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6033.12,17902.13,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],66888.05,,"Fee schedule rate ($66,888.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.5), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|PO",CASE-64491,APC,64491,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,APC,31653,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3659.98,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6788.03,,"Case rate ($6,654.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,167.40, add-ons for qualifying new technology services are included. If operating cost exceeds $46,712.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,132.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,170.45. The transfer operating threshold is the transfer adjustment factor * $6,167.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.48. The transfer capital threshold is the transfer adjustment factor * $484.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6654.93,20056.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21626.45,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20895.12,99969.33,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",111275.33,111275.33,111275.33,1 through 10,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10400.49,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,30861.41,Inpatient DRG
Gastrocnemius Recession|RIGHT SIDE,CASE-27687,APC,27687,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8938.88,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8513.22,25261.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],49664.75,,,,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24223.71,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12440.40,41073.77,All Other Inpatient
"Partical Excision Bone Phalanx Toe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,APC,54410,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20346.09,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,19658.06,20640.96,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6153.78,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6033.12,17902.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10682.39,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10173.70,41194.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],25199.53,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10455.00,90889.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8145.36,,"Case rate ($4,654.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.72. The transfer capital threshold is the transfer adjustment factor * $336.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4654.49,13811.29,All Other Inpatient
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3024.28,3024.28,3039.48,1 through 10,other,2994.77,3144.51,OPPS APC
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23376.81,,"Fee schedule rate ($23,376.81). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion F/E/E/N/L >4.0 Cm,CASE-11646,APC,11646,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Transoral Lower Esophageal Myotomy,CASE-43497,APC,43497,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, THIRD DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],47506.18,,,,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18559.00,,"Per diem ($18,559). If length of stay < 5.4, first 1 days paid at a per diem of $37,118 instead. Capped at $100,219.31.",,,,0,other,18559.00,141041.50,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Pyeloplasty,CASE-50544,APC,50544,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],115476.44,,,,,,0,other,38916.28,133824.90,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7963.57,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",7906.88,7906.88,7963.58,1 through 10,other,7694.27,22831.22,Inpatient DRG
HC Fem Pop Terr Plasty and Stent,CASE-37226,APC,37226,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],28005.17,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,28005.17,115392.91,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],41837.14,,"Fee schedule rate ($41,837.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy 2/>Compartments|RIGHT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt|LEFT SIDE|PO,CASE-27602,APC,27602,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Medium WO US|RIGHT SIDE|PO,CASE-20605,APC,20605,CPT,0510,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Bladder Instillation Anticarcinogenic Agent,CASE-51720,APC,51720,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9793.06,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9793.06,29058.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],66027.56,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,66027.56,228732.31,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],23935.30,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23125.89,68621.57,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],32296.30,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteoplasty Radius/Ulna Shortening,CASE-25390,APC,25390,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
Arthrs Knee Drill Osteochondritis Dissecans Grfg,CASE-29885,APC,29885,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24863.59,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23679.61,84629.16,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],37449.63,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,21399.79,63499.65,All Other Inpatient
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],36276.38,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36276.38,121107.98,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],44924.67,,"Fee schedule rate ($44,924.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8118.25,,"Case rate ($7,731.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $547.89. The transfer capital threshold is the transfer adjustment factor * $547.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7744.00,24853.45,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22524.08,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8940.00,63653.13,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|RIGHT SIDE|PO,CASE-23700,APC,23700,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",18043.60,18043.60,18043.60,1 through 10,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10915.75,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10915.75,32390.31,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],107489.55,,,,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8393.33,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8228.75,24417.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14721.71,,"Case rate ($14,020.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,164.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.55. The transfer capital threshold is the transfer adjustment factor * $993.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14043.03,54637.47,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23110.67,,"Fee schedule rate ($23,110.67). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11039.73,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6953.00,35389.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4120.09,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3980.76,11812.10,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10625.29,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10625.29,39295.53,Inpatient DRG
Excision Prepatellar Bursa|LEFT SIDE|SEPARATE STRUCTURE,CASE-27340,APC,27340,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
Tnols Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|LEFT SIDE|PO,CASE-25295,APC,25295,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15196.40,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14472.76,56135.46,Inpatient DRG
Open Tx Trimalleolar Ankle Fx W/Fixj Pst Lip|LEFT SIDE|PO,CASE-27823,APC,27823,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11080.19,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11080.19,32878.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9538.87,,"Case rate ($5,450.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $5,062.05, add-ons for qualifying new technology services are included. If operating cost exceeds $42,251.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,051.56. The transfer operating threshold is the transfer adjustment factor * $5,062.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.22. The transfer capital threshold is the transfer adjustment factor * $399.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5450.78,16705.77,All Other Inpatient
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10240.84,,"Fee schedule rate ($10,240.84). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11412.83,,"Case rate ($10,869.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,418.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $770.71. The transfer capital threshold is the transfer adjustment factor * $770.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10888.24,32825.17,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],102660.52,,"Fee schedule rate ($102,660.52). Adds an outlier to normal pricing equal to the per diem rate ($180,358.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4308.15,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",17426.68,17426.68,17426.68,1 through 10,other,3295.00,21715.49,Inpatient DRG
Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,CASE-26125,APC,26125,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17691.86,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16849.39,49997.29,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx,CASE-29884,APC,29884,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],29486.43,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,16849.39,49997.29,All Other Inpatient
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
HC Removal Subcutaneous Cardiac Rhythm Monitor,CASE-33286,APC,33286,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9913.38,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",653.18,653.18,653.18,1 through 10,other,9913.38,10409.05,OPPS APC
"PEPTIC ULCER AND GASTRITIS,MAJOR",241,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],15772.68,,"Case rate ($15,772.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15772.68,16561.31,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($55,128.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,APC,58260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4981.90,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4744.66,4981.90,OPPS APC
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6617.34,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5683.00,19635.68,Inpatient DRG
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3070.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21534.51,,,,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],31019.76,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31019.76,124854.72,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27528.12,,,,,,0,other,8981.78,27528.12,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
HC Cath Urethral Simple,CASE-51702,APC,51702,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],44.41,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",119.67,119.67,119.67,1 through 10,other,44.41,46.63,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7055.53,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",30801.00,30801.00,30801.00,1 through 10,other,5520.00,26638.96,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6284.66,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5985.39,17760.46,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",8365.53,8365.53,8365.53,1 through 10,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9312.29,,"Case rate ($9,312.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,604.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,072.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,638.62. The transfer operating threshold is the transfer adjustment factor * $8,604.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.67. The transfer capital threshold is the transfer adjustment factor * $673.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",2458.05,2458.05,2458.05,1 through 10,other,9312.29,27632.41,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11958.84,,"Case rate ($11,958.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,049.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,517.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,093.70. The transfer operating threshold is the transfer adjustment factor * $11,049.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.13. The transfer capital threshold is the transfer adjustment factor * $865.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11958.84,40774.00,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"RESPIRATORY FAILURE,MAJOR",133,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15553.16,,"Case rate ($14,812.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14812.53,15553.16,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10353.04,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9860.04,30039.61,Inpatient DRG
"GASTROINTESTINAL VASCULAR INSUFFICIENCY,MAJOR",246,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15139.74,,"Case rate ($14,418.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14418.80,15139.74,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10954.57,,"Case rate ($10,432.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,910.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.31. The transfer capital threshold is the transfer adjustment factor * $739.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10449.55,43409.67,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11519.18,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11519.18,34180.92,Inpatient DRG
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4470.15,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4257.29,12632.63,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13022.58,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12402.46,36801.89,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],41117.20,,"Fee schedule rate ($41,117.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Enterolysis Separate Procedure,CASE-44180,APC,44180,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],10940.41,,,,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
Optx Greater Humeral Tuberosity Fx W/Int Fixj,CASE-23630,APC,23630,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula|LEFT SIDE|PO,CASE-27641,APC,27641,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24452.40,,"Fee schedule rate ($24,452.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5938.30,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5938.30,18621.89,Inpatient DRG
Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins|LEFT SIDE|PO,CASE-25320,APC,25320,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL ABUSE AND DEPENDENCE,MODERATE",775,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7581.72,,"Case rate ($7,581.72). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7581.72,7960.81,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9373.98,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",8902.08,8902.08,8902.08,1 through 10,other,9056.99,33814.75,Inpatient DRG
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, THIRD DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15233.99,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14508.56,59513.03,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6749.69,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5683.00,19635.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],115171.02,,"Fee schedule rate ($115,171.02). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25267.19,,"Fee schedule rate ($25,267.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 2 day length of stay.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],45507.56,,"Fee schedule rate ($45,507.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,3295.00,50750.92,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
I&D Ischiorct/Intramural Absc W/WO Seton,CASE-46060,APC,46060,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11114.67,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11114.68,11114.68,11114.68,1 through 10,other,7000.00,32980.62,Inpatient DRG
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,APC,31654,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,2994.77,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,XS|T5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],45758.86,,,,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],70498.76,,,,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21262.22,,"Fee schedule rate ($21,262.22). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20300.16,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11600.09,48814.14,All Other Inpatient
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4517.87,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4517.87,13932.70,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19243.94,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19243.94,63510.03,Inpatient DRG
HC Rem Central Venous Cath,CASE-36589,APC,36589,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],594.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,594.98,624.73,OPPS APC
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,Zero final payments for the item or service in the 15 months prior to posting the file.
"SIGNS SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS,MAJOR",861,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],12844.91,,"Case rate ($12,233.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12233.25,12844.91,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28899.61,,,,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8272.58,,"Case rate ($7,878.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,729.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.31. The transfer capital threshold is the transfer adjustment factor * $558.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7891.21,23415.63,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7984.05,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7984.05,33319.56,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6953.00,,"Per diem ($6,953). If length of stay < 4.5, first 1 days paid at a per diem of $13,906 instead. Capped at $31,286.59.",,,,0,other,6953.00,35389.05,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10418.64,,"Fee schedule rate ($10,418.64). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,There are no additional notes associated with this service or procedure.
Sesamoidectomy First Toe Spx|BILATERAL PROCEDURE|PO,CASE-28315,APC,28315,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,APC,52351,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,APC,28270,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE,CASE-28200,APC,28200,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6940.28,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6940.28,20593.95,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE,CASE-27601,APC,27601,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5623.19,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5355.42,17067.11,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6710.53,,"Case rate ($6,390.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,624.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $452.89. The transfer capital threshold is the transfer adjustment factor * $452.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",115861.06,115861.06,115861.06,1 through 10,other,5669.00,18994.21,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],28837.12,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",28302.34,28302.34,28302.34,1 through 10,other,27861.95,82674.88,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER DISORDERS OF NERVOUS SYSTEM,MODERATE",058,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14428.95,,"Case rate ($13,741.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13741.86,14428.95,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10362.69,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10362.69,29367.82,Inpatient DRG
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",201232.71,201232.71,201232.71,1 through 10,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
Revasc lithotrip tibi/perone|LEFT SIDE,CASE-C9772,APC,C9772,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvc/Le Init 2nd|LEFT SIDE,CASE-36246,APC,36246,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|RIGHT SIDE|PO,CASE-28119,APC,28119,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10037.09,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10037.09,36934.96,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19630.80,,"Fee schedule rate ($19,630.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
Proctosgmdsc Rgd Dx W/WO Collj Spec Br/Wa Spx,CASE-45300,APC,45300,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],22152.42,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",22152.43,22152.43,22152.43,1 through 10,other,9370.00,65732.99,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12728.07,,"Case rate ($12,121.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,200.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,668.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,048.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,245.03. The transfer operating threshold is the transfer adjustment factor * $11,200.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $876.93. The transfer capital threshold is the transfer adjustment factor * $876.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12121.97,35969.56,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25507.30,,,,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",274.04,137.02,411.06,1 through 10,other,291.13,305.69,OPPS APC
HC Sel Cath Abd/Pelvc/Le Init 2nd,CASE-36246,APC,36246,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13.74,,,,,,0,other,13.28,13.94,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25741.45,,,,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24282.18,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23125.89,68621.57,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-24358,APC,24358,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14002.25,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13335.48,39570.45,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],35094.08,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,33422.93,112824.68,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6721.23,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5669.00,18994.21,Inpatient DRG
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
"PULMONARY EMBOLISM,MAJOR",134,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15851.98,,"Case rate ($15,097.12). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15097.12,15851.98,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],107249.77,,"Fee schedule rate ($107,249.77). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THIRD DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12280.26,,"Case rate ($11,695.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,999.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.78. The transfer capital threshold is the transfer adjustment factor * $828.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11714.14,49460.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Prostate Needle Biopsy Any Approach,CASE-55700,APC,55700,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],120.13,,,,,,0,other,120.13,126.14,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41187.90,,,,,,0,other,7285.00,41187.90,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4742.02,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4742.02,14071.02,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14142.64,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13664.39,40546.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto impl 4 or more,CASE-C9740,APC,C9740,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13889.46,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13228.06,39251.68,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19339.26,,of the excess amount.,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
Partial Excision Bone Fibula|LEFT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt,CASE-27602,APC,27602,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26280.60,,,,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],32749.19,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,32749.19,97176.83,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23262.15,,,,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5561.91,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5297.06,19049.64,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9056.99,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8599.88,8599.88,8599.88,1 through 10,other,9056.99,33814.75,Inpatient DRG
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7405.81,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7405.81,33747.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15751.44,,,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
HC Extremity Venogram|LEFT SIDE,CASE-36005,APC,36005,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1493.03,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33733.44,,"Fee schedule rate ($33,733.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3713.03,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy With Biopsy|SEPARATE STRUCTURE,CASE-52204,APC,52204,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19312.24,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8972.00,76376.03,Inpatient DRG
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
HC Rt Bronch Dx Clear Airway,CASE-31645,APC,31645,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3713.03,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],24790.92,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,24790.92,26030.46,OPPS APC
Unlisted Laps Px Hrnap Herniorrhaphy Herniotomy,CASE-49659,APC,49659,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],53462.72,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,50916.88,170142.20,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE,CASE-29825,APC,29825,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27982.66,,,,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21766.70,,,,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26291.41,,"Fee schedule rate ($26,291.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,8981.78,27528.12,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22158.27,,,,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12405.53,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,11986.02,54149.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13842.12,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12440.40,41073.77,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],24347.37,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",24347.38,24347.38,24347.38,1 through 10,other,10455.00,90889.11,Inpatient DRG
Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins|RIGHT SIDE|PO,CASE-25320,APC,25320,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11468.00,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11080.19,32878.30,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Leg/Ankle Subq <3cm|LEFT SIDE,CASE-27618,APC,27618,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MODERATE",191,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15493.68,,"Case rate ($14,755.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14755.89,15493.68,There are no additional notes associated with this service or procedure.
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt,CASE-27602,APC,27602,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10764.51,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",11078.29,11078.29,11078.29,1 through 10,other,6965.00,30861.41,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9743.09,,"Case rate ($9,279.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,573.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,041.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,607.86. The transfer operating threshold is the transfer adjustment factor * $8,573.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.28. The transfer capital threshold is the transfer adjustment factor * $671.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9279.13,27534.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4742.02,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4742.02,14071.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27249.60,,"Fee schedule rate ($27,249.60). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19137.85,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19137.85,64589.15,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],60675.70,,"Fee schedule rate ($60,675.70). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],48720.85,,"Fee schedule rate ($48,720.85). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MINOR",191,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6483.10,,"Case rate for a one day stay ($6,174.38). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6174.38,6483.10,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10389.39,,"Case rate ($9,894.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,872.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $701.17. The transfer capital threshold is the transfer adjustment factor * $701.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12377.45,12377.45,12377.45,1 through 10,other,9910.44,43344.00,Inpatient DRG
Rhinoplasty Secondary Intermediate Revision,CASE-30435,APC,30435,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7856.49,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7590.81,32847.45,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26800.70,,"Fee schedule rate ($26,800.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16682.55,,"Fee schedule rate ($16,682.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5365.09,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5279.36,5279.36,5279.36,1 through 10,other,5183.66,15743.06,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,XU|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE,CASE-29898,APC,29898,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16838.54,,"Case rate ($16,036.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,307.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.42. The transfer capital threshold is the transfer adjustment factor * $1,136.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16062.27,48077.57,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],31837.05,,"Fee schedule rate ($31,837.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],185834.07,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,185834.07,195125.77,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10208.65,,"Case rate ($9,722.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $688.97. The transfer capital threshold is the transfer adjustment factor * $688.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9738.02,28895.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15507.88,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15507.88,46016.63,Inpatient DRG
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE,CASE-27691,APC,27691,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9904.52,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9569.58,41116.55,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, SECOND DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6515.67,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6387.91,18954.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intra Lithotrip-Stent,CASE-C9765,APC,C9765,CPT,0481,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,EXTREME",425,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],21150.89,,"Case rate ($21,150.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,21150.89,22208.43,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9056.99,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8599.88,8599.88,8599.88,1 through 10,other,9056.99,33814.75,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|PO,CASE-64494,APC,64494,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MODERATE",282,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10059.80,,"Case rate ($9,580.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9580.76,10059.80,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,5007.28,16142.41,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5612.74,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5224.00,15861.63,Inpatient DRG
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy,CASE-27675,APC,27675,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17691.86,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16849.39,49997.29,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31567.81,,,,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13713.25,,"Fee schedule rate ($13,713.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36024.65,,,,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],25170.20,,"Case rate ($23,971.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,869.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.71. The transfer capital threshold is the transfer adjustment factor * $1,698.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10632.00,103714.29,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13983.36,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7770.00,50313.90,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12095.14,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11519.18,34180.92,Inpatient DRG
"AMPUTATION OF LOWER LIMB EXCEPT TOES,MAJOR",305,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],29554.60,,"Case rate ($29,554.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,29554.60,31032.33,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, SECOND DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],52092.32,,"Fee schedule rate ($52,092.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5549.19,,"Case rate ($5,549.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,050.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.42. The transfer capital threshold is the transfer adjustment factor * $402.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5549.19,16729.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|LEFT SIDE|PO,CASE-28120,APC,28120,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22405.95,,"Fee schedule rate ($22,405.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
HC Extremity Venogram|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10409.05,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9913.38,10409.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Transurethral Waterjet Ablation Prostate Compl,CASE-0421T,APC,0421T,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4.76,,,,,,0,other,4.76,4.76,There are no additional notes associated with this service or procedure.
HC Tib per Territory Plasty|RIGHT SIDE,CASE-37228,APC,37228,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],488.85,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6940.28,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6940.28,20593.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10080.86,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10080.86,33310.69,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9569.58,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9569.58,41116.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Lateral Release|LEFT SIDE|PO,CASE-29873,APC,29873,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10244.66,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,1188.00,17370.86,All Other Inpatient
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],34268.98,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32637.12,96844.29,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,55581.70,Estimated amount calculated based on 10 day length of stay.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],85483.72,,"Fee schedule rate ($85,483.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE|PO,CASE-28740,APC,28740,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-54840,APC,54840,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
Unlisted Procedure Abdomen Peritoneum & Omentum,CASE-49999,APC,49999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25698.16,,,,,,0,other,6965.00,25698.16,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13826.01,,"Fee schedule rate ($13,826.01). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13632.44,,"Fee schedule rate ($13,632.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4734.64,14273.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11055.00,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11055.00,49295.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17702.00,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,17103.38,50750.92,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],32296.30,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE,CASE-28306,APC,28306,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT SIDE|PO,CASE-28297,APC,28297,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4732.71,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4639.91,13771.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12100.11,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11690.93,56733.59,Inpatient DRG
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MODERATE",422,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2424.09,,"Case rate for a one day stay ($2,424.09). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2424.09,2545.29,There are no additional notes associated with this service or procedure.
Partial Excision Bone Fibula|LEFT SIDE|PO,CASE-27641,APC,27641,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8523.22,,"Case rate ($4,870.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,514.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,060.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,001.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,517.21. The transfer operating threshold is the transfer adjustment factor * $4,514.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.19. The transfer capital threshold is the transfer adjustment factor * $353.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4870.41,14682.98,All Other Inpatient
HC Cv Cath Plac WO Port>5yr (Tun),CASE-36558,APC,36558,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",2922.01,2883.68,2922.31,1 through 10,other,2994.77,3144.51,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],27696.47,,"Case rate ($26,377.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,869.21. The transfer capital threshold is the transfer adjustment factor * $1,869.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,26419.65,96304.23,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,APC,52287,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20110.39,,"Fee schedule rate ($20,110.39). Adds an outlier to normal pricing equal to the per diem rate ($69,590.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",30921.30,30921.30,30921.30,1 through 10,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8978.65,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",8778.40,8778.40,8778.40,1 through 10,other,8675.02,25741.45,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,APC,58550,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Iliac Territory Plasty Stent|LEFT SIDE,CASE-37221,APC,37221,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],460.53,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MODERATE",344,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11905.84,,"Case rate ($11,905.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11905.84,12501.13,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6480.75,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6480.75,29542.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10492.66,,"Case rate ($10,492.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,694.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,162.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,930.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,733.59. The transfer operating threshold is the transfer adjustment factor * $9,694.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.07. The transfer capital threshold is the transfer adjustment factor * $759.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10492.66,31134.92,Inpatient DRG
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7795.07,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7795.07,34198.12,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24308.97,,,,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE,CASE-29898,APC,29898,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Removal Subcutaneous Cardiac Rhythm Monitor|UNUSUAL NON-OVERLAPPING SERVICE,CASE-33286,APC,33286,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7848.94,,"APC Price ($7,848.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7848.94,8241.39,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41669.98,,,,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Metacarpal,CASE-26230,APC,26230,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24429.85,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23950.83,74869.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20343.42,,"Fee schedule rate ($20,343.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Angular Dfrm Toe Soft Tiss Px Only|BILATERAL PROCEDURE|SEPARATE STRUCTURE|PO,CASE-28313,APC,28313,CPT,0360,RC,,,50|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25863.45,,,,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6597.92,,"Case rate ($6,283.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,616.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $445.29. The transfer capital threshold is the transfer adjustment factor * $445.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6293.75,21908.95,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42003.98,,"Fee schedule rate ($42,003.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18043.98,,"Case rate ($17,184.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,388.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.77. The transfer capital threshold is the transfer adjustment factor * $1,217.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",18043.99,18043.99,29434.44,1 through 10,other,17212.14,64440.06,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],41320.17,,"Fee schedule rate ($41,320.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6474.12,19210.66,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],38225.27,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36405.02,110499.61,Inpatient DRG
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11710.82,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11710.82,34749.58,Inpatient DRG
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],57457.72,,"Fee schedule rate ($57,457.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,27370.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13811.29,,,,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7839.48,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7551.60,23262.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22434.01,,"Case rate ($21,365.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,685.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,514.05. The transfer capital threshold is the transfer adjustment factor * $1,514.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21399.79,63499.65,Inpatient DRG
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,APC,52352,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5297.06,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5297.06,19049.64,Inpatient DRG
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24888.65,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23703.48,110204.98,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,APC,58552,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11519.18,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11519.18,34180.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Laparoscopic Procedure Liver,CASE-47379,APC,47379,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,CASE-26125,APC,26125,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],28696.16,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,28696.16,118364.04,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32553.63,,,,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7362.51,,"Case rate ($7,011.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,678.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7011.91,27304.54,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Tenolysis Extensor Foot Single Tendon|LEFT SIDE|PO,CASE-28225,APC,28225,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],9242.00,,"Per diem ($9,242). If length of stay < 7.6, first 1 days paid at a per diem of $18,484 instead. Capped at $70,242.60.",,,,0,other,9242.00,76216.30,Estimated amount calculated based on 6 day length of stay.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5612.74,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5224.00,15861.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit W Pta|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36902,APC,36902,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|LEFT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],69392.91,,,,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
Litholapaxy Comp/Lg > 2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52318,APC,52318,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12883.25,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12883.25,44763.90,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15547.45,,"Fee schedule rate ($15,547.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],113934.44,,"Fee schedule rate ($113,934.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],8990.00,,"Per diem ($8,990). If length of stay < 6, first 1 days paid at a per diem of $17,980 instead. Capped at $53,939.67.",,,,0,other,8990.00,80069.53,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy With Biopsy,CASE-52204,APC,52204,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3313.96,3313.96,3313.96,1 through 10,other,3343.33,3510.50,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25784.85,,"Fee schedule rate ($25,784.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],31872.38,,"Case rate ($30,354.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,322.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,151.04. The transfer capital threshold is the transfer adjustment factor * $2,151.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30403.05,90685.00,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],36370.09,,"Fee schedule rate ($36,370.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10637.22,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10637.22,31563.88,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27528.12,,,,,,0,other,8981.78,27528.12,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],64621.61,,"Fee schedule rate ($64,621.61). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,22802.30,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4697.29,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4538.44,18815.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6240.68,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6240.68,18518.02,Inpatient DRG
Adjnt Tis Trnsfr/Reargmt Any Area 30.1-60 Sq Cm,CASE-14301,APC,14301,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6612.88,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27695,APC,27695,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14104.08,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13827.53,41030.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14518.91,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13827.53,41030.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9793.06,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",2458.05,2458.05,2458.05,1 through 10,other,9793.06,29058.99,Inpatient DRG
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12228.46,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11814.94,44591.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9913.89,,"Case rate ($9,441.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.08. The transfer capital threshold is the transfer adjustment factor * $669.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9456.85,28061.37,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15090.78,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15090.78,44778.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|PO,CASE-12032,APC,12032,CPT,0450,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6311.11,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6010.58,17835.23,Inpatient DRG
Partial Excision Bone Fibula|LEFT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8626.43,,"Case rate ($8,215.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,753.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $582.19. The transfer capital threshold is the transfer adjustment factor * $582.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8228.75,24417.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15196.40,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14472.76,56135.46,Inpatient DRG
"SICKLE CELL ANEMIA CRISIS,MODERATE",662,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10155.54,,"Case rate ($9,671.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9671.94,10155.54,There are no additional notes associated with this service or procedure.
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE|PO,CASE-27570,APC,27570,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],44339.99,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,44339.99,131570.26,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8513.22,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8513.22,25261.33,Inpatient DRG
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],140535.66,,"Fee schedule rate ($140,535.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,36167.61,140535.66,There are no additional notes associated with this service or procedure.
"Arthro, Loose Body + Chondro",CASE-G0289,APC,G0289,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],90878.22,,,,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],25983.55,,"Case rate ($24,746.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,924.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,753.60. The transfer capital threshold is the transfer adjustment factor * $1,753.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9242.00,76216.30,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,10492.66,31134.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12823.44,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12212.80,39290.21,Inpatient DRG
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FIFTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE|PO,CASE-28200,APC,28200,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
HC Tib per Territory Plasty,CASE-37228,APC,37228,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],505.96,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16452.87,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15896.49,51306.05,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16819.95,,"Fee schedule rate ($16,819.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|PO,CASE-64634,APC,64634,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY SAME PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,76|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],24790.92,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,24790.92,26030.46,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31617.34,,"Fee schedule rate ($31,617.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11156.45,42003.98,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5911.44,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5629.94,16705.77,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4319.82,,"Case rate ($4,114.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,462.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $291.54. The transfer capital threshold is the transfer adjustment factor * $291.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4120.67,13066.56,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41030.48,,,,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12263.59,,"Case rate ($11,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.66. The transfer capital threshold is the transfer adjustment factor * $827.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11698.23,34712.20,Inpatient DRG
Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent,CASE-36903,APC,36903,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7096.13,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",33392.75,7111.40,39857.60,1 through 10,other,7096.13,25801.23,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,27370.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],79366.60,,"Fee schedule rate ($79,366.60). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,MAJOR",512,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],32711.35,,"Case rate ($32,711.35). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,32711.35,34346.92,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,APC,43249,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC
"PULMONARY EMBOLISM,MAJOR",134,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],15097.12,,"Case rate ($15,097.12). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15097.12,15851.98,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],55900.95,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,55900.95,225294.39,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],24713.42,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,24713.42,73332.24,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12521.78,,"Fee schedule rate ($12,521.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,APC,31628,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3713.03,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9356.36,,"Case rate ($8,910.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,802.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.45. The transfer capital threshold is the transfer adjustment factor * $631.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8925.03,26628.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42003.98,,"Fee schedule rate ($42,003.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],42671.03,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,40639.08,120588.53,Inpatient DRG
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10536.15,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10034.43,29775.24,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17620.75,,,,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4326.70,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4120.67,13066.56,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],86162.15,,"Fee schedule rate ($86,162.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16406.86,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15852.04,50518.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28766.85,,"Fee schedule rate ($28,766.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,APC,58661,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5416.39,5416.39,5416.39,1 through 10,other,5733.99,6020.69,OPPS APC
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19312.24,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8972.00,76376.03,Inpatient DRG
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],185834.07,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,185834.07,195125.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27484.83,,,,,,0,other,1188.00,27484.83,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11156.55,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10625.29,39295.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11714.14,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11714.14,49460.19,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],20277.85,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8972.00,76376.03,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11084.14,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10556.32,32082.48,Inpatient DRG
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE|PO,CASE-28200,APC,28200,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],37160.23,,"Fee schedule rate ($37,160.23). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|BILATERAL PROCEDURE,CASE-52354,APC,52354,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MODERATE",385,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8533.78,,"Case rate ($8,127.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8127.41,8533.78,There are no additional notes associated with this service or procedure.
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE|PO,CASE-27427,APC,27427,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteoplasty Radius/Ulna Shortening,CASE-25390,APC,25390,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple,CASE-43239,APC,43239,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],903.26,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",913.91,456.96,913.91,1 through 10,other,860.25,903.26,OPPS APC
Removal Implant Deep|RIGHT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],24347.37,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10455.00,90889.11,Inpatient DRG
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,APC,45385,CPT,0360,RC,,,PT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Unlisted Procedure, Nervous System|UNUSUAL NON-OVERLAPPING SERVICE",CASE-64999,APC,64999,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34397.36,,,,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",6864.07,6864.07,6864.07,1 through 10,other,6882.29,7226.40,OPPS APC
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MODERATE",191,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14755.89,,"Case rate ($14,755.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14755.89,15493.68,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29049.23,,"Fee schedule rate ($29,049.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5783.33,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5507.93,20510.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13692.87,,"Case rate ($13,040.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,095.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $924.12. The transfer capital threshold is the transfer adjustment factor * $924.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13692.87,13692.87,13692.87,1 through 10,other,5970.00,38757.79,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29382.86,,"Fee schedule rate ($29,382.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16831.01,,"Fee schedule rate ($16,831.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8005.26,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8005.26,24549.95,Inpatient DRG
Fth/Gft Free W/Direct Closure S/a/L 20 Cm/<,CASE-15220,APC,15220,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6297.98,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38222.57,,,,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13230.71,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13230.71,39259.55,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],41439.32,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,23679.61,84629.16,All Other Inpatient
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20179.92,,"Fee schedule rate ($20,179.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,1188.00,20179.92,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],43128.05,,,,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,MODERATE",174,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],34261.33,,"Case rate ($32,629.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32629.84,34261.33,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19433.97,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18508.54,76171.92,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39854.32,,"Fee schedule rate ($39,854.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, SECOND DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Destruction Vaginal Lesions Simple,CASE-57061,APC,57061,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7096.13,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7096.13,7096.13,7113.36,15,other,7096.13,25801.23,Inpatient DRG
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|PO,CASE-26160,APC,26160,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1525.13,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],57305.33,,,,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9852.40,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5629.94,16705.77,All Other Inpatient
Tenotomy Open Extensor Foot/Toe Each Tendon,CASE-28234,APC,28234,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8588.20,,"Case rate ($8,179.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.61. The transfer capital threshold is the transfer adjustment factor * $579.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8192.28,24308.97,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5003.18,,"Case rate ($4,764.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,508.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.66. The transfer capital threshold is the transfer adjustment factor * $337.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4772.53,14161.54,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],187121.90,,"Fee schedule rate ($187,121.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",196861.98,196861.98,196861.98,1 through 10,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20426.70,,"Fee schedule rate ($20,426.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4060.38,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3980.76,11812.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,30966.53,Estimated amount calculated based on 11 day length of stay.
Arven Anast Opn Upr Arm Basilic Vein Trpos|LEFT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
Lengthening Tendon Extensor Hand/Finger Each,CASE-26476,APC,26476,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],36224.65,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36224.65,128473.68,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6785.78,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6785.78,20135.47,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28299,APC,28299,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18085.13,,,,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],77530.52,,"Fee schedule rate ($77,530.52). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],62824.73,,,,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],3686.99,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3209.85,10940.41,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5450.78,,"Case rate ($5,450.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $5,062.05, add-ons for qualifying new technology services are included. If operating cost exceeds $42,251.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,051.56. The transfer operating threshold is the transfer adjustment factor * $5,062.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.22. The transfer capital threshold is the transfer adjustment factor * $399.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5590.17,5590.17,5590.17,1 through 10,other,5450.78,16705.77,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7455.00,,"Per diem ($7,455). If length of stay < 6.8, first 1 days paid at a per diem of $14,910 instead. Capped at $50,692.24.",,,,0,other,7455.00,53076.74,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13090.35,,"Fee schedule rate ($13,090.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],31074.42,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,29594.69,124146.55,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],25667.66,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,25667.66,86123.60,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12167.07,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12167.07,36103.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],39694.61,,"Case rate ($38,916.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,957.67, add-ons for qualifying new technology services are included. If operating cost exceeds $71,425.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,986.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $36,100.97. The transfer operating threshold is the transfer adjustment factor * $35,957.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,815.30. The transfer capital threshold is the transfer adjustment factor * $2,815.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,38916.28,133824.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,CASE-55866,APC,55866,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE,CASE-29898,APC,29898,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5094.80,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5094.80,15365.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,APC,43246,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
HC Removal Subcutaneous Cardiac Rhythm Monitor|UNUSUAL NON-OVERLAPPING SERVICE,CASE-33286,APC,33286,CPT,0361,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8123.65,,"APC Price ($7,848.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7848.94,8241.39,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21913.36,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,12500.00,83592.64,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6770.53,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6770.53,20090.22,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4511.69,,"Case rate ($4,296.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,475.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $304.49. The transfer capital threshold is the transfer adjustment factor * $304.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4303.70,14124.38,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Supracrv Hysterec >250 G Rmvl Tube/Ovary,CASE-58544,APC,58544,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7244.14,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7102.10,21074.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14056.07,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9763.00,48626.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FIFTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr,CASE-27524,APC,27524,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3843.64,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17490.00,,"Per diem ($17,490). If length of stay < 1.2, first 1 days paid at a per diem of $34,980 instead. Capped at $20,988.02.",,,,0,other,7405.81,33747.30,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6105.10,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5985.39,17760.46,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32474.30,,"Fee schedule rate ($32,474.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MODERATE",422,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2545.29,,"Case rate for a one day stay ($2,424.09). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2424.09,2545.29,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
Repair Dislocating Peroneal Tendon W/Fib Osteot,CASE-27676,APC,27676,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],48125.72,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,45834.02,151120.97,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,APC,31628,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3536.22,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4743.76,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4517.87,13932.70,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6795.74,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6472.13,19204.75,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20301.31,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11600.75,34422.94,All Other Inpatient
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9255.92,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,27465.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28569.12,,"Fee schedule rate ($28,569.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5217.26,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4968.82,19848.33,Inpatient DRG
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE,CASE-28238,APC,28238,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39967.07,,"Fee schedule rate ($39,967.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21302.88,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20885.18,80720.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Ganglion Wrist Dorsal/Volar Primary|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6699.57,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6699.57,24060.08,Inpatient DRG
Gastrocnemius Recession|LEFT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4765.36,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4538.44,18815.35,Inpatient DRG
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|LEFT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE|PO,CASE-29875,APC,29875,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7359.83,,"Case rate ($7,009.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7020.54,28431.58,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12124.13,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11714.14,49460.19,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18559.00,,"Per diem ($18,559). If length of stay < 5.4, first 1 days paid at a per diem of $37,118 instead. Capped at $100,219.31.",,,,0,other,18559.00,141041.50,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],39168.53,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,37843.99,139522.22,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],11139.15,,,,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13890.29,,"Case rate ($13,228.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,108.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $937.44. The transfer capital threshold is the transfer adjustment factor * $937.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13669.79,13669.79,27339.58,1 through 10,other,13249.94,40085.35,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],112149.06,,,,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE|PO,CASE-28120,APC,28120,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THIRD DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14534.54,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,14043.03,54637.47,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34934.31,,"Fee schedule rate ($34,934.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19655.30,,"Fee schedule rate ($19,655.30). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5348.00,,"Per diem ($5,348). If length of stay < 2.7, first 1 days paid at a per diem of $10,696 instead. Capped at $14,438.66.",,,,0,other,5094.80,15365.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25741.45,,,,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],20094.74,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19137.85,64589.15,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12881.26,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12806.51,6730.17,22357.44,31,other,12881.26,38222.57,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE|PO,CASE-24073,APC,24073,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],23942.42,,"Case rate ($22,802.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,068.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,536.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,820.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $21,152.71. The transfer operating threshold is the transfer adjustment factor * $21,068.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,649.58. The transfer capital threshold is the transfer adjustment factor * $1,649.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22802.30,82749.58,Inpatient DRG
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21198.45,,"Fee schedule rate ($21,198.45). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FOURTH DIGIT|PO",CASE-26951,APC,26951,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],90287.21,,"Fee schedule rate ($90,287.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20.9), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, FIFTH DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,APC,11606,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],40546.43,,,,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],60241.14,,,,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6178.00,,"Per diem ($6,178). If length of stay < 3.9, first 1 days paid at a per diem of $12,356 instead. Capped at $24,092.63.",,,,0,other,6178.00,25225.91,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|LEFT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",679.50,679.50,679.50,1 through 10,other,669.51,702.98,OPPS APC
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,21229.52,There are no additional notes associated with this service or procedure.
HC Pbb Carpal Tunnel Inj Pmc|LEFT SIDE|PO,CASE-20526,APC,20526,CPT,0510,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1916.92,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14262.78,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9763.00,48626.00,Inpatient DRG
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,EXTREME",710,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],61894.94,,"Case rate ($58,947.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $48,300, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,58947.56,61894.94,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],41837.14,,"Fee schedule rate ($41,837.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,There are no additional notes associated with this service or procedure.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt,CASE-28291,APC,28291,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8906.59,,"Case rate ($8,605.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,951.18, add-ons for qualifying new technology services are included. If operating cost exceeds $43,419.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,982.86. The transfer operating threshold is the transfer adjustment factor * $7,951.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $622.54. The transfer capital threshold is the transfer adjustment factor * $622.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8605.40,42305.71,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],41225.50,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,39831.40,138208.82,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12093.45,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12093.45,35884.94,Inpatient DRG
Open Treatment Fracture Distal Tibia & Fibula,CASE-27828,APC,27828,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm|PO,CASE-11404,APC,11404,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1621.31,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],45128.69,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,43602.60,163229.10,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13409.25,,"Case rate ($12,770.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $904.98. The transfer capital threshold is the transfer adjustment factor * $904.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",13409.25,12899.46,89011.56,1 through 10,other,12791.07,43031.63,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|PO,CASE-64634,APC,64634,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE|SEPARATE STRUCTURE,CASE-27405,APC,27405,CPT,0360,RC,,,LT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
HC Tib per Territory Ather,CASE-37229,APC,37229,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],648.48,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12560.26,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11962.15,40923.09,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5034.82,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4795.07,19830.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16009.89,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16009.89,58554.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Vaginal Cyst/Tumor,CASE-57135,APC,57135,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE|PO,CASE-25608,APC,25608,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt|LEFT SIDE|PO,CASE-27602,APC,27602,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19905.14,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",18974.37,18974.37,18974.37,1 through 10,other,19232.02,68941.12,Inpatient DRG
"Partical Excision Bone Phalanx Toe|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,XS|T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
HC Lyr Clos Nk Hnd Ft <2.6cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-12041,APC,12041,CPT,0450,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9070.48,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8442.00,28788.33,Inpatient DRG
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8953.11,,"Case rate ($8,526.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,902.12, add-ons for qualifying new technology services are included. If operating cost exceeds $48,447.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,268.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $7,906.03. The transfer operating threshold is the transfer adjustment factor * $7,902.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.75. The transfer capital threshold is the transfer adjustment factor * $620.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,25698.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7763.72,,"Case rate ($7,394.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,695.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.97. The transfer capital threshold is the transfer adjustment factor * $523.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7405.81,33747.30,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5942.35,,"Case rate ($5,659.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,572.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.04. The transfer capital threshold is the transfer adjustment factor * $401.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5668.40,16903.82,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6814.63,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6681.01,19824.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,25698.16,There are no additional notes associated with this service or procedure.
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3784.78,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30846.83,,"Fee schedule rate ($30,846.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
Rhinoplasty Primary W/Major Septal Repair|PO,CASE-30420,APC,30420,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4803.66,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4574.91,13575.16,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4173.14,,"Case rate ($3,974.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,452.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $281.64. The transfer capital threshold is the transfer adjustment factor * $281.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3980.76,11812.10,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14807.87,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14102.73,41847.08,Inpatient DRG
Partial Excision Bone Talus/Calcaneus|LEFT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],75020.49,,"Fee schedule rate ($75,020.49). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],35466.15,,"Fee schedule rate ($35,466.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",15956.10,15956.10,15956.10,1 through 10,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26291.41,,"Fee schedule rate ($26,291.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,8981.78,27528.12,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4962.90,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",4962.91,4962.91,4962.91,1 through 10,other,4795.07,19830.58,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20906.62,,"Fee schedule rate ($20,906.62). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12721.71,,"Case rate ($12,115.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,029.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.57. The transfer capital threshold is the transfer adjustment factor * $858.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12135.23,49469.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17127.24,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17127.24,50821.76,Inpatient DRG
Laparoscopy Proctopexy Prolapse,CASE-45400,APC,45400,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,APC,58550,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride Subq First 20 Sq Cm,CASE-11042,APC,11042,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",370.91,370.91,376.23,14,other,385.57,404.84,OPPS APC
HC Intrvasc US Noncoronary 1st,CASE-37252,APC,37252,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],538.93,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
HC Debride Subq First 20 Sq Cm,CASE-11042,APC,11042,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-27680,APC,27680,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10177.68,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9833.51,45903.36,Inpatient DRG
Arthrodesis Midtarsometatarsal Single Joint|RIGHT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12490.63,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11895.84,35298.57,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4389.36,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4180.34,14351.57,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5427.58,,"Case rate ($5,244.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,859.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,405.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,029.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,862.27. The transfer operating threshold is the transfer adjustment factor * $4,859.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $381.77. The transfer capital threshold is the transfer adjustment factor * $381.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5244.04,15804.57,Inpatient DRG
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,APC,58661,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13927.77,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13264.54,50759.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
Laps Surg Esopg/Gstr Fundoplasty,CASE-43280,APC,43280,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14041.04,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14041.04,60059.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MAJOR",422,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2179.36,,"Case rate for a one day stay ($2,179.36). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2179.36,2288.33,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6088.84,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6024.52,2420.70,6088.84,17,other,6088.84,18067.42,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6387.91,18954.85,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18617.45,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10638.54,40729.62,All Other Inpatient
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28832.22,,"Fee schedule rate ($28,832.22). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9762.34,,"Case rate ($9,297.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,604.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,072.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,638.62. The transfer operating threshold is the transfer adjustment factor * $8,604.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.85. The transfer capital threshold is the transfer adjustment factor * $658.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",9762.35,9625.17,45132.55,14,other,9312.29,27632.41,Inpatient DRG
"Partical Excision Bone Phalanx Toe|LEFT FOOT, SECOND DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12560.26,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11962.15,40923.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11356.39,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9888.00,40658.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14659.16,,"Case rate ($13,961.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,160.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.33. The transfer capital threshold is the transfer adjustment factor * $989.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7770.00,50313.90,Inpatient DRG
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],65538.71,,"Fee schedule rate ($65,538.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13572.00,,"Per diem ($13,572). If length of stay < 5.8, first 1 days paid at a per diem of $27,144 instead. Capped at $78,720.12.",,,,0,other,13572.00,108637.77,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,21325.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms,CASE-27696,APC,27696,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],52471.79,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",42063.04,42063.04,42063.04,1 through 10,other,13061.00,162464.13,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17934.16,,"Fee schedule rate ($17,934.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.1), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10556.32,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10556.32,32082.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11152.68,,"Case rate ($10,621.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.68. The transfer capital threshold is the transfer adjustment factor * $752.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10638.54,40729.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE|PO,CASE-24342,APC,24342,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MODERATE",045,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13541.20,,"Case rate ($12,896.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12896.38,13541.20,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],64621.61,,"Fee schedule rate ($64,621.61). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24722.51,,"Case rate ($23,545.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,789.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,257.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,839.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,876.75. The transfer operating threshold is the transfer adjustment factor * $21,789.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,668.50. The transfer capital threshold is the transfer adjustment factor * $1,668.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",23564.51,23564.51,23564.51,1 through 10,other,23582.79,75543.62,Inpatient DRG
Laps Surg Esopg/Gstr Fundoplasty,CASE-43280,APC,43280,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE|PO,CASE-24073,APC,24073,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],54085.91,,"Fee schedule rate ($54,085.91). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19103.41,,"Case rate ($18,193.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,460.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.27. The transfer capital threshold is the transfer adjustment factor * $1,289.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",17947.04,17947.04,17947.04,1 through 10,other,18222.73,59942.55,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],88173.00,,"Fee schedule rate ($88,173.00). Adds an outlier to normal pricing equal to the per diem rate ($170,052.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5816.55,,"Case rate ($5,539.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,040.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $392.79. The transfer capital threshold is the transfer adjustment factor * $392.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5549.19,16729.39,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17934.16,,"Fee schedule rate ($17,934.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.1), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8394.53,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8394.53,24909.11,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11929.65,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5520.00,26638.96,All Other Inpatient
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,APC,57425,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],163229.10,,"Fee schedule rate ($163,229.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28157.55,,"Fee schedule rate ($28,157.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24533.10,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23703.48,110204.98,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],45711.64,,,,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Fibula Nonunion/Malunion W/Int Fixation,CASE-27726,APC,27726,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14737.18,,"Case rate ($14,448.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,349.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,817.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,216.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,402.99. The transfer operating threshold is the transfer adjustment factor * $13,349.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,045.22. The transfer capital threshold is the transfer adjustment factor * $1,045.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6940.00,42872.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Syndactylization Toes|RIGHT SIDE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc,CASE-34421,APC,34421,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6381.43,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6077.55,18033.97,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9495.32,,"Case rate ($9,495.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,773.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,858.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $8,808.40. The transfer operating threshold is the transfer adjustment factor * $8,773.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.92. The transfer capital threshold is the transfer adjustment factor * $686.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9495.32,42131.77,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7056.33,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6972.36,6971.42,6972.36,1 through 10,other,7056.33,28335.74,Inpatient DRG
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB|PO",CASE-26418,APC,26418,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15953.57,,"Case rate ($15,193.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,247.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,076.69. The transfer capital threshold is the transfer adjustment factor * $1,076.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15218.11,45156.75,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10257.31,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9910.44,43344.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10637.22,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10637.22,31563.88,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14742.58,,"Case rate ($14,040.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,166.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.96. The transfer capital threshold is the transfer adjustment factor * $994.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14062.94,61706.77,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|RIGHT SIDE|PO,CASE-27675,APC,27675,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12948.38,,"Fee schedule rate ($12,948.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20113.98,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,17274.00,73717.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6057.75,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5938.97,17858.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34889.29,,,,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8679.02,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8679.02,29908.27,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Claviculectomy Partial|LEFT SIDE|PO,CASE-23120,APC,23120,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64418,APC,64418,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],37255.80,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,21289.03,76326.34,All Other Inpatient
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13409.25,,"Case rate ($12,770.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $904.98. The transfer capital threshold is the transfer adjustment factor * $904.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12791.07,43031.63,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8825.21,,"Case rate ($8,526.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,902.12, add-ons for qualifying new technology services are included. If operating cost exceeds $48,447.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,268.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $7,906.03. The transfer operating threshold is the transfer adjustment factor * $7,902.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.75. The transfer capital threshold is the transfer adjustment factor * $620.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,25698.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7759.92,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7759.92,35376.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15896.49,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15429.79,15427.71,15429.79,1 through 10,other,15896.49,51306.05,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15896.49,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15427.71,15427.71,15427.71,1 through 10,other,15896.49,51306.05,Inpatient DRG
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4325.32,,"Case rate ($4,119.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,806.17, add-ons for qualifying new technology services are included. If operating cost exceeds $39,274.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,821.34. The transfer operating threshold is the transfer adjustment factor * $3,806.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.00. The transfer capital threshold is the transfer adjustment factor * $298.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4119.35,12223.35,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28108.97,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,16062.27,48077.57,All Other Inpatient
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6010.58,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6010.58,17835.23,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],33422.93,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,33422.93,112824.68,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],67460.63,,,,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34517.10,,"Fee schedule rate ($34,517.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10249.79,,"Fee schedule rate ($10,249.79). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
Unlisted Procedure Femur/Knee|RIGHT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],245.65,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,233.96,245.65,OPPS APC
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10334.84,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10334.84,30666.60,Inpatient DRG
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7665.01,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7405.81,33747.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18508.54,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18508.54,76171.92,Inpatient DRG
Manipulation Knee Joint Under General Anesthesia,CASE-27570,APC,27570,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],187121.90,,"Fee schedule rate ($187,121.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],40278.35,,"Case rate ($38,916.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,957.67, add-ons for qualifying new technology services are included. If operating cost exceeds $71,425.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,986.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $36,100.97. The transfer operating threshold is the transfer adjustment factor * $35,957.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,815.30. The transfer capital threshold is the transfer adjustment factor * $2,815.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,38916.28,133824.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12183.16,,"Case rate ($11,603.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,470.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $822.73. The transfer capital threshold is the transfer adjustment factor * $822.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",11623.17,11623.17,11623.17,1 through 10,other,1188.00,35040.80,Inpatient DRG
Tnot Elbow Lateral/Medial Debride Open,CASE-24358,APC,24358,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Open/Perq Place Stent Ea Add A,CASE-37237,APC,37237,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13715.15,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13446.23,39899.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Hrhc 2/> Col/Grp W/Fstulectmy Incl Fssrectmy,CASE-46262,APC,46262,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Esopg/Gstr Fundoplasty,CASE-43280,APC,43280,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15852.04,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15852.04,50518.01,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11348.73,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10808.31,46938.11,Inpatient DRG
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],130347.93,,"Fee schedule rate ($130,347.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30254.51,130347.93,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21991.57,,"Fee schedule rate ($21,991.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11674.21,,"Fee schedule rate ($11,674.21). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4119.35,12223.35,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,APC,45381,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],140535.66,,"Fee schedule rate ($140,535.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,36167.61,140535.66,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5886.58,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",830.81,830.81,830.81,1 through 10,other,5886.58,17467.27,Inpatient DRG
Sigmoidoscopy Flx Placement of Endoscopic Stent,CASE-45347,APC,45347,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MAJOR",710,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],37118.36,,"Case rate ($37,118.36). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,37118.36,38974.28,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11600.75,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11600.75,34422.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17161.77,,"Fee schedule rate ($17,161.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5985.95,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5700.90,30872.02,Inpatient DRG
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],34726.43,,"Case rate ($33,072.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,563.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,392.57. The transfer capital threshold is the transfer adjustment factor * $2,392.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,33072.79,98455.37,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3313.96,3313.96,3313.96,1 through 10,other,3343.33,3510.50,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
"HC Debrid,Subq Ea Addt'l 20sqcm",CASE-11045,APC,11045,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30658.90,,"Fee schedule rate ($30,658.90). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15261.14,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14534.42,59012.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|BILATERAL PROCEDURE,CASE-38570,APC,38570,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8005.26,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8005.26,24549.95,Inpatient DRG
"MALFUNCTION REACTION COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE,MAJOR",466,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14418.80,,"Case rate ($13,732.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13732.19,14418.80,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvic/Le 1st Ord,CASE-36245,APC,36245,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,46419.05,Estimated amount calculated based on 12 day length of stay.
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3713.03,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3536.22,3713.03,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],45214.92,,"Fee schedule rate ($45,214.92). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8915.73,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8915.73,26455.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Local Lesion Epididymis|RIGHT SIDE,CASE-54830,APC,54830,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],32614.59,,"Fee schedule rate ($32,614.59). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6601.57,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6472.13,19204.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9754.91,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9425.03,27966.92,Inpatient DRG
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22091.17,,"Fee schedule rate ($22,091.17). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11368.22,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10826.88,32126.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Metatarsophalangeal Joint Dislocation,CASE-28645,APC,28645,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE,CASE-29891,APC,29891,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12632.63,,,,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],44803.76,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,42670.25,133443.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],44924.67,,"Fee schedule rate ($44,924.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Complex Trunk 1.1-2.5 Cm,CASE-13100,APC,13100,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1621.31,1621.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12108.97,,"Case rate ($11,871.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,001.85, add-ons for qualifying new technology services are included. If operating cost exceeds $51,547.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,512.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,007.29. The transfer operating threshold is the transfer adjustment factor * $11,001.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.25. The transfer capital threshold is the transfer adjustment factor * $864.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11871.54,35778.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MAJOR",422,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2288.33,,"Case rate for a one day stay ($2,179.36). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2179.36,2288.33,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],40639.08,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",40639.10,40639.10,40639.10,1 through 10,other,40639.08,120588.53,Inpatient DRG
Sesamoidectomy First Toe Spx|BILATERAL PROCEDURE|PO,CASE-28315,APC,28315,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29775.24,,,,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],27777.08,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13572.00,108637.77,Inpatient DRG
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28285,APC,28285,CPT,0360,RC,,,T9|PO|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],41837.14,,"Fee schedule rate ($41,837.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],67008.32,,"Fee schedule rate ($67,008.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],48938.54,,"Case rate ($47,283.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,591.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,420.62. The transfer capital threshold is the transfer adjustment factor * $3,420.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,47283.61,169615.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5578.22,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5578.22,18148.00,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8049.03,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",7822.26,7822.26,7822.26,1 through 10,other,7891.21,23415.63,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11117.14,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10899.16,39746.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Plasty|RIGHT SIDE,CASE-37228,APC,37228,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],513.29,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
Trurl Dstrj Prstate Tiss Rf Thermoth,CASE-53852,APC,53852,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6690.16,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6558.98,19462.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],36249.82,,"Fee schedule rate ($36,249.82). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
Removal Implant Deep|SEPARATE STRUCTURE,CASE-20680,APC,20680,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],45128.69,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,43602.60,153667.90,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4793.22,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4564.97,13545.65,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",10321.99,10321.99,10321.99,1 through 10,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
"Amp Mtcrpl W/Finger/Thumb W/WO Inteross Transfer|RIGHT HAND, FIFTH DIGIT|PO",CASE-26910,APC,26910,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13632.44,,"Fee schedule rate ($13,632.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4734.64,14273.70,Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],57457.72,,"Fee schedule rate ($57,457.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16378.73,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15824.86,49371.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11138.80,,"Case rate ($10,608.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.75. The transfer capital threshold is the transfer adjustment factor * $751.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",11138.80,11138.80,11138.80,1 through 10,other,10625.29,39295.53,Inpatient DRG
HC N Block Inj Intercost Sng|RIGHT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],190.30,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
"Tendon Sheath Incision|LEFT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, SECOND DIGIT|SEPARATE STRUCTURE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T6|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],126615.59,,,,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],27060.29,,"Fee schedule rate ($27,060.29). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],43434.38,,"Fee schedule rate ($43,434.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],67348.11,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,66027.56,228732.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Arteriovenous Anastomosis Open Direct|LEFT SIDE,CASE-36821,APC,36821,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],27740.63,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,26419.65,96304.23,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|RIGHT SIDE|PO,CASE-27675,APC,27675,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],22152.42,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9370.00,65732.99,Inpatient DRG
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6503.29,19528.85,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12225.74,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,11986.02,54149.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20110.39,,"Fee schedule rate ($20,110.39). Adds an outlier to normal pricing equal to the per diem rate ($69,590.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7096.13,25801.23,Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],187121.90,,"Fee schedule rate ($187,121.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-24341,APC,24341,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7543.08,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7543.08,29489.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29008.87,,"Fee schedule rate ($29,008.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26270.73,,"Fee schedule rate ($26,270.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4681.50,,"Case rate ($4,523.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,179.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,647.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,498.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,195.97. The transfer operating threshold is the transfer adjustment factor * $4,179.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $327.22. The transfer capital threshold is the transfer adjustment factor * $327.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4523.19,16536.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10145.17,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,30103.84,Inpatient DRG
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],25070.79,,"Case rate ($23,876.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,863.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,692.00. The transfer capital threshold is the transfer adjustment factor * $1,692.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",25070.80,25070.80,25070.80,1 through 10,other,23915.01,121205.60,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, SECOND DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|PO,CASE-64494,APC,64494,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31790.24,,"Fee schedule rate ($31,790.24). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",39926.17,39926.17,39926.17,1 through 10,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FIFTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|BILATERAL PROCEDURE,CASE-49507,APC,49507,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6045.95,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5758.05,6045.95,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,MINOR",951,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],3805.19,,"Case rate for a one day stay ($3,805.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3805.19,3995.45,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17467.27,,,,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],47169.70,,,,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],115401.67,,,,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
HC Cath Urethral Simple,CASE-51702,APC,51702,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],45.97,,"APC Price ($44.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,44.41,46.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],8558.00,,"Per diem ($8,558). If length of stay < 5.4, first 1 days paid at a per diem of $17,116 instead. Capped at $46,215.75.",,,,0,other,8558.00,48389.68,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36780.25,,,,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7011.91,,"Case rate ($7,011.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,678.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7011.91,27304.54,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7712.73,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6308.00,21796.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn|PO,CASE-62321,APC,62321,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6311.11,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6010.58,17835.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],23895.30,,"Fee schedule rate ($23,895.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5625.00,,"Per diem ($5,625). If length of stay < 2.6, first 1 days paid at a per diem of $11,250 instead. Capped at $14,624.71.",,,,0,other,5160.45,15312.64,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15914.26,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15156.44,52672.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"RENAL DIALYSIS ACCESS DEVICE PROCEDURES,EXTREME",444,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],49522.92,,"Case rate ($49,522.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,49522.92,51999.07,There are no additional notes associated with this service or procedure.
Arthrodesis Iphal Jt W/WO Int Fixj Ea Iphal Jt,CASE-26861,APC,26861,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15845.32,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15090.78,44778.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],107489.55,,,,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5564.87,,"Case rate ($5,299.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.57. The transfer capital threshold is the transfer adjustment factor * $375.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5308.33,19857.20,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
"OTHER PNEUMONIA,MINOR",139,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2513.46,,"Case rate for a one day stay ($2,393.77). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2393.77,2513.46,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,APC,44970,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Litholapaxy Smpl/Sm <2.5 Cm|SEPARATE STRUCTURE,CASE-52317,APC,52317,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14041.04,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14041.04,60059.69,Inpatient DRG
Rhinoplasty Primary W/Major Septal Repair|PO,CASE-30420,APC,30420,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23385.84,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",22630.49,22630.49,22630.49,1 through 10,other,23385.84,71764.93,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7371.57,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7020.54,28431.58,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12180.79,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11600.75,34422.94,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY VASCULAR PROCEDURES,EXTREME",181,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],65353.13,,"Case rate ($62,241.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $46,166, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,62241.08,65353.13,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12707.80,,"Case rate ($12,102.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,200.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,668.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,028.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,245.03. The transfer operating threshold is the transfer adjustment factor * $11,200.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $857.64. The transfer capital threshold is the transfer adjustment factor * $857.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12121.97,35969.56,Inpatient DRG
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|RIGHT SIDE|PO,CASE-29883,APC,29883,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bx Anorectal Wall Anal Approach,CASE-45100,APC,45100,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4639.34,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4418.42,13110.79,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],46638.59,,"Fee schedule rate ($46,638.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|LEFT SIDE|PO,CASE-28306,APC,28306,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],40320.14,,,,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20179.92,,"Fee schedule rate ($20,179.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,1188.00,20179.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|LEFT SIDE,CASE-29825,APC,29825,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4060.38,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3980.76,11812.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy Limited Spx,CASE-29875,APC,29875,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5217.26,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4968.82,19848.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Laparoscopic Procedure Liver,CASE-47379,APC,47379,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39316.61,,,,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12768.28,,"Case rate ($12,160.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.72. The transfer capital threshold is the transfer adjustment factor * $861.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12179.66,36140.75,Inpatient DRG
Sesamoidectomy First Toe Spx|BILATERAL PROCEDURE|PO,CASE-28315,APC,28315,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
Wmhc Perc Implant Stim Lead Ea|PO,CASE-63650,APC,63650,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6044.58,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6044.58,6346.81,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5567.57,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5520.57,5520.57,5520.57,1 through 10,other,5379.29,15961.98,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18954.85,,,,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
"NEPHRITIS AND NEPHROSIS,MAJOR",462,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],18062.67,,"Case rate ($17,202.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17202.54,18062.67,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],25949.09,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24713.42,73332.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28899.79,,"Fee schedule rate ($28,899.79). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
Rhinoplasty Primary W/Major Septal Repair|PO,CASE-30420,APC,30420,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms,CASE-27696,APC,27696,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|RIGHT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20797.35,,"Fee schedule rate ($20,797.35). Adds an outlier to normal pricing equal to the per diem rate ($7,074.03) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10888.24,32825.17,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10614.84,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10109.37,38416.97,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10804.92,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10290.40,42115.80,Inpatient DRG
HC Tib per Territory Ather|LEFT SIDE,CASE-37229,APC,37229,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],626.55,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MODERATE",220,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],27964.48,,"Case rate ($27,964.48). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,27964.48,29362.70,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],89465.42,,,,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE|PO,CASE-64450,APC,64450,CPT,0450,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20062.75,,"Case rate ($19,107.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,525.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.01. The transfer capital threshold is the transfer adjustment factor * $1,354.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19137.85,64589.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"INFLAMMATORY BOWEL DISEASE,MODERATE",245,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10393.43,,"Case rate ($9,898.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9898.50,10393.43,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],61860.92,,"Fee schedule rate ($61,860.92). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21828.16,93157.39,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34397.36,,,,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt,CASE-26531,APC,26531,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11017.29,,"Case rate ($10,492.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,694.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,162.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,930.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,733.59. The transfer operating threshold is the transfer adjustment factor * $9,694.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.07. The transfer capital threshold is the transfer adjustment factor * $759.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10492.66,31134.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12536.42,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",12536.43,12536.43,12536.43,1 through 10,other,12536.42,46998.45,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12457.06,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12212.80,39290.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT SIDE|PO,CASE-26356,APC,26356,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8355.41,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4774.52,14406.59,All Other Inpatient
Dcmprn Fasct Leg Post Compartment Only,CASE-27601,APC,27601,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12384.51,,"Fee schedule rate ($12,384.51). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12577.67,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11978.73,60588.60,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5389.29,,"Case rate ($5,389.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,996, add-ons for qualifying new technology services are included. If operating cost exceeds $45,541.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,038.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,998.47. The transfer operating threshold is the transfer adjustment factor * $4,996.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.82. The transfer capital threshold is the transfer adjustment factor * $390.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5389.29,16247.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],134001.61,,"Fee schedule rate ($134,001.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE|PO,CASE-29898,APC,29898,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31350.48,,"Fee schedule rate ($31,350.48). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10888.24,32825.17,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38610.21,,,,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20986.65,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7826.00,90280.33,Inpatient DRG
Fth/Gft Fr W/Dir Clsr S/a/L Ea Addl 20 Cm/<,CASE-15221,APC,15221,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],85446.13,,"Fee schedule rate ($85,446.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19300.28,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18381.22,58579.45,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],72742.07,,"Fee schedule rate ($72,742.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE|PO,CASE-29888,APC,29888,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14719.62,,"Case rate ($14,018.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,164.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.41. The transfer capital threshold is the transfer adjustment factor * $993.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14041.04,60059.69,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9231.24,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8919.07,34453.70,Inpatient DRG
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MAJOR",192,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],25800.08,,"Case rate ($24,571.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24571.50,25800.08,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE|PO,CASE-23515,APC,23515,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DIABETES,MINOR",420,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6484.80,,"Case rate ($6,484.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6484.80,6809.04,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MODERATE",140,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8831.98,,"Case rate ($8,831.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8831.98,9273.58,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24977.98,,,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],37954.97,,,,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15382.83,,"Case rate ($14,650.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,209.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,038.17. The transfer capital threshold is the transfer adjustment factor * $1,038.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14673.67,43541.27,Inpatient DRG
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE|PO,CASE-28306,APC,28306,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],86162.15,,"Fee schedule rate ($86,162.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],38122.35,,"Fee schedule rate ($38,122.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6881.36,,"Case rate ($6,553.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $6,086.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,276.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,494.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,073.77. The transfer operating threshold is the transfer adjustment factor * $6,086.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.91. The transfer capital threshold is the transfer adjustment factor * $479.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6553.68,20086.28,Inpatient DRG
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>|RIGHT SIDE|PO,CASE-25071,APC,25071,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11251.73,,"Fee schedule rate ($11,251.73). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,48444.74,Estimated amount calculated based on 11 day length of stay.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",46719.82,46719.82,46719.82,1 through 10,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn,CASE-64448,APC,64448,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, SECOND DIGIT|SEPARATE STRUCTURE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T6|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciectomy Plantar Fascia Partial Spx|RIGHT SIDE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn,CASE-64415,APC,64415,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Iliac Territory Plasty Stent|RIGHT SIDE,CASE-37221,APC,37221,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],444.96,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22488.22,,"Case rate ($21,417.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,688.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,517.71. The transfer capital threshold is the transfer adjustment factor * $1,517.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8940.00,63653.13,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],26419.65,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",52839.32,52839.32,52839.32,1 through 10,other,26419.65,96304.23,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18222.73,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,18222.73,59942.55,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6399.53,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6094.79,22352.66,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16929.63,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,16929.63,63934.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],43128.06,,"Fee schedule rate ($43,128.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9987.59,,"Case rate ($9,511.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,845.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.05. The transfer capital threshold is the transfer adjustment factor * $674.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",9963.14,9963.14,9963.14,1 through 10,other,9527.16,28269.95,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15979.02,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15218.11,45156.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35640.95,,,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11202.49,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,31658.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19952.48,,,,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13435.65,,"Fee schedule rate ($13,435.65). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5625.00,,"Per diem ($5,625). If length of stay < 2.6, first 1 days paid at a per diem of $11,250 instead. Capped at $14,624.71.",,,,0,other,5160.45,15312.64,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],129256.37,,"Fee schedule rate ($129,256.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],43434.38,,"Fee schedule rate ($43,434.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula|LEFT SIDE|PO,CASE-27641,APC,27641,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Lesion Meniscus/Capsule Knee,CASE-27347,APC,27347,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33285.61,,,,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],67175.58,,"Fee schedule rate ($67,175.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",73164.55,73164.55,73164.55,1 through 10,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5743.41,,"Case rate ($5,549.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,050.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.42. The transfer capital threshold is the transfer adjustment factor * $402.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5549.19,16729.39,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8501.29,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6178.00,25225.91,Inpatient DRG
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7213.50,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7213.50,7213.50,7213.50,1 through 10,other,6965.00,21404.64,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F7|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10109.37,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10109.37,38416.97,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",16842.29,16842.29,16842.29,1 through 10,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],33779.42,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",92440.45,92440.45,92440.45,1 through 10,other,32637.12,96844.29,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6244.28,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6033.12,17902.13,Inpatient DRG
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy Limited Spx,CASE-29875,APC,29875,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],4525.50,,"Fee schedule rate ($4,525.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13142.28,,"Case rate ($12,516.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,058.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $886.96. The transfer capital threshold is the transfer adjustment factor * $886.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12536.42,37199.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4878.64,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4878.64,14476.37,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10638.54,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10638.54,40729.62,Inpatient DRG
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],60241.14,,,,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Stoma Dx Including Collj Spec Spx,CASE-44388,APC,44388,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,5450.78,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],59833.15,,"Fee schedule rate ($59,833.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13978.96,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13704.86,49911.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Needle Biopsy Muscle,CASE-20206,APC,20206,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1556.82,1556.82,1556.82,1 through 10,other,1566.49,1644.81,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41664.08,,,,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33285.61,,,,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8391.37,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4795.07,19830.58,All Other Inpatient
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17659.25,,"Fee schedule rate ($17,659.25). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,APC,11403,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],695.15,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,671.64,695.15,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rhinp Prim Lat&Alar Crtlgs&/Elvtn Nasal Ti|BILATERAL PROCEDURE|PO,CASE-30400,APC,30400,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],26181.01,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,25667.66,86123.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16691.31,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15896.49,51306.05,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24243.53,,"Case rate ($23,089.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,807.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.17. The transfer capital threshold is the transfer adjustment factor * $1,636.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23125.89,68621.57,Inpatient DRG
HC N Block Inj Suprascapular Nerv|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],37131.39,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,18559.00,141041.50,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7686.98,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7686.98,22809.58,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",2609.28,2609.28,2609.28,1 through 10,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14311.49,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",14547.72,14547.72,14549.68,1 through 10,other,13827.53,41030.48,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14112.34,,,,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6914.85,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6681.01,19824.58,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",43833.42,43833.42,43833.42,1 through 10,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],140535.66,,"Fee schedule rate ($140,535.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,36167.61,140535.66,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12862.50,,"Fee schedule rate ($12,862.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, GREAT TOE",CASE-28810,APC,28810,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],45983.18,,,,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3753.29,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3753.29,11765.59,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11621.00,,"Per diem ($11,621). If length of stay < 22.4, first 1 days paid at a per diem of $23,242 instead. Capped at $260,309.36.",,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10147.88,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9948.90,46199.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33483.49,,"Fee schedule rate ($33,483.49). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8078.98,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7694.27,22831.22,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4864.15,,"Case rate ($4,632.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.28. The transfer capital threshold is the transfer adjustment factor * $328.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4639.91,13771.19,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11170.47,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10638.54,40729.62,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18508.54,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18508.54,76171.92,Inpatient DRG
"Sesamoidectomy First Toe Spx|RIGHT FOOT, GREAT TOE|PO",CASE-28315,APC,28315,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8605.40,,"Case rate ($8,605.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,951.18, add-ons for qualifying new technology services are included. If operating cost exceeds $43,419.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,982.86. The transfer operating threshold is the transfer adjustment factor * $7,951.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $622.54. The transfer capital threshold is the transfer adjustment factor * $622.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8605.40,42305.71,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7544.23,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7184.98,21320.03,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30658.90,,"Fee schedule rate ($30,658.90). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24115.81,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9763.00,48626.00,All Other Inpatient
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12256.90,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7003.94,20782.85,All Other Inpatient
HC Debride Subq First 20 Sq Cm|SEPARATE STRUCTURE|PO,CASE-11042,APC,11042,CPT,0361,RC,,,XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Litholapaxy Smpl/Sm <2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52317,APC,52317,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE,CASE-28306,APC,28306,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8476.55,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8072.90,31159.55,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6503.29,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6503.30,6503.30,6503.30,1 through 10,other,6503.29,19528.85,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE|PO,CASE-25628,APC,25628,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,33843.71,Estimated amount calculated based on 10 day length of stay.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13264.54,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13264.54,50759.39,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15517.38,,"Fee schedule rate ($15,517.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5389.29,16247.30,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41492.89,,,,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,APC,58662,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE|PO,CASE-29823,APC,29823,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],73444.35,,"Fee schedule rate ($73,444.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6531.64,,"Fee schedule rate ($6,531.64). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MODERATE",191,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15493.68,,"Case rate ($14,755.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14755.89,15493.68,There are no additional notes associated with this service or procedure.
Syndactylization Toes|LEFT SIDE,CASE-28280,APC,28280,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Open Tx Fracture Phalanx/Phalanges Not Great Toe,CASE-28525,APC,28525,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"Open Treatment Metatarsal Fracture Each|RIGHT FOOT, FIFTH DIGIT",CASE-28485,APC,28485,CPT,0360,RC,,,T9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|RIGHT SIDE|PO,CASE-29883,APC,29883,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12482.98,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11888.55,35276.93,Inpatient DRG
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10282.48,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10080.86,33310.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31329.81,,"Fee schedule rate ($31,329.81). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,APC,51102,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6948.21,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11269.33,,"Case rate ($10,888.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,437.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10888.24,32825.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],69328.94,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,66027.56,228732.31,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],36370.09,,"Fee schedule rate ($36,370.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
HC Sel Cath Abd/Pelvic/Le 1st Ord,CASE-36245,APC,36245,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Bone,1st 20sqcm or Less",CASE-11044,APC,11044,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23703.48,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23703.48,110204.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10048.06,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9569.58,41116.55,Inpatient DRG
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5345.47,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5224.00,15861.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20853.68,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11916.39,58492.48,All Other Inpatient
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],42670.25,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,42670.25,133443.30,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],44778.95,,,,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|PO,CASE-28090,APC,28090,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins|LEFT SIDE|PO,CASE-25320,APC,25320,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MINOR",282,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7172.79,,"Case rate ($7,172.79). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7172.79,7531.43,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
Removal Implant Deep,CASE-20680,APC,20680,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2851.46,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],8990.00,,"Per diem ($8,990). If length of stay < 6, first 1 days paid at a per diem of $17,980 instead. Capped at $53,939.67.",,,,0,other,8990.00,80069.53,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],83871.28,,"Fee schedule rate ($83,871.28). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Tx Missed Abortion First Trimester Surgical,CASE-59820,APC,59820,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17776.11,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,16929.63,63934.22,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13886.20,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7934.97,23545.50,All Other Inpatient
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9820.91,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9820.91,29141.64,Inpatient DRG
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,APC,43239,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms|LEFT SIDE|PO,CASE-27696,APC,27696,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],6966.33,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,3980.76,11812.10,All Other Inpatient
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39198.44,,"Fee schedule rate ($39,198.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12255.94,,"Case rate ($11,672.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.14. The transfer capital threshold is the transfer adjustment factor * $827.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11690.93,56733.59,Inpatient DRG
Excision Tumor Soft Tis Foot/Toe Subq 1.5 Cm/>|RIGHT SIDE|PO,CASE-28039,APC,28039,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2851.46,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10810.31,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10810.31,32077.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOLIC LIVER DISEASE,EXTREME",280,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],30733.03,,"Case rate ($30,733.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,30733.03,32269.68,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],33095.90,,"Case rate ($31,519.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,404.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,233.61. The transfer capital threshold is the transfer adjustment factor * $2,233.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,31570.16,98176.71,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
Repair Non/Malunion Humerus W/O Graft|LEFT SIDE,CASE-24430,APC,24430,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12603.27,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29162.98,,"Fee schedule rate ($29,162.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5525.02,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",18108.65,18108.65,18108.65,1 through 10,other,5338.18,15839.99,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17620.75,,,,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE|PO,CASE-27680,APC,27680,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13022.58,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12402.46,36801.89,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrt Glenohmrl Jt W/Jt Expl W/WO Rmvl Loose/FB,CASE-23107,APC,23107,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6681.01,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6681.01,19824.58,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],92493.51,,"Fee schedule rate ($92,493.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.8), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39228.51,,"Fee schedule rate ($39,228.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13135.23,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13135.23,38976.20,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],45202.80,,"Fee schedule rate ($45,202.80). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19403.03,,"Case rate ($18,479.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,480.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,309.49. The transfer capital threshold is the transfer adjustment factor * $1,309.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",37680.50,37680.50,37680.50,1 through 10,other,18508.54,76171.92,Inpatient DRG
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12126.32,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11888.55,35276.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],90287.21,,"Fee schedule rate ($90,287.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20.9), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciotomy Foot&/Toe|LEFT SIDE,CASE-28008,APC,28008,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],34873.43,,"Fee schedule rate ($34,873.43). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8768.03,,"Case rate ($8,596.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,942.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,410.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,974.25. The transfer operating threshold is the transfer adjustment factor * $7,942.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.86. The transfer capital threshold is the transfer adjustment factor * $621.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8596.11,25507.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13061.00,,"Per diem ($13,061). If length of stay < 11, first 1 days paid at a per diem of $26,122 instead. Capped at $143,676.24.",117553.29,117553.29,117553.29,1 through 10,other,13061.00,162464.13,Estimated amount calculated based on 8 day length of stay.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6010.58,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6010.58,17835.23,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24370.50,,"Fee schedule rate ($24,370.50). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],20331.48,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19363.31,79918.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4728.85,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4568.94,13557.45,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],110217.19,,"Fee schedule rate ($110,217.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5297.06,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5297.06,19049.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21320.03,,,,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE,CASE-28200,APC,28200,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC I & D Simple,CASE-10060,APC,10060,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",184.47,184.47,184.47,1 through 10,other,190.30,199.81,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
Arthro/shoul surg; w/spacer|PO,CASE-C9781,APC,C9781,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13264.54,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13264.54,50759.39,Inpatient DRG
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
Arven Anast Opn Upr Arm Basilic Vein Trpos,CASE-36819,APC,36819,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5462.46,5541.62,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10522.17,,"Case rate ($10,021.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.13. The transfer capital threshold is the transfer adjustment factor * $710.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10037.09,36934.96,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MAJOR",720,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],18061.22,,"Case rate ($17,201.16). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17201.16,18061.22,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",163,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],81412.54,,"Case rate ($77,535.75). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $46,813, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,77535.75,81412.54,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14130.58,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14130.58,57770.11,Inpatient DRG
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE|PO,CASE-29806,APC,29806,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",17649.99,17649.99,17649.99,1 through 10,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea,CASE-28465,APC,28465,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE,CASE-29806,APC,29806,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12107.00,,"Per diem ($12,107). If length of stay < 2.8, first 1 days paid at a per diem of $24,214 instead. Capped at $33,900.69.",,,,0,other,11962.15,40923.09,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE,CASE-29825,APC,29825,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvc/Le Init 2nd|RIGHT SIDE,CASE-36246,APC,36246,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3074.87,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3074.87,3182.49,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20697.52,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20697.52,87921.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE",CASE-28299,APC,28299,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Aerosol, Hhn, Mdi, Ippb|ADJ",CASE-94640,APC,94640,CPT,0410,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21172.33,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,12500.00,83592.64,Inpatient DRG
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5224.00,,"Per diem ($5,224). If length of stay < 2.9, first 1 days paid at a per diem of $10,448 instead. Capped at $15,149.04.",,,,0,other,5224.00,15861.63,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],25459.44,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",25459.45,25459.45,25459.45,1 through 10,other,25459.44,80806.10,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23340.86,,,,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19491.06,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18562.91,73513.17,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11980.82,,"Fee schedule rate ($11,980.82). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Arthroplasty Glenohumeral Joint Total Shoulder|RIGHT SIDE,CASE-23472,APC,23472,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17461.77,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",17926.22,885.09,17926.22,1 through 10,other,16630.26,17461.77,OPPS APC
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23026.03,,,,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],31547.45,,"Case rate ($30,480.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,163.35, add-ons for qualifying new technology services are included. If operating cost exceeds $63,631.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,376.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,275.59. The transfer operating threshold is the transfer adjustment factor * $28,163.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,205.05. The transfer capital threshold is the transfer adjustment factor * $2,205.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",22619.81,22619.81,31020.04,1 through 10,other,30480.63,86382.02,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14262.78,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",13589.81,13589.81,13589.81,1 through 10,other,9763.00,48626.00,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],48779.11,,"Fee schedule rate ($48,779.11). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALNUTRITION FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS,MAJOR",421,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],13297.01,,"Case rate ($13,297.01). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13297.01,13961.86,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18954.85,,,,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6632.59,,"Case rate ($6,632.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,128.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,596.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,650.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,152.78. The transfer operating threshold is the transfer adjustment factor * $6,128.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.82. The transfer capital threshold is the transfer adjustment factor * $479.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6632.59,19680.94,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17522.17,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,16929.63,63934.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER ESOPHAGEAL DISORDERS,MAJOR",243,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],13917.31,,"Case rate ($13,917.31). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13917.31,14613.18,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18042.36,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",18583.38,18583.38,18583.38,1 through 10,other,18042.36,82749.58,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11359.17,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10818.26,38164.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5723.32,,"Case rate ($5,450.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $5,062.05, add-ons for qualifying new technology services are included. If operating cost exceeds $42,251.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,051.56. The transfer operating threshold is the transfer adjustment factor * $5,062.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.22. The transfer capital threshold is the transfer adjustment factor * $399.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5450.78,16705.77,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",53419.20,53419.20,53419.20,1 through 10,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25261.33,,,,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9021.29,,"Case rate ($8,591.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,951.18, add-ons for qualifying new technology services are included. If operating cost exceeds $43,419.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,982.86. The transfer operating threshold is the transfer adjustment factor * $7,951.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.84. The transfer capital threshold is the transfer adjustment factor * $608.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8605.40,42305.71,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7577.56,,"Case rate ($7,577.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,001.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,469.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,029.37. The transfer operating threshold is the transfer adjustment factor * $7,001.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.18. The transfer capital threshold is the transfer adjustment factor * $548.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7577.56,31445.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27601.28,,"Fee schedule rate ($27,601.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8212.69,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7934.97,23545.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Tibia|LEFT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
"ALLERGIC REACTIONS,MODERATE",811,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2859.96,,"Case rate for a one day stay ($2,859.96). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2859.96,3002.96,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11135.66,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10605.39,31469.43,Inpatient DRG
HC Hdr Vaginal Cyl Insertion,CASE-57156,APC,57156,CPT,0333,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],303.48,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,289.03,303.48,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14484.89,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7453.00,42138.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],38724.86,,"Fee schedule rate ($38,724.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6529.19,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5669.00,18994.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,APC,45378,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",846.40,846.40,846.40,1 through 10,other,882.03,926.14,OPPS APC
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MODERATE",710,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],24853.33,,"Case rate ($24,853.33). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24853.33,26096.00,There are no additional notes associated with this service or procedure.
Open Treatment Metatarsal Fracture Each|LEFT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10053.63,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9574.89,28411.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Mediastinoscopy With Lymph Node Biopsy/Ies,CASE-39402,APC,39402,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5416.39,5416.39,5416.39,1 through 10,other,5733.99,6020.69,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8349.83,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7952.22,25854.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6209.31,,"Case rate ($5,913.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,590.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $419.06. The transfer capital threshold is the transfer adjustment factor * $419.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5923.06,17575.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THUMB|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,FA|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8383.25,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7984.05,33319.56,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5967.84,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.66,16865.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6057.07,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5938.30,18621.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11106.00,,"Case rate ($10,888.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,437.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10888.24,32825.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|LEFT HAND, FIFTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7165.86,,"Case rate ($6,824.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.62. The transfer capital threshold is the transfer adjustment factor * $483.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",7165.86,7165.86,7165.86,1 through 10,other,6835.51,20283.05,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],41756.39,,"Case rate ($39,767.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,989.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,818.10. The transfer capital threshold is the transfer adjustment factor * $2,818.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",42378.36,42378.36,42378.36,1 through 10,other,39831.40,138208.82,Inpatient DRG
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11332.76,,"Case rate ($10,793.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,935.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $764.84. The transfer capital threshold is the transfer adjustment factor * $764.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",22334.83,22334.83,22334.83,1 through 10,other,10810.31,32077.45,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17575.50,,,,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE|PO,CASE-28615,APC,28615,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],41609.84,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",41481.54,41481.54,41481.54,1 through 10,other,40202.74,148703.60,Inpatient DRG
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,APC,45378,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",888.72,888.72,888.72,1 through 10,other,882.03,926.14,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6058.98,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",3453.26,3453.26,3453.26,1 through 10,other,1188.00,17370.86,Inpatient DRG
Laps Supracrv Hysterec >250 G Rmvl Tube/Ovary,CASE-58544,APC,58544,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",55.14,55.14,55.14,1 through 10,other,860.25,903.26,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula|LEFT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23801.30,,,,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],38550.83,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10105.00,120252.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto impl 4 or more,CASE-C9740,APC,C9740,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC
HC Revasc Intravasc Lithotripsy,CASE-C9764,APC,C9764,CPT,0481,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13557.45,,,,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5080.78,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4838.84,19587.42,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5338.18,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5316.89,5316.89,5338.18,1 through 10,other,5338.18,15839.99,Inpatient DRG
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,APC,31654,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,2994.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],61415.85,,,,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8919.07,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8919.07,34453.70,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20113.98,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,17274.00,73717.28,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17630.33,,"Case rate ($16,790.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,189.85. The transfer capital threshold is the transfer adjustment factor * $1,189.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16817.56,58510.23,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17584.61,,"Fee schedule rate ($17,584.61). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6204.88,19589.20,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],3607.42,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3607.42,11497.58,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5139.97,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4895.21,14525.56,Inpatient DRG
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20301.63,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20301.63,84714.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
Laps Supracrv Hysterec >250 G Rmvl Tube/Ovary,CASE-58544,APC,58544,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29162.98,,"Fee schedule rate ($29,162.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|LEFT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6399.53,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6094.79,22352.66,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],56694.72,,"Fee schedule rate ($56,694.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7956.44,,"Case rate ($7,577.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,001.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,469.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,029.37. The transfer operating threshold is the transfer adjustment factor * $7,001.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.18. The transfer capital threshold is the transfer adjustment factor * $548.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7577.56,31445.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15712.20,,"Fee schedule rate ($15,712.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE|PO,CASE-29888,APC,29888,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13768.00,,,,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4796.01,,"Case rate ($4,567.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $323.68. The transfer capital threshold is the transfer adjustment factor * $323.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4574.91,13575.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FIFTH DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|RIGHT SIDE|PO,CASE-11422,APC,11422,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac W/Port Tun >5|RIGHT SIDE,CASE-36561,APC,36561,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8476.55,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8072.90,31159.55,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22809.58,,,,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25244.27,,"Fee schedule rate ($25,244.27). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],79366.60,,"Fee schedule rate ($79,366.60). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15861.63,,,,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9292.89,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15196.40,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14472.76,56135.46,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4935.62,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4838.84,19587.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5625.00,,"Per diem ($5,625). If length of stay < 2.6, first 1 days paid at a per diem of $11,250 instead. Capped at $14,624.71.",,,,0,other,5160.45,15312.64,Estimated amount calculated based on 2 day length of stay.
Bronchoscopy W/Removal Foreign Body,CASE-31635,APC,31635,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1688.18,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1688.18,1772.59,OPPS APC
HC Rt Bronch Dx Clear Airway,CASE-31645,APC,31645,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3659.98,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7850.31,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,33946.09,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9299.56,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6972.00,26280.60,Inpatient DRG
"Partical Excision Bone Phalanx Toe|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,XS|T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13495.32,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",13430.61,13430.61,13430.61,1 through 10,other,13230.71,39259.55,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],45371.94,,"Fee schedule rate ($45,371.94). Adds an outlier to normal pricing equal to the per diem rate ($84,711.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10826.88,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10559.39,10559.39,10559.39,1 through 10,other,10826.88,32126.64,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],33451.55,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31858.62,94534.21,Inpatient DRG
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9569.58,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9569.58,41116.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6953.00,,"Per diem ($6,953). If length of stay < 4.5, first 1 days paid at a per diem of $13,906 instead. Capped at $31,286.59.",,,,0,other,6953.00,35389.05,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29162.98,,"Fee schedule rate ($29,162.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18748.84,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,18381.22,58579.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,868.26,OPPS APC
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
"MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,MAJOR",248,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14907.65,,"Case rate ($14,197.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14197.76,14907.65,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8938.88,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8513.22,25261.33,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE,CASE-29880,APC,29880,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6367.35,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,18893.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13514.94,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13249.94,40085.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15023.80,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15023.80,48104.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6748.64,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6748.64,20025.28,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,76310.36,Estimated amount calculated based on 21 day length of stay.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10415.81,,"Case rate ($9,919.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,874.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $702.95. The transfer capital threshold is the transfer adjustment factor * $702.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9935.64,29482.05,Inpatient DRG
Sesamoidectomy First Toe Spx|BILATERAL PROCEDURE|PO,CASE-28315,APC,28315,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32803.53,,,,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,APC,67900,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Mediastinoscopy With Lymph Node Biopsy/Ies,CASE-39402,APC,39402,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12169.44,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",11809.99,11809.99,11809.99,1 through 10,other,11757.91,34889.29,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],56787.82,,,,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],14651.02,,"Fee schedule rate ($14,651.02). Adds an outlier to normal pricing equal to the per diem rate ($61,007.55) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6474.12,,"Case rate ($6,474.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,981.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,449.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,005.76. The transfer operating threshold is the transfer adjustment factor * $5,981.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.35. The transfer capital threshold is the transfer adjustment factor * $468.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6474.12,19210.66,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10972.03,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10449.55,43409.67,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5355.42,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5355.42,17067.11,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39251.68,,,,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7152.15,,"Case rate ($7,011.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,678.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7011.91,27304.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20086.28,,,,,,0,other,6553.68,20086.28,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12833.49,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12833.49,58980.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36103.36,,,,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
Arthrp Kne Condyle&Platu Medial&Lat Compartments|RIGHT SIDE,CASE-27447,APC,27447,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",957.38,721.80,12542.29,23,other,12177.08,12785.93,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13272.11,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7231.00,38610.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],92493.51,,"Fee schedule rate ($92,493.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.8), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11135.66,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10605.39,31469.43,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Lesion Meniscus/Capsule Knee,CASE-27347,APC,27347,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17026.45,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17026.45,50522.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12565.29,,"Case rate ($11,966.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,019.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.02. The transfer capital threshold is the transfer adjustment factor * $848.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",12346.67,12346.67,12346.67,1 through 10,other,11986.02,54149.39,Inpatient DRG
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12223.35,,,,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],47595.65,,"Fee schedule rate ($47,595.65). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21404.64,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
HC Fem Pop Terr Plasty and Stent,CASE-37226,APC,37226,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9021.22,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8716.15,25863.45,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,37575.69,Estimated amount calculated based on 11 day length of stay.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13589.22,,"Fee schedule rate ($13,589.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7074.75,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6835.51,20283.05,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12883.25,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12883.25,44763.90,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26816.51,,"Fee schedule rate ($26,816.51). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
Suture Quadriceps/Hamstring Rupture Primary|RIGHT SIDE,CASE-27385,APC,27385,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE,CASE-29825,APC,29825,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MODERATE",282,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9580.76,,"Case rate ($9,580.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9580.76,10059.80,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16819.90,,,,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],115037.59,,"Fee schedule rate ($115,037.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21.9), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",23433.56,23433.56,23433.56,1 through 10,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
"CHOLECYSTECTOMY,MINOR",263,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14876.08,,"Case rate ($14,876.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14876.08,15619.88,There are no additional notes associated with this service or procedure.
Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT SIDE|PO,CASE-28750,APC,28750,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],20306.22,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc,CASE-24341,APC,24341,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],23723.08,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22593.41,90908.64,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],86795.47,,"Fee schedule rate ($86,795.47). Adds an outlier to normal pricing equal to the per diem rate ($211,362.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30626.53,106200.88,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10178.99,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10178.99,36468.17,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27304.54,,"Fee schedule rate ($27,304.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
"HC Excis Nail Matrix Perm Rmvl|LEFT FOOT, GREAT TOE|PO",CASE-11750,APC,11750,CPT,0450,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9056.04,,"Case rate ($8,624.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,782.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.18. The transfer capital threshold is the transfer adjustment factor * $611.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8442.00,28788.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, THIRD DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5826.65,,"Case rate ($5,549.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,050.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.42. The transfer capital threshold is the transfer adjustment factor * $402.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5549.19,16729.39,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11652.47,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11652.47,41507.02,Inpatient DRG
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,APC,43236,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14358.31,,,,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7409.15,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7056.33,28335.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6875.97,,"Case rate ($6,548.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,635.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $464.05. The transfer capital threshold is the transfer adjustment factor * $464.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13737.54,13737.54,13737.54,1 through 10,other,6558.98,19462.52,Inpatient DRG
Blepharoplasty Lower Eyelid Herniated Fat Pad|BILATERAL PROCEDURE|PO,CASE-15821,APC,15821,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2054.80,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.96,2054.80,OPPS APC
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5886.58,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5886.58,17467.27,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6146.14,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5938.30,18621.89,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9564.15,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9108.71,27028.33,Inpatient DRG
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],66951.94,,"Fee schedule rate ($66,951.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16916.32,,,,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
HC 3rd Order Sel Abd/Lower Ext,CASE-36247,APC,36247,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8.88,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC Sel Cath Abd/Pelvic/Le 1st Ord|BILATERAL PROCEDURE,CASE-36245,APC,36245,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FOURTH DIGIT|PO",CASE-26951,APC,26951,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Prostate Needle Biopsy Any Approach|SEPARATE STRUCTURE,CASE-55700,APC,55700,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4629.21,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4538.44,18815.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],8232.00,,"Per diem ($8,232). If length of stay < 9.8, first 1 days paid at a per diem of $16,464 instead. Capped at $80,676.47.",,,,0,other,8232.00,84471.39,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6365.49,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6240.68,18518.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32019.51,,"Fee schedule rate ($32,019.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25954.35,,"Fee schedule rate ($25,954.35). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34712.20,,,,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],90215.11,,,,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],48252.91,,"Fee schedule rate ($48,252.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Debridement Bone Each Additional 20 Sq Cm,CASE-11047,APC,11047,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7702.29,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7335.51,29792.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],34988.57,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,34988.57,110685.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16705.77,,,,,,0,other,5450.78,16705.77,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT|PO",CASE-28820,APC,28820,CPT,0360,RC,,,T1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],72742.07,,"Fee schedule rate ($72,742.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9466.07,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9280.46,39957.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26999.90,,"Fee schedule rate ($26,999.90). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9527.16,28269.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,APC,26437,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],64029.63,,"Fee schedule rate ($64,029.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.5), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4180.34,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4180.34,14351.57,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21991.57,,"Fee schedule rate ($21,991.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Great Toe Interphalangeal Joint,CASE-28755,APC,28755,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciectomy Plantar Fascia Partial Spx|RIGHT SIDE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21830.80,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21830.80,85124.35,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9954.21,,"Case rate ($9,480.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,773.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $8,808.40. The transfer operating threshold is the transfer adjustment factor * $8,773.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.80. The transfer capital threshold is the transfer adjustment factor * $671.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9495.32,42131.77,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5689.78,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5578.22,18148.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,APC,52318,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16062.27,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16062.27,48077.57,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],22593.41,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22593.41,90908.64,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],66445.54,,of the excess amount. Final payment is multiplied by 175%.,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
"HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AND UMBILICAL,MODERATE",227,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],19881.70,,"Case rate ($18,934.95). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18934.95,19881.70,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4319.82,,"Case rate ($4,114.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,462.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $291.54. The transfer capital threshold is the transfer adjustment factor * $291.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",7310.81,7310.81,7310.81,1 through 10,other,4120.67,13066.56,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14104.08,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13827.53,41030.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],3829.05,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3753.97,11139.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],29270.08,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,28696.16,118364.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10920.51,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,30861.41,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27331.50,,"Fee schedule rate ($27,331.50). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8764.55,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8764.55,32969.91,Inpatient DRG
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|LEFT FOOT, GREAT TOE|PO",CASE-28291,APC,28291,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6010.94,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",6005.66,6005.66,6005.66,1 through 10,other,5807.67,17233.12,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",63637.23,63637.23,63637.23,1 through 10,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14167.44,,,,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T4|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10080.22,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9739.34,40204.26,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23638.65,,"Fee schedule rate ($23,638.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],65555.62,,"Fee schedule rate ($65,555.62). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15496.63,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,53945.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",62017.34,62017.34,62017.34,1 through 10,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10233.67,,"Case rate ($9,746.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,861.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $690.66. The transfer capital threshold is the transfer adjustment factor * $690.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9761.89,37873.87,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],44339.99,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",44340.02,44340.02,44340.02,1 through 10,other,44339.99,131570.26,Inpatient DRG
Repair Fibula Nonunion/Malunion W/Int Fixation,CASE-27726,APC,27726,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
"Avulsion Nail Plate Partial/Comp Simple Ea Addl|LEFT HAND, FOURTH DIGIT|PO",CASE-11732,APC,11732,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],190.30,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14476.37,,,,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,APC,45171,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],28985.35,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,28005.17,115392.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,APC,11424,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34397.36,,,,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Radius Distal Third|RIGHT SIDE|PO,CASE-25350,APC,25350,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Tibia|LEFT SIDE|PO,CASE-27640,APC,27640,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12228.12,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11645.83,37502.92,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4558.56,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4341.49,12882.53,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6426.00,,"Fee schedule rate ($6,426). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9935.64,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9935.64,29482.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,APC,20552,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3733.68,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",3696.54,3696.54,3696.54,1 through 10,other,3607.42,11497.58,Inpatient DRG
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,APC,52287,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,APC,52332,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13138.89,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",13064.39,13064.39,29022.30,1 through 10,other,12881.26,38222.57,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7285.00,,"Per diem ($7,285). If length of stay < 5.4, first 1 days paid at a per diem of $14,570 instead. Capped at $39,337.51.",,,,0,other,7285.00,41187.90,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19079.41,,"Fee schedule rate ($19,079.41). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Leg/Ankle Subq <3cm|LEFT SIDE,CASE-27618,APC,27618,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,APC,52287,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|LEFT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],50916.88,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,50916.88,170142.20,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10224.92,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9738.02,28895.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],45202.80,,"Fee schedule rate ($45,202.80). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11026.52,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10810.31,32077.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9441.04,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,27465.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4341.49,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4341.49,12882.53,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7020.54,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7020.54,28431.58,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10091.46,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5766.55,17111.12,All Other Inpatient
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6367.35,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,18893.86,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34171.31,,"Fee schedule rate ($34,171.31). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11871.54,35778.69,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11993.07,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11757.91,34889.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16682.55,,"Fee schedule rate ($16,682.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Lesion Meniscus/Capsule Knee|LEFT SIDE|PO,CASE-27347,APC,27347,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10584.90,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10080.86,33310.69,Inpatient DRG
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Metatarsal W/Toe Single|LEFT FOOT, FIFTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T4,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10037.63,,"Case rate ($9,559.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,848.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.43. The transfer capital threshold is the transfer adjustment factor * $677.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9574.89,28411.62,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6383.11,,"Case rate ($6,079.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.79. The transfer capital threshold is the transfer adjustment factor * $430.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6088.84,18067.42,Inpatient DRG
"URETHRAL AND TRANSURETHRAL PROCEDURES,MINOR",446,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5872.41,,"Case rate for a one day stay ($5,592.77). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5592.77,5872.41,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
HC Intrvasc US Noncoronary Addl,CASE-37253,APC,37253,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],557.79,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,APC,43239,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17212.32,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],58656.71,,"Fee schedule rate ($58,656.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],28236.36,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,48444.74,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],32570.75,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31019.76,124854.72,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11054.89,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10528.47,44148.02,Inpatient DRG
Partial Excision Bone Tibia|LEFT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
Revascularization Iliac Art Angiop Ea Ipsi Vsl|LEFT SIDE,CASE-37222,APC,37222,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],168.02,,,,,,0,other,168.02,176.42,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14151.95,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6965.00,34379.15,All Other Inpatient
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,APC,64772,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arven Anast Opn Upr Arm Basilic Vein Trpos|RIGHT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],47804.40,,"Fee schedule rate ($47,804.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8042.38,,"Fee schedule rate ($8,042.38). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PO,CASE-20550,APC,20550,CPT,0510,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Mastectomy Simple Complete,CASE-19303,APC,19303,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6518.41,6518.41,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],42193.04,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37225.17,,"Fee schedule rate ($37,225.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],45226.79,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",45226.82,45226.82,45226.82,1 through 10,other,44339.99,131570.26,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
"MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,MAJOR",248,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14197.76,,"Case rate ($14,197.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14197.76,14907.65,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],20094.74,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19137.85,64589.15,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26270.73,,"Fee schedule rate ($26,270.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
Bx Prostate Strtctc Saturation Sampling Img Gid,CASE-55706,APC,55706,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7467.48,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,37575.69,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,APC,64493,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],29720.03,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",29720.05,29720.05,30083.96,1 through 10,other,13369.00,88188.38,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Ligation/Biopsy Temporal Artery|RIGHT SIDE,CASE-37609,APC,37609,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22000.90,,"Case rate ($20,953.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,655.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,484.82. The transfer capital threshold is the transfer adjustment factor * $1,484.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",43356.68,43356.68,43356.68,1 through 10,other,7826.00,90280.33,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],40835.64,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,38891.09,169197.98,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"MAJOR ABDOMINAL VASCULAR PROCEDURES,MAJOR",169,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],53961.70,,"Case rate ($53,961.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,53961.70,56659.79,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],92493.51,,"Fee schedule rate ($92,493.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.8), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4295.38,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2285.00,12138.74,Inpatient DRG
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,APC,20526,CPT,0510,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7920.23,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7543.08,29489.40,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8146.95,,"Fee schedule rate ($8,146.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
Open Treatment Fracture Distal Tibia & Fibula,CASE-27828,APC,27828,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20004.60,,"Fee schedule rate ($20,004.60). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],36511.04,,"Fee schedule rate ($36,511.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],73332.24,,,,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
Thorcoscpy W/Mediastinl & Regionl Lymphdenectomy,CASE-32674,APC,32674,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,2994.77,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11717.77,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11159.78,39897.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],34230.34,,"Case rate ($33,072.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,563.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,392.57. The transfer capital threshold is the transfer adjustment factor * $2,392.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,33072.79,98455.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9948.90,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9948.90,46199.76,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],22802.30,,"Case rate ($22,802.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,068.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,536.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,820.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $21,152.71. The transfer operating threshold is the transfer adjustment factor * $21,068.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,649.58. The transfer capital threshold is the transfer adjustment factor * $1,649.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22802.30,82749.58,Inpatient DRG
Inj for Sacroiliac Jt Anesth|LEFT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
Laparoscopy Nephrectomy W/Partial Ureterect|RIGHT SIDE,CASE-50546,APC,50546,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],339.97,,"APC Price ($339.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,339.97,339.97,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10899.16,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10899.16,39746.35,Inpatient DRG
HC Fem Pop Terr Plasty and Stent|RIGHT SIDE,CASE-37226,APC,37226,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],468.41,,,,,,0,other,468.41,491.83,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4657.67,,"Case rate ($4,435.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.34. The transfer capital threshold is the transfer adjustment factor * $314.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4442.95,13183.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10528.47,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10528.47,44148.02,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35485.50,,,,,,0,other,11958.84,40774.00,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",2922.01,2922.01,2922.31,1 through 10,other,2994.77,3144.51,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstrj Lesion Anus Extensive,CASE-46924,APC,46924,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Laparoscopic Procedure Liver,CASE-47379,APC,47379,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],59833.15,,"Fee schedule rate ($59,833.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],32105.45,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,31019.76,124854.72,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7041.91,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,21229.52,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24596.28,,"Fee schedule rate ($24,596.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5499.26,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5237.39,15540.89,Inpatient DRG
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5257.64,,"Case rate ($5,007.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,626.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,094.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,645.03. The transfer operating threshold is the transfer adjustment factor * $4,626.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.24. The transfer capital threshold is the transfer adjustment factor * $362.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5007.28,16142.41,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22353.48,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21289.03,76326.34,Inpatient DRG
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE|PO,CASE-28740,APC,28740,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],66380.55,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21546.25,,"Fee schedule rate ($21,546.25). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
HC Removal Subcutaneous Cardiac Rhythm Monitor|UNUSUAL NON-OVERLAPPING SERVICE,CASE-33286,APC,33286,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8241.39,,"APC Price ($7,848.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7848.94,8241.39,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5770.65,,"Case rate ($5,495.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.46. The transfer capital threshold is the transfer adjustment factor * $389.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5504.62,16333.88,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9727.58,,"Case rate ($9,264.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,573.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,041.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,827.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,607.86. The transfer operating threshold is the transfer adjustment factor * $8,573.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $656.50. The transfer capital threshold is the transfer adjustment factor * $656.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9279.13,27534.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20158.57,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11519.18,34180.92,All Other Inpatient
Excision Single External Papilla or Tag Anus,CASE-46220,APC,46220,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3162.78,3162.78,3162.78,1 through 10,other,3103.39,3258.56,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13051.67,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13051.67,38728.27,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10730.73,,"Case rate ($10,219.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,895.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.21. The transfer capital threshold is the transfer adjustment factor * $724.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10236.03,30589.82,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Proctosgmdsc Rgd Dx W/WO Collj Spec Br/Wa Spx,CASE-45300,APC,45300,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8431.66,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8431.66,25019.31,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
Sling Opration Corrj Male Urinary Incontinence,CASE-53440,APC,53440,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12513.57,,"APC Price ($12,513.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12513.57,13139.25,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10257.31,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9910.44,43344.00,Inpatient DRG
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE,CASE-29875,APC,29875,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10905.18,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10385.89,32176.55,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21687.14,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20654.42,69402.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8067.90,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7795.07,34198.12,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-24341,APC,24341,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8640.19,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8228.75,24417.19,Inpatient DRG
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11730.05,,"Case rate ($11,730.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,838.28, add-ons for qualifying new technology services are included. If operating cost exceeds $46,306.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,019.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,881.47. The transfer operating threshold is the transfer adjustment factor * $10,838.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.58. The transfer capital threshold is the transfer adjustment factor * $848.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11730.05,61348.24,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12948.38,,"Fee schedule rate ($12,948.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7770.00,,"Per diem ($7,770). If length of stay < 5.1, first 1 days paid at a per diem of $15,540 instead. Capped at $39,628.80.",,,,0,other,7770.00,50313.90,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5037.71,,"Case rate ($4,867.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.12. The transfer capital threshold is the transfer adjustment factor * $352.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4867.35,14442.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1537.76,1537.76,1537.76,1 through 10,other,1525.13,1601.38,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14682.98,,,,,,0,other,4870.41,14682.98,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12131.79,,"Fee schedule rate ($12,131.79). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5179.10,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5003.96,21742.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21967.53,,"Case rate ($20,921.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,653.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,482.57. The transfer capital threshold is the transfer adjustment factor * $1,482.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20954.82,62179.32,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12693.58,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12693.59,12693.59,12693.59,1 through 10,other,12693.58,46577.81,Inpatient DRG
Lengthening Tendon Extensor Hand/Finger Each,CASE-26476,APC,26476,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41929.72,,,,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1864.78,1849.14,1864.78,1 through 10,other,1820.02,1911.02,OPPS APC
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23915.01,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",27336.54,27336.54,27336.54,1 through 10,other,23915.01,121205.60,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],32201.56,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",32201.57,32201.57,32201.57,1 through 10,other,31570.16,98176.71,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],39168.53,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,37843.99,139522.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],14842.71,,"Fee schedule rate ($14,842.71). Adds an outlier to normal pricing equal to the per diem rate ($40,567.35) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8856.72,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6972.00,26280.60,Inpatient DRG
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE|PO,CASE-29888,APC,29888,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8218.35,,"Case rate ($7,827). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,725.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $554.65. The transfer capital threshold is the transfer adjustment factor * $554.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7551.60,23262.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MODERATE",282,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10059.80,,"Case rate ($9,580.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9580.76,10059.80,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9427.57,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],47889.67,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,45609.21,211906.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Implnt Bio Implnt for Soft Tissue Reinforcement,CASE-15777,APC,15777,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8355.45,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8072.90,31159.55,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12227.29,,,,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9097.45,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8919.07,34453.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12693.58,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12693.58,46577.81,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5938.97,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5938.97,17858.70,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14743.09,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14041.04,60059.69,Inpatient DRG
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
HC Removal FB Skin,CASE-10120,APC,10120,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,399.06,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE|PO,CASE-27427,APC,27427,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6684.75,,"Case rate ($6,553.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $6,086.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,276.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,494.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,073.77. The transfer operating threshold is the transfer adjustment factor * $6,086.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.91. The transfer capital threshold is the transfer adjustment factor * $479.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6553.68,20086.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit|RIGHT SIDE,CASE-36901,APC,36901,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1567.69,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16290.72,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6965.00,33447.35,All Other Inpatient
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9237.41,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8925.03,26628.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11202.49,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,31658.33,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],33779.42,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,32637.12,96844.29,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32297.83,,,,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],32749.19,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",32647.56,12609.13,36769.28,1 through 10,other,32749.19,97176.83,Inpatient DRG
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],42621.59,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40591.99,115037.59,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],34331.91,,"Case rate ($32,697.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,488.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,317.03. The transfer capital threshold is the transfer adjustment factor * $2,317.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",34215.89,21384.93,66194.12,1 through 10,other,32749.19,97176.83,Inpatient DRG
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21542.42,,"Fee schedule rate ($21,542.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14979.31,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14472.76,56135.46,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17439.12,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16849.39,49997.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9738.02,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9738.02,28895.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11468.94,,"Case rate ($6,553.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $6,086.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,276.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,494.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,073.77. The transfer operating threshold is the transfer adjustment factor * $6,086.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.91. The transfer capital threshold is the transfer adjustment factor * $479.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6553.68,20086.28,All Other Inpatient
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19807.67,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",20175.63,20175.63,20175.63,1 through 10,other,19137.85,64589.15,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8926.35,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6178.00,25225.91,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-29827,APC,29827,CPT,0360,RC,,,73,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5237.39,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5237.39,15540.89,Inpatient DRG
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28289,APC,28289,CPT,0360,RC,,,T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],61860.92,,"Fee schedule rate ($61,860.92). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21828.16,93157.39,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO|SEPARATE STRUCTURE",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,37575.69,Estimated amount calculated based on 11 day length of stay.
"HC Debrid,Bone,1st 20sqcm or Less|UNUSUAL NON-OVERLAPPING SERVICE",CASE-11044,APC,11044,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21872.86,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,21133.20,88801.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Pilonidal Cyst/Sinus Extensive,CASE-11771,APC,11771,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12833.49,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12833.49,58980.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5355.42,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5355.42,17067.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18227.38,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18227.38,54086.17,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],35038.21,,"Case rate ($33,369.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,535.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,364.69. The transfer capital threshold is the transfer adjustment factor * $2,364.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,33422.93,112824.68,Inpatient DRG
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|RIGHT SIDE,CASE-27130,APC,27130,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5355.42,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5355.42,17067.11,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12296.36,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11710.82,34749.58,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],41822.97,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,39831.40,138208.82,Inpatient DRG
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17490.00,,"Per diem ($17,490). If length of stay < 1.2, first 1 days paid at a per diem of $34,980 instead. Capped at $20,988.02.",,,,0,other,7405.81,33747.30,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7432.83,,"Case rate ($7,078.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,540.71, add-ons for qualifying new technology services are included. If operating cost exceeds $42,008.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,683.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,566.78. The transfer operating threshold is the transfer adjustment factor * $6,540.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.10. The transfer capital threshold is the transfer adjustment factor * $512.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7078.89,21005.20,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],62002.23,,,,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36239.13,,,,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21570.21,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,21570.21,72041.81,Inpatient DRG
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,APC,26080,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6630.72,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6630.72,19989.86,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11034.63,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10818.26,38164.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10851.58,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10334.84,30666.60,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16552.29,,,,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvic/Le 1st Ord|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,APC,36245,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13.94,,,,,,0,other,13.28,13.94,There are no additional notes associated with this service or procedure.
"OTHER ESOPHAGEAL DISORDERS,MAJOR",243,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14613.18,,"Case rate ($13,917.31). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13917.31,14613.18,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12275.48,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11690.93,56733.59,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23338.10,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23338.10,69251.23,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",855.44,855.44,855.44,1 through 10,other,838.89,880.84,OPPS APC
Arthrodesis Subtalar|LEFT SIDE|PO,CASE-28725,APC,28725,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14182.35,,"Fee schedule rate ($14,182.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],47978.53,,"Fee schedule rate ($47,978.53). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,XU|50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
Rpr Component Inflatable Penile Prosthesis,CASE-54408,APC,54408,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",163,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],77535.75,,"Case rate ($77,535.75). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $46,813, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,77535.75,81412.54,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT FOOT, GREAT TOE|PO",CASE-28297,APC,28297,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23703.48,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23703.48,110204.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,APC,43246,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12093.45,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12093.45,40067.60,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5697.28,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5504.62,16333.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],104605.60,,"Fee schedule rate ($104,605.60). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26544.78,,"Fee schedule rate ($26,544.78). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],93678.26,,,,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],37975.99,,"Case rate ($36,167.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,417.97, add-ons for qualifying new technology services are included. If operating cost exceeds $68,885.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,787.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $33,551.16. The transfer operating threshold is the transfer adjustment factor * $33,417.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,616.46. The transfer capital threshold is the transfer adjustment factor * $2,616.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36167.61,140535.66,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5003.96,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5003.96,21742.11,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],48094.52,,,,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
Carpectomy 1 Bone|RIGHT SIDE|PO,CASE-25210,APC,25210,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],140535.66,,"Fee schedule rate ($140,535.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,36167.61,140535.66,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11665.48,,"Fee schedule rate ($11,665.48). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4728.85,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4568.94,13557.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,27370.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10236.03,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10236.03,30589.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],27308.54,,"Fee schedule rate ($27,308.54). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19183.89,,"Fee schedule rate ($19,183.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,6553.68,20086.28,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HIV WITH MAJOR HIV RELATED CONDITION,MODERATE",892,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11194.16,,"Case rate ($10,661.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10661.10,11194.16,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20975.54,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,11986.02,54149.39,All Other Inpatient
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19635.68,,,,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15891.15,,,,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],66651.58,,"Fee schedule rate ($66,651.58). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea,CASE-28465,APC,28465,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8285.77,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7891.21,23415.63,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11863.29,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11298.37,44627.23,Inpatient DRG
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12833.49,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12833.49,58980.57,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13572.00,,"Per diem ($13,572). If length of stay < 5.8, first 1 days paid at a per diem of $27,144 instead. Capped at $78,720.12.",,,,0,other,13572.00,108637.77,Estimated amount calculated based on 4 day length of stay.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12299.85,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11714.14,49460.19,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14143.97,,"Case rate ($13,866.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,812.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,280.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,174.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,863.50. The transfer operating threshold is the transfer adjustment factor * $12,812.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,003.15. The transfer capital threshold is the transfer adjustment factor * $1,003.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13866.64,41146.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],27055.67,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,46419.05,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
Repair Brow Ptosis|BILATERAL PROCEDURE|PO,CASE-67900,APC,67900,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22653.31,,"Fee schedule rate ($22,653.31). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms|RIGHT SIDE,CASE-27696,APC,27696,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11156.45,,"Case rate ($11,156.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,308.28, add-ons for qualifying new technology services are included. If operating cost exceeds $45,776.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,349.36. The transfer operating threshold is the transfer adjustment factor * $10,308.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.09. The transfer capital threshold is the transfer adjustment factor * $807.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11156.45,11156.45,11156.45,1 through 10,other,11156.45,42003.98,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5490.50,,"Case rate ($5,229.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,541.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $370.55. The transfer capital threshold is the transfer adjustment factor * $370.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",5484.06,5484.06,5484.06,1 through 10,other,5237.39,15540.89,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],85446.13,,"Fee schedule rate ($85,446.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],60333.05,,"Fee schedule rate ($60,333.05). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,XS|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,301.32,305.69,OPPS APC
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12333.46,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11916.39,58492.48,Inpatient DRG
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, THIRD DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
"HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,EXTREME",890,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],39450.34,,"Case rate ($39,450.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,39450.34,41422.86,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
Blepharoplasty Lower Eyelid Herniated Fat Pad|BILATERAL PROCEDURE|PO,CASE-15821,APC,15821,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2025.45,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.96,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18033.97,,,,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26631.69,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,15218.11,45156.75,All Other Inpatient
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE|PO,CASE-64405,APC,64405,CPT,0450,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"INTESTINAL OBSTRUCTION,MAJOR",247,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12454.29,,"Case rate ($12,454.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12454.29,13077.00,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11350.83,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10810.31,32077.45,Inpatient DRG
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|RIGHT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],180.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16532.31,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16208.15,58123.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],39628.79,,of the excess amount. Final payment is multiplied by 175%.,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
Arthroplasty Interphalangeal Jt W/Prosthetic Ea,CASE-26536,APC,26536,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,CASE-58571,APC,58571,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",10003.65,10003.65,10003.65,1 through 10,other,10082.05,10586.16,OPPS APC
Sigmoidoscopy Flx Placement of Endoscopic Stent,CASE-45347,APC,45347,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13142.28,,"Case rate ($12,516.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,058.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $886.96. The transfer capital threshold is the transfer adjustment factor * $886.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12536.42,37199.37,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37225.17,,"Fee schedule rate ($37,225.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21939.88,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20895.12,99969.33,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32874.59,,"Fee schedule rate ($32,874.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7003.94,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7003.94,20782.85,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],85446.13,,"Fee schedule rate ($85,446.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,APC,53445,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20346.09,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,19658.06,20346.09,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],32749.19,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,32749.19,97176.83,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29288.89,,"Fee schedule rate ($29,288.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
"Ostc Prtl Exostc/Condylc Metar Head|LEFT FOOT, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28288,APC,28288,CPT,0360,RC,,,T1|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27304.54,,"Fee schedule rate ($27,304.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14518.91,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13827.53,41030.48,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15950.19,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,15950.19,63458.56,Inpatient DRG
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28308,APC,28308,CPT,0360,RC,,,RT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm,CASE-11401,APC,11401,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2755.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17522.17,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,16929.63,63934.22,Inpatient DRG
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9970.09,,"Case rate ($9,495.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,773.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,858.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $8,808.40. The transfer operating threshold is the transfer adjustment factor * $8,773.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.92. The transfer capital threshold is the transfer adjustment factor * $686.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9495.32,42131.77,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21938.74,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,12536.42,46998.45,All Other Inpatient
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8072.90,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8072.90,31159.55,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17323.07,,"Case rate ($16,498.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,340.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.12. The transfer capital threshold is the transfer adjustment factor * $1,169.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16524.47,58465.86,Inpatient DRG
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MODERATE",422,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2424.09,,"Case rate for a one day stay ($2,424.09). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2424.09,2545.29,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22922.34,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21830.80,85124.35,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4318.43,,"Case rate ($4,112.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,806.17, add-ons for qualifying new technology services are included. If operating cost exceeds $39,274.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,462.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,821.34. The transfer operating threshold is the transfer adjustment factor * $3,806.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $291.45. The transfer capital threshold is the transfer adjustment factor * $291.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4119.35,12223.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
Biopsy Vaginal Mucosa Simple,CASE-57100,APC,57100,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26123,APC,26123,CPT,0360,RC,,,F8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],28725.18,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27357.31,100904.68,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],44732.44,,"Case rate ($42,602.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,190.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,018.95. The transfer capital threshold is the transfer adjustment factor * $3,018.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,42670.25,133443.30,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14525.56,,,,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,APC,58552,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],84074.87,,"Fee schedule rate ($84,074.87). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26151.16,,"Fee schedule rate ($26,151.16). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
"INGUINAL FEMORAL AND UMBILICAL HERNIA PROCEDURES,MINOR",228,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13007.38,,"Case rate ($12,387.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12387.98,13007.38,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6804.79,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6480.75,29542.64,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14062.94,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14062.94,61706.77,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,30966.53,Estimated amount calculated based on 11 day length of stay.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6707.58,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6480.75,29542.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12516.72,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12093.45,35884.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,13588.14,40320.14,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10311.96,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9820.91,29141.64,Inpatient DRG
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16333.88,,,,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],24009.84,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10632.00,103714.29,Inpatient DRG
Ostc Prtl Exostc/Condylc Metar Head|LEFT SIDE|PO,CASE-28288,APC,28288,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Intrvasc US Noncoronary Addl|RIGHT SIDE,CASE-37253,APC,37253,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5668.18,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5398.26,5668.18,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10496.21,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10290.40,42115.80,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13334.16,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12883.25,44763.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Parathyroid Autotransplantation Add-On,CASE-60512,APC,60512,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11084.14,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10556.32,32082.48,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18244.92,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7455.00,53076.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6216.69,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6094.79,22352.66,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15718.12,,"Case rate ($8,981.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,671.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $657.72. The transfer capital threshold is the transfer adjustment factor * $657.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8981.78,27528.12,All Other Inpatient
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],63499.65,,,,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],29572.98,,"Fee schedule rate ($29,572.98). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,MODERATE",313,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],24206.78,,"Case rate ($24,206.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24206.78,25417.12,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8554.54,,"Fee schedule rate ($8,554.54). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
Excision Ganglion Wrist Dorsal/Volar Recurrent,CASE-25112,APC,25112,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],43263.82,,,,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
Revascularization Iliac Artery Angiop 1st Vsl|LEFT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],374.15,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6061.85,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5773.19,31196.82,Inpatient DRG
Synovectomy Tendon Sheath Foot Extensor|RIGHT SIDE|PO,CASE-28088,APC,28088,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9313.50,,"Fee schedule rate ($9,313.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10944.14,,"Case rate ($10,422.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,909.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $738.61. The transfer capital threshold is the transfer adjustment factor * $738.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10439.61,34540.67,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],5626.98,,"Fee schedule rate ($5,626.98). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|PO,CASE-11422,APC,11422,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26297.04,,"Fee schedule rate ($26,297.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,9279.13,27534.03,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7544.88,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7289.74,21630.93,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22230.95,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12500.00,83592.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Syndactylization Toes|LEFT SIDE,CASE-28280,APC,28280,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17185.35,,"Fee schedule rate ($17,185.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34934.31,,"Fee schedule rate ($34,934.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],69328.94,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,66027.56,228732.31,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6009.09,,"Case rate ($5,722.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,296.29, add-ons for qualifying new technology services are included. If operating cost exceeds $40,764.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,576.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,317.40. The transfer operating threshold is the transfer adjustment factor * $5,296.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $405.55. The transfer capital threshold is the transfer adjustment factor * $405.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5732.06,21720.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intrvasc US Noncoronary 1st|RIGHT SIDE,CASE-37252,APC,37252,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7068.60,,"Fee schedule rate ($7,068.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36008.91,,,,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12201.39,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11962.15,40923.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14625.15,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",15218.53,15218.53,15220.58,1 through 10,other,14130.58,57770.11,Inpatient DRG
Osteoplasty Radius/Ulna Shortening|RIGHT SIDE|PO,CASE-25390,APC,25390,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15547.45,,"Fee schedule rate ($15,547.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22878.60,,"Fee schedule rate ($22,878.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4817.40,,"Case rate ($4,654.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.72. The transfer capital threshold is the transfer adjustment factor * $336.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4654.49,13811.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],23723.08,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22593.41,90908.64,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
Surg Tx Anal Fistula Intersphincteric,CASE-46275,APC,46275,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|RIGHT SIDE,CASE-37765,APC,37765,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19377.46,,"Fee schedule rate ($19,377.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],48779.11,,"Fee schedule rate ($48,779.11). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|PO,CASE-64494,APC,64494,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17726.69,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,17127.24,50821.76,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17032.82,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16456.83,55350.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea,CASE-43277,APC,43277,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3784.78,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13140.27,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12514.54,37134.43,Inpatient DRG
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE|PO,CASE-64490,APC,64490,CPT,0361,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],34671.15,,"Case rate ($33,020.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,511.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,339.92. The transfer capital threshold is the transfer adjustment factor * $2,339.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,33072.79,98455.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ligj Divj & Stripping Short Saphenous Vein,CASE-37718,APC,37718,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],29165.93,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13572.00,108637.77,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12707.80,,"Case rate ($12,102.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,200.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,668.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,028.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,245.03. The transfer operating threshold is the transfer adjustment factor * $11,200.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $857.64. The transfer capital threshold is the transfer adjustment factor * $857.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12439.05,11057.06,46809.71,1 through 10,other,12121.97,35969.56,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],45371.94,,"Fee schedule rate ($45,371.94). Adds an outlier to normal pricing equal to the per diem rate ($84,711.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Insertion Uterine Tandem&/Vaginal Ovoids,CASE-57155,APC,57155,CPT,0342,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4910.73,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6098.05,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5807.67,17233.12,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24308.97,,,,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19210.66,,,,,,0,other,6474.12,19210.66,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11298.37,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11298.37,44627.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6178.00,,"Per diem ($6,178). If length of stay < 3.9, first 1 days paid at a per diem of $12,356 instead. Capped at $24,092.63.",,,,0,other,6178.00,25225.91,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6055.67,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6055.67,17969.04,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7744.00,24853.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6474.12,,"Case rate ($6,474.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,981.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,449.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,005.76. The transfer operating threshold is the transfer adjustment factor * $5,981.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.35. The transfer capital threshold is the transfer adjustment factor * $468.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6474.12,19210.66,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO,CASE-62323,APC,62323,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Mastectomy Partial|RIGHT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3713.66,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15547.45,,"Fee schedule rate ($15,547.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|PO,CASE-64636,APC,64636,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7951.41,,"Case rate ($7,572.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,707.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.63. The transfer capital threshold is the transfer adjustment factor * $536.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33946.09,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
"HC Excis Nail Matrix Perm Rmvl|LEFT FOOT, GREAT TOE|PO",CASE-11750,APC,11750,CPT,0450,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",28624.17,28624.17,28624.17,1 through 10,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7257.26,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7257.26,23445.98,Inpatient DRG
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],61415.85,,,,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10400.49,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10400.50,10400.50,21018.85,1 through 10,other,6965.00,30861.41,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,CASE-36556,APC,36556,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
Colsc Flx With Directed Submucosal Njx Any Sbst|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45381,APC,45381,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11986.02,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,11986.02,54149.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],39684.68,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10105.00,120252.50,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6644.63,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6328.22,27416.36,Inpatient DRG
"OTHER RESPIRATORY AND CHEST PROCEDURES,MODERATE",121,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],24082.45,,"Case rate ($24,082.45). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24082.45,25286.57,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
"PERIPHERAL AND OTHER VASCULAR DISORDERS,MODERATE",197,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8931.45,,"Case rate ($8,931.45). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8931.45,9378.02,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10970.77,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10970.77,2626.39,45904.35,1 through 10,other,10970.77,32553.63,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],61287.95,,,,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27597.52,,"Fee schedule rate ($27,597.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37225.17,,"Fee schedule rate ($37,225.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
HC Revasc Intravasc Lithotripsy|RIGHT SIDE,CASE-C9764,APC,C9764,CPT,0481,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7231.00,,"Per diem ($7,231). If length of stay < 5.1, first 1 days paid at a per diem of $14,462 instead. Capped at $36,875.62.",,,,0,other,7231.00,38610.21,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8764.55,32969.91,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
HC Debride/Musc/Fasc First 20 Sq Cm|SEPARATE STRUCTURE,CASE-11043,APC,11043,CPT,0361,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,11496.76,11496.76,OPPS APC
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11152.68,,"Case rate ($10,621.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.68. The transfer capital threshold is the transfer adjustment factor * $752.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10638.54,40729.62,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25534.84,,,,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY ANOTHER PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,77|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],29771.33,,"APC Price ($29,771.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,29771.33,31259.89,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,1188.00,27484.83,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7015.06,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6681.01,19824.58,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|PO",CASE-64491,APC,64491,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl,CASE-37232,APC,37232,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],189.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",853.10,853.10,6963.55,1 through 10,other,6882.29,7226.40,OPPS APC
"HC Bx,Vulva/Perineum,Addl Lesion",CASE-56606,APC,56606,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],904.16,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,873.59,917.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],52666.87,,"Fee schedule rate ($52,666.87). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],35363.23,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,18559.00,141041.50,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,APC,52352,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8467.97,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4838.84,19587.42,All Other Inpatient
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT SIDE|PO,CASE-26111,APC,26111,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34528.24,,"Fee schedule rate ($34,528.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9949.80,,"Fee schedule rate ($9,949.80). Adds an outlier to normal pricing equal to the per diem rate ($4,143.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,5389.29,16247.30,There are no additional notes associated with this service or procedure.
Circumcision Age >28 Days,CASE-54161,APC,54161,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1968.31,1968.31,1968.31,1 through 10,other,1982.66,2081.79,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],70101.28,,,,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
Revis Shoulder Arthrplsty Humeral&Glenoid Compnt,CASE-23474,APC,23474,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11814.94,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11814.94,44591.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
Arthrs Aid Tibial Fracture Proximal Unicondylar,CASE-29855,APC,29855,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14508.56,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14508.56,59513.03,Inpatient DRG
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12397.99,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11978.73,60588.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,APC,60220,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt,CASE-27602,APC,27602,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Arteriovenous Anastomosis Open Direct,CASE-36821,APC,36821,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3068.43,3068.11,3068.43,1 through 10,other,2994.77,3144.51,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30658.90,,"Fee schedule rate ($30,658.90). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],94720.48,,"Fee schedule rate ($94,720.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],28696.16,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,28696.16,118364.04,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8683.48,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",8687.84,8687.84,8687.84,1 through 10,other,8513.22,25261.33,Inpatient DRG
HC Add 2nd/3rd Order Abd/Le|RIGHT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],533.01,,"APC Price ($514.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,514.99,540.74,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],107320.33,,,,,,0,other,36167.61,140535.66,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39359.90,,,,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY SAME PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,76|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],25658.60,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,24790.92,26030.46,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,APC,31652,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3713.03,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10058.98,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5091.00,22010.11,All Other Inpatient
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE|PO,CASE-29806,APC,29806,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12803.67,,"Fee schedule rate ($12,803.67). Adds an outlier to normal pricing equal to the per diem rate ($91,038.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21929.44,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20885.18,80720.91,Inpatient DRG
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3162.78,3162.78,3162.78,1 through 10,other,3103.39,3258.56,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14476.37,,,,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
Removal Implant Deep|BILATERAL PROCEDURE,CASE-20680,APC,20680,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7801.48,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7648.51,27371.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Cysto W/Insert Ureteral Stent,CASE-52332,APC,52332,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3460.35,OPPS APC
Open Treatment Tarsometatarsal Joint Dislocation,CASE-28615,APC,28615,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
"OTHER PNEUMONIA,MODERATE",139,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9353.36,,"Case rate ($8,907.96). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8907.96,9353.36,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14390.10,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13704.86,49911.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,APC,45378,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],926.14,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC
"ACUTE MYOCARDIAL INFARCTION,EXTREME",190,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],25389.56,,"Case rate ($24,180.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24180.53,25389.56,There are no additional notes associated with this service or procedure.
HC Rem Central Venous Cath,CASE-36589,APC,36589,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],624.73,,"APC Price ($594.98). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,594.98,624.73,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5507.93,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5507.93,20510.35,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28296,APC,28296,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],31156.36,,"Case rate ($29,672.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,273.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,102.71. The transfer capital threshold is the transfer adjustment factor * $2,102.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13369.00,88188.38,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6590.75,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6461.52,21772.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19232.02,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19232.02,68941.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17161.77,,"Fee schedule rate ($17,161.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26986.80,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,15421.03,49137.17,All Other Inpatient
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16817.56,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16817.56,58510.23,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22592.15,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,21828.16,93157.39,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11895.84,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11895.84,35298.57,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33727.80,,"Fee schedule rate ($33,727.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],42193.04,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24722.51,,"Case rate ($23,545.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,789.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,257.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,839.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,876.75. The transfer operating threshold is the transfer adjustment factor * $21,789.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,668.50. The transfer capital threshold is the transfer adjustment factor * $1,668.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23582.79,75543.62,Inpatient DRG
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28289,APC,28289,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24782.12,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23602.02,108295.22,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13842.12,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12440.40,41073.77,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,APC,51990,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
Arven Anast Opn Upr Arm Basilic Vein Trpos|LEFT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5938.97,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5938.97,17858.70,Inpatient DRG
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1567.69,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1514.26,1514.26,1514.26,1 through 10,other,1493.03,1567.69,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],50235.38,,,,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],31024.96,,"Case rate ($29,547.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,264.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,093.84. The transfer capital threshold is the transfer adjustment factor * $2,093.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,29594.69,124146.55,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32474.30,,"Fee schedule rate ($32,474.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],42577.42,,"Fee schedule rate ($42,577.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11924.75,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11690.93,56733.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4523.19,16536.43,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surg Tx Anal Fistula Subq,CASE-46270,APC,46270,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, THIRD DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Medial Malleolus Fracture|RIGHT SIDE,CASE-27766,APC,27766,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],27022.53,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25735.75,27022.53,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE|SEPARATE STRUCTURE,CASE-27405,APC,27405,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16320.00,,"Per diem ($16,320). If length of stay < 2.1, first 1 days paid at a per diem of $32,640 instead. Capped at $34,272.79.",,,,0,other,12093.45,40067.60,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4657.67,,"Case rate ($4,435.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.34. The transfer capital threshold is the transfer adjustment factor * $314.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4442.95,13183.59,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36397.59,,"Fee schedule rate ($36,397.59). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],30403.05,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,30403.05,90685.00,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
"CELLULITIS AND OTHER SKIN INFECTIONS,MODERATE",383,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8583.10,,"Case rate ($8,174.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8174.38,8583.10,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],59361.57,,,,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,APC,29828,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],45507.56,,"Fee schedule rate ($45,507.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,3295.00,50750.92,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],20478.39,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19503.23,57872.02,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4303.70,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4303.70,14124.38,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20782.85,,,,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11196.90,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10818.26,38164.94,Inpatient DRG
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],40591.99,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,40591.99,115037.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13405.94,,,,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],52607.24,,"Fee schedule rate ($52,607.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28437.57,,"Fee schedule rate ($28,437.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
Debridement Nail Any Method 1-5,CASE-11720,APC,11720,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],58.75,,"APC Price ($55.95). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,55.95,58.75,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36247,APC,36247,CPT,0361,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
"OTHER RESPIRATORY AND CHEST PROCEDURES,MODERATE",121,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],25286.57,,"Case rate ($24,082.45). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24082.45,25286.57,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],51643.16,,"Fee schedule rate ($51,643.16). Adds an outlier to normal pricing equal to the per diem rate ($161,652.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",47921.75,47921.75,47921.75,1 through 10,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10837.80,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10625.29,39295.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Catheter Aorta|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36200,APC,36200,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3099.59,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32881.80,,"Fee schedule rate ($32,881.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,1188.00,35040.80,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6057.75,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5938.97,17858.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6077.55,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6077.55,18033.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],57305.33,,,,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16536.43,,"Fee schedule rate ($16,536.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11156.55,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10625.29,39295.53,Inpatient DRG
"Arthro, Loose Body + Chondro",CASE-G0289,APC,G0289,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9238.95,,"Fee schedule rate ($9,238.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6837.50,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6837.50,20288.95,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",29068.19,29068.19,29068.19,1 through 10,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32874.59,,"Fee schedule rate ($32,874.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride/Musc/Fasc First 20 Sq Cm,CASE-11043,APC,11043,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],700.99,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,700.99,736.04,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],46638.59,,"Fee schedule rate ($46,638.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Multiple External Papillae/Tags Anus,CASE-46230,APC,46230,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Supracervical Hysterectomy >250,CASE-58543,APC,58543,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36247,APC,36247,CPT,0361,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7694.27,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7694.27,22831.22,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7694.27,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7638.48,1455.18,7638.48,11,other,7694.27,22831.22,Inpatient DRG
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33947.68,,"Fee schedule rate ($33,947.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Intrauterine Device Iud,CASE-58301,APC,58301,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],289.03,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,289.03,303.48,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16729.39,,,,,,0,other,5549.19,16729.39,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],42138.30,,,,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],67661.33,,,,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],36249.82,,"Fee schedule rate ($36,249.82). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],26636.50,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15090.49,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,14580.18,57079.69,Inpatient DRG
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23996.10,,,,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28296,APC,28296,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16343.72,,,,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7060.32,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6724.11,19952.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7288.38,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,21229.52,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35566.18,,,,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21805.52,,"Fee schedule rate ($21,805.52). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5486.88,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5379.29,15961.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Implant Neurostim/Receiver,CASE-64590,APC,64590,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18400.38,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18400.38,19320.40,OPPS APC
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11588.33,,"Case rate ($11,036.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,227.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,773.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,451.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $10,233.04. The transfer operating threshold is the transfer adjustment factor * $10,227.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $803.46. The transfer capital threshold is the transfer adjustment factor * $803.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11036.50,33262.00,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13163.24,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12536.42,37199.37,Inpatient DRG
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC
"OTHER COMPLICATIONS OF TREATMENT,MODERATE",813,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9515.83,,"Case rate ($9,515.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9515.83,9991.62,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8021.19,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8021.20,8021.20,8021.20,1 through 10,other,6495.00,23801.30,Inpatient DRG
Ostectomy Complete 5th Metatarsal Head|RIGHT SIDE|PO,CASE-28113,APC,28113,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7393.80,,"Fee schedule rate ($7,393.80). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
Ligamentous Reconstruction Knee Extra-Articular,CASE-27427,APC,27427,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19952.48,,,,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6788.54,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6558.98,19462.52,Inpatient DRG
HC Intrvasc US Noncoronary 1st|RIGHT SIDE,CASE-37252,APC,37252,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],88173.00,,"Fee schedule rate ($88,173.00). Adds an outlier to normal pricing equal to the per diem rate ($170,052.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4743.76,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4517.87,13932.70,Inpatient DRG
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19503.23,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19503.23,57872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17620.75,,,,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24015.51,,"Case rate ($22,871.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,791.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,620.78. The transfer capital threshold is the transfer adjustment factor * $1,620.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22908.38,67976.16,Inpatient DRG
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,301.32,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALFUNCTION REACTION COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE,MODERATE",206,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2918.25,,"Case rate for a one day stay ($2,779.29). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2779.29,2918.25,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|LEFT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34934.31,,"Fee schedule rate ($34,934.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Removal Subcutaneous Cardiac Rhythm Monitor,CASE-33286,APC,33286,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10260.35,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9913.38,10409.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,APC,43239,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Subq Ea Addt'l 20sqcm|PBB CHARGE",CASE-11045,APC,11045,CPT,0361,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],29843.17,,"Case rate ($28,422.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,185.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,014.09. The transfer capital threshold is the transfer adjustment factor * $2,014.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8232.00,84471.39,Inpatient DRG
"HYPERTENSION,MODERATE",199,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2917.78,,"Case rate for a one day stay ($2,917.78). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2917.78,3063.67,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, SECOND DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5068.20,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4968.82,19848.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER CIRCULATORY SYSTEM DIAGNOSES,EXTREME",207,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],24667.17,,"Case rate ($23,492.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23492.54,24667.17,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19232.02,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19232.02,68941.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt,CASE-28291,APC,28291,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7289.74,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7289.74,21630.93,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],135336.44,,,,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19269.56,,"Case rate ($18,351.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,471.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,300.48. The transfer capital threshold is the transfer adjustment factor * $1,300.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",95718.02,95718.02,95718.02,1 through 10,other,18381.22,58579.45,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Vaginectomy Partial Removal Vaginal Wall,CASE-57106,APC,57106,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13827.53,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13827.53,41030.48,Inpatient DRG
HC Add 2nd/3rd Order Abd/Le|LEFT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5277.74,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC Sel Cath Abd/Pelvic/Le 1st Ord|LEFT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MIGRAINE AND OTHER HEADACHES,MINOR",054,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8272.68,,"Case rate ($7,878.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7878.74,8272.68,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15914.26,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15156.44,52672.70,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14478.52,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13789.07,57367.22,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6267.62,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",31782.03,31782.03,31782.03,1 through 10,other,6055.67,17969.04,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16269.19,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,15950.19,63458.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB|PO",CASE-64831,APC,64831,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],74873.19,,"Fee schedule rate ($74,873.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.6), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9425.03,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9589.38,9589.38,9589.38,1 through 10,other,9425.03,27966.92,Inpatient DRG
Repair Dislocating Peroneal Tendon W/Fib Osteot,CASE-27676,APC,27676,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11269.33,,"Case rate ($10,888.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,437.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10888.24,32825.17,Inpatient DRG
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20179.92,,"Fee schedule rate ($20,179.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,1188.00,20179.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,APC,45378,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|LEFT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
HC Extremity Venogram|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10409.05,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9913.38,10409.05,OPPS APC
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],890.35,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,860.25,903.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Ablation Renal Cysts|RIGHT SIDE,CASE-50541,APC,50541,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Cervical Node,CASE-38510,APC,38510,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3843.64,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6972.00,,"Per diem ($6,972). If length of stay < 3.6, first 1 days paid at a per diem of $13,944 instead. Capped at $25,099.93.",,,,0,other,6972.00,26280.60,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],66888.05,,"Fee schedule rate ($66,888.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.5), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],51131.99,,"Fee schedule rate ($51,131.99). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,EXTREME",710,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],58947.56,,"Case rate ($58,947.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $48,300, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,58947.56,61894.94,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18994.21,,,,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13714.70,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5970.00,38757.79,Inpatient DRG
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5942.94,17634.53,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16361.19,,"Fee schedule rate ($16,361.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,APC,25608,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE,CASE-24073,APC,24073,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3843.64,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3843.64,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24288.44,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",23516.67,23516.67,23516.67,1 through 10,other,23131.85,76404.43,Inpatient DRG
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, THIRD DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3514.75,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11588.85,,"Fee schedule rate ($11,588.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
Revj Total Knee Arthrp W/WO Algrft 1 Component,CASE-27486,APC,27486,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12693.58,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12693.58,46577.81,Inpatient DRG
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],37657.85,,"Fee schedule rate ($37,657.85). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6495.00,,"Per diem ($6,495). If length of stay < 3.5, first 1 days paid at a per diem of $12,990 instead. Capped at $22,732.01.",,,,0,other,6495.00,23801.30,Estimated amount calculated based on 4 day length of stay.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
HC Vasc Embolize Occlude Artery,CASE-37242,APC,37242,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35884.94,,,,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12498.29,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11903.13,48838.99,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6383.11,,"Case rate ($6,079.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.79. The transfer capital threshold is the transfer adjustment factor * $430.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6383.11,6383.11,6383.11,1 through 10,other,6088.84,18067.42,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19772.15,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11298.37,44627.23,All Other Inpatient
Ercp Dx Collection Specimen Brushing/Washing|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43260,APC,43260,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3784.78,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Vasc Embolize Occlude Artery,CASE-37242,APC,37242,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3753.97,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",3652.31,3652.31,3652.31,1 through 10,other,3753.97,11139.15,Inpatient DRG
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10834.31,,"Case rate ($10,318.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.20. The transfer capital threshold is the transfer adjustment factor * $731.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10334.84,30666.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,APC,52352,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13505.88,,"Case rate ($12,862.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,082.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $911.50. The transfer capital threshold is the transfer adjustment factor * $911.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12883.25,44763.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5629.94,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5629.94,16705.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE|PO,CASE-23515,APC,23515,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALNUTRITION FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS,MAJOR",421,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],13297.01,,"Case rate ($13,297.01). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13297.01,13961.86,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
"SIGNS SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS,MAJOR",861,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12233.25,,"Case rate ($12,233.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12233.25,12844.91,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],66951.94,,"Fee schedule rate ($66,951.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, FOURTH DIGIT",CASE-28234,APC,28234,CPT,0360,RC,,,T3,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8071.33,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7686.98,22809.58,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9365.02,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8919.07,34453.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],80943.80,,"Fee schedule rate ($80,943.80). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Medium WO US|LEFT SIDE,CASE-20605,APC,20605,CPT,0510,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],89465.42,,,,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16630.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,16630.26,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28966.51,,,,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
HC Tib per Territory Plasty|LEFT SIDE,CASE-37228,APC,37228,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],488.85,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19173.27,,,,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($55,128.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8679.02,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8679.02,29908.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],59188.55,,"Fee schedule rate ($59,188.55). Adds an outlier to normal pricing equal to the per diem rate ($203,441.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],33289.86,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",33537.54,33537.54,33537.54,1 through 10,other,32637.12,96844.29,Inpatient DRG
Incision & Drainage Leg/Ankle Abscess/Hematoma|LEFT SIDE,CASE-27603,APC,27603,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MINOR",191,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6174.38,,"Case rate for a one day stay ($6,174.38). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,6174.38,6483.10,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17760.46,,,,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, FIFTH DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],163229.10,,"Fee schedule rate ($163,229.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],48720.85,,"Fee schedule rate ($48,720.85). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6905.94,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6770.53,20090.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],8232.00,,"Per diem ($8,232). If length of stay < 9.8, first 1 days paid at a per diem of $16,464 instead. Capped at $80,676.47.",,,,0,other,8232.00,84471.39,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12632.63,,,,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],30403.05,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,30403.05,90685.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL CRANIAL AND AUTONOMIC NERVE DISORDERS,MODERATE",048,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10042.18,,"Case rate ($10,042.18). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10042.18,10544.29,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],51012.62,,,,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27597.52,,"Fee schedule rate ($27,597.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],36287.40,,"Fee schedule rate ($36,287.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],32105.45,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,31019.76,124854.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32101.06,,,,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6256.14,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5224.94,,"Case rate ($4,976.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.63. The transfer capital threshold is the transfer adjustment factor * $352.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4984.06,19757.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14495.80,,"Case rate ($13,805.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,149.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $978.31. The transfer capital threshold is the transfer adjustment factor * $978.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13827.53,41030.48,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14551.41,,"Case rate ($13,858.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,825.31, add-ons for qualifying new technology services are included. If operating cost exceeds $48,293.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,153.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,876.42. The transfer operating threshold is the transfer adjustment factor * $12,825.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $982.06. The transfer capital threshold is the transfer adjustment factor * $982.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7285.00,41187.90,Inpatient DRG
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, SECOND DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
"HC Bx,Vulva/Perineum,Addl Lesion",CASE-56606,APC,56606,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],873.59,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,873.59,917.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|PO,CASE-64636,APC,64636,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12470.75,,"Case rate ($11,876.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,012.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $841.64. The transfer capital threshold is the transfer adjustment factor * $841.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11895.84,35298.57,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5658.75,,"Case rate ($5,389.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,996, add-ons for qualifying new technology services are included. If operating cost exceeds $45,541.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,038.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,998.47. The transfer operating threshold is the transfer adjustment factor * $4,996.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.82. The transfer capital threshold is the transfer adjustment factor * $390.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5389.29,16247.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],31206.03,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13369.00,88188.38,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|RIGHT SIDE|PO,CASE-23430,APC,23430,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Trurl Dstrj Prstate Tiss Rf Thermoth,CASE-53852,APC,53852,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",30771.54,30771.54,30771.54,1 through 10,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],38891.09,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,38891.09,169197.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10519.38,,"Case rate ($10,018.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $709.94. The transfer capital threshold is the transfer adjustment factor * $709.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10034.43,29775.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19377.46,,"Fee schedule rate ($19,377.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],77530.52,,"Fee schedule rate ($77,530.52). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33242.94,,"Fee schedule rate ($33,242.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11730.05,61348.24,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4345.60,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4138.67,12473.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11634.20,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11080.19,32878.30,Inpatient DRG
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs,CASE-25116,APC,25116,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12140.54,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12140.54,36024.65,Inpatient DRG
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE|PO",CASE-64491,APC,64491,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9108.71,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9108.71,27028.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],53631.91,,"Fee schedule rate ($53,631.91). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],20193.62,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19232.02,68941.12,Inpatient DRG
HC Fem Pop Terr Plasty and Stent|LEFT SIDE,CASE-37226,APC,37226,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],484.80,,,,,,0,other,468.41,491.83,There are no additional notes associated with this service or procedure.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, GREAT TOE|PO",CASE-28160,APC,28160,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10432.42,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9935.64,29482.05,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",15022.47,15022.47,15022.47,1 through 10,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,5007.28,16142.41,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21542.42,,"Fee schedule rate ($21,542.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,APC,49650,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.5 Cm/<,CASE-11400,APC,11400,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],705.22,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,671.64,705.22,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11217.46,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11217.46,37366.25,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31767.69,,"Fee schedule rate ($31,767.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11036.50,33262.00,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7770.00,,"Per diem ($7,770). If length of stay < 5.1, first 1 days paid at a per diem of $15,540 instead. Capped at $39,628.80.",,,,0,other,7770.00,50313.90,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7474.95,,"Fee schedule rate ($7,474.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33906.16,,"Fee schedule rate ($33,906.16). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|RIGHT SIDE|PO,CASE-29884,APC,29884,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,APC,49594,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32101.06,,,,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20179.92,,"Fee schedule rate ($20,179.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,1188.00,20179.92,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5348.00,,"Per diem ($5,348). If length of stay < 2.7, first 1 days paid at a per diem of $10,696 instead. Capped at $14,438.66.",,,,0,other,5094.80,15365.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12490.63,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11895.84,35298.57,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],40835.64,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,38891.09,169197.98,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],43051.31,,,,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MAJOR",385,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12349.30,,"Case rate ($12,349.30). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12349.30,12966.77,There are no additional notes associated with this service or procedure.
HC Lyr Clos Nk Hnd Ft <2.6cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-12041,APC,12041,CPT,0450,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36801.89,,,,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE|PO,CASE-24359,APC,24359,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8912.15,,"Case rate ($8,487.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,772.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $601.47. The transfer capital threshold is the transfer adjustment factor * $601.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6178.00,25225.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],20173.98,,"Case rate ($19,213.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,532.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.52. The transfer capital threshold is the transfer adjustment factor * $1,361.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19243.94,63510.03,Inpatient DRG
Corrj Hallux Valgus W/Sesmdc W/2 Osteot,CASE-28299,APC,28299,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5139.97,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4895.21,14525.56,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20056.77,,,,,,0,other,6654.93,20056.77,There are no additional notes associated with this service or procedure.
"CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",163,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],77535.75,,"Case rate ($77,535.75). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $46,813, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,77535.75,81412.54,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15381.51,,,,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MODERATE",192,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],3832.30,,"Case rate for a one day stay ($3,832.30). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3832.30,4023.92,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12755.09,,"Case rate ($12,147.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.83. The transfer capital threshold is the transfer adjustment factor * $860.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12167.07,36103.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12285.95,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7020.54,28431.58,All Other Inpatient
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17118.14,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16302.99,55737.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28291,APC,28291,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,33843.71,Estimated amount calculated based on 10 day length of stay.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23262.15,,,,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12536.42,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,12536.42,46998.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28966.51,,,,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6474.12,,"Case rate ($6,474.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,981.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,449.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,005.76. The transfer operating threshold is the transfer adjustment factor * $5,981.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.35. The transfer capital threshold is the transfer adjustment factor * $468.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6474.12,19210.66,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7642.05,,"Case rate ($7,278.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.75. The transfer capital threshold is the transfer adjustment factor * $515.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7289.74,21630.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11084.14,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10556.32,32082.48,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],25459.44,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,25459.44,80806.10,Inpatient DRG
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26123,APC,26123,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4871.91,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4639.91,13771.19,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4234.02,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,2285.00,12138.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],41585.15,,"Fee schedule rate ($41,585.15). Adds an outlier to normal pricing equal to the per diem rate ($65,246.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",65301.64,65301.64,87645.83,1 through 10,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7287.29,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6940.28,20593.95,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8015.04,,"Case rate ($7,744). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,731.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $560.22. The transfer capital threshold is the transfer adjustment factor * $560.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7744.00,24853.45,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15522.47,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15218.11,45156.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13100.31,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,38110.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3607.42,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3607.42,11497.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,MODERATE",770,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5396.17,,"Case rate ($5,396.17). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5396.17,5665.98,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30145.85,,"Fee schedule rate ($30,145.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8683.48,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",8683.48,6856.58,8687.84,1 through 10,other,8513.22,25261.33,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
HC Intro Cath Dialysis Circuit,CASE-36901,APC,36901,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1493.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",1442.15,1442.15,1456.91,11,other,1493.03,1567.69,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19668.75,,"Fee schedule rate ($19,668.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],32807.56,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,32807.56,111191.81,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
HC Fem Pop Territory Plasty|LEFT SIDE,CASE-37224,APC,37224,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],401.21,,,,,,0,other,401.21,421.27,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],67175.58,,"Fee schedule rate ($67,175.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5475.37,,"Case rate ($5,368.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,959.91, add-ons for qualifying new technology services are included. If operating cost exceeds $40,427.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,559.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,979.68. The transfer operating threshold is the transfer adjustment factor * $4,959.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $388.34. The transfer capital threshold is the transfer adjustment factor * $388.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5368.01,15928.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Vaginal Cyst/Tumor,CASE-57135,APC,57135,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4138.67,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4138.67,12473.25,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10597.94,,"Case rate ($10,093.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,886.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $715.24. The transfer capital threshold is the transfer adjustment factor * $715.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10109.37,38416.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22509.90,,"Fee schedule rate ($22,509.90). Adds an outlier to normal pricing equal to the per diem rate ($4,143.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,6965.00,25698.16,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],26419.65,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,26419.65,96304.23,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7729.11,,"Case rate ($7,577.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,001.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,469.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,029.37. The transfer operating threshold is the transfer adjustment factor * $7,001.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.18. The transfer capital threshold is the transfer adjustment factor * $548.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7577.56,31445.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10999.76,,"Case rate ($10,475.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,694.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,162.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,913.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,733.59. The transfer operating threshold is the transfer adjustment factor * $9,694.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.36. The transfer capital threshold is the transfer adjustment factor * $742.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10492.66,31134.92,Inpatient DRG
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,APC,45385,CPT,0360,RC,,,PT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31699.87,,"Fee schedule rate ($31,699.87). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],3980.76,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3980.76,11812.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7839.48,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7551.60,23262.15,Inpatient DRG
Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc,CASE-34421,APC,34421,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Mastectomy Partial|RIGHT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",3623.82,3623.82,3623.82,1 through 10,other,3713.66,3713.66,OPPS APC
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16219.35,,"Fee schedule rate ($16,219.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
HC Fem Pop Terr Plasty and Stent|RIGHT SIDE,CASE-37226,APC,37226,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],491.83,,,,,,0,other,468.41,491.83,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion S/N/H/F/G 1.1-2.0 Cm,CASE-11622,APC,11622,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1621.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MINOR",282,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7172.79,,"Case rate ($7,172.79). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7172.79,7531.43,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",82135.79,82135.79,82135.79,1 through 10,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5091.00,,"Per diem ($5,091). If length of stay < 3.2, first 1 days paid at a per diem of $10,182 instead. Capped at $16,289.77.",,,,0,other,5091.00,22010.11,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula,CASE-27641,APC,27641,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,MINOR",175,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11860.62,,"Case rate for a one day stay ($11,860.62). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,11860.62,12453.65,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],43602.60,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,43602.60,153667.90,Inpatient DRG
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26455.73,,,,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8147.92,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7759.92,35376.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16865.38,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16062.27,48077.57,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5026.81,,"Case rate ($4,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,510.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $339.25. The transfer capital threshold is the transfer adjustment factor * $339.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",36938.57,36938.57,36938.57,1 through 10,other,4795.07,19830.58,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],60333.05,,"Fee schedule rate ($60,333.05). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14271.69,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13789.07,57367.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10249.98,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9761.89,37873.87,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6068.82,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5779.83,17150.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5911.44,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5629.94,16705.77,Inpatient DRG
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE|PO",CASE-28289,APC,28289,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Exc Tumor Soft Tissue Abdominal Wall Subq <3cm,CASE-22902,APC,22902,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5934.68,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],47991.51,,"Fee schedule rate ($47,991.51). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6240.68,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6240.68,18518.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13508.48,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13051.67,38728.27,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12196.66,,"Fee schedule rate ($12,196.66). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34556.75,,,,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22379.34,,"Fee schedule rate ($22,379.34). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
Chemodenervation Internal Anal Sphincter,CASE-46505,APC,46505,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5779.85,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5504.62,16333.88,Inpatient DRG
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],41015.72,,"Fee schedule rate ($41,015.72). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Femur/Knee|RIGHT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],233.96,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,233.96,245.65,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],24785.70,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",25134.05,25134.05,267979.16,1 through 10,other,9242.00,76216.30,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],27349.91,,"Fee schedule rate ($27,349.91). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10635.47,,"Case rate ($10,129.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $717.78. The transfer capital threshold is the transfer adjustment factor * $717.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,30103.84,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19377.46,,"Fee schedule rate ($19,377.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO,CASE-27601,APC,27601,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],163229.10,,"Fee schedule rate ($163,229.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7179.38,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6837.50,20288.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],47889.67,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,45609.21,211906.58,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7011.91,,"Case rate ($7,011.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,678.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7011.91,27304.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,Zero final payments for the item or service in the 15 months prior to posting the file.
HC I&D Hematoma Seroma Fluid,CASE-10140,APC,10140,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|RIGHT SIDE,CASE-37225,APC,37225,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],538.93,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm|PO,CASE-11421,APC,11421,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],705.22,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,695.15,705.22,OPPS APC
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13444.53,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12804.31,55145.09,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],31657.92,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30150.40,89465.42,Inpatient DRG
Unlisted Laps Px Hrnap Herniorrhaphy Herniotomy,CASE-49659,APC,49659,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
Prq Skeletal Fix Carpo/Metacarpal Fx Dislc Thumb,CASE-26650,APC,26650,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16307.62,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8558.00,48389.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12565.46,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12140.54,36024.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17634.53,,,,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10446.35,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9948.90,46199.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],31019.76,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31019.76,124854.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cv Cath Plac WO Port>5yr (Tun),CASE-36558,APC,36558,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3068.11,345.81,3068.43,1 through 10,other,2994.77,3144.51,OPPS APC
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE,CASE-28615,APC,28615,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21245.95,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12140.54,36024.65,All Other Inpatient
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13046.89,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",13046.89,13046.89,13046.89,1 through 10,other,12791.07,43031.63,Inpatient DRG
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15824.86,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15824.86,49371.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9754.91,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",9925.01,9925.01,9925.01,1 through 10,other,9425.03,27966.92,Inpatient DRG
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10034.43,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10034.43,29775.24,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23153.74,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13230.71,39259.55,All Other Inpatient
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FIFTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,13588.14,40320.14,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11634.20,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11080.19,32878.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7350.67,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7102.10,21074.07,Inpatient DRG
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12500.00,,"Per diem ($12,500). If length of stay < 4.8, first 1 days paid at a per diem of $25,000 instead. Capped at $60,002.29.",,,,0,other,12500.00,83592.64,Estimated amount calculated based on 5 day length of stay.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11297.91,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10759.91,46061.32,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29257.73,,,,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
HC Fem Pop Terr Plasty and Stent|LEFT SIDE,CASE-37226,APC,37226,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],468.41,,,,,,0,other,468.41,491.83,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12803.67,,"Fee schedule rate ($12,803.67). Adds an outlier to normal pricing equal to the per diem rate ($91,038.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FIFTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38792,APC,38792,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13866.64,,"Case rate ($13,866.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,812.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,280.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,174.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,863.50. The transfer operating threshold is the transfer adjustment factor * $12,812.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,003.15. The transfer capital threshold is the transfer adjustment factor * $1,003.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13866.64,41146.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13972.09,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7984.05,23691.11,All Other Inpatient
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],20277.85,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8972.00,76376.03,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9312.29,27632.41,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5482.46,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5297.06,19049.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, GREAT TOE|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15023.80,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15023.80,48104.19,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Synovectomy Metatarsophalangeal Joint Each,CASE-28072,APC,28072,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24819.03,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7308.00,42083.20,All Other Inpatient
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33771.02,,"Fee schedule rate ($33,771.02). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],29463.75,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8232.00,84471.39,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8675.02,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8294.89,8294.89,8294.89,1 through 10,other,8675.02,25741.45,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],43541.27,,,,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39259.55,,,,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
"RENAL DIALYSIS ACCESS DEVICE PROCEDURES,MAJOR",444,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],30791.53,,"Case rate ($29,325.27). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29325.27,30791.53,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6590.21,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,18893.86,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10114.68,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10114.68,30013.33,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
HC Tib per Territory Ather,CASE-37229,APC,37229,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],626.55,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27597.52,,"Fee schedule rate ($27,597.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14495.80,,"Case rate ($13,805.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,149.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $978.31. The transfer capital threshold is the transfer adjustment factor * $978.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",14732.96,14732.96,14732.96,1 through 10,other,13827.53,41030.48,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],27682.71,,of the excess amount.,20520.43,11250.39,32343.74,1 through 10,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16783.66,,"Fee schedule rate ($16,783.66). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7532.22,,"Case rate ($7,173.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.34. The transfer capital threshold is the transfer adjustment factor * $508.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7184.98,21320.03,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7125.07,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6785.78,20135.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4283.52,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4138.67,12473.25,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7102.10,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7102.10,21074.07,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, THUMB|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5102.84,1537.76,5102.84,1 through 10,other,1852.10,1944.70,OPPS APC
Bladder Instillation Anticarcinogenic Agent,CASE-51720,APC,51720,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4631.96,,"Case rate ($4,411.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,483.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.61. The transfer capital threshold is the transfer adjustment factor * $312.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4418.42,13110.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7891.21,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7891.21,23415.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33947.68,,"Fee schedule rate ($33,947.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5854.09,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,17370.86,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],50697.38,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13061.00,162464.13,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],110217.19,,"Fee schedule rate ($110,217.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,APC,49650,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf|LEFT SIDE,CASE-36825,APC,36825,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23895.30,,"Fee schedule rate ($23,895.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9025.92,,"Case rate ($8,596.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,942.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,410.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,974.25. The transfer operating threshold is the transfer adjustment factor * $7,942.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.86. The transfer capital threshold is the transfer adjustment factor * $621.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8596.11,25507.30,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11159.78,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11159.79,11159.79,11159.79,1 through 10,other,11159.78,39897.21,Inpatient DRG
Partial Excision Bone Fibula|LEFT SIDE|PO,CASE-27641,APC,27641,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],10704.29,,,,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5287.33,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5183.66,15743.06,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15312.64,,,,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6033.12,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6033.12,17902.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23624.56,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23624.56,83038.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36695.64,,,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],43602.60,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,43602.60,153667.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26820.85,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,15326.20,52511.19,All Other Inpatient
Crtj Arven Fstl Xcp Dir Arven Anast Nonautog Grf,CASE-36830,APC,36830,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6785.78,20135.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14064.85,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13789.07,57367.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28195.14,,"Fee schedule rate ($28,195.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25459.44,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,25459.44,80806.10,Inpatient DRG
Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|LEFT SIDE|PO,CASE-25290,APC,25290,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],33095.90,,"Case rate ($31,519.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,404.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,233.61. The transfer capital threshold is the transfer adjustment factor * $2,233.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",32186.73,32186.73,366079.17,1 through 10,other,31570.16,98176.71,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],70442.40,,"Fee schedule rate ($70,442.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28195.14,,"Fee schedule rate ($28,195.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16831.01,,"Fee schedule rate ($16,831.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24787.16,,"Case rate ($23,606.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.86. The transfer capital threshold is the transfer adjustment factor * $1,672.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23644.46,105789.11,Inpatient DRG
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8066.12,,"Case rate ($7,682.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,715.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.37. The transfer capital threshold is the transfer adjustment factor * $544.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7694.27,22831.22,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21229.52,,,,,,0,other,6965.00,21229.52,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5418.47,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5160.45,15312.64,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],47661.63,,,,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],67175.58,,"Fee schedule rate ($67,175.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11026.52,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10810.31,32077.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36556,APC,36556,CPT,0761,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,MODERATE",281,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11961.10,,"Case rate ($11,961.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11961.10,12559.16,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MODERATE",422,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2545.29,,"Case rate for a one day stay ($2,424.09). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2424.09,2545.29,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,APC,52332,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7285.00,,"Per diem ($7,285). If length of stay < 5.4, first 1 days paid at a per diem of $14,570 instead. Capped at $39,337.51.",,,,0,other,7285.00,41187.90,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt,CASE-25020,APC,25020,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33692.09,,"Fee schedule rate ($33,692.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19917.48,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,19243.94,63510.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],27453.55,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18843.46,,"Fee schedule rate ($18,843.46). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14367.19,,"Case rate ($13,683.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,140.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $969.63. The transfer capital threshold is the transfer adjustment factor * $969.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13704.86,49911.01,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8021.19,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6495.00,23801.30,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],135336.44,,,,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26800.70,,"Fee schedule rate ($26,800.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64418,APC,64418,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2,CASE-29822,APC,29822,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11651.83,,"Case rate ($11,096.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,957.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.37. The transfer capital threshold is the transfer adjustment factor * $786.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7000.00,32980.62,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10648.40,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10439.61,34540.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11674.21,,"Fee schedule rate ($11,674.21). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4119.35,12223.35,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23130.31,,,,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, THIRD DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14347.61,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13664.39,40546.43,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],57456.84,,,,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9498.54,,"Case rate ($9,312.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,604.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,072.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,638.62. The transfer operating threshold is the transfer adjustment factor * $8,604.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.67. The transfer capital threshold is the transfer adjustment factor * $673.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",9367.67,9366.41,63768.97,1 through 10,other,9312.29,27632.41,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19726.05,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29257.73,,,,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8405.52,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8005.26,24549.95,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
Ercp Dx Collection Specimen Brushing/Washing,CASE-43260,APC,43260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3784.78,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Vaginectomy Partial Removal Vaginal Wall,CASE-57106,APC,57106,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30013.33,,,,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],29816.75,,"Fee schedule rate ($29,816.75). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,APC,49650,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE|PO,CASE-27524,APC,27524,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],54542.68,,,,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
Revascularization Iliac Artery Angiop 1st Vsl|LEFT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],361.50,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],661.36,,"APC Price ($661.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,661.36,694.43,OPPS APC
"OTHER CIRCULATORY SYSTEM DIAGNOSES,MODERATE",207,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8957.70,,"Case rate ($8,957.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8957.70,9405.59,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14848.26,,,,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5958.34,,"Case rate ($5,674.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,573.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.12. The transfer capital threshold is the transfer adjustment factor * $402.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.66,16865.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12556.78,,"Case rate ($11,958.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,049.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,517.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,093.70. The transfer operating threshold is the transfer adjustment factor * $11,049.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.13. The transfer capital threshold is the transfer adjustment factor * $865.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11958.84,40774.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6010.58,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6010.58,17835.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Bone,1st 20sqcm or Less",CASE-11044,APC,11044,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32019.51,,"Fee schedule rate ($32,019.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,APC,43246,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],61348.24,,"Fee schedule rate ($61,348.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13704.25,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13051.67,38728.27,Inpatient DRG
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn|PO,CASE-62321,APC,62321,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",665.41,665.41,665.41,1 through 10,other,669.51,702.98,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],43051.31,,,,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6681.01,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6681.01,19824.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],66275.39,,"Fee schedule rate ($66,275.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15459.57,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15156.44,52672.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,APC,52332,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
HC Thromb Mech Vein,CASE-37187,APC,37187,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29521.40,,,,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,APC,94640,CPT,0410,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9495.16,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,33447.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],64029.63,,"Fee schedule rate ($64,029.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.5), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],42619.50,,"Fee schedule rate ($42,619.50). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],68446.35,,"Fee schedule rate ($68,446.35). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",22561.52,22561.52,22561.52,1 through 10,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9717.86,,"Case rate ($9,255.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,827.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.85. The transfer capital threshold is the transfer adjustment factor * $655.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9269.86,37852.57,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,APC,67900,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2367.72,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2254.97,2367.72,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16283.27,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15507.88,46016.63,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
Tx Missed Abortion First Trimester Surgical,CASE-59820,APC,59820,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8513.22,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8513.22,25261.33,Inpatient DRG
"Inject Nerv Blck,Paravert Sympath|PO",CASE-64520,APC,64520,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7178.36,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6382.95,21300.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],27815.10,,"Fee schedule rate ($27,815.10). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17958.55,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17103.38,50750.92,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,25698.16,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,XU|T6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14583.66,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13889.20,55846.16,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23542.31,,"Fee schedule rate ($23,542.31). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4263.95,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",1640.91,1640.91,1640.91,1 through 10,other,4180.34,14351.57,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,28788.33,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
Repair Brow Ptosis,CASE-67900,APC,67900,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf,CASE-36825,APC,36825,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10519.38,,"Case rate ($10,018.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $709.94. The transfer capital threshold is the transfer adjustment factor * $709.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10034.43,29775.24,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],46830.28,,"Fee schedule rate ($46,830.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20373.57,,,,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Brow Ptosis|BILATERAL PROCEDURE|PO,CASE-67900,APC,67900,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2333.89,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Gastrostomy W/O Constj Gstr Tube Spx,CASE-43653,APC,43653,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5605.96,5605.96,5605.96,1 through 10,other,5733.99,6020.69,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],64621.61,,"Fee schedule rate ($64,621.61). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,22802.30,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3076.69,3076.69,3076.69,1 through 10,other,3103.39,3258.56,OPPS APC
"SICKLE CELL ANEMIA CRISIS,MINOR",662,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7197.66,,"Case rate ($7,197.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7197.66,7557.54,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],92045.07,,,,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Add 2nd/3rd Order Abd/Le|LEFT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11878.75,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11645.83,37502.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,APC,58661,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],53232.25,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13061.00,162464.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
Syndactylization Toes|BILATERAL PROCEDURE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],102807.11,,"Fee schedule rate ($102,807.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17584.61,,"Fee schedule rate ($17,584.61). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6204.88,19589.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Ganglion Wrist Dorsal/Volar Primary|PO,CASE-25111,APC,25111,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,APC,52281,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2081.79,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1996.84,1996.84,1996.84,1 through 10,other,1982.66,2081.79,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],39867.32,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,66445.54,Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|RIGHT SIDE,CASE-37765,APC,37765,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Medium WO US|RIGHT SIDE|PO,CASE-20605,APC,20605,CPT,0510,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],88173.00,,"Fee schedule rate ($88,173.00). Adds an outlier to normal pricing equal to the per diem rate ($170,052.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",89340.04,89340.04,89340.04,1 through 10,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10849.96,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",10929.06,10929.06,10929.06,1 through 10,other,10637.22,31563.88,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8852.60,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8679.02,29908.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
Revasc lithotrip tibi/perone,CASE-C9772,APC,C9772,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
Tx Tibl Shft Fx Imed Implt W/WO Screws&/Cercla,CASE-27759,APC,27759,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6793.95,,"Case rate ($6,470.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,629.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $458.52. The transfer capital threshold is the transfer adjustment factor * $458.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6480.75,29542.64,Inpatient DRG
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
Ligj & Div Short Saph Vein Saphenopop Junct Spx,CASE-37780,APC,37780,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5354.09,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5354.09,15887.21,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14206.79,,,,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
Syndactylization Toes|LEFT SIDE,CASE-28280,APC,28280,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],99157.51,,"Fee schedule rate ($99,157.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34988.57,110685.97,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],190.30,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia & Fibula,CASE-27828,APC,27828,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",3531.97,3531.97,3531.97,1 through 10,other,3656.79,3839.63,OPPS APC
Arthrodesis Subtalar|LEFT SIDE|PO,CASE-28725,APC,28725,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35544.53,,,,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
Optx Greater Humeral Tuberosity Fx W/Int Fixj,CASE-23630,APC,23630,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6762.29,,"Case rate ($6,440.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,950.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,418.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,637.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,974.38. The transfer operating threshold is the transfer adjustment factor * $5,950.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $465.91. The transfer capital threshold is the transfer adjustment factor * $465.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6440.28,19110.30,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
Manipulation Knee Joint Under General Anesthesia,CASE-27570,APC,27570,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MODERATE",720,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11912.19,,"Case rate ($11,344.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11344.94,11912.19,There are no additional notes associated with this service or procedure.
Implant Neurostim/Receiver,CASE-64590,APC,64590,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19320.40,,"APC Price ($18,400.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",18852.96,18852.96,18852.96,1 through 10,other,18400.38,19320.40,OPPS APC
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8192.28,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8192.28,24308.97,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13802.22,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",13437.80,13437.80,13437.80,1 through 10,other,13335.48,39570.45,Inpatient DRG
Dstrj Lesion Anus Simple Laser Surg,CASE-46917,APC,46917,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14745.18,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14043.03,54637.47,Inpatient DRG
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14583.66,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13889.20,55846.16,Inpatient DRG
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5912.00,,"Per diem ($5,912). If length of stay < 2.4, first 1 days paid at a per diem of $11,824 instead. Capped at $14,188.72.",,,,0,other,5006.61,14856.14,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],37649.21,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,36910.99,126842.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39359.90,,,,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22524.26,,,,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T4|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,MAJOR",951,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],31795.41,,"Case rate ($31,795.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31795.41,33385.18,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],20306.22,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Medium WO US|LEFT SIDE,CASE-20605,APC,20605,CPT,0510,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
Exc Tumor Soft Tissue Leg/Ankle Subq <3cm|LEFT SIDE,CASE-27618,APC,27618,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9371.28,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8925.03,26628.31,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14858.10,,,,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|PO,CASE-64493,APC,64493,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",855.44,855.44,855.44,1 through 10,other,838.89,880.84,OPPS APC
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR PELVIS AND BACK,MODERATE",342,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9713.11,,"Case rate ($9,250.58). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9250.58,9713.11,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11924.75,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",12046.32,12046.32,12046.32,1 through 10,other,11690.93,56733.59,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17501.40,,"Fee schedule rate ($17,501.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE,CASE-27339,APC,27339,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7970.35,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7590.81,32847.45,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],31011.11,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,30403.05,90685.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10625.29,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10625.29,39295.53,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16320.00,,"Per diem ($16,320). If length of stay < 2.1, first 1 days paid at a per diem of $32,640 instead. Capped at $34,272.79.",,,,0,other,12093.45,40067.60,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],136003.49,,,,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],129893.46,,"Fee schedule rate ($129,893.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|LEFT HAND, FIFTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6387.91,18954.85,Estimated amount calculated based on 3 day length of stay.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29008.87,,"Fee schedule rate ($29,008.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15188.29,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8679.02,29908.27,All Other Inpatient
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14718.77,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14718.77,51765.74,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7056.33,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7056.33,28335.74,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17937.69,,"Fee schedule rate ($17,937.69). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11444.12,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10899.16,39746.35,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5595.76,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5486.04,17919.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],44803.76,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,42670.25,133443.30,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23014.22,,,,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],25949.09,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24713.42,73332.24,Inpatient DRG
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21300.35,,,,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34759.42,,,,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
Tendon Sheath Incision|PO,CASE-26055,APC,26055,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],3679.57,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3607.42,11497.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],29712.45,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,29129.85,86437.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],47660.93,,"Fee schedule rate ($47,660.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],45477.48,,,,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4090.84,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,2285.00,12138.74,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9711.08,,"Case rate ($5,549.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,050.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.42. The transfer capital threshold is the transfer adjustment factor * $402.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5549.19,16729.39,All Other Inpatient
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20806.46,,,,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],83439.30,,"Fee schedule rate ($83,439.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,APC,20552,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",7141.90,7141.90,7141.90,1 through 10,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
Transurethral Resection Bladder Neck|SEPARATE STRUCTURE,CASE-52500,APC,52500,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5504.62,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5504.62,16333.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11217.46,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11217.46,37366.25,Inpatient DRG
HC Intro Cath Dialysis Circuit|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-36901,APC,36901,CPT,0361,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1545.29,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Myomectomy Exc 1-4 Myomas 250 Gm/<,CASE-58545,APC,58545,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5623.19,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5355.42,17067.11,Inpatient DRG
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25225.91,,,,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17111.12,,,,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16149.61,,"Case rate ($15,380.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.92. The transfer capital threshold is the transfer adjustment factor * $1,089.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,55581.70,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",83363.81,83363.81,83363.81,1 through 10,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17214.39,,"Fee schedule rate ($17,214.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],68621.57,,,,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
Dir Rpr Aneurysm Axil-Brachial Arm Incision,CASE-35011,APC,35011,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
Unlisted Procedure Femur/Knee|RIGHT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],233.96,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,233.96,245.65,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15499.26,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6972.00,26280.60,All Other Inpatient
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12423.25,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12179.66,36140.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21112.63,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21112.63,62647.63,Inpatient DRG
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19137.85,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",19490.74,19490.74,19490.74,1 through 10,other,19137.85,64589.15,Inpatient DRG
"MAJOR SMALL BOWEL PROCEDURES,MAJOR",230,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],38303.69,,"Case rate ($38,303.69). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,38303.69,40218.87,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],45156.75,,,,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15407.35,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14673.67,43541.27,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21288.16,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20274.44,80940.99,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5942.94,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5942.94,17634.53,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13572.00,,"Per diem ($13,572). If length of stay < 5.8, first 1 days paid at a per diem of $27,144 instead. Capped at $78,720.12.",,,,0,other,13572.00,108637.77,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"MIGRAINE AND OTHER HEADACHES,MODERATE",054,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3426.76,,"Case rate for a one day stay ($3,263.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3263.58,3426.76,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MINOR",229,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15795.40,,"Case rate ($15,043.24). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15043.24,15795.40,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5183.66,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5183.66,15743.06,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
Laparoscopy Surgical Jejunostomy,CASE-44186,APC,44186,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],63653.13,,,,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10353.04,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9860.04,30039.61,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30493.52,,"Fee schedule rate ($30,493.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7078.89,,"Case rate ($7,078.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,540.71, add-ons for qualifying new technology services are included. If operating cost exceeds $42,008.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,683.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,566.78. The transfer operating threshold is the transfer adjustment factor * $6,540.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.10. The transfer capital threshold is the transfer adjustment factor * $512.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7078.89,21005.20,Inpatient DRG
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6346.81,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32364.15,,"Fee schedule rate ($32,364.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
Transurethral Resection Bladder Neck|SEPARATE STRUCTURE,CASE-52500,APC,52500,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,76376.03,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8078.98,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7694.27,22831.22,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22883.08,,"Case rate ($21,793.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,715.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,544.36. The transfer capital threshold is the transfer adjustment factor * $1,544.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",21352.00,21352.00,21352.00,1 through 10,other,21828.16,93157.39,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7266.26,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7020.54,28431.58,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27484.83,,,,,,0,other,1188.00,27484.83,There are no additional notes associated with this service or procedure.
"URETHRAL AND TRANSURETHRAL PROCEDURES,MINOR",446,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5872.41,,"Case rate for a one day stay ($5,592.77). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5592.77,5872.41,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12536.42,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12536.42,37199.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14532.48,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14041.04,60059.69,Inpatient DRG
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB|PO",CASE-26540,APC,26540,CPT,0360,RC,,,F5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28437.57,,"Fee schedule rate ($28,437.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
Tnols Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|LEFT SIDE|PO,CASE-25295,APC,25295,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6858.59,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6724.11,19952.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],14651.02,,"Fee schedule rate ($14,651.02). Adds an outlier to normal pricing equal to the per diem rate ($61,007.55) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation|RIGHT SIDE|PO,CASE-28615,APC,28615,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15454.71,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14718.77,51765.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Colon Ca Scrn Not Hi Rsk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],882.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21451.50,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8940.00,63653.13,Inpatient DRG
I&D Ischiorct/Intramural Absc W/WO Seton,CASE-46060,APC,46060,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10818.26,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10818.26,38164.94,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21005.20,,,,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|LEFT SIDE,CASE-27446,APC,27446,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",13615.64,13615.64,13615.64,1 through 10,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7590.81,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7590.81,32847.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39298.04,,"Fee schedule rate ($39,298.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13866.64,41146.57,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12093.45,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12093.45,35884.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Pyeloscopy Rescj Pelvic Tumor|LEFT SIDE,CASE-52355,APC,52355,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],903.26,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",262.68,262.68,262.68,1 through 10,other,860.25,903.26,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22002.56,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20954.82,62179.32,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],59684.28,,,,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26300.80,,"Fee schedule rate ($26,300.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18944.48,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18042.36,82749.58,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],3753.97,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3753.97,11139.15,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23950.83,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23950.83,74869.17,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6834.24,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6700.24,30254.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14321.86,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14041.04,60059.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6098.05,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",4062.71,4062.71,4062.71,1 through 10,other,5807.67,17233.12,Inpatient DRG
Mastectomy Partial|LEFT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC
Partial Excision Bone Fibula|RIGHT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14718.77,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14718.77,51765.74,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],47978.53,,"Fee schedule rate ($47,978.53). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],37541.70,,"Fee schedule rate ($37,541.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22946.70,,"Fee schedule rate ($22,946.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32876.47,,"Fee schedule rate ($32,876.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],58602.56,,"Case rate ($55,811.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,126.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,955.03. The transfer capital threshold is the transfer adjustment factor * $3,955.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,55900.95,225294.39,Inpatient DRG
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|LEFT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],180.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,APC,49593,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6140.21,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5792.73,5792.73,5792.73,1 through 10,other,6140.21,6447.22,OPPS APC
Fasciotomy Foot&/Toe|LEFT SIDE,CASE-28008,APC,28008,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO,CASE-62323,APC,62323,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",665.41,665.41,665.41,1 through 10,other,669.51,702.98,OPPS APC
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],25907.78,,"Case rate ($24,674.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,919.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,748.49. The transfer capital threshold is the transfer adjustment factor * $1,748.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24713.42,73332.24,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
"MAJOR PANCREAS LIVER AND SHUNT PROCEDURES,MINOR",260,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],24197.18,,"Case rate ($23,044.93). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23044.93,24197.18,There are no additional notes associated with this service or procedure.
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ligj Divj & Stripping Short Saphenous Vein,CASE-37718,APC,37718,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13466.94,,,,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10480.15,,"Fee schedule rate ($10,480.15). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8067.90,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",11430.91,11430.91,11430.91,1 through 10,other,7795.07,34198.12,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],40890.77,,,,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],87904.85,,"Fee schedule rate ($87,904.85). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12154.72,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11916.39,58492.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],33734.25,,"Case rate ($33,072.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,563.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,392.57. The transfer capital threshold is the transfer adjustment factor * $2,392.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",316774.55,316774.55,316774.55,1 through 10,other,33072.79,98455.37,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14789.23,,,,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26534.72,,"Fee schedule rate ($26,534.72). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12183.16,,"Case rate ($11,603.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,470.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $822.73. The transfer capital threshold is the transfer adjustment factor * $822.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,35040.80,Inpatient DRG
Tnot Elbow Lateral/Medial Debride Open,CASE-24358,APC,24358,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],163229.10,,"Fee schedule rate ($163,229.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5297.06,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5297.06,19049.64,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10210.03,,"Case rate ($9,723.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.07. The transfer capital threshold is the transfer adjustment factor * $689.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9739.34,40204.26,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14041.04,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14041.04,60059.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11034.63,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10818.26,38164.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5224.00,,"Per diem ($5,224). If length of stay < 2.9, first 1 days paid at a per diem of $10,448 instead. Capped at $15,149.04.",,,,0,other,5224.00,15861.63,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|PO",CASE-64491,APC,64491,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,EXTREME",951,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],57057.25,,"Case rate ($54,340.24). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,544, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,54340.24,57057.25,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Tum/Vas Mal Sft Tis Hand/Fngr Subfasc<1.5cm|LEFT HAND, THUMB|PO",CASE-26116,APC,26116,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1621.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, GREAT TOE",CASE-28810,APC,28810,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Removal Loose/Foreign Body,CASE-29874,APC,29874,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25830.00,,,,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19110.30,,,,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33104.58,,,,,,0,other,11156.45,42003.98,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15065.57,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15065.57,53815.71,Inpatient DRG
Bx Anorectal Wall Anal Approach,CASE-45100,APC,45100,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
"LOWER EXTREMITY VASCULAR PROCEDURES,MAJOR",181,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],41768.51,,"Case rate ($41,768.51). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,41768.51,43856.94,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21399.79,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21399.79,63499.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy 2/>Compartments|RIGHT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, SECOND DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Bimalleolar Ankle Fracture,CASE-27814,APC,27814,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17186.38,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16849.39,49997.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],45709.85,,"Case rate ($43,533.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,256.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,084.91. The transfer capital threshold is the transfer adjustment factor * $3,084.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,43602.60,153667.90,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],62827.80,,"Fee schedule rate ($62,827.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
"FOOT AND TOE PROCEDURES,MODERATE",314,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],17775.45,,"Case rate ($16,929.00). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16929.00,17775.45,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],48049.11,,"Case rate ($45,761.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,413.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,242.79. The transfer capital threshold is the transfer adjustment factor * $3,242.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,45834.02,151120.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],31426.50,,"Fee schedule rate ($31,426.50). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5982.12,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5779.83,17150.47,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10600.80,,"Fee schedule rate ($10,600.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5475.37,,"Case rate ($5,368.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,959.91, add-ons for qualifying new technology services are included. If operating cost exceeds $40,427.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,559.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,979.68. The transfer operating threshold is the transfer adjustment factor * $4,959.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $388.34. The transfer capital threshold is the transfer adjustment factor * $388.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",5353.40,5353.40,5353.40,1 through 10,other,5368.01,15928.53,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",45937.57,45937.57,45937.57,1 through 10,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30764.99,,,,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10295.54,,"Case rate ($9,805.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,865.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.84. The transfer capital threshold is the transfer adjustment factor * $694.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",10275.09,963.62,10295.54,13,other,9820.91,29141.64,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7345.46,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6308.00,21796.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23131.85,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23131.85,76404.43,Inpatient DRG
Revascularization Iliac Artery Angiop 1st Vsl|LEFT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],374.15,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11967.90,,"Fee schedule rate ($11,967.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7984.05,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7984.05,7984.05,7984.05,1 through 10,other,7984.05,23691.11,Inpatient DRG
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],55900.95,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",39871.09,39871.09,39871.09,1 through 10,other,55900.95,225294.39,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11895.84,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11895.84,35298.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],40862.09,,"Case rate ($38,916.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,957.67, add-ons for qualifying new technology services are included. If operating cost exceeds $71,425.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,986.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $36,100.97. The transfer operating threshold is the transfer adjustment factor * $35,957.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,815.30. The transfer capital threshold is the transfer adjustment factor * $2,815.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,38916.28,133824.90,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31617.34,,"Fee schedule rate ($31,617.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11156.45,42003.98,There are no additional notes associated with this service or procedure.
Colonoscopy Stoma Dx Including Collj Spec Spx,CASE-44388,APC,44388,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE,CASE-27339,APC,27339,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10594.29,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10236.03,30589.82,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8625.05,,"Case rate ($8,214.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,753.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $582.10. The transfer capital threshold is the transfer adjustment factor * $582.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8227.43,27001.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE|PO,CASE-25628,APC,25628,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15618.80,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8925.03,26628.31,All Other Inpatient
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy,CASE-27675,APC,27675,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21616.16,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",20987.06,20987.06,20987.06,1 through 10,other,20885.18,80720.91,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,Zero final payments for the item or service in the 15 months prior to posting the file.
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,EXTREME",137,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],23746.74,,"Case rate ($23,746.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,23746.74,24934.08,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10961.59,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10439.61,34540.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"CELLULITIS AND OTHER SKIN INFECTIONS,MINOR",383,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6279.58,,"Case rate ($5,980.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5980.55,6279.58,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvc/Le Init 2nd,CASE-36246,APC,36246,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13.28,,,,,,0,other,13.28,13.94,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14263.03,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7770.00,50313.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13061.62,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5970.00,38757.79,Inpatient DRG
HC Debrid Wound Tis 20 Cm/<|PBB CHARGE,CASE-97597,APC,97597,CPT,0761,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6374.64,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6230.00,21325.01,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11901.14,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11901.14,35314.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, THIRD DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27943.31,,"Fee schedule rate ($27,943.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],45226.79,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,44339.99,131570.26,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],86795.47,,"Fee schedule rate ($86,795.47). Adds an outlier to normal pricing equal to the per diem rate ($211,362.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30626.53,106200.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8925.03,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8925.03,26628.31,Inpatient DRG
"DIVERTICULITIS AND DIVERTICULOSIS,MAJOR",244,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],13946.32,,"Case rate ($13,946.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13946.32,14643.64,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6597.75,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6230.00,21325.01,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13572.00,,"Per diem ($13,572). If length of stay < 5.8, first 1 days paid at a per diem of $27,144 instead. Capped at $78,720.12.",,,,0,other,13572.00,108637.77,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Complete 5th Metatarsal Head|LEFT SIDE,CASE-28113,APC,28113,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24508.40,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23679.61,84629.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,66445.54,Estimated amount calculated based on 11 day length of stay.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7362.51,,"Case rate ($7,011.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,678.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7011.91,27304.54,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4341.49,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4341.49,12882.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10291.73,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10291.73,34803.35,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],24347.37,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10455.00,90889.11,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],36670.94,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,20954.82,62179.32,All Other Inpatient
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],39867.32,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],50977.24,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,29129.85,86437.13,All Other Inpatient
HC Iliac Territory Plasty Stent|LEFT SIDE,CASE-37221,APC,37221,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],460.53,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],53648.70,,"Fee schedule rate ($53,648.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cystostomy Cystotomy W/Drainage|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51040,APC,51040,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
HC Tib per Territory Ather|RIGHT SIDE,CASE-37229,APC,37229,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],657.88,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11356.39,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9888.00,40658.63,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
Fth/Gft Fr W/Dir Clsr S/a/L Ea Addl 20 Cm/<,CASE-15221,APC,15221,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17323.14,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",17269.72,17269.72,17323.15,1 through 10,other,16737.33,72192.67,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7041.82,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5843.00,27370.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10888.24,,"Case rate ($10,888.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,437.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10888.24,32825.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6153.78,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6033.12,17902.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],59216.74,,"Fee schedule rate ($59,216.74). Adds an outlier to normal pricing equal to the per diem rate ($89,749.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
"INTESTINAL OBSTRUCTION,MAJOR",247,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13077.00,,"Case rate ($12,454.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12454.29,13077.00,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28695.03,,"Fee schedule rate ($28,695.03).",,,,0,other,14182.35,53827.17,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FIFTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17255.07,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9860.04,30039.61,All Other Inpatient
Rhinp Prim Lat&Alar Crtlgs&/Elvtn Nasal Ti|BILATERAL PROCEDURE|PO,CASE-30400,APC,30400,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],195125.77,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,185834.07,195125.77,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Angular Dfrm Toe Soft Tiss Px Only|BILATERAL PROCEDURE|SEPARATE STRUCTURE|PO,CASE-28313,APC,28313,CPT,0360,RC,,,50|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11593.40,,"Fee schedule rate ($11,593.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,2285.00,12138.74,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18072.75,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17212.14,64440.06,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER CARDIOTHORACIC AND THORACIC CIRCULATORY PROCEDURES,MAJOR",167,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],56246.37,,"Case rate ($53,567.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $47,615, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,53567.97,56246.37,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|LEFT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18562.91,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18562.91,73513.17,Inpatient DRG
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|LEFT SIDE,CASE-37766,APC,37766,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6608.44,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6293.75,21908.95,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8143.74,,"Case rate ($7,755.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,166.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,634.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,194.85. The transfer operating threshold is the transfer adjustment factor * $7,166.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.08. The transfer capital threshold is the transfer adjustment factor * $561.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7755.94,35520.39,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34528.24,,"Fee schedule rate ($34,528.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4406.30,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4257.29,12632.63,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39228.51,,"Fee schedule rate ($39,228.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Destruction Lesions Vulva Extensive,CASE-56515,APC,56515,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.80,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.96,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Hrhc 2/> Col/Grp W/Fstulectmy Incl Fssrectmy,CASE-46262,APC,46262,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13061.62,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5970.00,38757.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18988.45,,"Fee schedule rate ($18,988.45). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5573.75,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5308.33,19857.20,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5747.99,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5091.00,22010.11,Inpatient DRG
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1968.31,1968.31,1968.31,1 through 10,other,1982.66,2081.79,OPPS APC
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19230.33,,,,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],32637.12,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,32637.12,96844.29,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE,CASE-29891,APC,29891,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT SIDE|PO,CASE-26160,APC,26160,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7285.00,,"Per diem ($7,285). If length of stay < 5.4, first 1 days paid at a per diem of $14,570 instead. Capped at $39,337.51.",,,,0,other,7285.00,41187.90,Estimated amount calculated based on 4 day length of stay.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26300.80,,"Fee schedule rate ($26,300.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20272.57,,"Fee schedule rate ($20,272.57). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14910.91,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7453.00,42138.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8218.35,,"Case rate ($7,827). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,725.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $554.65. The transfer capital threshold is the transfer adjustment factor * $554.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7551.60,23262.15,Inpatient DRG
Open Treatment Metatarsal Fracture Each|RIGHT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15961.98,,,,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29288.89,,"Fee schedule rate ($29,288.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10638.72,,"Fee schedule rate ($10,638.72). Adds an outlier to normal pricing equal to the per diem rate ($26,031.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,3753.97,11139.15,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,APC,43239,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17461.77,OPPS APC
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,APC,58661,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
Open Biopsy/Excision Inguinofemoral Nodes|LEFT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Debridement Bone Each Additional 20 Sq Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-11047,APC,11047,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,APC,49593,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6447.22,,"APC Price ($6,140.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6140.21,6447.22,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26636.50,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12948.38,,"Fee schedule rate ($12,948.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13602.19,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13335.48,39570.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],47978.53,,"Fee schedule rate ($47,978.53). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5263.48,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],29405.43,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,28005.17,115392.91,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11895.84,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11895.84,35298.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7467.48,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,37575.69,Inpatient DRG
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cv Cath Plac W/Port Tun >5|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-36561,APC,36561,CPT,0361,RC,,,73,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4203.08,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4120.67,13066.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8839.15,,"Case rate ($8,418.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,767.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.55. The transfer capital threshold is the transfer adjustment factor * $596.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8431.66,25019.31,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32876.47,,"Fee schedule rate ($32,876.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22927.75,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9370.00,65732.99,Inpatient DRG
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,APC,43266,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Plasty|LEFT SIDE,CASE-37228,APC,37228,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],488.85,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
Open Treatment Calcaneal Fracture|LEFT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"RENAL DIALYSIS ACCESS DEVICE PROCEDURES,MAJOR",444,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],29325.27,,"Case rate ($29,325.27). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,29325.27,30791.53,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7964.08,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33946.09,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16854.96,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16524.47,58465.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],103821.76,,,,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36177.30,,"Fee schedule rate ($36,177.30). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],37968.88,,of the excess amount.,26123.00,17047.15,41413.20,1 through 10,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11645.83,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11645.83,37502.92,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5083.74,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4984.06,19757.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7308.00,,"Per diem ($7,308). If length of stay < 5.5, first 1 days paid at a per diem of $14,616 instead. Capped at $40,192.59.",,,,0,other,7308.00,42083.20,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11055.00,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11055.00,49295.13,Inpatient DRG
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],192338.26,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,185834.07,195125.77,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],37540.13,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8940.00,63653.13,All Other Inpatient
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, SECOND DIGIT|PO",CASE-26357,APC,26357,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3258.56,3258.56,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7113.73,,"Case rate ($6,774.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,651.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.10. The transfer capital threshold is the transfer adjustment factor * $480.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6785.78,20135.47,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13575.16,,,,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],25148.37,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23950.83,74869.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],57872.02,,,,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],42212.88,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40202.74,148703.60,Inpatient DRG
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4342.44,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4257.29,12632.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5520.00,,"Per diem ($5,520). If length of stay < 3.5, first 1 days paid at a per diem of $11,040 instead. Capped at $19,319.20.",,,,0,other,5520.00,26638.96,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],9242.00,,"Per diem ($9,242). If length of stay < 7.6, first 1 days paid at a per diem of $18,484 instead. Capped at $70,242.60.",,,,0,other,9242.00,76216.30,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5888.65,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5773.19,31196.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45390,APC,45390,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5866.79,,"Case rate ($5,668.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,581.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.07. The transfer capital threshold is the transfer adjustment factor * $410.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5668.40,16903.82,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17252.16,,"Case rate ($16,430.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,335.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,164.33. The transfer capital threshold is the transfer adjustment factor * $1,164.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",5960.74,5960.74,5960.74,1 through 10,other,16456.83,55350.97,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE|PO,CASE-28120,APC,28120,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],25578.39,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,24713.42,73332.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32980.62,,,,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27028.33,,,,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
Lengthening Tendon Extensor Hand/Finger Each,CASE-26476,APC,26476,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22648.72,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,21570.21,72041.81,Inpatient DRG
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
HC Debrid Wound Tis 20 Cm/<|ADJ,CASE-97597,APC,97597,CPT,0761,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],31074.42,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,29594.69,124146.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,CASE-26125,APC,26125,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28094.66,,"Fee schedule rate ($28,094.66). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9456.85,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9456.85,28061.37,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21721.18,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7826.00,90280.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17634.53,,,,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],43344.00,,"Fee schedule rate ($43,344.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,Zero final payments for the item or service in the 15 months prior to posting the file.
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,APC,57250,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16278.78,,,,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5499.26,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",4385.84,4385.84,4385.84,1 through 10,other,5237.39,15540.89,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4523.19,,"Case rate ($4,523.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,179.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,647.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,498.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,195.97. The transfer operating threshold is the transfer adjustment factor * $4,179.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $327.22. The transfer capital threshold is the transfer adjustment factor * $327.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4523.19,16536.43,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4836.86,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4742.02,14071.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13090.16,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12833.49,58980.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32323.20,,"Fee schedule rate ($32,323.20). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
Revj Opn Arven Fstl W/O Thrmbc Dial Grf,CASE-36832,APC,36832,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5018.44,5018.44,5150.04,1 through 10,other,5277.74,5541.62,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],30626.53,,"Case rate ($30,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,386.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,215.60. The transfer capital threshold is the transfer adjustment factor * $2,215.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",30366.74,30366.74,30366.74,1 through 10,other,30626.53,106200.88,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],35744.54,,"Fee schedule rate ($35,744.54). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|RIGHT SIDE|PO,CASE-29884,APC,29884,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13983.36,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7770.00,50313.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Ligj Divj & Stripping Short Saphenous Vein,CASE-37718,APC,37718,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5669.00,,"Per diem ($5,669). If length of stay < 3.2, first 1 days paid at a per diem of $11,338 instead. Capped at $18,140.88.",,,,0,other,5669.00,18994.21,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10961.59,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10439.61,34540.67,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14673.67,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14673.67,43541.27,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Ankle W/Implant|LEFT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26636.50,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14534.23,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12440.40,41073.77,Inpatient DRG
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MAJOR",425,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2498.36,,"Case rate for a one day stay ($2,498.36). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2498.36,2623.28,There are no additional notes associated with this service or procedure.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, SECOND DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,Zero final payments for the item or service in the 15 months prior to posting the file.
Ant Vesicourethropexy/Urethropexy Smpl,CASE-51840,APC,51840,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13889.20,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13889.20,55846.16,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7238.05,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",7231.49,7231.49,7231.49,1 through 10,other,7096.13,25801.23,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5627.43,,"Case rate ($5,359.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,959.91, add-ons for qualifying new technology services are included. If operating cost exceeds $40,427.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,979.68. The transfer operating threshold is the transfer adjustment factor * $4,959.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $379.79. The transfer capital threshold is the transfer adjustment factor * $379.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5368.01,15928.53,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],83871.28,,"Fee schedule rate ($83,871.28). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14184.53,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13704.86,49911.01,Inpatient DRG
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, FIFTH DIGIT|PO",CASE-28308,APC,28308,CPT,0360,RC,,,T4|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bladder Instillation Anticarcinogenic Agent,CASE-51720,APC,51720,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64418,APC,64418,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9860.04,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9860.04,30039.61,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],26636.50,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24766.30,,"Case rate ($23,586.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,842.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,671.45. The transfer capital threshold is the transfer adjustment factor * $1,671.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23624.56,83038.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10249.98,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9761.89,37873.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22831.22,,,,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
Rpr Tdn/Musc Xtnsr F/Arm&/Wrist Prim 1 Ea Tdn|LEFT SIDE|PO,CASE-25270,APC,25270,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],37199.37,,,,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5461.17,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5354.09,15887.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4245.71,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3295.00,21715.49,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6178.00,,"Per diem ($6,178). If length of stay < 3.9, first 1 days paid at a per diem of $12,356 instead. Capped at $24,092.63.",,,,0,other,6178.00,25225.91,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,APC,51990,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24288.44,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23131.85,76404.43,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5902.03,,"Case rate ($5,620.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.32. The transfer capital threshold is the transfer adjustment factor * $398.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5629.94,16705.77,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35058.51,,,,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
"HIV WITH MAJOR HIV RELATED CONDITION,MODERATE",892,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11194.16,,"Case rate ($10,661.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10661.10,11194.16,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],107249.77,,"Fee schedule rate ($107,249.77). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8501.29,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6178.00,25225.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9494.70,,"Case rate ($9,042.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.79. The transfer capital threshold is the transfer adjustment factor * $640.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9056.99,33814.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38757.79,,,,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
"INFECTIONS OF UPPER RESPIRATORY TRACT,MAJOR",113,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2404.66,,"Case rate for a one day stay ($2,290.15). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2290.15,2404.66,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39481.90,,,,,,0,other,13305.64,39481.90,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22154.54,,"Case rate ($21,099.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,666.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,495.19. The transfer capital threshold is the transfer adjustment factor * $1,495.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21133.20,88801.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9425.03,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9425.03,27966.92,Inpatient DRG
"CELLULITIS AND OTHER SKIN INFECTIONS,MINOR",383,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5980.55,,"Case rate ($5,980.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5980.55,6279.58,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39187.16,,"Fee schedule rate ($39,187.16). Adds an outlier to normal pricing equal to the per diem rate ($47,534.60) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23691.11,,,,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6474.12,19210.66,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6230.15,,"Case rate ($5,933.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.47. The transfer capital threshold is the transfer adjustment factor * $420.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5942.94,17634.53,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12418.23,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7096.13,25801.23,All Other Inpatient
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24826.68,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23644.46,105789.11,Inpatient DRG
"Ostc Prtl Exostc/Condylc Metar Head|LEFT FOOT, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28288,APC,28288,CPT,0360,RC,,,T1|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13589.22,,"Fee schedule rate ($13,589.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7467.48,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,37575.69,Inpatient DRG
"HC Bx,Vulva/Perineum,Addl Lesion",CASE-56606,APC,56606,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],904.16,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,873.59,917.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],41320.17,,"Fee schedule rate ($41,320.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41492.89,,,,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],41015.72,,"Fee schedule rate ($41,015.72). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],107489.55,,,,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],115401.67,,,,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],38916.28,,"Case rate ($38,916.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,957.67, add-ons for qualifying new technology services are included. If operating cost exceeds $71,425.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,986.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $36,100.97. The transfer operating threshold is the transfer adjustment factor * $35,957.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,815.30. The transfer capital threshold is the transfer adjustment factor * $2,815.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,38916.28,133824.90,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|RIGHT SIDE|PO,CASE-28119,APC,28119,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|PO,CASE-27650,APC,27650,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],42061.45,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,40639.08,120588.53,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
Fth/Gft Fr W/Dir Clsr S/a/L Ea Addl 20 Cm/<,CASE-15221,APC,15221,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15196.40,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14472.76,56135.46,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"OTHER SMALL AND LARGE BOWEL PROCEDURES,MODERATE",223,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],19801.15,,"Case rate ($19,801.15). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19801.15,20791.21,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",14100.01,14100.01,14100.01,1 through 10,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10235.12,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10034.43,29775.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],37199.37,,,,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
"AMPUTATION OF LOWER LIMB EXCEPT TOES,EXTREME",305,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],52364.61,,"Case rate ($49,871.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,49871.06,52364.61,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8078.98,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7694.27,22831.22,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
Thrmbc Opn Arven Fstl W/O Revj Dial Grf,CASE-36831,APC,36831,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Plasty|RIGHT SIDE,CASE-37228,APC,37228,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],505.96,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7308.00,,"Per diem ($7,308). If length of stay < 5.5, first 1 days paid at a per diem of $14,616 instead. Capped at $40,192.59.",,,,0,other,7308.00,42083.20,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],26732.41,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25459.44,80806.10,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],32807.56,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,32807.56,111191.81,Inpatient DRG
Cystourethroscopy W/Dil Bladder General Anesth,CASE-52260,APC,52260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],81161.07,,"Fee schedule rate ($81,161.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,30480.63,86382.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Simple Removal Stone & Stent,CASE-52310,APC,52310,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],66888.05,,"Fee schedule rate ($66,888.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.5), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],68230.53,,"Fee schedule rate ($68,230.53). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE",CASE-28299,APC,28299,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18860.53,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,18222.73,59942.55,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8263.49,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7984.05,33319.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],41015.72,,"Fee schedule rate ($41,015.72). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, SECOND DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10725.38,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10920.08,10920.08,10920.08,1 through 10,other,10362.69,29367.82,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10652.43,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,30103.84,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13061.00,,"Per diem ($13,061). If length of stay < 11, first 1 days paid at a per diem of $26,122 instead. Capped at $143,676.24.",,,,0,other,13061.00,162464.13,Estimated amount calculated based on 8 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,Zero final payments for the item or service in the 15 months prior to posting the file.
Gastrocnemius Recession|RIGHT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5542.86,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5478.67,5478.67,5478.67,1 through 10,other,5355.42,17067.11,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9733.35,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9269.86,37852.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
Open Treatment Tarsometatarsal Joint Dislocation,CASE-28615,APC,28615,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10975.11,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10759.91,46061.32,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14446.45,,"Case rate ($13,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,146.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.98. The transfer capital threshold is the transfer adjustment factor * $974.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13762.85,13762.85,13762.85,1 through 10,other,9763.00,48626.00,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33132.06,,"Fee schedule rate ($33,132.06). Adds an outlier to normal pricing equal to the per diem rate ($83,058.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34353.60,,"Fee schedule rate ($34,353.60). Adds an outlier to normal pricing equal to the per diem rate ($257,654.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,12121.97,35969.56,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19363.31,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19363.31,79918.67,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21828.16,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21828.16,93157.39,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],35132.86,,"Fee schedule rate ($35,132.86). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
HC Debride/Musc/Fasc First 20 Sq Cm,CASE-11043,APC,11043,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],736.04,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,700.99,736.04,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],99157.51,,"Fee schedule rate ($99,157.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34988.57,110685.97,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9880.53,,"Case rate ($9,410.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,837.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.83. The transfer capital threshold is the transfer adjustment factor * $666.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9425.03,27966.92,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5967.84,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.66,16865.16,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20227.96,,,,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16682.55,,"Fee schedule rate ($16,682.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12664.07,,"Fee schedule rate ($12,664.07). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intra Lithotrip-Stent,CASE-C9765,APC,C9765,CPT,0481,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34517.10,,"Fee schedule rate ($34,517.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],92493.51,,"Fee schedule rate ($92,493.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.8), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|LEFT HAND, FIFTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13692.87,,"Case rate ($13,040.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,095.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $924.12. The transfer capital threshold is the transfer adjustment factor * $924.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5970.00,38757.79,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20788.82,,"Fee schedule rate ($20,788.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dilat Rct Strix Spx Under Anes Oth/Thn Local,CASE-45910,APC,45910,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,21715.49,Estimated amount calculated based on 9 day length of stay.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35495.34,,,,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],38199.28,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,21828.16,93157.39,All Other Inpatient
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27943.31,,"Fee schedule rate ($27,943.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10593.61,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10385.89,32176.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Implant Deep|SEPARATE STRUCTURE|PO,CASE-20680,APC,20680,CPT,0360,RC,,,XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10096.80,,"Fee schedule rate ($10,096.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],158423.11,,"Fee schedule rate ($158,423.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Non/Malunion Humerus W/Iliac/Oth Agrft|LEFT SIDE,CASE-24435,APC,24435,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17056.02,,,,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,APC,58558,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3099.34,3099.34,3099.34,1 through 10,other,3070.31,3223.82,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],29129.85,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,29129.85,86437.13,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],53232.25,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13061.00,162464.13,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4883.54,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4787.78,20006.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7840.85,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,37575.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea,CASE-43277,APC,43277,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3784.78,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10887.83,,"Case rate ($10,369.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $734.81. The transfer capital threshold is the transfer adjustment factor * $734.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10385.89,32176.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Rt Bronch Dx Clear Airway,CASE-31645,APC,31645,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3536.22,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>|RIGHT SIDE|PO,CASE-25071,APC,25071,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7078.89,,"Case rate ($7,078.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,540.71, add-ons for qualifying new technology services are included. If operating cost exceeds $42,008.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,683.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,566.78. The transfer operating threshold is the transfer adjustment factor * $6,540.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.10. The transfer capital threshold is the transfer adjustment factor * $512.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7072.48,7072.48,7078.89,1 through 10,other,7078.89,21005.20,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],67008.32,,"Fee schedule rate ($67,008.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6630.72,19989.86,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17212.14,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17212.14,64440.06,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25493.52,,,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
HC Pbb Carpal Tunnel Inj Pmc|LEFT SIDE|PO,CASE-20526,APC,20526,CPT,0510,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1916.92,1944.70,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],25199.53,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10455.00,90889.11,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18508.54,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18508.54,76171.92,Inpatient DRG
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MODERATE",425,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2502.86,,"Case rate for a one day stay ($2,502.86). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2502.86,2628.00,There are no additional notes associated with this service or procedure.
HC Rt Bronch Dx Clear Airway,CASE-31645,APC,31645,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3659.98,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16536.43,,"Fee schedule rate ($16,536.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12947.45,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12693.58,46577.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13713.25,,"Fee schedule rate ($13,713.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33727.80,,"Fee schedule rate ($33,727.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|BILATERAL PROCEDURE,CASE-64494,APC,64494,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,868.26,868.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],56476.93,,,,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23624.56,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23624.56,83038.88,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|PO,CASE-20552,APC,20552,CPT,0510,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",283.63,283.63,283.63,1 through 10,other,291.13,305.69,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20885.18,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20885.18,80720.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10325.19,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9833.51,45903.36,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22469.78,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21399.79,63499.65,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8878.97,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8704.87,25830.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Incision & Drainage Leg/Ankle Abscess/Hematoma|LEFT SIDE,CASE-27603,APC,27603,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27465.16,,,,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],39831.40,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,39831.40,138208.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11634.20,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11080.19,32878.30,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6552.71,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6240.68,18518.02,Inpatient DRG
Rhytidectomy Neck W/Platysmal Tightening,CASE-15825,APC,15825,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2333.89,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bronchoscopy W/Removal Foreign Body,CASE-31635,APC,31635,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1747.26,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1688.18,1772.59,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11203.52,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6350.00,33244.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7369.00,,"Per diem ($7,369). If length of stay < 2.4, first 1 days paid at a per diem of $14,738 instead. Capped at $17,686.09.",,,,0,other,6240.68,18518.02,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],43434.38,,"Fee schedule rate ($43,434.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13545.65,,,,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
"PEPTIC ULCER AND GASTRITIS,MODERATE",241,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3312.45,,"Case rate for a one day stay ($3,154.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3154.71,3312.45,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",23308.05,23308.05,23308.05,1 through 10,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19726.05,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36024.65,,,,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],24790.92,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,24790.92,26030.46,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16570.24,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",16570.25,16570.25,16570.25,1 through 10,other,16009.89,58554.60,Inpatient DRG
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T8,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Carpectomy All Bones Proximal Row|RIGHT SIDE|PO,CASE-25215,APC,25215,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20373.57,,,,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,APC,20552,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER BACK AND NECK DISORDERS FRACTURES AND INJURIES,MAJOR",347,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],16050.71,,"Case rate ($15,286.39). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15286.39,16050.71,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5970.00,,"Per diem ($5,970). If length of stay < 6.2, first 1 days paid at a per diem of $11,940 instead. Capped at $37,016.57.",,,,0,other,5970.00,38757.79,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11835.17,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11434.95,119072.21,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14580.18,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14580.18,57079.69,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13970.92,,"Case rate ($13,305.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,294.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,761.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,133.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,343.08. The transfer operating threshold is the transfer adjustment factor * $12,294.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.56. The transfer capital threshold is the transfer adjustment factor * $962.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13305.64,39481.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],56620.96,,"Fee schedule rate ($56,620.96). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20788.82,,"Fee schedule rate ($20,788.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
Arteriovenous Anastomosis Open Direct|LEFT SIDE,CASE-36821,APC,36821,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28035.79,,,,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Intralesional Up to & Includ 7 Lesions,CASE-11900,APC,11900,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
Dstrj Lesion Anus Simple Laser Surg,CASE-46917,APC,46917,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16662.45,,"Fee schedule rate ($16,662.45). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],36505.40,,"Fee schedule rate ($36,505.40). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",35563.06,35563.06,36457.78,1 through 10,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],40046.00,,"Fee schedule rate ($40,046.00). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Unlisted Procedure, Nervous System|UNUSUAL NON-OVERLAPPING SERVICE",CASE-64999,APC,64999,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14130.58,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",14703.89,14703.89,14705.87,1 through 10,other,14130.58,57770.11,Inpatient DRG
Grafting of Autologous Fat by Lipo 25 Cc or Less|PO,CASE-15773,APC,15773,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2025.45,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.96,2025.45,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
Arthroscopy Ankle Surgical Debridement Extensive|RIGHT SIDE|PO,CASE-29898,APC,29898,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9948.90,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9948.90,46199.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35884.94,,,,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],22152.42,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9370.00,65732.99,Inpatient DRG
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt,CASE-28291,APC,28291,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8526.77,,"Case rate ($8,526.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,902.12, add-ons for qualifying new technology services are included. If operating cost exceeds $48,447.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,268.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $7,906.03. The transfer operating threshold is the transfer adjustment factor * $7,902.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.75. The transfer capital threshold is the transfer adjustment factor * $620.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,25698.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,APC,52352,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent,CASE-36903,APC,36903,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10949.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,APC,58662,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms|LEFT SIDE|PO,CASE-27696,APC,27696,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17691.86,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16849.39,49997.29,Inpatient DRG
HC Debride Subq First 20 Sq Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-11042,APC,11042,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT|PO",CASE-26951,APC,26951,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc,CASE-34421,APC,34421,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE|PO,CASE-28615,APC,28615,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4442.95,,"Case rate ($4,442.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.41. The transfer capital threshold is the transfer adjustment factor * $321.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",4547.29,4547.29,4547.29,1 through 10,other,4442.95,13183.59,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6625.21,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5669.00,18994.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18518.02,,,,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,APC,58573,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
Laparoscopy Surg Pyeloplasty|RIGHT SIDE,CASE-50544,APC,50544,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE|PO,CASE-27427,APC,27427,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34180.92,,,,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|LEFT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-27680,APC,27680,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",1812.87,1812.87,1812.87,1 through 10,other,1852.10,1944.70,OPPS APC
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,APC,43275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9071.31,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8764.55,32969.91,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea,CASE-43277,APC,43277,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Crtj Arven Fstl Xcp Dir Arven Anast Nonautog Grf,CASE-36830,APC,36830,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19204.75,,,,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, SECOND DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],42012.71,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,40591.99,115037.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER AFTERCARE AND CONVALESCENCE,EXTREME",862,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9745.02,,"Case rate ($9,280.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9280.97,9745.02,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13880.59,,"Case rate ($13,880.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,825.31, add-ons for qualifying new technology services are included. If operating cost exceeds $48,293.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,876.42. The transfer operating threshold is the transfer adjustment factor * $12,825.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7285.00,41187.90,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14161.54,,,,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intra Lithotrip-Ather,CASE-C9766,APC,C9766,CPT,0481,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18256.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",18290.30,18290.30,18290.30,1 through 10,other,17386.97,18256.31,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12748.95,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12141.86,36028.59,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33968.35,,"Fee schedule rate ($33,968.35). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18403.21,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",18952.50,18952.50,18952.50,1 through 10,other,18042.36,82749.58,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
Gastrocnemius Recession|LEFT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9761.89,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5578.22,18148.00,All Other Inpatient
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7345.46,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6308.00,21796.21,Inpatient DRG
"KIDNEY AND URINARY TRACT INFECTIONS,MODERATE",463,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8836.96,,"Case rate ($8,416.15). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8416.15,8836.96,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],70037.75,,"Fee schedule rate ($70,037.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.9), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4851.08,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4755.96,21133.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16532.31,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16208.15,58123.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],81161.07,,"Fee schedule rate ($81,161.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,30480.63,86382.02,There are no additional notes associated with this service or procedure.
Lig&Div Long Saph Vein Saphfem Junct/Interrupj|LEFT SIDE,CASE-37700,APC,37700,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Angular Dfrm Toe Soft Tiss Px Only,CASE-28313,APC,28313,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18893.86,,,,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
Arthrt Elbow Capsular Excision Capsular Rls Spx,CASE-24006,APC,24006,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14108.15,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13831.52,59770.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,41333.08,Estimated amount calculated based on 10 day length of stay.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],14023.34,,"Fee schedule rate ($14,023.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4870.41,14682.98,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14347.61,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13664.39,40546.43,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21691.55,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12395.17,42174.37,All Other Inpatient
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5970.00,,"Per diem ($5,970). If length of stay < 6.2, first 1 days paid at a per diem of $11,940 instead. Capped at $37,016.57.",,,,0,other,5970.00,38757.79,Estimated amount calculated based on 6 day length of stay.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13305.64,,"Case rate ($13,305.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,294.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,761.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,133.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,343.08. The transfer operating threshold is the transfer adjustment factor * $12,294.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.56. The transfer capital threshold is the transfer adjustment factor * $962.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13305.64,39481.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14384.78,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14102.73,41847.08,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],28565.27,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,28005.17,115392.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Mediastinoscopy With Lymph Node Biopsy/Ies,CASE-39402,APC,39402,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11717.77,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11159.78,39897.21,Inpatient DRG
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17026.45,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17026.45,50522.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8726.77,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8431.66,25019.31,Inpatient DRG
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],53165.70,,"Fee schedule rate ($53,165.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],23871.38,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22734.65,70806.50,Inpatient DRG
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>|RIGHT SIDE,CASE-23071,APC,23071,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19668.75,,"Fee schedule rate ($19,668.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Syndactylization Toes|LEFT SIDE,CASE-28280,APC,28280,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|LEFT SIDE,CASE-37225,APC,37225,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],557.79,,,,,,0,other,538.93,557.79,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28296,APC,28296,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5711.51,,"Case rate ($5,439.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $5,062.05, add-ons for qualifying new technology services are included. If operating cost exceeds $42,251.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,402.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,051.56. The transfer operating threshold is the transfer adjustment factor * $5,062.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.97. The transfer capital threshold is the transfer adjustment factor * $387.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5450.78,16705.77,Inpatient DRG
Excision Malignant Lesion F/E/E/N/L >4.0 Cm,CASE-11646,APC,11646,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23097.92,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1132.92,1132.92,1132.92,1 through 10,other,1134.98,1191.72,OPPS APC
Laps Myomectomy Exc 1-4 Myomas 250 Gm/<,CASE-58545,APC,58545,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,EXTREME",192,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],42402.00,,"Case rate ($40,382.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40382.86,42402.00,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],25968.63,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,25459.44,80806.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],22001.61,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,21570.21,72041.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32878.30,,,,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10114.68,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10114.68,30013.33,Inpatient DRG
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15906.96,,"Fee schedule rate ($15,906.96). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26300.80,,"Fee schedule rate ($26,300.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Complete 5th Metatarsal Head,CASE-28113,APC,28113,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],32668.23,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31112.60,92731.42,Inpatient DRG
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9725.67,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,27484.83,Inpatient DRG
Laparoscopic Appendectomy,CASE-44970,APC,44970,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10637.22,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10637.22,31563.88,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],51643.16,,"Fee schedule rate ($51,643.16). Adds an outlier to normal pricing equal to the per diem rate ($161,652.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,18222.73,59942.55,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],58080.75,,"Fee schedule rate ($58,080.75). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8113.86,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7551.60,23262.15,Inpatient DRG
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, THIRD DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39198.44,,"Fee schedule rate ($39,198.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|SEPARATE PRACTITIONER,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XP,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",26405.50,26405.50,26405.50,1 through 10,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15160.18,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14438.27,55762.74,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19243.94,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19243.94,63510.03,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16302.99,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16302.99,55737.89,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21163.54,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12093.45,35884.94,All Other Inpatient
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],144298.29,,"Fee schedule rate ($144,298.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
"DIABETES,MINOR",420,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6809.04,,"Case rate ($6,484.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6484.80,6809.04,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5160.45,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5160.45,15312.64,Inpatient DRG
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE|PO,CASE-28322,APC,28322,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23262.15,,,,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24585.00,,"Fee schedule rate ($24,585.00). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10108.65,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9910.44,43344.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],55272.09,,"Fee schedule rate ($55,272.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],163229.10,,"Fee schedule rate ($163,229.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12804.31,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12804.31,55145.09,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
"HEART FAILURE,MODERATE",194,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10043.84,,"Case rate ($9,565.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9565.56,10043.84,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],78047.33,,"Fee schedule rate ($78,047.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"KIDNEY AND URINARY TRACT INFECTIONS,MINOR",463,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6663.01,,"Case rate ($6,663.01). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6663.01,6996.16,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|RIGHT SIDE|SEPARATE STRUCTURE,CASE-52332,APC,52332,CPT,0360,RC,,,RT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],22908.38,,"Case rate ($22,908.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,828.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.25. The transfer capital threshold is the transfer adjustment factor * $1,657.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22908.38,67976.16,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,8596.11,25507.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,APC,58550,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11978.73,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11978.73,60588.60,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8021.19,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6495.00,23801.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],41712.94,,"Fee schedule rate ($41,712.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33781.47,,,,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13557.45,,,,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Realignment Extensor Tendon Hand Each Tendon|RIGHT SIDE|PO,CASE-26437,APC,26437,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32341.12,,,,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE|PO,CASE-24359,APC,24359,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21630.93,,,,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
Open Treatment of Ulnar Shaft Fracture|RIGHT SIDE|PO,CASE-25545,APC,25545,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia & Fibula,CASE-27828,APC,27828,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18594.26,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10625.29,39295.53,All Other Inpatient
Tnot Elbow Lateral/Medial Debride Open|RIGHT SIDE|PO,CASE-24358,APC,24358,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25267.19,,"Fee schedule rate ($25,267.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30630.71,,"Fee schedule rate ($30,630.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19056.10,,"Fee schedule rate ($19,056.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],8558.00,,"Per diem ($8,558). If length of stay < 5.4, first 1 days paid at a per diem of $17,116 instead. Capped at $46,215.75.",,,,0,other,8558.00,48389.68,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Cystectomy Partial Simple,CASE-51550,APC,51550,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3460.35,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Gastrocnemius Recession|RIGHT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22035.98,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7826.00,90280.33,Inpatient DRG
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],44704.18,,,,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6503.29,19528.85,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23513.70,,"Fee schedule rate ($23,513.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
HC Fem Pop Territory Plasty|LEFT SIDE,CASE-37224,APC,37224,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],421.27,,,,,,0,other,401.21,421.27,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4558.56,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4341.49,12882.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2285.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,APC,58558,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4345.60,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4138.67,12473.25,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5723.32,,"Case rate ($5,450.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $5,062.05, add-ons for qualifying new technology services are included. If operating cost exceeds $42,251.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,051.56. The transfer operating threshold is the transfer adjustment factor * $5,062.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.22. The transfer capital threshold is the transfer adjustment factor * $399.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5450.78,16705.77,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],37766.32,,"Fee schedule rate ($37,766.32). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10003.52,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9527.16,28269.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20110.39,,"Fee schedule rate ($20,110.39). Adds an outlier to normal pricing equal to the per diem rate ($69,590.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
Bx Anorectal Wall Anal Approach,CASE-45100,APC,45100,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12093.45,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12093.45,35884.94,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7231.00,,"Per diem ($7,231). If length of stay < 5.1, first 1 days paid at a per diem of $14,462 instead. Capped at $36,875.62.",,,,0,other,7231.00,38610.21,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],45520.40,,"Fee schedule rate ($45,520.40). Adds an outlier to normal pricing equal to the per diem rate ($131,498.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],54920.47,,,,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],68639.28,,,,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8588.20,,"Case rate ($8,179.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.61. The transfer capital threshold is the transfer adjustment factor * $579.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",8588.20,7682.89,10818.20,1 through 10,other,8192.28,24308.97,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10759.91,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10759.91,46061.32,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9103.53,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8925.03,26628.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9009.54,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8704.87,25830.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4257.29,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4257.29,12632.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,APC,52281,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10650.12,,"Fee schedule rate ($10,650.12). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14898.14,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8513.22,25261.33,All Other Inpatient
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],59833.15,,"Fee schedule rate ($59,833.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],48720.85,,"Fee schedule rate ($48,720.85). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
Carpectomy 1 Bone|LEFT SIDE|PO,CASE-25210,APC,25210,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|RIGHT SIDE|PO,CASE-24341,APC,24341,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12514.54,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12514.54,37134.43,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18022.41,,"Case rate ($17,164.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.31. The transfer capital threshold is the transfer adjustment factor * $1,216.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17191.57,51012.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21714.81,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,21289.03,76326.34,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10747.83,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10236.03,30589.82,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24946.45,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23758.52,103116.16,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7956.44,,"Case rate ($7,577.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,001.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,469.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,029.37. The transfer operating threshold is the transfer adjustment factor * $7,001.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.18. The transfer capital threshold is the transfer adjustment factor * $548.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7577.56,31445.30,Inpatient DRG
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1132.92,1132.92,1132.92,1 through 10,other,1134.98,1191.72,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32126.64,,,,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,APC,58661,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],37131.39,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,18559.00,141041.50,Inpatient DRG
Biopsy Urethra,CASE-53200,APC,53200,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12139.16,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11901.14,35314.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10455.00,,"Per diem ($10,455). If length of stay < 6.6, first 1 days paid at a per diem of $20,910 instead. Capped at $69,000.38.",,,,0,other,10455.00,90889.11,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17244.38,,"Fee schedule rate ($17,244.38). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6644.63,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6328.22,27416.36,Inpatient DRG
"Sesamoidectomy First Toe Spx|RIGHT FOOT, GREAT TOE|PO",CASE-28315,APC,28315,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],50522.67,,,,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",62846.00,62846.00,62846.00,1 through 10,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],27696.47,,"Case rate ($26,377.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,869.21. The transfer capital threshold is the transfer adjustment factor * $1,869.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,26419.65,96304.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27654,APC,27654,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",165,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],78718.80,,"Case rate ($74,970.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,945, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,74970.29,78718.80,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12179.66,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12179.66,36140.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20113.98,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",8525.31,8525.31,8525.31,1 through 10,other,17274.00,73717.28,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
"MAJOR SMALL BOWEL PROCEDURES,MAJOR",230,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],40218.87,,"Case rate ($38,303.69). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,38303.69,40218.87,There are no additional notes associated with this service or procedure.
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MAJOR",344,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],17550.68,,"Case rate ($17,550.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,17550.68,18428.21,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MAJOR",045,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],18120.69,,"Case rate ($17,257.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17257.80,18120.69,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16785.91,,"Fee schedule rate ($16,785.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21236.65,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12135.23,49469.07,All Other Inpatient
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,APC,26356,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13135.23,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13135.23,38976.20,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10173.70,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10173.70,41194.64,Inpatient DRG
Wmhc Perc Implant Stim Lead Ea|PO,CASE-63650,APC,63650,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6346.81,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20788.82,,"Fee schedule rate ($20,788.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
Transoral Lower Esophageal Myotomy,CASE-43497,APC,43497,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6045.95,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5758.05,6045.95,OPPS APC
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3117.60,3117.60,3117.60,1 through 10,other,6882.29,7226.40,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15749.87,,"Case rate ($14,999.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,234.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,062.94. The transfer capital threshold is the transfer adjustment factor * $1,062.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15023.80,48104.19,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],88173.00,,"Fee schedule rate ($88,173.00). Adds an outlier to normal pricing equal to the per diem rate ($170,052.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-54840,APC,54840,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn,CASE-64415,APC,64415,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7616.83,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",30729.47,30729.47,30729.47,1 through 10,other,3295.00,37575.69,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],100343.25,,"Fee schedule rate ($100,343.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22840.42,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13051.67,38728.27,All Other Inpatient
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],8558.00,,"Per diem ($8,558). If length of stay < 5.4, first 1 days paid at a per diem of $17,116 instead. Capped at $46,215.75.",,,,0,other,8558.00,48389.68,Estimated amount calculated based on 4 day length of stay.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7601.43,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7601.43,23918.09,Inpatient DRG
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],47283.61,,"Case rate ($47,283.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,591.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,420.62. The transfer capital threshold is the transfer adjustment factor * $3,420.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,47283.61,169615.07,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13863.15,,"Fee schedule rate ($13,863.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],9799.00,,"Per diem ($9,799). If length of stay < 2.3, first 1 days paid at a per diem of $19,598 instead. Capped at $22,536.57.",,,,0,other,7952.22,25854.47,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],31219.40,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,30163.67,89504.77,Inpatient DRG
"PEPTIC ULCER AND GASTRITIS,MODERATE",241,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3154.71,,"Case rate for a one day stay ($3,154.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3154.71,3312.45,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",79641.46,79641.46,79641.46,1 through 10,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",2635.04,2635.04,2635.04,1 through 10,other,2632.62,2764.26,OPPS APC
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt|LEFT SIDE|PO,CASE-27602,APC,27602,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],60160.46,,,,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,APC,58542,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23320.23,,"Fee schedule rate ($23,320.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-29827,APC,29827,CPT,0360,RC,,,73,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9694.02,,"Fee schedule rate ($9,694.02). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14921.85,,"Case rate ($8,526.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,902.12, add-ons for qualifying new technology services are included. If operating cost exceeds $48,447.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,268.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $7,906.03. The transfer operating threshold is the transfer adjustment factor * $7,902.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.75. The transfer capital threshold is the transfer adjustment factor * $620.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6965.00,25698.16,All Other Inpatient
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE|PO,CASE-27680,APC,27680,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17233.12,,,,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
Bx Anorectal Wall Anal Approach,CASE-45100,APC,45100,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5549.19,16729.39,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22878.60,,"Fee schedule rate ($22,878.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],29712.45,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",28402.61,28402.61,28402.61,1 through 10,other,29129.85,86437.13,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6063.93,,"Case rate ($5,775.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.79. The transfer capital threshold is the transfer adjustment factor * $417.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5775.17,17136.70,Inpatient DRG
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6346.81,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6044.58,6346.81,OPPS APC
Transection/Avulsion Oth Spinal Nrv Xdrl|PO,CASE-64772,APC,64772,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15209.73,,"Case rate ($14,485.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,026.49. The transfer capital threshold is the transfer adjustment factor * $1,026.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14508.56,59513.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23912.68,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13664.39,40546.43,All Other Inpatient
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26909.70,,"Fee schedule rate ($26,909.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9495.32,42131.77,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7455.00,,"Per diem ($7,455). If length of stay < 6.8, first 1 days paid at a per diem of $14,910 instead. Capped at $50,692.24.",,,,0,other,7455.00,53076.74,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19138.75,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18227.38,54086.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13438.87,,"Fee schedule rate ($13,438.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13183.59,,,,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8184.82,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7795.07,34198.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|RIGHT SIDE,CASE-27446,APC,27446,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17849.32,,"Case rate ($16,999.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,375.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,204.63. The transfer capital threshold is the transfer adjustment factor * $1,204.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",17849.33,17849.33,17849.33,1 through 10,other,17026.45,50522.67,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7562.12,,"Case rate ($7,202.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.36. The transfer capital threshold is the transfer adjustment factor * $510.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],9242.00,,"Per diem ($9,242). If length of stay < 7.6, first 1 days paid at a per diem of $18,484 instead. Capped at $70,242.60.",,,,0,other,9242.00,76216.30,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5003.96,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5003.96,21742.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4654.49,,"Case rate ($4,654.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.72. The transfer capital threshold is the transfer adjustment factor * $336.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4654.49,13811.29,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23679.61,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23679.61,84629.16,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12107.00,,"Per diem ($12,107). If length of stay < 2.8, first 1 days paid at a per diem of $24,214 instead. Capped at $33,900.69.",,,,0,other,11962.15,40923.09,Estimated amount calculated based on 2 day length of stay.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC
HC Sel Cath Abd/Pelvic/Le 1st Ord|BILATERAL PROCEDURE,CASE-36245,APC,36245,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
Revise/Remove Neurostim/Receiver,CASE-64595,APC,64595,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3315.94,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3315.94,3481.74,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16320.00,,"Per diem ($16,320). If length of stay < 2.1, first 1 days paid at a per diem of $32,640 instead. Capped at $34,272.79.",,,,0,other,12093.45,40067.60,Estimated amount calculated based on 1 day length of stay.
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MAJOR",282,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14993.51,,"Case rate ($14,993.51). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14993.51,15743.19,There are no additional notes associated with this service or procedure.
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7826.00,,"Per diem ($7,826). If length of stay < 7.6, first 1 days paid at a per diem of $15,652 instead. Capped at $59,476.09.",,,,0,other,7826.00,90280.33,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",6272.30,6272.30,6272.30,1 through 10,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16705.77,,,,,,0,other,5450.78,16705.77,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39570.45,,,,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7335.51,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7335.51,29792.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,Zero final payments for the item or service in the 15 months prior to posting the file.
Suture Quadriceps/Hamstring Rupture Primary|RIGHT SIDE|PO,CASE-27385,APC,27385,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11468.00,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11080.19,32878.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13890.29,,"Case rate ($13,228.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,108.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $937.44. The transfer capital threshold is the transfer adjustment factor * $937.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13249.94,40085.35,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6531.00,,"Per diem ($6,531). If length of stay < 4.1, first 1 days paid at a per diem of $13,062 instead. Capped at $26,776.27.",,,,0,other,6531.00,35832.77,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,10625.29,39295.53,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],183848.16,,"Fee schedule rate ($183,848.16). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],129893.46,,"Fee schedule rate ($129,893.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],31206.03,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13369.00,88188.38,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],20277.85,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8972.00,76376.03,Inpatient DRG
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT HAND, FIFTH DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
Fasciotomy Foot&/Toe|BILATERAL PROCEDURE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE|PO,CASE-29823,APC,29823,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|RIGHT SIDE,CASE-26121,APC,26121,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Supracervical Hysterectomy >250,CASE-58543,APC,58543,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Revascularization Iliac Art Angiop Ea Ipsi Vsl|LEFT SIDE,CASE-37222,APC,37222,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],176.42,,,,,,0,other,168.02,176.42,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,10625.29,39295.53,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22296.59,,"Fee schedule rate ($22,296.59). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13228.06,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13228.06,39251.68,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12764.83,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",12543.35,12543.35,12543.35,1 through 10,other,12514.54,37134.43,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],65538.71,,"Fee schedule rate ($65,538.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Arthroscopy,CASE-29999,APC,29999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16378.73,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15824.86,49371.45,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn,CASE-64415,APC,64415,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Fibula Nonunion/Malunion W/Int Fixation,CASE-27726,APC,27726,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy 2/>Compartments|RIGHT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7213.50,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,21404.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT HAND, FIFTH DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
Mastectomy Partial|RIGHT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3713.66,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5183.66,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5183.66,15743.06,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],11812.10,,,,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE|PO,CASE-28238,APC,28238,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5700.90,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5700.90,30872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",642.91,642.91,653.31,1 through 10,other,669.51,702.98,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],6452.23,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,3209.85,10940.41,All Other Inpatient
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34556.75,,,,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Trigger Pt 1-2 Musc Grps|PO,CASE-20552,APC,20552,CPT,0510,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16063.95,,"Fee schedule rate ($16,063.95). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6699.57,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6699.57,6699.57,6699.57,1 through 10,other,6699.57,24060.08,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15236.84,,"Case rate ($14,511.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,199.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,028.32. The transfer capital threshold is the transfer adjustment factor * $1,028.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14534.42,59012.52,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6804.79,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6480.75,29542.64,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34576.42,,,,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALLERGIC REACTIONS,MODERATE",811,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3002.96,,"Case rate for a one day stay ($2,859.96). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2859.96,3002.96,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6045.24,,"Case rate ($5,757.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,579.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.99. The transfer capital threshold is the transfer adjustment factor * $407.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5766.55,17111.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8405.52,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8005.26,24549.95,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5122.57,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4878.64,14476.37,Inpatient DRG
HC Cystostomy Tube Change,CASE-51705,APC,51705,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Component Inflatable Penile Prosthesis,CASE-54408,APC,54408,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5669.00,,"Per diem ($5,669). If length of stay < 3.2, first 1 days paid at a per diem of $11,338 instead. Capped at $18,140.88.",,,,0,other,5669.00,18994.21,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MODERATE",254,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9584.90,,"Case rate ($9,584.90). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9584.90,10064.15,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],55272.09,,"Fee schedule rate ($55,272.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21474.76,,"Fee schedule rate ($21,474.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,7577.56,31445.30,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],64029.63,,"Fee schedule rate ($64,029.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.5), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6495.00,,"Per diem ($6,495). If length of stay < 3.5, first 1 days paid at a per diem of $12,990 instead. Capped at $22,732.01.",,,,0,other,6495.00,23801.30,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],96817.22,,"Fee schedule rate ($96,817.22). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16536.43,,"Fee schedule rate ($16,536.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MINOR",229,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15795.40,,"Case rate ($15,043.24). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15043.24,15795.40,There are no additional notes associated with this service or procedure.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, THIRD DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Open Repair of Rotator Cuff Chronic|LEFT SIDE,CASE-23412,APC,23412,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",14179.42,14179.42,14179.42,1 through 10,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12448.25,,"Fee schedule rate ($12,448.25). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19137.85,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19137.85,64589.15,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8716.15,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8601.70,5352.08,8716.16,1 through 10,other,8716.15,25863.45,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26571.62,,"Fee schedule rate ($26,571.62). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5341.02,,"Case rate ($5,086.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.46. The transfer capital threshold is the transfer adjustment factor * $360.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5094.80,15365.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26297.04,,"Fee schedule rate ($26,297.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,9279.13,27534.03,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Dislocating Peroneal Tendon W/Fib Osteot,CASE-27676,APC,27676,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29207.85,,"Fee schedule rate ($29,207.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11674.21,,"Fee schedule rate ($11,674.21). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4119.35,12223.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5026.81,,"Case rate ($4,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,510.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $339.25. The transfer capital threshold is the transfer adjustment factor * $339.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4795.07,19830.58,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6937.15,,"Case rate ($6,606.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.18. The transfer capital threshold is the transfer adjustment factor * $468.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],20516.26,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,17274.00,73717.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],35009.14,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,20005.22,74991.64,All Other Inpatient
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE|PO,CASE-28300,APC,28300,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11875.12,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6785.78,20135.47,All Other Inpatient
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE,CASE-28615,APC,28615,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],62179.32,,,,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],35148.55,,"Fee schedule rate ($35,148.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12402.46,36801.89,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5760.34,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5486.04,17919.05,Inpatient DRG
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13466.94,,,,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MODERATE",254,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9584.90,,"Case rate ($9,584.90). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9584.90,10064.15,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|LEFT SIDE|PO,CASE-27675,APC,27675,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14766.09,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14062.94,61706.77,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
HC Add 2nd/3rd Order Abd/Le,CASE-36248,APC,36248,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc,CASE-34421,APC,34421,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6835.51,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6835.51,20283.05,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6094.79,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6094.79,22352.66,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],187121.90,,"Fee schedule rate ($187,121.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],67331.56,,"Fee schedule rate ($67,331.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15818.04,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15507.88,46016.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34712.20,,,,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15750.74,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15218.11,45156.75,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14743.98,,,,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
Rpr Nonunion Scaphoid Carpal Bne W/WO Rdl Stylec|RIGHT SIDE|PO,CASE-25440,APC,25440,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7226.40,7226.40,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19988.17,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",19870.24,19870.24,19870.24,1 through 10,other,8972.00,76376.03,Inpatient DRG
Excision/Curettage Cyst/Tumor Phalanx Finger,CASE-26210,APC,26210,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6308.00,,"Per diem ($6,308). If length of stay < 3.3, first 1 days paid at a per diem of $12,616 instead. Capped at $20,817.01.",,,,0,other,6308.00,21796.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29997.59,,,,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64448,APC,64448,CPT,0360,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,APC,23430,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17212.32,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt,CASE-28309,APC,28309,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Tenodesis Long Tendon Biceps|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-23430,APC,23430,CPT,0360,RC,,,73,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr,CASE-27524,APC,27524,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32126.64,,,,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13889.20,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",13889.21,13889.21,13889.21,1 through 10,other,13889.20,55846.16,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5308.33,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5308.33,19857.20,Inpatient DRG
"Neuroplasty Other Arm/Leg Nerve,Open|SEPARATE STRUCTURE|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3240.11,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3240.11,3402.11,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|RIGHT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28832.22,,"Fee schedule rate ($28,832.22). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17468.03,,"Fee schedule rate ($17,468.03). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
I&D Ischiorct/Intramural Absc W/WO Seton,CASE-46060,APC,46060,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14719.62,,"Case rate ($14,018.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,164.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.41. The transfer capital threshold is the transfer adjustment factor * $993.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14041.04,60059.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14743.98,,,,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],44292.15,,"Fee schedule rate ($44,292.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13228.06,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13228.06,39251.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],8232.00,,"Per diem ($8,232). If length of stay < 9.8, first 1 days paid at a per diem of $16,464 instead. Capped at $80,676.47.",,,,0,other,8232.00,84471.39,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,APC,64493,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6194.88,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5985.39,17760.46,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6088.84,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6088.84,18067.42,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9056.04,,"Case rate ($8,624.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,782.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.18. The transfer capital threshold is the transfer adjustment factor * $611.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8442.00,28788.33,Inpatient DRG
HC Removal FB Skin|PO,CASE-10120,APC,10120,CPT,0450,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6940.28,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6940.28,20593.95,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13826.01,,"Fee schedule rate ($13,826.01). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32019.51,,"Fee schedule rate ($32,019.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11652.47,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11652.47,41507.02,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33771.02,,"Fee schedule rate ($33,771.02). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",21138.78,21138.78,21138.78,1 through 10,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Ankle Surgical Debridement Extensive|RIGHT SIDE,CASE-29898,APC,29898,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39251.68,,,,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10385.89,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10385.89,32176.55,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9778.92,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6531.00,35832.77,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],45782.73,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,43602.60,153667.90,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4376.13,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4167.74,12366.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],30626.53,,"Case rate ($30,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,386.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,215.60. The transfer capital threshold is the transfer adjustment factor * $2,215.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,30626.53,106200.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4755.96,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4755.96,21133.33,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13230.71,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13230.71,39259.55,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10899.16,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10899.16,39746.35,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
Arteriovenous Anastomosis Open Direct|LEFT SIDE,CASE-36821,APC,36821,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
Rpr Recrt Inguinal Hernia Any Age Reducible|LEFT SIDE,CASE-49520,APC,49520,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3514.75,OPPS APC
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB|PO",CASE-64831,APC,64831,CPT,0360,RC,,,F5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms,CASE-27696,APC,27696,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6367.35,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,18893.86,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23703.75,,"Fee schedule rate ($23,703.75). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE|PO,CASE-29875,APC,29875,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride Subq First 20 Sq Cm|PBB CHARGE,CASE-11042,APC,11042,CPT,0361,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6387.91,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6387.91,18954.85,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12138.74,,,,,,0,other,2285.00,12138.74,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",675.06,675.06,685.98,1 through 10,other,669.51,702.98,OPPS APC
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,APC,28270,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, GREAT TOE",CASE-28124,APC,28124,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],23941.46,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23131.85,76404.43,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13889.46,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13228.06,39251.68,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE,CASE-27695,APC,27695,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22727.25,,"Fee schedule rate ($22,727.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7744.00,,"Case rate ($7,744). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,731.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $560.22. The transfer capital threshold is the transfer adjustment factor * $560.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7744.00,24853.45,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],107320.33,,,,,,0,other,36167.61,140535.66,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,APC,20526,CPT,0510,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39228.51,,"Fee schedule rate ($39,228.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12605.95,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12179.66,36140.75,Inpatient DRG
"OTHER GASTROENTERITIS NAUSEA AND VOMITING,MODERATE",249,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2534.25,,"Case rate for a one day stay ($2,534.25). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2534.25,2660.96,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",101566.42,101566.42,101566.42,1 through 10,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],36370.09,,"Fee schedule rate ($36,370.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
"HC Excis Nail Matrix Perm Rmvl|LEFT FOOT, GREAT TOE|PO",CASE-11750,APC,11750,CPT,0450,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31469.43,,,,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11350.12,,"Case rate ($10,809.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,937.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $766.01. The transfer capital threshold is the transfer adjustment factor * $766.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",36897.02,36897.02,36897.02,1 through 10,other,10826.88,32126.64,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16849.39,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16849.39,49997.29,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],8990.00,,"Per diem ($8,990). If length of stay < 6, first 1 days paid at a per diem of $17,980 instead. Capped at $53,939.67.",,,,0,other,8990.00,80069.53,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20832.04,,,,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
Partical Excision Bone Phalanx Toe|LEFT SIDE|PO,CASE-28124,APC,28124,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11546.93,,"Case rate ($11,156.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,308.28, add-ons for qualifying new technology services are included. If operating cost exceeds $45,776.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,349.36. The transfer operating threshold is the transfer adjustment factor * $10,308.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.09. The transfer capital threshold is the transfer adjustment factor * $807.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11156.45,42003.98,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10439.61,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10439.61,34540.67,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13704.86,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13704.86,49911.01,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10575.35,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10367.99,37103.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12410.41,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12167.07,36103.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13135.23,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13135.23,38976.20,Inpatient DRG
Laparoscopy Surgical Jejunostomy,CASE-44186,APC,44186,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21938.74,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12536.42,37199.37,All Other Inpatient
Surgical Arthroscopy Shoulder Capsulorrhaphy|PO,CASE-29806,APC,29806,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE|PO,CASE-64421,APC,64421,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19879.67,,,,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5816.55,,"Case rate ($5,539.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,040.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $392.79. The transfer capital threshold is the transfer adjustment factor * $392.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",907.21,907.21,907.21,1 through 10,other,5549.19,16729.39,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, THUMB|PO",CASE-26055,APC,26055,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15117.84,,,,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15896.49,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15896.49,51306.05,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18615.14,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10637.22,31563.88,All Other Inpatient
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, GREAT TOE|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
"SKIN ULCERS,EXTREME",380,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],23659.02,,"Case rate ($22,532.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22532.40,23659.02,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4895.21,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4895.21,14525.56,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],30186.58,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,29594.69,124146.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13100.31,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,38110.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION,EXTREME",190,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],24180.53,,"Case rate ($24,180.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24180.53,25389.56,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,MAJOR",512,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],34346.92,,"Case rate ($32,711.35). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32711.35,34346.92,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11055.00,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11055.00,49295.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6358.45,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6055.67,17969.04,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14465.95,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7308.00,42083.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9112.97,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8679.02,29908.27,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10759.91,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10759.91,46061.32,Inpatient DRG
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,CASE-21552,APC,21552,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
Removal Non-Biodegradable Drug Delivery Implant,CASE-11982,APC,11982,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,5934.68,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11778.33,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11217.46,37366.25,Inpatient DRG
HC Extremity Venogram|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9913.38,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9913.38,10409.05,OPPS APC
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],51012.62,,,,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],36249.82,,"Fee schedule rate ($36,249.82). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites,CASE-31625,APC,31625,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3659.98,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33262.00,,,,,,0,other,11036.50,33262.00,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10449.55,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10449.55,43409.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15547.45,,"Fee schedule rate ($15,547.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, SECOND DIGIT|PO",CASE-26356,APC,26356,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11757.91,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11757.91,34889.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25698.16,,,,,,0,other,6965.00,25698.16,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI HEART FAILURE OR SHOCK,MODERATE",171,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],25933.53,,"Case rate ($24,698.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24698.60,25933.53,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16524.47,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16524.47,58465.86,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],65481.15,,"Fee schedule rate ($65,481.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
Partial Excision Bone Fibula|RIGHT SIDE|PO,CASE-27641,APC,27641,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,MODERATE",443,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5856.59,,"Case rate for a one day stay ($5,577.70). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5577.70,5856.59,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10969.93,,"Fee schedule rate ($10,969.93). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,40658.63,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],84471.39,,,,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,CASE-43762,APC,43762,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy With Biopsy,CASE-52204,APC,52204,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21828.16,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21828.16,93157.39,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14887.17,,"Case rate ($14,178.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.72. The transfer capital threshold is the transfer adjustment factor * $1,004.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7453.00,42138.30,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4964.70,,"Case rate ($4,867.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.12. The transfer capital threshold is the transfer adjustment factor * $352.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4867.35,14442.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17934.16,,"Fee schedule rate ($17,934.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.1), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm,CASE-11422,APC,11422,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5934.68,5934.68,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5614.23,,"Case rate ($5,346.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.90. The transfer capital threshold is the transfer adjustment factor * $378.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5355.42,17067.11,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Lengthening Tendon Extensor Hand/Finger Each,CASE-26476,APC,26476,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],43128.06,,"Fee schedule rate ($43,128.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7308.00,,"Per diem ($7,308). If length of stay < 5.5, first 1 days paid at a per diem of $14,616 instead. Capped at $40,192.59.",,,,0,other,7308.00,42083.20,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17252.16,,"Case rate ($16,430.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,335.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,164.33. The transfer capital threshold is the transfer adjustment factor * $1,164.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16456.83,55350.97,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Transoral Lower Esophageal Myotomy,CASE-43497,APC,43497,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11297.80,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10915.75,32390.31,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],88188.38,,,,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],44339.99,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",49072.13,49072.13,49072.13,1 through 10,other,44339.99,131570.26,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,MAJOR",351,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13548.44,,"Case rate ($12,903.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12903.28,13548.44,There are no additional notes associated with this service or procedure.
Lig&Div Long Saph Vein Saphfem Junct/Interrupj|LEFT SIDE,CASE-37700,APC,37700,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],131570.26,,,,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21697.80,,"Case rate ($20,664.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,635.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,464.36. The transfer capital threshold is the transfer adjustment factor * $1,464.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20697.52,87921.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rhinoplasty Secondary Intermediate Revision,CASE-30435,APC,30435,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7197.46,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7056.33,28335.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],86795.47,,"Fee schedule rate ($86,795.47). Adds an outlier to normal pricing equal to the per diem rate ($211,362.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30626.53,106200.88,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|RIGHT SIDE|PO,CASE-27405,APC,27405,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17887.18,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7455.00,53076.74,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],34268.98,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32637.12,96844.29,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19033.08,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,8990.00,80069.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5976.41,,"Case rate ($5,691.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.34. The transfer capital threshold is the transfer adjustment factor * $403.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5700.90,30872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8130.77,,"Case rate ($7,743.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,166.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,634.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,194.85. The transfer operating threshold is the transfer adjustment factor * $7,166.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.74. The transfer capital threshold is the transfer adjustment factor * $548.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7755.94,35520.39,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18675.44,,,,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19048.02,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10884.58,32297.83,All Other Inpatient
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30493.52,,"Fee schedule rate ($30,493.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Plasty|LEFT SIDE,CASE-37228,APC,37228,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],513.29,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26359.15,,"Fee schedule rate ($26,359.15). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Aid Tibial Fracture Proximal Unicondylar,CASE-29855,APC,29855,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27597.52,,"Fee schedule rate ($27,597.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10377.17,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10173.70,41194.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30145.85,,"Fee schedule rate ($30,145.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16831.01,,"Fee schedule rate ($16,831.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],199.81,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8113.86,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7551.60,23262.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6785.78,20135.47,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4656.27,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4564.97,13545.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7450.94,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7096.13,25801.23,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Angular Dfrm Toe Soft Tiss Px Only,CASE-28313,APC,28313,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20459.13,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11690.93,56733.59,All Other Inpatient
"FOOT AND TOE PROCEDURES,MODERATE",314,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],16929.00,,"Case rate ($16,929.00). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,16929.00,17775.45,There are no additional notes associated with this service or procedure.
Open Tx Tibial Fracture Proximal Unicondylar|LEFT SIDE,CASE-27535,APC,27535,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7445.33,,"Case rate ($7,090.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.48. The transfer capital threshold is the transfer adjustment factor * $502.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7102.10,21074.07,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26291.41,,"Fee schedule rate ($26,291.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,8981.78,27528.12,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],9799.00,,"Per diem ($9,799). If length of stay < 2.3, first 1 days paid at a per diem of $19,598 instead. Capped at $22,536.57.",,,,0,other,7952.22,25854.47,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE,CASE-27654,APC,27654,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE|PO,CASE-25607,APC,25607,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24754.48,,"Fee schedule rate ($24,754.48). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy,CASE-27675,APC,27675,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],5706.38,,"Fee schedule rate ($5,706.38). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
HC App Skin Sub T/a/L Tot <100 1st 25,CASE-15271,APC,15271,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],736.04,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,700.99,736.04,OPPS APC
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4463.04,,"Case rate ($4,250.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.20. The transfer capital threshold is the transfer adjustment factor * $301.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4257.29,12632.63,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5678.05,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5486.04,17919.05,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34422.94,,,,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
Excision Ganglion Wrist Dorsal/Volar Recurrent,CASE-25112,APC,25112,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28299,APC,28299,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9935.64,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9935.64,29482.05,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13589.22,,"Fee schedule rate ($13,589.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,APC,38571,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SIGNS SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS,MAJOR",861,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12233.25,,"Case rate ($12,233.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12233.25,12844.91,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23915.01,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23915.01,121205.60,Inpatient DRG
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2|LEFT SIDE|PO,CASE-29822,APC,29822,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19183.89,,"Fee schedule rate ($19,183.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,6553.68,20086.28,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],40480.74,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,23131.85,76404.43,All Other Inpatient
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],86162.15,,"Fee schedule rate ($86,162.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12521.78,,"Fee schedule rate ($12,521.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE|PO,CASE-24685,APC,24685,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Nerve Repair W/Conduit Each Nerve|LEFT SIDE|PO,CASE-64910,APC,64910,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8614.94,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8323.61,8739.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4564.97,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4564.97,13545.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7648.51,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7648.51,27371.98,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,55581.70,Estimated amount calculated based on 10 day length of stay.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],8940.00,,"Per diem ($8,940). If length of stay < 6.8, first 1 days paid at a per diem of $17,880 instead. Capped at $60,793.48.",,,,0,other,8940.00,63653.13,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9430.32,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9430.33,9430.33,9430.33,1 through 10,other,6965.00,45869.64,Inpatient DRG
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28285,APC,28285,CPT,0360,RC,,,T9|PO|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9308.98,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,33447.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
Corrj Hallux Valgus W/Sesmdc W/2 Osteot,CASE-28299,APC,28299,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16737.33,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16737.33,72192.67,Inpatient DRG
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|LEFT SIDE,CASE-19120,APC,19120,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE|PO,CASE-27691,APC,27691,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
"HC Debrid,Bone,1st 20sqcm or Less",CASE-11044,APC,11044,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Extremity Venogram|LEFT SIDE,CASE-36005,APC,36005,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1545.29,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14534.42,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14534.42,59012.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6226.00,,"Case rate ($5,929.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.19. The transfer capital threshold is the transfer adjustment factor * $420.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.97,17858.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,32980.62,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32645.32,,"Fee schedule rate ($32,645.32). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11519.18,34180.92,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33114.42,,,,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
HC Tib per Territory Ather|RIGHT SIDE,CASE-37229,APC,37229,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],648.48,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5605.09,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5338.18,15839.99,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],90215.11,,,,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12065.11,,"Fee schedule rate ($12,065.11). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9920.64,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6531.00,35832.77,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30861.41,,,,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12402.46,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12402.46,36801.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],92976.49,,"Fee schedule rate ($92,976.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.5), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12133.80,,"Fee schedule rate ($12,133.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12478.39,,"Case rate ($11,884.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.15. The transfer capital threshold is the transfer adjustment factor * $842.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11903.13,48838.99,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7184.98,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7184.98,21320.03,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22469.78,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21399.79,63499.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,APC,49320,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5080.78,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4838.84,19587.42,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],26689.86,,"Case rate ($25,418.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,972.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,801.27. The transfer capital threshold is the transfer adjustment factor * $1,801.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",113385.15,113385.15,113385.15,1 through 10,other,25459.44,80806.10,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22154.54,,"Case rate ($21,099.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,666.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,495.19. The transfer capital threshold is the transfer adjustment factor * $1,495.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21133.20,88801.87,Inpatient DRG
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],38728.26,,of the excess amount. Final payment is multiplied by 102%.,91196.31,91196.31,91196.31,1 through 10,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,APC,46200,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5773.19,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5773.19,31196.82,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20972.04,,"Case rate ($19,973.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,586.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,415.38. The transfer capital threshold is the transfer adjustment factor * $1,415.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20005.22,74991.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE,CASE-27524,APC,27524,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4376.13,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4167.74,12366.99,Inpatient DRG
Excision Ganglion Wrist Dorsal/Volar Recurrent,CASE-25112,APC,25112,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8463.05,,"Case rate ($8,060.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.16. The transfer capital threshold is the transfer adjustment factor * $571.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8072.90,31159.55,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16333.88,,,,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11410.61,,"Case rate ($10,867.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,941.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $770.09. The transfer capital threshold is the transfer adjustment factor * $770.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10884.58,32297.83,Inpatient DRG
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],57534.77,,"Fee schedule rate ($57,534.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],61860.92,,"Fee schedule rate ($61,860.92). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21828.16,93157.39,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5967.84,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.66,16865.16,Inpatient DRG
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12748.95,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12141.86,36028.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4506.79,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4418.42,13110.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5006.61,,"Case rate ($5,006.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,625.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,093.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,644.42. The transfer operating threshold is the transfer adjustment factor * $4,625.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.19. The transfer capital threshold is the transfer adjustment factor * $362.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5006.61,14856.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-24341,APC,24341,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, SECOND DIGIT|SEPARATE STRUCTURE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T6|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5970.00,,"Per diem ($5,970). If length of stay < 6.2, first 1 days paid at a per diem of $11,940 instead. Capped at $37,016.57.",,,,0,other,5970.00,38757.79,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20885.18,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20885.18,80720.91,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10899.16,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10899.16,39746.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride/Musc/Fasc First 20 Sq Cm|SEPARATE STRUCTURE|PO,CASE-11043,APC,11043,CPT,0361,RC,,,XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11080.19,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11080.19,32878.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
"FOOT AND TOE PROCEDURES,MODERATE",314,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],17775.45,,"Case rate ($16,929.00). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16929.00,17775.45,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5886.58,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5886.58,17467.27,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11591.72,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6953.00,35389.05,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10851.58,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10334.84,30666.60,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE|PO,CASE-27427,APC,27427,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tnot Elbow Lateral/Medial Debride Open|RIGHT SIDE|PO,CASE-24358,APC,24358,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6387.91,18954.85,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8111.26,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7952.22,25854.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4817.40,,"Case rate ($4,654.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.72. The transfer capital threshold is the transfer adjustment factor * $336.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4654.49,13811.29,Inpatient DRG
Removal Implant Deep|SEPARATE STRUCTURE,CASE-20680,APC,20680,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
Unlisted Px Skin Muc Membrane & Subq Tissue,CASE-17999,APC,17999,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6377.95,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6074.24,18024.13,Inpatient DRG
Ercp Dx Collection Specimen Brushing/Washing,CASE-43260,APC,43260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],47037.87,,,,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],35185.42,,"Fee schedule rate ($35,185.42). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
Gastrocnemius Recession|LEFT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19572.55,,"Fee schedule rate ($19,572.55). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11855.63,,"Case rate ($11,623.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,490.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.89. The transfer capital threshold is the transfer adjustment factor * $842.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,1188.00,35040.80,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Wmhc Perc Implant Stim Lead Ea|PO,CASE-63650,APC,63650,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6044.58,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6044.58,6346.81,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
Arthrt Elbow Capsular Excision Capsular Rls Spx|RIGHT SIDE|PO,CASE-24006,APC,24006,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10105.00,,"Per diem ($10,105). If length of stay < 10.6, first 1 days paid at a per diem of $20,210 instead. Capped at $107,110.70.",,,,0,other,10105.00,120252.50,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Unlisted Laparoscopy Procedure Stomach,CASE-43659,APC,43659,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Intrauterine Device Iud,CASE-58301,APC,58301,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],299.14,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,289.03,303.48,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",847.25,847.25,847.25,1 through 10,other,838.89,880.84,OPPS APC
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
HC Pbb Carpal Tunnel Inj Pmc|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-20526,APC,20526,CPT,0510,RC,,,LT|PO|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],44803.76,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,42670.25,133443.30,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4523.19,16536.43,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Olecranon Bursa|RIGHT SIDE|PO,CASE-24105,APC,24105,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4772.53,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4772.53,14161.54,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],45834.02,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,45834.02,151120.97,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10528.47,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10528.47,44148.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Vasc Embolize Occlude Artery,CASE-37242,APC,37242,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3884.66,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3753.29,11765.59,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,APC,94640,CPT,0410,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14351.97,,"Case rate ($13,866.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,812.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,280.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,174.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,863.50. The transfer operating threshold is the transfer adjustment factor * $12,812.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,003.15. The transfer capital threshold is the transfer adjustment factor * $1,003.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13866.64,41146.57,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],37794.93,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",35251.99,35251.99,35251.99,1 through 10,other,10105.00,120252.50,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21399.79,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21399.79,63499.65,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",596.84,24.97,1903.51,1 through 10,other,1852.10,1944.70,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23853.56,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,23385.84,71764.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6440.28,,"Case rate ($6,440.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,950.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,418.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,637.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,974.38. The transfer operating threshold is the transfer adjustment factor * $5,950.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $465.91. The transfer capital threshold is the transfer adjustment factor * $465.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6440.28,19110.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29141.64,,,,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16092.51,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15326.20,52511.19,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6881.36,,"Case rate ($6,553.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $6,086.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,276.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,494.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,073.77. The transfer operating threshold is the transfer adjustment factor * $6,086.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.91. The transfer capital threshold is the transfer adjustment factor * $479.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6553.68,20086.28,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9456.85,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9456.85,9456.85,9456.85,1 through 10,other,9456.85,28061.37,Inpatient DRG
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13335.48,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13335.48,39570.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13589.22,,"Fee schedule rate ($13,589.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13183.59,,,,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30630.71,,"Fee schedule rate ($30,630.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE,CASE-27695,APC,27695,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB|PO",CASE-26418,APC,26418,CPT,0360,RC,,,FA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|PO,CASE-28090,APC,28090,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Insertion Tunneled Intraperitoneal Catheter,CASE-49324,APC,49324,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER CIRCULATORY SYSTEM DIAGNOSES,MAJOR",207,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12752.70,,"Case rate ($12,752.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12752.70,13390.34,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5605.09,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5338.18,15839.99,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],42814.80,,"Fee schedule rate ($42,814.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29482.05,,,,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],30754.95,,"Fee schedule rate ($30,754.95). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],38550.83,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10105.00,120252.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",10969.57,10969.57,10969.57,1 through 10,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5520.00,,"Per diem ($5,520). If length of stay < 3.5, first 1 days paid at a per diem of $11,040 instead. Capped at $19,319.20.",,,,0,other,5520.00,26638.96,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Cysto W/Insert Ureteral Stent|RIGHT SIDE|SEPARATE STRUCTURE,CASE-52332,APC,52332,CPT,0360,RC,,,RT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,53945.28,Estimated amount calculated based on 17 day length of stay.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8638.80,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8227.43,27001.04,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30630.71,,"Fee schedule rate ($30,630.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29382.86,,"Fee schedule rate ($29,382.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],30586.34,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29129.85,86437.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],31657.92,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30150.40,89465.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12402.46,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12402.46,36801.89,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Pilonidal Cyst/Sinus Complicated,CASE-11772,APC,11772,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2892.78,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],43523.66,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,42670.25,133443.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",6306.22,6306.22,6306.22,1 through 10,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12791.07,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,12791.07,43031.63,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4138.67,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4138.67,12473.25,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41213.48,,,,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, SECOND DIGIT|PO",CASE-26356,APC,26356,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17018.56,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16208.15,58123.31,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7840.85,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,37575.69,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19680.94,,,,,,0,other,6632.59,19680.94,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3781.76,,"Case rate ($3,601.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,426.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $255.23. The transfer capital threshold is the transfer adjustment factor * $255.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3607.42,11497.58,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],9763.00,,"Per diem ($9,763). If length of stay < 4, first 1 days paid at a per diem of $19,526 instead. Capped at $39,053.73.",,,,0,other,9763.00,48626.00,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34749.58,,,,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28569.12,,"Fee schedule rate ($28,569.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Intrauterine Device Iud,CASE-58301,APC,58301,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],299.14,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,289.03,303.48,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9762.34,,"Case rate ($9,297.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,604.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,072.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,638.62. The transfer operating threshold is the transfer adjustment factor * $8,604.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.85. The transfer capital threshold is the transfer adjustment factor * $658.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9312.29,27632.41,Inpatient DRG
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7023.36,,"Case rate ($6,688.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.00. The transfer capital threshold is the transfer adjustment factor * $474.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6699.57,24060.08,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28299,APC,28299,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13831.52,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13831.52,59770.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],3980.76,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3980.76,11812.10,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17123.00,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8558.00,48389.68,Inpatient DRG
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,APC,43282,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],68338.52,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,66027.56,228732.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8227.43,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8227.43,27001.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Revision of Reconstructed Breast|RIGHT SIDE,CASE-19380,APC,19380,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6518.41,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],64778.65,,,,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23950.83,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23950.83,74869.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7875.66,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7500.63,22256.65,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5072.70,,"Case rate ($4,831.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,513.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.35. The transfer capital threshold is the transfer adjustment factor * $342.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4838.84,19587.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7007.50,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6770.53,20090.22,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9733.35,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9269.86,37852.57,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29058.99,,,,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9613.53,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9425.03,27966.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],14651.02,,"Fee schedule rate ($14,651.02). Adds an outlier to normal pricing equal to the per diem rate ($61,007.55) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",14664.18,14664.18,14664.18,1 through 10,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|BILATERAL PROCEDURE,CASE-52354,APC,52354,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],42607.90,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10455.00,90889.11,All Other Inpatient
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17836.44,,"Fee schedule rate ($17,836.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],66169.85,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,64872.40,212258.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30683.33,,"Fee schedule rate ($30,683.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"Avulsion Nail Plate Partial/Comp Simple Ea Addl|LEFT HAND, FOURTH DIGIT|PO",CASE-11732,APC,11732,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],190.30,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3228.61,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3074.87,3228.61,OPPS APC
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23409.73,,,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9071.41,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5183.66,15743.06,All Other Inpatient
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19133.87,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,18222.73,59942.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20895.12,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20895.12,99969.33,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31790.24,,"Fee schedule rate ($31,790.24). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",16099.00,16099.00,16099.00,1 through 10,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",867.84,867.84,867.84,1 through 10,other,5277.74,5541.62,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],63499.65,,,,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6987.68,,"Case rate ($6,654.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,167.40, add-ons for qualifying new technology services are included. If operating cost exceeds $46,712.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,132.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,170.45. The transfer operating threshold is the transfer adjustment factor * $6,167.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.48. The transfer capital threshold is the transfer adjustment factor * $484.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6654.93,20056.77,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4838.84,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4838.84,19587.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cv Cath Plac W/Port Tun >5|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-36561,APC,36561,CPT,0361,RC,,,73,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],47283.61,,"Case rate ($47,283.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,591.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,420.62. The transfer capital threshold is the transfer adjustment factor * $3,420.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,47283.61,169615.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Wmhc Perc Implant Stim Lead Ea|PO,CASE-63650,APC,63650,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6256.14,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|RIGHT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],186.30,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, SECOND DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],92320.55,,,,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5499.26,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5237.39,15540.89,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19460.03,,"Case rate ($18,533.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,484.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,313.34. The transfer capital threshold is the transfer adjustment factor * $1,313.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18562.91,73513.17,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|PO,CASE-64483,APC,64483,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17913.09,,"Fee schedule rate ($17,913.09). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31528.46,,,,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
Ostectomy Prtl 5th Metar Head Spx|RIGHT SIDE|PO,CASE-28110,APC,28110,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24555.13,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23385.84,71764.93,Inpatient DRG
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18751.65,,"Case rate ($17,858.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,436.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,265.53. The transfer capital threshold is the transfer adjustment factor * $1,265.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7455.00,53076.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",28639.28,28639.28,28639.28,1 through 10,other,9888.00,40658.63,Estimated amount calculated based on 3 day length of stay.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
HC Stent Place Initial Artery Ang|LEFT SIDE,CASE-37236,APC,37236,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, GREAT TOE|PO",CASE-28160,APC,28160,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],33422.93,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,33422.93,112824.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Excis Nail Matrix Perm Rmvl|LEFT FOOT, GREAT TOE|PO",CASE-11750,APC,11750,CPT,0450,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Mastectomy Partial W/Axillary Lymphadenectomy,CASE-19302,APC,19302,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6518.41,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9098.46,,"Case rate ($8,665.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,785.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.05. The transfer capital threshold is the transfer adjustment factor * $614.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8679.02,29908.27,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12536.42,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,12536.42,46998.45,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5970.00,,"Per diem ($5,970). If length of stay < 6.2, first 1 days paid at a per diem of $11,940 instead. Capped at $37,016.57.",,,,0,other,5970.00,38757.79,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1688.18,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1688.18,1772.59,OPPS APC
"MALFUNCTION REACTION COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE,MAJOR",466,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],13732.19,,"Case rate ($13,732.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13732.19,14418.80,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"HEART FAILURE,MAJOR",194,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15479.17,,"Case rate ($14,742.07). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14742.07,15479.17,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26800.70,,"Fee schedule rate ($26,800.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11410.61,,"Case rate ($10,867.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,941.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $770.09. The transfer capital threshold is the transfer adjustment factor * $770.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10884.58,32297.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5857.13,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5578.22,18148.00,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],35688.34,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",34177.43,34177.43,34177.43,1 through 10,other,34988.57,110685.97,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24555.30,,"Fee schedule rate ($24,555.30). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MAJOR",720,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],17201.16,,"Case rate ($17,201.16). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,17201.16,18061.22,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12677.91,,"Case rate ($12,074.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,026.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.62. The transfer capital threshold is the transfer adjustment factor * $855.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,40067.60,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6199.10,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6077.55,18033.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,MAJOR",174,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7653.61,,"Case rate for a one day stay ($7,653.61). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,7653.61,8036.29,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5942.94,17634.53,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19606.16,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6350.00,33244.29,All Other Inpatient
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36852.72,,"Fee schedule rate ($36,852.72). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13713.25,,"Fee schedule rate ($13,713.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],31889.78,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,18222.73,59942.55,All Other Inpatient
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
Open Treatment Ulnar Fracture Proximal End|RIGHT SIDE|PO,CASE-24685,APC,24685,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13589.22,,"Fee schedule rate ($13,589.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43277,APC,43277,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3865.18,,"Case rate ($3,681.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.86. The transfer capital threshold is the transfer adjustment factor * $260.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3209.85,10940.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4376.13,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4167.74,12366.99,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13589.22,,"Fee schedule rate ($13,589.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Tx Tibl Shft Fx Imed Implt W/WO Screws&/Cercla,CASE-27759,APC,27759,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
HC 3rd Order Sel Abd/Lower Ext|RIGHT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,46419.05,Estimated amount calculated based on 12 day length of stay.
Excision Tumor Soft Tiss Face/Scalp Subq 2 Cm/>,CASE-21012,APC,21012,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit W Pta|LEFT SIDE,CASE-36902,APC,36902,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5668.18,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5398.26,5668.18,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16175.36,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,55581.70,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8023.33,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7866.01,25247.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12167.07,36103.36,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Radial&Ulnar Shaft Fx W/Fixj Radius&Ulna|RIGHT SIDE|PO,CASE-25575,APC,25575,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7226.40,7226.40,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13525.32,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",10931.48,10931.48,10931.48,1 through 10,other,12881.26,38222.57,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15065.57,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15065.57,53815.71,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|LEFT FOOT, SECOND DIGIT|PO",CASE-28092,APC,28092,CPT,0360,RC,,,T1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN ULCERS,MODERATE",380,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9771.13,,"Case rate ($9,305.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9305.84,9771.13,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4755.96,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4755.96,21133.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12727.27,,"Case rate ($12,121.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,030.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.95. The transfer capital threshold is the transfer adjustment factor * $858.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",14156.96,14156.96,14156.96,1 through 10,other,12140.54,36024.65,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14755.41,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8431.66,25019.31,All Other Inpatient
Arthrt Glenohmrl Jt W/Jt Expl W/WO Rmvl Loose/FB,CASE-23107,APC,23107,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
"NEPHRITIS AND NEPHROSIS,MAJOR",462,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],17202.54,,"Case rate ($17,202.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,17202.54,18062.67,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31329.81,,"Fee schedule rate ($31,329.81). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
Removal Implant Deep|BILATERAL PROCEDURE,CASE-20680,APC,20680,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2755.03,,"APC Price ($2,755.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4263.53,,"Case rate ($4,119.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,806.17, add-ons for qualifying new technology services are included. If operating cost exceeds $39,274.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,821.34. The transfer operating threshold is the transfer adjustment factor * $3,806.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.00. The transfer capital threshold is the transfer adjustment factor * $298.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4119.35,12223.35,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16746.77,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9569.58,41116.55,All Other Inpatient
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15961.98,,,,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16624.45,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16062.27,48077.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31007.02,,,,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,APC,58552,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11356.39,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9888.00,40658.63,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
Blepharoplasty Upper Eyelid|BILATERAL PROCEDURE|PO,CASE-15822,APC,15822,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.80,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2054.80,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],45609.21,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,45609.21,211906.58,Inpatient DRG
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12764.83,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",12764.84,12764.84,12764.84,1 through 10,other,12514.54,37134.43,Inpatient DRG
HC Revasc Intra Lithotrip-Ather,CASE-C9766,APC,C9766,CPT,0481,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5949.17,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5091.00,22010.11,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],32973.67,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,31858.62,94534.21,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17274.00,,"Per diem ($17,274). If length of stay < 3.3, first 1 days paid at a per diem of $34,548 instead. Capped at $57,002.93.",,,,0,other,17274.00,73717.28,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|RIGHT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Mastectomy Partial|LEFT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
Arthrodesis Midtarsometatarsal Single Joint|RIGHT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],31024.96,,"Case rate ($29,547.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,264.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,093.84. The transfer capital threshold is the transfer adjustment factor * $2,093.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,29594.69,124146.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10362.69,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10362.69,9420.73,10552.22,1 through 10,other,10362.69,29367.82,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis 20 Cm/<|PBB CHARGE,CASE-97597,APC,97597,CPT,0761,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28299,APC,28299,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>|LEFT SIDE,CASE-23073,APC,23073,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT SIDE|PO,CASE-28750,APC,28750,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],129256.37,,"Fee schedule rate ($129,256.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],45834.02,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",45410.75,45410.75,45410.75,1 through 10,other,45834.02,151120.97,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
Bx Prostate Strtctc Saturation Sampling Img Gid,CASE-55706,APC,55706,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5942.35,,"Case rate ($5,659.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,572.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.04. The transfer capital threshold is the transfer adjustment factor * $401.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",44810.92,44810.92,44810.92,1 through 10,other,5668.40,16903.82,Inpatient DRG
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14102.73,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14102.73,41847.08,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,8596.11,25507.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
Colsc Flx With Directed Submucosal Njx Any Sbst|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45381,APC,45381,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|RIGHT SIDE,CASE-37225,APC,37225,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],565.88,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28832.22,,"Fee schedule rate ($28,832.22). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],37133.12,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",36797.86,36797.86,36797.86,1 through 10,other,36405.02,110499.61,Inpatient DRG
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11009.52,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",11088.29,11088.29,11089.78,1 through 10,other,10637.22,31563.88,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6803.69,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5843.00,27370.21,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5486.04,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5486.04,17919.05,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10651.94,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10291.73,34803.35,Inpatient DRG
"OTHER DISORDERS OF NERVOUS SYSTEM,MAJOR",058,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],19292.76,,"Case rate ($19,292.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19292.76,20257.40,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5766.55,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5766.55,17111.12,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],34091.39,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,33422.93,112824.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Ankle W/Implant|LEFT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22506.55,,,,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7120.66,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,20179.92,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5110.72,,"Case rate ($4,867.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.12. The transfer capital threshold is the transfer adjustment factor * $352.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4867.35,14442.92,Inpatient DRG
Laparoscopy Surgical Jejunostomy,CASE-44186,APC,44186,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO,CASE-27691,APC,27691,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6964.22,,"Case rate ($6,632.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,128.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,596.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,650.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,152.78. The transfer operating threshold is the transfer adjustment factor * $6,128.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.82. The transfer capital threshold is the transfer adjustment factor * $479.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6632.59,19680.94,Inpatient DRG
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],46482.88,,"Case rate ($44,269.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,308.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,137.08. The transfer capital threshold is the transfer adjustment factor * $3,137.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,44339.99,131570.26,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16991.47,,"Case rate ($16,182.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.74. The transfer capital threshold is the transfer adjustment factor * $1,146.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16208.15,58123.31,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11674.21,,"Fee schedule rate ($11,674.21). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt|LEFT SIDE|PO,CASE-27602,APC,27602,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7369.88,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,20179.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11953.81,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11384.58,33781.47,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26350.52,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,25459.44,80806.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Sesamoidectomy First Toe Spx|BILATERAL PROCEDURE|PO,CASE-28315,APC,28315,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],38035.88,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36224.65,128473.68,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4120.67,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4120.67,13066.56,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19432.35,,"Fee schedule rate ($19,432.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],67331.56,,"Fee schedule rate ($67,331.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20188.60,,,,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc,CASE-24341,APC,24341,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12556.78,,"Case rate ($11,958.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,049.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,517.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,093.70. The transfer operating threshold is the transfer adjustment factor * $11,049.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.13. The transfer capital threshold is the transfer adjustment factor * $865.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11958.84,40774.00,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11670.40,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7000.00,32980.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8259.31,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7866.01,25247.47,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Needle Biopsy Muscle,CASE-20206,APC,20206,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10637.22,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",33001.50,33001.50,91172.99,1 through 10,other,10637.22,31563.88,Inpatient DRG
"SKIN ULCERS,MODERATE",380,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9771.13,,"Case rate ($9,305.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9305.84,9771.13,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14324.77,,"Case rate ($13,642.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,137.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $966.76. The transfer capital threshold is the transfer adjustment factor * $966.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13664.39,40546.43,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14315.62,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13831.52,59770.39,Inpatient DRG
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],48019.46,,"Fee schedule rate ($48,019.46). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13283.92,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7590.81,32847.45,All Other Inpatient
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,APC,45171,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],35466.15,,"Fee schedule rate ($35,466.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Nonunion/Malunion Radius/Ulna W/Autograft|LEFT SIDE|PO,CASE-25405,APC,25405,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12560.26,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11962.15,40923.09,Inpatient DRG
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5578.22,18148.00,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11588.33,,"Case rate ($11,036.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,227.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,773.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,451.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $10,233.04. The transfer operating threshold is the transfer adjustment factor * $10,227.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $803.46. The transfer capital threshold is the transfer adjustment factor * $803.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11036.50,33262.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10556.32,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10556.32,32082.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24742.67,,"Case rate ($23,564.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,841.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,669.86. The transfer capital threshold is the transfer adjustment factor * $1,669.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23602.02,108295.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6515.12,,"Case rate ($6,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,620.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.88. The transfer capital threshold is the transfer adjustment factor * $448.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6204.88,19589.20,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33947.68,,"Fee schedule rate ($33,947.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7125.55,,"Case rate ($6,786.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,652.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.90. The transfer capital threshold is the transfer adjustment factor * $480.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6797.06,20168.93,Inpatient DRG
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|LEFT SIDE,CASE-38570,APC,38570,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10434.93,10586.16,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18137.85,,"Fee schedule rate ($18,137.85). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22885.85,,"Case rate ($21,796.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,715.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,544.54. The transfer capital threshold is the transfer adjustment factor * $1,544.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21830.80,85124.35,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16361.19,,"Fee schedule rate ($16,361.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],31205.66,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,30150.40,89465.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6608.44,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6293.75,21908.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39967.07,,"Fee schedule rate ($39,967.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6549.71,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6328.22,27416.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12276.79,,"Case rate ($11,692.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,999.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.55. The transfer capital threshold is the transfer adjustment factor * $828.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11710.82,34749.58,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9327.24,,"Fee schedule rate ($9,327.24). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, SECOND DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],33955.82,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,32807.56,111191.81,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],39736.19,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,37843.99,139522.22,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22168.26,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21112.63,62647.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2|RIGHT SIDE|PO,CASE-29822,APC,29822,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3258.56,3258.56,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17954.98,,"Case rate ($17,099.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,382.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,211.76. The transfer capital threshold is the transfer adjustment factor * $1,211.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17127.24,50821.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, SECOND DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6004.31,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",55521.51,55521.51,55521.51,1 through 10,other,5886.58,17467.27,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14807.87,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14102.73,41847.08,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6387.91,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6387.91,18954.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5049.39,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4878.64,14476.37,Inpatient DRG
HC Lyr Clos Sc Tk Ext 2.6-7 Cm,CASE-12032,APC,12032,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,399.06,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HIV WITH MAJOR HIV RELATED CONDITION,EXTREME",892,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],25095.09,,"Case rate ($25,095.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,25095.09,26349.84,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8716.15,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8600.55,8600.55,8600.55,1 through 10,other,8716.15,25863.45,Inpatient DRG
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE,CASE-27524,APC,27524,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4774.52,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",4656.95,2471.44,4774.52,1 through 10,other,4774.52,14406.59,Inpatient DRG
Removal Intrauterine Device Iud,CASE-58301,APC,58301,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],289.03,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,289.03,303.48,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11871.54,,"Case rate ($11,871.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,001.85, add-ons for qualifying new technology services are included. If operating cost exceeds $51,547.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,512.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,007.29. The transfer operating threshold is the transfer adjustment factor * $11,001.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.25. The transfer capital threshold is the transfer adjustment factor * $864.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11871.54,35778.69,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],52607.24,,"Fee schedule rate ($52,607.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10658.54,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10449.55,43409.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8526.58,,"Fee schedule rate ($8,526.58). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28157.55,,"Fee schedule rate ($28,157.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],35117.21,,"Fee schedule rate ($35,117.21). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|SEPARATE STRUCTURE|PO,CASE-62323,APC,62323,CPT,0360,RC,,,XS|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5542.86,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5355.42,17067.11,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10034.43,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10034.43,29775.24,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28296,APC,28296,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9494.70,,"Case rate ($9,042.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.79. The transfer capital threshold is the transfer adjustment factor * $640.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9056.99,33814.75,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
"ALCOHOLIC LIVER DISEASE,MAJOR",280,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],15582.03,,"Case rate ($15,582.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15582.03,16361.13,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4523.19,16536.43,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Insertion Uterine Tandem&/Vaginal Ovoids,CASE-57155,APC,57155,CPT,0342,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4910.73,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE,CASE-28200,APC,28200,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16278.78,,,,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6948.21,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7231.00,,"Per diem ($7,231). If length of stay < 5.1, first 1 days paid at a per diem of $14,462 instead. Capped at $36,875.62.",,,,0,other,7231.00,38610.21,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12167.07,36103.36,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9527.16,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9527.16,28269.95,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8566.62,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4895.21,14525.56,All Other Inpatient
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],61348.24,,"Fee schedule rate ($61,348.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14511.08,,"Case rate ($13,820.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,150.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.34. The transfer capital threshold is the transfer adjustment factor * $979.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12440.40,41073.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5169.74,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5169.74,15340.19,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6195.72,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6074.24,18024.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9910.44,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9910.44,43344.00,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",855.44,855.44,855.44,1 through 10,other,838.89,880.84,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],30163.67,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,30163.67,89504.77,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],56787.82,,,,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14182.30,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7308.00,42083.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],28090.46,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,27539.67,109237.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Aerosol, Hhn, Mdi, Ippb|ADJ",CASE-94640,APC,94640,CPT,0410,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],25459.44,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",26001.36,26001.36,26001.36,1 through 10,other,25459.44,80806.10,Inpatient DRG
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],25267.19,,"Fee schedule rate ($25,267.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
HC Vasc Embolize Occlude Artery,CASE-37242,APC,37242,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6055.67,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6055.67,17969.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE|PO,CASE-25607,APC,25607,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26270.73,,"Fee schedule rate ($26,270.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15602.53,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8915.73,26455.73,All Other Inpatient
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14472.76,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14472.76,56135.46,Inpatient DRG
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],50447.16,,"Fee schedule rate ($50,447.16). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Partial Nephrectomy|RIGHT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],34393.10,,"Case rate ($32,755.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,492.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,321.16. The transfer capital threshold is the transfer adjustment factor * $2,321.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",48361.20,48361.20,48361.20,1 through 10,other,32807.56,111191.81,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],33038.25,,"Fee schedule rate ($33,038.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites,CASE-31625,APC,31625,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3536.22,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],60241.14,,,,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5971.17,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,1188.00,17370.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6328.98,,"Case rate ($6,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,620.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.88. The transfer capital threshold is the transfer adjustment factor * $448.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6204.88,19589.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],35018.80,,"Fee schedule rate ($35,018.80). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
HC Sleep Study Unattended,CASE-95800,APC,95800,CPT,0920,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],211.96,,"APC Price ($204.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",150.33,150.33,150.33,29,other,204.80,215.04,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8898.75,,"Fee schedule rate ($8,898.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
Partial Excision Bone Fibula|RIGHT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4167.74,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4167.74,12366.99,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],8558.00,,"Per diem ($8,558). If length of stay < 5.4, first 1 days paid at a per diem of $17,116 instead. Capped at $46,215.75.",,,,0,other,8558.00,48389.68,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22878.60,,"Fee schedule rate ($22,878.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21313.02,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20895.12,99969.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],36949.14,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,36224.65,128473.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|LEFT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|BILATERAL PROCEDURE,CASE-38570,APC,38570,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
"Excision/Curettage Cyst/Tumor Phalanx Finger|RIGHT HAND, SECOND DIGIT|PO",CASE-26210,APC,26210,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1525.13,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Glenohumeral Joint Total Shoulder|RIGHT SIDE,CASE-23472,APC,23472,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9904.52,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9569.58,41116.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18673.84,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",18673.85,18673.85,18673.85,1 through 10,other,18042.36,82749.58,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7369.00,,"Per diem ($7,369). If length of stay < 2.4, first 1 days paid at a per diem of $14,738 instead. Capped at $17,686.09.",,,,0,other,6240.68,18518.02,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],3828.36,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3753.29,11765.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4697.29,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4538.44,18815.35,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10568.05,,"Case rate ($10,064.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.23. The transfer capital threshold is the transfer adjustment factor * $713.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10080.86,33310.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5034.82,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4795.07,19830.58,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE,CASE-28322,APC,28322,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Destruction of Lesions,CASE-52214,APC,52214,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],59664.81,,"Fee schedule rate ($59,664.81). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11434.95,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11434.95,119072.21,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10266.34,,"Case rate ($9,777.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,864.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.87. The transfer capital threshold is the transfer adjustment factor * $692.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",10056.16,10056.16,10266.34,1 through 10,other,9793.06,29058.99,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea,CASE-28092,APC,28092,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,APC,52351,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13983.36,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7770.00,50313.90,Inpatient DRG
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],102498.90,,"Fee schedule rate ($102,498.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,36167.61,140535.66,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8515.39,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8227.43,27001.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Tib/Pero W/Athrc/Angiop Uni Ea Vsl|RIGHT SIDE,CASE-37233,APC,37233,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.96,,,,,,0,other,291.75,306.34,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10037.09,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10156.77,10156.77,10156.77,1 through 10,other,10037.09,36934.96,Inpatient DRG
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,21229.52,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],67008.32,,"Fee schedule rate ($67,008.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27693.51,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,15824.86,49371.45,All Other Inpatient
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|LEFT SIDE,CASE-27130,APC,27130,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",12542.29,12476.58,12542.29,1 through 10,other,12177.08,12785.93,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10037.09,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10037.09,36934.96,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19377.46,,"Fee schedule rate ($19,377.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],38090.20,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36276.38,121107.98,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],45202.80,,"Fee schedule rate ($45,202.80). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5531.18,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5344.14,15857.69,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>,CASE-25071,APC,25071,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5344.14,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5352.08,5352.08,5352.08,1 through 10,other,5344.14,15857.69,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13889.46,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13228.06,39251.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7394.01,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,21229.52,Inpatient DRG
HC Vasc Embolize Occlude Artery,CASE-37242,APC,37242,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC
Blepharoplasty Lower Eyelid Herniated Fat Pad|BILATERAL PROCEDURE|PO,CASE-15821,APC,15821,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1956.96,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.96,2054.80,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14910.91,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7453.00,42138.30,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21399.79,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21399.79,63499.65,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15421.03,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15421.03,49137.17,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6495.00,,"Per diem ($6,495). If length of stay < 3.5, first 1 days paid at a per diem of $12,990 instead. Capped at $22,732.01.",,,,0,other,6495.00,23801.30,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5244.04,15804.57,There are no additional notes associated with this service or procedure.
HC Hdr Vaginal Cyl Insertion,CASE-57156,APC,57156,CPT,0333,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],289.03,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,289.03,303.48,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9594.31,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9269.86,37852.57,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],64005.35,,,,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9569.58,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9569.58,41116.55,Inpatient DRG
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,APC,57425,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",10330.04,10330.04,10330.04,1 through 10,other,10082.05,10586.16,OPPS APC
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10805.00,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10439.61,34540.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12833.49,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12833.49,58980.57,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],43344.00,,"Fee schedule rate ($43,344.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE|PO,CASE-27524,APC,27524,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20782.85,,,,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, SECOND DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31927.90,,,,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st < 3 Cm Reducible,CASE-49591,APC,49591,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T7,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],50901.17,,"Fee schedule rate ($50,901.17). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],25110.76,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23915.01,121205.60,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10535.25,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10535.27,10535.27,10535.27,1 through 10,other,10178.99,36468.17,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],47660.93,,"Fee schedule rate ($47,660.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14580.18,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14580.18,57079.69,Inpatient DRG
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19262.83,,"Fee schedule rate ($19,262.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5923.06,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5923.06,17575.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],37492.51,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",35502.67,35502.67,35502.67,1 through 10,other,36224.65,128473.68,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19871.72,,"Fee schedule rate ($19,871.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,7011.91,27304.54,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5403.00,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5297.06,19049.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],43344.00,,"Fee schedule rate ($43,344.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11623.17,,"Case rate ($11,623.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,490.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.89. The transfer capital threshold is the transfer adjustment factor * $842.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,35040.80,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13228.06,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13228.06,39251.68,Inpatient DRG
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],36370.09,,"Fee schedule rate ($36,370.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9464.71,,"Case rate ($9,279.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,573.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,041.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,607.86. The transfer operating threshold is the transfer adjustment factor * $8,573.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.28. The transfer capital threshold is the transfer adjustment factor * $671.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9279.13,27534.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21967.53,,"Case rate ($20,921.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,653.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,482.57. The transfer capital threshold is the transfer adjustment factor * $1,482.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",52069.33,52069.33,52069.33,1 through 10,other,20954.82,62179.32,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8005.26,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8005.26,24549.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE,CASE-28615,APC,28615,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25019.31,,,,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10003.52,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9527.16,28269.95,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",26661.78,26661.78,26661.78,1 through 10,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17584.61,,"Fee schedule rate ($17,584.61). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6204.88,19589.20,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14813.49,,"Case rate ($14,108.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,170.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $999.75. The transfer capital threshold is the transfer adjustment factor * $999.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14130.58,57770.11,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10655.47,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6088.84,18067.42,All Other Inpatient
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10614.84,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10109.37,38416.97,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partical Excision Bone Phalanx Toe|LEFT SIDE|PO,CASE-28124,APC,28124,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],26419.65,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,26419.65,96304.23,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23545.50,,,,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7956.44,,"Case rate ($7,577.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,001.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,469.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,029.37. The transfer operating threshold is the transfer adjustment factor * $7,001.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.18. The transfer capital threshold is the transfer adjustment factor * $548.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7577.56,31445.30,Inpatient DRG
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21282.78,,"Case rate ($20,269.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,607.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.35. The transfer capital threshold is the transfer adjustment factor * $1,436.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20301.63,84714.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],31858.62,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31858.62,94534.21,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,53945.28,Estimated amount calculated based on 17 day length of stay.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39228.51,,"Fee schedule rate ($39,228.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],38724.86,,"Fee schedule rate ($38,724.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12677.91,,"Case rate ($12,074.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,026.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.62. The transfer capital threshold is the transfer adjustment factor * $855.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,35884.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Ant&/Lat Compartments Only,CASE-27600,APC,27600,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE,CASE-29875,APC,29875,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",35828.30,35828.30,35828.30,1 through 10,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],65555.62,,"Fee schedule rate ($65,555.62). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32876.47,,"Fee schedule rate ($32,876.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE|PO",CASE-64491,APC,64491,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24956.34,,,,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5621.79,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5354.09,15887.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,28788.33,Estimated amount calculated based on 2 day length of stay.
HC Inj Tendon Sheath/Ligament|PO,CASE-20550,APC,20550,CPT,0510,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Rem Central Venous Cath,CASE-36589,APC,36589,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],615.80,,"APC Price ($594.98). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,594.98,624.73,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9611.27,,"Fee schedule rate ($9,611.27). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12804.31,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12804.31,55145.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],36505.40,,"Fee schedule rate ($36,505.40). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",104716.17,104716.17,104716.17,1 through 10,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8640.19,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8228.75,24417.19,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21929.44,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20885.18,80720.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Revise/Remove Neurostim/Receiver,CASE-64595,APC,64595,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3315.94,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3315.94,3481.74,OPPS APC
HC Stent Place Initial Artery Ang|LEFT SIDE,CASE-37236,APC,37236,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],22152.42,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9370.00,65732.99,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|PO,CASE-64636,APC,64636,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18987.72,,"Fee schedule rate ($18,987.72). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
"PEPTIC ULCER AND GASTRITIS,MODERATE",241,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3312.45,,"Case rate for a one day stay ($3,154.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3154.71,3312.45,There are no additional notes associated with this service or procedure.
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],190.30,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29049.23,,"Fee schedule rate ($29,049.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11623.17,,"Case rate ($11,623.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,490.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.89. The transfer capital threshold is the transfer adjustment factor * $842.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,35040.80,Inpatient DRG
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6358.45,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6055.67,17969.04,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4119.35,,"Case rate ($4,119.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,806.17, add-ons for qualifying new technology services are included. If operating cost exceeds $39,274.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,821.34. The transfer operating threshold is the transfer adjustment factor * $3,806.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.00. The transfer capital threshold is the transfer adjustment factor * $298.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4119.35,12223.35,Inpatient DRG
Excision/Curettage Cyst/Tumor Femur|RIGHT SIDE,CASE-27355,APC,27355,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE",CASE-28299,APC,28299,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,46419.05,Estimated amount calculated based on 12 day length of stay.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10670.93,,"Case rate ($10,162.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,891.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.17. The transfer capital threshold is the transfer adjustment factor * $720.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10178.99,36468.17,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, SECOND DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11778.33,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11217.46,37366.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
Inguinofem Lmphadec Supfc W/Cloquets Node Spx,CASE-38760,APC,38760,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5110.72,,"Case rate ($4,867.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.12. The transfer capital threshold is the transfer adjustment factor * $352.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4867.35,14442.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],29066.85,,of the excess amount. Final payment is multiplied by 105%.,28778.10,28778.10,28778.10,1 through 10,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18606.40,,"Fee schedule rate ($18,606.40). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],96291.48,,"Case rate ($91,706.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,669.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,498.62. The transfer capital threshold is the transfer adjustment factor * $6,498.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",96291.52,96291.52,96291.52,1 through 10,other,10249.47,96445.01,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],66275.39,,"Fee schedule rate ($66,275.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Mastectomy Simple Complete|BILATERAL PROCEDURE,CASE-19303,APC,19303,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intrvasc US Noncoronary 1st|RIGHT SIDE,CASE-37252,APC,37252,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5587.20,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4574.91,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4574.91,13575.16,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],32807.56,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",32807.57,32807.57,32807.57,1 through 10,other,32807.56,111191.81,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],49125.30,,"Fee schedule rate ($49,125.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4538.44,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4538.44,18815.35,Inpatient DRG
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm/1pct,CASE-15002,APC,15002,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],736.04,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,700.99,736.04,OPPS APC
Trluml Balo Angiop Ctr Dialysis Seg W/Img S&I,CASE-36907,APC,36907,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5668.18,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Capsulectomy/Capsulotomy Mtcarphlngl Joint Each,CASE-26520,APC,26520,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Subtalar|LEFT SIDE|PO,CASE-28725,APC,28725,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],22595.47,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9370.00,65732.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
HC Cystostomy Tube Change,CASE-51705,APC,51705,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
HC Extremity Venogram|LEFT SIDE,CASE-36005,APC,36005,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1493.03,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13445.25,,"Fee schedule rate ($13,445.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],43128.06,,"Fee schedule rate ($43,128.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],38694.84,,"Case rate ($36,852.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,782.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,611.48. The transfer capital threshold is the transfer adjustment factor * $2,611.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36910.99,126842.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7957.67,,"Case rate ($7,578.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,708.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $537.06. The transfer capital threshold is the transfer adjustment factor * $537.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7590.81,32847.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15156.44,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15156.44,52672.70,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18902.44,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18902.44,56089.29,Inpatient DRG
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29162.98,,"Fee schedule rate ($29,162.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],42193.04,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy,CASE-44970,APC,44970,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13867.29,,"Fee schedule rate ($13,867.29). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5742.54,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5629.94,16705.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,76376.03,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39228.51,,"Fee schedule rate ($39,228.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
"Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn|RIGHT HAND, THIRD DIGIT|PO",CASE-26145,APC,26145,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9269.86,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9269.86,37852.57,Inpatient DRG
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Biopsy/Excision Inguinofemoral Nodes|LEFT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10467.94,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9969.47,29582.40,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],51711.33,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13061.00,162464.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",56585.92,56585.92,56585.92,1 through 10,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
"MAJOR SMALL BOWEL PROCEDURES,MAJOR",230,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],38303.69,,"Case rate ($38,303.69). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,38303.69,40218.87,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8184.82,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7795.07,34198.12,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4119.35,,"Case rate ($4,119.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,806.17, add-ons for qualifying new technology services are included. If operating cost exceeds $39,274.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,821.34. The transfer operating threshold is the transfer adjustment factor * $3,806.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.00. The transfer capital threshold is the transfer adjustment factor * $298.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4119.35,12223.35,Inpatient DRG
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, SECOND DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16589.65,,"Case rate ($15,799.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,290.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,119.62. The transfer capital threshold is the transfer adjustment factor * $1,119.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6598.88,6598.88,6598.88,1 through 10,other,15824.86,49371.45,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25633.23,,,,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],81161.07,,"Fee schedule rate ($81,161.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,30480.63,86382.02,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",57865.62,57865.62,57865.62,1 through 10,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,CASE-49592,APC,49592,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5605.96,5605.96,5605.96,1 through 10,other,5733.99,5934.68,OPPS APC
Fasciotomy Foot&/Toe|BILATERAL PROCEDURE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8485.05,,"Fee schedule rate ($8,485.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],36287.40,,"Fee schedule rate ($36,287.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33132.06,,"Fee schedule rate ($33,132.06). Adds an outlier to normal pricing equal to the per diem rate ($83,058.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",10303.94,10303.94,10303.94,1 through 10,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,EXTREME",720,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],32886.18,,"Case rate ($31,320.17). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31320.17,32886.18,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15862.62,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15326.20,52511.19,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4742.02,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4742.02,14071.02,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],55272.09,,"Fee schedule rate ($55,272.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
Rcnstj Angular Dfrm Toe Soft Tiss Px Only,CASE-28313,APC,28313,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],25524.04,,"Case rate ($24,308.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,893.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,722.59. The transfer capital threshold is the transfer adjustment factor * $1,722.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10455.00,90889.11,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18865.34,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,18227.38,54086.17,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18513.23,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7455.00,53076.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7457.21,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7102.10,21074.07,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
"PERIPHERAL AND OTHER VASCULAR DISORDERS,MODERATE",197,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9378.02,,"Case rate ($8,931.45). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8931.45,9378.02,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10224.92,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9738.02,28895.67,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11901.14,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6307.17,6307.17,6307.17,1 through 10,other,11901.14,35314.31,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39854.32,,"Fee schedule rate ($39,854.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
Laps Insertion Tunneled Intraperitoneal Catheter,CASE-49324,APC,49324,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5416.39,5416.39,5416.39,1 through 10,other,5733.99,6020.69,OPPS APC
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE|PO,CASE-29891,APC,29891,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7106.33,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6866.02,27153.67,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18042.36,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18042.36,82749.58,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5450.78,,"Case rate ($5,450.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $5,062.05, add-ons for qualifying new technology services are included. If operating cost exceeds $42,251.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,051.56. The transfer operating threshold is the transfer adjustment factor * $5,062.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.22. The transfer capital threshold is the transfer adjustment factor * $399.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5450.78,16705.77,Inpatient DRG
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],27851.43,,of the excess amount. Final payment is multiplied by 105%.,8881.99,8881.99,16631.61,1 through 10,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],52607.24,,"Fee schedule rate ($52,607.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10226.31,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9739.34,40204.26,Inpatient DRG
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|RIGHT SIDE,CASE-38570,APC,38570,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16214.42,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",15736.26,15736.26,15736.26,1 through 10,other,15896.49,51306.05,Inpatient DRG
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|LEFT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9427.57,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Unlisted Procedure, Nervous System|UNUSUAL NON-OVERLAPPING SERVICE",CASE-64999,APC,64999,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12741.99,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12135.23,49469.07,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],58534.56,,"Fee schedule rate ($58,534.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9564.15,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9108.71,27028.33,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8981.78,,"Case rate ($8,981.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,671.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $657.72. The transfer capital threshold is the transfer adjustment factor * $657.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8981.78,27528.12,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11368.22,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10826.88,32126.64,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12180.79,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11600.75,34422.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18988.45,,"Fee schedule rate ($18,988.45). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Hemiphalangectomy/Interphalangeal Joint Exc Toe,CASE-28160,APC,28160,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7537.28,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6382.95,21300.35,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5623.19,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5355.42,17067.11,Inpatient DRG
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,APC,52281,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2081.79,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18988.45,,"Fee schedule rate ($18,988.45). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Add 2nd/3rd Order Abd/Le|LEFT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5462.46,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE|PO,CASE-27698,APC,27698,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvic/Le 1st Ord|BILATERAL PROCEDURE,CASE-36245,APC,36245,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],30150.40,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,30150.40,89465.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, SECOND DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30630.71,,"Fee schedule rate ($30,630.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6763.33,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6630.72,19989.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],38106.57,,"Fee schedule rate ($38,106.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE|PO,CASE-24685,APC,24685,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"HIV WITH MAJOR HIV RELATED CONDITION,MODERATE",892,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10661.10,,"Case rate ($10,661.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10661.10,11194.16,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4955.35,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4787.78,20006.29,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],41377.81,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,23644.46,105789.11,All Other Inpatient
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7601.43,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7601.43,23918.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18411.77,,,,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
Prostate Needle Biopsy Any Approach,CASE-55700,APC,55700,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],124.33,,,,,,0,other,120.13,126.14,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29382.86,,"Fee schedule rate ($29,382.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34517.10,,"Fee schedule rate ($34,517.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",34517.10,34517.10,34517.10,1 through 10,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],42577.42,,"Fee schedule rate ($42,577.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35884.94,,,,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE,CASE-27695,APC,27695,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|LEFT SIDE,CASE-19120,APC,19120,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49594,APC,49594,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4962.75,,"Case rate ($4,726.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,389.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,934.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,983.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,391.29. The transfer operating threshold is the transfer adjustment factor * $4,389.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.14. The transfer capital threshold is the transfer adjustment factor * $335.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4734.64,14273.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],61356.75,,"Fee schedule rate ($61,356.75). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8356.13,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8192.28,24308.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],46521.39,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,45609.21,211906.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Lympho for Sentinal Node|SEPARATE PRACTITIONER,CASE-38792,APC,38792,CPT,0361,RC,,,XP,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
Unlisted Procedure Arthroscopy,CASE-29999,APC,29999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11600.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11600.09,48814.14,Inpatient DRG
"RENAL DIALYSIS ACCESS DEVICE PROCEDURES,MAJOR",444,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],30791.53,,"Case rate ($29,325.27). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29325.27,30791.53,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Biopsy/Excision Inguinofemoral Nodes|LEFT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB|PO",CASE-26540,APC,26540,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17008.80,,,,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],35962.60,,"Fee schedule rate ($35,962.60). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
Transurethral Waterjet Ablation Prostate Compl,CASE-0421T,APC,0421T,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4.76,,,,,,0,other,4.76,4.76,There are no additional notes associated with this service or procedure.
HC Debrid Wound Tis Addl 20 Cm<,CASE-97598,APC,97598,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Rescj Pelvic Tumor|LEFT SIDE,CASE-52355,APC,52355,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],86437.13,,,,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7770.00,,"Per diem ($7,770). If length of stay < 5.1, first 1 days paid at a per diem of $15,540 instead. Capped at $39,628.80.",,,,0,other,7770.00,50313.90,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MAJOR",220,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],41243.54,,"Case rate ($41,243.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,41243.54,43305.72,There are no additional notes associated with this service or procedure.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, GREAT TOE|PO",CASE-28160,APC,28160,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5297.06,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5297.06,19049.64,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],110288.60,,"Fee schedule rate ($110,288.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,38916.28,133824.90,Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|LEFT FOOT, SECOND DIGIT|PO",CASE-28092,APC,28092,CPT,0360,RC,,,T1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5578.22,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5578.22,18148.00,Inpatient DRG
Arthrs Knee Drill Osteochondritis Dissecans Grfg,CASE-29885,APC,29885,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Lympho for Sentinal Node|SEPARATE PRACTITIONER,CASE-38792,APC,38792,CPT,0361,RC,,,XP,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23644.46,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23644.46,105789.11,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($60,119.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18269.32,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10439.61,34540.67,All Other Inpatient
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MAJOR",254,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14495.68,,"Case rate ($13,805.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13805.41,14495.68,There are no additional notes associated with this service or procedure.
Revascularization Iliac Artery Angiop 1st Vsl|RIGHT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],374.15,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
Excision Hidradenitis Axillary Smpl/Intrm Rpr,CASE-11450,APC,11450,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13384.89,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7648.51,27371.98,All Other Inpatient
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14002.25,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13335.48,39570.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12323.34,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6965.00,21229.52,All Other Inpatient
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17279.67,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16456.83,55350.97,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",33526.68,33526.68,33526.68,1 through 10,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26041.57,,"Fee schedule rate ($26,041.57). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],68007.59,,"Case rate ($64,769.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,760.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,589.76. The transfer capital threshold is the transfer adjustment factor * $4,589.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",66027.02,66027.02,66027.02,1 through 10,other,64872.40,212258.00,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],33398.30,,"Case rate ($31,807.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,425.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,254.02. The transfer capital threshold is the transfer adjustment factor * $2,254.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",33398.31,33398.31,33398.31,1 through 10,other,31858.62,94534.21,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],31640.16,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,31019.76,124854.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE|SEPARATE STRUCTURE,CASE-27339,APC,27339,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC Inj Trigger Pt 1-2 Musc Grps|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],28725.18,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27357.31,100904.68,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10455.00,,"Per diem ($10,455). If length of stay < 6.6, first 1 days paid at a per diem of $20,910 instead. Capped at $69,000.38.",,,,0,other,10455.00,90889.11,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11279.92,,"Case rate ($10,742.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.27. The transfer capital threshold is the transfer adjustment factor * $761.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10759.91,46061.32,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],61129.87,,"Fee schedule rate ($61,129.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
Revascularization Iliac Artery Angiop 1st Vsl|RIGHT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],361.50,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14478.52,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13789.07,57367.22,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12787.15,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12536.42,37199.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, THIRD DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MAJOR",720,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],17201.16,,"Case rate ($17,201.16). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,17201.16,18061.22,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12512.21,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11916.39,58492.48,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5091.00,,"Per diem ($5,091). If length of stay < 3.2, first 1 days paid at a per diem of $10,182 instead. Capped at $16,289.77.",,,,0,other,5091.00,22010.11,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6371.27,,"Case rate ($6,067.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.99. The transfer capital threshold is the transfer adjustment factor * $429.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6077.55,18033.97,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization,CASE-52005,APC,52005,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1968.31,1968.31,1968.31,1 through 10,other,1982.66,2081.79,OPPS APC
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16271.46,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,53945.28,Inpatient DRG
"MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,MODERATE",281,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],12559.16,,"Case rate ($11,961.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11961.10,12559.16,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
HC Intro Cath Dialysis Circuit|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-36901,APC,36901,CPT,0361,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1493.03,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE,CASE-27654,APC,27654,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8369.87,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,34379.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],48125.72,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,45834.02,151120.97,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Calcaneal Fracture|LEFT SIDE,CASE-28415,APC,28415,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6721.23,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5669.00,18994.21,Inpatient DRG
HC Intro Catheter Aorta|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36200,APC,36200,CPT,0361,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3099.59,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10961.59,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10439.61,34540.67,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13438.87,,"Fee schedule rate ($13,438.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX|74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18638.82,,"Fee schedule rate ($18,638.82). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39187.16,,"Fee schedule rate ($39,187.16). Adds an outlier to normal pricing equal to the per diem rate ($47,534.60) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5648.25,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5379.29,15961.98,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9240.86,,"Case rate ($5,280.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,879.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,346.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,553.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,898.48. The transfer operating threshold is the transfer adjustment factor * $4,879.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $382.00. The transfer capital threshold is the transfer adjustment factor * $382.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5280.49,17810.78,All Other Inpatient
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13867.35,,"Case rate ($13,207). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,107.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $935.89. The transfer capital threshold is the transfer adjustment factor * $935.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12952.82,12952.82,12952.82,1 through 10,other,13228.06,39251.68,Inpatient DRG
Arthrs Knee Debridement/Shaving Artclr Crtlg|LEFT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6730.91,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6503.29,19528.85,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
Rpr Tdn/Musc Xtnsr F/Arm&/Wrist Prim 1 Ea Tdn|LEFT SIDE|PO,CASE-25270,APC,25270,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>,CASE-25071,APC,25071,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13138.89,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",13138.89,13138.89,13138.89,1 through 10,other,12881.26,38222.57,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Excis Nail Matrix Perm Rmvl|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-11750,APC,11750,CPT,0450,RC,,,XS|T5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],46957.19,,,,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",9265.03,9265.03,9265.03,1 through 10,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE|PO",CASE-64491,APC,64491,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],44778.95,,,,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9448.23,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6531.00,35832.77,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13335.48,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13335.48,39570.45,Inpatient DRG
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5244.04,,"Case rate ($5,244.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,859.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,405.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,029.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,862.27. The transfer operating threshold is the transfer adjustment factor * $4,859.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $381.77. The transfer capital threshold is the transfer adjustment factor * $381.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5244.04,15804.57,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6881.36,,"Case rate ($6,553.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $6,086.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,276.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,494.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,073.77. The transfer operating threshold is the transfer adjustment factor * $6,086.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.91. The transfer capital threshold is the transfer adjustment factor * $479.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6553.68,20086.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6843.63,,"Fee schedule rate ($6,843.63). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],31734.85,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,31112.60,92731.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12312.19,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11895.84,35298.57,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6693.37,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6230.00,21325.01,Inpatient DRG
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE|PO,CASE-28306,APC,28306,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11338.31,,"Case rate ($10,798.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,936.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $765.21. The transfer capital threshold is the transfer adjustment factor * $765.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9888.00,40658.63,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",8676.80,8676.80,8676.80,1 through 10,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29162.98,,"Fee schedule rate ($29,162.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28411.62,,,,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39198.44,,"Fee schedule rate ($39,198.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|PO,CASE-29806,APC,29806,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|LEFT HAND, FIFTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21112.63,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21112.63,62647.63,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18579.92,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6220.95,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6010.58,17835.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8072.90,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8072.90,31159.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
"SEIZURE,MAJOR",053,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],13965.66,,"Case rate ($13,965.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13965.66,14663.94,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13662.46,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7231.00,38610.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9970.09,,"Case rate ($9,495.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,773.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,858.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $8,808.40. The transfer operating threshold is the transfer adjustment factor * $8,773.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.92. The transfer capital threshold is the transfer adjustment factor * $686.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9495.32,42131.77,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|BILATERAL PROCEDURE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Open Treatment of Ulnar Shaft Fracture|RIGHT SIDE|PO,CASE-25545,APC,25545,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
HC Intro Cath Dialysis Circuit,CASE-36901,APC,36901,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1493.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC
Arthroscopy Knee Removal Loose/Foreign Body,CASE-29874,APC,29874,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER CARDIOTHORACIC AND THORACIC CIRCULATORY PROCEDURES,MAJOR",167,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],53567.97,,"Case rate ($53,567.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $47,615, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,53567.97,56246.37,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19339.26,,of the excess amount.,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE,CASE-27570,APC,27570,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
"SICKLE CELL ANEMIA CRISIS,MINOR",662,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7557.54,,"Case rate ($7,197.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7197.66,7557.54,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],57457.72,,"Fee schedule rate ($57,457.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23189.34,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,22734.65,70806.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4993.11,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4895.21,14525.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10584.90,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10080.86,33310.69,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],24347.37,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10455.00,90889.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],115037.59,,"Fee schedule rate ($115,037.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21.9), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Radial&Ulnar Shaft Fx W/Fixj Radius&Ulna,CASE-25575,APC,25575,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5442.84,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5183.66,15743.06,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32341.12,,,,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13369.00,,"Per diem ($13,369). If length of stay < 6.3, first 1 days paid at a per diem of $26,738 instead. Capped at $84,226.47.",,,,0,other,13369.00,88188.38,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17958.55,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17103.38,50750.92,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19564.03,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,18902.44,56089.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,CASE-36556,APC,36556,CPT,0761,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28411.62,,,,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],29066.85,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7023.36,,"Case rate ($6,688.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.00. The transfer capital threshold is the transfer adjustment factor * $474.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",59733.44,59733.44,59733.44,1 through 10,other,6699.57,24060.08,Inpatient DRG
Ercp Dx Collection Specimen Brushing/Washing,CASE-43260,APC,43260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3784.78,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12171.73,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11592.12,38954.76,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30044.81,,,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45390,APC,45390,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],85150.25,,,,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13249.94,40085.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,MAJOR",042,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1522.68,,"Case rate for a one day stay ($1,522.68). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1522.68,1598.81,There are no additional notes associated with this service or procedure.
Open Treatment Fracture Distal Tibia & Fibula,CASE-27828,APC,27828,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17693.55,,"Fee schedule rate ($17,693.55). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23045.40,,"Fee schedule rate ($23,045.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33885.79,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,19363.31,79918.67,All Other Inpatient
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",104578.70,104578.70,104578.70,1 through 10,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4939.57,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4772.53,14161.54,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],14023.34,,"Fee schedule rate ($14,023.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4870.41,14682.98,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8671.32,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6178.00,25225.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"CHOLECYSTECTOMY,MODERATE",263,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],19059.28,,"Case rate ($19,059.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19059.28,20012.24,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43277,APC,43277,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18134.71,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10362.69,29367.82,All Other Inpatient
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion,CASE-52354,APC,52354,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7839.48,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7551.60,23262.15,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",34972.83,34972.83,34972.83,1 through 10,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8285.44,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8005.26,24549.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15454.71,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14718.77,51765.74,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20954.82,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20954.82,62179.32,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER COMPLICATIONS OF TREATMENT,MODERATE",813,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9991.62,,"Case rate ($9,515.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9515.83,9991.62,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17902.13,,,,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15454.71,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14718.77,51765.74,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6244.28,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6033.12,17902.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],103821.76,,,,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],41015.72,,"Fee schedule rate ($41,015.72). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13252.46,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12804.31,55145.09,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],49647.79,,"Case rate ($47,283.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,591.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,420.62. The transfer capital threshold is the transfer adjustment factor * $3,420.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,47283.61,169615.07,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],31767.24,,"Case rate ($30,254.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,954.41, add-ons for qualifying new technology services are included. If operating cost exceeds $63,422.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,359.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $28,065.82. The transfer operating threshold is the transfer adjustment factor * $27,954.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,188.69. The transfer capital threshold is the transfer adjustment factor * $2,188.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30254.51,130347.93,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27695,APC,27695,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE|POLICY CRITERIA APPLIED,CASE-27570,APC,27570,CPT,0360,RC,,,RT|CG,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE,CASE-15823,APC,15823,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2333.89,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12405.53,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,11986.02,54149.39,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10652.43,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,30103.84,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16819.90,,,,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4264.89,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4120.67,13066.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14438.27,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14438.27,55762.74,Inpatient DRG
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26540,APC,26540,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],20094.74,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19137.85,64589.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13664.39,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13664.39,40546.43,Inpatient DRG
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|RIGHT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16536.43,,"Fee schedule rate ($16,536.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24826.68,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23644.46,105789.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],38106.57,,"Fee schedule rate ($38,106.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT|PO",CASE-26951,APC,26951,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28195.14,,"Fee schedule rate ($28,195.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9738.02,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9738.02,28895.67,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],42872.25,,,,,,0,other,6940.00,42872.25,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13927.77,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13264.54,50759.39,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5003.96,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5003.96,21742.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,APC,43266,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Rt Bronchoscopy Alveolar Lavage,CASE-31624,APC,31624,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1772.59,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1680.98,1680.98,1680.98,1 through 10,other,1688.18,1772.59,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14534.42,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14534.42,59012.52,Inpatient DRG
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
Rcnstj Angular Dfrm Toe Soft Tiss Px Only|BILATERAL PROCEDURE|SEPARATE STRUCTURE|PO,CASE-28313,APC,28313,CPT,0360,RC,,,50|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9527.16,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9506.46,2543.98,29695.14,1 through 10,other,9527.16,28269.95,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11749.56,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11519.18,34180.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
Rhinp Prim Complete Xtrnl Parts|PO,CASE-30410,APC,30410,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9448.23,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6531.00,35832.77,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT SIDE|PO,CASE-28750,APC,28750,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14037.08,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6495.00,23801.30,All Other Inpatient
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE|PO,CASE-27570,APC,27570,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16151.86,,"Fee schedule rate ($16,151.86). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7097.74,,"Case rate ($6,759.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,650.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.02. The transfer capital threshold is the transfer adjustment factor * $479.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6770.53,20090.22,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12698.12,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,35884.94,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,Zero final payments for the item or service in the 15 months prior to posting the file.
Inguinofem Lmphadec Supfc W/Cloquets Node Spx,CASE-38760,APC,38760,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
Open Treatment Calcaneal Fracture|LEFT SIDE,CASE-28415,APC,28415,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE,CASE-27654,APC,27654,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE,CASE-28200,APC,28200,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE|PO,CASE-29883,APC,29883,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12304.65,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11888.55,35276.93,Inpatient DRG
Fasciectomy Plantar Fascia Radical Spx|RIGHT SIDE,CASE-28062,APC,28062,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-29827,APC,29827,CPT,0360,RC,,,73,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39899.05,,,,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],30770.61,,"Fee schedule rate ($30,770.61). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE,CASE-23700,APC,23700,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35058.51,,,,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17836.44,,"Fee schedule rate ($17,836.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,76376.03,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24555.13,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23385.84,71764.93,Inpatient DRG
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12482.98,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11888.55,35276.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64448,APC,64448,CPT,0360,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15852.04,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15852.04,50518.01,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14448.22,,"Case rate ($14,448.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,349.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,817.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,216.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,402.99. The transfer operating threshold is the transfer adjustment factor * $13,349.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,045.22. The transfer capital threshold is the transfer adjustment factor * $1,045.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6940.00,42872.25,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7866.01,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7866.01,25247.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14326.59,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12440.40,41073.77,Inpatient DRG
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,APC,43275,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3784.78,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER BACK AND NECK DISORDERS FRACTURES AND INJURIES,MAJOR",347,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],15286.39,,"Case rate ($15,286.39). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15286.39,16050.71,There are no additional notes associated with this service or procedure.
Ostectomy Complete 5th Metatarsal Head|RIGHT SIDE|PO,CASE-28113,APC,28113,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Bx Prostate Strtctc Saturation Sampling Img Gid,CASE-55706,APC,55706,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15522.47,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15218.11,45156.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE|PO,CASE-29883,APC,29883,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10884.58,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10884.58,32297.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
Patellectomy/Hemipatellectomy,CASE-27350,APC,27350,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Proximal Fibula/Shaft Fracture|RIGHT SIDE|PO,CASE-27784,APC,27784,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64418,APC,64418,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,EXTREME",890,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],39450.34,,"Case rate ($39,450.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,39450.34,41422.86,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19619.25,,"Fee schedule rate ($19,619.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
Manipulation Knee Joint Under General Anesthesia,CASE-27570,APC,27570,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27304.54,,"Fee schedule rate ($27,304.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12204.33,,"Case rate ($11,623.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,490.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.89. The transfer capital threshold is the transfer adjustment factor * $842.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,35040.80,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27753.50,,"Fee schedule rate ($27,753.50). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39198.44,,"Fee schedule rate ($39,198.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
Open Treatment Bimalleolar Ankle Fracture|RIGHT SIDE|PO,CASE-27814,APC,27814,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],20306.22,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15340.19,,,,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16292.85,,"Fee schedule rate ($16,292.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],29594.69,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,29594.69,124146.55,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10405.96,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9910.44,43344.00,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41213.48,,,,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13791.99,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13135.23,38976.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Musc/Fasc,Ea Add 20sqcm",CASE-11046,APC,11046,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],736.04,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,700.99,736.04,OPPS APC
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,APC,13160,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11848.43,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6770.53,20090.22,All Other Inpatient
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8134.95,,"Case rate ($7,747.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.02. The transfer capital threshold is the transfer adjustment factor * $549.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7759.92,35376.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],39117.75,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10105.00,120252.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],50116.50,,"Fee schedule rate ($50,116.50). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7146.39,,"Case rate ($6,806.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,653.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.30. The transfer capital threshold is the transfer adjustment factor * $482.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5520.00,26638.96,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40774.00,,"Fee schedule rate ($40,774.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11958.84,40774.00,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",39065.21,39065.21,39065.21,1 through 10,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,MODERATE",174,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],32629.84,,"Case rate ($32,629.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,32629.84,34261.33,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16691.31,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15896.49,51306.05,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13369.00,,"Per diem ($13,369). If length of stay < 6.3, first 1 days paid at a per diem of $26,738 instead. Capped at $84,226.47.",,,,0,other,13369.00,88188.38,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16865.38,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16062.27,48077.57,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F7|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THIRD DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Rcnstj Angular Dfrm Toe Soft Tiss Px Only|BILATERAL PROCEDURE|SEPARATE STRUCTURE|PO,CASE-28313,APC,28313,CPT,0360,RC,,,50|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THUMB|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,FA|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT FOOT, GREAT TOE",CASE-28297,APC,28297,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
Arthroplasty Ankle W/Implant|LEFT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],27022.53,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25735.75,27022.53,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22213.77,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12693.58,46577.81,All Other Inpatient
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21595.78,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",22582.16,22582.16,22582.16,1 through 10,other,12500.00,83592.64,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8230.55,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7952.22,25854.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8383.25,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7984.05,33319.56,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],92976.49,,"Fee schedule rate ($92,976.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.5), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy 2/>Compartments|RIGHT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18915.50,,,,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,APC,28270,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],926.14,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12141.86,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12141.86,36028.59,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,APC,52352,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13941.10,,"Fee schedule rate ($13,941.10). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,385.57,404.84,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39078.16,,"Fee schedule rate ($39,078.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],58656.71,,"Fee schedule rate ($58,656.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10810.31,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10810.31,32077.45,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20005.22,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20005.22,74991.64,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10529.78,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10173.70,41194.64,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6054.88,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5766.55,17111.12,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7934.97,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7934.97,23545.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29162.98,,"Fee schedule rate ($29,162.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7898.88,,"Case rate ($7,744). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,731.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $560.22. The transfer capital threshold is the transfer adjustment factor * $560.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7744.00,24853.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34611.07,,"Fee schedule rate ($34,611.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],24713.42,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,24713.42,73332.24,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14508.56,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14508.56,59513.03,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21256.76,,"Fee schedule rate ($21,256.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Bi Tot Pel Lmphadec & Pri-Aortic Lymph Bx 1,CASE-38572,APC,38572,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Removal Subcutaneous Cardiac Rhythm Monitor|UNUSUAL NON-OVERLAPPING SERVICE,CASE-33286,APC,33286,CPT,0361,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8123.65,,"APC Price ($7,848.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7848.94,8241.39,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,APC,52281,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3607.42,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3607.42,11497.58,Inpatient DRG
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15896.49,51306.05,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11024.48,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,10808.31,46938.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30683.33,,"Fee schedule rate ($30,683.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE|PO,CASE-27650,APC,27650,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,APC,13160,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
Axillary Lymphadenectomy Complete,CASE-38745,APC,38745,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22809.58,,,,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
"HC Debrid,Subq Ea Addt'l 20sqcm",CASE-11045,APC,11045,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19503.23,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19503.23,57872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5596.16,,"Case rate ($5,329.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,548.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $377.68. The transfer capital threshold is the transfer adjustment factor * $377.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5338.18,15839.99,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.5 Cm/<,CASE-11400,APC,11400,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],671.64,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,671.64,705.22,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7920.23,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7543.08,29489.40,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],5283.60,,"Fee schedule rate ($5,283.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10739.04,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10528.47,44148.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Kne Condyle&Platu Medial&Lat Compartments|LEFT SIDE,CASE-27447,APC,27447,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6654.93,,"Case rate ($6,654.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,167.40, add-ons for qualifying new technology services are included. If operating cost exceeds $46,712.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,132.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,170.45. The transfer operating threshold is the transfer adjustment factor * $6,167.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.48. The transfer capital threshold is the transfer adjustment factor * $484.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6654.93,20056.77,Inpatient DRG
Open Treatment Fracture Distal Tibia Only|RIGHT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],45477.48,,,,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
HC Extremity Venogram,CASE-36005,APC,36005,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1493.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1545.29,OPPS APC
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],131570.26,,,,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24516.04,,"Case rate ($23,348.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,825.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.56. The transfer capital threshold is the transfer adjustment factor * $1,654.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23385.84,71764.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6549.71,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6328.22,27416.36,Inpatient DRG
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7263.07,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,1188.00,20179.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Metacarpal,CASE-26230,APC,26230,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12514.54,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12514.54,37134.43,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6531.00,,"Per diem ($6,531). If length of stay < 4.1, first 1 days paid at a per diem of $13,062 instead. Capped at $26,776.27.",,,,0,other,6531.00,35832.77,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17385.28,,"Fee schedule rate ($17,385.28). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24782.12,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23602.02,108295.22,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],24347.37,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10455.00,90889.11,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6401.17,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5669.00,18994.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Carpectomy All Bones Proximal Row|RIGHT SIDE|PO,CASE-25215,APC,25215,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER PNEUMONIA,MODERATE",139,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8907.96,,"Case rate ($8,907.96). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8907.96,9353.36,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4851.08,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4755.96,21133.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27753.50,,"Fee schedule rate ($27,753.50). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",7051.56,7051.56,7051.56,1 through 10,other,6882.29,7226.40,OPPS APC
Open Treatment Medial Malleolus Fracture|RIGHT SIDE,CASE-27766,APC,27766,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],26636.50,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea,CASE-28465,APC,28465,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10325.19,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9833.51,45903.36,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7184.98,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7184.98,21320.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Lesion Tendon Sheath/Capsule Leg&/Ank,CASE-27630,APC,27630,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],133824.90,,"Fee schedule rate ($133,824.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,38916.28,133824.90,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6054.28,,"Case rate ($5,765.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,579.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.60. The transfer capital threshold is the transfer adjustment factor * $408.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6054.28,6054.28,35436.61,1 through 10,other,5775.17,17136.70,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],33451.55,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31858.62,94534.21,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],30758.38,,of the excess amount.,,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15960.77,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15421.03,49137.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20895.12,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20895.12,99969.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27779.85,,"Fee schedule rate ($27,779.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15326.20,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15326.21,15326.21,15326.21,1 through 10,other,15326.20,52511.19,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],82540.50,,"Fee schedule rate ($82,540.50). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8086.83,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,34379.15,Inpatient DRG
"ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,MINOR",198,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6684.29,,"Case rate ($6,365.99). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6365.99,6684.29,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15392.60,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15090.78,44778.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9913.89,,"Case rate ($9,441.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.08. The transfer capital threshold is the transfer adjustment factor * $669.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9456.85,28061.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16255.85,,"Fee schedule rate ($16,255.85). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24451.42,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23624.56,83038.88,Inpatient DRG
Laparoscopy Surg Pyeloplasty|RIGHT SIDE,CASE-50544,APC,50544,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE|PO,CASE-28238,APC,28238,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7934.97,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7934.97,23545.50,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],85483.72,,"Fee schedule rate ($85,483.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5970.00,,"Per diem ($5,970). If length of stay < 6.2, first 1 days paid at a per diem of $11,940 instead. Capped at $37,016.57.",,,,0,other,5970.00,38757.79,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Ant Vesicourethropexy/Urethropexy Smpl,CASE-51840,APC,51840,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8171.79,,"Case rate ($7,782.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,722.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $551.51. The transfer capital threshold is the transfer adjustment factor * $551.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7795.07,34198.12,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],43541.27,,,,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5900.43,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5700.90,30872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5005.27,,"Case rate ($4,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,508.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.80. The transfer capital threshold is the transfer adjustment factor * $337.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4774.52,14406.59,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4803.66,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4574.91,13575.16,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10687.94,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10178.99,36468.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14228.44,,,,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42003.98,,"Fee schedule rate ($42,003.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,There are no additional notes associated with this service or procedure.
"ABDOMINAL PAIN,MODERATE",251,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3022.90,,"Case rate for a one day stay ($2,878.95). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2878.95,3022.90,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],133824.90,,"Fee schedule rate ($133,824.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,38916.28,133824.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],41403.83,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,40591.99,115037.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39078.16,,"Fee schedule rate ($39,078.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28437.57,,"Fee schedule rate ($28,437.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
Excision Hidradenitis Axillary Smpl/Intrm Rpr,CASE-11450,APC,11450,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],64005.35,,,,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, SECOND DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],119293.78,,,,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
Rpr Recrt Inguinal Hernia Any Age Reducible|LEFT SIDE,CASE-49520,APC,49520,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3514.75,OPPS APC
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14523.10,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13831.52,59770.39,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],39831.40,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,39831.40,138208.82,Inpatient DRG
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6797.06,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6797.06,20168.93,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5080.78,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4838.84,19587.42,Inpatient DRG
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23983.51,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13704.86,49911.01,All Other Inpatient
Implant Neurostim/Receiver,CASE-64590,APC,64590,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19320.40,,"APC Price ($18,400.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,18400.38,19320.40,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13305.64,39481.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"HEART FAILURE,MAJOR",194,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14742.07,,"Case rate ($14,742.07). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14742.07,15479.17,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],70335.44,,,,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
Cystourethroscopy With Biopsy|SEPARATE STRUCTURE,CASE-52204,APC,52204,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE|PO,CASE-27654,APC,27654,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5553.06,,"Case rate ($5,288.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.77. The transfer capital threshold is the transfer adjustment factor * $374.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5297.06,19049.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5942.94,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5942.94,17634.53,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24826.68,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23644.46,105789.11,Inpatient DRG
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20697.52,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20697.52,87921.54,Inpatient DRG
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],903.26,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,860.25,903.26,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],38724.86,,"Fee schedule rate ($38,724.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",37132.27,37132.27,37132.27,1 through 10,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17535.40,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,17191.57,51012.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28921.04,,"Fee schedule rate ($28,921.04). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
Realignment Extensor Tendon Hand Each Tendon|RIGHT SIDE|PO,CASE-26437,APC,26437,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5254.16,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5003.96,21742.11,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],64872.40,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",72276.11,72276.11,72276.11,1 through 10,other,64872.40,212258.00,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",25542.23,25542.23,25542.23,1 through 10,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5911.44,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5629.94,16705.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4257.29,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4257.29,12632.63,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19847.56,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18902.44,56089.29,Inpatient DRG
Partial Excision Bone Tibia|RIGHT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27601.28,,"Fee schedule rate ($27,601.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12788.64,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12179.66,36140.75,Inpatient DRG
"OTHER CIRCULATORY SYSTEM DIAGNOSES,MODERATE",207,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9405.59,,"Case rate ($8,957.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8957.70,9405.59,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6681.01,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6681.01,19824.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],45609.21,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",179400.57,179400.57,179400.57,1 through 10,other,45609.21,211906.58,Inpatient DRG
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15166.20,,"Fee schedule rate ($15,166.20). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE|PO,CASE-29891,APC,29891,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",25034.05,25034.05,25034.05,1 through 10,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],37975.99,,"Case rate ($36,167.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,417.97, add-ons for qualifying new technology services are included. If operating cost exceeds $68,885.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,787.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $33,551.16. The transfer operating threshold is the transfer adjustment factor * $33,417.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,616.46. The transfer capital threshold is the transfer adjustment factor * $2,616.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36167.61,140535.66,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5080.78,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4838.84,19587.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MAJOR",344,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],18428.21,,"Case rate ($17,550.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17550.68,18428.21,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28086.14,,"Fee schedule rate ($28,086.14). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9910.44,43344.00,Zero final payments for the item or service in the 15 months prior to posting the file.
Ligj Divj & Stripping Short Saphenous Vein,CASE-37718,APC,37718,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17929.96,,"Case rate ($17,076.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.07. The transfer capital threshold is the transfer adjustment factor * $1,210.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17103.38,50750.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",10800.00,10800.00,10800.00,1 through 10,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
Rhinoplasty Secondary Intermediate Revision|PO,CASE-30435,APC,30435,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5811.28,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42003.98,,"Fee schedule rate ($42,003.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22476.02,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6965.00,38110.41,All Other Inpatient
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE|PO,CASE-24685,APC,24685,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7543.08,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7543.08,29489.40,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,48444.74,Estimated amount calculated based on 11 day length of stay.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, FOURTH DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1578.51,1601.38,OPPS APC
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE|PO,CASE-29883,APC,29883,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7177.29,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6835.51,20283.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],31570.16,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",30711.41,30711.41,30711.41,1 through 10,other,31570.16,98176.71,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14161.54,,,,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27135.21,,"Fee schedule rate ($27,135.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8605.40,,"Case rate ($8,605.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,951.18, add-ons for qualifying new technology services are included. If operating cost exceeds $43,419.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,982.86. The transfer operating threshold is the transfer adjustment factor * $7,951.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $622.54. The transfer capital threshold is the transfer adjustment factor * $622.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8605.40,42305.71,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15382.83,,"Case rate ($14,650.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,209.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,038.17. The transfer capital threshold is the transfer adjustment factor * $1,038.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",15142.06,15142.06,24227.44,11,other,14673.67,43541.27,Inpatient DRG
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10385.64,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10034.43,29775.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64450,APC,64450,CPT,0450,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17212.32,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13249.94,40085.35,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3162.78,3162.78,3162.78,1 through 10,other,3103.39,3258.56,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],36276.38,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36276.38,121107.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8141.32,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7866.01,25247.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
Litholapaxy Comp/Lg > 2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52318,APC,52318,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Litholapaxy Smpl/Sm <2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52317,APC,52317,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10405.96,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9910.44,43344.00,Inpatient DRG
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12457.06,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12212.80,39290.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7951.41,,"Case rate ($7,572.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,707.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.63. The transfer capital threshold is the transfer adjustment factor * $536.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33946.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Intercost Sng|BILATERAL PROCEDURE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
Ostectomy Prtl 5th Metar Head Spx|RIGHT SIDE|PO,CASE-28110,APC,28110,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],29463.75,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8232.00,84471.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE,CASE-27601,APC,27601,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11260.52,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6953.00,35389.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],52092.32,,"Fee schedule rate ($52,092.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",16679.00,16679.00,16679.00,1 through 10,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Supracervical Hysterectomy >250,CASE-58543,APC,58543,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MAJOR",191,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],19490.31,,"Case rate ($19,490.31). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19490.31,20464.83,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9030.79,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5160.45,15312.64,All Other Inpatient
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19138.75,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18227.38,54086.17,Inpatient DRG
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MODERATE",710,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],24853.33,,"Case rate ($24,853.33). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24853.33,26096.00,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9760.97,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9569.58,41116.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31350.48,,"Fee schedule rate ($31,350.48). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10888.24,32825.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, SECOND DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|LEFT FOOT, GREAT TOE|PO",CASE-28291,APC,28291,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],41590.28,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT HAND, THUMB",CASE-28750,APC,28750,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20984.05,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20274.44,80940.99,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4803.66,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4574.91,13575.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST AND SHOCK,MAJOR",196,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],12515.63,,"Case rate ($11,919.65). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11919.65,12515.63,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20299.11,,"Case rate ($19,332.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,541.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,369.97. The transfer capital threshold is the transfer adjustment factor * $1,369.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19363.31,79918.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9350.11,,"Case rate ($8,904.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,802.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.03. The transfer capital threshold is the transfer adjustment factor * $631.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",9120.95,9120.95,9120.95,1 through 10,other,8919.07,34453.70,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE|PO,CASE-25607,APC,25607,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,MODERATE",770,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5665.98,,"Case rate ($5,396.17). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5396.17,5665.98,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14532.48,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14041.04,60059.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21067.51,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20654.42,69402.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17274.00,,"Per diem ($17,274). If length of stay < 3.3, first 1 days paid at a per diem of $34,548 instead. Capped at $57,002.93.",,,,0,other,17274.00,73717.28,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7654.23,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7289.74,21630.93,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4120.67,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4120.67,13066.56,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6504.75,,"Case rate ($6,195). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.00. The transfer capital threshold is the transfer adjustment factor * $439.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6204.88,19589.20,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9411.54,,"Case rate ($8,963.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,653.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $639.31. The transfer capital threshold is the transfer adjustment factor * $639.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8981.78,27528.12,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6630.72,19989.86,There are no additional notes associated with this service or procedure.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE|PO,CASE-29888,APC,29888,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Kne Condyle&Platu Medial&Lat Compartments|RIGHT SIDE,CASE-27447,APC,27447,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12075.88,,"Case rate ($11,500.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,986.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $814.99. The transfer capital threshold is the transfer adjustment factor * $814.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11519.18,34180.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,APC,43236,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1911.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,MODERATE",663,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9370.77,,"Case rate ($9,370.77). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9370.77,9839.31,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
"HIP AND FEMUR FRACTURE REPAIR,MAJOR",308,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],30565.25,,"Case rate ($29,109.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29109.76,30565.25,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15090.78,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15090.78,44778.95,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],47170.72,,"Fee schedule rate ($47,170.72). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12065.11,,"Fee schedule rate ($12,065.11). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13022.58,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12402.46,36801.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31350.48,,"Fee schedule rate ($31,350.48). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10888.24,32825.17,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9495.32,,"Case rate ($9,495.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,773.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,858.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $8,808.40. The transfer operating threshold is the transfer adjustment factor * $8,773.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.92. The transfer capital threshold is the transfer adjustment factor * $686.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9495.32,42131.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],8232.00,,"Per diem ($8,232). If length of stay < 9.8, first 1 days paid at a per diem of $16,464 instead. Capped at $80,676.47.",,,,0,other,8232.00,84471.39,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7106.33,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6866.02,27153.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis Addl 20 Cm<,CASE-97598,APC,97598,CPT,0761,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,10625.29,39295.53,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5611.35,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5344.14,15857.69,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12592.92,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12167.07,36103.36,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
Open Treatment Bimalleolar Ankle Fracture,CASE-27814,APC,27814,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,APC,53445,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19658.06,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19658.06,20346.09,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],89504.77,,,,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41929.72,,,,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6886.93,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6558.98,19462.52,Inpatient DRG
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12728.07,,"Case rate ($12,121.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,200.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,668.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,048.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,245.03. The transfer operating threshold is the transfer adjustment factor * $11,200.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $876.93. The transfer capital threshold is the transfer adjustment factor * $876.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12121.97,35969.56,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11519.18,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11519.18,34180.92,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Plasty|LEFT SIDE,CASE-37228,APC,37228,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],505.96,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16062.27,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16062.27,48077.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29008.87,,"Fee schedule rate ($29,008.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11427.59,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6350.00,33244.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10205.14,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9860.04,30039.61,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
"MAJOR LARGE BOWEL PROCEDURES,MODERATE",231,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],26734.25,,"Case rate ($25,461.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25461.19,26734.25,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12881.26,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12881.26,38222.57,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],30770.61,,"Fee schedule rate ($30,770.61). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE|PO,CASE-64421,APC,64421,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15618.96,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15090.78,44778.95,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23045.28,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,22593.41,90908.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],71646.75,,"Fee schedule rate ($71,646.75). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21975.27,,,,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9774.43,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33447.35,Inpatient DRG
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],24785.70,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9242.00,76216.30,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33132.06,,"Fee schedule rate ($33,132.06). Adds an outlier to normal pricing equal to the per diem rate ($83,058.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",32791.75,32791.75,32791.75,1 through 10,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12829.00,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",11855.69,11855.69,11855.69,1 through 10,other,12395.17,42174.37,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5732.06,,"Case rate ($5,732.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,296.29, add-ons for qualifying new technology services are included. If operating cost exceeds $40,764.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,317.40. The transfer operating threshold is the transfer adjustment factor * $5,296.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.67. The transfer capital threshold is the transfer adjustment factor * $414.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5732.06,21720.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5308.33,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5308.33,19857.20,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12228.12,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11645.83,37502.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9920.64,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6531.00,35832.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4864.15,,"Case rate ($4,632.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.28. The transfer capital threshold is the transfer adjustment factor * $328.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4639.91,13771.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14043.03,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",14043.05,14043.05,14043.05,1 through 10,other,14043.03,54637.47,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12803.67,,"Fee schedule rate ($12,803.67). Adds an outlier to normal pricing equal to the per diem rate ($91,038.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],14842.71,,"Fee schedule rate ($14,842.71). Adds an outlier to normal pricing equal to the per diem rate ($40,567.35) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL AND OTHER VASCULAR DISORDERS,MODERATE",197,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9378.02,,"Case rate ($8,931.45). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8931.45,9378.02,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4793.22,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4564.97,13545.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10884.58,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10884.58,32297.83,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8392.15,,"Case rate ($7,992.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,737.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.38. The transfer capital threshold is the transfer adjustment factor * $566.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8005.26,24549.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22524.08,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8940.00,63653.13,Inpatient DRG
Open Treatment Talus Fracture|RIGHT SIDE,CASE-28445,APC,28445,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],48125.72,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,45834.02,151120.97,Inpatient DRG
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,MINOR",175,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],12453.65,,"Case rate for a one day stay ($11,860.62). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11860.62,12453.65,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],58656.71,,"Fee schedule rate ($58,656.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|PREVENTIVE SERVICES,CASE-45385,APC,45385,CPT,0360,RC,,,33,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17789.10,,"Fee schedule rate ($17,789.10). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
Cysto W/Simple Removal Stone & Stent,CASE-52310,APC,52310,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],57534.77,,"Fee schedule rate ($57,534.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8.46,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23290.05,,"Fee schedule rate ($23,290.05). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],67976.16,,,,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4665.10,,"Case rate ($4,442.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.41. The transfer capital threshold is the transfer adjustment factor * $321.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4442.95,13183.59,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|RIGHT SIDE|PO,CASE-11422,APC,11422,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7326.65,,"Case rate ($7,078.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,540.71, add-ons for qualifying new technology services are included. If operating cost exceeds $42,008.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,683.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,566.78. The transfer operating threshold is the transfer adjustment factor * $6,540.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.10. The transfer capital threshold is the transfer adjustment factor * $512.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7078.89,21005.20,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7848.16,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",44174.48,44174.48,44174.48,1 through 10,other,7694.27,22831.22,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MAJOR",229,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],33721.72,,"Case rate ($32,115.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32115.92,33721.72,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],78047.33,,"Fee schedule rate ($78,047.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12721.71,,"Case rate ($12,115.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,029.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.57. The transfer capital threshold is the transfer adjustment factor * $858.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12135.23,49469.07,Inpatient DRG
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31658.33,,,,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9262.54,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,27484.83,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5482.46,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5297.06,19049.64,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7592.25,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7335.51,29792.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Plmt Interstitial Dev Radiat Tx Prostate 1/Mult,CASE-55876,APC,55876,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1312.80,,"APC Price ($1,312.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",1270.24,1270.24,1270.24,1 through 10,other,1312.80,1378.44,OPPS APC
Excision Local Lesion Epididymis|RIGHT SIDE,CASE-54830,APC,54830,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
Wmhc Perc Implant Stim Lead Ea|PO,CASE-63650,APC,63650,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6256.14,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19750.58,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,19363.31,79918.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34176.45,,"Fee schedule rate ($34,176.45). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs|RIGHT SIDE|PO,CASE-25115,APC,25115,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],52092.32,,"Fee schedule rate ($52,092.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,APC,11404,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],129893.46,,"Fee schedule rate ($129,893.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28296,APC,28296,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],104605.60,,"Fee schedule rate ($104,605.60). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Sling Opration Corrj Male Urinary Incontinence,CASE-53440,APC,53440,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12513.57,,"APC Price ($12,513.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12513.57,13139.25,OPPS APC
Rmvl/Revj Sling Male Urinary Incontinence,CASE-53442,APC,53442,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Biopsy Vaginal Mucosa Simple,CASE-57100,APC,57100,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],47279.40,,"Fee schedule rate ($47,279.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4666.41,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4574.91,13575.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],42083.20,,,,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16263.68,,"Fee schedule rate ($16,263.68). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE,CASE-29875,APC,29875,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Arthroplasty Ankle W/Implant|RIGHT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],26636.50,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>,CASE-25071,APC,25071,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALNUTRITION FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS,MAJOR",421,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13961.86,,"Case rate ($13,297.01). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13297.01,13961.86,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10291.73,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10291.73,34803.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10826.88,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10826.88,32126.64,Inpatient DRG
"OTHER DISORDERS OF NERVOUS SYSTEM,MODERATE",058,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],13741.86,,"Case rate ($13,741.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13741.86,14428.95,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26300.80,,"Fee schedule rate ($26,300.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16785.91,,"Fee schedule rate ($16,785.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13292.96,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,38110.41,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27136.20,,"Fee schedule rate ($27,136.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE,CASE-28322,APC,28322,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],40890.77,,,,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20016.13,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|BILATERAL PROCEDURE,CASE-38570,APC,38570,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,APC,29807,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,APC,43239,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],65538.71,,"Fee schedule rate ($65,538.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8853.24,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8431.66,25019.31,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22168.26,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21112.63,62647.63,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
"Open Tx Fracture Phalanx/Phalanges Not Great Toe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28525,APC,28525,CPT,0360,RC,,,T9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia & Fibula|LEFT SIDE|PO,CASE-27828,APC,27828,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41729.01,,,,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10053.63,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9574.89,28411.62,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20654.42,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20654.42,69402.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1174.70,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
HC Fem Pop Territory Plasty|LEFT SIDE,CASE-37224,APC,37224,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],421.27,,,,,,0,other,401.21,421.27,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6942.60,,"Fee schedule rate ($6,942.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],22264.72,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,21828.16,93157.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],36145.24,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,20654.42,69402.59,All Other Inpatient
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29162.70,,"Fee schedule rate ($29,162.70). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],40591.99,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,40591.99,115037.59,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8704.87,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8704.87,25830.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10669.04,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,31658.33,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17622.72,,,,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|LEFT SIDE|PO,CASE-23430,APC,23430,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9833.51,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9833.51,45903.36,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14673.67,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14673.67,43541.27,Inpatient DRG
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20274.44,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20274.44,80940.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE|PO,CASE-25608,APC,25608,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Medium WO US|RIGHT SIDE|PO,CASE-20605,APC,20605,CPT,0510,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20090.22,,,,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18613.10,,"Fee schedule rate ($18,613.10). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,APC,58260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4744.66,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7537.28,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6382.95,21300.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE,CASE-27570,APC,27570,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22035.98,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7826.00,90280.33,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7412.81,,"Fee schedule rate ($7,412.81). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5338.18,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5338.18,5338.18,5338.18,1 through 10,other,5338.18,15839.99,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17130.80,,,,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,APC,11403,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],671.64,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,671.64,695.15,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3935.39,,"Case rate ($3,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,436.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $265.60. The transfer capital threshold is the transfer adjustment factor * $265.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3753.97,11139.15,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19033.08,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,8990.00,80069.53,Inpatient DRG
"Arthro, Loose Body + Chondro",CASE-G0289,APC,G0289,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,EXTREME",282,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],31957.04,,"Case rate ($31,957.04). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31957.04,33554.89,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23415.63,,,,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Cervical Node,CASE-38510,APC,38510,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9456.85,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9456.85,28061.37,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|RIGHT SIDE|PO,CASE-28238,APC,28238,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER DISORDERS OF NERVOUS SYSTEM,MAJOR",058,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],20257.40,,"Case rate ($19,292.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19292.76,20257.40,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],58424.69,,"Fee schedule rate ($58,424.69). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MODERATE",710,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],26096.00,,"Case rate ($24,853.33). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24853.33,26096.00,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12698.12,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,40067.60,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13691.04,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13228.06,39251.68,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],32004.66,,"Case rate ($30,480.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,163.35, add-ons for qualifying new technology services are included. If operating cost exceeds $63,631.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,376.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,275.59. The transfer operating threshold is the transfer adjustment factor * $28,163.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,205.05. The transfer capital threshold is the transfer adjustment factor * $2,205.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30480.63,86382.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Bimalleolar Ankle Fracture|RIGHT SIDE|PO,CASE-27814,APC,27814,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13305.64,39481.90,Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Ant&/Lat Compartments Only|RIGHT SIDE|PO,CASE-27600,APC,27600,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",11264.71,11264.71,11264.71,1 through 10,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],22645.02,,of the excess amount.,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6377.95,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6074.24,18024.13,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6061.85,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5773.19,31196.82,Inpatient DRG
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|PO,CASE-64483,APC,64483,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11934.78,,"Case rate ($11,366.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,976.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $805.47. The transfer capital threshold is the transfer adjustment factor * $805.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11384.58,33781.47,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9280.46,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9280.46,39957.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32077.45,,,,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7015.06,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6681.01,19824.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE|PO,CASE-27792,APC,27792,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT|PO",CASE-26951,APC,26951,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY SAME PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,76|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],26030.46,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,24790.92,26030.46,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Biopsy Vaginal Mucosa Simple,CASE-57100,APC,57100,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5532.56,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5224.00,15861.63,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],52317.98,,"Fee schedule rate ($52,317.98). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],59188.55,,"Fee schedule rate ($59,188.55). Adds an outlier to normal pricing equal to the per diem rate ($203,441.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
Arteriovenous Anastomosis Open Direct,CASE-36821,APC,36821,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8331.72,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7934.97,23545.50,Inpatient DRG
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7120.66,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,20179.92,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36577.58,,,,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4518.89,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4303.70,14124.38,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10114.68,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10114.68,30013.33,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE|PO,CASE-25607,APC,25607,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16169.08,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15852.04,50518.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],23942.42,,"Case rate ($22,802.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,068.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,536.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,820.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $21,152.71. The transfer operating threshold is the transfer adjustment factor * $21,068.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,649.58. The transfer capital threshold is the transfer adjustment factor * $1,649.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22802.30,82749.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11600.75,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11600.75,34422.94,Inpatient DRG
Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>|LEFT SIDE,CASE-23073,APC,23073,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12975.19,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,12536.42,46998.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Biopsy/Excision Inguinofemoral Nodes|LEFT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|RIGHT SIDE|PO,CASE-11422,APC,11422,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],70335.44,,,,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11698.23,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11698.23,34712.20,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15547.45,,"Fee schedule rate ($15,547.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12167.07,36103.36,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE,CASE-27405,APC,27405,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19668.75,,"Fee schedule rate ($19,668.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19363.31,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",19363.32,19363.32,19363.32,1 through 10,other,19363.31,79918.67,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
Laps Tot Hysterectomy Resj Malignancy W/Omntc,CASE-58575,APC,58575,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6045.24,,"Case rate ($5,757.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,579.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.99. The transfer capital threshold is the transfer adjustment factor * $407.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5766.55,17111.12,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],33463.71,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,32807.56,111191.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22591.80,,"Fee schedule rate ($22,591.80). Adds an outlier to normal pricing equal to the per diem rate ($3,889) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8981.78,27528.12,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14472.76,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",140497.21,140497.21,140497.21,1 through 10,other,14472.76,56135.46,Inpatient DRG
HC Vasc Embolize Occlude Organ|BILATERAL PROCEDURE,CASE-37243,APC,37243,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14071.02,,,,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],30163.67,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,30163.67,89504.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5775.17,,"Case rate ($5,775.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.79. The transfer capital threshold is the transfer adjustment factor * $417.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5775.17,17136.70,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17130.80,,,,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29257.73,,,,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7929.60,,"Fee schedule rate ($7,929.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15839.99,,,,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],47884.20,,"Fee schedule rate ($47,884.20). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26270.73,,"Fee schedule rate ($26,270.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12167.07,36103.36,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER DISORDERS OF THE LIVER,EXTREME",283,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],28340.05,,"Case rate ($26,990.52). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,26990.52,28340.05,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23624.56,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23624.56,83038.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE|PO,CASE-64450,APC,64450,CPT,0450,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12823.44,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12212.80,39290.21,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6515.12,,"Case rate ($6,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,620.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.88. The transfer capital threshold is the transfer adjustment factor * $448.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6204.88,19589.20,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10208.65,,"Case rate ($9,722.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $688.97. The transfer capital threshold is the transfer adjustment factor * $688.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9738.02,28895.67,Inpatient DRG
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>|RIGHT SIDE,CASE-23071,APC,23071,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5678.05,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5486.04,17919.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12881.26,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12881.26,38222.57,Inpatient DRG
Thoracoscopy W/Thoracic Sympathectomy,CASE-32664,APC,32664,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3099.59,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5602.41,,"Case rate ($5,335.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,549.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.10. The transfer capital threshold is the transfer adjustment factor * $378.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",5602.41,5602.41,5602.41,1 through 10,other,5344.14,15857.69,Inpatient DRG
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, SECOND DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
Arthrs Knee Drill Osteochondritis Dissecans Grfg,CASE-29885,APC,29885,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17370.86,,,,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22091.17,,"Fee schedule rate ($22,091.17). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20954.82,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20954.82,62179.32,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5139.97,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4895.21,14525.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],47506.18,,,,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
Sgmdsc Flx Dired Sbmcsl Njx Any Sbst,CASE-45335,APC,45335,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,912.91,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6308.00,,"Per diem ($6,308). If length of stay < 3.3, first 1 days paid at a per diem of $12,616 instead. Capped at $20,817.01.",,,,0,other,6308.00,21796.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",21323.56,21323.56,21323.56,1 through 10,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THUMB|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,APC,26080,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1578.51,OPPS APC
Fasciectomy Plantar Fascia Partial Spx|BILATERAL PROCEDURE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
HC Fem Pop Terr Plasty and Stent|RIGHT SIDE,CASE-37226,APC,37226,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],491.83,,,,,,0,other,468.41,491.83,There are no additional notes associated with this service or procedure.
Excision/Curettage Cyst/Tumor Femur|LEFT SIDE,CASE-27355,APC,27355,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24408.19,,"Case rate ($23,582.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,789.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,257.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,877.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,876.75. The transfer operating threshold is the transfer adjustment factor * $21,789.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,706.04. The transfer capital threshold is the transfer adjustment factor * $1,706.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",23271.35,23271.35,23271.35,1 through 10,other,23582.79,75543.62,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf|LEFT SIDE,CASE-36825,APC,36825,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8349.83,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7952.22,25854.47,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],65078.97,,of the excess amount.,,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
Ostectomy Complete 5th Metatarsal Head|RIGHT SIDE|PO,CASE-28113,APC,28113,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",1094.61,1094.61,1107.52,1 through 10,other,1134.98,1191.72,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26874.85,,,,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],68338.52,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,66027.56,228732.31,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26364.75,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,15065.57,53815.71,All Other Inpatient
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22469.78,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21399.79,63499.65,Inpatient DRG
Open Treatment Calcaneal Fracture|RIGHT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],40785.15,,"Fee schedule rate ($40,785.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18251.76,,"Fee schedule rate ($18,251.76). Adds an outlier to normal pricing equal to the per diem rate ($45,948.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6440.28,19110.30,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5389.29,,"Case rate ($5,389.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,996, add-ons for qualifying new technology services are included. If operating cost exceeds $45,541.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,038.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,998.47. The transfer operating threshold is the transfer adjustment factor * $4,996.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.82. The transfer capital threshold is the transfer adjustment factor * $390.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5390.01,5390.01,5390.01,1 through 10,other,5389.29,16247.30,Inpatient DRG
Revasc lithotrip tibi/perone|LEFT SIDE,CASE-C9772,APC,C9772,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],27851.43,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],38600.87,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,37843.99,139522.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Abdomen Peritoneum & Omentum,CASE-49999,APC,49999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE,CASE-29898,APC,29898,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],30760.23,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",109767.02,109767.02,109767.02,1 through 10,other,13369.00,88188.38,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5003.18,,"Case rate ($4,764.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,508.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.66. The transfer capital threshold is the transfer adjustment factor * $337.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4772.53,14161.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
Amp Mtcrpl W/Finger/Thumb W/WO Inteross Transfer,CASE-26910,APC,26910,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39967.07,,"Fee schedule rate ($39,967.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13802.22,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13335.48,39570.45,Inpatient DRG
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE,CASE-27570,APC,27570,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10114.68,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10114.69,10114.69,10114.69,1 through 10,other,10114.68,30013.33,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17103.38,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15646.38,15646.38,15646.38,1 through 10,other,17103.38,50750.92,Inpatient DRG
Fasciectomy Plantar Fascia Radical Spx|LEFT SIDE|PO,CASE-28062,APC,28062,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10145.17,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,30103.84,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32093.19,,,,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9056.99,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9056.99,33814.75,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20885.18,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20885.18,80720.91,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17836.44,,"Fee schedule rate ($17,836.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27943.31,,"Fee schedule rate ($27,943.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8596.11,,"Case rate ($8,596.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,942.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,410.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,974.25. The transfer operating threshold is the transfer adjustment factor * $7,942.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.86. The transfer capital threshold is the transfer adjustment factor * $621.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8596.11,25507.30,Inpatient DRG
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FOURTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
"OTHER CIRCULATORY SYSTEM DIAGNOSES,EXTREME",207,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],24667.17,,"Case rate ($23,492.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23492.54,24667.17,There are no additional notes associated with this service or procedure.
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,APC,49321,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
"HC Excis Nail Matrix Perm Rmvl|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-11750,APC,11750,CPT,0450,RC,,,XS|TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12698.12,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,35884.94,Inpatient DRG
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT|PO",CASE-26951,APC,26951,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|LEFT SIDE,CASE-19120,APC,19120,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16062.27,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16062.27,48077.57,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16456.83,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",16496.17,16496.17,16496.17,1 through 10,other,16456.83,55350.97,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],33895.41,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",33785.68,33785.68,33790.22,1 through 10,other,32749.19,97176.83,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9739.34,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9739.34,40204.26,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11503.68,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7000.00,32980.62,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
Arthroplasty Interphalangeal Jt W/Prosthetic Ea,CASE-26536,APC,26536,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7856.49,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7590.81,32847.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19881.64,,,,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|RIGHT SIDE|PO,CASE-24341,APC,24341,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,APC,54410,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19658.06,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19658.06,20640.96,OPPS APC
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MODERATE",220,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],27964.48,,"Case rate ($27,964.48). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,27964.48,29362.70,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7328.68,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7184.98,21320.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Trurl Dstrj Prstate Tiss Rf Thermoth,CASE-53852,APC,53852,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,50|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7034.55,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6699.57,24060.08,Inpatient DRG
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33771.02,,"Fee schedule rate ($33,771.02). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6348.33,,"Case rate ($6,046.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.44. The transfer capital threshold is the transfer adjustment factor * $428.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6055.67,17969.04,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8318.46,,"Case rate ($7,922.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.40. The transfer capital threshold is the transfer adjustment factor * $561.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7934.97,23545.50,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16785.97,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16456.83,55350.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31567.81,,,,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
"PEPTIC ULCER AND GASTRITIS,MAJOR",241,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],16561.31,,"Case rate ($15,772.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15772.68,16561.31,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23130.31,,,,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],41837.14,,"Fee schedule rate ($41,837.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Prst8ect Smpl Stot Robotic Assistance,CASE-55867,APC,55867,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4180.34,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4180.34,14351.57,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5368.01,15928.53,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11066.50,,"Case rate ($10,539.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $746.87. The transfer capital threshold is the transfer adjustment factor * $746.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10556.32,32082.48,Inpatient DRG
Dilation Esophagus Guide Wire,CASE-43453,APC,43453,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24516.04,,"Case rate ($23,348.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,825.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.56. The transfer capital threshold is the transfer adjustment factor * $1,654.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23385.84,71764.93,Inpatient DRG
HC Add 2nd/3rd Order Abd/Le|LEFT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dir Rpr Aneurysm Axil-Brachial Arm Incision,CASE-35011,APC,35011,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FOURTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Revj Opn Arven Fstl W/O Thrmbc Dial Grf,CASE-36832,APC,36832,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5194.09,5194.09,5194.09,1 through 10,other,5277.74,5541.62,OPPS APC
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5113.93,,"Case rate ($4,870.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,514.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,060.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,001.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,517.21. The transfer operating threshold is the transfer adjustment factor * $4,514.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.19. The transfer capital threshold is the transfer adjustment factor * $353.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4870.41,14682.98,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],41320.17,,"Fee schedule rate ($41,320.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],48375.90,,,,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],26030.46,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",919.27,322.52,919.27,13,other,24790.92,26030.46,OPPS APC
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FOURTH DIGIT|PO",CASE-26951,APC,26951,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39298.04,,"Fee schedule rate ($39,298.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13866.64,41146.57,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,27370.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5224.00,,"Per diem ($5,224). If length of stay < 2.9, first 1 days paid at a per diem of $10,448 instead. Capped at $15,149.04.",,,,0,other,5224.00,15861.63,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7693.94,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7543.08,29489.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],24009.84,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10632.00,103714.29,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9935.64,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9935.64,29482.05,Inpatient DRG
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE|PO,CASE-29888,APC,29888,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],694.43,,"APC Price ($661.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,661.36,694.43,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
Partial Excision Bone Talus/Calcaneus|LEFT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9934.13,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9739.34,40204.26,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7968.80,,"Case rate ($7,589.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,708.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $537.81. The transfer capital threshold is the transfer adjustment factor * $537.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7601.43,23918.09,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Rmvl Perm Intraperitneal Cath,CASE-49422,APC,49422,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8184.82,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7795.07,34198.12,Inpatient DRG
Ostectomy Complete 5th Metatarsal Head,CASE-28113,APC,28113,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],27777.08,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",23138.28,23138.28,23138.28,1 through 10,other,13572.00,108637.77,Inpatient DRG
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22091.17,,"Fee schedule rate ($22,091.17). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
Cystourethroscopy With Biopsy|SEPARATE STRUCTURE,CASE-52204,APC,52204,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,46419.05,Estimated amount calculated based on 12 day length of stay.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],44163.71,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,42670.25,133443.30,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",29995.72,29995.72,29995.72,1 through 10,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22976.48,,"Fee schedule rate ($22,976.48). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27632.41,,,,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19698.48,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8972.00,76376.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5614.71,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5504.62,16333.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Insertion Tunneled Intraperitoneal Catheter,CASE-49324,APC,49324,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12316.55,,"Case rate ($11,730.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,838.28, add-ons for qualifying new technology services are included. If operating cost exceeds $46,306.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,019.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,881.47. The transfer operating threshold is the transfer adjustment factor * $10,838.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.58. The transfer capital threshold is the transfer adjustment factor * $848.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11730.05,61348.24,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19232.02,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19232.02,68941.12,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11307.66,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6461.52,21772.28,All Other Inpatient
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6180.91,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5886.58,17467.27,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],30758.38,,of the excess amount.,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12139.16,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11901.14,35314.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],47978.53,,"Fee schedule rate ($47,978.53). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],10940.41,,,,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
Arthroplasty Ankle W/Implant|RIGHT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24209.85,,"Fee schedule rate ($24,209.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22256.65,,,,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16192.08,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15421.03,49137.17,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16682.55,,"Fee schedule rate ($16,682.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21320.03,,,,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32803.53,,,,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5968.38,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5766.55,17111.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10970.77,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10970.77,32553.63,Inpatient DRG
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],44339.99,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,44339.99,131570.26,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14263.03,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7770.00,50313.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9312.29,27632.41,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7209.32,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6866.02,27153.67,Inpatient DRG
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE|PO,CASE-29825,APC,29825,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15668.80,,,,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5555.89,,"Case rate ($5,368.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,959.91, add-ons for qualifying new technology services are included. If operating cost exceeds $40,427.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,559.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,979.68. The transfer operating threshold is the transfer adjustment factor * $4,959.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $388.34. The transfer capital threshold is the transfer adjustment factor * $388.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5421.86,2544.08,5555.89,1 through 10,other,5368.01,15928.53,Inpatient DRG
"TONSIL AND ADENOID PROCEDURES,MODERATE",097,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4531.56,,"Case rate for a one day stay ($4,531.56). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,4531.56,4758.14,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,8596.11,25507.30,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18602.85,,"Fee schedule rate ($18,602.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39481.90,,,,,,0,other,13305.64,39481.90,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],90287.21,,"Fee schedule rate ($90,287.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20.9), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30818.12,,,,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15751.44,,,,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
Open Treatment Tarsometatarsal Joint Dislocation|RIGHT SIDE|PO,CASE-28615,APC,28615,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3753.29,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3753.29,11765.59,Inpatient DRG
HC Cv Cath Plac WO Port>5yr (Tun),CASE-36558,APC,36558,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14718.27,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8410.44,24956.34,All Other Inpatient
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],61287.95,,,,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],76364.61,,"Fee schedule rate ($76,364.61). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19628.82,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,19243.94,63510.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13791.99,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13135.23,38976.20,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],22734.65,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22734.65,70806.50,Inpatient DRG
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|PO,CASE-26160,APC,26160,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1525.13,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8526.77,,"Case rate ($8,526.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,902.12, add-ons for qualifying new technology services are included. If operating cost exceeds $48,447.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,268.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $7,906.03. The transfer operating threshold is the transfer adjustment factor * $7,902.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.75. The transfer capital threshold is the transfer adjustment factor * $620.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,25698.16,Inpatient DRG
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX|74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17641.51,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10080.86,33310.69,All Other Inpatient
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystostomy Cystotomy W/Drainage|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51040,APC,51040,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,MODERATE",513,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],17396.85,,"Case rate ($16,568.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16568.43,17396.85,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16724.40,,"Fee schedule rate ($16,724.40). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6256.14,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16141.36,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15824.86,49371.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,APC,58260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4744.66,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4744.66,4981.90,OPPS APC
Revj/Rmvl Prosthetic Vaginal Graft Vaginal App,CASE-57295,APC,57295,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4744.66,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4744.66,4981.90,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33525.67,,,,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15774.99,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15023.80,48104.19,Inpatient DRG
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE|PO,CASE-28300,APC,28300,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4180.34,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4180.34,14351.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17118.14,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16302.99,55737.89,Inpatient DRG
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,APC,45381,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13996.50,,"Fee schedule rate ($13,996.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FIFTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9178.51,,"Fee schedule rate ($9,178.51). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27597.52,,"Fee schedule rate ($27,597.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE|PO,CASE-28300,APC,28300,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10896.97,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10528.47,44148.02,Inpatient DRG
Rhinp Prim Complete Xtrnl Parts|PO,CASE-30410,APC,30410,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Iliac Territory Plasty Stent,CASE-37221,APC,37221,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],467.21,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
HC Iliac Territory Plasty Stent,CASE-37221,APC,37221,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],444.96,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
"Tenolysis Extensor Tendon Hand/Finger Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26445,APC,26445,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19056.10,,"Fee schedule rate ($19,056.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11441.93,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11055.00,49295.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16330.09,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16009.89,58554.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],45128.69,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,43602.60,163229.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Prtl 5th Metar Head Spx|RIGHT SIDE|PO,CASE-28110,APC,28110,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE,CASE-27405,APC,27405,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],126615.59,,,,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7308.00,,"Per diem ($7,308). If length of stay < 5.5, first 1 days paid at a per diem of $14,616 instead. Capped at $40,192.59.",,,,0,other,7308.00,42083.20,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],102660.52,,"Fee schedule rate ($102,660.52). Adds an outlier to normal pricing equal to the per diem rate ($180,358.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5224.00,,"Per diem ($5,224). If length of stay < 2.9, first 1 days paid at a per diem of $10,448 instead. Capped at $15,149.04.",,,,0,other,5224.00,15861.63,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14118.54,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13446.23,39899.05,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5775.17,,"Case rate ($5,775.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.79. The transfer capital threshold is the transfer adjustment factor * $417.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5775.17,17136.70,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],50821.76,,,,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6630.72,19989.86,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],54859.35,,"Fee schedule rate ($54,859.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],36679.51,,"Case rate ($34,932.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,646.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,475.46. The transfer capital threshold is the transfer adjustment factor * $2,475.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,34988.57,110685.97,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],23777.27,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3980.76,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3980.76,11812.10,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14228.44,,,,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
Open Treatment Fracture Distal Tibia & Fibula|RIGHT SIDE,CASE-27828,APC,27828,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
"Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn|LEFT HAND, FOURTH DIGIT|PO",CASE-26145,APC,26145,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1525.13,OPPS APC
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27537.96,,,,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32390.31,,,,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6055.67,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6055.67,17969.04,Inpatient DRG
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29069.25,,"Fee schedule rate ($29,069.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7157.79,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5520.00,26638.96,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,40658.63,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],29345.97,,"Fee schedule rate ($29,345.97). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20938.30,,,,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5846.70,,"Case rate ($5,732.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,296.29, add-ons for qualifying new technology services are included. If operating cost exceeds $40,764.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,317.40. The transfer operating threshold is the transfer adjustment factor * $5,296.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.67. The transfer capital threshold is the transfer adjustment factor * $414.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5732.06,21720.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11621.00,,"Per diem ($11,621). If length of stay < 22.4, first 1 days paid at a per diem of $23,242 instead. Capped at $260,309.36.",,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, THIRD DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],125659.39,,"Fee schedule rate ($125,659.39). Adds an outlier to normal pricing equal to the per diem rate ($160,041.92) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8638.80,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8227.43,27001.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Mal Lesion Trunk/Arm/Leg 3.1-4.0 Cm,CASE-11604,APC,11604,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34528.24,,"Fee schedule rate ($34,528.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],37134.43,,,,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,APC,52352,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10632.00,,"Per diem ($10,632). If length of stay < 6.4, first 1 days paid at a per diem of $21,264 instead. Capped at $68,043.82.",,,,0,other,10632.00,103714.29,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],8990.00,,"Per diem ($8,990). If length of stay < 6, first 1 days paid at a per diem of $17,980 instead. Capped at $53,939.67.",,,,0,other,8990.00,80069.53,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13602.19,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",466251.52,466251.52,466251.52,1 through 10,other,13335.48,39570.45,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
Rhinp Prim Complete Xtrnl Parts|PO,CASE-30410,APC,30410,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],133824.90,,"Fee schedule rate ($133,824.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,38916.28,133824.90,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6230.15,,"Case rate ($5,933.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.47. The transfer capital threshold is the transfer adjustment factor * $420.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6274.94,6274.94,6274.94,1 through 10,other,5942.94,17634.53,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,50|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],42553.74,,"Case rate ($40,527.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,043.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,871.91. The transfer capital threshold is the transfer adjustment factor * $2,871.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40591.99,115037.59,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,APC,58550,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE,CASE-27570,APC,27570,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14041.04,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14041.04,60059.69,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13305.64,39481.90,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4687.38,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4464.17,13577.72,Inpatient DRG
Rmvl/Revj Sling Male Urinary Incontinence,CASE-53442,APC,53442,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Trluml Balo Angiop 1st Vein,CASE-37248,APC,37248,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5587.20,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5478.32,5478.32,5478.32,1 through 10,other,5398.26,5668.18,OPPS APC
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G > 4.0cm,CASE-11426,APC,11426,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15507.88,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15507.89,15507.89,15507.89,1 through 10,other,15507.88,46016.63,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],22802.30,,"Case rate ($22,802.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,068.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,536.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,820.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $21,152.71. The transfer operating threshold is the transfer adjustment factor * $21,068.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,649.58. The transfer capital threshold is the transfer adjustment factor * $1,649.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22802.30,82749.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7242.67,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4138.67,12473.25,All Other Inpatient
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11962.15,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11962.15,40923.09,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22703.10,,"Fee schedule rate ($22,703.10). Adds an outlier to normal pricing equal to the per diem rate ($7,074.03) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11871.54,35778.69,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13282.66,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12833.49,58980.57,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],56694.72,,"Fee schedule rate ($56,694.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Male Genital System,CASE-55899,APC,55899,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],245.27,,"APC Price ($236.97). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,236.97,248.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38080.90,,,,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14580.18,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14580.18,57079.69,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20832.04,,,,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6077.55,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6077.55,18033.97,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6503.29,19528.85,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15751.44,,,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],27682.71,,of the excess amount.,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],53055.45,,"Fee schedule rate ($53,055.45). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],64029.63,,"Fee schedule rate ($64,029.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.5), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Bladder Instillation Anticarcinogenic Agent|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51720,APC,51720,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31790.24,,"Fee schedule rate ($31,790.24). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,11217.46,37366.25,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16240.81,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9280.46,39957.56,All Other Inpatient
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],32201.54,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,31112.60,92731.42,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13305.64,,"Case rate ($13,305.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,294.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,761.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,133.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,343.08. The transfer operating threshold is the transfer adjustment factor * $12,294.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.56. The transfer capital threshold is the transfer adjustment factor * $962.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13305.64,39481.90,Inpatient DRG
"MALFUNCTION REACTION COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE,MAJOR",466,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],13732.19,,"Case rate ($13,732.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13732.19,14418.80,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6033.12,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6033.12,17902.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26909.70,,"Fee schedule rate ($26,909.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9495.32,42131.77,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],66275.39,,"Fee schedule rate ($66,275.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intravasc Lithotripsy,CASE-C9764,APC,C9764,CPT,0481,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9495.15,,"Fee schedule rate ($9,495.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7744.00,24853.45,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Metatarsal W/Toe Single|LEFT FOOT, FIFTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T4,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5160.45,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5160.45,15312.64,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15649.20,,"Fee schedule rate ($15,649.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23542.31,,"Fee schedule rate ($23,542.31). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,APC,29828,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7249.08,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7003.94,20782.85,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8355.90,,"Fee schedule rate ($8,355.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],46444.98,,"Fee schedule rate ($46,444.98). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE|PO,CASE-24359,APC,24359,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11298.37,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11298.37,44627.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE|PO,CASE-29826,APC,29826,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23895.30,,"Fee schedule rate ($23,895.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],163229.10,,"Fee schedule rate ($163,229.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,There are no additional notes associated with this service or procedure.
Excision/Curettage Bone Cyst/Tumor Tibia/Fibula,CASE-27635,APC,27635,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],694.43,,"APC Price ($661.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,661.36,694.43,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23415.63,,,,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13246.56,,,,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17212.14,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17212.14,64440.06,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12494.10,,"Fee schedule rate ($12,494.10). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7770.00,,"Per diem ($7,770). If length of stay < 5.1, first 1 days paid at a per diem of $15,540 instead. Capped at $39,628.80.",,,,0,other,7770.00,50313.90,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2285.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12380.83,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11962.15,40923.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13314.88,,"Fee schedule rate ($13,314.88). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4264.89,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4120.67,13066.56,Inpatient DRG
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13641.37,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7795.07,34198.12,All Other Inpatient
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8938.88,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8513.22,25261.33,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33947.68,,"Fee schedule rate ($33,947.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19056.10,,"Fee schedule rate ($19,056.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16810.38,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16009.89,58554.60,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17658.44,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16817.56,58510.23,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39187.16,,"Fee schedule rate ($39,187.16). Adds an outlier to normal pricing equal to the per diem rate ($47,534.60) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23189.34,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,22734.65,70806.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4574.91,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4574.91,13575.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9284.75,,"Case rate ($8,842.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,797.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.62. The transfer capital threshold is the transfer adjustment factor * $626.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",9085.38,5345.86,18209.40,21,other,6972.00,26280.60,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],40546.43,,,,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9633.09,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5504.62,16333.88,All Other Inpatient
Excision Malignant Lesion F/E/E/N/L >4.0 Cm,CASE-11646,APC,11646,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8688.34,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8394.53,24909.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, SECOND DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13706.27,,"Fee schedule rate ($13,706.27). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4442.95,,"Case rate ($4,442.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.41. The transfer capital threshold is the transfer adjustment factor * $321.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4442.95,13183.59,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],46830.28,,"Fee schedule rate ($46,830.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],94720.48,,"Fee schedule rate ($94,720.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,APC,54410,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19658.06,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19658.06,20640.96,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],63171.04,,,,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43277,APC,43277,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36239.13,,,,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE|PO,CASE-29825,APC,29825,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],68332.92,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
Aspiration Bladder Insert Suprapubic Catheter|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51102,APC,51102,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT HAND, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40774.00,,"Fee schedule rate ($40,774.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11958.84,40774.00,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15713.20,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",39553.33,39553.33,111557.15,1 through 10,other,3295.00,55581.70,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],110217.19,,"Fee schedule rate ($110,217.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15950.19,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,15950.19,63458.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7177.29,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6835.51,20283.05,Inpatient DRG
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FOURTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T8,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16865.38,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16062.27,48077.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn,CASE-64448,APC,64448,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8924.65,,"Case rate ($8,499.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,773.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $602.32. The transfer capital threshold is the transfer adjustment factor * $602.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8513.22,25261.33,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9094.04,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8915.73,26455.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9455.26,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9269.86,37852.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16672.53,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9527.16,28269.95,All Other Inpatient
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12881.26,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12881.26,38222.57,Inpatient DRG
"Inject Nerv Blck,Paravert Sympath|BILATERAL PROCEDURE|PO",CASE-64520,APC,64520,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28061.37,,,,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf,CASE-36825,APC,36825,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5018.44,5018.44,5018.44,1 through 10,other,5277.74,5541.62,OPPS APC
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7102.10,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7102.10,21074.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],65555.62,,"Fee schedule rate ($65,555.62). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7308.00,,"Per diem ($7,308). If length of stay < 5.5, first 1 days paid at a per diem of $14,616 instead. Capped at $40,192.59.",,,,0,other,7308.00,42083.20,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",31309.60,31309.60,31309.60,1 through 10,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8446.07,,"Fee schedule rate ($8,446.07). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
"HYPERTENSION,MAJOR",199,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2730.29,,"Case rate for a one day stay ($2,600.28). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2600.28,2730.29,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12121.97,,"Case rate ($12,121.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,200.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,668.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,048.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,245.03. The transfer operating threshold is the transfer adjustment factor * $11,200.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $876.93. The transfer capital threshold is the transfer adjustment factor * $876.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12121.97,35969.56,Inpatient DRG
Fasciectomy Plantar Fascia Partial Spx|RIGHT SIDE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
Trurl Dstrj Prstate Tiss Rf Thermoth,CASE-53852,APC,53852,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
Ant Vesicourethropexy/Urethropexy Smpl,CASE-51840,APC,51840,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
"MIGRAINE AND OTHER HEADACHES,MINOR",054,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7878.74,,"Case rate ($7,878.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7878.74,8272.68,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],37134.43,,,,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],41837.14,,"Fee schedule rate ($41,837.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9430.32,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,45869.64,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9710.19,,"Case rate ($9,247.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.33. The transfer capital threshold is the transfer adjustment factor * $655.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,27484.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Medial Malleolus Fracture|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27766,APC,27766,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35314.31,,,,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8939.84,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8764.55,32969.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
"OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,EXTREME",253,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],25656.47,,"Case rate ($24,434.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24434.73,25656.47,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],23777.27,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14273.70,,,,,,0,other,4734.64,14273.70,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],36249.82,,"Fee schedule rate ($36,249.82). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6934.05,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6699.57,24060.08,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
"Ostc Prtl Exostc/Condylc Metar Head|LEFT FOOT, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28288,APC,28288,CPT,0360,RC,,,T1|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,APC,43246,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],57018.97,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,55900.95,225294.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4747.58,,"Case rate ($4,654.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.72. The transfer capital threshold is the transfer adjustment factor * $336.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4654.49,13811.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Claviculectomy Partial|RIGHT SIDE|PO,CASE-23120,APC,23120,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32101.06,,,,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14580.18,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14580.18,57079.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10972.03,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10449.55,43409.67,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6700.24,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6700.24,30254.37,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31106.08,,"Fee schedule rate ($31,106.08). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49594,APC,49594,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],22734.65,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22734.65,70806.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|SEPARATE STRUCTURE,CASE-52332,APC,52332,CPT,0360,RC,,,50|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE,CASE-29876,APC,29876,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Brow Ptosis|BILATERAL PROCEDURE|PO,CASE-67900,APC,67900,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13575.16,,,,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9448.23,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6531.00,35832.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11916.39,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11916.39,58492.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12326.15,,"Case rate ($11,739.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,003.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $831.88. The transfer capital threshold is the transfer adjustment factor * $831.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12326.16,12326.16,12326.16,1 through 10,other,11757.91,34889.29,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7289.74,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7289.74,21630.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8848.52,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8675.02,25741.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Trigger Pt 1-2 Musc Grps|PO,CASE-20552,APC,20552,CPT,0510,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20301.63,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20301.63,84714.35,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],79366.60,,"Fee schedule rate ($79,366.60). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx,CASE-29884,APC,29884,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Lateral Release|LEFT SIDE|PO,CASE-29873,APC,29873,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7511.26,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7257.26,23445.98,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38228.48,,,,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6334.78,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6033.12,17902.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THIRD DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT SIDE|PO,CASE-28160,APC,28160,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10605.39,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10605.39,31469.43,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,21325.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],40046.00,,"Fee schedule rate ($40,046.00). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11055.00,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11055.00,49295.13,Inpatient DRG
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8477.66,,"Case rate ($8,073.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,743.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.15. The transfer capital threshold is the transfer adjustment factor * $572.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,34379.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33132.06,,"Fee schedule rate ($33,132.06). Adds an outlier to normal pricing equal to the per diem rate ($83,058.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11690.93,56733.59,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],57457.72,,"Fee schedule rate ($57,457.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11301.79,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11080.19,32878.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Ganglion Wrist Dorsal/Volar Primary|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],41822.97,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,39831.40,138208.82,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],42695.82,,"Fee schedule rate ($42,695.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Pelvis/Hip Joint|RIGHT SIDE,CASE-27299,APC,27299,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],233.96,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,233.96,245.65,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13892.25,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13230.71,39259.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8491.17,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,34379.15,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25027.80,,"Fee schedule rate ($25,027.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16729.39,,,,,,0,other,5549.19,16729.39,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],102807.11,,"Fee schedule rate ($102,807.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],86795.47,,"Fee schedule rate ($86,795.47). Adds an outlier to normal pricing equal to the per diem rate ($211,362.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30626.53,106200.88,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6681.01,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6681.01,19824.58,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7686.98,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7686.98,22809.58,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18673.84,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,18042.36,82749.58,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|LEFT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4325.32,,"Case rate ($4,119.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,806.17, add-ons for qualifying new technology services are included. If operating cost exceeds $39,274.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,821.34. The transfer operating threshold is the transfer adjustment factor * $3,806.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.00. The transfer capital threshold is the transfer adjustment factor * $298.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4119.35,12223.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride/Musc/Fasc First 20 Sq Cm|SEPARATE STRUCTURE|PO,CASE-11043,APC,11043,CPT,0361,RC,,,XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE|PO,CASE-27601,APC,27601,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Pyeloplasty|RIGHT SIDE,CASE-50544,APC,50544,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],61855.45,,"Fee schedule rate ($61,855.45). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,APC,57425,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THUMB|PO",CASE-26055,APC,26055,CPT,0360,RC,,,FA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Complete 1st Metatarsal Head,CASE-28111,APC,28111,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7177.29,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6835.51,20283.05,Inpatient DRG
HC Debrid Wound Tis 20 Cm/<|ADJ,CASE-97597,APC,97597,CPT,0761,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29179.02,,,,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
"OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,EXTREME",253,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],24434.73,,"Case rate ($24,434.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24434.73,25656.47,There are no additional notes associated with this service or procedure.
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3784.78,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4538.44,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",4492.49,4492.49,4538.44,1 through 10,other,4538.44,18815.35,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34528.24,,"Fee schedule rate ($34,528.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intrvasc US Noncoronary 1st,CASE-37252,APC,37252,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],557.79,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13137.86,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",12593.72,12593.72,12593.72,1 through 10,other,12693.58,46577.81,Inpatient DRG
Tenodesis Long Tendon Biceps|LEFT SIDE|PO,CASE-23430,APC,23430,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17983.60,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17127.24,50821.76,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10593.61,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10385.89,32176.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|PREVENTIVE SERVICES,CASE-45385,APC,45385,CPT,0360,RC,,,33,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Ankle W/Implant|RIGHT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5573.75,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5308.33,19857.20,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],39736.19,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,37843.99,139522.22,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4162.46,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,21715.49,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10925.79,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10556.32,32082.48,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],29119.50,,"Case rate ($27,732.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,136.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,965.25. The transfer capital threshold is the transfer adjustment factor * $1,965.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13572.00,108637.77,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13870.13,,"Case rate ($13,209.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,107.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.08. The transfer capital threshold is the transfer adjustment factor * $936.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13230.71,39259.55,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
Transperineal Plmt Biodegradable Matrl 1/Mlt Njx,CASE-55874,APC,55874,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER CIRCULATORY SYSTEM DIAGNOSES,MAJOR",207,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13390.34,,"Case rate ($12,752.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12752.70,13390.34,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11203.52,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6350.00,33244.29,Inpatient DRG
Syndactylization Toes|BILATERAL PROCEDURE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy Limited Spx,CASE-29875,APC,29875,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,APC,11606,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7464.79,,"Case rate ($7,109.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,674.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $503.79. The transfer capital threshold is the transfer adjustment factor * $503.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,20179.92,Inpatient DRG
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",283.63,283.63,283.63,1 through 10,other,291.13,305.69,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5886.58,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5886.58,17467.27,Inpatient DRG
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,APC,60220,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5791.08,5791.08,5791.08,1 through 10,other,5733.99,6020.69,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
"SYNCOPE AND COLLAPSE,EXTREME",204,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],19453.77,,"Case rate ($18,527.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18527.40,19453.77,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20188.60,,,,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|PO,CASE-64636,APC,64636,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
Arthroplasty Glenohumeral Joint Total Shoulder,CASE-23472,APC,23472,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",17072.59,17072.59,17072.59,1 through 10,other,16630.26,17461.77,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],40916.35,,,,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6503.29,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6503.30,2951.81,23397.82,1 through 10,other,6503.29,19528.85,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9296.14,,"Case rate ($8,981.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,671.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $657.72. The transfer capital threshold is the transfer adjustment factor * $657.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8981.78,27528.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],28419.19,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,27861.95,82674.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Tenotomy Open Extensor Foot/Toe Each Tendon,CASE-28234,APC,28234,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Gastrocnemius Recession|LEFT SIDE,CASE-27687,APC,27687,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17490.00,,"Per diem ($17,490). If length of stay < 1.2, first 1 days paid at a per diem of $34,980 instead. Capped at $20,988.02.",,,,0,other,7405.81,33747.30,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf,CASE-36825,APC,36825,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33676.90,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,19243.94,63510.03,All Other Inpatient
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8444.95,,"Fee schedule rate ($8,444.95). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],30753.41,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,30150.40,89465.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6495.00,,"Per diem ($6,495). If length of stay < 3.5, first 1 days paid at a per diem of $12,990 instead. Capped at $22,732.01.",,,,0,other,6495.00,23801.30,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6393.28,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6088.84,18067.42,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11710.82,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11710.82,34749.58,Inpatient DRG
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20134.80,,"Fee schedule rate ($20,134.80). Adds an outlier to normal pricing equal to the per diem rate ($4,143.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,21229.52,There are no additional notes associated with this service or procedure.
HC 3rd Order Sel Abd/Lower Ext|RIGHT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5277.74,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6180.91,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5886.58,17467.27,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28847.26,,"Fee schedule rate ($28,847.26). Adds an outlier to normal pricing equal to the per diem rate ($89,320.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10584.90,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10080.86,33310.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16573.70,,"Fee schedule rate ($16,573.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6632.59,19680.94,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-54840,APC,54840,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",45896.69,45896.69,45896.69,1 through 10,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,30966.53,Estimated amount calculated based on 11 day length of stay.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18022.41,,"Case rate ($17,164.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.31. The transfer capital threshold is the transfer adjustment factor * $1,216.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17191.57,51012.62,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31350.48,,"Fee schedule rate ($31,350.48). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10888.24,32825.17,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
HC Intro Catheter Aorta|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36200,APC,36200,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3099.59,OPPS APC
HC N Block Inj Suprascapular Nerv|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Carpectomy All Bones Proximal Row|RIGHT SIDE|PO,CASE-25215,APC,25215,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
Ligation/Biopsy Temporal Artery|RIGHT SIDE,CASE-37609,APC,37609,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],119293.78,,,,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16785.97,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16456.83,55350.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15043.80,,"Fee schedule rate ($15,043.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5308.33,19857.20,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],79916.14,,"Fee schedule rate ($79,916.14). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Back/Flank Subfascial 5 Cm/>,CASE-21933,APC,21933,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],42553.74,,"Case rate ($40,527.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,043.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,871.91. The transfer capital threshold is the transfer adjustment factor * $2,871.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40591.99,115037.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7776.10,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7405.81,33747.30,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8848.52,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8675.02,25741.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6940.00,,"Per diem ($6,940). If length of stay < 5.9, first 1 days paid at a per diem of $13,880 instead. Capped at $40,946.19.",,,,0,other,6940.00,42872.25,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],67775.08,,"Fee schedule rate ($67,775.08). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],49902.84,,,,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],58534.56,,"Fee schedule rate ($58,534.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|LEFT SIDE|PO,CASE-25290,APC,25290,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AND UMBILICAL,MODERATE",227,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],19881.70,,"Case rate ($18,934.95). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18934.95,19881.70,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20090.22,,,,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19989.86,,,,,,0,other,6630.72,19989.86,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13328.26,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12693.58,46577.81,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13230.71,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13230.71,39259.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],62647.63,,,,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24787.16,,"Case rate ($23,606.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.86. The transfer capital threshold is the transfer adjustment factor * $1,672.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",24787.17,24787.17,24787.17,1 through 10,other,23644.46,105789.11,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11744.97,,"Case rate ($11,185.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,963.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.66. The transfer capital threshold is the transfer adjustment factor * $792.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",11454.56,11454.56,11454.56,1 through 10,other,6350.00,33244.29,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24153.20,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",24122.70,24122.70,24122.70,1 through 10,other,23679.61,84629.16,Inpatient DRG
HC Sel Cath Abd/Pelvic/Le 1st Ord|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,APC,36245,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13.28,,,,,,0,other,13.28,13.94,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15253.26,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8716.15,25863.45,All Other Inpatient
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE|PO,CASE-25607,APC,25607,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Sesamoidectomy First Toe Spx|LEFT FOOT, GREAT TOE|PO",CASE-28315,APC,28315,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",12889.87,12889.87,12889.87,1 through 10,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE|PO,CASE-28615,APC,28615,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15309.19,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14580.18,57079.69,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28695.03,,"Fee schedule rate ($28,695.03).",,,,0,other,14182.35,53827.17,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE,CASE-27619,APC,27619,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12804.31,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12804.31,55145.09,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24555.13,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23385.84,71764.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7335.51,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7335.51,29792.90,Inpatient DRG
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Insertion Tunneled Intraperitoneal Catheter,CASE-49324,APC,49324,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Amp Mtcrpl W/Finger/Thumb W/WO Inteross Transfer,CASE-26910,APC,26910,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5342.14,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",5337.34,5337.34,5337.34,1 through 10,other,5237.39,15540.89,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24585.00,,"Fee schedule rate ($24,585.00). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, SECOND DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HIP AND FEMUR FRACTURE REPAIR,MAJOR",308,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],29109.76,,"Case rate ($29,109.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,29109.76,30565.25,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7907.62,,"Case rate ($7,531.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,704.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.68. The transfer capital threshold is the transfer adjustment factor * $533.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7543.08,29489.40,Inpatient DRG
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3162.78,3162.78,3162.78,1 through 10,other,6882.29,7226.40,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12167.07,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12167.07,36103.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],43434.38,,"Fee schedule rate ($43,434.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Open/Perq Place Stent Ea Add A,CASE-37237,APC,37237,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10949.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6681.01,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6681.01,19824.58,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],22908.38,,"Case rate ($22,908.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,828.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.25. The transfer capital threshold is the transfer adjustment factor * $1,657.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22908.38,67976.16,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21067.51,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20654.42,69402.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride Subq First 20 Sq Cm,CASE-11042,APC,11042,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC
HC Lyr Clos Sc Tk Ext 7.6-12cm|SEPARATE STRUCTURE,CASE-12034,APC,12034,CPT,0450,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3843.64,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|RIGHT SIDE,CASE-27446,APC,27446,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9969.47,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9969.47,29582.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
HC Vasc Embolize Occlude Organ|BILATERAL PROCEDURE,CASE-37243,APC,37243,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35359.57,,,,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13485.61,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,38110.41,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Transoral Lower Esophageal Myotomy,CASE-43497,APC,43497,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER GASTROENTERITIS NAUSEA AND VOMITING,MODERATE",249,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2660.96,,"Case rate for a one day stay ($2,534.25). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2534.25,2660.96,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],45371.94,,"Fee schedule rate ($45,371.94). Adds an outlier to normal pricing equal to the per diem rate ($84,711.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],35094.08,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,33422.93,112824.68,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11778.33,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11217.46,37366.25,Inpatient DRG
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,APC,58558,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE|SEPARATE STRUCTURE,CASE-27339,APC,27339,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17776.11,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,16929.63,63934.22,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15043.80,,"Fee schedule rate ($15,043.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5308.33,19857.20,Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7455.00,,"Per diem ($7,455). If length of stay < 6.8, first 1 days paid at a per diem of $14,910 instead. Capped at $50,692.24.",,,,0,other,7455.00,53076.74,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],125659.39,,"Fee schedule rate ($125,659.39). Adds an outlier to normal pricing equal to the per diem rate ($160,041.92) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Catheter Aorta,CASE-36200,APC,36200,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|RIGHT SIDE,CASE-28309,APC,28309,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7920.23,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7543.08,29489.40,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5781.77,,"Case rate ($5,668.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,581.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.07. The transfer capital threshold is the transfer adjustment factor * $410.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",20449.30,20449.30,20449.30,1 through 10,other,5668.40,16903.82,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],102660.52,,"Fee schedule rate ($102,660.52). Adds an outlier to normal pricing equal to the per diem rate ($180,358.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Metatarsal Fracture Each|LEFT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FIFTH DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],53537.18,,,,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
Arthroscopy Ankle Surgical Debridement Extensive|RIGHT SIDE|PO,CASE-29898,APC,29898,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl,CASE-37232,APC,37232,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],189.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6597.92,,"Case rate ($6,283.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,616.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $445.29. The transfer capital threshold is the transfer adjustment factor * $445.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6772.99,6772.99,6772.99,1 through 10,other,6293.75,21908.95,Inpatient DRG
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3390.91,3390.91,3390.91,1 through 10,other,3395.89,3565.69,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14891.42,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7308.00,42083.20,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39792.30,,"Fee schedule rate ($39,792.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20005.22,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20005.22,74991.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19262.83,,"Fee schedule rate ($19,262.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,APC,43239,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10976.58,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10605.39,31469.43,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11964.65,,"Case rate ($11,730.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,838.28, add-ons for qualifying new technology services are included. If operating cost exceeds $46,306.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,019.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,881.47. The transfer operating threshold is the transfer adjustment factor * $10,838.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.58. The transfer capital threshold is the transfer adjustment factor * $848.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11730.05,61348.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17123.00,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8558.00,48389.68,Inpatient DRG
Excision Malignant Lesion F/E/E/N/L >4.0 Cm,CASE-11646,APC,11646,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,CASE-36556,APC,36556,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11710.82,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11409.31,11407.77,11710.82,1 through 10,other,11710.82,34749.58,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29527.05,,"Fee schedule rate ($29,527.05). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33891.30,,"Fee schedule rate ($33,891.30). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,11958.84,40774.00,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18559.00,,"Per diem ($18,559). If length of stay < 5.4, first 1 days paid at a per diem of $37,118 instead. Capped at $100,219.31.",96002.69,96002.69,96002.69,1 through 10,other,18559.00,141041.50,Estimated amount calculated based on 3 day length of stay.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11623.17,,"Case rate ($11,623.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,490.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.89. The transfer capital threshold is the transfer adjustment factor * $842.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,35040.80,Inpatient DRG
"HEART FAILURE,EXTREME",194,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],29459.90,,"Case rate ($28,057.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,28057.05,29459.90,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],62584.20,,"Fee schedule rate ($62,584.20). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7120.66,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,20179.92,Inpatient DRG
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5452.38,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5224.00,15861.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|RIGHT SIDE,CASE-37225,APC,37225,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],538.93,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7500.63,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7500.63,22256.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19297.23,,,,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23784.60,,"Fee schedule rate ($23,784.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,EXTREME",137,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],24934.08,,"Case rate ($23,746.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23746.74,24934.08,There are no additional notes associated with this service or procedure.
HC Intro Cath Dialysis Circuit|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-36901,APC,36901,CPT,0361,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1567.69,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22555.75,,,,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
Insertion Intrauterine Device Iud,CASE-58300,APC,58300,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,APC,31628,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3659.98,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17366.98,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,17026.45,50522.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],59684.28,,,,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS AND MISCELLANEOUS DIAGNOSES,MODERATE",143,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2371.19,,"Case rate for a one day stay ($2,371.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2371.19,2489.75,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",4884.61,4884.61,4884.61,1 through 10,other,5085.49,5339.77,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10037.09,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10037.09,36934.96,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21660.31,,"Fee schedule rate ($21,660.31). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4376.13,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4167.74,12366.99,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16343.72,,,,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37225.17,,"Fee schedule rate ($37,225.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9634.79,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,33447.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7184.98,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7184.98,21320.03,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13022.58,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12402.46,36801.89,Inpatient DRG
Partical Excision Bone Phalanx Toe|LEFT SIDE|PO,CASE-28124,APC,28124,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12167.07,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12167.07,36103.36,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11932.19,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",11754.02,11754.02,11754.02,1 through 10,other,11698.23,34712.20,Inpatient DRG
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Syndactylization Toes|BILATERAL PROCEDURE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY ANOTHER PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,77|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],29771.33,,"APC Price ($29,771.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,29771.33,31259.89,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],41015.72,,"Fee schedule rate ($41,015.72). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],61415.85,,,,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5208.96,,"Case rate ($4,960.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,522.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $351.55. The transfer capital threshold is the transfer adjustment factor * $351.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4968.82,19848.33,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11151.30,,"Case rate ($10,620.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.59. The transfer capital threshold is the transfer adjustment factor * $752.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10637.22,31563.88,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9238.13,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9056.99,33814.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13859.90,,"Case rate ($13,588.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,555.10, add-ons for qualifying new technology services are included. If operating cost exceeds $48,023.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,154.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,605.14. The transfer operating threshold is the transfer adjustment factor * $12,555.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $983.00. The transfer capital threshold is the transfer adjustment factor * $983.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13588.14,40320.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9527.16,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9527.16,28269.95,Inpatient DRG
HC Removal FB Skin,CASE-10120,APC,10120,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,399.06,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15440.25,,"Fee schedule rate ($15,440.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],36910.99,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",46480.31,46480.31,46480.31,1 through 10,other,36910.99,126842.57,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],25949.09,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24713.42,73332.24,Inpatient DRG
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32406.65,,"Fee schedule rate ($32,406.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
HC Sleep Study Unattended,CASE-95800,APC,95800,CPT,0920,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],211.96,,"APC Price ($204.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",150.33,150.33,150.33,12,other,204.80,215.04,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5561.91,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5297.06,19049.64,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8410.44,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8410.44,24956.34,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],53147.51,,"Case rate ($50,616.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,758.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,586.87. The transfer capital threshold is the transfer adjustment factor * $3,586.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",53475.12,53475.12,53475.12,1 through 10,other,13061.00,162464.13,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
"HC Debrid,Subq Ea Addt'l 20sqcm",CASE-11045,APC,11045,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,APC,57250,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7209.32,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6866.02,27153.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5354.09,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5354.09,15887.21,Inpatient DRG
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE|PO,CASE-29823,APC,29823,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5747.99,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5091.00,22010.11,Inpatient DRG
Prostate Needle Biopsy Any Approach,CASE-55700,APC,55700,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],126.14,,,,,,0,other,120.13,126.14,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17546.22,,"Case rate ($16,710.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,355.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,184.18. The transfer capital threshold is the transfer adjustment factor * $1,184.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16737.33,72192.67,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9738.02,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9738.02,28895.67,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],72246.07,,,,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
"OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,MODERATE",182,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6280.07,,"Case rate for a one day stay ($5,981.02). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5981.02,6280.07,There are no additional notes associated with this service or procedure.
"OTHER CARDIOTHORACIC AND THORACIC CIRCULATORY PROCEDURES,MAJOR",167,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],53567.97,,"Case rate ($53,567.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $47,615, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,53567.97,56246.37,There are no additional notes associated with this service or procedure.
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE,CASE-28322,APC,28322,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,27370.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6866.02,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6866.02,27153.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
Biopsy Urethra,CASE-53200,APC,53200,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7577.56,,"Case rate ($7,577.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,001.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,469.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,029.37. The transfer operating threshold is the transfer adjustment factor * $7,001.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.18. The transfer capital threshold is the transfer adjustment factor * $548.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7577.56,31445.30,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
Open Tx Metatarsophalangeal Joint Dislocation,CASE-28645,APC,28645,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10109.37,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10109.37,38416.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32071.54,,,,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11593.40,,"Fee schedule rate ($11,593.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,2285.00,12138.74,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29382.86,,"Fee schedule rate ($29,382.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17191.57,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17191.57,51012.62,Inpatient DRG
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],38724.86,,"Fee schedule rate ($38,724.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5338.18,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5338.18,15839.99,Inpatient DRG
Ostc Prtl Exostc/Condylc Metar Head|LEFT SIDE|PO,CASE-28288,APC,28288,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24243.53,,"Case rate ($23,089.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,807.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.17. The transfer capital threshold is the transfer adjustment factor * $1,636.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",24243.54,24243.54,24243.54,1 through 10,other,23125.89,68621.57,Inpatient DRG
Revasc lithotrip tibi/perone|LEFT SIDE,CASE-C9772,APC,C9772,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Sigmoidoscopy Flx Placement of Endoscopic Stent,CASE-45347,APC,45347,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT SIDE|PO,CASE-26356,APC,26356,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19616.66,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,19232.02,68941.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13369.00,,"Per diem ($13,369). If length of stay < 6.3, first 1 days paid at a per diem of $26,738 instead. Capped at $84,226.47.",,,,0,other,13369.00,88188.38,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Ablation Renal Cysts|RIGHT SIDE,CASE-50541,APC,50541,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],29208.48,,"Case rate ($27,817.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,971.25. The transfer capital threshold is the transfer adjustment factor * $1,971.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",28662.73,28662.73,28662.73,1 through 10,other,27861.95,82674.88,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],33398.30,,"Case rate ($31,807.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,425.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,254.02. The transfer capital threshold is the transfer adjustment factor * $2,254.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31858.62,94534.21,Inpatient DRG
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE,CASE-27619,APC,27619,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3843.64,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],104605.60,,"Fee schedule rate ($104,605.60). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21991.57,,"Fee schedule rate ($21,991.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],86162.15,,"Fee schedule rate ($86,162.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],41320.17,,"Fee schedule rate ($41,320.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,40658.63,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HC Stent Place Initial Artery Ang,CASE-37236,APC,37236,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Transection/Avulsion Oth Spinal Nrv Xdrl|PO,CASE-64772,APC,64772,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],32004.66,,"Case rate ($30,480.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,163.35, add-ons for qualifying new technology services are included. If operating cost exceeds $63,631.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,376.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,275.59. The transfer operating threshold is the transfer adjustment factor * $28,163.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,205.05. The transfer capital threshold is the transfer adjustment factor * $2,205.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30480.63,86382.02,Inpatient DRG
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,APC,64585,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3315.94,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3315.94,3481.74,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7432.83,,"Case rate ($7,078.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,540.71, add-ons for qualifying new technology services are included. If operating cost exceeds $42,008.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,683.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,566.78. The transfer operating threshold is the transfer adjustment factor * $6,540.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.10. The transfer capital threshold is the transfer adjustment factor * $512.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7078.89,21005.20,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6472.13,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6472.13,19204.75,Inpatient DRG
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20697.52,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20697.52,87921.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE|PO,CASE-27427,APC,27427,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10455.00,,"Per diem ($10,455). If length of stay < 6.6, first 1 days paid at a per diem of $20,910 instead. Capped at $69,000.38.",,,,0,other,10455.00,90889.11,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4345.60,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4138.67,12473.25,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36780.25,,,,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
Revsc Opn/Prq Tib/Pero W/Athrc/Angiop Uni Ea Vsl|RIGHT SIDE,CASE-37233,APC,37233,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],306.34,,,,,,0,other,291.75,306.34,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, SECOND DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Synovectomy Tendon Sheath Foot Extensor,CASE-28088,APC,28088,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,APC,45381,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3784.78,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MINOR",282,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7531.43,,"Case rate ($7,172.79). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7172.79,7531.43,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12196.66,,"Fee schedule rate ($12,196.66). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],44924.67,,"Fee schedule rate ($44,924.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],34447.94,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32807.56,111191.81,Inpatient DRG
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11953.81,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11384.58,33781.47,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9774.43,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33447.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24571.82,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,14041.04,60059.69,All Other Inpatient
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9237.41,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8925.03,26628.31,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19989.86,,,,,,0,other,6630.72,19989.86,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],86795.47,,"Fee schedule rate ($86,795.47). Adds an outlier to normal pricing equal to the per diem rate ($211,362.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30626.53,106200.88,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE|PO,CASE-29806,APC,29806,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Blepharoplasty Lower Eyelid Herniated Fat Pad,CASE-15821,APC,15821,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.80,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.96,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intrvasc US Noncoronary 1st,CASE-37252,APC,37252,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],565.88,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
Excision/Curettage Cyst/Tumor Femur|LEFT SIDE,CASE-27355,APC,27355,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Hrhc 2/> Col/Grp W/Fstulectmy Incl Fssrectmy,CASE-46262,APC,46262,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
Rhinoplasty Secondary Intermediate Revision,CASE-30435,APC,30435,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20817.72,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11895.84,35298.57,All Other Inpatient
"KIDNEY AND URINARY TRACT INFECTIONS,MODERATE",463,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8416.15,,"Case rate ($8,416.15). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8416.15,8836.96,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,66445.54,Estimated amount calculated based on 11 day length of stay.
Parathyroid Autotransplantation Add-On,CASE-60512,APC,60512,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],11139.15,,,,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
HC Revasc Intra Lithotrip-Ather,CASE-C9766,APC,C9766,CPT,0481,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18256.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC
Exc Tumor Soft Tiss Shoulder Subfasc <5cm|LEFT SIDE,CASE-23076,APC,23076,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE|PO,CASE-27601,APC,27601,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31469.43,,,,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6328.22,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6328.22,27416.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",35973.56,35973.56,35973.56,1 through 10,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],14842.71,,"Fee schedule rate ($14,842.71). Adds an outlier to normal pricing equal to the per diem rate ($40,567.35) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],25667.66,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,25667.66,86123.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15496.63,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,53945.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7476.69,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,20179.92,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11690.93,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11690.93,56733.59,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
Tnols Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|LEFT SIDE|PO,CASE-25295,APC,25295,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8982.79,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8679.02,29908.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16452.87,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",15967.68,15967.68,15967.68,1 through 10,other,15896.49,51306.05,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4922.42,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4755.96,21133.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MAJOR",282,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15743.19,,"Case rate ($14,993.51). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14993.51,15743.19,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],78047.33,,"Fee schedule rate ($78,047.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20343.42,,"Fee schedule rate ($20,343.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],9242.00,,"Per diem ($9,242). If length of stay < 7.6, first 1 days paid at a per diem of $18,484 instead. Capped at $70,242.60.",,,,0,other,9242.00,76216.30,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,46419.05,Estimated amount calculated based on 12 day length of stay.
Excision/Curettage Cyst/Tumor Femur|RIGHT SIDE,CASE-27355,APC,27355,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17032.82,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16456.83,55350.97,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6644.63,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6328.22,27416.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17107.95,,"Fee schedule rate ($17,107.95). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
Open Treatment Tarsometatarsal Joint Dislocation,CASE-28615,APC,28615,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],37975.99,,"Case rate ($36,167.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,417.97, add-ons for qualifying new technology services are included. If operating cost exceeds $68,885.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,787.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $33,551.16. The transfer operating threshold is the transfer adjustment factor * $33,417.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,616.46. The transfer capital threshold is the transfer adjustment factor * $2,616.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36167.61,140535.66,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17634.53,,,,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 7 day length of stay.
Partical Excision Bone Phalanx Toe|LEFT SIDE|PO,CASE-28124,APC,28124,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,APC,43236,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16536.43,,"Fee schedule rate ($16,536.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4568.94,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4568.94,13557.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11170.47,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10638.54,40729.62,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciotomy Foot&/Toe|BILATERAL PROCEDURE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11010.89,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10638.54,40729.62,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10497.56,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10291.73,34803.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11080.19,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11080.19,32878.30,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15218.11,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15218.11,45156.75,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11916.39,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11916.39,58492.48,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20343.42,,"Fee schedule rate ($20,343.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],58656.71,,"Fee schedule rate ($58,656.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,APC,64772,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9948.90,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9948.90,46199.76,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22612.66,,"Case rate ($21,535.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,697.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,526.11. The transfer capital threshold is the transfer adjustment factor * $1,526.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",22612.67,22612.67,22612.67,1 through 10,other,21570.21,72041.81,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7308.00,,"Per diem ($7,308). If length of stay < 5.5, first 1 days paid at a per diem of $14,616 instead. Capped at $40,192.59.",,,,0,other,7308.00,42083.20,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23644.46,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23644.46,105789.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|LEFT SIDE|PO,CASE-25260,APC,25260,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8246.16,,"Case rate ($7,853.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.53. The transfer capital threshold is the transfer adjustment factor * $556.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7866.01,25247.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation,CASE-28615,APC,28615,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",16063.28,16063.28,16063.28,1 through 10,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],49452.90,,"Fee schedule rate ($49,452.90). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14228.44,,,,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19198.85,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10970.77,32553.63,All Other Inpatient
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,APC,57250,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",14430.22,14430.22,14430.22,1 through 10,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, SECOND DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Dx Collection Specimen Brushing/Washing|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43260,APC,43260,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5942.94,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5986.51,5942.94,5986.51,1 through 10,other,5942.94,17634.53,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15751.44,,,,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],59694.60,,"Fee schedule rate ($59,694.60). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,21715.49,Estimated amount calculated based on 9 day length of stay.
"Sesamoidectomy First Toe Spx|LEFT FOOT, GREAT TOE|PO",CASE-28315,APC,28315,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],38756.54,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36910.99,126842.57,Inpatient DRG
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, SECOND DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6293.75,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6293.75,21908.95,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
HC Intro Cath Dialysis Circuit W Pta|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36902,APC,36902,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15845.32,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15090.78,44778.95,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9579.88,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,27465.16,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13001.86,,"Case rate ($12,382.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,048.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.48. The transfer capital threshold is the transfer adjustment factor * $877.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12402.46,36801.89,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6797.83,,"Case rate ($6,474.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,981.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,449.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,005.76. The transfer operating threshold is the transfer adjustment factor * $5,981.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.35. The transfer capital threshold is the transfer adjustment factor * $468.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6474.12,19210.66,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],47889.67,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,45609.21,211906.58,Inpatient DRG
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE,CASE-29806,APC,29806,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",57318.75,57318.75,57318.75,1 through 10,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],41320.17,,"Fee schedule rate ($41,320.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16633.77,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8558.00,48389.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6905.94,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6770.53,20090.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21451.50,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8940.00,63653.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion S/N/H/F/G 2.1-3.0 Cm,CASE-11623,APC,11623,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6474.12,,"Case rate ($6,474.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,981.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,449.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,005.76. The transfer operating threshold is the transfer adjustment factor * $5,981.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.35. The transfer capital threshold is the transfer adjustment factor * $468.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6474.12,19210.66,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22002.56,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20954.82,62179.32,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],28332.62,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13572.00,108637.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20005.22,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20005.22,74991.64,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1188.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
Hrhc 2/> Col/Grp W/Fstulectmy Incl Fssrectmy,CASE-46262,APC,46262,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10037.63,,"Case rate ($9,559.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,848.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.43. The transfer capital threshold is the transfer adjustment factor * $677.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9574.89,28411.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],40320.14,,,,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12161.39,,"Case rate ($11,582.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,991.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.76. The transfer capital threshold is the transfer adjustment factor * $820.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11600.75,34422.94,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23674.26,,"Fee schedule rate ($23,674.26). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11178.84,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6387.91,18954.85,All Other Inpatient
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27632.41,,,,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,APC,11424,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36143.75,,"Fee schedule rate ($36,143.75). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],94720.48,,"Fee schedule rate ($94,720.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],144298.29,,"Fee schedule rate ($144,298.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],41117.20,,"Fee schedule rate ($41,117.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],52607.24,,"Fee schedule rate ($52,607.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Pelvis/Hip Joint|RIGHT SIDE,CASE-27299,APC,27299,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],242.14,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,233.96,245.65,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18473.56,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10556.32,32082.48,All Other Inpatient
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33891.30,,"Fee schedule rate ($33,891.30). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",34338.57,34338.57,34338.57,1 through 10,other,11958.84,40774.00,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7023.28,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6785.78,20135.47,Inpatient DRG
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
Ligamentous Reconstruction Knee Extra-Articular,CASE-27427,APC,27427,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13831.52,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13831.52,59770.39,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8032.50,,"Fee schedule rate ($8,032.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,41333.08,Estimated amount calculated based on 10 day length of stay.
Transoral Lower Esophageal Myotomy,CASE-43497,APC,43497,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6045.95,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20110.39,,"Fee schedule rate ($20,110.39). Adds an outlier to normal pricing equal to the per diem rate ($69,590.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7096.13,25801.23,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5113.93,,"Case rate ($4,870.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,514.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,060.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,001.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,517.21. The transfer operating threshold is the transfer adjustment factor * $4,514.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.19. The transfer capital threshold is the transfer adjustment factor * $353.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4870.41,14682.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,46419.05,Estimated amount calculated based on 12 day length of stay.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6387.91,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6281.72,6281.72,6281.72,1 through 10,other,6387.91,18954.85,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3843.64,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
"RESPIRATORY FAILURE,MAJOR",133,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15553.16,,"Case rate ($14,812.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14812.53,15553.16,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11384.58,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11384.58,33781.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"RENAL DIALYSIS ACCESS DEVICE PROCEDURES,EXTREME",444,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],49522.92,,"Case rate ($49,522.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,49522.92,51999.07,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13332.10,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12881.26,38222.57,Inpatient DRG
HC 3rd Order Sel Abd/Lower Ext,CASE-36247,APC,36247,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8.76,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11550.37,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11159.78,39897.21,Inpatient DRG
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13397.93,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13135.23,38976.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14319.06,,"Fee schedule rate ($14,319.06). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10178.99,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10178.99,36468.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],31239.06,,"Case rate ($30,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,386.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,215.60. The transfer capital threshold is the transfer adjustment factor * $2,215.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,30626.53,106200.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],36566.46,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,20895.12,99969.33,All Other Inpatient
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8383.25,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7984.05,23691.11,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
Colonoscopy Stoma Dx Including Collj Spec Spx,CASE-44388,APC,44388,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9361.52,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8915.73,26455.73,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11986.02,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,11986.02,54149.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9820.91,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9802.80,9802.80,9802.80,1 through 10,other,9820.91,29141.64,Inpatient DRG
Revascularization Iliac Artery Angiop 1st Vsl|LEFT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],379.58,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9308.98,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,33447.35,Inpatient DRG
"Capsulectomy/Capsulotomy Mtcarphlngl Joint Each|RIGHT HAND, FIFTH DIGIT|PO",CASE-26520,APC,26520,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",21305.57,21305.57,21305.57,1 through 10,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3361.98,3361.98,3361.98,1 through 10,other,3343.33,3510.50,OPPS APC
Partial Excision Bone Tibia|RIGHT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6077.55,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6077.55,18033.97,Inpatient DRG
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FIFTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15887.21,,,,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24849.04,,"Case rate ($23,665.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,848.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,677.04. The transfer capital threshold is the transfer adjustment factor * $1,677.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23703.48,110204.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4968.82,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4968.82,19848.33,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciotomy Foot&/Toe|RIGHT SIDE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],6568.26,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,3753.29,11765.59,All Other Inpatient
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE|PO,CASE-29888,APC,29888,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21851.57,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,21112.63,62647.63,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7303.30,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7056.33,28335.74,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],64770.78,,,,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11916.39,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11916.39,58492.48,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7984.05,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7984.05,23691.11,Inpatient DRG
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-12032,APC,12032,CPT,0450,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,XU|50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12846.75,,"Fee schedule rate ($12,846.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6803.69,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5843.00,27370.21,Inpatient DRG
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],28749.28,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13572.00,108637.77,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],29119.50,,"Case rate ($27,732.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,136.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,965.25. The transfer capital threshold is the transfer adjustment factor * $1,965.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",28132.52,24253.06,29119.51,1 through 10,other,13572.00,108637.77,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5747.99,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5091.00,22010.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Metatarsal W/Toe Single|LEFT FOOT, FIFTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7369.00,,"Per diem ($7,369). If length of stay < 2.4, first 1 days paid at a per diem of $14,738 instead. Capped at $17,686.09.",,,,0,other,6240.68,18518.02,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19173.27,,,,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42003.98,,"Fee schedule rate ($42,003.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35495.34,,,,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],25210.33,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10632.00,103714.29,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
Trurl Rescj Residual/Regrowth Obstr Prstate Tiss,CASE-52630,APC,52630,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
Revascularization Iliac Artery Angiop 1st Vsl|RIGHT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],374.15,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11962.15,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11962.15,40923.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,APC,11606,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
Syndactylization Toes,CASE-28280,APC,28280,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19024.56,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",30534.98,30534.98,30534.98,1 through 10,other,18381.22,58579.45,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6367.80,,"Case rate ($6,064.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.76. The transfer capital threshold is the transfer adjustment factor * $429.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6074.24,18024.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10446.35,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9948.90,46199.76,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,APC,43249,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1849.14,1849.14,1849.14,1 through 10,other,1820.02,1911.02,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12141.86,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12141.86,36028.59,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],37823.10,,"Fee schedule rate ($37,823.10). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],28725.18,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27357.31,100904.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22189.86,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21133.20,88801.87,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18902.44,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",19010.30,19010.30,19010.30,1 through 10,other,18902.44,56089.29,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11903.13,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11903.13,48838.99,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5814.92,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5700.90,30872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($55,128.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19183.89,,"Fee schedule rate ($19,183.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,6553.68,20086.28,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8383.25,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7984.05,23691.11,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31828.47,,"Fee schedule rate ($31,828.47). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],25968.63,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,25459.44,80806.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
Rcnstj Angular Dfrm Toe Soft Tiss Px Only|LEFT SIDE|PO,CASE-28313,APC,28313,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12006.70,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11434.95,119072.21,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5297.06,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5297.06,19049.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",9081.80,9081.80,9081.80,1 through 10,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14469.48,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9763.00,48626.00,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|PO,CASE-64494,APC,64494,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29997.59,,,,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15849.73,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9056.99,33814.75,All Other Inpatient
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],8940.00,,"Per diem ($8,940). If length of stay < 6.8, first 1 days paid at a per diem of $17,880 instead. Capped at $60,793.48.",,,,0,other,8940.00,63653.13,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7231.00,,"Per diem ($7,231). If length of stay < 5.1, first 1 days paid at a per diem of $14,462 instead. Capped at $36,875.62.",,,,0,other,7231.00,38610.21,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14184.53,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13704.86,49911.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dstrj Lesion Anus Extensive,CASE-46924,APC,46924,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],40666.46,,,,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],59361.57,,,,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
Surg Tx Anal Fistula Subq,CASE-46270,APC,46270,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],133824.90,,"Fee schedule rate ($133,824.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,38916.28,133824.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB|PO",CASE-26160,APC,26160,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8764.55,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8764.55,32969.91,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17814.56,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",17248.81,17248.81,17450.15,1 through 10,other,17212.14,64440.06,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],27357.31,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27357.31,100904.68,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11359.17,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10818.26,38164.94,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],28314.82,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,27357.31,100904.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4871.91,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4639.91,13771.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|ADJ,CASE-97605,APC,97605,CPT,0761,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC
HC Inj Trigger Pt 1-2 Musc Grps|PO,CASE-20552,APC,20552,CPT,0510,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],54099.15,,"Fee schedule rate ($54,099.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
HC Rt Bronchoscopy Alveolar Lavage,CASE-31624,APC,31624,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1747.26,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1688.18,1772.59,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8517.86,,"Case rate ($4,867.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.12. The transfer capital threshold is the transfer adjustment factor * $352.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4867.35,14442.92,All Other Inpatient
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
HC I & D Simple,CASE-10060,APC,10060,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
"Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn|LEFT HAND, FOURTH DIGIT|PO",CASE-26145,APC,26145,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1525.13,OPPS APC
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu,CASE-25260,APC,25260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15887.21,,,,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],28679.45,,"Case rate ($27,313.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,106.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,935.55. The transfer capital threshold is the transfer adjustment factor * $1,935.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27357.31,100904.68,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12326.86,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12326.86,53121.74,Inpatient DRG
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE|PO,CASE-28306,APC,28306,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB|PO",CASE-26418,APC,26418,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21828.16,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",21828.17,21828.17,21828.17,1 through 10,other,21828.16,93157.39,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16644.64,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15852.04,50518.01,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6178.00,,"Per diem ($6,178). If length of stay < 3.9, first 1 days paid at a per diem of $12,356 instead. Capped at $24,092.63.",,,,0,other,6178.00,25225.91,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE|PO,CASE-23515,APC,23515,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10805.00,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10439.61,34540.67,Inpatient DRG
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6797.78,,"Fee schedule rate ($6,797.78). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],37649.21,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,36910.99,126842.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21542.42,,"Fee schedule rate ($21,542.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6399.53,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6094.79,22352.66,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13230.00,,"Fee schedule rate ($13,230). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],92320.55,,,,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,33843.71,Estimated amount calculated based on 10 day length of stay.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4687.38,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4464.17,13577.72,Inpatient DRG
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",91908.41,91908.41,91908.41,1 through 10,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16616.81,,"Case rate ($9,495.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,773.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,858.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $8,808.40. The transfer operating threshold is the transfer adjustment factor * $8,773.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.92. The transfer capital threshold is the transfer adjustment factor * $686.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9495.32,42131.77,All Other Inpatient
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|LEFT SIDE|PO,CASE-27675,APC,27675,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22524.08,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8940.00,63653.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Tnot Elbow Lateral/Medial Debride Open|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-24358,APC,24358,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
HC Debride Subq First 20 Sq Cm|PBB CHARGE,CASE-11042,APC,11042,CPT,0361,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,385.57,404.84,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9934.13,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9739.34,40204.26,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5068.20,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4968.82,19848.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],57534.77,,"Fee schedule rate ($57,534.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FOURTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Needle Biopsy Muscle,CASE-20206,APC,20206,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,APC,20552,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17127.24,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17127.24,50821.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],46638.59,,"Fee schedule rate ($46,638.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13715.15,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13446.23,39899.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],54072.40,,,,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],41822.97,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,39831.40,138208.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13892.25,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13230.71,39259.55,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23026.03,,,,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,APC,94640,CPT,0410,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],81324.83,,"Fee schedule rate ($81,324.83). Adds an outlier to normal pricing equal to the per diem rate ($106,784.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23895.30,,"Fee schedule rate ($23,895.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER AFTERCARE AND CONVALESCENCE,MAJOR",862,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9745.02,,"Case rate ($9,280.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9280.97,9745.02,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],68332.92,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10334.84,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10334.84,30666.60,Inpatient DRG
HC >= 12 Lead Ekg|ADJ|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3182.49,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3074.87,3228.61,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17695.16,,of the excess amount.,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34353.60,,"Fee schedule rate ($34,353.60). Adds an outlier to normal pricing equal to the per diem rate ($257,654.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,12121.97,35969.56,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7144.02,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7003.94,20782.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE,CASE-27654,APC,27654,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE|PO,CASE-27650,APC,27650,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6061.85,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5773.19,31196.82,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],38651.97,,"Fee schedule rate ($38,651.97). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8031.52,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7759.92,35376.63,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25863.45,,,,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11412.83,,"Case rate ($10,869.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,418.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $770.71. The transfer capital threshold is the transfer adjustment factor * $770.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10888.24,32825.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9975.82,,"Fee schedule rate ($9,975.82). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8422.05,,"Fee schedule rate ($8,422.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6092.61,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5886.58,17467.27,Inpatient DRG
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29433.60,,"Fee schedule rate ($29,433.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12095.14,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11519.18,34180.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins|RIGHT SIDE|PO,CASE-25320,APC,25320,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, THUMB|PO",CASE-26445,APC,26445,CPT,0360,RC,,,FA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7952.22,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7952.22,25854.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],42842.73,,,,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6770.53,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6770.53,20090.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16443.72,,"Fee schedule rate ($16,443.72). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28203.13,,"Fee schedule rate ($28,203.13). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25689.33,,"Fee schedule rate ($25,689.33). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11958.84,40774.00,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33483.49,,"Fee schedule rate ($33,483.49). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],23260.04,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9370.00,65732.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],41712.94,,"Fee schedule rate ($41,712.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
Mastectomy Partial|LEFT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
Excision Interdigital Morton Neuroma Single Each|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
"MIGRAINE AND OTHER HEADACHES,MODERATE",054,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3426.76,,"Case rate for a one day stay ($3,263.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3263.58,3426.76,There are no additional notes associated with this service or procedure.
Open Treatment Bimalleolar Ankle Fracture|RIGHT SIDE|PO,CASE-27814,APC,27814,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1578.51,1601.38,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9833.51,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9833.51,45903.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,APC,57260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4744.66,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4744.66,4981.90,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5037.71,,"Case rate ($4,867.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.12. The transfer capital threshold is the transfer adjustment factor * $352.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4867.35,14442.92,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp,CASE-27691,APC,27691,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7744.00,24853.45,Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27982.66,,,,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4993.76,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4755.96,21133.33,Inpatient DRG
HC Peripheral Block - Femoral Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11690.93,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11808.53,11808.53,11808.53,1 through 10,other,11690.93,56733.59,Inpatient DRG
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],58696.00,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,55900.95,225294.39,Inpatient DRG
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, SECOND DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Laparoscopy Proctopexy Prolapse,CASE-45400,APC,45400,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15407.35,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14673.67,43541.27,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4787.78,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4787.78,20006.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,MODERATE",281,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11961.10,,"Case rate ($11,961.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11961.10,12559.16,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],40183.85,,of the excess amount.,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21005.48,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20005.22,74991.64,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",128473.68,128473.68,128473.68,1 through 10,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
HC Add 2nd/3rd Order Abd/Le,CASE-36248,APC,36248,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T8,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Fracture Phalanx/Phalanges Not Great Toe,CASE-28525,APC,28525,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],95067.22,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10249.47,96445.01,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31350.48,,"Fee schedule rate ($31,350.48). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10888.24,32825.17,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5003.96,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5003.96,21742.11,Inpatient DRG
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9140.11,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8704.87,25830.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Metatarsal Fracture Each|LEFT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11158.92,,"Fee schedule rate ($11,158.92). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg,CASE-29881,APC,29881,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",3012.17,3012.17,3012.17,1 through 10,other,3103.39,3258.56,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7049.08,,"Case rate ($6,713.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,646.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.73. The transfer capital threshold is the transfer adjustment factor * $475.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6724.11,19952.48,Inpatient DRG
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5224.00,,"Per diem ($5,224). If length of stay < 2.9, first 1 days paid at a per diem of $10,448 instead. Capped at $15,149.04.",,,,0,other,5224.00,15861.63,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],40987.53,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],45711.64,,,,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,Zero final payments for the item or service in the 15 months prior to posting the file.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, SECOND DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9441.04,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,27465.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12107.00,,"Per diem ($12,107). If length of stay < 2.8, first 1 days paid at a per diem of $24,214 instead. Capped at $33,900.69.",,,,0,other,11962.15,40923.09,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|SEPARATE STRUCTURE|PO,CASE-62323,APC,62323,CPT,0360,RC,,,XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16810.38,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16009.89,58554.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21451.50,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8940.00,63653.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11114.67,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7000.00,32980.62,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17268.22,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,16929.63,63934.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10767.45,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10556.32,32082.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST AND SHOCK,MAJOR",196,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],12515.63,,"Case rate ($11,919.65). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11919.65,12515.63,There are no additional notes associated with this service or procedure.
Fasciectomy Plantar Fascia Partial Spx|BILATERAL PROCEDURE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8856.72,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6972.00,26280.60,Inpatient DRG
Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT SIDE|PO,CASE-28160,APC,28160,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,APC,51102,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11814.94,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11814.94,44591.73,Inpatient DRG
Colon Ca Scrn Not Hi Rsk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6044.58,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7964.08,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33946.09,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14943.61,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14438.27,55762.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19363.31,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",19034.51,19034.51,19034.51,1 through 10,other,19363.31,79918.67,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|LEFT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO,CASE-27691,APC,27691,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],59833.15,,"Fee schedule rate ($59,833.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
Fth/Gft Fr W/Dir Clsr F/C/C/M/N/Ax/G/H/F 20 Cm/<|PO,CASE-15240,APC,15240,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.96,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.96,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Iphal Jt W/WO Int Fixj Ea Iphal Jt,CASE-26861,APC,26861,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20772.43,,"Fee schedule rate ($20,772.43). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8167.40,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7891.21,23415.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Malignant Lesion F/E/E/N/L >4.0 Cm,CASE-11646,APC,11646,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],22152.42,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9370.00,65732.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4870.41,,"Case rate ($4,870.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,514.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,060.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,001.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,517.21. The transfer operating threshold is the transfer adjustment factor * $4,514.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.19. The transfer capital threshold is the transfer adjustment factor * $353.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4870.41,14682.98,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11962.15,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11962.15,40923.09,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],62824.73,,,,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MAJOR",344,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],18428.21,,"Case rate ($17,550.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17550.68,18428.21,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",665.41,665.41,665.41,1 through 10,other,669.51,702.98,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7911.06,,"Case rate ($7,755.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,166.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,634.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,194.85. The transfer operating threshold is the transfer adjustment factor * $7,166.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.08. The transfer capital threshold is the transfer adjustment factor * $561.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7755.94,35520.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13446.23,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13446.23,39899.05,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE,CASE-29891,APC,29891,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18024.13,,,,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17370.86,,,,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
"OTHER ESOPHAGEAL DISORDERS,MODERATE",243,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10135.23,,"Case rate ($9,652.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9652.60,10135.23,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|RIGHT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
HC I&D Hematoma Seroma Fluid,CASE-10140,APC,10140,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],52607.24,,"Fee schedule rate ($52,607.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Add 2nd/3rd Order Abd/Le,CASE-36248,APC,36248,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5442.84,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5183.66,15743.06,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5349.54,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5094.80,15365.01,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28299,APC,28299,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB EXCEPT TOES,EXTREME",305,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],49871.06,,"Case rate ($49,871.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,49871.06,52364.61,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15979.02,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15218.11,45156.75,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
Arthrp Kne Condyle&Platu Medial&Lat Compartments|LEFT SIDE,CASE-27447,APC,27447,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",12363.12,12363.12,12363.12,1 through 10,other,12177.08,12785.93,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5683.66,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5683.66,16865.16,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
"MAJOR PANCREAS LIVER AND SHUNT PROCEDURES,MINOR",260,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],23044.93,,"Case rate ($23,044.93). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,23044.93,24197.18,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6324.70,,"Case rate ($6,023.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,598.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $426.85. The transfer capital threshold is the transfer adjustment factor * $426.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6033.12,17902.13,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13889.20,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13889.20,55846.16,Inpatient DRG
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|LEFT SIDE|PO,CASE-27675,APC,27675,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],93689.44,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10249.47,96445.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6698.65,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",6702.02,6702.02,6702.02,1 through 10,other,6472.13,19204.75,Inpatient DRG
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE,CASE-29891,APC,29891,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Metatarsal Fracture Each|LEFT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11260.52,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6953.00,35389.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Mal Lesion Trunk/Arm/Leg 3.1-4.0 Cm,CASE-11604,APC,11604,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27119.10,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,3295.00,53945.28,All Other Inpatient
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MODERATE",721,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10702.54,,"Case rate ($10,702.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10702.54,11237.67,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],31019.76,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31019.76,124854.72,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12604.80,,"Fee schedule rate ($12,604.80). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24585.00,,"Fee schedule rate ($24,585.00). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],35148.55,,"Fee schedule rate ($35,148.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12402.46,36801.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Unlisted Procedure, Nervous System",CASE-64999,APC,64999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",43833.42,43833.42,43833.42,1 through 10,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
"OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,MODERATE",663,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9839.31,,"Case rate ($9,370.77). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9370.77,9839.31,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO|UNUSUAL NON-OVERLAPPING SERVICE,CASE-14040,APC,14040,CPT,0360,RC,,,PO|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],31640.16,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,31019.76,124854.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7429.60,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6382.95,21300.35,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8898.95,,"Fee schedule rate ($8,898.95). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27304.54,,"Fee schedule rate ($27,304.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34528.24,,"Fee schedule rate ($34,528.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4665.10,,"Case rate ($4,442.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.41. The transfer capital threshold is the transfer adjustment factor * $321.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4442.95,13183.59,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
"HC ED Avulsion Nail Plate Single|LEFT FOOT, GREAT TOE|PO",CASE-11730,APC,11730,CPT,0450,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12317.68,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11901.14,35314.31,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5639.27,,"Case rate ($5,370.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,551.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.59. The transfer capital threshold is the transfer adjustment factor * $380.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5379.29,15961.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
"OTHER AFTERCARE AND CONVALESCENCE,EXTREME",862,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9280.97,,"Case rate ($9,280.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9280.97,9745.02,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvic/Le 1st Ord|LEFT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32758.27,,,,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15668.80,,,,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
Carpectomy All Bones Proximal Row,CASE-25215,APC,25215,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11441.93,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11055.00,49295.13,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9827.66,,"Case rate ($9,495.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,773.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,858.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $8,808.40. The transfer operating threshold is the transfer adjustment factor * $8,773.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.92. The transfer capital threshold is the transfer adjustment factor * $686.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9495.32,42131.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia|RIGHT SIDE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17445.45,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,17103.38,50750.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],8990.00,,"Per diem ($8,990). If length of stay < 6, first 1 days paid at a per diem of $17,980 instead. Capped at $53,939.67.",,,,0,other,8990.00,80069.53,Estimated amount calculated based on 5 day length of stay.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9070.48,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8442.00,28788.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Lateral Release|LEFT SIDE|PO,CASE-29873,APC,29873,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6693.37,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6230.00,21325.01,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|BILATERAL PROCEDURE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20705.40,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20005.22,74991.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7086.07,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6748.64,20025.28,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Thromb Mech Vein,CASE-37187,APC,37187,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ostc Prtl Exostc/Condylc Metar Head|LEFT SIDE|PO,CASE-28288,APC,28288,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21687.14,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20654.42,69402.59,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7543.08,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7543.08,29489.40,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16361.19,,"Fee schedule rate ($16,361.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit W Pta|LEFT SIDE,CASE-36902,APC,36902,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5587.20,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11863.29,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11298.37,44627.23,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9108.77,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8675.02,25741.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15845.32,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15090.78,44778.95,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],61972.71,,,,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11589.27,,"Case rate ($11,037.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.15. The transfer capital threshold is the transfer adjustment factor * $782.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11055.00,49295.13,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Suture Quadriceps/Hamstring Rupture Primary|RIGHT SIDE,CASE-27385,APC,27385,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10638.54,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10638.54,40729.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,48444.74,Estimated amount calculated based on 11 day length of stay.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,APC,45378,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",876.02,876.02,876.02,1 through 10,other,882.03,926.14,OPPS APC
"VERTIGO AND OTHER LABYRINTH DISORDERS,MODERATE",111,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3454.57,,"Case rate for a one day stay ($3,290.07). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3290.07,3454.57,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],34726.43,,"Case rate ($33,072.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,563.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,392.57. The transfer capital threshold is the transfer adjustment factor * $2,392.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,33072.79,98455.37,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34611.07,,"Fee schedule rate ($34,611.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12160.70,,"Case rate ($11,581.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,991.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.71. The transfer capital threshold is the transfer adjustment factor * $820.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11600.09,48814.14,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7916.21,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7648.51,27371.98,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24585.00,,"Fee schedule rate ($24,585.00). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],42577.42,,"Fee schedule rate ($42,577.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7328.68,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7184.98,21320.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12748.95,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12141.86,36028.59,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
HC Fem Pop Territory Plasty|RIGHT SIDE,CASE-37224,APC,37224,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],401.21,,,,,,0,other,401.21,421.27,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],98137.07,,,,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt,CASE-26531,APC,26531,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30013.33,,,,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Complete 5th Metatarsal Head,CASE-28113,APC,28113,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],34988.57,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,34988.57,110685.97,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33781.47,,,,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],45062.85,,"Fee schedule rate ($45,062.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],61348.24,,"Fee schedule rate ($61,348.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,There are no additional notes associated with this service or procedure.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11714.14,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11714.14,49460.19,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER GASTROENTERITIS NAUSEA AND VOMITING,MODERATE",249,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2534.25,,"Case rate for a one day stay ($2,534.25). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2534.25,2660.96,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],43128.06,,"Fee schedule rate ($43,128.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6225.29,,"Case rate ($5,928.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.30,18621.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12585.32,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,11986.02,54149.39,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9918.79,,"Fee schedule rate ($9,918.79). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8394.53,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8394.53,24909.11,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7035.25,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6700.24,30254.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,Zero final payments for the item or service in the 15 months prior to posting the file.
"Sesamoidectomy First Toe Spx|LEFT FOOT, GREAT TOE|PO",CASE-28315,APC,28315,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
HC Intro Cath Dialysis Circuit W Pta,CASE-36902,APC,36902,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5398.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12015.54,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6866.02,27153.67,All Other Inpatient
HC Peripheral Block - Femoral Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],104605.60,,"Fee schedule rate ($104,605.60). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MAJOR",140,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],12424.25,,"Case rate ($11,832.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11832.62,12424.25,There are no additional notes associated with this service or procedure.
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms|RIGHT SIDE,CASE-27696,APC,27696,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10325.19,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9833.51,45903.36,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10455.00,,"Per diem ($10,455). If length of stay < 6.6, first 1 days paid at a per diem of $20,910 instead. Capped at $69,000.38.",,,,0,other,10455.00,90889.11,Estimated amount calculated based on 7 day length of stay.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],38600.87,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,37843.99,139522.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
Rpr 1st Fem Hernia Any Age Incarcerated,CASE-49553,APC,49553,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,EXTREME",140,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],19861.94,,"Case rate ($19,861.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19861.94,20855.04,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30145.85,,"Fee schedule rate ($30,145.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level|RIGHT SIDE",CASE-64495,APC,64495,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16733.34,,"Fee schedule rate ($16,733.34). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4867.35,,"Case rate ($4,867.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.12. The transfer capital threshold is the transfer adjustment factor * $352.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4867.35,14442.92,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24849.04,,"Case rate ($23,665.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,848.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,677.04. The transfer capital threshold is the transfer adjustment factor * $1,677.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23703.48,110204.98,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],62002.23,,,,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
HC Add 2nd/3rd Order Abd/Le|RIGHT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],514.99,,"APC Price ($514.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,514.99,540.74,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Application Uniplane External Fixation System|PO,CASE-20690,APC,20690,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstrj Lesion Anus Extensive,CASE-46924,APC,46924,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10377.17,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10173.70,41194.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7828.37,,"Case rate ($7,455.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,699.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.33. The transfer capital threshold is the transfer adjustment factor * $528.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",50368.67,50368.67,50368.67,1 through 10,other,3295.00,37575.69,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17350.69,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16524.47,58465.86,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30103.84,,,,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE|PO,CASE-28322,APC,28322,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.5 Cm/<,CASE-11400,APC,11400,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],705.22,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,671.64,705.22,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38757.79,,,,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Nerve Repair W/Nerve Allograft First Strand|PO,CASE-64912,APC,64912,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8739.79,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8323.61,8739.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30630.71,,"Fee schedule rate ($30,630.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],25108.34,,"Case rate ($23,912.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,865.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,694.54. The transfer capital threshold is the transfer adjustment factor * $1,694.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23950.83,74869.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THUMB|PO",CASE-26735,APC,26735,CPT,0360,RC,,,FA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],67356.73,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],34386.65,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32749.19,97176.83,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19312.24,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8972.00,76376.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21316.71,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20301.63,84714.35,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7907.62,,"Case rate ($7,531.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,704.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.68. The transfer capital threshold is the transfer adjustment factor * $533.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7543.08,29489.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],6312.99,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,3607.42,11497.58,All Other Inpatient
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36247,APC,36247,CPT,0361,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6472.13,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6472.13,19204.75,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11043.42,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10826.88,32126.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33947.68,,"Fee schedule rate ($33,947.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($60,119.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],32201.56,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,31570.16,98176.71,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],37954.97,,,,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|ADJ,CASE-97605,APC,97605,CPT,0761,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],48120.10,,"Fee schedule rate ($48,120.10). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],50750.92,,,,,,0,other,3295.00,50750.92,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,APC,52332,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7759.92,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7759.92,35376.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5773.46,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5578.22,18148.00,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7736.54,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,33946.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Synovectomy Metatarsophalangeal Joint Each|LEFT FOOT, SECOND DIGIT",CASE-28072,APC,28072,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9703.25,,"Case rate ($9,241.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.86. The transfer capital threshold is the transfer adjustment factor * $654.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,27465.16,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7350.79,,"Case rate ($7,000.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.10. The transfer capital threshold is the transfer adjustment factor * $496.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7011.91,27304.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13495.32,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13230.71,39259.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rmvl/Revj Sling Stress Incontinence,CASE-57287,APC,57287,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3177.77,,"APC Price ($3,070.31). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion S/N/H/F/G 2.1-3.0 Cm,CASE-11623,APC,11623,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1605.02,1605.02,1605.02,1 through 10,other,1566.49,1644.81,OPPS APC
"HC Debrid,Bone,1st 20sqcm or Less",CASE-11044,APC,11044,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5256.94,,"Case rate ($5,006.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,625.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,093.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,644.42. The transfer operating threshold is the transfer adjustment factor * $4,625.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.19. The transfer capital threshold is the transfer adjustment factor * $362.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5006.61,14856.14,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent,CASE-36903,APC,36903,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10949.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33968.35,,"Fee schedule rate ($33,968.35). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14953.91,,"Case rate ($14,448.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,349.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,817.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,216.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,402.99. The transfer operating threshold is the transfer adjustment factor * $13,349.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,045.22. The transfer capital threshold is the transfer adjustment factor * $1,045.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6940.00,42872.25,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],43444.85,,,,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6474.12,19210.66,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
Rhinp Prim Complete Xtrnl Parts,CASE-30410,APC,30410,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MAJOR",710,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],37118.36,,"Case rate ($37,118.36). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,37118.36,38974.28,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5985.95,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5700.90,30872.02,Inpatient DRG
Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,CASE-26125,APC,26125,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],46638.59,,"Fee schedule rate ($46,638.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme,CASE-97605,APC,97605,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],196.96,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOLIC LIVER DISEASE,MAJOR",280,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],16361.13,,"Case rate ($15,582.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15582.03,16361.13,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12869.85,,"Fee schedule rate ($12,869.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6617.34,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5683.00,19635.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intravasc Lithotripsy|RIGHT SIDE,CASE-C9764,APC,C9764,CPT,0481,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",483.76,483.76,1301.76,1 through 10,other,838.89,880.84,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10318.40,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10318.40,10318.40,10318.40,1 through 10,other,9969.47,29582.40,Inpatient DRG
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],130347.93,,"Fee schedule rate ($130,347.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30254.51,130347.93,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],31570.16,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,31570.16,98176.71,Inpatient DRG
Tenodesis Long Tendon Biceps|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,APC,23430,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17461.77,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],41837.14,,"Fee schedule rate ($41,837.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,There are no additional notes associated with this service or procedure.
Cystourethroscopy With Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52204,APC,52204,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26540,APC,26540,CPT,0360,RC,,,F6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7807.09,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7543.08,29489.40,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],41837.14,,"Fee schedule rate ($41,837.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],42455.70,,"Fee schedule rate ($42,455.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10103.08,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5773.19,31196.82,All Other Inpatient
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",20981.55,20981.55,20981.55,1 through 10,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24413.25,,,,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4772.53,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4772.53,14161.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,APC,49594,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],52534.65,,"Fee schedule rate ($52,534.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10429.71,,"Case rate ($9,933.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.89. The transfer capital threshold is the transfer adjustment factor * $703.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9948.90,46199.76,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11593.40,,"Fee schedule rate ($11,593.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,2285.00,12138.74,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16156.34,,"Fee schedule rate ($16,156.34). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],873.59,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,873.59,917.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9202.78,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8764.55,32969.91,Inpatient DRG
"Synovectomy Metatarsophalangeal Joint Each|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-28072,APC,28072,CPT,0360,RC,,,XS|T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3258.56,3258.56,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis 20 Cm/<|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97597,APC,97597,CPT,0761,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13135.23,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13135.23,38976.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],133824.90,,"Fee schedule rate ($133,824.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,38916.28,133824.90,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7963.57,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7694.27,22831.22,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],14023.34,,"Fee schedule rate ($14,023.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4870.41,14682.98,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision/Curettage Cyst/Tumor Femur|LEFT SIDE,CASE-27355,APC,27355,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
Ostectomy Complete 5th Metatarsal Head|LEFT SIDE,CASE-28113,APC,28113,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MODERATE",720,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11912.19,,"Case rate ($11,344.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11344.94,11912.19,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],30028.95,,"Fee schedule rate ($30,028.95). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
HC Stent Place Initial Artery Ang,CASE-37236,APC,37236,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE|PO,CASE-24073,APC,24073,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15373.24,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14641.18,43444.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intra Lithotrip-Ather,CASE-C9766,APC,C9766,CPT,0481,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],131570.26,,,,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12275.48,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11690.93,56733.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],28696.16,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",27804.57,27804.57,27804.57,1 through 10,other,28696.16,118364.04,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23644.46,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23644.46,105789.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],69218.57,,"Case rate ($65,922.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,842.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,671.49. The transfer capital threshold is the transfer adjustment factor * $4,671.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",72483.27,72483.27,72483.27,1 through 10,other,66027.56,228732.31,Inpatient DRG
"AMPUTATION OF LOWER LIMB EXCEPT TOES,MODERATE",305,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],21103.09,,"Case rate ($20,098.18). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20098.18,21103.09,There are no additional notes associated with this service or procedure.
"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,MINOR",511,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6203.11,,"Case rate for a one day stay ($6,203.11). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,6203.11,6513.27,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],32389.95,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,18508.54,76171.92,All Other Inpatient
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17214.39,,"Fee schedule rate ($17,214.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],36405.02,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36405.02,110499.61,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16691.31,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15896.49,51306.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9581.25,,"Fee schedule rate ($9,581.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7143.87,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5843.00,27370.21,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE|PO,CASE-27524,APC,27524,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17161.77,,"Fee schedule rate ($17,161.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteoplasty Radius/Ulna Shortening|LEFT SIDE|PO,CASE-25390,APC,25390,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Debride Subq First 20 Sq Cm,CASE-11042,APC,11042,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",395.04,389.46,700.45,14,other,385.57,404.84,OPPS APC
HC Thromb Mech 1st Vssl,CASE-37184,APC,37184,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,APC,64585,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3481.74,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3315.94,3481.74,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8638.55,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8442.00,28788.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],110288.60,,"Fee schedule rate ($110,288.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,38916.28,133824.90,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Stent Place Initial Artery Ang,CASE-37236,APC,37236,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10949.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7457.21,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7102.10,21074.07,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Gastrocnemius Recession|RIGHT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13485.61,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,38110.41,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29521.40,,,,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open,CASE-24358,APC,24358,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],28916.65,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27539.67,109237.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16208.15,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16208.15,58123.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7952.22,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7952.22,25854.47,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10637.22,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10714.76,6033.73,53265.05,1 through 10,other,10637.22,31563.88,Inpatient DRG
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11607.75,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11055.00,49295.13,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17103.38,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17103.38,50750.92,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14534.42,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14534.42,59012.52,Inpatient DRG
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10282.48,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10080.86,33310.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB|PO",CASE-26418,APC,26418,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9430.32,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,45869.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],39831.40,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",40430.45,40430.45,40430.45,1 through 10,other,39831.40,138208.82,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",2002.41,2002.41,2002.41,1 through 10,other,1982.66,2081.79,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9151.96,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8716.15,25863.45,Inpatient DRG
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC 3rd Order Sel Abd/Lower Ext|RIGHT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14166.98,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",13813.59,13813.59,13813.59,1 through 10,other,13889.20,55846.16,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4257.29,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",4224.24,4224.24,4224.24,1 through 10,other,4257.29,12632.63,Inpatient DRG
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,APC,43248,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],890.35,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,860.25,903.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstrj Lesion Anus Extensive,CASE-46924,APC,46924,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32623.50,,"Fee schedule rate ($32,623.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MODERATE",140,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9273.58,,"Case rate ($8,831.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8831.98,9273.58,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Abdominal Wall Subq <3cm,CASE-22902,APC,22902,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5934.68,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],41225.50,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,39831.40,138208.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11717.77,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11159.78,39897.21,Inpatient DRG
Cystourethroscopy W/Dil Bladder General Anesth,CASE-52260,APC,52260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28195.14,,"Fee schedule rate ($28,195.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE,CASE-24073,APC,24073,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3899.35,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3843.64,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16193.10,,"Fee schedule rate ($16,193.10). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12029.98,,"Case rate ($11,623.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,490.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.89. The transfer capital threshold is the transfer adjustment factor * $842.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,35040.80,Inpatient DRG
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,EXTREME",191,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],29916.56,,"Case rate ($29,916.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,29916.56,31412.39,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6844.95,,"Fee schedule rate ($6,844.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
"OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,EXTREME",253,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],24434.73,,"Case rate ($24,434.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24434.73,25656.47,There are no additional notes associated with this service or procedure.
Osteotomy Radius Distal Third|LEFT SIDE|PO,CASE-25350,APC,25350,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],40046.00,,"Fee schedule rate ($40,046.00). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],3753.97,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",3753.97,3753.97,3753.97,1 through 10,other,3753.97,11139.15,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Iliac Territory Plasty Stent|LEFT SIDE,CASE-37221,APC,37221,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],444.96,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13572.00,,"Per diem ($13,572). If length of stay < 5.8, first 1 days paid at a per diem of $27,144 instead. Capped at $78,720.12.",,,,0,other,13572.00,108637.77,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],47329.09,,,,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MODERATE",191,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14755.89,,"Case rate ($14,755.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14755.89,15493.68,There are no additional notes associated with this service or procedure.
Ligj Divj & Stripping Short Saphenous Vein,CASE-37718,APC,37718,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Kne Condyle&Platu Medial&Lat Compartments|LEFT SIDE,CASE-27447,APC,27447,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",12363.12,12358.90,12363.12,1 through 10,other,12177.08,12785.93,OPPS APC
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,APC,31652,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3536.22,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm|PO,CASE-11421,APC,11421,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],695.15,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,695.15,705.22,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11674.21,,"Fee schedule rate ($11,674.21). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",6766.15,6766.15,6766.15,1 through 10,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
Excision Lesion Meniscus/Capsule Knee,CASE-27347,APC,27347,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein|RIGHT SIDE,CASE-37249,APC,37249,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5668.18,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5398.26,5668.18,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7209.32,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6866.02,27153.67,Inpatient DRG
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10886.39,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10367.99,37103.57,Inpatient DRG
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE,CASE-27691,APC,27691,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15069.40,,"Fee schedule rate ($15,069.40). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9456.85,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9456.85,28061.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4389.77,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4303.70,14124.38,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Axillary Lymphadenectomy Complete,CASE-38745,APC,38745,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27997.20,,"Fee schedule rate ($27,997.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
"DEPRESSIVE DISORDERS,MAJOR",751,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11304.88,,"Case rate ($11,304.88). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11304.88,11870.12,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6984.84,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6748.64,20025.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Transperineal Plmt Biodegradable Matrl 1/Mlt Njx,CASE-55874,APC,55874,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27753.50,,"Fee schedule rate ($27,753.50). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-23430,APC,23430,CPT,0360,RC,,,73,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct|SEPARATE STRUCTURE,CASE-43275,APC,43275,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],66141.13,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10105.00,120252.50,All Other Inpatient
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15547.45,,"Fee schedule rate ($15,547.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12521.78,,"Fee schedule rate ($12,521.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16208.15,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16208.15,58123.31,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12514.54,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12514.54,37134.43,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8147.92,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7759.92,35376.63,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26007.09,,,,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE|PO,CASE-28615,APC,28615,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8501.29,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6178.00,25225.91,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10145.17,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,30103.84,Inpatient DRG
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],25070.79,,"Case rate ($23,876.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,863.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,692.00. The transfer capital threshold is the transfer adjustment factor * $1,692.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23915.01,121205.60,Inpatient DRG
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5779.83,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5779.83,17150.47,Inpatient DRG
"OTHER PNEUMONIA,MAJOR",139,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13439.65,,"Case rate ($12,799.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12799.67,13439.65,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9165.43,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5237.39,15540.89,All Other Inpatient
Arthroscopy Knee Synovectomy 2/>Compartments|RIGHT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21616.16,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20885.18,80720.91,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5866.79,,"Case rate ($5,668.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,581.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.07. The transfer capital threshold is the transfer adjustment factor * $410.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5668.40,16903.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18579.92,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,30966.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|PO,CASE-64493,APC,64493,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12577.67,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11978.73,60588.60,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Interphalangeal Jt W/Prosthetic Ea,CASE-26536,APC,26536,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],29720.03,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13369.00,88188.38,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cystostomy Tube Change,CASE-51705,APC,51705,CPT,0761,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],26525.17,,of the excess amount.,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE|PO,CASE-64450,APC,64450,CPT,0450,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cv Cath Plac WO Port>5yr (Tun),CASE-36558,APC,36558,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12196.66,,"Fee schedule rate ($12,196.66). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16169.08,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15852.04,50518.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],66027.56,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,66027.56,228732.31,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
Laps Surg Gastrostomy W/O Constj Gstr Tube Spx,CASE-43653,APC,43653,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
Open Treatment Medial Malleolus Fracture|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27766,APC,27766,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14534.42,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14534.42,59012.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],24713.42,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,24713.42,73332.24,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28086.14,,"Fee schedule rate ($28,086.14). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",28209.62,28209.62,28209.62,1 through 10,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],99157.51,,"Fee schedule rate ($99,157.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",264544.55,264544.55,264544.55,1 through 10,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10597.94,,"Case rate ($10,093.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,886.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $715.24. The transfer capital threshold is the transfer adjustment factor * $715.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10109.37,38416.97,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8661.89,,"Fee schedule rate ($8,661.89). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6886.93,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6558.98,19462.52,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],43435.80,,"Fee schedule rate ($43,435.80). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5494.12,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5308.33,19857.20,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16536.43,,"Fee schedule rate ($16,536.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
Excision Tumor Soft Tis Foot/Toe Subq 1.5 Cm/>|RIGHT SIDE|PO,CASE-28039,APC,28039,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2851.46,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],126615.59,,,,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11710.82,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11710.82,34749.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18934.17,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,18562.91,73513.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6707.31,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6387.91,18954.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
HC Iliac Territory Plasty Stent|BILATERAL PROCEDURE,CASE-37221,APC,37221,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],460.53,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40774.00,,"Fee schedule rate ($40,774.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11958.84,40774.00,There are no additional notes associated with this service or procedure.
Laps Myomectomy Exc 1-4 Myomas 250 Gm/<,CASE-58545,APC,58545,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
Litholapaxy Smpl/Sm <2.5 Cm|SEPARATE STRUCTURE,CASE-52317,APC,52317,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4428.32,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4341.49,12882.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],27539.67,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27539.67,109237.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6393.28,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6088.84,18067.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],48103.65,,"Fee schedule rate ($48,103.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
Dstrj Lesion Anus Simple Laser Surg,CASE-46917,APC,46917,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7209.32,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6866.02,27153.67,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19750.58,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,19363.31,79918.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6195.72,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6074.24,18024.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32474.30,,"Fee schedule rate ($32,474.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4573.06,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4418.42,13110.79,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20697.52,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20697.52,87921.54,Inpatient DRG
Dcmprn Fasct Leg Post Compartment Only,CASE-27601,APC,27601,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arven Anast Opn Upr Arm Basilic Vein Trpos|LEFT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23628.41,,"Fee schedule rate ($23,628.41). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
Prostate Needle Biopsy Any Approach|SEPARATE STRUCTURE,CASE-55700,APC,55700,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,APC,58558,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",2951.75,2951.75,2951.75,1 through 10,other,3070.31,3223.82,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13527.41,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12883.25,44763.90,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5807.67,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5807.67,17233.12,Inpatient DRG
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],187121.90,,"Fee schedule rate ($187,121.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5923.06,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5923.06,17575.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10308.75,,"Case rate ($9,817.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,866.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.73. The transfer capital threshold is the transfer adjustment factor * $695.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9833.51,45903.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],59188.55,,"Fee schedule rate ($59,188.55). Adds an outlier to normal pricing equal to the per diem rate ($203,441.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6308.00,,"Per diem ($6,308). If length of stay < 3.3, first 1 days paid at a per diem of $12,616 instead. Capped at $20,817.01.",,,,0,other,6308.00,21796.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13061.00,,"Per diem ($13,061). If length of stay < 11, first 1 days paid at a per diem of $26,122 instead. Capped at $143,676.24.",,,,0,other,13061.00,162464.13,Estimated amount calculated based on 8 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1903.51,1903.51,1903.51,1 through 10,other,1852.10,1944.70,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20173.98,,"Case rate ($19,213.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,532.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.52. The transfer capital threshold is the transfer adjustment factor * $1,361.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19243.94,63510.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy With Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52204,APC,52204,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64418,APC,64418,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],81324.83,,"Fee schedule rate ($81,324.83). Adds an outlier to normal pricing equal to the per diem rate ($106,784.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-24341,APC,24341,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr,CASE-28238,APC,28238,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],20679.93,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20274.44,80940.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
Arthrodesis Iphal Jt W/WO Int Fixj Ea Iphal Jt,CASE-26861,APC,26861,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7197.84,,"Case rate ($6,855.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,656.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $485.78. The transfer capital threshold is the transfer adjustment factor * $485.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6866.02,27153.67,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC Revasc Intravasc Lithotripsy,CASE-C9764,APC,C9764,CPT,0481,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21570.21,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,21570.21,72041.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6150.94,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5942.94,17634.53,Inpatient DRG
"OTHER DISORDERS OF THE LIVER,EXTREME",283,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],28340.05,,"Case rate ($26,990.52). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,26990.52,28340.05,There are no additional notes associated with this service or procedure.
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,APC,67900,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2367.72,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12500.00,,"Per diem ($12,500). If length of stay < 4.8, first 1 days paid at a per diem of $25,000 instead. Capped at $60,002.29.",,,,0,other,12500.00,83592.64,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],62179.32,,,,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17469.78,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,17127.24,50821.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13061.00,,"Per diem ($13,061). If length of stay < 11, first 1 days paid at a per diem of $26,122 instead. Capped at $143,676.24.",,,,0,other,13061.00,162464.13,Estimated amount calculated based on 8 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5244.04,15804.57,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1964.61,679.50,1964.61,1 through 10,other,669.51,702.98,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26958.93,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,3295.00,55581.70,All Other Inpatient
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13423.13,,"Case rate ($12,783.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,077.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.91. The transfer capital threshold is the transfer adjustment factor * $905.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12804.31,55145.09,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,APC,11404,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14043.03,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14043.03,54637.47,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5779.83,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5779.83,17150.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],65538.71,,"Fee schedule rate ($65,538.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27135.21,,"Fee schedule rate ($27,135.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],92976.49,,"Fee schedule rate ($92,976.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.5), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10282.71,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9793.06,29058.99,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],36249.82,,"Fee schedule rate ($36,249.82). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23602.95,,"Fee schedule rate ($23,602.95). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|LEFT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],189.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5732.06,,"Case rate ($5,732.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,296.29, add-ons for qualifying new technology services are included. If operating cost exceeds $40,764.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,317.40. The transfer operating threshold is the transfer adjustment factor * $5,296.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.67. The transfer capital threshold is the transfer adjustment factor * $414.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5732.06,21720.81,Inpatient DRG
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE|PO,CASE-28300,APC,28300,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14438.27,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14438.27,55762.74,Inpatient DRG
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],58656.71,,"Fee schedule rate ($58,656.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Arthroscopy,CASE-29999,APC,29999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,APC,29807,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14398.00,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8227.43,27001.04,All Other Inpatient
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|BILATERAL PROCEDURE,CASE-37766,APC,37766,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],56476.93,,,,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],44924.67,,"Fee schedule rate ($44,924.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],46830.28,,"Fee schedule rate ($46,830.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8234.36,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8072.90,31159.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Kne Condyle&Platu Medial&Lat Compartments|RIGHT SIDE,CASE-27447,APC,27447,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],8558.00,,"Per diem ($8,558). If length of stay < 5.4, first 1 days paid at a per diem of $17,116 instead. Capped at $46,215.75.",,,,0,other,8558.00,48389.68,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7344.49,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",7361.33,3091.22,39227.82,1 through 10,other,7096.13,25801.23,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22317.90,,"Case rate ($21,255.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,677.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,506.21. The transfer capital threshold is the transfer adjustment factor * $1,506.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21289.03,76326.34,Inpatient DRG
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],46419.05,,of the excess amount. Final payment is multiplied by 175%.,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>|RIGHT SIDE,CASE-23071,APC,23071,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,APC,45381,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10349.85,,"Fee schedule rate ($10,349.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surgical Jejunostomy,CASE-44186,APC,44186,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],45834.02,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,45834.02,151120.97,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,APC,58260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4744.66,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4744.66,4981.90,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4303.70,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4303.70,14124.38,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",91750.42,91750.42,91750.42,1 through 10,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
HC Vasc Embolize Occlude Organ|BILATERAL PROCEDURE,CASE-37243,APC,37243,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12031.78,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11458.84,42820.42,Inpatient DRG
Rpr Aa Hernia Recr > 10 Cm Ncrc8/Strangulated,CASE-49618,APC,49618,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],208.80,,"APC Price ($201.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,201.74,211.83,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6324.70,,"Case rate ($6,023.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,598.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $426.85. The transfer capital threshold is the transfer adjustment factor * $426.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6324.70,6324.70,6324.70,1 through 10,other,6033.12,17902.13,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,XU|T6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14102.73,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14102.73,41847.08,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6350.00,,"Per diem ($6,350). If length of stay < 5, first 1 days paid at a per diem of $12,700 instead. Capped at $31,750.77.",,,,0,other,6350.00,33244.29,Estimated amount calculated based on 3 day length of stay.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],49647.79,,"Case rate ($47,283.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,591.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,420.62. The transfer capital threshold is the transfer adjustment factor * $3,420.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,47283.61,169615.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
Laps Myomectomy Exc 1-4 Myomas 250 Gm/<,CASE-58545,APC,58545,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7686.98,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7686.98,22809.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Ligamentous Reconstruction Knee Extra-Articular,CASE-27427,APC,27427,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],41756.39,,"Case rate ($39,767.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,989.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,818.10. The transfer capital threshold is the transfer adjustment factor * $2,818.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,39831.40,138208.82,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],40599.94,,"Fee schedule rate ($40,599.94). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,XU|50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],28503.56,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,27539.67,109237.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64418,APC,64418,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29997.59,,,,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],41712.94,,"Fee schedule rate ($41,712.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11428.81,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10884.58,32297.83,Inpatient DRG
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg,CASE-29881,APC,29881,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<|PO,CASE-11420,APC,11420,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1621.31,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6204.88,,"Case rate ($6,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,620.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.88. The transfer capital threshold is the transfer adjustment factor * $448.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6204.88,19589.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21950.25,,"Fee schedule rate ($21,950.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
HC Fem Pop Territory Plasty|LEFT SIDE,CASE-37224,APC,37224,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],415.25,,,,,,0,other,401.21,421.27,There are no additional notes associated with this service or procedure.
"INGUINAL FEMORAL AND UMBILICAL HERNIA PROCEDURES,MINOR",228,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12387.98,,"Case rate ($12,387.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12387.98,13007.38,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5618.09,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5507.93,20510.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12093.45,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12093.45,40067.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Subtalar|LEFT SIDE|PO,CASE-28725,APC,28725,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12333.46,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11916.39,58492.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31134.92,,,,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15507.88,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15507.89,15507.89,15507.89,1 through 10,other,15507.88,46016.63,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Prostate Needle Biopsy Any Approach,CASE-55700,APC,55700,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],120.13,,,,,,0,other,120.13,126.14,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6972.00,,"Per diem ($6,972). If length of stay < 3.6, first 1 days paid at a per diem of $13,944 instead. Capped at $25,099.93.",,,,0,other,6972.00,26280.60,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",26207.03,26207.03,26207.03,1 through 10,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16536.43,,"Fee schedule rate ($16,536.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,APC,45331,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE,CASE-27601,APC,27601,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",29946.65,29946.65,29946.65,1 through 10,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6833.56,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",6770.90,6770.90,6833.57,1 through 10,other,6699.57,24060.08,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],32495.79,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,31858.62,94534.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7742.63,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7590.81,32847.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31563.88,,,,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],47247.88,,"Fee schedule rate ($47,247.88). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],25658.60,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,24790.92,26030.46,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36620.12,,"Fee schedule rate ($36,620.12). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],48078.73,,"Fee schedule rate ($48,078.73). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22734.94,,"Fee schedule rate ($22,734.94). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12728.66,,"Case rate ($12,122.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,030.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $859.04. The transfer capital threshold is the transfer adjustment factor * $859.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12141.86,36028.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8716.15,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8716.15,25863.45,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
HC Fem Pop Territory Plasty|RIGHT SIDE,CASE-37224,APC,37224,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],401.21,,,,,,0,other,401.21,421.27,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12577.67,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11978.73,60588.60,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4742.02,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4742.02,14071.02,Inpatient DRG
"HEART FAILURE,MODERATE",194,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10043.84,,"Case rate ($9,565.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9565.56,10043.84,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6959.45,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6724.11,19952.48,Inpatient DRG
"HEART FAILURE,MODERATE",194,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9565.56,,"Case rate ($9,565.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9565.56,10043.84,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,APC,36245,CPT,0361,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8.76,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10353.04,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9860.04,30039.61,Inpatient DRG
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",72179.79,72179.79,72179.79,1 through 10,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11031.92,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9888.00,40658.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],64872.40,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,64872.40,212258.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],40252.28,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,38891.09,169197.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intravasc Lithotripsy,CASE-C9764,APC,C9764,CPT,0481,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],61868.44,,"Fee schedule rate ($61,868.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE,CASE-27698,APC,27698,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,APC,52318,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13126.10,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7500.63,22256.65,All Other Inpatient
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21012.19,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20301.63,84714.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Bimalleolar Ankle Fracture|RIGHT SIDE,CASE-27814,APC,27814,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7226.40,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],37975.33,,"Case rate ($36,166.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,734.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,562.92. The transfer capital threshold is the transfer adjustment factor * $2,562.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36224.65,128473.68,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],3787.79,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3607.42,11497.58,Inpatient DRG
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,APC,52352,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32876.47,,"Fee schedule rate ($32,876.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13912.44,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13249.94,40085.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26654.37,,"Fee schedule rate ($26,654.37). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|PO|LEFT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|PO|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5354.09,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5354.09,15887.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9637.19,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6531.00,35832.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14934.00,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14641.18,43444.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37225.17,,"Fee schedule rate ($37,225.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",71960.00,71960.00,71960.00,1 through 10,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17072.08,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16737.33,72192.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38728.27,,,,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Remove Retrievable Filter,CASE-37193,APC,37193,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3068.11,3068.11,3068.11,1 through 10,other,2994.77,3144.51,OPPS APC
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
HC Intrvasc US Noncoronary Addl|RIGHT SIDE,CASE-37253,APC,37253,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5587.20,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, SECOND DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6495.00,,"Per diem ($6,495). If length of stay < 3.5, first 1 days paid at a per diem of $12,990 instead. Capped at $22,732.01.",,,,0,other,6495.00,23801.30,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],86162.15,,"Fee schedule rate ($86,162.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THUMB|PO",CASE-26055,APC,26055,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6035.39,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5091.00,22010.11,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
Prq Skeletal Fix Carpo/Metacarpal Fx Dislc Thumb,CASE-26650,APC,26650,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19320.40,,"APC Price ($18,400.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,18400.38,19320.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8393.33,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8228.75,24417.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],30480.63,,"Case rate ($30,480.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,163.35, add-ons for qualifying new technology services are included. If operating cost exceeds $63,631.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,376.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,275.59. The transfer operating threshold is the transfer adjustment factor * $28,163.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,205.05. The transfer capital threshold is the transfer adjustment factor * $2,205.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",30199.83,30199.83,32206.09,1 through 10,other,30480.63,86382.02,Inpatient DRG
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,APC,49593,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6355.12,,"APC Price ($6,140.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6140.21,6447.22,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14271.69,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13789.07,57367.22,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],14023.34,,"Fee schedule rate ($14,023.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4870.41,14682.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14523.10,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13831.52,59770.39,Inpatient DRG
Rhytidectomy Neck W/Platysmal Tightening,CASE-15825,APC,15825,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],69977.32,,,,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30493.52,,"Fee schedule rate ($30,493.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",30149.53,30149.53,30149.53,1 through 10,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12364.41,,"Case rate ($12,121.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,200.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,668.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,048.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,245.03. The transfer operating threshold is the transfer adjustment factor * $11,200.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $876.93. The transfer capital threshold is the transfer adjustment factor * $876.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12121.97,35969.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10078.85,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9738.02,28895.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,APC,11404,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],29720.03,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13369.00,88188.38,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13228.06,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13228.06,39251.68,Inpatient DRG
HC Inj Tendon Sheath/Ligament|PO,CASE-20550,APC,20550,CPT,0510,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6328.22,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6328.22,27416.36,Inpatient DRG
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,MODERATE",174,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],32629.84,,"Case rate ($32,629.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,32629.84,34261.33,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6419.63,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6293.75,21908.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,APC,64585,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3481.74,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3315.94,3481.74,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14718.77,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14718.77,51765.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],96445.01,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10249.47,96445.01,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9202.78,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8764.55,32969.91,Inpatient DRG
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],890.35,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",57.07,57.07,57.07,1 through 10,other,860.25,903.26,OPPS APC
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE|PO,CASE-27691,APC,27691,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE|PO,CASE-24359,APC,24359,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5985.95,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5700.90,30872.02,Inpatient DRG
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],58602.56,,"Case rate ($55,811.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,126.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,955.03. The transfer capital threshold is the transfer adjustment factor * $3,955.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,55900.95,225294.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Fem Pop Terr Plasty and Stent,CASE-37226,APC,37226,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17026.45,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17026.45,50522.67,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20894.31,,"Fee schedule rate ($20,894.31). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|PO,CASE-64483,APC,64483,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12473.25,,,,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Revasc lithotrip tibi/perone,CASE-C9772,APC,C9772,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11496.76,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",17503.82,17503.82,17503.82,1 through 10,other,10949.29,11496.76,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],31112.60,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",31112.61,31112.61,31112.61,1 through 10,other,31112.60,92731.42,Inpatient DRG
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19635.68,,,,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14056.07,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9763.00,48626.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4295.38,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2285.00,12138.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6235.92,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.97,17858.70,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],50857.56,,"Fee schedule rate ($50,857.56). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,APC,58661,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5791.08,5791.08,5791.08,1 through 10,other,5733.99,6020.69,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],37994.32,,,,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11042.46,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,31658.33,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE,CASE-27654,APC,27654,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
"SKIN ULCERS,MAJOR",380,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14278.09,,"Case rate ($13,598.18). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14278.09,14278.09,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Pyeloplasty,CASE-50544,APC,50544,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Medial Malleolus Fracture|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27766,APC,27766,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6358.45,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6055.67,17969.04,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11106.00,,"Case rate ($10,888.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,437.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10888.24,32825.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14413.19,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",14413.19,14413.19,14413.19,1 through 10,other,14130.58,57770.11,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15016.36,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14508.56,59513.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cystostomy Cystotomy W/Drainage|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51040,APC,51040,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11184.66,,"Case rate ($10,652.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,925.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $754.84. The transfer capital threshold is the transfer adjustment factor * $754.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,31658.33,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE,CASE-29876,APC,29876,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28695.03,,"Fee schedule rate ($28,695.03).",,,,0,other,14182.35,53827.17,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Syndactylization Toes|BILATERAL PROCEDURE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],45156.75,,,,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
"Tenolysis Extensor Tendon Hand/Finger Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26445,APC,26445,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Arthro/shoul surg; w/spacer|PO,CASE-C9781,APC,C9781,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9430.87,,"Case rate ($8,981.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,671.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $657.72. The transfer capital threshold is the transfer adjustment factor * $657.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8981.78,27528.12,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],42577.42,,"Fee schedule rate ($42,577.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16333.88,,,,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,APC,57260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4910.73,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Lyr Clos Sc Tk Ext 7.6-12cm|SEPARATE STRUCTURE,CASE-12034,APC,12034,CPT,0450,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33771.02,,"Fee schedule rate ($33,771.02). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc,CASE-34421,APC,34421,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
Suture Quadriceps/Hamstring Rupture Primary|LEFT SIDE,CASE-27385,APC,27385,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18562.91,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18562.91,73513.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,76310.36,Estimated amount calculated based on 21 day length of stay.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13452.22,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7686.98,22809.58,All Other Inpatient
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9255.92,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,27465.16,Inpatient DRG
Ligation/Biopsy Temporal Artery|RIGHT SIDE,CASE-37609,APC,37609,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|RIGHT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10638.54,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10638.54,40729.62,Inpatient DRG
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15801.45,,"Fee schedule rate ($15,801.45). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5683.66,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5683.66,16865.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15340.19,,,,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7744.00,,"Case rate ($7,744). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,731.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $560.22. The transfer capital threshold is the transfer adjustment factor * $560.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7744.00,24853.45,Inpatient DRG
Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,CASE-21552,APC,21552,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7863.12,,"Case rate ($7,488.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7500.63,22256.65,Inpatient DRG
Ercp Remove Foreign Body/Stent Biliary/Panc Duct|SEPARATE STRUCTURE,CASE-43275,APC,43275,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14534.23,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12440.40,41073.77,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11298.37,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11298.37,44627.23,Inpatient DRG
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE|PO,CASE-29806,APC,29806,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],50916.88,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,50916.88,170142.20,Inpatient DRG
Osteotomy Radius Distal Third,CASE-25350,APC,25350,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Plmt Interstitial Dev Radiat Tx Prostate 1/Mult,CASE-55876,APC,55876,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1378.44,,"APC Price ($1,312.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1312.80,1378.44,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8856.72,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6972.00,26280.60,Inpatient DRG
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE,CASE-28200,APC,28200,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arven Anast Opn Upr Arm Basilic Vein Trpos|RIGHT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],66027.56,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,66027.56,228732.31,Inpatient DRG
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",3262.44,3262.44,3262.44,1 through 10,other,3343.33,3510.50,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24429.85,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23950.83,74869.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],134001.61,,"Fee schedule rate ($134,001.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
"OTHER PNEUMONIA,MAJOR",139,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12799.67,,"Case rate ($12,799.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12799.67,13439.65,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],14842.71,,"Fee schedule rate ($14,842.71). Adds an outlier to normal pricing equal to the per diem rate ($40,567.35) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|PO,CASE-64493,APC,64493,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",16789.10,16789.10,16789.10,1 through 10,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
Arthrodesis Subtalar|RIGHT SIDE,CASE-28725,APC,28725,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, SECOND DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Bladder Irrig Simple or Continuous,CASE-51700,APC,51700,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9758.87,,"Case rate ($9,294.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,829.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.62. The transfer capital threshold is the transfer adjustment factor * $658.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33447.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE,CASE-27601,APC,27601,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14727.04,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14438.27,55762.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms|RIGHT SIDE,CASE-27696,APC,27696,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9094.27,,"Case rate ($8,661.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,784.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $613.76. The transfer capital threshold is the transfer adjustment factor * $613.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8675.02,25741.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE,CASE-29876,APC,29876,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21282.78,,"Case rate ($20,269.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,607.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.35. The transfer capital threshold is the transfer adjustment factor * $1,436.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20301.63,84714.35,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15774.99,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15023.80,48104.19,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21474.76,,"Fee schedule rate ($21,474.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28157.55,,"Fee schedule rate ($28,157.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12167.07,36103.36,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Trigger Pt 1-2 Musc Grps|PO,CASE-20552,APC,20552,CPT,0510,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6010.58,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6010.58,17835.23,Inpatient DRG
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24282.18,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23125.89,68621.57,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],3871.34,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3209.85,10940.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5886.58,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5886.58,17467.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],38203.90,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,21830.80,85124.35,All Other Inpatient
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Back/Flank Subfascial 5 Cm/>,CASE-21933,APC,21933,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",2789.86,2789.86,2789.86,1 through 10,other,2755.03,2892.78,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12948.38,,"Fee schedule rate ($12,948.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13061.62,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5970.00,38757.79,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12342.01,,"Fee schedule rate ($12,342.01). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11717.77,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11159.78,39897.21,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC
Transection/Avulsion Oth Spinal Nrv Xdrl|PO,CASE-64772,APC,64772,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5497.08,,"Case rate ($5,389.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,996, add-ons for qualifying new technology services are included. If operating cost exceeds $45,541.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,038.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,998.47. The transfer operating threshold is the transfer adjustment factor * $4,996.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.82. The transfer capital threshold is the transfer adjustment factor * $390.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5389.29,16247.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14565.08,,"Fee schedule rate ($14,565.08). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
Prostate Needle Biopsy Any Approach|SEPARATE STRUCTURE,CASE-55700,APC,55700,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36103.36,,,,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T4,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT SIDE|PO,CASE-26111,APC,26111,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],67775.08,,"Fee schedule rate ($67,775.08). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],57534.77,,"Fee schedule rate ($57,534.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16854.96,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16524.47,58465.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17011.79,,"Fee schedule rate ($17,011.79). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST AND SHOCK,MAJOR",196,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11919.65,,"Case rate ($11,919.65). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11919.65,12515.63,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,EXTREME",282,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],33554.89,,"Case rate ($31,957.04). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31957.04,33554.89,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3934.69,,"Case rate ($3,747.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,436.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $265.55. The transfer capital threshold is the transfer adjustment factor * $265.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3753.29,11765.59,Inpatient DRG
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12482.98,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11888.55,35276.93,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8369.91,,"Case rate ($7,971.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,736.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.88. The transfer capital threshold is the transfer adjustment factor * $564.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7984.05,23691.11,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31323.82,,,,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],72742.07,,"Fee schedule rate ($72,742.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17387.37,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9935.64,29482.05,All Other Inpatient
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G > 4.0cm,CASE-11426,APC,11426,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula|RIGHT SIDE|PO,CASE-27641,APC,27641,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,APC,23430,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17212.32,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7231.00,,"Per diem ($7,231). If length of stay < 5.1, first 1 days paid at a per diem of $14,462 instead. Capped at $36,875.62.",,,,0,other,7231.00,38610.21,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rhinoplasty Primary W/Major Septal Repair|PO,CASE-30420,APC,30420,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11823.96,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11592.12,38954.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4660.32,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4568.94,13557.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10632.00,,"Per diem ($10,632). If length of stay < 6.4, first 1 days paid at a per diem of $21,264 instead. Capped at $68,043.82.",,,,0,other,10632.00,103714.29,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,CASE-49592,APC,49592,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,5934.68,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6350.00,,"Per diem ($6,350). If length of stay < 5, first 1 days paid at a per diem of $12,700 instead. Capped at $31,750.77.",,,,0,other,6350.00,33244.29,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5629.94,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8517.49,8517.49,8517.49,1 through 10,other,5629.94,16705.77,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,APC,64772,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10463.20,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10109.37,38416.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
Arthrotomy W/Meniscus Repair Knee,CASE-27403,APC,27403,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5233.26,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4984.06,19757.81,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],42671.03,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,40639.08,120588.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5486.88,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5379.29,15961.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8878.97,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8704.87,25830.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn,CASE-64415,APC,64415,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7409.15,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7056.33,28335.74,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,EXTREME",282,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],33554.89,,"Case rate ($31,957.04). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31957.04,33554.89,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21805.52,,"Fee schedule rate ($21,805.52). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7770.00,,"Per diem ($7,770). If length of stay < 5.1, first 1 days paid at a per diem of $15,540 instead. Capped at $39,628.80.",,,,0,other,7770.00,50313.90,Estimated amount calculated based on 6 day length of stay.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3182.49,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3074.87,3228.61,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE,CASE-27691,APC,27691,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, FIFTH DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15172.21,,"Case rate ($14,449.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,195.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.96. The transfer capital threshold is the transfer adjustment factor * $1,023.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14472.76,56135.46,Inpatient DRG
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7455.00,,"Per diem ($7,455). If length of stay < 6.8, first 1 days paid at a per diem of $14,910 instead. Capped at $50,692.24.",,,,0,other,7455.00,53076.74,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24177.55,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23703.48,110204.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5113.93,,"Case rate ($4,870.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,514.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,060.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,001.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,517.21. The transfer operating threshold is the transfer adjustment factor * $4,514.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.19. The transfer capital threshold is the transfer adjustment factor * $353.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4870.41,14682.98,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|PO,CASE-28090,APC,28090,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3885.36,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3753.97,11139.15,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],45128.69,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",43631.44,43631.44,43631.44,1 through 10,other,43602.60,153667.90,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12227.29,,,,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4734.64,,"Case rate ($4,734.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,389.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,934.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,991.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,391.29. The transfer operating threshold is the transfer adjustment factor * $4,389.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.35. The transfer capital threshold is the transfer adjustment factor * $343.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4734.64,14273.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Revision of Reconstructed Breast|RIGHT SIDE,CASE-19380,APC,19380,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6518.41,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27868.14,,"Fee schedule rate ($27,868.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18591.93,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,18227.38,54086.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|LEFT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"SKIN ULCERS,MODERATE",380,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9305.84,,"Case rate ($9,305.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9305.84,9771.13,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
Nerve Repair W/Nerve Allograft First Strand|PO,CASE-64912,APC,64912,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8739.79,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8323.61,8739.79,OPPS APC
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC
Exc Tumor Soft Tiss Back/Flank Subfascial 5 Cm/>,CASE-21933,APC,21933,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],65732.99,,,,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23652.30,,"Fee schedule rate ($23,652.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],40639.08,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,40639.08,120588.53,Inpatient DRG
Removal Implant Deep|PO,CASE-20680,APC,20680,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11757.91,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11757.91,34889.29,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4871.91,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4639.91,13771.19,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dil Bladder General Anesth,CASE-52260,APC,52260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5621.79,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5354.09,15887.21,Inpatient DRG
Split Agrft T/a/L 1st 100 Cm/&/1% Bdy Inft/Chld,CASE-15100,APC,15100,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2025.45,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2025.45,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5912.00,,"Per diem ($5,912). If length of stay < 2.4, first 1 days paid at a per diem of $11,824 instead. Capped at $14,188.72.",,,,0,other,5006.61,14856.14,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17410.58,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9948.90,46199.76,All Other Inpatient
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|LEFT FOOT, SECOND DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,T1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],28503.56,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,27539.67,109237.68,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],86382.02,,"Fee schedule rate ($86,382.02). Adds an outlier to normal pricing equal to the per diem rate ($147,722.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30480.63,86382.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Syndactylization Toes|RIGHT SIDE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15496.63,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,53945.28,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],3871.34,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3209.85,10940.41,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],20206.14,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19243.94,63510.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16271.46,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,53945.28,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24015.51,,"Case rate ($22,871.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,791.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,620.78. The transfer capital threshold is the transfer adjustment factor * $1,620.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22908.38,67976.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Circumcision Age >28 Days,CASE-54161,APC,54161,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23624.56,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23624.56,83038.88,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20283.05,,,,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4732.71,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4639.91,13771.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11188.67,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10810.31,32077.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14867.71,,"Case rate ($14,159.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,174.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,003.41. The transfer capital threshold is the transfer adjustment factor * $1,003.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",14867.71,14867.71,14867.71,1 through 10,other,7308.00,42083.20,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"CELLULITIS AND OTHER SKIN INFECTIONS,MODERATE",383,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8174.38,,"Case rate ($8,174.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8174.38,8583.10,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],38202.87,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",804243.26,804243.26,804243.26,1 through 10,other,36910.99,126842.57,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10903.13,,"Case rate ($10,383.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,906.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.84. The transfer capital threshold is the transfer adjustment factor * $735.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,30861.41,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13545.65,,,,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6293.75,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6293.75,21908.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, THIRD DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F7|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36556,APC,36556,CPT,0761,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",5407.54,5407.54,5407.54,1 through 10,other,5277.74,5541.62,OPPS APC
Gastrocnemius Recession|RIGHT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5428.23,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5169.74,15340.19,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13485.61,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,38110.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34528.24,,"Fee schedule rate ($34,528.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,APC,43275,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3784.78,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],23685.31,,"Case rate ($22,557.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,769.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.50. The transfer capital threshold is the transfer adjustment factor * $1,598.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22593.41,90908.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10057.24,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9860.04,30039.61,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],11137.18,,,,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",229.95,229.95,229.95,1 through 10,other,6882.29,7226.40,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30204.20,,,,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",43429.11,43429.11,43429.11,1 through 10,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13704.86,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13704.86,49911.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10536.15,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10034.43,29775.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
Rcnstj Angular Dfrm Toe Soft Tiss Px Only,CASE-28313,APC,28313,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4341.49,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4341.49,12882.53,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12546.24,,"Case rate ($12,121.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,200.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,668.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,048.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,245.03. The transfer operating threshold is the transfer adjustment factor * $11,200.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $876.93. The transfer capital threshold is the transfer adjustment factor * $876.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12121.97,35969.56,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14837.11,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14130.58,57770.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],65538.71,,"Fee schedule rate ($65,538.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5257.64,,"Case rate ($5,007.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,626.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,094.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,645.03. The transfer operating threshold is the transfer adjustment factor * $4,626.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.24. The transfer capital threshold is the transfer adjustment factor * $362.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5007.28,16142.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SMALL AND LARGE BOWEL PROCEDURES,MODERATE",223,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],20791.21,,"Case rate ($19,801.15). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19801.15,20791.21,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
Arthrodesis Subtalar|RIGHT SIDE,CASE-28725,APC,28725,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,30966.53,Estimated amount calculated based on 11 day length of stay.
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MODERATE",220,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],29362.70,,"Case rate ($27,964.48). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27964.48,29362.70,There are no additional notes associated with this service or procedure.
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE|PO,CASE-28300,APC,28300,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],125659.39,,"Fee schedule rate ($125,659.39). Adds an outlier to normal pricing equal to the per diem rate ($160,041.92) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17835.23,,,,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10311.96,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9820.91,29141.64,Inpatient DRG
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4341.49,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4341.49,12882.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",41164.47,41164.47,41164.47,1 through 10,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37423.05,,"Fee schedule rate ($37,423.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13305.64,39481.90,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7143.87,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5843.00,27370.21,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
Amp Mtcrpl W/Finger/Thumb W/WO Inteross Transfer,CASE-26910,APC,26910,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11997.84,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11592.12,38954.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16843.05,,"Fee schedule rate ($16,843.05). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Partial Nephrectomy|RIGHT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18893.86,,,,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",194148.22,194148.22,194148.22,1 through 10,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T8|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5442.84,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5183.66,15743.06,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16208.15,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",17420.39,17420.39,17420.39,1 through 10,other,16208.15,58123.31,Inpatient DRG
HC Sel Cath Abd/Pelvic/Le 1st Ord|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,APC,36245,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13.94,,,,,,0,other,13.28,13.94,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5826.99,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5827.00,5827.00,5827.00,1 through 10,other,5629.94,16705.77,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15187.25,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14673.67,43541.27,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4551.31,,"Case rate ($4,334.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,478.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.16. The transfer capital threshold is the transfer adjustment factor * $307.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4341.49,12882.53,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],61002.90,,"Fee schedule rate ($61,002.90). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Insert Ivc Filter,CASE-37191,APC,37191,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17995.51,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15023.80,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",14355.34,14355.34,14355.34,1 through 10,other,15023.80,48104.19,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22189.86,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21133.20,88801.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14641.18,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14641.18,43444.85,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24742.67,,"Case rate ($23,564.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,841.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,669.86. The transfer capital threshold is the transfer adjustment factor * $1,669.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23602.02,108295.22,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24045.51,,"Fee schedule rate ($24,045.51). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],40591.99,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,40591.99,115037.59,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4639.91,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4639.91,13771.19,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4179.80,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3980.76,11812.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AND UMBILICAL,MODERATE",227,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],18934.95,,"Case rate ($18,934.95). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,18934.95,19881.70,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12410.41,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12167.07,36103.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11354.75,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10970.77,32553.63,Inpatient DRG
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7867.48,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7601.43,23918.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Vasc Embolize Occlude Organ|BILATERAL PROCEDURE,CASE-37243,APC,37243,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp,CASE-27691,APC,27691,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],3941.67,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3753.97,11139.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE,CASE-28306,APC,28306,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12112.80,,"Fee schedule rate ($12,112.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27601.28,,"Fee schedule rate ($27,601.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13453.71,,"Case rate ($12,813.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,079.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.98. The transfer capital threshold is the transfer adjustment factor * $907.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12833.49,58980.57,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34561.80,,"Fee schedule rate ($34,561.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],40770.64,,"Case rate ($38,829.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,922.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,751.57. The transfer capital threshold is the transfer adjustment factor * $2,751.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,38891.09,169197.98,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],25459.44,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,25459.44,80806.10,Inpatient DRG
Proctosgmdsc Rgd Dx W/WO Collj Spec Br/Wa Spx,CASE-45300,APC,45300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FIFTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THUMB|PO",CASE-26055,APC,26055,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu,CASE-25260,APC,25260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6826.86,,"Fee schedule rate ($6,826.86). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8675.02,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8675.02,25741.45,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],72742.07,,"Fee schedule rate ($72,742.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10109.37,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10109.37,38416.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Inject Nerv Blck,Paravert Sympath|BILATERAL PROCEDURE|PO",CASE-64520,APC,64520,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13632.44,,"Fee schedule rate ($13,632.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4734.64,14273.70,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Intercost Sng|BILATERAL PROCEDURE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6934.75,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6700.24,30254.37,Inpatient DRG
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE|PO,CASE-28200,APC,28200,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25741.45,,,,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29382.86,,"Fee schedule rate ($29,382.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,APC,45385,CPT,0360,RC,,,PT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,APC,52601,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",4884.61,4884.61,4884.61,1 through 10,other,5085.49,5339.77,OPPS APC
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,APC,58552,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],30130.97,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,28696.16,118364.04,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5623.19,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5355.42,17067.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],36738.00,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,34988.57,110685.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10808.31,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,10808.31,46938.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],23710.17,,"Case rate ($22,908.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,828.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.25. The transfer capital threshold is the transfer adjustment factor * $1,657.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,22908.38,67976.16,Inpatient DRG
"HC Excis Nail Matrix Perm Rmvl|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-11750,APC,11750,CPT,0450,RC,,,XS|TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14508.56,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",57572.86,57572.86,57572.86,1 through 10,other,14508.56,59513.03,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],24785.70,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9242.00,76216.30,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,APC,58662,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT SIDE|PO,CASE-28297,APC,28297,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],45520.40,,"Fee schedule rate ($45,520.40). Adds an outlier to normal pricing equal to the per diem rate ($131,498.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE|PO,CASE-64450,APC,64450,CPT,0450,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8490.30,,"Fee schedule rate ($8,490.30). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26525,APC,26525,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13831.52,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13831.52,59770.39,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6219.21,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5923.06,17575.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13140.27,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12514.54,37134.43,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
Arthro/shoul surg; w/spacer,CASE-C9781,APC,C9781,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10163.42,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5807.67,17233.12,All Other Inpatient
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4574.91,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4574.91,13575.16,Inpatient DRG
Blepharoplasty Lower Eyelid|BILATERAL PROCEDURE,CASE-15820,APC,15820,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2333.89,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2254.97,2333.89,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10970.77,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10971.14,10971.14,10971.14,1 through 10,other,10970.77,32553.63,Inpatient DRG
HC I & D Simple,CASE-10060,APC,10060,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7024.05,,"Case rate ($6,689.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.05. The transfer capital threshold is the transfer adjustment factor * $474.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6700.24,30254.37,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],22595.47,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9370.00,65732.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
HC Intro Cath in Svc or Ivc|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36010,APC,36010,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
"ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,MINOR",198,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6365.99,,"Case rate ($6,365.99). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6365.99,6684.29,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6293.75,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6293.75,21908.95,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16156.34,,"Fee schedule rate ($16,156.34). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],66275.39,,"Fee schedule rate ($66,275.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7183.19,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6940.28,20593.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment of Ulnar Shaft Fracture,CASE-25545,APC,25545,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|LEFT SIDE,CASE-37765,APC,37765,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Malignant Lesion S/N/H/F/G 2.1-3.0 Cm,CASE-11623,APC,11623,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5648.25,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5379.29,15961.98,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],45520.40,,"Fee schedule rate ($45,520.40). Adds an outlier to normal pricing equal to the per diem rate ($131,498.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9312.29,,"Case rate ($9,312.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,604.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,072.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,638.62. The transfer operating threshold is the transfer adjustment factor * $8,604.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.67. The transfer capital threshold is the transfer adjustment factor * $673.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9312.29,27632.41,Inpatient DRG
Arthrodesis Iphal Jt W/WO Int Fixj Ea Iphal Jt,CASE-26861,APC,26861,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10669.04,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,31658.33,Inpatient DRG
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|RIGHT FOOT, SECOND DIGIT|PO",CASE-28092,APC,28092,CPT,0360,RC,,,T6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],36276.38,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36276.38,121107.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13230.71,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13230.71,39259.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10291.73,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10291.73,34803.35,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21697.80,,"Case rate ($20,664.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,635.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,464.36. The transfer capital threshold is the transfer adjustment factor * $1,464.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20697.52,87921.54,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11783.04,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11384.58,33781.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],34592.73,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,33422.93,112824.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5049.39,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5049.39,4994.26,5049.39,1 through 10,other,4878.64,14476.37,Inpatient DRG
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",13757.59,13757.59,13757.59,1 through 10,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5490.50,,"Case rate ($5,229.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,541.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $370.55. The transfer capital threshold is the transfer adjustment factor * $370.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5237.39,15540.89,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16705.77,,,,,,0,other,5450.78,16705.77,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Rescj Pelvic Tumor,CASE-52355,APC,52355,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],29129.85,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,29129.85,86437.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,MAJOR",443,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],3675.82,,"Case rate for a one day stay ($3,675.82). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3675.82,3859.61,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],107643.03,,,,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12585.32,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,11986.02,54149.39,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9910.44,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9910.44,43344.00,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10114.68,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10114.69,10114.69,10114.69,1 through 10,other,10114.68,30013.33,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7744.00,24853.45,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13937.68,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13664.39,40546.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],55272.09,,"Fee schedule rate ($55,272.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Revasc lithotrip tibi/perone|LEFT SIDE,CASE-C9772,APC,C9772,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20933.76,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11962.15,40923.09,All Other Inpatient
HC Extremity Venogram,CASE-36005,APC,36005,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1493.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1545.29,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13446.23,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13446.23,39899.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21372.40,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12212.80,39290.21,All Other Inpatient
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9448.23,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6531.00,35832.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],38756.54,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36910.99,126842.57,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],36287.40,,"Fee schedule rate ($36,287.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,70321.74,Estimated amount calculated based on 17 day length of stay.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],112882.03,,"Fee schedule rate ($112,882.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7574.18,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10290.40,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10290.40,42115.80,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14856.14,,,,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27304.54,,"Fee schedule rate ($27,304.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],47169.70,,,,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],42603.11,,"Case rate ($40,574.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,046.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,875.24. The transfer capital threshold is the transfer adjustment factor * $2,875.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",202319.69,42603.13,206108.03,1 through 10,other,40639.08,120588.53,Inpatient DRG
Dilation Esophagus Guide Wire,CASE-43453,APC,43453,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17018.56,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16208.15,58123.31,Inpatient DRG
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,APC,67900,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8638.80,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8227.43,27001.04,Inpatient DRG
HC Open/Perq Place Stent Ea Add A,CASE-37237,APC,37237,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10449.55,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10449.55,43409.67,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4878.64,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4878.64,14476.37,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29582.40,,,,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15717.99,,,,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30204.20,,,,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",10330.04,10330.04,10330.04,1 through 10,other,10082.05,10586.16,OPPS APC
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE|PO,CASE-24073,APC,24073,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO,CASE-62323,APC,62323,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,Zero final payments for the item or service in the 15 months prior to posting the file.
HC I & D Simple,CASE-10060,APC,10060,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9969.47,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9969.47,29582.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",9844.08,9844.08,9844.08,1 through 10,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,37575.69,Estimated amount calculated based on 11 day length of stay.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,30966.53,Estimated amount calculated based on 11 day length of stay.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16831.01,,"Fee schedule rate ($16,831.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14943.61,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14438.27,55762.74,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8618.40,,"Fee schedule rate ($8,618.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],37546.05,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,36276.38,121107.98,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10429.71,,"Case rate ($9,933.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.89. The transfer capital threshold is the transfer adjustment factor * $703.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9948.90,46199.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALFUNCTION REACTION COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE,MODERATE",206,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2918.25,,"Case rate for a one day stay ($2,779.29). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2779.29,2918.25,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10536.15,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10034.43,29775.24,Inpatient DRG
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4370.58,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,21715.49,Inpatient DRG
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, SECOND DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],183848.16,,"Fee schedule rate ($183,848.16). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
HC Debrid Wound Tis 20 Cm/<,CASE-97597,APC,97597,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],196.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",190.93,190.93,193.14,16,other,196.96,196.96,OPPS APC
HC Trigger Point 3 or More|LEFT SIDE|PO,CASE-20553,APC,20553,CPT,0510,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
Surgical Arthroscopy Shoulder Capsulorrhaphy|PO,CASE-29806,APC,29806,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Unlisted Procedure Abdomen Peritoneum & Omentum,CASE-49999,APC,49999,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-36901,APC,36901,CPT,0361,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1493.03,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],28005.17,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",27160.29,27160.29,27160.29,1 through 10,other,28005.17,115392.91,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24282.18,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23125.89,68621.57,Inpatient DRG
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10632.00,,"Per diem ($10,632). If length of stay < 6.4, first 1 days paid at a per diem of $21,264 instead. Capped at $68,043.82.",,,,0,other,10632.00,103714.29,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12791.07,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",12308.20,12308.20,12791.07,1 through 10,other,12791.07,43031.63,Inpatient DRG
Ostectomy Complete 1st Metatarsal Head,CASE-28111,APC,28111,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12943.20,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12326.86,53121.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",76522.05,76522.05,76522.05,1 through 10,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],38202.87,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,36910.99,126842.57,Inpatient DRG
"HC Unlisted Procedure, Nervous System",CASE-64999,APC,64999,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10053.63,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9574.89,28411.62,Inpatient DRG
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21254.28,,"Case rate ($20,242.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,605.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,434.43. The transfer capital threshold is the transfer adjustment factor * $1,434.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20274.44,80940.99,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4167.74,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4167.74,12366.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28299,APC,28299,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11593.40,,"Fee schedule rate ($11,593.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,2285.00,12138.74,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THIRD DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6707.31,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6387.91,18954.85,Inpatient DRG
HC Sleep Study Unattended,CASE-95800,APC,95800,CPT,0920,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],204.80,,"APC Price ($204.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",145.25,145.25,145.25,24,other,204.80,215.04,OPPS APC
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE|PO,CASE-64421,APC,64421,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE|PO,CASE-27680,APC,27680,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25019.31,,,,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28411.62,,,,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10605.39,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10605.39,31469.43,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, THUMB|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,FA|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
"DIABETES,EXTREME",420,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],24024.57,,"Case rate ($22,880.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22880.54,24024.57,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Radius Distal Third|RIGHT SIDE|PO,CASE-25350,APC,25350,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25332.30,,"Fee schedule rate ($25,332.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],37665.71,,,,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
Ostc Prtl Exostc/Condylc Metar Head|LEFT SIDE|PO,CASE-28288,APC,28288,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE|PO,CASE-28238,APC,28238,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6387.91,18954.85,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Application Uniplane External Fixation System|PO,CASE-20690,APC,20690,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,APC,38510,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,MAJOR",351,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12903.28,,"Case rate ($12,903.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12903.28,13548.44,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22230.95,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12500.00,83592.64,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],44704.18,,,,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8915.73,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8915.73,26455.73,Inpatient DRG
"TONSIL AND ADENOID PROCEDURES,MODERATE",097,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4758.14,,"Case rate for a one day stay ($4,531.56). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4531.56,4758.14,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],41888.70,,"Fee schedule rate ($41,888.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5614.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5814.92,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5700.90,30872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,30966.53,Estimated amount calculated based on 11 day length of stay.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11257.23,,"Case rate ($11,036.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,227.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,773.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,451.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $10,233.04. The transfer operating threshold is the transfer adjustment factor * $10,227.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $803.46. The transfer capital threshold is the transfer adjustment factor * $803.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11036.50,33262.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5968.38,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5766.55,17111.12,Inpatient DRG
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, THIRD DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE,CASE-28730,APC,28730,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19035.45,,"Fee schedule rate ($19,035.45). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13870.13,,"Case rate ($13,209.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,107.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.08. The transfer capital threshold is the transfer adjustment factor * $936.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13799.79,13799.79,13799.79,1 through 10,other,13230.71,39259.55,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14413.19,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,14130.58,57770.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9760.38,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,45869.64,Inpatient DRG
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19905.14,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,19232.02,68941.12,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9896.28,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9425.03,27966.92,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14813.49,,"Case rate ($14,108.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,170.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $999.75. The transfer capital threshold is the transfer adjustment factor * $999.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",15412.31,15412.31,15412.31,1 through 10,other,14130.58,57770.11,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26540,APC,26540,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15717.99,,,,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19155.70,,"Fee schedule rate ($19,155.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6654.93,20056.77,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7450.94,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7096.13,25801.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],130347.93,,"Fee schedule rate ($130,347.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30254.51,130347.93,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11962.15,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11962.15,40923.09,Inpatient DRG
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,APC,43248,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12006.70,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11434.95,119072.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],5146.14,,"Fee schedule rate ($5,146.14). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE|PO,CASE-29888,APC,29888,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5160.45,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5160.45,15312.64,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6953.28,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5520.00,26638.96,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],40916.35,,,,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10851.31,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10638.54,40729.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,APC,45331,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HYPERTENSION,MAJOR",199,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2730.29,,"Case rate for a one day stay ($2,600.28). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2600.28,2730.29,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis Addl 20 Cm<,CASE-97598,APC,97598,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms|LEFT SIDE|PO,CASE-27696,APC,27696,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6077.55,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6077.55,18033.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9011.55,,"Case rate ($8,582.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,942.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,410.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,974.25. The transfer operating threshold is the transfer adjustment factor * $7,942.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.18. The transfer capital threshold is the transfer adjustment factor * $608.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8596.11,25507.30,Inpatient DRG
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17877.77,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17026.45,50522.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE|PO,CASE-24073,APC,24073,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE,CASE-29880,APC,29880,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Intercost Sng|BILATERAL PROCEDURE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
HC Intro Cath Dialysis Circuit W Pta|LEFT SIDE,CASE-36902,APC,36902,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10538.94,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10037.09,36934.96,Inpatient DRG
Open Treatment Fracture Distal Tibia & Fibula|LEFT SIDE|PO,CASE-27828,APC,27828,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14523.10,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13831.52,59770.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17406.17,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16817.56,58510.23,Inpatient DRG
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],70963.13,,,,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],67175.58,,"Fee schedule rate ($67,175.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10353.04,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9860.04,30039.61,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],70037.75,,"Fee schedule rate ($70,037.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.9), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39078.16,,"Fee schedule rate ($39,078.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7694.27,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7694.27,22831.22,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12882.53,,,,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10569.94,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10362.69,29367.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],83871.28,,"Fee schedule rate ($83,871.28). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4772.53,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4772.53,14161.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY VASCULAR PROCEDURES,MODERATE",181,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],31027.29,,"Case rate ($31,027.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31027.29,32578.65,There are no additional notes associated with this service or procedure.
HC Repr Smp Not Face 2.6-7.5cm,CASE-12002,APC,12002,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],211.83,,"APC Price ($201.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,211.83,OPPS APC
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE|PO,CASE-64405,APC,64405,CPT,0450,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16222.26,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9269.86,37852.57,All Other Inpatient
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,APC,57260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4981.90,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,APC,52287,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5263.48,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6795.74,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6472.13,19204.75,Inpatient DRG
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, THIRD DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],23260.04,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9370.00,65732.99,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
Partial Excision Bone Tibia|LEFT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25622.07,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,14641.18,43444.85,All Other Inpatient
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28299,APC,28299,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11458.84,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11458.84,42820.42,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
Conv Prev Hip Tot Hip Arthrp W/WO Agrft/Algrft,CASE-27132,APC,27132,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12177.08,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29407.28,,,,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
"ALCOHOLIC LIVER DISEASE,EXTREME",280,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],32269.68,,"Case rate ($30,733.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30733.03,32269.68,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],70037.75,,"Fee schedule rate ($70,037.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.9), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],113934.44,,"Fee schedule rate ($113,934.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8764.55,32969.91,Zero final payments for the item or service in the 15 months prior to posting the file.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11698.23,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11698.23,34712.20,Inpatient DRG
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20697.52,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20697.52,87921.54,Inpatient DRG
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14062.94,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14062.94,61706.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14311.49,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13827.53,41030.48,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,APC,26080,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1578.51,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28847.26,,"Fee schedule rate ($28,847.26). Adds an outlier to normal pricing equal to the per diem rate ($89,320.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12212.80,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12212.80,39290.21,Inpatient DRG
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE|PO,CASE-29825,APC,29825,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4162.46,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,21715.49,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1772.59,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1688.18,1772.59,OPPS APC
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",12889.87,12889.87,12889.87,1 through 10,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],81718.58,,,,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7537.28,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6382.95,21300.35,Inpatient DRG
Partial Excision Bone Tibia|RIGHT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7968.80,,"Case rate ($7,589.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,708.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $537.81. The transfer capital threshold is the transfer adjustment factor * $537.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7601.43,23918.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5344.14,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5344.14,15857.69,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,APC,45381,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32297.83,,,,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],112882.03,,"Fee schedule rate ($112,882.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac W/Port Tun >5|RIGHT SIDE,CASE-36561,APC,36561,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17877.77,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17026.45,50522.67,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
Arteriovenous Anastomosis Open Direct,CASE-36821,APC,36821,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9456.85,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9456.85,28061.37,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn,CASE-64448,APC,64448,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],29358.62,,"Case rate ($27,960.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,152.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,981.38. The transfer capital threshold is the transfer adjustment factor * $1,981.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",28465.02,28465.02,29358.64,1 through 10,other,28005.17,115392.91,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28086.14,,"Fee schedule rate ($28,086.14). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39187.16,,"Fee schedule rate ($39,187.16). Adds an outlier to normal pricing equal to the per diem rate ($47,534.60) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],52092.32,,"Fee schedule rate ($52,092.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6684.75,,"Case rate ($6,553.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $6,086.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,276.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,494.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,073.77. The transfer operating threshold is the transfer adjustment factor * $6,086.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.91. The transfer capital threshold is the transfer adjustment factor * $479.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6553.68,20086.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",88401.35,88401.35,88401.35,1 through 10,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5263.66,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5160.45,15312.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],92045.07,,,,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6770.53,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6770.53,20090.22,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33771.02,,"Fee schedule rate ($33,771.02). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt,CASE-38570,APC,38570,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",627.87,627.87,627.87,1 through 10,other,5733.99,6020.69,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12093.45,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12093.45,40067.60,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11117.14,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10899.16,39746.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33987.79,,"Fee schedule rate ($33,987.79). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
Mastectomy Simple Complete|LEFT SIDE,CASE-19303,APC,19303,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",6356.97,6356.97,6356.97,1 through 10,other,6297.98,6612.88,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],39684.68,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10105.00,120252.50,Inpatient DRG
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",6715.77,6715.77,6715.77,1 through 10,other,6882.29,7226.40,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg,CASE-29881,APC,29881,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THUMB|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,FA|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6088.34,,"Case rate ($5,798.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.90. The transfer capital threshold is the transfer adjustment factor * $410.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6081.32,4054.42,26958.65,1 through 10,other,5807.67,17233.12,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|RIGHT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Tarsal Bones Oth/Thn Calcaneus/Talus|LEFT SIDE|PO,CASE-28304,APC,28304,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29912.98,,,,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Lig&Div Long Saph Vein Saphfem Junct/Interrupj|LEFT SIDE,CASE-37700,APC,37700,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22353.48,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21289.03,76326.34,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6816.94,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5520.00,26638.96,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER PNEUMONIA,MAJOR",139,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12799.67,,"Case rate ($12,799.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12799.67,13439.65,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5341.07,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5160.45,15312.64,Inpatient DRG
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE|PO,CASE-64624,APC,64624,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T3,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4639.34,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4418.42,13110.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",8050.60,8050.60,8050.60,1 through 10,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE,CASE-27822,APC,27822,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31161.99,,"Fee schedule rate ($31,161.99). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17026.45,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17026.45,50522.67,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8513.22,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8516.35,2626.39,8517.49,57,other,8513.22,25261.33,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28695.03,,"Fee schedule rate ($28,695.03).",,,,0,other,14182.35,53827.17,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,APC,49593,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6140.21,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6140.21,6447.22,OPPS APC
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MODERATE",220,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],29362.70,,"Case rate ($27,964.48). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27964.48,29362.70,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE,CASE-29875,APC,29875,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|TA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|LEFT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9637.19,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6531.00,35832.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10439.61,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10439.61,34540.67,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4887.21,,"Case rate ($4,654.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.72. The transfer capital threshold is the transfer adjustment factor * $336.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4654.49,13811.29,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],74873.19,,"Fee schedule rate ($74,873.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.6), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE,CASE-27691,APC,27691,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis 20 Cm/<|PBB CHARGE,CASE-97597,APC,97597,CPT,0761,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
Unlisted Procedure Femur/Knee,CASE-27599,APC,27599,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],245.65,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,233.96,245.65,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],27861.95,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27861.95,82674.88,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8027.40,,"Case rate ($7,755.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,166.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,634.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,194.85. The transfer operating threshold is the transfer adjustment factor * $7,166.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.08. The transfer capital threshold is the transfer adjustment factor * $561.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7755.94,35520.39,Inpatient DRG
HC Rmvl Perm Intraperitneal Cath,CASE-49422,APC,49422,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE|PO,CASE-64624,APC,64624,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6962.26,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6630.72,19989.86,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25389.98,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,14508.56,59513.03,All Other Inpatient
Rpr Aa Hernia 1st < 3 Cm Reducible,CASE-49591,APC,49591,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
Unlisted Procedure Femur/Knee|LEFT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],242.14,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,233.96,245.65,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|LEFT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC 3rd Order Sel Abd/Lower Ext|BILATERAL PROCEDURE,CASE-36247,APC,36247,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC
"SICKLE CELL ANEMIA CRISIS,MAJOR",662,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],15157.91,,"Case rate ($15,157.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15157.91,15915.81,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],82553.89,,"Fee schedule rate ($82,553.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6480.75,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6480.75,29542.64,Inpatient DRG
Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,CASE-49592,APC,49592,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,5934.68,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21013.65,,"Fee schedule rate ($21,013.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
Open Treatment of Ulnar Shaft Fracture|RIGHT SIDE|PO,CASE-25545,APC,25545,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Repr Smp Not Face 2.6-7.5cm,CASE-12002,APC,12002,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],208.80,,"APC Price ($201.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,211.83,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],183848.16,,"Fee schedule rate ($183,848.16). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9296.14,,"Case rate ($8,981.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,671.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $657.72. The transfer capital threshold is the transfer adjustment factor * $657.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8981.78,27528.12,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16175.36,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,55581.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Thromb Mech Vein,CASE-37187,APC,37187,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Metacarpal|LEFT SIDE|PO,CASE-26230,APC,26230,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30493.52,,"Fee schedule rate ($30,493.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4389.36,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4180.34,14351.57,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],62273.77,,,,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
"DIABETES,EXTREME",420,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],22880.54,,"Case rate ($22,880.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22880.54,24024.57,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],32106.67,,"Case rate ($30,577.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,338.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,166.85. The transfer capital threshold is the transfer adjustment factor * $2,166.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30626.53,106200.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16156.34,,"Fee schedule rate ($16,156.34). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],110217.19,,"Fee schedule rate ($110,217.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36028.59,,,,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",16041.00,16041.00,16041.00,1 through 10,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7984.05,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7984.05,33319.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|PO,CASE-12032,APC,12032,CPT,0450,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],86795.47,,"Fee schedule rate ($86,795.47). Adds an outlier to normal pricing equal to the per diem rate ($211,362.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",86436.95,86436.95,86436.95,1 through 10,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],103171.69,,"Fee schedule rate ($103,171.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE,CASE-27650,APC,27650,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14063.72,,"Case rate ($13,588.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,555.10, add-ons for qualifying new technology services are included. If operating cost exceeds $48,023.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,154.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,605.14. The transfer operating threshold is the transfer adjustment factor * $12,555.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $983.00. The transfer capital threshold is the transfer adjustment factor * $983.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13588.14,40320.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MAJOR",721,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],18480.43,,"Case rate ($17,600.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17600.41,18480.43,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],49033.12,,,,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],65538.71,,"Fee schedule rate ($65,538.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21894.53,,"Case rate ($20,851.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,648.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,477.64. The transfer capital threshold is the transfer adjustment factor * $1,477.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20885.18,80720.91,Inpatient DRG
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB|PO",CASE-26540,APC,26540,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34528.24,,"Fee schedule rate ($34,528.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10455.00,,"Per diem ($10,455). If length of stay < 6.6, first 1 days paid at a per diem of $20,910 instead. Capped at $69,000.38.",,,,0,other,10455.00,90889.11,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],49664.75,,,,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
HC Excis Nail Matrix Perm Rmvl|PO,CASE-11750,APC,11750,CPT,0450,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8072.90,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8072.90,31159.55,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12947.45,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",12411.21,12411.21,12411.21,1 through 10,other,12693.58,46577.81,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12470.75,,"Case rate ($11,876.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,012.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $841.64. The transfer capital threshold is the transfer adjustment factor * $841.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13086.22,13086.22,13086.22,1 through 10,other,11895.84,35298.57,Inpatient DRG
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,APC,43236,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MAJOR",425,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2623.28,,"Case rate for a one day stay ($2,498.36). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2498.36,2623.28,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],68332.92,,of the excess amount. Final payment is multiplied by 105%.,15449.25,15449.25,15449.25,1 through 10,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8925.03,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8925.03,26628.31,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32876.47,,"Fee schedule rate ($32,876.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33733.44,,"Fee schedule rate ($33,733.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19635.68,,,,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16721.04,,"Case rate ($15,924.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,299.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,128.49. The transfer capital threshold is the transfer adjustment factor * $1,128.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15950.19,63458.56,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34759.42,,,,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25255.45,,"Fee schedule rate ($25,255.45). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],63708.79,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,36405.02,110499.61,All Other Inpatient
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11134.07,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10915.75,32390.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,MODERATE",513,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],16568.43,,"Case rate ($16,568.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,16568.43,17396.85,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16208.15,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16208.15,58123.31,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22353.48,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21289.03,76326.34,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29765.40,,"Fee schedule rate ($29,765.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",665.41,665.41,665.41,1 through 10,other,669.51,702.98,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34353.60,,"Fee schedule rate ($34,353.60). Adds an outlier to normal pricing equal to the per diem rate ($257,654.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],85150.25,,,,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
"OTHER BACK AND NECK DISORDERS FRACTURES AND INJURIES,MAJOR",347,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],16050.71,,"Case rate ($15,286.39). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15286.39,16050.71,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13038.68,,"Fee schedule rate ($13,038.68). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6654.93,,"Case rate ($6,654.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,167.40, add-ons for qualifying new technology services are included. If operating cost exceeds $46,712.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,132.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,170.45. The transfer operating threshold is the transfer adjustment factor * $6,167.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.48. The transfer capital threshold is the transfer adjustment factor * $484.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6654.93,20056.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|LEFT SIDE|PO,CASE-29884,APC,29884,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21830.80,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21830.80,85124.35,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5732.06,,"Case rate ($5,732.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,296.29, add-ons for qualifying new technology services are included. If operating cost exceeds $40,764.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,317.40. The transfer operating threshold is the transfer adjustment factor * $5,296.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.67. The transfer capital threshold is the transfer adjustment factor * $414.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5732.06,21720.81,Inpatient DRG
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],134001.61,,"Fee schedule rate ($134,001.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],9763.00,,"Per diem ($9,763). If length of stay < 4, first 1 days paid at a per diem of $19,526 instead. Capped at $39,053.73.",,,,0,other,9763.00,48626.00,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE|POLICY CRITERIA APPLIED,CASE-27570,APC,27570,CPT,0360,RC,,,RT|CG,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],3787.79,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3607.42,11497.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36028.59,,,,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|ADJ|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3228.61,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3074.87,3228.61,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],67008.32,,"Fee schedule rate ($67,008.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Removal FB Skin|PO,CASE-10120,APC,10120,CPT,0450,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8143.74,,"Case rate ($7,755.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,166.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,634.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,194.85. The transfer operating threshold is the transfer adjustment factor * $7,166.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.08. The transfer capital threshold is the transfer adjustment factor * $561.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7755.94,35520.39,Inpatient DRG
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,APC,52351,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
Arven Anast Opn Upr Arm Basilic Vein Trpos|RIGHT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE|PO,CASE-24342,APC,24342,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,MINOR",361,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3987.92,,"Case rate for a one day stay ($3,798.02). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3798.02,3987.92,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,APC,52287,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10500.25,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,30103.84,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7275.69,,"Case rate ($6,929.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.03. The transfer capital threshold is the transfer adjustment factor * $491.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6940.28,20593.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],48720.85,,"Fee schedule rate ($48,720.85). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14887.17,,"Case rate ($14,178.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.72. The transfer capital threshold is the transfer adjustment factor * $1,004.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",120898.23,120898.23,120898.23,1 through 10,other,7453.00,42138.30,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8778.18,,"Fee schedule rate ($8,778.18). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12755.09,,"Case rate ($12,147.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.83. The transfer capital threshold is the transfer adjustment factor * $860.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12167.07,36103.36,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],23260.04,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9370.00,65732.99,Inpatient DRG
Removal Non-Biodegradable Drug Delivery Implant|LEFT SIDE,CASE-11982,APC,11982,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,5733.99,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5183.66,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5183.66,15743.06,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13979.96,,"Case rate ($13,314.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,114.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $943.49. The transfer capital threshold is the transfer adjustment factor * $943.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13608.90,13608.90,41645.04,1 through 10,other,13335.48,39570.45,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf|LEFT SIDE,CASE-36825,APC,36825,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10605.39,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10605.39,31469.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, THIRD DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26297.04,,"Fee schedule rate ($26,297.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,9279.13,27534.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41030.48,,,,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11170.47,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10638.54,40729.62,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21119.68,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,17274.00,73717.28,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],14651.02,,"Fee schedule rate ($14,651.02). Adds an outlier to normal pricing equal to the per diem rate ($61,007.55) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26357,APC,26357,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],144298.29,,"Fee schedule rate ($144,298.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],67008.32,,"Fee schedule rate ($67,008.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
Open Treatment Talus Fracture|RIGHT SIDE,CASE-28445,APC,28445,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16066.89,,"Case rate ($15,301.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,255.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,084.34. The transfer capital threshold is the transfer adjustment factor * $1,084.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",16145.02,16145.02,16145.02,1 through 10,other,15326.20,52511.19,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24233.69,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23758.52,103116.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE|PO,CASE-25609,APC,25609,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8431.66,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8431.66,25019.31,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],47283.61,,"Case rate ($47,283.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,591.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,420.62. The transfer capital threshold is the transfer adjustment factor * $3,420.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,47283.61,169615.07,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24766.30,,"Case rate ($23,586.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,842.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,671.45. The transfer capital threshold is the transfer adjustment factor * $1,671.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23624.56,83038.88,Inpatient DRG
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
Rmvl/Revj Sling Stress Incontinence,CASE-57287,APC,57287,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3070.31,,"APC Price ($3,070.31). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],27851.43,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],68265.75,,"Fee schedule rate ($68,265.75). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
"HC Debrid,Musc/Fasc,Ea Add 20sqcm",CASE-11046,APC,11046,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],700.99,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,700.99,736.04,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21872.86,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,21133.20,88801.87,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7096.13,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7096.13,25801.23,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25225.91,,,,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9777.90,,"Case rate ($9,312.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,604.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,072.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,638.62. The transfer operating threshold is the transfer adjustment factor * $8,604.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.67. The transfer capital threshold is the transfer adjustment factor * $673.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9312.29,27632.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16153.20,,"Fee schedule rate ($16,153.20). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],144298.29,,"Fee schedule rate ($144,298.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciotomy Foot&/Toe|LEFT SIDE,CASE-28008,APC,28008,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7354.14,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7003.94,20782.85,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10048.06,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9569.58,41116.55,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21005.48,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20005.22,74991.64,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|LEFT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9292.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16361.19,,"Fee schedule rate ($16,361.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT SIDE|PO,CASE-26540,APC,26540,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],31074.42,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,29594.69,124146.55,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32093.19,,,,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO,CASE-27691,APC,27691,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MAJOR",191,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],20464.83,,"Case rate ($19,490.31). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19490.31,20464.83,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],89469.71,,"Fee schedule rate ($89,469.71). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],189550.75,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,185834.07,195125.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4325.32,,"Case rate ($4,119.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,806.17, add-ons for qualifying new technology services are included. If operating cost exceeds $39,274.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,821.34. The transfer operating threshold is the transfer adjustment factor * $3,806.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.00. The transfer capital threshold is the transfer adjustment factor * $298.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4119.35,12223.35,Inpatient DRG
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5389.29,,"Case rate ($5,389.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,996, add-ons for qualifying new technology services are included. If operating cost exceeds $45,541.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,038.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,998.47. The transfer operating threshold is the transfer adjustment factor * $4,996.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.82. The transfer capital threshold is the transfer adjustment factor * $390.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5389.29,16247.30,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],29358.62,,"Case rate ($27,960.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,152.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,981.38. The transfer capital threshold is the transfer adjustment factor * $1,981.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,28005.17,115392.91,Inpatient DRG
HC Extremity Venogram|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9913.38,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9913.38,10409.05,OPPS APC
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11022.49,,"Fee schedule rate ($11,022.49). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27741.07,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,15852.04,50518.01,All Other Inpatient
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],35148.55,,"Fee schedule rate ($35,148.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12402.46,36801.89,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23582.79,,"Case rate ($23,582.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,789.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,257.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,877.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,876.75. The transfer operating threshold is the transfer adjustment factor * $21,789.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,706.04. The transfer capital threshold is the transfer adjustment factor * $1,706.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",59986.08,59986.08,59986.08,1 through 10,other,23582.79,75543.62,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],81177.46,,,,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7257.26,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7257.26,23445.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,APC,52332,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",95905.87,95905.87,95905.87,1 through 10,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
"MAJOR RESPIRATORY AND CHEST PROCEDURES,EXTREME",120,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],75465.15,,"Case rate ($71,871.57). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $52,189, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,71871.57,75465.15,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
HC Excis Nail Matrix Perm Rmvl|PO,CASE-11750,APC,11750,CPT,0450,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40774.00,,"Fee schedule rate ($40,774.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11958.84,40774.00,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],22908.38,,"Case rate ($22,908.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,828.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.25. The transfer capital threshold is the transfer adjustment factor * $1,657.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9247.31,9247.31,9247.31,1 through 10,other,22908.38,67976.16,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($60,119.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation|RIGHT SIDE|PO,CASE-28615,APC,28615,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
Rhinoplasty Secondary Intermediate Revision|PO,CASE-30435,APC,30435,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5811.28,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
"Inject Nerv Blck,Paravert Sympath|PO",CASE-64520,APC,64520,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34889.29,,,,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20005.22,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20005.22,74991.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4971.37,,"Case rate ($4,734.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,389.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,934.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,991.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,391.29. The transfer operating threshold is the transfer adjustment factor * $4,389.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.35. The transfer capital threshold is the transfer adjustment factor * $343.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4734.64,14273.70,Inpatient DRG
Laparoscopy Surg Pyeloplasty,CASE-50544,APC,50544,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18915.50,,,,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",64309.54,64309.54,64309.54,1 through 10,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12788.64,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12179.66,36140.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],40016.22,,"Fee schedule rate ($40,016.22). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11978.73,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11978.73,60588.60,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy US Scope W/Adj Strxrs|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43237,APC,43237,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8814.26,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8394.53,24909.11,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],9763.00,,"Per diem ($9,763). If length of stay < 4, first 1 days paid at a per diem of $19,526 instead. Capped at $39,053.73.",,,,0,other,9763.00,48626.00,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10747.83,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10236.03,30589.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11747.40,,"Fee schedule rate ($11,747.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
"Correction Hammertoe|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,XU|T6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6910.06,20832.04,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11945.04,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11710.82,34749.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12803.67,,"Fee schedule rate ($12,803.67). Adds an outlier to normal pricing equal to the per diem rate ($91,038.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18934.17,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,18562.91,73513.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12952.55,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12514.54,37134.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],89469.71,,"Fee schedule rate ($89,469.71). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
Excision Ganglion Wrist Dorsal/Volar Primary|LEFT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12861.93,,"Fee schedule rate ($12,861.93). Adds an outlier to normal pricing equal to the per diem rate ($47,786.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Dx Collection Specimen Brushing/Washing|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43260,APC,43260,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9774.43,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33447.35,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
HC Revasc Intravasc Lithotripsy|RIGHT SIDE,CASE-C9764,APC,C9764,CPT,0481,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26291.41,,"Fee schedule rate ($26,291.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,8981.78,27528.12,There are no additional notes associated with this service or procedure.
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29265.60,,"Fee schedule rate ($29,265.60). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
Excision Ganglion Wrist Dorsal/Volar Primary|LEFT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rhinp Prim Complete Xtrnl Parts,CASE-30410,APC,30410,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19243.94,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19243.94,63510.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4654.49,,"Case rate ($4,654.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.72. The transfer capital threshold is the transfer adjustment factor * $336.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4654.49,13811.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12140.54,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12140.54,36024.65,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],107249.77,,"Fee schedule rate ($107,249.77). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28695.03,,"Fee schedule rate ($28,695.03).",,,,0,other,14182.35,53827.17,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],28467.39,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8232.00,84471.39,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
"RENAL DIALYSIS ACCESS DEVICE PROCEDURES,EXTREME",444,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],51999.07,,"Case rate ($49,522.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,49522.92,51999.07,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17622.72,,,,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],33563.25,,"Fee schedule rate ($33,563.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20938.30,,,,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8638.55,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8442.00,28788.33,Inpatient DRG
"OTHER SMALL AND LARGE BOWEL PROCEDURES,MODERATE",223,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],20791.21,,"Case rate ($19,801.15). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19801.15,20791.21,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11905.90,,"Fee schedule rate ($11,905.90). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
Rpr Tdn/Musc Xtnsr F/Arm&/Wrist Prim 1 Ea Tdn|LEFT SIDE|PO,CASE-25270,APC,25270,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11934.78,,"Case rate ($11,366.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,976.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $805.47. The transfer capital threshold is the transfer adjustment factor * $805.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11384.58,33781.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13137.86,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12693.58,46577.81,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13248.91,,"Fee schedule rate ($13,248.91). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
Arthrt Elbow Capsular Excision Capsular Rls Spx|LEFT SIDE|PO,CASE-24006,APC,24006,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE|PO,CASE-15823,APC,15823,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11610.07,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5605.96,5605.96,5605.96,1 through 10,other,11217.46,37366.25,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],47660.93,,"Fee schedule rate ($47,660.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],79366.60,,"Fee schedule rate ($79,366.60). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
Curtg/Caut Anal Fissure W/Dilat Sphnctr Spx 1st,CASE-46940,APC,46940,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|LEFT SIDE,CASE-37225,APC,37225,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],538.93,,,,,,0,other,538.93,557.79,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7086.07,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6748.64,20025.28,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Interdigital Morton Neuroma Single Each|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DEPRESSIVE DISORDERS,MAJOR",751,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11304.88,,"Case rate ($11,304.88). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11304.88,11870.12,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14703.15,,"Fee schedule rate ($14,703.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10769.77,,"Fee schedule rate ($10,769.77). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18931.96,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10818.26,38164.94,All Other Inpatient
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19204.75,,,,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],35199.47,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,17274.00,73717.28,All Other Inpatient
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17927.62,,"Fee schedule rate ($17,927.62). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|RIGHT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],135336.44,,,,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],20478.39,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19503.23,57872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13594.35,,"Fee schedule rate ($13,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23338.10,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23338.10,69251.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8134.95,,"Case rate ($7,747.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.02. The transfer capital threshold is the transfer adjustment factor * $549.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7759.92,35376.63,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],45089.10,,"Fee schedule rate ($45,089.10). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
Laparoscopy Enterolysis Separate Procedure,CASE-44180,APC,44180,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CELLULITIS AND OTHER SKIN INFECTIONS,MODERATE",383,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8583.10,,"Case rate ($8,174.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8174.38,8583.10,There are no additional notes associated with this service or procedure.
Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT SIDE|PO,CASE-28160,APC,28160,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],99176.02,,,,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],88188.38,,,,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17056.02,,,,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13826.01,,"Fee schedule rate ($13,826.01). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7840.72,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7686.98,22809.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17776.11,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,16929.63,63934.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT SIDE|PO,CASE-28160,APC,28160,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"DIABETES,MAJOR",420,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12437.72,,"Case rate ($12,437.72). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12437.72,13059.61,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],24417.19,,,,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12514.54,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12514.54,37134.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33242.94,,"Fee schedule rate ($33,242.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11730.05,61348.24,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],59188.55,,"Fee schedule rate ($59,188.55). Adds an outlier to normal pricing equal to the per diem rate ($203,441.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5783.33,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5507.93,20510.35,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],58693.06,,"Fee schedule rate ($58,693.06). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
Cysto W/Simple Removal Stone & Stent,CASE-52310,APC,52310,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8476.55,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8072.90,31159.55,Inpatient DRG
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],42621.59,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40591.99,115037.59,Inpatient DRG
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE|PO,CASE-29826,APC,29826,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
Implant Neurostim/Receiver,CASE-64590,APC,64590,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19044.40,,"APC Price ($18,400.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,18400.38,19320.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9717.70,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",39888.11,39888.11,39888.11,1 through 10,other,9527.16,28269.95,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,66445.54,Estimated amount calculated based on 11 day length of stay.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18049.06,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,30966.53,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30493.52,,"Fee schedule rate ($30,493.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8272.58,,"Case rate ($7,878.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,729.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.31. The transfer capital threshold is the transfer adjustment factor * $558.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",8037.28,8037.28,8037.28,1 through 10,other,7891.21,23415.63,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB EXCEPT TOES,EXTREME",305,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],49871.06,,"Case rate ($49,871.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,49871.06,52364.61,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38757.79,,,,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7891.21,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7668.88,7668.88,7891.21,1 through 10,other,7891.21,23415.63,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6542.29,,"Case rate ($6,230.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.53. The transfer capital threshold is the transfer adjustment factor * $441.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6240.68,18518.02,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14583.66,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13889.20,55846.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Ant&/Lat Compartments Only|RIGHT SIDE|PO,CASE-27600,APC,27600,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,70321.74,Estimated amount calculated based on 17 day length of stay.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|LEFT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13249.94,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13249.94,40085.35,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],115171.02,,"Fee schedule rate ($115,171.02). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MAJOR",220,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],43305.72,,"Case rate ($41,243.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,41243.54,43305.72,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],71084.28,,"Fee schedule rate ($71,084.28). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32758.27,,,,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13228.06,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12359.11,12359.11,12359.11,1 through 10,other,13228.06,39251.68,Inpatient DRG
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11426.12,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6953.00,35389.05,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9860.04,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9860.04,30039.61,Inpatient DRG
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21732.40,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20697.52,87921.54,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Leg/Ankle Subq <3cm|LEFT SIDE,CASE-27618,APC,27618,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],77530.52,,"Fee schedule rate ($77,530.52). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],42695.82,,"Fee schedule rate ($42,695.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6864.73,,"Case rate ($6,632.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,128.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,596.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,650.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,152.78. The transfer operating threshold is the transfer adjustment factor * $6,128.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.82. The transfer capital threshold is the transfer adjustment factor * $479.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6632.59,19680.94,Inpatient DRG
Fasciotomy Foot&/Toe|LEFT SIDE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16092.51,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15326.20,52511.19,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13770.04,,"Case rate ($13,114.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.33. The transfer capital threshold is the transfer adjustment factor * $929.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13135.23,38976.20,Inpatient DRG
Rmvl/Revj Sling Male Urinary Incontinence,CASE-53442,APC,53442,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3514.75,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites,CASE-31625,APC,31625,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3536.22,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],48938.54,,"Case rate ($47,283.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,591.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,420.62. The transfer capital threshold is the transfer adjustment factor * $3,420.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,47283.61,169615.07,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6558.98,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6558.98,19462.52,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
"HC ED Avulsion Nail Plate Single|LEFT HAND, THIRD DIGIT|PO",CASE-11730,APC,11730,CPT,0450,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],199.81,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,196.96,199.81,OPPS APC
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12677.91,,"Case rate ($12,074.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,026.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.62. The transfer capital threshold is the transfer adjustment factor * $855.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,35884.94,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Surg Tx Anal Fistula Intersphincteric,CASE-46275,APC,46275,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7007.50,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6770.53,20090.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,APC,26356,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia Only|RIGHT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8331.72,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7934.97,23545.50,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7763.72,,"Case rate ($7,394.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,695.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.97. The transfer capital threshold is the transfer adjustment factor * $523.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7405.81,33747.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21714.81,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,21289.03,76326.34,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26297.04,,"Fee schedule rate ($26,297.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,9279.13,27534.03,Zero final payments for the item or service in the 15 months prior to posting the file.
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|LEFT FOOT, SECOND DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,T1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Implant Deep|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20680,APC,20680,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],27344.34,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,26419.65,96304.23,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12095.14,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11519.18,34180.92,Inpatient DRG
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7284.31,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,3295.00,21715.49,All Other Inpatient
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13061.62,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5970.00,38757.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto impl 4 or more,CASE-C9740,APC,C9740,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9427.57,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE|PO,CASE-27792,APC,27792,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10446.35,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9948.90,46199.76,Inpatient DRG
HC Removal Subcutaneous Cardiac Rhythm Monitor|UNUSUAL NON-OVERLAPPING SERVICE,CASE-33286,APC,33286,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7848.94,,"APC Price ($7,848.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7848.94,8241.39,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE|PO,CASE-27792,APC,27792,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42003.98,,"Fee schedule rate ($42,003.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6687.67,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6461.52,21772.28,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12345.81,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11757.91,34889.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27943.31,,"Fee schedule rate ($27,943.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],43344.00,,"Fee schedule rate ($43,344.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,32749.19,97176.83,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,MODERATE",182,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6280.07,,"Case rate for a one day stay ($5,981.02). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5981.02,6280.07,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4867.35,,"Case rate ($4,867.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.12. The transfer capital threshold is the transfer adjustment factor * $352.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4867.35,14442.92,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13527.41,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12883.25,44763.90,Inpatient DRG
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11903.13,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11903.13,48838.99,Inpatient DRG
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5244.04,,"Case rate ($5,244.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,859.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,405.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,029.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,862.27. The transfer operating threshold is the transfer adjustment factor * $4,859.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $381.77. The transfer capital threshold is the transfer adjustment factor * $381.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5244.04,15804.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12051.24,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11814.94,44591.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10961.59,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10439.61,34540.67,Inpatient DRG
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,APC,58260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4981.90,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33114.42,,,,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,APC,49329,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10463.20,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10109.37,38416.97,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12787.15,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,12536.42,46998.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],48252.91,,"Fee schedule rate ($48,252.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8679.02,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8679.02,29908.27,Inpatient DRG
Patellectomy/Hemipatellectomy,CASE-27350,APC,27350,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC Remove Retrievable Filter,CASE-37193,APC,37193,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15862.62,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15326.20,52511.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],24909.11,,,,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10296.75,,"Fee schedule rate ($10,296.75). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6204.88,,"Case rate ($6,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,620.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.88. The transfer capital threshold is the transfer adjustment factor * $448.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6204.88,19589.20,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8349.83,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7952.22,25854.47,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13640.72,,"Case rate ($12,991.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,091.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.60. The transfer capital threshold is the transfer adjustment factor * $920.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7231.00,38610.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18096.75,,"Fee schedule rate ($18,096.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18562.91,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18562.91,73513.17,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,27370.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5280.49,,"Case rate ($5,280.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,879.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,346.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,553.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,898.48. The transfer operating threshold is the transfer adjustment factor * $4,879.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $382.00. The transfer capital threshold is the transfer adjustment factor * $382.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5280.49,17810.78,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE,CASE-54840,APC,54840,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2052.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
"KIDNEY AND URINARY TRACT INFECTIONS,MINOR",463,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6663.01,,"Case rate ($6,663.01). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6663.01,6996.16,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE|PO,CASE-25607,APC,25607,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38080.90,,,,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30373.42,,,,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4639.34,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4418.42,13110.79,Inpatient DRG
HC Sleep Study Unattended,CASE-95800,APC,95800,CPT,0920,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],204.80,,"APC Price ($204.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,204.80,215.04,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9860.04,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9860.04,30039.61,Inpatient DRG
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],67008.32,,"Fee schedule rate ($67,008.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16644.64,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15852.04,50518.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],46638.59,,"Fee schedule rate ($46,638.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
Open Treatment of Ulnar Shaft Fracture,CASE-25545,APC,25545,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21652.62,,"Case rate ($20,621.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,632.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,461.31. The transfer capital threshold is the transfer adjustment factor * $1,461.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20654.42,69402.59,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5179.10,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5003.96,21742.11,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],59216.74,,"Fee schedule rate ($59,216.74). Adds an outlier to normal pricing equal to the per diem rate ($89,749.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16141.36,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15824.86,49371.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15703.80,,"Fee schedule rate ($15,703.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13713.69,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",13499.73,13499.73,13499.73,1 through 10,other,13249.94,40085.35,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6063.93,,"Case rate ($5,775.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.79. The transfer capital threshold is the transfer adjustment factor * $417.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5775.17,17136.70,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5504.62,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5504.62,16333.88,Inpatient DRG
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7034.55,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6699.57,24060.08,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],97349.99,,,,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12948.38,,"Fee schedule rate ($12,948.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19056.10,,"Fee schedule rate ($19,056.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",21855.03,21855.03,21855.03,1 through 10,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31373.34,,"Fee schedule rate ($31,373.34). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5507.93,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5507.93,20510.35,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13249.94,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5862.50,5862.50,5862.50,1 through 10,other,13249.94,40085.35,Inpatient DRG
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC App Skin Sub T/a/L Tot <100 1st 25|PBB CHARGE,CASE-15271,APC,15271,CPT,0361,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],700.99,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,700.99,736.04,OPPS APC
"Arthro, Loose Body + Chondro",CASE-G0289,APC,G0289,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs,CASE-25116,APC,25116,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7875.66,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7500.63,22256.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9089.85,,"Fee schedule rate ($9,089.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, THIRD DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20595.74,,"Fee schedule rate ($20,595.74). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
Trurl Rescj Residual/Regrowth Obstr Prstate Tiss,CASE-52630,APC,52630,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23954.78,,,,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],67175.58,,"Fee schedule rate ($67,175.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv,CASE-64418,APC,64418,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17461.77,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],53769.45,,"Fee schedule rate ($53,769.45). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7875.66,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7500.63,22256.65,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB|PO",CASE-26160,APC,26160,CPT,0360,RC,,,FA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,Zero final payments for the item or service in the 15 months prior to posting the file.
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE|PO,CASE-27427,APC,27427,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],31112.60,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31112.60,92731.42,Inpatient DRG
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7650.64,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7500.63,22256.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7770.00,,"Per diem ($7,770). If length of stay < 5.1, first 1 days paid at a per diem of $15,540 instead. Capped at $39,628.80.",,,,0,other,7770.00,50313.90,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12107.00,,"Per diem ($12,107). If length of stay < 2.8, first 1 days paid at a per diem of $24,214 instead. Capped at $33,900.69.",,,,0,other,11962.15,40923.09,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"OPEN EXTRACRANIAL VASCULAR PROCEDURES,MODERATE",024,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7367.46,,"Case rate for a one day stay ($7,367.46). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,7367.46,7735.83,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],25110.76,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23915.01,121205.60,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],44364.60,,"Fee schedule rate ($44,364.60). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,Zero final payments for the item or service in the 15 months prior to posting the file.
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36247,APC,36247,CPT,0361,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24575.30,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,14043.03,54637.47,All Other Inpatient
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12377.40,,"Case rate ($11,958.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,049.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,517.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,093.70. The transfer operating threshold is the transfer adjustment factor * $11,049.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.13. The transfer capital threshold is the transfer adjustment factor * $865.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11958.84,40774.00,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10078.85,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9738.02,28895.67,Inpatient DRG
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23996.10,,,,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],39736.19,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,37843.99,139522.22,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21805.52,,"Fee schedule rate ($21,805.52). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31329.81,,"Fee schedule rate ($31,329.81). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MODERATE",721,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10702.54,,"Case rate ($10,702.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10702.54,11237.67,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],48779.11,,"Fee schedule rate ($48,779.11). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39316.61,,,,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5233.26,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4984.06,19757.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4313.61,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4167.74,12366.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],24009.84,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10632.00,103714.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],26482.05,,"Fee schedule rate ($26,482.05). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, SECOND DIGIT|SEPARATE STRUCTURE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T6|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22139.25,,"Fee schedule rate ($22,139.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13305.64,39481.90,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|RIGHT SIDE,CASE-24073,APC,24073,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6921.50,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6785.78,20135.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7608.00,,"Case rate ($7,245.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.46. The transfer capital threshold is the transfer adjustment factor * $513.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7257.26,23445.98,Inpatient DRG
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, THIRD DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6960.45,,"Fee schedule rate ($6,960.45). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6074.24,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6075.10,6075.10,6075.10,1 through 10,other,6074.24,18024.13,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],45371.94,,"Fee schedule rate ($45,371.94). Adds an outlier to normal pricing equal to the per diem rate ($84,711.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Radius Distal Third|RIGHT SIDE|PO,CASE-25350,APC,25350,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvc/Le Init 2nd,CASE-36246,APC,36246,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13.28,,,,,,0,other,13.28,13.94,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13335.48,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13335.48,39570.45,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8688.34,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8394.53,24909.11,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8537.62,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4878.64,14476.37,All Other Inpatient
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19680.94,,,,,,0,other,6632.59,19680.94,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12012.63,,"Case rate ($11,440.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.72. The transfer capital threshold is the transfer adjustment factor * $810.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12129.81,12129.81,12129.81,1 through 10,other,11458.84,42820.42,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6788.03,,"Case rate ($6,654.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,167.40, add-ons for qualifying new technology services are included. If operating cost exceeds $46,712.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,132.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,170.45. The transfer operating threshold is the transfer adjustment factor * $6,167.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.48. The transfer capital threshold is the transfer adjustment factor * $484.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6654.93,20056.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT SIDE|PO,CASE-26111,APC,26111,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt|LEFT SIDE|PO,CASE-25020,APC,25020,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],66888.05,,"Fee schedule rate ($66,888.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.5), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16257.35,,"Case rate ($15,483.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,268.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,097.19. The transfer capital threshold is the transfer adjustment factor * $1,097.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15507.88,46016.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5183.66,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5183.66,15743.06,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, FOURTH DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9744.48,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9280.46,39957.56,Inpatient DRG
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,APC,49594,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32390.31,,,,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6867.26,,"Case rate ($6,540.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $6,086.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,276.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,480.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,073.77. The transfer operating threshold is the transfer adjustment factor * $6,086.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.48. The transfer capital threshold is the transfer adjustment factor * $466.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6553.68,20086.28,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,55581.70,Estimated amount calculated based on 10 day length of stay.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8919.07,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8919.07,34453.70,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16456.83,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16456.83,55350.97,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10336.56,,"Case rate ($9,844.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,868.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $697.60. The transfer capital threshold is the transfer adjustment factor * $697.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9860.04,30039.61,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18412.80,,"Fee schedule rate ($18,412.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|LEFT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
HC I&D Hematoma Seroma Fluid,CASE-10140,APC,10140,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],41015.72,,"Fee schedule rate ($41,015.72). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11693.81,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11298.37,44627.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16664.74,,"Case rate ($15,871.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,295.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,124.69. The transfer capital threshold is the transfer adjustment factor * $1,124.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15896.49,51306.05,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7891.21,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7891.21,23415.63,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER DISORDERS OF NERVOUS SYSTEM,EXTREME",058,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],25660.13,,"Case rate ($25,660.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,25660.13,26943.14,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6895.07,,"Fee schedule rate ($6,895.07). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
Repair Dislocating Peroneal Tendon W/Fib Osteot|LEFT SIDE,CASE-27676,APC,27676,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12803.67,,"Fee schedule rate ($12,803.67). Adds an outlier to normal pricing equal to the per diem rate ($91,038.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],51643.16,,"Fee schedule rate ($51,643.16). Adds an outlier to normal pricing equal to the per diem rate ($161,652.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,18222.73,59942.55,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24205.16,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13831.52,59770.39,All Other Inpatient
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12741.99,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12135.23,49469.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Bone,1st 20sqcm or Less",CASE-11044,APC,11044,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12632.63,,,,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
HC Iliac Territory Plasty Stent|BILATERAL PROCEDURE,CASE-37221,APC,37221,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],460.53,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10291.73,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10291.73,34803.35,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11744.97,,"Case rate ($11,185.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,963.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.66. The transfer capital threshold is the transfer adjustment factor * $792.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6350.00,33244.29,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, FOURTH DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,T3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],32485.09,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,18562.91,73513.17,All Other Inpatient
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11589.27,,"Case rate ($11,037.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.15. The transfer capital threshold is the transfer adjustment factor * $782.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11055.00,49295.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11159.78,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11159.78,39897.21,Inpatient DRG
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY ANOTHER PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,77|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],30813.32,,"APC Price ($29,771.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,29771.33,31259.89,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein,CASE-37249,APC,37249,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13527.41,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12883.25,44763.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34655.25,,"Fee schedule rate ($34,655.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15421.03,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15421.03,15421.03,15421.03,1 through 10,other,15421.03,49137.17,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34001.86,,,,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,21229.52,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MODERATE",710,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],26096.00,,"Case rate ($24,853.33). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24853.33,26096.00,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6795.74,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6472.13,19204.75,Inpatient DRG
"Inject Nerv Blck,Paravert Sympath|PO",CASE-64520,APC,64520,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19462.52,,,,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8969.40,,"Fee schedule rate ($8,969.40). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4454.33,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4303.70,14124.38,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28035.79,,,,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23801.30,,,,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4363.62,,"Case rate ($4,155.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,465.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $294.50. The transfer capital threshold is the transfer adjustment factor * $294.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,21715.49,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20340.55,,"Case rate ($11,623.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,490.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.89. The transfer capital threshold is the transfer adjustment factor * $842.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,1188.00,35040.80,All Other Inpatient
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23366.55,,"Case rate ($22,908.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,828.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.25. The transfer capital threshold is the transfer adjustment factor * $1,657.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,22908.38,67976.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8392.15,,"Case rate ($7,992.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,737.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.38. The transfer capital threshold is the transfer adjustment factor * $566.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8005.26,24549.95,Inpatient DRG
Rpr 1st Fem Hernia Any Age Incarcerated,CASE-49553,APC,49553,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3395.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13001.86,,"Case rate ($12,382.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,048.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.48. The transfer capital threshold is the transfer adjustment factor * $877.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13214.85,13214.85,24954.69,1 through 10,other,12402.46,36801.89,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",45352.38,45352.38,45352.38,1 through 10,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6962.26,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6630.72,19989.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE|PO,CASE-28300,APC,28300,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Prst8ect Smpl Stot Robotic Assistance,CASE-55867,APC,55867,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7620.12,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7257.26,23445.98,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],77530.52,,"Fee schedule rate ($77,530.52). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13307.04,,"Case rate ($12,673.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,069.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $898.08. The transfer capital threshold is the transfer adjustment factor * $898.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12752.38,12752.38,12752.38,1 through 10,other,12693.58,46577.81,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],130347.93,,"Fee schedule rate ($130,347.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30254.51,130347.93,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],43602.60,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,43602.60,153667.90,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12788.64,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12179.66,36140.75,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10658.54,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10449.55,43409.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11350.83,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10810.31,32077.45,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16156.34,,"Fee schedule rate ($16,156.34). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],29720.03,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13369.00,88188.38,Inpatient DRG
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10224.92,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9738.02,28895.67,Inpatient DRG
Gastrocnemius Recession|RIGHT SIDE,CASE-27687,APC,27687,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Excis Nail Matrix Perm Rmvl|PO,CASE-11750,APC,11750,CPT,0450,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,CASE-26125,APC,26125,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6862.80,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6630.72,19989.86,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6461.52,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6461.52,21772.28,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12124.13,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",12601.16,12601.16,12601.16,1 through 10,other,11714.14,49460.19,Inpatient DRG
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,APC,52318,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],62984.87,,"Fee schedule rate ($62,984.87). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],43374.98,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9242.00,76216.30,All Other Inpatient
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12496.20,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11901.14,35314.31,Inpatient DRG
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
Transurethral Resection Bladder Neck|SEPARATE STRUCTURE,CASE-52500,APC,52500,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|PO,CASE-26080,APC,26080,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula,CASE-27641,APC,27641,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
"Open Tx Fracture Great Toe/Phalanx/Phalanges|LEFT FOOT, GREAT TOE",CASE-28505,APC,28505,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea,CASE-28465,APC,28465,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5341.07,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5278.64,5278.64,5278.64,1 through 10,other,5160.45,15312.64,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7096.13,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7096.13,25801.23,Inpatient DRG
"Avulsion Nail Plate Partial/Comp Simple Ea Addl|LEFT HAND, FOURTH DIGIT|PO",CASE-11732,APC,11732,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],190.30,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16552.29,,,,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5091.00,,"Per diem ($5,091). If length of stay < 3.2, first 1 days paid at a per diem of $10,182 instead. Capped at $16,289.77.",,,,0,other,5091.00,22010.11,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12861.93,,"Fee schedule rate ($12,861.93). Adds an outlier to normal pricing equal to the per diem rate ($47,786.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13061.00,,"Per diem ($13,061). If length of stay < 11, first 1 days paid at a per diem of $26,122 instead. Capped at $143,676.24.",,,,0,other,13061.00,162464.13,Estimated amount calculated based on 8 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31563.88,,,,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11036.50,,"Case rate ($11,036.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,227.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,773.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,451.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $10,233.04. The transfer operating threshold is the transfer adjustment factor * $10,227.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $803.46. The transfer capital threshold is the transfer adjustment factor * $803.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11036.50,33262.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia Recr < 3 Cm Ncrc8/Strangulated,CASE-49614,APC,49614,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
HC Repr Smp Not Face 2.6-7.5cm|SEPARATE STRUCTURE,CASE-12002,APC,12002,CPT,0450,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18411.77,,,,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19711.65,,"Fee schedule rate ($19,711.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25267.19,,"Fee schedule rate ($25,267.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE|PO,CASE-24342,APC,24342,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DIABETES,MODERATE",420,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2650.80,,"Case rate for a one day stay ($2,650.80). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2650.80,2783.34,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT|PO",CASE-28820,APC,28820,CPT,0360,RC,,,T1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8405.52,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8005.26,24549.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13475.16,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12833.49,58980.57,Inpatient DRG
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|RIGHT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34171.31,,"Fee schedule rate ($34,171.31). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11871.54,35778.69,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,APC,52300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13163.24,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12536.42,46998.45,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],50916.88,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,50916.88,170142.20,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21828.16,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",21828.17,20370.57,21828.17,1 through 10,other,21828.16,93157.39,Inpatient DRG
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],85741.18,,"Fee schedule rate ($85,741.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,30254.51,130347.93,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19491.06,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18562.91,73513.17,Inpatient DRG
"HYPERTENSION,MAJOR",199,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2600.28,,"Case rate for a one day stay ($2,600.28). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2600.28,2730.29,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],86795.47,,"Fee schedule rate ($86,795.47). Adds an outlier to normal pricing equal to the per diem rate ($211,362.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30626.53,106200.88,Zero final payments for the item or service in the 15 months prior to posting the file.
Hrhc 2/> Col/Grp W/Fstulectmy Incl Fssrectmy,CASE-46262,APC,46262,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
Trluml Balo Angiop Ctr Dialysis Seg W/Img S&I,CASE-36907,APC,36907,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5668.18,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5398.26,5668.18,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|RIGHT FOOT, GREAT TOE|PO",CASE-28297,APC,28297,CPT,0360,RC,,,T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],82553.89,,"Fee schedule rate ($82,553.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24097.05,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23624.56,83038.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41073.77,,,,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6284.66,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5985.39,17760.46,Inpatient DRG
Laparoscopy Nephrectomy W/Partial Ureterect,CASE-50546,APC,50546,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],339.97,,"APC Price ($339.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,339.97,356.97,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12770.37,,,,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12775.42,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12167.07,36103.36,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29482.05,,,,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
Arthrodesis Subtalar|RIGHT SIDE,CASE-28725,APC,28725,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30188.45,,,,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],46830.28,,"Fee schedule rate ($46,830.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5807.67,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5807.67,5801.79,27093.95,14,other,5807.67,17233.12,Inpatient DRG
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2|LEFT SIDE|PO,CASE-29822,APC,29822,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11037.30,,"Case rate ($10,511.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,916.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.90. The transfer capital threshold is the transfer adjustment factor * $744.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10528.47,44148.02,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30683.33,,"Fee schedule rate ($30,683.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22035.98,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7826.00,90280.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21387.46,,"Fee schedule rate ($21,387.46). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5403.00,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5297.06,19049.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9166.71,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6972.00,26280.60,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27028.33,,,,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7770.00,,"Per diem ($7,770). If length of stay < 5.1, first 1 days paid at a per diem of $15,540 instead. Capped at $39,628.80.",,,,0,other,7770.00,50313.90,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs,CASE-25116,APC,25116,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Shoulder Subfasc <5cm|LEFT SIDE,CASE-23076,APC,23076,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6569.09,,"Case rate ($6,440.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,950.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,418.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,637.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,974.38. The transfer operating threshold is the transfer adjustment factor * $5,950.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $465.91. The transfer capital threshold is the transfer adjustment factor * $465.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6440.28,19110.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],45507.56,,"Fee schedule rate ($45,507.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,3295.00,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"HEART FAILURE,MINOR",194,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7087.14,,"Case rate ($7,087.14). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7087.14,7441.50,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19815.97,,"Case rate ($18,872.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,508.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,337.36. The transfer capital threshold is the transfer adjustment factor * $1,337.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",19104.67,19104.67,19104.67,1 through 10,other,18902.44,56089.29,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33525.67,,,,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6235.22,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.30,18621.89,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],81324.83,,"Fee schedule rate ($81,324.83). Adds an outlier to normal pricing equal to the per diem rate ($106,784.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Pyeloscopy Rescj Pelvic Tumor|LEFT SIDE,CASE-52355,APC,52355,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17136.70,,,,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO|SEPARATE STRUCTURE",CASE-28270,APC,28270,CPT,0360,RC,,,T6|PO|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6240.09,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5942.94,17634.53,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4295.38,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2285.00,12138.74,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],45507.56,,"Fee schedule rate ($45,507.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,3295.00,50750.92,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8764.55,32969.91,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
Removal Implant Deep|LEFT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12140.60,,"Case rate ($11,730.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,838.28, add-ons for qualifying new technology services are included. If operating cost exceeds $46,306.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,019.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,881.47. The transfer operating threshold is the transfer adjustment factor * $10,838.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.58. The transfer capital threshold is the transfer adjustment factor * $848.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11730.05,61348.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10670.93,,"Case rate ($10,162.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,891.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.17. The transfer capital threshold is the transfer adjustment factor * $720.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10178.99,36468.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11384.58,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11384.58,33781.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"RENAL DIALYSIS ACCESS DEVICE PROCEDURES,EXTREME",444,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],51999.07,,"Case rate ($49,522.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,49522.92,51999.07,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23950.83,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23950.83,74869.17,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5494.12,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5308.33,19857.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, FOURTH DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,T3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6910.06,,"Case rate ($6,910.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,405.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,149.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,408.97. The transfer operating threshold is the transfer adjustment factor * $6,405.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $501.10. The transfer capital threshold is the transfer adjustment factor * $501.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",32343.74,32343.74,32343.74,1 through 10,other,6910.06,20832.04,Inpatient DRG
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8601.89,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8192.28,24308.97,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
HC Iliac Territory Plasty Stent|BILATERAL PROCEDURE,CASE-37221,APC,37221,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],467.21,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|BILATERAL PROCEDURE,CASE-37766,APC,37766,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8605.40,,"Case rate ($8,605.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,951.18, add-ons for qualifying new technology services are included. If operating cost exceeds $43,419.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,982.86. The transfer operating threshold is the transfer adjustment factor * $7,951.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $622.54. The transfer capital threshold is the transfer adjustment factor * $622.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8605.40,42305.71,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],74873.19,,"Fee schedule rate ($74,873.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.6), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9312.29,27632.41,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8814.26,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8394.53,24909.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE,CASE-28238,APC,28238,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11593.40,,"Fee schedule rate ($11,593.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,2285.00,12138.74,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Trurl Dstrj Prstate Tiss Rf Thermoth,CASE-53852,APC,53852,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8926.35,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6178.00,25225.91,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MAJOR",561,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2488.95,,"Case rate for a one day stay ($2,488.95). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2488.95,2613.40,There are no additional notes associated with this service or procedure.
Brnchsc Brushing/Protected Brushings,CASE-31623,APC,31623,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3713.03,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3536.22,3713.03,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],14842.71,,"Fee schedule rate ($14,842.71). Adds an outlier to normal pricing equal to the per diem rate ($40,567.35) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],27357.31,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27357.31,100904.68,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9634.79,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,33447.35,Inpatient DRG
"HC Aerosol, Hhn, Mdi, Ippb|ADJ",CASE-94640,APC,94640,CPT,0410,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5507.93,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5507.93,20510.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22922.34,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21830.80,85124.35,Inpatient DRG
Injection Aa&/Strd Genicular Nrv Branches W/Img|PO,CASE-64454,APC,64454,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],72742.07,,"Fee schedule rate ($72,742.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],125659.39,,"Fee schedule rate ($125,659.39). Adds an outlier to normal pricing equal to the per diem rate ($160,041.92) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],27904.46,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,27357.31,100904.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],31313.42,,"Case rate ($30,254.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,954.41, add-ons for qualifying new technology services are included. If operating cost exceeds $63,422.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,359.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $28,065.82. The transfer operating threshold is the transfer adjustment factor * $27,954.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,188.69. The transfer capital threshold is the transfer adjustment factor * $2,188.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,30254.51,130347.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],38891.09,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,38891.09,169197.98,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8679.02,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8679.02,29908.27,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9140.11,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8704.87,25830.00,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Trigger Pt 1-2 Musc Grps|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18559.00,,"Per diem ($18,559). If length of stay < 5.4, first 1 days paid at a per diem of $37,118 instead. Capped at $100,219.31.",,,,0,other,18559.00,141041.50,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27304.54,,"Fee schedule rate ($27,304.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,APC,52351,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7866.01,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7866.01,25247.47,Inpatient DRG
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13444.53,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12804.31,55145.09,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17191.57,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17191.57,51012.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Crtj Arven Fstl Xcp Dir Arven Anast Nonautog Grf,CASE-36830,APC,36830,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5194.09,5194.09,5194.09,1 through 10,other,5277.74,5541.62,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22458.61,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12833.49,58980.57,All Other Inpatient
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7371.57,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7020.54,28431.58,Inpatient DRG
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|RIGHT SIDE|PO,CASE-29883,APC,29883,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17574.20,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16737.33,72192.67,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14848.26,,,,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19338.90,,"Fee schedule rate ($19,338.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],67348.11,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,66027.56,228732.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FIFTH DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8.88,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,APC,49329,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,APC,31628,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3659.98,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,APC,43236,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,APC,43266,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6045.95,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9269.86,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9269.86,37852.57,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-23430,APC,23430,CPT,0360,RC,,,73,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18777.76,,,,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
Excision Pilonidal Cyst/Sinus Simple,CASE-11770,APC,11770,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
Tnot Elbow Lateral/Medial Debride Open|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-24358,APC,24358,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC I & D Simple,CASE-10060,APC,10060,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],43344.00,,"Fee schedule rate ($43,344.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
Cystostomy Cystotomy W/Drainage|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51040,APC,51040,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",16624.25,16624.25,16624.25,1 through 10,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
"GASTROINTESTINAL VASCULAR INSUFFICIENCY,MAJOR",246,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14418.80,,"Case rate ($14,418.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14418.80,15139.74,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13682.43,,"Case rate ($13,030.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,094.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $923.41. The transfer capital threshold is the transfer adjustment factor * $923.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13051.67,38728.27,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Placement of Endoscopic Stent,CASE-45347,APC,45347,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6045.95,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],40013.98,,"Fee schedule rate ($40,013.98). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,APC,52352,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27943.31,,"Fee schedule rate ($27,943.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14682.53,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7770.00,50313.90,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16573.70,,"Fee schedule rate ($16,573.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6632.59,19680.94,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16775.44,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16208.15,58123.31,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|RIGHT SIDE|PO,CASE-23430,APC,23430,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16630.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,16630.26,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11428.81,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10884.58,32297.83,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11384.58,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11384.58,33781.47,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24834.32,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10455.00,90889.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11350.12,,"Case rate ($10,809.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,937.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $766.01. The transfer capital threshold is the transfer adjustment factor * $766.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10826.88,32126.64,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",50114.40,50114.40,50114.40,1 through 10,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein,CASE-37249,APC,37249,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32645.32,,"Fee schedule rate ($32,645.32). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
Ligj & Div Short Saph Vein Saphenopop Junct Spx,CASE-37780,APC,37780,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],45154.20,,"Fee schedule rate ($45,154.20). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31528.46,,,,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
Excision Prepatellar Bursa|LEFT SIDE|SEPARATE STRUCTURE,CASE-27340,APC,27340,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE,CASE-23700,APC,23700,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE|PO,CASE-25608,APC,25608,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25507.30,,,,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv,CASE-64418,APC,64418,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17461.77,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],54920.47,,,,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Lesion Tendon Sheath/Capsule Leg&/Ank,CASE-27630,APC,27630,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9269.86,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9269.86,37852.57,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7455.00,,"Per diem ($7,455). If length of stay < 6.8, first 1 days paid at a per diem of $14,910 instead. Capped at $50,692.24.",,,,0,other,7455.00,53076.74,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21074.07,,,,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
HC Revasc Intravasc Lithotripsy|RIGHT SIDE,CASE-C9764,APC,C9764,CPT,0481,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],50750.92,,,,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10625.29,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10625.29,10625.29,10625.29,1 through 10,other,10625.29,39295.53,Inpatient DRG
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],27904.46,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,27357.31,100904.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],55081.83,,,,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23243.85,,"Fee schedule rate ($23,243.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21229.52,,,,,,0,other,6965.00,21229.52,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11695.62,,"Case rate ($11,138.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,308.28, add-ons for qualifying new technology services are included. If operating cost exceeds $45,776.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,349.36. The transfer operating threshold is the transfer adjustment factor * $10,308.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.33. The transfer capital threshold is the transfer adjustment factor * $789.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11156.45,42003.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5549.19,,"Case rate ($5,549.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,050.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.42. The transfer capital threshold is the transfer adjustment factor * $402.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5549.19,16729.39,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,32980.62,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],37572.15,,"Fee schedule rate ($37,572.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23848.70,,"Fee schedule rate ($23,848.70). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7158.97,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,2285.00,12138.74,All Other Inpatient
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,EXTREME",191,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],31412.39,,"Case rate ($29,916.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29916.56,31412.39,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4755.96,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4755.96,21133.33,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19160.40,,"Fee schedule rate ($19,160.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
Tenolysis Extensor Tendon Hand/Finger Each,CASE-26445,APC,26445,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,MINOR",201,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3003.80,,"Case rate for a one day stay ($2,860.76). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2860.76,3003.80,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20589.45,,"Fee schedule rate ($20,589.45). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34611.07,,"Fee schedule rate ($34,611.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8811.18,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8513.22,25261.33,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7096.13,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7096.13,25801.23,Inpatient DRG
Split Agrft T/a/L 1st 100 Cm/&/1% Bdy Inft/Chld,CASE-15100,APC,15100,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2054.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2025.45,2054.80,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],22645.02,,of the excess amount.,50375.94,50375.94,50375.94,1 through 10,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10365.36,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5923.06,17575.50,All Other Inpatient
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],30403.05,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,30403.05,90685.00,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13664.39,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13664.39,40546.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],36370.09,,"Fee schedule rate ($36,370.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],38891.09,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,38891.09,169197.98,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6301.06,,"Case rate ($6,001.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,596.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.25. The transfer capital threshold is the transfer adjustment factor * $425.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6010.58,17835.23,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23804.86,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23338.10,69251.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein,CASE-37249,APC,37249,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cystostomy Tube Change,CASE-51705,APC,51705,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC App Skin Sub T/a/L Tot <100 1st 25,CASE-15271,APC,15271,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],700.99,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,700.99,736.04,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|PO",CASE-64491,APC,64491,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6987.68,,"Case rate ($6,654.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,167.40, add-ons for qualifying new technology services are included. If operating cost exceeds $46,712.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,132.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,170.45. The transfer operating threshold is the transfer adjustment factor * $6,167.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.48. The transfer capital threshold is the transfer adjustment factor * $484.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6654.93,20056.77,Inpatient DRG
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MAJOR",710,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],38974.28,,"Case rate ($37,118.36). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,37118.36,38974.28,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27135.21,,"Fee schedule rate ($27,135.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9766.39,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9574.89,28411.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB|PO",CASE-26160,APC,26160,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrotomy W/Meniscus Repair Knee,CASE-27403,APC,27403,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE|PO,CASE-23515,APC,23515,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10696.56,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10334.84,30666.60,Inpatient DRG
HC Iliac Territory Plasty Stent|LEFT SIDE,CASE-37221,APC,37221,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],444.96,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
Open Treatment Tarsometatarsal Joint Dislocation|RIGHT SIDE|PO,CASE-28615,APC,28615,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],70763.35,,"Fee schedule rate ($70,763.35). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
Unlisted Procedure Male Genital System,CASE-55899,APC,55899,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],245.27,,"APC Price ($236.97). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,236.97,248.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
"OTHER PNEUMONIA,MODERATE",139,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9353.36,,"Case rate ($8,907.96). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8907.96,9353.36,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9477.08,,"Fee schedule rate ($9,477.08). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6068.82,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5779.83,17150.47,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],85483.72,,"Fee schedule rate ($85,483.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20213.31,,"Fee schedule rate ($20,213.31). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
Gastrocnemius Recession|LEFT SIDE,CASE-27687,APC,27687,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE|PO,CASE-23700,APC,23700,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10109.37,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10109.37,38416.97,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16330.09,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16009.89,58554.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19108.28,,"Case rate ($18,198.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,460.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.60. The transfer capital threshold is the transfer adjustment factor * $1,289.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",18360.96,18360.96,19108.29,1 through 10,other,18227.38,54086.17,Inpatient DRG
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MAJOR",422,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2288.33,,"Case rate for a one day stay ($2,179.36). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2179.36,2288.33,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29433.60,,"Fee schedule rate ($29,433.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Bone Graft Any Donor Area Major/Large|PO,CASE-20902,APC,20902,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
Egd Flexible Foreign Body Removal,CASE-43247,APC,43247,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],38225.27,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36405.02,110499.61,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26270.73,,"Fee schedule rate ($26,270.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16296.51,,"Case rate ($9,312.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,604.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,072.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,638.62. The transfer operating threshold is the transfer adjustment factor * $8,604.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.67. The transfer capital threshold is the transfer adjustment factor * $673.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9312.29,27632.41,All Other Inpatient
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,APC,38900,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9920.64,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6531.00,35832.77,Inpatient DRG
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12107.00,,"Per diem ($12,107). If length of stay < 2.8, first 1 days paid at a per diem of $24,214 instead. Capped at $33,900.69.",,,,0,other,11962.15,40923.09,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,13588.14,40320.14,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16581.60,,"Fee schedule rate ($16,581.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6077.55,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6077.55,18033.97,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10451.28,,"Case rate ($9,953.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,876.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.35. The transfer capital threshold is the transfer adjustment factor * $705.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9969.47,29582.40,Inpatient DRG
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, GREAT TOE",CASE-28810,APC,28810,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($55,128.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,APC,29807,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],92320.55,,,,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7920.23,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7543.08,29489.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
HC Thromb Mech Vein,CASE-37187,APC,37187,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
"VERTIGO AND OTHER LABYRINTH DISORDERS,MODERATE",111,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3290.07,,"Case rate for a one day stay ($3,290.07). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3290.07,3454.57,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7648.51,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7648.51,27371.98,Inpatient DRG
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvic/Le 1st Ord|LEFT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|PO,CASE-64483,APC,64483,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1996.84,1996.84,1996.84,1 through 10,other,1982.66,2081.79,OPPS APC
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9427.57,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8978.63,9427.57,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14182.30,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7308.00,42083.20,Inpatient DRG
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,APC,49320,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
Mediastinoscopy With Lymph Node Biopsy/Ies,CASE-39402,APC,39402,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|LEFT SIDE,CASE-27130,APC,27130,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24472.02,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23644.46,105789.11,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],22908.38,,"Case rate ($22,908.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,828.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.25. The transfer capital threshold is the transfer adjustment factor * $1,657.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22908.38,67976.16,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,Zero final payments for the item or service in the 15 months prior to posting the file.
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MAJOR",561,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2488.95,,"Case rate for a one day stay ($2,488.95). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2488.95,2613.40,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17214.39,,"Fee schedule rate ($17,214.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36140.75,,,,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7289.74,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7289.74,21630.93,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5094.80,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5094.80,15365.01,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],35094.08,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,33422.93,112824.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12042.33,,"Fee schedule rate ($12,042.33). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12861.93,,"Fee schedule rate ($12,861.93). Adds an outlier to normal pricing equal to the per diem rate ($47,786.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7293.55,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4167.74,12366.99,All Other Inpatient
HC Intrvasc US Noncoronary Addl,CASE-37253,APC,37253,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],538.93,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23131.85,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23131.85,76404.43,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10665.88,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6094.79,22352.66,All Other Inpatient
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7482.22,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7335.51,29792.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|LEFT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],189.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10687.94,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10178.99,36468.17,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7984.05,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7984.05,33319.56,Inpatient DRG
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],140535.66,,"Fee schedule rate ($140,535.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,36167.61,140535.66,There are no additional notes associated with this service or procedure.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT HAND, FOURTH DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5621.79,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5354.09,15887.21,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
Claviculectomy Partial|LEFT SIDE,CASE-23120,APC,23120,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
"SEIZURE,MAJOR",053,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14663.94,,"Case rate ($13,965.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13965.66,14663.94,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30534.77,,,,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11732.57,,"Fee schedule rate ($11,732.57). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12490.63,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11895.84,35298.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],31923.20,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30403.05,90685.00,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],47978.53,,"Fee schedule rate ($47,978.53). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6749.69,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5683.00,19635.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10905.18,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10385.89,32176.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18286.71,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10449.55,43409.67,All Other Inpatient
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],25667.66,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,25667.66,86123.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39078.16,,"Fee schedule rate ($39,078.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],46830.28,,"Fee schedule rate ($46,830.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15749.87,,"Case rate ($14,999.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,234.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,062.94. The transfer capital threshold is the transfer adjustment factor * $1,062.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",15749.88,15749.88,15749.88,1 through 10,other,15023.80,48104.19,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7157.79,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5520.00,26638.96,Inpatient DRG
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE,CASE-27698,APC,27698,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11610.07,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11217.46,37366.25,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36780.25,,,,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6061.85,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5773.19,31196.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7620.12,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7257.26,23445.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",33474.27,33474.27,33474.27,1 through 10,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],34116.38,,"Fee schedule rate ($34,116.38). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10034.43,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10034.43,29775.24,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
Osteotomy Tarsal Bones Oth/Thn Calcaneus/Talus|LEFT SIDE|PO,CASE-28304,APC,28304,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Osteotomy Radius Distal Third|LEFT SIDE|PO,CASE-25350,APC,25350,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20589.45,,"Fee schedule rate ($20,589.45). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Partial Nephrectomy|RIGHT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],34130.65,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,19503.23,57872.02,All Other Inpatient
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|SEPARATE STRUCTURE,CASE-12032,APC,12032,CPT,0450,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,XS|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],40196.26,,"Fee schedule rate ($40,196.26). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25136.92,,"Fee schedule rate ($25,136.92). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr,CASE-28238,APC,28238,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride Subq First 20 Sq Cm,CASE-11042,APC,11042,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,385.57,404.84,OPPS APC
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],31698.46,,"Case rate ($30,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,386.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,215.60. The transfer capital threshold is the transfer adjustment factor * $2,215.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,30626.53,106200.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],20277.85,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8972.00,76376.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cv Cath Plac W/Port Tun >5|RIGHT SIDE,CASE-36561,APC,36561,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11519.31,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10970.77,32553.63,Inpatient DRG
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,APC,51990,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18222.73,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",18222.74,18222.74,18222.74,1 through 10,other,18222.73,59942.55,Inpatient DRG
HC 3rd Order Sel Abd/Lower Ext,CASE-36247,APC,36247,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8.46,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
Fasciotomy Foot&/Toe|LEFT SIDE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3055.06,3055.06,3055.06,1 through 10,other,5733.99,6020.69,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level|RIGHT SIDE",CASE-64495,APC,64495,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14062.94,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14062.94,61706.77,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8768.03,,"Case rate ($8,596.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,942.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,410.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,974.25. The transfer operating threshold is the transfer adjustment factor * $7,942.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.86. The transfer capital threshold is the transfer adjustment factor * $621.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8596.11,25507.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Stoma Dx Including Collj Spec Spx,CASE-44388,APC,44388,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13485.61,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,38110.41,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15156.44,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15156.44,52672.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8722.11,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4984.06,19757.81,All Other Inpatient
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13545.65,,,,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
Arthrodesis Subtalar|RIGHT SIDE,CASE-28725,APC,28725,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13691.04,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",13691.05,13691.05,13691.05,1 through 10,other,13228.06,39251.68,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],40835.64,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,38891.09,169197.98,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],55272.09,,"Fee schedule rate ($55,272.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia Only|LEFT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16209.45,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,1188.00,27484.83,All Other Inpatient
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31241.17,,,,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],33422.93,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,33422.93,112824.68,Inpatient DRG
Excision Malignant Lesion S/N/H/F/G 0.6-1.0 Cm,CASE-11621,APC,11621,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],671.64,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,671.64,695.15,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9901.84,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,45869.64,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],95212.54,,"Fee schedule rate ($95,212.54). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34640.55,,"Fee schedule rate ($34,640.55). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],22264.72,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",22264.73,22264.73,109035.51,1 through 10,other,21828.16,93157.39,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8231.45,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7551.60,23262.15,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],47978.53,,"Fee schedule rate ($47,978.53). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5612.85,,"Case rate ($5,345.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,549.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.81. The transfer capital threshold is the transfer adjustment factor * $378.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5354.09,15887.21,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10736.25,,"Fee schedule rate ($10,736.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7020.54,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7020.54,28431.58,Inpatient DRG
"HIV WITH MAJOR HIV RELATED CONDITION,EXTREME",892,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],26349.84,,"Case rate ($25,095.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25095.09,26349.84,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, THIRD DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6035.39,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5091.00,22010.11,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11986.02,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,11986.02,54149.39,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28892.85,,"Fee schedule rate ($28,892.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
Arthroplasty Ankle W/Implant|LEFT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],26636.50,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea,CASE-28092,APC,28092,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,APC,45381,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24909.11,,,,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE,CASE-28730,APC,28730,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8479.01,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",8360.22,8360.22,28738.04,1 through 10,other,8192.28,24308.97,Inpatient DRG
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33947.68,,"Fee schedule rate ($33,947.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],70264.60,,,,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24053.40,,"Fee schedule rate ($24,053.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
Rhytidectomy Smas Flap,CASE-15829,APC,15829,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3529.16,,"APC Price ($3,361.11). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3529.16,3529.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21975.27,,,,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7020.54,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7020.54,28431.58,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],58534.56,,"Fee schedule rate ($58,534.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],33072.79,,"Case rate ($33,072.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,563.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,392.57. The transfer capital threshold is the transfer adjustment factor * $2,392.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,33072.79,98455.37,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8351.93,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4772.53,14161.54,All Other Inpatient
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],163229.10,,"Fee schedule rate ($163,229.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],32749.19,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",88541.54,88541.54,88541.54,1 through 10,other,32749.19,97176.83,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22986.65,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13135.23,38976.20,All Other Inpatient
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10439.61,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9828.27,9828.27,9828.27,1 through 10,other,10439.61,34540.67,Inpatient DRG
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],63499.65,,,,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12152.35,,"Case rate ($11,573.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,991.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.15. The transfer capital threshold is the transfer adjustment factor * $820.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11592.12,38954.76,Inpatient DRG
"OTHER PNEUMONIA,MINOR",139,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2393.77,,"Case rate for a one day stay ($2,393.77). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2393.77,2513.46,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16573.70,,"Fee schedule rate ($16,573.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6632.59,19680.94,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5976.41,,"Case rate ($5,691.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.34. The transfer capital threshold is the transfer adjustment factor * $403.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5700.90,30872.02,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16916.32,,,,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE|PO,CASE-28200,APC,28200,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27695,APC,27695,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,48444.74,Estimated amount calculated based on 11 day length of stay.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],61868.44,,"Fee schedule rate ($61,868.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|RIGHT SIDE|PO,CASE-29883,APC,29883,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|LEFT SIDE,CASE-24341,APC,24341,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11184.66,,"Case rate ($10,652.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,925.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $754.84. The transfer capital threshold is the transfer adjustment factor * $754.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",10882.37,10882.37,10882.37,1 through 10,other,1188.00,31658.33,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx With Directed Submucosal Njx Any Sbst|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45381,APC,45381,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19879.67,,,,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,53945.28,Estimated amount calculated based on 17 day length of stay.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5504.62,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5504.62,16333.88,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33733.44,,"Fee schedule rate ($33,733.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Dx Collection Specimen Brushing/Washing,CASE-43260,APC,43260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arteriovenous Anastomosis Open Direct,CASE-36821,APC,36821,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",2922.01,2883.68,5018.44,1 through 10,other,2994.77,3144.51,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37225.17,,"Fee schedule rate ($37,225.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Talus Fracture|RIGHT SIDE,CASE-28445,APC,28445,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24417.19,,,,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41146.57,,,,,,0,other,13866.64,41146.57,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
Open Tx Radial&Ulnar Shaft Fx W/Fixj Radius&Ulna,CASE-25575,APC,25575,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,EXTREME",165,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],101691.42,,"Case rate ($101,691.42). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $55,584, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,101691.42,106775.99,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14089.82,,"Fee schedule rate ($14,089.82). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],41609.84,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,40202.74,148703.60,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],40546.43,,,,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21721.18,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7826.00,90280.33,Inpatient DRG
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"MAJOR LARGE BOWEL PROCEDURES,MODERATE",231,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],26734.25,,"Case rate ($25,461.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25461.19,26734.25,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11348.73,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10808.31,46938.11,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],56694.72,,"Fee schedule rate ($56,694.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37225.17,,"Fee schedule rate ($37,225.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18244.92,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",18244.93,18244.93,18244.93,1 through 10,other,7455.00,53076.74,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19815.97,,"Case rate ($18,872.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,508.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,337.36. The transfer capital threshold is the transfer adjustment factor * $1,337.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18902.44,56089.29,Inpatient DRG
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE|PO,CASE-28740,APC,28740,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23125.89,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23125.89,68621.57,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19952.48,,,,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18143.98,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10367.99,37103.57,All Other Inpatient
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],48138.00,,"Fee schedule rate ($48,138.00). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],25110.76,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23915.01,121205.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13905.59,,"Case rate ($13,243.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,109.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $938.47. The transfer capital threshold is the transfer adjustment factor * $938.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13276.42,13276.42,13276.42,1 through 10,other,13264.54,50759.39,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14891.42,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7308.00,42083.20,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16629.05,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16302.99,55737.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6004.31,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5886.58,17467.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8476.55,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8072.90,31159.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],28467.39,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8232.00,84471.39,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],55272.09,,"Fee schedule rate ($55,272.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Revasc lithotrip tibi/perone|LEFT SIDE,CASE-C9772,APC,C9772,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9624.30,,"Fee schedule rate ($9,624.30). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20806.46,,,,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],39785.64,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,22734.65,70806.50,All Other Inpatient
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],79366.60,,"Fee schedule rate ($79,366.60). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6601.57,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6472.13,19204.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20935.95,,"Fee schedule rate ($20,935.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23679.61,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23679.61,84629.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T7,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7981.50,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7601.43,23918.09,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25327.33,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,14472.76,56135.46,All Other Inpatient
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9860.04,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9860.04,30039.61,Inpatient DRG
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-54840,APC,54840,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3565.69,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19155.70,,"Fee schedule rate ($19,155.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6654.93,20056.77,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],40916.35,,,,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],37994.32,,,,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
HC Intro Catheter Aorta|RIGHT SIDE,CASE-36200,APC,36200,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7354.14,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7003.94,20782.85,Inpatient DRG
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,EXTREME",140,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],19861.94,,"Case rate ($19,861.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19861.94,20855.04,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],62647.63,,,,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|RIGHT SIDE|PO,CASE-24341,APC,24341,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5345.47,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5224.00,15861.63,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],83871.28,,"Fee schedule rate ($83,871.28). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,APC,52287,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO|SEPARATE STRUCTURE,CASE-62323,APC,62323,CPT,0360,RC,,,PO|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15405.10,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,55581.70,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
Incision & Drainage Leg/Ankle Abscess/Hematoma|LEFT SIDE,CASE-27603,APC,27603,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
Brnchsc Brushing/Protected Brushings,CASE-31623,APC,31623,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3536.22,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10400.49,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10400.50,10400.50,10400.50,1 through 10,other,6965.00,30861.41,Inpatient DRG
HC Cystostomy Tube Change,CASE-51705,APC,51705,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7686.98,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7686.98,22809.58,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8422.25,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6495.00,23801.30,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6883.61,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6748.64,20025.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13912.44,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13249.94,40085.35,Inpatient DRG
Synovectomy Tendon Sheath Foot Extensor,CASE-28088,APC,28088,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
Unlisted Procedure Femur/Knee|RIGHT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],242.14,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,233.96,245.65,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18559.00,,"Per diem ($18,559). If length of stay < 5.4, first 1 days paid at a per diem of $37,118 instead. Capped at $100,219.31.",,,,0,other,18559.00,141041.50,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit|RIGHT SIDE,CASE-36901,APC,36901,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1493.03,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
"HEART FAILURE,MAJOR",194,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15479.17,,"Case rate ($14,742.07). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14742.07,15479.17,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21316.71,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20301.63,84714.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64450,APC,64450,CPT,0450,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17212.32,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16630.26,17212.32,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4564.97,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4564.97,13545.65,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],45371.94,,"Fee schedule rate ($45,371.94). Adds an outlier to normal pricing equal to the per diem rate ($84,711.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],31923.20,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30403.05,90685.00,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7003.94,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7003.94,20782.85,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,55581.70,Estimated amount calculated based on 10 day length of stay.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35495.34,,,,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,MAJOR",951,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],31795.41,,"Case rate ($31,795.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31795.41,33385.18,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20188.60,,,,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],29843.17,,"Case rate ($28,422.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,185.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,014.09. The transfer capital threshold is the transfer adjustment factor * $2,014.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",178160.61,178160.61,178160.61,1 through 10,other,8232.00,84471.39,Inpatient DRG
Suture Infrapatellar Tendon Primary|LEFT SIDE,CASE-27380,APC,27380,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],33463.71,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,32807.56,111191.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT SIDE|PO,CASE-26540,APC,26540,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",26416.00,26416.00,26416.00,1 through 10,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 1.1-2.0 Cm,CASE-11402,APC,11402,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5934.68,6020.69,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],94534.21,,,,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4288.55,,"Case rate ($4,084.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,460.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $289.43. The transfer capital threshold is the transfer adjustment factor * $289.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2285.00,12138.74,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7211.17,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4120.67,13066.56,All Other Inpatient
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Tdn/Musc Xtnsr F/Arm&/Wrist Prim 1 Ea Tdn|LEFT SIDE|PO,CASE-25270,APC,25270,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7776.10,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7405.81,33747.30,Inpatient DRG
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24288.44,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23131.85,76404.43,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17186.59,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9820.91,29141.64,All Other Inpatient
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12180.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11600.09,48814.14,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],9799.00,,"Per diem ($9,799). If length of stay < 2.3, first 1 days paid at a per diem of $19,598 instead. Capped at $22,536.57.",,,,0,other,7952.22,25854.47,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,21325.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5982.12,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5885.96,3323.08,26965.05,1 through 10,other,5779.83,17150.47,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4464.17,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4464.17,13577.72,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14375.32,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",14018.62,14018.62,14375.33,1 through 10,other,13889.20,55846.16,Inpatient DRG
"OTHER ESOPHAGEAL DISORDERS,MODERATE",243,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10135.23,,"Case rate ($9,652.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9652.60,10135.23,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],48229.28,,"Case rate ($47,283.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,591.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,420.62. The transfer capital threshold is the transfer adjustment factor * $3,420.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,47283.61,169615.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",21855.03,21855.03,21855.03,1 through 10,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7409.15,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7056.33,28335.74,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8675.02,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8675.02,25741.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,APC,52352,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5224.94,,"Case rate ($4,976.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.63. The transfer capital threshold is the transfer adjustment factor * $352.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4984.06,19757.81,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7996.27,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7551.60,23262.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,APC,11606,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
"OTHER COMPLICATIONS OF TREATMENT,MODERATE",813,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9515.83,,"Case rate ($9,515.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9515.83,9991.62,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9021.22,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",8901.57,8901.57,9021.23,1 through 10,other,8716.15,25863.45,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14784.29,,"Case rate ($14,080.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.78. The transfer capital threshold is the transfer adjustment factor * $997.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14102.73,41847.08,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],59833.15,,"Fee schedule rate ($59,833.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12335.32,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12093.45,35884.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8049.03,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7891.21,23415.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7981.50,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7601.43,23918.09,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13438.87,,"Fee schedule rate ($13,438.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17214.39,,"Fee schedule rate ($17,214.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,55581.70,Estimated amount calculated based on 10 day length of stay.
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf|LEFT SIDE,CASE-36825,APC,36825,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,66445.54,Estimated amount calculated based on 11 day length of stay.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17018.56,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16208.15,58123.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|RIGHT SIDE,CASE-27130,APC,27130,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",12363.12,12363.12,12363.12,1 through 10,other,12177.08,12785.93,OPPS APC
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,APC,36245,CPT,0361,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8.46,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9760.38,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,45869.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Medial Malleolus Fracture|RIGHT SIDE,CASE-27766,APC,27766,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],45782.73,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,43602.60,153667.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7801.48,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7648.51,27371.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28966.51,,,,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20895.12,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20895.12,99969.33,Inpatient DRG
Biopsy Urethra,CASE-53200,APC,53200,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22002.56,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20954.82,62179.32,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4979.12,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4742.02,14071.02,Inpatient DRG
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Tibia|LEFT SIDE|PO,CASE-27640,APC,27640,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9341.82,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5338.18,15839.99,All Other Inpatient
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21875.01,,"Fee schedule rate ($21,875.01). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17902.13,,,,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12326.15,,"Case rate ($11,739.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,003.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $831.88. The transfer capital threshold is the transfer adjustment factor * $831.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11757.91,34889.29,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13714.70,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5970.00,38757.79,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],69328.94,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,66027.56,228732.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Bone,1st 20sqcm or Less|UNUSUAL NON-OVERLAPPING SERVICE",CASE-11044,APC,11044,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26525,APC,26525,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],39538.47,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,22593.41,90908.64,All Other Inpatient
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34517.10,,"Fee schedule rate ($34,517.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Calcaneal Fracture|LEFT SIDE,CASE-28415,APC,28415,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6311.11,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6010.58,17835.23,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
HC Debride/Musc/Fasc First 20 Sq Cm|SEPARATE STRUCTURE|PO,CASE-11043,APC,11043,CPT,0361,RC,,,XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5355.42,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5355.42,17067.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4793.22,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4564.97,13545.65,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10168.86,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9969.47,29582.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T3,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10432.42,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",10117.85,10117.85,10117.85,1 through 10,other,9935.64,29482.05,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],34988.57,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,34988.57,110685.97,Inpatient DRG
HC Sel Cath Abd/Pelvic/Le 1st Ord|LEFT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10815.28,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10115.51,10115.51,10115.51,1 through 10,other,10449.55,43409.67,Inpatient DRG
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],35363.23,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,18559.00,141041.50,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],42138.30,,,,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB|PO",CASE-26160,APC,26160,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],65732.99,,,,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],44611.07,,"Fee schedule rate ($44,611.07). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6474.12,19210.66,There are no additional notes associated with this service or procedure.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],195125.77,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,185834.07,195125.77,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6033.12,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6033.12,17902.13,Inpatient DRG
Colon Ca Scrn Not Hi Rsk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6308.00,,"Per diem ($6,308). If length of stay < 3.3, first 1 days paid at a per diem of $12,616 instead. Capped at $20,817.01.",,,,0,other,6308.00,21796.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5975.25,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5773.19,31196.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14508.56,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14508.56,59513.03,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],65078.97,,of the excess amount.,,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent,CASE-36903,APC,36903,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7275.69,,"Case rate ($6,929.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.03. The transfer capital threshold is the transfer adjustment factor * $491.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6940.28,20593.95,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],109526.12,,,,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Medium WO US|RIGHT SIDE|PO,CASE-20605,APC,20605,CPT,0510,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",722.56,722.56,5687.21,1 through 10,other,5733.99,6020.69,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7465.97,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,21404.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5181.84,,"Case rate ($5,006.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,625.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,093.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,644.42. The transfer operating threshold is the transfer adjustment factor * $4,625.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.19. The transfer capital threshold is the transfer adjustment factor * $362.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5006.61,14856.14,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],74873.19,,"Fee schedule rate ($74,873.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.6), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23602.02,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23602.02,108295.22,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7335.51,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7335.51,29792.90,Inpatient DRG
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, SECOND DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,APC,57425,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28285,APC,28285,CPT,0360,RC,,,T9|PO|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE|PO,CASE-24342,APC,24342,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14200.87,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7453.00,42138.30,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6972.22,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6835.51,20283.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5287.33,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5183.66,15743.06,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],70264.60,,,,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11953.81,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11384.58,33781.47,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12196.66,,"Fee schedule rate ($12,196.66). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11663.65,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11434.95,119072.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14682.53,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7770.00,50313.90,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE,CASE-28615,APC,28615,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Iliac Territory Plasty Stent|LEFT SIDE,CASE-37221,APC,37221,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],467.21,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|LEFT SIDE|PO,CASE-25260,APC,25260,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11901.14,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11901.14,35314.31,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],41117.20,,"Fee schedule rate ($41,117.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33692.09,,"Fee schedule rate ($33,692.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],51131.99,,"Fee schedule rate ($51,131.99). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,EXTREME",192,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],42402.00,,"Case rate ($40,382.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40382.86,42402.00,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13061.00,,"Per diem ($13,061). If length of stay < 11, first 1 days paid at a per diem of $26,122 instead. Capped at $143,676.24.",,,,0,other,13061.00,162464.13,Estimated amount calculated based on 8 day length of stay.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE|PO,CASE-29875,APC,29875,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7011.91,,"Case rate ($7,011.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,678.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7011.91,27304.54,Inpatient DRG
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT HAND, THUMB",CASE-28750,APC,28750,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,MODERATE",351,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8802.97,,"Case rate ($8,802.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8802.97,9243.12,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],130347.93,,"Fee schedule rate ($130,347.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30254.51,130347.93,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15824.86,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15513.36,15513.36,15513.36,1 through 10,other,15824.86,49371.45,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4523.19,16536.43,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4993.76,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4755.96,21133.33,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
HC Intro Cath in Svc or Ivc|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36010,APC,36010,CPT,0361,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO|SEPARATE STRUCTURE",CASE-28270,APC,28270,CPT,0360,RC,,,T6|PO|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10682.39,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10173.70,41194.64,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",665.41,656.68,679.50,1 through 10,other,669.51,702.98,OPPS APC
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],115171.02,,"Fee schedule rate ($115,171.02). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE|PO,CASE-28322,APC,28322,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7125.07,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6785.78,20135.47,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10886.39,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10367.99,37103.57,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,APC,52332,CPT,0360,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6308.00,,"Per diem ($6,308). If length of stay < 3.3, first 1 days paid at a per diem of $12,616 instead. Capped at $20,817.01.",,,,0,other,6308.00,21796.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32758.27,,,,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|SEPARATE STRUCTURE|LEFT SIDE,CASE-28306,APC,28306,CPT,0360,RC,,,XS|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12177.08,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6057.07,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5938.30,18621.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER PNEUMONIA,MINOR",139,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2393.77,,"Case rate for a one day stay ($2,393.77). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2393.77,2513.46,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|LEFT SIDE,CASE-37225,APC,37225,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],538.93,,,,,,0,other,538.93,557.79,There are no additional notes associated with this service or procedure.
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE|PO,CASE-28322,APC,28322,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,APC,58661,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26280.60,,,,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6399.53,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6094.79,22352.66,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12167.07,36103.36,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10528.47,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10528.47,44148.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10496.21,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10290.40,42115.80,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12383.35,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12140.54,36024.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27135.21,,"Fee schedule rate ($27,135.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11016.60,,"Fee schedule rate ($11,016.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,T6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28296,APC,28296,CPT,0360,RC,,,T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10468.69,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10114.68,30013.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18314.49,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19272.87,,"Fee schedule rate ($19,272.87). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],28916.65,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27539.67,109237.68,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],64029.63,,"Fee schedule rate ($64,029.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.5), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16573.70,,"Fee schedule rate ($16,573.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6632.59,19680.94,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9227.78,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8915.73,26455.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MAJOR",425,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2498.36,,"Case rate for a one day stay ($2,498.36). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2498.36,2623.28,There are no additional notes associated with this service or procedure.
Excision Lesion Meniscus/Capsule Knee,CASE-27347,APC,27347,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
Rpr 1st Fem Hernia Any Age Incarcerated,CASE-49553,APC,49553,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3395.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],90287.21,,"Fee schedule rate ($90,287.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20.9), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26357,APC,26357,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Transection/Avulsion Oth Spinal Nrv Xdrl|PO,CASE-64772,APC,64772,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Bladder Instillation Anticarcinogenic Agent,CASE-51720,APC,51720,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10702.51,,"Case rate ($10,492.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,694.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,162.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,930.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,733.59. The transfer operating threshold is the transfer adjustment factor * $9,694.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.07. The transfer capital threshold is the transfer adjustment factor * $759.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",10600.74,10600.74,10600.74,1 through 10,other,10492.66,31134.92,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE,CASE-27524,APC,27524,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|LEFT SIDE,CASE-37765,APC,37765,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16247.30,,,,,,0,other,5389.29,16247.30,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dil Bladder General Anesth,CASE-52260,APC,52260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10468.69,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10114.68,30013.33,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
Prq Skeletal Fix Carpo/Metacarpal Fx Dislc Thumb,CASE-26650,APC,26650,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23588.41,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23125.89,68621.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],9799.00,,"Per diem ($9,799). If length of stay < 2.3, first 1 days paid at a per diem of $19,598 instead. Capped at $22,536.57.",,,,0,other,7952.22,25854.47,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Prostate Needle Biopsy Any Approach|SEPARATE STRUCTURE,CASE-55700,APC,55700,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PO|SEPARATE STRUCTURE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|PO|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10806.32,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10291.73,34803.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],26908.14,,"Case rate ($25,626.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,987.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,816.00. The transfer capital threshold is the transfer adjustment factor * $1,816.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25667.66,86123.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],78047.33,,"Fee schedule rate ($78,047.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17934.16,,"Fee schedule rate ($17,934.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.1), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],43128.06,,"Fee schedule rate ($43,128.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6866.02,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6866.02,27153.67,Inpatient DRG
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,APC,38900,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
Excision Ganglion Wrist Dorsal/Volar Primary|LEFT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20986.65,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7826.00,90280.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Dx Collection Specimen Brushing/Washing,CASE-43260,APC,43260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],48094.52,,,,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5428.23,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5169.74,15340.19,Inpatient DRG
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16831.01,,"Fee schedule rate ($16,831.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
Nerve Repair W/Conduit Each Nerve|LEFT SIDE|PO,CASE-64910,APC,64910,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8323.61,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8323.61,8739.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9108.71,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9108.71,27028.33,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12135.23,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12135.23,49469.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12006.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11600.09,48814.14,Inpatient DRG
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],69218.57,,"Case rate ($65,922.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,842.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,671.49. The transfer capital threshold is the transfer adjustment factor * $4,671.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,66027.56,228732.31,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],51643.16,,"Fee schedule rate ($51,643.16). Adds an outlier to normal pricing equal to the per diem rate ($161,652.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,18222.73,59942.55,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1547.90,1547.90,1547.90,1 through 10,other,1852.10,1944.70,OPPS APC
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],26350.52,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,25459.44,80806.10,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22592.15,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",21086.38,21083.54,22522.48,1 through 10,other,21828.16,93157.39,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39570.45,,,,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14062.94,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14062.94,61706.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],36910.99,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",27336.54,27336.54,27336.54,1 through 10,other,36910.99,126842.57,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],56694.72,,"Fee schedule rate ($56,694.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6558.98,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6558.98,19462.52,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],133510.03,,"Fee schedule rate ($133,510.03). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs,CASE-25115,APC,25115,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14438.27,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14438.27,55762.74,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13728.80,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13264.54,50759.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE|PO,CASE-29825,APC,29825,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38792,APC,38792,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12120.70,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",11807.04,11807.04,11807.04,1 through 10,other,11710.82,34749.58,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6953.00,,"Per diem ($6,953). If length of stay < 4.5, first 1 days paid at a per diem of $13,906 instead. Capped at $31,286.59.",,,,0,other,6953.00,35389.05,Estimated amount calculated based on 2 day length of stay.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5182.53,,"Case rate ($5,007.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,626.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,094.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,645.03. The transfer operating threshold is the transfer adjustment factor * $4,626.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.24. The transfer capital threshold is the transfer adjustment factor * $362.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5182.53,5182.53,5182.53,1 through 10,other,5007.28,16142.41,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|RIGHT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41847.08,,,,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
Fasciectomy Plantar Fascia Partial Spx|RIGHT SIDE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|PO,CASE-11422,APC,11422,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1556.82,1556.82,1556.82,1 through 10,other,1566.49,1644.81,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11350.83,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10810.31,32077.45,Inpatient DRG
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15804.57,,,,,,0,other,5244.04,15804.57,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],68007.59,,"Case rate ($64,769.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,760.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,589.76. The transfer capital threshold is the transfer adjustment factor * $4,589.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,64872.40,212258.00,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30013.33,,,,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17695.16,,of the excess amount.,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|RIGHT SIDE,CASE-37225,APC,37225,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],538.93,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12326.86,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12326.86,53121.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Fracture Great Toe/Phalanx/Phalanges|LEFT FOOT, GREAT TOE",CASE-28505,APC,28505,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16849.39,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16849.39,49997.29,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21005.25,,"Fee schedule rate ($21,005.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],95067.22,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10249.47,96445.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8131.20,,"Case rate ($7,744). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,731.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $560.22. The transfer capital threshold is the transfer adjustment factor * $560.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7744.00,24853.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5751.18,,"Case rate ($5,477.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,559.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $388.14. The transfer capital threshold is the transfer adjustment factor * $388.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5486.04,17919.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Esopg/Gstr Fundoplasty,CASE-43280,APC,43280,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Radial&Ulnar Shaft Fx W/Fixj Radius&Ulna,CASE-25575,APC,25575,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12000.95,,"Fee schedule rate ($12,000.95). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13503.79,,"Case rate ($12,860.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,082.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $911.36. The transfer capital threshold is the transfer adjustment factor * $911.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13423.51,5627.43,72044.92,26,other,12881.26,38222.57,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20788.82,,"Fee schedule rate ($20,788.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29582.40,,,,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30538.70,,,,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10815.61,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9888.00,40658.63,Inpatient DRG
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],61129.87,,"Fee schedule rate ($61,129.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],44973.75,,,,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35040.80,,,,,,0,other,1188.00,35040.80,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21451.50,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8940.00,63653.13,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6828.45,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6503.29,19528.85,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
Optx Greater Humeral Tuberosity Fx W/Int Fixj,CASE-23630,APC,23630,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|BILATERAL PROCEDURE,CASE-37722,APC,37722,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY VASCULAR PROCEDURES,MODERATE",181,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],32578.65,,"Case rate ($31,027.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31027.29,32578.65,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13588.14,,"Case rate ($13,588.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,555.10, add-ons for qualifying new technology services are included. If operating cost exceeds $48,023.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,154.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,605.14. The transfer operating threshold is the transfer adjustment factor * $12,555.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $983.00. The transfer capital threshold is the transfer adjustment factor * $983.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13588.14,40320.14,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31567.81,,,,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6503.29,19528.85,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],133282.80,,"Fee schedule rate ($133,282.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",8358.52,8358.52,8358.52,1 through 10,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25863.45,,,,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
"CHOLECYSTECTOMY,MODERATE",263,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],19059.28,,"Case rate ($19,059.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19059.28,20012.24,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20274.44,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20274.44,80940.99,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8704.87,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8704.87,25830.00,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18988.45,,"Fee schedule rate ($18,988.45). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Rhytidectomy Neck W/Platysmal Tightening,CASE-15825,APC,15825,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvc/Le Init 2nd,CASE-36246,APC,36246,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13.94,,,,,,0,other,13.28,13.94,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13972.09,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7984.05,33319.56,All Other Inpatient
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|LEFT SIDE,CASE-27130,APC,27130,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",11945.04,11945.04,11945.04,1 through 10,other,12177.08,12785.93,OPPS APC
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MINOR",425,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2597.58,,"Case rate for a one day stay ($2,597.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2597.58,2727.46,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],3753.29,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3753.29,11765.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"DIABETES,MODERATE",420,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2783.34,,"Case rate for a one day stay ($2,650.80). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2650.80,2783.34,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6461.52,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6461.52,21772.28,Inpatient DRG
Rpr Recrt Inguinal Hernia Any Age Reducible|LEFT SIDE,CASE-49520,APC,49520,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3514.75,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],43344.00,,"Fee schedule rate ($43,344.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7289.81,,"Fee schedule rate ($7,289.81). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17835.23,,,,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17702.00,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,17103.38,50750.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Suture Infrapatellar Tendon Primary|RIGHT SIDE|PO,CASE-27380,APC,27380,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|RIGHT FOOT, GREAT TOE|PO",CASE-28297,APC,28297,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|LEFT SIDE,CASE-27130,APC,27130,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12223.35,,,,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,70321.74,Estimated amount calculated based on 17 day length of stay.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],63653.13,,,,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21828.16,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21828.16,93157.39,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11114.67,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7000.00,32980.62,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,APC,25608,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14149.80,,"Fee schedule rate ($14,149.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6531.00,,"Per diem ($6,531). If length of stay < 4.1, first 1 days paid at a per diem of $13,062 instead. Capped at $26,776.27.",,,,0,other,6531.00,35832.77,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5700.71,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5507.93,20510.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6088.84,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6088.84,18067.42,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22770.77,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7231.00,38610.21,All Other Inpatient
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, GREAT TOE",CASE-28124,APC,28124,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],29405.43,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,28005.17,115392.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22195.56,,"Case rate ($21,138.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,669.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.96. The transfer capital threshold is the transfer adjustment factor * $1,497.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12500.00,83592.64,Inpatient DRG
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],38877.85,,"Fee schedule rate ($38,877.85). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
HC Intro Cath Dialysis Circuit,CASE-36901,APC,36901,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1545.29,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1492.63,1492.63,1492.63,1 through 10,other,1493.03,1567.69,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],37794.93,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10105.00,120252.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5611.35,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5344.14,15857.69,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17658.44,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16817.56,58510.23,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24053.80,,"Case rate ($22,908.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,828.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.25. The transfer capital threshold is the transfer adjustment factor * $1,657.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22908.38,67976.16,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23915.01,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",23915.02,23915.02,23915.02,1 through 10,other,23915.01,121205.60,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO|SEPARATE STRUCTURE,CASE-62323,APC,62323,CPT,0360,RC,,,PO|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Biopsy/Excision Inguinofemoral Nodes|LEFT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3732.70,3732.70,3732.70,1 through 10,other,6297.98,6612.88,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,868.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],48720.85,,"Fee schedule rate ($48,720.85). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],25207.69,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",1036337.75,1036337.75,1036337.75,1 through 10,other,24713.42,73332.24,Inpatient DRG
Surg Tx Anal Fistula Subq,CASE-46270,APC,46270,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11179.35,,"Fee schedule rate ($11,179.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
"Amputation Metatarsal W/Toe Single|LEFT FOOT, FIFTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T4,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29521.40,,,,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13698.44,,"Fee schedule rate ($13,698.44). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6797.06,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6797.06,20168.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28895.67,,,,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21133.20,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21133.20,88801.87,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],36511.04,,"Fee schedule rate ($36,511.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12521.78,,"Fee schedule rate ($12,521.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11427.59,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6350.00,33244.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20306.22,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34603.80,,"Fee schedule rate ($34,603.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22091.17,,"Fee schedule rate ($22,091.17). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13662.46,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7231.00,38610.21,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15895.95,,"Fee schedule rate ($15,895.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13264.54,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13264.54,50759.39,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
HC Revasc Intravasc Lithotripsy|RIGHT SIDE,CASE-C9764,APC,C9764,CPT,0481,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inguinofem Lmphadec Supfc W/Cloquets Node Spx,CASE-38760,APC,38760,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],70037.75,,"Fee schedule rate ($70,037.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.9), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15632.72,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15326.20,52511.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39854.32,,"Fee schedule rate ($39,854.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15524.53,,"Fee schedule rate ($15,524.53). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6235.22,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.30,18621.89,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,13588.14,40320.14,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32825.17,,,,,,0,other,10888.24,32825.17,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4836.86,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4742.02,14071.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8852.60,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8679.02,29908.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|BILATERAL PROCEDURE,CASE-38570,APC,38570,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14096.07,,"Case rate ($13,424.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,122.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.33. The transfer capital threshold is the transfer adjustment factor * $951.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13446.23,39899.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5006.61,,"Case rate ($5,006.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,625.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,093.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,644.42. The transfer operating threshold is the transfer adjustment factor * $4,625.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.19. The transfer capital threshold is the transfer adjustment factor * $362.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5006.61,14856.14,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT SIDE|PO,CASE-26111,APC,26111,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],36287.40,,"Fee schedule rate ($36,287.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20090.22,,,,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,XU|T6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5605.09,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5338.18,15839.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7231.00,,"Per diem ($7,231). If length of stay < 5.1, first 1 days paid at a per diem of $14,462 instead. Capped at $36,875.62.",,,,0,other,7231.00,38610.21,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],37665.71,,,,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14766.09,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14062.94,61706.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6803.69,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6253.46,6253.46,6878.73,1 through 10,other,5843.00,27370.21,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11280.63,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10899.16,39746.35,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17969.04,,,,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9574.89,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9574.89,28411.62,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9932.78,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9738.02,28895.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],40046.00,,"Fee schedule rate ($40,046.00). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8006.09,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4574.91,13575.16,All Other Inpatient
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15793.67,,"Case rate ($15,041.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,237.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,065.90. The transfer capital threshold is the transfer adjustment factor * $1,065.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",15502.61,15502.61,15502.61,1 through 10,other,15065.57,53815.71,Inpatient DRG
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FOURTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4907.99,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4742.02,14071.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],107249.77,,"Fee schedule rate ($107,249.77). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16644.64,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15852.04,50518.01,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
"SEIZURE,MAJOR",053,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],13965.66,,"Case rate ($13,965.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13965.66,14663.94,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
Bone Graft Any Donor Area Major/Large|SEPARATE STRUCTURE,CASE-20902,APC,20902,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Medium WO US|RIGHT SIDE|PO,CASE-20605,APC,20605,CPT,0510,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13061.00,,"Per diem ($13,061). If length of stay < 11, first 1 days paid at a per diem of $26,122 instead. Capped at $143,676.24.",,,,0,other,13061.00,162464.13,Estimated amount calculated based on 8 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23996.10,,,,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
"HEART FAILURE,MINOR",194,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7441.50,,"Case rate ($7,087.14). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7087.14,7441.50,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9618.93,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,45869.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteoplasty Radius/Ulna Shortening|LEFT SIDE|PO,CASE-25390,APC,25390,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ligation/Biopsy Temporal Artery|RIGHT SIDE,CASE-37609,APC,37609,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16616.10,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15824.86,49371.45,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7728.84,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",24001.14,24001.14,27280.60,1 through 10,other,3295.00,37575.69,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19204.75,,,,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
Removal Implant Deep|LEFT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],40183.85,,of the excess amount.,39027.36,39027.36,39027.36,1 through 10,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
Aspiration Bladder Insert Suprapubic Catheter|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51102,APC,51102,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5760.34,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5486.04,17919.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MAJOR",385,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],12966.77,,"Case rate ($12,349.30). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12349.30,12966.77,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|RIGHT SIDE|PO,CASE-25609,APC,25609,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HEART FAILURE,EXTREME",194,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],29459.90,,"Case rate ($28,057.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,28057.05,29459.90,There are no additional notes associated with this service or procedure.
Curtg/Caut Anal Fissure W/Dilat Sphnctr Spx 1st,CASE-46940,APC,46940,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],48088.79,,"Fee schedule rate ($48,088.79). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7208.86,,"Case rate ($4,119.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,806.17, add-ons for qualifying new technology services are included. If operating cost exceeds $39,274.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,821.34. The transfer operating threshold is the transfer adjustment factor * $3,806.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.00. The transfer capital threshold is the transfer adjustment factor * $298.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4119.35,12223.35,All Other Inpatient
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19363.31,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19363.31,79918.67,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9743.09,,"Case rate ($9,279.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,573.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,041.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,607.86. The transfer operating threshold is the transfer adjustment factor * $8,573.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.28. The transfer capital threshold is the transfer adjustment factor * $671.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9279.13,27534.03,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],40470.31,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,23125.89,68621.57,All Other Inpatient
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],41015.72,,"Fee schedule rate ($41,015.72). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17268.22,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,16929.63,63934.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18579.92,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26291.65,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,15023.80,48104.19,All Other Inpatient
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10334.84,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10334.84,30666.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|RIGHT SIDE,CASE-24073,APC,24073,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,EXTREME",721,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],30791.05,,"Case rate ($30,791.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,30791.05,32330.60,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4867.98,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4772.53,14161.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],38035.88,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36224.65,128473.68,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4797.39,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4568.94,13557.45,Inpatient DRG
HC Thromb Mech 1st Vssl,CASE-37184,APC,37184,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22293.23,,"Fee schedule rate ($22,293.23). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
Unlisted Procedure Femur/Knee|RIGHT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],242.14,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,233.96,245.65,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6063.93,,"Case rate ($5,775.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.79. The transfer capital threshold is the transfer adjustment factor * $417.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5775.17,17136.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],28870.62,,"Case rate ($27,495.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,119.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,948.45. The transfer capital threshold is the transfer adjustment factor * $1,948.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27539.67,109237.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33931.02,,,,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],45834.02,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,45834.02,151120.97,Inpatient DRG
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14596.33,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14102.73,41847.08,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10283.39,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9935.64,29482.05,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24906.74,,"Case rate ($23,720.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,852.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,680.93. The transfer capital threshold is the transfer adjustment factor * $1,680.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23758.52,103116.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia Only|RIGHT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16197.86,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6965.00,27465.16,All Other Inpatient
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],60333.05,,"Fee schedule rate ($60,333.05). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9929.69,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9456.85,28061.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15818.85,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15065.57,53815.71,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER CIRCULATORY SYSTEM DIAGNOSES,MAJOR",207,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13390.34,,"Case rate ($12,752.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12752.70,13390.34,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11621.00,,"Per diem ($11,621). If length of stay < 22.4, first 1 days paid at a per diem of $23,242 instead. Capped at $260,309.36.",,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],82553.89,,"Fee schedule rate ($82,553.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15090.78,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15090.78,44778.95,Inpatient DRG
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52352,APC,52352,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5263.48,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MODERATE",385,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8127.41,,"Case rate ($8,127.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8127.41,8533.78,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13970.92,,"Case rate ($13,305.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,294.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,761.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,133.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,343.08. The transfer operating threshold is the transfer adjustment factor * $12,294.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.56. The transfer capital threshold is the transfer adjustment factor * $962.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13305.64,39481.90,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],26732.41,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25459.44,80806.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],38724.86,,"Fee schedule rate ($38,724.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8800.23,,"Case rate ($8,381.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,765.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.92. The transfer capital threshold is the transfer adjustment factor * $593.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",9465.73,9465.73,9465.73,1 through 10,other,8394.53,24909.11,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20380.20,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11645.83,37502.92,All Other Inpatient
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11888.55,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11888.55,35276.93,Inpatient DRG
"Partical Excision Bone Phalanx Toe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Iliac Territory Plasty Stent|BILATERAL PROCEDURE,CASE-37221,APC,37221,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],444.96,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],73546.72,,,,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,APC,52332,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4743.76,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4517.87,13932.70,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],31872.38,,"Case rate ($30,354.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,322.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,151.04. The transfer capital threshold is the transfer adjustment factor * $2,151.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30403.05,90685.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8816.90,,"Case rate ($8,397.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.04. The transfer capital threshold is the transfer adjustment factor * $595.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",8816.91,8787.79,33457.49,1 through 10,other,8410.44,24956.34,Inpatient DRG
Esophagogastroduodenoscopy US Scope W/Adj Strxrs|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43237,APC,43237,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
Dilation Esophagus Guide Wire,CASE-43453,APC,43453,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20434.05,,"Fee schedule rate ($20,434.05). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
Excision Mal Lesion Trunk/Arm/Leg 2.1-3.0 Cm,CASE-11603,APC,11603,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3899.35,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|PO,CASE-64493,APC,64493,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7970.35,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7590.81,32847.45,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4369.17,,"Case rate ($4,161.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,466.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $294.87. The transfer capital threshold is the transfer adjustment factor * $294.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4167.74,12366.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12803.03,,"Case rate ($12,193.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,035.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.06. The transfer capital threshold is the transfer adjustment factor * $864.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",8789.30,8789.30,8789.30,1 through 10,other,12212.80,39290.21,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8383.25,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7984.05,23691.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy,CASE-44970,APC,44970,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5605.96,5605.96,5605.96,1 through 10,other,5733.99,6020.69,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],56694.72,,"Fee schedule rate ($56,694.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|BILATERAL PROCEDURE,CASE-52354,APC,52354,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6675.07,,"Case rate ($6,357.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,621.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.49. The transfer capital threshold is the transfer adjustment factor * $450.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,18893.86,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE,CASE-29876,APC,29876,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|PO",CASE-64491,APC,64491,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvc/Le Init 2nd|LEFT SIDE,CASE-36246,APC,36246,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11010.89,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10638.54,40729.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THUMB|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,FA|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,MINOR",175,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11860.62,,"Case rate for a one day stay ($11,860.62). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,11860.62,12453.65,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28296,APC,28296,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB|PO",CASE-26540,APC,26540,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"Synovectomy Metatarsophalangeal Joint Each|LEFT FOOT, SECOND DIGIT",CASE-28072,APC,28072,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"OTHER SMALL AND LARGE BOWEL PROCEDURES,MINOR",223,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4446.92,,"Case rate for a one day stay ($4,446.92). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,4446.92,4669.27,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],113934.44,,"Fee schedule rate ($113,934.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Lateral Release,CASE-29873,APC,29873,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12823.44,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12212.80,39290.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr,CASE-28238,APC,28238,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14002.25,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13335.48,39570.45,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],40628.03,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,39831.40,138208.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],130347.93,,"Fee schedule rate ($130,347.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30254.51,130347.93,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24428.09,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23602.02,108295.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10944.14,,"Case rate ($10,422.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,909.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $738.61. The transfer capital threshold is the transfer adjustment factor * $738.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10439.61,34540.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10810.31,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10810.31,32077.45,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14428.65,,"Fee schedule rate ($14,428.65). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],48252.91,,"Fee schedule rate ($48,252.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34353.60,,"Fee schedule rate ($34,353.60). Adds an outlier to normal pricing equal to the per diem rate ($257,654.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,12121.97,35969.56,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],27357.31,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27357.31,100904.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|LEFT FOOT, SECOND DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12296.36,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11710.82,34749.58,Inpatient DRG
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22919.57,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21828.16,93157.39,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7964.08,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33946.09,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
Vaginectomy Partial Removal Vaginal Wall,CASE-57106,APC,57106,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20832.04,,,,,,0,other,6910.06,20832.04,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Partial Nephrectomy|RIGHT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9787.84,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9456.85,28061.37,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],43675.07,,,,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],27861.95,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27861.95,82674.88,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],133824.90,,"Fee schedule rate ($133,824.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,38916.28,133824.90,There are no additional notes associated with this service or procedure.
HC Rt Bronchoscopy Alveolar Lavage,CASE-31624,APC,31624,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1772.59,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1688.18,1772.59,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17584.61,,"Fee schedule rate ($17,584.61). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6204.88,19589.20,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11564.71,,"Case rate ($11,014.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,227.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,773.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,428.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $10,233.04. The transfer operating threshold is the transfer adjustment factor * $10,227.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.97. The transfer capital threshold is the transfer adjustment factor * $780.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11036.50,33262.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25515.32,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,14580.18,57079.69,All Other Inpatient
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20788.82,,"Fee schedule rate ($20,788.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],32876.47,,"Fee schedule rate ($32,876.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17556.38,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,17212.14,64440.06,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE|PO,CASE-27792,APC,27792,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16810.38,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16009.89,58554.60,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7308.00,,"Per diem ($7,308). If length of stay < 5.5, first 1 days paid at a per diem of $14,616 instead. Capped at $40,192.59.",,,,0,other,7308.00,42083.20,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9600.57,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5486.04,17919.05,All Other Inpatient
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13594.96,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13135.23,38976.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE,CASE-29806,APC,29806,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],81324.83,,"Fee schedule rate ($81,324.83). Adds an outlier to normal pricing equal to the per diem rate ($106,784.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],195125.77,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,185834.07,195125.77,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10528.47,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10528.47,44148.02,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8301.93,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6495.00,23801.30,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],35466.15,,"Fee schedule rate ($35,466.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10164.64,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10145.90,5278.64,20796.50,1 through 10,other,9820.91,29141.64,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5625.00,,"Per diem ($5,625). If length of stay < 2.6, first 1 days paid at a per diem of $11,250 instead. Capped at $14,624.71.",14624.71,14624.71,14624.71,1 through 10,other,5160.45,15312.64,Estimated amount calculated based on 2 day length of stay.
HC I & D Simple,CASE-10060,APC,10060,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14472.76,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14472.76,56135.46,Inpatient DRG
HC Peripheral Block - Femoral Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FOURTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE|PO,CASE-25628,APC,25628,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],96844.29,,,,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8410.44,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8410.44,24956.34,Inpatient DRG
Laparoscopy Enterolysis Separate Procedure,CASE-44180,APC,44180,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,APC,49650,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",5875.02,5687.21,5875.02,1 through 10,other,5733.99,6020.69,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12861.93,,"Fee schedule rate ($12,861.93). Adds an outlier to normal pricing equal to the per diem rate ($47,786.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|LEFT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",846.40,423.20,860.69,1 through 10,other,882.03,926.14,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7350.79,,"Case rate ($7,000.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.10. The transfer capital threshold is the transfer adjustment factor * $496.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7011.91,27304.54,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5451.02,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",5451.02,5451.02,5451.02,1 through 10,other,5344.14,15857.69,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31790.24,,"Fee schedule rate ($31,790.24). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,11217.46,37366.25,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14737.18,,"Case rate ($14,448.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,349.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,817.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,216.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,402.99. The transfer operating threshold is the transfer adjustment factor * $13,349.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,045.22. The transfer capital threshold is the transfer adjustment factor * $1,045.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6940.00,42872.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE|PO,CASE-28740,APC,28740,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28847.26,,"Fee schedule rate ($28,847.26). Adds an outlier to normal pricing equal to the per diem rate ($89,320.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE,CASE-28322,APC,28322,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],82553.89,,"Fee schedule rate ($82,553.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion,CASE-52354,APC,52354,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],34214.43,,"Case rate ($32,585.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,480.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,309.10. The transfer capital threshold is the transfer adjustment factor * $2,309.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32637.12,96844.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE,CASE-27695,APC,27695,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33483.49,,"Fee schedule rate ($33,483.49). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6531.00,,"Per diem ($6,531). If length of stay < 4.1, first 1 days paid at a per diem of $13,062 instead. Capped at $26,776.27.",,,,0,other,6531.00,35832.77,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16929.63,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,16929.63,63934.22,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|RIGHT SIDE,CASE-28309,APC,28309,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
Excision Ganglion Wrist Dorsal/Volar Primary|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac W/Port Tun >5|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-36561,APC,36561,CPT,0361,RC,,,73,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13827.53,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13827.53,41030.48,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11426.12,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6953.00,35389.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Partial Nephrectomy|RIGHT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36008.91,,,,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],72246.07,,,,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10669.04,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,31658.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27691,APC,27691,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE|PO,CASE-29898,APC,29898,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",9543.19,9543.19,9543.19,1 through 10,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7289.74,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7289.74,21630.93,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],26024.99,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9242.00,76216.30,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33186.01,,"Fee schedule rate ($33,186.01). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
Open Treatment Metatarsal Fracture Each|RIGHT SIDE,CASE-28485,APC,28485,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
Open Treatment Calcaneal Fracture|RIGHT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy W/Dil Bladder General Anesth,CASE-52260,APC,52260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Tibia|LEFT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],890.35,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,860.25,903.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,APC,43274,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6045.95,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5758.05,6045.95,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21086.06,,"Case rate ($20,081.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,594.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,423.08. The transfer capital threshold is the transfer adjustment factor * $1,423.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",81851.32,81851.32,81851.32,1 through 10,other,17274.00,73717.28,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI HEART FAILURE OR SHOCK,MODERATE",171,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],24698.60,,"Case rate ($24,698.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24698.60,25933.53,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn,CASE-64415,APC,64415,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13791.99,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13135.23,38976.20,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5007.28,,"Case rate ($5,007.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,626.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,094.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,645.03. The transfer operating threshold is the transfer adjustment factor * $4,626.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.24. The transfer capital threshold is the transfer adjustment factor * $362.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5297.06,5297.06,5297.06,1 through 10,other,5007.28,16142.41,Inpatient DRG
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12006.70,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11434.95,119072.21,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15717.99,,,,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",10405.88,10405.88,10405.88,1 through 10,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
HC Tib per Territory Plasty|RIGHT SIDE,CASE-37228,APC,37228,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],505.96,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20832.04,,,,,,0,other,6910.06,20832.04,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28061.37,,,,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21766.70,,,,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6633.36,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6503.29,19528.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20593.95,,,,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9371.28,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8925.03,26628.31,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8762.74,,"Case rate ($5,007.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,626.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,094.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,645.03. The transfer operating threshold is the transfer adjustment factor * $4,626.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.24. The transfer capital threshold is the transfer adjustment factor * $362.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5007.28,16142.41,All Other Inpatient
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7102.10,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7102.10,21074.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
"OTHER AFTERCARE AND CONVALESCENCE,EXTREME",862,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9280.97,,"Case rate ($9,280.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9280.97,9745.02,There are no additional notes associated with this service or procedure.
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, SECOND DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,MAJOR",174,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7653.61,,"Case rate for a one day stay ($7,653.61). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,7653.61,8036.29,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24924.90,,"Fee schedule rate ($24,924.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],135316.65,,"Fee schedule rate ($135,316.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,EXTREME",137,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],23746.74,,"Case rate ($23,746.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,23746.74,24934.08,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13397.93,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13135.23,38976.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7078.89,,"Case rate ($7,078.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,540.71, add-ons for qualifying new technology services are included. If operating cost exceeds $42,008.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,683.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,566.78. The transfer operating threshold is the transfer adjustment factor * $6,540.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.10. The transfer capital threshold is the transfer adjustment factor * $512.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7078.89,21005.20,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13430.62,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12791.07,43031.63,Inpatient DRG
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13811.29,,,,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36801.89,,,,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24472.02,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23644.46,105789.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],30149.39,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,29129.85,86437.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],92045.07,,,,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8086.83,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,34379.15,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12975.19,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12536.42,37199.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9840.60,,"Fee schedule rate ($9,840.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
Transperineal Plmt Biodegradable Matrl 1/Mlt Njx,CASE-55874,APC,55874,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",4884.61,4884.61,4884.61,1 through 10,other,5085.49,5339.77,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5970.00,,"Per diem ($5,970). If length of stay < 6.2, first 1 days paid at a per diem of $11,940 instead. Capped at $37,016.57.",,,,0,other,5970.00,38757.79,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
HC Intro Cath Dialysis Circuit,CASE-36901,APC,36901,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1493.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35884.94,,,,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14766.09,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14062.94,61706.77,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],93678.26,,,,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8143.73,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",8028.26,8028.26,8028.26,1 through 10,other,7984.05,23691.11,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12854.56,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6308.00,21796.21,All Other Inpatient
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE|PO,CASE-25628,APC,25628,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY VASCULAR PROCEDURES,MAJOR",181,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],43856.94,,"Case rate ($41,768.51). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,41768.51,43856.94,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4090.84,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,2285.00,12138.74,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],56694.72,,"Fee schedule rate ($56,694.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],102807.11,,"Fee schedule rate ($102,807.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4428.32,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4341.49,12882.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],30586.34,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29129.85,86437.13,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11156.55,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10625.29,39295.53,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT|PO",CASE-28820,APC,28820,CPT,0360,RC,,,T1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-20610,APC,20610,CPT,0510,RC,,,RT|73,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
Tendon Sheath Incision|PO,CASE-26055,APC,26055,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
HC Inj Tendon Sheath/Ligament|LEFT SIDE|PO,CASE-20550,APC,20550,CPT,0510,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6068.82,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5779.83,17150.47,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18781.54,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7455.00,53076.74,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20338.50,,"Fee schedule rate ($20,338.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,1188.00,27484.83,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB|PO",CASE-64831,APC,64831,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30145.85,,"Fee schedule rate ($30,145.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33931.02,,,,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",6864.07,6864.07,6864.07,1 through 10,other,6882.29,7226.40,OPPS APC
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10869.06,,"Case rate ($10,351.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,904.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10367.99,37103.57,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dil Bladder General Anesth,CASE-52260,APC,52260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6137.01,,"Case rate ($5,844.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.18. The transfer capital threshold is the transfer adjustment factor * $414.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,17370.86,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19056.10,,"Fee schedule rate ($19,056.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64448,APC,64448,CPT,0360,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5007.28,,"Case rate ($5,007.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,626.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,094.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,645.03. The transfer operating threshold is the transfer adjustment factor * $4,626.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.24. The transfer capital threshold is the transfer adjustment factor * $362.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5007.28,16142.41,Inpatient DRG
HC Open/Perq Place Stent Ea Add A,CASE-37237,APC,37237,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC
Transurethral Resection Bladder Neck|SEPARATE STRUCTURE,CASE-52500,APC,52500,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
"MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,MODERATE",281,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],12559.16,,"Case rate ($11,961.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11961.10,12559.16,There are no additional notes associated with this service or procedure.
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10405.96,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9910.44,43344.00,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],67142.93,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",65205.61,65205.61,65205.61,1 through 10,other,64872.40,212258.00,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12145.49,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6940.28,20593.95,All Other Inpatient
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6617.34,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5683.00,19635.68,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13529.83,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13264.54,50759.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],48252.91,,"Fee schedule rate ($48,252.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],47169.70,,,,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
Arthrs Knee Debridement/Shaving Artclr Crtlg|LEFT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
HC Pbb Carpal Tunnel Inj Pmc|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-20526,APC,20526,CPT,0510,RC,,,LT|PO|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19137.85,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19137.85,64589.15,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],53147.51,,"Case rate ($50,616.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,758.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,586.87. The transfer capital threshold is the transfer adjustment factor * $3,586.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13061.00,162464.13,Inpatient DRG
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9094.04,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8915.73,26455.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6374.64,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6230.00,21325.01,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12900.02,,"Fee schedule rate ($12,900.02). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],20331.48,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19363.31,79918.67,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],3418.46,,"Fee schedule rate ($3,418.46). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|RIGHT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],189.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4518.89,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4303.70,14124.38,Inpatient DRG
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16192.08,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15421.03,49137.17,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19616.66,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,19232.02,68941.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39228.51,,"Fee schedule rate ($39,228.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16747.70,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15950.19,63458.56,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10415.81,,"Case rate ($9,919.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,874.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $702.95. The transfer capital threshold is the transfer adjustment factor * $702.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6053.27,6053.27,6053.27,1 through 10,other,9935.64,29482.05,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20113.98,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,17274.00,73717.28,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5807.67,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5807.67,17233.12,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20086.28,,,,,,0,other,6553.68,20086.28,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12615.75,,"Fee schedule rate ($12,615.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12791.07,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,12791.07,43031.63,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|RIGHT SIDE|PO,CASE-29884,APC,29884,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],873.59,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,873.59,917.27,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23691.11,,,,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19044.40,,"APC Price ($18,400.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,18400.38,19320.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv,CASE-64418,APC,64418,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17212.32,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
Partial Excision Bone Talus/Calcaneus|LEFT SIDE|PO,CASE-28120,APC,28120,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Ather|RIGHT SIDE,CASE-37229,APC,37229,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],626.55,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10787.72,,"Case rate ($10,274.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,899.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.05. The transfer capital threshold is the transfer adjustment factor * $728.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",10289.46,10289.46,10289.46,1 through 10,other,10290.40,42115.80,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13232.13,,"Fee schedule rate ($13,232.13). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Chemodenervation Muscle Neck Unilat for Dystonia|RIGHT SIDE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",29.21,29.21,444.36,1 through 10,other,882.03,926.14,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],51012.62,,,,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12402.46,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12402.46,36801.89,Inpatient DRG
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12881.26,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12881.26,12881.26,14193.54,1 through 10,other,12881.26,38222.57,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6367.80,,"Case rate ($6,064.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.76. The transfer capital threshold is the transfer adjustment factor * $429.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6074.24,18024.13,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13249.94,40085.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis Addl 20 Cm<,CASE-97598,APC,97598,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,50750.92,Estimated amount calculated based on 22 day length of stay.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,55581.70,Estimated amount calculated based on 10 day length of stay.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16383.52,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16062.27,48077.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13322.85,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5970.00,38757.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Capsulectomy/Capsulotomy Mtcarphlngl Joint Each|LEFT SIDE|PO,CASE-26520,APC,26520,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3212.01,3258.56,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11759.58,,"Case rate ($11,199.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.64. The transfer capital threshold is the transfer adjustment factor * $793.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",8488.42,8488.42,8488.42,1 through 10,other,11217.46,37366.25,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7146.39,,"Case rate ($6,806.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,653.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.30. The transfer capital threshold is the transfer adjustment factor * $482.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5520.00,26638.96,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],35207.55,,"Fee schedule rate ($35,207.55). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21900.45,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12514.54,37134.43,All Other Inpatient
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24782.12,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23602.02,108295.22,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],53409.30,,"Fee schedule rate ($53,409.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9098.46,,"Case rate ($8,665.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,785.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.05. The transfer capital threshold is the transfer adjustment factor * $614.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6052.20,6052.20,6052.20,1 through 10,other,8679.02,29908.27,Inpatient DRG
Cystourethroscopy With Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52204,APC,52204,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13525.32,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12881.26,38222.57,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23320.23,,"Fee schedule rate ($23,320.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],42670.25,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,42670.25,133443.30,Inpatient DRG
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THIRD DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],66275.39,,"Fee schedule rate ($66,275.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
Laps Supracervical Hysterectomy >250,CASE-58543,APC,58543,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15896.49,51306.05,Zero final payments for the item or service in the 15 months prior to posting the file.
"HYPERTENSION,MODERATE",199,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3063.67,,"Case rate for a one day stay ($2,917.78). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2917.78,3063.67,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7369.00,,"Per diem ($7,369). If length of stay < 2.4, first 1 days paid at a per diem of $14,738 instead. Capped at $17,686.09.",,,,0,other,6240.68,18518.02,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12791.10,,"Fee schedule rate ($12,791.10). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12922.38,,"Fee schedule rate ($12,922.38). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10834.31,,"Case rate ($10,318.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.20. The transfer capital threshold is the transfer adjustment factor * $731.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10334.84,30666.60,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6748.64,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6748.64,20025.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7839.48,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7551.60,23262.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13119.35,,"Case rate ($12,494.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,056.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $885.41. The transfer capital threshold is the transfer adjustment factor * $885.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12889.87,12889.87,12889.87,1 through 10,other,12514.54,37134.43,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],3607.42,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3607.42,11497.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7125.55,,"Case rate ($6,786.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,652.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.90. The transfer capital threshold is the transfer adjustment factor * $480.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12415.77,12415.77,12415.77,1 through 10,other,6797.06,20168.93,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19312.24,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8972.00,76376.03,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4838.84,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4838.84,19587.42,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,APC,46200,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],51131.99,,"Fee schedule rate ($51,131.99). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11074.39,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6328.22,27416.36,All Other Inpatient
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8479.01,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8192.28,24308.97,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17969.04,,,,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6611.49,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6387.91,18954.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7102.10,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7102.10,21074.07,Inpatient DRG
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11136.51,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10759.91,46061.32,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cptr-Asst Surgical Navigation Image-Less,CASE-20985,APC,20985,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17212.32,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],48252.91,,"Fee schedule rate ($48,252.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4418.42,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4418.42,13110.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|LEFT SIDE,CASE-37766,APC,37766,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],42872.25,,,,,,0,other,6940.00,42872.25,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22565.55,,"Fee schedule rate ($22,565.55). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT SIDE|PO,CASE-26160,APC,26160,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4687.38,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4464.17,13577.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC 3rd Order Sel Abd/Lower Ext,CASE-36247,APC,36247,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8.46,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,APC,52351,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DEPRESSIVE DISORDERS,MAJOR",751,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11870.12,,"Case rate ($11,304.88). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11304.88,11870.12,There are no additional notes associated with this service or procedure.
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE|PO,CASE-27792,APC,27792,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5612.74,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5224.00,15861.63,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6334.78,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6033.12,17902.13,Inpatient DRG
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE,CASE-28238,APC,28238,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5237.39,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5237.39,5237.39,5237.39,1 through 10,other,5237.39,15540.89,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],76004.25,,"Fee schedule rate ($76,004.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],67331.56,,"Fee schedule rate ($67,331.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11895.84,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11895.84,35298.57,Inpatient DRG
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,MAJOR",201,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],12647.64,,"Case rate ($12,045.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12045.37,12647.64,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32711.70,,"Fee schedule rate ($32,711.70). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10385.64,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10034.43,29775.24,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16343.72,,,,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],86437.13,,,,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
Laps Surg Gastrostomy W/O Constj Gstr Tube Spx,CASE-43653,APC,43653,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19433.97,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18508.54,76171.92,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],53537.18,,,,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],41451.86,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",39888.98,39888.98,39888.98,1 through 10,other,40639.08,120588.53,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],40202.74,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,40202.74,148703.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER GASTROENTERITIS NAUSEA AND VOMITING,MAJOR",249,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2285.87,,"Case rate for a one day stay ($2,285.87). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2285.87,2400.16,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4757.78,,"Case rate ($4,531.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.10. The transfer capital threshold is the transfer adjustment factor * $321.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4538.44,18815.35,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22393.35,,"Fee schedule rate ($22,393.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12031.78,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11458.84,42820.42,Inpatient DRG
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3393.26,3393.26,3393.26,1 through 10,other,3343.33,3510.50,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6350.00,,"Per diem ($6,350). If length of stay < 5, first 1 days paid at a per diem of $12,700 instead. Capped at $31,750.77.",,,,0,other,6350.00,33244.29,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER PNEUMONIA,EXTREME",139,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],20973.98,,"Case rate ($19,975.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19975.22,20973.98,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10385.89,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10385.89,32176.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11039.73,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6953.00,35389.05,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18042.36,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18042.36,82749.58,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10440.75,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10236.03,30589.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13140.92,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12883.25,44763.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5245.79,,"Case rate ($4,995.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.03. The transfer capital threshold is the transfer adjustment factor * $354.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5003.96,21742.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33079.27,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,18902.44,56089.29,All Other Inpatient
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB EXCEPT TOES,MAJOR",305,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],31032.33,,"Case rate ($29,554.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29554.60,31032.33,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5648.94,,"Case rate ($5,379.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,996, add-ons for qualifying new technology services are included. If operating cost exceeds $45,541.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,029.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,998.47. The transfer operating threshold is the transfer adjustment factor * $4,996.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $381.47. The transfer capital threshold is the transfer adjustment factor * $381.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5389.29,16247.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Ankle Surgical Debridement Extensive|RIGHT SIDE|PO,CASE-29898,APC,29898,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39198.44,,"Fee schedule rate ($39,198.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17273.45,,"Fee schedule rate ($17,273.45). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
Arteriovenous Anastomosis Open Direct,CASE-36821,APC,36821,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11652.47,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11652.47,41507.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],158423.11,,"Fee schedule rate ($158,423.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,33843.71,Estimated amount calculated based on 10 day length of stay.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14798.73,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14508.56,59513.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,APC,25608,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34409.55,,"Fee schedule rate ($34,409.55). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE,CASE-29898,APC,29898,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Rmvl/Revj Sling Stress Incontinence,CASE-57287,APC,57287,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3223.82,,"APC Price ($3,070.31). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],32518.90,,"Case rate ($30,970.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,365.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,194.67. The transfer capital threshold is the transfer adjustment factor * $2,194.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31019.76,124854.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26291.41,,"Fee schedule rate ($26,291.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,8981.78,27528.12,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39854.32,,"Fee schedule rate ($39,854.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10863.50,,"Case rate ($10,346.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,904.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.17. The transfer capital threshold is the transfer adjustment factor * $733.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",18134.69,11059.13,97414.13,1 through 10,other,10362.69,29367.82,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|PO,CASE-64634,APC,64634,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",6529.99,6529.99,6529.99,1 through 10,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43277,APC,43277,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7964.08,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33946.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins|RIGHT SIDE|PO,CASE-25320,APC,25320,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17745.35,,"Fee schedule rate ($17,745.35). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6693.37,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6230.00,21325.01,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],27357.31,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27357.31,100904.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,76310.36,Estimated amount calculated based on 21 day length of stay.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],9242.00,,"Per diem ($9,242). If length of stay < 7.6, first 1 days paid at a per diem of $18,484 instead. Capped at $70,242.60.",,,,0,other,9242.00,76216.30,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],43128.06,,"Fee schedule rate ($43,128.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8562.42,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8394.53,24909.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8147.92,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7759.92,35376.63,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],26732.41,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25459.44,80806.10,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16833.60,,"Fee schedule rate ($16,833.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26270.73,,"Fee schedule rate ($26,270.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],103171.69,,"Fee schedule rate ($103,171.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6088.84,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6088.84,18067.42,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],10704.29,,,,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9280.46,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5417.39,5417.39,5417.39,1 through 10,other,9280.46,39957.56,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6552.71,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6240.68,18518.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER GASTROENTERITIS NAUSEA AND VOMITING,MAJOR",249,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2285.87,,"Case rate for a one day stay ($2,285.87). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2285.87,2400.16,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18085.97,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10334.84,30666.60,All Other Inpatient
Osteot W/WO Lngth Shrt/Corrj 1st Metar|LEFT SIDE|PO,CASE-28306,APC,28306,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6256.14,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13444.53,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12804.31,55145.09,Inpatient DRG
HC Trluml Balo Angiop 1st Vein,CASE-37248,APC,37248,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|LEFT SIDE,CASE-29825,APC,29825,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],14842.71,,"Fee schedule rate ($14,842.71). Adds an outlier to normal pricing equal to the per diem rate ($40,567.35) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10295.54,,"Case rate ($9,805.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,865.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.84. The transfer capital threshold is the transfer adjustment factor * $694.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9820.91,29141.64,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],41585.15,,"Fee schedule rate ($41,585.15). Adds an outlier to normal pricing equal to the per diem rate ($65,246.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14673.67,43541.27,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
Incision & Drainage Leg/Ankle Abscess/Hematoma|LEFT SIDE,CASE-27603,APC,27603,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],36505.40,,"Fee schedule rate ($36,505.40). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",11286.30,11286.30,11286.30,1 through 10,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,APC,58260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4910.73,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",855.44,855.44,855.44,1 through 10,other,838.89,880.84,OPPS APC
"Inject Nerv Blck,Paravert Sympath|RIGHT SIDE",CASE-64520,APC,64520,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8998.50,,"Fee schedule rate ($8,998.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10290.40,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10290.40,42115.80,Inpatient DRG
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE,CASE-28730,APC,28730,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],29890.76,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8232.00,84471.39,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13334.16,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12883.25,44763.90,Inpatient DRG
Arthroplasty Ankle W/Implant|RIGHT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],27022.53,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",17926.22,17926.22,17926.22,1 through 10,other,25735.75,27022.53,OPPS APC
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6290.26,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6077.55,18033.97,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11444.12,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10899.16,39746.35,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Revascularization Iliac Artery Angiop 1st Vsl|LEFT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],361.50,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14560.44,,"Case rate ($13,867.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,153.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $982.67. The transfer capital threshold is the transfer adjustment factor * $982.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",14195.21,14195.21,14195.21,1 through 10,other,13889.20,55846.16,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18926.21,,"Fee schedule rate ($18,926.21). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],30150.40,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,30150.40,89465.42,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13369.00,,"Per diem ($13,369). If length of stay < 6.3, first 1 days paid at a per diem of $26,738 instead. Capped at $84,226.47.",,,,0,other,13369.00,88188.38,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7826.00,,"Per diem ($7,826). If length of stay < 7.6, first 1 days paid at a per diem of $15,652 instead. Capped at $59,476.09.",,,,0,other,7826.00,90280.33,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11763.70,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6350.00,33244.29,Inpatient DRG
HC Inj Tendon Sheath/Ligament|PO,CASE-20550,APC,20550,CPT,0510,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],37495.71,,"Fee schedule rate ($37,495.71). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26300.80,,"Fee schedule rate ($26,300.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32988.90,,"Fee schedule rate ($32,988.90). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],86437.13,,,,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3899.35,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC 3rd Order Sel Abd/Lower Ext,CASE-36247,APC,36247,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8.88,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11690.93,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11690.93,56733.59,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13238.76,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,12791.07,43031.63,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33692.09,,"Fee schedule rate ($33,692.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35298.57,,,,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22148.78,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,21399.79,63499.65,Inpatient DRG
Open Treatment Bimalleolar Ankle Fracture,CASE-27814,APC,27814,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T7,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,APC,36245,CPT,0361,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8.88,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],42621.59,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40591.99,115037.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],28696.16,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,28696.16,118364.04,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22878.60,,"Fee schedule rate ($22,878.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19893.29,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,19503.23,57872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",665.41,665.41,665.41,1 through 10,other,669.51,702.98,OPPS APC
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,APC,54405,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19658.06,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19658.06,20640.96,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34528.24,,"Fee schedule rate ($34,528.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21991.57,,"Fee schedule rate ($21,991.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18067.42,,,,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],30163.67,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,30163.67,89504.77,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5442.84,,"Case rate ($5,183.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.00. The transfer capital threshold is the transfer adjustment factor * $375.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5183.66,15743.06,Inpatient DRG
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31767.69,,"Fee schedule rate ($31,767.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11036.50,33262.00,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Interphalangeal Jt W/Prosthetic Ea,CASE-26536,APC,26536,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21626.45,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",203329.39,203329.39,203329.39,1 through 10,other,20895.12,99969.33,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T8|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4749.35,,"Case rate ($4,523.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,179.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,647.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,498.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,195.97. The transfer operating threshold is the transfer adjustment factor * $4,179.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $327.22. The transfer capital threshold is the transfer adjustment factor * $327.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4523.19,16536.43,Inpatient DRG
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T8,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|LEFT SIDE,CASE-37766,APC,37766,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8228.75,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8228.75,24417.19,Inpatient DRG
"HC Debrid,Subq Ea Addt'l 20sqcm|PBB CHARGE",CASE-11045,APC,11045,CPT,0361,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,385.57,404.84,OPPS APC
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
Rhinp Prim Lat&Alar Crtlgs&/Elvtn Nasal Ti|BILATERAL PROCEDURE|PO,CASE-30400,APC,30400,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],68332.92,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11674.21,,"Fee schedule rate ($11,674.21). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4119.35,12223.35,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
"ALTERATION IN CONSCIOUSNESS,MAJOR",052,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15264.49,,"Case rate ($14,537.61). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14537.61,15264.49,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12012.63,,"Case rate ($11,440.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.72. The transfer capital threshold is the transfer adjustment factor * $810.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11458.84,42820.42,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6515.67,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6387.91,18954.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5942.94,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5942.94,5942.94,5942.94,1 through 10,other,5942.94,17634.53,Inpatient DRG
Laps Surg Esopg/Gstr Fundoplasty,CASE-43280,APC,43280,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7457.21,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7102.10,21074.07,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],32637.12,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",29094.86,26188.88,32875.52,1 through 10,other,32637.12,96844.29,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17150.47,,,,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7345.46,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6308.00,21796.21,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28695.03,,"Fee schedule rate ($28,695.03).",,,,0,other,14182.35,53827.17,Estimated amount calculated based on 3 day length of stay.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5034.82,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4795.07,19830.58,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23602.02,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23602.02,108295.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24888.65,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23703.48,110204.98,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11117.40,,"Fee schedule rate ($11,117.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32876.47,,"Fee schedule rate ($32,876.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],53076.74,,,,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
HC Removal Subcutaneous Cardiac Rhythm Monitor|UNUSUAL NON-OVERLAPPING SERVICE,CASE-33286,APC,33286,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8241.39,,"APC Price ($7,848.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7848.94,8241.39,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9371.28,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8925.03,26628.31,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16524.47,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16524.47,58465.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27691,APC,27691,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
Open Treatment of Ulnar Shaft Fracture|RIGHT SIDE|PO,CASE-25545,APC,25545,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19520.61,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,19137.85,64589.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6984.84,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6748.64,20025.28,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13682.43,,"Case rate ($13,030.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,094.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $923.41. The transfer capital threshold is the transfer adjustment factor * $923.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13402.98,13402.98,13402.98,1 through 10,other,13051.67,38728.27,Inpatient DRG
Capsulectomy/Capsulotomy Mtcarphlngl Joint Each,CASE-26520,APC,26520,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Tenolysis Flexor Tendon Palm/Finger Each Tendon,CASE-26440,APC,26440,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17279.67,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16456.83,55350.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Metatarsal Fracture Each|RIGHT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16573.70,,"Fee schedule rate ($16,573.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6632.59,19680.94,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11298.37,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11298.37,44627.23,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10400.49,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,30861.41,Inpatient DRG
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6910.06,,"Case rate ($6,910.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,405.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,149.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,408.97. The transfer operating threshold is the transfer adjustment factor * $6,405.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $501.10. The transfer capital threshold is the transfer adjustment factor * $501.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",22628.53,22628.53,22628.53,1 through 10,other,6910.06,20832.04,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6934.75,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6700.24,30254.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11054.89,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10528.47,44148.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
Dir Rpr Aneurysm Axil-Brachial Arm Incision,CASE-35011,APC,35011,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],57276.25,,"Fee schedule rate ($57,276.25). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],45202.80,,"Fee schedule rate ($45,202.80). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],45202.80,,"Fee schedule rate ($45,202.80). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12208.65,,"Case rate ($11,627.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,995.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.95. The transfer capital threshold is the transfer adjustment factor * $823.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11645.83,37502.92,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,41333.08,Estimated amount calculated based on 10 day length of stay.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"OTHER RESPIRATORY AND CHEST PROCEDURES,MODERATE",121,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],24082.45,,"Case rate ($24,082.45). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24082.45,25286.57,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],40666.46,,,,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14867.71,,"Case rate ($14,159.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,174.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,003.41. The transfer capital threshold is the transfer adjustment factor * $1,003.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7308.00,42083.20,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7648.51,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7648.51,27371.98,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10804.92,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10290.40,42115.80,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SMALL AND LARGE BOWEL PROCEDURES,MODERATE",223,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],19801.15,,"Case rate ($19,801.15). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19801.15,20791.21,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",10003.65,10003.65,10003.65,1 through 10,other,10082.05,10586.16,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9430.32,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,45869.64,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
Suture Infrapatellar Tendon Primary|RIGHT SIDE|PO,CASE-27380,APC,27380,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Lyr Clos Sc Tk Ext 7.6-12cm|SEPARATE STRUCTURE,CASE-12034,APC,12034,CPT,0450,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4922.42,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4755.96,21133.33,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17102.83,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16524.47,58465.86,Inpatient DRG
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6256.14,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13430.62,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12791.07,43031.63,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,Zero final payments for the item or service in the 15 months prior to posting the file.
"INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,MODERATE",817,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7792.53,,"Case rate ($7,421.46). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7421.46,7792.53,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8391.98,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8227.43,27001.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19871.72,,"Fee schedule rate ($19,871.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,7011.91,27304.54,Zero final payments for the item or service in the 15 months prior to posting the file.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6350.00,,"Per diem ($6,350). If length of stay < 5, first 1 days paid at a per diem of $12,700 instead. Capped at $31,750.77.",,,,0,other,6350.00,33244.29,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34934.31,,"Fee schedule rate ($34,934.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28832.22,,"Fee schedule rate ($28,832.22). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16929.63,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,16929.63,63934.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Vasc Embolize Occlude Organ,CASE-37243,APC,37243,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,APC,52601,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15928.53,,,,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-12032,APC,12032,CPT,0450,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],42083.20,,,,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16302.99,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16302.99,55737.89,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],34671.15,,"Case rate ($33,020.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,511.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,339.92. The transfer capital threshold is the transfer adjustment factor * $2,339.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,33072.79,98455.37,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9312.29,27632.41,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",43928.68,43928.68,43928.68,1 through 10,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|PO",CASE-64491,APC,64491,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE|PO,CASE-29825,APC,29825,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13249.94,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13249.94,40085.35,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6940.00,,"Per diem ($6,940). If length of stay < 5.9, first 1 days paid at a per diem of $13,880 instead. Capped at $40,946.19.",,,,0,other,6940.00,42872.25,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Transoral Lower Esophageal Myotomy,CASE-43497,APC,43497,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8704.81,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",8678.46,8678.46,8678.46,1 through 10,other,8410.44,24956.34,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],31621.43,,"Case rate ($30,115.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,305.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,134.10. The transfer capital threshold is the transfer adjustment factor * $2,134.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30163.67,89504.77,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",5687.21,5687.21,5875.02,1 through 10,other,5733.99,6020.69,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16878.39,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8558.00,48389.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41729.01,,,,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|PO,CASE-64634,APC,64634,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MAJOR",254,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],13805.41,,"Case rate ($13,805.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13805.41,14495.68,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6293.75,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6293.75,21908.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18314.49,,of the excess amount. Final payment is multiplied by 103.5%.,35640.82,35640.82,35640.82,1 through 10,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],32296.30,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
HC Intro Cath Dialysis Circuit W Pta|LEFT SIDE,CASE-36902,APC,36902,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16156.34,,"Fee schedule rate ($16,156.34). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Tot Hysterectomy Resj Malignancy W/Omntc,CASE-58575,APC,58575,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11594.10,,"Fee schedule rate ($11,594.10). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,APC,53445,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20346.09,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,19658.06,20346.09,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11461.54,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10915.75,32390.31,Inpatient DRG
Exc Tumor Soft Tiss Shoulder Subfasc <5cm|LEFT SIDE,CASE-23076,APC,23076,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,53945.28,Estimated amount calculated based on 17 day length of stay.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13249.94,40085.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10605.39,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10605.39,31469.43,Inpatient DRG
HC Cath Urethral Simple,CASE-51702,APC,51702,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],45.97,,"APC Price ($44.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,44.41,46.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC ARREST AND SHOCK,MAJOR",196,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11919.65,,"Case rate ($11,919.65). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11919.65,12515.63,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17852.70,,"Fee schedule rate ($17,852.70). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],50352.11,,"Fee schedule rate ($50,352.11). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],102660.52,,"Fee schedule rate ($102,660.52). Adds an outlier to normal pricing equal to the per diem rate ($180,358.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14560.44,,"Case rate ($13,867.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,153.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $982.67. The transfer capital threshold is the transfer adjustment factor * $982.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13889.20,55846.16,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11592.12,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11592.12,38954.76,Inpatient DRG
Patellectomy/Hemipatellectomy,CASE-27350,APC,27350,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31230.21,,"Fee schedule rate ($31,230.21). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5743.41,,"Case rate ($5,549.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,050.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.42. The transfer capital threshold is the transfer adjustment factor * $402.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5549.19,16729.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
Arthrt Elbow Capsular Excision Capsular Rls Spx|LEFT SIDE|PO,CASE-24006,APC,24006,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7167.95,,"Case rate ($6,826.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.76. The transfer capital threshold is the transfer adjustment factor * $483.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6837.50,20288.95,Inpatient DRG
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],27460.62,,"Fee schedule rate ($27,460.62). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22857.84,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5970.00,38757.79,All Other Inpatient
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
Revj Opn Arven Fstl W/O Thrmbc Dial Grf,CASE-36832,APC,36832,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",5269.36,5269.36,5269.36,1 through 10,other,5277.74,5541.62,OPPS APC
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,MINOR",511,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6513.27,,"Case rate for a one day stay ($6,203.11). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6203.11,6513.27,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31528.46,,,,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49594,APC,49594,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],49033.12,,,,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
Laps Bi Tot Pel Lmphadec & Pri-Aortic Lymph Bx 1,CASE-38572,APC,38572,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9638.88,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5507.93,20510.35,All Other Inpatient
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7915.12,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7759.92,35376.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Hemiphalangectomy/Interphalangeal Joint Exc Toe,CASE-28160,APC,28160,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6210.62,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6088.84,18067.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],39981.55,,"Fee schedule rate ($39,981.55). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],41117.20,,"Fee schedule rate ($41,117.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6633.36,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",6633.37,6633.37,8733.44,1 through 10,other,6503.29,19528.85,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,50750.92,Estimated amount calculated based on 22 day length of stay.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc,CASE-24341,APC,24341,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THUMB|PO",CASE-26735,APC,26735,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12557.64,,"Case rate ($11,959.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.50. The transfer capital threshold is the transfer adjustment factor * $847.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11978.73,60588.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],97349.99,,,,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6150.94,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",6196.88,6196.88,6196.88,1 through 10,other,5942.94,17634.53,Inpatient DRG
Excision Malignant Lesion S/N/H/F/G 1.1-2.0 Cm,CASE-11622,APC,11622,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1621.31,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|PO,CASE-64493,APC,64493,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10747.83,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10236.03,30589.82,Inpatient DRG
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],57534.77,,"Fee schedule rate ($57,534.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7182.75,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,21229.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33132.06,,"Fee schedule rate ($33,132.06). Adds an outlier to normal pricing equal to the per diem rate ($83,058.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11690.93,56733.59,Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10316.97,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",10316.98,10316.98,10316.98,1 through 10,other,10114.68,30013.33,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22524.26,,,,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27768.30,,"Fee schedule rate ($27,768.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|LEFT SIDE|PO,CASE-25260,APC,25260,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24249.78,,"Case rate ($23,095.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,807.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.59. The transfer capital threshold is the transfer adjustment factor * $1,636.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23131.85,76404.43,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10603.51,,"Case rate ($10,098.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,886.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $715.62. The transfer capital threshold is the transfer adjustment factor * $715.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10114.68,30013.33,Inpatient DRG
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7562.12,,"Case rate ($7,202.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.36. The transfer capital threshold is the transfer adjustment factor * $510.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
HC Intrvasc US Noncoronary Addl,CASE-37253,APC,37253,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],565.88,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,APC,58550,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14508.90,,"Fee schedule rate ($14,508.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7257.26,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7257.26,7257.26,53177.46,1 through 10,other,7257.26,23445.98,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14102.73,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14102.73,41847.08,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],44924.67,,"Fee schedule rate ($44,924.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16783.62,,"Case rate ($15,984.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,303.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.71. The transfer capital threshold is the transfer adjustment factor * $1,132.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16009.89,58554.60,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,1188.00,35040.80,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],65078.97,,of the excess amount.,39006.28,39006.28,39006.28,1 through 10,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia Recr < 3 Cm Ncrc8/Strangulated,CASE-49614,APC,49614,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],78395.14,,,,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11354.75,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10970.77,32553.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34576.42,,,,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Nerve Repair W/Nerve Allograft First Strand|PO,CASE-64912,APC,64912,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8323.61,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8323.61,8739.79,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
Split Agrft T/a/L Ea 100 Cm/Ea 1% Bdy Inft/Chld,CASE-15101,APC,15101,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.96,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.96,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15218.11,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15218.11,45156.75,Inpatient DRG
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MAJOR",140,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],12424.25,,"Case rate ($11,832.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11832.62,12424.25,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16616.10,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15824.86,49371.45,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],141944.91,,"Fee schedule rate ($141,944.91). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5668.40,,"Case rate ($5,668.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,581.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.07. The transfer capital threshold is the transfer adjustment factor * $410.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5668.40,16903.82,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6603.60,,"Case rate ($6,474.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,981.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,449.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,005.76. The transfer operating threshold is the transfer adjustment factor * $5,981.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.35. The transfer capital threshold is the transfer adjustment factor * $468.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6474.12,19210.66,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",23993.50,23993.50,23993.50,1 through 10,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf|LEFT SIDE,CASE-36825,APC,36825,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,APC,57250,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],34743.72,,"Fee schedule rate ($34,743.72). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm|PO,CASE-11421,APC,11421,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],695.15,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,695.15,705.22,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Treatment Metatarsal Fracture Each|RIGHT FOOT, FIFTH DIGIT",CASE-28485,APC,28485,CPT,0360,RC,,,T9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1188.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17630.33,,"Case rate ($16,790.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,189.85. The transfer capital threshold is the transfer adjustment factor * $1,189.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",17630.34,17630.34,17630.34,1 through 10,other,16817.56,58510.23,Inpatient DRG
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13446.23,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13446.23,39899.05,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|RIGHT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13575.16,,,,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC Fem Pop Terr Plasty and Stent,CASE-37226,APC,37226,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15170.63,,"Case rate ($14,448.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,349.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,817.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,216.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,402.99. The transfer operating threshold is the transfer adjustment factor * $13,349.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,045.22. The transfer capital threshold is the transfer adjustment factor * $1,045.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6940.00,42872.25,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
Excision Pilonidal Cyst/Sinus Complicated,CASE-11772,APC,11772,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2892.78,2892.78,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19413.74,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,8990.00,80069.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Parathyroid Autotransplantation Add-On,CASE-60512,APC,60512,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Partial Nephrectomy|RIGHT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",10148.63,10148.63,10148.63,1 through 10,other,10082.05,10586.16,OPPS APC
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5985.95,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5700.90,30872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],102807.11,,"Fee schedule rate ($102,807.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27534.03,,,,,,0,other,9279.13,27534.03,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15405.10,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,55581.70,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33727.80,,"Fee schedule rate ($33,727.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],25653.20,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9242.00,76216.30,Inpatient DRG
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20025.28,,,,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
Partial Excision Bone Tibia|LEFT SIDE|PO,CASE-27640,APC,27640,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7244.14,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7102.10,21074.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6630.72,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6630.72,19989.86,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25642.05,,"Fee schedule rate ($25,642.05). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23703.48,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23703.48,110204.98,Inpatient DRG
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39854.32,,"Fee schedule rate ($39,854.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",105312.05,105312.05,105312.05,1 through 10,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|LEFT SIDE,CASE-24341,APC,24341,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",6985.05,6985.05,6985.05,1 through 10,other,6882.29,7123.17,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4345.60,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4138.67,12473.25,Inpatient DRG
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis Addl 20 Cm<,CASE-97598,APC,97598,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY ANOTHER PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,77|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],31259.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,29771.33,31259.89,OPPS APC
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7450.94,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7096.13,25801.23,Inpatient DRG
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18751.65,,"Case rate ($17,858.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,436.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,265.53. The transfer capital threshold is the transfer adjustment factor * $1,265.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7455.00,53076.74,Inpatient DRG
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7369.88,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,20179.92,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15845.32,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15090.78,44778.95,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],37994.32,,,,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",45050.58,45050.58,45050.58,1 through 10,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],49033.12,,,,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25633.23,,,,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],31607.52,,"Case rate ($30,102.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,304.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,133.16. The transfer capital threshold is the transfer adjustment factor * $2,133.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30150.40,89465.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7544.23,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7184.98,21320.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
HC Debrid Wound Tis 20 Cm/<|PBB CHARGE,CASE-97597,APC,97597,CPT,0761,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>|LEFT SIDE,CASE-23071,APC,23071,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23703.48,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23703.48,110204.98,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13011.87,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7231.00,38610.21,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12514.54,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10428.37,10428.37,10428.37,1 through 10,other,12514.54,37134.43,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5354.09,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5354.09,15887.21,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13446.23,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13446.23,39899.05,Inpatient DRG
HC Sel Cath Abd/Pelvic/Le 1st Ord|BILATERAL PROCEDURE,CASE-36245,APC,36245,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],41320.17,,"Fee schedule rate ($41,320.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],48375.90,,,,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],10940.41,,,,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21399.79,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21399.79,63499.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5683.66,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5683.67,5683.67,5683.67,1 through 10,other,5683.66,16865.16,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20832.04,,,,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion S/N/H/F/G 0.6-1.0 Cm,CASE-11621,APC,11621,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],695.15,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,671.64,695.15,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5625.00,,"Per diem ($5,625). If length of stay < 2.6, first 1 days paid at a per diem of $11,250 instead. Capped at $14,624.71.",,,,0,other,5160.45,15312.64,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|SEPARATE STRUCTURE,CASE-52332,APC,52332,CPT,0360,RC,,,50|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9036.50,,"Fee schedule rate ($9,036.50). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7584.84,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,33946.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8318.46,,"Case rate ($7,922.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.40. The transfer capital threshold is the transfer adjustment factor * $561.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",23378.74,23378.74,23378.74,1 through 10,other,7934.97,23545.50,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8839.15,,"Case rate ($8,418.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,767.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.55. The transfer capital threshold is the transfer adjustment factor * $596.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8431.66,25019.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5854.09,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,17370.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11037.30,,"Case rate ($10,511.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,916.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.90. The transfer capital threshold is the transfer adjustment factor * $744.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10528.47,44148.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Fracture Great Toe/Phalanx/Phalanges|LEFT FOOT, GREAT TOE",CASE-28505,APC,28505,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10236.03,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10236.03,30589.82,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Excis Nail Matrix Perm Rmvl|PO,CASE-11750,APC,11750,CPT,0450,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17274.00,,"Per diem ($17,274). If length of stay < 3.3, first 1 days paid at a per diem of $34,548 instead. Capped at $57,002.93.",,,,0,other,17274.00,73717.28,Estimated amount calculated based on 3 day length of stay.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24508.40,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23679.61,84629.16,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8516.76,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8228.75,24417.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25435.24,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,14534.42,59012.52,All Other Inpatient
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1493.03,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",1442.15,1442.15,1442.15,1 through 10,other,1493.03,1567.69,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17726.69,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,17127.24,50821.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
"CELLULITIS AND OTHER SKIN INFECTIONS,MAJOR",383,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],12968.21,,"Case rate ($12,350.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12350.68,12968.21,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17343.27,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9910.44,43344.00,All Other Inpatient
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
HC Add 2nd/3rd Order Abd/Le|LEFT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,41333.08,Estimated amount calculated based on 10 day length of stay.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18781.54,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7455.00,53076.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5958.34,,"Case rate ($5,674.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,573.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.12. The transfer capital threshold is the transfer adjustment factor * $402.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.66,16865.16,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29049.23,,"Fee schedule rate ($29,049.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],41320.17,,"Fee schedule rate ($41,320.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8383.25,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7984.05,23691.11,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34588.05,,"Fee schedule rate ($34,588.05). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE|PO,CASE-24359,APC,24359,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE|PO,CASE-27698,APC,27698,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12179.66,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12179.66,36140.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17161.77,,"Fee schedule rate ($17,161.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY ANOTHER PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,77|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],29771.33,,"APC Price ($29,771.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,29771.33,31259.89,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10638.72,,"Fee schedule rate ($10,638.72). Adds an outlier to normal pricing equal to the per diem rate ($26,031.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4639.34,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4418.42,13110.79,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21111.47,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20697.52,87921.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15324.28,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15023.80,48104.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13264.54,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13264.54,50759.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],44580.21,,,,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
HC Open/Perq Place Stent Ea Add A,CASE-37237,APC,37237,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20245.58,,"Case rate ($19,281.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,537.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,366.35. The transfer capital threshold is the transfer adjustment factor * $1,366.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",20120.55,18419.46,20245.59,1 through 10,other,8972.00,76376.03,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8600.29,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8431.66,25019.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],65555.62,,"Fee schedule rate ($65,555.62). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7950.97,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7795.07,34198.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13405.94,,,,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],38225.27,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36405.02,110499.61,Inpatient DRG
HC Iliac Territory Plasty Stent|RIGHT SIDE,CASE-37221,APC,37221,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],460.53,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
HC Iliac Territory Plasty Stent,CASE-37221,APC,37221,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],467.21,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14721.71,,"Case rate ($14,020.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,164.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.55. The transfer capital threshold is the transfer adjustment factor * $993.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",14422.35,14422.35,14422.35,1 through 10,other,14043.03,54637.47,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23644.46,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23644.46,105789.11,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4785.59,,"Case rate ($4,557.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.97. The transfer capital threshold is the transfer adjustment factor * $322.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4564.97,13545.65,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17584.61,,"Fee schedule rate ($17,584.61). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MINOR",282,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7531.43,,"Case rate ($7,172.79). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7172.79,7531.43,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],48720.85,,"Fee schedule rate ($48,720.85). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11724.25,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6699.57,24060.08,All Other Inpatient
Partial Excision Bone Fibula|RIGHT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10652.43,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,30103.84,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],23871.38,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22734.65,70806.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12312.19,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11895.84,35298.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5629.94,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5629.94,16705.77,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],185834.07,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,185834.07,195125.77,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5668.40,,"Case rate ($5,668.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,581.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.07. The transfer capital threshold is the transfer adjustment factor * $410.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5668.40,16903.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9021.29,,"Case rate ($8,591.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,951.18, add-ons for qualifying new technology services are included. If operating cost exceeds $43,419.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,982.86. The transfer operating threshold is the transfer adjustment factor * $7,951.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.84. The transfer capital threshold is the transfer adjustment factor * $608.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8605.40,42305.71,Inpatient DRG
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26800.70,,"Fee schedule rate ($26,800.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, THUMB|PO",CASE-26525,APC,26525,CPT,0360,RC,,,FA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4120.67,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4120.67,13066.56,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],20206.14,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19243.94,63510.03,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18777.76,,,,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|LEFT SIDE|PO,CASE-28306,APC,28306,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17118.14,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16302.99,55737.89,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17095.74,,"Case rate ($16,281.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,324.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.77. The transfer capital threshold is the transfer adjustment factor * $1,153.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8558.00,48389.68,Inpatient DRG
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE|PO,CASE-29888,APC,29888,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|SEPARATE PRACTITIONER,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XP,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13632.44,,"Fee schedule rate ($13,632.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4734.64,14273.70,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
Ligj & Div Short Saph Vein Saphenopop Junct Spx,CASE-37780,APC,37780,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49594,APC,49594,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19504.80,,"Fee schedule rate ($19,504.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5614.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, GREAT TOE",CASE-28124,APC,28124,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
"OTHER PNEUMONIA,EXTREME",139,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],20973.98,,"Case rate ($19,975.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19975.22,20973.98,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",33234.37,33234.37,33234.37,1 through 10,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],107249.77,,"Fee schedule rate ($107,249.77). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18559.00,,"Per diem ($18,559). If length of stay < 5.4, first 1 days paid at a per diem of $37,118 instead. Capped at $100,219.31.",,,,0,other,18559.00,141041.50,Estimated amount calculated based on 3 day length of stay.
Removal Intrauterine Device Iud,CASE-58301,APC,58301,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],303.48,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,289.03,303.48,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],44339.99,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,44339.99,131570.26,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8171.79,,"Case rate ($7,782.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,722.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $551.51. The transfer capital threshold is the transfer adjustment factor * $551.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7795.07,34198.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4895.21,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4895.21,14525.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64418,APC,64418,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9739.34,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9739.34,40204.26,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10003.52,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9527.16,28269.95,Inpatient DRG
"AMPUTATION OF LOWER LIMB EXCEPT TOES,EXTREME",305,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],52364.61,,"Case rate ($49,871.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,49871.06,52364.61,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29382.86,,"Fee schedule rate ($29,382.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, SECOND DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17556.38,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,17212.14,64440.06,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],51935.22,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,50916.88,170142.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37423.05,,"Fee schedule rate ($37,423.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13305.64,39481.90,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
Tendon Sheath Incision|PO,CASE-26055,APC,26055,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39899.05,,,,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22506.55,,,,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21404.64,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],57534.77,,"Fee schedule rate ($57,534.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21012.19,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20301.63,84714.35,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11382.98,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11159.78,39897.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16785.91,,"Fee schedule rate ($16,785.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41669.98,,,,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,APC,45385,CPT,0360,RC,,,PT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13140.27,,"Case rate ($12,514.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,563.12, add-ons for qualifying new technology services are included. If operating cost exceeds $47,031.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,076.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,609.20. The transfer operating threshold is the transfer adjustment factor * $11,563.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.33. The transfer capital threshold is the transfer adjustment factor * $905.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12514.54,37134.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],134001.61,,"Fee schedule rate ($134,001.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7826.00,,"Per diem ($7,826). If length of stay < 7.6, first 1 days paid at a per diem of $15,652 instead. Capped at $59,476.09.",,,,0,other,7826.00,90280.33,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12405.69,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11814.94,44591.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Carpectomy 1 Bone|LEFT SIDE|PO,CASE-25210,APC,25210,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16149.61,,"Case rate ($15,380.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.92. The transfer capital threshold is the transfer adjustment factor * $1,089.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",36737.87,36737.87,36737.87,1 through 10,other,3295.00,55581.70,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|RIGHT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],30758.38,,of the excess amount.,,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11524.34,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11298.37,44627.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6953.00,,"Per diem ($6,953). If length of stay < 4.5, first 1 days paid at a per diem of $13,906 instead. Capped at $31,286.59.",,,,0,other,6953.00,35389.05,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Removal Implant Deep|PO,CASE-20680,APC,20680,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|LEFT FOOT, SECOND DIGIT|PO",CASE-28092,APC,28092,CPT,0360,RC,,,T1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10173.70,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10173.70,41194.64,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],89469.71,,"Fee schedule rate ($89,469.71). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4838.84,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4838.84,19587.42,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7960.75,,"Fee schedule rate ($7,960.75). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Prox Humeral Fx W/Int Fixj Rpr Tuberosity|LEFT SIDE,CASE-23615,APC,23615,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12880.35,,"Fee schedule rate ($12,880.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],61860.92,,"Fee schedule rate ($61,860.92). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21828.16,93157.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION,EXTREME",190,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],24180.53,,"Case rate ($24,180.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24180.53,25389.56,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19133.87,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,18222.73,59942.55,Inpatient DRG
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3068.11,3068.11,3068.11,11,other,2994.77,3144.51,OPPS APC
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21421.93,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20697.52,87921.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6886.93,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6558.98,19462.52,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6803.69,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6803.69,6803.69,6803.69,1 through 10,other,5843.00,27370.21,Inpatient DRG
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],30083.00,,"Case rate ($28,650.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,201.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.27. The transfer capital threshold is the transfer adjustment factor * $2,030.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,28696.16,118364.04,Inpatient DRG
Fasciectomy Plantar Fascia Partial Spx|BILATERAL PROCEDURE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Plasty,CASE-37228,APC,37228,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],513.29,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],183848.16,,"Fee schedule rate ($183,848.16). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12218.30,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11978.73,60588.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE,CASE-28090,APC,28090,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21805.52,,"Fee schedule rate ($21,805.52). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21796.21,,,,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THIRD DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7435.53,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7289.74,21630.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13978.96,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13704.86,49911.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10826.88,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10826.88,32126.64,Inpatient DRG
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4162.46,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,21715.49,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5747.99,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5091.00,22010.11,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6542.29,,"Case rate ($6,230.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.53. The transfer capital threshold is the transfer adjustment factor * $441.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",2580.95,2580.95,6893.20,1 through 10,other,6240.68,18518.02,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|BILATERAL PROCEDURE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17913.05,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10236.03,30589.82,All Other Inpatient
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6552.71,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6240.68,18518.02,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],27344.34,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,26419.65,96304.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Tx Tibl Shft Fx Imed Implt W/WO Screws&/Cercla,CASE-27759,APC,27759,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Trluml Balo Angiop 1st Vein|RIGHT SIDE,CASE-37248,APC,37248,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12196.66,,"Fee schedule rate ($12,196.66). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],3941.67,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3753.97,11139.15,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],30130.97,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,28696.16,118364.04,Inpatient DRG
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7795.07,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7795.07,34198.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6751.53,,"Case rate ($6,430.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,950.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,418.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,974.38. The transfer operating threshold is the transfer adjustment factor * $5,950.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.65. The transfer capital threshold is the transfer adjustment factor * $455.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6440.28,19110.30,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4968.82,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4968.82,19848.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26291.41,,"Fee schedule rate ($26,291.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,8981.78,27528.12,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6685.72,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,18893.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],37747.87,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,21570.21,72041.81,All Other Inpatient
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8491.17,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,34379.15,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],40591.99,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,40591.99,115037.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
Open Treatment Metatarsal Fracture Each|RIGHT SIDE,CASE-28485,APC,28485,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7023.28,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",7023.28,6965.73,7023.28,1 through 10,other,6785.78,20135.47,Inpatient DRG
HC Iliac Territory Plasty Stent|BILATERAL PROCEDURE,CASE-37221,APC,37221,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],444.96,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE|PO,CASE-27427,APC,27427,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16785.91,,"Fee schedule rate ($16,785.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],36511.04,,"Fee schedule rate ($36,511.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE|PO,CASE-27792,APC,27792,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Pyeloplasty,CASE-50544,APC,50544,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",9665.36,9665.36,9665.36,1 through 10,other,10082.05,10586.16,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23125.89,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23125.89,68621.57,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11443.29,,"Case rate ($10,898.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,943.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $772.30. The transfer capital threshold is the transfer adjustment factor * $772.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",11338.26,11338.26,11338.26,1 through 10,other,10915.75,32390.31,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",14568.10,14568.10,14568.10,1 through 10,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28296,APC,28296,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3843.64,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],85446.13,,"Fee schedule rate ($85,446.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5648.94,,"Case rate ($5,379.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,996, add-ons for qualifying new technology services are included. If operating cost exceeds $45,541.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,029.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,998.47. The transfer operating threshold is the transfer adjustment factor * $4,996.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $381.47. The transfer capital threshold is the transfer adjustment factor * $381.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5389.29,16247.30,Inpatient DRG
Arthroscopy Knee Synovectomy Limited Spx|RIGHT SIDE|PO,CASE-29875,APC,29875,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3258.56,3258.56,OPPS APC
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20804.96,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11888.55,35276.93,All Other Inpatient
Arven Anast Opn Upr Arm Basilic Vein Trpos|LEFT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12728.66,,"Case rate ($12,122.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,030.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $859.04. The transfer capital threshold is the transfer adjustment factor * $859.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12141.86,36028.59,Inpatient DRG
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|LEFT FOOT, SECOND DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28437.57,,"Fee schedule rate ($28,437.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],684.51,,"APC Price ($661.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,661.36,694.43,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5273.12,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5094.80,15365.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12605.95,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",12325.87,12325.87,12325.87,1 through 10,other,12179.66,36140.75,Inpatient DRG
Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,CASE-58571,APC,58571,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",9872.40,9872.40,9872.40,1 through 10,other,10082.05,10586.16,OPPS APC
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22555.75,,,,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],36287.40,,"Fee schedule rate ($36,287.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, GREAT TOE|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20343.42,,"Fee schedule rate ($20,343.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4558.56,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4341.49,12882.53,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Iliac Territory Plasty Stent|BILATERAL PROCEDURE,CASE-37221,APC,37221,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],467.21,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24851.52,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7453.00,42138.30,All Other Inpatient
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Forearm and/Wrist Subq 3cm/>,CASE-25071,APC,25071,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],3941.67,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3753.97,11139.15,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12212.80,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12212.80,39290.21,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16302.99,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",16302.99,16302.99,16302.99,1 through 10,other,16302.99,55737.89,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12803.67,,"Fee schedule rate ($12,803.67). Adds an outlier to normal pricing equal to the per diem rate ($91,038.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment of Ulnar Shaft Fracture,CASE-25545,APC,25545,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER DISORDERS OF THE LIVER,EXTREME",283,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],26990.52,,"Case rate ($26,990.52). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,26990.52,28340.05,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6962.26,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6630.72,19989.86,Inpatient DRG
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],926.14,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5217.26,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4968.82,19848.33,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6784.92,,"Case rate ($6,461.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,629.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.91. The transfer capital threshold is the transfer adjustment factor * $457.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",2541.74,2541.74,2541.74,1 through 10,other,6472.13,19204.75,Inpatient DRG
Revj Total Knee Arthrp W/WO Algrft 1 Component|LEFT SIDE,CASE-27486,APC,27486,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12785.93,12785.93,OPPS APC
Open Treatment Tarsometatarsal Joint Dislocation,CASE-28615,APC,28615,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26007.09,,,,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15686.92,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15156.44,52672.70,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10497.56,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10291.73,34803.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
Axillary Lymphadenectomy Complete|RIGHT SIDE,CASE-38745,APC,38745,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,5733.99,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4442.95,,"Case rate ($4,442.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.41. The transfer capital threshold is the transfer adjustment factor * $321.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4442.95,13183.59,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10226.31,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9739.34,40204.26,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27135.21,,"Fee schedule rate ($27,135.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31329.81,,"Fee schedule rate ($31,329.81). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],97176.83,,,,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
"ABDOMINAL PAIN,MODERATE",251,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2878.95,,"Case rate for a one day stay ($2,878.95). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2878.95,3022.90,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Leg/Ankle Subq <3cm|LEFT SIDE,CASE-27618,APC,27618,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35276.93,,,,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE,CASE-27822,APC,27822,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29141.64,,,,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8369.91,,"Case rate ($7,971.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,736.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.88. The transfer capital threshold is the transfer adjustment factor * $564.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7984.05,33319.56,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23582.79,,"Case rate ($23,582.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,789.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,257.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,877.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,876.75. The transfer operating threshold is the transfer adjustment factor * $21,789.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,706.04. The transfer capital threshold is the transfer adjustment factor * $1,706.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,23582.79,75543.62,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5773.19,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5773.19,31196.82,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22919.57,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21828.16,93157.39,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE|PO,CASE-29891,APC,29891,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64448,APC,64448,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
Ligj & Div Short Saph Vein Saphenopop Junct Spx|LEFT SIDE,CASE-37780,APC,37780,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,2994.77,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13927.77,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13264.54,50759.39,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],30352.35,,"Fee schedule rate ($30,352.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Radius Distal Third|RIGHT SIDE|PO,CASE-25350,APC,25350,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
Nerve Repair W/Nerve Allograft First Strand|PO,CASE-64912,APC,64912,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8614.94,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8323.61,8739.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13632.44,,"Fee schedule rate ($13,632.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4734.64,14273.70,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10311.96,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9820.91,29141.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,APC,58552,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10620.41,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10114.68,30013.33,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",111902.65,111902.65,111902.65,1 through 10,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE,CASE-28730,APC,28730,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,XU|50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenolysis Flexor Tendon Palm/Finger Each Tendon,CASE-26440,APC,26440,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,APC,51102,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18979.80,,"Fee schedule rate ($18,979.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
"SICKLE CELL ANEMIA CRISIS,MINOR",662,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7557.54,,"Case rate ($7,197.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7197.66,7557.54,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5531.18,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5539.40,5539.40,5539.40,1 through 10,other,5344.14,15857.69,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5102.58,,"Case rate ($4,859.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.37. The transfer capital threshold is the transfer adjustment factor * $344.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4867.35,14442.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Unlisted Procedure, Nervous System|UNUSUAL NON-OVERLAPPING SERVICE",CASE-64999,APC,64999,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride Subq First 20 Sq Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-11042,APC,11042,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Laps Insertion Tunneled Intraperitoneal Catheter,CASE-49324,APC,49324,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15043.80,,"Fee schedule rate ($15,043.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Radius Distal Third,CASE-25350,APC,25350,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Crtj Arven Fstl Xcp Dir Arven Anast Nonautog Grf,CASE-36830,APC,36830,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5018.44,5018.44,5150.04,1 through 10,other,5277.74,5541.62,OPPS APC
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22105.65,,"Fee schedule rate ($22,105.65). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
Bladder Instillation Anticarcinogenic Agent,CASE-51720,APC,51720,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19297.23,,,,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
"Synovectomy Metatarsophalangeal Joint Each|LEFT FOOT, SECOND DIGIT",CASE-28072,APC,28072,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Medium WO US|RIGHT SIDE|PO,CASE-20605,APC,20605,CPT,0510,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6910.06,20832.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],73546.72,,,,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
HC Repr Smp Not Face 2.6-7.5cm,CASE-12002,APC,12002,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,211.83,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6381.43,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6077.55,18033.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],32570.75,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31019.76,124854.72,Inpatient DRG
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE|PO",CASE-28289,APC,28289,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7601.43,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7601.43,23918.09,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30188.45,,,,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
"OTHER BACK AND NECK DISORDERS FRACTURES AND INJURIES,MAJOR",347,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],15286.39,,"Case rate ($15,286.39). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15286.39,16050.71,There are no additional notes associated with this service or procedure.
HC Intro Cath Dialysis Circuit W Pta|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36902,APC,36902,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5668.18,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5398.26,5668.18,OPPS APC
Application Uniplane External Fixation System|PO,CASE-20690,APC,20690,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16302.99,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16302.99,55737.89,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
HC Trluml Balo Angiop 1st Vein|RIGHT SIDE,CASE-37248,APC,37248,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11519.18,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11519.18,34180.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],158423.11,,"Fee schedule rate ($158,423.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],45609.21,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,45609.21,211906.58,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28299,APC,28299,CPT,0360,RC,,,T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32126.64,,,,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10865.40,,"Fee schedule rate ($10,865.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,76376.03,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14583.66,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13889.20,55846.16,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7577.56,,"Case rate ($7,577.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,001.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,469.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,029.37. The transfer operating threshold is the transfer adjustment factor * $7,001.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.18. The transfer capital threshold is the transfer adjustment factor * $548.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7577.56,31445.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12882.53,,,,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11270.49,,"Case rate ($6,440.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,950.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,418.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,637.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,974.38. The transfer operating threshold is the transfer adjustment factor * $5,950.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $465.91. The transfer capital threshold is the transfer adjustment factor * $465.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6440.28,19110.30,All Other Inpatient
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12060.31,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11652.47,41507.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
Nerve Repair W/Conduit Each Nerve|LEFT SIDE|PO,CASE-64910,APC,64910,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8323.61,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8323.61,8739.79,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9070.48,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8442.00,28788.33,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],75764.11,,"Fee schedule rate ($75,764.11). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11615.68,,"Case rate ($11,062.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,955.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.93. The transfer capital threshold is the transfer adjustment factor * $783.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11080.19,32878.30,Inpatient DRG
HC >= 12 Lead Ekg|ADJ|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3074.87,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3074.87,3228.61,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",18265.42,18265.42,18265.42,1 through 10,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31617.34,,"Fee schedule rate ($31,617.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11156.45,42003.98,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Tendon Sheath/Ligament|LEFT SIDE|PO,CASE-20550,APC,20550,CPT,0510,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5006.61,,"Case rate ($5,006.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,625.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,093.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,644.42. The transfer operating threshold is the transfer adjustment factor * $4,625.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.19. The transfer capital threshold is the transfer adjustment factor * $362.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5006.61,14856.14,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10500.25,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,30103.84,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],31834.92,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10308.75,,"Case rate ($9,817.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,866.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.73. The transfer capital threshold is the transfer adjustment factor * $695.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9833.51,45903.36,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],64029.63,,"Fee schedule rate ($64,029.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.5), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Axillary Lymphadenectomy Complete,CASE-38745,APC,38745,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
Removal Implant Deep|PO,CASE-20680,APC,20680,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,EXTREME",425,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],21150.89,,"Case rate ($21,150.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,21150.89,22208.43,There are no additional notes associated with this service or procedure.
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|RIGHT SIDE,CASE-26121,APC,26121,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9603.90,,"Case rate ($9,279.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,573.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,041.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,607.86. The transfer operating threshold is the transfer adjustment factor * $8,573.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.28. The transfer capital threshold is the transfer adjustment factor * $671.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9279.13,27534.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rhinp Prim Lat&Alar Crtlgs&/Elvtn Nasal Ti|BILATERAL PROCEDURE|PO,CASE-30400,APC,30400,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13826.01,,"Fee schedule rate ($13,826.01). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12536.42,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,12536.42,46998.45,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12107.67,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11698.23,34712.20,Inpatient DRG
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10858.54,,"Case rate ($6,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,620.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.88. The transfer capital threshold is the transfer adjustment factor * $448.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6204.88,19589.20,All Other Inpatient
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16098.60,,"Fee schedule rate ($16,098.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy 2/>Compartments|RIGHT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10034.43,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10034.43,29775.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
Open Biopsy/Excision Inguinofemoral Nodes|LEFT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6785.78,20135.47,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],89469.71,,"Fee schedule rate ($89,469.71). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Repair of Rotator Cuff Chronic|LEFT SIDE,CASE-23412,APC,23412,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6240.09,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5942.94,17634.53,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10808.31,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,10808.31,46938.11,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19312.24,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",19198.30,19198.30,19198.30,1 through 10,other,8972.00,76376.03,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],20972.04,,"Case rate ($19,973.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,586.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,415.38. The transfer capital threshold is the transfer adjustment factor * $1,415.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20005.22,74991.64,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24585.00,,"Fee schedule rate ($24,585.00). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn|RIGHT HAND, THIRD DIGIT|PO",CASE-26145,APC,26145,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1578.51,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5783.33,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5507.93,20510.35,Inpatient DRG
"IMPLANTABLE HEART ASSIST SYSTEMS,EXTREME",161,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],323068.41,,"Case rate ($323,068.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $121,386, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,323068.41,339221.83,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],23871.38,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22734.65,70806.50,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8640.19,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8228.75,24417.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Rmvl/Revj Sling Stress Incontinence,CASE-57287,APC,57287,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3070.31,,"APC Price ($3,070.31). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|PO,CASE-12032,APC,12032,CPT,0450,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10541.54,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10334.84,30666.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
Dilat Rct Strix Spx Under Anes Oth/Thn Local,CASE-45910,APC,45910,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|SEPARATE STRUCTURE|LEFT SIDE,CASE-28306,APC,28306,CPT,0360,RC,,,XS|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12177.08,OPPS APC
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],29405.43,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,28005.17,115392.91,Inpatient DRG
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33692.09,,"Fee schedule rate ($33,692.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7238.05,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",7255.63,7255.63,7255.63,1 through 10,other,7096.13,25801.23,Inpatient DRG
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],904.16,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,873.59,917.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE,CASE-15823,APC,15823,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9112.97,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8679.02,29908.27,Inpatient DRG
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12492.29,,"Case rate ($11,897.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $843.09. The transfer capital threshold is the transfer adjustment factor * $843.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11916.39,58492.48,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13264.54,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13264.54,50759.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13704.25,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13051.67,38728.27,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE|PO,CASE-29888,APC,29888,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10851.58,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10334.84,30666.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion,CASE-52354,APC,52354,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9710.19,,"Case rate ($9,247.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.33. The transfer capital threshold is the transfer adjustment factor * $655.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,27484.83,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,APC,29828,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],35363.23,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",34575.88,34571.23,35363.25,1 through 10,other,18559.00,141041.50,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",27259.60,27259.60,27259.60,1 through 10,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7160.95,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7020.54,28431.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13827.53,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13827.53,41030.48,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6837.50,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6837.50,20288.95,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],38106.57,,"Fee schedule rate ($38,106.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis 20 Cm/<|ADJ,CASE-97597,APC,97597,CPT,0761,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC
HC Extremity Venogram|LEFT SIDE,CASE-36005,APC,36005,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1493.03,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19243.94,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19243.94,63510.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],37968.88,,of the excess amount.,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Supracervical Hysterectomy >250,CASE-58543,APC,58543,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",20127.30,20127.30,20127.30,1 through 10,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5506.24,,"Case rate ($5,244.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,859.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,405.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,029.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,862.27. The transfer operating threshold is the transfer adjustment factor * $4,859.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $381.77. The transfer capital threshold is the transfer adjustment factor * $381.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5244.04,15804.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,APC,52332,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9613.53,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",9782.48,9782.48,58110.23,1 through 10,other,9425.03,27966.92,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT|PO",CASE-28820,APC,28820,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],50522.67,,,,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26636.50,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17127.24,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17127.24,50821.76,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|PO,CASE-11422,APC,11422,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10568.05,,"Case rate ($10,064.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.23. The transfer capital threshold is the transfer adjustment factor * $713.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10080.86,33310.69,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11217.46,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11217.46,37366.25,Inpatient DRG
HC Revasc Intra Lithotrip-Stent,CASE-C9765,APC,C9765,CPT,0481,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision/Curettage Cyst/Tumor Femur|RIGHT SIDE,CASE-27355,APC,27355,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28569.12,,"Fee schedule rate ($28,569.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,APC,57520,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride Subq First 20 Sq Cm|PBB CHARGE,CASE-11042,APC,11042,CPT,0361,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Sesamoidectomy First Toe Spx|RIGHT FOOT, GREAT TOE|PO",CASE-28315,APC,28315,CPT,0360,RC,,,T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|RIGHT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],180.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],47329.09,,,,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE,CASE-27695,APC,27695,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",6963.55,6963.55,6963.55,1 through 10,other,6882.29,7226.40,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],32324.96,,"Fee schedule rate ($32,324.96). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21805.52,,"Fee schedule rate ($21,805.52). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29049.23,,"Fee schedule rate ($29,049.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9739.34,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9739.34,40204.26,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20004.20,,"Fee schedule rate ($20,004.20). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
Cystectomy Partial Simple,CASE-51550,APC,51550,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3460.35,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39899.05,,,,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
Revascularization Iliac Art Angiop Ea Ipsi Vsl|LEFT SIDE,CASE-37222,APC,37222,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],176.42,,,,,,0,other,168.02,176.42,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,32980.62,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18748.84,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,18381.22,58579.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,EXTREME",425,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],22208.43,,"Case rate ($21,150.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21150.89,22208.43,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7003.89,,"Case rate ($6,670.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,643.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $472.69. The transfer capital threshold is the transfer adjustment factor * $472.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6681.01,19824.58,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12833.49,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12833.49,58980.57,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4172.66,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,2285.00,12138.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9946.41,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5683.66,16865.16,All Other Inpatient
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17934.16,,"Fee schedule rate ($17,934.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.1), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11698.23,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11698.23,34712.20,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Revis Shoulder Arthrplsty Humeral&Glenoid Compnt,CASE-23474,APC,23474,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5612.74,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5224.00,15861.63,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
Insertion Intrauterine Device Iud,CASE-58300,APC,58300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19300.28,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18381.22,58579.45,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35314.31,,,,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5005.27,,"Case rate ($4,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,508.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.80. The transfer capital threshold is the transfer adjustment factor * $337.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",15519.85,15519.85,15519.85,1 through 10,other,4774.52,14406.59,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],56023.80,,"Fee schedule rate ($56,023.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1903.51,28.57,1903.51,1 through 10,other,1852.10,1944.70,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6311.11,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6010.58,17835.23,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15818.34,,,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],129256.37,,"Fee schedule rate ($129,256.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4608.23,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4517.87,13932.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopic Appendectomy,CASE-44970,APC,44970,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5605.96,5605.96,5605.96,1 through 10,other,5733.99,6020.69,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9860.04,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9860.04,30039.61,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
Plmt Interstitial Dev Radiat Tx Prostate 1/Mult,CASE-55876,APC,55876,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1358.75,,"APC Price ($1,312.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1332.41,1332.41,1332.41,1 through 10,other,1312.80,1378.44,OPPS APC
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE,CASE-54840,APC,54840,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2052.05,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7335.51,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7335.51,29792.90,Inpatient DRG
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],35038.21,,"Case rate ($33,369.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,535.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,364.69. The transfer capital threshold is the transfer adjustment factor * $2,364.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,33422.93,112824.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13594.96,,"Case rate ($13,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,121.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.24. The transfer capital threshold is the transfer adjustment factor * $950.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13135.23,38976.20,Inpatient DRG
"OTHER AFTERCARE AND CONVALESCENCE,MAJOR",862,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9280.97,,"Case rate ($9,280.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9280.97,9745.02,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],42670.25,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,42670.25,133443.30,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
Claviculectomy Partial|RIGHT SIDE|PO,CASE-23120,APC,23120,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7455.00,,"Per diem ($7,455). If length of stay < 6.8, first 1 days paid at a per diem of $14,910 instead. Capped at $50,692.24.",,,,0,other,7455.00,53076.74,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28086.14,,"Fee schedule rate ($28,086.14). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9910.44,43344.00,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17776.11,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,16929.63,63934.22,Inpatient DRG
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,MINOR",951,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3995.45,,"Case rate for a one day stay ($3,805.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3805.19,3995.45,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36140.75,,,,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],52471.79,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13061.00,162464.13,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],41837.14,,"Fee schedule rate ($41,837.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29775.24,,,,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],55272.09,,"Fee schedule rate ($55,272.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,40658.63,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation,CASE-28615,APC,28615,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
"SIGNS SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS,MAJOR",861,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],12844.91,,"Case rate ($12,233.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12233.25,12844.91,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt,CASE-27602,APC,27602,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23131.85,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23131.85,76404.43,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
Prq Skeletal Fix Carpo/Metacarpal Fx Dislc Thumb,CASE-26650,APC,26650,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16508.45,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,15950.19,63458.56,Inpatient DRG
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25041.87,,"Fee schedule rate ($25,041.87). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10899.16,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10899.16,39746.35,Inpatient DRG
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT HAND, FIFTH DIGIT|PO",CASE-26356,APC,26356,CPT,0360,RC,,,F9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20593.95,,,,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12270.84,,"Case rate ($7,011.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,678.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7011.91,27304.54,All Other Inpatient
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11461.54,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10915.75,32390.31,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18902.44,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18902.44,56089.29,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27818.86,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,15896.49,51306.05,All Other Inpatient
Tenolysis Flexor Tendon Palm/Finger Each Tendon,CASE-26440,APC,26440,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12861.93,,"Fee schedule rate ($12,861.93). Adds an outlier to normal pricing equal to the per diem rate ($47,786.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33692.09,,"Fee schedule rate ($33,692.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],46016.63,,,,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,CASE-26125,APC,26125,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13061.00,,"Per diem ($13,061). If length of stay < 11, first 1 days paid at a per diem of $26,122 instead. Capped at $143,676.24.",,,,0,other,13061.00,162464.13,Estimated amount calculated based on 8 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Litholapaxy Smpl/Sm <2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52317,APC,52317,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
Revj/Rmvl Prosthetic Vaginal Graft Vaginal App,CASE-57295,APC,57295,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4910.73,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],70055.50,,"Fee schedule rate ($70,055.50). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5700.90,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11519.19,11519.19,11519.19,1 through 10,other,5700.90,30872.02,Inpatient DRG
Bladder Instillation Anticarcinogenic Agent|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51720,APC,51720,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21991.57,,"Fee schedule rate ($21,991.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30630.71,,"Fee schedule rate ($30,630.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9312.29,,"Case rate ($9,312.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,604.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,072.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,638.62. The transfer operating threshold is the transfer adjustment factor * $8,604.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.67. The transfer capital threshold is the transfer adjustment factor * $673.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9312.29,27632.41,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7826.00,,"Per diem ($7,826). If length of stay < 7.6, first 1 days paid at a per diem of $15,652 instead. Capped at $59,476.09.",,,,0,other,7826.00,90280.33,Estimated amount calculated based on 3 day length of stay.
HC Peripheral Block - Femoral Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26357,APC,26357,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],34988.57,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,34988.57,110685.97,Inpatient DRG
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11607.75,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11055.00,49295.13,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",35283.80,35283.80,35283.80,1 through 10,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6235.92,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.97,17858.70,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31350.48,,"Fee schedule rate ($31,350.48). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10888.24,32825.17,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|RIGHT SIDE,CASE-37225,APC,37225,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],557.79,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,APC,49594,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13011.87,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7231.00,38610.21,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15852.04,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15852.04,50518.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17406.17,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16817.56,58510.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32980.62,,,,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15405.10,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",63386.67,63386.67,63386.67,1 through 10,other,3295.00,55581.70,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12276.79,,"Case rate ($11,692.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,999.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.55. The transfer capital threshold is the transfer adjustment factor * $828.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11710.82,34749.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],62002.23,,,,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Femur/Knee,CASE-27599,APC,27599,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],242.14,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,233.96,245.65,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6785.78,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6785.78,20135.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],38724.86,,"Fee schedule rate ($38,724.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS OF UPPER RESPIRATORY TRACT,MAJOR",113,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2404.66,,"Case rate for a one day stay ($2,290.15). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2290.15,2404.66,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7003.89,,"Case rate ($6,670.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,643.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $472.69. The transfer capital threshold is the transfer adjustment factor * $472.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",40463.18,40463.18,40463.18,1 through 10,other,6681.01,19824.58,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15233.52,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8704.87,25830.00,All Other Inpatient
HC Inj Lympho for Sentinal Node|LEFT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],684.51,,"APC Price ($661.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,661.36,694.43,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10135.82,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9793.06,29058.99,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],30630.50,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,29594.69,124146.55,Inpatient DRG
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,APC,46200,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],29208.48,,"Case rate ($27,817.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,971.25. The transfer capital threshold is the transfer adjustment factor * $1,971.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27861.95,82674.88,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18796.76,,"Fee schedule rate ($18,796.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6632.59,19680.94,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13780.46,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9763.00,48626.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE|PO,CASE-64624,APC,64624,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],31112.60,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31112.60,92731.42,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
"SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,MINOR",361,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3798.02,,"Case rate for a one day stay ($3,798.02). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3798.02,3987.92,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15295.35,,"Fee schedule rate ($15,295.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
Partial Excision Bone Talus/Calcaneus|LEFT SIDE|PO,CASE-28120,APC,28120,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Arthroscopy Knee Lateral Release|LEFT SIDE|PO,CASE-29873,APC,29873,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Vaginal Cyst/Tumor,CASE-57135,APC,57135,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",674.12,674.12,674.12,1 through 10,other,5085.49,5339.77,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11031.92,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9888.00,40658.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4221.44,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4138.67,12473.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],59361.57,,,,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4389.36,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4180.34,14351.57,Inpatient DRG
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,CASE-43762,APC,43762,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6350.00,,"Per diem ($6,350). If length of stay < 5, first 1 days paid at a per diem of $12,700 instead. Capped at $31,750.77.",,,,0,other,6350.00,33244.29,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],134001.61,,"Fee schedule rate ($134,001.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Transection/Avulsion Oth Spinal Nrv Xdrl|PO,CASE-64772,APC,64772,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Repr Smp Not Face 2.6-7.5cm|SEPARATE STRUCTURE,CASE-12002,APC,12002,CPT,0450,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Exc Tumor Soft Tissue Leg/Ankle Subq <3cm|LEFT SIDE,CASE-27618,APC,27618,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],64872.40,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,64872.40,212258.00,Inpatient DRG
Ostectomy Prtl 5th Metar Head Spx|RIGHT SIDE|PO,CASE-28110,APC,28110,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26523.77,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,15156.44,52672.70,All Other Inpatient
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Aerosol, Hhn, Mdi, Ippb|ADJ",CASE-94640,APC,94640,CPT,0410,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,MODERATE",313,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],25417.12,,"Case rate ($24,206.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24206.78,25417.12,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19503.23,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19503.23,57872.02,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14096.07,,"Case rate ($13,424.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,122.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.33. The transfer capital threshold is the transfer adjustment factor * $951.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13446.23,39899.05,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11384.58,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11384.58,33781.47,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rmvl/Revj Sling Male Urinary Incontinence,CASE-53442,APC,53442,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35298.57,,,,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
Revsc Opn/Prq Tib/Pero W/Athrc/Angiop Uni Ea Vsl|RIGHT SIDE,CASE-37233,APC,37233,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],306.34,,,,,,0,other,291.75,306.34,There are no additional notes associated with this service or procedure.
Arthrs Knee Debridement/Shaving Artclr Crtlg|LEFT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4303.70,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4303.70,14124.38,Inpatient DRG
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE|PO,CASE-27698,APC,27698,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13525.32,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12881.26,38222.57,Inpatient DRG
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12006.70,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11434.95,119072.21,Inpatient DRG
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB|PO",CASE-26540,APC,26540,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9988.92,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9793.06,29058.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],31767.24,,"Case rate ($30,254.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,954.41, add-ons for qualifying new technology services are included. If operating cost exceeds $63,422.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,359.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $28,065.82. The transfer operating threshold is the transfer adjustment factor * $27,954.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,188.69. The transfer capital threshold is the transfer adjustment factor * $2,188.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30254.51,130347.93,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13503.79,,"Case rate ($12,860.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,082.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $911.36. The transfer capital threshold is the transfer adjustment factor * $911.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12881.26,38222.57,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20540.10,,"Fee schedule rate ($20,540.10). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19137.85,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19137.85,64589.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],31671.85,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30163.67,89504.77,Inpatient DRG
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],31065.30,,"Fee schedule rate ($31,065.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE,CASE-28306,APC,28306,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],110217.19,,"Fee schedule rate ($110,217.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6785.78,20135.47,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7288.38,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",1120.90,1120.90,1120.90,1 through 10,other,6965.00,21229.52,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20775.20,,"Case rate ($11,871.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,001.85, add-ons for qualifying new technology services are included. If operating cost exceeds $51,547.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,512.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,007.29. The transfer operating threshold is the transfer adjustment factor * $11,001.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.25. The transfer capital threshold is the transfer adjustment factor * $864.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11871.54,35778.69,All Other Inpatient
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18042.36,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18042.36,82749.58,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8212.69,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7934.97,23545.50,Inpatient DRG
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Removal Shoulder Foreign Body Deep Subfascial/Im,CASE-23333,APC,23333,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2851.46,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19339.26,,of the excess amount.,,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18381.22,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18381.22,58579.45,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],35466.15,,"Fee schedule rate ($35,466.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
"PERIPHERAL CRANIAL AND AUTONOMIC NERVE DISORDERS,MAJOR",048,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14011.25,,"Case rate ($14,011.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14011.25,14711.81,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],32807.56,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,32807.56,111191.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34611.07,,"Fee schedule rate ($34,611.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],81324.83,,"Fee schedule rate ($81,324.83). Adds an outlier to normal pricing equal to the per diem rate ($106,784.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula|RIGHT SIDE|PO,CASE-27641,APC,27641,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,48444.74,Estimated amount calculated based on 11 day length of stay.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17130.80,,,,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],57067.24,,,,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",867.84,867.84,867.84,1 through 10,other,838.89,880.84,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],20331.48,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19363.31,79918.67,Inpatient DRG
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6553.68,,"Case rate ($6,553.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $6,086.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,276.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,494.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,073.77. The transfer operating threshold is the transfer adjustment factor * $6,086.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.91. The transfer capital threshold is the transfer adjustment factor * $479.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6553.68,20086.28,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",11524.63,11524.63,11524.63,1 through 10,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],59188.55,,"Fee schedule rate ($59,188.55). Adds an outlier to normal pricing equal to the per diem rate ($203,441.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,APC,45381,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5847.81,,"Case rate ($5,569.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,565.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.66. The transfer capital threshold is the transfer adjustment factor * $394.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5578.22,18148.00,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14673.67,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",14673.68,14673.68,14673.68,1 through 10,other,14673.67,43541.27,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4568.94,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4568.94,13557.45,Inpatient DRG
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Gastrocnemius Recession|RIGHT SIDE,CASE-27687,APC,27687,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5544.51,,"Case rate ($5,280.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,879.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,346.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,553.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,898.48. The transfer operating threshold is the transfer adjustment factor * $4,879.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $382.00. The transfer capital threshold is the transfer adjustment factor * $382.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5280.49,17810.78,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33491.24,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,19137.85,64589.15,All Other Inpatient
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12215.62,,"Case rate ($11,633.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,995.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.42. The transfer capital threshold is the transfer adjustment factor * $824.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11652.47,41507.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AND UMBILICAL,MODERATE",227,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],18934.95,,"Case rate ($18,934.95). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,18934.95,19881.70,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple,CASE-43239,APC,43239,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],903.26,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,860.25,903.26,OPPS APC
Syndactylization Toes,CASE-28280,APC,28280,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX|74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36239.13,,,,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10311.56,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10109.37,38416.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE,CASE-27691,APC,27691,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC Extremity Venogram|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10260.35,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9913.38,10409.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
Tenolysis Extensor Foot Single Tendon,CASE-28225,APC,28225,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Destruction Mal Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-17266,APC,17266,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,399.06,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Non/Malunion Humerus W/O Graft|LEFT SIDE,CASE-24430,APC,24430,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12603.27,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"IMPLANTABLE HEART ASSIST SYSTEMS,EXTREME",161,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],339221.83,,"Case rate ($323,068.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $121,386, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,323068.41,339221.83,There are no additional notes associated with this service or procedure.
Revis Shoulder Arthrplsty Humeral&Glenoid Compnt,CASE-23474,APC,23474,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20110.39,,"Fee schedule rate ($20,110.39). Adds an outlier to normal pricing equal to the per diem rate ($69,590.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7096.13,25801.23,Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33733.44,,"Fee schedule rate ($33,733.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4789.75,,"Case rate ($4,561.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $323.26. The transfer capital threshold is the transfer adjustment factor * $323.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4568.94,13557.45,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5344.14,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5344.14,15857.69,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|PO|LEFT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|PO|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-23430,APC,23430,CPT,0360,RC,,,73,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,APC,51990,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36556,APC,36556,CPT,0761,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15888.93,,"Case rate ($15,132.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,243.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,072.33. The transfer capital threshold is the transfer adjustment factor * $1,072.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15156.44,52672.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE,CASE-27570,APC,27570,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8219.40,,"Fee schedule rate ($8,219.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4574.91,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4574.91,13575.16,Inpatient DRG
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],67775.08,,"Fee schedule rate ($67,775.08). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY VASCULAR PROCEDURES,MODERATE",181,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],31027.29,,"Case rate ($31,027.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31027.29,32578.65,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6284.66,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5985.39,17760.46,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5011.16,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4772.53,14161.54,Inpatient DRG
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7450.26,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4257.29,12632.63,All Other Inpatient
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6724.11,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6724.11,19952.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5379.29,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5379.29,15961.98,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],45200.40,,"Fee schedule rate ($45,200.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13970.92,,"Case rate ($13,305.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,294.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,761.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,133.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,343.08. The transfer operating threshold is the transfer adjustment factor * $12,294.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.56. The transfer capital threshold is the transfer adjustment factor * $962.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13305.64,39481.90,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10311.56,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10109.37,38416.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5559.80,,"Case rate ($5,450.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $5,062.05, add-ons for qualifying new technology services are included. If operating cost exceeds $42,251.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,051.56. The transfer operating threshold is the transfer adjustment factor * $5,062.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.22. The transfer capital threshold is the transfer adjustment factor * $399.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5450.78,16705.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,25698.16,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15772.78,,"Fee schedule rate ($15,772.78). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16271.46,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,53945.28,Inpatient DRG
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],57457.72,,"Fee schedule rate ($57,457.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Pilonidal Cyst/Sinus Extensive,CASE-11771,APC,11771,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",122445.39,122445.39,122445.39,1 through 10,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7943.78,,"Case rate ($7,565.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,001.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,469.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,707.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,029.37. The transfer operating threshold is the transfer adjustment factor * $7,001.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.12. The transfer capital threshold is the transfer adjustment factor * $536.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7577.56,31445.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE,CASE-27601,APC,27601,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9108.71,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9108.71,27028.33,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,Zero final payments for the item or service in the 15 months prior to posting the file.
Tendon Sheath Incision|PO,CASE-26055,APC,26055,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8764.55,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8764.55,32969.91,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7048.26,,"Case rate ($6,910.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,405.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,149.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,408.97. The transfer operating threshold is the transfer adjustment factor * $6,405.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $501.10. The transfer capital threshold is the transfer adjustment factor * $501.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6910.06,20832.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29008.87,,"Fee schedule rate ($29,008.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14267.55,,"Case rate ($13,588.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,555.10, add-ons for qualifying new technology services are included. If operating cost exceeds $48,023.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,154.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,605.14. The transfer operating threshold is the transfer adjustment factor * $12,555.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $983.00. The transfer capital threshold is the transfer adjustment factor * $983.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13588.14,40320.14,Inpatient DRG
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],47037.87,,,,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites,CASE-31625,APC,31625,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3713.03,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|LEFT SIDE,CASE-27446,APC,27446,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35969.56,,,,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10638.72,,"Fee schedule rate ($10,638.72). Adds an outlier to normal pricing equal to the per diem rate ($26,031.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,3753.97,11139.15,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18024.13,,,,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5862.95,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5091.00,22010.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],67331.56,,"Fee schedule rate ($67,331.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26999.90,,"Fee schedule rate ($26,999.90). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",57961.53,57961.53,57961.53,1 through 10,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],34214.43,,"Case rate ($32,585.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,480.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,309.10. The transfer capital threshold is the transfer adjustment factor * $2,309.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32637.12,96844.29,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],40252.28,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,38891.09,169197.98,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16682.55,,"Fee schedule rate ($16,682.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Sling Operation Stress Incontinence,CASE-57288,APC,57288,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10434.93,10586.16,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9725.67,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,27484.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, THUMB|PO",CASE-26525,APC,26525,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19155.70,,"Fee schedule rate ($19,155.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6654.93,20056.77,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],102359.22,,"Fee schedule rate ($102,359.22). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
HC Repr Smp Not Face 2.6-7.5cm,CASE-12002,APC,12002,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,211.83,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24413.25,,,,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8259.31,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7866.01,25247.47,Inpatient DRG
"OTHER DISORDERS OF NERVOUS SYSTEM,MODERATE",058,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],13741.86,,"Case rate ($13,741.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13741.86,14428.95,There are no additional notes associated with this service or procedure.
"HIV WITH MAJOR HIV RELATED CONDITION,EXTREME",892,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],26349.84,,"Case rate ($25,095.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25095.09,26349.84,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32406.65,,"Fee schedule rate ($32,406.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13464.97,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7694.27,22831.22,All Other Inpatient
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10334.84,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10334.84,30666.60,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7500.63,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7500.63,22256.65,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6700.24,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6700.24,30254.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6962.26,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6630.72,19989.86,Inpatient DRG
"KIDNEY AND URINARY TRACT INFECTIONS,MAJOR",463,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11310.41,,"Case rate ($11,310.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11310.41,11875.93,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9112.97,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8679.02,29908.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,MAJOR",253,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15389.24,,"Case rate ($14,656.42). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14656.42,15389.24,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15366.88,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15065.57,53815.71,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FOURTH DIGIT|PO",CASE-26951,APC,26951,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16536.43,,"Fee schedule rate ($16,536.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,There are no additional notes associated with this service or procedure.
"Neuroplasty Other Arm/Leg Nerve,Open|SEPARATE STRUCTURE|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3353.51,,"APC Price ($3,240.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3240.11,3402.11,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6044.58,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6044.58,6346.81,OPPS APC
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE|PO,CASE-24359,APC,24359,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],22001.61,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,21570.21,72041.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7055.53,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5520.00,26638.96,Inpatient DRG
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
Exc Tumor Soft Tissue Abdl Wall Subfascial <5cm,CASE-22900,APC,22900,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22256.65,,,,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Ankle W/Implant|LEFT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
"OTHER CIRCULATORY SYSTEM DIAGNOSES,MAJOR",207,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12752.70,,"Case rate ($12,752.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12752.70,13390.34,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6773.79,,"Case rate ($6,451.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.16. The transfer capital threshold is the transfer adjustment factor * $457.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6461.52,21772.28,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],39684.68,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10105.00,120252.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
Anesthesia Combined Upper&Lower GI Endoscopic Px,CASE-00813,APC,00813,CPT,0370,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,926.14,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28157.55,,"Fee schedule rate ($28,157.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],113934.44,,"Fee schedule rate ($113,934.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14112.34,,,,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|PO,CASE-64483,APC,64483,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11458.84,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11458.84,42820.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6644.63,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6328.22,27416.36,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10203.94,,"Fee schedule rate ($10,203.94). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19183.89,,"Fee schedule rate ($19,183.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,6553.68,20086.28,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5890.67,,"Case rate ($5,775.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.79. The transfer capital threshold is the transfer adjustment factor * $417.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",85843.39,85843.39,85843.39,1 through 10,other,5775.17,17136.70,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5614.71,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5504.62,16333.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,APC,58542,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21630.93,,,,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10367.99,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10367.99,37103.57,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE|PO",CASE-64491,APC,64491,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],4832.10,,"Fee schedule rate ($4,832.10). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],45758.86,,,,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5605.09,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5338.18,15839.99,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7592.25,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7335.51,29792.90,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19630.56,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11217.46,37366.25,All Other Inpatient
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],30314.43,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13369.00,88188.38,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12698.12,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,35884.94,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4735.03,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4574.91,13575.16,Inpatient DRG
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,APC,43282,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,50|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Trluml Balo Angiop 1st Vein,CASE-37248,APC,37248,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5668.18,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17008.80,,,,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],83099.91,,,,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12283.14,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11698.23,34712.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Trigger Point 3 or More|LEFT SIDE|PO,CASE-20553,APC,20553,CPT,0510,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12573.40,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12326.86,53121.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19297.23,,,,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
"PULMONARY EMBOLISM,MAJOR",134,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],15097.12,,"Case rate ($15,097.12). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15097.12,15851.98,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12536.42,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12536.42,37199.37,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27966.92,,,,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4523.19,16536.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],36600.94,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",35781.22,35781.22,35781.22,1 through 10,other,18559.00,141041.50,Inpatient DRG
Cysto W/Insert Ureteral Stent|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,APC,52332,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20343.42,,"Fee schedule rate ($20,343.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE,CASE-28615,APC,28615,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9280.46,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9280.46,39957.56,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16776.95,,"Fee schedule rate ($16,776.95). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],42945.05,,,,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13110.79,,,,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7394.01,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,21229.52,Inpatient DRG
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],38694.84,,"Case rate ($36,852.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,782.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,611.48. The transfer capital threshold is the transfer adjustment factor * $2,611.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36910.99,126842.57,Inpatient DRG
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11136.51,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10759.91,46061.32,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
Arthrodesis Great Toe Interphalangeal Joint,CASE-28755,APC,28755,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,APC,49594,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6833.56,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6699.57,24060.08,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8578.65,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8410.44,24956.34,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17056.02,,,,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
Synovectomy Metatarsophalangeal Joint Each,CASE-28072,APC,28072,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22612.66,,"Case rate ($21,535.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,697.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,526.11. The transfer capital threshold is the transfer adjustment factor * $1,526.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,21570.21,72041.81,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9466.07,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9280.46,39957.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19871.72,,"Fee schedule rate ($19,871.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,7011.91,27304.54,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],48049.11,,"Case rate ($45,761.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,413.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,242.79. The transfer capital threshold is the transfer adjustment factor * $3,242.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,45834.02,151120.97,Inpatient DRG
"AMPUTATION OF LOWER LIMB EXCEPT TOES,MODERATE",305,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],21103.09,,"Case rate ($20,098.18). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20098.18,21103.09,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],30403.05,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,30403.05,90685.00,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Ablation Renal Cysts|RIGHT SIDE,CASE-50541,APC,50541,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC
Fasciectomy Plantar Fascia Radical Spx|LEFT SIDE|PO,CASE-28062,APC,28062,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45390,APC,45390,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28175.50,,,,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20928.60,,"Fee schedule rate ($20,928.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5658.75,,"Case rate ($5,389.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,996, add-ons for qualifying new technology services are included. If operating cost exceeds $45,541.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,038.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,998.47. The transfer operating threshold is the transfer adjustment factor * $4,996.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.82. The transfer capital threshold is the transfer adjustment factor * $390.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5389.29,16247.30,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34171.31,,"Fee schedule rate ($34,171.31). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11871.54,35778.69,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15973.65,,"Fee schedule rate ($15,973.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],35094.08,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,33422.93,112824.68,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5847.81,,"Case rate ($5,569.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,565.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.66. The transfer capital threshold is the transfer adjustment factor * $394.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5578.22,18148.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
Proctosgmdsc Rgd Dx W/WO Collj Spec Br/Wa Spx,CASE-45300,APC,45300,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,21229.52,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33733.44,,"Fee schedule rate ($33,733.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32019.51,,"Fee schedule rate ($32,019.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE|PO,CASE-27654,APC,27654,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13713.69,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13249.94,40085.35,Inpatient DRG
"MALNUTRITION FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS,MAJOR",421,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13961.86,,"Case rate ($13,297.01). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13297.01,13961.86,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19319.53,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6953.00,35389.05,All Other Inpatient
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17351.73,,"Fee schedule rate ($17,351.73). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],70034.38,,,,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
Arthrt Elbow W/Exploration Drainage/Removal FB,CASE-24000,APC,24000,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24505.01,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23338.10,69251.23,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6883.61,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6748.64,20025.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY VASCULAR PROCEDURES,EXTREME",181,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],62241.08,,"Case rate ($62,241.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $46,166, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,62241.08,65353.13,There are no additional notes associated with this service or procedure.
Litholapaxy Comp/Lg > 2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52318,APC,52318,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,APC,51990,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
Excision Ganglion Wrist Dorsal/Volar Primary|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"INGUINAL FEMORAL AND UMBILICAL HERNIA PROCEDURES,MINOR",228,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12387.98,,"Case rate ($12,387.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12387.98,13007.38,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MAJOR",254,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14495.68,,"Case rate ($13,805.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13805.41,14495.68,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6041.52,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5923.06,17575.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17658.44,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16817.56,58510.23,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO|SEPARATE STRUCTURE",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12823.44,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12212.80,39290.21,Inpatient DRG
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,CASE-43762,APC,43762,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms,CASE-27696,APC,27696,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,APC,38571,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5951.82,,"Case rate ($5,668.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,581.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.07. The transfer capital threshold is the transfer adjustment factor * $410.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5668.40,16903.82,Inpatient DRG
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7263.07,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,1188.00,20179.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4172.66,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,2285.00,12138.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11699.11,,"Case rate ($11,142.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.56. The transfer capital threshold is the transfer adjustment factor * $789.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",24385.78,24385.78,24385.78,1 through 10,other,11159.78,39897.21,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE",CASE-28299,APC,28299,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",6963.55,6963.55,6963.55,1 through 10,other,6882.29,7226.40,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22158.27,,,,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10348.07,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,30103.84,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf|LEFT SIDE,CASE-36825,APC,36825,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],104605.60,,"Fee schedule rate ($104,605.60). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],112149.06,,,,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],22267.42,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,21830.80,85124.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6552.71,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6240.68,18518.02,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12345.81,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11757.91,34889.29,Inpatient DRG
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],52013.85,,"Fee schedule rate ($52,013.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15517.38,,"Fee schedule rate ($15,517.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5389.29,16247.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALFUNCTION REACTION COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE,MODERATE",466,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9687.00,,"Case rate ($9,225.71). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9225.71,9687.00,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21451.50,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8940.00,63653.13,Inpatient DRG
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5420.70,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5237.39,15540.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],81324.83,,"Fee schedule rate ($81,324.83). Adds an outlier to normal pricing equal to the per diem rate ($106,784.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21474.76,,"Fee schedule rate ($21,474.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,7577.56,31445.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
Excision Pilonidal Cyst/Sinus Simple,CASE-11770,APC,11770,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,32980.62,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15839.99,,,,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
Synovectomy Tendon Sheath Foot Extensor,CASE-28088,APC,28088,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt,CASE-26531,APC,26531,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rmvl/Revj Sling Male Urinary Incontinence,CASE-53442,APC,53442,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64448,APC,64448,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",40559.58,40559.58,40559.58,1 through 10,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20817.97,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,17274.00,73717.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg|ADJ|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3074.87,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3074.87,3228.61,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Femur/Knee|LEFT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],233.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,233.96,245.65,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6059.16,,"Case rate ($5,770.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,580.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.93. The transfer capital threshold is the transfer adjustment factor * $408.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",11921.82,4078.64,76833.46,1 through 10,other,5779.83,17150.47,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5142.73,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4968.82,19848.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],29720.03,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13369.00,88188.38,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8143.73,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7984.05,23691.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],99157.51,,"Fee schedule rate ($99,157.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",92666.05,92666.05,92666.05,1 through 10,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6504.75,,"Case rate ($6,195). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.00. The transfer capital threshold is the transfer adjustment factor * $439.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6504.75,6504.75,6504.75,1 through 10,other,6204.88,19589.20,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOLIC LIVER DISEASE,MAJOR",280,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],15582.03,,"Case rate ($15,582.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15582.03,16361.13,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
HC Add 2nd/3rd Order Abd/Le,CASE-36248,APC,36248,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],52786.42,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,30163.67,89504.77,All Other Inpatient
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5862.95,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5091.00,22010.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6130.37,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5923.06,17575.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25534.84,,,,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12490.63,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11895.84,35298.57,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13332.10,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",13254.74,11806.73,13332.10,11,other,12881.26,38222.57,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12770.37,,,,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10826.88,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10826.88,32126.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ALTERATION IN CONSCIOUSNESS,MAJOR",052,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15264.49,,"Case rate ($14,537.61). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14537.61,15264.49,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE|PO,CASE-27698,APC,27698,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11859.90,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11458.84,42820.42,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14727.04,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14438.27,55762.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39259.55,,,,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|SEPARATE STRUCTURE|PO,CASE-62323,APC,62323,CPT,0360,RC,,,XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5605.96,5605.96,5605.96,1 through 10,other,5733.99,6020.69,OPPS APC
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5779.85,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5504.62,16333.88,Inpatient DRG
Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,CASE-58571,APC,58571,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",9838.13,9838.13,9838.13,1 through 10,other,10082.05,10586.16,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7590.81,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7590.81,32847.45,Inpatient DRG
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6785.78,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6729.27,5238.51,6785.78,12,other,6785.78,20135.47,Inpatient DRG
Tenolysis Extensor Tendon Hand/Finger Each,CASE-26445,APC,26445,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],40628.03,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,39831.40,138208.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,APC,52332,CPT,0360,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33727.80,,"Fee schedule rate ($33,727.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT FOOT, GREAT TOE",CASE-28297,APC,28297,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],94720.48,,"Fee schedule rate ($94,720.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
HC App Skin Sub T/a/L Tot <100 1st 25|PBB CHARGE,CASE-15271,APC,15271,CPT,0361,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],725.52,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,700.99,736.04,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20984.05,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20274.44,80940.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13831.52,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13831.52,59770.39,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
HC 3rd Order Sel Abd/Lower Ext|RIGHT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Medium WO US|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-20605,APC,20605,CPT,0510,RC,,,XU|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6220.95,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6010.58,17835.23,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15013.15,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14718.77,51765.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10739.04,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10528.47,44148.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Talus Fracture|RIGHT SIDE,CASE-28445,APC,28445,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26464.27,,"Fee schedule rate ($26,464.27). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FIFTH DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36801.89,,,,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18944.48,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18042.36,82749.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6225.29,,"Case rate ($5,928.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.30,18621.89,Inpatient DRG
Rpr Aa Hernia Recr < 3 Cm Ncrc8/Strangulated,CASE-49614,APC,49614,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],59833.15,,"Fee schedule rate ($59,833.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29433.60,,"Fee schedule rate ($29,433.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Aid Tibial Fracture Proximal Unicondylar,CASE-29855,APC,29855,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Complete 5th Metatarsal Head,CASE-28113,APC,28113,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia & Fibula,CASE-27828,APC,27828,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],873.59,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,873.59,917.27,OPPS APC
Insertion Intrauterine Device Iud,CASE-58300,APC,58300,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21005.48,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20005.22,74991.64,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7543.08,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7543.08,29489.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Debridement/Shaving Artclr Crtlg|LEFT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10017.33,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",10000.20,9998.86,10017.33,1 through 10,other,9820.91,29141.64,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,32749.19,97176.83,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],47794.95,,"Fee schedule rate ($47,794.95). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6240.68,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6240.68,18518.02,Inpatient DRG
HC Sel Cath Abd/Pelvic/Le 1st Ord,CASE-36245,APC,36245,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Stent Place Initial Artery Ang|LEFT SIDE,CASE-37236,APC,37236,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC
Excision/Curettage Cyst/Tumor Femur|LEFT SIDE,CASE-27355,APC,27355,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|LEFT SIDE,CASE-29825,APC,29825,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,Zero final payments for the item or service in the 15 months prior to posting the file.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],130347.93,,"Fee schedule rate ($130,347.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30254.51,130347.93,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14472.78,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",14472.79,14472.79,14472.79,1 through 10,other,7770.00,50313.90,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15753.15,,"Fee schedule rate ($15,753.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",42671.88,42671.88,42671.88,1 through 10,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
Litholapaxy Smpl/Sm <2.5 Cm|SEPARATE STRUCTURE,CASE-52317,APC,52317,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|LEFT FOOT, GREAT TOE|PO",CASE-28092,APC,28092,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],24009.84,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10632.00,103714.29,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1903.51,1903.51,1903.51,1 through 10,other,1852.10,1944.70,OPPS APC
Cysto/Pyeloscopy Rescj Pelvic Tumor,CASE-52355,APC,52355,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Prox Humeral Fx W/Int Fixj Rpr Tuberosity|LEFT SIDE,CASE-23615,APC,23615,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],40639.08,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,40639.08,120588.53,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],112882.03,,"Fee schedule rate ($112,882.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
HC App Skin Sub T/a/L Tot <100 1st 25,CASE-15271,APC,15271,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],736.04,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,700.99,736.04,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29162.98,,"Fee schedule rate ($29,162.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
HC Revasc Intra Lithotrip-Stent,CASE-C9765,APC,C9765,CPT,0481,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5985.39,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6016.69,4603.96,82846.55,1 through 10,other,5985.39,17760.46,Inpatient DRG
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,CASE-43762,APC,43762,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],36511.04,,"Fee schedule rate ($36,511.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8248.57,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,34379.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE,CASE-29891,APC,29891,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35298.57,,,,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],20062.75,,"Case rate ($19,107.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,525.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.01. The transfer capital threshold is the transfer adjustment factor * $1,354.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19137.85,64589.15,Inpatient DRG
"OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,MINOR",663,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2942.52,,"Case rate for a one day stay ($2,802.40). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2802.40,2942.52,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|LEFT FOOT, SECOND DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,T1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17695.16,,of the excess amount.,10243.29,10243.29,10243.29,1 through 10,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15090.78,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15090.78,44778.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, FIFTH DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],45520.40,,"Fee schedule rate ($45,520.40). Adds an outlier to normal pricing equal to the per diem rate ($131,498.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12747.57,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12140.54,36024.65,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14448.22,,"Case rate ($14,448.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,349.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,817.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,216.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,402.99. The transfer operating threshold is the transfer adjustment factor * $13,349.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,045.22. The transfer capital threshold is the transfer adjustment factor * $1,045.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6940.00,42872.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13768.00,,,,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|PO",CASE-64491,APC,64491,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE|PO,CASE-29806,APC,29806,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5368.01,,"Case rate ($5,368.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,959.91, add-ons for qualifying new technology services are included. If operating cost exceeds $40,427.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,559.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,979.68. The transfer operating threshold is the transfer adjustment factor * $4,959.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $388.34. The transfer capital threshold is the transfer adjustment factor * $388.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5368.01,15928.53,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],61860.92,,"Fee schedule rate ($61,860.92). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
Rhinoplasty Primary W/Major Septal Repair|PO,CASE-30420,APC,30420,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC
HC >= 12 Lead Ekg|ADJ|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3228.61,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3074.87,3228.61,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bladder Instillation Anticarcinogenic Agent|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51720,APC,51720,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28895.67,,,,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],30150.40,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,30150.40,89465.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16873.59,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16302.99,55737.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14118.54,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13446.23,39899.05,Inpatient DRG
Trluml Balo Angiop Ctr Dialysis Seg W/Img S&I,CASE-36907,APC,36907,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5587.20,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13866.64,,"Case rate ($13,866.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,812.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,280.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,174.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,863.50. The transfer operating threshold is the transfer adjustment factor * $12,812.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,003.15. The transfer capital threshold is the transfer adjustment factor * $1,003.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13866.64,41146.57,Inpatient DRG
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu,CASE-25260,APC,25260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36695.64,,,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
Cysto/Pyeloscopy Rescj Pelvic Tumor|LEFT SIDE,CASE-52355,APC,52355,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Bx,Vulva/Perineum,Addl Lesion",CASE-56606,APC,56606,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],873.59,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,873.59,917.27,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],48085.72,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,50750.92,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11432.65,,"Case rate ($10,888.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,437.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10888.24,32825.17,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12565.46,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12140.54,36024.65,Inpatient DRG
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO,CASE-62323,APC,62323,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",665.41,665.41,665.41,1 through 10,other,669.51,702.98,OPPS APC
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],115401.67,,,,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6088.34,,"Case rate ($5,798.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.90. The transfer capital threshold is the transfer adjustment factor * $410.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5807.67,17233.12,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8119.84,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4639.91,13771.19,All Other Inpatient
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7742.63,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7590.81,32847.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27597.52,,"Fee schedule rate ($27,597.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Suture Quadriceps/Hamstring Rupture Primary|RIGHT SIDE|PO,CASE-27385,APC,27385,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10920.51,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,30861.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,APC,57425,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26465.57,,,,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Revsc Opn/Prq Tib/Pero W/Athrc/Angiop Uni Ea Vsl|RIGHT SIDE,CASE-37233,APC,37233,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.75,,,,,,0,other,291.75,306.34,There are no additional notes associated with this service or procedure.
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, THUMB|PO",CASE-26445,APC,26445,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Carpectomy All Bones Proximal Row|RIGHT SIDE|PO,CASE-25215,APC,25215,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10236.03,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10236.03,30589.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32390.31,,,,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16361.19,,"Fee schedule rate ($16,361.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],63171.04,,,,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
HC Hdr Vaginal Cyl Insertion,CASE-57156,APC,57156,CPT,0333,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],289.03,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,289.03,303.48,OPPS APC
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,APC,49320,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",5687.21,5687.21,5687.21,1 through 10,other,5733.99,6020.69,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5766.55,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5766.55,17111.12,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9427.51,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9108.71,27028.33,Inpatient DRG
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, THUMB|PO",CASE-26525,APC,26525,CPT,0360,RC,,,FA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",68156.69,68156.69,68156.69,1 through 10,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6422.05,,"Case rate ($6,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,620.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.88. The transfer capital threshold is the transfer adjustment factor * $448.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6204.88,19589.20,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
"PERIPHERAL CRANIAL AND AUTONOMIC NERVE DISORDERS,MODERATE",048,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10042.18,,"Case rate ($10,042.18). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10042.18,10544.29,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19984.73,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,8990.00,80069.53,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Revj Total Knee Arthrp W/WO Algrft 1 Component,CASE-27486,APC,27486,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11891.25,,"Fee schedule rate ($11,891.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
"SYNCOPE AND COLLAPSE,EXTREME",204,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],18527.40,,"Case rate ($18,527.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,18527.40,19453.77,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",18644.18,18644.18,18644.18,1 through 10,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE,CASE-29880,APC,29880,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39259.55,,,,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22901.56,,"Fee schedule rate ($22,901.56). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3295.00,,,,,,0,other,3295.00,50750.92,Estimated amount calculated based on 22 day length of stay.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17214.39,,"Fee schedule rate ($17,214.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],85446.13,,"Fee schedule rate ($85,446.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14166.98,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13889.20,55846.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14064.85,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13789.07,57367.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10851.58,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10334.84,30666.60,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION,EXTREME",190,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],25389.56,,"Case rate ($24,180.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24180.53,25389.56,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
HC Revasc Intra Lithotrip-Stent,CASE-C9765,APC,C9765,CPT,0481,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18902.44,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18902.44,56089.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],31858.62,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31858.62,94534.21,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],23723.08,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22593.41,90908.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9718.72,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,27465.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5379.29,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5379.29,15961.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7532.22,,"Case rate ($7,173.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.34. The transfer capital threshold is the transfer adjustment factor * $508.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",7450.97,7450.97,7450.97,1 through 10,other,7184.98,21320.03,Inpatient DRG
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5161.43,4884.61,5161.43,1 through 10,other,5085.49,5339.77,OPPS APC
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],30149.39,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,29129.85,86437.13,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15421.03,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15421.03,49137.17,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],59188.55,,"Fee schedule rate ($59,188.55). Adds an outlier to normal pricing equal to the per diem rate ($203,441.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],36511.04,,"Fee schedule rate ($36,511.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14390.10,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13704.86,49911.01,Inpatient DRG
Tenodesis Long Tendon Biceps|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,APC,23430,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16630.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17461.77,OPPS APC
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10134.35,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9935.64,29482.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21894.53,,"Case rate ($20,851.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,648.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,477.64. The transfer capital threshold is the transfer adjustment factor * $1,477.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",53438.16,53438.16,53438.16,1 through 10,other,20885.18,80720.91,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],45520.40,,"Fee schedule rate ($45,520.40). Adds an outlier to normal pricing equal to the per diem rate ($131,498.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",45006.90,45006.90,45006.90,1 through 10,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],68621.57,,,,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14200.87,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7453.00,42138.30,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],94720.48,,"Fee schedule rate ($94,720.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4802.31,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4639.91,13771.19,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15820.10,,"Case rate ($15,066.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,238.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,067.68. The transfer capital threshold is the transfer adjustment factor * $1,067.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15090.78,44778.95,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30145.85,,"Fee schedule rate ($30,145.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9685.23,,"Case rate ($9,495.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,773.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,858.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $8,808.40. The transfer operating threshold is the transfer adjustment factor * $8,773.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.92. The transfer capital threshold is the transfer adjustment factor * $686.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9495.32,42131.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],37840.12,,"Fee schedule rate ($37,840.12). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,APC,11606,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Medial Malleolus Fracture|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27766,APC,27766,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11592.12,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11592.12,38954.76,Inpatient DRG
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41042.29,,,,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24585.00,,"Fee schedule rate ($24,585.00). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],65538.71,,"Fee schedule rate ($65,538.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27654,APC,27654,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23284.87,,"Case rate ($13,305.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,294.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,761.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,133.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,343.08. The transfer operating threshold is the transfer adjustment factor * $12,294.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.56. The transfer capital threshold is the transfer adjustment factor * $962.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13305.64,39481.90,All Other Inpatient
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6710.53,,"Case rate ($6,390.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,624.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $452.89. The transfer capital threshold is the transfer adjustment factor * $452.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5669.00,18994.21,Inpatient DRG
"Tenolysis Extensor Tendon Hand/Finger Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26445,APC,26445,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27304.54,,"Fee schedule rate ($27,304.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Sgmdsc Flx Dired Sbmcsl Njx Any Sbst,CASE-45335,APC,45335,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,912.91,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15261.14,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14534.42,59012.52,Inpatient DRG
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,APC,52332,CPT,0360,RC,,,50|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34001.86,,,,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12095.14,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11519.18,34180.92,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5011.16,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4772.53,14161.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21913.36,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",22917.33,22917.33,22917.33,1 through 10,other,12500.00,83592.64,Inpatient DRG
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, SECOND DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Neuroplasty Other Arm/Leg Nerve,Open|SEPARATE STRUCTURE|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3240.11,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3240.11,3402.11,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],78047.33,,"Fee schedule rate ($78,047.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Vaginectomy Partial Removal Vaginal Wall,CASE-57106,APC,57106,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14511.08,,"Case rate ($13,820.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,150.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.34. The transfer capital threshold is the transfer adjustment factor * $979.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12440.40,41073.77,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14508.56,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14508.56,59513.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17214.39,,"Fee schedule rate ($17,214.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5379.29,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5379.29,15961.98,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17083.31,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9761.89,37873.87,All Other Inpatient
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36103.36,,,,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE,CASE-27695,APC,27695,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI HEART FAILURE OR SHOCK,MODERATE",171,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],24698.60,,"Case rate ($24,698.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24698.60,25933.53,There are no additional notes associated with this service or procedure.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB|PO",CASE-26418,APC,26418,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Colsc Flx With Directed Submucosal Njx Any Sbst|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45381,APC,45381,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18945.22,,"Fee schedule rate ($18,945.22). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,868.26,OPPS APC
Osteotomy Tarsal Bones Oth/Thn Calcaneus/Talus|LEFT SIDE|PO,CASE-28304,APC,28304,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22469.78,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21399.79,63499.65,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11443.29,,"Case rate ($10,898.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,943.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $772.30. The transfer capital threshold is the transfer adjustment factor * $772.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10915.75,32390.31,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8811.32,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8442.00,28788.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9464.78,,"Fee schedule rate ($9,464.78). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15233.93,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14718.77,51765.74,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10915.75,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10915.75,32390.31,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6035.39,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5091.00,22010.11,Inpatient DRG
"Inject Nerv Blck,Paravert Sympath|PO",CASE-64520,APC,64520,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],28870.62,,"Case rate ($27,495.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,119.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,948.45. The transfer capital threshold is the transfer adjustment factor * $1,948.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27539.67,109237.68,Inpatient DRG
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE,CASE-28200,APC,28200,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11814.94,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11814.94,44591.73,Inpatient DRG
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|LEFT HAND, FIFTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],129893.46,,"Fee schedule rate ($129,893.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],36224.65,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",36224.66,36224.66,36224.66,1 through 10,other,36224.65,128473.68,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13676.25,,"Fee schedule rate ($13,676.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
Open Treatment Calcaneal Fracture|LEFT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14534.23,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12440.40,41073.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Sesamoidectomy First Toe Spx|LEFT FOOT, GREAT TOE|PO",CASE-28315,APC,28315,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MODERATE",344,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],12501.13,,"Case rate ($11,905.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11905.84,12501.13,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9290.88,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9108.71,27028.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10440.75,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10236.03,30589.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arteriovenous Anastomosis Open Direct|LEFT SIDE,CASE-36821,APC,36821,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intrvasc US Noncoronary 1st,CASE-37252,APC,37252,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],557.79,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,APC,11424,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3182.49,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3074.87,3228.61,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15818.04,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15507.88,46016.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5244.04,,"Case rate ($5,244.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,859.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,405.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,029.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,862.27. The transfer operating threshold is the transfer adjustment factor * $4,859.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $381.77. The transfer capital threshold is the transfer adjustment factor * $381.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5244.04,15804.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8071.33,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7686.98,22809.58,Inpatient DRG
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,APC,46200,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19212.61,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,18562.91,73513.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14469.48,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9763.00,48626.00,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5614.23,,"Case rate ($5,346.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.90. The transfer capital threshold is the transfer adjustment factor * $378.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5355.42,17067.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],36505.40,,"Fee schedule rate ($36,505.40). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12881.26,38222.57,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5094.80,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5094.80,15365.01,Inpatient DRG
Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,CASE-49616,APC,49616,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8.91,,,,,,0,other,8.91,9.04,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7394.01,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,21229.52,Inpatient DRG
Colonoscopy Stoma Dx Including Collj Spec Spx,CASE-44388,APC,44388,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17161.77,,"Fee schedule rate ($17,161.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8491.17,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,34379.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
Ligation/Biopsy Temporal Artery|RIGHT SIDE,CASE-37609,APC,37609,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],42671.03,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,40639.08,120588.53,Inpatient DRG
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10597.42,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6055.67,17969.04,All Other Inpatient
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,APC,43239,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",456.96,456.96,456.96,1 through 10,other,1820.02,1911.02,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14784.29,,"Case rate ($14,080.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.78. The transfer capital threshold is the transfer adjustment factor * $997.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14102.73,41847.08,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],34423.90,,"Fee schedule rate ($34,423.90). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39570.45,,,,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20938.30,,,,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27622.57,,,,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],75545.91,,,,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11553.15,,"Fee schedule rate ($11,553.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
HC Debrid Wound Tis 20 Cm/<|PBB CHARGE,CASE-97597,APC,97597,CPT,0761,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],92976.49,,"Fee schedule rate ($92,976.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.5), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28569.12,,"Fee schedule rate ($28,569.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
"KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,MODERATE",443,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5856.59,,"Case rate for a one day stay ($5,577.70). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5577.70,5856.59,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21939.88,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20895.12,99969.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13518.78,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5970.00,38757.79,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13704.86,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13704.86,49911.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11757.91,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11757.92,11757.92,11759.58,1 through 10,other,11757.91,34889.29,Inpatient DRG
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6084.34,,"Fee schedule rate ($6,084.34). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
HC Intro Cath Dialysis Circuit W Pta,CASE-36902,APC,36902,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5668.18,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5398.26,5668.18,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5256.94,,"Case rate ($5,006.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,625.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,093.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,644.42. The transfer operating threshold is the transfer adjustment factor * $4,625.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.19. The transfer capital threshold is the transfer adjustment factor * $362.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5006.61,14856.14,Inpatient DRG
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],85446.13,,"Fee schedule rate ($85,446.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24153.20,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23679.61,84629.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE|PO,CASE-25609,APC,25609,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6700.24,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6700.24,30254.37,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",74999.77,74999.77,74999.77,1 through 10,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],38891.09,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,38891.09,169197.98,Inpatient DRG
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE,CASE-27601,APC,27601,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC Wound Vac <=50 Sq Cm Dme,CASE-97605,APC,97605,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],196.96,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],44580.21,,,,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12775.42,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12167.07,36103.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],29890.76,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8232.00,84471.39,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9904.85,,"Case rate ($9,433.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,839.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.47. The transfer capital threshold is the transfer adjustment factor * $668.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6531.00,35832.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],194815.15,,"Case rate ($185,538.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,319.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,147.88. The transfer capital threshold is the transfer adjustment factor * $13,147.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,185834.07,195125.77,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],43344.00,,"Fee schedule rate ($43,344.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit,CASE-36901,APC,36901,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1567.69,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1514.26,1514.26,1514.26,1 through 10,other,1493.03,1567.69,OPPS APC
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,APC,45378,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",895.20,895.20,895.20,1 through 10,other,882.03,926.14,OPPS APC
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX|74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24915.45,,"Fee schedule rate ($24,915.45). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22542.21,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12881.26,38222.57,All Other Inpatient
"Sesamoidectomy First Toe Spx|RIGHT FOOT, GREAT TOE|PO",CASE-28315,APC,28315,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11205.82,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10927.50,10927.50,10927.50,1 through 10,other,10826.88,32126.64,Inpatient DRG
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33692.09,,"Fee schedule rate ($33,692.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
Claviculectomy Partial|LEFT SIDE,CASE-23120,APC,23120,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],20707.66,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20301.63,84714.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8031.52,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",8031.52,8031.52,8031.52,1 through 10,other,7759.92,35376.63,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9680.60,,"Fee schedule rate ($9,680.60). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],41590.28,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9365.02,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8919.07,34453.70,Inpatient DRG
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7041.91,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,21229.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],113934.44,,"Fee schedule rate ($113,934.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Fem Hernia Any Age Incarcerated,CASE-49553,APC,49553,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15592.86,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15065.57,53815.71,Inpatient DRG
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11203.52,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8962.83,8962.83,8962.83,1 through 10,other,6350.00,33244.29,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12496.20,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11901.14,35314.31,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,13588.14,40320.14,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13826.01,,"Fee schedule rate ($13,826.01). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7770.00,,"Per diem ($7,770). If length of stay < 5.1, first 1 days paid at a per diem of $15,540 instead. Capped at $39,628.80.",,,,0,other,7770.00,50313.90,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11587.80,,"Fee schedule rate ($11,587.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25698.16,,,,,,0,other,6965.00,25698.16,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],54086.17,,,,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE,CASE-28238,APC,28238,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|RIGHT SIDE,CASE-37765,APC,37765,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5348.00,,"Per diem ($5,348). If length of stay < 2.7, first 1 days paid at a per diem of $10,696 instead. Capped at $14,438.66.",,,,0,other,5094.80,15365.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16682.55,,"Fee schedule rate ($16,682.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Complete 1st Metatarsal Head,CASE-28111,APC,28111,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],50821.76,,,,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
HC Bladder Irrig Simple or Continuous,CASE-51700,APC,51700,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4743.76,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4517.87,13932.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16573.70,,"Fee schedule rate ($16,573.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6632.59,19680.94,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,APC,43282,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],28651.60,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],33148.67,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,31570.16,98176.71,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],69392.91,,,,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22922.34,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21830.80,85124.35,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],38210.55,,"Fee schedule rate ($38,210.55). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7078.89,21005.20,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],99176.02,,,,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15160.18,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14438.27,55762.74,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],37968.88,,of the excess amount.,39411.70,39411.70,39411.70,1 through 10,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12883.25,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11966.13,11966.13,11966.13,1 through 10,other,12883.25,44763.90,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],88173.00,,"Fee schedule rate ($88,173.00). Adds an outlier to normal pricing equal to the per diem rate ($170,052.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Nephrectomy W/Partial Ureterect,CASE-50546,APC,50546,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],351.87,,"APC Price ($339.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,339.97,356.97,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10759.91,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10759.91,46061.32,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,APC,58661,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10815.61,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10354.33,10354.33,10354.33,1 through 10,other,9888.00,40658.63,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"HYPERTENSION,MODERATE",199,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2917.78,,"Case rate for a one day stay ($2,917.78). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2917.78,3063.67,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27982.66,,,,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],68332.92,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7850.31,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,33946.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4523.19,16536.43,There are no additional notes associated with this service or procedure.
Debridement Nail Any Method 1-5,CASE-11720,APC,11720,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],57.91,,"APC Price ($55.95). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,55.95,58.75,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],50522.67,,,,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
Open Treatment Bimalleolar Ankle Fracture,CASE-27814,APC,27814,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE,CASE-24685,APC,24685,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,25698.16,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO|SEPARATE STRUCTURE,CASE-62323,APC,62323,CPT,0360,RC,,,PO|XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18222.73,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,18222.73,59942.55,Inpatient DRG
Arthroscopy Ankle Surgical Debridement Extensive|RIGHT SIDE|PO,CASE-29898,APC,29898,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15824.86,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15824.86,49371.45,Inpatient DRG
Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent,CASE-36903,APC,36903,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,APC,45385,CPT,0360,RC,,,PT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9594.31,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9269.86,37852.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21851.57,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,21112.63,62647.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30683.33,,"Fee schedule rate ($30,683.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Rhinoplasty Secondary Intermediate Revision,CASE-30435,APC,30435,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],68639.28,,,,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6382.95,,"Fee schedule rate ($6,382.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18878.71,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,18508.54,76171.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, FOURTH DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,T3,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6632.59,,"Case rate ($6,632.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,128.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,596.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,650.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,152.78. The transfer operating threshold is the transfer adjustment factor * $6,128.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.82. The transfer capital threshold is the transfer adjustment factor * $479.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6632.59,19680.94,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6240.68,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6240.68,18518.02,Inpatient DRG
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB|PO",CASE-26540,APC,26540,CPT,0360,RC,,,F5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12677.91,,"Case rate ($12,074.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,026.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.62. The transfer capital threshold is the transfer adjustment factor * $855.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,40067.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, GREAT TOE",CASE-28810,APC,28810,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7665.01,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7405.81,33747.30,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12476.30,,"Case rate ($11,882.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.01. The transfer capital threshold is the transfer adjustment factor * $842.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",101965.48,101965.48,101965.48,1 through 10,other,11901.14,35314.31,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11330.66,,"Case rate ($10,791.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,935.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $764.69. The transfer capital threshold is the transfer adjustment factor * $764.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10808.31,46938.11,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Fth/Gft Fr W/Dir Clsr F/C/C/M/N/Ax/G/H/F 20 Cm/<|PO,CASE-15240,APC,15240,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2054.80,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.96,2054.80,OPPS APC
HC Add 2nd/3rd Order Abd/Le|LEFT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21197.40,,"Fee schedule rate ($21,197.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MODERATE",045,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12896.38,,"Case rate ($12,896.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12896.38,13541.20,There are no additional notes associated with this service or procedure.
"DEPRESSIVE DISORDERS,MAJOR",751,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11870.12,,"Case rate ($11,304.88). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11304.88,11870.12,There are no additional notes associated with this service or procedure.
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],594.98,,"APC Price ($594.98). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,594.98,624.73,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33781.47,,,,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
Rmvl/Revj Sling Male Urinary Incontinence,CASE-53442,APC,53442,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17469.78,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,17127.24,50821.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE,CASE-27601,APC,27601,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9509.84,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9056.99,33814.75,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11186.60,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,10808.31,46938.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12836.55,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12402.46,36801.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14469.48,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9763.00,48626.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|PO|LEFT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|PO|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
"HC Aerosol, Hhn, Mdi, Ippb|ADJ",CASE-94640,APC,94640,CPT,0410,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE,CASE-27691,APC,27691,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8394.53,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8394.53,24909.11,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7179.38,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6837.50,20288.95,Inpatient DRG
HC App Skin Sub T/a/L Tot <100 1st 25,CASE-15271,APC,15271,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],725.52,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,700.99,736.04,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,APC,49329,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Dislocating Peroneal Tendon W/Fib Osteot,CASE-27676,APC,27676,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9509.84,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9056.99,33814.75,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15348.76,,"Case rate ($14,617.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,207.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,035.87. The transfer capital threshold is the transfer adjustment factor * $1,035.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14641.18,43444.85,Inpatient DRG
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33733.44,,"Fee schedule rate ($33,733.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11155.62,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6230.00,21325.01,All Other Inpatient
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],11812.10,,,,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,XS|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs|RIGHT SIDE|PO,CASE-25115,APC,25115,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4523.19,,"Case rate ($4,523.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,179.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,647.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,498.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,195.97. The transfer operating threshold is the transfer adjustment factor * $4,179.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $327.22. The transfer capital threshold is the transfer adjustment factor * $327.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4523.19,16536.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34517.10,,"Fee schedule rate ($34,517.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
Revj Total Knee Arthrp W/WO Algrft 1 Component,CASE-27486,APC,27486,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],83871.28,,"Fee schedule rate ($83,871.28). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Transoral Biopsy Single/Multiple,CASE-43239,APC,43239,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],890.35,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",900.85,873.10,900.85,1 through 10,other,860.25,903.26,OPPS APC
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],36910.99,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36910.99,126842.57,Inpatient DRG
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],41006.79,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,40202.74,148703.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],59188.55,,"Fee schedule rate ($59,188.55). Adds an outlier to normal pricing equal to the per diem rate ($203,441.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6634.06,,"Case rate ($6,318.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,618.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.73. The transfer capital threshold is the transfer adjustment factor * $447.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",80298.76,80298.76,80298.76,1 through 10,other,6328.22,27416.36,Inpatient DRG
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT|PO",CASE-28820,APC,28820,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36907.51,,"Fee schedule rate ($36,907.51). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
"SKIN ULCERS,EXTREME",380,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],22532.40,,"Case rate ($22,532.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22532.40,23659.02,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5254.16,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5003.96,21742.11,Inpatient DRG
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,CASE-55866,APC,55866,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10451.28,,"Case rate ($9,953.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,876.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.35. The transfer capital threshold is the transfer adjustment factor * $705.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9969.47,29582.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Implant Neurostim/Receiver,CASE-64590,APC,64590,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18400.38,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18400.38,19320.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13453.71,,"Case rate ($12,813.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,079.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.98. The transfer capital threshold is the transfer adjustment factor * $907.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12833.49,58980.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,APC,43248,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],890.35,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,860.25,903.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MAJOR",282,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14993.51,,"Case rate ($14,993.51). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14993.51,15743.19,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],40202.74,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,40202.74,148703.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,37575.69,Estimated amount calculated based on 11 day length of stay.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($55,128.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],8232.00,,"Per diem ($8,232). If length of stay < 9.8, first 1 days paid at a per diem of $16,464 instead. Capped at $80,676.47.",,,,0,other,8232.00,84471.39,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21406.38,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7826.00,90280.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],107643.03,,,,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],78217.53,,"Fee schedule rate ($78,217.53). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28296,APC,28296,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20827.00,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11901.14,35314.31,All Other Inpatient
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],45507.56,,"Fee schedule rate ($45,507.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,3295.00,50750.92,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19564.03,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,18902.44,56089.29,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",124284.19,124284.19,124284.19,1 through 10,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
Vaginectomy Partial Removal Vaginal Wall,CASE-57106,APC,57106,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],90215.11,,,,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Synovectomy 2/>Compartments|RIGHT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],183848.16,,"Fee schedule rate ($183,848.16). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|PO|LEFT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|PO|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|LEFT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision/Curettage Cyst/Tumor Phalanx Finger,CASE-26210,APC,26210,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, GREAT TOE",CASE-28270,APC,28270,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,Zero final payments for the item or service in the 15 months prior to posting the file.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],130347.93,,"Fee schedule rate ($130,347.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30254.51,130347.93,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9356.36,,"Case rate ($8,910.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,802.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.45. The transfer capital threshold is the transfer adjustment factor * $631.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8925.03,26628.31,Inpatient DRG
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
Transurethral Resection Bladder Neck|SEPARATE STRUCTURE,CASE-52500,APC,52500,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE|PO,CASE-64450,APC,64450,CPT,0450,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE,CASE-29875,APC,29875,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5549.19,,"Case rate ($5,549.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,050.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.42. The transfer capital threshold is the transfer adjustment factor * $402.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5549.19,16729.39,Inpatient DRG
Carpectomy 1 Bone|RIGHT SIDE|PO,CASE-25210,APC,25210,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],94720.48,,"Fee schedule rate ($94,720.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Lympho for Sentinal Node|LEFT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8856.72,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8856.72,8856.72,8856.72,1 through 10,other,6972.00,26280.60,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23679.61,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23679.61,84629.16,Inpatient DRG
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THIRD DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],76163.76,,,,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, THUMB|PO",CASE-26445,APC,26445,CPT,0360,RC,,,FA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6170.85,,"Fee schedule rate ($6,170.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,APC,38900,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12496.20,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11901.14,35314.31,Inpatient DRG
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE,CASE-28322,APC,28322,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4838.84,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4838.84,19587.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],39867.32,,of the excess amount. Final payment is multiplied by 105%.,30640.72,22602.50,45066.79,1 through 10,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22288.76,,"Fee schedule rate ($22,288.76). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9759.75,,"Fee schedule rate ($9,759.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7003.34,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6866.02,27153.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|PO|LEFT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|PO|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],39117.75,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10105.00,120252.50,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15172.21,,"Case rate ($14,449.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,195.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.96. The transfer capital threshold is the transfer adjustment factor * $1,023.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",15821.42,15821.42,15821.42,1 through 10,other,14472.76,56135.46,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],3209.85,,"Fee schedule rate ($3,209.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8853.24,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8431.66,25019.31,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],120588.53,,,,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6025.78,,"Case rate ($5,738.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,577.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $406.67. The transfer capital threshold is the transfer adjustment factor * $406.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5091.00,22010.11,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],82423.02,,,,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,APC,58661,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],37001.91,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,36276.38,121107.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32645.32,,"Fee schedule rate ($32,645.32). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11519.18,34180.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciectomy Plantar Fascia Partial Spx|RIGHT SIDE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],37843.99,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,37843.99,139522.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],31657.92,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30150.40,89465.42,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7342.43,,"Case rate ($6,992.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,666.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.53. The transfer capital threshold is the transfer adjustment factor * $495.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7003.94,20782.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6953.13,,"Case rate ($6,622.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,128.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,596.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,640.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,152.78. The transfer operating threshold is the transfer adjustment factor * $6,128.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $469.26. The transfer capital threshold is the transfer adjustment factor * $469.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6632.59,19680.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|LEFT SIDE,CASE-27446,APC,27446,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5169.74,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",1468.56,1468.56,1468.56,1 through 10,other,5169.74,15340.19,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],28725.18,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27357.31,100904.68,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18796.76,,"Fee schedule rate ($18,796.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6632.59,19680.94,Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12141.86,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12321.55,12321.55,12321.55,1 through 10,other,12141.86,36028.59,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29783.11,,,,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],51131.99,,"Fee schedule rate ($51,131.99). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],88173.00,,"Fee schedule rate ($88,173.00). Adds an outlier to normal pricing equal to the per diem rate ($170,052.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",80743.94,80743.94,80743.94,1 through 10,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5625.00,,"Per diem ($5,625). If length of stay < 2.6, first 1 days paid at a per diem of $11,250 instead. Capped at $14,624.71.",,,,0,other,5160.45,15312.64,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|LEFT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],41822.97,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,39831.40,138208.82,Inpatient DRG
Rhytidectomy Neck W/Platysmal Tightening|PO,CASE-15825,APC,15825,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2367.72,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2333.89,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],624.73,,"APC Price ($594.98). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,594.98,624.73,OPPS APC
HC Wound Vac <=50 Sq Cm Dme|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10030.18,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9833.51,45903.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15117.84,,,,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8501.29,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6178.00,25225.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],31373.55,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-24358,APC,24358,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],68621.57,,,,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19073.53,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10899.16,39746.35,All Other Inpatient
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17969.04,,,,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PO,CASE-20550,APC,20550,CPT,0510,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
Open Treatment Talus Fracture|RIGHT SIDE,CASE-28445,APC,28445,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13163.24,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12536.42,37199.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24466.00,,"Case rate ($23,300.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,822.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,651.19. The transfer capital threshold is the transfer adjustment factor * $1,651.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23338.10,69251.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,APC,60220,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15824.86,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15824.86,49371.45,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15820.10,,"Case rate ($15,066.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,238.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,067.68. The transfer capital threshold is the transfer adjustment factor * $1,067.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15090.78,44778.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],47661.63,,,,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,Zero final payments for the item or service in the 15 months prior to posting the file.
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,APC,53445,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19658.06,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19658.06,20346.09,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11763.70,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6350.00,33244.29,Inpatient DRG
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20987.13,,"Fee schedule rate ($20,987.13). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,APC,49650,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],3871.34,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3209.85,10940.41,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],36505.40,,"Fee schedule rate ($36,505.40). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],41585.15,,"Fee schedule rate ($41,585.15). Adds an outlier to normal pricing equal to the per diem rate ($65,246.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14673.67,43541.27,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],81324.83,,"Fee schedule rate ($81,324.83). Adds an outlier to normal pricing equal to the per diem rate ($106,784.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, THIRD DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10048.06,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9569.58,41116.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5461.17,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5354.09,15887.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula,CASE-27641,APC,27641,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],27539.67,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27539.67,109237.68,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13905.59,,"Case rate ($13,243.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,109.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $938.47. The transfer capital threshold is the transfer adjustment factor * $938.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13264.54,50759.39,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],70264.60,,,,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
"KIDNEY AND URINARY TRACT INFECTIONS,MAJOR",463,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11875.93,,"Case rate ($11,310.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11310.41,11875.93,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4538.44,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4538.44,18815.35,Inpatient DRG
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],917.27,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,873.59,917.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto impl 4 or more,CASE-C9740,APC,C9740,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9292.89,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23385.84,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,23385.84,71764.93,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],45834.02,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,45834.02,151120.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,Zero final payments for the item or service in the 15 months prior to posting the file.
Ligj & Div Short Saph Vein Saphenopop Junct Spx,CASE-37780,APC,37780,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],3941.67,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3753.97,11139.15,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],70034.38,,,,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14472.76,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14472.76,56135.46,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7369.00,,"Per diem ($7,369). If length of stay < 2.4, first 1 days paid at a per diem of $14,738 instead. Capped at $17,686.09.",,,,0,other,6240.68,18518.02,Estimated amount calculated based on 2 day length of stay.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,MAJOR",351,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12903.28,,"Case rate ($12,903.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12903.28,13548.44,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE,CASE-29891,APC,29891,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20025.28,,,,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],48252.91,,"Fee schedule rate ($48,252.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
HC App Skin Sub T/a/L Tot <100 1st 25|PBB CHARGE,CASE-15271,APC,15271,CPT,0361,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],700.99,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,700.99,736.04,OPPS APC
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12758.30,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12326.86,53121.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16747.70,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15950.19,63458.56,Inpatient DRG
Gastrocnemius Recession|RIGHT SIDE,CASE-27687,APC,27687,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19339.26,,of the excess amount.,,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12093.45,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12093.45,35884.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],70335.44,,,,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17535.40,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,17191.57,51012.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8374.80,,"Fee schedule rate ($8,374.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],32807.56,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,32807.56,111191.81,Inpatient DRG
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion,CASE-52354,APC,52354,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Tibia|LEFT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],73332.24,,,,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10584.90,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10080.86,33310.69,Inpatient DRG
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|LEFT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],186.30,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7344.49,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7096.13,25801.23,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
Arthrodesis Subtalar|LEFT SIDE|PO,CASE-28725,APC,28725,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT FOOT, THIRD DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XU|T2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10226.31,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9739.34,40204.26,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12500.00,,"Per diem ($12,500). If length of stay < 4.8, first 1 days paid at a per diem of $25,000 instead. Capped at $60,002.29.",,,,0,other,12500.00,83592.64,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],67775.08,,"Fee schedule rate ($67,775.08). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7915.58,,"Case rate ($4,523.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,179.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,647.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,498.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,195.97. The transfer operating threshold is the transfer adjustment factor * $4,179.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $327.22. The transfer capital threshold is the transfer adjustment factor * $327.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4523.19,16536.43,All Other Inpatient
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7125.07,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6785.78,20135.47,Inpatient DRG
"SICKLE CELL ANEMIA CRISIS,MODERATE",662,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9671.94,,"Case rate ($9,671.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9671.94,10155.54,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE,CASE-54840,APC,54840,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2052.05,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8336.54,,"Case rate ($7,939.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,733.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $562.62. The transfer capital threshold is the transfer adjustment factor * $562.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7952.22,25854.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],20161.47,,"Case rate ($19,201.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,531.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,360.68. The transfer capital threshold is the transfer adjustment factor * $1,360.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19232.02,68941.12,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7213.50,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,21404.64,Inpatient DRG
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|RIGHT SIDE|PO,CASE-25260,APC,25260,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17123.00,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8558.00,48389.68,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],30626.53,,"Case rate ($30,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,386.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,215.60. The transfer capital threshold is the transfer adjustment factor * $2,215.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,30626.53,106200.88,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30103.84,,,,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|BILATERAL PROCEDURE,CASE-37722,APC,37722,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7345.46,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6308.00,21796.21,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18518.02,,,,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Carpectomy 1 Bone|LEFT SIDE|PO,CASE-25210,APC,25210,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14161.54,,,,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7035.25,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6700.24,30254.37,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13438.87,,"Fee schedule rate ($13,438.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],59833.15,,"Fee schedule rate ($59,833.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,MODERATE",817,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7792.53,,"Case rate ($7,421.46). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7421.46,7792.53,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",7809.80,7809.80,7809.80,1 through 10,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11645.83,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11645.83,37502.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10105.00,,"Per diem ($10,105). If length of stay < 10.6, first 1 days paid at a per diem of $20,210 instead. Capped at $107,110.70.",,,,0,other,10105.00,120252.50,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HC Hdr Vaginal Cyl Insertion,CASE-57156,APC,57156,CPT,0333,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],299.14,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,289.03,303.48,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn|RIGHT SIDE|PO,CASE-26480,APC,26480,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21704.31,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12402.46,36801.89,All Other Inpatient
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8764.55,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8764.55,32969.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22545.69,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12883.25,44763.90,All Other Inpatient
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
"ALCOHOL ABUSE AND DEPENDENCE,MODERATE",775,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7960.81,,"Case rate ($7,581.72). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7581.72,7960.81,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10455.00,,"Per diem ($10,455). If length of stay < 6.6, first 1 days paid at a per diem of $20,910 instead. Capped at $69,000.38.",,,,0,other,10455.00,90889.11,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20135.47,,,,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9137.38,,"Case rate ($8,702.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $616.67. The transfer capital threshold is the transfer adjustment factor * $616.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8716.15,25863.45,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23014.22,,,,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],53377.62,,"Case rate ($50,835.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,773.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,602.40. The transfer capital threshold is the transfer adjustment factor * $3,602.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,50916.88,170142.20,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6454.78,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6328.22,27416.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],32474.30,,"Fee schedule rate ($32,474.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,25698.16,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25266.97,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,14438.27,55762.74,All Other Inpatient
"Partical Excision Bone Phalanx Toe|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,XS|T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Repair Brow Ptosis|BILATERAL PROCEDURE|PO,CASE-67900,APC,67900,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2333.89,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],20478.39,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19503.23,57872.02,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9820.91,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9820.91,29141.64,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5912.00,,"Per diem ($5,912). If length of stay < 2.4, first 1 days paid at a per diem of $11,824 instead. Capped at $14,188.72.",,,,0,other,5006.61,14856.14,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
Aspiration Bladder Insert Suprapubic Catheter|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51102,APC,51102,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13011.87,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7231.00,38610.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6940.28,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6940.28,20593.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],10704.29,,,,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12351.25,,,,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9739.34,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9739.34,40204.26,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9761.89,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9761.89,37873.87,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,XU|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20056.77,,,,,,0,other,6654.93,20056.77,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],49568.76,,"Case rate ($47,208.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,516.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,345.35. The transfer capital threshold is the transfer adjustment factor * $3,345.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,47283.61,169615.07,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15517.38,,"Fee schedule rate ($15,517.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5389.29,16247.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MAJOR",422,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2179.36,,"Case rate for a one day stay ($2,179.36). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2179.36,2288.33,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14743.09,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14041.04,60059.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],65555.62,,"Fee schedule rate ($65,555.62). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,21715.49,Estimated amount calculated based on 9 day length of stay.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6531.00,,"Per diem ($6,531). If length of stay < 4.1, first 1 days paid at a per diem of $13,062 instead. Capped at $26,776.27.",,,,0,other,6531.00,35832.77,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",40721.50,40721.50,40721.50,1 through 10,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10135.82,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9793.06,29058.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],73546.72,,,,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16729.39,,,,,,0,other,5549.19,16729.39,There are no additional notes associated with this service or procedure.
Lengthening Tendon Extensor Hand/Finger Each,CASE-26476,APC,26476,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39967.07,,"Fee schedule rate ($39,967.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10080.86,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10080.86,33310.69,Inpatient DRG
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],40202.74,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,40202.74,148703.60,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19033.08,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,8990.00,80069.53,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Mastectomy Simple Complete|LEFT SIDE,CASE-19303,APC,19303,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|SEPARATE STRUCTURE,CASE-52332,APC,52332,CPT,0360,RC,,,50|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cv Cath Plac W/Port Tun >5|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-36561,APC,36561,CPT,0361,RC,,,73,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10972.03,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10449.55,43409.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,MODERATE",351,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8802.97,,"Case rate ($8,802.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8802.97,9243.12,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5368.01,15928.53,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7574.18,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,30966.53,Estimated amount calculated based on 11 day length of stay.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11823.96,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11592.12,38954.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Removal Subcutaneous Cardiac Rhythm Monitor,CASE-33286,APC,33286,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10260.35,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",676.04,676.04,676.04,1 through 10,other,9913.38,10409.05,OPPS APC
HC Trluml Balo Angiop 1st Vein|RIGHT SIDE,CASE-37248,APC,37248,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5587.20,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],92976.49,,"Fee schedule rate ($92,976.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.5), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY SAME PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,76|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],26030.46,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,24790.92,26030.46,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35884.94,,,,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29049.23,,"Fee schedule rate ($29,049.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23247.00,,"Fee schedule rate ($23,247). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34517.10,,"Fee schedule rate ($34,517.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,APC,20552,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PO|SEPARATE STRUCTURE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|PO|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],9763.00,,"Per diem ($9,763). If length of stay < 4, first 1 days paid at a per diem of $19,526 instead. Capped at $39,053.73.",,,,0,other,9763.00,48626.00,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|LEFT FOOT, SECOND DIGIT|PO",CASE-28092,APC,28092,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,MINOR",201,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2860.76,,"Case rate for a one day stay ($2,860.76). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2860.76,3003.80,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8.76,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
Arthrs Knee Drill Osteochondritis Dissecans Grfg,CASE-29885,APC,29885,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MINOR",191,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6483.10,,"Case rate for a one day stay ($6,174.38). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6174.38,6483.10,There are no additional notes associated with this service or procedure.
"SIGNS SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS,MODERATE",861,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1766.38,,"Case rate for a one day stay ($1,766.38). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1766.38,1854.70,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9464.71,,"Case rate ($9,279.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,573.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,041.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,607.86. The transfer operating threshold is the transfer adjustment factor * $8,573.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.28. The transfer capital threshold is the transfer adjustment factor * $671.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9279.13,27534.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Removal FB Skin|PO,CASE-10120,APC,10120,CPT,0450,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC
Trluml Balo Angiop Ctr Dialysis Seg W/Img S&I,CASE-36907,APC,36907,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5398.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19984.73,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,8990.00,80069.53,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20493.94,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11710.82,34749.58,All Other Inpatient
HC Debrid Wound Tis 20 Cm/<|ADJ,CASE-97597,APC,97597,CPT,0761,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12428.68,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7102.10,21074.07,All Other Inpatient
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,APC,57520,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",15808.66,15808.66,15808.66,1 through 10,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,1188.00,27484.83,Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7763.15,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7500.63,22256.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43277,APC,43277,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3784.78,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15950.19,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,15950.19,63458.56,Inpatient DRG
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,APC,38510,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32474.30,,"Fee schedule rate ($32,474.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10730.73,,"Case rate ($10,219.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,895.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.21. The transfer capital threshold is the transfer adjustment factor * $724.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",55302.91,55302.91,55302.91,1 through 10,other,10236.03,30589.82,Inpatient DRG
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,APC,43249,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level|RIGHT SIDE",CASE-64495,APC,64495,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10651.94,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10291.73,34803.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|BILATERAL PROCEDURE,CASE-37722,APC,37722,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT SIDE,CASE-28289,APC,28289,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29582.40,,,,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28847.26,,"Fee schedule rate ($28,847.26). Adds an outlier to normal pricing equal to the per diem rate ($89,320.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Complete 5th Metatarsal Head,CASE-28113,APC,28113,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15233.99,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14508.56,59513.03,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12404.38,,,,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15309.19,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14580.18,57079.69,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3361.98,3361.98,3361.98,1 through 10,other,5085.49,5339.77,OPPS APC
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE|PO",CASE-28289,APC,28289,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7690.02,,"Case rate ($7,323.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.99. The transfer capital threshold is the transfer adjustment factor * $518.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7335.51,29792.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19155.70,,"Fee schedule rate ($19,155.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6654.93,20056.77,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12643.07,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12395.17,42174.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
"Neuroplasty Other Arm/Leg Nerve,Open|SEPARATE STRUCTURE|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3240.11,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3240.11,3402.11,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12031.78,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11458.84,42820.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Unlisted Procedure, Nervous System|UNUSUAL NON-OVERLAPPING SERVICE",CASE-64999,APC,64999,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MAJOR",721,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],17600.41,,"Case rate ($17,600.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,17600.41,18480.43,There are no additional notes associated with this service or procedure.
HC App Skin Sub T/a/L Tot <100 1st 25|PBB CHARGE,CASE-15271,APC,15271,CPT,0361,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],725.52,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,700.99,736.04,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22132.97,,"Case rate ($21,079.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,664.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,493.73. The transfer capital threshold is the transfer adjustment factor * $1,493.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21112.63,62647.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28538.34,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8558.00,48389.68,All Other Inpatient
Laps Tot Hysterectomy Resj Malignancy W/Omntc,CASE-58575,APC,58575,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21766.70,,,,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17622.38,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,17026.45,50522.67,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29058.99,,,,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],38756.54,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36910.99,126842.57,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
Thoracoscopy W/Exc Mediastinal Cyst Tumor/Mass,CASE-32662,APC,32662,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3099.59,3099.59,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22927.75,,"Case rate ($22,152.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,773.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.56. The transfer capital threshold is the transfer adjustment factor * $1,602.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9370.00,65732.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5611.35,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5344.14,15857.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Synovectomy Metatarsophalangeal Joint Each,CASE-28072,APC,28072,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3686.99,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3209.85,10940.41,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7086.07,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6748.64,20025.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE|PO,CASE-28306,APC,28306,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6611.49,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6387.91,18954.85,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14789.23,,,,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4765.36,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4538.44,18815.35,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17700.69,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10114.68,30013.33,All Other Inpatient
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9564.15,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9108.71,27028.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8830.96,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8410.44,24956.34,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18559.00,,"Per diem ($18,559). If length of stay < 5.4, first 1 days paid at a per diem of $37,118 instead. Capped at $100,219.31.",,,,0,other,18559.00,141041.50,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE,CASE-27570,APC,27570,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8924.65,,"Case rate ($8,499.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,773.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $602.32. The transfer capital threshold is the transfer adjustment factor * $602.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",8926.66,2520.03,19037.65,55,other,8513.22,25261.33,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",16434.56,16434.56,16434.56,1 through 10,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],38724.86,,"Fee schedule rate ($38,724.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,APC,57520,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
Cysto W/Insert Ureteral Stent|RIGHT SIDE|SEPARATE STRUCTURE,CASE-52332,APC,52332,CPT,0360,RC,,,RT|XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Local Lesion Epididymis|RIGHT SIDE,CASE-54830,APC,54830,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6459.10,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6240.68,18518.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],81161.07,,"Fee schedule rate ($81,161.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,30480.63,86382.02,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],3753.29,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3753.29,11765.59,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16991.47,,"Case rate ($16,182.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.74. The transfer capital threshold is the transfer adjustment factor * $1,146.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16208.15,58123.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],31467.16,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,30403.05,90685.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
HC Debride Subq First 20 Sq Cm|PBB CHARGE,CASE-11042,APC,11042,CPT,0361,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE|PO,CASE-27792,APC,27792,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],125362.65,,"Fee schedule rate ($125,362.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],89469.71,,"Fee schedule rate ($89,469.71). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8011.50,,"Fee schedule rate ($8,011.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MAJOR",045,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],18120.69,,"Case rate ($17,257.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17257.80,18120.69,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23131.85,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23131.85,76404.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10080.86,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10080.86,33310.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3514.75,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7840.85,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,37575.69,Inpatient DRG
Carpectomy 1 Bone|LEFT SIDE|PO,CASE-25210,APC,25210,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3117.60,3117.60,3117.60,1 through 10,other,3103.39,3212.01,OPPS APC
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE,CASE-27654,APC,27654,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31446.03,,"Fee schedule rate ($31,446.03). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4162.46,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,21715.49,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|SEPARATE PRACTITIONER,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XP,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],56503.55,,"Fee schedule rate ($56,503.55). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
Nerve Repair W/Conduit Each Nerve|LEFT SIDE|PO,CASE-64910,APC,64910,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8739.79,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8323.61,8739.79,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],31570.16,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,31570.16,98176.71,Inpatient DRG
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|BILATERAL PROCEDURE,CASE-49507,APC,49507,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34517.10,,"Fee schedule rate ($34,517.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23594.49,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23131.85,76404.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],42193.04,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18860.53,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",17721.38,17721.38,17721.38,1 through 10,other,18222.73,59942.55,Inpatient DRG
Removal Implant Deep|BILATERAL PROCEDURE,CASE-20680,APC,20680,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
HC Extremity Venogram|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10409.05,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9913.38,10409.05,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6801.90,,"Fee schedule rate ($6,801.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33727.80,,"Fee schedule rate ($33,727.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4493.44,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4341.49,12882.53,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,1188.00,27484.83,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41073.77,,,,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],27861.95,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",50015.14,50015.14,50015.14,1 through 10,other,27861.95,82674.88,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11190.19,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",27614.56,27614.56,91259.77,1 through 10,other,10970.77,32553.63,Inpatient DRG
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",642.91,642.91,642.91,13,other,669.51,702.98,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8394.53,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",84653.65,84653.65,84653.65,1 through 10,other,8394.53,24909.11,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13579.86,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7759.92,35376.63,All Other Inpatient
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10112.24,,"Fee schedule rate ($10,112.24). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],41712.94,,"Fee schedule rate ($41,712.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12566.83,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12141.86,36028.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15818.85,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15065.57,53815.71,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY VASCULAR PROCEDURES,MAJOR",181,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],41768.51,,"Case rate ($41,768.51). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,41768.51,43856.94,There are no additional notes associated with this service or procedure.
Tenolysis Extensor Foot Single Tendon,CASE-28225,APC,28225,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bx Prostate Strtctc Saturation Sampling Img Gid,CASE-55706,APC,55706,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15729.45,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15421.03,49137.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11674.21,,"Fee schedule rate ($11,674.21). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4119.35,12223.35,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2|LEFT SIDE|PO,CASE-29822,APC,29822,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,APC,26437,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Chemodenervation Muscle Neck Unilat for Dystonia|RIGHT SIDE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11592.12,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11648.62,11648.62,11648.62,1 through 10,other,11592.12,38954.76,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4736.21,,"Case rate ($4,510.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4517.87,13932.70,Inpatient DRG
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE,CASE-29806,APC,29806,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7511.26,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7257.26,23445.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19183.89,,"Fee schedule rate ($19,183.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,6553.68,20086.28,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4772.53,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4772.53,14161.54,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11458.84,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11458.84,42820.42,Inpatient DRG
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],48125.72,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,45834.02,151120.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7167.95,,"Case rate ($6,826.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.76. The transfer capital threshold is the transfer adjustment factor * $483.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6837.50,20288.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5826.99,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5629.94,16705.77,Inpatient DRG
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],130347.93,,"Fee schedule rate ($130,347.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30254.51,130347.93,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7952.22,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7952.22,25854.47,Inpatient DRG
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
Gastrocnemius Recession|RIGHT SIDE,CASE-27687,APC,27687,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Catheter Aorta,CASE-36200,APC,36200,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, SECOND DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9431.26,,"Case rate ($5,389.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,996, add-ons for qualifying new technology services are included. If operating cost exceeds $45,541.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,038.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,998.47. The transfer operating threshold is the transfer adjustment factor * $4,996.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.82. The transfer capital threshold is the transfer adjustment factor * $390.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5389.29,16247.30,All Other Inpatient
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],136003.49,,,,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22524.08,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8940.00,63653.13,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6625.21,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5669.00,18994.21,Inpatient DRG
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23691.11,,,,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11425.90,,"Case rate ($10,881.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.12. The transfer capital threshold is the transfer adjustment factor * $771.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10899.16,39746.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Lengthening Tendon Extensor Hand/Finger Each,CASE-26476,APC,26476,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7289.74,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7289.75,7289.75,7289.75,1 through 10,other,7289.74,21630.93,Inpatient DRG
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MAJOR",229,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],33721.72,,"Case rate ($32,115.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32115.92,33721.72,There are no additional notes associated with this service or procedure.
Excision/Curettage Cyst/Tumor Phalanx Finger,CASE-26210,APC,26210,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],35688.34,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,34988.57,110685.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28437.57,,"Fee schedule rate ($28,437.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4336.75,,"Case rate ($4,130.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,940.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $292.86. The transfer capital threshold is the transfer adjustment factor * $292.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4138.67,12473.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE,CASE-28200,APC,28200,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3980.76,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3980.76,11812.10,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13780.46,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9763.00,48626.00,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],51643.16,,"Fee schedule rate ($51,643.16). Adds an outlier to normal pricing equal to the per diem rate ($161,652.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,18222.73,59942.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],890.35,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,860.25,903.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],31858.62,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31858.62,94534.21,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13664.39,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13664.39,40546.43,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10297.11,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9948.90,46199.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22091.95,,"Fee schedule rate ($22,091.95). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6474.12,,"Case rate ($6,474.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,981.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,449.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,005.76. The transfer operating threshold is the transfer adjustment factor * $5,981.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.35. The transfer capital threshold is the transfer adjustment factor * $468.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6474.12,19210.66,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE|PO,CASE-29806,APC,29806,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
Lig&Div Long Saph Vein Saphfem Junct/Interrupj|LEFT SIDE,CASE-37700,APC,37700,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6890.59,,"Fee schedule rate ($6,890.59). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
Litholapaxy Comp/Lg > 2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52318,APC,52318,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17260.03,,"Fee schedule rate ($17,260.03). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G > 4.0cm,CASE-11426,APC,11426,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21474.76,,"Fee schedule rate ($21,474.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,7577.56,31445.30,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],60333.05,,"Fee schedule rate ($60,333.05). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26999.90,,"Fee schedule rate ($26,999.90). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9527.16,28269.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Tibia|RIGHT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22885.85,,"Case rate ($21,796.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,715.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,544.54. The transfer capital threshold is the transfer adjustment factor * $1,544.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21830.80,85124.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8756.93,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5003.96,21742.11,All Other Inpatient
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],31621.43,,"Case rate ($30,115.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,305.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,134.10. The transfer capital threshold is the transfer adjustment factor * $2,134.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13420.39,13420.39,13420.39,1 through 10,other,30163.67,89504.77,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14523.60,,"Fee schedule rate ($14,523.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],38106.57,,"Fee schedule rate ($38,106.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5006.61,,"Case rate ($5,006.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,625.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,093.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,644.42. The transfer operating threshold is the transfer adjustment factor * $4,625.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.19. The transfer capital threshold is the transfer adjustment factor * $362.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5006.61,14856.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,APC,51990,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8926.35,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6178.00,25225.91,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],29255.05,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27861.95,82674.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12397.99,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11978.73,60588.60,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28269.95,,,,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein|RIGHT SIDE,CASE-37249,APC,37249,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8018.15,,"Case rate ($7,636.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,712.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.14. The transfer capital threshold is the transfer adjustment factor * $541.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7648.51,27371.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE|PO,CASE-28300,APC,28300,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],187121.90,,"Fee schedule rate ($187,121.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|RIGHT SIDE|PO,CASE-27405,APC,27405,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17490.00,,"Per diem ($17,490). If length of stay < 1.2, first 1 days paid at a per diem of $34,980 instead. Capped at $20,988.02.",,,,0,other,7405.81,33747.30,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE,CASE-27339,APC,27339,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Ostc Prtl Exostc/Condylc Metar Head|LEFT FOOT, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28288,APC,28288,CPT,0360,RC,,,T1|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|LEFT SIDE,CASE-27446,APC,27446,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12201.39,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11962.15,40923.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32474.30,,"Fee schedule rate ($32,474.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4660.32,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4568.94,13557.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,MINOR",663,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2802.40,,"Case rate for a one day stay ($2,802.40). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2802.40,2942.52,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9108.71,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9108.71,9108.71,9108.71,1 through 10,other,9108.71,27028.33,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21005.48,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20005.22,74991.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],44778.95,,,,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, SECOND DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,MAJOR",443,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3859.61,,"Case rate for a one day stay ($3,675.82). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3675.82,3859.61,There are no additional notes associated with this service or procedure.
HC Rt Bronch Dx Clear Airway,CASE-31645,APC,31645,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3536.22,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10178.99,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10178.99,36468.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,APC,58573,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",10148.63,10148.63,10148.63,1 through 10,other,10082.05,10586.16,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33968.35,,"Fee schedule rate ($33,968.35). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10753.00,,"Fee schedule rate ($10,753.00). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11978.73,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11978.73,60588.60,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],34331.91,,"Case rate ($32,697.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,488.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,317.03. The transfer capital threshold is the transfer adjustment factor * $2,317.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32749.19,97176.83,Inpatient DRG
"CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",166,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],67027.11,,"Case rate ($63,835.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,63835.34,67027.11,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],30626.53,,"Case rate ($30,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,386.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,215.60. The transfer capital threshold is the transfer adjustment factor * $2,215.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,30626.53,106200.88,Inpatient DRG
Dir Rpr Aneurysm Axil-Brachial Arm Incision,CASE-35011,APC,35011,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12500.00,,"Per diem ($12,500). If length of stay < 4.8, first 1 days paid at a per diem of $25,000 instead. Capped at $60,002.29.",,,,0,other,12500.00,83592.64,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme,CASE-97605,APC,97605,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",184.47,184.47,184.47,1 through 10,other,190.30,199.81,OPPS APC
Surgical Arthroscopy Shoulder Capsulorrhaphy|PO,CASE-29806,APC,29806,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9071.31,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",9053.42,9053.42,9053.42,1 through 10,other,8764.55,32969.91,Inpatient DRG
Removal Implant Deep|SEPARATE STRUCTURE|PO,CASE-20680,APC,20680,CPT,0360,RC,,,XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12228.12,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11645.83,37502.92,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE,CASE-27619,APC,27619,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9615.90,,"Fee schedule rate ($9,615.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6518.41,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15170.63,,"Case rate ($14,448.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,349.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,817.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,216.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,402.99. The transfer operating threshold is the transfer adjustment factor * $13,349.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,045.22. The transfer capital threshold is the transfer adjustment factor * $1,045.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6940.00,42872.25,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33132.06,,"Fee schedule rate ($33,132.06). Adds an outlier to normal pricing equal to the per diem rate ($83,058.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11690.93,56733.59,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29288.89,,"Fee schedule rate ($29,288.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],57018.97,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,55900.95,225294.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27601.28,,"Fee schedule rate ($27,601.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12500.00,,"Per diem ($12,500). If length of stay < 4.8, first 1 days paid at a per diem of $25,000 instead. Capped at $60,002.29.",,,,0,other,12500.00,83592.64,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",22195.60,22195.60,22195.60,1 through 10,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23188.20,,"Fee schedule rate ($23,188.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23385.84,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,23385.84,71764.93,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula|LEFT SIDE|PO,CASE-27641,APC,27641,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8526.77,,"Case rate ($8,526.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,902.12, add-ons for qualifying new technology services are included. If operating cost exceeds $48,447.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,268.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $7,906.03. The transfer operating threshold is the transfer adjustment factor * $7,902.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.75. The transfer capital threshold is the transfer adjustment factor * $620.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,25698.16,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],37199.37,,,,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6675.07,,"Case rate ($6,357.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,621.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.49. The transfer capital threshold is the transfer adjustment factor * $450.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,18893.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE|PO,CASE-25609,APC,25609,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6284.66,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5985.39,17760.46,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|LEFT FOOT, GREAT TOE|PO",CASE-28291,APC,28291,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9367.05,,"Fee schedule rate ($9,367.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21056.36,,,,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,APC,94640,CPT,0410,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE|PO,CASE-29888,APC,29888,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis 20 Cm/<|ADJ,CASE-97597,APC,97597,CPT,0761,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],29020.56,,"Fee schedule rate ($29,020.56). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6571.90,,"Fee schedule rate ($6,571.90). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4295.38,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2285.00,12138.74,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,APC,57520,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rhinp Prim Complete Xtrnl Parts,CASE-30410,APC,30410,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31241.17,,,,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6783.06,,"Case rate ($6,553.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $6,086.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,276.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,494.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,073.77. The transfer operating threshold is the transfer adjustment factor * $6,086.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.91. The transfer capital threshold is the transfer adjustment factor * $479.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",6889.80,6889.80,6889.80,1 through 10,other,6553.68,20086.28,Inpatient DRG
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9308.98,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,33447.35,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5775.17,,"Case rate ($5,775.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.79. The transfer capital threshold is the transfer adjustment factor * $417.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5775.17,5775.17,31507.65,1 through 10,other,5775.17,17136.70,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],34091.39,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,33422.93,112824.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4523.19,16536.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY VASCULAR PROCEDURES,EXTREME",181,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],62241.08,,"Case rate ($62,241.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $46,166, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,62241.08,65353.13,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10625.29,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10400.68,10400.68,10400.68,1 through 10,other,10625.29,39295.53,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7648.51,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7648.51,27371.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2,CASE-29822,APC,29822,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8005.26,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8005.26,24549.95,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5263.66,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",5202.85,5202.85,5202.85,1 through 10,other,5160.45,15312.64,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34611.07,,"Fee schedule rate ($34,611.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, GREAT TOE|PO",CASE-28160,APC,28160,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16456.83,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16456.83,55350.97,Inpatient DRG
Arteriovenous Anastomosis Open Direct|LEFT SIDE,CASE-36821,APC,36821,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE|PO",CASE-64491,APC,64491,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
Unlisted Procedure Femur/Knee|LEFT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],245.65,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,233.96,245.65,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23578.09,,"Fee schedule rate ($23,578.09). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13305.64,39481.90,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
Ostectomy Complete 5th Metatarsal Head|LEFT SIDE,CASE-28113,APC,28113,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5573.75,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5308.33,19857.20,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13789.07,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13789.07,57367.22,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24053.80,,"Case rate ($22,908.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,828.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.25. The transfer capital threshold is the transfer adjustment factor * $1,657.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22908.38,67976.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4551.31,,"Case rate ($4,334.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,478.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.16. The transfer capital threshold is the transfer adjustment factor * $307.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4341.49,12882.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6654.93,,"Case rate ($6,654.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,167.40, add-ons for qualifying new technology services are included. If operating cost exceeds $46,712.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,132.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,170.45. The transfer operating threshold is the transfer adjustment factor * $6,167.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.48. The transfer capital threshold is the transfer adjustment factor * $484.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6654.93,20056.77,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26270.73,,"Fee schedule rate ($26,270.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30846.83,,"Fee schedule rate ($30,846.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29382.86,,"Fee schedule rate ($29,382.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10367.99,37103.57,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21688.24,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20954.82,62179.32,Inpatient DRG
"HIP AND FEMUR FRACTURE REPAIR,MAJOR",308,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],29109.76,,"Case rate ($29,109.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,29109.76,30565.25,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],45983.18,,,,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9350.11,,"Case rate ($8,904.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,802.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.03. The transfer capital threshold is the transfer adjustment factor * $631.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8919.07,34453.70,Inpatient DRG
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4162.46,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,21715.49,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|PO,CASE-29806,APC,29806,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
Grafting of Autologous Fat by Lipo 25 Cc or Less|PO,CASE-15773,APC,15773,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2025.45,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.96,2025.45,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Corrj Hallux Valgus W/Sesmdc W/2 Osteot,CASE-28299,APC,28299,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13369.00,,"Per diem ($13,369). If length of stay < 6.3, first 1 days paid at a per diem of $26,738 instead. Capped at $84,226.47.",,,,0,other,13369.00,88188.38,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,66445.54,Estimated amount calculated based on 11 day length of stay.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],57457.72,,"Fee schedule rate ($57,457.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
HC Wound Vac <=50 Sq Cm Dme|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Rhinoplasty Secondary Intermediate Revision|PO,CASE-30435,APC,30435,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5811.28,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9793.06,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9793.06,29058.99,Inpatient DRG
HC Wound Vac <=50 Sq Cm Dme|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,APC,43239,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12473.25,,,,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
Curtg/Caut Anal Fissure W/Dilat Sphnctr Spx 1st,CASE-46940,APC,46940,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26909.70,,"Fee schedule rate ($26,909.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9495.32,42131.77,Zero final payments for the item or service in the 15 months prior to posting the file.
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
HC Debrid Wound Tis 20 Cm/<|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97597,APC,97597,CPT,0761,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",184.47,184.47,184.47,1 through 10,other,190.30,199.81,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12748.95,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12141.86,36028.59,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19433.97,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18508.54,76171.92,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,APC,49593,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6447.22,,"APC Price ($6,140.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",6082.37,6082.37,6082.37,1 through 10,other,6140.21,6447.22,OPPS APC
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],30758.38,,of the excess amount.,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27695,APC,27695,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11839.93,,"Fee schedule rate ($11,839.93). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],55900.95,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,55900.95,225294.39,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu,CASE-25260,APC,25260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|BILATERAL PROCEDURE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13230.71,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13230.71,39259.55,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23320.23,,"Fee schedule rate ($23,320.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16320.00,,"Per diem ($16,320). If length of stay < 2.1, first 1 days paid at a per diem of $32,640 instead. Capped at $34,272.79.",,,,0,other,12093.45,40067.60,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16849.39,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",16869.83,16869.83,16869.83,1 through 10,other,16849.39,49997.29,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12804.31,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12804.31,55145.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27484.83,,,,,,0,other,1188.00,27484.83,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9056.99,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9056.99,33814.75,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
Destruction Vaginal Lesions Simple,CASE-57061,APC,57061,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],29796.29,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,17026.45,50522.67,All Other Inpatient
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28832.22,,"Fee schedule rate ($28,832.22). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33796.42,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8972.00,76376.03,All Other Inpatient
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10997.18,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10625.29,39295.53,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14438.27,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14438.27,55762.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15023.80,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15023.80,48104.19,Inpatient DRG
Unlisted Procedure Femur/Knee|RIGHT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],245.65,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",116.92,116.92,116.92,1 through 10,other,233.96,245.65,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12065.11,,"Fee schedule rate ($12,065.11). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",11730.50,11730.50,11730.50,1 through 10,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT HAND, FIFTH DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
Dir Rpr Aneurysm Axil-Brachial Arm Incision|RIGHT SIDE,CASE-35011,APC,35011,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5462.46,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6503.29,19528.85,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],23777.27,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Repair Secondary Disrupted Ligament Ankle Coltrl|LEFT SIDE,CASE-27698,APC,27698,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7020.54,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7020.54,28431.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5104.04,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5003.96,21742.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9279.13,,"Case rate ($9,279.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,573.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,041.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,607.86. The transfer operating threshold is the transfer adjustment factor * $8,573.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.28. The transfer capital threshold is the transfer adjustment factor * $671.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9279.13,27534.03,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4984.06,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",2712.52,2712.52,2712.52,1 through 10,other,4984.06,19757.81,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11217.46,,"Case rate ($11,217.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.50. The transfer capital threshold is the transfer adjustment factor * $811.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8599.88,8599.88,11217.47,1 through 10,other,11217.46,37366.25,Inpatient DRG
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE,CASE-27822,APC,27822,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6235.22,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.30,18621.89,Inpatient DRG
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|RIGHT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Blepharoplasty Lower Eyelid|BILATERAL PROCEDURE,CASE-15820,APC,15820,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2333.89,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21133.20,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21133.20,88801.87,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,48444.74,Estimated amount calculated based on 11 day length of stay.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10849.96,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10637.22,31563.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MAJOR",425,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2623.28,,"Case rate for a one day stay ($2,498.36). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2498.36,2623.28,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17887.18,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7455.00,53076.74,Inpatient DRG
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1132.92,1132.92,1132.92,1 through 10,other,1134.98,1191.72,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],20478.39,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19503.23,57872.02,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7654.23,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7289.74,21630.93,Inpatient DRG
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17887.18,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7455.00,53076.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6514.03,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6293.75,21908.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13252.46,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12804.31,55145.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15153.62,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14641.18,43444.85,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21474.76,,"Fee schedule rate ($21,474.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,7577.56,31445.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12775.42,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12167.07,36103.36,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7049.08,,"Case rate ($6,713.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,646.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.73. The transfer capital threshold is the transfer adjustment factor * $475.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",591.35,591.35,591.35,1 through 10,other,6724.11,19952.48,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Grafting of Autologous Fat by Lipo 25 Cc or Less|PO,CASE-15773,APC,15773,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.96,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.96,2025.45,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9548.92,,"Case rate ($9,094.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,815.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.45. The transfer capital threshold is the transfer adjustment factor * $644.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9108.71,27028.33,Inpatient DRG
Thrmbc Opn Arven Fstl W/O Revj Dial Grf,CASE-36831,APC,36831,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27304.54,,"Fee schedule rate ($27,304.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15309.19,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14580.18,57079.69,Inpatient DRG
Laps Surg Esopg/Gstr Fundoplasty,CASE-43280,APC,43280,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],51073.62,,,,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13328.26,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12693.58,46577.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16737.33,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16737.33,72192.67,Inpatient DRG
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12385.94,,"Case rate ($11,796.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,007.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $835.91. The transfer capital threshold is the transfer adjustment factor * $835.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11814.94,44591.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,8596.11,25507.30,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8356.13,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",10261.55,10261.55,64897.69,1 through 10,other,8192.28,24308.97,Inpatient DRG
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|RIGHT FOOT, SECOND DIGIT|PO",CASE-28092,APC,28092,CPT,0360,RC,,,T6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1578.51,OPPS APC
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29912.98,,,,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw,CASE-37722,APC,37722,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17793.27,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,17191.57,51012.62,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6018.66,,"Case rate ($5,732.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,296.29, add-ons for qualifying new technology services are included. If operating cost exceeds $40,764.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,317.40. The transfer operating threshold is the transfer adjustment factor * $5,296.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.67. The transfer capital threshold is the transfer adjustment factor * $414.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5732.06,21720.81,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10905.18,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10385.89,32176.55,Inpatient DRG
"OTHER ESOPHAGEAL DISORDERS,MAJOR",243,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14613.18,,"Case rate ($13,917.31). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13917.31,14613.18,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20932.80,,"Fee schedule rate ($20,932.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20343.42,,"Fee schedule rate ($20,343.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8601.89,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8192.28,24308.97,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7228.30,,"Fee schedule rate ($7,228.30). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7648.51,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7648.51,27371.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8830.96,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8410.44,24956.34,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14934.00,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14641.18,43444.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29049.23,,"Fee schedule rate ($29,049.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4180.34,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4180.34,14351.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE|PO,CASE-29826,APC,29826,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|LEFT SIDE,CASE-29825,APC,29825,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15540.89,,,,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5614.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5419.81,5419.81,5419.81,1 through 10,other,5614.77,5895.51,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion,CASE-52354,APC,52354,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7285.00,,"Per diem ($7,285). If length of stay < 5.4, first 1 days paid at a per diem of $14,570 instead. Capped at $39,337.51.",,,,0,other,7285.00,41187.90,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],66746.40,,"Fee schedule rate ($66,746.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4418.42,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4418.42,13110.79,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7266.26,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7020.54,28431.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9668.40,,"Fee schedule rate ($9,668.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28695.03,,"Fee schedule rate ($28,695.03).",,,,0,other,14182.35,53827.17,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO,CASE-62323,APC,62323,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
Tnot Elbow Lateral/Medial Debride Open|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-24358,APC,24358,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12212.80,,"Case rate ($12,212.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,054.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $883.51. The transfer capital threshold is the transfer adjustment factor * $883.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12212.80,39290.21,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22325.17,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,21570.21,72041.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],35466.15,,"Fee schedule rate ($35,466.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12473.25,,,,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
"KIDNEY AND URINARY TRACT INFECTIONS,MINOR",463,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6996.16,,"Case rate ($6,663.01). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6663.01,6996.16,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],22593.41,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22593.41,90908.64,Inpatient DRG
Cysto W/Destruction of Lesions,CASE-52214,APC,52214,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18783.45,,"Fee schedule rate ($18,783.45). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34611.07,,"Fee schedule rate ($34,611.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy Limited Spx,CASE-29875,APC,29875,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",122800.38,122800.38,122800.38,1 through 10,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8982.79,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8679.02,29908.27,Inpatient DRG
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],45891.89,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,44339.99,131570.26,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5970.00,,"Per diem ($5,970). If length of stay < 6.2, first 1 days paid at a per diem of $11,940 instead. Capped at $37,016.57.",,,,0,other,5970.00,38757.79,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13508.48,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13051.67,38728.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29324.40,,"Fee schedule rate ($29,324.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],40183.85,,of the excess amount.,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],29066.85,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12424.65,,"Fee schedule rate ($12,424.65). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20052.97,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11458.84,42820.42,All Other Inpatient
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6817.59,,"Case rate ($6,492.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.11. The transfer capital threshold is the transfer adjustment factor * $460.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6744.94,1623.25,17554.35,1 through 10,other,6503.29,19528.85,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",9053.37,9053.37,9053.37,1 through 10,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13827.53,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",14055.77,14055.77,72279.59,1 through 10,other,13827.53,41030.48,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31790.24,,"Fee schedule rate ($31,790.24). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13916.85,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13446.23,39899.05,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30538.70,,,,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39187.16,,"Fee schedule rate ($39,187.16). Adds an outlier to normal pricing equal to the per diem rate ($47,534.60) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],29036.74,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8232.00,84471.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24428.09,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23602.02,108295.22,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15156.44,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15156.44,52672.70,Inpatient DRG
HC Repr Smp Not Face 2.6-7.5cm|SEPARATE STRUCTURE,CASE-12002,APC,12002,CPT,0450,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Glenohumeral Joint Total Shoulder|RIGHT SIDE,CASE-23472,APC,23472,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17212.32,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",17670.13,17670.13,17670.13,1 through 10,other,16630.26,17461.77,OPPS APC
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|RIGHT SIDE,CASE-38570,APC,38570,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE|PO,CASE-64490,APC,64490,CPT,0361,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33771.02,,"Fee schedule rate ($33,771.02). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7371.57,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7020.54,28431.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Male Genital System,CASE-55899,APC,55899,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],248.82,,"APC Price ($236.97). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,236.97,248.82,OPPS APC
Destruction Mal Lesion Trunk/Arm/Leg > 4.0 Cm|RIGHT SIDE,CASE-17266,APC,17266,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,404.84,404.84,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5196.70,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5094.80,15365.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT SIDE,CASE-28289,APC,28289,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18518.02,,,,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16284.93,,"Fee schedule rate ($16,284.93). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10620.41,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10114.68,30013.33,Inpatient DRG
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64450,APC,64450,CPT,0450,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17212.32,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16630.26,17212.32,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
Carpectomy All Bones Proximal Row,CASE-25215,APC,25215,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",3012.17,3012.17,3012.17,1 through 10,other,3103.39,3258.56,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],36213.17,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,34988.57,110685.97,Inpatient DRG
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO,CASE-27601,APC,27601,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17212.14,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17212.14,64440.06,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8695.44,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4968.82,19848.33,All Other Inpatient
Plmt Interstitial Dev Radiat Tx Prostate 1/Mult,CASE-55876,APC,55876,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1312.80,,"APC Price ($1,312.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1312.80,1378.44,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5027.17,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4787.78,20006.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6828.45,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6503.29,19528.85,Inpatient DRG
Ant Vesicourethropexy/Urethropexy Smpl,CASE-51840,APC,51840,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39967.07,,"Fee schedule rate ($39,967.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],102807.11,,"Fee schedule rate ($102,807.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26270.73,,"Fee schedule rate ($26,270.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Lateral Retinacular Release Open|RIGHT SIDE|PO,CASE-27425,APC,27425,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7226.40,7226.40,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14182.30,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7308.00,42083.20,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12171.73,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11592.12,38954.76,Inpatient DRG
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4887.21,,"Case rate ($4,654.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.72. The transfer capital threshold is the transfer adjustment factor * $336.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4654.49,13811.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19346.25,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11055.00,49295.13,All Other Inpatient
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14043.03,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14043.03,54637.47,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13438.87,,"Fee schedule rate ($13,438.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26455.73,,,,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein,CASE-37249,APC,37249,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7654.23,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7289.74,21630.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29482.05,,,,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9108.77,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8675.02,25741.45,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12283.14,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11698.23,34712.20,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5348.00,,"Per diem ($5,348). If length of stay < 2.7, first 1 days paid at a per diem of $10,696 instead. Capped at $14,438.66.",,,,0,other,5094.80,15365.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",49235.41,49235.41,49235.41,1 through 10,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21570.21,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,21570.21,72041.81,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7183.19,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6940.28,20593.95,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,APC,43236,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|ADJ,CASE-97605,APC,97605,CPT,0761,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,385.57,404.84,OPPS APC
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18051.15,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17191.57,51012.62,Inpatient DRG
Open Treatment Ulnar Fracture Proximal End|RIGHT SIDE|PO,CASE-24685,APC,24685,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11607.75,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11055.00,49295.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4772.53,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4772.53,14161.54,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],32668.23,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31112.60,92731.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],49568.76,,"Case rate ($47,208.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,516.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,345.35. The transfer capital threshold is the transfer adjustment factor * $3,345.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",48348.16,48348.16,48348.16,1 through 10,other,47283.61,169615.07,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21929.44,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20885.18,80720.91,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
HC Revasc Intra Lithotrip-Ather,CASE-C9766,APC,C9766,CPT,0481,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,28788.33,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],92493.51,,"Fee schedule rate ($92,493.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.8), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Dilat Rct Strix Spx Under Anes Oth/Thn Local,CASE-45910,APC,45910,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10048.06,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9569.58,41116.55,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7371.57,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7020.54,28431.58,Inpatient DRG
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52352,APC,52352,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5263.48,5339.77,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],99176.02,,,,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],38035.88,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36224.65,128473.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],29255.05,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27861.95,82674.88,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19462.52,,,,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,10492.66,31134.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10648.40,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10439.61,34540.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6770.53,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6770.53,20090.22,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],71069.39,,,,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy,CASE-27675,APC,27675,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MINOR",229,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],15043.24,,"Case rate ($15,043.24). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15043.24,15795.40,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21805.52,,"Fee schedule rate ($21,805.52). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw,CASE-37722,APC,37722,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5122.57,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4878.64,14476.37,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,APC,49329,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9880.53,,"Case rate ($9,410.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,837.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.83. The transfer capital threshold is the transfer adjustment factor * $666.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",9880.53,9880.53,9880.53,1 through 10,other,9425.03,27966.92,Inpatient DRG
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],46556.99,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,44339.99,131570.26,Inpatient DRG
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT SIDE|PO,CASE-26160,APC,26160,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25534.84,,,,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],44924.67,,"Fee schedule rate ($44,924.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5697.28,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5504.62,16333.88,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],36511.04,,"Fee schedule rate ($36,511.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19847.56,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18902.44,56089.29,Inpatient DRG
Arthrt Elbow Capsular Excision Capsular Rls Spx|LEFT SIDE|PO,CASE-24006,APC,24006,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,APC,29807,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],50235.38,,,,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7231.00,,"Per diem ($7,231). If length of stay < 5.1, first 1 days paid at a per diem of $14,462 instead. Capped at $36,875.62.",,,,0,other,7231.00,38610.21,Estimated amount calculated based on 2 day length of stay.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, THIRD DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7034.55,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6699.57,24060.08,Inpatient DRG
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|BILATERAL PROCEDURE,CASE-37722,APC,37722,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cath Urethral Simple,CASE-51702,APC,51702,CPT,0761,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],46.63,,"APC Price ($44.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,44.41,46.63,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Fem Pop Territory Plasty|RIGHT SIDE,CASE-37224,APC,37224,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],401.21,,,,,,0,other,401.21,421.27,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],8990.00,,"Per diem ($8,990). If length of stay < 6, first 1 days paid at a per diem of $17,980 instead. Capped at $53,939.67.",,,,0,other,8990.00,80069.53,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5486.04,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5486.04,17919.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14472.78,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7770.00,50313.90,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11871.54,,"Case rate ($11,871.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,001.85, add-ons for qualifying new technology services are included. If operating cost exceeds $51,547.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,512.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,007.29. The transfer operating threshold is the transfer adjustment factor * $11,001.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.25. The transfer capital threshold is the transfer adjustment factor * $864.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11871.54,35778.69,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28917.82,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,16524.47,58465.86,All Other Inpatient
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8675.02,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8675.02,25741.45,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],106601.82,,"Fee schedule rate ($106,601.82). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11593.40,,"Fee schedule rate ($11,593.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,2285.00,12138.74,Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10632.00,,"Per diem ($10,632). If length of stay < 6.4, first 1 days paid at a per diem of $21,264 instead. Capped at $68,043.82.",,,,0,other,10632.00,103714.29,Estimated amount calculated based on 5 day length of stay.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, SECOND DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11500.98,,"Case rate ($10,953.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,947.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.19. The transfer capital threshold is the transfer adjustment factor * $776.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",11499.72,11499.72,11499.72,1 through 10,other,10970.77,32553.63,Inpatient DRG
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, THIRD DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,T2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5774.12,,"Case rate ($5,499.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.69. The transfer capital threshold is the transfer adjustment factor * $389.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5507.93,20510.35,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],35363.23,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",34575.88,34575.88,34575.88,1 through 10,other,18559.00,141041.50,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17691.86,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16849.39,49997.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Extremity Venogram|LEFT SIDE,CASE-36005,APC,36005,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1545.29,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32874.59,,"Fee schedule rate ($32,874.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7285.00,,"Per diem ($7,285). If length of stay < 5.4, first 1 days paid at a per diem of $14,570 instead. Capped at $39,337.51.",,,,0,other,7285.00,41187.90,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],25524.04,,"Case rate ($24,308.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,893.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,722.59. The transfer capital threshold is the transfer adjustment factor * $1,722.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",24295.17,24295.17,24295.17,1 through 10,other,10455.00,90889.11,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11297.80,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10915.75,32390.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO|SEPARATE STRUCTURE,CASE-62323,APC,62323,CPT,0360,RC,,,PO|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],50996.22,,"Fee schedule rate ($50,996.22). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9725.67,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,27484.83,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
HC Sleep Study Unattended,CASE-95800,APC,95800,CPT,0920,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],215.04,,"APC Price ($204.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",152.51,54.00,209.83,66,other,204.80,215.04,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14771.95,,"Fee schedule rate ($14,771.95). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
HC Insertion Uterine Tandem&/Vaginal Ovoids,CASE-57155,APC,57155,CPT,0342,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4744.66,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4744.66,4981.90,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8761.57,,"Case rate ($5,006.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,625.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,093.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,644.42. The transfer operating threshold is the transfer adjustment factor * $4,625.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.19. The transfer capital threshold is the transfer adjustment factor * $362.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5006.61,14856.14,All Other Inpatient
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9231.24,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",9007.48,9007.48,9007.48,1 through 10,other,8919.07,34453.70,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16524.47,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16524.47,58465.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6724.11,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6724.11,19952.48,Inpatient DRG
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13183.59,,,,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5011.16,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4772.53,14161.54,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5900.43,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5700.90,30872.02,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE,CASE-28306,APC,28306,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE,CASE-27570,APC,27570,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1578.51,OPPS APC
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5091.00,,"Per diem ($5,091). If length of stay < 3.2, first 1 days paid at a per diem of $10,182 instead. Capped at $16,289.77.",,,,0,other,5091.00,22010.11,Estimated amount calculated based on 2 day length of stay.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15592.86,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15065.57,53815.71,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",642.91,642.91,642.91,1 through 10,other,669.51,702.98,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein|RIGHT SIDE,CASE-37249,APC,37249,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Debridement/Shaving Artclr Crtlg|LEFT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39854.32,,"Fee schedule rate ($39,854.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Cervical Node,CASE-38510,APC,38510,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC
"ALTERATION IN CONSCIOUSNESS,MAJOR",052,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14537.61,,"Case rate ($14,537.61). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14537.61,15264.49,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],35148.55,,"Fee schedule rate ($35,148.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12402.46,36801.89,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7620.12,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7257.26,23445.98,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],55081.83,,,,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12283.14,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11698.23,34712.20,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6634.06,,"Case rate ($6,318.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,618.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.73. The transfer capital threshold is the transfer adjustment factor * $447.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6328.22,27416.36,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32825.17,,,,,,0,other,10888.24,32825.17,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23258.35,,"Case rate ($22,802.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,068.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,536.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,820.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $21,152.71. The transfer operating threshold is the transfer adjustment factor * $21,068.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,649.58. The transfer capital threshold is the transfer adjustment factor * $1,649.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,22802.30,82749.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11731.65,,"Fee schedule rate ($11,731.65). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5932.68,,"Case rate ($5,732.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,296.29, add-ons for qualifying new technology services are included. If operating cost exceeds $40,764.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,317.40. The transfer operating threshold is the transfer adjustment factor * $5,296.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.67. The transfer capital threshold is the transfer adjustment factor * $414.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5732.06,21720.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16283.27,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15507.88,46016.63,Inpatient DRG
HC Cv Cath Plac W/Port Tun >5|RIGHT SIDE,CASE-36561,APC,36561,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],35843.85,,"Fee schedule rate ($35,843.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10367.99,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10367.99,37103.57,Inpatient DRG
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX|74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT SIDE|PO,CASE-28750,APC,28750,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8106.00,,"Fee schedule rate ($8,106). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
Unlisted Procedure Arthroscopy,CASE-29999,APC,29999,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Rhinoplasty Primary W/Major Septal Repair|PO,CASE-30420,APC,30420,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7776.10,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7405.81,33747.30,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],42577.42,,"Fee schedule rate ($42,577.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13927.77,,"Case rate ($13,264.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,256.10, add-ons for qualifying new technology services are included. If operating cost exceeds $47,724.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,130.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,304.94. The transfer operating threshold is the transfer adjustment factor * $12,256.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.59. The transfer capital threshold is the transfer adjustment factor * $959.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13264.54,50759.39,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16570.24,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16009.89,58554.60,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Trigger Pt 1-2 Musc Grps|PO,CASE-20552,APC,20552,CPT,0510,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
HC Extremity Venogram|LEFT SIDE,CASE-36005,APC,36005,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1567.69,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1493.03,1567.69,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],58245.60,,"Fee schedule rate ($58,245.60). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11901.14,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11901.14,35314.31,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],55081.83,,,,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6474.30,,"Fee schedule rate ($6,474.30). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
HC Intro Catheter Aorta|RIGHT SIDE,CASE-36200,APC,36200,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11612.27,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11384.58,33781.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17366.98,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,17026.45,50522.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|SEPARATE STRUCTURE,CASE-12032,APC,12032,CPT,0450,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33262.00,,,,,,0,other,11036.50,33262.00,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23596.66,,,,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8410.44,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8384.99,8384.99,8384.99,1 through 10,other,8410.44,24956.34,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10810.31,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10810.31,32077.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",21146.17,21146.17,21146.17,1 through 10,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|RIGHT SIDE|PO,CASE-29884,APC,29884,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Synovectomy Tendon Sheath Foot Extensor,CASE-28088,APC,28088,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Lig/Banding Angioaccess Arteriovenous Fistula,CASE-37607,APC,37607,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],37199.37,,,,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13438.87,,"Fee schedule rate ($13,438.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6059.16,,"Case rate ($5,770.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,580.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.93. The transfer capital threshold is the transfer adjustment factor * $408.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5779.83,17150.47,Inpatient DRG
Open Treatment Metatarsal Fracture Each|LEFT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9935.64,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9935.64,29482.05,Inpatient DRG
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,APC,43249,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13246.56,,,,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10393.20,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5938.97,17858.70,All Other Inpatient
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,APC,29828,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Peripheral Block - Femoral Continuous W/Img Gdn,CASE-64448,APC,64448,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10635.47,,"Case rate ($10,129.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $717.78. The transfer capital threshold is the transfer adjustment factor * $717.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,30103.84,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14347.61,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13664.39,40546.43,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5444.94,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5338.18,15839.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],45782.73,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,43602.60,153667.90,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|LEFT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Complete 1st Metatarsal Head,CASE-28111,APC,28111,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12565.29,,"Case rate ($11,966.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,019.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.02. The transfer capital threshold is the transfer adjustment factor * $848.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,11986.02,54149.39,Inpatient DRG
Tnot Elbow Lateral/Medial Debride Open|RIGHT SIDE|PO,CASE-24358,APC,24358,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25678.92,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,14673.67,43541.27,All Other Inpatient
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],125659.39,,"Fee schedule rate ($125,659.39). Adds an outlier to normal pricing equal to the per diem rate ($160,041.92) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22648.72,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,21570.21,72041.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3162.78,3162.78,3162.78,1 through 10,other,3103.39,3258.56,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
Excision Single External Papilla or Tag Anus,CASE-46220,APC,46220,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18085.13,,,,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16009.89,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16009.89,58554.60,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21256.76,,"Fee schedule rate ($21,256.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28017.31,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,16009.89,58554.60,All Other Inpatient
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3117.60,3117.60,3117.60,1 through 10,other,3103.39,3258.56,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4785.59,,"Case rate ($4,557.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.97. The transfer capital threshold is the transfer adjustment factor * $322.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4564.97,13545.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32019.51,,"Fee schedule rate ($32,019.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16009.89,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16009.89,58554.60,Inpatient DRG
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,70321.74,Estimated amount calculated based on 17 day length of stay.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
"CELLULITIS AND OTHER SKIN INFECTIONS,MAJOR",383,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],12968.21,,"Case rate ($12,350.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12350.68,12968.21,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],57615.08,,"Fee schedule rate ($57,615.08). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms,CASE-27696,APC,27696,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,APC,38900,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23530.90,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13446.23,39899.05,All Other Inpatient
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5091.00,,"Per diem ($5,091). If length of stay < 3.2, first 1 days paid at a per diem of $10,182 instead. Capped at $16,289.77.",,,,0,other,5091.00,22010.11,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
Bone Graft Any Donor Area Major/Large|SEPARATE STRUCTURE,CASE-20902,APC,20902,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6389.34,,"Case rate ($6,085.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,602.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.21. The transfer capital threshold is the transfer adjustment factor * $431.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12612.80,12612.80,12612.80,1 through 10,other,6094.79,22352.66,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12787.15,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,12536.42,46998.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40774.00,,"Fee schedule rate ($40,774.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11958.84,40774.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MAJOR",191,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],20464.83,,"Case rate ($19,490.31). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19490.31,20464.83,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE,CASE-27698,APC,27698,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21754.24,,"Fee schedule rate ($21,754.24). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],158423.11,,"Fee schedule rate ($158,423.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14596.33,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14102.73,41847.08,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6054.28,,"Case rate ($5,765.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,579.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.60. The transfer capital threshold is the transfer adjustment factor * $408.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5775.17,17136.70,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Partical Excision Bone Phalanx Toe|LEFT SIDE|PO,CASE-28124,APC,28124,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5549.19,,"Case rate ($5,549.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,050.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.42. The transfer capital threshold is the transfer adjustment factor * $402.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5549.19,16729.39,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10915.75,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10915.75,32390.31,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,50|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5766.55,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5766.55,17111.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9289.58,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5308.33,19857.20,All Other Inpatient
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],42603.11,,"Case rate ($40,574.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,046.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,875.24. The transfer capital threshold is the transfer adjustment factor * $2,875.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,40639.08,120588.53,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6094.79,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6094.79,22352.66,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],26024.99,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9242.00,76216.30,Inpatient DRG
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE,CASE-27691,APC,27691,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Open Treatment Calcaneal Fracture|LEFT SIDE,CASE-28415,APC,28415,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14641.18,43444.85,Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FOURTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20227.96,,,,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|RIGHT SIDE,CASE-27130,APC,27130,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29407.28,,,,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14518.91,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13827.53,41030.48,Inpatient DRG
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
HC Removal Subcutaneous Cardiac Rhythm Monitor,CASE-33286,APC,33286,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10409.05,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9913.38,10409.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>|RIGHT SIDE,CASE-23073,APC,23073,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2755.03,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11434.00,,"Fee schedule rate ($11,434.00). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
Lig/Banding Angioaccess Arteriovenous Fistula,CASE-37607,APC,37607,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21133.20,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21133.20,88801.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],83099.91,,,,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15043.80,,"Fee schedule rate ($15,043.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5308.33,19857.20,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24117.35,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23644.46,105789.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4765.36,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4538.44,18815.35,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5169.74,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5093.65,5093.65,5169.74,1 through 10,other,5169.74,15340.19,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19024.56,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,18381.22,58579.45,Inpatient DRG
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE|PO,CASE-25608,APC,25608,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5345.47,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5224.00,15861.63,Inpatient DRG
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,APC,52300,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16456.83,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16456.83,55350.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,70321.74,Estimated amount calculated based on 17 day length of stay.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,21325.01,Estimated amount calculated based on 2 day length of stay.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt,CASE-38570,APC,38570,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11691.77,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6681.01,19824.58,All Other Inpatient
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35544.53,,,,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6094.79,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6094.79,22352.66,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17836.44,,"Fee schedule rate ($17,836.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11888.55,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11888.55,35276.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],26951.04,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25667.66,86123.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7003.94,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7003.94,20782.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14626.50,,"Fee schedule rate ($14,626.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14690.43,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8394.53,24909.11,All Other Inpatient
Excision Tumor Soft Tis Foot/Toe Subq 1.5 Cm/>|RIGHT SIDE|PO,CASE-28039,APC,28039,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2851.46,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE|PO,CASE-27650,APC,27650,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
HC Thromb Mech Vein,CASE-37187,APC,37187,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5462.53,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",25987.80,25987.80,25987.80,1 through 10,other,5355.42,17067.11,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32645.32,,"Fee schedule rate ($32,645.32). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11519.18,34180.92,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],59684.28,,,,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24596.28,,"Fee schedule rate ($24,596.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
"OTHER DISORDERS OF THE LIVER,MAJOR",283,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15151.34,,"Case rate ($14,429.85). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14429.85,15151.34,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9447.79,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,1188.00,27484.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Revasc lithotrip tibi/perone,CASE-C9772,APC,C9772,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11496.76,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,MODERATE",513,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],16568.43,,"Case rate ($16,568.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,16568.43,17396.85,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15852.04,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15852.05,15852.05,15852.05,1 through 10,other,15852.04,50518.01,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8814.26,,"Case rate ($8,394.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,778.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.28. The transfer capital threshold is the transfer adjustment factor * $607.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8394.53,24909.11,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9166.71,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",8971.14,8971.14,9166.71,1 through 10,other,6972.00,26280.60,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4870.41,,"Case rate ($4,870.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,514.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,060.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,001.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,517.21. The transfer operating threshold is the transfer adjustment factor * $4,514.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.19. The transfer capital threshold is the transfer adjustment factor * $353.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4870.41,14682.98,Inpatient DRG
HC N Block Inj Intercost Sng|BILATERAL PROCEDURE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14406.59,,"Fee schedule rate ($14,406.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],158423.11,,"Fee schedule rate ($158,423.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Arthroscopy Ankle Surgical Debridement Extensive|RIGHT SIDE|PO,CASE-29898,APC,29898,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17490.00,,"Per diem ($17,490). If length of stay < 1.2, first 1 days paid at a per diem of $34,980 instead. Capped at $20,988.02.",,,,0,other,7405.81,33747.30,Estimated amount calculated based on 1 day length of stay.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],37492.51,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,36224.65,128473.68,Inpatient DRG
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12405.69,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11814.94,44591.73,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12133.76,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11895.84,35298.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14807.87,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14102.73,41847.08,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],38090.20,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36276.38,121107.98,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9035.67,,"Case rate ($8,605.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,951.18, add-ons for qualifying new technology services are included. If operating cost exceeds $43,419.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,982.86. The transfer operating threshold is the transfer adjustment factor * $7,951.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $622.54. The transfer capital threshold is the transfer adjustment factor * $622.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8605.40,42305.71,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],5369.70,,"Fee schedule rate ($5,369.70). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18051.15,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17191.57,51012.62,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20041.03,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,19363.31,79918.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Px Skin Muc Membrane & Subq Tissue|PO,CASE-17999,APC,17999,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7226.40,7226.40,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19787.25,,"Fee schedule rate ($19,787.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
"HC Unlisted Procedure, Nervous System",CASE-64999,APC,64999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13302.50,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7601.43,23918.09,All Other Inpatient
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33132.06,,"Fee schedule rate ($33,132.06). Adds an outlier to normal pricing equal to the per diem rate ($83,058.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",34000.30,34000.30,34000.30,1 through 10,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
"OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,MODERATE",182,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5981.02,,"Case rate for a one day stay ($5,981.02). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5981.02,6280.07,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE,CASE-27698,APC,27698,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],57067.24,,,,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THUMB|PO",CASE-26735,APC,26735,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26291.41,,"Fee schedule rate ($26,291.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (0), with a minimum of zero.",,,,0,other,8981.78,27528.12,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30683.33,,"Fee schedule rate ($30,683.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11188.67,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10810.31,32077.45,Inpatient DRG
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12498.29,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11903.13,48838.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5603.81,,"Case rate ($5,336.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,549.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.20. The transfer capital threshold is the transfer adjustment factor * $378.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5224.00,15861.63,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22831.22,,,,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],29626.85,,"Case rate ($16,929.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,395.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,224.73. The transfer capital threshold is the transfer adjustment factor * $1,224.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,16929.63,63934.22,All Other Inpatient
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6751.53,,"Case rate ($6,430.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,950.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,418.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,974.38. The transfer operating threshold is the transfer adjustment factor * $5,950.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.65. The transfer capital threshold is the transfer adjustment factor * $455.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6613.59,6613.59,6613.59,1 through 10,other,6440.28,19110.30,Inpatient DRG
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Midtarsometatarsal Single Joint|RIGHT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
Rpr Nonunion/Malunion Radius/Ulna W/Autograft,CASE-25405,APC,25405,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Lesion Tendon Sheath/Capsule Leg&/Ank,CASE-27630,APC,27630,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6665.69,,"Case rate ($6,440.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,950.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,418.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,637.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,974.38. The transfer operating threshold is the transfer adjustment factor * $5,950.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $465.91. The transfer capital threshold is the transfer adjustment factor * $465.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6440.28,19110.30,Inpatient DRG
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, THIRD DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25753.26,,,,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13826.01,,"Fee schedule rate ($13,826.01). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],32106.67,,"Case rate ($30,577.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,338.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,166.85. The transfer capital threshold is the transfer adjustment factor * $2,166.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30626.53,106200.88,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
Repair Primary Open/Prq Ruptured Achilles Tendon|RIGHT SIDE|PO,CASE-27650,APC,27650,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],48444.74,,of the excess amount. Final payment is multiplied by 175%.,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10976.58,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10976.58,10976.58,10976.58,1 through 10,other,10605.39,31469.43,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26909.70,,"Fee schedule rate ($26,909.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9495.32,42131.77,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],43128.05,,,,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],112294.67,,,,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
Claviculectomy Partial|RIGHT SIDE|PO,CASE-23120,APC,23120,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5094.80,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5094.80,15365.01,Inpatient DRG
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|LEFT FOOT, GREAT TOE|PO",CASE-28291,APC,28291,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
"INGUINAL FEMORAL AND UMBILICAL HERNIA PROCEDURES,MINOR",228,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13007.38,,"Case rate ($12,387.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12387.98,13007.38,There are no additional notes associated with this service or procedure.
Tenolysis Extensor Foot Single Tendon,CASE-28225,APC,28225,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE|PO,CASE-29825,APC,29825,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
HC Debrid Wound Tis 20 Cm/<|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97597,APC,97597,CPT,0761,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9042.09,,"Fee schedule rate ($9,042.09). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5549.19,16729.39,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5942.94,17634.53,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10432.42,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9935.64,29482.05,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8981.78,,"Case rate ($8,981.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,671.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $657.72. The transfer capital threshold is the transfer adjustment factor * $657.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8981.78,27528.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12463.10,,"Case rate ($11,869.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,012.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $841.12. The transfer capital threshold is the transfer adjustment factor * $841.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11888.55,35276.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12107.00,,"Per diem ($12,107). If length of stay < 2.8, first 1 days paid at a per diem of $24,214 instead. Capped at $33,900.69.",,,,0,other,11962.15,40923.09,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12198.02,,"Case rate ($11,958.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,049.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,517.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,093.70. The transfer operating threshold is the transfer adjustment factor * $11,049.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.13. The transfer capital threshold is the transfer adjustment factor * $865.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11958.84,40774.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE,CASE-29876,APC,29876,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|LEFT SIDE,CASE-27524,APC,27524,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6194.88,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5985.39,17760.46,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27304.54,,"Fee schedule rate ($27,304.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,APC,38510,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12975.19,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12536.42,37199.37,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10031.11,,"Case rate ($5,732.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,296.29, add-ons for qualifying new technology services are included. If operating cost exceeds $40,764.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,317.40. The transfer operating threshold is the transfer adjustment factor * $5,296.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.67. The transfer capital threshold is the transfer adjustment factor * $414.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5732.06,21720.81,All Other Inpatient
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10145.17,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,30103.84,Inpatient DRG
Removal Implant Deep|SEPARATE STRUCTURE,CASE-20680,APC,20680,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Repair Non/Malunion Humerus W/O Graft|RIGHT SIDE,CASE-24430,APC,24430,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7956.02,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7686.98,22809.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24596.28,,"Fee schedule rate ($24,596.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12126.32,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11888.55,35276.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28195.14,,"Fee schedule rate ($28,195.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC ED Avulsion Nail Plate Single|LEFT FOOT, GREAT TOE|PO",CASE-11730,APC,11730,CPT,0450,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29179.02,,,,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
"Inject Nerv Blck,Paravert Sympath|BILATERAL PROCEDURE|PO",CASE-64520,APC,64520,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],41117.20,,"Fee schedule rate ($41,117.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19377.46,,"Fee schedule rate ($19,377.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|LEFT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rmvl/Revj Sling Stress Incontinence,CASE-57287,APC,57287,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3177.77,,"APC Price ($3,070.31). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23131.85,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",22393.02,22390.01,27112.18,12,other,23131.85,76404.43,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39228.51,,"Fee schedule rate ($39,228.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],189550.75,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,185834.07,195125.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25783.26,,"Fee schedule rate ($25,783.26). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6700.71,,"Case rate ($6,474.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,981.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,449.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,005.76. The transfer operating threshold is the transfer adjustment factor * $5,981.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.35. The transfer capital threshold is the transfer adjustment factor * $468.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6474.12,19210.66,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,APC,52287,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5263.48,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8638.80,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8227.43,27001.04,Inpatient DRG
Ostectomy Complete 5th Metatarsal Head|LEFT SIDE,CASE-28113,APC,28113,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],76163.76,,,,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18562.91,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18562.91,73513.17,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16929.04,,"Fee schedule rate ($16,929.04). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],67661.33,,,,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
HC Wound Vac <=50 Sq Cm Dme|ADJ,CASE-97605,APC,97605,CPT,0761,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4639.91,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4639.91,13771.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12775.42,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12167.07,36103.36,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15960.77,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15421.03,49137.17,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21939.88,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20895.12,99969.33,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12167.07,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12167.07,36103.36,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea,CASE-28465,APC,28465,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4878.64,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",4826.02,4826.02,4878.64,1 through 10,other,4878.64,14476.37,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10638.72,,"Fee schedule rate ($10,638.72). Adds an outlier to normal pricing equal to the per diem rate ($26,031.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,3753.97,11139.15,Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Implant Deep|SEPARATE STRUCTURE|PO,CASE-20680,APC,20680,CPT,0360,RC,,,XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9033.85,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",9033.85,9033.85,9033.85,1 through 10,other,6972.00,26280.60,Inpatient DRG
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
"Ostc Prtl Exostc/Condylc Metar Head|LEFT FOOT, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28288,APC,28288,CPT,0360,RC,,,T1|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14071.02,,,,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Ablation Renal Cysts|RIGHT SIDE,CASE-50541,APC,50541,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE|PO,CASE-29891,APC,29891,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4564.97,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4564.97,13545.65,Inpatient DRG
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],50750.92,,,,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18559.43,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10605.39,31469.43,All Other Inpatient
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|RIGHT SIDE,CASE-27675,APC,27675,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34420.98,,,,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11688.02,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11458.84,42820.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3074.87,,"APC Price ($3,074.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3074.87,3228.61,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],53319.92,,"Fee schedule rate ($53,319.92). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, THIRD DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Ganglion Wrist Dorsal/Volar Primary|PO,CASE-25111,APC,25111,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
"Synovectomy Metatarsophalangeal Joint Each|LEFT FOOT, SECOND DIGIT",CASE-28072,APC,28072,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18829.84,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10759.91,46061.32,All Other Inpatient
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,APC,64493,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1301.76,1289.30,1301.76,1 through 10,other,838.89,880.84,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27654,APC,27654,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Partical Excision Bone Phalanx Toe|LEFT FOOT, SECOND DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],31160.85,,"Fee schedule rate ($31,160.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,APC,31653,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3536.22,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11863.29,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11298.37,44627.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13803.55,,"Fee schedule rate ($13,803.55). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|PO,CASE-11422,APC,11422,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, THIRD DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11725.42,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6700.24,30254.37,All Other Inpatient
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6033.12,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6033.12,17902.13,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15496.63,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,53945.28,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],83099.91,,,,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],23384.18,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,22593.41,90908.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sleep Study Unattended,CASE-95800,APC,95800,CPT,0920,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],204.80,,"APC Price ($204.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,204.80,215.04,OPPS APC
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32406.65,,"Fee schedule rate ($32,406.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18893.86,,,,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7078.89,21005.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Destruction of Lesions,CASE-52214,APC,52214,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|RIGHT SIDE|PO,CASE-23700,APC,23700,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5428.23,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5169.74,15340.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],67331.56,,"Fee schedule rate ($67,331.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9495.16,,"Case rate ($9,308.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.44. The transfer capital threshold is the transfer adjustment factor * $673.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,33447.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],23871.38,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22734.65,70806.50,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6803.69,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5843.00,27370.21,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MODERATE",254,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10064.15,,"Case rate ($9,584.90). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9584.90,10064.15,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],40046.00,,"Fee schedule rate ($40,046.00). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19462.52,,,,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],81718.58,,,,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7402.41,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7257.26,23445.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10105.00,,"Per diem ($10,105). If length of stay < 10.6, first 1 days paid at a per diem of $20,210 instead. Capped at $107,110.70.",,,,0,other,10105.00,120252.50,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
HC Intro Cath Dialysis Circuit W Pta|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36902,APC,36902,CPT,0361,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5587.20,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41664.08,,,,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
HC Inj Tendon Sheath/Ligament|PO,CASE-20550,APC,20550,CPT,0510,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29260.35,,"Fee schedule rate ($29,260.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
"ABDOMINAL PAIN,MODERATE",251,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3022.90,,"Case rate for a one day stay ($2,878.95). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2878.95,3022.90,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],61348.24,,"Fee schedule rate ($61,348.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13770.04,,"Case rate ($13,114.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,136.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,604.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,184.99. The transfer operating threshold is the transfer adjustment factor * $12,136.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.33. The transfer capital threshold is the transfer adjustment factor * $929.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13377.67,13377.67,13377.67,1 through 10,other,13135.23,38976.20,Inpatient DRG
"Arthro, Loose Body + Chondro",CASE-G0289,APC,G0289,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24053.80,,"Case rate ($22,908.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,828.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.25. The transfer capital threshold is the transfer adjustment factor * $1,657.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22908.38,67976.16,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26297.04,,"Fee schedule rate ($26,297.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,9279.13,27534.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],31074.42,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,29594.69,124146.55,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27622.57,,,,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11159.78,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11159.78,39897.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6835.51,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6835.51,20283.05,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5350.68,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",5350.68,5350.68,6966.33,1 through 10,other,5169.74,15340.19,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9804.90,,"Fee schedule rate ($9,804.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6632.59,19680.94,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8378.62,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4787.78,20006.29,All Other Inpatient
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25261.33,,,,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",19586.81,19586.81,19586.81,1 through 10,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,MINOR",951,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3805.19,,"Case rate for a one day stay ($3,805.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3805.19,3995.45,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-23430,APC,23430,CPT,0360,RC,,,73,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],23941.46,,"Case rate ($23,131.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.42. The transfer capital threshold is the transfer adjustment factor * $1,673.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",23941.49,23941.49,23941.49,1 through 10,other,23131.85,76404.43,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],25108.34,,"Case rate ($23,912.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,865.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,694.54. The transfer capital threshold is the transfer adjustment factor * $1,694.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23950.83,74869.17,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
Rhinp Prim Complete Xtrnl Parts|PO,CASE-30410,APC,30410,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",2635.04,2635.04,2635.04,1 through 10,other,2632.62,2764.26,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27597.52,,"Fee schedule rate ($27,597.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Dir Rpr Aneurysm Axil-Brachial Arm Incision|RIGHT SIDE,CASE-35011,APC,35011,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5462.46,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr,CASE-27524,APC,27524,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Iphal Jt W/WO Int Fixj Ea Iphal Jt,CASE-26861,APC,26861,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5034.82,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4795.07,19830.58,Inpatient DRG
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12498.29,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11903.13,48838.99,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13492.62,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13228.06,39251.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
Laparoscopy Nephrectomy W/Partial Ureterect,CASE-50546,APC,50546,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],356.97,,"APC Price ($339.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,339.97,356.97,OPPS APC
Inj for Sacroiliac Jt Anesth|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],33451.55,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31858.62,94534.21,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27966.92,,,,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19173.27,,,,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE|PO,CASE-29828,APC,29828,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],41058.15,,"Fee schedule rate ($41,058.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8800.23,,"Case rate ($8,381.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,756.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,224.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,765.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,787.24. The transfer operating threshold is the transfer adjustment factor * $7,756.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.92. The transfer capital threshold is the transfer adjustment factor * $593.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8394.53,24909.11,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7432.83,,"Case rate ($7,078.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,540.71, add-ons for qualifying new technology services are included. If operating cost exceeds $42,008.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,683.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,566.78. The transfer operating threshold is the transfer adjustment factor * $6,540.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.10. The transfer capital threshold is the transfer adjustment factor * $512.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7078.89,21005.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],83871.28,,"Fee schedule rate ($83,871.28). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12006.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11600.09,48814.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23954.78,,,,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30861.41,,,,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7755.94,,"Case rate ($7,755.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,166.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,634.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,194.85. The transfer operating threshold is the transfer adjustment factor * $7,166.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.08. The transfer capital threshold is the transfer adjustment factor * $561.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7755.94,35520.39,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],57456.84,,,,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5573.75,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5308.33,19857.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation|RIGHT SIDE|PO,CASE-28615,APC,28615,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],47368.65,,"Fee schedule rate ($47,368.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21289.03,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21289.03,76326.34,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11645.83,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11645.83,37502.92,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],78944.25,,"Fee schedule rate ($78,944.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7041.91,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,21229.52,Inpatient DRG
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|RIGHT SIDE,CASE-27446,APC,27446,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Biopsy Urethra,CASE-53200,APC,53200,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,CASE-36556,APC,36556,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7915.12,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7759.92,35376.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],27682.71,,of the excess amount.,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6953.00,,"Per diem ($6,953). If length of stay < 4.5, first 1 days paid at a per diem of $13,906 instead. Capped at $31,286.59.",,,,0,other,6953.00,35389.05,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,MODERATE",351,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9243.12,,"Case rate ($8,802.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8802.97,9243.12,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17274.00,,"Per diem ($17,274). If length of stay < 3.3, first 1 days paid at a per diem of $34,548 instead. Capped at $57,002.93.",,,,0,other,17274.00,73717.28,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23258.35,,"Case rate ($22,802.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,068.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,536.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,820.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $21,152.71. The transfer operating threshold is the transfer adjustment factor * $21,068.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,649.58. The transfer capital threshold is the transfer adjustment factor * $1,649.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,22802.30,82749.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],46957.19,,,,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6784.60,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6461.52,21772.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10178.99,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10178.99,36468.17,Inpatient DRG
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11888.55,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11888.55,35276.93,Inpatient DRG
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15668.80,,,,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],38891.09,,"Case rate ($38,891.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $35,934.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,402.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,984.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $36,077.60. The transfer operating threshold is the transfer adjustment factor * $35,934.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,813.48. The transfer capital threshold is the transfer adjustment factor * $2,813.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,38891.09,169197.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],25949.09,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24713.42,73332.24,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4676.00,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4517.87,13932.70,Inpatient DRG
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|RIGHT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,XS|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12326.86,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12326.86,53121.74,Inpatient DRG
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30493.52,,"Fee schedule rate ($30,493.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|LEFT SIDE|PO,CASE-25290,APC,25290,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
Colonoscopy Stoma Dx Including Collj Spec Spx,CASE-44388,APC,44388,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15407.35,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14673.67,43541.27,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14484.89,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7453.00,42138.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8716.15,25863.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6590.75,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6461.52,21772.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16156.34,,"Fee schedule rate ($16,156.34). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28285,APC,28285,CPT,0360,RC,,,T9|PO|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Amputation Toe Interphalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6387.91,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6387.91,18954.85,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4538.44,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4538.44,18815.35,Inpatient DRG
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],36287.40,,"Fee schedule rate ($36,287.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33727.80,,"Fee schedule rate ($33,727.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20274.44,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20274.44,80940.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7136.91,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6797.06,20168.93,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6328.22,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6328.22,27416.36,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Extremity Venogram|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10409.05,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9913.38,10409.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35884.94,,,,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28878.15,,"Fee schedule rate ($28,878.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14910.91,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7453.00,42138.30,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13765.52,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7866.01,25247.47,All Other Inpatient
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19320.40,,"APC Price ($18,400.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,18400.38,19320.40,OPPS APC
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Trurl Rescj Residual/Regrowth Obstr Prstate Tiss,CASE-52630,APC,52630,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20895.12,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20895.12,99969.33,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22229.55,,"Fee schedule rate ($22,229.55). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31323.82,,,,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7369.00,,"Per diem ($7,369). If length of stay < 2.4, first 1 days paid at a per diem of $14,738 instead. Capped at $17,686.09.",,,,0,other,6240.68,18518.02,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11749.56,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11519.18,34180.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
Arthrp Kne Condyle&Platu Medial&Lat Compartments|RIGHT SIDE,CASE-27447,APC,27447,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",11945.04,11945.04,11945.04,1 through 10,other,12177.08,12785.93,OPPS APC
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],67175.58,,"Fee schedule rate ($67,175.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7753.46,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7601.43,23918.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32071.54,,,,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],52135.70,,"Fee schedule rate ($52,135.70). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],49997.29,,,,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13572.00,,"Per diem ($13,572). If length of stay < 5.8, first 1 days paid at a per diem of $27,144 instead. Capped at $78,720.12.",,,,0,other,13572.00,108637.77,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,EXTREME",720,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],31320.17,,"Case rate ($31,320.17). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31320.17,32886.18,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn,CASE-64415,APC,64415,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3179.72,3162.78,3179.72,1 through 10,other,3103.39,3258.56,OPPS APC
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS AND MISCELLANEOUS DIAGNOSES,MODERATE",143,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2489.75,,"Case rate for a one day stay ($2,371.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2371.19,2489.75,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,APC,43275,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride/Musc/Fasc First 20 Sq Cm,CASE-11043,APC,11043,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],725.52,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,700.99,736.04,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs,CASE-25116,APC,25116,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|RIGHT SIDE|PO,CASE-24341,APC,24341,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Ostectomy Complete 1st Metatarsal Head,CASE-28111,APC,28111,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14102.73,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14102.73,41847.08,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17902.13,,,,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17622.38,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,17026.45,50522.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],44803.76,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,42670.25,133443.30,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],41117.20,,"Fee schedule rate ($41,117.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10316.97,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10114.68,30013.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16785.91,,"Fee schedule rate ($16,785.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],8232.00,,"Per diem ($8,232). If length of stay < 9.8, first 1 days paid at a per diem of $16,464 instead. Capped at $80,676.47.",,,,0,other,8232.00,84471.39,Estimated amount calculated based on 10 day length of stay.
Rpr Aa Hernia Recr > 10 Cm Ncrc8/Strangulated,CASE-49618,APC,49618,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],211.83,,"APC Price ($201.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,201.74,211.83,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],70160.31,,,,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13014.93,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12395.17,42174.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20676.15,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11814.94,44591.73,All Other Inpatient
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.5 Cm/<,CASE-11400,APC,11400,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],671.64,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,671.64,705.22,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],109526.12,,,,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12196.66,,"Fee schedule rate ($12,196.66). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],28236.36,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,48444.74,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7759.92,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7759.92,35376.63,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16573.70,,"Fee schedule rate ($16,573.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6632.59,19680.94,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16271.46,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,53945.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Bladder Irrig Simple or Continuous,CASE-51700,APC,51700,CPT,0761,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
"HYPERTENSION,MODERATE",199,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3063.67,,"Case rate for a one day stay ($2,917.78). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2917.78,3063.67,There are no additional notes associated with this service or procedure.
Patellectomy/Hemipatellectomy|RIGHT SIDE,CASE-27350,APC,27350,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
Fth/Gft Fr W/Dir Clsr S/a/L Ea Addl 20 Cm/<,CASE-15221,APC,15221,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|LEFT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],30163.67,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,30163.67,89504.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24596.28,,"Fee schedule rate ($24,596.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
Revision of Reconstructed Breast|RIGHT SIDE,CASE-19380,APC,19380,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6518.41,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20185.84,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,19503.23,57872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13842.12,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",13239.72,13239.72,13239.72,1 through 10,other,12440.40,41073.77,Inpatient DRG
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27371.98,,"Fee schedule rate ($27,371.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10665.38,,"Case rate ($10,157.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.80. The transfer capital threshold is the transfer adjustment factor * $719.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10173.70,41194.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11814.94,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11814.94,44591.73,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27868.14,,"Fee schedule rate ($27,868.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4935.62,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4838.84,19587.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27804.00,,"Fee schedule rate ($27,804). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23340.86,,,,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
Laps Myomectomy Exc 1-4 Myomas 250 Gm/<,CASE-58545,APC,58545,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12065.11,,"Fee schedule rate ($12,065.11). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],57857.48,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,55900.95,225294.39,Inpatient DRG
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17445.45,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,17103.38,50750.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciotomy Foot&/Toe|LEFT SIDE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12093.45,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12093.45,40067.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6210.62,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6088.84,18067.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13322.85,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5970.00,38757.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],25210.33,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10632.00,103714.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],30083.00,,"Case rate ($28,650.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,201.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.27. The transfer capital threshold is the transfer adjustment factor * $2,030.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",30083.03,30083.03,30083.03,1 through 10,other,28696.16,118364.04,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14193.90,,"Fee schedule rate ($14,193.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],32675.12,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",31786.31,31786.31,32675.13,1 through 10,other,31570.16,98176.71,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6146.79,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,17370.86,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12133.76,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11895.84,35298.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6972.00,,"Per diem ($6,972). If length of stay < 3.6, first 1 days paid at a per diem of $13,944 instead. Capped at $25,099.93.",,,,0,other,6972.00,26280.60,Estimated amount calculated based on 3 day length of stay.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
HC Insert Ivc Filter,CASE-37191,APC,37191,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17995.51,18256.31,OPPS APC
Osteot W/WO Lngth Shrt/Corrj 1st Metar|RIGHT SIDE,CASE-28306,APC,28306,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4867.35,,"Case rate ($4,867.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.12. The transfer capital threshold is the transfer adjustment factor * $352.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4867.35,14442.92,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5602.41,,"Case rate ($5,335.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,549.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.10. The transfer capital threshold is the transfer adjustment factor * $378.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5344.14,15857.69,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14167.44,,,,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8422.25,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6495.00,23801.30,Inpatient DRG
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE|SEPARATE STRUCTURE,CASE-27339,APC,27339,CPT,0360,RC,,,LT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],60160.46,,,,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5826.65,,"Case rate ($5,549.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,050.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.42. The transfer capital threshold is the transfer adjustment factor * $402.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5549.19,16729.39,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11885.52,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11652.47,41507.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4342.44,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4257.29,12632.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9758.87,,"Case rate ($9,294.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,601.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,069.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,829.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,635.54. The transfer operating threshold is the transfer adjustment factor * $8,601.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.62. The transfer capital threshold is the transfer adjustment factor * $658.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,33447.35,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15136.05,,"Case rate ($14,415.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,192.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,021.52. The transfer capital threshold is the transfer adjustment factor * $1,021.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14438.27,55762.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9638.22,,"Case rate ($9,312.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,604.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,072.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,638.62. The transfer operating threshold is the transfer adjustment factor * $8,604.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.67. The transfer capital threshold is the transfer adjustment factor * $673.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9312.29,27632.41,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5949.17,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5091.00,22010.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, GREAT TOE",CASE-28270,APC,28270,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7650.64,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7500.63,22256.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],62273.77,,,,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|LEFT SIDE,CASE-24073,APC,24073,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3899.35,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3843.64,3899.35,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,APC,44970,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],32019.51,,"Fee schedule rate ($32,019.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],47283.61,,"Case rate ($47,283.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,591.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,420.62. The transfer capital threshold is the transfer adjustment factor * $3,420.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,47283.61,169615.07,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cath Urethral Simple,CASE-51702,APC,51702,CPT,0761,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],46.63,,"APC Price ($44.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,44.41,46.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE|PO,CASE-25608,APC,25608,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12882.53,,,,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],59141.25,,"Fee schedule rate ($59,141.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
Ostectomy Complete 5th Metatarsal Head|RIGHT SIDE|PO,CASE-28113,APC,28113,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,APC,20526,CPT,0510,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15891.15,,,,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9299.56,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6972.00,26280.60,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],30150.40,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,30150.40,89465.42,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6972.00,,"Per diem ($6,972). If length of stay < 3.6, first 1 days paid at a per diem of $13,944 instead. Capped at $25,099.93.",,,,0,other,6972.00,26280.60,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12395.17,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12395.17,42174.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5951.82,,"Case rate ($5,668.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,581.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.07. The transfer capital threshold is the transfer adjustment factor * $410.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5668.40,16903.82,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16536.43,,"Fee schedule rate ($16,536.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1567.69,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1493.03,1567.69,OPPS APC
Carpectomy All Bones Proximal Row|LEFT SIDE|PO,CASE-25215,APC,25215,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,APC,43274,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21313.02,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20895.12,99969.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11186.60,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,10808.31,46938.11,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],39831.40,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,39831.40,138208.82,Inpatient DRG
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6621.30,,"Fee schedule rate ($6,621.30). Adds an outlier to normal pricing equal to the per diem rate ($4,143.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5520.00,,"Per diem ($5,520). If length of stay < 3.5, first 1 days paid at a per diem of $11,040 instead. Capped at $19,319.20.",,,,0,other,5520.00,26638.96,Estimated amount calculated based on 3 day length of stay.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5766.55,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5766.55,17111.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],32296.30,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9161.42,,"Case rate ($8,981.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,671.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $657.72. The transfer capital threshold is the transfer adjustment factor * $657.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8981.78,27528.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12319.74,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11903.13,48838.99,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16783.62,,"Case rate ($15,984.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,303.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.71. The transfer capital threshold is the transfer adjustment factor * $1,132.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16009.89,58554.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15373.24,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14641.18,43444.85,Inpatient DRG
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, SECOND DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],87972.15,,"Fee schedule rate ($87,972.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4464.17,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4464.17,13577.72,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22168.26,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21112.63,62647.63,Inpatient DRG
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33692.09,,"Fee schedule rate ($33,692.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33771.02,,"Fee schedule rate ($33,771.02). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE|PO,CASE-29806,APC,29806,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|PO,CASE-64483,APC,64483,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8422.25,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6495.00,23801.30,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18770.78,,"Fee schedule rate ($18,770.78). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE|PO,CASE-25607,APC,25607,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5639.27,,"Case rate ($5,370.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,551.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.59. The transfer capital threshold is the transfer adjustment factor * $380.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5379.29,15961.98,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|LEFT SIDE|PO,CASE-24341,APC,24341,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6235.92,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.97,17858.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],67331.56,,"Fee schedule rate ($67,331.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE,CASE-27695,APC,27695,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Trurl Rescj Residual/Regrowth Obstr Prstate Tiss,CASE-52630,APC,52630,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7807.09,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7543.08,29489.40,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|RIGHT SIDE|SEPARATE STRUCTURE,CASE-52332,APC,52332,CPT,0360,RC,,,RT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19262.83,,"Fee schedule rate ($19,262.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11698.23,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11698.23,34712.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
HC Pbb Carpal Tunnel Inj Pmc|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-20526,APC,20526,CPT,0510,RC,,,LT|PO|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC 3rd Order Sel Abd/Lower Ext|BILATERAL PROCEDURE,CASE-36247,APC,36247,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
HC Intrvasc US Noncoronary Addl,CASE-37253,APC,37253,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],565.88,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29058.99,,,,,,0,other,9793.06,29058.99,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39897.21,,"Fee schedule rate ($39,897.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt,CASE-25020,APC,25020,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6696.63,,"Case rate ($6,377.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,623.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.95. The transfer capital threshold is the transfer adjustment factor * $451.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6387.91,18954.85,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6748.64,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6748.64,20025.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, SECOND DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],35530.95,,"Fee schedule rate ($35,530.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11690.93,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11810.12,11810.12,72274.41,1 through 10,other,11690.93,56733.59,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($60,119.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12335.32,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12093.45,40067.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11710.82,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11710.82,34749.58,Inpatient DRG
HC 3rd Order Sel Abd/Lower Ext|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36247,APC,36247,CPT,0361,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4470.15,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4257.29,12632.63,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,11652.47,41507.02,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],92493.51,,"Fee schedule rate ($92,493.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.8), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Pyeloscopy Rescj Pelvic Tumor|LEFT SIDE,CASE-52355,APC,52355,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],67008.32,,"Fee schedule rate ($67,008.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8915.90,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5094.80,15365.01,All Other Inpatient
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8167.40,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7891.21,23415.63,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],71140.65,,"Fee schedule rate ($71,140.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18381.22,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",18381.23,18381.23,18381.23,1 through 10,other,18381.22,58579.45,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],23904.30,,"Case rate ($22,766). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,068.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,536.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,784.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $21,152.71. The transfer operating threshold is the transfer adjustment factor * $21,068.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,613.28. The transfer capital threshold is the transfer adjustment factor * $1,613.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22802.30,82749.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21805.52,,"Fee schedule rate ($21,805.52). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5428.23,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5169.74,15340.19,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30658.90,,"Fee schedule rate ($30,658.90). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],66380.55,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27691,APC,27691,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE|PO,CASE-64405,APC,64405,CPT,0450,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
HC Wound Vac <=50 Sq Cm Dme,CASE-97605,APC,97605,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14043.03,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14043.03,54637.47,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|RIGHT SIDE|PO,CASE-27405,APC,27405,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13780.46,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9763.00,48626.00,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11885.52,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11652.47,41507.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],89469.71,,"Fee schedule rate ($89,469.71). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.5), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5196.70,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5094.80,15365.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10432.42,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9935.64,29482.05,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
Arthro/shoul surg; w/spacer|PO,CASE-C9781,APC,C9781,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Brow Ptosis|BILATERAL PROCEDURE|PO,CASE-67900,APC,67900,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2367.72,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2254.97,2367.72,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8853.24,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8431.66,25019.31,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",41079.96,41079.96,41079.96,1 through 10,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],53076.74,,,,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],624.73,,"APC Price ($594.98). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,594.98,624.73,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE|SEPARATE STRUCTURE,CASE-27339,APC,27339,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7097.74,,"Case rate ($6,759.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,650.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.02. The transfer capital threshold is the transfer adjustment factor * $479.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",7041.86,7041.86,7041.86,1 through 10,other,6770.53,20090.22,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, SECOND DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5003.96,,"Case rate ($5,003.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.00. The transfer capital threshold is the transfer adjustment factor * $362.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5003.96,21742.11,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],90287.21,,"Fee schedule rate ($90,287.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20.9), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],40046.00,,"Fee schedule rate ($40,046.00). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Pyeloplasty,CASE-50544,APC,50544,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
Tendon Sheath Incision|PO,CASE-26055,APC,26055,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],62273.77,,,,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,APC,13160,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Parathyroid Autotransplantation Add-On,CASE-60512,APC,60512,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO|SEPARATE STRUCTURE,CASE-62323,APC,62323,CPT,0360,RC,,,PO|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45390,APC,45390,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula|RIGHT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Sigmoidoscopy Flx Placement of Endoscopic Stent,CASE-45347,APC,45347,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6045.95,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5758.05,6045.95,OPPS APC
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,APC,54405,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],20640.96,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,19658.06,20640.96,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],24009.84,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10632.00,103714.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],31011.11,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,30403.05,90685.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12512.21,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11916.39,58492.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22370.39,,"Fee schedule rate ($22,370.39). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
Repair Secondary Disrupted Ligament Ankle Coltrl|LEFT SIDE,CASE-27698,APC,27698,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13572.90,,"Case rate ($7,755.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,166.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,634.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,194.85. The transfer operating threshold is the transfer adjustment factor * $7,166.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.08. The transfer capital threshold is the transfer adjustment factor * $561.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7755.94,35520.39,All Other Inpatient
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7056.33,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7056.33,28335.74,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],31219.40,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,30163.67,89504.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5683.66,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5683.66,16865.16,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",22768.46,22768.46,22768.46,1 through 10,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|PO,CASE-26080,APC,26080,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs,CASE-25116,APC,25116,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10474.43,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5985.39,17760.46,All Other Inpatient
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],69251.23,,,,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],25148.37,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23950.83,74869.17,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],26951.04,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25667.66,86123.60,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Proctopexy Prolapse,CASE-45400,APC,45400,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26300.80,,"Fee schedule rate ($26,300.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6953.00,,"Per diem ($6,953). If length of stay < 4.5, first 1 days paid at a per diem of $13,906 instead. Capped at $31,286.59.",,,,0,other,6953.00,35389.05,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6848.95,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5683.00,19635.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15407.35,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14673.67,43541.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14673.67,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14673.67,43541.27,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],35148.55,,"Fee schedule rate ($35,148.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],37665.71,,,,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],66951.94,,"Fee schedule rate ($66,951.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7863.12,,"Case rate ($7,488.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7500.63,22256.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7952.22,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7952.22,25854.47,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],61129.87,,"Fee schedule rate ($61,129.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surgical Jejunostomy,CASE-44186,APC,44186,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29775.24,,,,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],3871.34,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3209.85,10940.41,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31617.34,,"Fee schedule rate ($31,617.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11156.45,42003.98,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20373.57,,,,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1772.59,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1680.98,1680.98,1680.98,1 through 10,other,1688.18,1772.59,OPPS APC
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,MODERATE",770,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5396.17,,"Case rate ($5,396.17). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5396.17,5665.98,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
Plmt Interstitial Dev Radiat Tx Prostate 1/Mult,CASE-55876,APC,55876,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1312.80,,"APC Price ($1,312.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1312.80,1378.44,OPPS APC
Dilat Rct Strix Spx Under Anes Oth/Thn Local,CASE-45910,APC,45910,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,APC,38510,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3843.64,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4470.15,,"Case rate ($4,257.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,933.62, add-ons for qualifying new technology services are included. If operating cost exceeds $39,401.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,479.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,949.29. The transfer operating threshold is the transfer adjustment factor * $3,933.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.98. The transfer capital threshold is the transfer adjustment factor * $307.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4257.29,12632.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10348.07,,"Case rate ($10,145.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,373.89, add-ons for qualifying new technology services are included. If operating cost exceeds $44,841.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,905.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,411.25. The transfer operating threshold is the transfer adjustment factor * $9,373.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.93. The transfer capital threshold is the transfer adjustment factor * $733.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,30103.84,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvic/Le 1st Ord|LEFT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MAJOR",561,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2613.40,,"Case rate for a one day stay ($2,488.95). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2488.95,2613.40,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13200.39,,"Case rate ($7,543.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,969.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,437.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,716.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,997.39. The transfer operating threshold is the transfer adjustment factor * $6,969.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.68. The transfer capital threshold is the transfer adjustment factor * $545.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7543.08,29489.40,All Other Inpatient
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],39831.40,,"Case rate ($39,831.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $36,803.21, add-ons for qualifying new technology services are included. If operating cost exceeds $72,271.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,052.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,949.89. The transfer operating threshold is the transfer adjustment factor * $36,803.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,881.50. The transfer capital threshold is the transfer adjustment factor * $2,881.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,39831.40,138208.82,Inpatient DRG
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,APC,45385,CPT,0360,RC,,,PT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],79366.60,,"Fee schedule rate ($79,366.60). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, SECOND DIGIT|SEPARATE STRUCTURE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T6|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Removal FB Skin|PO,CASE-10120,APC,10120,CPT,0450,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],404.84,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,385.57,404.84,OPPS APC
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7551.60,,"Fee schedule rate ($7,551.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32645.32,,"Fee schedule rate ($32,645.32). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11519.18,34180.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO,CASE-27691,APC,27691,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE,CASE-29806,APC,29806,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16943.57,,"Fee schedule rate ($16,943.57). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE|PO,CASE-64490,APC,64490,CPT,0361,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],134001.61,,"Fee schedule rate ($134,001.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17803.98,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10173.70,41194.64,All Other Inpatient
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT|PO",CASE-28820,APC,28820,CPT,0360,RC,,,T1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO|SEPARATE STRUCTURE",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Aid Tibial Fracture Proximal Unicondylar|RIGHT SIDE,CASE-29855,APC,29855,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB EXCEPT TOES,MODERATE",305,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],20098.18,,"Case rate ($20,098.18). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,20098.18,21103.09,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11600.75,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11600.75,34422.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11670.40,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7000.00,32980.62,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16269.19,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,15950.19,63458.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],3679.57,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3607.42,11497.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14478.52,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13789.07,57367.22,Inpatient DRG
"HIV WITH MAJOR HIV RELATED CONDITION,MAJOR",892,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2134.93,,"Case rate for a one day stay ($2,134.93). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2134.93,2241.68,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
Injection Intralesional Up to & Includ 7 Lesions,CASE-11900,APC,11900,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5544.51,,"Case rate ($5,280.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,879.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,346.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,553.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,898.48. The transfer operating threshold is the transfer adjustment factor * $4,879.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $382.00. The transfer capital threshold is the transfer adjustment factor * $382.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5280.49,17810.78,Inpatient DRG
Repair Dislocating Peroneal Tendon W/Fib Osteot|LEFT SIDE,CASE-27676,APC,27676,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6146.79,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,17370.86,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],66275.39,,"Fee schedule rate ($66,275.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14233.80,,"Fee schedule rate ($14,233.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],36738.00,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,34988.57,110685.97,Inpatient DRG
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7178.36,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6382.95,21300.35,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],115171.02,,"Fee schedule rate ($115,171.02). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],61868.44,,"Fee schedule rate ($61,868.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Synovectomy Tendon Sheath Foot Extensor|RIGHT SIDE|PO,CASE-28088,APC,28088,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DIABETES,MAJOR",420,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13059.61,,"Case rate ($12,437.72). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12437.72,13059.61,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FOURTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
Excision Local Lesion Epididymis|RIGHT SIDE,CASE-54830,APC,54830,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
"HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,EXTREME",890,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],41422.86,,"Case rate ($39,450.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,39450.34,41422.86,There are no additional notes associated with this service or procedure.
Arthrt Elbow Capsular Excision Capsular Rls Spx,CASE-24006,APC,24006,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",166,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],67027.11,,"Case rate ($63,835.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,63835.34,67027.11,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS AND MISCELLANEOUS DIAGNOSES,MODERATE",143,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2371.19,,"Case rate for a one day stay ($2,371.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2371.19,2489.75,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,48444.74,Estimated amount calculated based on 11 day length of stay.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",42303.14,42303.14,42303.14,1 through 10,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Lateral Release,CASE-29873,APC,29873,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26978.66,,"Fee schedule rate ($26,978.66). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12223.35,,,,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26280.60,,,,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14375.32,,"Case rate ($13,889.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,833.27, add-ons for qualifying new technology services are included. If operating cost exceeds $48,301.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,884.42. The transfer operating threshold is the transfer adjustment factor * $12,833.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.78. The transfer capital threshold is the transfer adjustment factor * $1,004.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13889.20,55846.16,Inpatient DRG
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11600.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11600.09,48814.14,Inpatient DRG
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
Cystostomy Cystotomy W/Drainage|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51040,APC,51040,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],41117.20,,"Fee schedule rate ($41,117.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|LEFT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT FOOT, GREAT TOE|PO",CASE-28297,APC,28297,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
HC Rmvl Perm Intraperitneal Cath,CASE-49422,APC,49422,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11138.80,,"Case rate ($10,608.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.75. The transfer capital threshold is the transfer adjustment factor * $751.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10625.29,39295.53,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],88862.06,,"Fee schedule rate ($88,862.06). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12160.70,,"Case rate ($11,581.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,991.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.71. The transfer capital threshold is the transfer adjustment factor * $820.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12160.71,12160.71,12160.71,1 through 10,other,11600.09,48814.14,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12171.73,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11592.12,38954.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",81026.67,81026.67,81026.67,1 through 10,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6503.29,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6503.29,19528.85,Inpatient DRG
Rpr 1st Fem Hernia Any Age Incarcerated,CASE-49553,APC,49553,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT HAND, THUMB",CASE-28750,APC,28750,CPT,0360,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12747.57,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12140.54,36024.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12804.31,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12804.31,55145.09,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7060.32,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6724.11,19952.48,Inpatient DRG
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,301.32,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5700.71,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5507.93,20510.35,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10266.34,,"Case rate ($9,777.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,864.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.87. The transfer capital threshold is the transfer adjustment factor * $692.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9793.06,29058.99,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],48779.11,,"Fee schedule rate ($48,779.11). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8322.93,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4755.96,21133.33,All Other Inpatient
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8431.66,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8431.66,25019.31,Inpatient DRG
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,APC,31652,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3659.98,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42003.98,,"Fee schedule rate ($42,003.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10997.18,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10764.70,10764.70,10764.70,1 through 10,other,10625.29,39295.53,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|RIGHT SIDE,CASE-38570,APC,38570,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],43602.60,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,43602.60,163229.10,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",492406.55,492406.55,492406.55,1 through 10,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],41837.14,,"Fee schedule rate ($41,837.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6940.00,42872.25,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,APC,52287,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE,CASE-27650,APC,27650,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE,CASE-27822,APC,27822,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC
Tenodesis Long Tendon Biceps|SEPARATE STRUCTURE,CASE-23430,APC,23430,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17212.32,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7525.28,,"Case rate ($7,166.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.87. The transfer capital threshold is the transfer adjustment factor * $507.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6382.95,21300.35,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7455.00,,"Per diem ($7,455). If length of stay < 6.8, first 1 days paid at a per diem of $14,910 instead. Capped at $50,692.24.",,,,0,other,7455.00,53076.74,Estimated amount calculated based on 3 day length of stay.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE|PO,CASE-29898,APC,29898,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|PO,CASE-64636,APC,64636,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
HC Lyr Clos Nk Hnd Ft <2.6cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-12041,APC,12041,CPT,0450,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31007.02,,,,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],8167.93,,"Fee schedule rate ($8,167.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24757.83,,"Fee schedule rate ($24,757.83). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5131.79,,"Case rate ($4,887.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.34. The transfer capital threshold is the transfer adjustment factor * $346.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4895.21,14525.56,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5938.30,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5938.30,5938.30,5938.30,1 through 10,other,5938.30,18621.89,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvic/Le 1st Ord|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,APC,36245,CPT,0361,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8.88,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
"PEPTIC ULCER AND GASTRITIS,MAJOR",241,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],16561.31,,"Case rate ($15,772.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15772.68,16561.31,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6454.78,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6328.22,27416.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Ankle W/Implant|RIGHT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26636.50,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,APC,52300,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12465.12,,"Case rate ($11,871.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,001.85, add-ons for qualifying new technology services are included. If operating cost exceeds $51,547.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,512.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,007.29. The transfer operating threshold is the transfer adjustment factor * $11,001.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.25. The transfer capital threshold is the transfer adjustment factor * $864.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11871.54,35778.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T8|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1188.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16705.77,,,,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,Zero final payments for the item or service in the 15 months prior to posting the file.
Tnot Elbow Lateral/Medial Debride Open|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-24358,APC,24358,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10249.98,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9761.89,37873.87,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT HAND, FIFTH DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Claviculectomy Partial|LEFT SIDE|PO,CASE-23120,APC,23120,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>|LEFT SIDE,CASE-23073,APC,23073,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17836.44,,"Fee schedule rate ($17,836.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10608.50,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,30861.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE|PO,CASE-29888,APC,29888,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],30290.89,,"Fee schedule rate ($30,290.89). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11194.16,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10716.73,10716.73,10716.73,1 through 10,other,9888.00,40658.63,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5611.35,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5344.14,15857.69,Inpatient DRG
Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT SIDE|PO,CASE-26111,APC,26111,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7525.28,,"Case rate ($7,166.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.87. The transfer capital threshold is the transfer adjustment factor * $507.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6382.95,21300.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21300.35,,,,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22488.22,,"Case rate ($21,417.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,688.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,517.71. The transfer capital threshold is the transfer adjustment factor * $1,517.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",474245.00,474245.00,474245.00,1 through 10,other,8940.00,63653.13,Inpatient DRG
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],31897.92,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,18227.38,54086.17,All Other Inpatient
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15914.26,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15156.44,52672.70,Inpatient DRG
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Capsulectomy/Capsulotomy Mtcarphlngl Joint Each|LEFT SIDE|PO,CASE-26520,APC,26520,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9733.35,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9269.86,37852.57,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31350.48,,"Fee schedule rate ($31,350.48). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10888.24,32825.17,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],23833.38,,"Case rate ($22,698.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,779.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,608.49. The transfer capital threshold is the transfer adjustment factor * $1,608.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",23833.39,23833.39,23833.39,1 through 10,other,22734.65,70806.50,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],24413.25,,,,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10249.47,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15326.20,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15326.20,52511.19,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],44973.75,,,,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7574.18,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17043.85,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9739.34,40204.26,All Other Inpatient
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,APC,46200,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21732.40,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20697.52,87921.54,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,41333.08,Estimated amount calculated based on 10 day length of stay.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
Syndactylization Toes|RIGHT SIDE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE,CASE-15823,APC,15823,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3514.75,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30534.77,,,,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12747.57,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12140.54,36024.65,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Rhinp Prim Complete Xtrnl Parts|PO,CASE-30410,APC,30410,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11434.95,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11434.95,119072.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12029.98,,"Case rate ($11,623.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,490.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.89. The transfer capital threshold is the transfer adjustment factor * $842.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,35040.80,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PEPTIC ULCER AND GASTRITIS,MODERATE",241,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],3154.71,,"Case rate for a one day stay ($3,154.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3154.71,3312.45,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10638.72,,"Fee schedule rate ($10,638.72). Adds an outlier to normal pricing equal to the per diem rate ($26,031.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,3753.97,11139.15,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23895.30,,"Fee schedule rate ($23,895.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5013.25,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4774.52,14406.59,Inpatient DRG
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5520.00,,"Per diem ($5,520). If length of stay < 3.5, first 1 days paid at a per diem of $11,040 instead. Capped at $19,319.20.",,,,0,other,5520.00,26638.96,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit,CASE-36901,APC,36901,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1545.29,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1492.63,1492.63,1492.63,1 through 10,other,1493.03,1567.69,OPPS APC
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11297.91,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10759.91,46061.32,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6274.65,,"Case rate ($5,975.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.47. The transfer capital threshold is the transfer adjustment factor * $423.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6274.65,6274.65,6274.65,1 through 10,other,5985.39,17760.46,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],30958.47,,"Fee schedule rate ($30,958.47). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Recrt Inguinal Hernia Any Age Reducible|LEFT SIDE,CASE-49520,APC,49520,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3514.75,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tiss Upper Arm/Elbw Subfasc 5cm/>|RIGHT SIDE,CASE-24073,APC,24073,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",2789.86,2789.86,2789.86,1 through 10,other,2755.03,2892.78,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6308.11,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",6308.11,6308.11,6308.11,1 through 10,other,6094.79,22352.66,Inpatient DRG
"HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,EXTREME",890,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],41422.86,,"Case rate ($39,450.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,39450.34,41422.86,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],115037.59,,"Fee schedule rate ($115,037.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21.9), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],119293.78,,,,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21688.24,,"Case rate ($20,954.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,361.73, add-ons for qualifying new technology services are included. If operating cost exceeds $54,829.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,687.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,438.89. The transfer operating threshold is the transfer adjustment factor * $19,361.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.92. The transfer capital threshold is the transfer adjustment factor * $1,515.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20954.82,62179.32,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|PO,CASE-29806,APC,29806,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8915.73,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8915.73,26455.73,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9527.16,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",140416.30,140416.30,140416.30,1 through 10,other,9527.16,28269.95,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct|SEPARATE STRUCTURE,CASE-43275,APC,43275,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6045.95,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],65078.97,,of the excess amount.,,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
Fth/Gft Fr W/Dir Clsr S/a/L Ea Addl 20 Cm/<,CASE-15221,APC,15221,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7544.23,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7184.98,21320.03,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8192.28,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8192.28,24308.97,Inpatient DRG
HC Rmvl Perm Intraperitneal Cath,CASE-49422,APC,49422,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",2922.01,2922.01,2922.01,1 through 10,other,2994.77,3144.51,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8408.84,,"Case rate ($8,008.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.50. The transfer capital threshold is the transfer adjustment factor * $567.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6495.00,23801.30,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],187121.90,,"Fee schedule rate ($187,121.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19847.56,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18902.44,56089.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21112.63,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21112.63,62647.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11166.74,,"Fee schedule rate ($11,166.74). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18400.38,,"APC Price ($18,400.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18400.38,19320.40,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15540.89,,,,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22091.17,,"Fee schedule rate ($22,091.17). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,16849.39,49997.29,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13140.92,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12883.25,44763.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43277,APC,43277,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3784.78,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5434.18,,"Case rate ($5,175.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,537.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $366.75. The transfer capital threshold is the transfer adjustment factor * $366.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5183.66,15743.06,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9255.92,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,27465.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7035.25,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6700.24,30254.37,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6440.28,,"Case rate ($6,440.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,950.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,418.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,637.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,974.38. The transfer operating threshold is the transfer adjustment factor * $5,950.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $465.91. The transfer capital threshold is the transfer adjustment factor * $465.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6440.29,6434.46,6441.20,1 through 10,other,6440.28,19110.30,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9574.89,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9574.89,28411.62,Inpatient DRG
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19879.67,,,,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],83871.28,,"Fee schedule rate ($83,871.28). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],82423.02,,,,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|LEFT SIDE|PO,CASE-29884,APC,29884,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5245.79,,"Case rate ($4,995.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,623.53, add-ons for qualifying new technology services are included. If operating cost exceeds $40,091.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,641.96. The transfer operating threshold is the transfer adjustment factor * $4,623.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.03. The transfer capital threshold is the transfer adjustment factor * $354.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5003.96,21742.11,Inpatient DRG
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3070.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
"OTHER GASTROENTERITIS NAUSEA AND VOMITING,MODERATE",249,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2660.96,,"Case rate for a one day stay ($2,534.25). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2534.25,2660.96,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Lateral Retinacular Release Open,CASE-27425,APC,27425,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Sigmoidoscopy Flx Placement of Endoscopic Stent,CASE-45347,APC,45347,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],31698.46,,"Case rate ($30,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,386.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,215.60. The transfer capital threshold is the transfer adjustment factor * $2,215.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,30626.53,106200.88,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
"HC Bx,Vulva/Perineum,Addl Lesion",CASE-56606,APC,56606,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],917.27,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,873.59,917.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteoplasty Radius/Ulna Shortening|RIGHT SIDE|PO,CASE-25390,APC,25390,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5158.50,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",2740.47,2740.47,2740.47,1 through 10,other,4984.06,19757.81,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14167.44,,,,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17103.38,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17103.38,50750.92,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],72742.07,,"Fee schedule rate ($72,742.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],36370.09,,"Fee schedule rate ($36,370.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
Tenolysis Flexor Tendon Palm/Finger Each Tendon,CASE-26440,APC,26440,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Recrt Inguinal Hernia Any Age Reducible|LEFT SIDE,CASE-49520,APC,49520,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3514.75,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7120.66,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,20179.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Bx Anorectal Wall Anal Approach,CASE-45100,APC,45100,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8231.45,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7551.60,23262.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11690.93,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11690.93,56733.59,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12141.86,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12141.86,36028.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4180.34,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4180.34,14351.57,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6025.78,,"Case rate ($5,738.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,577.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $406.67. The transfer capital threshold is the transfer adjustment factor * $406.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5091.00,22010.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Fem Pop Territory Plasty|RIGHT SIDE,CASE-37224,APC,37224,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],421.27,,,,,,0,other,401.21,421.27,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6146.14,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5938.30,18621.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,APC,45381,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],55272.09,,"Fee schedule rate ($55,272.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Musc/Fasc,Ea Add 20sqcm|SEPARATE STRUCTURE",CASE-11046,APC,11046,CPT,0361,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],725.52,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,700.99,725.52,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation,CASE-28615,APC,28615,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26465.57,,,,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
"CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,EXTREME",165,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],106775.99,,"Case rate ($101,691.42). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $55,584, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,101691.42,106775.99,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl|RIGHT SIDE,CASE-37225,APC,37225,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],557.79,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13527.41,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12883.25,44763.90,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,CASE-55866,APC,55866,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14678.68,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7308.00,42083.20,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20391.82,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11652.47,41507.02,All Other Inpatient
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13467.29,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7231.00,38610.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7113.73,,"Case rate ($6,774.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,651.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.10. The transfer capital threshold is the transfer adjustment factor * $480.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",7113.73,4819.20,36557.54,1 through 10,other,6785.78,20135.47,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5122.57,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4878.64,14476.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Iphal Jt W/WO Int Fixj Ea Iphal Jt,CASE-26861,APC,26861,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Partical Excision Bone Phalanx Toe|SEPARATE STRUCTURE|RIGHT FOOT, GREAT TOE|PO",CASE-28124,APC,28124,CPT,0360,RC,,,XS|T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],661.36,,"APC Price ($661.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,661.36,694.43,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay.
Cysto/Pyeloscopy Rescj Pelvic Tumor,CASE-52355,APC,52355,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],57102.65,,,,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4251.09,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4167.74,12366.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT HAND, THUMB",CASE-28750,APC,28750,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6724.11,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6724.11,19952.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10665.38,,"Case rate ($10,157.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.80. The transfer capital threshold is the transfer adjustment factor * $719.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10173.70,41194.64,Inpatient DRG
Lig&Div Long Saph Vein Saphfem Junct/Interrupj|LEFT SIDE,CASE-37700,APC,37700,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6346.81,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-36901,APC,36901,CPT,0361,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1493.03,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5985.39,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5985.39,17760.46,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
HC Thromb Mech Vein,CASE-37187,APC,37187,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10224.92,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9738.02,28895.67,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],90878.22,,,,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6328.98,,"Case rate ($6,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,620.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.88. The transfer capital threshold is the transfer adjustment factor * $448.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6204.88,19589.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10806.32,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10291.73,34803.35,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, SECOND DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7694.27,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7638.48,7638.48,7638.48,1 through 10,other,7694.27,22831.22,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
Chemodenervation Internal Anal Sphincter,CASE-46505,APC,46505,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Medium WO US|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-20605,APC,20605,CPT,0510,RC,,,XS|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5807.67,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5807.67,5807.67,5807.67,1 through 10,other,5807.67,17233.12,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9919.70,,"Case rate ($5,668.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,581.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.07. The transfer capital threshold is the transfer adjustment factor * $410.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5668.40,16903.82,All Other Inpatient
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19450.67,,"Fee schedule rate ($19,450.67). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31329.81,,"Fee schedule rate ($31,329.81). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,21715.49,Estimated amount calculated based on 9 day length of stay.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19155.70,,"Fee schedule rate ($19,155.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6654.93,20056.77,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],78047.33,,"Fee schedule rate ($78,047.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6189.75,,"Fee schedule rate ($6,189.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4774.52,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4774.52,14406.59,Inpatient DRG
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|RIGHT SIDE,CASE-37765,APC,37765,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],129256.37,,"Fee schedule rate ($129,256.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4870.01,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4774.52,14406.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],187121.90,,"Fee schedule rate ($187,121.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE,CASE-27619,APC,27619,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,APC,29828,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3753.29,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",2458.05,2458.05,2458.05,1 through 10,other,3753.29,11765.59,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23754.07,,,,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],46482.88,,"Case rate ($44,269.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,308.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,137.08. The transfer capital threshold is the transfer adjustment factor * $3,137.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",49630.73,42323.63,84647.26,1 through 10,other,44339.99,131570.26,Inpatient DRG
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7136.91,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6797.06,20168.93,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8285.77,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7891.21,23415.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],61348.24,,"Fee schedule rate ($61,348.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14641.18,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14641.18,43444.85,Inpatient DRG
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE,CASE-29891,APC,29891,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|LEFT HAND, FOURTH DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intrvasc US Noncoronary 1st,CASE-37252,APC,37252,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],538.93,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
HC Debride Subq First 20 Sq Cm,CASE-11042,APC,11042,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Litholapaxy Smpl/Sm <2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52317,APC,52317,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
Parathyroid Autotransplantation Add-On,CASE-60512,APC,60512,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC App Skin Sub T/a/L Tot <100 1st 25|PBB CHARGE,CASE-15271,APC,15271,CPT,0361,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],736.04,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,700.99,736.04,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],57311.08,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,32749.19,97176.83,All Other Inpatient
HC N Block Inj Intercost Sng|RIGHT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,10625.29,39295.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthro/shoul surg; w/spacer,CASE-C9781,APC,C9781,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO|UNUSUAL NON-OVERLAPPING SERVICE,CASE-14040,APC,14040,CPT,0360,RC,,,PO|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20041.03,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,19363.31,79918.67,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12536.42,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,12536.42,46998.45,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28195.14,,"Fee schedule rate ($28,195.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23895.30,,"Fee schedule rate ($23,895.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT SIDE|PO,CASE-26160,APC,26160,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE,CASE-27654,APC,27654,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",91.36,91.36,91.36,1 through 10,other,6882.29,7226.40,OPPS APC
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16916.32,,,,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18381.22,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18381.22,58579.45,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14118.96,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12440.40,41073.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],54072.40,,,,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16342.97,,"Fee schedule rate ($16,342.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5669.00,18994.21,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4679.91,,"Case rate ($4,457.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,486.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $315.84. The transfer capital threshold is the transfer adjustment factor * $315.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4464.17,13577.72,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9279.13,,"Case rate ($9,279.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,573.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,041.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,607.86. The transfer operating threshold is the transfer adjustment factor * $8,573.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.28. The transfer capital threshold is the transfer adjustment factor * $671.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9279.13,27534.03,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15271.20,,"Fee schedule rate ($15,271.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
Biopsy Vaginal Mucosa Simple,CASE-57100,APC,57100,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE|PO,CASE-64405,APC,64405,CPT,0450,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5912.00,,"Per diem ($5,912). If length of stay < 2.4, first 1 days paid at a per diem of $11,824 instead. Capped at $14,188.72.",,,,0,other,5006.61,14856.14,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Lympho for Sentinal Node|LEFT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5344.14,,"Case rate ($5,344.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,937.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,405.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,957.53. The transfer operating threshold is the transfer adjustment factor * $4,937.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.61. The transfer capital threshold is the transfer adjustment factor * $386.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5352.80,3823.51,5352.80,1 through 10,other,5344.14,15857.69,Inpatient DRG
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|LEFT SIDE|PO,CASE-27675,APC,27675,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30658.90,,"Fee schedule rate ($30,658.90). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5797.33,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5683.66,16865.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Nerve Repair W/Conduit Each Nerve|LEFT SIDE|PO,CASE-64910,APC,64910,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8739.79,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8323.61,8739.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],64621.61,,"Fee schedule rate ($64,621.61). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,22802.30,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr,CASE-28238,APC,28238,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE,CASE-29876,APC,29876,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34934.31,,"Fee schedule rate ($34,934.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv,CASE-64418,APC,64418,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17835.23,,,,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],46556.99,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,44339.99,131570.26,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35969.56,,,,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23125.89,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23125.89,68621.57,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],183848.16,,"Fee schedule rate ($183,848.16). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],85483.72,,"Fee schedule rate ($85,483.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Pyeloplasty|RIGHT SIDE,CASE-50544,APC,50544,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB|PO",CASE-26540,APC,26540,CPT,0360,RC,,,F5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],75039.30,,"Fee schedule rate ($75,039.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
HC Add 2nd/3rd Order Abd/Le|RIGHT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],540.74,,"APC Price ($514.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,514.99,540.74,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34934.31,,"Fee schedule rate ($34,934.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7602.55,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6308.00,21796.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16039.01,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3295.00,53945.28,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33656.04,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,19232.02,68941.12,All Other Inpatient
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5348.00,,"Per diem ($5,348). If length of stay < 2.7, first 1 days paid at a per diem of $10,696 instead. Capped at $14,438.66.",,,,0,other,5094.80,15365.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],97176.83,,,,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
Lig&Div Long Saph Vein Saphfem Junct/Interrupj|LEFT SIDE,CASE-37700,APC,37700,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HIV WITH MAJOR HIV RELATED CONDITION,MAJOR",892,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2134.93,,"Case rate for a one day stay ($2,134.93). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2134.93,2241.68,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|PO,CASE-11422,APC,11422,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10538.94,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10037.09,36934.96,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],36549.07,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,20885.18,80720.91,All Other Inpatient
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,27370.21,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7397.36,,"Case rate ($7,045.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,670.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.24. The transfer capital threshold is the transfer adjustment factor * $499.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7056.33,28335.74,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10236.03,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10236.03,30589.82,Inpatient DRG
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE,CASE-28200,APC,28200,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",3028.30,3028.30,3028.30,1 through 10,other,3103.39,3258.56,OPPS APC
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],42212.88,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40202.74,148703.60,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18944.48,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18042.36,82749.58,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6068.82,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5779.83,17150.47,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7178.36,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6382.95,21300.35,Inpatient DRG
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],890.35,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,860.25,903.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32874.59,,"Fee schedule rate ($32,874.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29433.60,,"Fee schedule rate ($29,433.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5541.48,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5354.09,15887.21,Inpatient DRG
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
"OPEN EXTRACRANIAL VASCULAR PROCEDURES,MODERATE",024,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7367.46,,"Case rate for a one day stay ($7,367.46). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,7367.46,7735.83,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE|PO,CASE-29823,APC,29823,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4598.45,,"Case rate ($4,442.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.41. The transfer capital threshold is the transfer adjustment factor * $321.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4442.95,13183.59,Inpatient DRG
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,There are no additional notes associated with this service or procedure.
Transection/Avulsion Oth Spinal Nrv Xdrl|PO,CASE-64772,APC,64772,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx|RIGHT SIDE|PO,CASE-29884,APC,29884,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3732.70,3732.70,3732.70,1 through 10,other,6297.98,6612.88,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],39672.94,,"Case rate ($37,783.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,848.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,677.49. The transfer capital threshold is the transfer adjustment factor * $2,677.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,37843.99,139522.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22555.75,,,,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26483.27,,,,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15326.20,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15326.20,52511.19,Inpatient DRG
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10696.56,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",8360.22,8360.22,8360.22,1 through 10,other,10334.84,30666.60,Inpatient DRG
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],112882.03,,"Fee schedule rate ($112,882.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Application Uniplane External Fixation System|PO,CASE-20690,APC,20690,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6381.43,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6077.55,18033.97,Inpatient DRG
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13681.67,,"Fee schedule rate ($13,681.67). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
Arthrodesis Great Toe Interphalangeal Joint,CASE-28755,APC,28755,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18944.48,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18042.36,82749.58,Inpatient DRG
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12093.45,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12093.45,40067.60,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23703.48,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23703.48,110204.98,Inpatient DRG
Synovectomy Tendon Sheath Foot Extensor|RIGHT SIDE|PO,CASE-28088,APC,28088,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9430.32,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,45869.64,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
Injection Intralesional Up to & Includ 7 Lesions,CASE-11900,APC,11900,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6914.85,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6681.01,19824.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8349.83,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7952.22,25854.47,Inpatient DRG
Laps Bi Tot Pel Lmphadec & Pri-Aortic Lymph Bx 1,CASE-38572,APC,38572,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],54542.68,,,,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24204.34,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",23138.52,23138.52,23138.52,1 through 10,other,23385.84,71764.93,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21939.88,,"Case rate ($20,895.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.61. The transfer capital threshold is the transfer adjustment factor * $1,511.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20895.12,99969.33,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",10711.20,10711.20,10711.20,1 through 10,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7744.00,,"Case rate ($7,744). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,731.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $560.22. The transfer capital threshold is the transfer adjustment factor * $560.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7744.01,7744.01,7744.01,1 through 10,other,7744.00,24853.45,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15686.92,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15156.44,52672.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11444.12,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10899.16,39746.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10362.69,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10362.69,29367.82,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,66445.54,Estimated amount calculated based on 11 day length of stay.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,21229.52,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23545.50,,,,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20283.05,,,,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|LEFT SIDE|PO,CASE-25290,APC,25290,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5066.54,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4895.21,14525.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13882.95,,"Fee schedule rate ($13,882.95). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21991.57,,"Fee schedule rate ($21,991.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],59216.74,,"Fee schedule rate ($59,216.74). Adds an outlier to normal pricing equal to the per diem rate ($89,749.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11524.34,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11298.37,44627.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],115037.59,,"Fee schedule rate ($115,037.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21.9), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7866.01,25247.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,APC,28270,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17212.14,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17212.14,64440.06,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Bi Tot Pel Lmphadec & Pri-Aortic Lymph Bx 1,CASE-38572,APC,38572,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12196.66,,"Fee schedule rate ($12,196.66). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21111.47,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20697.52,87921.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Medium WO US|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-20605,APC,20605,CPT,0510,RC,,,XU|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, THIRD DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,T7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC N Block Inj Suprascapular Nerv|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6472.13,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6472.13,19204.75,Inpatient DRG
Lengthening Tendon Extensor Hand/Finger Each,CASE-26476,APC,26476,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16456.83,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16456.83,55350.97,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23679.61,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23679.61,84629.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8231.45,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7551.60,23262.15,Inpatient DRG
Debridement Bone Each Additional 20 Sq Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-11047,APC,11047,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11341.31,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6480.75,29542.64,All Other Inpatient
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9125.56,,"Case rate ($8,691.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.88. The transfer capital threshold is the transfer adjustment factor * $615.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8704.87,25830.00,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13163.24,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12536.42,46998.45,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24946.45,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23758.52,103116.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT SIDE|PO,CASE-28160,APC,28160,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Supracervical Hysterectomy >250,CASE-58543,APC,58543,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22919.57,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21828.16,93157.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|LEFT HAND, FIFTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31617.34,,"Fee schedule rate ($31,617.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11156.45,42003.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4639.91,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4639.91,13771.19,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20283.05,,,,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5355.42,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5355.42,17067.11,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30846.83,,"Fee schedule rate ($30,846.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],36600.94,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,18559.00,141041.50,Inpatient DRG
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4442.95,,"Case rate ($4,442.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.41. The transfer capital threshold is the transfer adjustment factor * $321.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4442.95,13183.59,Inpatient DRG
"OTHER GASTROENTERITIS NAUSEA AND VOMITING,MAJOR",249,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2400.16,,"Case rate for a one day stay ($2,285.87). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2285.87,2400.16,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15940.24,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9108.71,27028.33,All Other Inpatient
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],85483.72,,"Fee schedule rate ($85,483.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7102.10,21074.07,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],22593.41,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22593.41,90908.64,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],43602.60,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,43602.60,163229.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12521.78,,"Fee schedule rate ($12,521.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4867.35,,"Case rate ($4,867.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,497.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,965.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,523.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,515.24. The transfer operating threshold is the transfer adjustment factor * $4,497.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.12. The transfer capital threshold is the transfer adjustment factor * $352.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4867.35,14442.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17144.86,,"Fee schedule rate ($17,144.86). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19503.23,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19503.23,57872.02,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],45484.41,,"Fee schedule rate ($45,484.41). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5689.78,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5578.22,18148.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12051.24,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11814.94,44591.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|SEPARATE STRUCTURE|PO,CASE-62323,APC,62323,CPT,0360,RC,,,XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Ganglion Wrist Dorsal/Volar Recurrent|LEFT SIDE|PO,CASE-25112,APC,25112,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1525.13,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14764.12,,"Fee schedule rate ($14,764.12). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13305.64,39481.90,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4797.39,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4568.94,13557.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4867.98,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4772.53,14161.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE,CASE-54840,APC,54840,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2052.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16009.89,,"Case rate ($16,009.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,792.73, add-ons for qualifying new technology services are included. If operating cost exceeds $50,260.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,329.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,851.68. The transfer operating threshold is the transfer adjustment factor * $14,792.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.20. The transfer capital threshold is the transfer adjustment factor * $1,158.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16009.89,58554.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5751.18,,"Case rate ($5,477.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,559.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $388.14. The transfer capital threshold is the transfer adjustment factor * $388.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5486.04,17919.05,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Ather|LEFT SIDE,CASE-37229,APC,37229,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],626.55,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10290.40,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10290.40,42115.80,Inpatient DRG
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,APC,52351,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],37051.58,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,12500.00,83592.64,All Other Inpatient
Trluml Balo Angiop Ctr Dialysis Seg W/Img S&I,CASE-36907,APC,36907,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5398.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9137.38,,"Case rate ($8,702.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $616.67. The transfer capital threshold is the transfer adjustment factor * $616.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",9014.91,5602.41,37414.71,1 through 10,other,8716.15,25863.45,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12141.86,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12141.86,36028.59,Inpatient DRG
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn|PO,CASE-62321,APC,62321,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7584.84,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,33946.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7984.05,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7984.05,23691.11,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],62031.01,,"Fee schedule rate ($62,031.01). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4955.35,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4787.78,20006.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],30480.63,,"Case rate ($30,480.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,163.35, add-ons for qualifying new technology services are included. If operating cost exceeds $63,631.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,376.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,275.59. The transfer operating threshold is the transfer adjustment factor * $28,163.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,205.05. The transfer capital threshold is the transfer adjustment factor * $2,205.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,30480.63,86382.02,Inpatient DRG
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvc/Le Init 2nd|LEFT SIDE,CASE-36246,APC,36246,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],31570.16,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",31570.17,31570.17,31570.17,1 through 10,other,31570.16,98176.71,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27943.31,,"Fee schedule rate ($27,943.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7553.93,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7405.81,33747.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",6963.55,6963.55,6963.55,1 through 10,other,6882.29,7226.40,OPPS APC
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1149.34,1149.34,1149.34,1 through 10,other,1134.98,1191.72,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27537.96,,,,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22922.34,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21830.80,85124.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14536.80,,"Case rate ($13,844.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,812.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,280.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,152.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,863.50. The transfer operating threshold is the transfer adjustment factor * $12,812.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $981.07. The transfer capital threshold is the transfer adjustment factor * $981.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13866.64,41146.57,Inpatient DRG
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6133.05,,"Fee schedule rate ($6,133.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|LEFT SIDE|SEPARATE STRUCTURE,CASE-27405,APC,27405,CPT,0360,RC,,,LT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],35461.65,,"Fee schedule rate ($35,461.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39967.07,,"Fee schedule rate ($39,967.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15236.84,,"Case rate ($14,511.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,199.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,028.32. The transfer capital threshold is the transfer adjustment factor * $1,028.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14534.42,59012.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21570.21,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,21570.21,72041.81,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26300.80,,"Fee schedule rate ($26,300.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15023.80,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15023.80,48104.19,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8811.18,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",8811.18,2401.82,8815.60,19,other,8513.22,25261.33,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],53462.72,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,50916.88,170142.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis 20 Cm/<|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97597,APC,97597,CPT,0761,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34934.31,,"Fee schedule rate ($34,934.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24054.45,,"Case rate ($23,582.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,789.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,257.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,877.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,876.75. The transfer operating threshold is the transfer adjustment factor * $21,789.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,706.04. The transfer capital threshold is the transfer adjustment factor * $1,706.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,23582.79,75543.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17574.20,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16737.33,72192.67,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10614.84,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10109.37,38416.97,Inpatient DRG
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|BILATERAL PROCEDURE,CASE-37722,APC,37722,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15312.64,,,,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11595.64,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6350.00,33244.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],14651.02,,"Fee schedule rate ($14,651.02). Adds an outlier to normal pricing equal to the per diem rate ($61,007.55) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",29805.69,29805.69,50054.69,1 through 10,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4418.42,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4418.42,13110.79,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5169.74,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5169.74,15340.19,Inpatient DRG
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64448,APC,64448,CPT,0360,RC,,,XU|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],61129.87,,"Fee schedule rate ($61,129.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12364.41,,"Case rate ($12,121.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,200.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,668.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,048.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,245.03. The transfer operating threshold is the transfer adjustment factor * $11,200.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $876.93. The transfer capital threshold is the transfer adjustment factor * $876.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",12366.15,12366.15,12366.15,1 through 10,other,12121.97,35969.56,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],20405.32,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20005.22,74991.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],31467.16,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,30403.05,90685.00,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],71069.39,,,,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6685.72,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,18893.86,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],50950.20,,"Fee schedule rate ($50,950.20). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28157.55,,"Fee schedule rate ($28,157.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",10255.93,10255.93,10255.93,1 through 10,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20227.96,,,,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39187.16,,"Fee schedule rate ($39,187.16). Adds an outlier to normal pricing equal to the per diem rate ($47,534.60) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, THIRD DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
"PULMONARY EMBOLISM,MODERATE",134,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3005.30,,"Case rate for a one day stay ($3,005.30). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3005.30,3155.57,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],29066.85,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14351.97,,"Case rate ($13,866.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,812.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,280.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,174.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,863.50. The transfer operating threshold is the transfer adjustment factor * $12,812.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,003.15. The transfer capital threshold is the transfer adjustment factor * $1,003.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",14329.42,14329.42,14329.42,1 through 10,other,13866.64,41146.57,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10290.40,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10290.40,42115.80,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21796.21,,,,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13305.64,,"Case rate ($13,305.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,294.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,761.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,133.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,343.08. The transfer operating threshold is the transfer adjustment factor * $12,294.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.56. The transfer capital threshold is the transfer adjustment factor * $962.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13305.64,39481.90,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20179.92,,"Fee schedule rate ($20,179.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,1188.00,20179.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15618.96,,"Case rate ($15,090.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,943.51, add-ons for qualifying new technology services are included. If operating cost exceeds $49,411.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,262.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,999.08. The transfer operating threshold is the transfer adjustment factor * $13,943.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.71. The transfer capital threshold is the transfer adjustment factor * $1,091.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15090.78,44778.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14697.90,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7453.00,42138.30,Inpatient DRG
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE|POLICY CRITERIA APPLIED,CASE-27570,APC,27570,CPT,0360,RC,,,RT|CG,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
"CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",165,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],74970.29,,"Case rate ($74,970.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,945, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,74970.29,78718.80,There are no additional notes associated with this service or procedure.
"Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn|RIGHT HAND, THIRD DIGIT|PO",CASE-26145,APC,26145,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,APC,57520,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Ather|LEFT SIDE,CASE-37229,APC,37229,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],626.55,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
"NEPHRITIS AND NEPHROSIS,MAJOR",462,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],17202.54,,"Case rate ($17,202.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,17202.54,18062.67,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24977.98,,,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10888.24,,"Case rate ($10,888.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,437.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10888.24,32825.17,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15065.57,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15065.57,53815.71,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17274.00,,"Per diem ($17,274). If length of stay < 3.3, first 1 days paid at a per diem of $34,548 instead. Capped at $57,002.93.",,,,0,other,17274.00,73717.28,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39187.16,,"Fee schedule rate ($39,187.16). Adds an outlier to normal pricing equal to the per diem rate ($47,534.60) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13525.32,,"Case rate ($12,881.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,901.95, add-ons for qualifying new technology services are included. If operating cost exceeds $47,369.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,949.38. The transfer operating threshold is the transfer adjustment factor * $11,901.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.86. The transfer capital threshold is the transfer adjustment factor * $931.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12881.26,38222.57,Inpatient DRG
"INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,MODERATE",817,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7421.46,,"Case rate ($7,421.46). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7421.46,7792.53,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
HC Tib per Territory Ather|RIGHT SIDE,CASE-37229,APC,37229,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],657.88,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6387.91,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6387.91,18954.85,Inpatient DRG
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE,CASE-27680,APC,27680,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23187.40,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13249.94,40085.35,All Other Inpatient
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,EXTREME",721,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],30791.05,,"Case rate ($30,791.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,30791.05,32330.60,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6617.34,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5683.00,19635.68,Inpatient DRG
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO,CASE-27654,APC,27654,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm|PO,CASE-11422,APC,11422,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4742.02,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4742.02,14071.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Fasciotomy Foot&/Toe|LEFT SIDE,CASE-28008,APC,28008,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],31019.76,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31019.76,124854.72,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,Zero final payments for the item or service in the 15 months prior to posting the file.
Patellectomy/Hemipatellectomy,CASE-27350,APC,27350,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],55394.25,,"Fee schedule rate ($55,394.25). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35778.69,,,,,,0,other,11871.54,35778.69,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15181.29,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8675.02,25741.45,All Other Inpatient
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],31302.57,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7455.00,53076.74,All Other Inpatient
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10237.83,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10037.09,36934.96,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15233.99,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14508.56,59513.03,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Vasc Embolize Occlude Artery,CASE-37242,APC,37242,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MODERATE",282,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9580.76,,"Case rate ($9,580.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9580.76,10059.80,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13051.67,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12788.63,12788.63,12788.63,1 through 10,other,13051.67,38728.27,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XS|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35506.19,,"Fee schedule rate ($35,506.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12536.42,37199.37,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14499.98,,"Case rate ($13,809.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,149.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $978.59. The transfer capital threshold is the transfer adjustment factor * $978.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13831.52,59770.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41213.48,,,,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],64005.35,,,,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11854.46,,"Fee schedule rate ($11,854.46). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12235.09,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11652.47,41507.02,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6074.24,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6028.94,6028.94,6028.94,1 through 10,other,6074.24,18024.13,Inpatient DRG
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,APC,60220,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],43128.06,,"Fee schedule rate ($43,128.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,APC,43274,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,APC,43239,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17461.77,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13983.36,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7770.00,50313.90,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],14651.02,,"Fee schedule rate ($14,651.02). Adds an outlier to normal pricing equal to the per diem rate ($61,007.55) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],46638.59,,"Fee schedule rate ($46,638.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7826.00,,"Per diem ($7,826). If length of stay < 7.6, first 1 days paid at a per diem of $15,652 instead. Capped at $59,476.09.",,,,0,other,7826.00,90280.33,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13446.23,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13446.23,39899.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Suture Quadriceps/Hamstring Rupture Primary|RIGHT SIDE|PO,CASE-27385,APC,27385,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS OF UPPER RESPIRATORY TRACT,MAJOR",113,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2290.15,,"Case rate for a one day stay ($2,290.15). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2290.15,2404.66,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4871.91,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4639.91,13771.19,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
Trurl Dstrj Prstate Tiss Rf Thermoth,CASE-53852,APC,53852,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Conv Prev Hip Tot Hip Arthrp W/WO Agrft/Algrft|RIGHT SIDE,CASE-27132,APC,27132,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12603.27,12785.93,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5807.67,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5807.67,17233.12,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9703.25,,"Case rate ($9,241.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.86. The transfer capital threshold is the transfer adjustment factor * $654.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,27465.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Osteoplasty Radius/Ulna Shortening|LEFT SIDE|PO,CASE-25390,APC,25390,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7654.23,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7289.74,21630.93,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",26814.24,26814.24,26814.24,1 through 10,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],46556.99,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,44339.99,131570.26,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21056.36,,,,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FIFTH DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15950.19,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,15950.19,63458.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],66951.94,,"Fee schedule rate ($66,951.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13335.48,,"Case rate ($13,335.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,321.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,789.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,135.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,370.76. The transfer operating threshold is the transfer adjustment factor * $12,321.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.72. The transfer capital threshold is the transfer adjustment factor * $964.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13335.48,39570.45,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12803.03,,"Case rate ($12,193.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,284.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,752.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,035.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,329.31. The transfer operating threshold is the transfer adjustment factor * $11,284.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.06. The transfer capital threshold is the transfer adjustment factor * $864.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12212.80,39290.21,Inpatient DRG
HC Fem Pop Terr Plasty and Stent|LEFT SIDE,CASE-37226,APC,37226,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],491.83,,,,,,0,other,468.41,491.83,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6472.13,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6476.25,6476.25,6476.25,1 through 10,other,6472.13,19204.75,Inpatient DRG
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],96445.01,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10249.47,96445.01,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7642.05,,"Case rate ($7,278.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.75. The transfer capital threshold is the transfer adjustment factor * $515.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7289.74,21630.93,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8228.75,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8228.75,24417.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE,CASE-15823,APC,15823,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2333.89,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Rt Bronch Dx Clear Airway,CASE-31645,APC,31645,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3713.03,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3536.22,3713.03,OPPS APC
Cysto W/Removal of Tumors Small,CASE-52234,APC,52234,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],57102.65,,,,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
HC Debrid Wound Tis 20 Cm/<|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97597,APC,97597,CPT,0761,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",193.69,193.69,193.69,1 through 10,other,190.30,199.81,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5760.34,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5486.04,17919.05,Inpatient DRG
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE|PO,CASE-64484,APC,64484,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15284.82,,"Case rate ($14,556.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,202.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,031.56. The transfer capital threshold is the transfer adjustment factor * $1,031.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",15284.82,15284.82,15284.82,1 through 10,other,14580.18,57079.69,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24177.55,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23703.48,110204.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt,CASE-25020,APC,25020,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,APC,38510,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, SECOND DIGIT",CASE-28234,APC,28234,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1578.51,OPPS APC
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18579.92,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, SECOND DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20110.39,,"Fee schedule rate ($20,110.39). Adds an outlier to normal pricing equal to the per diem rate ($69,590.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7096.13,25801.23,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30630.71,,"Fee schedule rate ($30,630.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,10625.29,39295.53,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7455.00,,"Per diem ($7,455). If length of stay < 6.8, first 1 days paid at a per diem of $14,910 instead. Capped at $50,692.24.",,,,0,other,7455.00,53076.74,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30846.83,,"Fee schedule rate ($30,846.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6094.79,,"Case rate ($6,094.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,612.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.91. The transfer capital threshold is the transfer adjustment factor * $440.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6094.79,6094.79,6094.79,1 through 10,other,6094.79,22352.66,Inpatient DRG
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34422.94,,,,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13983.36,,"Case rate ($13,983.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,182.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.59. The transfer capital threshold is the transfer adjustment factor * $1,011.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7770.00,50313.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],36276.38,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36276.38,121107.98,Inpatient DRG
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41042.29,,,,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
Litholapaxy Smpl/Sm <2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52317,APC,52317,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25493.52,,,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7405.81,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7405.81,33747.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],45202.80,,"Fee schedule rate ($45,202.80). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],32637.12,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,32637.12,96844.29,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],32296.30,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5549.19,16729.39,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
HC Intro Cath Dialysis Circuit W Pta,CASE-36902,APC,36902,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5587.20,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5478.32,5478.32,5478.88,1 through 10,other,5398.26,5668.18,OPPS APC
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5348.92,,"Case rate ($5,244.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,859.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,405.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,029.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,862.27. The transfer operating threshold is the transfer adjustment factor * $4,859.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $381.77. The transfer capital threshold is the transfer adjustment factor * $381.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5244.04,15804.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34611.07,,"Fee schedule rate ($34,611.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4370.58,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,21715.49,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT HAND, FOURTH DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],25564.74,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10455.00,90889.11,Inpatient DRG
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,APC,43236,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,T6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],28005.17,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,28005.17,115392.91,Inpatient DRG
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],40202.74,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,40202.74,148703.60,Inpatient DRG
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT HAND, THUMB",CASE-28750,APC,28750,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
"MIGRAINE AND OTHER HEADACHES,MINOR",054,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7878.74,,"Case rate ($7,878.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7878.74,8272.68,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14446.45,,"Case rate ($13,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,146.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.98. The transfer capital threshold is the transfer adjustment factor * $974.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9763.00,48626.00,Inpatient DRG
HC 3rd Order Sel Abd/Lower Ext|RIGHT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],917.27,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,873.59,917.27,OPPS APC
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Pelvis/Hip Joint,CASE-27299,APC,27299,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],233.96,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,233.96,245.65,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10905.18,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10385.89,32176.55,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],34447.94,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32807.56,111191.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14967.14,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14673.67,43541.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],196.96,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6866.02,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6866.02,27153.67,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
Rhytidectomy Neck W/Platysmal Tightening,CASE-15825,APC,15825,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2367.72,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HYPERTENSION,MAJOR",199,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2600.28,,"Case rate for a one day stay ($2,600.28). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2600.28,2730.29,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Pyeloplasty|RIGHT SIDE,CASE-50544,APC,50544,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14390.10,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13704.86,49911.01,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10556.32,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10556.32,32082.48,Inpatient DRG
Partial Excision Bone Metacarpal,CASE-26230,APC,26230,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, THIRD DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,T2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31329.81,,"Fee schedule rate ($31,329.81). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11055.00,49295.13,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FOURTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],85446.13,,"Fee schedule rate ($85,446.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19668.75,,"Fee schedule rate ($19,668.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],46638.59,,"Fee schedule rate ($46,638.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvic/Le 1st Ord|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36245,APC,36245,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13.28,,,,,,0,other,13.28,13.94,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11591.72,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6953.00,35389.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5486.04,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5486.04,17919.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",25770.89,25770.89,25770.89,1 through 10,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|PO,CASE-64636,APC,64636,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19699.24,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,8990.00,80069.53,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,APC,44970,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],3787.79,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3607.42,11497.58,Inpatient DRG
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE,CASE-15823,APC,15823,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2367.72,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7074.75,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6835.51,20283.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],86162.15,,"Fee schedule rate ($86,162.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.6), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, THIRD DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],31019.76,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31019.76,124854.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf,CASE-36825,APC,36825,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27868.14,,"Fee schedule rate ($27,868.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Torn Ligm&/Capsule Knee Collateral|RIGHT SIDE|PO,CASE-27405,APC,27405,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27465.16,,,,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24130.87,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,13789.07,57367.22,All Other Inpatient
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MAJOR",344,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],17550.68,,"Case rate ($17,550.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,17550.68,18428.21,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28157.55,,"Fee schedule rate ($28,157.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Great Toe Interphalangeal Joint,CASE-28755,APC,28755,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5131.79,,"Case rate ($4,887.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.34. The transfer capital threshold is the transfer adjustment factor * $346.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",5131.79,5131.79,5131.79,1 through 10,other,4895.21,14525.56,Inpatient DRG
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7178.36,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6382.95,21300.35,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11612.27,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11384.58,33781.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|RIGHT SIDE|PO,CASE-23430,APC,23430,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CELLULITIS AND OTHER SKIN INFECTIONS,MINOR",383,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5980.55,,"Case rate ($5,980.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5980.55,6279.58,There are no additional notes associated with this service or procedure.
Dilation Esophagus Guide Wire,CASE-43453,APC,43453,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16402.05,,"Fee schedule rate ($16,402.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",32588.40,32588.40,32588.40,1 through 10,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21542.42,,"Fee schedule rate ($21,542.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, FIFTH DIGIT|PO",CASE-28124,APC,28124,CPT,0360,RC,,,T4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19952.92,,"Case rate ($19,002.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,517.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,346.60. The transfer capital threshold is the transfer adjustment factor * $1,346.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,8990.00,80069.53,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6146.83,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5938.97,17858.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12829.00,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12395.17,42174.37,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple,CASE-43239,APC,43239,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],890.35,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",900.85,900.85,900.85,1 through 10,other,860.25,903.26,OPPS APC
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8675.02,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8675.02,25741.45,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30538.70,,,,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Aid Tibial Fracture Proximal Unicondylar,CASE-29855,APC,29855,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15658.71,,"Fee schedule rate ($15,658.71). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE,CASE-27650,APC,27650,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3753.97,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3753.97,11139.15,Inpatient DRG
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11297.91,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10759.91,46061.32,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7132.50,,"Case rate ($6,792.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,652.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.36. The transfer capital threshold is the transfer adjustment factor * $481.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5843.00,27370.21,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5561.91,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5297.06,19049.64,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],40639.08,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",39106.84,30707.28,40639.10,1 through 10,other,40639.08,120588.53,Inpatient DRG
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-24341,APC,24341,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],29594.69,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,29594.69,124146.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15309.19,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14580.18,57079.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9112.97,,"Case rate ($8,679.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,019.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,487.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,799.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,051.15. The transfer operating threshold is the transfer adjustment factor * $8,019.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.86. The transfer capital threshold is the transfer adjustment factor * $627.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8679.02,29908.27,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT SIDE,CASE-28292,APC,28292,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5520.00,,"Per diem ($5,520). If length of stay < 3.5, first 1 days paid at a per diem of $11,040 instead. Capped at $19,319.20.",,,,0,other,5520.00,26638.96,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
"INTESTINAL OBSTRUCTION,MAJOR",247,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12454.29,,"Case rate ($12,454.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12454.29,13077.00,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7041.91,,"Case rate ($7,041.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,158.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.67. The transfer capital threshold is the transfer adjustment factor * $510.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,21229.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
Dilat Rct Strix Spx Under Anes Oth/Thn Local,CASE-45910,APC,45910,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11591.72,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6953.00,35389.05,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],57067.24,,,,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12803.67,,"Fee schedule rate ($12,803.67). Adds an outlier to normal pricing equal to the per diem rate ($91,038.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10455.00,,"Per diem ($10,455). If length of stay < 6.6, first 1 days paid at a per diem of $20,910 instead. Capped at $69,000.38.",,,,0,other,10455.00,90889.11,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],92976.49,,"Fee schedule rate ($92,976.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.5), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Shoulder Foreign Body Deep Subfascial/Im,CASE-23333,APC,23333,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2851.46,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],61287.95,,,,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12536.79,,"Case rate ($11,939.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,049.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,517.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,093.70. The transfer operating threshold is the transfer adjustment factor * $11,049.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.10. The transfer capital threshold is the transfer adjustment factor * $846.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11958.84,40774.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23545.50,,,,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13475.16,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12833.49,58980.57,Inpatient DRG
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],38164.42,,"Case rate ($36,347.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,746.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,575.68. The transfer capital threshold is the transfer adjustment factor * $2,575.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36405.02,110499.61,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5857.13,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5578.22,18148.00,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|RIGHT SIDE,CASE-27130,APC,27130,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20135.47,,,,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
Sgmdsc Flx Dired Sbmcsl Njx Any Sbst,CASE-45335,APC,45335,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,912.91,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Thromb Mech 1st Vssl,CASE-37184,APC,37184,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],9763.00,,"Per diem ($9,763). If length of stay < 4, first 1 days paid at a per diem of $19,526 instead. Capped at $39,053.73.",,,,0,other,9763.00,48626.00,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6531.00,,"Per diem ($6,531). If length of stay < 4.1, first 1 days paid at a per diem of $13,062 instead. Capped at $26,776.27.",,,,0,other,6531.00,35832.77,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12384.70,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12141.86,36028.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10235.12,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10034.43,29775.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula|RIGHT SIDE|PO,CASE-27641,APC,27641,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7776.10,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7405.81,33747.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|LEFT SIDE,CASE-37765,APC,37765,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arven Anast Opn Upr Arm Basilic Vein Trpos|RIGHT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33163.37,,"Fee schedule rate ($33,163.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10382.57,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10178.99,36468.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8130.77,,"Case rate ($7,743.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,166.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,634.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,194.85. The transfer operating threshold is the transfer adjustment factor * $7,166.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.74. The transfer capital threshold is the transfer adjustment factor * $548.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",36435.14,36435.14,36435.14,1 through 10,other,7755.94,35520.39,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18675.44,,,,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],38035.88,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36224.65,128473.68,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10888.24,,"Case rate ($10,888.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,437.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10888.24,32825.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct|SEPARATE STRUCTURE,CASE-43275,APC,43275,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC
HC N Block Inj Intercost Sng|RIGHT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11829.30,,"Fee schedule rate ($11,829.30). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",32482.07,32482.07,32482.07,1 through 10,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],11137.18,,,,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15896.49,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15896.49,51306.05,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],70101.28,,,,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64448,APC,64448,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE|PO,CASE-23700,APC,23700,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1578.51,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8030.94,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7648.51,27371.98,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8811.32,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8442.00,28788.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21555.86,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",19377.02,19377.02,19377.02,1 through 10,other,21133.20,88801.87,Inpatient DRG
Tenodesis Long Tendon Biceps|SEPARATE STRUCTURE,CASE-23430,APC,23430,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17461.77,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],68332.92,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|PO,CASE-64454,APC,64454,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14577.15,,"Fee schedule rate ($14,577.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"INFLAMMATORY BOWEL DISEASE,MODERATE",245,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10393.43,,"Case rate ($9,898.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9898.50,10393.43,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22648.72,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,21570.21,72041.81,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23954.78,,,,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Non-Biodegradable Drug Delivery Implant,CASE-11982,APC,11982,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,5934.68,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrt Elbow Capsular Excision Capsular Rls Spx,CASE-24006,APC,24006,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10032.07,,"Case rate ($9,554.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,848.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.05. The transfer capital threshold is the transfer adjustment factor * $677.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9569.58,41116.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12384.70,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12141.86,36028.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16208.15,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16208.15,58123.31,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1576.45,669.80,6963.55,11,other,6882.29,7226.40,OPPS APC
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16817.56,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",16817.57,16817.57,16817.57,1 through 10,other,16817.56,58510.23,Inpatient DRG
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|PO|SEPARATE STRUCTURE,CASE-62323,APC,62323,CPT,0360,RC,,,PO|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],115171.02,,"Fee schedule rate ($115,171.02). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5224.00,,"Per diem ($5,224). If length of stay < 2.9, first 1 days paid at a per diem of $10,448 instead. Capped at $15,149.04.",,,,0,other,5224.00,15861.63,Estimated amount calculated based on 1 day length of stay.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],45782.73,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,43602.60,153667.90,Inpatient DRG
Cysto W/Simple Removal Stone & Stent,CASE-52310,APC,52310,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
Tx Missed Abortion First Trimester Surgical,CASE-59820,APC,59820,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30658.90,,"Fee schedule rate ($30,658.90). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],53232.25,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13061.00,162464.13,Inpatient DRG
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7956.02,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7686.98,22809.58,Inpatient DRG
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE,CASE-27570,APC,27570,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9140.11,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8704.87,25830.00,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38110.41,,,,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22034.15,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,21289.03,76326.34,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],89465.42,,,,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9290.88,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9108.71,27028.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9744.48,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9280.46,39957.56,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13870.50,,"Fee schedule rate ($13,870.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26800.70,,"Fee schedule rate ($26,800.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8640.19,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8228.75,24417.19,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25680.90,,"Fee schedule rate ($25,680.90). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7584.84,,"Case rate ($7,584.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,008.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,476.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,036.14. The transfer operating threshold is the transfer adjustment factor * $7,008.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.71. The transfer capital threshold is the transfer adjustment factor * $548.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,33946.09,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17279.67,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16456.83,55350.97,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6682.71,,"Case rate ($6,364.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.01. The transfer capital threshold is the transfer adjustment factor * $451.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",857.00,857.00,6593.74,1 through 10,other,6230.00,21325.01,Inpatient DRG
Circumcision Age >28 Days,CASE-54161,APC,54161,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2081.79,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1996.84,1996.84,1996.84,1 through 10,other,1982.66,2081.79,OPPS APC
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14762.22,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14472.76,56135.46,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia Recr < 3 Cm Ncrc8/Strangulated,CASE-49614,APC,49614,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3307.01,3162.78,3307.01,1 through 10,other,3103.39,3258.56,OPPS APC
Cysto Bladder W/Ureteral Catheterization,CASE-52005,APC,52005,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17233.12,,,,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|RIGHT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9910.44,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9910.44,43344.00,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],57456.84,,,,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17161.77,,"Fee schedule rate ($17,161.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Trluml Balo Angiop 1st Vein|RIGHT SIDE,CASE-37248,APC,37248,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10173.70,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10173.70,41194.64,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,41333.08,Estimated amount calculated based on 10 day length of stay.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12140.54,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",11900.84,11900.84,11900.84,1 through 10,other,12140.54,36024.65,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16536.43,,"Fee schedule rate ($16,536.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9761.89,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9761.89,37873.87,Inpatient DRG
Laparoscopy Nephrectomy W/Partial Ureterect,CASE-50546,APC,50546,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],351.87,,"APC Price ($339.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,339.97,356.97,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,APC,43274,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,Zero final payments for the item or service in the 15 months prior to posting the file.
Proctosgmdsc Rgd Dx W/WO Collj Spec Br/Wa Spx,CASE-45300,APC,45300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6770.53,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6770.53,20090.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
"OTHER DISORDERS OF NERVOUS SYSTEM,MODERATE",058,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14428.95,,"Case rate ($13,741.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13741.86,14428.95,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy With Biopsy,CASE-52204,APC,52204,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
HC Intro Cath in Svc or Ivc|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36010,APC,36010,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|LEFT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23754.07,,,,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11135.66,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10605.39,31469.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11434.95,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11434.95,119072.21,Inpatient DRG
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],45782.73,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,43602.60,163229.10,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE|PO,CASE-28615,APC,28615,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17370.86,,,,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],31112.60,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31112.60,92731.42,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17584.61,,"Fee schedule rate ($17,584.61). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",6718.00,6718.00,6718.00,1 through 10,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12404.38,,,,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26357,APC,26357,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
"Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn|LEFT HAND, FOURTH DIGIT|PO",CASE-26145,APC,26145,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1525.13,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],47506.18,,,,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|SEPARATE PRACTITIONER,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XP,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5541.62,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5277.74,5541.62,OPPS APC
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],58696.00,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,55900.95,225294.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21830.80,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21830.80,85124.35,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10884.58,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10884.58,32297.83,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10362.69,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10362.69,29367.82,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23504.29,,"Fee schedule rate ($23,504.29). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21304.71,,"Fee schedule rate ($21,304.71). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10747.83,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10236.03,30589.82,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13467.29,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7231.00,38610.21,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],65538.71,,"Fee schedule rate ($65,538.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4517.87,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4517.87,13932.70,Inpatient DRG
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs,CASE-25116,APC,25116,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Stoma Dx Including Collj Spec Spx,CASE-44388,APC,44388,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|SEPARATE PRACTITIONER,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XP,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Implant Neurostim/Receiver,CASE-64590,APC,64590,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18400.38,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18400.38,19320.40,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],29700.53,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",28777.73,28777.73,28777.73,1 through 10,other,28696.16,118364.04,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5774.12,,"Case rate ($5,499.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.69. The transfer capital threshold is the transfer adjustment factor * $389.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5507.93,20510.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9025.92,,"Case rate ($8,596.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,942.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,410.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,974.25. The transfer operating threshold is the transfer adjustment factor * $7,942.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.86. The transfer capital threshold is the transfer adjustment factor * $621.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8596.11,25507.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21172.33,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,12500.00,83592.64,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11117.94,,"Case rate ($10,588.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.34. The transfer capital threshold is the transfer adjustment factor * $750.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",11329.36,11329.36,11329.36,1 through 10,other,10605.39,31469.43,Inpatient DRG
Tenodesis Long Tendon Biceps|LEFT SIDE|PO,CASE-23430,APC,23430,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,APC,52351,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11519.31,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10970.77,32553.63,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15944.28,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3295.00,55581.70,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33733.44,,"Fee schedule rate ($33,733.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sleep Study Unattended,CASE-95800,APC,95800,CPT,0920,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],215.04,,"APC Price ($204.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,204.80,215.04,OPPS APC
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4568.94,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4568.94,13557.45,Inpatient DRG
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11835.17,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11434.95,119072.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10205.14,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10205.15,10205.15,10205.15,1 through 10,other,9860.04,30039.61,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10614.84,,"Case rate ($10,109.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,340.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,808.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,378.03. The transfer operating threshold is the transfer adjustment factor * $9,340.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.34. The transfer capital threshold is the transfer adjustment factor * $731.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10109.37,38416.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Procedure Stomach,CASE-43659,APC,43659,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12741.99,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12135.23,49469.07,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT HAND, THUMB",CASE-28750,APC,28750,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],112294.67,,,,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5742.54,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",29481.15,29481.15,29481.15,1 through 10,other,5629.94,16705.77,Inpatient DRG
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],37843.99,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,37843.99,139522.22,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3209.85,10940.41,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],70160.31,,,,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],66027.56,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,66027.56,228732.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arteriovenous Anastomosis Open Direct,CASE-36821,APC,36821,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19952.92,,"Case rate ($19,002.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,517.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,346.60. The transfer capital threshold is the transfer adjustment factor * $1,346.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",19940.62,19940.62,19940.62,1 through 10,other,8990.00,80069.53,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12296.36,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11710.82,34749.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16268.42,,"Fee schedule rate ($16,268.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10557.96,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6033.12,17902.13,All Other Inpatient
Open Tx Tibial Fracture Proximal Unicondylar|LEFT SIDE,CASE-27535,APC,27535,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21005.20,,,,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21555.86,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,21133.20,88801.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15013.15,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14718.77,51765.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7795.07,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7795.07,34198.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13811.29,,,,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|PO,CASE-64493,APC,64493,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
"KIDNEY AND URINARY TRACT INFECTIONS,MAJOR",463,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11310.41,,"Case rate ($11,310.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11310.41,11875.93,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,1188.00,35040.80,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],69251.23,,,,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|RIGHT FOOT, GREAT TOE|PO",CASE-28297,APC,28297,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17695.16,,of the excess amount.,23795.14,8417.74,34469.89,1 through 10,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21534.51,,,,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11458.84,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11458.84,42820.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13163.24,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12536.42,46998.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Hemiphalangectomy/Interphalangeal Joint Exc Toe,CASE-28160,APC,28160,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],11139.15,,,,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4639.91,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",595.24,595.24,595.24,1 through 10,other,4639.91,13771.19,Inpatient DRG
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4370.58,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,21715.49,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31486.12,,"Fee schedule rate ($31,486.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13246.56,,,,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28195.14,,"Fee schedule rate ($28,195.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Glenohumeral Joint Total Shoulder|RIGHT SIDE,CASE-23472,APC,23472,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17212.32,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, GREAT TOE",CASE-28270,APC,28270,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11114.67,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7000.00,32980.62,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],22802.30,,"Case rate ($22,802.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,068.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,536.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,820.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $21,152.71. The transfer operating threshold is the transfer adjustment factor * $21,068.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,649.58. The transfer capital threshold is the transfer adjustment factor * $1,649.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22802.30,82749.58,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR PELVIS AND BACK,MODERATE",342,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9713.11,,"Case rate ($9,250.58). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9250.58,9713.11,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5414.50,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5308.33,19857.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7911.06,,"Case rate ($7,755.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,166.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,634.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,194.85. The transfer operating threshold is the transfer adjustment factor * $7,166.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.08. The transfer capital threshold is the transfer adjustment factor * $561.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7755.94,35520.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER CIRCULATORY SYSTEM DIAGNOSES,EXTREME",207,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],23492.54,,"Case rate ($23,492.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,23492.54,24667.17,There are no additional notes associated with this service or procedure.
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, THUMB|PO",CASE-26445,APC,26445,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34611.07,,"Fee schedule rate ($34,611.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12212.80,39290.21,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],27851.43,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],59833.15,,"Fee schedule rate ($59,833.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Simple Removal Stone & Stent,CASE-52310,APC,52310,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5379.29,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5379.29,15961.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE,CASE-27654,APC,27654,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],44973.75,,,,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12152.35,,"Case rate ($11,573.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,991.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.15. The transfer capital threshold is the transfer adjustment factor * $820.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11592.12,38954.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7197.84,,"Case rate ($6,855.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,656.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $485.78. The transfer capital threshold is the transfer adjustment factor * $485.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",7197.84,7197.84,9199.47,1 through 10,other,6866.02,27153.67,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2285.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6972.00,,"Per diem ($6,972). If length of stay < 3.6, first 1 days paid at a per diem of $13,944 instead. Capped at $25,099.93.",,,,0,other,6972.00,26280.60,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13704.86,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13704.86,49911.01,Inpatient DRG
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12218.30,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11978.73,60588.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12559.96,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12135.23,49469.07,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
Ligation/Biopsy Temporal Artery|RIGHT SIDE,CASE-37609,APC,37609,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11688.60,,"Fee schedule rate ($11,688.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32878.30,,,,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19491.06,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18562.91,73513.17,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7476.69,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,20179.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9025.92,,"Case rate ($8,596.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,942.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,410.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,974.25. The transfer operating threshold is the transfer adjustment factor * $7,942.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.86. The transfer capital threshold is the transfer adjustment factor * $621.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8596.11,25507.30,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],50235.38,,,,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11652.47,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11652.47,41507.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Musc/Fasc,Ea Add 20sqcm|SEPARATE STRUCTURE",CASE-11046,APC,11046,CPT,0361,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],700.99,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,700.99,725.52,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6130.79,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6010.58,17835.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12500.00,,"Per diem ($12,500). If length of stay < 4.8, first 1 days paid at a per diem of $25,000 instead. Capped at $60,002.29.",,,,0,other,12500.00,83592.64,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34759.42,,,,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],27022.53,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],74574.31,,"Fee schedule rate ($74,574.31). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],67976.16,,,,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],115037.59,,"Fee schedule rate ($115,037.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21.9), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39792.30,,"Fee schedule rate ($39,792.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],31923.20,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",32079.71,32079.71,32079.71,1 through 10,other,30403.05,90685.00,Inpatient DRG
Repair Non/Malunion Humerus W/O Graft|RIGHT SIDE,CASE-24430,APC,24430,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38976.20,,,,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15759.45,,"Fee schedule rate ($15,759.45). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14448.22,,"Case rate ($14,448.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,349.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,817.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,216.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,402.99. The transfer operating threshold is the transfer adjustment factor * $13,349.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,045.22. The transfer capital threshold is the transfer adjustment factor * $1,045.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6940.00,42872.25,Inpatient DRG
"DIABETES,EXTREME",420,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],22880.54,,"Case rate ($22,880.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22880.54,24024.57,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10837.80,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10625.29,39295.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO,CASE-27691,APC,27691,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6804.79,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6480.75,29542.64,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18579.92,,of the excess amount. Final payment is multiplied by 105%.,15495.15,15495.15,15495.15,1 through 10,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|RIGHT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11621.00,,"Per diem ($11,621). If length of stay < 22.4, first 1 days paid at a per diem of $23,242 instead. Capped at $260,309.36.",,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,CASE-21552,APC,21552,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, FIFTH DIGIT|PO",CASE-28308,APC,28308,CPT,0360,RC,,,T4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,MAJOR",201,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],12647.64,,"Case rate ($12,045.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12045.37,12647.64,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],68824.32,,"Fee schedule rate ($68,824.32). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv,CASE-64418,APC,64418,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17461.77,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16630.26,17461.77,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9820.91,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9802.80,4009.08,19133.45,18,other,9820.91,29141.64,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],53462.72,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,50916.88,170142.20,Inpatient DRG
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7464.79,,"Case rate ($7,109.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,674.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $503.79. The transfer capital threshold is the transfer adjustment factor * $503.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,20179.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,APC,52332,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5549.19,,"Case rate ($5,549.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,050.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.42. The transfer capital threshold is the transfer adjustment factor * $402.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5549.19,16729.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|RIGHT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE|PO,CASE-29823,APC,29823,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5158.50,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4984.06,19757.81,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11043.42,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10826.88,32126.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],25667.66,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,25667.66,86123.60,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,868.26,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization,CASE-52005,APC,52005,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|RIGHT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7593.97,,"Fee schedule rate ($7,593.97). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dil Bladder General Anesth,CASE-52260,APC,52260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4787.78,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4787.78,20006.29,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],27055.67,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,46419.05,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14798.73,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14508.56,59513.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|LEFT SIDE,CASE-37722,APC,37722,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,2994.77,OPPS APC
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10759.91,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10759.91,46061.32,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],46638.59,,"Fee schedule rate ($46,638.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5882.59,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5683.66,16865.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,MINOR",951,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3995.45,,"Case rate for a one day stay ($3,805.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3805.19,3995.45,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6209.31,,"Case rate ($5,913.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,590.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $419.06. The transfer capital threshold is the transfer adjustment factor * $419.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5923.06,17575.50,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5233.26,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4984.06,19757.81,Inpatient DRG
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE|PO,CASE-27792,APC,27792,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64448,APC,64448,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11159.78,,"Case rate ($11,159.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.33. The transfer capital threshold is the transfer adjustment factor * $807.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11159.78,39897.21,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11147.93,,"Fee schedule rate ($11,147.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4119.35,12223.35,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],22593.41,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22593.41,90908.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12180.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11600.09,48814.14,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",43833.42,43833.42,43833.42,1 through 10,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
HC Fem Pop Terr Plasty and Stent,CASE-37226,APC,37226,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15774.99,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15023.80,48104.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9886.08,,"Case rate ($9,415.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,838.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $667.20. The transfer capital threshold is the transfer adjustment factor * $667.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,45869.64,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
Cysto/Pyeloscopy Rescj Pelvic Tumor|LEFT SIDE,CASE-52355,APC,52355,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],33451.55,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31858.62,94534.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18637.71,,"Fee schedule rate ($18,637.71). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],64624.35,,"Fee schedule rate ($64,624.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,MINOR",201,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3003.80,,"Case rate for a one day stay ($2,860.76). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2860.76,3003.80,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],30085.25,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,17191.57,51012.62,All Other Inpatient
Open Treatment Fracture Distal Tibia Only|RIGHT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
Repair Non/Malunion Humerus W/Iliac/Oth Agrft,CASE-24435,APC,24435,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12785.93,12785.93,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10749.40,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10385.89,32176.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28335.74,,"Fee schedule rate ($28,335.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
"Inject Nerv Blck,Paravert Sympath|RIGHT SIDE",CASE-64520,APC,64520,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10392.03,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5938.30,18621.89,All Other Inpatient
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],103171.69,,"Fee schedule rate ($103,171.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],50785.35,,"Fee schedule rate ($50,785.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27695,APC,27695,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30188.45,,,,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea|RIGHT SIDE|PO,CASE-28465,APC,28465,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,MODERATE",443,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5577.70,,"Case rate for a one day stay ($5,577.70). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5577.70,5856.59,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11276.10,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11055.00,49295.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],32406.65,,"Fee schedule rate ($32,406.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12141.19,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11903.13,48838.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Prostate Needle Biopsy Any Approach,CASE-55700,APC,55700,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],126.14,,,,,,0,other,120.13,126.14,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|PREVENTIVE SERVICES,CASE-45385,APC,45385,CPT,0360,RC,,,33,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5066.54,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4895.21,14525.56,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7577.56,,"Case rate ($7,577.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,001.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,469.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,029.37. The transfer operating threshold is the transfer adjustment factor * $7,001.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.18. The transfer capital threshold is the transfer adjustment factor * $548.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7577.56,31445.30,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],110217.19,,"Fee schedule rate ($110,217.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],69433.76,,"Fee schedule rate ($69,433.76). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19049.64,,"Fee schedule rate ($19,049.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6502.13,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6230.00,21325.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],47438.21,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,45834.02,151120.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32406.65,,"Fee schedule rate ($32,406.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17929.96,,"Case rate ($17,076.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.07. The transfer capital threshold is the transfer adjustment factor * $1,210.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17103.38,50750.92,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26800.70,,"Fee schedule rate ($26,800.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],903.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,860.25,903.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8898.75,,"Fee schedule rate ($8,898.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Stent Place Initial Artery Ang,CASE-37236,APC,37236,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,Zero final payments for the item or service in the 15 months prior to posting the file.
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, SECOND DIGIT|PO",CASE-26356,APC,26356,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10103.56,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9761.89,37873.87,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
"MAJOR SMALL BOWEL PROCEDURES,MAJOR",230,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],40218.87,,"Case rate ($38,303.69). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,38303.69,40218.87,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],58656.71,,"Fee schedule rate ($58,656.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,1188.00,35040.80,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Litholapaxy Comp/Lg > 2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52318,APC,52318,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18067.42,,,,,,0,other,6088.84,18067.42,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5263.48,5339.77,OPPS APC
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],61972.71,,,,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23385.84,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,23385.84,71764.93,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5027.17,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4787.78,20006.29,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],31156.36,,"Case rate ($29,672.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,273.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,102.71. The transfer capital threshold is the transfer adjustment factor * $2,102.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",31156.38,31156.38,31156.38,1 through 10,other,13369.00,88188.38,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE|PO,CASE-25607,APC,25607,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24728.52,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,14130.58,57770.11,All Other Inpatient
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16192.08,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15421.03,49137.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Tot Hysterectomy Resj Malignancy W/Omntc,CASE-58575,APC,58575,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17161.77,,"Fee schedule rate ($17,161.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],51643.16,,"Fee schedule rate ($51,643.16). Adds an outlier to normal pricing equal to the per diem rate ($161,652.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,18222.73,59942.55,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13588.14,,"Case rate ($13,588.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,555.10, add-ons for qualifying new technology services are included. If operating cost exceeds $48,023.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,154.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,605.14. The transfer operating threshold is the transfer adjustment factor * $12,555.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $983.00. The transfer capital threshold is the transfer adjustment factor * $983.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13588.14,40320.14,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],3940.95,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3753.29,11765.59,Inpatient DRG
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|LEFT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],25110.76,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23915.01,121205.60,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4676.00,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4517.87,13932.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9024.75,,"Fee schedule rate ($9,024.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
Revascularization Iliac Art Angiop Ea Ipsi Vsl|LEFT SIDE,CASE-37222,APC,37222,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],168.02,,,,,,0,other,168.02,176.42,There are no additional notes associated with this service or procedure.
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,APC,38571,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8764.55,32969.91,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],20193.62,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19232.02,68941.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17958.55,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17103.38,50750.92,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12883.25,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12885.07,12885.07,12885.07,1 through 10,other,12883.25,44763.90,Inpatient DRG
HC Trluml Balo Angiop 1st Vein,CASE-37248,APC,37248,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5587.20,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4724.74,,"Case rate ($4,564.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,217.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,685.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,234.73. The transfer operating threshold is the transfer adjustment factor * $4,217.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.24. The transfer capital threshold is the transfer adjustment factor * $330.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4564.97,13545.65,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],23777.27,,of the excess amount. Final payment is multiplied by 105%.,35964.69,35964.69,35964.69,1 through 10,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
Gastrocnemius Recession|RIGHT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|RIGHT SIDE,CASE-27675,APC,27675,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21163.54,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12093.45,40067.60,All Other Inpatient
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ESOPHAGEAL DISORDERS,MODERATE",243,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9652.60,,"Case rate ($9,652.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9652.60,10135.23,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6974.25,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6837.50,20288.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26999.90,,"Fee schedule rate ($26,999.90). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9527.16,28269.95,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
"DIABETES,MINOR",420,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6809.04,,"Case rate ($6,484.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6484.80,6809.04,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Bi Tot Pel Lmphadec & Pri-Aortic Lymph Bx 1,CASE-38572,APC,38572,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE,CASE-29875,APC,29875,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27601.28,,"Fee schedule rate ($27,601.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13014.93,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12395.17,42174.37,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6828.45,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6503.29,19528.85,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5669.00,,"Per diem ($5,669). If length of stay < 3.2, first 1 days paid at a per diem of $11,338 instead. Capped at $18,140.88.",,,,0,other,5669.00,18994.21,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intrvasc US Noncoronary Addl|RIGHT SIDE,CASE-37253,APC,37253,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-27680,APC,27680,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
Revascularization Iliac Artery Angiop 1st Vsl|RIGHT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],379.58,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34690.55,,,,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
Arven Anast Opn Upr Arm Basilic Vein Trpos|LEFT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
Colonoscopy Flx W/Endoscopic Mucosal Resection|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],594.98,,"APC Price ($594.98). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,594.98,624.73,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6784.60,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6461.52,21772.28,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11435.55,,"Fee schedule rate ($11,435.55). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16503.06,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6965.00,45869.64,All Other Inpatient
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12060.31,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11652.47,41507.02,Inpatient DRG
HC Joint Injection/Aspir Medium WO US|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-20605,APC,20605,CPT,0510,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],48375.90,,,,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12377.93,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12135.23,49469.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Parathyroid Autotransplantation Add-On,CASE-60512,APC,60512,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20286.21,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11592.12,38954.76,All Other Inpatient
HC Intro Cath Dialysis Circuit W Pta|LEFT SIDE,CASE-36902,APC,36902,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5587.20,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12227.29,,,,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15284.82,,"Case rate ($14,556.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,202.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,031.56. The transfer capital threshold is the transfer adjustment factor * $1,031.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14580.18,57079.69,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],51790.71,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,29594.69,124146.55,All Other Inpatient
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28437.57,,"Fee schedule rate ($28,437.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23320.23,,"Fee schedule rate ($23,320.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20179.92,,"Fee schedule rate ($20,179.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,1188.00,20179.92,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4341.49,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4341.49,12882.53,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5273.12,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5094.80,15365.01,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11714.27,,"Case rate ($11,156.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,308.28, add-ons for qualifying new technology services are included. If operating cost exceeds $45,776.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,978.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,349.36. The transfer operating threshold is the transfer adjustment factor * $10,308.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.09. The transfer capital threshold is the transfer adjustment factor * $807.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11156.45,42003.98,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11202.49,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,31658.33,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17153.91,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16817.56,58510.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16320.00,,"Per diem ($16,320). If length of stay < 2.1, first 1 days paid at a per diem of $32,640 instead. Capped at $34,272.79.",,,,0,other,12093.45,40067.60,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5349.54,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5094.80,15365.01,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18222.73,59942.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,868.26,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3607.42,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3607.42,11497.58,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
"OTHER SMALL AND LARGE BOWEL PROCEDURES,MINOR",223,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4446.92,,"Case rate for a one day stay ($4,446.92). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,4446.92,4669.27,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],40925.22,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,23385.84,71764.93,All Other Inpatient
Excision/Curettage Bone Cyst/Tumor Tibia/Fibula,CASE-27635,APC,27635,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4735.03,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4574.91,13575.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Unlisted Procedure, Nervous System",CASE-64999,APC,64999,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8005.26,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8005.26,24549.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Fracture Phalanx/Phalanges Not Great Toe,CASE-28525,APC,28525,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],65732.99,,,,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10236.03,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10236.03,30589.82,Inpatient DRG
Sesamoidectomy First Toe Spx|BILATERAL PROCEDURE|PO,CASE-28315,APC,28315,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16245.56,,"Case rate ($15,471.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.40. The transfer capital threshold is the transfer adjustment factor * $1,096.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,53945.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15160.18,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14438.27,55762.74,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18510.45,,"Fee schedule rate ($18,510.45). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",11524.63,11524.63,11524.63,1 through 10,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],139522.22,,"Fee schedule rate ($139,522.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4679.91,,"Case rate ($4,457.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,486.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $315.84. The transfer capital threshold is the transfer adjustment factor * $315.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4464.17,13577.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34911.45,,"Fee schedule rate ($34,911.45). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15713.20,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3295.00,55581.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11054.89,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10528.47,44148.02,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21229.52,,,,,,0,other,6965.00,21229.52,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
Open Tx Tarsal Fracture Xcp Talus & Calcaneus Ea,CASE-28465,APC,28465,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|RIGHT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],189.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12196.66,,"Fee schedule rate ($12,196.66). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE|PO,CASE-25608,APC,25608,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17720.85,,"Fee schedule rate ($17,720.85). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11922.35,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11519.18,34180.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21289.03,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21289.03,76326.34,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",34461.56,34461.56,34461.56,1 through 10,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8630.58,,"Fee schedule rate ($8,630.58). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7136.91,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6797.06,20168.93,Inpatient DRG
"Inject Nerv Blck,Paravert Sympath|RIGHT SIDE",CASE-64520,APC,64520,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12516.72,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12093.45,40067.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5977.30,,"Case rate ($5,775.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.79. The transfer capital threshold is the transfer adjustment factor * $417.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5775.17,17136.70,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14641.18,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14641.18,43444.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17574.20,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16737.33,72192.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],43675.07,,,,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],54542.68,,,,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14743.98,,,,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],71704.50,,"Fee schedule rate ($71,704.50). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6199.10,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6077.55,18033.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],52607.24,,"Fee schedule rate ($52,607.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"HC Debrid,Bone,1st 20sqcm or Less",CASE-11044,APC,11044,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6784.60,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6461.52,21772.28,Inpatient DRG
"OTHER ESOPHAGEAL DISORDERS,MODERATE",243,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9652.60,,"Case rate ($9,652.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9652.60,10135.23,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,APC,25608,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10888.24,,"Case rate ($10,888.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,093.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,639.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,437.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,098.65. The transfer operating threshold is the transfer adjustment factor * $10,093.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10888.24,32825.17,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],61129.87,,"Fee schedule rate ($61,129.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5244.04,15804.57,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16406.86,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15852.04,50518.01,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17136.70,,,,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26455.73,,,,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],41507.02,,"Fee schedule rate ($41,507.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11652.47,41507.02,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],32973.67,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,31858.62,94534.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21288.16,,"Case rate ($20,274.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,733.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,637.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,807.74. The transfer operating threshold is the transfer adjustment factor * $18,733.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,466.70. The transfer capital threshold is the transfer adjustment factor * $1,466.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20274.44,80940.99,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6401.17,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5669.00,18994.21,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3733.68,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3607.42,11497.58,Inpatient DRG
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE|PO,CASE-25608,APC,25608,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR PELVIS AND BACK,MODERATE",342,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9250.58,,"Case rate ($9,250.58). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9250.58,9713.11,There are no additional notes associated with this service or procedure.
Rpr Component Inflatable Penile Prosthesis,CASE-54408,APC,54408,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5621.79,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5354.09,15887.21,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18796.76,,"Fee schedule rate ($18,796.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6632.59,19680.94,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis 20 Cm/<|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97597,APC,97597,CPT,0761,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Tx Missed Abortion First Trimester Surgical,CASE-59820,APC,59820,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,8704.87,25830.00,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,32749.19,97176.83,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6707.58,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6480.75,29542.64,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE,CASE-27822,APC,27822,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18579.56,,"Fee schedule rate ($18,579.56). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],90287.21,,"Fee schedule rate ($90,287.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20.9), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9280.46,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9280.46,39957.56,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13948.68,,"Case rate ($13,284.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,294.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,761.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,343.08. The transfer operating threshold is the transfer adjustment factor * $12,294.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.38. The transfer capital threshold is the transfer adjustment factor * $941.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13305.64,39481.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE|PO,CASE-64490,APC,64490,CPT,0361,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21074.07,,,,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15153.62,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",9940.50,9940.50,9940.50,1 through 10,other,14641.18,43444.85,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29288.89,,"Fee schedule rate ($29,288.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10882.42,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,1188.00,31658.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Capsulectomy/Capsulotomy Mtcarphlngl Joint Each,CASE-26520,APC,26520,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Thrmbc Opn Arven Fstl W/O Revj Dial Grf,CASE-36831,APC,36831,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5018.44,5018.44,5018.44,1 through 10,other,5277.74,5541.62,OPPS APC
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB|PO",CASE-26540,APC,26540,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4138.67,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4138.67,12473.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17836.44,,"Fee schedule rate ($17,836.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|LEFT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bronchoscopy W/Removal Foreign Body,CASE-31635,APC,31635,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1688.18,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1688.18,1772.59,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12540.27,,"Case rate ($11,943.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.33. The transfer capital threshold is the transfer adjustment factor * $846.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11962.15,40923.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO|SEPARATE STRUCTURE",CASE-28270,APC,28270,CPT,0360,RC,,,T6|PO|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Unlisted Procedure Femur/Knee,CASE-27599,APC,27599,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],233.96,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",111.35,111.35,111.35,1 through 10,other,233.96,245.65,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6682.71,,"Case rate ($6,364.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.01. The transfer capital threshold is the transfer adjustment factor * $451.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6230.00,21325.01,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12536.42,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12536.42,37199.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17934.16,,"Fee schedule rate ($17,934.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.1), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],35466.15,,"Fee schedule rate ($35,466.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,APC,11421,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4744.66,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4744.66,4910.73,OPPS APC
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO|UNUSUAL NON-OVERLAPPING SERVICE",CASE-28285,APC,28285,CPT,0360,RC,,,T9|PO|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7350.67,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7102.10,21074.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14324.77,,"Case rate ($13,642.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,137.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $966.76. The transfer capital threshold is the transfer adjustment factor * $966.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13671.85,13671.85,13671.85,1 through 10,other,13664.39,40546.43,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],82674.88,,,,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Removal Foreign Body,CASE-31635,APC,31635,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1772.59,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1688.18,1772.59,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],34592.73,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,33422.93,112824.68,Inpatient DRG
Arthroplasty Interphalangeal Jt W/Prosthetic Ea,CASE-26536,APC,26536,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18362.16,,"Case rate ($10,492.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,694.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,162.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,930.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,733.59. The transfer operating threshold is the transfer adjustment factor * $9,694.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.07. The transfer capital threshold is the transfer adjustment factor * $759.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10492.66,31134.92,All Other Inpatient
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16324.35,,"Fee schedule rate ($16,324.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
Lig/Banding Angioaccess Arteriovenous Fistula,CASE-37607,APC,37607,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",20104.75,20104.75,20104.75,1 through 10,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15209.73,,"Case rate ($14,485.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,026.49. The transfer capital threshold is the transfer adjustment factor * $1,026.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14508.56,59513.03,Inpatient DRG
Excision/Curettage Bone Cyst/Tumor Tibia/Fibula|SEPARATE STRUCTURE|RIGHT SIDE,CASE-27635,APC,27635,CPT,0360,RC,,,XS|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,53945.28,Estimated amount calculated based on 17 day length of stay.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",888.72,888.72,888.72,1 through 10,other,882.03,926.14,OPPS APC
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10725.38,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10362.69,29367.82,Inpatient DRG
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],87077.35,,"Fee schedule rate ($87,077.35). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19503.23,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19503.23,57872.02,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27868.14,,"Fee schedule rate ($27,868.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10455.00,,"Per diem ($10,455). If length of stay < 6.6, first 1 days paid at a per diem of $20,910 instead. Capped at $69,000.38.",,,,0,other,10455.00,90889.11,Estimated amount calculated based on 7 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Lateral Retinacular Release Open,CASE-27425,APC,27425,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11039.73,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6953.00,35389.05,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization,CASE-52005,APC,52005,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17490.00,,"Per diem ($17,490). If length of stay < 1.2, first 1 days paid at a per diem of $34,980 instead. Capped at $20,988.02.",,,,0,other,7405.81,33747.30,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5386.10,,"Case rate ($5,280.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,879.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,346.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,553.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,898.48. The transfer operating threshold is the transfer adjustment factor * $4,879.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $382.00. The transfer capital threshold is the transfer adjustment factor * $382.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5280.49,17810.78,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Insertion Intrauterine Device Iud,CASE-58300,APC,58300,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, SECOND DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12650.51,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12402.46,36801.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6176.78,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6055.67,17969.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],64778.65,,,,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],42945.05,,,,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 2 day length of stay.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13369.00,,"Per diem ($13,369). If length of stay < 6.3, first 1 days paid at a per diem of $26,738 instead. Capped at $84,226.47.",21356.78,21356.78,21356.78,1 through 10,other,13369.00,88188.38,Estimated amount calculated based on 5 day length of stay.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6204.88,,"Case rate ($6,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,620.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.88. The transfer capital threshold is the transfer adjustment factor * $448.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6204.88,19589.20,Inpatient DRG
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THIRD DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],57102.65,,,,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
"CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",166,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],63835.34,,"Case rate ($63,835.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,63835.34,67027.11,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],70498.76,,,,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11698.23,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11698.23,34712.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11978.73,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11978.73,60588.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER DISORDERS OF THE LIVER,MAJOR",283,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14429.85,,"Case rate ($14,429.85). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14429.85,15151.34,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27943.31,,"Fee schedule rate ($27,943.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23320.23,,"Fee schedule rate ($23,320.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE|PO,CASE-28300,APC,28300,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MODERATE",344,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11905.84,,"Case rate ($11,905.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11905.84,12501.13,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19262.83,,"Fee schedule rate ($19,262.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],33072.79,,"Case rate ($33,072.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,558.44, add-ons for qualifying new technology services are included. If operating cost exceeds $66,026.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,563.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,680.23. The transfer operating threshold is the transfer adjustment factor * $30,558.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,392.57. The transfer capital threshold is the transfer adjustment factor * $2,392.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",25784.32,25784.32,25784.32,1 through 10,other,33072.79,98455.37,Inpatient DRG
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6721.23,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5669.00,18994.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],163229.10,,"Fee schedule rate ($163,229.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30666.60,,,,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],30475.39,,"Fee schedule rate ($30,475.39). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-27680,APC,27680,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9033.85,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",22279.92,22279.92,22279.92,1 through 10,other,6972.00,26280.60,Inpatient DRG
HC Peripheral Block - Femoral Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,EXTREME",721,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],32330.60,,"Case rate ($30,791.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30791.05,32330.60,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24805.79,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23624.56,83038.88,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],125570.55,,"Fee schedule rate ($125,570.55). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
"Amputation Metatarsal W/Toe Single|LEFT FOOT, FIFTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22919.57,,"Case rate ($21,828.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.10. The transfer capital threshold is the transfer adjustment factor * $1,579.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21828.16,93157.39,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6074.24,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6074.24,18024.13,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14273.70,,,,,,0,other,4734.64,14273.70,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12521.78,,"Fee schedule rate ($12,521.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11600.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11600.09,48814.14,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6480.75,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6480.75,29542.64,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15937.95,,"Fee schedule rate ($15,937.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1188.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18902.44,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18902.44,56089.29,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],27539.67,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27539.67,109237.68,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10638.72,,"Fee schedule rate ($10,638.72). Adds an outlier to normal pricing equal to the per diem rate ($26,031.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,3753.97,11139.15,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
Arthroplasty Ankle W/Implant|RIGHT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],27022.53,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25735.75,27022.53,OPPS APC
Debridement Nail Any Method 1-5,CASE-11720,APC,11720,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],55.95,,"APC Price ($55.95). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,55.95,58.75,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7848.16,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7694.27,22831.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Femoral Continuous W/Img Gdn,CASE-64448,APC,64448,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11621.00,,"Per diem ($11,621). If length of stay < 22.4, first 1 days paid at a per diem of $23,242 instead. Capped at $260,309.36.",,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6130.37,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5923.06,17575.50,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18915.50,,,,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
Arven Anast Opn Upr Arm Basilic Vein Trpos,CASE-36819,APC,36819,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5462.46,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4749.35,,"Case rate ($4,523.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,179.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,647.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,498.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,195.97. The transfer operating threshold is the transfer adjustment factor * $4,179.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $327.22. The transfer capital threshold is the transfer adjustment factor * $327.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4523.19,16536.43,Inpatient DRG
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],45983.18,,,,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],26948.04,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",27894.92,27894.92,27894.92,1 through 10,other,26419.65,96304.23,Inpatient DRG
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4895.21,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4895.21,14525.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],30403.05,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,30403.05,90685.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],67356.73,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],66951.94,,"Fee schedule rate ($66,951.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, GREAT TOE",CASE-28270,APC,28270,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9110.85,,"Fee schedule rate ($9,110.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6953.00,,"Per diem ($6,953). If length of stay < 4.5, first 1 days paid at a per diem of $13,906 instead. Capped at $31,286.59.",,,,0,other,6953.00,35389.05,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4890.97,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4795.07,19830.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4907.99,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4742.02,14071.02,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10000.20,,"Fee schedule rate ($10,000.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],68116.02,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,64872.40,212258.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],30130.97,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,28696.16,118364.04,Inpatient DRG
"OTHER DISORDERS OF NERVOUS SYSTEM,EXTREME",058,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],26943.14,,"Case rate ($25,660.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25660.13,26943.14,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],41585.15,,"Fee schedule rate ($41,585.15). Adds an outlier to normal pricing equal to the per diem rate ($65,246.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14673.67,43541.27,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
"Exc Tum/Vas Mal Sft Tis Hand/Fngr Subfasc<1.5cm|LEFT HAND, THUMB|PO",CASE-26116,APC,26116,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1621.31,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9574.89,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9574.89,28411.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit W Pta|LEFT SIDE,CASE-36902,APC,36902,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25034.48,,"Fee schedule rate ($25,034.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.75,34422.94,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11570.35,,"Fee schedule rate ($11,570.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5006.61,14856.14,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],61868.44,,"Fee schedule rate ($61,868.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27135.21,,"Fee schedule rate ($27,135.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18251.76,,"Fee schedule rate ($18,251.76). Adds an outlier to normal pricing equal to the per diem rate ($45,948.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",18167.19,18167.19,18167.19,1 through 10,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6987.68,,"Case rate ($6,654.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,167.40, add-ons for qualifying new technology services are included. If operating cost exceeds $46,712.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,132.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,170.45. The transfer operating threshold is the transfer adjustment factor * $6,167.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.48. The transfer capital threshold is the transfer adjustment factor * $484.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6654.93,20056.77,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],108024.76,,,,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, SECOND DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
Destruction Vaginal Lesions Simple,CASE-57061,APC,57061,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms,CASE-27696,APC,27696,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,10528.47,44148.02,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6518.41,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE,CASE-29806,APC,29806,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7995.65,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4568.94,13557.45,All Other Inpatient
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],42670.25,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,42670.25,133443.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7828.37,,"Case rate ($7,455.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,699.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.33. The transfer capital threshold is the transfer adjustment factor * $528.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,37575.69,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7544.23,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7184.98,21320.03,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm|PO,CASE-11404,APC,11404,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1621.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26999.90,,"Fee schedule rate ($26,999.90). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9527.16,28269.95,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],38756.54,,"Case rate ($36,910.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,104.83, add-ons for qualifying new technology services are included. If operating cost exceeds $69,572.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,841.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $34,240.75. The transfer operating threshold is the transfer adjustment factor * $34,104.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,670.23. The transfer capital threshold is the transfer adjustment factor * $2,670.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36910.99,126842.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,33843.71,Estimated amount calculated based on 10 day length of stay.
Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,CASE-58571,APC,58571,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",10148.63,10148.63,10148.63,1 through 10,other,10082.05,10586.16,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17279.67,,"Case rate ($16,456.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,205.70, add-ons for qualifying new technology services are included. If operating cost exceeds $50,673.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,361.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,266.30. The transfer operating threshold is the transfer adjustment factor * $15,205.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.53. The transfer capital threshold is the transfer adjustment factor * $1,190.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16456.83,55350.97,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42563.06,,"Fee schedule rate ($42,563.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12758.30,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12326.86,53121.74,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE|PO,CASE-29826,APC,29826,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
Revascularization Iliac Art Angiop Ea Ipsi Vsl|LEFT SIDE,CASE-37222,APC,37222,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],173.90,,,,,,0,other,168.02,176.42,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26540,APC,26540,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13572.00,,"Per diem ($13,572). If length of stay < 5.8, first 1 days paid at a per diem of $27,144 instead. Capped at $78,720.12.",,,,0,other,13572.00,108637.77,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],31923.20,,"Case rate ($30,403.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,091.66, add-ons for qualifying new technology services are included. If operating cost exceeds $63,559.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,370.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $28,203.62. The transfer operating threshold is the transfer adjustment factor * $28,091.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.43. The transfer capital threshold is the transfer adjustment factor * $2,199.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30403.05,90685.00,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39792.30,,"Fee schedule rate ($39,792.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11832.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11600.09,48814.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17836.44,,"Fee schedule rate ($17,836.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,Zero final payments for the item or service in the 15 months prior to posting the file.
"OPEN EXTRACRANIAL VASCULAR PROCEDURES,MODERATE",024,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7735.83,,"Case rate for a one day stay ($7,367.46). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7367.46,7735.83,There are no additional notes associated with this service or procedure.
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE,CASE-28120,APC,28120,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt,CASE-28291,APC,28291,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MAJOR",721,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],17600.41,,"Case rate ($17,600.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,17600.41,18480.43,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],30760.23,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13369.00,88188.38,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6374.64,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",36810.87,36810.87,36810.87,1 through 10,other,6230.00,21325.01,Inpatient DRG
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, FOURTH DIGIT",CASE-28234,APC,28234,CPT,0360,RC,,,T3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23758.52,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23758.52,103116.16,Inpatient DRG
"Inject Nerv Blck,Paravert Sympath|RIGHT SIDE",CASE-64520,APC,64520,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],3760.73,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3209.85,10940.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16737.33,72192.67,Zero final payments for the item or service in the 15 months prior to posting the file.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],30859.60,,"Case rate ($30,254.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,954.41, add-ons for qualifying new technology services are included. If operating cost exceeds $63,422.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,359.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $28,065.82. The transfer operating threshold is the transfer adjustment factor * $27,954.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,188.69. The transfer capital threshold is the transfer adjustment factor * $2,188.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,30254.51,130347.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22384.37,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,12791.07,43031.63,All Other Inpatient
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21172.33,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",22139.37,22139.37,22139.37,1 through 10,other,12500.00,83592.64,Inpatient DRG
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33242.94,,"Fee schedule rate ($33,242.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11730.05,61348.24,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11017.29,,"Case rate ($10,492.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,694.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,162.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,930.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,733.59. The transfer operating threshold is the transfer adjustment factor * $9,694.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.07. The transfer capital threshold is the transfer adjustment factor * $759.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10492.66,31134.92,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22576.15,,"Fee schedule rate ($22,576.15). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",6054.26,6054.26,6054.26,1 through 10,other,6297.98,6612.88,OPPS APC
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8405.52,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8005.26,24549.95,Inpatient DRG
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],26525.17,,of the excess amount.,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27506.48,,,,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
Hrhc 2/> Col/Grp W/Fstulectmy Incl Fssrectmy,CASE-46262,APC,46262,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28195.14,,"Fee schedule rate ($28,195.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
Osteoplasty Radius/Ulna Shortening|LEFT SIDE|PO,CASE-25390,APC,25390,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE",CASE-28299,APC,28299,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20471.90,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11698.23,34712.20,All Other Inpatient
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",13260.42,13260.42,13260.42,1 through 10,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Brow Ptosis,CASE-67900,APC,67900,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2333.89,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Revise/Remove Neurostim/Receiver,CASE-64595,APC,64595,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3481.74,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3315.94,3481.74,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6730.91,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",6730.92,6660.13,6730.92,1 through 10,other,6503.29,19528.85,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,70321.74,Estimated amount calculated based on 17 day length of stay.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5668.40,16903.82,Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30044.81,,,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4179.80,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3980.76,11812.10,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9430.87,,"Case rate ($8,981.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,671.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $657.72. The transfer capital threshold is the transfer adjustment factor * $657.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8981.78,27528.12,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],85150.25,,,,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,APC,52332,CPT,0360,RC,,,50|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11368.22,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10826.88,32126.64,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],87816.48,,,,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6178.00,,"Per diem ($6,178). If length of stay < 3.9, first 1 days paid at a per diem of $12,356 instead. Capped at $24,092.63.",,,,0,other,6178.00,25225.91,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15156.44,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15156.44,52672.70,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7891.21,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7891.21,23415.63,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6301.95,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6088.84,18067.42,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11384.58,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11384.58,33781.47,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10405.96,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9910.44,43344.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7934.97,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7934.98,7934.98,7934.98,1 through 10,other,7934.97,23545.50,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],64770.78,,,,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
Open Treatment Fracture Distal Tibia Only|LEFT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5368.01,15928.53,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],45520.40,,"Fee schedule rate ($45,520.40). Adds an outlier to normal pricing equal to the per diem rate ($131,498.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16062.27,48077.57,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],8940.00,,"Per diem ($8,940). If length of stay < 6.8, first 1 days paid at a per diem of $17,880 instead. Capped at $60,793.48.",,,,0,other,8940.00,63653.13,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7243.96,,"Fee schedule rate ($7,243.96). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],62647.63,,,,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|PO|UNUSUAL NON-OVERLAPPING SERVICE,CASE-14040,APC,14040,CPT,0360,RC,,,PO|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],36505.35,,"Fee schedule rate ($36,505.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2|LEFT SIDE|PO,CASE-29822,APC,29822,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Chemodenervation Internal Anal Sphincter,CASE-46505,APC,46505,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10300.50,,"Fee schedule rate ($10,300.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw,CASE-37722,APC,37722,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20110.39,,"Fee schedule rate ($20,110.39). Adds an outlier to normal pricing equal to the per diem rate ($69,590.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",33431.35,33431.35,33431.35,1 through 10,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],38106.57,,"Fee schedule rate ($38,106.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11039.73,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6953.00,35389.05,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19056.10,,"Fee schedule rate ($19,056.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrt Elbow W/Exploration Drainage/Removal FB|RIGHT SIDE|PO,CASE-24000,APC,24000,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE,CASE-29898,APC,29898,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC Sel Cath Abd/Pelvic/Le 1st Ord|LEFT SIDE,CASE-36245,APC,36245,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4979.12,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4742.02,14071.02,Inpatient DRG
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3070.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4493.44,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4341.49,12882.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21687.14,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20654.42,69402.59,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct|SEPARATE STRUCTURE,CASE-43275,APC,43275,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6045.95,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5758.05,6045.95,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18927.32,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9888.00,40658.63,All Other Inpatient
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10880.82,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10362.69,29367.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8184.82,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7795.07,34198.12,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, GREAT TOE",CASE-28270,APC,28270,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12573.72,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7184.98,21320.03,All Other Inpatient
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],36505.40,,"Fee schedule rate ($36,505.40). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12881.26,38222.57,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27753.50,,"Fee schedule rate ($27,753.50). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia Only|RIGHT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],45389.36,,"Fee schedule rate ($45,389.36). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],27777.08,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",20716.00,20716.00,20716.00,1 through 10,other,13572.00,108637.77,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24249.78,,"Case rate ($23,095.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,373.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,841.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,807.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $21,458.44. The transfer operating threshold is the transfer adjustment factor * $21,373.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.59. The transfer capital threshold is the transfer adjustment factor * $1,636.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",23468.74,23468.74,189878.39,1 through 10,other,23131.85,76404.43,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],70037.75,,"Fee schedule rate ($70,037.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.9), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],31671.85,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30163.67,89504.77,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27601.28,,"Fee schedule rate ($27,601.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,APC,43236,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8072.90,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8072.91,8072.91,8072.91,1 through 10,other,8072.90,31159.55,Inpatient DRG
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31329.81,,"Fee schedule rate ($31,329.81). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],50911.23,,"Fee schedule rate ($50,911.23). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
Revise/Remove Neurostim/Receiver,CASE-64595,APC,64595,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3432.00,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3315.94,3481.74,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",5687.21,5612.59,5687.21,1 through 10,other,5733.99,6020.69,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],66275.39,,"Fee schedule rate ($66,275.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,APC,45381,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,19232.02,68941.12,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE,CASE-27601,APC,27601,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|LEFT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],37794.93,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10105.00,120252.50,Inpatient DRG
Laps Supracrv Hysterec >250 G Rmvl Tube/Ovary,CASE-58544,APC,58544,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17445.75,,"Fee schedule rate ($17,445.75). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13110.79,,,,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11280.63,,"Case rate ($10,899.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,959.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10899.16,39746.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthro/shoul surg; w/spacer,CASE-C9781,APC,C9781,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21300.35,,,,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7457.21,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7102.10,21074.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],29890.76,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8232.00,84471.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19668.75,,"Fee schedule rate ($19,668.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5923.82,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5807.67,17233.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18051.15,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17191.57,51012.62,Inpatient DRG
Revj Opn Arven Fstl W/O Thrmbc Dial Grf,CASE-36832,APC,36832,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24752.04,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23915.01,121205.60,Inpatient DRG
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FOURTH DIGIT|PO",CASE-26765,APC,26765,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Knee Condyle&Plateau Medial/Lat Cmprt|RIGHT SIDE,CASE-27446,APC,27446,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],29594.69,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,29594.69,124146.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MINOR",425,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2727.46,,"Case rate for a one day stay ($2,597.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2597.58,2727.46,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25493.52,,,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5541.48,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5354.09,15887.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8422.25,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6495.00,23801.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12351.25,,,,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18918.04,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10810.31,32077.45,All Other Inpatient
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9529.80,,"Fee schedule rate ($9,529.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FIFTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T4|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20161.47,,"Case rate ($19,201.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,531.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,360.68. The transfer capital threshold is the transfer adjustment factor * $1,360.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19232.02,68941.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5605.96,5605.96,5605.96,1 through 10,other,5733.99,6020.69,OPPS APC
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
Arthrodesis Midtarsometatarsal Single Joint|RIGHT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],43541.27,,,,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],52135.70,,"Fee schedule rate ($52,135.70). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,APC,60220,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8383.25,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7984.05,33319.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciectomy Plantar Fascia Radical Spx|RIGHT SIDE,CASE-28062,APC,28062,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28035.79,,,,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],23600.38,,"Case rate ($22,802.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,068.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,536.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,820.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $21,152.71. The transfer operating threshold is the transfer adjustment factor * $21,068.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,649.58. The transfer capital threshold is the transfer adjustment factor * $1,649.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,22802.30,82749.58,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31167.59,,"Fee schedule rate ($31,167.59). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],40046.00,,"Fee schedule rate ($40,046.00). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",41859.28,41859.28,41859.28,1 through 10,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],32689.48,,"Fee schedule rate ($32,689.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,XU|50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],37794.93,,"Case rate ($37,794.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,905.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.18. The transfer capital threshold is the transfer adjustment factor * $2,734.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10105.00,120252.50,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18562.91,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18562.91,73513.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10080.86,,"Case rate ($10,080.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,314.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,782.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,900.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,351.58. The transfer operating threshold is the transfer adjustment factor * $9,314.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.27. The transfer capital threshold is the transfer adjustment factor * $729.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10080.86,33310.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15043.12,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14534.42,59012.52,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstrj Lesion Anus Extensive,CASE-46924,APC,46924,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17575.50,,,,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17887.18,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15783.67,15783.67,15783.67,1 through 10,other,7455.00,53076.74,Inpatient DRG
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
Removal Implant Deep,CASE-20680,APC,20680,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2851.46,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Synovectomy Tendon Sheath Foot Extensor|RIGHT SIDE|PO,CASE-28088,APC,28088,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11265.54,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10884.58,32297.83,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15496.63,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,53945.28,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],44786.63,,"Fee schedule rate ($44,786.63). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
HC Insertion Uterine Tandem&/Vaginal Ovoids,CASE-57155,APC,57155,CPT,0342,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4744.66,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4744.66,4981.90,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18222.73,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,18222.73,59942.55,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],51131.99,,"Fee schedule rate ($51,131.99). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],904.16,,"APC Price ($873.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,873.59,917.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
HC Intro Catheter Aorta|RIGHT SIDE,CASE-36200,APC,36200,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6054.88,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5766.55,17111.12,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",6718.00,6718.00,6718.00,1 through 10,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28157.55,,"Fee schedule rate ($28,157.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16383.52,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16062.27,48077.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE|PO,CASE-26615,APC,26615,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9070.48,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8442.00,28788.33,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17814.56,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,17212.14,64440.06,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],29066.85,,of the excess amount. Final payment is multiplied by 105%.,43804.44,33339.38,45827.54,1 through 10,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25267.19,,"Fee schedule rate ($25,267.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3295.00,,,,,,0,other,3295.00,33843.71,Estimated amount calculated based on 10 day length of stay.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],32570.75,,"Case rate ($31,019.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,415.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,244.05. The transfer capital threshold is the transfer adjustment factor * $2,244.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31019.76,124854.72,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21377.32,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20654.42,69402.59,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
HC Tib per Territory Plasty,CASE-37228,APC,37228,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],513.29,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22168.26,,"Case rate ($21,112.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,698.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.34. The transfer capital threshold is the transfer adjustment factor * $1,527.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21112.63,62647.63,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4878.64,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",14745.18,14745.18,14745.18,1 through 10,other,4878.64,14476.37,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24154.93,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23338.10,69251.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12275.48,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11690.93,56733.59,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Rmvl Perm Intraperitneal Cath,CASE-49422,APC,49422,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5013.25,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4774.52,14406.59,Inpatient DRG
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],67175.58,,"Fee schedule rate ($67,175.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15839.99,,,,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11901.14,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11901.14,35314.31,Inpatient DRG
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10915.75,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",2149.61,2149.61,2149.61,1 through 10,other,10915.75,32390.31,Inpatient DRG
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],27777.08,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13572.00,108637.77,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32553.63,,,,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac WO Port>5yr (Tun),CASE-36558,APC,36558,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3024.28,3024.28,3024.28,1 through 10,other,2994.77,3144.51,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4734.64,,"Case rate ($4,734.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,389.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,934.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,991.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,391.29. The transfer operating threshold is the transfer adjustment factor * $4,389.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.35. The transfer capital threshold is the transfer adjustment factor * $343.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4734.64,14273.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level|RIGHT SIDE",CASE-64495,APC,64495,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp,CASE-27691,APC,27691,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],37546.05,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,36276.38,121107.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,APC,58542,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14574.62,,"Case rate ($13,880.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,825.31, add-ons for qualifying new technology services are included. If operating cost exceeds $48,293.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,876.42. The transfer operating threshold is the transfer adjustment factor * $12,825.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7285.00,41187.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Plmt Interstitial Dev Radiat Tx Prostate 1/Mult,CASE-55876,APC,55876,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1358.75,,"APC Price ($1,312.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1314.70,1314.70,1314.70,1 through 10,other,1312.80,1378.44,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8246.16,,"Case rate ($7,853.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.53. The transfer capital threshold is the transfer adjustment factor * $556.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7866.01,25247.47,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4325.32,,"Case rate ($4,119.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,806.17, add-ons for qualifying new technology services are included. If operating cost exceeds $39,274.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,821.34. The transfer operating threshold is the transfer adjustment factor * $3,806.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.00. The transfer capital threshold is the transfer adjustment factor * $298.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4119.35,12223.35,Inpatient DRG
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34934.31,,"Fee schedule rate ($34,934.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],57534.77,,"Fee schedule rate ($57,534.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,20301.63,84714.35,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,32980.62,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8410.44,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8383.86,8383.86,8383.86,1 through 10,other,8410.44,24956.34,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],29594.69,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,29594.69,124146.55,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12366.99,,,,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],22645.02,,of the excess amount.,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8227.43,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8227.43,27001.04,Inpatient DRG
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12577.67,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11978.73,60588.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
Syndactylization Toes,CASE-28280,APC,28280,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
Carpectomy All Bones Proximal Row,CASE-25215,APC,25215,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",26029.24,26029.24,26029.24,1 through 10,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12235.09,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11652.47,41507.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7450.94,,"Case rate ($7,096.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.35. The transfer capital threshold is the transfer adjustment factor * $513.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7096.13,25801.23,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12275.48,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11690.93,56733.59,Inpatient DRG
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49594,APC,49594,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",5687.21,5687.21,5687.21,1 through 10,other,5733.99,6020.69,OPPS APC
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11747.40,,"Fee schedule rate ($11,747.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],29585.28,,"Fee schedule rate ($29,585.28). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|RIGHT SIDE,CASE-26121,APC,26121,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22035.98,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7826.00,90280.33,Inpatient DRG
Open Treatment Fracture Distal Tibia Only|LEFT SIDE|PO,CASE-27827,APC,27827,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11714.14,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11714.14,49460.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Split Agrft T/a/L Ea 100 Cm/Ea 1% Bdy Inft/Chld,CASE-15101,APC,15101,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.96,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.96,2054.80,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10536.15,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10034.43,29775.24,Inpatient DRG
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],50620.95,,"Fee schedule rate ($50,620.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOLIC LIVER DISEASE,EXTREME",280,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],32269.68,,"Case rate ($30,733.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30733.03,32269.68,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16616.10,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15824.86,49371.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8919.07,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8919.07,34453.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7086.07,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6748.64,20025.28,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5486.04,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5486.04,17919.05,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2285.00,,,,,,0,other,2285.00,12138.74,Estimated amount calculated based on 2 day length of stay.
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE|PO,CASE-29876,APC,29876,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,APC,52287,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5263.48,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Surg Tx Anal Fistula Subq,CASE-46270,APC,46270,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15043.12,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14534.42,59012.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"Ex Tum/Vasc Malf Sft Tiss Hand/Fngr Subq 1.5cm/>|RIGHT HAND, THIRD DIGIT|PO",CASE-26111,APC,26111,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19450.67,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7000.00,32980.62,All Other Inpatient
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8228.75,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8228.75,24417.19,Inpatient DRG
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|RIGHT SIDE|PO,CASE-28119,APC,28119,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Partical Excision Bone Phalanx Toe|LEFT SIDE|PO,CASE-28124,APC,28124,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE|PO",CASE-28296,APC,28296,CPT,0360,RC,,,T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, FOURTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Transection/Avulsion Oth Spinal Nrv Xdrl|PO,CASE-64772,APC,64772,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Thrmbc Opn Arven Fstl W/O Revj Dial Grf,CASE-36831,APC,36831,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8093.67,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7934.97,23545.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10057.24,,"Case rate ($9,860.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,884.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.30. The transfer capital threshold is the transfer adjustment factor * $713.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9860.04,30039.61,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE,CASE-28730,APC,28730,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34171.31,,"Fee schedule rate ($34,171.31). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11871.54,35778.69,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32974.20,,"Fee schedule rate ($32,974.20). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12482.98,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11888.55,35276.93,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],23723.08,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22593.41,90908.64,Inpatient DRG
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,APC,43236,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],98176.71,,"Fee schedule rate ($98,176.71). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,31570.16,98176.71,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39854.32,,"Fee schedule rate ($39,854.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],89402.25,,"Fee schedule rate ($89,402.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvc/Le Init 2nd|LEFT SIDE,CASE-36246,APC,36246,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5770.65,,"Case rate ($5,495.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.46. The transfer capital threshold is the transfer adjustment factor * $389.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",205.38,205.38,205.38,1 through 10,other,5504.62,16333.88,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
Arthro/shoul surg; w/spacer|PO,CASE-C9781,APC,C9781,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Px Skin Muc Membrane & Subq Tissue,CASE-17999,APC,17999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Cystourethroscopy With Biopsy,CASE-52204,APC,52204,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29008.87,,"Fee schedule rate ($29,008.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],89868.57,,"Fee schedule rate ($89,868.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,40591.99,115037.59,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10970.77,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10970.77,32553.63,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5008.20,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4838.84,19587.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE|PO,CASE-25609,APC,25609,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33483.49,,"Fee schedule rate ($33,483.49). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39078.16,,"Fee schedule rate ($39,078.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],28565.27,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,28005.17,115392.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26297.04,,"Fee schedule rate ($26,297.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,9279.13,27534.03,There are no additional notes associated with this service or procedure.
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE|PO,CASE-28322,APC,28322,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4558.56,,"Case rate ($4,341.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,011.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,479.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,485.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,027.42. The transfer operating threshold is the transfer adjustment factor * $4,011.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.07. The transfer capital threshold is the transfer adjustment factor * $314.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4341.49,12882.53,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|SEPARATE STRUCTURE|PO,CASE-62323,APC,62323,CPT,0360,RC,,,XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15405.10,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",16344.09,13513.37,48711.15,1 through 10,other,3295.00,55581.70,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],38106.57,,"Fee schedule rate ($38,106.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14142.64,,"Case rate ($13,664.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,625.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,093.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,159.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,675.88. The transfer operating threshold is the transfer adjustment factor * $12,625.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.52. The transfer capital threshold is the transfer adjustment factor * $988.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13664.39,40546.43,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
"KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,MAJOR",443,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3859.61,,"Case rate for a one day stay ($3,675.82). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3675.82,3859.61,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],23530.36,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,22734.65,70806.50,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14697.90,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7453.00,42138.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9645.99,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9456.85,28061.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent,CASE-36903,APC,36903,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22490.04,,"Fee schedule rate ($22,490.04). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|LEFT SIDE|PO,CASE-27675,APC,27675,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19807.67,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,19137.85,64589.15,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],20516.26,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,17274.00,73717.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
HC Intro Cath in Svc or Ivc|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36010,APC,36010,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24863.59,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23679.61,84629.16,Inpatient DRG
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],25658.60,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,24790.92,26030.46,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15156.44,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15156.44,52672.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39854.32,,"Fee schedule rate ($39,854.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13789.07,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13789.07,57367.22,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22132.97,,"Case rate ($21,079.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,507.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,975.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,664.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,585.30. The transfer operating threshold is the transfer adjustment factor * $19,507.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,493.73. The transfer capital threshold is the transfer adjustment factor * $1,493.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21112.63,62647.63,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia Recr < 3 Cm Ncrc8/Strangulated,CASE-49614,APC,49614,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,Zero final payments for the item or service in the 15 months prior to posting the file.
Biopsy Vaginal Mucosa Simple,CASE-57100,APC,57100,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22484.91,,,,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
Excision Vaginal Cyst/Tumor,CASE-57135,APC,57135,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
Destruction Mal Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-17266,APC,17266,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],385.57,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",370.91,370.91,370.91,1 through 10,other,385.57,399.06,OPPS APC
Manipulation Knee Joint Under General Anesthesia|RIGHT SIDE|POLICY CRITERIA APPLIED,CASE-27570,APC,27570,CPT,0360,RC,,,RT|CG,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6864.73,,"Case rate ($6,632.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,128.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,596.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,650.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,152.78. The transfer operating threshold is the transfer adjustment factor * $6,128.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.82. The transfer capital threshold is the transfer adjustment factor * $479.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6632.59,19680.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
Inguinofem Lmphadec Supfc W/Cloquets Node Spx,CASE-38760,APC,38760,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15170.63,,"Case rate ($14,448.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,349.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,817.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,216.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,402.99. The transfer operating threshold is the transfer adjustment factor * $13,349.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,045.22. The transfer capital threshold is the transfer adjustment factor * $1,045.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6940.00,42872.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision/Curettage Cyst/Tumor Phalanx Finger,CASE-26210,APC,26210,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13880.59,,"Case rate ($13,880.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,825.31, add-ons for qualifying new technology services are included. If operating cost exceeds $48,293.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,876.42. The transfer operating threshold is the transfer adjustment factor * $12,825.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7285.00,41187.90,Inpatient DRG
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35566.18,,,,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",115392.91,115392.91,115392.91,1 through 10,other,28005.17,115392.91,There are no additional notes associated with this service or procedure.
HC Repr Smp Not Face 2.6-7.5cm,CASE-12002,APC,12002,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",184.47,184.47,184.47,1 through 10,other,190.30,211.83,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8006.25,,"Fee schedule rate ($8,006.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE|PO,CASE-29891,APC,29891,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16737.33,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",16430.50,16430.50,16737.34,1 through 10,other,16737.33,72192.67,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,8005.26,24549.95,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19056.10,,"Fee schedule rate ($19,056.10). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21991.57,,"Fee schedule rate ($21,991.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11350.83,,"Case rate ($10,810.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,988.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,456.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,028.25. The transfer operating threshold is the transfer adjustment factor * $9,988.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.04. The transfer capital threshold is the transfer adjustment factor * $782.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10810.31,32077.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Sgmdsc Flx Dired Sbmcsl Njx Any Sbst,CASE-45335,APC,45335,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,912.91,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12922.60,,"Case rate ($12,307.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,043.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $872.13. The transfer capital threshold is the transfer adjustment factor * $872.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12326.86,53121.74,Inpatient DRG
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,MAJOR",512,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],34346.92,,"Case rate ($32,711.35). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32711.35,34346.92,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12791.07,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",12791.07,12791.07,12791.07,1 through 10,other,12791.07,43031.63,Inpatient DRG
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE,CASE-27695,APC,27695,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23691.11,,,,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],27022.53,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25735.75,27022.53,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8981.78,,"Case rate ($8,981.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,671.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $657.72. The transfer capital threshold is the transfer adjustment factor * $657.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8981.78,27528.12,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],4553.45,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4464.17,13577.72,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],65555.62,,"Fee schedule rate ($65,555.62). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17102.83,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16524.47,58465.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17695.16,,of the excess amount.,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
Dstrj Lesion Anus Simple Laser Surg,CASE-46917,APC,46917,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],112149.06,,,,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, THIRD DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,APC,58662,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12228.46,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11814.94,44591.73,Inpatient DRG
Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr|LEFT SIDE|PO,CASE-28238,APC,28238,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7076.81,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6837.50,20288.95,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16320.00,,"Per diem ($16,320). If length of stay < 2.1, first 1 days paid at a per diem of $32,640 instead. Capped at $34,272.79.",,,,0,other,12093.45,40067.60,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6785.78,,"Case rate ($6,785.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,269.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,737.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,294.88. The transfer operating threshold is the transfer adjustment factor * $6,269.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.90. The transfer capital threshold is the transfer adjustment factor * $490.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6785.78,20135.47,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9046.80,,"Fee schedule rate ($9,046.80). Adds an outlier to normal pricing equal to the per diem rate ($4,143.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6654.93,20056.77,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Lysis Adhesions W/WO Manj Spx,CASE-29884,APC,29884,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB|PO",CASE-26418,APC,26418,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16361.19,,"Fee schedule rate ($16,361.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],70037.75,,"Fee schedule rate ($70,037.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.9), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8331.72,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7934.97,23545.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8030.94,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7648.51,27371.98,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16785.91,,"Fee schedule rate ($16,785.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7078.89,21005.20,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8023.33,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7866.01,25247.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,APC,31653,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3713.03,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3536.22,3713.03,OPPS APC
HC Removal Subcutaneous Cardiac Rhythm Monitor,CASE-33286,APC,33286,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9913.38,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9913.38,10409.05,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21320.03,,,,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],59216.74,,"Fee schedule rate ($59,216.74). Adds an outlier to normal pricing equal to the per diem rate ($89,749.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],43602.60,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,43602.60,153667.90,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34385.40,,"Fee schedule rate ($34,385.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],9799.00,,"Per diem ($9,799). If length of stay < 2.3, first 1 days paid at a per diem of $19,598 instead. Capped at $22,536.57.",,,,0,other,7952.22,25854.47,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|LEFT SIDE|PO,CASE-20550,APC,20550,CPT,0510,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,APC,31628,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3536.22,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4985.81,,"Case rate ($4,748.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.49. The transfer capital threshold is the transfer adjustment factor * $336.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4755.96,21133.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|PO,CASE-28090,APC,28090,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Laparoscopic Procedure Liver,CASE-47379,APC,47379,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5895.43,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5779.83,17150.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6387.91,18954.85,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11600.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11600.09,48814.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],129893.46,,"Fee schedule rate ($129,893.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5553.06,,"Case rate ($5,288.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.77. The transfer capital threshold is the transfer adjustment factor * $374.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5297.06,19049.64,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstrj Lesion Anus Simple Laser Surg,CASE-46917,APC,46917,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],42061.45,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",31782.03,31782.03,40470.14,1 through 10,other,40639.08,120588.53,Inpatient DRG
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,APC,20526,CPT,0510,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13789.07,,"Case rate ($13,789.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.54. The transfer capital threshold is the transfer adjustment factor * $997.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13789.07,57367.22,Inpatient DRG
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|LEFT FOOT, GREAT TOE|PO",CASE-28291,APC,28291,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8131.20,,"Case rate ($7,744). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,731.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $560.22. The transfer capital threshold is the transfer adjustment factor * $560.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7744.00,24853.45,Inpatient DRG
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],25210.33,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10632.00,103714.29,Inpatient DRG
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31563.88,,,,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],32082.48,,"Fee schedule rate ($32,082.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10556.32,32082.48,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FOURTH DIGIT|PO",CASE-26951,APC,26951,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
HC Intrvasc US Noncoronary 1st|RIGHT SIDE,CASE-37252,APC,37252,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5668.18,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19212.61,,"Case rate ($18,562.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,151.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,514.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,220.03. The transfer operating threshold is the transfer adjustment factor * $17,151.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.89. The transfer capital threshold is the transfer adjustment factor * $1,342.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,18562.91,73513.17,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6054.88,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5766.55,17111.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Biopsy Urethra,CASE-53200,APC,53200,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32406.65,,"Fee schedule rate ($32,406.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22978.80,,,,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25284.00,,"Fee schedule rate ($25,284). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9279.13,27534.03,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14344.20,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14062.94,61706.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12377.93,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12135.23,49469.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28289,APC,28289,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10818.26,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10818.26,38164.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17446.57,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9969.47,29582.40,All Other Inpatient
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,APC,49594,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5605.96,5605.96,5605.96,1 through 10,other,5733.99,6020.69,OPPS APC
Musc Myocutaneous/Fasciocutaneous Flap Trunk,CASE-15734,APC,15734,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6518.41,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,APC,57260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4744.66,,"APC Price ($4,744.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4744.66,4981.90,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],9763.00,,"Per diem ($9,763). If length of stay < 4, first 1 days paid at a per diem of $19,526 instead. Capped at $39,053.73.",,,,0,other,9763.00,48626.00,Estimated amount calculated based on 3 day length of stay.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30683.33,,"Fee schedule rate ($30,683.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6531.00,,"Per diem ($6,531). If length of stay < 4.1, first 1 days paid at a per diem of $13,062 instead. Capped at $26,776.27.",,,,0,other,6531.00,35832.77,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenolysis Extensor Tendon Hand/Finger Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26445,APC,26445,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37423.05,,"Fee schedule rate ($37,423.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13305.64,39481.90,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11131.05,,"Fee schedule rate ($11,131.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
HC Wound Vac <=50 Sq Cm Dme|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33692.09,,"Fee schedule rate ($33,692.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Lesion Meniscus/Capsule Knee,CASE-27347,APC,27347,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
HC Tib per Territory Plasty|RIGHT SIDE,CASE-37228,APC,37228,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],488.85,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6948.21,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5418.47,,"Case rate ($5,160.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,768.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,236.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,544.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,787.13. The transfer operating threshold is the transfer adjustment factor * $4,768.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.32. The transfer capital threshold is the transfer adjustment factor * $373.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5160.45,15312.64,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm|PO,CASE-11401,APC,11401,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3258.56,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10970.77,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10970.77,32553.63,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|SEPARATE PRACTITIONER,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XP,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],31205.66,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,30150.40,89465.42,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9833.51,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9833.51,45903.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14742.58,,"Case rate ($14,040.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,166.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.96. The transfer capital threshold is the transfer adjustment factor * $994.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14062.94,61706.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XS|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24154.93,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23338.10,69251.23,Inpatient DRG
Excision Pilonidal Cyst/Sinus Simple,CASE-11770,APC,11770,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",2789.86,2789.86,2789.86,1 through 10,other,2755.03,2892.78,OPPS APC
Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt,CASE-26531,APC,26531,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19984.73,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,8990.00,80069.53,Inpatient DRG
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],140535.66,,"Fee schedule rate ($140,535.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,36167.61,140535.66,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31927.90,,,,,,0,other,10759.91,46061.32,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],48389.68,,,,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11945.04,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",11635.93,11635.93,11635.93,1 through 10,other,11710.82,34749.58,Inpatient DRG
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11391.45,,"Fee schedule rate ($11,391.45). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16618.15,,"Case rate ($15,826.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.54. The transfer capital threshold is the transfer adjustment factor * $1,121.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13505.88,13505.88,13505.88,1 through 10,other,15852.04,50518.01,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,37575.69,Estimated amount calculated based on 11 day length of stay.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],38090.20,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36276.38,121107.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19668.75,,"Fee schedule rate ($19,668.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",17675.30,17675.30,17675.30,1 through 10,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],58656.71,,"Fee schedule rate ($58,656.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Intercost Sng|LEFT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Genicular Nrv Branches W/Img|PO,CASE-64454,APC,64454,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],23384.18,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,22593.41,90908.64,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],87816.48,,,,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12843.44,,"Case rate ($12,843.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,867.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,100.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,914.32. The transfer operating threshold is the transfer adjustment factor * $11,867.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.13. The transfer capital threshold is the transfer adjustment factor * $929.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,38110.41,Inpatient DRG
Repair Primary Open/Prq Ruptured Achilles Tendon|RIGHT SIDE|PO,CASE-27650,APC,27650,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21347.55,,"Fee schedule rate ($21,347.55). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11434.95,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11434.95,119072.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13831.52,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13831.52,59770.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14534.42,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14534.42,59012.52,Inpatient DRG
Open Treatment Fracture Distal Tibia & Fibula|LEFT SIDE|PO,CASE-27828,APC,27828,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",665.41,665.41,665.41,1 through 10,other,669.51,702.98,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22575.03,,"Fee schedule rate ($22,575.03). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9833.51,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9833.51,45903.36,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],49137.17,,"Fee schedule rate ($49,137.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15421.03,49137.17,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8912.15,,"Case rate ($8,487.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,772.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $601.47. The transfer capital threshold is the transfer adjustment factor * $601.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6178.00,25225.91,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],77530.52,,"Fee schedule rate ($77,530.52). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12326.86,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12326.86,53121.74,Inpatient DRG
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,FA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11588.33,,"Case rate ($11,036.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,227.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,773.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,451.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $10,233.04. The transfer operating threshold is the transfer adjustment factor * $10,227.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $803.46. The transfer capital threshold is the transfer adjustment factor * $803.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11036.50,33262.00,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24590.07,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23758.52,103116.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],47978.53,,"Fee schedule rate ($47,978.53). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
"MAJOR LARGE BOWEL PROCEDURES,MODERATE",231,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],25461.19,,"Case rate ($25,461.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,25461.19,26734.25,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18263.70,,"Fee schedule rate ($18,263.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
Excision Interdigital Morton Neuroma Single Each|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6837.50,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6837.50,20288.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5668.40,,"Case rate ($5,668.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,581.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.07. The transfer capital threshold is the transfer adjustment factor * $410.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5668.40,16903.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis 20 Cm/<,CASE-97597,APC,97597,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],196.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",192.20,192.20,192.20,1 through 10,other,196.96,196.96,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],136003.49,,,,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5107.43,,"Case rate ($5,007.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,626.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,094.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,645.03. The transfer operating threshold is the transfer adjustment factor * $4,626.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.24. The transfer capital threshold is the transfer adjustment factor * $362.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5007.28,16142.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7934.97,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7934.97,23545.50,Inpatient DRG
Open Treatment Bimalleolar Ankle Fracture,CASE-27814,APC,27814,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrt Elbow W/Exploration Drainage/Removal FB,CASE-24000,APC,24000,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
"HC Debrid,Bone,1st 20sqcm or Less|UNUSUAL NON-OVERLAPPING SERVICE",CASE-11044,APC,11044,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],42212.88,,"Case rate ($40,202.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,146.33, add-ons for qualifying new technology services are included. If operating cost exceeds $72,614.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,079.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $37,294.37. The transfer operating threshold is the transfer adjustment factor * $37,146.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.37. The transfer capital threshold is the transfer adjustment factor * $2,908.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40202.74,148703.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9860.61,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",9518.84,9518.84,9518.84,1 through 10,other,9527.16,28269.95,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8919.07,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8919.07,34453.70,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4993.11,,"Case rate ($4,895.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,523.05, add-ons for qualifying new technology services are included. If operating cost exceeds $39,990.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,541.07. The transfer operating threshold is the transfer adjustment factor * $4,523.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.13. The transfer capital threshold is the transfer adjustment factor * $354.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4895.21,14525.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18796.76,,"Fee schedule rate ($18,796.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6632.59,19680.94,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4979.12,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4742.02,14071.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,MAJOR",248,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14907.65,,"Case rate ($14,197.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14197.76,14907.65,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32341.12,,,,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Genicular Nrv Branches W/Img|PO,CASE-64454,APC,64454,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE,CASE-27650,APC,27650,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Inject Nerv Blck,Paravert Sympath|RIGHT SIDE",CASE-64520,APC,64520,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23045.28,,"Case rate ($22,593.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,875.74, add-ons for qualifying new technology services are included. If operating cost exceeds $56,343.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,805.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $20,958.94. The transfer operating threshold is the transfer adjustment factor * $20,875.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,634.46. The transfer capital threshold is the transfer adjustment factor * $1,634.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,22593.41,90908.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5386.10,,"Case rate ($5,280.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,879.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,346.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,553.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,898.48. The transfer operating threshold is the transfer adjustment factor * $4,879.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $382.00. The transfer capital threshold is the transfer adjustment factor * $382.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5280.49,17810.78,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7712.73,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6308.00,21796.21,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,Zero final payments for the item or service in the 15 months prior to posting the file.
Litholapaxy Comp/Lg > 2.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52318,APC,52318,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3686.99,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3209.85,10940.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26297.04,,"Fee schedule rate ($26,297.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,9279.13,27534.03,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],41585.15,,"Fee schedule rate ($41,585.15). Adds an outlier to normal pricing equal to the per diem rate ($65,246.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14673.67,43541.27,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64418,APC,64418,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10030.18,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9833.51,45903.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10518.52,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6010.58,17835.23,All Other Inpatient
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10886.39,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10367.99,37103.57,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25457.25,,"Fee schedule rate ($25,457.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37852.57,,"Fee schedule rate ($37,852.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11588.33,,"Case rate ($11,036.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,227.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,773.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,451.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $10,233.04. The transfer operating threshold is the transfer adjustment factor * $10,227.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $803.46. The transfer capital threshold is the transfer adjustment factor * $803.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11036.50,33262.00,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5773.19,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5773.19,31196.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],44580.21,,,,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4613.65,,"Case rate ($4,523.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,179.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,647.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,498.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,195.97. The transfer operating threshold is the transfer adjustment factor * $4,179.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $327.22. The transfer capital threshold is the transfer adjustment factor * $327.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4523.19,16536.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16747.70,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15950.19,63458.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10114.70,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5779.83,17150.47,All Other Inpatient
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9929.69,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9456.85,28061.37,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15950.19,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,15950.19,63458.56,Inpatient DRG
Revj Opn Arven Fstl W/O Thrmbc Dial Grf,CASE-36832,APC,36832,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5356.55,5356.55,5356.55,1 through 10,other,5277.74,5541.62,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15117.46,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8442.00,28788.33,All Other Inpatient
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],37433.48,,"Case rate ($36,167.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,417.97, add-ons for qualifying new technology services are included. If operating cost exceeds $68,885.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,787.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $33,551.16. The transfer operating threshold is the transfer adjustment factor * $33,417.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,616.46. The transfer capital threshold is the transfer adjustment factor * $2,616.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,36167.61,140535.66,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49594,APC,49594,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
Ostectomy Complete 5th Metatarsal Head|LEFT SIDE,CASE-28113,APC,28113,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Fasciectomy Plantar Fascia Partial Spx|BILATERAL PROCEDURE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4418.42,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4418.42,13110.79,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6632.59,,"Case rate ($6,632.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,128.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,596.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,650.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,152.78. The transfer operating threshold is the transfer adjustment factor * $6,128.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.82. The transfer capital threshold is the transfer adjustment factor * $479.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6632.59,19680.94,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23602.02,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",21957.72,21957.72,23602.03,1 through 10,other,23602.02,108295.22,Inpatient DRG
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|PREVENTIVE SERVICES,CASE-45385,APC,45385,CPT,0360,RC,,,33,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36807.99,,"Fee schedule rate ($36,807.99). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16207.80,,"Fee schedule rate ($16,207.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5348.00,,"Per diem ($5,348). If length of stay < 2.7, first 1 days paid at a per diem of $10,696 instead. Capped at $14,438.66.",,,,0,other,5094.80,15365.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,Zero final payments for the item or service in the 15 months prior to posting the file.
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
"Exc Lesion Tendon Sheath/Capsule W/Synvct Toe Ea|LEFT FOOT, GREAT TOE|PO",CASE-28092,APC,28092,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10233.67,,"Case rate ($9,746.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,861.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $690.66. The transfer capital threshold is the transfer adjustment factor * $690.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9761.89,37873.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
Patellectomy/Hemipatellectomy,CASE-27350,APC,27350,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24946.45,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23758.52,103116.16,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8165.37,,"Case rate ($8,005.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,396.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,864.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,750.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,426.15. The transfer operating threshold is the transfer adjustment factor * $7,396.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.12. The transfer capital threshold is the transfer adjustment factor * $579.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8005.26,24549.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6630.72,19989.86,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|RIGHT SIDE|PO,CASE-23430,APC,23430,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7732.24,,"Case rate ($4,418.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,490.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4418.42,13110.79,All Other Inpatient
Excision/Curettage Cyst/Tumor Femur|RIGHT SIDE,CASE-27355,APC,27355,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,MINOR",511,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6513.27,,"Case rate for a one day stay ($6,203.11). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6203.11,6513.27,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T7|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],67008.32,,"Fee schedule rate ($67,008.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment of Ulnar Shaft Fracture,CASE-25545,APC,25545,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],129256.37,,"Fee schedule rate ($129,256.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17136.70,,,,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
"PULMONARY EMBOLISM,MAJOR",134,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15851.98,,"Case rate ($15,097.12). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15097.12,15851.98,There are no additional notes associated with this service or procedure.
"OTHER GASTROENTERITIS NAUSEA AND VOMITING,MAJOR",249,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2400.16,,"Case rate for a one day stay ($2,285.87). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2285.87,2400.16,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16831.01,,"Fee schedule rate ($16,831.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],30766.94,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,30163.67,89504.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|RIGHT SIDE|PO,CASE-28119,APC,28119,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE,CASE-27822,APC,27822,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt,CASE-28309,APC,28309,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22389.93,,"Fee schedule rate ($22,389.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12505.28,,"Fee schedule rate ($12,505.28). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],11137.18,,,,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-54840,APC,54840,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],661.36,,"APC Price ($661.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,661.36,694.43,OPPS APC
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE,CASE-27570,APC,27570,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE|PO,CASE-27650,APC,27650,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,76310.36,Estimated amount calculated based on 21 day length of stay.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14158.20,,"Case rate ($13,880.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,825.31, add-ons for qualifying new technology services are included. If operating cost exceeds $48,293.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,876.42. The transfer operating threshold is the transfer adjustment factor * $12,825.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7285.00,41187.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],38106.57,,"Fee schedule rate ($38,106.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16573.70,,"Fee schedule rate ($16,573.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6632.59,19680.94,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5248.57,,"Case rate ($4,998.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,625.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,093.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,644.42. The transfer operating threshold is the transfer adjustment factor * $4,625.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.22. The transfer capital threshold is the transfer adjustment factor * $354.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5006.61,14856.14,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14390.10,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13704.86,49911.01,Inpatient DRG
Repair Secondary Disrupted Ligament Ankle Coltrl|RIGHT SIDE|PO,CASE-27698,APC,27698,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE,CASE-27680,APC,27680,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11962.15,,"Case rate ($11,962.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,052.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,520.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,036.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,096.78. The transfer operating threshold is the transfer adjustment factor * $11,052.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.37. The transfer capital threshold is the transfer adjustment factor * $865.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11962.15,40923.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14108.15,,"Case rate ($13,831.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.61. The transfer capital threshold is the transfer adjustment factor * $1,000.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13831.52,59770.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Balloon Dilate Biliary/Panc Duct/Ampulla Ea,CASE-43277,APC,43277,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19377.46,,"Fee schedule rate ($19,377.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
"HC Debrid,Subq Ea Addt'l 20sqcm|PBB CHARGE",CASE-11045,APC,11045,CPT,0361,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],66275.39,,"Fee schedule rate ($66,275.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],33404.17,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",409852.01,409852.01,409852.01,1 through 10,other,32749.19,97176.83,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],158423.11,,"Fee schedule rate ($158,423.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14766.09,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14062.94,61706.77,Inpatient DRG
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,MODERATE",174,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],34261.33,,"Case rate ($32,629.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32629.84,34261.33,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19232.02,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19232.02,68941.12,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35520.39,,"Fee schedule rate ($35,520.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14344.20,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14062.94,61706.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],65555.62,,"Fee schedule rate ($65,555.62). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12521.78,,"Fee schedule rate ($12,521.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],25281.41,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9242.00,76216.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],45609.21,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,45609.21,211906.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36645.84,,"Fee schedule rate ($36,645.84). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10687.94,,"Case rate ($10,178.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,405.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,873.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,442.63. The transfer operating threshold is the transfer adjustment factor * $9,405.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10178.99,36468.17,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12135.23,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12135.23,49469.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Brow Ptosis,CASE-67900,APC,67900,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2367.72,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2254.97,2367.72,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7020.54,28431.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Brow Ptosis,CASE-67900,APC,67900,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17477.25,,"Fee schedule rate ($17,477.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15430.11,,"Case rate ($14,695.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,212.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,041.36. The transfer capital threshold is the transfer adjustment factor * $1,041.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",14611.86,14611.86,14611.86,1 through 10,other,14718.77,51765.74,Inpatient DRG
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE,CASE-28090,APC,28090,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6972.00,,"Per diem ($6,972). If length of stay < 3.6, first 1 days paid at a per diem of $13,944 instead. Capped at $25,099.93.",,,,0,other,6972.00,26280.60,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29947.05,,"Fee schedule rate ($29,947.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
Syndactylization Toes|BILATERAL PROCEDURE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
HC Intro Cath Dialysis Circuit W Pta,CASE-36902,APC,36902,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5398.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
Rpr Nonunion/Malunion Radius/Ulna W/Autograft|LEFT SIDE|PO,CASE-25405,APC,25405,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27868.14,,"Fee schedule rate ($27,868.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
Blepharoplasty Lower Eyelid|BILATERAL PROCEDURE,CASE-15820,APC,15820,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2333.89,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12107.67,,"Case rate ($11,698.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,808.87, add-ons for qualifying new technology services are included. If operating cost exceeds $46,276.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,017.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,851.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.28. The transfer capital threshold is the transfer adjustment factor * $846.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11698.23,34712.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14659.16,,"Case rate ($13,961.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,920.28, add-ons for qualifying new technology services are included. If operating cost exceeds $48,388.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,160.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,971.77. The transfer operating threshold is the transfer adjustment factor * $12,920.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.33. The transfer capital threshold is the transfer adjustment factor * $989.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",14659.17,14659.17,14659.17,1 through 10,other,7770.00,50313.90,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11888.55,,"Case rate ($11,888.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,984.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,452.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,028.49. The transfer operating threshold is the transfer adjustment factor * $10,984.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.05. The transfer capital threshold is the transfer adjustment factor * $860.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11888.55,35276.93,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],43434.38,,"Fee schedule rate ($43,434.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],115171.02,,"Fee schedule rate ($115,171.02). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],36070.49,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,18559.00,141041.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],31574.13,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,18042.36,82749.58,All Other Inpatient
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],9242.00,,"Per diem ($9,242). If length of stay < 7.6, first 1 days paid at a per diem of $18,484 instead. Capped at $70,242.60.",,,,0,other,9242.00,76216.30,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14525.56,,,,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4765.36,,"Case rate ($4,538.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,193.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,661.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,499.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,210.12. The transfer operating threshold is the transfer adjustment factor * $4,193.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.32. The transfer capital threshold is the transfer adjustment factor * $328.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4538.44,18815.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20499.75,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11714.14,49460.19,All Other Inpatient
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52352,APC,52352,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5263.48,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4120.67,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4120.67,13066.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],54086.17,,,,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Lig/Banding Angioaccess Arteriovenous Fistula,CASE-37607,APC,37607,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,APC,49321,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",627.89,627.89,627.89,1 through 10,other,5733.99,6020.69,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25636.16,,"Fee schedule rate ($25,636.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19881.64,,,,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Revasc lithotrip tibi/perone,CASE-C9772,APC,C9772,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10818.26,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10818.26,38164.94,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6010.58,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6010.58,17835.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7970.35,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7590.81,32847.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Tibia|LEFT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8228.75,,"Case rate ($8,228.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.29. The transfer capital threshold is the transfer adjustment factor * $595.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8228.75,24417.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arven Anast Opn Upr Arm Basilic Vein Trpos,CASE-36819,APC,36819,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5541.62,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",5269.36,5269.36,5269.36,1 through 10,other,5462.46,5541.62,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",56919.52,56919.52,56919.52,1 through 10,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6092.61,,"Case rate ($5,886.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,597.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.85. The transfer capital threshold is the transfer adjustment factor * $425.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5886.58,17467.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],81161.07,,"Fee schedule rate ($81,161.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,30480.63,86382.02,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14936.25,,"Fee schedule rate ($14,936.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
Partial Excision Bone Tibia|LEFT SIDE|PO,CASE-27640,APC,27640,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29049.23,,"Fee schedule rate ($29,049.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FOURTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T3|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6044.58,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6044.58,6346.81,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3781.76,,"Case rate ($3,601.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,426.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $255.23. The transfer capital threshold is the transfer adjustment factor * $255.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",3781.76,3781.76,3781.76,1 through 10,other,3607.42,11497.58,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,10492.66,31134.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],78047.33,,"Fee schedule rate ($78,047.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29407.28,,,,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6381.43,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6077.55,18033.97,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10003.52,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9527.16,28269.95,Inpatient DRG
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8856.72,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8667.77,4816.46,8856.72,25,other,6972.00,26280.60,Inpatient DRG
HC Joint Injection/Aspir Medium WO US|LEFT SIDE,CASE-20605,APC,20605,CPT,0510,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8410.44,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8410.44,24956.34,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10112.55,,"Fee schedule rate ($10,112.55). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15104.07,,"Fee schedule rate ($15,104.07). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14804.16,,"Fee schedule rate ($14,804.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],48758.41,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,27861.95,82674.88,All Other Inpatient
Corrj Hallux Valgus W/Sesmdc W/2 Osteot,CASE-28299,APC,28299,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",6631.95,6631.95,6631.95,1 through 10,other,6882.29,7226.40,OPPS APC
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32406.65,,"Fee schedule rate ($32,406.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10282.71,,"Case rate ($9,793.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $44,516.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,879.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,084.61. The transfer operating threshold is the transfer adjustment factor * $9,048.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.45. The transfer capital threshold is the transfer adjustment factor * $708.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9793.06,29058.99,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn,CASE-64448,APC,64448,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Circumcision Age >28 Days,CASE-54161,APC,54161,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5091.00,,"Per diem ($5,091). If length of stay < 3.2, first 1 days paid at a per diem of $10,182 instead. Capped at $16,289.77.",,,,0,other,5091.00,22010.11,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22695.45,,,,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],42053.55,,"Fee schedule rate ($42,053.55). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11962.14,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6835.51,20283.05,All Other Inpatient
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12335.32,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12093.45,40067.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10925.79,,"Case rate ($10,556.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,934.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.67. The transfer capital threshold is the transfer adjustment factor * $763.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",10925.79,10925.79,10925.79,1 through 10,other,10556.32,32082.48,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
Repair Primary Open/Prq Ruptured Achilles Tendon|RIGHT SIDE|PO,CASE-27650,APC,27650,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7335.51,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7335.51,29792.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],102660.52,,"Fee schedule rate ($102,660.52). Adds an outlier to normal pricing equal to the per diem rate ($180,358.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],36370.09,,"Fee schedule rate ($36,370.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
Open Tx Tibial Fracture Proximal Unicondylar|LEFT SIDE,CASE-27535,APC,27535,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7287.29,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6940.28,20593.95,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
Arthrs Aid Tibial Fracture Proximal Unicondylar|RIGHT SIDE,CASE-29855,APC,29855,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6074.24,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6074.24,18024.13,Inpatient DRG
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg,CASE-29881,APC,29881,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Fasciectomy Plantar Fascia Radical Spx|RIGHT SIDE,CASE-28062,APC,28062,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",25814.06,25814.06,25814.06,1 through 10,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31893.32,,"Fee schedule rate ($31,893.32). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17103.38,50750.92,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28291,APC,28291,CPT,0360,RC,,,T5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6816.94,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5520.00,26638.96,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],51711.33,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",52037.50,52037.50,52037.50,1 through 10,other,13061.00,162464.13,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7257.26,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7257.26,23445.98,Inpatient DRG
"MIGRAINE AND OTHER HEADACHES,MODERATE",054,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],3263.58,,"Case rate for a one day stay ($3,263.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3263.58,3426.76,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18508.54,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18508.54,76171.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12837.14,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7335.51,29792.90,All Other Inpatient
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,APC,43274,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|LEFT SIDE,CASE-27680,APC,27680,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis 20 Cm/<|ADJ,CASE-97597,APC,97597,CPT,0761,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|PO|LEFT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|PO|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transposition Ulnar Nerve Elbow|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5797.33,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5683.66,16865.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13272.11,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7231.00,38610.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Tibia|LEFT SIDE|PO,CASE-27640,APC,27640,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|BILATERAL PROCEDURE,CASE-49507,APC,49507,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5758.05,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5758.05,6045.95,OPPS APC
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24850.18,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10632.00,103714.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12500.00,,"Per diem ($12,500). If length of stay < 4.8, first 1 days paid at a per diem of $25,000 instead. Capped at $60,002.29.",,,,0,other,12500.00,83592.64,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],23223.02,,"Case rate ($22,117.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,738.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.30. The transfer capital threshold is the transfer adjustment factor * $1,567.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",17326.19,17326.19,17326.19,1 through 10,other,9370.00,65732.99,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9103.53,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8925.03,26628.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],39867.32,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29179.02,,,,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7686.98,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7686.98,22809.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
Tenolysis Flexor Tendon Palm/Finger Each Tendon,CASE-26440,APC,26440,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19033.08,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",19026.62,19026.62,19026.62,1 through 10,other,8990.00,80069.53,Inpatient DRG
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Vasc Embolize Occlude Organ|BILATERAL PROCEDURE,CASE-37243,APC,37243,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
"ALCOHOLIC LIVER DISEASE,MAJOR",280,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],16361.13,,"Case rate ($15,582.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15582.03,16361.13,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11953.81,,"Case rate ($11,384.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,519.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,986.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,994.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,560.98. The transfer operating threshold is the transfer adjustment factor * $10,519.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.59. The transfer capital threshold is the transfer adjustment factor * $823.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11384.58,33781.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER CIRCULATORY SYSTEM DIAGNOSES,MODERATE",207,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9405.59,,"Case rate ($8,957.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8957.70,9405.59,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15737.40,,"Fee schedule rate ($15,737.40). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11759.58,,"Case rate ($11,199.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,364.65, add-ons for qualifying new technology services are included. If operating cost exceeds $45,832.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,405.96. The transfer operating threshold is the transfer adjustment factor * $10,364.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.64. The transfer capital threshold is the transfer adjustment factor * $793.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11217.46,37366.25,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Cptr-Asst Surgical Navigation Image-Less,CASE-20985,APC,20985,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17212.32,OPPS APC
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7867.48,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7601.43,23918.09,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10325.19,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9833.51,45903.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg,CASE-29881,APC,29881,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MALFUNCTION REACTION COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE,MODERATE",206,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2779.29,,"Case rate for a one day stay ($2,779.29). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2779.29,2918.25,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10173.70,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10173.70,41194.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15507.88,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15507.88,46016.63,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9886.08,,"Case rate ($9,415.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,838.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $667.20. The transfer capital threshold is the transfer adjustment factor * $667.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",5590.11,5590.11,5590.11,1 through 10,other,6965.00,45869.64,Inpatient DRG
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,32749.19,97176.83,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],56089.29,,,,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, SECOND DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],80720.91,,"Fee schedule rate ($80,720.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20885.18,80720.91,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12961.20,,"Fee schedule rate ($12,961.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Extremity Venogram,CASE-36005,APC,36005,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1545.29,,"APC Price ($1,493.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1493.03,1545.29,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],49460.19,,"Fee schedule rate ($49,460.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,11714.14,49460.19,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30977.50,,,,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13312.70,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13051.67,38728.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25503.05,,"Fee schedule rate ($25,503.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9744.48,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9280.46,39957.56,Inpatient DRG
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],39297.79,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],25564.74,,"Case rate ($24,347.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,496.37, add-ons for qualifying new technology services are included. If operating cost exceeds $57,964.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,932.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,586.02. The transfer operating threshold is the transfer adjustment factor * $22,496.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.35. The transfer capital threshold is the transfer adjustment factor * $1,761.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10455.00,90889.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39198.44,,"Fee schedule rate ($39,198.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8925.03,26628.31,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5520.00,,"Per diem ($5,520). If length of stay < 3.5, first 1 days paid at a per diem of $11,040 instead. Capped at $19,319.20.",,,,0,other,5520.00,26638.96,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21172.33,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",14703.89,14703.89,14703.89,1 through 10,other,12500.00,83592.64,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],50697.38,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13061.00,162464.13,Inpatient DRG
Osteotomy Calcaneus W/WO Internal Fixation|RIGHT SIDE,CASE-28300,APC,28300,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"MALFUNCTION REACTION COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE,MODERATE",466,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9687.00,,"Case rate ($9,225.71). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9225.71,9687.00,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7702.29,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7335.51,29792.90,Inpatient DRG
Unlisted Procedure Male Genital System,CASE-55899,APC,55899,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],236.97,,"APC Price ($236.97). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,236.97,248.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],103171.69,,"Fee schedule rate ($103,171.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],38728.26,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,66445.54,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct|SEPARATE STRUCTURE,CASE-43275,APC,43275,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24204.34,,"Case rate ($23,385.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,607.93, add-ons for qualifying new technology services are included. If operating cost exceeds $57,075.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,862.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $21,694.05. The transfer operating threshold is the transfer adjustment factor * $21,607.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,23385.84,71764.93,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3162.78,3162.78,3162.78,1 through 10,other,6882.29,7226.40,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24906.74,,"Case rate ($23,720.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,852.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,680.93. The transfer capital threshold is the transfer adjustment factor * $1,680.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23758.52,103116.16,Inpatient DRG
HC Removal FB Skin|PO,CASE-10120,APC,10120,CPT,0450,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16775.44,,"Case rate ($16,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,975.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,443.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,343.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,035.61. The transfer operating threshold is the transfer adjustment factor * $14,975.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,172.54. The transfer capital threshold is the transfer adjustment factor * $1,172.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",280997.85,280997.85,280997.85,1 through 10,other,16208.15,58123.31,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7620.12,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7257.26,23445.98,Inpatient DRG
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|RIGHT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,XS|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia & Fibula|RIGHT SIDE,CASE-27828,APC,27828,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11055.00,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11055.00,49295.13,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,APC,20526,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18753.00,,"Fee schedule rate ($18,753). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7041.82,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5843.00,27370.21,Inpatient DRG
Incision & Drainage Leg/Ankle Abscess/Hematoma|LEFT SIDE,CASE-27603,APC,27603,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
Ostectomy Complete 5th Metatarsal Head|LEFT SIDE|PO,CASE-28113,APC,28113,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3103.39,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],14842.71,,"Fee schedule rate ($14,842.71). Adds an outlier to normal pricing equal to the per diem rate ($40,567.35) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5237.39,15540.89,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],41015.72,,"Fee schedule rate ($41,015.72). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Trluml Balo Angiop 1st Vein,CASE-37248,APC,37248,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12348.58,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7056.33,28335.74,All Other Inpatient
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],85483.72,,"Fee schedule rate ($85,483.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
Aspiration Bladder Insert Suprapubic Catheter|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51102,APC,51102,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],78395.14,,,,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SICKLE CELL ANEMIA CRISIS,MODERATE",662,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9671.94,,"Case rate ($9,671.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9671.94,10155.54,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
Rhytidectomy Neck W/Platysmal Tightening|PO,CASE-15825,APC,15825,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2333.89,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2333.89,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE|PO,CASE-24342,APC,24342,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14118.54,,"Case rate ($13,446.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,423.98, add-ons for qualifying new technology services are included. If operating cost exceeds $47,891.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,143.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,473.49. The transfer operating threshold is the transfer adjustment factor * $12,423.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.73. The transfer capital threshold is the transfer adjustment factor * $972.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13446.23,39899.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
"CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,EXTREME",165,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],106775.99,,"Case rate ($101,691.42). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $55,584, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,101691.42,106775.99,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21270.90,,"Fee schedule rate ($21,270.90). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],67775.08,,"Fee schedule rate ($67,775.08). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31790.24,,"Fee schedule rate ($31,790.24). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,11217.46,37366.25,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12623.63,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6965.00,21404.64,All Other Inpatient
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,Zero final payments for the item or service in the 15 months prior to posting the file.
Claviculectomy Partial|LEFT SIDE,CASE-23120,APC,23120,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],88188.38,,,,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28569.12,,"Fee schedule rate ($28,569.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16320.00,,"Per diem ($16,320). If length of stay < 2.1, first 1 days paid at a per diem of $32,640 instead. Capped at $34,272.79.",,,,0,other,12093.45,40067.60,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12065.11,,"Fee schedule rate ($12,065.11). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10638.72,,"Fee schedule rate ($10,638.72). Adds an outlier to normal pricing equal to the per diem rate ($26,031.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",5866.30,5866.30,5866.30,1 through 10,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],32296.30,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36028.59,,,,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],58534.56,,"Fee schedule rate ($58,534.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],69619.39,,"Fee schedule rate ($69,619.39). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",23891.96,23891.96,23891.96,1 through 10,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Disrupted Ligament Ankle Coltrl|LEFT SIDE,CASE-27698,APC,27698,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12603.27,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16865.16,,,,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4687.38,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4464.17,13577.72,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10730.87,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10367.99,37103.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42003.98,,"Fee schedule rate ($42,003.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21377.32,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20654.42,69402.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39228.51,,"Fee schedule rate ($39,228.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7984.05,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7984.05,33319.56,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7151.91,,"Case rate ($6,910.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,405.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,149.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,408.97. The transfer operating threshold is the transfer adjustment factor * $6,405.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $501.10. The transfer capital threshold is the transfer adjustment factor * $501.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6910.06,20832.04,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33771.02,,"Fee schedule rate ($33,771.02). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7003.94,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7003.94,20782.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16831.01,,"Fee schedule rate ($16,831.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, THUMB|PO",CASE-26525,APC,26525,CPT,0360,RC,,,FA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],68116.02,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,64872.40,212258.00,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",27725.18,27725.18,27725.18,1 through 10,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7763.15,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7500.63,22256.65,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],76163.76,,,,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],48194.42,,"Case rate ($27,539.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,445.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,913.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,163.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $25,547.38. The transfer operating threshold is the transfer adjustment factor * $25,445.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,992.29. The transfer capital threshold is the transfer adjustment factor * $1,992.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,27539.67,109237.68,All Other Inpatient
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7197.46,,"Case rate ($7,056.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,519.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,987.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,681.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,545.86. The transfer operating threshold is the transfer adjustment factor * $6,519.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.47. The transfer capital threshold is the transfer adjustment factor * $510.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7056.33,28335.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],108024.76,,,,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Cervical Node,CASE-38510,APC,38510,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7160.95,,"Case rate ($7,020.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,679.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.88. The transfer capital threshold is the transfer adjustment factor * $507.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7020.54,28431.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19698.48,,"Case rate ($19,312.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,568.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.10. The transfer capital threshold is the transfer adjustment factor * $1,397.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8972.00,76376.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt|BILATERAL PROCEDURE,CASE-38570,APC,38570,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Medial Malleolus Fracture|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27766,APC,27766,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,There are no additional notes associated with this service or procedure.
Ligj & Div Short Saph Vein Saphenopop Junct Spx,CASE-37780,APC,37780,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],14651.02,,"Fee schedule rate ($14,651.02). Adds an outlier to normal pricing equal to the per diem rate ($61,007.55) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",14498.75,14498.75,14498.75,1 through 10,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18591.93,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,18227.38,54086.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],69392.91,,,,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Multiple External Papillae/Tags Anus,CASE-46230,APC,46230,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7439.07,,"Case rate ($7,084.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,556.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,024.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,582.77. The transfer operating threshold is the transfer adjustment factor * $6,556.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.06. The transfer capital threshold is the transfer adjustment factor * $502.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",13828.41,7439.07,14910.14,1 through 10,other,7096.13,25801.23,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5379.29,15961.98,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41030.48,,,,,,0,other,13827.53,41030.48,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14625.15,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,14130.58,57770.11,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6105.10,,"Case rate ($5,985.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,530.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,998.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,552.39. The transfer operating threshold is the transfer adjustment factor * $5,530.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.00. The transfer capital threshold is the transfer adjustment factor * $433.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5985.39,17760.46,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4968.82,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4968.82,19848.33,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
Excision Vaginal Cyst/Tumor,CASE-57135,APC,57135,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE|PO,CASE-27792,APC,27792,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE|PO",CASE-28289,APC,28289,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5775.17,17136.70,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28825,APC,28825,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Rmvl/Revj Sling Stress Incontinence,CASE-57287,APC,57287,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3223.82,,"APC Price ($3,070.31). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
Rpr 1st Fem Hernia Any Age Incarcerated,CASE-49553,APC,49553,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3395.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42949.98,,"Fee schedule rate ($42,949.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10880.82,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10362.69,29367.82,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],75543.62,,"Fee schedule rate ($75,543.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23582.79,75543.62,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],32004.66,,"Case rate ($30,480.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,163.35, add-ons for qualifying new technology services are included. If operating cost exceeds $63,631.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,376.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,275.59. The transfer operating threshold is the transfer adjustment factor * $28,163.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,205.05. The transfer capital threshold is the transfer adjustment factor * $2,205.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30480.63,86382.02,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5732.06,,"Case rate ($5,732.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,296.29, add-ons for qualifying new technology services are included. If operating cost exceeds $40,764.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,317.40. The transfer operating threshold is the transfer adjustment factor * $5,296.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.67. The transfer capital threshold is the transfer adjustment factor * $414.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5732.06,21720.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16817.56,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16817.56,58510.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37305.91,,"Fee schedule rate ($37,305.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30683.33,,"Fee schedule rate ($30,683.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.5 Cm/<,CASE-11400,APC,11400,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],695.15,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,671.64,705.22,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],48389.68,,,,,,0,other,8558.00,48389.68,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",13574.76,13574.76,13574.76,1 through 10,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8021.19,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6495.00,23801.30,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9860.61,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9527.16,28269.95,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9896.28,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9425.03,27966.92,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21927.57,,"Fee schedule rate ($21,927.57). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,There are no additional notes associated with this service or procedure.
Partial Excision Bone Tibia|LEFT SIDE,CASE-27640,APC,27640,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],53537.18,,,,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12093.45,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12093.45,35884.94,Inpatient DRG
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, SECOND DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16831.01,,"Fee schedule rate ($16,831.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],77113.05,,"Fee schedule rate ($77,113.05). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30254.51,130347.93,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6953.00,,"Per diem ($6,953). If length of stay < 4.5, first 1 days paid at a per diem of $13,906 instead. Capped at $31,286.59.",,,,0,other,6953.00,35389.05,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],8558.00,,"Per diem ($8,558). If length of stay < 5.4, first 1 days paid at a per diem of $17,116 instead. Capped at $46,215.75.",,,,0,other,8558.00,48389.68,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9094.27,,"Case rate ($8,661.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,784.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $613.76. The transfer capital threshold is the transfer adjustment factor * $613.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8675.02,25741.45,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11699.11,,"Case rate ($11,142.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,311.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,779.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,352.44. The transfer operating threshold is the transfer adjustment factor * $10,311.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.56. The transfer capital threshold is the transfer adjustment factor * $789.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11159.78,39897.21,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16050.66,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15507.88,46016.63,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12235.09,,"Case rate ($11,652.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,014.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.97. The transfer capital threshold is the transfer adjustment factor * $842.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11652.47,41507.02,Inpatient DRG
Arven Anast Opn Upr Arm Basilic Vein Trpos|LEFT SIDE,CASE-36819,APC,36819,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],110217.19,,"Fee schedule rate ($110,217.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,38891.09,169197.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,APC,52351,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28028.68,,"Fee schedule rate ($28,028.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38228.48,,,,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,APC,51990,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL AND OTHER VASCULAR DISORDERS,MODERATE",197,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8931.45,,"Case rate ($8,931.45). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8931.45,9378.02,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC
HC Stent Place Initial Artery Ang|LEFT SIDE,CASE-37236,APC,37236,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9365.02,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8919.07,34453.70,Inpatient DRG
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20179.92,,"Fee schedule rate ($20,179.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,1188.00,20179.92,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6350.00,,"Per diem ($6,350). If length of stay < 5, first 1 days paid at a per diem of $12,700 instead. Capped at $31,750.77.",,,,0,other,6350.00,33244.29,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7179.38,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6837.50,20288.95,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15373.24,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14641.18,43444.85,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4870.41,,"Case rate ($4,870.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,514.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,060.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,001.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,517.21. The transfer operating threshold is the transfer adjustment factor * $4,514.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.19. The transfer capital threshold is the transfer adjustment factor * $353.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4870.41,14682.98,Inpatient DRG
"Open Treatment Metatarsal Fracture Each|RIGHT FOOT, FIFTH DIGIT",CASE-28485,APC,28485,CPT,0360,RC,,,T9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5486.04,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5486.04,17919.05,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8716.15,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8716.15,25863.45,Inpatient DRG
"Inject Nerv Blck,Paravert Sympath|PO",CASE-64520,APC,64520,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],29430.73,,"Case rate ($16,817.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,539.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,006.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,387.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,600.94. The transfer operating threshold is the transfer adjustment factor * $15,539.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.63. The transfer capital threshold is the transfer adjustment factor * $1,216.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,16817.56,58510.23,All Other Inpatient
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Metatarsal Fracture Each|RIGHT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
"FOOT AND TOE PROCEDURES,MODERATE",314,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],16929.00,,"Case rate ($16,929.00). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,16929.00,17775.45,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4741.79,,"Case rate ($4,515.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,179.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,647.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,491.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,195.97. The transfer operating threshold is the transfer adjustment factor * $4,179.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $320.02. The transfer capital threshold is the transfer adjustment factor * $320.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4523.19,16536.43,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Revj Opn Arven Fstl W/O Thrmbc Dial Grf,CASE-36832,APC,36832,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11763.70,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6350.00,33244.29,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12161.39,,"Case rate ($11,582.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,991.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.76. The transfer capital threshold is the transfer adjustment factor * $820.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11600.75,34422.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],31607.52,,"Case rate ($30,102.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,304.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,133.16. The transfer capital threshold is the transfer adjustment factor * $2,133.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30150.40,89465.42,Inpatient DRG
HC Iliac Territory Plasty Stent|RIGHT SIDE,CASE-37221,APC,37221,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],467.21,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12395.17,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12395.17,42174.37,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26892.77,,"Fee schedule rate ($26,892.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5233.26,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4984.06,19757.81,Inpatient DRG
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17490.00,,"Per diem ($17,490). If length of stay < 1.2, first 1 days paid at a per diem of $34,980 instead. Capped at $20,988.02.",,,,0,other,7405.81,33747.30,Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25225.91,,,,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, SECOND DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14536.80,,"Case rate ($13,844.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,812.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,280.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,152.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,863.50. The transfer operating threshold is the transfer adjustment factor * $12,812.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $981.07. The transfer capital threshold is the transfer adjustment factor * $981.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13866.64,41146.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9728.97,,"Case rate ($9,265.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,827.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $656.60. The transfer capital threshold is the transfer adjustment factor * $656.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9280.46,39957.56,Inpatient DRG
Colon Ca Scrn Not Hi Rsk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9605.28,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9280.46,39957.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intra Lithotrip-Ather,CASE-C9766,APC,C9766,CPT,0481,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,APC,67900,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2333.89,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],27861.95,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,27861.95,82674.88,Inpatient DRG
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],103171.69,,"Fee schedule rate ($103,171.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6610.37,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6480.75,29542.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],43344.00,,"Fee schedule rate ($43,344.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],64967.51,,"Fee schedule rate ($64,967.51). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15400.51,,"Fee schedule rate ($15,400.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21929.44,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20885.18,80720.91,Inpatient DRG
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35058.51,,,,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],27022.53,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25735.75,27022.53,OPPS APC
Excision Tumor Soft Tis Foot/Toe Subq 1.5 Cm/>|RIGHT SIDE|PO,CASE-28039,APC,28039,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2851.46,OPPS APC
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20168.93,,,,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,76310.36,Estimated amount calculated based on 21 day length of stay.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],107249.77,,"Fee schedule rate ($107,249.77). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,37843.99,139522.22,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8143.73,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7984.05,33319.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],58554.60,,"Fee schedule rate ($58,554.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
"Synovectomy Metatarsophalangeal Joint Each|LEFT FOOT, SECOND DIGIT",CASE-28072,APC,28072,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5507.93,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5507.93,20510.35,Inpatient DRG
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],61868.44,,"Fee schedule rate ($61,868.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21830.80,85124.35,Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29049.23,,"Fee schedule rate ($29,049.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
HC Wound Vac <=50 Sq Cm Dme|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97605,APC,97605,CPT,0761,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9782.85,,"Fee schedule rate ($9,782.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,4523.19,16536.43,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1132.92,1132.92,1132.92,1 through 10,other,1134.98,1191.72,OPPS APC
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16865.38,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16062.27,48077.57,Inpatient DRG
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],61348.24,,"Fee schedule rate ($61,348.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],55846.16,,"Fee schedule rate ($55,846.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13889.20,55846.16,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12347.61,,"Fee schedule rate ($12,347.61). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9455.26,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9269.86,37852.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],67041.51,,,,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
Laps Supracrv Hysterec >250 G Rmvl Tube/Ovary,CASE-58544,APC,58544,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],64269.45,,"Fee schedule rate ($64,269.45). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34353.60,,"Fee schedule rate ($34,353.60). Adds an outlier to normal pricing equal to the per diem rate ($257,654.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,12121.97,35969.56,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Inject Nerv Blck,Paravert Sympath|PO",CASE-64520,APC,64520,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19699.24,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,8990.00,80069.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],63653.13,,,,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
"Inject Nerv Blck,Paravert Sympath|BILATERAL PROCEDURE|PO",CASE-64520,APC,64520,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13542.23,,"Fee schedule rate ($13,542.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5775.17,17136.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Corrj Hallux Valgus W/Sesmdc W/2 Osteot,CASE-28299,APC,28299,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Gastrocnemius Recession|RIGHT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15366.88,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15065.57,53815.71,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6763.33,,"Case rate ($6,630.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,146.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,128.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,149.87. The transfer operating threshold is the transfer adjustment factor * $6,146.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.85. The transfer capital threshold is the transfer adjustment factor * $480.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6630.72,19989.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7755.94,35520.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",4884.61,4884.61,4884.61,1 through 10,other,5085.49,5339.77,OPPS APC
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],43602.60,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,43602.60,153667.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,APC,58550,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Chemodenervation Muscle Neck Unilat for Dystonia|RIGHT SIDE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],94720.48,,"Fee schedule rate ($94,720.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],30186.58,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,29594.69,124146.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1849.14,1849.14,1849.14,1 through 10,other,1820.02,1911.02,OPPS APC
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Talus Fracture|RIGHT SIDE,CASE-28445,APC,28445,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5923.06,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5923.06,17575.50,Inpatient DRG
Dilat Rct Strix Spx Under Anes Oth/Thn Local,CASE-45910,APC,45910,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],32201.54,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",32201.55,32201.55,88779.37,1 through 10,other,31112.60,92731.42,Inpatient DRG
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],57457.72,,"Fee schedule rate ($57,457.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],28314.82,,"Case rate ($27,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,150.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.10. The transfer capital threshold is the transfer adjustment factor * $1,979.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,27357.31,100904.68,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11710.82,34749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24826.68,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23644.46,105789.11,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],55948.90,,"Fee schedule rate ($55,948.90). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,There are no additional notes associated with this service or procedure.
Repair Secondary Achilles Tendon W/WO Graft|RIGHT SIDE,CASE-27654,APC,27654,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",6963.55,6963.55,6963.55,1 through 10,other,6882.29,7226.40,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],24713.42,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",23821.28,23821.28,23821.28,1 through 10,other,24713.42,73332.24,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11519.31,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10970.77,32553.63,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,10492.66,31134.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],31834.92,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5345.47,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5224.00,15861.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthro, Loose Body + Chondro",CASE-G0289,APC,G0289,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39792.30,,"Fee schedule rate ($39,792.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE,CASE-27822,APC,27822,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3514.75,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19103.41,,"Case rate ($18,193.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,460.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.27. The transfer capital threshold is the transfer adjustment factor * $1,289.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,18222.73,59942.55,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
Partial Excision Bone Fibula|LEFT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3295.00,,,,,,0,other,3295.00,37575.69,Estimated amount calculated based on 11 day length of stay.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17467.27,,,,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,868.26,880.84,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],43675.07,,,,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11025.00,,"Fee schedule rate ($11,025). Adds an outlier to normal pricing equal to the per diem rate ($4,143.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5244.04,15804.57,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5938.30,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5938.30,18621.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FIFTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10105.00,,"Per diem ($10,105). If length of stay < 10.6, first 1 days paid at a per diem of $20,210 instead. Capped at $107,110.70.",,,,0,other,10105.00,120252.50,Estimated amount calculated based on 10 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, SECOND DIGIT|PO",CASE-26356,APC,26356,CPT,0360,RC,,,F1|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16644.64,,"Case rate ($15,852.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,646.90, add-ons for qualifying new technology services are included. If operating cost exceeds $50,114.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,317.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,705.28. The transfer operating threshold is the transfer adjustment factor * $14,646.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.78. The transfer capital threshold is the transfer adjustment factor * $1,146.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15852.04,50518.01,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE|PO,CASE-25607,APC,25607,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],42670.25,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,42670.25,133443.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
Gastrocnemius Recession|LEFT SIDE,CASE-27687,APC,27687,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
HC Intro Cath Dialysis Circuit|RIGHT SIDE,CASE-36901,APC,36901,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1493.03,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1493.03,1567.69,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MAJOR",385,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],12966.77,,"Case rate ($12,349.30). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12349.30,12966.77,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],20405.32,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20005.22,74991.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,37575.69,Estimated amount calculated based on 11 day length of stay.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5549.19,16729.39,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],35466.15,,"Fee schedule rate ($35,466.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,12514.54,37134.43,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5308.33,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5308.33,19857.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Tibiofibular Joint Disruption|RIGHT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Partial Excision Bone Talus/Calcaneus|RIGHT SIDE|PO,CASE-28120,APC,28120,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13444.53,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12804.31,55145.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15577.08,,"Fee schedule rate ($15,577.08). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
"DIABETES,MODERATE",420,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2783.34,,"Case rate for a one day stay ($2,650.80). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2650.80,2783.34,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36835.94,,"Fee schedule rate ($36,835.94). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
"CELLULITIS AND OTHER SKIN INFECTIONS,MAJOR",383,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12350.68,,"Case rate ($12,350.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12350.68,12968.21,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10953.60,,"Fee schedule rate ($10,953.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
Excision Spermatocele W/WO Epididymectomy|LEFT SIDE,CASE-54840,APC,54840,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2052.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18222.73,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,18222.73,59942.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,There are no additional notes associated with this service or procedure.
Aspiration Bladder Insert Suprapubic Catheter|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51102,APC,51102,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Synovectomy Tendon Sheath Foot Extensor|RIGHT SIDE|PO,CASE-28088,APC,28088,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,MINOR",191,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6174.38,,"Case rate for a one day stay ($6,174.38). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,6174.38,6483.10,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],22734.65,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22734.65,70806.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9969.47,,"Case rate ($9,969.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,211.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,679.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,892.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,248.24. The transfer operating threshold is the transfer adjustment factor * $9,211.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.22. The transfer capital threshold is the transfer adjustment factor * $721.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9969.47,29582.40,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6074.24,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6074.24,18024.13,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12510.87,,"Fee schedule rate ($12,510.87). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12135.23,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12135.23,49469.07,Inpatient DRG
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE|PO,CASE-64405,APC,64405,CPT,0450,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dilation Esophagus Guide Wire,CASE-43453,APC,43453,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],70101.28,,,,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE,CASE-28090,APC,28090,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7755.94,,"Case rate ($7,755.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,166.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,634.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,194.85. The transfer operating threshold is the transfer adjustment factor * $7,166.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.08. The transfer capital threshold is the transfer adjustment factor * $561.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7755.94,35520.39,Inpatient DRG
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11434.95,,"Case rate ($11,434.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.23. The transfer capital threshold is the transfer adjustment factor * $827.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11434.95,119072.21,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14455.48,,"Case rate ($13,767.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,146.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13789.07,57367.22,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],108295.22,,"Fee schedule rate ($108,295.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4787.78,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4787.78,20006.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC App Skin Sub T/a/L Tot <100 1st 25,CASE-15271,APC,15271,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],700.99,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",1698.18,1698.18,1698.18,1 through 10,other,700.99,736.04,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,76310.36,Estimated amount calculated based on 21 day length of stay.
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE,CASE-29806,APC,29806,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],158423.11,,"Fee schedule rate ($158,423.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30373.42,,,,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10449.55,43409.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.5 Cm/<,CASE-11400,APC,11400,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],671.64,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,671.64,705.22,OPPS APC
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7143.87,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5843.00,27370.21,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9896.28,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9425.03,27966.92,Inpatient DRG
Arthrodesis Great Toe Interphalangeal Joint,CASE-28755,APC,28755,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12585.32,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,11986.02,54149.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28437.57,,"Fee schedule rate ($28,437.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12204.33,,"Case rate ($11,623.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,490.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.89. The transfer capital threshold is the transfer adjustment factor * $842.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,35040.80,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],60141.33,,"Fee schedule rate ($60,141.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7078.89,21005.20,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,APC,49320,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|PO,CASE-28090,APC,28090,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy US Scope W/Adj Strxrs|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43237,APC,43237,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC
Mastectomy Gynecomastia|BILATERAL PROCEDURE,CASE-19300,APC,19300,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3843.64,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28569.12,,"Fee schedule rate ($28,569.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8830.96,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8410.44,24956.34,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9564.15,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9108.71,27028.33,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10367.99,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10367.99,37103.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11307.45,,"Fee schedule rate ($11,307.45). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9354.57,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5224.00,15861.63,All Other Inpatient
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|LEFT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC
Conv Prev Hip Tot Hip Arthrp W/WO Agrft/Algrft|RIGHT SIDE,CASE-27132,APC,27132,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12603.27,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],33768.00,,"Fee schedule rate ($33,768). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT FOOT, GREAT TOE",CASE-28297,APC,28297,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5625.00,,"Per diem ($5,625). If length of stay < 2.6, first 1 days paid at a per diem of $11,250 instead. Capped at $14,624.71.",,,,0,other,5160.45,15312.64,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25753.26,,,,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17118.14,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16302.99,55737.89,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12395.17,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12395.17,42174.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5938.97,,"Case rate ($5,938.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,487.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,955.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,509.33. The transfer operating threshold is the transfer adjustment factor * $5,487.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.64. The transfer capital threshold is the transfer adjustment factor * $429.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5938.97,17858.70,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8890.47,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",39950.15,6881.32,64211.06,1 through 10,other,8716.15,25863.45,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21707.27,,"Fee schedule rate ($21,707.27). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5072.70,,"Case rate ($4,831.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,513.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.35. The transfer capital threshold is the transfer adjustment factor * $342.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4838.84,19587.42,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],92493.51,,"Fee schedule rate ($92,493.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.8), with a minimum of zero.",,,,0,other,32637.12,96844.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,76310.36,Estimated amount calculated based on 21 day length of stay.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],51131.99,,"Fee schedule rate ($51,131.99). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Calcaneal Fracture|LEFT SIDE,CASE-28415,APC,28415,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13622.40,,"Fee schedule rate ($13,622.40). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS AND MISCELLANEOUS DIAGNOSES,MODERATE",143,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2489.75,,"Case rate for a one day stay ($2,371.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2371.19,2489.75,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],64066.80,,"Fee schedule rate ($64,066.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12502.35,,"Fee schedule rate ($12,502.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5525.02,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5338.18,15839.99,Inpatient DRG
Egd Transoral Biopsy Single/Multiple,CASE-43239,APC,43239,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],20306.22,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8030.94,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7648.51,27371.98,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19280.49,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,18902.44,56089.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6328.22,,"Case rate ($6,328.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,847.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,315.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,628.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,870.42. The transfer operating threshold is the transfer adjustment factor * $5,847.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.80. The transfer capital threshold is the transfer adjustment factor * $457.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6328.22,27416.36,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4303.70,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4303.70,14124.38,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24610.15,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,14062.94,61706.77,All Other Inpatient
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5781.77,,"Case rate ($5,668.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,581.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.07. The transfer capital threshold is the transfer adjustment factor * $410.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5668.40,16903.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10225.95,,"Fee schedule rate ($10,225.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE,CASE-29806,APC,29806,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],91852.39,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10249.47,96445.01,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],50916.88,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",50916.91,50916.91,50916.91,1 through 10,other,50916.88,170142.20,Inpatient DRG
Esophagogastroduodenoscopy US Scope W/Adj Strxrs|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43237,APC,43237,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE|PO,CASE-27524,APC,27524,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT FOOT, THIRD DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XU|T2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23602.02,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23602.02,108295.22,Inpatient DRG
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],43263.82,,,,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],58492.48,,"Fee schedule rate ($58,492.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,11916.39,58492.48,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Intercost Sng|BILATERAL PROCEDURE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13685.02,,"Fee schedule rate ($13,685.02). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion S/N/H/F/G 0.6-1.0 Cm,CASE-11621,APC,11621,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],671.64,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,671.64,695.15,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
Patellectomy/Hemipatellectomy,CASE-27350,APC,27350,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, THIRD DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T2|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Single External Papilla or Tag Anus,CASE-46220,APC,46220,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],22645.02,,of the excess amount.,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29433.60,,"Fee schedule rate ($29,433.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],140535.66,,"Fee schedule rate ($140,535.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,36167.61,140535.66,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],112294.67,,,,,,0,other,37843.99,139522.22,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11428.81,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10884.58,32297.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5760.34,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5486.04,17919.05,Inpatient DRG
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|RIGHT SIDE|PO,CASE-28119,APC,28119,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14130.58,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14130.58,57770.11,Inpatient DRG
Laps Myomectomy Exc 1-4 Myomas 250 Gm/<,CASE-58545,APC,58545,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22382.59,,,,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],10862.18,,"Fee schedule rate ($10,862.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
Unlisted Procedure Arthroscopy,CASE-29999,APC,29999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16067.99,,"Fee schedule rate ($16,067.99). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21754.53,,"Fee schedule rate ($21,754.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9527.16,28269.95,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Prepatellar Bursa|LEFT SIDE|SEPARATE STRUCTURE,CASE-27340,APC,27340,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23992.64,,"Fee schedule rate ($23,992.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],78663.71,,"Fee schedule rate ($78,663.71). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14718.77,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",13940.24,13940.24,13940.24,1 through 10,other,14718.77,51765.74,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Destruction Lesions Vulva Extensive,CASE-56515,APC,56515,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.96,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.96,2054.80,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],75545.91,,,,,,0,other,25459.44,80806.10,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6063.93,,"Case rate ($5,775.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,336.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,804.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,357.38. The transfer operating threshold is the transfer adjustment factor * $5,336.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.79. The transfer capital threshold is the transfer adjustment factor * $417.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5775.17,17136.70,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],3828.36,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3753.29,11765.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,APC,52281,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|SEPARATE STRUCTURE|PO,CASE-62323,APC,62323,CPT,0360,RC,,,XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],36738.00,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,34988.57,110685.97,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15090.49,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,14580.18,57079.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14200.87,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7453.00,42138.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,40658.63,Estimated amount calculated based on 3 day length of stay.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12557.64,,"Case rate ($11,959.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.50. The transfer capital threshold is the transfer adjustment factor * $847.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11978.73,60588.60,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5348.92,,"Case rate ($5,244.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,859.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,405.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,029.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,862.27. The transfer operating threshold is the transfer adjustment factor * $4,859.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $381.77. The transfer capital threshold is the transfer adjustment factor * $381.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5244.04,15804.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",136950.56,136950.56,136950.56,1 through 10,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13051.67,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6982.52,6982.52,6982.52,1 through 10,other,13051.67,38728.27,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE,CASE-27691,APC,27691,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,There are no additional notes associated with this service or procedure.
"IMPLANTABLE HEART ASSIST SYSTEMS,EXTREME",161,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],339221.83,,"Case rate ($323,068.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $121,386, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,323068.41,339221.83,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE|PO,CASE-64624,APC,64624,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE,CASE-28090,APC,28090,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"KIDNEY AND URINARY TRACT INFECTIONS,MINOR",463,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6996.16,,"Case rate ($6,663.01). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6663.01,6996.16,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32034.45,,"Fee schedule rate ($32,034.45). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3295.00,,,,,,0,other,3295.00,66445.54,Estimated amount calculated based on 11 day length of stay.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13249.94,40085.35,Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5354.09,,"Case rate ($5,354.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.33. The transfer capital threshold is the transfer adjustment factor * $387.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5354.09,15887.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT HAND, FIFTH DIGIT|PO",CASE-26356,APC,26356,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8232.48,,"Fee schedule rate ($8,232.48). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27622.57,,,,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],33209.40,,"Fee schedule rate ($33,209.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,There are no additional notes associated with this service or procedure.
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MAJOR",220,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],43305.72,,"Case rate ($41,243.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,41243.54,43305.72,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5462.53,,"Case rate ($5,355.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,948.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,416.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,558.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,967.99. The transfer operating threshold is the transfer adjustment factor * $4,948.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.42. The transfer capital threshold is the transfer adjustment factor * $387.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5355.42,17067.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MALFUNCTION REACTION COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE,MODERATE",206,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2779.29,,"Case rate for a one day stay ($2,779.29). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2779.29,2918.25,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5434.18,,"Case rate ($5,175.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,789.58, add-ons for qualifying new technology services are included. If operating cost exceeds $40,257.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,537.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,808.66. The transfer operating threshold is the transfer adjustment factor * $4,789.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $366.75. The transfer capital threshold is the transfer adjustment factor * $366.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5183.66,15743.06,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12228.12,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11645.83,37502.92,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24466.00,,"Case rate ($23,300.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,822.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,651.19. The transfer capital threshold is the transfer adjustment factor * $1,651.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23338.10,69251.23,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16257.35,,"Case rate ($15,483.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,268.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,097.19. The transfer capital threshold is the transfer adjustment factor * $1,097.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15507.88,46016.63,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],32675.12,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,31570.16,98176.71,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],37072.29,,"Case rate ($35,306.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,673.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,501.97. The transfer capital threshold is the transfer adjustment factor * $2,501.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",36236.84,35038.23,41569.51,11,other,18559.00,141041.50,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],26689.86,,"Case rate ($25,418.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,972.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,801.27. The transfer capital threshold is the transfer adjustment factor * $1,801.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25459.44,80806.10,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21827.79,,"Case rate ($21,399.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $55,240.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,719.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,851.66. The transfer operating threshold is the transfer adjustment factor * $19,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.11. The transfer capital threshold is the transfer adjustment factor * $1,548.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,21399.79,63499.65,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,14043.03,54637.47,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10367.99,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10367.99,37103.57,Inpatient DRG
Egd Flexible Foreign Body Removal,CASE-43247,APC,43247,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|SEPARATE STRUCTURE,CASE-52332,APC,52332,CPT,0360,RC,,,50|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15751.44,,,,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5348.00,,"Per diem ($5,348). If length of stay < 2.7, first 1 days paid at a per diem of $10,696 instead. Capped at $14,438.66.",,,,0,other,5094.80,15365.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12135.23,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12135.23,49469.07,Inpatient DRG
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6346.81,,"APC Price ($6,044.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6044.58,6346.81,OPPS APC
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7136.91,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6797.06,20168.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12180.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11600.09,48814.14,Inpatient DRG
Unlisted Procedure Pelvis/Hip Joint|RIGHT SIDE,CASE-27299,APC,27299,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],233.96,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,233.96,245.65,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11249.70,,"Fee schedule rate ($11,249.70). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7257.33,,"Case rate ($7,011.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,678.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7011.91,27304.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],14023.34,,"Fee schedule rate ($14,023.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4870.41,14682.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|LEFT SIDE,CASE-37765,APC,37765,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Implant Deep|SEPARATE STRUCTURE,CASE-20680,APC,20680,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Add 2nd/3rd Order Abd/Le,CASE-36248,APC,36248,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Partial Excision Bone Fibula|LEFT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8301.93,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6495.00,23801.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],4819.61,,"Fee schedule rate ($4,819.61). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14641.18,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14641.18,43444.85,Inpatient DRG
Rpr Primary Disrupted Ligament Ankle Collateral|LEFT SIDE,CASE-27695,APC,27695,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
HC Vasc Embolize Occlude Organ|BILATERAL PROCEDURE,CASE-37243,APC,37243,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],82553.89,,"Fee schedule rate ($82,553.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],41585.15,,"Fee schedule rate ($41,585.15). Adds an outlier to normal pricing equal to the per diem rate ($65,246.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",25335.72,25335.72,25335.72,1 through 10,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12861.93,,"Fee schedule rate ($12,861.93). Adds an outlier to normal pricing equal to the per diem rate ($47,786.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, THIRD DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34749.58,,,,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13866.64,,"Case rate ($13,866.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,812.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,280.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,174.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,863.50. The transfer operating threshold is the transfer adjustment factor * $12,812.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,003.15. The transfer capital threshold is the transfer adjustment factor * $1,003.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13866.64,41146.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34420.98,,,,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
Osteotomy Tarsal Bones Oth/Thn Calcaneus/Talus|LEFT SIDE|PO,CASE-28304,APC,28304,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32874.59,,"Fee schedule rate ($32,874.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25330.37,,"Fee schedule rate ($25,330.37). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],31373.55,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,14182.35,53827.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inject Nerv Blck,Paravert Sympath|BILATERAL PROCEDURE|PO",CASE-64520,APC,64520,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8285.62,,"Case rate ($4,734.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,389.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,934.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,991.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,391.29. The transfer operating threshold is the transfer adjustment factor * $4,389.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.35. The transfer capital threshold is the transfer adjustment factor * $343.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4734.64,14273.70,All Other Inpatient
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Myomectomy Exc 1-4 Myomas 250 Gm/<,CASE-58545,APC,58545,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,There are no additional notes associated with this service or procedure.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT SIDE,CASE-28289,APC,28289,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Implant Deep|LEFT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],10936.72,,"Fee schedule rate ($10,936.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6939.76,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5843.00,27370.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],64029.63,,"Fee schedule rate ($64,029.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.5), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],59216.74,,"Fee schedule rate ($59,216.74). Adds an outlier to normal pricing equal to the per diem rate ($89,749.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, THIRD DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11458.84,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11458.84,42820.42,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18897.00,,"Fee schedule rate ($18,897.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",19230.88,19230.88,19230.88,1 through 10,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21542.42,,"Fee schedule rate ($21,542.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7601.43,23918.09,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8071.33,,"Case rate ($7,686.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.09. The transfer capital threshold is the transfer adjustment factor * $556.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7686.98,22809.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],49469.07,,"Fee schedule rate ($49,469.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12135.23,49469.07,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20576.34,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11757.91,34889.29,All Other Inpatient
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11757.91,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11757.91,34889.29,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1537.76,1537.76,1537.76,1 through 10,other,1525.13,1601.38,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18227.38,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18227.38,54086.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15632.72,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15326.20,52511.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12757.05,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7289.74,21630.93,All Other Inpatient
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
Thrmbc Opn Arven Fstl W/O Revj Dial Grf,CASE-36831,APC,36831,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],29255.05,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27861.95,82674.88,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35778.69,,,,,,0,other,11871.54,35778.69,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11600.09,,"Case rate ($11,600.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,760.90. The transfer operating threshold is the transfer adjustment factor * $10,718.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.18. The transfer capital threshold is the transfer adjustment factor * $839.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11600.09,48814.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1876.32,1876.32,1876.32,1 through 10,other,1852.10,1944.70,OPPS APC
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7345.46,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7343.04,4224.79,30264.35,16,other,6308.00,21796.21,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],81177.46,,,,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16747.70,,"Case rate ($15,950.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,737.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,205.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,325.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,796.32. The transfer operating threshold is the transfer adjustment factor * $14,737.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.88. The transfer capital threshold is the transfer adjustment factor * $1,153.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15950.19,63458.56,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],41712.94,,"Fee schedule rate ($41,712.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12402.46,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12402.46,36801.89,Inpatient DRG
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],113934.44,,"Fee schedule rate ($113,934.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
Mastectomy Simple Complete|BILATERAL PROCEDURE,CASE-19303,APC,19303,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],47889.67,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,45609.21,211906.58,Inpatient DRG
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11916.39,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11916.39,58492.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|RIGHT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24505.01,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23338.10,69251.23,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9056.99,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9056.99,33814.75,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
HC App Skin Sub T/a/L Tot <100 1st 25,CASE-15271,APC,15271,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],725.52,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,700.99,736.04,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|LEFT SIDE,CASE-24341,APC,24341,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39359.90,,,,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16616.10,,"Case rate ($15,824.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,621.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,089.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,315.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,680.05. The transfer operating threshold is the transfer adjustment factor * $14,621.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.81. The transfer capital threshold is the transfer adjustment factor * $1,144.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15824.86,49371.45,Inpatient DRG
Laparoscopy Surg Ablation Renal Cysts|RIGHT SIDE,CASE-50541,APC,50541,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15861.63,,,,,,0,other,5224.00,15861.63,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],67331.56,,"Fee schedule rate ($67,331.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4283.52,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4138.67,12473.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,APC,43239,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34528.24,,"Fee schedule rate ($34,528.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE,CASE-27601,APC,27601,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"LOWER EXTREMITY VASCULAR PROCEDURES,EXTREME",181,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],65353.13,,"Case rate ($62,241.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $46,166, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,62241.08,65353.13,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],51073.62,,,,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17747.81,,"Case rate ($16,902.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,642.56, add-ons for qualifying new technology services are included. If operating cost exceeds $51,110.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,368.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $15,704.90. The transfer operating threshold is the transfer adjustment factor * $15,642.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,197.78. The transfer capital threshold is the transfer adjustment factor * $1,197.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",17118.55,17118.55,19977.82,1 through 10,other,16929.63,63934.22,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|SEPARATE STRUCTURE,CASE-12032,APC,12032,CPT,0450,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F4|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT|PO",CASE-28820,APC,28820,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
HC Needle Biopsy Muscle,CASE-20206,APC,20206,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42003.98,,"Fee schedule rate ($42,003.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
"PULMONARY EMBOLISM,MODERATE",134,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3155.57,,"Case rate for a one day stay ($3,005.30). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3005.30,3155.57,There are no additional notes associated with this service or procedure.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|LEFT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20445.79,,"Case rate ($19,472.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,551.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,379.87. The transfer capital threshold is the transfer adjustment factor * $1,379.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19503.23,57872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13249.94,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13249.94,40085.35,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14315.70,,"Fee schedule rate ($14,315.70). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE|PO,CASE-29806,APC,29806,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22578.15,,"Fee schedule rate ($22,578.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16142.41,,"Fee schedule rate ($16,142.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
HC Cystostomy Tube Change,CASE-51705,APC,51705,CPT,0761,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17041.54,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9738.02,28895.67,All Other Inpatient
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf,CASE-36825,APC,36825,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st < 3 Cm Reducible,CASE-49591,APC,49591,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33114.42,,,,,,0,other,11159.78,39897.21,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",17484.59,17484.59,17484.59,1 through 10,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13505.88,,"Case rate ($12,862.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,082.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $911.50. The transfer capital threshold is the transfer adjustment factor * $911.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12883.25,44763.90,Inpatient DRG
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12154.72,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11916.39,58492.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Extremity Venogram|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10260.35,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9913.38,10409.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],85124.35,,"Fee schedule rate ($85,124.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34690.55,,,,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
"CELLULITIS AND OTHER SKIN INFECTIONS,MODERATE",383,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8174.38,,"Case rate ($8,174.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8174.38,8583.10,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24888.65,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23703.48,110204.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4382.37,,"Case rate ($4,173.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,466.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.76. The transfer capital threshold is the transfer adjustment factor * $295.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4180.34,14351.57,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,There are no additional notes associated with this service or procedure.
Fasciectomy Plantar Fascia Partial Spx|BILATERAL PROCEDURE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],41403.83,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,40591.99,115037.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE|PO,CASE-29846,APC,29846,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI HEART FAILURE OR SHOCK,MODERATE",171,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],25933.53,,"Case rate ($24,698.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24698.60,25933.53,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
Mediastinoscopy With Lymph Node Biopsy/Ies,CASE-39402,APC,39402,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Corrj Hallux Valgus W/Sesmdc W/1metar Medial Cnf|LEFT SIDE,CASE-28297,APC,28297,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12785.93,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],75976.83,,,,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],38173.36,,"Fee schedule rate ($38,173.36). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7465.97,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,21404.64,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9920.64,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6531.00,35832.77,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],79918.67,,"Fee schedule rate ($79,918.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Sel Cath Abd/Pelvic/Le 1st Ord|BILATERAL PROCEDURE,CASE-36245,APC,36245,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6130.79,,"Case rate ($6,010.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,553.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,021.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,605.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,575.76. The transfer operating threshold is the transfer adjustment factor * $5,553.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.82. The transfer capital threshold is the transfer adjustment factor * $434.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6010.58,17835.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16785.91,,"Fee schedule rate ($16,785.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Mastectomy Gynecomastia|BILATERAL PROCEDURE,CASE-19300,APC,19300,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3843.64,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3843.64,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,Zero final payments for the item or service in the 15 months prior to posting the file.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28175.50,,,,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10896.97,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10528.47,44148.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Flexible Foreign Body Removal,CASE-43247,APC,43247,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
Colonoscopy Flx W/Endoscopic Mucosal Resection|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39792.30,,"Fee schedule rate ($39,792.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10632.00,,"Per diem ($10,632). If length of stay < 6.4, first 1 days paid at a per diem of $21,264 instead. Capped at $68,043.82.",,,,0,other,10632.00,103714.29,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Femur/Knee,CASE-27599,APC,27599,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],233.96,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,233.96,245.65,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",34823.40,34823.40,34823.40,1 through 10,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,Zero final payments for the item or service in the 15 months prior to posting the file.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5779.83,,"Case rate ($5,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,340.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,808.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,589.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,361.69. The transfer operating threshold is the transfer adjustment factor * $5,340.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.13. The transfer capital threshold is the transfer adjustment factor * $418.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5779.83,17150.47,Inpatient DRG
Open Treatment Fracture Distal Tibia & Fibula|RIGHT SIDE,CASE-27828,APC,27828,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4517.87,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4517.87,13932.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only,CASE-27601,APC,27601,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Excis Nail Matrix Perm Rmvl|LEFT FOOT, GREAT TOE|PO",CASE-11750,APC,11750,CPT,0450,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14366.41,,"Case rate ($13,880.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,825.31, add-ons for qualifying new technology services are included. If operating cost exceeds $48,293.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,876.42. The transfer operating threshold is the transfer adjustment factor * $12,825.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7285.00,41187.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18072.75,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17212.14,64440.06,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37103.57,,"Fee schedule rate ($37,103.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6374.64,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6230.00,21325.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12167.07,36103.36,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14871.78,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,14580.18,57079.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12768.28,,"Case rate ($12,160.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.72. The transfer capital threshold is the transfer adjustment factor * $861.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",92339.92,92339.92,92339.92,1 through 10,other,12179.66,36140.75,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],88801.87,,"Fee schedule rate ($88,801.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
Claviculectomy Partial|LEFT SIDE,CASE-23120,APC,23120,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto impl 4 or more,CASE-C9740,APC,C9740,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8978.63,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8978.63,9427.57,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],32004.66,,"Case rate ($30,480.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,163.35, add-ons for qualifying new technology services are included. If operating cost exceeds $63,631.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,376.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,275.59. The transfer operating threshold is the transfer adjustment factor * $28,163.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,205.05. The transfer capital threshold is the transfer adjustment factor * $2,205.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30480.63,86382.02,Inpatient DRG
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,APC,58573,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2285.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4511.69,,"Case rate ($4,296.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,475.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $304.49. The transfer capital threshold is the transfer adjustment factor * $304.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4303.70,14124.38,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6654.93,,"Case rate ($6,654.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,167.40, add-ons for qualifying new technology services are included. If operating cost exceeds $46,712.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,132.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,170.45. The transfer operating threshold is the transfer adjustment factor * $6,167.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.48. The transfer capital threshold is the transfer adjustment factor * $484.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6654.93,20056.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg F/E/E/N/L/M 0.5cm/<|PO,CASE-11440,APC,11440,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5811.28,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Tumor Soft Tissue Abdl Wall Subfascial <5cm,CASE-22900,APC,22900,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2851.46,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16865.16,,,,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17111.12,,,,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5938.30,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5938.30,18621.89,Inpatient DRG
Open Tx Trimalleolar Ankle Fx W/Fixj Pst Lip|LEFT SIDE|PO,CASE-27823,APC,27823,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6178.00,,"Per diem ($6,178). If length of stay < 3.9, first 1 days paid at a per diem of $12,356 instead. Capped at $24,092.63.",,,,0,other,6178.00,25225.91,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],41320.17,,"Fee schedule rate ($41,320.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],52698.97,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,50916.88,170142.20,Inpatient DRG
HC N Block Inj Suprascapular Nerv|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|PO,CASE-64634,APC,64634,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14063.72,,"Case rate ($13,588.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,555.10, add-ons for qualifying new technology services are included. If operating cost exceeds $48,023.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,154.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,605.14. The transfer operating threshold is the transfer adjustment factor * $12,555.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $983.00. The transfer capital threshold is the transfer adjustment factor * $983.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13588.14,40320.14,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
Arthrs Aid Tibial Fracture Proximal Unicondylar,CASE-29855,APC,29855,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Dislocating Peroneal Tendon W/Fib Osteot|LEFT SIDE|PO,CASE-27676,APC,27676,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB|PO",CASE-26418,APC,26418,CPT,0360,RC,,,FA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31469.43,,,,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10880.82,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10362.69,29367.82,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15160.18,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14438.27,55762.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",20665.44,20665.44,20665.44,1 through 10,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22363.31,,"Fee schedule rate ($22,363.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6178.00,25225.91,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
Lateral Retinacular Release Open,CASE-27425,APC,27425,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12404.38,,,,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
Arthrodesis Subtalar|RIGHT SIDE,CASE-28725,APC,28725,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41492.89,,,,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|LEFT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9292.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",8885.14,8885.14,8885.14,1 through 10,other,8978.63,9427.57,OPPS APC
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,APC,43239,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MAJOR",229,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],32115.92,,"Case rate ($32,115.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,32115.92,33721.72,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5273.13,,"Case rate ($5,169.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,545.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",5194.82,5194.82,5194.82,1 through 10,other,5169.74,15340.19,Inpatient DRG
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41729.01,,,,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12385.94,,"Case rate ($11,796.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,007.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $835.91. The transfer capital threshold is the transfer adjustment factor * $835.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11814.94,44591.73,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,APC,64493,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Chemodenervation Muscle Neck Unilat for Dystonia|RIGHT SIDE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],45891.89,,"Case rate ($44,339.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,969.05, add-ons for qualifying new technology services are included. If operating cost exceeds $76,436.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,378.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $41,132.32. The transfer operating threshold is the transfer adjustment factor * $40,969.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,207.67. The transfer capital threshold is the transfer adjustment factor * $3,207.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",45891.92,45891.92,48855.72,1 through 10,other,44339.99,131570.26,Inpatient DRG
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4370.58,,"Case rate ($4,162.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,846, add-ons for qualifying new technology services are included. If operating cost exceeds $39,313.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $3,861.33. The transfer operating threshold is the transfer adjustment factor * $3,846.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.12. The transfer capital threshold is the transfer adjustment factor * $301.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,21715.49,Inpatient DRG
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8086.83,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,34379.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,21229.52,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F7|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23691.11,,,,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29288.89,,"Fee schedule rate ($29,288.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24204.30,,"Fee schedule rate ($24,204.30). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27868.14,,"Fee schedule rate ($27,868.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30846.83,,"Fee schedule rate ($30,846.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27601,APC,27601,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Catheter Aorta|RIGHT SIDE,CASE-36200,APC,36200,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5773.19,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5773.19,31196.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Hrhc 2/> Col/Grp W/Fstulectmy Incl Fssrectmy,CASE-46262,APC,46262,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6866.02,,"Case rate ($6,866.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,344.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,811.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,369.31. The transfer operating threshold is the transfer adjustment factor * $6,344.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6866.02,27153.67,Inpatient DRG
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,APC,51102,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],46199.76,,"Fee schedule rate ($46,199.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9948.90,46199.76,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],47398.78,,of the excess amount. Final payment is multiplied by 103.5%.,,,,0,other,3295.00,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|RIGHT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, SECOND DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",1485.76,1485.76,1485.76,1 through 10,other,1525.13,1601.38,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],70037.75,,"Fee schedule rate ($70,037.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.9), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],102498.90,,"Fee schedule rate ($102,498.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,36167.61,140535.66,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
Arthrotomy W/Meniscus Repair Knee,CASE-27403,APC,27403,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],43051.31,,,,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
Removal Implant Deep|PO,CASE-20680,APC,20680,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18400.38,,"APC Price ($18,400.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18400.38,19320.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],103714.29,,"Fee schedule rate ($103,714.29). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB|PO",CASE-64831,APC,64831,CPT,0360,RC,,,F5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,MAJOR",042,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1522.68,,"Case rate for a one day stay ($1,522.68). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1522.68,1598.81,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"HIP AND FEMUR FRACTURE REPAIR,MAJOR",308,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],30565.25,,"Case rate ($29,109.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29109.76,30565.25,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,There are no additional notes associated with this service or procedure.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],125659.39,,"Fee schedule rate ($125,659.39). Adds an outlier to normal pricing equal to the per diem rate ($160,041.92) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7357.77,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,21404.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],61706.77,,"Fee schedule rate ($61,706.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,14062.94,61706.77,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21001.99,,"Fee schedule rate ($21,001.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7694.27,22831.22,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",47301.98,47301.98,47301.98,1 through 10,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24505.01,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23338.10,69251.23,Inpatient DRG
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20301.63,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20301.63,84714.35,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,APC,20552,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac W/Port Tun >5|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-36561,APC,36561,CPT,0361,RC,,,73,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27465.16,,,,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
Hemiphalangectomy/Interphalangeal Joint Exc Toe,CASE-28160,APC,28160,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25247.47,,"Fee schedule rate ($25,247.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7866.01,25247.47,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY ANOTHER PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,77|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],30813.32,,"APC Price ($29,771.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,29771.33,31259.89,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32980.62,,,,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Metacarpal,CASE-26230,APC,26230,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6358.45,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6055.67,17969.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT SIDE|PO,CASE-26356,APC,26356,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|RIGHT SIDE,CASE-27680,APC,27680,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7359.83,,"Case rate ($7,009.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,486.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,954.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,667.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,512.64. The transfer operating threshold is the transfer adjustment factor * $6,486.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.71. The transfer capital threshold is the transfer adjustment factor * $496.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7020.54,28431.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],23942.42,,"Case rate ($22,802.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,068.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,536.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,820.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $21,152.71. The transfer operating threshold is the transfer adjustment factor * $21,068.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,649.58. The transfer capital threshold is the transfer adjustment factor * $1,649.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22802.30,82749.58,Inpatient DRG
HC N Block Inj Suprascapular Nerv|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21406.38,,"Case rate ($20,986.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,391.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,689.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,468.42. The transfer operating threshold is the transfer adjustment factor * $19,391.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.23. The transfer capital threshold is the transfer adjustment factor * $1,518.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7826.00,90280.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22727.16,,"Fee schedule rate ($22,727.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7405.81,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7405.81,33747.30,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7060.32,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6724.11,19952.48,Inpatient DRG
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FOURTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T8,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26909.70,,"Fee schedule rate ($26,909.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9495.32,42131.77,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],77530.52,,"Fee schedule rate ($77,530.52). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18587.18,,"Case rate ($18,222.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,837.35, add-ons for qualifying new technology services are included. If operating cost exceeds $52,305.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $16,904.45. The transfer operating threshold is the transfer adjustment factor * $16,837.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.28. The transfer capital threshold is the transfer adjustment factor * $1,318.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",18589.83,18589.83,18589.83,1 through 10,other,18222.73,59942.55,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Medial Malleolus Fracture|RIGHT SIDE,CASE-27766,APC,27766,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],25735.75,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25633.23,,,,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],31671.85,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30163.67,89504.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
HC Vasc Embolize Occlude Organ,CASE-37243,APC,37243,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5504.62,16333.88,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],129893.46,,"Fee schedule rate ($129,893.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12138.74,,,,,,0,other,2285.00,12138.74,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4878.64,,"Case rate ($4,878.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,524.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.93. The transfer capital threshold is the transfer adjustment factor * $352.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4878.64,14476.37,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10149.15,,"Fee schedule rate ($10,149.15). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21256.76,,"Fee schedule rate ($21,256.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10972.03,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10449.55,43409.67,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12296.36,,"Case rate ($11,710.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $46,288.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,863.63. The transfer operating threshold is the transfer adjustment factor * $10,820.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.19. The transfer capital threshold is the transfer adjustment factor * $847.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11710.82,34749.58,Inpatient DRG
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15326.20,,"Case rate ($15,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,161.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,628.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,279.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,217.46. The transfer operating threshold is the transfer adjustment factor * $14,161.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.74. The transfer capital threshold is the transfer adjustment factor * $1,108.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15326.20,52511.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],47329.09,,,,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12299.85,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11714.14,49460.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25261.33,,,,,,0,other,8513.22,25261.33,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MODERATE",192,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4023.92,,"Case rate for a one day stay ($3,832.30). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3832.30,4023.92,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16552.29,,,,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
"CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,EXTREME",165,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],101691.42,,"Case rate ($101,691.42). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $55,584, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,101691.42,106775.99,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,27861.95,82674.88,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Procedure Stomach,CASE-43659,APC,43659,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11621.00,,"Per diem ($11,621). If length of stay < 22.4, first 1 days paid at a per diem of $23,242 instead. Capped at $260,309.36.",,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9574.89,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9574.89,28411.62,Inpatient DRG
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33947.68,,"Fee schedule rate ($33,947.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Lateral Release,CASE-29873,APC,29873,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tendon Sheath Incision|PO,CASE-26055,APC,26055,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Tarsal Bones Oth/Thn Calcaneus/Talus|LEFT SIDE|PO,CASE-28304,APC,28304,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22648.72,,"Case rate ($21,570.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,930.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,398.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,731.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,009.75. The transfer operating threshold is the transfer adjustment factor * $19,930.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.44. The transfer capital threshold is the transfer adjustment factor * $1,560.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,21570.21,72041.81,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13011.87,,"Case rate ($13,011.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,112.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.31. The transfer capital threshold is the transfer adjustment factor * $941.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7231.00,38610.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|RIGHT FOOT, THIRD DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9932.78,,"Case rate ($9,738.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,997.69, add-ons for qualifying new technology services are included. If operating cost exceeds $44,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,033.55. The transfer operating threshold is the transfer adjustment factor * $8,997.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.47. The transfer capital threshold is the transfer adjustment factor * $704.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9738.02,28895.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10882.42,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,1188.00,31658.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7078.89,21005.20,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],42621.59,,"Case rate ($40,591.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,505.99, add-ons for qualifying new technology services are included. If operating cost exceeds $72,973.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,107.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $37,655.47. The transfer operating threshold is the transfer adjustment factor * $37,505.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,936.53. The transfer capital threshold is the transfer adjustment factor * $2,936.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40591.99,115037.59,Inpatient DRG
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|LEFT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn|PO,CASE-62321,APC,62321,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13142.28,,"Case rate ($12,516.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,058.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $886.96. The transfer capital threshold is the transfer adjustment factor * $886.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",11330.67,11330.67,11330.67,1 through 10,other,12536.42,46998.45,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,CASE-49592,APC,49592,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,5934.68,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7755.94,,"Case rate ($7,755.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,166.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,634.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,194.85. The transfer operating threshold is the transfer adjustment factor * $7,166.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.08. The transfer capital threshold is the transfer adjustment factor * $561.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7755.94,35520.39,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30861.41,,,,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
Laparoscopy Nephrectomy W/Partial Ureterect,CASE-50546,APC,50546,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],339.97,,"APC Price ($339.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,339.97,356.97,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11607.75,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11055.00,49295.13,Inpatient DRG
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6374.64,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6230.00,21325.01,Inpatient DRG
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],55111.35,,"Fee schedule rate ($55,111.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8753.58,,"Fee schedule rate ($8,753.58). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
"ALCOHOL ABUSE AND DEPENDENCE,MODERATE",775,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7960.81,,"Case rate ($7,581.72). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7581.72,7960.81,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19155.70,,"Fee schedule rate ($19,155.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6654.93,20056.77,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6235.22,,"Case rate ($5,938.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,486.84, add-ons for qualifying new technology services are included. If operating cost exceeds $40,954.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,600.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,508.71. The transfer operating threshold is the transfer adjustment factor * $5,486.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.59. The transfer capital threshold is the transfer adjustment factor * $429.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5938.30,18621.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,APC,43266,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",165,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],74970.29,,"Case rate ($74,970.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,945, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,74970.29,78718.80,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14367.19,,"Case rate ($13,683.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,140.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $969.63. The transfer capital threshold is the transfer adjustment factor * $969.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13704.86,49911.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Single External Papilla or Tag Anus,CASE-46220,APC,46220,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12140.54,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12140.54,36024.65,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,40658.63,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",2951.75,2951.75,2951.75,1 through 10,other,5733.99,6020.69,OPPS APC
"OTHER DISORDERS OF NERVOUS SYSTEM,EXTREME",058,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],26943.14,,"Case rate ($25,660.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25660.13,26943.14,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],70034.38,,,,,,0,other,23602.02,108295.22,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13892.25,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13230.71,39259.55,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,Zero final payments for the item or service in the 15 months prior to posting the file.
"MAJOR ABDOMINAL VASCULAR PROCEDURES,MAJOR",169,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],56659.79,,"Case rate ($53,961.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,53961.70,56659.79,There are no additional notes associated with this service or procedure.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22158.27,,,,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,APC,29828,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, THIRD DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",19230.88,19230.88,19230.88,1 through 10,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,APC,52300,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO|SEPARATE STRUCTURE",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21302.88,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20885.18,80720.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14358.31,,,,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],28467.39,,"Case rate ($28,467.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,303.15, add-ons for qualifying new technology services are included. If operating cost exceeds $61,771.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,230.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $26,407.98. The transfer operating threshold is the transfer adjustment factor * $26,303.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,059.40. The transfer capital threshold is the transfer adjustment factor * $2,059.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8232.00,84471.39,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7165.86,,"Case rate ($6,824.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.62. The transfer capital threshold is the transfer adjustment factor * $483.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6835.51,20283.05,Inpatient DRG
Syndactylization Toes,CASE-28280,APC,28280,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],26525.17,,of the excess amount.,,,,0,other,3295.00,46419.05,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],42842.73,,,,,,0,other,14438.27,55762.74,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10400.49,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,30861.41,Inpatient DRG
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23409.73,,,,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4326.70,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4120.67,13066.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],32167.14,,"Case rate ($18,381.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,500.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,329.74. The transfer capital threshold is the transfer adjustment factor * $1,329.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,18381.22,58579.45,All Other Inpatient
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16050.11,,"Fee schedule rate ($16,050.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6074.24,18024.13,There are no additional notes associated with this service or procedure.
Destruction Vaginal Lesions Simple,CASE-57061,APC,57061,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],48370.42,,"Fee schedule rate ($48,370.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Removal FB Skin,CASE-10120,APC,10120,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,399.06,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19896.15,,"Fee schedule rate ($19,896.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6910.06,20832.04,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,32749.19,97176.83,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],70963.13,,,,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],25653.20,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",12343.43,12343.43,12343.43,1 through 10,other,9242.00,76216.30,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10826.88,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10826.88,32126.64,Inpatient DRG
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE|PO,CASE-64421,APC,64421,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Catheter Aorta,CASE-36200,APC,36200,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8369.91,,"Case rate ($7,971.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,736.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.88. The transfer capital threshold is the transfer adjustment factor * $564.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",8369.91,8250.05,45421.04,1 through 10,other,7984.05,23691.11,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4090.84,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,2285.00,12138.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7984.05,,"Case rate ($7,984.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,377.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,844.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,748.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,406.46. The transfer operating threshold is the transfer adjustment factor * $7,377.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.59. The transfer capital threshold is the transfer adjustment factor * $577.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",7871.90,7870.84,7871.90,1 through 10,other,7984.05,23691.11,Inpatient DRG
Arthroscopy Knee Synovectomy Limited Spx|LEFT SIDE|PO,CASE-29875,APC,29875,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT SIDE|PO,CASE-26356,APC,26356,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4138.67,12473.25,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16849.39,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16849.39,49997.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19230.33,,,,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15291.15,,"Fee schedule rate ($15,291.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],36679.51,,"Case rate ($34,932.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,646.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,475.46. The transfer capital threshold is the transfer adjustment factor * $2,475.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",17118.55,17118.55,17118.55,1 through 10,other,34988.57,110685.97,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6137.01,,"Case rate ($5,844.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.18. The transfer capital threshold is the transfer adjustment factor * $414.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",5758.84,5758.84,5758.84,1 through 10,other,1188.00,17370.86,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24233.69,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23758.52,103116.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],41116.55,,"Fee schedule rate ($41,116.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Subq Ea Addt'l 20sqcm|PBB CHARGE",CASE-11045,APC,11045,CPT,0361,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Pyeloplasty,CASE-50544,APC,50544,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26869.70,,"Fee schedule rate ($26,869.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,27465.16,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],40320.14,,,,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
HC Fem Pop Terr Plasty and Stent|LEFT SIDE,CASE-37226,APC,37226,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],484.80,,,,,,0,other,468.41,491.83,There are no additional notes associated with this service or procedure.
HC Remove Retrievable Filter,CASE-37193,APC,37193,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,153667.90,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21904.95,,"Case rate ($20,861.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,649.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,478.34. The transfer capital threshold is the transfer adjustment factor * $1,478.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20895.12,99969.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|RIGHT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],47438.21,,"Case rate ($45,834.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,349.49, add-ons for qualifying new technology services are included. If operating cost exceeds $77,817.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,486.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,518.27. The transfer operating threshold is the transfer adjustment factor * $42,349.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,315.75. The transfer capital threshold is the transfer adjustment factor * $3,315.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,45834.02,151120.97,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19587.42,,"Fee schedule rate ($19,587.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22105.65,,"Fee schedule rate ($22,105.65). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15833.58,,"Fee schedule rate ($15,833.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6077.55,18033.97,There are no additional notes associated with this service or procedure.
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw,CASE-37722,APC,37722,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,APC,23430,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17461.77,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16630.26,17461.77,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5280.49,,"Case rate ($5,280.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,879.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,346.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,553.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,898.48. The transfer operating threshold is the transfer adjustment factor * $4,879.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $382.00. The transfer capital threshold is the transfer adjustment factor * $382.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5280.49,17810.78,Inpatient DRG
Gastrocnemius Recession|LEFT SIDE,CASE-27687,APC,27687,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],144298.29,,"Fee schedule rate ($144,298.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],144298.29,,"Fee schedule rate ($144,298.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,32749.19,97176.83,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10625.29,,"Case rate ($10,625.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,817.50, add-ons for qualifying new technology services are included. If operating cost exceeds $45,285.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,939.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,856.63. The transfer operating threshold is the transfer adjustment factor * $9,817.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.66. The transfer capital threshold is the transfer adjustment factor * $768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10625.29,39295.53,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],37574.25,,"Fee schedule rate ($37,574.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33234.37,,"Fee schedule rate ($33,234.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],107196.72,,"Fee schedule rate ($107,196.72). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30145.85,,"Fee schedule rate ($30,145.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10637.22,31563.88,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23097.92,,of the excess amount. Final payment is multiplied by 102%.,,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35969.56,,,,,,0,other,12121.97,35969.56,There are no additional notes associated with this service or procedure.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|RIGHT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|LEFT SIDE|PO,CASE-23430,APC,23430,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25830.00,,,,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32825.17,,,,,,0,other,10888.24,32825.17,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4774.52,14406.59,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],882.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],66951.94,,"Fee schedule rate ($66,951.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7996.27,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7551.60,23262.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6610.37,,"Case rate ($6,480.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,988.04, add-ons for qualifying new technology services are included. If operating cost exceeds $41,455.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,011.91. The transfer operating threshold is the transfer adjustment factor * $5,988.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.83. The transfer capital threshold is the transfer adjustment factor * $468.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6480.75,29542.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],20707.66,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,20301.63,84714.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,APC,94640,CPT,0410,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
Adjt Tis Trnsfr/Reargmt Defec Ea Addl 30 Sqcm,CASE-14302,APC,14302,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6297.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",10766.80,10766.80,10766.80,1 through 10,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8906.59,,"Case rate ($8,605.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,951.18, add-ons for qualifying new technology services are included. If operating cost exceeds $43,419.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,982.86. The transfer operating threshold is the transfer adjustment factor * $7,951.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $622.54. The transfer capital threshold is the transfer adjustment factor * $622.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",9741.90,9741.90,9741.90,1 through 10,other,8605.40,42305.71,Inpatient DRG
Rpr Nonunion/Malunion Radius/Ulna W/Autograft,CASE-25405,APC,25405,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7257.26,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7257.26,23445.98,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8181.61,,"Case rate ($8,021.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,411.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,879.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,751.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,440.91. The transfer operating threshold is the transfer adjustment factor * $7,411.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.27. The transfer capital threshold is the transfer adjustment factor * $580.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6495.00,23801.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],25170.20,,"Case rate ($23,971.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,869.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.71. The transfer capital threshold is the transfer adjustment factor * $1,698.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10632.00,103714.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],36405.02,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36405.02,110499.61,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14442.92,,,,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18227.38,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,18227.38,54086.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",5416.39,5416.39,5416.39,1 through 10,other,5733.99,6020.69,OPPS APC
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28285,APC,28285,CPT,0360,RC,,,T9|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11592.12,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11592.12,38954.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FOURTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],53462.72,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,50916.88,170142.20,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],106864.61,,"Fee schedule rate ($106,864.61). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
Open Treatment Medial Malleolus Fracture|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27766,APC,27766,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39187.16,,"Fee schedule rate ($39,187.16). Adds an outlier to normal pricing equal to the per diem rate ($47,534.60) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,13827.53,41030.48,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Brow Ptosis,CASE-67900,APC,67900,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2333.89,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9569.58,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9569.58,41116.55,Inpatient DRG
HC Extremity Venogram|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9913.38,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9913.38,10409.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
Repair Fibula Nonunion/Malunion W/Int Fixation,CASE-27726,APC,27726,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8513.22,,"Case rate ($8,513.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,866.01, add-ons for qualifying new technology services are included. If operating cost exceeds $43,333.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,787.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,897.36. The transfer operating threshold is the transfer adjustment factor * $7,866.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.87. The transfer capital threshold is the transfer adjustment factor * $615.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8513.22,25261.33,Inpatient DRG
HC Remove Retrievable Filter,CASE-37193,APC,37193,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6419.63,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6293.75,21908.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39078.16,,"Fee schedule rate ($39,078.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],56694.72,,"Fee schedule rate ($56,694.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,20005.22,74991.64,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
"PULMONARY EMBOLISM,MODERATE",134,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],3005.30,,"Case rate for a one day stay ($3,005.30). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3005.30,3155.57,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33814.75,,"Fee schedule rate ($33,814.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7486.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11580.35,,"Case rate ($6,617.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,649.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.72. The transfer capital threshold is the transfer adjustment factor * $478.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5683.00,19635.68,All Other Inpatient
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20743.80,,"Fee schedule rate ($20,743.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
Destruction Vaginal Lesions Simple,CASE-57061,APC,57061,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19857.20,,"Fee schedule rate ($19,857.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
Excision/Curettage Bone Cyst/Tumor Tibia/Fibula|SEPARATE STRUCTURE|RIGHT SIDE,CASE-27635,APC,27635,CPT,0360,RC,,,XS|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],103171.69,,"Fee schedule rate ($103,171.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17877.77,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17026.45,50522.67,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4523.19,,"Case rate ($4,523.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,179.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,647.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,498.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,195.97. The transfer operating threshold is the transfer adjustment factor * $4,179.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $327.22. The transfer capital threshold is the transfer adjustment factor * $327.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4523.19,16536.43,Inpatient DRG
"Repair Extensor Tendon Finger W/O Graft Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26418,APC,26418,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24596.28,,"Fee schedule rate ($24,596.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|LEFT SIDE|PO,CASE-27650,APC,27650,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13780.46,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9763.00,48626.00,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33727.80,,"Fee schedule rate ($33,727.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11901.14,35314.31,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20113.98,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,17274.00,73717.28,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],107643.03,,,,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
Fasciectomy Plantar Fascia Partial Spx|RIGHT SIDE|PO,CASE-28060,APC,28060,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5338.18,,"Case rate ($5,338.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,932.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,400.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,952.00. The transfer operating threshold is the transfer adjustment factor * $4,932.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.18. The transfer capital threshold is the transfer adjustment factor * $386.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5338.18,15839.99,Inpatient DRG
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],90909.00,,"Fee schedule rate ($90,909). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,12395.17,42174.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Proctosgmdsc Rgd Dx W/WO Collj Spec Br/Wa Spx,CASE-45300,APC,45300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],8940.00,,"Per diem ($8,940). If length of stay < 6.8, first 1 days paid at a per diem of $17,880 instead. Capped at $60,793.48.",,,,0,other,8940.00,63653.13,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6061.80,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5942.94,17634.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],38164.42,,"Case rate ($36,347.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,746.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,575.68. The transfer capital threshold is the transfer adjustment factor * $2,575.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36405.02,110499.61,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4336.75,,"Case rate ($4,130.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,940.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $292.86. The transfer capital threshold is the transfer adjustment factor * $292.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4138.67,12473.25,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],34837.65,,"Fee schedule rate ($34,837.65). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20025.28,,,,,,0,other,6748.64,20025.28,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
"OTHER CIRCULATORY SYSTEM DIAGNOSES,EXTREME",207,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],23492.54,,"Case rate ($23,492.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,23492.54,24667.17,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34453.70,,"Fee schedule rate ($34,453.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],56787.82,,,,,,0,other,19137.85,64589.15,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],42193.04,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,70321.74,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30764.99,,,,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23026.03,,,,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
"Sesamoidectomy First Toe Spx|LEFT FOOT, GREAT TOE|PO",CASE-28315,APC,28315,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],47813.44,,"Case rate ($45,536.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,398.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,226.88. The transfer capital threshold is the transfer adjustment factor * $3,226.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,45609.21,211906.58,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4787.78,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4787.78,20006.29,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5595.76,,"Case rate ($5,486.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,068.97, add-ons for qualifying new technology services are included. If operating cost exceeds $40,536.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,568.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,089.18. The transfer operating threshold is the transfer adjustment factor * $5,068.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.87. The transfer capital threshold is the transfer adjustment factor * $396.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5486.04,17919.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6940.00,,"Per diem ($6,940). If length of stay < 5.9, first 1 days paid at a per diem of $13,880 instead. Capped at $40,946.19.",,,,0,other,6940.00,42872.25,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3117.60,3117.60,3117.60,1 through 10,other,3103.39,3258.56,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12788.64,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12179.66,36140.75,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],74991.64,,"Fee schedule rate ($74,991.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20005.22,74991.64,There are no additional notes associated with this service or procedure.
"OTHER AFTERCARE AND CONVALESCENCE,EXTREME",862,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9745.02,,"Case rate ($9,280.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9280.97,9745.02,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3395.89,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3395.89,3565.69,OPPS APC
HC Fem Pop Territory Plasty|LEFT SIDE,CASE-37224,APC,37224,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],401.21,,,,,,0,other,401.21,421.27,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14682.98,,,,,,0,other,4870.41,14682.98,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24596.28,,"Fee schedule rate ($24,596.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE,CASE-27822,APC,27822,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Revascularization Iliac Artery Angiop 1st Vsl|LEFT SIDE,CASE-37220,APC,37220,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],379.58,,,,,,0,other,361.50,379.58,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8626.43,,"Case rate ($8,215.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,603.15, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,753.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,633.46. The transfer operating threshold is the transfer adjustment factor * $7,603.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $582.19. The transfer capital threshold is the transfer adjustment factor * $582.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8228.75,24417.19,Inpatient DRG
Excision Interdigital Morton Neuroma Single Each|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],5425.77,,"Fee schedule rate ($5,425.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",1334.02,1334.02,1334.02,1 through 10,other,3209.85,10940.41,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7354.14,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7003.94,20782.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10605.39,31469.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17564.91,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10037.09,36934.96,All Other Inpatient
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],36220.66,,"Case rate ($20,697.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,123.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,591.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,668.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,200.21. The transfer operating threshold is the transfer adjustment factor * $19,123.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.31. The transfer capital threshold is the transfer adjustment factor * $1,497.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,20697.52,87921.54,All Other Inpatient
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto impl 4 or more,CASE-C9740,APC,C9740,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9427.57,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8978.63,9427.57,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19893.29,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,19503.23,57872.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33931.02,,,,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],33422.93,,"Case rate ($33,422.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,881.96, add-ons for qualifying new technology services are included. If operating cost exceeds $66,349.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,589.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $31,005.03. The transfer operating threshold is the transfer adjustment factor * $30,881.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,417.90. The transfer capital threshold is the transfer adjustment factor * $2,417.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,33422.93,112824.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21073.23,,"Fee schedule rate ($21,073.23). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Medium WO US|RIGHT SIDE|PO,CASE-20605,APC,20605,CPT,0510,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34379.15,,"Fee schedule rate ($34,379.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4984.06,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10853.78,10853.78,10853.78,1 through 10,other,4984.06,19757.81,Inpatient DRG
Cysto/Pyeloscopy Rescj Pelvic Tumor|LEFT SIDE,CASE-52355,APC,52355,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14351.57,,"Fee schedule rate ($14,351.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4180.34,14351.57,There are no additional notes associated with this service or procedure.
Arthrt Elbow W/Exploration Drainage/Removal FB,CASE-24000,APC,24000,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Rem Central Venous Cath,CASE-36589,APC,36589,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],624.73,,"APC Price ($594.98). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,594.98,624.73,OPPS APC
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10541.54,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10334.84,30666.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20301.63,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20301.63,84714.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34719.93,,"Fee schedule rate ($34,719.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13446.23,39899.05,There are no additional notes associated with this service or procedure.
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",3099.34,3099.34,3099.34,1 through 10,other,3070.31,3223.82,OPPS APC
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12351.25,,,,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],53121.74,,"Fee schedule rate ($53,121.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12326.86,53121.74,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],63513.58,,"Fee schedule rate ($63,513.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,29129.85,86437.13,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29049.23,,"Fee schedule rate ($29,049.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4523.19,16536.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|RIGHT SIDE,CASE-27130,APC,27130,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7866.01,,"Case rate ($7,866.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,268, add-ons for qualifying new technology services are included. If operating cost exceeds $42,735.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,740.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,296.97. The transfer operating threshold is the transfer adjustment factor * $7,268.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.05. The transfer capital threshold is the transfer adjustment factor * $569.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7866.01,25247.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],70806.50,,"Fee schedule rate ($70,806.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
Split Agrft T/a/L 1st 100 Cm/&/1% Bdy Inft/Chld,CASE-15100,APC,15100,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1783.09,1783.09,2005.09,1 through 10,other,2025.45,2054.80,OPPS APC
Tenodesis Long Tendon Biceps|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,APC,23430,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17461.77,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16630.26,17461.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4665.10,,"Case rate ($4,442.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,105.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,573.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,492.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,121.54. The transfer operating threshold is the transfer adjustment factor * $4,105.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.41. The transfer capital threshold is the transfer adjustment factor * $321.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4442.95,13183.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],9657.05,,"Fee schedule rate ($9,657.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5224.00,15861.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC
"INFLAMMATORY BOWEL DISEASE,MODERATE",245,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9898.50,,"Case rate ($9,898.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9898.50,10393.43,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],66027.56,,"Case rate ($66,027.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $61,007.82, add-ons for qualifying new technology services are included. If operating cost exceeds $96,475.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,947.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $61,250.96. The transfer operating threshold is the transfer adjustment factor * $61,007.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,776.60. The transfer capital threshold is the transfer adjustment factor * $4,776.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",98465.39,98465.39,119791.50,1 through 10,other,66027.56,228732.31,Inpatient DRG
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bladder Instillation Anticarcinogenic Agent|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51720,APC,51720,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula|RIGHT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7130.55,,"Fee schedule rate ($7,130.55). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40923.09,,"Fee schedule rate ($40,923.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,11962.15,40923.09,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22979.19,,"Fee schedule rate ($22,979.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6972.00,26280.60,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],86123.60,,"Fee schedule rate ($86,123.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,25667.66,86123.60,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5379.29,15961.98,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Rt Bronch Dx Clear Airway,CASE-31645,APC,31645,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3536.22,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,Zero final payments for the item or service in the 15 months prior to posting the file.
Biopsy Vaginal Mucosa Simple,CASE-57100,APC,57100,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",82112.25,82112.25,82112.25,1 through 10,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FIFTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13430.62,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12791.07,43031.63,Inpatient DRG
Open Treatment of Ulnar Shaft Fracture,CASE-25545,APC,25545,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9778.92,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6531.00,35832.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15348.76,,"Case rate ($14,617.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,207.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,035.87. The transfer capital threshold is the transfer adjustment factor * $1,035.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14641.18,43444.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Dilation Esophagus Guide Wire,CASE-43453,APC,43453,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],36293.25,,"Fee schedule rate ($36,293.25). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8192.28,,"Case rate ($8,192.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,569.46, add-ons for qualifying new technology services are included. If operating cost exceeds $43,037.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,763.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,599.62. The transfer operating threshold is the transfer adjustment factor * $7,569.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.65. The transfer capital threshold is the transfer adjustment factor * $592.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8077.51,8077.51,8192.28,1 through 10,other,8192.28,24308.97,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23658.96,,"Fee schedule rate ($23,658.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7034.55,,"Case rate ($6,699.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,214.91. The transfer operating threshold is the transfer adjustment factor * $6,190.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.66. The transfer capital threshold is the transfer adjustment factor * $484.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6699.57,24060.08,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32297.83,,,,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39196.14,,"Fee schedule rate ($39,196.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11359.17,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10818.26,38164.94,Inpatient DRG
Arthroscopy Knee Synovectomy Limited Spx,CASE-29875,APC,29875,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|LEFT SIDE|PO,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21991.57,,"Fee schedule rate ($21,991.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27601.28,,"Fee schedule rate ($27,601.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9151.96,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8716.15,25863.45,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],32518.90,,"Case rate ($30,970.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,661.48, add-ons for qualifying new technology services are included. If operating cost exceeds $64,129.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,365.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,775.71. The transfer operating threshold is the transfer adjustment factor * $28,661.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,194.67. The transfer capital threshold is the transfer adjustment factor * $2,194.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31019.76,124854.72,Inpatient DRG
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,APC,43275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE|PO,CASE-28200,APC,28200,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],48720.85,,"Fee schedule rate ($48,720.85). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15421.03,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15421.03,49137.17,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Leg/Ankle Subfascial <5cm|LEFT SIDE|PO,CASE-27619,APC,27619,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42003.98,,"Fee schedule rate ($42,003.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11156.45,42003.98,There are no additional notes associated with this service or procedure.
HC Wound Vac <=50 Sq Cm Dme|PBB CHARGE,CASE-97605,APC,97605,CPT,0761,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],199.81,,"APC Price ($190.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenotomy Open Extensor Foot/Toe Each Tendon|LEFT FOOT, SECOND DIGIT",CASE-28234,APC,28234,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,APC,58542,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
Arthroscopy Knee Lateral Release|LEFT SIDE|PO,CASE-29873,APC,29873,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($60,119.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",34738.01,34738.01,34738.01,1 through 10,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE|PO,CASE-64483,APC,64483,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],44763.90,,"Fee schedule rate ($44,763.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],35359.80,,"Fee schedule rate ($35,359.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7362.51,,"Case rate ($7,011.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,678.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,504.65. The transfer operating threshold is the transfer adjustment factor * $6,478.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7011.91,27304.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64418,APC,64418,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],51073.62,,,,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18792.28,,"Fee schedule rate ($18,792.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8228.75,24417.19,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],67041.51,,,,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25616.64,,"Fee schedule rate ($25,616.64). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12345.81,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11757.91,34889.29,Inpatient DRG
Partial Excision Bone Tibia|LEFT SIDE|PO,CASE-27640,APC,27640,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],3787.79,,"Case rate ($3,607.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,333.16, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,432.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,346.44. The transfer operating threshold is the transfer adjustment factor * $3,333.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.97. The transfer capital threshold is the transfer adjustment factor * $260.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3607.42,11497.58,Inpatient DRG
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MAJOR",045,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],17257.80,,"Case rate ($17,257.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,17257.80,18120.69,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19262.83,,"Fee schedule rate ($19,262.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],48720.85,,"Fee schedule rate ($48,720.85). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,17191.57,51012.62,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE|PO,CASE-27601,APC,27601,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40774.00,,"Fee schedule rate ($40,774.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11958.84,40774.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10034.43,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10034.43,29775.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10954.57,,"Case rate ($10,432.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,910.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.31. The transfer capital threshold is the transfer adjustment factor * $739.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10449.55,43409.67,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34690.55,,,,,,0,other,11690.93,56733.59,There are no additional notes associated with this service or procedure.
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|RIGHT SIDE,CASE-27130,APC,27130,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",12363.12,12363.12,12363.12,1 through 10,other,12177.08,12785.93,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6389.34,,"Case rate ($6,085.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,631.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,602.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,653.89. The transfer operating threshold is the transfer adjustment factor * $5,631.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.21. The transfer capital threshold is the transfer adjustment factor * $431.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6094.79,22352.66,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38792,APC,38792,CPT,0361,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20185.84,,"Case rate ($19,503.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $53,488.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,582.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,092.32. The transfer operating threshold is the transfer adjustment factor * $18,020.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.91. The transfer capital threshold is the transfer adjustment factor * $1,410.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,19503.23,57872.02,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],29129.85,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,29129.85,86437.13,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9569.58,41116.55,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12280.26,,"Case rate ($11,695.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,999.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.78. The transfer capital threshold is the transfer adjustment factor * $828.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11714.14,49460.19,Inpatient DRG
HC Sel Cath Abd/Pelvic/Le 1st Ord,CASE-36245,APC,36245,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],185834.07,,"Case rate ($185,834.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $171,706.05, add-ons for qualifying new technology services are included. If operating cost exceeds $207,173.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $14,614.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $172,390.36. The transfer operating threshold is the transfer adjustment factor * $171,706.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $13,443.71. The transfer capital threshold is the transfer adjustment factor * $13,443.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,185834.07,195125.77,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14518.91,,"Case rate ($13,827.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,776.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,244.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,171.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,827.21. The transfer operating threshold is the transfer adjustment factor * $12,776.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,000.32. The transfer capital threshold is the transfer adjustment factor * $1,000.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13827.53,41030.48,Inpatient DRG
Debridement Bone Each Additional 20 Sq Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-11047,APC,11047,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
I&D Ischiorct/Intramural Absc W/WO Seton,CASE-46060,APC,46060,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],5358.15,,"Fee schedule rate ($5,358.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],45609.21,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,45609.21,211906.58,Inpatient DRG
Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>|RIGHT SIDE,CASE-23073,APC,23073,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2755.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6098.05,,"Case rate ($5,807.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,366.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,834.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,591.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,387.53. The transfer operating threshold is the transfer adjustment factor * $5,366.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5807.67,17233.12,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12975.19,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,12536.42,46998.45,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24505.01,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23338.10,69251.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13492.62,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13228.06,39251.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28086.14,,"Fee schedule rate ($28,086.14). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9910.44,43344.00,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],25281.41,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9242.00,76216.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22091.17,,"Fee schedule rate ($22,091.17). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],94699.75,,"Fee schedule rate ($94,699.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,32749.19,97176.83,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17212.14,,"Case rate ($17,212.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,903.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,371.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,416.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,966.96. The transfer operating threshold is the transfer adjustment factor * $15,903.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,245.17. The transfer capital threshold is the transfer adjustment factor * $1,245.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",16663.28,16663.28,17212.15,1 through 10,other,17212.14,64440.06,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,13588.14,40320.14,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33244.29,,,,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11814.94,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11814.94,44591.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10454.85,,"Fee schedule rate ($10,454.85). Adds an outlier to normal pricing equal to the per diem rate ($3,889) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6553.68,20086.28,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20939.04,,"Fee schedule rate ($20,939.04). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,APC,58661,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1287.29,1287.29,5687.21,1 through 10,other,5733.99,6020.69,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],30636.42,,"Fee schedule rate ($30,636.42). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
Rhinp Prim Complete Xtrnl Parts|PO,CASE-30410,APC,30410,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5614.77,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5614.77,5895.51,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23338.10,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23338.10,69251.23,Inpatient DRG
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9108.77,,"Case rate ($8,675.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,015.51, add-ons for qualifying new technology services are included. If operating cost exceeds $43,483.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,798.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,047.45. The transfer operating threshold is the transfer adjustment factor * $8,015.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8675.02,25741.45,Inpatient DRG
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE|PO,CASE-27570,APC,27570,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4518.89,,"Case rate ($4,303.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,976.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,444.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,482.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,992.35. The transfer operating threshold is the transfer adjustment factor * $3,976.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4303.70,14124.38,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16856.70,,"Fee schedule rate ($16,856.70). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
"PERIPHERAL CRANIAL AND AUTONOMIC NERVE DISORDERS,MODERATE",048,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10544.29,,"Case rate ($10,042.18). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10042.18,10544.29,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11368.22,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10826.88,32126.64,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],59188.55,,"Fee schedule rate ($59,188.55). Adds an outlier to normal pricing equal to the per diem rate ($203,441.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,20885.18,80720.91,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE|PO,CASE-64450,APC,64450,CPT,0450,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9108.71,,"Case rate ($9,108.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,416.22, add-ons for qualifying new technology services are included. If operating cost exceeds $43,884.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,830.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,449.77. The transfer operating threshold is the transfer adjustment factor * $8,416.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.95. The transfer capital threshold is the transfer adjustment factor * $658.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9108.71,27028.33,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],23320.23,,"Fee schedule rate ($23,320.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5668.40,,"Case rate ($5,668.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,237.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,705.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,581.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,258.34. The transfer operating threshold is the transfer adjustment factor * $5,237.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.07. The transfer capital threshold is the transfer adjustment factor * $410.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5668.40,16903.82,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16682.55,,"Fee schedule rate ($16,682.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
HC Intro Catheter Aorta|RIGHT SIDE,CASE-36200,APC,36200,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],45903.36,,"Fee schedule rate ($45,903.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9833.51,45903.36,There are no additional notes associated with this service or procedure.
"OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,MAJOR",253,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14656.42,,"Case rate ($14,656.42). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14656.42,15389.24,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16214.42,,"Case rate ($15,896.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,321.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.99. The transfer capital threshold is the transfer adjustment factor * $1,149.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15896.49,51306.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],40046.00,,"Fee schedule rate ($40,046.00). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,14130.58,57770.11,Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2285.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12053.43,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",12316.03,12316.03,12316.03,1 through 10,other,11645.83,37502.92,Inpatient DRG
"OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,MAJOR",253,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15389.24,,"Case rate ($14,656.42). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14656.42,15389.24,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64718,APC,64718,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Dcmprn Fasct Leg Post Compartment Only|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27601,APC,27601,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13748.11,,"Fee schedule rate ($13,748.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5683.66,16865.16,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,Zero final payments for the item or service in the 15 months prior to posting the file.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE|PO,CASE-64421,APC,64421,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],36405.02,,"Case rate ($36,405.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,637.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,105.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,804.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $33,771.38. The transfer operating threshold is the transfer adjustment factor * $33,637.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,633.63. The transfer capital threshold is the transfer adjustment factor * $2,633.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36405.02,110499.61,Inpatient DRG
HC Intrvasc US Noncoronary Addl,CASE-37253,APC,37253,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],557.79,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30044.81,,,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5091.00,,"Per diem ($5,091). If length of stay < 3.2, first 1 days paid at a per diem of $10,182 instead. Capped at $16,289.77.",,,,0,other,5091.00,22010.11,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5504.62,16333.88,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|PO|LEFT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|PO|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28269.95,,,,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
"CELLULITIS AND OTHER SKIN INFECTIONS,MINOR",383,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6279.58,,"Case rate ($5,980.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5980.55,6279.58,There are no additional notes associated with this service or procedure.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6795.74,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6472.13,19204.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64418,APC,64418,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Catheter Aorta|RIGHT SIDE,CASE-36200,APC,36200,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7369.00,,"Per diem ($7,369). If length of stay < 2.4, first 1 days paid at a per diem of $14,738 instead. Capped at $17,686.09.",,,,0,other,6240.68,18518.02,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17983.60,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17127.24,50821.76,Inpatient DRG
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5452.38,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5224.00,15861.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14910.91,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7453.00,42138.30,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16108.68,,"Fee schedule rate ($16,108.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6472.13,19204.75,Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($60,119.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22230.95,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12500.00,83592.64,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],20299.11,,"Case rate ($19,332.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,541.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,369.97. The transfer capital threshold is the transfer adjustment factor * $1,369.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19363.31,79918.67,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5747.99,,"Case rate ($5,747.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,311, add-ons for qualifying new technology services are included. If operating cost exceeds $40,778.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,586.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,332.16. The transfer operating threshold is the transfer adjustment factor * $5,311.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.82. The transfer capital threshold is the transfer adjustment factor * $415.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5091.00,22010.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5008.20,,"Case rate ($4,838.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,470.97, add-ons for qualifying new technology services are included. If operating cost exceeds $39,938.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,521.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,488.78. The transfer operating threshold is the transfer adjustment factor * $4,470.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.05. The transfer capital threshold is the transfer adjustment factor * $350.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4838.84,19587.42,Inpatient DRG
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12512.21,,"Case rate ($11,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,010.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,478.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,033.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,054.33. The transfer operating threshold is the transfer adjustment factor * $11,010.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.06. The transfer capital threshold is the transfer adjustment factor * $862.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11916.39,58492.48,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],42695.82,,"Fee schedule rate ($42,695.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26940.69,,"Fee schedule rate ($26,940.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11810.12,,"Case rate ($6,748.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,235.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,703.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,659.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,260.43. The transfer operating threshold is the transfer adjustment factor * $6,235.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.21. The transfer capital threshold is the transfer adjustment factor * $488.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6748.64,20025.28,All Other Inpatient
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5766.55,,"Case rate ($5,766.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,328.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,796.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,349.39. The transfer operating threshold is the transfer adjustment factor * $5,328.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.17. The transfer capital threshold is the transfer adjustment factor * $417.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5766.55,17111.12,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21742.11,,"Fee schedule rate ($21,742.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14182.30,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7308.00,42083.20,Inpatient DRG
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Metatarsal Fracture Each|RIGHT SIDE|PO,CASE-28485,APC,28485,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1188.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
Gastrocnemius Recession|RIGHT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30872.02,,"Fee schedule rate ($30,872.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],36511.04,,"Fee schedule rate ($36,511.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12883.25,44763.90,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis 20 Cm/<|UNUSUAL NON-OVERLAPPING SERVICE,CASE-97597,APC,97597,CPT,0761,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],196.96,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11359.17,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10818.26,38164.94,Inpatient DRG
"OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,MAJOR",253,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14656.42,,"Case rate ($14,656.42). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14656.42,15389.24,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],108637.77,,"Fee schedule rate ($108,637.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13572.00,108637.77,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16705.77,,,,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15806.56,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3295.00,53945.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],126842.57,,"Fee schedule rate ($126,842.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",57189.78,57189.78,57189.78,1 through 10,other,36910.99,126842.57,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5578.22,18148.00,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11276.10,,"Case rate ($11,055). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,214.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,682.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,255.25. The transfer operating threshold is the transfer adjustment factor * $10,214.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.75. The transfer capital threshold is the transfer adjustment factor * $799.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11055.00,49295.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31065.48,,"Fee schedule rate ($31,065.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10915.75,32390.31,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],96445.01,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10249.47,96445.01,Inpatient DRG
"Tenolysis Extensor Tendon Hand/Finger Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26445,APC,26445,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Tendon/Muscle Upper Arm/Elbow Ea Tdn/Musc|RIGHT SIDE|PO,CASE-24341,APC,24341,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9292.89,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8978.63,9427.57,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28395.88,,,,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],42193.04,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
Open Treatment Proximal Fibula/Shaft Fracture|RIGHT SIDE|PO,CASE-27784,APC,27784,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3816.03,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3209.85,10940.41,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tenolysis Extensor Tendon Hand/Finger Each|RIGHT HAND, FOURTH DIGIT|PO",CASE-26445,APC,26445,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,CASE-43762,APC,43762,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HC Debride Subq First 20 Sq Cm|SEPARATE STRUCTURE,CASE-11042,APC,11042,CPT,0361,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],399.06,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,399.06,399.06,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
"OTHER PNEUMONIA,MODERATE",139,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8907.96,,"Case rate ($8,907.96). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8907.96,9353.36,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20962.78,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11978.73,60588.60,All Other Inpatient
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],50359.05,,"Fee schedule rate ($50,359.05). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (49), with a minimum of zero.",,,,0,other,21830.80,85124.35,There are no additional notes associated with this service or procedure.
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,MAJOR",351,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13548.44,,"Case rate ($12,903.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12903.28,13548.44,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,10362.69,29367.82,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6365.49,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6240.68,18518.02,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27212.25,,"Fee schedule rate ($27,212.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10114.68,30013.33,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
"OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,MINOR",663,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2802.40,,"Case rate for a one day stay ($2,802.40). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2802.40,2942.52,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],24785.70,,"Case rate ($24,785.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,901.37, add-ons for qualifying new technology services are included. If operating cost exceeds $58,369.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,964.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,992.64. The transfer operating threshold is the transfer adjustment factor * $22,901.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,793.06. The transfer capital threshold is the transfer adjustment factor * $1,793.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9242.00,76216.30,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5564.87,,"Case rate ($5,299.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,546.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.57. The transfer capital threshold is the transfer adjustment factor * $375.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5308.33,19857.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9957.13,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9761.89,37873.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7467.48,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3295.00,37575.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
"Inject Nerv Blck,Paravert Sympath|RIGHT SIDE",CASE-64520,APC,64520,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, GREAT TOE|PO",CASE-28160,APC,28160,CPT,0360,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8477.66,,"Case rate ($8,073.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,743.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.15. The transfer capital threshold is the transfer adjustment factor * $572.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,34379.15,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7056.33,28335.74,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Non/Malunion Metarsal W/WO Bone Graft|LEFT SIDE,CASE-28322,APC,28322,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],81161.07,,"Fee schedule rate ($81,161.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,30480.63,86382.02,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8830.96,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8410.44,24956.34,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
"OTHER AFTERCARE AND CONVALESCENCE,MAJOR",862,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9280.97,,"Case rate ($9,280.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9280.97,9745.02,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13717.45,,"Fee schedule rate ($13,717.45). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9202.78,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8764.55,32969.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],24549.95,,"Fee schedule rate ($24,549.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8005.26,24549.95,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20992.72,,"Fee schedule rate ($20,992.72). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],102660.52,,"Fee schedule rate ($102,660.52). Adds an outlier to normal pricing equal to the per diem rate ($180,358.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Dx Collection Specimen Brushing/Washing,CASE-43260,APC,43260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3656.79,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3656.79,3839.63,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10859.90,,"Case rate ($10,492.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,694.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,162.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,930.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,733.59. The transfer operating threshold is the transfer adjustment factor * $9,694.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.07. The transfer capital threshold is the transfer adjustment factor * $759.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10492.66,31134.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,There are no additional notes associated with this service or procedure.
Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt,CASE-27602,APC,27602,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea,CASE-25290,APC,25290,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6972.00,,"Per diem ($6,972). If length of stay < 3.6, first 1 days paid at a per diem of $13,944 instead. Capped at $25,099.93.",,,,0,other,6972.00,26280.60,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11348.73,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10808.31,46938.11,Inpatient DRG
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE|PO,CASE-29823,APC,29823,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],65780.40,,"Fee schedule rate ($65,780.40). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],81324.83,,"Fee schedule rate ($81,324.83). Adds an outlier to normal pricing equal to the per diem rate ($106,784.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,28696.16,118364.04,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6290.26,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6077.55,18033.97,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
HC Wound Vac <=50 Sq Cm Dme,CASE-97605,APC,97605,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,APC,43239,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],24060.08,,"Fee schedule rate ($24,060.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6699.57,24060.08,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],23777.27,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4879.43,,"Case rate ($4,647.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,500.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $329.31. The transfer capital threshold is the transfer adjustment factor * $329.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4654.49,13811.29,Inpatient DRG
Axillary Lymphadenectomy Complete,CASE-38745,APC,38745,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7729.11,,"Case rate ($7,577.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,001.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,469.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,029.37. The transfer operating threshold is the transfer adjustment factor * $7,001.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.18. The transfer capital threshold is the transfer adjustment factor * $548.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7577.56,31445.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4968.82,,"Case rate ($4,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,530.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.46. The transfer capital threshold is the transfer adjustment factor * $359.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4968.82,19848.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Vaginectomy Partial Removal Vaginal Wall,CASE-57106,APC,57106,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23915.01,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23915.01,121205.60,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3295.00,,,,,,0,other,3295.00,48444.74,Estimated amount calculated based on 11 day length of stay.
"HC Debrid,Musc/Fasc,Ea Add 20sqcm",CASE-11046,APC,11046,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],725.52,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,700.99,736.04,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27753.50,,"Fee schedule rate ($27,753.50). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis 20 Cm/<|ADJ,CASE-97597,APC,97597,CPT,0761,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32093.19,,,,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64415,APC,64415,CPT,0360,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18010.53,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10291.73,34803.35,All Other Inpatient
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5683.66,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5683.66,16865.16,Inpatient DRG
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,44339.99,131570.26,Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],4774.52,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",21267.10,21267.10,21267.10,1 through 10,other,4774.52,14406.59,Inpatient DRG
"HC Aerosol, Hhn, Mdi, Ippb|ADJ",CASE-94640,APC,94640,CPT,0410,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6171.07,,"Case rate ($5,877.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,587.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.48. The transfer capital threshold is the transfer adjustment factor * $416.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5886.58,17467.27,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23338.10,,"Case rate ($23,338.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,563.82, add-ons for qualifying new technology services are included. If operating cost exceeds $57,031.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,859.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $21,649.76. The transfer operating threshold is the transfer adjustment factor * $21,563.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,688.34. The transfer capital threshold is the transfer adjustment factor * $1,688.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23338.10,69251.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,APC,38900,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE,CASE-27822,APC,27822,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
HC 3rd Order Sel Abd/Lower Ext,CASE-36247,APC,36247,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8.46,,,,,,0,other,8.46,8.88,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6219.21,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5923.06,17575.50,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7285.00,,"Per diem ($7,285). If length of stay < 5.4, first 1 days paid at a per diem of $14,570 instead. Capped at $39,337.51.",,,,0,other,7285.00,41187.90,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciotomy Foot&/Toe|LEFT SIDE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],33969.60,,"Fee schedule rate ($33,969.60). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11497.58,,"Fee schedule rate ($11,497.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30145.85,,"Fee schedule rate ($30,145.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15340.19,,,,,,0,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],50916.88,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,50916.88,170142.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE,CASE-27524,APC,27524,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29049.23,,"Fee schedule rate ($29,049.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],64589.15,,"Fee schedule rate ($64,589.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,19137.85,64589.15,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15451.84,,"Fee schedule rate ($15,451.84). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
Tnols Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea|RIGHT SIDE|PO,CASE-25295,APC,25295,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Arthroscopy,CASE-29999,APC,29999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
Arthroscopy Knee Lateral Release,CASE-29873,APC,29873,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14534.54,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,14043.03,54637.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23801.30,,,,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17323.14,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,16737.33,72192.67,Inpatient DRG
"OTHER PNEUMONIA,MINOR",139,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2513.46,,"Case rate for a one day stay ($2,393.77). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2393.77,2513.46,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],41712.94,,"Fee schedule rate ($41,712.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,14718.77,51765.74,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|XS|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6052.20,,"Case rate ($5,764). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,579.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.46. The transfer capital threshold is the transfer adjustment factor * $408.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5773.19,31196.82,Inpatient DRG
Open Tx Metatarsophalangeal Joint Dislocation,CASE-28645,APC,28645,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35314.31,,,,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
HC Iliac Territory Plasty Stent|RIGHT SIDE,CASE-37221,APC,37221,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],460.53,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
"CHOLECYSTECTOMY,MINOR",263,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15619.88,,"Case rate ($14,876.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14876.08,15619.88,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],85446.13,,"Fee schedule rate ($85,446.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,30150.40,89465.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt,CASE-28309,APC,28309,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17161.77,,"Fee schedule rate ($17,161.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,6055.67,17969.04,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14156.33,,"Fee schedule rate ($14,156.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4772.53,14161.54,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],38954.76,,"Fee schedule rate ($38,954.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Suprascapular Nerv|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16307.62,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8558.00,48389.68,Inpatient DRG
Surgical Arthroscopy Shoulder Capsulorrhaphy|LEFT SIDE|PO,CASE-29806,APC,29806,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],37891.56,,"Fee schedule rate ($37,891.56). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,21112.63,62647.63,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],47283.61,,"Case rate ($47,283.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $43,688.88, add-ons for qualifying new technology services are included. If operating cost exceeds $79,156.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,591.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $43,863.00. The transfer operating threshold is the transfer adjustment factor * $43,688.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,420.62. The transfer capital threshold is the transfer adjustment factor * $3,420.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,47283.61,169615.07,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19330.07,,"Fee schedule rate ($19,330.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],49371.45,,"Fee schedule rate ($49,371.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15824.86,49371.45,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],12635.27,,"Fee schedule rate ($12,635.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4867.35,14442.92,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11461.54,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10915.75,32390.31,Inpatient DRG
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],96445.01,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10249.47,96445.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5578.22,18148.00,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19280.49,,"Case rate ($18,902.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,465.38, add-ons for qualifying new technology services are included. If operating cost exceeds $52,933.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,538.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,534.99. The transfer operating threshold is the transfer adjustment factor * $17,465.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,367.45. The transfer capital threshold is the transfer adjustment factor * $1,367.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,18902.44,56089.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5003.96,21742.11,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21574.35,,"Fee schedule rate ($21,574.35). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21975.27,,,,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],615.80,,"APC Price ($594.98). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,594.98,624.73,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9777.90,,"Case rate ($9,312.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,604.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,072.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,844.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,638.62. The transfer operating threshold is the transfer adjustment factor * $8,604.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.67. The transfer capital threshold is the transfer adjustment factor * $673.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9312.29,27632.41,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
Revasc lithotrip tibi/perone,CASE-C9772,APC,C9772,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11332.52,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,LT|XU|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrt Glenohmrl Jt W/Jt Expl W/WO Rmvl Loose/FB,CASE-23107,APC,23107,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11169.08,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10637.22,31563.88,Inpatient DRG
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Repair of Rotator Cuff Chronic,CASE-23412,APC,23412,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],46016.63,,,,,,0,other,15507.88,46016.63,There are no additional notes associated with this service or procedure.
Synovectomy Metatarsophalangeal Joint Each,CASE-28072,APC,28072,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10638.54,,"Case rate ($10,638.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,829.75, add-ons for qualifying new technology services are included. If operating cost exceeds $45,297.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,868.93. The transfer operating threshold is the transfer adjustment factor * $9,829.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.62. The transfer capital threshold is the transfer adjustment factor * $769.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10638.54,40729.62,Inpatient DRG
Manipulation Knee Joint Under General Anesthesia|LEFT SIDE,CASE-27570,APC,27570,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO|SEPARATE STRUCTURE",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO|XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],91852.39,,"Case rate ($91,852.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $84,869.31, add-ons for qualifying new technology services are included. If operating cost exceeds $120,337.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $7,815.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $85,207.55. The transfer operating threshold is the transfer adjustment factor * $84,869.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,644.83. The transfer capital threshold is the transfer adjustment factor * $6,644.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10249.47,96445.01,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
Partial Excision Bone Fibula|LEFT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],31206.03,,"Case rate ($29,720.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,460.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,928.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,321.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,570.01. The transfer operating threshold is the transfer adjustment factor * $27,460.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,150.02. The transfer capital threshold is the transfer adjustment factor * $2,150.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13369.00,88188.38,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5932.68,,"Case rate ($5,732.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,296.29, add-ons for qualifying new technology services are included. If operating cost exceeds $40,764.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,317.40. The transfer operating threshold is the transfer adjustment factor * $5,296.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.67. The transfer capital threshold is the transfer adjustment factor * $414.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5732.06,21720.81,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12138.74,,,,,,0,other,2285.00,12138.74,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4464.17,13577.72,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19138.75,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18227.38,54086.17,Inpatient DRG
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14891.42,,"Case rate ($14,182.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,104.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,571.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,197.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,156.32. The transfer operating threshold is the transfer adjustment factor * $13,104.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,025.98. The transfer capital threshold is the transfer adjustment factor * $1,025.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7308.00,42083.20,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18670.82,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,1188.00,31658.33,All Other Inpatient
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],70037.75,,"Fee schedule rate ($70,037.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.9), with a minimum of zero.",,,,0,other,24713.42,73332.24,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],54072.40,,,,,,0,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6816.94,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5520.00,26638.96,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17810.78,,"Fee schedule rate ($17,810.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,Zero final payments for the item or service in the 15 months prior to posting the file.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7934.97,23545.50,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],38724.86,,"Fee schedule rate ($38,724.86). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,13664.39,40546.43,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19628.82,,"Case rate ($19,243.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,780.93, add-ons for qualifying new technology services are included. If operating cost exceeds $53,248.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,851.79. The transfer operating threshold is the transfer adjustment factor * $17,780.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.16. The transfer capital threshold is the transfer adjustment factor * $1,392.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,19243.94,63510.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38228.48,,,,,,0,other,12883.25,44763.90,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10037.09,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",9876.57,9876.57,9876.57,1 through 10,other,10037.09,36934.96,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38610.21,,,,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31350.48,,"Fee schedule rate ($31,350.48). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10888.24,32825.17,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],24308.97,,,,,,0,other,8192.28,24308.97,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12255.94,,"Case rate ($11,672.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,998.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.14. The transfer capital threshold is the transfer adjustment factor * $827.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",12377.45,12255.95,12377.45,1 through 10,other,11690.93,56733.59,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34528.24,,"Fee schedule rate ($34,528.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13588.14,40320.14,Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13932.70,,"Fee schedule rate ($13,932.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4517.87,13932.70,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],63934.22,,"Fee schedule rate ($63,934.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16929.63,63934.22,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13223.70,,"Fee schedule rate ($13,223.70). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8331.72,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7934.97,23545.50,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5857.13,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5578.22,18148.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER RESPIRATORY AND CHEST PROCEDURES,MODERATE",121,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],25286.57,,"Case rate ($24,082.45). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24082.45,25286.57,There are no additional notes associated with this service or procedure.
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE,CASE-23700,APC,23700,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit W Pta,CASE-36902,APC,36902,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5587.20,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5478.32,5478.32,5478.32,1 through 10,other,5398.26,5668.18,OPPS APC
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10400.15,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5942.94,17634.53,All Other Inpatient
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],12053.12,,"Fee schedule rate ($12,053.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4574.91,13575.16,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33483.49,,"Fee schedule rate ($33,483.49). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
Cystourethroscopy With Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52204,APC,52204,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE|PO,CASE-29882,APC,29882,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],70498.76,,,,,,0,other,23758.52,103116.16,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7602.55,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6308.00,21796.21,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31159.55,,"Fee schedule rate ($31,159.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, SECOND DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, GREAT TOE|PO",CASE-28270,APC,28270,CPT,0360,RC,,,XS|TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],121107.98,,"Fee schedule rate ($121,107.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],39621.50,,"Case rate ($37,734.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,921.57, add-ons for qualifying new technology services are included. If operating cost exceeds $70,389.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,845.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,060.75. The transfer operating threshold is the transfer adjustment factor * $34,921.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,674.02. The transfer capital threshold is the transfer adjustment factor * $2,674.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10105.00,120252.50,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12002.07,,"Fee schedule rate ($12,002.07). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5297.06,19049.64,There are no additional notes associated with this service or procedure.
Gastrocnemius Recession|LEFT SIDE|PO,CASE-27687,APC,27687,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],129893.46,,"Fee schedule rate ($129,893.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],82553.89,,"Fee schedule rate ($82,553.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29129.85,86437.13,Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5641.56,,"Case rate ($5,450.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $5,062.05, add-ons for qualifying new technology services are included. If operating cost exceeds $42,251.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,051.56. The transfer operating threshold is the transfer adjustment factor * $5,062.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.22. The transfer capital threshold is the transfer adjustment factor * $399.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5450.78,16705.77,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11151.30,,"Case rate ($10,620.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.59. The transfer capital threshold is the transfer adjustment factor * $752.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",11229.48,5057.85,11229.48,16,other,10637.22,31563.88,Inpatient DRG
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5349.54,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5094.80,15365.01,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],138208.82,,"Fee schedule rate ($138,208.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,39831.40,138208.82,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6816.94,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5520.00,26638.96,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9188.13,,"Case rate ($8,750.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,791.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.10. The transfer capital threshold is the transfer adjustment factor * $620.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8764.55,32969.91,Inpatient DRG
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14236.20,,"Fee schedule rate ($14,236.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5942.94,17634.53,There are no additional notes associated with this service or procedure.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, SECOND DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9901.84,,"Case rate ($9,430.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,713.39, add-ons for qualifying new technology services are included. If operating cost exceeds $44,181.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,853.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,748.12. The transfer operating threshold is the transfer adjustment factor * $8,713.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.21. The transfer capital threshold is the transfer adjustment factor * $682.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,45869.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15617.05,,"Fee schedule rate ($15,617.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6681.01,19824.58,There are no additional notes associated with this service or procedure.
Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins|RIGHT SIDE|PO,CASE-25320,APC,25320,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28061.37,,,,,,0,other,9456.85,28061.37,There are no additional notes associated with this service or procedure.
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,APC,58573,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Subtalar|RIGHT SIDE,CASE-28725,APC,28725,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER PNEUMONIA,EXTREME",139,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],19975.22,,"Case rate ($19,975.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19975.22,20973.98,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],36934.96,,"Fee schedule rate ($36,934.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10037.09,36934.96,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20788.82,,"Fee schedule rate ($20,788.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12335.32,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",12242.74,12242.74,12242.74,1 through 10,other,12093.45,35884.94,Inpatient DRG
Exc Tumor Soft Tissue Shoulder Subfascial 5 Cm/>|RIGHT SIDE,CASE-23073,APC,23073,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2755.03,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8926.35,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6178.00,25225.91,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18777.76,,,,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,APC,58552,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9269.86,,"Case rate ($5,297.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,894.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,362.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,554.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,913.86. The transfer operating threshold is the transfer adjustment factor * $4,894.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.20. The transfer capital threshold is the transfer adjustment factor * $383.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,5297.06,19049.64,All Other Inpatient
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],89682.20,,"Fee schedule rate ($89,682.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",47691.74,47691.74,47691.74,1 through 10,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, FOURTH DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tnot Flxr/Xtnsr Tendon Forearm&/Wrist 1 Ea,CASE-25290,APC,25290,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],23777.27,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,41333.08,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40658.63,,"Fee schedule rate ($40,658.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,40658.63,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5249.28,,"Case rate ($4,999.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,626.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,094.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,525.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,645.03. The transfer operating threshold is the transfer adjustment factor * $4,626.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.27. The transfer capital threshold is the transfer adjustment factor * $354.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",3725.00,3725.00,3725.00,1 through 10,other,5007.28,16142.41,Inpatient DRG
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],48104.19,,"Fee schedule rate ($48,104.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27597.52,,"Fee schedule rate ($27,597.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9738.02,28895.67,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6367.35,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6257.56,6257.56,6257.56,1 through 10,other,1188.00,18893.86,Inpatient DRG
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F9|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13305.64,39481.90,Zero final payments for the item or service in the 15 months prior to posting the file.
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3313.96,3313.96,3313.96,1 through 10,other,3343.33,3510.50,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23014.22,,,,,,0,other,7755.94,35520.39,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],51765.74,,"Fee schedule rate ($51,765.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|LEFT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10608.50,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,30861.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9987.59,,"Case rate ($9,511.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,845.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.05. The transfer capital threshold is the transfer adjustment factor * $674.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9527.16,28269.95,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24824.01,,"Case rate ($23,641.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,846.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,675.35. The transfer capital threshold is the transfer adjustment factor * $1,675.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23679.61,84629.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],912.91,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4984.06,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4984.06,19757.81,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,Zero final payments for the item or service in the 15 months prior to posting the file.
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,APC,53445,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19658.06,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19658.06,20346.09,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28308,APC,28308,CPT,0360,RC,,,RT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],30586.34,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29129.85,86437.13,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24850.18,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10632.00,103714.29,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19138.75,,"Case rate ($18,227.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,841.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,309.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,489.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,908.76. The transfer operating threshold is the transfer adjustment factor * $16,841.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.61. The transfer capital threshold is the transfer adjustment factor * $1,318.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18227.38,54086.17,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22353.48,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21289.03,76326.34,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16192.08,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15421.03,49137.17,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],57367.22,,"Fee schedule rate ($57,367.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
Laps Supracrv Hysterec >250 G Rmvl Tube/Ovary,CASE-58544,APC,58544,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"RESPIRATORY FAILURE,MAJOR",133,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14812.53,,"Case rate ($14,812.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14812.53,15553.16,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Vasc Embolize Occlude Organ,CASE-37243,APC,37243,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21256.76,,"Fee schedule rate ($21,256.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10538.94,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10037.09,36934.96,Inpatient DRG
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12994.21,,"Case rate ($12,375.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,048.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $876.97. The transfer capital threshold is the transfer adjustment factor * $876.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12395.17,42174.37,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],34447.94,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32807.56,111191.81,Inpatient DRG
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,MODERATE",351,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9243.12,,"Case rate ($8,802.97). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8802.97,9243.12,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12006.78,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11600.75,34422.94,Inpatient DRG
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,MAJOR",192,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],24571.50,,"Case rate ($24,571.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24571.50,25800.08,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9948.90,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9948.90,46199.76,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE",CASE-28299,APC,28299,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27416.36,,"Fee schedule rate ($27,416.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6328.22,27416.36,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],29165.93,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13572.00,108637.77,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9717.70,,"Case rate ($9,527.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,802.85, add-ons for qualifying new technology services are included. If operating cost exceeds $44,270.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,837.93. The transfer operating threshold is the transfer adjustment factor * $8,802.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.22. The transfer capital threshold is the transfer adjustment factor * $689.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9527.16,28269.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",32359.30,32359.30,32359.30,1 through 10,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",425.45,425.45,425.45,1 through 10,other,291.13,305.69,OPPS APC
Excision Malignant Lesion S/N/H/F/G 2.1-3.0 Cm,CASE-11623,APC,11623,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,MODERATE",817,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7421.46,,"Case rate ($7,421.46). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7421.46,7792.53,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|LEFT SIDE,CASE-27524,APC,27524,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft|LEFT SIDE,CASE-27130,APC,27130,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",12363.12,12298.35,12363.12,1 through 10,other,12177.08,12785.93,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14568.10,,"Fee schedule rate ($14,568.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],72192.67,,"Fee schedule rate ($72,192.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8934.86,,"Case rate ($8,509.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,902.12, add-ons for qualifying new technology services are included. If operating cost exceeds $48,447.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,251.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $7,906.03. The transfer operating threshold is the transfer adjustment factor * $7,902.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $603.37. The transfer capital threshold is the transfer adjustment factor * $603.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",33763.47,33763.47,33763.47,1 through 10,other,6965.00,25698.16,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],88173.00,,"Fee schedule rate ($88,173.00). Adds an outlier to normal pricing equal to the per diem rate ($170,052.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],24977.98,,,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13912.44,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13249.94,40085.35,Inpatient DRG
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15218.11,,"Case rate ($15,218.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,061.15, add-ons for qualifying new technology services are included. If operating cost exceeds $49,529.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,272.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,117.19. The transfer operating threshold is the transfer adjustment factor * $14,061.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.92. The transfer capital threshold is the transfer adjustment factor * $1,100.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,15218.11,45156.75,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"KIDNEY AND URINARY TRACT INFECTIONS,MODERATE",463,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8836.96,,"Case rate ($8,416.15). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8416.15,8836.96,There are no additional notes associated with this service or procedure.
Tenolysis Flxr/Xtnsr Tendon Leg&/Ankle 1 Each|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-27680,APC,27680,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT HAND, FIFTH DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],30966.53,,of the excess amount. Final payment is multiplied by 175%.,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],34386.65,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32749.19,97176.83,Inpatient DRG
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],93157.39,,"Fee schedule rate ($93,157.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,21828.16,93157.39,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8919.07,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8919.07,34453.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],91446.42,,"Fee schedule rate ($91,446.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,31858.62,94534.21,There are no additional notes associated with this service or procedure.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],60588.60,,"Fee schedule rate ($60,588.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11978.73,60588.60,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,21325.01,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11987.59,,"Case rate ($11,416.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,980.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.03. The transfer capital threshold is the transfer adjustment factor * $809.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11434.95,119072.21,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debrid Wound Tis Addl 20 Cm<,CASE-97598,APC,97598,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],190.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Lss&Rescj Ads|RIGHT SIDE,CASE-29825,APC,29825,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|SEPARATE STRUCTURE|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE,CASE-29880,APC,29880,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,5007.28,16142.41,Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],102807.11,,"Fee schedule rate ($102,807.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.8), with a minimum of zero.",,,,0,other,36276.38,121107.98,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],32874.59,,"Fee schedule rate ($32,874.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
"INFLAMMATORY BOWEL DISEASE,MODERATE",245,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9898.50,,"Case rate ($9,898.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9898.50,10393.43,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21830.80,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21830.80,85124.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Calcaneal Fracture|RIGHT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20288.95,,,,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac W/Port Tun >5|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-36561,APC,36561,CPT,0361,RC,,,73,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
"KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,MODERATE",313,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],24206.78,,"Case rate ($24,206.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24206.78,25417.12,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],37134.43,,,,,,0,other,12514.54,37134.43,There are no additional notes associated with this service or procedure.
Biopsy Urethra,CASE-53200,APC,53200,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6834.24,,"Case rate ($6,700.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,655.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.71. The transfer capital threshold is the transfer adjustment factor * $484.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6700.24,30254.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Primary Open/Prq Ruptured Achilles Tendon|PO,CASE-27650,APC,27650,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE,CASE-28200,APC,28200,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,APC,26437,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT|PO",CASE-26727,APC,26727,CPT,0360,RC,,,F4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],37843.99,,"Case rate ($37,843.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $34,966.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,434.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,908.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $35,106.27. The transfer operating threshold is the transfer adjustment factor * $34,966.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,737.73. The transfer capital threshold is the transfer adjustment factor * $2,737.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,37843.99,139522.22,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6470.10,,"Fee schedule rate ($6,470.10). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],25907.78,,"Case rate ($24,674.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,919.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,748.49. The transfer capital threshold is the transfer adjustment factor * $1,748.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",26994.10,26994.10,26994.10,1 through 10,other,24713.42,73332.24,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6461.52,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6461.52,21772.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Remove Retrievable Filter,CASE-37193,APC,37193,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],31953.72,,"Case rate ($30,432.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,163.35, add-ons for qualifying new technology services are included. If operating cost exceeds $63,631.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,327.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,275.59. The transfer operating threshold is the transfer adjustment factor * $28,163.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,156.52. The transfer capital threshold is the transfer adjustment factor * $2,156.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",31953.74,31415.02,70347.45,1 through 10,other,30480.63,86382.02,Inpatient DRG
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|RIGHT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],38787.92,,"Fee schedule rate ($38,787.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14469.48,,"Case rate ($13,780.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,732.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,200.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,168.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,783.53. The transfer operating threshold is the transfer adjustment factor * $12,732.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.91. The transfer capital threshold is the transfer adjustment factor * $996.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9763.00,48626.00,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],66445.05,,"Fee schedule rate ($66,445.05). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",3313.96,3313.96,3393.26,1 through 10,other,3343.33,3510.50,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6597.75,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",6511.71,6511.71,6511.71,1 through 10,other,6230.00,21325.01,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5967.84,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.66,16865.16,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20782.85,,,,,,0,other,7003.94,20782.85,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],77530.52,,"Fee schedule rate ($77,530.52). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Musc/Fasc,Ea Add 20sqcm",CASE-11046,APC,11046,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],725.52,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,700.99,736.04,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13475.16,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12833.49,58980.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15254.97,,"Fee schedule rate ($15,254.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5807.67,17233.12,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15233.99,,"Case rate ($14,508.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,405.55, add-ons for qualifying new technology services are included. If operating cost exceeds $48,873.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,220.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,458.97. The transfer operating threshold is the transfer adjustment factor * $13,405.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,049.59. The transfer capital threshold is the transfer adjustment factor * $1,049.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14508.56,59513.03,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE,CASE-27829,APC,27829,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3713.66,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6204.88,,"Case rate ($6,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,733.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,201.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,620.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,756.00. The transfer operating threshold is the transfer adjustment factor * $5,733.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.88. The transfer capital threshold is the transfer adjustment factor * $448.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6204.88,19589.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7744.00,,"Case rate ($7,744). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,731.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $560.22. The transfer capital threshold is the transfer adjustment factor * $560.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7744.00,24853.45,Inpatient DRG
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12498.29,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11903.13,48838.99,Inpatient DRG
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23125.89,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23125.89,68621.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
HC I&D Hematoma Seroma Fluid,CASE-10140,APC,10140,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",11176.20,11176.20,11176.20,1 through 10,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],211906.58,,"Fee schedule rate ($211,906.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,45609.21,211906.58,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,TA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20695.27,,"Fee schedule rate ($20,695.27). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22256.65,,,,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE|PO,CASE-24342,APC,24342,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE|PO,CASE-25447,APC,25447,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],47660.93,,"Fee schedule rate ($47,660.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33244.29,,,,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4941.63,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4774.52,14406.59,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6171.07,,"Case rate ($5,877.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,439.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,587.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,460.73. The transfer operating threshold is the transfer adjustment factor * $5,439.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.48. The transfer capital threshold is the transfer adjustment factor * $416.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5886.58,17467.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6972.00,,"Per diem ($6,972). If length of stay < 3.6, first 1 days paid at a per diem of $13,944 instead. Capped at $25,099.93.",66236.90,66236.90,66236.90,1 through 10,other,6972.00,26280.60,Estimated amount calculated based on 3 day length of stay.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26483.27,,,,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|LEFT SIDE|PO,CASE-28200,APC,28200,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1747.26,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1688.18,1772.59,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6696.63,,"Case rate ($6,377.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,623.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.95. The transfer capital threshold is the transfer adjustment factor * $451.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",6696.63,6696.63,6696.63,1 through 10,other,6387.91,18954.85,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12092.61,,"Case rate ($6,910.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,405.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,149.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,408.97. The transfer operating threshold is the transfer adjustment factor * $6,405.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $501.10. The transfer capital threshold is the transfer adjustment factor * $501.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6910.06,20832.04,All Other Inpatient
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],162464.13,,"Fee schedule rate ($162,464.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37873.87,,"Fee schedule rate ($37,873.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9761.89,37873.87,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],59942.55,,"Fee schedule rate ($59,942.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",59492.33,59492.33,59492.33,1 through 10,other,18222.73,59942.55,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrt Elbow Capsular Excision Capsular Rls Spx|RIGHT SIDE|PO,CASE-24006,APC,24006,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4221.44,,"Case rate ($4,138.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $3,835.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,380.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $1,949.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $3,837.39. The transfer operating threshold is the transfer adjustment factor * $3,835.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.30. The transfer capital threshold is the transfer adjustment factor * $301.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4138.67,12473.25,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31289.11,,"Fee schedule rate ($31,289.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10637.22,31563.88,There are no additional notes associated with this service or procedure.
"CHOLECYSTECTOMY,MODERATE",263,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],20012.24,,"Case rate ($19,059.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19059.28,20012.24,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19668.75,,"Fee schedule rate ($19,668.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],20306.22,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],20245.58,,"Case rate ($19,281.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,844.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,537.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,915.15. The transfer operating threshold is the transfer adjustment factor * $17,844.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,366.35. The transfer capital threshold is the transfer adjustment factor * $1,366.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8972.00,76376.03,Inpatient DRG
Ostectomy Complete 1st Metatarsal Head,CASE-28111,APC,28111,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16175.36,,"Case rate ($15,405.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,233.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,701.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,285.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,290.66. The transfer operating threshold is the transfer adjustment factor * $14,233.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.44. The transfer capital threshold is the transfer adjustment factor * $1,114.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,55581.70,Inpatient DRG
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE|PO,CASE-25111,APC,25111,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj 1st Metar|LEFT SIDE|PO,CASE-28306,APC,28306,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7123.17,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],9242.00,,"Per diem ($9,242). If length of stay < 7.6, first 1 days paid at a per diem of $18,484 instead. Capped at $70,242.60.",,,,0,other,9242.00,76216.30,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],52092.32,,"Fee schedule rate ($52,092.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],58696.00,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,55900.95,225294.39,Inpatient DRG
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Debridement Bone Each Additional 20 Sq Cm,CASE-11047,APC,11047,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",85770.12,85770.12,85770.12,1 through 10,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11114.67,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7000.00,32980.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",431.61,431.61,431.61,1 through 10,other,291.13,305.69,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37502.92,,"Fee schedule rate ($37,502.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4654.49,13811.29,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6350.00,,"Per diem ($6,350). If length of stay < 5, first 1 days paid at a per diem of $12,700 instead. Capped at $31,750.77.",,,,0,other,6350.00,33244.29,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7321.93,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6382.95,21300.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11651.83,,"Case rate ($11,096.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,957.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.37. The transfer capital threshold is the transfer adjustment factor * $786.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",724.12,724.12,28662.74,1 through 10,other,7000.00,32980.62,Inpatient DRG
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],36349.26,,"Fee schedule rate ($36,349.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9948.90,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9948.90,46199.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|LEFT SIDE,CASE-37766,APC,37766,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35389.05,,"Fee schedule rate ($35,389.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6953.00,35389.05,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27537.96,,,,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21720.81,,"Fee schedule rate ($21,720.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],22734.65,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22734.65,70806.50,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5669.00,,"Per diem ($5,669). If length of stay < 3.2, first 1 days paid at a per diem of $11,338 instead. Capped at $18,140.88.",,,,0,other,5669.00,18994.21,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,11714.14,49460.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE|PO,CASE-24685,APC,24685,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19232.02,,"Case rate ($19,232.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,769.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,237.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,562.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,840.72. The transfer operating threshold is the transfer adjustment factor * $17,769.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.29. The transfer capital threshold is the transfer adjustment factor * $1,391.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19232.02,68941.12,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18175.31,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10385.89,32176.55,All Other Inpatient
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12167.07,,"Case rate ($12,167.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,242.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,709.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,051.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,286.86. The transfer operating threshold is the transfer adjustment factor * $11,242.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.20. The transfer capital threshold is the transfer adjustment factor * $880.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12167.07,36103.36,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],39867.32,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",53862.93,53862.93,53862.93,1 through 10,other,23679.61,84629.16,There are no additional notes associated with this service or procedure.
"ABDOMINAL PAIN,MODERATE",251,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2878.95,,"Case rate for a one day stay ($2,878.95). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2878.95,3022.90,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13912.44,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13249.94,40085.35,Inpatient DRG
"HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,MINOR",279,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7028.08,,"The inlier payment is calculated as the lesser of the standard DRG payment $6,693.41 and the transfer payment, which is a per diem of $2,253.67. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6693.41,7028.08,Estimated amount calculated based on 1 day length of stay.
Arthroscopy Knee Removal Loose/Foreign Body,CASE-29874,APC,29874,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6797.06,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6797.06,20168.93,Inpatient DRG
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],59770.39,,"Fee schedule rate ($59,770.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],14023.34,,"Fee schedule rate ($14,023.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4870.41,14682.98,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23588.41,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23125.89,68621.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27540.60,,"Fee schedule rate ($27,540.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9738.02,28895.67,There are no additional notes associated with this service or procedure.
Mnpj W/Anes Shoulder Jt Appl Fixation Apparatus|LEFT SIDE,CASE-23700,APC,23700,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4464.17,,"Case rate ($4,464.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,124.78, add-ons for qualifying new technology services are included. If operating cost exceeds $39,592.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,141.22. The transfer operating threshold is the transfer adjustment factor * $4,124.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.95. The transfer capital threshold is the transfer adjustment factor * $322.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4464.17,13577.72,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4313.61,,"Case rate ($4,167.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,850.90, add-ons for qualifying new technology services are included. If operating cost exceeds $39,318.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,472.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,866.25. The transfer operating threshold is the transfer adjustment factor * $3,850.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.51. The transfer capital threshold is the transfer adjustment factor * $301.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4167.74,12366.99,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MAJOR",229,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],32115.92,,"Case rate ($32,115.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,32115.92,33721.72,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12948.38,,"Fee schedule rate ($12,948.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4568.94,13557.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MINOR",229,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],15043.24,,"Case rate ($15,043.24). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15043.24,15795.40,There are no additional notes associated with this service or procedure.
"MAJOR PANCREAS LIVER AND SHUNT PROCEDURES,MINOR",260,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],24197.18,,"Case rate ($23,044.93). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23044.93,24197.18,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1883.72,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR PELVIS AND BACK,MODERATE",342,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9250.58,,"Case rate ($9,250.58). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9250.58,9713.11,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22809.58,,,,,,0,other,7686.98,22809.58,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24408.19,,"Case rate ($23,582.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,789.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,257.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,877.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,876.75. The transfer operating threshold is the transfer adjustment factor * $21,789.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,706.04. The transfer capital threshold is the transfer adjustment factor * $1,706.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,23582.79,75543.62,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10603.51,,"Case rate ($10,098.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,886.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $715.62. The transfer capital threshold is the transfer adjustment factor * $715.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",17335.43,17335.43,17335.43,1 through 10,other,10114.68,30013.33,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21504.00,,"Fee schedule rate ($21,504). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15857.69,,,,,,0,other,5344.14,15857.69,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13916.39,,"Case rate ($7,952.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,347.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,815.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,746.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,376.94. The transfer operating threshold is the transfer adjustment factor * $7,347.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.28. The transfer capital threshold is the transfer adjustment factor * $575.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7952.22,25854.47,All Other Inpatient
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],120588.53,,,,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
"CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",163,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],81412.54,,"Case rate ($77,535.75). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $46,813, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,77535.75,81412.54,There are no additional notes associated with this service or procedure.
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26397.58,,"Fee schedule rate ($26,397.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28847.26,,"Fee schedule rate ($28,847.26). Adds an outlier to normal pricing equal to the per diem rate ($89,320.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],125659.39,,"Fee schedule rate ($125,659.39). Adds an outlier to normal pricing equal to the per diem rate ($160,041.92) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,44339.99,131570.26,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14438.27,,"Case rate ($14,438.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,215.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.50. The transfer capital threshold is the transfer adjustment factor * $1,044.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14438.27,55762.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28458.15,,"Fee schedule rate ($28,458.15). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15023.80,48104.19,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-20610,APC,20610,CPT,0510,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,301.32,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],113934.44,,"Fee schedule rate ($113,934.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|RIGHT SIDE,CASE-27691,APC,27691,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,APC,45171,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16737.33,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",16737.34,16737.34,16737.34,1 through 10,other,16737.33,72192.67,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",17368.93,17368.93,17368.93,1 through 10,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Midtarsometatarsal Single Joint|RIGHT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13249.94,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13249.94,40085.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],25148.37,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23950.83,74869.17,Inpatient DRG
Repair Brow Ptosis,CASE-67900,APC,67900,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2367.72,OPPS APC
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4608.23,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4517.87,13932.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only,CASE-27601,APC,27601,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28788.33,,"Fee schedule rate ($28,788.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,28788.33,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],212258.00,,"Fee schedule rate ($212,258.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,64872.40,212258.00,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",5210.57,4955.40,5210.57,1 through 10,other,5085.49,5339.77,OPPS APC
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,APC,45331,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30764.99,,,,,,0,other,10367.99,37103.57,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],57770.11,,"Fee schedule rate ($57,770.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14130.58,57770.11,There are no additional notes associated with this service or procedure.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE,CASE-27524,APC,27524,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14041.04,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14041.04,60059.69,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE|PO,CASE-27822,APC,27822,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3607.42,11497.58,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],48779.11,,"Fee schedule rate ($48,779.11). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5504.62,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5504.62,16333.88,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41042.29,,,,,,0,other,13831.52,59770.39,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11573.27,,"Case rate ($11,022.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,952.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.07. The transfer capital threshold is the transfer adjustment factor * $781.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6953.00,35389.05,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4755.96,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4755.96,21133.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11336.96,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7000.00,32980.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37423.05,,"Fee schedule rate ($37,423.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13305.64,39481.90,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,Zero final payments for the item or service in the 15 months prior to posting the file.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11987.59,,"Case rate ($11,416.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,565.62, add-ons for qualifying new technology services are included. If operating cost exceeds $46,033.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,980.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $10,607.73. The transfer operating threshold is the transfer adjustment factor * $10,565.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.03. The transfer capital threshold is the transfer adjustment factor * $809.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11434.95,119072.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8463.05,,"Case rate ($8,060.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.16. The transfer capital threshold is the transfer adjustment factor * $571.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8072.90,31159.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",34085.15,34085.15,34085.15,1 through 10,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29288.89,,"Fee schedule rate ($29,288.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],42577.42,,"Fee schedule rate ($42,577.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15023.80,48104.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|LEFT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3565.69,,"APC Price ($3,395.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3395.89,3565.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7527.99,,"Fee schedule rate ($7,527.99). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,There are no additional notes associated with this service or procedure.
Open Treatment Proximal Fibula/Shaft Fracture|RIGHT SIDE|PO,CASE-27784,APC,27784,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25180.05,,"Fee schedule rate ($25,180.05). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,17026.45,50522.67,There are no additional notes associated with this service or procedure.
Surg Tx Anal Fistula Intersphincteric,CASE-46275,APC,46275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9509.84,,"Case rate ($9,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,368.43, add-ons for qualifying new technology services are included. If operating cost exceeds $43,836.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,826.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,401.78. The transfer operating threshold is the transfer adjustment factor * $8,368.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.21. The transfer capital threshold is the transfer adjustment factor * $655.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9056.99,33814.75,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28086.14,,"Fee schedule rate ($28,086.14). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9910.44,43344.00,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],23530.36,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,22734.65,70806.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,APC,49321,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5605.96,5605.96,5605.96,1 through 10,other,5733.99,6020.69,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17494.85,,"Fee schedule rate ($17,494.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9574.89,28411.62,Zero final payments for the item or service in the 15 months prior to posting the file.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9299.56,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6972.00,26280.60,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10921.19,,"Case rate ($6,240.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,766.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,234.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,622.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,789.22. The transfer operating threshold is the transfer adjustment factor * $5,766.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.47. The transfer capital threshold is the transfer adjustment factor * $451.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6240.68,18518.02,All Other Inpatient
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14323.89,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,14043.03,54637.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,6077.55,18033.97,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6502.13,,"Case rate ($6,374.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,890.01, add-ons for qualifying new technology services are included. If operating cost exceeds $41,357.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,632.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,913.48. The transfer operating threshold is the transfer adjustment factor * $5,890.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6230.00,21325.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],46061.32,,"Fee schedule rate ($46,061.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10759.91,46061.32,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE|PO",CASE-64491,APC,64491,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34420.98,,,,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9361.52,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8915.73,26455.73,Inpatient DRG
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
Repair Dislocating Peroneal Tendon W/Fib Osteot,CASE-27676,APC,27676,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12943.20,,"Case rate ($12,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,062.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.76. The transfer capital threshold is the transfer adjustment factor * $891.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12326.86,53121.74,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,There are no additional notes associated with this service or procedure.
Fasciotomy Foot&/Toe|BILATERAL PROCEDURE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Tenolysis Extensor Foot Single Tendon,CASE-28225,APC,28225,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7795.07,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7795.07,34198.12,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12317.68,,"Case rate ($11,901.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,996.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,464.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,040.18. The transfer operating threshold is the transfer adjustment factor * $10,996.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.96. The transfer capital threshold is the transfer adjustment factor * $860.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11901.14,35314.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],37968.88,,of the excess amount.,,,,0,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21652.62,,"Case rate ($20,621.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,632.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,461.31. The transfer capital threshold is the transfer adjustment factor * $1,461.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",18338.87,18338.87,18338.87,1 through 10,other,20654.42,69402.59,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34749.58,,,,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12994.21,,"Case rate ($12,375.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,048.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $876.97. The transfer capital threshold is the transfer adjustment factor * $876.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12395.17,42174.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8638.55,,"Case rate ($8,638.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,981.81, add-ons for qualifying new technology services are included. If operating cost exceeds $43,449.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,796.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,013.62. The transfer operating threshold is the transfer adjustment factor * $7,981.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $624.94. The transfer capital threshold is the transfer adjustment factor * $624.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8442.00,28788.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],31570.16,,"Case rate ($31,570.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,170.04, add-ons for qualifying new technology services are included. If operating cost exceeds $64,637.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,455.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,286.29. The transfer operating threshold is the transfer adjustment factor * $29,170.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.86. The transfer capital threshold is the transfer adjustment factor * $2,283.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,31570.16,98176.71,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11948.40,,"Fee schedule rate ($11,948.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4257.29,12632.63,Zero final payments for the item or service in the 15 months prior to posting the file.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23320.23,,"Fee schedule rate ($23,320.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8228.75,24417.19,Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15806.56,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3295.00,53945.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],44163.71,,"Case rate ($42,670.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $39,426.24, add-ons for qualifying new technology services are included. If operating cost exceeds $74,894.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,258.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,583.36. The transfer operating threshold is the transfer adjustment factor * $39,426.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,086.87. The transfer capital threshold is the transfer adjustment factor * $3,086.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,42670.25,133443.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Revsc Opn/Prq Tib/Pero W/Athrc/Angiop Uni Ea Vsl|RIGHT SIDE,CASE-37233,APC,37233,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.96,,,,,,0,other,291.75,306.34,There are no additional notes associated with this service or procedure.
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,APC,31652,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3713.03,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3536.22,3713.03,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21248.26,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12141.86,36028.59,All Other Inpatient
HC Intro Cath Dialysis Circuit|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-36901,APC,36901,CPT,0361,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1545.29,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Bladder Irrig Simple or Continuous,CASE-51700,APC,51700,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],63574.18,,"Fee schedule rate ($63,574.18). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
"Inject Nerv Blck,Paravert Sympath|BILATERAL PROCEDURE|PO",CASE-64520,APC,64520,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],110685.97,,"Fee schedule rate ($110,685.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8764.55,32969.91,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],60333.05,,"Fee schedule rate ($60,333.05). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,21289.03,76326.34,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10635.71,,"Case rate ($6,077.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,615.51, add-ons for qualifying new technology services are included. If operating cost exceeds $41,083.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,637.89. The transfer operating threshold is the transfer adjustment factor * $5,615.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.67. The transfer capital threshold is the transfer adjustment factor * $439.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6077.55,18033.97,All Other Inpatient
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19390.33,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,11080.19,32878.30,All Other Inpatient
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19363.31,79918.67,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,7686.98,22809.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,APC,45381,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC
Removal Intrauterine Device Iud,CASE-58301,APC,58301,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],303.48,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,289.03,303.48,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
Repair Dislocating Peroneal Tendon W/Fib Osteot|LEFT SIDE|PO,CASE-27676,APC,27676,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10715.36,,,,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE|PO",CASE-28750,APC,28750,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Neuroplasty Other Arm/Leg Nerve,Open|SEPARATE STRUCTURE|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3402.11,,"APC Price ($3,240.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3240.11,3402.11,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22069.95,,"Fee schedule rate ($22,069.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11425.90,,"Case rate ($10,881.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,070.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,538.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,110.68. The transfer operating threshold is the transfer adjustment factor * $10,070.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.12. The transfer capital threshold is the transfer adjustment factor * $771.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10899.16,39746.35,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30846.83,,"Fee schedule rate ($30,846.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],76404.43,,"Fee schedule rate ($76,404.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23131.85,76404.43,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11472.73,,"Fee schedule rate ($11,472.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
Syndactylization Toes|RIGHT SIDE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14071.02,,,,,,0,other,4742.02,14071.02,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10362.69,,"Case rate ($10,362.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,920.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.66. The transfer capital threshold is the transfer adjustment factor * $749.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10362.69,29367.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14682.98,,,,,,0,other,4870.41,14682.98,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17103.38,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17103.38,50750.92,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7467.48,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",23505.54,23505.54,23505.54,1 through 10,other,3295.00,37575.69,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38976.20,,,,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,CASE-49616,APC,49616,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9.04,,,,,,0,other,8.91,9.04,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",870.39,870.39,870.39,1 through 10,other,860.25,903.26,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29783.11,,,,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],55737.89,,"Fee schedule rate ($55,737.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
"GASTROINTESTINAL VASCULAR INSUFFICIENCY,MAJOR",246,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14418.80,,"Case rate ($14,418.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14418.80,15139.74,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41847.08,,,,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],44591.73,,"Fee schedule rate ($44,591.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11814.94,44591.73,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27506.48,,,,,,0,other,9269.86,37852.57,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19363.31,,"Case rate ($19,363.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,891.22, add-ons for qualifying new technology services are included. If operating cost exceeds $53,359.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,571.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,962.52. The transfer operating threshold is the transfer adjustment factor * $17,891.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.79. The transfer capital threshold is the transfer adjustment factor * $1,400.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,19363.31,79918.67,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8896.97,,"Case rate ($8,596.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,942.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,410.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,974.25. The transfer operating threshold is the transfer adjustment factor * $7,942.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.86. The transfer capital threshold is the transfer adjustment factor * $621.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,8596.11,25507.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16302.99,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16302.99,55737.89,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5208.96,,"Case rate ($4,960.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,591.06, add-ons for qualifying new technology services are included. If operating cost exceeds $40,058.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,522.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,609.35. The transfer operating threshold is the transfer adjustment factor * $4,591.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $351.55. The transfer capital threshold is the transfer adjustment factor * $351.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4968.82,19848.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20082.30,,"Fee schedule rate ($20,082.30). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7544.88,,"Case rate ($7,289.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,735.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,203.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,698.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,762.40. The transfer operating threshold is the transfer adjustment factor * $6,735.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.36. The transfer capital threshold is the transfer adjustment factor * $527.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,7289.74,21630.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MAJOR",220,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],41243.54,,"Case rate ($41,243.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,41243.54,43305.72,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28431.58,,"Fee schedule rate ($28,431.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,7020.54,28431.58,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15233.93,,"Case rate ($14,718.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,599.78, add-ons for qualifying new technology services are included. If operating cost exceeds $49,067.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,235.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,653.98. The transfer operating threshold is the transfer adjustment factor * $13,599.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.79. The transfer capital threshold is the transfer adjustment factor * $1,064.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14718.77,51765.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE|PO,CASE-29879,APC,29879,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14200.87,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7453.00,42138.30,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|BILATERAL PROCEDURE|PO,CASE-29880,APC,29880,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,33946.09,There are no additional notes associated with this service or procedure.
HC Debrid Wound Tis 20 Cm/<|PBB CHARGE,CASE-97597,APC,97597,CPT,0761,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],190.30,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,190.30,199.81,OPPS APC
Open Tx Metatarsophalangeal Joint Dislocation,CASE-28645,APC,28645,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19881.64,,,,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],31858.62,,"Case rate ($31,858.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $29,436.57, add-ons for qualifying new technology services are included. If operating cost exceeds $64,904.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,475.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,553.88. The transfer operating threshold is the transfer adjustment factor * $29,436.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,304.73. The transfer capital threshold is the transfer adjustment factor * $2,304.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,31858.62,94534.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,APC,11403,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],671.64,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,671.64,695.15,OPPS APC
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17849.32,,"Case rate ($16,999.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,375.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,204.63. The transfer capital threshold is the transfer adjustment factor * $1,204.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17026.45,50522.67,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
Fasciotomy Foot&/Toe|LEFT SIDE,CASE-28008,APC,28008,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Dcmprn Fasct Leg Post Compartment Only|RIGHT SIDE|PO,CASE-27601,APC,27601,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33483.49,,"Fee schedule rate ($33,483.49). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6939.76,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5843.00,27370.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intrvasc US Noncoronary 1st,CASE-37252,APC,37252,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],538.93,,,,,,0,other,538.93,565.88,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18515.40,,"Fee schedule rate ($18,515.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6240.68,18518.02,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],49997.29,,,,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],48832.41,,,,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14124.38,,"Fee schedule rate ($14,124.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4303.70,14124.38,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],55762.74,,"Fee schedule rate ($55,762.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14438.27,55762.74,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9910.01,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9574.89,28411.62,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],73863.30,,"Fee schedule rate ($73,863.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10970.77,32553.63,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9760.97,,"Case rate ($9,569.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,842.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,309.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,877.30. The transfer operating threshold is the transfer adjustment factor * $8,842.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.29. The transfer capital threshold is the transfer adjustment factor * $692.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9569.58,41116.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Femur/Knee|LEFT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],233.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,233.96,245.65,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|PO,CASE-64636,APC,64636,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14112.34,,,,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],882.03,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, GREAT TOE",CASE-28810,APC,28810,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],110288.60,,"Fee schedule rate ($110,288.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,38916.28,133824.90,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9583.32,,"Fee schedule rate ($9,583.32). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],79366.60,,"Fee schedule rate ($79,366.60). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35064.25,,"Fee schedule rate ($35,064.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14673.67,43541.27,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8816.90,,"Case rate ($8,397.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.04. The transfer capital threshold is the transfer adjustment factor * $595.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8410.44,24956.34,Inpatient DRG
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7405.81,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7405.81,33747.30,Inpatient DRG
"KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,MODERATE",443,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5577.70,,"Case rate for a one day stay ($5,577.70). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5577.70,5856.59,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|LEFT SIDE|PO,CASE-23430,APC,23430,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10449.55,,"Case rate ($10,449.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,655.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,123.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,927.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,693.61. The transfer operating threshold is the transfer adjustment factor * $9,655.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.95. The transfer capital threshold is the transfer adjustment factor * $755.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10449.55,43409.67,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24946.45,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23758.52,103116.16,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],55145.09,,"Fee schedule rate ($55,145.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,12804.31,55145.09,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10594.29,,"Case rate ($10,236.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,457.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,925.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,911.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,495.53. The transfer operating threshold is the transfer adjustment factor * $9,457.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.50. The transfer capital threshold is the transfer adjustment factor * $740.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10236.03,30589.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10210.03,,"Case rate ($9,723.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,860.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.07. The transfer capital threshold is the transfer adjustment factor * $689.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9739.34,40204.26,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6494.70,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,1188.00,18893.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],57420.46,,"Fee schedule rate ($57,420.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,21399.79,63499.65,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],43344.00,,"Fee schedule rate ($43,344.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9910.44,43344.00,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16549.49,,"Case rate ($9,456.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,737.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,205.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,772.72. The transfer operating threshold is the transfer adjustment factor * $8,737.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.13. The transfer capital threshold is the transfer adjustment factor * $684.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,9456.85,28061.37,All Other Inpatient
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5578.22,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5578.22,18148.00,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Single External Papilla or Tag Anus,CASE-46220,APC,46220,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16302.99,55737.89,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],28332.62,,"Case rate ($27,777.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,665.32, add-ons for qualifying new technology services are included. If operating cost exceeds $61,133.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,180.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $25,767.60. The transfer operating threshold is the transfer adjustment factor * $25,665.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,009.46. The transfer capital threshold is the transfer adjustment factor * $2,009.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13572.00,108637.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Fracture Phalanx/Phalanges Not Great Toe,CASE-28525,APC,28525,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11903.13,,"Case rate ($11,903.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,998.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,466.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,032.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,042.03. The transfer operating threshold is the transfer adjustment factor * $10,998.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.10. The transfer capital threshold is the transfer adjustment factor * $861.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11903.13,48838.99,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10297.11,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9948.90,46199.76,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27395.06,,"Fee schedule rate ($27,395.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10810.31,32077.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Rhytidectomy Smas Flap|PO,CASE-15829,APC,15829,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2254.97,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2254.97,2254.97,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29288.89,,"Fee schedule rate ($29,288.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11903.13,48838.99,There are no additional notes associated with this service or procedure.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14499.98,,"Case rate ($13,809.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,779.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,247.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,149.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,830.90. The transfer operating threshold is the transfer adjustment factor * $12,779.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $978.59. The transfer capital threshold is the transfer adjustment factor * $978.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13831.52,59770.39,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],30586.34,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29129.85,86437.13,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7590.81,,"Case rate ($7,590.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,013.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,481.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,720.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,041.68. The transfer operating threshold is the transfer adjustment factor * $7,013.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.14. The transfer capital threshold is the transfer adjustment factor * $549.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7590.81,32847.45,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, FIFTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T4,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,30861.41,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],40666.46,,,,,,0,other,13704.86,49911.01,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15793.67,,"Case rate ($15,041.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,237.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,065.90. The transfer capital threshold is the transfer adjustment factor * $1,065.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15065.57,53815.71,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],30758.38,,of the excess amount.,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
Arthro/shoul surg; w/spacer|PO,CASE-C9781,APC,C9781,CPT,0360,RC,,,PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC
Dcmprn Fasct Leg Ant&/Lat Compartments Only,CASE-27600,APC,27600,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3212.01,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 2 day length of stay.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],119072.21,,"Fee schedule rate ($119,072.21). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11434.95,119072.21,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],61129.87,,"Fee schedule rate ($61,129.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21570.21,72041.81,Zero final payments for the item or service in the 15 months prior to posting the file.
Insertion Intrauterine Device Iud,CASE-58300,APC,58300,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38728.27,,,,,,0,other,13051.67,38728.27,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35485.50,,,,,,0,other,11958.84,40774.00,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15210.60,,"Fee schedule rate ($15,210.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5985.39,17760.46,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6531.00,,"Per diem ($6,531). If length of stay < 4.1, first 1 days paid at a per diem of $13,062 instead. Capped at $26,776.27.",,,,0,other,6531.00,35832.77,Estimated amount calculated based on 5 day length of stay.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],61860.92,,"Fee schedule rate ($61,860.92). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21828.16,93157.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],26951.04,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,25667.66,86123.60,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33946.09,,"Fee schedule rate ($33,946.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,33946.09,Zero final payments for the item or service in the 15 months prior to posting the file.
Carpectomy All Bones Proximal Row|RIGHT SIDE|PO,CASE-25215,APC,25215,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11169.08,,"Case rate ($10,637.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,828.53, add-ons for qualifying new technology services are included. If operating cost exceeds $45,296.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,940.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,867.70. The transfer operating threshold is the transfer adjustment factor * $9,828.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.52. The transfer capital threshold is the transfer adjustment factor * $769.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10637.22,31563.88,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],92731.42,,"Fee schedule rate ($92,731.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,31112.60,92731.42,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],124854.72,,"Fee schedule rate ($124,854.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,31019.76,124854.72,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],58465.86,,"Fee schedule rate ($58,465.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16524.47,58465.86,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],41333.08,,"Fee schedule rate ($41,333.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,41333.08,There are no additional notes associated with this service or procedure.
Excision Prepatellar Bursa|LEFT SIDE|SEPARATE STRUCTURE,CASE-27340,APC,27340,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE|PO,CASE-64450,APC,64450,CPT,0450,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7184.98,,"Case rate ($7,184.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,638.74, add-ons for qualifying new technology services are included. If operating cost exceeds $42,106.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,665.20. The transfer operating threshold is the transfer adjustment factor * $6,638.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.78. The transfer capital threshold is the transfer adjustment factor * $519.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7184.98,21320.03,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7759.92,,"Case rate ($7,759.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,169.97, add-ons for qualifying new technology services are included. If operating cost exceeds $42,637.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,732.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,198.54. The transfer operating threshold is the transfer adjustment factor * $7,169.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.37. The transfer capital threshold is the transfer adjustment factor * $561.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7759.92,35376.63,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10556.32,32082.48,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22441.41,,"Fee schedule rate ($22,441.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9793.06,29058.99,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,There are no additional notes associated with this service or procedure.
Syndactylization Toes|BILATERAL PROCEDURE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Stent Place Initial Artery Ang,CASE-37236,APC,37236,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10949.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5612.85,,"Case rate ($5,345.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,947.04, add-ons for qualifying new technology services are included. If operating cost exceeds $40,414.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,549.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,966.76. The transfer operating threshold is the transfer adjustment factor * $4,947.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.81. The transfer capital threshold is the transfer adjustment factor * $378.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5354.09,15887.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24533.10,,"Case rate ($23,703.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,901.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,369.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,885.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $21,988.71. The transfer operating threshold is the transfer adjustment factor * $21,901.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.77. The transfer capital threshold is the transfer adjustment factor * $1,714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23703.48,110204.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],58164.13,,"Fee schedule rate ($58,164.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,27861.95,82674.88,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6472.13,,"Case rate ($6,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,980.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,447.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,003.91. The transfer operating threshold is the transfer adjustment factor * $5,980.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.21. The transfer capital threshold is the transfer adjustment factor * $468.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6475.38,6475.38,43339.18,1 through 10,other,6472.13,19204.75,Inpatient DRG
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15365.01,,"Fee schedule rate ($15,365.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11986.02,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,11986.02,54149.39,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11948.42,,"Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,823.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,291.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,018.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,866.71. The transfer operating threshold is the transfer adjustment factor * $10,823.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.43. The transfer capital threshold is the transfer adjustment factor * $847.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11714.14,49460.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39746.35,,"Fee schedule rate ($39,746.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10899.16,39746.35,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7421.00,,"Case rate ($7,067.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,540.71, add-ons for qualifying new technology services are included. If operating cost exceeds $42,008.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,671.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,566.78. The transfer operating threshold is the transfer adjustment factor * $6,540.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.84. The transfer capital threshold is the transfer adjustment factor * $500.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",7324.40,7324.40,7324.40,1 through 10,other,7078.89,21005.20,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6088.84,,"Case rate ($6,088.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,625.93, add-ons for qualifying new technology services are included. If operating cost exceeds $41,093.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,611.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,648.35. The transfer operating threshold is the transfer adjustment factor * $5,625.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.48. The transfer capital threshold is the transfer adjustment factor * $440.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6088.84,6088.84,6088.84,1 through 10,other,6088.84,18067.42,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26874.85,,,,,,0,other,9056.99,33814.75,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],74873.19,,"Fee schedule rate ($74,873.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.6), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30666.60,,,,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32553.63,,,,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],26419.65,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,26419.65,96304.23,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,APC,52352,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm/1pct,CASE-15002,APC,15002,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],700.99,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,700.99,736.04,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,41333.08,Estimated amount calculated based on 10 day length of stay.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32019.51,,"Fee schedule rate ($32,019.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,11298.37,44627.23,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],74873.19,,"Fee schedule rate ($74,873.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.6), with a minimum of zero.",,,,0,other,26419.65,96304.23,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14102.73,,"Case rate ($14,102.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,030.57, add-ons for qualifying new technology services are included. If operating cost exceeds $48,498.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,191.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,082.50. The transfer operating threshold is the transfer adjustment factor * $13,030.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.23. The transfer capital threshold is the transfer adjustment factor * $1,020.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,14102.73,41847.08,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Lesion Tendon Sheath/Capsule Leg&/Ank,CASE-27630,APC,27630,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27654,APC,27654,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Tenolysis Extensor Foot Single Tendon,CASE-28225,APC,28225,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],9057.14,,"Fee schedule rate ($9,057.14). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4418.42,13110.79,Zero final payments for the item or service in the 15 months prior to posting the file.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11574.15,,"Fee schedule rate ($11,574.15). Adds an outlier to normal pricing equal to the per diem rate ($4,143.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5549.19,16729.39,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5578.22,,"Case rate ($5,578.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,154.14, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,574.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,174.68. The transfer operating threshold is the transfer adjustment factor * $5,154.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $403.54. The transfer capital threshold is the transfer adjustment factor * $403.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5578.22,18148.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"KIDNEY AND URINARY TRACT INFECTIONS,MAJOR",463,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11875.93,,"Case rate ($11,310.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11310.41,11875.93,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],38029.56,,"Case rate ($36,218.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,737.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,566.58. The transfer capital threshold is the transfer adjustment factor * $2,566.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",29223.72,29223.72,29223.72,1 through 10,other,36276.38,121107.98,Inpatient DRG
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],111191.81,,"Fee schedule rate ($111,191.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,32807.56,111191.81,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13693.78,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,13230.71,39259.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15729.45,,"Case rate ($15,421.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,248.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,716.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,286.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,305.42. The transfer operating threshold is the transfer adjustment factor * $14,248.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,115.60. The transfer capital threshold is the transfer adjustment factor * $1,115.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15421.03,49137.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7840.85,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3295.00,37575.69,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27370.21,,"Fee schedule rate ($27,370.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13640.72,,"Case rate ($12,991.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,022.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,490.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,091.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,070.57. The transfer operating threshold is the transfer adjustment factor * $12,022.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.60. The transfer capital threshold is the transfer adjustment factor * $920.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7231.00,38610.21,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|RIGHT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,XS|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11356.39,,"Case rate ($10,815.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,993.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,461.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,033.17. The transfer operating threshold is the transfer adjustment factor * $9,993.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.43. The transfer capital threshold is the transfer adjustment factor * $782.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9888.00,40658.63,Inpatient DRG
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],22267.42,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,21830.80,85124.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],33955.82,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,32807.56,111191.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"NEPHRITIS AND NEPHROSIS,MAJOR",462,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],18062.67,,"Case rate ($17,202.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17202.54,18062.67,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg|REPEAT PROCEDURE BY SAME PHYSICIAN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,76|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],24790.92,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,24790.92,26030.46,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],78047.33,,"Fee schedule rate ($78,047.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Brow Ptosis|BILATERAL PROCEDURE|PO,CASE-67900,APC,67900,CPT,0360,RC,,,50|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2367.72,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|RIGHT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9161.42,,"Case rate ($8,981.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.292, exceeds $8,341.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,531.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $2,671.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,324.06. The transfer operating threshold is the transfer adjustment factor * $8,341.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $657.72. The transfer capital threshold is the transfer adjustment factor * $657.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8981.78,27528.12,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],67775.08,,"Fee schedule rate ($67,775.08). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,17103.38,50750.92,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11190.19,,"Case rate ($10,970.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,136.72, add-ons for qualifying new technology services are included. If operating cost exceeds $45,604.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,964.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,177.12. The transfer operating threshold is the transfer adjustment factor * $10,136.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.65. The transfer capital threshold is the transfer adjustment factor * $793.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10970.77,32553.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB|PO",CASE-26540,APC,26540,CPT,0360,RC,,,FA|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],42083.20,,,,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4179.80,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3980.76,11812.10,Inpatient DRG
Rmvl/Revj Sling Stress Incontinence,CASE-57287,APC,57287,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3070.31,,"APC Price ($3,070.31). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MODERATE",254,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10064.15,,"Case rate ($9,584.90). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9584.90,10064.15,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],41303.54,,"Case rate ($23,602.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,807.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,275.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,878.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,894.59. The transfer operating threshold is the transfer adjustment factor * $21,807.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,707.43. The transfer capital threshold is the transfer adjustment factor * $1,707.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,23602.02,108295.22,All Other Inpatient
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],52092.32,,"Fee schedule rate ($52,092.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9574.89,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",8945.71,8945.71,8945.71,1 through 10,other,9574.89,28411.62,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],55294.18,,"Fee schedule rate ($55,294.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,8940.00,63653.13,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,APC,64585,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3315.94,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3315.94,3481.74,OPPS APC
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|RIGHT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16307.62,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8558.00,48389.68,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,28788.33,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15459.57,,"Case rate ($15,156.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,004.17, add-ons for qualifying new technology services are included. If operating cost exceeds $49,472.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,267.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,059.98. The transfer operating threshold is the transfer adjustment factor * $14,004.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.45. The transfer capital threshold is the transfer adjustment factor * $1,096.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,15156.44,52672.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4774.52,,"Case rate ($4,774.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,411.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,879.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,429.11. The transfer operating threshold is the transfer adjustment factor * $4,411.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.40. The transfer capital threshold is the transfer adjustment factor * $345.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4774.52,14406.59,Inpatient DRG
"HC Debrid,Musc/Fasc,Ea Add 20sqcm|SEPARATE STRUCTURE",CASE-11046,APC,11046,CPT,0361,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],700.99,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,700.99,725.52,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,APC,64493,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1283.15,1283.15,1283.15,1 through 10,other,838.89,880.84,OPPS APC
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,APC,64772,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28437.57,,"Fee schedule rate ($28,437.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10034.43,29775.24,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F8|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
Ostectomy Prtl 5th Metar Head Spx|RIGHT SIDE|PO,CASE-28110,APC,28110,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28122,APC,28122,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, FIFTH DIGIT|PO",CASE-28270,APC,28270,CPT,0360,RC,,,T9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Partial Excision Bone Fibula|RIGHT SIDE|PO,CASE-27641,APC,27641,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,APC,58552,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15386.31,,"Fee schedule rate ($15,386.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11298.37,,"Case rate ($11,298.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,988.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.35. The transfer capital threshold is the transfer adjustment factor * $817.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11298.37,44627.23,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,There are no additional notes associated with this service or procedure.
Biopsy Urethra,CASE-53200,APC,53200,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3177.77,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1968.31,1968.31,1968.31,1 through 10,other,3070.31,3223.82,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12140.54,,"Case rate ($12,140.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,217.55, add-ons for qualifying new technology services are included. If operating cost exceeds $46,685.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,262.25. The transfer operating threshold is the transfer adjustment factor * $11,217.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.28. The transfer capital threshold is the transfer adjustment factor * $878.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12140.55,12140.55,12140.55,1 through 10,other,12140.54,36024.65,Inpatient DRG
Musc Myocutaneous/Fasciocutaneous Flap Trunk,CASE-15734,APC,15734,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6518.41,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6061.80,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",6061.80,6061.80,6061.80,1 through 10,other,5942.94,17634.53,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT SIDE,CASE-28289,APC,28289,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
Laps Surg Retroperitoneal Lymph Node Bx 1/Mlt,CASE-38570,APC,38570,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
"CHOLECYSTECTOMY,MINOR",263,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14876.08,,"Case rate ($14,876.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14876.08,15619.88,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16307.62,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8558.00,48389.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Needle Biopsy Muscle,CASE-20206,APC,20206,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1644.81,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9269.86,,"Case rate ($9,269.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,565.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,033.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,599.25. The transfer operating threshold is the transfer adjustment factor * $8,565.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.60. The transfer capital threshold is the transfer adjustment factor * $670.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9269.86,37852.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Fibular Fracture Lat Malleolus|LEFT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34889.29,,,,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20168.93,,,,,,0,other,6797.06,20168.93,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
HC App Skin Sub T/a/L Tot <100 1st 25|PBB CHARGE,CASE-15271,APC,15271,CPT,0361,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],700.99,,"APC Price ($700.99). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,700.99,736.04,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19984.73,,"Case rate ($19,033.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,586.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,053.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,548.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,656.17. The transfer operating threshold is the transfer adjustment factor * $17,586.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.90. The transfer capital threshold is the transfer adjustment factor * $1,376.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,8990.00,80069.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6219.21,,"Case rate ($5,923.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,472.75, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,494.56. The transfer operating threshold is the transfer adjustment factor * $5,472.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.49. The transfer capital threshold is the transfer adjustment factor * $428.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5923.06,17575.50,Inpatient DRG
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3536.22,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3884.66,,"Case rate ($3,753.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,467.95, add-ons for qualifying new technology services are included. If operating cost exceeds $38,935.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,481.78. The transfer operating threshold is the transfer adjustment factor * $3,467.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.52. The transfer capital threshold is the transfer adjustment factor * $271.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3753.29,11765.59,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38525,APC,38525,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],121205.60,,"Fee schedule rate ($121,205.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23915.01,121205.60,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11742.15,,"Fee schedule rate ($11,742.15). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,10037.09,36934.96,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28165.35,,"Fee schedule rate ($28,165.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,Zero final payments for the item or service in the 15 months prior to posting the file.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7981.50,,"Case rate ($7,601.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,023.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,491.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,721.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,051.52. The transfer operating threshold is the transfer adjustment factor * $7,023.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.91. The transfer capital threshold is the transfer adjustment factor * $549.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7601.43,23918.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],110499.61,,"Fee schedule rate ($110,499.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (48), with a minimum of zero.",,,,0,other,36405.02,110499.61,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10817.50,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10605.39,31469.43,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13403.79,,"Fee schedule rate ($13,403.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6440.28,19110.30,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21700.35,,"Fee schedule rate ($21,700.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,MAJOR",174,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8036.29,,"Case rate for a one day stay ($7,653.61). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7653.61,8036.29,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14743.09,,"Case rate ($14,041.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,973.58, add-ons for qualifying new technology services are included. If operating cost exceeds $48,441.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,186.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,025.29. The transfer operating threshold is the transfer adjustment factor * $12,973.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.77. The transfer capital threshold is the transfer adjustment factor * $1,015.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14041.04,60059.69,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4789.75,,"Case rate ($4,561.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $323.26. The transfer capital threshold is the transfer adjustment factor * $323.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4568.94,13557.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-28090,APC,28090,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3212.01,3258.56,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6018.66,,"Case rate ($5,732.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,296.29, add-ons for qualifying new technology services are included. If operating cost exceeds $40,764.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,585.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,317.40. The transfer operating threshold is the transfer adjustment factor * $5,296.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.67. The transfer capital threshold is the transfer adjustment factor * $414.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5732.06,21720.81,Inpatient DRG
Excision Malignant Lesion S/N/H/F/G 1.1-2.0 Cm,CASE-11622,APC,11622,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1621.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42174.37,,"Fee schedule rate ($42,174.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12395.17,42174.37,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3980.76,11812.10,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17574.20,,"Case rate ($16,737.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,464.87, add-ons for qualifying new technology services are included. If operating cost exceeds $50,932.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,381.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,526.51. The transfer operating threshold is the transfer adjustment factor * $15,464.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.82. The transfer capital threshold is the transfer adjustment factor * $1,210.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16737.33,72192.67,Inpatient DRG
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31617.34,,"Fee schedule rate ($31,617.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11156.45,42003.98,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4568.94,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4568.94,13557.45,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17915.10,,"Fee schedule rate ($17,915.10). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
Arthrs Knee Debridement/Shaving Artclr Crtlg|LEFT SIDE|PO,CASE-29877,APC,29877,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5669.00,,"Per diem ($5,669). If length of stay < 3.2, first 1 days paid at a per diem of $11,338 instead. Capped at $18,140.88.",,,,0,other,5669.00,18994.21,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8248.57,,"Case rate ($8,086.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,472.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,939.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,756.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,501.81. The transfer operating threshold is the transfer adjustment factor * $7,472.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.02. The transfer capital threshold is the transfer adjustment factor * $585.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,34379.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39198.44,,"Fee schedule rate ($39,198.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13831.52,59770.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level|RIGHT SIDE",CASE-64495,APC,64495,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, SECOND DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F6|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],40183.85,,of the excess amount.,,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7381.19,,"Case rate ($7,029.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,528.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,073.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,146.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,531.25. The transfer operating threshold is the transfer adjustment factor * $6,528.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $498.45. The transfer capital threshold is the transfer adjustment factor * $498.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,21229.52,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Metatarsophalangeal Joint Dislocation|RIGHT FOOT, THIRD DIGIT|PO",CASE-28645,APC,28645,CPT,0360,RC,,,T7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Chemodenervation Internal Anal Sphincter,CASE-46505,APC,46505,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1191.72,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1134.98,1191.72,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5669.00,,"Per diem ($5,669). If length of stay < 3.2, first 1 days paid at a per diem of $11,338 instead. Capped at $18,140.88.",,,,0,other,5669.00,18994.21,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14979.31,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",15624.60,15624.60,15624.60,1 through 10,other,14472.76,56135.46,Inpatient DRG
"URETHRAL AND TRANSURETHRAL PROCEDURES,MINOR",446,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5592.77,,"Case rate for a one day stay ($5,592.77). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5592.77,5872.41,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],151120.97,,"Fee schedule rate ($151,120.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,45834.02,151120.97,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12566.83,,"Case rate ($12,141.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,218.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,686.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,263.48. The transfer operating threshold is the transfer adjustment factor * $11,218.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.37. The transfer capital threshold is the transfer adjustment factor * $878.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12141.86,36028.59,Inpatient DRG
Unlisted Procedure Pelvis/Hip Joint,CASE-27299,APC,27299,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],242.14,,"APC Price ($233.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,233.96,245.65,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THIRD DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],38164.94,,"Fee schedule rate ($38,164.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,10818.26,38164.94,There are no additional notes associated with this service or procedure.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],84471.39,,,,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
"HIV WITH MAJOR HIV RELATED CONDITION,MAJOR",892,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2241.68,,"Case rate for a one day stay ($2,134.93). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2134.93,2241.68,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29489.40,,"Fee schedule rate ($29,489.40). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7543.08,29489.40,Zero final payments for the item or service in the 15 months prior to posting the file.
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs,CASE-25116,APC,25116,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19598.07,,"Fee schedule rate ($19,598.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6835.51,20283.05,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21621.42,,"Fee schedule rate ($21,621.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8192.28,24308.97,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11634.20,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11080.19,32878.30,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11765.59,,"Fee schedule rate ($11,765.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.29,11765.59,There are no additional notes associated with this service or procedure.
HC Removal Subcutaneous Cardiac Rhythm Monitor|UNUSUAL NON-OVERLAPPING SERVICE,CASE-33286,APC,33286,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7848.94,,"APC Price ($7,848.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7848.94,8241.39,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THUMB|PO",CASE-26735,APC,26735,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11428.81,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10884.58,32297.83,Inpatient DRG
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],32157.86,,"Case rate ($30,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,386.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,215.60. The transfer capital threshold is the transfer adjustment factor * $2,215.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30626.53,106200.88,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],81311.94,,"Fee schedule rate ($81,311.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,32637.12,96844.29,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|PO,CASE-64634,APC,64634,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE|PO,CASE-25608,APC,25608,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|RIGHT HAND, THIRD DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F7|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<|SEPARATE STRUCTURE|PO,CASE-14040,APC,14040,CPT,0360,RC,,,XS|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16156.34,,"Fee schedule rate ($16,156.34). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.6), with a minimum of zero.",,,,0,other,5700.90,30872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],50313.90,,"Fee schedule rate ($50,313.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7770.00,50313.90,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],77530.52,,"Fee schedule rate ($77,530.52). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,27357.31,100904.68,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16050.66,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,15507.88,46016.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ligj & Div Short Saph Vein Saphenopop Junct Spx,CASE-37780,APC,37780,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17127.24,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17127.24,50821.76,Inpatient DRG
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, THIRD DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,Zero final payments for the item or service in the 15 months prior to posting the file.
Syndactylization Toes|BILATERAL PROCEDURE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27001.04,,"Fee schedule rate ($27,001.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8227.43,27001.04,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, THIRD DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Chemodenervation Muscle Neck Unilat for Dystonia|RIGHT SIDE|PO,CASE-64616,APC,64616,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10388.39,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10037.09,36934.96,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
Open Treatment Calcaneal Fracture|RIGHT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Laps Surg Esopg/Gstr Fundoplasty,CASE-43280,APC,43280,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12345.81,,"Case rate ($11,757.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,864.01, add-ons for qualifying new technology services are included. If operating cost exceeds $46,331.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,021.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,907.31. The transfer operating threshold is the transfer adjustment factor * $10,864.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.60. The transfer capital threshold is the transfer adjustment factor * $850.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11757.91,34889.29,Inpatient DRG
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8853.24,,"Case rate ($8,431.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,790.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,258.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,781.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,821.69. The transfer operating threshold is the transfer adjustment factor * $7,790.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.97. The transfer capital threshold is the transfer adjustment factor * $609.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8431.66,25019.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11268.60,,"Fee schedule rate ($11,268.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18085.13,,,,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35359.57,,,,,,0,other,11916.39,58492.48,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6461.52,21772.28,Zero final payments for the item or service in the 15 months prior to posting the file.
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5811.28,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5614.77,5895.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5379.29,,"Case rate ($5,379.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,970.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,438.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,560.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,990.14. The transfer operating threshold is the transfer adjustment factor * $4,970.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.15. The transfer capital threshold is the transfer adjustment factor * $389.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5379.29,15961.98,Inpatient DRG
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Add 2nd/3rd Order Abd/Le|RIGHT SIDE,CASE-36248,APC,36248,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],540.74,,"APC Price ($514.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,514.99,540.74,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9151.96,,"Case rate ($8,716.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,053.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,801.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,085.59. The transfer operating threshold is the transfer adjustment factor * $8,053.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $630.55. The transfer capital threshold is the transfer adjustment factor * $630.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8716.15,25863.45,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13066.56,,"Fee schedule rate ($13,066.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],51643.16,,"Fee schedule rate ($51,643.16). Adds an outlier to normal pricing equal to the per diem rate ($161,652.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,18222.73,59942.55,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29433.60,,"Fee schedule rate ($29,433.60). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10808.31,,"Case rate ($10,808.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,986.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,454.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,026.41. The transfer operating threshold is the transfer adjustment factor * $9,986.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.90. The transfer capital threshold is the transfer adjustment factor * $781.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,10808.31,46938.11,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13704.86,,"Case rate ($13,704.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,662.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,130.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,162.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,713.40. The transfer operating threshold is the transfer adjustment factor * $12,662.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $991.44. The transfer capital threshold is the transfer adjustment factor * $991.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13704.86,49911.01,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE|PO",CASE-64491,APC,64491,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],112824.68,,"Fee schedule rate ($112,824.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (116), with a minimum of zero.",,,,0,other,33422.93,112824.68,Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride Subq First 20 Sq Cm|PBB CHARGE,CASE-11042,APC,11042,CPT,0361,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1820.02,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",39238.44,39238.44,39238.44,1 through 10,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],42695.82,,"Fee schedule rate ($42,695.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15065.57,53815.71,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt,CASE-28309,APC,28309,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6797.06,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6797.06,20168.93,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9371.28,,"Case rate ($8,925.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,246.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,714.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,279.37. The transfer operating threshold is the transfer adjustment factor * $8,246.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.66. The transfer capital threshold is the transfer adjustment factor * $645.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8925.03,26628.31,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Subq Ea Addt'l 20sqcm|PBB CHARGE",CASE-11045,APC,11045,CPT,0361,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6608.44,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6293.75,21908.95,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
"HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,MINOR",279,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6693.41,,"Case rate ($6,693.41). For partially eligible cases, the expected reimbursement is prorated by the ratio of covered days to total length of stay. An outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,6693.41,7028.08,Estimated amount calculated based on 1 day length of stay.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6797.06,,"Case rate ($6,797.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,280.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,662.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,305.34. The transfer operating threshold is the transfer adjustment factor * $6,280.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.72. The transfer capital threshold is the transfer adjustment factor * $491.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6745.85,6745.85,6797.06,1 through 10,other,6797.06,20168.93,Inpatient DRG
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49594,APC,49594,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11301.79,,"Case rate ($11,080.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,237.82, add-ons for qualifying new technology services are included. If operating cost exceeds $45,705.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,972.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,278.62. The transfer operating threshold is the transfer adjustment factor * $10,237.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $801.57. The transfer capital threshold is the transfer adjustment factor * $801.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11080.19,32878.30,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27868.14,,"Fee schedule rate ($27,868.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9833.51,45903.36,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC Debrid,Subq Ea Addt'l 20sqcm",CASE-11045,APC,11045,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,EXTREME",137,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],24934.08,,"Case rate ($23,746.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23746.74,24934.08,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-28308,APC,28308,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9255.92,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6965.00,27465.16,Inpatient DRG
Open Treatment Tarsometatarsal Joint Dislocation|LEFT SIDE,CASE-28615,APC,28615,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18954.85,,,,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],36949.14,,"Case rate ($36,224.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,470.67, add-ons for qualifying new technology services are included. If operating cost exceeds $68,938.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,791.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $33,604.06. The transfer operating threshold is the transfer adjustment factor * $33,470.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,620.58. The transfer capital threshold is the transfer adjustment factor * $2,620.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,36224.65,128473.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14358.31,,,,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],115392.91,,"Fee schedule rate ($115,392.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,28005.17,115392.91,Zero final payments for the item or service in the 15 months prior to posting the file.
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|LEFT HAND, FOURTH DIGIT|PO",CASE-26123,APC,26123,CPT,0360,RC,,,F3|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4442.95,13183.59,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],58534.56,,"Fee schedule rate ($58,534.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26638.96,,"Fee schedule rate ($26,638.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5520.00,26638.96,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30846.83,,"Fee schedule rate ($30,846.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10884.58,32297.83,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27304.54,,"Fee schedule rate ($27,304.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7011.91,27304.54,There are no additional notes associated with this service or procedure.
Open Treatment Metatarsal Fracture Each|RIGHT SIDE,CASE-28485,APC,28485,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18008.20,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10290.40,42115.80,All Other Inpatient
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29581.69,,"Fee schedule rate ($29,581.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12121.97,35969.56,Zero final payments for the item or service in the 15 months prior to posting the file.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15041.99,,"Fee schedule rate ($15,041.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6088.84,18067.42,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],65196.60,,"Fee schedule rate ($65,196.60). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE,CASE-19120,APC,19120,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3899.35,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3899.35,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17470.95,,"Fee schedule rate ($17,470.95). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10462.84,,"Fee schedule rate ($10,462.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4167.74,12366.99,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],65555.62,,"Fee schedule rate ($65,555.62). Adds an outlier to normal pricing equal to the per diem rate ($94,473.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,23131.85,76404.43,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE,CASE-29898,APC,29898,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],7649.67,,"Fee schedule rate ($7,649.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.49,12882.53,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26559.09,,"Fee schedule rate ($26,559.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],120252.50,,"Fee schedule rate ($120,252.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10105.00,120252.50,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|SEPARATE PRACTITIONER,CASE-38792,APC,38792,CPT,0361,RC,,,XP,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7060.32,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6724.11,19952.48,Inpatient DRG
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11645.83,37502.92,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],24198.52,,"Fee schedule rate ($24,198.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|RIGHT FOOT, GREAT TOE|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrodesis Great Toe Interphalangeal Joint|LEFT FOOT, GREAT TOE|PO",CASE-28755,APC,28755,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,6882.29,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11205.82,,"Case rate ($10,826.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,003.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,471.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,954.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,043.63. The transfer operating threshold is the transfer adjustment factor * $10,003.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.24. The transfer capital threshold is the transfer adjustment factor * $783.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10826.88,32126.64,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9896.28,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9425.03,27966.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17350.69,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16524.47,58465.86,Inpatient DRG
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],87816.48,,,,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],44554.02,,"Case rate ($25,459.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,523.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,991.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,012.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,617.64. The transfer operating threshold is the transfer adjustment factor * $23,523.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,841.80. The transfer capital threshold is the transfer adjustment factor * $1,841.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,25459.44,80806.10,All Other Inpatient
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],90889.11,,"Fee schedule rate ($90,889.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19269.56,,"Case rate ($18,351.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,983.79, add-ons for qualifying new technology services are included. If operating cost exceeds $52,451.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,471.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,051.48. The transfer operating threshold is the transfer adjustment factor * $16,983.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,300.48. The transfer capital threshold is the transfer adjustment factor * $1,300.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18381.22,58579.45,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13889.20,55846.16,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8578.65,,"Case rate ($8,410.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,771.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,238.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,779.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,802.01. The transfer operating threshold is the transfer adjustment factor * $7,771.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.43. The transfer capital threshold is the transfer adjustment factor * $608.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",8552.69,8552.69,8552.69,1 through 10,other,8410.44,24956.34,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],58534.56,,"Fee schedule rate ($58,534.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20654.42,69402.59,Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11054.89,,"Case rate ($10,528.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,728.04, add-ons for qualifying new technology services are included. If operating cost exceeds $45,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,932.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,766.81. The transfer operating threshold is the transfer adjustment factor * $9,728.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.66. The transfer capital threshold is the transfer adjustment factor * $761.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10528.47,44148.02,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34556.75,,,,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],37626.75,,"Fee schedule rate ($37,626.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52332,APC,52332,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5627.43,,"Case rate ($5,359.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,959.91, add-ons for qualifying new technology services are included. If operating cost exceeds $40,427.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,979.68. The transfer operating threshold is the transfer adjustment factor * $4,959.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $379.79. The transfer capital threshold is the transfer adjustment factor * $379.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",22332.25,5627.43,38598.85,1 through 10,other,5368.01,15928.53,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion S/N/H/F/G 2.1-3.0 Cm,CASE-11623,APC,11623,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1621.31,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1566.49,1644.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26601.69,,"Fee schedule rate ($26,601.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9312.29,27632.41,There are no additional notes associated with this service or procedure.
Debridement Bone Each Additional 20 Sq Cm,CASE-11047,APC,11047,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10818.26,,"Case rate ($10,818.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,995.80, add-ons for qualifying new technology services are included. If operating cost exceeds $45,463.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,953.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,035.64. The transfer operating threshold is the transfer adjustment factor * $9,995.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.62. The transfer capital threshold is the transfer adjustment factor * $782.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10818.26,10818.26,10818.26,1 through 10,other,10818.26,38164.94,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],72742.07,,"Fee schedule rate ($72,742.07). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,25667.66,86123.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14967.14,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",14468.28,14468.28,14468.28,1 through 10,other,14673.67,43541.27,Inpatient DRG
Open Tx Trimalleolar Ankle Fx W/Fixj Pst Lip|LEFT SIDE|PO,CASE-27823,APC,27823,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21772.28,,"Fee schedule rate ($21,772.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6461.52,21772.28,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],43726.54,,"Fee schedule rate ($43,726.54). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5506.24,,"Case rate ($5,244.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $4,859.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,405.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,029.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,862.27. The transfer operating threshold is the transfer adjustment factor * $4,859.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $381.77. The transfer capital threshold is the transfer adjustment factor * $381.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5244.04,15804.57,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6608.44,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6293.75,21908.95,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],44627.23,,"Fee schedule rate ($44,627.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3843.64,,"APC Price ($3,713.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3713.66,3899.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35830.99,,"Fee schedule rate ($35,830.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12405.69,,"Case rate ($11,814.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,916.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,384.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,025.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,960.21. The transfer operating threshold is the transfer adjustment factor * $10,916.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.72. The transfer capital threshold is the transfer adjustment factor * $854.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11814.94,44591.73,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20946.97,,"Fee schedule rate ($20,946.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15090.78,44778.95,Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6724.11,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6724.11,19952.48,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8939.84,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",8922.22,8922.22,8922.22,1 through 10,other,8764.55,32969.91,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],49795.64,,"Fee schedule rate ($49,795.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,16849.39,49997.29,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21289.03,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21289.03,76326.34,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13051.67,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,13051.67,38728.27,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5504.62,,"Case rate ($5,504.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,086.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,554.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,106.40. The transfer operating threshold is the transfer adjustment factor * $5,086.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.22. The transfer capital threshold is the transfer adjustment factor * $398.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",5448.12,5448.12,5504.62,1 through 10,other,5504.62,16333.88,Inpatient DRG
Revascularization Iliac Art Angiop Ea Ipsi Vsl|LEFT SIDE,CASE-37222,APC,37222,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],168.02,,,,,,0,other,168.02,176.42,There are no additional notes associated with this service or procedure.
Grafting of Autologous Fat by Lipo 50 Cc or Less,CASE-15771,APC,15771,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6518.41,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6518.41,6518.41,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ant Vesicourethropexy/Urethropexy Smpl,CASE-51840,APC,51840,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5532.56,,"Case rate ($5,345.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,557.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.70. The transfer capital threshold is the transfer adjustment factor * $386.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5224.00,15861.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],14651.02,,"Fee schedule rate ($14,651.02). Adds an outlier to normal pricing equal to the per diem rate ($61,007.55) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5169.74,15340.19,Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],90287.21,,"Fee schedule rate ($90,287.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20.9), with a minimum of zero.",,,,0,other,31858.62,94534.21,Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,46419.05,Estimated amount calculated based on 12 day length of stay.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],140535.66,,"Fee schedule rate ($140,535.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,36167.61,140535.66,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17411.44,,"Fee schedule rate ($17,411.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6770.53,20090.22,Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,1188.00,20179.92,Estimated amount calculated based on 2 day length of stay.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12883.25,,"Case rate ($12,883.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,903.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,371.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,103.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $11,951.23. The transfer operating threshold is the transfer adjustment factor * $11,903.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.01. The transfer capital threshold is the transfer adjustment factor * $932.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12883.25,44763.90,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6837.50,,"Case rate ($6,837.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,317.68, add-ons for qualifying new technology services are included. If operating cost exceeds $41,785.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,342.86. The transfer operating threshold is the transfer adjustment factor * $6,317.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.64. The transfer capital threshold is the transfer adjustment factor * $494.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6837.50,20288.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],76376.03,,"Fee schedule rate ($76,376.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|LEFT SIDE|PO,CASE-25260,APC,25260,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4523.19,,"Case rate ($4,523.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,179.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,647.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,498.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,195.97. The transfer operating threshold is the transfer adjustment factor * $4,179.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $327.22. The transfer capital threshold is the transfer adjustment factor * $327.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4523.19,16536.43,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10430.89,,"Fee schedule rate ($10,430.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4564.97,13545.65,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],66888.05,,"Fee schedule rate ($66,888.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.5), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13713.25,,"Fee schedule rate ($13,713.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41669.98,,,,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
"RENAL DIALYSIS ACCESS DEVICE PROCEDURES,MAJOR",444,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],29325.27,,"Case rate ($29,325.27). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,29325.27,30791.53,There are no additional notes associated with this service or procedure.
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4654.49,,"Case rate ($4,654.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,300.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,768.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,317.77. The transfer operating threshold is the transfer adjustment factor * $4,300.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.72. The transfer capital threshold is the transfer adjustment factor * $336.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4654.49,13811.29,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20006.29,,"Fee schedule rate ($20,006.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],45371.94,,"Fee schedule rate ($45,371.94). Adds an outlier to normal pricing equal to the per diem rate ($84,711.83) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,16009.89,58554.60,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32874.59,,"Fee schedule rate ($32,874.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11600.09,48814.14,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31445.30,,"Fee schedule rate ($31,445.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,22802.30,82749.58,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26800.70,,"Fee schedule rate ($26,800.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Stent Place Initial Artery Ang|LEFT SIDE,CASE-37236,APC,37236,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],26117.70,,"Fee schedule rate ($26,117.70). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14200.87,,"Case rate ($14,200.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,121.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,589.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,198.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,173.54. The transfer operating threshold is the transfer adjustment factor * $13,121.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.33. The transfer capital threshold is the transfer adjustment factor * $1,027.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",13399.14,13399.14,13399.14,1 through 10,other,7453.00,42138.30,Inpatient DRG
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],46521.39,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,45609.21,211906.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],66888.05,,"Fee schedule rate ($66,888.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.5), with a minimum of zero.",,,,0,other,23602.02,108295.22,Zero final payments for the item or service in the 15 months prior to posting the file.
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX|74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13713.25,,"Fee schedule rate ($13,713.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4838.84,19587.42,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Stent Place Initial Artery Ang|LEFT SIDE,CASE-37236,APC,37236,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Correction Hammertoe|RIGHT FOOT, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],71244.51,,,,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11895.84,,"Case rate ($11,895.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,991.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,459.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,031.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,035.26. The transfer operating threshold is the transfer adjustment factor * $10,991.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.57. The transfer capital threshold is the transfer adjustment factor * $860.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11895.84,35298.57,Inpatient DRG
Revsc Opn/Prq Tib/Pero W/Angioplasty Uni Ea Vsl|LEFT SIDE,CASE-37232,APC,37232,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],180.00,,,,,,0,other,180.00,189.00,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21316.71,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20301.63,84714.35,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F1|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,CASE-29827,APC,29827,CPT,0360,RC,,,73,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,EXTREME",140,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],20855.04,,"Case rate ($19,861.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19861.94,20855.04,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],7315.60,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4180.34,14351.57,All Other Inpatient
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7702.29,,"Case rate ($7,335.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,777.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,245.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,701.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,804.84. The transfer operating threshold is the transfer adjustment factor * $6,777.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.67. The transfer capital threshold is the transfer adjustment factor * $530.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7335.51,29792.90,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7257.26,23445.98,Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,10109.37,38416.97,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,40658.63,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
HC Bladder Irrig Simple or Continuous,CASE-51700,APC,51700,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2052.05,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],76216.30,,"Fee schedule rate ($76,216.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,9242.00,76216.30,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11017.29,,"Case rate ($10,492.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,694.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,162.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,930.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,733.59. The transfer operating threshold is the transfer adjustment factor * $9,694.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.07. The transfer capital threshold is the transfer adjustment factor * $759.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10492.66,31134.92,Inpatient DRG
"RESPIRATORY FAILURE,MAJOR",133,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14812.53,,"Case rate ($14,812.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14812.53,15553.16,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Lmtd Dbrdmt 1/2,CASE-29822,APC,29822,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|PO,CASE-64721,APC,64721,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,APC,43275,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3839.63,,"APC Price ($3,656.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3656.79,3839.63,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],45869.64,,"Fee schedule rate ($45,869.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,45869.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Capsulorrhaphy|RIGHT SIDE|PO,CASE-29806,APC,29806,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],48838.99,,"Fee schedule rate ($48,838.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,23125.89,68621.57,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34198.12,,"Fee schedule rate ($34,198.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16192.05,,"Fee schedule rate ($16,192.05). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,27370.21,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],9799.00,,"Per diem ($9,799). If length of stay < 2.3, first 1 days paid at a per diem of $19,598 instead. Capped at $22,536.57.",,,,0,other,7952.22,25854.47,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Multiple External Papillae/Tags Anus,CASE-46230,APC,46230,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13713.25,,"Fee schedule rate ($13,713.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9744.48,,"Case rate ($9,280.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,574.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,042.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,842.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,609.09. The transfer operating threshold is the transfer adjustment factor * $8,574.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.37. The transfer capital threshold is the transfer adjustment factor * $671.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9280.46,39957.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],27111.73,,"Fee schedule rate ($27,111.73). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4883.54,,"Case rate ($4,787.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,423.79, add-ons for qualifying new technology services are included. If operating cost exceeds $39,891.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,517.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,441.42. The transfer operating threshold is the transfer adjustment factor * $4,423.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.36. The transfer capital threshold is the transfer adjustment factor * $346.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4787.78,20006.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24393.31,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23915.01,121205.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11674.21,,"Fee schedule rate ($11,674.21). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4119.35,12223.35,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3885.36,,"Case rate ($3,753.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,468.57, add-ons for qualifying new technology services are included. If operating cost exceeds $38,936.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,442.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,482.39. The transfer operating threshold is the transfer adjustment factor * $3,468.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $271.57. The transfer capital threshold is the transfer adjustment factor * $271.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",3885.36,3885.36,3885.36,1 through 10,other,3753.97,11139.15,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],89504.77,,,,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
Thoracoscopy W/Thoracic Sympathectomy,CASE-32664,APC,32664,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3099.59,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15022.47,,"Fee schedule rate ($15,022.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,5338.18,15839.99,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25813.65,,"Fee schedule rate ($25,813.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,6965.00,30103.84,There are no additional notes associated with this service or procedure.
Inguinofem Lmphadec Supfc W/Cloquets Node Spx,CASE-38760,APC,38760,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6334.78,,"Case rate ($6,033.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,574.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,042.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,607.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,596.68. The transfer operating threshold is the transfer adjustment factor * $5,574.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.45. The transfer capital threshold is the transfer adjustment factor * $436.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6033.12,17902.13,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19871.72,,"Fee schedule rate ($19,871.72). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,7011.91,27304.54,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],36370.09,,"Fee schedule rate ($36,370.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41664.08,,,,,,0,other,14041.04,60059.69,There are no additional notes associated with this service or procedure.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22091.17,,"Fee schedule rate ($22,091.17). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7795.07,34198.12,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",38075.52,38075.52,38075.52,1 through 10,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16039.01,,"Case rate ($15,496.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,318.49, add-ons for qualifying new technology services are included. If operating cost exceeds $49,786.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,292.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,375.55. The transfer operating threshold is the transfer adjustment factor * $14,318.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.06. The transfer capital threshold is the transfer adjustment factor * $1,121.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3295.00,53945.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],71244.51,,,,,,0,other,10632.00,103714.29,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11591.72,,"Case rate ($11,039.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,200.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,668.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,969.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,241.10. The transfer operating threshold is the transfer adjustment factor * $10,200.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.64. The transfer capital threshold is the transfer adjustment factor * $798.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6953.00,35389.05,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,8596.11,25507.30,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,APC,49329,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,APC,38571,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10173.70,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",13567.76,13567.76,13567.76,1 through 10,other,10173.70,41194.64,Inpatient DRG
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34180.92,,,,,,0,other,11519.18,34180.92,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],30624.30,,"Fee schedule rate ($30,624.30). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
Curtg/Caut Anal Fissure W/Dilat Sphnctr Spx 1st,CASE-46940,APC,46940,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
"Correction Hammertoe|RIGHT HAND, FOURTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17793.27,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",17251.90,17251.90,17251.90,1 through 10,other,17191.57,51012.62,Inpatient DRG
Trlml Balo Angiop Open/Perq W/Img S&I Addl Vein,CASE-37249,APC,37249,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11730.05,,"Case rate ($11,730.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,838.28, add-ons for qualifying new technology services are included. If operating cost exceeds $46,306.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,019.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,881.47. The transfer operating threshold is the transfer adjustment factor * $10,838.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.58. The transfer capital threshold is the transfer adjustment factor * $848.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11730.05,61348.24,Inpatient DRG
HC Sel Cath Abd/Pelvic/Le 1st Ord,CASE-36245,APC,36245,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18256.31,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,17386.97,18256.31,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19377.46,,"Fee schedule rate ($19,377.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22230.95,,"Case rate ($21,172.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,702.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.66. The transfer capital threshold is the transfer adjustment factor * $1,531.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12500.00,83592.64,Inpatient DRG
"CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",166,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],63835.34,,"Case rate ($63,835.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,63835.34,67027.11,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18621.89,,"Fee schedule rate ($18,621.89). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],113934.44,,"Fee schedule rate ($113,934.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.6), with a minimum of zero.",,,,0,other,40202.74,148703.60,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34712.20,,,,,,0,other,11698.23,34712.20,There are no additional notes associated with this service or procedure.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],115037.59,,"Fee schedule rate ($115,037.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21.9), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],68116.02,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,64872.40,212258.00,Inpatient DRG
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],45183.60,,"Fee schedule rate ($45,183.60). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,76376.03,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17919.05,,"Fee schedule rate ($17,919.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10385.89,,"Case rate ($10,385.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,596.31, add-ons for qualifying new technology services are included. If operating cost exceeds $45,064.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,922.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,634.55. The transfer operating threshold is the transfer adjustment factor * $9,596.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.34. The transfer capital threshold is the transfer adjustment factor * $751.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10385.89,32176.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Ankle W/Implant|LEFT SIDE,CASE-27702,APC,27702,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],27022.53,,"APC Price ($25,735.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Plasty,CASE-37228,APC,37228,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],488.85,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],61348.24,,"Fee schedule rate ($61,348.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11730.05,61348.24,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6293.75,,"Case rate ($6,293.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,815.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,283.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,626.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,838.43. The transfer operating threshold is the transfer adjustment factor * $5,815.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.31. The transfer capital threshold is the transfer adjustment factor * $455.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6293.75,21908.95,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],8558.00,,"Per diem ($8,558). If length of stay < 5.4, first 1 days paid at a per diem of $17,116 instead. Capped at $46,215.75.",,,,0,other,8558.00,48389.68,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Medial Malleolus Fracture|RIGHT SIDE,CASE-27766,APC,27766,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],27022.53,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25735.75,27022.53,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MAJOR",045,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],17257.80,,"Case rate ($17,257.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,17257.80,18120.69,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14837.11,,"Case rate ($14,130.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,056.30, add-ons for qualifying new technology services are included. If operating cost exceeds $48,524.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,193.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,108.33. The transfer operating threshold is the transfer adjustment factor * $13,056.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.24. The transfer capital threshold is the transfer adjustment factor * $1,022.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,14130.58,57770.11,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18697.35,,"Fee schedule rate ($18,697.35). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9299.56,,"Case rate ($8,856.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,183.39, add-ons for qualifying new technology services are included. If operating cost exceeds $43,651.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,811.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,216.01. The transfer operating threshold is the transfer adjustment factor * $8,183.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.72. The transfer capital threshold is the transfer adjustment factor * $640.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6972.00,26280.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4517.87,,"Case rate ($4,517.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,174.41, add-ons for qualifying new technology services are included. If operating cost exceeds $39,642.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,497.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,191.05. The transfer operating threshold is the transfer adjustment factor * $4,174.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $326.84. The transfer capital threshold is the transfer adjustment factor * $326.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4517.87,13932.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39368.30,,"Fee schedule rate ($39,368.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|LEFT SIDE,CASE-29891,APC,29891,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],153667.90,,"Fee schedule rate ($153,667.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,43602.60,153667.90,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29532.00,,"Fee schedule rate ($29,532.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,10884.58,32297.83,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, THIRD DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,T7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6052.20,,"Case rate ($5,764). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,579.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.46. The transfer capital threshold is the transfer adjustment factor * $408.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5773.19,31196.82,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39957.56,,"Fee schedule rate ($39,957.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12107.00,,"Per diem ($12,107). If length of stay < 2.8, first 1 days paid at a per diem of $24,214 instead. Capped at $33,900.69.",,,,0,other,11962.15,40923.09,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],30626.53,,"Case rate ($30,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,298.15, add-ons for qualifying new technology services are included. If operating cost exceeds $63,766.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,386.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,410.92. The transfer operating threshold is the transfer adjustment factor * $28,298.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,215.60. The transfer capital threshold is the transfer adjustment factor * $2,215.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,30626.53,106200.88,Inpatient DRG
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19262.83,,"Fee schedule rate ($19,262.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6387.91,18954.85,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Synovectomy Limited Spx,CASE-29875,APC,29875,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",903.72,888.72,903.72,1 through 10,other,882.03,926.14,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg,CASE-29881,APC,29881,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
"Inject Nerv Blck,Paravert Sympath|RIGHT SIDE",CASE-64520,APC,64520,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,Zero final payments for the item or service in the 15 months prior to posting the file.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|RIGHT SIDE|PO,CASE-27524,APC,27524,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],24853.45,,"Fee schedule rate ($24,853.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7744.00,24853.45,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],115037.59,,"Fee schedule rate ($115,037.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21.9), with a minimum of zero.",,,,0,other,40591.99,115037.59,Zero final payments for the item or service in the 15 months prior to posting the file.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,45869.64,There are no additional notes associated with this service or procedure.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, FIFTH DIGIT|PO",CASE-28308,APC,28308,CPT,0360,RC,,,T4|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9910.01,,"Case rate ($9,574.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,846.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,314.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,863.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,882.22. The transfer operating threshold is the transfer adjustment factor * $8,846.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.67. The transfer capital threshold is the transfer adjustment factor * $692.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9574.89,28411.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],36738.00,,"Case rate ($34,988.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,328.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,796.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,702.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,457.41. The transfer operating threshold is the transfer adjustment factor * $32,328.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,531.16. The transfer capital threshold is the transfer adjustment factor * $2,531.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,34988.57,110685.97,Inpatient DRG
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE|PO,CASE-29881,APC,29881,CPT,0360,RC,,,LT|XS|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"HC ED Avulsion Nail Plate Single|LEFT FOOT, GREAT TOE|PO",CASE-11730,APC,11730,CPT,0450,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16705.77,,,,,,0,other,5629.94,16705.77,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22127.25,,"Fee schedule rate ($22,127.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8410.44,24956.34,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24490.04,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10632.00,103714.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, THIRD DIGIT|PO",CASE-26080,APC,26080,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22382.59,,,,,,0,other,7543.08,29489.40,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13826.01,,"Fee schedule rate ($13,826.01). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Fracture Distal Tibia & Fibula|RIGHT SIDE,CASE-27828,APC,27828,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],63799.33,,"Fee schedule rate ($63,799.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8915.73,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8915.73,26455.73,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,Zero final payments for the item or service in the 15 months prior to posting the file.
"DIVERTICULITIS AND DIVERTICULOSIS,MAJOR",244,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],13946.32,,"Case rate ($13,946.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13946.32,14643.64,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18781.54,,"Case rate ($17,887.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,527.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,995.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,465.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $16,593.19. The transfer operating threshold is the transfer adjustment factor * $16,527.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.00. The transfer capital threshold is the transfer adjustment factor * $1,294.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7455.00,53076.74,Inpatient DRG
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, FIFTH DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F9|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7120.66,,"Case rate ($7,120.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,579.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,047.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,686.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,605.53. The transfer operating threshold is the transfer adjustment factor * $6,579.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.13. The transfer capital threshold is the transfer adjustment factor * $515.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,1188.00,20179.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],56135.46,,"Fee schedule rate ($56,135.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,14472.76,56135.46,Zero final payments for the item or service in the 15 months prior to posting the file.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17934.16,,"Fee schedule rate ($17,934.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.1), with a minimum of zero.",,,,0,other,6328.22,27416.36,Zero final payments for the item or service in the 15 months prior to posting the file.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|LEFT FOOT, GREAT TOE|PO",CASE-28291,APC,28291,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15381.51,,,,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7712.73,,"Case rate ($7,345.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,787.02, add-ons for qualifying new technology services are included. If operating cost exceeds $42,254.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,702.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,814.07. The transfer operating threshold is the transfer adjustment factor * $6,787.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.39. The transfer capital threshold is the transfer adjustment factor * $531.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6308.00,21796.21,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14244.84,,"Case rate ($13,566.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,555.10, add-ons for qualifying new technology services are included. If operating cost exceeds $48,023.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,132.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,605.14. The transfer operating threshold is the transfer adjustment factor * $12,555.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $961.37. The transfer capital threshold is the transfer adjustment factor * $961.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13588.14,40320.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC N Block Inj Intercost Sng|LEFT SIDE|PO,CASE-64420,APC,64420,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6178.00,,"Per diem ($6,178). If length of stay < 3.9, first 1 days paid at a per diem of $12,356 instead. Capped at $24,092.63.",,,,0,other,6178.00,25225.91,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10108.65,,"Case rate ($9,910.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,888.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.95. The transfer capital threshold is the transfer adjustment factor * $716.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9910.44,43344.00,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],73717.28,,"Fee schedule rate ($73,717.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,17274.00,73717.28,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],99969.33,,"Fee schedule rate ($99,969.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20895.12,99969.33,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15955.26,,"Fee schedule rate ($15,955.26). Adds an outlier to normal pricing equal to the per diem rate ($60,119.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,5629.94,16705.77,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],80790.13,,"Fee schedule rate ($80,790.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,13369.00,88188.38,There are no additional notes associated with this service or procedure.
HC Bladder Irrig Simple or Continuous,CASE-51700,APC,51700,CPT,0761,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1982.66,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1982.66,2081.79,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7157.79,,"Case rate ($6,816.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,298.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,766.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,664.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,323.79. The transfer operating threshold is the transfer adjustment factor * $6,298.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5520.00,26638.96,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32077.45,,,,,,0,other,10810.31,32077.45,There are no additional notes associated with this service or procedure.
"HC ED Avulsion Nail Plate Single|LEFT FOOT, GREAT TOE|PO",CASE-11730,APC,11730,CPT,0450,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3980.76,,"Case rate ($3,980.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,678.12, add-ons for qualifying new technology services are included. If operating cost exceeds $39,146.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,459.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,692.77. The transfer operating threshold is the transfer adjustment factor * $3,678.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $287.98. The transfer capital threshold is the transfer adjustment factor * $287.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",22808.59,22808.59,22808.59,1 through 10,other,3980.76,11812.10,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12179.66,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12179.66,36140.75,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17186.38,,"Case rate ($16,849.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,568.42, add-ons for qualifying new technology services are included. If operating cost exceeds $51,036.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,390.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,630.47. The transfer operating threshold is the transfer adjustment factor * $15,568.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.93. The transfer capital threshold is the transfer adjustment factor * $1,218.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,16849.39,49997.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20788.82,,"Fee schedule rate ($20,788.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4326.65,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4180.34,14351.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10730.87,,"Case rate ($10,367.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,579.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,047.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,617.95. The transfer operating threshold is the transfer adjustment factor * $9,579.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.05. The transfer capital threshold is the transfer adjustment factor * $750.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10367.99,37103.57,Inpatient DRG
"SYNCOPE AND COLLAPSE,EXTREME",204,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],19453.77,,"Case rate ($18,527.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18527.40,19453.77,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9448.23,,"Case rate ($9,448.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,729.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,197.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,854.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,764.73. The transfer operating threshold is the transfer adjustment factor * $8,729.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.51. The transfer capital threshold is the transfer adjustment factor * $683.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6531.00,35832.77,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10863.50,,"Case rate ($10,346.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,574.86, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,904.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,613.02. The transfer operating threshold is the transfer adjustment factor * $9,574.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.17. The transfer capital threshold is the transfer adjustment factor * $733.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10362.69,29367.82,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,3295.00,66445.54,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",675.06,675.06,685.98,1 through 10,other,669.51,702.98,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34803.35,,"Fee schedule rate ($34,803.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
HC 3rd Order Sel Abd/Lower Ext|RIGHT SIDE,CASE-36247,APC,36247,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5462.46,,"APC Price ($5,277.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5094.80,,"Case rate ($5,094.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,707.47, add-ons for qualifying new technology services are included. If operating cost exceeds $40,175.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,726.23. The transfer operating threshold is the transfer adjustment factor * $4,707.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.57. The transfer capital threshold is the transfer adjustment factor * $368.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5094.80,15365.01,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],46830.28,,"Fee schedule rate ($46,830.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16524.47,58465.86,Zero final payments for the item or service in the 15 months prior to posting the file.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16062.27,,"Case rate ($16,062.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,841.13, add-ons for qualifying new technology services are included. If operating cost exceeds $50,309.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,333.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,900.28. The transfer operating threshold is the transfer adjustment factor * $14,841.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.98. The transfer capital threshold is the transfer adjustment factor * $1,161.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,16062.27,48077.57,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],102660.52,,"Fee schedule rate ($102,660.52). Adds an outlier to normal pricing equal to the per diem rate ($180,358.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,36224.65,128473.68,Zero final payments for the item or service in the 15 months prior to posting the file.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],80069.53,,"Fee schedule rate ($80,069.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,8990.00,80069.53,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5882.59,,"Case rate ($5,683.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,251.56, add-ons for qualifying new technology services are included. If operating cost exceeds $40,719.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,582.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,272.49. The transfer operating threshold is the transfer adjustment factor * $5,251.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.17. The transfer capital threshold is the transfer adjustment factor * $411.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5683.66,16865.16,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
Dstrj Lesion Anus Extensive,CASE-46924,APC,46924,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3070.31,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3070.31,3223.82,OPPS APC
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],35527.85,,"Case rate ($20,301.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,758.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,226.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,639.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $18,832.96. The transfer operating threshold is the transfer adjustment factor * $18,758.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,468.67. The transfer capital threshold is the transfer adjustment factor * $1,468.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,20301.63,84714.35,All Other Inpatient
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25801.23,,"Fee schedule rate ($25,801.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",22703.12,22703.12,22703.12,1 through 10,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],105789.11,,"Fee schedule rate ($105,789.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,23644.46,105789.11,Zero final payments for the item or service in the 15 months prior to posting the file.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23895.30,,"Fee schedule rate ($23,895.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,8431.66,25019.31,Zero final payments for the item or service in the 15 months prior to posting the file.
Ligj Divj&Strip Long Saph Saphfem Junct Kne/Belw|BILATERAL PROCEDURE,CASE-37722,APC,37722,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15187.25,,"Case rate ($14,673.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,558.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,026.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,232.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,612.15. The transfer operating threshold is the transfer adjustment factor * $13,558.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,061.53. The transfer capital threshold is the transfer adjustment factor * $1,061.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",14951.67,14953.69,15187.26,1 through 10,other,14673.67,43541.27,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13588.14,,"Case rate ($13,588.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,555.10, add-ons for qualifying new technology services are included. If operating cost exceeds $48,023.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,154.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,605.14. The transfer operating threshold is the transfer adjustment factor * $12,555.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $983.00. The transfer capital threshold is the transfer adjustment factor * $983.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12753.64,12753.64,12753.64,1 through 10,other,13588.14,40320.14,Inpatient DRG
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",6963.55,6089.96,6963.55,1 through 10,other,6882.29,7226.40,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23366.55,,"Case rate ($22,908.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,166.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,634.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,828.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,251.14. The transfer operating threshold is the transfer adjustment factor * $21,166.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.25. The transfer capital threshold is the transfer adjustment factor * $1,657.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,22908.38,67976.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26628.31,,"Fee schedule rate ($26,628.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8925.03,26628.31,There are no additional notes associated with this service or procedure.
Fth/Gft Fr W/Dir Clsr F/C/C/M/N/Ax/G/H/F 20 Cm/<|PO,CASE-15240,APC,15240,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2025.45,,"APC Price ($1,956.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.96,2054.80,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,EXTREME",721,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],32330.60,,"Case rate ($30,791.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30791.05,32330.60,There are no additional notes associated with this service or procedure.
Wmhc Perc Implant Stim Lead Ea|PO,CASE-63650,APC,63650,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6044.58,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6044.58,6346.81,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6286.84,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6074.24,18024.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],36167.61,,"Case rate ($36,167.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,417.97, add-ons for qualifying new technology services are included. If operating cost exceeds $68,885.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,787.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $33,551.16. The transfer operating threshold is the transfer adjustment factor * $33,417.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,616.46. The transfer capital threshold is the transfer adjustment factor * $2,616.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36167.61,140535.66,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37423.05,,"Fee schedule rate ($37,423.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13305.64,39481.90,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28615.65,,"Fee schedule rate ($28,615.65). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],44474.65,,"Case rate ($43,602.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $40,287.71, add-ons for qualifying new technology services are included. If operating cost exceeds $75,755.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,325.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,448.27. The transfer operating threshold is the transfer adjustment factor * $40,287.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,154.32. The transfer capital threshold is the transfer adjustment factor * $3,154.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,43602.60,153667.90,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11080.19,32878.30,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Insert Ivc Filter,CASE-37191,APC,37191,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17995.51,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],141041.50,,"Fee schedule rate ($141,041.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18559.00,141041.50,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9833.51,,"Case rate ($9,833.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,085.92, add-ons for qualifying new technology services are included. If operating cost exceeds $44,553.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,882.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,122.13. The transfer operating threshold is the transfer adjustment factor * $9,085.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.38. The transfer capital threshold is the transfer adjustment factor * $711.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9833.51,45903.36,Inpatient DRG
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],692.94,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,669.51,702.98,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Calcaneal Fracture|LEFT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23758.52,,"Case rate ($23,758.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,952.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,889.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $22,039.77. The transfer operating threshold is the transfer adjustment factor * $21,952.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.75. The transfer capital threshold is the transfer adjustment factor * $1,718.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23758.52,103116.16,Inpatient DRG
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE|PO,CASE-29807,APC,29807,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12100.11,,"Case rate ($11,690.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,802.13, add-ons for qualifying new technology services are included. If operating cost exceeds $46,270.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,016.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,845.18. The transfer operating threshold is the transfer adjustment factor * $10,802.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.75. The transfer capital threshold is the transfer adjustment factor * $845.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",12062.81,12062.81,12062.81,1 through 10,other,11690.93,56733.59,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8093.67,,"Case rate ($7,934.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,331.72, add-ons for qualifying new technology services are included. If operating cost exceeds $42,799.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,745.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.94. The transfer operating threshold is the transfer adjustment factor * $7,331.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.04. The transfer capital threshold is the transfer adjustment factor * $574.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7934.97,23545.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Trluml Balo Angiop 1st Vein,CASE-37248,APC,37248,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5398.26,,"APC Price ($5,398.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5398.26,5668.18,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30137.22,,"Fee schedule rate ($30,137.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11710.82,34749.58,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24805.79,,"Case rate ($23,624.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,828.51, add-ons for qualifying new technology services are included. If operating cost exceeds $57,296.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,880.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $21,915.50. The transfer operating threshold is the transfer adjustment factor * $21,828.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,709.06. The transfer capital threshold is the transfer adjustment factor * $1,709.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23624.56,83038.88,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7056.33,28335.74,There are no additional notes associated with this service or procedure.
Colsc Flx With Directed Submucosal Njx Any Sbst|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45381,APC,45381,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],89504.77,,,,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
HC Trigger Point 3 or More|LEFT SIDE|PO,CASE-20553,APC,20553,CPT,0510,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,34379.15,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,XU|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11763.70,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6350.00,33244.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19848.33,,"Fee schedule rate ($19,848.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4968.82,19848.33,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],74869.17,,"Fee schedule rate ($74,869.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,23950.83,74869.17,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21534.51,,,,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],25210.33,,"Case rate ($24,009.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,184.50, add-ons for qualifying new technology services are included. If operating cost exceeds $57,652.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,908.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $22,272.91. The transfer operating threshold is the transfer adjustment factor * $22,184.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,736.93. The transfer capital threshold is the transfer adjustment factor * $1,736.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10632.00,103714.29,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19995.64,,"Fee schedule rate ($19,995.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7500.63,22256.65,There are no additional notes associated with this service or procedure.
Laparoscopy Nephrectomy W/Partial Ureterect,CASE-50546,APC,50546,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],356.97,,"APC Price ($339.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,339.97,356.97,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE|PO,CASE-64633,APC,64633,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31605.04,,"Fee schedule rate ($31,605.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,14102.73,41847.08,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],61860.92,,"Fee schedule rate ($61,860.92). Adds an outlier to normal pricing equal to the per diem rate ($124,533.23) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21828.16,93157.39,Zero final payments for the item or service in the 15 months prior to posting the file.
"CELLULITIS AND OTHER SKIN INFECTIONS,MAJOR",383,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12350.68,,"Case rate ($12,350.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12350.68,12968.21,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29008.87,,"Fee schedule rate ($29,008.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10236.03,30589.82,Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42305.71,,"Fee schedule rate ($42,305.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8605.40,42305.71,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11978.73,,"Case rate ($11,978.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,068.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,535.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,037.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,112.16. The transfer operating threshold is the transfer adjustment factor * $11,068.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.57. The transfer capital threshold is the transfer adjustment factor * $866.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11978.73,60588.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"HIV WITH MAJOR HIV RELATED CONDITION,MODERATE",892,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10661.10,,"Case rate ($10,661.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10661.10,11194.16,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6817.59,,"Case rate ($6,492.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.11. The transfer capital threshold is the transfer adjustment factor * $460.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6503.29,19528.85,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],103821.76,,,,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12741.99,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12135.23,49469.07,Inpatient DRG
"Arthroplasty Interphalangeal Jt W/Prosthetic Ea|LEFT HAND, FIFTH DIGIT|PO",CASE-26536,APC,26536,CPT,0360,RC,,,F4|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6461.52,,"Case rate ($6,461.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,970.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,438.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,638.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,994.07. The transfer operating threshold is the transfer adjustment factor * $5,970.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.44. The transfer capital threshold is the transfer adjustment factor * $467.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6461.52,21772.28,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31007.02,,,,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21289.03,,"Case rate ($21,289.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,670.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,138.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,711.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,748.93. The transfer operating threshold is the transfer adjustment factor * $19,670.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.10. The transfer capital threshold is the transfer adjustment factor * $1,540.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,21289.03,76326.34,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36863.90,,"Fee schedule rate ($36,863.90). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13061.62,,"Case rate ($13,061.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,068.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,536.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,116.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,116.70. The transfer operating threshold is the transfer adjustment factor * $12,068.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.91. The transfer capital threshold is the transfer adjustment factor * $944.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5970.00,38757.79,Inpatient DRG
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE,CASE-28740,APC,28740,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13046.89,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,12791.07,43031.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13719.09,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7551.60,23262.15,All Other Inpatient
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9586.73,,"Case rate ($9,262.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,558.37, add-ons for qualifying new technology services are included. If operating cost exceeds $44,026.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,841.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,592.48. The transfer operating threshold is the transfer adjustment factor * $8,558.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.08. The transfer capital threshold is the transfer adjustment factor * $670.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,27484.83,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19339.26,,of the excess amount.,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, THIRD DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7024.05,,"Case rate ($6,689.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,190.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,658.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,215.52. The transfer operating threshold is the transfer adjustment factor * $6,190.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.05. The transfer capital threshold is the transfer adjustment factor * $474.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6700.24,30254.37,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16666.25,,"Fee schedule rate ($16,666.25). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5578.22,18148.00,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],24640.46,,"Fee schedule rate ($24,640.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9108.71,27028.33,Zero final payments for the item or service in the 15 months prior to posting the file.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12960.17,,"Case rate ($7,405.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,842.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,706.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $6,870.05. The transfer operating threshold is the transfer adjustment factor * $6,842.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.75. The transfer capital threshold is the transfer adjustment factor * $535.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7405.81,33747.30,All Other Inpatient
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE|PO,CASE-64454,APC,64454,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
Rpr Component Inflatable Penile Prosthesis,CASE-54408,APC,54408,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5011.16,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4772.53,14161.54,Inpatient DRG
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,MAJOR",951,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],33385.18,,"Case rate ($31,795.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31795.41,33385.18,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],25207.69,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,24713.42,73332.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26800.70,,"Fee schedule rate ($26,800.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,9456.85,28061.37,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13328.26,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12693.58,46577.81,Inpatient DRG
Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs,CASE-25115,APC,25115,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1578.51,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Hemiphalangectomy/Interphalangeal Joint Exc Toe|LEFT FOOT, FOURTH DIGIT|PO",CASE-28160,APC,28160,CPT,0360,RC,,,T3|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4802.31,,"Case rate ($4,639.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,287.15, add-ons for qualifying new technology services are included. If operating cost exceeds $39,755.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,506.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,304.24. The transfer operating threshold is the transfer adjustment factor * $4,287.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.66. The transfer capital threshold is the transfer adjustment factor * $335.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4639.91,13771.19,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Prst8ect Smpl Stot Robotic Assistance,CASE-55867,APC,55867,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Pelvis/Hip Joint|RIGHT SIDE,CASE-27299,APC,27299,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],245.65,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,233.96,245.65,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13698.42,,"Fee schedule rate ($13,698.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4878.64,14476.37,Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7795.07,,"Case rate ($7,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,202.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,670.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,735.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,231.14. The transfer operating threshold is the transfer adjustment factor * $7,202.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.91. The transfer capital threshold is the transfer adjustment factor * $563.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7795.07,34198.12,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5348.00,,"Per diem ($5,348). If length of stay < 2.7, first 1 days paid at a per diem of $10,696 instead. Capped at $14,438.66.",,,,0,other,5094.80,15365.01,Estimated amount calculated based on 2 day length of stay.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],53232.25,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13061.00,162464.13,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10682.39,,"Case rate ($10,173.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,400.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,868.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,907.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $9,437.70. The transfer operating threshold is the transfer adjustment factor * $9,400.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.99. The transfer capital threshold is the transfer adjustment factor * $735.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10173.70,41194.64,Inpatient DRG
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],5718.68,,"Fee schedule rate ($5,718.68). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20510.35,,"Fee schedule rate ($20,510.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5507.93,20510.35,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT SIDE|PO,CASE-28750,APC,28750,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27725.18,,"Fee schedule rate ($27,725.18). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11384.58,33781.47,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,7289.74,21630.93,Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Surg Prst8ect Smpl Stot Robotic Assistance,CASE-55867,APC,55867,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,Zero final payments for the item or service in the 15 months prior to posting the file.
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,APC,54405,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19658.06,,"APC Price ($19,658.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19658.06,20640.96,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct|RIGHT SIDE|PO,CASE-29891,APC,29891,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5181.84,,"Case rate ($5,006.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,625.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,093.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,533.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,644.42. The transfer operating threshold is the transfer adjustment factor * $4,625.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $362.19. The transfer capital threshold is the transfer adjustment factor * $362.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5006.61,14856.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13893.65,,"Fee schedule rate ($13,893.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6010.58,17835.23,Zero final payments for the item or service in the 15 months prior to posting the file.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5603.81,,"Case rate ($5,336.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,939.08, add-ons for qualifying new technology services are included. If operating cost exceeds $40,406.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,549.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,958.76. The transfer operating threshold is the transfer adjustment factor * $4,939.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.20. The transfer capital threshold is the transfer adjustment factor * $378.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5224.00,15861.63,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",40046.00,40046.00,40046.00,1 through 10,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16973.76,,"Fee schedule rate ($16,973.76). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10970.77,32553.63,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Rescj Pelvic Tumor,CASE-52355,APC,52355,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, THUMB|PO",CASE-26525,APC,26525,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,42670.25,133443.30,Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],71085.16,,"Fee schedule rate ($71,085.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,30163.67,89504.77,There are no additional notes associated with this service or procedure.
"MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,EXTREME",951,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],57057.25,,"Case rate ($54,340.24). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,544, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,54340.24,57057.25,There are no additional notes associated with this service or procedure.
"HC Debrid,Bone,1st 20sqcm or Less|SEPARATE STRUCTURE",CASE-11044,APC,11044,CPT,0361,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1566.49,OPPS APC
Arthroscopy Knee Synovectomy 2/>Compartments|LEFT SIDE,CASE-29876,APC,29876,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE|PO,CASE-29827,APC,29827,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28470.63,,"Fee schedule rate ($28,470.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11888.55,35276.93,Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33319.56,,"Fee schedule rate ($33,319.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7984.05,33319.56,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8118.25,,"Case rate ($7,731.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,155.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,623.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,719.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,183.78. The transfer operating threshold is the transfer adjustment factor * $7,155.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $547.89. The transfer capital threshold is the transfer adjustment factor * $547.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7744.00,24853.45,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5520.00,,"Per diem ($5,520). If length of stay < 3.5, first 1 days paid at a per diem of $11,040 instead. Capped at $19,319.20.",,,,0,other,5520.00,26638.96,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6308.00,,"Per diem ($6,308). If length of stay < 3.3, first 1 days paid at a per diem of $12,616 instead. Capped at $20,817.01.",,,,0,other,6308.00,21796.21,Estimated amount calculated based on 3 day length of stay.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13892.25,,"Case rate ($13,230.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,224.85, add-ons for qualifying new technology services are included. If operating cost exceeds $47,692.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,273.57. The transfer operating threshold is the transfer adjustment factor * $12,224.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.14. The transfer capital threshold is the transfer adjustment factor * $957.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13230.71,39259.55,Inpatient DRG
"Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt|LEFT HAND, THIRD DIGIT|PO",CASE-26531,APC,26531,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,APC,45171,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2724.77,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38792,APC,38792,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,21133.20,88801.87,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8391.98,,"Case rate ($8,227.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,601.93, add-ons for qualifying new technology services are included. If operating cost exceeds $43,069.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,766.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,632.23. The transfer operating threshold is the transfer adjustment factor * $7,601.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.19. The transfer capital threshold is the transfer adjustment factor * $595.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8227.43,27001.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Neuroplasty Other Arm/Leg Nerve,Open|SEPARATE STRUCTURE|RIGHT SIDE|PO",CASE-64708,APC,64708,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3353.51,,"APC Price ($3,240.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3240.11,3402.11,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22883.08,,"Case rate ($21,793.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,168.67, add-ons for qualifying new technology services are included. If operating cost exceeds $55,636.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,715.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $20,249.05. The transfer operating threshold is the transfer adjustment factor * $20,168.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,544.36. The transfer capital threshold is the transfer adjustment factor * $1,544.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21828.16,93157.39,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],163229.10,,"Fee schedule rate ($163,229.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26099.40,,"Fee schedule rate ($26,099.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],66911.01,,"Fee schedule rate ($66,911.01). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],43031.63,,"Fee schedule rate ($43,031.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12791.07,43031.63,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9718.72,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,27465.16,Inpatient DRG
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33747.30,,"Fee schedule rate ($33,747.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7405.81,33747.30,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB EXCEPT TOES,MAJOR",305,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],29554.60,,"Case rate ($29,554.60). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,29554.60,31032.33,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8915.73,,"Case rate ($8,915.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,705.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,270.76. The transfer operating threshold is the transfer adjustment factor * $8,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.99. The transfer capital threshold is the transfer adjustment factor * $644.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8915.73,26455.73,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,838.89,880.84,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17983.60,,"Case rate ($17,127.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,825.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,410.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,888.22. The transfer operating threshold is the transfer adjustment factor * $15,825.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,239.03. The transfer capital threshold is the transfer adjustment factor * $1,239.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17127.24,50821.76,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,76376.03,Estimated amount calculated based on 6 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3295.00,,,,,,0,other,3295.00,21715.49,Estimated amount calculated based on 9 day length of stay.
Arthrodesis Subtalar|LEFT SIDE|PO,CASE-28725,APC,28725,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Ankle Surgical Debridement Extensive|LEFT SIDE|PO,CASE-29898,APC,29898,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16254.22,,"Fee schedule rate ($16,254.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
"DIVERTICULITIS AND DIVERTICULOSIS,MAJOR",244,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14643.64,,"Case rate ($13,946.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13946.32,14643.64,There are no additional notes associated with this service or procedure.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],169197.98,,"Fee schedule rate ($169,197.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (43), with a minimum of zero.",,,,0,other,38891.09,169197.98,There are no additional notes associated with this service or procedure.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO|POLICY CRITERIA APPLIED,CASE-27654,APC,27654,CPT,0360,RC,,,LT|PO|CG,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17095.74,,"Case rate ($16,281.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,324.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.77. The transfer capital threshold is the transfer adjustment factor * $1,153.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8558.00,48389.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40085.35,,"Fee schedule rate ($40,085.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13249.94,40085.35,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28269.95,,,,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
"Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT FOOT, THIRD DIGIT",CASE-28308,APC,28308,CPT,0360,RC,,,T2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35544.53,,,,,,0,other,11978.73,60588.60,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,55581.70,Estimated amount calculated based on 10 day length of stay.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Femur/Knee|LEFT SIDE,CASE-27599,APC,27599,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],233.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,233.96,245.65,OPPS APC
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],58656.71,,"Fee schedule rate ($58,656.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20697.52,87921.54,Zero final payments for the item or service in the 15 months prior to posting the file.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Tib per Territory Plasty|LEFT SIDE,CASE-37228,APC,37228,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],505.96,,,,,,0,other,488.85,513.29,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29049.23,,"Fee schedule rate ($29,049.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7285.00,41187.90,There are no additional notes associated with this service or procedure.
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, THUMB|PO",CASE-26445,APC,26445,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],28679.45,,"Case rate ($27,313.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,277.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,745.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,106.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,378.21. The transfer operating threshold is the transfer adjustment factor * $25,277.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,935.55. The transfer capital threshold is the transfer adjustment factor * $1,935.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",26751.93,26751.93,26751.93,1 through 10,other,27357.31,100904.68,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6240.09,,"Case rate ($5,942.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,491.13, add-ons for qualifying new technology services are included. If operating cost exceeds $40,959.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,601.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,513.02. The transfer operating threshold is the transfer adjustment factor * $5,491.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.93. The transfer capital threshold is the transfer adjustment factor * $429.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5942.94,17634.53,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Local Lesion Epididymis|RIGHT SIDE,CASE-54830,APC,54830,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Ostectomy Complete 5th Metatarsal Head|LEFT SIDE,CASE-28113,APC,28113,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
Egd Flexible Foreign Body Removal,CASE-43247,APC,43247,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,MAJOR",443,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3675.82,,"Case rate for a one day stay ($3,675.82). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3675.82,3859.61,There are no additional notes associated with this service or procedure.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],58579.45,,"Fee schedule rate ($58,579.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18381.22,58579.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteotomy Calcaneus W/WO Internal Fixation|LEFT SIDE|PO,CASE-28300,APC,28300,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5237.39,,"Case rate ($5,237.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,839.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,307.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,550.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,858.49. The transfer operating threshold is the transfer adjustment factor * $4,839.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.89. The transfer capital threshold is the transfer adjustment factor * $378.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5237.39,15540.89,Inpatient DRG
Arthroscopy Knee Removal Loose/Foreign Body|LEFT SIDE,CASE-29874,APC,29874,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3258.56,3258.56,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10103.56,,"Case rate ($9,761.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,019.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,487.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,877.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,055.69. The transfer operating threshold is the transfer adjustment factor * $9,019.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.20. The transfer capital threshold is the transfer adjustment factor * $706.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9761.89,37873.87,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,APC,58662,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7694.27,,"Case rate ($7,694.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,109.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,577.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,727.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,137.64. The transfer operating threshold is the transfer adjustment factor * $7,109.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.62. The transfer capital threshold is the transfer adjustment factor * $556.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7694.27,22831.22,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],41712.94,,"Fee schedule rate ($41,712.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,14718.77,51765.74,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent,CASE-52332,APC,52332,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3460.35,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21119.68,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,17274.00,73717.28,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27153.67,,"Fee schedule rate ($27,153.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6866.02,27153.67,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],9076.66,,"Fee schedule rate ($9,076.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4568.94,13557.45,There are no additional notes associated with this service or procedure.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],48814.14,,"Fee schedule rate ($48,814.14). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11600.09,48814.14,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30977.50,,,,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14555.14,,"Case rate ($14,062.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,993.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,461.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,188.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,045.59. The transfer operating threshold is the transfer adjustment factor * $12,993.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.35. The transfer capital threshold is the transfer adjustment factor * $1,017.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,14062.94,61706.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32645.32,,"Fee schedule rate ($32,645.32). Adds an outlier to normal pricing equal to the per diem rate ($58,905.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11519.18,34180.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Syndactylization Toes|RIGHT SIDE|PO,CASE-28280,APC,28280,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F8|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9365.02,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8919.07,34453.70,Inpatient DRG
HC Sel Cath Abd/Pelvc/Le Init 2nd,CASE-36246,APC,36246,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13.94,,,,,,0,other,13.28,13.94,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8919.07,34453.70,Zero final payments for the item or service in the 15 months prior to posting the file.
"HC ED Avulsion Nail Plate Single|LEFT FOOT, GREAT TOE|PO",CASE-11730,APC,11730,CPT,0450,RC,,,TA|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],39297.79,,of the excess amount. Final payment is multiplied by 103.5%.,43004.64,43004.64,43004.64,1 through 10,other,3295.00,66445.54,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4755.96,,"Case rate ($4,755.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,515.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.06. The transfer capital threshold is the transfer adjustment factor * $344.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4755.96,21133.33,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],67460.63,,,,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13142.28,,"Case rate ($12,516.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,058.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $886.96. The transfer capital threshold is the transfer adjustment factor * $886.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,12536.42,46998.45,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],32969.91,,"Fee schedule rate ($32,969.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8764.55,32969.91,There are no additional notes associated with this service or procedure.
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6055.67,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6055.67,17969.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],4795.07,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,4795.07,19830.58,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc Lesion Tendon Sheath/Capsule W/Synvct Foot|PO,CASE-28090,APC,28090,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29954.41,,"Fee schedule rate ($29,954.41). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6350.00,33244.29,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],123569.61,,"Fee schedule rate ($123,569.61). Adds an outlier to normal pricing equal to the per diem rate ($240,477.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,43602.60,163229.10,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],96304.23,,"Fee schedule rate ($96,304.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11017.65,,"Fee schedule rate ($11,017.65). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6474.12,19210.66,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13405.56,,"Fee schedule rate ($13,405.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],112315.30,,"Fee schedule rate ($112,315.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,40639.08,120588.53,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt,CASE-26531,APC,26531,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31196.82,,"Fee schedule rate ($31,196.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5773.19,31196.82,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE|PO,CASE-29826,APC,29826,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Tnot Elbow Lateral/Medial Debride Open,CASE-24358,APC,24358,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7500.63,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7500.63,22256.65,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],57079.69,,"Fee schedule rate ($57,079.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14580.18,57079.69,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15116.37,,"Fee schedule rate ($15,116.37). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,10605.39,31469.43,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9739.34,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9739.34,40204.26,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17560.25,,"Case rate ($10,034.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,271.57, add-ons for qualifying new technology services are included. If operating cost exceeds $44,739.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,308.52. The transfer operating threshold is the transfer adjustment factor * $9,271.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.92. The transfer capital threshold is the transfer adjustment factor * $725.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10034.43,29775.24,All Other Inpatient
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6267.62,,"Case rate ($6,055.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,595.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,609.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,617.59. The transfer operating threshold is the transfer adjustment factor * $5,595.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.08. The transfer capital threshold is the transfer adjustment factor * $438.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6055.67,17969.04,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21927.57,,"Fee schedule rate ($21,927.57). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13135.23,38976.20,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|SEPARATE STRUCTURE|RIGHT SIDE|PO,CASE-64415,APC,64415,CPT,0360,RC,,,XS|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11042.46,,"Case rate ($10,669.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,857.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,325.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,942.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,897.23. The transfer operating threshold is the transfer adjustment factor * $9,857.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.83. The transfer capital threshold is the transfer adjustment factor * $771.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,31658.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],4203.08,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4120.67,13066.56,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13809.62,,"Case rate ($7,891.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,291.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,759.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,742.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,320.34. The transfer operating threshold is the transfer adjustment factor * $7,291.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.87. The transfer capital threshold is the transfer adjustment factor * $570.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7891.21,23415.63,All Other Inpatient
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10105.00,,"Per diem ($10,105). If length of stay < 10.6, first 1 days paid at a per diem of $20,210 instead. Capped at $107,110.70.",,,,0,other,10105.00,120252.50,Estimated amount calculated based on 10 day length of stay.
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|BILATERAL PROCEDURE,CASE-37766,APC,37766,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Glenohumeral Joint Total Shoulder|LEFT SIDE,CASE-23472,APC,23472,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16630.26,,"APC Price ($16,630.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",17072.59,17072.59,17072.59,1 through 10,other,16630.26,16630.26,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11066.50,,"Case rate ($10,539.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,753.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,221.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,792.65. The transfer operating threshold is the transfer adjustment factor * $9,753.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $746.87. The transfer capital threshold is the transfer adjustment factor * $746.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",35253.80,35253.80,35253.80,1 through 10,other,10556.32,32082.48,Inpatient DRG
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],702.98,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,669.51,702.98,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4631.96,,"Case rate ($4,411.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,082.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,550.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,483.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,098.78. The transfer operating threshold is the transfer adjustment factor * $4,082.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.61. The transfer capital threshold is the transfer adjustment factor * $312.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4418.42,13110.79,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intra Lithotrip-Stent,CASE-C9765,APC,C9765,CPT,0481,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17995.51,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,17386.97,18256.31,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT|PO",CASE-26160,APC,26160,CPT,0360,RC,,,F2|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11593.40,,"Fee schedule rate ($11,593.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,2285.00,12138.74,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20654.42,,"Case rate ($20,654.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,084.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,552.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,665.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,160.23. The transfer operating threshold is the transfer adjustment factor * $19,084.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,494.19. The transfer capital threshold is the transfer adjustment factor * $1,494.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20654.42,69402.59,Inpatient DRG
HC Bladder Irrig Simple or Continuous,CASE-51700,APC,51700,CPT,0761,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2081.79,,"APC Price ($1,982.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1982.66,2081.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26268.02,,"Fee schedule rate ($26,268.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9969.47,29582.40,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,4120.67,13066.56,Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21256.76,,"Fee schedule rate ($21,256.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7500.63,22256.65,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],158423.11,,"Fee schedule rate ($158,423.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,55900.95,225294.39,Zero final payments for the item or service in the 15 months prior to posting the file.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,38110.41,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, SECOND DIGIT|PO",CASE-26860,APC,26860,CPT,0360,RC,,,F6|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],106200.88,,"Fee schedule rate ($106,200.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30626.53,106200.88,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],98455.37,,"Fee schedule rate ($98,455.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,33072.79,98455.37,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,1188.00,27484.83,Estimated amount calculated based on 5 day length of stay.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5700.90,,"Case rate ($5,700.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,267.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,735.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,583.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $5,288.49. The transfer operating threshold is the transfer adjustment factor * $5,267.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $412.42. The transfer capital threshold is the transfer adjustment factor * $412.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5700.90,30872.02,Inpatient DRG
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
"PULMONARY EMBOLISM,MODERATE",134,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3155.57,,"Case rate for a one day stay ($3,005.30). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3005.30,3155.57,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14762.22,,"Case rate ($14,472.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,372.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,840.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,218.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,425.75. The transfer operating threshold is the transfer adjustment factor * $13,372.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.00. The transfer capital threshold is the transfer adjustment factor * $1,047.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,14472.76,56135.46,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20705.40,,"Case rate ($20,005.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,484.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,618.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,557.99. The transfer operating threshold is the transfer adjustment factor * $18,484.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,447.23. The transfer capital threshold is the transfer adjustment factor * $1,447.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,20005.22,74991.64,Inpatient DRG
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22407.54,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12804.31,55145.09,All Other Inpatient
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|LEFT FOOT, GREAT TOE",CASE-28270,APC,28270,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],59513.03,,"Fee schedule rate ($59,513.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14508.56,59513.03,There are no additional notes associated with this service or procedure.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],31767.24,,"Case rate ($30,254.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,954.41, add-ons for qualifying new technology services are included. If operating cost exceeds $63,422.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,359.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $28,065.82. The transfer operating threshold is the transfer adjustment factor * $27,954.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,188.69. The transfer capital threshold is the transfer adjustment factor * $2,188.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30254.51,130347.93,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21028.61,,"Fee schedule rate ($21,028.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12440.40,41073.77,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE|PO,CASE-64405,APC,64405,CPT,0450,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],45597.35,,"Fee schedule rate ($45,597.35). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],880.84,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",1301.76,1301.76,1301.76,1 through 10,other,838.89,880.84,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13312.70,,"Case rate ($13,051.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,059.42, add-ons for qualifying new technology services are included. If operating cost exceeds $47,527.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,115.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,107.48. The transfer operating threshold is the transfer adjustment factor * $12,059.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.19. The transfer capital threshold is the transfer adjustment factor * $944.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13051.67,38728.27,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64446,APC,64446,CPT,0360,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40774.00,,"Fee schedule rate ($40,774.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11958.84,40774.00,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5091.00,,"Per diem ($5,091). If length of stay < 3.2, first 1 days paid at a per diem of $10,182 instead. Capped at $16,289.77.",,,,0,other,5091.00,22010.11,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20229.92,,"Fee schedule rate ($20,229.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10492.66,31134.92,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21314.41,,"Case rate ($12,179.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,253.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,721.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,052.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,298.55. The transfer operating threshold is the transfer adjustment factor * $11,253.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $881.11. The transfer capital threshold is the transfer adjustment factor * $881.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,12179.66,36140.75,All Other Inpatient
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],45507.56,,"Fee schedule rate ($45,507.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,3295.00,50750.92,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],9763.00,,"Per diem ($9,763). If length of stay < 4, first 1 days paid at a per diem of $19,526 instead. Capped at $39,053.73.",,,,0,other,9763.00,48626.00,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|RIGHT FOOT, SECOND DIGIT|PO|SEPARATE STRUCTURE",CASE-28270,APC,28270,CPT,0360,RC,,,T6|PO|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Syndactylization Toes|LEFT SIDE,CASE-28280,APC,28280,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],90685.00,,"Fee schedule rate ($90,685.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,30403.05,90685.00,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],50759.39,,"Fee schedule rate ($50,759.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],24723.88,,"Fee schedule rate ($24,723.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,8915.73,26455.73,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10620.41,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10114.68,30013.33,Inpatient DRG
Rpr Disloc Peroneal Tendon W/O Fibular Osteotomy|LEFT SIDE|PO,CASE-27675,APC,27675,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20817.97,,"Case rate ($20,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $18,584.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,052.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,626.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,658.87. The transfer operating threshold is the transfer adjustment factor * $18,584.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.10. The transfer capital threshold is the transfer adjustment factor * $1,455.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,17274.00,73717.28,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8501.29,,"Case rate ($8,501.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,854.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,322.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,786.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,886.28. The transfer operating threshold is the transfer adjustment factor * $7,854.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.00. The transfer capital threshold is the transfer adjustment factor * $615.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6178.00,25225.91,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13701.97,,"Fee schedule rate ($13,701.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5368.01,15928.53,Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],47205.53,,"Case rate ($45,609.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $42,141.78, add-ons for qualifying new technology services are included. If operating cost exceeds $77,609.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,470.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $42,309.73. The transfer operating threshold is the transfer adjustment factor * $42,141.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,299.49. The transfer capital threshold is the transfer adjustment factor * $3,299.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,45609.21,211906.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/2 Osteot|LEFT FOOT, GREAT TOE|PO",CASE-28299,APC,28299,CPT,0360,RC,,,TA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24117.35,,"Case rate ($23,644.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,846.89, add-ons for qualifying new technology services are included. If operating cost exceeds $57,314.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,881.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $21,933.96. The transfer operating threshold is the transfer adjustment factor * $21,846.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,710.50. The transfer capital threshold is the transfer adjustment factor * $1,710.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23644.46,105789.11,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cystourethroscopy With Biopsy|SEPARATE STRUCTURE,CASE-52204,APC,52204,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14326.59,,"Case rate ($13,842.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,789.77, add-ons for qualifying new technology services are included. If operating cost exceeds $48,257.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,172.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,840.74. The transfer operating threshold is the transfer adjustment factor * $12,789.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.37. The transfer capital threshold is the transfer adjustment factor * $1,001.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,12440.40,41073.77,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17711.39,,"Fee schedule rate ($17,711.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Continuous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64448,APC,64448,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26525,APC,26525,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],64621.61,,"Fee schedule rate ($64,621.61). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,22802.30,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5783.33,,"Case rate ($5,507.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,089.19, add-ons for qualifying new technology services are included. If operating cost exceeds $40,557.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,569.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,109.48. The transfer operating threshold is the transfer adjustment factor * $5,089.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.46. The transfer capital threshold is the transfer adjustment factor * $398.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5507.93,20510.35,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,6681.01,19824.58,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5114.41,,"Case rate ($4,870.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,507.73, add-ons for qualifying new technology services are included. If operating cost exceeds $39,975.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,525.69. The transfer operating threshold is the transfer adjustment factor * $4,507.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.17. The transfer capital threshold is the transfer adjustment factor * $345.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4878.64,14476.37,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28493.70,,"Fee schedule rate ($28,493.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
"MALFUNCTION REACTION COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE,MODERATE",466,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9225.71,,"Case rate ($9,225.71). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9225.71,9687.00,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12402.46,,"Case rate ($12,402.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,459.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,068.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,505.24. The transfer operating threshold is the transfer adjustment factor * $11,459.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.23. The transfer capital threshold is the transfer adjustment factor * $897.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",12607.43,12402.47,33137.41,1 through 10,other,12402.46,36801.89,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],63510.03,,"Fee schedule rate ($63,510.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,19243.94,63510.03,There are no additional notes associated with this service or procedure.
Partial Excision Bone Olecranon Process|RIGHT SIDE|PO,CASE-24147,APC,24147,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5544.51,,"Case rate ($5,280.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,879.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,346.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,553.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,898.48. The transfer operating threshold is the transfer adjustment factor * $4,879.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $382.00. The transfer capital threshold is the transfer adjustment factor * $382.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5280.49,17810.78,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],99157.51,,"Fee schedule rate ($99,157.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34988.57,110685.97,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14323.89,,"Case rate ($14,043.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,975.42, add-ons for qualifying new technology services are included. If operating cost exceeds $48,443.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,187.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,027.13. The transfer operating threshold is the transfer adjustment factor * $12,975.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.91. The transfer capital threshold is the transfer adjustment factor * $1,015.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,14043.03,54637.47,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33968.35,,"Fee schedule rate ($33,968.35). Adds an outlier to normal pricing equal to the per diem rate ($93,734.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5732.06,21720.81,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],56733.59,,"Fee schedule rate ($56,733.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11690.93,56733.59,Zero final payments for the item or service in the 15 months prior to posting the file.
"HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,MINOR",279,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6693.41,,"The inlier payment is calculated as the lesser of the standard DRG payment $6,693.41 and the transfer payment, which is a per diem of $2,253.67. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6693.41,7028.08,Estimated amount calculated based on 1 day length of stay.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],52607.24,,"Fee schedule rate ($52,607.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],120588.53,,,,,,0,other,40639.08,120588.53,There are no additional notes associated with this service or procedure.
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,APC,94640,CPT,0410,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22594.88,,"Case rate ($21,830.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,171.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,639.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,750.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,251.51. The transfer operating threshold is the transfer adjustment factor * $20,171.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,579.30. The transfer capital threshold is the transfer adjustment factor * $1,579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,21830.80,85124.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8058.48,,"Case rate ($7,674.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,102.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,570.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,715.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,130.87. The transfer operating threshold is the transfer adjustment factor * $7,102.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $543.86. The transfer capital threshold is the transfer adjustment factor * $543.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7686.98,22809.58,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],110204.98,,"Fee schedule rate ($110,204.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23703.48,110204.98,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28157.55,,"Fee schedule rate ($28,157.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9935.64,29482.05,Zero final payments for the item or service in the 15 months prior to posting the file.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5660.17,,"Case rate ($5,549.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $5,144.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,689.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,050.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,146.79. The transfer operating threshold is the transfer adjustment factor * $5,144.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.42. The transfer capital threshold is the transfer adjustment factor * $402.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5549.19,16729.39,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Non/Malunion Humerus W/O Graft|LEFT SIDE,CASE-24430,APC,24430,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12603.27,12785.93,OPPS APC
Laparoscopy Enterolysis Separate Procedure,CASE-44180,APC,44180,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],169615.07,,"Fee schedule rate ($169,615.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,47283.61,169615.07,There are no additional notes associated with this service or procedure.
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,APC,58542,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10082.05,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10082.05,10586.16,OPPS APC
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36556,APC,36556,CPT,0761,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5277.74,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5277.74,5541.62,OPPS APC
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5975.25,,"Case rate ($5,773.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,334.28, add-ons for qualifying new technology services are included. If operating cost exceeds $40,802.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,588.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,355.54. The transfer operating threshold is the transfer adjustment factor * $5,334.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.65. The transfer capital threshold is the transfer adjustment factor * $417.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,5773.19,31196.82,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],109237.68,,"Fee schedule rate ($109,237.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,27539.67,109237.68,Zero final payments for the item or service in the 15 months prior to posting the file.
"HIV WITH MAJOR HIV RELATED CONDITION,MAJOR",892,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2241.68,,"Case rate for a one day stay ($2,134.93). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2134.93,2241.68,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8676.42,,"Fee schedule rate ($8,676.42). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7102.10,,"Case rate ($7,102.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,562.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,030.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,684.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,588.31. The transfer operating threshold is the transfer adjustment factor * $6,562.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.78. The transfer capital threshold is the transfer adjustment factor * $513.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7102.10,21074.07,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10291.73,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10291.73,34803.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT|PO",CASE-26735,APC,26735,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],47325.03,,"Fee schedule rate ($47,325.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,3295.00,70321.74,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],31734.85,,"Case rate ($31,112.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $28,747.26, add-ons for qualifying new technology services are included. If operating cost exceeds $64,215.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,421.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,861.83. The transfer operating threshold is the transfer adjustment factor * $28,747.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.76. The transfer capital threshold is the transfer adjustment factor * $2,250.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,31112.60,92731.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],46577.81,,"Fee schedule rate ($46,577.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12693.58,46577.81,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16664.74,,"Case rate ($15,871.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,687.95, add-ons for qualifying new technology services are included. If operating cost exceeds $50,155.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,295.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,746.49. The transfer operating threshold is the transfer adjustment factor * $14,687.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,124.69. The transfer capital threshold is the transfer adjustment factor * $1,124.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",119179.38,16171.01,251077.35,1 through 10,other,15896.49,51306.05,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16634.04,,"Fee schedule rate ($16,634.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5779.83,17150.47,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17285.42,,"Fee schedule rate ($17,285.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,8596.11,25507.30,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1566.49,,"APC Price ($1,566.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15774.99,,"Case rate ($15,023.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,881.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,349.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,258.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,936.95. The transfer operating threshold is the transfer adjustment factor * $13,881.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.86. The transfer capital threshold is the transfer adjustment factor * $1,086.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15023.80,48104.19,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],128473.68,,"Fee schedule rate ($128,473.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,36224.65,128473.68,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16283.27,,"Case rate ($15,507.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $14,328.90, add-ons for qualifying new technology services are included. If operating cost exceeds $49,796.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,293.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,386.01. The transfer operating threshold is the transfer adjustment factor * $14,328.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,121.88. The transfer capital threshold is the transfer adjustment factor * $1,121.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15507.88,46016.63,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],29594.69,,"Case rate ($29,594.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,344.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,812.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,312.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $27,453.74. The transfer operating threshold is the transfer adjustment factor * $27,344.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.96. The transfer capital threshold is the transfer adjustment factor * $2,140.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,29594.69,124146.55,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22352.66,,"Fee schedule rate ($22,352.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27593.84,,"Fee schedule rate ($27,593.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7079.09,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6940.28,20593.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Removal of Tumors Small,CASE-52234,APC,52234,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37366.25,,"Fee schedule rate ($37,366.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11217.46,37366.25,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],54637.47,,"Fee schedule rate ($54,637.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14043.03,54637.47,There are no additional notes associated with this service or procedure.
"KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,MODERATE",313,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],25417.12,,"Case rate ($24,206.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24206.78,25417.12,There are no additional notes associated with this service or procedure.
HC Vasc Embolize Occlude Organ,CASE-37243,APC,37243,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10949.29,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10949.29,11496.76,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7934.97,23545.50,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14476.37,,,,,,0,other,4878.64,14476.37,There are no additional notes associated with this service or procedure.
"MAJOR RESPIRATORY AND CHEST PROCEDURES,EXTREME",120,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],71871.57,,"Case rate ($71,871.57). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $52,189, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,71871.57,75465.15,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,8227.43,27001.04,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13035.75,,"Fee schedule rate ($13,035.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],60333.05,,"Fee schedule rate ($60,333.05). Adds an outlier to normal pricing equal to the per diem rate ($143,359.22) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Distal Tibiofibular Joint Disruption|LEFT SIDE|PO,CASE-27829,APC,27829,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroplasty Interphalangeal Jt W/Prosthetic Ea,CASE-26536,APC,26536,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25847.37,,"Fee schedule rate ($25,847.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,30861.41,Zero final payments for the item or service in the 15 months prior to posting the file.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23433.56,,"Fee schedule rate ($23,433.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8716.15,25863.45,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30666.60,,,,,,0,other,10334.84,30666.60,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],58980.57,,"Fee schedule rate ($58,980.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,12833.49,58980.57,Zero final payments for the item or service in the 15 months prior to posting the file.
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],26030.46,,"APC Price ($24,790.92). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,24790.92,26030.46,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22484.91,,,,,,0,other,7577.56,31445.30,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],56973.00,,"Fee schedule rate ($56,973). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (97), with a minimum of zero.",,,,0,other,26419.65,96304.23,There are no additional notes associated with this service or procedure.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3295.00,,,,,,0,other,3295.00,21715.49,Estimated amount calculated based on 9 day length of stay.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15818.85,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15065.57,53815.71,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4796.01,,"Case rate ($4,567.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,494.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $323.68. The transfer capital threshold is the transfer adjustment factor * $323.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4574.91,13575.16,Inpatient DRG
Transoral Lower Esophageal Myotomy,CASE-43497,APC,43497,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5959.58,,"APC Price ($5,758.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5758.05,6045.95,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39295.53,,"Fee schedule rate ($39,295.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10625.29,39295.53,There are no additional notes associated with this service or procedure.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],80940.99,,"Fee schedule rate ($80,940.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20274.44,80940.99,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45390,APC,45390,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12392.10,,"Fee schedule rate ($12,392.10). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7289.74,21630.93,There are no additional notes associated with this service or procedure.
"MAJOR LARGE BOWEL PROCEDURES,MODERATE",231,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],25461.19,,"Case rate ($25,461.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,25461.19,26734.25,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FIFTH DIGIT|PO",CASE-26125,APC,26125,CPT,0360,RC,,,F9|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6707.31,,"Case rate ($6,387.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,902.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,370.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,633.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,925.79. The transfer operating threshold is the transfer adjustment factor * $5,902.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $462.12. The transfer capital threshold is the transfer adjustment factor * $462.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6387.91,18954.85,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19656.64,,"Fee schedule rate ($19,656.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7891.21,23415.63,Zero final payments for the item or service in the 15 months prior to posting the file.
Unlisted Procedure Abdomen Peritoneum & Omentum,CASE-49999,APC,49999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6612.88,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6297.98,6612.88,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5911.44,,"Case rate ($5,629.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,201.93, add-ons for qualifying new technology services are included. If operating cost exceeds $40,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,578.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,222.66. The transfer operating threshold is the transfer adjustment factor * $5,201.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.28. The transfer capital threshold is the transfer adjustment factor * $407.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5629.94,16705.77,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19520.61,,"Case rate ($19,137.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,682.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,150.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,555.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,753.37. The transfer operating threshold is the transfer adjustment factor * $17,682.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.48. The transfer capital threshold is the transfer adjustment factor * $1,384.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,19137.85,64589.15,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10835.56,,"Fee schedule rate ($10,835.56). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],72041.81,,"Fee schedule rate ($72,041.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,21570.21,72041.81,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12053.43,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11645.83,37502.92,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32474.30,,"Fee schedule rate ($32,474.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13475.16,,"Case rate ($12,833.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,857.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,325.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,099.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $11,905.09. The transfer operating threshold is the transfer adjustment factor * $11,857.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.41. The transfer capital threshold is the transfer adjustment factor * $928.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12833.49,58980.57,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4803.66,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4574.91,13575.16,Inpatient DRG
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],55900.95,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,55900.95,225294.39,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11478.22,,"Case rate ($6,558.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,060.34, add-ons for qualifying new technology services are included. If operating cost exceeds $41,528.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,645.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,084.50. The transfer operating threshold is the transfer adjustment factor * $6,060.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.49. The transfer capital threshold is the transfer adjustment factor * $474.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,6558.98,19462.52,All Other Inpatient
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19102.56,,"Case rate ($10,915.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,085.87, add-ons for qualifying new technology services are included. If operating cost exceeds $45,553.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,960.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,126.06. The transfer operating threshold is the transfer adjustment factor * $10,085.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.67. The transfer capital threshold is the transfer adjustment factor * $789.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,10915.75,32390.31,All Other Inpatient
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,APC,38571,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10434.93,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10082.05,10586.16,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
Fasciotomy Foot&/Toe|RIGHT SIDE|PO,CASE-28008,APC,28008,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23125.89,,"Case rate ($23,125.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,367.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,835.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,844.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $21,452.91. The transfer operating threshold is the transfer adjustment factor * $21,367.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.99. The transfer capital threshold is the transfer adjustment factor * $1,672.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",27543.97,23125.90,42667.95,1 through 10,other,23125.89,68621.57,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4180.34,14351.57,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],72246.07,,,,,,0,other,10455.00,90889.11,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24789.11,,"Case rate ($23,950.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,129.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,597.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,903.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,218.16. The transfer operating threshold is the transfer adjustment factor * $22,129.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,732.66. The transfer capital threshold is the transfer adjustment factor * $1,732.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,23950.83,74869.17,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],50697.38,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",51017.16,51017.16,51017.16,1 through 10,other,13061.00,162464.13,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],53815.71,,"Fee schedule rate ($53,815.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15065.57,53815.71,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],24525.10,,"Fee schedule rate ($24,525.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13438.87,,"Fee schedule rate ($13,438.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,4742.02,14071.02,Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],52672.70,,"Fee schedule rate ($52,672.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,15156.44,52672.70,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30589.82,,"Fee schedule rate ($30,589.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,10236.03,30589.82,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12698.12,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,40067.60,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",35387.82,35387.82,35387.82,1 through 10,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/Implt|RIGHT FOOT, GREAT TOE|PO",CASE-28291,APC,28291,CPT,0360,RC,,,T5|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19837.58,,"Fee schedule rate ($19,837.58). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11901.14,35314.31,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11117.94,,"Case rate ($10,588.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,921.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.34. The transfer capital threshold is the transfer adjustment factor * $750.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10605.39,31469.43,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],41194.64,,"Fee schedule rate ($41,194.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10173.70,41194.64,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31699.11,,"Fee schedule rate ($31,699.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,32980.62,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19113.53,,"Fee schedule rate ($19,113.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6724.11,19952.48,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10884.58,,"Case rate ($10,884.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,057.07, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,958.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,097.15. The transfer operating threshold is the transfer adjustment factor * $10,057.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.42. The transfer capital threshold is the transfer adjustment factor * $787.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10884.58,32297.83,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|LEFT SIDE,CASE-27685,APC,27685,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE|PO,CASE-27792,APC,27792,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6959.45,,"Case rate ($6,724.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,212.91, add-ons for qualifying new technology services are included. If operating cost exceeds $41,680.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,657.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,237.67. The transfer operating threshold is the transfer adjustment factor * $6,212.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.44. The transfer capital threshold is the transfer adjustment factor * $486.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6724.11,19952.48,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7875.66,,"Case rate ($7,500.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,930.40, add-ons for qualifying new technology services are included. If operating cost exceeds $42,398.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,713.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,958.02. The transfer operating threshold is the transfer adjustment factor * $6,930.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.61. The transfer capital threshold is the transfer adjustment factor * $542.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7500.63,22256.65,Inpatient DRG
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11592.12,,"Case rate ($11,592.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,710.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,178.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,009.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,753.52. The transfer operating threshold is the transfer adjustment factor * $10,710.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.60. The transfer capital threshold is the transfer adjustment factor * $838.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11592.12,38954.76,Inpatient DRG
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10147.88,,"Case rate ($9,948.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,192.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,660.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,890.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,229.17. The transfer operating threshold is the transfer adjustment factor * $9,192.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.73. The transfer capital threshold is the transfer adjustment factor * $719.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,9948.90,46199.76,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40204.26,,"Fee schedule rate ($40,204.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9739.34,40204.26,Zero final payments for the item or service in the 15 months prior to posting the file.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],4979.12,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4742.02,14071.02,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],103116.16,,"Fee schedule rate ($103,116.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,23758.52,103116.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],23904.30,,"Case rate ($22,766). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,068.75, add-ons for qualifying new technology services are included. If operating cost exceeds $56,536.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,784.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $21,152.71. The transfer operating threshold is the transfer adjustment factor * $21,068.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,613.28. The transfer capital threshold is the transfer adjustment factor * $1,613.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22802.30,82749.58,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],100904.68,,"Fee schedule rate ($100,904.68). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,27357.31,100904.68,Zero final payments for the item or service in the 15 months prior to posting the file.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],45156.75,,,,,,0,other,15218.11,45156.75,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],90908.64,,"Fee schedule rate ($90,908.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5244.04,15804.57,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7402.41,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7257.26,23445.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7321.93,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6382.95,21300.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf|LEFT SIDE,CASE-36825,APC,36825,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5462.46,,"APC Price ($5,277.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5277.74,5541.62,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],28005.17,,"Case rate ($28,005.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,876.09, add-ons for qualifying new technology services are included. If operating cost exceeds $61,343.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,197.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $25,979.22. The transfer operating threshold is the transfer adjustment factor * $25,876.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,025.97. The transfer capital threshold is the transfer adjustment factor * $2,025.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,28005.17,115392.91,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],59012.52,,"Fee schedule rate ($59,012.52). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14534.42,59012.52,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12135.23,,"Case rate ($12,135.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,212.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,680.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,049.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,257.33. The transfer operating threshold is the transfer adjustment factor * $11,212.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.89. The transfer capital threshold is the transfer adjustment factor * $877.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12135.23,49469.07,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14342.69,,"Fee schedule rate ($14,342.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",6721.70,6721.70,6721.70,1 through 10,other,5169.74,15340.19,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18579.92,,of the excess amount. Final payment is multiplied by 105%.,,,,0,other,3295.00,30966.53,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10789.41,,"Fee schedule rate ($10,789.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6382.95,21300.35,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],92976.49,,"Fee schedule rate ($92,976.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.5), with a minimum of zero.",,,,0,other,32807.56,111191.81,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32474.30,,"Fee schedule rate ($32,474.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19757.81,,"Fee schedule rate ($19,757.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4984.06,19757.81,Zero final payments for the item or service in the 15 months prior to posting the file.
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,APC,57520,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3223.82,,"APC Price ($3,070.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3070.31,3223.82,OPPS APC
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PO|SEPARATE STRUCTURE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|PO|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],301.32,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,291.13,305.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],44148.02,,"Fee schedule rate ($44,148.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10528.47,44148.02,There are no additional notes associated with this service or procedure.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36891.86,,"Fee schedule rate ($36,891.86). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16009.89,58554.60,There are no additional notes associated with this service or procedure.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,EXTREME",425,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],22208.43,,"Case rate ($21,150.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21150.89,22208.43,There are no additional notes associated with this service or procedure.
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,APC,46200,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],46938.11,,"Fee schedule rate ($46,938.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10808.31,46938.11,There are no additional notes associated with this service or procedure.
Partical Excision Bone Phalanx Toe|LEFT SIDE|PO,CASE-28124,APC,28124,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18433.80,,"Fee schedule rate ($18,433.80). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,8072.90,31159.55,There are no additional notes associated with this service or procedure.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7178.36,,"Case rate ($7,178.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,632.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,100.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,690.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,659.05. The transfer operating threshold is the transfer adjustment factor * $6,632.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.30. The transfer capital threshold is the transfer adjustment factor * $519.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6382.95,21300.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16278.78,,,,,,0,other,5486.04,17919.05,There are no additional notes associated with this service or procedure.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15263.85,,"Fee schedule rate ($15,263.85). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7096.13,25801.23,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22010.11,,"Fee schedule rate ($22,010.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5091.00,22010.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|BILATERAL PROCEDURE,CASE-52354,APC,52354,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],37915.54,,"Case rate ($36,110.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,417.97, add-ons for qualifying new technology services are included. If operating cost exceeds $68,885.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,730.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $33,551.16. The transfer operating threshold is the transfer adjustment factor * $33,417.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.88. The transfer capital threshold is the transfer adjustment factor * $2,558.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,36167.61,140535.66,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],64621.61,,"Fee schedule rate ($64,621.61). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,22802.30,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18403.21,,"Case rate ($18,042.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,476.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.23. The transfer capital threshold is the transfer adjustment factor * $1,305.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,18042.36,82749.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11595.64,,"Case rate ($11,203.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,351.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,819.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,981.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,393.04. The transfer operating threshold is the transfer adjustment factor * $10,351.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.49. The transfer capital threshold is the transfer adjustment factor * $810.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6350.00,33244.29,Inpatient DRG
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn|PO,CASE-62321,APC,62321,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],669.51,,"APC Price ($669.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,669.51,702.98,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35376.63,,"Fee schedule rate ($35,376.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7759.92,35376.63,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7930.65,,"Fee schedule rate ($7,930.65). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5886.58,17467.27,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],10943.82,,"Fee schedule rate ($10,943.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3753.97,11139.15,Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],33404.17,,"Case rate ($32,749.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,259.44, add-ons for qualifying new technology services are included. If operating cost exceeds $65,727.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,540.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,380.03. The transfer operating threshold is the transfer adjustment factor * $30,259.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,369.16. The transfer capital threshold is the transfer adjustment factor * $2,369.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,32749.19,97176.83,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit|RIGHT SIDE,CASE-36901,APC,36901,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1545.29,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1493.03,1567.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],53827.17,,of the excess amount. Final payment is multiplied by 175%.,,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],34447.94,,"Case rate ($32,807.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,313.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,781.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $30,434.17. The transfer operating threshold is the transfer adjustment factor * $30,313.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,373.38. The transfer capital threshold is the transfer adjustment factor * $2,373.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32807.56,111191.81,Inpatient DRG
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12791.07,,"Case rate ($12,791.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,818.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,286.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,096.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,865.72. The transfer operating threshold is the transfer adjustment factor * $11,818.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.34. The transfer capital threshold is the transfer adjustment factor * $925.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,12791.07,43031.63,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],43263.82,,,,,,0,other,14580.18,57079.69,There are no additional notes associated with this service or procedure.
"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,EXTREME",191,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],31412.39,,"Case rate ($29,916.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29916.56,31412.39,There are no additional notes associated with this service or procedure.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],170142.20,,"Fee schedule rate ($170,142.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,50916.88,170142.20,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],64029.63,,"Fee schedule rate ($64,029.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.5), with a minimum of zero.",,,,0,other,22593.41,90908.64,Zero final payments for the item or service in the 15 months prior to posting the file.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9108.71,27028.33,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9097.45,,"Case rate ($8,919.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,240.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,708.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,816.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,273.83. The transfer operating threshold is the transfer adjustment factor * $8,240.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8919.07,34453.70,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30658.90,,"Fee schedule rate ($30,658.90). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10818.26,38164.94,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26452.60,,"Fee schedule rate ($26,452.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12141.86,36028.59,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,50|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1916.92,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",1876.32,1876.32,1876.32,1 through 10,other,1852.10,1944.70,OPPS APC
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21904.95,,"Case rate ($20,861.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,306.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,774.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,649.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $19,383.53. The transfer operating threshold is the transfer adjustment factor * $19,306.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,478.34. The transfer capital threshold is the transfer adjustment factor * $1,478.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20895.12,99969.33,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],24713.42,,"Case rate ($24,713.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,834.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,302.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,958.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $22,925.59. The transfer operating threshold is the transfer adjustment factor * $22,834.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,787.83. The transfer capital threshold is the transfer adjustment factor * $1,787.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,24713.42,73332.24,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7728.84,,"Case rate ($7,467.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,899.76, add-ons for qualifying new technology services are included. If operating cost exceeds $42,367.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,711.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,927.26. The transfer operating threshold is the transfer adjustment factor * $6,899.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.22. The transfer capital threshold is the transfer adjustment factor * $540.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,3295.00,37575.69,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10620.41,,"Case rate ($10,114.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,345.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,902.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,382.96. The transfer operating threshold is the transfer adjustment factor * $9,345.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.72. The transfer capital threshold is the transfer adjustment factor * $731.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10114.68,30013.33,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22186.50,,"Fee schedule rate ($22,186.50). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,11645.83,37502.92,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39792.30,,"Fee schedule rate ($39,792.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25905.15,,"Fee schedule rate ($25,905.15). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9569.58,41116.55,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14580.18,,"Case rate ($14,580.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,471.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,939.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,225.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,525.41. The transfer operating threshold is the transfer adjustment factor * $13,471.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.77. The transfer capital threshold is the transfer adjustment factor * $1,054.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,14580.18,57079.69,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Revise/Remove Neurostim/Receiver,CASE-64595,APC,64595,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3481.74,,"APC Price ($3,315.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3315.94,3481.74,OPPS APC
Inguinofem Lmphadec Supfc W/Cloquets Node Spx,CASE-38760,APC,38760,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6612.88,OPPS APC
Carpectomy All Bones Proximal Row|LEFT SIDE|PO,CASE-25215,APC,25215,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3212.01,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22195.56,,"Case rate ($21,138.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,562.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,030.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,669.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,640.66. The transfer operating threshold is the transfer adjustment factor * $19,562.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.96. The transfer capital threshold is the transfer adjustment factor * $1,497.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",22195.57,22195.57,23206.03,1 through 10,other,12500.00,83592.64,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11735.41,,"Fee schedule rate ($11,735.41). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Transurethral Resection Bladder Neck|SEPARATE STRUCTURE,CASE-52500,APC,52500,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu,CASE-25260,APC,25260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],51131.99,,"Fee schedule rate ($51,131.99). Adds an outlier to normal pricing equal to the per diem rate ($106,675.43) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,18042.36,82749.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13589.22,,"Fee schedule rate ($13,589.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
"PERIPHERAL CRANIAL AND AUTONOMIC NERVE DISORDERS,MAJOR",048,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14711.81,,"Case rate ($14,011.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14011.25,14711.81,There are no additional notes associated with this service or procedure.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17026.45,,"Case rate ($17,026.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $51,199.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,402.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,794.71. The transfer operating threshold is the transfer adjustment factor * $15,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.74. The transfer capital threshold is the transfer adjustment factor * $1,231.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,17026.45,50522.67,Inpatient DRG
HC Debrid Wound Tis 20 Cm/<|PBB CHARGE,CASE-97597,APC,97597,CPT,0761,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],199.81,,"APC Price ($190.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,190.30,199.81,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],133443.30,,"Fee schedule rate ($133,443.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,42670.25,133443.30,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],38416.97,,"Fee schedule rate ($38,416.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10109.37,38416.97,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17067.11,,"Fee schedule rate ($17,067.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,5355.42,17067.11,There are no additional notes associated with this service or procedure.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],83592.64,,"Fee schedule rate ($83,592.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12500.00,83592.64,There are no additional notes associated with this service or procedure.
HC Sel Cath Abd/Pelvc/Le Init 2nd,CASE-36246,APC,36246,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13.74,,,,,,0,other,13.28,13.94,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13985.94,,"Fee schedule rate ($13,985.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5160.45,15312.64,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs|RIGHT SIDE,CASE-37765,APC,37765,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10334.84,,"Case rate ($10,334.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,549.13, add-ons for qualifying new technology services are included. If operating cost exceeds $45,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,918.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,587.19. The transfer operating threshold is the transfer adjustment factor * $9,549.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.65. The transfer capital threshold is the transfer adjustment factor * $747.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10334.84,30666.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13060.40,,"Case rate ($12,804.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,830.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,298.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,097.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,878.02. The transfer operating threshold is the transfer adjustment factor * $11,830.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.30. The transfer capital threshold is the transfer adjustment factor * $926.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,12804.31,55145.09,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],52607.24,,"Fee schedule rate ($52,607.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18562.91,73513.17,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12536.42,37199.37,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,4120.67,13066.56,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10283.39,,"Case rate ($9,935.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,180.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,648.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,889.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,216.86. The transfer operating threshold is the transfer adjustment factor * $9,180.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.77. The transfer capital threshold is the transfer adjustment factor * $718.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,9935.64,29482.05,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|RIGHT FOOT, GREAT TOE|PO",CASE-28292,APC,28292,CPT,0360,RC,,,T5|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12603.27,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],68116.02,,"Case rate ($64,872.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $59,940.48, add-ons for qualifying new technology services are included. If operating cost exceeds $95,408.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,864.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,179.36. The transfer operating threshold is the transfer adjustment factor * $59,940.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,693.03. The transfer capital threshold is the transfer adjustment factor * $4,693.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,64872.40,212258.00,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],76310.36,,"Fee schedule rate ($76,310.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,3295.00,76310.36,Zero final payments for the item or service in the 15 months prior to posting the file.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],54086.17,,,,,,0,other,18227.38,54086.17,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13014.93,,"Case rate ($12,395.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,452.83, add-ons for qualifying new technology services are included. If operating cost exceeds $46,920.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,067.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,498.47. The transfer operating threshold is the transfer adjustment factor * $11,452.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.70. The transfer capital threshold is the transfer adjustment factor * $896.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12395.17,42174.37,Inpatient DRG
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11297.91,,"Case rate ($10,759.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,941.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,409.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,949.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,981.50. The transfer operating threshold is the transfer adjustment factor * $9,941.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.40. The transfer capital threshold is the transfer adjustment factor * $778.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10759.91,46061.32,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],83038.88,,"Fee schedule rate ($83,038.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1525.13,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1525.13,1601.38,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7109.06,,"Case rate ($6,770.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,255.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,723.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,660.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,280.73. The transfer operating threshold is the transfer adjustment factor * $6,255.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.80. The transfer capital threshold is the transfer adjustment factor * $489.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6770.53,20090.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],73513.17,,"Fee schedule rate ($73,513.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,18562.91,73513.17,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13514.94,,"Case rate ($13,249.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,242.62, add-ons for qualifying new technology services are included. If operating cost exceeds $47,710.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,129.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,291.41. The transfer operating threshold is the transfer adjustment factor * $12,242.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $958.53. The transfer capital threshold is the transfer adjustment factor * $958.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,13249.94,40085.35,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5520.00,,"Per diem ($5,520). If length of stay < 3.5, first 1 days paid at a per diem of $11,040 instead. Capped at $19,319.20.",,,,0,other,5520.00,26638.96,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Bladder Instillation Anticarcinogenic Agent,CASE-51720,APC,51720,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3343.33,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3343.33,3510.50,OPPS APC
Lig&Div Long Saph Vein Saphfem Junct/Interrupj|LEFT SIDE,CASE-37700,APC,37700,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],43409.67,,"Fee schedule rate ($43,409.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10449.55,43409.67,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15743.06,,"Fee schedule rate ($15,743.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5183.66,15743.06,There are no additional notes associated with this service or procedure.
Cysto W/Removal of Tumors Small,CASE-52234,APC,52234,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23973.12,,"Fee schedule rate ($23,973.12). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14182.35,53827.17,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35383.73,,"Fee schedule rate ($35,383.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15928.53,,,,,,0,other,5368.01,15928.53,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4985.81,,"Case rate ($4,748.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,394.38, add-ons for qualifying new technology services are included. If operating cost exceeds $39,862.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,507.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,411.89. The transfer operating threshold is the transfer adjustment factor * $4,394.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.49. The transfer capital threshold is the transfer adjustment factor * $336.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4755.96,21133.33,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4939.57,,"Case rate ($4,772.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,409.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,877.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,516.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,427.27. The transfer operating threshold is the transfer adjustment factor * $4,409.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.26. The transfer capital threshold is the transfer adjustment factor * $345.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,4772.53,14161.54,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],63602.32,,"Fee schedule rate ($63,602.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23338.10,69251.23,Zero final payments for the item or service in the 15 months prior to posting the file.
"HEART FAILURE,MAJOR",194,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14742.07,,"Case rate ($14,742.07). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14742.07,15479.17,There are no additional notes associated with this service or procedure.
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE|PO,CASE-27427,APC,27427,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],34268.98,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32637.12,96844.29,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19433.97,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18508.54,76171.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21715.49,,"Fee schedule rate ($21,715.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",19981.48,19981.48,19981.48,1 through 10,other,3295.00,21715.49,There are no additional notes associated with this service or procedure.
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, THUMB|PO",CASE-26445,APC,26445,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,9820.91,29141.64,Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5971.17,,"Case rate ($5,854.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,409.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,876.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,594.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,430.59. The transfer operating threshold is the transfer adjustment factor * $5,409.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.50. The transfer capital threshold is the transfer adjustment factor * $423.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",5874.02,5874.02,5874.02,1 through 10,other,1188.00,17370.86,Inpatient DRG
Osteot W/WO Lngth Shrt/Angular Corrj Metar Mlt|LEFT SIDE|PO,CASE-28309,APC,28309,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,APC,43248,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],860.25,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,860.25,903.26,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10492.66,,"Case rate ($10,492.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,694.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,162.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,930.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,733.59. The transfer operating threshold is the transfer adjustment factor * $9,694.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.07. The transfer capital threshold is the transfer adjustment factor * $759.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10492.66,31134.92,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35832.77,,"Fee schedule rate ($35,832.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6531.00,35832.77,There are no additional notes associated with this service or procedure.
Bladder Instillation Anticarcinogenic Agent|UNUSUAL NON-OVERLAPPING SERVICE,CASE-51720,APC,51720,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5339.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],225294.39,,"Fee schedule rate ($225,294.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,55900.95,225294.39,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16785.91,,"Fee schedule rate ($16,785.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,5923.06,17575.50,Zero final payments for the item or service in the 15 months prior to posting the file.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8410.44,24956.34,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],58510.23,,"Fee schedule rate ($58,510.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
Rcnstj Angular Dfrm Toe Soft Tiss Px Only,CASE-28313,APC,28313,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,5938.30,18621.89,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39078.16,,"Fee schedule rate ($39,078.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13789.07,57367.22,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5419.59,,"Case rate ($5,161.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,776.71, add-ons for qualifying new technology services are included. If operating cost exceeds $40,244.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,536.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,795.75. The transfer operating threshold is the transfer adjustment factor * $4,776.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.76. The transfer capital threshold is the transfer adjustment factor * $365.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",5338.34,1607.37,44706.45,1 through 10,other,5169.74,15340.19,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9820.91,,"Case rate ($9,820.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,074.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,542.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,881.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,110.44. The transfer operating threshold is the transfer adjustment factor * $9,074.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.47. The transfer capital threshold is the transfer adjustment factor * $710.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9820.91,29141.64,Inpatient DRG
Unlisted Px Skin Muc Membrane & Subq Tissue,CASE-17999,APC,17999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10237.83,,"Case rate ($10,037.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,274.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,741.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,897.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,310.98. The transfer operating threshold is the transfer adjustment factor * $9,274.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.11. The transfer capital threshold is the transfer adjustment factor * $726.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,10037.09,36934.96,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5083.74,,"Case rate ($4,984.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,605.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,073.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,531.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,623.50. The transfer operating threshold is the transfer adjustment factor * $4,605.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.56. The transfer capital threshold is the transfer adjustment factor * $360.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,4984.06,19757.81,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],26401.20,,"Fee schedule rate ($26,401.20). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11298.37,44627.23,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4574.91,,"Case rate ($4,574.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,227.11, add-ons for qualifying new technology services are included. If operating cost exceeds $39,695.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,502.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.95. The transfer operating threshold is the transfer adjustment factor * $4,227.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.96. The transfer capital threshold is the transfer adjustment factor * $330.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",4574.91,4574.91,4574.91,1 through 10,other,4574.91,13575.16,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14267.55,,"Case rate ($13,588.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,555.10, add-ons for qualifying new technology services are included. If operating cost exceeds $48,023.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,154.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,605.14. The transfer operating threshold is the transfer adjustment factor * $12,555.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $983.00. The transfer capital threshold is the transfer adjustment factor * $983.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13588.14,40320.14,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5669.00,,"Per diem ($5,669). If length of stay < 3.2, first 1 days paid at a per diem of $11,338 instead. Capped at $18,140.88.",,,,0,other,5669.00,18994.21,Estimated amount calculated based on 5 day length of stay.
Open Treatment Fracture Distal Tibia & Fibula|LEFT SIDE|PO,CASE-27828,APC,27828,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES SIGNS AND SYMPTOMS,EXTREME",468,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],22461.94,,"Case rate ($22,461.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22461.94,23585.04,There are no additional notes associated with this service or procedure.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MODERATE",720,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11344.94,,"Case rate ($11,344.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11344.94,11912.19,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15818.34,,,,,,0,other,3295.00,33843.71,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4382.37,,"Case rate ($4,173.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,466.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.76. The transfer capital threshold is the transfer adjustment factor * $295.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4180.34,14351.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24695.21,,"Fee schedule rate ($24,695.21). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13335.48,39570.45,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39290.21,,"Fee schedule rate ($39,290.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,12212.80,39290.21,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],29129.85,,"Case rate ($29,129.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,915.25, add-ons for qualifying new technology services are included. If operating cost exceeds $62,383.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,278.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,022.52. The transfer operating threshold is the transfer adjustment factor * $26,915.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,107.33. The transfer capital threshold is the transfer adjustment factor * $2,107.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",29129.86,29129.86,29129.86,1 through 10,other,29129.85,86437.13,Inpatient DRG
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],51935.22,,"Case rate ($50,916.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $47,045.93, add-ons for qualifying new technology services are included. If operating cost exceeds $82,513.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,854.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,233.43. The transfer operating threshold is the transfer adjustment factor * $47,045.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,683.46. The transfer capital threshold is the transfer adjustment factor * $3,683.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,50916.88,170142.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18914.32,,"Case rate ($18,013.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $16,670.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,138.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,447.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $16,737.13. The transfer operating threshold is the transfer adjustment factor * $16,670.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,276.51. The transfer capital threshold is the transfer adjustment factor * $1,276.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",19476.09,18914.33,302049.44,1 through 10,other,18042.36,82749.58,Inpatient DRG
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10389.39,,"Case rate ($9,894.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,156.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,624.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,872.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,193.49. The transfer operating threshold is the transfer adjustment factor * $9,156.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $701.17. The transfer capital threshold is the transfer adjustment factor * $701.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9910.44,43344.00,Inpatient DRG
"MAJOR ABDOMINAL VASCULAR PROCEDURES,MAJOR",169,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],53961.70,,"Case rate ($53,961.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,53961.70,56659.79,There are no additional notes associated with this service or procedure.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MODERATE",425,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2628.00,,"Case rate for a one day stay ($2,502.86). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2502.86,2628.00,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22901.10,,"Fee schedule rate ($22,901.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6495.00,23801.30,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,1188.00,27484.83,Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",8905.60,8905.60,8905.60,1 through 10,other,7984.05,23691.11,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, THUMB|PO",CASE-26765,APC,26765,CPT,0360,RC,,,FA|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33447.35,,"Fee schedule rate ($33,447.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,33447.35,There are no additional notes associated with this service or procedure.
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10806.32,,"Case rate ($10,291.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,509.30, add-ons for qualifying new technology services are included. If operating cost exceeds $44,977.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,547.20. The transfer operating threshold is the transfer adjustment factor * $9,509.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.53. The transfer capital threshold is the transfer adjustment factor * $744.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10291.73,34803.35,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17261.15,,"Fee schedule rate ($17,261.15). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",4617.50,4617.50,4617.50,1 through 10,other,5578.22,18148.00,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],49911.01,,"Fee schedule rate ($49,911.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],99157.51,,"Fee schedule rate ($99,157.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34988.57,110685.97,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16195.65,,"Fee schedule rate ($16,195.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6748.64,20025.28,Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],84714.35,,"Fee schedule rate ($84,714.35). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20301.63,84714.35,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9579.88,,"Case rate ($9,255.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,552.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,020.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,840.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,586.33. The transfer operating threshold is the transfer adjustment factor * $8,552.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $669.60. The transfer capital threshold is the transfer adjustment factor * $669.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,27465.16,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23918.09,,"Fee schedule rate ($23,918.09). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7601.43,23918.09,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14858.10,,,,,,0,other,5007.28,16142.41,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],29930.92,,"Case rate ($17,103.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,803.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,270.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,408.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,866.07. The transfer operating threshold is the transfer adjustment factor * $15,803.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.30. The transfer capital threshold is the transfer adjustment factor * $1,237.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,17103.38,50750.92,All Other Inpatient
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16307.62,,"Case rate ($16,307.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,067.84, add-ons for qualifying new technology services are included. If operating cost exceeds $50,535.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,127.89. The transfer operating threshold is the transfer adjustment factor * $15,067.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.73. The transfer capital threshold is the transfer adjustment factor * $1,179.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8558.00,48389.68,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6503.29,,"Case rate ($6,503.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,008.88, add-ons for qualifying new technology services are included. If operating cost exceeds $41,476.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,641.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,032.82. The transfer operating threshold is the transfer adjustment factor * $6,008.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.46. The transfer capital threshold is the transfer adjustment factor * $470.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,6503.29,19528.85,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,5578.22,18148.00,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],3760.73,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,3209.85,10940.41,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7648.51,27371.98,Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Fibula Nonunion/Malunion W/Int Fixation|LEFT SIDE,CASE-27726,APC,27726,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7123.17,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],22734.65,,"Case rate ($22,734.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,006.25, add-ons for qualifying new technology services are included. If operating cost exceeds $56,474.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,815.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,089.97. The transfer operating threshold is the transfer adjustment factor * $21,006.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.68. The transfer capital threshold is the transfer adjustment factor * $1,644.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,22734.65,70806.50,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6495.00,,"Per diem ($6,495). If length of stay < 3.5, first 1 days paid at a per diem of $12,990 instead. Capped at $22,732.01.",,,,0,other,6495.00,23801.30,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14083.11,,"Fee schedule rate ($14,083.11). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6094.79,22352.66,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10226.31,,"Case rate ($9,739.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,998.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,466.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,875.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,034.78. The transfer operating threshold is the transfer adjustment factor * $8,998.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.57. The transfer capital threshold is the transfer adjustment factor * $704.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9739.34,40204.26,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],90280.33,,"Fee schedule rate ($90,280.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,7826.00,90280.33,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17858.70,,"Fee schedule rate ($17,858.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5938.97,17858.70,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11159.78,39897.21,Zero final payments for the item or service in the 15 months prior to posting the file.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19015.91,,"Fee schedule rate ($19,015.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Repair Secondary Achilles Tendon W/WO Graft|LEFT SIDE|PO,CASE-27654,APC,27654,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 1.1-2.0 Cm|PO,CASE-11402,APC,11402,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],671.64,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,671.64,671.64,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7839.48,,"Case rate ($7,839.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,243.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,711.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,272.36. The transfer operating threshold is the transfer adjustment factor * $7,243.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.13. The transfer capital threshold is the transfer adjustment factor * $567.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,7551.60,23262.15,Inpatient DRG
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17090.89,,"Case rate ($16,277.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,324.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.45. The transfer capital threshold is the transfer adjustment factor * $1,153.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16302.99,55737.89,Inpatient DRG
Esophagogastroduodenoscopy US Scope W/Adj Strxrs|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43237,APC,43237,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1911.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1820.02,1911.02,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],85844.94,,"Fee schedule rate ($85,844.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,30150.40,89465.42,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28530.23,,"Case rate ($16,302.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,063.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,531.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,350.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,123.58. The transfer operating threshold is the transfer adjustment factor * $15,063.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.40. The transfer capital threshold is the transfer adjustment factor * $1,179.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,16302.99,55737.89,All Other Inpatient
Arthrodesis Midtarsometatarsal Single Joint|LEFT SIDE|PO,CASE-28740,APC,28740,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21796.21,,,,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3510.50,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3343.33,3510.50,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30039.61,,"Fee schedule rate ($30,039.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9860.04,30039.61,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,7984.05,23691.11,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],99157.51,,"Fee schedule rate ($99,157.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34988.57,110685.97,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F2|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1852.10,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1852.10,1944.70,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15117.84,,,,,,0,other,5094.80,15365.01,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10439.61,,"Case rate ($10,439.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,645.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,113.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,926.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,684.38. The transfer operating threshold is the transfer adjustment factor * $9,645.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.23. The transfer capital threshold is the transfer adjustment factor * $755.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,10439.61,34540.67,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18148.00,,"Fee schedule rate ($18,148.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5578.22,18148.00,Zero final payments for the item or service in the 15 months prior to posting the file.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10336.56,,"Case rate ($9,844.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,110.43, add-ons for qualifying new technology services are included. If operating cost exceeds $44,578.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,868.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $9,146.74. The transfer operating threshold is the transfer adjustment factor * $9,110.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $697.60. The transfer capital threshold is the transfer adjustment factor * $697.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9860.04,30039.61,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6377.95,,"Case rate ($6,074.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,612.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,080.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,610.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,634.82. The transfer operating threshold is the transfer adjustment factor * $5,612.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.43. The transfer capital threshold is the transfer adjustment factor * $439.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6074.24,18024.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10536.75,,"Fee schedule rate ($10,536.75). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5280.49,17810.78,There are no additional notes associated with this service or procedure.
"MAJOR RESPIRATORY AND CHEST PROCEDURES,EXTREME",120,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],75465.15,,"Case rate ($71,871.57). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $52,189, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,71871.57,75465.15,There are no additional notes associated with this service or procedure.
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,CASE-36556,APC,36556,CPT,0761,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3099.59,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2994.77,3144.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21908.95,,"Fee schedule rate ($21,908.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6293.75,21908.95,There are no additional notes associated with this service or procedure.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],118364.04,,"Fee schedule rate ($118,364.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,28696.16,118364.04,There are no additional notes associated with this service or procedure.
Synovectomy Tendon Sheath Foot Extensor|RIGHT SIDE|PO,CASE-28088,APC,28088,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision/Curettage Cyst/Tumor Femur|RIGHT SIDE,CASE-27355,APC,27355,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,13264.54,50759.39,Zero final payments for the item or service in the 15 months prior to posting the file.
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],890.35,,"APC Price ($860.25). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,860.25,903.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Axillary Lymphadenectomy Complete,CASE-38745,APC,38745,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15059.45,,"Case rate ($8,605.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,951.18, add-ons for qualifying new technology services are included. If operating cost exceeds $43,419.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,793.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,982.86. The transfer operating threshold is the transfer adjustment factor * $7,951.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $622.54. The transfer capital threshold is the transfer adjustment factor * $622.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8605.40,42305.71,All Other Inpatient
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24543.13,,"Fee schedule rate ($24,543.13). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11592.12,38954.76,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15337.96,,"Case rate ($8,764.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,098.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,805.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,130.50. The transfer operating threshold is the transfer adjustment factor * $8,098.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.05. The transfer capital threshold is the transfer adjustment factor * $634.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,8764.55,32969.91,All Other Inpatient
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,18902.44,56089.29,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26709.96,,"Fee schedule rate ($26,709.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10034.43,29775.24,Zero final payments for the item or service in the 15 months prior to posting the file.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],58123.31,,"Fee schedule rate ($58,123.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16208.15,58123.31,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Revasc Intra Lithotrip-Stent,CASE-C9765,APC,C9765,CPT,0481,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17386.97,,"APC Price ($17,386.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,17386.97,18256.31,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],31657.92,,"Case rate ($30,150.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,858.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,326.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,352.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,969.24. The transfer operating threshold is the transfer adjustment factor * $27,858.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,181.16. The transfer capital threshold is the transfer adjustment factor * $2,181.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,30150.40,89465.42,Inpatient DRG
"CHOLECYSTECTOMY,MINOR",263,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15619.88,,"Case rate ($14,876.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14876.08,15619.88,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10605.39,,"Case rate ($10,605.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,799.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,267.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,938.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,838.17. The transfer operating threshold is the transfer adjustment factor * $9,799.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $767.22. The transfer capital threshold is the transfer adjustment factor * $767.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",10605.39,10605.39,10605.39,1 through 10,other,10605.39,31469.43,Inpatient DRG
Tenodesis Long Tendon Biceps|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16630.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,16630.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],58696.00,,"Case rate ($55,900.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $51,651.08, add-ons for qualifying new technology services are included. If operating cost exceeds $87,118.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $5,215.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $51,856.93. The transfer operating threshold is the transfer adjustment factor * $51,651.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,044.02. The transfer capital threshold is the transfer adjustment factor * $4,044.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,55900.95,225294.39,Inpatient DRG
Lngth/Shrt Tendon Leg/Ankle 1 Tendon Spx|RIGHT SIDE|PO,CASE-27685,APC,27685,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Rem Central Venous Cath,CASE-36589,APC,36589,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],594.98,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,594.98,624.73,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,There are no additional notes associated with this service or procedure.
Laps Insertion Tunneled Intraperitoneal Catheter,CASE-49324,APC,49324,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6020.69,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],4326.70,,"Case rate ($4,120.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,807.40, add-ons for qualifying new technology services are included. If operating cost exceeds $39,275.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,469.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,822.57. The transfer operating threshold is the transfer adjustment factor * $3,807.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $298.10. The transfer capital threshold is the transfer adjustment factor * $298.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4120.67,13066.56,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12510.87,,"Fee schedule rate ($12,510.87). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,5308.33,19857.20,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],50518.01,,"Fee schedule rate ($50,518.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15852.04,50518.01,There are no additional notes associated with this service or procedure.
Fth/Gft Free W/Direct Closure S/a/L 20 Cm/<,CASE-15220,APC,15220,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6297.98,,"APC Price ($6,297.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6297.98,6297.98,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20474.85,,"Fee schedule rate ($20,474.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8513.22,25261.33,Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20150.05,,"Fee schedule rate ($20,150.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6797.06,20168.93,Zero final payments for the item or service in the 15 months prior to posting the file.
"SICKLE CELL ANEMIA CRISIS,MAJOR",662,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],15157.91,,"Case rate ($15,157.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15157.91,15915.81,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE|PO,CASE-24359,APC,24359,CPT,0360,RC,,,RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40067.60,,"Fee schedule rate ($40,067.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12093.45,40067.60,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17093.73,,"Fee schedule rate ($17,093.73). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6033.12,17902.13,Zero final payments for the item or service in the 15 months prior to posting the file.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24393.31,,"Case rate ($23,915.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $22,096.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,564.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,901.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,184.94. The transfer operating threshold is the transfer adjustment factor * $22,096.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.07. The transfer capital threshold is the transfer adjustment factor * $1,730.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,23915.01,121205.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Nerve Repair W/Nerve Allograft First Strand|PO,CASE-64912,APC,64912,CPT,0360,RC,,,PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8323.61,,"APC Price ($8,323.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8323.61,8739.79,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Repair Brow Ptosis,CASE-67900,APC,67900,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2367.72,,"APC Price ($2,254.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2254.97,2367.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Aa Hernia 1st < 3 Cm Reducible,CASE-49591,APC,49591,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12585.32,,"Case rate ($11,986.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,074.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,542.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,038.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,118.92. The transfer operating threshold is the transfer adjustment factor * $11,074.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.10. The transfer capital threshold is the transfer adjustment factor * $867.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,11986.02,54149.39,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,28788.33,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7079.09,,"Case rate ($6,940.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,412.65, add-ons for qualifying new technology services are included. If operating cost exceeds $41,880.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,673.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,438.21. The transfer operating threshold is the transfer adjustment factor * $6,412.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.08. The transfer capital threshold is the transfer adjustment factor * $502.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6940.28,20593.95,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],71764.93,,"Fee schedule rate ($71,764.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23385.84,71764.93,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],68941.12,,"Fee schedule rate ($68,941.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,19232.02,68941.12,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11844.40,,"Case rate ($11,280.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,439.40, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,970.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,481.01. The transfer operating threshold is the transfer adjustment factor * $10,439.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.37. The transfer capital threshold is the transfer adjustment factor * $799.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",20971.63,20971.63,20971.63,1 through 10,other,11298.37,44627.23,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],52511.19,,"Fee schedule rate ($52,511.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10114.68,30013.33,Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT SIDE|PO,CASE-28750,APC,28750,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21880.53,,"Case rate ($21,451.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,820.65, add-ons for qualifying new technology services are included. If operating cost exceeds $55,288.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,723.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,899.64. The transfer operating threshold is the transfer adjustment factor * $19,820.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.86. The transfer capital threshold is the transfer adjustment factor * $1,551.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8940.00,63653.13,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],83871.28,,"Fee schedule rate ($83,871.28). Adds an outlier to normal pricing equal to the per diem rate ($214,712.47) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,29594.69,124146.55,Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],55350.97,,"Fee schedule rate ($55,350.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,16456.83,55350.97,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Intro Cath Dialysis Circuit|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-36901,APC,36901,CPT,0361,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1567.69,,"APC Price ($1,493.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1493.03,1567.69,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27396.83,,"Fee schedule rate ($27,396.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12140.54,36024.65,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Rescj Pelvic Tumor,CASE-52355,APC,52355,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5263.48,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5085.49,5339.77,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12340.90,,"Fee schedule rate ($12,340.90). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4838.84,19587.42,There are no additional notes associated with this service or procedure.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20885.18,,"Case rate ($20,885.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,297.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,682.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,374.30. The transfer operating threshold is the transfer adjustment factor * $19,297.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,510.89. The transfer capital threshold is the transfer adjustment factor * $1,510.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,20885.18,80720.91,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3295.00,,,,,,0,other,3295.00,66445.54,Estimated amount calculated based on 11 day length of stay.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23679.61,,"Case rate ($23,679.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,879.36, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,884.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,966.56. The transfer operating threshold is the transfer adjustment factor * $21,879.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,713.04. The transfer capital threshold is the transfer adjustment factor * $1,713.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,23679.61,84629.16,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],50821.76,,,,,,0,other,17127.24,50821.76,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],305.69,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",298.29,298.29,298.29,1 through 10,other,291.13,305.69,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6835.51,,"Case rate ($6,835.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,315.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,783.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,665.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.02. The transfer operating threshold is the transfer adjustment factor * $6,315.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.50. The transfer capital threshold is the transfer adjustment factor * $494.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",6835.51,6803.68,27389.24,1 through 10,other,6835.51,20283.05,Inpatient DRG
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE|PO,CASE-28122,APC,28122,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11688.02,,"Case rate ($11,458.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,587.68, add-ons for qualifying new technology services are included. If operating cost exceeds $46,055.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,000.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,629.87. The transfer operating threshold is the transfer adjustment factor * $10,587.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.96. The transfer capital threshold is the transfer adjustment factor * $828.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,11458.84,42820.42,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,28788.33,Estimated amount calculated based on 2 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27966.92,,,,,,0,other,9425.03,27966.92,There are no additional notes associated with this service or procedure.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1688.18,,"APC Price ($1,688.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1688.18,1772.59,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],80806.10,,"Fee schedule rate ($80,806.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,25459.44,80806.10,Zero final payments for the item or service in the 15 months prior to posting the file.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE|PO,CASE-64635,APC,64635,CPT,0360,RC,,,RT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],87921.54,,"Fee schedule rate ($87,921.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20697.52,87921.54,There are no additional notes associated with this service or procedure.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29908.27,,"Fee schedule rate ($29,908.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8679.02,29908.27,Zero final payments for the item or service in the 15 months prior to posting the file.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],53781.00,,"Fee schedule rate ($53,781). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,22593.41,90908.64,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.5 Cm/<,CASE-11400,APC,11400,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],695.15,,"APC Price ($671.64). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,671.64,705.22,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,APC,11424,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1566.49,,"APC Price ($1,566.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1566.49,1644.81,OPPS APC
Excision Single External Papilla or Tag Anus,CASE-46220,APC,46220,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1174.70,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42115.80,,"Fee schedule rate ($42,115.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10290.40,42115.80,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],65078.97,,of the excess amount.,,,,0,other,3295.00,76310.36,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],45477.48,,,,,,0,other,15326.20,52511.19,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7308.00,,"Per diem ($7,308). If length of stay < 5.5, first 1 days paid at a per diem of $14,616 instead. Capped at $40,192.59.",,,,0,other,7308.00,42083.20,Estimated amount calculated based on 3 day length of stay.
"Open Tx Fracture Great Toe/Phalanx/Phalanges|LEFT FOOT, GREAT TOE",CASE-28505,APC,28505,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7123.17,OPPS APC
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],48077.57,,"Fee schedule rate ($48,077.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,16062.27,48077.57,There are no additional notes associated with this service or procedure.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25174.94,,"Fee schedule rate ($25,174.94). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9280.46,39957.56,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],51306.05,,"Fee schedule rate ($51,306.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,15896.49,51306.05,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37225.17,,"Fee schedule rate ($37,225.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13135.23,38976.20,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G > 4.0cm,CASE-11426,APC,11426,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13328.26,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12693.58,46577.81,Inpatient DRG
Exc Tumor Soft Tissue Thigh/Knee Subfasc 5 Cm/>|LEFT SIDE|SEPARATE STRUCTURE,CASE-27339,APC,27339,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30282.76,,"Fee schedule rate ($30,282.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,38110.41,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Hdr Vaginal Cyl Insertion,CASE-57156,APC,57156,CPT,0333,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],289.03,,"APC Price ($289.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,289.03,303.48,OPPS APC
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],82749.58,,"Fee schedule rate ($82,749.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,18042.36,82749.58,There are no additional notes associated with this service or procedure.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],60059.69,,"Fee schedule rate ($60,059.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,14041.04,60059.69,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5895.51,,"APC Price ($5,614.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5614.77,5895.51,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],46998.45,,"Fee schedule rate ($46,998.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12536.42,46998.45,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28899.61,,,,,,0,other,9739.34,40204.26,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16903.82,,"Fee schedule rate ($16,903.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5668.40,16903.82,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31124.05,,"Fee schedule rate ($31,124.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,5970.00,38757.79,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21133.33,,"Fee schedule rate ($21,133.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4755.96,21133.33,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],148703.60,,"Fee schedule rate ($148,703.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,40202.74,148703.60,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,22734.65,70806.50,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19255.52,,"Fee schedule rate ($19,255.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6785.78,20135.47,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],38143.65,,"Fee schedule rate ($38,143.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15090.78,44778.95,There are no additional notes associated with this service or procedure.
Manipulation Knee Joint Under General Anesthesia,CASE-27570,APC,27570,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18559.00,,"Per diem ($18,559). If length of stay < 5.4, first 1 days paid at a per diem of $37,118 instead. Capped at $100,219.31.",,,,0,other,18559.00,141041.50,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29542.64,,"Fee schedule rate ($29,542.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6480.75,29542.64,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30254.37,,"Fee schedule rate ($30,254.37). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6700.24,30254.37,Zero final payments for the item or service in the 15 months prior to posting the file.
"Tendon Sheath Incision|RIGHT HAND, THUMB|PO",CASE-26055,APC,26055,CPT,0360,RC,,,F5|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1852.10,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],31671.85,,"Case rate ($30,163.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,870.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,338.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,353.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $27,981.55. The transfer operating threshold is the transfer adjustment factor * $27,870.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,182.12. The transfer capital threshold is the transfer adjustment factor * $2,182.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30163.67,89504.77,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6494.70,,"Case rate ($6,367.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,883.27, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,631.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,906.72. The transfer operating threshold is the transfer adjustment factor * $5,883.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.63. The transfer capital threshold is the transfer adjustment factor * $460.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,1188.00,18893.86,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],34268.98,,"Case rate ($32,637.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $30,155.89, add-ons for qualifying new technology services are included. If operating cost exceeds $65,623.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,532.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $30,276.07. The transfer operating threshold is the transfer adjustment factor * $30,155.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.05. The transfer capital threshold is the transfer adjustment factor * $2,361.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,32637.12,96844.29,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],838.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17245.50,,"Fee schedule rate ($17,245.50). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7648.51,27371.98,There are no additional notes associated with this service or procedure.
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Treatment Calcaneal Fracture|LEFT SIDE|PO,CASE-28415,APC,28415,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthroscopy Knee Removal Loose/Foreign Body,CASE-29874,APC,29874,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3460.35,,"APC Price ($3,343.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3343.33,3510.50,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17350.69,,"Case rate ($16,524.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,268.19, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,366.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,329.04. The transfer operating threshold is the transfer adjustment factor * $15,268.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.42. The transfer capital threshold is the transfer adjustment factor * $1,195.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16524.47,58465.86,Inpatient DRG
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12177.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC
Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Mu|RIGHT SIDE|PO,CASE-25260,APC,25260,CPT,0360,RC,,,RT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3212.01,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10632.00,,"Per diem ($10,632). If length of stay < 6.4, first 1 days paid at a per diem of $21,264 instead. Capped at $68,043.82.",,,,0,other,10632.00,103714.29,Estimated amount calculated based on 5 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Pilonidal Cyst/Sinus Extensive,CASE-11771,APC,11771,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2892.78,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2755.03,2892.78,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12536.42,,"Case rate ($12,536.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,583.34, add-ons for qualifying new technology services are included. If operating cost exceeds $47,051.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,078.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,629.50. The transfer operating threshold is the transfer adjustment factor * $11,583.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.92. The transfer capital threshold is the transfer adjustment factor * $906.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,12536.42,37199.37,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9425.03,,"Case rate ($9,425.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,708.49, add-ons for qualifying new technology services are included. If operating cost exceeds $44,176.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,852.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,743.19. The transfer operating threshold is the transfer adjustment factor * $8,708.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.83. The transfer capital threshold is the transfer adjustment factor * $681.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,9425.03,27966.92,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16497.38,,"Fee schedule rate ($16,497.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7102.10,21074.07,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42820.42,,"Fee schedule rate ($42,820.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11458.84,42820.42,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Primary Disrupted Ligament Ankle Collateral|SEPARATE STRUCTURE|LEFT SIDE|PO,CASE-27695,APC,27695,CPT,0360,RC,,,XS|LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7123.17,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15136.05,,"Case rate ($14,415.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,340.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,808.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,192.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,393.77. The transfer operating threshold is the transfer adjustment factor * $13,340.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,021.52. The transfer capital threshold is the transfer adjustment factor * $1,021.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14438.27,55762.74,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19589.20,,"Fee schedule rate ($19,589.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6204.88,19589.20,Zero final payments for the item or service in the 15 months prior to posting the file.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],10366.99,,"Fee schedule rate ($10,366.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5766.55,17111.12,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],57872.02,,,,,,0,other,19503.23,57872.02,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19661.25,,"Fee schedule rate ($19,661.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7308.00,42083.20,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11670.40,,"Case rate ($11,114.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,269.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,975.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,310.61. The transfer operating threshold is the transfer adjustment factor * $10,269.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.06. The transfer capital threshold is the transfer adjustment factor * $804.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7000.00,32980.62,Inpatient DRG
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],64440.06,,"Fee schedule rate ($64,440.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17212.14,64440.06,Zero final payments for the item or service in the 15 months prior to posting the file.
"GASTROINTESTINAL VASCULAR INSUFFICIENCY,MAJOR",246,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15139.74,,"Case rate ($14,418.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14418.80,15139.74,There are no additional notes associated with this service or procedure.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],50697.38,,"Case rate ($50,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $46,843.13, add-ons for qualifying new technology services are included. If operating cost exceeds $82,311.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,838.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $47,029.81. The transfer operating threshold is the transfer adjustment factor * $46,843.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,667.58. The transfer capital threshold is the transfer adjustment factor * $3,667.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",41480.62,41480.62,41480.62,1 through 10,other,13061.00,162464.13,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],48832.41,,,,,,0,other,16456.83,55350.97,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7143.87,,"Case rate ($6,803.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,286.43, add-ons for qualifying new technology services are included. If operating cost exceeds $41,754.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,663.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,311.49. The transfer operating threshold is the transfer adjustment factor * $6,286.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.20. The transfer capital threshold is the transfer adjustment factor * $492.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5843.00,27370.21,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],49295.13,,"Fee schedule rate ($49,295.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,11055.00,49295.13,There are no additional notes associated with this service or procedure.
"ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,MINOR",198,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6684.29,,"Case rate ($6,365.99). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6365.99,6684.29,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT HAND, THUMB",CASE-28750,APC,28750,CPT,0360,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
HC Debride Subq First 20 Sq Cm|PBB CHARGE,CASE-11042,APC,11042,CPT,0361,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],385.57,,"APC Price ($385.57). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,385.57,404.84,OPPS APC
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],37131.39,,"Case rate ($35,363.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $32,674.75, add-ons for qualifying new technology services are included. If operating cost exceeds $68,142.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,729.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,804.97. The transfer operating threshold is the transfer adjustment factor * $32,674.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.27. The transfer capital threshold is the transfer adjustment factor * $2,558.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,18559.00,141041.50,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],97176.83,,,,,,0,other,32749.19,97176.83,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20593.95,,,,,,0,other,6940.28,20593.95,There are no additional notes associated with this service or procedure.
Arthrp Kne Condyle&Platu Medial&Lat Compartments|LEFT SIDE,CASE-27447,APC,27447,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12785.93,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",12542.29,590.91,13876.81,19,other,12177.08,12785.93,OPPS APC
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],63458.56,,"Fee schedule rate ($63,458.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,15950.19,63458.56,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],72371.94,,"Fee schedule rate ($72,371.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],26419.65,,"Case rate ($26,419.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $24,411.09, add-ons for qualifying new technology services are included. If operating cost exceeds $59,878.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,082.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,508.38. The transfer operating threshold is the transfer adjustment factor * $24,411.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,911.26. The transfer capital threshold is the transfer adjustment factor * $1,911.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,26419.65,96304.23,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],8940.00,,"Per diem ($8,940). If length of stay < 6.8, first 1 days paid at a per diem of $17,880 instead. Capped at $60,793.48.",,,,0,other,8940.00,63653.13,Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],38106.57,,"Fee schedule rate ($38,106.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,13446.23,39899.05,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",5605.96,5605.96,5605.96,1 through 10,other,5733.99,6020.69,OPPS APC
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, FIFTH DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20100.36,,"Fee schedule rate ($20,100.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7003.94,20782.85,Zero final payments for the item or service in the 15 months prior to posting the file.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],73332.24,,,,,,0,other,24713.42,73332.24,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],36468.17,,"Fee schedule rate ($36,468.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10178.99,36468.17,Zero final payments for the item or service in the 15 months prior to posting the file.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],32847.45,,"Fee schedule rate ($32,847.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7590.81,32847.45,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],12764.84,,"Fee schedule rate ($12,764.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7551.60,23262.15,Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE|PO,CASE-64493,APC,64493,CPT,0360,RC,,,50|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39251.68,,,,,,0,other,13228.06,39251.68,There are no additional notes associated with this service or procedure.
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,APC,45171,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42131.77,,"Fee schedule rate ($42,131.77). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9495.32,42131.77,Zero final payments for the item or service in the 15 months prior to posting the file.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],69402.59,,"Fee schedule rate ($69,402.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20654.42,69402.59,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6937.15,,"Case rate ($6,606.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,114.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,582.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,639.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,138.63. The transfer operating threshold is the transfer adjustment factor * $6,114.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.18. The transfer capital threshold is the transfer adjustment factor * $468.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],305.69,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,291.13,305.69,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12698.12,,"Case rate ($12,093.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,174.05, add-ons for qualifying new technology services are included. If operating cost exceeds $46,641.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,046.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,218.58. The transfer operating threshold is the transfer adjustment factor * $11,174.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.87. The transfer capital threshold is the transfer adjustment factor * $874.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12093.45,35884.94,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6630.72,19989.86,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy US Scope W/Adj Strxrs|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43237,APC,43237,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20694.94,,"Fee schedule rate ($20,694.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,APC,43236,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1820.02,,"APC Price ($1,820.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1820.02,1911.02,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],84471.39,,,,,,0,other,8232.00,84471.39,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11645.83,,"Case rate ($11,645.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,760.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,228.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,013.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,803.35. The transfer operating threshold is the transfer adjustment factor * $10,760.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.49. The transfer capital threshold is the transfer adjustment factor * $842.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11645.83,37502.92,Inpatient DRG
Arthroscopy Knee Lateral Release|LEFT SIDE|PO,CASE-29873,APC,29873,CPT,0360,RC,,,LT|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE|PO,CASE-29824,APC,29824,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7226.40,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn|RIGHT HAND, THIRD DIGIT|PO",CASE-26145,APC,26145,CPT,0360,RC,,,F7|PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1578.51,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1525.13,1578.51,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,13704.86,49911.01,Zero final payments for the item or service in the 15 months prior to posting the file.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2632.62,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11600.75,,"Case rate ($11,600.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,718.80, add-ons for qualifying new technology services are included. If operating cost exceeds $46,186.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,010.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,761.52. The transfer operating threshold is the transfer adjustment factor * $10,718.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.23. The transfer capital threshold is the transfer adjustment factor * $839.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,11600.75,34422.94,Inpatient DRG
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],926.14,,"APC Price ($882.03). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,882.03,926.14,OPPS APC
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40729.62,,"Fee schedule rate ($40,729.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,10638.54,40729.62,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,There are no additional notes associated with this service or procedure.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26566.03,,"Case rate ($25,667.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $23,716.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,184.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,028.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,810.80. The transfer operating threshold is the transfer adjustment factor * $23,716.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,856.86. The transfer capital threshold is the transfer adjustment factor * $1,856.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,25667.66,86123.60,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Tenodesis Long Tendon Biceps|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-23430,APC,23430,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16630.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16630.26,17461.77,OPPS APC
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3899.35,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3713.66,3899.35,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6814.63,,"Case rate ($6,681.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,173.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,654.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,197.68. The transfer operating threshold is the transfer adjustment factor * $6,173.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.32. The transfer capital threshold is the transfer adjustment factor * $483.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6681.01,19824.58,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Sciatic Continuous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE|PO,CASE-64446,APC,64446,CPT,0360,RC,,,XU|RT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Fibula|LEFT SIDE,CASE-27641,APC,27641,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],23223.02,,"Case rate ($22,117.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $20,468.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,936.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,738.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,549.86. The transfer operating threshold is the transfer adjustment factor * $20,468.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.30. The transfer capital threshold is the transfer adjustment factor * $1,567.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9370.00,65732.99,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],43585.38,,"Fee schedule rate ($43,585.38). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,15507.88,46016.63,Zero final payments for the item or service in the 15 months prior to posting the file.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Tdn/Musc Xtnsr F/Arm&/Wrist Prim 1 Ea Tdn|LEFT SIDE|PO,CASE-25270,APC,25270,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11922.35,,"Case rate ($11,519.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,643.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,111.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,004.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,685.85. The transfer operating threshold is the transfer adjustment factor * $10,643.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.33. The transfer capital threshold is the transfer adjustment factor * $833.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,11519.18,34180.92,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33891.30,,"Fee schedule rate ($33,891.30). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,11958.84,40774.00,Zero final payments for the item or service in the 15 months prior to posting the file.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 7 day length of stay.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6387.91,18954.85,Estimated amount calculated based on 3 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10291.73,34803.35,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Peripheral Block - Brachial Plexus Single W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64415,APC,64415,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1134.98,,"APC Price ($1,134.98). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1134.98,1191.72,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4795.07,,"Case rate ($4,795.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,430.53, add-ons for qualifying new technology services are included. If operating cost exceeds $39,898.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,518.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,448.18. The transfer operating threshold is the transfer adjustment factor * $4,430.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.89. The transfer capital threshold is the transfer adjustment factor * $346.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",4733.32,4733.32,4733.32,1 through 10,other,4795.07,19830.58,Inpatient DRG
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],42671.03,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,40639.08,120588.53,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3686.99,,"Case rate ($3,686.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,406.68, add-ons for qualifying new technology services are included. If operating cost exceeds $38,874.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,437.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,420.26. The transfer operating threshold is the transfer adjustment factor * $3,406.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $266.73. The transfer capital threshold is the transfer adjustment factor * $266.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,3209.85,10940.41,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],42708.75,,"Fee schedule rate ($42,708.75). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16737.33,72192.67,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14641.18,,"Case rate ($14,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,528.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,995.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,230.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,582.00. The transfer operating threshold is the transfer adjustment factor * $13,528.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.18. The transfer capital threshold is the transfer adjustment factor * $1,059.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",14948.64,14948.64,14948.64,1 through 10,other,14641.18,43444.85,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26999.90,,"Fee schedule rate ($26,999.90). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9527.16,28269.95,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],8931.13,,"Fee schedule rate ($8,931.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4895.21,14525.56,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],32387.75,,"Fee schedule rate ($32,387.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12179.66,36140.75,Zero final payments for the item or service in the 15 months prior to posting the file.
Prostate Needle Biopsy Any Approach|SEPARATE STRUCTURE,CASE-55700,APC,55700,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5085.49,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14455.48,,"Case rate ($13,767.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,740.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,208.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,146.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,791.53. The transfer operating threshold is the transfer adjustment factor * $12,740.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13789.07,57367.22,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,Zero final payments for the item or service in the 15 months prior to posting the file.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6558.98,19462.52,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],36681.16,,"Fee schedule rate ($36,681.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,12881.26,38222.57,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18051.15,,"Case rate ($17,191.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $15,884.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,352.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $15,947.89. The transfer operating threshold is the transfer adjustment factor * $15,884.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,243.68. The transfer capital threshold is the transfer adjustment factor * $1,243.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,17191.57,51012.62,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13771.19,,"Fee schedule rate ($13,771.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4639.91,13771.19,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10477.95,,"Fee schedule rate ($10,477.95). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6387.91,18954.85,There are no additional notes associated with this service or procedure.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20179.92,,"Fee schedule rate ($20,179.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,1188.00,20179.92,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13889.46,,"Case rate ($13,228.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,222.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,690.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,128.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,271.11. The transfer operating threshold is the transfer adjustment factor * $12,222.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $956.95. The transfer capital threshold is the transfer adjustment factor * $956.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13228.06,39251.68,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33182.89,,"Fee schedule rate ($33,182.89). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,19503.23,57872.02,Zero final payments for the item or service in the 15 months prior to posting the file.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7144.02,,"Case rate ($7,003.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,471.47, add-ons for qualifying new technology services are included. If operating cost exceeds $41,939.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,677.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,497.26. The transfer operating threshold is the transfer adjustment factor * $6,471.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.68. The transfer capital threshold is the transfer adjustment factor * $506.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,7003.94,20782.85,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22034.96,,"Fee schedule rate ($22,034.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,8394.53,24909.11,Zero final payments for the item or service in the 15 months prior to posting the file.
Laparoscopy Proctopexy Prolapse,CASE-45400,APC,45400,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],291.13,,"APC Price ($291.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,291.13,305.69,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8704.87,,"Case rate ($8,704.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $8,043.08, add-ons for qualifying new technology services are included. If operating cost exceeds $43,510.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,800.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,075.14. The transfer operating threshold is the transfer adjustment factor * $8,043.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.73. The transfer capital threshold is the transfer adjustment factor * $629.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,8704.87,25830.00,Inpatient DRG
HC Intro Catheter Aorta|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36200,APC,36200,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2994.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2994.77,3099.59,OPPS APC
HC Pbb Carpal Tunnel Inj Pmc|LEFT SIDE|PO,CASE-20526,APC,20526,CPT,0510,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1944.70,,"APC Price ($1,852.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1916.92,1944.70,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],55581.70,,"Fee schedule rate ($55,581.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,3295.00,55581.70,Zero final payments for the item or service in the 15 months prior to posting the file.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],4797.39,,"Case rate ($4,568.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,221.59, add-ons for qualifying new technology services are included. If operating cost exceeds $39,689.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,501.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,238.42. The transfer operating threshold is the transfer adjustment factor * $4,221.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.53. The transfer capital threshold is the transfer adjustment factor * $330.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4568.94,13557.45,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22189.86,,"Case rate ($21,133.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $19,526.55, add-ons for qualifying new technology services are included. If operating cost exceeds $54,994.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,699.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,604.37. The transfer operating threshold is the transfer adjustment factor * $19,526.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,528.83. The transfer capital threshold is the transfer adjustment factor * $1,528.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21133.20,88801.87,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],41269.88,,"Case rate ($23,582.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $21,789.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,257.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,877.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,876.75. The transfer operating threshold is the transfer adjustment factor * $21,789.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,706.04. The transfer capital threshold is the transfer adjustment factor * $1,706.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,23582.79,75543.62,All Other Inpatient
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],30130.97,,"Case rate ($28,696.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $26,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $61,982.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,247.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $26,620.21. The transfer operating threshold is the transfer adjustment factor * $26,514.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.95. The transfer capital threshold is the transfer adjustment factor * $2,075.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,28696.16,118364.04,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11835.60,,"Fee schedule rate ($11,835.60). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,4787.78,20006.29,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],27682.71,,of the excess amount.,,,,0,other,3295.00,48444.74,There are no additional notes associated with this service or procedure.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24585.00,,"Fee schedule rate ($24,585.00). Adds an outlier to normal pricing equal to the per diem rate ($99,392.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8675.02,25741.45,Zero final payments for the item or service in the 15 months prior to posting the file.
Open Tx Trimalleolar Ankle Fx W/O Fixj Pst Lip|LEFT SIDE,CASE-27822,APC,27822,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],4389.36,,"Case rate ($4,180.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,862.54, add-ons for qualifying new technology services are included. If operating cost exceeds $39,330.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,473.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,877.94. The transfer operating threshold is the transfer adjustment factor * $3,862.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.42. The transfer capital threshold is the transfer adjustment factor * $302.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4180.34,14351.57,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15261.14,,"Case rate ($14,534.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,429.44, add-ons for qualifying new technology services are included. If operating cost exceeds $48,897.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,222.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,482.96. The transfer operating threshold is the transfer adjustment factor * $13,429.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.46. The transfer capital threshold is the transfer adjustment factor * $1,051.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14534.42,59012.52,Inpatient DRG
"ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,MINOR",198,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6365.99,,"Case rate ($6,365.99). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6365.99,6684.29,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10650.56,,"Case rate ($10,290.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,508.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,975.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,915.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $9,545.97. The transfer operating threshold is the transfer adjustment factor * $9,508.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.43. The transfer capital threshold is the transfer adjustment factor * $744.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103.5%.",,,,0,other,10290.40,42115.80,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5414.50,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,5308.33,19857.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|PO,CASE-64483,APC,64483,CPT,0360,RC,,,PO,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],868.26,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,838.89,880.84,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],40639.08,,"Case rate ($40,639.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $37,549.50, add-ons for qualifying new technology services are included. If operating cost exceeds $73,017.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $4,111.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,699.15. The transfer operating threshold is the transfer adjustment factor * $37,549.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,939.93. The transfer capital threshold is the transfer adjustment factor * $2,939.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,40639.08,120588.53,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15065.57,,"Case rate ($15,065.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $13,920.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,388.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,261.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,975.70. The transfer operating threshold is the transfer adjustment factor * $13,920.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.88. The transfer capital threshold is the transfer adjustment factor * $1,089.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",15065.58,15065.58,15065.58,1 through 10,other,15065.57,53815.71,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],838.89,,"APC Price ($838.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,838.89,880.84,OPPS APC
Stab Phlebt Varicose Veins 1 Xtr > 20 Incs|LEFT SIDE,CASE-37766,APC,37766,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3144.51,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2994.77,3144.51,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24438.02,,"Fee schedule rate ($24,438.02). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13230.71,39259.55,There are no additional notes associated with this service or procedure.
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,APC,45171,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2632.62,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2632.62,2764.26,OPPS APC
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29792.90,,"Fee schedule rate ($29,792.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],47660.93,,"Fee schedule rate ($47,660.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16817.56,58510.23,Zero final payments for the item or service in the 15 months prior to posting the file.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],66951.94,,"Fee schedule rate ($66,951.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23624.56,83038.88,Zero final payments for the item or service in the 15 months prior to posting the file.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20788.82,,"Fee schedule rate ($20,788.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7335.51,29792.90,Zero final payments for the item or service in the 15 months prior to posting the file.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],76171.92,,"Fee schedule rate ($76,171.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,18508.54,76171.92,Zero final payments for the item or service in the 15 months prior to posting the file.
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT SIDE|PO,CASE-26540,APC,26540,CPT,0360,RC,,,LT|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37575.69,,"Fee schedule rate ($37,575.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,3295.00,37575.69,There are no additional notes associated with this service or procedure.
Rpr Tdn Flxr Foot 1/2 W/O Free Grafg Each Tendon|RIGHT SIDE,CASE-28200,APC,28200,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, THIRD DIGIT|PO",CASE-26525,APC,26525,CPT,0360,RC,,,F7|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MODERATE",045,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12896.38,,"Case rate ($12,896.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12896.38,13541.20,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12215.62,,"Case rate ($11,633.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $10,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $46,234.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,995.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,809.50. The transfer operating threshold is the transfer adjustment factor * $10,766.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.42. The transfer capital threshold is the transfer adjustment factor * $824.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11652.47,41507.02,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($55,128.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",34164.88,34164.88,34164.88,1 through 10,other,12093.45,35884.94,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5308.33,,"Case rate ($5,308.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,904.77, add-ons for qualifying new technology services are included. If operating cost exceeds $40,372.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,555.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,924.31. The transfer operating threshold is the transfer adjustment factor * $4,904.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.02. The transfer capital threshold is the transfer adjustment factor * $384.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5308.33,19857.20,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25854.47,,"Fee schedule rate ($25,854.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7952.22,25854.47,There are no additional notes associated with this service or procedure.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],30254.51,,"Case rate ($30,254.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $27,954.41, add-ons for qualifying new technology services are included. If operating cost exceeds $63,422.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,359.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $28,065.82. The transfer operating threshold is the transfer adjustment factor * $27,954.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,188.69. The transfer capital threshold is the transfer adjustment factor * $2,188.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,30254.51,130347.93,Inpatient DRG
Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent,CASE-36903,APC,36903,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11496.76,,"APC Price ($10,949.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10949.29,11496.76,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],48626.00,,"Fee schedule rate ($48,626.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9763.00,48626.00,There are no additional notes associated with this service or procedure.
Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp|LEFT SIDE|PO,CASE-27691,APC,27691,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MODERATE",385,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8127.41,,"Case rate ($8,127.41). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8127.41,8533.78,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29288.89,,"Fee schedule rate ($29,288.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,10334.84,30666.60,Zero final payments for the item or service in the 15 months prior to posting the file.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],76326.34,,"Fee schedule rate ($76,326.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21289.03,76326.34,Zero final payments for the item or service in the 15 months prior to posting the file.
HC Iliac Territory Plasty Stent|RIGHT SIDE,CASE-37221,APC,37221,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],444.96,,,,,,0,other,444.96,467.21,There are no additional notes associated with this service or procedure.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],46957.63,,"Fee schedule rate ($46,957.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7455.00,53076.74,There are no additional notes associated with this service or procedure.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35696.10,,"Fee schedule rate ($35,696.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,3295.00,46419.05,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],99157.51,,"Fee schedule rate ($99,157.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34988.57,110685.97,Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20343.42,,"Fee schedule rate ($20,343.42). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,6382.95,21300.35,Zero final payments for the item or service in the 15 months prior to posting the file.
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3659.98,,"APC Price ($3,536.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3536.22,3713.03,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Open Repair of Rotator Cuff Chronic|LEFT SIDE,CASE-23412,APC,23412,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34540.67,,"Fee schedule rate ($34,540.67). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,10439.61,34540.67,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28454.65,,"Fee schedule rate ($28,454.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11080.19,32878.30,There are no additional notes associated with this service or procedure.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],124146.55,,"Fee schedule rate ($124,146.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,29594.69,124146.55,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16302.99,55737.89,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],54706.69,,"Fee schedule rate ($54,706.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31750.58,,"Fee schedule rate ($31,750.58). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12402.46,36801.89,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Neck/Thorax Subfasc 5 Cm/>,CASE-21554,APC,21554,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2755.03,,"APC Price ($2,755.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2755.03,2892.78,OPPS APC
HC Extremity Venogram|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-36005,APC,36005,CPT,0361,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10260.35,,"APC Price ($9,913.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9913.38,10409.05,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Excision Lesion Tendon Sheath/Capsule Leg&/Ank,CASE-27630,APC,27630,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.56,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.39,3258.56,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],84629.16,,"Fee schedule rate ($84,629.16). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,23679.61,84629.16,Zero final payments for the item or service in the 15 months prior to posting the file.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm,CASE-11422,APC,11422,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5934.68,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5934.68,5934.68,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],29255.05,,"Case rate ($27,861.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $25,743.75, add-ons for qualifying new technology services are included. If operating cost exceeds $61,211.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,186.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,846.34. The transfer operating threshold is the transfer adjustment factor * $25,743.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.60. The transfer capital threshold is the transfer adjustment factor * $2,015.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,27861.95,82674.88,Inpatient DRG
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],228732.31,,"Fee schedule rate ($228,732.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,66027.56,228732.31,There are no additional notes associated with this service or procedure.
Excision Multiple External Papillae/Tags Anus,CASE-46230,APC,46230,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2764.26,,"APC Price ($2,632.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2632.62,2764.26,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
Arthrd Midtarsl/Tarsometatarsal Mult/Transvrs|LEFT SIDE|PO,CASE-28730,APC,28730,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13533.35,,"Fee schedule rate ($13,533.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6837.50,20288.95,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12700.21,,"Case rate ($7,257.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,705.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,173.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,732.25. The transfer operating threshold is the transfer adjustment factor * $6,705.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.01. The transfer capital threshold is the transfer adjustment factor * $525.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,7257.26,23445.98,All Other Inpatient
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6410.25,,"Fee schedule rate ($6,410.25). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.09,15887.21,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],8298.54,,"Case rate ($4,742.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $4,381.51, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,514.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,398.97. The transfer operating threshold is the transfer adjustment factor * $4,381.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $343.05. The transfer capital threshold is the transfer adjustment factor * $343.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 175%.",,,,0,other,4742.02,14071.02,All Other Inpatient
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,21399.79,63499.65,Zero final payments for the item or service in the 15 months prior to posting the file.
"Rcnstj Angular Dfrm Toe Soft Tiss Px Only|LEFT FOOT, SECOND DIGIT|PO",CASE-28313,APC,28313,CPT,0360,RC,,,T1|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6401.17,,"Case rate ($6,401.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $5,914.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,382.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,634.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,938.09. The transfer operating threshold is the transfer adjustment factor * $5,914.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.08. The transfer capital threshold is the transfer adjustment factor * $463.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,5669.00,18994.21,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13577.72,,"Fee schedule rate ($13,577.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4464.17,13577.72,There are no additional notes associated with this service or procedure.
Lig/Banding Angioaccess Arteriovenous Fistula,CASE-37607,APC,37607,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2994.77,,"APC Price ($2,994.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",2922.01,2883.68,2922.01,1 through 10,other,2994.77,3144.51,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],32176.55,,"Fee schedule rate ($32,176.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10385.89,32176.55,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35955.24,,"Fee schedule rate ($35,955.24). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12167.07,36103.36,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4090.84,,"Case rate ($4,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $3,779.83, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,467.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,794.89. The transfer operating threshold is the transfer adjustment factor * $3,779.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.94. The transfer capital threshold is the transfer adjustment factor * $295.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,2285.00,12138.74,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18878.71,,"Case rate ($18,508.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $17,101.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,569.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,510.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,169.59. The transfer operating threshold is the transfer adjustment factor * $17,101.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.95. The transfer capital threshold is the transfer adjustment factor * $1,338.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,18508.54,76171.92,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8030.94,,"Case rate ($7,648.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,067.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,534.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,724.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,095.20. The transfer operating threshold is the transfer adjustment factor * $7,067.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.31. The transfer capital threshold is the transfer adjustment factor * $553.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7648.51,27371.98,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
Partial Excision Bone Talus/Calcaneus|LEFT SIDE|PO,CASE-28120,APC,28120,CPT,0360,RC,,,LT|PO,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6882.29,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6882.29,7226.40,OPPS APC
"OTHER DISORDERS OF NERVOUS SYSTEM,MAJOR",058,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],19292.76,,"Case rate ($19,292.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19292.76,20257.40,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, FOURTH DIGIT|PO",CASE-28232,APC,28232,CPT,0360,RC,,,T3|PO,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.39,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29583.47,,"Fee schedule rate ($29,583.47). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,13228.06,39251.68,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12922.60,,"Case rate ($12,307.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,389.72, add-ons for qualifying new technology services are included. If operating cost exceeds $46,857.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,043.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,435.11. The transfer operating threshold is the transfer adjustment factor * $11,389.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $872.13. The transfer capital threshold is the transfer adjustment factor * $872.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12326.86,53121.74,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17723.81,,"Fee schedule rate ($17,723.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7184.98,21320.03,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,11757.91,34889.29,Zero final payments for the item or service in the 15 months prior to posting the file.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],49568.46,,"Fee schedule rate ($49,568.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,20954.82,62179.32,Zero final payments for the item or service in the 15 months prior to posting the file.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11621.00,,"Per diem ($11,621). If length of stay < 22.4, first 1 days paid at a per diem of $23,242 instead. Capped at $260,309.36.",,,,0,other,10249.47,96445.01,Estimated amount calculated based on 18 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],54149.39,,"Fee schedule rate ($54,149.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11986.02,54149.39,Zero final payments for the item or service in the 15 months prior to posting the file.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],67175.58,,"Fee schedule rate ($67,175.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23703.48,110204.98,Zero final payments for the item or service in the 15 months prior to posting the file.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8234.36,,"Case rate ($8,072.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $7,459.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,927.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,755.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,488.89. The transfer operating threshold is the transfer adjustment factor * $7,459.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.01. The transfer capital threshold is the transfer adjustment factor * $584.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,8072.90,31159.55,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],76303.11,,"Fee schedule rate ($76,303.11). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,36276.38,121107.98,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3212.01,,"APC Price ($3,103.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.39,3258.56,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15540.89,,,,,,0,other,5237.39,15540.89,There are no additional notes associated with this service or procedure.
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,MODERATE",770,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5665.98,,"Case rate ($5,396.17). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5396.17,5665.98,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12204.33,,"Case rate ($11,623.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,774.95, add-ons for qualifying new technology services are included. If operating cost exceeds $51,320.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.01, exceeds $2,490.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,780.28. The transfer operating threshold is the transfer adjustment factor * $10,774.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.89. The transfer capital threshold is the transfer adjustment factor * $842.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1188.00,35040.80,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39980.63,,"Fee schedule rate ($39,980.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13664.39,40546.43,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31883.69,,"Fee schedule rate ($31,883.69). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,Zero final payments for the item or service in the 15 months prior to posting the file.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18815.35,,"Fee schedule rate ($18,815.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4538.44,18815.35,Zero final payments for the item or service in the 15 months prior to posting the file.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19830.58,,"Fee schedule rate ($19,830.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,4795.07,19830.58,Zero final payments for the item or service in the 15 months prior to posting the file.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21325.01,,"Fee schedule rate ($21,325.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,21325.01,There are no additional notes associated with this service or procedure.
HC Tib per Territory Ather|LEFT SIDE,CASE-37229,APC,37229,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],657.88,,,,,,0,other,626.55,657.88,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],36276.38,,"Case rate ($36,276.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $33,518.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,986.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $3,795.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,652.04. The transfer operating threshold is the transfer adjustment factor * $33,518.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,624.32. The transfer capital threshold is the transfer adjustment factor * $2,624.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",,,,0,other,36276.38,121107.98,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],36084.80,,"Fee schedule rate ($36,084.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14641.18,43444.85,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14574.62,,"Case rate ($13,880.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $12,825.31, add-ons for qualifying new technology services are included. If operating cost exceeds $48,293.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,175.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,876.42. The transfer operating threshold is the transfer adjustment factor * $12,825.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7285.00,41187.90,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18366.31,,"Fee schedule rate ($18,366.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6308.00,21796.21,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18862.20,,"Fee schedule rate ($18,862.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,7231.00,38610.21,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|LEFT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9427.57,,"APC Price ($8,978.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8978.63,9427.57,OPPS APC
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33310.69,,"Fee schedule rate ($33,310.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10080.86,33310.69,Zero final payments for the item or service in the 15 months prior to posting the file.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30069.78,,"Fee schedule rate ($30,069.78). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,11895.84,35298.57,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],53945.28,,"Fee schedule rate ($53,945.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,3295.00,53945.28,Zero final payments for the item or service in the 15 months prior to posting the file.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23445.98,,"Fee schedule rate ($23,445.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7257.26,23445.98,There are no additional notes associated with this service or procedure.
Arthrodesis Subtalar|RIGHT SIDE,CASE-28725,APC,28725,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12177.08,,"APC Price ($12,177.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12177.08,12785.93,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19047.86,,"Fee schedule rate ($19,047.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7078.89,21005.20,There are no additional notes associated with this service or procedure.
Laps Bi Tot Pel Lmphadec & Pri-Aortic Lymph Bx 1,CASE-38572,APC,38572,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10586.16,,"APC Price ($10,082.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10082.05,10586.16,OPPS APC
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7226.40,,"APC Price ($6,882.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6882.29,7226.40,OPPS APC
"HC Unlisted Procedure, Nervous System",CASE-64999,APC,64999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5733.99,,"APC Price ($5,733.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5733.99,6020.69,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12693.58,,"Case rate ($12,693.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $11,728.55, add-ons for qualifying new technology services are included. If operating cost exceeds $47,196.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $2,089.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,775.29. The transfer operating threshold is the transfer adjustment factor * $11,728.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.29. The transfer capital threshold is the transfer adjustment factor * $918.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.",97927.91,97927.91,101250.23,1 through 10,other,12693.58,46577.81,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],58421.49,,"Fee schedule rate ($58,421.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,22908.38,67976.16,There are no additional notes associated with this service or procedure.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33483.49,,"Fee schedule rate ($33,483.49). Adds an outlier to normal pricing equal to the per diem rate ($110,276.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11814.94,44591.73,Zero final payments for the item or service in the 15 months prior to posting the file.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6787.20,,"Fee schedule rate ($6,787.20). Adds an outlier to normal pricing equal to the per diem rate ($3,919.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3980.76,11812.10,There are no additional notes associated with this service or procedure.
"Tenolysis Flexor Tendon Palm/Finger Each Tendon|RIGHT HAND, SECOND DIGIT|PO",CASE-26440,APC,26440,CPT,0360,RC,,,F6|PO,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1601.38,,"APC Price ($1,525.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1525.13,1601.38,OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26544.90,,"Fee schedule rate ($26,544.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10826.88,32126.64,Zero final payments for the item or service in the 15 months prior to posting the file.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19528.85,,"Fee schedule rate ($19,528.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6503.29,19528.85,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10920.51,,"Case rate ($10,400.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $9,609.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,077.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,923.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,648.09. The transfer operating threshold is the transfer adjustment factor * $9,609.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.40. The transfer capital threshold is the transfer adjustment factor * $752.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6965.00,30861.41,Inpatient DRG
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],96112.80,,"Fee schedule rate ($96,112.80). Adds an outlier to normal pricing equal to the per diem rate ($6,691.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,13061.00,162464.13,There are no additional notes associated with this service or procedure.
Trurl Rescj Residual/Regrowth Obstr Prstate Tiss,CASE-52630,APC,52630,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5085.49,,"APC Price ($5,085.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5085.49,5339.77,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23117.63,,"Fee schedule rate ($23,117.63). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8704.87,25830.00,There are no additional notes associated with this service or procedure.
"MAJOR RESPIRATORY AND CHEST PROCEDURES,EXTREME",120,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],71871.57,,"Case rate ($71,871.57). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3797, exceeds an outlier threshold of the inlier plus a fixed threshold of $52,189, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,71871.57,75465.15,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7357.77,,"Case rate ($7,213.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.239, exceeds $6,665.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,132.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.008, exceeds $1,692.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,691.65. The transfer operating threshold is the transfer adjustment factor * $6,665.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.84. The transfer capital threshold is the transfer adjustment factor * $521.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.",,,,0,other,6965.00,21404.64,Inpatient DRG Zero final payments for the item or service in the 15 months prior to posting the file.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2070.00,,,,,,0,other,1188.00,35040.80,Estimated amount calculated based on 244 day length of stay.